December 2005

Chiropractic management of the scoliosis patient  -- Part 3 of 3

by Dr. Marc Lamantia

Adult vs. adolescent scoliosis protocols

The accepted medical paradigm considers the adult with scoliosis to be beyond the threshold of corrective procedure, and therefore is typically not offered treatment to stop progression, reduce degenerative processes or lessen painful postures.

A review of the literature supports the idea of curvature progression in adulthood (1) and therefore requires certain attention. Both Adult and Adolescent scoliosis has been shown to respond well to physical therapeutics,(2) although you may be hard pressed to find an American Orthopedist that agrees.

Although physical therapeutics and rigid bracing (Boston, Charleston, Wilmington) has been shown to be effective in retarding progression during the growth phases of adolescence, a rebound phenomenon with total relapse is reported when the rigid brace is removed (3).

This speaks volumes about the inappropriateness of rigid bracing, and the lack of neuro‑specific rehabilitation being offered during and after bone maturity.

A new approach to the management of adolescents offers much more than the antiquated "rigid brace" that is still being used today.

An emphasis on postural re‑education and active muscle activity using corrective postures is designed to rehabilitate the patient while growth is still occurring. The concept of bone remodeling during the growth phase is well accepted. The patient is taught to use a corrective movement strategy which allows for progressive reduction with every movement, creating a neuro‑rehabilitation which serves to improve central neurological balance.

Dr. Christine Collarid, inventor of the SpineCor device for scoliosis, has created an alternative to rigid bracing that is congruent with chiropractic philosophy of correction and preserved movement.

Adults with scoliosis

Adults with scoliosis require a slightly different algorithm of treatment. Since progression risk is low, and pain, dizziness and postural abnormalities are the major complaints, the desired outcomes are focused on postural re‑education, balance retraining and pain reduction.

The SpineCor device is a flexible dynamic postural re‑education tool designed specifically for Adolescent Idiopathic Scoliosis. It has recently been realized SpineCor can also serve as a postural re‑education and supportive device for adults with scoliosis, and patients with severe kyphosis.

I had the privilege of training with the inventors, Dr. Christine Collarid, and Dr. Charles Rivard at the St. Justine Hospital for Children in Montreal Canada. Dr. Collaird created the flexible dynamic device (SpineCor) to use tensile elastic bands to create a "corrective movement", which has been shown to reduce clinical and radiographic signs of scoliosis, even after a five year follow‑up out of brace (Research being presented at the European Spine Conference in Barcelona Spain, Sep/05).

One SpineCor published study reviewed Seven hundred and six five (765) children with Idiopathic Scoliosis fifty seven percent (57%) of the SpineCor group experienced a reduction in Cobb angle measurement.

Thirty two percent (32%) achieved stabilization without progression, and eleven percent (11%) became worse (Table 1).

The outcomes in the SpineCor group were far greater than in untreated populations, or those reported by other authors using rigid bracing.

One of the shortcomings, and there are many, to using a rigid brace is an inappropriate mechanism of action; mainly the use of a three (3) point lever system. The idea of creating counter pressures above and below the apex mainly serves to distort the thoracic cage even more, and not to restore normal mechanics of movement.

Some authors have described the rigid brace mechanism of action to be a "withdrawal response" from pain as a result of the brace construction. As I described earlier, the evidence suggests the forced posture induced by rigid bracing fails to make lasting reductions in cobb angle measurements.

Typical compliance with rigid bracing is quite low (4), and psychological ramifications and low self esteem are a significant concern.(5) This is true in both adolescent and adult populations.

Another concern in the adolescent group is the development of a "hypokyphotic (6) syndrome. Rigid bracing can cause the thoracic kyphosis to become further flattened. This happens because braces like the "Wilmington" were planned in only two dimensions (2D), and therefore does not allow for preservation of the sagittal curves.(7)

The use of lateral pressure is furthermore an inappropriate vector of force necessary to reduce the gibbosity associated with scoliosis, however, rotational pressure has been shown to be effective.(8) Furthermore, rigid bracing does not allow for normal movement, resulting in abnormal muscle recruitment in regards to posture (9) and breathing (10) depriving the brain and cerebellum of normal receptor activation from muscles, tendons and joints. The Lack of movement also affects the vestibular input to the brain, which has long been identified as abnormal in the scoliosis population.(11)

Dr. Collaird's research team identified the common three dimensional (3D) spinal configurations for twenty (20) different curvature patterns.(12) They recognized Scoliosis is a 3D deformity involving the sagittal curves as well as the abnormal lateral curvatures.(13) (Figure 1 ‑‑ see computer animation of three dimensional differences found in scoliosis curvatures).

Dr. Collaird identified a movement strategy which utilizes the natural coupling mechanisms of the spine to assist in preserving and rehabilitating the normal sagittal curves while reducing the cobb angle associated with abnormal lateral curvatures.

Dr. Collaird calls this the Corrective Movement Principle (CMP),(14) and has shown it's effectiveness in the adolescent scoliosis population.

Biomedical engineers developed the SpineCor bracing system so that it would provide a low‑intensity postural re-education over time. SpineCor is the first dynamic corrective device for scoliosis, it is nothing less than a breakthrough in the non‑surgical management of scoliosis.

Applied non‑surgical interventions like the SpineCor Corrective Device, and the identification of the Corrective Movement Principal (CMP) have spotlighted the need for rehabilitation of movement in the non‑surgical management of Scoliosis.

This is not only true in the adolescent group, but also in the adult population.

The SpineCor Corrective Device is utilized as a low intensity neuro‑muscular rehabilitation to be worn twenty (20) hours per day.

The proposed management also includes postural re‑education exercises specific for each curvature pattern, as well as resistance exercises into the corrective posture. This is appropriate for adult patients, but must be carried out with patient tolerance in mind. Adults may not tolerate high tensions or high intensity work‑outs which are shown to be effective in adolescent groups.

Furthermore, adults need gentle flexion distraction therapy to improve flexibility of tissues prior to corrective exercises. This differs considerable from the adolescent algorithm of care. Make no mistake about it, scoliosis is a disease, and can require surgery.

The standards of care should always be considered when accepting an adolescent or adult patient with scoliosis.

References

1. Biomechanical factors affecting progression of structural scoliotic curves of the spine. Lupparelli S, Pola E, Pitta L, Mazza O, De Santis V, Aulisa L. Stud Health Technol Inform. 2002;91:81‑5.

2. "Characteristics of physical therapy of scoliosis patients in adulthood," Weiss HR. Rehabilitation (Stuttg). 1992 Feb; 31(1): 38‑42

3. "Rehabilitation of adolescent patients with scoliosis ‑‑ what do we know? A review of the literature," Weiss HR. Pediatr Rehabil. 2004 Jul‑Dec; 6(3‑4): 183‑94

4. "Quantitative measurement of spinal brace use and compliance in the treatment of adolescent idiopathic scoliosis." Nicholson GP, Ferguson‑Pell MW, Smith K, Edgar M, Morley T. Stud Health Technol Inform. 2002;91:372‑7, Centre for Disability Research and Innovation, Institute of Orthopaedics and Musculo Skeletal Sciences, University College London, Brockley Hill, Stanmore, HA 7 4LP.

5. "Developmental psychological aspects of scoliosis treatment," Reichel D, Schanz J. Psychology Department of the Asklepios Katharina Schroth Spinal Deformities Rehabilitation Center, Bad Sobernheim, Germany.

6. "A new method of MR total spine imaging for showing the brace effect in scoliosis," J Orthop Sci. 2001;6(4):316‑9.Schmitz A, Kandyba J, Koenig R, Jaeger UE, Gieseke J, Schmitt O., Department of Orthopaedics, University of Bonn, Sigmund‑Freud Str. 25, D‑53105 Bonn, Germany.

7. "Rib cage‑spine coupling patterns involved in brace treatment of adolescent idiopathic scoliosis." Spine. 1997 Mar 15;22(6):629‑35. Aubin CE, Dansereau J, de Guise JA, Labelle H. Department of Mechanical Engineering, Ecole Polytechnique, Montreal, Quebec, Canada.

8. "A new Concept in the non‑invasive treatment of Idiopathic Scoliosis: The Corrective Movement Principle," C. Collaird -- Original Paper. Correspondence: Centre de recherche, Hospital Sainte‑Justine, 3175 ch. Cote, Ste Catherine Montreal, Quebec, Canada H3T 1C.

9. "Investigation of muscle recruitment patterns in scoliosis using a biomechanical finite element model," Stud Health Technol Inform. 2002;88:331‑5, Garceau P, Beausejour M, Cheriet F, Labelle H, Aubin CE. Ecole Polytechnique, Station Centre‑ville, Montreal, H3C 3A7, Canada

10. "Effect of bracing on respiratory mechanics in mild idiopathic scoliosis." Thorax. 1989 Jul;44(7):548‑53. Kennedy JD, Robertson CF, Hudson I, Phelan PD. Department of Thoracic Medicine, Royal Children's Hospital, Parkville, Victoria, Australia.

11. "Vestibular mechanisms involved in idiopathic scoliosis," Arch Ital Biol. 2002 Jan;140(1):67‑80. Manzoni D, Miele F. Dipartimento di Fisiologia e Biochimica, Universita di Pisa, Via S. Zeno 31, I‑56127 Pisa, Italy.

12. "SPINECOR: a new therapeutic approach for idiopathic scoliosis," Stud Health Technol Inform. 2002;88:215‑7. Coillard C, Leroux MA, Badeaux J, Rivard CH. Research Center, Sainte Justine Hospital, 3175 Cote Ste Catherine, Montreal, Canada.

13. "A new Concept in the non‑invasive treatment of Idiopathic Scoliosis: The Corrective Movement Principle," C. Collaird -- Original Paper. Correspondence: Centre de recherche, Hopital Sainte‑Justine, 3175 ch. Cote, Ste Catherine Montreal, Quebec, Canada H3T 1C

(Marc Lamantia DC, DACNB holds a Diplomate in Neurology and is Adjunct Faculty for New York Chiropractic College and Life Chiropractic College West. He maintains a private practice in Manhattan NY, and Garden City NY. For more information about SpineCor visit the website at www.scoliosissystems.com. Or contact Dr. Gary Deutchman at (212) 360‑7760. For more information or to attend a Scoliosis System Post Graduate event, visit www.scoliosissystems.com or www.nycc.edu for registration. Dr. Lamantia can also be reached via e‑mail at docotorlami@cs.com.)