Biomechanical characteristics and therapeutic effects of Traditional Chinese Medicine manual therapy in adolescent idiopathic scoliosis: study protocol for a randomized controlled trial

Purpose We aimed to determine the global effects of the Chêneau brace combined with Schroth exercises on adolescent idiopathic scoliosis (AIS). Methods We analyzed 192 patients with AIS who underwent the Chêneau brace treatment alone or combined with Schroth best practice (SBP) from June 2013 to October 2019. There were 138 patients in the Brace group and 54 patients in the Brace + SBP group. Radiographs were obtained at various treatment durations. Answers to the health-related quality of life (HRQoL) questionnaire were recorded before the intervention and at the time of treatment wean. Results The Cobb angle (–3.55°; p < 0.001) and C7-CSVL (–3.03 mm; p < 0.001) significantly decreased in the Brace + SBP group. Thoracic kyphosis (TK) decreased in both the Brace + SBP group (–1.85°; p = 0.0152) and the Brace group (–5.06; p < 0.001). Changes before and after treatment of TK were significantly different between groups (p < 0.001). The 22-item Scoliosis Research Society function score, self-image, mental health, and EuroQol 5-Dimension scores were significantly higher in the Brace + SBP group. The satisfaction score was higher in the Brace + SBP group (3.77 ± 0.63 vs. 3.13 ± 0.79; p < 0.001). Conclusions Compared to bracing alone, the Schroth exercises plus bracing had a better effect on coronal balance. Schroth exercises improve flatback deformity caused by bracing and positively influence the HRQoL in AIS patients who received the Chêneau brace treatment. Implications for Rehabilitation Bracing and physiotherapy are common treatments for adolescent idiopathic scoliosis (AIS). The Chêneau brace treatment causes flatback deformity and muscle stiffness in AIS patients. The Schroth method helps patients increase muscle strength, halt curve progression, increase vital capacity, and maintain improved posture. The Schroth exercises could improve flatback deformity caused by bracing and positively influence the health-related quality of life in AIS patients who received the Chêneau brace treatment.

Objective To characterize the lumbo-abdominal muscles activities of adolescent idiopathic scoliosis (AIS) patients in different standing postures by using surface electromyography (sEMG).Methods A total of 33 AIS patients and 15 healthy subjects were recruited.The sEMG signals from the lumbo-abdominal muscles of the healthy subjects and AIS patients were measured with the FlexComp Infiniti apparatus.The sEMG signals were recorded in different standing postures with and without visual and auditory input.The activation of the lumbo-abdominal muscles was compared between healthy subjects and AIS patients.Results In different standing posture with and without visual and auditory information input,the activation rate of the concave side of the apex level paraspinal muscle was 4.91％ MVIC,5.22％ MVIC,5.51％ MVIC,6.01％ MVIC,and the activation rate of the convex side of the apex level paraspinal muscle was 6.45％ MVIC,7.69％ MVIC,8.31％ MVIC,8.77％ MVIC.The activation of the paraspinal muscles at the concave side of the apex level was lower than that of the convex side in the AIS group in different standing postures with and without visual and auditory input.The activation of the paraspinal muscles at the convex side of the apex level was lower during standing on the stable plane with visual and auditory input than during standing on the soft cushion without visual and auditory input in the AIS group.Conclusion The activation of the bilateral apex level paraspinal muscles is asymmetry in AIS patients.It is easier to activate the paraspinal muscles at the convex side of the apex level during standing on the soft cushion without visual and auditory input in AIS patients. Key words: Adolescents; Scoliosis; Lumbo-abdominal muscles; Surface electromyography

227. Does baseline substance use predict subsequent development of mental health disorders in adolescent idiopathic scoliosis patients?

Cost-utility analysis OBJECTIVE.: To compare the cost utility of operative versus nonoperative treatment of adolescent idiopathic scoliosis (AIS) and identity factors that influence cost-utility estimates. AIS affects 1% to 3% of children aged 10 to 16 years. When the major coronal curve reaches 50°, operative treatment may be considered. The cost utility of operative treatment of AIS is unknown. A decision-analysis model comparing operative versus nonoperative treatment was developed for a hypothetical 15-year-old skeletally mature girl with a 55° right thoracic (Lenke 1) curve. The AIS literature was reviewed to estimate the probability, health utility, and quality-adjusted life years (QALYs) for each event. For the conservative model, we assumed that operative treatment did not result directly in any QALYs gained, and the health utility in AIS patients was the same as the age-matched US population mean. Costs were inflation-adjusted at 3.22% per year to 2015 US dollars. Costs and benefits were discounted at 3%. Probabilistic sensitivity analysis was performed using mixed first-order and second-order Monte Carlo simulations. Incremental cost utility ratio (ICUR) and incremental net monetary benefit were calculated. One-way sensitivity analyses were performed by varying cost, probability, and QALY estimates. Operative treatment was favored in 98.5% of simulations, with a median ICUR of $20,600/QALY (95% confidence interval, $20,500-$21,900) below the societal willingness-to-pay threshold (WTPT) of $50,000/QALY. The median incremental net monetary benefit associated with operative treatment was $15,100 (95% confidence interval, $14,800-$15,700). Operative treatment produced net monetary benefit across various WTPTs. Factors that most affected the ICUR were net costs associated with uncomplicated operative treatment, undergoing surgery during adulthood, and development of pulmonary complications. Cost-utility analysis suggests that operative treatment of AIS is favored over nonoperative treatment and falls below the $50,000/QALY WTPT for patients with Lenke 1 curves. 2.

BackgroundPostoperative neck tilt (PNT) is a phenomenon in adolescent idiopathic scoliosis (AIS) patients which is distinct form shoulder imbalance. There were scarce studies performed to explore the risk factors for PNT in Lenke 1 and 2 AIS patients, and whether it can be predicted after surgery remains unknown. The objective of this study is to explore the prevalence and risk factors for PNT, and introduce an index for prediction of PNT in Lenke 1 and 2 AIS patients after correction surgery.MethodsMedical records of Lenke 1 and 2 AIS patients who received correction surgery were reviewed from February 2013 to February 2015. Posteroanterior films were evaluated before surgery and at 2 years’ follow-up. Patients were divided into two groups according to whether PNT occurred at the 2 years’ follow-up. Risk factors of PNT were analyzed, and PNT Index was proposed and verified.ResultsOne hundred two Lenke 1 and 2 AIS patients were recruited in this study. The prevalence of PNT after correction was 40.2%. According to the postoperative CAT (Cervical Axis Tilt), patients were divided into two group: PNT group (CAT≧5°, n = 41) and non-PNT group (CAT< 5°, n = 61). Postoperative T1 tilt, preoperative proximal thoracic curve (PTC), postoperative PTC and postoperative coronal balance (CB) were significantly different between two groups. Logistic regression showed that postoperative PTC and postoperative CB were the primary risk factors for PNT, which could be predicted by the regression equation: PNT Index = 1.1 x postoperative PTC (degrees) - 0.9 x postoperative CB (millimeters). On the basis of ROC curve, if PNT Index was more than 10, the occurrence rate of PNT was 86%. On the contrary, the rate of no PNT phenomenon was 80%.ConclusionPostoperative PTC and postoperative CB were the important factors for PNT in Lenke 1 and 2 AIS patients. Sufficient correction of PTC and moderate correction of CB should be recommended when operating on Lenke1 and 2 AIS patients.

To investigate the association of vitamin D receptor (VDR) gene polymorphisms with abnormal growth pattern and low bone mass in adolescent idiopathic scoliosis (AIS) patients. Peripheral blood samples were obtained from 164 female patients with AIS, aged 14.4 +/- 2 (9 - 20), and 122 age-matched healthy girls. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique was used to detect the VDR gene distributions. The frequency of Bb genotype was significantly higher in the AIS patients than in the controls (P < 0.01). The frequency of B alleles of the AIS patients was significantly higher than that of the controls (P < 0.01). In AIS patients, the expression rate of Aa genotype of the AIS patients with the body mass index (BMI) > or = 18 kg/m(2) was significantly higher than those with the BMI < 18 kg/m(2) (P < 0.05), and the expression rate of Bb genotype of the AIS patients with the BMI < 18 kg/m(2) and arm span < 160 cm was significantly higher than that of the AIS patients with the BMI > or = 18 kg/m(2) and arm span > or = 160 cm (P < 0.05). The BsmI site polymorphism of vitamin D receptor gene may be associated with abnormal growth pattern and low bone mass in girls with AIS.

Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of the spine, which not only affects spinal anatomy, mobility and trunk symmetry, but also leads to the changes of human locomotion through pelvic. During the past 30 years, though great progress has been made in the treatment of AIS, the pathogeny of AIS is still uncertain. Most scholars believe that many factors contribute to the pathogeny of AIS, however, some studies have shown that poor posture during walking and poor manage of balance could lead to the progress of scoliosis. Gait is a behaviour characteristic during walking, and normal gait is the result of nervous system, musculoskeletal system, proprioception and vision. Any disease of the system above may cause abnormal gait. Gait analysis can spot the key links and impact factors of abnormal gait by observing and measuring the testers' walking, reflect the abnormal gait objectively and quantitatively, and provide reference opinions for the recovery and treatment of patients. At present, gait analysis has been mostly applied in hemiplegia, cerebral palsy and knee osteoarthritis. In recent years, gait analysis has been increasingly used in AIS patients. There have been many researches about the kinematics and kinetics of gait analysis in adolsecent idiopathic scoliosis abroad and some positive results have been reported. But in China, it's still in the initial stage. We reviewed the published papers about gait analysis in AIS patients, and summarized the kinematics, kinetics and different means of intervention on gait in AIS patients. We hope it will provide references for our researches.

A retrospective study was performed through measurements on MRI images in adolescent idiopathic scoliosis (AIS) patients and age-matched adolescents. To investigate the position of the cerebellar tonsil in AIS patients with a Cobb angle >40 degrees in comparison with age-matched healthy adolescents and to determine the relationships of the tonsil position with age, sex, curve severity, and curve patterns. There have been increasing evidences implying that AIS patients may present with subtle or subclinical neurologic dysfunction and a higher incidence of tonsillar ectopia was documented in AIS patients. However, the tonsil position has not been clearly addressed in AIS patients with a severe curve. According to the method described by Aboulezz et al, measurements of the tonsil position relative to the magnum foramen on magnetic resonance images were performed in 203 AIS patients with a Cobb angle >40 degrees and 86 age-matched healthy adolescents. The inferior displacement of the cerebellar tonsil with an extent within 5 mm was defined as tonsillar ectopia when it located below the magnum foramen. On the basis of measurement results, the incidence of tonsillar ectopia was determined in both AIS and control groups. The associations of tonsillar ectopia with curve severity and curve patterns for AIS patients and the relationships of the tonsil positions with age and gender in all subjects were analyzed. In AIS patients and healthy controls, the median position of the cerebellar tonsil was 0.8 and 2.9 mm above the magnum foramen, respectively. The incidence of tonsillar ectopia (0-4.8 mm below the magnum foramen) in AIS was found to be significantly higher than healthy adolescents (range 0-1.8 mm vs. 0-4.8 mm below the magnum foramen; ratio 34.5% vs. 5.8%; P < 0.01). No significant correlations were found between the position of the cerebellar tonsil with age or gender in AIS and control subjects. It was shown the position of the cerebellar tonsil was not significantly different among AIS patients with different curve severity. However, it was noted that there was a highest incidence (62.5%) of tonsillar ectopia in atypical scoliotic cases with a double thoracic curve. Additionally, a significantly higher incidence of tonsillar ectopia was found in patients with thoracic or thoracolumbar curves when compared with those with lumbar curves (37.4% vs. 21.6%, P = 0.049). Tonsillar ectopia with the extent >2 mm in AIS patients should be regarded as abnormal. AIS patients had a lower tonsil position and a higher prevalence of tonsillar ectopia than controls, and tonsillar ectopia was found to be associated with curve patterns. It is suggested that a lower position of the cerebellar tonsil might be associated with the etiopathogenesis of AIS and might contribute to subclinical neurologic dysfunction in AIS patients.

BackgroundPatient compliance is essential to the effectiveness of brace treatment for adolescent idiopathic scoliosis (AIS) patients. Subjective measurements like questionnaires and inquiries proved to be arguably inaccurate. Although some scholars have applied temperature/force monitors to measuring patient compliance objectively, few studies to date could monitor patient compliance in real time. The objective of this study is to describe and evaluate a compliance real-time monitoring system of the brace usage in AIS patients.MethodsA compliance real-time monitoring system (specifically consisting of a compliance monitor, a WeChat Mini Program, a cloud-based storage system and a website backstage management system) was designed to manage the brace treatment. Thirty patients receiving brace treatment were enrolled. They were told to upload the data at least once a day. Clinicians downloaded the compliance data and communicated with the patients online based on their analysis of data at least once every 3 months. The measured force, quality compliance (measured force / baseline force), measured time, and quantity compliance (measured time/ prescribed time) were used to evaluate patient compliance. Patients were also asked to rate their satisfaction at the final follow-up.ResultsTwenty-eight patients were included in the final analysis. The mean baseline force was 1.23 ± 0.28 N. The mean measured force was 0.79 ± 0.29 N. The mean quality compliance was 64.8 ± 22.2%. The prescribed time of all patients was 23 h. The mean measured time was 14.1 ± 2.9 h. The mean quantity compliance was 61.3 ± 12.6%. Both the quality and quantity compliance during the first 3 months of treatment was significantly lower than the latter 3 months. In this study, 96.4% (27/28) patients were satisfied with the use of the monitoring system, among whom 21.4% (6/28) are very satisfied and 75.0% (21/28) are somewhat satisfied.ConclusionsThe compliance real-time monitoring system, without evaluating the clinical and radiographic outcomes for now, has already shown some feasibility and effectiveness for the management of the brace usage in AIS patients. This system, as a useful tool for online patient management and patient-clinician communication, would be potentially employed on a large scale in future for clinicians to improve the compliance and satisfaction of AIS patients who have received brace treatment.

Objective Adolescent idiopathic scoliosis (AIS) is a relatively common spinal rotation deformity, and the pathogenesis of AIS is accompanied by metabolic dysfunction and changes in biochemical factors. In this study, plasma metabolite changes in AIS patients were analyzed based on nontargeted metabolomics to provide new insights for clarifying functional metabolic abnormalities in AIS patients. Methods Clinical indexes and blood samples were collected from 12 healthy subjects and 16 AIS patients. Metabolomics was used to analyze the changes in metabolites in plasma samples. The correlation between plasma metabolites and clinical indexes was analyzed by the Spearman rank correlation coefficient. Results Analysis of clinical data showed that the body weight, body mass index (BMI), and bone mineral density (BMD) index of the AIS group significantly decreased, while the blood phosphorus and Cobb angles increased significantly. Metabolomic analysis showed significant changes in 72 differential metabolites in the plasma of the AIS group, mainly including organooxygen compounds, carboxylic acids and derivatives, fatty acyls, steroids and steroid derivatives, and keto acids and derivatives. The Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway showed that arginine biosynthesis, D-glutamine and D-glutamate metabolism, alanine, aspartate and glutamate metabolism, and citrate cycle (TCA cycle) were significantly enriched in the AIS and healthy groups. Spearman rank correlation coefficient analysis showed that the plasma metabolites C00026 (oxoglutarate), C00062 (L-arginine, arginine), C01042 (N-acetylaspartate), and C00158 (citrate) were significantly correlated with clinical indexes in AIS patients. In the healthy group, the plasma metabolites C00122 (fumarate), C00025 (glutamate and L-glutamic acid) and C00149 (malate, L-malic acid) were significantly correlated with clinical indexes, while C00624 (N-acetylglutamate) was not significantly correlated with the clinical indexes. Conclusion The occurrence of AIS led to changes in clinical indexes and plasma metabolites. Plasma biomarkers and functional metabolic pathways were correlated with clinical indexes, which might provide new insights for the diagnosis and treatment of AIS.

Effect of long-term orthotic treatment on gait biomechanics in adolescent idiopathic scoliosis

Objective: The objective of this study was to determine the effectiveness of the conservative Schroth method in patients with adolescent idiopathic scoliosis. Methods: A total of 34 respondents, 24 male and 10 female, aged between 11 and 16 years, participated in the research. The study was a single-blind randomized trial, in which subjects were divided into control and experimental groups by stratified randomization according to the stratum of the Cobb angle. The control group performed the Schroth method at home without the supervision of Schroth therapists, while the experimental group performed the Schroth method under the supervision of Schroth therapists three times a week for 90 min over eight weeks. Initial and final outcome measurements were performed: Cobb angle, angle of trunk rotation, vital capacity, forced vital capacity, forced expiratory volume in the first second, the percentage of forced expiratory volume in the first second in forced vital capacity, and chest expansion. Results: There was a statistically significant improvement in all measured outcomes in the experimental group, while no statistically significant changes were recorded in the control group. The Cobb angle decreased by 2.12°, while ATR decreased by 2.88°; VC increased by 0.15 L, FVC by 0.13 L, FEV1 by 0.1 L, and CE increased by 0.78 cm. Conclusions: The application of an eight-week therapy program using Schroth method by subjects with adolescent idiopathic scoliosis had statistically significant changes in all measured outcomes in the group that was supervised by Schroth's therapists, while there was no statistically significant improvement in the group that applied therapy at home without supervision.

Objective To investigate the bone strength of adolescent idiopathic scoliosis (AIS) patients. Methods A total of 68 AIS patients and 20 healthy subjects were recruited. Speed of sound (SOS), Z-score and percentile of distal radius of normal subjects and AIS patients were measured using the quantitative ultrasound. Results Compared with normal controls, AIS had significantly lower average SOS, Z value and percentile. No significant difference was found among different curve patterns and gender of AIS patients. There was a positive correlation between SOS and age in AIS patients. However, there was no correlation between SOS and maximal Cobb angle in AIS patients. Conclusions AIS patients have lower bone strength generally. The bone strength has a positive correlation with the age, but no correlation with the curve pattern and gender in AIS patients. Key words: Adolescent; Idiopathic; Scoliosis; Bone strength

BackgroundsAbnormal vertebral growth and development have been found in adolescent idiopathic scoliosis (AIS) patients, and the proliferation and differentiation of bone development‐related cells play important roles in its pathogenesis. However, a comprehensive single‐cell‐level differentiation roadmap in AIS has not been achieved.MethodsThe present study compared the single‐cell level cellular landscapes of spinal cancellous bone tissues between AIS patients and healthy subjects using high throughput single‐cell RNA sequencing (scRNA‐seq), which covers multiple cellular lineages including osteoblast, chondrocyte, osteoclast and related immunocytes. We constructed the differentiation trajectories of bone development‐related cell lineages through pseudotime analysis, and the intercellular‐communication networks between bone development‐related cells and immunocytes were further developed.ResultsA total of 11 distinct cell clusters were identified according to the genome‐wide transcriptome profiles. t‐Distributed stochastic neighbor embedding (t‐SNE) analysis showed that mesenchymal stem cells (MSC) were classified into three subtypes: MSC‐LOXL2, MSC‐IGFBP5, and MSC‐GJA1. Gene ontology (GO) analysis showed that MSC‐GJA1 might possess greater osteoblast differentiation potential than the others. MSC‐IGFBP5 was the specific MSC subtype observed only in AIS. There were two distinct gene expression clusters: OB‐DPT and OB‐OLFML2B, and the counts of osteoblasts derived from AIS was significantly less than that of non‐AIS subjects. In AIS patients, MSC‐IGFBP5 failed to differentiate into osteoblasts and exhibited negative regulation of cell proliferation and enhanced cell death. CPC‐PCNA was found to be the specific chondrocyte progenitor cell (CPC) subtype observed only in AIS patients. The cell counts of OC‐BIRC3 in AIS were less than those in controls. Pseudotime analysis suggested two possible distinct osteoclast differentiation patterns in AIS and control subjects. Monocytes in AIS mainly differentiated into OC‐CRISP3.ConclusionsOur single‐cell analysis first revealed differences existed in the cellular states between AIS patients and healthy subjects and found the differentiation disruption of specific MSC and CPC clusters in AIS. Cell communication analysis provided the possible pathogenesis of osteoblast and chondrocyte differentiation dysfunction in AIS.

A case control study. To determine the clinical outcome of middle-aged patients surgically treated for adolescent idiopathic scoliosis and to compare their outcomes with assessments of age- and sex-matched healthy controls. Several long-term follow-up studies have been published on the clinical outcomes of surgical treatment for adolescent idiopathic scoliosis in patients who have reached their 20s or 30s. However, clinical outcomes in patients who have reached middle age remain unknown. This study included 256 patients surgically treated for adolescent idiopathic scoliosis (AIS) between 1968 and 1988. The Scoliosis Research Society Patient Questionnaire (SRS-22) and Roland-Morris Disability Questionnaire (RDQ) were used for evaluating long-term clinical outcomes. Sixty-six (25.8%; 62 females, 4 males; mean age, 46.0 years [range 34-56]) of the 256 patients responded to the questionnaires. The mean follow-up period was 31.5 (range 21-41) years. Seventy-six healthy age- and sex-matched individuals with neither a history of spinal surgery nor scoliosis were selected as a control (CTR) group. On the basis of the SRS-22 responses, AIS patients had significantly decreased function (AIS: 4.3 ± 0.6, CTR: 4.7 ± 0.5, P < 0.01) and decreased self-image (AIS: 3.0 ± 0.8, CTR: 3.7 ± 0.5, P < 0.01) in comparison with the controls, but the 2 groups were similar with respect to pain (AIS: 4.3 ± 0.6, CTR: 4.2 ± 0.5, P = 0.14) and mental health (AIS: 3.9 ± 0.9, CTR: 3.7 ± 0.7, P = 0.14). The RDQ responses indicated that low back pain was not significantly increased in the AIS group compared with the CTR group (AIS: 1.8 ± 3.5, CTR: 1.4 ± 3.1, P = 0.36). Surgery had no demonstrable adverse effects on pain or mental health in these middle-aged AIS patients 21-41 years after surgery, although the AIS patients did have significantly lower function and lower self-image than the controls.