Original Articles
Effect of chiropractic intervention on small scoliotic curves in younger subjects: A time-series cohort design*,**,

https://doi.org/10.1067/mmt.2001.116419Get rights and content

Abstract

Background: Chiropractors have long claimed to affect scoliotic curves, and case studies abound reporting on successful outcomes. No clinical trials exist, however, that evaluate chiropractic's effectiveness in the management of scoliotic curves. Objective: To assess the effectiveness of chiropractic intervention in the management of adolescent idiopathic scoliosis in curves less than 20°. Design: Cohort time-series trial with all subjects electing chiropractic care. Entry-level Cobb angle was compared with postmanagement curve. Methods: Forty-two subjects completed the program of chiropractic intervention. Age range at entry was 6 to 12 years, and patients were included if their entry-level x-ray films revealed curves of 6° to 20°. Participants had adjustments performed for 1 year before follow-up. Full-spine osseous adjustments were the major form of intervention, but heel lifts and postural and lifestyle counseling were used as well. Results: There was no discernable effect on the severity of the curves as a function of age, initial curve severity, frequency of care, or attending physician. Conclusion: Full-spine chiropractic adjustments with heel lifts and postural and lifestyle counseling are not effective in reducing the severity of scoliotic curves. (J Manipulative Physiol Ther 2001;24:385-93)

Introduction

The management of scoliosis poses formidable challenges to all health care practitioners. The changing attitude concerning the health risks of scoliosis has fostered a reevaluation of treatment methods and management programs for those with scoliosis.1 The significant cost2 and substantial risk3 of surgery for scoliosis, along with earlier identification of patients with scoliosis through school screening programs, have led to a reconsideration of the role of conservative therapies in scoliosis management.4, 5, 6

Patients have been clearly shown to reject the medical position of the “3 Os”: observation, orthosis, and operation. In a group of patients who were assigned to wear braces, 50% refused to wear them, and 50% of those who were recommended for surgery refused that procedure as well.7 Compliance with orthosis with medical bracing of scoliotic curves is a definite problem.8, 9, 10 It would seem reasonable, then, to search for more acceptable conservative methods of treatment. Growing numbers of patients are seeking alternatives such as chiropractic,11 and there has been a recent rise in popularity of electrical stimulation (ES), which has some problems of its own,12 and the development of alternative “dynamic” bracing systems.4, 13

Consideration of conservative management of scoliosis requires a thorough understanding of its diagnosis and all aspects of its treatment. The effectiveness and significance of conservative management programs can be understood only when they are considered in light of the assumptions and tenets concerning scoliosis progression. Emphasis in this report is placed on the management of idiopathic scoliosis, since scoliosis associated with more apparent, genetically related conditions may not respond to conservative14 or, for that matter, surgical15 procedures. Since scoliosis in its milder forms is not recognized to cause any significant cardiovascular impairment or organic dysfunction, management is directed at the curve itself in an attempt to prevent it from progressing.16 This is consistent with the trend in conservative management toward treating curves in their earlier stages of development, that is, milder curves, in an attempt to prevent future progression.17

Classically, conservative management of scoliosis has meant bracing and related orthotics administered under medical supervision.6, 7, 18 Little attention has been paid to other forms of conservative management from a medical perspective except for a brief upsurge in ES. Virtually no credence has been given to chiropractic management programs as evidenced by the almost complete absence of discussion of chiropractic in medical literature on scoliosis despite a substantial number of patients with scoliosis who are receiving chiropractic care.11

Chiropractic has long claimed to offer a significant alternative to medical treatment for scoliosis, and many chiropractors claim substantial effects of their treatments on scoliotic spines.19, 20 Chiropractic, however, like all other conservative methods, including many systems of bracing, has never been critically assessed by well-designed clinical trials.18 Mawhiney claims that “a lumbar scoliosis of 10° or less should show up to 80% correction in 90 days. Predictable and assured”20 but provides no evidence to support this contention. In light of what we know about the natural history of the condition, and the compelling logic of the biomechanical argument, such claims can appear reasonable. Whether this represents a significant improvement in the clinical picture, however, can only be assessed by large randomized controlled clinical trials. Simply reporting on cases that showed positive response21, 22, 23, 24 does not, as is shown in this study and elsewhere,25 provide an assessment of the efficacy of the procedure. Few would contest the assertion that not every single curve would be expected to respond. Thus, a program of careful monitoring is required to track each case. The idea that chiropractic has a positive clinical impact on scoliosis bears further investigation for several reasons. First, the claim is made by some chiropractors that such corrections are, at least occasionally, possible and, in fact, actually occur (“Predictable and assured”20). Second, most orthopedists resign themselves to a very passive role in the early stages of the process (observation), and in the intermediate stages they seek to halt the progression, not correct the curve. At the stage of curve development to be studied in this project, medicine, until recently,4 offered no active treatment programs.

Chiropractic management of scoliosis has classically consisted of spinal adjustments19, 26 or manipulation21, 27 sometimes augmented with exercises and postural counseling,27 as well as heel lifts.19, 28 ES has recently come into the chiropractic armamentarium as well.21 Virtually no formal research exists documenting chiropractic's effectiveness in managing scoliosis, although anecdotal reports abound. Several well-conducted case studies21, 22, 24, 26, 29, 30, 31, 32 suggest that chiropractic is, indeed, effective in managing scoliotic curves, but the definitive studies are lacking.

It is reasonably well established that chiropractic care can effectively alleviate the pain and discomfort associated with adult scoliosis,23, 26, 29, 33, 34 and in one article describing an algorithm for the management of scoliosis,35 the only situation in which manipulation was recommended was adult scoliosis with pain. Although other authors believe that chiropractic is beneficial for all age groups,19, 28 there is agreement in at least one area of efficacy of chiropractic in the management of scoliosis. Mawhiney, an outspoken chiropractor and self-described scoliosis expert, believes that “only manipulation can consistently bring about correction” of scoliotic curves,20 and for Barge,19 correction of curve is assured with correction of the (major) cause of scoliosis, subluxation.

One case of progressive adolescent idiopathic scoliosis responding to chiropractic management has been reported.21 The curve had progressed from 22° to 27° before the start of the treatment program and was reduced to 17° after 6 months' treatment. This was a single structural thoracolumbar curve in a 14-year-old girl. Treatment included Cox flexion distraction technique and ES. Another case study of adolescent idiopathic scoliosis30 reported double thoracic and lumbar curves of 30° each (weight bearing) that did not respond to Cox treatment combined with other modalities, including heat, massage, and muscle ES. Although the lumbar curve was arrested and even improved by 4°, the thoracic curve increased to 33° and the patient was referred to surgery. A similar case of double curve32 in a 33-year-old woman had been referred to surgery with a 51° thoracic and a 27° lumbar curve. After 6 months of chiropractic treatment, including osseous adjustments, Logan basic reflex technique, heel lifts, and hanging exercise, there were corrections of 5° and 7°, respectively, in the thoracic and lumbar curves. This case is remarkable on 2 counts; first is the age of the patient and second is the response of the thoracic component of the double curve. In yet another brief note24 it was shown by pretreatment and posttreatment x-ray films that mild thoracolumbar scoliosis was corrected by delivery of a “cervical manipulation” of a mobilizing type to an 11-year-old. The basis for this correction was proposed to be a correction of the cervical proprioceptive mechanisms that are believed to contribute to postural disturbances. In one study,36 a substantial (20%) but statistically insignificant (because of sample size) decrease in Cobb angle was observed in patients with scoliosis with mild curves (average 10.7° before treatment) after chiropractic adjustments. In his monograph on scoliosis, Barge19 presents about a dozen cases of scoliosis, all of which demonstrated improvement.

Another report37 cites improvement in 84% of a group of chiropractic patients undergoing treatment for scoliosis: total correction in 6.8%, significant correction in 35.6%, and small correction in 41.2%. In 16.4% of the patients, the curves remained the same or deteriorated. Although these statistics appear promising, details of the study and criteria for inclusion, as well as quantitative aspects of the categorization system and analysis, are notably lacking.

At least 2 attempts have been made to develop general guidelines for chiropractic management of scoliosis,35, 38 neither of which has been entirely satisfactory. Another report discusses the general details of chiropractic diagnosis and management of scoliosis.27 In a recent review of treatment methods of scoliosis in a chiropractic research journal,35 the medical model of “wait and see” with referral for surgery when the condition became severe enough was proposed as a standard for chiropractic practice. Danbert39 has provided an excellent review of biomechanical rationale for manipulative management of scoliosis and how it might relate to chiropractic care. The concepts in this work extend the more informal descriptions and rationale presented in the monograph by Barge.19 Although less biomechanical and more descriptive in nature, Mawhiney's book28 catalogs a number of distortional patterns and provides a systematic review of their management, including some limited prognoses. Although Barge19 provides numerous pretreatment and posttreatment x-ray studies to support his position on the effectiveness of chiropractic in treating scoliosis, and notwithstanding the several case studies cited above,21, 22, 24, 26, 29, 30, 31, 32 no truly systematic evaluation of the effectiveness of chiropractic management of scoliosis has ever been performed.34 It seems important to pursue such research in the hope of understanding more about the nature, etiology, and management of scoliosis. Although there is, as yet, no definitive proof of chiropractic's effectiveness in treating scoliosis, the works published to date serve the important functions of consolidating the conceptual basis of chiropractic management of scoliosis and generating hypotheses for further testing under more controlled conditions. Although it is openly acknowledged that chiropractic treatment programs for scoliosis are clinically unproven25, 40, 41, 42, 43 it must also be recognized that they are untested in the classical sense.18 Some of the major difficulties have been the lack of available funds,34 lack of a centralized organization in chiropractic, and lack of access to patient populations,20 as contrasted to medicine.2

The disparity between chiropractic and medical treatments reflects an underlying divergence in theoretical perspective between the two healing arts.44 Chiropractic has, until recently, traditionally stopped just short of prostheses, preferring instead to approach the problem from a more structural and functional normal point of view. The heated debate currently being waged in chiropractic concerning conservative management of scoliosis25, 31, 40, 42, 43, 45, 46 bears witness to the controversy over the efficacy and cost-effectiveness of management programs. Should adults with scoliosis be treated in the same way as adolescents or juveniles with scoliosis?3, 47, 48 What are the indications for care, and what types of care are most suited to which types of scoliosis and for which age groups?49 Most research on scoliosis has been performed in patients who visited orthopedic surgeons.7, 11 Little consideration has been given to the substantial numbers of patients from screening programs who visit chiropractors.11 Alternatively, the reduction in progressive scoliosis may be due to simply raising the level of consciousness of patients and their families about the existence of the problem.

The issue of mild curvature management deserves particular attention in conservative treatment programs. Medical programs traditionally do not provide positive treatment of mild curves, preferring a “wait and see” attitude.50 However, if curves are more likely to progress as they become more severe, then simply waiting until they become more severe to initiate treatment assures that a certain amount of progression will inevitably occur. The success of school screening programs in reducing the numbers of patients with scoliosis going to surgery is proof of the value of early recognition and treatment of scoliotic curves, even though the same medical logic is applied to the younger patients.7 Chiropractic, on the other hand, offers treatment alternatives that could be applied during the “observation” period of mild scoliotic curve management. Since such an approach has never been evaluated for smaller curves, we chose to evaluate chiropractic management for this group of patients with scoliosis.

Section snippets

Study design

The basic design of the study was that of a cohort time-series trial with all members of the study group electing chiropractic care. The entry-level Cobb angle served as the control value for each subject, and each subject served as his or her own control. Subjects followed a year course of chiropractic intervention, consisting primarily of osseous adjustive procedures, at the end of which time their condition was reevaluated by x-ray examination. The primary outcome measure was change in Cobb

Results

Forty-two subjects completed a sufficient course of care, ranging from 6.5 to 28.5 months between initial and first follow-up evaluations, with a mean of 14.5 months and a median of 14 months. There were 16 male and 26 female subjects, representing 53 curves ranging in size (at onset of care) from 4° to 22° (mean and median, 11°). The age range of the subjects was 6 to 17 years at entry into the study. Subjects were seen, on the average, 3 times per month, with a range of 0.5 to 10 times. Two

Discussion

The chiropractic clinical and popular literature is replete with overt claims and covert suggestions that chiropractic adjustments can correct scoliosis.19, 20, 21, 30, 36, 37, 39 The study reported here represents the first attempt, however, at a significant clinical trial of the effectiveness of chiropractic in the management of scoliosis. We chose to focus exclusively on the magnitude of the curve, rather than attempt to assess the effect on quality of life and symptoms, such as pain,

Conclusion

On the basis of the results presented here, it must be concluded that full-spine osseous adjustments, according to Diversified and Gonstead technique systems, supplemented with heel lifts and postural and lifestyle counseling, were not effective in the correction of curvature in scoliotic spines, as determined by PA projections on plane films in children between the ages of 6 and 17 years with curves less than 25°. The lack of a natural history of scoliosis less than 25° precludes determination

Acknowledgements

We thank John Barnard, Romier Visperas, Brian Gatterman, DC, Trent Bachman, DC, Sandra Coleman, and the children and their parents without whom this study would not have been possible.

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    *

    bAssistant Professor, School of Medicine, Oregon Health Sciences University, Portland.

    **

    This project was supported by funds from the Foundation for Chiropractic Education and Research.

    Submit reprint requests to: Charles A. Lantz, DC, PhD, Life Chiropractic College West, 2005 Via Barrett, San Lorenzo, CA 94580. E-mail: [email protected].

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