Returning to physical activity after surgery for adolescent idiopathic scoliosis

Sport and physical activity are essential for psychosocial and physical well-being in children and adolescents, and youngsters with scoliosis are not subject to any limitations in this regard: they can do sports and other physical activities just like their peers can.

In severe scoliosis, i.e., in individuals with curves measuring more than 50° and presenting significant aesthetic and developmental deformities despite undergoing orthotic/bracing treatment properly administered according to the SOSORT criteria, surgery is indicated. 

“In some cases, patients who undergo corrective surgery for scoliosis may reduce their level of physical activity postoperatively due to a loss of spinal flexibility and pain. This inevitably impacts negatively on their quality of life – says dr Carmelo Pulici, physiatrist – No guidelines have yet been published on the resumption of physical activity after surgery for adolescent idiopathic scoliosis, and “expert opinion” is therefore all we have to rely on. Consequently, different surgeons may give different indications, depending on their experience and the particular type of approach”.

There are also individual factors at play, and the decision to resume physical activity may therefore depend on: the type of surgery performed, how the body responds and adapts to the metal rods inserted to correct the spine, the extent of the fusion, how recently the surgery was carried out, the characteristics of the patient, and also the type of sport practised (non-contact, contact or collision).  

For example, while some surgeons allow contact sports to be resumed six months after surgery, others recommend waiting a year, and some even rule out the resumption of collision sports altogether (https://pubmed.ncbi.nlm.nih.gov/26920125/). 

“In one study, return to sport/physical activities after surgery was examined using a specially created questionnaire (https://pubmed.ncbi.nlm.nih.gov/28604495/). By six months, most patients had returned to the activities they did before the surgery” – explains Dr Pulici. “The authors found that patients returned to athletics much earlier than expected. Despite this, there were no cases of loss of correction, implant failure or complications among the 95 patients included in the study”. 

A new surgical technique

In recent years, there has been a growing interest in vertebral body tethering (VBT), a new surgical technique used only in children and in early adolescence and, even then, only in carefully selected patients, given that the method is still experimental. VBT is proposed as a possible alternative to spinal fusion (currently the most widely used technique for the surgical treatment of scoliosis). Unlike spinal fusion, it does not reduce the mobility of the spine. 

“According to a recent study, VBT allows daily activities and sports to be resumed within three months of the surgery” Dr Pulici goes on. “Furthermore, most of the patients examined in the study reported an improvement in their athletic performance, and some were found to be doing more sports than before undergoing VBT”.

Even though surgeons today tend to allow patients to return to sports (even high-intensity ones) earlier than in the past (https://pubmed.ncbi.nlm.nih.gov/34267153/), we are still a long way from seeing a common approach to the management of postoperative resumption of physical activity in this patient population.

In the absence of guidelines, we at Isico recommend that patients turn to an experienced therapist in the post-operative period to ensure a gradual and safe return to physical activity, obviously following the instructions received from their surgeon.

It is important to avoid falling into the vicious cycle of a sedentary lifestyle. The less active you are, the less you feel inclined to do physical activity and the greater the risks to your health due to your lack of movement.

Scoliosis in the mirror: aesthetic concerns and psychological support

We are all critical when we look at ourselves in the mirror, and we tend to focus on and analyse the smallest detail, to the point that we sometimes get quite worked up about perceived flaws or defects that others probably don’t even notice.
This also applies to curves and asymmetries due to conditions like scoliosis. Indeed, to a young scoliosis patient these changes can appear extremely prominent, even when their friends and relatives insist that they can’t see anything wrong with the youngster’s back.

First of all, a brief preliminary remark. As part of scoliosis treatment, it is crucial to consider the appearance of the patient’s back.
This is not only because improving its overall aesthetics is one of the aims of the treatment (Negrini et al., 2018), but also because any change in its appearance, major or minor, can have a considerable psychological impact on the individual in question.

Of course, the way we see our own body and other people’s bodies is highly subjective, and aspects of our own body that bother us might not be the same aspects other people notice.

“For some scoliosis patients, the presence of asymmetries of the waist or shoulder blades, or a hump, will be an unbearable problem, whereas other patients may be quite unconcerned about them” says Dr Irene Ferrario, Isico psychologist. “And this can be entirely independent of objective clinical assessments; it may depend on the individual’s mood at the time, or on how much importance is attached to physical appearance in a given setting”. 

Sometimes, patients’ concerns about their appearance become disproportionate, turning into actual fixations that lead to them pouring far too much time and mental energy into working out how they can conceal their perceived defects.

“Having said that, minimising the patient’s concerns or trying to convince them that they don’t have any defects can, in some cases, be counterproductive” warns Ferrario. “Indeed, in the most severe cases, trying to appeal to reason to dispel concerns only has the effect of losing you the patient’s trust.”

Why seek psychological support

Therefore, it is advisable to seek help from a psychologist or psychotherapist in these cases. Unfortunately, many patients are reluctant to take this step as they remain convinced that removing the physical defect is the only way to resolve the problem and feel better. 

This is why scoliosis treatment must also address psychological needs to be effective.

On the one hand, specialists need to understand their patients’ distress and show them that they recognise the reasons for it. Once it is clear that a patient feels heard and understood, the therapist should then gradually and cautiously begin the process of formulating and presenting other possible reasons for the distress, helping the patient to know where it comes from and how it can be impacted by their environment and the people around them.   

“When we look at ourselves in a photo or in the mirror, we think we are seeing exactly what other people see when they look at us,” says Dr Ferrario, “but our eye is well trained to focus on the things we do not like about ourselves and thus to play on our insecurities. Whereas others see us as a whole and do not to dwell so much on specific details, we tend to analyse ourselves in minute detail, and our attention is always immediately drawn to the particular thing we are uncomfortable with.”

The main objective of psychological counselling, therefore, is to reduce, as much as possible, the discrepancy between the way we would like others to see us (our ideal self), how we think others should see us (self-guide), and how others see us (our real self).

“The course of treatment we do with our patients aims to help them rebuild their body image by encouraging greater awareness of their strengths and weaknesses” Dr Ferrario concludes. “Gradually, over time, patients manage to internalise this new image and eventually form a more realistic view of themselves. Patients also become more accepting of the aspects of their body that they used to see in a negative light”.

The Risser sign, growth and scoliosis: let’s clear a few things up

When patients come for medical consultations or physiotherapy sessions, numerous measurements get taken and recorded, often without less expert eyes even noticing.

On the other hand, other measurements are quickly seized upon, both by parents and youngsters. Take height, for example. The sliding piece barely has time to touch the patient’s head before the patient, hopeful, blurts out: “Have I grown? Can I leave off my brace now?”

Another milestone we are promptly informed of is menarche in girls, as parents are often convinced that when their daughters start their periods, they have finished growing, meaning that their treatment can come to an end. But this isn’t always the case. On the contrary, this delicate phase can sometimes coincide with the most marked progression of the disease, making it all the more important to act with caution.

Although these are two important examples of the many factors that need to be taken into account to work out what point a youngster’s growth has reached, it has been shown that increases in height and menarche do not necessarily coincide with the individual patient’s growth peak [1] and may therefore not be helpful and/or sufficient when it comes to deciding on the best course of treatment.

Since these manifestations are secondary growth characteristics, they can only be seen as an indication that the patient’s growth spurt has begun. What they do not tell us is precisely how far on it is. There is a scientific explanation for the traditionally held belief that girls “develop earlier” than boys. In fact, because testosterone starts to be released into the body after oestrogens, boys start their pubertal growth spurt later than girls.[1]

To manage scoliosis and optimise the treatment results of the condition, it is crucial to have a good idea of the patient’s residual growth potential and the time remaining until he/she reaches skeletal maturity. An accurate prediction of the growth rate is also required to know when the deformity is likely to be most at risk of progressing. On the other hand, once it has been established with certainty that the patient has finished growing, this is the time at which preventive measures can be stopped with only minimal risk of further deterioration of the curve. [1]

There are various methods we can use to evaluate bone growth in adolescence, and one of them is called the Risser sign.

An individual’s Risser grade can be determined from an anteroposterior X-ray of the spine. An advantage of this method is that the same X-ray can be used to measure both the number of Cobb degrees (necessary to diagnose scoliosis) and the degree of skeletal maturity, thereby limiting the patient’s radiation exposure.

From 0 to 5, Risser grades are assigned based on the amount of calcification present in the iliac apophysis, and the scale thus measures progressive ossification. A Risser grade 0 indicates a low degree of bone maturity: this status is present from birth through puberty.

A Risser grade 5 means that the iliac apophysis has fused to the iliac crest, and the structure is 100% ossified: this status is present in adults  [2]. 

It would be misleading to imagine the transition from Risser 0 to Risser 5 as a continuous and constant progression that occurs over a fixed time and at a set pace. This is because growth is not constant but proceeds at different rates in the different phases. There are times when it pauses, times when it speeds up considerably, and times when it slows down.

The crucial stage in a youngster’s growth, also vital for understanding the course of their scoliosis, is the pubertal growth spurt, during which the disease can alter the shape of the patient’s back in the space of just a few weeks. From the perspective of a Risser evaluation of skeletal maturity, this stage corresponds to the transition from Risser 0 to the complete acquisition of Risser 1.

Between Risser 2 skeletal maturity and the end of the Risser 3 stage, the growth spurt slows down, but as far as the scoliosis treatment is concerned, we still cannot lower our guard: the patient should continue to receive treatment.

Scoliosis treatment is brought to an end gradually as skeletal maturity increases. Once the patient has reached Risser grade 5 (complete skeletal maturity), the treatment can be terminated safely without fearing that some of the hard-won gains might be lost 

The Risser classification varies slightly in different parts of the world, with some differences found, in particular, between Europe and America. In Europe, the successive grades tend to be assigned more cautiously, in the sense that a patient is deemed to have passed from one stage to the next only in the presence of precise levels of bone maturation. On the other hand, the American tendency is to assign the successive grades sooner.

Another method for assessing skeletal maturity is the Sanders classification, whose eight grades are assigned based on the assessment of hand bone growth [3]. Some studies have found the Sanders classification more precise than the Risser sign. It shows higher staging sensitivity when growth is most rapid and is therefore more reliable during certain growth phases [4]. The problem with the Sanders classification is that it requires a separate X-ray of the hand, which therefore means that it could increase the patient’s radiation exposure.

All this information clearly shows that residual growth is essential to evaluate, but at the same time, difficult to establish and interpret.

Specialists can, of course, use the classification they prefer, which will be the one that, in their experience, works best for identifying and evaluating the growth peak in adolescence. It is essential that they can correctly interpret all the data they collect, including from radiographs and patients themselves, to optimise the timing and results of the treatment. 

References

[1] Cheung JPY, Luk KD. Managing the Pediatric Spine: Growth Assessment. Asian Spine J. 2017 Oct;11(5):804-816. doi: 10.4184/asj.2017.11.5.804. Epub 2017 Oct 11. PMID: 29093792; PMCID: PMC5662865.

[2] Greiner KA. Adolescent idiopathic scoliosis: radiologic decision-making. Am Fam Physician. 2002 May 1;65(9):1817-22. PMID: 12018804.

[3] Sanders JO, Khoury JG, Kishan S, Browne RH, Mooney JF 3rd, Arnold KD, McConnell SJ, Bauman JA, Finegold DN. Predicting scoliosis progression from skeletal maturity: a simplified classification during adolescence. J Bone Joint Surg Am. 2008 Mar;90(3):540-53. doi: 10.2106/JBJS.G.00004. PMID: 18310704.

[4] Minkara A, Bainton N, Tanaka M, Kung J, DeAllie C, Khaleel A, Matsumoto H, Vitale M, Roye B. High Risk of Mismatch Between Sanders and Risser Staging in Adolescent Idiopathic Scoliosis: Are We Guiding Treatment Using the Wrong Classification? J Pediatr Orthop. 2020 Feb;40(2):60-64. doi: 10.1097/BPO.0000000000001135. PMID: 31923164.

Adults: can hyperkyphosis be improved?

With the passing years, many adults start to realise, when they look at themselves in the mirror, that they are getting increasingly stooped. Some people are unwilling to accept this situation and start wondering whether they can do anything to arrest this process. The question is, can this condition be improved or is it pointless even to try?

The condition we are talking about is HYPERKYPHOSIS. If you look at a person sideways on, you see that their back is not straight, but has natural curves, whose function is to cushion the forces that act on the spine. Following the back line from the top down, we see that first, at cervical level, there is a forward curvature, termed LORDOSIS, then a backward dorsal one, called KYPHOSIS, followed by another forward curve, at lumbar level, also called LORDOSIS. When the amplitude of the dorsal kyphotic curve, measured on an X-ray, exceeds the normal range, we speak of HYPERKYPHOSIS. Usually, this curve measures between 20 and 60 Cobb degrees.
Various factors explain this considerable range. Some are positional and related to the type of examination performed (for example the position of the arms), while others are linked to the associated disorder itself, which may be characterised by marked (e.g., scoliosis) or more prominent (e.g., idiopathic hyperkyphosis, Scheuermann’s disease) curves. Elderly people often present hyperkyphosis caused by the osteoporotic vertebral collapse. As the bones become more fragile, even minor movements can cause tiny fractures of the anterior portion of the vertebrae, resulting in progressive bending of the whole back

Everyone’s back bends forward more as the years go by, regardless of whether or not they have hyperkyphosis.
Why is this?  Most people spend much of their time, i.e., many hours of most days over many years, in a hunched position, with the head looking downwards. In fact, in our daily lives, we are often in the sitting position, which encourages forward flexion of the back; furthermore, many of the activities that require us to move around (cooking, cleaning, DIY, hobbies) also involve bending forwards. For all these reasons, dorsal kyphotic curves tend to get progressively worse over time, we become increasingly stiff, and the trunk extensor muscles grow weaker, resulting in postural collapse. In short, all these factors, combined, leave us “crushed” by the force of gravity.

What are the effects of hyperkyphosis? In adults and the elderly, hyperkyphosis can increase our risk of back pain and worsen our quality of life as we find it increasingly challenging to support our back, both when seated and when standing. Another effect is impaired balance and stability when walking.

So, to go back to our original question: is it possible to break this vicious cycle through physiotherapy and, in particular, through specific exercises? 

The answer is yes! The initial objectives of the treatment are to reduce the stiffness of the dorsal spine and strengthen the trunk muscles that oppose the force of gravity, so as to facilitate postural recovery, and to integrate the correction into daily life. Indeed, from the outset, the treatment approach based on specific exercises encourages patients to learn the crucial “self-correction” movement that allows them to achieve optimal realignment of the spine in the sagittal plane without compensating for this at other levels of the spine (reference: Exercise for improving age-related hyperkyphosis: a systematic review and meta-analysis with GRADE assessment. Ponzano M, Tibert N, Bansal S, Katzman W, Giangregorio L. Arch Osteoporos. 2021 Sep 21;16(1):140. doi: 10.1007/s11657-021-00998-3. PMID: 34546447)

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Once the improvement has been obtained, it needs to be made stable and lasting. This involves reducing the frequency of the specific exercises and integrating them with other types of physical or sporting activity, all the time continuing to maintain the correction in daily life.  

Together, all this translates into less pain, better physical function and a more attractive back.

Can bracing improve trunk asymmetries in young adults?

Scoliosis is a condition characterised by the presence of a vertebral deformity in the three planes of space. The extent to which this deformity is visible externally varies from case to case. As stated in the guidelines recently developed by SOSORT, one of the primary objectives of scoliosis rehabilitation treatment is to improve trunk asymmetries. Achieving this objective has important implications for quality of life — after all, having a positive self-image helps to ensure a good level of psychological wellbeing and this, in turn, translates into a better quality of life.

Not uncommonly, adolescents with scoliosis lack the willpower or motivation to undertake bracing treatment, or perhaps have never had a medical specialist recommend it to them; others, quite simply, may not even have realised that they had scoliosis.
Basically, many different factors can affect what scoliosis treatment a person received, or did not receive, in adolescence. But the fact is that some people reach adulthood before realising, for example, that they have one waist straighter than the other, that part of their rib cage protrudes, or that one breast is higher than the other.

What can be done to improve these asymmetries?

“Although there is no scientific evidence available to help us answer this question with precision, we at ISICO have performed some bracing treatments in young adults (up to 25 years of age)explains dr Fabio Zaina, physiatrist – In such cases, our doctors, during the consultation, are clear from the outset: this is a long and demanding course of treatment. For the first few months, the brace should be worn full time, i.e., for 23 hours a day, after which the brace-wearing time is reduced very gradually in an effort to maintain the results obtained”.

Patients wanting to start bracing must be absolutely convinced about it and highly motivated, too, because any sudden interruption of the treatment, without respecting the abovementioned weaning-off phase, can negatively affect the stability of the spine.

On the subject of stability, we should also point out that bracing treatment must always be combined with specific exercises based on self-correction. The purpose of these exercises is to keep the back muscles strong and teach the patient how to keep their trunk correctly positioned during the various activities of daily life.

Can adults obtain a radiographic improvement?

Unfortunately, radiographic improvements cannot be achieved in adulthood. In individuals who have reached full skeletal maturity, bracing is never proposed with this aim in mind.

In other words, bracing in adults can improve the external asymmetries related to the scoliotic curves, but it cannot reduce the Cobb degrees of the curves themselves.

Are there no other options available for adults who are reluctant to wear a brace?  

“Adults can always follow a specific physiotherapy programme based on self-correction exercises explains Valentina Premoli, physiotherapist- These exercises are a way to act on the postural component of scoliosis. They serve to counteract the spine’s tendency to collapse to one side, and can thus improve the functioning of the back generally. This type of treatment helps to limit the worsening of the asymmetries that accompanies the spine’s tendency to give way in the direction of the curves — a tendency that becomes increasingly marked as we get older”.

Scoliosis and pregnancy

For a woman, discovering she is pregnant is often one of the most memorable, most exciting and happiest moments in her life. Thinking about the baby, imagining it and talking about it, not to mention feeling it inside her, arouses a number of precious and positive emotions: hope, tenderness and love. However, at the same time, pregnancy leads to various changes, in her body, her self-image and her vision of the future.
Furthermore, she will need to make adjustments and seek new balances in her (often busy) daily life, her rhythms and her relations with others. 

All this can generate normal and entirely understandable fears, and these can be amplified in mothers-to-be who happen to be affected by a condition like scoliosis. Many such women will already have expressed anxiety over their ability to conceive, carry and give birth to a child.
Pregnancy and childbirth, on account of the physical demands they make, can indeed be quite a daunting prospect for these women.

An interesting recent review of the literature (Dewan MC, Mummareddy N, Bonfield C. The influence of pregnancy on women with adolescent idiopathic scoliosis. Eur Spine J. 2018 Feb;27(2):253-263. doi: 10.1007/s00586-017-5203-7. Epub 2017 Jun 29. PMID: 28664223.), focusing on the interaction between pregnancy and scoliosis, examines these very issues. Just to give an idea, in numerical terms, of the analysis carried out, this review included 134 articles and examined 22 studies, referring to a total of 3125 patients.

First of all, the review considered whether and how scoliosis affects the timing and outcomes of pregnancy. It would appear that women with idiopathic scoliosis need not worry about their possibility of having children, even though they have a slightly lower probability of becoming pregnant compared with age-matched women, and may be slightly more likely to receive fertility treatment. Furthermore, women with scoliosis, regardless of whether they underwent surgery or bracing treatment, can expect to have a similar number of children as healthy women. 

However, the studies considered have certain limitations: most of them failed to specify whether the women with scoliosis had been actively seeking or desired pregnancy. Similarly, it is not clear whether all the patients were followed up until menopause. Furthermore, marriage rates, often not even mentioned, were not uniform across the studies.
In the absence of indications on these aspects, the slightly higher rate among women with scoliosis who do not have children could be misinterpreted.

Bracing + exercises + adherence to treatment = a recipe for successful treatment!

Idiopathic scoliosis is a disease that causes abnormal growth of the spine. Once a spinal curve has appeared, the vertebrae of a young patient are liable to become deformed in the three planes of space. This risk persists until he or she has finished growing.
Through conservative treatment, we aim to ensure that our patients, as adults, will have a strong back. In other words, we want them to reach adulthood with a healthy and functional spine, and that does not necessarily mean a perfectly straight one!

Therapy is therefore undertaken in order to try and limit the natural worsening of scoliosis curves through treatments proportionate to the severity of the condition.

To this end, there exist two main methods: specific physical exercises and bracing, and both need to be applied correctly and with the necessary adherence to treatment.

To decide whether a young patient needs to be prescribed a brace, the treating physician considers a series of factors, for example the size of the curve, the patient’s bone age, and whether or not he/she presents asymmetries (of hips, pelvis, scapulae, shoulders and so on).

When bracing is deemed warranted, we urge our youngsters to adhere scrupulously to the instructions given in order not to compromise the effectiveness of the treatment, and indeed to obtain the best possible correction.
This means that they must fasten and tighten their brace correctly, as shown by our doctors during the testing phase. If they do this, their brace will be less visible under their clothing; it will also be less prone to move about when they are walking, running and even sitting, and therefore more comfortable.

In addition to being more visible under clothes, a brace that is worn too loosely is less effective: it will not give the results that would have been achieved by wearing it properly.

According to data we have gathered, bracing treatment should produce its most marked results in the first months, and adhering to the prescribed number of brace-on hours is what makes the difference in this regard.

Bracing treatment is always prescribed together with specific physical exercises, i.e., 15-20 minutes per day of spinal self-correction and stabilisation exercises that help patients get into the habit of regularly correcting their posture themselves, even during the hours they are permitted to leave their brace off. 

We constantly remind our patients that whenever they remove their brace, self-correction becomes all important, and that “voluntary and active” self-correction works just like the brace itself does. Clearly, though, this demands good self-awareness on their part and a willingness to collaborate.

In “Specific exercises performed in the period of brace weaning can avoid loss of correction in Adolescent Idiopathic Scoliosis (AIS) patients: Winner of SOSORT’s 2008 Award for Best Clinical Paper”, we  showed that patients who regularly did specific exercises obtained a stable result when they finally stopped wearing their brace. Instead, those who did specific exercises discontinuously showed a worsening of a few degrees, while the curves of those who did no exercises at all worsened by an average of 10 Cobb degrees or more.

And it is important to remember that all these patients were prescribed the same type of brace, and the same number of bracing hours.

Brace weaning, which is carefully monitored by the physician, must be done extremely gradually, as the spine needs time to adapt to the absence of an external support. This is particularly true in the case of patients treated for very severe curves. During this delicate phase, self-correction exercises become even more important, helping to prevent the spine from once again collapsing in the direction of the curve. 

We often say that strength comes from within: a patient’s own determination to wear his/her brace consistently and do his/her exercises correctly will together help to ensure that conservative treatment is a success – and it is important to understand correction of the scoliotic curve is not the only measure of success. Success also means stabilising the curve and curbing its tendency to worsen as the patient grows.

Scoliosis: why choose rehabilitation treatment?

I have scoliosis. What should I do? Do I absolutely have to follow a treatment, or is there no point? Will I need to be operated on? These are questions we often get asked by patients who have been diagnosed with scoliosis.

Therapeutic approaches to scoliosis fall into two categories: surgical treatment, indicated only in a limited number of cases, and conservative treatment, which we prefer to call rehabilitation treatment. This latter category comprises different approaches, which are based on the severity of scoliosis. 

First of all, there is simple clinical observation (for very mild cases), then treatment based on specific self-correction exercises (for mild scoliosis), and finally bracing (for the treatment of moderate forms). The braces used can be elastic, rigid or super-rigid. The choice of brace type and the number of prescribed brace-wearing hours (treatment dose) are always determined by two key factors: the severity of the curve(s) and the risk of worsening.

Even though surgical techniques have improved enormously over the years, surgery for scoliosis always entails vertebral fusion, and thus a complete loss of mobility (function) of the section of the spine involved, which is transformed into a single bone. It is the most difficult surgery in orthopaedics (apart from surgery for severe poly-trauma), and naturally it carries all the risks that derive from the fact that the spine encases and protects the spinal cord, which contains all the connections between the brain and the lower limbs.  

Rehabilitation treatment, therefore, must always be considered the first-choice treatment for scoliosis. This even applies to “surgical curves” (i.e., those with a Cobb angle greater than 45°–50°), if no attempt has ever been made to correct them through full-time bracing and specific exercises (1). In short, surgical treatment is used only when rehabilitation treatment has failed.

What are we aiming to achieve through rehabilitation treatment?

Basically, we are aiming to obtain a back that is not only strong and efficient but also aesthetically pleasing. This is, indeed, one of our main objectives, given that a person’s quality of life is strongly influenced by how they see themselves physically. Therefore, a brace needs to be built in such a way as to reduce the external deformity as well as the magnitude (i.e., the Cobb degrees) of the curve(s). In this regard, it is very important to underline the importance of preventing scoliosis from worsening, especially in puberty when it is at the greatest risk of doing so. Reducing the Cobb degrees of a scoliotic curve is always an objective, but given that scoliosis in puberty almost always worsens unless it is treated properly, simply blocking the evolution of the condition must, in itself, be considered a successful result.

Through rehabilitation treatment, we also try to prevent the onset of back pain in adulthood. To this end, as well as treating any pain that occurs in childhood and adolescence, we also do our best to preserve, as far as possible, the physiological curves present in the sagittal plane. Several studies have shown that back pain in adults with scoliosis is highly correlated with abnormalities in the sagittal plane, even more so than with scoliotic curve magnitude (2). And unfortunately, over the years, scoliosis that exceeds certain levels tends to progressively worsen; as a result, for purely mechanical reasons, the trunk progressively falls forwards.

Finally, rehabilitation treatment aims to prevent the respiratory system problems that can arise due to progressive deformation of the rib cage in the presence of a severe thoracic curve.

All these objectives were extensively discussed, and identified as therapeutic priorities, by international experts from the International Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) during the drafting of the SOSORT Guidelines (3). 

(1) Lusini M, Donzelli S, Minnella S, Zaina F, Negrini S. Brace treatment is effective in idiopathic scoliosis over 45°: an observational prospective cohort controlled study. Spine J. 2014 Sep 1;14(9):1951-6. doi: 10.1016/j.spinee.2013.11.040. Epub 2013 Dec 1. PMID: 24295798.

(2) Diebo BG, Shah NV, Boachie-Adjei O, Zhu F, Rothenfluh DA, Paulino CB, Schwab FJ, Lafage V. Adult spinal deformity. Lancet. 2019 Jul 13;394(10193):160-172. doi: 10.1016/S0140-6736(19)31125-0. Epub 2019 Jul 11. PMID: 31305254.

(3) 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.

Scoliosis? It can be treated in adulthood, too

The young scoliosis patients who come to us for conservative treatment often have parents (one or both) affected by scoliosis. Some of these parents received exercise-based and/or bracing treatment in adolescence; some never got any treatment at all, while others even discovered the condition late on, after reaching adulthood. Often, they are completely convinced that there is nothing more to be done for their scoliosis! But nothing could be further from the truth!

For these adults, the first obstacle to overcome is precisely this unwillingness to do something about their condition: some are reluctant to face up to a problem that has caused them suffering in the past, some believe there are no solutions, and others give priority, above all, to their child’s care needs.

These attitudes are entirely understandable, but unfortunately burying one’s head in the sand simply has the effect of increasing the risks as time goes by. It must be understood that if scoliosis is getting worse, this is not a momentary problem — it is a situation that could lead to more marked symptoms in the future, such as pain and back problems.

When scoliosis worsens, the spine may start to bend laterally following the curve direction, creating a so-called Tower of Pisa effect. What is more, this can be accompanied by forward bending of the upper body. As well as having negative aesthetic consequences, all this can seriously impair the individual’s quality of life.  

Specific self-correction exercises are an excellent way of dealing with a worsening situation like this. It is worth remembering that a worsening of scoliosis in adulthood is not necessarily accompanied by pain; however, if pain does occur, the exercises should target both problems. We often come across adults who say they realised there was “something wrong” when looking at themselves in the mirror.
There are a number of possible signs to look out for: asymmetry of the hips, skirts or trousers that don’t hang right, asymmetry of the shoulders, a more pronounced hump, the perception of having lost a few centimetres in height. All these are red flags that should prompt you to seek the advice of a spine specialist.

Because, when it comes to scoliosis, it is definitely best to act in a timely fashion, taking steps to find out whether something is changing or if everything is stable.

Various studies have shown that scoliosis measuring under 30° at the end of growth normally remains stable over time, even during adulthood, while curves greater than 50° almost always tend to worsen [1]. Obviously, there are exceptions to both these “rules”. 

We do not know for sure exactly what happens in the case of curves measuring between 30° and 50°; we only know that, in general, the risk of deterioration increases as curves become more prominent.

In adult cases, it is important to have the medical and radiographic check-ups prescribed by the doctor. At ISICO we follow protocols that are based mainly on the severity of the curve, recommending the following:

– for curves with a Cobb angle of less than 20 degrees that have been treated during adolescence, a medical check-up every 4-5 years;

– for curves with a Cobb angle of between 20 and 29 degrees, a medical check-up every 2-3 years;

– for curves with a Cobb angle of between 30 and 44 degrees, a medical check-up every 1-2 years;

– for curves with a Cobb angle greater than 45 degrees, an annual check-up.

These recommendations aside, the doctor can give different indications, based other factors, such as the patient’s age and how stable the curve has proved to be in the past.

As for X-rays, the antero-posterior view is recommended if there has been a worsening of the hump.

When spine specialists measure X-rays of adult patients with scoliosis, they know that what they are seeing represents the sum of two components: the structural deformity of the spine and the patient’s posture.

In adults, there is little that can be done to alter the bone component (structural deformity), given that the individual has finished growing. However, we can certainly intervene on the postural part, teaching our patients how to support the weight of their trunk under the effect of gravity.

One of the main aims of the specific exercises we prescribe at ISICO is to help patients learn the technique of ACTIVE SELF-CORRECTION. This refers to a series of movements that patients are taught as a means of realigning their spine as much as possible, so as to counteract its tendency to collapse on the side of the curve; they are also encouraged to try and maintain much of this correction in their everyday activities. In this way, patients have a means of reducing, albeit temporarily, their curve by a few degrees, and possibly also the imbalance of the trunk that it causes.

In short, given the risk of a slow deterioration of the condition, it is important to have regular check-ups, for preventive purposes [2].

Finally, one last crucial piece of advice.  Always make sure you get regular physical exercise, appropriate for your age and physical condition. There is no one sport or activity that is better than  others: the choice depends entirely on the individual patient’s situation.  

If, in addition to doing sport and physical exercise, you also need to do targeted exercises for the spine, contact a spine specialist, who will draw up an ad hoc exercise plan for you.

[1 ] 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Negrini et al. Scoliosis Spinal Disord 2018  

[2]  Natural history of progressive adult scoliosis. Marty-Poumarat et al. Spine 2007

Scoliosis: why appearance matters

To treat scoliosis solely on the basis of radiological images, assessing only the patient’s skeletal conditions, would be a huge mistake.

The evolution of scoliosis typically leads to spinal changes in the three planes of space, and it therefore causes a modification of the ribcage. Indeed, as scoliosis progresses, it also changes the appearance of the torso, and this, depending on the severity of the curve, can impact more or less markedly the patient’s appearance.
According to the international guidelines on the conservative approach to scoliosis drawn up by Sosort, improving the patient’s appearance is the second most important goal of treatment.
If the condition is not adequately treated, or the treatment is ineffective, the above-mentioned changes will become more and more marked, even to the point of severely impairing the patient’s quality of life.

The way we see our body is highly subjective. People with asymmetries of the hips or shoulder blades, or a hump, react differently to the problem, in the sense that a defect that one person hardly thinks about, may be quite unbearable to another.
“In treating scoliosis, we must be careful not to overlook this question of aesthetics, precisely because we can never assume that our patients see things the same way as we do: any asymmetry, be it major or minor, can have a considerable psychological impact says dr Irene Ferrario, Isico Psychologist – It is also important to remember that these changes occur in a period – adolescence – that is already full of challenges, and can sometimes see youngsters struggling to build, and accept, their own body image”.

For all these reasons, addressing patients’ aesthetic concerns should not be seen as indulging them; indeed, correcting aesthetic defects is not of secondary importance compared with correcting the curve: it is a therapeutic necessity. When a patient has, for example, one flank straighter than the other, a misaligned shoulder blade, or a hump that alters the line of the upper body, these changes may be perceived as more or less visible, depending both on the individual’s relationship with his/her body, and on his/her own (entirely subjective) aesthetic parameters. Over time, however, if the disease progresses, these changes can become objectively visible and psychologically damaging.
Obviously, we are referring here to the most severe cases, but these remarks nevertheless serve to illustrate that a scoliosis treatment plan cannot exclude the issue of aesthetics. Addressing this aspect is a necessary part of the treatment.

In short, good conservative practice absolutely must take into account aesthetic considerations. Regardless of whether or not the patient highlights this aspect, considering it to be of primary importance, the physician should in any case include it as a key objective of the treatment, which may contribute to its success.
In our care pathway, it is often the parents who first “raise the alarm”, alerting the therapeutic team to these concerns. This is because they are often the first to notice changes in the child’s body, especially if he or she is still too young to have a real awareness of his/her body and body shape.
Sometimes, these “alarm bells” are justified, and sometimes not, given that mild bodily asymmetries are normal, and do not always indicate an underlying problem. Purely aesthetic concerns, especially when raised by our young patients, should never be dismissed. Identifying and acknowledging a patient’s experiences and feelings is crucial to their all-round care. 

“Another aspect that should be underlined is brace wearing, as this treatment (when required) also has aesthetic implications –explains Lorenza Vallini, Isico PT – Many patients worry that their brace can be seen under their clothing, and addressing this concern is an important part of increasing the acceptability of the treatment: fitting patients with increasingly thin braces, moulded to their shape and therefore “almost invisible” to the onlooker, has proved to be a key factor in reducing and containing the deformity. Moreover, a good brace produces a truly remarkable aesthetic correction, not only immediately but also in the long term“.
Indeed, the brace wearer is rewarded with an improvement that lasts into adulthood. But arguments based on the long-term advantages are often lost on youngsters, and therefore an “invisible” brace is still crucial.
The main objective of the treatment will always be a well-balanced and harmonious body, which is as symmetrical as possible. After all, no one is perfect, not even Botticelli’s Venus. Indeed, her imperfections are part of her beauty!