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Information about etiology of the so-called idiopathic scoliosis. (Adolescent Idiopathic Scoliosis (AIS))[1-42] (Figures 1-3) and about “back pain.” In the years 1984-1995, in examination of many childrenin 2020 the total number of patients has reached 2500, it was found that “ idiopathic scoliosis ” is connected with the asymmetrical movement of hips and next with function-permanent “standing ‘at ease’ on the right leg” and “gait.” The limitation of adduction of the right hip, or even abduction contracture of this joint 5 to 10 degree is one of the symptoms of “ The Syndrome of Contractures and Deformities” [SofCD] according to Prof. Hans Mau from Tübingen, Germany [35,36] and Lublin observations [8-31]. In the diagnosis, the checking of hips movement is crucial. The examination of hips movement should be in the straight position of these joints-and it is similar to the “standing position” or to the “stance phase in walking.” The etiology of scoliosis is strictly biomechanical and development of spine deformity is through function-“standing” and “gait” (Figures 1-3). The standing on the right leg is permanent and once started at the age of two, lasts throughout the lifetime. So, the “cumulative time” of standing on the right leg is the cause of scoliosis and in adults the cause of “spine pain syndromes” (Figures 4, 5a, 5b, 6a, 6b) and in many cases of “arthrosis of the right hip” [21,23,25,30].

Figure 1: Three groups and four types of scoliosis. In the picture three (3) cases (A) (B) (C ) of “S” scoliosis in 1st epg. Causative influence: gait & standing. In case (B)-iatrogenic deformity, wrong exercises 5 years. In case (C ) beginning of degenerate changes. If scoliosis is not proper treated in childhood -is the cause of deformity and back pain in adults.

Figure 2: Three groups and four types of scoliosis. In the picture 4 cases of “C” and “S” scoliosis in 2nd/A/B epg. Causative influence: only standing ‘ at ease ’ on the right leg. In case (B) and (C) additionally laxity of joints and in result “S” scoliosis. If scoliosis is not proper treated in childhood-is the cause of back pain in adults.

Figure 3: Three groups and four types of scoliosis. In the picture 3 cases of “I” scoliosis in 3rd epg. Causative influence: only gait. The properties of such type of deformity is stiffness, without or with small curves. If scoliosis is not proper treated in childhood-is the cause of back pain in adults. Stiffness of spine is frequently cause of spine pain but diagnosed by doctors rare.

Figure 4: Patient at the age of 62. Degenerative scoliosis “S” in 2nd/B epg as a result of standing ‘at ease’ on the right leg since the childhood. Permanent pain with radiation to the left leg. Therapy-standing only on the left leg or in a special position, resting and sleeping in embryo position. Massages. Chair extension (see Figure 7).

Figure 5: (a,b) Girl, 13 years old. Example of anterior tilt of pelvis as a result of flexion contracture of the hips. Sacral bone in horizontal position, hiperlordosis of lumbar spine in clinical test & on X-ray. Deformity not treated in childhood-back pain in adult age.

Figure 6: (a,b) Patient 60 years old. Example of scoliosis “I” in 3rd epg. Spine without curves but totally stiff. Oblique position of os sacrum. Deformity not treated in childhood. Now back pain in every day situation.

Additional causes in development of scoliosis in children and back pain syndromes in adults [19,22-25]. In many children or adults with scoliosis we can see “neurological symptoms” and there are typical for the Minimal Brain Dysfunctions (MBD). These neurological disorders are mostly caused by complicated or pathological pregnancies and problems in delivery. During examination of children and adults suffering from scoliosis and back pain such anamnesis was constantly presented. The neurological disorders are:

Anterior tilt of pelvis and hiperlordosis of lumbar spine (Figures 5a and 5b), because of flexion contracture of hips flexors. In such situation the stability between pelvis and spine is diminished-it enables an easy development of scoliosis and next back pain,

Extension contracture of the trunk’s muscles as typical symptom of MBD-here we should remember that in “S” scoliosis in 1st epg group/ type and in “I” scoliosis in 3rd epg group/type-the spine is stiff in “ extension position ” and this symptom is typical for all scoliosis patients (Figures 6a and 6b). Stiffness of spine is one of many causes of back pains.

Laxity of joints-facilitates the development of scoliosis and is an important cause of back pain.

New classification of so-called idiopathic scoliosis [8-30,42] (Figures 1-3).

The type of spine deformity is connected with “model of hips movement” and etiological factors-“gait” and “standing ‘at ease’ on the right leg.”

Scoliosis 3D-“S” 1st etiopathological group (epg)-double curve. Stiff spine. Rib hump on the right side of the thorax. Connection with “gait” and permanent “standing ‘at ease’ on the right leg.” Mostly-rapid progression. This type of scoliosis “as example of the spine deformity” is described in orthopedic articles and in Internet.

Scoliosis 1D or 2D-“C” 2nd/A epg-one curve-lumbar left convex. Connected with permanent standing at ease on the right leg. In many orthopedic articles this type of scoliosis is mostly described “as paresis/ paretical scoliosis.”

Scoliosis 2D or 3D “S” 2nd/B epg-two curves. Connection with permanent standing ‘at ease’ on the right leg and additionally with laxity of joints or/and previous, harmful exercises. In older people the standing on the right leg is the cause of degenerative scoliosis and heavy back pain syndrome (Figure 4).

Scoliosis 2D or 3D-“I” 3rd epg Deformity has the form of a stiff spine. No curves or small ones. The only cause is gait. Clinical symptoms are “stiffness of the spine in children” and “pain syndromes in adults (Figure 6a and 6b). Till 2004 this type of spine deformity was no described as “scoliosis.”

Problems of back pain in context of scoliosis on material from 1984. In our orthopedic experience -the problem of back pain is connected mostly with abnormalities of spine anatomy-therefore we describe in article two causes-hiperlordosis of lumbar spine and scoliosis “C” and “ S ” in 2ndetiopathological group and type (epg) in Lublin classification. Back pain syndrome can appear also if the spine is stiff. Such symptoms are typical for “I” scoliosis in 3rd epg group/type in new Lublin classification. Other causes are connected with the anatomical anomalies such as spondylolisis and spondylolisthesis. Since 1984 we have gathered a material containing 2500 patients, adults but also young people treated in Pediatric Orthopedic and Rehabilitation Department in Medical University in Lublin, Poland in years 1995-2009 (in these years Prof. T. Karski was the Head if the Department). In all orthopedic, neurology or another departments in many hospitals we should remember about necessity of differential diagnosis-the “back pain syndromes” can be connected with above described “orthopedic spine disorders”-scoliosis or only stiffness of spine and not as the symptoms of neurology or oncology diseases.

Proper therapy of scoliosis and back pain. In the first plan-is very important to make proper, differential diagnosis to determinate “the causes of illness and correct diagnosis”. In therapy of scoliosis in children-flexion stretching exercises for hips are very important especially for right hip, for spine to cure the “contracture”-shortenings of soft tissues-muscles, fascias, tendons, capsules of the hips and spine joints. The aim of such therapy is-obtaining full, symmetrical movement of hips and spine what is essential for a correct development of spine. All these exercises are similar or the same as the ones in karate, taekwondo, aikido, kung fu or yoga. Here I would like to inform that flexion exercises in the treatment of scoliosis in Poland (1960-1970) were introduced by Prof. Stefan Malawski from Warsaw/Otwock [31-34] and with T. Karski personal discussions). Such early therapy in children we can see as “important prophylaxis program against “syndrome of back pain” in adults.

For patients with back pain we advise the resting and sleeping in embryo position, chair extension (Figures 7 and 8) to relieve the neuro-roots, exercises in warm water-especially in geothermal water and of course, in serious cases, adequate analgesics. It is extremely important to avoid standing on the right leg by all neurological and other patients groups. In many cases standing on the left or in special “therapeutically position” in abduction 20-30 degree and in internal rotation 20 degree is very beneficial, at once diminishing the pain.

Figure 7: Patient 22 year old. Anterior tilt of pelvis. Scoliosis “C” (2/A epg). Spondylolisthesis L5-S1. Pain with radiation to the left leg.

Figure 8: Patient 60 year old. Scoliosis lumbar left convex-in new classification-“C” scoliosis 2nd epg. Back pain syndrome from 10 years.

Treatment: Chair extension for the spine. The methods of therapy author (T. Karski) learned in Germany in 1968 in Orthopedic Department in Leipzig (in German: Perlsches Brett Behandlung). The extension therapy needs long time be realized-many days or weeks. Additionally exercises in geothermal water and special method of standing – in abduction and internal rotation.

Discussion to the problem of scoliosis and back pain

All old conceptions of etiology of “idiopathic scoliosis” [1,2,31,37-41] were never confirmed. The etiology of idiopathic scoliosis which deformity we called now “So-called Idiopathic Scoliosis” was described in 1995-2007.

In our opinion the “back pain syndromes” occur in the following cases and in scoliosis cases particularly:

Hiperlordosis of lumbar spine-because of “pressure syndromes” to nerve roots,

Scoliosis in the new classification “C” and “S” in 2ndA/B groupbecause of “presses on nerve roots” on concave site of curve or because of pulling on nerve root on convex side of spine,

Stiffness of the spine-in scoliosis “I” in 3 rd group in the new classification, because of “lost of movement of spine,”

Spondylolisthesis,

Back pain can be also as a symptom of various neurological or other illnesses.

Here I would like to explain that the cause of pain is situated in many places in the spine and surgery in such situation is not a proper method of therapy. According to our opinion-the proper method of treatment is only physiotherapy. Here I would like to repeat our explanation-the cause of pain is situated in many levels of the spine. As surgery concentrates on one or two levels of the spine it cannot cure the spine pain as a whole. In our praxis we have observed that physiotherapy is good in 30%of our patients, is excellent in 20% and sufficient in 50% of cases.

The back pain syndromes are mostly connected with the pathological changes in the anatomy of the spinedeformity of axis, changes of “intervertebral joints” and shortenings (contractures) of the soft tissues-ligaments, capsules, fascias, muscles of the spine.

The changed axis and disorders in the anatomy of spine are caused mostly by so-called Idiopathic Scoliosis. There are three groups and four types of this deformity.

The main causes of back pain are mostly:

Hiperlordosis of lumbar spine-in patients with primary MBD,

The “C” and “S” scoliosis in 2nd/A/B epg-in adults in form of degenerative spine deformity.

Stiffness of the spine in “I” 3 rdepg type of scoliosis-frequent spine pain cause but rare diagnosed till now.

Congenital or acquitter malformation of the spine like spondylolisthesis, congenital scoliosis, spine deformity in context of thorax deformity.

All cases of “back pain” need the precise differential diagnosis to explain the causes of the illness.

In prophylaxis of back pain in adults it is important to introduce to all children the rules of causal prophylaxis against scoliosis (see chapter above).

In therapy of back pain-on the first plan is:

To avoid the standing ‘at ease’ on the right leg,

Rest and sleep in embryo position,

In heavy cases “chair extension” and in the “pain-free phase” of the illness-exercises in geothermal water.

Physiotherapy-regularly at home and in rehabilitations centers.

Surgery in back pain syndromes is necessary only in very rare cases resistant to conservative treatment.

I would like to express my many thanks to Miss Honorata Menet for correction of the article.