The SOSORT Educational Committee

Presents:

Adult Scoliosis (AS) Rehabilitation:

Select Case Histories

Illustrating Treatment

Options for Adults with Scoliosis and

Related Complexities

ELENA SALVÀ INSTITUT

BARCELONA, SPAIN

Today’s Objectives

Discuss favorable adult outcomes

using 2 published case reports and 4

pending case histories in order to

1. Stimulate AS treatment innovation

2. Assist clinicians in setting and

meeting functional AS therapy goals

3. Create ideas for larger AS studies

Today’s Objectives

Taking a patient perspective

1. How can you change my life?

(Why should I see you and pay you for what you do?)

2. What good treatment options are available?

3. How will you decide on what treatment is right for me?

AS - Select Case Histories“What changes can you make in my life?”

• Radiologically:

– Cobb and rotation

– Segmental listhesis

• Posturally:

– Sagittal, frontal and rotational imbalance

• Functionally:

– Pain, disability, and quality of life

– Respiratory dysfunction

AS - Select Case Histories “What good treatment options are available?”

• Osteopathic/manual therapy

• Scoliosis-specific exercises (Schroth, Barcelona School, SEAS)

• Additional orthopedic exercises based upon objective clinical findings

• SI joint stabilization belts

• Shoe lifts for radiologically measured leg length discrepancy

• Scoliosis bracing

AS - Select Case Histories“How will you decide what’s right for me?”

• Exam: Exams should balance comprehensive clinical and radiological findings

• Goals: Goals should be patient-specific and functional

• Strategies: Scoliosis and non-scoliosis treatment should be targeted at improving key findings

• Evidence: Evidence-based medicine should be used along with innovative ideas founded on sound clinical judgment

• Outcomes: Outcomes should be measured using objective and reliable tools

Painful adult scoliosis with kyphosis evolution and sagittal anterior trunk imbalance treated with physical therapy techniques: a case report (Scoliosis2009) Villagrasa M, Rigo M, Quera-Salvá G, Ferrer M, Pou E.

Case 1: Question: Can you improve my

pain, rotary listhesis, and trunk deformity?

Treatment Provided (4 months):

Osteopathic manual therapy and BSRS exercises

ELENA SALVÀ INSTITUT

BARCELONA, SPAIN

Case 1 Results:2006

Pre -

Admission

2008 March

Admission

2008 July

After 4 mos

treatment

2009

At 1 yr f/u

Lumbar Cobb 63 NT 66 61

Rotation:

at apex (L2)

47

(Raymondi)

NT NT 35

(Raymondi)

Rotation:

at listhesis (L3)

31

(Raymondi)

NT NT 25

(Raymondi)

Formetric

trunk imbalance

NT 46.2 21.5 NT

Formetric

lateral deviation

NT 34.2 19.3 NT

Formetric

surface rotation

NT 14.9 10.3 NT

Pain Present Absent

ELENA SALVÀ INSTITUT

BARCELONA, SPAIN

Surface rotation

14.9º

Trunk imbalance

46.2 mm

Lateral deviation

34.2 mm

Surface rotation

10.3º

Trunk imbalance

21.5 mm

Lateral deviation

19.3 mm

Case 1 Results: Improved trunk position

March 2008 July 2008

ELENA SALVÀ INSTITUT

BARCELONA, SPAIN

2006

61ºC

10/2009

25º^R

at vertebra of

max listhesis

63ºC

2006

31º^R

at vertebra of

max listhesis

47º^R

apex

35º^R

apex

2009

Case 1 Results: Rotation Reduction

ELENA SALVÀ INSTITUT

BARCELONA, SPAIN

Case 2 Question: Can you reduce my Cobb

that has progressed during my adulthood?

Adult scoliosis can be reduced through specific SEAS

exercises: a case report. (Scoliosis 2008)

Alessandra Negrini, Silvana Parzini , Maria Gabriella Negrini

Michele Romano, Salvatore Atanasio , Fabio Zaina, Stefano

Negrini

Treatment Provided (one year):

SEAS (Scientific Exercise Approach to Scoliosis) for 30

min/day at home; clinic sessions every 2 months

Case 2 Results: Cobb Reduction

14 yrs old 19 yrs old 20 yrs old 25 yrs old 26 yrs old

Treatment Diagnosed Age 14-19:

Risser cast

and brace

Age 19-20:

None

Age 20-

25:

None

Age 25-

26:

SEAS

Thoracic

Cobb

35 37 32 35 32

Lumbar

Cobb

45 36 38 47 28

Case 2 Results: Cobb Reduction

Age 25

Cobb 35 and 47

Age 19

Cobb 37 and 36

Age 20

Cobb 32 and 38

Age 14

Cobb 35 and 45

One year f/u

Cobb 32 and 28

This case shows that when adult scoliosis progresses, specific exercises can help not just to get stability, but to recover previous years’ collapse. The reduction of scoliotic curve through rehabilitation presumably does not indicate a reduction of thedeformity, but recovers the upright postural collapse.

Case 3 Question: Can you improve my pain

and disability and lessen my recurring rib

fractures?

Ongoing Case: 72 y.o. with severe Cobb progressed 27

degrees in 4 years (current Cobb 97 deg), reporting

progressive disability and recurring rib fractures. Cindy Marti, Meg Gogin, Patrick Flanagan

Treatment Provided (9 months):

• Initial 3 weeks: Kinesio-tape for subacute rib fx (2/wk)

• At 1 month: Custom TLSO (worn 2 hrs daily)

• At 3 months: Schroth modified exercise (in clinic 1/wk x 3

months; ongoing at home 3-5 x week x 9 mos)

• Ongoing Massage Therapy: 1 x wk x 9 mos

Case 3 - Relevant History

2004

Pre-admission

Cobb 70 deg

2009

Admission - Cobb 97 deg

Treatment:

TLSO

Treatment:

Modified

Schroth

Case 3 Results: Short term reduction in

pain and disability without rib fracture

2009 – April

Admission

2010 – March

1 year follow up

Disability (Oswestry) 48% 36%

Pain (VAS) 8/10 3/10

Max. ambulation time 10 min 30 min

Max stance time 10 min 1 hr

Rib Fracture 2001, 2005, 2009 None to date

Case 3 Results: Improved Torso Shape

Admission 9 months Admission 9 months

Case 4 Question: Can you improve my

chronic pain and shortness of breath?

Ongoing Case: 47 y.o. with stable scoliosis (36 deg Th / 32 L),

reporting 20 year hx of worsening pain and SOB. Cindy Marti

Treatment Provided (4 months):

• Manual therapy (11 sessions): Soft tissue mobilization to

restrictions found in C-TH-L spine and diaphragm; joint

mobilization to restrictions found in C-TH-L spine and SIJ

• Schroth exercise (9 sessions)

• Adjunct: SIJ stability belt, ultrasound to hypomobile spinal

facets, scapular retraction taping for convex thoracic

shoulder, ergonomic assessment of work station

Case 4 Results: Improvements in

pain, disability, and respiration March 2009

Admission

June 2009

Discharge

March 2010

f/u at 9 mos

Pain (VAS) Worst 8/10

Least 2/10

Worst 3/10

Least 0/10

Worst 3/10

Least 0/10

SOB frequency Daily Weekly Resolved

Disability (Oswestry) 18% 9% NT

Chest wall circumference

(exhale to inhale)

Axilla

Xyphoid

12th rib

3 cm

1.5 cm

2.5 cm

3 cm

3.5 cm

3.0 cm

NT

NT

NT

NT

Case 5 Question: Can you lessen my pain

and improve my function even though I had

AIS spinal fusion over 20 years ago?

Ongoing Case: 47 y.o. with chronic unilateral (R) SIJ pain

and undiagnosed LLD (PMH: Surgical fusion thoracic, auto-

fusion lumbar, bilateral THA/TKA, failed past PT) Cindy Marti

Treatment Provided (Weekly for 2 months - 8 total visits):

• Supine CT for LLD: detected (R) leg 14 mm long

• Assistive devices: SIJ stability belt; 12 mm lift in left shoe

• Manual therapy: joint mobilization to hypomobile right hip

and SIJ

• Exercise: Daily home program for deficits found in right

hip/SIJ mobility and strength

Case 5 Results: Dramatically improved

pain and disability

Jan 2010

Admission

March 2010

Discharge

Disability

(Oswestry)

46% 6% (WOW!)

Pain (VAS) 10/10 worst

0/10 least

3/10 worst (WOW!)

0/10 least

Lumbar Cobb 53 deg (no heel lift) 53 deg (with 12 mm

heel lift in left shoe)

Case 5 ResultsDec 2009

No shoe lift

Dec 2009

No shoe lift

April 2010

12 mm left shoe lift

April 2010

12 mm left shoe lift

Case 6 Question: Can you stabilize my

progressive degenerative scoliosis and

lessen my pain and disability?

Current Case: 65 y.o. with progressive degenerative AS and

pain. Cindy Marti, Patrick Knott

Treatment Provided:

• 5 day intensive Schroth program – 4 hrs/day

• Daily home Schroth – 30 min/day for 4 months

• One refresher visit at 4 months

Case 6 Results: Short term stability and

improved pain and disability

2003

Pre-admit

2006

Pre-admit

2009

Admit

2010

4 mo f/u

Cobb L2 Apex 40 deg 46 50 52

Lateral Listhesis L2 15 mm 15 mm

ATR NT NT 14 deg 10 deg

Oswestry (ODI) NT NT 18% 6%

Pain (VAS) NT NT 7/10 worst

0/10 least

1/10 worst

0/10 least

Case 6 Results: Short term radiological

stability in Cobb and listhesis

2004 Pre-admit

Cobb 40 (L1)

2006 Pre-admit

Cobb 46 (L1)

2009 Dec - Admit

Cobb 50 (L1)

Listhesis 15 mm (L2)

2010 April f/u

Cobb 52 (L1)

Listhesis 15 mm

Case 6 Results: Immediate improved torso

shape with partial retention at 4 mos

Dec 2009

Admission

April 2009

4 mo Follow up

Dec 2009 - after 5 day

Intensive Schroth

Acknowledged limitations

• Not a scientific session…

– educational focused

• Variety of interventions…

– while clinically appropriate for selected

patients, make for challenging large

sample research

AS – Select Case Histories

Closing Comments

We sincerely hope these promising outcomes will

help you more effectively treat your patients and

plant seeds that will bloom into larger studies -

creating exciting evidence to support viable

options for adults with scoliosis.

Thank you - on behalf of the

SOSORT Educational Committee

ELENA SALVÀ INSTITUT

BARCELONA, SPAIN