Scoliosis treatment using a combination of manipulative
and rehabilitative therapy: a retrospective case series
Mark W Morningstar,
Dennis Woggon and Gary Lawrence
Abstract
Background: The
combination of spinal manipulation and various physiotherapeutic
procedures used to correct the curvatures associated with
scoliosis have been largely unsuccessful. Typically, the
goals of these procedures are often to relax, strengthen,
or stretch musculotendinous and/or ligamentous structures.
In this study, we investigate the possible benefits of combining
spinal manipulation, positional traction, and neuromuscular
reduction in the treatment of idiopathic scoliosis.
Methods:
A total of 22 patient files were selected to participate
in the protocol. Of these, 19 met the study criterion required
for analysis of treatment benefits. Antero-posterior radiographs
were taken of each subject prior to treatment intervention
and 4–6 weeks following the intervention. A Cobb angle was
drawn and analyzed on each radiograph, so pre and post comparisons
could be made.
Results: After
4–6 weeks of
scoliosis treatment, the treatment group averaged a
17° reduction in their Cobb angle measurements. None of
the patients' Cobb angles increased. A total of 3 subjects
were dismissed from the study for noncompliance relating
to home care instructions, leaving 19 subjects to be evaluated
post-intervention.
Conclusions: The
combined use of spinal manipulation and postural therapy
appeared to significantly reduce the severity of the Cobb
angle in all 19 subjects. These results warrant further
testing of this protocol.
Background
In the MEDLINE-
indexed literature, chiropractic treatment has shown to
be largely ineffective at significantly reducing scoliotic
curvatures. Chiropractic treatment for scoliosis typically
consists of spinal manipulation, electric stimulation, some
form of isotonic, active exercises, and shoe lifts [1].
However, Lantz et al [2] has shown that these procedures,
when applied over a one-year duration, were not sufficient
to significantly reduce the Cobb angle of a scoliotic curvature.
The
scoliosis treatment in this study focuses on the reduction
of scoliosis by manipulative and rehabilitative methods
not commonly used by most chiropractors. The major difference
in this
scoliosis treatment compared to others is that stimulation
of the involuntary postural reflexes is utilized in the
clinic setting as well as in home care. Many of the proposed
etiologies of idiopathic scoliosis are neurological in origin,
including brain asymmetry [3], neural axis deformities [4],
and central nervous system processing errors [5]. Additionally,
many coexistent neurological alterations are present in
scoliosis patients, such as visual deficiency [6] and decreased
postural stability [7,8]. Therefore, the goals of the proposed
scoliosis treatment are not only to reduce the scoliotic
curvatures, but also to rehabilitate any underlying postural
and neurological weaknesses or imbalances. Previous chiropractic
authors have investigated the effectiveness of various physiotherapeutic
modalities in the treatment of scoliosis, such as Pilates
[9], stretching and massage [10], therapeutic exercises
[11], orthotics [2], and ultrasound or electric stimulation
[1]. The purpose of the present study is to investigate
any possible benefits from combining manipulative and rehabilitative
techniques from a randomized sample collected from various
chiropractic facilities. Preliminary evidence [12] suggests
that these procedures may be beneficial for reducing the
curvatures associated with scoliosis.
Methods
A nonrandomized
set of 22 patients participated in the study. The age range
of the subject group was 15–65 years of age. The patients
were selected from 3 different chiropractic facilities in
the United States. Patients were evaluated according to
their chief complaint at initial presentation. Patients
were excluded from the study if neoplasm, malignancy, fracture,
scoliosis secondary to genetic disorders, or previous arthrodesis
were identified. Each patient was examined radiographically
for location and severity of scoliosis with standing anteroposterior
full spine imaging. All patients removed their shoes for
the imaging. Cobb angles were drawn on each radiograph to
identify the degree of curvature present. A specific treatment
plan was created based upon the results of each patient's
radiographic measurements before and after a sample trial
of the proposed clinical procedures. Initially, standing
lateral cervical, nasium, lateral lumbar, and anteroposterior
lumbopelvic views were taken. These views were taken to
quantify forward head posture, cervical lordosis, lumbar
lordosis, the sacral base angle, and the Cobb angle of the
major lateral curvature. We decided to use the radiographic
positioning and analysis outlined by Harrison et al [13-16],
due to its previously published reliability. After these
images were taken, each patient was fitted with a 4-lb anterior
headweight. They were instructed to walk around with the
headweight for 10 minutes. After 10 minutes, a follow-up
lateral cervical radiograph was taken while wearing the
anterior head-weight. The purpose of this lateral stress
view is to evaluate the potential improvement in cervical
lordosis and reduction in forward head posture from using
these procedures [17,18]. The basis for this aspect of the
protocol is based upon the inherent properties of a curved
column. In the spine, lateral spinal displacements may occur
when the normal sagittal spinal curves [19-22] are flattened,
reversed, or accentuated. These curves are necessary for
the overall strength and flexibility of the curved spinal
column, according to the Delmas Index [23]. Therefore, the
proposed treatment is intended to restore a normal cervical
and lumbar lordosis, and reduce forward head posture before
the scoliotic curvatures are addressed. The specific manipulative
and rehabilitative procedures used in this study are designed
to both reduce the scoliotic curvature and theoretically
retrain the involuntary neuromuscular, reflexive control
of posture and balance. However, the specific neurological
effects, if any, remain to be investigated. Some of the
procedures have been separately introduced or tested [17,18,24-26].
The manipulative procedures included an upper cervical adjustment
designed to mobilize the atlantal-occipital joint with the
use of a percussive instrument. This technique is shown
in Figure 1. This technique is delivered to patients whose
lateral cervical radiographs demonstrated atlanto-occipital
flexion. If atlanto-occipital extension was present on the
initial lateral cervical radiograph, a -Z drop piece was
used to mobilize the occiput into flexion. This is also
shown in Figure 1. An anterior thoracic adjustment was administered
with the patient's thoracic cage rotated opposite to the
rotational displacement. A thoracic drop piece was also
used to mobilize and correct the smaller upper thoracic
curvature. Side posture lumbopelvic adjustments were delivered
bilaterally to correct the rotational component of the pelvic
misalignment. These side posture manipulations were performed
on a 30°-incline bench to help pre-stress the spine out
of its existing scoliotic curvatures.
Certain traction
procedures are also employed. These procedures are delivered
using high-density foam blocks to pre-stress the spine into
specific positions so ligament deformation and stress-relaxation
can take place. Supine pelvic blocking was performed on
each patient for 15 minutes. The position of the blocks
was determined by each patient's pelvic rotation on radiograph
and posture analysis. One block is placed under the iliac
crest of the posterior ilium, and the other block is placed
under the femoral head of the opposite, anteriorly-rotated
ilium. Figure 2 illustrates the position of the pelvic blocks.
The rehabilitative procedures, demonstrated in Figure 3,
included the use of head, shoulder, and hip weighting devices.
These devices may be used while simultaneously performing
specific balancing exercises. These exercises include the
use of a Pettibon Wobble Chair ® and a Posturomed® [17].
Tjernstrom et al [27] showed that repeated performance of
a postural alteration induces a long-term motor memory for
achieving that novel postural position. The position of
the body weighting was also determined radiographically
for each patient. Initially, hip weights and shoulder weights
were applied according to each patient's posture analysis.
Anteroposterior cervicothoracic and lumbopelvic views were
taken while wearing the head and body weighting. Since changes
in spinal position are not reliably seen by visualization
[28,29], these stress radiographs were taken to confirm
their corrective effects. The attending physician treated
each patient 3 times per week for the first 4–6 weeks. A
total of 3 physicians performed the treatment intervention
for all patients. However, each patient did not receive
identical treatment at all visits. The physicians performed
only those manipulative procedures that were deemed necessary
based upon a visual posture analysis at the beginning of
each treatment session. However, the rehabilitative procedures
remained constant throughout the study for all patients.
Specific home care exercise programs were taught to each
patient. These exercises were performed on a daily basis.
Each patient was instructed to wear the head and body weighting
twice daily for 15 minutes each time. Secondly, each patient
was given a set of triangular foam blocks to lie on once
daily for 20 minutes, immediately prior to going to bed
at night. The foam blocks were positioned under the cervicothoracic
and thoracolumbar regions simultaneously.
The position
of these blocks is shown in Figure 4.
Patients participating
in any weightlifting activities were required to cease those
activities until further notice from the attending physician.
Patients who failedto perform the home care more than 3
times were dismissed from the study. A total of 3 subjects
were eventually dismissed, leaving 19 subjects to perform
post-intervention evaluations.
Results
At the conclusion
of the trial period, a post-intervention radiographic study
was conducted. The same anteroposterior full spine view
was taken, and Cobb angles were againmeasured at the same
vertebral levels. The average starting Cobb angle was found
to be 28°, while the post-intervention Cobb angles measured
an average of 11°, for an overall average reduction of 17°.
The picture on the left demonstrates the mechanically
assisted manipulation used when a patient's skull is
restricted in extension on lateral cervical radiograph
Figure 1.
The picture on the right is the procedure used when
the skull flexion is restricted.
Every patient made
at least a 25% improvement. The largest improvement measured
33°, and the smallest improvement measured 8°. Table 1 shows
the results of all 19 patients that followed through with
the entire treatment plan. Figure 5 is a sample of the improvements
made by a few of the patients. It is important to mention
that these patients were initially treated prior to this
study. Because of this, the pre and post treatment radiographs
had previously been analyzed for saggital curve and Cobb
angle measurements. For purposes of this study, however,
all of the radiographs were sent to a single chiropractic
physician to analyze each of the patient files. This physician
did not participate in the treatment process, nor did this
physician have contact with any of the patients. This was
performed to separate examiner bias from the treatment results.
While only radiographic procedures were reported for this
study, other physiologic parameters were utilized to document
patient progress. Unfortunately, since the patient files
were extracted from 3 different spine clinics, a consistent
functional or symptomatic measure was not used in all 22
cases. A functional rating index, a visual analog scale,
and SF-36 were used on the patients here. As a result, these
values are not reported to avoid variability in outcome
interpretation.
Discussion
Scoliosis has recently
been associated with a lower quality of life [30-32], lower
scores on the SF-36 health question-
This picture
shows the placement of the pelvic blocks for an anterior
right ilium Figure 2
This picture
shows the placement of the pelvic blocks for an anterior
right ilium. The blocks are placed opposite of the pelvic
rotation.
naire [33], and
makes patients prone to developing
chronic pain more often
than the general population [34].Therefore, reducing scoliotic
curvatures, even in the absence of symptoms, seems to be
a worthy outcome objective for clinical practice. This opinion
is further supported by recent evidence of the deleterious
effects of abnormal spinal loading [35-37]. Given that the
average curvature progression in idiopathic scoliosis is
7.03° per year [38], the traditional method of regular observation
without treatment seems to be reactionary rather than corrective
or preventive.
Spinal manipulation
alone does not appear to significantly alter spinal structure
when administered as a sole treatment modality [39,40].
Therefore, in the instance of scoliosis, treatment should
include the use of both manipulative and rehabilitative
procedures, so that structural changes can be attempted.
It is important to stress that spinal manipulation was avoided,
when possible, in the present study. Unpublished clinical
observation by the authors has shown that over-manipulating
or adjusting the spine seems to create a certain amount
of instability, possibly leading to further buckling of
the scoliotic curvature. The significance of home care to
the results was not reported here. It is unknown how the
omission of home care would have affected the outcome measurements,
given that 3 subjects were dropped from the study for noncompliance
in performing home care. Future research should account
for this potential variable to determine its necessity and
relevance. The outcome measures for this study are divided
into a series of both short-term and long-term goals. The
outcome of the initial stage of care is to reduce forward
head.
The above picture
illustrates a sample placement of the Pettibon Bodyweighting
SystemFigure 3
The above picture
illustrates a sample placement of the Pettibon Bodyweighting
System. Here we have an anterior headweight, right shoulderweight,
and left-back and right-front hipweights.
posture and improve
the sagittal cervical and lumbar curves. As the position
of the head migrates forward, or away from the body's vertical
axis, increased strain is placed upon the muscles of the
head, neck and shoulders. Cailliet and Zohn indicated that
an additional 10 inch/lbs of leverage is added to the spinal
system in a forward head posture [41,42]. Additionally,
this added leverage causes increased isometric contraction
of various spinal muscles, such as the splenius capitis,
trapezius, SCM, and levator scapula. Sjogaard et al [43]
reported that blood flow through a given muscle is decreased
as a muscles contraction increases, being virtually cut
off at 50–60% contraction. The resultant lack of blood flow
forces the muscle to rely on anaerobic metabolism. As anaerobic
metabolism progresses, metabolites such as substance P,
bradykinin, and histamine build up and excite chemosensitive
pain receptors, causing a barrage of nociceptive afferent
input [44], resulting in dysafferentation [45]. Being that
postural control is largely dependant upon cervical joint
mechanoreceptors and afferent input from ligament and musculotendinous
sources [46,47], correcting the postural distortions responsible
for this pathophysiologic process may be beneficial in patient
populations, such as scoliosis, where postural control is
significantly altered [48]. The effects of the loss of cervical
and lumbar lordosis have been previously reported [19,35-37].
Rhee et al [49] noted that correction of the sagittal curves
might be related to the long-term health of the spine in
scoliosis management. Harrison et al [35] illustrated how
a loss of the sagittal curve alters the mechanical properties
of the spinal.
This figure
shows a demonstration of the positional traction procedureFigure
4
This figure shows
a demonstration of the positional traction procedure. The
cervical block is placed under the patient's cervicothoracic
junction, allowing the head to extend back over the sloped
portion of the block. The low back support is placed under
the patient's thoracolumbar junction, posterior to the lowest
palpable ribs. The blocks are outlined in white cord and
nerve roots, which may change the firing patterns of involved
neurons. Schafer illustrated how an increased demand is
placed upon the cervical musculature when the cervical curve
is straightened or reversed [50]. It is important that the
cervical spine be in a normal structural alignment. A loss
of the cervical lordosis and concomitant forward head
posture may elicit the pelvoocular reflex, which causes
an anterior pelvic translation to balance the head's center
of gravity [51]. Wu et al [52,53] point out that in postural
control, preference is given to the position of the head,
neck, and trunk. Therefore, correction of the cervical spine
becomes imperative so that the rest of the spine can be
rehabilitated in relation to a normal reference point in
space. Once the cervical and lumbar lordoses are corrected,
coronal reduction of the scoliotic curvatures begins. Here
this was accomplished by adding a shoulderweight to the
right shoulder and a hipweight to the anterior right ilium
and posterior left ilium. Wu and Essien [53] have previously
reported the effects of adding external weight to the upper
body via a shoulder weight. They identified predictable
patterns in which the trunk would compensate for the amount
and position of the weight. Wu and MacLeod [52] identified
a shift in the center of mass toward the added weight when
placed on the side of the pelvis. However, the trunk and
head remained in the same position, while the pelvis and
lower extremities shifted to counteract the weight while
supporting the head and trunk [52]. In this protocol, we
created an environment where external weight was added to
the head, shoulder, and pelvic regions simultaneously. Knowing
the predictable patterns of compensatory shifting to an
altered center of gravity, we placed the headweight, shoulderweight,
and hip- weights in areas designed to reduce each patient's
specific spinal distortion patterns. Learning a new motor
coordination skill can be divided into 3 phases: cognitive,
associative, and autonomous [54]. In the cognitive phase,
the patient performs the motor task repetitively to learn
until the task requirements are understood. As the patient
progresses through the associative and autonomous phases,
the task becomes easier to perform, and may ultimately be
performed in a variety of practical contexts with decreased
repetitions [54]. While Lantz et al [2] have shown that
chiropractic management, consisting of a combination of
manipulative procedures, electric stimulation, and orthotic
inserts did not significantly reduce a scoliosis, this treatment
does not incorporate these physiotherapeutic procedures.
Instead, this treatment requires the use of specific rehabilitative
equipment that theoretically recruits the use of head, neck,
trunk, and extremity postural reflexes to create specific
adaptation to an altered center of gravity and field of
gaze. The study design used here does present specific limitations.
Due to the lack of a control group, comparative data and
conclusions cannot be made. Additionally, a retrospective
design does not blind the practitioners to treatment. Although
we attempted to select patient files at random from 3 separate
spine clinics, nonrandomized.
Table 1: Cobb
Angle Measurements after 4–6 Weeks (Degrees)
sample populations
such as ours do not necessarily reflect the potential outcomes
in a general population. Therefore, future studies in this
area should incorporate a control group and a randomized
patient population. Followup studies should also focus on
the potential long-term benefits of conservative scoliosis
treatment, given the relative scarcity of biomedical literature
available on longterm benefits from any scoliosis treatment.
Within the design
limitations of the present study, the combined use of manipulative
and neuromuscular rehabilitation seemed to reduce scoliotic
curvatures in 19 subjects by an average of 17°. This reduction
took place within a 4 to 6-week period. Although this treatment
was not tested over the long term, the magnitude of the
present results warrants further studies into its effectiveness.
This treatment should also be tested on specific types of
scoliosis in follow-up trials. A long-term investigation
of this protocol is desirable.
Competing interests
This manuscript
was submitted by Spinal Technologies, a BioMed Central institutional
member. The rehabilitation equipment used in this study
is patented by Burl R Pettibon, DC and Spinal Technologies.
MWM is the Director of Research for the Pettibon Biomechanics
Institute, and an active postgraduate instructor for Spinal
Technologies.
MWM does not receive
monetary compensation for this position. Rather, he is granted
funding from Spinal Technologies to obtain biomedical
literature and statistician services. DW is a past postgraduate
instructor for Spinal Technologies, founder and director
of the CLEAR Institute, and CEO of the Flex Neck Company.
GL is an active postgraduate instructor for Spinal Technologies.
The authors receive lecture fees for each continuing education
seminar conducted. All 3 authors maintain private.
This figure
illustrates some of the pre and post x-rays taken after
4–6 weeks of treatmentFigure 5
This figure
illustrates some of the pre and post x-rays taken after
4–6 weeks of treatment.
52° 19°
chiropractic practices
from where all of the patient files in this study were taken.
None of the above companies donated, funded, or reimbursed
any monies or equipment for this study. None of the authors
have any ownership in Spinal Technologies or its subsidiary
companies, and none will gain any financial interest as
a result of this paper.
Authors' contributions
Each author worked
on one-third of the patient population. The first author
was responsible for collecting the data and putting our
findings into written format.
Acknowledgements
The authors would
like to thank Darin Weeks and Cassi Little for procedure
demonstration.
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Published: 14 September 2004
BMC Musculoskeletal Disorders 2004, 5:32 doi:10.1186/1471-2474-5-32
Received: 22 April 2004
Accepted: 14 September 2004
Spine. 26(1):48-52, January 1, 2001. Catanzariti,
Jean F. MD; Salomez, Elisabeth MD +; Bruandet, Jean M. MD;
Thevenon, Andre MD
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