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3/20/2009
1
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.
3Scoliosis: Dr. Ajin Jayan Thomas
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
4Scoliosis: Dr. Ajin Jayan Thomas
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
7Scoliosis: Dr. Ajin Jayan Thomas
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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.
9Scoliosis: Dr. Ajin Jayan Thomas
PHYSICAL EXAMINATION
� Posture Alignment
� Muscle length (shortening/lengthening)
� Limb length
� Range of motion
� Muscle strength
� Cardiopulmonary status
� Neurological evaluation
� ADL’s , Functional Evaluation
10Scoliosis: Dr. Ajin Jayan Thomas
11Scoliosis: Dr. Ajin Jayan Thomas
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
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� 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
14Scoliosis: Dr. Ajin Jayan Thomas
Nash and Moe Method
15Scoliosis: Dr. Ajin Jayan Thomas
Cobbs Angle / method
16Scoliosis: Dr. Ajin Jayan Thomas
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,
17Scoliosis: Dr. Ajin Jayan Thomas
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
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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
20Scoliosis: Dr. Ajin Jayan Thomas
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� Longitudinal and Transverse forces
� To correct coronal and sagittal plane
deformities
22
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
23Scoliosis: Dr. Ajin Jayan Thomas
Milwaukee Brace� cervico-thoraco-lumbo-
sacral orthosis
• Blount and Schmidt
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Cheneau Brace
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Lyon Brace /Stagnara Brace
26Scoliosis: Dr. Ajin Jayan Thomas
Malaga Brace
27Scoliosis: Dr. Ajin Jayan Thomas
SpineCor Brace
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Sforzesco brace
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Providence Brace
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Others…..� RSC Brace (Rigo System Cheneau Brace)
� Charleston Brace
� Wilmington Brace
� Miami brace
31Scoliosis: Dr. Ajin Jayan Thomas
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.
32Scoliosis: Dr. Ajin Jayan Thomas
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
33Scoliosis: Dr. Ajin Jayan Thomas
34Scoliosis: Dr. Ajin Jayan Thomas
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.
35Scoliosis: Dr. Ajin Jayan Thomas
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
36Scoliosis: Dr. Ajin Jayan Thomas
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37
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
38Scoliosis: Dr. Ajin Jayan Thomas
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
39Scoliosis: Dr. Ajin Jayan Thomas
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
41Scoliosis: Dr. Ajin Jayan Thomas
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
43Scoliosis: Dr. Ajin Jayan Thomas
Step 5 Bending Front View
•Shoulders level?
•Is one side of torso morerounded than the other?
•Look for lumbar prominence
44Scoliosis: Dr. Ajin Jayan Thomas
Step 6 Side Bends
Ask the student to bend atThe waist to each side
Look for S curvatures
45Scoliosis: Dr. Ajin Jayan Thomas
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
46Scoliosis: Dr. Ajin Jayan Thomas
Structural Scoliosis� Brace
� Mobility Exercises
� Deep breathing Exercises
� Back to wall postural exercises
� Stretching
� Strengthening
� Traction: Hanging on stall bars, skin traction
� Hydrotherapy
47Scoliosis: Dr. Ajin Jayan Thomas
•INDICATIONS
•TYPES
•PHYSIOTHERAPY
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9
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
49Scoliosis: Dr. Ajin Jayan Thomas
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
50Scoliosis: Dr. Ajin Jayan Thomas
Post Surgical complications
� DVT
� Pulmonary embolism
� Stiffness of spine, neck, shoulder
� Wound infection
� Neuralgia
� Graft site pain
� Plaster sores
51Scoliosis: Dr. Ajin Jayan Thomas
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/
52Scoliosis: Dr. Ajin Jayan Thomas