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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:
Epidemiology:
• 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.
Classification:

1. Congenital “15 %”.

1. Idiopathic “75 %”.

1. Neuromuscular and Others “10%” .


Classification:
1) Congenital:

• Failure of formation.
• Failure of segmentation.
• Mixed.
Classification:

2) Idiopathic:

A. Infantile (0-3) years.


B. Juvenile (3- 10) years.
C. Adolescent ( 10 +) years.
Classification:

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.
Classification:
B) Juvenile:
• Seen in 12-21% scoliosis cases.

• Commonly progressive.

• In 25% cases, there is intraspinal


pathology.

• Note café-au-lait spots.

• Generally spine is flexible and responds


to bracing.
Classification:
C) Adolescent :
• 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.
Classification:

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 Shoulder Girdle


Block Block

Rib Cage Rib Cage


Block Block

Pelvic Girdle Pelvic Girdle


Block 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.

In progressive scoliosis, 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 .

• Adam’s Forward Bending Test : The patient bends


forward at the waist, with arms extended forward. The
physician looks for asymmetry thoracic prominence
(such as a shoulder blade), or a lumbar prominence.
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 patient’s


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 patient’s
symptoms include pain, numbness, tingling,
extremity weakness or sensation, muscle
tone, and bowel/bladder changes.
Radiological Assessment

Cobb’s 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-Sacral-Orthosis
(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-Lumbo-Sacral-
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.
Physiotherapy :

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 posture.
Physiotherapy :

Aims of Physiotherapy intervention in scoliosis


management :

• To Improve the spinal curve in non-progressive


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.


Physiotherapy :

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.
Physiotherapy :

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 B C D

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 70’s.

• It’s a “Scoliosis-Specific Back School”, scientifically


validated exercise approach , 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 :
 Postural correction training.
 Rotational Breathing.
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 “Mirror Therapy”.
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 = three-dimensionally.

• Tactile stimulation can be used.


Schroth Method

• Rotational Breathing can be effective only if it’s 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 Systematic Review “2011”
• A bibliographic search with strict inclusion criteria (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.
References:
• 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) 21:1099–1105
• 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): 274–279.
• Mir Sadat-Ali, Abdallah Al-Othman : Does scoliosis causes low bone mass? A comparative study
between siblings, European Spine Jornal 2008 July; 17(7): 944–947.
• C Fusco, F Zaina: Physical exercises in the treatment of adolescent idiopathic scoliosis: An updated systematic
review- Physiotherapy Theory and Practice, 27(1):80–114, 2011
Thank You