PLASTIC CHANGES IN SPINAL FUNCTION OF PRE-PUBESCENT SCOLIOTIC CHILDREN ENGAGED IN AN EXERCISE THERAPY PROGRAMME

■ by Gill Solberg, M A Rehabilitation Research Unit, Department of Human Movement Studies, Rhodes University, South Africa


INTRODUCTION
Previous studies have tended to dem onstrate that in cases of functional scoliosis, postural muscle "tightness" should be as sessed during musculo-skeletal exam inations, and that the treat m ent rationale should include appropriate m obilisation therapy along w ith improving im balances betw een antagonistic muscle groups along the spine (Janda, 1983;Alter, 1988; Nudelm an and Reis, 1990).However, no published data were found on the effect of these treatments on lateral deviations of the spine.
This study w as designed to determ ine whether or not it is possible to show reduction of the lateral deviation in a group of functional scoliotic children follow ing a 20 week period of thera peutic exercises, and to exam ine the extent to w hich spinal func tion can be improved.

METHOD
Ten scoliotic school-children (m ean age 10.6 years) were exam ined and measured by one trained observer via the following stages:

Subjective assessment
The presence or absence of the follow ing bodily symmetries w as recorded: • Shoulder height • Scapular level • Chest and hip prom inence • Lateral deviation of the spine.
The child w as then asked to bend forward looking at the floor, keeping the feet together, knees braced back, shoulders loose and hands positioned betw een the knees.A subjective assessment of asymmetry of the upper chest, m id-chest and lower chest, the lumbar region and sacrum w as m ade in this position.The pres ence of absence or a lateral spinal curvature (clinical evidence of scoliosis) w as recorded.

Objective assessment
At this stage data were collected in the follow ing categories: D em ographic data: Including age, mass, stature and family history of scoliosis, as well as medical, surgical and developm en tal history.

Anthropom etric measurem ents:
The anthropom etric param e ters chosen were those that have a functional role in the general aims of the clinical exam ination, and were aimed at observing any lateral sym m etries along the body.The follow ing measurements w ere made, all within tolerance limits of 5 mm: • Height of acromia: The vertical distance from each acromion to the floor.
• Scapula-spine distance: measured horizontally from the infe rior angle of each scapula to the nearest vertebral thoracic spinous process.
• Biacromial diam eter: The m axim um distance betw een right Previous studies (Stone et al., 1979) of the effect of exercise therapy on scoliosis have demonstrated progression of spinal curves despite vigorous exercise regimens.This study presents evidence to the contrary.Ten South African black school children with mild scoliosis and attendant upper thoracic asymmetries were analysed both before and after a specific exercise therapy programme, in order to determine the effect of the therapy on spinal functionality and the scoliotic curve.The effect of this intensive treatment, in which the subjects underwent a five-month exercise training programme with a total o[ 60 one-hour sessions, was investigated in a controlled clinical trial.A subjective and objective appraisal of posterior trunk asymmetry in school children aged 7 -1 8 years is reported.Selected functional and anthropomet ric measurements were made before and after the treatment, and antero posterior X-rays were used to indicate changes in the scoliotic curve.New methods are described for quantifying the scoliotic curves in each child.Post-treatment tests showed a significant (p) decrease in Cobb's angles as well as a significant reduction in all the spinal and thoracic functional asymmetries observed in the study.The findings suggest that selective exercise programmes can contribute to improvement in cases of functional scoliosis.The study sheds new light on problems related to scoliosis and the benefits of exercise rehabilitation.Data on the incidence of scoliosis amongst 1052 black children are presented and discussed too.
and left acromia, measured from behind with the subject stand ing.The pointer w as brought dow n onto each acrom ion from above.
• S i -Acromia distance: The distance betw een right and left acromia to S i w ith the subject standing.
• Height of anterior superior iliac spines (ASIS): The vertical distance from each ASIS to the floor.
• Low er limb length: M easured from the ASIS to the medial malleolus, w ith subject lying supine.
In order to be able to com pare different sym m etries at different sites on the same scale, an asym m etry ratio (AR) w as derived as follows: AR = H /L-l Where: H = higher shoulder height, and L = lower shoulder height.
Thus, all data were recorded as positive values.For each subject AR was calculated for selected anthropom etric m easure ments.
Functional measurem ents: • Trunk flexion (thoracolum bar spine): The distance betw een the spinous processes of C7 and S i in the start position w ith the subject standing, and at the limit of m otion w ith the subject flexing the trunk forward.
• Lateral bending test: M easurem ent of distance betw een C7 and seating plane w ith the subject sitting erect and at limit of motion w ith the subject bending laterally to the right and left sides.The pelvis w as stabilised to the plane of the seat.
• Spinal rotation: Rotation angle of the spine (cervical spine excluded) w ith the subject sitting and at the limit of motion with the subject rotating the spine to the right and left sides.Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2013.) The pelvis w as stabilised and a pointer was connected to the sternum to measure angular movement.• Shoulder flexibility: Both shoulder joint and shoulder girdle flexibility was examined.Test position: the right elbow was raised and the right hand reached down betw een the shoulders with the subject sitting erect.The left hand was placed in the small o f the back with the fingers pointing upward an d the palm facing away from the back.The distance between the hands if not overlapped or the amount of fingers overlap was measured.
• Ham string flexibility: M easurem ent of the angle of straight leg raising in a supine position, w ith the low er extrem ities ex tended.Scapular asym m etry: The angle of acromial plane scapular asymmetry was determ ined using linear distance betw een the acromia (h) and the vertical difference in acromial height meas ured from the floor (o) as depicted in Figure 1.Thus the angular asymmetry is given by: 9= Arc Sin o/h Several researchers have reported that the development of a curvature is m ost likely during periods of rapid growth (Taylor, 1983;Loncar et al, 1991).Since the developm ent of scoliosis is so intimately related to the developm ent and growth of the skeleton, physical anthropometry can be an im portant m easurem ent tool.
However, quantifying change of shape, over time, especially as it related to scoliotic progression or response to treatment, is also an im portant clinical problem .The precision of measurement tech niques is crucial to accurate detection of change, especially in the case of back-surface m easurem ent whose magnitude is small compared with the m agnitude of the underlying skeletal deform ity.One of the m ajor factors lim iting the understanding of the relationship betw een therapeutic physical activity and scoliosis is the lack of easily administered valid and reliable measures, which will obviate false conclusions (Figure 2).
As Figure 2 show s, a taller subject (with presum ably broader chest), appears to exhibit a greater asymmetry in terms of dispa rate heights of left (L) and right (R) acromia, while in fact this may be an artifact of body size.Even if stature is identical, an individ ual with larger bi-acromial axis may exhibit an apparent (but not real) increase in asym m etry.Thus, in the present study, asym m e try was viewed as an angular deviation w hich is independent of size, and 0 in Figure 2 is identical, despite a considerable apparent difference in left and right acromial height.On the assumption that a subject undergoing an adolescent growth spurt could con ceivably grow in stature and/or bi-acromial diam eter w ithout in fact changing the relative level of asym m etry, this would convey a spurious impression that the asymmetry had increased when in fact it might even have diminished.
Thus the angle 9 expresses acromial height asymmetry better, as a size-independent measure, and therapeutic interventions are then aimed at reducing 9 to zero, while grow th changes are factored-out.This will also enable data from different age groups to be pooled for statistical analysis.
M easurem ents on the Radiographs: One anteroposterior roentgenogram was taken of each subject in a standing position, using a large 36 x 43 cm cassette and directing the central ray horizontally to the m id-point of the film.The research protocol was approved by the appropriate sub-committee on ethical standards which required, inter-alia, the direct personal involvement of an orthopaedic surgeon during the X-ray phase, to ensure that only children deemed on medical grounds to require X-ray screening would be subjected to this intervention.These radiographs were analysed using the following meas urements: All spinal curvatures were measured in degrees as described by Cobb (1958.).Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2013.) • A plumb-line was drawn on the radiograph from the spinous process of C7.In cases of a cervical curve, this line was drawn from the first symmetrical vertebra.
• Five anatomical points were then identified on each vertebral body within the curve (Figure 3), and used to find the middle point of the vertebra.
• The distance betw een each vertebral centre and the plumb line was measured to the nearest millimetre and the spinal devia tion relative to this vertical line was then calculated using a sim ple ratio relationship: SD = Sd/H W here SD is the extent of spinal deviation; d is the distance of each vertebrae from the plumb line; and H is the height of the vertebral body of the twelfth thoracic vertebra.This ratio relation ship ensures standardisation of the measurement if the child grew in size and/or if projected X-ray image altered from test to test.
The area under the curve was measured, as follows: • A straight line was drawn betw een all the vertebral centra within the curve.• The area under the curve (i.e. between the plumb line and the curve) was measured in square centimetres using a com pen sating polar planimeter.
• For standardisation of the measurement, this result was di vided by the area of the body of T 12 as measured on the same X-ray.Thus: Where SRD is the size-relative curve amplitude encompassing spinal deviation, C is the area under the curve, and A is the area of the twelfth thoracic vertebra.This ratio relationship was used to ensure standardisation of the measurement.

Treatment
Following exam inations and X-rays, the subjects were re quested to participate in a 60-treatment exercise therapy pro gramme in which a graduated regime was provided to enhance each subject's muscular strength, neurom uscular coordination and joint range of motion (ROM) according to individual needs.The subjects were seen three times weekly for 20 weeks and a warm, well-lit room was utilised throughout.

Exercise procedures and programme
The aim of the treatment was to provide therapeutic regimens differentiated by each patient's initial functional condition.The treatment was specifically adjusted to the subjects, taking account of the direction and extent of the curve(s).The program m e was designed to release muscle contractures on the concave side of the spine, since soft tissue contracture in this area is one of the main forces maintaining the deformity, resisting correction and reject ing implants (Nudelman and Reis, 1990).
The lateral deviation of the spine might also reduce the ability of the intervertebral disc to distribute w eight effectively and a decrease in the disc height might occur, causing abnormal weight bearing by the facet joints and an alteration in facet joint alignment (Cailliet, 1975).Therefore, one of the general aims of treatment was to encourage awareness of the use of the spine in everyday life, and teach the application of mechanical principles of kinetic handling in activities of daily living.
The exercise system and procedures were developed by the author.The exercises were taught to the subject during an orien tation session.Before the subjects were allowed to participate in the study, they were required to perform the exercises correctly.

Pre-treatment Roentgenographic Findings
The criteria for the existence of scoliosis in this study included the presence of obvious truncal lateral symmetries as well as co n firm a tio n of those sig n s in the e re c t a n te ro p o ste rio r roentgenogram of the spine using as the criterion a minimum of 5", determined by Cobb's technique.

Anthropometric measurements:
The exercise programme had a positive effect on all the sym metries which were observed in the anthropom etric measure- The program m e-effects on Acromial Angle Asym m etry are presented in Table I.I).

Functional measurements:
Functional tests were used in this study as a means of the determ inating functional lim itations o f the scoliotic spines and extent of truncal symmetries.
The results of the functional m easurem ents concur w ith other studies of lateral sym m etries, w hich found that there is a relation betw een scoliosis and functional im balances (Nudelman and Reis, 1990; Kisner and Colby, 2985; Thom pson, 1989).The m ajor ity of the subjects in this study presented w ith tightness in pos tural muscles, predom inantly those maintaining the locom otor posture, to correlate w ith the concept that these muscles adap tively shorten and becom e tight (Janda, 1983).
The treatment apparently exerted a significant influence on all the observed functional symmetries, over the 20-week period of the program m e (p).

Results of measurements on the X-ray films:
In roentgenographic exam inations, m agnification of the image depends on the tube position.A magnification factor was taken into account to standardise this.Because all of the geometric inform ation was com pressed onto a single film plane, the magni fication varies w ith the position of the part of the skeleton being measured, since it is also dependent on the distance from the film plane.This m ay produce small differences on the radiograph and therefore all the m easurem ents on the X-rays in this study were standardised (using T 12 as a reference vertebra) by the method described earlier, before the data on the spinal deform ity could be obtained w ith confidence.

Cobb Angles:
The results o f pre-and post-treatm ent curves, as measured on the X-rays, show significant reduction in Cobb angles and are presented in Table II.The results of this study show that the area under the curve as

Measurement Procedures
The measurement techniques used in this study have been applied to studying the effects o f treatm ent, as well as to im prov ing our description of the scoliosis deform ity and our under standing of its aetiology.The test sequence presented facilitated observation in an ordered w ay to avoid unnecessary changes in starting positions.This further encouraged efficiency during the tests and was a practical method of evaluating the m usculoskele tal system in children.To ensure valid conclusions from the data, the reliability of all the m easurem ents w as determ ined.
The measurements used yielded acceptable test-retest reliabil ity, and can im prove the therapist's ability to decide the effective ness o f treatments.In this w ay m odifications of the treatm ent plan can be initiated at an earlier phase of therapy.The author believes that the methods which were developed in the study are rigorous and would appear to reflect the m agnitude of the scoliotic curve.Thus, clinicians should consider using the m ethods described when evaluating patients w ith suspected spinal problem s.

Exercise programme and treatment procedures:
Treatm ent of scoliosis by exercise therapy rem ains controver sial, w ith m ost of the investigators reporting poor results and questioning its effectiveness (Cobb, 1958;Keim , 1982;Road, 1956;Tarr, 1948;Kisner and Colby, 1985;Stone et al, 1979).M ost o f these authors contend that exercise of any kind is not beneficial in

Corinth Medical
SA J o u rn a l P h y s io th e ra p y , V o ! 5 2 N o I F e b ru a ry 1996 P a g e 19
Measurements of the general spinal deviation was developed, as follows: B la d sy 2 0 F e b ru a rie 1996 SA Tydskrif F is io te ra p ie , D e e l 5 2 N o 1 Subjects were individually supervised during their exercises to ensure correct execution.A log was kept, recording exercise dos age date in the following categories: intensity, repetition and frequency.Adjustments of exercise intensity were made for exer cise progression each month.T rea tment sessions were of one hour duration each.During the first two weeks, quality of performance of the exercises was emphasised.In addition to performing exer cises during the treatment sessions, the subjects were instructed to do these same exercises at home.The exercises were of two types.The first consisted of ten exercises and was a standard condi tioning routine to maintain the strength of the trunk muscles as well as its norm al range of motion.Vigorous exercises included incidental movem ents that are translated to active correction of the major curve.The second type comprised exercises involving specific movements designed to diminish the curve of the individual in question.After 20 weeks (60 treatments) subjects were re-evaluated and the initial measurements were com pared to post-program m e re sponses.Paired t tests were used to evaluate the effectiveness of the programme in reducing bodily imbalance, improving spinal functionality and altering the Cobb angle as measured on the X-rays.
SA J o u rn a l P h y s io th e ra p y , V o! 5 2 N o 1 F e b ru a ry 1996 P a g e 21 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2013.)merits.The general asym m etry scores (E H / L -l) were signifi cantly decreased (p) by the treatment programme.
The angle of acrom ial asym m etry appears to serve not only a good indicator o f the need for treatment, but as a quantitative m easurem ent of realignment.A com parison betw een pre-and post-treatm ent results show a significant improvement after the exercise program m e (Table well as the general spinal deviation scores w ere significantly lower in the post-treatm ent measurements.The significant posi tive changes in these m easurem ents, and in the Cobb angles give some indication of the success of the training program m e.The results seem to confirm the potential value of an intensive and rigorous therapeutic exercise program m e in the treatm ent of scoliosis, and argue against the opinions postulated by Kisner and Colby (1985) and others(Keim, 1982; Roaf, 1958), w ho consider exercises beneficial only when perform ed by patients wearing trunk orthoses.
inhibiting scoliotic developm ent.In 1941, the A m erican O rtho paedic A ssociation's Research Com m ittee cam e to the conclusion, after a study of 425 cases of end-result idiopathic scoliosis, that exercise should be avoided.This study found that approxim ately B la d sy 2 2 F e b ru a rie 1996 SA Tydskrif F is io te ra p ie , D e e l 52 N o 1

...c o n tin u e d fro m p a g e 2 2
rin th M edical.Please send me y our 'W o rking Holidays in B ritain' brochure.T el:.A nticipated date of tra ve l:-.Month .-Y e a r PTJRSA Post to: Corinth Medical, 5 Theobald Court, Theobald Street Borehamwood, Hertfordshire WD6 4RN.ENGLAND Tel: 09 44 181 207 0234 Fax: 09 44 181 207 6894 THE PROFESSIONAL STAFFING AGENCY SA J o u rn a l P h y s io th e ra p y , V o l 5 2 N o I F e b ru a ry 1996 P a g e 23 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2013.) after a study o f 425 cases o f end-result idiopathic scoliosis, that exercise should be avoided.This study found that approximately 60% of the patients treated w ith exercises had an increase in the deform ity, and 40% had no change.Recent work done by Stone et al (1979), has included a ninemonth exercise therapy program m e for 99 subjects w ith scoliosis and also reported poor results.How ever, the results o f this study showed the extent to which, under the optim al conditions out lined, therapeutic exercises were capable of correcting functional scoliosis and a significant change in both body position and spinal functionality w as show n after 20 weeks of treatment.The data revealed post-treatm ent values that suggested that som e positive changes had taken place due to the therapeutic programme.It appears that in cases of lateral symmetries, young children have high potential for balancing the trunk m uscles if the exercise intensity is well regulated and monitored.This should encourage clinicians to consider using exercise therapy as an important treatm ent for functional scoliosis.Extrem e care w as taken in the present study to control testing procedures and the conduct of the treatment program m e itself.It is admissible, w here other outcom es are the focus, to be less rigorous w ith respect to the treatment itself.Thus Stone et al (1979), had subjects perform an active exercise program m e at hom e with no supervision, as opposed to the individual attention given to each subject in the present study.However, it is the author's opinion that w ithout individual supervision, no valid inform ation on the effect o f exercise program m es on functional scoliosis can be achieved.T h e in fo r m a tio n p r e s e n te d h e r e is a n a tte m p t to s h o w th e r e s p o n s e s o f th e fu n c tio n a l s c o lio tic s p in e to a n in d iv id u a lis e d a n d c lo s e ly s u p e r v is e d e x e r c is e p r o g r a m m e .T h is k n o w le d g e m a y p r o v id e a u s e fu l b a s is fo r b e tte r u n d e r s ta n d in g a n d m a n a g e m e n t o f f u n c tio n a l s c o lio s is , a n d m ig h t s h e d a d d itio n a l lig h t o n th e e ffe c tiv e n e s s o f e x e r c is e th e r a p y in th e tr e a tm e n t o f th is p ro b le m .

TABLE 1 :
Effects of programme on acromioal angle asymmetry

TABLE II :
X-ray results pre/post-treatm enl curves (Cob ) angles) Reproduced by Sabinet Gateway under licence granted by the Publisher(dated 2013.)