Scoliosis in adults

Short answer: Adult scoliosis is not a single condition. A curve that began in adolescence and settled at a certain angle when growth finished behaves differently from a curve that appears later in life, as the joints and discs of the spine change with age. In childhood, scoliosis is usually silent, while in adults pain is what brings people to an appointment. Physiotherapy in an adult is aimed at managing pain and at building trunk endurance, balance, breathing and the capacity to get through an ordinary day, rather than at reducing the number written on an X-ray report. The evidence in this age group is thinner than the evidence in adolescents, and this page says exactly where it thins.

Two different conditions under one name

In adults the word scoliosis covers two situations that have little in common. The first is an idiopathic curve, meaning one whose cause is not known, that began in childhood or adolescence. It was formed while the spine was growing, and whatever angle it had reached at skeletal maturity (the point at which the skeleton has finished growing) largely sets the frame for the decades that follow. The second is degenerative scoliosis, called de novo scoliosis in the literature, which means a curve that appears for the first time later in life. Here the spine was straight before, and a curve develops, most often in the lower back, out of asymmetric age-related change in the discs and in the facet joints (the small joints that link one vertebra to the next). They differ in mechanism, in where they usually sit and in how they behave over the years.

The physician is the one who tells them apart, working from your history and a standing X-ray of the whole spine. The most valuable part of that history is often the old images you already have somewhere. A chest film taken years ago for something entirely unrelated can show whether the curve existed at that date, which makes it useful in a way that no description given from memory can be. It is worth spending the half hour it takes to find old films and reports before the appointment.

If you moved here from another country, those images may sit in a hospital system you no longer have access to, or on a disc in a drawer you have not opened since the move. A copy on a disc, an exported file, even a clear photograph of the report, all help. A report written in another language can be gone through together in the appointment.

The distinction between the two conditions can look like an academic detail. In practice it decides what the appointment is about. Where a curve has been carried over from adolescence, the conversation turns on how large it is and whether it has changed across the years. In the degenerative picture the subject is usually low back pain, symptoms running down into the leg, and how far you can walk before you have to stop. The general frame for the types of curve and for the definition itself is on the what scoliosis is page.

Silent in childhood, painful in adulthood

Does scoliosis hurt while a child is growing? Usually it does not, and that is the whole difficulty. In the majority of children the curve produces no pain at all, and that is exactly why it goes unnoticed for so long. The question parents ask afterwards, which is how they could have missed something that never hurt, is taken up on the parent questions page.

In adults the picture changes. What brings a person to the appointment is usually pain and difficulty with everyday tasks; what the back looks like in the mirror comes second. Behind that observation stands the longest follow-up study this guide relies on. Weinstein and colleagues followed untreated late-onset idiopathic scoliosis over fifty years, comparing 117 people with 62 matched controls. The average age of the participants was 66, with a range from 54 to 80. Chronic back pain was reported by 61 per cent of the group with scoliosis and by 35 per cent of the control group, and the difference was statistically significant.

The second half of the same study rarely gets passed on. Most of the pain reported was mild or moderate in severity. At fifty years, survival in the group with scoliosis was consistent with what would be expected for their age and sex, so these data did not show that untreated idiopathic scoliosis shortens life. Shortness of breath during routine daily activity was reported by 22 per cent of the group with scoliosis and by 15 per cent of the controls.

The two halves have to be read together. Someone with scoliosis is clearly more likely to report back pain over the years than someone without it. The same data give no support at all to the sentence you will meet all over the internet, that scoliosis shortens your life, and they indicate that the pain is usually not severe enough to shut a life down. Both halves belong in the same conversation. Hiding either one would leave you worse informed.

What people come in with

What people report with adult scoliosis varies a good deal from one person to the next. These are the problems that come up most often.

• Low back and mid-back pain that increases with standing or walking for long periods and eases somewhat on sitting down or leaning forward
• Back fatigue that becomes noticeable after the middle of the day, along with difficulty holding an upright position
• A shift of the trunk to one side or forwards, with visible asymmetry at the shoulders and at the waist
• A change in the way clothes sit, such as a hemline or a trouser leg hanging differently on one side
• Pain, numbness or pins and needles spreading from the hip down into the leg
• A shorter walking distance, and needing to sit and rest after a few hundred metres
• A sense of having lost height, and the abdomen appearing to come forward

No single item on that list makes a diagnosis, and the items are not set out in order of frequency. The same complaints arise from a great many causes that have nothing to do with scoliosis. Whether the pain comes from the curve itself, from a neighbouring joint, from pressure on a nerve root or from something else entirely is a question for the physician. Physiotherapy does not make that distinction. It works on the diagnosis the physician has already made.

One thing to think about before the appointment is how you would date the change. People often find they can place it in a particular season or after a particular stretch of heavy work, and that is the kind of detail a physician can actually use.

Does the curve progress once growth has stopped

This question comes most often from people who were given a diagnosis in childhood and have not been to a follow-up appointment since. The 2016 SOSORT guideline gives two thresholds. At skeletal maturity, a Cobb angle (the degree of curvature measured on an X-ray) above 30 degrees carries an increased risk of progression in adulthood. Above 50 degrees, the guideline records a consensus that progression in adulthood is almost certain. Those two figures also explain why care during the growing years is framed as arriving at maturity with a low angle, rather than as bringing down the angle a child has today.

In degenerative scoliosis, progression runs alongside the changes in the discs and the joints. A yearly rate would not be an honest figure to give, because no verified data show how many degrees a degenerative curve advances in a year. You will find numbers of that shape in circulation. A figure with no source attached is a poor basis for a personal plan. The interval between check-ups is better left to the physician.

How to read a difference in degrees between two reports of different dates is a separate question, and it involves the repeatability of the measurement itself. That is covered in detail on the diagnosis and follow-up page. The single point to make here is that differences of a few degrees usually sit inside the margin of the measurement.

What the physician looks at, and how the route works here

An adult assessment starts with a film of the whole spine taken standing up, not lying down. It is taken that way because what has to be seen is the alignment under load, and that alignment disappears the moment you lie flat. Which imaging is needed is a decision for the physician, and X-rays are not ordered in physiotherapy.

One difference from assessment during the growing years should be stated plainly. In children and adolescents the Risser stage, which reads skeletal maturity from the way a growth cartilage along the rim of the pelvis has turned to bone, carries real weight, because it helps estimate how much growth is left. In a person whose growth is complete, that information no longer tells anyone anything. An adult physician looks at a different set of things, and the list usually includes change in the heights of the discs, slippage between vertebrae, signs of pressure on a nerve root, how far the trunk has shifted forwards or to the side, and bone health.

Which of those findings explains your pain is not something this page can say. Several of them can sit together on the same film, and their relationship to pain differs from one person to the next. Which finding accounts for the picture is decided by the physician who reads the examination and the imaging together.

If you are new to the health system in Turkey, the route is worth knowing before you start, because it does not work the way it does in many other countries. Adults usually begin with the family physician at the family health centre (aile sağlığı merkezi) they are registered with, who examines them and refers them onwards. A referral is not compulsory, however. An outpatient appointment at a state or university hospital can be booked directly, and going to a private clinic is also possible. Either way the department to ask for is orthopaedics and traumatology or physical medicine and rehabilitation, and imaging follows only if the physician asks for it. Appointments at state and university hospitals are made through the national appointment system, while private clinics are booked with the clinic itself. The main difference between the two routes is how long you wait, and which of them suits you is not a choice this page can make on your behalf. The route is set out more fully on the diagnosis and follow-up page.

There is one more piece of local background that an adult who grew up elsewhere would have no way of knowing. Turkey has no national school screening programme for scoliosis, and where screening does happen it runs on protocols signed between provincial authorities. A curve that nobody caught at school is therefore a common story here, and it does not mean that anyone failed you. It is part of why some people first learn of the diagnosis in their thirties or forties.

One of the things adult readers ask most is whether never having gone back for a check-up since childhood is a loss that cannot be made up. The years cannot be recovered, but where things stand can be measured today. The clearest sign of whether anything has changed is usually your own observation. Has the way your clothes sit altered over the last few years? Has the length of time you can stand gone down? Is a task that used to be painless now hard work? Take those three observations into the appointment. A degree remembered from decades ago is much harder for anyone to act on. Outpatient appointments are short, and writing those observations down beforehand, together with the questions they raise, is the difference between asking them and remembering them in the corridor afterwards.

Why the aim is set differently in adults

In a growing child the case for conservative care is straightforward. The spine is still growing, so there is a window in which the size of the curve at maturity can be worked on. How that window operates is described on the scoliosis in children and adolescents page.

In an adult that window has closed, so a programme built around reversing the curve promises more than the evidence allows. The realistic aims of working with an adult are these.

• Managing pain: recognising the postures and loading patterns that increase pain, and settling on adjustments that can actually be kept up during a working day
• Trunk endurance: building the capacity of the back and hip muscles to hold an upright position over time, which has more to do with how long the muscles last than with how strong they are in one effort
• Balance and walking: control of the centre of mass of the trunk, particularly in the way it bears on the risk of falling in later life
• Breathing mechanics: working on the mobility of the rib cage and on the pattern of breathing itself
• Daily capacity: how long you can stand, how far you can walk, and getting through work and household tasks with less complaint

The principles of scoliosis-specific physiotherapy can be used in adults as well. Autocorrection, which means learning to bring your own trunk actively into a more balanced alignment, rotational breathing, and holding the alignment you have found across the course of the day are among them. The detail of those principles and where they came from are on the Schroth method page. What changes in an adult is the purpose those principles serve, rather than the principles themselves. The target becomes the way you use your spine through the day, and no longer the figure on the report.

The general frame of the assessment and of how a session runs is described on the how a session runs page. What tends to be added for an adult is the daily rhythm of the pain, the shape of the working day, walking tolerance, and any care already received elsewhere.

Where exactly the evidence thins for adults

The randomised trials this guide quotes for scoliosis-specific exercise were carried out in adolescents. Schreiber and colleagues enrolled patients between 10 and 18 years of age in their Schroth trial. The Turkish trial by Kuru and colleagues also studied adolescent idiopathic scoliosis. The participants in the most comprehensive review in the field are of adolescent age too. This body of evidence describes a growing spine.

The direct consequence is this. No randomised trial exists today measuring the effect of physiotherapy on pain and function in adult scoliosis. Programmes for adults are largely borrowed from the adolescent studies and from general musculoskeletal rehabilitation. It is better to decide knowing this than to hope without it, and that is why this section exists at all.

The adolescent data are themselves cautious. When the studies are pooled, the average change in degrees does not reach the threshold accepted as clinically meaningful, and the certainty of the evidence stays low. The detail of that argument, with its numbers and its sources, is on the bracing and exercise page.

The reason for not aiming at a smaller angle in adults therefore goes beyond the closed growth window. Above a certain curve size, the adolescent data do not support that aim either. In the same studies, improvement was reported in the quality of life measures, and quality of life is precisely the ground the adult conversation stands on.

At one point the adolescent data give an adult something to think about. In the trial by Kuru and colleagues, the group working in the clinic under a physiotherapist's supervision improved in curve angle and in trunk rotation, while the group doing the same exercises alone at home did not. In the same trial there was no difference between the groups in the quality of life measures. The study was small, with roughly fifteen people per group, it was run at a single centre, and it followed people for twenty-four weeks. The finding cannot be carried straight over to adults. It still gives a reason to think that work taught and supervised by a physiotherapist differs from work followed alone from a video.

Working seated or on your feet

Work is what adults ask about most. Long hours at a desk and long shifts on your feet can both increase back complaints, because what the two have in common is a position that does not change for hours. The most concrete adjustment available is to change position at regular intervals rather than to search for the one correct way to sit. For someone who works standing, spreading the weight evenly across both feet and noticing the habit of leaning into one hip does much the same job.

People who drive for long stretches usually ask how the seat should be set. What matters here is the break, not the seat setting. A back feels those two hours very differently when the drive is broken by short stops. There is no list of sleeping positions that suits everyone either. Your own measure is how long the stiffness lasts after you get up in the morning.

A list of forbidden movements would be the wrong thing to hand out. What you can lift depends on your capacity, and capacity is something that can be built. Keeping the load close to the body, avoiding lifting while the trunk is twisted, and splitting a large load instead of carrying it in one go are widely recommended adjustments that may help reduce strain. In everyday terms that means dividing the shopping between two hands rather than carrying it all in one, or not always settling a child on the same hip.

Whether pain means giving up a job is not a question this page can decide. It is discussed with your physician and, where your workplace has one, with the occupational physician.

Choosing exercise

Many adults with scoliosis move less than they used to, usually out of a fear of making the pain worse. Inactivity tends to work against you, because it can reduce trunk endurance and make the whole picture harder to manage. Walking and low-impact aerobic activity give most people a base they can keep up. Strength work is not an area to stay away from either, and it can be done as long as the load is increased gradually.

A practical way of telling that a programme is too much is to watch how the pain behaves over the days after a session. Feeling worked during the session itself is expected. If the pain that follows carries into the next day and does not settle, the load or the volume may have been above your capacity for that day. In that case the programme continues at a lower intensity, and how it behaves from then on is discussed with your physiotherapist.

Clinical pilates approaches and general conditioning work can be used alongside. No adult evidence shows that they have any scoliosis-specific effect, so they are best understood as a general base that raises trunk capacity. The widespread belief about swimming, and what the evidence actually says about it, are dealt with on the school, sport and daily life page.

Pregnancy and scoliosis

Two very different readers arrive at this section. One is a young woman with scoliosis herself. The other is a mother whose daughter has been given the diagnosis and who is already thinking years ahead. As parents put it, the question is whether their daughter will be able to become pregnant and give birth.

There is no finding showing that scoliosis prevents conception. Whether back pain increases during pregnancy, whether pregnancy makes a curve progress, and whether the mode of delivery is affected by it, are questions that verified data cannot answer. Those three belong to an obstetrician, and the most honest thing this page can do is write the question down by name and say that it has no answer here.

Exercise during pregnancy stands on firmer ground. In the absence of an obstetric or medical contraindication, physical activity in pregnancy is regarded as safe and desirable, and the level recommended is at least 150 minutes a week of moderate-intensity aerobic activity. The detail of exercise in pregnancy, and the warning signs that mean stopping, are on the exercise in pregnancy page. Pelvic floor topics are covered on the what the pelvic floor is page.

Whether an epidural can be given, particularly in someone who has had spine surgery, is assessed by the anaesthetist and the obstetrician together. Physiotherapy does not answer that question, and offering an opinion on it would be out of place.

Where physiotherapy stops, and who this is not suitable for

The limit deserves writing down, alongside the list of what can be done. Physiotherapy does not diagnose, does not order imaging, does not prescribe braces and does not recommend medication. All of that is the physician's field.

In the situations below, referral to a physician comes first and the exercise programme waits.

• New back or low back pain that has not yet been assessed by a physician and whose cause has not been established
• A picture that is still under investigation, with test results awaited
• Curves that have reached the band at which surgical assessment begins
• A programme set up for someone who has had spine surgery without knowing the movement and loading limits their surgeon has set

Once a curve has reached the band for surgical assessment, the questions being asked leave the field of physiotherapy altogether. Roughly where that band begins, why entering it does not mean a decision to operate has been made and a list of questions worth taking to the surgeon are all on the surgery decision page. Questions about what an operation achieves, what it risks, what the scar is like and what life is like afterwards belong to the spine surgeon. This page will not stand in for one.

Findings that need a physician without delay

The findings below call for assessment by a physician without waiting for a physiotherapy appointment.

• A change in bladder or bowel control, or numbness in the groin and around the back passage
• New or rapidly increasing weakness in the leg, numbness, pins and needles, or a foot that drags
• Pain that does not ease with rest and that wakes you from sleep at night
• Back pain occurring together with fever, unexplained weight loss, or a known history of cancer
• A marked drop in how far you can walk over a short period of time
• A change in posture noticed within a short time, or a shift of the trunk to one side becoming more obvious
• Breathlessness in daily activity that has newly appeared

The findings in the first item need emergency assessment rather than an appointment, and that is why they stand at the head of the list. For the rest, going early saves time in getting the source of the pain identified correctly.

At the practice in Bornova Evka 3, adult scoliosis assessment is by appointment and runs for 60 minutes, one to one. A free fifteen-minute introductory call comes first. Bringing whatever spine films and physician reports you have, old ones as well as recent ones, speeds up the first step. Everything, from that first call through to the sessions themselves, can be in English, which takes one layer of difficulty out of a conversation that is unfamiliar enough already. Details of the location and of how to get there, including the Evka 3 metro station in the same neighbourhood, are on the Bornova and Evka 3 page.