Physiotherapy for Scoliosis
Table of Contents
Physiotherapy is one of the available treatment options for those suffering from scoliosis. While a few years ago most patients needed to use a brace or maybe even go for surgery, there is now an alternative. More than that, physiotherapy offers an option that strengthens the back muscles while correcting the curvature of the spine.
What Is Scoliosis?
The human spine consists of 24 spinal bones that are termed vertebrae. The spinal column is composed of these vertebrae stacked on top of each other, and this forms the main support of the body.
Looking from the side, there are three curves that can be seen. The cervical spine, or the neck, has a slight inward curve while the thoracic spine has an outward one. The lumbar spine, or the lower back, and the cervical spine curve inward as well. Looking from the back, the vertebrae looks like a straight column, so that the head is positioned in the center of the body.
When one has scoliosis, this curvature is different, forming a spine deformity. Instead of the straight normal curvature of the spine, it is instead C-shaped (or one curve) or it may even be S-shaped (or two curves). Any curving of the spine that is more than 10 degrees is considered scoliosis.
Scoliosis can also be categorized depending on when it starts to develop. Before 3 years of age, cases are called infantile scoliosis. On the other hand, juvenile scoliosis happens between the ages of 4 and 9. Adolescent scoliosis occurs after 10 years and until growth is completed. No one develops classic scoliosis during adulthood, but some might have residual effects of childhood scoliosis.
Most infantile scoliosis happens in the low thoracic region and has only one curve but some vertebral rotation. When the vertebrae rotate, the ribs that are attached will shift and cause a hump that is very visible on one side. The hump is very visible when the child bends forward at the waist. These cases also normally bend to the right, especially after the patient reaches 2 years of age.
In the case of juvenile scoliosis, boys develop this condition earlier than girls. Because the curving might last until the skeleton matures and because this occurs later for boys compared to girls, they have a higher risk of curve progression.
Both juvenile and adolescent scoliosis normally curve at the right thoracic spine and develop into double curves.
Type Of Scoliosis Based On The Root Cause Of Curvature
1. Idiopathic Scoliosis
There is no known reason for the majority of scoliosis cases, which is why there is no overall treatment that will be successful for all. Those that have no clear cause are called idiopathic scoliosis. It affects about 2 to 3% of the population, and also runs in families. Lastly, it is more commonly found in girls than in boys and develops during the middle or late childhood, when the child is going through a rapid growth spurt.
There are also cases of scoliosis that are congenital or present at birth. Some may also develop due to some other neurological condition like cerebral palsy, spinal muscular atrophy, or spina bifida.
While scoliosis might affect any part of the spine, it is mostly observed in the thoracic and lumbar spines. In these cases, the vertebrae are curving to one side and may even rotate. This makes the shoulders, waist, or the hips look uneven. In the beginning, the spine develops a C-shape so that the hips and the shoulders appear to tilt low on one side. The body will attempt to correct this and keep the head in the middle, so the spine may curve the lower part of the spine into the other direction. This is when it starts to form an S-curve.
2. Structural Scoliosis
Structural scoliosis arises from issues where the musculoskeletal system develops. Specifically, when the spine loses the flexibility of the rotated vertebrae. They then become fixed and when the thoracic vertebrae are affected, the rib cage may become rigid as well. In these cases, the spine does not have the mobility required for a reversal of the extreme curvature of the spine.
3. Functional Scoliosis
On the other hand, functional scoliosis is caused by muscle imbalance, a discrepancy in leg lengths, and tissue inflammation. It might also be due to an injury to any intervertebral disc that follows with a secondary muscle spasm. In fact, when the patient is lying down or bending, the curve disappears. There may be some ways to correct this misalignment and prevent health problems in the future.
What Are The Symptoms Of Scoliosis?
Patients themselves do not really feel any symptoms, nor do they realize that the curve of their spine has changed. Instead, they may notice other signs like clothes not fitting anymore or that their posture is not straight. Sometimes, parents or teachers may observe an asymmetry. When the spine curves, the body tries to adapt so that the head stays in the middle above the pelvis.
Because of this, patients may notice their shoulders and hips to be uneven so that a sleeve or pant leg appears shorter. When the vertebrae rotate, the waist appears uneven, and patients may notice that their pants or skirts tend to twist to the side.
The most common and visible signs of scoliosis include uneven shoulders, hips, breasts or nipples. They may also notice a prominent shoulder blade winging on one side, or simply a tendency to lean to the side. Lastly, when bending forward, a bump can be seen on the side of the spine.
Once these signs are detected, the patient should be examined by an expert. This may be a pediatrician in the case of children, a physician, orthopedic surgeon or even a physiotherapist. In some cases like functional scoliosis, early detection and treatment can help avoid further health issues and even correct the curvature of the spine.
Because untreated scoliosis can become severe, it is important to get the advice of a professional to avoid problems. Severe scoliosis may one day exert too much pressure on the internal organs like the lungs, liver, heart, and others. Breathing and cardiovascular function may suffer if scoliosis is not managed.
Although having scoliosis has no symptoms of pain, the curving and rotation of the spine may eventually manifest in some pain that is coming from muscles, ligaments, or joints when there is uneven pressure on them.
How To Diagnose Scoliosis
In the case of schoolchildren, they are first observed to be suffering from scoliosis during the school’s screening program conducted by the school nurse, doctor, or another qualified individual. A forward bend test, also called the Adams test, is conducted to check for any prominent ribs or spinal changes, both of which may be signs of scoliosis. The test is conducted by having the child bend forward very slowly at the waist, much like when diving into the pool. The doctor or nurse will carefully observe the spine from behind.
If there are any signs or symptoms of scoliosis, the patient is referred to the family doctor to once again check out the spine and identify a probable cause of scoliosis. At times, there is no need to do an x-ray especially if it is not needed to diagnose it. This will then lessen the child’s exposure to radiation, which is neither necessary nor good for growing children.
Only in severe cases, when there are signs of unevenness or other changes, are x-rays needed and helpful in viewing the vertebrae’s rotation or tilt radiologically. However, if the doctor thinks the root cause is a tumor, an infection, or even issues in the nervous system, then an MRI may be requested.
If there is an x-ray done of the spine, the doctor will study the curvature using a technique named the Cobb method. It will search for the location and measure the degree of the curve. If there is more than a 10-degree curve, it is considered to be scoliosis.
Part of the treatment plan requires the maturity of the skeleton or the bone growth. This may also be accomplished through an x-ray. The Risser sign is used on these x-rays to observe whether the child is still growing or not. The stage of growth, as well as the amount of the spine’s curving, affects the treatment approach.
The Treatment Options
Based on the factors like the stage of the child’s growth and the age of the patient, various treatment options are available. First of all, there are also instances when no treatment is required, as it may go away on its own. This is common to infantile scoliosis, where up to 90% of cases will resolve itself or the child will simply grow out of it.
Other methods to treat scoliosis may be to use a brace, use an exercise plan, or have surgery. Adults who have lingering effects of childhood scoliosis might still consider exercise as a treatment plan, but most of these approaches are most likely to be effective when they are started as soon as possible, especially before the patient stops growing.
Beyond the age and skeletal maturity, the patient’s severity of curvature is another great factor in pinpointing a treatment option. Of course, the patient and the family (especially in the case of minors) also have a say or are able to choose a path based on their preferences. Physical exams and x-rays may be conducted regularly over the course of treatment to check whether the treatment is working or not. Normally, patients with a curvature of less than 45 degrees may be offered a brace or exercise as a treatment approach but those that are quickly changing or those with more than 45 degrees might be recommended to opt for surgery.
Option 1: Observation
The doctor is likely to propose observation when the curve of the spine is less than 30 degrees and the patient has stopped growing. Otherwise, the recommendation is to go for treatment, depending again on several factors.
Option 2: Bracing
Braces are the traditional approach for scoliosis, specifically those with curves that are slow to progress. However, it is much more successful once it is done early on. However, the disadvantage of this treatment is that physical activity becomes restricted while the patient has the brace on. This might lead to the weakening of muscles, especially in the core.
There are two types of braces that are used, the Milwaukee brace and the Boston brace (also called a thoracolumbosacral-orthosis or TLSO). Various research have shown that braces for scoliosis are highly effective in controlling the curves and prevents progression of the condition.
However, it is important to note that in a majority of the cases, it does not really correct the curving of the spine. Instead, it just prevents the curvature from becoming worse. Moreover, if the curve is more than 40 degrees or if there are double curves, bracing might be less effective.
Normally these braces are worn the whole day, but some doctors approve removing it for 2 to 3 hours every day, allowing the kids to participate in sports (also with the approval of the physician). But in general, sports that need flexibility or involve a lot of body contact are prohibited or not possible.
This type of treatment will usually last for 2 years or until there are no more signs of further changes in spinal curvature. The doctor will monitor regularly through follow-up visits or regular x-rays especially if there are rapid changes or the patient is undergoing a growth spurt.
Option 3: Exercise
For a long time, braces were the standard and the most accepted treatment approach for scoliosis. This is because previous studies have discounted the success of exercise. However, researchers have revisited this outcome and discovered that the patients in these previous studies have not followed the exercise regimen faithfully. This is the reason why there were no positive effects or changes that were observed in the past.
With the widespread use and the development of technology, it becomes easier to monitor changes due to exercise, like checking on muscle function. It has been observed that scoliosis patients have an asymmetry in their muscle function, specifically an unevenness in strength when rotating the trunk. This has an effect on the posture, on the body’s appearance, may bring about pain, and in worse cases may even hinder the lung’s ability to function fully especially when the curve is located in the thoracic spine.
Now physiotherapy offers another treatment option other than, or together with, the brace. Not only does it remove the disadvantages of the brace, like hindered flexibility, it also keeps the muscles stronger than when the spine is braced. Physiotherapy, through the use of a specifically prepared and appropriate exercise program, can stop or slow the progression of scoliosis. At the same time, patients can experience less pain and improve their posture and appearance. It will also retain the normal functioning of the lungs.
The recent guidelines state that physiotherapy or exercise is a good approach for those with curves less than 45 degrees, it may benefit all those with scoliosis by strengthening the core muscles that have been affected by the disease. Studies are also showing a combination of physiotherapy and braces as an effective approach to scoliosis.
Option 4: Surgery
In severe cases, surgery is necessary to install metal rods and screws in order to straighten the spine. The vertebrae become fused together to correct the curve. However, only a tiny amount of scoliosis patients may actually need surgery, normally those with curves of more than 50 degrees or more. Patients who have not seen any success in bracing may also be in line for surgery.
The surgery is minimally invasive due to new techniques and is done to possibly prevent the progression of the spinal curvature and to improve the appearance by reducing the existing deformity. After the procedure, post-rehabilitation physiotherapy will help the patient get back on his or her feet stronger than before.
What To Expect At Your Physiotherapy Treatment
The First Meetings
As with other scoliosis treatment options, physiotherapy is tailor-fit to the needs of the patient. This means, in the first few visits to the clinic, the physiotherapist will ask questions and look at all x-rays and tests conducted to understand the specific condition of the patient. It is also important to mention whether other treatments have been recommended or other professionals have been consulted.
A physical examination will also take place, using the hand to feel the spinal curve in various positions like standing, sitting down, or in a face-down position. How the patient moves is also of great interest, so the physiotherapist will ask the patient to do some actions in order to assess the spine’s movements, like bending to the side, twisting, and leaning back and forward. They will also most likely search for a thoracic rib hump; the more this is pronounced, the bigger the curve is.
Other parts of the body that should be affected by scoliosis will be carefully observed. Specifically, he or she will check the shoulders, the hips, the neck, and the low back in motion. If needed, certain exercises can be done to maintain their strength and motion.
After the physiotherapist is able to gather all the evidence, he or she will be able to determine how scoliosis affects the day-to-day movement.
The Treatment Part
The next step, of course, is to design a specific exercise program that can be done either at home or at the clinic. Especially if the child is still young, the parents may provide parental support or assistance.
The exercises that have been specifically designed for the patient may include some stretching exercises from the back all the way to behind the legs. In terms of exercises, there are quite a few to be done. Strengthening the area of the buttocks will ensure proper support for both the thoracic spine and the lower back.
Patients should also expect exercises like spinal rotation, side bending of the spine, and core stability exercises. In some cases, providing the patient with items that build resistance can lead to some progression in halting or even reversing the curvature.
It is highly important to always get advice from the physiotherapist to ensure that the exercises are properly done (should be observed). Incorrect movements or using a lot of weight may make scoliosis worse or might even lead to pain. If necessary, more repetitions might be done to correct an imbalance.
To counteract the effects of scoliosis on the lungs and breathing, the physiotherapist will require breathing exercises and cardiovascular activities as well. Of course, maintaining good posture will also be of great help so patients will be instructed on how to keep it for as long as possible. Even simple things such as posture, a proper way of sitting, walking and standing done properly can cause a huge difference.
Compared to those who use back braces, patients who are following an exercise regimen may report an overall improvement in muscle tone and strength beyond just an improvement in spine curvature, as opposed to bracing, which may not even allow the use of the important muscles in the back.
Of the three treatment approaches, physiotherapy is emerging as the new favorite. Physiotherapy itself already offers scoliosis patients with a long list of procedures that can help correct their curvature or relieve them of pain. Some of these examples may include manual therapy, joint mobilizations, and even resistance exercise.
Just make sure that when you choose physiotherapy to deal with scoliosis, you turn to a professional who has actual experience in this condition to not waste time and energy. Make sure that he or she has also tailor-fit the treatment after consulting with you, the patient, to know that it will be more effective.
Physiotherapy offers a unique approach to dealing with scoliosis. While in the past, patients have been immobilized by braces, new therapies use movement and exercise to correct the abnormal curvature of the spine. Whether as a stand-alone option or combined with other scoliosis treatments like braces, research has proven its effectivity.