Scoliosis

Assessment &
Conservative
Management

Physiotherapy Intern:
Nafla AlDossary

Outlines:

Introduction & Definitions.

Epidemiology.
Classification of scoliosis.
Basic Principles & Biomechanics of scoliosis.
Associated Problems & Prognosis.
Scoliosis Assessment.
Scoliosis Conservative Management
Orthosis.
Physiotherapy.

Evidence-Based study.

What is
Scoliosis?
Scoliosis is the Lateral Curvature of the spine.
It can be divided as :
Non-Structural Scoliosis:
Reversible lateral curvature without
rotation Postural.
Structural Scoliosis:
Irreversible lateral curvature of the
spine with rotation of the vertebral
bodies in the area of the major curve.
Major Curve is the largest structural curve.
Compensatory Curve is the curve that above or
below the major one that serves to maintain normal
body alignment.

Curve
Patterns:

Epidemiolo
gy:

Affects 7 million people in the US.

Females Males eight times higher.
AIS Affects 2 to 3% of normal children in
adolescence.
Large population studies have shown that 11%
of 1st degree relatives of patients with
idiopathic scoliosis have scoliosis Genetic
Role.
Recent studies have revealed that the
prevalence of scoliosis may be as high as 68%
within the elderly population.

Classificatio
n:

1.Congenital 15 %.
1.Idiopathic 75 %.
1.Neuromuscular and
Others 10% .

Classificatio
1) Congenital:
n:
Failure of formation.
Failure of
segmentation.
Mixed.

Classificatio
2) Idiopathic:
n:
A.

Infantile (0-3)
years.
B. Juvenile (3- 10)
years.
C. Adolescent ( 10 +)
years.

Classificatio
n:A) Infantile:
It is often associated with
plagiocephaly and hip
dysplasia.
Usually spontaneous resolution
occurs when < 20.
In some cases, it is secondary
to underlying spinal pathology;
so these curves progress.
If Cobb angle >20, treatment
is by bracing.

Classificatio
B) Juvenile:
n:
Seen in 12-21% scoliosis cases.
Commonly progressive.
In 25% cases, there is intraspinal
pathology.
Note caf-au-lait spots.
Generally spine is flexible and
responds to bracing.

Classificatio
C) Adolescent :
n:
Most common type (80-90%) .
Typically right sided thoracic curve,
left lumbar if 2nd curve .
Family history in 30%.
Females: more severe forms, Males:
25% incidence intrathecal
abnormalities.
Future growth potential.
Progressive.

Classificatio
n:
3) Neuromuscular :
Myopathic
Arthrogryposis.
Muscular Dystrophy.

Neuropathic
UML.
LML.

Others:

Trauma.
Tumors.

Basic Principles &

Biomechanics
Schroth Principles
Scoliosis is a 3-dimintional problem

Involves a curvature in the

sagittal, frontal, and
transverse plane.

Basic Principles &

Biomechanics
Schroth Principles

Basic Principles &

Biomechanics
Schroth Principles

Basic Principles &

Biomechanics
Schroth Principles

Shoulder
Girdle Block

Rib
Cage
Block
Pelvic
Girdle
Block

Shoulder
Girdle Block

Rib
Cage
Block
Pelvic
Girdle
Block

Basic Principles &

Biomechanics
Schroth Principles
The greater the rib prominence, the greater the
torsion of corresponding vertebrae.
Development of a Gibbus
hump :

Due to the muscular

imbalance. scoliosis,
In progressive
thoracic hump and
protrusion of the hip occurs
causing cardio-respiratory
restriction in infantile
scoliosis more than in
adolescent onset.

Associated Problems &

Prognosis
Pain in adult-onset or

untreated childhood scoliosis

slightly higher rate of back
pain in patients with AIS
(2011).

Effects on Bones
Osteopenia/Osteoprosis
(2008).

Cardiovascular & Respiratory

impairment (2012).
Emotional/Psychological
Impact (2005).

Scoliosis
Assessment

Physical
Assessment
Physical assessment : looking for
asymmetry of the trunk such as uneven
shoulders or hips, humpback, or listing to
one side and gait.
Cardiopulmonary Testing : To test the
function of the heart and lungs
Cardiopulmonary Exercise Testing, Spirometer.
Palpation : to feel the abnormalities,
tenderness if present.
Leg length discrepancy .
Adams Forward Bending Test : The
patient bends forward at the waist, with arms
extended forward. The physician looks for
asymmetry thoracic prominence (such as a

Physical
Assessment

Physical
Assessment
Plumb line test :
A plumb line is "dropped" from the
C7 vertebra (in the neck) and is
allowed to hang below the buttocks.
In scoliosis the line does not hang
between the glutei muscles.

Scoliometer :
If a rib hump is present,
Scoliometer test is to measure the
angle of rotation using a
inclinometer.

Physical
Assessment

Physical
Assessment
Range of motion : To measure
the patients ability to perform
flexion, extension, bending, and
rotation movements.
Muscle Power : To test the
muscle strength of the
flexion/extension and lateral
movements in both sides of the
trunk, upper & lower extremities.
Neurological assessment : In
addition to testing reflexes,
examine if the patients symptoms
include pain, numbness, tingling,
extremity weakness or sensation,
muscle tone, and bowel/bladder

Radiological
Assessment

Cobbs Method :
Universal standard for measuring the degree of a
lateral curvature by evaluating the AP radiographic
projection of the spine .
It is by identifying the vertebrae at both ends of
the curve end vertebrae.

Radiological
Assessment

Radiological
Assessment
Risser Sign : An x-ray to provide
information about skeletal maturation. The
Risser Sign looks at the iliac crest growth
plate, a fan-shaped part of the pelvis. The
crest fuses with the pelvis at maturity.
Nash-Moe : This method is used to
determine the degree of rotation of the
scoliotic spinal column. In the x-ray image,
the positions of the pedicles in relation to the
vertebral body are assessed in terms of 4
different degrees of rotation.

Radiological
Assessment

Scoliosis
Conservative
Management

Orthotic
Management
Goals of using the spinal orthosis :
To immobilize the spine.
Control the degree of the
deformity.
To reduce pain.
To correct the position of the
spinal joints.

Orthotic
Management :
1) Thoraco-Lumbo-SacralOrthosis (TLSO):
Boston Brace/ underarm brace.
ThermoPlastic-molded form.
23 hrs/day.
Apex of the scoliosis must be
below level 8 thoracic vertebra.

Orthotic
Management :
2) Cervico-Thoraco-LumboSacral-Orthosis :
Milwaukee brace.
Includes a neck ring held in
place by vertical bars attached
to the body of the brace.
23 hrs/day.

Orthotic
Management :
3) Charleston Bending
Brace :
Night-time brace.
Molded to the patient while
he/she is bent to the side, and
thus applies more pressure and
bends the child against the curve.
The apex of the curve needs to
be below the level of the shoulder
blade for the Charleston brace to
be effective.

Physiother
apy :
Has a role in the :
Mild Idiopathic ( < 20 )

scoliosis :
Where the conservative management
as physical therapy is needed by
itself.
Moderate Idiopathic scoliosis

( 20 - 40) :
Physiotherapy combined with bracing.
Sever Scoliosis ( 40) :
Physiotherapy is needed after the
surgical intervention to correct the
muscle imbalance and general

Physiother
apy :
Aims of Physiotherapy
intervention in scoliosis
management :
To Improve the spinal curve in nonprogressive nature Postural .
To halt the progression of the idiopathic
scoliosis.
To reduce the co-morbidities pain,
reduced mobility and functions ,
cardiopulmonary complications.
Enhance better functional levels and
lifestyle.

Physiother
apy :
Physiotherapy management
includes :

Postural Correction
awareness and training.

Cardiopulmonary exercises.

Spinal mobility exercises

AROM, Aerobic to maintain
maximum possible trunk
flexibility.

Stretching exercises for the

tight muscles.

Physiother
apy :
Physiotherapy management
includes :

Strengthening exercises for

the weak muscles.

Physical Agents for pain relief

and muscle spasm.

Alternatives include :
Massage.
Traction.
Spinal Mobilization.

Side-Shift and Hitching

Exercises :
Side-Shift Exercise :

Consists of the lateral trunk shift to the

concavity of the curve. Lateral tilt at the inferior
end vertebra is reduced or reversed, and the
curve is corrected in the side shift position.

The pt is instructed to side shift his trunk to the

concave side, holding the position for 10 sec. ,
then returned to neutral position.

Should be repeated 30 times at least per day.

Side-Shift and Hitching

Exercises :
A

A patient standing in the neutral (A)

Side shift Position (B).
No Bending(C)
No rotation (D)

Side-Shift and Hitching

Exercises :
Hitching Exercise :

For lumbar curve or thoracolumbar curve.

In the standing position, patients are instructed to lift

their heel on the convex side of their curve while
keeping their hip and knee straight.

In the hitch position, pelvis on the convex side is lifted,

lateral tilt at the inferior end vertebra is reduced or
reversed, curve is corrected, and asymmetry of the
indented waist line is reduced.

To hold the hitch position for 10 seconds, to return to

the neutral position, and to repeat this exercise at least
30 times a day.

Side-Shift and Hitching

Exercises :

Side-Shift and Hitching

Exercises :
Hitch/Shift exercise:

For a double major curve.

Patients are instructed to lift their heel on the convex
side of the lumbar curve as the hitch exercise.
To immobilize the lower curve by their hand, to shift
the trunk to the concavity of the thoracic curve.

Side-Shift and Hitching

Exercises :

Schroth Method
Developed by Ms. Katharina Schroth in the
early 70s.
Its a Scoliosis-Specific Back School,
scientifically validated exerciseapproach ,
concerns on treating the scoliosis according to
the 3 dimensional curve concept.
Aim : Postural Correction.
Patients learn to feel and understand the
maximal correction throughout the different
stages and training.
Main points :

Schroth Method
Postural Correction :
Overcorrection helps
reverse deformities
The pt is trained by the therapist to
take the opposite posture of the
scoliotic one.
Hence, the pt is going to
understand the correct posture and
will be able to assume it in his
functional and daily life activities.

The visual stimulation is very

important in understanding the
correct posture by the pt himself

Schroth Method

Schroth Method
Isometric Postures :
Isometric contractions of the
core while in mechanically
advantageous positions.
Patient is shown postures which
would help to reduce the
postural deformity associated
with his/her scoliosis, and asked
to hold those postures during
Schroth breathing .

Schroth Method
Rotational Breathing

Aim : To reduce vertebral rotation + improve

the pulmonary function in the collapsed

concave area during inspiration +
Strengthening the weak convex muscles by
isometric forceful contraction during
exhalation .
A Respiratory Thoracic Movement along the
sides of an imaginary right-angle:
Laterally + cephally + posteriorly = threedimensionally.
Tactile stimulation can be used.

Schroth Method
Rotational Breathing can be effective
only if its done after postural correction :
Trunk forward, Pelvis backward & unilateral
pelvis protrusion should be taken in toward
the line of gravity.

Schroth Method

Evidence-Based
Study
Physical Exercises in The Treatment Of
Adolescent
Idiopathic Scoliosis: An Updated
A bibliographic search with strict inclusion criteria
Systematic Review 2011
(patients treated
exclusively with exercises, outcome Cobb degrees, all
study designs) has been performed on the main
electronic databases.
Exercises were shown to be effective in reducing brace
prescription.
The Study showed that the PEs can improve the Cobb
angles of individuals with AIS and can improve strength,
mobility, and balance.

Referenc
es:

Scoliosis Spine Associates : http://www.scoliosisassociates.com/

Morphopedics : http://morphopedics.wikidot.com/spinal-scoliosis
Screening for AIS By Richard B. Goldbloom .
The Genetic Basis of Adolescent Idiopathic Scoliosis By Christopher R. Good, M.D.
Manchester Physio : http://www.manchesterphysio.co.uk/
The Schroth Method : http://www.schrothmethod.com/about/scoliosis-exercises
ScolioCare : http://www.scolicare.com.au/treatments
Scoliosis Systems : http://www.scoliosissystems.com/Scoliosis-Treatment/
International Encyclopedia of Rehabilitation- Scoliosis Rehabilitation :
http://cirrie.buffalo.edu/encyclopedia/en/article/49/
Dr. Enas F Yossef, Dammam Uniersity, PT Dept. : Spinal Deformities Lecture.
Hana Kim, MD, Hak Sun Kim, MD, Eun Su Moon, MD, Scoliosis Imaging: What
Radiologists Should Know- Radiographics Journal, November-December 2010 , doi:
10.1148/rg.307105061
Hans-Rudolf Weiss MD, Scoliosis Short-Term Rehabilitation (SSTR) A Pilot
Investigation -The Internet Journal of Rehabilitation. 2010 Volume 1 Number 1. DOI:
10.5580/e71
Dariusz Czaprowski , Tomasz Kotwicki : Physical capacity of girls with mild and
moderate idiopathic
scoliosis: influence of the size, length and number of curvatures- European Spine
Jornal, (2012) 21:10991105
Tsuyoshi Sato, Toru Hirano: Back pain in adolescents with idiopathic scoliosis:
epidemiological study for 43,630 pupils in Niigata City, Japan- European Spine
Jornal,2011 February; 20(2): 274279.
Mir Sadat-Ali, Abdallah Al-Othman : Does scoliosis causes low bone mass? A comparative study

Thank You