Effect of Physiotherapy On Spinal Alignment
Effect of Physiotherapy On Spinal Alignment
Effect of Physiotherapy On Spinal Alignment
EFFECT OF PHYSIOTHERAPY
ON SPINAL ALIGNMENT
IN CHILDREN WITH POSTURAL DEFECTS
ANNA ZMYŚLNA1,2, WOJCIECH KIEBZAK1,2, ARKADIUSZ ŻURAWSKI1,2, JUSTYNA POGORZELSKA1,2,
IRENEUSZ KOTELA1, TOMASZ J. KOWALSKI3, ZBIGNIEW ŚLIWIŃSKI1,4, and GRZEGORZ ŚLIWIŃSKI5
1
Jan Kochanowski University, Kielce, Poland
Faculty of Medicine and Health Sciences, Institute of Physiotherapy
2
Provincial Integrated Hospital in Kielce, Kielce, Poland
Świętokrzyskie Center for Pediatrics
3
Wye Valley Foundation Trust, Hereford, United Kingdom
Department of Orthopaedic Surgery, Hereford County Hospital
4
Rehabilitation Centre, Zgorzelec, Poland
5
Technical University in Dresden, Dresden, Germany
Faculty of Electrical and Computer Engineering, Institute of Biomedical Engineering
Abstract
Objectives: This paper assesses the effect of neurophysiological rehabilitation in children with postural defects on the depth of thoracic kyphosis, lateral
spinal deviation and rotation of spinal motor segments. Material and Methods: A total of 201 patients aged 8–15 years old with a postural defect diag-
nosed by medical examination were enrolled. The analyzed parameters were determined using the DIERS system before the first therapeutic session
and after 4 weeks of therapy. The angle of thoracic kyphosis, lateral deviation of the spine and spinal rotation were assessed. The therapy employed
techniques associated with the proprioceptive neuromuscular facilitation (PNF) and Vojta’s approaches. The results were analyzed separately for both
sexes and for patients rehabilitated solely with Vojta’s techniques vs. patients rehabilitated according to combined Vojta’s and PNF techniques. The
χ2 test was used for statistical analyses, at p < 0.05. Results: There was improvement in the angle of thoracic kyphosis, ranging from 0.14 (among boys
with kyphosis < 42°) to 5.47 (among girls with kyphosis ≥ 42°), spinal rotation, from 0.37 (among boys with kyphosis ≥ 42°) to 4.33 (among patients
with kyphosis ≥ 42° rehabilitated solely according to Vojta’s method), and lateral deviations, ranging from 1.32 mm (among boys with kyphosis < 42°)
to 2.99 mm (among patients with kyphosis ≥ 42° rehabilitated solely according to Vojta’s method). Conclusions: Neurophysiological rehabilitation of
patients with postural defects produced positive effects by improving the angle of thoracic kyphosis, spinal rotation and lateral deviation of the spine.
Children with reduced thoracic kyphosis achieved less improvement in the kyphosis angle, lateral spinal deviation and spinal rotation than children with
kyphosis ≥ 42°. The DIERS Formetric System enables precise monitoring of therapeutic outcomes. Int J Occup Med Environ Health. 2019;32(1):25–32
Key words:
postural defects, PNF, Vojta, DIERS, physiotherapy, rehabilitation
26 IJOMEH 2019;32(1)
MUSCULOSKELETAL DISEASES ORIGINAL PAPER
IJOMEH 2019;32(1) 27
28
Table 1. Rehabilitation outcomes by depth of kyphosis among patients rehabilitated according to a combination of Vojta’s and PNF techniques and according to Vojta’s
approach at the Division of Physiotherapy, Świętokrzyskie Center for Pediatrics in Kielce, Poland
Depth of kyphosis
IJOMEH 2019;32(1)
[°]
(M±SD)
ORIGINAL PAPER
Spinal rotation 5.59±3.79 4.41±2.21 5.55±2.74 3.7±1.56 6.29±3.69 4.85±2.54 7.65±1.87 3.32±2.41
Lateral deviation 5.78±3.24 4±2.91 6±3.17 3.87±2.46 7.25±5.69 4.85±2.54 6.31±3.62 3.32±2.51
Table 2. Rehabilitation outcomes by depth of kyphosis among boys and girls rehabilitated according to Vojta’s approach and a combination of Vojta’s and PNF
techniques at the Division of Physiotherapy, Świętokrzyskie Center for Pediatrics in Kielce, Poland
Depth of kyphosis
[°]
(M±SD)
boys girls
Parameter [N = 103] [N = 98]
kyphosis < 42° kyphosis ≥ 42° kyphosis < 42° kyphosis ≥ 42°
[N = 69] [N = 34] [N = 55] [N = 43]
examination 1 examination 2 examination 1 examination 2 examination 1 examination 2 examination 1 examination 2
Angle of thoracic kyphosis 33.32±6.73 33.46±7.11 47.01±4.73 42.55±10.07 31.79±6.52 33.53±9.08 48.99±5.19 43.52±7.54
Spinal rotation 5.22±3.39 4.63±2.37 4.38±1.96 4.01±2.32 5.19±3.02 4.79±2.53 5.59±2.81 4.92±2.24
Lateral deviation 6.17±4.29 4.85±2.54 7.11±6.34 5.67±4.17 6.17±4.29 4.85±2.54 7.39±4.87 5.92±4.24
MUSCULOSKELETAL DISEASES ORIGINAL PAPER
by 2.13 mm among patients with kyphosis ≥ 42° (p < 0.05). of reduction of the natural curvatures of the spine, are be-
The patients rehabilitated only according to the Vojta’s ing observed more and more frequently among children.
approach demonstrated improvement in the angle of tho- Such abnormal postural patterns lead to disorders associ-
racic kyphosis amounting to 0.76 (p < 0.05) among pa- ated with non-physiological loading of the spine and spi-
tients with kyphosis < 42° and 4.02 (p < 0.05) among pa- nal joints. The dorsum with attenuated curvatures is more
tients with kyphosis ≥ 42°. Both subgroups demonstrated prone to developing abnormal curvatures in the frontal
a reduction in vertebral rotation: of 1.44 among patients plane. Early detection of postural defects could contribute
with kyphosis < 42° (p < 0.05) and 4.33 among patients to effective prevention and treatment. It is extremely dif-
with kyphosis of ≥ 42° (p < 0.05). Lateral deviation of the ficult to obtain an effective and objective attitude assess-
spine was reduced by 2.4 mm among patients with kypho- ment both for diagnostic purposes and for monitoring the
sis < 42° (p < 0.05) and by 2.99 mm among patients with rehabilitation process [10].
kyphosis ≥ 42° (p < 0.05). The research regarding the causes of abnormal postures
Boys demonstrated improvement in the angle of thoracic among children has been conducted for many years, but an
kyphosis amounting to 0.14 (p > 0.05) among patients unambiguous explanation is yet to be provided. Children
with kyphosis < 42° and 4.46 (p < 0.05) among patients with scoliosis have been found to demonstrate more pro-
with kyphosis ≥ 42°(Table 2). Both subgroups demon- nounced problems with body balance, reduced response
strated a reduction in vertebral rotation: of 0.59 among to stimuli and prolonged baseline position recovery time.
patients with kyphosis < 42° (p < 0.05) and 0.37 among Abnormal lateral spinal curvatures are particularly dan-
patients with kyphosis ≥ 42° (p > 0.05). Lateral devia- gerous among postural defects; hence, the importance of
tion of the spine was reduced by 1.32 mm among patients early diagnosis [3].
with kyphosis < 42° (p > 0.05) and by 1.44 mm among The DIERS Formetric system is a non-invasive and ob-
patients with kyphosis ≥ 42° (p < 0.05). Girls demon- jective imaging technique that may be used for assessing
strated improvement in the angle of thoracic kyphosis body posture. Both static and dynamic postural imaging
amounting to 1.74 (p < 0.05) among patients with ky- may be performed and it may also be used for assessing
phosis < 42° and 5.47 (p < 0.05) among patients with treatment outcomes. The DIERS system was chosen for
kyphosis ≥ 42°. Both subgroups demonstrated a reduc- this study also in view of the short duration of the exami-
tion in vertebral rotation: of 0.4 among patients with nation, low cost and the possibility of an unlimited number
kyphosis < 42° (p < 0.05) and 0.67 among patients with of repetitions [11].
kyphosis ≥ 42° (p < 0.05). Lateral deviation of the spine According to the 2016 study, the DIERS Formetric 4D
was reduced by 1.32 mm among patients with kypho- system allows for objective assessment of the outcomes of
sis < 42° (p < 0.05) and by 1.47 mm among patients with on-going rehabilitation for patients with scoliosis [11].
kyphosis ≥ 42° (p < 0.05). The determination of a normal range for the angle of
thoracic kyphosis has been a problem for researchers for
DISCUSSION years. The Scoliosis Research Society has defined this
With the development of civilization, the level of physical range in the developing adolescent as 20–40° [12–14].
activity among children has decreased, eating habits have In a study of 316 healthy individuals aged 2–27 years
changed and, most importantly, a sedentary life-style has old, Wenger and Frick [14] found that the upper limit of
become dominant. Postural disorders, mostly in the form the normal range for thoracic kyphosis was 45. It was noted
IJOMEH 2019;32(1) 29
ORIGINAL PAPER A. ZMYŚLNA ET AL.
that average kyphosis increased with age, from 20 in child- and PNF), which resulted in improvement in the body axis
hood to 25 among teenagers to 40 in adults [14]. in all 3 planes. Similar results have also been obtained by
For the purposes of our study, the limit of the physiologi- other researchers utilizing these methods, which indicates
cal range of thoracic kyphosis was assumed at 42° in accor- that they are useful in the treatment of individuals with
dance with the protocol of the DIERS-based examination postural defects [23].
and guidelines [16]. Statistically significant improvement in the body axis was
The lack of consistent definition of kyphosis in literature obtained in both groups investigated, which leads to the
makes it difficult to compare different studies since the conclusion that the customization of therapy for individu-
inclusion criteria may vary, making it virtually impossible al patients and patient education are more important for
to distinguish the upper normal range of normal kyphosis a positive therapeutic outcome than the specific method
and severe juvenile deformity [17]. employed [24].
The problem of pronounced thoracic kyphosis merits fur-
ther studies because a sedentary life-style contributes to CONCLUSIONS
loss of the lumbar lordosis, further accentuation of kypho- Neurophysiological rehabilitation of patients with postur-
sis and an increase in the prevalence of postural defects in al defects produced positive effects by improving the angle
young people [18]. of thoracic kyphosis, spinal rotation and lateral deviation
As it has been demonstrated, restoration of physiologi- of the spine.
cal lumbar lordosis and thoracic kyphosis stabilizes the Children with reduced thoracic kyphosis achieved less im-
spine with regard to lateral deformity by improving spinal provement in the kyphosis angle, lateral spinal deviation
alignment in the frontal plane. This is confirmed by the and spinal rotation than children with kyphosis ≥ 42°.
research presented in this article [19]. The DIERS Formetric System enables precise monitoring
Sagittal spinal misalignment is also a significant contribu- of therapeutic outcomes.
tor to pain, which is often chronic [20,21].
According to the Society on Scoliosis Orthopedic and Re- REFERENCES
habilitation Treatment (SOSORT), postural control is the 1. Rosa K, Muszkieta R, Zukow W, Napierała M, Cieślicka M.
most important determinant of body axis improvement. [The incidence of defects posture in children from classes
Members of the SOSORT also consider that therapy must I to III elementary school]. J Health Sci. 2013;3(12):107–36.
necessarily include elements of elongation and proprio- Polish.
ceptive stimulation. The beneficial effect on therapy of 2. Janiszewska R, Tuzinek S, Nowak S, Ratyńska A, Biniasze-
exercise tasks that may be easily performed in the home wski T. [Abnormalities of posture in 6–12 year-old children –
setting is also underlined. Patients should perform such Pupils of primary schools from Radom – A pilot study]. Probl
exercises on their own for approximately 20 min/day. Hig Epidemiol. 2009;90(3):342–6. Polish.
These recommendations were reflected in our choice of 3. Perriman DM, Scarvell JM, Hughes AR, Lueck CJ, Dear KB,
the methods of treatment in the experimental group, and Smith PN. Thoracic hyperkyphosis: A survey of Australian
they produce a positive effect in therapy [22]. physiotherapists. Physiother Res Int. 2012;17(3):167–78,
The choice of the therapeutic approach is of key impor- https://doi.org/10.1002/pri.529.
tance for the final outcome. For this study, we used a com- 4. Górecki A, Kiwerski J, Kowalski J, Marczyński W, Nowotny J,
bination of neurophysiological approaches (Vojta’s one Rybicka M. [Prophylactics of postural deformities in children and
30 IJOMEH 2019;32(1)
MUSCULOSKELETAL DISEASES ORIGINAL PAPER
youth carried out within the teaching environment – Experts 15. Weiss HR, Turnbull D, Bohr S. Brace treatment for pa-
recommendations]. Pol Ann Med. 2009;16(1):168–77. Polish. tients with Scheuermann’s disease – A review of the litera-
5. Wilczyński J. [The most common faulty postures among boys ture and first experiences with a new brace design. Scolio-
aged 13–16 years measured by moiré’s photogrammetric sis. 2009;4:22, https://doi.org/10.1186/1748-7161-4-22.
method]. Med Pr. 2006;57(4):347–52. Polish. 16. Harzmann HCh. The value of the video scanning stereogram
6. Maciałczyk-Paprocka K, Krzyżaniak A, Kotwicki T, Kałuż- as a screening method of scoliosis and structural scoliosis
ny Ł, Przybylski J. [The body posture of preschool children]. [dissertation]. München: Ludwig-Maximilians-University,
Probl Hig Epidemiol. 2011;92(2):286–90. Polish. Faculty of Medicine; 2000.
7. Maciałczyk-Paprocka K, Krzyżaniak A, Kotwicki T, Sowiń- 17. Weiss HR, Werkmann M. Treatment of chronic low back pain
ska A, Stawińska-Witoszyńska B, Krzywińska-Wiewiorow- in patients with spinal deformities using a sagittal re-align-
ska M, et al. [Postural defects in primary school students in ment brace. Scoliosis. 2009;4:7, https://doi.org/10.1186/1748-
Poznań]. Probl Hig Epidemiol. 2012;93(2):309–14. Polish. 7161-4-7.
8. Paprocki M, Rychter P, Wilczyński J. [Accuracy of the opto- 18. Van Loon PJ, Kühbauch BA, Thunnissen FB. Forced lordo-
electronic test body posture Formetric Diers Method III 4D sis on the thoracolumbar junction can correct coronal plane
in comparison with the result of the X-ray pictures]. J Edu deformity in adolescents with double major curve pattern
Health Sport. 2016;6(4):385–98, https://doi.org/10.5281/ze- idiopathic scoliosis. Spine. 2008;33(7):797–801, https://doi.
nodo.50535. Polish. org/10.1097/BRS.0b013e3181694ff5.
9. Massimiliano M, Raimondi P, Paoloni M, Pellanera S, Di Mi- 19. Weiss HR, Werkmann M. Unspecific chronic low back pain –
chele A, Di Renzo S, et al. Vertebral rotation in adolescent A simple functional classification tested in a case series of
idiopathic scoliosis calculated by radiograph and back sur- patients with spinal deformities. Scoliosis. 2009;4:4, https://
face analysis-based methods: Correlation between the Rai- doi.org/10.1186/1748-7161-4-4.
mondi method and rasterstereography. Eur Spine J. 2013; 20. Weiss HR, Turnbull D. Physical and technical rehabilita-
22(2):367–71, https://doi.org/10.1007/s00586-012-2564-9. tion of patients with Scheuermann’s disease and kyphosis.
10. Tribus CB. Scheuermann’s kyphosis in adolescents and In: Stone JH, Blouin M, editors. International encyclo-
adults: Diagnosis and management. J Am Acad Orthop pedia of rehabilitation [Internet]. Buffalo: CIRRIE; 2010
Surg. 1998;6(1):36–43, https://doi.org/10.5435/00124635-199 [cited 2017 Nov 19]. Available from: https://gradebuddy.
801000-00004. com/doc/260544/physical-and-technical-rehabilitation-of-
11. Książek-Czekaj A, Wiecheć M, Śliwiński G, Śliwiński Z. patients-with-scheuermanns-disease-and-kyphosis.
Monitoring of scoliosis improvement results using the DI- 21. De Mauroy J, Weiss H, Aulisa A, Aulisa L, Brox J, Dur-
ERS system. Fizjoter Pol. 2016;16(3):124–34. mala J, et al. 7th SOSORT consensus paper: Conservative
12. Wenger DR. Roundback. The art and practice of children’s treatment of idiopathic and Scheuermann’s kyphosis. Sco-
orthopaedics. New York: Raven Press, Ltd; 1993. p. 422–54. liosis Spinal Disord. 2010;5:9, https://doi.org/10.1186/1748-
13. Lowe TG. Scheuermann disease. J Bone Joint Surg Am. 7161-5-9.
1990;72(6):940–5, https://doi.org/10.2106/00004623-199072 22. Lee BK. Influence of the proprioceptive neuromuscular fa-
060-00026. cilitation exercise programs on idiopathic scoliosis patient in
14. Wenger DR, Frick SL. Scheuermann kyphosis. Spine. the early 20s in terms of curves and balancing abilities: Sin-
1999;24(24):2630–9, https://doi.org/10.1097/00007632-19991 gle case study. J Exerc Rehabil. 2016;12(6):567–74, https://
2150-00010. doi.org/10.12965/jer.1632796.398.
IJOMEH 2019;32(1) 31
ORIGINAL PAPER A. ZMYŚLNA ET AL.
23. Steffan K. [Physical therapy for idiopathic scoliosis]. Or- exercises – A comprehensive review of 7 major schools.
thopade. 2015;44(11):852–8, https://doi.org/10.1007/s00132- Scoliosis Spinal Disord. 2016;11:20, https://doi.org/10.1186/
015-3174-0. German. s13013-016-0076-9.
24. Berdishevsky H, Lebel VA, Bettany-Saltikov J, Rigo M,
Lebel A, Hennes A, et al. Physiotherapy scoliosis-specific
This work is available in Open Access model and licensed under a Creative Commons Attribution-NonCommercial 3.0 Poland License – http://creativecommons.org/
licenses/by-nc/3.0/pl/deed.en.
32 IJOMEH 2019;32(1)