Scoliosis

What is scoliosis?

Scoliosis is a 3-dimensional spinal condition that causes a lateral (away from the center) curvature of the spine, and is typically coupled with rotation of the vertebrae and changes in the sagittal plane (side view).

Scoliosis strikes most frequently during adolescence, about 85% of scoliosis diagnoses. Onset in adolescence (ages 10-18) is known as “adolescent idiopathic scoliosis” or AIS. When scoliosis is diagnosed between the ages of 4 and 9 years-old, it is called “juvenile idiopathic scoliosis” and when scoliosis is diagnosed before 4 years-old, it is termed “infantile idiopathic scoliosis.”

In some cases, scoliosis may go undetected until adulthood. It can also begin during adulthood, though this is less common. This type of scoliosis is sometimes called “adult-onset scoliosis,” “late-onset scoliosis,” or “degenerative scoliosis.”

It is our intention to offer resources to parents and patients in search of scoliosis information. Please feel free to read more below about different scoliosis topics and/or contact us at info@scoliosis3dc.com if you have any treatment-related questions.

Is it scoliosis?

A child with scoliosis usually presents with certain postural asymmetries which can be seen during a visual examination. If you suspect your child may have scoliosis, here are some signs to look out for. To the untrained eye, mild scoliosis can sometimes be hard to detect so if you are unsure, we recommend taking your child to a healthcare practitioner for a scoliosis screening. A full spine standing x-ray showing a Cobb angle over 10° is needed for an official diagnosis.


What causes scoliosis?

According to the National Institute of Health, most cases of adolescent scoliosis (80-85%) are considered idiopathic in origin. The term “idiopathic” means “relating to or denoting any disease or condition that arises spontaneously or for which the cause is unknown.”

It is important to know that children with idiopathic scoliosis are normally healthy. Statistics show that when detected in adolescence, mild idiopathic scoliosis is present in males and females at a similar rate; however, females are 8 times more likely to experience curve progression.

Idiopathic scoliosis sometimes has a genetic component, so parents should be extra vigilant if there is a family history of scoliosis or when monitoring a younger sibling whose older sibling has scoliosis. If you are interested in reading more about the different theories of what may cause idiopathic scoliosis, check out this paper on scoliosis etiology.

Scoliosis that is not idiopathic may be due to congenital or neuromuscular conditions, or a connective tissue disorder such as Ehlers-Danlos Syndrome. To avoid confusion, when you see the word ‘scoliosis’ on our site, we are referring to scoliosis in general or idiopathic scoliosis unless otherwise noted.


Functional scoliosis vs. structural scoliosis

Functional scoliosis (or non-structural scoliosis) is a curve that disappears when the patient is lying down or bending to the side. Temporary scoliosis is not unheard of and clinical experience has shown it is most commonly seen in the lumbar spine as a result of an injury to an intervertebral disc with secondary muscle spasm.

Typically, structural curves are associated with a loss of spinal flexibility of the rotated vertebrae. Vertebrae become fixed and the rib cage can become rigid, especially when the thoracic vertebrae are involved. When x-rays are taken of a structural scoliosis, the curve is always present regardless of position (though the Cobb angle can vary in these different positions).

Functional scoliosis can eventually turn into structural scoliosis if the inciting factor and/or curve is not treated. This is why our tag line is “Not wait and see!”


Infantile scoliosis

Infantile scoliosis is a spinal curvature that appears in a child that is 3 years-old or younger. Sources sometimes differ on the exact age parameters between infantile scoliosis and juvenile scoliosis.


Juvenile scoliosis

Juvenile scoliosis is a spinal curvature that appears in a young child between the ages of 4 and 9. Statistics show that curves detected in the younger years may have an increased chance of progression; however, parents can take advantage of a child’s remaining growth by taking a proactive approach and starting treatment sooner rather than later.

The Schroth method for juvenile scoliosis can be challenging, but not impossible. We evaluate each case on an individual basis and make assessments on treatment and whether the child might benefit. Typically, we begin full Schroth instruction in children 10 years-old and up, since younger children often lack the attention and ability to understand the concepts taught. With our youngest patients, we begin quite simply and usually advise shorter appointments. We teach parents mobilizations and teach children activities of daily living (ADLs) in an attempt to have them understand how to avoid movements which feed into spinal curve progression. Cheneau-Gensingen bracing may also be appropriate depending on the child’s individual circumstances.

If your child has juvenile scoliosis and you are interested in finding out whether our conservative approach can help your child avoid progression, please contact us and request a consultation with Dr. Moramarco.


Adolescent scoliosis

Most cases of idiopathic scoliosis are diagnosed in adolescence. This condition (diagnosed between ages 10 and 18) is often referred to as adolescent idiopathic scoliosis or AIS for short.

Historically, treatment for AIS has typically consisted of ‘watch and wait’ for mild curves, scoliosis bracing (usually recommended once scoliosis reaches the moderate phase in a growing adolescent), and scoliosis surgery for severe curves (recommended by those in traditional circles).

Our treatment protocols take a more proactive approach. Rather than the do nothing advice of ‘watch and wait’, we offer Schroth method instruction for patients of all Cobb angles, including mild scoliosis. We also offer the Cheneau-Gensingen scoliosis brace, which has an asymmetric design and can address curves that are mild, moderate, or severe. The Cheneau-Gensingen brace can be worn as a nighttime brace or a full-time brace (dependent on individual patient circumstances and Dr. Moramarco’s recommendations).

Patients have been achieving impressive results with this brace. It differs from traditional scoliosis braces as it strives to reduce curvature (more readily achievable in compliant patients with flexible spines) and gives larger scoliosis curves the opportunity for conservative scoliosis treatment when they are often turned away for bracing. Bracing can be done alone or in conjunction with the Schroth program. To learn more about treatment for your child or to request a consultation, please contact us.


Adult scoliosis

Adult idiopathic scoliosis is often a continuation of adolescent idiopathic scoliosis; however, scoliosis can also develop in adulthood. Scoliosis that begins in adulthood is called degenerative scoliosis as it is usually the result of disc degeneration, and/or diminished bone density and muscle strength. In women, degenerative scoliosis is often associated with hormonal changes, menopause, and osteoporosis. Staying active can help mitigate the side effects of scoliosis such as pain, muscle imbalance, spinal collapse, and cosmetic/postural concerns. This is where our Schroth program can be a helpful tool in managing scoliosis in adulthood. Some adults with more moderate/severe curves opt for part-time bracing with the Chêneau-Gensingen brace. If you are interested in treatment and want to learn more, please contact us.


Progression Factors

Scoliosis progression is defined as an increase of more than 5° in between x-rays. Scoliosis curve progression is dependent on a number of variables including age, gender, degree (Cobb angle), curve pattern, growth potential (Risser sign), and type of scoliosis (i.e. idiopathic, neuromuscular disease, etc.). Progression risk is closely associated with remaining growth potential, but this is not the only factor. Cobb angle at the start of treatment and family history also play big roles. To learn more about scoliosis progression, click here to read our blog.


Cobb Angle

Cobb angle refers to the angle which measures the magnitude of spinal deformities (in degrees). This measurement is made in the frontal plane for scoliosis and in the sagittal plane for kyphosis. The Cobb angle measurement is an important indicator for treatment guidelines. Click to read more about Cobb angle.


Curve Pattern

Each scoliosis is unique. Since scoliosis is a three dimensional condition, there are numerous possibilities and variations of curve pattern. According to a study out of Taiwan, single thoracic curves appear to be the most common curve pattern, followed by single lumbar, double major (two curves of similar size), single thoracolumbar, and double thoracic curves. In addition, the authors noted that right single thoracic curves were most common, while left thoracic curves are considered atypical.

In reality, most people do not have “single” (C-shaped scoliosis) or even “double” (S-shaped scoliosis) curves. These names refer to the largest curve(s) or the ‘major curve’ and are a simplification as they do not explain the smaller compensatory curves that typically form above and below the major curve.

Our Schroth Best Practice® program takes both the major curve and compensatory curves into account, as we know that movement one way could be good for one side of the trunk, but harmful to the other. This is why we generally discourage patients from participating in yoga or scolio-pilates, especially if they have not already gone through our program and learned the particular movements that are not good for their scoliotic spine.

At Scoliosis 3DC, our treatment protocols are always according to individual curve pattern, which is why all Schroth programs and Cheneau-Gensingen braces are highly customized to the patient.


Risser Sign

Risser sign refers to the measurement (graded on a scale from 0-5) used to evaluate skeletal maturity or completed growth. Risser 0 indicates much potential growth remains while 5 indicates skeletal maturity. The Risser sign is determined from an x-ray image of the pelvis and references the appearance of a crescent-shaped line of bone formation – visualize a mushroom cap – which appears across the top of each side of the pelvis on a PA (or AP) x-ray image. This measurement may be noted on your child’s x-ray report.


Scoliosis Treatment Options

The traditional medical model for scoliosis treatment usually follows this protocol:

Upon diagnosis of Cobb angles of 20 – 25º and below, most physicians recommend observation – brilliantly dubbed ‘do nothing’ by one scoliosis surgeon. This is also known as ‘watch and wait’ or ‘wait and see.’ During this time, the physician will check every four to six months to see if a curve is progressing.

Each case of scoliosis is unique but in a growing child, once the curve reaches 20-25° (or greater) bracing is usually prescribed. Sometimes bracing will be recommended earlier if the scoliosis is detected at a very young age (due to increased risk of progression).

Surgery is recommended by some surgeons as early as 40º–45º (though this depends on the surgeon and the patient’s growth stage). At this Cobb angle range, many doctors will say that bracing is ineffective, however, newer asymmetric Chêneau-style braces are better suited to address moderate-to-severe scoliosis than braces from the past.

Many of our patients who were recommended for surgery prior to coming to Scoliosis 3DC have been able to avoid it using the Schroth Best Practice® program and Chêneau-Gensingen brace. Scoliosis surgery is a highly individual decision and one that should be met with careful consideration.

Many patients and parents seeking alternative treatments for scoliosis share the belief that scoliosis surgeries involving rod implantation and spinal fusions are serious and life-lasting procedures, that in some cases, are the beginning of a new set of problems for the patient, rather than a lasting solution without consequence.

In recent years, more and more parents and patients are choosing to take a proactive approach to scoliosis management rather than the traditional advice of “wait and see.” This proactive approach is what we offer to patients and parents of children with scoliosis.

Rather than observation for a mild curve (~15°-20°), we provide instruction in curve-pattern-specific activities of daily living, physiologic exercises, and simple 3D exercises that are tailored to the individual. Our treatment programs are designed to help prevent scoliosis progression and halt or improve the curve.

For those with Cobb angles >20°, treatment recommendations can vary dependent on several factors including but not limited to Cobb angle, age, age at diagnosis, Risser stage/bone age, and family history of scoliosis. We offer intensive Schroth programs, full-time bracing and night-time bracing. To learn more, check out our programs or contact us for a consultation with Dr. Moramarco.


Exercise for Scoliosis

For years, most orthopedic surgeons claimed that exercise won’t help improve scoliosis. This belief is still fairly common among surgeons. In general, this is true when that statement is taken at face value and refers to general exercise. While it’s important to remain active, doing jumping jacks or going for a run isn’t going to do a thing to help a kid with progressive scoliosis stop the curve from getting worse.

In order to be effective, exercise should be according to curve pattern and incorporate Schroth rotational breathing. Exercise specific to curve pattern can be beneficial when performed regularly and correctly. Scoliosis exercise programs are highly nuanced, individualized and require in-person training from a qualified practitioner.

Exercise for scoliosis is all about striving for spinal balance and stability. Generally, in patients with scoliosis, muscles on the side of the concavity are shortened and muscles on the side of the convexity are lengthened or stretched. Scoliosis-specific exercises are designed to help the individual performing them create stability. This happens when the supporting muscles are engaged. In doing so, the goal is to counteract “the vicious cycle” to hopefully halt or reduce scoliosis.

Postural rehabilitation is a critical component of scoliosis exercise programs since postural correction can be incorporated through the day and during activities. Postural rehabilitation is validated by Level 1 evidence and many studies point to the fact that posture influences scoliosis.

Which method should you chose?

With a quick scan on the internet, it’s no wonder parents are confused about scoliosis exercise methods. The Schroth method has the longest track record –it’s been around since the 1920s, although it wasn’t in the US until about a decade ago. It’s hard to argue with a technique that’s been in existence for nearly 100 years. In the last decade it has expanded internationally, under the leadership of Dr. Hans-Rudolf Weiss, as Schroth Best Practice® (SBP). There are an increasing number of studies to support Schroth and it is the one exercise method for scoliosis that has the most evidence based research to support it (see Resources).

When comparing scoliosis exercise approaches, there are numerous factors to consider. Not all scoliosis exercise approaches are created equally. First, the principles behind the varying correction methods are different. When there are published results for various methods, it is impossible to make direct comparisons due to differences in study populations (i.e. demographics and curve severity). When it comes to comparing techniques, ease of performing daily exercise in terms of time commitment and/or equipment required should also be considered. One advantage of Schroth Best Practice® is that it uses minimal equipment so exercise is easier to perform anytime, anywhere. When complicated equipment is required it adds to cost and reduces the ability to practice anywhere, which in turn decreases the likelihood of compliance.


Scoliosis Bracing

Scoliosis brace treatment is recommended by most physicians for adolescent patients with the potential for growth with moderate scoliosis 25º or more, or for younger adolescents, with a curve above 20º.

Bracing has been a topic of considerable debate in recent years, but with the publication of BrAIST (Bracing in Adolescents with Idiopathic Scoliosis Trial) : “Effects of Bracing in Adolescents with Idiopathic Scoliosis” that conversation has quieted. As unappealing as the idea is, if your child has growth potential and a moderate or severe curve – bracing is in their best interest.

Traditionally, the goal of bracing for scoliosis has been to halt progression. However, Chêneau-Gensingen bracing from Europe, by Weiss, has improved bracing and strives to bring about improved postural appearance and curve improvement whenever possible. In our experience, this rigid TLSO is the best choice for scoliosis bracing. It is a Schroth method compatible brace that offers advantages over other types of braces.

While we believe the Chêneau-Gensingen brace is the best scoliosis brace out there, Dr. Moramarco does work with local orthotists and those from around the country who fit braces skillfully. This method offers an optimal team management approach for the benefit of patients, no matter which brace parents decide upon for their child. Success with other types of braces and our Schroth method program are attainable. This is illustrated in the results of patients treated before we began to offer the Gensingen brace® in the U.S. We understand that each family and child has unique needs. Dr. Moramarco will offer his expertise and help guide your family for the best possible alternative for scoliosis treatment that aligns with your family’s needs.

Bracing is not only a science, but also an art. We can’t stress the importance of brace fit enough. It makes a difference when it comes to comfort, effect and compliance. The right physician, scoliosis rehabilitation program, brace and brace technician are of utmost importance to your child in terms of their physical appearance and Cobb angle measurements at skeletal maturity.

Our sole focus is to help your child avoid progression, or better yet, decrease the curve to some extent* (*case-dependent). Incorporating the right brace and conservative therapy, sooner rather than later, is, according to our clinical experience, in your child’s best interest.


Long-term Effects of Scoliosis

Getting a diagnosis of scoliosis can be scary and upsetting, especially if you do not know anyone else with the condition. While it is crucial to manage scoliosis in growing children to prevent it from getting worse, it is also important to keep in mind that you can live a long and healthy life with scoliosis. Link here to learn more about the long-term effects of scoliosis and how to manage them.