7 7i T3 \ UC-NRLF 3 772 ^12 fy 1 GIFT OF UL- THE NON-OPERATIVE "TR'EATMEN'T'b'F 'SCOLIOSIS BY WALTER TRUSLOVV, M. D. BROOKLYN, N. Y. ;' ill approaching what is perhaps the most difficult problem in ^Orthopedic practice, one would wish to be clear in defining the stbject. This paper will deal with true rotary lateral curvature ■ jf the spine — that is, with the well-known deformity, with struc- tural changes. Functional scoliosis must be dealt with carefully and thoroughly, but is not the bete noir that structural scoliosis is. It is necessary also to understand just what one may expect to accomplish, and not to pre-suppose what at present seems im- possible. Successful treatment of rotary lateral curvature of the spine contemplates (1) stopping the deforming process, (2) ma- terially lessening existing deformity, and (3) reasonably assuring the non-return of the deformity. The present writer agrees with tlie findings of the recent Scoliosis Committee of the American If Orthopedic Association, which stated that no known method had :^et been found to restore to body symmetry a structural scoliosis ; but he believes that the ends just outlined are worth striving for and are attainable. Every case must be considered individually; but, in general, the non-operative treatment of structural scoliosis consists in a careful weighing of the indications for and the proper use of (1) corrective plaster-of-Paris jackets, with pressure paddings and negative window spacing, and (2) of specific intensive exercises, with retention brace or corset — often an alternating use of these means. We usually state our procedure in treating deformities, thus: "Correct the deformity first, then insure its non-recur- rence." Practically, in the deformity under discussion, we find ro means completely to correct the deformity, and I think that nost of us agree that there is a very definite limit to the forces V hich we can exert on the individual patient. So it has long ap- peared to the writer that the one who assumes professional charge of these patients should outline a procedure which should allow the use of both means, and that he should demand for himself •easonable freedom of decision as to when either should be used. Practically, in the writer's hands an alternation of the plaster corrective jackets and of the retention-muscle training has often "'^een most effective. 228 57223^ *: iivV-OPERA^lVli.iltljAtMKNT OF (SCOLIOSIS 229 But it fe\6isi5lJcH*^tti*4tj\liie.*.jii^gment of the one in charge must be formed and controlled, not only by his observation of the patient's varying general condition, but particularly by a system of measuring of the specific elements of deformity which should be reasonably accurate and yet so easily applied as to be used at each change of plaster-of-Paris jacket and at monthly intervals while the intensive exercises are being taken. FIG. 1— The type, right-dorsal left lum- bar, showing deviation of spine, low left shoulder, upper trunk-lean to the right, and bulge of right-rear chest and of left low torso. Fig. 2 — Adhesive strip placed on spine, record of deviation and of carriage of shoulders marked and relation of upper trunk-lean to plumb line shown. (Note: In the pictures of the model, the spinous processes have been marked to show the effect of the exercises.) After first hunting for and eliminating, if possible, unequal lengths of legs and congenital bone asymmetries, the writer finds the following elements of deformity necessary to recoi'd at regu- lar intervals: 1. Deviation of the spine, standing. 2. Relative can-iage of shoulders, standing. 3. Relation of lateral upper trunk lean to a spinal per- pendicular, standing. 4. Deviation of spine, in prone lying. 5. Rotation of spine, in prone lying. 230 WALTER TRUSl.aW They can be recorded in f roni." fivQ 'to. .ten mirutes, and the succeeding records, rightly studied, are exceedingly valuable. The patient stands with back exposed from neck to buttocks' fold. (Fig. 1.) A strip of adhesive plaster is placed over the spinous processes, from seventh cervical to first sacral (at top of but- tocks' fold) ; the successive spinous processes are palpated and marked on the adhesive plaster ; the level of right and left scapular Fig. 3 — Transferred adhesive strip, marking the spinous processes, the spinal height, the shoulder levels and the lateral projection of sacral perpendicular opposite seventh cer- vical vertebra and showing the meas- urements. angles are projected and marked on the margins of the adhesive plaster. A plumb line, representing the "sacral perpendicular," is then hung in such a manner that its weight will be opposite the buttocks' fold and the upper end to right or left of the seventh cervi- cal marking. (Fig. 2.) Where the string is opposite the seventh cervical point, a mark is made on the adhesive plaster. To make a permanent record of this, the adhesive plaster is transferred from the patient's back to any flat surface, and the following lines drawn and distances measured. (Fig. 3.) A line is drawn, with ruler • 'C10-\-OPEfe'A'i;[Y!5'T«E»\.TME>T OF SCOLIOSIS 231 guide, from""s\3V^h'th:dei'Vtc:al]to.'§i\si-sacral dot. It is called "spinal height." A line is dra's\Ti from it to the dot, representing greatest dorsal deviation ; another to greatest lumbar deviation. Either marking, for scapular angle, is projected across the adhesive strip, to get its level relative to that of the opposite scapular angle. Measurements are taken as follows: a. of dorsal deviation. b. of lumbar deviation. c. of spinal height. d. of relative scapular levels. e. of projection, to right or left, of seventh cervical vertebra to sacral perpendicular. A history sheet record of the above reads, for example : Spine, standing; Spinal deviation 3.2 + 1.5 — = .1044 or 101/2% 45 Carries left shoulder 3.3 lower. Carries 7th cervical 1.6 to the right. The above is a record of certain elements of deformity in standing or weight-bearing posture. To obtain a record of bony changes, weight-bearing must be eliminated. The patient is placed in a standard position prone upon a table. Another strip of adhesive plaster is used upon the exposed back from seventh cervical to buttocks' fold. Succes- sive spinous processes, from seventh cervical to first sacral, ai"e palpated and marked. Rotations in degree are obtained by the use of the writer's rotatometer. (Fig. 4.) This consists of two hinged arms, with a recording sector fixed to one, and an indicator fixed to the other. The arm with the fixed sectoi- is placed across the back, at the position of greatest dorsal rotation. It takes such tilt to the horizontal as this back transverse may give it. The arm with the index has also a spirit level. This arm is moved up and down until it is levelled, and the degrees of rotation are read as at the place which its index takes on the sector of the other arm. The greatest lumbar I'otation (sector arm tilted in 232 WAI.TKK TIUSI.OW the opposite direction) is taken in the same way. The adhesive strip is transferred, and is ruled and measured for spinal height and for dorsal and lumbar deviations, as when taking these measurements with the patient in the standing position. The his- tory sheet record of these measurements would read, for example: Spine, prone; Spinal deviation 2.2 + 1.1 = .0733 (or 71/3%) 45 Rotations, 8 degrees and 5 degrees. Fig. 4 — Writer's rotatometer. Note arm to parallel the back transverse, the leveling arm and the sector and pointer. Comparison of the relative measurements of the standing and of the prone positions, of the amount of self-correction pos- sible and of the examiner's correction is an aid to prognosis, but is particularly important in determining how effective is the treat- ment, and what feature of deformity correction must be empha- sized in continuing treatment. JfON-OPERATIVE TREATMENT OF SCOLIOSIS 233 Details of the plaster-of-Paris corrective jacket will not be dealt with at this time. Effective methods of procedure are well kno'WTi. Each surgeon must use that which he knows best. But some features of technique seem worth emphasizing. First, one must have a very clear idea of the elements of deformity to be cor- rected. The writer finds it more effective to depend upon the ap- plication of the jacket to correct the faulty upper trunk-lean and the low shoulder, and upon the exact placing of subsequent pad- FiG. 5 — The starting position. I. Kneeling dings to correct the spinal deviations and the rotations ; rather than to emphasize the correction of all deformity elements by the position of the patient upon which the jacket is built. To this end the hips-flexed prone lying position upon the hammock in the frame is chosen. Before plaster dressings are applied, the pelvis is fixed and then the upper trunk is stretched longitudinally and in such a manner laterally as to carry faulty upper trunk-lean across to the opposite side and to lift the low shoulder. This, of course, lessens spinal deviation and, to a slight extent, rotation ; but the emphasis is placed upon the faulty upper trunk-lean and the low shoulder. Having in consideration proper counter pres- 234 WALTKU TBLSLOW SLires, when paddings shall be used, care is taken that the trans- verse of the shoulders shall be in the same plane as the trans- verse of the pelvis. This and succeeding plaster jackets are dis- tinctly corrective, but pressure forces are to be made quite within the limit of comfort. Negative window spaces are cut out and first paddings to correct spinal deviation and rotation are applied in two weeks. Succeeding paddings are applied once a week to six weeks from the application of the plaster jacket. During that period the plaster rigidity itself prevents any further correction in the faulty upper trunk-lean and in the low shoulder ; but much correction of the spinal deviations, of the rotation and of the anterior rib de- FiG. 6— Exercise I. 1. To lessen spinal deviation, hollow-back, winged right shoulder and rotation, and to over correct low left shoulder and lateral trunk-lean. formities may be obtained. The writer emphasizes this point, as he believes that hazy understanding of it accounts for indif- ferent success. The appointment for the application of the second corrective jacket must allow suflicient time to take the measurements, to ap- ply the plaster body mould (a rear half is sufficient), from which a cast is to be made for the retention brace or corset, and then to apply the second corrective jacket. The patient's position for the plaster mould for the brace cast is also hips-bend prone and with over-correction of the faulty upper trunk-lean and with levelled XON-OPERATIVE TREATMENT OF SCOLIOSIS 235 shoulders. The position for the second corrective jacket is hips- bend prone with marked over-correction of the faulty upper trunk-lean and with over-correction of the low shoulder. Its pro- gram of four to six weeks is similar to that of the first corrective jacket. It has been applied in greater length, to meet natural growth plus spinal lengthening due to lessening of spinal devia- tion and spinal rotation. During the wearing of it, further cor- rection of deviation and of rotation and front chest moulding will have been accomplished. At the end of three months, the figures representing spinal deviation should have been reduced about one-half and that rep- resenting spinal height should have been slightly increased. This Fig. 7 — The starling position, 11. On hands and knees. should reduce the ratio of deviation deformity about one-half, or, for example, a ten per cent deviation deformity should be about five per cent. The upper trunk-lean, as indicated by the relation of seventh cervical vertebra to sacral perpendicular, should have been carried nearly to, or, perhaps, passing across the vertical line; and the shoulders should have been levelled. In this time it is usually possible to reduce the figures indicating rotations also about one-half. Although the correcting forces have been but gradually yet steadily applied, and although the cooler months of the year have been chosen and the "scratcher" faithfully used daily, the patient's skin and the patient's disposition will not tol- erate more than three months of these jackets. 236 WAI/l'KK TRUSLOW What is now to be done? We know that much of the de- formity will recur if we do not hold what we have attained and so train the muscles by intensive exercises that they will increas- ingly be able to assume the task of natural support, with ever les- sening artificial support. The brace or corset, planned for at the time of changing the plaster corrective jackets, should now be ready. A truly retaining brace is difficult to attain, but is important. The requisites are (1) ability to hold correction attained; (2) "fool-proof" — the patient must be able to apply it with reasonable accuracy; (3) extensibility to meet normal growth, and longi- FiG. 8 — Exercise II, 1. To lessen spinal deviation and to over correct lateral trunk-lean and low shoulder. Not much effect on rotation. tudinal extensibility and lateral compressibility to follow further deformity improvement which proper exercises will surely give; and (4) finally, if possible, self-correction. (The writer believes that this last will be possible by the use of a laterally bending up- per segment of the brace and a stop-joint to prevent bending in the directions of deformity increase. The mechanical difficulties, however, are such as to make a presentation at this time of what has been accomplished premature) . The Knight spinal brace can be modified to meet all of the requisites outlined, except self-cor- rection. The brace must be worn by night as well as by day at first. >"0.\-OPERATIVE TREATMENT OF SCOLIOSIS 237 With the removal of corrective jackets and with the assump- tion of the retention brace, the intensive exercises begin. The brace is removed for the exercises only. The patient's back is exposed for all exercises, to observe every detail of movement. The starting positions are in kneeling, on hands and knees, in prone lying, on the back, half prone at end of table and finally sitting, to insure as little erect weight-bearing as possible and because from these positions best concentration on the parts to be exer- cised is obtainable. The muscles must gradually be trained to assume the responsibility of weight-bearing. As the muscles get stronger and bring the superimposed body segments nearer and nearer to the line of gravity of the body, the artificial support of the brace is less and less used. A simple reinforced corset be- comes possible. The relation of artificial support to natural sup- port may be expressed by the schematic diagram : Artificial support ; bracing Natural support; muscle training The exercises are classified as Preliminary and Deformity Correcting. The purpose of the preliminary exercises is : 1. To train the patient to take the starting positions and the simplest variations accurately ; 2. To 'iimber up" the stiffened muscles and ligaments of the trunk, the shoulder girdle and the hip-joints; and 3. To start the correction of the exaggerated antero-posteri- or spinal curves. All of the preliminary exercises are symmetrical. I. Kneeling. 1. With hands on hips ; trunk bending forward. 2. Alternate foot placing forward. II. On hands and knees. 1. Alternate head and mid-back raising. 2. Trunk swaying forward to prone lying, then back- ward to resting on heels. 3. Alternate thigh extensions backward to horizontal. 4. Alternate arm extensions forward. 238 WALTER TRUSLOW s«iiif'-immmmmimimm!smi'\ Fig. 9 — Exercise II, 2. To lessen spinal deviation, to lessen winged shoulder and rotation (especially lumbar) and to lessen hollow back. Fig. 10 — Exercise II, 3. Powerfully affecting all elements of the deformity. NO.V-OPEKATIVE TREATMENT OF SCOLIOSIS 239 III. Prone lying. 1. "Seal" — with hands clasped low behind the back; raise head and shoulders and arms. IV. Lying on back. 1. With knees drawn up (feet resting on the floor) ; bend both knees to the chest. 2. With arm stretched upward beyond the head ; arm flinging forward, raise trunk to sitting, to forward reach to toes. Fig. 11 — Exercise III, 1. To lessen winged right shoulder and to develop right vertebro-scapular muscles. Very little effect upon lumbar deformities. horizontal (knee V. Half prone lying at end of table. 1. Alternate thigh raising to straight) . 2. Raising both thighs to horizontal (knees straight). 3. With arms stretched out at sides ; raise head and shoulders and arms. VI. Sitting. 1. With feet apart and dumbbell on floor between; raise weight floor to right shoulder, to high, to shoulder, to floor, to left shoulder, to high, to shoulder, to floor. About a week is sufficient time to give to the preliminary exercises. 240 WALTKR TRf.SLOW The intensive corrective exercises are progressively based on the preliminary exercises. They are asymmetrical. They aim definitely to correct the specific features of the deformity (See Fig. 1.) — the upper side trunk-lean, the low shoulder, the compound spinal deviation, the exaggerated antero-posterior curves, and espe- cially the rotations. It is believed that this is accomplished by actively and progressively using the muscles which must be de- pended upon to maintain these corrections. For clearness of word- ing, the type — right dorsal left lumbar — is here chosen. Modifica- tions of the following exercises must be chosen in variations from this type. Fig. 12 — Exercise IV, 2. To develop abdominal muscles (especially of the left side) and to affect all elements of the deformity. Intensive Corrective (Rotation) Exercises. I. Kneeling. (Fig. 5.) 1. With cane in hands; bend trunk forward to the left, reaching left side of cane far forward to the left, carrying right arm (half bent) sideways upward, with upper trunk twist to the right. (Fig. 6.) II. On hands and knees. (Fig. 7.) 1. Stretch right thigh backward and left arm forward (synchronous movement). (Fig. 8.) NON-OPEKATIVE TREATMENT OF SCOLIOSIS 241 2. Place left foot forward on the floor and raise right arm sideways upward with upper trunk twist to the right (synchronous movement). (Fig. 9.) (Later). 3. Stretch right thigh far backward, sway trunk back- ward (to sitting on left heel), raise right arm sideways up- ward, twisting upper trunk to the right (synchronous move- ment). (Fig. 10.) III. Prone lying. 1. With left arm forward (to the left) on the floor, head resting on left arm, and with right arm out sideways on the floor; raise right arm sideways upward with upper trunk-twist to the right. (Fig. 11.) (Later, with increasing dumbbell weight in right hand). IV. Lying on back. 1. With knees drawn up (feet resting on the floor) ; keeping knees parallel, bend toward the chest, twisting so that knees point to the right (feet to the left). 2. With arms over head on the floor; raise trunk to sitting, to left hand touch to left toe and with right arm rais- ing sideways upward and upper trunk twist to the right (synchronous movement). (Fig. 12.) V. Half prone lying at end of table (feet on floor) . (Fig. 13.) 1. With upper trunk placed to the left on the table, left arm reaching far forward to grasp left side of table and right arm stretched out sideways; raise right thigh to horizontal (knee straight) and raise right arm sideways upward (syn- chronous movement). (Fig. 14.) (Later, add increasing dumbbell weight in right hand.) 2. (Later) Repeat V. 1, but raising both thighs to horizontal (gradually getting an increasing twist to the low spine, by elevating the left hip and thigh). VI. Left thigh support sitting on bench — "spring sitting." 1. The left thigh is supported on the bench, the right thigh-leg-foot is stretched far backwai'd, a dumbbell is held at each shoulder; bend trunk forward to the left, reaching left arm forward (over left knee) to the floor, raise right arm sideways upward, with upper trunk twist to the right (syn- chronous movement). (Fig. 15.) 242 WALTER TRUSLOW 2, Left hand-suppoi't "spring sitting" — The left hand rests on a table far forward, the remainder of the body in spring sitting; raise right arm sideways upward with upper trunk twist to the right. (Fig. 16.) The above exercises are planned with the least apparatus pos- sible, so that the patient may do them at home daily. Where the operator wishes to keep entire control of all of the exercises in his crwn gj^mnasium, much elaboration will suggest itself and such ap- paratus as the Swedish plinth, stall bars and bom, will add to the effectiveness of much of this. The writer outlines an exercise pro- gram as follows: (1) For first month, at office gymnasium once a Fig. 13 — The starting position. V. Half prone lying at end of table. week, (2) for second month, two office visits, (3) thereafter, once a month at office gymnasium. This is supplemented with a writ- ten gymnasium prescription (GR ) of daily home exercises, which is added to usually at each visit. Experience has shown that these exercises are truly corrective and especially of the rotation deformity. Now, to estimate the relative merits of the three procedures and the amount of time to be given to each: 1. The corrective plaster jacket lessens deformity more rap- idly than does brace-wearing or exercises. It affects rotation least of all of the elements of deformity. It has distinct time limitation because of skin-pressure intolerance and because of the patient's attitude toward it. It must be re-assumed after a shorter interval of bracing and exercises in the paralytic spine patient. NON-OPERATIVE TREATMENT OF SCOLIOSIS 243 Fig. 14 — Exercise V, 1. Passively correcting low shoulder and upper trunk-lean and hollow-back, and lessening spinal deviation; actively lessening winged right-shoulder and rotation. Fio. 15 — Exercise VI, 1. Actively affecting all elements of the deformity, but especially spinal deviation and rotation. 244 WAI/IKR TIUSI.OW 2. The retentive brace alone will delay deformity formation. It will bring about no correction of it, and unless constantly cared for, will allow increase in deformity. It is inadequate in the paralytic spine. 3. Exercises alone will not be sufficient to prevent an in- crease in a deformity in which the ratio of deviation is greater than four per cent. It must be used with very gradual progres- sion in the paralytic. When reinforced by an efficient retention brace and intermitted with an occasional short return to the cor- rective jacket, it is the best means available for insuring a stopping Fig. 16 — Exercise VI, 2. While passively correcting spinal deviation, low shoulder and upper trunk lean, to concentrate actively on lessening winged shoulder and rotation. of deformity progress, for insuring a large amount of deformity lessening, and, by its general hygienic, as well as local effect, for a reasonable assurance of non-return of deformity. As to time necessary, one would say that a structural scoliosis presenting five per cent deviation or less would require about one year of active treatment — plaster corrective jackets for three months, nine months of retentive brace and intensive supervised exercises; and that in the second year a girl could wear a NON-OPEBATIVE TREATMENT OF SCOLIOSIS 245 simpler reinforced corset and do her home exercises daily, with occasional supervision of the doctor. A ratio of deviation of five to ten per cent would require three months of corrective jackets; six months of retentive brace and intensive exercises; three months of corrective jackets, and a second year of bracing and supervised exercises. Greater amounts of deformity would require longer time. The paralytic, if treated non-operatively, must have a larger proportion of the time given to the cor- rective jacket and must be carried on for several years. Summary : 1. Successful treatment of structural scoliosis must depend upon a clear understanding of the elements of deformity, and the lessening, if not complete elimination, of all of them. 2. Uniform and regular measurement and numerical record of the elements of deformity are important as guides to continu- ance of treatment and as indicating elements most needing cor- reoion. 3. A balanced use of corrective plaster-of-Paris jackets, of retention brace and of intensive exercises is essential to satisfac- tory results. 4. The position of the patient when the plaster jacket is applied is responsible for improving body posture and shoulder carriage ; the successive paddings, for care of the spinal deviation and the rotation. 5. Essentials of a retention brace are (a) ability to hold correction attained; (b) application by the patient with reasonable accuracy; (c) extensibility and lateral compressibility to meet normal growth and progressive deformity decrease; (d) mechani- cal self-correction by the brace seems possible, but not yet fully attained. 6. Gymnastic exercises must be progressive, intensive and with a minimum of erect weight-bearing. They must aim to cor- rect all of the elements of deformity, especially that of rotation. Starting positions other than standing facilitate these ends. 7. Retention of deformity correction attained must be main- tained while exercise is developing natui'al muscular support. Artificial support may gradually give way to natural support. The paralytic scoliotic must receive a larger proportion of arti- ficial support than will be required for those not paralyzed in the trunk muscles. Internal splinting, by operative bone-fixation, may also be necessary in severe paralytic cases. RETURN NATURAL RESOURCES LIBRARY JQw^m^ 40 Gianinni Hall Tel. No. 642-4493 LOAN PERIOD 1 ALL BOOKS MAY BE RECALLED AFTER 7 DAYS DUE AS STAMPED BELOW S^S junaU^^ SUBJECT TO RfcO IMMECMMELY RECEIVED KLL , t\Jt i \ 4 t993 SlQSCiFNCE UNIVERSITY OF CALIFORNIA, BERKELEY FORM NO. DDO, 50m, 1/82 BERKELEY, CA 94720 ^ ^ I ^05331^^213 ^ 57??a<.' ttlOLOOT UNIVERSITY OF CALIFORNIA LIBR^Y ■% f M