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18 lutego 2020

Compensation treatment of scoliosis - the use of parameters evaluating a global trunk rotation value

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Scoliosis is a generic term covering a group of disorders involving a change in shape and position of the spine [18]. Scoliosis Research Society defines it as an abnormal curve of the spine for which the measured Cobb angle in a radiogram is at least 10° [25.30]. Also referred to as an abnormal lateralcurvature of the spine, it is, in fact, a three-dimensional deformity [6]. Parameters characterising idiopathic scoliosis include: unknown aetiology, three-dimensional nature of changes, appearance in the period of development, a tendency for progression in the period of fast growth of the spine, and more frequent occurrence in girls [6,30]. They represent 80% to 90% of all types of scolioses, regardless of classifications used in the literature [10,24,26,28]. Prevalence of juvenile idiopathic scoliosis corresponds to 2-3 % of the general population [20,22,27].

SUMMING PARAMETERS - COMPENSATION MECHANISM.

The vertebral axial rotation is a characteristic of the spine deformation in idiopathic scoliosis [8]. It is evaluated by the Adam’s test using the Bunnell’s scoliometer, which is a simple and easy to use measuring device characterised by high sensitivity and repeatability, and its availability makes it useful for screen tests [2,3,4,19]. A reduction in costal hump during treatment indicates that a three-dimensional correction was achieved, and represents an important part of the treatment result assessment by a patient [1].  The scoliometer can be used to evaluate an angle of rotation of individual arches and a global trunk rotation.

The angle of trunk rotation (ATR) is measured at a level of the scoliosis apex, both for the primary and the secondary scoliosis.
 

Figure 4.11.  Measurements of the angle of trunk rotation using a scoliometer, for cervical (A), thoracic (B) and lumbar (C) spine. Own material.


The global trunk rotation can be measured by using summing parameters. The sum of rotation (SR) represents a sum of angles of trunk rotation at a level of 12 thoracic and 5 lumbar vertebrae, with a correction for pelvis rotation.  A shorter method for evaluation of the global scoliotic deformation is the Hump Sum parameter, also known as the Suzuki Hump Sum. It is obtained by summing three values of a surface angle of trunk rotation, measured at three levels of the spine: thoracic proximal, thoracic middle, and lumbar [5,20].

In patients with double-curve scolioses (without a curve in the cervicothoracic spine), of type 1 and 2, according to King-Moe classification, a parameter of a sum of two rotations (SDR) can be used, obtained by summing two values of the angle of trunk rotation: at the apex of the thoracic curve and the apex of the lumbar spine. A simplified measurement provides quick information on behaviour of the two sections - primary and secondary (thoracic and lumbar), and represents an evaluation of the global value of trunk rotation in the double-curve scoliosis [29]. To evaluate behaviour of the cervicothoracic spine, the rotation can also be measured on a spinous process of the last cervical vertebra.
 

Figure Parameters determining global trunk rotation: Sum of rotation - SR (A), Hump Sum (B), sum of two rotations - SDR (C). Own material.


DISCUSSION

Structural deformations of the trunk and the spine can progress rapidly, especially during a period of intense growth (11–14 years) [23].  Nachemson et al. [8] report that in 10–15-years-old patients, the risk of progression is within the range of 70% to 90% for scolioses of up to 2nd degree according to Cobb. Monitoring of adverse changes in body structure and position represents an important part of health status assessment. Development of diagnostics and knowledge leads to objective results of the therapy. A three-dimensional nature of scoliosis requires a specific type of diagnostics, covering not only examination of the frontal plane, but of many other parameters that are also associated with sagittal and transverse planes [13,14,15]. The basic method for evaluation of the scoliosis progression is the measurement of the Cobb angle in the spine radiogram. However, because the examined patient is exposed to radiation, it cannot be repeated too often, and in consequence, a regular follow-up for the patient is not possible [19]. 

Reports of many authors show a correlation between measurements of trunk rotation with the scoliometer and the Cobb angle measured in the X-ray scan [1,7,11,12,16,17]. Thus, a measurement of the trunk asymmetry is appropriate for monitoring of treatment outcome in children with scoliosis. It can also be a valuable supplement of clinical examination and be used for evaluation of treatment effectiveness in children with scolioses [1,19].  A value of at least 3° is considered a significant change in the angle of trunk in successive measurements [21].

Presence of compensatory curves above and below the primary scoliosis requires monitoring of values of parameters at all levels of scoliosis. Verification of a value of the cervicothoracic spine rotation and of the secondary curve in double-curve scolioses provides an insight to a total assessment of the therapy results.

The FITS therapy uses development of advantageous compensation mechanisms; therefore, the authors demonstrate an increase in the angle of trunk rotation within compensatory curves [1,7]. Despite a significant improvement in the main curve, the angle of rotation in the upper and lower compensatory curves increases; they do not, however, demonstrate signs of statistical significance. The authors believe that changes observed by them and involving statistically significant reduction in rotation of the main curve, with simultaneous tendency for its increase in the compensatory curves, or possibly, for elongation of the primary curve, can be interpreted as development of a compensation mechanism in idiopathic scoliosis, resulting from the undertaken therapy. At the same time, they emphasise the need to measure and monitor compensatory curves in the process of treatment of a child with scoliosis [1]. Kotwicki and Śliwiński [21] report that development of secondary curves results from compensation mechanisms aiming at keeping the head and the chest aligned vertically; however, long-term disease results in development of compensatory mechanisms to such degree that they themselves become a clinical problem to the patient. They noted a need to examine the spine at different levels when diagnosing scolioses, using summing of trunk rotations in the Adam’s test, with measurements in the proximal thoracic (Th3–4), main thoracic (Th8–9), and lumbar (L2–3) sections at a level of maximum asymmetry, to monitor treatment as a measure of the total rotational deformation of the trunk.

Taking into account the above, the aim of the therapy should be to reduce the trunk rotation at a level of the primary and the secondary curves. Thus, a reduction in parameters describing the global trunk rotation will indicate a correction at all curves, while its stopping or increase will mean development of compensatory curves, i.e., reduction in the primary curve due to an increase in the compensatory curve.

The three levels of measurements are used for global evaluation of all types of scolioses. In the case of double curve scolioses, without a scoliotic curve in the cervicothoracic section (the rotation not exceeding 7°, as measured at a level of the seventh cervical vertebra with a scoliometer, and 10° Cobb angle, as measured in the X-ray scan), a measurement at two places of maximum rotation, at a level of the main thoracic and lumbar sections, can be used to evaluate the therapy [29]. Summing of two levels of rotation gives an insight into changes of these two values in the primary and in the compensatory section. The obtained value of summed rotations after the therapy indicates either the correction of scoliosis or a compensatory shift of the rotation from the primary to the secondary curve.  Therefore, the therapy should focus on reduction in these parameters.

In Poland, the use of summing parameters in diagnostics is not widely spread yet. However, the subject of compensation treatment of scolioses and the use of the global assessment of the trunk rotation is not new. Trzcińska et al. [29] achieved a statistical correction of all curves, including the global trunk rotation, in evaluation of the effectiveness of the FED method. Also Chowańska et al. [5] used the Hump Sum parameter, obtained by summing three values of a surface angle of trunk rotation, measured at three levels of the spine: thoracic proximal, thoracic middle, and lumbar, to measure scoliosis. Goldberg et al. [9] demonstrated a statistically significant correlation between a change in the Cobb angle value of the main curve, and the Hump Sum values.  Białek et al. [1] observed an increase in the angle of rotation of compensatory curves by measuring rotation with a scoliometer at three levels of the spine. Strategic regions included the primary curve, and the secondary proximal and distal scoliotic curves. In their research, they used summing of rotations at the above levels. However, for the Sum of Rotation (SR) parameter, the studies did not demonstrate a statistically significant difference after the therapy. The changes observed by them involved statistically significant reduction in rotation of the main curve, with simultaneous tendency for its increase in the compensatory curves.

Contact: Sandra Trzcińska, sandra-trzcinska@wp.pl

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Przypisy

    Sandra Trzcińska

    dr; Kierownik Fizjoterapii Ośrodka Ortopedyczno – Rehabilitacyjnego dla dzieci i młodzieży w Chylicach Mazowieckiego Centrum Rehabilitacji STOCER w Konstancinie – Jeziornie. Specjalista w dziedzinie fizjoterapii. Absolwent Akademii Wychowanie Fizycznego w Katowicach wydziału Fizjoterapii. W kompleksowym podejściu do zawodu fizjoterapeuty łączy zarówno aspekty praktyczne jako certyfikowany terapeuta licznych szkoleń, jak i merytoryczno – naukowe zdobyte jako wykładowca-asystent kinezyterapii i terapii manualnej Śląskiej Akademii Medycznej w Katowicach. Ukończyła szereg szkoleń z zakresu diagnostyki i leczenia funkcjonalnego narządu ruchu:: leczenie skolioz metodą FED i Lehnert – Schroth, terapię manualną Schmeitzky, wg koncepcji Kaltenborna- Evjentha oraz metodę strukturalnej osteopati i chiropraktyki dr Ackermanna. Certyfikowany terapeuta metody McKenzie, PNF, Kinesiology Taping, SET i Neurac 1. Ukończyła także cykl szkoleń z zakresu: diagnostyki różnicowej, obrazowej RTG i MR oraz leczenia dysfunkcji narządu ruchu. Laureat nagrody przyznanej przez Marszałka Województwa Mazowieckiego za osobisty wkład na rzecz ochrony zdrowia.

    Prelegent wielu konferencji, szkoleń oraz warsztatów dotyczących leczenia wad postawy i skolioz. Członek Komisji Naukowych Konferencji oraz autor licznych artykułów naukowych z zakresu diagnostyki i leczenia dysfunkcji narządu ruchu.

     

    Zbigniew Nowak

    prof. nadzw. dr hab.; Academy of Physical Education, Katowice