SCOLIOSISSCOLIOSIS REHABILITATIONREHABILITATION

SCOLIOSISSCOLIOSIS

A general term used to describe alateral curvature of the spinep

Most often develops on childhoodCan occur on cervical thoracic orCan occur on cervical thoracic or

lumbar vertebra

Types:Types:

1. Structural vs. Non Structural2. According to the direction of curves3 Major vs minor curve3. Major vs. minor curve4. According to the shape of the curve5 According to the severity of the curve5. According to the severity of the curve6. According to etiology

STRUCTURAL NON STRUCTURAL • vertebral bodies rotates towards convex

(functional scoliosis)• No change of

spinous process rotates towards concave

gstructurePositional or dynamic in ynature

Irreversible lateral Reversiblecurvature with fixed rotation of vertebrae.(+) rotation of vertebrae; apex:

(-) rotationp

greatest

(+) rib hump (posterior (-) rib hump( ) p (prib hump)

( ) p

(+) bony deformity ( ) bony deformity(+) bony deformity (-) bony deformity(+) progressive (-) progression(-) corrected by positioning or voluntary

(+) correctionforward bending/ lateral

efforts bendingpositional changesside bendingmuscle contraction

NOTE: Forward bending of trunk produces posterior rib hump on convex side (thoracicposterior rib hump on convex side (thoracic region) due to rotation of vertebra & rib cage (prominence of scapula)(prominence of scapula).

CONCAVE CONVEXShortened LengthenedMuscle & ligaments are contracted

Muscle & ligaments are stretched

Th iThoracic:• Spinous process

Compression of ribs• Vertebral body

Separation of ribs• Compression of ribs• Prominence of rib cage

anteriorly

• Separation of ribs• Prominence of rib hump

and scapula posteriorlyanteriorly and scapula posteriorly• Disc space widens• Pedicle in• Pedicle in

anteroposteriordirection

CONCAVE CONVEX

• Disc space narrow –lateral displacement oflateral displacement of nucleus pulposus. Wedging of vertebral bodyWedging of vertebral body on concave part of curve 2º pressure on epiphyseal2 pressure on epiphysealplate. Most especially seen on >25º curveseen on >25 curve.

• Pedicle more transverse

CONCAVE CONVEX

L bLumbar:Prominence of ES

lmuscle

Neck & Shoulder:Neck angle decreaseRib flatten

Neck angle increasesBulging of ribs

Shoulder decrease Shoulder increased

NOTE:Direction of the curve is always identified by the convexityidentified by the convexity® thoracic scoliosis – convexity is on right(L) thoracic scoliosis convexity is on left(L) thoracic scoliosis – convexity is on left

MAJOR •primary curve; most

MINOR•Less severe – mayprimary curve; most

significant•most significantly

Less severe may develop on the opposite direction of the majormost significantly

occurs in thoracic region

direction of the major curve on either above or below the major curveregion below the major curve.•Compensatory curve –structural or nonstructural or non structural

(+) structural (+) structural / non(+) structural (+) structural / non structural

(+) structural (+) structural / non structural

P i F d b l b thPrimary curveIdiopathic

li i i ht

Found below or above the major curveC t d h ld &scoliosis: right

thoracic T4 –T12Compensated – shoulders &

hips are leveledD t d/Decompensated/

uncompensated – when sum f d f thof degrees of the

compensatory curve does not l th d f d f itequal the degrees of deformity

of major curve.( ) li ti(+) listingshoulders not leveled

C-CURVE hi h h ld

S-CURVE l• high shoulder on

convex; high pelvis on • most commonly seen in idiopathic scoliosis

concave.

From thoracic to • Usually right thoracicFrom thoracic to lumbar

• Usually right thoracic curve & left lumbar curvecurve

Uncompensated/Decompensated

Compensatedpensated

Double Major curve – has 2 major curve of equal severity & significance; Both structuralq y g ;

Transitional vertebra – makes transition from one curve to another

Neutral vertebra – least rotated vertebra

Apical vertebra – most rotated vertebra

Severity of scoliosis is determined by the y yangle of curvature

The greater the rotation of vertebra; theThe greater the rotation of vertebra; the more severe the lateral curvature

The more severe the curve; the greaterThe more severe the curve; the greater the affectation on cardiopulmonary affectationaffectation

Decrease vital capacity & total lung capacitycapacity

Hypertrophy of the ® ventricle & atrium f l h t ifrom pulmonary hypertension

Measurement TechniquesMeasurement TechniquesX –ray measurement

Cobb methodmost commonly used; more reliablemost commonly used; more reliablea line is drawn perpendicular to the upper

margin of the vertebra that inclines mostmargin of the vertebra that inclines mosttoward the concavity. A line is also drawn onthe inferior border of the lower vertebra withthe inferior border of the lower vertebra withgreatest angulation toward the concavity. Theangle of these transecting lines is noted &angle of these transecting lines is noted &recorded

Risser Ferguson methodRisser Ferguson methodlook for 3 vertebra: uppermost, apical, and

lowermostlowermost

Nash Moe methodNormally pedicles are symmetricalNormally pedicles are symmetrical

positioned on either side of each spinous processprocessGrading:0 no vertebral rotation0 – no vertebral rotation+ & ++ - mild or minimal rotation+++ moderate rotation+++ - moderate rotation++++ - severe rotation

SEVERITY CURVE MANAGEMENT

Mild < 20º Observe; exercise

Moderate 20º- 40º Structural changeschangesBrace; exercise

Severe 40º - 50º Brace & surgerySevere 40 - 50 Brace & surgery40º > Pain & DJD

60º 70º Cardiopulmonary60 - 70 Cardiopulmonary affectationDecrease lifeDecrease life expectancy

NOTE: Curves < 10º - WNL – no tx.

Etiology of Structural Scoliosis:1. Idiopathic – unknown/ most common classification – idiopathic adolescent scoliosisp

Age of onsetAdolescent – most common type. Young yp g

girls age 10-15Juvenile – occurs between ages 4 & 9. g

seen often in girlsInfantile – from birth to age 3. seen often in g

boys

Causes: Causes1. Bone malformation during development2. Asymmetric muscle weaknessy3. Abnormal distribution of muscle spindle in

paraspinal musclesp p

2 Neuromuscular – 15-20%2. Neuromuscular 15 20%Neuropathic causes – problem in CNS. CP,

PolioPolioMyopathic causes – problem is on musclesMuscular dystrophyMuscular dystrophy

3 Osteopathic – problem in bones3. Osteopathic problem in bonesHemivertebra, osteomalacia, rickets, fracture,

dislocation of spinedislocation of spine

Etiology of Non Structural Scoliosis:1. LLD2. Spasm in back muscles3. Habitual asymmetric postures

Factors affecting Decision making to initiate Treatment

1. Etiology2. Typeyp3. Location4. Severityy5. Age6. Rate of progressionp g

EvaluationEvaluation

Postural assessment plumb line C7Postural assessment – plumb line – C7-gluteal cleft (S2)

The following deviation are often noted:The following deviation are often noted:Asymmetric shoulder levelProminence of the scapula on the sideProminence of the scapula on the side

of the convexityProtrusion of the hip in one sideProtrusion of the hip in one sidePelvic obliquityIncreased lumbar lordosisIncreased lumbar lordosis

Lateral bend test – done to determine whether the curve corrects or reverses as thewhether the curve corrects or reverses as the pt. side bends towards the convex side of the curvecurve.

Asymmetric side bending is an early sign that the structural changes may have begun tothat the structural changes may have begun to develop in the spine

Forward bending test – done to determinewhether the curve straightens out as the pt.bends forward and to identify a visible,rotational deformity of the rib cage.

MMT

Non-Operative treatment of Scoliosis1. Exercises2. Cast3. Traction4. Spinal bracing5. ES

Sites of curves:Sites of curves:Cervical: C1-C6Thoracic: T2-T12Thoracic: T2 T12Cervico Thoracic: C7-T1Lumbar: L1 & L4Lumbar: L1 & L4Lumbo Sacral: L5 or below

Exercise in scoliosis:1. exercise alone will not prevent progression of a

scoliotic spine nor will correct an existing scoliosis

2. exercise has been traditionally been used to t t h ti ht t k d hi l / t thstretch tight trunk and hip muscles/ strengthen

muscle of the trunk3 exercise may be beneficial as tx for pt with mild3. exercise may be beneficial as tx for pt. with mild

idiopathic scoliosis4 exercise will not alone halt the progression of or4. exercise will not alone halt the progression of or

correct an existing moderate or severe scoliosis5. exercise is used in conjunction with other5. exercise is used in conjunction with other

methods such as braces, cast, etc.

Exercise with Milwaukee brace:Exercise with Milwaukee brace:Goals: to strengthen the muscle that provides

stabilization to the trunkstabilization to the trunkDecrease or correct spinal curves

NOTE: The objective is to move away from the pads j y p

that are inside the brace.

Treatment is geared towards stretching of the CONCAVE side and strengthening of the g gCONVEX side

For C curve scoliosis:

Cross walkDone with the pt. in quadruped position.Done by initially crossing the UE along theDone by initially crossing the UE along the

concave side towards the convex side, followed by the advancement of the contralateral LE.by the advancement of the contralateral LE.

Cycle repeats until the pt. completes one whole round within the matwhole round within the mat.

EXAMPLE:Pt. has C-curve dextroscoliosis

Pt. assumes quadruped position.Crosses the (L) UE towards ® UE thenCrosses the (L) UE towards ® UE thenhold that position for 15-30 sec. Followedby crossing of the ® LE being crossed overby crossing of the ® LE being crossed overthe (L) LE hold for 15-30 sec. This followedby crossing over the ® UE over the (L)by crossing over the ® UE over the (L)UE…hold…then lastly…cross over the (L)LE th ® LE C l tLE over the ® LE. Cycle repeats

for S-curve scoliosis:

A bli lkAmbling walk

pt. in quadruped position. Advance the UE along the concave side followed by g yadvancing by the ipsilateral LE. hold is maintained after each extremity has been yadvanced

Klapp’s exerciseD i f t th f thDone in reference to the apex of the curve.Emphasis is placed on exercise designed

f i t i ht i f th th l ifor maximum straightening of the pathologic curves whatever their site, direction, &

it dmagnitude

T3 - sala position (lowered)

T6 – on elbows (semi-lowered)( )

T8 – on hands Horizontal quadruped)T8 on hands Horizontal quadruped)

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T11 – fingertips (semi straightened)

L4 – reversed position (reversed erect)

L2 t k li ’ ( t)L2 – erect kneeling pos’n (erect)

Dry Swimming exerciseBeginner’s exercise

1. In prone position

Beginner s exerciseDecrease static works of spinal muscles

1. In prone position2. prone (B) UE on the sides of the body3 prone; (B) UE abducted to 45º3. prone; (B) UE abducted to 454. prone; (B) UE in reverse T pos’n5 prone; (B) UE flying V5. prone; (B) UE flying V6. prone; (B) UE crossed against the nape

areaareaGeneral instruction: As pt. assumes the’ t lift t k ff th t & t t thpos’n: pt. lifts trunk off the mat & rotate the

trunk towards the convex side. 15-30 SH.

CAT & CAMELCAT & CAMELDesigned to increase and improve

fl ibili f h iflexibility of the spineCAT exercise – performed by increasing

thoracic kyphosisCAMEL exercise – performed by

increasing lumbar lordosis

CAMEL EXERCISE

CAT EXERCISE