+
MODEL
Journal of Bodywork & Movement Therapies (2014) xx, 1e6
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/jbmt
CASE REPORT
Improvement of clinical and radiographical presentation of Scheuermann disease after Schroth therapy treatment Tomer Bezalel, MScPT a, Leonid Kalichman, PT, PhD b,* a
Maccabi Health Care Services, Posture Clinic, Maccabi Hashalom, Tel Aviv, Israel Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health Sciences at Ben-Gurion University of the Negev, POB 653, Beer-Sheva 84105, Israel
b
Received 5 November 2013; received in revised form 28 February 2014; accepted 9 April 2014
KEYWORDS Kyphosis; Scheuermann; Schroth method; Physical therapy; exercises
Summary Background: Scheuermann’s disease is the most common cause of hyperkyphosis of the thoracolumbar spine. Few case reports have demonstrated the effectiveness of Schroth therapy in improving the thoracic angle curve in Scheuermann’s patients; however, additional verification is needed. Case description: A 14-year-old female patient presented with Scheuermann’s disease. On X-ray, thoracic kyphosis was 55 and lumbar lordosis 55 . The self-rated cosmetic disturbance was graded 10/10 on a verbal numeric scale. The patient received a course of seven weekly Schroth therapy sessions, in addition to daily home exercises tailored specifically for the patient’s posture. Five months later, follow-up X-rays revealed thoracic kyphosis of 27 and lumbar lordosis 35 . The patient graded the degree of her cosmetic disturbance as 3/10. Conclusions: Schroth therapy seems to be able to decrease the thoracic curve angle of Scheuermann’s patients; however, efficacy and effectiveness of this method should be investigated in future prospective controlled clinical trials. ª 2014 Elsevier Ltd. All rights reserved.
Introduction Scheuermann’s disease was first described by Sachs in 1987 as thoracic kyphosis greater than 45 (T3eT12), and at least one vertebra wedged minimum of 5 (Sachs et al., 1987).
* Corresponding author. E-mail address: [email protected] (L. Kalichman).
Scheuermann’s disease, occurring during adolescence, is the most common cause of hyperkyphosis of the thoracic and thoracolumbar spine (Holt et al., 1997). Following idiopathic scoliosis, it is most prevalent in patients with deformities of the spine (Graat et al., 2002; Holt et al., 1997). Scheuermann’s disease is characterized by vertebral body wedging, vertebral endplate irregularity, diminished anterior vertebral growth, Schmorl’s nodes, narrowing of the intervertebral disk spaces and premature disk degeneration (Fotiadis et al., 2008).
http://dx.doi.org/10.1016/j.jbmt.2014.04.008 1360-8592/ª 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Bezalel, T., Kalichman, L., Improvement of clinical and radiographical presentation of Scheuermann disease after Schroth therapy treatment, Journal of Bodywork & Movement Therapies (2014), http://dx.doi.org/10.1016/ j.jbmt.2014.04.008
+
MODEL
2 Scheuermann’s kyphosis appears during the adolescent growth spurt as a structural kyphotic deformity of the thoracic or thoracolumbar spine. The disease usually occurs between the ages of 10e16, most frequently between 12 and 15 years (Bick and Copel, 1951; Fotiadis et al., 2008; Murray et al., 1993; Wenger and Frick, 1999). According to the literature, controversial evidence exists as to the prevalence of Scheuermann’s among males and females. In Sorenson’s study (Sorensen, 1964), 58% of the patients were male; 42% were female. Other studies reported the male to female ratio as 1:2 (Bradford et al., 1974; Bradford et al., 1975), 1:1 (Montgomery and Erwin, 1981; Shufflebarger and Clark, 1992; Tribus, 1998) http://www.ncbi.nlm.nih. gov/pmc/articles/PMC3242958/ e CIT0019, 2:1 (Damborg et al., 2011; Fisk et al., 1984; Murray et al., 1993), or 7.3:1 (Scheuermann, 1920). The choice of treatment for Scheuermann’s disease is based on the severity of the deformity, the presence of pain, and age of the patient. Treatment of Scheuermann’s disease is primarily non-operative. Adolescents whose kyphosis remains less than 60 are usually treated only by exercise to increase flexibility and then followed periodically by imaging studies until skeletal maturity (Lowe, 1999). There is no standard protocol of follow-up radiographic evaluations for Scheuermann’s disease patients. In Israel, the decision is based on clinical evaluation. If during the evaluation, the physician/therapist suspects spinal deformity progression, the patient is referred to X-ray. A Schroth three-dimensional exercise therapy program was developed in Germany in the 1920s, by Katharina Schroth. She divided the trunk into three “blocks” (cervical, thoracic and lumbar body segments) which can be shifted against one another. Special exercises were designed to correct the relative position of the three blocks in the sagittal plane together with self-elongation of the vertebral column, proprietary corrective breathing techniques and re-education of the neuromuscular system in order to improve postural perception (Lehnert-Schroth, 1992; Otman et al., 2005; Weiss, 2011). The method is based on sensorimotor and kinesthetic principles. The initial force involved in every Schroth exercise is spinal selfelongation. The patient learns to strengthen the musculature surrounding the spine when they are in place associated with the newly formed posture. Using sensorimotor feedback mechanisms, the patients learn an individual correction routine. Mirror monitoring allows synchronizing the corrective movement and the postural perception with visual input. By viewing himself in a mirror, the patient is able to see how the kyphotic posture changes into a more favorable one, and how the skeletal imbalance and musculature gradually transform into an upright position. Corrective breathing is a major component of the Schroth method (Weiss, 1991). The focus is on changing the patient’s breathing pattern in order to decrease the risk of spinal deformity curve progression and to promote a more balanced posture. In addition, motivation and cooperation are essential components in the Schroth method. Patients receive a detailed explanation of the method in general and of each exercise specifically, to promote cooperation and improve motivation. The Schroth method corrects the kyphotic posture, with the help of proprioceptive and exteroceptive stimulation
T. Bezalel, L. Kalichman and mirror control in the sagittal plane, using specific corrective breathing patterns. These exercises are specifically tailored to each patient. Treatment objectives were passive and active reduction of the kyphotic hump, and stretching hamstring and pectoral muscles. During therapy, patients utilize corrective active trunk muscle forces and learn to maintain an erect posture. Then, the corrected posture is maintained throughout daily living activities and eventually results in a more erect trunk. Our clinical experience, in addition to a few case reports in the literature (Weiss et al., 2002a, 2002b), suggest that Schroth therapy may be effective in preventing deterioration and decreasing the thoracic angle curve in Scheuermann’s patients. Additional verification is needed to implement this method in an evidence-based clinical practice model.
Case presentation Initial evaluation A 14-year-old female patient presented with hyperkyphosis and was diagnosed in November 2011 as suffering from Scheuermann’s disease by two orthopedic surgeons. One surgeon identified the Cobb angle at 55 and advised Schroth therapy. The second surgeon identified the Cobb angle at 60 and advised treatment by the Milwaukee brace. The patient and her parents chose Schroth therapy. The patient’s general health was normal, no developmental problems in childhood, and no back or neck pain. She was eight months onset of post-menarch, height was 1.580 m and she had not participated in any sport or physical activity prior to treatment. Her familial history of spinal deformities was positive; her sister was treated with braces for Adolescent Idiopathic Scoliosis. No other proximate family members suffered from spinal deformations. In January 2012, the patient was examined by a physical therapist (T.B.) with more than 5 years’ experience in the daily treatment of spinal deformities and trained in the Schroth method. Radiographic evaluation of thoracic kyphosis was observed on a lateral view digital image of the spine in a standing position. Digital image software offers several tools for improving image quality i.e. zoom, increased contrast, silhouette enhancement, and a negative image effect. In a recent study, the Cobb method demonstrated high reliability (interclass correlation coefficient Z 0.96, CI 0.92, 0.97), clinical advantages and suitability to assess the scoliotic curvature in the frontal plane (Tanure et al., 2010). The thoracic kyphosis measured by the physical therapist at T3eT12 was 55 (normal kyphosis is between 26 and 46 ); the lumbar lordosis at L1eL5 was 55 (normal lumbar lordosis is between 32 and 56 ) (Fig. 1a). T7 and T8 vertebrae were anteriorly wedged at >5 (Fig. 2a). The C7 vertebral body vertical axis (posterior part of the vertebral body) was situated 7.92 cm from the sacral promontory. The scapula rested high on the rib cage with an anterior inclination (35 from the vertical line). Clinically, the patient had bilateral mild pes planus. Sagittal plane observation showed lumbar hyperlordosis,
Please cite this article in press as: Bezalel, T., Kalichman, L., Improvement of clinical and radiographical presentation of Scheuermann disease after Schroth therapy treatment, Journal of Bodywork & Movement Therapies (2014), http://dx.doi.org/10.1016/ j.jbmt.2014.04.008
+
MODEL
Clinical and radiographical improvement of Scheuermann
3
Figure 1 a. Initial evaluation: The thoracic kyphosis Cobb angle was 55 and the lumbar lordosis Cobb angle was 55 . The C7 vertebral body vertical axis was situated 7.92 cm from the sacral promontory. X2Y2 indicates the position of the scapula on the rib surface. b. Follow-up evaluation: The thoracic kyphosis Cobb angle was 27 and the lumbar lordosis Cobb angle was 31 . The C7 vertebral body vertical axis was situated 4.13 cm from the sacral promontory. X2Y2 indicates the position of the scapula on the rib surface.
and thoracic hyperkyphosis together with a mild forward head posture, mild rounded shoulders and sway back. Spinal range of motion and gait pattern were normal. Adams Forward Bending Test revealed classic configuration of the thoracic spine sharply angulated. Even though we provided feedback for active correction, the hyperkyphosis was fixed and remained visible upon hyperextension of the spine, denoting a structural component in the thoracic spine. In addition, the patient had mild right scoliosis. Structural scoliosis, commonly with minor curves, is noted in about one third of Scheuermann’s patients
(Somhegyi and Ratko, 1993). The goniometric measurements of passive shoulder flexion in the supine position showed significant restriction, approximately 150 in both shoulders (normal 180 ). Goniometric measurements were also used to measure hamstring flexibility during a standard passive straight leg raise. The range was found to be 5 (Fig. 2b). The C7 vertebral body vertical axis was situated 4.13 cm from the sacral promontory, and the scapula rested on the rib surface in a natural position and without inclination (8 from the vertical line). The patient’s height was 1.585 m (an increase of 0.5 cm from initial evaluation). All clinical findings had improved: head and shoulder positions were closer to “normal” posture compared to the initial evaluation, and
T. Bezalel, L. Kalichman less forward head position. The general appearance of the back was straighter, especially in the upper thoracic area. She appeared more balanced in the pelvic area, with a less prominent anterior tilt compared to the initial evaluation. Lumbar lordosis was also reduced. In the Adam Forward Bending Test the thoracic spine was less angulated and hamstring length improved (>60 in both legs). There was no change in shoulder flexion ROM (approximately 150 in both shoulders). The patient graded the degree of her cosmetic disturbance as 3/10 (seven points less than the initial evaluation).
Discussion Thoracic hyperkyphosis is the most common form of Scheuermann’s disease, and is associated with a nonstructural hyperlordosis of the lumbar and cervical spine (Jansen et al., 2006). Extension sports such as gymnastics, aerobics, swimming, basketball, cycling and hyperextension exercises are advised. However, sports associated with jumping, marked stress and functional overuse of the back, especially in patients with thoracolumbar and lumbar Scheuermann’s kyphosis, should be discouraged (Rachbauer et al., 2001; Sturm et al., 1993). Weiss et al. (2002a) reported their results of long-term physical therapy, osteopathy, manual therapy, exercise programs, and psycho-therapy of a group of 351 patients (17e21 years of age) with painful Scheuermann’s kyphosis. At the end of treatment, both the visual analog and the numerical rating scale showed pain reduction between 16% and 32%, significant in all cases. Soo et al. (2002) suggested that appropriate treatment for patients with Scheuermann’s kyphosis should be based on age, spinal deformity, and severity of back pain. Generally, skeletally immature patients with a kyphotic curve
MODEL
Journal of Bodywork & Movement Therapies (2014) xx, 1e6
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/jbmt
CASE REPORT
Improvement of clinical and radiographical presentation of Scheuermann disease after Schroth therapy treatment Tomer Bezalel, MScPT a, Leonid Kalichman, PT, PhD b,* a
Maccabi Health Care Services, Posture Clinic, Maccabi Hashalom, Tel Aviv, Israel Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health Sciences at Ben-Gurion University of the Negev, POB 653, Beer-Sheva 84105, Israel
b
Received 5 November 2013; received in revised form 28 February 2014; accepted 9 April 2014
KEYWORDS Kyphosis; Scheuermann; Schroth method; Physical therapy; exercises
Summary Background: Scheuermann’s disease is the most common cause of hyperkyphosis of the thoracolumbar spine. Few case reports have demonstrated the effectiveness of Schroth therapy in improving the thoracic angle curve in Scheuermann’s patients; however, additional verification is needed. Case description: A 14-year-old female patient presented with Scheuermann’s disease. On X-ray, thoracic kyphosis was 55 and lumbar lordosis 55 . The self-rated cosmetic disturbance was graded 10/10 on a verbal numeric scale. The patient received a course of seven weekly Schroth therapy sessions, in addition to daily home exercises tailored specifically for the patient’s posture. Five months later, follow-up X-rays revealed thoracic kyphosis of 27 and lumbar lordosis 35 . The patient graded the degree of her cosmetic disturbance as 3/10. Conclusions: Schroth therapy seems to be able to decrease the thoracic curve angle of Scheuermann’s patients; however, efficacy and effectiveness of this method should be investigated in future prospective controlled clinical trials. ª 2014 Elsevier Ltd. All rights reserved.
Introduction Scheuermann’s disease was first described by Sachs in 1987 as thoracic kyphosis greater than 45 (T3eT12), and at least one vertebra wedged minimum of 5 (Sachs et al., 1987).
* Corresponding author. E-mail address: [email protected] (L. Kalichman).
Scheuermann’s disease, occurring during adolescence, is the most common cause of hyperkyphosis of the thoracic and thoracolumbar spine (Holt et al., 1997). Following idiopathic scoliosis, it is most prevalent in patients with deformities of the spine (Graat et al., 2002; Holt et al., 1997). Scheuermann’s disease is characterized by vertebral body wedging, vertebral endplate irregularity, diminished anterior vertebral growth, Schmorl’s nodes, narrowing of the intervertebral disk spaces and premature disk degeneration (Fotiadis et al., 2008).
http://dx.doi.org/10.1016/j.jbmt.2014.04.008 1360-8592/ª 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Bezalel, T., Kalichman, L., Improvement of clinical and radiographical presentation of Scheuermann disease after Schroth therapy treatment, Journal of Bodywork & Movement Therapies (2014), http://dx.doi.org/10.1016/ j.jbmt.2014.04.008
+
MODEL
2 Scheuermann’s kyphosis appears during the adolescent growth spurt as a structural kyphotic deformity of the thoracic or thoracolumbar spine. The disease usually occurs between the ages of 10e16, most frequently between 12 and 15 years (Bick and Copel, 1951; Fotiadis et al., 2008; Murray et al., 1993; Wenger and Frick, 1999). According to the literature, controversial evidence exists as to the prevalence of Scheuermann’s among males and females. In Sorenson’s study (Sorensen, 1964), 58% of the patients were male; 42% were female. Other studies reported the male to female ratio as 1:2 (Bradford et al., 1974; Bradford et al., 1975), 1:1 (Montgomery and Erwin, 1981; Shufflebarger and Clark, 1992; Tribus, 1998) http://www.ncbi.nlm.nih. gov/pmc/articles/PMC3242958/ e CIT0019, 2:1 (Damborg et al., 2011; Fisk et al., 1984; Murray et al., 1993), or 7.3:1 (Scheuermann, 1920). The choice of treatment for Scheuermann’s disease is based on the severity of the deformity, the presence of pain, and age of the patient. Treatment of Scheuermann’s disease is primarily non-operative. Adolescents whose kyphosis remains less than 60 are usually treated only by exercise to increase flexibility and then followed periodically by imaging studies until skeletal maturity (Lowe, 1999). There is no standard protocol of follow-up radiographic evaluations for Scheuermann’s disease patients. In Israel, the decision is based on clinical evaluation. If during the evaluation, the physician/therapist suspects spinal deformity progression, the patient is referred to X-ray. A Schroth three-dimensional exercise therapy program was developed in Germany in the 1920s, by Katharina Schroth. She divided the trunk into three “blocks” (cervical, thoracic and lumbar body segments) which can be shifted against one another. Special exercises were designed to correct the relative position of the three blocks in the sagittal plane together with self-elongation of the vertebral column, proprietary corrective breathing techniques and re-education of the neuromuscular system in order to improve postural perception (Lehnert-Schroth, 1992; Otman et al., 2005; Weiss, 2011). The method is based on sensorimotor and kinesthetic principles. The initial force involved in every Schroth exercise is spinal selfelongation. The patient learns to strengthen the musculature surrounding the spine when they are in place associated with the newly formed posture. Using sensorimotor feedback mechanisms, the patients learn an individual correction routine. Mirror monitoring allows synchronizing the corrective movement and the postural perception with visual input. By viewing himself in a mirror, the patient is able to see how the kyphotic posture changes into a more favorable one, and how the skeletal imbalance and musculature gradually transform into an upright position. Corrective breathing is a major component of the Schroth method (Weiss, 1991). The focus is on changing the patient’s breathing pattern in order to decrease the risk of spinal deformity curve progression and to promote a more balanced posture. In addition, motivation and cooperation are essential components in the Schroth method. Patients receive a detailed explanation of the method in general and of each exercise specifically, to promote cooperation and improve motivation. The Schroth method corrects the kyphotic posture, with the help of proprioceptive and exteroceptive stimulation
T. Bezalel, L. Kalichman and mirror control in the sagittal plane, using specific corrective breathing patterns. These exercises are specifically tailored to each patient. Treatment objectives were passive and active reduction of the kyphotic hump, and stretching hamstring and pectoral muscles. During therapy, patients utilize corrective active trunk muscle forces and learn to maintain an erect posture. Then, the corrected posture is maintained throughout daily living activities and eventually results in a more erect trunk. Our clinical experience, in addition to a few case reports in the literature (Weiss et al., 2002a, 2002b), suggest that Schroth therapy may be effective in preventing deterioration and decreasing the thoracic angle curve in Scheuermann’s patients. Additional verification is needed to implement this method in an evidence-based clinical practice model.
Case presentation Initial evaluation A 14-year-old female patient presented with hyperkyphosis and was diagnosed in November 2011 as suffering from Scheuermann’s disease by two orthopedic surgeons. One surgeon identified the Cobb angle at 55 and advised Schroth therapy. The second surgeon identified the Cobb angle at 60 and advised treatment by the Milwaukee brace. The patient and her parents chose Schroth therapy. The patient’s general health was normal, no developmental problems in childhood, and no back or neck pain. She was eight months onset of post-menarch, height was 1.580 m and she had not participated in any sport or physical activity prior to treatment. Her familial history of spinal deformities was positive; her sister was treated with braces for Adolescent Idiopathic Scoliosis. No other proximate family members suffered from spinal deformations. In January 2012, the patient was examined by a physical therapist (T.B.) with more than 5 years’ experience in the daily treatment of spinal deformities and trained in the Schroth method. Radiographic evaluation of thoracic kyphosis was observed on a lateral view digital image of the spine in a standing position. Digital image software offers several tools for improving image quality i.e. zoom, increased contrast, silhouette enhancement, and a negative image effect. In a recent study, the Cobb method demonstrated high reliability (interclass correlation coefficient Z 0.96, CI 0.92, 0.97), clinical advantages and suitability to assess the scoliotic curvature in the frontal plane (Tanure et al., 2010). The thoracic kyphosis measured by the physical therapist at T3eT12 was 55 (normal kyphosis is between 26 and 46 ); the lumbar lordosis at L1eL5 was 55 (normal lumbar lordosis is between 32 and 56 ) (Fig. 1a). T7 and T8 vertebrae were anteriorly wedged at >5 (Fig. 2a). The C7 vertebral body vertical axis (posterior part of the vertebral body) was situated 7.92 cm from the sacral promontory. The scapula rested high on the rib cage with an anterior inclination (35 from the vertical line). Clinically, the patient had bilateral mild pes planus. Sagittal plane observation showed lumbar hyperlordosis,
Please cite this article in press as: Bezalel, T., Kalichman, L., Improvement of clinical and radiographical presentation of Scheuermann disease after Schroth therapy treatment, Journal of Bodywork & Movement Therapies (2014), http://dx.doi.org/10.1016/ j.jbmt.2014.04.008
+
MODEL
Clinical and radiographical improvement of Scheuermann
3
Figure 1 a. Initial evaluation: The thoracic kyphosis Cobb angle was 55 and the lumbar lordosis Cobb angle was 55 . The C7 vertebral body vertical axis was situated 7.92 cm from the sacral promontory. X2Y2 indicates the position of the scapula on the rib surface. b. Follow-up evaluation: The thoracic kyphosis Cobb angle was 27 and the lumbar lordosis Cobb angle was 31 . The C7 vertebral body vertical axis was situated 4.13 cm from the sacral promontory. X2Y2 indicates the position of the scapula on the rib surface.
and thoracic hyperkyphosis together with a mild forward head posture, mild rounded shoulders and sway back. Spinal range of motion and gait pattern were normal. Adams Forward Bending Test revealed classic configuration of the thoracic spine sharply angulated. Even though we provided feedback for active correction, the hyperkyphosis was fixed and remained visible upon hyperextension of the spine, denoting a structural component in the thoracic spine. In addition, the patient had mild right scoliosis. Structural scoliosis, commonly with minor curves, is noted in about one third of Scheuermann’s patients
(Somhegyi and Ratko, 1993). The goniometric measurements of passive shoulder flexion in the supine position showed significant restriction, approximately 150 in both shoulders (normal 180 ). Goniometric measurements were also used to measure hamstring flexibility during a standard passive straight leg raise. The range was found to be 5 (Fig. 2b). The C7 vertebral body vertical axis was situated 4.13 cm from the sacral promontory, and the scapula rested on the rib surface in a natural position and without inclination (8 from the vertical line). The patient’s height was 1.585 m (an increase of 0.5 cm from initial evaluation). All clinical findings had improved: head and shoulder positions were closer to “normal” posture compared to the initial evaluation, and
T. Bezalel, L. Kalichman less forward head position. The general appearance of the back was straighter, especially in the upper thoracic area. She appeared more balanced in the pelvic area, with a less prominent anterior tilt compared to the initial evaluation. Lumbar lordosis was also reduced. In the Adam Forward Bending Test the thoracic spine was less angulated and hamstring length improved (>60 in both legs). There was no change in shoulder flexion ROM (approximately 150 in both shoulders). The patient graded the degree of her cosmetic disturbance as 3/10 (seven points less than the initial evaluation).
Discussion Thoracic hyperkyphosis is the most common form of Scheuermann’s disease, and is associated with a nonstructural hyperlordosis of the lumbar and cervical spine (Jansen et al., 2006). Extension sports such as gymnastics, aerobics, swimming, basketball, cycling and hyperextension exercises are advised. However, sports associated with jumping, marked stress and functional overuse of the back, especially in patients with thoracolumbar and lumbar Scheuermann’s kyphosis, should be discouraged (Rachbauer et al., 2001; Sturm et al., 1993). Weiss et al. (2002a) reported their results of long-term physical therapy, osteopathy, manual therapy, exercise programs, and psycho-therapy of a group of 351 patients (17e21 years of age) with painful Scheuermann’s kyphosis. At the end of treatment, both the visual analog and the numerical rating scale showed pain reduction between 16% and 32%, significant in all cases. Soo et al. (2002) suggested that appropriate treatment for patients with Scheuermann’s kyphosis should be based on age, spinal deformity, and severity of back pain. Generally, skeletally immature patients with a kyphotic curve
