Adolescent Idiopathic Scoliosis, A Case Study Rhonda Wilkinson Sept 2013 Course Year July 2012-­2013 Rituel Studio, Paris, France Scoliosis refers to a lateral curvature of the spine and a corresponding rotation of the spine, which involves muscle imbalances associated not only with those muscles responsible for movement of the spine itself, due to the shortening and tightening of muscles on the concave side, and lengthening and stretching of the muscles on the convex side, but also muscles associated with the ribcage and the scapulae, the rectus abdominus, the chest, the hip flexors and extensors and the hip abductors and adductors. There may also be leg length discrepancy and a rotated and/or tilted pelvis. The rotational element of the spine can have a negative effect on the normal kyphotic and lordotic curves. In Adolescent Idiopathic Scoliosis (AIS) the individual is still growing, and the curve may also be increasing. Thus the aim of the exercise program is to improve and restore muscle balance, mobility and function, and develop habits which will help her feel in control of her body. Table of Contents: o Title page Page 1 o Abstract Page; description and purpose of study Page 2 o Table of Contents Page 3 o Anatomical description of a spine with scoliosis Page 4-­‐5 o Introduction to Adolescent Idiopathic Scoliosis (AIS) Page 6 o Case study: Hayley Dawson Page 6-­‐7 o Medical Diagnosis Page 6 o List of visible asymmetrical symptoms of AIS Page 7 o X-­‐ray of Hayley’s back Page 8 o Assessment Page 9 o Considerations when planning a program for Hayley Page 10 o Program Page 11, 12 o Conclusion Page 13 o Bibliography Page 14 Anatomical Description of a Spine with Scoliosis The spine, when observed from the posterior view, should be a straight vertical line, from the 5 cervical vertebrae, through the 12 thoracic vertebrae, through the 5 lumbar vertebrae, and finally the sacrum and coccyx. When lateral curves appear in the thoracic and /or lumbar region, the spine is considered to have the condition known as scoliosis. The lateral curvature(s) of the spine result from deformities in the bones, muscles, and ligaments. The bones of the spine actually twist on each other, forming a “C” curve, and there may be a continuing curvature in the thoracic and lumbar region, or an “S” shape. The curvatures can be relatively more or less pronounced in the thoracic or lumbar regions. The curvatures are created by deformities within and between the vertebrae, and are associated with a rotation of one or two vertebrae at the point of curvature. The vertebral bodies rotate towards the convex side of the curve, and the spinous processes rotate away from the convex side of the curve. Subsequently, the orientation and mechanics of the associated muscles and connective tissue are affected. The orientation of the ribs and sternum will also be affected. On the convex side the ribs and intercostal muscles between them move sideways, spread apart and rotate backwards with the spine. On the concave side the intercostals muscles are under-­‐developed and the ribs are compressed. Because of the rotation of the spine, these ribs are pushed forward. The sternum can be pulled towards the convexity. In severe cases there can be negative effects on ribcage mobility, meaning that breathing efficiency can be compromised. The orientation of the scapulae might be affected due to the ribcage deformity. It may be abducted, rotated upward, winging or tilting. The deformities can also affect the length and tone of the trunk muscles, with those on the concave side tending to be contracted and shortened, and those on the convex side to be stretched and lacking tone. The shoulders can be at different heights with one shoulder blade more prominent than the other, and one hip may be higher than the other, resulting in an uneven waist. The head is sometimes not centered directly above the pelvis and if the curvature is extreme the entire body can be leaning to one side. (Paterson, J. 2009. Teaching Pilates for Postural Faults, Illness & Injury. Oxford: Elsevier. Pgs 22) The diagram of the child on the right illustrates a severe case and the accompanying effects that scoliosis can have on the body, with the uneven rib cage, and asymmetrical scapulae and pelvis. The diagram on the right shows a healthy spine from the anterior, lateral, and posterior views, with the different sections of the vertebrae labeled. Introduction to Adolescent Idiopathic Scoliosis (AIS) Although there are actually four different kinds of Scoliosis, this paper will focus on the symptoms and problems associated with Adolescent Idiopathic Scoliosis (AIS). AIS affects healthy children between the ages of 10 and 18, affects girls more than boys (they are 10 times more likely to require treatment), and is the most common form of spinal deformity, affecting 3% of the population. It tends to be genetic, appearing in certain families indicating that it may be hereditary. Curves have been determined to progress more rapidly during growth spurts, indicating a relation between AIS and hormones. Case Study: Hayley was born in August of 2000, her scoliosis was diagnosed in spring of 2013, just after the onset of her menses; she started her period while she was twelve and a half years old. Her initial diagnosis was by her pediatrician. As is commonly the practice, Hayley was given the Adams forward bend test, where the adolescent takes a praying position with their hands, extends their arms, and slowly bends forward as if to touch their toes, until the torso is roughly parallel to the floor. The doctor then looked for abnormal elevation of back muscles, rotation of the rib cage, and/or visible lateral curvature of the spine. Hayley’s pediatrician used a Bunnell scoliometer, a plastic apparatus that is placed at various points of the back to detect discrepancies between elevations. As there were significant findings an x-­‐ray was performed, a front-­‐back and a side view, as is most common, and then a Cobb measurement ensued. The doctor will have used a protractor to determine the degree of the angle of curvature. The side view will show how much the spine is rotated. Her lateral curve is considered to be 14°. The difference in hip height seen on the x-­‐ray suggests that one leg is longer than the other, although this has yet to be determined by a bone measurement. It is independent of, and not related to her scoliosis. Hayley recently saw a chiropractor who, when studying the x-­‐ray of her lumbar vertebrae, was more inclined to see the tilted pelvis as a result of asymmetrical discs between the lower lumbar vertebrae; the left side of the bodies being tilted towards each other, with less space between them. At this time the reason for her hip tilt is not known. -­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐ List of visible asymmetrical symptoms of AIS, which can be observed by a Pilates teacher to assess an individual: •
One shoulder or hip may be higher than the other •
One shoulder blade may be higher and stick out farther than the other •
These deformities are more noticeable when bending over •
A "rib hump" may occur, which is a hump on your back that sticks up when you bend forward. This occurs because the ribs on one side angle more than on the other side •
One arm hangs longer than the other because of a tilt in the upper body •
The waist may appear asymmetrical (http://www.allaboutbackandneckpain.com/understand/scoliosis.asp#causes) Frontal x-­‐ray of Hayley’s right-­‐thoracic 14°C-­‐curve, and concurrent but unrelated right-­‐upwardly tilted pelvis. Assessment While assessing Hayley from the posterior view, one can see that her right knee crease is slightly higher than the left and tilts slightly upward laterally. Her right hip appears higher than the left, and her right buttock crease is slightly higher than the left. Her right shoulder blade is slightly more prominent than the left. When she bends forward into the Adams bend test position her slight right rib hump is apparent. She has attended Classical “Ballet Russe” classes for 5 years, going 2x per week in the first years and 4x per week this past year. Thus, she is used to moving her back into spine extension, maintaining her arms in a lifted position while depressing her scapulae, stretching her trunk laterally, stretching her hamstrings and quadriceps, externally rotating her hips and using her hip adductors. Nonetheless, she is not a naturally flexible person, especially in her hamstrings and quads, and has to work hard to achieve the positions and movements performed in ballet. She sometimes complains of lower back pain when standing for long periods of time or walking slowly, as during shopping, and needs to sit down and stretch her lower back. Because I could view the x-­‐ray taken in February of this year, 2013 (see page 8), I could clearly see the lateral thoracic curve, with convexity to the right, as is most typical of a simple C-­‐curve. The upward right lateral tilt of her pelvis is also very pronounced, but is atypical in that the left hip is usually the lifted one when there is a right convex thoracic curve; her hip tilt is not considered to be related to the scoliosis. Considerations when planning a program for Hayley: In planning her conditioning program I took into account the muscle imbalances probably existing due to her C curve, plus her own desire to improve the flexibility in her hamstrings and quadriceps, and to improve the strength of her ankles and plantar flexors and the flexibility of her feet for ballet. In some schools of thought it is contra-­‐indicated during lateral flexor training to perform concentric training on the concave side, as it is thought that the muscles are already shortened. However, the fact that they are short and tight doesn’t have to mean that they are strong. Therefore I included some lateral flexor training. Most challenging however, was her uneven hip alignment due to her tilted pelvis and the imbalances it creates; the abductors can be long and weak on the side that is hiked up, and the adductors can be tight and/or overactive, since the upward tilted side is to some extent perpetually adducted. Conversely, the lower side will have tighter, more used abductors, and weaker adductors. She also had discomfort in certain positions; she had too much pain in her hip to perform any side-­‐lying lateral work. I looked for exercises that would address her issues without adding to the imbalances, as her issues are different and opposing on the two sides of her body. I searched for exercises that would provide elongation of the trunk. I considered scoliotic wedging under her convex side, but I don’t think her degree of scoliosis warrants it. There is not a significant difference in her back rib contact with the floor on either side while in the supine position, although her right shoulder is elevated in comparison to her left while supine, and her head is not truly centered in this position. Realistically, I also had to take into account her age, which was still twelve when we started, and how that would play a role in her overall concentration and to some extent cooperation. Thus she does not perform the entire work-­‐out at every session, but we try to at least cover the blocks. Program: Pelvic Curl, + Pelvic Curl with roll-­‐up bar (adding arms overhead for elongation of the spine) Supine Twist Chest lift (sometimes with Magic Circle) Chest lift w/rotation Leg Changes (sometimes supine on the foam roller, arms at sides) Footwork on the Cadillac—Parallel Heels, Parallel Toes, V-­‐Shape Toes, The footwork was chosen on the Cadillac because of the hamstring stretch it provides, and because it availed the most comfortable position for her tilted pelvis; the Reformer and Wunda being more difficult to work in a balanced way due to the orientation of the pelvis. In the future we may practice footwork on the Wunda, as she enjoys the challenge the Wunda presents to her trunk stability, and because it resembles the positions in ballet. Abs on the Cadillac-­‐-­‐Mini Roll-­‐Up, Mini Roll-­‐Up with Rotation, Roll-­‐Up Top-­‐Loaded: These were chosen because of the beautiful stretch they provide while working the abs, again since working in elongation is especially important for a scoliotic back. Abs on Spine Corrector-­‐-­‐-­‐ Chest Lift, The Reach, Overhead Stretch: these were also chosen due to the back stretch element they all provide. They allow her to decompress her back but also to open up the ribs to some extent on the concave side. Hipwork on the Cadillac-­‐-­‐-­‐Single Leg: Frog, Hip Extension, Circles Down, Up, Bicycle + Reverse chosen to work the hips/legs independently because of the uneven pelvis. Spinal Articulation on the Spine Corrector-­‐-­‐-­‐Rollover Bottom Lift on the Reformer, with the goal of progressing to the Short Spine. Kneeling Lunge (with a view to progressing to the Full Lunge): To stretch her hamstrings we included Kneeling Lunge, in spite of the more difficult position it was more comfortable than the Standing for her hips. Up Stretch One—chosen because it allows for thoracic, shoulder and hamstring stretch, with added shoulder stabilization and pelvic disassociation. Shoulder Push + Shoulder Push Single Arm-­‐-­‐-­‐ chosen mainly for the scapula stabilization, and with single arm to promote the awareness of working through the scapular imbalances. Arms Supine-­‐-­‐-­‐ Extension, Adduction, Circles Down, Up, Triceps. We continued to the Supine Arm set on the Reformer, to maintain scapular stabilization whilst working on shoulder and lat strength. (The Arms Sitting Series provides key exercises for her issues, notably Rhomboids and Hug-­‐A-­‐Tree which we will progress to.) (Sitting Side Prep)-­‐-­‐-­‐ Although it was very challenging, I sometimes included Sitting Side Prep, with manual assistance, trying to education movement in the scapula without lateral movement in the trunk. -­‐-­‐-­‐When time allowed we added Side Split and Legwork on the spine Corrector (Side Split)-­‐-­‐-­‐added mostly because of the stretch for ballet, and adductor strength. (Legwork on the Spine Corrector)-­‐-­‐-­‐Scissors, Openings, Helicopter, Bicycle, Reverse Bicycle: these were also chosen because of the pelvic stability work and leg stretch and because her uneven hips posed less of a problem in this position. We also experimented with adding ankle weights. Side Kneeling Stretch-­‐-­‐-­‐This proved to be the most comfortable way to work the lateral flexors as she did not have to rest on her hip. Swan Basic + Back Extension Single Arm, although in single arm we modified by just lifting one arm while the other arm held the pedal down, without lifting the torso at first. This was already difficult for her. Swimming-­‐-­‐-­‐ Chosen for the trunk rotational stability called upon with the asymmetrical movement, also for use of shoulder extensors and scapular depressors assistors. Rest Position Shoulder Stretch Lying Side: The Shoulder Stretch Lying Side provides both shoulder stretch, and thoracic stretch; both especially important on her left side. She enjoyed adding this stretch at the end. Conclusion: There are differing opinions as to the relative benefits of ”exercise” for AIS, but one has to take into account that not all authors are really familiar with Pilates exercise. Thus when determining the relative benefits of exercise one should consider the type of exercise, and the intensity, prescription and frequency of that exercise, as well as the degree of the scoliotic curves, and to what extent the adolescent is still growing. The goals of the exercise program need also to be addressed. A “cure” for AIS cannot be expected, but important improvements in muscle balance can certainly be hoped for, and possibly relief of pain where pain is present, which it is not the case in all scoliotic persons. New and not so new research indicates that corrective exercise can have an effect both on the reduction of curve progression and the correction and re-­‐alignment of curves. “We now know that there is asymmetry in muscle function for everyone with scoliosis. More specifically, there is an uneven strength in trunk rotation. The former exercise programs of stretching and general strengthening may have been the wrong approach. Studies using exercise equipment that can measure muscle function show that progressive resistive exercises (PREs) are effective for curves.” (http://www.orthopediatrics.com/docs/Guides/scoloisis.html). A holistic approach is important as was the case with Hayley; it was not only her scoliosis but her upward-­‐tilted pelvis, in her case unrelated to the scoliosis that had to be considered. Pilates offers an excellent mode of exercise to address the complex imbalances and asymmetries inherent in her scoliotic condition. Bibliography: Isacowitz, R., Clippinger, K. 2011. Pilates Anatomy. Champaign, IL: Human Kinetics Johnson, J. 2012. Postural Assessment, An Illustrated Guide of 79 Steps. Champaign, IL: Human Kinetics Lyons, B. 1999. Scoliosis, Ascending the Curve. New York: M. Evans and Company, Inc. Paterson, J. 2009. Teaching Pilates for Postural Faults, Illness & Injury. Oxford: Elsevier. Pgs 21-­‐
24. All about back and neck pain-­‐-­‐
http://www.allaboutbackandneckpain.com/understand/scoliosis.asp#causes: © DePuy Synthes Spine, Inc. 2003-2012
A Patient’s Guide to Scoliosis-­‐-­‐http://www.orthopediatrics.com/docs/Guides/scoloisis.html: OrthoPediatrics Corp. Warsaw, Indiana, USA Role of the Family Doctor in the Management of Scoliosis-­‐-­‐ http://www.scoliosis-­‐
australia.org/scoliosis/doctor_role.html The Major Scoliotic Curves: http://www.yogaforscoliosis.com/WhatIsScoliosis.htm Pilates COREterly, spring 2011,Rehab Corner, Scolio-­‐Pilates: Working in Multiple Dimensions by Karena Thek Lineback-­‐-­‐ http://www.pilates.com/BBAPP/V/pilates/library/COREterly/2011-­‐
spring/rehab-­‐corner.html Scoliosis Exercise; with Scolio-­‐Pilates author Karena Thek Lineback http://www.youtube.com/watch?v=k8HefsmFekM