NEWSLETTER
ANINTRODUCTIONTO
Scoliosis is a lateral curvature to the spine normally diagnosed when it is >10°. It is a diagnosis most commonly observed in adolescents; however, it can be seen in adults as an incidental finding often without need for treatment. Scoliosis is considered aggressive in juveniles because it is exacerbated during early growth spurts. Early intervention and monitoring is imperative to prevent possible irreversible damage.
FUNCTIONALVSSTRUCTURAL
Functional scoliosis is the lateral curvature of the spine from extra-spinal causes. It can be idiopathic, from trauma, or even from other structural imbalance stemming from etiologies like leg length discrepancies. Functional scoliosis is also observed in many disease processes affecting muscle tone like Duchenne Muscular Dystrophy or neurologic processes such as Cerebral Palsy.
Structural scoliosis is caused by spinal pathologies. This is observed in congenital scoliosis in failure of segmentation or formation, when half of the vertebra does not form causing curvature. This is often diagnosed in utero and comes with a myriad of other health concerns for the fetus.
SCOLISOSIS
THERE ARE MANY WAYS TO DIAGNOSE A SCOLIOTIC PATTERN IN ADOLESCENTS AND ADULTS. ONE OF THE MOST UTILIZED DIAGNOSTIC TOOLS FOR EVALUATING SCOLIOTIC CURVATURES IS THE DIGITAL X-RAY. ALTHOUGH X-RAY IMAGING IS ONLY 2-D, FILM AND DIGITAL X-RAY IMAGES OFFER A CLEAR PICTURE OF WHAT IS HAPPENING TO THE PATIENT’S SPINE. MANY CHIROPRACTIC PHYSICIANS WANT TO KNOW THE PRECISE CURVATURE OF THE SPINE AS IT RELATES TO THE INDIVIDUAL. DIGITAL IMAGING IS OFTEN USED AS A BASELINE AND A REFERENCE POINT TO MONITOR IMPROVEMENTS AND TO HIGHLIGHT ANY CHANGES AS THE INDIVIDUAL AGES.
THE MOST UTILIZED MEASUREMENT IN THE MEDICAL COMMUNITY FOR ASSESSING AND QUANTITATIVELY DIAGNOSING THE SPINE’S CURVATURE IS THE COBB ANGLE. THE COBB ANGLE IS DRAWN BETWEEN THE TWO LINES OF THE MOST SUPERIORLY INVOLVED VERTEBRAE TO THE MOST INFERIORLY INVOLVED VERTEBRAE ABOVE THE APEX OF THE CONCAVITY. THE FIRST LINE IS DRAWN PERPENDICULAR TO THE UPPER ENDPLATE OF THE UPPERMOST VERTEBRAE, AND THE SECOND LINE IS DRAWN PERPENDICULAR TO THE LOWER ENDPLATE OF THE LOWERMOST VERTEBRAE. TO FINALIZE THE MEASUREMENT, AN ESTIMATE IS TAKEN BETWEEN THE TWO TANGENTS AS SEEN IN FIGURE.
COBB ANGLE PARAMETERS
10-20 DEGREES (MILD SCOLIOSIS)
20-40 DEGREES (MODERATE SCOLIOSIS) 40 DEGREES OR MORE (SEVERE SCOLIOSIS)
Cobb Angle
Scoliosis Classifications
AS WE’VE DISCUSSED, NIH DEFINES SCOLIOSIS AS A GENERAL TERM COMPRISING A HETEROGENEOUS GROUP OF CONDITIONS CONSISTING OF CHANGES IN THE SHAPE AND POSITION OF THE SPINE, THORAX, AND TRUNK. SCOLIOSIS CAN DEVELOP IN A VARIETY OF WAYS AND ARE CLASSIFIED UNDER A VARIETY OF DIFFERENT CATEGORIES. THE SPINE MAY CURVE TO THE LEFT, SOMETIMES CALLED LEVOSCOLIOSIS, OR CURVE TO THE RIGHT, REFERRED TO AS DEXTROSCOLIOSIS.
THE MOST RECENTLY UPDATED GUIDELINES FOR CLASSIFYING SCOLIOSIS WERE COMPLETED IN 2016 BY THE INTERNATIONAL SCIENTIFIC SOCIETY ON SCOLIOSIS ORTHOPAEDIC AND REHABILITATION TREATMENT (SOSORT). THREE MAJOR CATEGORIES ARE FREQUENTLY USED FOR SCOLIOSIS CLASSIFICATIONS, TOPOGRAPHIC, ANGULAR, AND CHRONOLOGICAL.
THE CHRONOLOGICAL CLASSIFICATION SYSTEM USES THE AGE OF THE INDIVIDUAL AT WHICH THE DEFORMITY WAS DIAGNOSED, THE ANGULAR CLASSIFICATION SYSTEM USES A STANDING FRONTAL RADIOGRAPH ACCORDING TO THE COBB METHOD, AND THE MOST COMMONLY USED TOPOGRAPHIC CLASSIFICATION SYSTEM THAT IS BASED ON THE ANATOMICAL SITE THE SPINAL DEFORMITY DEVELOPS IN THE FRONTAL PLANE. THE TOPOGRAPHIC SYSTEM DISTINGUISHES FOUR MAJOR TYPES OF SCOLIOSIS: THORACIC, LUMBAR, THORACO-LUMBAR AND S-SHAPED. THERE IS ALSO THE RIGO CLASSIFICATION SYSTEM BUT DUE TO THE SURGICAL NATURE OF THE SYSTEM, SOME OF ITS CRITERIA CANNOT INCLUDE NON-SURGICAL CASES.
Scoliosis Classifications
BY NATURE, IDIOPATHIC SCOLIOSIS HAS YET TO BE LINKED TO ANY SPECIFIC CAUSE, BUT SOME RESEARCH HAS PREVIOUSLY SUGGESTED THAT LEFT THORACIC SCOLIOSIS CONFIGURATIONS ARE INTRINSICALLY PATHOLOGIC, WHEREAS THE MORE USUAL RIGHT CURVE IS, IN A SENSE, "NORMAL." STUDIES HAVE FOUND THAT ALTHOUGH AN ASSOCIATION EXISTS BETWEEN LEFT THORACIC CURVES AND DISEASE, IT IS NOT STRONG ENOUGH TO DETERMINE WHETHER A DIFFERENT APPROACH SHOULD BE ADOPTED FOR TREATMENT ON THE BASIS OF SCOLIOSIS PATTERN ALONE.
SCOLIOSIS STARTS WITH A CURVE OF 10° AND CAN REACH 40°+, THE WORSE THE CURVE THE GREATER THE CLASSIFICATION OF SCOLIOSIS. THERE ARE SEVERAL CLASSIFICATIONS FOR SCOLIOSIS, WHILE THEY ALL JUDGE CURVES DIFFERENTLY THEY ARE ESSENTIAL FOR TREATMENT AND BRACING. SOME CLASSIFICATIONS ARE BETTER FOR ADULTS WHILE SOME WORK BETTER FOR THE ADOLESCENT POPULATION.
KING AND LENKE ARE BETTER FOR THE ADOLESCENT POPULATION WHILE AEBI, SCHWAB AND SRS ARE BETTER USED WITH THE ADULT POPULATION AS THE MATURITY OF THE SCOLIOSIS PLAYS A LARGE ROLE IN STABILITY AND PROGRESSION. WHILE THERE ARE MANY TYPES OF CLASSIFICATIONS THE ONES LISTED BELOW ARE THE MOST UTILIZED.
AEBI CLASSIFICATION
THIS CLASSIFICATION SYSTEM WAS CREATED IN 2005 BY MAX AEBI AND CONSISTS OF 3 TYPES OF CURVES:
PRIMARY DEGENERATIVE SCOLIOSIS (“DENOVO” SCOLIOSIS)
PROGRESSIVE IDIOPATHIC SCOLIOSIS OF THE LUMBAR AND/OR THE THORACOLUMBAR SPINE
SECONDARY ADULT SCOLIOSIS THORACOLUMBAR OR LUMBOSACRAL
DEFORMITY PROGRESSES DUE TO BONE WEAKNESS (OSTEOPOROTIC PATIENT)
LENKE CLASSIFICATION
LENKE CLASSIFICATION
THIS CLASSIFICATION SYSTEM WAS CREATED IN 2001 BY LAWRENCE LENKE AND CONSISTS OF 6 TYPES OF CURVES:
MAJOR CURVE MAIN THORACIC, MINOR, AND NON STRUCTURAL PROXIMAL THORACIC AND LUMBOTHORACIC
DOUBLE THORACIC MAIN AND PROXIMAL ARE STRUCTURAL, LUMBOTHORACIC IS NOT STRUCTURAL
MAJOR CURVE IN MAIN THORACIC, STRUCTURAL CURVE IN LUMBOTHORACIC
TRIPLE CURVES
MAJOR CURVE IN THORACOLUMBAR JUNCTION, CURVES IN PROXIMAL, MAIN THORACIC NON-STRUCTURAL
STRUCTURAL CURVE IN MAIN THORACIC, THROACOLUMBAR AND LUMBAR
SCHWAB CLASSIFICATION
THIS CLASSIFICATION SYSTEM WAS CREATED IN 2006 BY FRANK SCHWAB AND CONSISTS OF 6 TYPES OF CURVES:
THORACIC ONLY SCOLIOSIS
UPPER THORACIC MAJOR T4-T8
LOWER THORACIC MAJOR T9-T10
THORACOLUMBAR MAJOR CURVE T11-L1
LUMBAR MAJOR CURVE L2-L4
TYPE K DEFORMITY IN SAGITTAL PLANE ONLY
LENKE CLASSIFICATION
SRS CLASSIFICATION
THIS CLASSIFICATION SYSTEM WAS CREATED IN 2006 BY THE SCOLIOSIS RESEARCH SOCIETY AND CONSISTS OF 7 TYPES OF CURVES:
I. SINGLE THORACIC
II. DOUBLE THORACIC
III. DOUBLE MAJOR
IV. TRIPLE MAJOR
V. THORACOLUMBAR
VI. LUMBAR “DENOVO” IDIOPATHIC
VII. PRIMARY SAGITTAL PLANE DEFORMITY
KINGS CLASSIFICATION
THIS SYSTEM WAS CREATED IN 1983 BY HOWARD KING AND CONSISTS OF 5 TYPES OF CURVES:
I. LUMBAR CROSSING MIDLINE
II. THORACIC CROSSING MIDLINE
III. THORACIC
IV. LONG THORACIC
V. DOUBLE THORACIC
LENKE CLASSIFICATION TREATMENT OPTIONS
THE INTERNATIONAL SOCIETY ON SCOLIOSIS ORTHOPAEDIC AND REHABILITATION TREATMENT (SOSORT) USES THE TERM PHYSIOTHERAPEUTIC SCOLIOSIS-SPECIFIC EXERCISES (PSSES) FOR ALL SCHOOLS AND METHODS THAT APPLY CORRECTIVE EXERCISES TO DEVELOP STABILITY AND BALANCE IN PATIENTS WITH SCOLIOSIS. THERE ARE A FEW DIFFERENT METHODS OF PSSES USED TO TREAT IDIOPATHIC SCOLIOSIS. THE MOST WELL-KNOWN PSSE PHYSIOTHERAPY SCHOOLS OPERATING UNDER THE SOSORT ARE: SCHROTH IN GERMANY, LYON IN FRANCE, SEAS (SCIENTIFIC EXERCISE APPROACH TO SCOLIOSIS) IN ITALY, BSPTS (BARCELONA SCOLIOSIS PHYSICAL THERAPY SCHOOL) IN SPAIN, SIDE SHIFT IN THE UK, DOBOMED AND FITS (FUNCTIONAL INDIVIDUAL THERAPY OF SCOLIOSIS) IN POLAND, AND FED IN SPAIN. PSSES ALL UTILIZE SIMILAR CONCEPTS COMBINING EXERCISES THAT FOCUS ON MULTIDIRECTIONAL MOVEMENTS TO CORRECT SCOLIOTIC CURVE PATTERN DEVIATIONS. EACH PROTOCOL INDIVIDUALIZES TREATMENT PROGRAMMING TO SHIFT A SPECIFIC SPINAL CURVE TOWARD A NORMAL PATTERN.
TREATMENT OPTIONS
THE FIVE PRINCIPLES OF THE SCHROTH METHOD ARE AUTO-ELONGATION (DETORSION), DEFLECTION, DEROTATION, ROTATIONAL BREATHING, AND STABILIZATION. A STUDY LOOKING AT THE EFFICACY OF SCHROTH EXERCISES NOTED A DIFFERENCE BETWEEN INDIVIDUALS WITH COBB ANGLES 30 DEGREES AND BELOW AND INDIVIDUALS WITH COBB ANGLES GREATER THAN 30 DEGREES. THE BASIS OF THE LYON METHOD AVOIDS SPINAL EXTENSION DURING EXERCISE AND ENHANCES KYPHOSIS OF THE THORACIC REGION WITH LORDOSIS OF THE LUMBAR SPINE AS WELL AS FRONTAL PLANE CORRECTION, SEGMENTAL MOBILIZATION, CORE STABILIZATION, PROPRIOCEPTION, BALANCE, AND STABILIZATION. THE SEAS EXERCISES ARE BASED ON SELFCORRECTION AND STABILIZATION, WORKING ON ISSUES THAT MAY DEVELOP IN THE FUTURE BASED ON THE INITIAL EVALUATION. THE BSPTS CONCEPT FOLLOWS GLOBAL POSTURAL ALIGNMENT, APPLING HIGH INTENSITY FORCES CREATED INSIDE THE BODY, FOCUSING ON 3D POSTURAL CORRECTION, THE EXPANSION/CONTRACTION TECHNIQUE, STABILIZATION BY MUSCLE TENSION, AND INTEGRATION.
THE SIDE SHIFT METHOD’S TECHNIQUE IS BASED ON INTENSIVE TRUNKBENDING TRAINING, AN ACTIVE FORM OF AUTOCORRECTION. THE DOBOMED METHOD FOCUSES ON DEEPENING THE THORACIC KYPHOSIS, CLOSED KINEMATIC CHAINS, SYMMETRICAL BODY POSITION, ACTIVE STABILIZATION, POSTURAL HABITS, AND ROTATIONAL BREATHING. THE FITS METHODOLOGY WORKS TO ELIMINATE MYOFASCIAL RESTRICTIONS AND CONSTRUCT A SERIES OF NEW CORRECTIVE POSTURE PATTERNS IN EVERYDAY ACTIVITIES. THE FED METHODOLOGY STANDS FOR FIXATION, ELONGATION, AND DEROTATION AND IS DESCRIBED AS A THREE-DIMENSIONAL STABILIZATION OF THE SPINE USING SIMULTANEOUS EXTENSION AND DEROTATION AS WELL AS A SOPHISTICATED MECHANOTHERAPY DEVICE SO FORCES CAN ACT ON THE SPECIFIC ANGLE OF THE SCOLIOTIC CURVE.
FACULTY INTERVIEW
THE FIRST INTERVIEW IS DR. GREGORY PRIEST, DC, DABCO INTERVIEWED BY CIERRA
JENNESTREETDR. PRIEST HAD A STANDOUT CAREER WITH 34 YEARS IN PRIVATE PRACTICE THAT HE RETIRED FROM IN 2017. HE HAS SPENT THE LAST 21 YEARS AS AN INSTRUCTOR FOR POSTGRADUATE CONTINUED EDUCATION WITH HIS LAST 4.5 YEARS TEACHING AT KEISER UNIVERSITY, COLLEGE OF CHIROPRACTIC MEDICINE. DURING HIS TIME AS A CHIROPRACTOR, DR. PRIEST WAS GIVEN THE OPPORTUNITY TO BE AN EXPERT WITNESS IN COURT CASES, ONE INCLUDING THE TREATMENT OF A YOUNG WOMAN WITH SCOLIOSIS. THE FOLLOWING IS A SYNOPSIS OF HIS DISCUSSION OF TREATING SCOLIOSIS:
THE TREATING DOCTOR HAD BEEN SEEING THE PATIENT HER WHOLE LIFE WITHOUT DIAGNOSING AND SENDING THE PATIENT TO TREATMENT RESULTING IN THE PATIENT NEEDING RODS PUT INTO HER BACK BECAUSE THE CURVE HAD PROGRESSED TOO FAR. DR. PRIEST’S APPROACH TO TREATMENT OF SCOLIOTIC CASES WAS REFERRAL. HE HAD PATIENTS WITH IT, BUT DID NOT TREAT IT BECAUSE THERE ARE MANY ARGUMENTS FOR TREATMENT NOT BEING STRONG IN ANY DIRECTION. HE REFERRED TO IT AS A CONTROVERSIAL DISORDER AND THE DELAYING TREATMENT CAN BE CATASTROPHIC.
FACULTY INTERVIEW
THE FIRST INTERVIEW IS DR.
INTERVIEWED BY
GREGORY PRIEST, DC, DABCO CIERRA JENNESTREETTHIS IS PART OF THE REASON HE DID NOT PERFORM SCHOOL PHYSICALS. HE DID, HOWEVER, COMANAGE PATIENTS DURING TREATMENT TO HELP MAINTAIN MOBILITY IN THEIR SPINE. THAT BEING SAID WHEN CASES DID PRESENT THEMSELVES HE WOULD REFER THEM TO A TRUSTED PEDIATRIC ORTHOPEDIST IN HIS AREA. HE COMMONLY SAW THE FOLLOWING POPULATIONS WITH THE DISORDER: POST-POLIO SYNDROME PATIENTS, PUBERTY AGE FEMALES, AND POSTPARTUM WOMEN. HE SAID IT IS IMPERATIVE THAT SCOLIOSIS GET CAUGHT
EARLY ON BECAUSE IT IS EXACERBATED DURING PEAK HEIGHT VELOCITY GROWTH, NORMALLY AROUND PUBERTY. HIS FINAL ADVICE TO US AS STUDENT’S, “WE ARE CARING PEOPLE AND WE HAVE AN OVERWHELMING URGE TO HELP UPON GRADUATIONS. WHEN WE TRY TO BE EVERYTHING TO EVERYBODY I WOULD GO HOME QUESTIONING THE ADVICE I GAVE. SHOOTING FROM THE HIP RARELY DOES PEOPLE WELL. LEARN TO SAY “I CAN’T TELL AND I OWE YOU THE TRUTH” YOU WOULD BE AMAZED WHAT PEOPLE ASK YOU. “HAVE NO EGO AND STAY IN YOUR LANE.”
FACULTY INTERVIEW
THE NEXT INTERVIEW IS DR. ALEXANDER CASTELLANO DC, MSACN, ASSISTANT PROFESSOR INTERVIEWED BY CHRISTI HERFURTH DR. CASTELLANO IS ONE OF OUR CLINICIANS HERE IN OUR SPINE CARE CLINIC. HE HAS WORKED ALONGSIDE THE NEW YORK YANKEES STRENGTH AND CONDITIONING COACH AND EARNED A MASTER OF SCIENCE OF CLINICAL NUTRITION (MSACN) AND DOCTOR OF CHIROPRACTIC (DC) FROM NEW YORK CHIROPRACTIC COLLEGE (NYCC), GRADUATING WITH HONORS. DR. CASTELLANO ALSO HAS EXPERIENCE IN MULTIDISCIPLINARY SETTINGS, INCLUDING CHIROPRACTIC, PHYSICAL THERAPY AND NEUROLOGY. HE HAS ALSO WORKED WITH MAJOR ATHLETIC PROGRAMS SUCH AS THE BOSTON RED SOX, THE NEW ENGLAND PATRIOTS, BOSTON UNIVERSITY ATHLETICS AND HARVARD UNIVERSITY SPORTS MEDICINE. NOW HE TEACHES FOR KEISER UNIVERSITY’S CHIROPRACTIC PROGRAM AND HELPS OUR STUDENTS EXCEL IN THE CLINIC.
FACULTY INTERVIEW
INTERVIEW WITH DR. ALEXANDER CASTELLANO DC, MSACN, ASSISTANT PROFESSOR INTERVIEWED BY CHRISTI HERFURTH
HOW OFTEN HAVE YOU SEEN PATIENTS WITH SCOLIOSIS IN PRACTICE?
I SEE PATIENTS EVERY DAY WITH SCOLIOSIS! WE MUST FIRST DIFFERENTIATE BETWEEN FUNCTIONAL AND STRUCTURAL. REGARDLESS, IT IS A VERY COMMON OCCURRENCE
WHAT ARE THINGS TO CONSIDER WHEN TREATING SCOLIOSIS?
COBB'S ANGLE, QUANTIFY THE MAGNITUDE. AGE OF THE PATIENT, ACTIVITY LEVEL, GENDER, FUNCTIONAL ASSESSMENT, AND INDIVIDUAL GOALS OF THE PATIENT
WHAT KINDS OF THINGS HAVE YOU DONE TO TREAT SCOLIOSIS?
MULTIPLE OLDER (65+) PATIENTS WITH DEBILITATING SCOLIOSIS WHO BENEFIT FROM SEAS EXERCISES (SPECIFIC EXERCISE APPROACH TO SCOLIOSIS) WHICH AIMS TO REDUCE THE RISK OF BRACING, INCREASE CORRECTION, PREPARE WEANING, AND AVOID/REDUCE SIDE-EFFECTS OF SCOLIOSIS
FACULTY INTERVIEW
INTERVIEW WITH DR. ALEXANDER CASTELLANO DC, MSACN, ASSISTANT PROFESSOR INTERVIEWED BY CHRISTI HERFURTH
WHAT ARE YOUR THOUGHTS ON BRACING? BRACING + EXERCISES?
REFER BACK TO SEAS EXERCISES, MANY DETERMINANTS. TYPICALLY, ANY CONDITION CAN BE IMPROVED IN TERMS OF FUNCTION AND QUALITY OF LIFE WITH THE CORRECT ASSESSMENT AND APPROACH.
WHAT KIND OF RESULTS HAVE YOU SEEN?
FANTASTIC RESULTS INCLUDING GREATER ROM, REDUCED PAIN, INCREASE IN ACTIVITY LEVEL, AND DECREASED CATASTROPHIZING
ANY OTHER COMMENTS AND THOUGHTS YOU'D LIKE TO SHARE WITH THE NEXT GENERATION OF CHIROPRACTORS?
USAIN BOLT HAS SCOLIOSIS! HE ALSO HAS FLAT FEET. WE NEED TO BE HESITANT TO LABEL THESE FINDINGS AS GOOD OR BAD. THE BODY IS EXTREMELY ADAPTABLE AND RESILIENT. WE MUST TAKE AN INDIVIDUALIZED APPROACH FOR EACH PATIENT
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