ORTHO

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Case Study

Physical therapy on the conservative treatment on adolescent with Scheuermann’s Disease – a case report. Fisioterapia no tratamento conservador em adolescente portador de Doença de Scheuermann – relato de caso.

Rafael Turqueto Duarte(1), Felipe Serenza(1), Gabriel Peixoto Leão Almeida(1,2), Michel Kanas(3), Hélcio Gongora(1).

Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.

Abstract Introduction: The Scheuermann’s kyphosis may cause difficulties in social acceptance and in the practice of physi- cal activity in adolescents, mainly caused by deformity of the thoracic spine. This change is diagnosed by radiological imaging when at least three adjacent vertebrae submit a previous larger than 5° wedging. Patients who have a Cobb angle greater than 75° are indicated for surgery. However, to date there is no agreement on how best to approach the patient in the conservative treatment. Objective: To present the conservative treatment of the back pain on an ado- lescent with Scheuermann’s disease. Method: Case report of a young patient complaining of back pain and with the Cobb angle greater than 75°, treated with exercises and postural reeducation for 12 weeks. The changes on flexibili- ty of the spine was measured by the popliteal angle and with a fio de prumo. Moreover, it was evaluated the isometric strength of the trunk, the functional capacity by the Oswestry questionnare and the pain with a Visual Analogue Scale. Results: The patient improved with his pain and functional abilities, maintaining the practice of exercises by himself at home. Conclusion: After learning the exercises and practice it at home, with the orientation of a manual and the physical therapist, the patient do not presented any more complaining of pain. Keywords: Scheuermann’s Disease, Back Pain, Physical therapy

Resumo Introdução: A Hipercifose de Scheuermann pode trazer dificuldades de aceitação social e práticas de atividades físi- cas em adolescentes, causada principalmente pela deformidade da coluna torácica. Essa alteração é diagnosticada através de imagem radiológica quando ao menos três vértebras adjacentes apresentarem um acunhamento anterior maior do que 5°. Pacientes que possuem um ângulo de Cobb maior que 75° são indicados à cirurgia. Entretanto, até hoje não existe um consenso de qual a melhor forma de abordar o paciente no tratamento conservador. Objetivo: Apresentar o tratamento conservador para dorsalgia de um adolescente portador da Hipercifose de Scheuermann. Mé- todo: Relato de caso de jovem com queixa de dor na coluna e com ângulo de Cobb maior que 75°, tratado através de exercícios e reeducação postural por 12 semanas. As alterações na flexibilidade da coluna foi medida através do ângu- lo poplíteo e com um fio de prumo. Além disso, foi avaliada a força isométrica do tronco, da capacidade funcional pelo questionário Oswestry e finalmente da dor através da Escala Visual Analógica (EVA). Resultados: O paciente obteve melhora no quadro de dor e ganho de função após a sexta semana de tratamento, que se manteve até a última aval- iação após 12 semanas. Conclusão: Após aprender os exercícios e continuá-los em casa, sob orientação de um man- ual e do fisioterapeuta o paciente não apresentou mais queixas de dor. Palavras-chave: Doença de Scheuermann, Dor Lombar, Fisioterapia

Received: 11 December 2013. Accepted: 12 March 2014. Published: 30 March 2014.

1. Physical therapy department, Centro de Traumatologia do Esporte, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil. 2. Physical therapy school, Faculdade de Medicina, Universidade Federal do Ceará (UFC), Fortaleza (CE), Brazil. 3. Responsible physician by the Ambulatório de Coluna, Centro de Traumatologia do Esporte, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil.

Corresponding Author: Rafael Turqueto Duarte, Departamento de Fisioterapia, Rua Estado de Israel, 638 – São Paulo, SP – ZIP CODE: 04022-001, Brazil. E-mail: [email protected]

http://dx.doi.org/10.17784/mtprehabjournal.2014.12.174

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Physical therapy treatment on Scheuermann’s Disease.

INTRODUCTION

The Scheuermann’s disease is the most common

cause of back pain in adolescents(1,2) with a predomi-

nance of male subjects.(3) occurs between 10-12 years

of age and is characterized by the anterior plate disorder

growth of the vertebral body, leading to deformity in ky-

phosis.(2) There is a decrease of physical fitness induced

deformity, and social isolation, making the integration of

these adolescents in society.(2,4) The etiology is contro-

versial, but factors such as hormonal changes, circulato-

ry disorders and genetic factors appear to influence the

onset of the disease.(2,5)

The diagnosis is made by X-rays in profile was con-

sidered positive when at least three adjacent vertebrae

submit a previous larger than 5° wedging. Scoliosis and

decreased intervertebral joint space can also be found

as radiological changes.(6,7) The main clinical symptoms

are back pain and deformity, rarely leading to other

complications. In extreme cases can impair cardiorespi-

ratory fitness. Physical examination is expected to ky-

photic and rigid thoracic spine, which with hypomobility

during extension. Hamstring muscle retractions, added

to weakness of the extensor muscles of the trunk rein-

force the patient’s posture.(3,8)

Impaired quality of life of these patients is mainly

related to aesthetic factors and decreased functional ca-

pacity. The difficulty of sports activities and the accep-

tance of body image hinder their social interaction and

this is a critical age at which they are constructed per-

sonality traits of the patient.(7)

Surgical treatment is indicated for patients whose

Cobb angle is greater than 75 degrees or rapidly pro-

gressing disease that does not respond to conserva-

tive treatment. Despite this, conservative treatment be-

comes of utmost importance, even when the angle of

kyphosis is low (between 45 and 55 degrees) due to the

degenerative nature of the vertebrae deformity.(7,9) This

consists of core-training exercises for strengthening the

thoracic spine flexibility of the posterior thigh muscles

and strengthen the extensor muscles of the trunk.(9) The

use of brace is indicated when the kyphosis is median

(angles between 55 and 65 degrees) and with a good

degree of mobility of the thoracic spine.(3,6,7,10)

Few studies describing the evolution of the

treatment of adolescents with Scheuermann Hyperky-

phosis, the objective of this case study was to demon-

strate the effects of therapy on quality of life and func-

tion of a patient with this chest deformity with marked

kyphosis.

METHOD

Male patient, 17 years old, 1.70 m height, 95 kg

and Cobb angle of 78 °. Complaining of chest deformi-

ty and pain (VAS 2.5) in the transition from thoracic and

lumbar spine approximately two years ago with progres-

sive worsening. It was tried to perform physical activity at

that time and obtained improvement in frame with swim-

ming practice, but he do not continue with this activity

and there was regression. Since then, about six months

ago, referred pain for walking, lifting weights and real-

izes continually tries to correct your posture to feel un-

comfortable in the lumbar region. Never underwent treat-

ment for their pain with guidance of a physiotherapist.

Three evaluations were performed: pre-treatment,

after six weeks and after twelve weeks of treatment.

Postural assessment with plumb bob

The plumb line was used in this study to evaluate

the orthostatic posture curvature of the spine in the sag-

ital plane of the patient. During the evaluation, the pa-

tient remained facing a wall, barefoot, with both heels

touching the two together and hallux on the wall, keep-

ing a fixed look forward, shoulders relaxed and normal

respiration. A ruler with a plumb line is hung at its end

is leaning against the head and the upper pole of the

plumb line distance is measured from the spinous pro-

cesses of the vertebrae C7, T12 and L3 in relation to the

most prominent point of the thoracic kyphosis.(7)

Evaluation of popliteal angle

The evaluation was performed using the poplite-

al angle test. The test consists in performing knee ex-

tension evaluated passively until the therapist feels the

first endurance stretching. The evaluation of the poplite-

al angle was performed bilaterally.

Evaluation of trunk isometric force

Muscle strength was assessed with manual iso-

metric dynamometer. Three sets were performed, last-

ing five seconds each, followed by 30 seconds of rest

between each repetition. Four movements were mea-

sured: Flexion, extension and lateral inclinations.(11-13)

Pain Assessment and Functional Capacity

Pain was assessed by Visual Analogue Scale for Pain

(VAS) consisting of an aid in the assessment of pain in-

tensity in patients. Its score ranges from zero (no pain)

to ten (worst pain ever felt).

Functional capacity was assessed by the Oswestry

questionnaire in order to assess the perspective of the

patient, performing daily activities. It is a self-admin-

istered questionnaire consisting of ten questions each

with six alternatives. The amounts of the matters vary

from zero to five. The higher the score achieved by the

patient, the lower the functional level it presents.

Eleven physical therapy interventions divided in six

weeks were performed. Subsequently the patient con-

tinued with the in physical therapy exercises at home

for six weeks with the help of a manual, which consist-

ed of simple exercises to enhance and maintain the re-

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Rafael Turqueto Duarte, Felipe Serenza, Gabriel Peixoto Leão Almeida, Michel Kanas, Hélcio Gongora.

sults achieved in the first six weeks. Isometric and iso-

tonic invigoration exercises of the extensor muscles of

the trunk were prescribed, moreover, exercises for chest

mobility, flexibility of hip flexors, knee flexors and lower

chest, as well as exercises to increase body awareness.

The manual followed a model similar to those made in

the first six weeks to facilitate the achievement of exer-

cises by the patient. (Table 3)

The physical therapy intervention consisted of in-

creased mobility of the spine, strengthening exercises of

the trunk extensor muscles and stretching of the ham-

strings, lower chest and hip flexors. If in doubt, the pa-

tient was asked to come into contact with some of those

responsible for the work.

RESULTS

Postural assessment with plumb bob

The results are shown in Figure 1. Observe a slight

improvement in third evaluation results with respect to

the first two.

Popliteal angle

The results are outlined in Figure 2. After six weeks

of treatment there was an improvement in the flexibili-

ty of the right leg and loss of flexibility in the left lower

limb. After 12 weeks the flexibility was the same pattern

as the original, and the right lower limb smaller than the

left, however the two measurements with less angle.

Isometric strength of trunk

The results and their means are shown in Table 1.

All muscle groups tested showed increased isometric

strength compared from the first to the second evalu-

ation, values which have changed little in the third as-

sessment, except in flexion, which from the beginning of

treatment and its final had a significant increase.

Pain and Functional Capacity

The results are shown in Table 2. Observe a sig-

nificant improvement of the questionnaire with results

showing maximum score in relation to functional capaci-

ty and absence of pain in the last assessment.

DISCUSSION

The results of this case report showed that strength-

ening the extensor muscles of the trunk associated with

stretching of specific muscles brought improved func-

tional capacity and pain the patient with Scheuermann’s

Disease.

In a study of 351 patients aged 17-21 years, the

sum of strengthening exercises with postural orienta-

tion resulted in an average decrease of 2 points in the

VAS these patients. In the case of the patient described

in this article VAS decreased from 4 to 0 after six weeks

of treatment.(14)

During the assessment of trunk muscle strength

was found that all assessed muscle groups showed in-

creased strength, especially the flexors. Importantly,

this improvement was maintained at the last review oc-

curring after the period that the patient performed the

exercises under the guidance of a physiotherapist.

Table 1. Isometric strength of trunk.

Mean Pre-

treatment 6 weeks 12 weeks

Flexion 3.23 12.6 11.1

Extension 14.63 16.6 16.6

Right tilt 20.83 29.9 27.8

Left tilt 27.73 31.4 29.5

Table 2. Pain and Functional Capacity.

Pre- treatment 6 weeks 12 weeks

Questionnaire Oswestry 10 points = 20 % 6 points = 12 % 0 points = 0%.

EVA 04 2.5 0

VAS: Visual Analogic Scale.

Figure 1. Postural Assessment with Plumb Line. C-7: Seventh cervical vertebra, T-12: Twelfth thoracic vertebra, L-3: Third lumbar vertebra.

Figure 2. Popliteal Angle.

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Physical therapy treatment on Scheuermann’s Disease.

In static postural assessment, no significant chang-

es were found, probably due to structural disease is, dif-

ficult to correct by kinesiotherapy factor. However, the

functional improvement can be attributed to a higher

mobility of the thoracic spine acquired with the exer-

cises.

The realization of stretching the posterior muscles

of the thigh did not lead to an increase in the poplite-

al angle of the patient. Thus it has not been possible to

correlate the results of this intervention.

The first half of the intervention period was per-

formed in situ, with visits to the physical therapy. It is

noteworthy that the patient has a Cobb angle of 78 °

that characterizes a possible surgery, and although this

ceased to feel pain and obtained maximum scores of

functional capacity in the questionnaire. In the second

part, the exercises were performed by the patient at his

residence. Although a small decrease in muscle strength

of the trunk found after this period, the results of the

questionnaires remained the same, demonstrating that

the achievement of home exercises added guidance of

daily activities were sufficient to maintain the positive

results in the first half of job.

The latest consensus of conservative treatment of

idiopathic hyperkyphosis and Scheuerman’s disease of

SOSORT conducted in 2010, concluded that the best

measures to be taken in these cases are the use of the

brace and physical therapy. But what about physical ther-

apy modalities to be used there is still no consensus.(6)

CONCLUSION

There are few studies on the conservative treat-

ment of Scheuerman’s disease. Some doubts still remain

about the follow-up therapy as including more efficient

therapeutic modalities, type of brace to use, and prog-

nosis of conservative or pre-surgical treatment. In this

case report it was shown that it is possible to work with

exercises and gain body awareness for improved pos-

ture in everyday life. The patient began working in care

of physical therapy, but the end was performing the ex-

ercises as instructed alone in his house, and thus man-

aged to maintain the clinical improvement of pain.

Table 3. Exercises protocol.

Exercises Repetitions/Time

Week 1,2,3 Repetitions/Time

Week 4,5,6

Posteroanterior central (PAC) spinal mobilization associated with extension of the spinal column made on the top of the thoracic curve.

Level IV, 3 x 1 min Level IV, 3 x 1 min

Roll on the thoracic top: (length gain) Patient supine, is placed a roll (Figure X) under the top of the thoracic curve and the patient and is asked the patient to drop body weight and bend your arms so that they touch the stretcher.

3 x 1 min 3 x 1 min

Diaphragmatic breathing: patient supine, is asked to inhale using the strength of the diaphragm to inflate the stomach and depress the lower ribs, and then exhale.

3 x 15 rep 3 x 15 rep

Stretching of the pectoralis minor. Patient supine, place a towel between the shoulder blades and perform stretching the shoulders pushing the patient toward the stretcher.

3 x 1 min 3 x 1 min

Bascule on the ball Patient sitting on a therapy ball 65 cm. Perform movements anteversion and retrover- sion pelvic on the ball.

3 x 1 min 3 x 1 min

Stretching hip flexors: Patient supine with pending members on the stretcher, flex the contralateral hip stabiliz- ing it, while hip extension is made to be stretched.

3 x 1 min 3 x 1 min

Stretching posterior muscle chain: Patient supine, member to be stretched is placed in flexion of the hip and knee while the hip and knee of the contralateral limb is flexed.

3 x 1 min 3 x 1 min

Thoracic extension in pronation: Patient prone performs repeated spinal extension actively times.

3 x 30s a 1 min 3 x 1 min

Isometric paravertebral standing. 3 x 30 seg a 1 min 3 x 1 min

Ponte ventral: Patient supine performs the elevation of keeping the pelvis lined trunk.

3 x 20 seg a 1 min 3 x 1 min

Bilateral external rotators associated with thoracic extension with elastic resistance. 3 x 12 a 20 rep 3 x 20 rep

Low rowing with elastic resistance. 3 x 12 a 20 rep 3 x 20 rep

Subtitle: rep=repetitions; min=minutes.

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