Posts Tagged "Adolescent"

Case – Kyphosis Bracing

Posted on March 19th, 2018 by admin

Reduction of a Hyper-kyphosis in a 16-year-old female patient using a 3D designed kyphosis brace

Case Background

The patient presented to the ScoliCare clinic at 14 years of age with postural deformity and pain in the middle back.

Examination Findings

The patient was a pre-menarchal teenager who reported pain across the shoulder blades that extended from the upper thoracic spine down to the lower lumbar spine. The patient rated their pain as 6/10 on a visual analogue scale and stated that the pain and stiffness in their back was impacting on their daily activities. The patient was otherwise healthy. The physical examination revealed a significant increase in the patient’s thoracic kyphosis and lumbar lordosis (Figure 1), with marked angulation of the thoracolumbar spine during forward bending. There were no other significant clinical findings. A provisional diagnosis of Scheuermann’s kyphosis was made and confirmatory imaging was requested. Plain films taken soon after the examination highlighted an abnormal curvature in the sagittal plane – specifically a 67° hyper-kyphosis in the thoracic spine with an apex at T10. There was notable wedging of the T10 & T11 vertebrae in the lower thoracic spine.

Figure 1: Lateral postural photograph (Left).
Lateral x-ray indicating a hyper-kyphosis (Right)

Intervention

The patient was prescribed a customised 3D designed rigid kyphosis brace and specific exercise rehabilitation to address the spinal deformity. The patient was advised to wear the brace for 20 hours per day for a period of 18 months. With respect to the exercise rehabilitation, specific exercises were given to strengthen the spinal extensors. The exercises were administered during one-on-one sessions with an exercise physiologist initially, then the patient was instructed to perform these exercises daily at home to complement the action of the brace. Exercises were modified and/or progressed as the patient’s strength and endurance improved.

Outcomes

In-brace x-rays were taken one month after the brace fitting which indicated that the curve could be reduced from 67° down to 42° whilst wearing the brace (Figure 2).

After three months of brace wear an x-ray was taken with an independent radiology clinic. The images were taken with the patient standing in their normal relaxed posture after being out of the brace for 12 hours. These x-rays demonstrated a reduction in the curve from 67° down to 54°.

The patient wore the brace and continued the exercises for a further 12 months. Brace weaning was initiated after 15 months of brace wear. Plain films taken at the end of the brace weaning period revealed that the curve had remained stable at 54° (Figure 3). The patient was instructed to continue with the exercise rehabilitation after the cessation of brace wear, with the expectation that if the patient keeps up with their exercise program that their curve will remain under 60°.

Figure 2: In-brace X-rays one month

Figure 3: Lateral postural photograph (Left).
Lateral x-ray indicating 54° thoracic kyphosis after the brace fitting

Discussion

The normal angle of kyphosis in young patients ranges from 20-45°. One condition that may alter the normal thoracic curvature is Scheuermann’s disease. Classified as one of the osteochondroses, Scheuermann’s disease usually appears just prior to puberty with roughly equal prevalence between males and females. The condition is characterised by an increase in the normal thoracic kyphosis and is associated with structural changes in the vertebral bodies – namely wedging, endplate irregularities and diminished anterior vertebral body growth.

Long-term follow-up studies highlight that patients with Scheuermann’s disease tend to have more severe back pain, work lighter jobs and have more concerns regarding their appearance when compared with healthy patients. If left untreated, patients with kyphosis tend to experience a progression of their deformity and associated back pain. The scientific literature points to bracing being an effective treatment for patients with hyper-kyphosis. Bracing appears to not only prevent progression in this group but may also serve to restore the normal kyphosis in some patients. The best results from bracing are observed when treatment is initiated in skeletally immature patients who have curvatures of between 55-80°.

Conclusion

This case demonstrates the successful management of an adolescent patient with hyper-kyphosis using a customised 3D designed rigid kyphosis brace and specific exercise rehabilitation.

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.

Tags: Adolescent, Bracing, Girl, Kyphosis
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Case – Bracing & Exercise Rehab

Posted on February 16th, 2018 by admin

Reduction of a severe scoliosis in a young female gymnast using a 3D designed scoliosis brace

Case Background

The patient was a 14-year-old, high-level, competitive gymnast. The patient’s mother had noticed a curvature in her daughter’s spine and taken her to see a manual therapist. The therapist had made a diagnosis of Adolescent Idiopathic Scoliosis (AIS) and treated the patient for three months. Unfortunately, the patient had not responded to treatment and was referred to the ScoliCare clinic for an assessment.

Examination Findings

The examination revealed some significant postural changes. Specifically, notable curvature in the middle and lower sections of the patient’s spine, uneven heights of the pelvic bones, and torsion of the rib cage (Figure 1). X-rays taken at the time showed a large 71° curve in the thoracic spine and a secondary curve, measuring 40°, in the lumbar spine (Figure 1). The patient was only Risser 2, indicating that she still had a significant amount of growing to do.

Figure 1: A) Posterior-anterior view highlighting the scoliosis and pelvic tilt.
B) Superior to inferior view highlighting torsion of the rib cage associated with the thoracic spine curvature.
C) Posterior-anterior x-ray demonstrating the curvature of the spine and changes in the rib cage.

Intervention

As both the curves were quite large, and the patient was skeletally immature, it was recommended that the patient be seen by an orthopaedic surgeon. The surgeon’s recommendation was that the patient undergo surgery to correct the abnormal spinal curvatures. After careful consideration, both the patient and her parents declined the surgeon’s recommendation. Instead, they decided to go with a more conservative approach.

The patient was subsequently prescribed a customised 3D designed rigid brace , and rehabilitation exercises based on the SCHROTH principles. The recommendation was that the patient be braced for two years until she stopped growing. A daily scoliosis specific exercise program was designed for the patient to support the corrections being made by the brace. New exercises were added to the program as the patient progressed. Regular follow-ups were scheduled to ensure that A) the patient was responding to the treatment, and B) to monitor compliance with the bracing and exercise program.

Outcomes

The patient’s spine responded favourably to the treatment with one-month x-rays showing that the larger curve could be reduced from 71° down to 40° with the patient wearing the brace (Figure 2).

In total, the patient was braced for 18 months. The patient also participated in supervised exercise sessions at the clinic and performed similar exercises at home. At the end of the treatment period, the patient’s curves had reduced significantly (71° to 56°) as demonstrated in the out-of-brace x-rays in Figure 3. The patient’s posture was also notably improved.

Figure 2: In-brace frontal x-rays taken one
month after the brace fitting.

Figure 3: A) Post-treatment posterior-anterior view posture photo B) Post-treatment frontal x-rays.

Discussion

Normally, brace treatment is reserved for AIS patients with moderate (20-45°) scoliotic curves. Scoliosis specific exercise rehabilitation is used in mild (10-20°) scoliosis as a standalone treatment, and as a supplement to bracing in patients with moderate scoliosis. Patients with more severe scoliosis are typically managed surgically. There is very little research to support the use of bracing or exercise in patients with curves exceeding 45°. This case is unique in the sense that the patient/parents refused surgery and elected to try a more conservative option. Care was taken to explain to the patient/parents that surgical treatment is the recommended pathway for AIS patients with severe curves. The is a scarcity of evidence to support the use of bracing in curves >60° in this population.

Conclusion

This case demonstrates the reduction of a severe scoliosis in an AIS patient who declined surgical intervention.

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.

Tags: Adolescent, Bracing, Exercise Rehab, Girl
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