Accessory navicular syndrome refers to a condition when the accessory navicular bone and/or the attachment of the posterior tibialis tendon are irritated and inflamed. Treatment generally consists of non-steroidal anti-inflammatory drugs, physiotherapy, custom foot orthoses, shoe modification and steroid injection. Surgery is only indicated when all the conservative modalities fail to provide adequate symptomatic relief.
The accessory navicular (AN) is an accessory ossicle anatomically located on the medial side of the foot, proximal to the navicular and is continuous with the tibialis posterior tendon. It affects 4 - 20% of the population [3-5] and affects both feet in 50 - 90% of the cases . Kalboureh., et al. (2017) reviewed the foot radiographs of 1240 patients with chronic foot pain and reported that the incidence of AN varies with the three subtypes (Figure 1), which include: A case of accessory navicular syndrome which was refractory to conservative treatment but responded to vitamin D supplementation was reported. Prescription foot orthoses and repeated focused shockwave treatments did not resolve the pain in over one year. In view of her being a vegan for over 40 years, she was checked for vitamin D status. Results showed that she was moderately deficient in 25-hydroxyvitamin-D. Supplementation of 2,000 IU of vitamin D3 daily resulted in a reduction of VAS pain score from 4 to 0.5 in two weeks. The deficiency of vitamin D should be considered in patients with refractory accessory navicular syndrome.
Scoliosis is prevalent in elderlies over the age of 60. Of the different curve types, the thoracolumbar curve is the most common curve type operated upon, as it is associated with marked trunk shift and disability. Current physiotherapy treatments consist of electrotherapy, aquatic exercises, core-strengthening exercises, and dry needling. Outcome of these treatments has not been satisfactory. Long-term successful rate of conservative treatment of symptomatic adult scoliosis is low, as the treatment addresses symptoms but not the biomechanics involved in adult scoliosis. Recent studies have shown that physiotherapeutic scoliosis-specific exercises (PSSE) and bracing stabilized the curves in 80% of the subjects. Thus PSSE and bracing should be added to the standard physiotherapy care in the management of symptomatic adult scoliosis. For asymptomatic patients with thoracolumbar curve that has an increased risk of progression, PSSE should be considered as preventative exercises. Patients who do not respond to conservative treatments and have significant spinal stenosis should be referred for surgery.
Various methods have been used to treat Bell’s palsy, ranging from physical therapy, medications, to decompression surgery. The standard treatment is currently a prescription of corticosteroids with antiviral agents. All these medical approaches yield mixed results, and there is a need for additional investigation on treatment options. Recent studies have shown that facial palsy responds positively to phototherapy treatment, in particular the low-energy infrared laser. In the present report, we attempt to review the current clinical application of phototherapy, representing a conservative and safe medical approach in the treatment of Bell’s palsy. A literature review was performed. The results of the included studies suggested that low-level laser therapy (LLLT) is a significant treatment modality for patients recovering from Bell’s palsy. However, the risk of bias of the included studies was relatively high, and further research could change the estimate of effect of this treatment option. In conclusion, there is currently a moderate evidence to support the effectiveness of low-level laser therapy in the treatment of Bell’s palsy. Further randomized double-blind placebo-controlled trials and high-quality studies are needed to determine with certainty the benefits of this treatment option for Bell’s palsy.
Several theories have been proposed to explain the etiology of adolescent idiopathic scoliosis (AIS) until present. However, limited data are available regarding the impact of vitamin D insufficiency or deficiency on scoliosis. Previous studies have shown that vitamin D deficiency and insufficiency are prevalent in adolescents, including AIS patients. A series of studies conducted in Hong Kong have shown that as many as 30% of these patients have osteopenia. The 25-hydroxyvitamin D3 level has been found to positively correlate with bone mineral density (BMD) in healthy adolescents and negatively with Cobb angle in AIS patients; therefore, vitamin D deficiency is believed to play a role in AIS pathogenesis. This study attempts to review the relevant literature on AIS etiology to examine the association of vitamin D and various current theories. Our review suggested that vitamin D deficiency is associated with several current etiological theories of AIS. We postulate that vitamin D deficiency and/or insufficiency affects AIS development by its effect on the regulation of fibrosis, postural control, and BMD. Subclinical deficiency of vitamin K2, a fat-soluble vitamin, is also prevalent in adolescents; therefore, it is possible that the high prevalence of vitamin D deficiency is related to decreased fat intake. Further studies are required to elucidate the possible role of vitamin D in the pathogenesis and clinical management of AIS.
Study design: This is a pilot prospective cohort study.
Objectives: To investigate if outpatient Schroth exercises (SBP) affect thoracolumbar or lumbar curves in adult scoliosis patients.
Background: Adult scoliosis tends to progress and is associated with an increased prevalence of low back pain. The outcome of conservative treatment is not satisfactory, as treatment is not directed towards spinal deformity. This study investigates if SBP influences the thoracolumbar and lumbar curves in patients with adult scoliosis.
Materials and methods: Adult patients with thoracolumbar and lumbar curves ≥ 20o were taught SBP exercises once weekly for 4 weeks. They then performed the exercises at home three times a week, for 9 months. Baseline measurements included Cobb angles, coronal offset, sagittal vertical axis (SVA), T4-12 kyphosis, L1-S1 lordosis, sacral slope, pelvic incidence and pelvic tilt. They were compared to post-intervention measurements, using paired t tests.
Results: SBP exercises statistically significantly decreased the Cobb angle (p = 0.0032), improved the ATR (p = 0.012), increased the sacral slope (p = 0.03), decreased the pelvic tilt (p = 0.0032) and the SVA (p = 0.032).
Conclusion: The SBP exercises improved the Cobb angles and SVA in adult scoliosis patients with thoracolumbar and lumbar curves.
The paper reviews the current imaging methods in the diagnosis and monitoring of patients with adolescent idiopathic scoliosis. Radiography is generally used in the initial diagnosis of the condition. Postero-anterior erect full spine radiograph is generally prescribed, and is supplemented by lateral full spine radiograph when indicated. To reduce the radiation hazard, only the area of interest should be exposed, and follow-up radiographs should be taken with as few projections as possible. When available, EOS® stereoradiography should be used. The radiation of the microdose protocol is 45 times less than that of the conventional radiography. Surface topography offers another approach to monitoring changes of curvatures in AIS patients. Recently, 3D ultrasound has been found to be able to measure the Cobb angle accurately. Yet, it is still in the early developmental stages. The inherent intrinsic and external limitations of the imaging system need to be resolved before it can be widely used clinically. For AIS patients with atypical presentation, computed tomography (CT) and/or magnetic resonance imaging (MRI) may be required to assess for any underlying pathology. As CT is associated with a high radiation dose, it is playing a diminishing role in the management of scoliosis, and is replaced by MRI, which is also used for pre-operative planning of scoliosis.
The different imaging methods have their limitations. The EOS® stereoradiography is expensive and is not commonly available. The surface topography does not enable measurement of Cobb angle, particularly when the patient is in-brace. The 3D ultrasound scanning has inherent intrinsic technical limitation and cannot be used in all subjects. Radiography, however, enables diagnosis and monitoring of the adolescent idiopathic scoliosis (AIS). It is thus the gold standard in the evaluation and management of scoliosis curves.
The review evaluates the up-to-date evidence for the treatment of spinal deformities, including scoliosis and hyperkyphosis in adolescents and adults.
Material and Methods:
The PubMed database was searched for review articles, prospective controlled trials and randomized controlled trials related to the treatment of spinal deformities. Articles on syndromic scoliosis were excluded and so were the articles on hyperkyphosis of the spine with causes other than Scheuermann’s disease and osteoporosis. Articles on conservative and surgical treatments of idiopathic scoliosis, adult scoliosis and hyperkyphosis were also included. For retrospective papers, only studies with a follow up period exceeding 10 years were included.
The review showed that early-onset idiopathic scoliosis has a worse outcome than late-onset idiopathic scoliosis, which is rather benign. Patients with AIS function well as adults; they have no more health problems when compared to patients without scoliosis, other than a slight increase in back pain and aesthetic concern. Conservative treatment of adolescent idiopathic scoliosis (AIS) using physiotherapeutic scoliosis-specific exercises (PSSE), specifically PSSR and rigid bracing was supported by level I evidence. Yet to date, there is no high quality evidence (RCT`s) demonstrating that surgical treatment is superior to conservative treatment for the management of AIS. For adult scoliosis, there are only a few studies on the effectiveness of PSSEs and a conclusion cannot as yet be drawn.
For hyperkyphosis, there is no high-quality evidence for physiotherapy, bracing or surgery for the treatment of adolescents and adults. However, bracing has been found to reduce thoracic hyperkyphosis, ranging from 55 to 80° in adolescents. In patients over the age of 60, bracing improves the balance score, and reduces spinal deformity and pain. Surgery is indicated in adolescents and adults in the presence of progression of kyphosis, refractory pain and loss of balance.
The available evidence reviewed has suggested that different approaches are needed towards the management of different spinal deformities. Specific exercises should be prescribed in children and adolescents with a Cobb angle in excess of 15°. In progressive curves, they should be used in conjunction with bracing. Clarity regarding differences and similarities is given as to what makes PSSE and PSSR specific exercises. As AIS is relatively benign in nature, conservative treatment should be tried when the curve is at a surgical threshold, before surgery is considered. Similarly, bracing and exercises should be prescribed for patients with hyperkyphosis, particularly when the lumbar spine is afflicted. Surgery should be considered only when the symptoms cannot be managed conservatively.
There is at present high quality evidence in support of the conservative treatment of AIS. The current evidence supports the use of PSSE, especially those using PSSR, together with bracing in the treatment of AIS. In view of the lack of medical consequences in adults with AIS, conservative treatment should be considered for curves exceeding the formerly assumed range of conservative indications.
There is, however a lack of evidence in support of any treatment of choice for hyperkyphosis in adolescents and spinal deformities in adults. Yet, conservative treatment should be considered first. Yet to date, there is no high quality evidence (RCT`s) demonstrating that surgical treatment is superior to conservative treatment for the management of AIS and hyperkyphosis. Additionally, surgery needs to be considered with caution, as it is associated with a number of long-term complications.
Physiotherapeutic Scoliosis-Specific Exercises (PSSE) and bracing have been found to be effective in the stabilization of curves in patients with Adolescent Idiopathic Scoliosis (AIS). Yet, the difference among the many PSSEs and braces has not been studied. The present review attempts to investigate the role of curve correction in the outcome of treatment for PSSEs and braces.
Material and Methods:
A PubMed manual search has been conducted for studies on the role of correction in the effectiveness of PSSE and bracing. For the PSSEs, the key words used were “adolescent idiopathic scoliosis, correction, physiotherapy, physical therapy, exercise, and rehabilitation.” For bracing, the key words used were “adolescent idiopathic scoliosis, correction and brace”. Only papers that were published from 2001-2017 were included and reviewed, as there were very few relevant papers dating earlier than 2001.
Results:The search found no studies on the role of correction on the effectiveness of different PSSEs. The effectiveness of different PSSEs might or might not be related to the magnitude of curve correction during the exercises. However, many studies showed a relationship between the magnitude of in-brace correction and the outcome of the brace treatment.
Discussion:The role of correction on the effectiveness of PSSE has not been studied. In-brace correction, however, has been found to be associated with the outcome of brace treatment. An in-brace correction of < 10% was associated with an increased rate of failure of brace treatment, whereas an in-brace correction of >40-50% was associated with an increased rate of brace treatment success (i.e. stabilization or improvement of curves). Thus, in the treatment of AIS, patients should be advised to use highly corrective braces, in conjunction with PSSE since exercises have been found to help stabilize the curves during weaning of the brace. Presently, no specific PSSE can be recommended.
Conclusion:Braces of high in-brace correction should be used in conjunction with PSSEs in the treatment of AIS. No specific PSSE can be recommended as comparison studies of the effectiveness of different PSSEs are not found at the time of this study.
The effectiveness of spinal bracing in the treatment of adolescent idiopathic scoliosis has been controversial. Some studies have shown that bracing is only as effective as observation, whilst others have shown that bracing is superior to observation, halting progression and effectively reducing progression to surgical threshold. Recently, some studies have even shown improvement of curves with bracing. Yet, many of these studies have been judged to be of low methodological quality. In 2005, the Scoliosis Research Society (SRS) attempted to standardize the inclusion criteria and outcome measurements for bracing studies, to enable comparison among studies. In the guidelines, progression of ≤ 5o is regarded as success. It is apparent that SRS did not regard improvement of curves probable. Improvement which is defined as a decrease of ≥ 6o was not proposed until 2009. This may reflect an improvement in outcome with bracing in the last one to two decades.
The present review attempts to determine if there is a trend of improvement in outcome with bracing in the last 3 decades. Manual literature search was made in the PubMed using the keywords of brace, conservative treatment and adolescent idiopathic scoliosis. Relevant English articles on the outcome of wearing rigid braces from 1990-2016 were retrieved and reviewed to determine if there is a trend towards improvement in outcome with bracing and if bracing halts progression and improves curves.
Results show that there has been an apparent improvement in the effectiveness of bracing in reducing surgical rate since 2005. Close inspection shows that the reduction in surgical rate is not due to an improvement over time, but is related to the types of brace. The effectiveness of Boston brace is not consistent over the years. The surgical rates vary and no consistent trend of improvement can be discerned in the last 2-3 decades. The surgical rate reported in 2007 for TLSO was as high at 79% and that in 2014 for Boston brace was 28%. The surgical rates with European braces (Progressive Action Short Brace (PASB), Cheneau derivatives and Lyon/Sforzesco braces), however, are consistently lower, at less than 8%. Similarly, the European braces have been found to be able to improve curves in over 50% of the at risk patients. Bracing does not therefore only halt progression of curves. Given a well-constructed brace, with good patient compliance, improvement of curves in over 50% of the patients is possible, particularly when used in conjunction with scoliosis specific exercises.
Aim: Growing pains in children is not an uncommon condition. Relative local overuse, reduction of bone strength, reduction of pain threshold, hypovitaminosis D and abnormal foot postures have all been found to be associated with the condition. Yet the etiology of the condition has not yet been completely determined. At present, there is no standard treatment protocol of the condition. As the growing pains in children tend to disappear with age, many health care practitioners opt not to treat the condition or dismiss the patient on the ground that he or she would get better with time. The present mini-review aims at reviewing the current treatment approaches and recommendation.
Methods and materials: A manual search in the Pub med has been made, using the keywords growing pains in children, treatment, orthoses and vitamin D, for treatments of growing pains in children.
Results: A search of literature reveals a well-implemented muscle stretching program as the first line treatment. In spite of the rather equivocal findings from the numerous studies regarding the efficacy of foot orthoses, their success in reducing pain and symptoms related to growing pains cannot be denied. The prescription of foot orthotics is clinically advocated. Also, supplementation of vitamin D3 is suggested for children with hypovitaminosis D, as it has been found that the majority of children with growing pains have a low serum 25-hydroxyvitamin D level.
Conclusions: Children with growing pains should be assessed for their serum vitamin D level and their foot postures. Supplementation of vitamin D3 and foot orthoses may improve the signs and symptoms of patients, when indicated.
Long-term follow-up of untreated patients with adolescent idiopathic scoliosis (AIS) indicates that, with the exception of some extremely severe cases, AIS does not have a significant impact on quality of life and does not result in dire consequences. In view of the relatively benign nature of AIS and the long-term complications of surgery, the indications for treatment should be reviewed. Furthermore, recent studies have shown that scoliosis-specific exercises focusing on postural rehabilitation can positively influence the spinal curvatures in growing adolescents. Experiential postural re-education is a conservative, non-invasive approach, and its role in the management of AIS warrants further study. This article reviews current evidence for the inclusion of various forms of postural reeducation in the management of AIS. Recent comprehensive reviews have been researched including a manual and PubMed search for evidence regarding the effectiveness of physical/postural re-education/physiotherapy programs in growing AIS patients. This search revealed that there were few studies on the application of postural re-education in the management of AIS. These studies revealed that postural re-education in the form of exercise rehabilitation programs may have a positive influence on scoliosis; however, the various programs were difficult to compare. More research is necessary. There is at present Level 1 evidence for the effectiveness of Schroth scoliosis exercises in the management of AIS. Whether this evidence can be extrapolated to include other forms of scoliosis- pattern-specific exercises requires further investigation. Because corrective postures theoretically reduce the asymmetric loading of the spinal deformities and reverse the vicious cycle of spinal curvature progression, their integration into AIS programs may be beneficial and should be further examined.
Post-herpetic pain is an extraordinary drug-resistant neuropathic pain, which arises after the skin lesions disappear. The present case is a lady aged 57, who complained of severe herpetic pain on a scale 8 out of VAS 0-10, affecting the right T7 dermatome. She was prescribed acyclovir, nidol, famotidine, neutim and clinovir cream two days after the onset. These whilst reduced the extent of skin eruptions, did not control the neuropathic pain and allodynia. Even touching by clothes provoked severe pain. A week later, she felt “weak” and consulted a Chinese medical practitioner. She was then treated by Chinese medicine and acupuncture. The treatment lasted for one month. It reduced both the pain intensity and frequency. Pain was reduced from nearly 20 hours a day to occasional pain. She was then referred for treatment by monochromatic infra-red energy (MIRE), which has been documented to have similar effects to laser irradiation that is effective in reducing post-herpetic neuralgia. Immediately after the first treatment which lasted for 20 minutes, she felt pain reduction and relaxation of adjoining muscles. After 6 consecutive treatments which spanned over two weeks, she had complete relief and she felt that the circulation in the area returned.
The effects of MIRE are similar to low level laser, which has been found to reduce or control postherpetic pain effectively. It is suggested that MIRE be used in the treatment of post-herpetic neuralgia, given its effectiveness, the ease of use and that it is less dangerous than laser to operate.
Idiopathic scoliosis predominantly afflicts adolescents. Adolescents with mild curvatures do not generally have any symptoms. However spinal fusion is indicated when the deformity exceeds 45°. Treatment is thus necessary to prevent and/or reduce the progression of curvatures to that below which surgery is indicated. Conservative treatment of adolescent idiopathic scoliosis includes observation, scoliosis-specific exercises (SSE) and bracing. There is increasing evidence suggesting that SSE and brace treatment can significantly limit the progression of spinal curvatures. In growing adolescents with curvatures more than 20°, bracing is indicated and should be used in conjunction with SSE. The effectiveness of bracing varies according to the type of brace applied to the patient. In general rigid braces are preferable to soft flexible braces, as the latter falls short of halting curvatures progression. Also, preliminary evidence suggests that asymmetric braces which enable over-correction provide more correction when compared with symmetrical braces. Recently it has also been reported that high quality bracing can also reduce curvatures exceeding 45° in over 70% of growing adolescents. This new knowledge might possibly increase the threshold of surgical indications to beyond 50° or above in the near future.
A new development of correcting exercises has been derived from the original Schroth program in 2010 and the preliminary results have been published that year. Since then the program has been applied in some centers worldwide. As the original Schroth program was the only program so far to improve many signs and symptoms of scoliosis besides the angle of curvature (Cobb angle) it was interesting to look for the preliminary results of the recent development of scoliosis pattern specific corrective exercises derived from the original program, to see if similar effects can be achieved with this less complicated method.
A manual search in Pubmed was conducted, using the key words, Schroth, rehabilitation, and idiopathic scoliosis. Three papers have been found describing the short-term results of this new development today called Schroth Best Practice program (SBP). The papers were reviewed and analyzed with respect to the outcome parameters used.
Outcome parameters were Angle of Trunk Rotation (ATR), Vital Capacity (VC), surface topography, electromyography, stabilometry and Cobb angle before and after a course of treatment. There was a significant improvement of all parameters after the application of this new program in all the three papers in the short- to mid-term.
Scoliosis corrective exercises are supported by two randomized controlled trials (RCT) and should regularly be applied in mild scoliosis at risk for progression. Unspecific exercises such as Yoga, Dobomed cannot be regarded as effective as exercises using a well defined scoliosis pattern specific corrective routine.
Idiopathic scoliosis afflicts 2-3% of the population. For mild curvatures, observation is the treatment of choice. Though this passive "wait and see" approach has been used for many years, the practice is inconsistent among different countries. In Anglo-Saxon countries where scoliosis specific exercises are not practised, observation is indicated for curvatures below 25° in growing children and adolescents. In countries, such as France, Germany, Italy and Poland where scoliosis specific corrective exercises are employed, only patients with no signs of maturity and with curvatures below 15° are treated by observation. Patients with curvatures between 15 - 25° are treated by scoliosis specific exercises. In view of the unpredictability of the progression of scoliosis curvatures in immature patients and the lack of knowledge of long term biomechanical repercussions of mild idiopathic scoliosis on lumbar spine and lower extremities, it is proposed that active intervention through scoliosis specific exercises rather than passive observation be employed in the treatment of mild adolescent idiopathic scoliosis.
Spinal bracing is indicated in moderate to severe curves during growth. Brace effectiveness in halting progression of adolescent idiopathic scolisosis has been shown in a Cochrane review and in a randomized controlled trial (RCT). The outcome of brace treatment is dependent on the extent of in-brace correction and compliance. We have reviewed the literature on bracing to determine the types of brace that offer the best in-brace correction.
MATERIALS AND METHODS:
The literature has been searched for papers on bracing with documented in-brace corrections and long-term results.
The in-brace percentage of correction of asymmetric braces is generally higher than that of the symmetric braces. According to the literature found in our search, long-term corrections are possible when starting treatment early, at an immature stage and with asymmetric braces of recent standards.
Bracing today is supported by high quality evidence (Level I). Asymmetric braces have led to better corrections than that described for symmetric braces . An improvement of the average corrective effect has been described due to the latest CAD / CAM development. Long-term corrections are possible when starting brace treatment early, at an immature stage and with asymmetric braces of recent standards.
The purpose of the study is to describe the use of monochromatic infrared energy (MIRE) therapy in the management of 2 patients with Bell's palsy.
Two patients presented to a chiropractic clinic with Bell's palsy that was diagnosed by a medical physician. Both patients were treated using MIRE. The acute patient was a 32-year-old male. He presented with left facial palsy 1 day before the consultation. He was unable to puff the left cheek and close the left eyelid. He had difficulty raising the left eyebrow. The chronic case was a 46-year-old lady. Prior to the first consultation, she was treated with corticosteroid and electro-acupuncture for one and a half years, with incomplete recovery. When first seen, the left corner of mouth drooped and she had difficulty raising her left eyebrow.
Intervention and outcome
Monochromatic infrared energy therapy, emitting 890 nm infrared light, was placed on the post-auricular area, pre-auricular area, the temple and mandibular area of the affected side. Each treatment lasted 30 minutes. Photographs were taken every week to document changes. The acute case received 19 treatments in 6 weeks. He reported an improvement of 95%. The chronic case received a total of 45 treatments in 9 months. She rated an improvement of 50%. At the conclusion of treatment, she was able to close her left eyelid and puff her left cheek but still could not raise her left eyebrow.
These 2 patients seemed to respond to a different degree to the MIRE therapy. As 71% of patients with Bell's palsy recover uneventfully without any treatment, the present study describes the course of care but cannot confirm the effectiveness of MIRE therapy in the management of Bell's palsy.