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Idiopathic scoliosis

  • Patients come here from around the world for their scoliosis treatment. We're happy to be able to provide world-class care for them and for our local patients.

    --Spinal Program Team, Orthopedic Center

    If your child has been diagnosed with idiopathic scoliosis, we know that you and your family are under stress. So, at Children’s Hospital Boston, we’ll approach your child’s treatment with sensitivity and support—for your child and your whole family.

    You can have peace of mind knowing that the team in the Boston Children’s Spinal Program has treated many children with spinal problems—some of which are so rare that few pediatric doctors have come across them—and we can offer you expert diagnosis, treatment and care. Scoliosis is not usually a life-threatening condition, and most children grow up to lead normal, active lives.

    About scoliosis

    Scoliosis is a condition in which the spine—in addition to the normal front to back curvature—has an abnormal side-to-side “S-” or “C”-shaped curvature. The spine is also rotated or twisted, pulling the ribs along with it to form a multidimensional curve.

    The Scoliosis Research Society defines scoliosis as a curvature of the spine measuring 10 degrees or greater on x-ray. The condition isn’t rare. It mainly affects girls—many of whom have mild forms of scoliosis, are never even aware of it, and never need treatment.

    Three to five children out of every 1,000 develop spinal curves that are considered large enough to require treatment. Idiopathic scoliosis does tend to run in families, although no one genetic link has been confirmed.

    Scoliosis occurs, and is treated, as three main types:

    • idiopathic scoliosis: the most common form, with no definite cause, mainly affecting adolescent girls, but existing in three age groups:
      • adolescent idiopathic scoliosis
      • juvenile idiopathic scoliosis
      • infantile (early-onset) idiopathic scoliosis
    • neuromuscular scoliosis: associated with a neuromuscular condition such as cerebral palsy, myopathy or spina bifida
    • congenital scoliosis: present at birth, caused by a failure of the vertebrae to form normally—the least common form

    About idiopathic scoliosis

    “Idiopathic” simply means that there is no definite cause for a given disease or condition. Idiopathic scoliosis is a condition in which the child’s spine—in addition to the normal front to back curvature—has an abnormal side-to-side “S-” or “C”-shaped curvature. The spine is also rotated or twisted, pulling the ribs along with it to form a multidimensional curve.

    Idiopathic scoliosis is the most common form of the condition, and it mainly affects adolescent girls.

    The Boston Children's Hospital Boston approach

    Boston Children’s Spinal Program is known for clinical innovation, research and leadership. As a world center for the treatment of scoliosis—including a deep experience in treating infantile(early-onset) scoliosis—we’ll provide your child with the most advanced diagnostics and treatments—several of which were developed by our own researchers and clinicians.

    One of the first comprehensive programs, Boston Children’s Orthopedic Center is the largest and busiest pediatric orthopedic surgery center in the United States, performing more than 6,000 surgical procedures each year. Our program, ranked among the top in the country by U.S.News & World Report, is the nation’s preeminent care center for children and young adults with developmental, congenital, neuromuscular and post-traumatic problems of the musculoskeletal system.

    Some of our team’s unique accomplishments include our:

    • development of the Boston Brace, a custom bracing system widely used throughout the United States and Europe
    • unique experience in the treatment of adolescent hip conditions
    • success with the VEPTR (vertical expandable prosthetic titanium rib) procedure: In 1998, Children’s was selected as a site for the first extensive VEPTR use outside San Antonio, where it was developed. Children’s has the second most extensive VEPTR experience in the nation.
    • experience with, and emphasis on, treating infantile (early-onset) scoliosis
    • experience with, and research in, brachial plexus birth palsy, including our international, multi-center study of this complex condition
    • Sports Medicine Program, including its pioneering research into the regeneration of ACL tissue and growth plate-sparing surgeries for ACL repair in pre-adolescents
    • extensive orthopedic research laboratories
    • Orthopedic Clinical Effectiveness Research Center for the study of children’s musculoskeletal disorders

    We take a team approach to the treatment and care of idiopathic scoliosis:

    • A doctor, nurse, orthotist and physical therapist form the care team for most patients.
    • The team stresses non-surgical techniques whenever possible, with surgery a last resort. We use the safest and most efficacious techniques available.
      • We emphasize orthotic treatment for the effective control of idiopathic scoliosis.
    • Our team collaborates to tailor our program to the individual needs of each patient:
      • We adjust follow-up intervals and the x-ray needs to a child’s risk of a worsening curve.
    • When needed, we communicate with other disciplines, such as pulmonology (lungs) and neurology (nervous system).
    • We provide orthopedic care—including for scoliosis—at Boston Children’s satellite locations, as well as the main campus in Boston.
    • Infants and young children pose special problems with idiopathic scoliosis:
      • We can often treat babies and children with specially developed non-operative and surgical techniques.
      • Because we’re internationally known as a leading early-onset scoliosis center, our team is regularly consulted by other physicians and families around the globe.

    Each year, our Spinal Program caregivers provide comprehensive evaluation, diagnosis, consultation, treatment and follow-up care for children during more than 6,000 outpatient visits. And every year, our orthopedic surgeons perform more than 300 spine procedures on babies, children, adolescents and young adults.

    Idiopathic scoliosis: Reviewed by John Emans, MD© Boston Children's Hospital, 2010

    Orthopedic Center
    Boston Children's Hospital

    300 Longwood Avenue
    Fegan 2
    Boston MA 02115
    617-355-6021

    Boston Children's Hospital at Waltham
    9 Hope Avenue
    Waltham MA 02453
    617-355-6021

    Boston Children's Hospital at Lexington
    482 Bedford Street
    Lexington MA 02420
    617-355-6021

    Boston Children's North
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    Peabody MA 01960
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    Boston Children's Physicians South
    Stetson Medical Center
    541 Main Street
    Weymouth MA 02190
    617-355-6021

  • At Boston Children’s Hospital, our Spinal Program team develops innovative treatments for scoliosis and other spine conditions. And because our research informs our treatment, we’re known for our science-driven, experience-based approach.

    We’re home to the world’s most extensive pediatric hospital research enterprise, and we partner with elite health care and biotech organizations around the globe. But as specialists in innovative, family-centered care, our physicians never forget that your child is precious, and not just a patient.

    In dealing with your child’s idiopathic scoliosis, you may want to know the basics about the spine and about the several forms of this spinal condition.

    What is the spine?


    Spine viewed from the front and side

    Made up of many individual bones called vertebrae, the spine is joined together by muscles and ligaments. Flat, soft discs separate and cushion each vertebra from the next. Because the vertebrae are separate, the spine is flexible and can bend. Together the vertebrae, discs, muscles and ligaments make up the spine or vertebral column.

    Different regions of the spine are named differently. The cervical spine refers to the neck, the thoracic spine to the chest, and the lumbar and sacral spines to the lower back.

    What are normal and abnormal front-to-back spine curves?

    The normal spine is strong and mobile. While it varies in size and shape from person to person, the healthy spine has natural front-to-back curves that enable us to walk, balance, sit, stand and twist—all of which are complex interactive movements. When these natural front-to-back curves become too large, they can present a potential problem.

     Left: normal front-to-back spine curves; middle: kyphosis; right: hyper-lordosis.

    • When the backward curve in the thoracic spine is too great, the condition is called kyphosis (thoracic hyper-kyphosis, “round back”).
    • When there’s not enough backward curve in the thoracic spine, the condition is called hypo-kyphosis.
    • When the natural outward curve in the thoracic spine is actually reversed, curving into the chest, the condition is called thoracic lordosis.
    • When the inward curve in the lower back is too great, the condition is called hyper-lordosis (“swayback”).

    Are side-to-side-curves normal?

    No. Although the spine has natural curves from front to back, it shouldn’t curve sideways very much. A side-to-side curve is called scoliosis, and may take the shape of an “S” (double curve) or a long “C” (single curve).

    Left: normal spine; right: scoliotic spine

    The scoliotic spine is also rotated or twisted to form a multi-dimensional curve. Spinal curvature from scoliosis may occur on the right or left side of the spine, or on both sides in different sections. Both the mid- (thoracic) and lower (lumbar) spine may be affected by scoliosis.

    What is scoliosis?

    Scoliosis is a condition in which the spine, in addition to the normal front to back curvature, has an abnormal side-to-side “S-” or “C”-shaped curvature. The spine is also rotated or twisted, pulling the ribs along with it. In serious cases, lung function can be affected.

    The Scoliosis Research Society defines scoliosis as a curvature of the spine measuring 10 degrees or greater on x-ray. The condition isn’t rare. It mainly affects girls—many of whom have mild forms of scoliosis, are never even aware of it, and never need treatment. Three to five children out of every 1,000 develop spinal curves that are considered large enough to require treatment. Scoliosis does tend to run in families, although no one genetic link has been confirmed.

    What are the three main types of scoliosis?

    Scoliosis occurs, and is treated, as three main types:

    • idiopathic scoliosis: the most common form of scoliosis, most commonly seen in adolescent and pre-adolescent girls. “Idiopathic” simply means that there is no known cause. Nothing you or your child did caused it, and there’s nothing you could have done to prevent it.

      Fortunately, most cases require no intervention. Idiopathic scoliosis does tend to run in families, and girls are five to eight times more likely to develop it than boys. One exception is infantile idiopathic scoliosis, which occurs by the age of 3 years, and affects boys more than girls.

    Idiopathic scoliosis is sub-classified according to age at onset:

    • adolescent
      • the vast majority of cases
      • mostly occurring in girls ages 10 to 18 years
      • often not needing intervention
      • progression usually stops upon physical maturity
         
    • juvenile
      • about 10 percent of cases
      • occurring in children ages 3 to 9 years
      • usually progressive
         
    • infantile (early-onset)
      • up to 5 percent of cases; extremely rare
      • more often occurring in boys from birth to age 3 years
      • often self-resolving, but sometimes very serious
      • usually detected in first year of life

    What are the signs and symptoms of scoliosis?

    Because of the many possible combinations of curvatures, scoliosis can be very different in different people. Common signs and symptoms of scoliosis may include:

    • uneven shoulder heights
    • head not centered with the rest of the body
    • uneven hip heights or positions
    • uneven shoulder blade heights or positions
    • prominent shoulder blade
    • when standing straight, uneven arm lengths
    • when bending forward, the left and right sides of the back are asymmetrical

    Symptoms that suggest scoliosis can resemble those of other spinal conditions or deformities, or may result from an injury or infection.

        

    How do you diagnose scoliosis?

    Doctors will use medical and family histories, physical exams and diagnostic tests to determine the nature and extent of your child’s spinal condition. Testing can include:

    • x-rays
    • magnetic resonance imaging (MRI)
    • computerized tomography scan (CT or CAT scan)
    • blood tests
    • ultrasound (sonogram)
    • bone scans
    • bone density scans (dual-energy x-ray absorptiometry, DEXA, DXA)
    • pulmonary function tests

    Who will be on my child’s scoliosis treatment team at Boston Children’s?

    Your child’s team at Boston Children’s can include her doctor, orthotist (a specialist who makes braces), physical therapist and nurse, who will guide you through the treatment process. If your child requires bracing, the team will help her make the sometimes difficult adjustments involved in wearing a brace.

    The physical therapist will evaluate your child’s posture, muscle strength and flexibility, and will design a home exercise program just for her.

    The nurse will help with all your questions and appointments. The nurse can:

    • teach your child how to care for herself and her brace
    • design a schedule for her to follow
    • help her plan her day-to-day activities
    • help her meet others who wear braces, in person and/or online

    How do you treat idiopathic scoliosis?

    Treatment for your child’s scoliosis depends on the nature and severity of her condition. Boston Children’s Spinal Program provides comprehensive treatment—including evaluation, diagnosis, consultation and follow-up care.

    Treatments can include:

    • simple observation and monitoring: Once an abnormal spine curve has been detected, it’s important to monitor the curve as the child grows. In many cases, your child’s curve may require only close monitoring while her spine grows. Your physician will determine your child’s treatment plan and follow-up based chiefly on her x-rays and physical exams.
       
    • physical therapy: Scoliosis can often be helped by physical therapy. Our physical therapy team’s goal is to maximize your child’s physical functioning. Our therapists work closely with specialists in our Spinal Program to also provide exercise programs and additional therapies to address pain and the muscular imbalance that can be associated with spinal abnormalities.
    • bracing: If your growing child’s curve shows significant worsening or is already greater than 30 degrees, your physician may recommend a bracing program, in which a scoliosis brace is designed specifically for your child’s particular curve. The brace holds your child’s spine in a straighter position while she is growing—to partly correct the curve or to prevent it from increasing. This may help avoid the need for surgery.
    • casting: In certain situations—as in some cases of early-onset (infantile) scoliosis—body casting is done to help the spine to straighten.
    • surgery: If surgery becomes necessary, our Spinal Program’s orthopedic surgeons use the most advanced surgical techniques for correcting spinal problems, such as:
      • spinal fusion: the most common surgical procedure for treating spinal problems
        • Usually, a fusion and instrumentation are combined to correct and solidify the curve.
      • for younger growing children:
        • dual posterior growing rods (for early-onset scoliosis): control spinal deformity while allowing spinal growth with periodic lengthenings
        • expansion thoracostomy/VEPTR™ (titanium rib) procedure to control chest and spine deformity while permitting growth of both chest and spine
        • vertebral stapling (a minimally-invasive surgical alternative to bracing for scoliosis in some circumstances)
      • thoracoscopic anterior spinal surgery and instrumentation
      • hemivertebra and wedge resections (for congenital scoliosis)
      • spinal osteotomy: controlled breaking or cutting and realigning of bone into a corrected position; may be performed when there is significant rigid deformity
      • vertebral column resection: circumferential resection of a portion of the spine to permit correction of the most severe deformities

    Will my child be OK?

    Scoliosis is not a life-threatening condition, except in some early-onset scoliosis. The outlook for your child greatly depends on the nature and severity of her scoliosis and her age, since the amount of time remaining for her to achieve complete bone growth plays a big factor. Early diagnosis and early treatment can improve the outlook for many forms of scoliosis.

    Boston Children's Hospital research into spinal problems, including scoliosis, means that we can provide your child with the most innovative care available. As a result, the majority of children treated for scoliosis at Boston Children’s are able to walk, play and live full lives.

    FAQ

    Q: What is scoliosis?

    A: Scoliosis is a condition in which the spine, in addition to the normal front to back curvatures, has an abnormal side-to-side “S-” or “C”-shaped curvature. The spine is also rotated or twisted, pulling the ribs along with it. Sometimes, a child’s lung function can be compromised when the curvature is severe or starts very early in life. The condition isn’t rare. It mainly affects girls—many of whom have mild forms of scoliosis, are never even aware of it, and never need treatment.

    Q: What is idiopathic scoliosis?

    A: Idiopathic scoliosis is the most common type of scoliosis, most commonly seen in adolescent and pre-adolescent girls. “Idiopathic” means that there is no definite cause. Nothing you or your child did caused it, and there’s nothing you could have done to prevent it. There are different degrees of severity, but most cases require no intervention. Scoliosis tends to run in families, and girls are eight times more likely than boys to develop the condition.

    Q: If my child has scoliosis, will she be OK?

    A: Scoliosis is not a life-threatening condition, except in some early-onset scoliosis. The outlook for your child greatly depends on the nature and severity of her scoliosis and her age, since the amount of time remaining for her to achieve complete bone growth plays a big factor. Early diagnosis and early treatment can improve the outlook for many forms of scoliosis.

    Children’s Hospital Boston’s research into spinal problems, including scoliosis, directly informs how we care for your child. As a result, the majority of children treated for scoliosis at Children’s are able to walk, play and live full lives.

    Q: How does Children’s treat idiopathic scoliosis?

    A: Treatment for spinal problems depends on the nature and severity of a child’s condition. Boston Children’s Spinal Program provides comprehensive treatment—including evaluation, diagnosis, consultation and follow-up care. Treatments can include:

    • simple observation and monitoring
    • physical therapy
    • bracing
    • casting
    • surgery

    Q: What are the signs and symptoms of idiopathic scoliosis?

    A: Because of all the possible combinations of curvatures, scoliosis can look quite different from child to child. Common signs and symptoms of scoliosis may include:

    • uneven shoulder heights
    • head not centered with the rest of the body
    • uneven hip heights or positions
    • uneven shoulder blade heights or positions
    • prominent shoulder blade
    • when standing straight, uneven arm lengths
    • when bending forward, the left and right sides of the back appear asymmetrical

    Symptoms that suggest scoliosis can resemble those of other spinal conditions or deformities, or may result from an injury or infection.

    Q: How is a spinal problem usually detected?

    A: Most spinal problems are detected by a child’s parents or pediatrician, or by school screenings.

    Q: How is scoliosis usually diagnosed?

    A: Once a problem is detected, doctors will use a medical and family history, physical exams and diagnostic tests to determine the nature and extent of your child’s spinal condition and options for treatment. Testing can include:

    • x-rays
    • magnetic resonance imaging (MRI)
    • computerized tomography scan (CT or CAT scan)
    • blood tests
    • ultrasound (sonogram)
    • bone scans
    • bone density scans (dual-energy x-ray absorptiometry, DEXA, DXA)
    • pulmonary function tests

    Q: Is scoliosis related to poor posture?

    A: No. Scoliosis is a spinal abnormality. It’s neither a cause nor a result of poor posture.

    Q: How common is scoliosis?

    A: According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, three to five out of every 1,000 children develop spinal curves that are considered large enough to require treatment. Idiopathic (cause not definite) scoliosis is the most common type, more common in girls than boys.

    Q: Does scoliosis hurt?

    A: Actually, most scoliosis isn’t painful in adolescents and children. But there is still the potential for significant risk of pain developing in adulthood.

    Q: Will scoliosis affect my child’s lungs and/or other organs?

    A: The lungs may be affected by severe scoliosis, particularly early-onset scoliosis. But even a severe spinal deformity doesn’t usually affect the function of other organs.

    Q: Will my other children have spinal defects?

    A: The possibility of a genetic component of spinal defects is still being studied. What’s known is that idiopathic scoliosis does tend to run in families. If you have a child with a spinal defect, it’s advisable to consult a geneticist, who can take a family history and discuss your particular situation.

    Q: What is the long-term outlook for children with scoliosis?

    A: Scoliosis is not a life-threatening condition, except in some early-onset scoliosis. The outlook for your child greatly depends on the nature and severity of her scoliosis and her age, since the amount of time remaining for her to achieve complete bone growth plays a big factor. Early diagnosis and early treatment can improve the outlook for many forms of scoliosis. Most children and adolescents diagnosed with scoliosis can look forward to normal, active lives.

    As your child grows, your orthopedist will monitor her curve through frequent check-ups. Be sure to also follow her regular program of well-child checkups. If your child is a teen, encourage her to live normally and to participate in sports and/or school activities. These will add greatly to her general health and sense of well-being.

    Q: What causes scoliosis curves?

    A: In most cases, there is no definite cause (idiopathic scoliosis) of, or way to prevent, the spine’s failure to grow as straight as it should. Heredity may play a part, but no one genetic link has been confirmed.

    Q: What is Children’s experience treating scoliosis?

    A: At Boston Children’s Spinal Program, we’re known for our clinical innovations, research and leadership. As a world center for the treatment of scoliosis, we offer the most advanced diagnostics and treatments—several of which were pioneered and developed by Children’s researchers and clinicians.

    Q: What are Children’s spine research and innovations?

    A: Children’s Orthopedic Clinical Effectiveness Research Center (CERC) helps coordinate research and clinical trials to improve the quality of life for children with musculoskeletal disorders, such as scoliosis. This collaborative clinical research program is playing an instrumental role in establishing evidence-based standards of care for pediatric orthopedic patients throughout the world.

    Physicians in the Spinal Program are pursuing several areas of basic and clinical research based at Boston Children’s and the Harvard Orthopaedics Biomechanics Laboratory. Research topics include:

    • idiopathic scoliosis and congenital scoliosis
    • spondylolisthesis and spondylolysis
    • bone density studies of braced patients
    • in vitro mechanical testing of lumbosacral fixation devices
    • computer-assisted strength analysis of vertebral metastases

    Cause

    In idiopathic scoliosis, there's no definite cause of, or way to prevent, the spine’s failure to grow as straight as it should. Heredity may play a part, but no one genetic link has been confirmed.

    Signs and symptoms

    Because of all the possible combinations of curvatures, scoliosis can look different in different people. Common signs and symptoms of scoliosis may include:

    • uneven shoulder heights
    • head not centered with the rest of the body
    • uneven hip heights or positions
    • uneven shoulder blade heights or positions
    • prominent shoulder blade
    • when standing straight, uneven arm lengths
    • when bending forward, the left and right sides of the back are asymmetrical

    Symptoms that suggest scoliosis can resemble those of other spinal conditions or deformities, or may result from an injury or infection.

    When to seek medical advice

    Scoliosis will usually become apparent as your child grows. Consult your pediatrician if her:

    • shoulders are of uneven heights
    • head isn’t centered with the rest of her body
    • hips are of uneven heights or positions
    • shoulder blades are of uneven heights or positions
    • arms hang beside her body unevenly when she stands straight
    • left and right sides of her back appear different in height when she bends forward

    Questions to ask your doctor

    If your child is diagnosed with idiopathic scoliosis, you may feel overwhelmed with information. It can be easy to lose track of the questions that occur to you. Lots of parents find it helpful to jot down questions as they arise—that way, when you talk to your child’s doctors, you can be sure that all of your concerns are addressed. Some of the questions you may want to ask include:

    • What is happening to my child, and why?
    • Are other tests needed to diagnose my child?
    • What actions might you take after you reach a diagnosis?
    • What will happen with growth over time?
    • Will there be restrictions on my child’s activities?
    • Will there be long-term effects?
    • What can we do at home?

    Who’s at risk

    Risk factors for developing idiopathic scoliosis (the most common form) include:

    • age: With the onset of puberty, during the maximum growth spurt, signs and symptoms of scoliosis may begin to manifest themselves.
    • gender: Girls are five to eight times more likely than boys to develop scoliosis.
    • heredity: Idiopathic scoliosis tends to run in families.

    Complications

    Complications from adolescent idiopathic scoliosis after treatment are uncommon, the most common being back pain and residual curvature. However, if left untreated, adults with moderate or severe scoliosis can have progressively worsening curves that cause cosmetic disfigurement, back pain and in rare cases, difficulty breathing.

    Treatment in adulthood after the curve has already become severe may be somewhat less successful than treatment during childhood or adolescence. By treating your child’s progressive curves early, we hope to keep them from becoming problems when she reaches adulthood.

    Long-term outlook

    Scoliosis is not a life-threatening condition, except in some early-onset scoliosis. The outlook for your child greatly depends on the nature and severity of her scoliosis and her age, since the amount of time remaining for her to achieve complete bone growth plays a big factor. Early diagnosis and early treatment can improve the outlook for many forms of scoliosis. Most children and adolescents with scoliosis can look forward to normal, active lives.

    As your child grows, your orthopedist will monitor her curve through frequent check-ups. Be sure to also follow her regular program of well-child checkups. If your child is a teen, encourage her to live normally and to participate in sports and/or school activities. These will add greatly to her general health and sense of well-being.

    For teens

    Besides the typical issues any teenager faces—from social acceptance to body changes and more—if you’re undergoing bracing and physical therapy for scoliosis, it’s true that you’ll also have to deal with medical appointments, feeling different and assuming a big personal responsibility for maintaining your own good health. If your scoliosis is mild or moderate, you may wonder why we need to monitor and treat it, since it may not be painful or bothersome.

    It’s important for you to know that if left untreated until you’re an adult, your moderate or severe scoliosis can worsen, resulting in curves that cause cosmetic disfigurement, back pain and in severe cases difficulty breathing.

    Treatment in adulthood after the curve has already become severe may be somewhat less successful than treatment during your adolescence. So, by treating your progressive curves early, we hope to keep them from becoming problems when you reach adulthood.

    It may also help you to know that you can participate in sports and other normal activities—your general health will actually improve with an active lifestyle. Your brace can be removed for sports, and most braces are lightweight and can be worn, unseen, under your clothes.

    If you feel overwhelmed, depressed or anxious through this important time in your transition to adulthood, speak to your doctor or counselor to get help.

    For adult patients

    If you were treated for scoliosis as a child, you’re probably being followed by your orthopedist and/or family doctor. And you’re probably doing well, with perhaps occasional back pain.

    If your scoliosis was untreated during childhood, it may have:

    • remained the same
    • progressed (worsened), causing:
      • back pain
      • difficulty sitting or standing
      • stiffness, spinal rigidity
      • bodily asymmetry
      • deformity, gait dysfunction
      • rarely, and only in severe cases, impaired heart or lung function

    Adult scoliosis is often treated with non-surgical therapies, such as pain medication, applied heat and/or exercise. Bracing is rarely used for pain control in adults. And surgery for adults can be indicated to alleviate pain, increase function or decrease deformity.

    Adult scoliosis is often treated with non-surgical therapies, such as pain medication, applied heat and/or exercise. Bracing is rarely used for pain control in adults. And surgery for adults can be indicated to alleviate pain, increase function or decrease deformity.

    Adults who have been treated at Children’s during their childhood are often followed into adulthood for their pediatric condition by their Children’s orthopedist. We also see young adults with spine problems that originated in childhood.

    What you can do at home

    As your child grows, your orthopedist will monitor her curve through frequent check-ups. Be sure to also follow her regular program of well-child checkups. If your child is a teen, encourage her to live normally and to participate in sports and/or school activities. These will add greatly to her general health and sense of well-being.

    Prevention

    The great majority of scoliosis cases are idiopathic, meaning they have no definite cause. Nothing you or your child did caused it, and there’s nothing you could have done to prevent it.

    Idiopathic scoliosis glossary

    • Adams forward bending test: a screening tool for scoliosis
       
    • adolescent scoliosis: a classification of idiopathic scoliosis representing the vast majority of cases—mostly occurring in girls ages 10 to 18, often not needing intervention
       
    • brace, bracing (spinal orthosis): If your growing child’s curve shows significant worsening or is already greater than 30 degrees, your physician may recommend a bracing program, in which a scoliosis brace is designed specifically for your child’s particular curve. The brace holds your child’s spine in a straighter position while she is growing in order to partly correct the curve or prevent it from increasing.

    There are many types of brace, including the Boston Brace developed at Children’s. A bracing program may help avoid surgery.

    • casting: an option for holding your child’s spine in a straighter position while she's growing; used in specific situations, as in some cases of early-onset (infantile) idiopathic scoliosis
       
    • The Center for Families at Boston Children’s: dedicated to helping families find the information, services and resources they need to understand their child’s medical condition and take part in their care
       
    • Cobb angle: an angular measurement on x-ray to evaluate the severity and degree of scoliosis curves
       
    • congenital scoliosis: the spine forms and develops between three and six weeks after conception. Congenital scoliosis results from abnormal in utero spinal development, such as a partial or missing formation or a lack of separation of the vertebrae.
       
    • diagnosis: identifying disease or injury through examination, testing and observation
       
    • (dual posterior) growing rods: devices affixed to the spine (for early-onset scoliosis). These control spinal deformity while allowing spinal growth with periodic lengthenings.
       
    • idiopathic scoliosis: the most common form of scoliosis. “Idiopathic” simply means that there's no definite cause. Nothing you or your child did caused the problem, and there’s nothing you could have done to prevent it.
       
    • infantile idiopathic scoliosis (one of several types of early-onset scoliosis): a classification of idiopathic scoliosis representing about 5 percent of cases. The only type of scoliosis occurring more often in boys from birth to 3 years of age, often self-resolving but sometimes serious
       
    • instrumentation: the metal rods, hooks, screws and wires implanted during spinal fusion surgery to correct the spinal curve and secure the spine in position while the fusion heals and becomes solid
       
    • juvenile scoliosis: a classification of idiopathic scoliosis representing about 10 percent of cases—occurring in children ages 3 to 9 years
       
    • neuromuscular: affecting, or characteristic of, both neural (nerve) and muscular tissue
       
    • neuromuscular scoliosis: scoliosis that's associated with disorders of the nerve or muscular systems like cerebral palsy, spina bifida, muscular dystrophy or spinal cord injury
       
    • orthopedics: the medical specialty concerned with diagnosing, treating, rehabilitating and preventing disorders and injuries to the spine, skeletal system and associated muscles, joints and ligaments
       
    • orthopedic surgeon, orthopedist: a physician specializing in surgical and non-surgical treatment of the spine, skeletal system and associated muscles, joins and ligaments
       
    • orthotics: the science of designing and fitting of devices such as braces to treat orthopedic conditions
       
    • physical therapy: a rehabilitative health specialty that uses therapeutic exercises and equipment to help patients improve or regain muscle strength, mobility and other physical capabilities
       
    • progression, curve progression: worsening of a scoliosis curve
       
    • scoliometer: a surface measurement device for evaluating the angle of trunk rotation (ATR or scoliometer angle, which is not the ‘Cobb’ angle measured on x-ray)
       
    • scoliosis: a spinal condition in which the spine, in addition to the normal front to back curvature, has an abnormal side-to-side “S-” or “C”-shaped curvature. The spine is also rotated or twisted, pulling the ribs along with it. Scoliosis occurs in three main types: idiopathic (no definite cause), neuromuscular (associated with neuromuscular diseases) and congenital (present at birth).
       
    • spinal cord: a nerve bundle within the vertebral column that extends down from the brain stem. It conducts signals in both directions between the brain and extremities, and allows for bodily motion and sensation.
       
    • spinal abnormality (spinal problem): a condition in which the spine is abnormal. It may be that the spine’s structure has developed abnormally—for example, congenital scoliosis or congenital kyphosis. Some are the result of nerve or muscle (neuromuscular) diseases or injuries—for example, cerebral palsy. In some cases, there is no definite cause (idiopathic) for the spine’s failure to develop normally.
       
    • spinal fusion: usually a solid fusion (solidification) of the curved part of the spine, achieved by operating on the spine, adding bone chips and allowing the vertebral bones and bone chips to slowly heal together to form a solid mass of bone called a fusion
       
    • spine (spinal column, vertebral column): the series of moving vertebrae forming the axis of the skeleton and protecting the spinal cord
       
    • spine curves, normal and abnormal: front-to-back and sideways curves of the spine
      • All spines have normal front-to-back curves. Abnormal front-to-back curves can indicate “round back” (hyper-kyphosis) or “swayback” (hyper-lordosis).
      • Normal spines don't have much sideways curvature. An abnormal sideways “S” or “C” curve can indicate scoliosis.
         
    • VEPTR™ (titanium rib) procedure: an operation that expands the chest and allows continued growth of the chest and spine. A curved metal rod fits the back of the chest and spine, helping the spine to become straighter and allowing the lungs to grow and fill with enough air to breathe. The device is made longer as your child grows. The procedure is used for some early-onset scoliosis, with the device attaching to the ribs, spine or both.
       
    • vertebra, vertebrae: the individual bones that form the spinal column
       
    • vertebral stapling: a newer surgical technique that may prevent the curve progression in children and adolescents with moderate scoliosis. A minimally invasive procedure, stapling may be an alternative to bracing for some children at risk for progression of their scoliosis and the prospect of spinal fusion in their future.
  • At Boston Children's Hospital, we know that the first step in treating your child is forming an accurate and complete diagnosis.

    Even though doctors and some schools routinely screen for idiopathic scoliosis, the condition can be difficult to diagnose. Sometimes the curves are obvious, but other times they aren’t immediately visible. Since scoliosis curves often aren’t painful, and since they usually progress slowly, they can be overlooked until a child approaches puberty.

    Because detecting and treating scoliosis early are important for successful outcomes, pediatricians, family doctors and even some school programs routinely look for signs that scoliosis may be present.

    Once a problem is detected, doctors will use a medical and family history, physical exams and diagnostic tests to determine the nature and extent of your child’s scoliosis. Your doctor will review your child’s complete prenatal and birth history, as well as any family history of scoliosis.

    During your child’s physical exams, her physician will be looking for, and measuring, abnormal contours that indicate scoliosis. Through physical exams and diagnostic testing, the doctor will determine the:

    • shape of the curve (“S” or “C” shape; involvement of ribs and muscles)
    • location of the curve (upper [thoracic] spine; lower [lumbar] spine; or both [thoracolumbar])
    • direction of the curve (bend to left or right)
    • angle of the curve in degrees (Cobb angle)

    X-rays and other tests

    X-rays (front and side) are the main diagnostic tools for confirming the presence of scoliosis, as well as the severity of the curve. To get more information, or if the doctor suspects that an underlying condition might be causing the scoliosis, additional tests can include:

    The likely progression of an adolescent’s curves can often be predicted by assessing the magnitude of her existing curve(s), as well as her physiologic and skeletal maturity.

  • How we'll treat your child's scoliosis depends on the complexity and severity of her condition. Boston Children's Hospital's Spinal Program provides comprehensive treatment—including evaluation, diagnosis, consultation and follow-up care.

    Treatments can include:

    • simple observation and monitoring: Once an abnormal spine curve has been detected, it's important to monitor the curve as your child grows. In many cases, your child's curve may require only close monitoring during skeletal growth. Your Boston Children's physician will determine your treatment plan and follow-up based on your child's x-rays and physical exams.
       
    • physical therapy: Scoliosis can often be helped by physical therapy.Our physical therapy team's goal is to maximize your child's physical functioning. Our therapists work closely with the Spinal Program to also provide exercise programs and additional therapies to address pain and the muscular imbalance that can be associated with spinal abnormalities.
       
    • bracing: If your growing child's curve shows significant worsening or is already greater than 30 degrees, your physician may recommend a bracing program, in which a scoliosis brace is designed specifically for your child's particular curve. The brace holds your child's spine in a straighter position while she is growing in order to partly correct the curve or prevent it from increasing. A bracing program may help avoid surgery.
    • casting: In certain situations—as in some cases of early-onset (infantile) idiopathic scoliosis—body casting is indicated.
       
    • surgery: If surgery becomes necessary, our Spinal Program's orthopedic surgeons use the most advanced surgical techniques for correcting spinal problems, such as:
      • spinal fusion: the most common surgical procedure for treating spinal problems
        • Usually, a fusion and instrumentation are combined to correct and solidify the curve.
           
      • for younger growing children:
        • dual posterior growing rods (for early-onset scoliosis): control spinal deformity while allowing spinal growth with periodic lengthenings
        • expansion thoracostomy/VEPTR™ (titanium rib) procedure to control chest and spine deformity while permitting  growth of both chest and spine
        • vertebral stapling (a minimally-invasive surgical alternative to bracing for scoliosis in some circumstances)
           
      • thoracoscopic anterior spinal surgery and instrumentation
         
      • hemivertebra and wedge resections (for congenital scoliosis)
         
      • spinal osteotomy: controlled breaking or cutting and realigning of bone into a corrected position; may be performed when there is significant rigid deformity
         
      • vertebral column resection: circumferential resection of a portion of the spine to permit correction of the most severe deformities

    Typical treatments

    Your Boston Children's orthopedist will make treatment determinations depending on your child's age, the type and progression rate of her curve, the prediction of further curve progression and other factors. Typical treatment plans for idiopathic scoliosis can include:

    • adolescent idiopathic scoliosis: 10 to 18 years of age
      • curves less than 25 to 30 degrees observed and monitored regularly
      • bracing for curves 30 to 40 or 45 degrees (prefer to use on children who are still growing)
      • consider bracing for curves that progress rapidly to 20 to 25 degrees
      • consider surgery for curves larger than 40 to 50 degrees
         
    • juvenile idiopathic scoliosis: 3 to 9 years of age
      • diagnostic MRI if curve is more than 20 degrees or atypical
      • curves less than 20 degrees observed and monitored regularly
      • bracing for curves 20 to 50 degrees
      • bracing for smaller curves that progress rapidly to 20 to 25 degrees
      • growing rods or vertebral stapling for very large curves or some curves not responsive to bracing
         
    • infantile (early-onset) idiopathic scoliosis: birth to 3 years of age
      • brief observation to determine if curves are self-resolving
      • MRI for diagnosis in persistent curves
      • casting followed by bracing for persistent or larger curves
      • surgery for very large curves (often dual growing rods)

    Caring for your adolescent after surgery

    In the unlikely event that your child needs surgery (spinal fusion) to correct her scoliosis curves, preparation for—and attention to—her care during the healing period will help ensure a positive outcome:

    • For about three months after surgery—and to some extent throughout the healing period—she must restrict certain physical activities, such as running, sports, lifting, bending and twisting. After three months, she can gradually return to nearly all activities.
       
    • Some at-home modifications in advance of her surgery will help her avoid activities and motions that put her fusion at risk:
      • Place often-used items within easy reach—no bending.
      • Place groceries on shelves—no lifting heavy grocery bags.
      • Modify your expectations of her chores—no bed-making or other bending/twisting activities.
      • Consider putting her bed on the same floor as the bathroom.
         
    • Follow your doctor's directions for physical therapy (stretching, strengthening and appropriate aerobic activity).

    Caring for your child as she grows

    As your child grows, your orthopedist will monitor her curve through frequent check-ups. Also, be sure to follow her regular program of well-child checkups. If your child is a teen, encourage her to live normally and to participate in sports and/or school activities. These will add greatly to her general health and sense of well-being.

    Scoliosis is not a life-threatening condition, except in some early-onset scoliosis. The outlook for your child greatly depends on the nature and severity of her scoliosis and her age, since the amount of time remaining for her to achieve complete bone growth plays a big factor. Early diagnosis and early treatment can improve the outlook for many forms of scoliosis. Most children and adolescents diagnosed with scoliosis can look forward to normal, active lives.

    Coping and support

    At Boston Children's, we understand that a hospital visit can be difficult, and sometimes overwhelming. So, we offer many amenities to make your child's—and your own—hospital experience as pleasant as possible. Visit The Center for Families for all you need to know about:

    • getting to Boston Children's
    • accommodations
    • navigating the hospital experience
    • resources that are available for your family

    In particular, we understand that you may have a lot of questions when your child is diagnosed with scoliosis. How will it affect my child long term? What do we do next? Boston Children's can help you connect with extensive resources to help you and your family through this stressful time, including:

    • patient education: From doctor's appointments to physical therapy and recovery, our nurses and physical therapists will be on hand to walk you through your child's treatment and help answer any questions you may have—Will my child need surgery? How long will her recovery take? How should we manage home exercises and therapy? We'll help you coordinate and continue the care and support you received while at Children's.
       
    • parent-to-parent: Want to talk with someone whose child has been treated for your child's form of scoliosis? We can often put you in touch with other families who've been through the same process or procedure that you and your child are facing, and who will share their experiences.
       
    • faith-based support: If you're in need of spiritual support, we'll connect you with the Children's chaplaincy. Our program includes nearly a dozen clergy—representing Protestant, Jewish, Muslim, Catholic and other faith traditions—who will listen to you, pray with you and help you observe your own faith practices during your hospital experience.
       
    • social work: Our social workers and mental health clinicians have helped many other families in your situation. We can offer counseling and assistance with issues such as coping with your child's diagnosis, stresses relating to coping with illness and dealing with financial issues.

    A long line of orthopedic firsts

    With a long history of excellence and innovation and a team of clinicians and researchers at the forefront of orthopedic research and care, Boston Children's is home to many treatment breakthroughs:

    • advanced techniques and microsurgery care for complex fractures and soft tissue injuries to the hand and upper extremity
    • advances in our spinal program, such as video-assisted thorascopic surgery
    • the oldest and largest comprehensive center for the care of spina bifida
    • a hip program that has performed over 1,200 periacetabular osteotomies
    • one of the first scoliosis clinics in the nation
    • one of the first sports medicine clinics in the nation
    • one of the first centers in the nation to use adjuvant chemotherapy and perform limb salvage surgery for patients with osteosarcoma
  • For more than a century, orthopedic surgeons and investigators at Children’s Hospital Boston have played a vital role in the field of musculoskeletal research, pioneering treatment approaches and major advances in the care and treatment of ailments such as scoliosis, polio, tuberculosis, hip dysplasias and traumas to the hand and upper extremities.

    Our pioneering research helps answer the most pressing questions in pediatric orthopedics today—providing children with the most innovative care available.

    At Boston Children’s Orthopedic Center, we take great pride in our basic science and clinical research leaders, who are recognized throughout the world for their respective achievements. Our orthopedic research team includes:

    • five full-time basic scientists
    • 26 clinical investigators
    • a team of research coordinators and statisticians

    Clinical Effectiveness Research Center

    The Orthopedic Clinical Effectiveness Research Center (CERC) helps coordinate research and clinical trials to improve the quality of life for children with musculoskeletal disorders. This collaborative clinical research program is unique in the nation and plays an instrumental role in establishing—for the first time—evidence-based standards of care for pediatric orthopedic patients throughout the world.

    Major areas of focus for the CERC include:

    • spinal disorders
    • hip disorders
    • upper extremity disorders
    • brachial plexus birth palsy
    • trauma/fractures

    Spinal program

    Physicians in the CERC Spinal Program are active in several areas of ongoing basic and clinical research based at Children’s and the Harvard Orthopaedics Biomechanics Laboratory. Research topics include:

    • congenital scoliosis and idiopathic scoliosis
    • spondylolisthesis and spondylolysis
    • bone density studies of braced patients
    • in vitro mechanical testing of lumbosacral fixation devices
    • computer-assisted strength analysis of vertebral metastases

    Ongoing studies

    Ongoing clinical studies include:

    Spine Studies Partially Sponsored by the Spinal Deformity Study Group: The mission and purpose of the Spinal Deformity Study Group (SDSG) is to create a means and forum whereby multi-center studies can be developed and conducted both efficiently and effectively. The SDSG is comprised of fifty national and international spine surgeons from 35 participating sites worldwide. Drs. Emans and Hresko are members of the SDSG.

    • (SDSG) Prospective Pediatric and Adolescent Scoliosis Study

    This is a prospective multi-centered study focused on the outcomes of pediatric and adolescent idiopathic scoliosis. The main purpose of this observational study is to develop a prospective comprehensive radiographic and clinical database on consecutively treated pediatric and adolescent scoliosis surgical cases to assess outcome measures in patients with operative idiopathic scoliosis being treated with current surgical techniques.

    A secondary objective is to obtain data on currently available surgical approaches to treat idiopathic scoliosis in the thoracic, thoracolumbar and lumbar spine.

    • (SDSG) Prospective Pediatric and Adolescent Kyphosis Study

    The main objective of this prospective multi-center, observational study is to assess outcome measures in pediatric and adolescent patients with kyphosis, who are being treated non-operatively or operatively with current surgical techniques. Secondarily, data on currently available surgical approaches to treat pediatric kyphosis in the thoracic and/or thoracolumbar spine will be collected.

    • (SDSG) Prospective Study of Deformity Management and Pulmonary Function in Early-Onset Scoliosis

    The goal of this prospective multi-center study of children with “idiopathic” scoliosis is to document concomitantly: 1) control of spinal deformity, 2) growth of the thoracic spine longitudinally and transversely at a rate commensurate with the number of vertebrae involved and 3) increasing lung volume, absolute and relative to body size.

    • (SDSG) The Effect of Surgery on Sagittal Spino-pelvic Measures of Balance in Developmental Spondylolisthesis and Its Relation to Clinical Outcome

    The short-term goal of this prospective multi-center, observational study is to confirm the predictive value of sagittal spino-pelvic measurements in the surgical treatment of L5-S1 developmental spondylolisthesis. The long-term objective is to determine the optimal surgical treatment for L5-S1 developmental spondylolisthesis based on x-ray evaluation of sagittal trunk balance and functional outcome.

    Other Multicenter Studies of Importance: By combining efforts with other centers, the Division of Spine Surgery at Children’s in Boston is able to more quickly reach valid research conclusions applicable to clinical practice.

    • Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST)

    BrAIST is a multicenter randomized trial funded by the National Institutes of Health. Children’s Hospital Boston is one of 18 pediatric centers in North America participating in this clinical trial. The overall goal of this research is to determine whether bracing can slow or halt curve progression in patients with Adolescent Idiopathic Scoliosis (AIS), alleviating the need for surgical correction.

    The secondary aims of this study are to 1) investigate the effect of the diagnosis and treatment of AIS on the overall physical and mental well-being of subjects over time, 2) determine the relationship between bracing dose (wear time) and curve progression and 3) develop a predictive model for curve progression based on patient characteristics at their initial presentation and after bracing or watchful waiting.

    • Dual Growing Rod Instrumentation with Limited Fusion for the Treatment of Early Onset Scoliosis

    This multi-center project is sponsored by the Growing Spine Study Group (GSSG). Initially a retrospective study, it has become a prospective observational study with 14 clinical centers from around the world contributing data. The main goal is to determine how successful dual growing rods and Vertical Expandable Prosthetic Titanium Rib (VEPTR™) devices are in correcting progressive scoliosis in very young children.

    Secondarily, researchers want to know if children who undergo successful surgical intervention with these devices to control their curve during growth need to go on to receive a definitive final fusion, or if the hardware can be removed and the curve simply observed over time for possible progression.

    Recently, the study was modified to include a non-operative cohort of patients who are treated for early onset scoliosis with non-surgical methods, such as bracing and casting. Outcomes associated with operative and non-operative treatment will be compared in hopes that the most effective methods of correction can be identified.

    • Skeletal Complications in Neurofibromatosis Type 1 (NF1)

    This study is being conducted by researchers at Boston Children's Hospital and Beth Israel Deaconess Medical Center. The goal is to identify cell types associated with and responsible for skeletal defects and impaired bone healing associated with NF1.

    A large proportion of patients with NF1 display skeletal abnormalities such as alterations in bone size and shape, the presence of scoliosis, and a tendency to develop pseudoarthrosis. Tissue samples from patients with and without NF1 will be analyzed by microscopic examination. We hope the results will lead to a better understanding of the cells predominantly responsible for skeletal defects in NF1 and lead to new strategies for treating this patient population.

    Ongoing laboratory studies include:

    • Basic science studies
    • Biomechanical/instrumentation studies

    Orthopedic basic science laboratories

    Working in our labs are some of the leading musculoskeletal researchers in the nation. These labs include:

    Children speak: What's it like to be a medical research subject?

    View a video of a day in the life of Children’s Clinical and Translational Study Unit, through the eyes of children who are “giving back” to science. 

  • Patient spotlight: Visceria Givans

    Visceria Givans is a student athlete, diagnosed with scoliosis in grade school. She received corrective spine surgery at Children’s Hospital Boston a few years later and is actively playing sports again. In the following post she discusses her treatment, recovery and how she refused to let scoliosis define her or impact her self-esteem.

    Scoliosis is a curvature of the spine measuring 20 degrees or greater

    Getting checked for scoliosis at school is a little strange. First, you have to wear a bathing suit under your clothes that day because the school nurse needs to be able to see the entire line of your back to make sure your spine is growing correctly. Then, they disrupt the whole school day by checking all the kids for curvatures in their spine, one at a time. When I had my first scoliosis test back in the fourth grade, it was even stranger for me because after it was over the nurse mentioned that it looked like my back was growing a little crooked, and it was something we’d need to keep an eye on.

    I didn’t know exactly what to think, but the nurse didn’t seem too worried so my parents and I didn’t think much about it either. For the next few years my doctor checked my spine regularly and when it was clear the curve was getting worse he suggested I wear a brace to try to correct it.

    Wearing the brace took some getting used to. For starter’s it’s pretty big, so it stretched out a lot of my clothes. Secondly, it’s not the most comfortable thing in the world to spend 20 hours a day in brace that covers you from your shoulders to your belly, so even relaxing things like sitting and watching TV became kind of a chore. Not a perfect situation, but after awhile you get used to it and find ways to adapt. I bought bigger clothes that looked good but still left room for the brace, and quickly learned which positions were more comfortable with my brace on. The hardest part was when it prevented me from cheerleading and playing sports, which have always been a big part of my life, but I managed to find other ways to help the team. When my scoliosis kept me on the sidelines I assisted the coaches and offered suggestions and encouragement to my teammates.

    After a year with the brace it became such a regular part of my life I almost forgot I had it on. I think the brace may have forgot too, because by the time I turned 13, Dr. Karlin, the scoliosis specialist I saw at Children’s Hospital Boston, said it didn’t seem to be doing enough to correct the curvature in my spine. I didn’t feel any different, and it didn’t hurt in any way, but my doctor explained that as time went on it could get a lot worse. I could develop a hunch back, and if my spine got too crooked it could press against some of my organs which could lead to very serious medical problems as I got older. Dr. Karlin explained that best way to prevent this was surgery, where they’d permanently straighten my spine by fusing it with a metal rod.

    The surgery took over 9 hours, but when I woke up my spine was straighter and I was a full 2 inches taller. My mom couldn’t believe how different I looked standing that straight. She said she always thought my slumping was because I was a teenager and I was being moody, but it really was just the shape of my back!

    Even though my surgery was over, the biggest challenge of my scoliosis still lay ahead: physical therapy and recovery. At first everyday things like getting out of bed and walking up and down stairs were real challenges; I had to work closely with both my physical therapist and my parents to relearn how to do even the simplest tasks. I also lost a lot of weight because the medication I was on took away my appetite, but as soon as I got off the meds I started eating again.

    It’s been over a year since my surgery and I’m back to cheerleading and playing lots of sports, which feels great. It also feels good to know that my story can help other kids. Last year a girl a few years younger than me found out she had scoliosis, and I was happy to be able to tell her that it doesn’t have to affect her life too much, or keep her from doing the things she liked. It may not be the most original piece of advice, and really it applies to everyone and not just people with scoliosis, but I told her the best thing she could was to just be confident in who she was. If you are a strong person with a healthy self-esteem it’s easy to not let something like a curved spine, or any other medical condition, define who you are as a person.

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