October 2005

Chiropractic management of the scoliosis patient

by Dr. Marc Lamantia

Part 1 of 3

Did you know 80% of all Scoliosis is idiopathic? The numbers total close to one million new cases every year.

Did you also know non‑surgical treatments have been shown to reduce scoliotic curvatures? Of course "non‑surgical" doesn't necessarily mean "chiropractic," although doctors of chiropractic have certainly influenced curvature reductions in patients that may have otherwise experienced progression.

Recent studies by Freise et al confirm chiropractic doctors accept scoliosis patients and offer manipulation, physical therapy and exercise programs as adjunctive therapy. [1] However, non‑surgical treatment also includes Thoraco‑lumbo‑sacral orthoses, or a TLSO Brace.

Due to the restrictive nature of these rigid braces; i.e., Boston Brace, Charleston Brace, Wilmington etc., and the reluctance of most of our profession to use such a device, chiropractors have been left out of the management flow chart for scoliosis.

Our job now is to offer a complete management protocol for adolescent and adult scoliosis, and to include a supportive device that is congruent with the chiropractic paradigm.

Chiropractors possess the tools to offer complex evaluations, advanced neurodiagnostic interpretations and restorative procedures which allow us to offer a more complete intervention. If the scoliosis community begins to turn to the chiropractic profession, we stand to gain between one and three percent of the population, nearly a 20% growth from our current 10% penetration nationwide.

However, not every chiropractor offers scoliosis patients specialized treatment. Even so, if you see patients, you are seeing patients with scoliosis; the average practice sees 1.9 scoliosis patients per week. So, if you're the average DC, you most likely cared for close to 100 scoliosis patients last year.

Another interesting point is the majority of chiropractors treat adults with scoliosis. This makes perfect sense if you consider adults with scoliosis experience more back pain and have a greater incidence of disc injury than the general population. [2]

The non‑profit Scoliosis Care Foundation is currently supporting research, and the compilation of data on adult scoliosis and the efficacy of chiropractic management. One of the trends reported by the Foundation head, Dr. Gary Deutchman, is the lack of back pain in adolescent groups with scoliosis. Typically seen by the orthopedist, these patients are watched every six months with X‑ray analysis for curvature progression.

A typical orthopedist will prescribe a rigid brace (TLSO) when the Cobb angle measurement reaches 25 degrees. When the curvature exceeds 40 degrees, the patient is recommended for surgery.

There are of course more complex decisions to be made, but consider that for every one adolescent patient you see, thousands go directly to the orthopedist, and are discouraged from seeking any other form of treatment.

Many of these surgical cases could avoid invasive measures if non‑surgical management was offered. It will take nothing short of a national effort to alert the public and the press that there are non‑surgical alternatives, there are alternatives to rigid bracing, and chiropractors are the providers of choice.

Adult algorithms for the chiropractor are currently being developed by Scoliosis Systems. Adult interventions require comprehensive spinal rehabilitation, but also the expert examination of the vestibular and oculomotor systems; and the ability to construct specialized neuro‑rehabilitation techniques to correct underlying neurological dysfunctions.

Neurophysiologic dysfunction associated with subluxation has been a concept that has long caused disharmony within our own profession, but rest assured, the non‑chiropractic scientific community has accepted the idea of subtle nervous system abnormalities, and the association to disease.

The concepts of "neuro‑plasticity," and the advancements made in neuro‑rehabilitation have supported the use of sensory stimulations; i.e. manipulation, electric muscle stimulation, and vibration as an effective mediator of neuro repair. Both subtle and frank central nervous system abnormalities have been identified in the scoliosis population and have been linked with curvature direction and location.

Scoliosis has been linked to balance disturbances with vestibular and proprioceptive etiologies, eye movement disorders and abnormal movement strategies. Through clinical expertise in using advanced neurodiagnostics such as Video Electronystagmography (ENG), chiropractors can better assess outcomes and direct more appropriate treatment programs, giving the scoliosis community a service that cannot be reproduced elsewhere.

Current treatment options, as you know, are nothing short of barbaric, offering a virtual life sentence (to a teenager) in a rigid brace, or the implantation of medal rods with complete fusion of the spine, a true life sentence to anyone. Certainly there are cases that will not respond to non‑surgical interventions, but I consider it our duty to exhaust the possibilities of non‑invasive treatment before a recommendation of surgery be made.

This three‑part series outlines what I believe to be the necessary steps to develop accepted programs for the chiropractic management of scoliosis.

Identification of abnormal movement strategies, the corrective movement principle, and subluxation patterns in idiopathic scoliosis.

Chiropractic practice includes many different clinical evaluation techniques, and as many techniques for intervention.

The scoliotic spine typically presents with a three dimensional lateral deviation, commonly coupled with rotation of the vertebral body. What isn't so apparent is the universal flattening of the sagittal curves. Although there is a condition called "Kypho‑scoliosis," a thoracic kyphosis, or normal cervical lordosis is considered to be a sign of neurogenic dysfunction. A common finding in this group is Arnold Chiari Malformation (ACM) or Syringomyelia of the brainstem or spinal cord. A recent study of Adolescent Scoliosis by (Loder et al 2000) found just that, the authors linked any cervical lordosis (>0), or normal thoracic curves with a high incidence of neurogenic causes such as brainstem and cerebellar abnormalities. They also found the typical cervical lordosis in adolescent scoliosis (without ACM) to be (‑5) degrees.

This finding of cervical kyphosis is one of the most common subluxation patterns in idiopathic scoliosis; a condition which is commonly under treated and leads to early degeneration of the cervical spinal structures. [3]

Another common subluxation pattern found is a lateral head tilt, laterality of the atlas, or upper cervical lateral flexion malposition. If this is not a primarily structural misalignment, it can be a deficit of the "Righting Reflex." The righting reflex is mediated by the otolithic organs of the vestibular system, and we know otolithic imbalance has long been identified in the scoliosis population. [4]

This subluxation may require neuro‑rehabilitative techniques to restore resting vestibulo‑cerebellar tone, especially if the doctor has not evidenced a reduction in misalignment after appropriate upper cervical management. As many of us know, simply adjusting into the open wedge does not consistently reduce a head tilt.

As a result, techniques have evolved to include sustained traction and head weighting.

Another such evolution now includes the careful evaluation of vestibular and oculomotor reflexes, as well as scientifically sound approaches to using chiropractic techniques to improve brainstem function. Chiropractic Vestibular Rehabilitation (CVR) uses manipulation and habituation exercises to reduce neurogenic causes of head tilts and abnormal nystagmus associated with vestibulo‑cerebellar deficits. Advances in brainstem testing, including Video Electronystagmography (ENG) has given the chiropractor the tools necessary to assess subtle brainstem dysfunction.

This functional brainstem testing also gives the practitioner the added information necessary to construct "neuro‑specific" rehabilitation. Video ENG testing is the gold standard to assess vestibular and oculomotor function (in both children and adults), and is an accepted test for brainstem and cerebellar function.

The evaluation of eye movements is considered a superior method of assessing for cerebellar ataxia, and is well considered as a window to motor control in general.

Video ENG is an invaluable tool which can give information about techniques which are effective in restoring central controls of movement and posture, as well as those that are not. Chiropractic adjustments are a unique and effective procedure that can be used to restore normal vestibular output [5] but personalized patient management requires an understanding of the central connections of the vestibulum, and its relationship with the spinal structures. Vestibular rehabilitation using the cervical spine musculature has been shown to improve brainstem vestibular function [6], but again, we must be expert in its neurology and evaluation to take full advantage of this information. Every subluxation pattern in scoliosis is affected by vestibulo‑cerebellar dysfunction, which makes its correction of paramount importance.

Another subluxation pattern is revealed in the movement strategies, or coupling patterns of thoracic and lumbar curvatures. Lateral flexion and rotation coupled movements are abnormal in thoracic curvatures.

The deviant rotation is mostly responsible for the hallmark "Rib Humping" associated with thoracic curvatures. As a result, abnormal movement strategies and muscular recruitment patterns tend to drive the progression of the lateral curvature, making movement counterproductive in a growing patient with scoliosis. This may be the reason dancers and gymnasts who train for many hours each day, seem to have a higher incidence of spinal curvatures. New concepts in chiropractic rehabilitation include the re‑education of movement along with central nervous system exercises to restore normal resting tone of the vestibular system.

When looking at this from a mechanical standpoint, it is important to realize that as the spine goes in extension due to the flattening of the thoracic kyphosis, the tendency is to lose the mechanical advantage allowing for excessive rotation and buckling of the vertebral column. Techniques which emphasize a three- dimensional "de‑rotation" as a corrective movement during mobilization, are necessary to reduce this subluxation pattern.

"The Corrective Movement Priciple," as described by Dr. Christine Collaird [7,8] may give a more significant reduction of scoliosis subluxation postures. Dr. Collaird is the inventor the SpineCor Corrective Device for Scoliosis. SpineCor uses a low‑force, low‑intensity postural re‑education to be worn 20 hours a day.

The device if fitted based on the corrective posture identified through over 20 million dollars in research over the past 10 years. SpineCor is an elastic flexible system which gently reminds the patient of the most correct posture, effectively reducing their postural deformity over time.

The "Corrective movement" is not necessarily equal and opposite of the postural distortion.

For instance, Collaird found the thoracic curvatures commonly reduced when a detorsion movement was made between the thoracic cage and the shoulder girdle, not a lateral bending which is so often used in rigid bracing. Dr. Collaird identified 10 sub‑types of thoracic curvatures, each differing in presentation and responsiveness to corrective maneuvers.

She also subdivided Thoracolumbar curvatures into four groups, two left and two right.

The sagittal x‑ray is used in this curvature to differentiate the two subgroups, those with a junctional kyphosis, and those with near normal sagittal curves.

In total, 20 different sub types were identified and defined, providing an updated guide of structural phenotypes which respond differently to movement and rehabilitation.

References

1. "An inquiry into chiropractors' intention to treat adolescent idiopathic scoliosis: a telephone survey." Feise RJ. J Manipulative Physiol Ther. 2001 Mar‑Apr;24(3):177‑82

2. "Disc morphology in health and disease." Roberts S. Biochem Soc Trans. 2002 Nov;30(Pt 6):864‑9

3. "Influence of spine morphology on intervertebral disc loads and stresses in asymptomatic adults: implications for the ideal spine." Keller TS, Colloca CJ, Harrison DE, Harrison DD, Janik TJ. Spine J. 2005 May‑Jun;5(3):297‑309

4. "Asymmetric otolith vestibulo‑ocular responses in children with idiopathic scoliosis." Wiener‑Vacher SR, Mazda K. J Pediatr. 1998 Jun;132(6):1028‑32. Otorhinolaryngology Department, Hopital Robert Debre, Paris, France

5. "Nystagmus as an objective assessment of the cervical spine syndrome and its treatment." Moser M, Simon H, HNO. 1977 Aug;25(8):265‑8

6. "The acute cervical vertigo under otologic and osteopathic view." Hulse M, Partsch CJ, Wolff HD., Laryngol Rhinol Otol (Stuttg). 1975 Mar;54(3):263‑7. (author's transl)]

7. "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

8. "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

(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.)