Classification

Idiopathic scoliosis 

Idiopathic scoliosis, constituting approximately 80% of all cases, is diagnosed when other potential causes of spinal curvature have been excluded. In the adult population, scoliosis has a prevalence of more than 8% among individuals over the age of 25, and this prevalence rises to 68% in those aged over 60 due to degenerative changes in the aging spine. Moreover, there is a 2.5% prevalence of scoliosis in the general population with a Cobb angle larger than 10 degrees. Adolescent idiopathic scoliosis, the most common type, typically emerges during puberty and accounts for around 90% of cases of idiopathic scoliosis in children.

This condition is further classified into distinct subgroups based on the age of onset. Infantile scoliosis, developing between the ages of 0 and 3 years, exhibits a prevalence of 1%. Juvenile scoliosis, occurring between the ages of 4 and 10 years, constitutes 10–15% of all idiopathic scoliosis cases in children. Notably, untreated curves in juvenile scoliosis can lead to serious cardiopulmonary complications, and surgical intervention becomes necessary in 95% of cases with curves measuring 30 degrees or more. Adolescent scoliosis, emerging between the ages of 11 and 18 years, is the most prevalent subgroup, representing approximately 90% of cases in children. 

Congenital scoliosis 

Congenital scoliosis is a condition that results from embryological malformations affecting one or more vertebrae, and it can occur in any segment of the spine. The abnormalities in the vertebrae lead to curvature and other deformities of the spine, as one specific area of the spinal column tends to lengthen at a slower rate compared to the rest. The geometry and location of these abnormalities play a crucial role in determining the rate at which scoliosis progresses in magnitude as the child grows.

Unlike idiopathic scoliosis, congenital scoliosis is present at birth, as it arises from developmental issues during the embryonic stage. Due to its congenital nature, this form of scoliosis is typically detected at a younger age than idiopathic scoliosis. Early identification is facilitated by thorough examinations and imaging studies, allowing healthcare professionals to assess the extent of the malformations and plan appropriate management strategies. 

Neuromuscular Scoliosis 

Secondary or non-idiopathic scoliosis encompasses cases where spinal curvature is a consequence of underlying neurological or muscular diseases. This category includes scoliosis associated with conditions such as cerebral palsy, spinal cord trauma, muscular dystrophy, spinal muscular atrophy, and spina bifida. Unlike idiopathic scoliosis, this type tends to progress more rapidly, often necessitating surgical intervention for effective management. 

Characteristics  

Scoliosis presents clinically with a distinct curvature of the spine, forming an “S” or “C” shape when viewed from the front or back. This curvature leads to noticeable asymmetries, including one shoulder appearing higher than the other, uneven hips, and a tilted waistline. A characteristic feature, particularly in thoracic scoliosis, is the presence of a rib hump, observable when the individual bends forward. Clothing may not hang symmetrically, and postural changes such as leaning to one side can be apparent. While not always present, some individuals with scoliosis may experience back pain or discomfort. In adolescents, the condition may progress during growth spurts, emphasising the importance of regular monitoring 

Examination and diagnosis 

Scoliosis is usually confirmed through a physical examination, an x-ray, spinal radiograph, CT scan or MRI. The curve is measured by the Cobb Method and is diagnosed in terms of severity by the number of degrees.

The Cobb angle, measured on X-rays, serves as a crucial parameter in defining the severity of scoliosis. A minimum angulation of 10 degrees is considered the threshold to diagnose scoliosis. When the curvature falls between 15 and 20 degrees, some studies suggest that specific treatment may not be immediately necessary, advocating regular check-ups to monitor progression until bone maturity. Physiotherapy including exercise sessions both at the clinic and through a home program is recommended. 

In the range of 20 to 40 degrees, orthopaedic doctors commonly prescribe back braces to impede further curvature development. The type of brace recommended depends on factors such as the patient’s lifestyle, discipline, and the severity of the curve. A scoliosis-intensive rehabilitation program must be introduced. 

When the curvature exceeds 40 to 50 degrees or more, surgery may be deemed necessary to correct the spinal deformity. Various surgical procedures exist, with spinal fusion being a recurrent choice. This procedure involves linking the vertebrae together, preventing further curvature progression. The decision to pursue surgery is typically influenced by the degree of the curvature, the impact on the individual’s quality of life, and the potential for continued progression. 

Role of physiotherapist 

The role of a physical therapist in the management of scoliosis involves three crucial tasks: informing, advising, and instructing. It is imperative to provide the patient and/or parents with clear and comprehensive information about the individual’s specific situation. This includes explaining the nature of scoliosis, its potential progression, and the available treatment options. Some physical therapists may recommend braces, such as the Milwaukee brace, to prevent the worsening of scoliosis.

A significant focus for physical therapists is guiding patients in performing the correct exercises tailored to their condition. Numerous studies suggest that exercises can have beneficial effects on individuals with idiopathic scoliosis. Beyond physical interventions, physiotherapists also consider biopsychosocial factors. For adolescents with idiopathic scoliosis experiencing chronic low back pain, therapists may assess and address additional factors such as insomnia, depression, anxiety, stress, and daytime sleepiness. Recognizing and managing these contributing factors becomes crucial in providing comprehensive care for individuals with scoliosis, addressing both the physical and psychosocial aspects of their experience.

One of the best approaches for scoliosis management is to use physiotherapeutic scoliosis-specific exercises (PSSE).A PSSE physiotherapy methodology must be based on scientific evidence and customised for each patient.

The SOSORT emphasises that PSSE physiotherapy used for the treatment of Adolescent Idiopathic Scoliosis differs from nonspecific physiotherapy in that it aims at three-dimensional self-correction of posture, stabilisation of corrected posture, patient education, and the integration of corrective positions into daily activities. The frequency of PSSE physiotherapy varies from 2 to 7 days per week, depending on the complexity of the technique used, the need of the patients, and their ability to follow the prescribed program. Long-term outpatient programs typically occur two–four times a week if the patient is ready to cooperate. Typically, PSSE physiotherapy is only performed by professionally trained instructors, as physical exercises are chosen based on the type and severity of scoliosis in each patient, and the nature of the exercises themselves depends on the methodology applied.

The most well-known PSSE physiotherapy schools of thought is The Schroth Method. Schroth exercises serve as a targeted and non-invasive approach to address scoliosis by focusing on de-rotating, elongating, and stabilising the spine in three dimensions. These exercises, conducted through physical therapy, center around restoring muscular symmetry and aligning posture. By specifically targeting imbalances in muscle strength and tone, the exercises work towards achieving a more balanced and aligned spine. Integral to Schroth exercises is the incorporation of breathing techniques, directing breath into the concave side of the body. This emphasis aims to facilitate improved spinal alignment and enhanced muscular control. Additionally, Schroth exercises prioritise developing awareness of posture, enabling individuals to actively maintain correct spinal alignment in various daily activities.

Role of chiropractor 

Chiropractors may use spinal adjustments or manipulations to help improve spinal alignment and mobility. While chiropractic adjustments cannot reverse the curvature of scoliosis, they may help reduce discomfort, improve function, and enhance the overall health of the spine. 

Differences between chiropractic and physiotherapy 

Chiropractors and physiotherapists approach the treatment of scoliosis from different perspectives, utilising distinct techniques and interventions. There are some key differences between chiropractic care and physiotherapy in treating scoliosis: 

Philosophy and Approach:

Chiropractic care often focuses on spinal manipulation and adjustments to improve spinal alignment and function. Chiropractors believe that misalignments in the spine (subluxations) can affect overall health and well-being.

Physiotherapy employs a variety of techniques such as exercises, manual therapy, and modalities to improve movement, function, and overall physical well-being. Physiotherapists often focus on restoring mobility, strength, and flexibility while addressing pain and dysfunction.

Treatment Techniques:

Chiropractors primarily use spinal adjustments, mobilisations, and manipulations to address spinal misalignments and restore proper movement and function to the spine.

Physiotherapists utilise a broader range of treatment techniques including exercises, stretches, manual therapy (such as joint mobilisations and soft tissue techniques), modalities (such as ultrasound and electrical stimulation), and postural training to address muscle imbalances, improve mobility, and alleviate pain.

Emphasis on Exercise and Rehabilitation:

Physiotherapy places a strong emphasis on exercise and rehabilitation to strengthen muscles, improve flexibility, and promote proper movement patterns. Physiotherapists often design personalised exercise programs tailored to the individual needs and goals of the patient.

While chiropractors may incorporate exercise and rehabilitation into their treatment plans, the emphasis may not be as prominent as in physiotherapy. 

Scope of Practice:

Chiropractors primarily focus on spinal health and musculoskeletal conditions, including scoliosis. They may use adjustments and manipulations to address spinal misalignments and related symptoms.

Physiotherapists have a broader scope of practice and can address a wide range of musculoskeletal, neurological, and cardiopulmonary conditions. They may use a variety of techniques to address functional limitations and promote overall physical well-being.