Managing the Geriatric Spine

Orthotic Management of the Geriatric Spine

Andrew J Mills MBAPO MISPOOrthotist

Managing the Geriatric Spine

Orthotic Management of Degenerative Scoliosis in Adults

Managing the Geriatric Spine

Prevalence of Scoliosis in Adults

Managing the Geriatric SpinePrevalence of Scoliosis in Adults

General Population

• 0.3% – 0.5% in Children (of which 80% are idiopathic)

• 2% – 4% above the age of 18 years

• 9% in over 40 year olds

• 30%+ in over 60 year olds

Patients with Low back Pain

Robin et al; Study 554 LBP Patients

30% had scoliosis >10° in the 50 to 84 age groupAnd at 5 year follow up

- 40% had scoliosis >10° an additional 10%

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Managing the Geriatric SpineTypes of Scoliosis in Adults

Types of Scoliosis in Adults

Managing the Geriatric SpineTypes of Scoliosis in Adults

1. Adolescent Scoliosis in the Adult (ASA)

2. Degenerative De-Novo scoliosis (DDS)

Two main types;

Important, however, to rule out scoliosis due to pathological disease prior to brace treatment

• Usually smaller flexible curves in younger adults 18-30 years old

• Posture and Cosmetic issues are the main problem.

• Pain can be an issue particularly in unbalanced curves.

• Potential reducibility in both abnormal posture and Cobb.

Managing the Geriatric SpineASA 1

• Usually larger more rigid curves in middle aged adults 30-40

• Pain and posture equally issues.

• Pain can be an issue even in balanced curves.

• Often start to see early degenerative changes

• Intervention in ASA 2 could potentially to stop progression to ASA 3

(This idea of early intervention is suggest by Schwab Spine 2002)

Managing the Geriatric SpineASA 2

• Usually large, rigid curves in older adults 40+

• Pain is the primary issue.

• Moderate to severe degenerative changes present.

• Most commonly lumbar curves.

No previous history of scoliosis could indicate Degenerative De Novo Scoliosis DDS.

Managing the Geriatric SpineASA 3

• New curve in adult developed as a result of degenerative instability.

• Usually lumbar curve, unbalanced.

• Large, rigid curves in older adults 50+

• Pain is the primary issue.

• Moderate to severe degenerative changes present.

Managing the Geriatric SpineDegenerative De-Novo Scoliosis (DDS)

• Both ASA and DDS have vertebral rotation.

• In ASA rotation of the vertebra is initially related to the 3D vertebral deformity

Managing the Geriatric SpineVertebral Rotation

• With DDS the vertebra are NOT deformed.

• Instability allows one or more of them to rotate.

• This rotation is greater than the normal coupling limits would allow.

• Therefore it is considered a subluxation.

Managing the Geriatric SpineRotary Subluxation

• This subluxation is a typical feature of DDS.

• It can appear latter on with ASA on top of the true rotational deformity.

Managing the Geriatric SpineRotary Subluxation

Managing the Geriatric Spine

Research demonstrates that;

• Cobb Magnitude and • Degenerative Changes • Menopause

Alone do not necessarily relate to Pain or Progression

Managing the Geriatric Spine

Are there Biomechanical Factors relating to Pain and Progression that could be managed by Spinal Bracing?

Managing the Geriatric Spine

Clinical & Radiological Features that relate to pain with Adult Scoliosis

“Adult Scoliosis - A Quantitative Radiographic and Clinical Analysis”, Schwab et al. Spine

2002,

He identifies these correlations with pain:

•Lateral vertebral olisthesis, (side slip)

•L3 and L4 endplate obliquity angles,

•Decrease in lumbar lordosis,

• Increased thoraco-lumbar Kyphosis

Managing the Geriatric SpineRadiological features correlating with Pain

“Adult Scoliosis - A Quantitative Radiographic and Clinical Analysis”,

Schwab et al. Spine 2002,

• The Cobb angle of the scoliotic deformity had no statistically significant correlation to the VAS pain scores.

Suggests that; Early intervention in a middle-

aged adult with scoliosis may be preferable to treating advanced deformity in that same person once he or she has become elderly.

Managing the Geriatric Spine Cobb angle correlation with pain

The most significant findings were:

•Positive (anterior) Sagittal Balance

- Greater pain

- Diminished physical function

- Poorer self image

- Poorer social function

Managing the Geriatric Spine Sagittal Balance

“Correlation of Radiographic Parameters and Clinical Symptoms in Adult Scoliosis” Glassman, et al. Spine 2003

The most significant findings were:

•Coronal shift > 4 cm

- Poorer function

- Greater pain

•Compared to patients with a coronal shift < 4 cm.

Managing the Geriatric Spine Coronal Balance

“Correlation of Radiographic Parameters and Clinical Symptoms in Adult Scoliosis” Glassman, et al. Spine 2003

No differences based on:

• Curve magnitude

• Apical rotation,

• Or single vs. double major curves.

More favourable scores for thoracic curves versus thoracolumbar or

lumbar curves

Managing the Geriatric SpineGlassman Study Non-correlation Findings

“Correlation of Radiographic Parameters and Clinical Symptoms in Adult Scoliosis” Glassman, et al. Spine 2003

By its self severity of degeneration not a predictor of Pain or Progression

• In combination with rotary subluxation it is a predictor for progression.

• In combination with end plate obliquity it is a predictor for ongoing pain

Managing the Geriatric Spine Severity Of Degeneration (DDD/Spinal Stenosis)

Managing the Geriatric Spine Glassman/Schwab Studies

Summary of Key Findings:

Feature Alone correlates to pain/progression

Correlates to pain/progression only with associated feature

Positive (anterior) Sagittal imbalance

Yes

Coronal Imbalance Yes over 40mm

Lateral vertebral olisthesis, (side slip)

Yes

Significant L3 and L4 endplate obliquity angles

Yes

Decreased lumbar lordosis Yes

Increased thoraco-lumbar Kyphosis

Yes

Managing the Geriatric Spine Glassman Schwab Studies

Summary of Key Findings:

Feature Alone correlates to pain/progression

Correlates to pain/progression only with associated feature

Menopause No Large Cobb Magnitude/Recent progression/ Increased instability/Rotary Subluxation

Cobb Magnitude No Menopause/Recent progression/Increased instability

Curve Type No Thoracic curves have lower VAS pain scores

Spinal Stenosis No Rotary Subluxation/Lateral Olisthesis/ SignificantL3/4 end plate obliquity angle

Rotary Subluxation No Lateral Olisthesis/Significant L3/4 end plate obliquity angle

Lumbar DDD No Rotary Subluxation/Lateral Olisthesis/ SignificantL3/4 end plate obliquity angle

Managing the Geriatric Spine Orthotic Strategies

Orthotic Strategies to manage pain and progression in Adult Scoliosis

Primary objectives are to;

• Improve/correct Sagittal imbalance.

• Improve/correct Coronal imbalance.

• Strengthen Spinal Muscles.

• Reduce pathological mechanical loads.

• Provide Dynamic Corrective Movement

• Provide Postural Re-education

That ultimately reduce pain and progression!

Managing the Geriatric Spine Orthotic Strategies

The primary bracing objectives in adult scoliosis do not relate to curve correction!

Rigid

• Muscle Atrophy causing further destabilization of the spine.

• Limitation of movement

• Self image issues

• Comfort issues

• Not well tolerated in long term use

• Useful as a last resort in severe Neuro-degenerative cases

Dynamic

• Muscle rehabilitation and stabilization

• Allows movement

• Not visible under clothing

• Relatively comfortable

• Suitable for long term use

• Generally Not suitable for severe Neuro-degenerative cases

Managing the Geriatric SpineRigid Vs Dynamic Orthotic Treatment

Managing the Geriatric Spine

Dynamic Bracing Approach in Adults

Clearly a dynamic bracing approach has significant advantages to a rigid one in Adults.

• No issues with muscular atrophy

• Possible to increase general muscle strength and core stability

• Increases rather than limiting mobility

• Allows sustainable improvement/corrections of coronal and sagittal imbalances key to reduction of pain an progression.

Managing the Geriatric SpineRigid Vs Dynamic Orthotic Treatment

• To use case specific Corrective Movements for spinal rehabilitation and correction/improvement of to patient’s postural imbalances.

• The Corrective Movement strategy is determined by the curve type, region of pain and plane of maximum postural imbalance.

• The same basic brace components are utilized for all patients only the number, configuration and tensions of the corrective bands vary.

Managing the Geriatric SpineDynamic Bracing Treatment Approach

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2

3

Managing the Geriatric SpineCorrective Movement Principle

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2

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Managing the Geriatric SpineCorrective Movement Principle

Overcorrection of the Postural disorganisation

Using Dynamic Forces

Compressive forces Distractive forces

Managing the Geriatric SpinePostural Overcorrection

Managing the Geriatric Spine:Corrective Movement & Spinal Loading

Classification, Corrective Movement & Brace in Place

Managing the Geriatric SpineSpineCor Treatment

Brace Adjustment to Optimize Corrective Movement

Clinically measureable objectives.

Managing the Geriatric SpineSpineCor Treatment

• Degenerative De-Novo Scoliosis (DDS)

• Adolescent Scoliosis in Adults (ASA)

• Hyperkyphosis

• Pain; particularly lower back pain associated with postural & spinal and deformities. i.e. hyperkyphosis, coronal/sagittal imbalance.

• Postural Imbalance; correction/rehabilitation of abnormal postural alignment.

• Progression; slow or prevent progression of spinal and postural deformities.

Managing the Geriatric Spine

Indications for bracing

Managing the Geriatric SpinePatient Example A

26 year old female,

Painful adolescent idiopathic scoliosis as an adult (ASA1).

Pain 7/10.

32 deg right thoracic scoliosis.

8 to 12 hours for 3 months

Gradual relief of pain to 2/10.

Improvement of 8 degrees to 24 deg.

Pain relief of 1-2/10 and spinal correction have been maintained for over 2 years .

Courtesy of Dr Tom Pappas

Managing the Geriatric SpinePatient Example B

47 year old female

Degenerative De-Novo Adult Scoliosis. (DDS)

Pain 7/10.

A 40 deg degenerative lumbar scoliosis.

Immediate relief of pain to 3/10.

Pain relief of 0-3/10 maintained for over 2 years

Note the improved left lateral shift showing “spinal off loading”.

Courtesy of Dr Tom Pappas

Thank you

The End Managing the Geriatric Spine