Wednesday, April 23, 2014

The Frisco Chiropractic and CLEAR Institute Method for the Conservative, Non-Surgical, Analysis and Treatment of Scoliosis.


Webster’s Dictionary defines scoliosis as: a lateral curvature of the spine.  We know that scoliosis involves much more than this.

A Couple of Common Misconceptions
Before we get to far into the Clear approach to scoliosis I think we need to clear up a few common misconceptions about scoliosis that are still widely believed by many people.  This is important so that we can continue from this point with a better understanding of this condition, in order to have a better perspective of why we have developed the methods for treating scoliosis that we are currently using.

The Myth about Muscle Spasms
Based on current research it is important to recognize that imbalances of the paraspinal musculature has  little to nothing to do with the development of the scoliosis curvature in its earliest stages.  (Biomechanical Factors in the Progression of Idiopathic Scoliosis. Schultz A. 1984, Annals of Biomedical Engineering, Vol 12, pp 621-630), (Motor Unit Analysis Of Paraspinalis Muscles In Idiopathic Scoliosis”, Koo, Cheng, Xia, Dept. Of Pediatrics, Prince of Wales Hospital, Chinese University of Hong Kong, Children’s Hospital of Michigan, Wayne State University) This has been a common misconception for many years.  However, it has been shown by paraspinal EMG studies that the activity of the paraspinal musculature in the early stages of the developing scoliosis are not abnormal or out of balance.  (Trunk strengths in structurally-normal spines and 48 girls with idiopathic scoliosis. Spine 7:551-554, 1982) This means that it is not the muscles pulling on the spine that causes the scoliosis curves to develop.  This fact has led us to look for other causes to the early development of this debilitating condition.  In fact, it has been determined that the significant and obvious imbalances of the paraspinal musculature seen in an advanced scoliosis curvature is nothing more than the body’s reaction to the scoliosis curvature as it continues to advance or develop.  These musculature imbalances are the body’s attempt at stabilizing the scoliosis, and not the initial cause.

Skeletal Maturity and Curve Progression
Another misconception that needs to be briefly discussed is the belief that the scoliosis curve that begins to develop in a child will stop once the individual reaches skeletal maturity.  Recent studies published over the last few years by the medical community tracked scoliosis patients through their adult lives.  These studies were designed to determine the percentage of childhood scoliosis patients that continue to get worse as adults and at what rate in their adult life the scoliosis continues to advanced or progress, (at ages well beyond the point of skeletal maturity).  (Scoliosis & the Risk of Progression, Spine 2007;32(11):1227-1234), (Idiopathic scoliosis: evaluation of the results Bull Acad Natl Med 1999;183(4):757-768) To accomplish this, they followed the development of the scoliosis curvatures in several hundred patients through their adult life. These studies showed that the curvatures in the vast majority of children with Idiopathic Scoliosis will continue to develop throughout their adult life, and in virtually every patient with “progressive” scoliosis as a child.  (Weinstein et el, Idiopathic scoliosis: long term follow-up and progress in untreated patients, J Bone Joint Surg AM. 1981:63:702-712)


This shows the continued development of scoliosis in adult patients
that had progressive scoliosis as a child.

The following diagram shows the percentage incidence of progression of scoliosis patients after skeletal maturity as a compilation of several studies showing continued progression of the Cobb angle of scoliosis patients in adult life at a rate of 72.8%. 

Table 1.1, Incidence of Curvature Progression: After skeletal maturity

Study Number of Scoliosis Cases Initial Cobb angle Incidence of Progression
Ascani et al., 1986 187 <20 - >60 100%
Bjerkrein & Hassan., 1982 70 10-154 60%
Collis & Ponseti., 1968 134 <50 - >100  69%
Korovessis et al., 1994 91 >10 67%
Weinstein & Ponseti., 1983 102 15-135 68%
Totals & Averages 584 10 – 154 72.8%

Obviously, there are many factors that can affect this, but the fact that the scoliosis curves continue to develop in the vast majority of adult scoliosis patient that had scoliosis as a child (especially progressive scoliosis) is well established, and has to be recognized.

Scoliosis is not a Simple Fix
As we begin to look at scoliosis and recognize that much of our earlier understanding of this condition is not accurate, and because of this, we realize that we must look more closely to uncover the causative factors involved with scoliosis.  It is important to be able to recognize and identify these factors before any effective conservative approach can be developed to treat this condition.  Clear Institute has worked hard to identify these underlying factors and develop a treatment plan that addresses all of these conditions in a cohesive treatment plan that can be adapted to patients of all ages with all types of scoliosis configurations. 

Because of this, scoliosis treatment through the CLEAR Institute is not the usual chiropractic office visit.  Depending on the severity and complexity of a particular scoliosis, the time required to effectively treat a scoliosis patient can take anywhere from 2 -3 hours per visit (or more for the most severe cases).  As a patient in the CLEAR Scoliosis Center you will see that the methods developed by the Clear Institute to treat scoliosis reflect the complexities of this condition.  We have found from our time working with this condition that anything less just doesn’t work.

If you are reading this, you are most likely aware of the difficulties involved with conservative treatment of scoliosis.  Any treatment plan that has, as its goal, the treatment and correction of scoliosis, without the use of bracing or surgery, is a monumental undertaking even under the best circumstances.  This kind of treatment will take time and effort on the part of the doctor and patient alike.  We at the Clear Scoliosis Center pledge to do our very best in the treatment of every patient under our care, and require the same level of commitment from the patients receiving care.

Common Findings Associated with the Development of Scoliosis
There are many conditions involved with the development of a scoliosis, and we have found that it is a combination of these conditions that allows the lateral curvatures of a scoliosis to begin to develop.

Loss of the Normal Curves
One of the most common findings related to the development of a scoliosis is the loss of the normal curves of the spine.  (The Relationship between cervical kyphosis and idiopathic scoliosis Morningstar, Stitzel, JVSR, October 13, 2008, pp 1-4) The spine is designed to have normal front to back cures.  These normal curves give the spine stability, flexibility and strength.  As the body begins to loss these normal curves due to external stress, trauma or pathology, it starts to lose the stability inherent in a normal spine.  This lose of normal curvature also causes the development of significant adverse mechanical tension on the spine as a whole.  This loss of stability due to the loss of normal curves has a lot to do with the initial development of the abnormal lateral curvatures called scoliosis.

Adverse Mechanical Traction
The straightening of the spine has another very significant effect on the spinal cord.  As the spine loses its normal curvatures it causes a tractioning or tethering of the spinal cord itself due to the lengthening of the spinal canal.  (Relative shortening and functional tethering of spinal cord in AIS study with multiplanar MRI and SEP Spine 2006 Jan Vol 31(1) P E19-25), (Effect of Mechanical Stresses on the Spinal Cord in Cervical Spondylosis Breig et al, Dept of Pathology, University of Umea, Sweden) In addition to this stretching of the cord there is also an internal pressure developed as the outer covering of the spinal cord itself, called the Dura Mater, Latin for tough mother, collapses down on the spinal cord, kind of like the action of a Chinese finger trap (the harder you pull the tighter it gets).  All of this causes significant adverse mechanical tension on the cord beyond what it can normally overcome in day to day life.  This adverse mechanical pressure must be diminished or relieved to prevent possible damage to the cord itself.  The body’s need to reduce this pressure on the spinal cord also becomes a driving force for the development of the condition of scoliosis.

Upper Cervical Subluxation and Associated Neurological Considerations
Another common, and almost universal finding related to the development of a scoliosis, is the loss of normal alignment (subluxation) of the skull and the first two cervical vertebrae (the upper cervical complex).  This misalignment has profound effects on the spine as a whole.  Research again has shown that this misalignment causes pressure on the spinal cord as it passes through the base of the skull (the Foramen Magnum),  (Spinal Canal Capacity in Simulated Displacements of the Atlantoaxial Segment: a Skeletal Study. JBJS, 1998; 80(6):1073-1078) interfering with the communication of the brain and the core muscles via the corticospinal and spinocerebellar tracts.  Misalignment of the upper cervical complex (C0-C1-C2) can also have a significant effect on spinal proprioception and overall spinal balance.

Pelvic Instability and Rotation
Pelvic instability is another very common finding when working with a scoliosis patient.  (Sagittal plane analysis of the spine and pelvis in AIS according to the coronal curve type Spine 2003;28(13):1404-9)  This instability allows the pelvis to rotate (Analysis of sagittal alignment in thoracic and thoracolumbar curves in adolescent idiopathic scoliosis: how do these two curves types differ? Spine 2007; 32(12):1355-9) causing rotation of the lumbar spine leading to further development of the lumbar Cobb angle as well as problems with gait and posture (Gait analysis in patients with idiopathic scoliosis Eur Spine J 2004 13:449-456)

A Convergence of Conditions
Based on our findings, it is apparent that the cause of scoliosis is based on a combination of these and other factors allowing the spine to become destabilized.  The spine cannot function without curves, and it unfortunately does not seem to be able to re-establish the normal curves that have been lost over time.  It is the combination of these conditions which causes the spinal column, through the formation of the lateral curvatures, to find a position of relative stability in a new dimension.  This process replaces, in part, the stability lost by the spine as it lost its normal spinal curves, with the lateral scoliotic curves, allowing the spine to settle into a relative “resting state”.  It is this new abnormal stability developed by the formation of the lateral curvatures that allows the scoliosis to become stable and continue to progress with time.  To say it another way, a scoliotic spine is, unfortunately, more stable than a spine that has lost its normal curves and is under significant adverse mechanical tension due to the conditions discussed in the previous paragraphs.  It appears that these are the initial conditions that become, or develop into, a scoliosis.

Developing an effective treatment for scoliosis requires that we address all of these different causative conditions at the same time.  As scoliosis doctors, we can not only restore the normal curvatures and expect the scoliosis to correct.  We cannot try only to push the scoliosis out and expect to get any real long term correction.  We cannot restore normal alignment of the upper cervical complex (C0-C1-C2), and teach the patients some spinal exercises, and expect the curve to correct.  The truth of the matter is that we have to do all of these things at the same time, working in unity with the patient to achieve the overall goal of obtaining stability, and ultimately correction, to the scoliotic spine.

Even under the very best conditions, scoliosis is challenging to treat.  This will take a dedicated effort on the part of everyone involved for treatment to be successful.  I will do everything I can to make this program work, and we must ask the same of you in return.  Any activities that are high impact or strenuous can have a negative effect on a scoliosis and need to be seriously evaluated, and eliminated as much as possible.  If you, as the patient, continue these types of activities, you have to realize that they will have a detrimental effect on your scoliosis and will interfere with the treatment you will receive in this clinic.  For this reason we will make recommendations as to the daily activities that the patient under care should avoid, as well as specific recommendations aimed at improving daily posture and study habits.  Our ability to effectively treat a scoliosis involves much more than just the treatment received in the clinic, your daily activities and your willingness to perform the daily exercises on a regular schedule at home, as prescribed by your doctor, will have a profound effect in the long term outcomes you can expect.

As you should begin to realize at this point, the lateral curvatures involved with scoliosis are not much more than a symptom of a much more complex condition.

Remember that the goal of this clinic is to prevent the continued progression of the scoliosis, to restore proper biomechanics to the spine, to make correction in the lateral curvatures (Cobb angles), and to prevent the need for debilitating scoliosis surgery.

Psychological and Social Aspects of Scoliosis
In addition to the significant physical complications to scoliosis, there are some very real social and psychological challenges as well.  Research shows that three out of four women with scoliosis never marry.  (An Algorithm for the Management of Scoliosis. JMPT 1986;9:1-14) Children with this condition often suffer from jokes and teasing by their classmates due to the deformity associated with their scoliosis.  They are commonly unwilling to be involved with school activities that require them to wear a swimming suit or other clothing that might easily reveal the curvatures in their spine, all of which leads to social isolation.  To complicate the issue, many of these children are told to wear bulky and uncomfortable braces for up to 23 hours a day, further limiting their physical activities and involvement with other children.  In another study the attitude of the patients parents, (most notably the mother), and the child, toward their scoliosis were strongly related to the child’s ability to adjust to the condition.  (Psychological Impact of Idiopathic Scoliosis on the Adolescent Female, A Preliminary Multi-Center Study, Neil Kahanovitz, MD and Sherri Weiser, MA: The Back Service, Hospital for Joint Disease, New York, New York, May 24, 1988, pp. 483-485)  Long term statistical studies also show these patients are more prone to depression & alcoholism later in life.  (Does scoliosis have a psychological impact and does gender make a difference? Spine 1997, 22:1380-4)

Bracing as a Treatment for Scoliosis
As the medical treatment for scoliosis continued to advance, bracing was a logical approach.  The idea of preventing the scoliosis curve from continued development by stabilizing the spine made a lot of sense.  Over the past 50+ years several different braces have been developed to attempt to accomplish this task.  Based on the medical model, successful bracing is based on stabilization or preventing the scoliosis from getting worse.  Unfortunately, the results over the last 30 to 40 years have constantly demonstrated that bracing has been ineffective at treating or even stabilizing the scoliotic spine.  (Adolescent idiopathic scoliosis: is the search for aetiology constrained by the orthosis? Stud Health Tech Inform 2002; 88:222-5)  This is true because, as soon as you stabalize a body part with an outside force or support (like putting an arm into a cast) the associated musculature no longer has to do its job.  As a result the muscles that are responsible for this part of the body become deconditinoed and weakened, primarily due to lack of activity.  The spine is the same as any other part of the body in this respect, and when you stabalize the spine with a brace the core musculature becomes significantly deconditioned allowing for overall long term continued progression of the scoliosis.   Recent studies have shown no difference in the development of scoliosis between braced and non-braced patients.  (Adolescent idiopathic scoliosis: the effect of brace treatment on the incidence of surgery.  Spine 2001 Jan 1;26(1)42-7 Children’s Research Center, Dublin, Ireland), (Surgical rates after observation and bracing for AIS: an evidence-based review Spine 2007, Sep 1, Vol 32 (19 Suppl) P S91-S100)

The Truth About Spinal Rod Surgery for the Correction of Scoliosis
Based on an article that came out recently, many medical doctors are not even recommending the spinal rod implantation surgery until the Cobb angle has advanced to 70 degrees.  This is a drastic change from the previously accepted 45 degree Cobb angle that has used for years as the standard at which these surgeries have been recommended and most commonly performed.  The change in procedure recommended by the authors of this paper is not because they don’t recognize the seriousness of scoliosis, but because they are recognizing the seriousness and potential complications of the surgery itself.  (End-result study of the treatment of idiopathic scoliosis. Report of the Research Committee of the American Orthopedic Association. JBJS 1941;23:963-997) It is our belief that in almost all cases the surgery is doing nothing more than replacing one form of spinal abnormality (a bent but functional spine), with a worse abnormality (a straighter but functionless spine), unfortunately leaving many of these patient in chronic pain.  (Adolescent idiopathic scoliosis report increased pain at five years compared with two years after surgical treatment. Spine 2008 May 1;33(10):1107-12) As Dr. Harrington (the developer of this type of surgery) stated years ago, “Metal does not cure the disease of scoliosis, which is a condition involving much more than the spinal column.”  Some of the more serious complications to this type of surgery include implant rejection, failure of the surgery to control the scoliosis, heavy metal poisoning, chronic or constant pain, long term degeneration of the spine above and the fusion, and hardware failure.  (Rate of complications in scoliosis surgery – a systemic review of the PubMed literature. Scoliosis 2008;3:9) Many of these complications lead to the need for subsequent spinal surgeries. 
It is also important to note that a large majority of these surgeries are performed for aesthetic purposes like reducing the rib deformity or correcting postural abnormalities.  These problems are commonly not corrected with the initial rod implantation surgery, and require subsequent surgeries to address these issues.  (The crankshaft phenomenon after posterior spinal arthrodesis for congenital scoliosis: a review of 54 patients. Spine 2003; 28(3):267-271), (Impact of spine surgery on signs and symptoms of spinal deformity Pediatr Rehab 2006;9:318-339)

The CLEAR Institute Approach to the Conservative Treatment of Scoliosis - Mix, Fix, Set
As we have learned, scoliosis is a complex combination of biomechanical alterations or abnormalities beyond just the commonly recognized lateral bend in the spine.  To effectively treat scoliosis, you first need to recognize, Identify, and quantify the contributing conditions.  The CLEAR method for treating scoliosis reflects the complexity of this condition.

The first part of the treatment protocol is called Mix.  The purpose of the Mix is to warm up the spine, and prepare it for the rest of the treatment.  In this portion of the program the patient performs several activities to warm up and loosen up the spine.  These activities include the wobble chair, and different tractioning devices designed put motion into the spine.

The second part of the treatment protocol is the Fix.  This is where the chiropractic adjustments take place.  We also perform other modalities that begin to cause correction of the spinal curvatures.

The last part of the program is the Set.  During this part of the treatment the patient receives several treatments that are designed to stabilize the spine in a more corrected position.

Learn more about the Mix, Fix, Set process by clicking here.

We recognize that scoliosis is a difficult condition to deal with both physically and emotionally.  We believe that we have developed the best current treatment for scoliosis available today.  The treatment offered by any certified Clear Institute clinics has been proven to be safe for patients of all ages, and we believe that treatment of this nature should be a first option for anyone dealing with scoliosis.  It is safe, effective, and has none of the negative effects of the more aggressive and invasive treatment available.

We have other research and reference articles and papers available upon request.

If you have any questions or need more information, please call the clinic and set up a free consultation, we are here to help.

Dr. Glenn Robinson
Director of The Frisco Chiropractic Clinic

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