Last week Dr. James Wyss, an assistant Attending Physiatrist in the Department of Physiatry at the Hospital for Special Surgery in New York City and a member of our Medical Advisory Board, wrote about scoliosis in response to a common question that I hear often from patients in my practice. Carla, who was 60, had noticed that her clothes no longer fit properly. She wrote that she exercised, was fit and maintained the same weight she had always been as an adult. She learned from her tailor that she seemed to have a slight curve in her spine that was affecting sleeve length on one side. In addition, her waist was no longer at the same height due to the shoulder and hip on one side being higher than the other. Carla saw a spine specialist who confirmed the tailor’s suspicion: scoliosis. Carla questioned why she had been unaware of this development before and wanted to know how it happened. She also asked what she could do to prevent the mild scoliosis from becoming worse.
I explained that scoliosis diagnosed in an adult for the first time is nearly always subtle early on. Patients may complain of back pain and the diagnosis of scoliosis may be made as part of the evaluation. Other patients may not have pain but the diagnosis is determined by a physical exam. Muscle spasm and poor ergonomic design of how we sit at work may, over time, affect the shape of the spine as we do the kind of work so many of us do: interviewing people, taking meetings, slaving over the computer, often with legs crossed and not sitting back on the tailbone the way we should. When I examine patients, I include an exam of the spine and often discover exactly what Carla described: one side of the body will have an elevation in a shoulder and hip with subsequent alteration in waist and over time, a change in rib cage anatomy and even a tummy pooch that is not related to fat.
Today’s post will cover (from three physicians’ perspectives) key treatments and strategies in the medical management of scoliosis.
Dr. James Wyss Responds:
Most adults who come to my office for an evaluation and/or treatment of scoliosis are already aware of their diagnosis, can recall when they were diagnosed, how severe their curvature is, and know which side of their body shows the curve. Less commonly, adults come in concerned that they are developing scoliosis. Under these less common circumstances, their primary-care physician, family member, friend, or even their spouse may have told them that their spine is becoming curved or their shoulders are uneven and they should get it “checked out.” Under either circumstance, your physician’s responsibility is to obtain a detailed history, perform a physical examination, and if necessary obtain X-rays to determine the type and severity of scoliosis.
Once a specific diagnosis is made, your physician will help you establish a plan to manage your condition. At times, acute management of scoliosis is necessary. For example, scoliosis may contribute to muscle and/or joint pain from the spine. Under these circumstances, medications, physical therapy, or even spinal injections may be necessary to relieve pain and improve function.
Another example of acute management of scoliosis would be the development of a pinched nerve at the spine, due to scoliosis, that requires consultation and management with and by a physiatrist and/or spine surgeon to restore function and relieve pain.
More commonly, patients come to my practice for long-term plans to manage their scoliosis. Their primary goal is typically to prevent worsening of their scoliotic curve or even to reduce the degree of the curve. I usually take the time to explain to my patients that reasonable goals are to prevent the progression of your scoliosis. The most important goal may be to prevent secondary postural problems (e.g., kyphosis) and to help them maintain their active lifestyle despite a chronic spinal condition. If you are nodding your head while reading this post, then a physiatrist (aka a doctor of physical medicine and rehabilitation) might be the right specialist to help you accomplish your goals.
As a physiatrist who treats various musculoskeletal and spinal conditions, my primary goal is to help my patients maintain their function (exercise, work, chores, etc.). To accomplish this goal, I try to educate my patients on the type of spinal curvature they have as well as postures and even activities that they need to avoid (e.g., always wearing a shoulder bag on one side or leaning to the same side while sitting or standing). I also try to teach them about the benefits of a comprehensive fitness plan that includes endurance, flexibility, strength, and postural and balance training. To create this plan I rely heavily on the expertise of physical therapists, who will teach my patients ways to achieve better muscle balance and postural alignment by stretching tight muscles and strengthening weak muscles. Exercise, physical therapy, and some emerging techniques (e.g. the Schroth method) will be the focus of the final post on scoliosis.
I frequently provide care as part of a medical team, and for some patients with scoliosis I need the expertise of metabolic bone specialists, like Dr. Alana Serota, of New York City’s Hospital for Special Surgery, and orthopedic spine surgeons, like Dr. Matthew Cunningham, of the same hospital. In the remainder of this post they will share their clinical expertise and knowledge, as well as highlight the most important medical management tips for those with scoliosis.
In addition to the right fitness plan, women with scoliosis also need a plan to maintain normal, healthy, and strong bones (aka normal bone density). This helps to ward off osteoporosis, spinal fractures, and secondary postural problems such as thoracic kyphosis (aka rounded back posture). These issues are at times complex and require the care of a metabolic bone expert.