Adult female with severe progressive scoliosis possibly secondary to benign tumor removal at age 3 treated with Scoliosis Specific Schroth Physiotherapy (SSSPT) after refusing surgery: case study ANDREA LEBEL, M.PT., Schroth Certified Physiotherapist, Ottawa, Canada VICTORIA ASHLEY LEBEL, M.Sc., M.D. Candidate 2016 Drawings by C. Lehnert-Schroth Drawings by C. Lehnert-Schroth Ottawa & District Physiotherapy Clinic, Scoliosis Physiotherapy and Posture Centre, Ottawa, Canada

Background: In Canada, adult patients are not referred for Scoliosis Specific Physiotherapy, however, Schroth physiotherapy could be effective in improving scoliosis curves, vital capacity, and quality of life, and reducing pain. Adult curve progression, averaging 1-degree per year, can be stopped and even reversed in some cases. PA Radiograph (2008 ) Photograph taken during Schroth physiotherapy exercise group session in 2009. Ottawa & District Physiotherapy Clinic, Scoliosis Physiotherapy and Posture Centre, Ottawa, Canada

Design/Methods: In 1988, a 4 cm benign ganglioneuroblastoma was surgically removed from the left posterior rib cage, adjacent to the thoracic spine, of a 3-year-old girl. At age 11, she was diagnosed with AIS and was managed with the “wait and watch” method until the age of 17 when spinal fusion surgery was recommended. The patient refused. Fusion of 4th and 5th ribs on AP radiographs from 1993 and 2008 Early sign of Scoliosis visible on MRI (1993) CT scans and Radiographs and MRI were stored at the SickKids Hospital. Images are Showing progression between 1988 post surgery until 1993 when patient was 6 years old. Early signs of scoliosis and fused ribs were visible at an early age but not until age 11 this patient was diagnosed with AIS by her family physician and was managed by the Wait and Watch” method until age 17, when surgery was recommended. No records were kept but the family physician 10 years after patient moved away. At age 3 post surgery ribcage looks balanced and no sign of scoliosis. At age 6 visible vertebra rotation and ribcage asymmetry is noticeable RVAD is 24 degrees. According to Mehta this indicates a progressive scoliosis. Other than observation and surgery no other treatment was offered to this patient. At age 23 … Ottawa & District Physiotherapy Clinic, Scoliosis Physiotherapy and Posture Centre, Ottawa, Canada

In November 2008, at the age of 23 years, during initial physiotherapy evaluation, the patient complained of a 2-year history of severe intermittent episodes of low back pain and shortness of breath, which had progressively worsened to the point where she had to discontinue all physical activities. A radiograph from 2006 showed a 68-degree Cobb angle thoracic curve and a 47-degree Cobb angle lumbar curve. Thoracic ATR was 19-degrees, chest expansion was 1.5 cm at the nipple line, and no breath sounds were heard over the left lower lobe. Photos were taken to document body image. A follow-up radiograph revealed a 70-degree Cobb angle thoracic curve and a 48- degree Cobb angle lumbar curve. In addition to curve progression, the follow-up radiograph also showed fused 4th and 5th left ribs. In November 2008, the patient began Schroth physiotherapy, focusing on directional breathing and 3C curve-specific exercises. Patient has not had any more follow-up radiographs since 2009, but continued to be monitored by ATR, chest expansion, VC, and incentive spirometry. Schroth Physiotherapy Exercise, Muscle-cylinder (July 2009) Initial Photograph (2008) Source: Ottawa & District Physiotherapy Clinic, Scoliosis Physiotherapy and Posture Centre, Ottawa, Canada Source: Ottawa & District Physiotherapy Clinic, Scoliosis Physiotherapy and Posture Centre, Ottawa, Canada

Results: Vital Capacity Measurements (2008-2014) Within one month of beginning SSSPT, the patient reported no more back pain and within 2 months, reported improved breathing. In January 2009, physiotherapy visits were decreased to 2-4 times a month while the patient continued with 45-60 min home exercise program (HEP) 3-5 times a week. Over the next several months, air entry into the left lung improved and chest expansion increased from 1.5 cm to 4.0 cm from November 2008 to May 2009. In July 2009, 9 months after beginning SSSPT, radiographs showed reduced thoracic and lumbar Cobb angles of 58 and 43 degrees, respectively. Private radiographs arranged by the patient taken during Schroth exercise showed thoracic and lumbar Cobb angles of 48 and 33 degrees, respectively. The patient showed continued improvement in VC and ATR. She became more active and resumed all athletic activity by summer 2009. Since 2009, she continues to improve with Schroth home physiotherapy exercises 2-3 times a week. Her VC increased from <2,000 mL in July 2010 to 3,200 mL in December 2014 T-58° L-43° T-48° L-33° T-38° L-30° T-70° L-48° a) b) c) d) a) Radiograph taken before Schroth Physiotherapy started (2008). b) 9 months after beginning Schroth Physiotherapy (2009). c) In active self correction position during Schroth physiotherapy exercise. d) In brace, in preparation for rib surgery (patient decided not to do surgery for 4th and 5th rib separation. She obtained the brace to be used after surgery as recommended). Vital Capacity Measurements (2008-2014) mL Mean of SRS/22 mL mL 2011: 4.50 2012: 4.73 2013: 4.68 2015: 4.64 mL mL mL mL Ottawa & District Physiotherapy Clinic, Scoliosis Physiotherapy and Posture Centre, Ottawa, Canada

Since 2009, the patient has been enjoying running marathons, mountain climbing, snow boarding, scuba diving and raising 2 young children with her husband. Conclusion: Adult scoliosis patients are not routinely referred for SSSPT, even though SSSPT has been shown to be effective in this case study. Schroth PT should be part of scoliosis management in adults in Canada to avoid a 1-degree average annual progression and to improve quality of life. The authors would like to thank the patient for sharing her case. Ottawa & District Physiotherapy Clinic, Scoliosis Physiotherapy and Posture Centre, Ottawa, Canada