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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