Posts Tagged "Exercise Rehab"

Case – Infantile Bracing

Posted on March 19th, 2018 by Belinda Andrews

Treatment of an infantile scoliosis using a 3D designed scoliosis brace

Case Background

The 3-year-old female patient presented to the ScoliCare clinic with postural deformity and lateral shifting of her trunk. The deformity had been picked up by the child’s parents who had then consulted with a GP. X-ray imaging ordered by the GP revealed a left thoracolumbar curve measuring 40° and a mild (10°) compensatory right thoracic curve (Figure 1). The GP had made a diagnosis of infantile scoliosis and referred the patient on to an orthopaedic surgeon for an appraisal. After assessing the patient and reviewing the x-rays, the surgeon suggested that bracing would be the most suitable treatment in this case.

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Figure 1: Posteroanterior postural photograph (Left), Initial posteroanterior x-ray (Middle),
In-Brace [Hospital TLSO] posteroanterior x-ray (Right)

The patient was subsequently issued with a rigid brace (thoraco-lumbo-sacral orthosis [TLSO]) that had been designed and fitted by the hospital orthotist. In-brace x-rays taken soon after the TLSO fitting showed a reduction in the size of the primary curve from 40° to 33° (Figure 1). While a reduction in the curve was evident, the parents of the patient had concerns that there was still significant deformity present despite wearing the TLSO. This prompted them to seek a second opinion from the ScoliCare clinic.

Examination Findings

The history and physical examination performed at the ScoliCare clinic aligned with the findings from the previous imaging results. The patient’s trunk was significantly translated to the left during both the postural and gait analyses, without evidence of leg length discrepancy or pelvic anomaly. The primary curve appeared flexible (Figure 2) which was a favourable sign for brace therapy.

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Figure 2: Photograph of the patient side-lying
over a traction fulcrum orthotic device

Intervention

A new custom 3D designed scoliosis brace was prescribed for the patient along with some home based stretching and exercises to help with the abnormal trunk shift. The patient was advised to wear the brace full-time (up to 23 hours per day) and perform the rehabilitation exercises on a daily basis.

Outcomes

In-brace x-rays taken at the time of the brace fitting revealed that the deformity could be completely reduced (Figure 3). The patient continued to wear the brace with good self-reported compliance from the parents. Unfortunately, the daily exercises were performed on a more haphazard basis. Bracing treatment continued for approximately 24 months. Several modifications were made to the brace along the way to accommodate the patient’s growth.

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Figure 3:  In-Brace (Custom 3D designed brace)
posteroanterior x-ray

By the end of the bracing period, the patient’s scoliosis had been reduced from 40° down to 14° out of the brace (Figure 4).At this point in time the patient is still under care, however the recommendation is for the patient to wear a more flexible style brace to maintain the correction achieved with the custom 3D designed brace, and also to further reduce the left postural shift.

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Figure 4: Out-of-brace x-ray

 Discussion

This case highlights the management of an infantile idiopathic scoliosis (IIS) case using a custom 3D designed scoliosis orthosis. Patients with IIS typically present before the age of 3 years and are classified into two categories – resolving and progressive. Curves in patients with the resolving type tend to reduce spontaneously over time, whereas curves in patients with the progressive type continue to worsen leading to crippling deformity and reduced quality of life if not treated. Casting is typically initiated before the age of two years in these patients as it is more difficult to attain a complete resolution of the deformity if treatment is initiated after this point. After a significant result has been obtained with casting, the patient is usually placed into a rigid brace to stabilise the correction.

There are unique features to this particular case. Thoracolumbar presentations are less common compared to thoracic presentations in IIS patients, and the presence of compensatory curves is also somewhat unusual in this population. In this case, bracing has been used as a first-line management approach versus the more traditional approach involving serial casting. The patient’s initial hospital-made-brace was substandard as evidenced by the small (17.5% reduction) in-brace correction, and had the patient continued with this brace it is likely that the curve would have continued to progress.

At this point in time the evidence to support the use of bracing as a primary treatment in patients with IIS is sparse, however the results observed in this case would suggest that a more comprehensive investigation of ‘over corrective’ 3D bracing is justified.

Conclusion

This case demonstrates the reduction of a severe thoracolumbar scoliosis in a young child using a custom 3D designed scoliosis orthosis.

NB: Results vary from case to case. Our commitment is to recommend the most appropriate treatment based on the patients type and severity of scoliosis.

© ScoliCare & The ScoliCare Clinic Sydney

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Case – Bracing and Exercise Rehabilitation

Posted on January 27th, 2017 by Belinda Andrews

Patient aged 13 years with a 33 degree left thoracolumbar scoliosis.

Background:

This patient was 13 years old at the time of diagnosis. She had noticed her posture was off centre and was experiencing mild back pain. Sports participation included ballet, other dance styles and netball. The Scoliosis was diagnosed 4-5 weeks before the initial consultation at Sydney Scoliosis Clinic.

The medical history was unremarkable with the neurological examination within normal limits. Birth and developmental milestones were within normal limits (as reported by her mum). There was tenderness to palpation of the spine at the Thoracolumbar junction. There was pain on left lateral flexion of the spine.

The patients’ grandfather was diagnosed with Scoliosis.

Initial X-rays showed a 33 degree left thoracolumbar scoliosis. There was also significant lumbar spine rotation on x-ray. The Risser sign on the pelvis was Risser 1-2, indicating that the patient was skeletally immature and more growth and progression was expected without treatment.

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Treatment:

As the patient was still growing, was a Risser 1 and the curve was greater than 30 degrees, there was a high risk of progression. A combination of a customised 3D designed rigid brace, scoliosis specific rehabilitation exercises and use of a scoliosis orthotic device were recommended.

The scoliosis brace was to be worn full-time. This is 23 hours per day with extra time up to a maximum of 4 hours out of the brace if the patient was actively participating in sports during those out of brace hours. The weaning into the brace was started with 2 hours of brace wear on the first day followed by adding another 2 hours every subsequent day until the required full-time hours were attained.

The scoliosis specific exercises were initially implemented as twice a week for 3 weeks, followed by once per month. The patient was required to complete the exercise protocol at home daily.

A scoliosis orthotic device was also used daily for 20 minutes to stretch the spine at the Thoracolumbar junction. This device was placed at the left apex with the patient lying on her left side. Exercises were performed on the device.

Results:

At the one month in-brace x-ray the curve had reduced to 13 degrees. At the 3 month out of brace x-ray the curve had reduced to 26 degrees. At this point extra corrective padding was added to the brace to increase the 3-dimensional corrective action of the brace. At the 12 month mark an out-of-brace x-ray was taken. The results of which showed that the spine was 11 degrees without using the brace.

The last x-ray was taken 22 months after the start of treatment. This x-ray was an out-of-brace x-ray where the patient was required to be out of the brace for at least 6 hours. The results of which show her spine to have a 6 degree curvature, which according to definition cannot be classified as a scoliosis.

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The postural assessment showed continuous improvements of her posture with her body showing good balance after 4 months of treatment to the point that she was symmetrical by the 12 month mark. The postural improvements have been maintained throughout the treatment period.

The functional assessment of fatigue ability and strength of her core muscles, together with the flexibility of her spine showed no deterioration of strength, endurance or flexibility.

A rigid custom designed 3D scoliosis brace, in combination with a  scoliosis specific rehabilitation program, may achieve reduction in Cobb angle in similar cases.  This approach follows the SOSORT criteria as was shown in the literature review to have a positive prognostic impact on Thoracolumbar curvatures.

This approach is a team approach that allows the patient to learn a scoliosis specific exercise program, together with a bracing technique that does not use a 3 point pressure system, but rather is an over-corrective custom designed brace that is designed to address all aspects of the scoliosis from sagittal and coronal balance to lateral translation at the apex and vertebral rotation of the curve.

This patient is still undergoing treatment and is expected to wear their scoliosis brace a minimum of 20 hours per day for 2 years in total. The prognosis for this patient is to maintain a similar amount of correction as seen at the 22 month mark.

NB: All cases are different and results may vary case to case. Our commitment is to recommend the most appropriate treatment based on the patient’s type and severity of scoliosis.

 

© ScoliCare & Sydney Scoliosis Clinic 2016

 

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Case – Exercise Rehabilitation

Posted on November 20th, 2015 by Belinda Andrews

Patient aged 18 with a left thoracolumbar curve measured at 39 degrees and a thoracic compensatory curve.

Background

Patient presented to the Sydney Scoliosis Clinic aged 18 at the time of initial examination. The patient had been diagnosed with scoliosis at 16 years of age, after reporting back pain and noting some postural issues (asymmetry of the waist and hips).

She was diagnosed with a left thoracolumbar curve measured at 39 degrees with a thoracic compensatory curve.

The patient had previously seen an Osteopath and Chiropractor for the pain but couldn’t seem to get relief. Her pain averaged a 6-7/10 and 9/10 at its worst. Playing sport and standing for long periods made the pain worse.

In the two years since diagnosis, the scoliosis had progressed 10 degrees. It was unlikely that the curve would progress any further with minimal growth expected due to her age.

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Treatment

6 scoliosis specific rehabilitation sessions based on the SEAS approach were intitally prescribed to help stabilise the curve and decrease pain. The self-correction prescribed to the patient was specific to her scoliosis and other exercises were prescribed to increase core and lower back strength and stability.

The treatment also included the use of a scoliosis treatment aid, namely a tractioning device that the patient could use at home. She spent approximately 40mins a day at home doing the specific exercises and using the orthotic, and 1 hour a week with the Exercise Physiologist.

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Results

After 4 weeks of treatment, the patient’s back pain had decreased to minimal if any, and her body had adapted to the self-correction and scoliosis orthotic allowing her to improve the range of movement of her spine.

By the 6th week, there were noticeable changes to her relaxed posture and the waist and hips were now more symmetrical. Her muscular endurance tests showed that she had improved by over 1min in both abdominals and trunk extensors over the 6 weeks. At this point the patient’s back pain averaged 0/10 most of the time and 2-3/10 occasionally when leaning over her desk studying.

The patient felt that the exercises had helped reduce the pain and her back felt a lot stronger. She also noted that lying on the orthotic helped her get relief when she was in pain.

After 4 months of treatment, an x-ray was taken and the curve had reduced from the initial 39 degrees to 29 degrees.

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Conclusion

The patient now attends the clinic regularly to review exercises and assess her progress. The duration of the exercises is now approximately 10mins a day, 7 days a week to make it more manageable for the patient long-term.

Since starting the exercises program, the patient’s ability to maintain her self-correction has greatly improved and she is challenged with more advanced exercises each time she comes in for review. She is very pleased with her results, particularly the improvement in the hip asymmetry and the reduction of her pain.

 NB: Results vary from case to case. Our commitment is to recommend the most appropriate treatment based on the patient’s type and severity of scoliosis.

© ScoliCare 2015

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Case – Bracing and Exercise Rehabilitation

Posted on October 23rd, 2015 by Belinda Andrews

Male patient aged 14 years with a right thoracic curve measured at 49 degrees.

Background 

This patient was diagnosed with Scoliosis by his Physiotherapist at the age of 13 years old with a curve of 39 degrees. They first consulted a surgeon about the case who suggested surgery or bracing.

A year later they presented to the Sydney Scoliosis Clinic for bracing and the curve had progressed a further 10 degrees. The patient was not experiencing any pain from the scoliosis, but did notice the asymmetrical shape of his torso. This patient is a National medallist in Athletics and also previously played representative Australian Rules Football. Due to his regular training, this patient had a good general strength and flexibility.

 

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Treatment

This patient’s treatment involved wearing a customised rigid brace for 23 hrs per day, ongoing scoliosis specific exercise sessions and tractioning exercises with a scoliosis treatment aid. His brace wear started at 2 hrs per day, which was built up gradually over the following weeks to 23 hours each day. The patient does not compete in the brace but is very diligent in putting it back on straight after an event.

The scoliosis specific exercises require him to position his body in an active self-correction, which is the mirror image of his scoliosis, and to also work on strengthening his core and lower back muscles with exercises specifically prescribed for his case. He regularly sees the exercise physiologist to assess his progress and increase the difficulty of the exercises to ensure he keeps improving.

The patient does quite advanced  exercises and we have now started incorporating his active self-correction to warm-up movements he does at training to help keep his spine in good alignment when he is out of the brace. The home exercises are done every day and take approximately 40mins to complete.

Results

From examining xrays and posture photos, there has been an improvement in this patient’s posture in the first 12 months of treatment. The intial curve of 49 degrees, has now decreased to 35 degrees.

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Due to his age and currently being Risser 4, it is essential for the brace treatment to continue while he is still growing. If left untreated, the scoliosis can progress further with growth.

At the beginning of the treatment, the patient was not competing at his best, but after a period of adaptation and the inclusion of specific exercises, he is now excelling and is back to the optimal form he was in prior to starting his scoliosis treatment.

The patient and his family are very committed to his treatment and to helping him succeed.

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Conclusion

This  case demonstrates the reduction of a large curve that was at a surgical level to a moderate curve no longer at risk of needing surgery. The combination of a rigid custom designed 3D scoliosis brace, with scoliosis specific exercise, may achieve reduction in curve and cosmetic improvement in similar cases.

The patient was also able to continue competing at an elite level without compromising his ability.

NB: All cases are different and results may vary case to case. Our commitment is to recommend the most appropriate treatment based on the patient’s type and severity of scoliosis.

© ScoliCare & The ScoliCare Clinic Sydney

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Case – Bracing and Exercise Rehabilitation

Posted on September 13th, 2015 by Belinda Andrews

Patient aged 17 with scoliosis curve measured 44 degrees reduced to 29 degrees.

Background: 

Patient presented to the Sydney Scoliosis Clinic aged 17 at the time of initial examination. Adolescent Idiopathic Scoliosis was diagnosed 18 months earlier and no treatment was undertaken during this time. At the initial consultation the  scoliosis curve measured 44 degrees. This patient had seen a surgeon and was recommended to undergo surgery.  She reported having bad back pain (7-8/10) most days. The pain was worse after dance classes.

The patient was on track to become a professional ballet dancer however the pain and the effect of the scoliosis on the body posture and the effect that surgery would have on the spinal flexibility meant that this future career was at risk.

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Treatment:

A combination of customised 3D designed rigid brace wear, and a scoliosis specific exercise program based on the SEAS principles was recommended.  It was recommended to use the brace for 6-8 hours per day and to do the exercises twice per day for 20 minutes. This intensive regime was recommended for 3-6 months.

Results:

As seem from x-rays and posture photos, a cosmetic improvement in the body was seen within the first 4 weeks.  This improvement was maximised at 6 months. After the end of intensive treatment, the body posture settled to its new corrected position which is demonstrated at the 12 months photo.  At the 12 month mark an x-ray was taken with an independent radiology clinic with the patient standing in her relaxed normal posture.  This shows an improvement in the scoliosis curve and the alignment of the spine.  The curve was corrected by 15 degrees, reducing from 44 degrees to 29 degrees.

The patient’s pain was reduced to 2-3/10 and was only present on an occasional basis. As the body posture improved so did the performance at ballet. At the end of the intensive part of the treatment program the patient was selected to join a top ballet institution overseas.  As a result of these improvements surgery was cancelled.

Discussion:

This case demonstrates the potential for a combination of customised 3D designed rigid brace wear and scoliosis specific exercise to improve the cosmetic look of the body, the spinal alignment and degree of curve, and the pain associated with the scoliosis. Although relatively mature this patient was able to achieve 15 degrees of correction of her curve.

Although this may not be achievable in every case it shows that in cases where the patient is flexible and there is an aspect of the scoliosis that is not fixed it may be possible to make correction even after growth has finished. Continuation of the exercise program may be required to maintain the correction.

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Conclusion:

In this case it was possible to reduce a large curve that was at a surgical level to a moderate curve no longer in need of surgery. Choosing the right treatment to achieve the goals of cosmetic improvement, curve reduction, and pain relief was successful in this case.

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NB: All cases are different and results may vary case to case. Our commitment is to recommend the most appropriate treatment based on the patient’s type and severity of scoliosis.

© ScoliCare & The ScoliCare Clinic Sydney

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Case – Bracing and Exercise Rehabilitation

Posted on September 10th, 2015 by Belinda Andrews

Patient aged 13 with scoliosis curve measured 44° in the thoracic spine and 43° in the lumbar spine reduced to 35° and 15° in 8 months!

Background:

Patient presented to the Sydney Scoliosis Clinic aged 13 at the time of initial examination. Postural issues had been noticed 6 months earlier. At the initial consultation the scoliosis curve measured 44° in the thoracic spine and 43° in the lumbar spine. Her pelvic growth plates were open and graded as Risser stage 1. Adolescent Idiopathic Scoliosis was diagnosed. This patient had been recommended to undergo surgery.

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Treatment:

A combination of full time bracing using a customised 3D designed rigid brace and a daily home rehabilitation program, using a scoliosis treatment aid and Mirror Image exercises, was recommended.  It was recommended to wear the brace for 23 hours per day and to use the treatment aid once per day for 20 minutes. This treatment regime was recommended for a minimum 24 months as the patient was immature and had substantial growth remaining.

Results:

As can be seen from the photos, a cosmetic improvement in the body was seen within the first 3 months. This improvement was maintained at 12 and 18 months. At the 3 month mark an in-brace x-ray was taken showing very good correction of the curve. The thoracic curve reduced from 44 to 20 degrees and the lumbar curve reduced from 43 to 14 degrees (in the brace).

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At the 8 month mark an out-of-brace x-ray was taken at an independent radiology clinic, with the patient standing in her relaxed normal posture. This showed a significant improvement in the scoliosis curves. The lumbar curve was corrected by a staggering 28 degrees!

The thoracic spine curve was corrected by 9°.

The patient has continued with compliant treatment, and postural photographs at the 12 and 18 month mark show stability of the result. She is continuing with treatment.

Discussion:

Xrays and posture photos from this case have shown that this combination of treatment has been able to improve the cosmetic look of the body, the spinal alignment and the degree of curve. Although still immature and undergoing treatment, this case represents a positive initial result that will likely result in this patient avoiding spinal fusion surgery in the future.

Conclusion:

A rigid custom designed 3D scoliosis brace, in combination with a scoliosis specific exercise program, may achieve reduction in Cobb angle in similar cases. Choosing the right treatment with the aim of curve reduction and cosmetic improvement, are so far proving to be successful in this case.

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NB: Results vary from case to case. Our commitment is to recommend the most appropriate treatment based on the patient’s type and severity of scoliosis.

© ScoliCare & The ScoliCare Clinic Sydney

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