|Movement Experiences for Children|
|Instructor:||Dr. Shannon S.D. Bredin|
|Important Course Pages|
- 1 Introduction
- 2 Etiology of Structural Scoliosis
- 3 Signs and Symptoms
- 4 Diagnosis
- 5 Treatment Options
- 6 Effects of Different Treatments on Movement
- 7 Recommendations for Parents and Caregivers
- 8 References
Scoliosis is an abnormal lateral curvature of the spine (often “S” or “C” shaped) with a Cobb angle of 10° or more, and is most commonly seen in the thoracic and lumbar spinal regions (Boston Children’s Hospital; Gielen & Van Den Eede, 2008; Setting Scoliosis Straight). However, in many cases it can also seen as a three dimensional rotational deformity of the vertebrae within the spine as well as the trunk rotation (Boston Children’s Hospital; Gielen & Van Den Eede, 2008; Negrini et. al, 2013). In the frontal plane this causes a lateral curvature, and in the horizontal plane, axial rotation is seen (Negrini et al., 2013).
Scoliosis can also be defined as being either structural or functional (Negrini et al, 2013). In functional scoliosis, no vertebral deformity is seen, and is due to secondary causes such as muscle tone asymmetry and slight limb asymmetry (Gielen & Van Den Eede, 2008; Negrini et al, 2013). This type of scoliosis is not a true form of scoliosis and diminishes once the underlying issue is resolved (Negrini, 2013). In structural scoliosis, however, there is an actual deformity of the spine (Gielen & Van Den Eede, 2008). Structural scoliosis will be discussed here.
In the United States, scoliosis affects 2-3 percent of the population, which is approximately 6 to 9 million people (National Scoliosis Foundation, 2007). The incidence of scoliosis has remained relatively stable over the past 25 years (Asher & Burton, 2006). No Canadian statistics are available. Development of scoliosis can occur in infancy and early childhood, however, it is mainly diagnosed in children aged 10-15 (American Association of Neurological Surgeons, 2007). Overall, scoliosis occurs equally among both genders; however, females are 80% more likely to develop a progressive curvature of the spine and are more likely to require treatment (American Association of Neurological Surgeons, 2007).
In some cases, mostly later in life, pain, limited activity, and reduced respiratory function can reduce an individual’s quality of life (National Scoliosis Foundation, 2007). However, most children do not experience a reduced quality of life for these reasons but are sometimes plagued with diminished self-esteem (Walker, 2003).
Etiology of Structural Scoliosis
Scoliosis can either be caused by a primary issue that is directly related to the spine, seen in idiopathic scoliosis and congenital scoliosis, or it can be a secondary problem caused by another disorder, seen with neuromuscular and syndromic scoliosis (Kusumi, 2010). For the purpose of this report we will focus on idiopathic and congenital scoliosis.
Idiopathic scoliosis means that there is no known definite cause (Boston Children’s Hospital). However, many studies have suggested that heredity of certain genes may play a factor in the development of idiopathic scoliosis (Wise et al, 2008). Idiopathic scoliosis is the most common type of scoliosis accounting for 80% of the cases (Negrini et al, 2012; Wise et al, 2008). It can develop at anytime, but it is most common between the ages of 6-24 months, 5-8 years, and 11-14 years when growth spurts are common (Negrini et al, 2012). Idiopathic scoliosis is classified by the age at which the child is diagnosed and consists of infantile, juvenile, and adolescent idiopathic scoliosis (Gielen & Van Den Eede, 2008).
Infantile Idiopathic Scoliosis
In infantile idiopathic scoliosis the abnormal lateral curvature of the spine is detected by the age of 3 years, with most diagnoses being made by 6 months of age (Asher & Burton, 2006; Dobbs & Weinstein, 1999). Infantile scoliosis represents less than 1% of scoliosis cases in the United States (Dobbs & Weinstein, 1999). This type of scoliosis in found more frequently in boys than it is in girls, and is the only type of scoliosis that has an 85% probability of resolving itself without any need for treatment (Dobbs & Weinstein, 1999; Gielen & Van Den Eede, 2008). Infantile scoliosis is different from juvenile and adolescent scoliosis because it is represented by a left thoracic curve as opposed to a right thoracic curve (Gielen & Van Den Eede, 2008).
Juvenile Idiopathic Scoliosis
The onset of juvenile idiopathic scoliosis is seen between the ages of 4 and 10 years old, and represents 12%-21% of all cases of idiopathic scoliosis (Dobbs & Weinstein, 1999). Unlike infantile and adolescent idiopathic scoliosis juvenile scoliosis progresses during ages when growth spurts are not normally occurring (Dobbs & Weinstein, 1999). Juvenile idiopathic scoliosis is represented by a right thoracic curve pattern and found more frequently in girls than in boys (Gielen & Van Den Eede, 2008). Girls are also more likely to develop progressive curves that will most likely require surgery to correct the spine; this is due to the remaining growth spurt (Gielen & Van Den Eede, 2008; Janicki & Alman, 2007; Setting Scoliosis Straight). If left untreated, juvenile scoliosis has the greatest potential for trunk deformities, as well as restricting cardiac and pulmonary function (Janicki & Alman, 2007).
Adolescent Idiopathic Scoliosis
Adolescent idiopathic scoliosis is the most common type of scoliosis and is seen in patients between the ages of 10-18 years of age (Scoliosis Research Society). As seen with juvenile idiopathic scoliosis, more girls than boys are affected by adolescent idiopathic scoliosis and present a right thoracic curve pattern (Gielen & Van Den Eede, 2008).
Congenital scoliosis occurs when the spine does not develop properly during fetal development causing spinal deformation and misalignment of the spine (Kasumi, 2010). This type of scoliosis is the least common and usually occurs during the first 6 weeks of development (Boston Children’s Hospital; Scoliosis Research Society). Congenital scoliosis can be caused through failure of formation or failure of segmentation (Scoliosis Research Society). Failure of formation is more common than failure of segmentation and is caused by a disruption to the normal shape of the vertebrae; these vertebrae appear as triangles as opposed to rectangles (Scoliosis Research Society). Failure of segmentation occurs when one or more vertebrae fuse together on one side, resulting in normal growth on one side and slowed growth on the fused side (Scoliosis Research Society).
Signs and Symptoms
Since there are many different curvatures that can occur in scoliosis, the signs and symptoms may vary between people, however, there are some common signs to look for (Boston Children’s Hospital; American Association of Neurological Surgeons, 2007): • Shoulder heights may be uneven heights with one shoulder blade sticking out • Head not centered on the body • Uneven hip heights • Uneven rib cage height • Uneven waist • Entire body leans to one side • Uneven arm lengths when standing • Asymmetry between the left and right sides when bending forward • Shifting of trunk and ribcage • Uneven hanging of clothing In most cases scoliosis is not painful, and does not usually cause problems until later in life if it is left untreated; however, many individuals who do not receive treatment are physically unaffected (Asher & Burton, 2006; Scoliosis Research Society). Some females with curves greater than 40° reported some difficulties with exercise and physical activity, which could in turn cause negative effects on physical well-being (Gielen &Van Den Eede, 2008). If cases are more severe, treatment should be carried out to correct the problem and prevent any other health problems from occurring that could affect the lungs, heart, and joints (Kids Health).
When scoliosis is thought to be present through observations made by parents, teachers, coaches, physicians or even the child, they should be taken into the doctor’s for further screening (Kotwicki, 2008). First, the physician will go over medical and family history, followed by a physical exam and then other diagnostic tests such as an x-ray or MRI will be carried out (Boston Children’s Hospital). The first thing the physician should check for during a physical exam is the overall appearance of the skin and the neuromuscular system before examining the physical appearance of the back (Janicki & Alman, 2007). If there are abnormalities in the skin such as “café-au lait” spots or abnormal reflexes there may be an underlying pathology causing the signs, which could rule out scoliosis (Gielen & Van Den Eede, 2008). During the physical exam, the physician will be checking for abnormalities that may indicate a scoliosis diagnosis (Janicki, 2007). The child should be examined from all angles, front, back, side, and bent over, as well as during walking for asymmetries (Kotwicki, 2008). The main abnormalities a physician will be looking for in the spine includes what type of curve is present, “S” or “C” shaped, an “S” shaped spine represents a double curve; the location of the curve, thoracic, lumbar, or both; the direction of the curve; and the cobb angle of the curve (Boston Children’s Hospital). Cobb angle measures the amount of lateral curvature of the spine in degrees, which helps determine the severity of scoliosis (Kids Health). After scoliosis is detected a posterior-anterior x-ray needs to be taken to confirm the diagnosis (Janicki & Alman, 2007; Kotwicki, 2008). Other methods such as magnetic resonance imaging (MRI) or computerized tomography scan (CT) may be used as well (Boston Children’s Hospital). The severity of the scoliosis diagnosis is determined by the age of the child, as well as the degree of and type of curvature present (Kotwicki, 2008). In general, curves that are less than 20° are seen as mild curvature and do not usually progress any further; curves that are between 25°-40° are seen as moderate curvature and may progress in the future depending on the child’s growth stage; and curves that are greater than 50° are seen as severe and will progressively get worse (Kusumi, 2010; Gielen, 2008).
The treatment approach taken for idiopathic scoliosis is based on the type of scoliosis, age of the individual, curve magnitude, location of curve, risk of progression (patients who have large curves prior to their growth spurts are more likely to have a higher risk of curve progression), and whether or not the child is still growing (Janicki & Alman, 2007; Kusumi, 2010). The three main broad types of treatments include observation, bracing, and surgery (Kusumi, 2010). Other treatments that have yet to be proven or disproven to be effective include physiotherapy and occupational therapy (Casella & Hall, 1991).
Observation is usually recommended for mild cases of scoliosis where curves are less than 25° for individuals who are still growing and 40° for individuals who have reached skeletal maturity (Gielen & Van Den Eede, 2008). Observation involves monitoring the progression of the spine every four to twelve months through an x-ray and a physical exam (Setting Scoliosis Straight). The frequency observation appointments depend on the age of the child and what stage of growth they are in (Setting Scoliosis Straight). If the child is in a fast stage of growth they will be monitored more frequently (Boston Children’s Hospital).
In general, bracing is used for patients with moderate spinal curves, between 25° and 40°, who have not yet reached skeletal maturity (Schlenzka & Yrjonen, 2013). The main goal of bracing is to prevent a child’s spinal curve from progressing further during periods of growth (Hoashi et al, 2012; Romine & Talwalker, 2008; Boston Children’s Hospital). The brace does this by holding the spine in a straighter position through counter pressure, and it is usually worn until skeletal maturity has been reached (Hoashi et al, 2012; Romine & Talwalker, 2008; Boston Children’s Hospital). In many cases, bracing prevents the need for surgery to correct the spine in the future (Heary & Madhavan, 2008). Most of the braces used are constructed with rigid, solid, plastic that have been molded to the individual (Schlenzka & Yrjonen, 2013). Most braces extend from just below the armpit to the pelvis area and sit below the shoulder blades in the back (Johns Hopkins Medicine). Braces are recommended to be worn 22 hrs a day; however, night braces and part time braces have now been introduced to make bracing less uncomfortable and improve the individual’s compliance to wearing the brace (Schlenzka & Yrjonen, 2013). There are many types of braces available and the one that the orthopedist chooses depends on the child (Boston Children’s Hospital; Kids Health; Pajack et al, 2011): • Boston Brace • Charleston Brace • Milwaukee Brace • Wilmington Brace • Chaneau Brace
Surgery is usually required for patients with more severe curvature of the back, 50° or more; these severe curves are very likely to continue to progress (Kusumi, 2010). The main aims of the surgery are to correct and straighten the spine as much as possible, as well as to prevent further curve progression (Gielen & Van Den Eede, 2008). Either a posterior or anterior approach is used during the surgery (American Association of Neurological Surgeons, 2007). The posterior approach is the most common and it involves posterior spinal fusion and instrumentation with rods to straighten the spine (American Association of Neurological Surgeons, 2007). This same surgery can be done anteriorly through the chest (Scoliosis Research Society). One of the negatives of fusion spinal surgery in young children is that it may restrict the growth of the spine, which can affect the development of the child (Scoliosis Research Society). Growth friendly surgeries have now been developed that avoid spinal fusions and they include: Distraction based (uses expandable rods that can lengthen with the spine), Guided Growth (uses wires to guide the spine during growth), and Compression based (prevents growth on the convex side of the curve) (Scoliosis Research Society).
Effects of Different Treatments on Movement
The effectiveness of bracing depends on the person’s compliance with wearing the brace (Janicki & Alman, 2007). Positive outcomes of wearing a brace include a straighter back and better posture (Gratz & Papalia-Finlay, 1984). Physiotherapy in conjunction with wearing a brace has been seen to be beneficial because it helps to strengthen the core muscles and help correct muscle strength asymmetries (Cassella & Hall, 1991). Emphasis on exercises that improve the range of motion of hip flexors, hamstrings, tensor fasciae latae, and low back muscles of the trunk and shoulders is important for physiotherapists to include for individuals who wear a brace in order for the brace to be successful (Cassella & Hall, 1991; Schlenzka & Yrjonen, 2013). Bracing can have some negative drawbacks on movement ability (Gratz & Papalia-Finlay, 1984). With some braces it is impossible to look down or bend over, which causes restrictions in movement (Gratz & Papalia-Finlay, 1984). However, many braces are now trying to create maximum freedom in the Activities of Daily Life, so that individuals wearing a brace are still able to carry out normal daily activities in comfort (Anastasio et al, 2008). By this standard, individuals wearing a brace should still be able to walk, run, exercise, and participate in sports freely, with the exclusion of trunk flexion, bending and rotation (Anastasio et al, 2008; Johns Hopkins Hospital). It is important to note that in order for bracing to be successful, individuals should continue to live normally while wearing the brace in order for it to become a natural part of their life (Cassella & Hall, 1991). However, children are usually allowed to take off their brace when participating in organized sports (National Scoliosis Foundation). Physiotherapists often prescribe exercise programmes to individuals who have to wear a brace to help them adapt to wearing the brace and feel natural in the brace (National Scoliosis Foundation). The exercises are also prescribed to help the individual maintain muscle strength in the trunk region (National Scoliosis Foundation). Stretches that are aimed at increasing mobility and flexibility are also often prescribed (National Scoliosis Foundation).
In the long-term individuals with scoliosis should be able to live a normal active and healthy lifestyle with few or no restrictions (Scoliosis Research Society). After surgery, children are able to carry out normal activities such as walking, getting dressed, and walking up stairs after one week, and return to school in about one month (Dayton’s Children; Kids Health). Six months is usually when the bone fusion is healed; individuals may feel stiffer but they are still able to bend and move in rotate in all directions (Kids Health). Also after about six months, children are permitted to return to their competitive sports, run, and attend gym classes but not participate in contact or high velocity sports (Children’s Dayton). One year after surgery, children are able to resume most of their previous activities without restriction except for high impact sports such as horseback riding, football, and rugby (American Academy of Orthopedic Surgeons). It is important that children exercise after their surgery to improve balance and promote healing of the spine (Children’s Dayton).
Recommendations for Parents and Caregivers
Children with scoliosis should be encouraged to participate in organized sports, school physical education classes, and other recreational activities (National Scoliosis Foundation). Scoliosis is not caused from exercising, and therefore individuals with scoliosis should be able to participate in normal physical activities without adverse effects (National Scoliosis Foundation). Being able to participate in sports is not only good for improving fitness in children with scoliosis but it also helps a child with scoliosis to feel like a normal healthy person (National Scoliosis Foundation). This ability to participate in physical activity also increases confidence and psychosocial well-being in children with scoliosis (Walker, 2003). For children with scoliosis, playing sports and joining in, in physical activities with their peers is important for stimulating self-esteem and physical fitness (Gielen & Van Den Eede, 2008). Orthopedic surgeons promote and recommend that children with scoliosis participate in physical activities and sports with their peers, and that participating in these activities does not worsen their degree of spinal curvature (Gielen & Van Den Eede, 2008). Parents and other caregivers including teachers should encourage children with scoliosis to remain active and to let them know that they can still so everything they used to do before being diagnosed (Setting Scoliosis Straight).
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