Scoliosis: How Physiotherapy Can Make a Difference

Scoliosis is a complex musculoskeletal condition characterized by an abnormal curvature of the spine. This condition can manifest at any age, but it typically becomes noticeable during adolescence. The main hallmark of scoliosis is the presence of a lateral curve in the spine, which, if left untreated, can lead to pain, postural issues, and functional limitations.

As a physiotherapist, the aim is to manage and treat scoliosis. The focus is on improving the overall musculoskeletal health and quality of life of individuals dealing with this condition.

 

Is Scoliosis really genetic?

Scoliosis has a genetic component, but its exact cause is still not fully understood. There is evidence to suggest that genetics can play a role in the development of scoliosis, particularly in cases of idiopathic scoliosis, which is the most common form and it can run in families. Studies have shown that individuals with a family history of scoliosis are at a higher risk of developing the condition themselves.

Environmental factors can also contribute to the development of scoliosis. It's essential to note that there are different types of scoliosis, including congenital scoliosis (present at birth) and neuromuscular scoliosis (related to conditions like cerebral palsy or muscular dystrophy), which may have different causes and risk factors.

 

Types of Scoliosis

• Idiopathic Scoliosis - most common type of scoliosis, and its exact cause is unknown. It typically appears during adolescence and can be categorized into three subtypes:

1. Infantile idiopathic scoliosis (birth to age 3)
2. Juvenile idiopathic scoliosis (ages 4 to 10)
3. Adolescent idiopathic scoliosis (ages 11 to 18)

• Congenital Scoliosis - is present at birth and is typically the result of abnormal spinal development during fetal growth. It occurs due to malformation of the vertebrae.
• Neuromuscular Scoliosis - is associated with neuromuscular conditions such as cerebral palsy, muscular dystrophy, or spinal cord abnormalities. The curvature is often a result of muscle weakness or imbalance.
• Degenerative Scoliosis - also known as adult-onset scoliosis, this type occurs later in life as a result of age-related changes in the spine, such as disc degeneration, arthritis, and spinal stenosis. It is more common in older adults.
• Syndromic Scoliosis - associated with underlying genetic syndromes or disorders, such as Marfan syndrome or Ehlers-Danlos syndrome. The curvature is one of many symptoms of the syndrome.
• Functional Scoliosis - it is not caused by a structural abnormality in the spine but is rather the result of other factors, such as leg length discrepancies, muscle imbalances, or poor posture. It can often be corrected with appropriate treatment.

Classification of scoliosis can be done as following also:

Location of the Curve:

• Thoracic Scoliosis: A curve in the upper or thoracic spine.
• Lumbar Scoliosis: A curve in the lower or lumbar spine.
• Thoracolumbar Scoliosis: A curve that involves both the thoracic and lumbar regions.
• Double Major Curve: Two primary curves, often thoracic and lumbar.

Degree of Curvature:

• Mild Scoliosis: Curvature is less than 20 degrees.
• Moderate Scoliosis: Curvature is between 20-50 degrees.
• Severe Scoliosis: Curvature is greater than 50 degrees.

Differentiating between Lumbar and Thoracic Scoliosis

 

Scoliosis and Cobb Angle

The Cobb angle helps to assess the severity of spinal curvature, particularly in conditions like scoliosis. It aids in determining the degree of deviation from a straight line in the spine and is instrumental in diagnosing, monitoring, and planning treatment for scoliosis.

Here's how it works:

1. Identification of Key Vertebrae: To calculate the Cobb angle, we first identify the two most tilted vertebrae at the apex of the spinal curve, one at the upper end (the proximal vertebra) and one at the lower end (the distal vertebra).
2. Drawing Perpendicular Lines: A line is drawn along the superior (upper) endplate of the proximal vertebra, and another line is drawn along the inferior (lower) endplate of the distal vertebra.
3. Angle Measurement: The angle formed at the intersection of these two lines is then measured. This angle represents the Cobb angle, and it is typically measured in degrees.

A Cobb angle of less than 10 degrees is considered within the range of normal spinal curvature.

• A Cobb angle between 10 and 25 degrees is classified as mild scoliosis.
• A Cobb angle between 25 and 40 degrees indicates moderate scoliosis.
• A Cobb angle greater than 40 degrees is categorized as severe scoliosis.

The Cobb angle is crucial for monitoring the progression of scoliosis over time. Regular X-rays are used to measure the Cobb angle, and changes in this angle help healthcare professionals determine whether the condition is stable or progressing. Additionally, the Cobb angle plays a significant role in treatment decisions, such as whether bracing or surgery may be necessary to manage the scoliosis effectively.

Symptoms of Scoliosis

• Uneven Shoulder and iliac crest
• Asymmetrical Waist
• Prominence of the ribs may be visible on one side of the back when bending forward.
• Visible Spinal Curve
• Back Pain
• Muscle Imbalance
• Reduced Range of Motion
• Fatigue
• Respiratory Issues

 

Causes of Scoliosis

• Idiopathic Scoliosis
• Congenital Scoliosis
• Neuromuscular Scoliosis
• Degenerative Scoliosis
• Syndromic Scoliosis
• Traumatic Scoliosis
• Muscular Imbalances
• Connective Tissue Disorders

 

Diagnosis

Patient History: 

Begin by taking a thorough patient history. Ask the patient about any symptoms he may be experiencing, such as back pain, postural changes, or discomfort during physical activities. Inquire about the onset and progression of symptoms and any relevant medical history.

Visual Assessment: 

Physiotherapists can visually assess the patient's posture and spinal alignment looking for the signs listed above.

Physical Examination: 

Perform a physical examination to assess spinal mobility, muscle strength, and any signs of scoliosis-related functional limitations. Pay attention to any muscular imbalances or weakness that may be contributing to the spinal curvature.

Here is a list of clinical tests commonly used to diagnose scoliosis:

Adam's Forward Bend Test:

1. In this test, the patient is asked to bend forward at the waist with his feet together and arms hanging freely.
2. The physiotherapist observes the patient's back for any asymmetry, such as a rib hump or an uneven spinal alignment.
3. This test helps assess the structural nature of the scoliosis and provides a visual indication of spinal curvature.

Plumb Line Test:

1. The patient stands with his feet together while the physiotherapist observes his posture from the front and side.
2. A plumb line or weighted string is used to assess alignment. The line should pass through the earlobe, shoulder, hip, and ankle on the side view.
3. Deviations from the normal alignment may suggest scoliosis or other postural issues.

Other Methods include:

• Shoulder Height Assessment
• Hip Symmetry Check
• Gait Examination
• Pelvic Tilt Assessment
• Measurement of Trunk Rotation by scoliometer or inclinometer 

Patient Education: 

If scoliosis is suspected based on the physical assessment, provide the patient with information about the condition, its potential causes, and the importance of further evaluation and diagnosis by a medical specialist.

 

Research Based Evidence on Scoliosis Treatment Methods

Physiotherapy Scoliosis Specific Exercises Schroth method:

It aims to treat deformities that occur in sagittal plane. It focusses on following domains

• Mobilization and Stretching
• Muscle activation technique 

Lyon method

The Lyon method is primarily associated with the use of a specific type of spinal brace called the Lyon brace, which is designed to manage scoliosis in growing adolescents. below are some key points about the Lyon method:

• based on the principle of 3D correction, which means that it aims to correct scoliosis in three dimensions: the side-to-side curvature (frontal plane), the rotation of the vertebrae (transverse plane), and the alignment of the spine (sagittal plane).
• to be worn 23 hours a day by adolescents with scoliosis.
• includes pads and pressure points to address the rotational component of the deformity. It is designed to provide a three-dimensional correction.
• Often used as early intervention - the rationale is that the adolescent spine is more responsive to correction during the growth phase.
• Regular adjustments required to ensure that the brace continues to provide effective correction.

 

SEAS (Scientific Exercise Approach to Scoliosis) method

It follows the phenomenon of Active Self-Correction. Patients are taught specific exercises and techniques to actively correct their spinal posture and alignment. This includes learning how to engage specific muscles to reduce the spinal curvature. It has following benefits:

• No Brace Dependency - SEAS aims to provide patients with tools to manage their condition through exercise and self-correction.
• It aims to stimulate neuromotor receptors to activate the self-correcting reflex during daily activities and neurosensory receptors to ‘maintain’ the correct posture.
• primary goal of the muscular activation of the SEAS exercises is the stabilization of the torso

 

Barcelona Scoliosis Physical Therapy School (BSPTS) method

The Barcelona Scoliosis Physical Therapy School (BSPTS), also known as the Schroth Method, is a specialized physical therapy approach designed to treat scoliosis and other spinal deformities. It acts in following domains:

• Breathing and Postural Control - to improve lung capacity and postural control. Proper breathing is believed to help correct spinal misalignment.
• Isometric and Eccentric Exercises - to strengthen specific muscle groups on both sides of the spine. These exercises aim to correct muscle imbalances and promote spinal stability.

  

Side Shift method:

This method is often associated with the SEAS (Scientific Exercise Approach to Scoliosis) and Schroth-based scoliosis rehabilitation programs. Key principles of the Side Shift method include:

• Active Self-Correction - it involves actively shifting the spine away from the convexity (the side of the curve) to create a more balanced and aligned posture.
• Three-Dimensional Approach - it aims to address the frontal (side-to-side), sagittal (front-to-back), and transverse (rotational) components of the spinal curvature.
• Mirror Feedback - to visually assess and correct their posture and spinal alignment. This helps individuals develop self-awareness and the ability to actively self-correct their posture.
• Breathing Techniques - to help engage the core muscles and support spinal stability.

 

Scoliosis Treatment 

Breathing Exercises:

Breathing exercises can help improve lung capacity and support the muscles around the spine. Diaphragmatic breathing techniques may be taught to encourage deep, controlled breaths. Some examples are listed below:

• Deep Belly Breathing
• 360-Degree Breathing
• Segmental Breathing
• Pursed-Lip Breathing

 

Stretching Exercises:

Gentle stretching exercises are employed to improve flexibility and reduce muscle tightness. Common stretches target the chest, hip flexors, and muscles along the spine.

• Child's Pose
• Cat-Cow Stretch
• Thoracic Extension Stretch
• Seated Forward Bend
• Side Stretch
• Hip Flexor Stretch
• Chest Opener Stretch
• Wall Angels

 

Strengthening Exercises:

Exercises to strengthen the muscles that support the spine are essential. Core and back muscles are particularly targeted. These exercises may include:

• Core Strengthening Exercises
• Planks
• Bridge

 

Back Strengthening Exercises:

• Prone Y and T Raises: Lie face down with arms extended either in a "Y" or "T" position. Lift your arms off the ground while squeezing your shoulder blades together. Hold for a few seconds and lower.

 

Shoulder Blade Strengthening:

• Scapular Squeezes: Sit or stand with your arms by your sides. Squeeze your shoulder blades together as if you're trying to hold a pencil between them. Hold for a few seconds and release.

 

Hip and Leg Strengthening:

• Clamshells
• Squats
• Neck and Shoulder Strengthening
• Neck Retractions

 

Specific Scoliosis Exercises:

Scoliosis-specific exercises are tailored to the individual's curve pattern. These may include exercises that encourage side-bending and rotation to help reduce spinal curvature.

Examples include the Side Shift method, Schroth exercises, or other scoliosis-specific techniques.

Brace for scoliosis

Boston Brace (Thoraco-Lumbar Sacral Orthosis - TLSO):

• Used for thoracic or thoracolumbar scoliosis.
• Covers the torso from below the axilla to the hips.
• Typically made of rigid plastic and designed to be worn under clothing.
• Worn for most of the day, usually 16-23 hours a day.

Milwaukee Brace (Cervico-Thoraco-Lumbar-Sacral Orthosis - CTLSO):

• Used for cervical, thoracic, and lumbar scoliosis.
• Includes a cervical ring that extends down the spine and a pelvic section.
• Often used for more severe curvatures or when the scoliosis affects multiple regions of the spine.
• May need to be worn for 23 hours a day.

Charleston Bending Brace:

• Used for nighttime bracing for thoracolumbar or lumbar curves.
• Custom-made to apply pressure in the opposite direction of the curve while the wearer sleeps.
• Typically worn for 8-10 hours a night.

TLSO Brace with a Rigo-Cheneau Design (Cheneau Brace):

• A type of TLSO brace designed specifically for adolescent idiopathic scoliosis.
• Custom-made and fitted to the individual's body shape.
• Utilizes a series of pads and pressure points to encourage correction of the curve.
• Worn for 16-23 hours a day.

SpineCor Brace:

• A dynamic brace designed to allow more natural movement while still providing corrective forces.
• Often used for adolescent idiopathic scoliosis.
• Worn during waking hours.

Gensingen Brace (GBW):

• A brace with a design similar to the Cheneau brace.
• Custom-made and designed to provide three-dimensional correction.
• Often used for scoliosis patients in Europe.

Risser Cast:

• Used for very young children with infantile or juvenile scoliosis.
• A plaster or fiberglass cast applied over the torso to guide the spine's growth as the child grows.

 

Complications

• individuals with scoliosis are at risk of developing cervical dystonia
• Pelvic obliquity associated with neuromuscular scoliosis in cerebral palsy
• Idiopathic scoliosis can lead to reduced lung capacity and breathing difficulties and may put pressure on the heart and affect its function.
• Congenital Scoliosis cause spinal cord compression, neurological deficits, and other spinal abnormalities.
• Neuromuscular scoliosis often have underlying neuromuscular disorders (e.g., muscular dystrophy, cerebral palsy
• Pressure sores due to limited mobility in some cases can lead to skin breakdown and pressure sores.
• Joint contractures
• Adolescent Scoliosis may experience psychological and social challenges due to changes in appearance and self-esteem.
• Adult scoliosis may experience chronic back pain and discomfort.