What are the treatment options for relieving pain from scoliosis?

Treatment Options for Relieving Pain from Scoliosis

For pain relief in scoliosis, prioritize non-pharmacologic interventions including scoliosis-specific physical therapy exercises, spinal manipulation, and superficial heat, with NSAIDs or acetaminophen as first-line pharmacologic options when needed. 1, 2

Initial Pain Management Approach

Non-Pharmacologic Interventions (First-Line)

Physiotherapy Scoliosis-Specific Exercises (PSSE) should be the cornerstone of conservative management, as these exercises provide 3-dimensional self-correction, training in activities of daily living, and stabilization of corrected posture. 3 PSSE can produce significant benefits beyond Cobb angle reduction, including:

• Improved back asymmetry and posture 3
• Correction of secondary muscle imbalance 3
• Direct pain relief through improved flexibility 4
• Enhanced breathing function in severe thoracic curves 3

Spinal manipulation (including osteopathic manipulative treatment) demonstrates moderate effectiveness for both acute and chronic back pain associated with scoliosis, with a remarkably safe profile and rare serious adverse events. 2 The American College of Physicians recommends this as a treatment option based on moderate-quality evidence. 1, 2

Superficial heat application shows good evidence for moderate benefits in acute pain episodes and should be used as an adjunctive measure. 1

Pharmacologic Options (When Non-Pharmacologic Measures Are Insufficient)

NSAIDs (such as ibuprofen) or acetaminophen (up to 3000mg/day) are recommended as first-line medications for pain relief. 1 However, in one study of 30 adult scoliosis patients with chronic pain, only 2 of 30 required continued NSAIDs after completing a specialized exercise program (F.E.D. method), suggesting that proper physical therapy can eliminate medication dependence in most cases. 4

Avoid systemic corticosteroids as they have not demonstrated superiority over placebo for back pain. 1

Avoid opioids due to limited evidence of long-term effectiveness and significant risks. 5

Algorithm for Pain Management Based on Severity

Mild to Moderate Pain (Cobb angle <40 degrees)

1. Initiate PSSE immediately (20-60 sessions typically needed, mean 45 sessions) 4
2. Add spinal manipulation if pain persists beyond 2-4 weeks 1, 2
3. Consider short-term NSAIDs or acetaminophen for acute exacerbations 1
4. Apply superficial heat during acute pain episodes 1
5. Maintain home exercise program for sustained benefit 4

Severe Pain or Progressive Curves (Cobb angle ≥40 degrees)

Early physiotherapy remains essential to mitigate contractures and pain, though surgical consultation may be warranted for progressive deformity. 6 The decision for surgical intervention requires individualized assessment through regular surveillance, as chest wall bracing can negatively impact vital capacity and respiratory compliance. 6

Multidisciplinary Team Approach

PSSE should be delivered within a multidisciplinary framework including orthopedic physicians, physical therapists, orthotists, and mental health providers when needed. 3 This is particularly important because:

• Psychosocial factors predict chronic disability in back pain 1
• Depression commonly coexists with chronic back pain and requires appropriate screening and treatment 1
• Cognitive-behavioral therapy shows good evidence of moderate efficacy for chronic pain 1

Evidence-Based Outcomes

The F.E.D. method study demonstrated that specialized scoliosis exercises produced sustained pain relief with improvement in flexibility index (Schöber score improved from 1.32 to 2.88), and this analgesic effect remained permanent when patients maintained home programs. 4 This suggests that exercise-based interventions address the root cause of pain (muscular imbalance and overuse) rather than merely masking symptoms. 4

Critical Pitfalls to Avoid

Do not prescribe bed rest - it is contraindicated and may worsen outcomes. 1, 5

Avoid "wait and see" without intervention for curves between 10-25 degrees, as early PSSE can prevent progression and establish pain management strategies. 3

Do not rely solely on imaging findings - MRI changes are often nonspecific and do not correlate with pain severity or guide treatment. 1

Avoid continuous or intermittent traction as it has not shown effectiveness. 1, 5

Do not use lumbar supports as they have not demonstrated clear benefits for chronic pain. 5

When to Escalate Care

Refer to a specialist if:

• Curve exceeds 20 degrees in patients ≥10 years old 7
• Atypical features present 7
• Associated neurological abnormalities 7
• Pain persists beyond 4 weeks despite conservative management 1
• Rapid progression or respiratory decline occurs 6