Eur Spine 2012 Mar;21 指導老師 : 譚仕馨主任 報告人 : 連煜

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1 Eur Spine 2012 Mar;21 指導老師 : 譚仕馨主任 報告人 : 連煜 1

2 Introduction 2

3 Adolescent idiopathic scoliosis (AIS) is deemed to be multi-factorial Genetic predisposition Anterior and posterior spinal growth Abnormalities connective tissue, skeletal muscle, muscle contractile mechanisms and neurology. 3

4 Surgery is a well-recognised treatment of AIS The role of conservative therapies including exercises, physiotherapy,and bracing has been the source of much debate Although it is rather difficult to explain how exercise therapy could correct a complex three-dimensional structural deformity that occurs in AIS 4

5 A number of papers have been published by some centres that heavily endorse exercise therapy as an effective treatment option and have purpose built rehabilitation centres specifically for this use 5

6 Clearly, there is a need for an independent review of current evidence on this topic to avoid inevitable reviewer bias. The aim of the current study was to provide an unbiased literature review regarding the use of exercise therapy in the treatment of AIS. 6

7 Materials and methods 7

8 An electronic literature search was performed using the following search engines Pubmed (end of December 2010) Embase (1980 December 2010) Medline (1950 December 2010) Cinahl ( ) The Cochrane Library 2010, Issue 12. 8

9 9

10 Total 155 elimination of 45 duplicated Of remaining 110 were reviewed by the two authors 98 studies were not relevant inclusion criteria The 12 relevant studies were then categorised according to their level of evidence using a simplified adaption 10

11 Inclusion criteria Treatment involving only exercise therapy At least level IV evidence At least 1 month follow-up Minimum of one defined outcome measure. 11

12 12

13 Results 13

14 Table 3 highlights the key aspects from each paper. Overall, No studies representing level I evidence, nine studies representing level II, two studies representing level III, one study representing level IV evidence. A total of 997 patients, mean age 15.8 years with an average follow-up period of 15 months. 14

15 15

16 Analysis 16

17 SEAS Negrini et al The primary outcome included the number of braced patients, Cobb angle and the angle of trunk rotation In the SEAS exercises group, 23.5% of patients improved and 11.8% worsened, In the usual physiotherapy group 11.1% improved and 13.9% worsened. The authors concluded that SEAS is more effective than usual PT 17

18 18

19 McIntire KL Initial Cobb angle between 20 and 60 Patients received 4 months supervised training consisting of using MedX Rotary Torso Machine unsupervised training at home utilising a Thera-Band for resistance training. Quantified trunk rotational strength training significantly increased strength. It was not effective for 50 to 60 degrees. It appeared to help stabilize curves in the 20 to 40-degree ranges. 19

20 MedX Rotary Torso Machine &spfreload=10 20

21 Weiss and Klein Equally into two groups( Treatment group was 34.5 degrees,control group was 31.6 degrees ) each receiving a 4-week programme of SIR the treatment group had the addition the Physio-logic exercise programme. Surface rotation improved at average 1.2 degrees in the treatment group and 0.8 degrees in the controls while Kyphosis angle did not improve in both groups 21

22 SIR physiologic exercise (Schroth Best Practice ) spfreload=10 22

23 Otman et al We treated them as, 5 days a week, in a 4-hour program for the first 6 weeks. After that, they continued with the same program at home. We evaluated the Cobb angle, vital capacity and muscle strength According to the results of evaluations before treatment, after 6 weeks, 6 months and one year, we observed an increase in muscle strength and recovery of the postural defects in all patients 23

24 Cobb angle FVC Before treatment ml After 6 weeks ml After 6 months ml After one year ml Schroth s 3D exercise 24

25 Mooney and Brigham On 20 patients, years old Cobb angle 15 to 41 Underwent computerized MedX rotary torso machine with torso rotation strength training. and were treated twice a week until curve reduction or skeletal maturity. Though 16 patients demonstrated curve reduction Lack of basic patient demographics, small sample size, and exact period of follow-up bring the accuracy of results into question. 25

26 computerized MedX rotary torso machine freload=10 26

27 Weiss et al With AIS matched by age and sex the treatment group (115 patients) underwent a 4 6 week SIR programme followed by at home daily exercises to maintain postural balance and the control group (107 patients) had no treatment. They found statistically higher progression rates in the control group than the treatment group after 35 months follow-up The authors concluded that exercise based therapies are effective when compared 27

28 Stirling et al English girls 0.4 and 2.2% in of 9 to 11 years Boys 0.1 and 0.3% in of 9 to 11 years Soucacos et al Greek 82,900 Greek school children 9 to 14 years old a prevalence of 1.7% in his study, in total 2.6% of the girls and 0.9% of the boys Wong et al Singaporean 0.04% by the age of 7, 0.19% by the age of 10, 1.44% by the age of 14 while the overall children 9 to 14 years of age was 0.78% (1.23% in girls and 0.33% in boys). 28

29 El-Sayyad and Conine 30 children assigned to one of three groups (a) exercise, (b) exercise and Milwaukee brace (c) exercise and electrical stimulation. For the purpose of this review, only results of patients in group A are discussed. The exercise programme consisted of daily activity, home exercise and exercise three times per week under supervision of a therapist for 12 weeks. Average moiré topography reduced from to which the authors say was significant. 29

30 Moiré Topography pfreload=10 30

31 Weiss On 107 patients with an average age 21.7, who underwent a 4 6 week in-patient exercise program according to the Schroth method. Average Cobb angles reduced from to A curve improvement of 5 or more in 44%, 53% were unchanged and 2.8% had a curve increase of 5. These results show that even in severe scoliosis of the curve can be reduced by a specific rehabilitation program of physiotherapy 31

32 Mamyama et al On 69 patients with only by side shift exercise after skeletal maturity. The average age of patients was 16.3 years with an average follow-up of 4.2 years. from 31.5 to 30.3 at the end of the follow-up period. But 44 out of the 69 patients had no change in curve angle and the average 1.2 decrease observed is far too small to be of any significance. 32

33 Dobosiewicz et al Dobosiewicz's method The method developed since 1979, comprises active 3- dimensional auto-correction, with special emphasis on the kyphotization of the thoracic spine, carried on in closed kinematic chains, and developed on a symmetrically positioned pelvis and shoulder girdle, followed by active stabilization of the corrected position 33

34 Kyphotization in sitting position Rotation against a Escape wall from the pad a. the patient On is seated; all four Rotation kyphotization (simple) a. the patient is seated a. the near patient a wall is seated; b. the arms and a. the elbows patient a. the are patient is flexed positioned at is 90 ; seated; on all fours b. the trunk is rotated b. the against rib hump the pad is detached as far as possible c. the elbows are pushed b. the forward. trunk is rotated against from the the pad pad 34

35 Chromy et al Of five adolescent girls (14 16 years) using the LTX 3000 Lumbar Underwent 3 months treatment of 10 min twice a day providing axial lumbar spine unloading. Initial mean standing Cobb angle of 13.7 reduced to 8 at 3 months but increased to 10.0 at 4 month The authors concluded that the intervention resulted in significant reduction in Cobb angles immediately post treatment 35

36 LTX

37 Discussion 37

38 1.While such RCT assessing exercise therapy in AIS are difficult to perform, this finding reflects the paucity of good quality research on this topic 2. Several weaknesses were identified in all studies including lack of clarity on recruitment of patients, or on indications or contraindications for treatment 38

39 3. If the changes were short lived then would need to be continued lifelong. This contradicts the idea that exercise therapy is an effective treatment option that can restore normal lifestyle. 4.Two studies reported on Moire fringe topography, which has been shown to be inaccurate in detecting small changes in curve dimensions 39

40 5.Many studies had short follow-up periods and hence none of the studies commented on long term results, thereby doubts on whether any changes observed would be maintained. 40

41 Conclusions 41

42 All studies endorsed the role of exercise therapy in AIS but several shortcomings were identified lack patient recruitment and in the method of assessment of curve magnitude, and lack of outcome scores. Many studies reported significant changes in the Cobb angle after treatment, which were actually of small magnitude and did not take into account error rate. 42

43 43