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Adult Scoliosis: look after yourself!

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Adults with scoliosis are often convinced there is nothing more that can be done for their problem, partly because it has long been thought that scoliosis, in any case, doesn’t get any worse once you have finished growing. Unfortunately, now it has been shown not to be the case. We at ISICO, as well as monitoring patients through periodic checks, know that there is treatment available that may improve these patients’ conditions.

We frequently tell our patients that they will only be able to effectively manage their back and their scoliosis if they have a clear understanding of their condition and how to address it, which means: keeping fit, regularly doing appropriate exercises, and implementing strategies to avoid overstraining their back in everyday life. 

“Scoliosis in adults, treated or otherwise, may be one of three types: scoliosis that was discovered in adolescence, scoliosis that came to light in adulthood, and so-called de novo scoliosis. This latter form, typically seen in old age, is associated with often significant clinical symptoms, says our orthopaedic specialist, Dr Monia Lusini. For adolescent-onset scoliosis (which may have been discovered either in adolescence or in adulthood), the severity threshold beyond which the condition may worsen in adulthood is 30°, while curves greater than 50° are obviously much more likely to go on evolving, so much so that 50° is considered the cut-off point for surgery. Scoliosis worsens much more gradually in adulthood (by around 0.5-1 degree per year on average) often leading to the lateral and forward bending of the trunk typically seen in old age. The severity of de novo scoliosis, on the other hand, is generally mild to moderate, with the curve not normally exceeding the 30° threshold; nevertheless, this form can be associated with quite marked clinical symptoms.”

According to the data we have, mild curves (measuring less than 30°) are generally stable, whereas more severe scoliosis needs to be monitored, as a precautionary measure, through regular checks every 1-5 years.

And what happens if these checks show that the condition is worsening? “In that case, it may be useful to have a specific exercise programme drawn up by experienced and expert professionals in order to keep the situation stable” replies ISICO physiotherapist Alessandra Negrini. “Scoliosis is associated with several problems: a risk of back pain, aesthetic issues, progressive deformity, and problems with the internal organs (these are usually significant only in patients with curves greater than 70° and those with childhood-onset scoliosis)”.

This is why we at ISICO encourage our patients to do as much physical activity as they can, and to work out with their physiotherapist, a programme of specific exercises designed to strengthen the muscles that support the spine and combat the pain.

It has been scientifically proven (in two studies published by our group: Adult scoliosis can be reduced through specific SEAS exercises: a case report and Scoliosis-Specific exercises can reduce the progression of severe curves in adult idiopathic scoliosis exercises: a long-term cohort study) that appropriate and specific exercises tend to slow down or arrest the evolution of scoliosis.

Alongside physiotherapy, we at ISICO are currently trying out, in patients with scoliosis pain and ascertained progression of the condition, an elastic brace called Spinecor: when patients feel their back “giving way”, this device, even though it cannot be expected to lead to an improvement visible on X-rays, provides extra external support and can give them a few hours relief.

Scoliosis? It can be treated in adulthood, too

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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

Bracing adults with scoliosis: a new published study

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The research paper “Bracing adults with chronic low back pain secondary to severe scoliosis: six months results of a prospective pilot study”, has just been published by the European Spine Journal.
It is one of the few articles published in the literature on the use of braces for adults affected by scoliosis. Although scoliosis has been estimated to affect up to 68% of the population over 60, there is scant literature about conservative treatment for adult scoliosis.
While during growth, the main concern is aesthetic, with a quite good quality of life and pain is quite unusual, backache characterizes adult scoliotic patients.

“For our research, we took into account twenty adults with chronic low back pain (cLBP) secondary to Idiopathic Scoliosis (IS) – explains dr Fabio Zaina, a specialized physiatrist of Isico and the author of the publication – Patients were evaluated at baseline immediately before starting with the brace and after six months. We have used a new brace, called “Peak”, designed to alleviate pain for adult patients with chronic pain secondary to scoliosis.”

The objective of the study was to test the efficacy of a prefabricated brace in reducing pain in adult scoliosis patients because the quality of life and pain are the main reason for seeking treatment. 
Patients, especially women with severe scoliosis, wore the brace for a few hours, from 2 to 4, a day: “This study has some shortcomings: including a limited number of females only patients, as well as not having a control group. It would have been interesting to compare this group with those who refused to wear the brace or to another similar group that only did exercises – ends dr Zaina – from the data collected, we found an initial impact on pain reduction, none instead on the quality of life according to the questionnaires filled in by patients. Considering that the extension of follow-up produced improved results, our recommendation could be to pursue the part-time brace-wearing permanently. Starting with such a short period of brace wear (2–4 h per day) would also allow the expert clinicians to increase the dosage in case of need”.

Physical activity in adults with scoliosis: what and how much?

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Before we start talking about scoliosis and physical activity in adults, a few background considerations are called for.

It is important to remember that every patient has a unique history. Even though different patients can present similar scoliosis features, it should not be assumed that the same kind of physical exercise will suit all of them.  

It is also necessary to bear in mind certain thresholds of curvature: scoliosis curves measuring less than 25°-30°, especially if treated in adolescence, are extremely unlikely to worsen over time. Conversely, curves that exceed 45°-50° must be monitored, through specialist check-ups, throughout adulthood.

Then there is the “pain” factor. Scoliosis is not necessarily associated with pain. Nevertheless, pain is a factor that needs to be taken into account when choosing what physical activity or sport to do. As a rule, any kind of movement that does not worsen pain, or that alleviates it, can be considered a great help.

Exercise, in a general sense, helps to relieve pain, improve functionality and improve quality of life: and these are the real objectives. A healthy back, which does not necessarily mean a straight back, is one that is capable of withstanding the stresses of everyday life.
Furthermore, when you have scoliosis, it is especially important to train the muscles that support the spine, so as to stabilise it.

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 a therapeutic purpose. On the other hand, there is no sport or general physical activity of any kind that can be said to “treat” scoliosis.

It is also necessary to beware of certain old “beliefs” regarding scoliosis and sport. In the past, it has been claimed that certain sporting activities can “treat” or vice versa exacerbate scoliosis.

In reality, however, the literature contains no reliable data showing that certain sports activities might be harmful for adults with scoliosis.
The only question mark concerns activities (e.g. belly dancing) that demand considerable flexibility and mobility of the spine, since these could destabilise it and lead to a worsening of the condition.
To date, there are no sports that are specifically prohibited or recommended. Indeed, contrary to what some believe, swimming and Pilates cannot be guaranteed to be beneficial, while running and tennis do not need to be considered risky activities.
In adulthood, any sport, providing it is started gradually, practiced regularly, enjoyed and performed within your own limits, can only be good for you.

In conclusion, it is worth underlining that adults with scoliosis can and MUST do some form of physical activity, at least 2-3 times a week, choosing from the various disciplines. Those whose scoliosis causes them pain must make sure their chosen activity respects this limitation.

Conservative or surgical treatment in adults? Two steps of therapy

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Is there an alternative treatment to another in adults with scoliosis who suffer from back pain? The answer is no, simply because therapy is made up of several steps. 

It just has been published by the scientific journal Annals of Translational Medicine the editorial comment of Isico “Symptomatic adult spinal deformity: implications for treatment“. A comment to another editorial, namely “Operative Versus Nonoperative Treatment for Adult Symptomatic Lumbar Scoliosis” which compared the treatment for adults with conservative asymptomatic scoliosis with that for surgical scoliosis.

Let’s start with a premise.

Lumbar scoliosis is particularly relevant for its significant correlation with back pain. There are two main common etiologies for this pattern, degenerative scoliosis and idiopathic. Degenerative curves, also called “de novo” scoliosis, derives from pathological changes at the level of the facet joints and discs in the lumbar spine. Usually, they are not very large but frequently very painful and rapidly progressive. The other type is idiopathic scoliosis appeared during growth that starts its progression in adulthood, usually depending on the size of the curve as previously stated. There is a further type of adult scoliosis called metabolic, which is less frequent.

The most common treatment for scoliosis patients with chronic low back pain, according to current practice, is the surgical one. This has the aim of both preventing progression and improving pain and quality of life. Unfortunately, surgery in such patients is associated with a relevant number of complications, so that it cannot be considered appropriate for every patient. Moreover, some patients don’t want to be operated.

“The study we considered – explains Dr Francesca di Felice, physician of Isico – presents a mixed design, with a randomized and an observational arm. In both arms, conservative treatment was compared to surgery. The general conclusions were driven from the observational arm, since in the randomized one the rate of crossover was dramatically high (64%): this led to similar results for both the approaches in the intent to treat analysis (ITT). For the observational arm, the success of surgery in improving pain and reducing disability was clearly higher than for the conservative approach as supported by the as-treated analysis. We think that this study raises a number of interesting points that should be discussed in the scientific community. The authors tried to apply the best possible design, which is the randomized control trial, but its results were not really informative for the high crossover rate. Hence our comment.”

The ITT is considered more conservative in such cases, and this could be an advantage in case some efficacy is equally demonstrated, but it also underestimates the side effects, and this is a significant shortcoming. We think it’s thus evident that the RCT design cannot be applied to the comparison of surgery and conservative treatment at least in this specific field of spine care. When patients have to face big issues like painful scoliosis, and/or very invasive treatments like fusion for scoliosis, they want to choose their treatment. Some of them want to be operated in case the conservative treatment is not effective, and others are scared of surgery and decide to avoid it. 

Another limitation of the study is that there was no distinction between degenerative and idiopathic scoliosis. We know that the progression rate of the two is different, and also the association with pain. Degenerative scoliosis is more challenging for the conservative treatment, and focusing on this would have been more informative.

Furthermore, the most severe surgical complications for the patient compared to conservative exercise and brace treatment were not considered in the study.

“We are convinced that the choice between one treatment or another cannot be an alternative and thus dichotomous – concludes Dr Di Felice – both treatments must be considered as a step of therapy, if conservative treatment is not sufficient, it is necessary to resort to surgery.

 Surgical complications are a big challenge in adult patients with scoliosis, so we cannot consider surgery as the best option for a problem that can affect QoL but is not life-threatening. We strongly believe that surgery can be a good option for very selected and motivated patients, but we need more data about the advantages of a surgery over the conservative treatment, and hopefully a further improvement of the surgical approach. On the other side, the conservative treatment protocol applied in this study doesn’t rely on the Guidelines on the conservative treatment currently available, we need an appropriately conservative approach to be studied, based on the current guidelines and evidence and managed by experts in the field.”