Scoliosis can be effectively treated in kids and teens without surgery; no curve should be ignored regardless of its size. Adolescent idiopathic scoliosis worsens rapidly with growth; however the pubertal growth spurt can be utilized to straighten the spine instead of allowing it to worsen the scoliosis. Comprehensive scoliosis treatment allows the child to stay in control of the scoliosis. By addressing the root cause of nerve tension, in combination with use of a brace and scoliosis exercises, curvatures can be treated successfully: not only preventing worsening of the curve BUT ALSO straightening the spine. Seizing this golden opportunity of the pubertal growth spurt has a drastic effect on treatment results.
12 Things Parents Need To Know About Their Child’s Scoliosis
1. Scoliosis Worsens With Growth: The faster a Child Grows, the Faster Scoliosis Worsens.
What Is Your Child’s Rate of Growth?
Idiopathic scoliosis is, at its root, a growth problem that progresses relative to the rate of growth. As a child’s body grows and develops, it undergoes periods of rapid growth commonly known as “growth spurts” which occur during puberty. It is during these growth spurts that curves worsen the fastest.
Research has shown that the more growing a child still has to do, the greater the chance their scoliosis will progress. Similarly, the younger a child is when scoliosis is first discovered, the greater their risk of progression as they still have much more to grow. It is important to note that the RATE of growth is of paramount importance: The more rapid the rate of growth (during the growth spurt), the more rapidly the scoliosis can progress. You can learn more about the relationship between rate of growth and scoliosis progression here.
0463-6. Also adapted from: Cousminer, Diana L et al. “Genome-wide association and longitudinalanalyses reveal genetic loci linking pubertal height growth, pubertal timing and childhood adiposity.” Human molecular genetics vol. 22,13 (2013): 2735-47
Notice that the peak rates of growth occur within a very small time frame of 1.5 – 2.5 years; this is the window of opportunity. This short time period is where most scoliosis cases are either won or lost. What actions you take during this time make all the difference for the rest of the life of your child’s spine.
The time when peak growth speed is reached varies from child to child and can be difficult to predict even when examining other indicators of going through puberty. Considering this, and knowing that adolescent idiopathic scoliosis progressing is linked to rapid growth, it is difficult to understand why any parent would wait to begin treatment to straighten their child’s spine. In fact, it has even been suggested that the peak rate of growth during puberty can be higher in children with scoliosis than those without.
The rapid growth of the adolescent growth spurt can be your worst enemy, but it also can be your best friend. Read on to discover how you can turn the adolescent growth spurt into your ally.
2. Scientific Research Contradicts "Watch and Wait" as a Safe Treatment.
Have you been recommended to watch and wait to see what happens to your child’s curve? Think about it: this really amounts to doing nothing to try to resolve the problem. You might be shocked to know that the scientific literature debunks the validity of this approach, and instead states that “early intervention comprising of physiotherapy and bracing can avoid surgery in most cases”. Which “Watch and Wait” group is your child in?
Kids with Cobb Angle between 10-25 degrees:
When curves are this small there is a golden opportunity to correct them down to under 10 degrees. You can view many of the curves we’ve treated that were in the 10-25 degree range, and see how quickly they reduce back down towards straight. A study published in the journal “Scoliosis” concluded that:
“Best results were obtained in 10-25 degrees scoliosis which is a good indication to start therapy before more structural changes within the spine establish.” (Białek 2011)
Kids with Cobb Angle between 25-50 degrees:
In 2013 a study was published comparing “watch and wait” to wearing a brace. Patients were randomly assigned to one of the two groups (with their permission). As the study progressed it became very obvious that almost ALL of the kids who actually wore their brace were staying straighter than kids who were receiving the “watch and wait” treatment.
The difference in outcome was so dramatic, that the ethics review board that had originally approved the study now stepped in to prematurely stop the study. It was determined to be unethical to prescribe “watch and wait” treatment to kids knowing that it would cause them harm.
“There are risks and costs to action. But they are far less than the long range risks of comfortable inaction.” – JFK
3. The Longer The Scoliosis Is Present, the More “Stuck” It Becomes.
There are two big changes that occur to the spine when it is left in a bent position for too long:
- Bones become asymmetric
- Ligaments and muscles become short and stiff (This is called a “Contracture”)
The combined effect of both these changes makes it very difficult to return a spine to straight. The best treatment for this is prevention: By treating scoliosis the moment it is discovered, changes to the shape of bones, muscles and ligaments can be prevented. If your child has a curve that has been there a while, or has grown large in size, then odds are you will have to contend with these challenges.
While surgeons will perform surgical “release” of soft tissue, there are non-surgical solutions to stiff “contractures” of the spine due to scoliosis, and as well to helping bones grow more symmetric again. We will cover these solutions later in this treatment section.
4. It Has Been PROVEN That Scoliosis Can Be Straightened Without Surgery.
There is a growing body of scientific literature and evidence supporting the fact that scoliosis CAN be straightened without the need for surgery; with early intervention utilizing bracing and physiotherapy preventing surgery. Yet many doctors and clinicians still prescribe antiquated and ineffective treatments. A disconnect exists between the beliefs of doctors versus what the published medical literature reveals.
A 2005 study conducted by the orthopaedic surgeon Dr. Mehta demonstrated that growth can be utilized as a corrective force, enabling a spine to grow straighter when held in a highly corrective brace. Dr. Mehta has published multiple scientific publications regarding treating scoliosis; providing evidence that growth can be utilized to not only prevent progression, but reduce the scoliosis curves.
beginning at 3 years, 7 months of age through 17 years, 6 months of age. Individual utilized bracing beginning at age 3 years, 7 months with brace being discarded after 2 years, 2 months of bracing.
A 2016 study by Dr. Berdishevsky et al. provided a thorough review of scientific literature regarding the use of scoliosis specific exercises (PSSE: physiotherapy scoliosis-specific exercises) for treatment of adolescent idiopathic scoliosis. Their review concluded that “evidence supporting the effectiveness of PSSE is growing, with more high quality research studies being published in recent years”; providing strong examples of scoliosis corrections being made non-surgically.
Our own clinical experience and observations at Scoliosis Care Centers also supports the scientific literature. For mild scoliosis curves of 10-24 degrees, we have prevented all patients from requiring surgery with an average curve reduction of 47%. For moderate scoliosis curves of 25-39 degrees, we have a 98% success rate for preventing surgery and an average curve reduction of 36%.
The take home message from the current scientific literature and our own clinical observations is that IT IS POSSIBLE to enable a scoliotic spine to grow straighter without surgery; or as Dr. Shakil eloquently put it:
“Early intervention with conservative treatment like physiotherapy and bracing can prevent surgery.”
5. The Sooner Treatment Begins, The Higher The Success Rate. The Later Treatment Begins, The Lower The Success Rate.
The ultimate goal for any scoliosis patient is to straighten the spine; whether or not this remains an option depends directly on how early treatment begins. The earlier the curve is discovered, and the earlier an appropriate (ie. NOT watch and wait) treatment begins, the greater the chance of success in guiding the spine to grow straight. Sadly, this does not happen often.
The adolescent growth spurt can quickly and exponentially worsen scoliosis curves; providing a small window of opportunity to act and guide the spine straight through a child’s pubescent growth spurt. If this opportunity is missed, the ability to straighten the spine when treating scoliosis is severely reduced; thus early detection and early intervention are key are directly related to treatment success.
This is the actual success rate curve taken directly from Scoliosis Care Centers’ own treatment database. For this graph success is defined as finishing with a curve less than 40 degrees (the surgical threshold).
The Early Treatment Group
Some cases begin treatment when their curves are small, such as 10º – 30º
100% Success Rate
for ALL patients in this group
The Crisis Treatment Group
Other cases which began treatment when their curves were 30º – 50º have a success rate that drops from:
100% down to 60%
The Late Treatment Group
Cases which began treatment when their curves were 50º – 80º have a success rate that drops from:
60% down to 0%
6. How To Predict Your Child's Scoliosis Will Worsen or Progress to Surgery
In general, the younger the child and the larger the scoliosis, the greater the risk for getting worse. Knowing if a child is still growing as well as where they are in their growth cycle (ie. how far along in their growth spurts) is critical in making treatment decisions for your child’s scoliosis. Determining a child’s Risser helps determine where they are in their growth, as well as their risk of progression.
The Risser sign (or Risser scale) assesses if the skeleton has completed growing and is mature by looking at the bones of the pelvis. As the skeleton matures, new bone ossifies along the ilium and is graded on a scale of 1 to 5; Risser 0 corresponds to an immature skeleton (a lot of growth left) while Risser 5 corresponds to full fusion of the bone and maturity.
You will find a calculator below that will estimate the likelihood that a curve will worsen, or progress. You can find a full version of this calculator that also includes your potential prognosis for treatment based on our own clinic results on our website as well. Additionally, thanks to new scientific research, we now can estimate scoliosis surgical risk (whether or not a curve will progress to 45 degrees or more and require surgery).
Along with Risser, the age of the child and how large their curve currently is can be plugged into a formula for predicting progression:
Scoliosis Progression Risk Calculator
Calculate your risk for progression by entering your cobb angle, risser sign, and age below. Your risk for progression (in percentage) is displayed after you click the “Calculate Progression Risk” button below. Please try our fully featured risk calculator which also provides realistic expectations for correction!
Your risk of progression (%) :
Understanding Risser Signs
As the body grows and the skeleton grows and matures, new bone is laid down (ossification). The Risser sign (or Risser scale) assesses if the skeleton has completed growing and is mature by looking at the bones of the pelvis. As the skeleton matures, new bone ossifies along the ilium and is graded on a scale of 1 to 5. A Risser scale of 0 corresponds to an immature skeleton of someone with a lot of growing left to do, and no ossification is observed along the ilium. As they go through puberty, new bone is laid down until they reach Risser 5, at which point all new bone has fused to the ilium and now appears as one solid bone.
The Risser can also be assessed using a hand X-ray, thus avoiding harmful radiation to the organs of young patients. If you are curious how that works, you can learn more here.
7. Many Doctors Do Not Make Eliminating Scoliosis the Treatment Goal
It is easy to assume that the goals set for a child or teen’s scoliosis treatment by the parents would align with those of the doctor. However, most doctors define success as preventing curve progression past 50º (preventing progression into surgical range). Based on this “defensive” treatment goal, what would a “successful” outcome look like? Conversely, what would success look like if we set a treatment goal of making the spine straighter?
Look at the defensive approach “success” above: Even though the patients 19º curve increased in size to 47º, this is considered a success by traditional treatment standards because it stayed below 50º. At Scoliosis Care Centers, success is defined as reaching the maximum potential for straightening the spine. For many cases, this can mean straightening the curve to less than 10 degrees.
Which of the 2 “success” cases above is likely to have the healthier spine in adulthood? Which one is more likely to suffer from pain or disability as a result of their scoliosis?
Many scoliosis braces and treatments are designed with the “status-quo” goal of “preventing progression to 50 degrees”; the braces prescribed are incapable of causing the spine to grow straighter. If a case grows worse, even by 30 degrees such as in the example above, the brace is considered successful because the curve did not exceed the surgical threshold of 50 degrees.
While avoiding surgery is a very good goal, isn’t setting the goal of reaching your fullest potential a more inspiring goal? Knowing that scoliosis can be effectively straightened without surgery, why not set higher, more ambitious treatment goals for our children? What would provide greater confidence of a healthy, happy adulthood?
The more ambitious the goal, the more proactive we must be in our detection and treatment approach; after all, the best defense is a good offense. For adolescent idiopathic scoliosis a good offense is not only stopping the curve from worsening, but treating to help the spine grow as straight as possible.
8. Things Your Doctor May Not Tell You About Scoliosis Surgery
Talk of scoliosis surgery can sometimes leave the impression that surgery will solve the problem, making the spine “normal” again. Unfortunately surgery is FAR more complicated and is NOT a “magic bullet” by any means. Scoliosis surgery consists of inserting rods fastened to the spine as well as spinal fusion; however, in order to fasten the rods to the spine, connective tissue and muscle must be removed, much of it permanently, by the surgeon. As you would imagine, removal of ligaments, muscle and connective tissue directly affect mobility, as does the fusion of vertebrae in the spine; so to call the spine “normal” post-op would be incorrect as you have already limited mobility.
If the patient is actively growing, the hardware sometimes must be adjusted as they grow, requiring multiple surgeries; additionally due to accidents or injury, damage to the hardware can occur (ie. a broken rod) requiring additional surgery with the possibility of further injury to the patient due to the damaged hardware. When you factor in potential complications from surgery (infection, paralysis, and even death), it is difficult to understand why surgery is considered for anyone other than highly severe cases.
Fun scoliosis surgery fact:
A scientific study was performed in 2016 which highlighted the large amount of force needed to overcome contractures, tight nerves, and other factors to allow the spine to be SURGICALLY straightened. The average amount of force applied to a segment of the spine during surgery was ~121 pounds, with a maximum of over 220 lbs of force. Why wait until the problem gets this bad when puberty provides its own corrective force which can be easily harnessed with the help of a brace?
9. A Tight Spinal Cord Limits the Surgeon’s Ability to Make A Scoliosis Straight
One orthopedic surgeon noted, “I could make every crooked spine perfectly straight if it wasn’t for the tight spinal cord!” What does the surgeon mean by this? In order to straighten a scoliosis, all resistance to being straightened must be overcome. Resistance from short, tight ligaments and asymmetric bones can be surgically cut out. However, the tight (short) spinal cord also prevents straightening of the scoliosis, and the spinal cord is one structure you don’t want to cut!
Straightening a scoliosis results in a longer and taller spinal canal, and the spinal cord which traverses this canal experiences a tension as the surgeon performs the straightening procedure. If the surgeon makes the spine “perfectly straight”, the increased length of the canal and the resultant elongation of the spinal cord has lead to paralysis is some kids.
Paralysis from over-straightening scoliosis had been a common problem in the earlier decades of scoliosis spinal fusion surgery. To remedy this, it has now become routine to monitor the spinal cord during surgery to assure that the spine is not made too long for the short spinal cord. This means the surgeons must limit their correction to the spine based on the tolerance of the short, tight spinal cord.
It seems well accepted among surgeons that the spinal cord IS short and tight. What is debated is the significance of this tight spinal cord. Since 1968 it has been hypothesized that the tight spinal cord may be the CAUSE of most “idiopathic” childhood scoliosis. When the tight spinal cord which drives many cases is ignored, it is like leaving a wildfire to burn unhindered. This wildfire will cause the spine to coil down into a tighter and tighter scoliosis as the child hits their pubertal growth spurt.
If a short, tight spinal cord limits how straight a surgeon can make a scoliosis, then shouldn’t it also limit non-surgical treatment? At Scoliosis Care Centers we are developing therapies for the short, tight spinal cord, to increase its flexibility and make it longer.. Developing ways to improve the flexibility of the spinal cord is like dumping water on the wildfire of scoliosis, allowing the brace and exercises a better chance to successfully accomplish their work.
10. A Brace Is the Only Tool Proven To Work For Curves Over 25 Degrees
Attempting to treat scoliosis curves over 25 degrees in kids without a brace is very risky. When things go wrong, the result can be a surgery, and lost opportunity to grow straight. If a spine is being held in a bent scoliosis position during growth, then it will solidify into that shape as an adult. Just like the sapling grows as it is directed, for a spine to grow straight it must be held straight 24/7. This is achieved only through bracing, and a brace is the only non-surgical treatment proven to straighten the spine.
Multiple recent scientific studies have confirmed this including the 2013 Weinstein et al. study; a 2005 study focusing on growth as a corrective force; as well as a 2017 study which went on to show that curvature reductions made utilizing a brace can be maintained over 15 years later; providing better long term outcomes than some surgical studies. It should also be reiterated that bracing has been shown to be effective when worn 24/7 or as close to this as possible so that the spine is correctly guided during growth and during daily weight bearing activities (ie. Walking, sitting).
What About “No Brace” Treatment For Kids over 25 Degrees?
“Braceless” Treatment programs for kids with curves over 25 degrees are dangerous. Beware of those promising a solution scoliosis that does not require a brace. The chances of failure are high… so don’t risk it.
What About Nighttime Only Bracing?
Merely bracing at night was shown to be no different than “watch and wait” in preventing progression to surgical range; this study also further substantiated the fact that children with Risser 0 and mild idiopathic scoliosis are at HIGH risk for progression to 25 degrees or greater.
As bracing has been shown to have “a strong positive association between the amount of time spent wearing the brace and the rate of success” as compared to observation-only, why gamble on simply watching and waiting for something bad to happen?
11. Successful Brace Treatment Depends on How Straight The Brace Makes the Spine
A study published by Clin et al in the Spine journal found that “immediate in-brace correction” could predict long-term outcome of brace treatment; it simply cannot be over-emphasized how important it is to get the spine straight in the brace when treating scoliosis!
The smaller the curve can become before adulthood, the less it will potentially progress in adulthood
A study observing over 100 patients over 40 years found that curves “less than 30 degrees at skeletal maturity tended not to progress regardless of curve pattern”; while those with 50-75 degree curves progressed the most after skeletal maturity. If in-brace correction is maximized, the degree to which the spine can grow straight will be maximized as well, allowing for greater short and long term treatment results.
12. Unreliable Predictors for Scoliosis Worsening
In addition to Risser and age being utilized to determine how far through puberty a child is, the age at which a girl has her first period (menarche) is also frequently used. However, assuming that because a girl has had her first period that she is “out of the woods” and does not need to worry about her curve progressing is a mistake commonly made in assessing scoliosis progression risk. This is incorrect simply because the presence of menses (starting your period) DOES NOT necessarily indicate that the peak rates of growth have passed.
While menarche has been associated with the peak rate of growth having passed, every individual is different with more recent studies suggesting development of secondary sex characteristics are a more accurate indication of puberty; and that girls may continue to grow after menarche. Additionally, patients with severe scoliosis (>50 Cobb angle) have been observed to have a delayed menarche (~6 months later) as compared to those with mild scoliosis (<30); suggesting additional variability in pubertal timing.
With this in mind as well as scoliosis being a growth problem, we can see that an individual’s true risk of progression depends on the size of their curve and their true skeletal maturity; as opposed to a single indicator of pubertal development.
Conclusion and Take Home Messages
Based on current scientific literature, it should be apparent to all those involved in treating scoliosis that inaction is one of the worst courses of action that can be taken; especially given the rapid growth rate encountered during the pubertal growth spurt. Yet ‘status quo’ treatment continues to neglect children with scoliosis until surgery seems to be the only option left. The myth that scoliosis surgery is the only viable option is a self-fulfilling prophecy. If one truly believes that nothing will help but surgery, then no real effort is made to alter the course of the scoliosis until surgery is needed.
In contrast, treatment which utilizes scoliosis specific exercises and wearing highly corrective braces can reliably prevent progression to surgical range. A study by Fusco et al makes several key points which serve as a great summary of the above points:
- Scoliosis can be more easily corrected when treatment begins PRIOR to puberty
- Treatment should be individualized to maximize results and benefit
- There is a high likelihood of scoliosis progression in younger patients
- Strong treatment should be utilized from the beginning instead of “watching and waiting”
- The pubertal growth spurt can greatly worsen scoliosis curves
- Bracing combined with scoliosis specific exercises can prevent surgery and curve progression
- Bracing and treatment should be continued until bone maturity (child has finished growing)
- Because childhood scoliosis has a serious potential to progress, “fearing” scoliosis from the beginning, with early treatment in childhood is a good course of action; allowing for entering puberty with the smallest curve possible in the event it still worsens during the growth spurt
Given this information, catching scoliosis and treating it early (early intervention) PRIOR to the explosive growth of puberty can correct the spine and PREVENT progression; severe scoliosis; and all of its long-term troubles. This prepubescent window of opportunity is the CRITICAL time to intervene and treat early signs of scoliosis before it gets a chance to progress. While the adolescent growth spurt is one of the biggest threats to scoliosis progressing, it can be utilized as an ally and as a corrective force to allow the spine to grow straighter.
Scoliosis Care Centers Treatment Success Rate
Scoliosis Curves Ranging 10º – 25º
100% Avoidance of Surgical Need
Scoliosis Curves Ranging 25º – 39º
98% Avoidance of Surgical Need
A Brief Afterword About "Curing" Scoliosis
CAN YOU CURE SCOLIOSIS IN CHILDREN?
If you knew that the CAUSE of your child’s scoliosis could be identified, and then completely eliminated, would you want this treatment for your child? If you knew there was a way to successfully straighten you child’s spine without surgery, but it required more work, would you do it? For a surprising number of children, it is now becoming possible not only to identify the cause of the curve, but also to provide a treatment that will result in the elimination of the scoliosis.
By identifying the underlying cause of a curve, we can then treat it, and ideally finish with a curve under 10 degrees (which is no longer considered scoliosis). If a curve is reduced to less than 10 degrees it now no longer meets the medical criteria for scoliosis, and the treatment outcome now becomes very close to resembling a cure.
It is important to understand though that for very large curves, such as an 80 degree structural scoliosis, even surgery cannot make the spine completely straight due to “stiffness” of the spine from contracture and structural changes. However, small curves (10-35 degrees) which are detected early and treated early have been able to now grow straighter without the need for surgery.
By detecting and treating curves early when a child is still skeletally immature, continuing treatment through the end of growth and skeletal maturity, and gradually weaning off the brace while strengthening supporting muscles, we can match the results of surgery and come closer than ever to a “cure” for scoliosis.
If you would like to read more on a variety of educational topics related to scoliosis treatment; scoliosis exercises; kyphosis; scoliosis spinal surgery; how many hours a day your scoliosis brace should be worn; and more, please be sure to check out our educational blog!
1. Aulisa, Angelo G.; Guzzanti, Vincenzo; Falciglia, Francesco; Galli, Marco; Pizzetti, Paolo; Aulisa, Lorenzo (2017): Curve progression after long-term brace treatment in adolescent idiopathic scoliosis. Comparative results between over and under 30 Cobb degrees – SOSORT 2017 award winner. In Scoliosis and spinal disorders 12, p. 36. DOI: 10.1186/s13013-017-0142-y.
2. Berdishevsky, Hagit; Lebel, Victoria Ashley; Bettany-Saltikov, Josette; Rigo, Manuel; Lebel, Andrea; Hennes, Axel et al. (2016): Physiotherapy scoliosis-specific exercises – a comprehensive review of seven major schools. In Scoliosis and spinal disorders 11, p. 20. DOI: 10.1186/s13013-016-0076-9.
3. Białek, Marianna (2011): Conservative treatment of idiopathic scoliosis according to FITS concept. Presentation of the method and preliminary, short term radiological and clinical results based on SOSORT and SRS criteria. In Scoliosis 6, p. 25. DOI: 10.1186/1748-7161-6-25.
4. Charles, Yann Philippe; Daures, Jean-Pierre; Rosa, Vincenzo de; Diméglio, Alain (2006): Progression risk of idiopathic juvenile scoliosis during pubertal growth. In Spine 31 (17), pp. 1933–1942. DOI: 10.1097/01.brs.0000229230.68870.97.
5. Chidambaran, V.; Ding, L.; Moore, D. L.; Spruance, K.; Cudilo, E. M.; Pilipenko, V. et al. (2017): Predicting the pain continuum after adolescent idiopathic scoliosis surgery. A prospective cohort study. In European journal of pain (London, England) 21 (7), pp. 1252–1265. DOI: 10.1002/ejp.1025.
6. Clin, Julien; Aubin, Carl-Éric; Sangole, Archana; Labelle, Hubert; Parent, Stefan (2010): Correlation between immediate in-brace correction and biomechanical effectiveness of brace treatment in adolescent idiopathic scoliosis. In Spine 35 (18), pp. 1706–1713. DOI: 10.1097/BRS.0b013e3181cb46f6.
7. Cousminer, Diana L.; Berry, Diane J.; Timpson, Nicholas J.; Ang, Wei; Thiering, Elisabeth; Byrne, Enda M. et al. (2013): Genome-wide association and longitudinal analyses reveal genetic loci linking pubertal height growth, pubertal timing and childhood adiposity. In Human molecular genetics 22 (13), pp. 2735–2747. DOI: 10.1093/hmg/ddt104.
8. Fairhurst, H.; Little, J. P.; Adam, C. J. (2016): Intra-operative measurement of applied forces during anterior scoliosis correction. In Clinical biomechanics (Bristol, Avon) 40, pp. 68–73. DOI: 10.1016/j.clinbiomech.2016.10.014.
9. Fusco, Claudia; Donzelli, Sabrina; Lusini, Monia; Salvatore, Minnella; Zaina, Fabio; Negrini, Stefano (2014): Low rate of surgery in juvenile idiopathic scoliosis treated with a complete and tailored conservative approach. End-growth results from a retrospective cohort. In Scoliosis 9, p. 12. DOI: 10.1186/1748-7161-9-12.
10. Granados, Andrea; Gebremariam, Achamyeleh; Lee, Joyce M. (2015): Relationship Between Timing of Peak Height Velocity and Pubertal Staging in Boys and Girls. In Journal of clinical research in pediatric endocrinology 7 (3), pp. 235–237. DOI: 10.4274/jcrpe.2007.
11. Hung, Alec L. H.; Chau, W. W.; Shi, B.; Chow, Simon K.; Yu, Fiona Y. P.; Lam, T. P. et al. (2017): Thumb Ossification Composite Index (TOCI) for Predicting Peripubertal Skeletal Maturity and Peak Height Velocity in Idiopathic Scoliosis. A Validation Study of Premenarchal Girls with Adolescent Idiopathic Scoliosis Followed Longitudinally Until Skeletal Maturity. In The Journal of bone and joint surgery. American volume 99 (17), pp. 1438–1446. DOI: 10.2106/JBJS.16.01078.
12. Janusz, Piotr; Kotwicka, Malgorzata; Andrusiewicz, Miroslaw; Czaprowski, Dariusz; Czubak, Jaroslaw; Kotwicki, Tomasz (2014): Estrogen receptors genes polymorphisms and age at menarche in idiopathic scoliosis. In BMC musculoskeletal disorders 15, p. 383. DOI: 10.1186/1471-2474-15-383.
13. Loncar-Dusek, M.; Pećina, M.; Prebeg, Z. (1991): A longitudinal study of growth velocity and development of secondary gender characteristics versus onset of idiopathic scoliosis. In Clinical Orthopaedics and Related Research (270), pp. 278–282.
14. Lonstein, J. E.; Carlson, J. M. (1984): The prediction of curve progression in untreated idiopathic scoliosis during growth. In The Journal of bone and joint surgery. American volume 66 (7), pp. 1061–1071.
15. Mehta, M. H. (2005): Growth as a corrective force in the early treatment of progressive infantile scoliosis. In The Journal of bone and joint surgery. British volume 87 (9), pp. 1237–1247. DOI: 10.1302/0301-620X.87B9.16124.
16. Nachemson, A. L.; Peterson, L. E. (1995): Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. A prospective, controlled study based on data from the Brace Study of the Scoliosis Research Society. In The Journal of bone and joint surgery. American volume 77 (6), pp. 815–822.
17. Nakamoto, J. M. (2000): Myths and variations in normal pubertal development. In The Western journal of medicine 172 (3), pp. 182–185. DOI: 10.1136/ewjm.172.3.182.
18. Roth, M. (1968): Idiopathic scoliosis caused by a short spinal cord. In Acta radiologica: diagnosis 7 (3), pp. 257–271.
19. Shakil, Halima; Iqbal, Zaheen A.; Al-Ghadir, Ahmad H. (2014): Scoliosis. Review of types of curves, etiological theories and conservative treatment. In Journal of back and musculoskeletal rehabilitation 27 (2), pp. 111–115. DOI: 10.3233/BMR-130438.
20. Utiger, R. D. (1992): Melatonin–the hormone of darkness. In The New England journal of medicine 327 (19), pp. 1377–1379. DOI: 10.1056/NEJM199211053271909.
21. Weinstein, S. L.; Ponseti, I. V. (1983): Curve progression in idiopathic scoliosis. In The Journal of bone and joint surgery. American volume 65 (4), pp. 447–455.
22. Weinstein, Stuart L.; Dolan, Lori A.; Wright, James G.; Dobbs, Matthew B. (2013): Effects of bracing in adolescents with idiopathic scoliosis. In The New England journal of medicine 369 (16), pp. 1512–1521. DOI: 10.1056/NEJMoa1307337.
23. Wiemann, John M.; Shah, Suken A.; Price, Charles T. (2014): Nighttime bracing versus observation for early adolescent idiopathic scoliosis. In Journal of pediatric orthopedics 34 (6), pp. 603–606. DOI: 10.1097/BPO.0000000000000221.