WORKSHOP AND EDUCATIO MEETING

Transkrypt

WORKSHOP AND EDUCATIO
MEETING "PHYSIOTHERAPY 1 1 IOPATHle SCOLIOSIS" th
Poznan, Poland, Saturday, 8 April 2006
11:00-13:30
- SESSION A - CONSERVATIVE MANAGEMENT OF IDiOPATHIC
SCOLIOSIS
T. Kotwicki (Poznan, Po/a nd)
Idiopathi e scoliosis - definition, pathology, diagnosis.
Th.B. Grivas (Attica, Greece)
Idiopathie seo liosis - basic nomenclature.
J.C. de Mauroy (Lyon, France)
Progression of scoliosis during puberty making therapeutie decision.
A. Nowakowski (Poznan, Po/and)
Conservative treatment of scoliosis in the past centu ri es .
C. Coillard (Montrea/, Canada)
New rad iological classification and corrective movement.
J. Cheneau (Tou/ouse, France)
Mechanism of correction of seoliosis by brace .
J. O 'Brien (USA)
Scolios is Patient Care: More than just a method!
DISCUSSION
13:30-14:15
- LUNCH
14:15-17:15
- SESSION B - PHYSIOTHERAPY - WORKSHOP
J. Durmala (Katowice, Po/and)
Role of physiotherapy in seoliosis .
K. Dobosiewicz (Katowice, Po/and)
Dobosiewicz method.
S. Negrini, M. Romano (Mi/an, /ta/y)
Scientific Exe reises Approach to Seoliosis S EAS.02.
M. Bialek, A. M'hango (Wroclaw, Po/and)
Functional individual therapy of scoliosis .
H.R. Weiss (Bad Sobernheim, Germany)
Bad Sobernh eim Concept (Lehnert-Schroth-Weiss method) .
DISCUSSION
17:15-17:30
M. Riga (Barce/one, Spain)
Concl usion conservative treatment of scoliosis.
17:30
- END OF THE EDUCATION MEETING
EDUCATION MEETING, SATU RDAY, 8th of APRI L 2006
Dr med.Tomasz Kotwicki
Katedra 1Klinika Ortopedil l Traumatologti 02Îec l~cej AM w Poznaniu Depar1ment of Paediatric Or thopedies and Traumatology, Poznan Skolioza idiopatyczna - wprowadzenie Idiopathie scoliosis - introduction SOSO RT Ed ucati on Meeting Poznan 2006 Plan wyktadu
Plan of the lecture
• Definicja
• Patomoriologia
• Ptaszczyzna strzalkowa
• Definition
• Patomoriology
• Sagittal plane
• Scoliometer
• Skoliometr
• Historia naturalna
• Leczeni e operacyjne
• Natural history
• Operative treatment
• Podsumowanie
• Conclusion
Wvst~powanie
_..
skolioz idiop.
Prevalenee of IS
strukturalna skolioza 2-3 % dzieci
..Wada postawy·' 20-30-40%?
to nie jest skolioza idiopatyczna
structural scoliosis 2-3 % population
in the growin g age
" bad posture" 20-30-40% ?
it is not idiopathie seoliosis
T. Kotwicki/ 1
_-
EDUCATION MEETI NG, SATURDAY, 8th of APRIL 2006
Pierwsze badanie dzieeka ze skoli ozq
First exam of a child with seoliosis
• Czy to jest skolioza
strukturalna ?
• Is il slructural
scoliosis ?
• Czy 10 jes! skolioza
idiopatyczna ?
• Is il idiopathie
scoliosis ?
• Jakie jesl ryzyko
progresj! ?
• What is the risk of
progression ?
Sposoby leczenia skolioz idiopatycznych Methods of treatment of idiopathie seoliosis • éwiczenia
• Gorsety
.Operacje
• Exercises
• Bracing
• Operation
Cobb angle Kq.t Cobba
Upper IIm,l v N tabra
G<lrny i<fQ9 gronlçzny
ApIcal vortetlla
KI'lffi szczytQwy
Lowe. Ilmlt vertOOra
DOi11y krW granlczny
T. Kotwicki / 2
EDUCATION MEETING, SATURDAY, 8th of APRIL 2006
Dawny podzial Grucy i Weisfloga
Historical classification
0° - 30°
éwiczenia
• Skoliozy 11
• Skoliozy III"
30° - 60°
pow.60°
gorsety
operacje
• Scoliosis 1°
• Scoliosis II"
• Scoliosis 111°
0° - 30°
30° - 60°
exercises
brace
> 60°
operation
• Skoliozy 1°
0
nieaktualny
no more valid
Obecny podzial (wiek dorastania) Current classific ation (growing age) 0" - 10°
10° - 25°
• Norma
• Skoliozy 1°
~ Skoliozy II"
25° - 45°
• Skoliozy III"
> 45'-50°
• Normal
• Scoliosis 1
0° - 10°
10' - 25'
25 ' - 45°
• Scoliosis II"
• Scoliosis III"
nic
éwiczenia, kontrole
gorset i éwiczenia
operacje, ewen!.
gorsety z éwiczeniam
strefa sporna 40° - 50°
no tt
exercises, observation
brace and exercises
> 45'-50°
operation , even!.
brace with exercises
grey zone 40' - 50'
Kqt Cobba nie jest jedynym parametrem decyzyjnym ! Cobb angle is not a unique decisive parameter
!
•
Prognoza progresii
•
Prognosis of progression
•
Wiek bio!ogiczny
•
Biolagical age
•
•
•
•
Test Rissera
Lokali zacia skoliozy
Liczba /u k6w
Wielkosc rotacji
.,
Ri sser test
•
Localion of scoli asis
•
Number of curvatures
•
•
Rolalion
Constiluliona/ fac/ors
• Typ budow'j
• Wiotkosé tkanek
• Psychika dziecka
• Oczekiwania rodzicôw
• Przeciwskazania do operacj i
• Tissue lalOly
• Psych%gy of the chi /d
• Parenls' expectances
•
Contraindications for surgery
T. Kotwicki / 3
-
Definicja
Definition
• ROzwa]OWl3
zniek.s.l.tatconte
krl(lgoslupa Ilulo",,"
• przyc:zyna schornJnl.
lesi niernana
•
DeveloptJ1enlal
deformll)' allhe
splne and the lI\Jnk
• UkI'IO'M"l cause
• Charakler delonnacji
Inil Ir6/flIaszczymowy
•
• K'l.1 na radiogromuJ:
wynosl co nalmnlel
• Mtmmum Cobb
• poga,.za IQ
3-D deformllY
angle 10
W
okresaoh sl)/bklego
\VZf8s1an ia krQg:oslupa
•
Progression ratat
10 rap ' groWlh
Patomortologia skolioz Patomorphology of scoliosis obrazowanie tr6jplaszczyznowe
3-D visualisation
.. ... t ...
T. Kotwicki / 4
3-D deformity
Galen - sco/losis - " boczne skrzywienie" ta jest
my1ttce uproszczenie
Galen - scofiosis - " Iateral deviation " Is a
misleading simplification
Tr6jpfaszczyznowosé
3-D deform ity
plaszczyzna czolowa - wy gi~cie w bok
plaszczyzna strzalkowa - zaburzenie krzywizn fizlolog .
plaszczyzna poprzeczna - rotacja osiowa kr~g 6w
---
\
-
. .ti.
coronal plane - lateral curvature
sagittal plane - disturbanee of physiologie curvatures
transver se plane - axial rotation
Trzy kolumny kr~gos+upa
Three columns of the spine
r
T. Kotwicki / 5
Skolioza i garb
• Rolacja osiowa
k r~g6w
Scolios is and hump
• Vertebral axial
ro tation
T. Kotwicki / 6
Dubousset : "garb wew n~trzny"
Dubousset: "internai hump"
Th 8 E.ll'CtiOn in f\on r,:a l
Subl~t
Th 8 {ertKln JI:
50 ~
5COU01:ii:
Dubou sse t : "garb wewn ~trzny"
Dubousset: "internai hump"
Sk",)na IordolyzaCja Kni goslupa p,erslowego . ktory wypel ma klalkç ple rsio wa.. VC=24 %
Extreme tnoradc lordosls, sp ln a occupies thora cie cage, VC =24%
P6i:ne powiklania sercowo-plucne LaIe cardio-pulmonary complications T. Kotwicki / 7
EDUCATION MEETING, SATU RDAY, 8th of APRIL 2006
Patomorfologia skolioz - wnioski Palomorphology of scoliosis - conclusions , . Zmmejszanoe six fizjologicznej
kilnzy
pîllrsiowt!j~esl
slal;j cecha
progresuj",csj sk,ozy p<erslowel .
1 . Decreasing 01 physiologieal
thoracic kyphosls is a conslant
find/ng in progressive tMrsclc
seo 10516 .
~.
3-D scohoSis corec1,on
necesslles 19.10"ng of
~callhorac,c
OS'5. 3 Inlensywne éwicz.enlB wzmacniania dlugich mi~snl grzbietu dziala)", QQ
po deciW1e
u ordozy kieru u
pogleblanra derormaql
cirerae luku wSkOIlOZ;&1
ru
Zabl okowanie iul190slupa plersiowego w lordotycznym ustawieniu - bl~d ' Thoracic splne blOCked in hypokyphosis - errar
1
Funkcja przestrzeni odcii\zaji\cych
Importance of free space
pozycja swobodna
reJaxed
wdech
breathing in
T. Kotwicki / 8
Funkcja przestrzeni odciê\zajê\cych
Importance of free space
pozycja swobodna
relaxed
wdech
breathing ln
rozpoznawanie
pozycja le~ca
supine
diagnosis
skoliometr
scoliometer
T. Kotwicki / 9
EDUCATION MEETING, SATU RDAY, 8th of APRI L 2006
Badanie w skJonie ma najwi~kszct czutosé
Adams forward bending test is most sensitive
Skoliometr mierzy kqt rotacji tutowia KRT
Scoliometer measures the angle of trunk rotation
ATR
Interpretacja badan ia skoliometrem Interpretation of scoliometer exam • 0-3 0 - fizjo logiczna
asymetri a tulowia
• 0-3 0 - physiologie
trunk asymmetry
• 40 _6° - powt6rzyé
badanie za 3 mies.
• 4°_6° - repeat exam in
3 monlhs
• 7° i wi!i!eej - skolioza ,
do speejalisly
• 7 or more - seoliosis ,
10 speeialist
T. Kotwicki /10
EDUCATION MEETING, SATURDAY, 8th of APRI L 2006
Skolioza i sport
scoliosis and sport Nie zwalniaé chorych ze skolioZé\ z zajqé WF Do not dispense puplls trom school sport Iylko 7 % spoleczeristwa polsklego ragulam ie uprawla sport
7% o oly 01 pollsh population praclise sporl regularly
70 % w kriljach akandynawskich
70% in scandinavian counlrles
Pierwsze badan ie dziecka ze skoliozq
First exam of a child with scol iosis
• Czy to jest skolioza
strukturalna ?
• Is it structural
scoliosls?
• Czy to jest skol ioza
idiopatyczna ?
• Is it idiopathie
scoliosis ?
• Jakie jest ryzyko progresji ?
• What is the ri sk of
progression?
T. Kotwicki / 11
skolioza funkcjonalna
functional scoliosis
dZiewC2:. 12 laI , nie leczona, stwlerdZono progresjf1. zaJecono
o peracj ~ 12 y. girl , no trealment , corlSiderecJ progressive. 8clvised to undergo
surg e ~1 Leczenie - epifizjodeza chrz<tstki nasadowej kol ana prawego Trealmen l - right knee distal lemoral eplphysiodesis wklad ka Ikd 2.5 cm
2. 5 cm under lell fool
Wniosek Z omawianego przypadku: Conclusion tram this case: Badaé pacjenta Examine the patient T. Kotwicki / 12
EDUCATION MEETING, SATURDAY, 8th of APR IL 2006
Historia naturalna nieleczo nej skoliozy
Natural history 01 non-treated scoliosis
Lon stein i Carlson J Bane Join t Surg 1984; 66 -A: 106 1- 1071 • oraz test Risse ra
o lub 1
• Sco liosis trom
20° to 29 0
• an d Risse r test 0
or 1
.68%
progresuje .68% progressive
• Skoliozy od 20°
do 29°
s. Weinstein, 1. Ponseti J Bone Joint Surg 1983 j 65-A: 447-455 JAMA 2003; 289: 559-567 • 102 chorych ze
skoliozq
• 102 patients wilh
scoliosis
• 50 lat obserwacji
• 50 years lollow-up
• Cobb < 30°
• Cobb < 30°
• Stabilne przez
cafe zycie
• Stable throughout
the lite
T. Kotwicki / 13
cel leczenia nieoperacyjnego
objective for conservative treatment
Uzyskaé kélt < 30°
po zakonczeniu
wzrastania
Cobb < 30°
after pubertal
growing phase
Leczenie operacyjne mote byé konieczne Surgery may be necessary Nie odwlek aè jesli prog resja Do not delay il progression Matka nie operowana, c6rka operowana
Mother not treated , daughter operated
po operaCjI
aller surgery
T. Kotwicki / 14
EDUCATION MEETING, SATU RDAY, 8th of APRIL 2006
Skoliozy wrodzone progresywne - operacja
Congenital progressive scoliosis - surgery
skolioza w neurofibrom atozie - operacja
scoliosis in neurofibromatosis - surg ery
Podsumowanie
Conclusion
• Co leczyé ? W hal ta treal ?
Skolioza a wada postawy
Scoliosis vs postural curves
• Kiedy leczyé ? When ta Ireat ')
W okresie zag rozenia prog re sjl\
Wh en risk of progression
• Jak leczyé ? How la treat ?
Trôjplaszczyznowl\ korekcj1t
With 3-D corrective methods
T. Kotwicki / 15
"Ruch Jako czynnik leczenia"
1963
~
'"
profesor Wiktor Dega
. Rueh m~ . i byé prm piuny li! wszyslk imi
szcze g6/Qmi, po cJobn ie ja ~ tek. LDklOm
motna wylllC'zyé. tecz laide :rarru~ . (...]
Podan!e IlIkJego tek~ wym8 !}lJ
pra wdzJwego mistr:wsfWII. PmJkazanie go
choremu W r.ll Z o s "b owo~c/~ 1 .o,cern czyn;
ten leh
nieZlJs~pio flym . "
Th e moveme nt should be prescribed with ail details. as a mediclne.
A me dicine ca n either cu re or poi son .
Mastership is to apply su ch a med lclne. Oellver it to the pati ent w it
heart an d passIOn makes al1 irrep la ceab le trea tment.
T. Kotwicki /16
Progression of Scoliosis during pubeny - making therapeutic decision - Je de Mauroy
page 3
PROGRESSION OF SCOLIOSIS DURING PUBERTY . MAKING THERAPEUTIC DECISION Jean Claude de Mauroy
There is a consensus ra begin an Orrhopaedic Conservarive
T'rearment when the Cobb's angle of rhe scoliosis exceeds 25°
concerniog children and reenagers.
The firring of a nighr brace, besides irs cosr for rhe society, invo\ve
some physical and psychological consequences on rhe growrh of
rhe child.
This rrearmenr enables a srabilisarioo of rhe Cobb's angle of
scoliosis bur is far from allowing rhe rerurn of a recrilinear spine.
(failure of rhe objecrive zero)
The earlier and earlier screening of sco\iosis leads ro the facr
that one may see in consultation man)' curves whose angulation
are compound between 10 and 25°, and for which one is nor
sure about ifS evolution . Thus, concerning a scoliosis of 15° for
instance, rwo ways of reacring are possible:
- A preventive rrearmenr as saon as rhe scoliosis is discovered,
wich a risk of bracing for a scoliosis which is noc evolucive.
- Waiüug unril a worsening co 25°, knowing chat ic is bercer ra
scabilize a sco\iosis ac 15° rhan ac 25°.
The recene use of che chaos cheory enables us co be more precise
about our cherapeucic scraregy and che Buckminsrer FulJer's
biomechanics concepc of the tensional inregrity allows us co be
more precise abouc prorocols.
0
l."Wh.at is the role of lateralisation in the occurrence of a
scoliosis?
The homo habilis's developmene of speech 2 millions years ago
made rhe (wo hemi-brains asymmetrical and had for consequences
the fàcc thac 90% of homo sapiens were right-handed and 10%
lefr-handed.
The onragen)' reproducing the phylogeny, chis Iateralisation arises
when a child is about 7, when he begins [0 hold the righc hand
spomaneousl)' and when he walks on two legs and acquires an
adult gaie. This is also the mo ment when his sagirral morphotype
is constitute.
Before che age of seven, che thoracic scoliosis are spread half ou
the right side, half on che lefr side.
Mer che age of seven, [he cUI"Ves are right thoracic in 90%
cases, lefr-handed ofren shows left thoracic scoliosis. Thus it
is not the asymmeuy of organs (heart, leaver), but the brain
asymmetry which is conditioning on which side the scoliosis
will cake place. (figure 1) The puberty growth is also an homo
sapiens characteristic, in SCt he grows of25cm during a few years
essentially at the sp ine Ievel.
This is during this puberry growth that most of the scoliosis will
be discovered. This growth which is raking place essenrially at the
verrebral body level, is sIowed by ligaments, muscles, and fascias.
The "slowing clown" asymmerrical ma)' explain the developmenr
of a scoliosis. When there is no slowing down, as what can be
observed in Martàn's disease, we notice mljor modifications in
the bone structure most of them in l sagit(al plan.
2. What is the role of asymmetry in the evolution of a scoliosis? The spine is working as a tensional integrity system wirh a
bone srructure in a disconrinuous compression and a muscle
lnd lig:llnenr srructure in a conrinuous tension . The tension al
ineegrity explains the fact clut the movemenr of the spine is omni
direcriolul . In a period of quick growrh, this system is more used
lnd one can compare a scoliosis with l car whose brlkes would
not be halanced.
Thus the plasrer cast will play tbis role at the beginning of the
creacmenr: ic will balance clIe lig:llI1em tensions herween convexity
and conc:1vity. The growlh tlking place mosdy at night, the
conservJtjve rreatmenr ma}' be nocturnal for :1 scoliosis whose
angulatio n will be inferior co 30°.
3. Is it possible to foresee the progression of a scoliosis?
Ir is generaUy admicred, thlt rue origin of a scoliosis is mulci
fac corial.
onsidering the scoliosis which are caused by a poliomyeliris,
Mrs Duval Beaupère has described a progressive curve affin/! by
parts with two points of inflexion: the firsc one is localised at the
beginning of the pubeIty growth, the second at the maturir)' of
the bones. (figure 2)
This concepc doesn't fit for idiopathic scoliosis. In f.1Ct, clIe growth
is IlOC liue:ll' between the age of 11 and 15 years old and the first
poim of infk.xion happens frequendy in the middle or at the end
of the pubeny growth.
Lower than 25° of Cobb's angle, the evolution of a scoliosis can Ilot be foreseen, that is ro sa)' that one minor elemem may Iaunch a major scoliosis which is likely co progress, thus one ma)' ralk about a dererminist chaos. Beyond 25°, there is a biomech:ll1ical progressive vicious circle. Admirring a fromal plan, the apical vereebra moves away from the gravity line, which is increasing considerably the concave pressures, it's called the vertebral balance. (figure 3) Admirring an horiwneal plan. an apical rOtation more than 25°, emails aucomatically a worsening of the scoLiosis during the fo[\vard bending of the trunk. (figure 4) Considering the Wolf and Delpech Iaws, during (he period of grovv'th, the conClve hyperpression, slows down the bony growth and contributes thus the cuneiformisation of the apical vertebra. Admic[ing a sagittal plan. the Rat back diminishes the spi ne resistance and a "buckling~ phenornena still accemuates the evolucion of the scol1osis. 4. Are there sorne clinical or radiological signs to predict
a progressive scoliosis?
No. If one knows the c1inical and radiological signs characterising
Clinique du Parc - 84 Bd des Belges 69006 Lyon - www.demauroy.net
Progression of Scoliosis during puberty - making rherapeuric decision - Je de Mauroy
['arricu[é temporo-mandibulaire ou d'un pied plat, il faudra
rraiter chaque symptôme séparément sans avoir la prétention
de corriger unt: scoliose par un traitement orrhodontique ou des
semelles orthopédiques.
2. Pour une scoliose de 15° par exemple, il faut avoir conscience de l'imprévisibilité de cerre scoliose et en informer les parents, afin d'éviter deux arritudes rotalement opposées : - rassurer à rorr ce qui pourrait abolltir à l'absence de surveillance et de contrôle, - inquiéter à tort en mettant en place un corset préventif inutile pOUf des scolioses non évolutives, comme cela a été le cas dans certains schoo[-screerung aux Etats Unis. 3. Il {l'existe pas de traitement préventif de la scoliose, par contre dans certains cas, nous pouvons être amenés à effectuer un traitement précoce. 4. EXISTE-IL DES ÉLÉMENTS CLINIQUES OU RADIOLOGIQUES,
POUVANT
JUSTIFIER
UN TRAITEMENT PRÉCOCE POUR UNE ANGULATION COMPRISE ENTRE 10 ET 25° ? Oui. Cassociation de deux prédicteurs peut justifier un traitement précoce : - familiarité au premier degré (frères et sœurs, oU parents présentant une scoliose de + 25°) - évolution de plus de 10° par an, - courbure lombaire ou thoraco- Iombaire, - syndrome du dos plat avec cyphose inférieure à 10° - rotation de plus de 25°, ou gibbosité de plus de 25mm au niveau thoracique et 15mm au niveau lombaire, ). QUAND ET QUELLE REEDUCATION PRESCRIRE ?
La kinésithérapie ne freine que très peu l'évolution d'une
scoliose idiopathique en période pubertaire. Cévocation de la
théorie du chaos permet de mieux faire percevoir la place de la
kinésithérapie. Si l'on peut assinüler l'évolution scoliotique à un
autre phénomène chaotique td que le tremblement de terre,
Scoliose thoracique gauche chez un
gaucher
la kinésithérapie constitue une construction anti-sismique qui
n 'empêche pas le tremblement de terre, mais qui en limite les
effets. Si la scoliose évolue malgré la rééducation, cc nc sera pas la
fàute du kinésithérapeute.
Notre protocole prévoit de débuter systématiquement [a
kinésithérapie dès le premier bilan d'une scoliose structurale,
supérieure à 10°. Il s'agir essentiellement d'une prise de conscience
de la position du rachis dur~uH les gestes de la vie quotidienne et
notamment en position assise et éventuellement d'une correction
posturale.
Par la suite, cette rééducation sera éventllellement poutsuivie
en fonction de la symptomatologie clinique: raideur, asymétrie
musculaire, troubles de l'équilibre ...
Nous avons vu en biomécanique que la scol,iose s'accentuait lors
de la Aexion du tronc en avant, i[ faudra donc veiller à limiter
cette Aexion antérieure dans les gestes de la vie quotidienn e et lors
de la pratique du sport.
La kinésithérapie est systématiquement associée à la réalisation
d'un traitement orthopédique conservateur.
En conclusion,
[indication d'un traitement orthopédique conservateur pour
une scoliose inférieure à 25° est sans dout l' un des actes les plus
délicats pour le spécialiste. Nous avons bien conscience du regard
réprobateur de la maman lorsque nous démarrons le traitemem
après aggravation alors qu'elle nous avait montré l'enfant six mois
auparavant.
Il faut bien expliquer cene difficulté aux parents lors de la
première consultation afin d'éviœr tout malentendu .
Cévo[urion d'une scoliose de moins de 25° est chaotique, il
n'existe aucun signe clinique ou radiologique permettant avec
exactitude d'affirmer le caractère évolutif de la scoliose, par comre
certains éléments permettent d'envisager un traitement précoce.
La rééducation n'empèche pas l'aggravation d'une scoliose
évollltive.
Loi de Duval-Beaupère
11 ans
Figure 1
page 2
Figure 2
--
' 13 ans
15 ans
Progression of ScoLiosis during puberry - making therapeutic decision - Je de Mauroy
progressive scoliosis, none of rhose signs is a crüeria allowing
ro make a prognosis . The only element which is srriking .From
compurerised srudies, is [he angularion abovc 35° during rhe
puberry growth which corresponds ro rhe vicious biomechanical
circle rhar we have already menrioned.
5. In practice, what are the consequences of the
application of the theory of chaos?
1. The rreatment of a scoliosis may only be sympromatic. One
;;- not going to hunt butterflies in Bl'azil to escape ftom the Texan
Tol7lfldo. If the scoliosis is accompanied by a physical defect of the
temporo-mandibular joint or a Bat foot, one have to treat each
symptom separa tel y without wanting ro correct a scoliosis by an
orthodontie rreatment or by orthopaedic soles.
2. Considering a scoliosis of 15° for instance. one must be
conscious of [he unpredictabiliry of the scoliosis and ro inform
the parents about thar, therefore one must avoid twO drastically
opposed attitudes:
- reassure with no practical basis and this could Icad to no
supervision and no control,
- worry wirh no practical basis by fining a preventive brace which
is useless for a non progressive scoliosis, as it has been do ne in
some school-screening in the United States.
3. There is no prevemive trearment tor scoliosis, bur in sorne
cases, one may be lead to make an early treatment.
6. Are there clinical or radiolo~ca1 elements which can
justify an early treatmem consldering an angulation
compounds between 10° and 25°?
Yeso The association of MO predictive dements may justify an
carly trearment:
- familiarities concerning siblings, or parents who have a scoliosis
more than 25°.
- evolution of more than 10° each year,
- lumbar curves or thoracolumbar curves
- syndrome of Bat spine with a Kyphosis inferior to 10
- rotarion more than 25°, or gibbosity more tnan 25111111 at the
rhoracic lcvel and 15mm at the lumbar level
0
7.When and what physiotherapy should one prescribe?
The physiorherapy is on ly slowillg down a lirde bit the progression
of an idiopathic scoliosis during puberry. The evocarion of
rhe theory of chaos let in a netter way perceive the role of the
physiotherapy. If one can assimilare the progression of a scoliosis
ro another chaotic phcnomena as the earthquakes, physiotherapy
may be cOllsidered as an aIHi-seislllic building which doeslù
prevent from earthquakes, but which is limiring the negarive
effects. If the scoliosi~ is progressing in spire of rehabilitation. it
will IlOt be the physiotherapist fault.
Our prorocoI foresee ro begin sysrematically physiotherapy
for the first checkup of a structural scoliosis, above 10°. Ir is
essemially about being conscious of the place of the spine during
the everyday gesrures and especially while sitting and eventually
in a postural correcrion.
Following, rhe rehabiliration will be evemllally cominued
according of the c1inical sympromarology: straightness, llluscular
asymlllerry, troubles of balance . . .
Ir has been seen in biolllechallicai rhar scoliosis would increase
during the forward bending of the [funk, one must be careful
ro limit this <lnterior flexion in everyday gestures and while
practJcll1g sports.
The physiotherapy is systematically associated to rhe realisa[ion of"
an orthopaedic conservative trcatment.
Conclusion,
The indication of an orthopaedic conservative tl'eatmellt làr
a scoliosis Jess than 25° is without any doubtl' one of the most
delicate act jà,· a specittlist. ~ are all aware ofthe accusative look
ofthe mothe/' when we start a tl'eatment after aggravation ofthe
scoliosis even ifwe have sem the child 6 momhs before.
This difJiculty has to be explaÏlled to the parmtl' dllrùlg the first
appointment in 01""'" to avoid any misunderstood.
This evolutiOIl of a Jess than 25° scoliosis is chaoûc, there are
no clinical or radiological signs al/owing to affirm precisely
the character progressive of the scoliosis, 011 the other side sorne
elementl' allO/v to view an early tl'eatmeut.
The rehabilitatioll does not prevent the aggravation of a
progressive scoliosis.
Contraintes dans le plan Frontal
>". ~
Hypersolllcltiition de la
musculature convexe pour
maintenir l'éqUilibre
La déviation de l'axe
OCCipital et de la ceinture
scapulaire diminuent la
contrainte en cas
d'Insuffisance de la
musculature
Figure 3
page 4
Figure 4
IIisloryczny pru ghld nieoperacyjnyc.h mctod Iccr.cnia skoHozy . Obowil1zujqcy algory tm post'tpowan ia. fŒ"ik:. Chiruq:.ii Kntl!.u~lup" , Orlujlnlii i TrOlUl11atllltlj!.ii
Andrzl'j Nowakowsk i
~------------------------~ llipokr atcs - 460 p.n.c.
Scamnum - Vid,us l..JI:u·y:i:a opis l ru ku IS54
d)'slrakcjfl .. zdluzna
Ambroi)' Parc - 1550 r.
Gorset I11ctalow)'
Piotr j Mikolaj Scottowie - Utrecht
(lata l'içùJzÎcSÎ'II< XVII w .)
-rndzaj Illclalo",ych ",.kk
A. Nowakowski / 1
EDUCATION MEETII\JG, SATURDAY, 8th of APRIL 2006
Levachar -1764 r. - Paryi:
rndoda mnszlu lub prçgierza
glow~ umoiliwia chodzenia
wyci'lg la
Venel - 1776 r. - Orbe Szwajcaria
liiicczko wyci;'lgowc
Lewis Sayre -1814 r. - Nowy Jork
Kor~kcja
wzùluina + opatrunek gip!iOwy
Bradford i Brackett - 1895 r.
rama wyciqgowa (fiNitlokalizer cast)
-4~
~!1lr~
.
..
"
\
.. .,=
.
~
•
.!>
~.J~ i
A. Nowakowski / 2
Joseph Risser - 1937 r. - 1952 r. - Passadena
- dYSIr.1kcj" + uci,k bouny
- gips kort!kcyjn}' (l urnbuckle wedging cas!)
Yves Cotre.l - 1965 r. - Berg sur mer
gorscl ED F(elong:llion, dcrol al ion. rIni" !:lIe ralis)
kon c(': llcj a Ri se ra rOl.sz.tl'.tunU 0 korekcj ç rotilcji
(s161 C Ol re la)
Walter DIou nt i Albert S,hnùdt - 1946 r. Milwaukee
sku ttcm) gOrsl" '" niC'll1l' racyjnym ICCll'lliu
bounych skr.tyvdc.n krç-goslupa
A. Nowakowski / 3
Lata 1960 do 1970
- gorsct CTLSO
John Hall - 1975 r. - Boston
- gorsct podramienny TLSO
Poc74tkowy entuzjazm leczenia gorsetam i
ni e zawsze byl uzasadniony
-skrzywienia szkieletowo-niedojrzale
przekraczaj:!ce 50°
Aigorytm
post~powania
nieoperacyjnego
A. Nowakowski / 4
EDUCATION MEETII'JG, SATURDAY, 8th of APRIL 2006
Og61ny plan leczcnia u rosn:tcego dziecka
- obselwacja pod l'lltem ewentualnego
post~pll skrzywienia
25° do 30° - przy udokumentowanej progresji
wdroienie leczenia gorsctowego
30° do 40° - natychmiastowe podjçcie leczenia
gorsetem
40° do 45° - szara strefa
Nicktôrc typy gorsetôw stosowane obecnie w
leczeniu nieoperacvjnym skolioz idiopatycznych.
- CTLSO ( œr\'ico-thoraco-lumbosacral-orthosis)
- gorset Milwaukcc
- TLSO (thoruco-Illmbosacral-orthosis)
- gorsct podramicnny (Boston)
- Cheneau (Chencau TOIIlIIsc - Münster)
- Wilmillgton
- Charleston
- Providcnce
- Garchois
- Spine Cor
Wiclo~é
r6inych typùw
stosowanych gorsctow wskazuje,
i.e zaùclI z nich nie jest wystarczajqco
skllteczny w lcczenill nieopcra cyjnym skolioz
Kazdy z nich ma
odrçbll~
charakterystykç
i spcC)'ficzne wskazania.
r
A. Nowakow ki / 5
EDUCATION MEETING, SATURDAY, 8th of APR IL 2006
Wq,eSl1ie zaq,llna;qca siC! skolioza
- przet! 5 rokiem ivcia
- opatrunek gipsowv EDF (elongatio, dcrotatio,
Ilcxio lateralis) skrzywienia > 30° - umiarkowana
korekcja w opatrunku gipsowym w skoliozie
wczesnodzieciçcej a n8stfpnjc kontyouacj8 leczenia
gorsetem W okresie dziecinstw8 i mlodzicnczym
P,JÙw 7.l/cz vnajqca sie skofiozn po 5 rokll ll'cill
( do okre.S.rt wzroslu pok",itall;o wego - pllberly (TI/1111er II).
- dobra prognoza leczcoia gorsetem w skrzywieniach
< 35° i RVAD (rib vcrtcllraJ angle difference) < 200
- zia prognoza W skrzywieruach > 45° i RVAD > 20° Zia progn oza dlll stosowanill gorsctu nie znW!lze i
nickonicc:t.nic
o~naall
bez7.,~l uc zlI ~
inlc rwcncjç
chir ll rgicz n~ .
• l)obru dupüsowllny gorscl moie przyham olVaé po ·tç p
IIU
skrzywicll ia
pOlwlll aj1lc
krçgosl upa ploud wykon anic lll
opcr ocyj ncj i uS7.lywnicniu .
dodat ko wy
wzrost
OSllIlcczncj ko rckcji
OpMnicllic /cclcnia opcra cyj nego pomimo poslçp ll
skrzywicnia na wct d o 55 i 60° pozwala na uzyskllnic
le pszcj dojrLalosci kost ncj i przl'suni çcie ope rllcji do
o kolo 10 rokll iyCÎll.
A. Nowakowski / 6
Ogolny schemat leczenia gorsetem
gorStl ",. pdnym ""-ymiane godzin -23 golizillY na lJobç (fulllimd
1
kllnlrulo skrl.vwLcnia
1.
"
slosuwanil'l;!ul':"du w skr{K:on)'1ll wymiaru gudzin (P.3rt lime)
./
1
klmlmlnwanic !ikn.\'wicnia
gnrset p.ul timl!
.-:-
dojn..a losê Illciowa
kontrolowane sknywicnie
(pubUh - TJJnnt'r Il)
gurwl full lime
/ .
kOIl(rolowanc skn.ywit'ule
1
J!orsct fuiltillll!
.,/'
----
POSf(P skn.ywienia
'--....
d;llszy postrr skrL)'wicnia
1
IL"\,-œnie nperacyjnc
pOSlfP skn.ywienia
(dals~e stusnw:mil' g:nnitln)
J
pnwni( du gursc:tu
(ew. Icucnie chiruf'J.:kl.nc)
Podsumowanie
Konieczna wiedza
0
przebiegu naturalnym sknywienia
- PolwienJzono zJlacz~co lepSlC olhlzialywanie gorsetu "_l wolno
postçl'uj~ce sknywienia
- Skn)'wienia rozpoznanc pneu okrescm pokwitllnia 0 wartosci k<ltowej
< 30 Cl
-
rokujlt w prl.)'szlosci pnnnJopoLlobienstwo operacji w 15% > 35'do 45 ' -
rokuj~
w przyszlosci prawdopodobienstwo operncji w 60 'X} i wiçcej > 50'do 60 ' - I)'z}'ko operu9jne pnekracza 90%
A, Nowakowski / 7
- Skrzywienia 0 znacznym potencjale
progresji nje reagujll nn inden
gorset
éwiczenia lizyczne
nic odg rywaj ll iadnej wiçkszl:j roli w leuen iu
skolioz)'
(l OSlçpuj~c-cj
• zapew nlllj q ODe wprawdzic ogol nic ICpS7,Jj ko ndycjç
ps choflzycznll (co Je -1 bard;w wazne) nie zlIIieniajll
j cdnak przebicgu uaturnlnl!go sknywicniu
• w przypadku kiedy ch ory ju ;' no i gorsct 10 dobne
dobrllny i rCllli7.ownny prognlln éwiczeil jcsi obo\\ illzkowy
- Elektryczna stymu la cja miçSni pO wypuklej
stronie skrzywienia LESS (Iateral electrical
surface stim ulation) okazala si~ metodl!
nieskutecznl!.
A. Nowakowski / 8
THE BRACE
~~
~--------------------~
State 2006
Result; on angles, rotation,
rib s..atic and vertebra
wedging.
~~
Introduction
• Do tor Jacques Chêneau, France.
• Doc or Gudrun Engels, Germany.
• Herta ennani , Technician, Germany
• 1912. ABBOn
• BASED HIS PLASTER
CASTS ON BENDING ,
TRACTIO NS AND
LATER AL PRESSURES,
PLUS HUGES FREE
EXPAN SION SPACES;
HE GOT
HYPE RCORRECTION EVEN IN ADUL TS J. Cheneau /1
Periodical adju tment is nece sary,
~tly con ' idting in giving place,
even \n concave sides, or (here) OD
\
breast .
J. Cheneau / 2
~
ain prÎllciples :
4 Passive
1.1 Chenoy stone effect;
.2. migratio n of a s lice of tissues ;
1 3. clamp on greater diameter of
th rax;
l.4.bending
5 Act LVe 2.1.
Growth; 2.2 . respiratio
2.3 .l lovements; 2 .4. secondary pressur
pad n R. front thorax ; 2.5. anti
gravi' tionnal effect.
-n~
CHERRY STONE
EFFECT
'~
1
1.2.
ELECTIVE TISSUE TRANS FER CONVEX CONCAVE J. Cheneau /3
EDUCATION MEETING, SATURDAY,8th of APRIL2006
1. 3. CLAMP GREATER
~IAMETER OF THORAX;
\
1.4. BENDING
1
2.4
Se ondary
pre sure part
7+19_5
See
later
(active
aCLion)
1.4. BENDING 2.5. ANTI
VITATIONNAL EFFECT
See later
ACTIVE ACTIONS
2.1.
GROWTH
J. Cheneau / 4
ACTIVE ACTIONS 2.2. BREA TIllNG VE ACTIONS
2.3. MOVEMENTS . . Anterior brace wall
2.5. A . ti-Gravitation Effekt
(Î1readY seen)
J. Cheneau / 5
ROTATION
(
'<..7"1-
WEDGE
RESULTS
Cobb . (But only 26 curves, 21 _58°)
revious 38° Br. 15,96 =58%
R tat.
14.5 BI. 7,33 = 49%
Rib static «
15.86
8.29 = 48%
Wedges
15.92
6.19 = 61 %
<
J. Cheneau / 6
40 . , . - - - -
35
30
25
20
15
10
5
o
Cobb
Rotation
Rib statie
wedge shape
DISCUSSION
Cobb :
Great in itial angle, 38°. Bettering 58,3%
Previous treatment. But few cases.
Noti e. Pression where rib s vertical, makes
Ihem less vertical.
Wedges
Meas rment chan ges with incidence
> 60 bettering
J. Cheneau / 7
CONCLUSION
BRA
S ARE EFFICIENTS
Mos
important action:
BETTERED
(= cl anges of bones)
J. Cheneau / 8

WORKSHOP AND EDUCATIO MEETING

Transkrypt

Podobne dokumenty