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Scoliosis Research: Sagittal Corrective Care

The current paradigm for the treatment of idiopathic scoliosis (IS) in the United States consists of observation from 10 to 30 degrees, bracing from 30 to 40 degrees, and surgery at 40 degrees.1,2,3 It is interesting to note that these demarcations were initially established as an arbitrary standard, and have since been generally accepted and never formally disputed.4

Since 1922, it has been recognized that the majority of scoliosis cases can be classified as having no directly attributable cause (idiopathic).5 Idiopathic scoliosis can be further divided into infantile (before 3 years), juvenile (4 to 8 years), adolescent (9 years until the end of growth), and adult (past skeletal maturity); these categories are typically assigned according to the age of detection, rather than when the true onset of scoliosis occurred.6

In 2004, CLEAR Institute presented a paper in BMC Musculoskeletal Disorders explaining a new approach to scoliosis care without bracing and surgery.7 Since then, there have been additional reports in the literature regarding the efficacy of chiropractic or osteopathic manipulative therapy in scoliosis – in combination with deep tissue massage and physical therapy – that have demonstrated positive results.8-10 Provided the use of a complete comprehensive approach, there is very little doubt that it is possible to reduce the rate of surgery in AIS treatment.11

It cannot be argued against that there is a need for the advancement of research into manners by which a mild case of scoliosis can be prevented from developing into a serious visible deformity.11a Also, there is increased need for physicians of all specialties to collaborate in the realm of scoliosis treatment.12
It is well-recognized that two of the main factors involved in the progression & etiology of idiopathic scoliosis (IS) are biomechanical and neuromuscular.13 It is also proposed that the biomechanical and neuromuscular factors involved in the progression of scoliosis contribute to a cyclical pattern that leads to further progression (‘vicious cycle’).14

Millner & Dickson described a biomechanical conceptual understanding of scoliosis in 1996 when they pointed out that, “For centuries, engineers have recognised that the mechanical behaviour of a column under load is influenced by geometry, as well as by material properties; it is clear that the spinal column also obeys these well-described laws.” They then went on to extrapolate on this concept when they described scoliosis as a viscoelastic, three-dimensional “buckling” of the spine in both the coronal and sagittal plane, and noted that successful reproduction of scoliosis in an animal model occurs only when the normal sagittal alignment of the spinal column has been disrupted.15 This sagittal disruption has been noted and confirmed by several other authors.16-21 Researchers have even been able to predict the thoracic kyphosis by evaluating the coronal thoracic curvature, the lumbar lordosis, and the slope of the first lumbar vertebra.22 New research has discovered that a kyphotic cervical curvature occurs more frequently in patients with severe scoliosis than in a normal population.23 Axial rotation of vertebrae has been implicated as a risk factor for progression of scoliotic curvature.24 A positive correlation between the degree of the sagittal & axial disruption and the magnitude of the resultant lateral curvature has been documented.25 It has also been documented that spinal imbalances have the capability of producing forces which can influence curve progression.26 It could be taken as an axiom that if certain forces are capable of influencing progression, other biomechanical forces should be capable of influencing the regression of spinal curvature, and it has been suggested that a chiropractic physician who understands the biomechanics of scoliosis may have a rationale for the treatment of scoliotic curvatures.27 Many authors have opined that the etiology behind so-called idiopathic scoliosis is extensively biomechanical and driven in a large part by neuromuscular imbalances.28,29 Addressing & reversing the neuromuscular & biomechanical imbalances should be the goal of any preventative or early-stage treatment, and could potentially be advantageous in the later stages of scoliotic deformities as well.