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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. Contents. What is Scoliosis? Medical Management Pre Operative Planning Hospital Admission Challenges post discharge.
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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
Contents • What is Scoliosis? • Medical Management • Pre Operative Planning • Hospital Admission • Challenges post discharge
What is Scoliosis? • Complex three dimensional deformity where the curve is greater than 10 degrees
Prevalence of Neuromuscular Scoliosis • 20% of children with Cerebral Palsy • 60% of children with Myelodysplasia • 90% of children with Duchenne Muscular Dystrophy
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)
Initial Assessment 06.02.2007 14yrs 6mth 66 o 108 o Pelvis ? o S.G., ♂
Progression of curve – 4 months 06.02.2007 14yrs 6mth 26.06.2007 14yrs 10mth 66o 58o 108o 122o Pelvis ? o Pelvis 34 o S.G., ♂
Preventing Progression of Scoliosis • Prolong mobility • Steroids • 24 hour postural management • Spinal bracing (not always effective particularly in progressive neuromuscular curves)
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
Initial Spinal ClinicAssessment • 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
Medical Management • Dependent on: • Severity of scoliosis • Pelvic obliquity • Age/Skeletal maturity – risser grade • Rib deformity/ Impingement/ Pain • Complexity of past medical history
Medical Management • Cardiac • Respiratory • Anaesthetics • Neurology/ Neurosurgery • Endocrinology • GI
Medical Management - DMD • Respiratory Function • Functional Ability • Symptoms • Quality of Life questionnaire • Reduction in surgery
Medical Management - CP • Respiratory Function • Functional Ability • Symptoms • Quality of Life questionnaire • Surgery
Medical Management - mylominingecele • Respiratory Function • Functional Ability • Symptoms • Surgery
Medical Management • Every case is very individual • Function • Medical Stability • MDT decision
Medical Management • Continue to monitor curve • Use of conservative treatment • PSF
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
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
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
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
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
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
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
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!
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
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
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,
Hospital Admission • Usually admitted the day prior to surgery • Introduction/assessment by inter-disciplinary team • Discussion of post operative management
Operation – Posterior Spinal Fusion 20.09.2007 15yrs 1mth 40 o 62 o Pelvis 6 o S.G., ♂
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
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
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
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
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
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
School • ASL Profile provided • Return to School – graded • School seating • Desk height/ position • Hand function – writing skills • Manual handling/hoisting • Toileting • Feeding
Challenges after Discharge • Home Environment • Mobility • Self propelling wheelchairs • Change to Physiotherapy Program – Hippotherapy, Rebound etc • Feeding • Family Support • Transport • Holidays • Anxieties
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