Posted by: Dr. Paul Zemella - Santa Barbara Chiropractor | August 21, 2011

Chiropractic Services And Treatment For Scoliosis

Oh the joys of spam!  It’s usually very annoying, but just occasionally it provides a useful stimulus for a bit of investigation.  This turned out to be the case when a link to an article (oddly) on the Weight Loss Health Ways … Healthy Ways to Loose Weight website advocating Chiropractic services and treatment for Scoliosis popped into my spam filter.
According to the UK NHS Choices website:

“Scoliosis is an abnormal curvature of the spine to one side. In those who have the condition, the spine bends either to the left or to the right.

The bend can occur at any point along the spine from the top to the bottom. The curvature also varies from slight to severe. However, the chest area (thoracic scoliosis) and the lower part of the back (lumbar scoliosis) are the most common regions to be affected.

[…]Scoliosis affects three to four children out of every 1,000 in the UK. In 90% of cases of scoliosis, treatment is not required because the condition corrects itself as the child grows.
Most of the remaining 10% of cases can be successfully treated by using a back brace to prevent further curvature. Three out of every 1,000 children with scoliosis will need surgical treatment.”

Now, what does the chiropractic services promoting article have to say?  First, it describes the condition and two conventional approaches – bracing and Spinal Fusion Surgery  – before launching into a wholly unjustified promotion of Chiropractic.
“Using Chiropractic Approach Nowadays, chiropractic services are recognized as a valid solution to scoliosis. Since chiropractors follow a standard procedure of initial examination and assessment of patients health history, most scoliotic patients undergo the Adam’s Forward Bending Test to see if chiropractic care is really for you. On top of that are a variety of range [sic] of motion studies to see if you should be referred to a specialist.”

No mention here that most childhood cases do not require treatment, as it corrects itself as the child grows.  It does make a bold claim that, “chiropractic care is recognized as a valid solution to scoliosis”.  Outside the peculiar world of this chirophile, this statement would appear to be false.

For instance, the NHS choices website comments on alternative therapies.  It mentions a number, “that may be helpful in correcting scoliosis”, namely: osteopathy, reflexology, acupuncture and the electronic stimulation of nerves in the back.   Chiropractic services is not mentioned at all.  The “may” in the introductory sentence is nothing more than a weasel word, as the final pronouncement on these therapies reveals:

It seems a bit odd to lump physiotherapy in with ‘alternative therapies’.  Perhaps, this is to lend a bit of credibility to the nonsensical approaches in the list.  One thing is clear: although the NHS information is quite CAM-friendly there is no real evidence that any of these approaches work.  Chiropractic is not even mentioned.
“There is no reliable evidence that other techniques such as osteopathy, chiropractic, physiotherapy, reflexology, acupuncture, neurostimulation, and so on can make any difference to a potentially increasing spinal curvature. However, these complimentary techniques can be useful if backache or pain is present. Most spinal curvatures are relatively painless. If you are told that an established spinal curvature can be cured by any of these techniques, do not accept that as true. It is certainly true that many mild curvatures will not increase whatever is done, since the natural history (what would happen if a curve were left untreated) is very variable. Only surgery and sometimes bracing can substantially affect the natural history of the curvature.”
They are willing to accept that some of these approaches may lessen back pain, but the message is clear: there is no reliable evidence that chiropractic can make any difference to spinal curvature.  So “chiropractic care” is not “recognized as a valid solution to scoliosis” by reputable healthcare providers or patient support groups.

“Chiropractic services for scoliosis utilize [sic] a variety of treatment methods including spinal manipulation, shoe lifts, electric stimulation, and isotonic or active exercise methods. The idea behind employing chiropractic for scoliotic treatment is to arrive at a combination treatment that is both manipulative and rehabilitative.” As is usual for chiropractic advocates the emphasis is on spinal manipulation, but other approaches are also co-opted into the ‘chiropractic’ treatment package.   So, let’s look at the evidence* for spinal manipulation being able to provide a solution for scoliosis.

Given that this is a condition that can resolve itself with time, I am not interested in case studies, case series or trials without control groups.  Unfortunately, most of the published articles fall into these categories. For instance, Lantz and Chen (2001) reported on a, “Cohort time-series trial”. Fourty-two children between the ages of six and twelve apparantly chose to have chiropractic care. The main intervention used was, “Full-spine osseous adjustments […] but heel lifts and postural and lifestyle counseling were used as well.” The authors concluded, after a year of treatment, “Full-spine chiropractic adjustments with heel lifts and postural and lifestyle counseling are not effective in reducing the severity of scoliotic curves.”

For all its limitations, this negative trial is certainly more suggestive of the efficacy of chiropractic than the single ‘positive’ case studies published by Chen and Chiu (2008) along with Hawes and Brooks (2002). The same is true of the three “atypical presentations” discussed by Morningstar and Joy (2006) or the retrospective case series of nineteen patients presented by Morningstar, Woggon and Lawrence (2004).  “Conservative [non-surgical] care in general may be a helpful option in the care of adult deformity, but evidence for this is lacking. Unfortunately, no treatment option within conservative care has support within the literature as a preferred solution. Basic clinical research at any level would be helpful to further clarify the options.”
And that is all the evidence that I could find.  For the treatment of children it amounts to a pilot study, with no reliable clinical outcomes, which warns that chiropractors treating this condition were relying on customary practise and anecdotes – not scientific evidence.  It doesn’t look like this position has changed.  In the case of adults it would appear that evidence is lacking for non-surgical interventions in general.

So, it looks like shoe lifts might help; however, the evidence is sparse.  This single small study could not really be relied upon to guide clinical practise.  It is an interesting but limited study: it makes no comment on whether this might reduce the degree of spinal curvature over time, delay the need for other interventions, or even improve the quality of life of the children in the short-term.

There appears to be some evidence that particular exercise programmes might be helpful, though this is far from convincing.  For instance, Negrini et al. (2003) published a review that concluded there was no reliable evidence either for or against the use of exercises.  The main problem appears to have been the poor quality of the published evidence.  However, since this review the results of several trials have been published.

Mooney and Brigham (2003) published the results of a small trial in the same year.  Twenty adolescent patients with, “scoliosis ranging from 15 degrees to 41 degrees in their major curve were treated with a progressive resistive training program for torso rotation” with the result that, “Sixteen […] patients demonstrated curve reduction, and no patient showed an increase in curve.”  Again, this trial suffers from the lack of any kind of control group.

Negrini et al. (2006) observed that there was, “low evidence on the possible efficacy of exercises to treat idiopathic scoliosis”.  This article then went on to describe a trial that aimed to, “verify if exercises quality [sic] has an effect on results.”  This was a, “Prospective controlled study on idiopathic scoliosis patients” who only used exercises to avoid progression of the condition.  One group (n=48) used the SEAS.02 (Scientific Exercises Approach to Scoliosis, version 2002) protocol the other used, “different protocols preferred by the treating therapists”.  The result was that, “Cobb degrees improved with treatment (P<0.05) only in the SEAS group”.  The author felt that this study proved, “the short term efficacy of SEAS.02 when compared to usual care.”

In the same year Weiss et al. (2006) reported on a, “new ADL (Activities of Daily Living) approach in scoliosis rehabilitation.”  However, this was a small trial comparing thirteen patients given a two-week programme with an equal number of, “age-, sex-, Cobb-angle and curve pattern-matched controls” who received a, “4 weeks [sic] programme of exercise based rehabilitation (EBR) only.”  The results indicated that, “ABR seems to provide a better time efficiency, however a prospective controlled study with a larger sample of patients is desirable before final conclusions can be drawn.”
Weiss and Klein (2006) looked at, “An exercise programme (physio-logic exercises) aiming at a physiologic sagittal profile”.  Their approach was to conduct a, “Prospective controlled trial of pairs of patients with idiopathic scoliosis matched by sex, age, Cobb angle and curve pattern.”  This small study had, “18 patients in the treatment group (SIR + physio-logic exercises) and 18 patients in the control group (SIR only), all in matched pairs.”  They found that, “Lateral deviation (mm) decreased significantly after the performance of the physio-logic programme and highly significantly in the physio-logic ADL posture; however, it was not significant after completion of the whole rehabilitation programme.”

Many of the same authors also commented that, “Results show that in literature there is proof of level 1b on exercises but no studies on manual therapy. High quality exercises like Scientific Exercises Approach to Scoliosis (SEAS) have more efficacy than usual physiotherapy, significantly reducing brace prescription in one year from 25% of cases to 6%. Moreover, such exercises help to obtain the best results in bracing first correction. The Sforzesco brace has proved to have more efficacy than the Lyon brace, whereas it has the same efficacy–but reduced side effects and impact on quality of life–than the Risser brace.” (Negrini, Atanasio and Zaina et al., 2008)

So, there might be something in the use of exercises.  It’s clear that there is much better evidence to support the use of some specific forms of exercise than there is for Chiropractic.  Then again, that’s not saying very much. Alarmingly, the chiropractic propaganda piece continues, asserting the superiority of chiropractic over conventional treatments:

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Responses

  1. A standing side view radiograph of the thoracolumbar spine is suggested if significant deformity is present in the front-to-back (sagittal) plane. Radiographs are assessed for spinal column contour and to rule out congenital, developmental, degenerative or neoplastic abnormalities. The amount of each deformity is calculated using a standard, reproducible measurement technique. An estimate of skeletal maturity is made by assessment of the growth areas at the upper pelvis and hips.:


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