Demystifying Scoliosis: Finding Symmetry in an Asymmetrical World
I think we all can agree when we hear scoliosis, we automatically have dreaded memories of going into the nurse’s office in middle school to see if “my back is curved and broken.” Scoliosis will always have a negative connotation to it, but the goal of this article is to demystify what can seem like a daunting diagnosis and empower you to understand scoliosis is more than a curved spine. Anatomically, we have a symmetrical body, but I want you to reflect on your day-to-day tasks. Do you consistently lean on one armrest more than another when you sit? Do you drive with torqued hips and/or shoulders? Is your computer monitor positioned more to one side? Do you stand with more weight on one leg more than another? If standing while reading this, which leg are you standing on? I’m going to guess your left. 75% of people stand on their left leg the majority of the time. This reflection helps us to understand that we live in an asymmetrical world, which plays an important role in scoliosis.
To begin this conversation it is important to understand that there are two things the body doesn’t like; compression and tension. Compression is the act of flattening through use of pressure (think of someone gently squeezing your head for hours on end, uncomfortable right?). Tension is the state of being stretched (think of someone bending your finger back for prolonged periods, also uncomfortable!). What leads to these normal forces becoming disrupting forces is repetition. Repetition is what your body consistently does over a period of time. In the end, our body is controlled by our brain, which can learn bad habits very quickly in its pursuit to be efficient but sometimes what is efficient is not effective. For example, if you were standing on your left leg when first reading this, that stance is resting on the hip joint and not using the hip muscles for support. Using the hip muscles requires energy, which for survival, it is more efficient to save that energy. For musculoskeletal pain, it is a worthwhile and effective use of energy to use those hip muscles. Nearly all injuries can be broken down into this idea of repetitive forces (compression or tension).
When it comes to scoliosis, broken down simply it is a miscommunication between your shoulders and hips and the spine gets caught in the middle. We explain it best in this capacity because it literally is your spine bending from the top and from the bottom. The goal of treatment is not to manually put the spine back in alignment but to figure out where this miscommunication is happening. There may be a deficiency in your shoulders and/or hips, or what connects the two together (your core). Identify where this is happening, relearn that movement pattern and the spine will respond in a positive fashion.
Typically, patients ask: how can I fix my back pain or how can I correct my scoliosis? In order to answer this question, you have to know the why? More often than not, treatment first requires a mindset shift and new questions asked: How do your hips work? How do your shoulders work? (followed up by why don’t they work well?) Typically one hip/shoulder works completely different than the other. How on earth can the spine feel good and stay straight when above and below it is out of balance and can’t function? The body takes the path of least resistance so the spine bending to accommodate repetitive use is easier than learning how to move through the hip or shoulder resistance.
In more clinical language, scoliosis is a condition that refers to the abnormal sideways or rotational curvature of the spine. There are two different subsets of scoliosis; structural and functional. Structural is typically the one found in childhood. Functional refers to the repetitive asymmetrical use explained above, where your functional use has created a curve. Although scoliosis can happen at any time, it is less likely during adulthood once a person has reached skeletal maturity. So if you were just diagnosed with scoliosis at 25/45/65, its most likely functional scoliosis (again think about the questions above, do you use your body asymmetrically?) Most often, scoliosis occurs in children just before puberty—ages 10-20—and affects 2-3% of the population in the U.S. (an estimated 7 million people). Standard treatment for scoliosis that you’ll hear from your PCP or orthopedic doctor varies and depends on the severity of the curve, the location of the curve and the patient’s age, and for more severe cases surgery is recommended. Causes may be genetic, environmental or oftentimes, unknown. However, beginning to identify the asymmetries through the use of physical therapy, we can help slow the progression of the spinal curve or when a patient begins to develop other conditions (pains) as a result.
How is scoliosis diagnosed?
When viewed from the back, a healthy spine appears as a straight line. A person with scoliosis will appear to have a side-to-side curve in their spine. An x-ray is the gold-standard to measure spinal curvature (the point of the first shift of the vertebrae and the last shift of the vertebrae), known as the Cobb angle. There are two types of curvatures, a C-curve (1 curve) or an S-curve (2 curves), the severity of which depends on the degree of the curve’s angle. A spinal curve of 10 degrees or greater is classified as scoliosis while a curve measured greater than 25-30 degrees is considered severe.
We all probably remember going through a scoliosis check back in grade school. During this test, known as the Adam’s Forward Bend Test, a medical professional looks for one or more of the following signs:
• One shoulder is higher than the other when standing at rest
• One side of the rib cage is higher than the other when bent forward (a visible “rib hump”)
• One side of the hip appears higher or more prominent than the other
• An uneven waistline
Scoliosis is not always associated with pain although changes in a patient’s alignment, posture and movement patterns may affect the surrounding muscles and joints, resulting in irritation and painful symptoms. The body doesn’t like compression and it doesn’t like being stretched too much, both of which take place with scoliosis. If you have a Right C-curve (a backwards ‘C’ when looking from the back), the left side of your body is compressed including the facet joints in the back, discs, ribs and muscles throughout your rib cage, back and chest. The same right side tissues are being excessively stretched. All of these things have the potential to be pain sources. Remember the scenario above of squeezing your head or bending your finger back? Which would be more bothersome to you? The majority of people would think an excessive head squeeze would bother them more. Remember that’s compression. The body typically feels the same way, meaning the painful side is typically the compressed side.
When should I seek scoliosis treatment?
Anytime! Clinically, treatment for scoliosis is based on the patient’s age, how likely they’re able to continue growing and the degree of the spinal curve. However, the body is very resilient and efficient at healing when given the proper environment so it’s important to seek out treatment for scoliosis as soon as possible if there is any concern that it may be present. As you may imagine, it’s best to begin treatment before the curve progresses (better to treat someone with a 10 degree curve rather than a 40 degree curve). Based on the severity, medical professionals may recommend intrinsic or extrinsic bracing to counteract further progression of the curve. If return to function can’t be achieved, surgery consult may be the next steps.
How can physical therapy help with scoliosis?
When it comes to scoliosis, like any other condition, each body is different. Your physical therapist will assess your hips, core, shoulders, and ability to stabilize/mobilize each joint with the goal to manage any resulting pain occurring as a result of muscle imbalances. They’ll also take into account any repetitive movements you may perform on a regular basis that may be causing the spine to bend further, progressing the spinal curvature. The whole physical therapy mindset is geared toward providing an exercise-based option for scoliosis treatment which aims to improve posture, eliminate pain and stop curve progression. Your PT will help to make sure that you understand any factors causing you to fall out of alignment so that if and when it happens again, you have the tools necessary to train your body out of the curve.
Each PT program can be broken down into four flexible phases:
1. Inhibit irritated issues: this means to reduce pain or “shut up” the tissues that are yelling at you.
2. Lengthen compressed/tight tissues: Remember compression typically comes first so reducing that compression will help create a healing environment more quickly.
3. Activate inhibited (weak) muscles: Turn on muscles to restore symmetrical use. We like to say muscles go on vacation cause they aren’t being used, but we need to get them back from vacation which can take time.
4. Integrate into daily life/function: Learn how to use these activated muscles in functional positions (squats, walking, running, single leg balance, jumping, etc.)
Whether a scoliosis patient has a curve to the right side or the left side, there can be a compensatory lean or rotation of the trunk, or mid section, over one of their legs that over time, which allows the spine to bend further. The goal of your physical therapist is to address these imbalances around the spine through various treatments, some of which may include:
• Manual therapy techniques to inhibit and lengthen tissues to restore mobility to any joints or tissues that may be restricted due to scoliosis. Some muscles may be stronger or tighter than others because of the curvature of the spine. Your PT will work on removing restrictions from those muscles to reduce pain, relax the tissue and retrain your movement patterns.
• Postural education to help activate and integrate muscles to actively elongate the spine, reduce pressure on the back and teach you how to use your muscles properly. Depending on the level of curvature, your physical therapist may adjust certain aspects of your posture to re-establish spinal symmetry as efficiently as possible.
• Custom exercises to improve range of motion and strengthen muscles surrounding the spine that may be weakened. Your PT will work to ensure your hips, core and shoulders are properly strengthened to reduce pressure from spinal misalignment.
While many people may automatically think surgery when it comes to scoliosis, depending on the severity, working with a physical therapist can teach you how to stretch and strengthen yourself to reduce symptoms of pain by unloading tissues. Physical therapy can be a great option as it can help to strengthen against the curve to try and stabilize it and improve the communication between the brain and the muscles. Whether you’re undergoing spinal surgery or feeling general symptoms of back pain, your physical therapist can tailor treatment to your individual needs.
One last analogy to sum up this scoliosis mindset shift. Pain that occurs as a result of scoliosis can be thought of similar to a car that is out of alignment. If you notice that your right front tire is wearing more than usual, you wouldn’t just think the tire is wearing (facet arthritis, disc herniation, muscle strain, etc) and pulling your car out of alignment (scoliosis). No, your car was already out of alignment, resulting in the tire wearing out more. Figure out why your tire is worn in the first place instead of just putting a temporary fix on it by pumping it up.
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