SCOLIOSIS SCOLIOSIS REHABILITATION

SCOLIOSIS
A general term used to describe a lateral curvature of the spine p Most often develops on childhood Can occur on cervical thoracic or lumbar vertebra

Types:
1. 2. 3. 3 4. 5. 5 6. Structuralvs.NonStructural Accordingtothedirectionofcurves Majorvs.minorcurve Major vs minor curve Accordingtotheshapeofthecurve Accordingtotheseverityofthecurve According to the severity of the curve Accordingtoetiology

STRUCTURAL vertebral bodies rotates towards convex spinous process rotates towards concave Irreversible lateral curvature with fixed rotation of vertebrae. (+) rotation of p vertebrae; apex: greatest

NON STRUCTURAL (functional scoliosis) g No change of structure Positional or dynamic in y nature Reversible

(-) rotation

( ) (+) rib hump (p p (posterior (-) rib hump () p rib hump) (+) bony deformity (+) progressive (-) corrected by positioning or voluntary efforts (-) ( ) bony deformity (-) progression (+) correction forward bending/ lateral bending positional changes side bending muscle contraction

NOTE: Forward bending of trunk produces posterior rib hump on convex side (thoracic region) due to rotation of vertebra & rib cage (prominence of scapula) scapula).

CONCAVE Shortened Muscle & ligaments are contracted Thoracic: Th i Spinous process Compression of ribs Prominence of rib cage anteriorly

CONVEX Lengthened Muscle & ligaments are stretched Vertebral body Separation of ribs Prominence of rib hump and scapula posteriorly Disc space widens Pedicle in anteroposterior direction

CONCAVE Disc space narrow lateral displacement of nucleus pulposus. Wedging of vertebral body on concave part of curve 2 2 pressure on epiphyseal plate. Most especially seen on >25 curve >25 curve. Pedicle more transverse

CONVEX

CONCAVE Lumbar: L b Prominence of ES muscle l

CONVEX

Neck & Shoulder: Neck angle decrease Rib flatten Shoulder decrease

Neck angle increases Bulging of ribs Shoulder increased

NOTE: Direction of the curve is always identified by the convexity thoracic scoliosis convexity is on right (L) thoracic scoliosis convexity is on left

MAJOR primary primary curve; most significant most significantly most occurs in thoracic region

MINOR Less Less severe may develop on the opposite direction of the major curve on either above or below the major curve. curve Compensatory curve structural or non structural

(+) structural

(+) structural / non structural

(+) structural Primary curve Pi Idiopathic scoliosis: right li i i ht thoracic T4 T12

(+) structural / non structural Found b l F d below or above th b the major curve Compensated shoulders & C t d h ld hips are leveled Decompensated/ D t d/ uncompensated when sum of degrees of the fd f th compensatory curve does not equal the degrees of d f l th d f deformity it of major curve. (+) listing ( ) li ti shoulders not leveled

C-CURVE hi h shoulder on high h ld convex; high pelvis on concave. From thoracic to lumbar

S-CURVE most commonly seen l in idiopathic scoliosis Usually right thoracic curve & left lumbar curve

Uncompensated/Decom Compensated pensated

Double Major curve has 2 major curve of q y g ; equal severity & significance; Both structural Transitional vertebra makes transition from one curve to another Neutral vertebra least rotated vertebra Apical vertebra most rotated vertebra

Severity of scoliosis is determined by the y y angle of curvature The greater the rotation of vertebra; the more severe the lateral curvature The more severe the curve; the greater the affectation on cardiopulmonary affectation Decrease vital capacity & total lung capacity Hypertrophy of the ventricle & atrium from pulmonary h f l hypertension t i

Measurement Techniques
X ray measurement

Cobb method
most commonly used; more reliable a line is drawn perpendicular to the upper margin of the vertebra that inclines most toward the concavity. A line is also drawn on the inferior border of the lower vertebra with greatest angulation toward the concavity. The angle of these transecting lines is noted & recorded

Risser Ferguson method

look for 3 vertebra: uppermost, apical, and lowermost

Nash Moe method

Normally pedicles are symmetrical positioned on either side of each spinous process Grading: 0 no vertebral rotation + & ++ - mild or minimal rotation +++ - moderate rotation ++++ - severe rotation

SEVERITY Mild Moderate

CURVE < 20 20- 40

MANAGEMENT Observe; exercise Structural changes Brace; exercise Brace & surgery Pain & DJD Cardiopulmonary affectation Decrease life expectancy

Severe

40 50 40 - 50 40 > 60 70 60 - 70

NOTE: Curves < 10 - WNL no tx.

Etiology of Structural Scoliosis:

1. Idiopathic unknown/ most common classification idiopathic adolescent scoliosis p Age of onset Adolescent most common type. Young yp g girls age 10-15 g Juvenile occurs between ages 4 & 9. seen often in girls Infantile from birth to age 3. seen often in g boys

Causes Causes: 1. Bone malformation during development y 2. Asymmetric muscle weakness 3. Abnormal distribution of muscle spindle in p paraspinal muscles p 2. 2 Neuromuscular 15-20% 15 20% Neuropathic causes problem in CNS. CP, Polio Myopathic causes problem is on muscles Muscular dystrophy

3. 3 Osteopathic problem in bones Hemivertebra, osteomalacia, rickets, fracture, dislocation of spine Etiology of Non Structural Scoliosis: 1. LLD 2. Spasm in back muscles 3. Habitual asymmetric postures

1. 2. 3. 4. 5. 6.

Factors affecting Decision making to initiate Treatment Etiology yp Type Location y Severity Age p g Rate of progression

Evaluation
Postural assessment plumb line C7 C7gluteal cleft (S2) The following deviation are often noted: Asymmetric shoulder level Prominence of the scapula on the side of the convexity Protrusion of the hip in one side Pelvic obliquity Increased lumbar lordosis

Lateral bend test done to determine whether the curve corrects or reverses as the pt. side bends towards the convex side of the curve. curve Asymmetric side bending is an early sign that the structural changes may have begun to develop in the spine Forward bending test done to determine whether the curve straightens out as the pt. bends forward and to identify a visible, rotational deformity of the rib cage. MMT

Non-Operative treatment of Scoliosis 1. Exercises 2. Cast 3. Traction 4. Spinal bracing 5. ES Sites of curves: Cervical: C1-C6 Thoracic: T2-T12 T2 T12 Cervico Thoracic: C7-T1 Lumbar: L1 & L4 Lumbo Sacral: L5 or below

Exercise in scoliosis:
1. exercise alone will not prevent progression of a scoliotic spine nor will correct an existing scoliosis 2. exercise has been traditionally been used to stretch tight trunk and hip muscles/ strengthen t t h ti ht t k d hi l / t th muscle of the trunk 3. 3 exercise may be beneficial as tx for pt with mild pt. idiopathic scoliosis 4. 4 exercise will not alone halt the progression of or correct an existing moderate or severe scoliosis 5. exercise is used in conjunction with other methods such as braces, cast, etc.

Exercise with Milwaukee brace: Goals: to strengthen the muscle that provides stabilization to the trunk Decrease or correct spinal curves NOTE: j y pads The objective is to move away from the p that are inside the brace. Treatment is geared towards stretching of the CONCAVE side and strengthening of the g g CONVEX side

For C curve scoliosis:

Cross walk
Done with the pt. in quadruped position. Done by initially crossing the UE along the concave side towards the convex side, followed by the advancement of the contralateral LE. Cycle repeats until the pt. completes one whole round within the mat mat.

EXAMPLE: Pt. has C-curve dextroscoliosis Pt. assumes quadruped position. Crosses the (L) UE towards UE then hold that position for 15-30 sec. Followed by crossing of the LE being crossed over the (L) LE hold for 15-30 sec. This followed by crossing over the UE over the (L) UEholdthen lastlycross over the (L) LE over th LE C l repeats the LE. Cycle t

for S-curve scoliosis:

Ambling A bli walk lk
pt. in quadruped position. Advance the UE g y along the concave side followed by advancing by the ipsilateral LE. hold is y maintained after each extremity has been advanced

Klapps exercise
Done i reference t the apex of the curve. D in f to th f th Emphasis is placed on exercise designed for f maximum straightening of the pathologic i t i ht i f th th l i curves whatever their site, direction, & magnitude it d

T3 - sala position (lowered)

T6 on elbows (semi-lowered) ( )

T8 on hands Horizontal quadruped)

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T11 fingertips (semi straightened)

L4 reversed position (reversed erect)

L2 erect k t kneeling posn (erect) li ( t)

Dry Swimming exercise

Beginner s Beginners exercise Decrease static works of spinal muscles

1. 2. 3. 3 4. 5. 5 6.

In prone position prone (B) UE on the sides of the body prone; (B) UE abducted to 45 45 prone; (B) UE in reverse T posn prone; (B) UE flying V prone; (B) UE crossed against the nape area

General instruction: As pt. assumes the posn: pt. lift t k off th mat & rotate th t lifts trunk ff the t t t the trunk towards the convex side. 15-30 SH.

CAT & CAMEL Designed to increase and improve flexibility f h fl ibili of the spine i CAT exercise performed by increasing thoracic kyphosis CAMEL exercise performed by increasing lumbar lordosis

CAMEL EXERCISE

CAT EXERCISE