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Acta orthop. scand. 50,303-306 ,1979

THE EFFECT OF PHYSICAL TRAINING ON EXERCISE

ABILITY IN ADOLESCENT IDIOPATHIC SCOLIOSIS

J. M. SHNEERSON R. MADGWICK

Department of Respiratory Physiology, Cardiothoracic Institute, Brompton Hospital, London, England

Twenty subjects with adolescent idiopathic scoliosis, aged11-17 years,were studied before spinal fusion. Half the pa tien ts underw ent a pro-gra mm e of daily physical exercises for 6-10 weeks. Before and after thisperiod all the patients carried out a range of lung function tests and a pro-gressive exercise test. There were no significant differences in any of theresults between the control group and th e training group. T h e cardiac andrespiratory complications of spinal fusion are therefore unlikely to belessened by preoperative physical training, except in selected subjects.

Key words: exercise testing; physical training; scoliosis; spinal fusion

Accepted 9.i.79

Although physical exercises have been used inan attempt to correct spinal curvatures therehave been no reports of their use to improvecardiac and respiratory performance pre-operatively. This is surprising in view of thewell-established diminution in lung volumes(Schaub et al. 1954) and the hyperven-tilation, and reduced maximal ventilation andmaximal oxygen uptake during exercise inadult scoliotics (Shneerson 1978a). In th isstudy half the patients carried out aprogramme of daily exercises to see whether

their cardiorespiratory function could beimproved preoperatively and the complica-tions of surgery thereby minimized.

PATIENTS AND METHODS

Twenty successive subjects with adolescentidiopathic scoliosis in which the primary curveaffected the thoracic spine were studied. None ofthe subjects had any cardiac or respiratory diseasecomplicating the scoliosis. All the patientsperformed a range of lung function tests and anexercise test and were then randomly allocated tothe control o r the training groups. T h e latter were

instructed to carry out a daily regime of physicalexercises, including repeated step-ups, hopping,

jumping, and reaching up above their head. Theexercises were performed initially in the presenceof the authors and in each patient the heart raterose above 160/minute. T h e exercises were super-vised by their parents and records kept of theirperforman ce. After 6-10 weeks both the controland the training groups were recalled and the lungfunction and exercise te sts were repeated.

The angle of scoliosis was determined by themethod of Cobb (1948). The vital capacity (VC)was measured with a dry spirometer (Vitalo-graph) and the maximum voluntary ventilation

with a wet spirometer (P.K.

Morgan).Exercise was performed while sitting on anelectrically-braked bicycle ergometer (Lode). Theinspiratory minute volume was measured by adrygas meter. T he gas meter was connected to a lowresistance two-way respiratory valve (P. K.Morgan 71522) with a dead space of 60ml. Theexpired gas passed to a mixing chamber contain-ing a fan. A sample of the mixed expired gas wasdried with magnesium perchlorate and passedthrough a paramagnetic Servomex OA 150 oxygenanalyser, and an infra-red absorptionCO, analyser(URAS 4). Both machines were connected electri-cally to a direct writing ink jet recorder(Mingograf 81).

The patients rested on the ergometer until their

0001-6470/79/030303-04$02.50/0 0 979 Munksgaard, Copenhagen

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304 J. M. SHNEERSON & R. MADGWICK

inspired ventilation, mixed expired gas com-position and heart rate were steady. They thenbegan pedalling, initially at a work rate of 15watts. T he work rate was increased by 15 wattseach minute and the patients were encouraged tokeep exercising for as long as possible, which wasusually 6-10 minu tes. Th er e were no compli-cations of the procedure.

The s lope of the relationship between theminute ventilation (VE) and heart rate (HR) an dthe oxygen uptake (VO,) was calculated by theleast squares method. The VE and HR responsesw ere expressed as m axim al values ( V E ~ ~ ~ )nd atinterpolated values of. To, of 0.75 L, 1.0 L and1. 5 L ( V ~ o . 7 5 , ~ i . 0 , ~ i . 5 ; Ro.75, HRi.0, HRi.5)(Cotes 1969, Spiro et al. 1974).

RESULTS

Persona I details

Both the control and training groups includednine girls and one boy. The mean age of thecontrols was 14.1 years (s.d. 1.7) and of thetraining group was 13.9 years (s.d. 0.9). T h etwo groups had similar weights (controlgroup: mean 50.4 kg, s.d. 7.4; training g roup:48.9 kg, s.d. 7.0) and angles of scoliosis(control group: mean 62.2O, s.d. 10.5;training group: 61.4O, s.d. 11.1).

Resting lung functio n tests

There was no significant difference betweenthe mean VC or MVV of the two groups attheir fist attendance. Both VC and M Wwere slightly improved when tested a second

time, but there wa s no d ifference between thetwo groups (Table 1).

Progressive exercise te sts

No significant changes in the submaximalvalues of ventilation or heart rate wereobserved between the control and traininggroups initially or after 6-10 weeks (Figure1). The dyspnoeic index and the maximal

values of minute ventilation, tidal volume andoxygen uptake were not affected by thetraining programme (Table 1).

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T R A I N I N G A N D EXERCISE ABILITY IN SCOLIOSIS 305

Figure 1. Minute ventilation and heart rateresponses during exercise tests.

DISCUSSION

This study was carried out to determinewhether t he exercise capacity of patients withadolescent idiopathic scoliosis could beimproved by a course of physical training.Scoliotics develop a variety of cardiac andrespiratory abnormalities (Bergofsky et al.1959) and it is therefore important that theyare as fit as possible, especially prior tosurgery such as spinal fusion. The exerciseschosen were simple and practicable and

utilized all the main muscle groups. Moreintensive and supervised exercises could havebeen designed if the subjects had beenadmitted to hospital for the period oftraining. However, hospitalization for severalweeks is undesirable and unacceptable tomany patients and it was thought preferableto use a simple regime. Th e effectiveness of atraining programme depends on the severityof the physiological stress it presents.

Exercise which induces a rise in heart rateabove 150 beatdminute is sufficient toproduce measurable improvement (Saltin et

al. 1969). The heart rate rose above 160beatdminute in all the subjects of this study.A significant increase in Vo, max can beproduced by an exercise course of8 weeks(Saltin et al. 1968), which was the approx-imate duration of this training course.

The group of control patients who did notundergo physical training was comparablewith the training group in age, sex, weight,and angle and level of scoliosis. The previousstudies of the effects of exercise in scoliotics(Bjure et al. 1969, Gotze et al. 1974, Stoboy& Speierer, 1975) have not included a controlgroup, but instead have studied the samepatients on two or more occasions. Theimprovements they have observed couldtherefore be due to lessening of anxiety onthe later occasions, familiarity with theapparatus (McHardy 1978), or to the physio-logical consequences of growth of thesubjects. For instance, the FEV, and VC arerelated to height andarm span (G odfrey et al.1970), the heart rate response during exerciseis inversely proportional to lean body mass(Cotes et al. 1973), and V q max varies with

body w eight (Davies etal. 1972).An improvement in physical fitness due to

the exercise course should result in a higherdyspnoeic index with an unchanged MVV, aslower heart rate at any givenVO,, and agreater VO, max. Both the trained anduntrained subjects improved slightly at theirsecond attendance in several ways, but thetrained group did not show any significantbenefit compared with the control group.

There was no difference in response betweenthe milder and more severe subjects withinthe trained group. Even a slight improve-ment in the most severely affected subjectsmight be of symptomatic benefit, butShneerson (1978b) has shown that severepulmonary hypertension can develop duringand after exercise in scoliotics with a vitalcapacity less than 1.0-1.5 litres. Physicaltraining should, therefore, not be advised for

these subjects. T h e best results from a courseof training would probably be achieved byselecting those who are habitually the least

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306 J. M. S H N E E R S O N& R. MADGW ICK

act ive. A high propo rt ionof active subjects inthe p resen t s tudy may have obscu red thebenefit tha t m ore sedentary adolescents wouldachieve from a course of t ra in ing s imilar tothe present one.

A C K N O W L E D G E M E N T S

We would like to thank Dr. F. J. Prime for hishelp and advice, Mr. M. Edgar for allowing us tostudy patients under his care, and Mrs. J.MacGuigan for preparing the m anuscript. J.M. S.held the app ointment of Clinical Lecturer in theDep artm ent of Respiratory Physiology, Cardio-thoracic Institute, Brompton Hospital, London,and was supported by grants from the ResearchCommittee of the Brompton Hospital and byBoehringer Ingelheim Ltd .

REFERENCES

Bergofsky, E. H., Twino, G. M.& Fishman, A. P.(1959) Cardio-respiratory failure in kypho-scoliosis.Medicine 38,263-3 17.

Bjure, J., Grimby, G., Nachemson,A. & Lindh,M. (1969) The effect of physical training ingirls with idiopathic scoliosis.Acta orthop.scand. 40, 325-333.

Cobb, J. R. (1948) Outline for the study ofscoliosis. Instructional Course Lectures.Amer.

Cotes, J. E. (1969) Relationships of oxygen con-sumption, ventilation, and cardiac frequency tobody weight during standardized submaximalexercise in normal subjects. Ergonomics 12 ,41 5-427 .

Cotes, J. E., Berry, G., Burkinshaw, L., Davies,

C. T. M ., Hall , A . M . , Jones, P. R . M . &Knibbs, A. V. (1973) Cardiac frequency duringsubmaximal exercise in young adults: relationto lean body mass, total body potassium and

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amount of leg muscle.Quart . J . exp. Physiol.

Davies, C. T. M., Barnes, C. & Godfrey, S. (1972)Body composition and maximal exercise per-formance in children.Hum. Biol. 44, 195-214.

Godfrey, S., Kamburoff, P. L. & Nairn, J. R.(1970) Spirometry, lung volumes and airwayresistance in normal children aged5-18 years.Bri t . J . Dis. Chest 64, 15-24.

Gotze, H. G ., Su nram, F., Scheele, K.& Klisa, B.(1974) Der Einfluss eines vierwochigenKonditionstrainings auf die organischeLeistungsfahigkeit jugendlicher Skoliose-Patienten. Dtsch. med. Wschr.99, 1761-1769.

McHardy, G. J. R. (1978) Assessment of exercisetherapy. J . Roy. SOC.Med. 71,63-64.

Saltin, B., Blomqvist, G., Mitchell,J. H., Johnson,R. L., W ildenthal, K.& Chapman, C.B. (1968)Response to exercise after bed rest and aftertraining. Circulation 38, Suppl. 5.

Saltin, B., Hartley, L. H., K ilbom, A. & Astrand,I. (1969) 11. Oxygen uptake, heart rate, andblood lactate concentration at submaximal andmaximal exercise.Scand. J . din. Lab. Znoest.

Schaub, F., Buhlmann,A. & Kalin, R. (1954) DasKyphoskolioseherz und seine Pathogenese.Cardiologia25 , 147-152.

Shneerson, J. M. (1978a) The cardio-respiratoryresponse to exercise in thoracic scoliosis.Thorax 33, 457-463.

Shneerson, J. M. (197813) Pulmonary arterypressure in thoracic scoliosis during and afterexercise while breathing air and pure oxygen.Thorax 33,747-754.

Spiro, S. G., Juniper, E., Bowman, P. &Edwards, R. H.T. (1974) An increasing workrate test for assessing the physiological strainof submaximal exercise.Clin. Sci. Mol. Med.

Stoboy, H. Speierer, B. (1975) Lungenfunktion-swerte und spiroergometrische Parameter

wahrend der Rehabilitation von Patienten mitidiopathischer Skoliose (Fusionsoperation derWS nach Harrington und Training).Arch.orthop. Unfall-Chir. 81, 247-254.

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Correspondence to: J. M. Shneerson, D.M., Westminster Hospital, Horseferry Road, London,SW1,England.

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