Physiotherapy Management of Neuromuscular Scoliosis

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Physiotherapy Management of Neuromuscular
Scoliosis

• Hannah Waugh
• 0131 536 0000 Bleep 9126
• Specialist Physiotherapist,
• The Royal Hospital for Sick Children,
• Edinburgh

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Contents

• What is Scoliosis?
• Medical Management
• Pre Operative Planning
• Hospital Admission
• Challenges post discharge

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What is Scoliosis?

• Complex three dimensional deformity where the
  curve is greater than 10 degrees

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Prevalence of Neuromuscular Scoliosis

• 20 of children with Cerebral Palsy
• 60 of children with Myelodysplasia
• 90 of children with Duchenne Muscular Dystrophy

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Neuromuscular Scoliosis Development

• Spinal curvature may begin very early in life
• Often after the patient starts supported sitting
• Curve may progress rapidly once patient becomes
  non ambulant (averaging 10 degrees/year)

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Initial Assessment
06.02.2007 14yrs 6mth
66 o
108 o
Pelvis ? o
S.G., ?
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Progression of curve 4 months
06.02.2007 14yrs 6mth
26.06.2007 14yrs 10mth
66 o
58 o
108 o
122 o
Pelvis ? o
Pelvis 34 o
S.G., ?
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Preventing Progression of Scoliosis

• Prolong mobility
• Steroids
• 24 hour postural management
• Spinal bracing (not always effective particularly
  in progressive neuromuscular curves)

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Referral Criteria

• Consultant to consultant referral only
• Confirmed scoliosis - requesting specialist
  assessment for surgical intervention
• Neurological usually after the age of 10 as
  surgery unlikely prior to this
• DMD when patient becomes non ambulant

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Initial Spinal Clinic Assessment

• In-depth history is taken
• scoliosis progression, pain, function
• past medical history
• medication
• social history
• Objective Assessment
• X-rays standing or sitting to establish
  severity, bending films to identify flexibility
  cobb angle, also check risser grade

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Cobb Angle

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Medical Management

• Dependent on
• Severity of scoliosis
• Pelvic obliquity
• Age/Skeletal maturity risser grade
• Rib deformity/ Impingement/ Pain
• Complexity of past medical history

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Medical Management

• Cardiac
• Respiratory
• Anaesthetics
• Neurology/ Neurosurgery
• Endocrinology
• GI

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Medical Management - DMD

• Respiratory Function
• Functional Ability
• Symptoms
• Quality of Life questionnaire
• Reduction in surgery

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Medical Management - CP

• Respiratory Function
• Functional Ability
• Symptoms
• Quality of Life questionnaire
• Surgery

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Medical Management - mylominingecele

• Respiratory Function
• Functional Ability
• Symptoms
• Surgery

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Medical Management

• Every case is very individual
• Function
• Medical Stability
• MDT decision

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Medical Management

• Continue to monitor curve
• Use of conservative treatment
• PSF

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Physiotherapy Service Aims

• To ensure smooth pathway from pre admission to
  discharge
• To be available for contact to reduce any
  anxieties throughout the patient journey
• To be a resource for local therapists / services
  for Scotland

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Spinal Surgery Pathway
Contact made with local services family
Pre-op assessment completed
Theatre list to Physio OT
Equipment requirements identified commenced
Local services review
Discharge
Admission
Post-op
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Physiotherapy Role

• To ensure that optimal functional abilities are
  achieved post operatively
• Those functional abilties include
• respiratory function
• muscle strength
• transfers/ mobility
• postural management
• Overall aim is to maximise independence following
  surgery in activities of daily living
• Postural management is vital and should be
  considered through out all stages of spinal
  surgery

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Physio Pre op Planning

• Commenced as soon as the patient is listed for
  theatre (approx 6 weeks)
• Facilitate smooth admission and discharge from
  hospital
• Early contact with local services is essential

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Pre-operative Planning

• Unfortunately due to geographic location of
  clinics, unable to attend
• Contact will usually be made with the family and
  local therapists initially by telephone
• If patients admitted for respiratory tests, trial
  of NIV or attend for anaesthetic assessment we
  will meet and assess on ward if possible

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Initial Pre-Op Assessment Physio /OT

• Establish current abilities of
• Seating (wheelchairs,other seating systems
  school, home)
• Transfers (independent, assisted, hoist)
• Mobility- use of walking aids
• Personal Hygiene (toileting, bathing/showering,
  level of assistance ,specific equipment)
• Respiratory function
• Other ADL activities (feeding, self dressing)
• School
• Environmental issues (access to and within
  house)- child may need to live downstairs

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Seating

• Wheelchairs
• Should be in suitable corrective seating system
  pre op- consider lateral supports, harness head
  support
• Tilt recline facilities recommended pre-op for
  any patient with scoliosis (Bushby et al, 2005)
• Tilt recline vital post op if fused to pelvis
• Moulded wheelchairs are not appropriate post op
• Local services to review post op to ensure
  corrective seating system

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Seating

• If fused to pelvis other seating systems can be
  used if have recline
• Local therapists to review postural support from
  seating systems post op
• Post op head rests, lateral supports, harnesses
  will still be required to maintain optimal
  postural alignment
• Sofas, beanbags are not acceptable seating
  systems!

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Transfers

• Hoisting
• Children that are lifted pre-op may require to be
  hoisted
• Hoisting is dependent on age, size, weight and
  complexity
• High backed slings with head support recommended
• Bones in slings not necessary
• Thinner sling ideal- will be left in situ
  initially
• Remember to consider that child may require
  increased sling length post op
• Responsibility of local services to provide hoist
  training if new/ different equipment has been
  supplied

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Personal Care

• Toileting
• Ideal is recline tilt- limited resources may
  result in tilt only
• Showering
• Recommended in acute post op period
• Alternative shower chair may be required
• for postural support
• Bathing
• Long term extra postural support in bath
• may be required

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Pre-operative Respiratory Function

• Extremely beneficial if families have been taught
  lung volume recruitment techniques and chest
  clearance techniques prior to admission
• British Thoracic Society (www.brit-thoracic.org.uk
  
• Scottish Muscle Network DMD Profile
  (www.smn.scot.nhs.uk)
• Peak cough flow can be assessed by using a mask
  and a peak flow meter,

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Hospital Admission

• Usually admitted the day prior to surgery
• Introduction/assessment by inter-disciplinary
  team
• Discussion of post operative management

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Operation Posterior Spinal Fusion
20.09.2007 15yrs 1mth
40 o
62 o
Pelvis 6 o
S.G., ?
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Posterior Spinal Fusion /- pelvic fixation

• Performed via a large midline incision
• Spinous processes, interspinous ligaments and
  facet joints excised
• Pedicle Screws or hooks attached to spine
• If fusing to the pelvis wires or pelvic screws
  are placed
• Rods applied down either side of the spine and
  attached to screws and hooks as spinal deformity
  derotated
• Bone grafts placed around rods usually femoral
  heads from bone bank or bone substitutes
• Wound is closed with redivac drain insitu

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Anterior Release /- posterior spinal fusion

• Performed via a thoracotomy on the convexity of
  scoliosis
• A rib is excised for most of its length to access
  spine (and kept) rib resection
• Rib heads may be removed around the apex of the
  scoliosis to improve cosmetic result internal
  costoplasty
• Pleura is excised
• Discs are excised and growth plates, cartilage
  removed
• Wound closed with intercostal chest drain insitu

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In patient Physiotherapy

• Reviewed day one post op
• Chest physiotherapy commenced
• Passive/active assisted movements
• Bed mobility log rolling
• Mobility/ hoisting once medically stable
• Liaison with local therapists
• Ongoing until discharge from hospital

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Acute Post Op Challenges

• Surgical considerations e.g. pelvic fixation-
  reclining seating positions
• Medical stability e.g. respiratory distress
• Comfort pain control
• Tone
• Psychosocial anxiety
• Nutrition

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Discharge Advice

• Advise parents to cont passive/active assisted
  movements
• To increase mobility or duration sitting in
  wheelchair
• If wheelchair reclined- to reduce recline as
  tolerated
• To ensure postural alignment maintained avoid
  forced flexion/ extension or rotation of spine
• Ongoing respiratory management as required

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Discharge Advice

• Unable to use standing frame and some walking
  aids
• Unable to swim/ hydrotherapy/ participate in
  sports
• Discretion of Consultant on reviewing patient and
  x-rays at clinic

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School

• ASL Profile provided
• Return to School graded
• School seating
• Desk height/ position
• Hand function writing skills
• Manual handling/hoisting
• Toileting
• Feeding

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Challenges after Discharge

• Home Environment
• Mobility
• Self propelling wheelchairs
• Change to Physiotherapy Program Hippotherapy,
  Rebound etc
• Feeding
• Family Support
• Transport
• Holidays
• Anxieties

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Conclusion

• There is variability with each child and we aim
  to make the pathway as smooth as possible for the
  patient / carers and local therapists

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