Abstract
Background: Adult degenerative scoliosis (ADS) is a coronal deviation of the spine greater than 10° resulting from the progressive degeneration of the vertebral elements in middle age, which is a three-dimensional deformity. In this study, the effect of conservative treatment methods on pain, disability, and quality of life of patients with ADS was evaluated.
Methods:Thirty females with ADS were included in the present study. Demographic characteristics, Cobb angles, Visual Analog Scale (VAS), Short Form-36 (SF-36), Scoliosis Research Society-22 (SRS-22) and Roland Morris Disability Questionnaires (RMDQ) were noted. Fifteen sessions of physical therapy (hotpack, TENS and ultrasound) and exercises were administered to all patients. All assessment scales were used for evaluation at baseline as well as one month and three months after treatment.
Results:Visual Analog Scale scores statistically differed between the first, second and third measurements (p<0,001). There was a significantly improvement in RMDQ between periods of time (p<0,001). While the second assessment was significantly lower than the first measure (p=0,001), there was no difference between the third and second measures (p=0,496). Similarly, quality of life assessments (SRS-22, SF-36) significantly differed between the first and second assessments and continued at the third assessment.
Conclusion:Given the difficulties of surgical treatment and patients’ comorbidities, conservative treatment methods are becoming important for ADS. Non-surgical treatments for ADS should be taken into consideration to improve pain, disability and quality of life outcomes.
Keywords:adult, intervertebral disc degeneration, scoliosis, spinal diseases.
INTRODUCTION
Adult scoliosis is a spinal deformity manifested by more than 10 degrees of deviation of the spine from midline to lateral in the coronal plane and deviation of more than 2 cm from the vertical axis in the sagittal plane in skeletally mature individuals (1).
Adult degenerative scoliosis (ADS) is a type of scoliosis that usually starts after the age of 50 due to degenerative changes in the spine. It is a deformity caused by the degeneration of facets and discs and the resulting rotational and translational listhesis. It usually occurs in the lumbar and thoracolumbar regions, and its reported incidence is 6%. The average age of onset is 60. It is often associated with decreased lordosis or kyphosis (2).
The Aebi classification system of ADS has gained popularity in recent years. It consists of four groups (types I, II, IIIa and IIIb) distinguished according to the causes of the deformity (1). All four types of scoliosis can present as degenerative scoliosis at a certain stage, and therefore, degenerative scoliosis is the basis of adult scoliosis. In de novo scoliosis, other degenerative changes such as disc degeneration, arthrosis, degenerative spondylolisthesis and spinal stenosis accompany the scoliosis. Pain and neurologic involvement may coexist. It can seriously impair physical function (3).
The first line treatment of ADS is a conservative approach which comprises medical, exercise, physical therapy (PT) and bracing. Surgical treatment is required in the presence of neurological deficit, instability and progressive deformity (4-6). In the literature, studies on the effectiveness of conservative treatment in ADS are very limited and their results are contradictory due to the diversity of patient groups and treatment methods involved (6, 7).
In this study, the effectiveness of conservative treatment on pain, disability and quality of life in patients with ADS was investigated.
MATERIAL AND METHODS
Study design
This prospective study was approved by the Institutional Review Board (Decision no: 2018/0423) in accordance with the Declaration of Helsinki. Informed consent was obtained from all patients. This study conforms to all CONSORT guidelines and reports the required information accordingly.
Patients
Forty individuals who presented to the Physical Medicine and Rehabilitation outpatient clinic between July 2019 and September 2021 and were diagnosed with thoracolumbar ADS by an experienced specialist, had an orthorontgenogram, did not undergo a surgical intervention, and had cognitive function to fulfill the commands were included in this study. However, active patient recruitment could not be made in 2020, as treatment programs were disrupted due to pandemic conditions. All participants were informed about the content and methods of the study and their written consent was obtained. Individuals with cognitive dysfunction and those who either underwent a surgical intervention or had a health condition (malignant, chronic infection, etc) contraindicated to PT and exercise applications were excluded from the study.
Evaluation methods
Patients’ age, gender, height, weight, body mass index, comorbidities, smoking status and Cobb angles were recorded. All study particioants were evaluated before the treatment program, and then after one month and three months.
The Visual Analog Scale (VAS) was used for pain assessment, Scoliosis Research Society-22 (SRS-22), the Short Form-36 (SF-36) for the quality of life assessment and Rolland Morris Disability Questionnaire (RMDQ) for disability assessment.
The VAS is a subjective assessment method used to measure the severity of pain. Boonstra et al proved its validity and reliability (8). Using a scale ranging from 0 to 10 cm, individuals are asked to mark the intensity of pain they feel on that scale.
Scoliosis Research Society-22 (SRS-22) patient questionnaire was developed by Haher et al, in 1999, as a simple and practical inquiry form to evaluate the quality of life for idiopathic scoliosis. It is a valid and reliable assessment method for the quality of life assessment in patients with scoliosis (9, 10).
The RMDQ consists of 24 questions about functional inabilities, and patients are asked to answer “yes” if it is appropriate for their situation or “no” if it is not. Calculating “yes” answers as “1” and “no” answers as “0”, the total score varies between 0-24, with a higher score indicating more disability (11).
Conservative treatment program
Forty patients who met the inclusion criteria received 15 sessions of physical therapy (PT modalities) (TENS, Hotpack and ultrasound) and an exercise program (stretching, strengthening, core stabilization, posture and balance-coordination exercises for three weeks, five days a week, 60 min/day) in the PT unit.
The following PT modalities were used: 1) Hotpack (HP): 60°C, 20 minutes; 2) therapeutic ultrasound (US): 1.5 watt\cm², three minutes + three minutes, to the paravertebral region; and 3) transcutaneous nerve stimulation (TENS): conventional TENS, 20 minutes to the paravertebral region.
One patient whose PT program was completed continued the exercises as a home program. All patients were advised to take paracetamol for pain control if needed (max. 4000 mg/day). Ten patients could not continue treatment due to transportation problems, occupational and familial reasons, accompanying health problems and pandemic conditions. Those whose treatment was completed were reevaluated the first and third month.
Statistical analysis
Descriptive statistics of categorical variables are given as numbers and percentages, and descriptive statistics of numerical variables as mean, standard deviation (SD), median, minimum, and maximum. The conformity of variables to the normal distribution was examined using the Shapiro-Wilk test. The analysis of variance method was used for repeated measurements to compare the means of repeated measurements. Bonferroni correction was used for multiple comparisons (post hoc). Friedman and Cochran q tests were used to compare repeated measures of categorical variables. The statistical significance level was taken as 0.05. The SPSS-22 package program was used in calculations.
RESULTS
All study participants were women (n=30) with a mean age of 55.5 (min: 42, max: 80) years. Patients’ demographic data are summarized in Table 1. The mean of Cobb angle measurements was 16 (min: 10; max: 40).
Table 2 shows the descriptive statistics and p values obtained as a result of the comparison of VAS averages measured at different times.
A significant difference in average RMDQ scores between the periods of time was observed (p<0.001). While the mean value of the second measurement was significantly lower than that of the first measurement (p=0.001), no significant difference was observed between the mean values of the second and third measurement (p=0.496) (Table 3).
Table 4 shows a change in SRS-22 scores. A significant difference in mean values of the SRS-22 function subscale between the periods of time was observed (p<0.001). The mean values of the second and third measurements were found to be significantly higher than those of the first measurement (p=0.014; p=0.046).
A significant difference in mean values of SRS-22 pain subscale between the periods of time was observed (p<0.001). The mean values of the second and third measurements were significantly higher than those of the first measurement (p<0.001).
A significant difference in mean values of the SRS-22 self-image subscale between the periods of time was observed (p<0.001). The mean value of the first measurement was significantly lower than that of the third measurement (p=0.05).
A significant difference in mean values of SRS-22 mental health subscale between the periods of time was observed (p<0.001). The mean values of the second and third measurements were significantly higher than those of the first measurement (p=0.040; p=0.027).
The mean SRS-22 satisfaction subscale score of the third measurement was significantly lower than that of the second measurement (p<0.001).
A significant difference in mean values of the SRS-22 total score between the periods of time was observed (p<0.001). The mean values of the second and third measurements were significantly higher than those of the first measurement (p<0.001; p=0.001).
The SF-36 quality of life scale evaluated nine parameters, including physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional, and mental health. Table 5 shows the change in SF-36 scores.
The mean values of the first measurement of the physical functioning subscale were significantly lower than those of the second and third measurements (p<0.001; p=0.027). The mean values of the first measurement of the role physical role subscale were significantly lower than those of the second measurement (p<0.001). There was no significant difference between the mean values of the first and third measurement (p=0.182). The mean values of the first measurement of the pain subscale were significantly lower than those of the second and third measurements (p<0.001; p=0.007). The mean value of the first measurement of the general health subscale was significantly lower than the second and third measurements (p=0.002; p=0.05). The vitality subscale of the first measurement average was significantly lower than the second and third measurements (p=0.001; p=0.016). The mean value of the first measurement of the social functioning scale was significantly lower than that of the third measurement (p=0.010). There was no significant difference between the second and third measurements (p=0.160). The mean value of the first measurement of the role emotional subscale was significantly lower than the second and third measurements (p=0.008; p<0.001). The mean value of the first measurement of the mental health scale was significantly lower than the third measurement (p=0.031). There was no significant difference between the second and third measurements (p=0.236).
DISCUSSION
Adult degenerative scoliosis is a lumbar deformity disease that occurs as a sequelae of asymmetric degenerative changes of the spine in skeletally mature individuals and has become an important public health problem. If there is no neurological involvement, instability and progressive deformity, treatment is primarily aimed at relieving pain by using a conservative approach (medical, exercise, PT modalities, bracing) (12-14).
In PT, thermal treatments and electrotherapy methods are used together with exercise therapy (14). However, in the literature there are only few studies on the effectiveness of PT methods in ADS and there is not enough evidence about PT in ADS because of the variability of defined patient groups and treatment methods.
The present study investigated the effectiveness of exercise and PT modalities as conservative treatment on pain as well as the quality of life and functional improvement in ADS patients. PT modalities consisting of hot pack, tens and ultrasound were administered to patients by a PT technician in 15 sessions every weekday for three weeks, then specific scoliosis exercises were performed under the supervision of the physiotherapist, with paracetamol being recommended when necessary. After finishing treatment, patients continued the exercises at home for one hour a day, at least three days a week. Significant improvements were found in the patients' quality of life, functional status and pain scores.
Adult degenerative scoliosis typically begins around the age of 50 (mean age of presentation 70.5 years) (15). In the present study, the mean age of participants are compatible with the literature.
Previous studies reported that ADS was more commonly found in women, in whom it showed more progression and required treatment more frequently than men (3, 16). Consistent with the literature, all patients included in the current study were females.
Cobb angle is a measurement method with a radiographic two-dimensional index that measures the lateral curvature of the spine and determines the severity of scoliosis (17). A study conducted by Perennou et al found a correlation between Cobb angle and age (18). Cobb angles are typically measured below 40° in ADS compared to the >50° measurements commonly seen in adult idiopathic scoliosis (3). In this study, patients’ mean values of Cobb angles were measured as 16° (range: 10°-40°).
Low back pain is the most common complaint in patients with degenerative thoracolumbar scoliosis. Low back pain is the result of balance disorders caused by degeneration and deformity, presence of instability and overwork and fatigue of muscles for compensation. It was observed that patients’ physical activities decreased due to low back and leg pain (3, 19, 20). Kostuik and Bentivoglio (21) investigated the association with the incidence of scoliosis and low back pain in adults. They observed that the severity of pain increased with the degree of curvature, especially for curves greater than 45 degrees, and there was a high correlation between the radiological changes in the apex of the curve and pain. In the same study, the authors found no relationship between age and incidence of pain. Since surgery for scoliosis in adults carries a high risk and long-term effectiveness has not been proven, all conservative measures should be tried before operation.
In a study conducted in adult patients with chronic low back pain, it was found that a combined approach with exercise, medical treatment and physiotherapy was more effective than exercise and medical treatment alone (22). In this study, a combined treatment with PT and exercise was used for all participants, and improvements in pain and quality of life scores were detected.
In a study investigating the effects of a program including task-oriented exercises and cognitive behavioral therapy (CBT) in adults with idiopathic scoliosis, the effect of task-oriented exercises in enhancing functional outcomes and the effect of CBT in changing pain perception were shown (23).
In a study conducted by Vasiliadis and Grivas, 32 girls diagnosed as adolescent idiopathic were treated conservatively, including physiotherapy, and the changes in the subjects’ quality of life and pain were investigated. Significant changes in pain scores and quality of life measures and physical functionality were reported at two-year follow-up (24). In their study, Çolak et al (25) observed a higher increase in the quality of life with conservative treatment than after surgical treatment. The studies conducted by Aulisa et al (10) and Monticone et al (26) in patients with adolescent idiopathic scoliosis found significant changes in SRS-22 quality of life criteria after conservative treatment and exercise.
In a 2007 systematic literature review by Everett et al (27), there was ambiguous, level III/IV evidence for the efficacy of any conservative treatment option in adult scoliosis. Specifically, there is level IV evidence for PT and chiropractic. There is level III evidence for injections in the conservative treatment of adult deformity. There is insufficient research and very weak evidence to recommend a treatment beyond level 2c. In a systematic review conducted in 2018, the effects of exercise on pain, quality of life and disability in adult scoliosis were questioned, but only one article met the study criteria. The authors interpreted it as despite the high prevalence of AS, there was an important gap in the literature with limited evidence reporting the effect of exercise on back pain in adults with scoliosis (28). In our study, which was carried out to fill this gap in the literature, PT modalities and supervised exercise programs used for three weeks showed significant improvements in the patients’ quality of life, functional status and pain scores.
Study limitations
All study participants were females, and since psychosocial factors affecting pain and the quality of life may differ between genders, this may have affected the results. Due to the limitations of the pandemic, many patients discontinued the study or did not participate. The current study only covered a narrow area where access to the hospital was easy.
As a result, although further studies are required, exercise and PT modalities as conservative treatment can reduce pain and increase the quality of life and functionality in ADS patients.
CONCLUSION
Non-surgical treatments in ADS should be taken into consideration to improve the pain, disability and quality of life outcomes, due to difficulties of surgical treatment and patients’ comorbidities.
Financial support: none declared.
Ethical approval: This prospective study was approved by the Institutional Review Board of Istanbul Medeniyet University, Istanbul, Turkey, in accordance with the Declaration of Helsinki. Informed consent was obtained from all patients. This study conforms to all CONSORT guidelines and reports the required information accordingly.
TABLE 1.
Demographic data of study participants
TABLE 2.
VAS score evaluation
TABLE 3.
Roland Morris Disability Questionnaire results
TABLE 4.
SRS-22 results
TABLE 5.
SF-36 results
Contributor Information
Fethullah BAYRAM, Goztepe Prof Dr Suleyman Yalcin City Hospital, Physical Medicine and Rehabilitation Clinic, Istanbul, Turkey.
Bilinc Dogruoz KARATEKIN, Goztepe Prof Dr Suleyman Yalcin City Hospital, Physical Medicine and Rehabilitation Clinic, Istanbul, Turkey.
Belgin ERHAN, Istanbul Medeniyet University, Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Istanbul, Turkey.
Ozge PASIN, Bezmialem Foundation University Faculty of Medicine, Department of Biostatistics, Istanbul, Turkey.
Yasemin YUMUSAKHUYLU, Istanbul Medeniyet University, Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Istanbul, Turkey.
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