Welcome, everybody. Thank you for joining us on a Saturday afternoon. Appreciate you all tuning in. I know it's 4 p.m. Right now we'd be out and about in Nashville, but again, appreciate you guys all joining in. So I'm excited to moderate this session today. My name is Aaron. I work at Vanderbilt University Medical Center. And so we've got some great speakers joining us and we'll be focusing on the topic of scoliosis. So I have no relevant financial disclosures. Again, I have the easy job of moderating this session and hearing from other experts. And so we had three primary learning objectives. The first is I'm hoping to improve your understanding of how physical therapists and spine surgeons may approach a patient with scoliosis. The second learning objective is to identify when it is the most appropriate to refer a patient to a therapist or surgeon. And lastly, list some evidence-based practices from a physiatrist standpoint when treating a patient with scoliosis. So really brief outline. We'll be hearing from, as I mentioned, a surgeon, therapist, and physiatrist. And then hopefully we'll have some time for somewhat of a round table or panel discussion. And so why do we choose this topic? First, I think that the treatment for a patient with scoliosis can really vary depending on who is the primary treating provider. And really as physiatrists ourselves, we play an important role when directing care for these patients. And oftentimes it works best in a team-wise approach. And so that's why I'm bringing together a surgeon, physical therapist, and spine physiatrist to discuss how to specifically approach these patients and hear from each other's specialties. So I want to encourage you guys to use the chat box function, send in questions, and we'll try to get to these questions at the end. Sometimes the faculty may want to answer them as they come in, but hopefully we'll have some time to go over it specifically at the end. So I have one polling question. And so we're going to bring this question up here. How many of you guys treat or see patients with scoliosis? Give it a couple of seconds before we get the results up. All right, great. Organizers can show us the percentage here. Okay, great. I mean, obviously you're at this session, but it's always great to just see who we're talking to. So fantastic. So on to the speakers, and I'm going to introduce all three of them now, and they will hand off the screen to each person. But first we'll have Dr. Zhang from UCSF. She's a clinical assistant professor. She has done many talks, is very involved with research, and has been very fortunate to hear from her yesterday, and very fortunate to have her speak today in terms of approaching this scoliosis from a physiatrist standpoint. And afterwards we'll have Dr. Flavio Silva speak to us, and he's a PT extraordinaire here at Vanderbilt. And so we're really fortunate to have him. He is certified in manual therapy, dry needling, ergonomics. And so really fortunate to have him speak, and speak from his expertise, as well as our last speaker, Dr. Byron Stevens. And he is an assistant professor here in the Department of Orthopedic Surgery. He's the division chief of spine surgery and associate program director of the orthopedic surgery residency here. So again, really thankful for all three of them for speaking here today and making my life easier just to moderate. And so with that, I'm going to stop my screen sharing and let Dr. Zhang share her screen. So good afternoon, everyone, and thank you, Dr. Yang, for introducing me and for including me in this session. So let me get my screen share up. It takes one moment here. And so I think it's great that we're doing this talk at AAPMR this year, because managing scoliosis is really such a multidisciplinary effort. And I remember when I first started my job, I was always somewhat nervous to manage non-operatively these patients. Part of this was I just wasn't sure what to do with them, like when to follow up with them, and when I should refer them to my physical therapy or my surgeon colleagues. And so my goal in this talk, as the physiatrist speaking, is to hopefully clarify, from my point of view, what is a physiatrist's role in non-operative care of these scoliosis patients? I have no relevant financial disclosures. Let me start right off the bat. I want to cover some situations when I think non-operative care may no longer be appropriate and when I would think about a surgical referral. So here we have the pre- and the post-operative x-rays of Marcia. And she's a patient who was featured on the Scoliosis Research Society website. She was initially diagnosed with a curve of about 40 degrees, which over the next five years actually kept on rapidly increasing as with her symptoms. So soon her pain became debilitating. She couldn't walk for more than 15 minutes at a time. Sitting was even very difficult. She had sharp shooting pains down her leg and developed weakness in that leg. And so after all this, she knew she had to have surgery because her curve had already progressed to 70 degrees. And she writes on the website that, you know, definitely surgery had risks and the recovery took months, but it actually really gave her back her life. And she was able to ski again and spend some quality time with her grandchildren. And so when I see scoliosis patients in my non-operative practice, the first thing I do is to screen for whether they need surgery, right? And so in my mind, Marcia's case actually did highlight some of the contraindications to prolonged non-operative care, which includes neurological deficits. So for her, she actually started to become weak in one of her legs. She also mentioned that she had a rapidly progressive curve and, you know, we get worried that the curve is so rapidly progressive, does it get to a point where, you know, they're going to have perhaps cardiopulmonary compromise where their heart and their lungs can no longer work as well. And, you know, the first feature I look for is, of course, just pain that's entirely refractory and completely debilitating. And I think in patients who do not have these four cardinal features, continued non-operative care is fair and can be pursued. And then so during the rest of my presentation today, I want to follow up with what are some of the history and physical exam features that a physiatrist should look for during non-operative evaluation for scoliosis? What are some of the imaging needs and how frequently should we be getting these imagings? And what are some of the pain management strategies we have? And to do this, let me start off with a case similar to one of the first scoliosis patients that I saw in my clinic after starting. You know, she was a 60-year-old female pediatrician and she just came in because she needed to follow up with her scoliosis and it turned out that she has been diagnosed with scoliosis ever since her adolescence, but it was too late at the time for her to be raised. She was already close to skeletal maturity and her full adult height. She's not really sure if she's actually having a loss of height over the years. She doesn't actually have that much debilitating pain, just pain sometimes. That's been her norm, but what really precipitated this visit was that she was recently diagnosed with pretty bad osteoporosis and her endocrinologist actually recommended her to follow up. And so just kind of breaking down some of the things we just covered there. You know, when I see a patient with scoliosis, I often do want to ask them about whether they were previously diagnosed with scoliosis, if they've ever been braced or offered bracing or, of course, if they ever had surgery. In California, where I practice, scoliosis screening for girls was made mandatory at a certain point in the 1980s in grade seven, and boys too, they were screened at grade eight. The American Academy of Family Physicians actually now recommends against routine scoliosis screening, and that in part is because the cases found at schools tend to be low risk and don't even require treatments. But some of my patients that I see in clinic now, their scoliosis was found as part of the screening, and so I do like to ask about that. And just some things I keep in mind is that for adolescent allopathic scoliosis bracing is pretty rarely offered if the curve is less than 20 degrees. And so if I see someone in my clinic and their curve in front of me is like 35 degrees and they were told it was pretty mild when they were adolescent and they never needed bracing, that kind of already makes me think maybe the curvature has progressed over time. But, you know, I do treat these scoliosis patients like my other patients. I ask about their pain or dysfunction. And some of these patients report, you know, pain, especially if they stand or walk or maybe even sit for a long time. And they tell me they've had achiness in their spine for even decades, and it's just been part of their lives. It is important to also do what we normally do, which is to screen for neurological deficits, so radicular symptoms, motor and sensory changes. One thing I specifically pay attention to is, you know, if they have any reports of changes in height, because that might make me think perhaps the scoliosis has progressed. I ask about lifestyles and comorbidities. So weight status is something I pay attention to more. Obesity can sometimes worsen symptoms of scoliosis as the skeletal frame has to carry more weight. And so for these patients, I talk about weight optimization. I ask them if they smoke tobacco or use any tobacco products, because some studies have shown that tobacco can accelerate spine degeneration and just worsen pain in general. And of course, I advise for them to stop smoking if possible. And I ask about osteoporosis. So some studies do, almost surprisingly to me, not all studies actually do find the association between curb regression and soft bone, like osteoporosis. And then so, you know, in patients who's never been screened for, but who might be at the age and have risk factors, I do encourage screening. And if they're diagnosed, and I do want them to think about treatments, and I even refer them to our endocrinologist here at UCSF, if I think they need help to decide whether they need a bisphosphonate or one of the newer anabolic agents that actually increase bone formation. On a physical exam, most of us have heard about the Adams-Ford-Bend test. I have patients stand on both their feet and just basically bend forward. And I'm looking for a rotational deformity where a rib hump like this, and you can actually use a scoliometer if you had one to try to measure the curve. I have to be really honest, I have no idea where all these scoliometers go, because I definitely always have trouble finding the one in my clinic room. And so one nice feature now is most of our smartphones, you can actually download that inclinometer, and they're usually free. And so sometimes if I just kind of want some measurement right there, I can actually use my phone to help serve as a scoliometer. And you know, when I look at the patient with scoliosis, I do like to look at their skin. So over where the rib hump is, I want to see if there's any skin breakdown, because sometimes I can rub against a chair or so when people are seated for too long, and in this kind of anterior lateral fold, I look for rashes if it's really severe scoliosis, because moisture can trap there. And, you know, again, neurological examination is important. I check strength, sensation, reflexes, tone. Besides physical examination, I do think x-rays can be helpful. Adult scoliosis is defined as the lateral curvature of the spine in the coronal plane that is greater than 10 degrees. And just to kind of review again, how do we measure a Cobb angle? So you want to find the angle that is formed by the intersection of a line that's parallel to the most cephaloid vertebra here, in a particular curve, along with a line that's made parallel to the most caudal vertebra of the curve. And so as you can imagine, if you drew these lines out, the intersection, the place where this intersect would actually be entirely off of the border of the actual film. So by conventions and some geometric proofs that I can no longer remember, if you drew perpendicular lines and measured the angle here, that can, that is going to be the same angle, and that's how you can calculate a Cobb angle on paper. So, you know, a lot of us, we have PACS systems where you can do these calculations in the computer if you just drew out for the PACS system exactly where this line should be placed. And it's important to get these x-rays because it's, you know, like scoliosis is not always static even in a skeletally mature patient, and actually 60 to 70% of adult scoliosis patients have some evidence of curve progression. And the pace of progression is actually super variable, so some curves may be stable for many, many years and then progress suddenly. And then so in one longitudinal study of 42 patients with degenerative lumbar scoliosis, 11 progressed five degrees or more during a mean follow-up period of 12 years. And this is actually a set of x-rays from a paper by Pritchett and colleagues. And so initially, this 69-year-old woman had a 15-degree curve, but 10 years later, the curve had progressed 35 degrees, and you can actually see the development of a lateral asthesis here between the L3 and L4 vertebral body, and this actually led to new radicular symptoms that brought her back into the clinic. And so in that same Pritchett study, he looked at 41 patients who he followed with radiographs spanning 10 to 30 years with an average follow-up of 12 years. And he was really looking for factors that determine the likelihood of curve progression. So during the follow-up period in this 41 patients, you will see that 73% of them had more than 10-degree documented increase in curve over the period. The rate of progression was about three degrees per year on average. And this table actually tabulated some factors associated with progression. The two that I look at the most would be the Cobb angle right here. And so if the Cobb angle is greater than 30 degrees, then there's an increased risk of curve progression. Another thing I take a peek at would be the amount of rotation. So this diagram here kind of helps you figure out how to really measure rotation on a scoliosis film. And so, you know, at a vertebral body, if there's no rotation, then the pedicles, those little two dots should be in their regular position. But if there is more and more rotation, you will see that on the concave side of the curve, the pedicle starts to be lost as the vertebral body is rotated. And on the convex side of the curve, that pedicle starts to move more and more towards midline. And so what you can see here is that once the pedicle starts to be a little bit harder to see and become lost, those patients have significant rotation and they might be more likely to undergo curve progression. And it's really not clear, at least when I was reviewing the literature, how often should these x-ray scoliosis be followed up over time. And, you know, things I think about would be the degree of curvature, right? So if someone only has a 20 degree curve, then I'm not, you know, as cautious about following up the curve, especially if I already have two over time that's been stable. But if the curve is 40 degrees, close to 50 degrees, then I am more eager to follow these curves to just make sure that it's not getting worse. And patient factors also matter, right? So if someone's still in their 20s and 30s, then I think it's less likely they're going to have a gender contribution to scoliosis worsening, whereas if they're in their 50s and 60s, and I've already seen a lot of the gender changes in addition to the scoliosis, I might be more eager to follow up with serial x-rays and trajectory matters. So if someone's curve was 39 when they were 18 and 39 when they were 42, and now they're 43, then I'm like, well, it seems like it's been pretty stable. I'm not as suspicious that things are rapidly getting worse. But if someone's curve was 37 degrees last year and 45 degrees this year, then, you know, I'd be more eager to keep on following those patients. So for these patients, what can we offer, right? So right off the bat, I talk about lifestyle changes that would be good for them regardless, which would be optimizing weight, avoiding smoking, monitoring bone density. But when it comes to symptom management non-operatively, you know, I really treat them pretty similarly to non-scoliosis patients. And some of this is guided, if you wanted to review this, by a literature review done by Erit and Patel in 2007. So they, you know, through the review of the available studies at that time, they found the highest level of evidence, though it was only a level 2C level evidence of what should be done as non-operative management of scoliosis is actually activity modification to avoid pain and the use of NSAIDs. And they actually concluded in their review that they recommend non-operative scoliosis care to just mirror the best clinical practices for all degenerative aging spine, because we really don't have much evidence to suggest otherwise. And then so, you know, for me, PT is a must because I recommend the physical therapy for almost all spine conditions. And physical therapy to me really is built upon trying to build flexibility and strength on the side of the rotation and working on extension opposite to the curves configuration. And I look forward to Dr. Flavio Silvio's talk right after mine to learn more about his particular approach. There's also some studies that just general conditioning exercises can be helpful. So one study out of Uruguay and 31 female PT students actually showed that modified Pilates can just be helpful in managing pain and building strength in this population. And there's recognition of the evolving role of bracing these patients, right? So Palazzo and colleagues, they said bracing in two tertiary care hospitals, they actually prescribed these kind of custom-moded lumbar sacro-orthosis in the patients with adult scoliosis and they actually required a wear of six hours a day, so a pretty large commitment. And they assess progression as defined by an increase of 10 degrees in cob angle from prior to bracing. And here's a figure showing what they found in their 29 degenerative scoliosis patients. X is time, Y is cob angle, black is the kind of trajectory of the curve before bracing and gray is after. And you can see that actually some of these patients, it almost looked like there's been some reversal of curve after bracing, but as a whole, the rate of progression decreased from 1.2 degrees per year to just 0.2 degrees per year. And so I think this is something that we still need more data about. And I am an interventional physiatrist, a spine physiatrist, and so I treat these patients like my other non-scoliotic patients. And so I would offer them epiduracy injections if they had axial pain. And I have actually a higher suspicion of SI joint-mediated pain in this population. Some studies have pointed out that there's a higher prevalence of SI joint pain in patients with scoliosis. And because of that, sometimes I might actually offer them more SI joint-targeting interventions. The one thing I would say, though, is that when you're pursuing in spine injections in a patient with scoliosis, it's really important to find that true APE before starting injection. So this is a picture taken from right L5S1 transforaminal by this paper by Nam and Park, looking at whether TFC transforaminal epidurals or injections can help with pain and dysfunction in patients with spina stenosis and concurrent scoliosis. And so I thought they did a pretty good job here, because what you really want to do is make sure the spinous process is midway between the flanking pedicles before you start injecting. And so they were able to do that here at L5S1. And the study was really small. It only had 36 patients. And the inclusion and excursion criteria were not very rigorous. But they did show that compared to baseline at two weeks, one month, and three months, injections with S, which was with steroid, did, I guess, yield decreased pain on VAS as compared to injections with lidocaine. And so, yeah, let's kind of wrap this up. So the patient I introduced at the beginning, it actually became apparent in my discussion with her at the initial visit, her non-operative map management strategy had actually been pretty well optimized over the years. She had a great home exercise program and periodic team up with a physical therapist that she trusted. She sometimes got care elsewhere, too, with acupuncture, chiropractors, massage. She knew when to use NSAIDs. She was monitoring her bone density. And so I really felt like she had already gotten a lot of the optimization I would have wanted for her. And so just to summarize some of the things we discussed in this talk, you know, in these non-optimum evaluations for scoliosis, I asked about height changes, neurological deficits, worsening pain, and pay attention to modifiable risk factors. We discussed a little bit about the role of x-rays and how often to get these serial imagings. And, you know, one of the questions we want to address is when should a physiatrist refer these patients out to surgery? And, you know, these are the four things I really look out for, neurological deficits, cardiopulmonary compromise, rapidly progressive curve, and refractory pain. So with that, here's my work cited. And let me turn this over to Dr. Flavio Silva, who's the clinical coordinator of physical therapy at Vanderbilt University Medical Center. And I look forward to learning from him about his approach in these patients with scoliosis. Thank you, Dr. Zhang. I appreciate it. Let me share my screen. So I want to thank everybody for being here. And I want to thank Dr. Yang for inviting me to actually talk about physical therapy management of patients with scoliosis. The management of those patients can be almost a subspecialty in physical therapy because of the complexity and because it's not something that we, it's taught in schools in a regular basis. So the treatment for those patients kind of vary according to each region and which person. So I'm kind of trying to bring some of the information that kind of brings it all together here. So I have no relevant financial disclosures. So exercise therapy has been shown to be a great option for the conservative management of patients with scoliosis. The International Society on Scoliosis, Orthopedic and Rehabilitation Treatment has issued some working guidelines for the management of scoliosis with exercises in 2016. Exercise therapy may also be used in conjunction with bracing and postoperative for improvements of posture and strength. The benefits of exercises is not only local, but they also include improvements in quality of life and better management of disability. The standards of management of patients with scoliosis, they differ kind of significantly between the United States and Europe. In the United States, the center of care to manage those patients usually involve more observation, bracing, and surgery. There was a study done in 2015 where the Scoliosis Research Society surveyed physicians in the U.S. with the majority of the physicians being in the U.S., and the results show that only 22% of the respondents actually use physical therapy specific exercises for managing scoliosis. So I'm hoping that trend is kind of starting to change, and we're going to see more referrals to physical therapy, especially on the early stages of scoliosis. In Europe, it's a little bit different where there's a little more support for exercises for the management of scoliosis patients, and surgical interventions are a little less common. There are several schools of thought for the management of scoliosis, and because the majority of PSSCs are preached in Europe, the majority of those schools of thought are actually from Europe. So the Schroth is the most common that everybody knows, followed the Barcelona scoliosis physical therapy approach. Those two schools of thought, they're actually taught in the United States. They have continued education courses to certify physical therapists, but again, the last I researched, there's only two physical therapists in the state of Tennessee that are actually certified on the Schroth approach. Other schools of thought are Lyon from France, and the scientific exercise approach from Italy, double mat approach from Poland, side shift approach from the United Kingdom, and functional individual therapy of scoliosis approach from Poland. They share a lot of similarities, but they also have lots of differences in their approaches. The Schroth method is still the best known method for physiotherapy-specific exercises, and is customized for each patient according to the curvature. So after the initial evaluation, when we determine the type of curvature that the patient presents, we'll come up with the strategies to actually treat the patient. It's commonly used in conjunction to bracing, as well as with therapeutic exercises, Pilates, and yoga interventions. So what's the evidence for supporting scoliosis-specific exercises? The research is still at early stages and somewhat limited. There has been an effort to support more research for the use of exercises for the management of patients with scoliosis with better methodology and quality. This is a recent systematic review by Fent et al, assessing the effectiveness of scoliosis-specific exercises for the management of adolescent idiopathic scoliosis. The study suggests evidence with moderate quality supporting that SSE, or scoliosis-specific exercises, can significantly reduce scab angle and improve truncus symmetry. The effect of scoliosis-specific exercise with brace wearing on treating moderate scoliosis is not very clear, and there's insufficient evidence available to implicate any effects of those exercises in changes of quality of life. This is another study, a randomized controlled trial, down in South Africa by Glenn Royan in 2019, and looked at the effectiveness of Schroth exercises in adolescents with idiopathic scoliosis. And this study found that the Schroth exercises have a significant effect on reducing the scab angle and improving quality of life in adolescents with idiopathic scoliosis. Again, they only found four randomized controlled trials that were included in the study, and some of the level of the evidence wasn't as high quality as we would like. This is RCT from 2020, where they compared Schroth combined with core Pilates program with a control group for patients with scoliosis, and they found that the exercise program combining the Schroth with a regular Pilates and core-based exercises provided benefit on the cab angle, angle of trunk rotation, chest expansion, trunk flexion, quality of life in adolescents. And lastly, this is another study looking at the effect of core-based exercises in people with scoliosis. It's a systematic review published in 2021, where they found nine studies with 325 patients, and the review showed evidence of improvements of cab angle and better quality of life in subjects when compared to control groups. So, there are plenty of exercises that show that exercise therapy is efficient for the treatment of scoliosis when the referrals are appropriate, and we're going to talk about some of the different indications and how to refer those patients. In 2016, SOHRT came with guidelines for indication of physical therapy-specific exercises. So, these are the patients that will be referred that will have the best outcomes. So, the guidelines for SOHRT treatment is our adolescents with a cab angle of less than 20 degrees, and risks are zero to three. Adolescents with cab angle from 20 degrees to 29 degrees with a risk of progression of 40 to 60 percent according to Lonstein formula. Then adolescents with cab angle for less than 35 degrees, risks are four to five. Adults with painful scoliosis and patients who choose not to have surgery. Again, the type of patients that are referred will kind of dictate how successful the interventions are as far as reducing cab angles and improving rotation on this patient population. Combined treatment with physical therapy-specific exercises has positive results with bracing with adolescents with cab angle between 25 and 40 degrees, and adolescents with cab angle with more than 35 degrees, risks are four and five, and after spinal fusion. And those exercises can be easily combined with the use of bracing. The principles for therapeutic exercises are for SOHRT and that will affect the quality of the outcomes for those patients is number one, self-correction 3D. So, our exercises to enhance motor control using visual and physical cues to self-correct the curvature of the patient. Training of daily activities or activities of daily living, progressing to sitting, to standing, lifting, jogging, and other activities while maintaining this 3D correction. Stabilizing the corrected posture, especially during daily living activities and physical activities. And lastly, patient education about activity and fitness. So, the 3D correction of curvature is one of the main principles that we use when we're rehabilitating patients in the clinic, and we try to maintain that correction, that 3D correction when we're actually performing other core strengthening exercises, flexibility exercises, and progressive functional retraining of the patient. These are what we normally use in our clinic. We use a combination of physical therapy-specific scoliosis exercise or PSSC following some of the Schroth strategies, mobility and strengthening exercise, which are core-based exercises, and Pilates-based exercise in the clinic. In our clinic, we don't have anybody that are certified in Schroth, but we have lots of therapists with plenty of experience in the different approaches and then how on progression of those patients with scoliosis. Now, one of the things that we also use for most of our spine patients is cognitive behavior interventions, and we tend to use that for pretty much every spine patient that comes in the clinic, and we're going to talk a little bit more about that towards the end of the presentation. And then, as the patients progress and they do well, we start talking about sports prescription. We notice that a lot of the patients that come into the clinic, they are somewhat afraid of progressing with exercises because they're afraid of progression of the curvature, and then what we try to do is provide them with an approach that can allow them to gradually progress those activities and feel safe while starting to do sports participation. So, before we see the patients, we'll do a thorough evaluation where we look at history that may include the history of back pain, headaches, any neurological symptoms that they may have, any family history that they have, the age to try to see what's the risk of progression, and their fitness history. We try to get as much information as possible to facilitate kind of coming up with a program that will kind of meet their needs, not only to try to improve their curvature or decrease their pain, but also progress them to some sort of fitness activity where they'll continue and give longevity to their program. After the history, we do a detailed posture evaluation, and we'll look at them in standing, usually from an anterior and posterior view, sitting, and also lying down on the right and on the left. What we try to do is look at the patients on all those different positions to make sure that we are able to see any kind of deviations, any kind of amount of rotation that it's noticeable on the spine and may affect how we do the exercises with them. So this is just kind of what we look at for on the initial evaluation. So this is a patient with moderate scoliosis, so we look at shoulder height, any kind of scapular asymmetry and trunk rotation, the presence of pelvic obliquity that may be caused by a leg length discrepancy, trunk rotation, waist asymmetry. In case of a leg length discrepancy or significant pelvic obliquity, we tend to kind of compensate to make it easier for them to be able to correct that with some of the strategies that we use in the clinic. After the posture evaluation, we also do the Adam's flexion test, just like it was described by Dr. Zhang. We do use a scoliometer to try to assess the amount of rotation because that's one of the objective items that we can kind of track to see if there's change or improvement during therapy. We also have a tendency to look at joint mobility for the spine and looking at cervical, thoracic, and lumbar spine and hips. Those are dysfunctions of those areas, they'll tend to kind of affect more the curvature and how the patient actually behaves with the exercises. We look at flexibility for lower extremities and trunk, strength specifically for trunk and extremities, especially core muscles, and it all depends on the level of fitness of the patient and how much they're doing and able to do at this point. And then if necessary, and we'll do a neurological assessment that may include neural tension testing for lower extremities and upper extremities. We can look at deep tendon reflexes, we can look at strength specifically with myotomes and things of that nature. So, these are some examples of exercises that are included in the Schroth program. After the initial evaluation, we try to get a little more detail on what type of curvature the patient has, what kind of limitations of mobility and strength that they have, and try to kind of tailor some of the exercises to those limitations of mobility. So again, these are examples of some of the Schroth exercises. We use some of those in the clinic, some are more efficient for us, and we kind of tend to use, and we'll talk a little more in detail about those later on. This is basically a list of some of the core and mobility exercises you can also have for trunk and lower extremities that may help patients with scoliosis. What we like to do is do a combination of the Schroth-based exercises that really address that 3D correction of the spine with core and flexibility exercises that will allow them to maintain and maybe even improve that 3D correction of the exercises. Again, no exercise fits everybody. It's really hard because it's dependent on the curvature of the patient, what kind of limitation of mobility and flexibility they have, and what kind of strain deficit they may have. So again, very tailored to each individual case. This is one of the most common exercises of the Schroth program. This is basically a stretch of the convexity side, and we try to level the pelvis, make sure the pelvis is level and properly aligned, and if there is some sort of difficulty leveling the pelvis, we may use some padding or some other things to kind of help promote that balance. And again, depending on the level of the scoliosis, you may use the upper extremity or the lower extremity to further stretch that segment. These exercises combine with breathing exercises that can help control rotation. We try to promote expansion of the concave side on those patients, and the patient usually will stay in this position for five to seven minutes. This is pretty much part of everybody's home exercise program, and they're supposed to be doing this at home almost every day. So this is a 3D autocorrection in sitting, okay? The, again, the pictures are kind of flipped here. The left is before correction. This is what we call a sail exercise as part of the program. The left is before correction. The right is after correction. So we use those sticks for, to produce some traction that will kind of improve their posture and also to help balance the spine. So the patient gets visual feedback. They see what they're doing. You're kind of giving them some manual feedback at the same time, and you're combining this with rotational angular breathing to try to improve some of the rotation of the segments of the spine. So again, they'll do this for a series of seven to ten sequences of five breaths each, and then relax. This exercise can be progressed to more functional activities, such as getting up from a sitting to standing while maintaining the 3D correction, and even lifting weights from that position while maintaining the 3D correction. Same exercise in a standing position. Again, now the left is before correction. The right is after correction. I don't know if you guys can notice, but I added a little heel lift. Patient's standing on something to kind of level the pelvis, and she's using the sticks to promote traction and balance in the spine. As the patients get better with this, what we normally see after we start treating them and teaching them for a while, they're able to maintain this and correct very, very easily, and we use that as a beginning before we start giving more progressive daily activity exercises, sitting, standing, walking, lifting, and things of that nature. So this is a patient doing a self-correction by herself now. As you can see, we kind of did four different pictures. They can use the upper extremity to kind of help with the self-correction. They might abduct the shoulder or use a little bit of kind of putting their hands on their hips to kind of help promote some traction to balance them out, and again, this can progress for more functional type activities. In this case here, she's using the mirror. It's very common for us in the clinic that they don't even need the mirror anymore. They kind of learn how to to do that 3D self-correction, and then we can kind of start the exercises. Again, these are other examples of exercises, a combination of some of the chest expansion exercises and trunk mobility. The exercise on the top left, she's basically doing angular breathing to try to expand the area of the convexity a little bit more. We teach them how to do that, and give a lot of verbal cues to kind of help with that. The Swiss ball helps balance them as they're doing the activity. The bottom left is a mobility exercise. We call it threading the needle. After the 3D correction established, we can use some reaching type activities to help them promote more mobility on the trunk. We try to give them verbal cues as needed to maintain the correction. The top one is what we call a child's pose. It's kind of a relaxation exercises. It also helps a little bit with correction. We can add some side bending to the right, side bending to the left to facilitate. And then the last one is basically just a breathing exercise where we're trying to do more of that angular breathing to try to expand the convex side. Now, from there, you can progress to a little more aggressive exercises. The exercise on the right after, on the top right, after doing 3D angular correction, she's actually lifting a kettlebell. These are kind of more aggressive exercises that not every patient kind of gets to do it. But if you are able to establish a good correction, we kind of will do that. And again, we try to tailor the exercises to what the patient wants to do, wants to be able to progress. The two exercises in the bottom are strengthening exercise for abdominals while maintaining stability of the spine. So this is a more progressive exercise. Again, there's no sound on this video and it just kind of plays very easily. So this is a bird dog exercise that is used a lot in physical therapy. Now for scoliosis patients, sometimes we tend to use a Swiss ball under their stomach to help them stabilize their spine a little bit better as they're trying to use their spinal extensors in their glutes. If the patient has trouble with the 3D correction and struggling to stabilize that segment, again, we use the ball to facilitate that. As the patient gets better and stronger, we'll try to move away from the ball a little bit and the patient will kind of start doing those exercises without as much support. Again, with the ball. So we're constantly giving manual cues and sometimes just verbal cues to the patient to try to maintain some of the 3D correction as they're doing those specific exercises. This is a much more advanced exercise. Again, after doing the 3D correction from seating, he's going to stand up while maintaining his score engaged. And we're kind of trying to visualize and doing 3D correction. Now, another progression of this exercise would be doing unstable surface under his feet or even elevating the shoulder, flexing the shoulder and kind of reaching overhead with that weight. Again, some of the exercises are more difficult and patients have to actually progress to be able to do those exercises without any problems. And lastly, I mean, we talk about sensory motor balance training with a mirror to monitor posture and using balance board. We do a lot of motor control type activity and we can use cameras sometimes, we can use a mirror to give them feedback. The other thing that we use with those patients in general is some cognitive behavior education. This is something that we use in our clinic for pretty much every spine patient, okay? And what we're trying to do is help them manage pain and their tolerance to activity and decrease the catastrophizing, which is very common for patients with scoliosis because they're afraid that their curve will progress, decrease their kinesiophobia and improve their behavior. This is a study from Monte Cone from 2016 that actually shows great benefit from using cognitive behavior education along with motor control activities for the patients with scoliosis. So some of the interventions that we use is pain neuroscience education, graded exercise progression, graded exposure to activities, especially we ask them what they want to be able to do so we can actually give them the progression and kind of start to expose them to those activities slowly as they're kind of tolerate better and then motivation and interviewing to try to help with compliance. So in summary, there's scientific evidence supporting PSSC and therapeutic exercise in scoliosis treatment. The exercise can be used as a sole treatment for light to mild scoliosis in adolescents and for adult scoliosis and can also be combined with bracing during growth. It can also be used as a post-op intervention to make sure that the patient will continue to maintain strength and flexibility and mobility. And more quality research and clinical education is needed to further develop the role of therapeutic exercise for the management of scoliosis in the USA. This is some of my cited references. Thank you, everyone. I'm gonna move this to Dr. Byron Scott. Thanks, Flavio. And thank you, Aaron and program committee for having me talk tonight. So I'm gonna provide sort of the surgical perspective to the management of the adult deformity patient. By way of disclosure, my department division received some research support from Stryker Spine. And my disclaimer for this talk is that I have a reasonably high volume spinal deformity practice, but I ultimately try to not operate on every single patient that I meet. Of course, we've come a long way in the treatment of spinal deformity. Hippocrates was perhaps the first, one of the first recorded physicians to treat scoliosis and provided us with these entertaining diagrams. And one of my favorite quotes about the treatment of scoliosis that may or may not be true today is that the physician or some person who is strong and not uninstructed should apply forces on the Hippocratic board to correct deformity. These methods included things as advanced as standing and sitting on the deformity to correct it as well. I would say that adult spinal deformity is a extremely complex clinical problem. It requires careful attention to detail and a lot of time to plan. It requires the surgeon to have significant discipline regarding when to say no. These can be patients that are very miserable and look to you as the person who's going to fix their problem. And sometimes really is like a terminal cancer that cannot be fixed. And really Bill Horton from my fellowship at Emory really instilled the level of detail required to appropriately address these patients in us and a failure to plan is a plan to fail. The deformity evaluation, I think has been covered very well by our previous speakers, but I will say you've got to spend a lot of time assessing these people and be aware of concomitant myelopathy and or vascular disease or hip arthritis, which can actually be the patient's primary issue. We have a tremendous amount of tools at our disposal to assess these patients radiographically. This program SurgeryMap is something that really, I think has changed the game when it comes to planning surgery and whole body x-rays through EOS machines also provide a lot of information regarding not only what the deformity is doing, but also what the lower extremity compensation is doing, which can be sometimes again, just as important. And you can really get bogged down in these details. And this is a live picture of me after a clinic full of deformity patients where we've drawn thousands of angles and measurements and trying to figure out the best way to correct these patients. But I think the biggest message from my standpoint and what I tell my patients is that the spine really has two jobs. One job is to hold the head centered over the sacrum and pelvis and both the sagittal and coronal planes. And then the other job is to protect and provide adequate space for the spinal cord and nerve roots. And it's really that simple. Some of our spines may ultimately accomplish these jobs where they take a circuitous route to get there. And you really have got to sort of explain it like that to these patients, I think to kind of calm them down about this. A lot of people come in and they think they have a 20 degree thoracic curve and it just has to be fixed. And you've got to sort of explain it to them and telling people these in these simple terms, I think has really helped me kind of talk people off the ledge a lot. In terms of questions that I asked myself and I think that we should all sort of ask ourselves when considering whether or not to refer a patient for a surgical evaluation. One of the biggest questions is how miserable are they? And really, the fundamental principle of the fact that suffering should be commensurate with the magnitude of the surgery proposed. We use a lot of patient outcomes, patient reported outcomes data in our clinics now. I think the PROMIS-CAT is probably my favorite. We traditionally have used other things like ODI and SRS-22 which is a scoliosis specific outcome measure. Second big question I ask is what conservative treatment has been attempted and physical therapy, I think is at the top of this list. And for me, the who is really important here. I have specific therapists, Flavia, I've been lucky enough to practice with Flavia and refer patients to him and his partners all the time. So the who, the when, the where, the how, and really how earnest was the attempt? Did you give it a good college try or did we go to therapy with a negative sort of mindset that this is just something I have to do to check the insurance box to get my surgery? I'm a big fan of aquatic therapy. I send every single adult deformity patient that I am considering operating on to aquatic therapy. Not everybody completes it, but I do send them all to aquatic therapy. I actually think it's a game changer. I've seen people be saved from surgery with aquatic therapy programs. As it allows them, of course, to do exercises that they can't do on dry land and stabilize their trunk and core. And just the act of some exercise, I think, releases endorphins and can make them feel better. Also, what procedures have been done? Epidural steroids, transforaminals for radicular symptoms, ablations and facet procedures. Really jotting down a detailed log of what's been done is important. The third big question I ask myself is, are they optimized? And this really requires a multidisciplinary team of all the people that you see here. The surgeons are at the bottom because we make bad decisions in isolation and we really rely on all the people above us. What major medical comorbidities do they have? How frail are they? And what is their bone density like? There's been a lot of work done on frailty and adult spinal deformity surgery. And really the two big measures of frailty that we look at are the adult spinal deformity specific frailty index and then the modified frailty index five-item questionnaire. The adult spinal deformity frailty index does accurately predict complications following surgery, but it is just frankly too complicated for daily use. But patients that were classified as severely frail, according to this index, were four and a half times more likely to suffer a severe complication and had a 20% longer hospital stay. I do use the MFI-5, which has been shown in multiple studies to identify complications after this type of surgery. And it's simply these five items that you can easily ascertain from the intake sheet, usually, and an initial evaluation with the patient. In terms of osteopenia and osteoporosis, there's an extremely high incidence of these comorbid conditions in this population. Patients should be screened appropriately. An early referral to an endocrinologist to consider some of the newer anabolic medications is often indicated. Questions remain regarding timing and surgery, but I do try to get a lot of these patients on these medicines, and I'm fortunate to work with some great endocrinologists here that are just a phone call away. Then one of the final questions is, what is the smallest surgery that I can offer them to provide them with a durable result? My go-to approach for these patients is really an all-posterior approach. It is faster, avoids sort of approach morbidity of anterior surgery, and we'll talk a little bit more about that. Anterior surgery is powerful, so sort of a combined anterior-posterior approach is very powerful surgery, but it does come at a cost associated with the approach. And I do use anterior approaches in select cases, particularly for patients with very stiff lumbosacral fractional curves, which can be difficult to correct, and if not corrected, can result in iatrogenic coronal imbalance, and a significant need to correct the sagittal plane. The next question really is, how well do they understand the morbidity of surgery? These are incredibly complicated surgeries. It's hard for my residents and fellow to even understand what we're doing, let alone the patients and families, and this was a study that showed in a somewhat scary way that they, a prospective cohort of 56 patients only had a 45% immediate recall of the risk of surgery discussed with them. Breeze through a couple of cases in the last couple of minutes. This is a 33-year-old that came to me asking for surgical correction. She was told by multiple friends and family members that she needed to be fixed, but she really had no pain. She was highly functioning, and she had young children and wished to have more children, and her ODI score was very low. And this is a patient that you spend a lot of time with and sort of explain what surgical correction means, and she gets no surgery. Sort of on the opposite end of the spectrum, this is a 72-year-old female who came to me severely with a severe deformity, combined coronal and sagittal deformity. She was highly frail, multiple comorbidities, and she was totally miserable in a wheelchair. She also had terrible osteoporosis, was on Forteo. But due to how frail she was and the multiple medical comorbidities she had after a multidisciplinary conference, it was decided that she got no surgery. And finally, cases like this sort of hit the sweet spot between those two. A patient that's failed extensive conservative care with a high ODI, no major medical comorbidities, low BMI, good bone density. You see a severe combined coronal and sagittal deformity. I use a lot of 3D models to sort of assist my brain in understanding these deformities. I find this very helpful, and we can achieve good coronal and sagittal correction with a complex surgery, but a good outcome. So with that, I'll sort of turn it back over to Aaron if there's any questions or things we can talk about together. Thanks. Great. Thank you, Byron. Thank you for all the speakers for being a part of this. I know we don't have much time. A quick question I had for Flavio. You know, one of the biggest problems is access to shock-trained therapists, and someone put in a great link for telehealth, but if you're in an area that may not have access to one, you know, any recommendations for things that we could specify in a physical therapy order that may help out a therapist who's not trained? So maybe something we could put in the physical therapy order, or, you know, would there be anything on your end that would be beneficial to do something differently? Basically, the best case scenario would be to find out if the therapist that you're sending to actually has any experiencing treating scoliosis patients. Patients with a milder to lesser curve, they actually do well with just general core exercises, and it's easier to rehabilitate, but patients that are a little more complex. And just hope that the therapist will be honest enough to tell you that, hey, I'm not comfortable with this. It might be a good idea to refer to somewhere else. There's a few people here in town. There's a Pilates studio that they, all they do is scoliosis patients in here, and I can kind of send resources from them to you guys, and, but basically see if they're comfortable treating those patients. What about, you know, and Byron, you might be able to speak on this, or Patricia, if you've taken care of any pediatric patients or experience in the past, you know, it seems like, you know, we're not thinking surgical intervention right off the bat, obviously, but it seems like it always requires closer follow-up, more frequent follow-up. You know, what are some thoughts about bracing? I don't, I mean, I think we could all be in great agreement. We don't brace a lot of the adult population. And again, I'd be curious if there are any indications for bracing adult population, but it tends to be pediatrics. And so any thoughts on that? So bracing in the pediatric world should definitely be, you know, driven by the, I think the pediatric orthopedic surgeon, and it has a great role and can prevent curve progression, has been shown in a very high level study funded by the NIH, the Braced, B-R-A-I-S-T study to prevent curve progression in surgery. I agree with you, Aaron. I don't use braces in adults, except as a sign of total desperation to offer the patient something. But quite honestly, I tell them, I don't think this is going to help you. And in fact, it's probably going to be counterproductive to what we want to do in terms of core stability. But if you want to use it on your bad days or when you're in the garden or doing something and you seem to find that it helps you, I'm fine with it. Anything, Patricia, from your end? Yeah, I mean, I totally agree with that. I have mostly an adult practice. And so our pediatric folks does more of the bracing consideration for adolescent idiopathic scoliosis, and there's definitely a role for bracing there. For adults, you know, there's one study I talked about in my presentation that was the only one I found that actually showed some favorable thing for bracing in adult scoliosis patients, and it was not very large and has not been validated since. So we definitely also do not recommend bracing normally for our patients, only, as Dr. Stephens said, for symptom management in people who are not surgical candidates. And even then, you know, I tried to not have them brace for too long for fear that they're going to contribute to muscle atrophy. So only using it if they absolutely need it. Great. Well, thank you, everyone. I know we're out of time. So I really appreciate all you guys speaking here and for all the engagement from the audience. And so hope you guys have a great rest of the evening, and thanks again for joining everybody. Appreciate it. Thank you.

scoliosis

physical therapy

surgery

physiatry

scoliosis management

multidisciplinary approach

evidence-based practices

non-operative care

individualized treatment plans

patient-reported outcomes