When talking about scoliosis, one often immediately thinks of a condition that affects young people, but that is not always the case. In a study of 554 people aged between 50 and 84 years, scoliosis was diagnosed in 70% of cases, showing that this is also a common condition in older people, too.However, there are certain distinctions to be drawn, and it is important to understand when scoliosis in an older person first developed. This is possible only if the patient is able to supply previous X-rays that document the period of onset.

Scoliosis in the elderly can be divided into three types.

– Primary degenerative scoliosis, also known as the “de novo” form, is scoliosis that occurs as a result of disc degeneration, and it causes considerable pain and stiffness. This makes it very difficult for the patient to create curves able to compensate for the lateral or forward bending of the spine inevitably seen in those affected by this condition.  

–  Progressive idiopathic scoliosis in adults is scoliosis that they have had since they were  young, as it is the form that is diagnosed in adolescence. With this type of scoliosis it is important to bear in mind a couple of parameters, because the likelihood of the condition worsening depends on the severity of the curve.

According to literature data, scoliosis with a Cobb angle greater than 50° will almost inevitably worsen; instead, a curve measuring less than 30° will give little cause for concern in adulthood.

–  Secondary degenerative scoliosis can have various causes, some found directly in the patient’s back (such as a lumbosacral abnormality) and others (such as hip disease) found elsewhere in the body. Metabolic disorders and osteoporosis leading to multiple fractures are also among the causes of this type of scoliosis.

Regardless of their causes, all these forms of elderly scoliosis have certain characteristics in common.

Elderly people affected by scoliosis inevitably experience postural changes. Particularly prominent is forward or lateral bending of the back: in other words, their back seems to be “falling” forward or to one side.

These changes can result in loss of the normal inward curvature (lordosis) of the lower back, causing the trunk to bend forwards and leading to accentuated dorsal kyphosis.

A further characteristic of all these types of scoliosis is pain, and it is one of the main reasons why individuals with elderly scoliosis decide to try to do something in order to improve their back and, as a result, their overall health. 

Another type of alteration observed in elderly scoliosis is a lateral collapse of the spine caused by an increase in the scoliotic curve that the patient is unable to counter; this results in a lateral imbalance.

To try to improve the situation, it is necessary to undertake a course of rehabilitation involving specific exercises for the spine.

These exercises have several purposes; the main one is to reduce pain. The therapist will  “explore” the patient’s back, performing assessments and seeking to identify pain-free positions that can be taken as a starting point both for providing some relief and for starting to plan a programme of work designed to help the patient’s back cope with more active exercises.

As with youngsters, with elderly people, too, it is crucial to teach self-correction, even though, in this case, the objectives will be different.
An elderly person with scoliosis, by definition, has a stiff back and can therefore have mobility problems; obviously in these circumstances self-correction should not be seen as a means of obtaining the best possible correction of the back, but rather as a way of supporting it and countering, as far as possible, the abnormalities that have developed.  

In the presence of lateral bending, the aim will be to support the back as much as possible against the direction of the curve, whereas forward bending will be tackled by attempting to restore lordosis and mobility of the lumbar spine, so as to move the patient’s back into an upright position. A key element in both these cases is an axial extension of the spine, which serves to reduce dorsal kyphosis and open, as much as possible, the scoliotic curve.

However, when embarking on a rehabilitation pathway, patience is always the key, because exercises, unlike drugs, cannot eliminate or reduce pain in the space of a few hours.

The very term “pathway” implies the need to allow a certain amount of time in order for the desired results to appear.
In fact, the treatment demands not only patience but also constancy over time, as patients have to do much of the work on their own, having first been taught the exercises and instructed to do them independently at home.

It is also important not to make the mistake of becoming complacent as soon as there is some improvement; indeed, it is crucial to continue following the programme consistently so as to consolidate the results achieved.

All this is the only way of obtaining the kind of results that, over time, will lead to improvements in different areas of the patient’s life.

The first positive result perceived by the patient will be a reduction of the pain experienced; subsequently, he/she will become aware, both in the course of the day, but also when standing in front of a mirror, that his/her posture has also improved.

An equally important development will be better general physical conditions and a better quality of life, as the patient, starting to feel better and happier about his/her appearance, will start resuming his/her previous activities.

The specific exercises prescribed are very important for preventing/limiting possible deterioration over the years, and patients will therefore need to go on doing them for the rest of their lives: since these are patients who have difficulty supporting their backs, it is essential to work on strengthening all the relevant physical abilities. And this can be achieved solely and exclusively through specific exercises.
All the other treatments that exist for scoliosis have other objectives, e.g. to provide pain relief (drugs) or to replace lost function (bracing or surgery), and they are, in any case, more invasive.

www.scoliosi.org: the Isico blog that gives patients a voice!

Over the past 13 years or more, we have published dozens of posts and thousands of comments on our forum dedicated to scoliosis.
The Isico forum is a dedicated space where patients can ask questions and swap experiences, but it is also a place where those involved in treating scoliosis can take a more in-depth look at a series of topics and also engage with the patient.  Here is one of our published posts.

ISICO in Italy: “Same language, same treatment”

ISICO works with many operators – physicians and rehabilitation specialists – in clinics covering most of Italy. Sometimes patients aren’t sure (and will therefore ask us) which specialists or centre they should contact. It actually makes no difference, since we strive daily to ensure that each of our clinics offers exactly the same high level of professionalism and quality of care. Everyone in the ISICO family speaks “the same language” and pursues the same goals. For us, who work here, this goes without saying, as this is our established modus operandi.

Scoliosis is not only an infrequent condition (it affects 2 to 4 people in every 100), it can also be devious, that is to say unpredictable! Highly aggressive forms are even rarer. The challenge for the physician is to understand whether your scoliosis is going to be as gentle as a kitten or as aggressive as a tiger that needs to be caged. It follows that only a physician with experience of many cases of scoliosis is fully equipped to interpret the multiple aspects of this complex disease.

According to the relevant international guidelines (http://www.scoliosisjournal.com/content/7/1/3),  the specialist who deals with the treatment of scoliosis must be an expert and must comply with the following criteria:

1. an apprenticeship of at least 2 years alongside a physician experienced in the treatment of vertebral growth disorders (that is, who has at least 5 years of experience in the field);

2. at least two consecutive years of experience in the treatment of scoliosis with a brace;

3. at least one brace prescription per week (corresponding to about 45 per year) in the last two years;

4. At least 4 examinations per week of subjects with scoliosis (corresponding to about 150 per year, for at least two consecutive years).

Consequently, what usually happens is that the expert physician sees patients in large cities that are easily reached and moves from one city to another in order to be able to see a sufficient number of cases and therefore become an “expert.” This is the traditional pattern: physicians move from city to city, and patients often have to travel from small towns to big cities in order to have a consultation with an expert physician.

When ISICO was founded it only had one physician who used to travel around Italy, seeing patients. But then the number of physicians increased, and so did the number of ISICO clinics. But the original concept has remained the same: our physicians travel around, in order to examine patients in other branches; they also regularly frequent the Milan clinic, not only to carry out examinations but also, and above all, to keep up to date with their colleagues and exchange information and opinions.

The therapists, too, work in multiple clinics and regularly meet up, among themselves and also with the physicians, to get updates and to guarantee the teamwork that characterises ISICO.

All this is also facilitated by the use of sophisticated software that, on the one hand, allows constant communication between all the operators involved and constant monitoring of each patient’s situation, and on the other, ensures consistency in terms of the assessment methods and practices adopted.

Even the orthopaedic technicians who work with ISICO as external consultants meet up regularly in Milan: on these occasions, they also see physicians and therapists to discuss the braces our patients are being offered.

Every day we work to build a close-knit and competent team and to organise our work in such a way as to provide patients with the best care available and with as little travelling as possible.

Each ISICO clinic, therefore, has the same characteristics as the others: in Rome, you can see the same physician you would have seen on another day in Milan; similarly, the physician who was in Pescara yesterday is in Asti today. The same goes for the therapists, and this guarantees a consistently high level of performance quality everywhere.

At ISICO, everyone speaks “the same language”, uses the same clinical software, and pursues the same goals: therefore, you don’t need to worry if, when you come to try out your brace, you do not find the same physician who prescribed it.

The experience of our physicians and therapists is guaranteed by the large number of patients treated and by the ongoing professional exchanges between all the ISICO team members.

An Isico study entitled “Clinical Evaluation of Spinal Coronal and Sagittal Balance in 584 Healthy Individuals: Normal Plumb Line Values and their Correlation with Radiographic Measurements” has just been published in the journal Physical Therapy.

The aim of the research was to assess plumb line distances (PDs) in a large, healthy population in an age range representative of the adolescent population with spinal deformities, and to correlate the resulting normative values with X-ray measurements.

In fact, the scientific literature lacks normal data from a healthy population (i.e. without spinal disease) that can be used to establish what constitutes a correct sagittal profile and thus to identify, in patients, the presence of certain abnormalities.

The study involved a very large sample: 584 healthy individuals (341 females) with X-rays showing no spinal deformities.

The participants were not randomly chosen from the general population: all were X-rayed because they were suspected of having a spinal deformity.

The whole sample (OVERALL) was divided into five groups, classifying all those aged 10 or over on the basis of their proximity to puberty, as follows: 6-9 years old (n = 106); >10 years, Risser 0 with triradiate cartilage open (n = 129) or closed (n = 104); Risser 1-2 (n = 126); and Risser 3-5 (n = 119).

It is worth recalling that PDs are widely used in conservative clinical practice to evaluate the sagittal shape of the spine.
Using a plumb line it is possible to evaluate the frontal and lateral profile of the trunk: in evaluation of the frontal profile, with the individual standing, the first cervical vertebra (visible at the base of the neck) is identified and the plumb line is dropped from this point; it should naturally fall in the gluteal cleft (groove between the buttocks). Any displacement (to the right or left) from this reference indicates the presence of lateral bending of individual’s trunk, a sign that can indicate scoliosis.
The lateral  profile of the trunk, too, is evaluated with the individual standing; in this case, the  plumb line is positioned so that it touches the point of maximum protrusion of the dorsal area (between the shoulder blades).
The PDs are then measured at the points where the plumb line is most distant from the individual’s back. These measurements may indicate the presence of a curved spine.

PDs were evaluated by maintaining a tangent to the thoracic kyphosis apex at C7, T12, L3, and S2. Sagittal index (C7 + L3), and sagittal and coronal balances (C7 related to S2) were calculated.

This study showed a correlation between the plumb line data and the radiographic measurements, and also provided normative data to be used in clinical practice.

“In the near future, plumb lines will likely make way for lasers, whose use has already been validated by a study” concluded Alessandra Negrini, physiotherapist and one of the authors of the study “At Isico, we have already introduced the laser method” she added. “There are advantages and disadvantages to both: the laser beam is static, and this could distort the data if the child moves; the plumb line on the other hand follows the child’s movements: if the child moves so does the plumb line”.