Scoliosis Bracing in Older Adults, New Research

If you’ve been following the blog this Scoliosis Awareness month, you’ll know that Adult Scoliosis is generally defined as any scoliosis case that exists either in those over 18, or those having reached skeletal maturity – either definition is valid but most scoliosis specialists would prefer the latter since we are focused more on the condition itself than an arbitrary point of “adulthood.”

There are two main types of adult scoliosis. Pre-existing adult scoliosis is essentially a case of scoliosis which is continuing from an earlier age (usually adolescent scoliosis). In adulthood, a continuing case of scoliosis typically becomes known as Adolescent Scoliosis in Adults or ASA. ASA can be discovered in adults of any age, but many ASA cases are already known from treatment earlier in life.

The second type is Degenerative De-Novo Scoliosis– this is the development of a new scoliosis case, usually as a result of spinal degeneration.

Much recent (and not so recent) research into scoliosis treatment, especially bracing, has focused on younger patients – this is primarily because this group stands to gain the most from bracing – proper treatment of, say a 15 year old with mild to moderate scoliosis stands a good chance of allowing him or her to live the rest of their life free of the condition. Those who have reached adulthood with a scoliotic curve, or develop one through ageing have less of a chance for improvement in the cobb angle (degree of scoliosis) but equally, lower rates of progression in the curve itself. Bracing, however, has been shown to have positive effects for older individuals, primarily around daily function and pain reduction. A recent literature review of relevant studies has confirmed this view.

 

What causes Scoliosis in Adults?

Since there are two kinds of scoliosis in adults, we should take a moment to understand why and how they are different.

ASA is scoliosis carried into adulthood from adolescence, isn’t caused in adulthood – it may or may not worsen depending on a number of factors, but the condition originated at an earlier point in life.

Degenerative scoliosis, by contrast, does occur in adult life and is attributable to wear and tear on the spine, but is also strongly associated with a variety of conditions. Osteoporosis, degenerative disc disease, compression fractures and spinal canal stenosis have all been implicated in the development of degenerative scoliosis.

Since De-Novo scoliosis is a consequence of spinal degeneration with age, it rarely presents before 40 years of age. For many patients, drawing a distinction between the two types may be academic at any rate, since in patients with no known history of scoliosis it may well be impossible to say whether a newly discovered case is a Do-Novo one, or ASA. It is thought that as many as 30% of over 60’s suffer from De-novo scoliosis[1], although a percentage of these cases will be undiscovered scoliosis from earlier in life. In fact, a good number of adult scoliosis cases are discovered through an investigation for another condition (such as back pain).

 

Recent study

The newest study[2] taking a broad view of the literature on scoliosis bracing for older adults was a review of relevant papers published between 1967 and 2018 – the study investigators used standardised criteria to select relevant papers for inclusion in their work.

In total, ten studies (four case reports and six cohort studies) were included which detailed the clinical outcomes of soft (2 studies) or rigid bracing (8 studies), used as a standalone therapy or in combination with physiotherapy/rehabilitation, in 339 adults with various types of scoliosis. Most studies included female participants only. Right away, this shows one of the biggest issues with Scoliosis research, especially in older adults – there is a clear gender bias (probably due to the higher incidence of adolescents in females, about 75% of cases) and overall a lack of research, only 8 studies considering rigid bracing of the kind now most frequently employed isn’t a huge number!

In the studies, brace wear prescriptions ranged from 2 to 23 hours per day, and there was mixed brace wear compliance reported, both are consistent with our actual experience of bracing in older adults. Most of the included studies reported modest or significant reduction in pain and improvement in function at follow-up. There were mixed findings with regards to Cobb angle changes in response to bracing.

 

Study conclusions

After their review, the study authors reported some key conclusions which are well worth noting. Firstly, they showed that there is evidence to suggest that spinal brace/orthosis treatment may have a positive short – medium-term influence on pain and function in adults with either de novo degenerative scoliosis or progressive idiopathic scoliosis. This finding essentially supports the use of bracing in older adults and tallies with our own experience in helping older patients to reduce and manage pain as well as improve function through bracing.

Secondly, and importantly, it was noted that a particular focus on female patients with thoracolumbar and lumbar curves made it difficult to make firm conclusions on the efficacy of bracing for males, and other curve types. It would therefore be highly desirable for further research in this area to focus on a wider variety of case types, in order for us to better understand treatment pathways for older individuals.

 

[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.

[2] Jeb McAviney et al. A systematic literature review of spinal brace/orthosis treatment for adults with scoliosis between 1967 and 2018: clinical outcomes and harms data BMC Musculoskeletal Disorders volume 21, Article number: 87 (2020)

Adult Scoliosis – How to Screen

This month, the UK Scoliosis clinic is raising awareness about Scoliosis in adults, as part of our work for Scoliosis awareness month. Over the last few weeks, we’ve looked at the kinds of scoliosis that impact adults, and older adults in particular. This week, we’ll take a look at how you can recognise the signs and symptoms of Scoliosis, as an adult.

 

Recap : Scoliosis in adults

There are two main types of adult scoliosis. Pre-existing adult scoliosis is essentially a case of scoliosis which is continuing from an earlier age (usually adolescent scoliosis). In adulthood, a continuing case of scoliosis typically becomes known as Adolescent Scoliosis in Adults or ASA. ASA can be discovered in adults of any age, but many ASA cases are already known from treatment earlier in life. While many Scoliosis cases which are carried into adulthood progress very slowly (and may not progress at all for some time if they are small enough at skeletal maturity)[1] cases can begin to worsen again as we age and the spine (particularly the intervertebral discs) start to degenerate. Accordingly, worsening scoliosis in an ASA case is often referred to as Adult Degenerative Scoliosis.

The second type is Degenerative De-Novo Scoliosis (sometimes noted as DDS) – this is the development of a new scoliosis case, usually as a result of spinal degeneration – the cause is essentially the same as degeneration in ASA, however, we usually refer to De-Novo separately, since there is no prior history of Scoliosis. This being said, it may not always be possible to disambiguate a De-Novo case from an ASA case, since the lack of detection of a scoliosis case does not equate to the absence of scoliosis itself!

 

Adult Scoliosis – General signs

Not all signs of Scoliosis, especially in adults, are of the specific kind which tend to be noticed in children and younger teenagers – in fact, many adult scoliosis cases are discovered as a result of an investigation for back pain rather than concerns about Scoliosis.

Adults with scoliosis very often experience more generalised symptoms than younger people, due to the degeneration of the spinal discs and joints also taking place – this commonly leads to the narrowing of the openings for the spinal sac and nerves, a condition called spinal stenosis which can range from uncomfortable to extremely painful.

Many patients with adult scoliosis may adopt unusual postures in an attempt to avoid and reduce this pain – some patients with adult scoliosis may lean forward to try and open up space for their nerves. Others may lean forward because of loss of their natural curve (lordosis, sway back) in their lumbar spine (low back). The imbalance causes the patients to compensate by bending their hips and knees to try and maintain an upright posture.

Accordingly, back pain, and specifically Low back pain and stiffness are common issues for those with adult scoliosis. Numbness, cramping, and shooting pain in the legs due to pinched nerves, as well as fatigue resulting from strain on the muscles of the lower back and legs are all common issues.

Finally, while not a diagnostic indicator, it is worth noting that many older adults may also experience arthritis, which commonly affects joints of the spine and leads to the formation of bone spurs.

 

Adult Scoliosis – Traditional symptoms

The more traditional, physical symptoms associated with scoliosis of course also apply to adult cases, and it’s these which are easiest to screen for.

Degenerative Scoliosis linked to ASA can often occur in the thoracic (upper) and lumbar (lower) spine, with the same basic appearance as that in teenagers, such as shoulder asymmetry, a rib hump, or a prominence of the lower back on the side of the curvature.

De-Novo cases are typically seen more in the lumbar spine (lower back) and are usually accompanied by straightening of the spine from the side view (loss of lumbar lordosis).

 

Home Screening for Scoliosis

While the more general, painful symptoms are best investigated by a spinal professional (whether scoliosis is the cause or not), a basic home screening for the physical signs of scoliosis is easy to do. Simply follow the steps here!

 

 

 

 

[1] Weinstein SL, Ponseti IV: Curve progression in idiopathic scoliosis. J Bone Joint Surg (Am) 1983, 65:447-455.

Scoliosis Screening – For Older Adults!

Scoliosis screening is a topic which we regularly write about on our blog – in our view (and safe to say, in the view of most of the scoliosis treatment community) screening represents a relatively inexpensive way to detect scoliosis as early as possible. In young people, early detection is particularly important – the majority of scoliosis cases progress (at least to come extent) without treatment, whereas early intervention allows for relatively simple, non-surgical approaches to be used in preventing and correcting curve progression. Studies have shown that a large percentage of scoliosis cases are detected between the ages of 11 and 14[1] although the young people outside of this bracket certainly can and do develop scoliosis.

Young people, with their whole life ahead of them, have the highest risk of progression from scoliosis –  however, when the condition is caught early, they also have some of the best prognoses. These two factors together mean that younger patients tend to attract the attention of most medical studies. It’s essential however, that we also recognise the importance of screening in older adults – as many of 1 in 3 of whom will develop the condition in later life.[2]

 

Why screening older people matters

No matter what the age of the individual concerned, spotting scoliosis early is always a benefit, and, put simply, since there are forms of scoliosis – such as “De-Novo” scoliosis –  which begin development later in life, scoliosis is a condition which we need to be vigilant for throughout life.

It’s true that Scoliosis cases (even more significant cases) tend to progress much more slowly throughout adulthood than they do in childhood (something around 1 degree per year is a commonly cited figure[3]) however we also have to keep in mind that one spends much more time as an adult than as a child! Since conditions such as De-Novo Scoliosis are related to the natural ageing process rather than the genetic factors which (as per the latest research available) looks to be the most likely culprit for adolescent scoliosis cases, it’s also possible for someone with no history of scoliosis at all to develop the condition in their 60’s or 70’s.

The good news is that even without public health provision, scoliosis screening is quick, easy and can even be done yourself at home (although it’s easier with someone to help).

It’s for this reason that scoliosis screening is considered a beneficial stage of treatment amongst the Orthopaedic community, as it is reported in the Consensus Paper which has been published by the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT).[4]

 

So why have I never heard about scoliosis screening?

At present, scoliosis screening isn’t widely provided in the UK – The latest review from the NHS concluded that screening for the condition isn’t worth doing – as a scoliosis clinic, you can well imagine that we disagree with this!

There are three main reasons which explain the lack of screening in the UK – unfortunately, they’re all pretty poor excuses!

The first is simply the fact that many health professionals have little or no training on Scoliosis, and the general public has even less. We don’t just mean GP’s here – while many professionals, such as Chiropractors, who specialise in spinal health can recognise a scoliosis case, most have not had the benefit of specialist training on how to treat the condition. As the UK Scoliosis clinic we’re thrilled to take referrals from concerned chiropractors from miles around, but not all healthcare professionals have a clear referral route for scoliosis cases. This is an issue for the healthcare community itself to work on as a major step toward improving outcomes for patients.

This raises a question – why are we so ignorant when it comes to scoliosis, especially in older people?  This is the second major problem – the belief held for much of history, that scoliosis is treatable only with surgery, or (often for older adults) that progression was inevitable and simply something one had to “live with” – therefore, it followed that screening to catch it early was of little value.

Until recently, this has been a valid point – but it’s critical to recognise that today there are far more options for scoliosis sufferers, and we’re now able to help many patients overcome scoliosis without ever thinking about surgery. Much of the evidence suggesting scoliosis can only be treated with surgery dates as far back as the 1940’s[5] so it makes sense for us to re-examine the evidence and technology we now have available.

This is all the more important given the results of more recent research which show that exercise[6] and bracing[7][8] based treatments can reduce pain and curve progression as well as improve quality of life in older people, even when used as a part time treatment.

The third reason is cost – and the cost-based argument against screening also flows from the same line of thought – if surgery is the only treatment option, why invest in screening? To be fair it has been true, even in the recent past, that accessing a scoliosis screening in the UK meant attending a specialist clinic, and inevitably that meant incurring a cost. Given that screening should be done yearly at least, and many older adults are working with a fixed income this clearly makes the proposition less attractive.

Today, however, screening need not be expensive – or actually cost anything at all. There are now several guided screening apps available, which, while not a substitute for a professional opinion, are a great initial screening tool. These include our own ScoliCheck app.

 

 

[1]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.

[2]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

[3] Weinstein SL, Ponseti IV: Curve progression in idiopathic scoliosis. J Bone Joint Surg (Am) 1983, 65:447-455.

Weinstein SL, Zavala DC, Ponseti IV: Idiopathic scoliosis: longterm follow-up and prognosis in untreated patients. J Bone Joint Surg (Am) 1981, 63:702-712.

Ascani E, Bartolozzi P, Logroscino CA, Marchetti PG, Ponte A, Savini R, Travaglini F, Binazzi R, Di Silvestre M: Natural history of untreated idiopathic scoliosis after skeletal maturity. Spine 1986, 11:784-789.

[4] TB Grivas, MH Wade, S Negrini, JP O’Brien, T Maruyama, M Rigo, HR Weiss, T Kotwicki, ES Vasiliadis, LS Neuhaus, T Neuhous, School Screening for Scoliosis. Where are we today? Proposal for a consensus. Scoliosis 2(1)  (2007) 17

[5] AR Shands, JS Barr, PC Colonna, L Noall, End-result study of the treatment of idiopathic scoliosis. Report of the Research Committee of the American Orthopedic Association.  J Bone Joint  Surg 23A  (1941) 963-977.

[6] ‘Scoliosis-Specific exercises can reduce the progression of severe curves in adult idiopathic scoliosis: a long-term cohort study’
Negrini A, Donzelli S, Negrini M, Negrini S, Romano M, and Zaina F 2015,, Scoliosis Jul 11 10:20

[7] 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.

[8]Effects of Bracing in Adult With Scoliosis: A Retrospective Study
Palazzo C, Montigny JP, Barbot F, Bussel B, Vaugier I, Fort D, Courtois I, Marty-Poumarat C, Arch Phys Med Rehabil. 2016 Jun 22. pii: S0003-9993(16)30256-8. doi: 10.1016/j.apmr.2016.05.019

 

Scoliosis Awareness Month – Raising Awareness of Adult Scoliosis

Scoliosis is a condition which affects people of all ages – patients right from birth to old age present at scoliosis clinics around the world, seeking help for many forms of the condition every year. Despite this, there is somewhat of a bias toward thinking of scoliosis as a “young persons” condition – while there are some legitimate reasons for this perception, it’s not an accurate one. As many as one in three over 60’s actually suffer from Scoliosis, struggling with issues such as pain and discomfort which, in many cases, could be treated. This Scoliosis awareness month the UK Scoliosis clinic is focusing on raising awareness about scoliosis in adults – a lesser discussed, but equally important condition.

 

What is adult Scoliosis?

Scoliosis, for those who don’t know – is a condition in which the spine “curves” from side to side. A normal spine can and should have a natural curvature – however, this should be “Front to back”, so that when viewed from the side the spine looks something like an “S”. This natural curvature is not only normal but is actually critical to allowing us to move and remain balanced properly! Scoliotic curves, in which the spine looks like an “S” when viewed from behind are the opposite – they destabilise the spine causing pain, discomfort, aesthetic problems and, in serious cases, can even interfere with breathing. Scoliosis is a condition which tends to progress over time, meaning it usually gets worse without treatment.  Very often, scoliosis is diagnosed in younger teenagers – with girls between the ages of roughly 10 and 15 being the “classic” risk group. This group also attracts the attention of much of the scientific literature, and almost all of the “social” content relating to the condition – but in fact, far more adults, especially older adults, suffer with scoliosis than do younger people.

Adult Scoliosis then, is technically any scoliosis case that exists either in those over 18, or those having reached skeletal maturity, either definition is valid but most scoliosis specialists would prefer the latter since we are focused more on the condition itself than an arbitrary point of “adulthood.”

There are two main types of adult scoliosis. Pre-existing adult scoliosis is essentially a case of scoliosis which is continuing from an earlier age (usually adolescent scoliosis). In adulthood, a continuing case of scoliosis typically becomes known as Adolescent Scoliosis in Adults or ASA. ASA can be discovered in adults of any age, but many ASA cases are already known from treatment earlier in life.

The second type is Degenerative De-Novo Scoliosis (sometimes noted as DDS) – this is the development of a new scoliosis case, usually as a result of spinal degeneration.

 

What causes Scoliosis in Adults?

ASA – that was scoliosis carried into adulthood from adolescence, isn’t caused in adulthood – it may or may not worsen depending on a number of factors, but the condition originated at an earlier point in life. Degenerative scoliosis is somewhat unusual in the scoliosis world since we understand its cause well – it’s due to wear and tear on the spine, but it is also strongly associated with a variety of conditions. Osteoporosis, degenerative disc disease, compression fractures and spinal canal stenosis have all been implicated in the development of degenerative scoliosis.

Since De-Novo scoliosis is a consequence of spinal degeneration with age, it rarely presents before 40 years of age – although, in patients with no known history of scoliosis, differentiation from degenerative idiopathic scoliosis may be difficult. It is thought that as many as 40% of over 60’s suffer from de-novo scoliosis[1], although a percentage of these cases will be undiscovered scoliosis from earlier in life. In fact, a good number of adult scoliosis cases are discovered through an investigation for another condition (such as back pain).

 

What is the prognosis and treatment for Adult Scoliosis?

ASA can be considered both stable (progression is very slow or non-existent) or unstable, progression is continuing. Whether an ASA case will progress quickly, slowly, or not at all may well depend on the size of the curve itself when adulthood is reached. Research has suggested that simply put, large curves tend to get worse – smaller curves may well be stable. Weinstein et al. and Ascani et al. have reported results showing that children with curves < 30° at skeletal maturity did not demonstrate curve progression into adulthood, while the majority of curves > 50° progress at approximately 1° per year.[2] The degree of progression will be the best guide for treating ASA cases – bracing, exercise or even just periodic monitoring could all be the right approach, depending on the case.

De-Novo scoliosis is a condition related to ageing – and since we can’t stop ageing itself, De-Novo Scoliosis always continues – however, the impact upon a person’s life can be greatly minimised with the correct treatment. 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 medication, or through more standard conservative treatment (such as chiropractic or physiotherapy) and they are not suitable for surgery due to osteoporosis i.e. bone weakening.

The good news is that recent advances in non-surgical treatment have shown significant improvement in terms of reduction of pain and symptoms in those with adult scoliosis.  One approach involves the patient learning how to self-correct their abnormal posture, not just strengthen their lower back or core –  indeed, studies show that simple, exercise based approaches can reduce pain in adult scoliosis cases.[3]

The most effective approach would be the use of a customised brace, such as a ScoliBrace which helps to support the posture in a more comfortable position, pain is reduced (even with part-time bracing)[4] and quality of life is improved. Indeed, De-Novo Scoliosis 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.

 

Treatment for adult scoliosis

The main takeaway from this blog, and from our Scoliosis awareness efforts this month, should be that treatment options for adults with scoliosis do exist and, if you’re within travelling distance, they’re available at the UK Scoliosis Clinic!

 

 

 

[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.

[2] Weinstein SL, Ponseti IV: Curve progression in idiopathic scoliosis. J Bone Joint Surg (Am) 1983, 65:447-455.

Weinstein SL, Zavala DC, Ponseti IV: Idiopathic scoliosis: longterm follow-up and prognosis in untreated patients. J Bone Joint Surg (Am) 1981, 63:702-712.

Ascani E, Bartolozzi P, Logroscino CA, Marchetti PG, Ponte A, Savini R, Travaglini F, Binazzi R, Di Silvestre M: Natural history of untreated idiopathic scoliosis after skeletal maturity. Spine 1986, 11:784-789.

[3] ‘Scoliosis-Specific exercises can reduce the progression of severe curves in adult idiopathic scoliosis: a long-term cohort study’
Negrini A, Donzelli S, Negrini M, Negrini S, Romano M, and Zaina F 2015,, Scoliosis Jul 11 10:20

[4] 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

Effects of Bracing in Adult With Scoliosis: A Retrospective Study
Palazzo C, Montigny JP, Barbot F, Bussel B, Vaugier I, Fort D, Courtois I, Marty-Poumarat C, Arch Phys Med Rehabil. 2016 Jun 22. pii: S0003-9993(16)30256-8. doi: 10.1016/j.apmr.2016.05.019

 

June is Scoliosis Awareness month

The UK Scoliosis Clinic recognizes June as Scoliosis Awareness Month – as usual, it’s an important opportunity for us to reflect on the importance of ongoing developments in scoliosis treatment as well as to advocate for further research. Critically, scoliosis awareness month is an opportunity to raise awareness of scoliosis, and, the words of the scoliosis research society “Speak Up For Scoliosis”

 

What is Scoliosis?

Scoliosis is a condition that causes the spine to abnormally curve sideways. Although many people have not heard of the condition it is surprisingly common, impacting infants, adolescents and adults of all races, classes, and all genders. Despite this, adolescents (of which a majority are female) and those over 60 are the most commonly diagnosed and should be especially vigilant.

According to the Scoliosis Research Society, Approximately one out of every six children diagnosed with scoliosis will have a curve that requires active treatment, sometimes involving surgery. Early diagnosis is the key to taking important first steps to providing treatment that may prevent more serious problems. Today there are more non-surgical treatment options (such as bracing or exercise based therapy) than ever, but to have the best chance of success early detection is key.

 

What is Scoliosis awareness month?

Every June, National Scoliosis Awareness Month highlights the growing need for education, early detection and awareness about scoliosis and its prevalence.  The campaign also unites scoliosis patients, families, physicians, clinicians, institutions, and related businesses in collaborative grassroots networking throughout the month.

Around the world, Scoliosis screening as a public service is not uniformly provided – in the UK, there’s no provision at all and in the US, on about two-thirds of states mandate or recommend scoliosis screening in schools – this means it is important that friends and family members learn to recognize the signs and symptoms of the condition and know that help is available. It is often parents or primary care providers who first identify the issue. Fortunately, an examination and X-ray can confirm the diagnosis and an expert can recommend treatment, if necessary.

 

About the UK Scoliosis Clinic

The UK Scoliosis Clinic is one of the UK’s most well established specialist scoliosis clinics, we focus on non-surgical treatment of scoliosis in Children and Adults primarily through bracing with the unique ScoliBrace system supported by complementary approaches. To learn more about scoliosis, or how to screen for the condition please see our website at https://scoliosisclinic.co.uk

 

Gamifying scoliosis treatment – could it work?

One of the most important factors in delivering successful scoliosis treatment is ensuring that patient compliance is high enough to derive a positive outcome. Put simply, treatment only works if you actually do it!

In terms of bracing, it’s easy to measure compliance – a brace is either worn, or it is not. If the brace is being worn, the treatment is being applied, if it is not, the brace does no good. Actually measuring bracing compliance has been a methodological issue in many bracing-based studies, since patients often do not accurately report the length of time for which they really wore the brace. More recent studies have relied on temperature based sensors to objectively measure when a brace is, or is not, being worn, which has been successful from the point of view of study investigators and is generally viewed favourably by patients.[1]

When it comes to scoliosis specific exercises, however, the picture is more complicated – patients must perform their exercises daily in order to have any chance of success, however, they must also perform them correctly. Therefore, simply taking the time to do a scoliosis specific exercise regime does not guarantee results – you must also ensure that you do it right from start to finish.  The need to perform exercise regularly and correctly is a limitation which needs to be considered especially when working with younger children – it’s no slight on any young person to question whether they will have the strength and indeed memory, to be able to perform exercises with precision every single day. What’s more, studies have actually shown that young children perform better when higher volumes of feedback are given  – by contrast, in adults, less feedback leads to higher precision[2] , therefore, home-based exercise approaches may lend themselves more naturally to adults, although it is often children with smaller curves who stand the benefit the most from them.

 

Gamifying Treatment

One novel, but interesting approach to this problem has been to develop video games and interactive apps which can guide young children in performing these kinds of exercises – these have the dual benefit of providing the additional feedback children seem to desire, and also adding some fun to what can be an otherwise boring routine.  One recent study looked at the effectiveness of a so called “Physiogame”, developed by the IT department of the FH JOANNEUM, University of Applied Sciences, Graz, Austria.[3]   The concept is simple, but effective – using the game with an interactive controller the player is instructed so that they remain within a desired splaying space and adopt correctly the 3D positions of the trunk and extremities which are individually adjusted to the corrective posture desired – the game only continues when the posture is correct. This provides both motivation and constant feedback which suits the need of younger participants.

A recently study[4] examing the impact of using such a game showed some real promise for this approach – While the study was small scale (8 patients) and the actual use time of the game in question varied, significant improvements in the accuracy of exercise performed were observed.

In the first month, the participants managed to stay in the predefined 3D space 73% of the gross playing time, and by the last month of the observation period, this increased to 83%. The children improved their performance of the exercise on average by 15%.  The improvement in staying in the corrective posture autonomously and being able to focus more on the game was reflected in the average increase of positive hits per second in-game: they increased from 0.33 in the first month to 0.56 in the last month, for an average increase of 66%.[5]

As part of the program, participants were also asked to evaluate their own performance – interestingly, the study showed that the self-assessment of general performance (“today I did well”) stayed almost the same over the study period, with an average of 2.7 (good) in the first month and 2.3 (very good) in the last month. Similarly, self-assessed stabilization of the vertebral column changed only slightly from 2.6 (good) in the first month to 2.3 (very good) in the last month[6] – hence, the patients improved in their accuracy of exercise without actually being aware of it.

 

Further research

The study authors conclude that further research into the use of these kinds of “gamified” treatments may well pay dividends, especially for younger patients. In the post-covid world, where pandemic resilience and an increased desire to perform more tasks from home are a key features, this kind of interactive “take-home therapist” may well play a key role in treatment in the future.

 

 

 

[1] Sabrina Donzelli et al. Adolescents with idiopathic scoliosis and their parents have a positive attitude towards the Thermobrace monitor: results from a survey Scoliosis and Spinal Disorders volume 12, Article number: 12 (2017)

[2] Sullivan KJ, Kantak SS, Burtner PA. Motor learning in children: feedback effects on skill acquisition. Phys Ther. 2008;88(6):720–32.

[3] Lohse K, Shirzad N, Verster A, Hodges N, Van der Loos HF. Video games and rehabilitation: using design principles to enhance engagement in physical therapy. J Neurol Phys Ther. 2013;37(4):166–75.

[4] Christine Wibmer et al. Video-game-assisted physiotherapeutic scoliosis-specific exercises for idiopathic scoliosis: case series and introduction of a new tool to increase motivation and precision of exercise performance Scoliosis and Spinal Disorders volume 11, Article number: 44 (2016)

[5] Christine Wibmer et al. Video-game-assisted physiotherapeutic scoliosis-specific exercises for idiopathic scoliosis: case series and introduction of a new tool to increase motivation and precision of exercise performance Scoliosis and Spinal Disorders volume 11, Article number: 44 (2016)

[6] Christine Wibmer et al. Video-game-assisted physiotherapeutic scoliosis-specific exercises for idiopathic scoliosis: case series and introduction of a new tool to increase motivation and precision of exercise performance Scoliosis and Spinal Disorders volume 11, Article number: 44 (2016)

I think my Child has Scoliosis – 3 things NOT to do

As parents, we all want to do the best for our children – and when you suspect Scoliosis it can be hard to know what to do. Despite efforts from the Scoliosis community the condition is still widely unknown in the general population which can lead to confusion and that feeling of not knowing where to turn. The most important step to take if you do suspect scoliosis is simply to get active – reach out for help and get the ball rolling.

There are however, a few things you should definitely not do – these three issues are, in our experience the biggest pitfalls for parents of children with scoliosis, so wherever possible do not:

 

1 – Be passive

Because Scoliosis is a lesser known condition, you may well not know anyone who has suffered with the condition. The reality is that Scoliosis should be treated as quickly as possible, as treatment is much easier with a smaller curve, however the lack of awareness in the community can lead to a false sense of lack of urgency. Even amongst those who do know about Scoliosis, many are still unaware that new, non-surgical treatment options now exist. 10- 15 years ago, it was thought that surgery was the only effective option for treating scoliosis, so even many medical professionals were simply taught that the best approach to scoliosis is to “wait and see” if the curve becomes bad enough for treatment. The problem is that scoliosis almost never resolves on its own[1] so while it’s possible it may not progress further “wait and see” is never a good option – at the very least see a scoliosis specialist and ensure the condition is being monitored.

 

2 – Ignore the costs

Unfortunately, very little non-surgical Scoliosis treatment is available in the UK through the NHS. This means that if you’re looking for non-surgical treatment, you’ll probably be taking about private care. Please do see your GP to find out what is available in your area, but you should expect that Scoliosis treatment will cost you money.

It’s easy to react to these costs by either ignoring them (which isn’t responsible) or failing to contextualise them properly (which isn’t realistic). There are two major factors to consider here. Firstly, if you are seeking help for a scoliosis case which is already severe, the chances for successful treatment without surgery are lower – the larger the existing curve, the higher the chance non-surgical approaches will fail. A reputable scoliosis practitioner will give you the best indication they can as to the possible outcomes of treatment and what you might expect in a best or worst case scenario – you should base your decision on the cost of treatment on your own expectations for outcomes, and how likely they are. In some cases, you may be paying simply to delay surgery which will be required anyway and this is important to remember.

At the other end of the scale, it’s critical to remember that Scoliosis treatment is a long process – the totality of your scoliosis treatment will extend from discovery of the condition through until your child has reached adulthood – it’s therefore essential to remember that the costs for treatment are spread over a very long period of time. The price of a Scoliosis brace, for example, is therefore best considered as a monthly one over duration of the brace, rather than a single one off cost.

 

3 – Forget about mental health

Scoliosis can be stressful for everyone involved – and since it’s a condition which commonly affects teens and young adults, it comes at a time of life which is already delicate for many. There are two main approaches to scoliosis treatment plans to choose from – one is group based treatment, and one is individual treatment. Group based settings offer no privacy, but can potentially foster a ready made support group, whereas private one to one settings offer privacy without peer support.

The right kind of environment for you will of course depend on your own child’s preferences – so try to keep this in mind when choosing a clinic. At the UK Scoliosis clinic, we provide a private one to one environment, although we welcome as many relatives or friends that your child would like to have around them to attend consultations, exercise sessions and treatment reviews. Research has shown that having a calming and private environment to discuss and perform treatment can actually lead to better clinical outcomes, although this won’t be ideal for every child. [2]

 

Getting help

If you’re concerned about Scoliosis, please don’t hesitate to get in touch with us – we offer Scoliosis consultations online as well as at the clinic with no obligation to take up treatment, whatever you do – be active!

 

 

[1] Angelo G Aulisa et al. ‘Brace treatment in juvenile idiopathic scoliosis: a prospective study in accordance with the SRS criteria for bracing studies – SOSORT award 2013 winner, Scoliosis 2014 9:3

[2] Elisabetta D’Agata et al. Introversion, the prevalent trait of adolescents with idiopathic scoliosis: an observational study Scoliosis and Spinal Disorders (2017) 12:27

What is the most common treatment for Scoliosis?

If you look around online, you’ll quickly see that lots of people are looking for advice on what the most common treatment for scoliosis is – in fact, “what is the most common treatment for scoliosis” is one of the most popular asked questions on google search!

 

 

The problem with “common” treatment as a concept…

We understand why this is – but for us, this question speaks to a real problem with most people’s understanding of Scoliosis! It’s essential to understand that Scoliosis is a highly individualised condition – yes, it has common hallmarks whenever it is present, but almost every aspect of the condition will, in fact, vary between patients. Because of this, treating scoliosis successfully requires a treatment approach which is personalised, rather than common or generic.

Usually, it’s not even enough to describe a broad treatment pathway when treating a Scoliosis case – simply saying that an exercise-based approach is used, for example, does not mean much – since a scoliosis specific exercise routine will be (or should be!) designed from the ground up to counteract the specific scoliosis which the patient is experiencing.

Furthermore, it’s rare that only one approach will be used in treating scoliosis. Surgery is a possible exception to this, but even in this case, most surgeons do recommend some form of physiotherapy post-surgery to speed recovery and promote health after the operation. It’s therefore much more helpful to think about the possible components of scoliosis treatment and to speak to a scoliosis professional about your specific case and how a treatment plan can be put together.

 

Components of scoliosis treatment plans

With that said, let’s look at a high level, at some of the most common options for treating scoliosis.

 

Wait and see

Wait and see used to be a common refrain amongst GP’s encountering scoliosis cases – for many years, surgery was thought to be the only option for correcting scoliosis (it’s now been shown that this is not the case), therefore the only real option was to watch a scoliosis case and see if it got bad enough to require surgery. It goes without saying that this is not a treatment, and today there is almost no circumstance where “wait and see” is truly a good approach.

 

Surgery

Spinal fusion surgery is the most common surgical treatment for severe scoliosis in adolescents. Using metal rods, hooks, screws, and wires (known as instrumentation), the procedure straightens the spine and solidifies the bone to prevent further abnormal curving. Such a procedure will stop scoliosis from progressing and can typically straighten the spine to a considerable degree. The main downside is the risk of complications from surgery as well as the longer-term issues associated with living with a fused spine. For those with large scoliotic curves, however, these issues are often far preferable to living with severe scoliosis.

 

Bracing

Scoliosis bracing has come a long way over the last 10-20 years. Once thought of as a way to potentially slow scoliosis progression, modern “over corrective” scoliosis braces can be effective in reducing and even totally eliminating scoliosis cases given the right conditions. For bracing to be effective, the patient typically needs to be young enough for their spine to remain flexible and have not yet reached spinal maturity. Luckily, this window aligns perfectly with the 10-15 age range where the majority of scoliosis cases are first spotted. Modern scoliosis braces are relatively comfortable to wear, low profile and effective when used as prescribed. Today, bracing is the best option for those with scoliosis cases over roughly 30 degrees and under 60 degrees. Larger curves may still be treated with bracing, but the degree of correction possible is likely to be less.

 

Exercise-based approaches

Also commonly used today, exercised based approaches utilise specialist disciplines within physiotherapy to allow a patient to actively oppose scoliosis with their own body – exercise-based approaches require commitment to show results, but can be effective in reducing smaller scoliotic curves when applied diligently. Exercise is very often used alongside bracing, as it has an especially noticeable effect on muscular strength and tends to oppose some of the muscular weakening which can occur with bracing.

 

Complementary approaches

There are many other complementary approaches which have been shown to have supportive benefits for scoliosis sufferers – these include disciplines such as massage, yoga or Pilates. None of these approaches have been shown to actively correct scoliosis, but they may play a valuable role in helping to reduce pain or discomfort associated with the condition.

 

Experimental methods  – more research required

Scoliosis treatment is an area where a great deal of research has been taking place recently, and there are a number of other approaches being investigated with a view to determining their effectiveness as scoliosis treatments. Some approaches, such as vibration-based therapy show promise in augmenting existing methodologies – at least one study has suggested that combining a vibration plate with scoliosis specific exercise may improve results.

Other areas not currently seen as effective treatments for scoliosis, such as chiropractic, are being actively investigated by organisations such as CLEAR. Indeed, some of these experiments have published promising results. Programmes such as CLEAR have not yet met the bar in terms of demonstrating efficacy for scoliosis treatment, but may do so in the future. At the UK Scoliosis Clinic, we stay on top of many developing methodologies and will be open to incorporating new ones if and when the literature supports this step.

 

Which scoliosis treatment is right for me?

This article is intended as a quick overview of some of the approaches which can go to make up the unique course of scoliosis treatment that all patients deserve. The critical thing is to find a clinic that has the breadth and depth of experience to provide the treatment which best fits you. At the UK Scoliosis clinic, we provide all of the non-surgical options listed above (except the experimental ones) and work closely with expert and highly respected spinal surgeons to refer those cases which would not benefit from non-surgical intervention.

For more information about any of these approaches, please browse our website and articles, or feel free to get in touch.

 

 

 

 

Bracing vs Exercise – Which Scoliosis Treatment is Cheapest?

When it comes to treating scoliosis, you shouldn’t just be trying to find the cheapest option – it’s critical to consider the likely outcome of treatment over the long term, and to remember that in many cases the cost of treatment will be spread out over many years. Quality treatment is always going to be more expensive, and the sad fact is that “cheap” treatment may not have any positive impact at all. This being said, it’s also only right that you do consider cost as part of your treatment selection process. Let’s look at some of the considerations to keep in mind when choosing between exercise-based, or bracing based treatment.

 

Bracing

Scoliosis bracing is the most effective way to treat Scoliosis, in terms of Cobb angle, without undergoing surgery. Bracing has the best chance of any treatment to not only stop the development of scoliosis but also to reverse the condition. Bracing is typically recommended for curves between about 30 and 60 degrees, but certainly can be used to treat smaller curves.

Scoliosis braces (at least ones worthy of the name) are custom made for the wearer and are expensive – the average brace will cost anywhere between 3000 and 4000 Uk Pounds. Some braces, such as the ScoliBrace we offer at the UK Scoliosis Clinic are adjustable within a certain degree, meaning you can get more life out of the brace.

While bracing does come with a high upfront cost it should be kept in mind that a brace will, in the vast majority of cases, last for many years. In adolescents with larger curves, more than one brace may be needed, since eventually, the scoliosis could improve to a point where a new brace would need to be fitted in order to keep up the reduction, but in many cases an adjustable brace such as ScoliBrace can cover an entire course of treatment. In younger children requiring bracing either to correct scoliosis or prevent a relapse multiple braces will be needed, but this will still be spread out over 10-15 years. On the other hand, when buying a brace as an adult, you can (assuming you do not go through significant weight loss or gain) essentially consider it as a lifetime investment.

Bracing also has the benefit of incurring next to no ongoing costs – it’s advisable to have check-up appointments at scheduled intervals, but other than this the treatment is paid for.

In real terms then, the cost of bracing in those not having reached skeletal maturity should be considered as between £1000 and £2000 per year. For those buying a brace as an adult, the cost would be considerably less when annualised.

Exercise-based approaches

Scoliosis specific exercise approaches are often offered alongside bracing as additional support but are mostly used to treat smaller scoliotic curves, at or below 20 degrees. There are essentially two ways to approach this – either through a “Bootcamp” style intensive course, which seeks to teach the patient how to establish and maintain an exercise program or through regularly scheduled appointments over the period of treatment.

Bootcamp style classes can be an attractive prospect – lasting only a few weeks to a month, however, they do not address the need for scoliosis specific exercises to be constantly evaluated and adjusted to keep the correction going. For those looking simply to prevent a small scoliotic curve getting worse, a Bootcamp may work well – but for longer-term treatment, regular appointments with a therapist are usually preferable.

A critical factor to consider with exercise-based approaches is the ability of the patient to perform the exercises correctly – either SEAS or Schroth exercises are not easy, and require physical strength, this means this many younger children may struggle to perform the techniques correctly, even if their compliance with the schedule is 100%.

Scoliosis specific exercise boot camps can cost anywhere from £2000-£5000, depending on the location and whether accommodation is included. Individual sessions range from £50 to £100 per session, based on 1 session per month this comes out to roughly £600 – £1200 per year, plus ongoing travel costs.

As you can see, in real terms, the annualised cost of bracing compares favourably with a Bootcamp style approach and bracing is likely to be only slightly more expensive than a session-based approach to treatment. Taking a Bootcamp type introduction to scoliosis specific exercise, and then following up with periodic appointments with a specialist to review will probably cost more than bracing.

 

Which should I choose?

Although the figures above represent rough guides  (the cost of any treatment will always be individualised and could be more or less than this) it’s hopefully clear to see that there is not likely to be a huge difference in cost when considered over a period of years.

The main factor to consider should, therefore, be the most appropriate treatment for your case. Certain situations are easy to determine – very large curves in young people require bracing in order to have a chance of avoiding surgery, Small curves in adults with a stable spine, without any pain can be easily managed with an exercise approach and curves of say, 45 degrees in young people require bracing for the fastest possible reduction before skeletal maturity is reached and the spine is too ridged to correct.

Often, convenience is more of consideration – for example, the parents of a young teen with a small curve may consider wearing a brace part-time a better investment than paying for ongoing exercise therapy, given that it’s much more effort to comply with an exercise prescription and almost no effort at all to put on a brace. Similarly, an older person might prefer to treat a smaller scoliotic curve which is not too bothersome with the session-based exercise approach, since raising a large amount of cash up-front for the purchase of a brace may not be justifiable.

Unfortunately, there is no easy answer as to which treatment ends up being the cheapest since treatment for scoliosis is always as individual as the patient, but in many cases, you will find that the real terms cost between the two isn’t that great.

 

 

Kyphosis Vs Hyperkyphosis

While Scoliosis is the main focus of our clinic, we also treat associated spinal conditions such as Hyperkyphosis – it’s a lesser-known condition, not least because Hyperkyphosis is often a progression of “regular” kyphosis, a common condition that can often be managed through approaches targeting postural adjustments, such as chiropractic or physiotherapy.

 

What is HyperKyphosis

Scoliosis is a condition of the spine that, ideally should not exist (or should be very small in a healthy individual)  whereas Kyphosis, in and of itself isn’t a problem as a kyphosis is essential for a healthy spine!

The spine is made up of three main sections: cervical, thoracic, and lumbar. When viewed from the front or back, the spine should appear straight (however in scoliosis it appears curved), and when viewed from the side, it has a slight ‘S’ shape.

This S shape is actually a critical characteristic of the spine which allows it to perform its job. The natural curves of the cervical spine (neck) and lumbar spine (lower back) bend outwards and are referred to as ‘lordosis’. The thoracic spine (middle and upper back) features a curve that bends inwards, and this type of curve is referred to as ‘kyphosis’ – so, kyphosis is in fact, a totally normal condition for the spine to exhibit.

So, if kyphosis is a normal inwards bending of the spine, Hyperkyphosis is said to exist when the kyphotic curve becomes excessive, leading to a rounded appearance of the upper back, a “hunched” posture and often, back pain. We are all individuals with a slightly different spinal and physical makeup, it’s therefore hard to say what an “ideal” kyphotic curve is – for most people a healthy figure is between 20 and 45 degrees, but when a curve falls beyond that healthy range, problems can occur.

When a kyphotic curve exceeds approximately 50 degrees, this is referred to as ‘Hyperkyphosis’ – in many circles, the word “kyphosis” is also often used to mean “Hyperkyphosis” which is unhelpful!

 

 

Types of Hyperkyphosis

There are three main types of Hyperkyphosis – broken down by cause, these are postural, congenital and Scheuermann’s

Postural kyphosis is the most common type and is associated with the “hunched” posture we often expect in adolescents. While it’s not true that the use of electronic devices actually causes Hyperkyphosis, the terrible posture this tends to promote most certainly can. Postural kyphosis is the simplest diagnosis to treat, since the condition is caused by poor posture and weakened muscles resulting from it – any treatment approach which aims to address this problematic posture will generally resolve postural Hyperkyphosis.

Congenital Kyphosis is more complex – whereas, in postural kyphosis an individual is born with a normal spine that develops an issue through misuse, a person with congenital kyphosis is born with the condition. There are a number of malformations in the spine which fall under the category of congenital Kyphosis – these include vertebrae not forming properly, or multiple vertebrae fusing together into one solid bone, rather than forming separate and distinct vertebrae.

Some congenital Kyphosis cases may benefit from bracing, but the best treatment will vary considerably depending on the individual.

Finally, Scheuermann’s Kyphosis is a structural condition which affects the way that vertebra develop. In a person with a “normal” spine, vertebrae are rectangular in shape – thus, they sit on top of each other in a fairly level alignment. In patients with Scheuermann’s kyphosis, a number of consecutive vertebrae are more triangular in shape, meaning that they naturally want to curve irrespective of the health of surrounding supporting muscle.

Abnormal spinal curvatures caused by this type of kyphosis are often angular, stiff, sharp, and rigid, which is why this form is more complex to treat and can’t simply be corrected with a change of position. Scheuermann’s is more common in boys and is progressive during growth, which is why proactive treatment is so important.

 

 

Kyphosis, which treatment is right for me?

The vast majority of Hyperkyphosis cases tend to be postural in nature, so, while expertise is required to provide a suitable treatment there are many approaches that can help. Chiropractic and physiotherapy are two approaches we utilise at the UK Scoliosis Clinic, but any approach which alters the problematic posture will, over time tend to resolve this condition. It’s also true that many kyphosis cases which are visible, or cause pain do not reach the threshold for Hyperkyphosis – you should, however, look to treat the condition as early as possible, since it will tend to progress without intervention -, even if that only means getting some professional advice on improving your workspace to promote good posture.

Congenital cases and Scheuermann’s kyphosis can often benefit from more specialist treatment through a spinal clinic, like the UK Scoliosis clinic. Spinal bracing, similar to that used for Scoliosis can be appropriate in some circumstances – in others, the best approach may still be a manual therapy coupled with postural work although for more complex cases it’s often worth coordinating this through a specialist centre.