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Cervical scoliosis:
apex of curve at or between C1 and C6
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CT curve:
apex of curve at C7, C8 or T1
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Thoracic curve:
- apex of curve at or between T2 and T11
- Most common
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TL curve:
apex of curve at L2, L3 or L4
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LS curve:
- apex of curve at L5 or S1
- Double curves also common
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Euler’s theory of elastic buckling
- curve progression
- ----slow plastic deformity without load
- ----congenital
- ----spine curve whether they cure or not
- critical load
- ----where the spine begins to bend and the spine commences
- ----C/S a lot
- curve magnitude of spine increases, ability to carry load without deformity decreases as magnitude of critical load decreases
- ----as the curve gets bigger it cant accept as much and bends more
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Predictors of curve progression
- Curve Pattern
- ----Double curve Progress faster
- Curve Magnitude
- ----Larger curve, only going to get bigger
- Age
- ----Younger w/ dx greater chance of bigger curve bc greater chance of skeletal growth
- Menarche Status
- ----Increased change of curve if dx’ed before puberty
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Predictors of curve progression
- (+) Risser Sign
- ----fusion at the pelvic epiphysis
- ----1-5
- ----5 is fused
- Rib Vertebral Angle Difference (RVAD)
- ----Resolving curve
- --------RVAD < 20’
- --------convex ribs do not overlap vertebral body (don’t articulate with vertebral body any more)
- ----Progressive curve
- --------RVAD > or = 20’
- --------convex ribs overlap vertebral body
- Imaging
- ----X-ray taken with orthosis donned determines pad position and overall efficiency in terms of curve reduction
- --------Want max control at apex
- --------Don’t lordosis at T/S
- type and location of curve
- quantify degree and magnitude of rotation
- assess trunk balance/decompensation
- determine skeletal age either Risser sign or wrist/hand bone age
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Pt assessment
- Subjective history
- ----Onset
- ----Premorbid factores
- ----Age
- ----Who dx
- ----Family hx
- ----Have they worn orthoses in past
- ----Pain
- Postural Exam (in standing)
- ----Frontal plane
- --------Head neck position
- --------Shoulder position (Dominant should be lower)
- --------Muscle girth
- ----Sagittal Plane
- Balance
- Scoliometer
- ----Measures degree of rotation deformity
- Adams Test
- LLD
- MMT trunk and LE
- Abdominal reflexes
- ----Absent or diminished might indicate intraspinal pathology
- Integumentary check
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Orthotic intervention for scoliosis Indications/ Contraindications
- Indications
- ----Treat 3D progressive deformity or curvature of the spine
- ----Cobb angle: measure degree of curvature
- --------Curve < 25’
- ------------ observe and re-eval every 6 mo including ht/wt, X-ray to measure curve progression and estimated time until skeletal maturity
- --------Curve > 25’ or if increases > or = 5’ over 6 months
- Contraindications
- ----thoracic lordosis or skeletal mature curves >45’ or <25
- ----Need surgery after skeletal maturity
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Factors determining orthotic prescription
- location of apex of curve 1’ factor
- skeletal age
- curve magnitude
- compliance
- orthotic acceptance by child and parents
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Orthotic principles of scoliosis management
- End point control
- ----fixation that occurs 2’ mechanical constraint of orthosis on trunk
- ----substantially improves spinal stability by increasing critical load
- ----able to support without further deformation
- Transverse loading
- ----applied at apex of curve increases critical load
- ----curves < 25’ application of non-translatory transverse support raises critical load from 50% to 70% of normal and could prevent further deformity
- ----curves <15’ application of transverse support raises critical load from 20% to 30% which is not sufficient to prevent progression
- Correction of the curve
- ----Increase critical load beyond level provided by transverse support
- ----Larger the initial curve, greater need to reverse magnitude to prevent curve prevention
- ----Degree of correction dependent upon placement of pads, i.e. magnitude/direction/ duration or corrective forces
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Types of scoliosis
- Idiopathic
- Neuromuscular (paralytic)
- Congenital
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Idiopathic scoliosis
- most common
- unknown etiology
- most likely 2’ underlying mechanisms, one related to curve development and second related to curve progression
- potential contributors: growth velocity, genetics, musculoskeletal irregularities, muscle strength imbalances, vestibular and CNS dysfunction, biochemical factors
- orthotic management may be enough to prevent surgery
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