Conservative treatment of scoliosis

1. CONSERVATIVE TREATMENT OF
SCOLIOSIS
Name : AL-ZUBAIDI AYA RIDHA
GROUP: 616
C.F.U
TRUMATOLOGY

2. DEFENTIONS
 Kyphosis is excessive curvature of the spine in the
sagittal (A-P) plane. The normal back has 20° to
45° of curvature in the upper back, and anything in
excess of 45° is called kyphosis.
 Scoliosis is abnormal curvature of the spine in the
coronal (lateral) plane. Scoliosis of between 10°
and 20° is called mild. Less than 10° is postural
variation.
 Lordosis or hyperlordosis is excessive curving of
the lower spine and is often associated with
scoliosis or kyphosis. It can be exaggerated by poor
posture.

3. NOTE
 'structural scoliosis', or just scoliosis, is very
different from 'functional scoliosis', which is a spinal
curvature secondary to known extra-spinal causes
(eg, shortening of a lower limb or paraspinal muscle
tone asymmetry). It is usually partially reduced or
completely subsides after the underlying cause is
eliminated

4.  Definitions and staging
• Infantile scoliosis occurs before age 3 and is seen more
frequently in boys. Although neurological involvement is
possible, many resolve spontaneously but some may
progress to severe deformity.
• Juvenile scoliosis is found more frequently in girls
between the ages of 3 and 10. These curves are at a
high risk for progression and often require surgical
intervention.
• AIS occurs between age 10 and maturity. AIS may start
at the onset of puberty or become apparent during an
adolescent growth spurt. Females are at higher risk,
often requiring surgical treatment, if non-operative
treatment fails to halt curvature.
• Adult scoliosis occurs after maturity.

5.  Symptoms
• Mild disease is usually painless but, as deformity
grows, pain will usually increase.
• Scoliosis in children or adolescents is often
detected on routine screening.
• Patients with AIS most often present with unlevel
shoulders, waistline asymmetry (one hip 'sticking
out' more than the other), or a rib prominence.[2]
• Ask about family history of scoliosis.

6. 
- Sideways curvature of the spine
- Sideways body posture
- One shoulder raised higher than the other
- Clothes not hanging properly
- Local muscular aches
- Local ligament pain


8.  Decreasing pulmonary function is a major
concern in progressive severe scoliosis. The
progression of scoliosis leads to thoracic
cage deformity and concomitant pulmonary
compromise. Based on the results of the
present study, impairment of function was
seen in more severe cases of spinal
deformity, proximally-located curvature and
older patients

9. 
I. Conservative treatment
 With regard to conservative treatment of patients with congenital scoliosis, it
should be noted that there are limited data available in the literature. A
review (level of evidence 2) concluded that patients with specific types of
segmentation failures, like unilateral unsegmented bars, will not benefit from
conservative treatment, while the same applies to formation failures with
curves of > 20 degrees in infancy. Nevertheless, there are reports that a
conservative approach might be beneficial in mild cases with formation
failures in the first three years of life. Furthermore, the review concluded that
in patients with formation failures further investigation is needed to document
where a conservative approach (bracing treatment) would be necessary. In
general, most congenital scoliotic curves are not flexible and therefore are
resistant to repair with bracing. For this reason, the use of braces mainly
aims to prevent the progression of secondary curves that develop above and
below the congenital curve, causing imbalance. In these cases, they may be
applied until skeletal maturity[12].


10.  Some physical therapists recommend a brace to prevent
the worsening of the scoliosis. An often used brace is
the Milwaukee brace. Nevertheless the evidence for
bracing is controversial. Maruyama T., Nakao Y. and
Takeshita T. studied the effect of bracing in a review
(2011). They compared brace treatment with no-
treatment, other conservative treatments or surgery. The
analyzed outcome measures were the radiological
progression of the curve, surgery and quality of life.
Results demonstrate that brace treatment is better than
no-treatment (observation) or electrical stimulation.
There is also no negative influence on the quality of life
of patients with an idiopathic scoliosis. We can conclude
that bracing is recommended as a treatment for female
patients with a Cobb angle of 25-35°. The evidence level
of some studies in the review was limited, so further
research is necessary.

11.  Types of scoliosis
• Idiopathic (80%). This is not associated with dysmorphic
features, skin lesions or neuromuscular disease.
• Congenital malformations of the vertebrae (10%) can
cause deformity. These are commonly associated with
genitourinary anomalies.
• Neuromuscular conditions (15%) include cerebral
palsy, spina bifida and poliomyelitis.
• Metabolic problems such as Hunter's syndrome.
• Crush fracture from
trauma, osteoporosis, tuberculosis or malignancy.
• Dysmorphic syndromes such
as neurofibromatosis, Marfan's syndrome, osteogenesis
imperfecta.

12. INVESTIGATIONS
 PA and lateral X-rays of the spine. A commonly
used parameter is Cobb's angle:
 To use the Cobb's method of measuring the degree
of scoliosis, the most tilted vertebrae above and
below the apex of the curve are chosen.
 The angle between intersecting lines drawn
perpendicular to the top of the top vertebrae and
the bottom of the bottom vertebrae is Cobb's angle.
 As a general rule, a Cobb's angle of 10° is regarded
as the minimum angulation to define scoliosis.

13. MANAGEMENT
 Management depends upon the type of condition,
the severity, the prognosis and the patient's
tolerance for various interventions. Early diagnosis
and intervention are beneficial. Management may
be divided into:
• Observation
• Orthosis
• Operation

14.  The aims of comprehensive conservative treatment
of idiopathic scoliosis are:
 To stop curve progression at puberty (or possibly
even reduce it).
 To prevent or treat respiratory dysfunction.
 To prevent or treat spinal pain syndromes.
 To improve aesthetics via postural correction.

15.  Conservative scoliosis therapy according to the
FITS Concept is applied as a unique treatment or in
combination with corrective bracing. The aim of the
study was to present author's method of diagnosis
and therapy for idiopathic scoliosis FITS-Functional
Individual Therapy of Scoliosis and to analyze the
early results of FITS therapy in a series of
consecutive patients.

16.  Methods
 The analysis comprised separately: (1) single structural
thoracic, thoracolumbar or lumbar curves and (2) double
structural scoliosis-thoracic and thoracolumbar or lumbar
curves. The Cobb angle and Risser sign were analyzed at the
initial stage and at the 2.8-year follow-up. The percentage of
patients improved (defined as decrease of Cobb angle of
more than 5 degrees), stable (+/- 5 degrees), and progressed
(increase of Cobb angle of more than 5 degrees) was
calculated. The clinical assessment comprised: the Angle of
Trunk Rotation (ATR) initial and follow-up value, the plumb
line imbalance, the scapulae level and the distance from the
apical spinous process of the primary curve to the plumb line.

17. DESCRIPTION OF THE FITS METHOD
Main principles of FITS concept
1.To make the child aware of existing deformation of
the spine and the trunk as well as indicate a direction
of scoliosis correction.
2.To release myofascial structures which limit three-
plane corrective movement.
3.To increase thoracic kyphosis through myofacial
release and joint mobilization.
4.To teach correct foot loading to improve position of
pelvis and to realign scoliosis.

18. 5.To strengthen pelvis floor muscles and short rotator muscles of
the spine in order to improve stability in the lower trunk.
6.To teach the correct shift of the spine in frontal plane in order to
correct the primary curve while stabilizing (or maintaining in
correction) the secondary curve.
7.To facilitate of three-plane corrective breathing in functional
positions (breathing with concavities).
8.To indicate correct patterns of scoliosis correction and any
secondary trunk deformation related to curvature (asymmetry of
head position, asymmetry of shoulders' lines, waist triangles and
pelvis).
9.To teach balance exercises and improvement of neuro-muscular
coordination with scoliosis …
10. To teach correct pelvis weight bearing in sitting and correction of
other spine segments in gait and ADL.

19. STAGES
 Stage I
 Examination of child with scoliosis using classical assessment but also in terms of
FITS method.
 Stage II
 Preparation for correction-examination, detection and elimination of myofascial
restriction which limits three-plane corrective movement by using different
techniques of myofascial relaxation.
 Stage III
 Three-dimensional correction-building and fixation of new corrective patterns in
functional positions.
 Stage I. Patient examination and making the child aware of the trunk deformity
 Classical assessment includes: history, course of treatment, X-ray analysis and
examination of patient in three different planes. Afterwards clinical assessment is
performed according to FITS:
 □ Distance from plumb line to: anal cleft, the apex of primary and secondary curve,
the edge of the scapula,

20.  Stage I. Patient examination and making the child aware of the trunk
deformity
 Classical assessment includes: history, course of treatment, X-ray
analysis and examination of patient in three different planes. Afterwards
clinical assessment is performed according to FITS:
 □ Distance from plumb line to: anal cleft, the apex of primary and
secondary curve, the edge of the scapula,
 □ checking position of both scapulas,
 □ observation of type and location of compensation,
 □ position of pelvis and measurement of angle trunk rotation (ATR) using
Bunnell scoliometer,
 □ assessment of the settings of the lower limbs in standing and gait,
 □ assessment of the length of muscles in lower limbs, pelvic girdle,
shoulder girdle and trunk,