**2.6. Assessment of the patient with ASD**

The objective examination should begin with the assessment of alignment using a posture grid. In this section, we only discuss the evaluation of the sagittal alignment. With the patient standing sideways to the posture grid, the examiner can obtain sagittal alignment in a variety of ways, utilizing tools such as an inclinometer, a flexi-ruler, or a plumbline. The amount of cervical lordosis, thoracic kyphosis, lumbar lordosis, thoracolumbar junction transitional area, pelvic tilt, as well as description of hip and knee position can be measured. An increase in thoracic kyphosis (hyper-kyphosis), and loss of lordosis either in the cervical or in the lumbar/ thoracolumbar region, may lead to alignment faults accompanied by muscle length/strength/ activation changes that will need to be tested and addressed. See **Table 1** for a description of predicted implications of various alignment faults on mobility, muscle length, strength, and muscle performance. This is not an all-inclusive list and does not substitute for a careful evaluation of alignment and contributing factors to the clinical presentation of the client. See **Table 2** for take-home messages regarding radiological parameters as were discussed in this chapter.

Specific intervention strategies are beyond the scope of this chapter. The authors recommend that clinicians interested in working with this patient population pursue additional training in scoliosis education as most experts view it as a sub-specialty in physiotherapy practice [34].


**Table 1.** Common sagittal alignment faults and predicted impairments.



area, pelvic tilt, as well as description of hip and knee position can be measured. An increase in thoracic kyphosis (hyper-kyphosis), and loss of lordosis either in the cervical or in the lumbar/ thoracolumbar region, may lead to alignment faults accompanied by muscle length/strength/ activation changes that will need to be tested and addressed. See **Table 1** for a description of predicted implications of various alignment faults on mobility, muscle length, strength, and muscle performance. This is not an all-inclusive list and does not substitute for a careful evaluation of alignment and contributing factors to the clinical presentation of the client. See **Table 2** for take-home messages regarding radiological parameters as were discussed in this

Specific intervention strategies are beyond the scope of this chapter. The authors recommend that clinicians interested in working with this patient population pursue additional training in scoliosis education as most experts view it as a sub-specialty in physiotherapy

**or lordotic**

**faults**

**deficits**

• abdominals (imbalance of coordination/recruitment of abdominal musculature) • scapular adductors • global trunk extensors and hip extensors, knee

extensors

**Compensatory alignment** 

• increased thoracic hypo-kyphosis (usually

preexisting) **Mobility deficits** • thoracic mobility • ribcage mobility **Muscle length deficits** • short/stiff or overactive thoracic extensors • short/stiff rectus **Muscle performance** 

**PI and hip pathology**

Novel theory hypothesizing relationship between low PI and femoral acetabular impingement (FAI)

Low PI → anterior pelvic tilt with gait → artificial anterior acetabular over coverage and recurrent FAI that increases risk for CAM morphology

[33]

**Thoracic hyper-kyphosis Loss of LL with TLJ in kyphosis Loss of LL with TLJ normal** 

**Compensatory alignment** 

• increased thoracic and global kyphosis • increased pelvic tilt • increased hip/knee flexion

• shoulder range of motion (ROM): flexion and external

**Mobility deficits**

rotation • thoracic mobility • ribcage mobility **Muscle length deficits** • short/stiff pectorals • short/stiff latissimus dorsi • short/stiff rectus abdominus **Muscle performance deficits** • abdominals (imbalance of coordination/recruitment of abdominal musculature)

• scapular adductors • global trunk extensors and hip extensors, knee

extensors

**Table 1.** Common sagittal alignment faults and predicted impairments.

**faults**

126 Innovations in Spinal Deformities and Postural Disorders

chapter.

practice [34].

**faults**

**Compensatory alignment** 

• excess cervical lordosis with forward head • excess lumbar lordosis

• shoulder range of motion (ROM): flexion and external rotation • thoracic mobility • ribcage mobility **Muscle length deficits** • short/stiff pectorals • short/stiff latissimus

**Muscle performance deficits** • abdominals (imbalance of coordination/recruitment of abdominal musculature) • scapular adductors • thoracic extensors

**Mobility deficits**

dorsi • short/stiff rectus abdominus


**Table 2.** Take-home messages on radiological measurements.

#### **2.7. Implications of sagittal alignment and spinopelvic parameters for the orthotist managing adolescents with spine deformity**

#### *2.7.1. The evolution of orthoses for patients with spinal deformity*

Spinal bracing has evolved significantly since the days of Dr. Sayre's tripod device and Dr. Taylors "spinal assistant," both notable historical reference points [35]. The ideas that they employed are still found in orthoses designed today. The concepts of spinal elongation, application of pressure to the prominence of the deformity, and "windows" to create areas of relief are still basic concepts of almost all bracing types still used today. This demonstrates to us that we are not starting a new form of treatment but merely using research to advance ideas started long ago. For further reference, please refer to the SRS bracing manual [36].

The pivotal *Bracing in Adolescent Idiopathic Scoliosis trial* (BrAIST) has altered the medical community's recommendation on bracing in the AIS population. The study was originally designed as a randomized controlled study, but when enrollment goals were not being met, a preference arm was added. This meant that families who opted against randomization were able to choose which group they would like to enter [37]. The study used 44% of patients assigned to the randomized cohort to calculate their intention to treat analysis. They found that the Number Needed to Treat (NNT) in order to prevent one case of curve progression was 3.0 and reduction in relative risk with bracing was 56% [37]. This is no small matter as scoliosis fusion surgery was second only to appendicitis in terms of the total cost in children aged 10–17 years [37, 38]. The BrAIST study linked the success of the brace with more hours of wear time, an average of 17.7 h per day [37].

#### *2.7.2. Role of the sagittal profile in scoliosis orthoses—our theory*

It has long been known that scoliosis is a three-dimensional deformity, and even in the presence of spinal deformity, the body will try to regain balance. Historically, the focus of intervention has been on the control of the frontal and transverse plane. However, the sagittal plane may play a larger role in spinal deformity than previously suspected. The pelvic incidence parameter, described earlier in this chapter, may be a key factor in driving sagittal alignment and an important factor in brace design [19]. It is known that spinal loading occurs mainly via axial compression. However, vertebral bodies are also subjected to shear forces in an anterior or posterior direction. The more posterior the shear force, the less stable the spine is in rotation [39]. It may be theorized that increased posteriorly directed shear forces increase the risk of scoliotic deformity. A study by Schlosser in 2015 noted that the spines of girls during the peak growth spurt are more posteriorly inclined [40]. If accounting for sagittal forces during the peak growth phase can reduce this rotational instability, it may lead to further efforts both clinically and research-wise to address scoliosis based on parameters in addition to the Cobb angle. It may be, according to the hypothesis of the authors, that an increase in Cobb angle is a reaction to the above-described imbalance and instability. Is it possible to predict at-risk patients based on parameters other than the Cobb angle and treat these patients proactively? These questions warrant more clinical research.

#### *2.7.3. Brace construction*

Up to now, the goal in orthoses fabrication has been to maintain "normal" lumbar lordosis and kyphosis values. However, there is a wide range of "normal" ranges in pediatrics. The original scoliosis TLSO used 0° of lordosis as its default value. It was noted that orthoses may achieve the same coronal correction with a lumbar lordosis of 15°, which led to increased patient comfort level. This point is referenced in the SRS bracing manual and in an editorial response in which research has proven the original Boston brace set at 0° of lordosis "produced significant curve correction of the spinal deformity in the frontal plane at the expense of a significant reduction of thoracic kyphosis in the sagittal plane" [36, 41] (**Figure 11**). With respect to the sagittal profile, the authors feel it is imperative to match a patient's individual pelvic incidence to their ideal lumbar lordosis when constructing a brace. In a study using biomechanical modeling, we have the first opportunity to trial several braces on the same patient to observe outcomes based on 15 different design factors [42] (**Figure 12**). This study had some interesting conclusions which may help guide the future of brace treatment.

**Figure 11.** It would be difficult to treat both of these patients when using a "standard" amount of lumbar lordosis. Both of these patients require individualized parameters for treatment success.

Sagittal Alignment in Spinal Deformity: Implications for the Non-Operative Care Practitioner http://dx.doi.org/10.5772/intechopen.69455 129

**Figure 12.** Example of a brace correcting sagittal balance while maintaining thoracic kyphosis.

or posterior direction. The more posterior the shear force, the less stable the spine is in rotation [39]. It may be theorized that increased posteriorly directed shear forces increase the risk of scoliotic deformity. A study by Schlosser in 2015 noted that the spines of girls during the peak growth spurt are more posteriorly inclined [40]. If accounting for sagittal forces during the peak growth phase can reduce this rotational instability, it may lead to further efforts both clinically and research-wise to address scoliosis based on parameters in addition to the Cobb angle. It may be, according to the hypothesis of the authors, that an increase in Cobb angle is a reaction to the above-described imbalance and instability. Is it possible to predict at-risk patients based on parameters other than the Cobb angle and treat these patients proactively?

Up to now, the goal in orthoses fabrication has been to maintain "normal" lumbar lordosis and kyphosis values. However, there is a wide range of "normal" ranges in pediatrics. The original scoliosis TLSO used 0° of lordosis as its default value. It was noted that orthoses may achieve the same coronal correction with a lumbar lordosis of 15°, which led to increased patient comfort level. This point is referenced in the SRS bracing manual and in an editorial response in which research has proven the original Boston brace set at 0° of lordosis "produced significant curve correction of the spinal deformity in the frontal plane at the expense of a significant reduction of thoracic kyphosis in the sagittal plane" [36, 41] (**Figure 11**). With respect to the sagittal profile, the authors feel it is imperative to match a patient's individual pelvic incidence to their ideal lumbar lordosis when constructing a brace. In a study using biomechanical modeling, we have the first opportunity to trial several braces on the same patient to observe outcomes based on 15 different design factors [42] (**Figure 12**). This study had some interesting

**Figure 11.** It would be difficult to treat both of these patients when using a "standard" amount of lumbar lordosis. Both

These questions warrant more clinical research.

128 Innovations in Spinal Deformities and Postural Disorders

conclusions which may help guide the future of brace treatment.

of these patients require individualized parameters for treatment success.

*2.7.3. Brace construction*


All of these concepts need to be tested in the real world and on a much larger scale but they are great starting points for developments of new treatments. A global method to assess bracing

**Figure 13.** New digital imaging can be used to match clinical photos and digital X-rays to patient-specific morphology.

is the concept of overall balance summation, but this is only valid in the frontal plane [44]. The implications for sagittal plane malalignment that continues into adulthood have been well documented and discussed in this chapter; therefore, they should also play a part in brace design [27].

In conclusion, further work is needed with regard to the role of the orthotist in treating sagittal deformity in scoliosis patients, and clear protocols need to be developed. This field is ripe for an infusion of new ideas. The paper that found the number to treat to be three patients also reported that this number was only for patients who were considered compliant. It also reads "routine bracing without efforts to maximize brace compliance are likely to be less effective than the brace trial indicates" [45]. It has been suggested that all conservative care centers should make a strong effort to maximize brace compliance and this should be the new routine, or standard of care as Karol has shown in a recent article. Karol's study demonstrated that if patients engage in compliance counseling, then patients will wear their brace an extra 3 h per day. This increase in bracing compliance also correlated with a decreased surgical rate of 11% [45]. This topic requires further consideration of factors involved in setting up clinics that can handle this portion of treatment.
