Hippocrates might have described as in good health (idiopathic), those with natural

conformations (congenital), those with curves due to habit (neuromuscular), and those who
are bent from old age and pains (degenerative and traumatic).
Colloquially, scoliosis is often used as a term to include all spinal deformities.
The term was coined by Galen in the second century A.C.E
(1). It is derived from the Greek word skolios
(2), meaning bent, twisted, or curved.
As such, it could include any spinal curvature.
However, Galen defined it as the (abnormal) curve of the spine in the coronal (aka frontal)
plane. Sagittal plane pathology results from excess or reversal of the spines natural sagittal
curves.
Kyphosis, the word Galen applied to sagittal curves with a posterior vertex
(concave anteriorly)
o derives from the Greek word kuphos

meaning bent forward or humped. Within a range of degrees,

it is normal in the thoracic spine.
Lordosis is the word used to describe a sagittal curve with an anterior vertex
(concave posteriorly).
o It derives from lordos
meaning excessive posterior bending. Within a range of
degrees, it is normal in the cervical and the lumbar spine
- deLisa
Scoliosis
Scoliosis is a deformity in which there are one or more lateral curvatures of the lumbar or
thoracic spine; it is this spinal deformity that was suffered by the "Hunchback of Notre
Dame." (In the cervical spine, the condition is called torticollis.)
TYPES OF SCOLIOSIS
1. Structural Scoliosis
An irreversible lateral curvature of the spine with fixed rotation of
the vertebrae
The vertebral bodies rotate toward the convex side of the
curve, and the spinous processes rotate from the convex side
of the curve.
The greatest rotation of the vertebrae occurs at the apex of
the curve.
As the curve increases, the amount of rotation increases.
Forward bending of the trunk produces a posterior rib hump in the
thoracic region of the convex side of the curve because of the
rotation of the vertebrae and rib cage.
Compression of the ribs occurs on the concave side of the
curve, and separation of the ribs occurs on the convex side.

The net result, which is accentuated with forward bending, is

prominence of the ribs and scapula posteriorly on the convex
side of the curve.

Prominence of the rib cage can also be noted along the anterior
aspect of the chest on the concave side of the curve.
Associated structural changes in the spine:
Lateral displacement of the nucleus pulposus in the
intervertebral disk space.
Eventual wedging of the vertebral body on the concave side
of the curve because of pressure on epiphyseal plates,
particularly in curves of 25 deg or greater
(kisner)
Structural scoliosis cannot be corrected by positioning or voluntary
effort.
primarily involves bony deformity, which may be congenital or acquired or
excessive muscle weakness as seen in a long term quadriplegic.

Types of Structural Scoliosis

Idiopathic
most common), may be transmitted as an autosomal dominant or
multifactorial trait (appears in a previously straight spine during the
growing years..
a. Infantile
most affects male infants between birth and 3 years and
causes left thoracic and right lumbar curves
b. Juvenile
affects both sexes between ages 4 and 10 and causes varying
types of curvature
c. Adolescent
generally affects girls from age 10 until skeletal maturity and
causes varying types of curvature.
Congenital scoliosis
a. Failure of vertebral formation (hermivertebra)
b. Failure o segmentation (partial or complete bar)
c. Abnormal spinal canal or cord (myelodysplasia)
Neuromuscular scoliosis
a. Neurophatic
Due to disease or anomalies of nerve tissue.
b. Myopathic
Due to disease or anomalities of the musculature.
Neurofibromatosis with scoliosis

 Suggested by the presence of caf au lait spots- light

brown irregular areas of skin pigmentation).
Scoliosis with desease of vertebra(tumor, infection, metabolic
disease, arthritis)
2. Non-structural scoliosis
- A reversible lateral curve of the spine that tends to be positional or
dynamic in nature.
- There are no structural or rotational changes in the alignment of the
vertebrae.
- Correction of the lateral curve is possible by
o Forward or side bending
o Positional changes and alignment of the pelvis or spine
o Muscle contraction
- The curve also disappears when the patient is supine or prone.
- It is also called functional or postural scoliosis.
Postural
Caused by leg length inequality
Caused by nerve root irritation
Caused by contractures about the hip
- (brashear,caillet)
STRUCTURAL
NON STRUCTURAL
vertebral bodies rotates towards
(functional scoliosis) No chan ge of
convex spinous process rotates
structure Positional or d ynamic in
towards concave
nature
Irreversible lateral curvature with fixed Reversible
rotation of vertebrae.
(+) rotation of vertebrae; a pex:
(-) rotation
greatest
( +) rib hump (posterior rib hump)
(-) rib hump
(+) bony deformity (+) bony deformity
(-) bony deformity
(+) progressive
(-) progression
(-) corrected by positioning or
(+) correction forward bending/ lateral
voluntary efforts
efforts bending positional changes side
bending muscle contraction
TYPES OF CURVES
The direction of the curve is always identified by the convexity
E.g. If a patient has a right thoracic scoliosis, the convexity of the
curve will be on the patients right and the concavity of the curve on
the patients left
Primary curve or major curve
The largest curve with the greatest angulation
is the most significant curve of the scoliotic deformity

The major curve usually occurs in the thoracic region and has
structural changes in the vertebrae
The term major curve is used by the Scoliosis Research Society of
North America and is preferable to the term primary curve
The major curve in idiopathic scoliosis is usually a right thoracic
curve occurring bet. T4 & T12

Secondary or Compensatory Curve

Develops above or below the major curve in an attempt to maintain
normal body alignment.
A minor compensatory curve that is less severe may develop in the
opposite direction above and/or below a major curve
The compensatory curve may be non-structural or structural
This compensatory curve produces a compensated scoliosis in which
the shoulders are level and positioned directly over the pelvis
If the sum of degrees of the compensatory curve(s) does not equal
the degrees of deformity of the major curve, the scoliosis is said to
decompensate.
The shoulders are not level
There is lateral shift of the trunk to one side
Double Major curve
Are most frequently a thoracic and a somewhat larger lumbar
curve.
If 2 major curves develop of equal severity and significance, a
double major curve is said to be present
Both curves of a double major curve are usually structural

SITES & SHAPES OF CURVES

An important factor when considering prognosis & treatment.
Site of the curve
A lateral curvature of the s pine may develop in the cervical, thoracic,
lumbar, or multiple areas of the spine.
Cervical curve has its apex from C1 or to C6
Thoracic curve its apex at C1 to T12
Cervicothoracic curve arbitrarily having its apex at C7 or T1
Lumbar curve has its apex between L1 & L4
Thoracolumbar curve has its apex at T12 or L1
Lumbosacral curve has its apex at L5 or below
Scoliotic curve
Kyphos

Is an increase in the posterior convex angulation of the spine in the

sagittal plane.
- 20-40 of kyphosis is considered a normal range.
Kyphoscoliosis
- When excessive kyphosis is associated with lateral curvature
Lordoscoliosis
- A kyphos less than 20 in the thoracic spine
- An increase in anterior curvature
Lordosis
- Is a curve with convexity anteriorly and is physiological
-

Shapes of Curves
1. Long C-Curve
Usually extends the length of the thoracic and lumbar spine
Often compensated, leading to a high shoulder on the convex side
of the curve and high pelvis on the concave side
May be due to long-term asymmetric positioning, muscle weakness,
or inadequate control sitting balance
2. S Curve
Most common type of curve seen in idiopathic scoliosis; It is usually
a right thoracic, left lumbar curve
Involves major curve & compensatory curve
Associated with structural changes in the vertebra of the major
curve

Severity of Scoliosis

Determined by the angle of the curvature and rotation of the spine

1) The more severe the lateral curvature, the greater the rotation of
the vertebra
2) The more severe the curve, the greater the impact & secondary
changes in the cardiopulmonary system.
Decreased vital capacity and total lung capacity
Hypertrophy of the right ventricles & strium from pulmonary
hypertension.
Classification of Severity of The Curvature
1. Mild Scoliosis
Curves of less than 20 degrees.
Curves of less than 10 degrees are considered by some to be within
the limits of normal in the general population and do not warrant
treatment.

2. Moderate Scoliosis
Curves from 20 to 40 degrees.
Moderate scoliosis is associated with early structural changes in the
vertebrae and rib cage.
3. Severe scoliosis
Curves of 40 to 50 degrees or greater.
It involves significant rotational deformity of the vertebrae and ribs.
Curves of 60 to 70 degrees or greater are associated with
significant cardiopulmonary changes and decreased life expectancy.
SEVERI
TY
Mild
Moder
ate
Severe

CURVE

MANAGEMENT

< 20
20- 40

Observe; exercise
Structural
changes
exercise
Brace & surgery

40 - 50

40 >
60 - 70

Brace;

Pain & DJD

Cardiopulmonary
affectation
Decrease life Decrease life
expectancy

EPIDEMIOLOGY

Age: People of all ages can have scoliosis.

The most common type is idiopathic scoliosis in children age 10 to 12 and
in their early teens. This is the time when children are growing fast.
Sex: Girls are more likely than boys to have this type of scoliosis.
Scoliosis can run in families.

ANATOMY AND PHYSIOLOGY

ETIOLOGY
Etiology of Structural Scoliosis
Idiopathic
About 75 to 85% of all scoliosis develops without any known cause in
otherwise normal, healthy children and progresses with skeletal growth
Age onset
a. Adolescent scoliosis is the most common type of scoliosis and
develops most often in young girls from age 10 to the end of
skeletal growth (abt. 15 or 16)
b. Juvenile scoliosis occurs between ages 4 & 9 & seen more often
in boys than girls
Theories of causes of Idiopathic Scoliosis
a. Possible bone malformation during development
b. Asymmetric muscle weakness
c. Abnormal postural control because of possible dysfunction of the
vestibular or proprioceptive system
d. Abnormal distribution of muscle spindles in paraspinal
musculature
Neuromuscular
About 15 to 20% of structural scoliosis occurs as the result of
congenital or acquired neuropathic or myopathic diseases or disorders
Neuropathic causes
a. Congenital
(cerebral
palsy,
myelomeningocele,
neurofibromatosis)
b. Acquired (ant. Horn cell disease, traumatic paraplegia)
Myopathic Causes
a. Congenital (amyotonia congenital, arthrogryposis)
b. Acquired (muscular dystrophy)
Osteopathic
Congenital (2 to hemivertebra)
Acquired (osteomalacia, rickets, fracture & spine dislocation)
Etiology of Non-Structural Scoliosis
Leg Length Discrepancy
1. True actual difference in bony length
2. Apparent measurable difference because of a dislocated hip, asymmetric
leg or foot postures, or rotated innominate

3. Congenital or acquired deformities can cause asymmetric variations that

lead to pelvic obliquity (high pelvis on one side) and a compensatory
lateral curvature of the spine

Spasm in the Back

1. Splinting of the back muscles may occur in response to injury of any tissue
in the back
2. Sciatic scoliosis often accompanies a posterolateral disk protrusion in
lumbar spine. The deviation usually occurs away from the painful side.
Habitual Asymmetric Postures
1. Sitting with weight shifted onto one hip or standing with weight primarily
supported on one leg results in asymmetric flexibility and tightness in soft
tissue of the trunk & hips
2. In children, continued asymmetric postures may affect remodeling of bone
and adaptation of soft tissue

PATHOPHYSIOLOGY

Bone Malformation

Abnormal distributionof muscle spindles

Asymmetric Muscle Weaknesss

Lateral curvature of spine

Muscle imbalance

Pain

SCOLIOSIS

CLINICAL MANIFESTATION
Signs and Symptoms
1. Spinal curvature that rises in the thoracic segment, with convexity to the
right, and compensatory curves (S curves) in the cervical segment above
and the lumbar segment below, both with convexity to the left
2. Backache, fatigue, and dyspnea (after disease is well-established)
3. Pulmonary insufficiency (curvature may decrease lung capacity), back
pain, degenerative arthritis of the spine, disk disease, and sciatica (in
untreated disease)
Physical Examinations Shows
1. Unequal shoulder heights, elbow levels, and height of iliac crest
2. Uneven hemlines or pant legs that appear unequal in length
3. One hip that appears higher than the other
4. Asymmetrical thoracic cage and misalignment of the spinal vertebrae
when the patient bends over
5. Asymmetrical paraspinal muscles, rounded on the covex side of the curve
and flattened on the concave side
6. Asymmetrical gait
Complications
While most people with scoliosis have a mild form of the disorder, scoliosis
may sometimes cause complications, including:

Lung and heart damage

- In severe scoliosis, the rib cage may press against the lungs and
heart, making it more difficult to breathe and harder for the
heart to pump.

Back problems
- Adults who had scoliosis as children are more likely to have
chronic back pain than are people in the general population.

Appearance
- As scoliosis worsens, it can cause more noticeable changes
including unleveled shoulders, prominent ribs, uneven hips, and
a shift of the waist and trunk to the side. Individuals with
scoliosis often become self-conscious about their appearance.

TEST AND MEASUREMENT

Evaluation Procedures
1. Postural Assessment
a. Anterior, posterior & lateral postural assessments are done with the
child standing
b. A plumb line is used to note any deviations in alignment
Asymmetric shoulder level
Prominence of the scapula on the side of the convexity
Protrusion of one the hip on one side
Pelvic obliquity
Increased lumbar lordosis
2. Ability of the curve
a. Lateral Bending Test
Done to determine curve corrects or reverses as the child
side bends towards the convex side of the curve
Asymmetric side bending is an early sign that structural
changes may have already begun to develop in the spine
b. Forward bending Test
This test is done to determine whether the curve straightens
out as the child bends forward and to identify a visible,
rotational deformity of the rib cage
If structural changes are present, the examiner will see a
posterior rib hump on the side of the convexity of the
thoracic when the child bends forward
In the lumbar spine, prominence of the erector spinae
muscles may be evident on the side of the convexity. This is
due to the posterior rotation of the transverse process of the
vertebra on the side that pushes the muscle outward.
Procedure
o Sit in front or in back of the child. Ask the child to bend
forward to a 90 deg angle and allow the arms to hang
loosely
o Examine the thoracic and lumbar spine and note any
asymmetry or prominence of the ribs or scapula on the
convex side of the curve

c. The following structures may be limited if asymmetry is noted

during flexibility testing
Muscles (erector spinae, oblique abdominals, intercostals,
quadratus lumborum. Hip muscles may also be involved if
there is faulty pelvic posture
Ligaments (ant. & post. Longitudinal, ligamentum flavum and
interspinous
3. Related Diagnostic Information
a. Complete medical history & physical examination
b. X-ray series:
o Standing - to determine the location & severity of the curve
o Side Bending to determine the flexibility of the curve
c. Moire Topography detects asymmetry on opaque surfaces
d. Pulmonary Function Test a decrease in vital capacity & total lung
capacity are often seen in patients with moderate and severe
curves.
DIFFERENTIAL DIAGNOSIS
1) Lordosis
Characterized by an increase in lumbosacral angle (N=30)
2) Kyphosis
Describe an increased convexity of the thoracic spine. This is
usually obvious when the patient is viewd from the side.

MANAGEMENT
MEDICAL MANAGEMENT
Surgical management

Surgical management of scoliosis is generally intended to prevent future

consequences of progressive deformity. Although most adolescents have
little impairment or symptoms related to their deformity, future
consequences include the possible:

o
o
o
o
o

development of progressive pain

pulmonary or cardiac compromise
progressive
deformity
and
appearance
neurological deterioration
greater than 45 to 50 degrees

Two Main Types of Surgery

A. Anterior Fusion
This surgical approach is through an incision
at the side of the chest wall.

For curves that are mainly at the

thoracolumbar junction (T12-L1),
the scoliosis surgery can be done
entirely as an anterior approach.
This approach to scoliosis surgery
requires an open incision and the
removal of a rib (usually on the
left side). Through this approach
the diaphragm can be released
from the chest wall and spine.
The discs are removed and this
loosens up the spine.
Screws can then be placed in the vertebral
bodies and a reduction of the curvature
obtained and held with a rod.
Bone is added to the disc space (either the
patients own bone, taken from the
patients hip, or cadaver bone), to
to fuse together.
This fusion process usually takes
months, and can continue for up to
months.
B. Posterior fusion

unacceptable

(cut)

allow the spine

about 3 to 6
12

This surgical approach is through an incision on

back
and
involves
the
use
of
metal
instrumentation to correct the curve.
After making the incision, the muscles are then
stripped up off the spine to allow the surgeon
access to the bony elements in the
spine
The spine is then instrumented
(screws are inserted) and the rods are
used to reduce the amount of the
curvature
Bone is then added (either the patients own
bone, taken from the patients hip, or cadaver
bone), which in turn incites a reaction that results
the spine fusing together.
This fusion process usually takes about 3 to 6
months, and can continue for up to 12 months.

the

in

PT MANAGEMENT

Klapps Exercise
T3 Heel sitting position (Allah position)
T6 on knees and elbows
T9 on knees and hands (quadruped position)
T12 on knees and finger tips
L2 reverse T
L4 tall kneeling

Dry Swimming Exercise

Pt in prone position
Pt prone with (B) UE on side of the body
Pt in prone with (B) UE in ABD (45 degree)
Pt in prone with (B) UE in reverse T position
Pt in prone with (B) UE in flying V position
Pt in prone with (B) UE crossed against the nape
Gen. Instruction: As Pt assumes the position, he is instructed to lift his
trunk off the surface of the treatment table and he is instructed to
rotate his trunk towards the convex side. 15-30 SH is maintained for
stretch.

For C-Curve---(Levothoracolumbar Scoliosis)

Cross walk
Pt in quadruped position
15-30 SH
For S - Curve(Dextrothoracic Levolumbar Scoliosis)
Ambling walk
Pt in quadruped position

 15-30 SH

Breathing Exercise
To expand the lungs on the concave side
Inhale maximally through the nose, then slowly exhale through the
mouth
Do it by 3 repititions

Pelvic Tilting
Lying on your back with hips and knees bent, flatten arch of the back
Do it by 5 seconds hold
Initial = 5reps, Max = 20reps

Sit ups
Breath in while lying down, breath out while doing sit ups
Arms place at the patients side, while maintaining pelvic tilt, reach for
your knees and hold (5 SH)
Initial = 5reps; Max = 20reps

Distraction exercise with postural weights

Place weights on both hands (4-8lbs)
Patients tries to elongate spine upward against the weight then hold
the position
Do chin tuck position to lessen the neck curve and pelvic tilt to lessen
the low back curves and to decrease trunk curve

Resisted Extension
Pt in kneeling position and both legs are stabilize on the bed
Starting position trunk bend forward with hands across the chest,
head touching the bed
Pt then tries to raise trunk from bent position to upright position, hold
it for 5 sec.
Initial = 5reps, Max = 20reps

Kneeling Extension with Lateral Flexion

Starting position trunk bend forward with hands across the chest,
head touching the bed
Then raise the trunk and rotate to the concave then side bend to the
convex side and hold the position for 5sec
Initial = 5reps, Max = 20reps

Stabilization Exercise
Stabilization exercises for spinal control may be beneficial for
strengthening and conditioning when there is scoliosis.
Patient position and procedure: Standing. Place elastic resistance
under the foot or have the patient hold a weight in the hand on the
side of the concavity; then have him or her side-bend the trunk in
the opposite direction.

Patient position and procedure: Side-lying on the concave side of

the curve with the apex at the edge of the table or mat so the
thorax is lowered. If you have access to a split table with one end
that can be lowered, begin with the apex of the curve at the bend of
the table. Have the patient place the lower arm folded across the
chest and upper arm along the side of the body and side-bend the
trunk up against gravity. Progress by having the patient clasp both
hands behind the head (Fig. 16.49). Stabilization of the pelvis and
lower extremities must be provided.

Casts
Turn-buckle cast
o Applied with the child supported spine on a scoliosis frame
o Spine elongated & ribs derotated during application of the
cast
o Must be worn for several years & must be reapplied many
times
o Significant muscle weakness can occur over the years.
Traction

Cotrel Traction
o Primary used to gain the greatest flexibility possible prior to
spinal fusion
o Spinal traction is applied nightly and for specified periods of
time during the day while the child is in bed
o It consist of removable head halter & pelvic girdle, which are
attached to weight & pulley system

Skeletal Traction
o Prolonged skeletal traction, usually up to 3 weeks, is used
preoperatively with severe or resistant curves to elongate the
spine as much as possible prior to spinal fusion.
Cephalopelvic
o This type of traction plus localized lateral pads in a traction
frame facilitate correction of scoliosis for ultimate casting or
surgery.
Halo-pelvic
o In severe scoliosis, of various causes, halo-pelvic femoral or
halo-pelvic traction has been employed. The halo is applied
directly to the head with pin fixation to the skull. The femoral
counter traction is applied through pins inserted through the
distal femurs. Weights are applied in small increments
approaching 30 pounds on the head and 15 pounds on each
legs.

Spinal Bracing
Major goal is to prevent the progression of a curve or give some
permanent correction and stabilization of the curve.
Milwaukee Brace
o It is a high-profile brace that fits closely to the body. It has
adjustable metal uprights attached to a molded plastic pelvic
girdle & a metal neck ring & throat mold (chin rest).
o It is based on 3 point principle of fixation. A dorsal pad is
placed on the apex of the thoracic curve on the convex side
to decrease the rotational deformity
o Primary used for high thoracic & high magnitude curves
o The brace is worn 23-24 hours a day for several years until
the patient approaches full skeletal growth & the correction is
stable.
o Expected Results
Progression of the deformity has been halted in 70% of
mild & moderate curves
Up to 50% correction of curve can be attained.
Younger patients with milder curves have the best
chance for correction.

Boston Brace
o The purpose of the brace is to keep the spinal curvature from
worsening to control back pain, and immobilize the spine to
assist in stabilizing weak and injured portions of the spine
o It corrects curvature by pushing with small pads placed
against the ribs, which are also used for rotational correction

REFERENCES:
Calliet, Rene M.D, SCOLIOSIS
Kisner, Carolyn, PT, MS & Colby, Lynn Allen, PT, MS, Therapeutic
Exercise, 5th Edition
Lippincott Williams & Wilkins Professional Guide to Pathophysiology
2nd edition
Magee, David J. Orthopedic Physical Assessmnet, 4th edition
Handout on Therapeutic Exercise 2