Adult Scoliosis

As the baby boomer population continues to increasingly age in the United States, adult scoliosis has become a significant health care challenge.¹  Recent studies have revealed that the prevalence of scoliosis may be as high as 68% within the elderly population.^2,3  Adult scoliosis may arise from numerous factors and has been directly related to disability.¹  Pain is the most common reason driving adults to seek care for their scoliosis.⁴  In fact, approximately 90% of patients report pain as their primary complaint.  While pain is a primary concern, potential disability is probably even more unsettling to this population. 

 Since abnormal spinal curvature of the spine breeds changes in not only the spine itself, but connecting structures, causes of pain may include everything from muscle fatigue and muscle spasm to disc rupture and/or nerve root irritation. 

 Some of the various factors precipitating adult scoliosis include progression from a pre-existing scoliosis, such as adolescent idiopathic scoliosis (AIS), compensatory spinal changes as a result of poor posture, trauma, tumor, etc., or from degenerative changes often in the lower back region.⁵  Adult scoliosis arising from degenerative changes in the lower back is the primary focus of this article.

Effects of Degenerative Lumbar Scoliosis

Spinal Stenosis

One growing sector of the population is individuals in the age range of 60-70 years old.  Individuals at this age are especially susceptible to radiculopathies and stenosis symptoms (neurogenic claudications).  Stenosis symptoms often cause pain or numbness in your legs, cramping, loss of sensation, and/or bladder dysfunction.  This is caused by a narrowing of the spinal column, whereby pressure is placed on sensitive structures such as nerve(s) and nerve root(s).   

 

 Other Effects Include:

Psychological Distress Decreased Lung Volume Torso Disfigurement Asymmetric hip and shoulder height Decreased Work Capacity Decreased Sitting Balance Reduced ROM Loss of Balance Accelerated Aging of Discs

Given the evidence revealing numerous changes of both bony and soft tissue make-up in the adolescent scoliosis, it would not be surprising that many cases of adult degenerative scoliosis are a result of ongoing progression from adolescent idiopathic scoliosis. 

Research has identified certain characteristic patterns within the adult population that enable us to identify which individuals are more susceptible to faster rates of progression.  One subclass of adult scoliosis tends to progress more rapidly and typically occurs later on in life.  This group commonly exhibits a greater magnitude of abnormal vertebral rotation early on, signifying the “initial event”, with increased rate of progression to follow.  Menopause seems to significantly deteriorate spinal curvature within this subclass.  This pattern of increased abnormal rotation early on correlates with a timeline of hormonal changes enabling us to distinguish them from another subclass.  In another subclass, abnormal vertebral rotation tends to occur not so much initially, rather in accordance to ongoing curve progression.⁶  Understanding and recognizing the aforementioned subclass differences now enables us to appropriately apply treatment methods based on inherent identifiable variables which are obtained through a thorough case history, clinical exam, and radiographic findings.

An interesting natural phenomenon within the human body is the ever-evolving bony tissue.  As scoliosis progresses throughout one’s lifetime, the bone remodels accordingly in response to the abnormal stresses placed upon it, typically laying down more bone under areas of stress and resorbing the bone under lower stress.   This perpetuates asymmetry in the vertebral body itself, thus creating a vicious cycle of spinal imbalance and continual progression.  Patients with osteoporosis and lumbar scoliosis are also more inherently susceptible to instability of the spine on a segmental level as compared to individuals with only lumbar scoliosis.⁷  Having osteoporosis in addition to adult scoliosis is certainly treatable; however, it does add complexity to the case.  This is one of many reasons why CLEAR^TM Institute incorporates methods such as vibration therapy when treating scoliosis.  For a complete explanation of vibration therapy used by CLEAR^TM Institute, please visit www.vibeforhealth.com. 

Abnormal Spinal Structure Causes Pain and Disability

Normal       Loss of curve

Lordosis   Decreased Lordosis

There are several key factors related to spinal alignment that have been shown to correlate with pain.  Interestingly, the degree of side-ways curvature in the lower back, as measured by a Cobb angle (which is the most common and widely accepted analysis), actually hasn’t been shown to correlate well with pain levels in degenerative lumbar scoliosis.8  Loss of curve in the lower back (lumbar lordosis) when viewed from the side and tilting of the vertebrae when viewed from front to back in the lower spine have been shown to correlate well with pain. 9 Furthermore, the apex of the curvature and intervertebral subluxation have been shown to correlate well with disability levels. 10

Given these factors showing a correlation to pain and disability, these are the targeted areas of conservative treatment through CLEAR^TM Institute.  While not all factors relating to treatment will be discussed, several key concepts incorporating exercise and neuromuscular re-education will be emphasized.  Adults commonly ask, “Isn’t there any exercise, stretch, etc. that I can do?”  The answer is YES!  However, while many exercise programs such as Yoga, Pilates, etc. may and often do offer benefit for adults with degenerative scoliosis, they may not be the most effective.  I’d like to stress “The Most Effective”, since I’m sure some individuals reading this right now have received benefits from these various techniques.  But, we need to look at the facts.  Unfortunately, yoga or similar methods typically do not account for specific vertebral alignment issues on a segmental level.  A thorough radiographic evaluation is necessary for this and only then does one have a precise “blue print” to work from.  That being said, the “blue print” in cases of adult scoliosis, and any scoliosis for that matter, is the underlying issue of asymmetry, thus necessitating the need for a dose of unilateral exercise prescription.  Dr. Woggon has an excellent analogy for this by comparing this concept to a crooked telephone pole.  If a telephone pole is leaning to one direction with one tight and one loose guide wire and our goal is to straighten that pole, do I want to pull on the tight wire?  Of course not.  This would essentially create further imbalance, just as it will in your spine by exercising muscles that are already tight.  “Can I do routines such as Yoga and still do a CLEAR^TM Treatment protocol?”  Certainly, however, you will be recommended to discontinue any movements such as stretching and strengthening exercises that are counterproductive to the end goal.   

Methods for Success

Interestingly, one of the indicators for success in adult scoliosis surgery, regardless of the underlying cause, is to what extent the lumbar lordosis is restored post-surgically^.4  This goal parallels the precise exercise prescription through CLEAR^TM Treatment Methods minus the operation, of course.  Follow-up x-ray analysis enables us to appropriately measure to what degree the lumbar lordosis has been restored.  Although CLEAR^TM protocols use passive stretching procedures for spinal re-shaping in many cases, the use of specific exercises for each patient that re-train the mind-muscles will also be incorporated for effective long lasting results.  These fall under a general category called “Neuromuscular Re-Educative Exercises.”  This means that the mind and muscles are actively engaged in re-training the faulty postural patterns and movements that are associated with abnormal curvature. 

We would like to stress that no one is too old to begin scoliosis treatment.  The right attitude and expertise offered through CLEAR^TM Institute is a recipe for success, which has previously been tried and trued through numerous individuals including Marvin, who was 82 years young when he began treatment.  Marvin’s success story may be viewed here.

References:

1. Schwab, JF, Lafage V, Farcy PJ, Bridwell HK, Glassman S, Shainline RM.  “Predicting outcome and complications in the surgical treatment of adult scoliosis.”  Spine 2008;20:2243-2247.
2. Schwab F, Dubey A, Pagala M, et al.  “Adult scoliosis:  a health assessment analysis by SF-36.”  Spine 2003;28:602-6.
3. Schwab F, Dubey A, Gamez L, El Fegoun AB, Hwang K, Pagala M, Farcy JP.  “Adult scoliosis:  prevalence SF-36, and nutritional parameters in an elderly volunteer population.”  Spine 2005;9:1082-5.
4. Birknes KJ, White PA, Albert JT, Shaffrey IC, Harrop SJ.  “Adult degenerative scoliosis:  A Review.”  Neurosurgery 2008;63:A94-A103.
5. Hawes CM, O’Brien PJ.  “The transformation of spinal curvature into spinal deformity:  pathological processes and implications for treatment.”  Scoliosis 2006,1:3.
6. Poumarat CM, Scattin L, Marpeau M, Garreau de Loubresse C, Aegerter P.  “Natural history of progressive adult scoliosis.”  Spine 2007;11:1227-34.
7. Velis KP, Healey JH, Schneider R.  “Osteoporosis in unstable adult scoliosis.”  Clin Orthop.  1988;237:132-41.
8. Schwab FJ, Smith V, Biserni M, et al.  “Adult scoliosis:  A quantitative radiographic and clinical analysis.”  Spine 2002;27:387-92.
9. Schwab F, el-Fegoun AB, Gamez L, et al.  “A lumbar classification of scoliosis in the adult patient:  preliminary approach.”  Spine 2005;30:1670-3.
10. Schwab F, Farcy JP, Bridwell K, et al.  “A clinical impact classification of scoliosis in the adult.”  Spine 2006;31:2109-14.