Five Mistakes Chiropractors Make When Treating Scoliosis
TECHNIQUE
Marc J. Lamantia
According to the American Association of Neurological Surgeons (AANS), currently between six and nine million people have idiopathic scoliosis (IS) in the United States. Although males and females are equally diagnosed, females are eight times more likely to have a curvature that is progressive, and therefore more likely to seek treatment. According to the National Scoliosis Foundation, scoliosis patients make approximately 600,000 doctor visits in any given 12-month period. There aie somewhere around 30,000 children being fitted for scoliosis braces each year, and 38,000 spinal fusion surgeries aie performed here in the US. The current and seemingly only medical recommendation for scoliosis consists of ruling out nonidiopathic scoliosis, then observation of the curvature for progression, followed by bracing if progression is evident, and eventually back fusion surgery. Below is an excerpt from the AANS website:
Treatment
When there is a confirmed diagnosis of scoliosis, there ai e several issues to assess that can help determine treatment options: • Spinal maturity - is the patient’s spine still growing and changing?
• Degree and extent of curvature - how severe is the curve and how does it affect the patient’s lifestyle?
• Location of curve - according to some experts, thoracic curves are more likely to progress than curves in other regions of the spine.
• Possibility of curve progression - patients who have large curves prior to their adolescent growth spurts ai e more likely to experience curve progression.
After these variables are assessed, the following treatment options may be recommended:
• Observation
• Bracing • Surgery
It’s important for doctors of chiropractic to be aware of the medical recommendations, but it is not our duty to follow them. As portal-of-entry physicians, we aie trained to diagnose and to make referrals for medical care when appropriate. We are not as well trained in the management of idiopathic scoliosis patients using chiropractic methods. I’ve been teaching chiropractors how to manage adult and pediatric scoliosis for the past 12 or so years. In that time, I’ve identified five mistakes chiropractors tend to make when caring for a patient with IS.
■ ^ We are not as well trained in the management of idiopathic scoliosis patients using chiropractic methods. 5 5
Mistake 1: Following the current medical treatment standards without providing alternative care.
The nonprofit Scoliosis Care Foundation is dedicated to education and research concerning nonsurgical scoliosis treatment. The foundation’s president and cofounder of Scoliosissystems. com, Dr. Gary Deutchman, is a chiropractor who pioneered nonsurgical treatment for adults with scoliosis, and has authored guidelines for chiropractors heating adults and children, which were adopted by the Congress of Chiropractic Colleges in 2008. (Visit scoliosiscaie.org to become a regional representative and to learn more about the recommendations.) According to Dr. Deutchman, recommending "observation” after early diagnosis is a medical blunder. Dr. Deutchman points out that all curvatures start out below 25 degrees, and that “the time wasted during the observation phase of treatment is leaving a bad situation to only get worse.”
■ ^Dr. Deutchman points out that all curvatures start out below 25 degrees,
and that “the time wasted during the observation phase of treatment is leaving a bad situation to only get worse.” J ?
Dr. Deutchman is correct. His statements are well supported by recent advances in neuroskeletal and mechanobiology. Most experts agree, the forces created by the spinal curvature influence tlie curvature to worsen. Furthermore, the newest findings support the notion that the autonomic nervous system is responsible for the initiation of the bone deformity that leads to the curvature’s emergence. Dr. Deutchman recommends immediate intervention after diagnosis regardless ofthe curvature’s magnitude, giving the patient the greatest opportunity to avoid curvature progression as a result of secondary causes.
Mistake 2: Applying typical chiropractic procedures to an atypical spinal problem.
Many patients with scoliosis seek chiropractic care in the hopes that we can offer a better solution than our medical counterparts.
What patients often get depends on the type of chiropractor they visit—those who go to a Gonstead practitioner get Gonstead technique, while those who visit a DNFT doctor get DNFT. Although you can make the argument that the patient can benefit from DNFT or any other technique, these methods aie not designed to treat scoliosis, and shouldn’t be offered as such. I’m not picking on DNFT because this is trae for all techniques that aren’t specifically designed for scoliosis.
Scoliosis is an entire-organism phenomenon, and patients with scoliosis need entire-organism-style health care. Identifying what factors aie heavily weighted for the patient will help you match the most appropriate interventions with tlie patient. For example, consider one patient with scoliosis who has hyperflexibility and ligament laxity, and another who has a wedge-shaped vertebra contributing to his or her scoliosis. The best intervention is different for each case. In the first case, stabilization appliances (dynamic braces) and exercises most likely will be appropriate, whereas the second patient may require a totally different intervention.
Scoliosis will challenge you. So, for best results, be flexible in your thinking and provide care on an individual basis, and not because it’s what a particular technique protocol requires.
Mistake 3: Trying to “traction ” or “stretch ” the scoliotic spine straight.
Since the time of Hippocrates (430 BC), physicians have been hying to stretch scoliosis straight The first known technique to manage scoliosis was in fact the Hippocratic ladder seen in figure A.
Scoliosis will challenge you. So, for best results, be flexible in your thinking and provide care on an individual basis, and not because it’s what a particular technique protocol requires. ÏÏ
The great physician Galen’s methods didn’t vary much. He used a similar technique, which was applied in the recumbent posture using the Hippocratic board. When seeing these images, it’s
pretty evident chiropractors aie still hying these same methods. Unfortunately, techniques such as these have not been shown to make meaningful changes for patients with scoliosis, and despite transient changes that may be evidenced on X-ray, the long-term effects of sustained traction aie without merit. Furthermore, these methods tend to create a stress response, which may exacerbate bone demineralization and curvature progression.
Mistake 4: Inadequate recommendations that put the patient and the professional at risk.
It seems everyone dabbles in nonsurgical scoliosis treatment. Orthopedists may provide a hand out with stretches the patient can perform; orthotists make rigid braces for adolescents who aie at risk for surgical recommendations. Then there are treatments by physical therapists, personal trainers, yoga instructors, Pilâtes instructors, Chinese medicine practitioners, Rolfers, and on and on. They all offer what might be a piece of the puzzle, but rarely do they provide a comprehensive program that can be successful. Part of the problem is the level of understanding of exactly what scoliosis is and what may be required to manage it, beyond what seems to be the obvious bracing of the spine. Of course, scoliosis is an orthopedic problem, but is it much more? Scoliosis is considered a whole-organism phenomenon, meaning it is much more than just an imbalance of posture. The postural imbalance is the hallmark sign we all recognize, but it is a consequence of something far more involved. In fact, many researchers believe the curvature measured by the Cobb angle, which is the current target for treatment, is actually a secondary consequence of median or sagittal plane deformity. The clinical effects of this misconception are further compounded by strong tendencies towards certain neurological and hormonal imbalances that have been shown to be aggravating factors of curvature progression, but are not currently the target of clinical care. These nongenetic factors can be treated to mitigate the effects of the genetically initiated curvature. Often, doctors will try to offer “a little” treatment, especially soon after initial diagnosis or if the curvature is still mild. This is a clinical trap. Remember all curvatures begin small, so early diagnosis is a great opportunity to begin “full” treatment right away.
**Many of us have had some success with certain types of scoliosis, but remember this condition involves much more than one clinician can provide. 5 J
Mistake 5: Trying to manage the case alone.
The fifth mistake is one we often make out of financial need. If you send your patient to someone else, that doctor might recommend the patient stop seeing you! Or we may not think the patient needs anything other than the treatment we offer. It’s important to realize what role you can play in the patient’s needs, but it’s as important to know the role others might play as well. Many of us have had some success with certain types of scoliosis, but remember this condition involves much more than one clinician can provide.
I routinely comanage my patients with other professionals who have greater knowledge in certain areas. Patients need a clinical community that does not take ownership over them, but helps direct their care wherever they aie best served.
To learn more about scoliosis education opportunities, visit Scoliosissystems.com or call 800-281-5010. Semináis aie available in 2016.
Dr. Lamantia is recognized as one of the profession ’s foremost experts on nonsurgical scoliosis care. In 2008, Dr. Lamantia graduated with a master ’s degree in neuropsychology rehabilitation and earned his diplomate status in Chiropractic Neurology in 2006. Dr. Lamantia is a graduate of Logan College of Chiropractic, and holds a bachelor ’s degree in biology. Dr Lamantia is heavily involved in the field as a founding member of the conservative orthopedic group SOSORT; the science advisor for the nonprofit Scoliosis Care Foundation; and certified Schroth method practitioner and SpineCor bracing specialist. Dr Lamantia ’s dynamic background led him to be the cofounder of Scoliosis Systems LLP, a leading company in nonsurgical scoliosis treatment. Dr Lamantia currently practices in the New York office for Scoliosis Systems LLP and is an adjunct faculty member with New York Chiropractic College and National University of Health Sciences where he teaches postgraduate education in scoliosis and neurology. Visit scoliosiscare.org to become a regional representative and to learn more about the recommendations. To learn more about scoliosis education opportunities, visit Scoliosissystems.com or call 800-281-5010. Seminars are available in 2016.
