EBM FOR MANUAL THERAPY AS A CONSERVATIVE TREATMENT

OF SCOLIOSIS: A NARRATIVE REVIEW

Paris 12 - 14 October 2018

Salvatore Minnella Saveri F, Donzelli S, Asero G, Gourjon A, Zaina F

DISCLOSURE

NO CONFLICT OF INTEREST TO DECLARE

DEFINITION

The name was introduced by Hippocrates: ‘’Scolios’’ (awry or curved)

SCOLIOSIS IS A ‘’ TRIDIMENSIONAL TORSIONAL DEFORMITY

OF SPINE AND TRUNK’’ Grivas et al. 2006

DEFINITION

‘’ TRIDIMENSIONAL TORSIONAL DEFORMITY OF SPINE AND TRUNK’’

• Frontal plane: lateral curvature

• Horizontal plane: axial rotation

• Sagittal plane: alteration of normal curvatures

(kyphosis and lordosis) usually towards a flat back

DEFINITION

NO !

DEFINITION

NOT EXACTLY!

DEFINITION

YES!

EPIDEMIOLOGY

•Prevalence: 2-3% of population •Incidence: F > M ( AIS severe much more frequent in female) from 10° to 20° F : M= 1,3 : 1 from 20° to 30° F : M= 5,4 : 1 when > 30° F : M= 7 : 1

ETIOPATHOGENESIS

BIOMECHANICAL FACTORS WHICH SUPPORT PROGRESSION

• HUETER- VOLKMANN LAW • PREEXISTENT AXIAL ROTATION PATTERN

ETIOPATHOGENESIS

HUETER- VOLKMANN LAW

Epiphysis will grow symmetric with equal pressure on the epiphyseal plates; but if an area go under a greater pressure (concavity) it will not grow so rapidly and completely like the area which instead go under a lighter pressure (convexity)

ETIOPATHOGENESIS

PREEXISTENT AXIAL ROTATION PATTERN • Normal spine is not a symmetrical structure

• There’s an axial rotational pattern which is different in different regions of the spine and at different ages

• Once the spine starts to decompensate into scoliosis

it seems to follow this preexistent rotational pattern • Asimmetric growth and closure of the NCJs occur in

development of pathological rotation of the spine as is known in naturally occuring scoliosis

R.M. Castelein et al. The Spine Journal 2013

ETIOPATHOGENESIS

BIOMECHANICAL POINT OF VIEW

Scoliosis spine is an unstable 3D asimmetric structure

Which needs correction

through stability

The Society on Scoliosis Orthopaedic and

Rehabilitation Treatment

SOSORT

http://guides.mclibrary.duke.edu/c.php?g=158178&p=1035972

PYRAMID OF EVIDENCE

Paolo Sibilla’s theory of gradual approach to scoliosis

PYRAMID OF EVIDENCE

MANUAL THERAPY

• Professionalized at the end of the 19th century as a treatment of spine disorders

• First of all Osteophaty and Chiropratic then in the 20th century the development of Orthopedic Manual Medicine by R. Maigne • Strong uncertainty exist still now on evidence of efficacy of manual therapy as a conservative treatment for scoliosis

AIM OF THE STUDY

To assess the efficacy of Manual Therapy as a conservative treatment

for idiopathic scoliosis from an evidence based point of view

We started with a Systematic Review

Search Strategy • Data sources: pubmed/medline and cochrane

libraries until November 2017

• Mesh terms: ‘scoliosis’, ‘manual therapy’, ‘spinal manipulation’ and ‘muscoloskeletal manipulations’

• Inclusion criteria: systematic reviews, randomized

control trials (RCTs), observational prospective cohort study; age of the subjects between 10 and 18 years old, Risser sign from 0 to 2 at the beginning of treatment

SYSTEMATIC REVIEW

The research was done by two operators specialized in Spine Pathology. They also made the selection of the works, that met

inclusion criteria, among all the titles first and the abstracts in a second step

SYSTEMATIC REVIEW

36 works elegible for abstract reading

NO ONE met the SRS criterion for scoliosis studies of Risser sign 0-2 at the beginning of therapy

TO BE OR NOT TO BE…

We turned into a Narrative review and assessed completely the 8 studies

(all systematic reviews) which met the other

inclusion criteria

SYSTEMATIC REVIEW OCTOBER 2016

• Systematic Reviews, • Treatment with manual therapy, chiropractic, osteopathy • Patients with idiopathic scoliosis

Papers on scoliosis-specific physiotherapy, bracing and scoliosis developing secondary to other conditions were excluded from the analysis

• Scoliosis specific physiotherapy treatment • bracing • Patients with scoliosis secondary to other

conditions

Gotlib A, Rupert R.

1. Assessing the evidence for the use of chiropractic manipulation in pediatric health

conditions – a systematic review. Pediatr Child Health 2005; 10(3): 157-61.

2. Chiropractic manipulation in pediatric

health conditions - an updated systematic review.

Chiropr Osteopat 2008; 16: 11

Aim of the studies: Efficacy of chiropractic manipulation in pediatric diseases Results: • 1731 studies (2005) 1235 studies(2008) • Unchanged studies in 3,5 years • Only one pilot study (Rowe et al 2006)

Conclusion: • Greater scientific rigor needed for assessing efficacy of manipulation in

pediatrics patients • Integration of clinical expertise with scientific research • Use of chiropractic techniques in paediatric conditions supported by weak

scientific evidence

3.Romano M, Negrini S.

Manual therapy as a conservative treatment for adolescent idiopathic

scoliosis.

Scoliosis 2008; 3: 2.

Aim of the study: • Efficacy of manual therapy (manipulation e

mobilization)

Results: • 145 studies • No one being a controlled one Conclusions: The gap of scientific results does not permit to draw any conclusion on the efficacy of manual therapy as a treatment of adolescent idiopathic scoliosis

4. Gleberzon BJ, Arts J, Mei A, McManus EL.

The use of spinal manipulative therapy

for pediatric health conditions: a systematic review of the literature.

J Can Chiropr Assoc 2012; 56: 128-41.

Aim of the study: • Efficacy of chiroprcatic manipulation in pediatric

diseases

Results: • 16 papers included about chiropractic or HVLA

manipulations • Only one pilot study (Rowe et al 2006) Conclusions: • The most part of the studies had methodology limits • We need to increase the number of the studies in

this field

5. Posadzki P, Lee MS, Ernst E. Osteopathic manipulative treatment for

pediatric conditions: a systematic review. Pediatrics 2013; 132: 140-52.

Aim of the study: Efficacy of osteopathic manipulation for the treatment of pediatric diseases

Results: • 19059 studies • 1 work on idiopathic scoliosis (Hasler at al. 2010) 2

groups, no significative differences

Conclusioni: Efficacy of osteophatic treatment is not supported by evidence for the little and low methodological quality of the studies assessed

6. McKenney K, Sinclair Elder A, Elder C, Hutchins A.

Myofascial release as a treatment for orthopaedic conditions: a systematic

review. J Athl Training 2013; 48: 522-7.

Aim of the study: • Efficacy of myofascial treatment in orthopedic

diseases

Results: • 88 studies • 1 case study on idiopathic scoliosis (Lonstein Je,

Carlson JM 1984)

Conclusions: • Level of evidence too much various • RCTs are needed

Systematic Reviews July 2017

Spinal Manipulative Therapy for Adolescent Idiopathic Scoliosis: A Systematic Review. Théroux J, Stomski N, Losco CD, Khadra C, Labelle H, Le May S. J Manipulative Physiol Ther. 2017 Jul - Aug;40(6):452-458. doi: 10.1016/j.jmpt.2017.03.009. Review. PMID: 28822477

• 145 Studi

• 4 soddisfavano i criteri di

inclusione/esclusione

2 assessed in previous reviews

Effect of chiropractic intervention on small scoliotic curves in younger subjects: a time-series cohort design.

Lantz CA, Chen J.

J Manipulative Physiol Ther. 2001 Jul-Aug;24(6):385-93.

PMID: 11514815

Chiropractic manipulation in adolescent idiopathic scoliosis: a pilot study.

Rowe DE, Feise RJ, Crowther ER, Grod JP, Menke JM, Goldsmith CH, Stoline MR, Souza TA, Kambach B.

Chiropr Osteopat. 2006 Aug 21;14:15.

PMID: 16923185

2 not assessed before

Incidence of curvature progression in idiopathic scoliosis patients treated with scoliosis in-patient rehabilitation (SIR): an age- and sex-matched controlled study. Weiss HR, Weiss G, Petermann F. Pediatr Rehabil. 2003 Jan-Mar;6(1):23-30.

SIR (Scoliosis In-patient Rehabilitation) : too much things together (acupunture, exercise, traction, osteopathic manipulation, soft tissue therapy

Aim of the study: • Efficacy of chiropractic manipulation on Cobb degres in AIS

Recruitment: • 20 childs from a Taekwondo school • 12 volunteers • 5 selected by X-ray (Cobb 11.2±1.3)

The effect of chiropractic techniques on the Cobb angle in idiopathic scoliosis arising in adolescence. Byun S, Han D. J Phys Ther Sci. 2016 Apr;28(4):1106-10. doi: 10.1589/jpts.28.1106. Epub 2016 Apr 28.

Conclusions (by authors):. This study showed that chiropractic tecniques can effectively reduce Cobb angle in the first 4 weeks Then we can say that chiropratics tecniques are effective in reducing the curvature in idiopathic scoliosis.

Subjects* Before intervention After 4 weeks After 8 weeks

1 (M) 10 0 0

2 (M) 10 0 0

3 (M) 13 7 0

4 (M) 11 5 5

5 (F) 12 0 0

Mean±SD 11.2±1.3 2.4±3.4 1.0±2.2

The changes in Cobb angle in each subject (Unit: degrees)

CONCLUSIONS

• There is currently insufficient evidence to establish whether spinal manual therapy may be beneficial for idiopathic scoliosis

• Few papers in fact have been published to date and the majority are experimental studies with poor scientific methodology or observational case studies, so all at substantial risk of bias

• Therefore it’s necessary to conduct further research based on appropriate and accurate methods: randomized controlled trials and observational prospective cohort study.

ORTHOPEDIC MANUAL MEDICINE AND SPINE DEFORMITY

We must search and treat

DDIM by

• global mobility examination • regional mobility examination

• segmentary examination • CPM syndrome examination

ORTHOPEDIC MANUAL MEDICINE AND SPINE DEFORMITY

PARTICULAR CAUTIONS DURING CHILHOOD IN SCOLIOTIC PATIENTS

SCOLIOSIS in PROGRESSIVE PHASE: needs stabilizing therapy (physioterapic specific exercise)

Too many manipulations could be too much MOBILIZING

ORTHOPEDIC MANUAL MEDICINE AND SPINE DEFORMITY

GRAZIE

MERCI

“The most beatiful thing we can experience is the mysterious . I t is the fundamental emotion

that stands at the cradle of true art and true science” A.Einstein

Thank you Salvatore Minnella

www.isico.it

salvatore.minnella@isico.it sminnella74@alice.it

“The human mind becomes more developed, more enlightened as new discoveries are made, new thruths discovered and manners and opinions change w ith the change of circumstances” T. Jefferson