Idiopathic Scoliosis

• Use culturally safe, trauma- and violence-informed care. Explain why questions matter, seek permission before sensitive topics, and adapt communication to the patient’s age, language, identity, culture, disability and previous health care experiences (Public Health Agency of Canada 2018).
• Sociodemographic information: age, sex, gender identity, language, living arrangement, school or occupation, caregiving responsibilities, health literacy, supports and communication or access needs. For adolescents, involve the young person directly and include a parent or caregiver according to consent, capacity and preference.

Primary concerns

• Onset and curve history: when and by whom spinal or trunk asymmetry was first noticed; known curve location, direction and Cobb angle; age at diagnosis; prior comparison measurements; change in posture, clothing fit or appearance; and the person’s understanding of whether the curve is idiopathic.
• Growth and skeletal maturity: recent height change or growth spurt; pubertal development; age at menarche and time since menarche when relevant; available skeletal maturity information; and whether growth or curve monitoring is underway.
• Symptoms and course: back, chest wall, neck, buttock or leg pain; night or rest pain; headache; numbness, tingling, weakness, altered coordination or gait; bladder, bowel, sexual or saddle sensory change; breathlessness, exercise intolerance or chest symptoms; fever, weight change, fatigue and whether symptoms or asymmetry are stable, improving or worsening.
• Baseline and current functioning: mobility, sitting and standing tolerance, sleep, self-care, school, work, caregiving, lifting and carrying, physical activity, sport, recreation, social participation and assistance or adaptations needed.
• Body image and emotional impact: concerns about appearance, clothing, photographs, examination, brace visibility, stigma, confidence, mood, anxiety, social participation and the effect on identity or relationships. Ask without assuming that appearance is a concern.
• Body systems review: neurological; musculoskeletal, including the neck, chest wall, hips and lower limbs; cardiovascular and respiratory; skin; genitourinary and gastrointestinal; endocrine, metabolic and nutritional; vision and hearing; sleep; cognition; and mood symptoms that may affect diagnosis, safety, growth or care.
• Health, lifestyle and family history: scoliosis or spinal deformity in relatives; congenital, neurological, muscular, connective-tissue, inflammatory, bone-health or developmental conditions; cancer, infection or immunosuppression; fracture or significant trauma; previous surgery or hospitalization; medicines, including corticosteroids; nutrition; physical activity; sleep; tobacco, alcohol or substance use when relevant; and general health behaviours.
• Previous assessment and care: prior screening, clinical measures, radiographs or magnetic resonance imaging; orthopaedic, paediatric, neurological, respiratory, orthotic or rehabilitation care; observation, scoliosis-specific or general exercise, bracing, symptom-relieving care or medicines; response, burden, adverse effects and reasons care changed or stopped.
• Brace history when relevant: brace type, prescribed schedule, fit and recent adjustment; skin or breathing concerns; pain, numbness or weakness while wearing it; ability to manage clothing, hygiene, school, sleep and activity; actual wear pattern; and access to orthotic and scoliosis-team review.
• Social determinants of health: housing, income, food security, discrimination, social support, caregiver strain, school or workplace flexibility, transportation, digital access and availability or affordability of specialty care, imaging, bracing and rehabilitation (Public Health Agency of Canada 2026).
• Patient and family perspective: priorities, goals, preferences, cultural context, acceptable burden, confidence, concerns, expectations and previous experiences of care. Clarify whether the current priority is curve monitoring, symptoms, activity, brace management, appearance, participation or another concern.
• Flag review: check Red Flags and refer to the separate fixed Orange Flags and Yellow Flags modules when relevant.

Outcome measures

• Use a small outcome set that reflects the person’s age, presentation and goals and can be repeated safely. Clinical curve monitoring and patient-reported outcomes answer different questions; one does not replace the other.
• Patient-specific functioning: Patient-Specific Functional Scale (PSFS).
• Disability and participation: WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) when age and setting are suitable.
• Quality of life: WHOQOL-BREF for adults when it fits the clinical question.
• Scoliosis-specific health-related quality of life: the Scoliosis Research Society-22r (SRS-22r) is validated from age 10 and is suitable for adults.
• Symptoms and clinical findings: a consistent pain rating; angle of trunk rotation, height and relevant neurological, respiratory, movement or activity findings; brace wear and skin findings; and the latest specialist Cobb angle when these will guide care. Record the method and source so repeated values are comparable.
• Individual goals: agree on patient-defined goals and how progress will be recognized. SMART wording may be used when helpful.

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

• Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
• Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
• Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

• Suicide or self-harm thoughts: thoughts without immediate danger.
• Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
• Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

• Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
• Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
• Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
• Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

• Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
• Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
• Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
• Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
• Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
• Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

• Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
• Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
• Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
• Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
• Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.

Select examination elements that answer a clinical question or may change care. Adapt the examination to age, development, presentation, comfort, consent, abilities and prior specialist findings.

• Consent, privacy and communication: explain the purpose of viewing the back and trunk, provide choices about clothing, draping, positioning, caregiver presence and photographs, and confirm ongoing consent. Avoid comments that increase shame or imply that asymmetry defines the person.
• General observation and growth: general health, distress, height and change from prior measurements when available, body proportions, pubertal or skeletal maturity information already documented, standing tolerance and signs of systemic illness.
• Standing alignment: observe from the front, back and side for head position, shoulder and scapular height, waist and trunk asymmetry, rib cage prominence, trunk shift, pelvic height or obliquity and sagittal alignment. Note whether asymmetry changes with stance or correction of an apparent leg-length difference.
• Adams forward bend test: observe thoracic rib and lumbar prominence with the person bending forward. Use a scoliometer to record angle of trunk rotation when it may change referral or monitoring, using the same position and method for comparison.
• Gait, balance and functional tasks: walking pattern, heel and toe walking when appropriate, balance, sit-to-stand, stairs and patient-prioritized school, work, caregiving, sport or daily tasks.
• Neurological examination: relevant upper- and lower-limb motor, sensory and reflex findings; gait and coordination; upper motor neuron findings such as hyperreflexia, clonus or an extensor plantar response; lower motor neuron findings such as focal weakness, reduced reflexes, wasting or fasciculation; and abdominal reflex symmetry when a neural-axis disorder is plausible.
• Spinal and regional movement: active cervical, thoracic and lumbar movement as needed, noting asymmetry, restriction, pain and movement strategy. Examine the hips, lower limbs, apparent or structural leg-length difference and other regions when they may explain a functional curve or affect activity.
• Strength, endurance and breathing: trunk and limb performance through age-appropriate functional or resisted tasks, breathing pattern, chest expansion and exercise response when symptoms or curve severity raise concern.
• Skin and morphology: midline dimples, pits, hairy patches or vascular lesions; café-au-lait spots; unusual bruising; foot deformity; marked hypermobility or contracture; muscle bulk; and other findings that may suggest a congenital, neurological, connective-tissue or syndromic cause.
• Pain assessment: location, intensity, irritability and relationship to posture, movement, activity, sleep and growth; spinal or rib tenderness; and whether pain is proportionate to the mechanical findings or points to another diagnosis.
• Brace assessment when relevant: confirm the specialist and orthotic plan. Check comfort, skin, breathing, movement, neurological symptoms, clothing and daily-task effects, and whether fit or wear has changed with growth. Orthotic adjustment remains with the appropriate brace provider.
• Imaging: review available standing whole-spine radiographs, Cobb measurements and growth information when relevant. Standing whole-spine radiography can confirm suspected adolescent idiopathic scoliosis and inform specialty planning. Magnetic resonance imaging is not routine for a typical adolescent presentation but may be part of medical assessment for early onset, rapid progression, functionally disruptive pain, neurological findings or an atypical curve. Avoid duplicate imaging and coordinate timing with the responsible medical or scoliosis team (American College of Radiology 2018).
• Repeat and adapt: repeat focused measures using the same method when they may change the working presentation, referral, brace review or care. A clinical surface measure does not substitute for a medically interpreted Cobb angle.

Working clinical presentations

These presentations can overlap or change. Use them to organize assessment and care, not as fixed stages or substitutes for medical diagnosis or radiographic classification.

• Suspected spinal asymmetry without radiographic confirmation: shoulder, scapular, waist, rib, lumbar or pelvic asymmetry is present, but scoliosis has not been confirmed and positional, leg-length, pain-related or other contributors remain possible.
• Adolescent idiopathic scoliosis during growth under observation: a medically confirmed idiopathic curve is being monitored, no current brace or surgical plan is in place, and clinical care focuses on participation, symptoms, repeated outcomes and coordination with the monitoring team (Scoliosis Research Society n.d.-c).
• Adolescent idiopathic scoliosis during growth with bracing: a scoliosis-specialty team has identified progression risk and prescribed a brace, with rehabilitation needs related to exercise, activity, comfort, skin, confidence, daily routines and adherence to the shared plan (Negrini et al. 2018; Scoliosis Research Society n.d.-a).
• Skeletally mature idiopathic scoliosis with few symptoms: the curve and health are stable, daily activities are not materially limited, and the main needs are information, physical activity, self-monitoring and appropriate medical follow-up.
• Adult idiopathic scoliosis with pain or activity limitations: a longstanding idiopathic curve is accompanied by back or leg symptoms, reduced walking or activity tolerance, deconditioning, balance concerns or participation limits, without current serious neurological or systemic findings (NHS n.d.-a).
• Body-image, confidence or participation concerns: appearance, brace wear, stigma, fear, mood or social context has a meaningful effect on school, work, relationships, sport or care, with or without substantial pain.
• Presentation outside routine idiopathic scoliosis care: early-onset, congenital, neuromuscular, syndromic or adult degenerative scoliosis; previous scoliosis surgery; rapid progression; serious neurological, respiratory or systemic findings; or another diagnosis requires the relevant medical, paediatric, spinal deformity or postoperative pathway.

Base care on the working presentation, medical and scoliosis-specialty plan, growth, safety, symptoms, goals, context and response. Develop the plan with the patient and family when relevant, and repeat meaningful outcomes to guide change.

Education, self-management and participation

• Understanding scoliosis: clear information can cover the three-dimensional deformity, the difference between spinal asymmetry and radiographic scoliosis, the role of growth and observed change, limits of individual prediction, current monitoring plan and warning signs in Red Flags (Scoliosis Research Society n.d.-c).
• Daily life and goals: care can address sleep, school or workplace setup, clothing, carrying, caregiving, activity pacing and practical ways to participate without making posture or appearance the sole focus. Difficulty following a plan may reflect comfort, access, family demands, stigma or competing priorities rather than poor motivation.

Medical and scoliosis-specialty coordination

• Curve monitoring and referral: the responsible medical or scoliosis team determines whether and when radiography, skeletal maturity assessment, orthopaedic review, bracing or surgical discussion is needed. Clinical appearance, scoliometer readings and symptoms can inform referral but do not replace radiographic measurement or specialty decision-making (American College of Radiology 2018; Scoliosis Research Society n.d.-c).
• Shared records: record the source and date of Cobb measurements, growth information, brace plan and specialty advice. Coordinate rather than duplicate imaging or provide a conflicting progression schedule.

Bracing during growth

• Brace care: bracing can reduce progression risk for selected growing adolescents and is delivered through a scoliosis-specialty and orthotic program. Brace type, wear schedule, fit, skin care, exercise and review reflect growth, curve characteristics, response, tolerance and the specialist plan (Negrini et al. 2018; Scoliosis Research Society n.d.-a).
• Rehabilitation during bracing: options include movement and exercise in and out of the brace as directed, breathing practice, activity and sport planning, skin and comfort strategies, dressing and school routines, confidence support and prompt orthotic review for pressure injury, breathing difficulty, neurological symptoms or loss of fit.

Physical activity and exercise

• General physical activity and sport: usual physical activity, school physical education and sport can continue around interests, symptoms, abilities and specialist restrictions. Activity supports health and participation but is not presented as a way to correct a structural curve or replace indicated monitoring or bracing (NHS n.d.-b; Scoliosis Research Society n.d.-c).
• Physiotherapeutic scoliosis-specific exercise during growth: scoliosis-specific postural correction, breathing, movement and functional practice can form part of care when delivered by a clinician with relevant training and coordinated with observation or bracing. The method and dose reflect the curve, growth, goals, tolerance and available expertise; evidence does not establish one program for every adolescent (Romano et al. 2024; Negrini et al. 2018).
• Symptom-focused exercise for adults: general or individualized strength, mobility, aerobic, balance and functional exercise can target pain, capacity and participation. Exercise is not expected to reverse a mature structural curve (NHS n.d.-a).

Hands-on and symptom-relieving care

• Hands-on care: gentle mobilization, soft-tissue care and other symptom-relieving approaches can be used as adjuncts when they help a specific pain, movement or activity goal. They do not replace active care, curve monitoring or bracing and are not presented as methods to correct the curve or prevent progression.
• Comfort strategies: positioning, heat or cold, pacing and short-term activity modification can be used for symptom relief when acceptable and safe. Persistent, severe, night or disproportionate pain follows Red Flags rather than routine symptom management.

Psychological, social and interdisciplinary support

• Body image and confidence: respectful education, choice about examination and photographs, practical brace strategies, peer or family support and access to counselling can address distress, stigma, self-consciousness or participation concerns without assuming dissatisfaction with appearance.
• Interdisciplinary care: primary care, paediatrics, orthopaedics or spinal deformity services, orthotics, physiotherapy, chiropractic care, occupational therapy, respiratory care, psychology, school health and social services can be coordinated around diagnosis, progression risk, symptoms, brace needs, participation and access.

Medication coordination

• Pain medicines: coordinate with an authorized prescriber or pharmacist when pain limits sleep or activity, medicines cause adverse effects or questions arise about safe use. Medicine changes remain within the appropriate provider’s scope.

Approaches not used routinely

• Stand-alone passive care or generic posture correction: manual therapy, massage, traction, passive modalities or generic posture instruction do not replace observation, specialty review, indicated bracing, physical activity and active rehabilitation, and are not described as ways to halt progression or correct a structural curve.
• Uncoordinated brace or imaging plans: a brace is not initiated or altered outside the responsible scoliosis and orthotic program, and radiographs are not repeated solely because conservative care is underway.

Monitoring and reassessment

• Agree on a reassessment point based on age, growth, presentation, safety, goals, care being tried, the scoliosis-team plan, patient and family needs and access rather than a routine visit schedule.
• Repeat the small outcome set recorded at baseline and review pain, neurological and respiratory findings, height and angle of trunk rotation when relevant, brace fit and burden, physical activity, functioning, participation, benefits, harms and progress toward patient-defined goals.
• Continue what is useful and acceptable; adapt or stop what is not; and revisit the working presentation, Red Flags, medical or scoliosis-specialty plan, imaging coordination or shared care when growth, symptoms, clinical asymmetry or repeated outcomes change.

• Expected course: many adolescents with idiopathic scoliosis have few symptoms, and not every curve progresses. Progression is more likely during rapid growth and usually slows after skeletal maturity, although larger curves can continue to change in adulthood. Adult pain, neurological symptoms and activity limitations vary and do not follow directly from one Cobb measurement (Scoliosis Research Society n.d.-c; NHS n.d.-a).
• Factors associated with a less favourable course: more remaining growth, a larger curve, documented progression and some thoracic curve patterns are associated with greater progression risk during adolescence. Atypical neurological, respiratory or systemic findings, severe or persistent pain, missed specialty follow-up, poor brace fit or tolerance and barriers to care may also complicate the course. These are group-level patterns and do not determine an individual’s outcome (Negrini et al. 2018; Scoliosis Research Society n.d.-c).
• Potential supports for recovery: timely assessment during growth, continuity with the responsible medical and scoliosis team, an acceptable brace plan when indicated, appropriate physical activity and exercise, symptom management, confidence and body-image support, family and school or workplace flexibility and access to follow-up may support health and participation (Negrini et al. 2018; Romano et al. 2024).
• Discussing prognosis: explain what is known about the person’s age, growth, curve and observed course without promising that a curve will or will not progress. Separate curve-related prognosis from pain and participation, discuss uncertainty plainly, and update the outlook when growth, imaging, symptoms, repeated outcomes or the specialty plan changes.