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Scoliosis and posture: the two go hand in hand

Let us start with one thing we know for sure: idiopathic scoliosis is not a postural complaint, but rather a progressive spinal disorder that causes three-dimensional deformation of the vertebrae.

Although it is still not clear exactly why scoliosis occurs, its progression is known to be due, in part, to the force of gravity (i.e., the force of gravity does not cause the disorder, it simply helps it to progress).

Let us try to explain this in simple terms: our spine is like a tower of building bricks that serves to support us, and the bricks distribute evenly the weight it has to bear. If we have scoliosis, some of our bricks are not correctly shaped.
As a result, they are not properly aligned and our tower (spine) may have curve(s) in it. A spine with curve(s) is no longer able to distribute evenly the weight it has to bear; indeed, this presses down harder on the inside of the scoliotic curve, and less on its outside. 

If our spine is well supported, this effect can be lessened, because the support allows the blocks to realign, and this, in turn, reduces the extent of the curve(s). Conversely, without support, the bricks will slide even further to one side, increasing the angle of curvature and shortening the trunk even more.

What does all this mean? That our scoliotic curve will worsen more rapidly unless we continually correct it.

This is why the exercise-based treatment method used at Isico is based on the principle of SELF-CORRECTION: affected youngsters learn to intervene independently to control and align their spine as correctly as possible, thereby countering its tendency to collapse in the direction of the scoliotic curve.

Let us consider another aspect. On a spinal X-ray, we can measure the degrees of curvature present. The angle of curvature is actually the sum of two components: the deformity itself and the effect of postural sagging in the direction of the curve. The contribution of this second component is largely dependent on our capacity for “self-correction”.

How can we distinguish between these two components, i.e., actual bone deformity and postural sagging, so as to be able to intervene effectively on each of them? Again, on an X-ray, but in this case, it must be taken with the patient lying down, so that the degrees of curvature caused by postural sagging disappear, and all that can be seen, and measured, are those due to the deformity itself.

One study, now rather old but still valid, published in Spine in 1976 (Standing and supine Cobb measures in girls with idiopathic scoliosis, G Torell, A Nachemson, K Haderspeck-Grib, A Schultz), showed that postural sagging in scoliosis causes, on average, 9 degrees of curvature (ranging from 0 to a maximum of 20), and that the degrees attributable to postural failure are independent of the severity of the curve. Another interesting study published in Spine, in this case in 1993 (Diurnal variation of Cobb angle measurement in adolescent idiopathic scoliosis, M Beauchamp, H Labelle, G Grimard, C Stanciu, B Poitras, J Dansereau), shows that back “fatigue” can also affect the Cobb angle. In this study, youngsters with moderate to severe scoliosis (an average of 60 Cobb degrees) were X-rayed in the morning and then in the evening. The X-ray taken in the evening showed an average 5-degree increase in curve severity.

What should we do in treatment terms? Clearly, exercises alone cannot alter the actual bone deformity resulting from the scoliosis, which needs to be treated with a combination of exercises and brace wearing.
Nevertheless, specific exercises and self-correction can do a lot to address the problem of postural sagging. And if this “sagging” is responsible for an increased Cobb angle, we need to work hard at our exercises in order to “eat away” at (reduce) the part of the curve that is due to this component.

A perfectly straight back? That’s pretty rare!

It is as rare to have a perfectly straight back and perfectly symmetrical body as it is to have scoliosis, a condition that affects no more than 5% of the population. Scoliosis is linked to different factors that influence the shape and development of the spine in the three planes of space.
What causes it? In most cases, we still don’t know.

On the other hand, we are very familiar with how the condition typically evolves. We know that scoliosis that is left untreated will worsen as an effect of bone growth. Therefore, to limit its effects, it is essential to obtain an early diagnosis and undertake an effective treatment, guided by experts in the field.  

  • When should scoliosis be treated? Let’s look at two key parameters  

There are two elements that tell us the seriousness of a case of scoliosis, namely, the amplitude of the curve (measured in Cobb degrees) and the individual’s bone age (Risser sign).

Briefly, with regard to the amplitude of the curve

  • 0 – 10 Cobb degrees → no scoliosis
  • 10 – 15 Cobb degrees → mild scoliosis
  • 16 – 34 Cobb degrees → moderate scoliosis
  • 35 – 44 Cobb degrees → moderately severe scoliosis
  • 45 Cobb degrees or more → severe scoliosis

Instead, to evaluate bone age we use a scale of 0 to 5 (where 5 corresponds to complete bone maturation).

The phase in a youngster’s development in which scoliosis is most likely to worsen is the pubertal growth spurt, a period in which their growth rate speeds up and they grow considerably. On average, this phase begins between the ages of 11 and 13 years in girls, and 12 and 14 years in boys, and this generally corresponds to the passage from level 0 to level 1 on the Risser scale.

The subsequent phases, of course, are not risk free, but in most cases the speed of growth progressively declines, and for this reason, so does the risk of progression of scoliosis.

  • 0-10 Cobb degrees: is it correct that even if there’s an asymmetry we don’t need to worry?

If a patient has an X-ray that shows a curve measuring less than 10 Cobb, he/she will not be diagnosed with scoliosis and no treatment will be prescribed, only further monitoring of the situation according to how much the patient is still expected to grow.

Nevertheless, the image will show some asymmetry of the spine, and on observing this, even slight, curvature, patients and parents quite often become alarmed.

No one likes to be told that their spine or their child’s spine is “asymmetrical”, and they can be sceptical or even disappointed to learn that nothing needs to be done.

  • “We don’t all come out of the same mould!”

It is probably as rare to have a perfectly straight spine and a perfectly symmetrical trunk as it is to have scoliosis.

We often tell our patients that “we don’t all come out of the same mould”, in order to explain, in simple terms, that everyone of us presents some (more or less visible) physical asymmetries. 

Think of the different parts of the body that we have two of. If we were to measure the precise length and size of our hands, feet, arms and legs, we would almost certainly find they show some minor differences.

In the presence of a difference in length of the lower limbs (typical during growth), for example, it is quite common to find a proportional inclination of the pelvis and, consequently, of the spine.

In this case, however, the scoliosis serves a “functional” purpose, as its contributes to the maintenance of the body’s balance and can thus be interpreted as a useful compensatory response and unlikely to worsen as the youngster grows.

My kid is always slouching: bad posture or a medical problem?

In today’s digital age, the incredible exponential curves of technological growth and innovation are increasingly reflected in curves of another kind, namely those affecting our spines, as we assume various odd and unnatural positions when using our electronic devices.  

Parents are the first to notice their youngsters’ tendency to adopt these awkward and unattractive positions. The most frequent is the hunched back position, where the upper spine, shoulders and head are bent forward in relation to the rest of the body.
As a consequence, we now see countless humps like that of Quasimodo, the famous “Hunchback of Notre Dame”.

The tendency to slouch or adopt slumped postures is prevalent among the young. Youngsters (and adults too) often assume incorrect postures simply because it is easier and requires less effort.
As a result, they simply allow the force of gravity to take its toll on their backs, without trying to counteract it. 
Some situations, however, require careful assessment, as incorrect postures can sometimes indicate a spinal disorder.

Initially, it is up to parents to check their children’s backs, and if they have any doubts at all they should seek the opinion of expert medical spine specialists.

How do you tell the difference between incorrect posture and a spinal disorder?

If you have the youngster stand in front of you with his/her back exposed and look at him/her sideways on, you should immediately notice the classic shape of back, created by two natural and opposing curves; starting from the base of the spine and moving upwards, you will see the first, lower curve.
Known as lumbar lordosis, this is a physiological curve in which the lumbar spine appears more anteriorly positioned and concave. Immediately above it, you will see that the dorsal spine instead shows a posterior convex curve.

In normal conditions, these two curves are harmonious and not too pronounced. However, if, on observing the youngster, you notice that one curve is more pronounced or protruding, or that both are marked, then this could be a sign of a spinal disorder. In such cases, screening by a qualified professional or a consultation with a specialist spine doctor is strongly recommended.

In the same way, you might notice that the youngster’s back appears flat, with the physiological curves barely visible or not visible at all. This profile, too, can indicate the presence of a spinal disorder.

The spinal disorder most commonly associated with the rounded back or hunchback posture is hyperkyphosis, i.e. excessive curvature of the thoracic spine, evident on clinical examination as posterior protrusion of a section of the thoracic spine, often with the protruding vertebrae clearly visible under the skin.  

But how can a parent distinguish between incorrect posture and hyperkyphosis, which is a fairly frequent condition among youngsters?
Incorrect posture is always easily remedied simply by reminding the youngster to stand up straight: indeed, in this case, this action is enough to completely straighten his/her back.
In the presence of a spinal disorder, on the other hand, he/she will show more or less marked stiffness: even when he/she tries to stand up straight, part of the spine will remain curved as a result of the disease having stiffened his/her back.

Long kyphosis is another frequent vertebral alteration. In this case, the thoracic convexity extends down as far as the lumbar vertebrae, invading the space normally occupied by the upper part of the lumbar lordotic curve: the back therefore presents with a long convexity that reaches down to the base of the back.

Dorsal hyperkyphosis and long kyphosis are sometimes caused by Scheuermann disease, which is characterised by a wedge-shaped deformity of the vertebral bodies with anterior thinning of the vertebrae.
This makes it difficult and sometimes impossible for affected youngsters to hold their back straight: as a result, they become curled up like hedgehogs, and unfortunately their growth exacerbates the vertebral deformity.

Conclusion

Like scoliosis, spinal deformities in the sagittal plane need to be diagnosed early in order to allow timely and effective treatment. Families have the important task of trying to spot spinal disorders as opposed to simple cases of poor posture. Whenever they are in any doubt, they should always contact a specialist spine doctor for a proper diagnosis and any necessary treatment.