Because most chiropractors will see on average a couple of scoliosis cases in their practice each year they are often not familiar with the “best practices” for the management of a patient with scoliosis. This lecture is designed to help the practicing chiropractor better understand scoliosis so that they can provide optimal care for their patients with scoliosis.
Understanding the types of scoliosis is the first step in good chiropractic management for scoliosis, whether it be in scoliosis in adults or scoliosis in children. This is a guide for the professional to use to gain a better clinical insight into scoliosis treatment to help them better manage or co-manage their scoliosis cases.
The word is derived from the ancient Greek – σκολίωσις or “skoliosis ” which means “obliquity or bending”. On a plane x-ray it appears to be curved from side to side but in reality it is a far more complex three-dimensional deformity than that.
- Lateral Curvature of Spine (C or S Curve) >10 degrees
- 3 Dimensional Dysfunction of the Spine –Missing Dimension Rotational Dysfunctiona) Spiral of Spineb) Rib Hip & Lumbar Humpc) Dysfunction of Postural ms in the Spiral Lines of Bodyd) Counter Torsion of 3 Main Body Segments(Shoulder Girdle, Trunk, Pelvis)
- AffectsGeneral Population
- 2- 4% Adolescents (80% are female)
- 5- 10% Adults (18 – 49)
- Up to 30% in Adult females (50 – 55)
- Dancers and Gymnasts (up to 20%)
What Drives a Scoliosis?
Tighter curve Primary Driver of Curvature in Spine –(AIS – Genetic Pre-disposition Temporary Growth Plate Delay, Hemi-vertebra)
Mild, Long Sloping, Secondary to Another Problem Driving Curve
(ie: Short leg, pelvic obliquity, C1 Sublux, etc.)
Gravitional Effects on Scoliosis
Once a scoliosis curvature gets past about 25 degrees gravity starts to take advantage of it and causes it to progressively worsen at a slow rate of about 1 degree per year.
Repetitive Movements and Scoliosis
Re-enforces patterns of abnormal movement and causes the person to continue to collapse into their scoliosis curvature.
e) Hormonal Affects on Scoliosis
There are three pimary times in a woman’s life that a scoliosis have a propensity to progress rapidly.
Child Bearing Years
Risks for Rapid Progression of Scoliosis
There are many epigenetic factors that appear to cause a gradul progression in scoliosis but most that have the potential to cause a rapid progression are related to family history and growth factors.
- Younger the Onset of Scoliosis
- Greater the magnitude of curvature
- Family History of Rapid Progression
Risk for Slow Progression of Scoliosis
While the riks of a rapid progression usually stops at skeletal maturity these is still a chance of scoliosis progression Into adulthood once a curvature passes the 30 degree mark. After it reaches that threshold gravity starts to take advantage of it and slowly wornsen the curvature over time, unless something is done to stabilize the scoliosis back.
Goals of Clinical Evalation of Scoliosis
Identify the scoliosis curve pattern and degree of curvatures (C or S Curve, R Thoracic, L Lumbar, Double Major, Kyphosis, etc.) – Treatment must be specific for pattern
History (Pertinent Points)
- Family History of Scoliosis or Kyphosis? (Genetic Predisposition)
- When was any deformity first noticed? (Start & Duration of scoliosis)
- Have You Been Diagnosed with Scoliosis? If so, When was first diagnosed?(Type -Infantile, Juvenile, Adolescent, Adult Onset, Congenital, Neuromuscular, Traumatic, Mesenchymal, etc.)
- Females – Onset of Menses? (Growth Spurts)
- Males – Onset of voice change? (Growth Spurts)
- Major Growth Spurts? (Curvature Progression)
- Pain Related to Scoliosis? (Secondary Changes)
- Ever Been Treated for Scoliosis? (What’s Not Helped, What’s Worsened It)
- If so, What Kind of Treatment? (What’s Not Helped, What’s Worsened It)
- Ever had Orthodontic Treatment? (Maxillo-facial Connection)
- Ever had Foot Orthotics (Foot and Pelvic Imbalances)
- Headaches, Upper Neck Pain or Stiffness? (Upper Cervical Dysfunction)
- Trauma to the Spine (Initiating or exacerbating events)
- Breathing, Vascular or Digestive Difficulties (Heart, Lung & Intestinal – severe cases)
- Generalized Fatigue (Muscular Strain of holding body up Saps Energy)
Physical Examination –
Palpation of Spine (Particular attention to C1 and SI Joints)
- Adam’s Test – Use Scoliometer to Measure Trunk Rotation Angle to quantify for later comparison)
- Counter Rotation of Segments
(Shoulders, Rib Cage, Hips) Clockwise or Counterclockwise
- Tilt – (Shoulders, Rib Cage, Hips) – CW or CCW?
- Lateral Shift of Spine – Coronal and Sagittal
- Waist Angle Open – R. or L.?
- 3D Scapular Deformity
- Apparent Leg Length – (Short Leg R. or L.?) 7
- True Leg Length (One leg is actually longer than the other. Measured from the greater trochanter to medial malleolus)
- Foot Imbalances – Valgus or Varus, heal wear, etc.
Height – Standing & Sitting (Adolescents)
Reflexes – (biceps, triceps, brachioradialis, knee ankle, abdominal, Babinsky)
Vestibular Function Screening Tests*
Romberg’s – Sway eyes open & closed – difference suggests vestibular problem
Fukuda Stepping Test – (March with Eyes Closed for 100 steps + turns 45 degrees
Eye Movements – Erratic tracking of eye(s) on Cranial Nerve Testing
* If any of the vestibular function screening tests are positive then a referral to a Chiropractic Neurologist and MRI of brainstem to further evaluate vestibular, cerebellar and ocular function.
X-ray Evaluation – PA and Lateral Full Spine (breast shields, pelvic shields and T filters
*Very Important – Orient film so as looking at it from the back. (view spine this way)
Print Copy of x-rays to have available when treating patient (take picture on camera phone)
- Curve(s) Apex
- Upper Limit of each Curvature
- Lower limit of each Curvature
- Cobb Angle Measurement(Mild = 10 – 25, Moderate = 26 – 40, Severe > 40)
- Center Sacral Line (CSL)
- T1 Relative to CSL
- T12 Relative to CSL
- Rib Angle Imbalances (R. to L.)
- Rotation of T/S (CW, CCW or Neutral)
- Rotation of L/S (CW, CCW or Neutral)
- Tilt of L3 on L4 relative to Horizon (CW, CCW or N)
- Pelvic Tilt (S1) (CW, CCW or Neutral)
- Risser Sign 0 – 5 (Stage of Growth for Adolescents)
- T/S Kyphosis Measurements – (Normal/Hyper/Hypo)(40 degrees +/- 10 degrees)
- L/S Lordosis Measurement (Normal/Hyper/Hypo)(44 degrees +/- 12 degrees)
- Apex of Kyphosis
- Apex of Lordosis
- Sagittal Balance of C7
- Sagittal Balance of T12 7
Chiropractic Management for Scoliosis
Spinal adjustments are often a part of chiropractic management of a scoliosis, but adjusting a scoliositc spine is very different than adjusting a non-twisted spine. With scoliosis you need to be sure that the adjustments are specifically directed to reduce the curve pattern and are in the direction to de-rotate the spine; otherwise you risk inadvertently worsening the curvature.
Paradoxially, one of the most critical portions of the spine to make sure is in proper alignment is the first cervical vertebra, called the atlas. It is named so since it sits directly underneath the skull and balances the head over the body.
For more information about how adjusting the atlas may help a scoliosis watch this video:
Adjusting involved segments below the atlas can also be important for the management of scoliosis but finding a practitioner who has knowledge and experience in adjusting your particular curve pattern is essential. For more information about how to properly adjust a scoliosis spine see the following video:
It should be noted that the adjustments should not be the only treatment used for the management of scoliosis. Research studies show that a treatment plan that combines chiropractic adjustments with specific corrective movement spinal rehabilitation therapy is the most effective method of chiropractic treatment.
Deciding on What Other Types of Treatment to use in conjunction with the adjustment should be based on the scoliosis curvature pattern and degree of the curve. In general, the therapies should be unilateral and done only into the direction of correction and also do not adversely affect other areas of the spine.
When establishing a treatment plan in today’s medical/legal environment it important that it have “Evidence Based” support, even when the “Standards of Care” in the Medical arena are so lacking (as is the case with non-surgical scoliosis treatment), otherwise, you still risk a malpractice suit if your treatment plan is outside of that standard.
Therefore, every Chiropractic treatment plan should, in someway, address or adhere to these “standards” in some way. So what are the current medical standards for the treatment of scoliosis?
The Current Medical Standard of Care for Scoliosis
Moderate Scoliosis (26 – 40 degrees) – Static Bracing* with Physical Therapy and Exercise
Severe Scoliosis (>40 degrees) – Surgery
*For most chiropractors static bracing goes against all that we hold true and it should. From a chiropractic standpoint our bodies are intended to move and keeping it moving is a critical part of good health. That’s why so many chiropractors, on principle are against scoliosis bracing. Most scoliosis braces are designed to immobilize the spine, much like a body cast.
Yet, there is one type of scoliosis brace that does not immobilize the spine, instead it flexible and moves with the body. It is called the SpineCor Dynamic Scoliosis brace (or Orthosis). In fact, it probably shouldn’t even be called a scoliosis brace because it is more like a corrective movement rehabilitative device that you wear, rather than a rigid brace.
Chiropractic Treatment Plans (May Include the Following):
Here are a variety of recommended treatment plans for scoliosis based on the severity of curvatures.
Mild Scoliosis (10 – 25 Degrees)
- Adjustments – Specific for Scoliosis Pattern (R. T/S, L. L/S, Double Major, etc.)
- Apex of Curvature – Avoid generalized adjusting, low force in opposite direction of curve pattern
- Preload Spine in De-rotation Before adjusting
- Specific Adjusting for C1 or SI joints
- Full length shoe lifts or custom orthotics (may also need external shoe lift too)
- Upper Cervical Specific Adjusting (Atlas Orthogonal, NUCCA, Grostic)
- Chiropractic Adjustments for scoliosis should be performed in conjunction with scoliosis specific exercise treatments as well. (1)
- Soft Tissue Stretching
- A.R.T. Or Other Specific Myofascial Release of Adhesions in the Postural & Spiral Lines
- Flexion/Distraction with Specific de-rotation
- Specific Axial Traction with De-rotation (Clear Chair)
- Wobble Chairs
- Scoliosis Specific Exercises – Corrective Movement Therapy
- Schroth Method, Nu-Schroth, SEAS Method, Pettibon Weighting for Scoliosis
Goal is to establish new movement patterns that lengthen and strengthen specific muscles on the inside of the scoliosis cuvratures to help de-rotate spine and restore balance to spine to reduce strain to muscles on the outside of the curvature.
Schroth Method has been around for over 80 years and well established results in research literature. (2)
- Can Include SpineCor Tension Orthosis
Moderate Scoliosis (26 – 40 degrees)
- May Include Any of the Above That Are Clinically Warranted in Combination with Below
- Recommend Co-managing Cases with a Scoliosis Specialist in your field that can provide Scoliosis Specific Exercises (such as the Schroth Method) and the following types of treatment:SpineCor – A Dynamic Tension Orthosis – Corrective Movement Therapy
Dynamic approach used instead of a Static Braces because hard braces immobilize the spine and can cause atrophy & stiffness that can cause worsening curvatures after brace is removed. From a medical legal perspective this allows you to stay in keeping with the “Standard of Care” for treating a moderate scoliosis because SpineCor is considered a brace.
SpineCor Dynamic Tension Orthosis
- Developed by 2 Orthopedic Scoliosis surgeons who got a $12 million grant by the Canadian Government to study scoliosis.
- Moves with Body to promote movement into the direction of correction while wearing it. Helps establish new movement patterns in body that helps the body de-rotate and un-tilt the spine. 7
- Lasting Results with SpineCor – In 2 & 5 year post treatment studies vast majority retain their correction. Up to 1/3 had further reductions of their curvatures than after completing the treatment program.
- 20 Years of SpineCor Clinical Research Backed results(3)
Comprehensive Scoliosis Treatment (Combines Dynamic Bracing and Scoliosis Exercise)
- Society on Scoliosis Orthopedic and Rehabilitative Treatment (SOSORT) is an international organization of orthopedic surgeons, physical therapists, chiropractors and others specializing in treatment of scoliosis.
- SOSORT endorses a comprehensive treatment approach for adolescent idiopathic scoliosis as the best method for stopping the progression of scoliosis curvatures and avoiding surgery. (4)
Severe Scoliosis (> 40 degrees)
- Recommendation to see an Orthopedic Surgeon for an evaluation, if they haven’t already (Standard of Care)
- Don’t Recommend Managing these cases alone
- Comprehensive Scoliosis Treatment Program is Highly Recommended
- 15 Locations Across the US
- Doctors of Chiropractic – Support chiropractic and can help you better manage case
- Provide Best Possible Treatment for Patient while Retaining Control of Your Patient
- For More Info About Co-Managing Your Scoliosis Patients with our scoliosis specialists contact Dr. Brett Diaz, D.C. at (800) 943-1254.
Clinical Research Support for Scoliosis Treatment Alternative’s Chiropractic Management for Scoliosis