Scoliosis: Diagnosing, Symptoms, and Treatments

As a physical therapist, I often work with individuals who have scoliosis, of various forms. I am going to break down scoliosis for you and some of the treatments that are used for correcting or delaying progression of scoliosis. All the information I have provided below is based on research (posted at the end of this article), but not meant to replace medical advice provided by your doctors or other healthcare professionals.

There are 4 types of movements in the spine:

Flexion:

Extension:

Side Bending:

Rotation:


What is Scoliosis?

Scoliosis is a deformity of the spine that occurs in 3 dimensions. This means it is not simply an “S” or “C” but that it also has some degree of spine flexion, spine side bending, and spine rotation involved. Usually scoliosis is idiopathic, meaning it occurs without a known reason but in some cases it can be associated with genetics or aging. 75-80% of scoliosis occurs without a know reason (idiopathic scoliosis) (Larson, 2011). Scoliosis can occur at any point in aging but is mostly seen in growing adolescents and older adults. Scoliosis can occur in 2-3% of adolescents between ages of 10 and skeletal maturity and there is no difference in occurrence between males and females (Kotwicki et al, 2013), although females are 8 times more likely to progress to a scoliotic curve that will require conservative treatment (Fishman et al, 2014). This means although males tend to get scoliosis at the same percentage as females, males tend to have a more mild form that does not usually require treatment.

How is Scoliosis Diagnosed?

Diagnoses usually occurs between about 10 years of age and skeletal maturity by a medical doctor using an x-ray. When an x-ray is taken, there is a measurement called the Cobb angle that is used to measure the degree of scoliosis. If the Cobb angle measurement is greater than 10 degrees, it is considered significant for scoliosis. At this point, x-rays will be taken every 6-12 months after initial diagnosis to monitor for progression as the individual continues to grow. There is also an easy way to screen for scoliosis that physical therapists and other clinicians use- a test called Adam’s Test (or Forward Bend Test) that must be performed both in sitting and in standing to maximize the accuracy. If this test is performed only in standing it could have a false positive caused by hamstring tightness, leg length discrepancy, or just someone who may not bend exactly straight down. The test is performed as seen below:

The test is considered positive if there is a hump on one side of the rib cage.


Symptoms of Scoliosis:

Some individuals may not be symptomatic at all. Most commonly symptoms will include back, shoulder, hip, and/or knee pain due to asymmetry of the spine. Someone may also notice difficulty with breathing, incontinence (urinary leaking during activity or forceful movements like coughing), uneven hips or shoulders, and tightness. Most commonly, individuals who have scoliosis at a young age may have concerns with appearance, difficulty with sports participation, and a hard time socializing with peers.

Treatment for Scoliosis:

All of the treatment stated below is based on the guidelines in current literature for treating scoliosis. The treatment for scoliosis will be dependent on the Cobb angle at the time of diagnosis. If the Cobb angle is 10-20 degrees, the wait and see approach will be taken. At this point there is no treatment but the doctor may recommend x-rays every 3-12 months following diagnosis to assess for worsening (Larson, 2011). If the Cobb angle is 20-45 degrees in an individual who is still growing, bracing will most likely be recommended (Larson, 2011). There are multiple different approaches to bracing that will be selected based on the individual. Mostly likely, the brace will be worn for 23 hours per day (Negrini et al, 2011). As a clinician, I have seen that children have a hard time with wearing the brace as long as they are supposed to. There are many reasons for this. Braces can be sweaty, uncomfortable, feel restricted, or make these children feel different than their peers. It is important to remember that even if they wear the brace 16-18 hours per day it still won’t be as successful as wearing it 23 hours per day (Negrini et al, 2011). It is very important to wear the brace for the length of time that the doctor has prescribed to get the maximum therapeutic benefit, especially to decrease risk for further issues in the future. If bracing is used as prescribed, about 80% of these people can avoid surgery (Zhu et al, 2017). Surgery is usually used as treatment in a Cobb angle of 50 degrees or higher, if the Cobb angle increases 6-10% in 1 year (71% prognosis for surgery), or an increase >10 degrees (100% prognosis for surgery) (Larson, 2011). Physical therapy can be prescribed at any point in time for individuals of scoliosis regardless of Cobb angle but is dependent on the doctor. Physical therapy can reduce Cobb angle, reduce risk of progression, or limit the amount of progression. Physical therapy can also provide improved alignment, aesthetics, and decreased need for surgery (Kotwicki et al, 2013). Overall, physical therapy can improve breathing, strength, flexibility, and alignment in those who have scoliosis.

It is important to remember that even if the curve worsens by 5 degrees with conservative measurements this is considered successful treatment. This is because it may have worsened more than 5 degrees had conservative measurements not been taken.

Exercise Specifics for Scoliosis:

There are 2 things to consider with scoliosis when thinking of specific exercises- weakness and tightness. To make it easy, let’s talk about someone who has a “C” curve. The not so anatomically correct picture below is the best I can draw to easily represent this description (have I said I’m a physical therapist? definitely not an artist!):

If you look at this picture, this is a back view. You can see that the spine is shaped like a forward C. The red side is called the concave side and the purple side is called the convex side. In someone with a C shape, the concave side will be tight (as depicted by the red lines) and the convex side will be weak (depicted by purple lines). Although there is asymmetry, I still tend to perform stretches and strengthening on both sides with my patients. Side planks tend to be a great exercise for these individuals. A study by Fishman et al, (2014) had individuals with scoliosis perform a side plank for an average of 1.5 minutes daily for 5-7 days a week with the convex side down for 3-22 months. The result was a decrease in curve by an average of 32%. The important thing to note is that the side plank needs to be done correctly. If you are performing this on your own, it is good to do it in front of a mirror to make sure your hips and shoulders are all level with each other. In terms of the tightness, especially on the concave side, performing a side bend stretch is helpful. Stretching the concave side can improve the length of the tight muscles which can allow for more motion of the spine. I have often noticed that someone with scoliosis will rest in the position that their spine naturally assumes. So if someones has a curve as shown above in the drawing, they might stand with more weight on their right leg, sit with right leg crossed over left, or might sleep on their left side. I spend a lot of time educating my patients to make sure they do the opposite of what their body naturally wants to do. We want to promote symmetry not only during exercises but in everything we do 99% of the rest of the day. If someone is spending majority of their day resting in their scoliosis curve (because that is comfortable for them) they are only reinforcing their scoliosis. In addition to trying to promote spine symmetry during the day and night, there are additional exercises that can be done. See below for pictures of specific stretches and exercises:

Side Plank on Forearm (Hold 10 seconds for 5 reps)
Modified Side Plank on Forearm
Plank on Hands (hold 10 seconds for 10 reps)
Modified Plank on Hands (keep your back flat as stated above)
Prayer Stretch hold 1 minute
Prayer Stretch to the Right
Prayer Stretch to the Left

Disclaimer: do not perform any of these exercises if they are painful.

Thanks for reading!

Katie PT, DPT


References for Further Reading:

1. Berdishevsky, Lebel, Bettany-Saltikov, Rigo, Lebel, al E. Physiotherapy scoliosis-specific exercises- a comprehensive review of seven major schools. Scoliosis Spinal Disord. 2016;11(20):1-52.

2. Kotwicki, Chowanska, Kinel, Czaprowski, Tomaszewski, Janusz. Optimal management of idiopathic scoliosis in adolescence. Adolesc Health Med Ther. 2013;4:59-73.

3. Du, Yu, Zhang, Jiang, Lai, al E. Relevant areas of functioning in people with adolescent idiopathic scoliosis on the international classification of functioning, disability, and health: The patients’ perspective. J Rehabil Med. 2016;48:806-814.

4. Weiss, Karavidas, Moramarco, Moramarco. Long-term effects of untreated adolescent idiopathic scoliosis: A review of the literature. Asian Spine J. 2016;10(6):1163-1169.

5. Minsk, Venuti, Daumit, Sponseller. Effectiveness of the Rigo Cheneau versus Boston-style orthoses for adolescent idiopathic scoliosis: A retrospective study. Scoliosis Spinal Disord. 2017;12(7):1-6.

6. Larson. Early onset scoliosis: What the primary care provider needs to know and implications for practice. J Am Acad Nurse Pract. 2011;23(8):392-403.

7. Fishman, Groessl, Sherman. Serial case reporting yoga for idiopathic and degenerative scoliosis. Glob Adv Health Med. 2014;3(5):16-21.

8. Negrini, Aulisa, Aulisa, Circo, Mauroy, al E. 2011 SOSORT guidelines: Orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis. 2012;7(3):1-35.

9. Huh, Eun, Kim, Jung, Choi, Kim. Cardiopulmonary function and scoliosis severity in idiopathic scoliosis children. Korean J Pediatr. 2015;58(6):218-223.

10. Zhu, Xu, Jiang, Sun, Qiao, al E. Is brace treatment appropriate for adolescent idiopathic scoliosis patients refusing surgery with Cobb angle between 40 and 50 degrees. Clin Spine Surg. 2017;30(2):85-89.

11. Margonato, Fronte, Rainero, Merati, Veicsteneinas. Effects of short term cast wearing on respiratory and cardiac responses to submaximal and maximal exercise in adolescents with idiopathic scoliosis. Eur Medicophys. 2005;4(1):135-140.

12. Gillingham, Fan, Akbarnia. Early onset idiopathic scoliosis. J Am Acad Orthop Surg. 2006;14(2):101-112.

13. Atici, Aydin, Atici, Buyukkuscu, Arikan, Balioglu. The effect of kinesio taping on back pain in patients with Lenke Type 1 adolescent idiopathic scoliosis: A randomized controlled trial. Acta Orthop Traumatol Turc. 2017:1-6.

14. Morningstar, Stitzel, Siddiqui, Dovorany. Chiropractic treatments for idiopathic scoliosis: A narrative review based on SOSORT outcome criteria. J Chiropr Med. 2017;16(1):64-71.

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