BEST PRACTICE FITNESS EXERCISE RECOMMENDATIONS FOR ADULTS WITH SPINAL DISORDERS

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): 

1. Type 1: Primary degenerative scoliosis is attributed to asymmetric disc disorder and/or facet joint arthritis, with predominantly back pain symptoms, often accompanied by signs of spinal stenosis. It is often classified as ‘‘de novo’’ scoliosis and occurs mostly as a lumbar or thoracolumbar curve with a sagittal deviation in the form of flat back or lumbar kyphosis. 
2. Type 2: Idiopathic adolescent scoliosis is thoracic and/or lumbar spine scoliosis which progresses in adult life and is usually combined with secondary degeneration.  
3. Type 3: Secondary adult curves:  

• Due, for example, to a leg length discrepancy or hip pathology. 
• Due to a metabolic bone disease (mostly osteoporosis) combined with asymmetric arthritic disease and/or vertebral fractures.  

All three types of scoliosis may appear as degenerative scoliosis, and the primary cause is often difficult to determine once the degeneration has significantly progressed.  

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:

• > 30 deg Cobb:   probable progression .5-.75°/year 
• > 50 deg Cobb:   certain progression of 1°/year 

Spine instability refers to excessive movement at vulnerable spinal segments.  In scoliosis and hyper-kyphosis these segments tend to be transitional areas of the spine that occur above and below the curve apex - which is more rigid.   
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:

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• PSSE: Physiotherapy Scoliosis Specific Exercise is provided by physical therapists certified in this evidence-based intervention.  PSSE such as the Schroth Method is considered a “corrective” form of exercise intervention. General principles of PSSE are “elongation and expansion” - principles that can also be applied to fitness activities.   
• Fitness: strength and flexibility exercises to maintain overall health and independence, or to prepare for sports and/or recreation. While fitness exercise is not corrective in nature, the health benefits are numerous.  Adults with spinal disorder are vulnerable to progression, and care must be taken to reduce risk when selecting exercises. 
• Sports and recreation: “competitive games or active leisure” that enhances quality of life.   

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: 

• a more forward flexed posture (offset of trunk in relation to pelvis) 

• increased posterior pelvic tilt  

• reduced lumbar lordosis  

Coronal Plane Imbalance:   

• the presence of a lumbar curve 

• increased coronal offset of the pelvis in relation to the trunk 

Radiological risk factors are called “adult spine modifiers” in surgical terminology and may be used by therapists and fitness instructors to determine the risk of spinal instability for a patient/client.  Modifiers may be used with a physical examination focusing on gait, posture and movement competence to obtain a risk stratification to determine optimal treatment planning that includes fitness exercises: 

• When the level of risk is high due to the presence of modifiers, a stability program is recommended.    
• When there are no spine modifiers, there is less risk and no need to restrict spinal motion in a fitness program.   

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: 

1. Symmetric and/or asymmetric degeneration (that can be new from degenerative changes in adulthood or an add-on to existing scoliosis from adolescence).   
2. Asymmetric load will continue and most likely create instability of the spine: listhesis in 3D which can give rise to progression, pain and disability.

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: 

• Scoliometer assessment(4) to find the presence of primary lumbar curve  
• C7 to Wall Distance(2) to determine the presence of Sagittal Imbalance  
• Plumb Line(5) to determine the presence of Coronal Imbalance  

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: 

• any movement examination that would inform the exercise plan 
• a person’s change of position or location 
• a judgement or evaluation 
• an estimation of ability 

What are the outcomes of a Movement Competence Test and what do they tell us about risk assessment?   

• Challenged Mover:   A person who requires on-going coaching to maintain optimal alignment during fitness exercises:  Mod-high risk  
• Competent Mover:  A person who is appropriate for a self-guided exercise program based on their Movement Competence Assessment: low risk 

EXERCISE SELECTION
Now we can use risk factors (both structural and movement) to develop an exercise plan that includes the following exercise categories: 

• Basic Spine Stability category 
• Advanced Spine Stability category 
• Controlled Spine Movement category 

This flow chart depicts exercise selection and advancement based on risk: 

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: 

1. Symmetric and/or asymmetric degeneration (that can be new from degenerative changes in adulthood or an add-on to existing scoliosis from adolescence).   
2. Asymmetric load will continue and most likely create instability of the spine: listhesis in 3D which can give rise to progression, pain and disability.   

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

1. Aebi. The adult scoliosis.  Eur spine J 2005 Dec;14(10):925-48. Pub 2005 Nov 18.
2. Amatachaya P, Wongsa S, Sooknuan T, Thaweewannakij T, Laophosri M, Manimanakorn N, Amatachaya S.  Validity and reliability of a thoracic kyphotic assessment tool measuring distance of the seventh cervical vertebra from the wall. Hong Kong Physiother J. 2016,13;35:30-36. 
3. Berjano P, Lamartina C. Classification of degenerative segment disease in adults with deformity of the lumbar or thoracolumbar spine. Eur Spine J. 2014;23(9):1815-1824. 
4. Cote P, Kreitz BG, Cassidy JD et al.  A study of the diagnostic accuracy and reliability of the Scoliometer and Adam's forward bend test.  Spine. 1998, 1;23(7):796-802.
5. Grunstein E, Fortin C, Parent S, Houde M, Labelle H, Ehrmann-Feldman D.   Reliability and validity of the clinical measurement of trunk list in children and adolescent with idiopathic scoliosis.  Spine Deform. 2013, Nov;1(6):419-424.
6. Lima LV, Abner TSS, Sluka KA. Does exercise increase or decrease pain? Central mechanisms underlying these two phenomena. J Physiol. 2017 Jul 1;595(13):4141-4150. doi: 10.1113/JP273355. Epub 2017 May 26. PMID: 28369946; PMCID: PMC5491894.
7. Pope MH, Panjabi M. Biomechanical definitions of spinal instability. Spine. 1985 Apr;10(3):255-6
8. Schwab F, Farcy JP, Bridwell K, Berven S, Glassman S, Harrast J, Horton W. A clinical impact classification of scoliosis in the adult. Spine. 2006, 31:2109-2114.
9. Schwab F, Ungar B , et al.  Scoliosis Research Society-Schwab adult spinal deformity classification: a validation study.  Spine.  2012, 20;37(12):1077-82.
10. Silva B, Rodrigues LP, Clemente FM, Cancela JM, Bezerra P. Association between motor competence and Functional Movement Screen scores. PeerJ. 2019,7:e7270.
11. Suwannarat P, Amatachaya P, Sooknuan T, Tochaeng P, Kramkrathok K, Thaweewannakij T, Manimmanakorn N, Amatachaya S.  Hyperkyphotic measures using distance from the wall: validity, reliability, and distance from the wall to indicate the risk for thoracic hyperkyphosis and vertebral fracture.  Archives of Osteoporosis.  2018, 13 (1): 25.  
12. Teyhen DS, Shaffer SW, Lorenson CL, Halfpap JP, Donofry DF, Walker MJ, Dugan JL, Childs JD. The Functional Movement Screen: a reliability study. J Orthop Sports Phys Ther. 2012 Jun;42(6):530-40. doi: 10.2519/jospt.2012.3838. Epub 2012 May 14. PMID: 22585621.
13. Terran J, Schwab F, Shaffrey CI, Smith JS, Devos P, Ames CP, Fu KM, Burton D, Hostin R, Klineberg E, Gupta M, Deviren V, Mundis G, Hart R, Bess S, Lafage V; International Spine Study Group. The SRS-Schwab adult spinal deformity classification: assessment and clinical correlations based on a prospective operative and nonoperative cohort. Neurosurgery. 2013 Oct;73(4):559-68.
14. Weinstein SL. Idiopathic scoliosis. Natural history. Spine (Phila Pa 1976). 1986 Oct;11(8):780-3. doi: 10.1097/00007632-198610000-00006. PMID: 3810292.