Postural deviations
By
Dr. Ibrahim Abdel hakim
Lecturer of physical therapy
Faculty of Physical Therapy
MTI University
LECTURE OBJECTIVES
At the end of this lecture the student will be able to:
➢ Describe spinal development
➢Describe normal posture
➢Interpret terminology of spinal curvature
➢Define scoliosis
➢Discuss types of scoliosis
➢Discuss screening and Measurement of Scoliosis
➢Enumerate management of scoliosis
➢Discuss Physical Therapy Management .
The Spine Functions
1. Support the upright posture.
2. Mobility: permit movement, absorb
shock that allows spinal flexibility.
3. Protective function for the spinal cord &
cauda equina.
4. provide muscle attachment
Spinal Development
Number of vertebrae in vert. col.
cervical 7
thoracic 12
lumbar 5
Sacral 5
Coccygeal 4
Spinal curvature development
1-New born
Convex posteriorly
Concave anteriorly
2-Between 3 and 6 months of age
Child learns to hold head upright
➔Cervical lordosis 2ry curve
Change from concave to
Convex anteriorly
2-Between 10 and 18 months of age
Child learns to stand and walk
➔Lumbar lordosis
2ry curve
Change from concave to
Convex anteriorly
Spinal curvature development
Curvatures of the Spine
Posterior Lateral
Spinal Column
Spinal Column
Terminology of spinal
curvatures
kyphosis
• Normal dorsal kyphosis: 20˚ - 40˚
• Between 45 ˚- 55 ˚ (Marginal)
• < 20˚ → hypo-kyphosis
• > 55 ˚ → hyper-kyphosis
(rounded back deformity) with hypotonia children
Lordosis
• Normal lumber
lordosis:→ 20˚-60˚
• < 20˚ → hypo-
lordosis (Flat back)
• > 60 ˚ → hyper-
lordosis
(lordotic deformity)
Scoliosis
• Lateral deviation of the
spine in excess of 10˚
• Mild scoliosis < 20˚
• Moderate scoliosis →
20˚- 40˚ or 50˚
• Severe scoliosis → >50˚
with hemiplegia -myopthy - erb palsy children
Definition
• Scoliosis is defined as lateral deviation
of the normal vertical line of the spine,
which when measured on a radiograph, is
greater than 10 degrees, with associated
rotation of vertebrae.
• Scoliosis affects about 2% of females
and 0.5% of males
Causes
•Idiopathic scoliosis: In most cases, the cause of
scoliosis is unknown.
•Neuromuscular scoliosis: scoliosis is secondary to
neurological or muscular diseases such as scoliosis
associated with cerebral palsy, spinal cord trauma,
•Congenital scoliosis: curves are caused by anomalous
vertebral development in utero. muscular dystrophy,
spinal muscular atrophy and spina bifida.
Scoliosis
Nonstructural structural
curves
• correct on lateral • fixed or not correct with
trunk bending lateral
• Etiology trunk bending or traction.
• have a rotary component
➢ a pelvic obliquity,
visible with trunk is
➢ limb length discrepancy, flexed forward.
➢ medical factors such • Identified by the location
as a tumor or muscle and direction of the apex
spasm. of the curve.
Idiopathic Scoliosis
According to the age of onset.
➢Infantile idiopathic scoliosis If a scoliosis is recognized in patients less than 3
years of age.
➢Juvenile idiopathic scoliosis detected between the ages of 3 and 10 years.
➢Adolescent idiopathic scoliosis(AIS) The most common form and is termed as
such when the curve is detected after age 10 years but prior to skeletal
maturity.
➢Adult scoliosis is detected after skeletal maturity.
Diagnosis
skeletal maturity
•The Risser sign is a skeletal radiographic marker or indicator for
skeletal maturity based on the ossification of the iliac apophysis.
Prognosis
primary prognostic factors:
•Curve size
•Chronological age
•Risser sign
•Curve pattern
Curve progression
Greater risk of progression is present when
1. The younger the patient at diagnosis.
2. Double-curve patterns have a greater risk for progression than single-
curve patterns.
3. The lower the Risser sign (a skeletal radiographic marker or indicator for
skeletal maturity based on the ossification of the iliac apophysis).
4. Curves with greater magnitude.
5. Risk of progression in females is approximately 10 times that in males
with curves of comparable magnitude.
6. curves develop before menarche.
Classification of the Curve
According to the convexity of the curve.
– C shaped or S- shaped
curve
– S- shaped is usually
compensatory
• Scoliosis generally
progresses during growth
spurts.
Measurement of Scoliosis
• The goal of measurement is to determine a
baseline and monitor progression of the curve.
• A common method of measurement is a
radiograph and the Cobb measure.
the Cobb measure
• The angle between
intersecting lines drawn
perpendicular to the top of
the top vertebrae and the
bottom of the bottom
vertebrae is the Cobb angle.
SCREENING
• Screenings for scoliosis occur in many schools and
target the early adolescent population between 10
and 15 years of age.
• A screening should include
➢Anterior and posterior views of the trunk with the
shirt removed and
➢A forward-bend test
[A] Evaluation
− Quick visual test to assess static posture (Plumb line test).
− Active and passive movements of the spine.
− Flexibility of the curve (Adam forward bend test).
− Severity of the curve (Cobb angle)
− Muscle strength.
− Pulmonary functions.
Treatment Goals
• Goals: 5-year-old boy 8 weeks post
1. Stop curve progression at therapy
puberty(or possibly even
reduce it).
2. Prevent or treat respiratory
dysfunction.
3. Prevent or treat spinal
pain syndromes.
Lehnert-Schroth C. 2007
4. Improve aesthetics via
postural correction.
The Team Approach” (Rehabilitation)
Orthotist Speak the same language, involve the
patient and family
Family
Physical Doctor
Therapist
[B] Interventions
• Treatment intervention is based on the sex, age, and
skeletal maturity of the adolescent and the severity of
the curvature
• Curves ≤25 ° regular monitor and observation
progression of the curve.
• 25 - 40° nonsurgical treatment.
• Adolescents ≥40 ° surgical intervention.
(I) Non-operative Treatment
• The primary objectives of the non-operative intervention is to
successfully arrest progression of the curves and to maintain the
curvature during growth, not to correct the curvature although
improved alignment can occur.
• Non-operative intervention methods include orthoses,
electrical stimulation and exercise.
Orthotic treatment
The indication for spinal orthoses
• A curve of 25° to 40°.
• A curve less than 25° that have shown documented progression of 5° to 10°
in six months (progression of more than 1°/month).
• Age 10yrs or older.
• Risser grade 0-2
• A curves of 20° to 25° in those with pronounced skeletal immaturity.
Orthotic devices
• Most orthotic devices
operate on the principle
of three-point pressure
against the apex of the
curve.
• The Milwaukee brace was the
first orthotic devices developed
for scoliosis.
• Adolescents wear the orthosis between
18 and 23 hours a day until skeletal
maturity or surgery is indicated.
• Physical therapist role
✓Instruction donning and doffing orthosis
✓ Developing a wearing schedule.
✓skin care.
✓Exercise program to maintain ROM and
strength.
•The Milwaukee brace was one of the first orthoses developed for scoliosis.
•a custom-molded trunk shell with metal uprights attached to a collar that supports the
chin and occiput.
•Create a rigid framework from which a series of corrective pads and straps
•The primary advantages:
✓the ability to apply corrective forces at the convexity of a deformity
✓the location, magnitude and direction of the forces being applied can
be easily adjusted.
✓ maximal stability of a scoliotic curve is achieved.
•Disadvantages: Poor self-image
Boston brace (Hall and Miller,1971)
❑Its design consists of a prefabricated,
symmetric thoracolumbar-pelvic
module that is customized to the patient
based on shape and the radiographic
parameters needing to be addressed.
❑It is based on the principle of
applying corrective forces at the
❑The Boston brace has been shown to be as
effective in controlling curve progression as
the Milwaukee brace and is one of the most
common orthoses used today.
❑The brace is effective in treating either
single- or double-curve located at T7 or below.
Wilmington brace, 1980
The indications for the
Wilmington brace are the same as
those for the Boston brace. It also
has the same limitations (i.e., it is
not effective in curves with an
apex above T7–8).
The Charleston brace
▪Was developed based on the concept
that part-time use may be effective.
▪ Worn at night for only 8 to 10 hours,
this orthosis is designed to take
advantage of the recumbent position to
shift the convexity of the curve as much
as possible toward the midline.
Time of application
•Several studies concluded that bracing (with TLSOs or
the Milwaukee orthosis) is more effective in controlling
curve progression in idiopathic scoliosis when applied
full-time (23 hours per day) than part-time (8 to 16
hours per day).
•In case of emotional distress, and poor compliance with
brace part-time use is preffered.
Therapeutic exercises
• Aims:
− Decrease curve progression.
− Reduce pain.
− Increase vital capacity.
− Improve posture and appearance.
Methods:
• Spinal stabilization
• Balance activities
• Core strengthening
• Postural correction including lateral shifts
• Flexibility exercises
• Respiratory exercises
OPERATIVE MANAGEMENT
• The goal of surgery is to obtain
correction and to stabilize the spine
and maintain the correction over
time
• Indication
➢ the curve is greater than 40 degrees,
➢ the curve is progressing with
conservative management
➢ there is decompensation of the
spine or thoracic cavity.
PHYSICAL THERAPY
• Preoperative
➢ROM and trunk-strengthening exercises.
➢deep breathing and coughing exercises
• Postoperatively
➢Early mobilization, including transfers and
gait training.
