Introduction
The rotation and sideward curvature of the spine causes the three-dimensional deformity known as Scoliosis (pronounced “sko-lee-o-sis”).
Idiopathic scoliosis is used when this condition most frequently has no known cause.
Idiopathic scoliosis does have a tendency to run in families, even though the reason is unknown. There could be other influences besides genetics, and not all of the individual genes implicated have been found yet. Although scoliosis can develop in people with diseases like cerebral palsy and muscular dystrophy, most infantile scoliosis has an unexplained origin.
Spinal curvature in the “coronal” (frontal) plane is a standard definition of scoliosis.
The typical curves of the spine are located in the so-called “sagittal” plane at the cervical, thoracic, and lumbar regions.
The head is positioned over the pelvis by these organic curves, which also serve as shock-absorbers to transfer mechanical stress while moving. The term “coronal” (frontal) spinal curvature is frequently used to describe scoliosis.
The coronal axis is used to evaluate the degree of curvature, although scoliosis is a more complicated, three-dimensional issue that encompasses the following planes:
- Coronal plane
- Sagittal plane
- Axial plane
The body is divided into anterior (Ventral/front) and posterior (Dorsal/back) halves by the coronal plane, which runs vertically from head to foot and parallel to the shoulders. The body’s right and left halves are separated by the sagittal plane. The coronal and sagittal planes are at right angles to the axial plane (transverse plane), which is parallel to the ground plane.
The Cobb’s angle of spine curvature in the coronal plane, which also frequently includes vertebral rotation in the transverse plane and hypokyphosis in the sagittal plane, is used to characterize scoliosis.
A “convex” and “concave” hemithorax is the result of these anomalies in the spine, costal-vertebral joints, and rib cage.
As scoliosis worsens, the rotation component begins to develop. It is known as torsion-scoliosis and results in a gibbus.
Significant Clinical Anatomy
The vertebral column typically includes 24 different bony vertebrae, as well as the sacrum, which is made up of 5 fused vertebrae, and the coccyx, which is typically made up of 4 fused vertebrae.
- 7 cervical vertebrae
- 12 thoracic vertebrae
- 5 lumbar vertebrae.
- Hemi-vertebrae and fused vertebrae are examples of variations.
The spinal column exhibits five curves while standing straight when viewed from the side:
- Cervical curves – There are two naturally occurring curves in the cervical spine: the upper curve, which runs from the occiput to the axis, and the lengthier lower curve, called the lordotic curve, which runs from the axis to the second thoracic vertebra. The lower cervical curve is opposite to the upper cervical curve, which is convex forward.
- Thoracic curves – A forward concavity extends from T2 to T12. The additional depth of the posterior sections of the vertebral bodies in this area is what causes the concavity. A minor lateral curve with the convexity pointing to the right or left is frequently present in the upper section.
- Lumbar curve – From L1 to the lumbosacral junction, it is convex forward.
- Sacral curve – The anterior concavity, which runs from the lumbosacral junction to the coccyx, is concave and faces forward and downward.
Epidemiology
Approximately six to nine million individuals in the United States, or 2 to 3 percent of the population, are considered to be affected by scoliosis.
Early childhood or infancy can both be affected by scoliosis.
Scoliosis typically develops between the ages of 10 and 15, and both sexes are equally susceptible to it.
Eight times more frequently than males, females advance to a curve magnitude that needs therapy.
More than 600,000 people with scoliosis visit private doctors’ offices each year; 30,000 kids are probably equipped with braces; and 38,000 people get spinal fusion surgery (US figures)
Etiology
By etiology, scoliosis may be divided into three categories: neuromuscular, congenital, and idiopathic.
Idiopathic scoliosis
About 80% of all cases are diagnosed after ruling out all other possibilities.
More than 8% of people over the age of 25 and 68% of individuals over the age of 60 have adult scoliosis, which is brought on by degenerative changes in the aging spine, and a frequency of 2.5 percent in the local population for a Cobb angle greater than 10 degrees.
The most prevalent kind of scoliosis, adolescent idiopathic, is often identified during puberty. Divided into the following categories:
- Infantile scoliosis: Infantile scoliosis often appears between the ages of 0 and 3 and has a 1% rate.
- Juvenile scoliosis: Juvenile scoliosis often appears between the ages of 4 and 10 years. It accounts for 10% to 15% of all pediatric cases of idiopathic scoliosis. If left untreated, curves of 30 degrees or more tend to worsen, and 95% of these individuals require surgery.
- Adolescent scoliosis: Amounting to around 90% of all occurrences of idiopathic scoliosis in children, adolescent scoliosis develops between the ages of 11 and 18 years.
Congenital scoliosis
Results from one or more vertebrae being malformed during embryonic development and can develop anywhere along the spine.
Due to vertebral anomalies, one part of the spinal column lengthens more slowly than the other, resulting in curvature and other malformations of the spine.
The pace at which a child’s scoliosis increases in severity as they become older depends on the geometry and placement of the deformities.
Congenital scoliosis is often discovered earlier than idiopathic scoliosis since these anomalies are evident at birth.
Neuromuscular scoliosis
Includes scoliosis that develops as a result of neurological or muscular conditions.
Encompasses spinal cord injuries, muscular dystrophy, spinal muscular atrophy, spina bifida, and scoliosis linked to cerebral palsy.
The progression of this kind of scoliosis is typically faster than that of idiopathic scoliosis, and surgery is frequently needed to correct it.
Scoliosis’s root cause might also include spinal wounds and infections.
Identifying Features/Clinical Presentation
There are a number of symptoms that might point to scoliosis:
- Lateral Curve of the Spine
- Lateral body posture
- One shoulder is positioned higher than the other
- Improperly hanging clothes
- Localized muscular pains
- Localized ligament pain
The main issue in severe scoliosis that is progressing is declining lung function.
According to one study, back discomfort was evident at the time of initial diagnosis in roughly 23% of individuals with idiopathic scoliosis. A spinal tumor, herniated disc, tethered cord, syringomyelia, spondylolisthesis, or other related disease was discovered in 10% of these individuals. Patients with idiopathic scoliosis are encouraged to get a comprehensive examination to rule out other possible causes of pain if they experience increasingly severe back pain.
Idiopathic scoliosis may impair pulmonary function as a result of changes to the size and shape of the thorax. In patients with mild to moderate idiopathic scoliosis, recent results on pulmonary function tests revealed decreased pulmonary function. More severe spinal deformities, proximally-located curvature, and older individuals all showed impairment of function.
Diagnosis
A physical examination, an x-ray, a spinal radiograph, a CT scan, or an MRI are typically used to determine the presence of scoliosis.
The Cobb Method is used to gauge the severity of the curve and the number of degrees.
The Adam’s Forward Bend Test is a common examination done occasionally by pediatricians and in grade school screenings.
Outcome Measures
- The patient’s perspective, as determined by patient-reported outcome measures, should be considered in the evaluation of scoliosis treatment.
- The SF-36 survey and the EuroQol5D measure.
- The quality of life profile for spinal deformity (QLPSD) and the SRS-22 Patient Questionnaire.
- Several measures, including the Walter-Reed Visual Assessment Scale (WRVAS), the Spinal Appearance Questionnaire (SAQ), and the Trunk
- Appearance Perception Scale (TAPS), can measure the patient’s perception of trunk deformity and body image.
- Specific measures, including the Bad Sobernheim Stress Questionnaire (BSSQ) and the Brace Questionnaire (BrQ), can be used to assess the effects of brace use.
NB available tools that are currently used to assess the effectiveness of non-idiopathic scoliosis therapy have not undergone enough validation and analysis.
Examination
Differentiating between poor posture and true idiopathic scoliosis is the goal of the functional examination.
- The cervical, thoracic, and lumbar segments of the spine are examined during dynamic movements (flexion, extension, and side flexion).
- The Adam forward bend test can be used to determine if the cervical to lumbar spine has structural or non-structural scoliosis. Both standing and sitting are acceptable positions for administering the test.
- The Cobb angle is a frequently employed metric to assess and monitor the development of scoliosis.
- The scoliometer is an inclinometer used to gauge axial trunk rotation or trunk asymmetry. It is implemented in three regions:
- Upper thoracic (T3-T4)
- Middle thoracic (T5-T12)
- Thoraco-lumbar area (T12-L1 or L2-L3)
At the specific level of the trunk, there is symmetry if the measurement is 0°. If the scoliometer result is equivalent to any other value, there is an imbalance at that specific level of the trunk.
- Performing a pulmonary function test on patients before surgery is helpful.
- Spirometer:
- FVC measures lung volume.
- FEV1 offers a flow function evaluation.
Medical Administration
When the major curvature persists despite conservative treatment (Cobb angle 50 degrees or more) in patients with early-onset scoliosis, which is defined as a lateral curvature of the spine under the age of 10, surgery is an option. In this age range, spinal fusion is not advised since it inhibits pulmonary and spinal development.
Conservative Treatment
The majority of scoliosis patients have minor curvature, thus they most likely won’t require surgery or a brace for therapy. Children who have mild scoliosis may need regular checks to evaluate whether there have been changes in the curvature of their spines as they grow.
Braces
The doctor could advise a brace for children whose bones are still developing and have mild scoliosis. While wearing a brace typically stops the curvature from progressing further, it won’t reverse or treat scoliosis.
- The sort of brace that is used most frequently is composed of plastic and is molded to fit the body. Since it fits under the arms and wraps over the rib cage, lower back, and hips, this brace is nearly undetectable when worn under clothing. e.g., Milwaukee brace
- Most people wear braces day and night. A brace gets more efficient the longer it is worn. Braced children typically have few limitations and can engage in most activities. Children can remove the brace if necessary in order to engage in sports or other active activities.
- After the bones fully develop, braces are removed. Generally, this happens:
- Around two years after girls start to menstruate
- When boys have to shave every day
- When the height does not change any further.
The majority of congenital scoliotic curves are often rigid and consequently resistant to bracing correction. Because of this, the primary goal of utilizing braces is to stop the advancement of secondary curves that form above and below the congenital curve and lead to imbalance. They may be used in certain circumstances until skeletal maturity.
Surgical Intervention
Usually, severe scoliosis progressively worsens over time.
In order to lessen the severity of the spinal curvature and stop it from growing worse, a physician may advise scoliosis surgery.
- Spinal fusion is the most highly regarded scoliosis surgery procedure.
- In spinal fusion, two or more vertebrae are merged together so that they are immobile on their own. Between the vertebrae are placed fragments of bone or a substance that resembles bone. While the old and new bone material fuse together, metal rods, hooks, screws, or wires are usually used to hold that section of the spine erect and steady.
- Surgeons can implant a rod that can change length as the child grows if the child’s scoliosis is advancing quickly at a young age. The top and bottom portions of the spinal curvature are joined to a developing rod, which is typically prolonged every six months.
- Bleeding, infection, discomfort, and nerve damage are perhaps several possible impacts of spinal surgery. Hardly ever, the bone fails to restore, requiring further surgery.
Physical Therapy Management
To preserve cosmesis and prevent surgery, mild cases of scoliosis are treated with physical therapy and bracing.
Scoliosis is a three-dimensional disorder, not only a lateral curvature of the spine.
Work in three planes: sagittal, frontal, and transverse, to manage scoliosis.
Conservative treatment includes:
- Physical exercises
- Bracing
- Manipulation
- Electrical stimulation
- Insoles.
There are three crucial responsibilities of the physical therapist.
Inform, counsel, and educate.
- It’s crucial to perform the appropriate exercises.
- Educate the patient’s parents or both about the issue.
- Some physical therapists advise wearing a brace to stop scoliosis from getting worse. example: Milwaukee brace However, there is disagreement regarding the bracing evidence.
- Exercises have been shown to be helpful for those with idiopathic scoliosis.
- The biopsychosocial variables may also be addressed by physiotherapists.
- Adolescents who present with idiopathic scoliosis and symptoms of chronic low back pain may also have additional conditions like insomnia, depression, anxiety, and stress, as well as daytime sleepiness, which need to be evaluated and treated as contributing factors to a chronic low back pain experience.
Aims
Physiotherapy’s objectives are:
- Stabilization
- Coordination
- Equilibrium
- Ergonomical corrections
- Muscle endurance/ strength
- Spinal Neuromotor control
- Increase of ROM
- Respiratory capacity/ education
- Side-shift
- Autocorrection 3D
