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Objectives:
A. Integrate a postural screening exam into a standard physical exam.
B. Recall the differential diagnosis for patients who have various postural abnormalities, including
kyphosis, lordosis or scoliosis.
C. Recognize the indications for screening exams for scoliosis.
D. Recognize the indications for radiologic exams related to posture and know which tests to order.
E. Recall first-line interventions for postural abnormalities once they are identified.
F. Identify sacral-base unleveling.
G. Apply heel-lift therapy for patients with sacral base unleveling
H. Using a postural-balance model, identify which muscle groups are prone to weakness and which ones
are prone to tightness.
I. Design a simple home exercise program or physical therapy prescription for patients who have postural
abnormalities.
A. Integrate a postural screening exam into a standard physical exam.
C. Recognize the indications for screening exams for scoliosis.
Be sure the foundation is level and all will be well. -A.T. Still, MD, DO
A full standing postural screening exam (SPSE), which includes a screen for scoliosis, should be a part of your
standard complete history and physical. This exam can be performed in about 2 minutes. How and when a
physician chooses to perform this exam is variable, but it is recommended
that you perform it regularly in the same order. Dr. Gustowski performs
this exam first, as part of the transition of the patient sitting in the chair to
sitting on the examination table.
The state of Texas mandates that spinal screening for scoliosis be
performed at 6th and 9th grade. You can find out more at this website:
http://www.dshs.state.tx.us/spinal/spinalguide.shtm
The intention is to identify adolescents
with small spinal curves and refer them
for treatment before these curves
become too severe. Literature does not
support or refute the usefulness of this
screening exam. Scoliosis is present
when there is a rib hump. There may be
1 or 2, depending on if the curve is C- or
S-shaped.
INFANTILE
Birth to 3 yr
1:1 to 2:1
Incidence
Curve types
Associated findings
Risk of
cardiopulmonary
compromise
Risk of curve
progression
JUVENILE
4 to 9 yr
<6 yr: 1:3
>6 yr: 1:6
United States: 12%-15%
Great Britain: 12%-15%
Right thoracic
R:L (6:1)
ADOLESCENT
10 to 20 yr
1:6
None
None
Intermediate
Low
67%
23%
Curve resolution
Curve magnitude and
maturity
Orthotic management
Surgical treatment
Risk of crankshaft
Gradual progression: 2 to 3
degrees/yr
Malignant progression: 10
degrees/yr
<1 yr: 90%
>1 yr: 20%
Gradual progression: 70 to
90 degrees
Malignant progression: >90
degrees
Effective at delaying and
slowing rate of progression
Ultimate progression: 100%
Instrumentation without
fusion <8 yr
After 8 y: ASF-PSF
After 11 y: PSF
High
Progression at puberty: 6
degrees/yr
Malignant progression: 10
degrees/yr
20%
1 to 2 degrees/month during
puberty
Progression at puberty: 50 to
90 degrees
Malignant progression: >90
degrees
Decreases rate of progression
until puberty (failure rate: 30%
to 80%)
Instrumentation without fusion
<8 yr
After 8 y: ASF-PSF
After 1 y: PSF
High
Rare
Modified from Mardjetko SM: Infantile and juvenile scoliosis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia,
1997, Lippincott-Raven.
Scoliosis also can be classified based on the etiology and associated conditions. Idiopathic scoliosis is the
most common type seen, but the exact etiology of this type of scoliosis is not known. Congenital scoliosis is
caused by a failure in vertebral formation or segmentation of the involved vertebrae. Scoliosis also can be
classified based on associated conditions, such as neuromuscular disorders (cerebral palsy, muscular
dystrophy, or other neuromuscular disorders), associated syndromes, or generalized disease
(neurofibromatosis, Marfan syndrome, bone dysplasia, tumors, or post irradiation). A distinction should be
made between early-onset and late-onset scoliosis because the deformity may affect cardiopulmonary
development. During childhood, not only do the lungs grow in size, but also the alveoli and arteries multiply
and the pattern of vascularity changes. The alveoli in the pulmonary tree increase by about 10-fold between
infancy and 4 years of age and are not completely developed until 8 years of age. Scoliotic deformity limits the
space available for lung growth, and children who develop significant scoliosis before the age of 5 years
generally have disabling dyspnea or cardiorespiratory failure.
Scoliosis
1:20 children develop some scoliosis by age 10-15, and
1:200 have symptoms.
The curve is amed by side of convexity. If kyphosis is also
present, then the curve may be called a kyphoscoliosis
Severity classification is based on an x-ray measurement
called the Cobb angle:
Mild = 5-15 degrees.
The use of a brace is recommended with curves
greater than 25. Literature regarding the use of
exercise, physical therapy or OMT is scant, but
those modalities are recommended
Moderate = 15-45 degrees
Surgery is indicated with curves that reach 45
Severe = >50 degrees
This degree of curvature can compromise cardiac
and lung function.
Causes of Scoliosis
Causes of scoliosis are divided into Congenital, Acquired or
Idiopathic. Between 70-90% of cases of scoliosis are
idiopathic- that means that no one knows the cause. However,
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OMT may be primary treatment in cases where somatic dysfunction is the cause
Idiopathic
No known cause= no definitive treatment. Rule out other causes (congenital and acquired). OMT may be
primary treatment.
NOT ON EXAM, but some food for thought: The metaphysical/alternative medicine practitioners relate scoliosis to The
inability to flow with the support of life; fear and trying to hold onto old ideas; not trusting life; lack of integrity; no courage
of convictions. For more information about metaphysical causations, try You Can Heal Your Life by Louise L. Hay, or
Anatomy of the Spirit by Carolyn Myss.
E. Recall first-line interventions for postural abnormalities once they are identified.
Up to 70% of the population has a short leg. (Hoffman Kent S., Hoffman Lorrie L.: Effects of adding sacral
base leveling to osteopathic manipulative treatment of back pain: a pilot study. JAOA 1994;94:217-226.)
Out of 1100 patients with an unlevel sacral base, leveling the discrepancy partially or completely alleviated
symptoms of 90% of the patients. However, disparities less than 9 mm (3/8 inch) seldom cause low back pain.
(Beal M. D.: A review of the short leg problem. JAOA 1950;50:109-121.)
Severe curves identified early in life require more aggressive treatment due to the associated
cardiopulmonary risks. Otherwise, treatment is based on each patients presentation, associated conditions
and desire for cosmetic correction (for self-esteem, etc.). There is no definitive treatment for scoliosis and one
treatment does not fit all. OMT can be performed in conjunction with other treatments. OMT is directed at
removing somatic dysfunction anywhere in the body to promote optimal
In addition to standard care, physical therapy and home exercise programs are indicated. Home exercise
programs may include home stretching & strengthening, weight training, swimming, yoga, pilates, tai-chi.
Exercises which are performed bilaterally and include the spine are best.
Osteopathic physicians are in a unique position to identify and treat scoliosis due to sacral- base
unleveling with a combination of OMT, home exercises, and use of a heel lift.
H. Using a postural-balance model, identify which muscle groups are prone to weakness and which
ones are prone to tightness.
The following is from: Robert Kessler, D.O., Department of Osteopathic Manipulative Medicine, 2010, Touro
University Nevada College of Osteopathic Medicine
Muscle Imbalance
An initial musculoskeletal injury causes hypertonic muscles. Hypertonic muscles:
have lower excitability thresh holds (facilitation).
become activated more easily during movements when they should not be active.
more powerfully inhibit their antagonists (Sherringtons law of reciprocal inhibition).
delay the activation of agonists in the same group, which are relatively inhibited.
This leads to improper firing patterns during activity. These effects are proportional to the degree of hyper
tonicity. The longer these adaptive patterns of facilitation and inhibition last, the greater the ceroplastic
reprogramming (engrains) of movement occur as coordinated between the central and peripheral nervous
systems. (hard wiring abnormal movement patterns into place)
Muscle Imbalance Results in:
Abnormal proprioception from the periphery, changing normal motor response.
Decreased range of motion.
Abnormal gait.
Unequal pressure on weight bearing joints.
Centralization of the adaptation but uncoordinated movements from the periphery.
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Region
Lower Extremity
Upper Extremity
Muscles prone to hypertonicity should be stretched. Muscles prone to inhibition (also called weakness) should
be strengthened. Stretch just up to point of pain- stretches should not hurt. Strengthen to the point of fatigue,
not pain. Keep good posture when exercising.
Case History to illustrate postural balance model
A 32 year old patient presents with chronic back pain. He was fine when he started medical school 2 years
ago but over the last 6 months he has developed a dull lumbar ache, which is worst when he first gets out of
bed or gets out of a chair after sitting for a long time. After a class he has trouble straightening up but after he
slowly stretches he feels better. He also has dull infrascapular aching and a frequent sub occipital headache.
The following are your findings from a Standing Postural Screening Exam and one reason why these
dysfunctions occur, according to a biomechanical/muscle balance model
Increased lumbar and cervical lordosis
The lumbar lordosis is maintained by the hypertonic iliopsoas, which causes a deep dull ache in the
lumbar area and a difficulty in extension (hard to get up from chair). This begins because he
habitually sits 14 hours a day, with shortened iliopsoas, and doesnt stretch. The deep, anterior
cervicals are inhibited while the superficial cervicals become hypertonic, leading to the neck moving
anteriorly, its lordosis increasing and hypertonicity of the suboccipital muscles , which must now
contract to keep the patients eyes forward
Increased thoracic kyphosis
Round shoulders
The latissimus dorsi, and pectorals become hypertonic leading to round shoulders and an increases
thoracic kyphosis.
Arms internally rotated
To allow the scapula to protract, the hypertonic pectoralis inhibit the lower trapezius and rhomboids.
Now there is instability of the scapula and the upper trapezius and levator scapula become
hypertonic to stabilize it.
Knees flexed
At the same time, the hypertonic iliopsoas inhibits the gluteal muscles.
You get hypertonicity of the hamstrings.
Flat feet
Reflexive inhibition of the tibialis anterior and peroneus longus and brevis cause flat feet.
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