Friday, November 25, 2016

Chiropractic treatment in scoliosis

If one searches the web for information on chiropractic care and scoliosis, the American Chiropractic (ACA) Association would be a logical place.  According to the ACA, “chiropractic is a health care profession that focuses on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health. Chiropractic services are used most often to treat neuromusculoskeletal complaints, including but not limited to back pain, neck pain, pain in the joints of the arms or legs, and headaches.” So scoliosis is not a diagnosis directly referred to, but the “not limited to” part of this statement does not eliminate scoliosis from the conditions they may advocate to treat.

Further digging around on the ACA website one finds very little information about scoliosis or chiropractic treatment of scoliosis.  One item that is posted is a patient information handout produced by the ACA which states “Spinal manipulation, therapeutic exercise, and electrical muscle stimulation have also been advocated in the treatment of scoliosis. None of these therapies alone has been shown to consistently reduce scoliosis or to make the curvatures worse. For patients with back pain along with the scoliosis, manipulation and exercise may be of help.”  Let’s break down and analyze these three sentences.  Sentence one is factually correct, these therapies along with many others have been advocated in the treatment of scoliosis, with most therapies eventually being shown to be ineffective.  The second sentence of this quote one can essentially boil this down to this revised statement: we (the ACA) can’t come right out and say it, but there really isn’t any evidence spinal manipulation, therapeutic exercise and electrical stimulation really prevents scoliosis from getting worse.  The third sentence is partially accurate, short-term back pain may be helped with manipulation and exercise may be of help.  Long-term back pain related to scoliosis has not proven responsive to chiropractic treatment.

Another website to search on this topic is from the Scoliosis Research Society (SRS).  This is the most authoritative website, produced by medical doctors and doctors of osteopathy who specialized in spinal deformity in children and adults.  This website has a section of FAQs on scoliosis, and it is here one can find the following information:

Will chiropractic treatment help my scoliosis? 
Chiropractic is a controversial method of treatment that seems most effective in treating acute, short-term pain. Chronic conditions do not seem effectively managed by long-term chiropractic care. Patients who have scoliosis and choose chiropractic treatment should be referred to a spinal orthopaedist or neurosurgeon if their curves keep increasing. Insurance may or may not cover chiropractic treatment.

Thee two large organization can obviously be biased in their position on this subject, and one would expect both organization to support their mission and members.  So let’s look at the science behind this topic.  In this era of evidence-based medicine we should constantly strive for the highest level of evidence to support our treatments.  By searching Pubmed, the U.S. National Library of Medicine and National Institute of Health’s online search engine, one can search over 26 million citations for biomedical literature from MEDLINE, life science journals and online books.  This is a good place to search for information on “scoliosis and chiropractic treatment”.  If one does this the results of the search will demonstrate a lack of scientific evidence supporting the position that chiropractic treatment/manipulation alters the natural history of scoliosis (prevents progression or worsening of the deformity).  The existing literature on this topic is replete with cases reports and small, retrospective, single center case series which lack control groups, have inadequate numbers of patients, insufficient follow-up, lack rigorous statistical analysis and are generally underpowered statistically.  Testimonial medicine advertisements, however appealing, should not be used as evidence a treatment is helpful and safe.

Hence based on the currently available data, there is no scientific evidence that chiropractic therapies alter the natural history is scoliosis.  This statement, though grounded in evidence based medicine, is often vigorously contested by some chiropractic or homeopathic practitioners. Often talking about chiropractic treatments with families is much like discussing politics and religion, individuals often have firm beliefs in either direction and will not be swayed by a five-minute conversation in the office.

When my patients ask me about my perspective of chiropractic treatment of their child/adolescent with a spinal deformity I state the following:

1.      Spinal manipulation should never be done on a spinal deformity.  Catastrophic injuries (fractures, paralysis, etc…) have occurred when the spine was “manipulated”.

2.      There is no scientific chiropractic treatments prevent progression of scoliosis.

3.      Often when chiropractic treatment is initiated the recommended plan of treatment (with multiple x-rays) to parents/caregivers is for several treatments per week for months or years.  This can be extremely expensive, and time consuming, for families and can drain Health Savings Accounts quickly.

4.      The only benefit chiropractic treatments may help is acute, short-term back pain.

5.      The most effective interventions for pediatric and adolescent back pain related to scoliosis are:

a.       Rule out more serious and non-muscular causes of back pain (such as urinary tract infection, hip pathology, and fractures).

b.      Develop a physical fitness program in which the individual is doing some type of aerobic activity (raising the heart rate and breaking into a sweat) for 20-30 minutes a time, 3 times per week.

c.       Maintain ideal body weight

d.      Do not use tobacco products.

I hope this helps. Let me know if there are any questions.  Happy Holidays.

Wednesday, November 9, 2016

Spine Bracing in Early-Onset Scoliosis (EOS)

Bracing in EOS is a commonly utilized nonsurgical intervention.  Braces are constructed of either rigid or semi-rigid plastic, and are designed on an individual basis. The orthotist (the person who makes the brace) analyzes each patients’ anatomy and radiographic deformity, then constructs the brace.  The brace is contoured to place pressure points on the ribs and pelvis, with padding, and that force is then transmitted to the spine, ideally straightening it. 

In EOS one of the concerns of bracing is altering the rib development and alignment.  Hence, most often brace use in EOS is not recommended to be worn full-time.  Conceptually, having time out of the brace the chest can develop more normally.  This is more of a theoretical concern, as there is little information that bracing can permanently deformed the chest in a negative way.

Though there are medical centers and providers which report, and sometimes advocate or market, for one brand of spine brace over another, there are three main types: flexible, semi-rigid and rigid.  Flexible braces, typically constructed from a highly-elastic material like neoprene (with straps), may be appropriate for children with mild to moderate deformities and have low neurologic tone.  This brace exerts less force to the spine so it cannot be used in patients with normal or increased tone or moderate to larger deformities.  In my practice these have been used occasionally in the neuromuscular patient (cerebral palsy, spina bifida, spinal muscle atrophy, etc…) who are low demand physically and have low muscle tone.  Semi-rigid braces are a step up in stiffness, and subsequently can exert more corrective force to the body and spine.  These braces are more typically used in children under 3 years of age with milder deformities.  

Rigid braces (TLSO: thoraco-lumbo-sacral orthoses) are the most commonly used brace in EOS and in spine bracing in general.  There are several subtypes of rigid braces: Boston, Wilmington, Charleston, etc…  which have different corrective forces and wear schedule.  Regardless of which brace is used a key issue to brace is simply that the brace must be appropriately worn by the patient for the recommended length of time each day.  A brace will not have the ability to help the patient if it not being worn.  The goal of a spine brace is to maintain the deformity, not to correct the deformity.  In EOS it can be used a primary treatment for milder, more flexible deformities or after a series of spine casts.  It is difficult, if not impossible, to create a long-term plan for each patient, so the length of time each patient will need to be braced is difficult to determine.

Next blog post: Chiropractic treatment of scoliosis