Spinal Deformities PDF

Spinal deformities  ILOs of this lectures By the end of this lecture the student would be able to answer the following questions: How to define Tonic and Phasic Muscle Systems What is meant by muscle imbalance? How can describe the upper crossed syndrome? How can describe the lower crossed syndro...

Spinal deformities  ILOs of this lectures By the end of this lecture the student would be able to answer the following questions: How to define Tonic and Phasic Muscle Systems What is meant by muscle imbalance? How can describe the upper crossed syndrome? How can describe the lower crossed syndrome? How can identify the Scoliosis, its causes and types? How can develop an objective assessment for scoliosis? How can design a specific physical therapy exercises program? Muscle balance can be defined as a relative equality of muscle length or strength between an agonist and an antagonist; this balance is necessary for normal movement and function Janda believed that muscles predominantly static, tonic, or postural (slow)in function which are more activated in various movements have a tendency to get tight. While muscles that are predominantly dynamic and phasic in function, which are less activated in various movements have a tendency to grow weak.  Classification of Muscles Prone to Tightness or Weakness UPPER QUARTER Tonic system muscles Phasic system muscles prone prone to tightness to weakness Suboccipitals Middle and lower trapezius Pectorals (major and minor) Rhomboids Upper trapezius Serratus anterior Levatorscaplua Deep cervical flexors SCM Scalenes* Scalenes* Upper-extremity extensors Latissimus dorsi and supinators Upper-extremity flexors and pronators Masticators Classification of Muscles Prone to Tightness or Weakness LOWER QUARTER Tonic system muscles Phasic system muscles prone prone to tightness to weakness Iliosoase Rectus abdominals Rectus femoris Transvers and obliques Hamstrings abdominals Erectror spinea Gluteus Maximus, medias Tensor fascia lata and minimums Quadratus lumborum Vastus latralis and medialis Piriformis Tibialis anterior and posterior Calf muscles Peroneus longus Hip adductors  Muscle imbalance is an impaired relationship between muscles prone to tightness and muscles prone to inhibition, resulting in a condition in which some muscles become inhibit and weak and others become short and tight. (Janda concept). Such imbalance can bring changes in tissues causes inappropriate movement patterns. causes side effects such as pain and inflammation. Janda attributes these patterns due to the immobile conditions and repetitive tasks.  Theses muscles imbalance can lead to Upper crossed syndrome if affect the upper quarter (causing neck pain) or/and Lower crossed syndrome if affect the lower quarter (causing low back pain). The two syndromes together are called the layer syndrome  Upper Crossed Syndrome (UCS) is also referred to as shoulder girdle crossed syndrome. In UCS, tightness of the upper trapezius, Suboccipitals, SCM, and levator scapulae (dorsally) pectoralis major and minor (ventrally). Weakness of the deep neck flexors (ventrally), as are the rhomboids, serratus anterior, and the middle &lower trapezius. This pattern of imbalance creates joint dysfunction, particularly at the atlanto-occipital joint, C4-C5 segment, cervicothoracic joint, glenohumeral joint, and T4-T5 segment.  Postural changes associated with UCS 1- Forward head posture 2-increase cervical lordosis 3- Thoracic kyphosis 4- Round shoulders: elevated, protracted, abducted or winging scapula.  LOWER Crossed Syndrome (LCS) Muscle imbalance that is characterized by specific patterns of muscle weakness and tightness that cross between the dorsal and the ventral sides of the body. In LCS there is over activity and tightness of hip flexors and lumbar extensors, underactivity and weakness of the deep abdominal muscles and of the gluteus maximus and medius. This muscle imbalance creates: joint dysfunction (ligamentous strain and increased pressure) at the L4-L5 and L5-S1 segments, the SI joint and the hip joint) joint pain (lower back, hip and knee) Postural changes associated with (LCS) Increasing lumbar lordosis anterior pelvic tilt lateral lumbar shift, increased flexion of the hips and external rotation knee hyperextension. Posture changes in other parts of the body, such as: increased thoracic kyphosis and increased cervical lordosis. The weak gluteals result in over activity of the hamstrings and erector spinae to assist hip extension and to pull the pelvis backward to compensate for the anterior tilting. Weakness of gluteus medius results in increased activity of the quadratus lumborum and tensor fasciae latae on the same side. This syndrome is often seen in conjunction with upper crossed syndrome. Scoliosis  Scoliosis was defined as a sideways curvature of the spine that occurs most often during the growth just before puberty. But recently defined as a three-dimensional deformative abnormality of the spine. Scoliosis is defined by the Cobb's angle of lateral spine curvature in the frontal plane, and is often accompanied by vertebral rotation in the transverse plane and hypokyphosis in the sagittal plane.  The rotation starts when the scoliosis becomes more pronounced. Causing abnormalities in the spine, costal-vertebral joints, and the ribcage produce a ‘convex’ and ‘concave’ spine. Scoliosis can appear at any age, but it often presents between the ages of 10 and 12 years or during a person’s teens Types of Scoliosis Structural or Non-structural. A structural curve: an irreversible lateral curvature with fixed rotation of the vertebrae. A posterior rib hump is detected on forward bending. A nonstructural curve: is reversible and can be changed with forward or side bending and with positional changes, “the spine is structurally normal. It is also called functional or postural scoliosis.  Lateral curvature of the spine scoliosis will cause a sideways C- or S-shaped curve in the spine. usually involves the thoracic and lumbar regions.  Causes of Structural & Non- Structural Structural: ❑Idiopathic: 80% of cases. ❑Neuromuscular conditions, such as cerebral palsy, muscular dystrophy or spina bifida ❑Congenital ❑Birth defects affecting the development of the bones of the spine ❑Injuries or infections of the spine Non- Structural: ❑Leg-length discrepancy (structural or functional). ❑Muscle guarding or spasm from a painful stimuli in the back or neck. ❑Habitual or asymmetrical postures.  Impairments Mobility impairment in joints, muscles, and fascia on the concave side of the curves. Stretch and weakness in the musculature on the convex side of the curves. With advanced structural scoliosis, there is decreased rib expansion; cardiopulmonary impairments may result in difficulty breathing.  Rotation of vertebra in scoliosis. Rotation of the vertebral bodies is toward the convexity of the curve while the spinous process toward the concavity. In the thoracic spine, the ribs rotate with the vertebrae, so there is prominence of the ribs posteriorly on the side of the spinal convexity and prominence anteriorly on the side of the concavity.  The pedicle method for estimation of the rotation of the vertebrae , in which the examiner determines the relation of the pedicles to the lateral margins of the vertebral bodies. Normal vertebra is in neutral position when the pedicles appear to be at equal distance from the lateral margin of the peripheral bodies on the film. Rotated vertebra, the pedicles appear to move laterally toward the concavity of the curve. Measurement of Spinal Curvature for Scoliosis The Cobb method  The diagnosis is confirmed when the Cobb angle is10°or higher and axial rotation can be recognized. Structural scoliosis can be seen with a Cobb angle under10° 10-25°: screen, diagnosis and prevention+ PSSE 25-45°: PSSE + orthopedic therapy >50°: surgical TTT  Clinical presentation Most cases of scoliosis are mild but some get more severe as children grow. Signs and symptoms of scoliosis may include: Uneven (asymmetry) shoulders, waist, hips, pelvis, and lower extremities. One scapula appears more prominent than the other If a scoliosis curve gets worse, the spine will also rotate or twist. Muscle fatigue and ligamentous strain on the side of the convexity Nerve root irritation on the side on the concavity Joint irritation from approximation of the facets on the concavity Observations If one hip is adducted, the adductor muscles on that side have decreased flexibility, and the abductor muscles are stretched and weak. The opposite occurs on the contralateral extremity. Hypokyphotic thoracic spine One hip higher than the other Head not centered over pelvis Larger space from arm to the side of the body when comparing both sides Uneven waist creases  Conservative Treatment Factors to be considered include: Sex. Girls have a much higher risk of progression than do boys. Severity of curve. Larger curves are more likely to worsen with time. Curve pattern. Double curves, also known as S-shaped curves, tend to worsen more often than do C-shaped curves. Location of curve. Curves located in the center (thoracic) section of the spine worsen more than do curves in the upper or lower sections of the  Maturity If a child's bones have stopped growing, the risk of curve progression is low. That also means that braces have the most effect in children whose bones are still growing. Most children with scoliosis have mild curves and probably won't need treatment with a brace or surgery. Children who have mild scoliosis may need regular checkups to see if there have been changes in the curvature of their spines as they grow. The objectives of conservative treatment: 1.To stop curve progression at puberty(or possibly even reduce it) 2.To prevent or treat respiratory dysfunction 3.To prevent or treat spinal pain syndromes 4.To improve appearance via postural correction Bracing Spine core system Boston brace also known as a thoraco-lumbo-sacral orthosis, or TLSO Physiotherapeutic Scoliosis Specific Exercises (PSSE) Define as consisting of: 1- Auto-correction in 3D 2- patient education 3- stabilizing the corrected posture. 4- Training activities of daily living. Physiotherapeutic Scoliosis Specific Exercises (PSSE) Stretching Ex Stabilizing Ex.  Surgical Treatment scoliosis surgery is indicated for severe scoliosis to reduce the severity of the spinal curve and to prevent it from getting worse. The most common type of scoliosis surgery is called spinal fusion. In spinal fusion, surgeons connect two or more of the bones in the spine (vertebrae) together, so they can't move independently. Questions?