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621

Kinesiologic Analysis of Dynamic Side-Shift in Patients With


Idiopathic Scoliosis
Osamu Shirado, AID, Toshikazu lto, RPT, Kiyoshi Kaneda, MD, Thomas E. Strax, MD
ABSTRACT. Shirado O, Ito T, Kaneda K, Strax TE. Kinesiologic analysis of dynamic side-shift in patients with
idiopathic scoliosis. Arch Phys Med Rehabil 1995;76:621-6.
Objectiw,s: The purpose of this study was to analyze the ability of the patients with idiopathic scoliosis to
transfer the body weight in the frontal plane. Design: Randomized and controlled study. Setting: A referral center
and institutional practice and outpatient care. Subjects: Fifty patients with idiopathic scoliosis (three men and
forty-seven women; average age 15.3 years) and 15 normal women (average age 17.3 years) participated in this
study. Thirty patients were treated with underarm braces. Main Outcome Measures: Computer-assisted force
plates were used to evaluate the laterally shifted weight and the time period during side-shift on sitting. Results:
During both slow and fast side-shifts, shifted weight in the patients with idiopathic scoliosis was significantly less
than in the normal controls (p < 0.05). The shifted weight was less on the concave side than on the convex one.
The time ~ r the shift to the concave side was longer in the patients than in the normal controls (p < 0.05). The
brace was effective in correcting the imbalance of shifted weight in the patients with idiopathic scoliosis. Conclusions: The current study demonstrated the different patterns of weight side-shift between normal subjects and
patients with idiopathic scoliosis. The patients transferred less weight laterally than the normal subjects during
slow and fast random movements. The patients also showed slower side-shift patterns than the normal subjects
during the fast random movement.
1995 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and
Rehabilitation

Idiopathic scoliosis is a complex, three-dimensional, and


structural abnormality of the spine consisting of deformities
in the sagittal, coronal, and frontal planes. It appears most
often in the adolescent group, ranging from 10 to 16 years
of age, and is more common in women. 1.2 The etiology of
idiopathic scoliosis remains unclear, although disturbances
in equilibrium and vestibular function have been reported in
the literature) -1
In terms of posmral control, two different types of equilibrium should be taken into account: static and dynamic]
Maintenance of a certain body position is the function of
static equilibrium mechanism. On the other hand, dynamic
equilibrium is the ability to regain position when there is a
disturbance in the supporting surface or the ability to maintain a well-balanced posture during locomotion. In order to
evaluate the static equilibrium in the patients with idiopathic
scoliosis, investigators have performed studies regarding the
body's center of gravity in static upright posture. 2-7'9'1 The
data in the literature has contributed, not only to assessing
the etiology, but also to evaluating the compensation of the
patients with idiopathic scoliosis. However, the data was
obtained only under the static situation in which the patients
were asked to maintain the same position. To the authors'
From the Departments of Orthopaedic Surgery and Physical Therapy (Drs. Shirado,
Ito, Kaneda), Hokkaido University School of Medicine, Sapporo, Japan; and the
Department of Rehabilitation Medicine (Dr. Strax), JFK Johnson Rehabilitation Institute, UMDNJ-Robert Wood Johnson Medical School, Edison, NJ.
Submitted for publication October 20, 1994. Accepted in revised from January 24,
1995.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the authors or upon any
organization with which the authors are associated.
Reprint requests to Osamu Sbirado, MD, Department of Orthopaedic Surgery,
Hokkaido University School of Medicine, Kita-15 Nishi-7, Kita-Ku, Sapporo 060,
Japan.
1995 by the American Congress of Rehabilitation Medicine and the American
Academy of Physical Medicine and Rehabilitation
0003-9993/95/7607-32.7453.00/0

knowledge, no studies in idiopathic scoliosis have been conducted regarding the body's center of gravity in a dynamic
situation.
In the dynamic equilibrium studies, the ability to actively
redistribute standing weight support has been investigated
in many individuals with sensorimotor deficits caused by
several disorders such as stroke and Parkinson's disease,
but not idiopathic scoliosis.~l A common observation among
hemiparetic adults was an impaired ability to transfer the
weight during locomotion. Thus, one of the major objectives
of therapeutic exercises for hemiparetic patients has been to
improve this ability.11 If the patients with idiopathic scoliosis
had an impaired ability to actively redistribute trunk weight,
therapeutic exercises might also be helpful to correct it.
An exercise to redistribute trunk weight laterally has already been considered as a possible therapeutic exercise to
correct the scoliotic curvature. This is called the "side-shift
technique" in which patients actively shift the trunk away
from the convexity of the curve and hold this position, t2
This technique can provide active correction of the curve by
using the shift of the body's center of gravity. However,
no basic knowledge on this technique has been obtained
regarding how the patients could transfer the body weight
laterally during this technique. One of the principal techniques in therapeutic exercises used in both upper and lower
motor neuron disorders is the identification of the specific
movement or task to be achieved.13 If the abnormal movement pattern during lateral weight-transfer in idiopathic scoliosis could be clarified, side-shift technique might be useful
not only for correcting curvature, but also for improving the
dynamic balance.
The purpose of this study was, therefore, to analyze the
ability of the subjects to transfer the body weight in the
frontal plane and to evaluate the difference between normal
subjects and patients with idiopathic scoliosis.
Arch Phys Med Rehabil Vol 76, July 1995

622

D Y N A M I C SIDE-SHIFT IN IDIOPATHIC SCOLIOSIS, Shirado

Table 1: Description on Normal Subjects and Patients


With Idiopathic Scoliosis

Age (years)
Mean
Range
Weight (kg)
Mean
Range
Height (m)
Mean
Range

Normal Subjects
(n = 15)

Idiopathic Scoliosis
(n = 50)

17.3
15-18

15.3
10-17

51.2
43-60

49.2
40-60

1.60
1.54-1.68

1.57
1.53-1.66

M A T E R I A L S AND M E T H O D S
Subjects

A total of 65 subjects participated in this project. The first


group consisted of 15 normal women who volunteered as
the control group. They were carefully screened by one of
the spine surgeons (O.S.) for physical signs of scoliosis and
demonstrated no spinal deformities. Their ages ranged from
15 to 18 years, with a mean age of 17.3 years. The second
group was 50 patients with idiopathic scoliosis, 3 men and
47 women. All patients were selected from the scoliosis
clinic in the department of orthopaedic surgery at a University hospital. Criteria for selection included single curve over
20 and motivation for this project. Ages ranged from 10 to
17 years, with a mean age of 15.3 years. The mean weight
and height for subjects appear in table 1.
The mean scoliotic curve was 26.1 , ranging from 20 to
35 . The fight single thoracic curve was present in 37 patients, the left single thoracic curve in 5, and the left lumbar
single curve in 8. Thirty of 50 patients were treated with the
underarm brace.14 This brace corrects the scoliotic curvature
with a three-point correction system, in which the three
points are at the upper, lower, and apex points of the curvature. 14'15 This brace also prevents progression of the curvature in idiopathic scoliosis if appropriately prescribed and
worn. 14'~5All 30 patients were instructed to wear the braces
all day, except for a couple of hours for taking a bath. This
is based on the description of Blount and Moe. 14 Duration
of the brace treatment was 1 month to 2 years. No patients
were surgical candidates at the time when this project was
performed. Decompensation of the spinal curvature was
evaluated in the following technique: while standing upright,
the string attached with a small weight was hung down vertically from the spinous process of C7. The distance between
the gluteal cleft and the string was measured. This was less
than lcm in all patients. None of the patients had decompensated when being evaluated with this technique.
Informed consent was obtained from all of the subjects,
and the procedure for this project was reviewed by an Institutional Review Board.
Experimental

Device and Procedure

A gravicorder G6100" was used to quantify the lateral


shift of the body weight during the performance (fig 1).
The gravicorder consisted of two force plates with the same
Arch Phys Med RehabilVol 76, July 1995

dimensions (55 60cm), connected to a computer (PC9801 VX) b programmed to display in real time the center of
gravity and a total amount of laterally transferred body
weight during each procedure. Weight was detected with a
strain-gauge type load cell in the force plates. The measuring
range of the load cell was 10 to 300kg. The accuracy of the
center of gravity, and of the measured weight, was indicated
by the manufacturer to be less than l m m and 1.0%, respectively. The analogue data from the load cell was converted
through a 16-channel A/D converter and subsequently was
stored into the hard disc in the computer. The sampling rate
was 90Hz.
Subjects with their eyes open were asked to sit on the
seat and were placed on the force plates in a comfortable
fashion. The seat had a flat sitting plane without a back rest
and was set horizontally parallel to the force plates and floor.
Subjects' arms were crossed in front of the chest, and the
feet were kept free from contact with the force plates and
floor. Under the relaxed upright sitting posture, the subjects
were asked to perform the two types of maximum side-shift
of body weight (1) slow side-shift and (2) fast random sideshift (fig 1). The side-shift of body weight was obtained by
moving the trunk laterally with both hips kept in touch with

Fig 1 - - E x p e r i m e n t a l setup and the performance in this study.


The seat was placed on the two force plates that were connected
to the personal computer. Subjects were asked to sit on the
seat with the feet free from the floor and to transfer the weight
laterally to the maximum.

DYNAMIC SIDE-SHIFT IN IDIOPATHIC SCOLIOSIS, Shirado

TM

a -i-

-i

,I..:1:

623

compared between the fight and left shifts with and without
the brace.
Before the data acquisition, each subject had enough practice to be familiar with each procedure and sat on the seat
for 30 seconds before the recording to reduce the sway factor. The lateral shift began when the trunk sway was minimized 30 seconds after the subject sat on the chair, while
the subject assumed a self-selected natural sitting posture. I1
This was confirmed on the display of the computer before
the testing.
Statistical analysis was performed with a Student's t test
when comparing different groups and with a paired t test
when comparing differences between sides or brace conditions within groups. The 95% confidence interval of the
difference was determined.

. . . .!o~,
i und$o
-,,:.-~..................................................................
~
. . . . . . . . . . .

TIME(sec.)
Fig 2mRepresentative graph of right side-shift, obtained in a
normal subject during a fast random movement. (a) Dead time.
This corresponded to the elapsed time from beep sound to the
initial response. (b) The time from the initial response to the
maximum weight transfer to the right side. During each sideshift, reverse response to the opposite side (*) was always observed, followed by maximum side-shift (**).
the seat. For the slow side-shift, subjects were asked to transfer their body weight laterally to the maximum, in approxirnately 2 to 3 seconds. This procedure was repeated 10 times
on each side. Velocity of this performance was controlled
with a metronome placed near the subjects. For the fast
random side-shift, 10 to 15 beep sounds per minute were
randomly made by the computer and were audible to the
subjects. In response to the first beep sound, the subjects
were asked to transfer the body weight to the fight side, as
fast as possible, fi)llowed by returning to the original position
as fast as possible also. The subjects were asked to perform
side-shift movements alternately to both sides for a minute.
Kinesiologie Analysis
During each performance, percentage shifted weight
[(mean shifted weight/total weight) 100] was calculated,
and mean value (+SD) of percentage shifted weight was
compared between the fight and left shifts and between the
groups. During the random fast-shift, elapsed time (seconds)
was evaluated at two points: (1) from the beep sound to
initiating the side-shift (dead time) and (2) from the initiation
of the side-shift to the maximum lateral transfer of the body
weight. "Dead time" corresponds to the neuroconductive
time in which stimulus from the beep sound was transferred
via central nervous system to the peripheral muscles.16 Mean
elapsed time (+_SD) was calculated and was compared between the right and left shifts and between the groups. Representative gravicorder test plots during a fast random sideshift in a normal subject appear in figure 2.
Thirty-four patients who were treated with the brace, performed the slow side-shift with and without the brace. This
performance was repeated 10 times on each side. After the
procedure without the brace, a 15-minute time interval was
allowed before subjects performed the procedure with the
brace. During each performance, percentage shifted weight
[(mean shifted weight/total weight) 100] was calculated,
and mean value (+_SD) of percentage shifted weight was

RESULTS
1. S h i f t e d W e i g h t D u r i n g t h e S l o w a n d F a s t
R a n d o m Shift
Figure 3A demonstrates the percentage-shifted weight
during the slow side-shift in both groups. The percentageshifted weight to the right and left sides in the control group
was the same at 70.7 _ 2.2%. On the other hand, the percentage-shifted weight in the patients with idiopathic scoliosis
was significantly smaller than in the normal controls (p <
0.05). To the convex side, it was 67.4 _ 3.2%, and to the
concave side, 64.1 _+ 3.7%. There was no significant difference between the convex and concave sides.
Figure 3B shows the percentage-shifted weight during the
fast random side-shift in both groups. The percentage-shifted
weight to the fight and left sides in the control group was
also the same at 71.2 _ 4.1%. On the other hand, the percentage-shifted weight in the patients with idiopathic scoliosis
was 70.8 _+ 3.8% and 64.7 _ 3.9% to the convex and concave
sides, respectively. The percentage of shifted weight to the
concave side in the patients was significantly smaller than
in the normal controls (t9 < 0.05), although there was no
significant difference between the side-shift to the convex
side in the patients and that in normal controls.
2. P e r f o r m a n c e T i m e D u r i n g the F a s t R a n d o m
Side-Shift
Table 2 demonstrates the performance time during the fast
random side-shift. Maximum side-shift was always preceded
by reverse response in which subjects first moved to the
opposite side after the beep sound. The time from the beep
sound to initiation of the side-shift (dead time) was the same
in both directions in the normal controls. There were no
significant differences between the control and patient
groups. In the patients, there was also no significant difference between the side-shifts to the convex and concave sides.
The time from the initiation of the side-shift to maximum
lateral transfer of body weight was also the same in both
directions in the normal controls. On the other hand, the
time for the shift to the concave side in the patients was
significantly longer than to the con~,ex side, and also longer
than in the normal controls (p < 0.05).
Arch Phys Med Rehabil Vol

76,July1995

624

DYNAMIC SIDE-SHIFT IN IDIOPATHIC SCOLIOSIS, Shirado

A
*

N.S.

L=:

Side-shift
to both sides

I.OR.A, I=

Side-shift
to convex side

Side-shift
to concave side

Side-shift
to both sides

I.o,opAr..csco..os,s I

I NORMA'11

Side-shift
to convex side

Side-shift
to concave side

I I=OPATHIC SCO.IOSIS II

Fig 3raThe percent of shifted weight in normal controls and patients with idiopathic scoliosis. (A) During the slow side-shift;
(B) During the fast random side-shift. *p < 0.05; N.S., not significant.
3. S h i f t e d W e i g h t W i t h a n d W i t h o u t t h e B r a c e
Without the braces, the percentage of shifted weight to
the convex side in the patients was significantly greater than
that to the concave one (p < 0.05). However, when the
patients were in the braces, there was no significant difference between the side-shifts to either side (fig 4).

DISCUSSION
The major goal of this project was to analyze the ability
of the patients with idiopathic scoliosis to transfer the body
weight in the frontal plane and to investigate the difference
between normal controls and patients with idiopathic scoliosis. The sitting posture was selected for this project, rather
than the standing one, because balance during standing posture is influenced by the ability of lower extremities to maintain the posture. Thus, the authors intended to minimize the
effect of lower extremity function.
Studies regarding equilibrium and postural control have
been performed by many investigators because these parameters appear to be related to the cause of idiopathic scoliosis. 2-~ Many studies concentrated on postural control under
static conditions, such as standing and sitting. However, no
Table 2: Comparison of Performance Time
Between Two Groups
T i m e From

N o r m a l subjects
Side-shift to both sides
Idiopathic scoliosis
Side-shift to c o n v e x side
Side-shift to concave side

M a x . Weight

0.19 ___ 0.03*

0.46 + 0.05"*

0.21 0.03*
0.22 +_ 0.04*

0.48 + 0.03"*
0.58 + 0.05 *'~

Arch Phys Med Rehabil Vol 76, July 1995

8("

7c

Response to

Time From
Beep Sound to
Response

*, not significant.
*'*p < 0.05.

studies have been conducted regarding the dynamic situation


during motion. In terms of side-shift to the concave side of
the scoliotic curve, the patients demonstrated less amount
of shifted weight during slow and fast movements than the
normal controls. Moreover, the time from initiation to completion of the side-shift was significantly delayed on the
concave side than on the convex side. In other words, the
weight transfer to the concave side was more impaired ~n
the patients than in the healthy controls.
Although it is difficult to determine the real causes of
these phenomena in patients with idiopathic scoliosis, several explanations can be made as follows: (1) a certain abnormality of dynamic equilibrium is present; (2) structural ab-

Transfer

WlO BRACE
W/BRACE
Fig 4 - - T h e percent shifted weight with and without brace.
CONVEX, side-shift to the convex side; CONCAVE, side-shift
to the concave side. *p < 0.05; N.S., not significant.

DYNAMIC SIDE-SHIFT IN IDIOPATHIC SCOLIOSIS, Shirado

625

normality caused by the scoliosis causes the abnormality; patients' own trunk muscles. 12She also noted in her prelimiand (3) inequality of the bilateral trunk muscles is the cause. nary report that this procedure was more easily accepted by
Many investigators have reported disturbances of postural the patients than the brace and was effective for the patients
equilibrium in idiopathic scoliosis. 2-~ Yamada and col- who had a curve less than 40 . From the results in this
leagues evaluated the equilibrium function of 150 patients project, repetitions of weight-shift exercise to the concave
with idiopathic scoliosis by investigating righting reflex, drift side of the curvature might be effective not only for correctreaction, and optokinetic nystagmus. 8 They found that 119 ing the curve, but also for improving the abnormal weight
of 150 patients (79%) showed marked equilibrium dysfunc- shift pattern. However, it is said that many millions of repetition in at least one of the tests, whereas only one of 20 tions are necessary to establish appropriate patterns and that
control subjects showed any dysfunction. They concluded any errors in correct performance delay the development
that dysfunction of the postural reflex regulation induced by of the proper pattern. 13 Other therapeutic exercise widely
functional or organic disorders at the brain stem center might recommended in the conservative management of idiopathic
play an important role in the development of idiopathic scoli- scoliosis is trunk muscle strengthening program, in conjuncosis. However, other researchers found in their studies using tion with brace treatment. 14
There is another possible clinical application to this proja posturographic analysis under static erect position that
ect.
In the patients who undergo the surgery with correction
there was no difference of equilibrium between normal controis and patients and questioned whether the postural dis- of the curve by spinal arthrodesis, trunk imbalance can be
equilibrium could be an etiologic factor in idiopathic scolio- one of the major problems after the surgery. ~'~ However,
sis. 3'4'6'9 Because there was a small number of subjects in this this has been detected in only static situations by taking
study and all vestibuloocular functions were not investigated, radiograms in an upright position. Thus, to investigate and
further studies were needed to emphasize the relationship compare the ability to actively redistribute trunk weight in
between disequilibrium and asymmetrical side-shift pattern. the patients before and after surgery may be a good indicator
Structural deformity itself might be one of the possible in understanding whether the surgery was successful in terms
factors to explain the results. During the side-shift to the of dynamic postural balance, z~
Braces such as the Milwaukee and underarm braces reconcave side, the', patients move their trunk, and with their
main
a mainstay for the conservative treatment of idiopathic
own muscle contraction may correct by some degree the
scoliosis.
~2'~4 The current study proved the efficacy of the
curvature. ~2 On file other hand, the curve may be bent more
underarm
brace to correct the imbalanced side-shift ability
than as it is during the side-shift to the convex side. It might
in
the
patients
with idiopathic scoliosis.
be easier for the patients to bend than to correct the curve,
However,
it
is
essential to state that the current study had
because correction of the scoliotic curvature is against the
several
limitations.
First, degrees of scoliotic curve may have
gravity during upright posture. ~5This might be a reason why
influenced
the
results
in this study. The greater the curve,
the patients showed the abnormal weight-transfer pattern to
the more difficult it is to correct. 14'15In addition, the scoliotic
the concave side. However, radiographic observation during
curve changes the resting tension of some back-muscle fibers
tile procedure would be needed to clarify this issue.
because the distance between the origin and insertion of
Several articles have been published regarding the trunk
some back muscles alters with the degree of curve. This
muscles in patients with idiopathic scoliosis. Hoppenfeld
may have influenced the back muscle strength, and thus the
and Fidler noted in their histochemical studies that type I
results. However, a large number of subjects is needed to
fibers were more dominant in back muscles of convexity of
clarify the relationship between the degree of curve and the
tile scoliosis. ~7"~8Yarom and Robin found that a type I fiber
side-shift ability in idiopathic scoliosis. Second, it is unclear
atrophy occurred in spinal muscles on the concave side and whether correction of the curve was obtained in this study
that morphological pathology was worse on the concave using the side-shift performance. No radiographs could be
side.~9 Shimada evaluated trunk muscle strength during lat- performed during this procedure because irradiation, directly
eral bending in 45 patients with idiopathic scoliosis. 2 He unrelated to the treatment, appeared to be a large ethical
concluded that trunk muscle strength was weaker on the problem in young girls. There would be no way to determine
convex side than on the concave side. Although it is difficult whether any relationship between the curve correction and
to say whether these findings are causative or resultant phe- the side-shift ability existed, unless the radiograms were
nomena in idiopathic scoliosis, abnormal characteristics of taken during the procedure. However, the subjects were
trunk muscles might influence the side-shift patterns in pa- asked to do the same procedure as Mehta reported in her
tients with idiopathic scoliosis. It is well documented that study ~2 and were familiar with this procedure before testing.
trunk muscles play a significant role to control trunk move- It was believed that some correction of the curve would be
ment in other disease conditions. 2~'22
obtained in this project. Third, the period of brace treatment
From the clinical standpoint, the side-shift evaluated in varied among the patients. Contracture of soft tissues around
this study has the potential to be used for the conservative the spine progresses as the period of brace treatment contintreatment of idiopathic scoliosis, although it appears to be ues because of inunobilization. 14,~5This also might influence
difficult to maintain voluntary muscle contraction and apply the flexibility of the spine, and thus, results in this study.
forces to the scoliotic spine long enough for resisting visco- However, more subjects are needed to clarify the effect of
elastic structures to yield.~5 Mehta demonstrated radiographi- the period of brace treatment on the ability of side-shift
cally that the scoliosis was actually corrected during the performance.
side-shift, which implied the "active autocorrection" using
In conclusion, the current study demonstrated that the
Arch Phys Med RehabU Vol 76, July 1995

626

D Y N A M I C S I D E - S H I F T IN I D I O P A T H I C SCOLIOSIS, Shirado

side-shift during sitting posture had different patterns between normal subjects and patients with idiopathic scoliosis.
The patients transferred less weight laterally than the normal
subjects during slow and fast r a n d o m movements. The patients also showed slower side-shift patterns than the n o r m a l
subjects during the fast r a n d o m movement. The brace was
effective in correcting the a b n o r m a l l y shifted-weight in the
patients with idiopathic scoliosis. Further studies are needed
to clarify the influence of curve degree and brace treatment
period.

Acknowledgment: The authors thank RPTs H. Suzuki, N. Sarashina,


and T. Kikumoto for assistance with the data collection, all attendings at
the Spine Service of the Department of Orthopaedic Surgery, Hokkaido
University Hospital, for referring the patients, and Ms. Joan Goddard for
assistance with the preparation of this manuscript.
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