There are traditional and non-traditional conservative methods for treatment of idiopathic scoliosis (IS). It is important to understand that there are important differences between idiopathic scoliosis and other forms of spinal curvature. Idiopathic is basically Greek for “We don’t know where it comes from.” Other forms of scoliosis include congenital, neuromuscular, and syndromic. For this discussion, I will focus on the idiopathic form.
Treatment of IS depends on a number of factors. The two most important factors are age at presentation and the size of the curvature (measured in degrees by the Cobb Method). Scoliosis can progress rapidly in the growing child. The younger the child, the more growth potential that exists, and therefore the larger the spinal deformity can get. The size of the curve at presentation is very important as well. Larger curves create more visible deformity, and can potentially get big enough to cause problems with the heart and lungs, and lead to painful spinal arthritis. Therefore, large curvatures in young patients are the most worrisome.
From long term studies on scoliosis patients, we know that curves less than 30 degrees tend not to cause many problems in adulthood. However, curves in excess of 50 degrees tend to get larger with time- by about 1-2 degrees per year. For this reason, most spinal deformity surgeons will recommend stabilizing scoliosis greater than 50 degrees in skeletally mature patients, and at 40 degrees in the growing child. Those curvatures between 30-50 degrees in the adult are in a grey zone and are generally observed and treated conservatively.
So…. our goal in the child diagnosed with scoliosis is to keep that curvature below 40 degrees. So how do we do that? Traditionally we have had two treatment options- observation and bracing. Obviously, observation does nothing to prevent progression, but does allow us to intervene with bracing or surgery before the scoliosis gets to be too big. Traditional spinal bracing can work to keep the curve where it is, but it is not easy for patients or families. The braces, also known as thoracolumbosacral orthoses (TLSO), are rigid, and can be uncomfortable. Bracing studies show that best results occur when the brace is worn 18-23 hours per day. Soft braces, unfortunately, have not been shown to work in clinical trials. Brace wear often becomes a point of contention between kids and their parents. And even with a compliant brace patient, the scoliosis can get worse and need an operation anyway.
A third option for treatment exists. It is known as the Schroth Method. Schroth is a non-tradional physical therapy regimen aimed specifically at controlling scoliosis. It incorporates some traditional exercises, but focuses on strengthening weak muscles, and loosening tight areas. It includes breathing exercises, because the rib cage attaches to the spine, and is affected by the scoliosis. Core strengthening and general conditioning are also emphasized. Often, night-time bracing is instituted as well. Most importantly, the exercises are done every day. My personal experience with Schroth Therapy over the last few years is very encouraging. Unfortunately, there really is not any clinical studies to back this up, but hopefully there will be in the next few years.
In my practice, for children with idiopathic curves more than 20 degrees, but less than 30 degrees (maybe up to 40 degrees), I at least recommend a night brace and Schroth Therapy. I certainly see no significant downside to an intensive therapy program. The most difficult part of all is finding a properly trained and certified Schroth Therapist in the area. Only a few exist in our large metropolitan program.
Now what about adults with scoliosis? Again, those curves larger that 50 degrees may best be treated with surgical intervention. But often, patients will only consider that option if all else fails. Or perhaps a patient may not be able to tolerate a surgery for any number of reasons. In these cases, once again, I have been impressed with the Schroth Method, often combined with pain management programs that can include medications and injections. In conclusion, surgery is generally recommended for idiopathic scoliosis greater than 40 degrees in the growing child and 50 degrees in an adult. In terms of non-operative treatment for AIS, observation and rigid bracing can be combined with the Schroth Method. Schroth Therapy is appropriate for both adults and children.
© Christopher J. Bergin, MD and The Spine Center, SC