Tag: adult scoliosis

Scoliosis Bracing in Older Adults, New Research

Posted on June 24, 2022 by - Blog

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

Posted on June 18, 2022 by - Blog

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 awareness month – Adult Scoliosis

Posted on June 25, 2021 by - Blog

Adult Scoliosis 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, being in many ways a consequence of time itself, always continues – however, the impact upon a persons life can be greatly minimised with the correct treatment. While postural deformity can be a major issue, one of the most commonly reported complaints arising from de-Novo scoliosis is pain – what’s more, a small increase in scoliosis could cause a large increase in pain,  the deformity shifts the spine and pressure is applied to nerves.

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. 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)[3] and quality of life is improved.

When non-surgical treatment is ineffective, surgery is often the only option, especially when leg pain becomes incapacitating and walking is almost impossible. Unfortunately, surgery at this stage is always complex and with significant risk. This is why it is important to find not only a good spinal surgeon but also one who specialises in scoliosis for the best possible outcome.

 

What does Adult Scoliosis look Like?

The below X-ray shows an example adult Scoliosis case. It’s usually not possible to tell how severe scoliosis is without taking an X-ray, although external signs can suggest that the condition may be present. This is why regular screening is so important!

 

 

 

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

Scoliosis specific exercise can reduce curve progression in adult scoliosis patients

Posted on July 13, 2018 by - Blog

While many of the patients we see at our clinic are children with juvenile or adolescent scoliosis, adult scoliosis cases also represent a significant percentage of those we help. There are many approaches which can be used in tackling adult scoliosis, but one of the most commonly chosen is scoliosis specific exercise. It was once thought that surgery was the only effective treatment for adult scoliosis, but today research is confirming that high quality, individualised treatment programs can be effective in stopping the progression of scoliosis in adults.

 

Adult scoliosis – an important field of research

While scoliosis clinicians often tend to focus on scoliosis in adolescents, it has long been known that idiopathic scoliosis can (and often does) continue to progress during adulthood after skeletal maturity[1], when growth has stopped.

While the development of scoliosis in adults is slower, over time the curve does worsen which can lead to a reduction in functional capacity and the development or the worsening of spinal pain and associated radicular symptoms[2](pain which radiates from the root of a nerve at the spinal column into the arms or legs), as well as spinal degenerative changes. This means that research into the best ways to tackle adult scoliosis is equally important as in adolescent scoliosis.

In fact, more than 60 % of cases of adult scoliosis progress, particularly in the case of curves exceeding 30 ° Cobb at skeletal maturity, regardless of the curve pattern[3]. Unlike adolescent scoliosis however, Marty-Poumarat[4] has shown that the rate of progression in adult scoliosis is linear (regular and constant) and can therefore be used to establish an individual prognosis. This rate of progression, if left untreated is deemed to be around 0.5-1 °per year[5].

While the prevailing view for some time has been that adult idiopathic scoliosis was only suitable for treatment with surgery when the curve becomes significant enough – more recent research clearly suggests that non-surgical approaches can be effective in reducing curve magnitude and halting progression, potentially eliminating the need for surgery in many cases.

In a short-term case series Weiss et al. showed 43.93 % of 107 patients improved 5 or more Cobb degrees immediately after 4 – 6 weeks of in-patient scoliosis specific exercise program[6], while Morningstar et al. showed that 19 patients treated with spinal manipulation and various physiotherapeutic procedures reported immediately after the therapy an average correction of 17 ° Cobb [7][8]. In an earlier case report, Negrini et al. showed a 18.5 Cobb degrees reduction after one year of Scoliosis Specific SEAS exercises[9].

 

Treating adult scoliosis with scoliosis specific exercise – new research

Now, a larger study by Negrini et al. has now gone further in establishing the effectiveness of SEAS exercises in reducing the progression of scoliotic curves. SEAS exercises (one of the types we utilise in our own clinic) are scoliosis-specific exercises. In adult patients they are aimed to recover postural collapse, postural control and vertebral stability through the process known as active self-correction. Typically, therapy includes at least two weekly exercise sessions each lasting 45 min – but exercise prescription varies significantly in both length and frequency, since to be effective an exercise program must be individually tailored.

The study considered adults (18 years or more) who exhibited curves larger than 30° and documented curve progression during adulthood (at least 6° Cobb) or adults with curves larger than 40° who had refused surgical treatment. Patients were prescribed Scoliosis Specific SEAS Exercises exclusively and were required to practice their exercises regularly for at least ten months per year. Patients were assessed a minimum of 1 year after their first assessment, via x-rays which were independently verified.

 

Results

The results from the study were highly encouraging – it confirmed that that Scoliosis Specific Exercises can be effective to obtain stability and, in some cases, to reduce the Cobb angles by degrees. In highly progressive curves, exercises appear to slow down the progression of the curvature (worsening).  Of the 34 patients included in the study, an average reduction of 4.1 degrees cobb was achieved after one year. [10]

More broadly, the study also went to confirm the fact that scoliosis specific exercise programs need to be maintained and monitored, and that the patient must continue to adhere to the exercise program in the long term in order to see sustained improvement.[11]

While the authors of the study were pleased with the outcome, it’s fair to say that more research on scoliosis specific exercise is required and will continue to be published over the coming months and years. Future larger, long term, observational studies will provide us with more insight on defining the best Scoliosis Specific Exercises management approach and explore other very important issues associated with adult progressive spinal deformities, such as, sagittal global balance, back pain, disability and quality of life.

 

Treatment for adult scoliosis at the UK Scoliosis Clinic

At the UK Scoliosis clinic, we utilise a variety of approaches as part of our scoliosis specific exercise program. This allows us to tailor our approach to our patient’s specific needs – this might include exercise programs based on the SEAS or Schroth methodologies as well as bracing if required. It’s because our scoliosis specialists have such a wide variety of tools at their disposal that we’re able to achieve targeted, measured and provable results for our patients.

 

 

[1] Collis DK, Ponseti IV. Long-term follow-up of patients with idiopathic scoliosis not treated surgically. J Bone Joint Surg Am. 1969;51(3):425 – 45

[2] Guigui P, Rillardon L. Adult spinal deformities. Rev Prat. 2006;56(7):701– 8

[3] Weinstein SL, Dolan LA, Spratt KF, Peterson KK, Spoonamore MJ, Ponseti IV. Health and function of patients with untreated idiopathic scoliosis: a 50-year natural history study. JAMA, J Am Med Assoc. 2003;289(5):559 – 67, Weinstein SL. Natural history. Spine. 1999;24(24):2592–600

[4] Marty-Poumarat C, Scattin L, Marpeau M, Garreau De Loubresse C, Aegerter P. Natural history of progressive adult scoliosis. Spine. 2007;32(11):1227 – 34, discussion 1235.

[5] Ibid.

[6]Weiss HR. Influence of an in-patient exercise program on scoliotic curve. Ital J Orthop Traumatol. 1992;18(3):395 – 406

[7] Morningstar MW, Woggon D, Lawrence G. Scoliosis treatment using a combination of manipulative and rehabilitative therapy: a retrospective case series. BMC Musculoskelet Disord. 2004;5:32.

[8] We wish to note that in this instance, the term ‘immediately’ should be taken literally – more research is needed to establish the long term prognosis offered by CLEAR  and associated approaches.

[9] Negrini A, Parzini S, Negrini MG, Romano M, Atanasio S, Zaina F, et al. Adult scoliosis can be reduced through specific SEAS exercises: a case report. Scoliosis. 2008;3:20

[10] Negarini et al. Scoliosis-Specific exercises can reduce the progression of severe curves in adult idiopathic scoliosis: a long-term cohort study. Scoliosis (2015) 10:20

[11] Ibid.