SCOLIOSIS MANAGEMENT

By Neha Dhobale(PT)

MANAGEMENT

• Most important aspect- early detection of the curve.

• Curve that is obvious in standing position; has already approached 30 to 40 degrees.

• Curves over 20 degrees tend to progress.

• Treatment depends on age and severity of the curve.

NON- SURGICAL TREATMENT

• Observation – for curves <20˚.

• Orthosis - for curves between 20-40˚.

• Operation – for curves > 40˚.

• Other measures – exercises, electrical stimulation etc.

Curves < 40˚Mild Postural Curves ( till 20˚)• Active correction - Moving and placing the legs or trunk in such

a position that optimal self-correction of curve is achieved.

• Passive correction -

– Unequal traction: Instruct the patient to hang from suspension with one hand.

– Hanging in the head suspension apparatus.

– Axial traction: Patient in supine. 1 PT grasps the pelvis and gives traction towards the leg, other PT grasps the chin and occiput and stretches the spine in opp. direction.

• Maintenance of correction – by active efforts.

• Management of Postural Scoliosis (Progressive re-education of bad posture)

– Whole body relaxation techniques

– Passive correction by physiotherapist

– Repeated sessions of maintenance of corrected posture till it becomes automatic

– General free mobility exercises

– Deep breathing exercises

– Balance exercises

– Soft tissue stretching

– Patient trained to feel and hold corrected posture.

Management of structural scoliosis(Curves25-45˚)Active self-correction as well as maintenance of braced (orthosis) • Braces for spine i. TLSO: Thoracolumboscaral orthosis (Boston brace, Wilmington TLSO ii. CTLSO: Cervicothoracolumboscaral orthosis (Milwaukee brace) iii. CTO: Cervicothoracic orthosis iv. Other – Charleston bending brace.

• Exercises i. Mobility exercises ii. Deep Breathing exercises iii. Exercises to reduce and correct the anterior pelvic tilt. iv. Stretching of hip flexors and hamstrings v. Hanging in head suspension apparatus or on stall bars – effective stretch to whole spine.

Charleston Bending Brace Milwaukee Brace

Boston Brace Wilmington Back Brace

Severe structural curves (Curves >40˚)

•Pre-operative assessment and training.

•Various forms of traction

•Surgical treatment

• Measurement of the rib hump in prone.

• Assessment of the pulmonary function.

• Muscle charting of the body and limbs especially below the level of fusion.

• Detailed neurological examination to detect compression of spinal cord.

• Vigorous ATM, isometrics to gluteal and quadriceps muscles taught.

• Gait analysis and functional status assessed and requirements of normal gait explained

• Postural Guidance

• Spinal stretching and mobility

Pre-op PT assessment and training

Various forms of Traction

• Skeletal traction in form of: i.) Halofemoral traction

ii.) Halopelvic traction

iii.) Halo-wheelchair traction

• Non-skeletal methods of traction: i.) Intermittent traction followed by sustained traction - Low back pain patients.

ii.) Cotrel traction – Superimposition of continuous and intermittent traction.

iii.) Gravitational traction – Twice as effective as effective as the Cotrel traction.

Surgical Treatment

Indications• Curves > 60˚

• High degree Thoracic curve which is inflexible and associated with secondary changes in the rib.

• Spinal cord compression.

• Pain

• Respiratory problem

• Cosmetic reasons.

Spinal Instrumentation

POST-OP PT MANAGEMENT

• During the First 4 Days

1. Vigorous chest physiotherapy improve the reduced vital capacity of the lungs

2. Patient is turned to the sides every 2 hours to reduce on the back.

3. Active ROM- shoulder and ankle joints

Passive ROM to lower limbs to relieve pain and stiffness.

4. By end of 4th day – Active and Passive ROM - Hip and Knee joints.

•After 4 DaysWith assisted guidance patient is taught to sit, roll and stand.1.Getting out of the bed: Reverse climb down technique. Log rolling → Prone Position → Prone Kneeling → Getting down slowly from the foot end of the bed Climbing up the bed is done in reverse manner2. Sitting - Initial sitting should not exceed 15 minutes. Initially with support and back rest.3. Standing - Unsupported sitting should precede standing.4. Walking – Initiated in parallel bars. Later, provided with cane or elbow crutches for ambulation.

•Additional physiotherapy measures

1.For one level anterior fusion - Corset or POP jacket for 3 months - Isometrics to back muscles - After 3 months, back exercises are begun

2.For two level anterior fusion - Corset or POP jacket for 3 months - Isometrics to back muscles - After 3 months, back exercises are begun

3.Posterior fusion - Corset or POP jacket is advised for 6 months - Hip Spica if L5- S1 joints are fused.

4.Combined anterior and posterior fusion

- Log rolling and later table tilt activity - POP jacket or corset for 6 months.5.If anterior and posterior fusion is

done with a gap of 2 weeks, hydrotherapy is suitable as there is considerable muscle weakness.

Rest of the measures are the same as mentioned earlier.

Reference• Essential of Orthopaedics and applied Physiotherapy -

Jayant Joshi

• Essentials of Orthopaedics for Physiotherapists – John Ebnezar