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Curves measuring less than 10 degrees: should we treat them?

As suggested by the Scoliosis Research Society (SRS), a scoliosis diagnosis is confirmed when a patient presents a Cobb angle measuring 10° or more and axial vertebral rotation. Maximum axial rotation is measured at the apical vertebra. (1) The SRS established this threshold in 1977, replacing the previous one of 7°. Ever since, 10 ° has conventionally been accepted, worldwide, as the threshold for diagnosing scoliosis.
However, structural scoliosis, with a potential for progression, can also be observed in the presence of Cobb angles measuring less than 10°. In fact, initial wedging of the vertebral bodies and disks can sometimes be registered with curves of 4°–7°. (2)

Idiopathic scoliosis, being a developmental disorder, most commonly arises and progresses during periods of accelerated growth (growth spurts).

The first such period occurs in infancy/early childhood, generally between 6 and 24 months of age, and the second between the ages of 5 and 8 years; finally, there is the pubertal growth spurt, which generally occurs at 11–14 years of age. (1)

Although the later stages of development are obviously not risk free, after puberty the rate of growth usually slows down, reducing the risk of progression of scoliosis. 

Can the risk of scoliosis progression be predicted in the case of curves measuring less than 10°?
There is, of course, always a chance that these curves will become more pronounced as the youngster grows, even, in some cases, to the point of requiring the use of a brace. But it is also true that most of them will remain stable over time without reaching the minimum criteria for a diagnosis of scoliosis. Certain factors may possibly be associated with an increased risk of scoliosis progression: a positive family history of scoliosis, laxity of ligaments, flattening of physiological thoracic kyphosis, a greater than 10° angle of trunk rotation (ATR), and growth spurts. All these factors should be evaluated by the attending physician. 

So, should we be treating these youngsters? In short, no. First of all, it is worth remembering, that the main aim of conservative treatment of scoliosis is to improve the patient’s appearance, but curves as mild as this rarely have an aesthetic impact; at most there may be some slight asymmetry of the trunk, but nothing that can be considered to exceed physiological parameters. With very rare exceptions, the only advice necessary in these cases is to opt for clinical monitoring of the patient, which can be considered to all intents and purposes a treatment, in the sense that it allows us to overcome the critical phases of development (which also correspond to the periods of greatest risk of progression of scoliosis) and also to intervene if any progression does occur. Monitoring is the first step in an active approach to idiopathic scoliosis, and it consists of clinical evaluations performed at regular intervals, ranging from every 2-3 months to every 36-60 months depending on the single case. 

In conclusion, any active treatment in this population of patients is actually overtreatment. Even just specific exercises, whose prescription constitutes first therapeutic step after monitoring alone, would cost these youngsters in time and effort, as well as being an economic cost.

A further aspect, not to be underestimated, is the psychological impact: starting a treatment amounts to confirming that the individual has a disease that needs to be treated, and this can lead them to start thinking of themselves as “sick”.

Furthermore, even though an exercise programme is not a particularly arduous undertaking, starting a treatment when there is no real need for one could compromise the youngster’s collaboration and commitment should a treatment be needed later on. This is an important consideration, because if their scoliosis does progress as they grow, specific exercises, rather than being useful, could become crucial, in order to avoid bracing for example.  

1 – 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth

https://pubmed.ncbi.nlm.nih.gov/29435499/

2 – Radiographic Changes at the Coronal Plane in Early Scoliosis. Xiong, B., Sevastik, J. A., Hedlund, R., & Sevastik, B. (1994). Spine, 19(Supplement), 159–164. doi:10.1097/00007632-199401001-00008

https://pubmed.ncbi.nlm.nih.gov/8153824/

Scoliosis? It can be treated in adulthood, too

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

SEAS in adults

Over the past 13 years or more, we have published dozens of posts and thousands of comments on our blog dedicated to scoliosis.
The Isico blog is a dedicated space where patients can ask questions and swap experiences, but it is also a place where those involved in treating scoliosis can take a more in-depth look at a series of topics and also engage with patients.


SEAS in adults

“You’re too old now”, “Your scoliosis has stopped now that you’ve finished growing”, “If you want to, do some exercise”… How often do adults with vertebral deformities like scoliosis or hyperkyphosis hear things like this?
Our patients often tell us that on reaching adulthood they become aware of physical changes, in their back, their balance and their height, and these patients therefore start looking for answers and treatments.
The natural ageing process does not spare our back and changes are quite normal and to be expected: when they occur, it is important to get active in order to restore elasticity and strength to joints and muscles. But ageing is an entirely different situation compared with the occurrence of deviations of the spine in young people, in whom we seek to modify the bone structures and consequently reduce the degrees of curvature.
 
Scientific studies in recent years have clarified a number of aspects, that are worth bearing in mind:

1. Scoliosis exceeding 30 degrees at bone maturity, generally reached between 17 and 19 years of age, is at risk of progressing over the years, resulting in a worsening of the existing curves: and the higher the measurement, the greater the risk of worsening.
2. Will scoliosis inevitably lead to back pain? Absolutely NOT!
3. Does having a correct lateral spinal profile (lordosis-kyphosis) protect us against reduction of our quality of life due to disability and pain? YES, it does.

In the light of all this, it is important to know that in adults, too, it is possible to intervene both to correct postural abnormalities and to prevent and/or slow down worsening of scoliosis over time: our approach (SEAS) aims to do just this.
As an effect of the force of gravity, and also the curves that are already present, a scoliotic back will tend to drop down in the direction of the curve, and in many cases, there will also be a forward shift of the trunk. Simple physical activity alone, however useful and beneficial this might be, is not sufficient to counteract this phenomenon.
This can only be achieved through specific exercises designed to provide support for the structures of the spine in the opposite direction, and these reinforcement exercises must have precise and individual characteristics, in other words, they must be tailored to the individual patient.

The movements to be carried out must be chosen according to very specific priorities, and this is why it is necessary to turn to qualified professionals who have expertise in dealing with these conditions in adults, using approaches that have been shown to be effective.
The SEAS method requires constant collaboration on the part of the patient and seeks to make him “responsible for himself”.
The exercises are carefully worked out for each individual patient. They are initially performed under the guidance of the therapist and then performed independently, with the patient doing daily repetitions, at home.
Sessions with the therapist are initially scheduled monthly, although this frequency is subsequently reduced, possibly even to only once every three months, and patients are given exercise sheets to follow at home.
It takes at least six months to obtain appreciable results, sufficient to motivate patients to continue and thereby ensure they remain fit well into old age.