November 2005

Chiropractic management of the scoliosis patient ... Part 2 of 3

by Dr. Marc Lamantia

Neurological patterns of imbalance associated with idiopathic scoliosis

As it stands today, the majority of patients diagnosed with Adolescent Idiopathic Scoliosis are not seeking out chiropractic care on a consistent basis.

For every two patients with scoliosis who consult with a chiropractor, there are thousands who go directly to an orthopedic surgeon. It is my opinion this is inappropriate for a child or adult who obviously needs spinal and neurological rehabilitation. The chiropractic profession has an opportunity to position itself as the provider of choice for non‑surgical management of scoliosis.

There are three keys we must possess to be considered expert in the non‑surgical scoliosis community.

The first is the identification of subluxation patterns and corrective procedures to reduce abnormal movement strategies. Chiropractic is the only health care discipline concerned with spinal subluxation and the associated neurological dysfunction, of which children with scoliosis are not exempt. (For more information on this component, see Part 1 of this series, published in the Oct. 2005 edition of The Chiropractic Journal available online at www.worldchiropracticalliance.org/tcj.)

The second key is to identify neurological patterns of interference associated with scoliosis, and construct neuro‑rehabilitative techniques to restore more normal control of movement and posture.

The expert evaluation of nervous system interference requires the use of sophisticated instrumentation such as Video Electronystagmography (ENG) and other brainstem testing. Today's technology is sensitive to even the most subtle neurological interference, which gives the chiropractor information he has been trying to attain since the days of the neurocalometer.

The third key, which we will discuss in detail in Part 3, is to embrace a spinal orthosis that is congruent with the Chiropractic paradigm, including postural and neuromuscular re‑education.

Brainstem/Cerebellum Malformation: a discussion of the literature in regards to neurological disturbances associated with scoliosis reveals a significant correlation to Arnold Chiari Malformation (ACM) of the cerebellum.

The cerebellar tonsilar herniation can be otherwise asymptomatic and still be the underlying cause of scoliosis. An MRI of the posterior fossa and brainstem can be considered a routine procedure when scoliosis presents on plan film studies, when a left thoracic convexity is present, or the sagittal curves are near normal.

Due to the positioning of the heart, left thoracic curvatures are unlikely unless a space occupying lesion or other central nervous system dysfunction is present. Although in the pediatric or infantile version of the disease leftward curvatures are more common and enjoy spontaneous remission at higher frequencies.[1]

Another common central pathology is the presence of a Syrinx, or expansion of the central spinal canal. This can occur in the spinal cord, or the brainstem. Symptoms may include sensory disturbances in a shawl‑like distribution about the upper limb.

Cortical Imbalances: Another common finding is the increased incidence of proprioceptive and vibratory sense dysfunction with scoliosis.

The dorsal column system which conveys vibration sense has been identified as a potential contributor to the progressive nature of scoliosis confirmed by abnormalities on Somatosenory Evoked Potentials (SSEP).[2] A greater incidence of EEG abnormalities has been identified, and suggests a higher cortical neglect syndrome in scoliosis. A triad of symptoms includes scoliosis, learning disorders and dyslexia.[3]

The use of advanced imaging and neurodiagnostics, as well as expert neurological evaluations is paramount for the practitioner interested in becoming the provider of choice. I am reminded by a passage written by BJ Palmer;

"Even as a boy, in the very youth of my life and Chiropractic, I made a vow; that I would live to so develop chiropractic that it would find and locate and be able to correct a specific cause for every dis‑ease in the human body; and to so develop this philosophy and art that it would be made scientific, where it would be made scientific by scientific men, and so proved by the use of scientific instruments." (page 49 vol xviii)

As doctors of chiropractic, we have a unique ability to use the spine as a tool to evoke changes in the central and peripheral nerve system. Regardless if the patient is subluxated, a manipulation, or specific adjustment both evoke receptor potentials which synapse on the cerebellum and ultimately affect brainstem function. Through the use of 'scientific instruments," we can so develop chiropractic to the standards set by B.J. himself.

Vestibular Neurology Review: Video ENG is the gold standard to identify central imbalances in vestibular control of posture; recognized by the American Academy of Neurology, and the ACA Neurology Board.

An important aspect that should be considered when using any type of imaging or diagnostic procedure is whether or not the test being ordered will lead to a change in treatment. Research has shown specific rehabilitation protocols based on the patient's specific vestibular or oculomotor imbalance, to have significantly better outcomes with treatment than a less personalized program.

A brief refresher course on vestibular neurology is suggested. There are eight vestibular nuclei which occupy the floor of the fourth ventricle in the pontomedullary area of the brainstem. They convey information about gravity and movement of the head from the inner ear (semicircular canals and otolith) to the brainstem, cerebellum and cortical brain.

Descending motor projections are sent to the ventral horn of the postural musculature and muscles of the lower limb and trunk. The Vestibulospinal reflexes (VSR) can be measured by EMG activity during Posturography; another objective measure of central controls of posture, which has been shown to be abnormal in scoliosis patients.

Motor projections also are sent rostrally (to the head) to innervate the brainstem nuclei of the extra‑ocular musculature; and are responsible for the Vestibulo‑ocular reflexes (VOR). Post rotational VOR can be measured using video infra‑red goggles (Frenzel), and has been shown to be abnormal is Idiopathic scoliosis well.[4]

The good news is that vestibular rehabilitation is successful in creating compensation and habituation of these abnormal responses. Unfortunately, more research is needed to determine if vestibular rehabilitation as provided by a chiropractor improves outcomes in a scoliosis population.

Subtle disturbances in sensory systems (i.e. subluxation) can cause documentable imbalances in the vestibular tone, and oculomotor (eye movement) controls.

Specific adjustments, as well as neuro‑muscular re‑education procedures can be used to restore balanced neurological tone as measured by Vido ENG, EEG, EMG and SSEP. The chiropractic profession can offer advanced evaluation and rehabilitation programs to the scoliosis community.

Continuing education on the evaluation and management of the scoliosis patient is co‑sponsored by New York Chiropractic College and offered in New York, Chicago, Dallas, and Los Angeles.

References:

1. "Prognosis in infantile idiopathic scoliosis." Ceballos T, Ferrer‑Torrelles M, Castillo F, Fernandez‑Paredes E J Bone Joint Surg Am. 1980 Sep;62(6):863‑75

2. "Adolescent idiopathic scoliosis and joint laxity. A study with somatosensory evoked potentials." Fernandez‑Bermejo E, Garcia‑Jimenez MA, Fernandez‑Palomeque C, Munuera, Spine 1993 Jun 1;18(7):918‑22

3. "Idiopathic scoliosis and the central nervous system: a motor control problem." The Harrington lecture, 1983. Scoliosis Research Society Herman R, Mixon J, Fisher A, Maulucci R, Stuyck J., Spine 1985 Jan‑Feb;10(1):1‑14

4. "Horizontal postrotatory nystagmus response in female subjects with adolescent idiopathic scoliosis," Jensen GM, Wilson KB. Phys Ther 1979 Oct;59(10):1226‑33

(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 New York in Manhattan and Garden City. 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.)