Transcript Conservative Management of Idiopathic Scoliosis in an Adolescent

Conservative Management of
Idiopathic Scoliosis in an
Adolescent
Rita B. Shapiro, PT, MA, DPT
CDR, USPHS
COF Annual Symposium
Therapist Category Day- May 25, 2010



Scoliosis is defined as a partially-fixed lateral
curvature of the spine observed on a
standard radiograph.
In truth, the deformity is three-dimensional
and rotation is a critical component.
In approximately 85% of diagnosed cases,
etiology is unknown.
Adolescent Idiopathic Scoliosis (AIS)




AIS is most common type in children from an
average age of 10 years to maturity.
About 10 percent of all adolescents have some
degree of scoliosis.
Less than 1 percent, require medical attention
other than careful observation of the problem.
Females are predominately affected, with a
female to male ratio of 1.4:1 for curves 11
degrees to 20 degrees, and the ratio increases
to 5:1 for curves greater than 20 degrees
Diagnosis

Scoliosis is usually diagnosed clinically with
objective measurements via plain
radiographs measuring the Cobb angle.

The Cobb Angle is the angle between two
lines drawn perpendicular to the upper
endplate of the uppermost vertebrae involved
and the lower endplate of the lowest
vertebrae involved. For patients who have
two curves, Cobb angles are measured for
both curves.
Cobb Angle Measurement for Dextroscoliosis
Case Description


The patient was a 13.5 year old otherwise
healthy female middle school (8th grade)
student
She had been complaining of "nagging" neck
and lower back pain of approximately six
months duration.
Review of Systems


Patient was hypothyroid and was under the
care of a pediatric endocrinologist
Medications:



Synthroid® prescribed by physician for
hypothyroid
Minocycline® prescribed by the physician for acne
control
One daily multivitamin and sometimes Tylenol® or
Motrin® for pain control.
ROS-Continued

Patient was slightly active but not athletic and
had to carry a heavy back pack to and from
school

Patient's body mass index was 23.33 Kg/m²
(height 156.2 cm, weight 56.6 kg)
Physical Observation-posterior
Initial Physical Therapy Examination
Standing Rear View note elevated right shoulder
and right iliac crest
Physical Observation-Anterior
Initial Physical Therapy Examination
Standing Front View, note elevated right ASIS
Forward Bend Test
Initial Examination
Bent over Test eliciting right rib hump
X-ray Findings



The x-ray report revealed an approximately 8 degrees
dextroscoliosis from the superior endplate of T1 and extending to
the inferior endplate of T8 measured by the Cobb method.
The orthopaedist measured the curve to be 10 degrees by the
Cobb method.
Bone Age study had been ordered by an endocrinologist when
the patient was 11 years old. The results of that study indicated
that the patient's bone age was 14 years versus the
chronological age of 11 years and 4 months, thus indicating that
the bones were at a higher level of maturity possibly due to the
thyroid disease or early puberty.
Treatment Interventions

Initially intervention included:


Pain Management-Heat/Ice/MFR
Hands on stretching
Hands on stretch guidance demonstration only
(Not the patient in this case report)
Schroth Method

The three dimensional method advocated by
Schroth includes the placement of hands by
the therapist in the clinic, or a family member
at home, to make the patient aware of the
narrow segments of the scoliotic spine, and
how to stretch those narrowed segments, and
the use of a mirror for self guided postural
correction
Patient Education



Education in Scoliosis management
Pt. and her mother were educated in individual
exercises and movement patterns
Proper back pack lifting techniques and how to
utilize the chest harness and the waist strap
Patient Education

The drawbacks of picking the back pack with
one hand and slinging it over one shoulder,
right in her case, were explained to the
patient in detail. She was shown how
continuous load over one muscle group or
one anatomical region would eventually
cause that group to fail without adequate
counter balance.
Patient's Exercise Program
Exercise Program-Contd.
Exercise Program-Contd.
Hippotherapy

Many studies have been published on the
effects of horseback riding (Hippotherapy) on
posture improvement which is accomplished
through strength improvement of the small
spinal muscles, achieving muscular balance,
core strength and hence, scoliosis
stabilization.
Horseback Riding
A: Profile
B: Lateral view
C: Back view
Patient began horse back riding program at approximately
six months of beginning the Physical Therapy program.
Note excellent posture attained.
Follow up X-rays



At six months, the results indicated the curve
had increased to 12 degrees
At one year the curve had reduced back to 10
degrees.
No radiographs past one year were taken
Three year Follow Up
Front view: note
improved posture
Rear view: note
no right shoulder
elevation
Bent over test:
Rib Hump
unchanged
Three Year Follow Up
Initial front view (left) and at three year follow up (right)
Note improved posture, no shoulder elevation and level ASIS
Discussion

During a thorough review of the patient's
medical record, it was noted that only six
months prior to patient's first visit to physical
therapy clinic (self referred), she was seen by
an adolescent primary care provider for
school physical. The provider had made an
incidental remark in the assessment as "mild
scoliosis is noted will follow". However, no
instructions or further follow-up plans were
given to the patient or her mother
Discussion



It has been documented that untreated, idiopathic
scoliosis will invariably arrest without requiring any
interventions.
Studies by Negrini et al and Hawes and O'Brien
demonstrate that approximately 10 percent of
untreated cases of mild idiopathic scoliosis will lead
to permanent spinal deformities and other related
medical problems.
Asher and Burton demonstrated that though rare,
untreated curves can progress to more than 100
degrees range even after skeletal maturity.
Final Take Aways

Though AIS may not progress to the point of
disability, once discovered, the asymmetry
must be properly documented, a definitive
follow up plan must be established and,
appropriate information provided to the
adolescent and the family.
Final Take Aways-Contd.

A simple baseline test and a sound follow up
strategy can allow for simple remedies and
adoption of healthy lifestyles in our youth that
is already on the rough road of many
morbidities due to lack of physical activity.
Questions????