Scoliosis describes the nature of the spine's curve. Some curvature in the neck, upper trunk, and lower trunk is normal. Humans need these spinal curves to help the upper body maintain proper balance and alignment over the pelvis. However, when there are abnormal side-to-side (lateral) curves in the spinal column, it is referred to as scoliosis.

There are many causes of scoliosis, including congenital spine deformities, genetic conditions, neuromuscular problems, and limb-length inequality. More than 80% of scoliosis cases, however, are idiopathic, which means that there is no known cause. Most idiopathic scoliosis cases are found in otherwise healthy people. People with a family history of spinal deformity are at greater risk for developing scoliosis.

Idiopathic scoliosis is broken down into four categories based on age: (1) infantile: children ages 3 and under; (2) juvenile: ages 3 to 9; (3) adolescent: ages 10 to 18; and (4) adult: after skeletal maturity. The most common form of scoliosis, representing approximately 80% of idiopathic scoliosis cases, is adolescent idiopathic scoliosis (AIS), which develops in young adults around the onset of puberty.

There are two other types of scoliosis: functional and neuromuscular. In functional scoliosis, the spine is normal, but an abnormal curve develops because of a problem somewhere else in the body. This could be caused by one leg being shorter than the other or by muscle spasms in the back. In neuromuscular scoliosis, there is a problem when the bones of the spine are formed. Either the bones of the spine fail to form completely, or they fail to separate from one another. This type of scoliosis develops in patients with other disorders including birth defects, muscular dystrophy, cerebral palsy, or Marfan's disease. This type of scoliosis is often much more severe and needs more aggressive treatment than other forms of scoliosis.

TREATMENT OPTIONS

Treatment of scoliosis is based on the severity of the curve and the chances of the curve getting worse. Certain types of scoliosis have a greater chance of getting worse, so the type of scoliosis also helps to determine the proper treatment.

As functional scoliosis is caused by an abnormality elsewhere in the body, such as a difference in leg length, this type of scoliosis is addressed by treating that abnormality. There is no direct treatment of the spine because the spine is normal in these patients. Neuromuscular scoliosis, caused by an abnormal development of the bones of the spine, has the greatest chance for getting worse. Observation and bracing do not normally work well for these patients. The majority of these patients will eventually need surgery to stop the curve from getting worse.

Treatment of idiopathic scoliosis is based on the person's age when it develops. AIS is the most common form of scoliosis. If the curve is small when first diagnosed, it can be observed with routine x-rays and measurements. If the curve stays below 25º, no other treatment is needed. If the curve is between 25º and 40º, a brace may be recommended. If the curve is greater than 40º, then surgery may be recommended.

BRACING OPTIONS

There are several different types of braces commonly used to treat the spinal curves associated with scoliosis.

Thoraco-Lumbo-Sacral-Orthosis (TLSO)

There are a variety of TLSO braces, but the one most commonly used to treat scoliosis is the Boston Scoliosis Brace by Boston Brace. TLSO braces are often called "low-profile" or "underarm" braces. They are not as large or bulky as the Milwaukee Brace (see below), and their plastic components are custom-molded to fit the patient's body.

The Boston Brace extends from below the breast to the beginning of the pelvic area in the front and from below the shoulder blades to the tailbone in the back. This type of brace works by applying three-point pressure to the curve to prevent its progression. It forces the lumbar area to flex, which pushes in the abdomen and flattens the posterior lumbar curve. Strategically placed pads place pressure on the curve, and "relief voids" are located opposite the areas of pressure. The Boston Brace is typically prescribed for curves in the lumbar (low-back) or thoraco-lumbar (mid- to low-back) sections of the spine.

Charleston Bending Brace

Another bracing option is the Charleston Bending Brace, known as a "part-time" brace since it is worn only at night. The Charleston Bending Brace is molded to conform to the patient's body while he or she is bent toward the convexity—or outward bulge—of the curve, the concept behind this design being that it "overcorrects" the curve during the 8 hours the brace is worn. The Charleston brace is typically recommended for spinal curves of 20º to 35º, with the apex of the curve below the level of the shoulder blade.

Milwaukee Brace

(Cervico-Thoraco-Lumbo-Sacral-Orthosis)

The Milwaukee Brace is commonly used for high thoracic (mid-back) curves. It extends from the neck to the pelvis and consists of a specially contoured plastic pelvic girdle and a neck ring connected by metal bars in the front and the back of the brace. The metal bars help extend the length of the torso, and the neck ring keeps the head centered over the pelvis. Pressure pads, strategically placed according to the patient's curve pattern, are attached to the metal bars with straps.

Other braces include:

• The Providence Brace, a computer-fitted brace worn only at night.
• "A bracing method called SpineCor™, by Spinecorporation Ltd, which uses adjustable bands and a cotton vest that allows flexibility.
• "The Wilmington Brace, a total-contact orthosis typically fabricated from a lightweight plastic material called orthoplast. The brace is designed as a "body jacket," with a front closure and adjustable Velcro straps.

PHYSICAL THERAPY AND EXERCISE

The goals of physical therapy are to help improve back posture, foster aerobic fitness, maximize range of motion and strength, and clarify ways to manage the symptoms of scoliosis. A well-rounded rehabilitation program assists in calming pain and inflammation, improving mobility and strength, and helping with daily activities. Adolescents with idiopathic scoliosis should be encouraged to continue their normal activities, including sports. Exercise has not proven helpful for changing the curves of scoliosis. However, it can be helpful in maintaining flexibility, especially in the hamstrings and low back.

Therapeutic exercises can help maximize patients' physical abilities, including flexibility, stabilization, coordination, and fitness conditioning.

Flexibility

Exercises that increase flexibility help to reduce pain and make it easier for the patient to keep his or her spine in a healthy position. Flexibility exercises are helpful for establishing safe movement. Tight muscles cause imbalances in spinal movements. This can make injury of these structures more likely. Gentle stretching increases flexibility, eases pain, and reduces the chance of reinjury.

Stabilization

The "core" muscles you'll be working on are closer to the center of the body and act as stabilizers. These key muscles are trained to help position the spine safely and to hold the spine steady as routine activities are performed. These muscles form a stable platform that let the limbs move with precision. If the stabilizers aren't doing their job, the spine may be overstressed with daily activities.

Coordination

Strong muscles need to be coordinated. As the strength of the spinal muscles increases, it becomes important to train these muscles to work together. Learning any physical activity takes practice. Muscles must be trained so that the physical activity is under control. Spine muscles that are trained to control safe movement help reduce the chance of reinjury.

Fitness Conditioning

Improving overall fitness levels aids in recovery of spine problems. Fitness conditioning involves safe forms of aerobic exercise, including swimming laps, walking on a treadmill, using a cross country ski machine, or using a stair stepper.

Functional Training

Therapists use functional training when patients need help doing specific activities with greater ease and safety. Examples include posture, body mechanics, and ergonomics.

Posture

Using healthy posture keeps the spine in safe alignment, reducing strain on the joints and soft tissues around the spine. The time and effort taken to use good posture are vital to spine care, including prevention of future spine problems. As strength and control are gained with stabilization exercises, proper posture and body alignment will be easier to remember and apply with all activities.

Body Mechanics

Think of body mechanics as putting safe posture into action. It's one thing to sit or stand with good posture, it's another to keep safe posture as one actually moves with activity. The body must be kept in its safest alignment as daily tasks, such as getting out of a chair, taking out the trash, getting clothes out of the dryer, brushing one's teeth, and lifting are performed.

Ergonomics

It's possible that even minor changes in the way patients do their work or hobby activities could keep pain and symptoms in check while protecting the spine from further injury. Ergonomics doesn't usually involve expensive changes. Even minor adjustments in the way activities are done can make a huge difference in easing pain and preventing further problems.

Assessment Trends

Recently, there has been a push to prioritize scoliosis screening in schools. Schools perceive early screening tests to lack cost efficiency. However, early screening is a crucial aspect in detecting scoliosis at a manageable state. Four major medical associations—the American Academy of Orthopaedic Surgeons, the Scoliosis Research Society, the Pediatric Orthopaedic Society of North America, and the American Academy of Pediatrics—have joined forces to get the word out about the importance of screening in schools for scoliosis, giving lawmakers the information they need to decide on mandating early screening in schools, and hence increasing early detection and treatment.

Jane Haverfield, PT, is a staff therapist at Peak Physical Therapy in Portland, Ore. For more information, contact .