Rehabilitation on Scoliosis

Peni Kusumastuti
Fatmawati Hospital
Jakarta , Indonesia
Solo , 7 Oktober 2016
The Impact of Scoliosis on Life Function

• Pain : 40%-90% of adult Scoliosis

• Degenarative of the spine
• Mobility: Increase sagital/ lateral
sway
Decrease stability
Asymetric stress of LE
• Cardiopulmonary Function:
Restrictive Lung Disease
Decreased Vital Capacity
• Psychology : emotion and
behavior
 Risk factors for progression
Sex.  Curve magnitude.
• Female > Male Curve magnitude at
• Within 12 mo after menses the time of
 Skeletal growth . diagnosis
• Risser 1 or less, progress  Greater curve 
60 – 70%. more progress
• Risser 3 progress 10%
 Family history
 Curve location.
 Connective tissue
• Apex T12 or above >
progress than isolated defect (hyperlaxity)
Lumbar curve .  Flattening of
• Double curves progress thoracic kyphosis
more than single  Trunk rotation
> 10 degrees
Bunnel reported the risk of progression
 At the beginning of puberty is 20 % in 10 degrees ,
60% in 20 degrees scoliosis , 90% in 30 degrees
 At the age of peak height growth ( 13 years osseous
girls ) is 10 % , 30% and 60%
 At the final stage of puberty ( at least Risser II )
become lower to 2% in 10 degrees , 20% in 20
degrees and 30% in 60 degrees
( Bunnell WP. 1988 & Bunnell WP. 2005 )
 The Aims of conservative treatment of
Scoliosis
1. to stop curve progression at puberty (or possibly
even reduce it),
2. to prevent or treat respiratory dysfunction,
3. to prevent or treat spinal pain syndromes,
4. to improve aesthetics via postural correction,

Consequences of untreated
1. Mortality rate  low , especially >900.
2. Pulmonary and cardiac function.
3. Back pain.
2011 SOSORT
The Conservative Treatment of Scoliosis
 Observation 
< 250 immature and < 500 mature.
Rő 3 mo after first visit, then every 6-9 mo
for <200 and 4-6 mo >200
Significant change  progression >100 for
curve < 200 and > 50 for curve >200
 Bracing
 Specific Therapeutic Exercise
 Respiratory Function Exercise
Rehabilitation Modalities for Scoliosis

• Brace Treatment
• Therapeutic Specific Exercise
• Physical modalities for pain
management : heat & cold
therapy , TENS etc
• Education : postural control ,
body-mechanics compliance
Physical Modalities for
Modalities Pain Management
Brace Treatment
 The Spine
The Spine :
 A series of semi-rigid links
 Six degrees of freedom – each link
 Different stiffness at different spinal level
 Other tissues separate the spine from
orthosis

 Influence the biomechanics and type of

the Brace
 The outcome is mainly the halting of
curve progression
 Factors that Influence the Final Result
in Brace Treatment

 Dosage of wearing
 Quality of bracing,
 Compliance to
treatment, The Chêneau
 Family history, The Chêneau light

 Type of scoliosis
 The Exercise
The Milwaukee brace
 Team approach

The Lyon brace

 Dosage of Bracing
The greater number of hours
 Night Time Rigid Bracing of brace wear correlated
• (8-12 hours per day) : with lack of curve
wearing a brace mainly in progression.
bed.
 Part Time Rigid Bracing
• Curves did not progress in
• (12-20 hours per day) :
mainly outside school and 82% of patients who wore
in bed the brace more than twelve
 Full Time Rigid Bracing hours per day, compared
with only 31% of those who
• (20-24 hours per day) or
cast : wearing a brace all the wore the brace fewer than
time. seven hours per day.

( SOSORT Guideline , 2011 ) ( Negrini S et al., Study Health Technol Inform 2008 )
 Brace Prescription
Criteria for brace treatment :
Structural curve patterns with
documented progression over 30
degrees and remaining skeletal
growth
• Milwaukee (CTLSO) for apex above T8.
• Boston (TLSO) up to T8 apex.
1. Boston Lumbar Brace for lumbar
curves (apex below L1)
2. Boston Thoracolumbar brace for
lumbar curves (apex at T12 and L1)
and low thoracic curves (apex at
T10 and T11)
3. Boston Thoracic Brace for thoracic
curves (apex up to T6)
Other type of braces
 Quality of Bracing
Brace Construction :
The 3 D Correction

The proper pad placement

on the thoracic convexity,
reaching or involving the
apical or acting caudal to the
apical vertebra

The direction of the vector

Force  ‘dorso lateral
to ventro medial’
The Factors That Decrease the Effectiveness
of Brace Treatment
• Severe thoraxic Lordosis; the transverse forces of
the lateral pads worsen the lordotic spine
• Persistent worsening of hypo-kyphosis
• Major psychological reaction to the brace ,
bracing need the active participation of the
patient in order to achieve a good result
• Massive obesity
• The inability to actively shift the trunk away
from the lateral pad

( SOSORT Guideline , 2011 )

 The Compliance
Factors That Influence
the Compliance in Using
Brace
• Psychological acceptance
condition
• Patient’s self understanding
regarding the importance of
brace treatment to prevent
the curve progression
• Treatment inconsistency
• General health Condition (
skin rash / ulcerations ,
COPD)
Compliance and the
Outcome
 The Compliance is correlated
with the final results
 Compliance to bracing is
correlated to Quality of Life
and psychological issue
 If patient are not compliant,
bracing is not effective
 Need the interaction between
the treatment and the patients
( Negrini S. et al. SOSORT Consensus 2008 ,
Scoliosis 2009 4(1)2 )
 Follow Up

• In brace immediate correction is important to

predict the long term out come of bracing
treatment
• Brace check : must be a clinical and radiographic
• Follow -up :
 Check the brace and patient compliance regularly
 Follow-up the braced patient at least every 3- 6
months and reduced according to individual
needs
 The brace has to be changed to a new one as soon
as the child grows or the brace losses efficacy
 Which Brace is Better ??

High variability among results of bracing confirmed

High mainly with rigid bracing
Soft braces can have better result or at least comparable to
The best results have been achieved by rigid bracing
( Negrini S, 2011 & Zaborowska –Sapeta K. et al 2011 )

Today it is not possible to state with any certainty

which one brace is better than other
( Negrini S , Grivas TB , in Scoliosis 5(1):2 & Grivas TB et al , 2010 )
An RCT found a TLSO more effective than SpineCor;
( Wong MS. Spine 2008 )

One meta-analysis that was in favor of the Milwaukee brace,

Charleston being the less efficacious; ( Rowe DE, 1997 )

The success rates were 60% for TLSO and 53% for SpineCor.
No significant difference was found
Patients who reached 45 degrees, the success rates were 80% for
TLSO and 72% for SpineCor ,
No significant difference ( Gammon SR, et al . , 2010 )

Surgery rates:
Boston Brace 12-17% ; Boston-Charleston-TLSO 27-41% ;
Night time braces (Providence or Charleston braces) 17-25%;
Rosenberg brace 25-33%; Wilmington 19-30%; ( Dolan LA. 2007 )
The Exercise
 Recommendations on "Physiotherapeutic Specific
Exercises to prevent scoliosis progression during
growth"
• Physiotherapeutic Specific Exercises are recommended as the first step
to treat idiopathic scoliosis to prevent/limit progression of the
deformity and bracing (SoR: B) (SoE: II)
 Physiotherapeutic Specific Exercises follow SOSORT Consensus and are
based on auto-correction in 3D, training in ADL, stabilizing the corrected
posture, and patient education (SoR: B) (SoE: VI)

 Exercise are performed during brace treatment :

 Spinal mobilization exercises are used in preparation of bracing
 Stabilization exercises in auto-correction are used during brace
weaning period
 Respiratory function exercises are used during the brace treatment to
improve respiratory function

( SOSORT Guideline, 2011 )

 Conservative treatment of idiopathic scoliosis according to FITS
concept / FITS-Functional Individual Therapy of Scoliosis
( Białek M., 2011 )
The 115 of 10 years patients or more Results:
older , presented Cobb from 10 to 40 In the Group A:
degrees and Risser sign 0 or 1 or 2  (1) in single structural scoliosis 50,0%
received treatment to the FITS of patients improved, 46,2% were stable
concept and 3,8% progressed,
 (2) in double scoliosis 50,0% of
78 patients scoliosis of 10 -25 degrees ( patients improved, 30,8% were stable
group A ) , 37 patients-scoliosis 26-40 and 19,2% progressed.
degrees ( group B ) In the Group B:
 (1) in single scoliosis 20,0% of patients
• Group A : once a month for 60 improved, 80,0% were stable, no patient
minutes , progressed,
• GroupB : FITS + Bracing  (2) in double scoliosis 28,1% of patients
• both do once a day prescribed set improved, 46,9% were stable and 25,0%
of exercises (45 minutes ) progressed

Best results were obtained in 10-25 degrees scoliosis which

is a good indication to start therapy before more structural
changes within the spine establish
 Therapeutic exercise

Treatment decisions should be:

 auto-correction in 3D, training
 individualized, in ADL, stabilizing the corrected
 considering the probability posture, and patient education
of curve progression,  performed regularly throughout
 based on curve pattern, treatment to achieve best
 skeletal maturity, results
 patient age and
sexual maturity

( Weiss H et al. 2005. ;Negrini S, et al J Rehabil

Med 2008. ) ; Weinstein & Dolan , 2008 ,
Weinstein S & Dolan , 2008, )
 The Exercise ( in Brace )
Isometric Back Strengthening

a. Develop postural awareness and ability to maintain

corrected alignment as provided by brace
b. To achieve the spinal balance
 The Exercise( out of Brace )
a. To develop postural awareness and ability to maintain corrected
alignment,
b. To maintain and/or increase chest mobility for proper respiration,
c. To maintain and/or increase muscle strength as indicated and
spinal flexibility and prevent contractures in hip flexors,
f. To provide a good general physical condition and endurance

Depending on individual curve patterns,

The elevation of both arms the patients are assigned to special
leads to an increase of the exercise for the individualized to suit
flatback deformity the patient’s needs
 Stretching

Latihan
Penguatan

Stretching Thoracal Convex

dan Penguatan
Penguatan Ekstensor Trunk
 Respiratory and Exercises
De-conditioning due It is important to In scoliosis girls
to : perform general wearing a Boston-
lack of regular aerobic activities and type brace, a two-
exercise respiratory training to month aerobic
improve exercise training sustained or
the severity of the capacity and improved
scoliosis curve : respiratory muscles significantly the
• The deformity of functioning, parameters of
lateral flexion decreasing de- pulmonary function,
• Vertebral rotation conditioning and while they were
and stiffness thoracic stiffness reduced in the
• The sagital control group with
( Vercauteren M,et al, Spine
diameter, overall 1982 ) no exercises in
dimensions Milwaukee brace.
• Stiffness of the 1.Margonato V,. Eura Medicophys
2005.
thoracic cage 2.Athanasopoulos S. Et al :, Scand J
Med Sci Sports 1999.
Stop the Conservative Treatment
Indication of Surgery

Progressive curves > 45- 500

in growing children

Failure of bracing

Progressive curves
beyond 500 in adults
 Summary

Crucial Elements of Rehabilitation in Scoliosis

• Do the proper assessment at the first visit
• Attention to the risk of progression
• Choose the proper conservative treatment :
* Brace : prescription , construction , check out ,
evaluation / follow-up
* Exercise : specific exercise , tailored individually
• Evaluate Patient’s compliance to
the treatment
• Patient Education
• Systematic monitoring of outcomes of the treatment