Conservative Management of Idiopathic Scoliosis in an Adolescent Rita B. Shapiro, PT, MA, DPT CDR, USPHS COF Annual Symposium Therapist Category Day- May 25, 2010

Scoliosis is defined as a partially-fixed lateral curvature of the spine observed on a standard radiograph. In truth, the deformity is three-dimensional and rotation is a critical component. In approximately 85% of diagnosed cases, etiology is unknown.

Adolescent Idiopathic Scoliosis (AIS) AIS is most common type in children from an average age of 10 years to maturity. About 10 percent of all adolescents have some degree of scoliosis. Less than 1 percent, require medical attention other than careful observation of the problem. Females are predominately affected, with a female to male ratio of 1.4:1 for curves 11 degrees to 20 degrees, and the ratio increases to 5:1 for curves greater than 20 degrees

Diagnosis Scoliosis is usually diagnosed clinically with objective measurements via plain radiographs measuring the Cobb angle. The Cobb Angle is the angle between two lines drawn perpendicular to the upper endplate of the uppermost vertebrae involved and the lower endplate of the lowest vertebrae involved. For patients who have two curves, Cobb angles are measured for both curves.

Cobb Angle Measurement for Dextroscoliosis

Case Description The patient was a 13.5 year old otherwise healthy female middle school (8th grade) student She had been complaining of "nagging" neck and lower back pain of approximately six months duration.

Review of Systems Patient was hypothyroid and was under the care of a pediatric endocrinologist Medications:  Synthroid® prescribed by physician for hypothyroid  Minocycline® prescribed by the physician for acne control  One daily multivitamin and sometimes Tylenol® or Motrin® for pain control.

ROS-Continued Patient was slightly active but not athletic and had to carry a heavy back pack to and from school Patient's body mass index was Kg/m² (height cm, weight 56.6 kg)

Physical Observation-posterior Initial Physical Therapy Examination Standing Rear View note elevated right shoulder and right iliac crest

Physical Observation-Anterior Initial Physical Therapy Examination Standing Front View, note elevated right ASIS

Forward Bend Test Initial Examination Bent over Test eliciting right rib hump

X-ray Findings The x-ray report revealed an approximately 8 degrees dextroscoliosis from the superior endplate of T1 and extending to the inferior endplate of T8 measured by the Cobb method. The orthopaedist measured the curve to be 10 degrees by the Cobb method. Bone Age study had been ordered by an endocrinologist when the patient was 11 years old. The results of that study indicated that the patient's bone age was 14 years versus the chronological age of 11 years and 4 months, thus indicating that the bones were at a higher level of maturity possibly due to the thyroid disease or early puberty.

Treatment Interventions Initially intervention included:  Pain Management-Heat/Ice/MFR  Hands on stretching Hands on stretch guidance demonstration only (Not the patient in this case report)

Schroth Method The three dimensional method advocated by Schroth includes the placement of hands by the therapist in the clinic, or a family member at home, to make the patient aware of the narrow segments of the scoliotic spine, and how to stretch those narrowed segments, and the use of a mirror for self guided postural correction

Patient Education  Education in Scoliosis management  Pt. and her mother were educated in individual exercises and movement patterns  Proper back pack lifting techniques and how to utilize the chest harness and the waist strap

Patient Education The drawbacks of picking the back pack with one hand and slinging it over one shoulder, right in her case, were explained to the patient in detail. She was shown how continuous load over one muscle group or one anatomical region would eventually cause that group to fail without adequate counter balance.

Patient's Exercise Program

Exercise Program-Contd.

Hippotherapy Many studies have been published on the effects of horseback riding (Hippotherapy) on posture improvement which is accomplished through strength improvement of the small spinal muscles, achieving muscular balance, core strength and hence, scoliosis stabilization.

Horseback Riding Patient began horse back riding program at approximately six months of beginning the Physical Therapy program. Note excellent posture attained. A: Profile B: Lateral view C: Back view

Follow up X-rays At six months, the results indicated the curve had increased to 12 degrees At one year the curve had reduced back to 10 degrees. No radiographs past one year were taken

Three year Follow Up Front view: note improved posture Rear view: note no right shoulder elevation Bent over test: Rib Hump unchanged

Three Year Follow Up Initial front view (left) and at three year follow up (right) Note improved posture, no shoulder elevation and level ASIS

Discussion During a thorough review of the patient's medical record, it was noted that only six months prior to patient's first visit to physical therapy clinic (self referred), she was seen by an adolescent primary care provider for school physical. The provider had made an incidental remark in the assessment as "mild scoliosis is noted will follow". However, no instructions or further follow-up plans were given to the patient or her mother

Discussion It has been documented that untreated, idiopathic scoliosis will invariably arrest without requiring any interventions. Studies by Negrini et al and Hawes and O'Brien demonstrate that approximately 10 percent of untreated cases of mild idiopathic scoliosis will lead to permanent spinal deformities and other related medical problems. Asher and Burton demonstrated that though rare, untreated curves can progress to more than 100 degrees range even after skeletal maturity.

Final Take Aways Though AIS may not progress to the point of disability, once discovered, the asymmetry must be properly documented, a definitive follow up plan must be established and, appropriate information provided to the adolescent and the family.

Final Take Aways-Contd. A simple baseline test and a sound follow up strategy can allow for simple remedies and adoption of healthy lifestyles in our youth that is already on the rough road of many morbidities due to lack of physical activity.

Questions????