Scoliosis Adolescent (Thoracic Spine) Rehabilitation Protocol

Pathophysiology

Adolescent Idiopathic Scoliosis (AIS) is a three-dimensional deformity of the spine, characterized by lateral curvature and vertebral rotation. It typically develops during the adolescent growth spurt, primarily affecting individuals between 10 and 18 years of age. The exact cause of AIS remains unknown (idiopathic), but genetic factors, biomechanical imbalances, and neuromuscular abnormalities are suspected contributors.

The thoracic spine is the most common location for AIS curves. The curvature results in asymmetrical loading on the vertebral bodies, discs, and surrounding musculature. This asymmetry leads to muscle imbalances (tightening on the concave side and lengthening/weakness on the convex side), rib cage distortion, and potential cardiopulmonary compromise in severe cases. The Cobb angle is used to measure the severity of the curve on radiographs. Scoliosis is typically defined as a Cobb angle of 10 degrees or more.

Physical therapy aims to address these imbalances, improve posture, enhance core stability, and prevent curve progression. Treatment approaches often involve a combination of exercises, manual therapy, and bracing (if indicated by an orthopedic surgeon).

Phase I: Protection (Acute/Early Phase)

Goals:

• Reduce pain and muscle spasm
• Improve awareness of posture
• Initiate core stabilization exercises
• Educate patient on proper body mechanics

Treatment:

• Pain Management:
  • Modalities: Heat/cold packs as needed, electrical stimulation (TENS) for pain relief.
  • Gentle soft tissue mobilization to address muscle spasm around the spine and rib cage.
• Postural Education:
  • Mirror exercises: Focus on aligning shoulders and pelvis, identifying and correcting postural deviations.
  • Verbal and tactile cues to improve posture awareness during activities of daily living (ADLs).
• Core Stabilization:
  • Diaphragmatic breathing exercises: Promote proper breathing patterns and core muscle activation.
  • Transversus abdominis (TrA) activation: Drawing-in maneuver with stable spine.
  • Pelvic tilts: Anterior and posterior pelvic tilts in supine, emphasizing neutral spine.
• Gentle Stretching:
  • Hamstring stretches: To address pelvic alignment.
  • Chest stretches: To open up the chest and improve posture.
• Bracing Education (if applicable): Proper wearing schedule, skin care, and monitoring for pressure areas.

Precautions:

• Avoid activities that exacerbate pain or muscle spasm.
• Monitor for signs of nerve compression (numbness, tingling, weakness).
• Adhere to bracing instructions from the orthotist.

Phase II: Loading (Intermediate Phase)

Goals:

• Improve spinal mobility and flexibility.
• Strengthen core and spinal musculature.
• Enhance balance and proprioception.
• Progress functional activities.

Treatment:

• Spinal Mobility:
  • Cat-cow stretches: Promote spinal flexion and extension.
  • Thoracic rotation exercises: Gentle rotations within a comfortable range of motion, focusing on mobilization of stiff segments.
  • Side bending stretches: Addressing muscle imbalances on the concave and convex sides of the curve.
• Strengthening:
  • Core strengthening: Progress to planks (modified to full), side planks, bird dog exercises, dead bugs.
  • Back extensor strengthening: Prone trunk extensions (modified to full range), rows with resistance band.
  • Scapular stabilization exercises: Rhomboid and lower trapezius strengthening (scapular squeezes, rows).
  • Latissimus dorsi strengthening: Lat pull-downs (modified weight), theraband exercises.
• Balance and Proprioception:
  • Single-leg stance: Progress to unstable surfaces (foam pad, balance board).
  • Weight shifting exercises: Anterior-posterior and lateral weight shifts.
  • Reaching activities: Reaching for objects while maintaining balance.
• Schroth Method Principles: Initiation of auto-correction and rotational angular breathing.

Precautions:

• Monitor for signs of curve progression.
• Avoid excessive spinal loading or compression.
• Progress exercises gradually based on patient tolerance.

Phase III: Return to Function (Advanced Phase)

Goals:

• Maintain spinal stability and postural control.
• Improve endurance and functional capacity.
• Return to sport or recreational activities (if applicable).
• Develop a home exercise program for long-term management.

Treatment:

• Functional Training:
  • Lifting and carrying techniques: Emphasize proper body mechanics and core engagement.
  • Simulated sport-specific activities: Gradual return to sport with modified techniques.
• Endurance Training:
  • Cardiovascular exercises: Walking, jogging, cycling, swimming.
  • Progressive resistance training: Increased weight and repetitions.
• Advanced Core Stabilization:
  • Dynamic core exercises: Medicine ball throws, rotational exercises.
  • Plyometric exercises: Box jumps, jump squats (if appropriate).
• Home Exercise Program:
  • Develop a personalized exercise program that includes core strengthening, spinal mobility, and postural exercises.
  • Provide instructions on proper form and technique.

Precautions:

• Monitor for recurrence of symptoms.
• Emphasize proper body mechanics during all activities.
• Encourage regular follow-up appointments with the orthopedic surgeon and physical therapist.

Common Special Tests

• Adam's Forward Bend Test: Performed to visually assess for scoliosis. The patient bends forward at the waist, and the examiner observes for rib hump asymmetry.
• Scoliometer Measurement: Quantifies trunk rotation during the Adam's Forward Bend Test.
• Range of Motion (ROM) Assessment: Measures spinal flexion, extension, lateral flexion, and rotation.
• Muscle Strength Testing: Assesses the strength of core, back, and shoulder musculature.
• Neurological Assessment: Evaluates for nerve root compression (sensory, motor, reflex testing).