symptomatic scoliosis

62 M A S S A G E & B O DY WO R K • A P R I L / M AY 2 0 0 6

B y E r i k D a l t o n

Figure 1 — Scoliosis. If discovered intime, this commonly seen functionalscoliosis responds well to manualtherapy as leg length discrepancy,pelvic balance and related compensa-tions are assessed and corrected.Adapted from Bill Allen with permission.

A P R I L / M AY 2 0 0 6 • M A S S A G E & B O DY WO R K 63

During adolescence, most of usrecall our mother’s marchingorders to “Stand up straight!”

Fortunately, standing up straight was-n’t a problem for many: simply retractthe shoulders, contract the abdominals,allow the head to come back, and liftthe torso out of the pelvis. Yet for oth-ers, the act of standing upright wasn’t,and still isn’t, quite that easy — onehip may be higher than the other, oneside of the rib cage lower — whateverthe case, all the pelvic tucking, shoulderretracting and chin-raising are usuallyin vain. For these individuals, “straight-ening up” is a frustrating experience,like they are fighting their bodies justto get through the day.

The reality is some people really arefighting their bodies and those bodieshave acquired an unusual amount oflateral “curvature” where they shouldbe “straight.” Eventually, most ofthese individuals end up in the office of their family doc-tor, chiropractor or massage therapist hoping to findways to alleviate the postural strain and pain they arefeeling. Following an assessment of their condition, theymay be introduced to the meaning of the word “scolio-sis.”

When the general population hears the word scoliosis,the visualization of a hump-backed, crooked and painfulbody usually comes to mind (see Figure 1). It is, indeed,a frightening experience when parents receive a callfrom the school nurse informing them that a scoliotic“deformity” has been discovered during their child’s rou-tine screening exam. Ten in every two hundred childrendevelop scoliosis between the ages of 10 and 15.Although boys and girls seem equally affected, the curva-tures in females are three to five times more likely toprogress into more pronounced aberrant postural pat-terns.1 As scoliosis is frequently asymptomatic, it is oftenoverlooked, and the parent may only notice that thechild’s clothing no longer fits properly.

Fortunately, scoliosis takes many forms and need notalways fall into a frightful medical category. Although itcan be a very complex musculoskeletal condition, suc-cessful treatment options are available if the disorder isdiscovered in time. This article offers an overview of sco-liotic classifications, types of curvatures, accompanyingsymptoms, and hands-on examples for correcting thedysfunction.

Is it Fixable or Is it Fixed?Scoliosis may be classified in a myriad of ways: by its

reversibility, severity, etiology, or type and location. Aprimary consideration for manual therapists is the typeof scoliosis … Is it “structural” or “functional?” Spinalcurves that improve during forward-bending, sidebend-ing and specific rotational movements are generallyreferred to as “functional” or “secondary” scolioticcurves. If the curve does not straighten during any ofthese maneuvers, it is considered a “structural,” “fixed”or “primary” scoliosis. Many functional curves remainin the body too long and may become fixed as the brainvaliantly attempts to compensate for asymmetry by alter-ing length-tension balance in associated soft tissues, i.e.,muscle guarding. Prolonged postural compensationseventually decompensate in adjacent structures. Thenthe client begins experiencing increased symptoms, signsand disease.

Spinal Curves — Types and Motion

Abnormal spinal curves can occur in more than oneof the body’s planes (see Figure 2). Names familiar

to manual therapists like hyperkyphosis and hyperlordo-sis describe excessive sagittal plane curvatures, whereashorizontal (transverse plane) compensations are com-monly referred to as rotations or torsions. Although scol-iotic (side-to-side) curves are primarily considered coro-

Figure 2 — Planes of the body. Scoliotic curves may include sagittal andtransverse plane compensations. MediClip, Lippincott, Williams & Wilkins, 2005 usedwith permission.

nal plane deviations, sagittal and coronal influencesoften occur in tandem. An excellent example is the fre-quently seen humped-back (lateral and posterior) scol-iokyphotic deformity (see Figure 3).

Around the turn of the century, osteopathic physicianHarrison Fryette introduced the “Laws of SpinalMotion” in his classic book entitled Principles ofOsteopathic Technique.2 By studying movements of cadav-er spines, Fryette not only helped manual therapistsunderstand how vertebral segments respond to normalmovements but also aberrant spinal fixations such asscoliosis. Although his second law appears slightlyflawed, these classic spinal biomechanical principleswonderfully detail underlying vertebral motion charac-teristics during the acts of forward bending, backwardbending, rotation and sidebending.

Comprehension of basicjoint biomechanics is funda-mentally essential whenassessing and treating struc-tural and functional scoliot-ic clients. For example,when confronted with aright thoracic scoliosis, ther-apists must recognize thatvertebrae at the apex of thecurve are sidebending leftand rotating right causingassociated ribs to form aconvex hump. Conversely, alumbar scoliotic curve thatsidebends right and rotatesleft produces bulging in thelower left torso (see Figure4). Formation of these dis-torted postures is explainedin Fryette’s first law whichstates that lumbar and tho-racic joint coupling typical-ly occur to opposite sides.

Therapists must learn to immediate-ly identify aberrant joint couplingresponsible for these crooked pat-terns so hands-on activating forcescan restore balance and symmetry toall affected spinal and soft tissuestructures.

Hands-on approaches

As a rule, scoliotic curves arenamed according to the side of

the convexity. Thus, in the mostcommonly seen right thoracic scolio-sis, the ribcage will be convex rightwith an accompanying posteriorbulge on the right between the spinalcolumn and scapula. When thera-

pists encounter this knotty protruding ribcage, they usu-ally begin digging on the thin layer of overstretched par-avertebral fascia covering the bony ribs mistakenlybelieving they are releasing fibrotic muscles. In mostinstances, this well-intentioned maneuver may actuallyworsen the condition.

During the formation of a right thoracic scoliosis, thespinal transverse processes sidebend left and rotate rightpushing the longissimus and iliocostalis erectors laterally.The weakened serratus posterior superior musclesresponsible for binding the erectors close to midline,allow the erectors to spread much like the linea albaoften permits rectus abdominis spreading during a moth-er’s third trimester of birth. When distended, compensa-tions develop as bulging babies and protruding ribs areleft with a terribly inadequate support system.

Figure 4 — Right thoracic and left lumbar scoliosis.At the apex of the right thoraciccurve, the vertebrae are sidebent left and rotated right. Adapted from Bill Allen with permission.

Figure 3 — Scoliokyphosis.The above right structural scoliosis is formed bycoronal and sagittal plane influences.The ribcage hump becomes moreprominent during forward bending. Courtesy of Erik Dalton.


s y m p t o m a t i c s c o l i o s i s


Stretch-weakened muscles, ligaments and fascia arereciprocally overpowered as hypertonic erectors on theopposite side shorten forcing the spine to “bow.”Typically, these myofascial tissues become neurologicallyinhibited due to joint dysfunction, trauma, overuse syn-dromes, faulty posture, or paralysis. In Figure 5 the ther-apist’s fingers tonify stretch-weakened erectors and ser-ratus posterior muscles with fast-paced spindle stimulat-ing maneuvers via the dynamic gamma motoneuron sys-tem. Extended fingers then hook and reposition the lat-erally migrated paravertebrals back on top of the bulgingribs. To lengthen the erector spinae muscles on the con-cave side, the therapist reaches across with extended fin-gers, digs into the left lamina groove, scoops out the wiryspinalis muscles, and stretches all the erectors laterally.Once some spinal bowing has been removed, additionalribcage flattening can be accomplished by depressing thescapula (see Figure 6), lengthening latissimus dorsi (seeFigure 7), releasing the diaphragm and obliques (seeFigure 8), and stretching the inferior end of the transab-dominal fascial column (see Figure 9).

Classifying spinal curves

Scoliotic curvatures are generally classified by fourdegrees of severity:

1. Optimal spine — no scoliotic dysfunction. 2. Mild scoliosis — demonstrates a thoracic curve of 5

degrees to 15 degrees. 3. Moderate scoliosis — denoted by 20 to 45 degrees of

curvature. 4. Severe scoliosis — represents curvature of 50

degrees or more.3

(Note: Radiologists usually allow a gray zone that rep-resents a 5 degree range between each classification.)

Etiology and Bone Density

Approximately 70 percent to 90 percent of scoliosis istermed “idiopathic,” implying no known cause for

the dysfunction. However, structurally trained manualtherapists often find that many idiopathic scoliotic defor-mities labeled as fixed (irreversible) are actually compen-sations due to sacral or cranial base unleveling (seeFigure 10). If sacral and cranial base unleveling indeedprove to be causal factors in a portion of presumedidiopathic cases, the “no-known-cause” definitionshould no longer apply. Information sharing amongcomplementary medical professionals concerning pos-sible biomechanical and biochemical origins of scolio-sis provides hope that someday many more cases willlose their idiopathic classification.

It is also possible that the term idiopathic scoliosismay become outdated, as recent studies demonstrate aclear link between scoliosis and lowered bone densi-ties. For years, various research groups have focusedon finding a “scoliosis gene” or singular cause for thedisorder. Yet searching for a single solution for a com-plex problem may only serve to slow down the process.

Scoliosis is closely linked to low bone densities thatmay be influenced by a wide variety of overlappingfactors that includes genes, estrogen levels, nutrition,exercise, and drugs. In animal studies, lowered bonedensity is known to be caused by a wide variety ofconditions including lack of physical activity, pesticideexposure and nutritional deficiencies. Some of thesesame conditions, especially the lack of exercise andnutritional deficiencies, are known to also lower bonedensity in humans.4 Based on these facts; it seems, aswith most human conditions, illogical to assume thathuman scoliosis would be caused by a single gene, oreven by genetic factors alone.

And while idiopathic scoliosis is considered to haveno discernible cause, hereditary links have been estab-lished. Thus, if one child in a family presents with sco-liosis, it's well worth the time to check the others.Since this disorder can pass to offspring, parents with

Figure 5 — Energize the erectors. Fast-paced, spindle-stimulating maneuvers tonify stretch-weakened erec-tors. Courtesy of Erik Dalton.

Figure 6 — Reposition scapula.The therapist’s righthand lifts the scapula so the left hand can depresshumped ribs.The client inhales while gently pulling hisshoulder toward the table against the therapist’s resist-ance to a count of five and relaxes.The therapist’sextended right arm pulls and left hand gently depressesscapula to stretch pec major/minor, open anterior chestwall, and flatten protruding ribcage. Courtesy of Erik Dalton.

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scoliosis should watch their children for any relatedsigns, particularly during early teenage years.

Closer look at Structural ScoliosisEver since Hippocrates coined the term “scoliosis” to

describe deformity of the spinal column, “structural scol-iosis” (the fixed type) has occupied the attention ofresearchers and physicians. Early treatment modalitieswere often crude and sometimes violent, as well-mean-ing practitioners would walk on the scoliotic hump orapply excessive force using homemade, full-body tractiondevices. Nevertheless, these pioneering therapists diddevelop a number of sound therapeutic principles thatstill constitute essential features of many modern treat-ments, including:

• Reducing gravitational exposure; • Using traction as a basic corrective force; • Applying pressure over the convexity of the curve;

and• Creating myofascial extensibility to the concavity.Structural scoliosis as a physical deformity is often

accompanied by functional changes in the thoracic andabdominal organs as well as psychological and emotionaldisturbances. The extent of functional change in theheart, lungs, and other viscera is in direct proportion tothe degree of the physical deformity. From pubertythrough middle age, scoliotic symptoms such as back-aches, head/neck pain, arthritic symptoms, chest pain,and organ dysfunction cause people to seek help.

Fundamentals of functional scoliosis“Nonstructural” or “functional” scoliosis refers to a

structurally normal spine that appears curved. This con-dition can be a temporary abnormality — caused by vari-ous conditions — leg length inequality, spasmodic mus-cles, or inflammatory conditions such as appendicitis.Although the disorder is considered temporary, propermuscle and spinal biomechanical approaches are oftenneeded to address the underlying imbalance pattern.

Functional scoliosis is characterized by an asymmetricposition of the trunk and back that usually diminishesduring forward bending, sidebending, rotational, or trac-tioning maneuvers. Functional scoliotic cases are fre-quently accompanied by other signs of faulty and relaxedposture, such as rounded shoulders, prominent abdomenand flat feet (see Figure 11). Occurring with equal fre-quency in boys and girls, functional cases appear in alarge percentage of all school-age children as well asadults. People presenting with crooked spines commonlysuffer from a condition termed rotoscoliosis where thebase of the spine “corkscrews” headward as the vertebralcolumn turns on its axis (see Figure 12). These coronaldeviations often result from leg length discrepancy orpelvic imbalances.

An interesting note: Functional scoliosis is a physio-logic posture that can be assumed by any “normal” childor adult simply by bearing more weight on one leg whilestanding. It is pathologic only if it becomes habitual. One

Figure 9 — Lower transabdominal column release.Thetherapist’s left hand gently braces the lower respiratorydiaphragm while the right hand elevates and left rotatesthe torso.The client inhales to a count of five, gentlypulls the right shoulder toward the therapy table, andrelaxes.The therapist’s right hand left rotates the scoli-otic ribcage and the left hand stretches the lower pole ofthe transabdominal column.Courtesy of Erik Dalton.

Figure 7 — Lengthen lats and stretch scoliotic concavity.The client’s left hand grasps the therapy table, while thetherapist’s right forearm hooks the lateral lat fascia, andthe left hand braces the ilium.The client inhales to a countof five, gently pulls up on the table, and relaxes.The thera-pist deep hooks lat fascia and slowly moves headward tolengthen lateral ribcage. Courtesy of Erik Dalton.

Figure 8 — Diaphragm, obliques, and transabdominal col-umn release.The therapist’s extended fingers hook the res-piratory diaphragm, obliques, and transabdominal fascia byslowly sinking on exhalation and resisting on inhalation.


may justifiably assume the existence of a constitutionaldefect in muscles, ligaments, body alignment, nutrition,or structure of the bones. Such a deficiency explainswhy, for instance, some people naturally sit and standerectly, while others may tend to slouch and slump —whether sitting, walking, or standing.

Common functional patterns

Pain management therapists are often presented witha predictable functional scoliotic postural pattern that

closely follows the description in Figure 13. If seen fromthe back, the following asymmetries are exhibited:

• Pronated left foot/supinated right;• Up-slipped left innominate (posterior/superior);• Cephalad left pubic symphysis;

• Left on left sacral torsion;• Lumbar spine sidebent left/rotated right;• Compensatory thoracic scoliosis convex left;• Low left shoulder; • Torsioned shoulder girdle (right forward and left

back);• Compensatory left rotation of atlas on axis, and• Left sidebending of occiput on atlas.In a forward-bent position, the left side of the upper

back may be more posterior than the right, while at thethoracolumbar junction, the right side is more promi-nent than the left. The ability to recognize the variousrotational components and compensations is highlyimportant during the functional scoliotic screeningexam. Typically, the vertebrae in the curve tend tosidebend in one direction and rotate oppositely. If threeor more consecutive vertebrae sidebend together to oneside and rotate in the opposite direction, osteopaths referto this as a “type 1 group curve” or a functional scolioticpattern (see Figure 14).

During the initial screening exam, the client is seatedand asked to forward bend. Typically, the thoracic verte-brae will rotate to the side of the hump and sidebend to

the opposite side. Occasionally, when assessing asymmet-rical type 1 group curves, the therapist will find non-neutral vertebral coupling of rotation and sidebending tothe same side. This usually depends on whether thetherapist is examining above or below the apex of thethoracic curve and whether sidebending or rotation isintroduced first.

Figure 10 — Cranial and sacral influences on scolioticcurves. Notice how functional scoliosis develops from thetop down from cranial sideshift. Courtesy of Erik Dalton.

Figure 12 — “Roots” of rotoscoliosis.The corkscrewshown here develops as the lumbar spine right sidebendsand left rotates to accommodate the left sidebent/rightrotated sacral base.Adapted from Bill Allen with permission.

Figure 11 — Functional right thoracic scoliosis.The“before” photos show asymmetric positioning of thetrunk and back including rounded shoulders, prominentabdomen and forward head posture. Courtesy of Erik Dalton.



Short leg syndromesIn cases of functional scoliosis,

some may exhibit asymmetry with-out leg-length differences, but rarelywill one find a leg-length discrepancywithout structural asymmetry. Manyyounger clients develop a long C-shaped lateral curvature with theconvexity toward the short-leg sidesimilar to that shown in Figure 15.Most of this population present withonly minimal symptoms, if any.Correction of the short leg is usuallyaccomplished by balancing theiliosacral joints which allows theyouthful spine to grow straight.Early pelvic-balancing work preventsthe development of more severecurves with accompanying second-ary musculoskeletal changes later inlife.

If the convexity of the curve isopposite the short-leg side, the thera-pist should look for non-neutral dys-functions (facets stuck open orclosed) in the lower lumbar verte-brae and lumbosacral junction.These individuals fill our practicesdaily complaining of low back andhip pain where no pathology is present. Attempting torelieve functional scoliotic pain without a good under-standing of spinal and muscle biomechanics is usually

futile. Functional scolio-sis is extremely commonand treatment optionsmust be developed tohelp this ailing popula-tion. Of course, earlydetection and deep-tis-sue corrections are vitalin preventing painfulcompensatory spinalproblems that couldmanifest throughoutadulthood.

The SearchContinues

The etiology of scolio-sis has received great

attention during the lastcentury and, while con-siderable progress hasbeen made, much greaterknowledge is needed toclarify and completelyexplain the predominatedysfunctional mechanics

of the scoliotic deformity.The search for more effective ther-

apy continues, and the present sys-tems or methods of treatment are agreat deal more effective than olderprocedures. In particular, posturaldistortions are being recognized at anearlier age (sometimes at inception),allowing the immediate use of manu-al therapy modalities to treat the sco-liotic pattern while still in a mild tomoderate stage. This alone frequent-ly prevents progression to a severestage that brings with it attendantfunctional disturbances.

So there’s good news and badnews when approaching the ques-tion of scoliosis. On the one hand,it’s all too prevalent a disorder —linked to factors that need more care-ful monitoring, such as environmen-tal toxins, nutrition, and generalactivity levels. On the other hand,with more attention being given tothe condition through objective and

subjective research, comes anincrease in medical and manu-al therapy treatment options,and perhaps, soon, a cure foridiopathic and structural scoli-otic cases.

Erik Dalton, Ph.D., originator of theMyoskeletal Alignment Techniques andfounder of the Freedom From PainInstitute, shares a broad therapeuticbackground in Rolfing and manipula-tive osteopathy in his innovative pain-management workshops. Visit

www.ErikDalton.com to view additional Myoskeletal Technique articles,and new products, and to register for a free monthly technique newsletter.Call 800/709-5054 for additional information..

References1 Peterson, B. Ed. Postural balance and imbalance. American Academy of Osteopathy Yearbook. 2003:

148–152.2 Fryette, H.H. Principles of Osteopathic Technique. Indianapolis, Ind.; 1918: 231–255.3 Kuchera, M.L. Biomechanical considerations in postural realignment. Journal of the American

Academy of Osteopathy. 1987 Nov: 781–782.

4 Walker, J.M. Musculoskeletal Development. Physical Therapy. 2002 71: 879–899.

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Figure 14 — Type I groupcurve.When three ormore consecutive verte-brae bend to one side androtate in the oppositedirection, osteopathslabel this a “type 1 groupcurve” or functional scol-iosis. Courtesy of Erik Dalton.

Figure 15 — Scoliosis and theshort leg syndrome. Long C-shaped scoliotic patterns fromshort leg syndromes arise frompsoas imbalance, sciatic irritabil-ity, healed leg fracture, hyper-pronation, unlevel hip prothesis,etc. Courtesy of Erik Dalton.

Figure 13 — Common functionalscoliotic pattern.The right archattempts supination in an effort tolevel the ilia, but is unsuccessful asthe pelvic bowl side-shifts over theleft femur and up-slipped left ilium.Courtesy of Erik Dalton.



symptomatic scoliosis

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