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1 Physiotherapy Management of Neuromuscular Scoliosis Hannah Waugh 0131 536 0000 Bleep 9126 Specialist Physiotherapist, The Royal Hospital for Sick Children,

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Presentation on theme: "1 Physiotherapy Management of Neuromuscular Scoliosis Hannah Waugh 0131 536 0000 Bleep 9126 Specialist Physiotherapist, The Royal Hospital for Sick Children,"— Presentation transcript:

1 1 Physiotherapy Management of Neuromuscular Scoliosis Hannah Waugh Bleep 9126 Specialist Physiotherapist, The Royal Hospital for Sick Children, Edinburgh

2 2 Contents What is Scoliosis? Medical Management Pre Operative Planning Hospital Admission Challenges post discharge

3 3 What is Scoliosis? Complex three dimensional deformity where the curve is greater than 10 degrees

4 4 Prevalence of Neuromuscular Scoliosis 20% of children with Cerebral Palsy 60% of children with Myelodysplasia 90% of children with Duchenne Muscular Dystrophy

5 5 Neuromuscular Scoliosis Development Spinal curvature may begin very early in life Often after the patient starts supported sitting Curve may progress rapidly once patient becomes non ambulant (averaging 10 degrees/year)

6 6 Initial Assessment yrs 6mth 108 o S.G., 66 o Pelvis ? o

7 yrs 6mth 108 o S.G., 66 o Pelvis ? o yrs 10mth 122 o 58 o Pelvis 34 o Progression of curve – 4 months

8 8 Preventing Progression of Scoliosis Prolong mobility Steroids 24 hour postural management Spinal bracing (not always effective particularly in progressive neuromuscular curves)

9 9 Referral Criteria Consultant to consultant referral only Confirmed scoliosis - requesting specialist assessment for surgical intervention –Neurological – usually after the age of 10 as surgery unlikely prior to this –DMD – when patient becomes non ambulant

10 10 In-depth history is taken –scoliosis progression, pain, function –past medical history –medication –social history Objective Assessment X-rays : standing or sitting to establish severity, bending films to identify flexibility – cobb angle, also check risser grade Initial Spinal Clinic Assessment

11 11 Cobb Angle

12 12 Medical Management Dependent on: –Severity of scoliosis –Pelvic obliquity –Age/Skeletal maturity – risser grade –Rib deformity/ Impingement/ Pain –Complexity of past medical history

13 13 Medical Management Cardiac Respiratory Anaesthetics Neurology/ Neurosurgery Endocrinology GI

14 14 Medical Management - DMD Respiratory Function Functional Ability Symptoms Quality of Life questionnaire Reduction in surgery

15 15 Medical Management - CP Respiratory Function Functional Ability Symptoms Quality of Life questionnaire Surgery

16 16 Medical Management - mylominingecele Respiratory Function Functional Ability Symptoms Surgery

17 17 Medical Management Every case is very individual Function Medical Stability MDT decision

18 18 Medical Management Continue to monitor curve Use of conservative treatment PSF

19 19 Physiotherapy Service Aims To ensure smooth pathway from pre admission to discharge To be available for contact to reduce any anxieties throughout the patient journey To be a resource for local therapists / services for Scotland

20 20 Spinal Surgery Pathway Theatre list to Physio & OT Contact made with local services & family Pre-op assessment completed Equipment requirements identified & commenced Admission Post-op Discharge Local services review

21 21 Physiotherapy Role To ensure that optimal functional abilities are achieved post operatively Those functional abilties include: respiratory function muscle strength transfers/ mobility postural management Overall aim is to maximise independence following surgery in activities of daily living Postural management is vital and should be considered through out all stages of spinal surgery

22 22 Physio Pre op Planning Commenced as soon as the patient is listed for theatre (approx 6 weeks) Facilitate smooth admission and discharge from hospital Early contact with local services is essential

23 23 Pre-operative Planning Unfortunately due to geographic location of clinics, unable to attend Contact will usually be made with the family and local therapists initially by telephone If patients admitted for respiratory tests, trial of NIV or attend for anaesthetic assessment we will meet and assess on ward if possible

24 24 Initial Pre-Op Assessment Physio /OT Establish current abilities of –Seating (wheelchairs,other seating systems school, home) –Transfers (independent, assisted, hoist) –Mobility- use of walking aids –Personal Hygiene (toileting, bathing/showering, level of assistance,specific equipment) –Respiratory function –Other ADL activities (feeding, self dressing) –School –Environmental issues (access to and within house)- child may need to live downstairs

25 25 Seating Wheelchairs –Should be in suitable corrective seating system pre op- consider lateral supports, harness & head support –Tilt & recline facilities recommended pre-op for any patient with scoliosis (Bushby et al, 2005) –Tilt & recline vital post op if fused to pelvis –Moulded wheelchairs are not appropriate post op –Local services to review post op to ensure corrective seating system

26 26 Seating If fused to pelvis other seating systems can be used if have recline Local therapists to review postural support from seating systems post op Post op head rests, lateral supports, harnesses will still be required to maintain optimal postural alignment Sofas, beanbags are not acceptable seating systems!

27 27 Transfers Hoisting –Children that are lifted pre-op may require to be hoisted –Hoisting is dependent on age, size, weight and complexity –High backed slings with head support recommended –Bones in slings not necessary –Thinner sling ideal- will be left in situ initially –Remember to consider that child may require increased sling length post op –Responsibility of local services to provide hoist training if new/ different equipment has been supplied

28 28 Personal Care Toileting –Ideal is recline & tilt- limited resources may result in tilt only Showering –Recommended in acute post op period –Alternative shower chair may be required for postural support Bathing –Long term extra postural support in bath may be required

29 29 Pre-operative Respiratory Function Extremely beneficial if families have been taught lung volume recruitment techniques and chest clearance techniques prior to admission –British Thoracic Society ( – Scottish Muscle Network DMD Profile ( Peak cough flow can be assessed by using a mask and a peak flow meter,

30 30 Hospital Admission Usually admitted the day prior to surgery Introduction/assessment by inter-disciplinary team Discussion of post operative management

31 31 S.G., Operation – Posterior Spinal Fusion yrs 1mth 62 o 40 o Pelvis 6 o

32 32 Posterior Spinal Fusion +/- pelvic fixation Performed via a large midline incision Spinous processes, interspinous ligaments and facet joints excised Pedicle Screws or hooks attached to spine If fusing to the pelvis wires or pelvic screws are placed Rods applied down either side of the spine and attached to screws and hooks as spinal deformity derotated Bone grafts placed around rods – usually femoral heads from bone bank or bone substitutes Wound is closed with redivac drain insitu

33 33 Anterior Release +/- posterior spinal fusion Performed via a thoracotomy – on the convexity of scoliosis A rib is excised for most of its length to access spine (and kept) – rib resection Rib heads may be removed around the apex of the scoliosis to improve cosmetic result – internal costoplasty Pleura is excised Discs are excised and growth plates, cartilage removed Wound closed with intercostal chest drain insitu

34 34 In patient Physiotherapy Reviewed day one post op Chest physiotherapy commenced Passive/active assisted movements Bed mobility – log rolling Mobility/ hoisting once medically stable Liaison with local therapists Ongoing until discharge from hospital

35 35 Acute Post Op Challenges Surgical considerations – e.g. pelvic fixation- reclining seating positions Medical stability – e.g. respiratory distress Comfort – pain control Tone Psychosocial – anxiety Nutrition

36 36 Discharge Advice Advise parents to cont passive/active assisted movements To increase mobility or duration sitting in wheelchair If wheelchair reclined- to reduce recline as tolerated To ensure postural alignment maintained – avoid forced flexion/ extension or rotation of spine Ongoing respiratory management – as required

37 37 Discharge Advice Unable to use standing frame and some walking aids Unable to swim/ hydrotherapy/ participate in sports Discretion of Consultant on reviewing patient and x-rays at clinic

38 38 School ASL Profile provided Return to School – graded School seating Desk height/ position Hand function – writing skills Manual handling/hoisting Toileting Feeding

39 39 Challenges after Discharge Home Environment Mobility Self propelling wheelchairs Change to Physiotherapy Program – Hippotherapy, Rebound etc Feeding Family Support Transport Holidays Anxieties

40 40 Conclusion There is variability with each child and we aim to make the pathway as smooth as possible for the patient / carers and local therapists

41 41

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