Education – Scoliosis Update from Susie

Making Sense of the Curve

was the title of the excellent one day workshop I attended in March 2017. It was hosted through the Physiotherapy Association of BC and led by Andrea Mendoza, founder of “The Scoliclinic” (www.scoliclinic.ca) in Vancouver and Carl Ganzert, an orthotist who does bracing for people with scoliosis.
Having received instructions in the Schroth method during my physiotherapy training in Germany and having since then attended a couple of weekend long workshops in Pilates for Scoliosis, I was intrigued to see what and if anything had changed in the approach to scoliosis management.

After an in depth review of the many types of scoliosis, the main focus was on AIS (Adolescent/ Adult Idiopathic scoliosis).
It is reported that around 6% of teenager have a structural scoliosis (where the bone structure is affected rather than a non structural scoliosis which essentially is due to poor postural habits and affects muscle but not bones). Over 8 % of the population 25 years and over is affected by AIS. This number rises to a staggering 68 % over the age of 60 due to degenerative changes in the ageing spine. These changes might be arthritis in the spine, disc degeneration or collapse or wedging of vertebrae into the space between the vertebrae.

Scoliosis is a complex condition – ranging from a simple C-curve to a more complex S curve or even a double S-curve. Some curves are very obvious, others are “hidden” curves.
Scoliosis is defined as a three dimensional structural deformity of the curvature of the spine. In the typical normal spine all the vertebrae grow at the same time and rate from side to side and front to back. But in a scoliotic spine, one or multiple vertebrae stop growing normally. We end up with a “keystone” culprit vertebra which is shorter on one side as well as shorter in the front of the vertebral body compared to the back. As these changes are happening these keystone vertebrae also move forward, then sideways and finally rotating on the vertebrae above and below. This is when the spine changes its appearance to a C- shape or an S-Shape with accompanying “humps” in the ribcage. These “humps” appear as your ribs start to change shape and rotate backwards on one side. The muscles on that side get overly tight and hypertrophy.

No-one knows exactly why these vertebra are changing their growth pattern, but here are some possible factors:

Vitamin D deficiency
A genetic component
Protein deficiency
Hormonal changes
Growth spurt related
Asymmetrical load and compression – carrying a heavy backpack / load on one side especially during the growth spurt years
Geographic
Ethnicity

You are also at more risk of a curve progressing if you are

Hypermobile
taking longer to reach skeletal maturity
Already having a larger curve at time of your diagnosis
Suffering from Anorexia which tends to cause poor bone health

Diagnosis:

Clinically :
Simple inspection – often times a person with scoliosis will spot changes when looking at themselves in the mirror or it may be commented on by another person; a visit to your health professional might pick it up. In teenagers the curve can progress quite quickly to the extend of not here one day and here the next.

A positive Adams forward bend test: a simple forward bend test. This is usually done in standing. With your knees straight, slowly bend forward. Looking from behind, if there is an obvious deformity, you will see it.

Screening from your physiotherapist with the use of a scoliometer (a tool to measure the angle of trunk rotation when you bend forward. Rotation of 6 or more degrees is significant.

XRays : specific XRays have to be requested looking for scoliosis.

Whether you have just recently been diagnosed or have had it for a while, here is the
latest on management:

What is the best way to manage a scoliosis

Stay active – any activity is better than none No sport is better than another.

Seek professional advise. The physiotherapists in our clinic will assess you thoroughly and set you up with some Physiotherapy Scoliosis Specific Exercises (PSSE). Massage therapy has been shown to be a valuable tool in relaxing tight muscles and allowing you to find length in your spine.

Our goals for your treatment are:
a. Prevent / slow down / hold curve progression
b. Prevent respiratory dysfunction
c. Prevent / treat pain
d. Improving the aesthetics by improving your posture..
e. Consistent Treatment.

So what has changed?
Based on the latest clinical research and evidence there have been some significant changes in the management and exercises. Once the vertebra is deformed there is no way that you are able to change it back again to how it looked and where it came from. Most of the time the major curve tends to be in your thoracic spine where we also find the ribs attaching to the spine. Consequently there are changes to the ribcage as well with ribs on one side being squished and on the other side being opened too much. This affects people’s breathing capacity. Be aware of hidden compensatory curves – ones that are not obvious – remember the body always tries to keep your eyes and feet facing forward. So if there is one curve going in one direction there will usually be another curve going in the other direction. Bending forward pushes vertebrae against one another, which leads to more compression and possibly more deformity. These are the reasons why we need to now modify our exercises and poses in Pilates, Yoga and the Gym.

i. No prolonged loaded general trunk rotation.
ii. No sideflexion out of the curve,no mermaid, no saw, no threading a
needle.
iii. Noextensionworktocorrectthekyphosis-noarchingoverwedgeor
foamroller or ball or spine corrector , even if it feels good. No kobra. .
iv. Nounilateralstrengtheningexercisestocorrectmuscleimbalance.
v. No compression.
vi. No sideflexion – you are often actually compressing and rotating the
already compressed and rotated ribs more. This has now been shown on functional XRays even though from the outside it all looks fine and looks like it does something good. But really it does not.
vii. no flexion – no sit ups no crunches, no short spine , no rolling like a ball, no roll downs, no roll ups etc. Modify childpose by propping the arms and shoulders up on bolsters, so they are level with the body.

What are you allowed to do then?

Do not hang in your curves! Think of / Work on lengthening – elongation – out of your curve(s)
Strengthen both sides equally.
Address any breathing dysfunction – work on taking deep breaths evenly into both sides of your lungs and back. Your instructor can give you some really good exercises.
Work in all different positions – lying on your back, sitting, four point kneeling and standing, just not lying on your back.
Hanging form the cadillac (the eagle)
Planks, side planks, opposite arm and leg (superman)
Work on loosening up your shoulder blades.
Same reps on both sides.

If you are not sure if what you do is correct, please check in with either the physiotherapists or myself. You may also wish to add some very specific exercises designed by us for your curve and train one on one.

Bracing?
Can certainly help, but you must collaborate with the instructions on how and how often to wear it. And better still combine it with your exercise program. There are different types of braces around – ranging from hard to soft shell to what looks like bandages wrapped around your body in a certain fashion.

Surgery?
The current guidelines are clear: If your biggest curve has a Cobb angle of 50 degrees or more regardless of the presence or not of pain, you will go for surgery as the impact on your internal organs is too massive. If adults have a curve of 31 degrees or more AND chronic pain, then you may be recommended to have surgery as well.
The most common surgery is fusion of the spine with rods along the side of your spine. But a new technique called Vertebral Body Tethering has been used for a little while now too. This latest technique is not quite as traumatic as fusion and promises to do well. However only time will tell how long the tethering lasts, can it break etc….?

Susie Higgins is proud to have once again been selected to present at this years IADMS (International Association of Dance Medicine and Sciences) conference in Houston, Texas, in October. She presented with Astrid Sherman at the 2015 IADMS conference in Pittsburgh on idiopathic scoliosis in the adolescent dancer. This years joint presentation (with Erika Mayall and Astrid Sherman) will focus on the Death of the Classical Port de Bras in the Smart Generation.

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