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how many dimensions of spine are screwy in scoliosis?
3 - med/lat, rotation, sagital plane
nonstructural deformity - 3 traits
- no rotation
- leg length discrepancy or habitual
3 traits of structural deformity
- fixed rotation (rib hump/prominence)
- adolescent idiopathic scoliosis or neuromuscular scoliosis
how do you name a C curve? 2 qualities...
- name it for the convex side (R/L)
- and for the location of the apex of the curve (thoracic, cervical...)
if there's a C curve, how will the shoulders and hips angle?
shoulder is higher and hip is lower on convex side of C
hip and shoulder angling with an S curve?
shoulder and hip are higher on the same side
in an S curve, 3 traits of the major curve?
- it's the more severe curve
- commonly in the T-spine
- always has a rotational component
4 traits of the compensatory curve in an S curve
- minor and less severe
- it's the body's attempt to keep the head and trunk aligned vertically
- develops in opp. dir. above and/or below major curve
- may or may not have a rotational component
what's a "double major curve?"
- S curve where both curve are of equal severity and significance
- both usually have rotation
if there's a L thoracic curve, which way will the vertebrae and ribs rotate
- Left - towards the convex side, in an effort to bring th body back up
- this creates a rib hump on the post L side
which way do the SPs angle in a L thoracic curve?
to the right
3 classifications by age of idiopathic pediatric scoliosis
- infantile - 0-4 y/o
- juvinile - 4-10 y/o
- adolescent - 10 y/o to skeletal maturity - 89% of all diagnosed idiopathic scoliosis
what percent of the population gets adolescent idiopathic scoliosis (AIS)?
what angle do you have to have to get diagnosed with adolescent idiopathic scoliosi?
radiograph showing at least 10 degrees
where is AIS most common?
what causes neuromuscular scoliosis?
abnormal forces acting on the vertebrae of an individual with decreased postural control of spine -- seen in cerebral palsy and muscular dystrophy
problems seen with neuromuscular scoliosis
- hip sublux/dislocation (often comes w scoliosis - one condition triggers the other)
- compomised pulmonary system
- digestion - no appetite, nausea
osteopathic scoliosis can result from the following bony abnormalities
- wedge vertebra (it slants down on med or lat side)
- hemi vert - it's just a triangular bit of vert on med or lat sid
- unsegmented bar - in a bunch of vert the med, lat, or full bodies are connected/same piece of bone
- fused ribs
- or a tumor in the bone
center sacral line ... what is this in radiology?
line drawn perpendicular t the horizontal center of the sacrum (SP of S2)
what's the "transitional (stable) vertebra"
- the vert most clearly bisected by the center sacral line
- this vert marks the transition from one curve to the next
apical vertebra (apex)
- the vertebra furthest from the midline (center sacral line) of the spine
- it's the part of a curve that sticks out furthest
formd by the intersection of the perpendicular lines drawn to the 2 most tilted vertebrae
utilized to classify severity o curve and to monitor progression of curve
if S curve, get 2 Cobb angles
angles of mild, mod, and severe scoliosis
- mild: <20 derees
- mod: 20-50 w rotational deformity beginning
- severe: >50 w signif rotational deformity
purpose of having pt side-bend
evaluates pre-op flexibility of the curve -- tells if it' structural or non-structural
radiograph taken while pt's side-bent TOWARD convex side, and Cobb angle is measured now
why might a surgeon pt not to correct a non-structural curve?
if there's more than one curve -- not operating may decrease blood loss, preserve motion, decrease stress n remaining segments, decrease risk of non-union ... the doc might only fix the structural/fixed one, and hope the other may resolve itself
Nash and Moe method of looking at scoliosis
- looks at rotation of the vert by looking at the locations of the pedicles
- 0=symmetrical distances from mid-line
- 1=pedicle moving in
- 3=pedicle at midline
- 4=ped crossed midline
2 traits of conservative management
3 types of surgery
- conservative: PT, bracing
- surgery: posterior spinal fusion, anterior, or combo of AP
symptoms to look for for scoliosis
- asymmetry of shoulder and scap
- pelvic obliquity
- trunk curve
- head off to one side
- leg length discrepancy
- knee recurvatum
4 types of spinal stabilization exercises
- abdominal setting
- Sahrmann's lower abs progression
and for stretching, lay the convex side on a physioball - this also increases mobility between ribs during expiration
ab strengthening with the ball... some exercises?
- supine, pass the ball from hands to feet and back
- prone, thighs on the ball, hands on ground in a plank
some scap exercises
- use theraband for scap depression and core stabilization -- ex - seated, pull back into rows
- slide ulnar side of forearms up and down wall
principles of Scroth method
- sagittal straightening
- angular breathing
- facilitation with stabilization
what does Schroth require from pts?
- it uses their cognitive, sensory-motor, and kinesiomotor training to improve a pt's scoliotic posture
- pt must have sufficient insight into their body
e-stim on convex side?
Negrini's "Scientific Exercise Approach to Scoliosis" (SEAS)
when to brace?
25-45 degree curve progressing more than 5-10 degrees in 6 mo
goal of a brace?
to prevent further curving, not to correct what's there
how much do you have to wear a brace? who can wear it?
- 23 hrs/day
- the skeletally immature
- sign of skeletal immaturity
- Graded I, II, III, IV, V
- I - if ant portion of iliac cress is fully ossified,
- II if more...
- IV is almost all,
- V is the whole thing
implications of Risser sign
- the lower the sign the greater risk for further curve progression
- but also the more receptive to bracing
Milwaukee brace - for whom?
- curves w apex higher than T8
TLSO brace - for whom?
curves w apex lower than T7
4 indications for surgery
- failure of conservative managemnt
- curves >50 degrees
- cardiopulm complications
- signif back pain
what's fused in spinal fusion
first and last vert of major curv w one level above and below
details of post. spinal fusion (PSF)
- most common
- midline incision along spine
- remove facet joints
- fusion is achievd from bone graft from iliac crest and a bunch of tools
ant spinal fusion (ASF) - used when? where's the inision? what is removed?
- more severe curves
- anterolat incision on convex side of curve
- remove ligament and discs
- bone grafts from rib are packed int disc space
when would you wnat a combined ASF/PSF
large and stiff curves
post op day 1, what must pt urgently not do?
BLT - bend, lift, twist
POD 1, what activities are ok?
- review spine precautions & brace edu
- log rolling (to get out of bed)
- incentive spirometry
- amb as tolerated w walker
POD 2-3 activities
- progress amb distance
- switch from walker to hand-held 150-300 ft
- sitting, WC modifications
POD 4-5 activities
- indep tranfers via log rolling
- indep amb w/o AD
- indep stairs w 1 rail
- indep w brace
out patient PT post-op - 3 things to work on, 1 precaution
- postural retraining
- scap mobs, soft tissue release after incision heals
- body mechanics
precaution - hamstring/hip flexor stretching
PT ideas both pre and post op
- spinal stabilization
- muscle strengthening
how's the prospect for returning to sport after spinal fusion?
- 60% go back at equal or higher level
- pts are allowed to return 6-12 months post-op