ORTHOTIC MANAGEMENT OF SCOLIOSIS Prepared by: MUHAMMAD IBRAHIM KHAN BS.PT(Pak), MS.PT(Pak), NCC(AKUH)
Scoliosis– 3-dimensional deformity of the spine affecting all the 3 planes.– Can be difficult to visualize with 2-dimensional radiographs– Scoliosis is a lateral deviation of the normal vertical line of the spine which, when measured by an X-ray, is greater than 10 degrees accompanied by vertebral rotation.
Scoliosis“Normal” alignment• Spinous processes all line up in a straight line over the sacrumScoliosis is a combination of• Angular displacement• Lateral displacement
Types of Scoliosis• Congenital• Idiopathic• Neuromuscular• Post Traumatic• Infective• Degenerative• Inflammatory• Tumor
CONGENITAL SCOLIOSISThe critical time is the time of segmentationprocess (First Six weeks) and congenitalanomalies develop during this period of time.In the presence of vertebral anomalies, thereis an imbalanced growth of spine resulting incongenital scoliosis.
ClassificationBy MacEwen et al. later modified by Winter, Moe, and Eilers• FAILURE OF FORMATION Partial failure of formation (wedge vertebra) Complete failure of formation (hemi vertebra)• FAILURE OF SEGMENTATION Unilateral failure of segmentation (unilateral un segmented bar) Bilateral failure of segmentation (block vertebra)
Congenital ScoliosisFailure of Formation Failure of Segmentation
Patient Evaluation Examine the skin of back for hair patches, dimples, and scars. Look for the evidence of neurological involvement, such as clubfoot, calf atrophy, absent reflexes and atrophy of one lower extremity compared with the other. Look for the other congenital anomalies.
Screening hints• Shoulders are different heights• Head is not centered directly above the pelvis• Appearance of a raised, prominent hip• Rib cages are at different heights• Uneven waist• Changes in look or texture of skin overlying the spine (dimples, hairy patches, color changes)• Leaning of entire body to one side
ScoliometerAn inclinometer (Scoliometer) measuresdistortions of the torso.•The patient bends over, arms danglingand palms pressed together, until a curvecan be observed in the upper back(thoracic area).•The Scoliometer is placed on the backand measures the apex (the highestpoint) of the upper back curve.•The patient continues bending until thecurve can be seen in the lower back(lumbar area). The apex of this curve isalso measured.
Adam’s forward bend testFor this test, the patient is asked to lean forward withhis or her feet together and bend 90 degrees at thewaist. The examiner can then easily view from thisangle any asymmetry of the trunk or any abnormalspinal curvatures.
Measure spinal curvature using Cobb method- Choose the most tilted vertebrae above & below apex of the curve.- Angle b/w intersecting lines drawn perpendicular to the top of the superior vertebrae and bottom of the inferior vertebrae is the Cobb angle.
Diagnosis• Physician Physical Exam• Scoliometer measurements• X Ray• MRI
Observation Non progressive curves and Minor curves (>20 degrees) and with other congenital anomalies. Skeleton is close to maturity Exercises may help with surrounding muscular strength. Limited value in patients with congenital scoliosis.
Bracing• Usually works on the vertebrae outside the actual congenital deformity.• Compensatory curves also can be successfully managed for several years with orthotic treatment.• Lumbar curves can be treated in a TLSO, but thoracic curves require a Milwaukee brace.
Bracing• Duration and time in brace – 23 hours per day – Wear until skeletally mature
BracingTypes – Milwaukee – Thoraco-lumbar-sacral orthosis (TLSO or Boston brace) – Charleston night time bending brace
BracingMilwaukee brace Three types of curves respond to brace management:1- Long, flexible curves,2- Curves that could be corrected either in traction or on side bending,3- Curves with a mixture of anomalous and non-anomalous vertebrae.
Successful Bracing• Prevent curve progression – Randomized study • Braced 74% did not progress • Not braced 34% did not progress• Charleston brace still controversial
Problems with Braces• Argued efficacy• Narrow treatment window to initiate• Poor compliance• Must have good orthotist – Curves corrected by 20 degrees in brace do better