results of chiropractic scoliosis rehabilitation treatment ...case report results of chiropractic...

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Journal of Bodywork & Movement Therapies (2014) xx, 1e5

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CASE REPORT

Results of chiropractic scoliosisrehabilitation treatment at two yearspost-skeletal maturity in identical femaletwins

Brian Dovorany, DC a, Mark W. Morningstar, DC, PhD b,*,Clayton Stitzel, DC c, Aatif Siddiqui, DC d

a Private Practice of Chiropractic Medicine, 2031 S Webster Avenue, Green Bay, WI 54301, USAb Private Practice of Chiropractic Medicine, 8293 Office Park Dr, Grand Blanc, MI 48439, USAc Private Practice of Chiropractic Medicine, 504 W Orange St, Lititz, PA 17543, USAd Private Practice of Chiropractic Medicine, 2 W 45th Street, 4th Floor, New York, NY 10036, USA

Received 14 June 2014; received in revised form 17 November 2014; accepted 18 November 2014

Summary Background: Scoliosis treatment guidelines for non-operative management sug-
gest that patients should be followed for two years beyond skeletal maturity to appropriatelyevaluate treatment effect. This report outlines the results of identical twin girls’ treatmentwith chiropractic rehabilitation treatment at two years post skeletal maturity.Findings: The twins participated in a treatment lasting two weeks, followed by home caremaintenance and periodic follow-ups for they reached skeletal maturity. Two year follow upshowed reduced Cobb angles of 19� and 15�, respectively.Conclusion: Identical twin girls who were evaluated two years after skeletal maturity showedclinically significant improvements in Cobb angle measurements. Controlled, prospective studydesign for future patients treated in this manner will provide greater insight into how thetreatment may have impacted the observed changes.ª 2014 Elsevier Ltd. All rights reserved.
* Corresponding author.E-mail address: [email protected] (M.W. Morningstar).

Please cite this article in press as: Dovorany, B., et al., Results of chiropmaturity in identical female twins, Journal of Bodywork & Movement

http://dx.doi.org/10.1016/j.jbmt.2014.11.0151360-8592/ª 2014 Elsevier Ltd. All rights reserved.

Introduction

Adolescent idiopathic scoliosis occurs in approximately2e3% of the population (Negrini et al., 2012). The con-ventional treatment pathway for adolescent idiopathicscoliosis involves observation for curves below 20�, bracingfor curves from 20 to 40�, and surgery above 40�e45�

ractic scoliosis rehabilitation treatment at two years post-skeletalTherapies (2014), http://dx.doi.org/10.1016/j.jbmt.2014.11.015

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2 B. Dovorany et al.

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(Negrini et al., 2011). However, these values can varywidely (Dolan and Weinstein, 2007). Although bracing andsurgery have remained the gold standard of treatment inthe US, newer research is questioning the safety andeffectiveness of their routine use (Weiss and Goodall,2008). This has created a bigger focus on exercisemethods for scoliosis (Weiss et al., 2006).

While earlier reviews have shown that manual therapymethods for scoliosis treatment, including chiropractic, werelacking (Romano and Negrini, 2008), more recent research isbeing published regarding the chiropractic treatment ofscoliosis. Some of these studies evaluate manipulation-onlyas a treatment (Chen and Chiu, 2008; Tarola, 1994), othershave reported results with manipulation plus bracing (Roweet al., 2006), manipulation under anesthesia (Morningstarand Strauchman, 2010), manipulation plus postural educa-tion and heel lifts (Lantz and Chen, 2001), manipulation pluselectric stimulation (Aspegren and Cox, 1987), and manipu-lation plus exercises for adult patients (Morningstar, 2011a,b;Blum, 2002). Weiss previously recommended that any non-surgical management strategy for adolescent idiopathicscoliosis should be conducted through twoyears post-skeletalmaturity to evaluate treatment results (Weiss, 2012). Onlyone study to date has evaluated the ability of a chiropractictreatment to positively affect scoliosis over the course ofadolescent growth through skeletal maturity (Morningstar,2011a,b). More studies are needed to identify chiropractic’srole in scoliosismanagement. This study reports the results ofidentical female twins who both had adolescent idiopathicscoliosis and were treated using a conservative chiropracticrehabilitation treatment. Both patients gave their writteninformed consent to have their data and demonstrationphotos published.

Case report

In 2009, at age 13, the twins were diagnosed with idiopathicscoliosis during a routine physical by their pediatrician. Both

Figure 1 Radiographic Studies Prior to Treatment: (Pt A) eThoracT11-L4.


girls were negative for any comorbid conditions, and had nosignificant history of chronic disease. Both girls were wellnourished, energetic, and pleasant adolescent females whohappen to be diagnosed with idiopathic scoliosis. Both girlsdid list occasional back pain as a complaint and one also listedoccasional shortness of breath. No treatment was recom-mended at that time other than a future annual visit. Follow-up routine visit with their pediatrician demonstrated signifi-cant progression visually which resulted in a radiographicassessment. This was evaluated by an orthopedic specialistwho then recommended a rigid spinal orthosis for one twin(Patient B), whichwas not obtained, while fusion surgery wastentatively scheduled for December 2010 for the other (Pa-tient A). Both girls were considered highly progressive. Bothgirls began menstruation at 13 years, 4 months.

Both girls were evaluated by the lead author (BD) on 05/10/2010 prior to engaging in an intensive chiropracticscoliosis program and home therapy. Standard spinal examprocedures demonstrated normal physiological ranges ofmotion both passively and actively. No functional deficitswere observed in spinal ranges of motion, balance testing,hip and sacroiliac ranges of motion, or abdominal strengthtesting. Radiographic study at this time revealed a thor-acolumbar dextroscoliosis of 47� from T7-L2 with a T10/T11apex (Patient A), and a thoracolumbar levoscoliosis of 37�

from T11-L4 with an apex of L1 (Patient B). These radio-graphs are shown in Fig. 1. Based upon this assessment, theparents and patients decided to proceed with a conserva-tive chiropractic rehabilitation treatment.

Intervention and outcome

Given the degree of scoliosis, and its history of progression,a course of intensive short term chiropractic rehabilitationwas initiated. This treatment included multiple daily officevisits (three per day) for a total of 10 days (5 days per weekfor two consecutive weeks). During each office visit, thepatient received motorized flexion distraction (shown in

ic 47� Cobb angle T7-L2 (Pt B) eThoracolumbar 37� Cobb angle


Figure 2 An illustration of motorized lateral flexiondistraction for scoliosis.

Figure 4 Sample setup of a patient sitting in a scoliosistraction chair.

Results of chiropractic scoliosis rehabilitation treatment 3

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Fig. 2) using specialized scoliosis brackets that help tomobilize the apex of the scoliosis for 20 min. Patient thenreceived motorized cervical extension traction for aboutseven minutes using five pounds of resistance weight whilealso lying on pelvic blocks (see Fig. 3). After these warm-upprocedures were performed, chiropractic manipulation wasadministered using manual, instrument-assisted, and droptable techniques according to the chiropractic exam eachday. Patients then sat in a scoliosis traction chair for 30 minwhile lateral strapping attempted to de-rotate and laterallyreduce the scoliosis. This was done while the patient per-formed lumbar mobilization exercises on an inflatabletherapy disc, which is illustrated in Fig. 4. Finally, the pa-tients performed proprioceptive balancing while wearing a

Figure 3 Patient setup for the vibration cervical extensiontraction.


scoliosis cantilever with four pounds of resistance and alateral hipweight with 12 pounds while balancing on a 24-inch vestibular disc sitting on a vibration platform set at30Hz. This was performed for 20 min. This setup is shown inFig. 5. This procedure has been the subject of previousstudy in adolescent idiopathic scoliosis (Dovorany andMorningstar, 2013).

Following the first 10 days of treatment, the Cobb anglesmeasured 19� (Patient A) and 16� (Patient B). The patientswere sent home with specific exercise instructions. Theirroutines included 30 min a day in the scoliosis tractionchair, followed by 20 min of proprioceptive balancing onthe 24-inch disc with scoliosis cantilever and hipweight.The scoliosis traction chair has also been previously studiedin adolescent patients (Woggon and Martinez, 2013). Theseprocedures were repeated three times daily for 24 months.At that time, the scoliosis traction chair was discontinuedwhile the proprioceptive balancing was continued. Periodicfollow-up visits occurred every three months from May 2010through December 2012. Cobb angles measurements weremaintained at this interval. Follow-ups then decreased toevery six months.

Daily use of the home exercise equipment was dis-continued in July of 2013 after the lead author determinedthat both girls had reached a Risser 5 and had showedconsistent, stable postural assessments. Since curves ofapproximately 30� at skeletal maturity still have a signifi-cant risk for progression throughout adulthood (Marty-Poumarat et al., 2007) the lead author felt it importantto maintain home care for two years following skeletalmaturity. The twins were re-examined in January of 2014,without having performed any treatment or home care forthe previous six months. Radiographic images obtainedduring this follow-up appointment showed that Patient B’s


Figure 5 Illustration of girls wearing their cantilever device with hipweights on vestibular disc.

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scoliosis had been corrected to 26�, while Patient A’sscoliosis measured 22�. Fig. 6 shows these radiographicstudies and corresponding postural grid photography. Thisrepresents a curve deterioration of 7� and 6�, respectively,compared to the post 2-week treatment trial.

Discussion

This is the first study on chiropractic rehabilitation treat-ment for scoliosis to report the results of identical twinsfrom the initiation of exercise-based treatment through atleast two years post skeletal maturity, as recommended byboth the Scoliosis Research Society (Richards et al., 2005)and Weiss (2012) for non-operative therapies. This studydoes provide evidence that non-bracing, scoliosis-specificexercise treatments may have beneficial impacts on skel-etally immature patients affected with scoliosis. The

Figure 6 (A) eThoracic Cobb angle 26� T7-L2


treatment outlined for these two patients was multimodalin nature. Both patients had received the biggest correc-tions immediately following the 2-week treatment. Thesecorrections were essentially maintained throughout theduration of the active treatment process (until the end ofDecember 2012). Although curve deterioration occurredduring the follow-up phase, the resultant changes were stillclinically significant. This is an important point to empha-size, since juvenile and early adolescent patients need tobe monitored more carefully, and perhaps more frequently,in the active phase of treatment.

The initial treatment design (the two-week initialperiod) is specifically designed so that patients travelingfrom a distance can complete this therapy in a relativelyshort period of time, while simultaneously providingextensive home care instruction so that the patients cancontinue afterward on their own with infrequent follow-up.In our experience, this treatment design seems to be

(B) eThoracolumbar Cobb angle 22� T11-L4.


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preferred by patients over more traditional therapy path-ways that require more frequent and prolonged in-clinictreatment programs. Given the intense extracurricularschedule many American adolescents maintain, this pro-gram is a more likely fit.

Limitations

Since this study design was observational, and retrospec-tive, there is no way to determine which applied modalitiesprovided the biggest impact on these patient’s curves. Thecurve pattern presenting in both of these patients was athoracolumbar curve pattern. In previous studies usingchiropractic rehabilitation techniques, this pattern showedthe greatest response to scoliosis-specific exercise treat-ment (Morningstar, 2011a,b). Because both girls had athoracolumbar curve pattern, the results in this study areonly applicable to this type of curve pattern specifically. Noextrapolations can be made about other curve patterns,such as thoracic, lumbar, or double major. The patients inthis study will continue to be followed to acquire morelongitudinal data. Selection bias is also inherent in anyretrospective design. However, the objective here wasmultifactorial. First, we felt it important to show howidentical twins could have opposing curve patterns. Second,that they responded initially to chiropractic rehabilitation,and third, that they avoided bracing and surgery as the onlyother recommended treatment options.

Conclusion

Two years after skeletal maturity, and six months afterchiropractic rehabilitation treatment, a pair of identicaltwin females had a correction of their thoracolumbarscoliosis by 21� and 15�, respectively. Without a controlgroup, it is unknown how the specific procedures employedcontributed to the observed improvement in their respec-tive scoliosis. The multimodal nature of their treatmentalso precludes our ability to determine which modalitiesprovided the biggest impact. Future outcomes-basedresearch on chiropractic rehabilitation of scoliosis shouldfollow the currently recommended guidelines for non-operative treatment, such as those set forth by the Scoli-osis Research Society.

Competing interests

The authors state that they have no conflicts of interest inthe publication of this manuscript.

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