What is the management approach for patients with moderate scoliosis and back pain?

Management of Moderate Scoliosis with Back Pain

For patients with moderate scoliosis and back pain, initiate a stratified conservative management approach prioritizing active reactivation over bed rest, combined with NSAIDs for pain control, and reserve bracing specifically for pain relief rather than curve correction in adults. 1, 2

Initial Assessment and Risk Stratification

• Use the STarT Back tool after 2 weeks of pain to stratify patients based on their risk of developing persistent disabling pain, which will guide the intensity of intervention needed. 3, 4
• Screen for red flags requiring urgent imaging or specialist referral: progressive neurological deficits, cauda equina symptoms (bladder/bowel dysfunction, saddle anesthesia), night pain, constant pain, or abnormal neurologic examination. 1, 5
• Avoid routine imaging in the absence of red flags, as it provides no clinical benefit and may lead to unnecessary healthcare utilization. 3

Pharmacological Management

• Start with NSAIDs (such as naproxen) as first-line therapy, assessing cardiovascular and gastrointestinal risk factors before prescribing, and use the lowest effective dose for the shortest duration necessary. 1, 3
• Acetaminophen is a reasonable alternative if NSAIDs are contraindicated, though it provides slightly weaker analgesia (less than 10 points difference on a 100-point pain scale). 1
• Consider gabapentin for neuropathic pain components if radicular symptoms are present, as radicular pain responds poorly to simple analgesics. 3, 5
• Avoid systemic corticosteroids, as they have not demonstrated efficacy superior to placebo. 3

Non-Pharmacological Interventions Based on Risk Level

Low-Risk Patients:

• Encourage self-management with comprehensive resources including online materials, telephone helplines, and evidence-based educational materials like "The Back Book." 1, 3
• Advise remaining active and avoiding bed rest, as activity is more effective than bed rest for back pain. 1
• Apply heat via heating pads or heated blankets for short-term relief. 1

Medium-Risk Patients:

• Refer to physiotherapy for a patient-centered management plan with personalized, supervised exercise programs incorporating stretching and strengthening. 3, 4
• Consider acupuncture, massage therapy, spinal manipulation, or yoga, which have shown moderate effectiveness for chronic back pain. 1, 3

High-Risk Patients:

• Refer for comprehensive biopsychosocial assessment within a multidisciplinary team context. 3, 4
• Implement intensive interdisciplinary rehabilitation, which is moderately effective for chronic back pain. 4
• Consider high-intensity cognitive behavioral therapy for persistent pain after 12 weeks of standard treatment. 4

Bracing Considerations for Adults

• The Peak Scoliosis Brace can provide short-term pain improvement when worn at least 2 hours daily in adult women with scoliosis and chronic low back pain, with 75% reporting improved worst pain and 60% improved leg pain at 1 month. 2
• Bracing in adults is primarily for pain relief rather than curve correction, unlike in adolescents where bracing aims to prevent curve progression. 2
• Conservative management including bracing significantly reduces the need for surgery (incidence of 5.6-14.1% with treatment versus 28.1% without intervention). 6, 7

Timing for Specialist Referral

• Refer urgently (within 2 weeks) if pain is disabling or if motor/sensory deficits are present. 5
• Refer to specialist services no later than 3 months if symptoms persist despite conservative management, with earlier referral if pain severity increases or functional disability worsens. 5
• Consider referral to specialist spinal surgical service for progressive deformity or neurological deterioration. 4

Critical Pitfalls to Avoid

• Do not prescribe bed rest; staying active is superior for back pain management. 1, 5
• Avoid the "physical therapy for all" approach; use stratified care to direct resources appropriately based on risk level. 3, 4
• Do not rely on signposting to advice alone; direct support, reinforcement, and frequent contact are necessary for effective self-management. 3, 4
• Avoid delayed treatment for patients with progressive neurological deficits, as this is associated with worse outcomes. 5
• Do not assume imaging abnormalities mandate surgery; disc abnormalities are common in asymptomatic patients and findings must correlate with clinical presentation. 5