The SOSORT Educational Committee

Transcription

1 The SOSORT Educational Committee Presents: Adult Scoliosis (AS) Rehabilitation: Select Case Histories Illustrating Treatment Options for Adults with Scoliosis and Related Complexities

2 ELENA SALVÀ INSTITUT BARCELONA, SPAIN

3 Today s Objectives Discuss favorable adult outcomes using 2 published case reports and 4 pending case histories in order to 1. Stimulate AS treatment innovation 2. Assist clinicians in setting and meeting functional AS therapy goals 3. Create ideas for larger AS studies

4 Today s Objectives Taking a patient perspective 1. How can you change my life? (Why should I see you and pay you for what you do?) 2. What good treatment options are available? 3. How will you decide on what treatment is right for me?

5 AS - Select Case Histories What changes can you make in my life? Radiologically: Cobb and rotation Segmental listhesis Posturally: Sagittal, frontal and rotational imbalance Functionally: Pain, disability, and quality of life Respiratory dysfunction

6 AS - Select Case Histories What good treatment options are available? Osteopathic/manual therapy Scoliosis-specific exercises (Schroth, Barcelona School, SEAS) Additional orthopedic exercises based upon objective clinical findings SI joint stabilization belts Shoe lifts for radiologically measured leg length discrepancy Scoliosis bracing

7 AS - Select Case Histories How will you decide what s right for me? Exam: Exams should balance comprehensive clinical and radiological findings Goals: Goals should be patient-specific and functional Strategies: Scoliosis and non-scoliosis treatment should be targeted at improving key findings Evidence: Evidence-based medicine should be used along with innovative ideas founded on sound clinical judgment Outcomes: Outcomes should be measured using objective and reliable tools

8 Case 1: Question: Can you improve my pain, rotary listhesis, and trunk deformity? Painful adult scoliosis with kyphosis evolution and sagittal anterior trunk imbalance treated with physical therapy techniques: a case report (Scoliosis 2009) Villagrasa M, Rigo M, Quera-Salvá G, Ferrer M, Pou E. Treatment Provided (4 months): Osteopathic manual therapy and BSRS exercises ELENA SALVÀ INSTITUT BARCELONA, SPAIN

9 Case 1 Results: March 2008 July 2009 Pre - Admission Admission After 4 mos treatment At 1 yr f/u Lumbar Cobb 63 NT Rotation: at apex (L2) Rotation: at listhesis (L3) 47 (Raymondi) 31 (Raymondi) NT NT 35 (Raymondi) NT NT 25 (Raymondi) Formetric trunk imbalance Formetric lateral deviation Formetric surface rotation NT NT NT NT NT NT Pain Present Absent ELENA SALVÀ INSTITUT BARCELONA, SPAIN

10 Case 1 Results: Improved trunk position Trunk imbalance 46.2 mm March 2008 July 2008 Trunk imbalance 21.5 mm Lateral deviation 34.2 mm Surface rotation 14.9º Lateral deviation 19.3 mm Surface rotation 10.3º ELENA SALVÀ INSTITUT BARCELONA, SPAIN

11 Case 1 Results: Rotation Reduction ºC 47º^R apex 61ºC 35º^R apex 31º^R at vertebra of max 2006 listhesis 25º^R at vertebra of max listhesis 10/2009 ELENA SALVÀ INSTITUT BARCELONA, SPAIN

12 Case 2 Question: Can you reduce my Cobb that has progressed during my adulthood? Adult scoliosis can be reduced through specific SEAS exercises: a case report. (Scoliosis 2008) Alessandra Negrini, Silvana Parzini, Maria Gabriella Negrini Michele Romano, Salvatore Atanasio, Fabio Zaina, Stefano Negrini Treatment Provided (one year): SEAS (Scientific Exercise Approach to Scoliosis) for 30 min/day at home; clinic sessions every 2 months

13 Case 2 Results: Cobb Reduction 14 yrs old 19 yrs old 20 yrs old 25 yrs old 26 yrs old Treatment Diagnosed Age 14-19: Risser cast and brace Thoracic Cobb Lumbar Cobb Age 19-20: None Age 20-25: None Age 25-26: SEAS

14 Case 2 Results: Cobb Reduction Age 14 Cobb 35 and 45 Age 19 Cobb 37 and 36 Age 20 Cobb 32 and 38 Age 25 Cobb 35 and 47 One year f/u Cobb 32 and 28 This case shows that when adult scoliosis progresses, specific exercises can help not just to get stability, but to recover previous years collapse. The reduction of scoliotic curve through rehabilitation presumably does not indicate a reduction of the deformity, but recovers the upright postural collapse.

15 Case 3 Question: Can you improve my pain and disability and lessen my recurring rib fractures? Ongoing Case: 72 y.o. with severe Cobb progressed 27 degrees in 4 years (current Cobb 97 deg), reporting progressive disability and recurring rib fractures. Cindy Marti, Meg Gogin, Patrick Flanagan Treatment Provided (9 months): Initial 3 weeks: Kinesio-tape for subacute rib fx (2/wk) At 1 month: Custom TLSO (worn 2 hrs daily) At 3 months: Schroth modified exercise (in clinic 1/wk x 3 months; ongoing at home 3-5 x week x 9 mos) Ongoing Massage Therapy: 1 x wk x 9 mos

16 Case 3 - Relevant History 2004 Pre-admission Cobb 70 deg 2009 Admission - Cobb 97 deg Treatment: TLSO Treatment: Modified Schroth

17 Case 3 Results: Short term reduction in pain and disability without rib fracture 2009 April 2010 March Admission 1 year follow up Disability (Oswestry) 48% 36% Pain (VAS) 8/10 3/10 Max. ambulation time 10 min 30 min Max stance time 10 min 1 hr Rib Fracture 2001, 2005, 2009 None to date

18 Case 3 Results: Improved Torso Shape Admission 9 months Admission 9 months

19 Case 4 Question: Can you improve my chronic pain and shortness of breath? Ongoing Case: 47 y.o. with stable scoliosis (36 deg Th / 32 L), reporting 20 year hx of worsening pain and SOB. Cindy Marti Treatment Provided (4 months): Manual therapy (11 sessions): Soft tissue mobilization to restrictions found in C-TH-L spine and diaphragm; joint mobilization to restrictions found in C-TH-L spine and SIJ Schroth exercise (9 sessions) Adjunct: SIJ stability belt, ultrasound to hypomobile spinal facets, scapular retraction taping for convex thoracic shoulder, ergonomic assessment of work station

20 Case 4 Results: Improvements in pain, disability, and respiration March 2009 Admission Pain (VAS) Worst 8/10 Least 2/10 June 2009 Discharge Worst 3/10 Least 0/10 March 2010 f/u at 9 mos Worst 3/10 Least 0/10 SOB frequency Daily Weekly Resolved Disability (Oswestry) 18% 9% NT Chest wall circumference NT (exhale to inhale) Axilla 3 cm 3 cm NT Xyphoid 1.5 cm 3.5 cm NT 12 th rib 2.5 cm 3.0 cm NT

21 Case 5 Question: Can you lessen my pain and improve my function even though I had AIS spinal fusion over 20 years ago? Ongoing Case: 47 y.o. with chronic unilateral (R) SIJ pain and undiagnosed LLD (PMH: Surgical fusion thoracic, autofusion lumbar, bilateral THA/TKA, failed past PT) Cindy Marti Treatment Provided (Weekly for 2 months - 8 total visits): Supine CT for LLD: detected (R) leg 14 mm long Assistive devices: SIJ stability belt; 12 mm lift in left shoe Manual therapy: joint mobilization to hypomobile right hip and SIJ Exercise: Daily home program for deficits found in right hip/sij mobility and strength

22 Case 5 Results: Dramatically improved pain and disability Disability (Oswestry) Jan 2010 Admission March 2010 Discharge 46% 6% (WOW!) Pain (VAS) 10/10 worst 0/10 least 3/10 worst (WOW!) 0/10 least Lumbar Cobb 53 deg (no heel lift) 53 deg (with 12 mm heel lift in left shoe)

23 Case 5 Results Dec 2009 No shoe lift April mm left shoe lift Dec 2009 No shoe lift April mm left shoe lift

24 Case 6 Question: Can you stabilize my progressive degenerative scoliosis and lessen my pain and disability? Current Case: 65 y.o. with progressive degenerative AS and pain. Cindy Marti, Patrick Knott Treatment Provided: 5 day intensive Schroth program 4 hrs/day Daily home Schroth 30 min/day for 4 months One refresher visit at 4 months

25 Case 6 Results: Short term stability and improved pain and disability 2003 Pre-admit 2006 Pre-admit 2009 Admit mo f/u Cobb L2 Apex 40 deg Lateral Listhesis L2 15 mm 15 mm ATR NT NT 14 deg 10 deg Oswestry (ODI) NT NT 18% 6% Pain (VAS) NT NT 7/10 worst 0/10 least 1/10 worst 0/10 least

26 Case 6 Results: Short term radiological stability in Cobb and listhesis 2004 Pre-admit Cobb 40 (L1) 2006 Pre-admit Cobb 46 (L1) 2009 Dec - Admit Cobb 50 (L1) Listhesis 15 mm (L2) 2010 April f/u Cobb 52 (L1) Listhesis 15 mm

27 Case 6 Results: Immediate improved torso shape with partial retention at 4 mos Dec 2009 Admission Dec after 5 day Intensive Schroth April mo Follow up

28 Acknowledged limitations Not a scientific session educational focused Variety of interventions while clinically appropriate for selected patients, make for challenging large sample research

29 AS Select Case Histories Closing Comments We sincerely hope these promising outcomes will help you more effectively treat your patients and plant seeds that will bloom into larger studies - creating exciting evidence to support viable options for adults with scoliosis. Thank you - on behalf of the SOSORT Educational Committee ELENA SALVÀ INSTITUT BARCELONA, SPAIN