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Scheuermann's Disease: Juvenille Kyphosis treatment approaches

Pain, General | June 25, 2014 | Author: The Super Pharmacist

Children, spine

Scheuermann's Disease: Juvenille Kyphosis treatment approaches

Scheuermann's disease, also called juvenile kyphosis, is a deformity in the spine that causes three or more of the vertebra to bow outward. In fact, the term kyphosis describes a condition in which the spine is not straight, but the upper body instead leans forward (the opposite of lordosis, where the curve of the spine is in the other direction). Scheuermann's disease is sometimes painful. If the disease affects the thoracic spine, about one in five children will experience pain in the affected vertebra. However, 4 out of 5 children with the disease in the lumbar spine will experience pain. In those that do experience pain, it usually gets worse with activity and improves with rest.

Strengthening and Stretching Exercises

Exercises can be helpful in Scheuermann's disease when the degree of spinal curvature is not too severe. Physicians have ways of determining whether strengthening and stretching exercises are likely to be of any use in treating Scheuermann's disease. In technical terms, if the kyphosis Cobb angles are less than 40 to 60° then exercises may be of some use. More severe kyphosis likely requires some sort of brace.

Note that the use of exercises is not always effective for Scheuermann's disease and even their use is somewhat controversial among healthcare professionals.

Stretching Exercises

shutterstock_69607726Since there is some debate among experts about what causes juvenile kyphosis, the exercises that are prescribed vary somewhat. Many believe that the muscles around the affected area of the spine become pathologically shortened. Therefore, the belief is that stretching exercises that link in these paraspinal muscles can improve movement and perhaps reduce activity-dependent pain.

One of the main stretching exercises for Scheuermann's disease is to try to elongate the spine. 

The adolescent lies on his back and places a firm but comfortable support under the affected area of the spine. The patient then extends his legs and raises his arms above his head, placing slow and steady pressure on the muscles of the spine. Since the patient will only be able to achieve a modest amount of elongation, a trusted assistant can put additional downward pressure on the patient's shoulders to further stretch the spinal muscles. As with any muscle stretching exercise, the goal is not to strain a muscle or pulse but rather to slowly lengthen the muscle fibers. There should be a pulling sensation, but pain indicates that the stretching is too aggressive. Hamstring stretching exercises may also be helpful. Almost all professionals recommend patients pay particular attention to posture when sitting and standing. Even if it is slightly uncomfortable, people with Scheuermann's disease should try to maintain straightness of the spine when possible.

Strengthening Exercises

The main strengthening exercise for Scheuermann's disease is similar to a lunge. The weight of the body is pressed forward onto one bended knee while the opposite leg is kept mostly straight. The patient should keep their chin up and their spine as straight as possible during the move. Unlike a lunge, there is not a need to deeply bend the knee. Some professionals also recommend exercises to strengthen the abdominal muscles.

Bracing

Patients tend to reject or resist the use of braces because of the way they look and the fact that the disease strikes children in early adolescence when physical appearance is especially important. However, unlike in scoliosis, the use of braces can be very effective in the treatment of Scheuermann's disease, especially if the kyphosis is detected early.

Despite their effectiveness, most physicians tend to use back braces in children who have moderate to severe disease. There are various types of braces for juvenile kyphosis with names like the Milwaukee brace, the Boston brace, the Lyon brace, the Maguelone brace, and the Lapadula-Sibilla brace. The most commonly used brace for juvenile kyphosis is the Milwaukee brace. It is a rigid structure that is affixed to the back of the patient with pads that press on the lower and upper back. The brace puts constant pressure on the spine, 23 hours per day, to straighten it over time. The tightness of the brace is adjusted once a month as the muscles, bones, and ligaments adjust in the back. Most children and young adults will wear the brace for one to two years. The Boston brace is almost like a tall cummerbund that so well the entire lower torso. The idea behind the Boston brace is to strain the lower back, which will hopefully straighten the upper back as well. There is evidence to suggest that the Boston brace is effective.The Lyon, Maguelone, and Lapadula-Sibilla braces are somewhat larger and work by slightly different mechanisms. Evidence from small clinical trials have shown that each brace can be effective; however, no single brace is considered superior to the others at this point.

Surgery

Surgery is almost never indicated in the treatment of Scheuermann's disease. It is reserved for patients who have very severe kyphosis. Very severe disease would be situations such as bending of the spine that is greater than 75°, a curvature that is getting progressively worse, severe pain that cannot be treated with nonsteroidal anti-inflammatory drugs, or the patient is experiencing some sort of neurological problem, such as tingling or pain in the legs. The primary surgery for Scheuermann's disease if spinal fusion. In spinal fusion surgery, the ligaments that are holding the vertebra together at diseased area are cut (anterior release). This allows the vertebra to move more freely so that the spine can be straightened. At the same time, the individual vertebra are connected to one another by a metal plate (posterior instrumentation) that runs up the back of the spine. If a vertebra has been crushed, the surgeon may inject a sort of cement or epoxy to reconstruct the damaged area. If two or more vertebra have been fused together, it may be necessary to remove the abnormal vertebral body.

Patients with Scheuermann's disease who are contemplating surgery should be aware that even though the surgery is usually successful, the results are not always as expected. People with greater than 70° of curvature are usually less likely to be fully satisfied with the result. In addition, the recovery from juvenile kyphosis surgery can be extensive and prolonged.

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References

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Negrini S, Aulisa L, Ferraro C, et al. Italian guidelines on rehabilitation treatment of adolescents with scoliosis or other spinal deformities. Eura Medicophys. Jun 2005;41(2):183-201.

Zaina F, Atanasio S, Ferraro C, et al. Review of rehabilitation and orthopedic conservative approach to sagittal plane diseases during growth: hyperkyphosis, junctional kyphosis, and Scheuermann disease. Eur J Phys Rehabil Med. Dec 2009;45(4):595-603.

Lowe TG. Scheuermann's disease. Orthop Clin North Am. Jul 1999;30(3):475-487, ix.

Gutowski WT, Renshaw TS. Orthotic results in adolescent kyphosis. Spine (Phila Pa 1976). May 1988;13(5):485-489.

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