We have received a number of queries about the recent SMH article detailing Australian swimming star Jessica Ashwood’s scoliosis journey. Jessica is not a patient of ours, and I do not know the unique facts of her case, but since June is Scoliosis Month I believe it provides a meaningful learning opportunity to learn about adolescent idiopathic scoliosis (AIS).
The article, penned by sports journalist, Phil Lutton, notes that Jessica was diagnosed with ‘mild’ scoliosis during a school screening program at aged 13. The article states that Jessica’s scoliosis progressed rapidly during the first year and that her first x-ray was in the 40 degree range. I feel that the lesson here is that, if you have a positive school screen, then an x-ray is indicated and should be performed soon after the positive screen . We encourage our patients to access the new low-dose very accurate EOS Scan x-ray machines. This initial x-ray should allow for early and appropriate intervention.
Early imaging is indicated and advisable following a positive screen.
Bracing is effective. Jessica mentions two treatment options in the article, bracing and surgery. She describes a “plastic thing worn on the outside of the clothes for 22 hours per day”. It then appears that Jessica decided against bracing treatment. Current braces, made of rigid materials, are worn on the inside of clothes (but over a body hugging shirt) and are mostly unnoticeable. I do not underestimate the impact that bracing has on our adolescent patients but need to stress that they are an effective option for treating scoliosis in the early stages of its presentation. A 2013 New England Journal of Medicine article reported a 70%-75% overall effectiveness rate in reducing the progression to surgery. This effectiveness rate increased considerably more in cases where the brace was worn above 18 hours per day. In fact the published trial had to be abandoned early due to the non-bracing group doing so poorly.
Image above: Example of 3D corrective spine bracing.
Current bracing principles tend to consider exercise time within bracing time and encourages vigorous involvement in sporting activities, even elite level sporting activities. i.e. Sporting activities are considered as in-brace time, not out of brace time, and are encouraged.
The Link between scoliosis and back pain is not clearly established.
Jessica under the guidance of her swim coach, Vince Raleigh, with discipline and dedication achieved international success including medals at the world championships and the Olympics. Only once retiring from sport, and with growing discomfort and concern she underwent surgical correction of her asymmetric spine. The article states that she “wasn’t in heaps of pain” and that discomfort was present when sitting or standing for long periods of time. The prevalence and severity of back pain associated with scoliosis is only slightly more than the non-scoliotic population. i.e. I often discuss with my patients that back pain and even severe back pain is so common in the general population that it is difficult to distinguish whether there is a significant contribution from the scoliotic curve.
Most untreated scoliosis cases do not result in long term disability.
The article also states that Jessica was concerned about the curve worsening and the effect it would have on her ability to care for a family. A landmark study of the 50 year natural history of untreated scoliosis in 117 American patients with BIG curves (average 80 degrees and range from 23-156 degrees) showed there was no difference in mortality rate, education level, marital status and number of children between those affected with scoliosis and not. The study authors therefore concluded that untreated scoliosis causes little impairment apart from possible back pain and cosmetic concerns. Scoliosis is therefore, not a fatal disease and apart from back pain and cosmetic concerns, should not lead to significant disability throughout life.
Scoliosis surgery has progressed significantly and is typically well tolerated.
Jessica’s surgery reportedly lasted almost 6 hours and with multiple safety mechanisms, including the monitoring of spinal cord health. The surgery involved the insertion of multiple screws and rods into the spine to straighten the curve. The post-operative x-ray (from the back) shows a well-balanced spine with an excellent correction. Apart from the severe and transient post-operative pain, these surgeries are safe and effective in reducing scoliosis curves.
Image above: Jessica’s pre-operative and post-operative x-rays.
Post-surgery scoliosis patients are vulnerable to premature spinal degeneration.
Spinal surgeries involving multiple level fusions of the spine may increase long term risk for premature degenerative changes at the ends of the fusions. I am confident that Jessica is aware of this and is able to channel her obvious exercise discipline into maintaining a lifelong program that ensures the strength, flexibility and functional movement capacity of her spine. However, we stress that everyone, including scoliosis patients, should maintain a lifelong exercise program.
Scoliosis treatment continues to evolve and patients should always consider short and long term implications.
Interestingly, recent advances in spine surgery have resulted in the development of fusionless techniques to correct scoliosis curves but these are almost exclusively performed in growing adolescents. One of these new techniques is called vertebral body tethering (VBT) and involves affixing a semi flexible tether to the spine which partly corrects the curve and enables the remaining growth of the spine to continue to correct the curve. See article of Irish teenager Alice Mcloughlin operated by Dr Ahmed Alanay in Turkey from the Irish Post (her x-rays are below).
Image above: Alice Mcloughlin’s x-rays
Although the current indications of VBT surgery are children with remaining growth, there are a growing number of leading spine surgeons who are pioneering these types of surgeries in adults with large curves. These surgeries are, however, still novel and we don’t know the long term outcomes. However, the VBT surgeons claim that traditional fusion surgery is still a viable option in case of failure of the VBT systems.
Physiotherapy specific exercises are proving effective in scoliosis care.
Traditional physiotherapy, chiropractic and osteopathy treatment have not shown to be beneficial in preventing scoliosis progression. There is a growing body of evidence, however, that a specific type of exercise called physiotherapy specific scoliosis exercises (PSSE) has been shown to halt or delay the progression of curves and in some cases to improve the curves. PSSE’s have also shown benefit in assisting quality of life factors associated with scoliosis, such as pain, activity levels, appearance, and mental health. These quality of life measures are distinct from the scoliosis curve measurements (cobb angles) and patients report improvement in their back without significant changes in their scoliosis curve.
Image above: pre- and post- PSSE training for scoliosis
Scoliosis is more than just an asymmetry of the spine,
Growing adolescents with scoliosis typically have to deal with hormonal, psycho-social and societal issues during this time. Scoliosis treatment needs to involve CARE, not just the mechanical correction of bony asymmetry. The scoliosis patient needs to be encouraged, assured and reassured that spinal asymmetry does not need to be considered as a deformity with all its negative connotations. It should not lead to a reduced lifespan nor quality of life.
It is important to remember that there are many different aspects that need to be considered in scoliosis care. Every case is different and treatment should be individualised towards your situation. Our therapists at UprightCare invest considerable time and effort keeping abreast of the surgical and non-surgical advances in scoliosis care and would be happy to discuss your case if you have any queries.
We are holding a free community workshop on Thursday the 20th of June. Click here for more information.