| | The Potential Use of Axial Spinal Unloading in the Treatment of Adolescent Idiopathic Scoliosis: A Case SeriesAbstract Chromy CA, Carey MT, Balgaard KG, Iaizzo PA. The potential use of axial spinal unloading in the treatment of adolescent idiopathic scoliosis: a case series. ObjectiveTo assess potential benefits of axial spinal unloading (LTX 3000 Lumbar Rehabilitation System) over a brief 3-month period. DesignBefore-after pilot study. SettingUniversity research laboratory. ParticipantsFive adolescent girls with scoliosis. InterventionsThree laboratory sessions: (1) initial baseline, (2) immediately after 3-month treatment period (axial unloading by using LTX 3000 for two 10-minute treatments daily), and (3) 1 month posttreatment. Main Outcome MeasuresInitial baseline postural data were obtained from 2 sets of radiographs (standing anteroposterior [AP] and lateral, sitting AP and lateral), back range of motion measurements, and numeric pain scales. The following were assessed: static postural changes; potential functional benefits; and therapeutic compliance. ResultsAll subjects elicited reductions in lumbar Cobb angles immediately after 3 months of treatment; initial average scoliotic curves of 13.7° were reduced 42% to 8° (α=.05, P=.004). Additionally, such reductions were evident 1 month posttreatment; average original curves were reduced by 27%. Subjects’ range of motion and lumbar lengthening were not significantly altered by this therapeutic protocol. Reported subject compliance was high (95%). ConclusionsThe LTX 3000 is a potential adjunct therapy for the treatment of adolescent scoliosis. This therapy resulted in curvature reductions and was widely accepted by subjects that were compliant with self-administration. THE GREEK WORD SCOLIOSIS, meaning crookedness, is classically used to define an abnormal lateral curvature of the spine.1 In the patient with clinical scoliosis, a primary or structured lumbar scoliotic curve is often accompanied by a secondary curve that develops as the patient compensates for an altered weight distribution over the primary curve.1, 2 These later curves can typically be distinguished by instructing a patient to bend to his/her side; the primary (structural) curve will remain largely unchanged, whereas the secondary curve will tend to reduce.2, 3 Many of such abnormalities are considered to be caused by elastic changes secondary to the muscle and connective tissue properties of the spine.4, 5 Furthermore, there is commonly some degree of 3-dimensional rotation accompanying any such lateral curvature, with the underlying etiologies being largely unknown.6, 7 Nevertheless, relevant to the present study, these specifically defined changes are considered to be potentially influenced by distractive and derotational treatments.8, 9, 10, 11, 12, 13, 14 In the past, scoliosis was initially detected by screening for back asymmetry by using the forward-bend test (the Adam test).15, 16 Clinical significance was considered with lateral curvature greater than 10°.15, 16 Subsequently, numeric analyses of radiographs, typically of anteroposterior (AP) (frontal) and lateral (sagittal) views, were used as the criterion standard for detection of idiopathic scoliosis.6 More specifically, the determination of Cobb angles has been commonly used to estimate degrees of spinal curvature.8, 14, 17, 18 Briefly, the Cobb angle is determined by drawing on a radiograph perpendicular lines from the top of any 2 vertebral bodies chosen.7, 9, 14, 19 Currently, more sophisticated image analyses are being used that may allow for better assessment of total spinal 3-dimensional rotations.20, 21, 22, 23, 24 The progression of scoliotic curves in adolescents is considered to be influenced by both future growth potential and the magnitude of the curvature at the time of initial diagnoses.1, 7 Importantly, moderate to severe scoliosis can cause overall trunk deformities and postural changes that might distort a person’s self-image.7, 25 Ultimately, progressive scoliosis may lead to joint misalignment, pain, decreased lung volume, and/or asymmetric hip and shoulder height; there may also be associated compromises in range of motion, balance, and/or work capacity.7, 10, 14 It should be noted that idiopathic scoliosis typically accounts for 70% to 80% of all documented scoliosis cases, and adolescent idiopathic scoliosis accounts for 80% to 85% of that number.11, 26 Commonly reported treatments for reducing curve progression include bracing, various surgeries, intensive exercise programs, manual therapy, and/or muscle re-education through biofeedback and electric stimulation.14, 17, 27, 28, 29 Of these alternatives, bracing remains the most commonly used method today.7, 12, 22 Although there are numerous reports on the effectiveness of bracing to treat adolescent scoliosis, the findings are varied. For example, Wever et al30 studied the effectiveness of the Boston brace and reported a significantly reduced progression of assessed Cobb angles in an adolescent population treated with bracing compared with no therapy. Bracing is typically recommended for adolescent patients with curves ranging from 20° to 50°; once a patient’s curve progresses to 50°, spinal surgery is generally considered as necessary. 3, 9, 12, 31, 32 In general, therapy resulting in some degree of curvature correction has been correlated with increased spinal elasticity; furthermore, the more bendable the spine, the greater the amount of correction that can be achieved.31 Yet, numerous investigators25, 27, 33, 34 have considered treatments for scoliosis as relatively ineffective for most people because these treatments have provided mixed outcomes results. In addition, the overall medical management for treating scoliosis is considered expensive and time consuming.26 Yet, untreated scoliosis has been associated with long-term health problems,26 thus reducing one’s overall quality of life.18, 35 To date, because most treatment approaches have reported mixed results27, 34, 36 and are considered generally unsuccessful in preventing the progression of scoliosis,34, 36 new treatments or combined treatment approaches for scoliosis are still needed. Interestingly, the application of traction to alter spinal deformities has a long history, with the oldest reference found in Hindu mythologic epics written between 3500 and 1800 bc.11, 13 On the other hand, most current treatment programs for scoliosis have not typically used traction or spinal unloading in their approaches.8, 10, 11, 12, 13 In general, a review of the literature has not supported its application (gravitational or standard) to induce reductions of spinal deformity. Yet, 1 study has indicated that standard lumbar traction can increase intervertebral spaces, increase the diameter of intervertebral foramen, flatten lumbar lordosis, and/or distract facet joints.8 In addition, gravitational traction such as lumbar unloading has been shown to decrease lateral curvature in an adult nonpathologic population, lengthen the lumbar spine,37 and decrease low back pain.13, 38 However, clinical trials evaluating the effectiveness of traction in a home-management program for scoliosis treatment have not been reported. Our laboratory previously investigated the use of the LTX 3000 Lumbar Rehabilitation Systema for administering gravity-dependent lumbar traction, also called axial spinal unloading.13 The LTX 3000 (fig 1) is a portable lumbar traction unit that immobilizes the thoracic spine and uses gravity to separate the lumbar vertebrae. The specific aims of the present study were 3-fold: (1) to assess the AP and lateral effects of lumbar axial unloading in a pilot population of subjects with idiopathic adolescent scoliosis, by having them self-administer spinal unloading by using the LTX 3000 over a 3-month period (general treatment protocol introduced by Hales et al13); (2) to evaluate potential posttreatment benefits on reducing lateral scoliotic curves assessed both while seated in the LTX 3000 and standing; and (3) to gain new insights on therapy acceptance and compliance by this adolescent patient group. Methods  This study protocol was approved by the University of Minnesota’s Human Subjects Committee and Radiation Safety Committee. In addition, participant assents and parental consents were obtained for all 5 subjects who completed the study. All subjects satisfied the following inclusion criteria: (1) 14 to 18 years old, (2) positive Adam’s bend test, (3) physician’s diagnosis of scoliosis, (4) not pregnant (as required by our Radiation Safety Committee), (5) no specific treatment for scoliosis during 6 months before the study, and (6) ability to operate the LTX 3000 independently. Subjects participated in an initial training session during which we showed correct techniques for assembling, using, and disassembling the LTX 3000. In addition, subjects viewed an educational videotape featuring the correct usage of the LTX 3000. After training, each subject correctly showed use by (1) assembling the unit, (2) administering unloading therapy for 10 minutes, and (3) disassembling the unit. In addition, each subject was given a preformatted journal to monitor her individual compliance with the home-intervention program by using the LTX 3000. For each therapeutic session, subjects documented the date, time of day, analog pain rating (see later), total duration of unloading, and any additional subjective comments. Each subject participated in 3 laboratory investigative sessions over a 5-month period: (1) initial session (baseline data), (2) session immediately posttreatment (ie, after 3 months of self-administered unloading therapy), and (3) final session 1 month postunloading. During each of these laboratory sessions, the following data were collected: (1) range of motion (ROM) measurements (flexion, extension, side bending right and left, rotation right and left) by using the back range of motion (BROM), (2) 4 radiographs (AP standing, AP sitting in the LTX 3000, lateral standing, lateral sitting in the LTX 3000), (3) visual analog numeric pain-assessment rating, and (4) general subjective feedback. As required for these laboratory investigations, a specially designed LTX 3000 was constructed of Plexiglas to allow for minimally obstructed view lateral radiographs.37 Between the first and second laboratory data-collection sessions, subjects were instructed to self-administer unloading therapy by using the LTX 3000 twice a day for 10 minutes per session. In addition, we contacted each subject by telephone after 2 weeks of unloading therapy to assess her progress and address any of her concerns. Pain Assessment A standardized visual analog numeric rating scale for pain was used to subjectively quantify the current status of a participant’s back pain posttherapy. In other words, subjects self-reported their current pain intensity by assigning a number to their pain level (range, 0 [no pain] to 10 [severe pain]). This was done as a means to ensure that minimal or no harm (sustained discomfort) was associated with this research protocol. Flexibility The BROM deviceb was used to assess flexion, extension, rotation, and side-bending ROM in the lumbar spine.13 A single researcher performed BROM measurements on each of the 5 subjects during each laboratory session. It should be noted that, to the best of our ability, we attempted to blind this researcher to all other measurements or prior results. In addition to recording raw-data values, we also determined the relative motions of right and left rotation and right and left side bending as normalized to the subjects’ relative curvatures; thus, these motions were noted as rotation toward the convexity or concavity and side bending toward convexity or concavity. Radiographs Standard sets of AP and lateral radiographs were taken by an experienced technician, blinded to the study design. Specifically, the University of Minnesota Medical Center, Fairview (University of Minnesota Radiology) supplied radiographic services by using a portable radiograph.c For seated radiographs, each subject was positioned in the modified Plexiglas LTX 3000 with both feet on the floor, hips and knees at 90°, shoulders relaxed, and the neck and head in a neutral posture as our laboratory has previously reported.13 To analyze the radiographs, a single researcher overlaid a transparency in a fixed position and marked specific vertebral landmarks.13 The superior-inferior left and right corners of the vertebral bodies (T12-L5) were marked in the frontal plane radiographs (Fig 2, Fig 3); anterosuperior, posterior-superior, inferior-anterior, and inferior-posterior points of the vertebral bodies (L1-5) were marked in the sagittal plane radiographs. The same researcher marked all radiographs for these analyses. In a previous study, this assessment approach was determined to provide a measurement error of less than or equal to one tenth of a millimeter relative to the obtained images.10 Note that the accuracy described in this study and others is related to the reliability of assessing the structures in such obtained radiographs.10, 39 A UMAX Astra 600s Scannerd was used to digitize the transparency at 150dpi (accuracy grayscale, ±0.1mm), and data were transferred to a Macintosh computer by using Adobe Photoshop.e The coordinates of each of the vertebral landmarks were then converted from pixels to millimeter locations by using an appropriate conversion factor, as determined by analyses of the diameters (in millimeters) of snap electrodes appearing on the radiographs by using Photoshop.13 All coordinates were then multiplied by the given conversion factors to convert measurements from pixels to millimeters. The Cobb angles were assessed by perpendicular lines drawn from the top of 2 vertebral bodies that represented the top and bottom of given scoliotic curves.9 In this study, the angles of lateral Cobb curvatures were measured between the T12 and L5 vertebrae. Specifically, such Cobb angles were determined via Photoshop by using the drawing tool to construct lines connecting the relative left and right corners of the T12 vertebral bodies and the relative corners of the L5 vertebral bodies (see Fig 2, Fig 3); for each subject, the same sets of landmarks were used throughout. Angles of these lines from horizontal were calculated by using geometric postulates to equate the values to the more traditional way of determining Cobb angles from a radiograph.40 Statistical analyses were performed on the relative changes observed in determined Cobb angles, the degrees of lumbar lengthening, ROM measurements, and recorded compliance data. Comparisons between trials were done by using analysis of variance; additionally, Bonferroni adjustments were used, and P less than .05 was considered as statistically significant. Results In this case series, the subject pool consisted of 5 adolescent females (1) ranging from 14 to 16 years of age, (2) between 160 to 178cm (63−70in) in height, and (3) weighing 46 to 72kg (102−160lb). Each subject displayed a scoliotic curve in the lumbar region; such curves could have been either primary or secondary in nature. Three of the 5 subjects had rightward lumbar curves, and 2 subjects presented with leftward lumbar curves. All subjects were previously diagnosed with scoliosis by their primary physicians (ie, with large lateral curvature and/or significant vertebral rotation). Subjects’ Cobb angles before treatment ranged from 4.1° to 26.3° while standing (fig 4) and from 6.0° to 11.3° while seated in the LTX 3000 (table 1). All 5 subjects elicited decreases in Cobb angles from the initial baseline session to the end of the 3-month treatment period in both their standing and sitting radiographs. Thus, there was a statistically significant difference in the mean standing Cobb angles between the initial session and immediately posttreatment (−5.7°, P<.05), yet this response was less significant when one considers the sitting LTX 3000 radiographs (average decrease, −3.1°; P<.05). Importantly, changes in standing Cobb angles were significantly sustained at reduced levels (smaller curves) 1 month posttreatment (−3.7°, P<.05) (see fig 4). There were no statistically significant differences between the second and third laboratory sessions for either the standing or seated measures. Yet, one should consider that within the standing Cobb angle values, the reversal of the curves (return toward initial values, or +2.0°) may signify a reversal of considered therapeutic benefits. Similarly, the obtained measures in Cobb angles while seated in the LTX 3000 also showed immediate posttreatment and 1 month posttreatment Cobb angles that mimicked the trend of the standing Cobb angle values (see table 1). Induced AP deviations of the subjects’ spines were assessed by examining their lateral-sagittal view radiographs. However, for this case series of subjects, we observed minimal or no changes in curvatures over time. More specifically, minimal changes were noted across all treatment sessions for both standing (P=.802) and sitting sets of radiographs (P>.05). Lumbar lengthening was assessed by examining the lengthening of the lumbar spine in standing and sitting radiographs.10, 13 The distances from the bottom of T12 and L5 vertebrae were determined for both the concave and convex sides of the curvatures. As was the case for the AP curvatures, we noted minimal or no changes in measured lumbar spinal lengths between sessions for both the standing (P>.05) and sitting anterior to posterior radiographs (P=.630). A significant finding in this study was that the average compliance of this self-administered 3-month unloading therapy was 95%, a very high compliance rate for a program of this nature. As reported by subjects, this was in part attributed to the ease and short duration of daily use; all subjects expressed satisfaction with the home-intervention program. For the analyses of potential benefits of unloading therapy relative to ROM, we normalized the averaged data per the subjects’ direction of curvatures (left or right). In general, we observed no relative change in these 5 subjects’ ROM measures for any combination of comparisons between the 3 laboratory sessions (table 2). In addition, no significant changes in pain assessment were observed, and no subjects reported any consistent pain. It should be noted that initially there was minor irritation reported by 2 subjects after therapeutic unloading sessions with the LTX 3000; their noted discomfort was primarily caused by applied force on the ribs by the support pads. Fortunately, this irritation subsided within minutes of initial use and was not subsequently reported after the subjects became accustomed to using the LTX 3000 (ie, within several days). Discussion In the present case series, we consider that positive therapeutic benefits were observed for the 5 adolescent scoliotic subjects who self-administered axial spinal unloading therapy via the LTX 3000. Specifically, reductions in Cobb angles were observed after 3 months of treatment, and these benefits were somewhat sustained at 1 month posttreatment. This pilot therapeutic protocol required subjects to self-administer unloading, twice a day for 10 minutes each session. Individuals found this therapeutic approach acceptable and were highly compliant (95%). Yet, it should be noted that the observed changes in Cobb angles were relatively modest and perhaps even within the limits of this assessment tool.19, 41 Nevertheless, we believe that future studies are warranted with a large subject pool. In addition, if possible, it may be useful to use other imaging modalities (eg, computed tomography or magnetic resonance imaging). Furthermore, it is recognized that this study likely raises more questions than it answers, such as (1) Are there even longer-term benefits to the use of this unloading therapy (eg, beyond 1 month or at maturity)? (2) How could one improve the administered therapeutic protocol (eg, length of unloading session and number of sessions per day)? (3) What type of scoliosis patients might best be served by using this adjunct self-administered therapy? (4) Can a curve progression be slowed or stopped by this form of treatment? and/or (5) Might this treatment represent an alternative solution to bracing or at least help limit bracing times? Ideally, clinicians and researchers hope to provide a therapy to improve patients’ quality of life, yet what this means relative to changes in degrees of curvature is not fully known. However, in general, the overall goal of any form of therapy to treat scoliosis is to induce sustained curvature reductions. We acknowledge that, in this case series, we have not provided long-term follow-ups beyond 1 month. Nevertheless, we suspect that with continued use of spinal unloading, one could achieve maintained benefits. It is important to note that, despite previously reported successes in treating adolescent scoliosis with bracing, many have questioned its overall effectiveness partly because of the psychological component of wearing such devices.20, 21, 22, 23, 42 For example, in 1 study of 31 adolescent females, it was reported that 84% of these subjects perceived the initial bracing period as stressful.6, 14, 43, 44, 45 Such factors have likely contributed to reduced compliance rates among those using bracing as an adjunct treatment for adolescent scoliosis. Reported noncompliance figures have ranged widely (ie, between 20% and 85%).45 For example, Vandal et al44 studied the compliance rates of subjects who used an orthopedic brace for 18 months or less; these subjects reported compliance of 88%, whereas the actual rate of compliance measured by researchers was 33%. Here we report a 95% compliance rate for this self-administered home therapy, yet this was assessed from journal entries subjects were asked to maintain. In future studies, one could assess compliance by a direct approach such as monitoring temperature changes on the LTX 3000 rib pads.12, 45 Nevertheless, we believe that an important aspect of this self-administered therapy is that it may help to engage people in their own overall treatment program. We observed minimal changes in the assessment of posttherapy lumbar lengthening in this subject pool. However, it is likely that during the unloading therapy in the LTX 3000 increases within the intervertebral spaces occurred as previously reported.10 When considering the finding of no sustained lengthening, one should note that these recruited subjects were young, otherwise healthy, active individuals who might still be growing. In other words, we could predict that they had normal static compression status levels. Nevertheless, an associated consideration accompanying the lumbar length measurements is the likely presence of rotational scoliotic components in these subjects. It is often the case that scoliosis not only results in spinal curvature but also slight rotations in each vertebra. In future studies, these types of issues will need to be accounted for when assessing such outcomes.20, 39, 41 The subject pool studied here did not elicit significant changes in any of their ROM assessments. However, it is important to note that 4 of 5 subjects were actively participating in high school athletics, and all subjects were considered healthy, active people. Therefore, it may not be surprising that their ROMs did not significantly change, being they were already within or beyond normal limits. Nevertheless, it is possible that significant changes might be observed for a more sedentary population, and this should be assessed in future studies.12, 39, 46 It should be specifically noted that the current study design varied in 2 quite distinct ways from that of a previous study by our laboratory.13 First, the subject pool here was composed entirely of adolescents; it was speculated that the most beneficial therapeutic changes for subjects with scoliosis may occur when the spine is in a more elastic state.31, 34 It is generally considered that as people age, their spines lose some of this elasticity; thus, most would agree that it is important to treat scoliotic individuals as early as possible.1, 4, 5, 6, 7, 8, 9, 14, 15, 16, 17, 30, 45, 47 Second, spinal dimensional changes were assessed from sets of radiographs obtained in both standing and sitting postures.48 In the previous study, we investigated adults only and their radiographs were taken while they remained seated in the LTX 3000. In the present study, we determined that assessing outcomes in both of the postures would likely be of more clinical significance, especially to medical professionals who are looking for other alternatives for their scoliosis patients. Nevertheless, future studies using functional magnetic resonance imaging or other characterization modalities of the spine will likely yield more insight into underlying scoliotic curves and their treatment.20, 24 It should be pointed out that the LTX 3000 is a lumbar unloading device that was initially designed for an adult population, and, thus, it fits the average-sized adult. For several of our subjects (ie, the smaller, more slender subjects), individualized adjustments were required to securely immobilize their rib cages. One potential subject was turned away because of the fact that she could not be fit properly in the equipment. This is a concern that we have brought to the attention of the manufacturer, and the device is currently in the process of redesign. Overall, we consider that the preliminary results presented here were highly positive. Thus, we believe that future studies are warranted to further validate the potential use of the LTX 3000 Lumbar Rehabilitation System for treatment of adolescent scoliosis. For example, it would be of interest to include a better profile of the pretherapeutic status of the subjects’ scoliosis and to extend the therapeutic period beyond 3 months. By increasing the therapeutic duration, it is possible that the changes would not be as quickly reversible, as was observed in one of the subjects. Finally, a larger and more diverse subject pool (ie, sedentary to active subjects) would improve the generalizability of such research and the use of adjunct therapies for optimizing treatment.12, 28 Nevertheless, the pilot study performed here lays a foundation for such future work. Ideally, in a future prospective study, it would be desirable to include a comparative control population and/or better documentation of the natural histories of curvature progression in such individuals. We should stress that the high compliance rates for this self-administered therapy and the reasonable time required for unloading are considered extremely advantageous. In fact, many of our subjects reported the ability to multitask during treatment sessions (eg, read, do homework, or talk on the telephone). Conclusions Axial spinal unloading therapy using the LTX 3000 Lumbar Rehabilitation System has strong potential as a viable adjunctive treatment for adolescent scoliosis. Ten minutes of self-administered unloading twice a day for a 3-month period resulted in reductions in Cobb angles, as observed from radiographs obtained in both standing and sitting positions. In addition, these reductions in curvature were maintained, to a degree, in 4 of 5 subjects 1 month posttreatment. The compliance for this home therapy was found to be extremely high (95%). Although these findings require further validation, they provide support that unloading therapy might be useful as an adjunct to bracing in selected persons. Suppliers Acknowledgment We thank Monica Mahre for her assistance in preparing this manuscript. References 1. 1Peterson LE, Nachemson AL. Prediction of progression of the curve in girls who have adolescent idiopathic scoliosis of moderate severity (Logistic regression analysis based on data from the Brace Study of the Scoliosis Research Society). J Bone Joint Surg Am. 1995;77:823–827. MEDLINE 2. 2Schulte TL, Liljenqvist U, Hierholzer E, et al. Spontaneous correction and derotation of secondary curves after selective anterior fusion of idiopathic scoliosis. Spine. 2006;31:315–321.
CrossRef
3. 3Lonstein JE. Scoliosis: surgical versus nonsurgical treatment. Clin Orthop Relat Res. 2006;(443):248–259. 4. 4Maiocco B, Deeney VF, Coulon R, Parks PF. Adolescent idiopathic scoliosis and the presence of spinal cord abnormalities (Preoperative magnetic resonance imaging analysis). Spine. 1997;22:2537–2541. MEDLINE |
CrossRef
5. 5Raso VJ, Lou E, Hill DL, Mahood JK, Moreau MJ, Durdle NG. Trunk distortion in adolescent idiopathic scoliosis. J Pediatr Orthop. 1998;18:222–226. MEDLINE |
CrossRef
6. 6Negrini S, Grivas TB, Kotwicki T, et al.members of the Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) Why do we treat adolescent idiopathic scoliosis? What we want to obtain and to avoid for our patients (SOSORT 2005 consensus paper). Scoliosis. 2006;1:4. 7. 7Asher MA, Burton DC. Adolescent idiopathic scoliosis: natural history and long term treatment effects. Scoliosis. 2006;1:2. 8. 8Pellecchia GL. Lumbar traction: a review of the literature. J Orthop Sports Phys Ther. 1994;20:262–267. MEDLINE 9. 9Miller NH. Cause and natural history of adolescent idiopathic scoliosis. Orthop Clin North Am. 1999;30:343–352. Full Text |
Full-Text PDF (1009 KB)
|
CrossRef
10. 10Janke AW, Kerkow TA, Griffiths HJ, Sparrow EM, Iaizzo PA. The biomechanics of gravity-dependent traction of the lumbar spine. Spine. 1997;22:253–260. MEDLINE |
CrossRef
11. 11Kumar K. Spinal deformity and axial traction. Spine. 1996;21:653–655. MEDLINE |
CrossRef
12. 12Richards BS, Bernstein RM, D’Amato CR, Thompson GH. Standardization of criteria for adolescent idiopathic scoliosis brace studies: SRS Committee on Bracing and Nonoperative Management. Spine. 2005;30:2068–2075.
CrossRef
13. 13Hales J, Larson P, Iaizzo PA. Treatment of adult lumbar scoliosis with axial spinal unloading using the LTX3000 Lumbar Rehabilitation System. Spine. 2002;27:E71–E79.
CrossRef
14. 14Lenssinck ML, Friijlink AC, Berger MY, Bierma-Zeinstra SM, Verkerk K, Verhagen AP. Effect of bracing and other conservative interventions in the treatment of idiopathic scoliosis in adolescents: a systematic review of clinical trials. Phys Ther. 2005;85:1329–1339. MEDLINE 15. 15Korovessis P, Kyrkos C, Piperos G, Soucacos PN. Effects of thoracolumbosacral orthosis on spinal deformities, trunk asymmetry, and frontal lower rib cage in adolescent idiopathic scoliosis. Spine. 2000;25:2064–2071. MEDLINE |
CrossRef
16. 16Lonstein JE. Adolescent idiopathic scoliosis. Lancet. 1994;344:1407–1412.
CrossRef
17. 17Lowe TG, Edgar M, Margulies JY, et al. Etiology of idiopathic scoliosis: current trends in research. J Bone Joint Surg Am. 2000;82:1157–1168. 18. 18Morrissy RT, Goldsmith GS, Hall EC, Kehl D, Cowie GH. Measurement of the Cobb angle on radiographs of patients who have scoliosis. J Bone Joint Surg Am. 1990;72:320–327. MEDLINE 19. 19Kuklo TR, Potter BK, Schroeder TM, O’Brien MF. Comparison of manual and digital measurements in adolescent idiopathic scoliosis. Spine. 2006;31:1240–1246. 20. 20Perie D, De Gauzy JS, Sevely A, Hobatho MC. CTM brace effect on scoliotic intervertebral discs using MRI method. Stud Health Technol Inform. 2002;88:230–234. MEDLINE 21. 21Perie D, De Gauzy JS, Baunin C, Hobatho MC. In vivo quantitative analysis of scoliotic vertebrae. Stud Health Technol Inform. 2002;88:405–409. MEDLINE 22. 22Rahman T, Bowen JR, Takemitsu M, Scott C. The association between brace compliance and outcome for patients with idiopathic scoliosis. J Pediatr Orthop. 2005;25:420–422. MEDLINE |
CrossRef
23. 23Matsunaga S, Hayashi K, Naruo T, Nozoe S, Komiya S. Psychologic management of brace therapy for patients with idiopathic scoliosis. Spine. 2005;30:547–550.
CrossRef
24. 24Adams CJ, Izatt MT, Harvey JR, Askin GN. Variability in Cobb angle measurements using reformatted computerized tomography scans. Spine. 2005;30:1664–1669.
CrossRef
25. 25Jeng CL, Sponseller PD, Tolo VT. Outcome of Wisconsin instrumentation in idiopathic scoliosis (Minimum 5-year follow up). Spine. 1993;18:1584–1590. MEDLINE |
CrossRef
26. 26Bridwell KH, Shufflebarger HL, Lenke LG, Lowe TG, Betz RR, Bassett GS. Parents’ and patients’ preferences and concerns in idiopathic adolescent scoliosis: a cross-sectional preoperative analysis. Spine. 2000;25:2392–2399. MEDLINE |
CrossRef
27. 27Bertrand SL, Drvaric DM, Lange N, et al. Electrical stimulation for idiopathic scoliosis. Clin Orthop Relat Res. 1992;(276):176–181. 28. 28Morningstar MW, Woggon D, Lawrence G. Scoliosis treatment using a combination of manipulative and rehabilitative therapy: a retrospective case series. BMC Musculoskelet Disord. 2004;5:32. MEDLINE |
CrossRef
29. 29Morningstar MW, Joy T. Scoliosis treatment using spinal manipulation and the Pettibon Weighting System: a summary of 3 atypical presentations. Chiropr Osteopat. 2006;14:1. 30. 30Wever DJ, Tonseth KA, Veldhuizen AG, Cool JC, van Horn JR. Curve progression and spinal growth in brace treated idiopathic scoliosis. Clin Orthop Relat Res. 2000;(377):169–179. 31. 31Soucacos PK, Soucacos PN, Beris AE. Scoliosis elasticity assessed by manual traction: 49 juvenile and adolescent idiopathic cases. Acta Orthop Scand. 1996;67:169–172. MEDLINE 32. 32Bridwell KH. Surgical treatment of idiopathic adolescent scoliosis. Spine. 1999;24:2607–2616. MEDLINE |
CrossRef
33. 33Bradford DS, Tay BK, Hu SS. Adult scoliosis: surgical indications, operative management, complications, and outcomes. Spine. 1999;24:2617–2629. MEDLINE |
CrossRef
34. 34Ensink FB, Saur PM, Frese K, Seeger D, Hildebrandt J. Lumbar range of motion: influence of time of day and individual factors on measurements. Spine. 1996;21:1339–1343. MEDLINE |
CrossRef
35. 35Rinsky LA, Gamble JG. Adolescent idiopathic scoliosis. West J Med. 1988;148:182–191. MEDLINE 36. 36Nachemson AL, Peterson LE. Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis (A prospective, controlled study based on data from the Brace Study of the Scoliosis Research Society). J Bone Joint Surg Am. 1995;77:815–822. MEDLINE 37. 37Goldberg CJ, Dowling FE, Hall JE, Emans JB. A statistical comparison between natural history of idiopathic scoliosis and brace treatment in skeletally immature adolescent girls. Spine. 1993;18:902–908. MEDLINE |
CrossRef
38. 38MacLean WE, Green NE, Pierre CB, Ray DC. Stress and coping with scoliosis: psychological effects on adolescents and their families. J Pediatr Orthop. 1989;9:257–261. MEDLINE 39. 39Kuklo TR, Potter BK, Polly DW, O’Brien MF, Schroeder TM, Lenke LG. Reliability analysis for manual adolescent idiopathic scoliosis measurements. Spine. 2005;30:444–454.
CrossRef
40. 40Arlet V, Marchesi D, Aebi M. Correction of adolescent idiopathic scoliosis with a new type of offset apical instrumentation: preliminary results. J Spinal Disord. 1998;11:404–409. MEDLINE 41. 41Bunnell WP. Selective screening for scoliosis. Clin Orthop Relat Res. 2005;(434):40–45. 42. 42Pope MH, Stokes IA, Moreland M. The biomechanics of scoliosis. Crit Rev Biomed Eng. 1984;11:157–188. 43. 43Leong JC, Lu WW, Luk KD, Karlberg EM. Kinematics of the chest cage and spine during breathing in healthy individuals and in patients with adolescent idiopathic scoliosis. Spine. 1999;24:1310–1315. MEDLINE |
CrossRef
44. 44Vandal S, Rivard CH, Bradet R. Measuring the compliance behavior of adolescents wearing orthopedic braces. Issues Compr Pediatr Nurs. 1999;22:59–73. MEDLINE |
CrossRef
45. 45Helfenstein A, Lankes M, Öhlert K, et al. The objective determination of compliance in treatment of adolescent idiopathic scoliosis with spinal orthoses. Spine. 2006;31:339–344.
CrossRef
46. 46Feise RJ, Donaldson S, Crowther ER, Menke JM, Wright JG. Construction and validation of the scoliosis quality of life index in adolescent idiopathic scoliosis. Spine. 2005;30:1310–1315.
CrossRef
47. 47Haasbeek JF. Adolescent idiopathic scoliosis. Postgrad Med. 1997;101:207–209. MEDLINE 48. 48Escalada F, Marco E, Duarte E, et al. Growth and curve stabilization in girls with adolescent idiopathic scoliosis. Spine. 2005;30:411–417.
CrossRef
a Physical Therapy Program, University of Minnesota, Minneapolis, MN b Departments of Surgery and Physiology and the Biomedical Engineering Institute, University of Minnesota, Minneapolis, MN.  Reprint requests to Paul A. Iaizzo, PhD, Dept of Surgery, University of Minnesota, B172 Mayo, MMC 107, 420 Delaware St SE, Minneapolis, MN 55455
Supported by Spinal Designs International, Minneapolis, MN (unrestricted research gift). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. PII: S0003-9993(06)01266-4 doi:10.1016/j.apmr.2006.08.325 © 2006 The American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved. | |
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