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- Dufvenberg, Marlene, 1961-
(author)
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Adolescent Idiopathic Scoliosis : Postural Stability, Prognostic factors and Impact of Conservative Treatments on Radiologic, Clinical and Self-Reported Outcomes
- 2024
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Doctoral thesis (other academic/artistic)abstract
- Background: Adolescent idiopathic scoliosis (AIS) is a three-dimensional distortion of spinal curvature of unknown cause that develops during puberty. If the frontal plane curvature exceeds a Cobb angle of 24°, full-time bracing is recommended to prevent curve progression, negative health consequences or need for surgery. However, many patients decline full-time bracing, and limited evidence exists regarding alternative conservative treatments. Increasing knowledge of risk factors enables better identification of high-risk patients, thereby reducing the risk of over- or undertreatment. The overall aim of this thesis was to evaluate evidence of association between scoliosis and postural stability to inform a potential treatment target, to investigate the effectiveness of three alternative conservative treatments for patients who declined full-time bracing, and to develop a prognostic model for future risk of increased curvature in AIS. Methods: Data collection is based on one systematic literature review and meta-analysis, and one randomised controlled trial (RCT) for patients with AIS. In Paper I, literature was reviewed, and utilized posturography data to assess static postural stability to identify potential differences between patients with AIS and the control group (CON). In Papers II and III, patients were randomly assigned to either physical activity combined with hypercorrective Boston scoliosis night brace (NB), scoliosis-specific exercises (SSE), or a control group with physical activity alone (PA). Effects on trunk rotation, Cobb angle, self-reported physical activity, spinal appearance, and health-related quality of life were evaluated. Likewise, adherence, capability, and motivation in performing self-managed treatment were assessed. Follow-up was conducted at 6 months intervals until endpoint. The endpoint was defined as non-progression if the curvature increased by 6° or less at skeletal maturity, i.e., less than 1cm of growth over 6 months, or progression if the curvature increased by more than 6° before skeletal maturity. In Paper IV, data from the RCT were used for a longitudinal cohort analysis, developing and validating a prognostic model using Cox Proportional Hazards survival analysis. Results: Paper I found reduced postural stability in AIS patients compared to CON with increased sway area, mediolateral and anteroposterior range, and a posterior shift in the sagittal plane. The RCT included 135 individuals, mean age of 12.7 years (SD1.4) and Cobb angle of 31° (SD5.3). At 6 months, patients reported high adherence (72-95%) and motivation (65-92%) to the treatment, particularly in the NB group. Both the SSE and PA groups increased physical activity levels compared to the NB group. At endpoint, adherence remained adequate, but better in the NB and PA groups compared with the SSE group (50-89%). Adherence increased with higher capability and motivation, which explained 53% of the variance in adherence at endpoint. The SSE group had higher proportion of moderate problems in mobility and usual activities than the NB and PA groups, with no other clinically relevant between-group differences. The prognostic model (n=127) for curve progression showed acceptable discriminative ability (0.791), with risk factors including skeletal immaturity, larger major curve, and worsening spinal appearance. The model was adjusted for treatment exposure, as NB reduced the risk of curve progression. Conclusions: Patients with AIS have decreased postural stability with a posterior positional shift. Treatment evaluation at endpoint showed few between-group differences. However, the SSE group had higher proportion of moderate problems in mobility and usual activities compared to the other groups. Treatment adherence was adequate, but better in the NB and PA groups. Higher capability and motivation increased long-term adherence to the treatment. The treatment alternatives could be considered as the first option following a clinical decision on treatment. Including self-reported spinal appearance as a risk factor in the prognostic model may be clinically important for predicting which patients are at risk of curve progression.
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| 2. |
- Lindbäck, Yvonne, 1967-
(author)
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Pre-surgery physiotherapy and pain thresholds in patients with degenerative lumbar spine disorders
- 2018
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Doctoral thesis (other academic/artistic)abstract
- Background: Patients scheduled for spinal surgery often experience long duration of pain, which may influence the pain-regulation system, function and health and have an impact on post-surgery outcome. Prehabilitation potentially augments functional capacity before surgery, which may have beneficial effects after surgery.Aim: The overall aim of the thesis is to study pre-surgery physiotherapy and somatosensory function in patients with degenerative lumbar spine disorders and to explore the patients’ experiences of pre-surgery physiotherapy.Methods: Somatosensory function was measured with quantitative sensory testing (QST). Pre-surgery physiotherapy was evaluated with patient-reported outcome measures (n = 197). Patients’ experiences of how symptoms are explained and their experiences of the influences on back-related health after pre-surgery physiotherapy were explored.Results: Half of the patients reported back or leg pain for more than 2 years. On a group level, the somatosensory profiles were within the reference range. On an individual level, an altered somatosensory profile was found in 23/105 patients, these were older, more often women, and reported higher pain, larger pain distribution and worse SF-36 MCS (mental health component summary). Patients with disc herniation, more sensitive to pressure pain in the hand presurgery, was associated with poorer function, self-efficacy, anxiety and depression score pre-surgery, worse function, self-efficacy and leg pain 3 months post-surgery and worse health related quality of life, self-efficacy, depression score 1 year postsurgery. The results for sensitivity for cold pain were similar, except that it even was associated with poorer function and pain 1 year post-surgery. The pre-surgery physiotherapy group had less back pain, better function, health, self-efficacy, fear avoidance score, depression score and physical activity level than the waiting-list group after the pre-surgery intervention. The effects were small. Both groups improved significantly after surgery, with no differences between groups, except that the higher physical activity level in the physiotherapy group remained at the 1-year follow-up. Only 58% of the patients reported a minimum of one visit for rehabilitation during the 1 year preceding the decision to undergo surgery. Patients experienced that pre-surgery physiotherapy had influenced symptoms, physical function, coping, well-being and social functioning to various degrees. Pre-surgery physiotherapy was experienced as a tool for reassurance and an opportunity to reflect about treatment and lifestyle. The patients mainly used biomedical explanatory models based on image reports to explain their backrelated symptoms. Both broader and more narrow, as well as lack of explanations of symptoms emerged. Further, wanting and sometimes struggling to be wellinformed about symptoms and interventions were described.Conclusions: Being more sensitive to pressure- and cold pain in the hand, as a sign of widespread pain pre-surgery, was associated with poorer function, pain and health at post-surgery in patients with disc herniation. Pre-surgery physiotherapy decreased pain, fear avoidance, improved health related quality of life; and it decreased the risk of a worsening in psychological well-being before surgery. The improvements were small, and improvements after surgery were similar for both groups. At the 1-year follow-up, the physiotherapy group still had a higher activity level than the waiting list group. The pre-surgery physiotherapy was well tolerated. Patients’ reported experiences also illustrates the influence on function, pain and health. Patients experienced that pre-surgery physiotherapy provided reassurance and gave time to reflect on treatments and lifestyle. Symptoms were mainly described in line with a biomedical explanatory model. Those using a broader explanation were confident that physiotherapy and self-management could influence their back-related symptoms.
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| 3. |
- Vavruch, Ludvig
(author)
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Adolescent Idiopathic Scoliosis : A Deformity in Three Dimensions
- 2018
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Doctoral thesis (other academic/artistic)abstract
- Scoliosis is a complex three-dimensional deformity of the spine. Even though it has been known for centuries, treatment of the deformity has focused on correcting only in the frontal plane. In the last decades, the need for three-dimensional assessment regarding scoliosis has been highlighted to better understand the cause and the principles of treating scoliosis. The overall aim of this dissertation is to provide knowledge to assess scoliosis as a three-dimensional problem.The severity of scoliosis is measured with the Cobb angle from standing radiographs. Computed tomography (CT) examinations are used throughout this thesis. The first paper investigates the difference in Cobb angle measured from standing radiographs and supine CT examinations. The standing radiographs had larger Cobb angles with a mean difference of 11° and a linear correlation between the two examinations from 128 consecutive patients with adolescent idiopathic scoliosis (AIS) planned for surgery.The second paper compares the axial shape of vertebrae in 20 patients with AIS with a reference group. Clear asymmetry was observed in all vertebrae – superior and inferior end vertebrae as well as the apical vertebra – compared with corresponding vertebrae among the reference group. The asymmetry was most pronounced in the apical vertebra. A novel parameter, frontal vertebral body rotation (FVBR), was introduced to describe the internal rotation of the vertebrae in the axial plane.Pelvic incidence (PI) is a measurement of the position of the sacrum in relation to the femoral heads. This is relevant in scoliosis because PI determines the pelvic configuration acting as a foundation to the spine. PI has traditionally been measured from standing radiographs. The third study investigates PI three-dimensionally, based on low-dose CT examinations, in 37 patients with Lenke type 1 or 5 curves compared with a reference group. A significantly higher PI was observed in patients with Lenke type 5 curves compared with the reference group and patients with Lenke type 1 curves.Severe AIS is treated with corrective surgery. Two approaches are available: the predominant posterior approach and the anterior approach. In the fourth paper, these two approaches are evaluated with regard to three-dimensional correction, how well the correction is maintained over a 2-year follow-up and patient-reported outcome measures. Twenty-seven patients treated with the posterior approach and 26 patients treated with the anterior approach, all with Lenke type 1 curves, were included. Fewer vertebrae were fused in the anterior group, but the posterior group had a better correction of the deformity in the frontal plane. No difference was observed regarding three-dimensional correction and patient-reported outcome measures.AIS is truly a complex three-dimensional deformity. More research is needed to fully comprehend the complexity of the scoliotic spine.
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