nypta district meeting - c.ymcdn.com · pdf filescoliosis affects a combination of all 3...

NYPTADistrictmeetingNovember9,2017

Slidesmaynotbereproducedwithoutexpresspermissionfromspeakers

Prachi Bakarania, DPTHagit Berdishevsky, DPT

Kelly Grimes, DPTNYPTA District Meeting

November 9, 2017

1. Define structural spinal deformity2. Recall key clinical and radiological tests/measures to identifying a

spinal deformity3. Understand key clinical and radiological features of structural

spinal deformity that may predict decreased quality of life and pain4. Describe current non-operative and operative management

strategies for individuals with structural spinal deformity5. Describe precautions/contra-indications in working with individuals

with spine deformity and key indicators for referring out to physiotherapists with specialized training in spine deformity

▪ Classification✓Age (infantile, juvenile, adolescent, adult)✓Cause (idiopathic, neuromuscular, syndromic, thoracogenic,

congenital, iatrogenic)✓Plane of alignment affected

• Sagittal, Frontal, TransverseoEg. Scoliosis affects a combination of all 3 planesoEg. Hyperkyphosis or flatback syndrome primarily affects the

sagittal plane✓Location of apices

• Thoracic, thoracolumbar, lumbar

▪ Cobb Angle✓ID central sacral line✓ID apex: vertebrae that is most

laterally translated away from CSL✓Identify most tilted vertebra above

and below each apex✓Draw line parallel to top of UEV,

bottom of LEV✓Draw a perpendicular line from

each of the above lines✓Measure the angle where these

perpendicular lines intersect

27°

(Berdishevsky H. SBIC2CertificationCourseManual,2016)

▪ Scoliosis Research Society: lateral spinal curvature with Cobb angle of 10 degrees or more and identification of axial rotation

▪ Definition of Adult Spinal Deformity: wide range of conditions àabnormal spinal alignment involving any combination of the sagittal, frontal, and transverse planes (Ailon T, et al, 2015)

▪ Definition of idiopathic scoliosis: a complex, three-dimensional deformity of the spine/trunk, which appears in apparently healthy children, and can progress in relation to multiple factors during any rapid period of growth, or later in life (Rigo M, Grivas T, 2010)

CobbAngle=80°



▪ 80% of scoliosis is idiopathic▪ Prevalence: 1-3% of children ages 10-16▪ 10% of these cases require non-operative treatment▪ 0.1-0.3% of general population require operative treatment

▪ Etiology▪ Pathogenesis/Pathomechanism

▪ Etiology✓multi-factorial and heterogeneous (genetics, intra-uterine factors)

▪ Pathogenesis: what happens first to initiate structural change?✓Changes to bony tissues? Muscles?

▪ Pathomechanism✓What is the process by which the structural change is created?

▪ Progression factors✓What influences progression?


Nervous System (CNS and ANS) responds and reacts

Goal is to achieve symmetry

Skeleton changes during growth spurts

Many factors at play: ✓ Hormonal✓ Biological✓ physiological

Growth Spurts: ▪ Age 6-8 years old▪ Puberty

Problem:Interactionbetweenmusculoskeletal system,autonomicnervoussystemandcentralnervoussystembecomesfaultyà structuralchangetospinethatisnotcorrectedbythenervoussystem

(BurwellRG,2016)

▪ Vertebrae grows faster in the front vs the back of the vertebrae

▪ Vertebrae grows faster and taller on one side (side of convexity vs the other

▪ Vertebrae undergoes a rotational change within itself àrotation in the spine as a whole

(Perdriolle R,1993)

ViciousCycle

PhaseITriggeringEvent

PhaseIISpinal

curvatureAsymmetricLoading

PhaseIIISpinal

DeformityTorso

Deformity

PhaseIVProgression

(StokesIAF. 1996)

▪ Role of…✓ Leptin and Body Mass Index

• (Clark EM, et al, 2014); (Burwell GR, 2016)

✓ Melatonin• (Dubousset J, et al, 1983); (Lowe TG, et al, 2000); (Girardo M, et al, SOSORT oral

presentation, 2016)

✓ Bone mineral density• (Hon Yei Yip B, et al, SOSORT oral presentation, 2016); (Ishida K, et al, SOSORT oral

presentation 2016)

✓ Disc Wedging• (Qiu Y, et al, SOSORT oral presentation, 2016)

✓ Ribcage changes• (Grivas T, SOSORT oral presentation, 2015)




▪ Definition: scoliosis that develops in adulthood or after skeletal maturity

▪ Wide range of reported prevalence: 32% - 68%

asymmetricdegenerationofdisc

andfacetjoint

asymmetricloadingofspinal

segment

asymmetricloadingof

spinalcolumn

three-dimensionaldeformity

osteoporosis

(KotwalSetal,2011)

Visualizethetrunkin3DLookfor“mountains”and“valleys”

Mountains=potentialconvexityValleys=potentialconcavity

Wheredoyousee“mountains”and“valleys”?Starttomakepredictions

Namecurvesaccordingtosideofpredictedconvexity

38°

L R



1.Rib Asymmetry noted or Angle of Trunk Rotation (ATR)✓Measured with scoliometer

2.Lateral deviation of spinous process line

3.(+) modified Adam’s test✓seen from a lateral view✓disruption of normal arc of flexion

with forward bend✓occurs due to relative anterior

spinal overgrowth

(BerdishevskyH.SchrothBarcelonaInstituteC1CourseManual,2016)

▪ Cobb Angle

✓ ID most tilted vertebra for each curve

✓ Draw line parallel to top of Upper End Vertebrae (UEV) and bottom of Lower End Vertebrae (LEV)

✓ Draw a perpendicular line to each of the above lines

✓ Measure angle where perpendicular lines intersect

38°

Body“wellstacked”fromacoronalview(posteriororanterior)

(KendallFPetal,2005) (Lenhert-Schrothetal,2007)

(reprod fromRigo M.C1coursemanual2014)

CobbAngle=80°


▪ Mark either C7 or T1 (pick one and stay consistent)

▪ Drop a plumbline from C7 or T1▪ Measure horizontal distance from

plumbline and gluteal cleft

Ask patient where they tend to weight bear?

(BerdishevskyH.SchrothBarcelonaInstituteC1CourseManual,2016)

Ceilingcameraview

LegendV=ventralD=dorsal ForwardbendorAdam’stest

V

D

VertebralRotationonx-ray




Scoliometerorsmartphoneapp

▪ No “absolute” measurements of normal, but general “ranges” of acceptability

✓Kyphosis (T1-T12): 26-46° (average 35°)• < 9° pathological > 53°

✓Lordosis (L1-L5): 32-56° (average 44°)• < 14° pathological > 69°

✓Thoracolumbar junction (T12-L1) neutral

(BernhardtM,BridwellKH,1989)

(KendallFPetal,2005)


(Katzmanetal,2010)(SchrothBarcelonaInstituteC1CertificationCourseManual,2016)

▪ Thoracolumbar or lumbar curves have worse outcomes than thoracic curves (Jackson etal 1983,1989) (Glassman etal, 2005)

▪ Degenerative instability (listhesis- lateral and rotatory) predicts pain and instability (Schwab et al 2002) (Hong et al, 2010)

▪ Positive (anterior) sagittal balance predicts clinical symptoms in adult spinal deformity (Glassman et al 2005)

▪ Loss of lumbar lordosis particularly in individuals with thoracolumbar/lumbar curves (Schwab etal 2002, 2006)

▪ Significant coronal imbalance was associated with pain and dysfunction

COBB ANGLE NOT CORRELATED WITH PAIN AND FUNCTION (Schwab et al 2006) (Hill et al 2008) (Hong et al 2010) (Urrutia, et al 2011)



1.Halt or reduce curve progression2.Improve 3D trunk shape and global posture3.Improve general health4.Help individuals with scoliosis to cope with their condition and the treatment process

5.Diminish functional limitations

▪ Age group: 10-18 years old

▪ Non-operative options✓Physiotherapeutic Scoliosis-Specific Exercise (PSSE)

• Curve magnitude 15 degrees and above✓Bracing

• Curve magnitude between 20-30 degrees and above with remaining growth potential

▪ Exercises adapted to an individual’s specific curve pattern, according to medical and physiotherapist evaluation of particular curve characteristics



Schreiber S, Parent EC, Khodayari moez E, et al. Schroth Physiotherapeutic Scoliosis-Specific Exercises Added to the Standard of Care Lead to Better Cobb Angle Outcomes in Adolescents with Idiopathic Scoliosis - an Assessor and Statistician Blinded Randomized Controlled Trial. PLoS ONE. 2016;11(12):e0168746

Schreiber S, Parent EC, Moez EK, et al. The effect of Schroth exercises added to the standard of care on the quality of life and muscle endurance in adolescents with idiopathic scoliosis-an assessor and statistician blinded randomized controlled trial: "SOSORT 2015 Award Winner". Scoliosis. 2015;10:24.

Kuru T, Yeldan İ, Dereli EE, Özdinçler AR, Dikici F, Çolak İ. The efficacy of three-dimensional Schroth exercises in adolescent idiopathic scoliosis: A randomised controlled clinical trial. Clin Rehabil. 2015

Monticone, M, Ambrosini, E, Cazzaniga, D, Rocca, B, Ferrante, S. Active self-correction and task-oriented exercises reduce spinal deformity and improve quality of life in subjects with mild adolescent idiopathic scoliosis. Results of a randomised controlled trial. European Spine Journal Eur Spine J. 2014:1204–1214.

Noh DK, You JS-H, Koh J-H, Kim H, Kim D, Ko-S-M, et al. Effects of novel corrective spinal technique on adolescent idiopathic scoliosis as assessed by radiographic imaging. J Back Muscuoloskelet Rehabil. 2014;27:331-8

▪ Goals:

✓Prevent progression of structural change

✓Prevent need for spinal fusion

▪ Indicans

✓children and adolescents

✓Curves between 20-40 degrees

✓2 years remaining growth

▪ 2013 New England Journal of Medicine multi-center RCT

▪ Bracing vs Observation

▪ Results

✓Treatment success 72% after bracing vs 48% after observation

✓Increased benefit with longer hours of brace wear

✓Evidence that in-brace correction affects success

▪ Collaboration between healthcare providers✓Physiotherapist✓Primary care✓Physiatry✓Orthopedic surgeon

▪ Options✓PSSE✓Pharmacological and non-operative interventional management✓Bracing

Author,Year DistinguishingFeatures Conclusions

Everettetal,2007 - 2articlesonbracing/casting

- 3articlesmetcriteriaforexercise

- 2articlesonchiro- 1article

injections/epidurals

- LevelIVevidenceforbracing/castinginadultscoliosis

- LevelIVevidenceforuseofexercisetherapy

- LevelIVevidenceforuseofchiropractic

- LevelIIIevidenceforuseofepiduralinjections

Smith JS et al, 2016 Glassman SD et al 2010

Liu S, et al 2014 Bridwell KH et al 2009

Study Design Multi-center, prospective cohort

Prospective cohort study

Multicenter, prospective, consecutive case series

Prospective observational cohort study

Population Adults (>18yr) with ASD

Adults with ASD Adults with ASD > 18 yrs

Adults with lumbar scoliosis over 30 degrees without prior surgery

Intervention operative 8 types of non-op intervention

Operative patients Operative patients

Comparator non operative No intervention Non-operative patients

Non-operative patients

Outcome HRQOL measures HRQOL measures HRQOL measures QOL measures

Key Findings Improved HRQOL for operative group

No sig change in QOL measures in exposure groupMean Rx costs: $10, 815

Surgical pts with higher likelihood to achieve MCID improvement across HRQOL measures

Significant improvement in operative group in QOL; no change in non-op group

Follow- Up 2 years 2 years 1 year 2 years



MonticoneMetal,2016

StudyDesign Randomized,parallel-groupsuperiority-controlledtrial,singlecenter

Population Adultswithidiopathicscoliosis

Intervention Activeself-correction,task-orientedexerciseandCBT

Comparator Generalphysiotherapy(active/passivemobilizations,stretching,trunkstrengthening)

OutcomeMeasures ODI,Tampascaleforkinesiophobia,paincatastrophizingscale,painnumericalratingscale,SRS-22;Cobbangle;ATR

KeyFindings StatisticallysignificantreductionindisabilityinexperimentgroupRadiologicalmeasuresstatisticallyimprovedbutnotmeaningful

▪ Growth-friendly procedures✓Early Onset Scoliosis surgical options

• Vertical Expandable Prosthetic Titanium Rib (VEPTR)• MCGR• Growing rods for Early Onset Scoliosis• Shilla Growth Guidance System

✓AIS• Vertebral body stapling• Vertebral Body Tethering

▪ Fusion✓Posterior Approach✓Anterior approach: becoming less common

▪ Minimally Invasive Techniques

▪ Anterior approach

▪ Posterior approach✓Posterior Vertebral Column Resection✓Osteotomies



▪ Factors in Determining Risk for Progression✓Cobb angle at detection

• Higher = increased risk✓Age

• Younger = increased risk, especially during periods of growth spurt (6-8 years old, adolescence)

✓Remaining bone growth• Determined by various methods by physician/surgeon

✓Other factors that may place patient in ”non-idiopathic” category• Co-morbidities, joint hypermobility

▪ If you receive a referral from a physician for eval/treatment of AIS, suggest to consult/refer patient to a physiotherapist with increased scoliosis knowledge (see end of presentation for directory of therapists)

▪ Medical screening and Red Flags✓Significant weight changes unexplained✓History of cancer✓Loss of control bowel/bladder✓Saddle anesthesia✓Loss of strength/motor coordination in arms/legs✓Balance changes

▪ Additional questions: presence of osteopenia or osteoporosis

▪ Presence of structural and/or dynamic instability✓Clinical signs

• Subjective: o symptoms with transitional

movements and sustained positions

• Objective: o Alignment: segmental

creasing in spine, faulty frontal, transverse, sagittal alignment

o inability to maintain trunk stability against limb movement with tests

✓Radiological signs• Presence of “listhesis”

o Lateral, rotatory, sagittal

▪ Consideration of three-dimensional nature of structural scoliosis✓To influence one plane of alignment is to ultimately influence

another• Risk: by addressing just one plane of alignment, there is the

potential to worsen the other two planes

▪ Wide variety of stiffness to structural changes in adult spine deformity✓Careful observation and handling skills to assess active vs

passive ranges of motion and to respect end feels



▪ Consult with a practitioner with scoliosis education training (see directory of therapists)

▪ Intervention strategies✓Stable base of support; optimize initial alignment as close to

neutral as possible, with respect for patient’s capabilities✓Train self-elongation or auto-elongation: ability of the patient to

utilize respiration and co-activation of deep stabilizing muscles to create spinal elongation

▪ Schroth Barcelona Institute✓www.schroth-barcelonainstitute.com

▪ Hunter College List of Schroth Therapists✓http://www.hunter.cuny.edu/pt/the-schroth-method-of-

management-of-scoliosis

▪ Schroth Method (German trained therapist list)✓http://www.schroth-

skoliosebehandlung.de/liste_therapeuten_eng.pdf

▪ Schroth Barcelona Institute✓www.schroth-barcelonainstitute.com

▪ SEAS through Schroth NYC✓www.schrothnyc.com

▪ Yoga and Scoliosis Intro Courses✓ http://kiokotherapy.com/workshops-events/

▪ Pilates and Scoliosis Intro Courses✓www.schrothnyc.com

▪ Medbridge courses- Cindy Marti✓Adolescent and Adult Scoliosis

Prachi Bakarania: [email protected] Berdishevsky: [email protected]

Kelly Grimes: [email protected]

▪ Ailon T, Smith JS, Shaffrey CI, et al. Degenerative Spinal Deformity. Neurosurgery. 2015;77 Suppl 4:S75-91. ▪ Berdishevsky H, Rigo M. Schroth Barcelona Institute C2 Certification Course Manual, 2016.▪ Berdishevsky H, Rigo M. Schroth Barcelona Institute C1 Certification Course Manual, 2016.▪ Bernhardt M, Bridwell KH. Segmental analysis of the sagittal plane alignment of the normal thoracic and lumbar spines

and thoracolumbar junction. Spine. 1989;14(7):717-21.▪ Burwell RG, Clark EM, Dangerfield PH, Moulton A. Adolescent idiopathic Scoliosis (AIS): a multifactorial cascade

concept for pathogenesis and embryonic origin. Scoliosis and Spinal Disorders. 2016;11:8.▪ Buttermann GR, Mullin WJ. Pain and disability correlated with disc degeneration via magnetic resonance imaging in

scoliosis patients. Eur Spine J. 2008;17(2):240-9.▪ Clark EM, et al. Association between components of body composition and scoliosis: a prospective cohort study

reporting differences identifiable before the onset of scoliosis. JBMR. 2014;29(8):1729-36.▪ Dubousset J, Queneau P, Thillard MJ. Experimental scoliosis induced by pineal and diencephaic lesions in young

chickens. Its relation with clinical findings in idiopathic scoliosis. Orthop. Trans. 1983;7:7.▪ Everett CR, Patel RK. A systematic literature review of nonsurgical treatment in adult scoliosis. Spine. 2007;32(19

Suppl):S130-4.▪ Glassman SD, Berven S, Bridwell K, Horton W, Dimar JR. Correlation of radiographic parameters and clinical symptoms

in adult scoliosis. Spine. 2005;30(6):682-8

▪ Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F. The impact of positive sagittal balance in adult spinal deformity. Spine. 2005;30(18):2024-9.

▪ Glassman SD, Carreon LY, Shaffrey CI, et al. The costs and benefits of nonoperative management for adult scoliosis. Spine. 2010;35(5):578-82.

▪ Hill D, Parent E, Lou E, Mahood J. Can future back pain in AIS subjects be predicted during adolescence from the severity of the deformity?. Stud Health Technol Inform. 2008;140:249-53.

▪ Hong JY, Suh SW, Modi HN, Hur CY, Song HR, Park JH. The prevalence and radiological findings in 1347 elderly patients with scoliosis. J Bone Joint Surg Br. 2010;92(7):980-3.

▪ Jackson RP, Simmons EH, Stripinis D. Coronal and sagittal plane spinal deformities correlating with back pain and pulmonary function in adult idiopathic scoliosis. Spine. 1989;14(12):1391-7.

▪ Jackson RP, Simmons EH, Stripinis D. Incidence and severity of back pain in adult idiopathic scoliosis. Spine. 1983;8(7):749-56.▪ Katzman WB, Wanek L, Shepherd JA, Sellmeyer DE. Age-related hyperkyphosis: its causes, consequences, and management.

J Orthop Sports Phys Ther 2010;40:352-60.▪ Kendall FP, McCreary EK, Provance PG, Rodgers MM, Romani WA. Muscles Testing and Function with Posture and Pain. 5th

ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.▪ Kotwal S, Pumberger M, Hughes A, et al. Degenerative Scoliosis: A Review. HSSJ. 2011;7:257-264.▪ Kuru T, Yeldan İ, Dereli EE, Özdinçler AR, Dikici F, Çolak İ. The efficacy of three-dimensional Schroth exercises in adolescent

idiopathic scoliosis: A randomised controlled clinical trial. Clin Rehabil. 2015



▪ Lehnert-Schroth, C. Three- Dimensional Treatment for Scoliosis: A Physiotherapeutic Method for Deformities of the Spine. Palo Alto, CA: The Martindale Press; 2007.

▪ Liu S, Schwab F, Smith JS, et al. Likelihood of reaching minimal clinically important difference in adult spinal deformity: a comparison of operative and nonoperative treatment. Ochsner J. 2014;14(1):67-77.

▪ Lowe T, Berven SH, Schwab FJ, Bridwell KH. The SRS classification for adult spinal deformity: building on the King/Moe and Lenke classification systems. Spine. 2006;31(19 Suppl):S119-25.

▪ Lowe T, et al. Etiology of Idiopathic Scoliosis: Current Trends in Research. JBJS. 2000;82-A(8):1157-68.▪ Monticone M, Ambrosini E, Cazzaniga D, et al. Adults with idiopathic scoliosis improve disability after motor and cognitive rehabilitation: results of a

randomised controlled trial. Eur Spine J. 2016;25(10):3120-3129.▪ Negrini S, Aulisa AG, Aulisa L. 2011 SOSORT guidelines: Orthopaedic and Rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis.

2012;7:3▪ Noh DK, You JS-H, Koh J-H, Kim H, Kim D, Ko-S-M, et al. Effects of novel corrective spinal technique on adolescent idiopathic scoliosis as

assessed by radiographic imaging. J Back Muscuoloskelet Rehabil. 2014;27:331-8▪ Perdriolle R, et al. Mechanical process and growth cartilages. Spine. 1993;18(3):343-349.▪ Rigo M, Grivas TB. “Rehabilitation schools for scoliosis” thematic series: describing the methods and results. Scoliosis. 2010;5:27.▪ Rigo M. 3-D Treatment of Scoliosis according to the Principles of C.L Schroth. Level 1 Certification Course Manual. 2014.▪ Schreiber S, Parent EC, Khodayari moez E, et al. Schroth Physiotherapeutic Scoliosis-Specific Exercises Added to the Standard of Care Lead to

Better Cobb Angle Outcomes in Adolescents with Idiopathic Scoliosis - an Assessor and Statistician Blinded Randomized Controlled Trial. PLoSONE. 2016;11(12):e0168746

▪ Schreiber S, Parent EC, Moez EK, et al. The effect of Schroth exercises added to the standard of care on the quality of life and muscle endurance in adolescents with idiopathic scoliosis-an assessor and statistician blinded randomized controlled trial: "SOSORT 2015 Award Winner". Scoliosis. 2015;10:24.

▪ Schwab F, Dubey A, Pagala M, Gamez L, Farcy JP. Adult scoliosis: a health assessment analysis by SF-36. Spine. 2003;28(6):602-6.

▪ Schwab F, Farcy JP, Bridwell K, et al. A clinical impact classification of scoliosis in the adult. Spine. 2006;31(18):2109-14.

▪ Schwab FJ, Blondel B, Bess S, et al. Radiographical spinopelvic parameters and disability in the setting of adult spinal deformity: a prospective multicenter analysis. Spine. 2013;38(13):E803-12.

▪ Schwab FJ, Smith VA, Biserni M, Gamez L, Farcy JP, Pagala M. Adult scoliosis: a quantitative radiographic and clinical analysis. Spine. 2002;27(4):387-92.

▪ Smith JS, Lafage V, Shaffrey CI, et al. Outcomes of Operative and Nonoperative Treatment for Adult Spinal Deformity: A Prospective, Multicenter, Propensity-Matched Cohort Assessment With Minimum 2-Year Follow-up. Neurosurgery. 2016;78(6):851-61.

▪ Stokes IA, et al. Mechanical Modulation of Vertebral Body Growth: Implications for Scoliosis Progression. Spine. 1996;21:1162-1167.

▪ Urrutia J, Espinosa J, Diaz-ledezma C, Cabello C. The impact of lumbar scoliosis on pain, function and health-related quality of life in postmenopausal women. Eur Spine J. 2011;20(12):2223-7.

▪▪

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