ANDREA LEBEL, M.PT., Schroth Certified Physiotherapist, Ottawa, Canada Unexpected late progression of Adolescent Idiopathic Scoliosis (AIS) treated with short-term, aggressive, full-time bracing and Physiotherapy Scoliosis Specific Exercises (PSSE) based on the Schroth Method with excellent preliminary result: case study ANDREA LEBEL, M.PT., Schroth Certified Physiotherapist, Ottawa, Canada Ottawa & District Physiotherapy Clinic, Scoliosis Physiotherapy & Posture Center VICTORIA ASHLEY LEBEL, M.Sc., M.D. Candidate 2016 SOSORT 2015 POSTER PRESENTATION “ Progression of scoliosis can be arrested, or even reversed, if sufficient force is applied to the involved vertebrae and the external loading imbalance is removed”. (Stokes and Aaronsson, 2001)

Background: The risk of progression in female patients with AIS decreases as age increases and vertical growth potential decreases 1-2 years post-menarche. Relatively late, unexpected progression of AIS post-menarche could potentially lead to surgery if these patients are managed with observation and left without non-surgical treatment options. Adults with curves <30 degrees have promising outcomes, however, larger curves will progress throughout adulthood an average of 1 degree annually, possibly leading to irreversible structural changes and spinal surgeries, having a significant impact on an individual’s quality of life. The purpose of this study is to evaluate the effectiveness of conservative management in a patient with late progression of AIS. a) b) c) d) Unexpected late progression of scoliosis in case study patient. Patient refused “wait and see” method and was treated with PSSE Schroth Method combined with bracing (TLSO made by Rigo-Cheneau Principles). a) Before PSSE. b) After 14 months of PSSE and bracing. Unexpected late progression of scoliosis in a similar patient. Patient was not offered PSSE or bracing and was observed for 4 years prior to surgery at age 18. c) Before surgery. d) After surgery.

Design/Methods: A 13-year and 10-month old female, 1 year post-menarche, with self-diagnosed postural asymmetry, was diagnosed with AIS on June 11th, 2013. Radiographs demonstrated a 31-degree left convex T6-L2 curve and a 15-degree right convex L2-L5 curve. Follow-up radiographs 6 months later on December 12th, 2013 showed curve progression to 40-degrees of the left convex T6-L2 curve and 18-degree of the right convex L2-L5 curve. The patient began 30-40 min daily home Schroth physiotherapy exercise sessions and once a month 1-hr clinic sessions in December 2013. She received a TLSO brace, based on Rigo-Cheneau principles, in February 2014 to prevent curve progression. An in-brace radiograph from March 2014 showed a 22-degree overcorrection to the right side. The patient was followed from July 2013 to the present date. The patient’s progression and improvement were monitored by measuring ATR, VC, chest expansion, height, and follow-up radiographs. Initial photographs, Postural imbalance, positive Adam’s test and poor proprioception. PSSE started 2 months before, full time bracing Ottawa & District Physiotherapy Clinic, Scoliosis Physiotherapy and Posture Centre, Ottawa, Canada

  Results: Short-term, full-time (21-23 hrs/day) bracing combined with daily Schroth physiotherapy improved thoracic and lumbar Cobb angles from 40 and 18 degrees, respectively, in December 2013 to 18 and 13 degrees (after 24 hours out of brace) in July 2014. Vital capacity in July 2013 was 2500 mL. In February 2014, after 2 months of daily Schroth physiotherapy and 2 weeks of aggressive, full-time bracing, the vital capacity improved to 3200 mL. Most recently, in July 2014, after 7 months of daily Schroth physiotherapy and 5 months of full-time bracing, vital capacity was measured at 3700 mL. Bracing was fully discontinued in December 2014. Patient was monitored by ATR measurements (fluctuated between 3-5 degrees) until her final radiograph in February 2015. The final report of her February radiograph showed an 11 degree Cobb angle. The measurements were taken at the local Children’s Hospital by a CHEO radiologist resident and reviewed by a radiologist. The patient is now pain-free. Initial photograph December 2013 Final photograph February 2015 Vital Capacity Measurements SRS-22 Mean Score (2013-2015) (2013-2015)

Objective Imaging: MRI, radiographs, and photographs used to document progression and improvement Imaging obtained from the film library of Children’s Hospital of Eastern Ontario Date of Radiograph taken (source: CHEO film library) Primary curve Cobb Angle 2013-06-11 31° (left convex) 2013-12-12 40° (left convex) 2014-03-06 (in brace) 22° (overcorrection, right convex) 2014-07-24 (24 hours out of brace) 18° (overcorrection, right convex) 2015-02-15 (2 month after bracing was discontinued) 11° (overcorrection, right convex) Supine MRI one month after Scoliosis diagnosis of 31° Cobb angle showing axial rotation and muscular imbalance. 2013-07-11 2013-06-11 2013-12-12 2014-03-06 2014-07-24 2015-02-15

Conclusion: Late progression of AIS may occur unexpectedly. Even though late bracing of mature patients has not been the standard of care in Canada, AIS patients should be monitored until the very end of growth, despite the low risk of progression, and offered short-term, aggressive, full-time bracing and Schroth physiotherapy if progression unexpectedly occurs. In this case study, short-term, aggressive, full-time bracing combined with daily Schroth physiotherapy proved effective in halting curve progression, reducing Cobb angles, and improving postural correction, vital capacity, and future quality of life. Scoliosis Specific Schroth Physiotherapy combined with RC Bracing for 6-9 months Reference: Lehnert-Schroth C: Three-dimensional treatment for scoliosis: a physiotherapeutic method for deformities of the spine. California; 2007. Lonstein JE, Carlson JM. The prediction of curve progression in untreated idiopathic scoliosis during growth. J Bone Joint Surg [Am]. 1984;66:1061–71. Rigo M, et al.: Scoliosis intensive outpatient rehabilitation based on Schroth method. Stud Health Technol Inform 2008. "Biomechanical Spinal Growth Modulation and Progressive Adolescent Scoliosis – a Test of the 'vicious Cycle' Pathogenetic Hypothesis: Summary of an Electronic Focus Group Debate of the IBSE Ian AF Stokes1, R Geoffrey Burwell2* and Peter H Dangerfield3." (n.d.): n. pag. Print. Authors would like to thank the patient for her permission to present this case study