Lecture 7: Module 2: Musculoskeletal (MSK) Conditions
___ = no ossification
0
____ = highest risk for curve progression
0,1 and 2
Three major contributing concepts to Schroth method?
1) postural correction 2) correction of breathing patterns 3) correction of postural perception.
___ to ___ = ossification (25% to 100%)
1-4
Refers to a three-dimensional curvature of the spine Curvature in the coronal plane must be greater than _______ on the radiograph Spinal deformities are classified according to origin, location, magnitude, and direction. Curvatures may be idiopathic, neuromuscular, or congenital and may be further classified by the area of the spine in which the apex of the curve is located
10° with a vertebral rotation component
Dosing is a big factor in orthotic management in AIS 0-6 hrs/day - no effect > ____ hrs = > 90% success rate
12.9
Wear time for serial casting?
2-3 months between castings
Prevalence of idiopathic scoliosis?
2-3% of children aged 10 years old - skeletal maturity
Kyphosis: Abnormal posterior convexity of the spine; normal thoracic kyphosis measures ____ to ___ degrees between vertebral segments T5 through T12 with a lumbar
20; 40
Decisions on Non-surgical Intervention - Patients with 'curves' with the following characteristics are evaluated in clinical examination every 4 to 6 months. Idiopathic curves < ____° -Curves of nonsurgical magnitude in skeletally mature patient -Nonprogressive congenital curves are Radiographs are taken at ____ visit unless the scoliometer examination shows unnchanged results - this could reduce # of radiographs - but that depends on physician and institution practice.
25; each
Early skeletal, muscular and neural system development Week ___ (approx.) - cell proliferation forming trilaminar structures - ectoderm, mesoderm, endoderm and somites Week 4 & 5 - development of muscle and vertebrae at each side of the notochord (Differentiation of vertebrae begins in three phases) (dorsal, medial, ventral) Ossification - Begins in Fetal period
3
___ = lower risk b/c progressing skeletal maturity
3
Fetal Development - 3 phases 1. Pre-embryonic - first ___ weeks 2. Embryonic - ____ - ___ weeks (Organ development) 3. Fetal - ___ weeks - birth Maturation and growth of all structures and organs
3; 3-8; 8
___ = lower risk b/c near end of spinal growth
4
Surgical - Curves greater than ____ - difficult to manage with orthotics; significant risk of progression after skeletal maturity
40 degrees
Surgical - Major indication - documented progressive idiopathic curve with a Cobb angle greater than or equal to ____ degrees or greater in an immature spine
45
Minimal measurement of at least ___° by the scoliometer is considered a good criterion for identifying lateral curvatures of the spine with Cobb angles of 20° or greater.
5
Scoliometer reading of ___° or greater warrants further evaluation and is an indication for a radiograph.
5
__ = least risk b/c of skeletal maturity
5
____ = skeletal maturity.
5
Idiopathic scoliosis - natural history : progressive curve - defined as sustained increase of greater than or equal to ____ degrees on 2 consecutive examinations at ___ to ___ month intervals
5; 4; 6
____ correlates with the severity of the scoliosis.
ATR
Orthotics goal?
Alter the natural history of curve progression in AIS
Magnetic resonance imaging, computed tomography, myelography, and bone scans can be used to identify subtle _____ and for additional information to aid in diagnosis and detection of spinal conditions.
CNS abnormalities
Types of orthotics?
CTLSO - Milwaukee Brace (Effective but not very acceptable to patients) TLSO - Boston Brace (Lower profile - more acceptable to patients; Effective - but a bit less effective than CTLSO) Other types of TLSOs (Wilmington, Charleston, Osaka)
Conditions that may have neuromuscular scoliosis?
Cerebral palsy Duchennes Muscular Dystrophy Spinal Muscular Atrophy
3 types of kyphosis?
Congenital Postural Roundback Scheurerman's
_____ - bilateral posterior failure of segmentation
Congenital lordosis
3 categories - age of onset for idiopathic scoliosis infantile? juvenile? adolescent?
Current terminology - Early Onset Scoliosis (EOS) & Late Onset Scoliosis (LOS) Infantile - 0-3 yo (rare) Juvenile - 4-9 yo Adolescent - 10-19 yo - most common (80% of youth; mostly girls)
3 strong factors that correlate with curve progression for idiopathic scoliosis?
Curve magnitude Risser sign Patient's chronologic age at the time of diagnosis
Indication for orthotics? Typically prescribed for children with idiopathic scoliosis who are...
Curve type, magnitude, and location skeletally immature with a Risser sign of 0, 1, or 2 Curves from 25° to 45° Curve with a greater magnitude at time of detection - increased risk of progression Effect an orthosis on prevention of curve progression decreases as the magnitude of the curve increases.
Serial casting is done by who?
Done by the surgeon under general anesthesia
Serial casting is successful in cases of ______ (May resolve the curve) Sometimes used in cases of ___ (Slows curve; Delays surgery)
EOS; LOS
Abnormal posterior convexity of the spine; normal thoracic kyphosis measures 20° to 40° between vertebral segments T5 through T12 with a lumbar
Kyphosis
General alignment including shoulder and pelvic symmetry, spinal alignment by forward bend test, trunk compensation using a plumb line, and leg length measurement =
MD Physical exam
Idiopathic scoliosis - potential impact to other systems like ...
MSK - may impact ribs Cardiopulmonary - may decrease respiratory or aerobic capacity and function -Thoracic insufficiency syndrome - "the inability of the thorax to support normal respiration or lung growth" Vestibular system and balance control - may be compromised - important to examine and treat in PT
Besides x-ray what other imaging can we use for scoliosis?
Magnetic resonance imaging, computed tomography, myelography, and bone scans can be used to identify subtle CNS abnormalities and for additional information to aid in diagnosis and detection of spinal conditions.
Are structural or nonstructural curves better?
Non-structural curves are usually better because they are correctable
____ - a longitudinal flexible rod of cells that in the lowest chordates (such as a lancelet) and in the embryos of the higher vertebrates forms the supporting axis (spine) of the body
Notochord
Complications for serial casting may include?
Pulmonary compromise Skin Irritation
Are there any mid or long term studies for Schroth method?
Researchers - there are no mid- or long-term studies and more research is needed
Exercise protocol tailored to each patient to achieve maximal postural correction. Decrease curve progression, reduce pain, increase vital capacity, and improve posture and appearance. Which non-surgical intervention method for idiopathic and congenital scoliosis?
Schroth Method (introduced in the 1930s)
______ - measures rib hump with the forward bend test
Scoliometer
Types of non-surgical interventions?
Serial casting Orthotics PT
Decisions on type of intervention for idiopathic and congenital scoliosis?
Surgical or Non-surgical (Risser sign, Growth potential, Curve magnitude)
Kyphosis: Abnormal posterior convexity of the spine; normal thoracic kyphosis measures 20° to 40° between vertebral segments _____ through ____ with a lumbar
T5; T12
When do you discontinue orthotic?
Treatment failure - curve no longer controlled (> 45 degrees) - surgery Treatment success - curve 'controlled' - wear until skeletal maturity - wean
Main factors for probability of progression in skeletally immature patients
Younger the patient at diagnosis Double-curve patterns - greater risk than single-curve patterns. Lower Risser sign - greater risk Larger curves at initial presentation - more likely to progress Risk of progression in females is approximately 10 times that in males Curves develop before menarche - greater risk
Untreated progressive curve - potential to increase in ____
adulthood
Curvatures may be idiopathic, neuromuscular, or congenital and may be further classified by the area of the spine in which the ____ of the curve is located
apex
Curves are named by the direction of the ...
apex (top pic is right thoracic, left lumbar scoliosis)
Idiopathic scoliosis --> Maybe _____, ____, ______ and forces on the growing bone (Wolf's Law) Newer research points to a genetic basis - but not clarified yet
biomechanics, growth, compression
Mixed congenital scoliosis = _____
both
Congenital scoliosis basis?
both a genetic and environmental basis
____ angle - to measure spinal curvature
cobb's
Abnormalities appear to be sporadic
congenital scoliosis
Anomalous vertebral development in utero
congenital scoliosis
Non-surgical interventions for idiopathic and congenital scoliosis- Exercise Research ongoing that evaluates potential for physiotherapy scoliosis-specific exercises (PSSE) to improve postural awareness and subsequent spinal alignment in AIS. PSSE includes: -self-______, elongation, and chest wall expansion with focus on incorporation of the corrected posture into one's daily activities of living Different PSSE approaches have emerged in recent years - from various countries and ortho/PT/scoliosis groups
correction
Kyphosis - Both fixed and flexible, found in children with variety of ______
diagnoses
Spinal deformities are classified according to origin, location, magnitude, and ____
direction
Spinal growth in the Child Two periods of rapid growth _____ - 0 - 5 yo ____ growth spurt (in White populations) Girls - 8-14 yo Boys - 11-16 yo
early childhood; adolescent
Organ development in what phase of fetal development?
embryonic
Detection of Scoliosis - Identification of trunk, shoulder, or pelvic asymmetries Interventions (Screening, MD exam, PT/ Exercise or Bracing, Surgery) Baseline ____ by pediatric ortho (spine) surgeon including (Thorough Patient History; Review of all systems (neuro, MSK, etc)
exam
-Anterior failure of formation - kyphosis A partial unilateral defect of formation - wedge-shaped hemivertebra
failure of formation
Categories of congenital scoliosis?
failure of formation failure of segmentation mixed
-Non-segmented hemivertebra - completely fused to the adjacent proximal and distal vertebrae. -Semi-segmented hemivertebra - fused to one adjacent vertebra and separated from other by normal end plate and disc
failure of segmentation
Maturation and growth of all structures and organs in what phase of fetal development?
fetal
Ossification - Begins in ____ period
fetal
____ plane correction- application of force directly opposite to the natural tendency of the curve Forces at apex of the curve & opposing forces - applied both above and below
frontal
Main objective of spinal fusion surgery - obtain solid arthrodesis because the ______ is what prevents further progression
fusion mass
Lateral curvature of the spine of unknown cause
idiopathic scoliosis
This is the most common form of scoliosis in children
idiopathic scoliosis
Risser sign - determine skeletal maturity Quantifies ossification of the _____ Grades 0 = no ossification 1 to 4 = ossification (25% to 100%) 5 = skeletal maturity. Grades 0, 1, and 2 = highest risk for curve progression 3 = lower risk b/c progressing skeletal maturity 4 = lower risk b/c near end of spinal growth 5 = least risk b/c of skeletal maturity
iliac crest
Radiographs - Standing radiographs - two initial views ____ and Anterior-Posterior (A/P) - determine location, type, and magnitude of the curve, A/P view - monitor skeletal age over time
lateral
What views do we take for scoliosis?
lateral and A/P
Anterior convexity (or a posterior concavity) of a segment of spine is termed a ____
lordosis
____ types - Spondylolysis and Spondylolisthesis
lordosis
Scoliosis grade increases as child ____ (we want them to reach that skeletal maturity)
matures
How long may the program be for Schroth school?
may be up to 3 months
associated with systemic or chronic diseases and often has a rapid progression what type of scoliosis?
neuromuscular scoliosis
curves tend to progress more rapidly and to have more disabling outcomes such as decreased ability to sit, diminished hand function, respiratory compromise due to intercostal muscle weakness and decreased lung capacity and are highly associated with pelvic obliquity. what type of scoliosis?
neuromuscular scoliosis
Monitor _____ curves during growth because - may develop into structural deformities
nonstructural
_____ curve is usually nonprogressive
nonstructural
Most often caused by a shortened lower extremity on the side of the apex of the curve
nonstructural curve
fully corrects clinically and radiographically on lateral bend toward the apex of the curve and lacks vertebral rotation
nonstructural curve
Two major types of curvatures?
nonstructural curve structural curve
Cobbs angle - to measure spinal curvature Identify the end vertebrae 1. Most cephalad vertebra of a curve whose upper surface maximally tilts toward the curve's concavity 2. And the most caudal vertebra with maximal tilt toward the convexity. 3. Lines are drawn as extensions of the end vertebrae from end plate or ____. 4. The degree of curvature is measured as the angle formed by the intersection of lines perpendicular to these end vertebral lines
pedicles
The degree of curvature is measured as the angle formed by the intersection of lines ____ to these end vertebral lines
perpendicular
Orthotics - shell with customized ____ and ____
relief and padding
Recommendation for the treating therapist for Schroth method - incorporate exercises including spinal stabilization, balance activities, core strengthening, and postural correction, including lateral shifts, flexibility exercises, and _____ activities into the plan of care.
respiratory
_____ - determine skeletal maturity
risser sign
Important to note - _____ method is copyrighted and certification is required
schroth
_______ - affect postural control one must first change his postural perception. Incorporates ADLs training to prevent loss of postural control throughout daily activities.
schroth school
Congenital lordosis = bilateral posterior failure of ______
segmentation
_____ are segmental axial structures of vertebrate embryos that give rise to vertebral column, ribs, skeletal muscles, and subcutaneous tissues.
somites
Surgical = ____
spinal fusion
Scoliometer - measures rib hump with the forward bend test Placed over the ____ at the apex of the curve to measure the angle of trunk rotation (ATR). ATR correlates with the severity of the scoliosis. Minimal measurement of at least 5° by the scoliometer is considered a good criterion for identifying lateral curvatures of the spine with Cobb angles of 20° or greater. Scoliometer reading of 5° or greater warrants further evaluation and is an indication for a radiograph.
spinous process
A fixed thoracic prominence or rib hump in a child with a thoracic deformity or a lumbar paraspinal prominence in a child with a lumbar curve is evidence of rotation when observed on clinical examination
structural curve
Cannot be voluntarily, passively, or forcibly fully corrected
structural curve
Rotation of the vertebrae is toward the convexity of the curve
structural curve
Surgical - Ideal correction system - correction in all ____ planes of the scoliosis, provide rigid fixation, and maximal correction with minimal fusion levels
three
Serial casting - Child is on a frame with ____ when casting is done
traction
Home exercise program (HEP) - for Idiopathic and congenital scoliosis maintain or improve ____ and ____ strength and flexibility Spinal stabilization, balance activities, core strengthening, and postural correction, including lateral shifts, flexibility exercises, and respiratory activities. Some protocols - Patient may be instructed to actively corrects posture with a goal of maximal curve correction and follows a specific exercise program designed to increase spinal stability, improve balance reactions, and retain physiologic sagittal spinal curvatures.
trunk and pelvic
Post - operative Interventions for Idiopathic and congenital scoliosis - Acute postoperative phase includes instruction in body mechanics for bed mobility, transfers, dressing, and ambulation. Avoid ______ - instruct patient in log-rolling and transitioning from a supine position to sitting without rotation. Shoes and socks are donned or removed with the legs in a "figure four" seated position with negligible forward flexion - neither lower extremity exceeds hip flexion greater than 90° PT may instruct patient in donning or removing the orthosis while in bed, moving side-lying to a supine, or while standing with assistance (with MD clearance) Patient instructed in general ROM & strengthening exercises Guidance on return to ADL's, sports, etc - dependent on fusion, healing, and MD clearance PT provides exercise, mobility training, education and resources as indicated
trunk rotation
Are there surgical and non-surgical interventions for neuromuscular scoliosis?
yes
Is there surgical and non-surgical interventions for kyphosis?
yes