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Scoliosis

What is scoliosis? Scoliosis is an abnormal curvature of the spine. The spine normally has front to back curves, but in scoliosis, there is an additional lateral curve of the spine with a rotational component. The ribs are connected to the spine, and move with the spine, so if the spine is bent to the left (which will rotate the spine to the right), that will cause the ribs on the right to protrude in the back. The muscles on the right upper back in this example are overstretched and usually weak, and tight on the left upper back on the inside (concave) portion of the curve. Abnormal curves are called an “S” (more common, see diagram A below) or a “C” curve depending on shape of curve and location in the spine. It is not just ‘poor posture’, although how the spine looks is often the main reason for seeking medical advice initially versus pain. Typical signs of scoliosis are: one shoulder higher than another; one shoulder blade sticking out more than the other; one side of the pants or dress hem hanging lower; and most importantly, is there a bulge on one side of the upper back when bending forward (rib hump).

Scoliosis usually develops during the years when the bones are growing the fastest (early adolescence), and is often detected around age 11. As many as 5-10% of children from ages 9-14 will develop scoliosis, but most of these will be mild and will not require more than regular exams to make sure that the curve does not worsen. This is the major concern, for as the curve progresses, it becomes more difficult to correct, and may impact cardiopulmonary function in severe cases. Almost 80% of the time its cause is unknown (called idiopathic), and for some reason, occurs much more often in the severe form in girls, although occurrence is about equal in its mildest form.

For the more common ‘mild’ curves (considered under 15 o, measured by X-ray), the treatment is usually ‘watchful waiting’ where the child is reexamined every 6 months to make sure that the curve is not progressing. Physical therapy is often ordered to instruct the child and their family in basic stretching and spinal stabilization exercises to help correct imbalances in muscle length, and strengthen the support muscles in the spine, pelvis and shoulder girdle. Although a rote basic exercise program has not been shown to be as helpful, a more tailored program with the patient focusing on fine motor control of the abdominal, pelvis and spinal muscles seems to be more effective in decreasing curve progression, and in some cases helping partial curve reversal. Additional selective soft tissue stretching of the tight myofascia can be useful also.

Other additional treatments in the under 20 o curve are electric muscle stimulation used at night to strengthen weak muscles on one side of the curve. This treatment has shown some success, but more research needs to be done. For curves over 20 o or a curve that is rapidly progressing, bracing is used on a 23 hour/day basis. The patient is allowed out for bathing and spinal exercises, but is allowed/ encouraged to be active in many sports activities while in the brace. These rigid braces like the Boston or Milwaukee brace, immobilize the entire upper/lower back, and for some patients up to the neck. They will need to be used until the patient reaches skeletal maturity so the curve will not progress further to prevent additional medical problems. Severe cases may need surgery.

In adults, scoliosis is also quite common, and although the curve usually will not progress, the abnormal stresses on the spine can cause/exacerbate spinal pain. An undetected structural, or a functional (ie tight quadratus lumborum causing the iliac crest to be elevated) leg length discrepancy can be easily be a major contributor to the curve, and can be corrected with a small heel lift (see diagram B). However, the adult patient, like the adolescent, will still need to stretch all tight spinal and pelvic girdle muscles, and strengthen weaker muscles to correct muscle imbalances and movement impairments to have optimal results. Surprisingly, some patients have a major decrease in the amount of their curve, as well as greatly decreased pain with a scoliosis exercise program, although a ‘miracle cure’ to eliminate the curve is not possible.