Sarah Charlton – Specialist spinal and scoliosis physiotherapist

Physiotherapy provision after scoliosis surgery varies across the country – at Addenbrooke’s Hospital in Cambridge we have run a rehabilitation programme for over 10 years. As a physiotherapist I have worked with this group of patients for over 20 years. The programme was developed based on experience of helping referred patients who were struggling post operatively and turning the process around to offer all patients postoperative management to promote a good recovery for everyone.

The role of the physiotherapist in the Addenbrookes scoliosis service begins before surgery. We treat and help manage patients while they are waiting for surgery and guide them in the recovery phase. We meet patients on every part of their journey, from diagnosis to discharge. My colleague Claire and I work alongside our two spinal surgeons. The first part of the surgical pathway is scoliosis counselling about surgery which takes place as part of a combined assessment day, including MRI, lung function testing, and medical risk assessment with a paediatrician. We call this the Scoliosis One Stop Shop or “SOSS” because we endeavour to complete all the appointments in 1 day, although Covid has made this more difficult. At the counselling stage we introduce advice about posture correction, fitness, and stretching, to improve flexibility of the curve in preparation for surgery.

After discussion at our scoliosis multi-disciplinary team meeting, patients will be added to the waiting list for surgery. Whilst on the waiting list patients can access the physiotherapy service to help manage their symptoms. As a result, we know our patients coming through the system.

The post-operative period starts with our physiotherapist on the ward who works on early mobilisation and gentle exercises in the first few days post-surgery and sets the patient up with advice and gentle exercises to do at home during the first 6 weeks. Our scoliosis nurse practitioner will contact the patient to check on their progress and one or two patients will be referred to physiotherapy in the early period so we can do a video or telephone call if necessary.

Patients return to clinic at 6 weeks post-surgery for their post-operative consultation including an X-ray. On the same day we start our physiotherapy and hydrotherapy rehabilitation programme. We begin by looking at the X-ray and comparing the correction to the preop X-rays, which helps us to identify areas of postural correction to work on. Patients tend to lean or side shift towards their ‘old’ position because this is where they feel stronger and have better balance. We use a mirror to show them how to do small corrective movements and then assess which soft tissue structures are tight and therefore reinforcing the old movement patterns.

The main areas to work on are: –

• Shoulder posture – shoulders are adjusting to the change in position of the ribs.
• Lean or shift – due to muscle imbalance.
• Derotation or unwinding – due to the correction, if tighter muscles cannot curve the spine, they can sometimes cause trunk rotation instead.

The X-ray images help us to look at the framework of the bony skeleton and then explain how the soft tissues (muscles and skin) all to need to stretch and grow to fit the new, more balanced, and improved symmetry of the skeleton. At this stage the surgeons have completed their task of ‘correcting’ the skeleton and stabilising the curve, and physiotherapy can help improve any residual muscle imbalance as the soft tissues adjust.

The programme starts with a simple set of exercises promoting range of movement through the whole trunk and tight structures through the hips and shoulders. Everyone is offered sessions of guided exercise in the hydrotherapy pool; the warm water is a great environment to gain confidence in movement.

Between 2 and 6 months post-surgery most patients will complete up to four physiotherapy rehabilitation sessions. It is a group format, with two patients in the pool and two doing 1:1 exercise with the physiotherapist. The group sessions provide a great forum to discuss progress and advise about returning to school, activity levels, and participation in school PE and other sport. It is also a good opportunity for parents to chat, compare experiences, and reassure each other. Exercises are gradually progressed to include rotation and increase range of movement. The next stage is to work on balance and stability in their corrected posture and towards the end we are looking to improve fitness and stamina. Throughout the process we are checking posture and adding hints and tips for correction exercises – highlighting particularly tight areas such as the hip flexors being tighter on one side than on the other, which tends to cause trunk rotation and exacerbate rib prominence.

There are many facets to the recovery journey. We focus on three main areas to promote physical fitness: –

• Spine range of movement and stretching – moving the areas of spine that are not fused.
• Balance and stability in the new corrected posture.
• Regaining strength and cardiovascular fitness.

It is also a huge experience to process mentally and emotionally, and our group setting provides a forum to meet other patients who have had surgery and answer questions whilst also offering 1:1 advice and reassurance.

Patients return to clinic for formal review and X-ray at 6 months. As physiotherapists we lead these appointments on behalf of the consultants and are therefore able to check on individual progress. We focus on progress with return to school or work and activities. We can offer guidance on different activities and work through returning to sport with sports-specific advice. Many of our patients are still growing, and this can also affect their posture during the post-op years – this can usually be remedied with resumption of exercises and stretches to improve flexibility and accommodate skeletal growth. We are a regular port of call for parents and patients offering advice during their recovery and answering their questions – after the 6-month appointment patients are reviewed at 1, 2 and 3 years or until they have finished growing.

In the first year following surgery some patients wonder why they still find their normal day tiring, especially as they look well from the outside and feel like they should be doing better or more. It is always worth remembering how much work the bodies’ systems are doing on the inside to strengthen the spinal fusion around the implants, heal the wounds, and recover from the anaesthetic and blood loss as well as the enforced rest period and lack of normal activity, reducing fitness levels. The best plan for a good recovery is to pace it carefully. The trunk muscles fatigue quickly when working to hold the longer straighter spine. Take rest periods, lie down for short periods, if able, to rest those stretched spinal muscles so that they can recover regularly, ache less, and recharge for the next bout of activity that will ultimately help regain fitness. It is better to build strength and stability in the new posture for shorter periods with regular rests than it is to struggle on with an activity for too long and resort to a deteriorating posture to achieve it.

We always advise the patients to change position regularly, move often, and avoid prolonged postures – especially sitting for too long. This is great advice but hard to implement in the school / work setting so it helps to be able to discuss with a physiotherapist and work out the best way of achieving a steady recovery.

In the later stages, we encourage resumption of school PE, dance, and other sporting activities following the recommended guidelines for return to activity. For patients who were not sporty or active before their surgery we encourage simple exercise routines to maintain their comfort and flexibility.

Working with this group of patients is hugely rewarding, following patient’s scoliosis journey, seeing them grow in confidence with relieved happy faces following the anxious pre surgery months gives great job satisfaction. I never lose enthusiasm for working on the little details that will make a difference and promote a healthy and active lifestyle into old age with a good knowledge of how to look after their back’s and keep them moving comfortably.