Scoliosis

Scoliosis is a condition involving an abnormal sideways curvature of the spine. It can be caused by congenital, developmental or degenerative problems, but most cases of scoliosis actually have no known cause called idiopathic scoliosis. Scoliosis usually develops in the thoracic spine or the thoracolumbar area of the spine.

Scoliosis can develop in infancy or early childhood.

The primary age of onset for scoliosis is 10-15 years old, occurring equally among both genders.

Females are eight times more likely to progress to a curve magnitude that requires treatment.

Signs and symptoms of scoliosis may include:

• Uneven shoulders
• One shoulder blade that appears more prominent than the other
• Uneven waist
• One hip higher than the other

If a scoliosis curve gets worse, the spine will also rotate or twist, in addition to curving side to side. This causes the ribs on one side of the body to stick out farther than on the other side.

Scoliosis symptoms in adolescents

• The head is slightly off center
• The ribcage is not symmetrical – the ribs may be at different heights
• One hip is more prominent than the other
• Clothes do not hang properly
• One shoulder, or shoulder blade, is higher than the other
• The individual may lean to one side
• Uneven leg lengths

Scoliosis symptoms in infants

·         A bulge on one side of the chest

·         The baby might consistently lie curved to one side

In more severe cases, the heart and lungs may not work properly, and the patient may experience shortness of breath and chest pain.

Scoliosis can be classified on the basis of causes: idiopathic, congenital or neuromuscular.

Idiopathic scoliosis:

The diagnosis when all other causes are excluded and comprises about 80 percent of all cases.

Adolescent idiopathic scoliosis is the most common type of scoliosis and is usually diagnosed during puberty.

Classified into the following subgroups:

1.      Infantile scoliosis: Infantile scoliosis develops at the age of 0–3 years and shows a prevalence of 1 %.

2.      Juvenile scoliosis: Juvenile scoliosis develops at the age of 4–10 years, comprises 10–15 % of all idiopathic scoliosis in children, untreated curves may cause serious cardiopulmonary complications, and curves of 30 and more tend to progress, 95 % of these patients need a surgical procedure.

3.      Adolescent scoliosis: Adolescent scoliosis develops at the age of 11–18 years, accounts for approximately 90 % of cases of idiopathic scoliosis in children.

Congenital scoliosis:

·         Results from embryological malformation of one or more vertebrae and may occur in any location of the spine.

·         The vertebral abnormalities cause curvature and other deformities of the spine because one area of the spinal column lengthens at a slower rate than the rest.

Neuromuscular scoliosis:

·         Encompasses scoliosis that is secondary to neurological or muscular diseases.

·         Includes scoliosis associated with cerebral palsy, spinal cord trauma, muscular dystrophy, spinal muscular atrophy and spina bifida.

·         This type of scoliosis generally progresses more rapidly than idiopathic scoliosis and often requires surgical treatment.

Scoliosis is diagnosed by X-rays, MRI, CT- scans , spinal radiographs, and physical examination.

The aim of the functional examination is to distinguish between faulty posture and actual idiopathic scoliosis.

1. Examination of the active movements(flexion, extension and side flexion) of the spine in the cervical, thoracic and lumbar segment.

2. The Adam forward bend test- can be used to make a distinction between structural scoliosis or non-structural scoliosis of the cervical to lumbar spine. The test can be performed in the standing and sitting position. See image R

3.The Cobb angle - is a standard measurement to determine and track the progression of scoliosis

The scoliometer is an inclinometer designed to measure trunk asymmetry, or axial trunk rotation. It’s used at three areas:

·         Upper thoracic (T3-T4)

·         Middle thoracic (T5-T12)

·         Thoraco-lumbar area (T12-L1 or L2-L3)

If the measurement is equal to 0°, there is a symmetry at the particular level of the trunk. An asymmetry at the particular level of the trunk is found, if the scoliometer measurement is equal to any other value.

5. Pulmonary function testing is useful in the preoperative evaluation of patients.
Spirometer

·         FVC gives an assessment of lung volume

·         FEV1 provides an assessment of flow function.

The following factors will be considered by the doctor when deciding on treatment options:

• Sex – females are more likely than males to have scoliosis that gradually gets worse.
• Severity of the curve – the larger the curve, the greater the risk of it worsening over time. S-shaped curves, also called “double curves,” tend to get worse over time. C-shaped curves are less likely to worsen.
• Curve position – if a curve is located in the center part of the spine, it is more likely to get worse compared with curves in the lower or upper section.
• Bone maturity – the risk of the curve worsening is much lower if the patient’s bones have stopped growing. Braces are more effective while bones are still growing.

Medical management: Most people with scoliosis have mild curves and probably won't need treatment with a brace or surgery. Children who have mild scoliosis may need regular checkups to see if there have been changes in the curvature of their spines as they grow.

Braces- When childens' bones are still growing and he or she has moderate scoliosis, the doctor may recommend a brace. Wearing a brace won't cure scoliosis or reverse the curve, but it usually prevents further progression of the curve.

The most common type of brace is made of plastic and is contoured to conform to the body. This brace is almost invisible under the clothes, as it fits under the arms and around the rib cage, lower back and hips. Milwaukee brace.

Surgical treatment: A specialist may suggest scoliosis surgery to reduce the severity of the spinal curve and to prevent it from getting worse.

The most common type of scoliosis surgery is spinal fusion.

In spinal fusion two or more of the vertebrae are fused together, so they can't move independently.

If the scoliosis is progressing rapidly at a young age, surgeons can install a rod that can adjust in length as the child grows.

Complications of spinal surgery may include bleeding, infection, pain or nerve damage. Rarely, the bone fails to heal and another surgery may be needed.

Physical therapy management:

The aims of physical therapy are:

·         Autocorrection 3D

·         Coordination

·         Equilibrium

·         Ergonomical corrections

·         Muscular endurance/ strength

·         Neuromotor control of the spine

·         Increase of ROM

·         Respiratory capacity/ education

·         Side-shift

·         Stabilisation

Exercises: The Schroth Method is a nonsurgical option for scoliosis treatment.It uses exercises customized for each patient to return the curved spine to a more natural position. The goal of Schroth exercises is to de-rotate, elongate and stabilize the spine in a three-dimensional plane.

There are also other exercises that have been found effective eg Scientific Exercises Approach to Scoliosis (SEAS) exercises.

The SEAS exercises are, according to the Italian Scientific Spine Institute (ISICO), based on a specific form of Active Self-correction (ASC), that is taught individually to each single patient. This is to achieve the maximum possible correction. ASC is then associated with stabilizing exercises that include neuromotor control, proprioceptive training and balance.

Klapp Exercises are another exercise program. It was a nonsurgical method established with the aim of correcting the spinal curvature by stretching and strengthening the back muscles.

Breathing Exercises combined with the thoracic active mobilizations are another important aspect of physiotherapy.