Age, bone maturity, menarche, peak growth age and curve pattern are key factors to be considered in choosing the ideal treatment option for people with idiopathic scoliosis ‘IS’ (7). The following information covers how these factors can influence the ‘IS’ treatment protocol.
- Age – There are 2 periods of rapid growth spurts that occur in life; one in infantile years and the other is in adolescent years. The height of an individual increases very fast during this time – about 9cm per year. Also, the second highest spinal height growth occurs between ten years of age until puberty (7; 8). During this period, as the curve progression is faster – it is best to start treatment if needed, instead of just monitoring as this is the golden window for spinal bracing.
- Peak Growth Age (PGA) – This is the period that both girls and boys show peak height velocity (PHV). It is very important to identify scoliosis patients before PGA, because there is a strong correlation with scoliosis curve progression with PGA. Many who had missed the opportunity to identify ‘IS’ between the age of ten until puberty were unable to seize this period for bracing (7).
- Bone Maturity – The amount of growth remaining is typically estimated by the Risser sign indicator. Risser Sign is a bony marker based on the iliac crest ossification. It ranges from 0-5; 0 indicating immature bone profile and 5 for matured bone profile. Immature bones have yet to grow – thus worsens the scoliosis as the bones in the spine start to their growth (7). Therefore, a Risser sign of 0-3 informs that curve progression is faster and early bracing is needed to prevent any further undesired development of the curve.
- Menarche – The onset of menstruation in girls and the development of an adult voice in boys are indicators showing signs of growth rate slowing down – as with curve progression. Therefore, the requirement of scoliosis treatment will mainly be based on the magnitude of the curve as mentioned in the SRS guidelines. In this case, parents and school nurses should be responsible and active in screening for curve developments in the spine after reaching the mature body state (7).
- Curve Pattern – Evaluation of patient history reports that the curve pattern also has a direct relationship with curve progression. Many researchers have noted that single lumbar and single Thoracolumbar curves are less progressive and more responsive to orthotic treatment. Also, Single Thoracic curves and Double curves are more likely to progress faster (7).
7. Weibin Shi, Amy Strouse, Davis R Gater Jr. Orthoses for Spinal Deformities. [book auth.] American Association of Orthopeadic surgeons. Atlas of Orthoses and Assistive Devices. Philadelphia : Mosby Elsevier, 2019, Vol. 65.
8. Physiology of Growth. Rosenbloom, Arlan L. Basel : Nestec Ltd, 2007, Vol. 65.
There is much global debate about when and how to treat Idiopathic Scoliosis (IS). The American Association for Orthopaedic Surgeons (6) indicates that “A scoliosis curve will not get straighten up by itself” and “Spinal Braces or Spinal Fusion with Physiotherapy are essential in scoliotic curve management”. The Scoliosis Research Society (SRS) (5) has gathered information and evidences globally surrounding the ideal treatments along with factors that should be considered when treating ‘IS’.
We have summarized SRS treatment recommendations for your easy understanding in the above picture. Any treatment for ‘IS’ should be re-evaluated in every 6 months with X-rays. Though there are certain negative effects with frequent exposure to X-rays, these are necessary in observing the ‘IS’ curve progression (6).
The above treatment options are suggested mainly considering the curve magnitude as the base. But there are also other factors taken into consideration when prescribing the above treatment options.
5. Scoeity, Scoliosis Research. Conditions & Treatments: For Parents: Scoliosis. https://www.srs.org. [Online] Scoliosis Research Scoeity, 2020. [Cited: March 9, 2020.] https://www.srs.org/patients-and-families/conditions-and-treatments/parents/scoliosis.
6. Surgeons, American Association for Orthopaedic. OrthoInfor. Nonsurgical Treatment Options for Scoliosis. [Online] 1995-2020. https://orthoinfo.aaos.org/en/treatment/nonsurgical-treatment-options-for-scoliosis/.
When you consult a professional, you will be guided through a few examinations to ensure your spinal condition is diagnosed accurately.
- You will need to undergo a spinal X-ray from the sagittal (side) and coronal (front) views to confirm the curvature – it is recommended to take a full spine X-ray from neck to pelvis.
- After an X-ray exam, the medical professional will provide you with information regarding:
- Magnitude of the curvature (Cobb measure)
- Laterality of the curve
- Bone maturity
- Curve pattern
Scoliosis has a typical range of characteristics, also known as clinical presentations or physical compensations. These signs help determine the severity of each individual when medical professionals perform physical examinations to assess and differentiate a scoliotic (bent) spine from a normal one. According to the Scoliosis Research Society,
- When you stand in a relaxed position with your hands by the sides of your body; the back view may present with lateral (side) curvature, uneven shoulder blades, hips and trunk shift:
- When you bend forward from the hips, a hump and a flank may be see from the back.
If you notice these signs, you should consult a professional that can refer you for further examinations.
When there is a frontal misalignment in the spine, it will present with a lateral curvature of more than ten degrees to the left or right with vertebral rotation. This spinal condition is called scoliosis. This is the most common abnormal curvature that occurs in the spine, considered as a global health problem with its prevalence at 0.5% to 3% of the world’s school population. On an x-ray of a scoliotic spine, you will be able to see the presentation of a “C” or “S” shape, instead of a straight spine. 80% of scoliotic curves belong to the “Idiopathic Scoliosis” category because it cannot be explained under a particular reason.
The vertebral column, also known as the backbone or spinal column, is structurally balanced in front and by the side to support our body weight and maintain optimum flexibility. There are 3 gentle curves (Cervical, Thoracic and Lumbar) that maintains a straight alignment.
The body’s Center of Gravity (COG) lies around the level of the naval area and all of the spine’s flexibility helps to maintain this COG within the Base of Support (BOS) to stabilise the body during various activities. Maintenance of correct alignment helps to reduce fatigue and the work load of the spinal muscles during these times.
As seen above, sagittal (side view) and coronal (front view) spinal deformities can occur in the human spine due to various reasons.
When the spine is deformed, the body posture and position of the COG changes. The muscles and body joints are required to work hard with an extra effort to stabilise the body with these changes.
Flat Head Syndrome
Over the years of treating babies with flat head syndrome, we have received referrals from doctors as well as enquiries from parents seeking treatment for their children above 2 years of age.
Unfortunately, head shape would have been fully formed by age 2 – cranial helmet therapy is no longer a treatment option.
Untreated cranial asymmetries have been linked to developmental delays, visual defects, ear infections, middle ear malfunction, jaw bone changes, learning difficulties and other psychomotor delays.
While we need long-term research to support if uncorrected plagiocephaly will affect a child’s neurological development, there is no doubt that cranial asymmetry can have an effect on the child’s social well-being later in life, as his/her head will remain misshapen in adulthood.
Flat head syndrome often occurs due to constant pressure on one side of baby’s head during sleeping. Hence, supervised tummy time and repositioning can be very effective in correcting a baby’s flat head between 0-4 months old, as he/she is constantly in sleeping positions.
However, when babies above 4 months of age reach their milestones of constant tummy time, sitting up and moving about, these methods may not be as effective anymore.
In 1994, the Back to Sleep campaign was launched in the US to encourage parents to place their babies sleeping on their backs in hope to reduce the occurrence of SIDS.
Flat head syndrome had never been a concern when we were babies, so why is there heightened awareness now?
The current adult population was born when plagiocephaly is uncommon, as babies were placed on their stomachs to sleep. The Sudden Infant Death Syndrome (SIDS)* led to the 1994 launch of the Back to Sleep campaign in the US.
Parents were informed of the importance of back sleeping and encouraged to place their babies sleeping on their backs instead of tummies. While it has successfully reduced the occurrence of SIDS, there is a significant increase in the number of plagiocephaly cases (statistics for Asia is unavailable at this point).
*Sudden Infant Death Syndrome (SIDS) refers to the sudden, unexpected death of an infant under 1 year of age – a major cause of death in infants between 1 month and 1 year of age in the United States and this happens most often during sleep.
Prolonged time spent in car seats, infant carriers and slings may possibly contribute to the flattening of a baby’s head. Reduction of time spent in these devices is recommended. It is also beneficial to encourage regular supervised tummy time and repositioning techniques. View Tummy Time Tools.
There is currently no research confirming that plagiocephaly has any harmful effects on a baby’s neurological development.
While it may be easy to identify if your baby has flat head, the best way to determine the severity is through a full evaluation including measurement. Head shape assessment is available at Orthopaedia.
Cranial Remolding Therapy
Yes, most babies adjust to the band quickly in a matter of days. It is highly recommended that a baby wears the helmet on for 23 hours daily.
The cranial remoulding helmet is a customised orthosis and cannot be bought off the shelf. Once prescribed, the customised helmet will be ready for fitting approximately 2 weeks from day of scan.
You may like to note that this is a medical device. If your baby has mild flat head syndrome, we do not prescribe this treatment even if you request for it.
We follow strict clinical guidelines and protocols for prescription. However, if severe flat head syndrome with asymmetry is present in your baby, it is completely your decision on the best course of action. Your considerations include:
- Will you be happy with your child’s head shape and/or facial features when he/she is 5, 10, 20 years old?
- Will it affect your child’s social well-being later in life, especially if he/she has visible facial asymmetry?
As your baby’s helmet is unique and unusual, people will generally notice. So we asked parents how do they manage this.
People often ask if they are able to purchase the helmet because they think that it is for protective purpose.
Parents usually take the opportunity to educate others on flat head syndrome and the true purpose of the helmet.
In Japan, square watermelons are grown in glass boxes to encourage the cubed shapes.
For easier understanding, we liken the helmet therapy’s reshaping or correction to the concept of the square watermelon. The wearing of the cranial remoulding helmet encourages re-direction of growth towards the flattened side of head. There is no pressing against the baby’s head at all.
We treat babies as young as 3 months old.
Early treatment has shown to reduce overall treatment time, as natural head growth is rapid in the first 6 months of life.
The golden period for treatment is between 4 to 8 months old as the fontanelle may start to close up when they are approaching age 1.
We have also seen babies with fontanelle closing up as early as 9 months old.
The length of treatment is greatly dependent on:
- Severity of flat head
- Growth rate of baby
- Helmet wearing compliance
Early treatment has shown to reduce overall treatment time, as natural head growth is rapid in the first 6 months of life. Most babies generally need between 3 to 5 months of wear.
The results from the treatment is dependent on several factors:
- Helmet wearing compliance
- Speed of baby’s growth development
- The fontanelle (or commonly termed soft spot) is not closed yet
The golden period for helmet treatment is between 4 to 8 months of age. The natural head growth is rapid in the first 6 months of life.
Helmet therapy is not an immediate option for every baby with cranial asymmetry. There are several factors that determine if helmet therapy is an immediate prescription.