Adolescent Idiopathic Scoliosis

Consistent PT findings with patients with scoliosis

Consistent findings: Strength of trunk rotation is weaker to one side compared with contralateral Inhibition of paraspinal musculature Normal adolescents of the same age w/o AIS have equal rotation/parapsinal EMG activation patterns bilaterally

Explain scoliosis curve progression

Curve progression depends on Curve size and Risser sign Curves < 20 degrees that are Risser type 0-1: 22% progress Curves <20 degrees that are ≥ Risser 2: 1.6% progression Curves 20-30 degrees that are Risser 0-1: 68% progression Curves 20-30 degrees that are ≥ Risser 2: 22% progression Curves > 50 deg and Risser 4-5, will continue to progress over time Lead to progressive deterioration and can lead to decreased lung capacity -> restrictive lung disease Incidence of back pain is similar to general population

Indications for surgery with scoliosis

Curves > 50 deg in skeletally mature patients Curves progressed > 40 deg in skeletally mature patients Curves > 30 deg w/marked rotation Double major curves > 30 deg

Factors that influence treatment of scoliosis

Depends on kind and degree of the curve, child's age, number of years until the child reaches skeletal maturity

symptoms of scoliosis

Generally does not result in pain, respiratory problems or neurologic symptoms unless very severe Concern over cosmetic appearance Possible increase in low back pain -Especially in very active adolescents with poor core control Very severe curves (>90 degrees) may cause respiratory compromise, compression on thoracic organs

Describe the King system

King System Type I: primary lumbar and secondary thoracic curves Type II: primary thoracic and secondary lumbar curves Type III: thoracic curves only Type IV: large thoracic cures extending into the lumbar spine Type V: double thoracic curves Reliability issues with King System

Describe the Risser classification

Risser Classification - grades remaining skeletal growth based on ossification of the iliac epiphysis Type I: ossification of lateral 25% Type II: ossification of lateral 50% Type III: ossification of lateral 75% Type IV: complete excursion Growth in females is usually complete here Type V: fusion to the ilium

CAUSES OF IAS

Role of genetics has been debated Family history is not helpful in determining curve magnitude Possibly a polygenic inheritance pattern Possibly asymmetry in the brain stem that affects proprioceptive system and equilibrium imbalances

Gold standard for diagnosis of scoliosis

x-ray

Curves >20 degrees 7:1 female to male ratio Curves >30 degrees 10:1 female to male ratio

yup

Only __% of adolescents diagnosed require medical intervention

10%

Scale for Cobb angle in determining severity of scoliosis

Cobb angle Mild: 10-20 deg Moderate: 20-45/50 deg Severe >45/50 deg

Prevalence of AIS in 10-16 year olds:

2-3%

Scoliosis screening recommendations

American Academy of Orthopedic Surgeons Girls twice: ages 11 and 13 years Boys once: age 13 or 14 American Academy of Pediatrics Adam's Test routine health visits at ages 10, 12, 14 and 16 Society on Spinal Orthopaedic and Rehabilitation Treatment (SOSORT): "screening is vitally important, but we do not want to screen out a whole bunch of people who don't need medical attention because it's very costly; we're not looking for the cheapest way to screen - we're looking for a better quality outcome for our patients"

___% of scoliosis cases are idiopathic

80-85%

What are the 3 main types of braces

Boston Brace Milwaukee Brace Charleston Brace

Key components of bracing

Bracing: Must be changed every 12-18 months; depending on growth and body changes Most effective when worn 23 hours a day until skeletal maturity is achieved The more the brace is worn, the better the outcome Primary corrective force: lateral Reduction in hyperlordosis is also needed to reduce the curve

Indications for bracing for scoliosis

Bracing: prevent curves from worsening Curves < 30 deg that progress 5 deg or more over 12 months should be braced Curves > 30 deg, bracing should be initiated immediately NOT indicated in skeletal mature patients Curves WITHOUT severe lumbar hyperlordosis, thoracic lordosis or hyperkyphosis respond best to bracing

Signs of scoliosis

Change in shoulder height Leg length discrepancy Abnormal neurological findings? Only when severe Lateral shift of rib cage Adam's Test

surgical procedures and outcomes

Implantation made up of rods, hooks, screws and or wires are used -Bone graft from bone bank or hip may also be utilized Usually walking by 2nd day; discharged in 1 week; resume ADLs Return to sporting activities in 6-9 months But due to limitation of the spine after surgery, high impact sports are discouraged

PT roles in scoliosis

Important for screening, training screeners, oversee pre-op and post-op conditioning progress as well as progression in rehab programs Pain management, either before or after bracing and or surgery

What muscles tend to be weak in scoliosis

In scoliosis, muscles to the contralateral side tend to be weak (opposite side to rib hump)

Describe lateral electric stimulation (Les)

Lateral Electrical Stimulation (LES) Combined with or without bracing shows to be ineffective Small amounts of data in the literature regarding use but the theory is to increase the strength on the opposite side of the curve to improve muscular strength and stability to the curvature Low quality studies show no effect/benefit; one high quality study demonstrated combo of exercise and LES to be insignificant in the control and study groups

conclusion regarding exercise in patients with scoliosis

Machine-based exercise training in which progressive loads are gradual and measurable is effective in: Reducing/stopping progression of spinal curvature Reducing strength asymmetries Improving strength

Describe Adam's test

Patient bends forward with arms dangling, feet together with the knees straight Structural Scoliosis Curve is more apparent with forward bending May observe rib hump Measure with Flexicurve, rulers Referred to as "angle of trunk rotation (ATR)" Functional Scoliosis The curve and rotatory components will resolve

Predictive validity of scoliosis screening

Predictive validity questioned PPV relatively low Every curve > 10 deg detected, 1-5 false positives Every curve > 20 deg detected, 3-24 false positive

Describe the differences in the types of braces

QOL scores are higher with the milwaukee and Boston Brace!!! Boston brace appears more effective for preventing curves from progressing Surgical rates are 50% more likely with the charleston brace Milwaukee brace best for curves with an apex at or above T7 (has a cervical component)

T/F Scoliosis usually includes a rotatory component

True

describe the Lenke System

Uses three components: curve type, lumbar spine modifiers and sagittal thoracic modifiers to determine surgical intervention treatments Every aspect of the curve is also evaluated for relative stiffness or flexibility on SB x-rays More reliable than King

What can be expected from surgery

What can be expected from Surgery? Reduces major coronal curve by ~50%, vertebral rotation by 10% and apical translation by ~60%