What are good support systems for someone with severe scoliosis?

Support Systems for Severe Scoliosis

Early and continued physiotherapy is the cornerstone of support for severe scoliosis, as it mitigates contractures and scoliosis progression, while chest wall bracing should be used cautiously as it can negatively impact respiratory function. 1

Physiotherapy and Exercise-Based Support

Physiotherapy should be initiated early and maintained consistently to prevent or minimize the effects of contractures and progressive spinal deformity. 1 The evidence demonstrates that:

• Scoliosis-specific exercises (PSSE) can temporarily stabilize progressive curves and produce significant reductions in Cobb angle in non-progressive cases, while also improving back asymmetry, muscle imbalance, and pain. 2
• Three-dimensional self-correction training, activities of daily living training, and stabilization of corrected posture are the standard features of effective physiotherapy interventions. 2
• Multiple established schools of scoliosis-specific exercise exist (Lyon, Schroth, SEAS, Barcelona BSPTS, Dobomed, Side Shift, FITS), each offering evidence-based approaches that can be incorporated into treatment plans. 2

Bracing Considerations

Chest wall bracing has significant limitations and should be approached with caution:

• Bracing is a temporizing measure, never curative, and can have negative impacts on vital capacity while decreasing respiratory system compliance and tidal ventilation. 1
• Success rates of orthoses vary widely, and brace applications can cause physical discomfort, psychological distress, and pain. 3
• If bracing is used, standardized computer-aided design (CAD) libraries and appropriate patient information based on published guidelines should guide the selection and fitting process. 3

Multidisciplinary Support Framework

A comprehensive support system requires coordination across multiple specialties:

• Regular pulmonology evaluation is essential to assess baseline lung function and screen for sleep hypoventilation with nocturnal oximetry or polysomnography, particularly as scoliosis progresses. 1, 4
• Nutritional assessment should occur at least annually, with supplemental calories provided orally or enterally for those with worsening nutritional status. 1
• Speech and language therapy reviews are vital for patients developing swallowing difficulties, with early advice on feeding modifications and body posture during meals. 1
• Psychological support should be integrated into the care model to address the emotional impact of progressive deformity and treatment burden. 2

Monitoring and Surveillance

Proactive surveillance is critical for optimal outcomes:

• Regular assessments at least twice yearly provide an impression of disease progression and allow for early intervention. 1
• Peak cough flow rate and forced vital capacity maneuvers are mainstays in clinical assessment for patients with progressive scoliosis. 1
• Overnight polysomnography should be considered in adolescents with clinical suspicion of sleep-related breathing abnormalities, rapid decline in lung function, or developing scoliosis. 1

Surgical Timing Considerations

Spinal stabilization using various surgical techniques is the standard approach for treating neuromuscular scoliosis, but timing must be individually determined through regular and proactive surveillance. 1 Key considerations include:

• Surgery is typically recommended when Cobb angle exceeds 50 degrees in skeletally mature patients due to risk of continued progression. 4
• Pre-operative optimization is essential, including pulmonology evaluation, nutritional optimization, and cardiology assessment to minimize perioperative complications. 4
• Multidisciplinary disease-specific peri-operative evaluation with optimization of pulmonary function should be ensured to improve outcomes. 1

Critical Pitfalls to Avoid

• Do not rely solely on chest wall bracing without considering its negative respiratory effects, particularly in patients with compromised lung function. 1
• Avoid delaying physiotherapy initiation, as early intervention is more effective at preventing contractures and progression. 1
• Do not overlook nutritional status, as progressive nutritional insufficiency can compound respiratory deterioration. 1
• Ensure "one-stop" multidisciplinary service provision rather than fragmented care across multiple appointments and locations. 1