Scoliosis Awareness Month

June is scoliosis awareness month, so there is no better time to get some information out about how we here at Spriggs Chiropractic work with our scoliosis patients and how we are now working in partnership with DM Orthotics®.

What is Scoliosis?

Scoliosis is derived from the Greek word Skoli-osis meaning curve¹. Scoliosis is described in the medical literature as abnormal curvature(s) of the spine exceeding 10°². The angle of curvature is known as the Cobb angle, which can only be measured accurately by using standing, weight-bearing x-rays of the whole spine. Scoliosis is not just sideward curves and shifts of the spine, it is actually a 3-dimensional deformity of the spine³. To make things simpler, whilst also making this appear more complicated, I will try to describe in better detail exactly what scoliosis is as it relates to the spine before moving on to treatment and management methods.

Using the Cartesian coordinate system as described by White & Panjabi⁴ and Harrison et al⁵, during the development of the spinal deformity of scoliosis, the spine will shift side-wise (translate), then bend over itself (laterally flex) and finally, it will rotate around itself (Y-axis rotation). The spine will do this in any combination when developing your individual deformity, at varying severities in any of the 3-axes of movement (x, y, and z). Scoliosis can be a single curve, or what is called a double major, meaning the spine curves in one direction at the bottom of the spine, whilst also in the opposite direction at the top. There are also associated deformities of the rib cage.

Scoliosis can affect all age groups, and is broken down into several categories depending on the age of the patient:

• Infantile (<3 years of age)
• Juvenile (3-10 years of age)
• Adolescent (10-18 years of age)
• Adult (>18 years) also known as adult spinal deformity (ASD)

Most commonly, scoliosis is diagnosed as adolescent idiopathic scoliosis, which often has a growth period from 10-16 years of age.

There are many proposed causes of scoliosis, but two key terms used are idiopathic and neuromuscular². It is stated that approximately 85% of cases are idiopathic^6–8, which is a fancy medical term for we don’t know the cause. Ladies are between five and ten times more likely to develop severe forms of scoliosis (>40°)^2,8–11. However, genetic factors have been posed as the main cause^8,12 with Horne et al (2014) stating that; “children from parents (both mother and father) with scoliosis are 50 times more likely to require scoliosis treatment” referencing Smith et al (2008). However, upon reading the Smith et al paper, I was unable to find this statement in their paper, so I cannot verify this claim.

Evaluation and Diagnosis.

The earlier the diagnosis of scoliosis is made, the better the outcomes of treatment and management. The gold standard method of evaluating, diagnosing, and managing scoliosis is x-ray analysis^13,14. However, screening tools include a simple bending forward test called Adam’s test, with or without a scoliometer. Here at Spriggs Chiropractic, our scoliosis assessments utilise both Adam’s test with a scoliometer and x-rays. A scoliometer measuring up to 10° has been shown to correlate to a spinal curvature of 20° on x-ray¹⁵.

Postural displacements are an important aspect of any scoliosis assessment. Here at Spriggs Chiropractic, we use static postural analysis as well as 3D postural assessment. This is the same technology we use with our 3D foot scanning for our custom foot orthotics. Utilising 3D scanning technology provides us an easy tool for re-assessment of our patients whilst wearing their DM Orthotics® scoliosis suits. Check out our YouTube video showing a 3D surface contour scan of one of our scoliosis patients https://youtu.be/Y9g9BuGKdNs. 

Lonstein et al (1984) found factors such as “the magnitude of the curve, the Risser sign, and the patients’ chronological age” were the strongest correlation factors for predicting curve progression¹¹. The authors found that the greater the magnitude of the curve increased the likelihood of progression, the lower the Risser sign, the greater the risk of curve progression, but the incidence of curve progression decreased with age. The Risser sign is the value given when evaluating the amount of fused growth plate along the top of the pelvis.

Risser Sign is a radiographic sign demonstrating the point of skeletal maturity of the patient. The growth plate from the top of the iliac crest fuses in a specific pattern from back to front. Illustration copied from Reamy B V., Slakey JB. Adolescent idiopathic scoliosis: Review and current concepts. Am Fam Physician. 2001;64(1):111-116.

Therefore, in cases of an adult-onset (>18 years of age) will naturally have a Risser sign of 0 with a mild curve (<20°), is less likely to progress, thus the patient is not a surgical candidate. However, it the patient presents with pain, then physical therapy, exercises, and either bracing or a scolisuit may be recommended or appropriate to reduce the likelihood of progression or the recurrence of future pain.

Whereas a curvature of >20° in a 10-year-old female with a Risser sign of 3 or 4 is highly likely to progress. Therefore, observing the curve progression is sensible to see if the curve progresses to >40°. In fact, using the Lonstein et al (1984) predictive formula states that a curve of 20-29° first diagnosed in a child <10 years of age is 100% likely to progress.

The two main types of scoliosis we will be discussing are commonly known as Adolescent Idiopathic Scoliosis (AIS) and Adult Spinal Deformity (ASD).

Adolescent Idiopathic Scoliosis

AIS is defined as “a structural curve with no clear underlying cause”⁸ found in patients between 10 and 18 years of age. As discussed above, the likelihood and rate of progression is dependant on the magnitude of the curve and the level of skeletal maturity (Risser sign) of the patient at the point of diagnosis. However, it has been stated that females with AIS are 10 times greater risk of their curve progressing the males^8,16. It has been suggested that this is due to the rate of adolescent growth spurts, but “the greater the growth potential and the larger the curve, the greater the likelihood of curve progression⁸. Thus, the longer the spinal column is potentially going to be, the greater the risk of curve progression.

People with connective tissue disorders, such as Marfan’s syndrome and Ehlers-Danlos syndrome (EDS) are at increased risk of developing AIS due to loss of structural integrity¹⁶. However, one might argue that scoliosis in these patients is not idiopathic, because it is likely the result of lost ligamentous and connective tissue strength and integrity. Therefore, the scoliosis is a symptom or an effect of Marfan’s or EDS. But scoliosis is not found in everyone with connective tissue disorders and is found in people without them, so the conundrum continues.

Adult Spinal Deformity

ASD is a condition that includes a spectrum of spinal deformities including de-novo scoliosis, progressive adolescent idiopathic scoliosis in adulthood, hyperkyphosis, iatrogenic spinal deformity, focal deformity due to multiple degenerative disc disease with global deformity and post-traumatic spinal deformity^17–20. De-novo scoliosis differs from idiopathic because it presents much later in life, with a mean age of 70.5 years of age¹⁷. Risk factors for the development of ASD include reduced bone mineral density (osteopenia), osteoporosis, spinal degeneration, reduced mobility, impaired balance, and neurodegenerative disorders, such as Alzheimer’s and dementia²¹.

Scoliosis in all its forms is a significant health issue that can impact on pain levels, function, and disability, pulmonary and cardiovascular complications. The research and published literature all state the same conclusions, that the earlier it is diagnosed, the better long-term outcomes for the patient. AIS during adolescence can have a significant impact on body image and self-esteem in teenagers who are under increasing pressure from social media and their peers on how they look. Here at Spriggs Chiropractic, we use the latest technology including 3D scanning and x-ray analysis to assess postural distortions and scoliosis to provide patients with a detailed understanding of what treatment options are available to them and what the best course of action might be. To get a full scoliosis assessment, give us a call on 01635 432383 or email to hello@spriggschiropractic.co.uk to make your appointment. We run specific scoliosis assessment hours at our clinic for specialist clinic days/times to make sure we get all the information we need for your health.

For more information on scoliosis specific exercises and info, I recommend this great book Your Plan for Natural Scoliosis Prevention and Treatment: Health In Your Hands by another Chiropractor Dr. Kevin Lau DC.

References:

1. Matthews M, Crawford R. The use of dynamic Lycra orthosis in the treatment of scoliosis: A case study. Prosthet Orthot Int. 2006;30(2):174-181. doi:10.1080/03093640600794668
2. Horne JP, Flannery R, Usman S. Adolescent idiopathic scoliosis: Diagnosis and management. Am Fam Physician. 2014;89(3):193-198.
3. White AA 3rd, Panjabi M. The Clinical Biomechanics of Spine Pain. In: Clinical Biomechanics of the Spine. 2nd ed. Lippincott Williams & Wilkins; 1990:379-474.
4. White AA 3rd, Panjabi MM, Brand RAJ. A system for defining position and motion of the human body parts. Med Biol Eng. 1975;13(2):261-265.
5. Harrison DE, Janik TJ, Harrison GR, Troyanovich SJ, Harrison DE, Harrison SO. Chiropractic biophysics technique: A linear algebra aproach to posture and chiropractic. J Manipulative Physiol Ther. 1996;19(8):525-535.
6. Lonstein JE. Adolescent idiopathic scoliosis. Lancet. 1994;344(8934):1407-1412. doi:10.1016/S0140-6736(94)90572-X
7. Smith JR, Sciubba DM, Samdani AF. Scoliosis: a straightforward approach to diagnosis and management. JAAPA. 2008;21(11):40-45. doi:10.1097/01720610-200811000-00009
8. Reamy B V., Slakey JB. Adolescent idiopathic scoliosis: Review and current concepts. Am Fam Physician. 2001;64(1):111-116.
9. Bunnell WP. Selective screening for scoliosis. In: Clinical Orthopaedics and Related Research. Lippincott Williams and Wilkins; 2005:40-45. doi:10.1097/01.blo.0000163242.92733.66
10. Tan KJ, Moe MM, Vaithinathan R, Wong HK. Curve progression in idiopathic scoliosis: Follow-up study to skeletal maturity. Spine (Phila Pa 1976). 2009;34(7):697-700. doi:10.1097/BRS.0b013e31819c9431
11. Lonstein JE, Carlson JM. The prediction of curve progression in untreated idiopathic scoliosis during growth. J Bone Jt Surg – Ser A. 1984;66(7):1061-1071. doi:10.2106/00004623-198466070-00013
12. Ogilvie J. Adolescent idiopathic scoliosis and genetic testing. Curr Opin Pediatr. 2010;22(1):67-70. doi:10.1097/MOP.0b013e32833419ac
13. Oakley PA, Ehsani NN, Harrison DE. The Scoliosis Quandary: Are Radiation Exposures From Repeated X-Rays Harmful? Dose-Response. 2019;17(2):155932581985281. doi:10.1177/1559325819852810
14. Knott P, Pappo E, Cameron M, et al. SOSORT 2012 consensus paper: Reducing x-ray exposure in pediatric patients with scoliosis. Scoliosis. 2014;9(1). doi:10.1186/1748-7161-9-4
15. Korovessis PG, Stamatakis M V. Prediction of scoliotic Cobb angle with the use of the scoliometer. Spine (Phila Pa 1976). 1996;21(14):1661-1666. doi:10.1097/00007632-199607150-00010
16. Miller NH. Cause and natural history of adolescent idiopathic scoliosis. Orthop Clin North Am. 1999;30(3):343-352. doi:10.1016/S0030-5898(05)70091-2
17. Diebo BG, Shah N V., Boachie-Adjei O, et al. Adult spinal deformity. Lancet. 2019;394(10193):160-172. doi:10.1016/S0140-6736(19)31125-0
18. Ailon T, Smith JS, Shaffrey CI, et al. Degenerative spinal deformity. Neurosurgery. 2015;77(4):S75-S91. doi:10.1227/NEU.0000000000000938
19. Youssef JA, Orndorff DO, Patty CA, et al. Current Status of Adult Spinal Deformity. Glob Spine J. 2013;3(1):051-062. doi:10.1055/s-0032-1326950
20. Smith JS, Shaffrey CI, Bess S, et al. Recent and emerging advances in spinal deformity. Clin Neurosurg. 2017;80(3):S77-S85. doi:10.1093/neuros/nyw048
21. Fehlings MG, Tetreault L, Nater A, et al. The aging of the global population: The changing epidemiology of disease and spinal disorders. Neurosurgery. 2015;77(4):S1-S5. doi:10.1227/NEU.0000000000000953
22. Harrison DE, Cailliet R, Harrison DD, Janik TJ, Troyanovich SJ, Coleman RR. Lumbar coupling during lateral translations of the thoracic cage relative to a fixed pelvis. Clin Biomech. 1999;14:704-709.