SCOLIOSIS

Spinal deviation of more than 10 degrees in the frontal plane is referred to as scoliosis.

CURVE PLACEMENT

There are numerous Curve  patterns that scoliotic malformations can take on, and various helpful classification schemes have been created. The Scoliosis Research Society's (SRS) Terminology Committee provides a thorough technical explanation of curve placement.

The following list of areas of the spine that are affected by scoliosis are determined by the placement of the apical vertebrae.

1-The apex of the cervical spine is between C2 and C6 
2-The apex of the cervicothoracic spine is between C7 and Tl
3-The apex of the thoracic spine is between T2 and T11
4-The apex of the lumbar spine is between L2 and L4
5-The apex of the lumbosacral spine is at L5 or below
  

CLASSIFICATION OF SCOLIOSIS

1-By age
2-By Size Of Curve 
3-By Location Of Curve
4-By Cause Of The Condition

         BY AGE 

INFANTILE SCOLIOSIS

Birth to 3 yr old

Infantile scoliosis further classified in to two types ; 

1-Idiopathic : Cause unknown

2-Congenital : The spine curves because of missing or irregularly formed vertebra that throw off the spine's balance. This particular form of scoliosis may be linked to defects in other organs, including the heart and kidneys.        

JUVENILE SCOLIOSIS

3 to 10 yr old 

1-Idiopathic : Idiopathic means that the reasons of juvenile scoliosis are, for the most part, unknown.  

ADOLESCENT SCOLIOSIS 

10 to 18 yr old 

1-Idiopathic : Girls have severe and progressive curvature more commonly than boys experience, for unexplained reasons.

Compared to infantile idiopathic scoliosis, juvenile scoliosis is more prevalent, whereas adolescent idiopathic scoliosis is less common.

BY SIZE OF CURVE

Conditions with a Cobb angle of 25 degrees or less are considered to have mild scoliosis.

Scoliosis that has a Cobb angle between 25 and 40 degrees is considered moderate.

Scoliosis that is severe is defined as having a Cobb angle of at least 40 degrees for adolescents and 50 degrees for adults.

*COBB ANGLE : Cobb postulated that the 'angle of curvature' be determined by drawing lines parallel to the upper border of the upper vertebral body and the lower border of the lowest vertebra of the structural curve, and then erecting perpendiculars from these lines to cross each other.

BY LOCATION OF CURVE

1-Thoracic 

 ‘C’ shaped curvature in the middle portion of the spine

  symptoms 

• Uneven shoulder height
• Uneven rib cage
• Back pain
• Uneven shoulder blades
• Uneven waist height
• Breast difference
• Difficulty breathing

2-Lumbar

 ‘C’ shaped curve in the lower section of the spine

symptoms 

• Uneven shoulders
• Unusually raised hips
• Uneven rib cage alignment
• Uneven waist
• Body leaning to one side
• Back pain

3-Thoracolumbar

‘S' shaped curvature at the junction of mid back (lower thoracic) and low back (upper lumber) region

Symptoms

• Uneven shoulders
• One-shoulder blade protruding more on one side than the other
• Uneven waistline
• Uneven hips
• One side of the rib cage protruding more (rib arch)
• Back pain (more common in adult)

5-Dextroscoliosis

 spine curve to the right

6-Levoscoliosis

spine curve to the left

BY CAUSE OF THE CONDITION

Degenerative scoliosis is a type of scoliosis in which a spinal curvature develops as a result of degenerative changes to the spine that occur as a natural part of aging.

This is most prevalent in older people.

Idiopathic scoliosis is a type of scoliosis in which there is no known single cause. 

Scoliosis caused by trauma to the spine, such as a fall or car accident, is called traumatic scoliosis.

Neuromuscular scoliosis is a type of scoliosis that occurs in children who have medical conditions that make it difficult for the body to control the muscles that support the spine. Muscular dystrophy, cerebral palsy, and spina bifida are the most common causes.

Those cases of pathological scoliosis in which tumors are present It is possible for a tumor to push against the spine, resulting in a curvature.

Congenital scoliosis is a condition in which a bone defect developed during pregnancy. An abnormal curvature of the spine is caused by a defect in the formation of the bones.

Adult De Novo Scoliosis case in which adults develop scoliosis without a history of the condition. Adults can develop idiopathic scoliosis in some cases, but the majority of cases fall into the degenerative, traumatic, neuromuscular, or pathological categories.

CAUSES OF SCOLIOSIS

• The cause of scoliosis is unknown in 80% of cases .
• Physical Abnormalities : cause muscle and bone imbalance . Some physical abnormalities are as follow ;

                                     1-Children who have muscular imbalances surrounding their                                           vertebrae may develop spinal deformities as they grow.

                                     2-Idiopathic scoliosis patients have unusually high arches in                                           their feet, which may indicate that impaired balance is a                                                   problem in some circumstances.

                                     3-some children with scoliosis may develop their spines                                                     asymmetrically due to congenital abnormalities in perception                                         or coordination.

• Biologic factors: Scoliosis can be caused by a variety of biological reasons
• In addition, conditions like muscular dystrophy, polio, or cerebral palsy may cause muscle paralysis or degeneration, leading to scoliosis. 
• Albers-Schonberg disease, rheumatoid arthritis, Friedreich ataxia, Marfan's syndrome, and osteogenesis imperfecta are further illnesses that can result in scoliosis. 
• Scoliosis can also result from damage to the spinal cord. 
• Scoliosis has been linked to a relatively uncommon genetic condition known as familial dysautonomia.
• Scoliosis has been linked to birth abnormalities such as spinal bifida and myelomeningocele .
• The causes of scoliosis in young children may involve more than previously believed tumours, growths, or minor anomalies on the spinal column. 
• The risk of spinal deformity is increased by back surgery to remove benign tumors.
• Muscle spasms, poor posture, and variations in leg length can all contribute to nonstructural scoliosis.

SYMPTOMS

• Scoliosis typically causes little pain. 
• Atypical posture, which includes a tilted head, an outstretched shoulder blade, and one hip or shoulder that is higher than the other, resulting in an uneven shirt hem or collar. 
• The child may slant more to one side than the other.
• Fatigue may occur in after prolonged sitting or standing in cases of more severe scoliosis. 
• Pain can occasionally be induced by spinal curves brought on by muscle spasms or tumors.

DIAGNOSIS 

The degree of spinal curvature and the angle of trunk rotation (ATR) help diagnose scoliosis and determine if it requires therapy . Each is measured in degrees.

When the curve is 11 degrees or more, scoliosis is diagnosed; however, treatment is typically avoided until the curve is 30 degrees and the ATR is 7 degrees.

Forward Bend Test

With their knees straight and palms pressed together, the patient leans forward at the waist. This examination should be carried out 

• From the side (to check for kyphosis), 
• From the front (to check for upper thoracic rotation), 
• From the back (to check for lumbar and midthoracic rotation).
  
  
  

The height of the prominence in centimeters should be used to assess any asymmetry of the upper thoracic, midthoracic, thoracolumbar, and lumbar areas. This can be done with a scoliometer  to determine the angle of trunk rotation (ATR).

Other Physical Tests

• In most cases, the patient is asked to walk on their toes, then their heels, and finally to jump up and down on one foot. Such movements indicate balance and leg strength. 
• Examine the back of the leg for tight tendons, which are common in adolescence but could potentially be signs of nerve root irritation or spondylolisthesis, a disease in which one vertebra has moved forward over the other. 
• By evaluating reflexes, nerve sensitivity, and muscle function, the doctor will also look for neurologic impairment.

Further Assessment, Limb Length

• A thorough scoliosis examination also includes looking for cutaneous signs of an underlying disease on the skin, both on the back and elsewhere. 
• While dimpling or a hairy patch in the lumbosacral region may signal an underlying spinal dysraphism, cafe-au-lait patches and/or axillary freckles suggest a probable neurofibromatosis. 
• A connective tissue disease may be responsible for excessive laxity of the skin or joints.
• If a pelvic tilt is detected during the standing test, limb length should also be evaluated in the supine position.
• A compensatory spinal curvature that arises from a discrepancy in limb length works to rebalance the trunk over the pelvis .

IMAGING TEST

Currently, the most economical way to diagnose scoliosis is using X-rays.

          In many aspects, X-rays are necessary for a precise diagnosis of scoliosis.

•  X-rays show the severity and extent of scoliosis.
• X-rays reveal any further spinal anomalies, such as hyperlordosis and kyphosis  (swayback).
• X-rays also assist in determining when skeletal growth has developed.
• Patients who are bending can distinguish between structural and nonstructural scoliosis using X-rays.When a person bends over, structural curves remain while nonstructural curves typically vanish.

     Calculating the Curve  

     Cobb Method : Typically used to determine the curve's degree.

The examiner makes two lines on an X-ray of the spine: From the border of the top vertebrae of the curve, one line runs forth and upward. Outward and downward from the bottom vertebrae is the second line. Then, a line perpendicular to the two lines is drawn. The degree of curvature is calculated from the intersection angle.

The Cobb technique has limitations since it is unable to properly account for the spine's three-dimensional nature. Therefore, it is less useful in describing spinal rotation or kyphosis. Additionally, the curve is often overestimated. To make a diagnosis that is more precise, further diagnostic techniques are required.

TREATMENT

Scoliosis is often treated by monitoring the disease if the curve is less than 20 degrees and by treating it if it is more than 25 degrees or if it progresses by 10 degrees while being observed.

BRACES OR SURGERY

Although surgery is recommended for more severe curves and braces for mild curves, the decision may not always be clear-cut.

•  Children with curvatures between 25 and 40 degrees who are still expected to have significant growth typically wear braces. 
• Patients with curvatures greater than 50 degrees, those who are untreated, or those whose braces have failed may benefit from surgery. 
• Scoliosis rarely advances over 40 degrees in adults, although surgery can be necessary if the patient is in severe discomfort or if it is dealing with their ability to function.

PHYSICAL THERAPY

• Physiotherapy Scoliosis Specific Exercises is the concept used by SOSORT (PSSE).
• Cobb angle, angle of trunk rotation, discomfort, and quality of life were all improved with PSSE.
• In addition to the Lyon approach from France, the Katharina Schroth Asklepios approach from Germany, the Scientific Exercise Approach to Scoliosis (SEAS) from Italy, the Barcelona Scoliosis Physical Therapy School (BSPTS) from Spain, the Dobomed approach from Poland, the Side Shift approach from the United Kingdom, and the Functional Individual Therapy of Scoliosis (FITS) from Poland are also among them.

The Lyon approach (France) 

Traditionally, the Lyon method combined PSSE with the Lyon brace and casting, but more recently, PSSE with bracing alone under the new Lyon ART brace (Asymmetrical Rigid Torsion brace).

Physiotherapeutic Treatment includes the spine is mobilized in three dimensions, the ilio-lumbar angle is mobilized to treat lumbar scoliosis, patients are educated, and daily living activities are improved, including the sitting position.

Principles of the Lyon method

The Lyon method of scoliosis treatment involves five

stages:

1. The Lyon approach to assessment

The Cobb angle, the patient's age, and the postural imbalance are the three considerations made by the Lyon approach while determining the treatment plan to follow.

2. Awareness of trunk deformity

The Lyon method employs visualization using mirrors and video to aid with curve adjustment.

                                              3. What to do: sample exercises

The Lyon method's basic principles are to avoid spinal extension during exercise, improve kyphosis of the thoracic area with lumbar spine lordosis, as well as frontal plane correction, segmental mobilization, core stabilization, proprioception, balance, and stabilization. Exercises performed in the plaster cast both before and during bracing are heavily emphasized in the Lyon approach in order to promote balance and muscular strength and endurance while wearing the cast or brace.

Active thoracic mobilization, promoting kyphosis, using the Lyon method

Active lumbar correction, promoting lordosis, using the Lyon method

Active thoracic shift exercise with a dowel (a) and a Swiss-ball (b) using the Lyon method

Active thoracic shift and de-rotation exercise using the Lyon method

Balance and proprioception exercises on a Swiss-ball (a) and on a balance board (b) using the Lyon method

Spinal stabilization exercises using the Lyon method

Several standard Lyon exercises in a Lyon plaster cast promoting core strength (top left), breathing and thoracic shift (bottom), and elongation

Several standard Lyon exercises in a Lyon plaster cast promoting postural correction (a) and core strengthening (b)

4. What not to do and why

The Lyon approach stays away from activities that make you gasp for air and sagittal plane severe movements (flexion and extension).

5. Sport or only physiotherapy?

The Lyon technique teaches patients how to exercise and which sports are best and the worst for scoliosis.

The use of breathing mechanics, muscle activation, and mobilization

To expand lung capacity, the Lyon method combines rotational angular breathing with the diaphragm and a breathing machine. 

The Lyon approach emphasizes mobilization to enhance correction and enhances the deep paraspinal and core musculature's endurance.

Active thoracic mobilization using the Lyon method

Active lumbar mobilization using the Lyon method

Mobilization of the costovertebral joints using the Lyon method

The Schroth method (Germany) 

The major objectives of the Schroth technique are to give patients effective care and to educate and train physiotherapists. The therapy strategy combines intensive inpatient rehabilitation with residential outpatient physical therapy delivered by certified Schroth therapists.

The Schroth classification system provides a clear orientation for the standardized therapy plan that includes the therapy diagram, exercise-program with home-exercises, and necessary mobilizing technique. It also provides the direction of the side deviation and rotation of the main important body blocks (major curves).

The Schroth classification system states that each kind of scoliosis always begins with the major curve and is followed by any relevant secondary curves.

Schroth body blocks:

H – Hip-pelvic block including the lower limbs reaching the lower end vertebra (LEV) of the lumbar curve.

L – Lumbar block enclosed by upper end vertebra

(UEV) and LEV of the lumbar curve or thoracolumbar

curve respectively.

T – Thoracic block between UEV and LEV of the

thoracic curve.

S – Shoulder block represents the cervical thoracic

(proximal thoracic) curve located between UEV of the

thoracic curve and UEV of the proximal thoracic curve.

Description of Schroth method exercises 

The "50 x Pezziball," "Prone," "Sail," and "Muscle-cylinder" exercises are four of the Schroth method's most frequently performed exercises.

These exercises can be used to any form of curve.

 "50 x Pezziball" workout causes the trunk's convexities to move "ahead and inward" and its concavities to move "outward and backward," by activating muscles in the trunk.

The "Prone exercise" corrects the lumbar curve by activating the iliopsoas muscle and the thoracic curve by utilizing shoulder traction (ST) and shoulder counter-traction (SCT).

The Sail exercise helps lengthen the thoracic concavity and is a particularly efficient stretching exercise.

The quadratus lumborum muscle is activated by the muscular cylinder to adjust the lumbar curve in oppose to gravity.

Scientific exercise approach to scoliosis (Italy) 

The SEAS approach for treating scoliosis aims to improve spinal stability and regain postural control with exercises that actively correct the scoliotic posture in three dimensions.

Right thoracic curve mobilization in preparation for bracing is aimed at increasing the range of motion of the spine according to the SEAS method

SEAS exercises in brace. The patient is in a relaxed position lying prone (a) and then lifts the trunk away from the sternal part of the brace to increase the thoracic kyphosis (b). Similarly, the patient is in a relaxed standing position (c) and moves the abdomen posteriorly away from the abdominal part of the brace to increase the force on the lumbar pressure pad (d)

SEAS mobilization and flexibility exercises of the spine to improve joint mobility for better posture correction

Assistive devices like balance boards are used at the beginning of learning the SEAS method

SEAS principles of maintaining self-correction during activities of daily living such as sitting (a), sitting leaning forward in preparation for standing and sit-to-stand (b, c), standing (d), and landing on a wall (e, f)

SEAS exercises aimed to improve balance while maintaining active self-correction either by standing on one leg on a balance board (a) or by performing a knee-bending exercise on the balance board (b)

Barcelona scoliosis physical therapy school (Spain)

The BSTPS method aims to:

1) correct the "scoliotic posture" and improve appearance

2) stabilize the spine and prevent the progression of the curve

3) inform patients and their families about the condition and available treatments; 4) enhance breathing function

5) increase activity, including daily activities and functional mobility

6) improve overall self-image and self-esteem

7) reduce pain

The Dobomed method (Poland) 

The Dobomed approach aims to stabilise and repair the spinal deformity as well as prevent the evolution of the scoliosis and/or decrease its curvature.

The enhancement of the patient's total functional status, particularly respiratory function, is another goal of this approach.

The Dobomed method's primary requirement is cooperation. Dobomed is therefore not advised for young children who are unable to understand and complete the tasks. Instead of active 3D correction, stabilising exercises are emphasized for older patients.

Side shift (United Kingdom)

The Side Shift technique of scoliosis therapy aims to actively correct the spinal curvature aimed at the apex of the scoliosis by moving the trunk in a concave direction and making active postural corrections in all planes.

Functional individual therapy of scoliosis (Poland)

The nine main goals of the FITS concept:

1. Awareness of existing deformation of the spine and the trunk, and of the direction of the scoliosis correction.

2. Sensory-motor balance training 

3. Release of myofascial structures that limit three-plane corrective movement 

4. Lumbo-pelvic stabilization 

5. Correction shift of the spine in frontal plane in order to correct the primary curve while stabilizing (or maintaining in correction) the secondary curve . 

6. Facilitation of three-plane corrective breathing in functional positions and brace wearing 

7. Correction patterns of scoliosis. Postural re-education. 

8. Auto-correction in activities of daily living. 

9. Clinical improvement, decrease or stabilization of the scoliosis curvatures.

SCOLIOSIS STREGTHNING EXERCISE

OPEN BOOK EXERCISE

• Begin on hands and knees with one hand behind head. Rotate away from your stationary arm to open chest, then rotate in to bring your elbows together, closing the chest

 • Improves thoracic mobility and strength

SIDE PLANK EXERCISE

• Laying on your side, tighten abdominal muscles and lift hips off the table maintaining a neutral spine

• Begin exercise from knees and progress to your feet as your build strength.

• Perform for 10 seconds and progress to 30 seconds as tolerated.

BIRD DOG EXERCISE

• Maintaining a neutral spine, tighten abdominals and slowly raise

one arm or one leg at a time. Do not pass horizontal.

• To increase difficulty, raise opposite arm and opposite leg at the same time.

PELVIC TILT:

·    Lie face-up on the floor with knees bent, feet flat, and arms at your sides.

·    Tighten your belly and buttocks to curl your pelvic bone inward, feeling your lower back flatten out against the floor.

·    Hold for five seconds, breathing normally, before releasing. repeat.

SUPERMAN

·         Lie on your stomach with your arms extended in front of you, palms down.

·         Lift both feet and arms.

·         Hold, then release.

ARM/LEG RAISE

·         Lie on your stomach with your chin or forehead to the ground (you can place a towel underneath). Keep your legs straight and arms extended overhead.

·         Slowly raise one arm off the ground, hold for a moment, and lower it back to the ground.

·         Now repeat this for your other arm and legs, 15 repetitions each.

CAT/CAMEL

·         Start on your hands and knees (quadruped position), place your wrists just below your shoulders and place your knees just below your hips.

·         Try to straighten your shoulder, spine and, hip in one line.

·         Maintain spine in neutral position.

BREATH IN FOR CAT POSE

·         Take a breath in try to take your back down towards the floor

·         Then you lift your neck towards the ceiling.

·         Now sticking your tailbone out to make a curve with your spine.

·         Take a big breath out at the same time.

BREATH OUT FOR CAMEL POSE

·         Now you breath out Tuck in your chin and tailbone in

·         Try to upward your spine towards ceiling you have to look over floor.

          Try to make hump over your spine

SPIDER

·     Stand facing the wall with your feet together.

·     Lean forward and place your hands on the wall at chest height. Tighten your abs and walk your fingers up the wall.

·    As you extend your arms over your head, come up on your tiptoes.

·    Once your arms are extended, with a straight line from hands to heels, walk your fingers back down.

·    Repeat, keeping abs and lower back muscles engaged.

 

FOAM ROLLER BALANCING

·    Lie longwise on a foam roller with your tail on one end, head on the other and feet about hip-width apart.

·     Lift one knee so your calf is parallel to the floor while lifting the opposite arm so straight up so your fingers are pointing at the ceiling.

·     Return to the starting position and repeat on the other side.

BRIDGING

·         Lie on your back with your knees bent (A). Keep your back in a neutral position, not arched and not pressed into the floor. Avoid tilting your hips. Tighten your abdominal muscles.

·         Raise your hips off the floor until your hips are aligned with your knees and shoulders

ABDOMINAL CRUNCH

·         Lie on your back and place your feet on a wall so that your knees and hips are bent at 90-degree angles. Tighten your abdominal muscles.

·         Raise your head and shoulders off the floor. To avoid straining your neck, cross your arms on your chest rather than locking them behind your head. Hold for three deep breaths.

BACK EXTENSION

• ·    Lie with your stomach and quads on a stability ball and your feet braced against the wall.
•      lift up

 

KNEE TO CHEST

·         Lie on your back.

·         Bring your knee toward your chest.

·         Using your hands, gently pull your leg in until you feel a comfortable stretch.

·         Hold for 10 seconds, then place your leg to the floor.

·         Repeat with the other leg and hold for 10 seconds.