Scheuermann's disease: cure and physiotherapy treatment

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Scheuermann's disease, or Scheuermann's diseaseis a pathology characterised by a hypercous condition of the thoracic/thoracolumbar spine (1). Hypercosis is defined as a pathological increase (>40°) in the physiological curve of the dorsal tract. 

It is a rather rare syndrome, affecting 0.4 -10% of the population (1). It mainly manifests itself at a young age and is the most frequent disorder in this population after scoliosis. Given the age range in which it manifests itself, it is important to recognise the psychological and social significance of this pathologywhich creates discomfort and altered body image in affected young people (2).

In most cases it is a benign disorder and therefore rarely requires surgery. The progression of the disorder stops with the end of the subject's development.

The main features of this syndrome will be explained below.

Scheuermann's disease: what is it?

Scheuremann's disease, or juvenile hyperkyphosis, is a pathology that affects the thoracic spine. It can be distinguished into typical (apex of the kyphotic curve at T7-T9) and atypical, when the peak of the kyphotic curve is at the thoracolumbar level (t10-12) (1).

This curve is defined as fixed, as it does not reduce with extension and is accentuated by the anterior flexion movement of the trunk. This characteristic is one of the key points in the differential diagnosis with a postural defect.

Scheuermann's disease is also referred to as juvenile vertebral osteochondrosis. Indeed, manifests itself mainly in adolescencebetween the ages of 12 and 17 (3). Osteochondrosis refers to a pathology of the bone growth cartilage (in this case of the growth cores of the vertebral plates), which results in a defect in the development of the vertebra itself. Thus, the vertebrae of affected individuals, particularly in the thoracic tract, take on a wedge-shaped appearance, which manifests itself macroscopically in increased kyphosis. 

From a diagnostic point of view, Scheurmann's disease is evidenced on instrumental examinations by the presence of at least 3 vertebrae of wedge-shaped appearance with an anterior orientation of at least 5° (1). On instrumental examination images, reduction of the interbody space, progressive dehydration of the intervertebral disc and the presence of Schmorl nodules (protuberances of the cartilage of the nucleus pulposus of the intervertebral disc) are observed (4).

Scheuermann's disease: causes

Possible causes of this disorder include:

• Hereditary growth hormone abnormalities (1)
• Genetic predisposition (1)
• Different mineralisation and ossification of the vertebral plate with non-proportional body growth and consequent wedge-shaped appearance (3)

Scheuermann's disease: symptoms and signs

The kyphotic angle can be more or less wideTherefore, different signs and symptoms are distinguished according to severity. 

Symptoms: 

• Pain (when sitting and after physical activity, in about 1/5 of the subjects and not in the acute phase) (2)
• Balance problems or feeling of instability

Signs: 

• Alteration of physiological curves by compensation (lumbar and cervical hyperlordosis) (1)
• Anteposition of the head and protrusion of the shoulders, resulting in restriction of the anterior flexion movement of the shoulder (2)
• Reduction of ROM (Range Of Motion) in trunk extension (1)
• Stiffness of hamstrings (3.5)

Associated problems: 

• In advanced stages: cardiac and pulmonary problems, resulting in reduced lung capacity and exercise tolerance (1,6)
• Spondylolysis and scoliosis (1)

Scheuermann's disease: Treatment

The treatment differs depending on the width of the kyphosis angle. Generally, the following criteria apply (3):

• Kyphosis < 60°, asymptomatic: stretching therapeutic exercise.
• Kyphosis 60-80°: corset for 12-24 months/ 16-23 h per day. The corset does not have the function of reversing or modifying the curve, but allows the progression of the curve to be limited. Among the most commonly used types are the Milkwaukee, Kyphologic, Boston. It is preferable to use it for subjects still in the growth phase. 
• Kyphosis > 75° with major deformity/pain/neurological deficit: surgery.

surgical treatment

I two main surgical approaches are the antero-posterior (involving posterior fixation with titanium rods and an anterior release with thoracic access), and posterior fixation alone (4). The low incidence of pathology and the low percentage of patients undergoing the operation have not led to the identification of a gold standard for the surgical approach, although both are thought to be valid without major differences (7).

In general, surgery is the last option to be considered, as there is not enough data on its long-term effectiveness. The literature reports a frequency of complications of 10% and 5% of recurrence. Full recovery after surgery has an average duration of 2 years (4).

Physiotherapy care and treatment

The physiotherapist fits into the care pathway of the patient with Scheuermann's disease from a biopsychosocial perspective, educating the patient about increasing awareness of their disorderthus improving adherence to treatment. The educational role is fundamental for patients wearing a corset, with the aim of making them autonomous in the use of the orthosis (3). Therapy for this condition involves the setting up of a therapeutic exercise programme aimed at the following objectives:

• Stretching of the flexor muscles of the knee (hamstrings) (2,3,5,8), suboccipital and pectoral muscles (2,8)
• Reinforcement of the extensor muscles of the trunk (1.5) and abdomen (5)
• Postural education to facilitate the performance of ADLs (Activities of Daily Living) (3.5)

Since these are young patients, it is essential that physical activity is encouraged, taking care to recommend low-impact aerobic sports, such as swimming or cycling. Recommended sports include gymnastics and those involving movements and positions held in hyperextension. It is good to avoid activities involving jumping or high impact, which would lead to overloading of the spine (9).

Scheurmann's disease: exercises

The exercises proposed for Scheuermann's disease patients are aimed at: 

• stretching of stiff and short muscles, such as the suboccipital, pectoral and hamstrings. 
• strengthening of the stabilising muscles of the abdomen and thoracic extensors
• the increase in ROM in extension of the column

Conclusion

Scheuermann's disease is a juvenile disease affecting the thoracic spine and has a high psychosocial impact on the adolescent's general health and quality of life. The alteration of the thoracic curve can lead to dysfunctions in the movement of the spine, with the acquisition of incorrect postural attitudes and altered muscle relationships. Physiotherapeutic treatment aims to restore muscle balance and recover ROM. Surgical treatment is used as a last option and does not guarantee certain results.

Further studies will be useful to investigate the aetiology of this condition and to identify a specific, targeted exercise protocol for this type of patient.

Bibliography

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2. Bezalel T, Carmeli E, Levi D, Kalichman L. The Effect of Schroth Therapy on Thoracic Kyphotic Curve and Quality of Life in Scheuermann's Patients: A Randomized Controlled Trial. Asian Spine J. 2019 Jun;13(3):490-499. doi: 10.31616/asj.2018.0097. Epub 2019 Jan 24. 
3. Mansfield JT, Bennett M. Scheuermann Disease. 2021 Jul 26. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. 
4. Arlet V, Schlenzka D. Scheuermann's kyphosis: surgical management. Eur Spine J. 2005 Nov;14(9):817-27. doi: 10.1007/s00586-004-0750-0. Epub 2005 Apr 14. 
5. Bettany-Saltikov J, Turnbull D, Ng SY, Webb R. Management of Spinal Deformities and Evidence of Treatment Effectiveness. Open Orthop J. 2017 Dec 29;11:1521-1547. 
6. Lorente A, Barrios C, Lorente R, Tamariz R, Burgos J. Severe hyperkyphosis reduces the aerobic capacity and maximal exercise tolerance in patients with Scheuermann disease. Spine J. 2019 Feb;19(2):330-338. 
7. Riouallon G, Morin C, Charles YP, Roussouly P, Kreichati G, Obeid I, Wolff S; French Scoliosis Study Group. Posterior-only versus combined anterior/posterior fusion in Scheuermann disease: a large retrospective study. Eur Spine J. 2018 Sep;27(9):2322-2330. 
8. Papagelopoulos P, Mavrogenis A, Savvidou O, Mitsiokapa E, Themistocleous G, Soucacos P. Current concepts in Scheuermann's kyphosis. Orthopedics 2008;31(1):52-60
9. Damborg F, Engell V, Andersen M, Kyvik KO, Thomsen K. Prevalence, concordance, and heritability of Scheuermann kyphosis based on a study of twins. J Bone Joint Surg Am. 2006 Oct;88(10):2133-6.