Will exercise or spinal manipulations prevent scoliosis from progressing? Will these things correct already diagnosed scoliosis? Are there any activities a child or adolescent with scoliosis cannot do? Defining scoliosis, classifying scoliosis, and learning about different methods of treatment can help answer these questions.

According to Stopka & Todorovich (2005), “Scoliosis is a lateral curvature, accompanied by vertebral rotation of the spinal column (p57).” Many schools perform routine scoliosis screenings in middle and high school. A forward bending test is used to look for symmetry between the left and right side of the spine. An observer stands behind or in front of the student while the child bends forward toward their knees and toes.

The observer examines the region between the upper thoracic and lumbar regions of the spine. If the observer sees anything that appears asymmetrical, the child is referred to their primary physician for further diagnosis. Examples of asymmetrical findings include one shoulder higher than the other, a “winged” scapula, or a rib hump on one side, uneven waist, leaning to one side, and one hip higher than the other (Staff, 2007).

Scoliosis curves can be identified as functional or structural. Functional curves resolve when the cause of the curve is rectified (Lonstein, 1999). Examples include leg length discrepancies that are fixed with a heel lift, or ruptured discs that are repaired through physical therapy or surgery. Structural curves have three main causes; congenital scoliosis, neuromuscular scoliosis, or idiopathic scoliosis (Lewis, 2008).

Congenital scoliosis is present at birth, and means the vertebrae did not form correctly or the ribs fused during fetal development. Neuromuscular scoliosis is caused by muscle weakness or paralysis due to disease. Possible disease causes are cerebral palsy, muscular dystrophy, and polio. Idiopathic scoliosis is from an unknown cause and includes the majority of adolescent scoliosis diagnoses. According to Yochum & Maola, “Of all causes, an inherited genetic defect appears to play a significant role with up to 30 percent of patients having another family member with significant scoliosis (p14).” However, this genetic link does not appear to determine the progression or severity of the curve (Yochum D.C. & Maola D.C., 2008).

A physician typically uses three diagnostic steps. These include a physical examination of the spine, shoulders, hips, and legs, including the forward bending test, x-rays, and possibly an MRI. The doctor uses the x-ray to calculate the degree of the spinal curvature, and determines the treatment based on this, the child’s age, and where the child is in their growth spurt. An MRI is only used if the x-ray shows something abnormal, or the physical exams shows neurologic changes (Lewis, 2008).

After diagnosing scoliosis, the physician describes the curve according to its shape, C-or S-shaped; the location of the curve, thoracic, lumbar, or thoracolumbar; the direction of the curve, left or right; and the angle of the curve. The degree of each curve is measured by the Cobb method (see figure 2). The Cobb method determines the angle of the curve by measuring the angle between the two most slanted vertebrae (Lonstein, 1999). Scoliosis is identified as a curve larger than 10 degrees, regardless of spinal level.

According to the Mayo Clinic, when considering treatment, physicians look at six different risk factors for progression (Staff, 2007). The first of these factors is growth. A growth spurt often worsens an existing curve. A second factor is sex; scoliosis in girls is more likely to worsen than scoliosis in boys. The age of a child also contributes to the progression of a curve. If a child is very young when scoliosis is identified, chances are the curve will increase. Size of the curve is a fourth factor: the larger the angle of the curve, the more likely that it will worsen.

The location of the curve also determines the potential for progression. Curves in the thoracic region are more likely to worsen than those in the lumbar or thoracolumbar region. A final determinant for progression is whether there were spinal problems at birth. Congenital scoliosis is more likely to progress than other types of scoliosis.

Treatment for scoliosis is based mainly on the degree of the curve, how quickly the curve is progressing, and where the child is in their growth spurt. According to Lonstein (1999), “If a curve is less than 20 degrees, an increase in the curve of 10 degrees or more is required before bracing is started. A 20 – 29 degree curve must change by five degrees before treatment is initiated. A curve between 30 and 40 degrees requires immediate bracing if the child is still growing. If a curve is between 40 degrees and 100 degrees, surgery is typically indicated (p. 599).”

There are three types of braces commonly used in scoliosis, the Boston brace, the Milwaukee brace, and the Charleston Bending brace. Bracing is only effective if the skeleton of the child is not mature. For girls, the skeleton is mature between the ages of 15 and 16 years, and for boys the skeleton is mature between the ages of 17 and 18 years. The Boston brace is also called a thoraco-lumbo-sacral-orthosis, and is often referred to as an “underarm” brace. This brace works by applying three points of pressure to the curve to prevent progression. The most common application is for curves in the lumbar or thoraco-lumbar spine. The brace is made out of hard plastic that has been molded to the child’s body. It is worn 23 hours a day, but can be removed for gym class, swimming and other sports.

The Milwaukee brace is a cervico-thoracic-lumbo-sacral-orthosis. This brace looks like the other brace, but has a neck ring that is attached to the body of the brace to hold it in place. Like the Boston brace, this one is worn 23 hours a day and can be removed during the day for physical activity. This brace is suggested for thoracic spine curvatures. A final brace is the Charleston Bending brace (figure 4).

The Charleston brace is molded to the child’s body when they are bent toward the convexity of the curve, thus applying more pressure to the curve (McAffee, 2002). Because the brace is only worn at night, many self-esteem issues are avoided. Self-consciousness due to wearing a brace at school, or a student’s friends “finding out” is avoided. This brace is recommended for curvatures of 25-40 degrees with the apex of the curve below the height of the shoulder blade (McAffee, 2002).

Surgical intervention is required for curvatures between 40 degrees and 100 degrees. According to the Mayo Clinic, “Scoliosis surgery is one of the longest and most complicated orthopedic surgical procedures performed on children (Scoliosis: Surgery).” The operation lasts approximately six hours and requires a 5-7 day hospitalization. Mayo clinic surgeons perform a posterior spinal fusion that uses a modified two-rod system originally invented in 1984 by two French surgeons. The rods and screws are attached to the spine in an effort to correct the curve as much as possible (figure 5). Part of the spine fuses to maintain the correction. The hardware is not removed, even after the fusion is healed. A person’s movement may be slightly altered.

A second type of surgery that Mayo clinic surgeons are investigating is for early onset scoliosis (Scoliosis: Surgery). This technique uses “growing rods.” Two parallel rods are attached at each end of the curve. As the term “growing rods” implies, the center of the rods are adjustable as a child grows. The lengthening of the rods is done during outpatient surgery. This surgery helps prevent heart and lung difficulties associated with early onset scoliosis.

Other treatments for scoliosis include neuromuscular electrical stimulation of muscles, chiropractic manipulation, and physical therapy. Limited information is available on the use of these methods to treat or prevent scoliosis. Clinical trials using neuromuscular electrical stimulation of muscles alone to correct a scoliosis curvature, or to prevent the progression of a curve, have not been published. A type of trial published in a 2001 issue of the Journal of Manipulative and Physiological Therapeutics reports in their study, spinal manipulations alone, “…were not effective in the correction of curvature of scoliotic spines… (Lantz D.C. & Chen D.C., 2001).”

However, a case study done by Kao-Chang Chen, M.D. and Elley H.H. Chiu, M.D. in The Journal of Alternative and Complimentary Medicine used chiropractic manipulation to decrease a Cobb angle of 460 to 300 in a 15 year old girl after 18 months of intervention (p. 749). A literature review by Martha C. Hawes, published in Pediatric Rehabilitation “…supports the hypothesis that exercise-based therapies can be used to reverse the signs and symptoms of scoliosis in children and adults (p. 178).” The review also points out that, “…there does not appear to be a single study supporting the dogma that scoliosis will not respond to exercise-based therapies applied early in the disease process (p. 178).”

Physical activity is not limited for adolescents with scoliosis that are receiving brace treatment, physical therapy, or chiropractic. The brace can be taken off for physical activities that require more flexibility, or for contact sports or swimming. Physical activity is only contraindicated for adolescents that have had surgery. Each doctor will likely have their own protocol, but the Mayo Clinic’s protocol for post-surgical fusion follows these activity guidelines. Post-surgery includes a restriction of activities for several days, and a restriction from physical activities like running and gym class for three months after surgery.

According to the Mayo clinic’s protocol, patients can return to normal activity excluding gym class, diving, contact sports, horseback riding, amusement park rides and lifting more than 25 pounds after three months (Scoliosis: Surgery). After six months, the patient can rejoin gym class and participate in all activities except contact sports with their doctor’s permission. One year after surgery without complications, and with their doctor’s permission, a patient can return to full activity including contact sports.

Although the literature supports varying theories on the effectiveness of bracing, surgery, chiropractic manipulation, and physical therapy, it seems clear that most adolescents with idiopathic scoliosis can lead a full, active life. Children with scoliosis can participate in school sports, recreational sports, and individual activities during treatment for scoliosis. And students that have surgery to correct a scoliosis curve can resume participation in most activities after six months and full activity after a year.

Works Cited
Chen, K.-C., & Chiu, E. H. (2008). Adolescent Idiopathic Scoliosis Treated by Spinal Manipulation: A Case Study. The Journal of Alternative and Complementary Medicine , 749-751.

Hawes, M. C. (2003). The use of exercises in the treatment of scoliosis: and evidence-based critical review of the literature. Pediatric Rehabilitation , 171-182.

Lantz D.C., C. A., & Chen D.C., J. (2001). Effect of Chiropractic Intervention on Small Scoliotic Curves in Younger Subjects: A Time-series Cohort Design. Journal of Manipulative and Physiological Therapeutics , 385-393.

Lewis, R. A. (2008, February 27). Medical Encyclopedia: Scoliosis. Retrieved March 22, 2009, from Medline Plus: http://www.nim.nih.gov/medlineplus/ency/article/001241.htm

Lonstein, J. E. (1999). Scoliosis update: Managing school screening referrals. Journal of Musculoskeletal Medicine , 593.

McAffee, P. C. (2002, March 26). Types of Scoliosis Braces. Retrieved March 28, 2009, from Spine Health: http://www.spine-health.com/conditions/scoliosis/types-scoliosis-braces

Scoliosis: Surgery. (n.d.). Retrieved March 28, 2008, from MayoClinic.com: http://www.mayoclinic.org/scoliosis/surgery.html

Staff, M. C. (2007, December 14). Scoliosis. Retrieved March 22, 2009, from MayoClinic.com: www.mayoclinic.com/health/scoliosis/DS00194

Stopka, C., & Todorovich, J. R. (2005). Applied Special Physical Education and Exercise Therapy. Boston: Pearson Custom Publishing.

Yochum D.C., T. R., & Maola D.C., C. J. (2008). Scoliosis. The American Chiropractor , 14-16.

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