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Introduction

Scoliosis is a disease process that has received much attention in the postural correction field, largely due to the relative failure of traditional, chiropractic, and other alternative methods in correcting this affliction. Scoliosis may be responsible for a number of problems, including cardiopulmonary1, psychosocial1,2, as well as neuromusculoskeletal.1,2 Scoliosis is defined as a curvature of the spine greater than 10° as measured by Cobb’s angle3. The objective of this case report is to illustrate and identify the diagnostic and corrective procedures used to reduce a scoliosis in a 32-year-old male patient after only 4 weeks, which have previously shown promise in treating idiopathic scoliosis.4-6

Case Report

            A 32-year-old male patient reported to the Grand Blanc Spine Center with a laundry list of symptoms, including excessive thirst and urination, episodic constipation, weakness and coldness in both the hands and feet, mood swings, poor memory, depression, nervousness, chronic sinus problems, frequent muscle spasms, and right sided low back and hip pain, with radicular pain into the back of the right thigh above the knee. Golfing and running increased his back and hip pain, while stretching and rest alleviated the pain. The back/hip pain was rated as a 10/10 at worst and a 7/10 at best. He described the pain as a stiffness and ache with episodes of sharp pain shooting down the back of his right leg to the knee. All of his symptoms started within the past 2 years. The patient had previously been to his GP who ran a complete thyroid panel, which produced no abnormal findings. His GP prescribed rofecoxib (Vioxx) for his back/hip pain. This patient had also seen another chiropractor who identified a curvature in the thoracolumbar spinal region, and a loss of the cervical curve. The patient was not treated there due the clinic’s long distance from his home and work. Besides the rofecoxib, the patient was taking Motrin, a coral calcium supplement, and a multivitamin.  

            Upon evaluation, the patient’s blood pressure, temp, pulse and respirations were as follows: 122/76, 98.4° F, 68 bpm with +2 amplitude and contour, and 10 r/min shallow. The following orthopedic tests produced positive findings: Kemp’s Test, One-Legged Stork Test, and the Spinal Meningeal Tension Test. Several additional orthopedic tests reproduced the patient’s back and hip pain, including Ely/Nachlas Test, Hibb’s Test, Gaenslen’s Test, Lasegue’s Test, Lewin-Gaenslen’s Test, and the Femoral Stretch Test. Graphognosis was altered in the right palmar surface compared to the left. Paresthesia was present in the right C6 dermatome. Muscle testing produced a 4/5 bilaterally for the C4 and C5 levels, as well as L1-L4 on the right side. Lumbar range of motion was restricted in all movements, but produced no pain findings. Cervical range of motion was restricted in flexion and extension, but also failed to produce pain.

            Due to the radicular pain and positive sensory findings, a series of xrays were ordered. The xrays were taken using the positioning protocol previously illustrated by Jackson et al,7 so that pre and post treatment xrays would be comparable. The lateral cervical xray revealed a 9° cervical curve and 34mm of forward head posture. These values should be at least 34° and <10mm, respectively.8 The lateral lumbar xray revealed an 18° lumbar curve and a 9° sacral base angle. In the seated position, these values should be 35° and 35-39° respectively.9 Also noted on the lateral lumbar view was a retrolisthesis of L5 measuring 6mm. Because of this finding, L4 was used to determine the amount of curve present in the lumbar spine. This, as a result, would alter the normal measurement when taken from this level. However, this same vertebra was also used on the follow-up xray. On the anteroposterior lumbopelvic view, as already diagnosed by the previous chiropractor, a right Cobb angle of 14° was present between the superior endplate of T10 and the inferior endplate of L1. These xrays are shown in Figures 1-3.

            The initial treatment plan for this patient consisted of 12 visits in a 4-week period. The treatment procedures included the manipulative and rehabilitative techniques taught by Pettibon.9,10 The goal of this treatment was to restore the normal cervical and lumbar curves so that correction of the A-P scoliosis could begin. Additionally, proprioceptive neuromuscular facilitation (PNF) stretching was performed on the right hip at the conclusion of each office visit, and the patient was taught to perform this stretch at home with the aid of a bath towel. The attending physician also prescribed a high-dose vitamin B supplement, to be taken by the patient on a daily basis.

            After the 4-week treatment period, a follow-up physical exam and post xrays were performed. The follow-up exam produced a positive One-Legged Stork, and those tests that specifically targeted the hip joint (Hibb’s, Femoral Stretch, Lewin-Gaenslen, and Gaenslen), and cervical and lumbar ranges of motion were increased. The hip joint however was still limited and stiff, although the radicular pain had been eliminated. The patient reported a significant reduction in most of his symptoms, such as the excessive thirst and urination, constipation, and nervousness. His Borg pain scale improved from an 8/10 on the first visit to a 2/10 on the 12^th visit. The post treatment radiographs showed significant improvements in all of the measured areas. The cervical curve increased to 35°, the forward head posture was reduced to 6mm, the lumbar curve increased to 21°, and the sacral base angle increased to 13°. Incidentally, although the initial goal of the treatment plan was not to correct the retrolisthesis or the A-P thoracolumbar curvature, both of these were corrected to significant degrees. The retrolisthesis measured 3mm on the post, and the Cobb angle was reduced to 8° on the post AP lumbopelvic xray.

            The second phase of care consisted of an increase in active care exercises performed on a Pettibon Linked Trainerä exercise machine. This machine is shown in Figure A. The exercise protocol for the Linked Trainerä has been previously illustrated by Pettibon.9 Following the initial 12 visits, the visit frequency decreased to 9 visits in the next 7 weeks. Therefore, the patient was seen a total of 19 visits in 11 weeks. The B vitamin supplement was discontinued after the first 4 weeks. Following the final visit, the patient was again subjected to a post-radiographic examination, consisting of A-P and Lateral Lumbar views. The Cobb angle from T10-L1 had been decreased to 5°, and the L5 retrolisthesis corrected to 2mm. The lumbar lordosis, measured from L1 to L4 instead of L5, due to the retrolisthesis, measured 24° (The normal measurement would be 28° instead of 35°). The sacral base angle remained at 13°. For the final 7 weeks, his Borg pain scale averaged a 3/10 in the remaining visits, with the final visit being a 1/10. The patient experienced one flare-up during the early part of the second phase of treatment (the 14^th overall visit). This visit corresponded to the visit frequency being reduced to weekly instead of three times weekly. The initial and final sets of xrays are shown in Figure B.

Discussion

            In this patient, rehabilitative care began using specific equipment designed to re-enforce the restoration of the normal sagittal curves. It is very noteworthy to point out that the present patient was extremely compliant with his home care exercises. The treatment protocol utilized here employs a large amount of home care therapy, designed to enhance treatment and facilitate patient independence. Without this compliance, the current results probably would not have been obtained in this short of a timeframe.

Restoring the normal sagittal spinal curves has been identified as an important outcome objective following various spinal surgeries.11 The importance of these curves to normal physiologic and mechanical function has also been well documented.11-16 More research into scoliosis restoration should focus more on methods that address all of the tissues inherent in the spinal system, due to previous literature showing that spinal manipulation and orthotics have little or no effect on reducing the severity of scoliosis.4 The present author agrees with the previously published opinion of Drs. Gary Lawrence and Dennis Woggon that chiropractors should be able to reduce scoliosis if they truly are the “spinal experts.”17     

Posture Magazine, October issue

References

1. Cailliet R. Scoliosis: Diagnosis and Management. 1975 F.A. Davis Company
2. Shapiro GS, Taira G, Boachie-Adjei O. Results of surgical treatment of adult idiopathic scoliosis with low back pain and spinal stenosis. Spine 2003; 28: 358-363
3. Marchiori DM. Clinical Imaging With Skeletal, Chest, and Abdomen Pattern Differentials. 1999 Mosby, Inc.
4. Lawrence G, Woggon D. Scoliotic children: How spinal experts can help. Canadian Chiropractor 2001; 6(3): 10-13
5. Cohen C, Woggon D. Scoliosis- A case study. Canadian Chiropractor 2002; 7(3): 10-13
6. Lawrence G. Scoliosis: Postural analysis and patient compliance are key. Posture 2003; 1(2): 18-21
7. Jackson BL, Barker WF, Pettibon BR, Woggon D, Bentz J, Hamilton D, Wiegand M, Hester R. Reliability of the pettibon patient positioning system for radiographic production. J Vertebral Sublux Res 2000;4;1
8. Harrison DD, Janik TJ, Troyanovich SJ, Harrison DE, Colloca CJ. Evaluation of the assumptions used to derive an ideal normal cervical spine model. JMPT 1997; 20: 246-256
9. Pettibon BR. Posture Correction and Spinal Rehabilitation. Seminar Session #1 2001
10. Woggon D. The Science of Pettibon Spinal Biomechanics System Adjusting 2000
11. Kawakami M, Tamaki T, Ando M, Yamada H, Yoshida M. Relationships between sagittal alignment of the cervical spine and morphology of the spinal cord and clinical outcomes in patients with cervical spondylotic myelopathy treated with expansive laminoplasty. J Spinal Disord 2002; 15: 391-397
12. Harrison DE, Cailliet R, Harrison DD, Troyanovich SJ, Harrison SO. A review of biomechanics of the central nervous system- part III: Spinal cord stresses from postural loads and their neurologic effects.
13. Harrison DD, Troyanovich SJ, Harrison DE, Janik TJ, Murphy DJ. A normal sagittal spinal configuration: a desirable clinical outcome. J Manipulative Physiol Ther 1996;19:398-405
14. Harrison DD, Harrison DE, Troyanovich SJ. Structural rehabilitation of the spine and posture: rationale for treatment beyond the resolution of symptoms. J Manipulative Physiol Ther 1998;21:37-50
15. Harrison DE, Harrison DD, Troyanovich SJ, Harmon S. A normal spinal position: it’s time to accept the evidence. J Manipulative Physiol Ther 2000;23:632-644
16. Cailliet R. Neck and arm pain. F.A. Davis and Company 1964
17. Lawrence G, Woggon D. Scoliotic Children: How ‘Spinal Experts’ Can Help. Canadian Chiropractor 2001; 6:10-13