Scoliosis Assessment & Conservative ManagementPhysiotherapy 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 :

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.

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.

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:

Congenital 15 %.

Idiopathic 75 %.

Neuromuscular and Others 10% .

Classification:1) Congenital:

Failure of formation. Failure of segmentation. Mixed.

Classification: 2) Idiopathic:

Infantile (0-3) years. Juvenile (3- 10) years. 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 caf-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.

NeuropathicUML.LML.

Others: Trauma. Tumors.

Basic Principles & Biomechanics Schroth PrinciplesScoliosis 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 PrinciplesShoulder Girdle BlockShoulder Girdle BlockRib Cage BlockRib Cage BlockPelvic GirdleBlockPelvic GirdleBlock

Basic Principles & Biomechanics Schroth PrinciplesThe greater the rib prominence, the greater the torsion of corresponding vertebrae.In progressive scoliosis, thoracic hump and protrusion of the hip occurs causing cardio-respiratory restriction in infantile scoliosis more than in adolescent onset.Development of a Gibbus hump : Due to the muscular imbalance.

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 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 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 changes.

Radiological AssessmentCobbs 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.

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.

Orthotic Management :

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.

A patient standing in the neutral (A)Side shift Position (B).No Bending(C)No rotation (D) A B C 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 :

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 : Postural correction training. Rotational Breathing.

Schroth MethodPostural 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 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 StudyPhysical Exercises in The Treatment Of AdolescentIdiopathic Scoliosis: An Updated Systematic Review 2011 A bibliographic search with strict inclusion criteria (patients treatedexclusively 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 idiopathicscoliosis: 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 between siblings, European Spine Jornal 2008 July; 17(7): 944947. C Fusco, F Zaina: Physical exercises in the treatment of adolescent idiopathic scoliosis: An updated systematic review- Physiotherapy Theory and Practice, 27(1):80114, 2011

Thank You

****the most common form of the condition, late-onset idiopathic scoliosis, is physiologically harmless and self-limiting.[2][3] The rarer forms of scoliosis pose risks of complications.Most common one is the right thoracic curve in adolescent females.*Risk factors for progression include female gender, curve magnitude of greater than 50 at maturity, curve type and remaining growth. idiopathic scoliosis is diagnosed when a patient has asymmetry on forward bending combinedwith a curve of at least 10.

Schwab F, Dubey A, Pagala M, et al. Adult scoliosis: a health assessment analysis by SF-36. Spine 2003;28:602-6. Schwab F, Dubey A, Gamez L, El Fegoun AB, Hwang K, Pagala M, Farcy JP. Adult scoliosis: prevalence SF-36, and nutritional parameters in an elderly volunteer population. Spine 2005;9:1082-5.

*Classification here is by the cause :Congenital : caused by vertebral anomalies present at birth.Idiopathic : unknown cause.Neuromuscular and others are secondary due to a problem like CP,Spina bifida, traumaetc*May require early surgery due to the severity of the spinal deformity.Children with congenital scoliosis sometimes have other health issues, such as kidney or bladder problems.Even though congenital scoliosis is present at birth, it is sometimes impossible to see any spine problems until a child reaches adolescence.

*idiopathic scoliosis is diagnosed when a patient has asymmetry on forward bending combinedwith a curve of at least 10.

*Plagiocephaly also known as flat head syndrome,[1][2] is a condition characterized by an asymmetrical distortion (flattening of one side) of the skull. It is characterized by a flat spot on the back or one side of the head caused by remaining in a supine position for too long*Onset age 3 to pre-puberty Diagnosed when 4-9 years old Assess same as with adolescent idiopathic scoliosis

*Frequency 1.9-3% (25 in 1,000). *Arthrogryposis, also known as arthrogryposis multiplex congenita (AMC), is a rare congenital disorder that is characterized by multiple joint contractures and can include muscle weakness and fibrosis. It is a non-progressive disease. The disease derives its name from Greek, literally meaning 'curved or hooked joints.

Cerebral Palsy Scoliosis :Scoliosis common in children with cerebral palsy overall incidence is 20%the more involved and severe the cerebral palsy, the higher the likelihood of scoliosis spastic quadriplegic at highest risk, especially if no ability to sit independently.for bedridden children incidence approaches 100%spinal deformity is rare in children who are able to ambulateScoliosis in patients with cerebral palsydiffers from idiopathic scoliosis in that curves aremore likely to progress (scoliosis progresses 1 to 2 per month starting at age 8 to 10 years)curve begins at earlier agecurve is a long, c-shaped curve in CPbracing is less effective

****The ribs are rotated anteriorly on the concave side of the scolioticcurve and posteriorly on the convex side. Consequently, (a)there is a costal depression (rib valley) on the concave side anda thoracic gibbus (hump) on the convex side (fig 2b); there is alumbar hump below the rib valley and a concavity below thethoracic hump (fig 2c); and (c) the shoulder girdle is drawnposteriorly above the rib valley(A) Subdivision into three rectangular superimposed blocks (pelvic girdle, rib cage, shoulder girdle)(B) In scoliosis, three blocks of trunk deviate from vertical axis. This results in lateral shifting of spine(C) The three blocks develop 'wedge-like' form, depending on severity of scoliosis, and rotate against each other around vertical axis.Ribs and spine follow these distortions. Scoliotic torsion is created(D) Additional lumbosacral counter curvature. This pattern demands additional special pelvic corrections in order to influence existingpelvic torsion, explanations of which would go far beyond this paper.*as ribs and musculature move with the rotation and developdorsal elevations (humping of ribs, lumbar hump, elevatedshoulder') or depressions (concavities of the back).

*Back Pain -2011Pain in adult-onset or untreated childhood scoliosis often develops because of posture problems that cause uneven stresseson the back, hips, shoulders, neck and legs. Patients who were surgically treated with fusion techniques lose flexibility andmay experience weakness in back muscles due to injuries during surgery. Those who had eight or more fused vertebrae are athigher-than-average risk for disk degeneration in their 30s and 40s.

Spondylosis : Spondylosis. Nearly all individuals with untreated scoliosis at some point develop spondylosis, an arthritic condition in thespine. The joints become inflamed, the cartilage that cushions the disks may thin, and bone spurs may develop. If the diskdegenerates or the curvature progresses to the point that the spinal vertebrae begin pressing on the nerves, pain can bevery severe and may require surgery. Even surgically treated patients are at risk for spondylosis if inflammation occurs invertebrae around the fusion site.

Bone density : A comparative study between siblings on 2008suggests that scoliosis does induce low bone mass while siblings remain with normal bone mineral density. Moreover, the severity of osteopenia and osteoporosis depends on the degree of Cobb angle in children with AIS.

**Also the triangle between the arms and the trunk mia differ in width if there is a scoliosis.*The conservative management depends on the maturity and the risk of progression*The scoliometer has a small metal ball inside it so it works as a scale which indicates the dgree of the rotation.Scoliometer or inclinometer readings of 5 degrees or more have high likelihood of Cobb angle greater than 10 degrees on X-rays.The therapist places the instrument over mid-thoracic area and records the degree measure. Next, a measurement is taken over the mid-lumbar area, approximately 2 inches above iliac crest. If either measurement is 5 degrees or more, scoliosis may be present.

*The scoliometer has a small metal ball inside it so it works as a scale which indicates the dgree of the rotation.Scoliometer or inclinometer readings of 5 degrees or more have high likelihood of Cobb angle greater than 10 degrees on X-rays.The therapist places the instrument over mid-thoracic area and records the degree measure. Next, a measurement is taken over the mid-lumbar area, approximately 2 inches above iliac crest. If either measurement is 5 degrees or more, scoliosis may be present.

*The conservative management depends on the maturity and the risk of progression** The pedicle levels with the greatest tilt from the horizontal plane. With the use of the Goniometer : A line is constructed along the superior endplate of highest vertebra and inferior endplate of the lowest vertebra. By drawing lines perpendicular to those lines, the angle will be determined.

*The Risser sign refers to the amount of calcification of the human pelvis as a measure of maturity.On a scale of 5, it gives a measure of progression of ossification; the grade of 5 means that skeletal maturity is reached. Risser sign is based on the observation of an X-ray image. Grade 1 is given when the ilium (bone) is calcified at a level of 25%; it corresponds to prepuberty or early puberty. Grade 2 is given when the ilium (bone) is calcified at a level of 50%; it corresponds to the stage before or during growth spurt. Grade 3 is given when the ilium (bone) is calcified at a level of 75%; it corresponds to the slowing of growth. Grade 4 is given when the ilium (bone) is calcified at a level of 100%; it corresponds to an almost cessation of growth. Grade 5 is given when the ilium (bone) is calcified at a level of 100% and the iliac apophysis is fused to iliac crest; it corresponds to the end of growth.OnemethodiscalledtheRissersign,whichgradestheamountofboneintheareaatthetopofthehipbone.Alowgradeindicates that the skeleton still has considerable growth; a high grade means that the child has nearly stopped growing and asmallcurveisunlikelytoprogressmuchfurther.TheRisserscalediffersbetweengendersandinboys.

*The Risser sign refers to the amount of calcification of the human pelvis as a measure of maturity.On a scale of 5, it gives a measure of progression of ossification; the grade of 5 means that skeletal maturity is reached. Risser sign is based on the observation of an X-ray image. Grade 1 is given when the ilium (bone) is calcified at a level of 25%; it corresponds to prepuberty or early puberty. Grade 2 is given when the ilium (bone) is calcified at a level of 50%; it corresponds to the stage before or during growth spurt. Grade 3 is given when the ilium (bone) is calcified at a level of 75%; it corresponds to the slowing of growth. Grade 4 is given when the ilium (bone) is calcified at a level of 100%; it corresponds to an almost cessation of growth. Grade 5 is given when the ilium (bone) is calcified at a level of 100% and the iliac apophysis is fused to iliac crest; it corresponds to the end of growth.

*************A patient with left thoracolumbar curve (A), standing in the neutral (B), and hitch (C) position. She is instructed to lifther heel on the convexity of the curve while keeping her hip and knee straight. Note that asymmetry of the waistline reduced in thehitch position.*toimmobilize the lower curve by their hand, to shift the 15trunk to the concavity of the upper curve*For double curve, hitch shift exercise is indicated. A patient is instructed to lift her heel on the convex side of the lowercurve as the hitch exercise, to immobilize the lower curve by her hand, and shift her trunk to the concavity of the upper curve.*The Schroth technique is a scoliosis-specific back school.all possibilities for postural correction,including respiration, are used in order to enable the patients tohelp themselves** Overcorrection of the right thoracic curve.*Scoliosis is not a primary problem with the muscles, however, the stabilizer muscles of the trunk, pelvis and spine do become imbalanced, and, can be reconditioned to help slow, stop and reverse the scoliosis curvature.*Because ribs are connected by articulations with the lateralprocesses of the vertebrae (fig 4), they can, with the help ofrespiration, reduce the torsion of the trunk during the Schrothexercises.On the depressed(concave) side the ribs which have sunk inwards anddownwards need to be widened from the inside by specificrespiratory exercises. Following the idea of doing exactly theopposite of what the body shape presents, they have to be liftedto the outside (laterally) and upwards (cephally). By doing so, a wider space is created which allows the ribs to bemoved backwards.When trunk and spine have reached their optimal length,the trunk sections which are rotated against each other areable to move without mutual interference.Postural correction enable the trunk sections to work together in rotational breathing. Some braces help in maintaing the correct posture during the rotational breathing*Because ribs are connected by articulations with the lateralprocesses of the vertebrae (fig 4), they can, with the help ofrespiration, reduce the torsion of the trunk during the Schrothexercises.On the depressed(concave) side the ribs which have sunk inwards anddownwards need to be widened from the inside by specificrespiratory exercises. Following the idea of doing exactly theopposite of what the body shape presents, they have to be liftedto the outside (laterally) and upwards (cephally). By doing so, a wider space is created which allows the ribs to bemoved backwards.When trunk and spine have reached their optimal length,the trunk sections which are rotated against each other areable to move without mutual interference.Postural correction enable the trunk sections to work together in rotational breathing. Some braces help in maintaing the correct posture during the rotational breathing*Because ribs are connected by articulations with the lateralprocesses of the vertebrae (fig 4), they can, with the help ofrespiration, reduce the torsion of the trunk during the Schrothexercises.On the depressed(concave) side the ribs which have sunk inwards anddownwards need to be widened from the inside by specificrespiratory exercises. Following the idea of doing exactly theopposite of what the body shape presents, they have to be liftedto the outside (laterally) and upwards (cephally). By doing so, a wider space is created which allows the ribs to bemoved backwards.When trunk and spine have reached their optimal length,the trunk sections which are rotated against each other areable to move without mutual interference.Postural correction enable the trunk sections to work together in rotational breathing. Some braces help in maintaing the correct posture during the rotational breathing*Because ribs are connected by articulations with the lateralprocesses of the vertebrae (fig 4), they can, with the help ofrespiration, reduce the torsion of the trunk during the Schrothexercises.On the depressed(concave) side the ribs which have sunk inwards anddownwards need to be widened from the inside by specificrespiratory exercises. Following the idea of doing exactly theopposite of what the body shape presents, they have to be liftedto the outside (laterally) and upwards (cephally). By doing so, a wider space is created which allows the ribs to bemoved backwards.When trunk and spine have reached their optimal length,the trunk sections which are rotated against each other areable to move without mutual interference.Postural correction enable the trunk sections to work together in rotational breathing. Some braces help in maintaing the correct posture during the rotational breathing**