I came across a pt with a condition today that I had heard of, but was not very familiar with. So prior to seeing this pt I did some research into what it was, any precautions needed to Ax them and Rx ideas…. So I thought id share it incase anyone else comes across it!
The condition was Scheuermann's disease
I asked the other PT’s I was working with about it aswell and found out some handy info..
One of the PT’s actually had it. She had had an Xray for an unrelated problem, and the findings came back to say she actually had Scheuermanns aswell. She had been asymptomatic apart from some occasional mild stiffness in her mid thoracic spine. Another PT’s sister had it, and she said her sister had been very good with her initial PT ex’s and was also now asymptomatic.
So what is it?
Scheuermanns disease refers to osteochondrosis of the secondary ossification centers of the vertebral bodies.
The etiology and pathogenesis are unknown. Probably multifactorial - including mechanical, metabolic, and endocrinologic causes.
The condition affects children aged 13-16 years, and the diagnosis is rarely made in patients younger than 10 years. Usually occurs through adolescence with initial growth spurts. It is quoted in some studies as occurring in 25% of all children to varying degrees. Patients are generally taller comparably than aged peers, and have advanced skeletal versus chronologic age.
Boys are affected more frequently than girls.
Signs and Symptoms:
It usually develops with some sort of spinal deformity, and it can be accompanied by backache and stiffness, usually aggravated by sitting. During the onset, the child's posture often changes. The back curve may become exaggerated.
A diagnosis can be established if wedging of vertebral bodies is evident, in association with other changes, including intervertebral disc space narrowing, Schmorl's nodes, and deformity. These changes can occur with or without pain. Small changes in the growing parts of the vertebrae may be seen. These changes may persist and predispose the lower thoracic spine to degenerative changes later in life.
It usually lasts as a symptomatic pain producing problem between 6 months and 3 years. It is a problem in growing adolescent, and once the growth is finished the condition recovers. The function of the spine and hamstring muscles is usually mildly affected in the long term, emphasizing a need for rehabilitative exercises.
Treatment:
Depends on the severity of pain and the degree of mechanical changes seen on examination. When more severe pain, relative rest from activity is necessary. The traditional treatment was rest, especially in large back braces, however, this treatment was excessive.
Physio involvement and Exercises:
Important to maintain mobility. As the thoracolumbar region is most affected, rotation and stretching ex’s in all ranges is needed. Strengthening exercises associated with postural modification is also important. plus Mx STRATEGIES and BEHAVIOUR MODIFICATION!!
is very important to advise the pt to keep up general fitness by adapting behaviour modification and Mx strategies ie lumbar roll in sitting. A whole body biomechanic Ax can also help eg looking at foot position/need for orthotics ect..
The more the condition is accompanied by pain, back mobility changes, postural deformities and hamstring tightness, the more that rest will be required. This can mean complete rest from active contact sports such as football, and rest from activities requiring repetitive overload, e.g. long distance running, bowling in cricket, gymnastics, ballet dancing, etc.
Sometimes mobilization and manipulation aimed at the stiffness in the lower Thoracic spine can be indicated, although it needs to be performed with care and only continued if improvement seen from that and not attributed to other exercises. swimming can be very beneficial (in heated pool) to encourage spinal rotation.
Scheuermann's disease is just one of the many conditions found in the population incidentally. Treatment should address the signs and symptoms of the presenting condition, and not the incidental radiological findings.
Unfortuntely the pt I had admitted having a ‘denial’ attitude towards having it (she was Dx at age 11) and had not managed herself well. She had had previous PT and not been compliant at all. She was now in her early 40’s and had severe chronic back pain with frequent flare ups. she is now on panadeine forte and valium every 4 hours (and has been for the last 5 years) She was so irritable, the first Rx involved giving TENS for home use (as she had used this before with good effect) and pain Mx strategies. The aim is to get her pain under control, commence Hydro (as this has previously also helped) and gentle ex’s and aim to get her out of bed as she is currently RIB most of the day. she says she is so now so debilitated that she is adament to comply to PT ex's and wish she hadnt let herself get to this stage....
info found from a number of sources including:
http://www.emedicine.com/pmr/topic129.htm
http://members.optushome.com.au/physio/schmann.html
http://www.emedicine.com/pmr/topic129.htm
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just an addition to the post to discuss follow up treatments and the overall experience....
As I did some research into the condition before hand, especially on Rx/Mx strategies, I felt like I may be better prepared to assist this pt. i also talked to some other physio's about the condition, one of which actually had it. They all said that although it can be quite debilitating early on, with good Mx and Rx it can become relativley or completely asymptomatic, and also the pt can 'grow out of it' in their 20's.
the referal from the GP said chronic LBP and may benefit from hydro. It was also interesting to see that this pt was 44 years old.
i had a pre-conceived notion about this pt, that she may have some intermittent pain and be a bit stiff and that i would be able to give some good education and mobility ex's and have a quick and effective outcome.
the pt was barely able to walk in to the cubicle and after 5 mins of subjective Ax asked to lie on the bed as she was in too much pain to sit. I then realised that my whole plan was obsolete and the thing i had to focus on was strategies for immediate pain relief.
she was already taking alot of meds and muscle relaxants, and had had 10/10 pain for 5 years. i had never come across someone who had such severe chronic pain and i didnt know what to do.
we gave her TENS which was beneficial, but she reported she was too sore for any hands on Ax or Rx, so and i then booked her in to see with one of the senior physio's.
the next Ax, the physio was adamant on breaking this cycle of chronic pain, and as Shueremanns doesnt go into later age, and the later effects are generally arthritic, she checked all the investigations for CI's or red flags (there were none) and so did PAIVMS on a few levels in her Lsp as they were completely locked up from not moving for so many years. although this caused pain, she had alot better movement post Rx and was significantly better aligned.
there were a number of lessons i learnt from this experience, due to the little clinical experience i am always going to be coming across new conditions. although it was beneficial to do research to know a bit about the condition, i shouldnt have thought out such a stringent plan of action and focused more on the pt's presentation. it is something hopefully that will come with more experience, being able to relate the subjective and objective findings for a Dx and therefore Rx options. i also learnt not to be overwhelmed with someone who presents in so much pain, my initial reaction was that i didnt want to touch her for fear of causing more pain! but as my senior showed me, someone in such severe chronic pain has been dealing with severe pain, so if it is indicated that PT can help (ie with mob's) then you can actually ease the long term pain even if the Rx is painful. she also showed me how important education is to the pt to let me know they need to break this cycle. i know i will be more prepared next time for someone who presents with severe chronic pain, and not scared to put my hands on!
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