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September 5th – 8th 2013 Nottingham Conference Centre, United Kingdom

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1 September 5th – 8th 2013 Nottingham Conference Centre, United Kingdom

2 Osteopathic Management of Adolescent Idiopathic Scoliosis

3 Adolescent Idiopathic Scoliosis
Lateral spinal curvature that forms in patients aged 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 year olds. Affects girls more than boys.

4 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.

5 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.

6 Physical Examination Adams Forward Bending Test Leg Length – measure.
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

7 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.

8 Lenke Classification

9 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.

10 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.

11 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).

12 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.

13 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.

14 Case Presentation Pt: F, 39yrs Presentation:
Difficulty walking, sitting and standing due to low back, thoracic and right leg pain; extreme fatigue; morning stiffness. PMH: Non-progressive Adolescent Idiopathic Scoliosis. Rheumatologist, physio & hydrotherapy. Assessment: Right thoracic scoliosis with 36° thoracic curve (T4-T12) and compensatory left lumbar scoliosis of 34°; stiff curve. Osteopathic Evaluation: Restrictions right SIJ-T2 in flexion. T2-4 left and T5-T8 right restrictions in extension. TTT given: Articulation of Tsp & Lsp to address restrictions, stretch soft tissues through hips and scapulo-thoracic joints. Pre TTT ODI: 40% Post TTT ODI: 24%

15 Case Presentation Pt: F, 15yrs Presentation:
Pain in right trapezius area. PMH: AIS - Instrumented fixation T4-T11. Chiari malformation type I (decompressed). Diagnosis: AIS (posterior correction). Osteopathic Evaluation: Restriction at L3-T4 & C4-T1 right in flexion. Restricted extension at L5-T4 & C4-T1 left. TTT given: Treatment to adjust above levels and to improve tone in trapezius and periscapular muscles. Pre TTT ODI: 15% Post TTT ODI: 6%

16 Case Presentation Pt: F, 26 yrs Presentation:
Mid-thoracic and lumbar pain. No radicular symptoms. PMH: Onset ±5 yrs previously, becoming more constant. Hypermobility syndrome, possible Marfanoid trait. Assessment: Focal right mid thoracic scoliosis (22°). Small syrinx C6 to C7 (incidental finding). Osteopathic Evaluation: Restricted T4-T7 on left in extension. Restricted in flexion: T3 & T4 right, T7-9 left, L2-L5 left and S1 right. TTT given: Soft tissue and articulation throughout spine, addressing areas of restriction and improving muscle balance and tone. Pre TTT ODI: 26% Post TTT ODI: 24%

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