What is Scoliosis?

Sometimes a person’s spine curves and rotates making it look like an “S” or a “C”. This is called “Scoliosis”. Because your ribs attach to your spine, when the spine rotates, it raises the ribs and creates a rib hump.
Scoliosis is the most common spinal disorder in children and adolescents. A scoliosis is characterized by a side-to-side curvature of the spine >10°, usually combined with a rotation of the vertebrae and most often a reduced kyphosis in thoracic curves. This is especially noticeable when you b end forward.
You may also notice differences in your chest or breast size, your shoulders, or your waist. They may appear uneven. The curve may become larger as you grow. Curves in the middle of your back that reach 45 to 50 degrees will probably increase throughout life. If the curve is greater than 70 degrees, it can affect your breathing.
Scoliosis does not come from carrying something heavy like your backpack or from bad posture. Scoliosis does not cause back pain in most patients.

Causes & Types of Scoliosis

In most cases, we don’t know what causes scoliosis, and we call that “Idiopathic Scoliosis”. Scoliosis patients are classified in different types according to age of onset, etiology, severity and type of curve. Each type shows different characteristics as rate of curve progression, degree and pattern of the three-dimensional deformity. The major groups of scoliosis is idiopathic scoliosis.

• Juvenile scoliosis:
  Juvenile scoliosis develops at the age of 4–10 years and comprises 10–15 % of all idiopathic scoliosis in children, untreated curves may cause serious cardiopulmonary complications, and curves of 30 and more tend to progress, 95 % of these patients need a surgical procedure.
• Adolescent scoliosis:
  Adolescent scoliosis develops at the age of 11–18 years and accounts for approximately 90 % of cases of idiopathic scoliosis in children. Adult scoliosis (de novo scoliosis in adults): this type of scoliosis has a prevalence of more than 8 % in adults over the age of 25 and rises up 68 % in the age of over 60 years, caused by degenerative changes in the aging spine.^[1]Answer et al described a prevalence of 2,5 % in the general population with a Cobb angle larger than 10 degrees.^[2]

Characteristics/Symptoms

1. Sideways curvature of the spine
2. Sideways body posture
3. One shoulder raised higher than the other
4. Clothes not hanging properly
5. Local muscular aches
6. Local ligament pain
7. Decreasing pulmonary function is a major concern in progressive severe scoliosis.
8. 6% report chronic thoracic pain that lasted for at least 3 months during the last 12 months^[3]
9. 6% report chronic lumbar pain that lasted for at least 3 months during the last 12 months ^[3]

Examination

The aim of the functional examination is to distinguish between faulty posture and actual idiopathic scoliosis

1. Examination of the active movements(flexion, extension and side flexion) of the spine in the cervical, thoracic and lumbar segment.
2. The Adam Forward Bend Test can be used to make a distinction between structural or non-structural scoliosis of the cervical to lumbar spine. The test can be performed in the standing and sitting position.

• In standing position, the examined person is asked to bend forward looking down, keeping the feet together, the knees straightened, shoulders loose and hands positioned in front of knees or shins with elbows straight and palms opposed. If the condition is present in both standing as bending position, the scoliosis is structural. If the condition is present in standing position but disappears when the examined person bends forward, the scoliosis is not structural.
• In the sitting position, the examined person is seated on a chair with a height of 40 cm. The examined person is asked to bend forward and place his head between the knees, with his shoulders loose, elbows straight and hands positioned between the knees. The position of spinal processes and presence of a costal hump are evaluated.

3. The Cobb’s Angle is a standard measurement to determine and track the progression of scoliosis:

• 
• Locate the most tilted vertebra at the top of the curve and draw a parallel line to the superior vertebral end plate.
• Locate the most tilted vertebra at the bottom of the curve and draw a parallel line to the inferior vertebral end plate.
• Erect intersecting perpendicular lines from the two parallel lines.
• The angle formed between the two parallel lines is the Cobb angle.

Chang Ju Hwang. (2017), Progression of trunk imbalance in adolescent idiopathic scoliosis with a thoracolumbar/lumbar curve: is it predictable at the initial visit?, Journal of Neurosurgery: Pediatrics ,Volume 20

4. The Scoliometer is an inclinometer designed to measure trunk asymmetry, or axial trunk rotation. It’s used at three areas:

• Upper thoracic (T3-T4)
• Middle thoracic (T5-T12)
• Thoraco-lumbar area (T12-L1 or L2-L3)
• If the measurement is equal to 0°, there is a symmetry at the particular level of the trunk. An asymmetry at the particular level of the trunk is found, if the scoliometer measurement is equal to any other value.^[4]

Prediction of Progress

Evaluating Risser sign to help estimate bone age (and thus skeletal maturity and risk for scoliosis progression) is easily done during a spine x-ray as the pelvis is imaged at the time of the spine.

Hacquebord, Jacques H.; Leopold, Seth S. (2012): In brief. The Risser classification: a classic tool for the clinician treating adolescent idiopathic scoliosis. In Clinical Orthopaedics and Related Research 470 (8), pp. 2335–2338.

A Risser scale of 0 corresponds to an immature skeleton of someone with a lot of growing left to do, and no ossification is observed along the ilium.

As they go through puberty, new bone is laid down until they reach Risser 5, at which point all new bone has fused to the ilium and now appears as one solid bone.

Peterson, L. E.; Nachemson, A. L. (1995): Prediction of progression of the curve in girls who have adolescent idiopathic scoliosis of moderate severity. Logistic regression analysis based on data from The Brace Study of the Scoliosis Research Society. In The Journal of bone and joint surgery. American volume 77 (6), pp. 823–827.

Lonstein, J. E.; Carlson, J. M. (1984): The prediction of curve progression in untreated idiopathic scoliosis during growth. In The Journal of bone and joint surgery. American volume 66 (7), pp. 1061–1071.

Treatments

There are many treatment for the curved spine condition. Doctor and Physiotherapist will consider the size and type of your curve, how much growing you have left to do, and if you have any other medical conditions.

Sometimes, wearing a brace is effective for curves between 20 and 40 degrees in children who are growing. But, wearing a brace does not make the curve smaller. The goal is to prevent a curve from progressing or getting bigger.

Patients with early-onset scoliosis, defined as a lateral curvature of the spine under the age of 10 years, are offered surgical treatment when the major curvature remains progressive despite conservative treatment (Cobb angle 50 degrees or more). Spinal fusion is not recommended in this age group, as it prevents spinal growth and pulmonary development.^[5]

Physical Therapy Management of Scoliosis

The physical therapist (Physiotherapist) has three important tasks: to inform, advice and instruct. For the treatment of scoliosis, it’s not only important to do the correct exercises but the physical therapist also needs to inform the patient &/or parents about his/her situation. An educational program makes sure that the therapy accuracy from the patient improves. Some physical therapists recommend a brace to prevent the worsening of the scoliosis.

We can conclude that bracing is recommended as a treatment for female patients with a Cobb angle of 25-35°.

The patient needs to be focused about re-establishing spinal symmetry. The key to a successful physiotherapy is to work consistently to correct the spine. 

• Schroth Method:

The Schroth Method is a nonsurgical option for scoliosis treatment. It uses exercises customized for each patient to return the curved spine to a more natural position. The goal of Schroth exercises is to de-rotate, elongate and stabilize the spine in a three-dimensional plane.

• Redcord Sling Therapy:

Redcord is offering a unique treatment method for musculoskeletal ailments called Neurac® (Neuromuscular Activation). With over 20 years of experience with pain treatment and rehabilitation, Redcord is the common thread between healthcare and an active life. Redcord® is the leading provider of solutions for functional enhancing exercise. The solutions will enhance physical functioning and general well-being as well as sports performance. Redcord offers high-level competence related to treatment of musculoskeletal pain and neuromuscular dysfunction.

References

1. Konieczny MR, Senyurt H, Krauspe R. Epidemiology of adolescent idiopathic scoliosis. J Child Orthop. 2012;7(1):3–9.
2. Johari J, Sharifudin MA, Ab Rahman A, Omar AS, Abdullah AT, Nor S, Lam WC, Yusof MI. Relationship between pulmonary function and degree of spinal deformity, location of apical vertebrae and age among adolescent idiopathic scoliosis patients. Singapore medical journal. 2016 Jan;57(1):33.
3. Wong AY, Samartzis D, Cheung PW, Cheung JP. How Common Is Back Pain and What Biopsychosocial Factors Are Associated With Back Pain in Patients With Adolescent Idiopathic Scoliosis?. Clinical Orthopaedics and Related Research®. 2019 Apr 1;477(4):676-86.
4. Patias P, Grivas TB, Kaspiris A, Aggouris C, Drakoutos E. A review of the trunk surface metrics used as Scoliosis and other deformities evaluation indices. Scoliosis. 2010 Dec;5(1):12.
5. Helenius IJ. Treatment strategies for early-onset scoliosis. EFORT open reviews. 2018 May;3(5):287-93.