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????