“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. 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.

As many of our readers know, the Scoliosis Research Society, the American Academy of Orthopaedic Surgeons, and over 23 states suggest or require school screening for abnormal spinal curvatures. In September of 1992, Dr. William P. Bunnell, Professor and Chairperson, Loma Linda University Medical Center, presented his paper, “Outcome of Spinal Screening” to members of the Scoliosis Research Society; his findings will also be published in an upcoming issue of Spine. Dr. Bunnell is a developer of the Scoliometer, a hand-held device used in assisting spinal screening programs across the country. What follows are excerpts from an interview that the NSF conducted with Dr. Bunnell about his study:

Q: Dr. Bunnell, would you start by giving us some background information about spinal screening as it pertains to your study?
A: The major criticism of spinal screening, as it is being practiced today, is that schools are referring too many students who do not require treatment. The primary cause of over-referral is lack of objective screening criterion; in the state of California, for example, any amount of asymmetry of the thoracic ribs or the lumbar area is an indication for referral. As a result of over-referral, many screening programs are cost ineffective. Youngsters who are referred–whether they need treatment or not–will be sent to a doctor for a medical consultation; they may have several x-rays taken; and then they’ll be asked to return to the doctor six months or a year later for another consultation. All of this adds up to skyrocketing costs.

Q: What were some of the goals you wanted to achieve by undertaking this study?
A: One of my many goals was to determine the prevalence of scoliosis–i.e., how many in the general population presently have it. Another was to use the data on prevalence in combination with previous studies to determine what is a reasonable level orcriterion for recommending referrals.

Q: What were some of your findings?
A: In our study of 1,000 physically mature high school students–in which we used the Scoliometer as the screening device–we found that only 16 out of 1,000 students (1.6%) had a clinically straight spine. Eighty percent had three or more degrees of rotation at one or more levels of the spine. We also learned that within this population, if “any degree of deformity” (i.e. one degree) is used as the criterion, then 98.4 % of students will be referred.

Q: Would you explain the criterion–the degree of deformity–that screeners currently look for, and tell us why you feel this criterion should be changed?
A: When I first started out in practice, everybody thought we should treat 20 degree curves with low profile braces. There is a direct correlation between 20 degree curve and a 5 degree Angle of Trunk Rotation (ATR), so screeners referred anybody with 5 degrees of ATR or greater, and they’re sill using 5 ATR as the criterion. Today, we know that at least 4 out of 5 kids with 20-degree idiopathic (causes unknown) curves will never get any worse. In fact, most doctors wait until a youngster with this type of curvature reaches 30 degrees before starting treatment. So it’s clear that we should be screening for these children in the 30 degree and above category.

Q: Based on the data from your study, what are some of your recommendations?
A: We know that spinal screening programs must have defined referral criteria and “treatment-eligible” degrees of scoliosis in order to judge their effectiveness. The ideal criteria will minimize both the number of referrals and the number of false-negative examinations. In view of the new prevalence data from my study and the current recommendations to wait until scoliosis approaches 30 degrees (Cobb angle) before starting brace treatment, I am recommending changing the screening referral criterion to seven degrees ATR at any level of the spine and changing the definition of false-negative (treatment-eligible curves that are missed) to 30 degrees Cobb angle for the purposes of spinal screening.

Q: If it is implemented in screening programs across the country, what will your new recommendation accomplish?
A: It will accomplish a referral rate of 3% and detect 95% of all “treatment eligible” curvatures, thus preserving an acceptably low false-negative rate and helping maintain cost effectiveness of spinal screening programs.

Q: What about youngsters whose curves are below that “treatment eligible” line–let’s say, between 20 and 25?
A: Those youngsters should be rescreened within six months or a year. Rescreening would take place at school, which would keep it a public health issue.

Q: In light of your findings, how do you now view the importance of screening for spinal deformity?
A: Screening is vitally important, but we do not want to screen out a whole bunch of people who don’t need medical attention because it’s very costly. We’re not looking for the cheapest way to screen–we’re looking for a better quality outcome for our patients.

The post Outcome of Spinal Screening 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.

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.

Q: Dr. Moskovich, would you give us a brief overview of early onset scoliosis?
A: It’s important to know that early onset scoliosis is idiopathic, which means we do not know what causes it. Early onset scoliosis occurs before the age of five, and occurs more often in boys than in girls, though we don’t know why. It was formerly referred to as ‘infantile scoliosis’, a term some people still use. It also must be stressed that early onset scoliosis is a very rare condition: the incidence of it is only 1 or 2 per 10,000 people. The vast majority of cases improve spontaneously, which means even fewer need to be treated.

Q: Is early onset scoliosis the same as congenital scoliosis?
A: Not at all. Whereas congenital scoliosis involves a curvature caused by an abnormality such as a hemivertebra or other bone structure problem, early onset scoliosis stems from no known cause-as we’ve said, it’s idiopathic. There is no obvious abnormality in the development of the vertebrae that we can identify in patients who have early onset scoliosis.

Q: How severe must a child’s curvature be before you would define it as an early onset scoliosis?
A: If a child under the age of five has a 10 to 15 degree curve or greater, we would say that child had early onset scoliosis.

Q: Once you’ve identified that the child’s curve is 10 degrees or more, what steps do you take?
A: Of course we would watch the curve closely; we’d also take an x-ray which would alert us to signs of an increased risk of progression. For example, we’d look for a larger curve or marked asymmetry of the ribs, both of which can be signs that a curve may progress. The x-ray could provide us other valuable information as well: whether the child had structural problems indicative of congenital scoliosis, or whether the child had abnormalities of the heart, kidneys, or hips, all of which are more common with early onset scoliosis.

Q: Are any special tests required apart from x-rays?
A: It is important to confirm that the patient is neurologically normal. Examination of the abdominal and plantar reflexes which may alert a physician to subtle neurologic abnormalities should not be neglected. In certain cases, a magnetic resonance imaging (MRI) may be used to evaluate the spinal cord and to exclude neurologic anomalies at the base of the skull if there is any suggestion of neurological problem.

Q: At what point do you begin treatment?
A: If a curve progresses beyond 15 to 20 degrees, we would treat the child by using a plaster cast to keep the curvature from progressing.

Q: Why plaster instead of plastic?
A: There are several reasons of that choice. it can be awfully difficult to keep a young child in a plastic brace which has to be put on and taken off each day. Also, plaster casts are actually more comfortable-they create less pressure on the body because they’re molded to the body. And because plaster casts are generally easier to deal with, we find we get better correction with them. The plaster cast will be changed every 3 to 4 months depending on the growth rate of the child. Plastic bracing is used once initial correction has been achieved or may be used from the outset on larger children.

Q: How successful is plaster casting?
A: Very-about 90-plus percent of patients get better due to casting.

Q: If the curve continues to progress despite the plaster cast, what other treatment options are available?
A: If a curve progresses, we’d do surgery involving an anterior and a posterior fusion.

Q: Why would you have to do two fusions?
A: If you only do a posterior fusion, two things happen: first, it may not fuse, because the back of the spine is the ‘tension’ side of the spine, and bone under tension tends not to heal very well. Second, the front of spine will continue to grow and will twist out, causing the spine to bend backwards into a lordosis.

Q: When surgery is necessary, is it important to fuse patients at the earliest age possible?
A: In many cases, we would try to delay surgery until the child had reached a reasonable size, say at the age of 10, but sometimes that’s not possible, and early surgical treatment is necessary. Also, it is well known that by the age of two, children have reached almost half of their adult spinal growth size. It’s better to have a relatively short, straight spine than a longer, crooked spine.

Q: When a curve is left untreated, what can happen?
A: An untreated curvature can progress rapidly-as much as 40 degrees or more in just months. As the curve progresses, the size of the actual chest cavity can diminish, affecting the developing lungs, which can create respiratory problems for the child that will persist throughout life.

Q: You mentioned earlier that early onset scoliosis is idiopathic-but do you have any thoughts about what might cause this condition?
A: Besides possible heritable factors, there may be an environment trigger. We’re not really sure why, but in low socioeconomic groups in England there’s a greater prevalence of this type of scoliosis, which may be due to post-natal positioning-the way that babies are positioned in their cribs. In England, mothers are taught to lay babies down on their sides. This can cause the spine to sag, and can cause molding of the head and an increased incidence of dislocation of the hip. By contrast, here in North American we tend to put babies down in a prone (face-down) or supine (face-up) position, which results in much more even pressure on the spine.

Q: Based on this knowledge, what do you recommend?
A: In my own practice, I recommend that swaddling babies so that they can’t move and putting babies persistently on one side should be avoided. However, infant positioning should be individualized and one should consult their pediatrician.

Q: Any other advice?
A: If there’s a family history of scoliosis, make sure the family pediatrician carefully examines the child: check for asymmetries. As with all types of idiopathic scoliosis, early detection and early treatment are imperative.

The post Early Onset Scoliosis 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.

Because so many adults have contacted the NSF, we asked Nancy Schommer, author of Stopping Scoliosis, to provide us with an update about adult scoliosis. In the course of her research, she interviewed Dr. David B. Levine, Clinical Professor of Orthopedic Surgery at Cornell University Medical College and Director of Orthopedic Surgery at the Hospital for Special Surgery in New York City. Following are excerpts from their conversation.

Q: Dr. Levine, is it possible for an adult, a person 21 years of age or older, to suddenly “get” scoliosis?
A: It’s possible but extremely rare. When it happens, it is usually because the patient has experienced some sort of trauma, such as a fractured spine, or because the person develops a neuromuscular condition like muscular dystrophy, or a metabolic condition like osteoporosis that softens the bones. Most often, however, adult scoliosis develops in adolescence, and is the “idiopathic” variety, which means it occurs for no apparent reason.

Q: Will untreated adult scoliosis get worse year after year?
A: I’ve followed patients for over twenty years, and have found that probably 60% of adult patients do not get worse. Of the remaining 40% about 10% show a very significant progression, while the other 30% will show a very mild progression, maybe less than one degree per year.

Q: Are there any factors that can decrease or increase one’s risk of progression?
A: Yes, there are. The person who is sedentary and overweight is inviting problems.

Q: What treatments are available for adults with scoliosis?
A: First, one has to understand that many adults who have scoliosis never require treatment; they do not have obvious deformities or breathing problems, and they have no pain. But when an adult has a curvature that is approximately 50 degrees or more, then we begin to consider the possibility of spinal fusion surgery.

Q: How do you decide on who’s a proper candidate for spine surgery?
A: We look at four factors; pain, progression, appearance, and pulmonary. Pain must be significant, and must be related to the scoliosis. Regarding progression, anything under 5 degrees within a year is questionable. A 5 degree change can be the result of any number of variables. For example an x-ray taken of a 40-year-old woman early in the morning might show a 50 degree curve, but an x-ray of the same woman taken at 5 p.m. when she’s tired and slumping could show a curve that’s 5-10 degrees greater.

Q: And what about appearance and pulmonary?
A: While we cannot document appearance with x-rays, simple photographs can be helpful in revealing whether one’s vertebral rotation has gotten worse over time, whether ribs are sticking out more, or whether one has lost height due to an increased curvature. Regarding pulmonary, patients who are at risk for restrictive lung disease are usually those individuals who have a scoliotic curvature of more than 75 degrees in the thoracic (upper back) area. Patients who have lumbar (lower back) or thoraco-lumbar (mid back) curves will usually have pulmonary functions that are normal.

Q: What factors increase the complication of surgery?
A: If surgery involves correction of two curves instead of just one, the patient may have to undergo two surgeries, which of course increases the odds for complications. The patient’s general health is a factor that can affect complication rates, as is the experience and skill level of the surgeon performing the operation.

Q: We know that healing time will vary depending upon the type of surgery performed, and the age and health of the patient. But in general, when can adult surgical patients expect to return to work?
A: You’re right, it is quite variable. But a motivated person, living a reasonable distance from an office location, could return to work in six weeks. Of course, a patient should follow the advice of his or her orthopedist.

Q: Any suggestions for helping patients heal properly?
A: In addition to proper rest, and whatever exercise is recommended by their orthopedist, surgical patients should consume foods that are high in calcium and vitamin D skim milk, for example as well as foods such as yogurt, cheese, bony fish, vegetables such as broccoli, even Japanese seaweed. Avoid excess alcohol, coffee, and tobacco; these will decrease the rate and quality of bone formation

Q: Any other guidelines for adult surgical patients?
A: Each patient’s surgeon will make his or her own recommendations, but during convalescence, one should avoid strenuous physical activities and heavy lifting. Six weeks after surgery, it’s all right to have sex, but actual details of positions should be discussed with one’s surgeon. In my opinion, women who’ve had scoliosis surgery should not consider delivering a child until at least two years after the surgery; it takes that long for fusion to become as hard as it should.

Q: One last question. Will you set the record straight for us about exercise and what it can do for scoliosis?
A: Exercise can help pain that may be associated with scoliosis; the best you can do is swimming the sidestroke and the backstroke. But exercise is not a treatment for scoliosis it cannot stop a cuve from progressing.

The post Adult Scoliosis first appeared on National Scoliosis Foundation.