Sagittal Alignment in Spinal Deformity: Implications for the Non-Operative Care Practitioner

Sagittal alignment has become a hot topic in the world of orthopedics, particularly as it pertains to adults with spine deformities and coexisting pain, activity limitations, and health-related quality of life. It is reported that the prevalence of spinal deformity in the older adult will continue to increase. Clinicians across disciplines recognize the myriad of variation that exists in sagittal alignment, and that there is not one ideal norm to ascribe to. Relatively new to the spine deformity community has been the discovery of the relationship between the pelvis and the femur (pelvic incidence) in dictating lumbar lordosis and overall spinal alignment. While it is acknowledged that variation exists, there is now evidence that there is a limited range within which we can compensate for loss of sagittal alignment and still function well. When compensations run out, the quality of life becomes affected. These alignment variations, compensations, and in some cases, loss of alignment all together have clinical implications for the physiotherapist working with the older adult population. The purpose of this chapter is to describe the current state of evidence-informed knowledge around spinopelvic parameters as they relate to the adult with spine deformity and offer clinical implications for the conservative care practitioner

Posturalna adaptacija idiopatskih adolescentnih skolioza (ias)

Idiopathic adolescent scoliosis (IAS) is a pathologic postural adaptation in 65% of cases of scolioses. The causes of this condition are determined or suggested by a series of scientific studies and clinical experience. The results of the studies imply the correlation of IAS, the pathologic movement pattern and the pathologic postural adaptation which is governed by the central nervous system’s mode of function. The pattern of pathologic postural adaptation has been confirmed by different methods and procedures: a physiological analysis of the soft tissues and of the specific functioning of organs’ systems, a biomechanical analysis of the muscles and joints, an analysis of mobility and the degree of motor function of body segments as well as of the whole body and also by the clinical experience gained from surgical and treatment procedures on children with IAS.Idiopatska adolescentna skolioza patološka je posturalna adaptacija u 65% slučajeva između ostalih skolioza. Uzroci nastanka utvrđeni su ili se pretpostavljaju kroz niz znanstvenih istraživanja i klinička iskustva. Istraživanja ukazuju na povezanost IAS s patološkim obrascem pokretanja i patološkom posturalnom adaptacijom koju uvjetuje način funkcioniranja središnjeg živčanog sustava. Obrazac patološke posturalne adaptacije potvrđen je iz više kutova; fiziološkom analizom mekih tkiva i specifičnosti funkcioniranja organskih sustava, biomehaničkom analizom muskulature i zglobnih sustava, analizom pokretljivosti i stupnja motoričke funkcije segmenata tijela i cijelog tijela te kliničkim iskustvom tijekom operativnih zahvata i terapijskih postupaka kod djece s IAS

Biomechanical Modeling and Characterization of the Postural Parameters in Adolescent Idiopathic Scoliosis

RÉSUMÉ La scoliose est une déformation 3D de la colonne vertébrale qui influence la morphologie et l'alignement de la colonne vertébrale, du bassin et de la cage thoracique. Bien que plusieurs paramètres soient introduits pour identifier et évaluer les courbes chez les sujets scoliotiques, la relation biomécanique entre la colonne vertébrale et le bassin ainsi que ses impacts sur la posture et l'équilibre général des sujets scoliotiques n’est pas encore élucidée. Le but de ce projet doctoral était d'examiner l'interaction spino-pelvienne en mesurant les paramètres biomécaniques chez les sujets atteints de scolioses idiopathiques adolescentes (SIA). La cinématique pelvienne, l'orientation spino-pelvienne relative et le chargement biomécanique lombo-sacré ont été examinés chez des sujets avec des courbures différentes. L’hypothèse que nous souhaitons vérifier est que l'interaction spino-pelvienne (au niveau des paramètres statiques, cinématiques et des chargements biomécaniques à l’interface entre le rachis et le bassin) est non seulement différente entre les SIA et les contrôles, mais varie aussi entre les sujets présentant différents types de scolioses. De plus, l'effet d’une instrumentation chirurgicale du rachis sur l’équilibre ainsi que sur l'interaction biomécanique spino-pelvienne a été étudié post opérativement. Donc, après avoir examiné la littérature pertinente, trois chapitres ont été consacrés pour examiner l'hypothèse générale de ce projet. Chaque chapitre aborde un aspect de l'interaction spino-pelvienne chez les sous-groupes scoliotiques et compare les résultats avec un groupe de contrôles de la même catégorie d'âge-sexe. Bien que l'orientation pelvienne entre les sujets SIA et le groupe contrôle était différente, il n'est pas vérifié dans quelle mesure l'orientation pelvienne et l'alignement spino-pelvien affectent la cinématique du bassin chez les sujets présentant différents types de courbures. Par la suite, l’interférence entre l'orientation du bassin et le mouvement spino-pelvien a été étudiée.----------ABSTRACT Scoliosis is a 3D spinal deformity which impacts the morphology and alignment of the spine, the pelvis, and the ribcage. Although several spinal parameters are introduced to identify and evaluate scoliotic curves, there is not much known about the biomechanical relationship between the spine and the pelvis and its impact on the overall posture and equilibrium of the scoliotic patients. The focus of this Ph.D. project was to investigate the spino-pelvic biomechanical interaction in adolescent idiopathic scoliosis (AIS) more closely. Spine and pelvic kinematic, relative spino-pelvic orientation in static, and lumbosacral biomechanical loading were investigated in subjects with different curve patterns. We hypothesized that spino-pelvic interaction is not only different between AIS and controls, but also varies between subjects with different scoliotic types in static, kinematic, and biomechanical loading. Furthermore the hypothetical effect of the spinal operation on equilibrating the spino-pelvic biomechanical interaction was tested postoperatively. Hence, after reviewing the pertinent literatures, 3 chapters were devoted to investigate the general hypothesis of this project. Each chapter tries to investigate one aspect of the spine and pelvis interaction in scoliotic subgroups and compares the results with an age-gender match group of controls. Although the pelvic alignment in the AIS group was different from the age-gender matched control group, it is not closely verified to what extent the pelvic orientation and the spino-pelvic alignment affect the pelvis kinematic in subjects with different curve types and subsequently its impact on the spino-pelvic movement is not determined. An experimental setup was designed to investigate the pelvic 3D motion during simple trunk movement in vivo

Physiotherapy scoliosis-specific exercises: a comprehensive review of seven major schools

In recent decades, there has been a call for change among all stakeholders involved in scoliosis management. Parents of children with scoliosis have complained about the so-called “wait and see” approach that far too many doctors use when evaluating children’s scoliosis curves between 10° and 25°. Observation, Physiotherapy Scoliosis Specific Exercises (PSSE) and bracing for idiopathic scoliosis during growth are all therapeutic interventions accepted by the 2011 International Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT). The standard features of these interventions are: 1) 3-dimension self-correction; 2) Training activities of daily living (ADL); and 3) Stabilization of the corrected posture. PSSE is part of a scoliosis care model that includes scoliosis specific education, scoliosis specific physical therapy exercises, observation or surveillance, psychological support and intervention, bracing and surgery. The model is oriented to the patient. Diagnosis and patient evaluation is essential in this model looking at a patient-oriented decision according to clinical experience, scientific evidence and patient’s preference. Thus, specific exercises are not considered as an alternative to bracing or surgery but as a therapeutic intervention, which can be used alone or in combination with bracing or surgery according to individual indication. In the PSSE model it is recommended that the physical therapist work as part of a multidisciplinary team including the orthopeadic doctor, the orthotist, and the mental health care provider - all are according to the SOSORT guidelines and Scoliosis Research Society (SRS) philosophy. From clinical experiences, PSSE can temporarily stabilize progressive scoliosis curves during the secondary period of progression, more than a year after passing the peak of growth. In non-progressive scoliosis, the regular practice of PSSE could produce a temporary and significant reduction of the Cobb angle. PSSE can also produce benefits in subjects with scoliosis other than reducing the Cobb angle, like improving back asymmetry, based on 3D self-correction and stabilization of a stable 3D corrected posture, as well as the secondary muscle imbalance and related pain. In more severe cases of thoracic scoliosis, it can also improve breathing function. This paper will discuss in detail seven major scoliosis schools and their approaches to PSSE, including their bracing techniques and scientific evidence. The aim of this paper is to understand and learn about the different international treatment methods so that physical therapists can incorporate the best from each into their own practices, and in that way attempt to improve the conservative management of patients with idiopathic scoliosis. These schools are presented in the historical order in which they were developed. They include the Lyon approach from France, the Katharina Schroth Asklepios approach from Germany, the Scientific Exercise Approach to Scoliosis (SEAS) from Italy, the Barcelona Scoliosis Physical Therapy School approach (BSPTS) from Spain, the Dobomed approach from Poland, the Side Shift approach from the United Kingdom, and the Functional Individual Therapy of Scoliosis approach (FITS) from Poland

State of the art of current 3-D scoliosis classifications: a systematic review from a clinical perspective

Scoliosis is a complex three dimensional (3D) deformity: the current lack of a 3D classification could hide something fundamental for scoliosis prognosis and treatment. A clear picture of the actually existing 3D classifications lacks. The aim of this systematic review was to identify all the 3D classification systems proposed until now in the literature with the aim to identify similarities and differences mainly in a clinical perspective. After a MEDLINE Data Base review, done in November 2013 using the search terms "Scoliosis/classification" [Mesh] and "scoliosis/classification and Imaging, three dimensional" [Mesh], 8 papers were included with a total of 1164 scoliosis patients, 23 hyperkyphosis and 25 controls, aged between 8 and 20 years, with curves from 10\ub0 to 81\ub0 Cobb, and various curve patterns. Six studies looked at the whole 3D spine and found classificatory parameters according to planes, angles and rotations, including: Plane of Maximal Curvature (PMC), Best Fit Plane, Cobb angles in bodily plane and PMC, Axial rotation of the apical vertebra and of the PMC, and geometric 3D torsion. Two studies used the regional (spinal) Top View of the spine and found classificatory parameters according to its geometrical properties (area, direction and barycenter) including: Ratio of the frontal and the sagittal size, Phase, Directions (total, thoracic and lumbar), and Shift. It was possible to find similarities among 10 out of the 16 the sub-groups identified by different authors with different methods in different populations. In summation, the state of the art of 3D classification systems include 8 studies which showed some comparability, even though of low level. The most useful one in clinical everyday practice, is far from being defined. More than 20 years passed since the definition of the third dimension of the scoliosis deformity, now the time has come for clinicians and bioengineers to start some real clinical application, and develop means to make this approach an everyday tool

Dynamic surface topography and its application to the evaluation of adolescent idiopathic scoliosis

Dynamic surface topography is a method to quantify the surface and locations of features acquired from moving and distorting shapes against time. This thesis describes the application of the technique to the potential evaluation of adolescent idiopathic scoliosis patients. Scoliosis or curvature of the spine is one of the major skeletal diseases in adolescents where in the majority of cases the cause is unknown or idiopathic. The progression of the disease occurs in three dimensions with the spine simultaneously curving towards the arms and rotating as it collapses with the first indications usually being changes in body symmetry and back surface shape. Following diagnosis, most children do not exhibit any significant worsening of their condition and are routinely monitored using radiography as frequently as every three months whilst vertebral growth potential remains. In a small number of patients, the lateral curvature can unpredictably worsen requiring, in some cases, surgical intervention to prevent further deterioration and to diminish the deformity. Earlier work by many researchers concentrated on attempting to reduce patient exposure to ionizing radiation by investigating if there was a reliable correlation between progression of the scoliosis and changes in surface topography. The techniques have not gained acceptance as the relational algorithms were found to be insufficiently robust in all cases and measurements acquired from available technologies were prone to artefacts introduced by stance, breathing, 'posture and sway. For many patients the motivation in seeking treatment is for the improvement of their appearance rather than to correct the underlying deformity, so cosmetic concerns and an understanding of the psychosocial and physical impacts of the disease and treatments remain important factors in the clinical decision-making process. In the current environment of evidence based medicine there is a growing need to quantify back surface shape, general body asymmetry and patient capability with the objective of producing an agreed scoring to be used in developing treatment plans and assessing outcomes but to date many clinics continue to rely on qualitative methods to describe cosmetic deformity and ability. The aim of the research was to develop an original, low cost and inherently safe apparatus using well understood video based motion capture technology that overcame the disadvantages of earlier work by simultaneously acquiring multiple samples of back surface shape and the locations of bony landmarks to provide averaged results for a quantitative and reliable analysis of cosmetic defect and physical impairment. 172,650 data samples were acquired from thirty skeletally mature subjects not exhibiting any musculoskeletal disease to define normality limits for Page 2 established morphological measurements and to compare the specificity of the approach with existing single sample techniques. Three novel calculations of back paraspinous volumetric asymmetry were tested of which two were found to be potentially useful clinical indicators of deformity and an index was proposed and tested using simulated data that could offer a single value to describe patient back shape asymmetry. Previous research has found that there is a loss of trunk ranges of motion among postoperative patients that has a direct impact on their quality of life, function and physical capability. Data were acquired from the mature subjects and similar results were observed when compared with published data for preoperative scoliosis patients. This thesis has shown that using averaged tri-dimensional morphological and back shape data combined with measurement of dynamic capability acquired using an inherently safe apparatus have the potential to be clinically useful. The opportunity to routinely and safely quantify the cosmetic defect and trunk ranges of motion of adolescent idiopathic scoliosis patients should stimulate more important research to help improve the quality of life of many affected children throughout the world

Physical Rehabilitation in the Management of Symptomatic Adult Scoliosis

Scoliosis is prevalent in elderlies over the age of 60. Of the different curve types, the thoracolumbar curve is the most common curve type operated upon, as it is associated with marked trunk shift and disability. Current physiotherapy treatments consist of electrotherapy, aquatic exercises, core-strengthening exercises, and dry needling. Outcome of these treatments has not been satisfactory. Long-term successful rate of conservative treatment of symptomatic adult scoliosis is low, as the treatment addresses symptoms but not the biomechanics involved in adult scoliosis. Recent studies have shown that physiotherapeutic scoliosis-specific exercises (PSSE) and bracing stabilized the curves in 80% of the subjects. Thus PSSE and bracing should be added to the standard physiotherapy care in the management of symptomatic adult scoliosis. For asymptomatic patients with thoracolumbar curve that has an increased risk of progression, PSSE should be considered as preventative exercises. Patients who do not respond to conservative treatments and have significant spinal stenosis should be referred for surgery

A Novel Classification of 3D Rib Cage Deformity in Subjects With Adolescent Idiopathic Scoliosis

Study Design: This was a multicentric cross-sectional descriptive study. Objective: To analyze patterns of 3D rib cage deformity in subjects with adolescent idiopathic scoliosis (AIS) and their relationship with the spinal deformity. Summary of Background Data: Subjects with AIS present with rib cage deformity that can affect respiratory functions. The 3D rib cage deformities in AIS and their relationship to the spinal deformity are still unelucidated. Methods: A total of 200 AIS and 71 controls underwent low-dose biplanar x-rays and had their spine and rib cage reconstructed in 3-dimensional (D). Classic spinopelvic parameters were calculated in 3D and: rib cage gibbosity, thickness, width, volume and volumetric spinal penetration index (VSPI). Subjects with AIS were classified as: group I with mild rib cage deformity (n=88), group II with severe rib cage deformity (n=112) subgrouped into IIa (high gibbosity, n=48), IIb (high VSPI, n=48), and IIc (both high gibbosity and VSPI, n=16). Results: Groups IIa and IIb had a higher Cobb angle (33 vs. 54 degrees and 46 degrees, respectively) and torsion index (11 vs. 14 degrees and 13 degrees, respectively) than group I. Group IIb showed more severe hypokyphosis (IIb=21 degrees; IIa=33 degrees; I=36 degrees; control=42 degrees) with a reduced rib cage volume (IIb=4731 cm3; IIa=4985 cm3; I=5257 cm3; control=5254 cm3) and thickness (IIb=135 mm; IIa=148 mm; I=144 mm; control=144 mm). Group IIa showed an increasingly large local gibbosity descending from proximal to distal levels and did not follow the axial rotation of the spine. Group IIc showed characteristics of both groups IIa and IIb. Conclusions: This new classification of 3D rib cage deformity in AIS shows that the management of cases with high VSPI (groups IIb and IIc) should focus on restoring as much kyphosis as possible to avoid respiratory repercussions. Treatment indications in groups I and IIa would follow the consensual basic principles reported in the literature regarding bracing and surgery