S ince devoting my life to helping people with scoliosis through chiropractic. I have spoken with hundreds of chiropractors about their personal experiences with scoliosis. Scoliosis is often something that many DCs dont think much about until they "re confronted by it. Once they arc. though, main chiropractors have confessed to me privately that they felt inadequately prepared for the experience. In some chiropractic offices, scoliosis patients arc managed much the same way as nonscoliotic patients. While there arc exceptions, research suggests there is little benefit to treating scoliosis with general full-spine adjustments even in mild, low-risk cases.1 A chiropractic protocol not designed for scoliosis is less likely to achieve a successful outcome in the same way that seoliosis-specific exercises arc generally more successful than traditional physical therapy.2 For chiropractors who insist on providing every patient with an individualized, case-specific treatment plan, scoliosis presents a unique challenge. This article provides five steps toward empowering you to provide the best possible care to the scoliosis patients in your community. Step One: Recognize the need to serve. Scoliosis represents an undcrscrved demographic. Scoliosis is the most common spinal deformity in adolescents."' and it affects approximately 5% of the total population (equating to more than 2 million individuals in the US alone), with nearly 100.000 new cases diagnosed every year. However, public awareness of this condition remains deprcssingly poor. Furthermore, despite demand for alternatives to bracing and surgery, there are few cvidcncc-bascd options for those who find bracing and/or surgery unacceptable. Scoliosis is the most commonly researched orthopedic condition on the World Wide Web.4 If you want to help, then potential patients arc already searching for you. Scoliosis patients and doctors alike are interested in new information. The most highly accessed article of all-time in BMC Musculoskelctal Disorders is a case scries on the chiropractic management of idiopathic scoliosis. out-ranking the number two article on chronic nonspecific low back pain, a condition often seen as the hallmark of our profession, by more than 16.000 hits.5 Step Two: Acquire the skills and tools to succeed. My father is a long-time golfer who is fond of saying that if you want to compete with the pros, you "re going to need a full set of clubs. Most chiropractors do not receive comprehensive education about scoliosis as part of their schooling, and many of the tools we were given to treat it. such as electrical muscle stimulation, are now recognized as outdated and ineffective. It is necessary' to seek training from additional sources, such as postgraduate seminars and conferences focused around scoliosis rehabilitation like SOSORT. Since you will be cotrcating with orthopedists regularly, you" 11 need to understand scoliosis not only from a chiropractic point of view, but also medically. When patients come to you with questions about bracing and surgery, you must be prepared to provide them with honest and accurate advice. A great place to start is the book Scoliosis and the Human Spine by Martha Hawcs. PhD. available from the National Scoliosis Foundation (www.scoliosis.org/storc). Learn more about scoliosis-spccific exercise programs: many European physicians have achieved great strides in the physio-therapeutic treatment of scoliosis. and this know ledge lias begun making its way to the US. Combining physical therapy with certain advanced chiropractic spinal rehabilitation techniques may achieve a superior outcome than treating with physical therapy alone.6 You will need an x-ray machine with a minimum 72-inch focal film distance, or access to one. so that you can accurately track your patients" progress in accordance with established standards of scoliosis care.7 Additional equipment, such as spirometers8 and scoliometers.1' can assist in this goal while limiting radiation exposure. Step Three: Be prepared to make hamburger out of a few sacred cows. Scoliosis patients often have liganicntous abnormalities.1" and this includes the cervical spine."-12 Furthermore, these ligament problems arc not purely mechanical, but contribute to posture and proprioccption." According to the World Health Organization, the successful application of chiropractic therapy involves the mobilization of restricted areas, while avoiding areas of hypcrmobility.u Some chiropractic researchers question whether the application of rotation-based cervical adjustments may be worsening the preexisting hypcrmobility and ligamen-tous deficits in the cervical spines of mam people with scoliosis. Loss of thoracic kyphosis is one of the primary causative factors in idiopathic scoliosis:15 for this reason. P-A thoracic adjusting may be contraindicated in this population. Lateral electrical surface stimulation (LESS), was commonly used as a treatment for idiopathic scoliosis in the 1980s. Recent research suggests that electrical muscle stimulation as a treatment for scoliosis is ineffective."' and that long-tcnn usage could actually cause harm.17-18 Ultimately, in order to provide the best care to scoliosis patients, every therapy must be evaluated to ensure it is part of the solution, and not the problem. Step Four: Establish yourself within the scoliosis community and in your community. Working with scoliosis requires you to step outside the "chiropractic bubble." Understand how to communicate effectively with patients and MDs who have no prior experience of chiropractic because many have been told for years that treating scoliosis with chiropractic is ineffective. Work together with orthopedists, so they come to see you as a tnistcd resource and not a charlatan. Respect the differences between various approaches and focus on what you can do to help patients who choose a chiropractic solution, rather than on convincing those who select a different path. Educate people in your community about the various types of chiropractic by explaining why a scoliosis-specific approach may succeed where others fail. Empower the profession without alienating your fellow DCs by reaching out to them to offer your aid with their scoliosis cases. As people experience positive results with chiropractic, they arc more likely to encourage others to try chiropractic for their health ailments: the result of referring complex cases to DCs specializing in their treatment is a net benefit for our profession. Step Five: Record your results and learn from your failures. Mild scoliosis in a skelctally mature individual is the only type of scoliosis any chiropractor should accept initially. A doctor only should accept patients with Cobb angles above 25 degrees, especially in individuals with remaining growth potential, only after he or she has documented consistent successes in these cases. These cases are likely to progress and time is of the essence: a high-risk patient who selects an ineffective treatment will be left with a permanent spinal deformity and no chance to go back to when the disease was less severe to try another option. Regularly and accurately measuring the Cobb angle is considered a mandatory part of good practice standards. If the Cobb angle shows signs of worsening, you must be prepared to change your approach or refer the patient to a different doctor because failing to do so is unethical and grounds for malpractice. The chiropractic adjustment is a dynamic force with great healing potential. To recognize this potential, we as chiropractors must be prepared to make some adjustments in how we manage complex spinal disorders such as scoliosis. To simply refer all of these patients to orthopedists robs them of their chance to discover the chiropractic healing potential, while treating them when lacking the necessary skills and equipment guarantees this potential will not be fully realized. The key is to advance your skills to the level with which you are comfortable, and recognizing those patients who present with a condition that need treatment beyond this level. Then, ethically and in good conscience, it is important to provide the advice and recommendations you would if a member of your family were in the same situation. References 1. Lant/ CA. Chen J: Effect of chiropractic intervention on small scoliotic curves in younger subjects: a time-series cohort design. JMPT 2001 Jul-Aug:(6):385-93. Ncgrini S. Atanasio S. Zaina F, Romano M: Rehabilitation of ado lescent idiopathic scoliosis: results of exercises and bracing from a scries of clinical studies. Europa Mcdicophysica-SIMFER 2007 Award Winner. EurJ Phys Rchabil Mcd. 2008 Jun:44(2): 169-76. Mirtz T. Tliompson M. Leon Greene L. Lawrence A Wyatt L. Akagi C: Adolescent idiopathic scoliosis screening for school, community, and clinical health promotion practice utilizing the PRECEDE-PROCEED model: Chiropractic & Osteopath) 2005. 13:25. Beall MS 3rd. Golladay GJ. Greenfield ML. Hcnsingcr RN. Bicr- inann JS: Use of the Internet by pediatric orthopaedic outpatients. J Pcdiatr Orthop. 2002 Mar-Apr;22(2):261-4. Morningstar MW. Woggon DA. Lawrence G: Scoliosis treatment using a combination of manipulative and rehabilitative therapy: a retrospective case scries. BMC Musculoskclctal Disorders 2004. 5:32. Diab AA: The role of forward head correction in manage ment of adolescent idiopathic scoliotic patients: a randomized controlled trial. Clin Rchabil. 2012 Dcc:26(12):1123-32. doi: 10.1177/0269215512447085. Epub2O12 Jul 16. Facrbcr EN ct al: ACR-SPR Practice Guideline fortlic Performance of Radiography for Scoliosis in Children. 2009. Wasserman K. Hanscn JE. Sue DY ct al: Principles of exercise testing. Baltimore: Lippincott Williams and Wilkins: 1999. Bonagamba GH. Coclho DM. dc Olivcira AS: Inter- and intra-ratcr reliability of the scoliomctcr. Rev Bras Fisiotcr. 2010 Oct:14(5). Czaprowski D. Kotwicki T. Pawlowska P. Stoliiiski L: Joint hy- pcrmobility in children with idiopathic scoliosis: SOSORT award 2011 winner. Scoliosis. 2011 Oct 7:6:22. Rivard CH. Rhalmi S. NewmanN. Yahia LH: Morphological study of the inncrvation of spiral ligaments in scoliotic patients | Article in Frcnch|. Ann Chir. 1993:47(9):869-73. Jiang H. Russell G. Raso VJ. Morcau MJ. Hill DL. Bagnall KM: The nature and distribution of the inncrvation of human supraspi- nal and intcrspinal ligaments. Spine (Phila Pa 1976). 1995 Apr 15:20(8):869-76. Jiang H. Grcidanus N. Morcau M. Mahood J. Raso VJ. Russell G. Bagnall K: A comparison of the inncrvation characteristics of the lateral spinal ligaments between normal subjects and patients with adolescent idiopathic scoliosis. Acta Anat (Basel). 1997:160(3):2OO-7. Gattcrman MI: Contraindications and complications of spinal manipulative therapy. Journal of tlic American Chiropractic As sociation. 1981:15:575-586. Dickson R A: The etiology and pathogencsis of idiopathic scoliosis. Acta Orthop Belg. 1992:58 Suppl 1:21-5. Lcnssinck MLB. Frijlink AC. BcrgcrMY. ctal: Effect of bracing and other conservative interventions in the treatment of idiopathic scoliosis in adolescents: a systematic review of clinical trials. Phys Thcr 2005: 85:1329-1339. Szarck J. Kowalski IM. van Dam F. Zarzycki D. Pawlicki R. Fabczak J: Pathomorpliological pattern of paravcrtcbral muscles of rabbits after long-term experimental clcctrostimulation. Patliol Res Pract. 2003:199(9):613-8. Kowalski IM. Szarck J. Babiiiska I. Wojtkiew icz J. Andrzejcw ska A. Lipiriska J. Majcwski M: Ultrastnictural features of supra- spinal muscles in rabbits after long-term transcutancous lateral electrical surface stimulation (LESS). Folia Histochcm Cytobiol. 2005:43(4):243-7. Dr. A. Joshua U'oggon, a 2010 Graduate of Parker College, serves as the Director of Research for the CLEAR Scoliosis Institute, a Xon-Profil Organization dedicated to advancing chiropractic scoliosis care (www.clear-institiite.org). He can be contacted at jwoggon(d,clear-institute.org
