Review of the Literature: Non-operative Scoliosis Treatment
By Marc Lamantia M.S. D.C.,DACNB
Progression and Protocols : Without intervention, Adolescent idiopathic scoliosis
(AIS) is a condition which is likely to progress between the time of detection and
the time of skeletal maturity.1 This makes early detection, with the intent of early
intervention of paramount importance to the success of a non-surgical treatment
regiment.2 Unfortunately, the current medical standards recommend observation
until a curvature has shown progression of five (5) degrees or more, and the
measurement exceeds thirty (30) degrees. This leaves a very small window
where brace treatment is suggested, and more importantly lessens the patients’
chances of successful non-surgical treatment. Studies confirm, as the curvature
increases, the likelihood of further progression increases as well. 3 Therefore, the
current standards are not congruent with the scientific observations reported in
these studies. Early intervention should be coupled with early detection.
Nachemson et al 4 reported both girls and boys between the ages of ten (10) and
twelve (12), who had at least a thirty (30) degree curvature at the time of
detection, have the highest risk of progression before skeletal maturity,
approaching 100%. If this is in fact accurate, recommendations of early
screening and early intervention until the patient reaches skeletal maturity make
the most sense. Unfortunately, the pediatric orthopedic community continues to
recommend watchful waiting, often waiting until surgery is the only option.
Although the highest risk of progression is clearly between the time of detection
and skeletal maturity, a second significant progression has been reported to
occur between skeletal maturity and a thirty (30) year follow-up.5 In a longitudinal
study, Weinstein et al (1981) followed one hundred and twenty (120) patients
over forty (40) years. The authors reported a high likelihood of adult progression
in those patients with thirty (30) degree lumbar and thoracolumbar curvatures at
the time of skeletal maturity. Thoracic curvatures of fifty (50) degrees or more
were also reported to have a high likelihood of progression during this same time
frame. This is an important study because it highlights the necessity to treat
lumbar curvatures which are thirty (30) degrees or more, even when progression
is not suspected.
Although bracing alone has been the only accepted medical standard since
1951, as of 1984, there had not been any prospective or randomized clinically
controlled studies to demonstrate its efficacy. In 1984, Miller et al demonstrated
insignificant differences between bracing and observation in regards to the
natural progression of AIS. 6 Researchers such as Focarile et al (1991) and
Goldberg et al (1993) corroborated these findings, and went as far as to
recommend discontinuance of screening programs and challenged the
usefulness of bracing at all.78 In a 1997 article printed in the Journal of Bone and
Joint Surgery, a meta-analysis was performed to evaluate the efficacy of Non-
Operative treatment of AIS. Nineteen studies were included in the analysis, with
over 1900 participants. Although the findings clearly showed full time bracing (23
hours per day) did in fact significantly alter the natural progression of the disease,
current trends continue towards reduced bracing hours and in some cases, no
recommendation of bracing at all.9 Furthermore, the type of brace being
prescribed was also a significant variable. The Charleston brace was significantly
less successful than the Milwaukee brace (64%), however the authors admit
difficulties in comparing the cases due to reporting parameter and classifications
amongst patient groups.
In general, rigid bracing uses three point pressure systems to reduce the lateral
deviation of the spine. More recently, the Spinecor Brace has been gaining
popularity among non-surgical providers (we have been providing Spinecor in our
offices for the past 5 years). Invented in 1992, the brace consists of a fabric
bolero designed to help control rib cage positioning, four fabric elastic band and a
pelvic belt. The brace is fitted to induce a corrective posture as first described by
Dr. Christine Collaird Collaird16. Depending upon curvature location the brace is
fitted accordingly. Spinecor is the first dynamic elastic tension brace designed to
provide neuromuscular rehabilitation through de-rotation of the rib cage in
relation to the shoulder and pelvic girdle. In a study published in the Journal of
Pediatric Orthopedics, patients fitted with the Spinecor brace were monitored
continuously for two years beyond the weaning period. Of the 172 participants
with a definitive outcome, thirty-nine required surgery prior to skeletal maturity
and twelve dropped out; 14 patients were weaned out due to positive outcomes
and stability prior to skeletal maturity. So the remaining one hundred and one
patients observed had a 59.4% success rate, with an additional 10.6% who had
progression of more than 6 degrees but did not require surgery. Of the 59.4%
who achieved curvature reduction or stabilization, 95.7% maintained the
corrections achieved two years prior. Five (5) of the patients continued to
improve despite being out of brace for two years. Interestingly, the authors report
lumbar curvatures to respond most favorably (83.3%), then thoracolumbar
curvatures (69.4%), Thoracic (56.8%) and double curvatures of equal
magnitudes being least favorable (42.8%). Furthermore, when initial curvatures
measured between 25 and 29 degrees the rate of success was 70.1% as
compared to 50.2% success when the curvatures measured from 30-40 degrees.
These findings are consistent with findings of others who report early detection
and intervention as necessary for the most successful outcomes. Furthermore,
these findings are suggestive that Spinecor is more successful than any other
brace when the patient begins treatment with curvatures measuring between 25
and 29 degrees.
In May 2007, Dr. Gary Deutchman and I presented the first study on the use of
Spinecor in adults entitled, A retrospective study of twenty-three adults treated
for scoliosis using the Spinecor Orthosis. 10Although adult treatment has been
relegated to pain relief, it was our belief that neuromuscular rehabilitation would
be a successful approach to reducing spinal deformities in adults as well as
children. The patients were separated into three groups based on curvature
location. The patients in the "thoracic" group (n = 20) had a mean average
change of -5.27 degrees. This is considered by the Scoliosis Research Society to
be a borderline significant reduction. The "thoracolumbar" group (n = 3) had a
mean average change of -6.0 degrees, and the Lumbar group (n = 15) had a
mean average change of -4.40 degrees. A questionnaire survey revealed the
adult group to be “extremely satisfied” and would recommend Spinecor to other
adults. I should also add, due to the comorbid nature of scoliosis, chronic pain
and degenerative joint disease, alterations were made to the brace
configurations on a case by case basis. Many of the adults treated were fitted in
an extension-type set-up, (often used to treat kyphosis), irrespective of curvature
location. After the patients were tolerant of brace wearing, we then switched
many to a more conventional “Spinecor” set-up as described by Collaird.
Although pain reduction was the most significant finding, this study highlighted
the possibility of adult curvatures responding to non-surgical management. In my
experience, adults with scoliosis are unaware that anything can be done to help
them in regards to curvature or pain reduction. Of course, cosmesis is another
consideration, improving posture and outward appearance is oftentimes the
motivating factor for adults who seek treatment. Studies performed by Griffet et al
indicated gibbosity reduction as a significant outcome of treatment with the
spinecor brace.11
Neuromuscular Influences in Idiopathic Cases: Neuromuscular rehabilitation of
the posture in both adults and children should include a thorough neurological
evaluation of the vestibular system. Studies confirm the presence of vestibular
disturbances in scoliosis patients12 which may not resolve without specific
rehabilitation techniques. In an article published in the Scoliosis Journal 2007, I
reported on my findings of vestibular dysfunction in a population of scoliosis
patients.13 Vestibular dysfunction left untreated influences postural tone, in
particular extensor musculature activity during dynamic balance. This includes
ambulation as well as specific balancing tasks. Studies confirm abnormal
activation of extensor musculature during walking in scoliosis patients.14 The
authors of this particular study were concerned with post operative changes, but
failed to explore possible non-surgical approaches to influencing muscle
recruitment patterns. It is my belief, from a clinical standpoint, following a
comprehensive evaluation of vestibular function, movement analysis, gait
evaluation and the like, patients can be trained to optimize postural muscle
synergies through repetitive movement therapy and vestibular rehabilitation.
Although vestibular rehabilitation is well accepted, scoliosis care providers rarely
offer evaluations and treatment along these lines. Interestingly, the adolescent
population with vestibular pathology, are often without symptoms, much in the
same way they are typically without pain. On the other hand, the adult population
often suffers from dizziness, imbalance, anxiety and vestibular headaches as a
direct result of their vestibular disorder, and experience chronic pain syndromes
as well. For those who embark on a course of postural rehabilitation for patients,
whether it be working on sagital curve restoration, or otherwise, its efficacy will
be lessened in the presence of abnormal vestibulospinal function. Treatment of
any movement disorder is most effective when vestibular function is robust, as
would be the case in any population, adult or adolescent. To date, vestibular
rehabilitation, and really any rehabilitation of movement remains controversial in
the United States.
Imaging for the 21st Century:
Since the first spinal x-ray in 1895, the healthcare professions have championed
the use of x-ray as the imaging of choice to visualize the spine. Despite its
shortcomings: two dimensional rendering of a three dimensional structure and
the ill effects of ionizing radiation, radiography has served us well helping to
uncover the sometimes grotesque deformities and anomalies which are
oftentimes effectively hidden beneath the skin. But let’s face it, using ionizing
radiation repeatedly in a female population during the time of rapid proliferation of
radiation-sensitive tissues is less than ideal. This is especially concerning to me
when I receive x-rays exposed in most orthopedic offices; without sufficient
collimation, filtering or breast and gonadal shielding. New technology has
emerged and will undoubtedly reduce our need to expose follow-up x-rays.
Raster Stereography was introduced many years ago, and is now used
extensively in scoliosis management in throughout Europe. Through the use of
an optical light scanner and computational models, Raster Stereography
software produces a 3 dimensional representation of the spine without using
ionizing radiation. The software analyzes 10,000 points on the back, effectively
mapping both the sagital and frontal contours of the spine. A recreation of the
spinal column is formulated using sophisticated modeling programs, and the end
result is for the most part, dead on accurate. In 2008, researchers confirmed it to
be both reliable and sensitive to curvature progression during longitudinal studies
on scoliosis patients.17 This is very important to us in the Chiropractic profession,
as it will allow us in clinical practice to reduce the amount of x-rays necessary
throughout a patient’s lifetime. Our offices now boast one of the first Formetric
Raster Stereography scanners in the United States. Formetric also include a
mechanically driven dynamic footplate which allows for further testing of balance,
vestibulospinal function and podiatric function. I truly believe this technology can
help to enhance our patient care, as well as our public image as being concerned
with the welfare of our young people. Clearly, there is still a need for x-ray in the
management of scoliosis, however, its role will diminish as newer imaging
technologies like these become commonplace in Chiropractic practices.
Marc Lamantia D.C.,DACNB and Gary Deutchman D.C. are co-founders of
Scoliosis Systems LLP. They see patients in 14 locations in 7 states including
NY, FL, IL, GA, AZ, CA, TX, NC, and CO. For more information visit
www.scoliosissystems.com or call 1-800-281-5010
1 Rowe D., Bernstein S., Riddick M., et al. A meta-Analysis of the Efficacy of Non-Operative
Treatments for Idiopathic Scoliosis. J Bone Joint Surg 1997: 79-A; 664-74
2 Focarile, F.;Bonaldi, A.; Giarolo, M.;Ferrari, U.; Zilioli,E.; and Ottaviani, C.: Effectiveness of
nonsurgical treatment for Idiopathic Scoliosis. Overview of Available Evidence. Spine 1991;
15:395-401
3 Weinstein, S., Zavala, D., Ponseti, I.; Idiopathic Scoliosis. Long-term follow up and prognosis in
untreated patients. J. Bone and Joint Surg. June 1981: 63-A:702-712
4 Nachemson, A.,: Lonstein, J. E.; and Weinstein, S. L: Prevalence and Natural History
Committee report. Rea dat the Annual Meeting of the Scoliosis Research Society, Denver
Colorado, Sept 25, 1982
5 Weinstein, S., Zavala, D., Ponseti, I.; Idiopathic Scoliosis. Long-term follow up and prognosis in
untreated patients. J. Bone and Joint Surg. June 1981: 63-A:702-712
6 Miller, J.; Nachemson, A.; Schultz A.: Effectiveness of braces in mild idiopathic scoliosis. Spine
1984; 9:632-635.
7 Focarile, F.;Bonaldi, A.; Giarolo, M.;Ferrari, U.; Zilioli,E.; and Ottaviani, C.: Effectiveness of
nonsurgical treatment for Idiopathic Scoliosis. Overview of Available Evidence. Spine 1991;
15:395-401
8 Goldberg, C.;Dowling, F.; Fogarty, E.; and Moore, D.: School Scoliosis screening and the U.S.
Preventive Services Task Force. An examination of Long-term results. Orthop. Trans. 1995-1996;
19:590-591
9 Rowe D., Bernstein S., Riddick M., A meta-Analysis of the Efficacy of Non-Operative
Treatments for Idiopathic Scoliosis. et al. J Bone Joint Surg 1997: 79-A; 664-74
10 Deutchman, G.; Lamantia M.,; Indelacato J.; Raykhman M.: A Retrospective Study of twenty
three adults treated for scoliosis using the Spinecor Orthosis. From 4th International Conference
on Conservative Management of Spinal Deformities Boston, MA, USA. 13–16 May 2007
Scoliosis 2007, 2(Suppl 1):S23doi:10.1186/1748-7161-2-S1-S23
11 Griffet et al. Relationship between gibbosity and cobb angle during treatment of idiopathic
scoliosis with the spinecor brace. Eur Spine J (2000) 9:516-522
12 Manzoni D, Miele F.Dipartimento di Fisiologia e Biochimica
Vestibular mechanisms involved in idiopathic scoliosis (Arch Ital Biol 2002 Jan;140(1):67-80
Universita di Pisa, Via S. Zeno 31, I-56127 Pisa, Italy)
13 Lamantia et al. A retrospective study of thirty six cases of vestibular hypofunction in
adolescents with idiopathic scoliosis. Scoliosis Oct 2007. 2(suppl 1):s37.
14 Hopf C, Scheidecker M, Steffan K, Bodem F, Eysel P. Orthopaedic Department, Lubinus Klinik
Kiel, Germany Gait analysis in idiopathic scoliosis before and after surgery: a comparison of the preand postoperative muscle activation pattern. Eur Spine J. 1998;7(1):6-11
15
SPINECOR: a new therapeutic approach for idiopathic scoliosis.
Coillard C, Leroux MA, Badeaux J, Rivard CH.
Research Center, Sainte Justine Hospital, 3175 Côte Ste Catherine, Montreal, Canada.
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16
Schulte TL, Hierholzer E, Boerke A, Lerner T, Liljenqvist U, Bullmann V, Hackenberg LRaster
stereography versus radiography in the long-term follow-up of idiopathic scoliosis.
Department of Orthopedics, Münster University Hospital, Albert-Schweitzer-Strasse 33, D-48149
Münster, Germany. J Spinal Disord Tech. 2008 Feb;21(1):23-8