Somewhere as 2012 became 2013, I dipped my toes in what I’ll call “The Lake of Scoliosis”. Soon after, I dove all the way in, started splashing around, and have never fully emerged. I’d long been fascinated by the spine in all its wonder, and in particular, asymmetries of the spine. I’d wonder about side-to-side differences when I’d reach the alignment segment of the objective exam. I could see some nuances, but couldn’t take my clinical reasoning process any further.
Eight years later, I’m still floating around, although I’ve ventured to different lakes, streams, waterfalls along the way. The adventure continues and there is still much to be explored.
But for now, these are 4 things I wish I knew about adult scoliosis back when all I had under my belt was the one hour of scoliosis education from physio school (insert stick figure draped sideways over a physioball with the words “stretch” on one side of the trunk, and “strengthen” on the other side of the trunk).
1) THERE ARE DIFFERENT TYPES OF ADULT SCOLIOSIS
This distinction will come up in the subjective portion of the exam if scoliosis is part of your client’s main concern, or it will come up during the objective as the spine differences come to light.
If there is already a recognition by the client that there’s scoliosis and it is part of the client’s chief concern, the follow-up question will be, “At what point in life did you or anyone close to you recognize that there was a side-to-side difference in your spine?”
If the client clearly remembers the discovery being made during childhood or adolescence, they have adolescent idiopathic scoliosis and are now an adult. (1) We can then explore further how their scoliosis was managed at the time and throughout their lives up to this point.
If the client says something like, “I started noticing it about 3 years ago when looking in the mirror” or “My partner says she noticed it in the last 10 years when she would walk behind me and see me tilting to one side a bit”, you can make the prediction that they have what’s called “de novo” scoliosis or adult-onset scoliosis. (1) This means that the spine variation came about after skeletal maturity.
How does this affect clinical decision making? First, it affects the client’s story and their story affects our collaboration. Adults with scoliosis that came about during childhood/adolescence may have a different way in which they’ve integrated scoliosis into their life narrative. This integration runs the gamut, from full acceptance, to varying levels of satisfaction with appearance, to a broad spectrum of belief about how scoliosis affects their musculoskeletal and movement system as a whole. Like any patient, better understanding our clients’ beliefs and perspectives can help create a richer process. Adults with a more recent discovery of scoliosis may present with a different perspective, a different narrative. For some, it can be alarming to recognize at some point in life the development of an asymmetry. There may be a level of fear and anxiety surrounding the change in the spine. For others, the information is accepted matter-of-factly and immediately leads to, “What can I do to help myself?”
2) SIZE OF COBB ANGLE DOES NOT CORRELATE WITH MAGNITUDE OF PAIN
Just like structure does not equal pain for any other tissue issue we treat in the movement world, the magnitude of the curve we see clinically and on radiographs does not mean that the individual we’re measuring is that amount likely to experience pain. (2) In the same way that I have a client with a full rotator cuff tear able to do pushups and lift weight overhead largely without pain, I have a client with negative imaging who is unable to perform these functions due to pain. Similarly, I have clients with curve magnitudes upwards of 70 degrees running several times/week in Central Park, and then also have clients with 28 degree curve experiencing a lot of pain.
If Cobb angle is not the end-all/be-all, there are a few markers that come from the world of orthopedic surgery, that can be helpful to us non-operative movement professionals.
3) PAY ATTENTION TO THAT PLUMBLINE
You know the good ol’ plumbline that I for sure memorized in physio school.
Slightly posterior to apex of the coronal suture
Through external auditory meatus
Through the odontoid process of axis
Midway through shoulder
Through lumbar vertebral bodies
Through sacral promontory
Slightly posterior to center of hip joint
Slightly anterior to axis of knee joint
Slightly anterior to lateral malleolus
Through calcaneocuboid joint
Midline of skull
Midline of sternum and spine
Midline of pelvis
Midway between lower extremities
Midway between heels
Table 1: “Ideal” Plumb Alignment (3)
What orthopedic surgeons have taught us over the last decades about adults with scoliosis is that though we can live well with some variation in sagittal (side view) and frontal (front/back view) alignment, there is a seeming “point of no return”.
From the side view, it’s best for C7 to stay as lined up with the posterior superior sacral base as possible. If the spine variation changes the side alignment to the point where the cervicothoracic junction and shoulders migrate too far forward in relation to the pelvis, the energy demand on the musculature of the entire kinetic chain to stay upright shoots way up, and quality of life issues often ensue. It’s called anterior sagittal imbalance. (4)
From the front/back view, if C7 ventures to far to the right/left in relation to the gluteal cleft (or, butt crack, as it was called in my upbringing?), it also increases the demand on active and passive structures to maintain healthy center of mass.
The true reference values come from radiographic measures where a full-spine x-ray is needed.
Sagittal Vertical Axis (SVA) taken on a lateral full spine x-ray
- vertical line dropped from C7
- vertical line through posterosuperior sacral base
Problematic if C7 > 4cm anterior to sacrum (4)
Central Sacral Vertical Line (CSVL) taken via a full spine x-ray AP or PA view
- vertical line from C7
- vertical line from center of sacrum
Problematic if C7 is >3cm to either direction (right or left) in relation to sacrum (5)
Table 2: Radiographic reference values for SVA and C7-CSVL (4,5)
However, we can get a good gist clinically. Using the plumbline values as reference points, how do the parts “stack” up from the side view? How do they stack up from front/back views?
From there, try to ascertain how “fixed” the alignment is. Meaning, does the alignment change if the free-standing position is compared to a more unloaded position.
Examples of unloaded positions- in each position, ask “How do the parts stack up?”
- standing with back supported against wall (heels about 1-2 inches away from wall
- sitting supported and unsupported
If the client is able across unloaded positions to come to a more centered alignment from the sagittal and frontal plane views, it shows there’s the potential to modify. If not, the prognosis isn’t going to be as great for exercise to be helpful.
4) STABILITY > MOBILITY
This part I’ve learned the hard way. The client will feel compressed and tight. Their instinct will often be to want to hang from something, hang upside down, round, sidebend, and rotate the back to reduce the unpleasant sensations and experiences they’re having. Historically, me being the helpful person that I am, I’ve gone with it. I’ve let them. They’re fine in the moment. Then, there’s a latent effect of increased symptoms later. Darn it!
What was helpful for me to learn in the last 8 years was that often, adults with scoliosis of either type, but especially the “de novo” or adult-onset type scoliosis, have spondylolisthesis. A scary-sounding word, but simply stated, two adjacent vertebrae are not stacked on top of each other in a congruent manner. Beyond the sagittal plane spondylolisthesis that I learned about in physio school that often affects individuals who participated in activities requiring a lot of spine hyperextension, in adults with scoliosis, the spondylolisthesis happens across multiple planes. (2) At times, a client may have imaging that demonstrates spondylolisthesis in multiple adjacent vertebrae affecting all three planes (antero/retro-, latero-, rotatory). There are still plenty of ligaments, muscles and connective tissues holding the spine up quite well. However, the system must learn to control their systems to a higher level.
Low kneel//prone on knees for both stability and elongation in closed chain
For this reason, the safest, best route to take is to build (create) space within, in an active way. The client is trained with a skilled clinician to create the proper amount of internal pressure and space for the task at hand and the healthiest coordination of the muscles around the trunk. A good start is to work first in neutral spine, with the ribcage stacked as best as possible over the pelvis within the client’s available capacity.
There we have it. Four concepts I wish my 2012-self had known about adults with scoliosis.
My training in scoliosis and adult scoliosis, in particular, comes from the following wonderful resources. I’d highly recommend the coursework offered by these organizations.
Kelly Grimes (IG handle: @physio_kellyg) is a physiotherapist living and practicing with Columbia University Irving Medical Center in New York City. A California native, she’s been living in the Big Apple for the past 5 years, where an opportunity showed up in 2015 to pursue her passion for bettering her understanding of scoliosis. An instructor for Movement Links from 2014 – 2020, Kelly has taken a step back from teaching while she pursues some personal dreams. She still helps with the ML Blog, social media accounts, and is an all-around through and through fan of Team Movement Links. xxoo
1) Aebi M. The adult scoliosis. Eur Spine J. 2005;14:925-948.
2) Schwab F, Farcy JP, Bridwell K et al. A clinical impact classification of scoliosis in the adult. Spine. 2006;31(18):2109-2114.
3) Kendall FP, McCreary EK, Provance PG, et al. Muscles- Testing and Function with Posture and Pain, 5th Ed. Baltimore, MD: Lippincott Williams & Wilkins; 2005.
4) Schwab F, Ungar B, Blondel B, et al. Scoliosis Research Society- Schwab Adult Spinal Deformity Classification- A validation study. Spine. 2012;37(12)1077-1082.
5) Lowe T, Berven SH, Schwab FJ, et al. The SRS Classification for Adult Spinal Deformity- Building on the King/Moe and Lenke Classification Systems. Spine. 2006;31(19)S119-S125.