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A general term used to describe a lateral curvature of the spine p Most often develops on childhood Can occur on cervical thoracic or lumbar vertebra
1. 2. 3. 3 4. 5. 5 6. Structural vs. Non Structural According to the direction of curves Major vs. minor curve Major vs minor curve According to the shape of the curve According to the severity of the curve According to the severity of the curve According to etiology
STRUCTURAL • vertebral bodies rotates towards convex spinous process rotates towards concave Irreversible lateral curvature with fixed rotation of vertebrae. (+) rotation of p vertebrae; apex: greatest
NON STRUCTURAL (functional scoliosis) g • No change of structure Positional or dynamic in y nature Reversible
( ) (+) rib hump (p p (posterior (-) rib hump () p rib hump) (+) bony deformity (+) progressive (-) corrected by positioning or voluntary efforts (-) ( ) bony deformity (-) progression (+) correction forward bending/ lateral bending positional changes side bending muscle contraction
NOTE: Forward bending of trunk produces posterior rib hump on convex side (thoracic region) due to rotation of vertebra & rib cage (prominence of scapula) scapula).
CONCAVE Shortened Muscle & ligaments are contracted Thoracic: Th i • Spinous process • Compression of ribs • Prominence of rib cage anteriorly
CONVEX Lengthened Muscle & ligaments are stretched • Vertebral body • Separation of ribs • Prominence of rib hump and scapula posteriorly • Disc space widens • Pedicle in anteroposterior direction
CONCAVE • Disc space narrow – lateral displacement of nucleus pulposus. Wedging of vertebral body on concave part of curve 2 2º pressure on epiphyseal plate. Most especially seen on >25º curve >25 curve. • Pedicle more transverse
CONCAVE Lumbar: L b Prominence of ES muscle l
Neck & Shoulder: Neck angle decrease Rib flatten Shoulder decrease
Neck angle increases Bulging of ribs Shoulder increased
NOTE: Direction of the curve is always identified by the convexity ® thoracic scoliosis – convexity is on right (L) thoracic scoliosis – convexity is on left
MAJOR primary •primary curve; most significant •most significantly most occurs in thoracic region
MINOR Less •Less severe – may develop on the opposite direction of the major curve on either above or below the major curve. curve •Compensatory curve – structural or non structural
(+) structural / non structural
(+) structural Primary curve Pi Idiopathic scoliosis: right li i i ht thoracic T4 –T12
(+) structural / non structural Found b l F d below or above th b the major curve Compensated – shoulders & C t d h ld hips are leveled Decompensated/ D t d/ uncompensated – when sum of degrees of the fd f th compensatory curve does not equal the degrees of d f l th d f deformity it of major curve. (+) listing ( ) li ti shoulders not leveled
C-CURVE • hi h shoulder on high h ld convex; high pelvis on concave. From thoracic to lumbar
S-CURVE • most commonly seen l in idiopathic scoliosis • Usually right thoracic curve & left lumbar curve
Uncompensated/Decom Compensated pensated
Double Major curve – has 2 major curve of q y g ; equal severity & significance; Both structural Transitional vertebra – makes transition from one curve to another Neutral vertebra – least rotated vertebra Apical vertebra – most rotated vertebra
Severity of scoliosis is determined by the y y angle of curvature The greater the rotation of vertebra; the more severe the lateral curvature The more severe the curve; the greater the affectation on cardiopulmonary affectation Decrease vital capacity & total lung capacity Hypertrophy of the ® ventricle & atrium from pulmonary h f l hypertension t i
X –ray measurement
most commonly used; more reliable a line is drawn perpendicular to the upper margin of the vertebra that inclines most toward the concavity. A line is also drawn on the inferior border of the lower vertebra with greatest angulation toward the concavity. The angle of these transecting lines is noted & recorded
Risser Ferguson method
look for 3 vertebra: uppermost, apical, and lowermost
Nash Moe method
Normally pedicles are symmetrical positioned on either side of each spinous process Grading: 0 – no vertebral rotation + & ++ - mild or minimal rotation +++ - moderate rotation ++++ - severe rotation
SEVERITY Mild Moderate
CURVE < 20º 20º- 40º
MANAGEMENT Observe; exercise Structural changes Brace; exercise Brace & surgery Pain & DJD Cardiopulmonary affectation Decrease life expectancy
40 50 40º - 50º 40º > 60 70 60º - 70º
NOTE: Curves < 10º - WNL – no tx.
Etiology of Structural Scoliosis:
1. Idiopathic – unknown/ most common classification – idiopathic adolescent scoliosis p Age of onset Adolescent – most common type. Young yp g girls age 10-15 g Juvenile – occurs between ages 4 & 9. seen often in girls Infantile – from birth to age 3. seen often in g boys
Causes Causes: 1. Bone malformation during development y 2. Asymmetric muscle weakness 3. Abnormal distribution of muscle spindle in p paraspinal muscles p 2. 2 Neuromuscular – 15-20% 15 20% Neuropathic causes – problem in CNS. CP, Polio Myopathic causes – problem is on muscles Muscular dystrophy
3. 3 Osteopathic – problem in bones Hemivertebra, osteomalacia, rickets, fracture, dislocation of spine Etiology of Non Structural Scoliosis: 1. LLD 2. Spasm in back muscles 3. Habitual asymmetric postures
1. 2. 3. 4. 5. 6.
Factors affecting Decision making to initiate Treatment Etiology yp Type Location y Severity Age p g Rate of progression
Postural assessment – plumb line – C7 C7gluteal cleft (S2) The following deviation are often noted: Asymmetric shoulder level Prominence of the scapula on the side of the convexity Protrusion of the hip in one side Pelvic obliquity Increased lumbar lordosis
Lateral bend test – done to determine whether the curve corrects or reverses as the pt. side bends towards the convex side of the curve. curve Asymmetric side bending is an early sign that the structural changes may have begun to develop in the spine Forward bending test – done to determine whether the curve straightens out as the pt. bends forward and to identify a visible, rotational deformity of the rib cage. MMT
Non-Operative treatment of Scoliosis 1. Exercises 2. Cast 3. Traction 4. Spinal bracing 5. ES Sites of curves: Cervical: C1-C6 Thoracic: T2-T12 T2 T12 Cervico Thoracic: C7-T1 Lumbar: L1 & L4 Lumbo Sacral: L5 or below
Exercise in scoliosis:
1. exercise alone will not prevent progression of a scoliotic spine nor will correct an existing scoliosis 2. exercise has been traditionally been used to stretch tight trunk and hip muscles/ strengthen t t h ti ht t k d hi l / t th muscle of the trunk 3. 3 exercise may be beneficial as tx for pt with mild pt. idiopathic scoliosis 4. 4 exercise will not alone halt the progression of or correct an existing moderate or severe scoliosis 5. exercise is used in conjunction with other methods such as braces, cast, etc.
Exercise with Milwaukee brace: Goals: to strengthen the muscle that provides stabilization to the trunk Decrease or correct spinal curves NOTE: j y pads The objective is to move away from the p that are inside the brace. Treatment is geared towards stretching of the CONCAVE side and strengthening of the g g CONVEX side
For C curve scoliosis:
Done with the pt. in quadruped position. Done by initially crossing the UE along the concave side towards the convex side, followed by the advancement of the contralateral LE. Cycle repeats until the pt. completes one whole round within the mat mat.
EXAMPLE: Pt. has C-curve dextroscoliosis Pt. assumes quadruped position. Crosses the (L) UE towards ® UE then hold that position for 15-30 sec. Followed by crossing of the ® LE being crossed over the (L) LE hold for 15-30 sec. This followed by crossing over the ® UE over the (L) UE…hold…then lastly…cross over the (L) LE over th ® LE C l repeats the LE. Cycle t
for S-curve scoliosis:
Ambling A bli walk lk
pt. in quadruped position. Advance the UE g y along the concave side followed by advancing by the ipsilateral LE. hold is y maintained after each extremity has been advanced
Done i reference t the apex of the curve. D in f to th f th Emphasis is placed on exercise designed for f maximum straightening of the pathologic i t i ht i f th th l i curves whatever their site, direction, & magnitude it d
T3 - sala position (lowered)
T6 – on elbows (semi-lowered) ( )
T8 – on hands Horizontal quadruped)
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T11 – fingertips (semi straightened)
L4 – reversed position (reversed erect)
L2 – erect k t kneeling pos’n (erect) li ’ ( t)
Dry Swimming exercise
Beginner s Beginner’s exercise Decrease static works of spinal muscles
1. 2. 3. 3 4. 5. 5 6.
In prone position prone (B) UE on the sides of the body prone; (B) UE abducted to 45º 45 prone; (B) UE in reverse T pos’n prone; (B) UE flying V prone; (B) UE crossed against the nape area
General instruction: As pt. assumes the pos’n: pt. lift t k off th mat & rotate th ’ t lifts trunk ff the t t t the trunk towards the convex side. 15-30 SH.
CAT & CAMEL Designed to increase and improve flexibility f h fl ibili of the spine i CAT exercise – performed by increasing thoracic kyphosis CAMEL exercise – performed by increasing lumbar lordosis
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