Efficacy of rehabilitation physiotherapy combined with brace correction in patients with mild to moderate scoliosis secondary to cerebral palsy

Abstract

BACKGROUND:

Scoliosis secondary to cerebral palsy is one of the common complications of cerebral palsy in children with cerebral palsy.

OBJECTIVE:

This study aimed to explore the efficacy of rehabilitation combined with brace correction in patients with scoliosis secondary to cerebral palsy.

METHODS:

A total of 52 patients with scoliosis secondary to cerebral palsy were selected from our hospital from April 2019 to April 2022 and divided into the control group and experimental group according to the statistical randomization method ( $n=$ 26 in each group). Control group: mean age (14.28 $\pm$ 2.31) years; 16 males and 10 females. Experimental group: average age (14.24 $\pm$ 2.35) years; 15 males and 11 females. The control group wore scoliosis orthopedic brace, while the experimental group was treated with rehabilitation manipulation and rehabilitation training (including gymnastic training and weight training) on the basis of the control group for 1 year. The clinical efficacy of the two groups was compared and observed; the number of degrees of scoliosis (Cobb angle), the angle of vertebral rotation (AVR) and the distance of the parietal vertebrae from the sacral midline (AVT) were compared before and after treatment; the incidence of adverse events during treatment was observed in the two groups.

RESULTS:

After treatment, both groups showed significant improvement in the overall effectiveness of treatment, Cobb’s angle, AVR and AVT compared with those before treatment ( $P<$ 0.05). The experimental group had a significantly higher overall effective rate of treatment than the control group ( $P<$ 0.05), a significantly smaller Cobb’s angle and AVR than the control group ( $P<$ 0.05) and a significantly shorter AVT than the control group ( $P<$ 0.05). The incidence of adverse events during treatment was lower in both groups and was not significantly different ( $P>$ 0.05).

CONCLUSION:

The combination of rehabilitation physiotherapy and bracing is effective in optimizing the clinical outcome of patients with scoliosis secondary to cerebral palsy, improving their scoliosis dysfunction and providing a high level of safety in treatment.

Keywords

Rehabilitation brace correction cerebral palsy scoliosis outcome

1. Introduction

Cerebral palsy is a common childhood movement disorder, which is a syndrome of chronic movement and postural disorders resulting from abnormal or damaged brain development in early childhood [1]. The disease may result in uncoordinated movements of limb muscles and impaired postural control. These abnormal muscle controls may lead to muscle imbalances and abnormal body postures, which can lead to scoliosis [2]. Scoliosis secondary is one of the common complications of the disease It is a complication of spasticity and relaxation of muscle tissue due to brain lesions, which in turn leads to scoliosis [3]. Patients with this disease mainly present with low back discomfort, lumbar pain, head deviation and spinal curvature, as well as other symptoms such as abnormal gait and uncoordinated arms and legs due to brain muscle control disorders, which not only aggravate the patient’s motor dysfunction but also cause back pain, restricted cardiopulmonary function and other complications, seriously affecting the patient’s health and quality of life [4, 5]. Although traditional brace treatment is effective, there are still limitations such as unstable effect and poor efficacy in severe cases [6]. The various types of scoliosis orthoses currently chosen in the clinic all use fixed and continuous squeezing pressure on the spine and require wearing until the patient reaches skeletal maturity, leading to direct restrictions on normal life and activities of adolescents, and the process is mostly long and painful, and many patients give up wearing them because of intolerance or complications, and the deformity inevitably worsens or recurs. Studies have shown that rehabilitation can effectively delay the progression of various skeletal dysfunctions and improve the quality of life of patients, but few studies have reported its application to the treatment of scoliosis secondary to cerebral palsy [7, 8]. Rehabilitation physiotherapy can be used to correct scoliosis by adjusting the patient’s position and changing the posture of the spine. Common positions include lying position, lateral position, prone position, and the appropriate position can be chosen according to the patient’s specific situation. In addition, the normal growth and development of the spine can be promoted through active spinal activities, including spinal rotation, lateral flexion and forward flexion of the spine, or the use of instruments to assist in the practice [9, 10]. Instruments for treating scoliosis usually consist of one or more metal spools, connectors, and adjustable straps. The metal axes are usually curved to accommodate the degree of scoliosis of the spine. The connectors are used to secure the metal spools and straps to ensure the stability of the brace [11]. The straps are then secured to the patient’s body in locations such as the lower back, chest, or neck. Appropriate pressure is applied to the patient through the above structures to correct the scoliosis and maintain the correct posture of the spine [12]. Based on the above background, this paper investigates the value of rehabilitation combined with bracing in the treatment of patients with scoliosis secondary to cerebral palsy, with the aim of providing a new perspective on the clinical management of the disease.

2. Materials and methods

2.1 Research design

This study is a prospective study, carried out in the form of blinding, a total of 52 cases, randomly divided into the control group and the experimental group, respectively, using different treatment methods, after which the clinical efficacy of the two groups and their adverse reactions were observed (Registration ID: ChiCTR1900019389).

2.2 General information

A total of 52 patients with scoliosis secondary to cerebral palsy at our hospital from April 2019 to April 2022 were selected based on the following criteria: Age 6 to 18; meeting the diagnostic criteria for cerebral palsy [13]; positive and lateral thoracolumbar radiographs in the standing position suggestive of scoliosis; meeting the diagnostic criteria of the International College of Spine Surgery for neuromuscular scoliosis [14]; patients not receiving any form of treatment prior to the pilot study; no anterior thoracolumbar convexity; no history of plastic allergy; patients with spastic cerebral palsy with spasticity grades 0 to 3; mild to moderate scoliosis (Cobb angle $\leqslant$ 70^∘). Exclusion criteria: combination of neurological disorders other than cerebral palsy; combination of skeletal disorders other than scoliosis; combination of respiratory disorders; skin disorders; study subjects who dropped out; unwillingness or inability to cooperate with the study.

2.3 Randomized grouping

The research subjects were divided into a control group ( $n=$ 26) and an experimental group ( $n=$ 26) based on the statistical randomisation method. The sample size is calculated by the formula: $N=Z^{2}$ * $\sigma^{2}$ / $d^{2}$ , where $Z$ is the confidence interval, n is the sample size, d is the sampling error range, and $\sigma$ is the standard deviation, which is 0.5 percent. Generating a set of random numbers by using a table of random numbers. One by one, the study subjects are sequentially assigned to the control and experimental groups in the order of the random number table [15]. Even numbers in the random number table represent the control group and odd numbers represent the experimental group. The allocation process should be unpredictable and non-manipulable. This is a prospective study which started in January 2019 and ended in May 2023. Informed consent was obtained from the patients and their families; the study was approved by a vote of the hospital ethics committee. This study followed the CONSORT guidelines and the Declaration of Helsinki.

2.4 Treatment

2.4.1 Control group

The patients wore a scoliosis orthosis made by Ottobock Germany (Model: J01). Based on the spinal X-ray taken, the degree of scoliosis and flexibility, Ottobock’s rehabilitation engineering therapists designed and manufactured a scoliosis orthosis that is suitable for all patients included. The rehabilitation engineering therapist used a laser alignment device to check the fit of the patients wearing the orthosis and used $X$ -rays to check the amount of pressure and the appropriate area of pressure [16]. Notes on wearing the orthosis: Those with a scoliosis angle of 30^∘ wore the orthosis lying down, first closing the clasp and then pulling the clasp tight, placing both hands at the waist to press the orthosis downwards to stretch the spine upwards. For the first 2 weeks, the orthosis is worn 3 to 4 times a day during the day. On days 1 and 2, the orthosis is worn for 0.5 to 1.0 hours each time and is removed before going to sleep; on days 3 and 4, the orthosis is worn for 2 to 3 hours each time and for 1 to 2 hours at night before going to sleep; on days 5 to 7, the orthosis is worn for 4 hours each time and is still worn when going to sleep, but can be removed if there is difficulty [17]. From the 3rd week onwards, the duration is adjusted to 18h per day until the end of the treatment. The entire course of treatment lasts 1 year.

2.4.2 Experimental group

The experimental group received rehabilitation manual physiotherapy and rehabilitation training on top of the control group. Rehabilitation manual physiotherapy: The rehabilitation physiotherapist applies direct force to the scoliosis joint in the reverse direction, while releasing the tense paraspinal muscles and strengthening the relaxed muscles to balance the muscle tension on both sides of the spine. Each session is 40 minutes, 6 times a week [18]. Rehabilitation training: (1) therapeutic movement exercises, to passively stretch the muscles on the concave side to reduce muscle tone on the concave side; (2) plyometric exercises, to strengthen the muscles of the low back by performing swallow and arch bridge exercises for 20 min twice daily (each movement lasts for 5 s and is repeated after an interval of 3 s) [19]. The entire course of treatment lasts 1 year.

2.5 Efficacy assessment methods

Spinal X-rays taken before and after 48 weeks of treatment were used to compare the number of main bending scoliosis, vertebral rotation angle, distance of the parietal spine from the sacral midline and the effectiveness of treatment in the two groups before and after treatment. The distance between the spinous process of the lateral lordosis and the sacral midline was measured to determine the distance of the parietal deviation from the sacral midline (AVT) [20]. In accordance with the criteria for assessing the effectiveness of scoliosis orthosis treatment correction standardized at the 2005 SRS Annual Meeting [21]. See Table 1.

Table 1
Criteria for assessment of effectiveness

Rank	Standard
Cured	X-ray shows loss of scoliosis deformity and Cobb angle $\leqslant$ 5^∘
Significant effect	reduction of scoliosis deformity and decrease in Cobb’s angle by $>$ 5^∘ or more
Valid	Cobb angle drop $<$ 5^∘
Ineffective	no drop in Cobb angle

Note: Cobb angle is the primary observation, all others are secondary observations.

Table 2

Sociodemographic and clinical characteristics

Norms	Experimental group ( $n=$ 26)	Control group ( $n=$ 26)	$t$ / $\chi^{2}$	$P$
Age (years)	14.24 $\pm$ 2.35	14.28 $\pm$ 2.31	0.062	0.951
Gender (examples)
Male	15	16	0.080	0.777
Female	11	10
Duration of scoliosis (months)	15.25 $\pm$ 7.39	14.92 $\pm$ 6.88	0.167	0.868
BMI (kg/m²)	22.83 $\pm$ 2.16	22.92 $\pm$ 2.13	0.151	0.880
Site of onset (cases)
Chest section	8	6	0.810	0.666
Waist section	10	9
Combined thoracolumbar segment	8	11
Cobb angle (^∘)	25.34 $\pm$ 10.97	25.78 $\pm$ 11.06	0.144	0.886

Note: body mass index (BMI).

2.6 Observation indicators

Compare the total effective rate of treatment between the two groups. Total effective rate of treatment $=$ (cure $+$ significant $+$ effective)/ $n$ $\times$ 100%.

Compare the Cobb angle, AVR and AVT before and after treatment between the two groups.

Observe the incidence of adverse events during treatment between the two groups, including skin ulcers, back pain, thoracic deformity and restricted breathing.

2.7 Statistical methods

SPSS 22.0 software was used to analyse the data. The measurement data are shown as $\bar{x}$ $\pm$ s and compared by $t$ -test. Count data are shown as $n$ (%) and compared by the $\chi$ 2 test. Differences were considered statistically significant at $P<$ 0.05.

3. Results

3.1 Comparison of general information between the two groups

Of the 52 patients, 31 were male and 21 were female; age ranged from 10 to 17 years; duration of scoliosis ranged from 6 months to 24 months; there were 14 cases of thoracic segmental scoliosis, 19 cases of lumbar segmental scoliosis and 19 cases of combined thoracolumbar segmental scoliosis; Cobb angle ranged from 14^∘ to 38^∘. The general data of the two groups were not significantly different ( $P>$ 0.05) and were comparable. See Table 2.

3.2 Comparison of clinical outcomes between the two groups

All 52 patients with scoliosis secondary to cerebral palsy included in the trial were free of derangement and all entered the outcome analysis. After treatment, the total effective rate of treatment was significantly higher in the experimental group than in the control group (92.31% vs 69.23%, $p<$ 0.05). See Table 3.

Table 3
Comparison of clinical outcomes between the two groups [n (%)]

Group	Healing	Visible effect	Effective	Invalid	Total validity
Experimental group ( $n=$ 26)	1 (3.85)	13 (50.00)	10 (38.46)	2 (7.69)	24 (92.31)
Control group ( $n=$ 26)	0 (0.00)	10 (38.46)	8 (30.77)	8 (30.77)	18 (69.23)
$\chi^{2}$					4.457
$P$					0.035

3.3 Comparison of Cobb’s angle, AVR and AVT before and after treatment in both groups

After treatment, both groups showed significant improvement in Cobb angle, AVR and AVT compared with those before treatment ( $P<$ 0.05), with the experimental group having significantly smaller Cobb angle and AVR than the control group ( $P<$ 0.05) and significantly shorter AVT than the control group ( $P<$ 0.05). See Table 4.

Table 4
Comparison of Cobb’s angle AVR grades, AVT grades before and after treatment between the two groups ( $\bar{x}$ $\pm$ s)

Group	Time	Cobb’s angle (^∘)	AVR (^∘)	AVT (mm)
Experimental group ( $n=$ 26)	Before treatment	25.34 $\pm$ 10.97	2.56 $\pm$ 0.42	26.52 $\pm$ 3.44
	After treatment	8.92 $\pm$ 3.20^*#	1.02 $\pm$ 0.25^*#	16.35 $\pm$ 2.62^*#
Control group ( $n=$ 26)	Before treatment	25.78 $\pm$ 11.06	2.53 $\pm$ 0.37	26.12 $\pm$ 3.76
	After treatment	12.62 $\pm$ 3.68^*	1.39 $\pm$ 0.86^*	21.26 $\pm$ 3.28^*

Note: ^*P< 0.05 compared to this group before treatment; ^#P< 0.05 compared to control group after treatment; apical vertebral rotation (AVR); Vertical distance between the center of the parietal vertebrae or intervertebral space and the CSVL (AVT).

3.4 Incidence of adverse events during treatment in both groups

The incidence of adverse events during treatment was lower in both groups and was not significantly different ( $p>$ 0.05). See Table 5.

Table 5
Incidence of adverse events during treatment in both groups [n (%)]

Group	Number of examples	Skin ulcers	Back pain	Thoracic deformities	Restricted breathing	Total incidence
Experimental group	26	1 (3.85)	0 (0.00)	1 (3.85)	0 (0.00)	2 (7.69)
Control group	26	1 (3.85)	1 (3.85)	0 (0.00)	1 (3.85)	3 (11.54)
$\chi^{2}$						0.221
$P$						0.638

4. Discussion

Scoliosis secondary to cerebral palsy is a musculoskeletal lesion that occurs in adolescents and is often accompanied by muscle spasm and paralysis, resulting in excessive muscle contraction on one side and severe muscle atrophy on the other side, which causes the spine to bend to one side, and the condition is more complex, with the scoliotic spine affecting the flexion, extension, lateral flexion, and rotation of each spinal vertebrae segment [22, 23]. The progression of the disease not only affects the spine, thorax, pelvis and other tissues and organs, but even involves the spinal cord causing paraplegia [24], so early correction of scoliosis and control of deformity development are particularly important. The current treatment for this disease can be divided into surgical and non-surgical treatments, of which scoliosis orthopedic surgery has many disadvantages, such as painful operation and postoperative internal fixation affecting height development [25]. Therefore, combining the characteristics of adolescents as the most prevalent group, the principle of treatment for mild to moderate patients is based on early correction and control of deformity progression, and non-surgical treatment is particularly important, taking into account growth and developmental factors [26, 27]. Several studies have demonstrated the efficacy of brace orthoses in halting the progressive worsening of mild to moderate scoliosis deformities. Patients are typically fitted with orthoses during the critical phase of curve progression to deter further advancement and minimize the need for surgical intervention [28, 29]. Notably, the authors observed asymmetrical muscle tone on both sides of the spine in scoliosis patients, a factor considered by some researchers as a primary contributor to scoliosis. While brace correction has proven effective, it is not deemed conclusive [30, 31]. Therefore, in this study, the anatomical and normal physiological characteristics of the spine were considered, and rehabilitation physiotherapy techniques were combined with brace braces to improve the corrective effect.

It was found that after treatment, the total efficiency of treatment in the experimental group was significantly higher than that in the control group, the Cobb angle and AVR were significantly smaller than that in the control group, and the AVT was significantly shorter than that in the control group, suggesting that rehabilitation treatment combined with brace correction can effectively optimize the clinical efficacy in treating patients with scoliosis secondary to cerebral palsy. Analyzing the reasons, under the intervention of rehabilitation manipulative therapy, the target muscles in the scoliotic vertebral body area of the patients achieved the effect of modification and fixation of the motor program involving the target muscles due to the direct influence of external forces, their neural control ability was improved, the muscle tension on both sides of the spine was gradually balanced, and the forces on both sides of the vertebral body were equalized, thus increasing the coordination of spinal movements, adjusting the proprioceptive and motor control of the spine, regulating asymmetric stress on both sides of the scoliosis vertebrae, and promote the recovery of spinal vertebral joint function and subtle flexion [32, 34]. In addition, patients in the experimental group underwent active functional rehabilitation training, focusing on motor pattern strengthening, which could enhance the strength of the lumbar back muscles and improve overall trunk coordination [35, 36]. In addition, the development of scoliosis secondary to cerebral palsy is closely related to the regulation of the nervous system and the strength and flexibility of the muscles around the spine, and through rehabilitation manipulative therapy and functional training, the development and functional recovery of the neuromuscular system can be promoted, and the transmission of information and coordination between neurons and muscles can be improved, thus reducing symptoms such as paralysis and muscle spasm and facilitating the correction of scoliosis [37, 38]; it can promote muscle development and recovery, improve muscle strength and flexibility, and reduce the symptoms of scoliosis; it can improve the curvature and bending angle of the spine and reduce the degree of scoliosis by correcting patients’ poor posture; it can also maintain muscle strength and flexibility to ensure the durability of the treatment effect and prevent the recurrence of scoliosis [39, 40]. In addition, this study also found that the incidence of adverse events during treatment was low in both groups with no significant differences, suggesting that rehabilitation combined with brace orthosis treatment is also safer [41]. The authors concluded that in patients with mild to moderate scoliosis secondary to cerebral palsy, wearing a brace orthosis in combination with rehabilitation physiotherapy can directly and accurately apply force to the target muscles and vertebrae, and the force is stronger and more durable. Sathish et al. [42] found that therapeutic exercise training can effectively improve the daily mobility of scoliosis patients and increase their life satisfaction. Zapata et al. [43] found that therapeutic exercise training can significantly reduce the degree of Cobb’s angle in scoliosis patients with significant efficacy. All of the above literature findings are compatible with the results of this study. In addition, a study by Ng et al. [44] showed that rehabilitative manipulative therapy improved the efficacy of scoliosis secondary to cerebral palsy and significantly reduced Cobb’s angle, but did not have a significant effect in improving AVT, which may be related to the large sample size of the study and incomplete consistency of the rehabilitative manipulative maneuvers. Rahmatika et al. [45] demonstrated that rehabilitative manipulative therapy did not increase the number of adverse events that occurred during scoliosis treatment, and this result is consistent with the conclusion that the rehabilitative therapy methods in this study were safe. adverse effects that occur during the process, a result that is consistent with the conclusion that the rehabilitative treatment method was safer in this study.

Furthermore, it is essential to acknowledge the limitations of this study, including a small sample size and a single center design. To establish more definitive conclusions, future multi-center, large-sample studies are required. Additionally, the scope of this study is restricted to mild to moderate scoliosis patients. Future investigations will prioritize exploring rehabilitation strategies for individuals with severe scoliosis.

5. Conclusion

In conclusion, rehabilitation physiotherapy combined with brace correction can effectively optimize the clinical efficacy of treating patients with scoliosis secondary to cerebral palsy and improve their scoliosis dysfunction with high treatment safety.

Author contributions

ZY, QPL and YYB conceived and designed experiments; ZY, QPL and YYB performed experiments and data analysis; YPH, MMW, QG, LYY and XLL provided technical support, data collection and analysis; and ZY, QPL and YYB wrote the manuscript. All authors read and approved the final manuscript.

Data availability

The data are available from the corresponding author upon request.

Ethical approval

The study approved by the Ethics Committee of the Children’s Rehabilitation Center of Ordos Traditional Chinese Medicine Rehabilitation Hospital (IRB approval no. 2019032).

Funding

The study was supported by the Shanghai Philosophy and Social Science Planning Project: Study on Risk prediction of Abnormal spinal curvature in Adolescents and Multi-Agent Collaborative Intervention (No. 2022BTY003).

Informed consent

Written informed consent was obtained from all patients.

Footnotes

Conflict of interest

None of the authors declare any conflicts of interest.

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