Adult scoliosis and fracture risk: a frequently overlooked connection

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In elderly patients, the fracture risk is often attributed solely to bone fragility. However, one frequently overlooked factor is the presence of adult scoliosis, which can significantly increase the risk of falls and, therefore, fractures.

This condition, which may stem from progressive juvenile scoliosis, arises as “de novo” scoliosis in adulthood or is degenerative — that is, related to arthritic, degenerative phenomena and metabolic alterations — often leads to changes in postural alignment, particularly in the sagittal plane. The trunk leans forward, lumbar lordosis is lost, and the pelvis rotates backwards; thus, it develops what is known as a flexed posture, a typical condition of pathological ageing, which heavily impacts balance and mobility.

These biomechanical changes are not only aesthetic or functional issues; they are determining factors for static and dynamic balance and, therefore, significantly increase the risk of falls. Scientific studies confirm this: hyperkyphotic posture, for example, has been associated with a higher incidence of falls and, in a 2004 study involving over 1,300 adults, was found to be an independent predictor of mortality.

For an older adult with bone fragility, falling may result in a fractured femur, vertebra, or wrist — events that often lead to hospitalisation, loss of independence, and, in many cases, irreversible functional decline.

Worsening the clinical picture is often the presence of sarcopenia, the progressive loss of muscle mass and strength, common among older adults with scoliosis, as documented in the 2017 study “Sarcopenia and falls in patients with adult scoliosis”. This condition further reduces stability and reaction capacity, creating a vicious circle: less balance → more fear of falling → less activity → more weakness → even greater risk.

Even surgery does not represent a definitive solution: as reported by Glassman et al. (2016), even after the operation, sagittal alignment alterations may persist, maintaining a high risk of falls.

In light of this evidence, the message is clear: adult scoliosis cannot be considered a “benign” condition simply because it has stabilised. On the contrary, it requires clinical attention, monitoring, and personalised interventions. During adulthood, particularly between the ages of 40 and 60,the overall trunk alignment must be carefully monitored to detect the first signs of postural changes and take action to correct them. At the same time, the spine is still sufficiently mobile. When ageing progresses further and the older adult begins to bend forward, full recovery becomes difficult, and treatment aims to prevent further deterioration.

Fortunately, physiotherapy can offer effective responses: specific programmes to restore sagittal alignment, exercises for stability and postural control, pain management and functional improvement. Muscle strengthening and balance training have proven useful in reducing fall risk and, therefore, in preventing fractures and hospitalisation.

In conclusion, considering adult scoliosis as an independent risk factor for fractures — on par with osteoporosis — means acknowledging the importance of a multidimensional approach.

Early and targeted treatment of scoliosis can serve as a key lever in reducing fracture events, hospitalisations, and loss of independence in older adults. Fall prevention also starts with the spine.

Is scoliosis harmed by high-impact sports?

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Periodically, ISICO launches the “Concorsetto,” an initiative in the form of a competition in which patients share their experience with wearing a brace, demonstrating that they can do almost anything: horse riding, dancing, rhythmic gymnastics, skating, and much more. This proves that sports and scoliosis are not incompatible.

But what about high-impact sports? Can they make scoliosis worse?

When it comes to scoliosis, one of the most common questions we receive from parents and coaches concerns sports that involve impacts on the spine (shocks, falls, landings from jumps…). Activities such as horse riding, long jump, high jump, and running often raise concerns.

In the common imagination, it is believed that repeated shocks may generate compressive and torsional forces on the spine, worsening the scoliotic curve. In reality, the spine, thanks to its sagittal plane curves, joints, and tendon structures, has a highly efficient system for “absorbing” impacts and withstanding intense forces without negative effects on its three-dimensional structure.

A recent study of ours has shown that the more sports young people engage in, the lower the likelihood of scoliosis worsening and the greater the chances of improvement with physiotherapy treatment [source 1]. It is no coincidence that mild scoliosis is successfully treated with specific exercises aimed at improving posture and triggering corrective reactions in the curves—an effect similar to that of sports, albeit in a less specific and more global manner.

So, is there anything that can actually worsen scoliosis?

According to the available data, an asymmetrical load on the vertebrae promotes uneven spinal growth in individuals already predisposed to developing scoliosis, contributing to its progression in children and adolescents. This is known as Stokes’ vicious cycle.

What should be done, then?

It is essential to counteract these factors using the tools available. Combined with specific treatments such as physiotherapy exercises and/or a brace, sporthelps develop reflexive corrective automatisms, integrating them into daily life. All sports are suitable in these cases, but every case of scoliosis is unique. Since sport reduces the risk of curve progression, it is advisable to encourage young people to choose an activity they enjoy and are motivated to practise consistently.

Even asymmetrical activities, such as tennis, should not be demonised; in fact, they can be a valuable ally in preventing and managing scoliosis. Often, it is enough to combine them with targeted exercises that strengthen the spinal muscle groups under strain.

Sport and the brace: Can physical activity be practised while wearing a brace?

A recent study confirms that those who wear a brace and engage in sport more frequently achieve better results. Moreover, an ISICO study has shown that wearing a brace does not hinder physical activity.

We just remind you that, in case of doubt, it is important to consult your specialist doctor.

In conclusion

Sport should be experienced as a moment of relaxation and recharge. The impacts on the spine that are inevitable when practising sports should not be a cause for concern, as they do not worsen scoliosis. The brace should not excessively restrict the patient’s movement and freedom but should support them in counteracting spinal deformity.

With the guidance of a scoliosis specialist, each patient can find the best way to manage physical activity—whether with or without a brace—because the confidence and psychological well-being derived from engaging in sport are fundamental to the success of the therapy.

SEAS: How it trains active self-correction

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Physical exercises, whether in a sporting or rehabilitative context, are motor actions repeated to improve a function or skill. This function may be as simple as muscle strength or joint mobility or as complex as balance or coordination.

SEAS, our approach to scoliosis-specific exercises, was conceived with a different perspective compared to most other specific treatment methods.

In other approaches, unlike SEAS, the exercise involves adopting a position to achieve the maximum possible spine realignment and reduction of curves. This correction is typically static and passive, focusing primarily on achieving the best geometric realignment of curves, with little regard for movement.

Achieving this outcome often necessitates external aids, such as unusual body positions or physical supports. In other treatment methods, tools like pushing against a rigid instrument such as a stick, hanging from wall bars, or placing a support under the pelvis are commonly used to assist in aligning the scoliotic spine. These actions are identified as exercises and serve as a shortcut to achieving the best passive correction of the curves.

In the SEAS approach, the focus is on training active self-correction of curves. Exercises are designed to progressively destabilise this active (rather than passive) correction, compelling the patient to stabilise and regain it when necessary.

Correct and Controlled Exercises

The key role of the experienced therapist is selecting the appropriate level of destabilisation. As in any active training, the exercise should progressively increase the challenge of the targeted action.

An exercise is “correct” when it is selected after a thorough assessment of the level of destabilisation the patient can handle. It is “controlled” when it is neither excessively destabilising—risking loss of correction control—nor insufficiently destabilising, rendering it ineffective for training the ability to maintain correction in more complex situations.

The World Organisation for the Conservative Treatment of Scoliosis (SOSORT) recommends exercises focused on self-correction: movements that counteract spinal curves, stabilising and integrating them into daily life. In the SEAS method, exercises involve actively reaching and maintaining the self-corrected position despite various challenges. Gradually, through continuous practice, patients learn to integrate self-correction into everyday activities such as eating, walking, or doing homework.

A Practical Example

Long-term training, gradually increasing both distance and speed, is essential to prepare for a marathon and build sufficient strength and endurance to run 42 kilometres.

In our approach, exercises represent progressively chosen challenges to destabilise appropriate corrections. If the correction becomes too simple and the disruption fails to adequately destabilise it, the exercise cannot effectively train the ability to manage self-correction in more complex situations.

How Much Time Should Be Spent on Exercises?

The recommended daily practice is 20 minutes, with one rest day per week, totalling approximately two hours per week. Although this represents a significant commitment, especially given the duration of therapy, keeping a balance is crucial. Some parents, especially at the start, ask whether more practice is possible. Our response is that the training should be sustained without causing fatigue in a therapy that may span years.

Learning a musical skill is a practical comparison that illustrates the importance of consistency. A pianist cannot master complex pieces in a week but must practice daily with dedication, gradually progressing. Similarly, the SEAS approach requires continuous and progressive training, continuing until skeletal maturity reduces the risk of scoliosis progression.

Through the SEAS method, patients can actively train self-correction, transforming it into a stable and enduring skill that supports their daily life.

Is Life Turning You Kyphotic? Here’s How to Prevent It

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The spine supports the torso and allows the head to stay upright, keeping the gaze towards the horizon. Proper alignment in the sagittal plane helps maintain the torso in the correct position with minimal energy expenditure and optimal load distribution along the spine.

Over time, particularly in older adults, a forward imbalance tends to develop, causing the torso to lean forward. Researchers have identified the age range of 50 to 60 as the period when this imbalance typically begins to manifest, progressively worsening with age. Compensatory mechanisms then come into play, creating a vicious cycle involving the pelvis and the entire spine, leading to specific degenerative changes.
The pelvis tilts backwards, lumbar lordosis decreases, and the upper torso bends forward. In some cases, these changes in sagittal alignment occur rapidly and progressively, developing into pathological conditions.
Certain factors may exacerbate this, such as the presence of scoliosis, disc disorders leading to reduced lordosis, or stiffness in the spine. Severe kyphosis or kyphosis resulting from vertebral fractures also contributes to forward collapse, as does weakness in the spinal extensor muscles, leading to forward lean.

Now, let’s consider our daily activities.
Most of what we do involves looking downward or at least keeping the head tilted forward. For example, how much strain is placed on the cervical vertebrae when the head is tilted forward at 30 degrees? (Remember that we usually tilt our heads much more than 30 degrees when we look at our phones.)

At this angle, the discs experience 400% more stress than when the head is upright and looking forward. The natural tendency towards forward collapse, combined with daily activities that increasingly involve static, flexed postures and potential degenerative spinal conditions, accelerates the forward tilt of the torso. This forward imbalance results in pain, reduced spinal functionality, fatigue, aesthetic concerns, and, most importantly, a decline in quality of life.

What Can We Do?

  1. Resist Gravity: Throughout the day, whether standing or sitting, try to sit or stand up straight and hold this position for a few seconds.
  2. Engage in Regular Physical Activity: Any exercise is beneficial, but activities that engage the trunk extensor muscles are especially helpful. Don’t stop moving! It’s also a good idea to vary your exercises over time, which will benefit your back as well.
  3. Seek Medical Advice: If you notice yourself leaning forward when tired, especially in the evening, or if those around you point out that you’re becoming more stooped, it’s time to seek a medical evaluation.

…And if life pushes us forward? Let’s straighten it out!

SEAS Therapy: 20 Minutes of Daily Exercises at Home – Too Much or Too Little?

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The International Society for Conservative Scoliosis Treatment (SOSORT) recommends exercises based on self-correction, which involves movement aimed at counteracting spinal curves, stabilising this position, and integrating it into daily life【1.

At ISICO, we have developed and use the SEAS approach. These exercises involve actively achieving the self-corrected position and working to maintain it despite various challenges. The exercises are designed to test the stability of the correction, requiring the patient to stabilise their spine and recover the correction if control is lost【2.
Gradually, as therapy progresses and through continuous practice, patients become more adept at incorporating self-correction into their daily lives—for example, while eating, walking, or doing homework.

How much time should be dedicated to practising the exercises each day?
Typically, 20 minutes daily is a significant commitment, especially as this therapy can last for a long time—sometimes several years. Patients are given one rest day per week, making the total weekly commitment about two hours.

Some parents, particularly at the beginning, ask whether more than the prescribed amount can be done. We usually respond that it is important to train without overwhelming the patient. For example, consider marathon training: a young person should not exhaust all their energy at the start and then abandon therapy, but instead maintain endurance and continue until skeletal maturity. At this point, we can say that the risk of scoliosis progression has decreased.
Conversely, reducing the duration would result in an insufficient period of practice. When we think about how much time young people spend on their phones daily, 20 minutes is not much.

How much time is needed for exercises in other scoliosis treatment approaches?
According to current data, the other most widely used approach globally is the Schroth therapy, developed in Germany.
This method involves hospitalisation in a specialised clinic for 3–4 weeks, during which patients undergo daily two-hour sessions to learn the exercises properly. After the training period, patients are instructed to continue the exercises at home and visit the clinic one to four times a month to ensure proper execution【3.
Alternatively, patients can learn the exercises through closely spaced individual sessions with a therapist, lasting 60–90 minutes, followed by weekly group sessions of 60 minutes, combined with a daily home exercise programme lasting 30–45 minutes【4.
This represents a significantly greater commitment than the 20 minutes required for SEAS therapy.

1. Negrini S, Donzelli S, Aulisa AG, Czaprowski D, Schreiber S, de Mauroy JC, Diers H, Grivas TB, Knott P, Kotwicki T, Lebel A, Marti C, Maruyama T, O’Brien J, Price N, Parent E, Rigo M, Romano M, Stikeleather L, Wynne J, Zaina F. 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis Spinal Disord. 2018 Jan 10;13:3. doi: 10.1186/s13013-017-0145-8. PMID: 29435499; PMCID: PMC5795289.

2. Romano M, Negrini A, Parzini S, Tavernaro M, Zaina F, Donzelli S, Negrini S. SEAS (Scientific Exercises Approach to Scoliosis): a modern and effective evidence based approach to physiotherapic specific scoliosis exercises. Scoliosis. 2015 Feb 5;10:3. doi: 10.1186/s13013-014-0027-2. PMID: 25729406; PMCID: PMC4344739.

3. Rigo M, Reiter C, Weiss H-R. Effect of conservative management on the prevalence of surgery in patients with adolescent idiopathic scoliosis. Pediatr Rehabil. 2003;6(3–4):209–14.

4. Burger M, Coetzee W, du Plessis LZ, Geldenhuys L, Joubert F, Myburgh E, van Rooyen C, Vermeulen N. The effectiveness of Schroth exercises in adolescents with idiopathic scoliosis: A systematic review and meta-analysis. S Afr J Physiother. 2019 Jun 3;75(1):904. doi: 10.4102/sajp.v75i1.904. PMID: 31206094; PMCID: PMC6556933.

Rastereography vs 3D ultrasound imaging system: when should we choose one instead of the other?

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Let’s start with the thing they have in common: to lower radiation exposure. Indeed, these two methods, although unable to accurately reproduce the Cobb angle, were both created to reduce the radiation exposure of patients being monitored for spinal disorders, especially during pubertal growth.

Non-invasiveness and absence of radiation exposure are huge advantages of these methods, used for evaluating the curves of the spine, physiological and otherwise; combined with clinical measurements and evaluations, they allow the specialist to decide on the course of the patient’s treatment. And in many cases without the need for a follow-up X-ray. 

We have already explored the features and peculiarities of these methods in one previous post and another one

THE ROLE OF 3D ULTRASOUND IMAGING IN THE CLINICAL DIAGNOSIS AND MONITORING OF SCOLIOSIS DURING GROWTH

So, when should we opt for one as opposed to the other?

Rasterstereography: In clinical practice, this method is mainly used to study changes in the patient’s sagittal plane since it appears to be much more reliable in this plane than in the frontal plane. 

Moreover, current scientific evidence has failed to show the reliable correlation between diagnostic measurements between radiography (Cobb angle) and rasterstereography (1,2). We use rasterstereography to evaluate and monitor, over time, postural and structural problems affecting the sagittal plane, such as various forms of hyperkyphosis, long kyphosis, hyperlordosis, and so on.

This method is also very useful for evaluating the effectiveness of bracing or specific exercises over time.

3D ultrasound imaging system: This is the first ultrasound imaging system capable of detecting and evaluating scoliosis. The only one currently available in Italy is at the Isico offices in Milan. 

Even though research (3) has shown very good correlations and agreements between ultrasound and radiographic measurements (respectively UCA – Ultrasound Curve Angle  and Cobb angle), the reliability of the system is not yet sufficient to allow the 3D ultrasound imaging system — and the same goes for rasterstereography — to replace radiography, which remains the diagnostic tool of reference for diagnosing scoliosis and for confirming its evolution.  

Based on our experience to date, we use the 3D ultrasound imaging system as a valuable ally in the frequent monitoring (every 3-4 months) of patients at increased risk of scoliosis progression, as it allows prompt detection of any worsening of the curves.

It should be recalled that this examination is suitable in patients with certain characteristics: e.g., for patients with a Risser sign of 0-1 who are undergoing either bracing or exercise-based treatment, for patients who are only being monitored for a possible scoliosis diagnosis, and finally for children over 5 years of age to reduce (annual) radiation doses/exposure.

Even though, according to current guidelines, standing anteroposterior and lateral-projection radiographs are the most reliable method for diagnosing scoliosis and sagittal deformities, both rasterstereography and 3D ultrasound imaging system can be considered valid and useful tools for monitoring the clinical condition over time, the first being used for more extensive assessments (of sagittal problems) and the second for targeted assessments (of scoliosis). Some authors suggest that they could be used for carrying out early screening in large populations (e.g., in schools) (2). 

1. Multicenter Comparison of 3D Spinal Measurements Using Surface Topography with Those From Conventional Radiography
DOI: 10.1016/j.jspd.2015.08.008

2. Is rasterstereography a valid noninvasive method for the screening of juvenile and adolescent idiopathic scoliosis?  DOI: 10.1007/s00586-018-05876-0

3. 3D ultrasound imaging provides reliable angle measurement with validity comparable to X-ray in patients with adolescent idiopathic scoliosis 10.1016/j.jot.2021.04.007

Full-time treatment: no stress!

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We talk of “full-time treatment” whenever a brace needs to be worn round (or almost round) the clock, i.e., for 23 or 24 hours a day.  When patients with scoliosis are treated using a brace, it is not unusual to have to wear the device full time in order to effectively address severe curves (those measuring more than 40 Cobb degrees) or high-risk situations (a pubertal growth spurt).  

Full-time treatment is a tough challenge, especially if you consider that it usually begins at between 11 and 15 years of age, in other words, just before or during adolescence, which is a notoriously tricky time that already brings plenty of changes. Youngsters of this age no longer see the world through children’s eyes. Instead, they begin to experience all kinds of doubts and insecurities, and sometimes they are unhappy about the changes in their appearance, or about having to wear dental braces or glasses. It is therefore entirely understandable that being prescribed bracing treatment can be upsetting for them, and also for their parents who would do anything to spare their child any suffering.

In the literature, it is suggested that the start of bracing treatment (the first 6 months) can negatively affect the patient’s quality of life.
Even though there is no scientific proof of this — on the contrary, research tells us that treatment, ultimately, does not negatively impact quality of life —, there can be no denying that the early stage of bracing is hard and must be overcome. In particular, it is crucial to avoid poor adherence to the treatment that might potentially lead to its early and total abandonment and thus expose the patient to all the risks, in terms of progression and consequent severity of the condition, that are associated with scoliosis in childhood and adolescence. 

“This is a very important issue for us at Isico”, remarks physiotherapist Lorenza Vallini. “We have long been aware of the difficulties youngsters face at the start of this experience, which we liken to a marathon rather than a sprint: our youngsters have to get to the finish line on their own two feet, but we healthcare professionals are alongside them all the way, guiding and helping them and their families.”

And what about friends? Well, friends are like fans on the terraces; if they feel involved, they will cheer the patient on.

All this is perhaps easy for us to say because the fact is that when full-time bracing is prescribed, which means 23 or even 24 hours a day, the patient can feel like their world is falling apart. That is why we at Isico like to make sure we always have a chat with the family and the youngster after their appointment.

“We know very well that this is a key moment, a watershed moment that needs to be addressed together”, Vallini continues. “Our therapists are trained to listen to doubts, answer a thousand questions, and provide all the necessary explanations. We try to get the youngsters involved, showing them videos of other young “brace wearers” doing all kinds of everyday activities, including sports, with their brace on. They are often visibly surprised to see their counterparts happily taking a dip in the sea or swimming pool.”

It is also important not to overlook the aesthetics of brace-wearing!

We at Isico are always careful never to overlook the aesthetic aspect. Many of our patients are girls who are of an age at which comparing yourself with others is a normal part of growing up: “We always stress that braces are hardly visible under clothes, and we give patients tips and advice about their appearance”, Vallini says. “This moment is an opportunity to start building an alliance with the patient. Obviously, our work and involvement don’t end with that one chat, which on the contrary is the starting point for a process that will continue over the monthly sessions we have with these youngsters thereafter. The first session after delivery of the brace is particularly important, as it is when we try to present this “intruder” as a friend, not the easiest to be sure, but a friend nonetheless.”

That is why this particular session is designed to be motivating as well as technical, an opportunity to tackle any issues or doubts that have arisen and gather the patient’s reactions – both the tears and the laughter. 

As soon as the brace arrives, it is tested by an Isico doctor, who provides a series of explanations in order to get the treatment off to a good start. As a rule, whenever possible, a meeting with the therapist is also arranged so that youngsters are not left to face their fears and doubts alone. When this is not possible, a telephone contact is offered and, after the first session, the patient is also contacted by email to find out if there have been any difficulties.

Availability, care and assistance are the cornerstones of our approach: “We never underestimate any request, from the simplest to the most complicated”, Vallini says. “We make sure patients realise we are always there for them, as we want them to be reassured that there is always someone available for them.”

The importance of listening
The Isico team includes all the specialists necessary to support and monitor young brace wearers, so not only doctors and orthopaedic technicians, but also therapists and a psychologist (who sees patients directly on the rare occasions when this is felt to be necessary, but usually intervenes through the other professionals). All the team members will accompany the patient for a part of their journey, to support them and ensure that the therapy is going as it should, particularly at the start.

Will there be any other particular crisis moments? Undoubtedly! In the course of a long and demanding treatment process, undertaken in the midst of a thousand other emotional interferences from the outside, this is only to be expected: “The main thing for us is to remain vigilant so that we know when a family might be needing extra help”, Vallini says. “Everyone is ready to add the right input at the right time to help patients reach the finish line. And when they do, the smiles and hugs we get from them are quite wonderful, as is their tangible sense of pride”.

Can leg length discrepancy cause or worsen scoliosis?

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Leg length discrepancy (LLD) is a common orthopaedic condition among children and adults, with a prevalence of 90% in the general population and 40% among athletes. LLD occurs when the lower limbs are of unequal length; the discrepancy is typically less than 10 mm and asymptomatic.
Individuals easily compensate for it through small adaptations of which they are very often unaware (such as bending or extending one leg more than the other). Some children are born with LLD; in other cases, the condition is acquired due to causes such as tumours, radiation, infections or injuries.

LLD can be classified as functional or structural depending on the aetiology, i.e., the underlying cause.

Functional LLD refers to an apparent asymmetry, in the absence of real shortening or elongation of the osseous components of the lower limb. It is typically a result of pelvic obliquity related to adaptive soft-tissue shortening, joint or muscle contractures, ligamentous laxity, or axial misalignment. As the pelvis rotates, the legs are pulled into apparent different lengths.

Structural LLD, on the other hand, is a primary disorder causing actual physical shortening or lengthening of a limb, with the osseous change occurring between the ilium and the foot. The causes of shortening are more common than those of lengthening, and they may be congenital or acquired: shortening is most often due to fractures along the physis (Salter-Harris fractures), which can stop bone growth and lead to LLD.

LLD can be associated with several musculoskeletal disorders, including scoliosis and resultant degenerative spinal changes. However, the degree of LLD required to cause such disorders is still debated. LLD has been shown to cause pelvic obliquity in the frontal plane. In order to maintain shoulder balance and compensate for the pelvic obliquity, the condition that most frequently occurs is lumbar scoliosis with convexity directed towards the shorter limb. Scoliosis caused by LLD is not true scoliosis.

Should scoliosis due to LLD be treated?

This type of scoliosis, termed functional scoliosis, is non-progressive and involves a structurally normal spine with an apparent lateral curvature: it is evident in the erect position, but reduced when the subject is seated, supine or prone. The greater the degree of LLD, the more apparent the functional scoliosis may be. 

This type of scoliosis regresses fully or partially when its cause (i.e., the LLD) is removed. 

A simple remedy is to use shoe lifts, which may be internal or external depending on the degree of LLD.

If, after clinical evaluation, the functional scoliosis is found to be reducible (in part or totally) with a shoe lift, this solution will also be useful for reducing the overloading of the spinal joints and for reducing the structural and disc changes that occur over the years in the presence of scoliosis due to LLD (particularly when the difference between the two limbs is greater than 9 mm), as various studies have shown.

In a patient with structural and functional (LDD-related) scoliosis, it is appropriate to carry out tests to evaluate the usefulness or otherwise of a shoe lift. A shoe lift does not treat true scoliosis and the decision on whether or not to use it is a complex and individual one that should be made by the specialist.

Applebaum A, Nessim A, Cho W. Overview and spinal implications of leg length discrepancy: narrative review.  Clin Orthop Surg. 2021;13(2):127-34.

Giles LG, Taylor JR. Lumbar spine structural changes associated with leg length inequality. Spine (Phila Pa 1976). 1982;7(2):159-62.

Adams MA, Hutton WC. The effect of posture on the role of the apophyseal joints in resisting intervertebral compressive forces. J Bone Joint Surg Br. 1980;62(3):358-62. 

Murray KJ, Azari MF. Leg length discrepancy and osteoarthritis in the knee, hip and lumbar spine. J Can Chiropr Assoc. 2015;59(3):226-37.

Why the therapeutic team is part of the treatment

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Scoliosis treatment, whether we are talking about exercises alone or also bracing, can be an uphill battle in which adherence to the therapy itself is always fundamental. 

“A famous study conducted in the US and published in 2013 (Weinstein SL, Dolan LA, Wright JG, Dobbs MB. Effects of bracing in adolescents with idiopathic scoliosis. N Engl J Med. 2013 Oct.) confirmed beyond doubt the effectiveness of brace therapy in arresting the evolution of idiopathic scoliosis. And the patient’s adherence to the treatment was the factor that most influenced the result,” underlines physiotherapist Alessandra Negrini.

To ensure that a youngster manages to be collaborative in carrying out this demanding therapy, especially considering that it is often undertaken during early adolescence which is a notoriously tricky time, it is essential that all those interacting with the patient and with their family make sure they are always on the same page, giving clear and consistent messages.

With this in mind, it is easy to see why the therapeutic team, by encouraging patient compliance, plays such an important role in achieving the goals set.

Educating children and parents means explaining the nature of the disease, together with its possible course and potential consequences, setting and explaining realistic therapeutic objectives and rules to follow while performing physical (including home-based) exercises, and ensuring that there is cooperation with the physiotherapist and physician supervising the treatment. Specific physiotherapeutic exercises should be conducted by a trained and certified physiotherapist operating within a therapeutic team that includes a psychologist, orthotist, orthopaedist, and medical rehabilitation specialist.  

The team that takes on the patient’s care needs to manage to lighten the burden of the treatment, and help the patient and their family to cope with the situation. 

Within the multidisciplinary team, the physiotherapist is the patient’s point of reference, the one who motivates and, when necessary, re-motivates them. The physiotherapist is also the linchpin of the team itself.

 “In view of this important role, the physiotherapist should always bear in mind three key rules that I always think of (in Italian) as the 3 As, explains physiotherapist Marta Tavernaro. The first “A” stands for addestrare (coaching), which reminds me of the need to explain to patients what is happening to them, what scoliosis actually means, and how we and they can prevent it from getting worse. The second “A” stands for approccio (approach), which in this case means being enthusiastic about what we are doing and conveying this to the patient; the third “A”, both in Italian and English, stands for “acquire”, in the sense of collecting the information you need to know whether the youngster in your care has been working effectively.”

During the rehabilitation process, the therapist may become aware of specific problems concerning the family and/or the young person that could jeopardise the treatment. The psychologist is the team member ideally placed to manage these difficulties.

In this regard, it is important to remember that this course of treatment is followed in what is already a difficult and delicate life stage, characterised by sudden changes that influence the young person’s developing personality and how they view their role in society: all of this can have important repercussions on the therapy.

“When we are working within a biopsychosocial model of care, we must of course also keep the psychological aspects in mind,” points out ISICO psychologist Dr Irene Ferrario. “In this case, adopting a person-centred approach means not only measuring the individual patient’s Cobb angle, but also taking into account their emotions and feelings at this particular time in their life. When the doctor or therapist senses that there is an underlying problem, they seek the intervention of the psychologist on the team, who, through individual counselling or psychotherapy, will probe and identify the factors responsible for the change.”

An ISICO study published a few years ago (Importance of team to increase compliance in adolescent spinal deformities brace treatment: a cross-sectional study of two different settings) highlighted the role of the therapeutic team. As pointed out by one of the authors, ISICO physiatrist Dr Andrea Zonta, “the concept of compliance has to be understood in a broad sense, and therefore as adherence not so much to the use of the brace or the prescribed programme of exercises, as to the entire therapeutic pathway, which can last years. After all, we will not obtain lasting results if we think we can intensify the exercises for a certain amount of time and then just abandon them”.
In our research, the population was split into two groups according to the setting in which the treatment was performed and the two groups were administered two questionnaires: the SRS-22 [3, 4], and another, specially developed, one (QT) with 25 multiple choice questions about adherence to treatment (sections: brace, exercises, team).In fact, since the population was chosen as having been treated by the same orthotist and physician, the only distinction between the two populations was in the physiotherapeutic and general team approach.

“If the therapeutic team is not working properly, and I refer particularly to the professionals involved, there is a great risk of pain and decreased QoL. The same is true with regard to compliance with bracing” concludes Dr Zonta. “Moreover, this study has shown that the SOSORT management criteria can be important for brace treatment. The results seem to confirm that the management of patients is sometimes neglected, probably because it is an aspect not understood or perceived by the people involved; nevertheless, effective patient management could (through increased compliance) be a main determinant of the final results and/or the patient’s immediate QoL”.

Scoliosis and back pain: physical activity is the best prevention

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In the world’s richest countries, low back pain is so common that it has become one of the leading causes of disability and healthcare expenditure. Back pain in children should be taken seriously as it can reduce the amount of physical exercise they get, result in absences from school, and limit them in their everyday activities.

These brief opening remarks prompt a series of questions that our physiotherapist, Martina Poggio, here tries to answer in the light of the latest published data regarding a possible link with adolescent scoliosis.

How prevalent is low back pain in children and adolescents? 

In recent decades, a high prevalence (39.9%) of low back pain has been found in children and adolescents: one study found back pain to be associated with age (>12 years), a family history of the condition, spending more than two hours a day studying or watching TV, having an uncomfortable desk at school, suffering from generalised pain, and sleep problems. Evidence on the impact of heavy backpacks is conflicting.2

How common is idiopathic scoliosis among adolescents with back pain? 

Aetiologically speaking (in other words, when examining the possible causes of the condition), one retrospective study, conducted in almost 2000 patients under the age of 21 years, found the following underlying conditions: scoliosis, followed by Scheuermann’s disease and spondylolisthesis.1 However, since the role of spinal deformities in back pain is unclear, we reviewed recent literature on the association between pain and the most common adolescent spinal deformity, i.e., idiopathic scoliosis, which affects 1 to 3% of adolescents. Although idiopathic scoliosis was considered painless condition until a few decades ago, more recently patients seem to show a higher prevalence of back pain. What is not clear, however, is whether there is a marked association between this symptom and the spinal deformity. In studies specifically exploring its prevalence in adolescents with scoliosis, the rates range considerably: from 23% to 85%.

Does the severity of the curve correlate with pain intensity? 

One of main reasons for scepticism over a possible association between pain and scoliosis is the current debate in the literature on the link between the severity of the deformity and the intensity of the pain, and the association, more convincing, between pain and psychological factors (such as self-image and mental health status). Indeed, some patients with less pronounced curves showed more intense pain and vice versa, suggesting that spinal morphology is not the only factor at play.4

Some evidence from the literature suggests that the association between pain and scoliosis is not strongly linked to a biomechanical problem. Indeed, in most studies, pain did not correlate strongly with the magnitude of the curve (Cobb angle); untreated cases did reasonably well from a back pain perspective; epidemiological data revealed a much greater gender difference in scoliosis as opposed to back pain incidence; and patients’ self-image was found to be related to their pain. All these findings argue against a strong aetiological role of idiopathic scoliotic deformity in adolescent back pain.1 

Does back pain in adolescents with idiopathic scoliosis predispose them to pain in adulthood? What factors predispose adolescents with scoliosis to developing back pain?

In adolescents, early onset and persistence of back pain appear to be predictors of future back pain. A retrospective study showed that patients with thoracic scoliosis noted in their medical records were four times more likely to experience thoracic pain than those with no thoracic curve.5 Patients with scoliosis and back pain, compared with asymptomatic scoliosis patients, showed poorer physical function and sleep problems. Given that back pain has multiple causes, it is necessary to take into account depression, anxiety, catastrophising (i.e., having an exaggeratedly negative mindset towards actual or anticipated pain), and level of physical activity: all these factors can influence the perception and perpetuation of pain. 4,5 

In conclusion

“What recent studies show is that it is crucial to evaluated the youngster’s overall health in order to correctly evaluate back pain or possible risk factors,” explains Martina Poggio. “That means not just performing a physical assessment and encouraging the patient to get regular physical exercise, but also a psychological one, evaluating their self-perception and looking for anxiety, depression and drowsiness. These factors, although they may seem secondary in a case of scoliosis, could predispose the individual to the onset of back pain. Finally, it’s important to remind youngsters and their families that current data show no clear correlation between the deformity and pain, only that some people are more predisposed to pain”.

  1. “Prevalence of low back pain in adolescents with idiopathic scoliosis: a systematic review” Jean Théroux, Norman Stomski, Christopher J. Hodgetts, Ariane Ballard, Christelle Khadra, Sylvie Le May  and Hubert Labelle Chiropractic & Manual Therapies (2017)
  2. “Adolescent idiopathic scoliosis and back pain” Federico Balagué and Ferran Pellisé Scoliosis and Spinal Disorders (2016)
  3. “Back Pain in Children and Adolescents” Suraj Achar, Jarrod Yamanaka. Am Fam Physician (2020).
  4. “Back pain in adolescents with idiopathic scoliosis: the contribution of morphological and psychological factors” Alisson R. Teles, · Maxime St‐Georges, · Fahad Abduljabbar, · Leonardo Simões, · Fan Jiang, Neil Saran, · Jean A. Ouellet, · Catherine E. Ferland. European Spine Journal (2020)
  5. “How Common Is Back Pain and What Biopsychosocial Factors Are Associated With Back Pain in Patients With Adolescent Idiopathic Scoliosis?” Arnold Y. L. Wong , MPhil, Dino Samartzis , Prudence W. H. Cheung, Jason Pui Yin Cheung  Clin Orthop Relat Res (2019)
  6. “Prevalence of low back pain in adolescents with idiopathic scoliosis: a systematic review” Jean Théroux, Norman Stomski, Christopher J. Hodgetts, Ariane Ballard, Christelle Khadra, Sylvie Le May and Hubert Labelle. Chiropractic & Manual Therapies (2017)
  7. “Adolescent idiopathic scoliosis and back pain” Federico Balagué and Ferran Pellisé. Scoliosis and Spinal Disorders (2016)
  8. “Back pain in children and adolescents” Suraj Achar, Jarrod Yamanaka. American Family Physician (2020)
  9. “Back pain in adolescents with idiopathic scoliosis: the contribution of morphological and psychological factors” Alisson R. Teles, Maxime St‐Georges, Fahad Abduljabbar, Leonardo Simões, Fan Jiang, Neil Saran, Jean A. Ouellet, Catherine E. Ferland. European Spine Journal (2020)
  10. “How Common Is Back Pain and What Biopsychosocial Factors Are Associated With Back Pain in Patients With Adolescent Idiopathic Scoliosis?” Arnold Y. L. Wong, Dino Samartzis, Prudence W. H. Cheung, Jason Pui Yin Cheung. Clinical Orthopaedics and Related Research (2019)