“During a recent school screening, it was determined that your son/daughter may have a condition called scoliosis, or curvature of the spine. Please consult your physician for further information and available treatment options.”

For most parents, this news can be both alarming and confusing, especially when a child appears to be both healthy and active at the time of diagnosis. Clearly, routine spinal screenings have done much to increase the population’s awareness of scoliosis in general, but serious questions rarely arise until a parent discovers that his or her child may have the disorder.

What’s the best way to treat scoliosis?

This is the first and most obvious question parents ask following an initial diagnosis. The answer is determined by such factors as age, gender, and degree of curve and usually involves the following three options: (1) watch and wait, (2) fit the child for a rigid brace, or (3) schedule spinal surgery. Regardless of the preferred option, however, parents usually experience some feelings of guilt and fear related to their treatment of choice. For example, those who choose to watch and wait often wonder, “What if we do nothing, and then the problem gets worse?” Others, however, who opt to have a child fitted for a rigid fitted brace still worry because correction always depends on compliance: “Will my child feel too embarrassed to wear the device?” “Will it restrict my child’s motion to the point of altering personality?” “What will happen to my child’s back if he or she decides to stop wearing it?” These are serious questions, to be sure. But the final option, invasive surgery, causes parents the greatest anxiety, and rightfully so, with questions such as: “How dangerous is this surgery?” “What’s involved in my child’s post-surgical recuperation?” and “Can our family afford this investment of both time and money at this point in our lives?” Unfortunately, there are no easy answers to these questions. And regardless of professional advice, parents still worry about the choices they have made. Recently, however, a new alternative has been announced, and for countless children diagnosed with minor idiopathic scoliosis, this treatment may be the one that some parents have been waiting for.

SpineCor: An Innovative Approach to Corrective Bracing

On September 16, 1998, at an orthopedics symposium in New York City, Dr. Christine Coillard and Dr. Charles Rivard, pediatric surgeons from Sainte-Justine Hospital in Montreal, presented clinical findings on a promising, new, therapeutic approach for idiopathic scoliosis. As pediatric orthopedists, Drs. Coillard and Rivard had long concurred that bracing was the most conservative option available for children with minor scoliosis. However, they also realized the challenges presented by a child’s growth patterns as well as his or her physical and psychological need for normal mobility. Their studies were based upon these challenges, and as a result of their research, the SpineCor bracing system evolved. Together with their team of researchers from anthropology, biomechanics, and physiotherapy they seek to minimize the three dimensional deformity of scoliosis by addressing what they believe to be four important aspects of the condition, deformation of the spine, postural disorganization, muscle dysfunction, and unsynchronized growth.

What’s different about the SpineCor brace?

Primarily, the SpineCor bracing method is an adjustable, non-invasive technique that provides flexible, inconspicuous correction that continues as a child moves and grows. Unlike traditional rigid systems, the SpineCor brace consists of four major components: (1) a plastic pelvic base, (2) a cotton bolero or vest, (3) tie bands and (4) four adjustable or “dynamic” bands. Proponents of the brace, distributed by Biorthex, Inc., state that this unique combination of components is simple to use, comfortable to wear, and most importantly, effective in its results. The goal of the dynamic brace is to maintain and improve spinal deformity while re-educating the body to return to a more normal posture.

Does the SpineCor Brace work for everyone?

None of the current braces will work for everyone, and SpineCor is no exception. Biorthex states that results so far are similar to other braces for curves greater than 30 degrees and “the best results” occur with those patients who are skeletally immature with Cobb angle curvatures of less than 30 degrees. While determining the initial degree of measurement is essential to the success of the SpineCor system, the growth velocity of the curve is an even more important factor to consider when choosing the SpineCor brace. Specifically regarding such rates of growth, children experience three major growth spurts that can impact the severity of scoliosis: infantile (before age 2), juvenile (between ages 5 – 10), and adolescent (age 11 or the onset of puberty). Based upon clinical studies with children of all ages, the SpineCor system appears to provide greatest benefit to children between the juvenile and early adolescent stages, which generally occur between the ages of 6 and 11. In addition to the patient’sage, two other factors also tend to influence the success of this bracing alternative. As such, children who are either clinically obese, or girls who have already begun menstruating, would not be considered primary candidates for this type of treatment.

How can a patient get started with the SpineCor system?

Because the system is new, not all physicians are currently equipped to treat patients with the SpineCor brace, but information is readily available to qualified practitioners who routinely diagnose idiopathic scoliosis. The orthopedist may use the digital imaging system and assistant software in their office, or arrange an appointment with either an orthotist or a physical therapist to take the initial body measurements and to arrange for follow-up visits. The brace will then be fitted, and the patient is taught how to use it effectively. Generally, to achieve maximum results, the brace should be worn during the day and may be worn for up to 20 hours at a time. Therapists may offer suggestions for improved body mechanics while wearing the brace, and follow-up visits may be needed every 3 to 6 months, depending on the patient’s growth, to make the necessary adjustments to the elastic bands.

What are the expected results of using the SpineCor brace?

Data from clinical trials presented at the New York symposium in September 1998, revealed the following findings. Specifically, from August 1995 to the present, 41% of patients who met the diagnostic guidelines of skeletal immaturity with a progressive curvature of less than 30 degrees have experienced improvement using the SpineCor system. Among these patients, their curvatures were reduced by 25% to 50%. The study also indicated that another 41% of the patients showed no improvement after using the SpineCor brace, but to date, their curvatures have remained stable. Only 4% of the patients treated with the SpineCor brace noted an increase in their initially diagnosed curvatures. These results so far are very positive, however more long term “out of brace” data will be needed to conclusively show the effectiveness of SpineCor.

How can I receive more information about the SpineCor bracing system?

As with any new mode of treatment, it is always best to begin by speaking with your family physician or a referred specialist. This system shows great promise for young children with mild curvatures, and it will be considered among the available scoliosis treatment alternatives. However, you may wish to review the product information before deciding to use the SpineCor system. In order to make the most informed decisions possible, you may contact the NSF office to ask about the device, or you can contact Biorthex, Inc. directly by calling (514) 382-4800 or visit their website at www.biorthex.com.

The Pioneers of the SpinCor Brace

Dr Christine Coillard, Clinical Assistant Professor, Department of Surgery, University of Montreal, and Pediatric Orthopedic Surgeon

Dr Charles H. Rivard, Pediatric Orthopedic Surgeon and Head of the Department of Surgery at the University of Montreal

The post A New Alternative Treatment for Idiopathic Scoliosis first appeared on National Scoliosis Foundation.

Q: Dr. LaGrone, what is flat- back syndrome?
A: Flat-back syndrome is the loss of lumbar lordosis of the spine after one has scoliosis surgery. The normal lumbar curvature becomes flat, or you may even get a reverse curvature (called lumbar kyphosis). The condition is characterized by the inability to stand up straight, and typically patients will have back pain in their upper or lower spine. It can occur in patients of any age, but it is more likely to be found in older adults who have had scoliosis surgery.

Q: What causes the condition?
A: The most common cause is the use of distraction instrumentation such as a Harrington rod, in the lumbar spine. Obviously, the patients who have the most severe flat-back syndrome will be those who have had distraction instrumentation placed all the way down to the sacrum. Occasionally, we will see patients who have thoracolumbar kyphosis-a deformity above the lumbar area which would aggravate the forward positioning of the spine and cause flat-back syndrome. But far and away the most common etiological factor would be the use of distraction instrumentation in the lumbar spine.

Q: What are spine surgeons doing about this?
A: Most-but not all-spine surgeons now know that this is something you don’t do. In the early days of scoliosis surgery, surgeons were more concerned with the frontal plane of the deformity and were not as aware of the sagittal or lateral plane, and over time they began to see patients presenting with these problems. It soon became apparent that the sagittal plane was just as important as the frontal, and we realized the importance of not using distraction instrumentation in the lumbar spine. As a result, the incidence of flat-back syndrome has diminished, but we still see it.

Despite contouring for lordosis, the lumbar spine can be flattened by the force of s distraction rod(arrows). Also note the kyphotic deformity just above the rod. (click image to enlarge)

Q. When would a patient realize he or she had flat-back syndrome? Immediately after surgery?
A: Actually, the syndrome is usually noticed over a gradual period of time and can worsen. The distraction rod will immediately flatten the spine but some patients can compensate for it by extending their upper spine or extending their hips. Over time they can become more symptomatic-they may lean forward more or they may lose hip flexibility. And if their fusion wasn’t solid to begin with, they’ll gradually lose even more of their lordosis.

Q: What can be done about flat back syndrome?
A: Prevention is the key, by which I mean avoiding the use of distraction instrumentation in the lumbar spine. Today we use segmental, instrumentation systems with multiple hooks, wires and pedicle screws. These enable us to maintain the normal sagittal contours of the spine.

Q: In addition to using segmental instrumentation, what else are surgeons doing to prevent this problem?
A: We know the importance of maintaining the patient’s lordosis during surgery. We do that by positioning patients with their hips extended so that we can preserve the lordosis while we are performing the surgery.

Q: What is the surgical treatment for flat-back syndrome?
A: Surgical treatment is very complex and complications are high. Typically, we do what are known as closing wedge osteotomies: we remove wedges of bone from the fusion mass and close the wedges down so that we can re-establish the lordotic curvature. Generally, patients do better and have a higher fusion rate if we precede the osteotomies with an anterior discectomy and fusion of the lumbar spine. Then we do our posterior osteotomies and use rigid segmental instrumentation to maintain correction.

Q: After surgery, what can patients expect?
A: In older adults, I would probably recommend wearing a lightweight protective brace for 6 to 9 months while the spine is healing. For adolescents, a brace might not be needed if the internal fixation is rigid enough.

Q: Do many patients suffer from complications after the surgery to correct flat-back syndrome?
A: In one of our studies, done in 1988, we found that 47% of (55) patients continued to have some symptoms of leaning forward and 36% continued to have moderate to severe back pain. Thankfully, our results are better today because of our increased knowledge and improved techniques.

Q: What should patients do if they have flat-back syndrome?
A: The majority of those who have mild to moderate flat-back syndrome will probably be fine-they’ll be able to keep their spine balanced by compensating for it above their fusion or below, and by keeping fit. It’s difficult to predict whose flat-back will get worse, so it’s a good idea to monitor patients every year or so. If the condition is already severe, and the individual is unable to stand erect, that patient will probably be a candidate for surgical correction.

The post Understanding Flat-Back Syndrome first appeared on National Scoliosis Foundation.

Q: What exactly is a rib thoracoplasty and why is it performed?
A: Simply stated, a rib thoracoplasty involves shortening of certain ribs in the thoracic or chest area. It is done to reduce the size and severity of a rib hump which may accompany scoliosis. The procedure is usually performed after the patient has had corrective surgery for scoliosis.

Q: What are the goals of a rib thoracoplasty?
A: For moderately severe deformities, the procedure appears to result in a significantly greater improvement in a patient’s overall appearance, though it will not result in perfect symmetry. The procedure also relieves pain that may be associated with a rib hump, such as when an individual leans up against a chair.

Q: Are there a lot of different surgical techniques being used today for a rib thoracoplasty?
A: As far as I know, most surgeons use fairly similar techniques. However, some surgeons make an incision over the peak of the rib hump, whereas I prefer, as do many others, to use a midline incision-that is, to use the same incision that’s used for a posterior spinal fusion. Patients seem to prefer having a single midline incision.

Q: What determines which ribs are shortened, and how do you decide how much to shorten them?
A: We determine which ribs are shortened based on which ones are prominent and are not expected to be reduced by correction of the curvature. As far as deciding how much to shorten ribs, we decide on a case by case basis; it depends on the nature of a patient’s curve, as well as the severity of the rib hump.

Q: When the ribs grow back after surgery, do they actually form new rib bone and reconnect to the spine, and how long does it take for this to happen?
A: Yes, the ribs do grow back, forming a new rib. This takes approximately two to three months.

Q: Is the new growth as strong as the original rib?
A: The new rib, once it is completely healed, will be as strong as the original rib.

Q: Is there any chance of the rib hump returning?
A: That would only occur if the curvature progresses.

Q: Could a rib grow back crooked or out of place?
A: This is rarely, if ever, encountered.

Q: Is it always necessary to wear a brace following this surgery? Will wearing or not wearing a brace affect the outcome of the surgery?
A: The use of a brace appears to protect the ribs from rubbing against the chest cavity and seems to result in less likelihood of fluid collection and the subsequent need for a chest tube. Not wearing a brace will not affect the long term outcome of the surgery, but in the short term a brace could avoid the complications as mentioned.

Q: During recovery, is there any danger for the unprotected chest wall?
A: Not in the course of normal activities. There might be a theoretical risk of a very forceful blunt trauma causing damage, but this would, of course, be very unusual.

Q: Can a patient damage the rib cage during recovery by stretching or moving incorrectly? Are there any movement restrictions once the healing is complete?
A: A patient wouldn’t damage the rib cage during the course of normal activities. Once healing is complete, there are no movement restrictions. In fact, tennis and golf would be possible within the constraints of spine fusion limitations.

Q: How long is recovery time?
A: For patients who choose to undergo thoracoplasty surgery as a separate procedure, full time in hospital is 5 to 7 days; recovery is 2 to 3 months for this procedure.

Q: Aside from the risks of anesthesia, what are the possible complications from this procedure, and what can be done about them?
A: The main complications would be: fluid or air collection in the lungs, both of which can be treated with a special device called a chest tube. There might be too much resection resulting in a rib concavity, and there could be a temporary decrease of lung capacity.

Q: Can a patient go back to surgery after the corrective spine surgery and have a rib thoracoplasty done?
A: Yes, many patients elect to have the thoracoplasty performed after recovery from their major spinal corrective surgery.

The post Rib Thoracoplasty first appeared on National Scoliosis Foundation.

Q: Dr. Winter, is pain a symptom of scoliosis in the adolescent?
A: Very rarely. In fact, if a typical 12 to 14 year old adolescent with scoliosis visits our clinic and her main complaint is “I hurt,” we would be concerned, because most patients of that age simply don’t hurt. We would wonder (1) Why is this girl different from the usual patient? and (2) Is there something else going on besides scoliosis? Then we would order a variety of tests to find out whether she has a bone infection, a bone tumor, a spinal cord tumor, or some other type of problem.

Q: Let’s say the patient mentioned above undergoes various test, and you find that she has no abnormal condition other than scoliosis. What might be causing her pain?
A: Some adolescents with scoliosis may experience pain which is truly “organic” in other words, they experience a muscular type of pain which occurs because the muscles on the convexity of the curve are working overtime trying to control the curve. When muscles are overworked, they hurt.

Q: What about adult patients with scoliosis who complain of pain; is their pain due to scoliosis, or to something else?
A: This is one of the toughest questions doctors face when confronted with the scoliotic adult who complains of pain; how to distinguish between conventional low back pain and pain due to scoliosis. First, it should be noted that all adults-whether they have scoliosis or not-can have low back pain. It’s just part of being a human being who stands upright and is growing older. As we age, all of us eventually experience disc degeneration-i.e., the fibrous, spongy discs between our vertebrae wear out. Moreover, various joints of the body tend to wear out with age-a condition known as degenerative or “wear and tear” arthritis (also know as osteoarthritis). When these conditions occur, bone rubs against bone, which causes pain-but the pain may be due to disc degeneration or wear and tear arthritis, problems that everyone faces with age.

Q: If an adult with scoliosis is experiencing pain that is not due to disc degeneration or arthritis, what might be causing the discomfort?
A: The answer to your question has to do with mechanics. You need to understand that the discs in your back are being loaded with weight by gravity every day. If the vertebrae of the spine are perfectly straight, then the loading will occur symmetrically. However, if the spine is curved, the loading will be asymmetric and highly concentrated in the concavity of the curve. When discs and joints are loaded asymmetrically, they wear out asymmetrically, and at a much faster rate than they would normally. In these cases, we would say that the patient has scoliotic pain: the back pain, usually found in the thoracolumbar (mid-back) or lumbar area (lower back), is due to the spinal curvature which is causing asymmetric loading of discs and joints. Scoliotic pain usually does not occur in persons in their twenties or thirties but rather in those in their forties and beyond.

Q: Is there any connection between the magnitude of a curvature and the amount of pain one might feel?
A: Let me answer the question this way, I’ve seen adult patients at our clinic who have 30 degree curves and they’re miserable; yet just down the hall I’ll visit a patient who is 67 years old with a 95 degree curve and she’ll say it doesn’t hurt at all. Generally speaking, thoracic (upper back) curves don’t hurt even if they’re 90-100 degrees; in this case, breathing capacity may be diminished, but the lungs wouldn’t hurt. Lumbar Curves over 45 degrees tend to hurt over time, yet I’ve seen 95 degree lumbar curves that didn’t hurt at all.

Q: In terms of diagnosing a patient, how do doctors determine whether a patient has conventional low back pain or scoliotic pain?
A: We would begin with a physical examination and then look at routine x-rays. We might also use special diagnostic techniques such as a myelogram (an x-ray of the spinal cord); high-tech scanning devices such as Magnetic Resonance Imaging (MRI), which uses a computer to produce three-dimensional images; and/or discography which is the injection of a dye into the disc which can assess both the patient’s pain response to the injection as well as the radio graphic pictures of the discs.

Q: If the doctor determines that the patient has disc degeneration or arthritis, what can be done to treat the pain?
A: The first step for the doctor is to block scoliosis from the mind-i.e., treat the patient as though she came in with a straight spine and low back pain. The next step is patient education; learn all you can about body mechanics so that you know how to lift, sit and sleep properly; find out from your doctor which type of exercise will help you (some patients with arthritis of a spinal joint or joints, for example, may benefit more from isometric toning than from aerobic motion exercise). Third, learn not to panic when you have a little back pain. I’m a great believer in doing simple things when you can: perhaps a non-steroidal anti-inflammatory drug (NSAID) such as aspirin or ibuprofen will help. Quite often, wearing a corset, using a heating pad, lying on the floor with your feet propped on a chair, or resting in a fetal position for 10 minutes, can give you relief. As for the use of chiropractic treatment of pain, if it works for a patient, it’s fine. I’m not particularly enthusiastic about biofeedback or acupuncture for treatment of pain.

Q: What about treatment for true scoliotic pain?
A: Once the doctor has determined without a doubt that the pain is caused by the scoliotic curve, surgical techniques can be designed to solve the problem. It is crucial that the diagnosis be accurate. If the pain is strictly in the curvature, then by treating the curve surgically you treat the pain and patients do very well. On the other hand, if the doctor thinks the pain is due to the curve but in reality it’s due to disc degeneration outside the curve, you can treat the curve from now until doom’s day and the pain won’t go away.

Q: We’ve heard that there are some situations which may give rise to pain after surgery. Examples include flat back syndrome and a broken rod. Would you comment on these?
A: Flat back syndrome is a condition that occurred more frequently ten years ago, when doctors weren’t cognizant of the fact that you just can’t use a Harrington distraction rod on the lumbar spine and get good results. Today, we know that a long fused segment in the lumbar area places a great deal of stress on the remaining joints and wears them out. The condition can be corrected surgically with reconstruction techniques, but we prefer to prevent it from occurring in the first place. We still do low fusions, but we do not use Harrington distraction rods in the lumbar area. When a rod breaks, it usually happens because the patient has a pseudarthosis part of the fusion doesn’t heal properly. In this situation (which can be corrected surgically with good results), it’s the pseudarthosis of the fusion that causes pain, not the broken rod.

Q: What can you tell us about patients who have scoliosis and osteoporosis, the condition that is accompanied by brittle and/or porous bones and is associated with loss of calcium from bones?
A: Osteoporosis in and of itself does not hurt, but if you get a compression fracture because of it, it will hurt a lot. Such fractures can occur in individuals who have scoliosis; when they do, they appear either at the concave or convex side of the curvature. It’s important to note, however, that osteoporosis does not cause scoliosis; it causes kyphosis, the skeletal abnormality we associate with a rounded or humped back.

Q: Is there anything that can be done to prevent osteoporosis?
A: Here are a few guidelines: (1) From the age of 18, all women (particularly postmenopausal women) should be taking 1500 milligrams of calcium per day plus the amount of vitamin D that you’d find in a multi-vitamin. (2) In the first five years after menopause, all women should be taking the hormones estrogen and progesterone-unless they have a history of breast cancer or uterine cancer. After five years, women can stop the hormone treatment and return to taking the vitamin D and calcium combination. (3) Exercise in moderation to keep in shape.

The post Pain first appeared on National Scoliosis Foundation.

Q: Dr. Emans, let’s begin our discussion by talking about the difference between scoliosis and idiopathic scoliosis.
A: The term “scoliosis” is used to describe a spinal deformity that is characterized by a lateral (side to side) curvature and vertebral rotation. As described, scoliosis can be caused by a birth defect, a severe accident, or neuromuscular disease such as muscular dystrophy and polio, but in 80 percent of all cases, it is “idiopathic”, it occurs for no apparent reason.

Q: Since we’re now talking about the idiopathic (cause unknown) variety, will you explain the difference between infantile, juvenile, and adolescent idiopathic scoliosis?
A: Infantile idiopathic scoliosis is extremely rare. It occurs from birth to three years of age and is found mostly in males and usually results in a left thoracic (upper spine) curve. Many infantile idiopathic curves correct themselves spontaneously without treatment but should be monitored. Juvenile idiopathic scoliosis usually occurs from about age 4 to the onset of puberty-roughly age 10 or 11 for girls, age 12 for boys. Most of these curves, which can occur both in males and females, are right thoracic curves. Adolescent idiopathic scoliosis usually occurs during early puberty, with the most rapid worsening occurring during the early adolescent growth spurt. For unknown reasons, this variety strikes females more than males-at a ratio of roughly 5 to l. The most common curve pattern among adolescents is right thoracic.

Q: Most of our readers are generally familiar with the kinds of treatment available for adolescent idiopathic scoliosis-i.e., rigid bracing until bone maturity, or spinal fusion surgery, depending on the severity of the curve. Is treatment different for those who have infantile or juvenile scoliosis?
A: On the rare occasions when we do see a child with infantile idiopathic scoliosis that requires treatment, we might consider rigid bracing or fusion without instrumentation. Of course, our, choice would depend on the severity of the child’s curve. For juveniles whose cases warrant it, we would select from any number of surgical techniques available today. For juveniles, the threshold for bracing is lower than that for adolescents. We are more likely to brace a 7-year-old with a 20-degree curve because of the high likelihood of worsening of the curve with remaining growth. For the sake of comparison, we would not brace the 20-degree curve of the 14-year-old or 15-year-old who has little growth left.

Q: What is kyphosis?
A: Before answering that question, let’s talk about the normal spine for a moment. When you look at a person with a normal spine, viewing him or her from the side, you see that the back is anything but straight. In the cervical (neck) area, the spine curves slightly forward (a lordosis), then slopes gently backward (a kyphosis) through the chest area, then forward again in the lumbar (lower back) area toward the sacrum (tailbone). In other words, everyone has some kyphosis of the spine (and some lordosis). Normal thoracic kyphosis will be centered in the chest area and range in size from 20 to 45 degrees. An abnormal kyphosis may exceed 45 degrees or may be centered at the thoraco-lumbar (mid- spine) area. Often there is wedging of the vertebra on x-ray in an abnormal kyphosis. “Scheuermann’s kyphosis” is a generally progressive abnormal kyphosis, which occurs most frequently in adolescent males.

Q: How is abnormal kyphosis treated?
A: Most abnormal thoracic kyphosis in growing individuals of less than 70 to 75 degrees can be successfully treated with rigid bracing. Often a Milwaukee type brace is needed. Unlike bracing in idiopathic scoliosis, the brace treatment of Scheuermann’s kyphosis can often result in actual correction.

Q: What is kypho-scoliosis?
A: Most idiopathic scoliosis in the thoracic spine is “lordo-scoliosis” or “hypo-kypho-scoliosis” (less than the normal kyphosis). There is usually a flattening of the normal thoracic kyphosis associated with idiopathic thoracic scoliosis. The old outmoded term for scoliosis in general was “kypho-scoliosis.” This term was employed before physicians realized the three dimensional nature of most scoliotic deformities. There is also true kypho-scoliosis in which the spine is de- formed both in the direction of scoliosis and kyphosis. It is treated in the same way as idiopathic scoliosis.

Q: What are congenital scoliosis and kyphosis?
A: Congenital scoliosis and kyphosis are caused by birth defects in the spine itself. Abnormally formed vertebra produce the spinal deformity. Both congenital kyphosis and scoliosis can worsen drastically during the first few years of growth and often need extremely early surgical treatment. Bracing is rarely used for either type of congenital curve. Some individuals with congenital curves experience no worsening of the curve with growth and need no treatment.

The post Let’s Get The Terms Straight first appeared on National Scoliosis Foundation.

Exercise patterns of adults with scoliosis vary widely, as they do for the general population. Avoidance of exercise because of fear of causing harm to the spine is fairly common, however, in those with scoliosis, especially following spine surgery. This is certainly understandable. However, exercise or sport participation will have no effect on non-fused spinal curves. Although curves tend to increase by several degrees with advanced age, this appears to be unrelated to activity or exercise levels. For patients with solid spinal fusion, exercise and participation in recreational sports should not harm the fused segments. The segments of the spine not involved with the fusion operation are under some increased stress to make up for the loss of function in the fused segment, but this additional stress is present for all daily activities. Several hours per week of exercise or sports participation should not exert any harmful additional stress into these areas. A note of caution however may be appropriate for some adults with only one or two mobile lumbar vertebrae below their fusion. For these patients, excessive twisting or loading of the spine during sports has often been discouraged as it is theorized that this may accelerate degeneration of the discs at the remaining levels. In general however, adults with scoliosis can engage in exercise and recreational sports without undue risk.

As most of us are aware, regular exercise and sports participation has many health advantages. These include improved cardiovascular heart and lung conditioning, improved strength and flexibility of muscles and joints, and better weight control. Exercise helps prevent osteoporosis in women. Exercise has also been reported to result in an improved sense of well-being. It can relieve or reduce daily stress and most people who exercise regularly find it enjoyable. These advantages of exercise can, and should be enjoyed by adults with scoliosis.

Exercise can be therapeutic for adults with scoliosis who have had spinal fusion. When the mobility of the spine is limited because of the fusion, one can feel somewhat inflexible for normal daily movements such as bending over or reaching for objects. A potential solution to this problem can be found by realizing that most of us adults only use a portion of the potential flexibility in our hip joints. The full mobility of the hip can be developed by daily stretching of the ham-strings, quadriceps, hip flexor and muscles. This increase in hip flexibility can then be substituted for the loss in spine mobility, and make it easier to move in desired directions.

In our practices, we also advise exercise for adults with scoliosis who have developed back pain symptoms. As mentioned above, the stresses on the back during daily activities can be reduced by improving the mobility of the hips. This can lead to a reduction in pain. Improving the strength of the back muscles can also help to reduce pain and improve tolerance for daily activities. This can be accomplished by performing vigorous strengthening exercises at home or in a fitness facility several times per week. Endurance levels can be improved by regular walking, bicycling or other aerobic activities. This frequently results in improved tolerance for shopping, yardwork and other sustained activities. In general, a person with a back which is flexible and strong will feel and function better than if that same back (regardless of whether scoliosis is present) is weak or stiff. Favorable results, in terms of improved functional abilities and reduced back pain, have been reported to us by our patients with scoliosis and back pain. Most have continued their stretching and exercise programs for many years.

NFS expresses sincere appreciation to co-authors James Rainville, MD, and Alexander Wright, MD. Exercise illustrations reprinted by permission of VHI, Inc. These exercises are shown as examples only. We recommend all readers to seek the advice of their physician for activities and exercise programs suitable for their situation.

The post Exercise and Adults with Scoliosis first appeared on National Scoliosis Foundation.

1. Can exercise correct or stop the progression of the scoliosis curve?
2. Are recreational exercise and sports participation advised?

In this article, we will present some of the advantages and limitations of exercise for adolescents with scoliosis. Adults with scoliosis, including those with corrective surgeries, often also seek advice about exercises, especially if they begin experiencing discomfort and stiffness in their backs. Therapeutic and recreational exercise for adults will be presented in a future article.

Programs

Several programs aimed at correcting or arresting scoliosis have been proposed over the decades. Through these programs one attempts to exert corrective forces on the spine by active contraction of trunk muscles in directions thought to reverse the scoliosis curves. Some approaches seek positions and postures which are noted to reduce the scoliosis deformity.
Additionally, stretches are often performed, which aim to increase the mobility of the spine in a corrective direction. After mastering these exercises, postures and stretches under the supervision of a physical therapist, attempts are made to maintain corrective muscle tone and postures during daily activities.

Some programs also include breathing exercises. Chest movements noted during deep breaths cause temporary rotation of the thoracic vertebrae in a corrective direction in some people with scoliosis. Minor reductions in measurable lung capacities are often found in people with scoliosis and large thoracic curves, and breathing exercises have also been directed at improving this.

Bracing and Exercise

Exercise programs have often been prescribed for those wearing corrective scoliosis braces. These are intended to help the wearer adapt to the brace, to encourage the active correction of the spinal deformity, and to maintain the trunk musculature during the bracing program. This is done by actively shifting laterally in the direction of the correction (away from the brace pad), by extending the trunk while in the brace, and by taking deep breaths.
Other trunk and pelvic exercises are also taught and the brace-wearer is instructed to perform these several times per day. Most programs are initially supervised by physical therapists, and are followed by the development of daily home exercise regimens.

Benefits of Exercise

In general, little scientific evidence exists about the effectiveness of exercise programs for preventing progression of scoliosis curves, or for reversing curves to any clinically or cosmetically significant degree.

By scientific evidence we refer to carefully designed clinical studies where a true effect of exercise has been demonstrated. Some short-term reduction of curve angles (by several degrees), and minor improvement in breathing volumes have been observed for small groups of people with scoliosis who have undergone exercise programs.

Others in these programs, however, were not helped, and some were noted to have curve progression during exercise. For those with slight improvement in curves, it was not determined whether these changes had any lasting effect, nor were these noted to be cosmetically or functionally noticeable.

Even for exercise programs directed at improving the results of scoliosis bracing, the results have been disappointing. Bracing alone has been found to be as effective as bracing and exercise.
Because of this, therapeutic exercise programs are not universally recommended by scoliosis experts. When prescribed, exercise programs are usually initiated in addition to, and not instead of bracing treatment. Careful monitoring of curve angles remains essential, regardless of exercise.

Therapeutic exercise should never be considered as an alternative to recommended surgery when a scoliosis curve is severe and progressive, and the patient and family have decided on surgical correction.
Fortunately, most people with scoliosis are completely normal in their ability to participate in sports and recreational exercises. For some with severe deformities leading to respiratory function changes, and for those post-scoliosis surgery patients, some sports restrictions may be advised. Your scoliosis specialist can make recommendations concerning these. No information exists to suggest that recreational exercise and sports participation worsens, or in any other way affects scoliosis curves.

“Scoliosis is not caused by a deficiency of strength or flexibility, and therefore exercise is relatively ineffective in correcting scoliosis. Equally important, scoliosis is not a result of exercise, and therefore normal physical activities can be enjoyed by people with scoliosis without concern”.

Children and adolescents with scoliosis can be expected to participate in organized sports, school physical education programs, and normal neighborhood recreational activities. For most, resistive exercise training to build muscle strength and endurance training to improve cardiovascular conditioning can be performed when desired.

Children enrolled in a scoliosis bracing program are generally allowed out of the brace for organized sports. In addition to the lack of adverse effects and improved fitness, regular recreational exercise can reinforce that one is normal and healthy despite scoliosis.

The causes of scoliosis appear to be independent of exercise. Scoliosis is not caused by a deficiency of strength or flexibility, and therefore exercise is relatively ineffective in correcting scoliosis. Equally important, scoliosis is not a result of exercise, and therefore normal physical activities can be enjoyed by people with scoliosis without concern.

The NSF would like to thank co-authors, James Rainville, M.D., and Frank Rand, M.D., for their work on this article. Dr. Rainville, a Physiatrist, is Assistant Clinical Professor, Department of rehabilitation Medicine, Tufts University Medical School-Boston, and also Director of rehabilitation, New England Spine Care Center, Chestnut Hill, MA. Dr. Rand is Instructor in Surgery (Orthopedics), Harvard Medical School, Boston, and Director of Orthopedic Programs, New England Deaconess Hospital, Boston

The post Exercise for Adolescents first appeared on National Scoliosis Foundation.

Nature and Practice

Chiropractic is a system of treatment based on the principle that a person’s health is determined largely by the nervous system and that interference with this system impairs normal functions and lowers resistance to disease. Chiropractors treat patients primarily by manual manipulation (adjustments) of parts of the body, especially the spinal column.
Because of the emphasis on the spine and its position, most chiropractors use X-rays to aid in locating the source of patients’ difficulties. In addition, most chiropractors use supplementary measures such as water, light, ultrasound, electric and heat therapy, and prescribe diet, supports, exercise, and rest. State laws specify the types of supplementary treatment permitted. Chiropractors do not use prescription drugs, nor do they perform surgery.

Basic Theories

Simply stated the science of chiropractic is based on the following principles:
There are two hundred and nine bones and numerous adjacent structures, such as muscle, tendon and ligamentous tissue, within the human body, most of which are capable of movement, particularly where two bones come together to form a joint, and each bone has a particular position and its own predetermined range of motion.

Many of these moving parts, like the moving parts of a finely tuned machine, may become subluxated or misaligned and deviate from their normal position.

Such misalignments are apt to occur as the result of external trauma, a sudden and forceful movement of the body such as a quick turning of the head, a whiplash injury, heavy sneezing, or the lifting, pushing or pulling of a heavy object. These deviations, which are usually referred to as a “subluxation complex”, can cause contact, irritation, pressure or tension on surrounding nerves.

Pressure or pinching on a nerve may cause abnormal function, such as limitation of movement and pain, to the locally affected area; however, the pain is also likely to radiate along the involved or nerves and cause distress and functional instability to other parts of the body.

A subluxation usually can be corrected by means of adjustment or realignment whereby the disjointed member is restored to its proper position, thereby alleviating or eliminating the pressure or irritation to the nerve that is the source of discomfort. It is also a basic tenet of chiropractic that the elimination of nerve interference and the restoration of the body to its normal and natural function in a significant number of cases enables the inherent recuperative powers of the body to operate without interference or impediment and restore the afflicted area to good health.

Of all the moving parts of the human body, among the most delicate and the most likely to fall into displacement are the numerous joints of the spinal column, and it is for this reason that the chiropractor is usually thought of specifically in terms of conditions of the spine and is not always considered when an abnormality is experienced in other parts of the body. However, the spinal column with its infinite network of branching nerves can serve as a vehicle by which pain is radiated to various parts of the body. Consequently, there are situations in which a pain in the arm, neck, hand, foot, leg or elsewhere may be properly and successfully treated by a chiropractor.

It is the function of a chiropractor, after taking the patient’s case history, to diagnose by way of physical examination, X-ray and palpation or probing by hand, a possible subluxation or a misalignment as a cause of nerve interference, and to eliminate that condition by corrective manipulative adjustment. Since the nerve system is the very essence of chiropractic healing, a brief description of its three major components is necessary.

First, the brain acts as the central computer where information from all parts of the body is processed, stored and acted upon. Second, the spinal cord, an extension of the brain, acts as a facilitator in the transmission of information between the brain and various parts of the body; Finally, the peripheral nerve system connects the spinal cord directly or indirectly with virtually all the tissues of the body. The spine is composed of twenty-four movable vertebrae, which house and protect the spinal cord, but because they are movable, they can interfere with the spinal cord and nerve roots they were created to protect.

There are many things that can interfere with the nerve system, such as drugs, physical trauma, poisons, or toxic environments. However, the chiropractor is concerned with the misalignment of the vertebrae known as the Vertebral Subluxation.

The Vertebral Subluxation is a condition where a vertebra has lost its normal juxtaposition with the one above or the one below or both, to the extent that it impinges nerves and interferes with the normal flow of nerve impulses from brain to tissue cells. The Vertebral Subluxation usually distorts the normal curves and motion of the spine, and causes interference to the nerve system.

Vertebral Subluxations are usually corrected by means of a Spinal Adjustment. The Spinal Adjustment is a specific concussion of forces given by the chiropractor along the spinous or transverse processes of the vertebra into that vertebra’s normal facet angle. The restoration of that vertebra to its proper position will alleviate or eliminate the pressure or irritation to the nerve and restore normal function to the spinal motor unit.

Chiropractic and Scoliosis

Charles A. Lantz, D.C., Ph.D. is Director of Research at the Life Chiropractic College West in San Lorenzo, California. Dr. Lantz and his colleagues are currently conducting a scoliosis research project to explore the effectiveness of chiropractic in the management of children ages 9-15 with mild to moderate scoliosis (less than 25″ curve). This is the first clinical trial ever to look at the effect of chiropractic on scoliosis.

NSF first met Dr. Lantz. and his associate Jasper Chen, D.C. in conjunction with the 1994 Northern California Spine Conference. This was the beginning of a series of dialogs regarding the need for scientifically valid information about chiropractic treatment of scoliosis and the value of working together with the Scoliosis Research Society to enhance the credibility and acceptance of the design and outcomes of such a study. We applaud Dr. Lantz in his efforts to spear- head a major randomized controlled trial with a collaborative team which includes S.R.S. members, Dr. William Bunnell, Loma Linda University; Dr. Ronald Blackman, Kaiser Hospital, Oakland; Dr. Peter Slabaugh, Children’s Hospital, Oakland; and Dr. Serena Hu, U.C. San Francisco.

“Virtually no formal research exists documenting chiropractic’s effectiveness in managing scoliosis. We are excited about the potential benefits of this study and we believe the scoliosis community is well served by a collaborative effort such as this. This is perhaps best expressed in their project grant application, “Given that chiropractic has long claimed success in treating patients with mild scoliosis, it seems reasonable and timely to validate the extent to which that claim is valid.”
In his in-depth article titled Conservative Management of Scoliosis which was published in the October 1994 issue of Chiropractic: The Journal of Chiropractic: Research and Clinical Investigation, Volume 9, Number 4, Dr. Lantz underscores the need for large randomized clinical trials for both adolescents and adults with scoliosis:

“Chiropractic management of scoliosis has classically consisted of spinal adjustments or manipulation sometimes augmented with exercise and postural counseling, as well as heel lifts. Electrical stimulation has recently come into the chiropractic armamentarium as well. Virtually no formal research exists documenting chiropractic’s effectiveness in managing scoliosis, although anecdotal reports abound. Several well-conducted case studies suggest that chiropractic is, indeed, effective in managing scoliotic curves, but the definitive studies are lacking. It is widely stated that chiropractic care is effective in alleviating the pain and discomfort associated with adult scoliosis, however, no studies to date have adequately documented this effect.”

Dr. Lantz concludes his article by pointing out the need for immediate attention by the Chiropractic community to questions such as, “Should adults with scoliosis be treated in the same way as adolescents or juveniles with scoliosis? What are the indications for care, and what types of care are most suited to which types of scoliosis for which age groups?”
Scoliosis often seems to be a condition which has more questions than answers. This appears to apply to the issue of chiropractic management of scoliosis as well. We are grateful for Dr. Lantz and others like him who are dedicated to asking the questions and committed to finding the answers.

The post Chiropractic first appeared on National Scoliosis Foundation.

Throughout history man has tried to straighten out that which nature has bent, twisted, or curved. Hippocrates not only gave a name to scoliosis but he also tried to correct it. Over the centuries since then physicians have used a wide, and sometimes strange, variety of devices to straighten a crooked spine.
In today’s world when a growing adolescent is diagnosed with progressive idiopathic scoliosis and the curve is between 25 and 40 degrees, the physician will prescribe the wearing of a brace to keep the curve from worsening. Depending on the severity of the curve, the curve pattern, and the amount of growth remaining, the physician may not wait to document progression but will prescribe bracing on the initial visit.

In 1985, the Scoliosis Research Society (SRS) initiated a study to investigate the effectiveness of bracing as a treatment for scoliosis. Many previous studies of full time bracing showed that braces stop about 80% of curves. All of these studies, however, were “uncontrolled” which means there were no simultaneous groups of untreated, unbraced patients for comparison. Therefore, there was some doubt that brace treatment of scoliosis was effective, and concern that bracing may be no different than “natural history” or what happens when no treatment is undertaken. In the SRS controlled clinical trial, involving centers from around the world and conducted by Dr. Alf L. Nachemson Sahlgren Hospital, Gothenberg Sweden, patients of the same age, curve pattern and curve severity were divided into two groups, one treated with bracing, one not treated. As reported in the 1993 issue of the Spinal Connection, results of this study demonstrated with statistical certainty that bracing is effective compared to natural history.

In another study by Drs. John Lonstein and Robert Winter, the records and X-rays of 1,020 patients treated with the Milwaukee Brace were reviewed and compared with the findings of a study by Drs. Lonstein and J.M. Carlson which documented patients at the same hospitals who had not been braced but who had been followed for progression of the curve. This retrospective study also showed that bracing is an effective treatment, halting the progression of the curve in statistically significant numbers compared with those patients not treated.

While it is true that there are some patients (20-25%) for whom bracing does not work and unfortunately, it is not possible to predict who they will be parents and physicians can be reassured by these recent findings that bracing for those youngsters who meet the generally accepted criteria is a wise course of action.

What does bracing achieve?
It is important for parents and patients to realize that the purpose of bracing is to keep the curve from progressing as a child grows. While the curve will demonstrate improvement during the time the child is braced, it will typically revert to its original degree of severity when the use of the brace is eventually discontinued at the cessation of growth. Some individuals do achieve permanent correction, but holding the curve to an acceptable level, thus avoiding surgery, should be deemed a success.

What Kinds of Braces are Used?

The Milwaukee Brace
The Milwaukee Brace was the first modern brace designed for the treatment of scoliosis. Developed by Drs. Walter Blount and Albert Schmidt of the Medical College of Wisconsin and Milwaukee’s Children’s Hospital in 1945, it underwent design changes over the years, reaching its present form around 1975. It is still used today, particularly for high thoracic curves. Metal bars in the front and back of the brace extend the length of the torso and are attached to a form-fitting plastic pelvic girdle and to a throat mold or ring which encircles the neck. Straps attached to the metal bars hold pressure pads, which are precisely placed depending on the individual’s curve pattern. While the bars hold the body erect, the neck ring keeps the head centered over the pelvis and the pads push against the curve. Everything works together to keep the body straight and to prevent progression of the curve while the patient is growing.

TLSO Braces
There are many TLSO (thoracic-lumbar-sacral orthosis) systems available today. They are also often referred to as “underarm” or “low profile” braces. They are made of modern plastic materials and are contoured to conform to the patient’s body. While they all differ somewhat in construction, they work on basically the same principle.

The Boston Brace
In the early seventies, the most popular of the TLSO systems, the Boston Brace, was developed by Dr. John Hall and Dr. William Miller of The Boston Children’s Hospital. The Boston Brace was the first brace to utilize symmetrical standardized modules eliminating the need for casting. It was alsothe brace used in the Scoliosis Research Society’s bracing study. The Boston Brace extends from below the breast to the beginning of the pelvic area in front and just below the scapulae to the middle of the buttocks in the back. It is designed to keep the lumbar area of the body in a flexed position by pushing the abdomen in and flattening the posterior lumbar contour. Pads are strategically placed to provide pressure to the curve, and areas of “relief” or “voids” are provided opposite the areas of pressure.

The Charleston Bending Brace
The Charleston Bending Brace was introduced in 1979. Developed by Dr. Frederick Reed and Mr. Ralph Hooper, CPO, this brace is worn only at night during sleep. It is molded to conform to the patient’s body while bending towards the convexity of the curve, thus “over-correcting” the curve during the eight hours it is worn. A preliminary study and subsequent longer term follow-up of those using the nighttime bending brace are encouraging, particularly for a single curve. Although the studies show no evidence of improved compliance the potential for a patient to wear a part-time brace, especially while sleeping, rather than the usual full-time (22-23 hours) regimen is cited as an important benefit.

“The purpose of bracing is to keep the curve from progressing as a child grows.”

To achieve a successful outcome from bracing it is necessary that a highly skilled orthotist or brace maker work hand in hand with the orthopedist to craft a brace precisely tailored to the patient’s needs. In many cases an exercise pro- gram is also provided. After that, the physician will have the patient return for routine checkups and order X-rays to make sure the brace is doing its job. He will prescribe periodic adjustments as necessary.
The brace is worn until the physician has determined that skeletal maturity has been reached at which time the patient will be gradually weaned from the brace.

Compliance on the patient’s part in wearing the brace according to the prescribed schedule is a crucial factor, of course. Several studies have demonstrated the importance that the mother’s attitude has on the child’s perception of her own condition and acceptance of treatment. While no one would suggest that adapting physically and psychologically to bracing is easy for children and teenagers, many studies show that after an initial adjustment period, youngsters who are braced live very normal lives, engaging in appropriate activities, including sports, and that they have good psychosocial adjustment, no matter which brace they wear.

The post Bracing for Adolescent Idiopathic Scoliosis first appeared on National Scoliosis Foundation.

Q: Dr. Bunnell, we’ve been told that one in ten persons has scoliosis but we know that most curvatures will remain mild and never require treatment. What percent of curves remain mild?
A: Ninety-five percent of the curvatures will not require treatment.

Q: How does an orthopedist determine whether or not a curve is mild?
A: We begin with a physical examination that involves bending the patient forward so that we can see whether the curvature is causing a rotation of the spine and a rib deformity. We then may take an x-ray of the patient’s spine to determine precisely the nature and degree of the curvature.

Q: Which curves are considered mild?
A: We usually label a curve mild if it’s under 20 degrees. And if a curve is less than 10 degrees, we don’t even dignify it by calling it scoliosis. Instead, we might refer to it as a postural variation.

Q: What factors do doctors take into account in order to predict whether or not a mild curve will progress and require treatment?
A: One of those factors is skeletal maturity or bone age. The classic way of determining bone age is to take an x-ray of the patient’s wrist and then compare it to scores of other wrist x-rays that have been catalogued in a special book called The Greulich and Pyle Atlas. Such a comparison might reveal that a child who is chronologically fourteen actually has a bone age of thirteen. Another way to discover skeletal maturity is to simply look at the appearance of the pelvis on an x-ray; by doing so, we can tell whether or not the patient is near the end of growth. Menstrual history also helps us predict the chances of curve progression in a girl. We know that young girls grow rapidly during the year prior to their first period, and that’s when most girls’ curves get worse. On the other hand, if a youngster has had her first period, we know that she’ll continue to grow for one to two years after that, but at a reduced rate. Thus, we can say that if a patient’s curve is around 25 degrees, but she hasn’t had her first period yet, there’s a significant chance the curve will increase. The risk of progression is lower, however, if she’s already had her first period.

Q: Once a youngster has been diagnosed as having a mild curvature, what steps should he or she take?
A: It will depend upon the size of the patient’s curve and the growth status. A young patient (6-8 years old) with a very mild curve (15 degrees) might only need to be seen once every 6-12 months since the risk of progression is low. A pre-teen (11-12 years old) with a larger curve (25 degrees) will require much closer observation (every 3-4 months) because of the higher risk of curve progression. There is no need to restrict physical activities during this period, nor are physical exercises of any benefit in preventing curve progression.

Q: During the observation period, would you take x-rays each time you saw the patient, or could you use the Scoliometer?
A: Although an x-ray is the only way to be absolutely sure about whether or not a curve is progressing, I believe that the Scoliometer is effective in determining significant progression of mild curves. Its use easily reduces the need for x-ray (not clinical examinations) by 50%.

Q: Can anything be done to reduce a mild curve? What about exercise or manipulation?
A: There’s not an ounce of scientifically documented evidence that exercise or manipulation can reduce a curvature. There is a place for exercise in children who have poor posture; it can help create body awareness so they don’t slouch.

Q: If the patient is still growing and the mild curve does progress beyond 25 degrees, what type of treatment would you recommend?
A: I’d probably recommend a rigid brace of some sort, and my choice would depend on whether the patient had a single or double curve as well as the location of the curve(s) along the spine.

Q: Wouldn’t you consider electro-stimulation as a treatment?
A: Let me put it to you this way: Most doctors thought the electro-stimulation was going to be a fantastic idea, and so did patients. But now that we have subjected the research results to critical review, it appears that patients who were getting that type of treatment were statistically no better off than those who got no treatment at all.

Q: One final question. We know some youngsters who, despite the fact that their curves are well below 25 degrees, believe they are “deformed.” What would you say to that?
A: It’s my contention that mild curves are extremely prevalent in the population. In fact in 1988, I personally looked at 1,000 high school students and found only 16 youngsters who had perfectly straight spines. It’s important to realize that almost everybody has a little bit of irregular curvature. And that’s why it’s so important that we don’t treat everybody.

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