What is scoliosis?
Scoliosis is a spinal deformity characterised by a twisting of the spine in the three planes of space. Basically the spine turns round on itself like a bent corkscrew.
How many types of scoliosis are there?
Scoliosis is a curvature of the spine that can be caused by different conditions, in which case it is termed secondary scoliosis. The first thing to do, therefore, is rule out possible underlying diseases. In 85–90% of cases, however, scoliosis is primary, or as we say, idiopathic. Idiopathic is just an elegant way of saying that we don’t know the cause of the problem.
How is scoliosis detected?
Scoliosis worsens with physical growth — especially during the pubertal growth spurt (10–13 years of age in girls, 12–15 years of age in boys) — and up to the end of skeletal maturation (1–2 years after the end of growth in height). Scoliosis does not really have symptoms as such. It is a good idea to monitor youngsters’ backs,especially in the period of greatest risk, and you can do this by means of a very simple test called the Adams forward bend test.
Why screen for scoliosis?
Screening allows us to assess, early on, the possibility of vertebral deformities developing later, in a high risk period. Indeed, in this way, any problems can be picked up on at the very start. This is important because prevention is better than cure: identification of a spinal deformity at an early stage allows the best possible outcome of conservative treatment.
Who should be consulted for scoliosis?
Your first port of call is your family doctor or paediatrician, who should be consulted immediately, especially if the patient has back pain or is going through a growth spurt. Indeed, the problem with scoliosis is that it is a disease that evolves, sometimes very rapidly, especially during puberty: at this stage, without timely intervention, there is a risk of the patient developing severe scoliosis, which will require much more demanding and challenging treatment.
If the family doctor finds that scoliosis is present, he/she will refer you to a medical spine specialist, like us at Isico. However, be careful, because not all physiatrists and orthopaedic specialists are also spine specialists, and unfortunately those who routinely deal with osteoarthritis or trauma, for example, but rarely see kids with back problems, are more likely to make mistakes. Isico’s doctors are specialised in diseases of the spine, and therefore do not run this risk.
At Isico, this is not a problem.
What is the forward bend test?
The simplest test for scoliosis is the forward bend test: the youngster stands with his legs straight and arms relaxed and bends forward from the waist keeping his head bowed. This position reveals the presence of any rib humps, which must be measured at the point where the difference in height between the two sides is greatest. Rib humps are measured using a scoliometer to determine the angle of rotation of the trunk. If an angle greater than 5° is found, it is necessary to consult a spine specialist.
Are X-rays measured too?
Certainly, and in fact this is a good way of telling whether the specialist you are seeing is actually a spine specialist: a spine specialist will always measure X-rays in cases of scoliosis.
What purpose do exercises serve?
At Isico we use the SEAS (Scientific Exercises Approach to Scoliosis), a method that is constantly evolving on the basis of scientific research. This approach is the first one we apply in patients with mild curves (less than 15°), whereas in the presence of more severe curves (generally greater than 20°), we combine it with bracing. The purpose of exercises is to train the body, but they are not a substitute for wearing a brace in patients in whom this is required.
Why do some people say exercises are unnecessary?
Many practitioners use techniques that are sometimes unnecessary, and even harmful, in scoliosis patients. These techniques tend to be “masked” by important-sounding names (often foreign) and terms —Mézières, Souchard, global postural reeducation, osteopathy, chiropractics, Sohier, Klapp —, and they include different kinds of manipulation, the use of various dental bite appliances, custom-made plantar orthoses, thicknesses and absurd wedges, not to mention massages, electrostimulation and a whole range of passive techniques.
They are all based on the principles espoused by the masters who invented them, and not on the requirements of the disease and, specifically, the patient. As a result they can only do considerable harm, first of all to patients, but also to the reputation of those who work well in this field, also using exercises.
There are numerous published papers in the literature that support the usefulness of exercises. It is true, as argued by detractors of exercises, that they report studies that lack the methodological rigour that is demanded of medical research before it can be used as a basis for affirming with certainty that a therapy is effective, but it is equally true that if this were a requisite for all existing scoliosis treatments, then none would be up to the mark and patients would have no treatments at all!
Indeed, as with exercises, there are no definitive studies on the other treatments (bracing, surgery) either. However, what we do know for sure is that correct exercises, such as those proposed by Isico (based on rigorous theoretical-scientific foundations and supported by the existing evidence in the medical literature), constitute both a form of prevention, when scoliosis is mild, and an essential factor in obtaining the best final result from a brace.
When is a brace recommended?
In our patients who have curves of between 15° and 25° we use Spinecor, a minimally invasive and dynamic brace that allows ample freedom of movement; the next step is a rigid brace (the Chaneau brace), while for curves greater than 35° the Sforzesco brace is prescribed.
How long does it have to be worn each day, on average?
From the outset, it is always worn for 18 hours upwards, depending on the clinical situation. It should be remembered that, as demonstrated in the literature, the brace becomes effective when it is worn all the time, and its use for 18 hours a day is therefore a compromise for the initial period.
And for how many years?
It depends on individual bone growth, and should be decided case by case.
What happens in the case of adult scoliosis?
Scoliosis that remains stable at less than 30° is considered resolved. With curves greater than 30°, on the other hand, there may be a risk of deterioration and therefore the back should be checked periodically.
Can you do sport if you have scoliosis?
Yes, certainly, perhaps with the exception, in more severe cases, of competitive sport and intensive training. Sport is actually thought to be an important complement to a specific re-education activity, as it naturally promotes good neuromotor maturation of the adolescent growing body. Moreover, it reinforces the physiological abilities of an impaired spine while reducing the side effects of bracing (if a brace is worn).
Furthermore, doing physical activity with a brace on (when this isfeasible) enhances the modelling action of the forces applied by the brace pads.
Can you swim if you have scoliosis?
Swimming is a great all-round sport in the sense that it is good for thelimbs, heart and lungs, but it is not beneficial for the back: the spine is designed to cope with the force of gravity and must be trained with this in mind. In water, no force is exerted on the shoulders: this is useful in acute conditions, but it is not helpful for training the back.
The use of swimming to correct scoliosis is a tradition that dates back to the time when it was thought that scoliosis could be treated by eliminating the force of gravity. In Eastern Europe there were even centres where they tried to cure severe scoliosis by confining patients to bed for months. Nowadays, through rehabilitation training, we try to train certain physical abilities in order to overcome the force of gravity, but this cannot be done so well in water.
Why don’t you use the Milwaukee brace?
At Isico we have “pensioned off” plaster casting and the Milwaukee brace because we have another brace that is equally effective (if not more so, considering that it is more progressive and therefore able to continue exerting a corrective action over time): the Sforzesco brace.
The Milwaukee, of course, allows excellent correction of scoliosis, and if we focus on this aspect alone, then there is no need to switch to another brace. But there are other aspects to consider, too. If we want to consider the patient’s psychological wellbeing (as well as his/her back) and the future function of his/her spine (and not just its anatomy), and if our real aim is to help patients wear braces (and not simply to prescribe them), then we would definitely say that there are far more grounds for abandoning the Milwaukee than for continuing to prescribe it.
Can wearing a brace be a problem for teenagers?
Isico uses underarm corrective braces that are easily hidden under t-shirts (providing these are a slightly loose fitting), and they are very well tolerated and unobtrusive. They can be worn for sport and for physical exercise at school, and indeed allow the wearer to lead a perfectly normal life. When we say they “can” be worn, we mean they must be worn! Because the more active the patient is when wearing his/her brace, the better its results will be. A brace is a rather challenging treatment, but it is certainly not an armour! It is a medical appliance just like a dental appliance and, as such, it is anti-aesthetic and can be a bit annoying, but it is nevertheless useful. A dental brace is actually more anti-aesthetic than a back brace, just more socially accepted. In the case of a back brace, however, the advantage is not only aesthetic but also important for the patient’s adult life, as it will reduce the likelihood of pain and back problems later on.
When is surgery necessary?
When it becomes inevitable, i.e. in situations in which it has not proved possible to treat the scoliosis non-surgically and the curve has become so severe that it risks creating problems for the rest of the patient’s life, and patients and their families accept this.
Is the spine put at risk by long periods spent sitting at a desk?
The sitting position has similar effects in children as it does in adults, but in children they are more marked. The spine is not designed to remain in the sitting position for long periods of time, in other words in a forward bent position, which is a reversal of the normal curvature of the lower back (lordosis). This position stresses the spine causing discomfort that needs to be relieved through frequent changes of position; this is necessary to avoid both minor damage and even actual “asphyxia” due to impaired supply of oxygen to the spinal cord.
What can schools do to help?
Children who are uncomfortable from sitting for too long will often fidget in order to relieve their discomfort. If a class becomes restless, the teacher could have them all stand up for a few seconds and walk round their chairs: the children will then quieten down, both because they will have relieved their backs and because they will have been provided with a minor distraction. It is absolutely wrong to make children skip recess or spend their break sitting at their desks; finally, children should be given the opportunity to walk between lessons, preferably every 30–40 minutes.
Do “school-induced” orthopaedic problems actually exist?
No. There only exist correct and incorrect postures. There is certainly no school desk capable of causing scoliosis. The only thing is that a chair that is too high in relation to the desk, resulting in a protracted forward bent position, can cause round shoulders.
Are the UNI standards, followed by manufacturers, correct?
These dimensions are certainly adequate from an ergonomic point of view. However, modern ergonomics teaches us that no chair or desk, alone, can guarantee that problems will be avoided. All tools can be used well, or they can be used badly: even if we have the most ergonomic chair possible and the best designed desk, they will be of little use if we don’t use them correctly.
Can scoliosis be cured?
Reaching the end of treatment for scoliosis does not mean that the condition is cured, since this would mean returning to 0°, i.e. no curve at all, and this hardly ever happens. What really matters is not achieving a perfectly straight spine, but ending up with an only mild curve. Treatment for scoliosis usually ends at the end of bone growth, exceptions being cases that are detected very late or patients in whom bone maturation is slower than average. The end of treatment is followed by a monitoring phase, during which the patient undergoes periodic checks (once a year, once every two years or three-yearly, depending on the extent of the curve). If at a certain point the scoliosis begins to worsen, there are two possibilities: surgery or regular exercises to keep the situation stable.
What results can you expect from treatment for scoliosis?
Unfortunately, with scoliosis, there is no guarantee of a result. In our experience, controlling curves of less than 30° detected in adolescence is not a problem (unlike the infantile and juvenile forms,which almost always worsen in puberty, despite treatment). Instead, it is not uncommon for curves greater than 50° to deteriorate, even when treated. The problem with curves measuring more than 50° is that it is not enough to stabilise them; they need to be improved. This is possible, but it requires considerable effort, perfectly fabricated braces, which must then be used exactly as they should be, and the right exercises, well adapted to the ongoing treatment, i.e. perfectly complementing the use of the brace. In patients with curves measuring between 30° and 50°, deterioration is very rare (a rate of well below one in every hundred cases, providing everything is done as it should be), but unfortunately it cannot be excluded.
Is a scoliotic posture/attitude considered a disease?
A scoliotic posture is not a disease: it is simply the presence of slight asymmetries, like for example the physiological leg length discrepancies during growth. It is important to distinguish between a paramorphism like scoliosis, which is a deformity, and the dysmorphism which is instead a scoliotic posture.
Indeed, the classical clinical signs of scoliosis, namely the hump, caused by vertebral rotation, and the presence of bone deformities on X-rays are absent in an individual with a scoliotic posture. Therefore, if there is no radiographic evidence of a curve and no rotation of the spine, then there is, by definition, no scoliosis. In the case of leg length discrepancies, a shoe lift may be useful, but not always necessary, to have both legs evened. In particular cases the specialist could prescribe specific exercises, but they are not always recommended to avoid overtreatment. If general muscle strengthening through regular physical exercise proves insufficient in a case of scoliotic posture, specific exercises can be useful. Specialist checks during development are advisable, in order to be sure that a scoliotic posture does not conceal a minor, but true (structural) scoliosis. Should this turn out to be the case, more specific treatment would be required.
What do scientific studies say?
- Scoliosis is not psychological in origin.
- Muscles are not responsible for scoliosis (except in very exceptional cases, readily diagnosable).
- The bone deformities, once acquired, are practically impossible, if not impossible, to modify without using instruments external to our body. It is possible to correct postures, but not bones, and scoliosis is a deformity of the bones.
- There exists no treatment that can completely correct true scoliosis. In other words, complete correction cannot be achieved through surgery or bracing,let alone exercises.
- Whenever spines are straightened, this is because they were not true scoliosis, but rather a scoliotic posture/attitude(which, as such, only required a little sport in order to recover, not treatment).
Is osteopathy effective in the treatment of scoliosis?
At present there is no evidence about the effectiveness of osteopathy as a treatment for scoliosis. Those who treat scoliosis using osteopathy alone are taking a considerable risk, because they are doing so without having first verified the real effectiveness of what they are doing, or, if they have verified this, then they have failed to publish their findings and share them with the entire scientific community. There is no doubt that osteopathy seems to be a far more fascinating route to go down than bracing, and an easier one too. Some, instead, suggest that osteopathy could be used in association with the other treatments, in other words, not as an alternative to them but as an extra approach. Again, it is not possible to say for sure whether this may be beneficial. Finally, all that we have said here about osteopathy also applies to chiropractic and manual medicine techniques generally, as illustrated by a literature review published some time ago by our group.
Medicine, by definition, evolves in a scientific setting, where the results obtained are rigorously verified; all the rest is unscientific. Patients should only trust methods and practitioners who have evolved in a scientific setting. Accordingly, they should avoid all that that does not fall into this category, which includes “methods” that, as their names often suggest, are based solely on the ideas of those who invented them. Although these inventors are often highly charismatic and very able individuals, this is not enough. Mézières, Souchard (with his global postural, “champ clos” or postural re-education techniques), Bertelè, Pancafit, Sohier, and ID (Istituto Duchenne) are just some of the methods used in this field that are based not on scientific knowledge, but on the ideas of those who invented them.
Are all braces the same?
Prescribing a brace (a “Cheneau” or “Lyon” brace, for example) is like ordering a piece of furniture (a dresser or a kitchen table, say). You can choose to go to a master furniture maker (for this, read orthopaedic technician) whose products are always made to order, and who never supplies prefabricated goods (a solution that would be entirely pointless for vertebral deformities). What is more, the most forward-thinking doctors in this field will specify how many pads the brace must have, where these should be located, and how high the brace should be, and so on (rather as though they were specifying how tall they want the dresser and how many drawers it should have). But even with this input, the furniture maker still has a considerable margin of discretion. This is why experts in this field have stipulated, at international level, that only direct collaboration between a physician and an orthopaedic technician is valid, because this is the only way of ensuring that you have a product that exactly matches the patient’s needs. They also maintain that the two should work together regularly and consult each other about each single case in order to ensure patients receive the very best product. Having said all this, it is clear that not all braces are the same.We ourselves firmly believe that brace tolerability is a key objective, as is minimal visibility. Indeed, we have stopped using certain models of brace precisely because they are visible, bulky and often painful.
When is surgery inevitable?
Surgery must be the patient’s choice, taken together with the doctor and the patient’s family. Given its risks and possible complications, surgery is not a decision that can be imposed on a patient. What doctors must do is make sure patients and their families are given all the correct information about their condition (based on scientific evidence and not just on their personal opinions) and then the right tools, so as to ensure that they are treated as effectively as possible. It is important to remember that surgery is a definitive choice, and once it is undertaken, there is no going back.
What is one of the main complications after scoliosis surgery?
Sometimes (not often) the rod breaks. But since the rod is located in scar tissue or even bone tissue, it is unlikely to cause particular problems. The situation would need to be evaluated, and the decision on whether or not to perform further surgery would have to be taken after considering the damage that the rod could cause and weighing this up against the risks of a second surgery. This is something that, in order to make an informed and conscious choice, would have to be discussed directly with the surgeon.
Scoliosis and yoga
Yoga, on the other hand, has not yet been scientifically proven to have any effectiveness in the conservative treatment of scoliosis. Yoga is one of a number of alternative movement techniques that in some cases, especially in the United States, are also used as a form of treatment for health problems.Yoga consists of exercises or repetitions of certain positions that have absolutely nothing to do with the concept of active self-correction and, moreover, are not specifically ‘tailored’ to the individual patient. The only possible similarity between certain yoga positions and the specific physiotherapy exercises we have mentioned is that yoga is intended to have an increasing stabilising effect, but this, too, remains to be scientifically proven.
Can you bathe (in the sea or in a swimming pool) with a brace on?
Yes, you can bathe with a brace on! Just bear in mind the following rules, take care and remember that unfortunately not all braces allow you to do this.
Six rules for bathing if you wear a brace:
- If you wear a Thermobrace device, this must be removed before you enter the water. Do not leave it in the sun, and put it back in place when you have finished bathing.
- If you have been in the sea, you will need to rinse the brace well in freshwater to get rid of the saltiness.
- Dry the brace thoroughly.
- Do not use hot air from a hairdryer to dry the brace pads and do not expose your brace to the summer sun, because the sun can overheat the metal parts and, as well as making them hot, will cause them to dilate. Basically, as the brace heats up, the holes where the where the hinges are attached to the plastic shells will expand and become deformed. The danger is that this can ruin the brace, because as the brace subsequently cools down, the metal part will return to its original size while the plastic will remain permanently enlarged and deformed.
- If the brace pads are covered in Alcantara® , let them dry out thoroughly, as this material is easily spoiled.
- As an extra precaution, you could use a stretchy seamless fabric tube to “line” your brace before going in the water (SOFT-TUBE or a similar product).
- You cannot bathe or swim with your brace on if the strip protecting your abdomen is made from leather (another material that will be spoiled if it is allowed to get wet: you must first replace it with a plastic one (talk to your orthopaedic technician about this);
- If you are trying out your brace, or just about to do so, contact the orthopaedic laboratory for more information, and to find out about the procedures to follow for your type of brace;
- It is important to follow the above precautions carefully: a brace is a medical device provided by the National Health Service and you should not let it get damaged through negligence.
Do not go in water where you are out of your depth, even if you can swim!
Can you ride a bike, motorbike or moped with a brace on?
The Highway Code contains nothing that expressly prohibitsbike riding when wearing a brace. The only clause that might theoretically be applicable states that “cyclists must have free use of their arms and hands and must keep at least one hand on the handlebar; they must, at all times, have a clear view in front of themselves and on both sides, and they must be able to perform the necessary manoeuvres with the utmost freedom, readiness and ease”. Pedaling might be tricky if the position of the handlebar in relation to the saddle forces the rider to bend much more than 90° at the hip. If this is the case, it is indispensable to adjust the height (or shape) of the handlebar and saddle as necessary in order to be able to pedal freely.
- Mopeds, scooters and motorbikes.
There is nothing in the Highway Code to suggest that driving vehicles of any kind is a problem. If you are able to use your hands and legs, you can even drive a spaceship!
Warning! In the event of an accident, you could find that there are problems with your insurance claim. If you drive a car or motorbike, it is advisable to inform your insurance company of this. If they ask for further information about the brace you wear, talk to your doctor.
Why do the hours of brace wearing have to be continuous?
The first reason, as we showed in a recently published study (http://www.ncbi.nlm.nih.gov/pubmed/24859575), is that it takes at least two hours, once the brace has been put on, for the spine to reach the desired correction. This means that we have to consider not only the brace-free hours in a day, but also the hours taken to return to full correction inside the brace when it is put back on. Therefore, even though the total number of hours with the brace on is the same, the treatment may be less effective on days when frequent breaks are taken.
The second reason is that it feels good when you take your brace off (even young children soon learn this!), but putting it back on is far less pleasant, so patients tend to procrastinate, dawdling in the shower, taking a little bit longer to finish a phone call, or staying out late with friends for example. But in is way, their brace-free hours add up without them really realising it. And if they get into the habit of doing this in the course of the day, it will become more and more difficult for them to comply with their doctor’s directions.
Are X-rays harmful?
Can a back become bent again once the treatment is finished?
In our experience, documented in data we have published, it is certainly not true to say that spines treated for scoliosis, once the treatment is over, almost always go back to being as bent as they were before, if not more so. If everything has been done correctly, the result will generally be stable, at least in the medium term.
Any deterioration after the end of therapy can depend on various factors, which may act individually or together:
– the exercises weren’t done
– the wrong exercises were done
– the brace treatment was ended too soon
– the brace treatment was ended too quickly
For example, in a study we published, we showed that, with braces of comparable quality, worn for the same amount of time, patients who do the right exercises will have a substantially stable result after leaving off the brace, those whose exercises are not sufficiently specific will experience a deterioration of a few degrees, and those who do not do exercises will worsen by 5° or even as much as 10°.
The end of brace treatment is a crucial and delicate phase. As with the exercises, use of the brace should be brought to an end extremely gradually. The spine must be allowed to become accustomed to being unsupported very gradually, and this is especially true in the presence of a very severe curve.
Finally, it must be remembered that what happens in adulthood also depends on the end result obtained: those whose curve is under 30° at the end of treatment normally remain stable, those with a curve greater than 50° generally find that the condition tends to worsen gradually over time, while final curves of between 30° and 50° are associated with a risk of deterioration, and this risk increases the greater the curve is. This is another thing that needs to be taken into account.
When should a brace be recommended?
We know from the literature that scoliotic curves with a Cobb angle measuring more than 30° in adulthood can go on progressing and give rise to problems, such as back pain. The likelihood of this happening increases progressively the higher above the 30° threshold the measurement rises, becoming a virtual certainly in the presence of curves measuring 45°-50°, the level corresponding to the threshold for surgery.
Therefore, the aim of conservative treatment is, as far as possible, to ensure that patients reach bone maturity (Risser 5) with a scoliosis curve of less than 30°, or as close as possible to this measurement.
Scoliosis therapy differs according to the severity of the condition, as indicated below. The necessary treatment is established and managed by a physician, who also takes into account various other factors (the stage of growth, any associated deformities, risk factors for worsening of the scoliosis, family history, patient’s/parents’ preferences, and so on).
- Scoliosis <13-15°: observation or exercises in the presence of risk factors for a significant deterioration;
- Scoliosis <20°: exercises and follow-up at 3-4/6 months, depending on the patient’s growth stage (whether or not she/he has had, or is having, a pubertal growth spurt);
- Scoliosis of 20°-25°: either exercises or an elastic brace (Spinecor), with the choice depending on the patient’s growth stage (as in the point above) and on aesthetic considerations. A rigid brace may also be used; in this case the brace will be chosen by the physician and will depend on the patient’s bone maturity and on aesthetic considerations.
- Scoliosis of 25°-30°: an elastic or rigid (Cheneau) brace, used at doses that will depend on the patient’s growth stage (whether or not she/he has had or is having a growth spurt) and on the rigidity of the curve: it may be worn all the time (i.e. 23 hours a day) or for part of the day (18 hours a day);
- Scoliosis >30°: a rigid brace (at Isico we use the Sforzesco brace) whose use will depend on the patient’s pubertal growth and the rigidity of the curve. In some cases, it will need to be worn all day (this is certainly true in the presence of scoliosis measuring more than 35°-40°).
At the start of bracing therapy, the brace is usually prescribed for 23 hours per day; subsequently this time will gradually be reduced, initially by one hour and then by two hours every 4-6 months. It is sometimes possible to start with a lower dose, if the patient’s conditions allow this, but the dose must never be less than 18 hours per day, otherwise the brace will have no therapeutic effect. The dose also depends on the patient’s Risser stage (the Risser test is a staging system used to measure maturation of the spine): the dose is never less than 18 hours in patients who have not yet reached Risser 3 (because until that bone age is reached, there is always an increased risk of the condition worsening, especially if the brace is not worn for a sufficient number of hours).
Why was plaster casting replaced by the Sforzesco brace?
Plaster can be wrapped around a trunk in order to immobilise a deviated spine in the correct position. The aim is to exploit the considerable pressure exerted by this rigid material on the protruding or non-homogeneous parts of the trunk, so as to obtain a definite correction. The rationale is to ensure, immediately, a big improvement and then to control the trunk through rigid braces.
This is, in fact, what seems to happen. If you look at an X-ray taken immediately after the application of a plaster cast, you will probably be amazed by the result, as the image will usually show remarkably gentle curves in place of the tight ones that were visible on the X-ray taken before the cast was applied.
However, once the plaster cast is removed, the spine will tend to revert to its starting condition, although this collapse is, to an extent, controlled by the rigid brace the patient is given to wear immediately afterwards. Overall, what this means, at the end of the day, is that the improvement obtained with a plaster cast is far less marked that it initially seemed to be.
Ever since 2004 we at Isico have been developing and using the Sforzesco brace, which has been shown to be as effective as plaster casting (if not more so, because its effect is more progressive, and therefore it is able to go on correcting over time); furthermore, it has fewer side effects, is clearly less obtrusive and therefore aesthetically less problematic, and it allows the patient wearing it to continue with his/her normal daily activities. In our view, the main advantages of this treatment are related to the individual’s quality of life: in short, if you want to consider your patients’ psychological wellbeing as well as just their back; if you are concerned about the future functionality of the spine in addition to its anatomical correctness; and if, rather than just prescribing braces, you want to find ways of helping your patients to wear them, then you clearly have far more reasons to abandon plaster casts rather than to go on prescribing them.
Studies published in prestigious international scientific journals have demonstrated the superior results obtained with the Sforzesco brace.
The right way to wear your brace
A brace must be worn for the number of hours prescribed by the doctor: this is essential in order to obtain the desired correction and avoid the risk of compromising the treatment. It is important always to fasten it tightly. In this way, it will be less visible, will allow the best possible results to be achieved more quickly, and will be less uncomfortable when walking, running or sitting down.
It is always best first to slip the brace on and then lie down on the floor or a bed to tighten it: scoliotic curves are less pronounced when a patient is lying down, therefore, tightening the brace in this way will have the effect of “stabilising” the spine in a more correct position.
Immediately after meals, a brace can press uncomfortably on the abdomen: to reduce this sensation the belts can be loosened a little, but without removing the brace altogether.
Can you bathe (in the sea or in a swimming pool) with a brace on?
Our answer to this question refers to the braces that we prescribe at Isico. Yes, you can bathe with a brace on!
Don’t forget that in hot weather there are a few things you can do to prevent possible problems: wash often, make sure you wear a fresh t-shirt (always change your t-shirt as quickly as possible), and apply thin pads (pantyliners) on the armpit part of the brace; you can change these frequently, especially when you are sweating a lot.
Just bear in mind the following rules, take care and remember that unfortunately not all braces allow you to do this.
6 rules for bathing/swimming in a brace:
- If you use a Thermobrace device, this must be removed before you enter the water. Do not leave it in the sun, and remember to put it back in place when you have finished bathing.
- If you have been in the sea, you will need to rinse the brace well in freshwater to get rid of the saltiness.
- Dry the brace thoroughly
- Do not use a hairdryer to dry the brace pads as this would dry out the glue used to apply them; for the same reason do not use a hairdryer on areas where there is padding. Direct sunlight exposure is harmful to the brace, in particular, the metal parts, exposed to the sun, will not only become scorching hot, but will also dilate. As a result, the holes where the hinges are attached to the plastic shells will expand and become deformed. The danger is that this can ruin the brace, because as the brace subsequently cools down, the metal parts will return to their original size while the plastic will remain permanently enlarged and deformed.
- If the brace pads are covered in Alcantara®, let them dry out thoroughly in the sun, as this material is easily spoiled.
- As an extra precaution, you could use a stretchy seamless fabric tube to “line” your brace before going in the water (SOFT-TUBE or a similar product).
- Since leather is a material that is spoiled if it gets wet, you cannot bathe or swim with your brace on if the strip protecting your abdomen is made from leather. You must first replace it with a plastic strip.
- If you are trying out your brace, or just about to do so, contact the orthopaedic laboratory for more information, and to find out about the procedures to follow for your type of brace.
Never go in water where you are out of your depth, even if you can swim!
Do school backpacks cause scoliosis?
Scoliosis is an idiopathic familial condition that certainly has nothing to do with the weight of school backpacks. Although carrying heavy backpacks can be linked to back pain, it will not cause any structural damage. Actually, what really matters is not the weight of a backpack but how long it is worn for, and how fit the youngster is. In fact, the first rule for protecting our children’s backs is to keep them fit and active, encouraging them to move whenever they get the chance to. That means avoiding sedentariness at home, making sure they do as much sport as possible, and even just giving them plenty of opportunities to have a run around in the park!
Is natural childbirth contraindicated in a woman who has had scoliosis surgery?
There is no problem as far as her back is concerned. As regards epidural anaesthesia, this may be possible. It depends on which section of the back was involved in the spinal fusion surgery. If the surgery was performed at the level of the dorsal spine, then there will be no problem. If, instead, the lumbar level was also involved in the surgery the anaesthesiologist will establish which was the last vertebra involved and, on this basis, decide whether or not an epidural can be administered.
Should the siblings of scoliosis patients be screened for the condition?
Yes, we strongly recommend that they undergo screening, because scoliosis is a condition that runs in families. In other words, it occurs more frequently in individuals who have affected relatives. Furthermore, the earlier any problems are detected, the less aggressive the subsequent treatment will be. Therefore, Isico recommends that any siblings under the age of 15 years should undergo preventive screening once a year.
How should I carry my brace on a plane?
The answer to those questions is easy: the best way to carry your brace is simply to keep it on.
There are several reasons why this is a good idea. First of all, it will save space in your luggage and stop you from having to worry about what bag or case to try and fit it in. Also, this way, it’s much less likely to get damaged.
There is another advantage to keeping your brace on while travelling: if you do, you won’t be losing any treatment hours during the day, and therefore when you arrive at your destination, you will be free to take it off for a while and enjoy a bit of freedom.
Be sure to ask your doctor, in good time, to give you a medical certificate that stresses the importance of wearing the brace even when travelling. This certificate can be in Italian and English, and you can present it to the metal detector control so that you don’t have any problem even when you go abroad.
If you are travelling by train or plane it is a good idea to try and get an aisle seat, so that you can get up for a little walk every now and then, to stretch your legs and change position.
Does scoliosis worsen in menopause?
Idiopathic scoliosis mainly affects females. Once reached adulthood, there are periods in a woman’s life in which there are major body transformations that necessitate greater watchfulness.
One of them is menopause. When and in subsequent years the risks of a sudden worsening of the clinical situation increase. The body changes and the ageing process that undergoes acceleration upon entering menopause can cause the worsening of existing curves and the appearance of new curves, so-called “de novo scoliosis”. This is why it is important to make periodic visits and keep your curve checked.
Scoliosis: can I face multiple pregnancies?
Just as it is not true that those who have scoliosis cannot have children, it is also not true that those who have scoliosis can have only one. Scientific studies do not relate pregnancies to worsening scoliosis in adulthood; therefore, there is no reason to avoid multiple pregnancies if this is the desire. It is advisable, in any case, to consult an expert in spinal deformities who keeps the scoliosis curves monitored and who invites, if necessary, to undertake a path with specific exercises to give the back greater strength in the critical period that follows childbirth.
With each new brace, should patients expect the same initial discomfort they experienced with their first one?
Youngsters are often anxious at the prospect of changing their brace, fearing that the new one will be as uncomfortable as the first one. Actually, however, they are unlikely to experience the same discomfort they had at the very start of the treatment. In fact, in most cases, they will find the new brace is more “comfortable”, given that it replaces one that had become too short and tight, and so no longer adequate. Furthermore, having already had to get used to wearing a brace, these “experienced” patients will be better able to recognise, quickly, any problems with the new one. This will allow them to give the orthopaedic technician clear feedback, useful for making it fit better.
A comparison of the Chêneau and Sforzesco braces
Unfortunately, it has become common to think of braces in the same way as we do drugs. But before we go any further, we need to make one thing clear: whereas we all know that aspirin is not the same as paracetamol, in the case of a brace, the name doesn’t really mean anything specific. A brace is a product that is made to measure for the individual patient, and therefore the success of bracing treatment depends not on the name of the brace, but on how correctly it has been constructed for the particular patient. If the pads are incorrectly positioned, or if the brace is constructed so that it sits too low or presses too much on one side, it may even contribute to worsening rather than improving scoliosis.
So, how do the Sibilla-Chêneau and the Sforzesco differ? They differ in several features, which determine the choice of one over the other on a case-by-case basis. The decision to prescribe one type of brace rather than another must always be taken by a medical specialist.
Let’s start with the material: the Sibilla-Chêneau, used at Isico, is of mono valve construction and it is made of polyethylene, whereas the Sforzesco has two valves and is made from a much more rigid material. Its two parts are linked to posterior fasteners, and there is sometimes an aluminium rod at the back, too. Being more rigid, the Sforzesco has shown the same efficacy as the old system of plaster casting, but with the huge advantage of being removable for bathing/showering.
The Sibilla-Chêneau tends to be used to treat milder cases with less rigid scoliotic curves; it is also preferred for pre-pubertal patients. The Sforzesco, on the other hand, is used for more severe scoliosis with more rigid curves (for example, in youngsters with greater bone maturation).
Are postural collapse and vertebral collapse the same thing?
Absolutely not. Vertebral collapse is a pathological situation in which structurally-weakened vertebrae give way and fracture. It can be imagined as a “brick” in a tower that, weakened by a lack of calcium, collapses on itself and gets crushed under the weight of the others. On the other hand, postural collapse, also closely linked to the spine, is a normal and natural phenomenon. It is very common, arising whenever our muscles are unable to ensure that we maintain a correct posture. Postural collapse is due to our spine being unable to actively cope with gravity, with the result that it becomes crushed by its own weight. Put simply, we might say that our back has “given way”.
Basically, because the muscles aren’t strong enough or aren’t working correctly, our posture becomes more relaxed and the spine tends to appear more bent. Postural collapse, then, is a natural phenomenon, and the better balanced the trunk, the easier it is to control. Physiotherapy combined with muscle strengthening is a highly effective way of counteracting it. Poor posture drives postural collapse.
Is a normal back perfectly straight?
It is probably as rare to have a perfectly straight spine and a perfectly symmetrical trunk as it is to have scoliosis.
Because the fact is we all present some (more or less visible) physical asymmetries.
Just think of the different parts of the body that you have two of. If we were to measure the precise length and size of your hands, feet, arms and legs, we would almost certainly find they show some minor differences.
A physical asymmetry only really becomes a problem when it throws the body off balance.
What is the real goal of scoliosis treatment?
Straight and symmetrical = healthy?
Although people tend to think that you have to be straight and symmetrical to be healthy, this does not always apply. In fact, it is important to understand that physical asymmetries do not preclude good health.
Functional = healthy!
The real objective is functionality and this needs to be made clear from the outset: we mustn’t aim to achieve a perfectly straight back, rather one that works well and looks as attractive and normal as possible.
Physical activity in adults with scoliosis: what and how much?
Exercise helps relieve pain, improve functionality and improve quality of life.
A healthy back, which does not necessarily mean a straight back, is one that is capable of withstanding the stresses of everyday life.
When you have scoliosis, it is especially important to train the muscles that support the spine, so as to stabilise it. However, it is important that we distinguish clearly between sport and self-correction exercises, i.e. active movements designed to lead to better positioning of the spine in the three planes of space, which the patient performs independently. These exercises, prescribed specifically for scoliosis, with the aim of stabilising the condition, serve as therapeutic purpose. On the other hand, there is no kind of general physical activity or sport that can be said to “treat” scoliosis.
Adults with scoliosis can and MUST do some form of physical activity, at least 2-3 times a week, choosing between the various disciplines according to their own inclinations and being careful to respect their own limits. Those whose scoliosis causes them pain must make sure their chosen activity respects this limitation.
What is secondary scoliosis?
In 20% of cases, scoliosis is caused by another condition.
In particular, scoliosis can be the manifestation of congenital defects, i.e. abnormalities that originate before birth, such as abnormalities of vertebral formation, rib or vertebra fusions. It can also occur in inherited genetic syndromes, involving the nervous and/or musculoskeletal systems, and in diseases such as neurofibromatosis, Marfan’s disease, Willi-Prader syndrome and syringomyelia.
In a further subgroup of cases, scoliosis can be secondary to iatrogenic causes, i.e. a “side effect” of medical treatments such as radiotherapy, or surgical procedures such as laminectomy or thoracotomy.
Finally, scoliosis can also have other causes, such as burns or retracted scars, post-traumatic paraplegia, spinal tumours, or bacterial or parasitic spinal infections.
Overall, these forms are more aggressive and less treatment responsive than idiopathic scoliosis.
In all these cases, whether secondary scoliosis is suspected or has already been diagnosed, it is crucial to consult a medical spine specialist.
Is there a link between scoliosis and flat feet?
To date, there are no articles in the literature that actually link the problem of flat feet to the development of scoliosis. Some articles just point out that flat feet and scoliosis are problems that can coexist in growing subjects.
Therefore, although a spine specialist may as well ask a patient to stand on a podoscope (in order to carefully assess the pressure areas under the feet), beware of thinking that flat feet can affect the spine or cause it to deviate.
How to accept a treatment that “gets in the way”, like back bracing?
It isn’t always easy balancing our children’s psychological needs with what needs to be done for the sake of their health, especially when the specialists consulted contradict one another, leaving parents confused and unable to trust them. Wearing a back brace is not the same as wearing dental braces or a pair of glasses. A back brace is far bulkier and, moreover, less common, and this naturally makes us more wary of it. This is why it is so important to make brace wearing as “normal” as possible, not just for the patient, but also for his or her friends, classmates and family members. Youngsters who have to wear a brace are not objects of pity; in the same way, parents who support and encourage their children in this course of treatment are certainly not cruel!
Making brace wearing a normal part of everyday life helps youngsters overcome the feeling of being somehow different, and allows them to enjoy their adolescence with greater peace of mind. And don’t forget, feeling different, or out of step, is something all adolescents experience at some point, whether or not they wear a brace! It is not the brace, in itself, that spoils a childhood or adolescence. The problem, if anything, is how the experience is approached. Fortunately, this is something we can work on, and change if necessary. Sometimes, patients manage to do this by themselves, but in other cases they can find it useful to consult a psychologist, who can provide the support they need in order to put their difficulties into perspective.
Bracing: is it normal to feel scared?
Among the many feelings and emotions, patients feel at the idea of having to wear a back brace, sadness is undoubtedly one of the most frequent. It is perfectly normal to feel down at first, and apprehensive, but you need to gather all your strength — youngsters can be surprisingly strong and resilient! — in order to react, and face up to what, only, to begin with, may seem like an insurmountable obstacle. It is crucial to remember that the real enemy is your scoliosis, not your brace and that a brace, by itself, certainly can’t spoil your adolescence, whereas seeing limits where none exist certainly can.
There is no need to feel ashamed about your brace. On the contrary, wearing it should make you feel proud because it shows that you are courageous and ready to face a challenge. The harder you try to overcome your difficulties, even if you feel a bit scared, the more you will grow, also in the sense of growing stronger and better able to deal with whatever life throws at you.
What is scapular winging?
The medial borders of shoulder blades (scapulae), i.e. the two triangular bones located on either side of the spinal column, can sometimes be raised from the trunk, making these bones appear more prominent. This defect often referred to as scapular winging, is usually bilateral and mainly affects youngsters aged 12-14 years.
Scapular winging in itself is not really a problem, but it is important to be aware that any asymmetry of the shoulder blades can indicate more serious disorders affecting the spine.
An excellent way to exclude, or detect, a scoliotic curve is to have the youngster bend forwards with the knees kept straight and the arms hanging down. Once he/she is bent forwards as far as possible, look to see if a protuberance (hump) has appeared on his/her back, to one side of the spine, making that side of the back look higher than the other.
Scoliosis: what positions to sleep in?
Bearing in mind that we have no control over the positions we adopt when sleeping, our advice to patients is to carry on sleeping in the positions they find most comfortable because there is no such thing as more or less correct positions during sleep. Just make sure that the surface supporting your mattress (usually slats, metal bedsprings or a flat platform) ensures that it remains parallel with the ground and that the central part does not sag. If you sleep in a brace, this isn’t even an issue, as your spine will remain correctly aligned, whatever position you sleep in.
It is important to have an active lifestyle, do sport and, for those doing rehabilitation treatment, to follow the prescribed programme of physiotherapy exercises and/or brace wearing. A final piece of advice: try not to spend too much time lying on your bed or on the sofa, unless it is to rest or watch something on TV!
Will a scoliosis curve of around 30° get worse or give me back pain during pregnancy?
It is hard to predict the evolution of scoliosis. In adults, we normally talk of surgical scoliosis, which is associated with an increased risk of worsening, pain and disability, when the curve exceeds 45°–50°. In the presence of a curve measuring less than 30°, on the other hand, the situation can be considered stable. And the further below that 30° threshold we are, the more stable it will be. Don’t forget, though, that scoliosis is about more than just the severity of the curve. In fact, when examining a patient, a specialist will measure many parameters in order to define the situation and establish the risk of worsening. Therefore, if you have any concerns at all, we recommend you see your specialist.
According to reports in the scientific literature, back pain is very frequent in pregnancy, generally affecting one in two women (although it tends to disappear spontaneously after the baby is born). For this reason, it is crucial to keep active: regular sport is an excellent form of prevention. And if physical activity alone is not enough, you can always ask for a specific programme of self-correction exercises, to help keep your back strong and well supported right through to the post-partum period, when you will often have your baby in your arms.
When scoliosis is just posture?
Parents often get concerned when they see their children (or teenagers) slouching or sitting or walking badly, with one shoulder higher than the other, neck drooping forward, and so on. And they start wondering whether it might be scoliosis.
In this regard, let’s be quite clear on one thing. There is a world of difference between scoliosis and scoliotic posture. In scoliosis, there is a structural deformity of the spine that needs a structured medical and rehabilitation treatment; with scoliotic posture, on the other hand, because it is a postural problem that can be attenuated through good muscle strengthening, it can often be enough for the individual to start doing regular physical activity.
That said, spinal screening of youngsters is always worth doing, just to make sure that a scoliotic posture is not masking a case of scoliosis proper.
Up to what age can scoliosis get worse?
Growth is the “fuel” driving the progression of scoliosis: the more rapid an individual’s growth, the worse their scoliosis will get, and unless it is treated, it will continue to get worse as long as they keep on growing.
It is impossible to say exactly when growth will speed up, or predict when it will stop: every youngster is different. Most stop growing at between 16 and 19 years of age, boys later than girls.
There are two ways in which a doctor can work out when a teenager has nearly finished growing: one is to monitor their growth rate (on average, growth halves every year after puberty until it stops) and the other is to carry out X-rays, looking for progressive reduction of the growth plates. When a patient’s growth rate drops below 2 cm per year, their scoliosis is probably stabilising.
Can scoliosis get worse in spite of bracing treatment?
Yes, unfortunately, it can. Assuming that the patient’s brace is well constructed and has been properly checked, the most likely reason for any worsening is that it is not being worn for enough hours each day: to
be effective, a brace must be worn for a number of hours commensurate with the risk of the scoliosis worsening, which is something only the treating physician can establish.
The prescribed number of dose-wearing hours should also vary over time, depending on the risk: when the risk is high, it needs to be worn all the time, and the patient should remove it only in order to take a shower. When the risk is low, they will be asked to wear it only at night. The other possible reason for scoliosis worsening in spite of bracing therapy is, instead, much more rare: the presence of a highly aggressive form of scoliosis. A brace is worn with the aim of avoiding the need for surgery. If the brace proves unable to contain the progression and the curve exceeds 45-50°, then it will probably be necessary to consult a spine surgeon. If there is a worsening of scoliosis, but the curve nevertheless remains below this threshold, then the treatment has been effective.