Advanced Treatments & Rehabilitation Approaches for Treating Scoliosis

Introduction

Scoliosis is a benign three-dimensional deformity of the spine that affects between 2%-4% of the pediatric population. The most affected age group is adolescence, representing 90% of cases diagnosed in children. Girls are more commonly affected by scoliosis with a ratio of 1.5-3:1 boys. Scoliosis is defined as a lateral spinal curvature of at least 10 degrees combined with spinal rotation.

The impact of scoliosis is multifaceted ranging from asymptomatic in mild cases, to back pain, cardiopulmonary compromise and psychological and physical disability in moderate and severe cases. Management of scoliosis has revolutionized multidisciplinary rehabilitation approaches with scoliotic specific exercises, Pilates-based exercises, three-dimensional bracing and robotic-assisted therapy.

Understanding Scoliosis

Scoliosis in the pediatric population consists of two types:

• Idiopathic type: Comprises 80% of cases and the exact cause is unknown. Genetic abnormalities, alterations in muscle and connective tissue, abnormal rib cage anatomy, melatonin secretion, endocrine disorders, and mineral metabolism have been proposed as causes of idiopathic scoliosis.  It is classified based on age of presentation. Adolescent scoliosis, which is present at age 10 years or older, is the most common form of IS.
• Non-idiopathic type: Comprises 20% of cases and it is associated with certain conditions such as neuromuscular dysfunction (i.e. cerebral palsy) and congenital vertebral malformations.

Adult scoliosis consists of two main groups:

• The first is due to the progression of adolescent scoliosis curves after skeletal maturity.
• The second occurs in adults after the age of 40 and is referred to as degenerative or “de novo” scoliosis. Degeneration of the spine from disc and facet joint dysfunction is the main culprit in de novo scoliosis.

Idiopathic Scoliosis (IS) is diagnosed when the lateral curvature of the spine (Cobb angle) is at least 10 degrees. Mild scoliosis is diagnosed when a curve is between 10-20 degrees, with patients often being asymptomatic. A curve of 20-40 degrees is diagnosed as moderate scoliosis, where patients can complain of back pain due to disc pathology. Severe scoliosis is diagnosed when a curve is greater than 40 degrees with risk of cardiopulmonary symptoms. Individuals with curves of > 50 degrees are at risk for shortness of breath and diminished lung volumes. The risk of scoliotic curve progression remains a clinical challenge in modern medicine. The progression of IS has been linked to periods of rapid growth in adolescence.

There are several scoliosis screening tools which can be instituted in schools and in pediatric settings. The goal of scoliosis screening is to detect mild cases so that early and effective conservative management can be provided for individuals with IS, which in turn can slow or prevent curve progression before skeletal maturity.

• Forward Bend Test (FBT): also known as an Adams test, it is the most common scoliotic screening tool used by school nurses and pediatricians.
• Scoliometer: a handheld, noninvasive device used to measure the angle of trunk rotation (ATR). This can be performed with FBT.
• Additional Tools: Plumb Line Test and Moire Surface Topography are also used for screening.  

Multidisciplinary Team Approach

The Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) guidelines recommend stage-specific treatment strategies in the management of scoliosis. Thus, scoliotic management involves multiple healthcare providers.

• Orthopedic Surgeons: physicians who specialize in monitoring and surgical correction in severe scoliosis cases.
• Physiatrists: physicians who specialize in monitoring, pain management and prescribing specific therapies programs in mild to moderate cases.
• Physical Therapists: providers to help develop personalized programs to improve posture and core strength.
• Chiropractors: providers who perform manual adjustments to correct or improve spinal alignment and mobility.
• Psychologists or Psychiatrists: professionals who treat mental health concerns such as anxiety, depression, body image alterations related to scoliosis deformities.

The goals of scoliotic rehabilitation are first to keep the curve size below 30 degrees (if possible) and to halt curve progression and, secondly, to prevent potential complications such as asymmetrical spinal deformity, back pain, and psychosocial effects. The choice of therapy is determined by the degree of curvature and potential for further growth, as those factors contribute to the risk of curve progression. In mild scoliosis, observation is the main stay of treatment. In moderate cases, both physiotherapeutic exercises and bracing are recommended. Surgery is recommended in severe cases.

Cutting-Edge Rehabilitation Techniques

• Physical Therapy: The Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) promotes physiotherapeutic scoliosis-specific exercises (PSSE) as a mainstay treatment along with bracing in managing moderate scoliosis. PSSE are individualized exercises which include patient education, 3D-autocorrection, training in adjusted daily living and stabilization of the correct posture. The Schroth method is one of most popular used PSSE strategies. This method employs 3D correction of the specific curve pattern of the patient in daily activities using a combination of sensorimotor, postural, and corrective breathing exercises. With 30-90 minutes exercise sessions 3 times weekly, patients receiving PSSE show a decrease in scoliotic curves and improve quality of life. The scientific exercise approach to scoliosis (SEAS) is another most used PSSE interventions in scoliosis rehabilitation.
• Chiropractic Care: Chiropractic sessions involving message therapy, flexion distraction spinal traction and spinal manipulation in conjunction with other conservative programs like bracing and PSSE may potentially be effective in treating IS. If patients practice 2-3 times weekly, these interventions can help correct muscular imbalances, relax stiff muscles, realign abnormal posture and stabilize scoliotic curves.
• Occupational Therapy: Occupational therapists assess the impact of changes in motor function, sensation, coordination, proprioception, and cognition on a person's capacity to manage daily life tasks. Occupational therapists work closely with scoliotic patients to develop compensatory strategies to help patients live independently.

• Bracing Technology: Bracing has acted as the primary nonoperative intervention for managing moderate curves for several decades. Its goals are to straighten the spine, align the pelvis and shoulders, eventually controlling the alignment of the entire body. It is recommended for part-time use (8-10 hours) or nighttime bracing for patients with curves <35 degrees and full-time use (18-23 hours) for patients with curves >35 degrees.

Traditional braces such as Milwaukee or Boston braces utilize 3-point pressure systems for control of body motions and correction for scoliotic curves. These orthoses are custom fabricated from a mold of the patient’s body. Bracing technology has changed in the past several decades to make wearing braces comfortable and improve compliance.

• The Milwaukee Brace: also known as cervico-thoracic-lumbar-sacral orthosis, was the first brace that was recommended to patients who have a high thoracic curve with apex above T7. It consists of a contoured leather pelvic girdle and a neck ring connected through a metal bar both at the front and at the back. It is heavy, cumbersome to wear and can cause jaw damage with headpieces.
• The Boston Brace: an improved thoracolumbosacral orthosis and recommended for scoliotic patients with curves below T7. It consists of plastic components without the head piece, leathers and metal bars. The brace acts to stop curve progression by pushing in the abdomen and flattening the lumbar curve. Compared to Milwaukee brace, the Boston brace is more comfortable, lighter, and can be worn underneath clothes.
• Charleston and Providence Nighttime Braces: prescribed for scoliotic patients with smaller curves. ISJ-3D brace, a Providence brace evolution, utilizes computer assisted CAD-CAM in their design and the brace acts through compression forces at various points applying a lateral-rotational pressure to correct patient’s spinal deformity.
• ScoliBrace: the latest advanced brace that utilizes 3D scanning technology along with Xray, posture photos, and patient’s clinical information to create a unique scoliotic brace for each patient. In contrast to the traditional 3-point pressure system, ScoliBrace targets to stop the curve progression and overcorrect body posture by controlling spinal coupling.
• Aquatic Therapy: The soothing aquatic setting relaxes tight muscles, alleviating spinal stiffness which can help improve patients’ posture. The aquatic effect shows a significant increase in the total length of the spine by decreasing the angle of thoracic kyphosis and the angle of lumbar lordosis. Shoulder, hip and pelvic mobility are also improved with aquatic exercises.
• Yoga and Pilates: Various physiotherapeutic exercises, like core stabilization (CS), Pilates, and Yoga, have recently been used in the conservative treatment of IS. These exercises focus on spinal stability and core strength training. Increasing spinal stability is one of the main therapeutic goals of the CS approach. CS exercises focus on strengthening the deep trunk muscles in both static postures and in functional movements. CS exercises improve pain, posture and curve size in patients with mild and moderate scoliosis.

Innovating Technologies in Scoliosis Treatment

• 3D Imaging and Custom Braces: The technology of computer-aided design (CAD) and computer-aided manufacturing (CAM) has made orthotics fabrication today faster and more accurate than the old plaster cast method. The BioScanner Biosculptor, which uses CAD, laser scanning, 3-D imagery and motion tracking technology, is one of the CAD-CAM systems available in designing scoliotic braces. A 3-D image of the body part is connected to the computer and the software analyzes the data. ISJ-3D Providence brace and ScoliBrace are examples of 3D scoliotic braces.
• Robotic-Assisted Therapy: Balance dysfunction and motor weakness affecting upper and lower limbs can occur because of severe scoliosis or after a neurological injury. Robotic-assisted therapy such as body weight-supported treadmill training (BWSTT), in conjunction with a motorized robotic driven gait orthosis has been used in tertiary rehabilitation centers to improve patients’ motor strength, balance and gait function. The hand of hope robotic hand system (HOH) is an external type of robot that provides active-assisted training guiding the patient’s fingers for grasp and release task or pinch and release task, which ultimately help patients improve hand dexterity function to perform daily tasks.
• Telehealth and Remote Monitoring: Telemedicine has revolutionized physician-patient interaction. Through digital technology patients can send messages to their doctors, schedule their office appointments and receive responses from their physicians at their convenience. Telehealth offers virtual face-to-face visits and allows physicians close monitoring of patients’ medical needs.

Living Well with Scoliosis

With multidisciplinary management strategies individuals with scoliosis can live in their communities productively and independently.  Maintaining a well-balanced diet, healthy body weight along with vitamin D, calcium supplements and calcitonin hormonal injection are important to improve bone health in children and adults with scoliosis. Screening tests like DEXA can detect osteopenia and osteoporosis in scoliotic patients as various treatment options like oral medications or injections are available and can be administered to prevent fractures.

Conclusion

Scoliosis is a unique spinal deformity which can result in various health complications. Impacts on function and quality of life worsen as curve severity increases. Patients with scoliosis who receive effective conservative treatments or who undergo surgery can enjoy a good quality of life and avoid long-term health complications. Therefore, scoliotic individuals are recommended to be proactive in seeking physicians who help monitor their disease and guide appropriate medical interventions. To schedule a visit with a Rothman specialist to discuss scoliosis treatment options for you, visit our appointments page today.