Scoliosis

The normal spine in a growing person has a precise, precarious, delicate mechanical balance. Asymmetrical changes in primary structures, support structures, growth centers, the position of the spine and related neural or muscular components can result in the development of scoliosis.
– AA White

Scoliosis is defined as an abnormal 3-dimensional curvature of the spine measuring greater than 10 degrees. Scoliosis that occurs spontaneously without any injury or noticeable causation is classified as idiopathic scoliosis (IS), and is the most common form of spinal deformity accounting for roughly 80% of all cases of spine deformities.

Adolescent IS (AIS) is the most common form of spinal deformity, affecting 3-4% of children worldwide, and presents between the ages of 10 and 18 when children are undergoing puberty and a period of rapid growth. Females are five times more likely to develop AIS, and are ten times more likely to progress to a stage where surgery is necessary.

Causes

There are many theories as to what causes scoliosis to occur from genetics to stem cells, and from hormones to neurologic deficiencies. We are movement scientists and will restrict this overview to biomechanical causes.

Here are some common theories:

R.G. Burwell… “There is a view that there are two types of pathogenesis factors for idiopathic scoliosis: initiating (or inducing) factors and those that cause curve progression“.

“Progressive AIS, mainly affecting girls, is generally attributed to relative anterior spinal overgrowth from a mechanical mechanism (torsion) during the adolescent growth spurt.”

There is a balancing act going on during growth between the autonomic nervous system, and the bones and muscles of the spine as they interact with gravity and ground reaction forces as a children and adolescents move though the world.

Skeletal growth of the spine is driven hormonally and supplemented by the function of the sympathetic nervous system which releases hormones to facilitate growth of the spine on both the left and right side. At the same time, the trunk musculature, ligaments, fascia and bones work to continually adapt to the growing and changing skeleton as well as to the forces and loads acting on the body with movement.

It is hypothesized that a disharmony develops in the spine and trunk between the two nervous systems, the sympathetic nervous system, and the central nervous systems control of the muscles.

The second theory we describe is called the Nottingham Concept. In this hypothesis there is a mismatch between the rotation that is created in the spine by the pelvis during human gait and movement and the ability of the spinal muscle to effectively control these forces. Abnormal hip motion and pelvis motion can lead to excessive forces and movements that the spinal muscles fail to effectively dampen leading to scoliosis.

Lastly, some studies show that there are anomalies of balance function and proprioception in the AIS patient.

Classical Treatment Approach

The traditional medical approach involves…

Observation

This typically involves X-rays of the spine and a curve measurement called the Cobb angle. Once a baseline is established, appointments are made periodically to evaluate the progress of the curve.

Generally speaking, those with curves of 10 to 25 degrees are monitored for surveillance with serial x-rays. This is usually at 3, 6 or 12-month intervals.
Those with curves greater than 25 degrees but less than 40 to 45 degrees are candidates for bracing. The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) was an NIH funded randomized control trial that illustrated the effectiveness of bracing in the adolescent population. Even though braces are widely prescribed, these uncomfortable devices have low compliance rates and their overall success remains questionable.
Those with curves over 40 to 45 degrees who are skeletally immature are operative candidates. The mainstay of operative treatment is surgical fusion.

Braces

If your child has moderate scoliosis and the bones are still growing, your health care provider may recommend a brace. Wearing a brace won’t cure scoliosis or reverse the curve, but it usually prevents the curve from getting worse. The most common type of brace is made of plastic and is contoured to conform to the body. This brace is almost invisible under the clothes, as it fits under the arms and around the rib cage, lower back and hips.

Most braces are worn between 13 and 16 hours a day. A brace’s effectiveness increases with the number of hours a day it’s worn. Children who wear braces can usually participate in most activities and have few restrictions. If necessary, a child can take off the brace to participate in sports or other physical activities

Surgery

Severe scoliosis typically progresses with time, so your health care provider might suggest scoliosis surgery to help straighten the curve and prevent it from getting worse.

Surgical options include:

  • Spinal fusion. In this procedure, surgeons connect two or more of the bones in the spine, called vertebrae, together so they can’t move independently. Pieces of bone or a bonelike material is placed between the vertebrae. Metal rods, hooks, screws or wires typically hold that part of the spine straight and still while the old and new bone material fuses together.
  • Expanding rod. If the scoliosis is progressing rapidly at a young age, surgeons can attach one or two expandable rods along the spine that can adjust in length as the child grows. The rods are lengthened every 3 to 6 months either with surgery or in the clinic using a remote control.
  • Vertebral body tethering. This procedure can be performed through small incisions. Screws are placed along the outside edge of the spinal curve, and a strong, flexible cord is threaded through the screws. When the cord is tightened, the spine straightens. As the child grows, the spine may straighten even more.

Functional Approach

At PróMotion Physical Therapy we have put together a bio-psycho-social approach that combines manual therapy and auto-mobilization, the dynamic movement approach as taught by the Gray Institute for Functional Transformation and the SEAS (scientific exercise approach to scoliosis).

All of these approaches to scoliosis exercise treatment are based on a strong modern neuro-muscular-physiological basis.

SEAS

SEAS is an individualized exercise program adapted to all situations of conservative treatment of scoliosis. It is a stand-alone approach in low-medium degree curves during growth to reduce the risk of bracing; complimentary to bracing in medium-high degree curves during growth.

The goal with this approach is to…

  • Increase patient’s awareness of the deformity
  • Emphasize an independent auto-correction by the patient
  • Use of exercises in which balance reactions are elicited
  • Exercises to increase spinal stabilization.
  • A focus on a cognitive-behavioral approach of the patient to increase compliance to treatment
  • Gray Institute Approach to Scoliosis

In this approach, we use dynamic 3 dimensional mobility exercises and dynamic resistive muscular loading of the spine.

The mobility exercises are performed to unwind the curve and the muscular exercises are performed to reflexively stimulate the muscles that will help control the scoliotic curve.

Mobilization Exercises

Passive mobility exercises are instructed to stretch the tight connective tissue and muscle that develop as a result of the curvature.

Psycho-Social approach

Research studies on scoliosis and adolescents uncover the complex biopsychosocial needs of adolescents with scoliosis. The postural dysfunction and pain can lead to body image concerns, chronic pain, embarrassment with brace wearing and concerns with the limitations scoliosis can create in everyday activities.

At PróMotion we use PACT (perception action context targeting) to help our clients develop a sense of what they perceive to be limiting their ability to make progress toward their desired goals.

This approach helps clients define clear goals and then identify any external and internal factors that may prevent them from moving forward toward their goals. The pathway towards a healthier spine is seen as a journey, and the prescribed exercises as vehicles to get to the goals identified. Emphasis is placed on using the goals to create a destination which serves as motivation to move forward. With committed action toward the goals, the identification of perceived roadblocks leads to the creating of countermeasures that will help keep things moving forward.