1. Orthotic Management of the Geriatric Spine
Managing the Geriatric Spine
Managing problems associated with the geriatric spine is growing problem for doctors, due to the rapidly increasing elderly population and a lack of effective treatments.
Orthotic management of problems associated with the geriatric spine is currently under utilized yet recent research suggests there is significant potential for orthoses to manage pain and progression in a number of degenerative spinal conditions.
Orthotic Management of the Geriatric Spine
Andrew J Mills MBAPO MISPO
Orthotist

2. Orthotic Management of Degenerative Scoliosis in Adults
Managing the Geriatric Spine
Today I am going to limit my presentation to orthotic management of degenerative scoliosis in adults, however, many of the same principles can be applied to treating progression and pain in the Hyperkyphotic spine.
Orthotic Management of Degenerative Scoliosis in Adults

3. Prevalence of Scoliosis in Adults
Managing the Geriatric Spine
Most orthotists will be fairly familiar with the statistics for the prevalence of Scoliosis in children at between % with an approximate split between Idiopathic and other causes, largely being Neuromuscular in origin.
I believe, however, as a profession we are not so familiar with the prevalence of adult scoliosis or its causes largely because orthotic management has not played as significant role in its treatment.
Principally this is because in the past most bracing has been quite static in nature, leading to muscular atrophy, limitation of movement and poor acceptability.
The advent of dynamic spinal bracing now gives new possibilities to practically manage pain, improve mobility and improve quality of life for this group of patients.
Prevalence of Scoliosis in Adults

4. Managing the Geriatric Spine Prevalence of Scoliosis in Adults
General Population
0.3% – 0.5% in Children (of which 80% are idiopathic)
2% – 4% above the age of 18 years
9% in over 40 year olds
30%+ in over 60 year olds
A recent study by J Y Hong et al; JBJS 2010 reports the prevalence of scoliosis in the population over 60 to be 35.5%
Not all of these patient’s are symptomatic of course requiring treatment but a significant number do have LBP. when we look at the prevalence of scoliosis in back pain sufferers as apposed to the general population the incidence is still very significant. The prevalence and progression of scoliosis amongst LBP sufferers appears to be directly related to advancing age.
As you can imagine the number of patients potentially requiring orthotic treatment, especially in light of an increasing elderly population is extremely large.
Patients with Low back Pain
Robin et al; Study 554 LBP Patients
30% had scoliosis >10° in the 50 to 84 age group
And at 5 year follow up
- 40% had scoliosis >10° an additional 10% “

5. Types of Scoliosis in Adults
Managing the Geriatric Spine
Types of Scoliosis in Adults
Types of Scoliosis in Adults

6. 1. Adolescent Scoliosis in the Adult (ASA)
Managing the Geriatric Spine
Types of Scoliosis in Adults
Two main types;
There are two main categories of scoliosis in adults.
Adolescent scoliosis in the Adult (ASA)
De-Novo Degenerative Scoliosis (DDS)
Although these are the two most common presentations it is important that scoliosis due to pathological disease is ruled out.
1. Adolescent Scoliosis in the Adult (ASA)
2. Degenerative De-Novo scoliosis (DDS)
Important, however, to rule out scoliosis due to pathological disease prior to brace treatment

7. Managing the Geriatric Spine ASA 1
Usually smaller flexible curves in younger adults years old
Posture and Cosmetic issues are the main problem.
Pain can be an issue particularly in unbalanced curves.
Potential reducibility in both abnormal posture and Cobb.
ASA1 are usually smaller more flexible curves in younger adults years old. Posture and Cosmetic issues tend to be the main problem. Pain can be an issue particularly in unbalanced curves i.e. RT1. There is a potential reducibility in both the abnormal posture and cobb magnitude.
The picture shows a relatively well balanced thoraco-lumbar curve. Pain and Aesthetics were both considerations for this 21 year old female. 7

8. Managing the Geriatric Spine ASA 2
Usually larger more rigid curves in middle aged adults 30-40
Pain and posture equally issues.
Pain can be an issue even in balanced curves.
Often start to see early degenerative changes
Intervention in ASA 2 could potentially to stop progression to ASA 3
(This idea of early intervention is suggest by Schwab Spine 2002)
ASA 2 is usually larger more rigid curves in middle aged adults 30 to 40 years of age. Pain and posture equally issues. Pain can be an issue even in balanced curves, usually because the spine is less flexible and an early degenerative process is starting. Intervention in ASA 2 could potentially to stop progression to ASA 3 - (This idea of early intervention at “middle age” is also suggest by Schwab Spine 2002) 8

9. Managing the Geriatric Spine ASA 3
Usually large, rigid curves in older adults 40+
Pain is the primary issue.
Moderate to severe degenerative changes present.
Most commonly lumbar curves.
No previous history of scoliosis could indicate Degenerative De Novo Scoliosis DDS.
ASA 3 is usually larger, very rigid curves in older adults 40+. Pain is the primary issue. Moderate to severe degenerative changes are present.
ASA 3 is commonly present as lumbar curves. Or other curves with lumbar pain. The only way to distinguish ASA 3 lumbar curves and DDS Lumbar curve is via history of scoliosis. If there is no previous history of scoliosis this could indicate a Degenerative De Novo Scoliosis DDS. 9

10. Managing the Geriatric Spine Degenerative De-Novo Scoliosis (DDS)
New curve in adult developed as a result of degenerative instability.
Usually lumbar curve, unbalanced.
Large, rigid curves in older adults 50+
Pain is the primary issue.
Moderate to severe degenerative changes present.
Degenerative De-Novo Scoliosis is a new scoliotic curve that develops in the Adult as a result of degenerative instability. These are usually lumbar curves and are unbalanced. There magnitude can be large, and they are always rigid curves in older adults usually 50+. Pain is the primary issue although these cases have a high rate of progression than ASA. There are moderate to severe degenerative changes present. 10

11. Managing the Geriatric Spine Vertebral Rotation
Both ASA and DDS have vertebral rotation.
In ASA rotation of the vertebra is initially related to the 3D vertebral deformity
Both ASA and DDS have vertebral rotation. In ASA rotation of the vertebra is initially related to the 3D vertebral deformity 11

12. Managing the Geriatric Spine Rotary Subluxation
With DDS the vertebra are NOT deformed.
Instability allows one or more of them to rotate.
This rotation is greater than the normal coupling limits would allow.
Therefore it is considered a subluxation.
In DDS the vertebra themselves are NOT deformed. However instability allows one or more of them to rotate. This rotation is greater than the normal coupling limits would allow. Therefore it is considered a subluxation. 12

13. Managing the Geriatric Spine Rotary Subluxation
This subluxation is a typical feature of DDS.
It can appear latter on with ASA on top of the true rotational deformity.
This subluxation is a typical feature of DDS. It can appear latter on with ASA on top of the true rotational deformity. 13

14. Managing the Geriatric Spine
LBP associated with
Adult Scoliosis

15. Managing the Geriatric Spine Pain And Adult Scoliosis
ASA 1&2 can have pain to varying degrees, usually unbalanced curves are more painful.
ASA 3 and DDS are usually painful and have traditionally been difficult cases to treat.
Drugs surgery and chiropractic offer little long term relief as they don’t deal with the underlying factors.
While progression is a factor. PAIN is the main issue in adult scoliosis.
ASA 1&2 can have pain to varying degrees, usually unbalanced curves are more painful.
ASA 3 and DDS are usually painful and have traditionally been difficult cases to treat, Drugs surgery even chiropractic offer little long term relief as they don’t deal with the underlying factors. 15

16. Prevalence Adult Scoliosis in LBP sufferers
Managing the Geriatric Spine
Prevalence Adult Scoliosis in LBP sufferers

17. Managing the Geriatric Spine
Prevalence of Adult Scoliosis in Back Pain
Robin et al;
554 LBP patients
- Aged 50 to 84
- 30% scoliosis >10°
At 5 year follow up
- 40% scoliosis >10°
- Additional 10%
“a significant number of older
people have an adult scoliosis and
its prevalence and progression is directly related to advancing age”
Robin et al. found that out of 554 LBP patients aged 50 to 84, 30% had a spinal curvature greater than 10 degrees. At 5 year follow up an additional 10% had this magnitude of scoliosis
These studies suggest that a significant number of older people have an adult scoliosis and its prevalence and progression is directly related to advancing age and that is strongly associated with lower back pain in this population. 17

18. Cobb Magnitude and Managing the Geriatric Spine
Research demonstrates that;
Cobb Magnitude and
Degenerative Changes
Menopause
Alone do not necessarily relate to Pain or Progression
This raises the question???

19. Managing the Geriatric Spine
Are there Biomechanical Factors relating to Pain and Progression that could be managed by Spinal Bracing?
Are there Biomechanical Factors relating to Pain and Progression that could be managed by Spinal Bracing?

20. Managing the Geriatric Spine
Clinical & Radiological Features that relate to pain with Adult Scoliosis
In order to answer this Question we need to look at the Clinical an Radiological features that DO correlate to Pain and progression in Adult scoliosis sufferers.

21. Managing the Geriatric Spine
Radiological features correlating with Pain
“Adult Scoliosis - A Quantitative Radiographic and Clinical Analysis”, Schwab et al. Spine 2002,
He identifies these correlations with pain:
Lateral vertebral olisthesis, (side slip)
L3 and L4 endplate obliquity angles,
Decrease in lumbar lordosis,
Increased thoraco-lumbar Kyphosis
He identifies these correlations with pain:
Lateral vertebral olisthy, (also referred to as lateral listhesis)
L3 and L4 endplate obliquity angles,
Decrease in lumbar lordosis,
Increased thoraco-lumbar Kyphosis 21

22. Managing the Geriatric Spine Cobb angle correlation with pain
“Adult Scoliosis - A Quantitative Radiographic and Clinical Analysis”, Schwab et al. Spine 2002,
The Cobb angle of the scoliotic deformity had no statistically significant correlation to the VAS pain scores.
Suggests that;
Early intervention in a middle-aged adult with scoliosis may be preferable to treating advanced deformity in that same person once he or she has become elderly.
The Cobb angle of the scoliotic deformity had no statistically significant correlation to the VAS.
Early intervention in a middle-aged adult with scoliosis may be preferable to treating advanced deformity in that same person once he or she has become elderly. 22

23. Managing the Geriatric Spine Coronal Balance
“Correlation of Radiographic Parameters and Clinical Symptoms in Adult Scoliosis” Glassman, et al. Spine 2003
The study hypotheses were that;
Major curve location
Rotatory subluxation
Coronal shift
Apical vertebral rotation
Positive sagittal balance
SHOULD CORRELATE with Increased Pain, decreased function and self-image
Glassman et, al. studied 298 patients, 172 with no prior surgery. We will review these non surgical group results. The purpose of the study was to correlate radiographic measures of deformity with patient-based quality of life and health status assessments in adult scoliosis.
The study hypotheses were that the major curve location, rotatory subluxation, coronal shift, apical vertebral rotation, and positive sagittal balance correlated with increased pain and decreased function and self-image; 23

24. Adult Scoliosis : Coronal Balance
“Correlation of Radiographic Parameters and Clinical Symptoms in Adult Scoliosis” Glassman, et al. Spine 2003
An additional hypothesis was that;
Curve magnitude SHOULD NOT CORRELATE with pain or function.
And that curve magnitude should not correlate with pain or function 24

25. Managing the Geriatric Spine Sagittal Balance
“Correlation of Radiographic Parameters and Clinical Symptoms in Adult Scoliosis” Glassman, et al. Spine 2003
The most significant findings were:
Positive (anterior) Sagittal Balance
Greater pain
Diminished physical function
Poorer self image
- Poorer social function
Patients with positive sagittal balance measured from C7 to the posterior margin of the sacrum had the most significant compromise in health status when compared to patients who were in neutral balance or negative global sagittal balance. Patients with positive sagittal balance reported greater pain, diminished physical function poorer self image and social function 25

26. Managing the Geriatric Spine Coronal Balance
“Correlation of Radiographic Parameters and Clinical Symptoms in Adult Scoliosis” Glassman, et al. Spine 2003
The most significant findings were:
Coronal shift > 4 cm
- Poorer function
- Greater pain
Compared to patients with a coronal shift < 4 cm.
The most significant findings for patients with no prior surgery were noted in the assessment of coronal and sagittal balance.
Patients with coronal shift greater than 4 cm reported poorer function based on the SRS-22 and greater pain on the SF-12 and ODI compared to patients with a coronal shift less than 4 cm. 26

27. Managing the Geriatric Spine
Glassman Study Non-correlation Findings
“Correlation of Radiographic Parameters and Clinical Symptoms in Adult Scoliosis” Glassman, et al. Spine 2003
No differences based on:
Curve magnitude
Apical rotation,
Or single vs. double major curves.
More favourable scores for thoracic curves versus thoracolumbar or lumbar curves
No statistical differences in health status measures based on curve magnitude, apical rotation, or comparison between single and double major curves. Comparison based on curve location revealed more favourable scores for thoracic curves versus thoracolumbar or lumbar curves 27

28. Managing the Geriatric Spine
Severity Of Degeneration (DDD/Spinal Stenosis)
By its self severity of degeneration not a predictor of Pain or Progression
In combination with rotary subluxation it is a predictor for progression.
In combination with end plate obliquity it is a predictor for ongoing pain
Degeneration of the spine in adult scoliosis cases is not by its self a predictor of Pain or Progression. However when is occurs with rotatory subluxation it is a predictor for progression and when it appears with end plate obliquity it is predictor for ongoing pain 28

29. Managing the Geriatric Spine Glassman/Schwab Studies
Summary of Key Findings:
Feature
Alone correlates to pain/progression
Correlates to pain/progression only with associated feature
Positive (anterior) Sagittal imbalance
Yes
Coronal Imbalance
Yes over 40mm
Lateral vertebral olisthesis, (side slip)
Significant L3 and L4 endplate obliquity angles
Decreased lumbar lordosis
Increased thoraco-lumbar Kyphosis
Positive (anterior) sagittal balance predicts clinical symptoms in adult spinal deformity.
Thoracolumbar and lumbar curves have worse outcomes than thoracic curves.
Significant coronal imbalance was associated with pain and dysfunction. 29

30. Managing the Geriatric Spine Glassman Schwab Studies
Summary of Key Findings:
Feature
Alone correlates to pain/progression
Correlates to pain/progression only with associated feature
Menopause No
Large Cobb Magnitude/Recent progression/ Increased instability/Rotary Subluxation
Cobb Magnitude
Menopause/Recent progression/Increased instability
Curve Type
Thoracic curves have lower VAS pain scores
Spinal Stenosis
Rotary Subluxation/Lateral Olisthesis/ SignificantL3/4 end plate obliquity angle
Rotary Subluxation
Lateral Olisthesis/Significant L3/4 end plate obliquity angle
Lumbar DDD
Positive (anterior) sagittal balance predicts clinical symptoms in adult spinal deformity.
Thoracolumbar and lumbar curves have worse outcomes than thoracic curves.
Significant coronal imbalance was associated with pain and dysfunction. 30

31. Orthotic Strategies to manage pain and progression in Adult Scoliosis
Managing the Geriatric Spine
Orthotic Strategies
Orthotic Strategies to manage pain and progression in Adult Scoliosis

32. Managing the Geriatric Spine
Orthotic Strategies
The primary bracing objectives in adult scoliosis do not relate to curve correction!
Primary objectives are to;
Improve/correct Sagittal imbalance.
Improve/correct Coronal imbalance.
Strengthen Spinal Muscles.
Reduce pathological mechanical loads.
Provide Dynamic Corrective Movement
Provide Postural Re-education
That ultimately reduce pain and progression!

33. Managing the Geriatric Spine Rigid Vs Dynamic Orthotic Treatment
Muscle Atrophy causing further destabilization of the spine.
Limitation of movement
Self image issues
Comfort issues
Not well tolerated in long term use
Useful as a last resort in severe Neuro-degenerative cases
Dynamic
Muscle rehabilitation and stabilization
Allows movement
Not visible under clothing
Relatively comfortable
Suitable for long term use
Generally Not suitable for severe Neuro-degenerative cases
The majority of SpineCor practitioners have experience treating AIS. In Adult treatment it is important to realise that both the natural history and the goals of treatment are very different when dealing with Adults compared to Adolescents.
In Adolescents the scoliosis is generally, more highly progressive, (although common) Pain is Not over riding issue, the curves are often flexible and correction or progression stabilization are the primary goals.
In Adults the curves are generally slowly progressive (with the exception of some types of DDS). Pain is the main issue. The curves are usually rigid and therefore only a limited amount of correction can be achieved. 33

34. Dynamic Bracing Approach in Adults
Managing the Geriatric Spine
Dynamic Bracing Approach in Adults

35. Managing the Geriatric Spine Rigid Vs Dynamic Orthotic Treatment
Clearly a dynamic bracing approach has significant advantages to a rigid one in Adults.
No issues with muscular atrophy
Possible to increase general muscle strength and core stability
Increases rather than limiting mobility
Allows sustainable improvement/corrections of coronal and sagittal imbalances key to reduction of pain an progression.
The SpineCor Pain Relief Brace can also treat the neuromuscular effects of abnormal posture and spinal alignment. A corrective movement
to gently guide the posture and spinal alignment into the optimal direction. It is note worthy that in adults, this can be based on the
SpineCor Scoliosis “categorisation” or a regionally specific set up for spinal offloading e.g. Lower back Pain Relief Setting. The elastic
corrective bands of the brace act to resist the body’s movement back to the abnormal position. This constant correction, relaxation,
correction, relaxation is in reality a corrective postural exercise which has a strong neuromuscular effect. However instead of the patient
just of doing repetitions a day, the brace trains the body to do 10’s of 1000’s of repetitions of the corrective movement per day. The
SpineCor Pain Relief Brace therefore has two modes of action. 1) It creates dynamic spinal offloading and 2) It provides neuromuscular
Rehabilitation.

36. Managing the Geriatric Spine Dynamic Bracing Treatment Approach
To use case specific Corrective Movements for spinal rehabilitation and correction/improvement of to patient’s postural imbalances.
The Corrective Movement strategy is determined by the curve type, region of pain and plane of maximum postural imbalance.
The same basic brace components are utilized for all patients only the number, configuration and tensions of the corrective bands vary.
The SpineCor Pain Relief Brace can also treat the neuromuscular effects of abnormal posture and spinal alignment. A corrective movement
to gently guide the posture and spinal alignment into the optimal direction. It is note worthy that in adults, this can be based on the
SpineCor Scoliosis “categorisation” or a regionally specific set up for spinal offloading e.g. Lower back Pain Relief Setting. The elastic
corrective bands of the brace act to resist the body’s movement back to the abnormal position. This constant correction, relaxation,
correction, relaxation is in reality a corrective postural exercise which has a strong neuromuscular effect. However instead of the patient
just of doing repetitions a day, the brace trains the body to do 10’s of 1000’s of repetitions of the corrective movement per day. The
SpineCor Pain Relief Brace therefore has two modes of action. 1) It creates dynamic spinal offloading and 2) It provides neuromuscular
Rehabilitation.

37. Managing the Geriatric Spine Corrective Movement Principle2 3 1

38. Managing the Geriatric Spine Corrective Movement Principle2 3 1

39. Overcorrection of the Postural disorganisation
Managing the Geriatric Spine
Postural Overcorrection
Overcorrection of the Postural disorganisation
Using Dynamic Forces
Compressive forces
Distractive forces

40. Treating Adult Scoliosis: Coronal Balance+ + +

41. Managing the Geriatric Spine:
Corrective Movement & Spinal Loading

42. Managing the Geriatric Spine
SpineCor Treatment
Classification, Corrective Movement & Brace in Place

43. Managing the Geriatric Spine
SpineCor Treatment
Brace Adjustment to Optimize Corrective Movement
Clinically measureable objectives.

44. Managing the Geriatric Spine
Indications for bracing
Degenerative De-Novo Scoliosis (DDS)
Adolescent Scoliosis in Adults (ASA)
Hyperkyphosis
Pain; particularly lower back pain associated with postural & spinal and deformities. i.e. hyperkyphosis, coronal/sagittal imbalance.
Postural Imbalance; correction/rehabilitation of abnormal postural alignment.
Progression; slow or prevent progression of spinal and postural deformities.

45. Managing the Geriatric Spine Patient Example A
26 year old female,
Painful adolescent idiopathic scoliosis as an adult (ASA1).
Pain 7/10.
32 deg right thoracic scoliosis.
8 to 12 hours for 3 months
Gradual relief of pain to 2/10.
Improvement of 8 degrees to 24 deg.
Pain relief of 1-2/10 and spinal correction have been maintained for over 2 years .
Patient A
26 year old female, painful adolescent idiopathic scoliosis as an adult (ASA1).
Pain prior to SpineCor average daily pain of 7/10.
Using the SpineCor daily 8 to 12 hours for 3 months she had a gradual relief of her pain to an average 2/10.
The initial x-ray shows a 32 deg right thoracic scoliosis.
In the SpineCor 1 month after fitting the x-ray shows an improvement of 8 degrees to 24 deg.
Her pain relief of 1-2/10 and spinal correction have been maintained for over 2 years by using the SpineCor Pain Relief brace on an occasional basis.
Courtesy of Dr Tom Pappas

46. Managing the Geriatric Spine Patient Example B
47 year old female
Degenerative De-Novo Adult Scoliosis. (DDS)
Pain 7/10.
A 40 deg degenerative lumbar scoliosis.
Immediate relief of pain to 3/10.
Pain relief of 0-3/10 maintained for over 2 years
Note the improved left lateral shift showing “spinal off loading”.
Patient B
47 year old female with Degenerative De-Novo Adult Scoliosis. (DDS)
Her pain prior to treatment was rated as an average daily pain of 8/10.
In the SpineCor brace she had an immediate relief of her pain to 3/10.
The initial x-ray shows a 40 deg degenerative lumbar scoliosis.
In the SpineCor x-rays show an improvement of 7 degrees to 33 deg.
Her pain relief of 0-3/10 and spinal correction have been maintained for over 2 years, using the SpineCor Pain Relief Brace on a daily basis.
Note the improved left lateral shift showing “spinal off loading”.
Courtesy of Dr Tom Pappas

47. Left Lumbar: Corrective Band #1(Left Thoracic Band)
Managing the Geriatric Spine
SpineCor Treatment
Left Lumbar: Corrective Band #1(Left Thoracic Band)
The size of Bolero is obtained by measuring the distance from T4 to T12. The size this is in centimetres give the actual size of the bolero i.e. a 22cm measurement would indicate the need for a 22 com Bolero. 1 1

48. Left Lumbar: Corrective Band #2 (Right Thoracic Band)
Managing the Geriatric Spine
SpineCor Treatment
Left Lumbar: Corrective Band #2 (Right Thoracic Band)
The size of Bolero is obtained by measuring the distance from T4 to T12. The size this is in centimetres give the actual size of the bolero i.e. a 22cm measurement would indicate the need for a 22 com Bolero. 2

49. Left Lumbar: Corrective Band #3 (Right Shoulder Band)
Managing the Geriatric Spine
SpineCor Treatment
Left Lumbar: Corrective Band #3 (Right Shoulder Band) 3
The size of Bolero is obtained by measuring the distance from T4 to T12. The size this is in centimetres give the actual size of the bolero i.e. a 22cm measurement would indicate the need for a 22 com Bolero. 3

50. Left Lumbar: Corrective Band #4 (Left Shoulder Band)
Managing the Geriatric Spine
SpineCor Treatment
Left Lumbar: Corrective Band #4 (Left Shoulder Band) 4
The size of Bolero is obtained by measuring the distance from T4 to T12. The size this is in centimetres give the actual size of the bolero i.e. a 22cm measurement would indicate the need for a 22 com Bolero. 4

51. Left Lumbar: Brace holding the Corrective Movement Position
Managing the Geriatric Spine
SpineCor Treatment
Left Lumbar: Brace holding the Corrective Movement Position 3 4 4
The size of Bolero is obtained by measuring the distance from T4 to T12. The size this is in centimetres give the actual size of the bolero i.e. a 22cm measurement would indicate the need for a 22 com Bolero. 1 2 3 1 2 4

52. Managing the Geriatric Spine
The End
Thank you 52