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* From the Physical Therapy Department (Ms. Alves), Santa Isabel Hospital; and Internal Medicine Department, Pneumology Division (Dr. Stirbulov), and Orthopedics Department (Dr. Avanzi), Santa Casa School of Medicine, São Paulo, Brazil.
Correspondence to: Vera Lúcia dos Santos Alves, PT, MBS, Av. Dr. Arnaldo, 2088, Sumaré, CEP:01255-000, São Paulo, SP, Brazil; e-mail: fisioterapiasc{at}uol.com.br
Abstract
Background: Idiopathic adolescent scoliosis (AIS) causes not only spinal deformities but rib cage abnormalities that lead to abnormal volumes and pulmonary capacity on pulmonary function testing (PFT). The objective of this study was to analyze the impact of a physical rehabilitation program on respiratory function in surgical patients with AIS.
Methods: From October 2003 to October 2004, a total of 34 patients (age range, 10 to 18 years) presenting with AIS and a thoracic curvature between 45° and 88° were studied prospectively at a tertiary academic hospital. The patients underwent clinical and radiographic evaluations of the vertebral deformity, chest radiographs, PFT, evaluation of peak expiratory flow, and 6-min walk tests (6MWTs) before and after joining a physical rehabilitation program for 4 months.
Results: An improvement in FVC, inspiratory capacity, FEV1, expiratory reserve volume, and performance assessed by 6MWT were observed after rehabilitation.
Conclusions: Global conditioning improved after the rehabilitation program. This was expressed by both PFT and 6MWT results.
Key Words: adolescents • measurements of pulmonary volume • physical therapy • rehabilitation • scoliosis • spirometry
Patients with idiopathic adolescent scoliosis (AIS) present with abnormal volumes and pulmonary capacity on pulmonary function testing (PFT).12345 A number of studies678910 have shown a strong correlation between abnormal pulmonary function and the severity of the spinal deformity. However, other factors, such as the distortion of the rib cage associated with the vertebral deformity, may also contribute to the altered ventilation mechanics and to the reduced capacity of these individuals to perform physical activities. Progressive and chronic muscle weakness contribute to the lack of cardiorespiratory and musculoskeletal conditioning. These associated factors play an important role in final reduced pulmonary volumes.11121314151617
Pulmonary problems have been more frequently reported in adolescents with spine curvature > 45°. Lethal cardiorespiratory abnormalities are known to develop in these patients, demanding surgical correction of the spinal deformities.18192021
Despite the extensive literature describing pulmonary abnormalities in patients with AIS, there are a lack of reports on the contribution of physical and pulmonary rehabilitation for these patients. Thus, the objective of this study was to evaluate the impact of physical rehabilitation on the respiratory function of patients with AIS.
Materials and Methods
From October 2003 to October 2004, a total of 34 adolescents from the spine division of the orthopedics department of a tertiary teaching hospital were studied. The patients ranged in age from 10 to 18 years (mean, 13 years and 11 months); 31 patients were female and 3 patients were male. The patients were surgical candidates for correction of AIS spinal curves > 45° and had no history of pulmonary and cardiovascular problems (Fig 1 ). The patients were included in the study only after formal informed consent was provided. Exclusion criteria were spinal curvature < 45°, unwillingness to comply with the rehabilitation program as designed, or current or previous heart and lung disease.
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All of the patients underwent clinical and radiographic evaluation of the vertebral deformity, chest radiographs, PFT, evaluation of the peak expiratory flow (PEF) following exercise, and 6-min walk test (6MWT), before and after joining a physical rehabilitation program for 4 months. This rehabilitation protocol was inspired by the work of Bouchard and Shepard22 and Covey et al,23 who proposed three weekly sessions of 60 min each supervised by a qualified physical therapist. The first 10 min of the sessions were for warm-up exercises (stretching and low-energetic-demand aerobic exercises, such as slow and progressive walks); 40 min of the session concentrated on aerobic exercises on a treadmill or stationary bicycle with the patient working at 60 to 80% of his/her maximum heart rate (HR)24; and the final 10 min of the session were for cooling down and relaxing (stretching and low-energetic-demand aerobic exercises followed by relaxation techniques).
Statistical analysis was performed using the t test, Wilcoxon test, analysis of variance, and Kruskal-Wallis, where applicable, with a significance level of 5%. This study was approved by the Institutional Ethics Committee on Medical Research.
Results
The types of spinal curvature found in the studied population were as follows: a single high right thoracic curve (n = 12); a single high left thoracic curve (n = 1); combined high right thoracic curve and lower left lumbar curve (n = 20); and combined high left thoracic curve and lower right lumbar curve (n = 1). The angular value of the thoracic deformities ranged from 45° to 88°, with mean initial and final value of 60° and median initial and final value of 59°. The angular value of the kyphosis ranged from 9° to 69°, with an initial and final mean of 39° and initial and final median of 40°. The rib hump measured through the Adams test ranged from 23 to 86 mm, with initial and final mean of 55 mm and initial and final median of 52°. Using the degree of vertebral rotation measured on plain radiographs according to criteria of Nash and Moe,25 7 patients were classified as stage I, 24 patients were classified as stage II, and 3 patients were classified as stage III.
Plain chest radiograph obtained in all patients and were analyzed by experienced independent radiologists. No lung abnormalities were found.
PFT
All the measured parameters of PFT were significantly lower in the studied population than the standard for age and gender, both before and after the rehabilitation program. A significant improvement in the FVC, FEV1, PEF, slow vital capacity, inspiratory capacity (IC), and expiratory reserve volume were observed after rehabilitation (Table 1
). The same trend of improvement was observed for the forced expiratory flow (FEF25–75%), FEV1/FVC ratio, and FEF25–75%/FVC ratio, although these differences were not statistically significant (Table 2
).
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Discussion
AIS is prevalent in female patients,22026 and the most common deformity is the single high right thoracic curve.8202627282930 The current study conforms to these findings.
Several studies34567810273132333435 that have focused on the factors that influence the onset of restrictive disease in AIS state that the greater the spinal deformity, the greater the compression on the lungs with consequent smaller lung volumes.10 In the current series, both baseline and postrehabilitation PFT parameters were lower that those attributed to the normal population with same age and gender. Spinal deformity should be preferably evaluated by a combination of parameters, such as vertebral rotation, rib cage deformities, and possible limitations of the respiratory muscles, which when combined distort the mechanics of the chest and cause impaired pulmonary function to different degrees.11121314151617
Several authors24151718363738 have reported on the difficulties encountered by patients with AIS in performing physical activities. According to Shneerson,4 up to 80% of the patients with such difficulties have ventilation problems. A direct relation between the decrease in maximum aerobic capacity and FVC has also been reported.4815 It has also been observed that physical conditioning improves the FCV and IC of patients and positively influences the maximum aerobic capacity with improvement in HR and RR as well.30
Studies3137 that have analyzed pulmonary volumes before and after surgical correction in patients with spinal deformities have not found significant improvement. In fact, a trend of decrease in PFT parameters has been reported in the first 2 years after corrective surgery.3738 These findings emphasize the need to improve the respiratory capacity of such patients prior to surgery.
Lacasse et al39 state that global physical activities in patients with COPD improve peripheral muscle function and reduce the index of perceived effort, but the authors also call attention to the need for associated specific respiratory muscle rehabilitation for final improvement in the overall pulmonary function. This study39 referred to patients with COPD and not rib cage abnormalities, but the same rationale regarding the importance of physical conditioning in long-term patients can be transferred to AIS patients.
The current study found a significant increment in FVC, IC, forced expiratory volume, and FEV1, even though no specific respiratory muscle training was used. This can be explained by the standard training offered, which has been poorly defined in other studies1527282930 of patients with AIS. The current program allowed optimum ventilation efficiency with a small increase in SpO2. Although our study was not designed to establish improvement in ventilation/perfusion, it is expected that an increase in SpO2 and a decrease in HR and RR may lead to improved ventilation/perfusion after rehabilitation.404142 Studies specifically designed for this purpose could better illustrate such association.
The small increase in the FEF25–75% was not significant due to the weak reproducibility of this index.34 The FEV1/FVC and FEF25–75%/FVC coefficients did not show significant differences either, but this may be explained by the similar increases in all these parameters.
The observed increase in the distance walked during 6MWT is also a predictive factor of the improvement in the tolerance and capacity to exercise,4344 especially when associated to a decrease in the index of perceived effort. The absolute values of the latter parameter show a linear correlation with physiologic factors and, when associated with increments in SpO2, are directly correlated to cardiorespiratory conditioning.4546 We found no reports in the literature of the use of 6MWT for the evaluation of patients with AIS; however, in this study, a significant increase in the distance walked during this test was observed after completion of the 4-month rehabilitation protocol.
There was no significant modification in the physical characteristics of spinal and secondary deformities, such as rib cage hump, vertebral rotation, angular values of the scoliosis, and kyphosis after the 4-month training period. Thus, these parameters did not influence the final respiratory function or physical capacity of our patients.
Conclusions
The physical activity proposed by the rehabilitation protocol was beneficial to patients, improving their pulmonary capacity and volumes, and performance on 6MWT, and decreasing the perceived effort, HR, and RR, suggesting that patients with AIS who are surgical candidates may benefit from preoperative physical rehabilitation.
Footnotes
Abbreviations: AIS = adolescent idiopathic scoliosis; FEF25–75% = forced expiratory flow; HR = heart rate; IC = inspiratory capacity; 6MWT = 6-min walking test; PEF = peak expiratory flow; PFT = pulmonary function testing; RR = respiratory rate; SpO2 = peripheral oxygen saturation
The authors disclose that they have no conflicts of interest related to this topic.
Received for publication December 1, 2005. Accepted for publication January 30, 2006.
References
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