Scoliosis and Exercise Prescription

Scoliosis Defined

Scoliosis is a skeletal condition defined by a lateral "C" or "S" shaped curvature of the spine, which is also accompanied by vertebral rotation (Stopka & Todorovich, p.57). In order to be classified as scoliosis, the lateral curvature must be at least 10 degrees in magnitude (Scoliosis Association). In some severe cases, the curvature and rotation of the spine is severe enough that the visceral organs are crushed by the rib cage, causing discomfort and, with curves greater than 100 degrees, even problems breathing.

Prevalence

Scoliosis occurs in about 2-4% of children between the ages of 10 and 16 years of age, with only 10% of these children having curvatures that progress and require a type of medical intervention (Reamy & Slakey, 2001). Prevalence decreases with increasing curve magnitude, as only 0.2 percent of curvatures are greater than 30 degrees and 0.1 percent is greater than 40 degrees (Reamy & Slakey, 2001). Although mild scoliosis is equally prevalent in boys and girls, it is 5-8 times more likely for a curvature in a girl to become serious. (Scoliosis Association).

Worldwide studies have shown that the prevalence of scoliosis cases are evenly scattered; there is no variation among races or ethnicities (Scoliosis Association).

Types of Scoliosis

There are several types of scoliosis, depending on what the cause of the condition is. Scoliosis can be classified as non-structural scoliosis or true scoliosis, depending on the type of curve involved.

In non-structural, or mobile, scoliosis, there is no rotational component to the curvature. This type of scoliosis is compensatory due to an outside condition, such as leg length discrepancy, and will disappear when that problem has been corrected. In the case of leg length discrepancy (LLD), the curvature will correct upon sitting or wearing a heel lift in the individual's shoe. Also, children with non-structural scoliosis due to LLD, might benefit from stretching exercises (University of Maryland). True scoliosis, or structural scoliosis, has both a rotational and lateral component, which is sometimes accompanied by the wedging of vertebrae (Jamil, 2004).

Under the classification of true scoliosis falls idiopathic scoliosis, or neuromuscular scoliosis. Idiopathic scoliosis (IS), which occurs in 80-85% of scoliosis cases, typically occurs in healthy children, predominantly girls, older than ten years, and has no known cause to this day (Scoliosis Association). Although the rate of progression of the curve varies between children, it is generally a slow progression. On the other hand, neuromuscular scoliosis (NMS) is a type of scoliosis that occurs early in childhood and it usually has a faster curve progression than IS. In addition to skeletal deformity, NMS is associated with systemic and chronic illnesses. Cases of NMS will occur in nearly all children with Duchenne muscular dystrophy, 60% to 75% of children with quadriplegic cerebral palsy, and 90% of children with spina bifida above the sacral level. (Murphy, Firth, Jorgensen, and Young, 2006). Although surgery can be an option for treatment in individuals with IS and NMS, those who undergo surgery for NMS will usually be required to spend much longer times in the hospital, have more diagnoses, undergo more procedures, and will more often will develop infections such as respiratory, urinary tract, and those caused by surgical wounds (Murphy et al., 2006).

Adolescent idiopathic scoliosis (AIS) is most known to rapidly progress at the onset of secondary sex characteristics and adolescent growth spurt, in girls with comparable curves to their male counterparts, and in individuals that have both thoracic and lumbar ("S" shaped) curvatures. Progression is less common after the onset of menarche and in individuals with only lumbar ("C"shaped) curvatures (Lonstein, 2006).

About 20% of scoliosis cases are hereditary, with the individual having some family members with the same condition, although the magnitude of the curvature is not related to the magnitude of the curvature in relatives. Daughters of mothers who have scoliosis are more likely than any other children to exhibit this type of spinal curvature (Jamil, 2004).

Signs To Look For

It is important to monitor children during their developmental years, especially if signs of scoliosis are present. These signs include shoulders being different heights (one shoulder appears to be depressed with the other one elevated), one shoulder blade is more prominent than the other, the child's head is not centered directly over the pelvis, an appearance of one hip being raised and prominent when compared to the other, rib cages are different heights, a greater distance between the body and one arm when arms are hanging loosely at the side, an uneven waist, the entire body leaning to one side, or a larger crease at one side of the waist when compared to the other side. (Jamil, 2004 and Scoliosis Association) If any of these signs are present, the child should be sent to a doctor for further examination and diagnoses.

An easy test to perform in order to detect potential scoliotic problems is the Adam's Forward Bend Test. In this test, the tester stands behind the subject as the individual places his or her feet together and bends 90 degrees at the waist. By looking directly across the subject's back, the tester can view an asymmetrical rib hump; the side opposite the rib hump is due to depression of the rib cage from vertebral rotation. (Jamil, 2004). This is a simple test that can be performed at home if scoliosis is suspected.

In order to determine the exact severity of the curvature, the individual would have to get posteroanterior and lateral x-rays taken and should be evaluated by a doctor or chiropractor. Using a measurement technique called the Cobb angle, the doctor will measure the degree of curvature from the posteroanterior standing x-ray of the spine. This angle is calculated using two perpendicular lines, one drawn perpendicular to the top of the highest vertebra on the curve and the other drawn along the bottom of the lowest vertebrae of the scoliotic curve (Reamy & Slakey, 2001).

Types of Treatment

Treatment options will fall into a category such as observation, bracing, or surgery, depending on the severity of the curve and whether or not the curve is continuing to worsen. For small curves in individuals who have completed growth and have little risk of progression, observation is the only necessary treatment, as these curves should present very little problems into adulthood. During this treatment, a follow-up x-ray should be taken each year for several years, or as an adult, as there are symptoms. Orthopedic bracing is the common treatment for growing patients diagnosed with a curve between 25 and 40 degrees. In this type of treatment, the goal is to prevent further progression of the curve during the rest of the child's developmental years. Braces have shown to be 60-75% effective in preventing progression of the diagnosed curvature. Surgery is an option for patients with curves greater than 45-50 degrees, or for patients who do not respond to the bracing techniques. In this type of treatment, a rod, such as a Harrington rod, is surgically attached to the spine, with the purpose of preventing further curvature progression and diminishing existing spine deformity (Jamil, 2004).

Low Bone Density Concerns

Individuals with scoliosis show a correlation in changes in the lumbar curve and the amount of displacement in pelvic rotation during a normal gait cycle (Mahaudens, Thonnard, and Detremleur, 2005). Mahaudens et al. performed a study on adolescents with IS to look at the effects of pelvic rotation, due to scoliosis, on gait. In this study, it was shown that in a normal walking cycle, the abnormal displacement of the pelvis is compensated by an increase in the activation of lower back muscles, specifically the erector spinae and quatradum lumborum, however, this increased activation leads to an earlier failure of the proper mechanism of gait due to excess work. Therefore, though individuals with scoliosis should have no problem with normal walking cycles, their muscles that control locomotion will tend to tire more readily (Mahaudens et al., 2005). This could be a reason why young girls with scoliosis participate in less weight-bearing activities such as walking or running.

Lee et al. performed a research study to evaluate lifestyles of adolescent girls both with and without adolescent idiopathic scoliosis. This study looked at calcium consumption, protein consumption, and weight bearing physical activity. The results of this study showed that girls with and without scoliosis consumed, on average, the same amounts of calcium and protein. However, those with scoliosis participated in less weight bearing physical activity, and consequently, had significantly lower bone mineral densities than the girls of the same age who did not have the condition (Lee, Cheung, Tse, Guo, Qin, Ho, Lau, and Cheng, 2005). Low bone density in females with adolescent idiopathic scoliosis is quite common (Lee et al., 2005). This presents a problem since adolescents with low bone density carry it into adulthood, with their bone density only decreasing from the already low value once they reach adulthood. Therefore, this study shows the importance for girls with scoliosis to participate in weight bearing activities in order to reach peak bone mineral density and prevent osteoporosis in the future.

Exercise and Scoliosis

According to the National Scoliosis Foundation, sports and physical education classes are recommended for children and adolescents with scoliosis. No research has shown that normal recreational activities, such as organized sports and physical education classes, will make one's condition of scoliosis worse. On the other hand, no studies have proven that exercise alone will decrease one's scoliosis. Despite the programs prescribed by hopeful therapists to lessen progression of the curve, exercise alone has not been shown in clinical studies to significantly improve true scoliosis in all people. However, some therapists believe that strengthening postural muscles will delay progression of the curvature. Although their beliefs have not been proven, it has been shown that strengthening exercise can lead to lifestyle improvements and less impairments from scoliosis.

A recent study shows no significant evidence of preventing progression, yet the authors do recommend exercises for stabilizing the spine and preventing debilitating conditions and impairments that can come about with scoliosis (Negrini, Antonini, Carabalona, and Minozzi, 2003). Therefore, reasons for recommending individuals with scoliosis participate in regular physical activity and recreation seem to be to improve health and enable the individual to realize that he or she is able to live a normal life, rather than preventing curve progression (National Scoliosis Foundation).

Contrary to what has been said about normal recreational activity, girls who participate in rhythmic gymnastics have a ten-fold increase in prevalence of scoliosis, compared to girls their age who did not participate in the strenuous sport (Tanchev, Dzherov, Parushev, Dikov, and Todorov, 2000). Tanchev et al. performed a study comparing rhythmic gymnasts to girls of same age who were not training. This study found that girls who participated in rhythmic gymnastics followed a very strict diet, were about ten kilograms lighter than other girls their age, had delayed menarche, were required to be extremely flexible, participated in strict regimens that produced overload on the spine for around 30 hours a week, and had an asymmetric loading on the spine and pelvis (Tanchev et al., 2000).

This study found that not only might these activities predispose young girls to scoliosis due to what the author has called a " 'dangerous triad' of generalized joint laxity, delayed maturity, and asymmetric overloading of the spine," (Tanchev et al., 2000, pp. 1371), but also that this triad of risk factors might also cause scoliosis in individuals not involved in rhythmic gymnastics (Tanchev et al., 2000). Therefore, sports such as rhythmic gymnastics, that cause asymmetric spinal loading, require low body fat percentages that will delay menarche, or require extreme flexibility should be avoided in children and adolescents who show signs of or who have been diagnosed with scoliosis. For those children and adolescents, with or without scoliosis, who participate in such sports, effort should be taken to highly monitor for signs or progression of a scoliosis curvature.

For individuals who have undergone surgical treatment for correction of their scoliosis, there appears to be little restriction in the types of physical activity and recreational sports that they may be involved in. Parsch et al. performed a study regarding sports involvement of adults with and without scoliosis. For those patients with scoliosis, both individuals who were treated with and without surgery were included, and there was an average curve of about 54 degrees. This study showed that in adulthood, individuals with scoliosis were less active in sports than those without the spinal condition, with their main limiting factor being back pain. Interestingly, however, those individuals who had similar degrees of curvature during follow-up, regardless of whether their treatment was surgical or not, participated in sports of similar intensity, such as skiing, jogging, and swimming.

Therefore, according to this study, it can be said that surgical treatment of scoliosis does not necessarily restrict sports involvement in patients with similar follow-up degrees anymore than those with non-surgical treatment (Parsch, Gartner, Brocai, Carstens, and Schmit, 2002). Some experts slightly disagree, however, and will discourage exercises that cause excessive torsion of the spine in patients who have one or two mobile lumbar vertebrae distal to the area of spinal fusion; they believe that this will cause spinal degeneration to accelerate (University of Maryland).

Physical Education Goals

Physical education goals for children and adolescents with scoliosis should encompass organic, neuromuscular, interpretive, social, and emotional aspects of development (Stopka & Todorovich, p.58). It is important to enable the individual to participate in activities that their peers are involved in, emphasizing the importance of staying healthy and living a normal lifestyle, free of focus on the disability. For those individuals wearing braces, it is especially important to emphasize self-discipline with performing strengthening exercises for the torso. While wearing a brace, it is extremely important to strengthen the torso muscles and maintain flexibility, as the back is immobilized while in the brace, which will lead to atrophy of these muscles and further impairment. Goals of exercise should be to prevent further impairment and postural problems, not to decrease the spinal curvature (Negrini et al, 2003).

Also, as previously stated, it is important to involve the child in weight-bearing activities to enhance bone mineral density, since the child with scoliosis is more susceptible to have osteoporosis later in life (Lee et al., 2005).

Children should be taught awareness of their condition, balance, and ability, with children wearing bracing devices being taught how to adapt to activities of recreation and daily living using their brace (Stopka & Todorovich, p.58). With the exception of those who have only one or two movable lumbar vertebrae under the site of fusion surgery, unless a doctor specifically states otherwise, there aren’t any regular physical activities that the student cannot participate in, and physical activity should be encouraged (Parsch et al., 2002 and University of Maryland).

References
Jamil, T. (2004, Novemnber 8). Could that problem back be scoliosis? Pulse, 68-69.

Lee, W.T.K., Cheung, C.S.K., Tse, Y.K., Guo, X., Qin, L., Ho, S.C., Lau, J., & Cheng, J.C.Y. (2005, Sept). Generalized low bone mass of girls
     with adolescent idiopathic scoliosis is related to inadequate calcium intake and weight bearing physical activity in peripubertal period.
     Osteoporos  Int, 16, 1024-1035.

Lonstein, J.E. (2006). Scoliosis: surgical versus nonsurgical treatment. Clinical Orthopaedics and Related Research, 443, 248-259.

Mahaudens, P., Thonnard, J.L., & Detremleur, C. (2005, Jul-Aug). Influence of structural pelvic disorders during standing and walking in
     adolescents with idiopathic scoliosis. The Spine Journal, 5(4), 427-33.

Murphy, N. A., Firth, S., Jorgensen, T., & Young, P. (2006 March). Spinal surgery in children with idiopathic and neuromuscular scoliosis: what’s
     the difference? Journal of Pediatric Orthopedics, 26(2), 216-220.

National Scoliosis Foundation. Exercise for adolescents. Retrieved 10 April, 2006, from      http://www.scoliosis.org/resources/medicalupdates/exerciseadolescents.php.

Negrini, S., Antonini, G., Carabalona, R., & Minozzi, S. (2003). Physical exercises as a treatment for adolescent idiopathic scoliosis: a systematic      review. Pediatric Rehabilitation, 6(3-4), 227-235.

Parsch, D., Gartner, V., Brocai, D.R.C., Carstens, C., & Schmit, H. (2002). Sports activity of patients with idiopathic scoliosis at long-term
       follow-up. Clinical Journal of Sport Medicine, 12, 95-98.

Reamy, B.V., & Slakey, J.B. (2001, July 1). Adolescent idiopathic scoliosis: review and current concepts. American Family Physician, 64(1), 111-116.

Scoliosis Association, Inc. Scoliosis Facts. Retrieved 4 April, 006, from http://www.scoliosis-assoc.org.

Stopka, C., & Todorovich, J.R. (2005). Applied special physical education and exercise therapy. Boston: Pearson Custom Publishing

Tanchev, P.I., Dzherov, A.D., Parushev, A.D., Dikov, D.M., & Todorov, M.B. (2000). Scoliosis in rhythmic gymnasts. SPINE, 25(11), 1367-1373.

University of Maryland Medical Center. (2002). What are nonsurgical measures for managing the effects of scoliosis? Retrieved 10 April, 2006, from http://www.umm.edu/patiented/articles/what_nonsurgical_measures_managing_effects_of_scoliosis_000068_8.htm.

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