Transcript 02. Osteopathic Management of Adolescent Idiopathic Scoliosis

September 5th – 8th 2013
Nottingham Conference Centre, United Kingdom
www.nspine.co.uk
Adolescent Idiopathic Scoliosis
 Lateral spinal curvature that forms in patients aged 10-
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18 years of age, with unknown cause.
Scoliosis is defined as a spinal curvature of more than
10° (Cobb angle measurement), accompanied by
vertebral rotation.
Scoliosis can resemble an ‘S’ or ‘C’.
Affects 2-4% of 10-16 year olds.
Affects girls more than boys.
Presentation
 AIS generally does not result in pain or neurological
symptoms.
 Low back pain may be present, but it is often due to
poor spinal mechanics, poor core strength and lack of
flexibility in the hamstrings, rather than as a result of
the AIS specifically.
 Deformity can cause marked psychological distress.
Observation
 Shoulder height asymmetry – one appears higher than the
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other.
A side shift of the body – especially with a C-shaped
scoliosis (no secondary curve to re-balance).
Waist asymmetry – one hip appears higher than the other –
one leg may seem longer in standing.
Uneven musculature on one side of the spine.
Prominent rib hump secondary to the rotational aspect of
the scoliosis (most apparent on forward flexion).
Typically, normal appearance when viewed from the side.
Physical Examination
 Adams Forward Bending Test
Patient holds arms straight down, with palms of hands together and
flexes forwards → unilateral prominence is noted with scoliosis.
 Leg Length – measure.
 Plumb Line
Plumb line is dropped from C7 & allowed to hang below buttocks
→ in scoliosis, the line does not hang between the buttocks.
 Range of Motion
Measure patients ability to perform flexion, extension,
sidebending & rotation → determine flexibility of curves.
 Palpation
 Neurological exam
Diagnostic Tests
 Scoliometer – measures rib prominence when patient is
forward flexed.
 X-rays – upright and bending.
 Cobb angle measurement – lines drawn on x-ray
perpendicular to lines along the superior edge of
the vertebra at the top of the curve & along inferior
edge of the vertebra at the bottom of the curve →
gives angle.
 Risser Sign – x-ray of iliac crest growth plate indicates skeletal
maturity.
 Lenke classification – determines what levels of the spine to
fuse & instrument.
Lenke Classification
Other Signs
 Severe pain or an abnormal neurologic examination
are red flags that point to a secondary cause for spinal
deformity.
 Other signs that may indicate underlying cause:
 Altered gait.
 Dimple, hairy patch, lipoma or haemangioma (spina
bifida).
 Café au lait spots on skin (neurofibromatosis).
 Cavovarus deformity of feet.
 Abnormal abdominal reflexes.
 Altered muscle tone for spasticity.
Progression
 AIS curves progress during the rapid growth period.
 While most curves slow their progression significantly
at the time of skeletal maturity, some, especially
curves >60°, continue to progress during adulthood.
[In general, girls grow until approximately 14yrs (or
2yrs after their first menstrual period), while boys
grow until about 18yrs].
 Of those diagnosed, only 10% have curves that
progress & require medical intervention.
Management Options
Management of scoliosis is complex & is determined by the
severity of the curvature & skeletal maturity, which together
predict the likelihood of progression.
 10-20° curve
monitor
 20-45° curve
may be a case for bracing – but success
is heavily dependant on compliance –
have to wear brace for 22hrs/day until
skeletal maturity.
 45-50° curve
case for surgery
 >50° curve
studies show that the curve will
continue to worsen by 1-1.5°/year beyond
20yrs (regardless of skeletal maturity).
Osteopathic Considerations
 Flexion restrictions tend to be over convexity, whereas extension
restrictions tend to be present on concavity – restrictions zig zag
up the spine.
 Often, most symptomatic area is the Tsp, & generally at the
‘junction’ where lumbar flexion & cervical restrictions meet.
 Stress points occur at junctional areas where contra-rotations
occur → patient reports pain in these areas.
 Soft tissues are stretched on side of convexity and
contracted/shortened on side of concavity.
 Scapula winging often occurs over the rib hump → altered
shoulder mechanics.
 Anterior rib restrictions – almost always remain fixed down even
with arm elevation – involvement of pectorals, infraspinatus &
teres muscles.
Treatment Strategy
 Primary objective is to improve spinal mobility at a segmental level.
 Deal with flexion restrictions initially before addressing extension
restrictions (overcoming limitations of Tsp extension is challenging).
 Articulate into de-rotation to encourage rotational mobility.
 Mobilise rib and sternal restrictions.
 Soft tissue techniques to address shortened scalenes, trapezii, levator
scapulae (often ipsilaterally), shortening through rotator cuff &
rhomboids.
 Also address large span muscles, e.g. latissimus dorsi.
 Muscles tend to respond well to passive stretching.
 Look at influence of LEX.
Case Presentation
Pt:
F, 39yrs
Presentation:
Difficulty walking, sitting and standing due to low
back, thoracic and right leg pain; extreme fatigue;
morning stiffness.
PMH:
Non-progressive Adolescent Idiopathic Scoliosis.
Rheumatologist, physio & hydrotherapy.
Assessment:
Right thoracic scoliosis with 36° thoracic curve (T4T12) and compensatory left lumbar scoliosis of 34°;
stiff curve.
Osteopathic
Evaluation:
Restrictions right SIJ-T2 in flexion.
TTT given:
Articulation of Tsp & Lsp to address restrictions,
stretch soft tissues through hips and scapulo-thoracic
joints.
Pre TTT ODI:
40%
Post TTT ODI:
24%
T2-4 left and T5-T8 right restrictions in extension.
Case Presentation
Pt:
F, 15yrs
Presentation:
Pain in right trapezius area.
PMH:
AIS - Instrumented fixation T4-T11.
Chiari malformation type I (decompressed).
Diagnosis:
AIS (posterior correction).
Osteopathic
Evaluation:
Restriction at L3-T4 & C4-T1 right in flexion.
Restricted extension at L5-T4 & C4-T1 left.
TTT given:
Treatment to adjust above levels and to
improve tone in trapezius and periscapular
muscles.
Pre TTT ODI:
15%
Post TTT ODI: 6%
Case Presentation
Pt:
F, 26 yrs
Presentation:
Mid-thoracic and lumbar pain.
No radicular symptoms.
PMH:
Onset ±5 yrs previously, becoming more constant.
Hypermobility syndrome, possible Marfanoid trait.
Assessment:
Focal right mid thoracic scoliosis (22°).
Small syrinx C6 to C7 (incidental finding).
Osteopathic
Evaluation:
Restricted T4-T7 on left in extension.
Restricted in flexion: T3 & T4 right, T7-9 left, L2-L5 left
and S1 right.
TTT given:
Soft tissue and articulation throughout spine, addressing
areas of restriction and improving muscle balance and tone.
Pre TTT ODI:
26%
Post TTT ODI: 24%