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That hated hump!

In a person with scoliosis, forward bending of the trunk will cause a protuberance to appear on their back, at the level of the scoliotic curve: this anomaly is commonly referred to as a hump.

Scoliosis alters the alignment of the spine, and this alteration can be seen in the three dimensions of space: the affected vertebrae move sideways, taking on a different shape when viewed from the side; they also rotate, and this, especially if they are dorsal vertebrae, also causes a rotation of the rib cage. 

This hump is an aesthetic problem for people with scoliosis, as they fear that it is obvious to everyone else. But that is not the case at all. There is often a world of difference between the problem itself and how it appears in everyday life. 

During a thorough postural analysis or a medical examination, the doctor or examiner will position the patient’s body to emphasise any asymmetries present precisely so that they can be identified and measured.

Nobody is perfectly symmetrical in daily life: when we move, we frequently twist our bodies and bend and rotate our joints, our movements involving different segments of our body in various combinations. As a result, we constantly develop asymmetries, humps, and combinations of bent and straight segments without even being aware of it.

Let’s take an example. A doctor examining a patient’s hump will have the youngster stand with his knees straight and body bent forwards so as to emphasise the protuberance on the side of the curve. Is it visible? Yes, if the patient’s scoliosis is sufficiently marked, it will be visible even to the untrained eye. 

Now, what if we ask someone with a healthy back to tie up their shoelace? To do this, most people will push their foot forward, bend their knees asymmetrically, and lean forwards, with their trunk deviating to one side (the side of the shoe needing to be tied). As they do this, their spine will be turned to one side, and a hump can be seen on their back, on the side of the leg, with the shoe needing to be tied. Does that hump mean they have scoliosis? Of course not! It is caused by them twisting their spine in order to reach their shoe.  

We can explain the scoliosis-induced asymmetry of the hips in a similar way. If we stand still with our feet parallel, our knees straight and our trunk aligned, our side and our hips will look symmetrical; in people with scoliosis, on the other hand, one hip will appear straighter in respect to the other. 

Now, let’s imagine how we normally stand. Do we ever actually stand with our feet positioned symmetrically and our bodyweight perfectly distributed between them? No! We usually stand with our weight on one foot and one hip thrust out. How do we look in this position? It is completely asymmetrical, but this asymmetrical appearance is due to our natural posture; it is not caused by scoliosis! 

Nobody ever notices these natural asymmetries because our bodies repeatedly assume them throughout the day. For this reason, even asymmetries caused by scoliosis are never really noticed by others. 

Going back to our “hump”: is it really such a bad thing, to the point that we should do everything in our power to get rid of it?

The back brace sometimes worn by youngsters with scoliosis, seeks to optimise the alignment of the vertebrae involved in the scoliosis curve, but how? It works by pushing “from the outside” directly on the affected portion to restore its symmetry. The force it exerts on the rib cage or on the soft tissues of the hips also affects the spine. 

 What is meant by an optimal alignment of the spine? The straightest possible? 

This isn’t an easy question to answer. Equally, it is not easy for the doctor to identify the correct balance of forces to be exerted on the spine by the brace pads. 

The best alignment will enable the treated spine to remain as stable as possible and to withstand the forces to which it is subjected in daily life. 

The strength of the spine depends to a large extent on its shape, as seen from the side. From this perspective, our spine is characterized by two curves, called lordosis and kyphosis. These curves must be well balanced: neither too pronounced nor too slight. 

Unfortunately, in scoliosis, and this applies particularly to dorsal scoliosis, the kyphotic curve is reduced, causing the back to appear flat or even hollow. In other words, the normal direction of spinal curvature is reversed, and the spine is weaker as a result. 

Unfortunately, the brace has no way of counteracting this problem, as all it can do is push. In fact, its corrective forces, which are applied to the hump to help align the vertebrae involved in the curve, have a flattening effect on the back’s upper part (dorsal section). 

Therefore, the doctor’s task is to find and maintain the best possible balance, considering the importance of all the planes of the spine.

What this means in practice is that it is sometimes necessary not to “go too far” in trying to eliminate the hump. Because if this objective can be achieved only by excessively reducing the dorsal kyphosis angle, the result will be a weaker and less healthy spine.  

Back and neck pain and smartphone: is there a correlation?

Can being bent over the smartphone too often cause back- and neck pain in younger people? Data coming out of the study Posture and time spent using a smartphone are not correlated with neck pain and disability in young adults: A cross-sectional study, published some time ago by the Journal of Bodywork and Movement Therapies are not confirming this.

The cross-sectional correlational study was conducted in a sample of students selected through convenience sampling between September 2016 and March 2017: the inclusion criteria were university students at the School of Medicine and Surgery, routine/daily use of mobile devices with advanced computing and connectivity capability built on an operating system, and aged 18–30 years. A total of 238 volunteers were recruited.

“The objective of the study – explains Prof. Stefano Negrini, scientific director of Isico and one of the authors of the research – was to determine the impact of smartphone use on neck impairment and functional limitation in university students. Neck pain was assessed using a visual analogue pain score (VAS) and a pain drawing (PD); disability status was measured using the Neck Disability Index (NDI-I); cervical postures while using the phone were captured using the Deluxe Cervical Range of Motion (CROM) device”.

While half of the young medical students reported neck pain, the use of smartphones was not correlated with neck pain and disability. “While we wait for future prospective studies – ends Prof. Negrini – there is no reason to recommend a change in smartphone use habits among young adults in the meantime”.

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.

Low back pain

Every year, the Italian Scoliosis Study Group selects the best published papers on conservative spine treatment from the global scientific literature.
Here is the abstract from one of these papers. 

Long-term follow-up of untreated Scheuermann’s kyphosis
  Enrique Garrido, Simon B Roberts, Andrew Duckworth, Joseph Fournier 
PMID: 34212306 DOI: 10.1007/s43390-021-00354-y

Abstract

Study design: Long-term cross-sectional study.

Objectives: To investigate the long-term effects of untreated Scheuermann’s kyphosis on quality of life, and its relationship to radiographic parameters of spinal deformity. Previous studies reported reduced self-image, increased pain and impaired physical status. Little is known of the long-term impact of sagittal plane deformity in untreated SK.

Methods: One hundred and thirteen consecutive untreated patients with SK were identified from a national service database prior to 2000, when surgery was not offered at this unit. 81 of these patients were available for evaluation; 66 (81%) consented to questionnaire and clinical evaluation, and 47 (58%) consented to additional radiological evaluation. Health-related quality of life (HRQoL) was compared to normative population values. Mean age was 45.1 years (31-65), and mean follow-up was 27 years (16-36). 57 patients had thoracic kyphosis and 9 had thoracolumbar deformity.

Results: SRS-22 and SF-36 scores were lower, and ODI was greater in patients with untreated SK compared to normative population values. Kyphosis progressed from mean 66° at skeletal maturity to 78° (p < 0.001) after mean follow-up of 27 years. Long-term progression of untreated SK was 0.45°/year (n = 47). Multilinear regression showed good correlation between increasing SVA and worse ODI scores (r = 0.59; p = 0.001). Increasing SVA also correlated with worse function, pain and mental health scores reported by SRS-22, and with worse physical function and bodily pain scores reported by SF-36. Increasing CL correlated with worse SF-36 physical function scores. Increasing cSVA and increasing TK correlated with worse SRS-22 self-image scores.

Conclusion: SRS-22 and SF-36 scores were lower, and ODI was greater in patients with untreated SK compared to normative data. Long-term progression of untreated SK was 0.45°/year (n = 47). Increasing SVA correlated with worse SF-36 physical function, SRS-22 function, SRS-22 pain and higher ODI scores. Total kyphosis (TK) and cSVA were independent predictors of low SRS self-image.

Level of evidence: III.

Keywords: Disease; Kyphosis; Natural history; Outcome; Scheuermann’s.

https://pubmed.ncbi.nlm.nih.gov/34212306/

Low back pain

Every year, the Italian Scoliosis Study Group selects the best published papers on conservative spine treatment from the global scientific literature.
Here is the abstract from one of these papers. 

Low back pain
 Nebojsa Nick Knezevic, Kenneth D Candido, Johan W S Vlaeyen, Jan Van Zundert, Steven P Cohen
PMID: 34115979 DOI: 10.1016/S0140-6736(21)00733-9

Abstract

Low back pain covers a spectrum of different types of pain (eg, nociceptive, neuropathic and nociplastic, or non-specific) that frequently overlap. The elements comprising the lumbar spine (eg, soft tissue, vertebrae, zygapophyseal and sacroiliac joints, intervertebral discs, and neurovascular structures) are prone to different stressors, and each of these, alone or in combination, can contribute to low back pain. Due to numerous factors related to low back pain, and the low specificity of imaging and diagnostic injections, diagnostic methods for this condition continue to be a subject of controversy.
The biopsychosocial model posits low back pain to be a dynamic interaction between social, psychological, and biological factors that can both predispose to and result from injury, and should be considered when devising interdisciplinary treatment plans.
Prevention of low back pain is recognised as a pivotal challenge in high-risk populations to help tackle high health-care costs related to therapy and rehabilitation. To a large extent, therapy depends on pain classification, and usually starts with self-care and pharmacotherapy in combination with non-pharmacological methods, such as physical therapies and psychological treatments in appropriate patients.
For refractory low back pain, a wide range of non-surgical (eg, epidural steroid injections and spinal cord stimulation for neuropathic pain, and radiofrequency ablation and intra-articular steroid injections for mechanical pain) and surgical (eg, decompression for neuropathic pain, disc replacement, and fusion for mechanical causes) treatment options are available in carefully selected patients.
Most treatment options address only single, solitary causes and given the complex nature of low back pain, a multimodal interdisciplinary approach is necessary. Although globally recognised as an important health and socioeconomic challenge with an expected increase in prevalence, low back pain continues to have tremendous potential for improvement in both diagnostic and therapeutic aspects.
Future research on low back pain should focus on improving the accuracy and objectivity of diagnostic assessments, and devising treatment algorithms that consider unique biological, psychological, and social factors.
High-quality comparative-effectiveness and randomised controlled trials with longer follow-up periods that aim to establish the efficacy and cost-effectiveness of low back pain management are warranted.

https://pubmed.ncbi.nlm.nih.gov/34115979/

WHO rehabilitation task force: Isico is also there

Some of Isico’s are part of an international project promoted by WHO (World Health Organization) which aims to draw up rehabilitation guidelines for all countries, including those in the developing world, available to all Ministries of Health.
These rehabilitation guidelines need to be applicable in any context, taking into account the economic means and therapeutic possibilities that differ from country to country.

A large-scale and very ambitious project, involving Isico with three specialists, namely Dr Fabio Zaina, Dr Sabrina Donzelli and Dr Francesca Di Felice. 
The supervision is given by Prof Stefano Negrini, also involved as director of Cochrane Rehabilitation.
“In this process of developing guidelines, we were asked to deal specifically with back pain – explains Dr Zaina – in the first phase, already completed now, we dealt with the bibliographic research. In the second phase, we were asked to collect the scientific evidence in respect to the data collected so as to build the guidelines. At the moment we are working on the final phase: drawing up the guidelines, with great attention also to the sustainability of costs in different countries, and presenting them to the referents of the various countries for their application”.

Back pain and scoliosis

What causes back pain? Well, having a back and two legs to begin with! That’s right! As humans, we have one particular body part that is always going to be more exposed than the others to the risk of discomfort and overloading. And that body part is the spine.

You have probably sometimes wondered why certain people who do heavy jobs and spend their entire lives “mistreating their spine” don’t even know what it means to have back pain.

It is well established that “good” or “bad” loading of the spine is a result of its conformation in the sagittal (lateral) plane, in other words, on the distribution of its curves.
Unfortunately, the lateral profile of the spine, meaning the particular way in which the spine’s natural curves, called lordosis and kyphosis, are distributed, does not depend on the will of the individual, but on a genetic predisposition to one pattern or another.

Basically, whether or not we are predisposed to back problems is a matter of luck.

So, what should we do? Simply resign ourselves to the fact that, morphologically speaking, we are among the less fortunate? Simply accept that we are prone to back pain and put up with it, since there’s nothing that can be done?

No, absolutely not! Because back pain, affecting our work, mood and social activities, can really condition our lives!

Things to know

– You have to take care of your back because, for better or worse, it’s yours and it’s the only one you’re ever going to have.

– Taking care of your back means keeping it fit and knowing how to use it properly. So, make sure you do regular physical activity to keep your spinal muscles in shape, but also your leg and arm muscles. What kind of activity? There’s no “best” kind of physical activity; the important thing is to choose something you enjoy and do it at least twice a week, or better still three times. 

– Knowing how to use your back means making sure that you do not spend too long sitting down. You need to alternate sitting with spells of movement. Also learn to sit correctly, and if your work means you have to spend hours sitting at a desk, look at how to set everything (computer, seat, etc.) at the right height. Also, you need to think about how to correctly manage your body under stress, in other words when it is subjected to loads and also during physical effort.

It is important to learn about the shape of your own spine and how forces are distributed over the body, and then to assess your particular limits and strengths. It can be helpful to do all this with the support of a specialist who can help to familiarise you with your own specific ergonomic and training needs.

What if I have scoliosis?

Even though there is still a lot to be discovered and learned in this field, we know that scoliosis, as it progresses, creates an abnormal alignment of the vertebrae, which is seen both in the frontal plane (as scoliotic curves) and in the sagittal plane (as changes in physiological lordosis and kyphosis).

Indeed, treatment of scoliosis aims to curb this progression and remodel the spine so that, by the time the individual finishes growing, it is as well aligned as possible.

According to scientific studies, if we can achieve good spinal balance in the sagittal plane (in particular, this means maintaining good lumbar lordosis), and if we can keep the scoliotic curves under 25-30°, the scoliosis outcome will not affect the proper functioning of the spine.

In such cases, the risk of back pain will be the same as that seen in people without scoliosis.

In the presence of more severe curves, it is necessary to be even more aware of the need to safeguard the spine. In the knowledge that it is a delicate and vulnerable part of the body, you must take good care of it and do physical activity to keep your back fit.