 INTRODUCTION The research community coined the term “Adult Spinal Deformity” (ASD) to represent specific abnormalities of the lumbar or thoracolumbar spine in adults. ASD includes scoliosis, a 3-dimensional spinal condition, and kyphosis or hyper-kyphosis, a sagittal plane spinal condition. In this discussion we will refer to ASD as Adult Spinal Disorder - more sensitive characterization of the term. ASD is of growing interest in health care because of its prevalence in a population that has expanded due to increased longevity. ADULT SCOLIOSIS TYPES ASD includes 3 types of adult scoliosis(1):
PROGRESSION People with ASD are at risk for progression resulting in spine instability, pain and disability. Research by Weinstein et al(14) examined progression of scoliosis based on the cobb angle:
Progression of the spinal disorder occurs at these vulnerable transitional segments and results in degeneration and further compression of the concavities. EXERCISE Exercise has been shown to improve muscle mass and strength, both of which tend to decrease in older adults. There are 3 main exercise categories: 
WHAT TYPE OF EXERCISE IS RECOMMENDED? Current exercise recommendation for ASD is vague. So my collaborators (Hagit Berdishevsky, Sanja Schreiber and Jean Claude de Mauroy) and I conducted a Scoping Review in search of any research articles that refer to exercise recommendations for adults with scoliosis. After finding no studies that fit our criteria, we developed an algorithm based on risk to help adults with spinal disorders determine safe exercise choices. EXERCISE RECOMMENDATION BASED ON RISK ASSESSMENT Ideally, the client with scoliosis would receive scoliosis specific exercises (PSSE) with a PSSE trained physical therapist, then progress to a home program including fitness exercises that support their PSSE training. They could then theoretically continue their sport activity. A conflict occurs when a fitness program focuses on sport mastery, such as improving golf swing, and then the selected exercises contribute to spinal compression, sheer forces and scoliosis progression. The fitness program design should be based on risk assessment, where exercises are selected according to the adult’s stabilization requirement. A fitness program serves as “stability cross training” to allow the adult to continue the sport/activity they love, for as long as possible. MEDICAL RESEARCH CLASSIFICATION SYSTEM Research on ASD and progression has been done primarily in the surgical management of ASD. Classification systems have been designed to help guide management choices for spinal disorders. In 2006 Schwab and others(8) developed a classification system for ASD that was validated in 2012.(9) This large retrospective cohort study examined people with ASD who consulted a surgeon about their pain and disability. Some eventually received a surgical fusion (the ultimate stabilization). Those who were not fused received a conservative plan of care that often included PT and exercise. Characteristics shared by those who had fusion surgery were analyzed. A classification was established based on their shared characteristics. These shared characteristics were then used to help predict which patients would be more likely to benefit from fusion surgery. High-risk patients shared the following radiological criteria: (9)  SUMMARY OF RADIOLOGICAL RISK FACTORS Sagittal Plane Imbalance:
Pain Pain is a complex experience and differs from person to person. It is a warning that something is not quite right. It can cause a person to avoid certain actions (fear avoidance). Pain is part of the vicious cycle of ASD as described by Weinstein in 1986.(14) The ASD vicious cycle starts with:
WHAT IF THERE IS NO X-RAY? Sometimes there is no x-ray available. This is mostly true in a fitness setting. The fitness instructor must determine if their adult client is at high-risk for pain and disability in the future. When no x-ray is available, the following clinical tests may be used. These tests correlate with three of the radiological criteria: 
MOVEMENT COMPETENCE RISK FACTORS Movement Competence is the effectiveness of a person’s underlying processes of movement including coordination, control and movement quality. Movement competence improves reaction to any destabilizing forces on the spine. Movement Competence Assessment can be: a formal standardized test such as the Functional Movement Screen(12) or a formal non-standardized test like the Polestar Assessment Tool:  Courtesy Polestar Pilates an informal test such as:
EXERCISE SELECTION Now we can use risk factors (both structural and movement) to develop an exercise plan that includes the following exercise categories:
 Additionally, fitness exercises can be modified to reduce compressive forces on concavities (collapsed areas in ASD) in the frontal and sagittal planes:  PAIN Pain is a complex experience and differs from person to person. It is a warning that something is not quite right. It can cause a person to avoid certain actions (fear avoidance). Pain is part of the vicious cycle of ASD as described by Weinstein in 1986.(14) ASD vicious cycle starts with:
 DOES EXERCISE HELP? Exercise reduces pain perception and can affect mental health, mood elevation and reduction of stress and depression. It can produce an analgesic effect through activation of the central nervous system inhibitory pathways. Pain has both physical and psychological components.6 Adults tend to have mild to moderate pain as part of their daily life. If pain continues despite an appropriate fitness program based on an assessment, then we call this "persistent pain". Ultimately, if the adult has failed to improve and pain is no longer tolerated, then referral to a specialist in ASD is recommended. DELPHI STUDY My colleagues and I tested our theory of exercise selection based on structural and movement competence risk factors to see if experts in our field agreed with us. We sent an anonymous survey to 50 physical therapists around the world who specialize in PSSE for adults with spinal disorder. Two rounds of questions were sent, and respondents were provided results and feedback from the first round to help them achieve consensus in the second. 21/50 experts in ASD responded and a consensus of 75% agreement on all questions was achieved, resulting in the following exercise recommendations for people with ASD:  We are currently preparing a second Delphi Study to increase the strength of these findings. WHAT ABOUT SPORTS? Recreational sports have a positive impact on quality of life, perhaps even justifying any potential risks they may impose on those with scoliosis and adult modifiers. It would be prudent for adults with ASD and risk factors who want to continue their sport, to work with a qualified fitness instructor who can provide an exercise program emphasizing stability as cross training. The adult with higher risk for instability should understand its ramifications and make an informed decision about continuing their sport. If they decide to continue their sport, they should be supported. We can help them be happy and safe!  REFERENCES
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