Orthotic management of scoliosis

1. ORTHOTIC MANAGEMENT OF SCOLIOSIS Prepared by: MUHAMMAD IBRAHIM KHAN BS.PT(Pak), MS.PT(Pak), NCC(AKUH)

2. Scoliosis 3-dimensional deformity of the spine affecting all the 3 planes. Can be difficult to visualize with 2-dimensional radiographs Scoliosis is a lateral deviation of the normal vertical line of the spine which, when measured by an X-ray, is greater than 10 degrees accompanied by vertebral rotation.

3. Scoliosis “Normal” alignment Spinous processes all line up in a straight line over the sacrum Scoliosis is a combination of Angular displacement Lateral displacement

4. Scoliosis Lateral displacement

5. Scoliosis Angular displacement

6. Genetics 11% incidence in first relatives of patients Normal incidence < 3% Monozygote twins more common No gene identified to date

7. Degrees of Curvature MILD MODERATE SEVERE

8. Types of Scoliosis Congenital Idiopathic Neuromuscular Post Traumatic Infective Degenerative Inflammatory Tumor

9. CONGENITAL SCOLIOSIS The critical time is the time of segmentation process (First Six weeks) and congenital anomalies develop during this period of time. In the presence of vertebral anomalies, there is an imbalanced growth of spine resulting in congenital scoliosis.

10. Classification By MacEwen et al. later modified by Winter, Moe, and Eilers FAILURE OF FORMATION Partial failure of formation (wedge vertebra) Complete failure of formation (hemi vertebra) FAILURE OF SEGMENTATION Unilateral failure of segmentation (unilateral un segmented bar) Bilateral failure of segmentation (block vertebra)

11. Failure of Formation Failure of Segmentation Congenital Scoliosis

12. Patient Evaluation Examine the skin of back for hair patches, dimples, and scars. Look for the evidence of neurological involvement, such as clubfoot, calf atrophy, absent reflexes and atrophy of one lower extremity compared with the other. Look for the other congenital anomalies.

13. Screening hints Shoulders are different heights Head is not centered directly above the pelvis Appearance of a raised, prominent hip Rib cages are at different heights Uneven waist Changes in look or texture of skin overlying the spine (dimples, hairy patches, color changes) Leaning of entire body to one side

14. Scoliometer The patient bends over, arms dangling and palms pressed together, until a curve can be observed in the upper back (thoracic area). The Scoliometer is placed on the back and measures the apex (the highest point) of the upper back curve. The patient continues bending until the curve can be seen in the lower back (lumbar area). The apex of this curve is also measured. An inclinometer ( Scoliometer ) measures distortions of the torso.

15. Adam’s forward bend test For this test, the patient is asked to lean forward with his or her feet together and bend 90 degrees at the waist. The examiner can then easily view from this angle any asymmetry of the trunk or any abnormal spinal curvatures .

16. Measure spinal curvature using Cobb method Choose the most tilted vertebrae above & below apex of the curve. - Angle b/w intersecting lines drawn perpendicular to the top of the superior vertebrae and bottom of the inferior vertebrae is the Cobb angle.

17. Diagnosis Physician Physical Exam Scoliometer measurements X Ray MRI

18. Scoliosis Treatment Observation Spinal curvature<25 Brace Spinal curvature 25-40 Surgery Spinal curvature >40

19. Observation Non progressive curves and Minor curves (>20 degrees) and with other congenital anomalies. Skeleton is close to maturity Exercises may help with surrounding muscular strength. Limited value in patients with congenital scoliosis.

20. ORTHOTIC MANAGEMENT

21. Bracing Usually works on the vertebrae outside the actual congenital deformity. Compensatory curves also can be successfully managed for several years with orthotic treatment. Lumbar curves can be treated in a TLSO, but thoracic curves require a Milwaukee brace.

22. Bracing Duration and time in brace 23 hours per day Wear until skeletally mature

23. Bracing Types Milwaukee Thoraco-lumbar-sacral orthosis (TLSO or Boston brace) Charleston night time bending brace

24. Bracing TLSO Brace

25. Bracing Milwaukee Brace

26. Bracing Charleston night time bending brace

27. Bracing Milwaukee brace Three types of curves respond to brace management: 1- Long, flexible curves, 2- Curves that could be corrected either in traction or on side bending, 3- Curves with a mixture of anomalous and non-anomalous vertebrae.

28. Successful Bracing Prevent curve progression Randomized study Braced 74% did not progress Not braced 34% did not progress Charleston brace still controversial

29. Problems with Braces Argued efficacy Narrow treatment window to initiate Poor compliance Must have good orthotist Curves corrected by 20 degrees in brace do better

30. SURGERY