Conservative Management of Idiopathic Scoliosis in an Adolescent Rita B. Shapiro, PT, MA, DPT CDR,...
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Transcript of Conservative Management of Idiopathic Scoliosis in an Adolescent Rita B. Shapiro, PT, MA, DPT CDR,...
Conservative Management of Idiopathic Scoliosis in an Adolescent
Rita B. Shapiro, PT, MA, DPTCDR, USPHSCOF Annual Symposium Therapist Category Day- May 25, 2010
Scoliosis is defined as a partially-fixed lateral curvature of the spine observed on a standard radiograph.
In truth, the deformity is three-dimensional and rotation is a critical component.
In approximately 85% of diagnosed cases, etiology is unknown.
Adolescent Idiopathic Scoliosis (AIS) AIS is most common type in children from an
average age of 10 years to maturity. About 10 percent of all adolescents have some
degree of scoliosis. Less than 1 percent, require medical attention
other than careful observation of the problem. Females are predominately affected, with a
female to male ratio of 1.4:1 for curves 11 degrees to 20 degrees, and the ratio increases to 5:1 for curves greater than 20 degrees
Diagnosis Scoliosis is usually diagnosed clinically with objective
measurements via plain radiographs measuring the Cobb angle.
The Cobb Angle is the angle between two lines drawn perpendicular to the upper endplate of the uppermost vertebrae involved and the lower endplate of the lowest vertebrae involved. For patients who have two curves, Cobb angles are measured for both curves.
Cobb Angle Measurement for Dextroscoliosis
Case Description
The patient was a 13.5 year old otherwise healthy female middle school (8th grade) student
She had been complaining of "nagging" neck and lower back pain of approximately six months duration.
Review of Systems
Patient was hypothyroid and was under the care of a pediatric endocrinologist
Medications: Synthroid® prescribed by physician for
hypothyroid Minocycline® prescribed by the physician for acne
control One daily multivitamin and sometimes Tylenol® or
Motrin® for pain control.
ROS-Continued
Patient was slightly active but not athletic and had to carry a heavy back pack to and from school
Patient's body mass index was 23.33 Kg/m²
(height 156.2 cm, weight 56.6 kg)
Physical Observation-posterior
Initial Physical Therapy Examination
Standing Rear View note elevated right shoulder
and right iliac crest
Physical Observation-Anterior
Initial Physical Therapy ExaminationStanding Front View, note elevated right ASIS
Forward Bend Test
Initial ExaminationBent over Test eliciting right rib hump
X-ray Findings
The x-ray report revealed an approximately 8 degrees dextroscoliosis from the superior endplate of T1 and extending to the inferior endplate of T8 measured by the Cobb method.
The orthopaedist measured the curve to be 10 degrees by the Cobb method.
Bone Age study had been ordered by an endocrinologist when the patient was 11 years old. The results of that study indicated that the patient's bone age was 14 years versus the chronological age of 11 years and 4 months, thus indicating that the bones were at a higher level of maturity possibly due to the thyroid disease or early puberty.
Treatment Interventions
Initially intervention included: Pain Management-Heat/Ice/MFR Hands on stretching
Hands on stretch guidance demonstration only(Not the patient in this case report)
Schroth Method
The three dimensional method advocated by Schroth includes the placement of hands by the therapist in the clinic, or a family member at home, to make the patient aware of the narrow segments of the scoliotic spine, and how to stretch those narrowed segments, and the use of a mirror for self guided postural correction
Patient Education
Education in Scoliosis management Pt. and her mother were educated in individual
exercises and movement patterns Proper back pack lifting techniques and how to
utilize the chest harness and the waist strap
Patient Education
The drawbacks of picking the back pack with one hand and slinging it over one shoulder, right in her case, were explained to the patient in detail. She was shown how continuous load over one muscle group or one anatomical region would eventually cause that group to fail without adequate counter balance.
Patient's Exercise Program
Exercise Program-Contd.
Exercise Program-Contd.
Hippotherapy
Many studies have been published on the effects of horseback riding (Hippotherapy) on posture improvement which is accomplished through strength improvement of the small spinal muscles, achieving muscular balance, core strength and hence, scoliosis stabilization.
Horseback Riding
Patient began horse back riding program at approximately six months of beginning the Physical Therapy program.
Note excellent posture attained.
A: Profile B: Lateral view C: Back view
Follow up X-rays
At six months, the results indicated the curve had increased to 12 degrees
At one year the curve had reduced back to 10 degrees.
No radiographs past one year were taken
Three year Follow Up
Front view: note improved posture
Rear view: note no right shoulder elevation
Bent over test: Rib Hump unchanged
Three Year Follow Up
Initial front view (left) and at three year follow up (right)Note improved posture, no shoulder elevation and level ASIS
Discussion
During a thorough review of the patient's medical record, it was noted that only six months prior to patient's first visit to physical therapy clinic (self referred), she was seen by an adolescent primary care provider for school physical. The provider had made an incidental remark in the assessment as "mild scoliosis is noted will follow". However, no instructions or further follow-up plans were given to the patient or her mother
Discussion
It has been documented that untreated, idiopathic scoliosis will invariably arrest without requiring any interventions.
Studies by Negrini et al and Hawes and O'Brien demonstrate that approximately 10 percent of untreated cases of mild idiopathic scoliosis will lead to permanent spinal deformities and other related medical problems.
Asher and Burton demonstrated that though rare, untreated curves can progress to more than 100 degrees range even after skeletal maturity.
Final Take Aways
Though AIS may not progress to the point of disability, once discovered, the asymmetry must be properly documented, a definitive follow up plan must be established and, appropriate information provided to the adolescent and the family.
Final Take Aways-Contd.
A simple baseline test and a sound follow up strategy can allow for simple remedies and adoption of healthy lifestyles in our youth that is already on the rough road of many morbidities due to lack of physical activity.
Questions????