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Regarding the thoracic curve correction: Sitting tail with the spine in as good an anteroposterior alignment as possible, the subject reaches in a diagonally upward direction, slightly forward from the coronal plane. The aim is to practice holding the corrected position to develop a new kinesthetic sense of what is straight. The faulty position has become so habitual that the straight position feels abnormal.

All too often, early cases of lateral curvature are "treated" merely by observation, with radiographs obtained at specified intervals. Early tendencies toward a lateral curvature are potentially more serious than the anteroposterior deviations seen in the usual faulty postures. Instruction in good body mechanics and appropriate postural exercises, plus the necessary shoe alteration to mechanically assist in the correction of alignment, constitutes more rational treatment than mere observation.

Correction of lateral pelvic tilt associated with a lateral curvature can be helped by proper heel lifts. The cooperation by the subject is of utmost importance. The lifts need to be used in all shoes and bedroom slippers. No amount of lift can help if the subject continues to stand with the weight predominantly on the leg with the higher hip and with the knee flexed on the side of the lift.

For use of a lift in connection with a tight tensor fasciae latae and iliotibial band, see page 450. For use of a lift in the heel of the opposite shoe to relieve strain on a weak gluteus medius, see page 439.

Along with the use of appropriate exercises, it is important to avoid those exercises that would have an adverse effect. Increasing the overall flexibility of the spine carries an inherent danger. Gains in flexibility in the direction of correcting the curves are indicated, provided that strength is also increased to maintain the corrections. If the subject has the potential for gaining strength and is dedicated to a strict program of strengthening exercises and wearing a support, exercises that increase flexibility can have a desirable end result.

A subject who is developing a kyphoscoliosis along with a lordosis should not do back extension exercises from a prone position because in an effort to obtain better extension in the upper back, the low back problem increases. Extension of the upper back may be done while sitting on a stool with the back against a wall, but the low back must not arch in an effort to make it appear that the upper back is straight. In this same instance, "upper" abdominal exercises by trunk curls or sit-ups should be avoided even if the upper abdominals are weak. The exercise would be counterproductive, because curling the trunk is rounding the upper back. If there is a developing kyphoscoliosis, such an exercise would increase the kyphotic curve. Exercise of the lower abdominals in the form of pelvic tilt or of pelvic tilt and leg sliding, emphasizing the action by the external oblique, however, would be strongly indicated. (See p. 215.)

The significance of muscle imbalance and overall faulty posture as etiological factors in idiopathic scolio-sis should not be overlooked. Scoliosis is a complex postural problem. As such, it calls for thorough evaluation procedures to determine any weakness or tightness of muscles that results in distortion of alignment. Verification can come only from repeated testing, but the testing must be done with precision. There must be adherence to the principles on which manual muscle testing is founded. (See p. 14.) Using a long lever whenever appropriate is vitally important to distinguish differences in strength of some of the large muscles (e.g., hip abductors) when comparing one side with the other.

SUPPORTS

In addition to exercise and proper shoe corrections, many patients with early scoliosis need some support. It may be that only a corset type of support is needed or. as in more advanced cases, a more rigid support. The Kendalls made many of these rigid supports.

In the illustration opposite, the subject is shown wearing a removable cellulose jacket of the type often used for scoliosis cases. The procedure for making this jacket follows.

The subject was placed in a standing position with head traction from a Say re head sling. A heel raise was used to level the pelvis, and straps of adhesive tape or moleskin were placed diagonally from the rib cage to the opposite iliac crest to obtain the best possible correction of the trunk position before the original plaster case was made. For girls, a brassiere with small extra padding was put on under the stockinet to allow room for development of the breasts.

After the positive plaster mold was poured and dry. further adjustments were made by shaving down slightly on the side of convexity and adding an equal amount of plaster at places of concavity at the same level to maintain the necessary circumference measurements. The jacket was then made over the plaster mold.

Today, newer materials provide greater versatility and ease of handling, but the basic principles for use of supports have changed little: Obtain the best possible alignment, allow for expansion in the area of concavity, and apply pressure in the area of convexity to the extent tolerated without adverse effects or discomfort.

IMPORTANCE OF EARLY INTERVENTION

Instead of waiting to see if a curve gets worse before deciding to do something about it, why not treat the problem to help prevent the curve from getting worse?

Doing something in the very early stages of a lateral curve does not mean getting involved in a vigorous, active program of exercises. Rather, it means prescribing a few carefully selected exercises that help establish a kinesthetic sense of good alignment. It means providing good instruction to the patient and the parents in how to avoid habitual positions or activities that clearly are conducive to increasing the curvature.

It may mean taking a picture of the child's back in the usual sitting or standing position, and then another in a corrected position, so that the child can see the effect of the exercise on posture. It also means providing incentives to help keep the person interested and cooperative, because achieving correction is an ongoing project.

For those in whom the curve has become more advanced, in many instances it is necessary and advisable to provide some kind of a support to help maintain the improvement in alignment that has been gained through an exercise program.

CLASSIC KENDALL

Henry O. Kendall was the first physical therapist at the Children's Hospital in Baltimore, beginning work there in June 1920. The following is a quote from some handwritten notes made by him in the early 1930s regarding scoliosis:

Symmetrical exercises should not be attempted. A careful muscle examination should be made and muscles graded according to their strength. If one group or one muscle is too strong for its antagonist, that muscle or group should be stretched and the weaker antagonist built up to sufficient strength to compete with it.

In examination of more than one hundred cases of lateral curvature, I have yet to find a case with weak erector spinae muscles, each and every case was able to hyperextend the spine against gravity and in most cases against resistance as well.

The muscle weakness was almost always found in the lateral abdominals, anterior abdominals, pelvic, hip and leg muscles. This weakness caused the body to deviate from either the lateral median plane or the anterior-posterior median plane, causing the patient to compensate for the deviation by substituting other muscles in order to maintain equilibrium. In doing the substituting, the patient invariably develops muscles which cause lateral rotatory movements and it is easy to see why we have lateral curvature with rotation.

By correcting muscle imbalance we get at the primary cause of many cases of lateral curvature.

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