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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 54  |  Issue : 1  |  Page : 29-32

Functional independence in left dorsolumbar congenital kyphoscoliosis – An occupational therapy perspective : A case report


1 Occupational Therapy School and Center, BYL Nair Ch Hospital and TN Medical College, Mumbai, Maharashtra, India
2 P D Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India

Date of Submission30-Jan-2021
Date of Decision14-Feb-2022
Date of Acceptance01-Mar-2022
Date of Web Publication25-Mar-2022

Correspondence Address:
Poornima Raikar
Clinical Occupational Therapist, Department of Occupational Therapy, B. Y. L Ch. Nair Hospital, Mumbai Central, Mumbai - 400 008, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijoth.ijoth_17_21

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  Abstract 


Congenital scoliosis is caused by early embryologic errors in formation of vertebral column. The goal of treatment is to improve the children's quality of life and to give them the best chance to develop as an independent adult. The objectives were to assess the effects of occupational therapy (OT) intervention on balance, gait, and activities of daily living (ADL) in a case of congenital scoliosis. A 14-year-old young female studying in 10th standard diagnosed as left-sided dorsolumbar congenital kyphoscoliosis with apex of scoliosis at 11th dorsal segment level was assessed. She presented with lower extremity spasticity, imbalance, and scissoring gait. Assessment was done using the Berg Balance Scale (BBS) and Modified Barthel Index (MBI). Immediate postoperative OT intervention was started inclusive of balance and gait training. Significant improvement was observed on BBS score preoperatively before therapy from score 11 to post therapy score 50 after therapy was initiated and MBI score preoperatively 11 to post therapy 20 after ADL training at 8 months of therapy.

Keywords: Balance, Congenital Scoliosis, Functional Independence, Gait


How to cite this article:
Raikar P, Vaidya PM, Chaudhary KS. Functional independence in left dorsolumbar congenital kyphoscoliosis – An occupational therapy perspective : A case report. Indian J Occup Ther 2022;54:29-32

How to cite this URL:
Raikar P, Vaidya PM, Chaudhary KS. Functional independence in left dorsolumbar congenital kyphoscoliosis – An occupational therapy perspective : A case report. Indian J Occup Ther [serial online] 2022 [cited 2022 May 29];54:29-32. Available from: http://www.ijotonweb.org/text.asp?2022/54/1/29/340892




  Introduction Top


Congenital scoliosis is the least common of three types of scoliosis affecting 1 in 10,000 newborns.[1],[2] It is caused by early embryologic errors in the formation of vertebral column. It occurs when the vertebrae do not form normally or do not separate correctly before a baby is born. Congenital scoliosis is classified by both anatomic location and type of anomaly.[1],[2] There are associated anomalies in growth of neural structures, leading to neurological deficit in lower limbs.[2] Factors that contribute to this spinal deformity include asymmetric paraplegia, imbalance of mechanical forces, intraspinal and congenital anomalies of the spine, altered sensory feedback, and abnormal posture via central pathways. Spinal deformity combined with limitations due to an underlying neuromuscular condition lead to significant physiologic impairments that affect limb movement, cardiopulmonary function, gait, standing, sitting, balance, trunk stability, bimanual activities, activities of daily living, and pain, as well as concerns with self-image and social interactions.[3]

Early appropriate treatment modality will preserve their lifestyle and minimize their handicap. Poor spinal alignment is compensated in the lower extremities, but deformity beyond compensation is associated with a risk of severe postural instability.[4] The postural control system operates as a feedback control circuit between the brain and the musculoskeletal system. Sensory organization and muscle coordination are involved in maintaining upright posture.[5],[6]

General rehabilitation principle aims at restoring the patient's full function as early as possible without risking the surgical intervention performed. Early mobilization is necessary to prevent deconditioning and to minimize the causes of other secondary postoperative morbidities.


  Patient Information Top


A 14-year-old female patient studying in 10th standard with the diagnosis of left-sided dorsolumbar (DL) congenital kyphoscoliosis with 11th dorsal segment (D11) hemivertebrae with apex of scoliosis at D11 level was assessed. She presented with lower extremity spasticity, imbalance, and scissoring gait.[1] She stays with her parents and elder brother. Her hobbies are cycling, dancing, and playing badminton. She was given total contact spinal brace at a private hospital. As her symptoms were progressing, she came to a government hospital for further treatment.


  Clinical Findings Top


Preoperative

Tingling and numbness in both lower limbs at L1 L2, L3 L4, L5 S1 dermatome. Difficulty in walking and maintaining balance since december 2019. Prior to December 2019, the patient did not have any symptoms. Clinical evaluation revealed bilateral lower extremity spasticity (grade 2) as per Modified Ashworth Scale (MAS), muscle strength grade 3+ in right lower limb as per Oxford Grading Scale (OGS), paresthesia in both lower limb, bilateral ankle clonus, exaggerated knee and ankle reflexes in both lower limbs, bilateral extensor plantar reflexes, imbalance,[V1] and scissoring gait,[V1] inability to climb stairs, degree of Cobb angle 41.5. Apex of scoliosis was at D11 level, upper-end vertebra at D8 level, and lower-end vertebra at L2 level [Figure 1].
Figure 1: Preoperative Anteroposterior View X-Ray (January 19, 2020)

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Postoperative

On February 6, 2020, she underwent D11 corpectomy with laminectomy with pedicle screw fixation and kyphoscoliosis correction. Spasticity persisted in the right lower limb (grade 1+) as per MAS with no paresthesia. Bilateral ankle clonus and brisk knee and ankle reflexes, bilateral extensor plantar reflexes, imbalance while walking,[V2] and mild scissoring gait,[V2] difficulty in climbing stairs was observed, muscle strength grade 3+ as per OGS in the right lower limb and reduction in the degree of Cobb angle to 15° [Figure 2].
Figure 2: Postoperative X-Ray Anteroposterior View (February 07, 2020) and Single-Leg Stance Post 8 Months of Intervention

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Timeline

Assessment and therapy period was 8 months from February 2020 to November 2020.


  Assessment Top


Clinical evaluation of tone, reflexes, range of motion, sensation, coordination, and muscle strength was done. Objective evaluation of tone was done using the Modified Ashworth Scale (MAS), balance using the Berg Balance Scale (BBS), and activities of daily living (ADL) using the Modified Barthel Index (MBI). Videographic evaluation was done for gait. Assessment was done preoperatively[V1] on February 4, 2020, 2 days prior to surgery and at the end of 1 month[V2] and 8 months postoperatively[V3] [Table 1].
Table 1: Assessment

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  Intervention Top


Immediate goals were set to improve transfer from bed to chair and sit to stand, stand with and without support, walk with good balance, stair climbing, and carry out ADL like toilet activities, bathing, and dressing independently. Further management was planned to focus on increasing physical endurance and improving quality of life by achieving independence in her recreational activities. Immediate postoperative occupational therapy (OT) intervention was started inclusive of balance and gait training along with conventional OT. Intervention protocol is described in [Table 2]. Each session lasted for a duration of 45 min, once a week, for a period of 8 months. Home program was explained between each follow-up. The patient followed up once a week for balance, gait, and ADL training [Figure 3].
Table 2: Treatment Protocol

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Figure 3: Balance Training and Stair Climbing at 3 Months

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  Follow-Up and Outcomes Top


The scores on BBS indicated high fall risk score of 11 preoperatively to medium fall risk score of 24 post therapy at 1 month to low fall risk score of 50 8 months post therapy. The patient's ADL score improved post therapy from moderate disability to no disability, as indicated in [Table 1]. Videographic analysis[V2,V3] showed significant improvement in her gait and balance, as indicated in [Table 1].


  Discussion Top


In this case study, the main objective was to improve gait, balance, functional activity, and the hobbies pursued by a 14-year-old female patient with DL kyphoscoliosis. The major goal established was to increase participation in ADL and satisfy the patient's needs, based on cultural and social context using sensory motor and vestibular inputs and balance training modalities.

Byl N. N. and Gray J. M. noted that when visual and somatosensory systems were challenged, idiopathic scoliosis patients had higher sway than normal control group.[7] Guo et al. commented that balance control requires the contribution of somatosensory, visual, and vestibular inputs and noted the presence of abnormal somatosensory function in patients with idiopathic scoliosis.[8]

Back and abdominal muscles have an active part in gait balance by controlling the anteroposterior trunk sways and rotational movements of shoulder girdle.[9]

In this case study, the use of gait and balance training along with other somatosensory modalities and visual cues showed significant improvement in the patient's gait pattern, step length, stride length, and cadence. This was analyzed using videographic data. Significant reduction of scissoring in gait pattern was observed at the end of 1 month, and by the end of 8 months, the patient's gait pattern was near normal.

The patient showed moderate disability in functional tasks by the end of 1 month postoperatively. By the end of 8 months, the patient was completely independent in all functional tasks. Along with functional independence, the patient could engage in activities such as cycling, dancing, and playing badminton that can be noted in the videographic recording.

Schell et al. commented that a person's function is shaped by a variety of contextual factors to gain, restore, or sustain skills and abilities that promote self-efficacy and independence as well as social involvement and engagement.[10]

Thus, it can be said that gait and balance training protocol using somatosensory and visual cue and conventional OT was beneficial in this case with DL spine scoliosis.


  Patient's Perspective Top


The patient expressed that she could do her ADL like toilet activities, bathing, dressing, walking, and stair climbing independently. She was overwhelmed that she could perceive her hobbies of dancing, cycling, and playing badminton.

Declaration of Patient Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Acknowledgment

I sincerely thank the Dean of B.Y.L. Nair hospital for allowing me to conduct study. Dr. Trupti Nikharge(clinical occupational therapist) for her support. Patient and her relatives for the cooperation.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.



 
  References Top

1.
Hedequist D, Emans J. Congenital scoliosis. J Am Acad Orthop Surg 2004;12:266-275.  Back to cited text no. 1
    
2.
Maheshwari J. Essential Orthopedics: Scoliosis and Other Spinal Deformities. 5th ed. New Delhi, India: The Health Sciences Publisher; 2015. p. 280-283.  Back to cited text no. 2
    
3.
Allam AM, Schwabe AL. Neuromuscular scoliosis. PM R 2013;5:957-963.  Back to cited text no. 3
    
4.
Ishikawa Y, Miyakoshi N, Kobayashi T, Abe T, Kijima H, Abe E, et al. Activities of daily living and patient satisfaction after long fusion for adult spinal deformity: A retrospective study. Eur Spine J 2019;28:1670-1677.  Back to cited text no. 4
    
5.
Horak FB, Nashner LM, Diener HC. Postural strategies associated with somatosensory and vestibular loss. Exp Brain Res 1990;82:167-177.  Back to cited text no. 5
    
6.
Shumway-Cook A, Horak FB. Assessing the influence of sensory interaction on balance. Suggestion from the field. Physical therapy, 1986;66:1548-50.  Back to cited text no. 6
    
7.
Byl NN, Gray JM. Complex balance reactions in different sensory conditions: Adolescents with and without idiopathic scoliosis. J Orthop Res 1993;11:215-227.  Back to cited text no. 7
    
8.
Guo X, Chau WW, Hui-Chan CW, Cheung CS, Tsang WW, Cheng JC. Balance control in adolescents with idiopathic scoliosis and disturbed somatosensory function. Spine (Phila Pa 1976) 2006;31:E437-E440.  Back to cited text no. 8
    
9.
Hopf C, Scheidecker M, Steffan K, Bodem F, Eysel P. Gait analysis in idiopathic scoliosis before and after surgery: A comparison of the pre- and postoperative muscle activation pattern. Eur Spine J 1998;7:6-11.  Back to cited text no. 9
    
10.
Schell BA, Gillen G, Scaffa ME, Cohn ES. Willard and Spackman's Occupational Therapy: Contemporary Occupational Therapy Practice. 12th ed. Philadelphia: Lippincott Williams & Wilkins; 2014. p. 47-58.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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Abstract
Introduction
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Clinical Findings
Assessment
Intervention
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