Scoliosis is an abnormal curvature of the spine, which occurs in all three dimensions. It may originate in the structure of the bones, or it may be created by the muscles. It may present as a single or double curve.
Severe presentations of scoliosis may cause excessive forward rounding of the upper back—known as kyphosis—with rounded shoulders and a forward head posture. This may also lead to upper crossed syndrome, which is a muscle imbalance between the chest and neck muscles, which are in a shortened position, and the upper back and throat muscles, which are held in lengthened positions.
Lower crossed syndrome describes a similar muscular imbalance between the low back, abdominal, gluteal, and thigh muscles, which may present alongside an anterior pelvic tilt or a posterior pelvic tilt.
The first time I remember hearing the word scoliosis was in assessment class at school. My spine was crooked, one of my shoulders rolled forward, and one hip was higher than the other. My classmates discussed my abnormal structure, while I shifted my perception of my own posture from “good” to “bad”.
As a manual therapy student, I learned how to assess posture with a plumb line. We talked about shortened, contracted muscles and lengthened, weakened muscles due to scoliosis. Scoliotic curves were presented as a problem in need of correction, and support. I later learned that, to some degree, these structural variances are quite common and not always linked to pain and dysfunction.
Symptoms of scoliosis can vary widely, depending on the type of scoliosis and the reasons for it. Some people are completely asymptomatic and find out they have scoliosis when they have X-ray imaging done for another reason.
Others may experience symptoms, such as back and leg pain or neurological complaints like numbness, tingling, shooting pains, or cramping in one or both legs. In a 2010 study, researchers Hong et al. found that adults with scoliosis are slightly more likely than the general population to have back pain, but the degree of pain is not necessarily related to the severity of the curve. The incidence of these symptoms has been found to increase with age.
In severe cases, there may be such a degree of bending and twisting of the spinal column that lung and heart function are negatively impacted. Surgery may be required in these situations to increase life quality and expectancy.
Psychosocial symptoms of scoliosis should also be considered. Researchers in one study found that subjects were more likely to experience low self-esteem and depression and reported a lower quality of life related to physical health.
In a 2006 study which examined the natural progression and long term treatment outcomes of idiopathic scoliosis patients, researchers Asher and Burton found that people with scoliosis may experience negative psychological and social effects of this condition. These factors may be amplified if surgical treatment or bracing is required, or if the patient’s ability to participate in sports or other meaningful activities is impacted.
Types of scoliosis
There are four main types of scoliosis: idiopathic scoliosis, congenital scoliosis, degenerative scoliosis, and neuromuscular scoliosis.
Some literature also identifies other subtypes of scoliosis, including secondary or adaptive curves. These adaptive curves happen as a result of the muscles attempting to bring the head back over the top of the pelvis. This may be seen when the muscles are adapting to a scoliosis lower in the back or other asymmetry, such as leg length discrepancy, that causes a slanted pelvis. Adaptive scoliosis may also happen in painful conditions as a functional adaptation to avoid pain.
Adaptive scoliosis, which accompanies muscle imbalances, can sometimes be seen in athletes, especially those in sports that require repetitive powerful movements in one direction or of one limb, such as volleyball or baseball. It is not known whether the imbalanced muscle usage leads to scoliosis or if there is a higher prevalence of scoliotic individuals in certain sports.
Idiopathic scoliosis accounts for 80% to 90% of all scoliosis diagnosis. It develops for unknown reasons, usually in adolescence. Adolescent Idiopathic Scoliosis (AIS) is the most common type of scoliosis and is more frequently seen in girls. Girls with AIS are more likely than boys to have a curve which progresses to more than 40 degrees, which is considered severe scoliosis. Although the cause of AIS is not clearly understood, it has been suggested that this may occur secondary to the large growth spurts which are characteristic of adolescence.
In the majority of AIS patients, little or no treatment is required. As older adults, these people may have a slightly higher incidence of back pain than the general population, as shown by Hong et al. The differences in occurrence and severity between genders increases with age. This means that, as women get older, they are increasingly more likely than men both to have a scoliosis and to have a more severe degree of scoliosis. Most cases of adult scoliosis begin in adolescence, although it may not be discovered until later in life.
Congenital scoliosis occurs when a person is born with a malformation of the bones of the spine. The malformation can be mild, and require no intervention, or severe, which may require surgery.
Congenital scoliosis occurs within the first six weeks of embryonic development. The causes of congenital scoliosis are not clearly understood but are likely numerous and may include both genetic and environmental factors. It does not appear to be an inherited condition.
The bones may fail to form properly, separate properly, or both. This tends to happen at more than one spinal level, and often more on one side. In severe cases, this may also be accompanied by fusion of the ribs, and compression of the rib cage on one side, leading to problems with breathing and heart function. A secondary, adaptive curve may also be present.
Degenerative scoliosis happens secondary to degenerative conditions of the bones and joints of the spine, such as degenerative disc disease, osteoporosis, facet disease, or arthritic changes.
The spine is made of vertebrae which stack on top of one another, like bricks. If this support becomes damaged or breaks down on one side, the spine above will deviate. An adaptive curve may occur in order to maintain balance and keep the head on top of the body.
Degenerative scoliosis can create further problems, as the body is forced to accommodate loads in new ways, and the muscles have to work harder to adapt to degenerative structural changes. The degenerative changes causing the curve also often come with associated painful symptoms, which creates a further need for postural adaptation.
Treatments for degenerative scoliosis will range, and may include a combination of lifestyle and exercise recommendations, pharmaceutical pain control, and/or surgical interventions, depending on the individual situation. Treatment should be aimed at addressing the structural degeneration if necessary, but more so managing unpleasant, painful, or debilitating symptoms. The curve itself is not the problem, but rather a symptom or even an adaptation.
Neuromuscular scoliosis occurs secondary to a medical condition which affects the ability of the nervous system to appropriately control the muscles around the spine. Conditions which may cause neuromuscular scoliosis include cerebral palsy, Jeune syndrome, Marfan’s syndrome, spina bifida, and muscular dystrophy. Researchers have found that the incidence of scoliosis ranges from 20% to as high as 64% in cerebral palsy patients. Neuromuscular scoliosis can also present subsequent to a spinal cord injury.
Neuromuscular scoliosis is often only one symptomatic presentation of what can be very complex health conditions. These conditions often present with multiple comorbidities and long term health effects, as well as impacting the patients’ psychological and social well-being.
A 2013 review of the literature concluded that “Evaluation and management of this population requires understanding of disease progression, pulmonary status, functional limitations, indications for conservative and surgical interventions, and social considerations.” The researchers noted that this type of scoliosis is far more likely than AIS to be severe and progressive, and contribute to further health problems.
Diagnosis of scoliosis
On examination, scoliosis presents as asymmetry of the spine and trunk from left to right. One shoulder may be lowered and rolled forward, with ‘winging’ of the shoulder blade, while the other shoulder may be elevated. The left and right sides of the ribcage may be different, and one hip may be higher than the other.
Creases in the soft tissue at the waist, if present, may be more numerous or noticeable on one side and at different levels from left to right. In a relaxed position, one arm may hang closer to the body than the other. The patient may report that their clothes do not fit them properly.
Weight-bearing may be shifted to one side in seated and standing, as the scoliosis may cause the center of gravity to be off, relative to the legs and feet. In milder cases, it can appear as if the person is simply standing with their weight off to one side, with the torso shifted over one leg.
In more severe cases, there may be adaptive forward bending of the spine as well as a forward and off-center position of the head. There may also be an adaptive curve present elsewhere in the back. The thorax may have a ‘windswept’ appearance where it no longer sits over top of the pelvis, and the ribcage is compressed on the side of the concavity and bulging on the side of the convexity.
Scoliosis often includes an element of spinal rotation. If so, the prominence of the muscles down either side of the spine will be uneven. The Adams Forward Bend test has long been used to better observe this positional asymmetry, but researchers have determined that this test may frequently be positive in individuals who do not actually have scoliosis and is inadequate as a diagnostic tool.
The standard measurement used to give a definitive diagnosis of scoliosis is called the Cobb angle. This angle is calculated based on the positions of the vertebrae at the beginning and end of the curve when viewed on an X-ray. A Cobb angle of more than 10 degrees indicates scoliosis, and an angle of more than 40 degrees is considered to be severe scoliosis. A curve under 10 degrees is considered as a normal structural variance.
Researchers have questioned the validity of using this measurement as a diagnostic tool as it is a two-dimensional measurement of a three-dimensional reality, and it is prone to error in defining the beginning and end points of the scoliosis.
If congenital, neuromuscular, and degenerative scoliosis have been ruled out, in the presence of a clear scoliotic curve, a diagnosis of idiopathic scoliosis can be made.
Scoliosis surgery: do you need it?
The short answer is: it depends. Surgical intervention is generally only necessary for those with a curve of greater than 40 degrees, or whose scoliosis is progressing and creating problematic symptoms. The overall health of the patient and involved structures must be considered, as well as the significant short and long term risks associated with spinal surgery.
Surgery for scoliosis may include removal of bone, fusing of vertebrae to limit movement, and insertion of hardware to provide support and guidance to growing structures. Older surgical approaches, like the insertion of Harrington rods, resulted in a rigidly straight back and limited range of motion. Over time, surgical approaches and instrumentation have been adapted and greatly improved upon. Newer approaches, like Anterior Vertebral Body Tethering, offer surgical options which do not necessarily result in significant mobility loss.
Cases of severe congenital scoliosis are often corrected with surgery. In these cases, the surgery may be required in order to allow the individual to breathe and grow properly. Surgery for severe congenital scoliosis may be done to prevent progression of the curve and allow for more normal growth or may be corrective in nature, according to Arlet et al. in their 2003 paper, “Congenital Scoliosis”.
In cases of neuromuscular scoliosis, researchers found that surgery may contribute to increased family and caregiver satisfaction rates, in addition to providing added stability to the patient, which may also help with seated balance.
Two systematic reviews of AIS patient outcomes, done in 2009 and 2017, noted no benefit of corrective surgery for this population versus allowing scoliosis to follow its natural course, or applying conservative treatment approaches. Both reviews noted the traumatic and invasive nature of surgery, which must be considered in examining long term outcomes. The majority of the literature indicates that surgery should be considered only as a last option, if at all, for those with AIS.
Another 2010 review examined surgical outcomes for adult scoliosis patients. The authors noted a lack of standardized outcome measures, making it difficult to draw general conclusions from the research. They found post-surgical improvements in disability, physical, social, and mental health measurements. Peri-surgical complications occurred in as many as 40% of cases, and non-union of fused segments in almost 13% of cases. They concluded that the likelihood of benefit should be seriously weighed against the significant risks of surgery.
Between observation for the mildest cases, and surgery for the most severe, there are many different therapeutic approaches geared towards helping manage scoliosis symptoms and progression.
Lateral Electrical Surface Stimulation (LESS) is one conservative approach which has been used in the treatment of scoliosis. A 2005 systematic review found no evidence to support the effectiveness of this treatment approach.
In a 2009 study, however, Polish researchers found that two hours per day of LESS therapy over 24 months was effective at decreasing progression rate in those with a scoliosis of less than 20 degrees. The study compared results with an exercise control group, as well as a group which received nine hours per day of LESS. Interestingly, they found no difference in outcomes between those who received two and nine hours of treatment per day.
Manual therapies, such as massage therapy, chiropractic, and osteopathic care, have long been used in the management of orthopedic concerns. These disciplines historically lack well-conducted research to back up their claims of effectiveness. This does not mean these approaches are never helpful in individual cases, but it does mean that quality research is needed to provide more information about their potential usefulness.
There are numerous reasons for the lack of high-quality manual therapy research, including the fact that many manual therapy professionals receive their training or education at private institutes. These schools are likely not equipped to support high quality research in the way that a traditional university is able to, both in terms of research framework and education, as well as funding, to promote research.
Manual therapies can be difficult to study using a randomized controlled trial design. Blinding is difficult to achieve, as subjects are able to tell whether they have received treatment or not. Use of a control group can be problematic if the control group participants are aware of their group assignment, (although some researchers use a “sham” treatment approach to get past this hurdle). While the general goal of a randomized controlled trial is to eliminate as many variables as possible, this may be problematic in approaching the study of manual therapy interventions, where contextual factors of treatment can be extremely important.
A systematic review conducted in 2008 found that there was simply no good evidence from which to draw conclusions about the effectiveness of manual therapy approaches in managing scoliosis. This study found only three papers which were relevant to its scope, and none of them met criteria for study inclusion, as they all examined mixed manual therapy approaches to scoliosis treatment.
In a more recent 2019 review of manual therapy approaches for AIS, researchers broadened the scope of the review to include any relevant published English language research, regardless of quality, including case studies. Case studies do not replace higher quality and larger scale objective research, but these “n=1” studies may provide some insight into the potential for manual therapies in supporting scoliosis management.
By broadening the inclusion parameters, the researchers were able to get a better consensus of the existing research. The authors found that all case studies showed improvement in all measured parameters, while observational studies had mixed results, and one randomized controlled trial found no benefit in manual therapy for improving trunk shape and spinal flexibility.
Ultimately, the researchers still concluded that there was no high-quality research from which to draw any conclusions about the effectiveness of manual therapies for scoliosis treatment. The authors did note that the research reviewed provided some basis to justify and promote further study, as the available literature suggested potential for benefit when manual therapy approaches are used as part of a multi-pronged approach to treatment.
Physiotherapists and other health care providers often work together to facilitate a multidisciplinary approach to conservative care of scoliosis and its symptoms. Treatment approaches may incorporate active exercises, manual therapy approaches, bracing, pharmaceutical management of symptoms, and mental and occupational health care and support, depending on the individual case.
Amberly Horton, a Registered Physiotherapist in Grimsby, Ontario, encourages considering both structural and functional aspects of scoliosis in assessment and treatment.
“This means looking at the position and shape of the vertebrae, as well as the movement patterns, body awareness, general strength and flexibility, and strength in muscles that contribute to posture. The role of physiotherapy in treating scoliosis is to retrain the brain and body to slow the curve progression and manage the patient’s pain.”
Horton emphasizes the importance of working with each patient to assess and meet their individual needs and goals, and aiming to support them in living successfully with scoliosis.
Please note that the information in this article is not intended to replace the advice of a qualified professional. Readers should consult with a physician or other qualified health professional in order to determine appropriate treatment approaches for them, if needed.
Scoliosis braces: do they work?
Bracing has been used to treat AIS for many years. The idea behind bracing for scoliosis is to control and direct the growth of the spine and ribcage, resulting in a decreased scoliotic presentation. Bracing is considered when the patient is still growing, the scoliosis is progressing, or has exceeded 40 degrees, and/or in the presence of progressively worsening symptoms such as pain.
Treatment with a brace takes a long time, and involves significant physical discomfort and even pain. As well, there may potentially be aesthetic and social concerns for the brace wearer, especially when the age group of these patients is considered.
There are three main types of braces: the Boston brace, Milwaukee brace, and the Charleston bending brace, also known as the “nighttime brace.” The Boston and Milwaukee braces are similar, except that the Milwaukee brace has a neck ring for added stabilization. The Charleston bending brace is intended only for sleeping in, whereas the other two are intended to be worn 23 hours per day. This dosage of bracing has been found to be effective.
These braces are usually made of rigid plastic, custom molded to the patient’s body. They are designed to put pressure on the convex portions of the scoliosis, and to provide space in the concave area. The theory is that, over time, spinal growth will accommodate the brace, and the curve will be reduced.
The Cheneau brace is another type of rigid plastic brace which is designed to overcorrect and force the trunk into an opposite position to that of the scoliosis, with the same essential goal of gradual correction as the patient grows.
In a 2005 systematic review done by Lenssinck et al., researchers found that the effectiveness of bracing and exercises for scoliosis had not yet been established, but could have potential as a treatment approach. The researchers wrote that “many researchers agreed that people with scoliosis experience problems in their psychological and social development. It appears that quality of life, although measured differently in various studies, is affected not only by the presence of but also by the treatment (especially bracing) for adolescent idiopathic scoliosis.”
The authors of a meta-analysis published in 2019 found that bracing was a safe and efficient treatment approach for AIS. Researchers combed academic databases looking for high quality studies assessing the effectiveness of this approach to treatment. They found seven studies which were of high enough quality to be used, which compared bracing with no specific treatment. They excluded non-randomized studies, those which examined approaches other than bracing, or those which did not have outcome measures.
The authors noted that the research was limited by a lack of follow up data on patients, and a lack of reporting of adverse effects associated with bracing. They found significant differences between successful outcomes in bracing treatment groups versus observation groups. They also determined that quality of life scores between the two groups showed a significant difference, although they noted that bracing treatment comes with its own challenges and potential complications, including pain, skin irritation, and detrimental effects on lung and kidney function.
Does scoliosis cause back pain?
In a study by Hong et al., the researchers found that more than 1,300 elderly people with scoliosis are more likely to experience some symptoms of back pain versus those without. Interestingly, this study found that there was no correlation between the degree of the scoliosis and the severity of the symptoms. The researchers also found that back pain was more prevalent in those who had received surgery to treat scoliosis.
In Asher and Burton’s 2006 study that examined the natural history and long-term treatment outcomes of AIS, the researchers found that although back pain is more common in populations with scoliosis, there may not be a significant difference in the severity or duration of back pain episodes when compared to a non-scoliotic sample.
Pain also does not relate to the severity of the curvature, although different types and locations of curves may have different potentials for causing pain. The authors also found that arthritic changes did not increase the probability of pain, but a “translatory shift of the thoracolumbar spine” may be related to an increased incidence of pain.
In a recently published study, researchers found that back pain in AIS patients was multifactorial, and influenced by the physical scoliosis as well as psychological factors. Those patients who tended to engage in ‘pain catastrophizing’ were more likely to have self-reported pain independent of the severity of the scoliotic curve. Those patients who were found to have lower pain catastrophization scores were found to have a more direct relationship between the severity of their pain and the degree of curvature. This research reinforces current concepts about the multifactorial nature of pain, and the role of mental health support and psychology in scoliosis pain management.
Exercises have long been a part of standard scoliosis treatment approaches, especially in cases of AIS. Exercise approaches have good evidence in support of their effectiveness in treatment of AIS. There could be both physiological and psychosocial reasons for the effectiveness of this active approach to treatment.
In one study, researchers extensively reviewed the approaches used by seven different schools of Physiotherapy Scoliosis-Specific Exercise (PSSE). They found that all the methods had some shared goal of functionally restoring a less problematic three dimensional alignment between the spine, shoulders, ribcage, and pelvis, using movements and exercises, although each method had its own unique approach to achieving this.
They also found reasonably good evidentiary support for the use of these exercises in the treatment of AIS, the most common form of scoliosis. The researchers indicated that further investigation is required to directly compare these approaches and determine which, if any, specific methods and exercises may yield the best outcomes for patients.
The Schroth Method is one of the methods evaluated above. It is an individualized exercise program used by clinicians with a goal of returning the spine to a more neutral position by de-rotating, elongating and stabilizing. Researchers have found some support for this specific method, although they caution that support is limited, and therefore these exercises are best used in combination with other conservative approaches.
A team of Italian researchers have published a series of systematic reviews examining the efficacy of exercise as a treatment for AIS. Their 2008 review reinforced the findings of previous research, which indicated that targeted exercise programs can be effective at slowing progression of scoliosis, decreasing Cobb angle, and reducing the need for brace prescription.
A 2009 paper also determined that exercise is effective at reducing regression in scoliosis after a patient has stopped using a brace.
In terms of participation in “regular”, or non-prescriptive exercise, patients may wonder if it is safe, or if there are activities which should be avoided.
A systematic review also published in 2009 found that braced and post-surgical scoliosis patients were able to participate in sports at a comparable level to non-surgical participants. They further noted that scoliosis is not a contraindication for exercise, and that general exercise is recommended and encouraged for scoliosis patients.
A study published in 2015 seeking to create guidelines for return to activity after scoliosis surgery concluded that the majority of surgeons would allow running after three months, contact sports after six months, and ‘collision’ type sports after twelve months. The researchers did touch on a cautionary tale of a patient who went snowboarding two weeks after surgery with undesirable results.
Scoliosis and massage therapy
When treating a patient with scoliosis, therapists should consider the patient’s goals for treatment, as well as the origin and nature of the scoliosis, in order to best develop an appropriate treatment plan.
During an assessment, patients should be encouraged only to move in a comfortable range, and to speak up if anything recreates unpleasant symptoms or feels unsafe. Therapists should understand that movements will not appear symmetrical. This may be normal for this person, and not something to be corrected. Movement testing will provide information about how the patient is moving, how they feel about moving, and what is being protected in movement.
Patients should be positioned comfortably, with pillows or bolsters for support if needed. They should be reminded that their comfort is important, and given options for positioning.
If the patient finds that any position increases symptoms, care should be taken to accommodate this and avoid that position. As well, if anything being done during the session begins to increase symptoms, the treatment should be adjusted accordingly. Therapists should check in frequently regarding patient comfort and symptom levels.
Treatment should generally be geared towards relief of symptoms rather than correction of the curve, and therapists should take care to avoid alarming clinical terminology when communicating with patients. It may be helpful for patients to understand that the degree of curve does not determine the level of pain or dysfunction.
Patients should be encouraged to be as mobile and active as is appropriate for them, and to especially engage in meaningful activities which they find to be enjoyable. Therapists should help patients learn how to pay attention to cues from their body when exercising, in order to gain confidence that they can move safely without overdoing it or causing further pain.
Years after massage therapy school, as a long-distance runner experiencing stubborn hip pain, I had X-rays of my pelvis taken and found out that I have a congenital fusion between my lowest lumbar vertebra and the top of my pelvic bone on one side (probably not the main contributor to the pain, although possibly a factor). I have consistently experienced low back pain on one side since my late teens. Who knows if this is related to the curve in my back? The idea that it was, was reinforced to me many times. Perhaps the negative messaging about pain has also played a role in the presence of pain.
It seems possible that what I thought for 20 years was scoliosis may actually fall within the parameters of normal structural variance, although there is a mild congenital malformation of my spine. If I do have a mild scoliosis, as defined by a 10 degrees or greater curve, I don’t need a diagnosis because I already know that, for me, being a little crooked is really not that big of a deal anyway. And if it ever were to feel like a problem, I know there are lots of good options available for safe, effective, and non-invasive symptom management.