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

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”.

Pain perception? It’s also about the mind

A very nice patient of mine, who suffers from low back pain, recently left my studio, after a check-up, with a prescription for a psychological consultation as well as one for specific physiotherapy sessions.

Judging by the look on her face, she was clearly thinking “but my pain is for real, I’m not making it up!”.
This is the reaction I have also had from several other chronic patients when trying to explain the concept of “central sensitisation” to them.

So, let’s try and clear up this question. It is necessary to understand that pain acts as a defence mechanism for the body, as it allows us to understand if, and when, we are in danger.

This mechanism can sometimes end up not working efficiently, producing either not enough pain or too much. In the first instance, we have a problem: if we are unable to perceive danger, we run the risk of doing ourselves serious harm.

In the second case, on the other hand, even non-painful stimuli, such as a light pinch or normal movements, cause us pain.

Such excessive pain is due to nerves in the body that have become too sensitive and fire too easily.

At an early stage after a trauma it is a physiological, ie normal, event due to the brain releasing chemicals that make the nerves more sensitive.
Essentially, pain is, as we have said, a protective mechanism whereby the brain reminds us to be careful with the part of the body that has just been damaged. This kind of pain is reversible and wears off in the space of a few weeks.
Sometimes, however, this protective response can persist longer than it should, to the point of interfering with our perception of pain.

In the literature, this phenomenon is termed “central sensitisation” and it can be compared to a badly set home alarm system that tends to be triggered unnecessarily.

So, signals of peripheral origin can lead us to perceive pain without real cause, or transmission errors can occur centrally. In other words, the problem can lie with our brain incorrectly modulating how much pain we feel.

It is now common knowledge that stress, sleep disorders and depression can negatively influence healing and favour chronicisation. This is why it is important, when faced with chronic patients, also to investigate all the psychological factors that can come into play. 
As a further consideration, literature data show that even the most powerful painkillers currently on the market are able to reduce pain by no more than 30-40%, and do so in no more than 50% of patients.  

In short, the pharmacological approach alone may not be sufficient for treating chronic pain. It can therefore sometimes be necessary to use complementary psychological approaches designed to help patients manage their pain in a more adaptive way, and understand how an individual’s relationship with his pain influences its intensity and the limitations it brings.
They need to appreciate that the brain plays a key role in our perception of pain, and that this perception merely reflects the way it is being processed.

In addition to the perceptual aspects described above, pain also has an experiential component that is entirely personal and subjective; in other words, emotional, cognitive and socio-cultural factors come into play influencing our experience of pain. If we step on a drawing pin, for example, our brain will register pain, but if we step on the same drawing pin while escaping from a lion, our brain may not register any pain at all. 

Many patients really need to understand the true cause of their back pain, even though it is notoriously difficult for us to establish whether it is a bone, joint, muscle or nerve problem. Often, it is none of these, being due, rather, to an area that is working badly and needs to be re-educated to withstand loading. But patients can find it very hard to understand and accept our explanations of how the brain, too, plays a decisive role in the whole experience of pain.
When we tell a patient this, we are not saying that they are inventing their pain, only that there are highly complex mechanisms that can come into play, which must be understood and, if necessary, reset in order to manage the condition.

Nowadays, the scientific community shares the view that patients are more than just the result of their X-rays or MRI scans; that the detection of a herniated disc means nothing unless it is seen in the context of the patient’s clinical conditions and symptoms. We need to stop telling patients, on the basis of these examinations, that their back is in poor shape or looks like that of a 90-year-old woman, because such negative messages serve only to feed a vicious circle that can be difficult to break.
The idea of having a broken, fragile and irreparably damaged body will only make the pain even more entrenched, and condition other aspects of the patient’s life, causing them to limit their movements or physical activity.

And these, too, are responses that can contribute to the persistence of pain.