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3/20/2009

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Dr. Ajin Jayan Thomas

Lecturer,

Dept. Of Physiotherapy,

Pad. Dr. D.Y Patil University

Outline � Introduction

� Definition, classification, clinical aspects

� Evaluation

� Management

� Braces

� Physiotherapy

� Screening

� Conservative

� Surgery

� Post Surgical management

2Scoliosis: Dr. Ajin Jayan Thomas

� The Scoliosis Research Society (SRS) : Lateral

curvature of the spine greater than 10° as measured

by the Cobb method on a standing x-ray of the

thoraco-lumbar spine

� 2% to 4% of children between 10 and 16 years of age

have measurable but small curves.


ClassificationI. Non structural Scoliosis

� Postural scoliosis

� Compensatory Scoliosis

II. Transient structural Scoliosis� Sciatic scoliosis

� Hysterical scoliosis

� Inflammatory scoliosis

III. Structural scoliosis

A. Idiopathic Scoliosis

� Infantile

� Juvenile

� Adolescent


B. Congenital

I. Vertebral- Open and Closed

II. Extravertebral

C. Neuromuscular

I. Neuropathic

II. Myopathic

III. Others

D. Neurofibromatosis

E. Mesenchymal disorders

F. Trauma

G. Secondary to irritative phenomena

H. Others5

Scoliosis: Dr. Ajin Jayan Thomas 6

Scoliosis: Dr. Ajin Jayan Thomas

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Progressive Idiopathic Scoliosis


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HISTORY

� Chronological age

� Age at recognition of deformity

� Impression of rate of progression

� Associated symptoms

� Developmental factors

� Genetic factors

� History of measles, mumps, chicken pox, whoopingcough, polio, rickets diphtheria, pneumonia,torticollis, chorea.


PHYSICAL EXAMINATION

� Posture Alignment

� Muscle length (shortening/lengthening)

� Limb length

� Range of motion

� Muscle strength

� Cardiopulmonary status

� Neurological evaluation

� ADL’s , Functional Evaluation



RADIOGRAPHIC EVALUATION

� X rays

� PA and Lateral views (in standing)

� Right and left bending views (evaluation for surgery and bracing)

� Stagnara Derotation view- obliterates rotational component

�Cobbs angle & Bunnel Method

�Nash and Moe Method : For Rotation

�Risser sign- development of illiac apophysis

�Rib hump

� Moire’ topography- three-dimensional

� ISIS Scanning12

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Moire’ topography Stagnara Derotation view


� Rib Hump: linear distance between the left and right post rib prominence-lateral X ray

� Apical vertebral body – rib ratio: Linear measurements from the apical vertebral body to the chest wall on AP x ray


Nash and Moe Method


Cobbs Angle / method


Classification of Curves� King Classification: one of five patterns, which can

help determine surgical treatments. Has limitations,

� Lenke Classification: Takes more features of the curve into consideration , more reliable. six curve patterns plus additional factors that modify each of these curves.

DESCRIPTION OF CURVE:

rt/lt, site, angle, cobb’s/other, reference vertebrae,


RISSER GRADE

� For skeletal maturity

� Children usually progress from a Risser grade 1 to a grade 5 over a two-year period.

Risser grade/ Sign


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Scoliometer / Inclinometer


Curve (degrees) Risser grade X-ray/refer Treatment

10 to 19 0 to 1 Every 6 months/no Observe

10 to 19 2 to 4 Every 6 months/no Observe

20 to 29 0 to 1 Every 6 months/yes

Brace after 25 degrees

20 to 29 2 to 4 Every 6 months/yes

Observe or brace

29 to 40 0 to 1 Refer Brace

29 to 40 2 to 4 Refer Brace

>40 0 to 4 Refer Surgery

Guidelines & Treatment


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� Longitudinal and Transverse forces

� To correct coronal and sagittal plane

deformities

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Boston Brace

1. Correcting the lateral curve2. Correcting the malrotation

3. Returning the torso to a balanced position over the

sacrum4. Properly aligning the spine in the sagittal plane


Milwaukee Brace� cervico-thoraco-lumbo-

sacral orthosis

• Blount and Schmidt


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Cheneau Brace


Lyon Brace /Stagnara Brace


Malaga Brace


SpineCor Brace


Sforzesco brace


Providence Brace


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Others…..� RSC Brace (Rigo System Cheneau Brace)

� Charleston Brace

� Wilmington Brace

� Miami brace


Exercises in/out of Brace Purpose of exercise program (out of brace):

� a. Develop postural awareness and ability to maintain corrected alignment.

� b. Maintain and/or increase chest mobility for proper respiration.

� c. Maintain and/or increase muscle strength.

� d. Maintain and/or increase spinal flexibility.

� e. Maintain and/or increase range of motion (prevent contractures, especially in hip flexors).

� f. Provide a good general physical condition.


Purpose of exercise program (in brace):

� a. Develop postural awareness and ability to maintain corrected alignment as provided by brace

� b. Enhance patient’s comfort

� c. Assist patient to resume previous activity level.

� Functional

� Social

� Recreational



Postural alignment: Done as frequently as possible, both in and out of brace.

� a. Lumbar Flexion (posterior pelvic tilt)

� This serves to maintain the anterior-posterior

balance of the spine by elongating the posterior

structures and enhancing the contractile elements of

the anterior structures. This keeps the pelvis and

lower spine in optimum alignment as the patient

attempts proper trunk alignment.

� b. Trunk Alignment Patient attempts to align head,

neck and trunk over pelvis.


Points to remember……..

� Bracing will reduce lung function by 10 to 15%

� Skin care very important

� Break-in time for a brace should be about 2-3 weeks(6 hours, 10 hours and 18-23 hours)

� Brace checkout done by orthotist regularly

� Each brace to be custom made


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SCREENING 6 Step Process

1. Front standing position

2. Back standing position

3. Back bending away from you

4. Side bending position

5. Front bending toward you

6. Side bends


Step 1 Front View

• Shoulders should be level

and at the same height

•Distance between arm and torso equal on both sides

•Crest of hips level on horizontal plane

•Head straight and centeredAbnormal Normal


Step 2 Back Standing View•Shoulders should be level andthe same height

•Distance between arm and

torso equal on both sides

•Crest of hips level on

horizontal plane

•Head straight and centered

•Scapula level on both sides40Scoliosis: Dr. Ajin Jayan Thomas

Adam’s Bending Technique

�Feet slightly apart

�Palms together

�Arms outstretched with straight elbows

�Head out

�Bend forward at waist

�Place hands between legs at knee level


Step 3 Back Bending Away

Look For:•Rib prominence

•Lumbar Prominence

•Differences in height of hip crests


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Step 4 Side View

Look for exaggerated

rounding of the backKyphosis


Step 5 Bending Front View

•Shoulders level?

•Is one side of torso morerounded than the other?

•Look for lumbar prominence


Step 6 Side Bends

Ask the student to bend atThe waist to each side

Look for S curvatures


POSTURAL CURVES� General body relaxation

� Passive correction

� Maintenance of corrected posture

� Stretching to tight structure

� Strengthening of weak muscles

� Deep breathing exercises

� Balance exercises

� Symmetrical movements should NOT be advised

� Ergonomic advice

� Aerobic conditioning programme


Structural Scoliosis� Brace

� Mobility Exercises

� Deep breathing Exercises

� Back to wall postural exercises

� Stretching

� Strengthening

� Traction: Hanging on stall bars, skin traction

� Hydrotherapy


•INDICATIONS

•TYPES

•PHYSIOTHERAPY

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TYPES

� Spinal fusion

� Spinal instrumentation

� Harringtons Instrumentation- Rod and Hooks

� Luque Instrumentation- multiple wires and two rods

� Dwyer’s Instrumentation- cable and screws (Anterior

approach)

� Zielke’s Instrumentation- Rod and screws


PRE OPERATIVE POST OPERATIVE

� Improve vital capacity & chest expansion

� Muscle charting: Improve muscle power

� Stretching

� Explain about post op management

� Improve vital capacity

� DBE, vibrations with coughing

� U/E – AROM Ex

� L/E- PROM Ex

� Sitting- Reverse Climb down technique

� Standing – Walking

� Ergonomic principles taught

� Spinal ex- after 3 months

� Use of corset/POP jacket

� Hydrotherapy

PHYSIOTHERAPY


Post Surgical complications

� DVT

� Pulmonary embolism

� Stiffness of spine, neck, shoulder

� Wound infection

� Neuralgia

� Graft site pain

� Plaster sores


Resources � Scoliosis Research Society- http://www.srs.org/

� Cambells Operative Orthopedics

� Essentials of Orthopeadics and Applied Physiotherapy: Jayant Joshi

� Therapeutic Exercises : Carolyn Kissner

� http://scoliosisjournal.com

� www.bracingscoliosis.com

� National Scoliosis Foundation http://www.scoliosis.org/


[email protected]

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