Scoliosis is a multifactorial disorder that requires multidisciplinary research and treatment. The primary age of onset for scoliosis is 10 to 15 years old, and it occurs equally among both genders. However, females are usually more likely to progress to a curve magnitude that requires treatment. The vast majority of people with this condition are not expected to require treatment. Despite physicians trying to treat this spinal deformity for centuries, most cases are classified as idiopathic.

Clinical Assessment

When one views a normal spine from behind, the back appears straight and the trunk appears symmetrical. When the normal spine is viewed from the side, curves are seen in the neck, upper trunk, and lower trunk. The upper trunk has a gentle, rounded contour called kyphosis, and the lower trunk has a reverse direction of the rounded contour called lordosis. Certain amounts of cervical (neck) lordosis, thoracic (upper back) kyphosis, and lumbar (lower back) lordosis are normally present and are needed to maintain appropriate trunk balance over the pelvis. Deviations from this normal alignment may reflect abnormal kyphosis or lordosis or, more commonly, scoliosis.

Deformity due to scoliosis occurs in varying degrees in all three planes: back to front, side to side, and top to bottom. Scoliosis is a descriptive term and not a diagnosis. Conditions known to cause spinal deformity are congenital spinal-column abnormalities, neurological disorders, genetic conditions, and a multitude of other causes. Scoliosis does not come from carrying heavy things, athletic involvement, sleeping/standing postures, or minor lower-limb length inequality.

Clinical evaluation focuses on history and physical-examination findings. Consideration is given to circumstances surrounding the patient's birth, delivery, and development histories. Was the pregnancy full term? What was the child's birth weight? When did the child begin to walk? Abnormalities in these areas may lead one to consider neuromuscular or congenital etiologies. Intermittent backache may occur with idiopathic scoliosis, but complaints of pain radiating into the legs, night pain, or systemic complaints (for example, changes in bowel or bladder habits) are highly abnormal and are not common complaints in patients with idiopathic scoliosis and usually require further study. A family history of spinal deformity is sought, since certain types of spinal deformity are more prevalent within families.

Physical examination centers on assessment of trunk symmetry. Most people are familiar with the Adam's forward bend test, which is done with the patient bending forward with arms extended and knees straight. Asymmetry of the trunk when viewed from the front or the back, as well as abnormal increases or decreases in lordosis or kyphosis when viewed from the side, are assessed. This test is used during school screening for scoliosis. The test is sensitive to detect trunk asymmetry, but it is not specific for spinal deformity. A common finding that is often misinterpreted as spinal deformity is truncal asymmetry from unequal trunk-muscle development on the patient's dominant-hand side.

Further physical findings depend on the patient's deformity location and magnitude. Shoulder heights may be uneven, and there may be an increased space between the elbow and trunk because of trunk deviation. Prominence of a "hip", pelvis, or breast may be seen. Examination of the skin overlying the spine assesses the presence of dimples, sinuses, hairy patches, and skin-pigmentation changes. The effect of any limb-length inequality is tested with the patient standing on blocks to level the pelvis or seated on a flat surface. Neurological examination includes evaluation of the function of the muscles and nerves of the upper and lower limbs.

Nonsurgical Treatment Options

The treatment prescribed for scoliosis varies with the individual patient. Severity and location of the curve, age, potential for further growth, and general health of the patient all must be taken into account. A mild curvature (up to 20º) generally needs only periodic observation to watch for signs of further progression. Bracing is the usual treatment for children and adolescents with curves of 25º to 40º, and in other special circumstances.

Treatment decisions are based primarily on the patient's skeletal maturity (or rather, how much more growth can be expected) as well as the degree of curvature. The younger the patient and the bigger the curve, the more likely the curve is to progress.

There are essentially three treatment options for adolescents with scoliosis: observation, bracing, and scoliosis surgery. There have been large trials of other forms of treatments, none of which have been shown to be effective.

Because idiopathic scoliosis is considered a deformity, scoliosis treatment is largely centered on reducing or limiting the progression of the deformity and is not focused on treating pain.

Observation and Analysis

The curvature is measured on x-rays by what is known as the Cobb method, and this form of measurement is accurate to within 3º to 5º.

Curves that are less than 10º are not considered to even represent scoliosis but rather spinal asymmetry. These types of curves are extremely unlikely to progress and generally do not need any treatment. If the child is very young and physically immature, then the progress of the curve can be followed during the child's regular check-up with his or her pediatrician. If the curve is noticed to progress beyond 20º, then the child should be referred to an orthopedic surgeon for continued treatment.

Curves that are between 20º and 30º in a growing child can be observed at 4- to 6-month intervals. Any progression that is less than 5º is not considered significant. If the curve progresses more than 5º, then it will need treatment. Any curve measuring more than 30º in a skeletally immature patient (for example, a child who is still growing) will need treatment.

Technological Advancements in Bracing

Treatment for patients with progressing curves, or curves measuring more than 30º in a skeletally immature patient, is usually centered on use of a back brace.

Bracing is designed to stop the progression of the spinal curve, but it does not reduce the amount of angulation already present. The majority of curve progression happens during a child's growth phase; and once the growth has ended, there is little likelihood of progression of a curve. Therefore, bracing is continued until the child is skeletally mature and finished growing.

The only curves that tend to continue to progress after skeletal maturity are those that are greater than 50º in angulation, so the treatment objective is to try to get the child into adulthood with less than a 50º curvature.

There are two types of commonly used scoliosis braces: a thoracolumbar sacral orthosis (TLSO) and a Charleston bending brace. The TLSO is a custom-molded, form-fitting, plastic back brace that applies three-point pressure to the curvature to prevent its progression. It can be worn under loose-fitting clothing, and it is usually worn 23 hours per day. It can be taken off to swim or to play sports. Provided that the rigid brace is well-fitted, it is able to limit approximately 50% of the motion in the spine. Fractures (or broken bones) can often be treated with a rigid brace and may also be used after a fusion surgery.

A Charleston bending back brace applies more pressure and bends the child against the curve. It is worn only at night while the child is asleep.

Since bracing works only to stop the progression of the curvature in a growing child, it is not used for those children who are already skeletally mature or almost mature. It is used only for younger children. If an older child has a curve greater than 30º and is almost mature, his or her curvature will be treated with observation only, as there is little growth left and bracing will be unlikely to do much good.

Unfortunately, even with appropriate bracing, some spinal curves will continue to progress. For these cases, especially if the child is very young, bracing may still be continued to allow the child to grow before fusing the spine. Many times it is very difficult to predict which curves will continue to progress and will need surgery later, especially if the child is young and skeletally immature. When in doubt, many physicians will recommend treatment with a brace.

A recent advancement in nonsurgical scoliosis care is the Spinecor™ brace, developed by orthopedic surgeon Christine Collaird, MD. The Spinecor brace can be fitted for the patient and worn home the same day. Instead of the hard shell found in most current braces, the Spinecor features fitted elastic bands. The sequence, direction, and tension in each band are carefully selected to allow the use of natural muscle activity to reduce the scoliotic deformity immediately. The Spinecor uses movement and increased muscle activity to change the spine.

Case Study

There are many new reports that reveal exercise as an alternative treatment for adolescent scoliosis. MedX, Gainesville, Fla, recently published results of its study, which included the use of the Core Spinal Fitness Systems. The study showed that children reduced or completely reversed the curvature of their spine.

One example is the case of Giovonne Vernacchia, a competitive gymnast and varsity track athlete, who was diagnosed with Adolescent Scoliosis. Vernacchia wore a brace for more than a year. However, her scoliosis had worsened to 39º.

Vernacchia was selected to participate in the study. She threw out her braces and started exercising for less than 10 minutes, three times per week, on the core Torso Rotation machine, part of the Core Spinal Fitness Systems. Her spine curvature returned to 36º.

Steven Pierce, PT, is a rehabilitation specialist at the New Horizons Physical Therapy Center in Ottowa, Canada. For more information, contact .