Spinal deformities rehabilitation - state of the art review

Background

Medical rehabilitation aims at an improvement in function, capacity and participation. For the rehabilitation of spinal deformities, the goal is to maintain function and prevent secondary symptoms in the short- and long-term. In patients with scoliosis, predictable signs and symptoms include pain and reduced pulmonary function.

Materials and methods

A Pub Med review was completed in order to reveal substantial evidence for inpatient rehabilitation as performed in Germany. No evidence has been found in general to support claims for actual inpatient rehabilitation programmes as used today. Nevertheless, as there is some evidence that inpatient rehabilitation may be beneficial to patients with spinal deformities complicated by certain additional conditions, the body of evidence there is for conservative treatment of spinal deformities has been reviewed in order to allow suggestions for outpatient conservative treatment and inpatient rehabilitation.

Discussion

Today, for both children and adolescents, we are able to offer intensive rehabilitation programmes lasting three to five days, which enable the patients to acquire the skills necessary to prevent postures fostering scoliosis in everyday life without missing too much of school teaching subjects at home. The secondary functional impairments adult scoliosis patients might have, as in the opinion of the author, still today require the time of 3-4 weeks in the clinical in-patient setting. Time to address psychosocial as well as somatic limitations, namely chronic pains and cardiorespiratory malfunction is needed to preserve the patients working capability in the long-term.

Conclusion

Outpatient treatment/rehabilitation is sufficient for adolescents with spinal deformities. Inpatient rehabilitation is recommended for patients with spinal deformities and pain or severe restrictive ventilation disorder.     

Aetiology of skeletal deformities in the Zebra Danio fish (Bruchydanio rerio, Hamilton-Buchanan)

Laboratory bred Zebra Danio ( Brachydanio rerio , Hamilton-Buchanan) tropical fish are prone to skeletal deformities resembling scoliosis and lordosis. This condition appears related to diet and has been studied by breeding from different broods of fish for three generations. Two broods bred using two commercially available tropical flaked foods developed severe spinal curvature three to six weeks post-hatching. A third brood of fish fed exclusively on live food did not develop any deformity. The results demonstrate that a dietary factor is responsible for the deformities and that the Zebra Danio is especially susceptible to this factor as other species breed normally when fed the same commercial diet. Analysis of the diets showed no deficiency in either ascorbic acid (Vitamin C) or tryptophan, deficiency of either being associated with scoliosis and lordosis in fish. The analysis did show, however, a relationship between the lead content of the diet and the incidence of deformities. Lead has previously been implicated in skeletal deformities in second and third generation Brook trout, Salvelinus fontinalis.     

Historical overview of spinal deformities in ancient Greece

Little is known about the history of spinal deformities in ancient Greece. The present study summarizes what we know today for diagnosis and management of spinal deformities in ancient Greece, mainly from the medical treatises of Hippocrates and Galen. Hippocrates, through accurate observation and logical reasoning was led to accurate conclusions firstly for the structure of the spine and secondly for its diseases. He introduced the terms kyphosis and scoliosis and wrote in depth about diagnosis and treatment of kyphosis and less about scoliosis. The innovation of the board, the application of axial traction and even the principle of trans-abdominal correction for correction of spinal deformities have their origin in Hippocrates. Galen, who lived nearly five centuries later impressively described scoliosis, lordosis and kyphosis, provided aetiologic implications and used the same principles with Hippocrates for their management, while his studies influenced medical practice on spinal deformities for more than 1500 years.     

An image-based method to automatically propagate bony landmarks: application to computational spine biomechanics

In attempts to elucidate the underlying mechanisms of spinal injuries and spinal deformities, several experimental and numerical studies have been conducted to understand the biomechanical behavior of the spine. However, numerical biomechanical studies suffer from uncertainties associated with hard- and soft-tissue anatomies. Currently, these parameters are identified manually on each mesh model prior to simulations. The determination of soft connective tissues on finite element meshes can be a tedious procedure, which limits the number of models used in the numerical studies to a few instances. In order to address these limitations, an image-based method for automatic morphing of soft connective tissues has been proposed. Results showed that the proposed method is capable to accurately determine the spatial locations of predetermined bony landmarks. The present method can be used to automatically generate patient-specific models, which may be helpful in designing studies involving a large number of instances and to understand the mechanical behavior of biomechanical structures across a given population.     

Inflammation as a potential risk factor for spinal deformities in farmed Atlantic salmon (Salmo salar L.)

Inflammation is an overall protective response and can be defined as a cellular and non specific immune response to irritation, injury, or infection leading to the local accumulation of leukocytes and fluid. In intensive farming conditions, fish are usually transported, sorted, vaccinated and subjected to stressful handling procedures which may potentially lead to local inflammation and affect the integrity of the spine. The present mini‐review aims to introduce the reader in the field of spinal deformities in salmon, propose inflammation as a risk factor for spinal deformities and emphasize the need for conducting further research in the area having an integrated and multidisciplinary perspective.     

Environmentally induced limb malformations in mink frogs (Rana septentrionalis).

In recent years, there has been an increase in the incidence of frog deformities throughout many of the northern states of North America. The most readily noticed malformations involve the hindlimbs of peri-metamorphic animals. We have analyzed skeletal preparations of metamorphosing mink frogs (Rana septentrionalis) collected from a site in Minnesota, in order to develop a better understanding of the possible causes. In this paper we describe the categories of abnormalities found at this site. The spectrum of deformities includes missing limbs, truncated limbs, extra limbs (including extra pelvic girdles), and skin webbings. We also describe a newly recognized malformation of the proximal-distal limb axis, a bony triangle. In this abnormality, the proximal and distal ends of the bone are adjacent to one another forming the base of a triangle. The shaft of the bone is bent double and protrudes laterally, the midpoint of the bone forming the apex of the triangle. In this paper we consider several recently proposed explanations for the recent outbreak of amphibian deformities. Based on our analysis, we conclude that the spectrum of abnormalities seen in these frogs is remarkably similar to the range of abnormalities that has been reported as a result of exposure of developing vertebrates to exogenous retinoids. Given the potential implications of this possibility for the welfare of humans as well as wildlife, further studies are needed to determine whether environmental retinoids are responsible for the frog deformities at the site we have examined.     

Allometric growth of the trunk leads to the rostral shift of the pelvic fin in teleost fishes

The pelvic fin position among teleost fishes has shifted rostrally during evolution, resulting in diversification of both behavior and habitat. We explored the developmental basis for the rostral shift in pelvic fin position in teleost fishes using zebrafish (abdominal pelvic fins) and Nile tilapia (thoracic pelvic fins). Cell fate mapping experiments revealed that changes in the distribution of lateral plate mesodermal cells accompany the trunk-tail protrusion. Presumptive pelvic fin cells are originally located at the body wall adjacent to the anterior limit of hoxc10a expression in the spinal cord, and their position shifts rostrally as the trunk grows. We then showed that the differences in pelvic fin position between zebrafish and Nile tilapia were not due to changes in expression or function of gdf11. We also found that hox-independent motoneurons located above the pelvic fins innervate into the pelvic musculature. Our results suggest that there is a common mechanism among teleosts and tetrapods that controls paired appendage positioning via gdf11, but in teleost fishes the position of prospective pelvic fin cells on the yolk surface shifts as the trunk grows. In addition, teleost motoneurons, which lack lateral motor columns, innervate the pelvic fins in a manner independent of the rostral-caudal patterns of hox expression in the spinal cord.     

The uroprotection of mesna on cyclophosphamide cystitis in rats. Its consequences on behaviour and brain activities.

We studied the uroprotective effect of mesna, at doses of 40-300 mg/kg/i.p., in single or fractioned injections, on the development of cyclophosphamide (CP, 100 mg/kg/i.p.) cystitis in rats. The study concerns the histological, behavioural and nervous aspects of the disease. The specific effects of mesna, when injected alone, have also been considered. The mesna itself does not have specific deleterious effects, except at a dose of 300 mg/kg which provokes a moderate vesical inflammation although without consequence on the animal's behaviour. Mesna offers good protection against CP cystitis for only certain posologies. The uroprotective effects of mesna reach maxima at doses of 40-100 mg/kg and for fractioned injections given over the entire time frame of the urinary toxic release. The uroprotective effects of other posologies are only partial. The nervous activities were studied through the expression of Fos protein. The repetitive intraperitoneal injection of mesna induced a spinal activity and a preferential contralateral activity of the trigemino/reticular areas of the brainstem spinal cord junction--an effect which was reduced in the presence of CP. The prevention of cystitis by mesna was accompanied only by a reduction in spinal Fos activity, the supraspinal activities remaining high and in strict relationship with the vagal afferent activity. In conclusion, the uroprotective effect of mesna, which requires appropriate posologies, has led to the confirmation of the spinal actions of the CP cystitis, probably via the pelvic nerve, but did not allow a clear distinction between the consequences of the systemic (vagal) and local (spinal, pelvic) actions of CP at supraspinal level.     

Mechanical effects of continuous passive motion on the lumbar spine in seating

The aim of this study was to develop a model which describes the mechanical spinal response to small alternating pelvic stimulation induced by an active rotational movement of a normal chair. The rotary continuous passive motion (RCPM) of the seat about a vertical axis of only 0.6 degrees resulted in an increased in spinal length as opposed to the normal daily shrinkage, and back patients experienced pain relief. Passive and active exercies have been broadly applied for treating and healing spinal disorders. A rigid body package (ADAMS Android) was used to translate the stimulation of the ischial tubersoity in caudo-cranial handing-over visualisation. The parameters of the model were set so that the values of the global stiffness and geometry of the intervertebral discs could be changed. In vivo validation of the model was based on force and moment measurements using an internal AO fixator. The predicitons of the model concerning natural frequency (4.5Hz) in vertical direction and the axial torsion response on small pelvic torsion are comparable with experimental data.     

Effects of lumbo-pelvic rhythm on trunk muscle forces and disc loads during forward flexion: A combined musculoskeletal and finite element simulation study

Previous in-vivo studies suggest that the ratio of total lumbar rotation over pelvic rotation (lumbo-pelvic rhythm) during trunk sagittal movement is essential to evaluate spinal loads and discriminate between low back pain and asymptomatic population. Similarly, there is also evidence that the lumbo-pelvic rhythm is key for evaluation of realistic muscle and joint reaction forces and moments predicted by various computational musculoskeletal models. This study investigated the effects of three lumbo-pelvic rhythms defined based on in-vivo measurements on the spinal response during moderate forward flexion (60°) using a combined approach of musculoskeletal modeling of the upper body and finite element model of the lumbosacral spine. The muscle forces and joint loads predicted by the musculoskeletal model, together with the gravitational forces, were applied to the finite element model to compute the disc force and moment, intradiscal pressure, annular fibers strain, and load-sharing. The results revealed that a rhythm with high pelvic rotation and low lumbar flexion involves more global muscles and increases the role of the disc in resisting spinal loads, while its counterpart, with low pelvic rotation, recruits more local muscles and engages the ligaments to lower the disc loads. On the other hand, a normal rhythm that has balanced pelvic and lumbar rotations yields almost equal disc and ligament load-sharing and results in more balanced synergy between global and local muscles. The lumbo-pelvic rhythm has less effect on the intradiscal pressure and annular fibers strain. This work demonstrated that the spinal response during forward flexion is highly dependent on the lumbo-pelvic rhythm. It is therefore, essential to adapt this parameter instead of using the default values in musculoskeletal models for accurate prediction of muscle forces and joint reaction forces and moments. The findings provided by this work are expected to improve knowledge of spinal response during forward flexion, and are clinically relevant towards low back pain treatment and disc injury prevention.     

Truncal changes in children with mild limb length inequality: a surface topography study

Background

Limb length Inequality (LLI) in children and adults may affect posture, gait, and several truncal parameters, and it can cause spinal scoliosis. In literature, however, there is a paucity of assessment of truncal and spinal changes due to mild LLI in children. This report presents children with LLI, and it aims to provide information in pelvic imbalance, spinal posture, and scoliotic curve, using surface topography analysis which is a novel methodological approach for this condition.

Study design

This is an ongoing prospective research study on patient series suffering LLI.

Material and method

Twenty children, attending the Scoliosis Clinic of the department, 7 boys, 13 girls, 9–15?years old, range 7.5–15, mean 15.5?years, having mild LLI, were assessed. The LLI was 0.5 to 2?cm, mean 1.2?cm. There was not any post-traumatic LLI. We evaluated the LLI in correlation to pelvic and spinal posture parameters. The 4D Formetric DIERS apparatus (4DF) was used for the surface topography assessment. The following were assessed: in the coronal plane, the coronal imbalance, the pelvic obliquity, the lateral deviation, and the 4DF scoliosis angle; in the sagittal plane, the sagittal imbalance, the 4DF kyphotic angle, the kyphotic apex, the 4DF lordotic angle, the lordotic apex, the pelvic tilt, and the trunk inclination; and in the transverse plane, the pelvis rotation, the pelvic torsion, the surface rotation, and the 4DF vertebral rotation. LLI was measured using a tape. The data were statistically analyzed, and reliability study for the LLI was also performed.

Results/discussion

The LLI was statistically significantly correlated to the 4DF reading of pelvis rotation, pelvic tilt (pelvic obliquity), and surface rotation. The scoliometer readings (angle trunk rotation ATR or trunk inclination ATI) in the lumbar region were statistically significantly correlated to the 4DF readings of pelvic tilt (pelvic obliquity). The normally symmetric truncal parameters were also statistically significantly changed (all these deviating from the line of gravity through the vertebral prominence). Interestingly, LLI was not correlated to the scoliosis angle and the scoliometer reading at the lumbar level.The following 4DF readings are presented: in the coronal plane, the coronal imbalance, pelvic obliquity, lateral deviation, and 4DF scoliosis angle; in the sagittal plane, the sagittal imbalance, kyphotic angle, kyphotic apex, lordotic angle, lordotic apex, pelvic tilt, and trunk inclination; and in the transverse plane, the pelvic rotation, pelvic torsion, surface rotation, and vertebral rotation.

Conclusions

Previous studies have reported the results after simulation of LLI in order to evaluate the effects on the pelvic balance and spinal posture parameters. This report is not a LLI simulation study but it presents the effects of mild LLI on truncal changes in the main cardinal planes in children suffering LLI. These changes undoubtedly affect not only the standing truncal posture but also the gait’s economy as well.As mild LLI affects the pelvic balance and spinal posture parameters, our therapeutic approach is that mild LLI (less than 2.0?cm) has to be corrected using shoe elevation, in order to equalize the pelvic obliquity and, consequently, the spinal posture parameters.

     

Teleosts as models for human vertebral stability and deformity

Vertebral development is a dynamic and complicated process, and defects can be caused by a variety of influences. Spinal curvature with no known cause (idiopathic scoliosis) affects 2-3% of the human population. In order to understand the etiology and pathogenesis of complex human skeletal defects such as idiopathic scoliosis, multiple models must be used to study all of the factors affecting vertebral stability and deformity. Although fish and humans have many of the same types of offenses to vertebral integrity, they have been overlooked as a resource for study. The most common morphological deformity reported for fish are those that occur during the development of the spinal system, and as with humans, curvature is a common morphological consequence. Here we review spinal curvature in teleosts and suggest that they are an unexploited resource for understanding the basic elements of vertebral stability, deformity, development and genetics. Fish can be a value to vertebral research because they are tractable, have a diversity of non-induced vertebral deformities, and substantial genomic resources. Current animal models lack non-induced deformities and the experimental tractability necessary for genetic studies. The fact that fish are free of an appendicular skeleton should allow for analysis of basic spinal integrity without the biomechanical constraints observed in quadrupedal and bipedal models. To illustrate the point we review human idiopathic scoliosis and the potential contribution teleosts can make for the identification of causes, risk factors, and treatment options.     

Configuration of the cervical part of the spinal column in various age periods

In order to estimate pathological deformities of the spinal column, it is necessary to know its normal configuration during various age periods. For this 240 men and women in age groups from 15 up to 60 years and older, having not any complaints, have been investigated. Each patient is subjected to a standard x-ray examination of the cervical part of the spinal column in 2 projections with a subsequent roentgenography In the roentgenograms (lateral projection) angles between ventral bodies CII and CVII are measured, as well as angles in every segment. Indices of the cervical lordosis for every age group in men and women are estimated. The form of the cervical part of the spinal cord in men and women is not equal and changes in different age periods. During the middle age lordosis decreases both in men and women and again increases in the elderly age.     

Evidence-based hydro- and balneotherapy in Hungary—a systematic review and meta-analysis

Balneotherapy is appreciated as a traditional treatment modality in medicine. Hungary is rich in thermal mineral waters. Balneotherapy has been in extensive use for centuries and its effects have been studied in detail. Here, we present a systematic review and meta-analysis of clinical trials conducted with Hungarian thermal mineral waters, the findings of which have been published by Hungarian authors in English. The 122 studies identified in different databases include 18 clinical trials. Five of these evaluated the effect of hydro- and balneotherapy on chronic low back pain, four on osteoarthritis of the knee, and two on osteoarthritis of the hand. One of the remaining seven trials evaluated balneotherapy in chronic inflammatory pelvic diseases, while six studies explored its effect on various laboratory parameters. Out of the 18 studies, 9 met the predefined criteria for meta-analysis. The results confirmed the beneficial effect of balneotherapy on pain with weight bearing and at rest in patients with degenerative joint and spinal diseases. A similar effect has been found in chronic pelvic inflammatory disease. The review also revealed that balneotherapy has some beneficial effects on antioxidant status, and on metabolic and inflammatory parameters. Based on the results, we conclude that balneotherapy with Hungarian thermal-mineral waters is an effective remedy for lower back pain, as well as for knee and hand osteoarthritis.     

Costal cartilage sculpturing as an adjunct to augmentation mammaplasty

Costal cartilage irregularities are a major component of most congenital thoracic-wall deformities. A significant number of patients with these cartilage irregularities may either refuse major reconstruction or in fact have disorders of insufficient magnitude to justify such endeavors. In patients undergoing augmentation mammaplasty, recontouring or sculpturing of these abnormal costal cartilages may correct or improve the underlying chest-wall deformity and thus enhance the final aesthetic result. This method has had application in mild to moderate asymmetrical cases of both pectus excavatum and pectus carinatum, thoracic hypoplasia (Poland's syndrome), isolated cartilage deformities, and spinal scoliosis. In our hands, the combination of cartilage sculpturing with submuscular augmentation mammaplasty is performed as an outpatient local anesthetic procedure requiring not more than 90 minutes.     

Immunohistochemical characterisation of sympathetic and parasympathetic pelvic neurons projecting to the distal colon in the male rat

The pelvic ganglia are mixed ganglia containing both sympathetic and parasympathetic neurons that receive spinal input via the hypogastric (lumbar cord) and pelvic nerves (sacral cord), respectively. A recent study has utilised immunohistochemistry against synaptophysin (a protein associated with small vesicles) to visualise the preganglionic terminals in these ganglia. By selectively cutting the hypogastric or pelvic nerves and allowing subsequent terminal degeneration, the populations of parasympathetic and sympathetic preganglionic terminals, respectively, can be visualised. The present study has used this method in conjunction with retrograde labelling of pelvic neurons from the distal colon and double label immunofluorescence against tyrosine hydroxylase and vasoactive intestinal polypeptide (VIP) to identify and characterise the sympathetic and parasympathetic neurons projecting to the distal colon from the major pelvic ganglia of the male rat. Approximately equal numbers of distal colonic-projecting pelvic neurons are sympathetic and parasympathetic. Almost all noradrenergic neurons are sympathetic. Of the VIP neurons that project to the distal colon approximately one third are sympathetic, one third parasympathetic and the remaining third are possibly innervated by both the lumbar and sacral cord. Extrapolation from our results also suggests that the majority of non-noradrenergic neuropeptide Y neurons (which are known to comprise the remainder of the neurons) are parasympathetic. These studies have demonstrated that the pelvic ganglia are a major source of sympathetic innervation to the distal bowel and have further shown that the distal colon is another target for the non-noradrenergic sympathetic neurons of the pelvic ganglia.     

Differential diagnosis of back pain in adult scoliosis (non operated patients)

Background

This report is the SOSORT Consensus Paper on Terminology for use in the treatment of conservative spinal deformities. Figures are provided and relevant literature is cited where appropriate.

Methods

The Delphi method was used to reach a preliminary consensus before the meeting, where the terms that still needed further clarification were discussed.

Results

A final agreement was found for all the terms, which now constitute the base of this glossary. New terms will be added after being discussed and accepted.

Discussion

When only one set of terms is used for communication in a place or among a group of people, then everyone can clearly and efficiently communicate. This principle applies for any professional group. Until now, no common set of terms was available in the field of the conservative treatment of scoliosis and spinal deformities. This glossary gives a common base language to draw from to discuss data, findings and treatment.