PT Critically Appraised Topics

Document Type

Critically Appraised Topic

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Clinical Scenario

There are two patients who lead me to pursue this clinical question. Both were adolescent females, one was 13 years old and the other 15 years old with a diagnosis of moderate Adolescent Idiopathic Scoliosis (AIS). Both were referred to physical therapy for back pain. Medical treatment included general lumbar and thoracic stabilization exercises, stretches of concave areas, a home exercise program, and patient education on posture. Both patients were non-athletic and were not compliant with their home exercise program. Neither patient returned to physical therapy after their third appointment.

Clinical Question

Does the use of modalities or specific exercises as compared to the standard treatment of general back strengthening and stretching reduce and prevent reoccurrence of back pain, and/or reduce the Cobb angle of the patient?

Clinical Bottom Line

Based on the results from the two studies by Diab and Zakaria et al., scoliosis-specific stretches and exercises can be considered a low-cost and effective treatment intervention for AIS when comparing these to mechanical traction and forward head posture correction. Zakaria et al. compared the effects of scoliosis-specific stretches to general low back mechanical traction in 40 female adolescents with AIS and found that the scoliosis-specific stretch group had significant improvements in pain (as measured by the Visual analog scale (VAS)) and in Cobb’s angle after performing four scoliosis-specific exercises three times per week for three months. The scoliosis-specific stretching group demonstrated a clinically meaningful mean (95% CI) reduction in pain (as measured by VAS scores) of 4.53 (4.01 - 5.04) points and a measurable reduction in Cobb’s angle of 9.15° (7.41 - 10.89). Mechanical traction also produced a clinically meaningful reduction in mean VAS scores with 4.20 (3.70 - 4.70) points within-group mean difference but, did not produce any actual measurable change in Cobb’s angle (2.4°; 0.65 - 4.17). The between-group results showed the scoliosis-specific stretching group had statistically significant improvement compared to the mechanical traction group with a between-group mean difference of 5.95° (95% CI, 4.32 - 7.58) in Cobb’s angle but, neither group outperformed one another with their VAS between-group mean difference of 0.27 (-0.09 - 0.63) points. In addition, I have determined that use of mechanical traction would be more costly and would have a higher risk to administer than using a scoliosis-specific stretching program. Diab’s study consisted of 76 adolescents diagnosed with AIS who were randomized into a scoliosis-specific exercise group (control group) who performed their exercises three times a week for 10 weeks to a group who performed four additional exercises to correct for forward head posture four times a week for 10 weeks. Diab found that the forward head posture group had statistically significant improvements at 10 weeks and three months post-treatment for lateral deviation and statistically significant improvements at three months for the functional rating index (FRI) when compared to the control group. However, Diab did not provide any statistical support to conclude that the scoliosis-specific exercises (control group) or the addition of forward head posture treatment contributed to the reduction of pain or scoliosis severity when analyzing the within and between-group differences at 10 weeks or three months post-treatment. At three months, the forward head posture treatment group’s within-group mean difference was 2.10 (0.94 – 3.26) and the control group within-group mean difference was 0.40 (-.48 – 1.28). I was unable to draw a conclusion from these data due to the absence of unit labeling, no reporting of accuracy for the measurement tool, and lack of minimal clinically important differences (MCID). The FRI scores at the three-month mark showed that the forward head posture group was able to maintain their improvement gained at week 10 (within-group mean difference of 3.90% (3.22 - 4.58), while the control group scores increased to pretreatment (within-group mean difference of 2.30% (1.40 – 3.2)) resulting in a between-group mean difference of 3.8% (3.05 - 4.55) in favor of the forward head posture treatment group. These differences were not enough to meet the FRI MCID of 15% and therefore the improvement would likely not be clinically meaningful. Both studies had fair to good internal validity (Diab PEDro score (7/10), Zakaria et al (6/10)). While Diab had several threats to internal validity especially with the lateral deviation outcome measure, assumptions had to be made regarding internal validity for the Zakaria et al. article, who left out information as to study losses, intention to treat, power analysis, and blinding.

In conclusion, I would not include additional interventions to correct forward head posture in patients with AIS to specifically address reduction of Cobb’s angle or decrease low back pain (LBP) based on the Diab results. However, I would include a scoliosis-specific stretching protocol over manual traction to address the concave curvature of a patient’s spine and decrease pain based on the information presented in the Zakaria et al. study and my own clinical experience and academic training that a scoliosis-specific stretching protocol is more cost-effective and less risky to administer than mechanical traction. I would like to see additional studies performed in the United States or England that compare general back strengthening exercises and stretches to scoliosis-specific exercises and stretches. Studies should be mindful to ensure adequate sample size and use meaningful outcome measures to ensure the data can produce statistically meaningful results.