Bracing adults with scoliosis: a new published study

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?

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

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 Scoliosiswhich 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.”