ebm for manual therapy as a conservative ......ebm for manual therapy as a conservative treatment of...
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EBM FOR MANUAL THERAPY AS A CONSERVATIVE TREATMENT
OF SCOLIOSIS: A NARRATIVE REVIEW
Paris 12 - 14 October 2018
Salvatore Minnella Saveri F, Donzelli S, Asero G, Gourjon A, Zaina F
DISCLOSURE
NO CONFLICT OF INTEREST TO DECLARE
DEFINITION
The name was introduced by Hippocrates: ‘’Scolios’’ (awry or curved)
SCOLIOSIS IS A ‘’ TRIDIMENSIONAL TORSIONAL DEFORMITY
OF SPINE AND TRUNK’’ Grivas et al. 2006
DEFINITION
‘’ TRIDIMENSIONAL TORSIONAL DEFORMITY OF SPINE AND TRUNK’’
• Frontal plane: lateral curvature
• Horizontal plane: axial rotation
• Sagittal plane: alteration of normal curvatures
(kyphosis and lordosis) usually towards a flat back
DEFINITION
NO !
DEFINITION
NOT EXACTLY!
DEFINITION
YES!
EPIDEMIOLOGY
•Prevalence: 2-3% of population •Incidence: F > M ( AIS severe much more frequent in female) from 10° to 20° F : M= 1,3 : 1 from 20° to 30° F : M= 5,4 : 1 when > 30° F : M= 7 : 1
ETIOPATHOGENESIS
BIOMECHANICAL FACTORS WHICH SUPPORT PROGRESSION
• HUETER- VOLKMANN LAW • PREEXISTENT AXIAL ROTATION PATTERN
ETIOPATHOGENESIS
HUETER- VOLKMANN LAW
Epiphysis will grow symmetric with equal pressure on the epiphyseal plates; but if an area go under a greater pressure (concavity) it will not grow so rapidly and completely like the area which instead go under a lighter pressure (convexity)
ETIOPATHOGENESIS
PREEXISTENT AXIAL ROTATION PATTERN • Normal spine is not a symmetrical structure
• There’s an axial rotational pattern which is different in different regions of the spine and at different ages
• Once the spine starts to decompensate into scoliosis
it seems to follow this preexistent rotational pattern • Asimmetric growth and closure of the NCJs occur in
development of pathological rotation of the spine as is known in naturally occuring scoliosis
R.M. Castelein et al. The Spine Journal 2013
ETIOPATHOGENESIS
BIOMECHANICAL POINT OF VIEW
Scoliosis spine is an unstable 3D asimmetric structure
Which needs correction
through stability
The Society on Scoliosis Orthopaedic and
Rehabilitation Treatment
SOSORT
http://guides.mclibrary.duke.edu/c.php?g=158178&p=1035972
PYRAMID OF EVIDENCE
Paolo Sibilla’s theory of gradual approach to scoliosis
PYRAMID OF EVIDENCE
MANUAL THERAPY
• Professionalized at the end of the 19th century as a treatment of spine disorders
• First of all Osteophaty and Chiropratic then in the 20th century the development of Orthopedic Manual Medicine by R. Maigne • Strong uncertainty exist still now on evidence of efficacy of manual therapy as a conservative treatment for scoliosis
AIM OF THE STUDY
To assess the efficacy of Manual Therapy as a conservative treatment
for idiopathic scoliosis from an evidence based point of view
We started with a Systematic Review
Search Strategy • Data sources: pubmed/medline and cochrane
libraries until November 2017
• Mesh terms: ‘scoliosis’, ‘manual therapy’, ‘spinal manipulation’ and ‘muscoloskeletal manipulations’
• Inclusion criteria: systematic reviews, randomized
control trials (RCTs), observational prospective cohort study; age of the subjects between 10 and 18 years old, Risser sign from 0 to 2 at the beginning of treatment
SYSTEMATIC REVIEW
The research was done by two operators specialized in Spine Pathology. They also made the selection of the works, that met
inclusion criteria, among all the titles first and the abstracts in a second step
SYSTEMATIC REVIEW
36 works elegible for abstract reading
NO ONE met the SRS criterion for scoliosis studies of Risser sign 0-2 at the beginning of therapy
TO BE OR NOT TO BE…
We turned into a Narrative review and assessed completely the 8 studies
(all systematic reviews) which met the other
inclusion criteria
SYSTEMATIC REVIEW OCTOBER 2016
• Systematic Reviews, • Treatment with manual therapy, chiropractic, osteopathy • Patients with idiopathic scoliosis
Papers on scoliosis-specific physiotherapy, bracing and scoliosis developing secondary to other conditions were excluded from the analysis
• Scoliosis specific physiotherapy treatment • bracing • Patients with scoliosis secondary to other
conditions
Gotlib A, Rupert R.
1. Assessing the evidence for the use of chiropractic manipulation in pediatric health
conditions – a systematic review. Pediatr Child Health 2005; 10(3): 157-61.
2. Chiropractic manipulation in pediatric
health conditions - an updated systematic review.
Chiropr Osteopat 2008; 16: 11
Aim of the studies: Efficacy of chiropractic manipulation in pediatric diseases Results: • 1731 studies (2005) 1235 studies(2008) • Unchanged studies in 3,5 years • Only one pilot study (Rowe et al 2006)
Conclusion: • Greater scientific rigor needed for assessing efficacy of manipulation in
pediatrics patients • Integration of clinical expertise with scientific research • Use of chiropractic techniques in paediatric conditions supported by weak
scientific evidence
3.Romano M, Negrini S.
Manual therapy as a conservative treatment for adolescent idiopathic
scoliosis.
Scoliosis 2008; 3: 2.
Aim of the study: • Efficacy of manual therapy (manipulation e
mobilization)
Results: • 145 studies • No one being a controlled one Conclusions: The gap of scientific results does not permit to draw any conclusion on the efficacy of manual therapy as a treatment of adolescent idiopathic scoliosis
4. Gleberzon BJ, Arts J, Mei A, McManus EL.
The use of spinal manipulative therapy
for pediatric health conditions: a systematic review of the literature.
J Can Chiropr Assoc 2012; 56: 128-41.
Aim of the study: • Efficacy of chiroprcatic manipulation in pediatric
diseases
Results: • 16 papers included about chiropractic or HVLA
manipulations • Only one pilot study (Rowe et al 2006) Conclusions: • The most part of the studies had methodology limits • We need to increase the number of the studies in
this field
5. Posadzki P, Lee MS, Ernst E. Osteopathic manipulative treatment for
pediatric conditions: a systematic review. Pediatrics 2013; 132: 140-52.
Aim of the study: Efficacy of osteopathic manipulation for the treatment of pediatric diseases
Results: • 19059 studies • 1 work on idiopathic scoliosis (Hasler at al. 2010) 2
groups, no significative differences
Conclusioni: Efficacy of osteophatic treatment is not supported by evidence for the little and low methodological quality of the studies assessed
6. McKenney K, Sinclair Elder A, Elder C, Hutchins A.
Myofascial release as a treatment for orthopaedic conditions: a systematic
review. J Athl Training 2013; 48: 522-7.
Aim of the study: • Efficacy of myofascial treatment in orthopedic
diseases
Results: • 88 studies • 1 case study on idiopathic scoliosis (Lonstein Je,
Carlson JM 1984)
Conclusions: • Level of evidence too much various • RCTs are needed
Systematic Reviews July 2017
Spinal Manipulative Therapy for Adolescent Idiopathic Scoliosis: A Systematic Review. Théroux J, Stomski N, Losco CD, Khadra C, Labelle H, Le May S. J Manipulative Physiol Ther. 2017 Jul - Aug;40(6):452-458. doi: 10.1016/j.jmpt.2017.03.009. Review. PMID: 28822477
• 145 Studi
• 4 soddisfavano i criteri di
inclusione/esclusione
2 assessed in previous reviews
Effect of chiropractic intervention on small scoliotic curves in younger subjects: a time-series cohort design.
Lantz CA, Chen J.
J Manipulative Physiol Ther. 2001 Jul-Aug;24(6):385-93.
PMID: 11514815
Chiropractic manipulation in adolescent idiopathic scoliosis: a pilot study.
Rowe DE, Feise RJ, Crowther ER, Grod JP, Menke JM, Goldsmith CH, Stoline MR, Souza TA, Kambach B.
Chiropr Osteopat. 2006 Aug 21;14:15.
PMID: 16923185
2 not assessed before
Incidence of curvature progression in idiopathic scoliosis patients treated with scoliosis in-patient rehabilitation (SIR): an age- and sex-matched controlled study. Weiss HR, Weiss G, Petermann F. Pediatr Rehabil. 2003 Jan-Mar;6(1):23-30.
SIR (Scoliosis In-patient Rehabilitation) : too much things together (acupunture, exercise, traction, osteopathic manipulation, soft tissue therapy
Aim of the study: • Efficacy of chiropractic manipulation on Cobb degres in AIS
Recruitment: • 20 childs from a Taekwondo school • 12 volunteers • 5 selected by X-ray (Cobb 11.2±1.3)
The effect of chiropractic techniques on the Cobb angle in idiopathic scoliosis arising in adolescence. Byun S, Han D. J Phys Ther Sci. 2016 Apr;28(4):1106-10. doi: 10.1589/jpts.28.1106. Epub 2016 Apr 28.
Conclusions (by authors):. This study showed that chiropractic tecniques can effectively reduce Cobb angle in the first 4 weeks Then we can say that chiropratics tecniques are effective in reducing the curvature in idiopathic scoliosis.
Subjects* Before intervention After 4 weeks After 8 weeks
1 (M) 10 0 0
2 (M) 10 0 0
3 (M) 13 7 0
4 (M) 11 5 5
5 (F) 12 0 0
Mean±SD 11.2±1.3 2.4±3.4 1.0±2.2
The changes in Cobb angle in each subject (Unit: degrees)
CONCLUSIONS
• There is currently insufficient evidence to establish whether spinal manual therapy may be beneficial for idiopathic scoliosis
• Few papers in fact have been published to date and the majority are experimental studies with poor scientific methodology or observational case studies, so all at substantial risk of bias
• Therefore it’s necessary to conduct further research based on appropriate and accurate methods: randomized controlled trials and observational prospective cohort study.
ORTHOPEDIC MANUAL MEDICINE AND SPINE DEFORMITY
We must search and treat
DDIM by
• global mobility examination • regional mobility examination
• segmentary examination • CPM syndrome examination
ORTHOPEDIC MANUAL MEDICINE AND SPINE DEFORMITY
PARTICULAR CAUTIONS DURING CHILHOOD IN SCOLIOTIC PATIENTS
SCOLIOSIS in PROGRESSIVE PHASE: needs stabilizing therapy (physioterapic specific exercise)
Too many manipulations could be too much MOBILIZING
ORTHOPEDIC MANUAL MEDICINE AND SPINE DEFORMITY
GRAZIE
MERCI
“The most beatiful thing we can experience is the mysterious . I t is the fundamental emotion
that stands at the cradle of true art and true science” A.Einstein
Thank you Salvatore Minnella
www.isico.it
[email protected] [email protected]
“The human mind becomes more developed, more enlightened as new discoveries are made, new thruths discovered and manners and opinions change w ith the change of circumstances” T. Jefferson