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September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom www.nspine.co.uk. Osteopathic Management of Adolescent Idiopathic Scoliosis. Adolescent Idiopathic Scoliosis. Lateral spinal curvature that forms in patients aged 10-18 years of age, with unknown cause.
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September 5th – 8th 2013 Nottingham Conference Centre, United Kingdom www.nspine.co.uk
Adolescent Idiopathic Scoliosis • Lateral spinal curvature that forms in patients aged 10-18 years of age, with unknown cause. • Scoliosis is defined as a spinal curvature of more than 10° (Cobb angle measurement), accompanied by vertebral rotation. • Scoliosis can resemble an ‘S’ or ‘C’. • Affects 2-4% of 10-16 year olds. • Affects girls more than boys.
Presentation • AIS generally does not result in pain or neurological symptoms. • Low back pain may be present, but it is often due to poor spinal mechanics, poor core strength and lack of flexibility in the hamstrings, rather than as a result of the AIS specifically. • Deformity can cause marked psychological distress.
Observation • Shoulder height asymmetry – one appears higher than the other. • A side shift of the body – especially with a C-shaped scoliosis (no secondary curve to re-balance). • Waist asymmetry – one hip appears higher than the other – one leg may seem longer in standing. • Uneven musculature on one side of the spine. • Prominent rib hump secondary to the rotational aspect of the scoliosis (most apparent on forward flexion). • Typically, normal appearance when viewed from the side.
Physical Examination • Adams Forward Bending Test Patient holds arms straight down, with palms of hands together and flexes forwards → unilateral prominence is noted with scoliosis. • Leg Length – measure. • Plumb Line Plumb line is dropped from C7 & allowed to hang below buttocks → in scoliosis, the line does not hang between the buttocks. • Range of Motion Measure patients ability to perform flexion, extension, sidebending & rotation → determine flexibility of curves. • Palpation • Neurological exam
Diagnostic Tests • Scoliometer–measures rib prominence when patient is forward flexed. • X-rays–upright and bending. • Cobb angle measurement – lines drawn on x-ray perpendicular to lines along the superior edge of the vertebra at the top of the curve & along inferior edge of the vertebra at the bottom of the curve → gives angle. • Risser Sign – x-ray of iliac crest growth plate indicates skeletal maturity. • Lenke classification – determines what levels of the spine to fuse & instrument.
Other Signs • Severe pain or an abnormal neurologic examination are red flags that point to a secondary cause for spinal deformity. • Other signs that may indicate underlying cause: • Altered gait. • Dimple, hairy patch, lipoma or haemangioma (spina bifida). • Café au lait spots on skin (neurofibromatosis). • Cavovarus deformity of feet. • Abnormal abdominal reflexes. • Altered muscle tone for spasticity.
Progression • AIS curves progress during the rapid growth period. • While most curves slow their progression significantly at the time of skeletal maturity, some, especially curves >60°, continue to progress during adulthood. [In general, girls grow until approximately 14yrs (or 2yrs after their first menstrual period), while boys grow until about 18yrs]. • Of those diagnosed, only 10% have curves that progress & require medical intervention.
Management Options Management of scoliosis is complex & is determined by the severity of the curvature & skeletal maturity, which together predict the likelihood of progression. • 10-20° curve monitor • 20-45° curve may be a case for bracing – but success is heavily dependant on compliance – have to wear brace for 22hrs/day until skeletal maturity. • 45-50° curve case for surgery • >50° curve studies show that the curve will continue to worsen by 1-1.5°/year beyond 20yrs (regardless of skeletal maturity).
Osteopathic Considerations • Flexion restrictions tend to be over convexity, whereas extension restrictions tend to be present on concavity – restrictions zig zag up the spine. • Often, most symptomatic area is the Tsp, & generally at the ‘junction’ where lumbar flexion & cervical restrictions meet. • Stress points occur at junctional areas where contra-rotations occur → patient reports pain in these areas. • Soft tissues are stretched on side of convexity and contracted/shortened on side of concavity. • Scapula winging often occurs over the rib hump → altered shoulder mechanics. • Anterior rib restrictions – almost always remain fixed down even with arm elevation – involvement of pectorals, infraspinatus & teres muscles.
Treatment Strategy • Primary objective is to improve spinal mobility at a segmental level. • Deal with flexion restrictions initially before addressing extension restrictions (overcoming limitations of Tsp extension is challenging). • Articulate into de-rotation to encourage rotational mobility. • Mobilise rib and sternal restrictions. • Soft tissue techniques to address shortened scalenes, trapezii, levator scapulae (often ipsilaterally), shortening through rotator cuff & rhomboids. • Also address large span muscles, e.g. latissimus dorsi. • Muscles tend to respond well to passive stretching. • Look at influence of LEX.
