Scoliosis

Submitted by:
Adela, John Conrad
Cuenco, Jeni-Yen D.
Mallari, Jemmalyn
Pamintuan, Katrina Louisse
Rivera, Adrian Miguel
Sanchez, Marielle
Supan, Millen
Trinidad, Katrina
Zapanta, Jannela

Submitted to:
Mr. Marvey Velasquez PTRP
Ms. Giannella Aleckz Argao PTRP

PT SEMINAR
Case: A 14-year-old girl together with her mother came to the clinic with complaints of back pain
and difficulties with everyday activities such as sustained walking and standing, as well as lifting
and picking up objects from the floor. Her back pain is absent at rest but exacerbated when
playing volleyball. Because of this the patient demonstrates decreased athletic performance. It
can be observed that her (R) shoulder is higher and presents with uneven waistline. When she
attempts to bend forward, there is a lump on her back prominent on the right side. The radiologic
evaluation of her spine x-ray showed a R thoracic lateral curve of 40° with apex at T8 level.
Neurological assessment appears to be normal. She was diagnosed with Adolescent Idiopathic
Dextroscoliosis.

GENERAL INFORMATION
Name: Barbie Forteza
Age: 14 years old
Gender: Sapang Bato Angeles City, Pampanga
Civil status: Single
Occupation: Student
Religion: Catholic
Nationality: Filipino
Referring Dr.: Dr. Derek Shepherd
Rehab dr: None
Date of consultation: October 13, 2020
Date of referral: October 15, 2020
Date of IE: October 15, 2020
Diagnosis: Dextroscoliosis

HISTORY OF PRESENT ILLNESS:

A mother of a 14-year-old girl decided to bring her daughter to the hospital to seek
medical help last Oct.13, 2020, when she had observed vast changes in the pt’s posture such as
uneven shoulder and waist as well as a visible curve on her back. The pt’s main complaint is pain
on the upper back that interferes with her day-to-day activities for at least 6wks now. The pain
worsens when she stands and walks for long periods of time and when she plays volleyball. This
greatly affected her athletic performance. Only at rest when the pain somehow decreases. She
also reported that gardening with her mom is one of the hobbies that the pt. enjoys, however
lately the pt. had difficulty lifting and picking gardening tools and materials from the ground and
when she did so, a prominent bump on her right upper back can be observed. She then was
advised to have her back checked through x-ray the next day. The radiograph results revealed a
right lateral curve on thoracic region with a Cobb angle of 40 degrees and apex at T8. She was
diagnosed with Moderate Thoracic Dextroscoliosis and referred to PT clinic to benefit from PT
rehab.

ANCILLARY PROCEDURE

DATE/TIME PROCEDURE RESULT

October 14, 2020 X-Ray of the Spine; Cobb (+) 40 degrees AIS Thoracic
method Dextroscoliosis; Apex: T8

DRUG HISTORY

Medications Duration Dosage Indication

Ibuprofen As needed 200-400mg Back pain relief

for pain or 4
to 6 hours

PAST MEDICAL HISTORY

(-) Previous hospitalization
(-) HTN
(-) Cardiovascular Dse
(-) DM
(-) Surgery
(-) Trauma
(-) Lung Dse
(-) Allergies
(-) Seizures
(-) Other Conditions

FAMILY MEDICAL HISTORY

CONDITION MOTHER SIDE FATHER SIDE

Cancer (-) (-)

Heart Disease (-) (-)

Lung Disease (-) (-)

Stroke/TIA (-) (-)

Diabetes Mellitus (-) (-)

Hypertension (+) (-)

Myocardial Infarction / Coronary (-) (-)

Artery Bypass Surgery

Findings: Pt. mother reports having family hx of HTN

Significance: No significance of mothers genetic familial factors affecting the Pt. condition

PERSONAL, SOCIAL, ENVIRONMENTAL HISTORY

● Personality: Type A; outgoing person
● Lifestyle: Active
● Hobbies: Volleyball, gardening, running
● Level of Education: Current grade 8 student
● Religion: Catholic
● Type of house: Lives with her parents in a two-storey house

SUBJECTIVE:
● C/C: Pt. Reports, “Masakit po likod ko and nahihirapan po akong tumayo at maglakad ng
maayos kapag malayo na nalalakad, pati na rin sa pagbibihis ng damit at kapag yumuyuko
po ako nahihirapan ako dahil sumasaket po likod ko. I noticed din po na kapag naglalaro
ako volleyball lalo sumasaket. Nawawala lang po kapag nakapahinga ako.”

● PT TRANSLATION:
Pt. came to the clinic referred by a doctor. Pt. complains of dull and diffused back pain
(PS 4-5/10) in the thoracic region, w/c is aggravated when standing for a long period and
when walking long distances. Pt. also reports difficulty in ADLs d/t back pain and is
relieved at rest.

● PATIENT’S GOAL: “Ayoko na nang may nararamdamang sakit kaya’t, gusto ko nang maalis
ang aking bump sa likod para makapag laro na po ako ng volleyball pati rin po makapag-
garden nang maayos. Gusto ko din po na maging independent na kahit sa simpleng
pagsuot lang ng mga damit at paggamit ng CR ay di ko na maabala yung nanay ko.”

● PT TRANSLATION:
 The Pt. aims to reduce her back pain and to get rid of the curve on her back so that she
will be able to play volleyball and do her IADLs (gardening) normally again. The Pt. also
aims to ↑ independence in ADLs such as dressing and bathing.

● PRIOR LEVEL OF FUNCTION: Pt. can play Volleyball 1-3 hrs. a day with breaks. 3-4x a wk.
Pt. can garden w/ mother for 1-2 hrs. a day 3x a wk. s̅ experiencing pain on her back. Pt.
is able to do ADLs (UE & LE dressing, bathing) s̅ supervision

OBJECTIVE

I. Vital Signs
● Blood pressure: Pt. seated, (L) UE 115/75 mmHg, Normal
● Pulse rate: ® Radial artery: 86 bpm, normal & regular
● Respiratory rate: (seated): 16 breaths/min, regular, eupnea

II. Systems Review

Cardiovascular/ Pulmonary system: unimpaired. BP 115/75. Pulse rate 86 bpm. RR 16
breaths/min. Pt. exhibits (-) SOB and chest pain symptoms at rest and during functional
activities. Integumentary system: unimpaired. Musculoskeletal system: Height: 159.6 cm
Weight: 45.8 kg Gross symmetry: impaired Gross ROM: impaired. Thoracolumbar lateral
flexion and spinal rotation presents LOM. (B) hip abduction and ® hip adduction presents
tightness. Gross strength: weakness on trunk rotators, lateral flexors, hip abductors, and
adductors. Locomotion: impaired. Pt. presents difficulty in ambulation as well as
performing ADLs and transfers. Neuromuscular system: Gait impaired. Slight dec. stride
length, step length, and gait speed on the affected side. Balance: unimpaired. Motor
function: unimpaired. Communication: unimpaired. Affects: behavioural/ emotional
unimpaired. Cognition: unimpaired. Learning Barriers: none. Pt. best learns: Positive
feedback & reward system. Educational needs: Pt. will learn to manage postural training
and plan daily activities in accordance with the priority to enable Pt. to do activities
without the recurrence of back pain and gradually play volleyball.

III. Test and Measures

Amb: indep. S AD. Transfers: sit↔️stand, supine ↔ sit, bed mobility, grooming &
eating activities are presented to be indep. UE & LEs: LOM and dec. strength on LE is
detected. Aerobic capacity & endurance: Vital signs at rest: BP 115/75. Pulse rate 86 bpm.
RR 16 breaths/min.
 IV. OI
● Ambulatory s AD
● Alert/ Coherent/ Cooperative
● Mesomorph
● (+) Postural deviation (see PA)
● (+) Gait deviation (see GA)
● (-) Attachment
● (-) Atrophy
● (-) Ecchymosis
● (-) Scars
● (-) Wounds

V. Palpation
● Normothermic on all exposed body parts
● (+) Muscle Tightness on (L) trunk muscles
● (+) Muscle Spasm on (L) trunk muscles
● (-) Crepitus
● (-) Dislocation
● (-) Edema
● (-) Swelling
● (-) Tenderness

VI. ROM
Equipment used: Goniometer
All joints were actively and passively measured and WNL, except for the following:

DIFFEREN DIFFERENC END FEEL (N)

MOTION ACTIVE PASSIVE (N) CES ES END
(ACTIVE) (PASSIVE) FEEL
R L R L R L R L R L
Thoracolumbar 0-23° 0- 0° - 0° -
Spine (painful 32° 24° 34° 0° - 12° 3° 11° 1° Empty Firm Firm
Lateral Flexion upon (painful 35°
motion) upon
motion
)
Thoracolumbar 0° - 32° 0° - 0° - 0° - 0° -
Spine (painful 39° 33° 42° 45° 13° 6° 12° 3° Empty Hard Hard
Rotation upon (painful
motion) upon
 motion
)

Trunk Flexion 0-70°

(painful upon 0-75° 0-80° 10° 5° Empty Firm Firm
motion)
Hip Abduction 0° - 36° 0° - 0° - 38° 0° - 0° - 4° 10° 2° 10° Firm Empty Empty
30° 30° 40°
Hip Adduction 0° - 14° 0° - 0° - 14° 0° - 0° - 6° 2° 6° 0° Empty Firm Firm
18° 20° 20°
Cervical 0-35° 0- 0-40° 0- 0-45° 10° 2° 5° 0° Firm Firm Firm
Lateral Flexion 43° 45°

Findings: (B) thoracolumbar lateral flexion and spinal rotation presents LOM 2° to pain; (B) hip
abduction and ® hip adduction presents tightness and weakness.
Significance: Difficulty in (B) trunk muscles and hypomobility is evident during performing ADLs
2° tightness and weakness.

VII. MMT
All muscles on (B) UE and LE were graded normal except for the following:

Muscle Grade

(R) Trunk Rotators 3/5

(R) Trunk Lateral 3/5

Flexors

Thoracic Extensors 3/5

Abdominals 3/5
 (L) Hip Abductors 4/5

(R) Hip Adductors 4/5

(R) Hip Extensors 3/5

Findings: Pt. presents (+) Fair to Good mm strength on trunk rotators, lateral flexors, thoracic
extensors, abdominals, hip abductors, adductors and extensors.

Significance: Difficulty of trunk motions in performing ADLs, standing completely upright, and
slight deviance in gait d/t muscle weakness and tightness 2° dextroscoliosis.

VIII. Anthropometric Measurements

1. Leg Length Measurement
Equipment used: Tape measure

Right Left

True Leg Length (TLL) 78 cm 79 cm

Apparent Leg Length (ALL) 86 cm 83 cm

Findings: TLL is (N) while ALL has a 3cm difference; left leg is shorter
Significance: (+) Apparent LLD d/t pelvic obliquity 2° to scoliosis

2. Scoliosis Evaluation

Equipment used: Scoliometer

Right Left

Degree of Spine 40° 0°

 Findings: ® spine on thoracic region indicates a 40° curvature.

Significance: (+) Moderate Dextroscoliosis.

Weight: 101.41 lbs.

Height: 4’10”

BMI: 21.2, Normal

IX. Special Tests

Special Test Findings Significance

Adam’s Forward (+) posterior rib hump on the (+) Dextroscoliosis

Bend Test px.’s ® side

Slump Test No pertinent findings (-) Impingement of spinal cord or

nerve roots

Schober Test No pertinent findings (-) Ankylosing Spondylosis

X. Sensory Assessment

Superficial Sensations: No pertinent findings

Deep Sensations: No pertinent findings

XI. DTRs
Findings: Grade 2 (Normoreflexive) on all bilateral UE and LE
Significance: Intact reflex arc

XII. Postural Analysis

Patient Position: Standing

Landmarks Anterior Lateral Posterior

Head Head tilted Forward Head tilted
head
Shoulders R shoulder is R shoulder R shoulder is
higher more higher
compared to the L prominent compared to the L
Scapula — R scapula R scapula is more
is more prominent
prominent
Rib Cage More visible to R Rib More visible to the
the R hump R
Thoracic — — Shifting towards R
Spine
Lumbar — Inc. Shifting towards L
Spine lumbar
lordosis
Pelvis L PSIS is more Lateral L PSIS is more
prominent and Pelvic prominent and
higher than R Tilt higher than R
Knees ® Knee not leveled — —
w/ (L) Knee
 Ankles ® Lat. & ® Med. — ® Lat. & ® Med.
Malleolus are Malleolus are
lower than (L) Lat. lower than (L) Lat.
& (Med) Malleolus & (Med) Malleolus

Findings: Thoracic Idiopathic Dextroscoliosis

Significance: Postural deviations 2° to scoliosis affect performance of ADLs and ambulation

XIII. Gait Analysis

Phases Right Left

Stance

HS (+) (+)

FF (+) (+)

MS (+) (+)

HO (+) (+)

TO (+) (+)

Swing

ACC
↑ ↓

MS
↑ ↓

DEC
↑ ↓

Gait Parameters (R) (L) Normal Values (male)

Stride Length 131 cm 147 cm 146 cm
Step Length 68 cm 74 cm 73 cm
 Gait Parameters Values Obtained Normal Values (male)
Cadence 106 steps/min. 110 steps/min.
Gait Speed Velocity/Speed 85m/min. or 1.2m/sec 86m/min. or 1.4m/sec

Findings: Pt. presents with dec. arm swing, time in stance, slight dec. stride length, step length,
and gait speed on the affected side.
Significance: Pt. has dec. arm swing, time in stance, slight dec. stride length, step length, and gait
speed on affected side d/t dec. pelvic rotation, asymmetric posture from scoliosis.
(+) Short leg gait

XIV. Functional Analysis

Interpretation:
7 - Complete independence (timely and safely)
6 - Modified independence (device)
5 - Supervision (subject = 100%)
4 - Minimal assist (subject = 75%)
3 - Moderate assist (subject = 50%)
2 - Maximal assist (subject = 25%)
1 - Total assist (subject = less than 25%)

Activity FIM Grade

Self-Care
Eating 7
Grooming 7
Bathing 5
Dressing (UE) 5

Dressing (LE) 5

Transfers
Bed/Chair 7
Toilet 7
 Tub/Shower 7
Locomotion
Walking 5
Stairs 5

● Difficulty in standing and walking for a long period of time

● Difficulty in bending forward
● Difficulty lifting and picking up weighted objects
● Difficulty with exacerbating sports
● Difficulty doing gardening

Findings: Pt. is indep. in eating, grooming. Needs supervision when doing bathing, dressing and
locomotive activities such as during amb. including ascending/descending stairs.

Significance: Pt. is not fully indep. and will require supervising assist. especially in doing some
self-care, ambulation, ADLs and I-ADLs.

XV. Instrumentation

Name: Barbie Forteza

Date: Oct 13, 2020

Trunk Appearance Perception Scale (TAPS)

Which one of the following drawings from each SET do you believe best represents your body’s
appearance? Pick only one (1) from each SET.
* Each drawing is scored from 1 (greatest deformity) to 5 (smallest deformity) and a mean score
is obtained by adding the scores for the drawings and dividing by 3
Findings: Patient scored 2, 3, and 4 = mean: 3
Significance: Px has greater self-perception of scoliosis deformity

ASSESSMENT

A. Evaluation

Pt. has shown functional difficulty in ambulation as well as performing ADLs and playing sports.
Pt.’s functional deficiency corresponds to LOM, ↓ mm performance, and back pain especially
after a tough activity. Elimination of pain, ↑ ROM and mm strength will lead to a complete
independence,↑ functional mobility and athletic performance. Hence, stretching exercises,
strengthening exercises, aerobic exercises, postural awareness and functional activities should
be incorporated in the rehab to enhance functional outcomes.

B. Diagnosis

Primary diagnostic category on this date is spinal deformity where the pt. presented a (R) 40°
lateral thoracic curvature and rib hump on convex side during forward flexion, and difficulty in
performing functional activities associated with back pain in response to the medical dx of
Adolescent Idiopathic Moderate Dextroscoliosis

C. Prognosis
Pt. has shown good rehab. potential and has willingness to return to his normal function and
posture. Should be able to improve functional mobility within 4 months, c̅ follow up pt. 's home
care visit therapy exercise.

D. PLAN OF CARE

PROBLEM LIST:

● 4-5/10 Upper back pain

● 40° Cobb angle- Moderate Dextroscoliosis
● MM imbalance in the trunk specifically on upper back
● ↓ AROM or flexibility on concave side of spine (L), cervical lateral flexion, and hip
abduction & adduction
● ↓ strength of (R) trunk mm, abdominals, (L) hip abductors and (R) hip adductors, ® hip
extensors
● Poor posture
● Difficulty prolonged standing and walking; (+) Short leg gait
● ↓ athletic ability
● FIM score of 5 (c̅ supervision) in self-care activities like bathing and dressing, as well as
in locomotion
● Difficulty doing gardening tasks such as bending forward and picking up tools from the
ground

LTG: The pt. will demonstrate from c̅ supervision to complete indep. in locomotion for unlimited
distances and time within 4 mos to allow the pt to indep. walk inside and outside home and use
stairs s discomfort.

STG:

1. Pt. will be able to ↑ bilat. LE AROM p 3 Rx sessions to aid Pt. improve indep. ambulation
safely
2. Pt. will be able to ↑ bilat. LE strength p 3 Rx sessions to aid Pt. in improving endurance of
indep. ambulation inside & outside home safely
3. Pt. will be able to ↑ bilat. Hip abductors and adductors strength to 5/5 and AROM to near
normal p 3 Rx sessions to help the Pt. ↑ symmetry of pelvis at the same time improve
gait pattern
4. Pt. will be able to demonstrate proper body mechanics for at least 90% correctness in
obstacle courses p 4 Rx sessions to aid Pt. for observing upright posture
 5. Pt. will be able to amb. on level surfaces for 30 ft. x 3 p 4 Rx sessions to progress Pt. in
amb. for long distances safely
6. Pt. will be able to ascend & descend on staircases p 4 Rx sessions to progress Pt. in amb.
in elevated surfaces safely in home s̅ pain

LTG: The pt. will be able to show ↑ athletic performance s̅ difficulty within 4 mos to allow the
pt to safely return and play volleyball.

STG:

1. Pt. will be able to report decreased pain scale to 1-2/10 p 3 Rx sessions to make Pt.
comfortable in playing volleyball
2. Pt. will be able to ↑ trunk rotation AROM to at least 40° p 3 Rx sessions to aid Pt. in proper
body mechanics in playing volleyball safely s̅ difficulty
3. Pt. will be able to ↑ core strength to 5/5 p 3 Rx sessions to provide Pt. proper stability
when playing volleyball
4. Pt. will demonstrate ↓ cobb angle from mod 40° to 25° and prevent the curve from
progressing to help Pt. experiencing minimize back pain when playing volleyball
5. Pt. will be able to demonstrate at least 90% correctness in kinesthetic awareness activities
p 4 Rx sessions to prevent Pt. from further injuries when playing volleyball

LTG: The pt. will be able to lift and pick up objects from the ground comfortably s̅ supervision
from her mother within 3 mos to allow her return to one of her hobbies which is gardening.

STG:

1. Pt. will be able to ↑ trunk flexion AROM to at least 75° p 3 Rx sessions to aid Pt. in
reaching/lifting gardening tools from ground indep. s̅ experiencing pain
2. Pt. will be able to ↑ core strength to 5/5 p 3 Rx sessions to aid Pt. in improving stability
when in flexed position during gardening
3. Pt. will be able to ↑ thoracic extensors strength to 5/5 p 4 Rx sessions to aid Pt. getting
up from flexed position after gardening activity

LTG: The pt. will be able to perform self-care activities from c supervision to complete
independence within 4 mos to allow the pt. to indep. execute bathing as well as UE and LE
dressing easily.

STGs:

1. Pt. will be able to improve FIM score to 7 in bathing p 3 Rx sessions to progress Pt. toward
indep ADLs at home.
 2. Pt. will be able to improve FIM score to 7 in UE dressing p 3 Rx sessions to progress Pt.
toward indep ADLs at home.
3. Pt. will be able to improve FIM score to 7 in LE dressing p 3 Rx sessions to progress Pt.
toward indep ADLs at home.
4. Pt. will be able to ↑ cervical lateral flexion AROM to at least 40° p 3 Rx sessions to aid Pt.
in indep. UE dressing safely and easily
5. Pt. will be able to ↑ thoracolumbar lateral flexion AROM to at least 30° p 3 Rx sessions
to aid Pt. in indep. UE dressing safely and easily
6. Pt. will be able to ↑ trunk flexion AROM to at least 75° p 3 Rx sessions to aid Pt in indep.
LE dressing and bathing safely and easily
7. Pt. will be able to ↑ thoracic extensors strength to 5/5 p 4 Rx sessions to aid Pt. getting
up from flexed position after doing LE dressing and bathing

PTMx: Px will be treated 3x/wk for 4 wks c the following:

1. HMP on the thoracic region x 20 mins to minimize muscle spasm

2. TENS on (B) trunk muscles x 20 mins. to reduce pain
3. Schroth Physiotherapeutic Scoliosis-Specific Exercises x 45 min to prevent scoliosis from
progressing, to restore muscle symmetry and posture alignment, and facilitate breathing
to help reshape the rib cage and soft tissue around it.
4. Myofascial release on concave side of thoracic spine x 5 min to prevent progression of
curve and improve posture.
5. Stretching exercises on (L) trunk muscles x 15 sh x 10 reps x 1 set to increase lateral
flexibility of the spine
6. Stretching exercises of SCM, scalenes x 15SH x 10 reps x 1 set to increase cervical mobility
and correct tilting of head on one side.
7. Klapps exercises on hands position x 15SH x 10 reps x 1 set to stretch tight structures on
the concave side of the spine.
8. Stretching exercises on erector spinae x 15SH x 10 reps x 1 set to increase trunk flexion
and improve posture.
9. Stretching exercises on (B) hip abductors and adductors x 15SH x 10 reps x 1 set to
decrease pelvic obliquity.
10. Strengthening exercises on trunk muscles on (R) side in sidelying position x 6 sh x 10 reps
x 3 sets to increase muscle power, strength and control on convex side
11. Partial sit-up c̅ posterior pelvic tilt x 6sh x 10 reps x 3 sets to strengthen abdominals or
increase core muscle strength
12. Trunk extension exercise c̅ chin tucked in prone position x 10 reps x 3 sets to increase
strength of thoracic extensors
 13. Strengthening exercises on (L) hip abductors and (R) hip adductors x 6sh x 10 reps x 3 sets
to strengthen the hip muscles and decrease mm imbalance.
14. Leg lift exercise in quadruped position x 6sh x 10 reps x 3 sets to increase strength of
gluteus maximus.
15. Partial squat exercises x 10 reps x 3 sets to improve LE performance or endurance.
16. Gait training exercises x 5 rounds to improve safe ambulation and gait performance.

(Note: Stretching and strengthening exercises begin once pain subside)

HI:

1. Wear Milwaukee brace for 23 hrs/day to stabilize and prevent progression of the lateral
curvature of the spine.
2. Hot compress on the thoracic area x 20 mins once daily or prn to decrease back pain
3. Cat and Camel exercises on thoracic spine x 15SH x 10 reps x 1 set once daily to increase
flexibility of the spine and centralize pain.
4. Stretching exercises on (L) trunk muscles x 15 sh x 10 reps x 1 set once daily to increase
lateral flexibility of the concave side of thoracic spine
5. Strengthening exercises on (R) trunk muscles x 6 sh x 10 reps x 3 sets once daily to increase
muscle performance.
6. Strengthening exercises on abdominal muscles x 6sh x 10 reps x 3 sets once daily to
increase core muscle strength
7. Diaphragmatic breathing exercises x 4 cycles to improve pulmonary functions
8. Instead of sleeping in a prone position, sleep on the side of the prominent curve in a
side-lying position.
9. Do not lift or pick up heavy objects using only one hand.
10. Refrain from doing high-contact sports.
11. Always practice proper body mechanics and good posture.
12. Sleep in a firm and comfortable mattress to avoid excessive stress on the spine.