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Scoliosis: why appearance matters

To treat scoliosis solely on the basis of radiological images, assessing only the patient’s skeletal conditions, would be a huge mistake.

The evolution of scoliosis typically leads to spinal changes in the three planes of space, and it therefore causes a modification of the ribcage. Indeed, as scoliosis progresses, it also changes the appearance of the torso, and this, depending on the severity of the curve, can impact more or less markedly the patient’s appearance.
According to the international guidelines on the conservative approach to scoliosis drawn up by Sosort, improving the patient’s appearance is the second most important goal of treatment.
If the condition is not adequately treated, or the treatment is ineffective, the above-mentioned changes will become more and more marked, even to the point of severely impairing the patient’s quality of life.

The way we see our body is highly subjective. People with asymmetries of the hips or shoulder blades, or a hump, react differently to the problem, in the sense that a defect that one person hardly thinks about, may be quite unbearable to another.
“In treating scoliosis, we must be careful not to overlook this question of aesthetics, precisely because we can never assume that our patients see things the same way as we do: any asymmetry, be it major or minor, can have a considerable psychological impact says dr Irene Ferrario, Isico Psychologist – It is also important to remember that these changes occur in a period – adolescence – that is already full of challenges, and can sometimes see youngsters struggling to build, and accept, their own body image”.

For all these reasons, addressing patients’ aesthetic concerns should not be seen as indulging them; indeed, correcting aesthetic defects is not of secondary importance compared with correcting the curve: it is a therapeutic necessity. When a patient has, for example, one flank straighter than the other, a misaligned shoulder blade, or a hump that alters the line of the upper body, these changes may be perceived as more or less visible, depending both on the individual’s relationship with his/her body, and on his/her own (entirely subjective) aesthetic parameters. Over time, however, if the disease progresses, these changes can become objectively visible and psychologically damaging.
Obviously, we are referring here to the most severe cases, but these remarks nevertheless serve to illustrate that a scoliosis treatment plan cannot exclude the issue of aesthetics. Addressing this aspect is a necessary part of the treatment.

In short, good conservative practice absolutely must take into account aesthetic considerations. Regardless of whether or not the patient highlights this aspect, considering it to be of primary importance, the physician should in any case include it as a key objective of the treatment, which may contribute to its success.
In our care pathway, it is often the parents who first “raise the alarm”, alerting the therapeutic team to these concerns. This is because they are often the first to notice changes in the child’s body, especially if he or she is still too young to have a real awareness of his/her body and body shape.
Sometimes, these “alarm bells” are justified, and sometimes not, given that mild bodily asymmetries are normal, and do not always indicate an underlying problem. Purely aesthetic concerns, especially when raised by our young patients, should never be dismissed. Identifying and acknowledging a patient’s experiences and feelings is crucial to their all-round care. 

“Another aspect that should be underlined is brace wearing, as this treatment (when required) also has aesthetic implications –explains Lorenza Vallini, Isico PT – Many patients worry that their brace can be seen under their clothing, and addressing this concern is an important part of increasing the acceptability of the treatment: fitting patients with increasingly thin braces, moulded to their shape and therefore “almost invisible” to the onlooker, has proved to be a key factor in reducing and containing the deformity. Moreover, a good brace produces a truly remarkable aesthetic correction, not only immediately but also in the long term“.
Indeed, the brace wearer is rewarded with an improvement that lasts into adulthood. But arguments based on the long-term advantages are often lost on youngsters, and therefore an “invisible” brace is still crucial.
The main objective of the treatment will always be a well-balanced and harmonious body, which is as symmetrical as possible. After all, no one is perfect, not even Botticelli’s Venus. Indeed, her imperfections are part of her beauty!

My treatment hasn’t had the desired effect: why?

Sometimes, even when a patient has followed the prescribed course of treatment (bracing and exercises), the final outcome isn’t what they expected and there are no marked improvements. Why is this?

Let’s start by reiterating something we all know to be a fact.

Scoliosis is a disease that can strike with varying degrees of severity and, as we have said many times, its origin is not known. However, although we don’t know what causes it, thanks to scientific research we are learning more and more about how it evolves and how to treat it.

The vast body of scientific literature now available on this topic has shown us the importance of monitoring scoliosis and its evolution during skeletal growth, in particular during the pubertal growth spurt, which is known to be the most critical phase in the course of this disease.

The aim of conservative treatment, which includes specific exercises and bracing, is to limit the progression of scoliosis during growth, so as to prevent problems from arising in adulthood, and to try and avoid the need to perform highly invasive surgery.

The risk of the disease worsening differs from patient to patient and from curve to curve. Unfortunately, there are no elements that allow us to predict this risk; all we have are indicators that can tell us how likely it is that the condition will worsen and, even then, we are only talking in terms of probabilities. Therefore, the task of the medical team responsible for making the diagnosis and treating the patient is to constantly monitor the situation and adjust the treatment as necessary. After all, we do not want to be too aggressive, but at the same time we need to avoid the risk of underestimating the case and prescribing an ineffective treatment.

The other key factor for a successful outcome is the patient’s “adherence” to the prescribed treatment, in other words his/her ability to follow it constantly and with precision.

How much do these two factors influence the result?

A few years ago, we did a study of “extreme” cases (less than 3% of the total), i.e. those patients showing the best and worst treatment outcomes, defined respectively as a greater than 20° improvement or a greater than 20° worsening of the curve. 

We found that all the patients (100%) who obtained exceptional results were treated with both bracing and exercises. But we also found that 50% of the patients with the poorest outcomes had nevertheless followed the treatment perfectly. In these cases, while the treatment had failed to arrest the course of particularly aggressive forms of scoliosis, the patients’ adherence to it had undoubtedly slowed down the worsening of the curve and prevented it from being as marked as it would have been without any treatment at all. And this brings us back to what we said at the start: although some cases show no apparent improvements, scoliosis that has worsened a little at the end of treatment must be considered a great success if the outcome of no treatment would have been a far more severe deterioration.

So, what do we ask of our patients? To collaborate, adhering to the treatment fully and regularly attending check-ups, so as not to run the risk of obtaining disappointing results, despite being treated.

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.”

Can scoliosis be treated with exercises?

The answer is yes, and they are indeed fundamental, but sometimes exercises alone are not enough. Whether or not an exercise-based treatment is sufficient depends, above all, on the severity of the curves and the evolutionary potential of the scoliosis itself, which is partly determined by growth.
Therefore, exercises sometimes need to be combined with another treatment, such as bracing. Rigid  brace wearers always need to do specific exercises in order to minimse the side effects of the brace and maximise its corrective impact.
Patients prescribed the Spinecor wrapping system, a dynamic brace, do not need to do any specific exercises since this device allows movement and therefore guarantees the natural trunk muscle strengthening  that favours correction of the spine. 

Scoliosis treatment can be likened to climbing a mountain; a true climber is well aware that the path ahead of him will present obstacles, but he  is confident he will be able to overcome them in order to reach the top.
That is his goal and he is determined to achieve it, whatever it takes and however long it takes him, because he already anticipates the enormous satisfaction he will feel on finally reaching the summit .

The various treatment options can be seen as different steps on a ladder, where the lowest is the one that has the least impact on the individual, but is also the least effective; instead, the highest step represents the very most that can be done in terms of treatment, and the treatment that will have the greatest impact on the youngster’s daily life. 

The ideal therapy is one that allows the best possible results with the least possible impact.

The first step on the treatment ladder is simple observation; at this level the patient needs to attend frequent medical check-ups in order to keep the scoliosis monitored, and the physician needs to be ready to intervene if the need arises.
The next step involves exercises alone, which are sufficient to control scoliosis of mild and mild-medium severity.
At the next level, patients are offered braces consisting of soft bands, and then, if the condition warrants it, braces made of more or less rigid materials.

Sometimes parents immediately want a therapy that, in their view, gives greater guarantees of success, regardless of the impact on their child.
This attitude is generated by the mistaken belief that opting for  the most aggressive therapy will allow the worst outcome to be avoided, and also by the idea that bracing is more convenient .
To return to the metaphor of the mountain, this amounts to starting the ascent running, in the hope of getting to the top more quickly, but it is an approach that may see the climber paying a very high price in terms of his health and even ending up having to end his career early.

Since scoliosis is an evolving disorder, the treatment, too, needs to be constantly evolving: the best strategy is to be ready  to introduce timely changes in response to emerging needs.

It is important to see the treatment from a global perspective: a patient who starts off simply doing exercises, and does them well for a certain number of months, before then being obliged to wear a brace  will at least have avoided some months of brace wearing, which is certainly a good thing.
Changing treatment does not mean that the previous one was unsuccessful, it simply means that it has become apparent that a  stronger method is needed order to win the struggle (like an arm wrestling contest!) with the scoliosis.