CONSERVATIVE TREATMENT OF SCOLIOSIS

Name : AL-ZUBAIDI AYA RIDHA GROUP: 616 C.F.UTRUMATOLOGY

DEFENTIONS

Kyphosis is excessive curvature of the spine in the sagittal (A-P) plane. The normal back has 20° to 45° of curvature in the upper back, and anything in excess of 45° is called kyphosis.

Scoliosis is abnormal curvature of the spine in the coronal (lateral) plane. Scoliosis of between 10° and 20° is called mild. Less than 10° is postural variation.

Lordosis or hyperlordosis is excessive curving of the lower spine and is often associated with scoliosis or kyphosis. It can be exaggerated by poor posture.

NOTE

'structural scoliosis', or just scoliosis, is very different from 'functional scoliosis', which is a spinal curvature secondary to known extra-spinal causes (eg, shortening of a lower limb or paraspinal muscle tone asymmetry). It is usually partially reduced or completely subsides after the underlying cause is eliminated

Definitions and staging• Infantile scoliosis occurs before age 3 and is seen more

frequently in boys. Although neurological involvement is possible, many resolve spontaneously but some may progress to severe deformity.

• Juvenile scoliosis is found more frequently in girls between the ages of 3 and 10. These curves are at a high risk for progression and often require surgical intervention.

• AIS occurs between age 10 and maturity. AIS may start at the onset of puberty or become apparent during an adolescent growth spurt. Females are at higher risk, often requiring surgical treatment, if non-operative treatment fails to halt curvature.

• Adult scoliosis occurs after maturity.

Symptoms• Mild disease is usually painless but, as deformity

grows, pain will usually increase.• Scoliosis in children or adolescents is often

detected on routine screening.• Patients with AIS most often present with unlevel

shoulders, waistline asymmetry (one hip 'sticking out' more than the other), or a rib prominence.[2] 

• Ask about family history of scoliosis.

- Sideways curvature of the spine - Sideways body posture - One shoulder raised higher than the other - Clothes not hanging properly - Local muscular aches - Local ligament pain 

Decreasing pulmonary function is a major concern in progressive severe scoliosis. The progression of scoliosis leads to thoracic cage deformity and concomitant pulmonary compromise. Based on the results of the present study, impairment of function was seen in more severe cases of spinal deformity, proximally-located curvature and older patients

I. Conservative treatment With regard to conservative treatment of patients with congenital

scoliosis, it should be noted that there are limited data available in the literature. A review (level of evidence 2) concluded that patients with specific types of segmentation failures, like unilateral unsegmented bars, will not benefit from conservative treatment, while the same applies to formation failures with curves of > 20 degrees in infancy. Nevertheless, there are reports that a conservative approach might be beneficial in mild cases with formation failures in the first three years of life. Furthermore, the review concluded that in patients with formation failures further investigation is needed to document where a conservative approach (bracing treatment) would be necessary. In general, most congenital scoliotic curves are not flexible and therefore are resistant to repair with bracing. For this reason, the use of braces mainly aims to prevent the progression of secondary curves that develop above and below the congenital curve, causing imbalance. In these cases, they may be applied until skeletal maturity[12].

Some physical therapists recommend a brace to prevent the worsening of the scoliosis. An often used brace is the Milwaukee brace. Nevertheless the evidence for bracing is controversial. Maruyama T., Nakao Y. and Takeshita T. studied the effect of bracing in a review (2011). They compared brace treatment with no-treatment, other conservative treatments or surgery. The analyzed outcome measures were the radiological progression of the curve, surgery and quality of life. Results demonstrate that brace treatment is better than no-treatment (observation) or electrical stimulation. There is also no negative influence on the quality of life of patients with an idiopathic scoliosis. We can conclude that bracing is recommended as a treatment for female patients with a Cobb angle of 25-35°. The evidence level of some studies in the review was limited, so further research is necessary.

Types of scoliosis• Idiopathic (80%). This is not associated with dysmorphic

features, skin lesions or neuromuscular disease.• Congenital malformations of the vertebrae (10%) can

cause deformity. These are commonly associated with genitourinary anomalies.

• Neuromuscular conditions (15%) include cerebral palsy, spina bifida and poliomyelitis.

• Metabolic problems such as Hunter's syndrome.• Crush fracture from trauma, osteoporosis, tuberculosis

 or malignancy.• Dysmorphic syndromes such as neurofibromatosis, 

Marfan's syndrome, osteogenesis imperfecta.

INVESTIGATIONS

PA and lateral X-rays of the spine. A commonly used parameter is Cobb's angle:

To use the Cobb's method of measuring the degree of scoliosis, the most tilted vertebrae above and below the apex of the curve are chosen.

The angle between intersecting lines drawn perpendicular to the top of the top vertebrae and the bottom of the bottom vertebrae is Cobb's angle.

As a general rule, a Cobb's angle of 10° is regarded as the minimum angulation to define scoliosis.

MANAGEMENT

Management depends upon the type of condition, the severity, the prognosis and the patient's tolerance for various interventions. Early diagnosis and intervention are beneficial. Management may be divided into:

• Observation• Orthosis• Operation

The aims of comprehensive conservative treatment of idiopathic scoliosis are:

To stop curve progression at puberty (or possibly even reduce it).

To prevent or treat respiratory dysfunction. To prevent or treat spinal pain syndromes. To improve aesthetics via postural correction.

Conservative scoliosis therapy according to the FITS Concept is applied as a unique treatment or in combination with corrective bracing. The aim of the study was to present author's method of diagnosis and therapy for idiopathic scoliosis FITS-Functional Individual Therapy of Scoliosis and to analyze the early results of FITS therapy in a series of consecutive patients.

Methods The analysis comprised separately: (1) single structural

thoracic, thoracolumbar or lumbar curves and (2) double structural scoliosis-thoracic and thoracolumbar or lumbar curves. The Cobb angle and Risser sign were analyzed at the initial stage and at the 2.8-year follow-up. The percentage of patients improved (defined as decrease of Cobb angle of more than 5 degrees), stable (+/- 5 degrees), and progressed (increase of Cobb angle of more than 5 degrees) was calculated. The clinical assessment comprised: the Angle of Trunk Rotation (ATR) initial and follow-up value, the plumb line imbalance, the scapulae level and the distance from the apical spinous process of the primary curve to the plumb line.

DESCRIPTION OF THE FITS METHOD

Main principles of FITS concept1.To make the child aware of existing deformation of the spine and the trunk as well as indicate a direction of scoliosis correction.2.To release myofascial structures which limit three-plane corrective movement.

3.To increase thoracic kyphosis through myofacial release and joint mobilization.4.To teach correct foot loading to improve position of pelvis and to realign scoliosis. 

5.To strengthen pelvis floor muscles and short rotator muscles of the spine in order to improve stability in the lower trunk. 6.To teach the correct shift of the spine in frontal plane in order to correct the primary curve while stabilizing (or maintaining in correction) the secondary curve. 7.To facilitate of three-plane corrective breathing in functional positions (breathing with concavities). 8.To indicate correct patterns of scoliosis correction and any secondary trunk deformation related to curvature (asymmetry of head position, asymmetry of shoulders' lines, waist triangles and pelvis). 9.To teach balance exercises and improvement of neuro-muscular coordination with scoliosis …10. To teach correct pelvis weight bearing in sitting and correction of other spine segments in gait and ADL.

STAGES Stage I Examination of child with scoliosis using classical assessment but also in terms of

FITS method.

Stage II Preparation for correction-examination, detection and elimination of myofascial

restriction which limits three-plane corrective movement by using different techniques of myofascial relaxation.

Stage III Three-dimensional correction-building and fixation of new corrective patterns in

functional positions.

Stage I. Patient examination and making the child aware of the trunk deformity Classical assessment includes: history, course of treatment, X-ray analysis and

examination of patient in three different planes. Afterwards clinical assessment is performed according to FITS:

□ Distance from plumb line to: anal cleft, the apex of primary and secondary curve, the edge of the scapula,

Stage I. Patient examination and making the child aware of the trunk deformity

Classical assessment includes: history, course of treatment, X-ray analysis and examination of patient in three different planes. Afterwards clinical assessment is performed according to FITS:

□ Distance from plumb line to: anal cleft, the apex of primary and secondary curve, the edge of the scapula,

□ checking position of both scapulas,

□ observation of type and location of compensation,

□ position of pelvis and measurement of angle trunk rotation (ATR) using Bunnell scoliometer,

□ assessment of the settings of the lower limbs in standing and gait,

□ assessment of the length of muscles in lower limbs, pelvic girdle, shoulder girdle and trunk,