Transcript UCC Performance, June 05 - Scottish Muscle Network

Physiotherapy Management of
Neuromuscular Scoliosis
Hannah Waugh
0131 536 0000 Bleep 9126
Specialist Physiotherapist,
The Royal Hospital for Sick Children,
Edinburgh
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Contents
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What is Scoliosis?
Medical Management
Pre Operative Planning
Hospital Admission
Challenges post discharge
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What is Scoliosis?
• Complex three dimensional deformity
where the curve is greater than 10 degrees
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Prevalence of Neuromuscular Scoliosis
• 20% of children with Cerebral Palsy
• 60% of children with Myelodysplasia
• 90% of children with Duchenne Muscular
Dystrophy
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Neuromuscular Scoliosis Development
• Spinal curvature may begin very early in life
• Often after the patient starts supported sitting
• Curve may progress rapidly once patient
becomes non ambulant (averaging 10
degrees/year)
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Initial Assessment
06.02.2007
14yrs 6mth
66 o
108 o
Pelvis ? o
S.G., ♂
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Progression of curve – 4 months
06.02.2007
14yrs 6mth
26.06.2007
14yrs 10mth
66 o
58 o
108 o
122 o
Pelvis ? o
Pelvis 34 o
S.G., ♂
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Preventing Progression of Scoliosis
• Prolong mobility
• Steroids
• 24 hour postural management
• Spinal bracing (not always effective particularly in
progressive neuromuscular curves)
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Referral Criteria
• Consultant to consultant referral only
• Confirmed scoliosis - requesting specialist
assessment for surgical intervention
– Neurological – usually after the age of 10
as surgery unlikely prior to this
– DMD – when patient becomes non
ambulant
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Initial Spinal Clinic
Assessment
• In-depth history is taken
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scoliosis progression, pain, function
past medical history
medication
social history
• Objective Assessment
• X-rays : standing or sitting to establish severity, bending films
to identify flexibility – cobb angle, also check risser grade
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Cobb Angle
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Medical Management
• Dependent on:
– Severity of scoliosis
– Pelvic obliquity
– Age/Skeletal maturity – risser grade
– Rib deformity/ Impingement/ Pain
– Complexity of past medical history
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Medical Management
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Cardiac
Respiratory
Anaesthetics
Neurology/ Neurosurgery
Endocrinology
GI
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Medical Management - DMD
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Respiratory Function
Functional Ability
Symptoms
Quality of Life questionnaire
Reduction in surgery
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Medical Management - CP
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Respiratory Function
Functional Ability
Symptoms
Quality of Life questionnaire
Surgery
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Medical Management - mylominingecele
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Respiratory Function
Functional Ability
Symptoms
Surgery
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Medical Management
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Every case is very individual
Function
Medical Stability
MDT decision
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Medical Management
• Continue to monitor curve
• Use of conservative treatment
• PSF
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Physiotherapy Service Aims
• To ensure smooth pathway from pre admission to
discharge
• To be available for contact to reduce any
anxieties throughout the patient journey
• To be a resource for local therapists / services for
Scotland
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Spinal Surgery Pathway
Theatre list to
Physio & OT
Contact made with
local services &
family
Pre-op
assessment
completed
Equipment
requirements
identified &
commenced
Local services
review
Discharge
Post-op
Admission
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Physiotherapy Role
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To ensure that optimal functional abilities are achieved post operatively
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Those functional abilties include:
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respiratory function
muscle strength
transfers/ mobility
postural management
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Overall aim is to maximise independence following surgery in activities of daily
living
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Postural management is vital and should be considered through out all stages of
spinal surgery
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Physio Pre op Planning
• Commenced as soon as the patient is
listed for theatre (approx 6 weeks)
• Facilitate smooth admission and
discharge from hospital
• Early contact with local services is essential
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Pre-operative Planning
• Unfortunately due to geographic location of clinics,
unable to attend
• Contact will usually be made with the family and local
therapists initially by telephone
• If patients admitted for respiratory tests, trial of NIV or
attend for anaesthetic assessment we will meet and
assess on ward if possible
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Initial Pre-Op Assessment
Physio /OT
• Establish current abilities of
– Seating (wheelchairs,other seating systems school, home)
– Transfers (independent, assisted, hoist)
– Mobility- use of walking aids
– Personal Hygiene (toileting, bathing/showering, level of
assistance ,specific equipment)
– Respiratory function
– Other ADL activities (feeding, self dressing)
– School
– Environmental issues (access to and within house)- child may
need to live downstairs
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Seating
• Wheelchairs
– Should be in suitable corrective seating system
pre op- consider lateral supports, harness & head
support
– Tilt & recline facilities recommended pre-op for
any patient with scoliosis (Bushby et al, 2005)
– Tilt & recline vital post op if fused to pelvis
– Moulded wheelchairs are not appropriate post
op
– Local services to review post op to ensure
corrective seating system
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Seating
• If fused to pelvis other seating systems can be
used if have recline
• Local therapists to review postural support from
seating systems post op
• Post op head rests, lateral supports, harnesses
will still be required to maintain optimal postural
alignment
• Sofas, beanbags are not acceptable seating
systems!
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Transfers
• Hoisting
– Children that are lifted pre-op may require to be
hoisted
– Hoisting is dependent on age, size, weight and
complexity
– High backed slings with head support recommended
– Bones in slings not necessary
– Thinner sling ideal- will be left in situ initially
– Remember to consider that child may require
increased sling length post op
– Responsibility of local services to provide hoist
training if new/ different equipment has been
supplied
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Personal Care
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Toileting
– Ideal is recline & tilt- limited resources may result in tilt
only
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Showering
– Recommended in acute post op period
– Alternative shower chair may be required
for postural support
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Bathing
– Long term extra postural support in bath
may be required
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Pre-operative Respiratory Function
• Extremely beneficial if families have been taught lung
volume recruitment techniques and chest clearance
techniques prior to admission
– British Thoracic Society (www.brit-thoracic.org.uk
– Scottish Muscle Network DMD Profile
(www.smn.scot.nhs.uk)
• Peak cough flow can be assessed by using a mask and
a peak flow meter,
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Hospital Admission
• Usually admitted the day prior to surgery
• Introduction/assessment by inter-disciplinary
team
• Discussion of post operative management
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Operation – Posterior Spinal Fusion
20.09.2007
15yrs 1mth
40 o
62 o
Pelvis 6 o
S.G., ♂
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Posterior Spinal Fusion +/- pelvic
fixation
• Performed via a large midline incision
• Spinous processes, interspinous ligaments and facet
joints excised
• Pedicle Screws or hooks attached to spine
• If fusing to the pelvis wires or pelvic screws are placed
• Rods applied down either side of the spine and
attached to screws and hooks as spinal deformity
derotated
• Bone grafts placed around rods – usually femoral
heads from bone bank or bone substitutes
• Wound is closed with redivac drain insitu
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Anterior Release +/- posterior spinal
fusion
• Performed via a thoracotomy – on the convexity of
scoliosis
• A rib is excised for most of its length to access spine
(and kept) – rib resection
• Rib heads may be removed around the apex of the
scoliosis to improve cosmetic result – internal
costoplasty
• Pleura is excised
• Discs are excised and growth plates, cartilage
removed
• Wound closed with intercostal chest drain insitu
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In patient Physiotherapy
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Reviewed day one post op
Chest physiotherapy commenced
Passive/active assisted movements
Bed mobility – log rolling
Mobility/ hoisting once medically stable
Liaison with local therapists
Ongoing until discharge from hospital
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Acute Post Op Challenges
• Surgical considerations – e.g. pelvic
fixation- reclining seating positions
• Medical stability – e.g. respiratory distress
• Comfort – pain control
• Tone
• Psychosocial – anxiety
• Nutrition
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Discharge Advice
• Advise parents to cont passive/active assisted
movements
• To increase mobility or duration sitting in wheelchair
• If wheelchair reclined- to reduce recline as tolerated
• To ensure postural alignment maintained – avoid
forced flexion/ extension or rotation of spine
• Ongoing respiratory management – as required
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Discharge Advice
• Unable to use standing frame and some
walking aids
• Unable to swim/ hydrotherapy/ participate in
sports
• Discretion of Consultant on reviewing patient
and x-rays at clinic
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School
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ASL Profile provided
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Return to School – graded
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School seating
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Desk height/ position
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Hand function – writing skills
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Manual handling/hoisting
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Toileting
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Feeding
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Challenges after Discharge
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Home Environment
Mobility
Self propelling wheelchairs
Change to Physiotherapy Program – Hippotherapy, Rebound etc
Feeding
Family Support
Transport
Holidays
Anxieties
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Conclusion
• There is variability with each child and we aim
to make the pathway as smooth as possible
for the patient / carers and local therapists
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