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What are the main types of scoliosis?
Idiopathic, Congenital, and Neuromuscular.
Define Idiopathic Scoliosis.
Idiopathic Scoliosis is of unknown cause, and appears in a previously straight spine.
Define Congenital Scoliosis.
Congenital Scoliosis is due to a problem with the formation of vertebrae or fused ribs during prenatal development.
Define Neuromuscular Scoliosis.
Neuromuscular Scoliosis is caused by problems such as poor muscle control or muscular weakness or paralysis due to diseases such as cerebral palsy, muscular dystrophy, spina bifida, and polio.
When a patient's Cobb Angle is equal or greater than 10 degrees, it is called what?
If a patient's Cobb Angle is less than 10 degrees, it is called what?
What is a Cobb Angle?
The Cobb Angle measures the curve magnitude in the spine.
How is the Cobb Angle measured?
1. Locate the most tilted vertebra at the top of the curve and draw a parallel line to the superior vertebral end plate.
2. Locate the most tilted vertebra at the bottom of the curve and draw a parallel line to the inferior vertebral end plate.
3. Erect intersecting perpendicular lines from the two parallel lines.
4. The angle formed between the two parallel lines is Cobb angle
What are the typical age ranges of a person's main growth spurts.
0 - 2 years and Adolescence. The fastest is in the 0 - 1 year range.
How many degrees of change are required to state that a spinal curve has progressed?
5 or more.
Name the different Curve Classification Systems.
- 1. Curve Apex
- 2. King
- 3. Lenke
- 4. Schroth
- 5. Barcelona
Describe the Curve Apex Classification system.
Curve Apex is the simplest method, just by the largest spot of the curve;
- Double (which is a Thoracic and a Lumbar curve)
How many curve types are in the King's Classification system?
There are 5 types of curves.
Describe the Type 1 curve in King's Classification system.
- Type 1:
- ° S-shaped curve in which both thoracic curve lumbar curve cross midline.
° Lumbar curve larger than thoracic curve on standing roentgenogram.
° Flexibility index a negative value (thoracic curve < lumbar curve on standing roentgenogram, but more flexible on side-bending).
Describe the Type 2 curve in King's Classification system.
° S-shaped curve in which thoracic curve and lumbar curve cross midline
° Thoracic curve < lumbar curve
° Flexibility index < 0
Describe the Type 3 curve in King's Classification system.
Thoracic curve in which lumbar curve does not cross midline (so-called overhang)
Describe the Type 4 curve in King's Classification system.
Long thoracic curve in which L5 is centered over sacrum but L4 tilts into long thoracic curve.
Describe the Type 5 curve in King's Classification system.
Double thoracic curve with T1 tilted into convexity of upper curve; upper curve structural on side-bending.
When is the Lenke Classification system used?
The Lenke Classification system is used for orthopedic surgical decision making.
Briefly describe the Lenke Classification system.
The Lenke classification for adolescent idiopathic scoliosis has gained popularity and consists of three steps:
- 1. Label primary curve at Type 1-6
- 2. Assign lumbar modifier (A,B,C)
- 3. Assign sagittal modifier (-,N,+)
Briefly describe the Schroth Classification System.
- The Schroth method involves identifying-
- major curve location
- body blocks rotation
- relative position of the pelvis and lumbar block
- prominent hip location
- body weight balance
Describe the signs of scoliosis.
With the entire trunk must be visible-
Head: centered over pelvis
Shoulders: height (note if one is higher than the other), prominent scapula/breast
Rib Cage: uneven?
Hip: height, prominent IC (iliac crest)
Entire Body: leaning to one side?
Describe the Adam's Forward Bend Test.
Bend until spine horizontal
Refer: 7 degree angle of trunk rotation (curve > 30 degrees)
You refer a child to an orthopedist when the angle of rotation is 7 degrees or more because there’s a small chance that the curve might be more than 30 degrees. (Need to use a scoliometer.)
When is a physical exam done in idiopathic scoliosis cases?
Idiopathic scoliosis is a diagnosis of exclusion, a thorough physical exam in necessary to rule out other causes of the deformity and determine exactly what kind of scoliosis you’re dealing with.
What skin anomalies do you take note of when doing a physical exam in AIS?
Hair tufts (occurs in congenital scoliosis) or lumbosacral dimples (is a small hole located just above the buttocks, may be a sign of Spina Bifida).
When performing a neuromuscular exam in an AIS, why would you perform a abdominal reflex test?
To see if an MRI is needed to RO Syringomyelia. Syringomyelia is a generic term referring to a disorder in which a cyst or cavity forms within the spinal cord. This cyst, called a syrinx, can expand and elongate over time, destroying the spinal cord. The damage may result in pain, paralysis, weakness, and stiffness in the back, shoulders, and extremities.
What is the purpose of Abdominal Reflex Test?
To test the upper abdominal reflexes which are supplied by nerve roots T9-T11. (The lower abdominal reflexes are supplied by roots T11-T12.)
How do you perform the Abdominal Reflex Test?
These reflexes can be tested by lightly stroking the abdominal wall diagonally towards the umbilicus in each of the four quadrants of the abdomen. If the reflex between the sides is asymmetrical, then this indicates an abnormal test. Reflex contractions of the abdominal wall are absent in upper motor neurone lesions above the segmental level and also in patients who have had surgical operations interrupting the nerves. They can also be absent in normal people. Often abdominal reflexes are lost early in multiple sclerosis, but late in motor neurone disease.
What areas do you look at when doing a physical exam for AIS?
- 1. Skin Anomalies
- 2. Neuromuscular exam
- 3. MMT of the Lower Extremities
- 4. Spinal Balance; looking for atypical curve
What is Coronal Balance?
The head is positioned directly over the pelvis.
How do you measure coronal balance?
Place a plumb line from C7 down to the gluteal crease along the Central Sacral Line.
This line shouldn’t deviate more than 2 cm. If it does, then it means that the head is not centered over the pelvis. If so, RO a coexisting neurologic pathology.
How do you measure Trunk Balance?
Measure the distance between the central sacral line and the edge of the ribs at the edge of the apical vertebra.
Unlike Coronal Balance, there’s typically a trunk imbalance over the pelvis, especially in patients with single thoracic curves.
Describe the use of different views for Xrays in AIS.
Posteroanterior View: used to determine the Cobb Angle
Lateral View: Used to determine if someone has either kyphosis or lordosis.
Bending View: Helps determine the curve’s flexibility which helps mainly with surgical planning
Describe the basic facts of AIS.
Unknown Cause, but there are many theories on cause, including hormonal imbalance or CNS changes.
Most Common Type (4/5 scoliosis cases)… occurs mainly in adolescence.
Mostly adolescents (30% family history)
What are the basic facts of infantile IS?
- 1. Males > Females
- 2. Left Thoracic curves more common
- 3. Most curves (58%) resolves.
Name the main type of Infantile IS.
What is Rib-Vertebral-Angle-Difference (RVAD)?
The difference between the angle formed by a vertical line through the centre of the apical vertebral body on a PA film and the rib on the convex side and the same angle on the concave side.
At what angle is a case of RVAD likely to progress?
20 or more.
What phase of RVAD is in when it's less than 20?
Phase 1; a resolving curve.
What phase of RVAD is in when it's more than 20?
Phase 2; You can see the rib overlaps the vertebral body.
What is the age range of Juvenile IS?
4 - 9 YO.
What are the demographic features of Juvenile IS?
1. Younger: Male > Females; predominately left-sided curves.
2. Older: Females > Males; predominately right-sided curves.
3. 20% of curves that have greater than 20 degrees of curvature have an underlying spinal condition.
4. Curves that are greater than 30 degrees typically worsen without treatment.
What are some of the underlying conditions of juvenile IS?
1. Syringomyelia (acquired, Syrinx: spinal cord cyst)
2. Arnold-Chiari Malformation (if congenital, then considered AC malformation: brainstem or cerebellum protrudes into the cervical portion of the spinal cord.)
What is the age range for Adolescent IS?
10 - 18 YO.
What are the main features of AIS?
1. The most common type of scoliosis
2. Greater in Females than Males (Ratio: 7 to 1)
3. Tend to be Right Sided Curves (if double curve, then right T and left L)
What are the factors that predict the progression of AIS?
2. Maturity at curve discovery; Chronological Age of patient, Bone Age: Risser Sign & triradiate cartilage, and Menarche, if they’re female. The younger the age at diagnosis, the higher the progression risk.
3. Curve Magnitude; large curves tend to worsen. Girls are more likely to progress as the curves were found to be initially bigger.
4. Curve Pattern; T-curves and double curves are more progressive then thoracolumbar curves. Lumbar curves are the least likely to progress.
What are the levels on the Riser scale?
1: 0% Ossification
2: 1 – 25% Ossification
3: 25 – 50% Ossification
4: 50 – 75% Ossification
5: 76% - 100% Ossification
Why is Peak Growth a concern in AIS?
Peak Growth is highly correlated with curve progression.
What is Peak Height Velocity (PHV)?
When a child grows the most. The growth rate then slows down in the years after their initial PHV. (With boys it’s more difficult to plot the PHV but that’s why you look at the Risser grade.)
When does the Triradial Cartilage close?
It will close after PHV and before Menarche & Risser grade 1.
How does Curve Magnitude affect curve progression in AIS?
1. Adolescents with at least 20 degrees of a curve are more likely to progress.
2. Curves of greater than 45 degrees who are growing may continue to progress over time.
3. Patients with curves of 50 degrees or greater and have done growing, still may progress slowly over time.
4. If the child is done growing skeletally, they still may get worse if the curve is big enough.
What are the main features of Congenital Scoliosis?
1. Develops in the first 6 weeks of embryonic formation.
2. Unknown cause. It’s not genetic and may not be noticeable until adolescence.
3. In infants under 3 months before vertebrae ossify, an US can scan for spinal cord abnormalities.
4. Urology or cardiology consult may be needed in infants 3 months or younger.
What types of anomalies maybe present in an infant with Congenital or Infantile Scoliosis?
1. 25% chance of a urologic anomaly.
2. 10% chance of a cardiac anomaly.
3. Possible Hemivertebrae; most common in T8.
What are the two main types of Congenital Scoliosis?
1. Defects of Segmentation
2. Defects of Formation
The most common type of Congenital Scoliosis is a Formation Defect, where the growth plate above and below a disc can cause a deformity.
What are the main features of Neuromuscular (Nm) Scoliosis?
1. Secondary to condition due to a primary diagnosis; Most common causes CP & DMD (Duchenne MD).
2. Lose control of spinal nerves/muscles supporting the spine.
3. Younger age than IS; equal occurrence in both sexes.
4. Progression greater in NMS than IS.
5. Spine is more rigid.
6. Curves typically are Long sweeping TL curve, or in C-curves.
What are the common problems seen in NMS?
1. Poor Sitting; due to pelvic obliquity; which is caused by hip joint contractures, LE asymmetry or in combination of the two. Also hip dysplasia is associated with NMS.
2. Skin Pressure; improper Seating & Brace.
3. IT pressure; pelvic obliquity from the end vertebrae of the lowest curve. So you must examine the wheelchair to make any necessary modifications.
4. Trunk Decompensation; typically occurs and can be fixed with pillows or a customized wheelchair. (Decompensation means that the centre of gravity in the torso has moved to one or other side. Thus the head is not centered over the pelvis. This puts a significant asymmetrical strain on the intervertebral discs and this is particularly important in the lumbar region.)
What is the percentage of prevalence of NMS with such conditions as CP, Myelomeningocele (Spina Bifida), DMD, SMA, SCI (before puberty)?
- CP: 40%
- Myelomeningocele: 60%
- DMD: 90%
- SMA: 90%
- SCI: 100%
What are the typical treatment options for children under 10 YO for Scoliosis?
If curve under 25 degrees; Observation. Recheck in 3 - 6 months.
If curve over 25 degrees; Bracing. May also use bracing-casting-traction cycle. (Bracing not recommended for children with NM scoliosis.)
What is the most commonly used form of bracing with children who have scoliosis?
Usually Thoracolumbar Sacral Orthosis (TLSO) brace.
What is the success rate for infantile casting?
What are the indications for infantile casting?
- 1. Idiopathic…works for this groupii)
- 2. Ambulatory… betteriii)
- 3. Younger age (ideally < 4 years old)iv)
- ♦Can be definitive treatment in very young children
- ♦Can delay surgery in severe EOS…Early Onset Scoliosis
What are the difficulties associated with infantile casting?
- 1. Time consuming
- 2. Requires special table that facility may not have
- 3. Knowledge of Special Techniques required
- 4. Open Design required
What are the Contraindications to infantile casting?
- 1. Very Large Curves.
- 2. Rigidity…that may not correct much.
- 3) Skin/Chest wall tolerance.
- 4) Respiratory Issues.
- 5) Cognitive Delays or Weakness may also not tolerate casting.
What are the benefits of Halo traction for infantile scoliosis?
1. Can use with many Diagnoses/Ages Ranges/Types of Scoliosis
2. Provides Pre-operative correction or Surgical Delay
3. Improve curve flexibility
4. Mobilize patients… who are weak and have respiratory issues.
5. Pulmonary improvements
6. Increased Height (Avg. 29%)
7. Decreased Kyphosis (26%)
8. Decreased Scoliosis (34%)
9. Decreased Trunk Shift (1.8 cm)
How is Halo traction applied?
1. 6-8 pins…around the head
2. 1 lb torque/yr age
3. Increase weight per pt. tolerance to max of 50% BW
4. Day: Max traction
5. Night: Comfort
6. Treatment Length: 4 – 8 weeks
What other forms of treatment are available for infantile scoliosis besides Halo traction?
2. Growing rods (surgery)
What are the benefits from bracing, casting, and traction in infantile scoliosis?
1. Delayed serial surgeries.
2. Casting & bracing are effective for mild-moderate curves.
3. Traction is effective for small children or those with severe curves.
What are the general surgical options for infants and small children with scoliosis?
1. Hemivertebra Resection
2. Fusionless Instrumentation (Growing Rods, Expansion Thoracoplasty)
What occurs during a hemivertebra resection?
Remove hemivertebra, fuse vertebra above & below (often with instrumentation).
What occurs during a fusionless instrumentation procedure?
Insertion of growing rods and a vertical expandable prosthetic titanium ribs (or hybrids of the two).
Not truly fusionless…the proximal and distal vertebras, serves as the anchors, are fused to the vertebras above and below them.
What occurs during a fusion procedure?
Rods attach to anchors, span the curve. The rods are subcutaneous except at the anchor points.
What occurs during a expansion thoracoplasty?
An expandable rib prosthesis is used to expand the ribs to allow lungs to grow.
Why would spinal fusion be delayed for a child with scoliosis?
It is typically delayed until adolescence because it will lead to:
1. Decreased Pulmonary Function Tests
2. Decreased growth of thoracic spine length, which can cause decreased growth of thorax & contents, which then leads to adult TIS.
When are fusion surgeries typically done with a child who has scoliosis?
10 years of age and older, when most thoracic growth is finished.
What are the features with a posterior spinal fusion of a child with scoliosis?
1. Considered a Permanent fixation.
2. Metal implants hold spine until bone fuses.
3. No cast or brace is used.
4. Hooks or Screws are be used. Hooks are placed in the lamina and screws are placed in the pedicles.
What are the features with a anterior spinal fusion of a child with scoliosis?
This is done to prevent the “crankshaft” phenomenon.
1. Usually done on children under 10 YO,
2. and those that have a single curve.
What is the “crankshaft” phenomenon?
This is a curve that can worsen with rotation above and below the instrumentation.
What are the appropriate treatment options for adolescents with scoliosis?
What are the conditions for Observation only treatment for adolescents with scoliosis?
1. Skeletally immature: if curve < 25 degrees
2. Skeletally mature: if curve < 45 degrees
When is bracing used in AIS?
When the curves are 25 – 40 degrees during growth.
What is the primary goal for bracing in AIS?
Prevent curve progression; avoid surgery.
What are the secondary goals for bracing in AIS?
1. Reduce the curve in-brace; acceptable in-brace correction level is 30-50% reduction.
2. Educate patient on required wear schedule.
3. Target the adolescent growth spurt.
What are the risks of progression with AIS?
1. Decreased Risser sign, 0 – 2, hardly any fusion of the iliac apophysis.
2. Increased Curve magnitude, larger.
3. Decreased age.
What's the role of PT in AIS in the US?
Unclear; no nationwide standard of care, it varies greatly by institution.
What's the role of PT in AIS in Europe?
Clear role; Germany, Italy, and Spain has specialized centers. England, Russia beginning to develop specialized centers.
What is the European standard of care for scoliosis regardless of cause?
If curve =/> 15 degrees: Outpatient PT
If curve =/> 20 degrees: Scoliosis Intensive Rehab (SIR); a 3-5 week program, 4-6 hours a day training, with or without bracing.
What is the SOSORT guideline?
SOSORT- Society On Scoliosis & Rehabilitative Treatment. This guideline is based off the progression formula- Cobb Angle - (Risser Sign x 3)/Chronological Age.
What this means is simply that a child with a higher Cobb Angle or is younger are more likely to progress.
According to the SOSORT guideline, what factors are considered when prescribing PT?
- 1. Child's Cobb Angle
- 2. Progression Risk Factor
- 3. Risser Sign
- 4. Age
What are the general prescription SOSORT guidelines for patients with scoliosis?
- If Curve less than 15 degrees: Observation
- If Curve > 15 degrees: Outpatient PT
- If Curve > 20 degrees: Refer to SIR
- If Curve > 25 degrees: Brace + PT
Who are the two most published methods for PT treatment of AIS?
How is the Scroth and SEAS methods similar?
Both methods aim to correct an asymmetric posture and have the child maintain the corrected posture with ADLs. They use Auto Correction Principles: the ability to decrease spinal deformities through active and autonomous postural realignment in 3 dimensions.
Who started the Scroth Method?
Started in 1920 Germany by Katharina Schroth.
What are the two main branches of the Scroth method?
ISR: Integrated Scoliosis Rehabilitation, started by Dr. Weis, grandson of Katharina Shroth.
Barcelona Scoliosis PT School: started by Dr. Rigo, a classmate of Weiss.
What are the goals of both the ISR & Barcelona Methods?
- 1. Correct the asymmetrical posture.
- 2. Maintain Corrected Posture with ADLs.
- 3. If Curve large enough, Bracing w/PT.
What are the main principles of the Scroth Method?
1. Correct asymmetrical posture with proprioceptive & external stimulation (light, touch, pole use, etc).
2. Corrective breathing; autoelongation and opening concavities.
3. A developed exercise program based on the patient's curve patterns using the Scroth classification system.
In the Scroth Method, how do you instruct the patient in auto-elongation?
Telling someone to grow ‘tall’ or grow ‘long’ with their exercises but also throughout the day [mental imaginary].
In the Scroth Method, how do you 'open concavities'?
you tell the child to imagine a balloon “opening up” in the concave side of the curve.
What are the major curve patterns according to the Schroth Classification System?
There is either a 3 or a 4 curve pattern. The spine is grouped into blocks, where each block of the spine can be translated and or rotated in 3D space.
According to the Scroth Method, what are the blocks of spine in a 3-curve pattern?
Block 1: LumboPelvic Region.
Block 2: Thoracic Region.
Block 3: Neck-Shoulder Region.
According to the Scroth Method, what are the blocks of spine in a 4-curve pattern?
Block 1: Pelvis
Block 2: Lumbar
Block 3: Thorax
Block 4: Neck-Shoulder
How does the Barcelona Method classify curves?
A clinical and radiological exam is done. A line is drawn along the Central Sacral Line. The Transition Point is found (which is the middle point between the lower end of thoracic curve and the upper end of the lumbar curve). The curve type is then figured by what side T1 and the TP is on of the CSL.
What does the acronym SEAS stand for?
Scientific Exercise Approach to Scoliosis
When was the SEAS method developed?
Since 1980, there has been 6 revisions and is practiced mostly in Italy.
What is the basic premise of the SEAS method?
SEAS method focuses on active self-correction by activating the deep paraspinal muscles to promote spinal stabilization.
What is the greatest benefit of PT in scoliosis?
That exercise decreases curve progression. Although to date, there haven't been enough high quality studies to properly access as to whether exercise is effective alone.
What is the second greatest benefit of PT in scoliosis treatment?
Exercise decreases brace prescriptions.
What is the third greatest benefit of PT in scoliosis?
Exercise decreases low back pain.
When does LBP occur in adolescents?
Mostly during periods of high growth;
- Males 12.5 years old +/- 2 years.
- Females 10 years of age.
Does incidents of adolescent LBP put one at higher risk of it when one becomes an adult?
Yes; there is a correlation between adolescent and adult onset of LBP.
What are the risk factors for adolescent LBP?
1. Low Isometric Back Extensor Muscle Endurance;
o High lumbar mobility to Lumbar Extension Endurance/Strength Ratios(Those that had a lot of motion in their lumbar region but low strength)
o The above suggests the need for lumbar stability and lumbar extension strength.
- 2. High levels of physical activity;
- o Repetitive movements from a high level sporting activity.
3. Part-Time work
4. Psychosocial Difficulties
5. Spinal Asymmetry
What is the life time prevalence of LBP with adolescence with and with out AIS?
With IS: 59%.
Without IS: 33%
What are the associated problems with adolescent LBP?
- 1. Increased health care utilization.
- 2. Use of analgesics.
- 3. Increased school absences.
- 4. Physical activity limitations
- o Obesity in adolescents (will help)
- 5. Decreased quality of life
What are the 3 pain scale rating that are commonly used in accessing LBP?
1. Wong-Baker Faces Pain Rating Scale.
2. Visual analog Scale.
3. Numeric Pain Scale.
What are the two common types of Quality of Life questionnaires used?
1. Modified Oswestry Disability Questionnaire.
2. Scoliosis Research Society-22 Health-Related QOL Questionnaire.
What are the features of the Modified Oswestry Questionnaire?
- 1. Typically used with kids who have LBP.
- 2. It has not been validated in adolescents.
- 3. But it is helpful for those with LBP only.
- 4. Scores range from 0 – 100 with higher scores indicating more disability.
- 5. If there’s at least a 50% improvement in the score then the outcome is determined to be successful.
What are the features of the Scoliosis Research Society-22 Questionnaire (SRS-22)?
- 1. Disability specific.
- 2. 22 questions regarding pain, self-image, function, mental health, and management sanctification/dissatisfaction.
- 3. Validated for kids with AIS.
- 4. Allows picture of patient's physco-social image as well.
What are the two common trunk muscle endurance test?
1. Sorensen Test. The most widely used.
2. Prone double leg raise. The most accurate for patients with LBP as compared to the Sorensen Test.
What are the two major types of hamstring flexibility test?
1. Passive SLR
2. Popliteal test
What are the published norms for the passive SLR test?
Females: 76 degrees +/- 10
Males: 69 degrees +/1 7
What are the published norms for the Popliteal hamstring test?
- Females- 28 degrees +/- 8
- Males- 39 degrees +/- 8
- Children: 5-10 YO
- 26 degrees (0-50)
- if over 50 degrees, hamstrings are tight.
How is Right Periscapular pain managed?
1. Stretching. Stretching the Rhomboid and/or Pec muscles individually or by hanging from a bar.
2. Postural Cues. R) Shoulder tends to be forward. Or auto-elongate by telling them to breath & ‘grow tall’.
3. Right Rib Mobilizations. If pain originating from the ribs.
What are some of the basic features of spinal stabilization with AIS?
- 1. More reps with kids (100+ reps).
- 2. Abdominal bracing. Have them do this throughout the day when they’re doing activities that caused them pain.
- 3. Activity specific exercises. You must select exercises that have carry over into activities that have caused them pain in the past.
How do you manage LBP for AIS patients?
- 1. Ice/Heat
- 2. Back Pack; must be 10% of child's BW
- 3. Proper Lifting techniques
- 4. Proper sitting posture (proper lumbar support)
- 5. Proper bed mobility
- 6. Physical activity recommendations