Scheuermann's Disease Rehabilitation Protocol (Thoracic Spine)

This protocol outlines a comprehensive physical therapy rehabilitation program for individuals diagnosed with Scheuermann's Disease in the thoracic spine. It is crucial to individualize this protocol based on the patient's specific presentation, pain levels, radiographic findings, functional limitations, and overall progress. Close communication between the physical therapist, physician, and patient is essential.

Pathophysiology

Scheuermann's disease, also known as Scheuermann's kyphosis, is a structural deformity of the spine primarily affecting adolescents. It is characterized by wedging of at least three adjacent vertebral bodies by 5 degrees or more, along with endplate irregularities (Schmorl's nodes) and narrowing of the intervertebral disc spaces. The exact etiology remains unclear but is believed to involve genetic predisposition, mechanical stress during growth spurts, and abnormal collagen formation. This results in increased thoracic kyphosis, often accompanied by compensatory lumbar hyperlordosis. Patients may experience pain, fatigue, postural imbalances, and restricted spinal mobility. The condition is typically diagnosed based on radiographic findings. Untreated, Scheuermann's disease can lead to chronic pain, limited function, and potential long-term spinal degeneration.

Common Special Tests

• Adam's Forward Bend Test: Assesses structural scoliosis or kyphosis. In Scheuermann's disease, the kyphosis will remain present during forward flexion.
• Thoracic Mobility Assessment: Includes assessment of flexion, extension, lateral flexion, and rotation using visual estimation and/or inclinometry. Restricted extension is a common finding.
• Muscle Length Testing: Assessment of pectoral muscles (pec major and minor), hamstrings, hip flexors (iliopsoas and rectus femoris), and latissimus dorsi. Tightness in these muscles can contribute to postural imbalances.
• Neurological Examination: Assess sensation, motor strength, and reflexes to rule out nerve root compression or other neurological involvement.
• Postural Assessment: Observation of posture in sagittal and coronal planes to identify kyphosis, lordosis, and shoulder or pelvic asymmetries.

Phase I: Protection (Acute/Pain Relief)

Goals: Reduce pain and inflammation, protect affected structures, improve postural awareness, and initiate gentle mobility exercises.

• Pain Management:
  • Rest and activity modification: Avoid activities that exacerbate pain.
  • Modalities: Heat, ice, TENS, and ultrasound may be used to manage pain and muscle spasm.
  • Pain medication education: Emphasize the importance of adhering to physician-prescribed medication regimens.
• Postural Education:
  • Mirror exercises: Visual feedback to correct posture and promote upright spinal alignment.
  • Verbal cues: Reminders to maintain proper posture throughout the day (e.g., "Shoulders back, chin tucked").
  • Ergonomic assessment: Modify work or school environments to promote good posture.
• Gentle Range of Motion Exercises:
  • Thoracic spine mobility exercises: Cat-cow stretch, seated thoracic rotation, lateral trunk flexion. Focus on pain-free range.
  • Scapular retractions: To improve scapular stability and counteract rounded shoulders.
  • Chin tucks: To correct forward head posture.
• Breathing Exercises:
  • Diaphragmatic breathing: To improve lung capacity and reduce stress.
  • Thoracic expansion exercises: To improve rib cage mobility.
• Core Activation:
  • Transversus abdominis activation: Drawing-in maneuver in supine position.
  • Pelvic tilts: To improve lumbopelvic stability.

Phase II: Loading (Strengthening/Endurance)

Goals: Improve strength and endurance of postural muscles, increase spinal mobility, restore normal movement patterns, and gradually increase activity levels.

• Strengthening Exercises:
  • Thoracic extensors: Prone trunk extensions, bird dog exercises. Progress resistance gradually.
  • Scapular stabilizers: Rows, rhomboid squeezes, lower trapezius strengthening (prone Y raises).
  • Core strengthening: Planks, side planks, bridges, dead bugs. Focus on maintaining neutral spine position.
  • Hip extensors: Glute bridges, hip thrusts.
• Flexibility Exercises:
  • Pectoral stretches: Corner stretch, doorway stretch.
  • Hamstring stretches: Standing toe touches, seated hamstring stretch.
  • Hip flexor stretches: Kneeling hip flexor stretch, Thomas test position.
  • Latissimus dorsi stretches: Overhead reach stretch, side-lying lat stretch.
• Spinal Mobilization:
  • Thoracic spine manipulation/mobilization (if indicated and within the physical therapist's scope of practice).
  • Self-mobilization techniques: Foam rolling of the thoracic spine.
• Cardiovascular Exercise:
  • Low-impact activities: Walking, cycling, swimming. Gradually increase duration and intensity.
• Functional Training:
  • Lifting mechanics: Proper lifting techniques to prevent spinal strain.
  • Carrying techniques: Carrying objects close to the body.

Phase III: Return to Function (Activity Specific)

Goals: Return to pre-injury activity level, maintain optimal posture, prevent recurrence of symptoms, and promote long-term spinal health.

• Activity-Specific Training:
  • Simulate activities: Practice activities specific to the patient's sport or occupation.
  • Gradual return to sport or work: Gradually increase the intensity and duration of activities.
• Advanced Strengthening Exercises:
  • Progressive resistance training: Increase weight or resistance as tolerated.
  • Plyometric exercises: Jumping jacks, box jumps (if appropriate).
• Maintenance Program:
  • Home exercise program: Continue performing strengthening, stretching, and postural exercises.
  • Regular follow-up appointments: To monitor progress and address any concerns.
• Education:
  • Spinal hygiene: Proper posture, lifting mechanics, and ergonomic principles.
  • Self-management strategies: Techniques for managing pain and preventing recurrence.

Progression Criteria: Progression through each phase of this protocol is based on pain levels, functional abilities, and the absence of adverse reactions. The physical therapist will closely monitor the patient's progress and adjust the treatment plan accordingly.

Disclaimer: This protocol is intended as a general guideline and should not be used as a substitute for professional medical advice. Consult with a qualified healthcare provider for a personalized treatment plan.