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CLEAR Scoliosis Treatment: Clinical data proves effectiveness in treating scoliosis

The article, “Scoliosis treatment using a combination of manipulative and rehabilitative therapy: a retrospective case series,” published by Drs. Morningstar, Woggon, & Lawrence in BMC Musculoskeletal Disorders, on September 14th, 2004, was a landmark in the realm of conservative scoliosis treatment.

Within two years of its publication, it achieved the status of Most-Highly Accessed Article of All-Time in this journal, and continues to hold this title as of 2009, with over 36,000 views (number two has just under 24,000).

Since 2004, there have been additional reports in the literature regarding the efficacy of chiropractic or osteopathic manipulative therapy in the treatment of scoliosis, in combination with deep tissue massage and physical therapy, that have demonstrated positive results. Our most recent research endeavor followed 140 patients from ages 9 to 84 with Cobb Angles ranging from 5 to 109, and demonstrated an average reduction of 37.7% after 12 visits. 23 patients were no longer classified as having clinically-diagnosable scoliosis after treatment. (full text can be found at bottom of this blog)

Unlike a surgical or braced reduction of the Cobb Angle, the reductions achieved through our methods also correlate with improved lung function, increased rib expansion, decreased pain, increased physical functioning, and better quality of life overall.

Treating the patient and the cause, not just the curve.

References:

1) Chen KC, Chiu EH: Adolescent idiopathic scoliosis treated by spinal manipulation: a case study. JACM 2008, 14(6):749-751.
2) Brooks WJ, Krupinski EA, Hawes MC: Reversal of curvature magnitude in response to physical methods: a 15-year followup in an adult female diagnosed with moderately severe scoliosis at age eleven years. Scoliosis 2007, 2(Suppl I):P2. From: 4th International Conference on Conservative Management of Spinal Deformities, Boston, MA, USA. 13-16 May 2007.
3) Morningstar MW, Joy T: Scoliosis treatment using spinal manipulation and the Pettibon Weighting System

Case Report

Scoliosis treatment using a combination of manipulative and rehabilitative therapy: a retrospective case series on 140 patients with adolescent or adult idiopathic scoliosis.

Woggon D*1, Kalla W2, Gulliver K3, Chong S4, Woggon A5                                                                                              

Address: 1Director, CLEAR Institute; 437 North 33rd Ave; St. Cloud, Minnesota 56303; 2Director, Precision Spine Chiropractic; 350 Orchard Road Shaw House #13-02; Singapore 238868; 3Associate, St. Cloud Chiropractic Clinic; 437 North 33rd Ave; St. Cloud, Minnesota 56303; 4Associate, St. Cloud Chiropractic Clinic; 437 North 33rd Ave; St. Cloud, Minnesota 56303; 5Director of Research, CLEAR Institute; 2618 Electronic Lane, Suite 102; Dallas, Texas 75220.

Email: Dennis A. Woggon* - This email address is being protected from spambots. You need JavaScript enabled to view it. ; Will Kalla – This email address is being protected from spambots. You need JavaScript enabled to view it. ; Kristin Gulliver – This email address is being protected from spambots. You need JavaScript enabled to view it. ; SuYen Chong – This email address is being protected from spambots. You need JavaScript enabled to view it. ; A. Joshua Woggon – This email address is being protected from spambots. You need JavaScript enabled to view it.

* Corresponding author

Abstract

BACKGROUND:  Scoliosis is the presence of 1 or more lateral curves of the spine.  Although defined as a side-to-side deformity, it involves all three dimensions.  The majority of scoliosis cases have no known cause (idiopathic).  There are biomechanical & neuromuscular aspects that contribute to the progression of idiopathic scoliosis.

METHODS:  140 adolescent & adult patients diagnosed with idiopathic scoliosis were treated with a combination of spinal manipulation therapy and physical rehabilitation.  Cobb Angle was the primary outcome assessment used.

RESULTS:  After an average of 12.6 treatment sessions, the subjects demonstrated an average reduction in the Cobb angle of 12.7 degrees.  23 patients (16.4%) were no longer classified as having clinically-diagnosable scoliosis post-intervention.

CONCLUSIONS:  Due to the observational nature of the study, no conclusions can be drawn by the authors as to the interpretation of the results.  Additional research into how spinal manipulation therapy combined with physical rehabilitation may be able to intervene in the natural history of scoliosis is merited.

 

Background

Scoliosis is a three-dimensional spinal deformity characterized primarily by a lateral deviation in the coronal plane.1

Since 1922, it has been recognized that the majority of scoliosis cases can be classified as having no directly attributable cause (idiopathic).2  It is likely than the causes of scoliosis are multifactorial, and the onset may be indirectly affected by a variety of factors, ranging from genetic to environmental.3-6

Idiopathic scoliosis (IS) is often described as asymptomatic, although it can be associated with changes in pulmonary function, which does not always correlate with the degree of curvature –patients with mild IS may present with reduced vital capacity (VC), and patients with severe curvature may present with VC within normal limits.7-14  Patients with no readily apparent pulmonary deficiencies may reveal decreased ventilatory function during maximal exercise.15,16  Cosmetic appearance and self-image may be affected.17-22  Pain is not always present in idiopathic scoliosis, although it increases in incidence & severity with age in both adolescents & adults.23-27

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 when the scoliosis occurred.28   While there may be some overlap between the top range of juvenile IS and the bottom range of adolescent idiopathic scoliosis (AIS), juvenile curves are similar to adolescent curves.29 

Scoliosis is the leading orthopedic problem seen in school age children.30  Two to four percent of children 10 to 16 years of age are diagnosed with adolescent idiopathic scoliosis.31  In 3,210 female college students (mean age 19.7 +/- 2.1 years) screened over a 3-year period, scoliosis was present in nearly 12%.32  This is similar to the 15% incidence rate reported in a screening of one-hundred 20 to 23 year-old college students.33  Scoliosis was found in 8.85% of adults over 40 using lumbar DEXA scans; in 19.9% of 1299 adults presenting with low back pain with lumbar MR imaging; and, in 68% of healthy adults over 60 screened via radiograph.34-36  The prevalence of scoliosis increases with age.34

The current paradigm for the treatment of adolescent idiopathic scoliosis (AIS) in the United States is based upon radiographic measurement of the lateral deviation using the method of Cobb Angle, and consists of observing the curvature from 10 to 30 degrees, bracing from 30 to 40 degrees, and surgery at 40 degrees.37-39  These demarcations were initially established as an arbitrary standard, but have since been generally accepted and have never been formally disputed.40

In the treatment of AIS, the rationale for observation of curves below 30 degrees is based upon the premise that, once the patient reaches skeletal maturity, the scoliosis will not progress.

Reamy & Slakey stated in 2001 that only ten percent of cases of AIS will progress and require surgical intervention.31  However, in 1969, Collis & Ponseti documented a mean progression of 15 degrees in 215 cases of AIS after cessation of spinal growth.41  Weinstein and Ponseti in 1983 showed that 68% of cases of scoliosis progress after skeletal maturity.42  Korovessis at al reported a mean progression of 2.4 degrees per year over the course of 5 years in skeletally mature patients.43  Danielson and Nachemson in 2003 found that 36% of adolescents with scoliosis had progressed by more than 10° after 22 years.44  In adult patients with documented progression, the rate of progression is linear and can be used to establish an individual prognosis.45

Bracing treatment is applied with the goal of stabilizing the curvature and reducing the chance of surgical intervention.  In certain populations, it is effective in doing so; in others, there appears to be no difference between brace treatment and observation only.46  The side effects of brace treatment can include psychological effects such as stress, anxiety, fear, anger, shame, social withdrawal, & depressed mood, and physical effects such as pain, discomfort while being seated or engaging in physical activities, & impaired cardiopulmonary function while in the brace.47-50

Spinal fusion surgery for scoliosis is performed for AIS when bracing fails to stabilize a progressing curvature, and for adult idiopathic scoliosis to manage pain, cosmetic deformity, pulmonary problems, and/or continued progression after skeletal maturity.  The goal of scoliosis surgery is to reduce the Cobb Angle, halt progression, decrease pain (if present), and reduce the cosmetic deformity.51  For most patients, reduction of the Cobb angle can be achieved through one or more spinal fusion surgeries; however, surgery has not been proven to be a reliable way to relieve back pain, correct the cosmetic deformity, or halt progression; it is accompanied by a risk of complications, and follow-up re-operations may be necessary in some cases.52-54

Adult idiopathic scoliosis is generally regarded as undeserving of treatment unless merited by pain, cosmetic reasons, pulmonary problems, and/or progression.29  Bracing is traditionally recommended only for skeletally immature patients; surgery is the sole recommended treatment for adults with severe scoliosis.  Surgery for adult idiopathic scoliosis, in a review of 11 studies, was shown to have a 44% (SD 24) pooled rate of complications.53  When previous cardiopulmonary compromise is evident, 23% of operated adult patients die of post-surgical complications within one year.54  Severe scoliosis is often accompanied by cardiopulmonary compromise.14,55,56

There is a need for advancement of research into manners by which a mild case of scoliosis can be prevented from developing into a serious visible deformity.53  Also, there is increased need for physicians of all specialties to collaborate in the realm of scoliosis treatment.58  The goal of this study is to provide evidence to promote research into alternative methods of scoliosis treatment and more extensive collaboration amongst physical rehabilitation specialists. 

Manual therapy alone does not significantly alter the natural history of scoliosis; research supports a comprehensive approach to the treatment of idiopathic scoliosis. 59,60   The results of combining manipulative & rehabilitative therapy in 19 patients with scoliosis was presented in 2004.61  Since 2004, there have been additional reports in the literature regarding the efficacy of chiropractic or osteopathic manipulative therapy in the treatment of scoliosis, in combination with deep tissue massage and physical therapy, that have demonstrated positive results.62-65

 

METHODS

Procedures

137 patients presented with idiopathic lordoscoliosis; 3 patients presented with idiopathic kyphoscoliosis and a previous orthopedic diagnosis of Scheuermann’s Disease.  Patients were categorized based upon the age of presentation for treatment, with 65 patients ages 9 to 17 being classified as adolescent, and 66 patients ages 18 to 64 as adult.  There were also 9 patients ages 65 and older which were classified into a third group, informally termed geriatric idiopathic scoliosis.  The age range of the subject group was 9-84 years of age, with the mean age being 28.1 (SD: 18.7).  115 patients (82%) were female and 25 (18%) were male.  In 111 (79.3%) patients, the thoracic convexity was to the right; in 25 (17.9%), the thoracic convexity was to the left.  Four (2.8%) presented with a single lumbar curve.  The Cobb Angles ranged from 5 to 109 degrees, with the mean Cobb Angle being 37.2 degrees (SD: 19.7).

The patients presented for treatment of idiopathic scoliosis at the Saint Cloud Chiropractic Clinic in Saint Cloud, Minnesota.  All patients were negative for malignancy, fracture, previous arthrodesis, and scoliosis secondary to congenital or pathologic disorders.  Informed consent to treatment & to the collection of data for research purposes was obtained from all patients. 

First, a series of radiographic images were obtained of each patient.  The views taken were: standing barefoot scoliosis, seated lateral cervical neutral, flexion, and extension; seated nasium with head clamps; seated base posterior with head clamps; seated lateral lumbar; and seated anteroposterior lumbopelvic.  All of these radiographs were taken in an identical manner, where focal film distance, center ray position, patient position, and cassette size were clearly specified (see Table 1.1).  Each film was sent to an independent examiner with 17 years’ experience in x-ray analysis, who had no direct contact with any of the patients, for review.

Table 1.1 – Radiographic Protocols

 

Focal Film Distance

Center Ray Position

Patient Position

Cassette Size

Lateral Cervical Neutral

60”

C1

Seated, with hips, knees, & ankles at 90⁰.

10” x 12”

Lateral Cervical Flexion/Extension

60”

C1

As LCN.  Go into full flexion/extension 5 times; drop chin then flex with no active muscle contraction for flexion; raise chin then extend with no active muscle contraction for extension.

10” x 12”

Base Posterior

42”

Through C1 & External Auditory Meatus

Seated with hips, knees & ankles at 90⁰.  Head in full extension, headclamps on ears.

10” x 12”

Nasium (APOM)

 

C1

Seated with hips, knees, & ankles at 90⁰.  Headclamps placed on ears.

7” x 17”

Lateral Lumbar

42”

L5, 2” below iliac crest

Seated as above with arms crossed & hands on shoulders.

7” x 17”

A-P Lumbar

42”

L5, 2” below iliac crest

Seated as above with arms crossed & hands on shoulders.

14” x 17”

Standing Scoliosis

72”

Centered to apex of curvature

Barefoot, standing erect in a relaxed posture.

Two 14” x 17” (to minimize distortion)

 

Next, measurements were made on the appropriate radiographs to quantify:

  1. The cervicodorsal, thoracic, and/or lumbar Cobb angle(s);
  2. The degree of forward head posture;
  3. The amount of cervical lordosis;
  4. The axial rotation of the atlas (C1) and the axis (C2);
  5. The sagittal relationship of the occiput (C0), the atlas (C1), and the axis (C2);
  6. The kinematic relationship of the cervical vertebrae;
  7. the degree of coronal deviation of the following spinal segments:
    1. the occiput (C0) relative to the atlas (C1);
    2. the atlas (C1) in relation to the upper cervical spine (C2-C4);
    3. the upper cervical spine (C2-C4) in relation to the lower cervical spine (C5-C7);
    4. the lower cervical spine (C5-C7) in relation to the upper thoracic spine (T1-T6);
    5. the upper thoracic spine in relation to the lower thoracic spine (T6-T12);
    6. the lower thoracic spine (T7-T12) in relation to the upper lumbar spine (L1-L3);
    7. the upper lumbar spine (L1-L3) in relation to the lower lumbar spine (L4-L5);
  8. the degree of sacral tilt in the coronal plane;
  9. the sacral base angle;

10)  the amount of lumbar lordosis. 

11)  In the 3 patients who presented with hyperkyphosis of the thoracic spine, lateral thoracic radiographs were also taken, and the amount of thoracic kyphosis measured.   

These specific measurements were used to quantify the degree of abnormal sagittal spinal curvature as well as the coronal & axial deviations, the aim being to better understand the biomechanical forces which act upon the spinal column & influence curve progression, and to direct the goal of treatment towards restoring normal structure & function of the spinal column in three dimensions.  This information was used to determine the specific manual & instrument-assisted manipulative therapies that were performed to reduce the spinal misalignments, the spinal weighting protocols, and the physical therapies the patient performed to address neuromuscular re-education and soft tissue rehabilitation.

Protocol

The treatment provided to the patients in this study, informally described as “Mix, Fix Set,” consisted of “warm-up” preparation aimed at relaxing the soft tissue components involved in and around the spinal column, most notably the intervertebral discs (Mix); followed by specific chiropractic manipulative therapy (performed by hand and also by a mechanical adjusting instrument) aimed at achieving a quantifiable improvement in the radiographic measurements of the 3-dimensional structure of the spine (Fix); and a “cooling down” period which aimed to solidify the achieved correction through a combination of core muscle strengthening and proprioceptive neuro-muscular re-education to re-train the body to adapt to a more balanced posture (Set).

Warm-up (“Mix” therapy) has five components. 

  1. Treatment began with the patient seated upon an Active Rehabilitation Chair (figure 1) performing a series of repetitive exercises, that are specific to each patient, to improve spinal soft tissue flexibility & rehabilitate the intervertebral discs. 
  2. Next, cervical lordotic traction was performed in a standing position to aid in ligament deformation & cervical sagittal curve restoration (figure 2).
  3. Then, mechanical tapotement (percussive deep tissue massage therapy) was performed on the core postural muscles using a hand-held device (figure 3).
  4. Vibration therapy was applied to the apex of the cervical & lumbar lordoses in a supine position at a specific frequency that may have an unloading effect upon the spinal column (figure 4).66
  5. The patient was then positioned prone on a motorized flexion/distraction table, coupled with lateral traction belts & spinal blocking, which is designed to create a “mirror-image” position of the spine and utilizes continual motion to aid in soft-tissue deformation & relaxation and to activate the properties of osmosis & imbibition within the intervertebral discs (figure 5).

Spinal manipulation (“Fix” therapy) was then performed.  All manipulative therapies were performed according to the patient’s specific radiographic & physical exam findings.

  1. First, anterior thoracic adjustments were performed with the patient in a supine position to restore normal thoracic kyphosis, with the patient’s rib cage rotated opposite to the displacement (figure 6). 
  2. Side posture adjustments, performed on a 30-degree inclined bench to aid in pre-stressing the spine, were delivered bilaterally to correct axial & coronal deviations of the lumbopelvic spine (figure 7). 
  3. Prone lumbar adjustments were delivered with the aid of a drop piece to restore the normal lumbar lordosis (figure 8). 
  4. Adjusting of the cervical spine was performed to restore normal structural & kinematic relationships of the occiput (C0), atlas (C1), & axis (C2) in the axial, coronal, and sagittal planes and normal cervical sagittal curvature, and accomplished with the use of a mechanical adjusting instrument (figures 9 & 10). 
  5. Additional adjustments were performed as needed to address the coronal, sagittal, & axial spinal deviations measured on the radiographs, and as clinically necessary based on the patient’s needs.

Neuromuscular re-education (“Set” therapy) was then done by the patient in a supervised setting.

  1. First, weights were placed on the head, shoulders, torso, and/or hips.  These spinal weighting procedures were prescribed differently for each patient, based upon the radiographic analysis of the biomechanical factors acting upon the patient’s spine, and are designed to activate specific postural muscles (figure 11). 
  2. The patient then performed active, dynamic gait therapy while wearing the spinal weights.
  3. The patient then stood upon a whole-body vibration therapy platform to aid in neuromuscular proprioceptive re-education while wearing the prescribed spinal weights.
  4. The final phase consisted of the patient seated in a customizable traction chair that combines axial & lateral traction with whole-body vibration therapy (figure 12).

The average length of one treatment session was between 150 and 180 minutes.

Each patient was instructed to perform specific exercise therapies, that were prescribed based upon the measurements made to their individual radiographs, at home on a daily basis, and to sleep on their back with spinal fulcrums under the cervical and lumbar lordoses.  The home exercise programs were assigned based upon the individual patient’s radiographic measurements.  Video fluoroscopy (digital motion x-ray) was used to test the effectiveness of the exercises, and ensure that each exercise positively influenced the structure of the spine in the desired manner.  Research has shown that specific, customized exercise protocols designed individually for the patient are more effective than generalized exercises.67  The spinal fulcrums were used to aid in restoration of the normal cervical & lumbar lordoses through soft-tissue deformation (figure 13).

The frequency of the treatment sessions was customized for each patient.  The majority of the treatment sessions consisted of two visits each weekday for two weeks, for a total of 10 visits.  Some patients also presented for an additional visit on the weekends, for a total of 12.  110 patients followed this treatment regimen.  Six patients were treated for 5 or 6 visits; the other 24 patients presented for more than 12 visits.  The average number of treatment sessions was 12.6 visits. 

After the last treatment session, radiographs were taken that included the barefoot standing anteroposterior scoliosis view, and measurements, including the Cobb angle, were made using the same radiographic landmarks on the identical vertebrae.

 

RESULTS: 

The average thoracic Cobb angle before treatment was 42.6 degrees; after treatment, the average thoracic Cobb angle was 29.4 degrees, which is an average improvement of 13.2 degrees (36%).

The average lumbar Cobb angle before treatment was 38.8 degrees; after treatment, the average lumbar Cobb angle was 26.1 degrees, which is an average improvement of 12.7 degrees (37.9%). 

The average cervicothoracic Cobb angle before treatment was 30.1 degrees; after treatment, the average cervicothoracic Cobb angle was 18 degrees, which is an average improvement of 12.1 degrees (43.3%).

In 140 case studies, 140 out of 140 (100%) showed improvement in the Cobb angle.  The average improvement in each individual Cobb angle was 12.7 degrees (39.1%).  The average total improvement was 29.7 degrees (37.7%).  23 patients were no longer classified as having clinically-diagnosable scoliosis post-intervention.

[Insert Table 1.2 (Figure 14)]

The average total improvement in the 65 patients classified as having adolescent idiopathic scoliosis (9 to 17 years of age) was 32.2 degrees, or 36.2%.  Amongst the 66 patients with adult idiopathic scoliosis (18 to 64 years of age), the average total improvement was 28 degrees, or 38.8%.  Amongst the 9 patients 65 years of age or older, the average total improvement was 24.2 degrees, or 39.6%.

The three patients who presented with hyperkyphosis of the thoracic spine had an average sagittal thoracic kyphosis of 69 degrees; the average sagittal thoracic kyphosis angle after treatment was 45 degrees, which is an average improvement of 24 degrees, or 35%. 

Although every patient demonstrated improvement, not every patient elected to continue follow-up care and home rehabilitation.  Seven patients discontinued follow-up care after their last treatment session and elected to pursue surgical intervention. 

 

DISCUSSION:

Veldhuizen et al suggested a two-stage hypothesis that involves neuromuscular factors in the etiology of scoliosis, and biomechanical factors in its progression.68  As stated before, idiopathic scoliosis is multifactorial; it is unlikely that there is one single etiological agent, and it is possible that different factors may be involved in different cases of idiopathic scoliosis.

Biomechanical forces influence scoliosis progression (shear forces and asymmetrical loading of the vertebrae leading to vertebral wedging as per the Heuter-Volkmann Law, often referred to as the ‘vicious cycle’).69  Castelein et al suggested that abnormalities in the sagittal orientation of the vertebrae in humans contribute to the progression of AIS.70  Millner & Dickson stated that ‘the problem is one of front-back asymmetry and not right-left.’71 Loss of the sagittal curves, resulting in a straightening of the spine, could contribute to scoliosis progression.72  Vertebral wedging occurs in scoliosis not only in the coronal plane, but in the sagittal dimension as well.73  The possibility of preventing scoliosis through treatment aimed at sagittal correction has been previously suggested.74  Spinal imbalances & disruptions in the sagittal (& axial) plane have the capability of producing biomechanical imbalances which can influence curve progression in the coronal plane.75-83  The 3-dimensional involvement of the spine in scoliosis is generally accepted; what remains controversial is its role as a primary factor in the etiology of scoliosis.84,85  One goal of the therapeutic interventions provided in this study was reduction of the described biomechanical factors which may influence curve progression.

The neuromuscular factors involved in scoliosis are one probable aspect of a multifactorial etiology.4,86  A dysponesis between the sensory input and motor feedback systems (Central Pattern Generators & Proprioceptive Mismatch Correctors, or CPG’s and PMC’s) of the body could drive a neuromuscular imbalance that would lead to failures in the rotation-control systems; symmetrical function of neuromuscular mechanisms is necessary for ideal spinal alignment.87-89  The hypothesis that vestibular asymmetry plays a role in the etiology of scoliosis was supported in an animal model.90  Improving proprioceptive function could have benefit in reducing the risk factors involved in progression of scoliosis.91,92

Proprioceptive deficits & issues with balance have been reported to occur in scoliosis, with some authors suggesting a causative link.93,94  Repeated exercise, whole-body vibration therapy, and gait therapy can influence neuromuscular function.95-98  Theoretically, the treatment provided in this study is designed to affect the neuromuscular factors involved in scoliosis, although this has not been specifically investigated.

The limitations of this study are recognized by the authors.  First, it is a retrospective observational study lacking a control group; there can be no extrapolation beyond the 140 subjects.  Second, the only outcome assessment reported in the study was Cobb angle.  While additional functional & cosmetic measurements including spirometry, standardized posture pictures, and scoliometer measurements prone and in Adam’s position, are part of the standardized scoliosis physical examination performed at this clinic, and were taken before and after treatment on each patient, these secondary outcome measures were not included in the study.  Third, the treatment protocol was designed as a whole, and the predominance of each part cannot be known.  Fourth, because each treatment plan was customized to suit the needs of the individual patient, not every patient underwent the same number of treatments at the same frequency.  Fifth, the ages of the patients in the study encompass adolescent, adult, & geriatric scoliosis; comparisons between the differing natural histories of these conditions may not necessarily be valid, and not every inference may accurately apply to each patient.  Future studies should include a prospective design with an age-matched control group, a standardized treatment schedule, and additional outcome measures to determine the effect of the treatment protocol upon aesthetics, quality of life, disability, back pain, psychological well-being, and breathing function.

CONCLUSIONS:  Due to the observational nature of the study, no conclusions can be drawn by the authors as to the interpretation of the results.  However, based upon these described results, additional research into how it may be able to intervene in the natural history of scoliosis without the use of bracing or surgery is merited.

COMPETING INTERESTS: Woggon D received financial compensation from St. Cloud Chiropractic Clinic for his role as the primary treating doctor of the patients in this study.  He is also the Director of CLEAR Institute Non-Profit Organization; he receives no financial compensation for this role.  Gulliver K underwent a preceptorship at the St. Cloud Chiropractic Clinic during part of the period when the patients were being treated and the data was being gathered; she received no financial compensation for this role.  Chong S served as an Associate Doctor at the St. Cloud Chiropractic Clinic during part of the period when patients were being treated and the data was being gathered; she received compensation from St. Cloud Chiropractic Clinic for this role.  Woggon A is the Director of Research for CLEAR Institute Non Profit Organization; he receives no financial compensation for this role.  He is also the CEO of Vibe For Health, which provided some of the equipment used in this study, and Woggon A receives a fixed monthly salary from this For Profit Organization.  Kalla W operates a CLEAR-certified Clinic in Singapore; he received no financial compensation from CLEAR Institute for his assistance with this article.

None of the authors received any direct financial compensation from any source for their efforts in the preparation & publication of this research article.

AUTHORS’ CONTRIBUTIONS: Woggon D was responsible for providing treatment to the patients in this study, and was assisted in part in this regard by Gulliver K and Chong S. Gulliver K and Chong S assisted in the compilation & analysis of the accumulated data.  Chong S wrote the initial draft of the article and assisted in editing & proofreading.  Kalla W assisted in editing, proof-reading, and referencing the article.  Woggon A wrote & oversaw the final draft and provided the majority of the references for this article.  Woggon D approved the final draft.  Woggon A and Kalla W had no direct contact with any of the patients.

AUTHOR INFORMATION:  Woggon D graduated cum laude from Palmer College of Chiropractic in 1974; he is the founder of the Saint Cloud Chiropractic Clinic and CLEAR Institute.  Gulliver K is a graduate from Palmer College of Chiropractic Florida and practices in Florida.  Chong S holds a degree in chiropractic from Palmer College of Chiropractic; she is an Associate Doctor at Saint Cloud Chiropractic Clinic.  Kalla W graduated from the Scandinavian College of Chiropractic in Sweden, and operates a private practice in Singapore.  Woggon A holds a degree in chiropractic from Parker College of Chiropractic; he is an Associate Doctor at the CLEAR Scoliosis Clinic in Dallas, Texas, and is the Director of Research for CLEAR Institute.

ACKNOWLEDGEMENTS: The authors would like to convey their gratitude to Daniel Martinez, DC, who provided invaluable feedback in the drafting of this article.  Written consent for publication was obtained from all patients and/or relatives featured in the photographs in this article.

REFERENCES:

  1. Perdriolle R, Le Borgne P, Dansereau J, de Guise J, Labelle H: Idiopathic scoliosis in three dimensions: a succession of two-dimensional deformities? Spine 2001;26:2719-2726.
  2. Kleinberg S: The operative treatment of scoliosis. Arch Surg 1922, 5:631-45.
  3. Cheng JCY, Tang NLS, Yeung HY, Miller N: Genetic association of complex traits using idiopathic scoliosis as an example.  Clin Orthop Relat Research 2007;462:38-44.
  4. Potoupnis M, Kenanidis E, Papavasiliou K, Kapetanos G: The role of exercising in a pair of female monozygotic (high-class athletes) twins discordant for adolescent idiopathic scoliosis. Spine 2008;33(17):E607-E610.
  5. Ahn U, Ahn N, Nallamshetty L, Buchowski J, Rose P, Miller N, Kostuik J, Sponseller P: The etiology of adolescent idiopathic scoliosis. Am J Orthop (Belle Mead NJ) 2002;31(7):387-395.
  6. Burwell R: Aetiology of idiopathic scoliosis: current concepts.  Pediatric Rehabilitation 2003;6(3-4):137-170.
  7. Kleinberg S: The operative treatment of scoliosis. Arch Surg 1922, 5:631-45.
  8. Hawes M: Impact of spine surgery on signs and symptoms of spinal deformity. Pediatric Rehabilitation 2006; 9(4): 318-339.
  9. Szeinberg A, Canny G, Rashed N, Veneruso G, Levison H: Forced vital capacity and maximal respiratory pressures in patients with mild and moderate scoliosis. Pediatric Pulmonology 1987; 4(1):8-12.

10)  Vedantam R, Crawford A: The role of preoperative pulmonary function tests in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion.  Spine 1997;22(23):2731-2734.

11)  Kearon C, Viviani GR, Kirkley A, Killian KJ: Factors determining pulmonary function in adolescent idiopathic scoliosis.  Am Rev Respir Dis. 1993;148(2):288-294.

12)  Smyth R, Chapman K, Wright T, Crawford J, Rebuck A: Pulmonary function in adolescents with mild IS.  Thorax 1984;39(12):901.

13)  Zaba R: Peak expiratory flow in children and adolescents with idiopathic scoliosis.  Wiad Lek. 2003;56(11-12):552-5. 

14)  Koumbourlis A: Scoliosis and the respiratory system. Paediatric Respiratory Reviews 2006; 7:152–160.

15)  Barrios C, Pérez-Encinas C, Maruenda J, Laguía M: Significant ventilator functional restriction in adolescents with mild or moderate scoliosis during maximal exercise tolerance test. Spine 2005;30(14):1610-1615.

16)  Alves VL, Avanzi O: Objective assessment of the cardiorespiratory function of adolescents with idiopathic scoliosis through the six-minute walk test. Spine 2009;34(25):E926-E929.

17)  Lonstein J: Idiopathic scoliosis. In: Lonstein J, Bradford D, Winter R, Oglivie J, ed., Moe’s Textbook of scoliosis and other spinal deformities. 3rd ed., Philadelphia, PA: W.B. Saunders; 1995:219-256.

18)  Payne W, Oglivie J, Resnick M, Kane R, Transfeldt E, Blum R: Does scoliosis have a psychological impact and does gender make a difference? Spine 1997;22:1380-1384.

19)  Smith F, Latchford G, Hall R, Milner P, Dickson R: Indications of disordered eating behavior in adolescent patients with idiopathic scoliosis. JBJS 2002;84-B:392-394.

20)  Friedel K, Petermann F, Reichel D, Steiner A, Warschburger P, Weiss H: Quality of life in women with IS. Spine 2002;27:E87-E91.

21)  Korovessis P, Zacharatos S, Koureas G, Megas P: Comparative multifactorial analysis of the effects of idiopathic adolescent scoliosis and Scheuermann kyphosis on the self-perceived health status. Eur Spine J. 2007;16(4):537-546.

22)  Tones M, Moss N, Polly D: A review of quality of life and psychosocial issues in scoliosis. Spine 2006;31(26):3027-3038.

23)  Ramirez N, Johnston C, Browne R: Prevalence of back pain in children who have IS. JBJS 1997;79-A:364-368.

24)  Brown D: The pain drawing in AIS.  Proceedings of the SRS Annual 36th meeting, Cleveland Oh, 2001.

25)  Schwab F, Dubey A, Pagala M, Gamez L, Farcy J, Pagala M: Adult scoliosis: a health assessment analysis by SF-36. Spine 2003;28:602-606.

26)  Mayo N, Goldberg M, Poitras B, Scott S, Hanley J: The Ste-Justine AIS cohort study: back pain. Spine 1994;19:1573-1581.

27)  Weinstein S, Dolan L, Spratt K, Peterson K, Spoonamore M, Ponseti I: Health and function of patients with untreated idiopathic scoliosis: a 50-year natural history study. JAMA 2003;289:559-567.

28)  Savastik JA, Stokes IAF: Idiopathic scoliosis: Terminology. Spine: State of the Art Reviews 2000, 14:299-303.

29)  Asher MA, Burton DC: Adolescent idiopathic scoliosis: natural history and long term treatment effects. Scoliosis 2006, 1:2.

30)  Mirtz T, Thompson M, Leon Greene L, Lawrence A Wyatt L, Akagi C: Adolescent idiopathic scoliosis screening for school, community, and clinical health promotion practice utilizing the PRECEDE-PROCEED model: Chiropractic & Osteopathy 2005, 13:25.

31)  Reamy B, Slakey J: Adolescent idiopathic scoliosis: review and current concepts. American Family Physician, 2001;64:111-116.

32)  Francis RS: Scoliosis screening of 3,000 college-aged women. The Utah Study – Phase 2. Phys Ther 1988 Oct;68(10).

33)  Avikainen VJ, Vaherto H: A high incidence of spinal curvature: a study of 100 young female students. Acta Orthop Scand. 1983 Apr;54(2):267-73.

34)  Voros G, Neubauer P, Khoshnevisan M: Prevalence of scoliosis in adults age 40 years and older: A study of 2,973 individuals. Paper #2. Presented at the North American Spine Society 22nd Annual Meeting. Oct. 23-27, 2007. Austin, Texas.

35)  Anwar Z, Zan E, Gujar SK, Sciubba DM, Riley LH 3rd, Gokaslan ZL, Yousem DM: Adult lumbar scoliosis: underreported on lumbar MR scans. AJNR Am J Neuroradiol. 2010 Jan 6 [Epub ahead of print].

36)  Schwab F, Dubey A, Gamez L, El Fegoun AB, Hwang K, Pagala M, Farcy JP: Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population. Spine 2005 May 1;30(9):1082-5.

37)  Weinstein SL, Dolan LA, Cheng JC, Danielsson A, Morcuende JA: Adolescent idiopathic scoliosis. Lancet 2008 May 3;371(9623):1527-37. Review.

38)  Green NE: Part-time bracing of adolescent idiopathic scoliosis. J Bone Joint Surg Am. 1986 Jun;68(5):738-42.

39)  Rogala EJ, Drummond DS, Gurr J: Scoliosis: incidence and natural history. A prospective epidemiological study. J Bone Joint Surg Am. 1978 Mar;60(2):173-6.

40)  Kane WJ: Scoliosis prevalence: a call for a statement of terms. Clin Orthop Relat Res. 1977 Jul-Aug;(126):43-6.

41)  Collis DK, Ponseti IV: Long-term follow-up of patients with IS not treated surgically. J Bone Joint Surg, 1968;51A:425-445.

42)  Weinstein SL, Ponseti IV: Curve progression in IS. J Bone Joint Surg, 1983;65A:702-712.

43)  Korovessis P, Piperos G, Sidiripoulos P, et al. Adult idiopathic lumbar scoliosis. Spine 1994;190:1926-1932.

44)  Danielson AJ, Nachemson AL. Back pain and function 22 years after brace treatment for adolescent idiopathic scoliosis: A case control study-Part I. Spine 2003;28:2078-2166.

45)  Marty-Poumarat C, Scattin L, Marpeau M, Garreau de Loubresse C, Aegerter P: Natural History of Progressive Adult Scoliosis. Spine 2007;32(11):1227-1234.  

46)  Oglivie J, Nelson L, Chettier R, Ward K: Does bracing alter the natural history of adolescent idiopathic scoliosis?  Scoliosis 2009, 4(Suppl 2):O59.  From: 6th International Conference on Conservative Management of Spinal Deformities, Lyon, France, 21-23 May 2009.

47)  Sapountzi-Krepia D, Psychogiou M, Peterson D, Zafiri V, Iordanopoulou E, Michailidou F, Christodoulou A: The experience of brace treatment in children/adolescents with scoliosis.  Scoliosis 2006;1:8.

48)  MacLean W, Green N, Pierre C, Ray D: Stress and coping with scoliosis: psychological effects on adolescents and their families.  J Pediatr Orthop. 1989;9(3):257-261.

49)  Korovessis P, Filos K, Georgopoulos D: Long-term alterations of respiratory function in adolescents wearing a brace for idiopathic scoliosis.  Spine (Phila Pa 1976) 1996;21(17):1979-1984.

50)  Refsum H, Naess-Andresen C, Lange J: Pulmonary function and gas exchange at rest and exercise in adolescent girls with mild idiopathic scoliosis during treatment with Boston thoracic brace.  Spine (Phila Pa 1976) 1990;15(5):420-423.

51)  Haher T, Merola A, Zipnick R: Meta-analysis of surgical outcome in AIS: a 35-year English literature review of 11,000 patients.  Spine 1995;20:1575-1584.

52)  Hawes M, O’Brien J: A century of spine surgery: what can patients expect? Disabil Rehabil. 2008;30(10):808-817.

53)  Hawes M: Impact of spine surgery on signs and symptoms of spinal deformity.  Pediatric Rehabilitation 2006;9(4):318-339.

54)  Weiss HR, Goodall D: Rate of complications in scoliosis surgery – a systematic review of the Pub Med literature.  Scoliosis 2008;3:9.

55)  Rizzi P, Winter R, Lonstein J, Denis F, Perra J: Adult spinal deformity and respiratory failure. Spine 1997;22:2517-2531.

56)  Takahashi S, Suzuki N, Asazuma T, Kono K, Ono T, Toyama Y: Factors of thoracic cage deformity that affect pulmonary function in adolescent idiopathic thoracic scoliosis. Spine 2007;32(1):106-112.

57)  Maruyama T, Takeshita K: Surgical treatment of scoliosis: a review of techniques currently applied. Scoliosis 2008;3:6.

58)  Negrini S: Approach to scoliosis changed due to causes other than evidence: patients call for conservative (rehabilitation) experts to join in team orthopedic surgeons. Disabil Rehabil. 2008;30(10):731-41.

59)  Romano M, Negrini S: Manual therapy as a conservative treatment for adolescent idiopathic scoliosis: a systematic review. Scoliosis 2008, 3:2.

60)  Negrini S, Atanasio S, Zaina F, Romano M, Parzini S, Negrini A: End-growth results of bracing and exercises for adolescent idiopathic scoliosis: prospective worse-case analysis. Stud Health Technol Inform, 2008;135:395-408.

61)  Morningstar MW, Woggon DA, Lawrence G: Scoliosis treatment using a combination of manipulative and rehabilitative therapy: a retrospective case series. BMC Musculoskeletal Disorders 2004, 5:32.

62)  Chen KC, Chiu EH: Adolescent idiopathic scoliosis treated by spinal manipulation: a case study. JACM 2008, 14(6):749-751.

63)  Brooks WJ, Krupinski EA, Hawes MC: Reversal of curvature magnitude in response to physical methods: a 15-year followup in an adult female diagnosed with moderately severe scoliosis at age eleven years.  Scoliosis 2007, 2(Suppl I):P2. From: 4th International Conference on Conservative Management of Spinal Deformities, Boston, MA, USA. 13-16 May 2007.

64)  Morningstar MW, Joy T: Scoliosis treatment using spinal manipulation and the Pettibon Weighting System: a summary of 3 atypical presentations. Chiropr Osteopat 2006, 14:1.

65)  Morningstar M, Strauchmann, Gilmour G: Idiopathic scoliosis treatment using the Pettibon corrective procedures: a case report.  J Chiropr Med. 2004;3(3): 96–103.

66)  Bonney R, Corlett E: Vibration and spinal lengthening in simulated vehicle drivingApplied Ergonomics, 2003;34(2):195-200.

67)  Negrini S, Zaina F, Romano M, Negrini A, Parzini S: Specific exercises reduce brace prescription in adolescent idiopathic scoliosis: a prospective controlled cohort study with worst-case analysis. J Rehabil Med. 2008;40(6):451-5.

68)  Veldhuizen A, Wever D, Webb P: The aetiology of idiopathic scoliosis: biomechanical and neuromuscular factors.  Eur Spine J 2000;9:178-184.

69)  Stokes IA, Burwell RG,  Dangerfield PH, IBSE: Biomechanical spinal growth modulation and progressive adolescent scoliosis—a test of the ‘vicious cycle’ pathogenic hypothesis: summary of an electronic focus group debate of the IBSE. Scoliosis 2006, Oct 18;1:16.

70)  Castelein R, van Dieën J, Smit T: The role of dorsal shear forces in the pathogenesis of adolescent idiopathic scoliosis – a hypothesis.  Med Hypotheses, 2005;65(3):501-508.

71)  Millner PA, Dickson RA: Idiopathic scoliosis: biomechanics and biology, Eur Spine J 1996;5:362-373.

72)  Poussa M, Mellin G: Spinal mobility and posture in adolescent idiopathic scoliosis at three stages of curve magnitude. Spine 1992;17:757-760.

73)  Deacon P, Dickson RA: Vertebral shape in the median sagittal plane in idiopathic thoracic scoliosis: a study of true lateral radiographs in 150 patients. Ortho, 1987;10:893-895.

74)  Dickson R: Spinal disorders and low back pain. JBJS 1999;81B:378-379.

75)  Rigo M, Quera-Salvá G, Villagers M: Sagittal configuration of the spine in girls with idiopathic scoliosis: progressing rather than initiating factor. Stud Health Technol Inform. 2006;123:90-4.

76)  Stokes IA: Mechanical modulation of spinal growth and progession of adolescent scoliosis. Stud Health Technol Inform. 2008;135:75-83.

77)  Veldhuizen AG, Wever DJ, Webb PJ: The aetiology of idiopathic scoliosis: biomechanical and neuromuscular factors. Eur Spine J, 2000;9:178-184.

78)  de Jonge T, Dubousset JF, Illés T: Sagittal plane correction in idiopathic scoliosis. Spine 2002 Apr 1;27(7):761.

79)  Dickson RA, Lawton JO, Archer IA, Butt WP: The pathogenesis of idiopathic scoliosis. Biplanar spinal asymmetry. J Bone Joint Surg Br. 1984 Jan;66(1):8-15.

80)  Inoue K. The sagittal curvature of spine in idiopathic scoliosis--its morphological features and the correlation among sagittal and frontal curvatures and rotation of apical vertebra. Nippon Seikeigeka Gakkai Zasshi. 1985 May;59(5):505-16.

81)  Schultz A: Biomechanical factors in the progression of idiopathic scoliosis. Annals of Biomedical Engineering, 1984;12:621-630.

82)  Danbert RJ: Scoliosis: Biomechanics and Rationale for Manipulative Treatment. JMPT 1989;12(1).

83)  Karski T: New clinical observations connected with “biomechanical aetiology of so called idiopathic scoliosis” (2006-2007). Research into Spinal Deformities 6, P.H. Dangerfield (ed.), IOS Press, 2008.

84)  Xiong B, Sevastik B, Sevastik J, Hedlund R: Early three dimensional radiographic changes in scoliosis.  In: Dansereau J (ed.), International Symposium on 3-D Scoliotic Deformities joined with the 7th International Symposium on Spinal Deformity and Surface Topography, 1992.

85)  Lowe T, Edgar M, Margulies J, Miller N, Raso J, Reinker K, Rivard C: Etiology of idiopathic scoliosis: current trends and relevance to new treatment approaches.  JBJS 2000;82-A:1157-1168.

86)  Nault M, Allard P, Hinse S, Le Blanc R, Caron O, Labelle H, Sadeghi H: Relations between standing stability and body posture parameters in adolescent idiopathic scoliosis.  Spine (Phila Pa 1976) 2002;27(17):1911-1917.

87)  Burwell R, Cole A, Cook T, Grivas T, Kiel A, Moulton A, Thirlwall A, Upadhyay S, Webb J, Wemyss-Holden S, Whitwell D, Wojcik A, Wythers D: Pathogenesis of idiopathic scoliosis: the Nottingham concept.  Acta Orthopedica Belgica, 1992;58(Suppl I):33-58.

88)  Manzoni D, Miele F: Vestibular mechanisms involved in idiopathic scoliosis. Arch Ital Biol. 2002;140(1):67-80.

89)  Burwell R, Dangerfield P: How does skeletal growth affect the onset and progression of adolescent idiopathic scoliosis?  The Red Queen concept applied to trunk growth and #D balance. A speculation.  10th International Philip Zorab Symposium: Programme and abstracts, Oxford, 1998, 47-48.

90)  Lambert FM, Malinvaud D, Glaunès J, Bergot C, Straka H, Vidal PP: Vestibular asymmetry as the cause of idiopathic scoliosis: a possible answer from Xenopus.  J Neurosci 2009 Oct 7;29(40):12477-83. 

91)  Byl N, Holland S, Jurek A, Hu S: Postural imbalance and vibratory sensitivity in patients with idiopathic scoliosis.  J Orthop Sports Phys Ther. 1997;26(2):60-68.

92)  Smania N, Picelli A, Romano M, Negrini S: Neurophysiological basis of rehabilitation of adolescent idiopathic scoliosis. Disabil Rehabil. 2008;30(10):763-771.

93)  Keessen W, Crowe A, Hearn M: Proprioceptive accuracy in idiopathic scoliosis.  Spine 1992;17(2):149-155.

94)  Simoneau M, Mercier P, Blouin J, Allard P, Teasdale N: Altered sensory-weighting mechanisms observed in adolescent idiopathic scoliosis.  BMC Neurosci. 2006;7:68.

95)  Tjernström F, Fransson P, Hafström A, Magnusson M: Adaptation of postural control to perturbations – a process that initiates long-term motor memory. Gait & Posture 2002;15(1):75-82.

96)  Fontana T, Richardson C, Stanton W: The effect of weight-bearing exercise with low frequency, whole body vibration on lumbosacral proprioception: a pilot study on normal subjects. Aust J Physiother., 2005;51(4):259-63.

97)  Issurin V: Vibrations and their applications in sport: a review.  J S

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