Spotting the signs of scoliosis at home

Short answer: A check done at home does not diagnose scoliosis. It only helps you decide whether to see a physician. The child is looked at from behind with the back uncovered, comparing the two shoulders, the shoulder blades, the space between the arm and the waist, and the level of the hips. The child then bends forward with the knees straight, and you watch whether one side of the back stands higher than the other. An uneven appearance that comes from a standing habit largely disappears on bending forward, while in a structural curve the raised side stays. Seeing nothing raised does not rule scoliosis out, and curves in the lower back and curves of a small degree are easy to miss in a home check. Marked back pain, pain that wakes a child at night, numbness or weakness in the legs, asymmetry that becomes obvious within a few months, and a curve that starts before the age of ten all mean seeing a physician rather than postponing the appointment.

Why scoliosis goes unnoticed

The main reason it is found late is that it does not hurt. In a study of 2,442 children with idiopathic scoliosis, meaning scoliosis with no identifiable cause, 23 per cent had back pain when they first presented, and a further 9 per cent of the same group developed pain during follow-up. In the great majority of children the curve causes no symptoms at all. With no pain, nobody thinks to look at the back. Whether a curve will go on to progress is a separate question, and the answer depends on where the child stands in growth and on the degree measured on an X-ray.

The second reason has to do with age. Curves change fastest during the growth spurt, which is also the age at which children start wanting privacy about their bodies. The back of an eight-year-old is seen several times a day at home; the back of a thirteen-year-old may not be seen for weeks. Families usually notice by accident: at the sea, at the edge of a pool, while a t-shirt is being changed, or later on, looking again at a photograph from a holiday.

The third reason is specific to Turkey, and it is the one an international family here has no way of guessing. Scoliosis screening is not among the national screening programmes run by the General Directorate of Public Health at the Ministry of Health. That list holds newborn screening, hearing and vision screening, the developmental hip dysplasia programme, premarital carrier screening for spinal muscular atrophy and a haemoglobinopathy control programme. Scoliosis appears nowhere on it. Where scoliosis screening does happen, it happens at province level, through protocols signed between a provincial health directorate and the corresponding provincial directorate of national education. The programme announced in Samsun on 7 March 2022 is a documented example: it covered pupils in grades five to eight, the examinations were carried out by physiotherapists, and children in whom scoliosis was suspected were referred on to a physical medicine and rehabilitation hospital.

In practice this comes down to something blunt. Whether a child is ever screened for scoliosis depends on which province they are at school in and in which year. If your province has no protocol that year, nothing happens and no letter arrives to tell you that your child's back was never looked at. School health here does not work the way it may in the country you came from, so an assumption carried over from there will quietly mislead you. For a family living in Bornova the picture is no different from anywhere else. Rather than trusting that the school will catch it, knowing how a check that takes a few minutes is done at home puts you on firmer ground.

Getting ready for the check

Five minutes is enough for the check itself. Whether it tells you anything depends largely on the preparation. Choose a room with good light and a level floor. The child stands without shoes, because even a small difference between the soles of two shoes changes the level of the shoulders and the hips. The upper body needs to be uncovered, and for girls a sports bra does not get in the way. Long hair has to be tied up, or the line of the neck and shoulders disappears underneath it.

Give no instruction about posture. A child who is told to stand up straight stiffens, and the very difference you were trying to see disappears. A few relaxed seconds are enough, with the feet together, the arms hanging loose at the sides, the weight spread evenly over both feet and the eyes looking ahead. The person doing the looking stands behind the child, far enough back to take in the whole back comfortably.

For an adolescent this is also a question of privacy. If you ask permission, let the child choose which parent does it and close the door, the check can be repeated later without a struggle. If the child feels uncomfortable, the check is not done that day and is left for another one.

What to look at from behind

Looking from behind means asking whether the right side and the left side resemble each other. Starting at the level of the neck and moving the eye down towards the hips in an orderly way works better than looking everywhere at once.

• Shoulder level. Look at whether the tips of the two shoulders sit on the same horizontal line. One shoulder that is persistently higher is among the findings families notice most often.
• The shoulder blades. Look for one shoulder blade sitting higher than the other, or for its inner edge standing further out from the back.
• The waist triangle. With the arms hanging at the sides, a gap is left between the inside of the arm and the waist. That gap is expected to be the same size on both sides. Narrow and deep on one side and wide on the other is a striking clue, and it can be picked out even with clothes on.
• Hip and waist level. Look at whether one hip sits higher, and whether the trunk as a whole appears shifted to one side.
• The axis of the head and trunk. Judge whether the head sits directly over the middle of the hips. The two small dimples either side of the tailbone sitting at the same height belong to this axis as well. A trunk that has shifted to one side as a whole carries more meaning than a single difference in shoulder height.

Small differences are common and mean nothing on their own. In Bunnell's screening study of 1,000 high school students, a trunk rotation angle of 3 degrees or more was measured in 80 per cent of them. In other words, once a measurement is taken, some degree of asymmetry is found in most children. A parent looking at a back at home is not expected to hunt for flawless symmetry. Noting a difference that is obvious, one-sided and still there weeks later is enough.

The Adams forward bend test at home

Once the standing look is done, the forward bend adds the part the eye cannot otherwise reach. In scoliosis the spine bends sideways and at the same time turns around its own axis. Bending forward brings that turning up to the surface of the back and makes it visible. Doing it is simple.

1. The child stands with the feet together and the knees straight.
2. The arms hang freely downwards and the hands are brought together with the palms facing each other.
3. The trunk bends slowly forward with the head hanging down, and carries on until the back is close to horizontal.
4. The person looking stands behind and brings their eye down to the level of the child's back. Looking from above hides the difference; the line of sight has to be close to the surface of the back and run along the spine.
5. The spine is judged section by section from top to bottom: first the upper back where the shoulder blades sit, then the lower back.

Look for one side standing higher than the other. In the upper back this appears as a hump formed by the ribs. In the lower back it looks flatter and broader, more like a fullness of muscle. Having the child bend slowly and stay in the position for a few seconds once the bend is complete makes it easier to compare the two sides. Looking a second time from the same position clears up most of the errors of the first impression.

The most useful thing about this test is that it separates an appearance caused by posture from a structural one. Asymmetry that comes from a standing habit largely disappears on bending forward. In a structural curve, where the vertebrae (the separate bones stacked one above the other to form the spine) have rotated, the raised side does not disappear and often stands out more. Having a second person in the family look from the same angle raises the chance of catching a difference that one pair of eyes might miss. Even so, this is not a measurement, and a conclusion reached at home does not stand in for an examination by a physician.

The reverse of this needs stating just as plainly. Seeing no raised side on bending forward does not prove that there is no scoliosis. Curves in the lower back and curves of a small degree are missed easily in a check done at home. It is known that small curves can be missed even in an examination carried out by a trained eye with an instrument. So if there is pain, if an asymmetry is becoming obvious quickly, or if any of the findings listed further down is present, a physician is consulted even when the forward bend looks normal.

What this check can and cannot tell you

A check done at home makes no diagnosis. Scoliosis is diagnosed when the Cobb angle (the degree of curvature measured on an X-ray film) measures 10 degrees or more on a standing front-to-back film of the whole spine and rotation around the axis can be recognised. The 2016 SOSORT guideline states plainly that a diagnosis of scoliosis should not be made below 10 degrees. What comes out of an observation at home is neither a degree nor a diagnosis. Its single output is a decision about whether to go and see a physician.

There is no single answer to the question of how reliable the test is. The sensitivity and specificity values reported in the literature swing across a very wide range from one study to the next. The reasons for that spread are known: the threshold chosen for referral, the age and sex distribution of the group screened, the training of the person taking the measurement, and which X-ray criterion the comparison was made against all change the result at its root. The two measures also move against each other. Lowering the threshold catches more children and at the same time sends more healthy children for an X-ray they did not need. That is why no single sensitivity figure appears on this page: the numbers in circulation do not agree with one another.

Honesty calls for one more point. Screening itself is contested. In 2018 the US Preventive Services Task Force concluded that the available evidence was insufficient to weigh the benefits and harms of screening adolescents aged 10 to 18 for scoliosis. Insufficient evidence is not a verdict against screening, nor a statement about how serious scoliosis is. The comparison it asks for, screened against unscreened children followed over years, has simply never been run. SOSORT, for its part, holds a position in favour of school screening. Two bodies looked at the same gap and came to different conclusions. Looking at home has neither a cost nor a dose of radiation, and its only output is an appointment with a physician if one is needed.

Clues that show up in daily life

A great many families notice scoliosis through some ordinary detail, and in each case the clothing is showing up an asymmetry underneath it.

• A skirt or a trouser leg hangs longer on one side, and it returns to that same side after being straightened.
• A bag strap slides off the same shoulder again and again, and the child keeps pulling it back up without noticing.
• A t-shirt or a shirt collar always slips off the same shoulder, and a bra strap leaves a different mark on each side.
• Family photographs show the trunk tilted slightly to the same side every time.

None of these clues is evidence. A tailor taking up a hem often notices the same thing, and it means no more in their hands than it does in yours. Their value lies in pulling the family's attention towards the back and in creating an occasion to look at it once with the back uncovered.

Bags deserve a separate word, because they lie behind one of the questions parents ask most. A heavy school bag is not the cause of scoliosis. Idiopathic scoliosis is currently understood to arise from a multifactorial genetic predisposition, and the picture cannot be pinned on a single environmental factor. Lightening the bag is a good habit, but it does not change a curve that is already there. The only meaning of a bag sliding off the same shoulder is that it makes a difference in shoulder height visible in daily life.

Things that look similar but are not scoliosis

Not every asymmetry on a back is scoliosis. The table below sets out the appearances most often confused at home and where the distinction is drawn. Drawing it belongs to the physician; the purpose of the table is to let a family know in advance what it is looking at.

The difference between poor posture and structural scoliosis deserves particular emphasis, because this is where the guilt that weighs on families most often begins. There is no evidence that sitting badly leads to scoliosis. Structural scoliosis is a three-dimensional deformity of the vertebrae themselves. It cannot be produced by a sitting habit and it cannot be undone by correcting posture. A parent who blames themselves for not having nagged enough is holding on to something with no foundation.

At the physician: the scoliometer and trunk rotation

At the examination the child bends forward in the same way, except that this time a small instrument called a scoliometer is placed on the back. The scoliometer reads, in degrees, how far the surface of the back sits away from the horizontal. That value is called the angle of trunk rotation, and reports usually shorten it to ATR.

The angle of trunk rotation does not stand in for the Cobb angle measured on an X-ray, and the relationship between the two is approximate. The scoliometer helps the physician decide who should be sent for an X-ray, and it shows whether anything has changed at the checks that follow.

The referral threshold varies with the choice made by the team doing the screening. Bunnell reported a trunk rotation angle of 7 degrees at any level of the spine as a suitable referral criterion. In the same study, a threshold of 7 degrees sent 3 per cent of the students to a physician, and lowering the threshold to 5 degrees raised that share to 12 per cent. In a later paper Bunnell suggested that borderline cases be rescreened after an interval rather than referred straight away.

Turkey's own field study used a lower threshold, and it describes the population your child belongs to. In a study that screened 16,045 pupils aged 10 to 15 across 85 schools in 40 provinces, pupils whose trunk rotation angle measured 5 degrees or more on the scoliometer, or whose Adams forward bend test was positive, were sent for an X-ray, and the diagnosis was confirmed by a Cobb angle of 10 degrees or more. The same study reported the frequency of adolescent idiopathic scoliosis as 2.3 per cent. That figure is 3.1 per cent in girls and 1.5 per cent in boys. Of the cases identified, 90.5 per cent were mild curves in the 10 to 19 degree range.

Whether an X-ray is requested is the physician's decision. If the examination findings raise no suspicion, follow-up without imaging may be preferred. The route through the health system is the part most likely to be unfamiliar, so here it is in plain terms. A family that suspects something usually starts with a family physician or a paediatrician, who can refer the child on to orthopaedics and traumatology (ortopedi ve travmatoloji), to physical medicine and rehabilitation (fiziksel tıp ve rehabilitasyon) or to paediatric orthopaedics. Waiting times differ between the state route and the private one, and which of them suits a family is not a decision this page can make. The timetable of what follows is set out on the diagnosis and follow-up page.

Findings that mean seeing a physician without waiting

A check at home helps you decide when to book a routine appointment. Other findings should not wait for one and need to be assessed straight away.

• Marked and persistent back pain. In most children scoliosis is painless. Where there is pain, it cannot be waved away as the pain of the scoliosis.
• Pain that wakes the child at night. Pain that does not settle with rest and lifts a child out of sleep is assessed on its own terms.
• Neurological symptoms. Numbness, tingling or weakness in the legs, a change in the way the child walks, loss of balance, or a change in bladder control.
• Asymmetry that progresses quickly. A difference in the shoulders or the waist that visibly increases within a few months.
• Onset before the age of ten. Curves that appear early are placed in a separate group, and the growth period ahead of them is far longer.
• Fever alongside the pain. Fever together with back pain is not something to wait out.

The reasoning behind these items rests on evidence too. In the same study of children with back pain, 48 of the 560 patients who had pain, that is 9 per cent of those in pain, were found to have another condition involving the spine as the source of it. In the great majority of children with pain no such condition was found. That possibility is still enough to mean that pain should not be passed over without being looked into. The same authors noted that history, physical examination and plain radiographs are sufficient in most cases, and that comprehensive investigation is not needed in every patient.

When there is no need to panic

The picture is not grave for every child whose back shows a difference, and the numbers say so. The large Turkish screening study found the frequency of adolescent idiopathic scoliosis to be 2.3 per cent and classified 90.5 per cent of the cases identified as mild curves. In an average class, one or two children with scoliosis are to be expected, and nine out of ten of them fall in the mild group.

Small asymmetries are genuinely widespread. When measurements are taken, some trunk rotation is found in most students. Where the Cobb angle stays below 10 degrees no diagnosis of scoliosis is made. That is a different picture, and according to the guideline bracing does not come into it. The decision about care rests with the physician in every case.

There is also a fear families hesitate to put into words, and it concerns the long run. In a study that followed 117 patients with untreated idiopathic scoliosis for fifty years and compared them with matched controls, chronic back pain was reported in 61 per cent of the patients and 35 per cent of the controls. Most of that pain was mild or moderate in severity. In the same study the probability of survival was consistent with what would have been expected. Scoliosis raises the likelihood of back pain in adulthood, and there is no finding that it shortens life.

Seeing a difference on a back does not mean you are too late either. Because scoliosis progresses quietly, most families notice it only once it has become visible to the eye. The delay comes from the silent course of the condition itself. The most useful preparation is to arrive at the appointment able to describe what you saw: when you noticed it, which side it is on, whether the raised side stayed on bending forward, and, if you have them, two photographs taken on different dates. All of that makes the physician's first assessment easier.

How often to repeat the check

Growth sets the pace here. A curve can change fastest during the growth spurt. The 2016 SOSORT guideline gives the risk of progression during the peak of height growth by tying it to the size of the curve as measured on an X-ray: 10 per cent for a curve of 10 degrees, 30 per cent for a curve of 20 degrees and 60 per cent for a curve of 30 degrees. Those figures apply to children who have been diagnosed and whose curve has been measured. They do not describe the risk carried by a child who has not yet been assessed. The same guideline states that the risk of progression falls markedly once the last stage of puberty is reached.

How often you repeat the check at home therefore follows the pace of the child's growth. If height is picking up, if trouser legs are getting short and shoe sizes are changing often, the interval between checks is shortened. Writing height measurements into the same notebook helps, since height and curvature move on the same timetable. In girls, a first menstrual period is a clinical sign that the peak of the growth spurt has passed, and it is asked about at the examination.

If follow-up with a physician has started, the check at home does not take its place. The 2016 SOSORT guideline does not reduce the follow-up interval to a single number. It uses a decision table that weighs the stage of growth together with the severity of the curve, and in that table the intervals range from 3 months to 36 months. Between two appointments, the family's own observation is there to notice whether anything has changed.

How to talk to the child about it

For a twelve-year-old, having their back looked at is not an ordinary event. Commenting in front of a mirror, measuring in front of siblings or sharing the photograph in the family group chat all make a child refuse the next check. If a photograph is going to be taken, agree beforehand where it will be kept and who will see it.

How you explain it shapes the outcome as well. Scoliosis does not come from anything the child did. It did not happen because of sitting badly, carrying a heavy bag or playing sport. Saying that plainly lifts a needless sense of guilt, and if there really is a curve it makes it easier for the child to take part in what follows. The purpose of the check is to make sure a physician is seen in good time when that is needed.

Parents often ask about siblings. Because the predisposition behind idiopathic scoliosis is genetic and multifactorial, looking at the back of a sibling in the same age window is a sensible precaution. It is a precaution rather than a programme, and it says nothing about whether that child has a curve.

The check on this page is the step before the diagnostic process. The growth period, the risk of progression and what the Cobb thresholds mean are covered on the scoliosis in children and adolescents page, and the definition of scoliosis together with the misconceptions heard most often on the what is scoliosis page. Questions worth taking to the examination are gathered on the parents' questions page. The practice is in Evka 3 in Bornova, and the introductory call and the assessment can both be held in English, which matters when a family has seen something on a child's back but does not yet have the Turkish words for it. A physiotherapy assessment is not a diagnosis: where a curve is suspected, the physician's examination comes first, along with imaging if the physician asks for it.