Telehealth consultations – Now available!

Posted on May 1, 2020 by - Blog

The COVID-19 Crisis sweeping the world is making everyday life hard for all of us. While there are many issues which can be put “on the back burner” a scoliosis consultation should not be one of these. For patients at a high risk of progression – for example, those between 10 and 18 – scoliosis can evolve very quickly, which means a swift consultation is a must.

Effective immediately, Dr Paul Irvine, Dr of Chiropractic and founder of the clinic, will be offering Scoliosis consultations online in a highly secure, private environment. While a teleconsultation is not a replacement for an in-person appointment, it represents an excellent way to get an initial diagnosis and further information about next steps.

We will be posting more information about this option shortly – in the meantime, if you are urgently seeking an appointment please get in touch via our normal phone number and we will arrange an appointment with you, and answer any questions you have.

Scoliosis and Kyphosis, what’s the difference?

Posted on May 1, 2020 by - Blog

Given our name being the UK Scoliosis clinic you would expect or focus to be on the non-surgical treatment of scoliosis, however, we also work with many patients suffering from another common spinal condition – Kyphosis. But what’s the difference between Scoliosis and Kyphosis?

 

Kyphosis

Kyphosis is the condition which causes what’s sometimes called a “hunchback”, people with this condition tend to hunch forward, and, as you may have already realised, it’s getting far more common today than ever before.

But isn’t the spine supposed to bend forward slightly? – yes, it certainly is, however, when this forward bend becomes too pronounced it can become an issue. As a general guide,  it’s normal to have a mid-back kyphosis (backward c-shape curve) at approximately 40 degrees. Above this, unpleasant symptoms may result.

Typically, patients complain of aching and stiffness in their mid-back and lower back. It worsens when weight-bearing, especially when doing activities that require repeated bending such as gardening. Often, teenagers are noticeably hunched from spending hours on their phones, tablet’s or PC’s – a trend which often worsens into adulthood. Most age groups are at risk of Kyphosis, although there is probably a stronger link with lifestyle than with age per se.

 

Causes of Kyphosis

Like scoliosis, there can be different underlying causes of kyphosis, but unlike scoliosis, we understand these potential causes well. There are 4 main underlying issues which can lead to Kyphosis, these are:

 

Postural Kyphosis – is the most common form and the one which is increasing faster than ever before. Postural kyphosis is noticeable, in that it will appear when standing and sitting and disappear when laying face down. Postural kyphosis isn’t a structural problem caused by an abnormal shape of the vertebra that make up the spine, but rather by the supporting muscles and tissues. Over time, as we remain in a slouched position (such as sitting at a desk all day or hunched forward gaming for hours on end) certain muscles become too tight, others become weak and loose, leaving us with a “hunchback” look. Postural kyphosis, disappears when laying face down as the spine is able to return to its normal position, without the need the need for the surrounding muscles muscles to work and support the spine against the force of gravity.

 

Scheuermanns kyphosis

Scheuermann’s disease – is far less common, and results in an increased kyphosis throughout the teenage years whilst growth is occurring. It is a growth plate disorder in the vertebrae themselves, which causes them to become more wedged and compressed at the front, hence the increase in kyphosis. This will result in structural deformity as the bone formation is altered. Scheuermann’s cannot be “cured” or reversed, however, the right treatment at the right time, can help to significantly reduce the progression of the deformity. Bracing in the right cases has been shown to be a very effective treatment when combined with specific posture exercises.

 

 

 

 

 

Osteoporatic fracture, and kyphosis

Osteoporosis of the spine – is a common cause in older individuals – here, the fundamental cause is vertebrae undergoing compression fractures due to a loss of bone strength. Osteoporosis of the spine can cause a large increase in the kyphosis in people over 60. It will often continue to progress with age, thus it is vital that patients keep their posture upright and keep their bones strong for as long as possible. While again, this condition is not “curable” the right management can make a huge difference to the quality of life.

 

 

 

 

 

 Spinal malformations & birth defects – account for the majority of the remaining Kyphosis cases – there are a number of conditions which can cause the vertebra to not develop properly. Depending on the underlying condition and the severity, it may need surgical intervention.

 

Treatment Of Kyphosis

In most cases of Kyphosis, the condition can be treated effectively with specific postural correction exercises & stretches, postural traction and kypho-bracing when necessary. Advanced manual approaches such as Chiropractic Biophysics can be highly effective in resolving Kyphosis cases. Beyond initial treatment, the same approach can be used to manage and reduce the severity of symptoms, often so that the impact on daily life is very little. Only in very severe cases is surgery typically required, and this is usually due to the risk of progression and further complications. Many cases of postural kyphosis can be improved or resolved.

The pictures below show the correction in an adult male with hyper-kyphosis, through the Chiropractic Biophysics technique. The pictures are approximately 1 year apart.

Scheuermann’s disease, and cases related to osteoporosis in particular, can often benefit from part-time bracing with a specialised Kyphosis brace, such as Kyphobrace – in these cases, a “cure” is not possible, but with proper management, it is entirely possible to live a normal and healthy life with Kyphosis.

In senior’s with kyphosis, caused by underlying osteoporosis, further compression fractures become more likely as the spine becomes progressively more hunched. Hence, treatment & exercise programs need to be gentle and designed to help keep patients more upright, improve balance to resist falls, and include nutritional support to help maintain bone strength. Gentle supportive bracing in senior’s can also be effective in helping them stay upright when whey are standing and walking.

 

 

Scoliosis

Whereas Kyphosis causes “forward hunching” posture, related to an excessive forwards bend in the spine, scoliosis causes a side to side curvature of the spine resulting in a distinctive scoliosis profile.

Unlike Kyphosis, Scoliosis tends more often to be a serious condition which, in most cases, progresses (sometimes rapidly) without proper treatment. While Scoliosis can cause pain, it does not always, and in many cases it is only detected through screening or is noticed by friends of family members during a trip to the beach or when changing clothes. Whereas Kyphosis is quite easy to spot. Scoliosis can progress to a significant degree without any obvious signs, so screening is a very good idea to enable early detection.

 

Causes of Scoliosis

Whereas the causes of Kyphosis are well understood, and (with a bit of planning) you can reduce your risk through targeted exercise and fitness approaches, most cases of scoliosis have no known cause – in a large number of cases, the condition is described as ”idiopathic” – literally meaning “without known cause”.  The underlying pathologies are therefore:

 

Idiopathic scoliosis – Idiopathic scoliosis is most commonly found in younger teenagers, with the most at-risk group thought to be between the ages of roughly 11 and 16. Girls are affected more often than boys, but boys can and do develop scoliosis.  While the cause is not currently known, research suggests that genetics may play an important role. It’s also believed that participation in some activities such as ballet or gymnastics, in which there is a contortion of the spine, may hasten or promote the development of scoliosis.

 

Degenerative Scoliosis – Degenerative scoliosis is a condition typically seen in people over the age of 60. In this case, we do know the cause – degenerative or “de novo” scoliosis is simply caused by wear and tear as we age, involving changing in the shape of the vertebrae and weakening of the spinal ligaments and muscles enabling the vertebrae to twist and turn.

 

Scoliosis from other causes – Other, less common causes of scoliosis include congenital deformities and problems with the formation of the spine such as hemi-vertebra or butterfly vertebra, and are usually present from birth. Other cases may be caused by underlying neurological and syndromic conditions that may or may not have already been diagnosed.

 

Treatment for scoliosis

Scoliosis in older individuals (de novo scoliosis) cannot be “cured”, in the same way as kyphosis in older individuals cannot be “cured” – however, similar approaches can be used to significantly reduce the impact of scoliosis on one’s life, and in some instances, it is also possible to reduce the scoliotic curve itself. Scoliosis bracing can be highly effective as a means to achieve this and has also been shown to reduce pain where it exists.

Scoliosis in younger individuals is almost invariably a case of idiopathic scoliosis – the treatment for this depends on the severity of curve at time of diagnosis, but in all cases, the objective is to straighten the spine as much as possible. In cases which are caught very early, when the curve is still small, scoliosis can sometimes be corrected using scoliosis specific exercises – a regime of scientifically based movements and stretches designed to counteract the scoliotic curve. In very young patients (who are not able to perform scoliosis specific exercise) or in larger curves, scoliosis bracing is the preferred method of treatment. While bracing results vary according to the brace type that is used, today a very high number of cases treated with corrective bracing achieve a reduction of the curve down to a “normal” scoliosis value.

 

Is it Scoliosis, or Kyphosis?

If you’re unsure about an unusual posture or spinal issue you have noticed, an excellent place to start is a professional consultation at the UK Scoliosis Clinic, just get in touch!

5 scoliosis facts that may shock you!

Posted on April 11, 2020 by - Blog

If you’ve been reading this blog for a while, or if you have an interest in scoliosis, you will certainly have noticed some themes which come up again and again. Even a quick browse through the recent research in the field, demonstrates that the main areas of interest are fairly constant – adolescent idiopathic scoliosis, the genetic links for scoliosis and the most effective methods for reducing cobb angle come up more often than not. There’s more to scoliosis treatment than just these factors however – so this week, we look at some lesser-known but potentially surprising scoliosis facts.

 

Surprising scoliosis fact number 1

The group most at risk from scoliosis is older adults.

Because of the risk of progression, and the potential consequences if treatment is not forthcoming, much research, advertising and awareness campaigning in the scoliosis field concentrates on adolescent idiopathic scoliosis – next in line is probably juvenile scoliosis. The fact is, only about        2-3% of the population in these groups will develop scoliosis. That’s still a very large number of cases, all with a significant risk of progression, but when you crunch the numbers, its clear that older people are, in fact, the most likely to suffer from scoliosis – the risk is nearly 10 times higher!

Research indicates that approximately 30% of those over 60 suffer from scoliosis[1] – the majority of cases are termed “de-novo” which is a scoliosis that develops due to spinal degeneration and can respond well to treatment.

 

Surprising scoliosis fact number 2

Scoliosis is sometimes more common in males 

It’s true that 75% of adolescent idiopathic scoliosis cases are females, and since this gets the lions share of attention in the field, it’s little surprise that most screening campaigns and tools are targeted at young girls. That being said, in some instances scoliosis is actually more common in boys. Specifically, this is the case in cases of infantile scoliosis. Infantile scoliosis is the least common of all forms of idiopathic scoliosis and comprises only about 1% of all idiopathic scoliosis in children. However, about 60% of patients in this group are boys. Infantile scoliosis can sometimes resolve spontaneously, but presents the highest possible risk for progression, so should be monitored and treated urgently.

 

Surprising scoliosis fact Number 3

Which is better, bracing or exercise? …. Actually, it’s both!

When it comes to treatment methodologies, it’s usually a case of picking the best approach and sticking with it. As it concerns scoliosis treatment, a multiple studies have confirmed that when bracing and exercise approaches are combined the results are greater than the sum of the parts. Curve correction with a dual approach is superior to either approach alone.[2]  What’s more, it seems that using exercise approaches before and after bracing can speed correction, and then prevent loss of correction after bracing.[3]

 

Surprising scoliosis fact Number 4

Your GP knows a lot less about scoliosis treatment than you might hope.

This point isn’t about criticising GP’s – they do a fantastic job, but there’s only so much any one person can know, and as it goes, scoliosis is fairly low down the list of major concerns for the general population. The situation is especially difficult in the UK, since the National Health Service (NHS) is (understandably) not in the business of recommending private companies, and the best bracing technologies on the market today are only available privately. It’s for this reason, that you must seek a specialist scoliosis consultation whenever possible – the braces on offer through the NHS are still mainly “passive” options, which don’t correct scoliosis, just try to stop it progressing.

 

Surprising scoliosis fact number 5

Active bracing is often the most cost-effective option.

Active scoliosis braces, like ScoliBrace, are advanced medical devices and aren’t cheap – and while no one would claim that the cost of a scoliosis bracing treatment is insignificant, in many cases it can be substantially less financially impactful than many other options.

Lets briefly consider the main treatment methodologies available:

Surgery – Through the NHS in the UK, surgery for scoliosis is of course free. So naturally the issue here isn’t a financial one, but rather the cost of surgery is often in terms of complications after the event – or with the disruption that it can cause to a young persons’ life. The UK Scoliosis Clinic isn’t anti-surgery – on the contrary, we know that spinal surgeons can do fantastic work for patients who have no other option – we do, however, believe that surgery should be the last resort since for many, recovery is long and complicated. While it won’t be the case for everyone, recent meta-analyses of published research have suggested that the complication rate could be as high as 89%.[4]

Exercise – Exercise-based treatment plans are only supported by research  for small curves with a low risk of progression and while exercise might initially seem cheaper than bracing, this is only true if the treatment is appropriate. In young growing spines, the risk of scoliosis progressing in moderate to large curves is high, thus a curve must be constantly straightened via a brace rather than through the intermittent use of scoliosis specific exercise. In cases where a brace has been required and only scoliosis specific exercise used, curves will often progress and surgical correction will be required.

Other forms of bracing – Regular readers will know that Scoliosis braces are not created equal. Passive models, which don’t correct scoliosis but attempt to hold the curve in its current position, do absolutely nothing to “treat” the condition.  Other braces on the market, while still active in nature, unlike Scolibrace are often not adjustable – meaning that their corrective capacity is limited, thus a new brace is frequently required as the curve changes. This means that in many cases, an advanced adjustable brace, like ScoliBrace will be cheaper in the long term.

 

 

 

[1] Scoliosis in adults aged forty years and older: prevalence and relationship to age, race, and gender‘
Kebaish KM, Neubauer PR, Voros GD, Khoshnevisan MA, Skolasky R, Spine 2011 Apr 20;36(9):731-6.

‘The prevalence and radiological findings in 1347 elderly patients with scoliosis‘
Hong JY, Suh SW, Modi HN, Hur CY, Song HR, Park JH.,  Journal of bone and joint surgery 2010 Jul;92(7):980-3

 

[2] ‘The effectiveness of combined bracing and exercise in adolescent idiopathic scoliosis based on SRS and SOSORT criteira: a prospective study‘
Negrini S, Donzelli S, Lusini M, Minnella S and Zaina F 2014, BMC Musculoskelet Disord. 2014; 15: 263, Published online 2014 Aug 6. doi:  10.1186/1471-2474-15-263

‘Adult scoliosis treatment combing brace and exercises‘
Papadopolous D 2013, Scoliosis 20138(Suppl 2):O8, DOI: 10.1186/1748-7161-8-S2-O8

 

[3] Negrini S, Negrini A, Romano M, Verzini N, Parzini S: A controlled prospective study on the efficacy of SEAS.02 exercises in preparation to bracing for idiopathic scoliosis. Stud Health Technol Inform 2006, 123:519-522.

 

[4] Hans-Rudolf Weiss and Deborah Goodall, Rate of complications in scoliosis surgery – a systematic review of the Pub Med literature, Scoliosis, 2008, 3:

What is Night Time Bracing?

Posted on April 1, 2020 by - Blog

Today, Scoliosis bracing is recognised as the most effective non-surgical scoliosis treatment to reduce cobb angle in scoliosis cases – and to do so relatively quickly. This isn’t to say that bracing is a total solution – scoliosis also creates muscle and posture imbalances which are best addressed by methods such as scoliosis specific exercise, however, we now understand that Bracing is far more effective than exercise in reducing cobb angle itself. [1]

Research also shows that the longer scoliosis braces are worn, the more quickly the underlying cobb angle can be corrected[2] – this means that typically, bracing will be almost full time with a view to achieving rapid change. However, for some smaller curves night time bracing, a part-time bracing option, maybe a viable way to go – so what’s the evidence for night time bracing?

 

Night time bracing

Whereas most scoliosis bracing takes place on a nearly full-time basis, night time bracing is a part-time approach – which, as you may have guessed, takes place in the evening and at night.

Night time bracing is one approach which has been considered as a way of addressing concerns relating to poor patient compliance, which is often noted with the use of full-time bracing. Night time braces will, by their nature, tend to correct a curve more slowly than a full-time brace – however, based on the clinical results available, a recent study concluded that night time braces constitute an attractive option for single-major lumbar/thoracolumbar curves not exceeding 35 degrees in magnitude. [3]

Like all approaches, night time braces have some pros and cons, however, and it’s a decision that should be discussed with a scoliosis professional. Some factors to consider are:

 

Advantages of night-time braces

More attractive wear time – many patients find that wearing a brace in the evening or at night is easier for them to manage from a social point of view, and it’s an attractive option for parents who are worried about bracing their children during school hours.

Higher compliance – Compliance with prescribed brace wear time is one of the most critical aspects of scoliosis treatment, and with young children and adults, in particular, maintaining compliance is perhaps the most difficult part of treatment. Higher compliance rates, even at a slower correction speed, may prove better in the long term than a full-time brace which is not worn properly.

Ideal for maintaining results – Night time braces represent an excellent option for preventing scoliosis returning in patients who have successfully completed treatment, but need to maintain curve correction until skeletal maturity has been achieved. Unlike an exercise-based approach, a night time brace requires very little effort from the user.

Suitable for early intervention – Night time braces may be a good choice for patients who have a curve unsuitable for exercise-based treatment, or for those who are too young or weak to be able to perform exercise properly.

 

Disadvantages of night-time braces

Slower curve correction – cobb angle correction correlates with brace wear time, so a lower wear time means a longer duration of treatment. In some situations, a shorter course of more intensive bracing may be preferable.

Not suitable for large curves –  larger curves require full time bracing, meaning that night time braces are not likely to be effective for more serious scoliosis cases. Our ScoliNight brace is recommended for curves less than 25 degrees.

Less cost-effective –  night time braces achieve less correction over the same course of time than a full-time brace. In growing children, this may mean multiple braces need to be purchased, rather than just one full-time brace.

 

In most cases, we recommend a full time (or near full time) brace for scoliosis treatment, especially for larger curves. In most cases, correcting the curve as soon as possible is the main concern – however as suggested above, night time bracing could be an excellent option for correction maintenance over the longer term.

It’s also important to stress that modern scoliosis braces do go quite some way to alleviate the main issues associated with low compliance – the model we prefer, the ScoliBrace, is designed using a fully individualised CAD/CAM process to fit the wearer snugly but comfortably. ScoliBrace comes in a wide variety of colours and can be virtually invisible under clothes if this is the look you prefer. Similarly, it’s flexible enough to allow the wearer to participate in sporting activities and normal play with no significant hindrance.

 

Want more information about night time Bracing?

To find out if night time bracing might be the right option for you, book a consultation today! The UK Scoliosis Clinic offers consultations at our clinic, or online, via webex

 

 

[1] Yu Zheng, MD PhD et al. Whether orthotic management and exercise are equally effective to the patients with adolescent idiopathic scoliosis in Mainland China? – A randomized controlled trial study SPINE: An International Journal for the study of the spine [Publish Ahead of Print]

[2] ‘Effects of Bracing in Adolescents with Idiopathic Scoliosis’
Stuart L. Weinstein, Lori A. Dolan, James G. Wright, and Matthew B. Dobbs, N Engl J Med 2013; 369:1512-1521 October 17, 2013DOI: 10.1056/NEJMoa1307337

[3] Grivas TB, Rodopoulos GI, Bardakos NV. Biomechanical and clinical perspectives on nighttime bracing for adolescent idiopathic scoliosis. Stud Health Technol Inform. 2008;135:274-90. PMID: 18401098.

Why Scoliosis screening can save you money

Posted on March 22, 2020 by - Blog

When you’re dealing with scoliosis, the least important factor should be finances – you should always select a treatment plan based on it’s long term prospects and what’s best for you or your child. This being said, it’s true that the earlier Scoliosis is caught, the easier and (usually) more cheaply it can be treated. It’s for this reason that scoliosis screening can actually save you a great deal of money…..

 

Scoliosis screening is really cheap

It’s certainly true that scoliosis bracing and even exercise-based therapies are not cheap – the costs of treating scoliosis can be a burden and we understand this – however the first step on the ladder, a scoliosis screening, can be incredibly cheap, or even free. A scoliosis screening involves performing just a few simple movements and standing in a normal posture while you are observed from behind – you can even use our free scoliscreen app to guide you through the process.

For those who have a family history of scoliosis, or have concerns following an initial screening, the UK Scoliosis clinic offers inexpensive initial consultations both online and in person, which are an excellent way to get a professional opinion – not just on scoliosis, but also on the case of a complaint, even if it is not scoliosis related.

We cannot stress enough that knowing your “scoliosis status” early on, makes a huge difference to your prognosis, and to the cost of care, and this is because…

 

Scoliosis costs more to treat, the longer it is left.

Like most conditions, scoliosis is easier – and therefore usually cheaper – to treat when its caught early on. [1] In many counties, scoliosis screenings are provided to all children at school, since it’s public health benefit is well recognised. While there is some traction for the idea here in the UK, it does seem unlikely this will become normal procedure any time soon. This is a great shame, since scoliosis can often be noticeable via a simple screening well in advance of any of the usual “symptoms” becoming visible day to day.

All scoliosis cases are highly individual, which is one of the things which makes it a complex condition to treat correctly – but speaking generally, If scoliosis is caught early it is often possible to treat with exercise-based approaches which usually represent the cheapest way forward. Other options for a relatively mild case include night time or part-time bracing – which, while somewhat more expensive is easier for many families to manage.  Once scoliosis cases have progressed beyond approximately 30 degrees cobb, bracing will likely be the only form of treatment which is likely to succeed – while bracing is infinitely preferable to spinal surgery if at all avoidable, braces can be expensive. Innovative braces, such as our favoured model, the ScoliBrace, can help to reduce cost by extending the life of a brace through an adaptive design – but there’s no question that letting the case develop will raise the cost of treatment.

In serious cases, which have reached the surgical threshold of 50 degrees with time left for spinal growth ie curve progression, corrective bracing like Scolibrace can be used and is often successful in either reducing the curve or stopping the curve from progressing until growth has finished. This can mean that surgery can be avoided or that just one surgery can be perfomed rather than multiple surgeries that would be required as the spine grows. . Realistically, however, the costs of treating a larger curve will be higher again – often, multiple braces as well as complementary therapies will be required to achieve curve improvement.

What’s critical to remember here is that ALL scoliosis cases develop over time – all cases start out small, and therefore start out cheaper to treat. As time passes, the difficulty of treatment and the cost only rise.

 

So, Is surgery cheaper?

The UK is unusual, in that our NHS provides spinal surgery to those who need it – free of charge. The truth is that spinal surgery is immensely expensive – the cost of an operation to correct scoliosis would run to tens of thousands of pounds if purchased privately – but in the UK, we do not pay this cost directly. In an absolute sense then, yes, spinal surgery is cheaper – however, it’s critical to consider the social and emotional costs of allowing scoliosis to develop to the surgical threshold, as well as the possible financial implications of surgery in the long term. Especially for those who are already in work, or perhaps attending university – what would be the cost of 6 months to a year of recovery?

The other point to keep in mind here is that “opting for surgery” is not quite the same in the UK, as it would be in, for example, the US. While the NHS will provide scoliosis surgery for those in need, it will not do so for those who are not badly enough effected  – this is to say, those who have reached the surgical threshold. While scoliosis does generally tend to develop over time, the rate is not always uniform and is certainly possible that an individual “opting for surgery” by simply waiting for the scoliosis to reach the threshold may actually never reach it – meaning they are left with scoliosis forever.

 

Don’t wait, screen today!

Scoliosis screening is free with our ScoliScreen app – and for those with concerns, affordable consultations are available at our clinic, or now even online via a secure web chat. Please do not let worries about the cost of treatment prevent you from finding out the true cause of an issue as doing so will not save money – in the long term, it will cost far more, both financially and emotionally!

 

[1] Fong DY, Cheung KM, Wong YW, Wan YY, Lee CF, Lam TP, Cheng JC, Ng BK, Luk KD, ‘A population-based cohort study of 394,401 children followed for 10 years exhibits sustained effectiveness of scoliosis screening’ Spine J. 2015 May 1;15(5):825-33.

Can scoliosis get worse as you age?

Posted on March 2, 2020 by - Blog

Scoliosis is a progressive condition – it does tend to get worse as you age. However, scoliosis is somewhat unusual in that it does not have what we might call a “predictable trajectory” – this is to say that you cannot simply assume that after X years, scoliosis will have increased by X degrees. Rather, it often accelerates during growth spurts – and even outside of this develops at an unpredictable rate. It’s for this reason that we encourage people never to “wait and see” when it comes to scoliosis – a year waiting may see very little change in the condition, or it might be a lot…

It is possible to predict the rate of growth to some extent – and indeed, in cases of adult scoliosis (that is to say scoliosis which began in childhood and was carried into adulthood), we can estimate the increase in curvature to be approximately 0.82° per year.[1] By contrast,  the rate at which scoliosis increases in young patients depends more upon risk factors such as the severity of scoliosis considering age, the rigidity of curve, and family history. What we do know, is that Juvenile scoliosis greater than 30 degrees tends to increase rapidly and left untreated presents a 100% prognosis for surgery, whereas curves from 21 to 30 degrees are more difficult to predict but can frequently end up requiring surgery, or at least causing significant disability.[2]

With scoliosis, there is therefore a very real need to act quickly and proactively if the condition is to be halted and the curvature corrected before either surgery is required, or full correction is no longer possible.

 

Rapid progression in scoliosis cases

While we know that scoliosis is subject to rapid and unpredictable changes in severity, most of the research in this regard has only targeted more serious cases – however, it’s likely that the same basic principles apply to smaller curves, again underpinning the need for fast action when scoliosis is suspected.

Recent research by the British scoliosis society[3] has shown that in patients already waiting for scoliosis surgery, curve progression can be considerable just during the consultation process. Their 2018 study specifically looked at scoliosis progression whilst waiting for a consultation and eventual surgery. In the study, 41 females and 20 males with a mean age of 11.8 years with a mean Cobb angle (curvature) of 58° were followed –  Average waiting time to be seen in the clinic for an initial consultation was 16 months – thereafter, the average waiting time for surgery was 10 months. Rapid curve progression was seen in twelve patients, of which 10 required more extensive surgery than originally planned. Their mean Cobb angle at presentation was 48° which increased to a mean of 58° at surgery.

Perhaps the saddest part about the study from the British scoliosis society was the specific data on the curves of the participants at the beginning of the research. While the study sought to examine curves which were already at the “surgical threshold”, the range of curves studied was actually between 17°–90°[4], and while a 90-degree curve would certainly be likely to require surgery, a 17-degree curve would almost certainly have not – indeed, a 17-degree curve would be an excellent candidate for the kind of conservative, non-surgical treatment we offer at the UK scoliosis clinic.

By the end of the study, however, after such a short time, the smallest curve was  30°and the largest was 120°. While it is certainly easier to treat a smaller curve,  a 30-degree curve still has a good prognosis with modern conservative treatment through active bracing, such as scolibrace.  This study goes to show that the right information at the right time makes a significant difference in scoliosis cases.  Indeed –  in stark contrast to the above – one recent study of 113 scoliosis patients treated with non-surgical approaches showed that vast majority achieved a significant curve correction and only  4.9% of patients needed surgery.[5]

 

Older adults

As we already mentioned, adult scoliosis cases – that is to say, childhood scoliosis which is carried into adulthood – does tend to progress at a more predictable rate, however as we age, there is an additional risk from Scoliosis.

Older adults are at considerable risk of another common form of scoliosis, known as “de-novo” (degenerative) scoliosis. De-novo scoliosis is caused by wear and tear to the spinal discs as we age, and is therefore quite common – research suggests that as many as 30% of the over 60’s suffer from scoliosis. Although de-novo scoliosis progresses much more slowly than childhood or adolescent scoliosis it can still have a major impact on quality of life, if not properly treated.[6]

Patients with de-novo or degenerative scoliosis, will often experience constant back and leg pain which makes it difficult for them to walk or stand for any period of time. They may become aware that they cannot stand up straight and lean towards one side, this becomes more noticeable the longer they are upright. Frequently they don’t find relief with standard conservative treatment such as chiropractic or physiotherapy and they are not suitable for surgery due to osteoporosis ie bone weakening. These patients often respond well to a gentle supportive brace, which helps to keep them upright and less tilted thus they can walk or stand more comfortably for longer periods of time.

 

[1] Progression risk of idiopathic juvenile scoliosis during pubertal growth, Charles YP, Daures JP, de Rosa V, Diméglio A. Spine 2006 Aug 1;31(17):1933-42.

[2] Progression risk of idiopathic juvenile scoliosis during pubertal growth, Charles YP, Daures JP, de Rosa V, Diméglio A. Spine 2006 Aug 1;31(17):1933-42.

[3] H V Dabke, A Jones, S Ahuja, J Howes, P R Davies, SHOULD PATIENTS WAIT FOR SCOLIOSIS SURGERY?  Orthopaedic ProceedingsVol. 88-B, No. SUPP_II

[4] H V Dabke, A Jones, S Ahuja, J Howes, P R Davies, SHOULD PATIENTS WAIT FOR SCOLIOSIS SURGERY?  Orthopaedic ProceedingsVol. 88-B, No. SUPP_II

[5] ‘Brace treatment in juvenile idiopathic scoliosis: a prospective study in accordance with the SRS criteria for bracing studies –SOSORT award 2013 winner‘ Angelo G Aulisa, Vincenzo Guzzanti, Emanuele Marzetti,Marco Giordano, Francesco Falciglia and Lorenzo Aulisa, Scoliosis 2014 9:3 DOI: 10.1186/1748-7161-9-3

[6] ‘Scoliosis in adults aged forty years and older: prevalence and relationship to age, race, and gender‘
Kebaish KM, Neubauer PR, Voros GD, Khoshnevisan MA, Skolasky R, Spine 2011 Apr 20;36(9):731-6.

‘The prevalence and radiological findings in 1347 elderly patients with scoliosis‘
Hong JY, Suh SW, Modi HN, Hur CY, Song HR, Park JH.,  Journal of bone and joint surgery 2010 Jul;92(7):980-3

 

Can scoliosis be cured?

Posted on February 20, 2020 by - Blog

For those who are diagnosed with scoliosis, the first question is almost always “can scoliosis be cured?”.  Scoliosis is a complex condition – and so is the answer to this question, but this week we’ll try to make it easy to understand!

 

What is scoliosis anyway?

Before we can address the issue of a cure, we first need to properly understand the problem.

Scoliosis is a complex condition which consists of several issues occurring all at once. While a normal spine will appear straight when viewed from behind, in Scoliosis a 3-dimensional shift in the spine takes place, most notably causing a curvature to one side or the other, but it also tends to lead to rotation of the spine itself. Over time, scoliosis affects the balance of the body, leading to muscle imbalances, postural problems and issues with range of movement.

Scoliosis, especially in the early stages, can be hard to spot – scoliosis has typically progressed for some time before there are visual signs – however, once signs have appeared:

  • From the back, the spine may have a C or S shape curve rather than that of a straight line, this can make the waistlines uneven or one shoulder lower than the other.
  • From the side view, the normal spinal curves are often straightened, which makes the mid-back appear flat. Shoulder blades may be prominent.
  • While looking from the head down to the feet, there is a rotation or twist which can cause ribs or one side of the lower back to appear humped or more prominent.

Scoliosis is typically divided into two main categories – adult, and childhood scoliosis. Adult scoliosis is caused either by the degeneration of spinal discs with age or as a result of childhood scoliosis which was not treated. Childhood scoliosis (affecting infants through to young adults) has several known causes, but in 80% of cases, the exact cause is unknown. This is termed “Idiopathic” scoliosis. The remaining 20% of cases are typically caused by congenital or genetic conditions, spinal malformations, underlying neuromuscular conditions, metabolic conditions or trauma.

 

Can Scoliosis be cured?

It’s important to be clear about what we mean when we talk about a “cure”. As we’ve described, scoliosis isn’t a single issue condition. Whereas something like a throat infection is unpleasant, it has a single root cause and once correctly identified it’s easy for your GP to provide you with some appropriate medication – over a couple of weeks you can expect your condition to have fully resolved, or been “cured”.

In most cases, the underlying cause of scoliosis is unknown – and in some which are known (such as de-novo scoliosis), the underlying cause (here ageing) cannot be cured, but can certainly be managed.

Let’s look at an example – In an idiopathic cases (which typically affects children and teenagers) an initial diagnosis typically involves an existing scoliotic curve, and often some pain or muscle weakness. It’s possible to correct the scoliotic curve using approaches such as modern “active” bracing, as long as it is caught soon enough[1]. Muscle imbalances can be eliminated with appropriate physical therapy approaches, such as Schroth therapy, or Scoliosis specific exercise. Pain associated with scoliosis may be helped with complementary therapy such as massage in the short term, whereas evidence suggests that approaches such as bracing also reduce pain over the longer term.[2]

In many ways then, the symptoms of scoliosis can be cured – however, ongoing treatment is required to prevent the scoliosis from returning, since the underlying condition itself cannot be fully overcome. This being said, once a patient has reached skeletal maturity, scoliosis progression typically halts, and any further development can be prevented with appropriate exercises.

So, overall, it is more realistic to say that while scoliosis cannot be fully “cured” it’s entirely possible for the patient to live the rest of their life “scoliosis free” –  as long as the curve is caught early enough to be corrected.

 

Scoliosis requires ongoing monitoring.

One of the most notable aspects of scoliosis is its tendency to develop at a varying pace – and with a fairly unpredictable rate of progression, so it’s critical for anyone who has been diagnosed with scoliosis to continue to be monitored, at least until they reach skeletal maturity. Modern approaches to treatment do have a very high success rate, and research is now helping us to understand how we can best avoid any reduction in curve correction after a treatment plan has concluded[3] but ongoing monitoring is the simple and effective way to address any problems which may develop along the way to skeletal maturity.

At the UK Scoliosis Clinic, we’re keen to ensure all of our patients feel supported right from their initial consultation, through to skeletal maturity.

 

[1] ‘A population-based cohort study of 394,401 children followed for 10 years exhibits sustained effectiveness of scoliosis screening’
Fong DY, Cheung KM, Wong YW, Wan YY, Lee CF, Lam TP, Cheng JC, Ng BK, Luk KD, Spine J.  2015 May 1;15(5):825-33. doi: 10.1016/j.spinee.2015.01.019. Epub 2015 Jan 20.

 

[2] Scoliosis bracing and exercise for pain management in adults—a case report
Weiss et al, J Phys Ther Sci. 2016 Aug; 28(8): 2404–2407.

 

[3] Fabio Zaina et al. Specific exercises performed in the period of brace weaning can avoid loss of correction in Adolescent Idiopathic Scoliosis (AIS) patients: Winner of SOSORT’s 2008 Award for Best Clinical Paper,  Scoliosis 2009, 4:8

 

What is the main cause of Scoliosis?

Posted on February 10, 2020 by - Blog

One of the most common questions which we are asked is perhaps an obvious one, “what causes scoliosis?”. While this seems a simple question, it’s actually quite a complex issue – the exact cause of many scoliosis cases is not known, although there are some factors which are known to be a risk. So today, rather than one answer, let’s look at a few.

 

Answer number one – “We don’t know”.

While this might seem like a shocking answer given all the modern science we are able to bring to bear on the issue, the honest answer is that science is still to determine why some people develop scoliosis, and why some people don’t. Stranger still, about 85% of all scoliosis cases fall into this “idiopathic” (meaning without known cause) group.[1]

There are a number of working theories as to factors which may predispose individuals to scoliosis – much research (and the bulk of scientific opinion at the moment) points towards genetic inheritance, but everything from vitamin and mineral deficiencies to certain types of exercise have been suggested as a potential cause. It has at least been confirmed that scoliosis certainly can run in families[2]–  which is why we recommend that anyone who has a parent or sibling with scoliosis should have regular screenings

Most idiopathic scoliosis cases occur in children between the ages of 10 and 18[3] and many adult scoliosis cases (as opposed to de-novo, see below) are in fact cases which started at this age and progressed into adulthood. There are certain trends which suggest a pathology here – most cases are female, in their early teens and often come from scoliosis affected families – but alone, that information is not enough to attribute a cause. Hopefully, research will reveal the real answer in the near future!

 

Answer number two – “It’s ageing”

Back pain, stiffness and reduced mobility are often expected as part of the ageing process (although it certainly does not have to be this way!), so can scoliosis also be caused by age? Actually, yes it can – a specific type of scoliosis, known as “de novo” scoliosis, occurs as the spinal discs wear and tear with age. De-novo scoliosis tends to be less aggressive than teenage scoliosis, and presents a far lower risk for extreme progression – but its much more common than you might think. Recent estimates suggest that about 30% of those over 60 may be suffering from scoliosis. [4]

Answer number three – “it’s a comorbidity”.

While scoliosis is often a “standalone” condition, and this is what we tend to mean when we talk about the condition, it can also occur as a co-morbidity, that is to say, a condition which arises from the presence of another.

Some of the more common explanations are scoliosis caused by an underlying genetic or neurological condition, by a spinal issue such as a problem affecting bone growth or development or simply by injury. Some scoliosis cases can even be caused by issues with hip alignment, or by uneven leg growth. The correct treatment path in each case will depend entirely upon the underlying condition – and this is why it’s vital to see a scoliosis specialist whenever scoliosis is suspected.

 

I think I may have Scoliosis, What should I do?

If you think you or a loved one may have scoliosis – it’s important to seek a scoliosis specialist consultation as soon as possible. While a consultation may not be able to explain exactly why you have developed scoliosis, we are typically able to rule out other underlying conditions, leaving you with a clear diagnosis and a path to treatment.

Despite what many people say, today, it’s entirely possible to treat scoliosis without surgery – at the UK Scoliosis clinic, it’s all we do – however, the earlier scoliosis treatment is started, the better outcomes tend to be. Don’t delay, book a consultation today!

 

 

 

 

[1] ‘Adolescent Idiopathic Scoliosis: Screening, Treatment and Referral’
Gutknecht S, Lonstein J & Novacheck T 2009, A Pediatric Perspective, vol. 18, no. 4, pp. 1-6.

[2] ‘Understanding Genetic Factors in Idiopathic Scoliosis, a Complex Disease of Childhood’
Carol A Wise, Xiaochong Gao, Scott Shoemaker, Derek Gordon, and John A Herring, Curr Genomics. 2008 Mar; 9(1): 51–59. doi:  10.2174/138920208783884874

[3] ‘School Scoliosis Screening Programme – A Systematic Review’
Sabirin J, Bakri R, Buang SN, Abdullah AT & Shapie A 2010, Medical Journal of Malaysia, December issue, vol. 65, no. 4, pp. 261-7.

[4] ‘Scoliosis in adults aged forty years and older: prevalence and relationship to age, race, and gender‘
Kebaish KM, Neubauer PR, Voros GD, Khoshnevisan MA, Skolasky R, Spine 2011 Apr 20;36(9):731-6.

‘The prevalence and radiological findings in 1347 elderly patients with scoliosis‘
Hong JY, Suh SW, Modi HN, Hur CY, Song HR, Park JH.,  Journal of bone and joint surgery 2010 Jul;92(7):980-3

 

How to choose a scoliosis brace – questions to ask your practitioner

Posted on February 4, 2020 by - Blog

Regular readers of this blog will know that at the UK Scoliosis clinic, we believe that scoliosis bracing is the best approach to reducing cobb angle in the majority of scoliosis cases, and indeed, it is becoming clear from larger-scale studies that this is the case. [1]

It’s certainly true that some smaller degree curves can be effectively treated with exercise approaches alone, however even these cases treatment with a brace will often be faster, and much easier in terms of effectiveness and compliance with younger patients.

In many instances then, parents of patients or patients may find themselves interested in the idea of bracing, but unsure about which type of brace will be the most appropriate. This week, let’s look at the factors you may want to consider when choosing a brace, and questions you may want to ask your scoliosis bracing practitioner.

 

 

1 – Active, or passive?

Once upon a time, the only kinds of scoliosis brace available were what are now known as “passive” braces – these include models such as the “Boston brace”. Passive braces are not really intended as a treatment for scoliosis, instead as a method to slow its progression. Passive braces work by holding the spine in its current, scoliotic position – this can slow and perhaps stop the progression of the condition but will do nothing to reverse it, and therefore nothing to alleviate the symptoms.

Passive braces are still offered by some clinics and are sometimes provided via the NHS – we would strongly recommend that you avoid passive braces since in the long run they will not improve the condition.

The below image shows a adolescent with idiopathic scoliosis, with a right thoracic curve measuring 49.50 degrees out of brace, and in the second X-ray (with a passive brace on)  shows the curve as almost the same, as the goal of a passive brace is too just hold the current spinal position not straighten the spine.

Active braces, such as our recommended model, the ScoliBrace, are the opposite – over time they are designed to gently guide the spine back into the correct position so that the longer the user wears the brace the greater their spine correction will be.

The below image shows a right thoracic curve similar to that of the first patient – The curve measured 41 degrees – however, this time when the In-brace x-ray was taken,  the curve reduced to 13 degrees.

 

2- Flexibility

Most modern scoliosis braces are designed using a CAD/CAM process and are therefore perfectly fitted for their users – this makes the majority of models low profile, but low profile braces are not necessarily also flexible braces. Braces such as Scolibrace are designed to be minimally restrictive when being worn and even allow the user to participate in sporting activities while wearing the brace. This may be more or less of a factor depending upon your lifestyle, but it worth keeping in mind.

 

3 – Adjustability

A big factor differentiating the cost of modern braces is their durability for use over the course of scoliosis treatment. Some cheaper scoliosis braces are manufactured to fit your body at a specific time and for a specific degree of correction only. Once you have either outgrown the brace, or you have reached the maximum degree of correction which the brace can provide, a new brace will need to be fitted. If your case is not a severe one, a single brace may be enough to correct your scoliosis – but many patients will end up paying for multiple braces, thus driving up longer-term costs when non-adjustable braces are used.

An alternative (albeit an alternative which will be slightly more expensive upfront) is an adjustable brace. Scolibrace falls into this category and allows for periodic adjustment and augmentation of the brace to allow it to follow along with your scoliosis correction. Patients with significant curves may still need more than one scolibrace, but by contrast, 3 or even 4 fixed shape braces would certainly cost more in its place.

In the picture below you can see the effect of a corrective brace pad reducing the curve from 13 degrees down to just 7.5.

 

4 – User-friendliness

An often-overlooked factor for scoliosis braces is the ease with which they can be put on, or taken off. Depending on your treatment protocol you may only need to wear your brace for a certain part of the day, only at night or may be able to take the brace off for physical activity. This is, of course, only possible if the brace is easy for the user to take it off, or put it back on!

Pay special attention to this factor if you live alone, or have children who require a brace, since a brace which is not correctly fitted will not do its job!

 

5- Style

While style probably isn’t the best criteria to judge the success of a brace by, compliance  – that is to say how often patients actually wear the brace – is certainly a major factor. Braces such as Scolibrace are available in a range of colours and patterns so that they can either be produced in a style which matches your own preference, or in colour designed to blend in under clothing, especially school uniform.

 

[1] Yu Zheng, MD PhD et al. Whether orthotic management and exercise are equally effective to the

patients with adolescentidiopathic scoliosis in Mainland China? –A randomized controlled trial study

SPINE: An International Journal for the study of the spine [Publish Ahead of Print]

Wait and see, wait for treatment, wait for surgery…

Posted on January 8, 2020 by - Blog

The UK Scoliosis clinic blog isn’t a political platform, but it’s clear for anyone in the UK to see that in many areas, NHS waiting times are a real problem. What’s perhaps even more of a problem are waiting times to see specialists (and therefore the time to access proactive treatment)  – or indeed, time wasted on a “wait and see” approach to scoliosis progression. The problem is that scoliosis is a progressive condition – if caught early it can often be treated without surgery, but if you wait too long, your options can narrow.

 

Scoliosis, its progressive condition.

In most cases, scoliosis is a progressive condition – to be sure, there are some cases (mainly adult cases) where the risk of progression may be lower, but certainly, in children and young people, the rate of progression can be rapid.

Whereas cases of adult scoliosis (that is to say scoliosis which began in childhood and was carried into adulthood) increase in curvature by approximately 0.82° per year, the rate at which scoliosis increases in young patients depends upon risk factors such as the severity of scoliosis considering age, rigidity of curve, and family history. Research has demonstrated that Juvenile scoliosis greater than 30 degrees increases rapidly and left untreated presents a 100% prognosis for surgery, whereas curves from 21 to 30 degrees are more difficult to predict but can frequently end up requiring surgery, or at least causing significant disability.[1]

With scoliosis, there is, therefore, a very real need to act quickly and proactively if the condition is to be halted and the curvature corrected before either surgery is required, or full correction is no longer possible.

 

Wait to see your GP

For most of us, the GP is the first port of call for all things medical – this is exactly how it’s supposed to be, and while we’re certainly not looking to criticise GP’s, there are a couple of points to keep in mind. Firstly, if you suspect scoliosis, consider the waiting time for a non-urgent appointment at your local doctor’s surgery – scoliosis suspected in younger patients can develop even over a few weeks, so no time should be spared in seeking an evaluation.

Secondly, it’s true that most GP’s do not have specialist training in Scoliosis – and where training is given, the message often reflects out of date attitudes to the condition – specifically, the outdated notion that scoliosis can only be effectively treated with surgery. Because of this, GP’s often lack the specialist training, time and knowledge of the treatments available to do anything other than refer you to a specialist, or, simply ask you to “wait and see”.

 

Wait to see a specialist

With any luck, a visit to your GP will net you an appointment to see a spinal specialist, who, when you finally do get an appointment, will certainly be able to diagnose scoliosis. The problem again is that you may wait many months for such an appointment, during which time scoliosis can continue to progress. Even once scoliosis has been diagnosed, many specialists will still recommend a further “wait and see” approach (which can sometimes last for years) in the hope that the scoliosis may resolve on its own. While this can happen in a very small number of cases, it is incredibly uncommon.

Some specialists are more sympathetic to scoliosis cases, and through training and awareness more and more health professionals are becoming aware of the non-surgical treatments available. You may be offered a brace to help stop scoliosis progressing at this point – but the options available through the NHS are currently limited.

 

Wait for surgery

Some specialists still take the view that scoliosis can only be treated surgically (this is false!) and other times you may be seen by a specialist once scoliosis has developed beyond 45 degrees, which is typically considered the threshold for surgery. Bracing and other non-surgical methods are certainly still possible up to 60 degrees however, and should still be considered.

Recent research by the British scoliosis society[2] has shown that even at this stage, most patients face another long wait for treatment during which scoliosis tends to progress. This 2018 study specifically looked at scoliosis progression whilst waiting for a consultation and eventual surgery. In the study, 41 females and 20 males with a mean age of 11.8 years with a mean Cobb angle (curvature) of 58° were followed –  Average waiting time to be seen in the clinic for an initial consultation was 16 months – thereafter, the average waiting time for surgery was 10 months. Rapid curve progression was seen in twelve patients, of which 10 required more extensive surgery than originally planned. Their mean Cobb angle at presentation was 48° which increased to a mean of 58° at surgery.

 

Scoliosis – DON’T WAIT!

The “wait and see” approach to scoliosis was once prevalent – based on the idea that scoliosis could only be treated with surgery, doctors justifiably took the view that it was better to hope that scoliosis would not progress too much, and would put off the decision to undertake surgery for as long as possible. Today, however, the choice is very different – modern clinics, like the UK Scoliosis clinic, specialise in the non-surgical treatment of scoliosis and can reduce and often totally eliminate scoliotic curves through non-invasive techniques such as active bracing and scoliosis specific exercise.

While we certainly would not discourage you from seeking an opinion from your GP if you have concerns about scoliosis, we strongly recommend that parents of children or teenagers with potential scoliosis also make an appointment with a scoliosis specialist. Rather than waiting months, perhaps years, a scoliosis specialist appointment can usually be arranged with a few weeks, and non-surgical treatment can begin almost immediately.

Perhaps the saddest part about the study from the British scoliosis society was the specific data on the curves of the participants at the beginning of the research. The range of curves studied was between 17°–90°[3], and while a 90-degree curve would certainly be likely to require surgery, a 17-degree curve would almost certainly have not – indeed, a 17 degree curve would be an excellent candidate for the kind of conservative, non surgical treatment we offer at the UK scoliosis clinic.

By the end of the study, the smallest curve was  30°and the largest was 120°. While it is certainly easier to treat a smaller curve,  a 30-degree curve still has a good prognosis with modern conservative treatment through active bracing, such as scolibrace.  This study goes to show that the right information at the right time makes a significant difference in scoliosis cases.  Indeed –  in stark contrast to the above – one recent study of 113 scoliosis patients treated with non-surgical approaches showed that vast majority achieved a significant curve correction and only  4.9% of patients needed surgery.[4]

If you have Scoliosis, or have a child with scoliosis – consider getting a second (or first) opinion from a scoliosis professional, whichever stage of the process you are at!

 

[1] Progression risk of idiopathic juvenile scoliosis during pubertal growth, Charles YP, Daures JP, de Rosa V, Diméglio A. Spine 2006 Aug 1;31(17):1933-42.

[2] H V Dabke, A Jones, S Ahuja, J Howes, P R Davies, SHOULD PATIENTS WAIT FOR SCOLIOSIS SURGERY?  Orthopaedic ProceedingsVol. 88-B, No. SUPP_II

[3] H V Dabke, A Jones, S Ahuja, J Howes, P R Davies, SHOULD PATIENTS WAIT FOR SCOLIOSIS SURGERY?  Orthopaedic ProceedingsVol. 88-B, No. SUPP_II

[4] ‘Brace treatment in juvenile idiopathic scoliosis: a prospective study in accordance with the SRS criteria for bracing studies –SOSORT award 2013 winner‘ Angelo G Aulisa, Vincenzo Guzzanti, Emanuele Marzetti,Marco Giordano, Francesco Falciglia and Lorenzo Aulisa, Scoliosis 2014 9:3 DOI: 10.1186/1748-7161-9-3