Managing the adult consequences of a pediatric condition.
Adolescent idiopathic scoliosis (AIS) remains the most common deforming orthopedic condition of children, accounting for up to 85 per cent of all types of scoliosis seen clinically. The diagnosis is confirmed by the presence of a spinal curve greater than 11 degrees on full-spine radiographs in patients between the ages of 10 and 16. In its most aggressive forms, it is characterized clinically by progressive spinal curvature and vertebral rotation that subsides, usually, at the completion of growth. Although there remains a genetic and familial predisposition in the etiology of scoliosis, its true cause remains unknown. Some explanations include disproportionate growth velocities and nervous system dysfunction. More research is required.
While the etiology of scoliosis remains less clear, the natural history is better understood. Estimates of prevalence of mild curvature, ranging from five to 20 degrees, is thought to be between 1 to 3 per cent of adolescents, with a male to female ratio of 1:2 (Leaver, 1982, Moe, 1978). In moderate to severe curves requiring medical management, the prevalence ranges between .03 and .09 per cent (Drennan, 1977, Robitaille, 1984), with a male to female ratio of 1:7 (Robitaille 1984, Morais, 1985).
The medical management of scoliosis is typically based on curve magnitude. Curves less than 20 degrees are observed over time for progression. Curves greater than 30 degrees at the time of diagnosis are customarily braced (Rowe, 1998). Children or adults who are still growing and whose curves exceed 45 degrees are recommended for arthrodesis (Rowe, 1998).
Although bracing remains the accepted form of treatment for curves between 30 and 40 degrees, its therapeutic value remains inconclusive. Rowe et al. performed a meta-analysis of 20 studies comparing bracing, lateral electrical surface stimulation and no treatment (Rowe, 1998). Results of the meta-analysis suggest that bracing conducted for anything less than 23 hours per day remained ineffective. Unfortunately, compliance among fashion-conscious teens and the general discomfort associated with such braces make their application at a therapeutic level unlikely.
For adolescents and teens undergoing surgical interventions for progressive curve changes, there remain those risks commonly associated with surgical interventions. One study of 555 individuals having undergone surgical treatment for AIS revealed that 17 per cent experienced rod failure rate while another 10 per cent experienced wound infections (Goldberg, 1994). For many parents, the thought of such a significant surgical event for their child is a terrifying experience.
EVALUATING TREATMENT SUCCESS OR FAILURE
Early medical research used cessation of curve progression as the primary outcome measure for evaluating the success and failure of treatment. Once the curve progression was halted, treatment was successful. Wasn’t it? A large cohort study conducted by Goldberg et al. of St. Justine’s Hospital, Montreal, determined that the experience of having had AIS and having undergone treatment in the form of bracing or treatment led to some profound challenges as adults (Poitras, 1994, Goldberg, 1994, Mayo, 1994). Both men and women who had scoliosis reported poorer perception of body image and greater difficulty with strenuous activity. Back pain was found to be more prevalent in both genders and when present was more severe and chronic. Those with scoliosis were 1.3 times more likely to have had back pain within the last year. Women were generally more likely to have had challenges lifting heavy objects, walking longer distances and sitting and standing, although for men sitting, standing and walking were problematic. Women experienced higher levels of self-reported arthritis, poorer perceptions of health and more days lost to sickness, injury and other health problems than a similarly matched cohort. Clearly, the negative consequence of having had AIS, in the form of pain, self-perception, functional and vocational activities for both genders, continued on well after curve progression and formal treatment had been completed. For researchers, this offered one of the first indicators that AIS is not necessarily a pediatric condition.
More recent knowledge has added to our awareness of the adult-related implications of AIS. One study identified significantly greater degenerative disc changes, disc height reduction and end-plate changes for both the upper and lower end-plate of non-fused vertebrae (Danielsson, 2001). Similar results were seen in braced individuals where greater thoracic and lumbar degenerative changes were evident (Danielsson, 2003). For AIS patients having undergone both bracing and/or surgical interventions, spinal mobility and muscle endurance was still a problem 20 years after treatment was complete (Danielsson, 2006). For women, there are other concerns. Among adult women having had AIS, there remains greater frequency of negative effect in their sexual life. This appears to be a factor of increased back pain, physical inability to participate and poor body self-image (Danielsson, 2001).
THE CHIROPRACTIC ROLE
Most patients typically present to chiropractors for treatment of neck and back pain. Since back pain remains highly prevalent in scoliosis, it may be reasonable to suggest that a considerable number of patients with scoliosis present for treatment of scoliosis and scoliosis-related problems. Extrapolated data from the 1993 National Board of Chiropractic Examiners’ survey of the practice patterns of U.S. chiropractors suggests that up to 2,500,000 to 5,000,000 patient visits per year are made to chiropractors for scoliosis (NBCE, 1993). A similar pro-rated extrapolation is not unreasonable in the Canadian environment. Will we be ready as chiropractors to address the needs of both our pediatric and adult patients when they present to our offices for care?
For the pediatric patient, the approach to assessment and treatment is better understood. The primary challenge is to identify the true nature of the curvature and monitor its progress safely over time. For curves that approach 20 degrees, referral to a pediatric orthopedic specialist is advised. Decisions concerning the initiation of bracing and surgical treatment will be made through the medical specialist in consultation with the parents and child.
There is an important management role for the chiropractor. Given the prevalence of back pain in this group of patients, a traditional chiropractic approach can be instituted. Although there are no randomized-controlled trials published to date, our anecdotal experiences suggest manual therapies, electrotherapy and exercise as a reasonable approach to treatment. In a survey of American chiropractors, Feise (2004) identified a general approach to care of the pediatric patient with AIS that includes three visits per week for four weeks, two visits per week over the next month, followed by one visit per week in the third month. Visit frequency declined to one visit every two weeks in a supportive care manner in the following three months. Although not a certain approach established by more robust research, this survey considers the usual and customary approach of our colleagues in treatment frequency for managing AIS.
As there is no clear research to guide the effectiveness of our treatment objective, outcome measures are needed to assess the response to care. Pediatric face pain scales, rather than numeric pain rating scales, are useful and available for young children. Quality of life instruments, such as the Scoliosis Quality of Life Index developed by Feise, consider such aspects such as self-esteem, body self-image, and physical ability, providing the chiropractor with important information concerning the quality of life of the young patient (Feise, 2005). These specialized instruments, in addition to standard physical examination findings and radiographic evaluation, can give valuable information concerning your patient’s pain, function, and quality of life response to treatment.
Recent studies suggest that the negative effects associated with AIS do not end when spinal curve progression does. While the treatment protocol for the management of back pain in pediatric patients with AIS is less clear, management of the adult is more certain. Generalizing from randomized-controlled trials and clinical guidelines, manual manipulative therapies in non-surgical patients may provide short- to intermediate-term pain relief for individuals (AHCPR, 1994, van Tulder, 1997). For patients who have undergone surgical interventions, massage therapy is beginning to show promise in short- to intermediate-term pain management.
For poor back function, spinal mobility, and endurance, general exercise may be helpful. Keeping in mind the limitations of exercise prescription in patients having undergone surgical interventions, the principles of the Paris Task Force on Exercise and Back Pain still hold true (Abenhaim, 2000). General exercise that focuses on improving the strength and endurance of the muscles of the low back, enhances flexibility and improves general levels of fitness, and delivered within the exercise culture and experience of the patient, can be helpful in managing low back pain and related sequelae.
The Scoliosis Research Society Quality of Life Questionnaire, similar to quality of life instruments used with children, can shed light on the health perceptions of adult patients (Asher, 2003). While simple cognitive behavioural strategies are often helpful for patients with minimal problems, more complex issues may require a referral to a mental health professional for counselling.
Ongoing research has identified that AIS is not simply a disorder of childhood. The mental and physical effects of having had AIS and having progressed through a lengthy medical treatment regime often leaves adults with residual problems that include poor self-image, greater self-report of arthritis and disability, more prevalent and severe low back pain, poor sexual function and lower levels of general functional abilities.
As chiropractors, we need to begin to consider AIS as a broader condition that begins in adolescence and continues on into adulthood. This challenges us to consider longer treatment strategies that link both the adolescent and adult phases of care over a broader spectrum.
Editor’s Note: For a full list of references, view this article online at www.cndoctor.ca.
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