Paulina Pawłowska

Joint hypermobility in children with idiopathic scoliosis: SOSORT award 2011 winner

BackgroundGeneralized joint hypermobility (JHM) refers to increased joint mobility with simultaneous absence of any other systemic disease. JHM involves proprioception impairment, increased frequency of pain within joints and tendency to injure soft tissues while performing physical activities. Children with idiopathic scoliosis (IS) often undergo intensive physiotherapy requiring good physical capacities. Further, some physiotherapy methods apply techniques that increase joint mobility and thus may be contraindicated.The aim of this paper was to assess JHM prevalence in children with idiopathic scoliosis and to analyze the relationship between JHM prevalence and the clinical and radiological parameters of scoliosis. The methods of assessment of generalized joint hypermobility were also described.Materials and methodsThis case-control study included 70 subjects with IS, aged 9-18 years (mean 13.2 ± 2.2), Cobb angle range 10°-53° (mean 24.3 ± 11.7), 34 presenting single curve thoracic scoliosis and 36 double curve thoracic and lumbar scoliosis. The control group included 58 children and adolescents aged 9-18 years (mean 12.6 ± 2.1) selected at random. The presence of JHM was determined using Beighton scale complemented with the questionnaire by Hakim and Grahame. The relationship between JHM and the following variables was evaluated: curve severity, axial rotation of the apical vertebra, number of curvatures (single versus double), number of vertebrae within the curvature (long versus short curves), treatment type (physiotherapy versus bracing) and age.Statistical analysis was performed with Statistica 8.1 (StatSoft, USA). The Kolmogorov-Smirnov test, U Mann-Whitney test, Chi2 test, Pearson and Spermann correlation rank were conducted. The value p = 0.05 was adopted as the level of significance.ResultsJHM was diagnosed in more than half of the subjects with idiopathic scoliosis (51.4%), whilst in the control group it was diagnosed in only 19% of cases (p = 0.00015). A significantly higher JHM prevalence was observed in both girls (p = 0.0054) and boys (p = 0.017) with IS in comparison with the corresponding controls. No significant relation was found between JHM prevalence and scoliosis angular value (p = 0.35), apical vertebra rotation (p = 0.86), the number of vertebrae within curvature (p = 0.8), the type of applied treatment (p = 0.55) and the age of subjects (p = 0.79). JHM prevalence was found to be higher in children with single curve scoliosis than in children with double curve scoliosis (p = 0.03).ConclusionsJHM occurs more frequently in children with IS than in healthy sex and age matched controls. No relation of JHM with radiological parameters, treatment type and age was found. Systematically searched in IS children, JHM should be taken into account when physiotherapy is planned.

Intra- and interobserver repeatability of the assessment of anteroposterior curvatures of the spine using Saunders digital inclinometer.

INTRODUCTION According to the requirements of Evidence Based Medicine, every research tool and method should be subjected to reliability evaluation. A variety of inclinometers are used for the assessment of sagittal plane spinal curvatures in clinical practice. The aim of the study was to evaluate the intra- and interobserver repeatability of measurements of the anterior-posterior spinal curvatures taken with Saunders digital inclinometer. MATERIAL AND METHODS The study involved 30 healthy subjects (5 males, 25 females) aged 20 to 35 years. The anteroposterior curvatures of the spine were measured in all subjects using a Saunders digital inclinometer. In order to evaluate the intraobserver repeatability of measurements, the results obtained by one investigator were compared. To evaluate interobserver repeatability, the results obtained by three investigators were compared. Additionally, the levels of reliability and measurement error were determined. RESULTS The measurements conducted by one investigator showed good repeatability for sacral slope, lumbar lordosis, and thoracic kyphosis, including the angle of proximal (Th1-Th6) and distal (Th6-Th12) thoracic kyphosis (p>0.05). For measurements taken by three investigators, interobserver repeatability was achieved for thoracic kyphosis (p>0.05). The reliability of the measurements was good (Cronbachs alpha was 0.9> α ≥0.8), and the measurement error was between 2.8°-3.8°. CONCLUSIONS The assessment of anteroposterior curvatures of the spine by one investigator provided good repeatability and reliability of measurements. Measurements performed by more than one investigator displayed partial repeatability. The value of the observational error should be taken into account in the interpretation of results of measurements performed with the Saunders inclinometer. The assessment of anteroposterior curvatures of the spine should be preceded by a verification of measurement reliability.

Evaluation of the Stress Level of Children with Idiopathic Scoliosis in relation to the Method of Treatment and Parameters of the Deformity

Stress level due to existing body deformity as well as to the treatment with a corrective brace is one of factors influencing the quality of life of children with idiopathic scoliosis undergoing non-surgical management. The purpose of the study was to evaluate the stress level among children suffering from idiopathic scoliosis in relation to the method of treatment and the parameters of the deformity. Seventy-three patients with idiopathic scoliosis participated in the study. Fifty-two children were treated by means of physiotherapy, while 21 patients were treated with both Cheneau corrective brace and physiotherapy. To assess the stress level related to the deformity itself and to the method of treatment with corrective brace, the two Bad Sobernheim Stress Questionnaires (BSSQs) were applied, the BSSQ Deformity and the BSSQ Brace, respectively.

The Comparison of the Effects of Three Physiotherapy Techniques on Hamstring Flexibility in Children: A Prospective, Randomized, Single-Blind Study

The aim of the study was to evaluate changes in hamstring flexibility in 120 asymptomatic children who participated in a 6-week program consisting of one physiotherapy session per week and daily home exercises. The recruitment criteria included age (10–13 years), no pain, injury or musculoskeletal disorder throughout the previous year, physical activity limited to school sport. Subjects were randomly assigned to one of the three groups: (1) post-isometric relaxation – PIR (n = 40), (2) static stretch combined with stabilizing exercises – SS (n = 40) and (3) stabilizing exercises – SE (n = 40). Hamstring flexibility was assessed with straight leg raise (SLR), popliteal angle (PA) and finger-to-floor (FTF) tests. The examinations were conducted by blinded observers twice, prior to the program and a week after the last session with the physiotherapist. Twenty-six children who did not participate in all six exercise sessions with physiotherapists were excluded from the analysis. The results obtained by 94 children were analyzed (PIR, n = 32; SS, n = 31; SE, n = 31). In the PIR and SS groups, a significant (P<0.01) increase in SLR, PA, FTF results was observed. In the SE group, a significant (P<0.001) increase was observed in the SLR but not in the PA and FTF (P>0.05). SLR result in the PIR and SS groups was significantly (P<0.001) higher than in the SE group. As far as PA results are concerned, a significant difference was observed only between the SS and SE groups (P = 0.014). There were no significant (P = 0.15) differences regarding FTF results between the three groups. Post-isometric muscle relaxation and static stretch with stabilizing exercises led to a similar increase in hamstring flexibility and trunk forward bend in healthy 10–13-year-old children. The exercises limited to straightening gluteus maximus improved the SLR result, but did not change the PA and FTF results.

The Examination of the Musculoskeletal System Based Only on the Evaluation of Pelvic-Hip Complex Muscle and Trunk Flexibility May Lead to Failure to Screen Children for Generalized Joint Hypermobility

Objective The aim of the study was to evaluate whether the clinical assessment of the pelvic-hip complex muscle and trunk flexibility is sufficient for diagnosing generalized joint hypermobility (GJH). Design A cross-sectional study. Setting Center of Body Posture in Olsztyn, North East Poland. Participants The study included 136 females and 113 males aged 10–13 years. Main outcome measures In order to assess muscle flexibility, the straight leg raise (SLR) test (for hamstring) and modified Thomas test for one- (O-JHF) and two-joint (T-JHF) hip flexors were performed. To evaluate trunk flexibility the fingertip-to-floor (FTF) and lateral trunk flexion (LTF) tests were used. The GJH occurrence was assessed with the use of nine-point Beighton scale (threshold value ≥5 points for females, ≥4 for males). The analysis was carried out separately for females and males. Results There were no significant differences between females with versus without GJH, and males with versus without GJH regarding SLR (p = 0.86, p = 0.19 for females and males, respectively), O-JHF (p = 0.89, p = 0.35 for females and males, respectively), T-JHF (p = 0.77, p = 0.4 for females and males, respectively), FTF (p = 0.19, p = 0.84 for females and males, respectively) and LTF (p = 0.58, p = 0.35 for females and males, respectively) tests results. Conclusions Clinical examination of the pelvic-hip complex muscles and trunk flexibility by use of SLR, O-JHF, T-JHF, FTF and LTF revealed to be insufficient in diagnosing GJH in children aged 10–13 years. Thus, the Beighton scale should be considered a standard element of physiotherapeutic examination of the musculoskeletal system in children and youth.

The influence of generalized joint hypermobility on the sagittal profile of the spine in children aged 10-13 years.

BACKGROUND Children commonly attend exercise programs to correct abnormal sagittal curvatures of the spine. The presence of generalized joint hypermobility (JH) is often disregarded during exercise planning. The aim of the study was to assess the influence of JH on the sagittal curvatures of the spine. MATERIAL AND METHODS The JH group included 38 girls and 37 boys aged 10-13 years with known JH (Beighton test cut-off ≥ 5 points for girls, and ≥ 4 for boys). A control group included 197 girls and 150 boys. The children were matched for age, height, weight and BMI. The sacral slope (SS), lumbar lordosis (LL), thoracic kyphosis (TK), distal thoracic kyphosis (DK), and proximal thoracic kyphosis (PK) were assessed with a Saunders inclinometer. The results in children with and without JH were compared. RESULTS There were no significant (p>0.05) differences between girls with and without JH with respect to SS (22.5° ± 9.9 vs 23.0° ± 8.0), LL (31.0° ± 14.0 vs 33.0° ± 10.0), TK (39.0° ± 10.4 vs 39.6° ± 10.0), DK (8.7° ± 6.9 vs 7.9° ± 7.8) or PK (31.3° ± 7.1 vs 32.3° ± 7.3). The differences among boys were similarly non-significant (p>0.05) (19.0° ± 7.9 vs 19.7° ± 6.6; 30.6° ± 9.0 vs 31.9° ± 8.4; 42.7° ± 8.0 vs 40.6° ± 8.7; 9.7° ± 7.9 vs 8.2° ± 7.8; 33.7° ± 5,0 vs 32.8° ± 7.0, for SS, LL, TK, DK and PK, respectively). CONCLUSIONS 1. The sagittal profile of the spine did not differ between children with and without JH, which may lead to suboptimal exercise plans. 2. The routine examination of the musculoskeletal system should be extended to include an assessment of JH.

The Influence of the “Straighten Your Back” Command on the Sagittal Spinal Curvatures in Children with Generalized Joint Hypermobility

Objectives. The aim of the study was to assess the change of sagittal spinal curvatures in children with generalized joint hypermobility (GJH) instructed with “straighten your back” command (SYB). Methods. The study included 56 children with GJH. The control group consisted of 193 children. Sacral slope (SS), lumbar lordosis (LL), global thoracic kyphosis (TK), lower thoracic kyphosis (LK), and upper thoracic kyphosis (UK) were assessed with Saunders inclinometer both in spontaneous positions (standing and sitting) and after the SYB. Results. Children with GJH after SYB presented the following: in standing, increase in SS and decrease in TK, LK, and UK (P < 0.01), with LL not significantly changed; in sitting: decrease in global thoracic kyphosis (35.5° (SD 20.5) versus 21.0° (SD 15.5), P < 0.001) below the standards proposed in the literature (30–40°) and flattening of its lower part (P < 0.001). The same changes were observed in the control group. Conclusions. In children with generalized joint hypermobility, the “straighten your back” command leads to excessive reduction of the global thoracic kyphosis and flattening of its lower part. Therefore, the “straighten your back” command should not be used to achieve the optimal standing and sitting positions.

Joint hypermobility in girls with idiopathic scoliosis: relation with age, curve pattern and curve size

Methods The study group included 147 Caucasian girls with IS, aged 9-18 years (mean 13.6 ±2.2), Cobb angle range 11°65°, mean 27.9 ±11.9, comprising 42 single thoracic, 31 single lumbar and 74 double curve scoliosis. According to the Cobb angle, there were 70 mild (10-24o), 54 moderate (25-40o) and 23 severe (> 45o) curves. The control group included 147 girls aged 9-18 years (mean 13.1 ±.3), selected at random from the group of 300 girls free of IS (angle of trunk rotation <5°). The presence of JH was assessed with the 9-point Beighton scale [1], using the cutoff ≥5 points.

The influence of self-stretch based on post-isometric relaxation, static stretch combined with stabilization exercises and stabilization exercises only on hamstring, one-joint and two-joints hip flexors flexibility and finger-to-floor test results

Methods 94 children (46 boys and 48 girls) aged 10-13 years (11.5 ±0.5), were randomly divided into 3 groups. Each group underwent a 6-week therapeutic programme aiming to correct muscles flexibility. The first group-GI (31 children) realized the programme of post isometric muscle relaxation (PIR), the second one-GII (31 children) performed static stretching with stabilization exercises, the third group-GIII (32 children) realized only stabilization exercises. The shortening of hamstring, one-joint and two-joint hip flexors was assessed clinically according to Kendall. The straight leg raise (SLR test) angle and the popliteal angle were measured for hamstrings, the angle in sagittal plane in hip for one-joint and the knee flexion was measured for twojoint hip flexors. Fingertips-to-floor distance (FTF test) in trunk flexion was also noted. The examination was conducted twice – before therapy and a week after its completion, by the blinded observers.

Joint hypermobility syndrome in children with idiopathic scoliosis

Background Joint hypermobility syndrome is diagnosed when the mobility of small and large joints is increased in relation to standard mobility for any given age, gender and race, and after excluding systemic diseases [1][2][3]. It is assessed by clinical examination using specific scales (Beighton) [4]. Some methods of physiotherapy used to treat scoliotic children, include exercises that aim at increasing the range of spinal mobility to achieve curve correction [5][6][7][8][9].