A scoliosis curve is made of many different components, including a postural one. Duval-Beaupére [19] described the case of three different radiographs: standing (SR), lying down (LR) and in correction e.g. using a cast (CR). The structural bony component can be measured with the CR; the structural ligamentous component comes from the difference between LR and CR; the postural component from the difference between SR and LR (Figure 7). In other words the CR gives the fixed deformity, while the classical SR gives the entire scoliosis, made up of the three components. The reduction of scoliotic curve through rehabilitation presumably does not indicate a reduction of the bone deformity, but rely on a recovery of the postural collapse, which is present in upright posture [11].
There is evidence that in adolescents, regardless of curve magnitude, the mean difference between a standing radiograph and a supine one is 9° Cobb [20], or 19% [21]. There are no data in the literature to indicate precisely what this difference is in adult scoliotic patients, even if it has been shown in scoliotics deformities with severe curves (mean Cobb angle 60 degrees) that performing an x-ray in different hours of the day [22] can give a measurement error due to worsening while the days goes on. This is another proof of the postural collapse. In adolescents, the curve decreases in mild scoliosis and in younger, less stiff patients, while an increase occur in older, more skeletally mature and heavier individuals [21]: accordingly, the postural collapse could be more important in adults than during growth.
While in adolescents exercises' aim is to reduce postural collapse and rehabilitate movement in this way allowing a better growth of the vertebrae [11, 23], in adults the process to be controlled is bony deformation due to degeneration. Again, postural collapse can have a role, in the long term, of facilitating progression because of chronic asymmetric increase of compression. Obviously, also the increased quality of movement and the biomechanical changes of the spinal soft tissues could play a role in decreasing the risk of progression. [23, 24]
This case opens the possibility that when adult scoliosis aggravates it is possible to intervene with specific exercises not just to get stability, but to recover last years collapse. We hypothesize that this reduction of Cobb degrees is due to a reduction of the postural collapse, that in turn can decrease the chronic asymmetric load on the spine and, in the long run, reduce the progression.
In this case report, we hypothesize that the worsening before the beginning of exercise therapy was due to an inadequacy of antigravitary trunk muscles due to all the years B.I. used casts and braces. During those years, she unfortunately never exercised to maintain or to restore these muscles. The only sport she played was swimming, which doesn't stress such muscles. With exercises, she could completely recover the worsening of the last five years.
Obviously exercises can lead to results other than stabilization of the curve, including pain, postural control, balance, strength, but in the indexed literature no data have been published on this topic. There are few works in literature showing it is possible improving the curvature in adult scoliosis with exercises, but no study has a long follow-up. The only case report with a long follow-up showed stability over time [25]. In our opinion, the recovery of the postural collapse we obtained in this case can possibly reduce the risk of future worsening, aside from the absolute decrease of the curves we had. In fact, the functional, cosmetic and psycho-social damages caused by scoliosis are directly proportional to curve magnitude [26, 27], so any improvement over time must be considered a remarkable success in adult scoliosis therapy.
This case opens up a new perspective in the approach to adult scoliosis patients that appear to progressively worsen. Instead of a fatalistic "wait and see" approach, an active one could be envisioned and could help in some cases at least to postpone, and eventually avoid surgery. The advantage of maintaining spine mobility function and avoiding the risks of surgery is counterbalanced by the need of exercising regularly and being followed up carefully in a specialised Center by a rehabilitation team [28]. Spinal mobility allow a distribution of static and dynamic loads all over the spine, avoiding undue overload on single segments; it also permits to continue activities of daily life without any of the limitations that caution impose to fused patients. The final choice is obviously up to the patient [29, 30], made aware of advantages and disadvantages of each option, understanding the difference between a risky one-shot treatment and a long-term, continuous one that requires collaboration and motivation, while in any case giving the possibility to go back to the other therapeutic option in case of failure. If other studies will confirm this case report, exercises could be considered and discussed with patients, allowing them to reach the best individual solution for their long term scoliosis management [30].
Another question opened up by this paper is: which kind of exercises can reduce adult scoliosis? We applied specific exercises (SEAS) that already showed to be useful in adolescent idiopathic scoliosis when compared to other exercises [17, 31]. In the literature there are published results only on very short-term treatments, using Scoliosis Intensive Rehabilitation (SIR) [7], or manipulations [8, 9]; there are no long-term answers on the possible efficacy in reducing the curve of specific exercises for adults, nor there are comparisons of different kind of exercises.
Finally, another issue: should we consider these changes to be real? In this paper all measurements have been made blindly twice by an expert physicians (SN), whose repeatability error has been previously evaluated to be less than 3° [18]. Obviously we must add to this value the repositioning error due to different radiographs in different days [32]. In any case, we used the average of the two measurements, so reducing even more the probability of error. All changes recorded were over the 5° classically considered in the literature; moreover, the radiographic variations have been accompanied by clinical significant changes (humps). Accordingly, we can be confident that all changes were real.
