CLINICAL CORRELATION 1 (LAB) OPT 3107.

SCOLIOSIS
PROF. LEONARD P. QUILANTANG | BSPT 3-6

○ Musculoskeletal involvement (e.g.,

OUTLINE
A. Definition
B. Classification
a. Patterns
b. Classification of IS
C. Epidemiology
D. Risk Factors
E. Pathophysiology
F. Diagnosis
G. Clinical Manifestations
H. Management and Treatment
a. Management Guidelines
b. Conservative Management Guidelines
c. Goals of Treatment
Definition
● According to Goodman, scoliosis is an abnormal lateral
curvature of the spine. The direction of the curve can
either be left or right (right is more common in thoracic
curves, whereas left is more common in lumbar curves).
● The spinal column rotates about its axis, which results in
a malformation of the rib cage.
● Kyphosis and lordosis are frequently present alongside
scoliosis.
○ The term "kyphosis," which refers to sagittal
curves with a posterior vertex (concave
anteriorly), comes from the Greek word
"kuphos," which means "bent forward or
humped." It is typical in the thoracic spine to a
certain extent.
○ The term "lordosis" refers to a sagittal curve with
an anterior vertex (concave posteriorly). Its
origins are "lordos," which is Latin for "excessive
posterior bending." It is also typical in the
cervical and lumbar spine to a certain extent.
● Any curve that is larger than or equal to 10 degrees, with
or without a rotatory component, is considered to be a
medically significant frontal plane curve (scoliosis),
according to the Scoliosis Research Society (SRS).
○ The normal range for thoracic kyphosis,
according to the SRS, is 20 to 50 degrees.
○ Depending on the measuring method, the range
of normal for lumbar lordosis is much larger, with
readings that might vary from 31 to 79 degrees.
osteoporosis, spinal tuberculosis, rheumatoid
arthritis)
○ Neuromuscular involvement (e.g., cerebral
palsy, polio, myelomeningocele, muscular
dystrophy)
○ Could be Idiopathic
● Non-structural / Functional scoliosis is reversible and can
be corrected with promotion of forward or side bending
and with positional changes, such as lying in supine,
correction of a leg-length discrepancy to realign pelvis, or
with muscle contraction techniques. Functional scoliosis
can become structural if untreated.
○ Poor posture
○ Compensation to relieve nerve root irritation
○ Inflammation to the spine
○ Leg length discrepancy
○ Hip contracture
Patterns of Scoliosis
● Direction of deviation of the curve:
○ Dextroscoliosis - right leaning curve of the spine
■ Dextrothoracic Scoliosis of the spine is
the MC curve especially for 85-90% of
AIS cases.
○ Levoscoliosis - left leaning curve of the spine
● Structure of the curve
○ C curve - single curve
○ S curve - double curve

Classification
● Kisner classified scoliosis into two main categories,
structural and nonstructural.
○ Non-structural is also termed functional or
postural scoliosis.
Classification of Idiopathic Scoliosis
● Structural scoliosis is characterized by an irreversible
● Infantile Idiopathic Scoliosis
lateral curvature and fixed vertebral rotation, accompanied
○ Onset occurs before the age of 3
by asymmetry of its ligamentous supporting structures. In
○ Most of the time, the condition is benign, and
other words, the bone undergoes a structural alteration,
80% to 85% of cases spontaneously resolve.
and the spine loses its natural flexibility.
● Juvenile Idiopathic Scoliosis
○ Could be genetic
○ Includes children who are older than 3 but
○ Pathological wedging of your vertebra
younger than the age of 10 at which physical
○ Failure of vertebral segmentation or
maturity begins to show. It represents two
hemivertebra
distinct populations, the first population as "late
○ Incomplete development of the spine
infantile" and the other as "early adolescent."

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 ○ In juvenile scoliosis, the rate of curve
progression is variable.
● Adolescent Idiopathic Scoliosis
○ Curves that appear after the start of puberty are
the hallmark of adolescent idiopathic scoliosis,
which typically occur between the ages of 10-17.
○ The magnitude of the curve at onset, which is
positively connected with progression, as well as
the patient's age and level of maturity, are used
to evaluate patients with adolescent idiopathic
scoliosis.
Epidemiology
● Spinal abnormalities can impair not only the
musculoskeletal system, but also many other organs and
systems, particularly in persons who are already dealing
with various impairments caused by chronic debilitating
illnesses.
○ There are between 0.3% and 2% of Americans
who have idiopathic scoliosis, according to
reports.
○ Degenerative scoliosis is reported to occur at a
rate of 6% in those over 50 and 36% in people
over 50 who have osteoporosis.
○ Between 0.4% and 8.3% of people have
Scheuermann's disease, a prevalent cause of
pathological thoracic kyphosis.
○ People with numerous neuromuscular disorders
can have a spinal deformity rate of up to 100%.
● The U.S. has a high incidence of scoliosis in the
population, for the same reason the US Preventive
Services Task Force has advised that teenagers be
checked for scoliosis at school. Screening is done using
the Adam's bending test, and around 3% to 9% of the
youngsters who tested positive had curves that require
active therapy.
Risk Factors
● Age
○ Signs and symptoms typically begin in
adolescence.
○ Majority of cases of progressive idiopathic
scoliosis are found in the adolescent age group
when the growth velocity of the spine increases
after relatively slow growth period between the
ages of 5 and 11 years for girls and up to age 13
years for boys/
● Sex
○ Adolescent idiopathic scoliosis of greater than
30 degrees is seen most often in females without
any neurologic impairments in a 10:1 female-to-
male ratio.
● Family history
○ Scoliosis can run in families, but most children
with scoliosis don't have a family history of the
disease.
Pathophysiology
● The pathogenesis of scoliosis remains unclear but may be
better understood in relation to the underlying cause.
● Abnormal embryonic formation and segmentation of the
spinal column are possible pathologic pathways in
congenital scoliosis. Neuromuscular scoliosis is often the
result of an imbalance or asymmetry of muscle activity
through the trunk and spine.
● The earliest pathologic changes associated with idiopathic
scoliosis occur in the soft tissues as the muscles,
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ligaments, and other tissues become shortened on the
concave side of the curve.
● Hypothesize that scoliosis sets up abnormal forces across
the spine as a consequence of the differences in length
tension relationships, with the muscles on the convexity
being in a lengthened position.
● Bone deformities occur, as compression forces on one
side of the vertebral bodies apply asymmetric forces to the
epiphyseal ossification center, resulting in increased bone
density on that side.
● The compressive force is greatest on the vertebrae in the
apex of the concavity, so the apical vertebrae become
most deformed.
Diagnosis
● Diagnosis by clinical examination requires the client to
bend forward 90 degrees with the hands joined in the
midline. Scoliometer can also be used to measure the
angle of trunk rotation.
● An abnormal finding includes asymmetry of the height of
the ribs or paravertebral muscles on one side.
● The examiner also checks for leg length discrepancy and
other asymmetries and for the presence of hair patches,
nevi, pits, or areas of abnormal skin pigmentation in the
midline indicating possible underlying spinal abnormality.
● Physicians also perform a neurologic examination to rule
out an underlying neurologic disorder, especially in the
presence of left thoracic curvature.
● The radiographs are evaluated using the Cobb method to
measure the degree of curvatures. A curve must be larger
than 10 degrees to be considered scoliotic.
○ To perform the Cobb measurement, the
examiner should first note the upper border,
lower border, and vertex of the curve.
○ The curve is classified by the position of the
vertex into thoracic, thoracolumbar or lumbar.
○ The upper and lower borders are identified by
the “end vertebrae.” They are the first and last
vertebrae that tilt into the concavity of the curve.
○ To define the angle, a line is drawn on the
radiograph parallel to the upper end plate of the
upper end vertebra. A second angle is drawn
parallel to the lower end plate of the lower end
vertebra. In most cases, these lines will not
intersect on the film and, therefore, the angle
cannot be measured directly. The angle formed
by the intersection of the perpendicular lines is
equal to the angle made by the upper and lower
end vertebrae and is measured and reported as
the Cobb angle.
● The Risser sign is also determined from the film as an
indication of maturation and is used as a prognostic
predictor of progression.
○ Risser divided the crest into four quarters
according to ossification, grading the ossification
from 1 to 4, with a grade 5 indicating that the
whole apophysis has ossified and is fused to the
iliac crest.
● It is important to assess the presence and degree of
rotation associated with the curve, as well as its rate of
progression. The degree of rotation can be graded using
the system of Nash and Moe.
● Nash and Moe method describes the percentage
displacement of the convex pedicle with respect to the
vertebral body width which is used to approximate the
angle of vertebral rotation. It has 0 - 4 grading;
2
 ○ Grade 0 - pedicles are seen symmetrically
positioned at the lateral border of the vertebral
bodies;
PROGRESSION OF CURVES IN UNTREATED IS
○ Grade I - slight asymmetry;
○ Grade II - one pedicle is almost out of view;
○ Grade III - only one pedicle is seen, positioned Cobb angle 10-12 yo 13-15 yo 16 yo
at the center of the vertebral body;
○ Grade IV - only one pedicle is seen, positioned <19° 25% 10% 0%
lateral to the center of the vertebral body
● Neuroimaging beyond plain films may be necessary. 20-29° 60% 40% 10%

Clinical Manifestations 30-39° 90% 70% 30%

Common characteristics include:
● Asymmetric shoulder >40° 100% 90% 70%
● Rib hump/bump
○ Rib hump convex side
Management and Treatment
○ Rib bump = concave side ● Prevention is key to management of scoliosis
● Protrusion of hip on one side ● Early detection = early treatment without surgical
● Pelvic obliquity intervention, good for long-term
● ↑ lumbar lordosis ● Main goal: prevent severe and progressive deformity
● Uneven waist crease
● Uneven leg length d/t or 2° to scoliosis Management Guidelines
○ May cause short-leg gait Management Guidelines (Horne et al., 2014)
● C or S curve of spine
○ Convexity of curve to right = dextroscoliosis
○ Convexity of curve to left = levoscoliosis
○ S curve has one primary curve and a secondary
or compensatory curve
■ 2 primary curves may happen mainly
with ® thoracic and (L) lumbar curve
○ If curve is compensated, head is in proper
alignment to pelvis
● Mobility problems in joints, muscles, and fascia in concave
side of curve
● Stretched and weakness in muscles on the convex side of
curve
● If one hip is adducted, adductor muscles on that side have
decreased flexibility and abductors are stretched and
weak; opposite for CL extremity
● Severe structural scoliosis may lead to:
○ Decreased rib expansion
○ Cardiopulmonary impairment
○ Difficulty in breathing
● Razor back deformity Conservative Management Guidelines
○ Thoracic scoliosis with very poor cosmetic Conservative Management Guidelines (Negrini et al., 2018)
appearance 1. stop curve progression at puberty (or possibly even
○ Deformation of ribs with spin reduce it)
○ Mild rib hump to severe rotation of vertebrae ● Bracing, physiotherapeutic scoliosis-specific
exercises
● Back pain is not typical in children/adolescents with mild 2. prevent or treat respiratory dysfunction
scoliosis 3. prevent or treat spinal pain syndromes
○ If there is pain: rule out for spondylolisthesis, 4. improve aesthetics via postural correction
tumor, infection, or occult trauma
Goals of Treatment
● Back pain may be associated with curve progression after Goals of treatment according to the SOSORT consensus paper.
brace treatment for idiopathic scoliosis (starting from the most important) (Negrini et al., 2018)
● Adult scoliosis presents with back pain (great and ● Esthetics
persistent) which is multifactorial in nature ● Quality of life
○ muscle fatigue, trunk imbalance, facet ● Disability
arthropathy, spinal stenosis, degenerative disk ● Back pain
disease, radiculopathy ● Psychological well-being
● Progression in adulthood
● Breathing function
● Scoliosis Cobb degrees
● Need of further treatments in adulthood

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Bracing
● Goal: passive restraint to maintain curves within 5 degrees
of curve measurement at time of initial application
● Curves with apex between T8-L2 and compensated
thoracolumbar curves, bracing is best while curves with
apex T6 and above have poorer response
● Indicated for curves more than 20° if skeletally immature
or earlier if progression is noted
● Worn 18-23 hours a day; Adherence is key factor
Stikeleather, L., . . . Zaina, F. (2018). 2016 SOSORT
guidelines: orthopaedic and rehabilitation treatment of
idiopathic scoliosis during growth. Scoliosis and Spinal
Disorders, 13(1). https://doi.org/10.1186/s13013-017-
0145-8
Frontera, W. R. (2015). Delisa's physical medicine and
rehabilitation: Principles and practice, two volume set.
Lww.

Goodman, C. C., & Fuller, K. S. (2020). Goodman and Fuller's

Brace Use
pathology: Implications for the physical therapist. Elsevier.

Milawaukee (CTLO) Curvature at T8 or above Kisner, C., Colby, L. A., & Borstad, J. (2018). Therapeutic exercise:
Foundations and techniques.
Boston (TLO) Curvature apex lower then T9-
T10 Magee, D. J. (2014). Orthopedic physical assessment - E-book.
Elsevier Health Sciences.
Lyon IS c thoracic hypokyphosis

Charleston IS fabricated for maximum side-

bend correction

Physiotherapeutic scoliosis-specific exercises (PSSE)

● Goal: secondary prevention (stop or slow progression of
curves)
● Include 3D autocorrection, stabilization, and theoretical
information for patient and family
● 3D correction
○ Conscious series of active movements done by
patient aiming to realign scoliotic curves
● Self-correction can be done passive or active
○ Passive – patient performs corrections with
external tool or specific positions prompting
correction
○ Active – patient performs movements to realign
scoliotic curve without relying on external tools
or specific positions of body

Surgical Management
● Indicated for
○ curves >45°
○ Chronic pain
○ Curvature is causing neurologic changes
● Goal: halt progression, prevent pulmonary problems,
eliminate pain
● Severe cases: anterior fusion
● Instrumented fusion is not possible for skeletally
immature; rods or a vertical expandable prosthetic
titanium rib is considered
○ Allows thoracic cavity to continue developing
● Minimally invasive surgery = anterior release and spinal
fusion
○ Decrease morbidity associated with open
thoracotomy
○ Maximize stability of spine

References
Horne, J.P., Flannery, R., & Usman, S. (2014). Adolescent
idiopathic scoliosis: diagnosis and management.
American Family Physician, 89(3), 193–198.
https://pubmed.ncbi.nlm.nih.gov/24506121/

Negrini, S., Donzelli, S., Aulisa, A. G., Czaprowski, D., Schreiber,

S., de Mauroy, J. C., Diers, H., Grivas, T. B., Knott, P.,
Kotwicki, T., Lebel, A., Marti, C., Maruyama, T., O’Brien,
J., Price, N., Parent, E., Rigo, M., Romano, M.,

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