S O A P I E R
-SCOLIOSIS CASE STUDYSUBJECTIVE
Name: Everlynn
Age: 28
Gender: Female
Occupation: Lecturer
Dominant hand: Right hand
Chief Complaint: Ms Everlynn has been suffering neck pain for 5 years.
Present History:
● Mode of onset - how did it happen? ( start gradually or sudden)
● Duration - how long have you had this pain/when did you get this injury?
● Did you have seek doctor ?
o If yes, what is the doctor diagnosis
o What is the dacotor management?
o Any medication?
● Previous physiotherapy treatment: ● Others health issues: o diabetes/hypertension/heart-related/cholesterol
Past History:
● Past medical hx:
● Past medication hx: ● Past surgery hx: Investigation history(Have you done any investigation before?)
Medicine history:
● Using painkiller when having severe headache
Family history : Social History
● Marital status: single
● Hobby : reading
● No smoking and drinking
Environment History
● Type of pillow - memory foam
● Sleeping pattern - leg crisscross
Nature of job
● working in front of a computer for 12 hours per day
Workplace Ergonomic:
●
●
●
●
Normal plastic chair
Elbow level of desk height
Monitor height same level with eye
Working duration: 12 hours per day, usually take break in between long last for 1 to 2
hours
Expected Outcome
● Reduce neck pain
Pain Assessment
Side & Site: bilateral side of neck, entire cervical region
Onset of pain: sudden/gradual
Duration: 5 years
Type of Pain: dull aching/ sharp/ shooting
Nature of Pain: no radiating
Aggravating Factor
● Working
● VAS 5/10
Easing Factor
● Take pain killer and rest
● VAS 3/10
Severity: once a week
Irritability - High
● After using the pain killer, it takes about 30 minutes to subside
24 hours’ pattern:
● Usually feel the pain after working, and it becomes worsens during night
OBJECTIVE
I. POSTURE ANALYSIS
Head
SIDE VIEW
FRONT VIEW
Forward Head
Posture
Slightly rotated to the Left Slightly rotated to the Left
Cervical spine Normal extension
Shoulders
Thoracic
spine
Straight
Left side Higher
Scapulae
BACK VIEW
Left side elevated
Scapular retracted
Left scapular lateral
winging
Normal Flexion
Convex towards Left
Lumbar spine Excessive
extension
(lordosis)
Ribcage
Rotated to the Right
Pelvis
Anterior Pelvic
Tilting
Hip Joints
Right side hip
hiking (flexed)
Femur
Right iliac crest and ASIS
is higher.
Left side is rotated
anti-clockwise.
Right side higher
Normal
Straight
Knees
Neutral
Ankle Joints
Neutral
Feet
Convex towards Left
Knock knees
Knock knees
Normal
Parellel
II. GAIT ANALYSIS
● Reduce arm swing
● Right side pelvic hike
III. PALPATION
● Left scapula lateral winging
● No tightness
● No warmthness
● No swelling
● Sternocleidomastoid and cervical para-spinal muscle tenderness grade II
● Posterior neck sore
● Right Rib higher
● Right xiphoid higher
IV. DEEP TENDON REFLEX (DTR)
Bicep
● Grade 2+ Normal
Tricep
● Grade 2+ Normal
Brachioradialis
● Grade 2+ Normal
Knee
● Grade 2+ Normal
Archilles Tendon
● Grade 2+ Normal
V. SENSORY EXAMINATION
Sensation
Result
Superficial
Sensation
Touch
Pain
Temperature
Pressure
Deep sensation
Kinesthesia
Proprioception
Vibration
Intact
Stereognosis
Barognosis
Tactile Localization
2 point discrimination
Graphesthesia
Intact
Cortical
Sensation
Intact
VI. CHEST EXPANSION ASSESSMENT
Axillary level
Nipple level
Xyphoid level
Exhale
Inhale
Exhale
Inhale
Exhale
Inhale
1st measurement
(cm)
70cm
74cm
70cm
72.5cm
57cm
63.5cm
2nd
Measurement
(cm)
70cm
74.5cm
68cm
72cm
56cm
63cm
3rd measurement
(cm)
70cm
74.5cm
67cm
72cm
56cm
63.5cm
Average
Differences
4.33cm
3.83cm
VII. LIMB LENGTH MEASUREMENT
Apparent Limb Length:
● Left: 86cm
● Right: 86cm
True Limb Length:
● Left: 79cm
● Right: 79cm
VIII. GIRTH MEASUREMENT
7cm
Arm Girth:
● Left: 20cm
● Right: 20cm
● Forearm Girth
● Left: 8cm
● Right: 8cm
Thigh Girth
● Left: 41cm
● Right: 42cm
● Calf Girth
● Left: 33cm
● Right: 32cm
IX. RANGE OF MOTION
Cervical
Active ROM
Passive ROM
End - Feel
Flexion
40°
45°
Empty
Extension
60°
75°
Empty
Left Lateral Flexion
50°
60°
Firm
Right Lateral Flexion
45°
55°
Firm
Left Rotation
50°
80°
Firm
Right Rotation
90°
95°
Firm
Trunk
Active ROM
Passive ROM
Difference
Flexion
50cm
52cm
2cm
Left – 62cm
Left – 42cm
20cm
Right – 60cm
Right – 25cm
35cm
Left – 105cm
Left – 102cm
Firm
Right – 106.5cm
Right –105.5cm
Firm
Lateral Flexion
Rotation
X. MUSCLE STRENGTH ASSESSMENT (MMT)
Muscles
MMT Grading
Neck Flexors
4/5
Neck Extensors
5/5
Neck Rotators
5/5
Neck Side Flexors
5/5
Trunk Flexors
5/5
Trunk Extensors
5/5
Trunk Side Flexors
5/5
Trunk Rotators
4/5
XI. BALANCE ASSESSMENT
Static balance
Balance test
Four stage balance test:
1. Stand with both feet side by
side – 10s
2. Semi tandem stance – 10s
3. Tandem stance – 10s
4. Stand with one foot – 10s
Result
Excellent
Dynamic balance
Four step square test: 7s
Excellent
XII. SPECIAL TEST
Adam’s Forward Bending Test
Finding:
● Visible left thoracic hump with 15° higher than right side.
● Visible left side thoracic curve
Interpretation
● Positive (10 degrees is the cut-off point for scoliosis )
ANALYSIS
Physiotherapist’s Analysis
● Reduce range of motion of neck flexion, left rotations are due to forward head posture
and compensation to left curvature on the thoracic spine.
● Reduce range of motion of trunk left rotations is due to weakness of left thoracic region
paraspinal muscle and tightness of right.
● Reduce muscle power of neck flexor and trunk rotators due to left curvature of scoliosis
Short-Term Goals
1. Reduce sternocleidomastoid (SCM) and cervical para-spinal muscle from tenderness
grade II to grade 0 within 2/52.
2. Improve the AROM of neck flexion from 40° to 45° within 3/52.
3. Improve the AROM of neck left rotation from 50° to 60° within 3/52.
4. Improve the ROM of trunk left rotation from 20cm to 35cm within 3/52.
5. Strengthen neck flexors from MMT 4/5 to MMT 5/5within 3/52.
6. Strengthen trunk rotators from MMT 4/5 to MMT 5/5within 3/52.
Long-Term Goals
1. Correct the gait pattern within 2/12.
2. Correct the posture within 3/12.
3. Reduce the scoliosis curve from 15° to 10° within 4/12.
PLANS
Pain Relief
Hot Pack
● Rationale: Hot packs improve blood flow and promote muscle relaxation as well as
reduce the pain through sedation effect by acting on A-delta and C fibres and muscle
spindles. And this method can specify the entire cervical region
Stretching Exercises
Suboccipital Stretch
● Rationale: This stretch will help to loosen the tight muscles at the base of skull, the
suboccipital.
SCM stretches
● Rationale: based on the ROM examination, the neck rotation is reduced. The function of
SCM is the rotation of neck towards opposite side or rotate the head obliquely. A tight
SCM muscle not only reduce the neck rotation ROM, it also can contribute to neck pain,
and is one of the most common muscles involved in forward head posture. Loosening the
SCM muscle helps in improve neck rotation ROM, reduce neck pain and also correct the
forward head posture.
Sail Exercises (Schroth Method)
● Rationale: The Sail exercise is a very effective stretching exercise, which helps elongate
the thoracic concavity. It combines the elongation of the concave side and expansion of
convex side to correct the thoracic curve.
Strengthening exercises
Chin In Exercises
● Targeted muscle: Mainly the deep cervical flexors.
● Rationale: Chin in is the most effective postural exercise for relieving neck pain and
correcting the forward head posture. This exercise helps strengthen the muscles that pull
the head back into alignment over the shoulders (upper thoracic extensors) and also
stretches the scalene and suboccipital muscles.
Chin In with Head Lift
● Rationale: This is the progression of the chin in exercises.
Shoulder Shrug with Resistance
● Targeted muscle: Left Upper Trapezius
● Rationale: Hypertonicity tends to pull the head down and back, the cervical spinal
processes lateral, and the shoulder girdle medial.
Left Middle Trapezius Strengthening
● Targeted muscle: Left Middle Trapezius
● Rationale: Based on the posture analysis, the patient is having left scapular lateral
winging. Strengthening the middle trapezius tends to pull the T1-T4 (or C7-T3)spinous
process lateral and draws the scapula medially.
Superman
● Targeted muscle: Left lower trapezius
● Rationale: Increased tone tends to pull the T4–T12 spinous processes lateral and the
shoulder girdle medial and inferior.
Left Rhomboids Strengthening
● Targeted muscle: Left Rhomboids
● Rationale: Increased tone tends to pull the T2–T4 spinous processes lateral and inferior
and the inferior vertebral border up and toward the midline.
Patient Education
● Rationale: Other than the treatment session, home exercise program (HEP) and the
precautions to patient is very important. Therapist has to educate them the proper way to
do the HEP and also remind them about the dos and donts.
INTERVENTION
Hot Pack
Position: Prone lying
Equipment: Towel and hot packs
Procedure
1. Fold the towel into 8 layers. Separate the towel into 2 layers at the top, 6 layers at the
bottom. Put the hot packs in between.
2. Place the towel over the entire cervical region
Duration: 20 minutes
Suboccipital Stretch
Targeted muscle: Suboccipitals Muscles
Position: Seated
Procedure:
1. To activate the cervical retraction, tuck the chin in.
2. Look down to the jugular notch.
3. Placing two fingers at the chin to passively retract cervical using one hand.
4. Then, place another hand behind the head and passively force the occipital towards the
anterior with another hand
Duration: Hold 30 to 60s, 2-3 repetitions, 1-2 times per day
SCM stretches
Targeted muscle: Left SCM
Position: Seated or Stand
Procedure
1. Start with the head in a neutral posture.
2. To stretch the left SCM muscle to start, rotate the head towards the right side, then gently
tilt your head back, to engage and stretch the SCM muscle fibres.
3. Hold the stretch for 30-60 seconds, then gently rotate your head back towards neutral.
Protocol: 30-60s, 2-3 repetitions, 1-2 times per day.
Sail Exercises (Schroth Method)
Position: Erect standing and leg open shoulder width.
Procedure:
1. Patient stands on a half foam roll with two poles
2. Right hand higher than the left.
3. Performs active stabilization.
4. The red circle represents the concavity (weak side according to Schroth).
During active stabilization, the patient is consciously expanding the right rib
cage with left directional breathing, opening the collapsed right lung.
Protocol: Hold 30-60s, 2-3 repetitions, 1-2 times per day.
Chin In Exercises
Targeted muscle: Deep Cervical Flexors
Position: Supine lying ( against gravity)
Procedure
1. Start with a neutral posture.
2. Place two fingers at the chin to gently push the neck backwards
3. Pull your chin straight backwards, in effect attempting to make a double chin.
4. Therapist palpates the activated muscle while patient doing the exercises
Protocol: Hold for3-5s, repeat 10-15, 3 sets per day.
Chin In with Head Lift (Progression)
Targeted muscle: Deep Cervical Flexors
Position: Supine lying ( against gravity)
Procedure
1. Start with a neutral posture.
2. Place two fingers at the chin to gently push the neck backwards
3. Pull your chin straight backwards, in effect attempting to make a double chin.
4. Slightly lift the head off the bed and hold.
5. Therapist palpates the activated muscle while patient doing the exercises
Protocol: Hold for 3-5s, repeat 10-15, 3 sets per day.
Shoulder Shrug with Resistance
Targeted muscle: Left Upper Trapezius
Position: Prone Lying
Procedure
1. Perform the chin in then depress the bilateral shoulder.
2. Therapist places the resistance manually on the left shoulder with one hand.
3. Instructs patient to lift the left shoulder against the resistance and hold.
Protocol: Hold for 3-5s, repeat 10-15, 3 sets per day.
Left Middle Trapezius Strengthening
Targeted muscle: Left Middle Trapezius
Position: Prone Lying
Procedure
1. Perform the chin in then depress the bilateral shoulder.
2. Exercise to strengthen the middle trapezius muscle using a long lever arm for resistance.
Abduct both shoulders to 90 degrees and both elbows straight.
3. Therapist instructs patient to contract the middle trapezius muscle with retracts and
adducts her scapulae, lifting her arms toward the ceiling. And hold for 3-5s, with 10-15
repetitions.
4. Instruct patient to remain left hand at the side of body while keeping right hand beside the
body.
5. Therapist palpates the activated muscle while the patient doing the exercises
Protocol: Hold for 3-5s, repeat 10-15, 3 sets per day.
Superman
Targeted muscle: Left lower trapezius
Position: Prone Lying
Procedure
1. Perform the chin in then depress the bilateral shoulder.
2. To activate the lower trapezius, lift both hands over the head like a “Y-shape”. Then lift
the shoulder off the plinth. Hold for 3-5s, repeat 10-15.
3. Instruct patient to remain left hand over the head with the elbow straight while keeping
right hand beside the body.
4. Lift the shoulder off the plinth and hold.
5. Therapist palpates the activated muscle while patient doing the exercises
Protocol: Hold for 3-5s, repeat 10-15, 3 sets per day.
Left Rhomboids Strengthening
Targeted muscle: Left Rhomboids
Position: Prone Lying
Procedure
1. Perform the chin in then depress the bilateral shoulder.
2. To activate the rhomboids, bring both hands toward the midline of back. Then, lift both
shoulders off the plinth and squeeze the muscles together. Hold for 3-5s, repeat 10-15.
3. Instruct patient to remain left at the back while keeping right hand beside the body.
4. Lift the left shoulder off the plinth and hold.
5. Therapist palpates the activated muscle while patient doing the exercises
Protocol: Hold for 3-5s, repeat 10-15, 3 sets per day.
EVALUATION
Evaluation in post-treatment:
● Visual Analogue Scale: to reassess the neck pain scale after the treatment
● Range of Motion Assessment: to reassess the neck and trunk ROM after the treatment
Response from patient
● Evaluate the cooperative and attention level of patient can help in the further
improvement. If notice the patient is not able to focus on the treatment or easily gets
fatigued and needs to take a longer duration to rest. Therapist can do some adjustments to
the intervention to make the treatment become more effective.
REVIEW
Component that will check in next appointment
● VAS
● ROM
● MMT
● Scoliometer
To come again: Next appointment date and time
REFERENCE
1. Journal of Orthopaedic & Sports Physical Therapy
Published Online:October 31, 2013Volume43Issue11Pages841-847
https://www.jospt.org/doi/10.2519/jospt.2013.4659
2. Berdishevsky, H., Lebel, V.A., Bettany-Saltikov, J. et al. Physiotherapy scoliosis-specific
exercises – a comprehensive review of seven major schools. Scoliosis 11, 20 (2016).
https://doi.org/10.1186/s13013-016-0076-9