Scoliosis

1. Subject Name: Musculoskeletal
Physiotherapy
Topic Name: Scoliosis

2. HISTORY:
 Hippocrates (460-375 BC): Hippocratic Ladder
 Galien (AD 130-200): He first used the
terms Scoliosis, Kyphosis and Lordosis
 American named Russel Hibbs (1860-1932), who was the first
surgeon ever to perform a spinal fusion
 Dr. Paul Harrington, who in the 1950′s performed for the first time
surgery using the so called Harrington Rod.

3. DEFINITION:
o Skolios”, "crooked
o The Scoliosis Research Society (SRS) : Lateral curvature of the spine
greater than 10° (from Central Axis) as measured by the Cobb method on a
standing x-ray of the thoraco-lumbar spine.
o 2% to 4% of children between 10 and 16 years of age have measurable but
small curves.

4. CLASSIFICATION:
I. Non structural Scoliosis (Lateral Curvature but not such structural abnormality present)
 Postural scoliosis
 Compensatory Scoliosis
II. Transient structural Scoliosis
 Sciatic scoliosis
 Hysterical scoliosis
 Inflammatory scoliosis
III. Structural scoliosis (Involves both lateral curvature and rotation of the vertebrae)
A. Idiopathic Scoliosis
 Infantile
 Juvenile
 Adolescent

5. CLASSIFICATION Continued:
B. Congenital (Bone abnormality present at birth)
I. Vertebral- Open and Closed
II. Extravertebral
C. Neuromuscular (Abnormal muscle or nerves)
I. Neuropathic
II. Myopathic
III. Others

7. Progressive Idiopathic Scoliosis

8. EVALUATION

9. History:
 Chronological age
 Age at recognition of deformity
 Impression of rate of progression
 Associated symptoms
Genetic factors
 History of measles, mumps, chicken pox, whooping cough, polio, rickets
diphtheria, pneumonia, torticollis, chorea.

10. Physical Examination:
Posture Alignment
Muscle length (shortening/lengthening)
Limb length
Range of motion
Muscle strength
Cardiopulmonary status
Neurological evaluation
ADL’s , Functional Evaluation

11. o All bony elements are
altered
o Vertebrae are wedge shaped
o Poorly developed concave
side
o Pedicles are rotated
o Discs are wedged as well. .

13. RADIOGRAPHIC EVALUATION:
 X rays
 PA and Lateral views (in standing)
 Right and left bending views (evaluation for surgery and bracing)
 Stagnara Derotation view- obliterates rotational component
 Cobbs angle & Bunnel Method
 Nash and Moe Method (Rotation)
 Risser sign- Measurement of skeletal maturity
 Rib hump
 Moire’ topography- Biostereometric method (3 dimensional)
 ISIS (Integrated Shape Imaging Systems) Scanning

14.  Rib Hump: linear distance between the
left and right post rib prominence- lateral
X ray
 Apical vertebral body – rib ratio: Linear
measurements from the apical vertebral
body to the chest wall on AP x ray

15. Nash and Moe Method

16. Cobbs Angle / method

17. CLASSIFICATION OF CURVES:
King Classification: one of five patterns, which can help determine
surgical treatments.

18. King’s Classification:

19. RISSER GRADE / SIGN:
 For skeletal maturity
 Children usually progress from a Risser grade 1 to a grade 5 over a two-year period.

20. RISSER SIGN

21. Scoliometer / Inclinometer: Type of Protractor used to measure the
vertebral rotation and rib humping usually seen in forward bending.

22. GUIDELINES & TREATMENT:
Curve
(degrees) Risser grade X-ray/refer Treatment
10 to 19 0 to 1 Every 6 months/no Observe
10 to 19 2 to 4 Every 6 months/no Observe
20 to 29 0 to 1 Every 6
months/yes
Brace after 25
degrees
20 to 29 2 to 4 Every 6
months/yes
Observe or brace
29 to 40 0 to 1 Refer Brace
29 to 40 2 to 4 Refer Brace
>40 0 to 4 Refer Surgery

24. BOSTON BRACE MILWAUKEE BRACE CHENEAU BRACE

25. Lyon Brace /Stagnara Brace

26. MALAGA BRACE

27. SpineCor Brace

28. Exercises in/out of Brace:
Purpose of exercise program (out of brace):
 a. Develop postural awareness and ability to maintain corrected alignment.
 b. Maintain and/or increase chest mobility for proper respiration.
 c. Maintain and/or increase muscle strength.
 d. Maintain and/or increase spinal flexibility.
 e. Maintain and/or increase range of motion (prevent contractures, especially in hip
flexors).
 f. Provide a good general physical condition.

29. Purpose of exercise program (in brace):
 a. Develop postural awareness and ability to maintain corrected alignment as
provided by brace
 b. Enhance patient’s comfort
 c. Assist patient to resume previous activity level.
 Functional
 Social
 Recreational

30. Postural alignment:
Done as frequently as possible, both in and out of brace.
 a. Lumbar Flexion (posterior pelvic tilt):
This serves to maintain the anterior-posterior balance of the spine by
elongating the posterior structures and enhancing the contractile elements of
the anterior structures. This keeps the pelvis and lower spine in optimum
alignment as the patient attempts proper trunk alignment.
 b. Trunk Alignment Patient attempts to align head, neck and trunk
over pelvis.

31. Points to remember……..
 Bracing will reduce lung function by 10 to 15%
 Skin care very important
 Break-in time for a brace should be about 2-3 weeks
(6 hours, 10 hours and 18-23 hours)
 Brace checkout done by orthotist regularly
 Each brace to be custom made

32. PHYSIOTHERAPY
MANAGEMENT

33. SCREENING 6 Step Process:
1. Front standing position
2. Back standing position
3. Back bending away from you
4. Side bending position
5. Front bending toward you
6. Side bends

34. Step 1 Front View
• Shoulders should be level and at
the same height
• Distance between arm and torso
equal on both sides
• Crest of hips level on horizontal
plane
• Head straight and centered

35. Step 2 Back Standing
View
• Shoulders should be level and the
same height
• Distance between arm and torso
equal on both sides
• Crest of hips level on horizontal
plane
• Head straight and centered
• Scapula level on both sides

36. Adam’s Bending
Technique
 Feet slightly apart
 Palms together
 Arms outstretched with straight
elbows
 Head out
 Bend forward at waist
 Place hands between legs at knee
level

37. Step 3 Back Bending Away
Look For:
• Rib prominence
• Lumbar Prominence
• Differences in height of hip
crests

38. Step 4 Side View
Look for exaggerated
rounding of the back
Kyphosis

39. Step 5 Bending Front
View
• Shoulders level?
• Is one side of torso more
rounded than the other ?
• Look for lumbar
prominence

40. Step 6 Side Bends
Ask the student to bend
at the waist to each side
Look for S curvatures

41. Management for Postural curves:
 General body relaxation
 Passive correction
 Maintenance of corrected posture
 Stretching to tight structure
 Strengthening of weak muscles
 Deep breathing exercises
 Balance exercises
 Symmetrical movements should NOT be advised
 Ergonomic advice
 Aerobic conditioning programme

42. Structural Scoliosis:
 Brace
 Mobility Exercises
 Deep breathing Exercises
 Back to wall postural exercises
 Stretching
 Strengthening
 Traction: Hanging on stall bars, skin traction
 Hydrotherapy

43. Scientific Exercises Approach to Scoliosis (SEAS)
 Postural rehabilitation
 Active Self-Correction
 Muscular endurance strengthening in the correct posture
(paravertebral, abdominal, lower limbs and scapulo-humeral
girdle muscles)
 Development of balance reactions (static and dynamic balance
of the trunk)

44. SURGERY
• INDICATIONS
• TYPES
• PHYSIOTHERAPY

45. Indications for surgery Curves > 50o (in patients
still growing)
Curve progression > 10o
(after skeletal maturity)
Functional deterioration
Pain
Cardiopulmonary
compromise

46. TYPES:
 Spinal fusion
 Spinal instrumentation
 Harringtons Instrumentation-
Rod and Hooks
 Luque Instrumentation-
multiple wires and two rods
 Dwyer’s Instrumentation- cable
and screws (Anterior approach)
 Zielke’s Instrumentation- Rod
and screws

50. Physiotherapy management:
PRE OPERATIVE
 Improve vital capacity & chest expansion
 Muscle charting: Improve muscle power
 Stretching
 Sleeping Position
 Explain about post op management
POST OPERATIVE
 Improve vital capacity
 DBE, vibrations with coughing
 U/E – AROM Ex
 L/E- PROM Ex
 Sitting- Reverse Climb down technique
 Standing – Walking
 Ergonomic principles taught
 Spinal ex- after 3 months
 Use of corset/POP jacket
 Hydrotherapy

51. Post Surgical complications:
 DVT
 Pulmonary embolism
 Stiffness of spine, neck, shoulder
 Wound infection
 Neuralgia
 Graft site pain
 Plaster sores

52. Refernces:
 Scoliosis Research Society- http://www.srs.org/
 Cambells Operative Orthopedics
 Essentials of Orthopeadics and Applied Physiotherapy: Jayant Joshi
 Therapeutic Exercises : Carolyn Kissner
 http://scoliosisjournal.com
 www.bracingscoliosis.com
 National Scoliosis Foundation http://www.scoliosis.org/

53. THANK YOU