FROM:
Chiropractic & Osteopathy 2006 (Aug 21); 14: 15 ~ FULL TEXT
Dale E Rowe (1), Ronald J Feise (2), Edward R Crowther (3), Jaroslaw P Grod (3), J Michael Menke (4), Charles H Goldsmith (5), Michael R Stoline (6), Thomas A Souza (7), and Brandon Kambach (1)
(1) Kalamazoo Center of Medical Studies, Michigan State University, 1000 Oakland Drive, Kalamazoo, Michigan, USA
(2) Institute of Evidence-Based Chiropractic, 6252 Rookery Road, Fort Collins, Colorado, USA
(3) Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario, USA
(4) Program in Integrative Medicine, University of Arizona, 1503 East University Boulevard, Tucson, Arizona, USA
(5) McMaster University, 1280 Main Street West, Hamilton, Ontario, USA
(6) Western Michigan University, 1903 West Michigan Avenue, Kalamazoo, Michigan, USA
(7) Palmer-West College of Chiropractic, 90 East Tasman Drive, San Jose, California, USA
Background: Adolescent idiopathic scoliosis (AIS) remains the most common deforming orthopedic condition in children. Increasingly, both adults and children are seeking complementary and alternative therapy, including chiropractic treatment, for a wide variety of health concerns. The scientific evidence supporting the use chiropractic intervention is inadequate. The purpose of this study was to conduct a pilot study and explore issues of safety, patient recruitment and compliance, treatment standardization, sham treatment refinement, inter-professional cooperation, quality assurance, and outcome measure selection.
Methods: Six patients participated in this 6-month study, 5 of whom were female. One female was braced. The mean age of these patients was 14 years, and the mean Cobb angle was 22.2 degrees. The study design was a randomized controlled clinical trial with two independent and blinded observers. Three patients were treated by standard medical care (observation or brace treatment), two were treated with standard medical care plus chiropractic manipulation, and one was treated with standard medical care plus sham manipulation. The primary outcome measure was Cobb, and the psychosocial measure was Scoliosis Quality of Life Index.
Results: Orthopedic surgeons and chiropractors were easily recruited and worked cooperatively throughout the trial. Patient recruitment and compliance was good. Chiropractic treatments were safely employed, and research protocols were successful.
Conclusion: Overall, our pilot study showed the viability for a larger randomized trial. This pilot confirms the strength of existing protocols with amendments for use in a full randomized controlled trial.
From the Full-Text Article:
Discussion
Detailed reviews by Harrison et al [35-37] and Rhee et al [14] suggest that preserving a normal sagittal spinal contour
may be important for long-term health. De Jonge et al [15] described how correction of lateral scoliotic curvatures
caused a spontaneous restoration of the sagittal spinal curves, suggesting that loss of sagittal spinal curves
may somehow be related to scoliotic curvatures. Scoliosis places otherwise symmetrical muscle groups
under longstanding, isometric, asymmetrical loads [38-41], which may compromise circulation within the muscle,
ultimately leading to myofascial trigger points and chronic inflammation [42]. Weinstein et al [3] reported
that scoliosis patients may retain high levels of function in later life, but do report higher instances of chronic back
pain.
In addition to higher instances of chronic back pain, significant psychological issues may arise from concern over
cosmesis and conventional treatment. Freidel et al [43] measured the self-perceived quality of life in women with
scoliosis using the SF-36 questionnaire. They concluded that the psychosocial aspects of scoliosis and scoliosis
treatment should be addressed in the treatment of this group of patients. Similarly, Sapountzi-Krepia et al [44]
described the psychological distress that adolescents encounter while going through bracing treatment for scoliosis.
A case-control study by Danielsson et al [45] identified a potential negative impact on the ability to
function sexually due to conventional treatment restraint or self-consciousness of physical appearance.
Aside from back pain and psychological disturbance, several studies also suggest that scoliosis affects more than
the musculoskeletal system. Curvatures of the thoracic spine are associated with restrictive lung disease due to
ribcage deformity and decreased chest wall compliance [46]. Chest wall compliance is inversely proportional to
the magnitude of the Cobb angle down to 10°, and vital capacity is reduced by decreased chest wall compliance
directly [46,47]. Exercise endurance is also inversely diminished with increasing Cobb angle, even in patients
with normal resting vital capacity [48]. Thoracic scoliosis may also cause shortness of breath and recurrent respiratory
infections [46,49]. Indeed, scoliosis affects more than the musculoskeletal system.
Concerning coronal Cobb angle measurement for scoliosis, manual radiographic measurement has consistently
shown good to excellent inter- and intra-observer reliability [50-53]. Previous studies demonstrate a manual Cobb
angle measurement error on full-spine radiographs of 2.5 – 4.5° [51-53]. However, to achieve this low error, it is
imperative that the same end vertebrae, same protractor, and same endplates are consistently chosen. Importantly,
these measurement errors were extracted from data collected on full-spine radiographs. Patient positioning can
significantly negatively impact measurements on fullspine radiographs [17]. The Cobb angle measurements in
our study were taken from sectional radiographs, which reduce the positional distortion caused by inconsistent
patient positioning. It is unknown to what extent the use of sectional radiography has on Cobb angle measurement
error, if any.
The treatments outlined here required home care exercises, as described earlier. However, these exercises, which
take up a combined 60 minutes per day, can be done in private, away from scrutiny by peers, neighbors, or relatives.
This is in contrast to bracing treatment, where the brace must be worn at least 18 hours per day to achieve a
good clinical result [54].
We placed the headweight, shoulderweight, and hipweights in areas designed to reduce our patient's specific spinal distortion patterns on radiograph. The patient was evaluated radiographically while wearing the headweight and shoulderweights to determine optimal position and
weight. Our repeated clinical observation has demonstrated that patients may visually appear to improve with
a shoulderweight in a certain position. However, they can look dramatically different on radiograph (migration
away from the vertical axis) than they appear in visual posture analysis. This is consistent with recent failed attempts to objectify visual posture analysis as a valid clinical tool [55]. It is prudent to develop alternative methods of evaluation to avoid unnecessary radiation exposure to
patients.
Because of the anterior wedging from T7–T10 in case #2, it is not surprising that over time a thoracic hyperkyphosis
and swayback developed in this patient. As a result,
marked anterior weight bearing of the head was required
to maintain a horizontal eye level, thus satisfying the postural
reflexes [56-61] Additionally, the marked forward
head posture elicits the pelvo-ocular reflex, causing a forward
shift of the pelvic girdle under the forward head
position [32]. Therefore, the postural distortions seen in
this case may represent compensatory changes over time
as a result of thoracic buckling, a posture known to commonly
cause increased mechanical stress at the spinal
transition areas [4,24]. Correcting these compensatory
postural changes proved to be a challenge, given that the
impetus for them (the anteriorly wedged thoracic vertebra)
could not be immediately, if ever, changed. However,
within the confines of the Hueter-Volkmann law, we postulate
that sustained correction of the asymmetrical
mechanical spinal loading may theoretically help these
vertebrae to remodel to some degree. Although the forward
head posture is a compensatory reaction to the
hyperkyphosis, the cervical spine soft tissue has likely
remodeled to the forward head posture, given the likely
duration of its existence [62]. Therefore, we felt that direct
correction of the forward head posture must also be
achieved to improve overall sagittal alignment, given the
neurological control and importance of head position on
upright spinal position [63]. This hypothesis remains to
be definitively evaluated.
The significance of cases #2 and #3 lies in the location of
the scoliotic curvatures. In the vast majority of cases, double
major curvatures usually maintain a right thoracic/left
lumbar pattern. In this case, the pattern was reversed,
showing a left thoracic/right lumbar scoliosis. Several
authors have previously discussed the unique presence of
a left thoracic – right lumbar curvature pattern. McCarver
et al [64] showed that only 1% of 550 patients with idiopathic
scoliosis had double major curvatures consisting of
a left thoracic – right lumbar configuration. Winter and
Lonstein [65] maintained that any left thoracic curvature
should be further evaluated for neurological abnormalities,
such as neurofibromatosis, spina bifida, or syringomyelia.
Finally, Schwend et al [66] also concluded that
additional testing was necessary in left thoracic curvatures,
given an observed higher incidence of neurological clinical
signs. Case #3 seems to correlate these findings given
the left thoracic scoliosis secondary to Scheuermann's Disease.
It is important to note, however, that treating the
Scheuermann's Disease itself was not our aim. Rather, our
goal was to reduce the thoracic scoliosis secondary to it.
We are not attempting to show that this treatment may
affect the Scheuermann's Disease. In this case, however,
additional testing was conducted at the initial time of discovery
of the scoliosis. Further, my initial neurological
examination also failed to produce any remarkable neurological
findings.
Recently, several authors have discussed the relationship
between the sagittal spinal contour and scoliosis
[14,15,67,68]. Harrison et al [35-37] have discussed the
pathophysiologic changes associated with the loss of the
sagittal curves. Based on this evidence, we decided that it
was important to the long-term outcome to address these
spinal parameters.
Cases #1 and #2 present what appears to be inconsistent
findings. Case #1 initially had a 23° cervical lordosis,
below asymptomatic 31–40° range identified by McAviney
et al [30], and the normal 34° identified by Harrison
et al [28]. However, case #2 displayed a 32° initial cervical
lordosis despite having a thoracic hyperkyphosis. In case
#1, the patient had 31 mm of forward head posture. Since
forward head posture reduces the magnitude of the cervical
lordosis [69,70], a 23° cervical lordosis may not be
normal for this patient. Additionally, recent evidence suggests
that sagittal balance may more closely correlate to
symptoms than sagittal alignment [71] Cervical lordosis
by itself may not provide an accurate assessment of normal
for each patient. Therefore, we suggest that both the
cervical lordosis and forward head posture be weighed
before a patient's cervical spine may be considered "normal."
In contrast, case #2 had a both a normal cervical lordosis
and forward head posture (32° and 22 mm,
respectively). Therefore, we classified this patient's cervical
spine as normal, despite the thoracic hyperkyphosis.
We feel that the 55° lumbar hyperlordosis is a direct compensation
for the swayback posture created by the thoracolumbar
vertebral remodeling. This is consistent with the
post treatment reductions in the swayback posture and
lumbar lordosis.
In the Pettibon system, most of the manipulative treatment
is not administered on a vertebral segmental basis.
Rather, it is delivered to a specific region of segments so
that the entire region may be mobilized. The goal of
manipulative therapy in the Pettibon system is to mobilize
several vertebral joints so that the rehab procedures
can target the joints while they temporarily have an
increased range of motion [33].
The purpose of the Pettibon Weighting System™ is to artificially
alter the centers of mass of the head, trunk, and
pelvis, causing reactive corrections by the postural reflexes
[72-74]. The goal of postural reflexes is to maintain efficient
body stance and locomotion using the least energy
expenditure possible [56,63,75]. In the present cases, each
patient was instructed to continue with their home exercise
routine on a once weekly basis in attempts to maintain
the change in spinal configuration.
The procedures that comprise the Pettibon system have
been previously examined in specific clinical cases [5,76].
Although these techniques have been investigated for preliminary
treatment of idiopathic scoliosis [5], they have
not, until this point, been used in cases of scoliosis due to
structural deformity or left thoracic primary curvatures.
Given the perceived results of the cases outlined here, it is
worthy of future investigations in such cases. However,
case reports and case series designs do not provide substantive
evidence of therapeutic effectiveness. This
remains the realm of properly conducted prospective clinical
trials.
Conservative treatment for scoliosis needs to be examined
much more closely in the biomedical literature, as side
effects [44-46] and compliance issues [54] make conventional
treatments such as bracing less attractive to patients
and parents of minor patients.
Conclusion
In this case series, we reported the clinical results for 3 distinct
types of scoliosis patients. While no firm conclusions
relative to cause and effect can be made from these results,
the moderation of the spinal curves may have merit.
Although reductions in self-rated disability and pain
scores were reported, they may not be attributable to the
improvement in spinal alignment. Further investigation is
required to determine the potential benefits of sagittal
spine alignment in the correction of scoliosis and other
health benefits.
![[SWIRL 2]](../GRAPHICS/SWIRL-2.GIF)