Helena Normelli

Long-term results of Boston brace treatment on vertebral rotation in idiopathic scoliosis

The long-term effect of Boston brace treatment was investigated by computed tomography measurements before treatment, after bracing, and at mean follow-up at 8.5 years in 25 patients with idiopathic scoliosis. At follow-up, the pretreatment Cobb angle, the vertebral rotation, the rib hump, and the translation of the apical vertebra were not significantly changed. The sagittal diameter of the thoracic cage was significantly decreased at follow-up. The current study demonstrates that the Boston brace does not improve, but prevents progression of vertebral rotation, translation, rib hump, and Cobb angle in idiopathic scoliosis. The reduced sagittal diameter is noteworthy and may be of importance for cosmesis and pulmonary function.

Anthropometric data relating to normal and scoliotic Scandinavian girls.

The increase in height and weight and the age at the menarche have been determined in girls with Idiopathic scollosis and in age-matched normal girls. The scollotic girls were classified according to the position of the curve. The menarche was found to occur significantly later in girls with either a thoracolumbar or a double primary curve than in the control group; it was also significantly later in those two groups combined than in the girls with a right convex thoracic curve. At the time of the menarche, the girls with a thoracolumbar or a double primary curve were significantly taller than those in the control group. The girls with a double primary curve, and these together with girls with a thoracolumbar curve, were also significantly taller than those with a right convex thoracic curve. Those in the control group were significantly heavier, and in some age groups significantly taller, than children born during the period 1953–1958 and providing earlier Swedish research data. The average age at the menarche did not differ from that for a normal population for this country. The observed differences between the group with a right convex thoracic curve and that with a thoracolumbar or a double primary curve indicate that the pathomechanism, and even the etiology, may vary with the form of idiopathic scollosis.

Long-term Follow-up of Functioning After Spinal Surgery in Patients With Neuromuscular Scoliosis

Study Design. A prospective study of 100 consecutive preoperative patients with neuromuscular scoliosis whose activities and function were evaluated in a long-term follow-up. Objectives. To evaluate long-term follow-up of functioning in patients with neuromuscular scoliosis. Summary of Background Data. Few studies of patients operated for neuromuscular scoliosis are prospective, with long-term follow-up based on assessments of activities and function. Methods. The follow-up included 82 patients with neuromuscular scoliosis who were evaluated before surgery from 1992 to 1996. The follow-up time was 84.5 months on average. The assessments comprised sitting, angle of scoliosis, lung function, reaching, pain estimation, activities of daily living (ADL), care given, and time used for resting. A follow-up questionnaire as well two open-ended questions about the positive and negative effects of the surgery were sent to the patients/parents. Results. Improvements after surgery were shown in the Cobb angle, lung function, seating position, ADL, and time used for resting. In a comparison between the 1-year follow-up and the long-term follow-up, there were further improvements in sitting, ADL, and care given but an increased Cobb angle. These results were in line with the assessments reported by patients and relatives. Only minor differences were shown in long-term outcome in subgroups according to understand/not understand verbal instructions. Patient age 21 years or less seemed more improved than those age 22 years and older at the time of surgery. Conclusions. The comparison of the preoperative and long-term follow-ups showed that patients were mostly improved. Further improvements were shown beyond the 1-year follow-up. The subjective assessments also confirmed the results. The heterogeneity of patients with neuromuscular scoliosis makes it important to evaluate the patients in subgroups and in relation to age.

The symmetry of the breasts in normal and scoliotic girls.

Mammary asymmetry was estimated visually by different investigators in three series of scoliotic girls and in three control groups. The breasts of each girl were classified as being equal in size or as being obviously different in size, note being made of which breast was the larger. Breast asymmetry was significantly more common among the scoliotic than the normal girls. Moreover, the left breast was significantly more often larger in the scoliotic series of girls. On the other hand, there was no significant difference in the frequency of breast asymmetry in respect of the classifications according to curve type (right convex thoracic vs. other types) and to Cobb angle (35° or less vs. more than 35°).

Long-term results of Harrington instrumentation in idiopathic scoliosis

The long-term effect of Harrington instrumentation was investigated using posteroanterior radiographs and computed tomographic measurements preoperatively, postoperatively, and at a mean follow-up at 10.8 years in 33 patients with idiopathic scoliosis. No patient was lost form long-term follow-up. At follow-up, the mean Cobb angle was improved by 23.7 (40%) compared with the preoperative findings. The rotation of the apical vertebra was increased significantly. The rib hump, the translation of the apical vertebra, and the sagittal diameter of the thoracic cage were unchanged. At follow-up, the mean thoracic kyphosis was 17.3 and lumbar lordosis was 22.0 This study demonstrated that the long-term effect of Harrington instrumentation was limited to an improved Cobb angle; no correction of the rotational or sagittal deformities were achieved.

Description of functioning in sickness certificates

Aims: Sickness certificates are to provide information on a disease and its consequences on the patient’s functioning. This information has implications for the patient’s rights to sickness benefits and return-to-work measures. The objective of this study was to investigate the description of functioning in sickness certificates according to WHO’s International Classification of Functioning, Disability, and Health (ICF), and to describe the influence of patients’ age, gender, diagnostic group, and affiliation of certifying physician. Method: A content analysis of written statements regarding how the disease limits the patient’s functioning with ICF as a framework was performed in 475 sickness certificates, consecutively collected in Östergötland County, Sweden. Results: Musculoskeletal diseases (MSD) were the largest diagnostic group, followed by mental disorders (MD). Certificates were mainly issued from physicians at hospitals and in primary health care (PHC). ICF was applicable for classifying statements regarding functioning in 311 certificates (65%). The distribution of components was 58% body functions, 26% activity, and 7% participation. The descriptions were primarily restricted to the use of at least one component; namely, body functions. Subgroup analysis showed that descriptions of activity and participation were more common in certificates for MD and MSD, or those issued by PHC physicians. A multiple regression analysis with the activity component as dependent variable confirmed the results by showing that activity was related to both diagnosis and affiliation. Conclusions: In a consecutive sample of sickness certificates, it was shown that information on functioning is scarce. When functioning was described, it was mainly body oriented.

Scoliosis. Experimental and clinical studies.

The hypothesis, advanced on the basis of experimental and clinical observations, that asymmetric growth of the ribs may be the primary cause of the thoracospinal deformity at least in some cases of right convex, thoracic, idiopathic scoliosis finds further support in the results of the anthropometric studies referred to below. There is also the possibility that asymmetric growth and more pronounced vascularization of the often larger breast may stimulate enough longitudinal growth at the underlying costosternal cartilage to upset the balance of forces acting on the normal spine. Muscular and other mechanical forces might be responsible for the further development of the deformity. Whether the data and evidence in this article will ultimately support or advance the hypothesis presented above remains to be seen. However, this hypothesis and the observations reported to date would seem to be capable of explaining the main characteristics of at least some cases of thoracic idiopathic scoliosis, i.e., the predominance in girls, the occurrence in the teens, and the predominant right convexity.

Prevalence of Back Problems in 1069 Adults With Idiopathic Scoliosis and 158 Adults Without Scoliosis.

Study Design. Multicenter case-control study. Objective. To investigate the prevalence of back problems in adults with idiopathic scoliosis. Summary of Background Data. Information on the prevalence of back problems in adults with idiopathic scoliosis is scarce, especially in untreated individuals, males, and individuals with an age at the onset of scoliosis of less than 10 years. Methods. A total of 1069 individuals with idiopathic scoliosis and 158 individuals without scoliosis, all aged 20 to 65 years, answered a questionnaire on back problems. Individuals with scoliosis were diagnosed between ages 4 and 20 years and any treatment was terminated before the age of 20 years. Logistic regression or analysis of variance was used for group comparisons. Results. Mean (SD) age at the time of investigation in individuals with scoliosis (123 males and 946 females) was 41 (9) years, and in individuals without scoliosis (75 males and 83 females) 45 (13) years. Three hundred seventy-four individuals with scoliosis were untreated, 451 had been brace treated, and 244 were surgically treated. The mean prevalence of back problems was 64% in the individuals with scoliosis and 29% in the individuals without scoliosis (P < 0.001). Among the untreated individuals with scoliosis, 69% reported back problems; among the brace treated, 61%; and among the surgically treated, 64% (P = 0.06). When comparing females and males with scoliosis, and individuals with juvenile and adolescent scoliosis, there were no statistically significant differences in the prevalence of back problems (P = 0.10 and P = 0.23, respectively). Conclusion. Adults with idiopathic scoliosis have a higher prevalence of back problems than individuals without scoliosis. Treatment, sex, and juvenile or adolescent onset of diagnosis was not related to the prevalence of back problems in adulthood. Level of Evidence: 2

The thermal emission from the skin and the vascularity of the breasts in normal and scoliotic girls

The vascularity of the breasts was examined by thermographic and diaphanographic methods in normal and scoliotic girls. The thermal emission from the skin registered with an AGA Thermovision 750 camera (Stockholm, Sweden) on black and white Polaroid film was evaluated visually by 10 independent observers. No significant differences between the thermal images of the left and the right breast were found in the control or scoliotic groups or in girls with a right convex thoracic curve, nor was there any significant difference between the groups in this respect. Image analysis of diaphanograms of the breasts using the GOP 300 system showed a significantly greater vascularity of the left breast than of the right, both in the scoliotic series as a whole and in the subgroup with a right convex thoracic curve, but not for the reference group. The vascularity of the left breast but not of the right one was significantly greater for the girls with a right convex thoracic curve than for the control group. The results of the diaphanographic study confirm earlier observations and together provide substantial evidence that unilateral stimulation of rib growth due to a greater vascularity of the left breast and the underlying costosternal junctions might be one initiating factor in the development of right convex thoracic idiopathic scoliosis in adolescent girls.

Weight distribution in the sitting position in patients with paralytic scoliosis: pre- and postoperative evaluation

Abstract. Patients with paralytic scoliosis spend most of their time in the sitting position. The spinal deformity, pelvic obliquity and uneven weight distribution on the seating surface necessitates frequent seating adaptations in the wheelchair. In this prospective study, 45 wheelchair-bound patients were evaluated preoperatively and 43 postoperatively. The pre- and postoperative evaluation was done by an independent observer. Surgical correction was performed between 1993 and 1996. Assessments included sitting balance on a box; number of seating supports in the wheelchair; weight distribution on the seating surface, measured with a computerized EMED system; Cobb angle; hip dislocation; mediolateral translation of T1 and of the apex vertebra with reference to a perpendicular line drawn upwards from the spinal process of S1; and pelvic obliquity from a line drawn between the most proximal points in the iliac crests. X-rays for the measurement of Cobb angle and pelvic obliquity were performed in sitting position. Reference values for normal weight distribution on the seating surface were obtained for 27 normal subjects and revealed a mean value of 59% of weight supported on one side. A stepwise regression analysis on the preoperative results showed that pelvic obliquity and thoracolumbar/lumbar spinal imbalance explained weight distribution on the seating surface (R2=0.45). There were significant improvements in all variables except in sitting balance and imbalance of T1, 1 year postoperatively. When dividing the material into two subgroups, the results showed no significant difference in any of the assessed parameters of the scoliosis, pelvic obliquity, or sitting position between individuals with even (50–59% on one side) and those with uneven (60–100% on one side) weight distribution postoperatively. The results of the assessment showed a significant improvement after surgical correction, but the majority still had pelvic obliquity and uneven weight distribution in a sitting position. The weight distribution on the seating surface preoperatively was explained by thoracolumbar/lumbar spinal imbalance and pelvic obliquity, with R2 = 0.45. There were no significant differences in any variables in comparisons between individuals with even weight distribution and those with uneven weight distribution. For the group with even weight distribution, however, the mean pelvic obliquity was 6° and in the group with uneven weight distribution the mean pelvic obliquity was 12°. Attention to seating surface and adjustment of seating position is needed for patients with paralytic scoliosis.