Scoliosis: Degenerative & Idiopathic

1
Scoliosis Degenerative Idiopathic

• Dr. James Cox presents treatment of scoliosis due
  to various causes, latest published literature
  findings, and in-office patient cases.

2
Sciatic Scoliosis

• Sciatic scoliosis is due to irritation of the
  spinal neurons in radiculopathic stimulation and
  its resultant muscle activity.
• Hirayama et al in Spine 200126(6)602-9 reported
  on the effects of electrical stimulation of the
  sciatic nerve on background electromyography and
  static stretch reflex activity of the trunk
  muscles in rats. They verified the hypothesis
  that sciatic scoliosis is induced reflexively by
  radiculopathic pain, and that scoliosis might be
  maintained by prolonged asymmetric alteration of
  the trunk muscle tonus caused by central
  sensitization of the spinal neurons that
  constitute the postural reflex pathways.

3
Sciatic Scoliosis

• Sciatic scoliosis usually occurs with convexity
  to the side of the herniated disc. The neuronal
  mechanism of sciatic scoliosis has not been well
  clarified.
• In spinalized rats (transection of the spinal
  cord), the sciatic nerve was stimulated
  electrically as a conditioning stimulus. Muscle
  stretch elicited by bending of the lumbar spine
  was applied as a test stimulus.

4
Sciatic Scoliosis

• It was found that the pattern of
  electromyographic activity of the trunk muscles
  evoked by sciatic nerve stimulation coincided
  with the typical direction of sciatic scoliosis
  in patients with lumbar disc herniation. It was
  supposed that the prolonged asymmetric alteration
  of the trunk muscle tonus was caused by central
  sensitization, and that central sensitization of
  spinal neurons may underlie the neuronal
  mechanism of sciatic scoliosis. 

5
Sciatic Scoliosis

• As opposed to the work of Finneson and Herlin,
  the sciatic scoliosis may not be, or not only be,
  the mechanical embarrassment of the nerve root or
  dorsal root ganglion by disc invasion of
  territory, but the embarrassment of the
  neurological bed of the nerve root resulting in
  the resultant muscle spasm and scoliosis.
• This is what we are discussing in this course.
  Let's start with a patient case presentation and
  treatment...

6
Left Thoracolumbar Scoliosis in a Young Male

• Cox Technic Flexion-Distraction and
  Decompression done to all curves using all
  motions of the Cox Table lying supine and
  side-lying.

• Side Notes This patient moved to Fort Wayne from
  another city where he was treated by a
  chiropractic physician with Cox Technic. He came
  to our office seeking the same care.
• At the second visit, the patient reports a drop
  in his VAS score from a 7 to a 1 with improvement
  noted in his shoulder and low back.

7
Dr. Cox introduces this discussion of
degenerative scoliosis and its management.

• Fu KMG, Smith J, Sansur CA et al Standardized
  measures of health status and disability and the
  decision to pursue operative treatment in elderly
  patients with degenerative scoliosis.
  Neurosurgery 2010 66(1)42-47 Link to Journal
  Abstract
• Glassman SD, Carreon LY, Shaffrey CI, Polly DW et
  al The costs and benefits of nonoperative
  management for adult scoliosis. Spine 2010
  35(5)578-582  Link to Journal Abstract

8
Dr. Cox shows imaging and discusses scoliosis
cases.
9
Degenerative Scoliosis (cont.)

• Bautmans I, Can Arken J, Van mackelenberg M, Mets
  T Rehabilitaiton using manual mobilization for
  thoracic kyphosis in elderly postmenopausal
  patients with osteoporosis. J of Rehabilitation
  Medicine 2010 42(2)129-135    Link to Journal
  Abstract
• Masharawi Y, Dar G, Peleg S, Steinberg N, Medlej
  B, May J, Abbas J, Hershkovitz I A morphological
  adaptation of the thoracic and lumbar vertebrae
  to lumbar hyperlordosis in young adult females.
  European Spine Journal 2010 19(5)768-773 Link
  to Journal Abstract
• Upendra B, Meena D, Kandwal P, Ahmed A, Chowdhury
  B, Jayaswal A Pedicle morphometry in patients
  with adolescent idiopathic scoliosis. Indian
  Journal of Orthopedics 2010 44(2)169-176  Link
  to Journal Abstract
• Hee HT, Zhang JT, Wong HKEffects of cyclic
  dynamic tensile strain on previously compressed
  inner annulus fibrosus and nucleus pulposus cells
  of human intervertebral disc. An in-vitro Study.
  J of Orthopaedic Research 2010
  28(4)503-509 Link to Journal Abstract
• Beresford ZM, Kendall RW, Willick SE Lumbar
  facet syndromes. Current Sports Medicine Reports
  2010 9(1)50-56   Link to Abstract
• Mayer JM, Haldeman S, Tricco AC, Dagenais S
  Management of chronic low back pain in active
  individuals. Current Sports Medicine Reports
  2010 9(1)60-66   Link to Abstract

10
Motions of Treatment

• In the following videos, Dr. Cox demonstrates
  treatment application options for specific
  conditions. The caudal section of the
  flexion-distraction instrument The Cox7 Table
  is used here - may be used or the thoracic
  restraint or the automated feature or the
  cervical spine headpiece or its restraint. Any
  condition can be treated in any number of ways.
  To clarify how Dr. Cox makes the table move,
  please review the following images.

11
Foot Switch Strip to Activate Long-Y-Axis while
treating the Thoracic Spine
12
Tiller Bar Handle Button (top) to Activate
Long-Y-Axis while treating the Thoracic Spine
13
Table Handle Locks
14
Treatment DemonstrationCharite Disc
Replacement/Dextrorotatory Scoliosis

• This is a case of L4 Charite Disc Replacement
  with and L5 Disc herniation and dextrorotatory
  scoliosis. 
• The Rule of 50 is discussed in relation to the
  treatment plan to relieve S1 dermatome pain.

15
Hyperkyphosis Scheuermann's Disease treated in
the supine position.
16
Hyperkyphosis / Scheuermann's Disease /
Osteoporosis / Any Condition needing thoracic
adjusting

• Dr. Cox demonstrates flexion-distraction
  long-y-axis decompression spinal adjusting
  (low-velocity, low-amplitude adjusting)  for any
  condition needing gentle thoracic spinal
  adjusting. Patients working on computers and
  carry much stress really appreciate this care.

17
Hyperkyphosis / Scheuermann's Disease / Upper
Thoracic Spine Low-Velocity/Low-Amplitude
(LVLA) Adjusting using the Cervical Headpiece

• Highlights
• Use of the cervical spine restraint to treat the
  thoracic spine curvature.
• Long Y axis automated distraction with cervical
  headpiece restraint in place.
• Goals
• drop intradiscal pressures
• increase foraminal area
• restore physiological ranges of motion

18
Hyperkyphosis / Thoracic Spine Adjusting in the
Side-Lying Position

• For some patients, this very gentle application
  is preferred.

19
Compression Fracture Treated in the Supine
Position
20
Case - Scheuermann's Disease

• Here is a patient case of Scheurmann's Disease
  treated in the office.
• use of occipital restraint to treat hyperkyphosis
• use of long y axis automated to treat thoracic
  spine (LVLA low velocity low amplitude)
• treatment without occipital restraint
• use of foramen magnum pump
• Initial Visit 25 year old, post-partum 8 months,
  hyperkyphosis, extension irritates low back pain
• Outcome of Case At the third visit, the patient
  reported that the neck and shoulder pain is gone
  and the low back pain is over 50 gone.

21
Demonstration of the Mehta exercises with a male
spine

• Exercises for scoliosis are for strengthening the
  convex side of the curve and ensuring its 
  mobility, the same goals for adjusting scoliosis.
  We are not looking to necessarily correct the
  curve or reverse it, but rather ensure its
  mobility. Mehta Exercises are excellent tools the
  patient can do alone or, optimally, with a
  helper. Both ways are demonstrated, first alone
  in this video and with a helper in the next.
• Source for Mehta Exercise in denBoer W, Anderson
  P, Limbeek J, Kooljman M Treatment of Idiopathic
  Scoliosis with Side-Shift Therapy An initial
  comparison with a brace treatment historical
  cohort. European Spine Journal 1999 8406-410
  (Reference 10 - Mehta MH in 1985 which is active
  correction by side shift In Warner JO, Mehta MH
  on scoliosis prevention from Proceedings of the
  P. Zorab Scoliosis Symposium 1983, Praeger, New
  York, p 126-40)

22
Mehta Exercises for Scoliosis Curve Strengthening

• Here is a demonstration with a helper assisting.

23
Latest Research On Scoliosis

• The following slide presentations are discussions
  of the latest published articles related to
  scoliosis, both idiopathic as well as
  degenerative bracing, exercise, diagnosis
  strategies, causes, biomechanics, potential
  solutions.
• Each slide has a list of the articles discussed
  with a link to the abstract of the article or
  book chapter for your later study.

24
Scoliosis Literature Bracing Sources

• Negrini, S Minozzi, S Bettany-Saltikov, J
  Zaina, F Chockalingam, N Grivas, TB Kotwicki,
  T Maruyama, T Romano, M Vasiliadis, ES. 
  Braces for Idiopathic Scoliosis in Adolescents.
  Spine 2010 35 (13) 1285-1293 Link to Abstract
• Danielsson, Aina J. Hasserius, Ralph Ohlin,
  Acke Nachemson, Alf L. Health-Related Quality of
  Life in Untreated Versus Brace-Treated Patients
  With Adolescent Idiopathic Scoliosis A Long-term
  Follow-up. Spine 2010 35(2)199-205 Link to
  Abstract
• Lou, E Hill, D Raso, J Brace Treatment for
  Adolescent Idiopathic Scoliosis. Conservative
  Scoliosis Treatment 1st SOSORT Instructional
  Course Lectures Book 135. 2009 Link to Book
• Scoliosis. Grivas, TB Rodopoulos, GI Bardakos,
  NV Biomechanical and Clinical Perspectives on
  Nighttime Bracing for Adolescent Idiopathic.
  Conservative Scoliosis Treatment 1ST SOSORT
  Instructional Course Lectures Book 135.
  Amsterdam I O S Press, 2009 Link to Book
• Katz, DE Herring, JA Browne, RH Kelly, DM
  Birch, JG. Brace Wear Control of Curve
  Progression in Adolescent Idiopathic Scoliosis.
  Journal Of Bone And Joint Surgery-American 2010
  92A (6)1343-1352 Link to Abstract
• Fayssoux, RS Cho, RH Herman, MJ. A History of
  Bracing for Idiopathic Scoliosis in North
  America. Clinical Orthopaedics And Related
  Research 2010468 (3) 654-664  Link to Abstract

25
Scoliosis Literature Bracing Discussion
26
Scoliosis Research II - Sources

• Schiller, JR Thakur, NA Eberson, CP. Brace
  Management in Adolescent Idiopathic Scoliosis.
  Clinical Orthopaedics And Related Research
  2010468 (3)670-678 Link to Abstract
• Burwell, RG Dangerfield, PH Moulton, A
  Anderson, SI Etiologic theories of idiopathic
  scoliosis autonomic nervous system and the
  leptin-sympathetic nervous system concept for the
  pathogenesis of adolescent idiopathic scoliosis.
  Research Into Spinal Deformities 6 140. 2008.
  p.197-207 I O S PRESS, AMSTERDAM  Link to Book
• Bettany-Saltikov, J Warren, J Stamp, M
  Carrying a Rucksack on either Shoulder or the
  Back, Does it matter? Load Induced Functional
  Scoliosis in "normal" young subjects. Research
  Into Spinal Deformities 6 140. 2008. p.221-224 I
  O S PRESS, AMSTERDAM Link to Book
• Domenech, J Tormos, JM Barrios, C
  Pascual-Leone, A. Motor cortical
  hyperexcitability in idiopathic scoliosis could
  focal dystonia be a subclinical etiological
  factor?
• Kirby, AS Moulton, A Dangerfield, PH Freeman,
  BJC Cole, AA Polak, FJ Pratt, RK. Ultrasound
  femoral anteversion (FAV) and tibial torsion (TT)
  after school screening for adolescent idiopathic
  scoliosis (AIS). Research Into Spinal Deformities
  6 140. 2008. p.225-230 I O S PRESS, AMSTERDAM 
  Link to Book
• Burwell, RG Aujla, RK Freeman, BJC
  Dangerfield, PH Cole, AA Kirby, AS Polak, FJ
  Pratt, RK Moulton, A. The posterior skeletal
  thorax rib-vertebral angle and axial vertebral
  rotation asymmetries in adolescent idiopathic
  scoliosis. Research Into Spinal Deformities 6
  140. 2008. p.263-268 I O S PRESS, AMSTERDAM Link
  to Book
• Stokes, IAF McBride, CA Aronsson, DD.
  Intervertebral disc changes in an animal model
  representing altered mechanics in scoliosis.
  Research Into Spinal Deformities 6 140. 2008.
  p.273-277  Link to Book

27
Scoliosis Research II - Discussion
28
Scoliosis Research III - Sources

• Fong, Daniel Yee Tak Lee, Chun Fan Cheung,
  Kenneth Man Chee Cheng, Jack Chun Yiu Ng, Bobby
  Kin Wah Lam, Tsz Ping Mak, Kwok Hang Yip, Paul
  Siu Fai Luk, Keith Dip Kei. A Meta-Analysis of
  the Clinical Effectiveness of School Scoliosis
  Screening. Spine 2010 35(10)1061-1071 Link to
  Abstract
• Ugras, AA Yilmaz, M Sungur, I Kaya, I
  Koyuncu, Y Cetinus, ME. Prevalence of scoliosis
  and cost-effectiveness of screening in schools in
  Turkey. Journal Of Back And Musculoskeletal
  Rehabilitation 23 (1). 2010. p.45-48  Link to
  Abstract
•  Wang, Chuanfeng Xu, Weidong He, Shisheng Gu,
  Suxi Zhao, Yingchuan Zhang, Jingtao Zhu,
  Xiaodong Li, Ming. Differences in Postoperative
  Quality of Life Between Adolescent Patients With
  Idiopathic Scoliosis Residing in Urban and Rural
  Environments. Spine 2010. 35(6)652-656, March
  15, 2010. Link
• Ogilvie, J. Adolescent idiopathic scoliosis and
  genetic testing. Current Opinion in Pediatrics
  2010 22 (1)67-70 Link
• Akoume, MY Azeddine, B Turgeon, I Franco, A
  Labelle, H Poitras, B Rivard, CH Grimard, G
  Ouellet, J Parent, S Moreau, A. Cell-Based
  Screening Test for Idiopathic Scoliosis Using
  Cellular Dielectric Spectroscopy. Spine 201035
  (13)E601-E608  Link 
• Grivas, TB Vasiliadis, ES Rodopoulos, G.
  Aetiology of Idiopathic Scoliosis. What have we
  learned from School Screening? Research Into
  Spinal Deformities 6 140. 2008. P.240-244 I O S
  Press, Amsterdam Link
• Yong, F Wong, HK Chow, KY. Prevalence of
  Adolescent Idiopathic Scoliosis among Female
  School Children in Singapore. Annals Academy Of
  Medicine Singapore 38 (12). DEC 2009. p.1056-1063
  Link

29
Scoliosis Research III - Discussion
30
Scoliosis Research IV - Sources

• Ciazynski D, Czernicki K, Dumala J Knowledge
  about idiopathic scoliosis among students of
  physiotherapy. Research into Spinal Deformities
  2008 6(140)281-285 Link to Book Online 
• Weiss H, Maier-Hennes A Specific exercises in
  the treatment of scoliosis. Conservative
  Scoliosis Treatment 1st SOSORT Instructional
  Course Lectures Book 135 2009 Link to Book 
• Romano M, Negrini A, Parzini S et al Scientific
  Exercises Approach to Scoliosis (SEAS) Efficacy,
  Efficiency and Innovation. Conservative Scoliosis
  Treatment 1st SOSORT Instructional Course
  Lectures Book 135 2009 Link to Book 
• Rigo M, Quera-Salva F, Villagrasa M et al
  Scoliosis intensive out-patient rehabilitation
  based on Schroth Method. Conservative Scoliosis
  Treatment 1st SOSORT Instructional Course
  Lectures Book 135 2009 Link to Book 
• Dobosiewicz K, Drumala J, Kotwicki T Dobosiewicz
  Method physiotherapy for idiopathic scoliosis.
  Conservative Scoliosis Treatment 1st SOSORT
  Instructional Course Lectures Book 135 2009 Link
  to Book 
• Weiss H, Rigo M The Cheneau Concept of Bracing -
  Actual Standards. Conservative Scoliosis
  Treatment 1st SOSORT Instructional Course
  Lectures Book 135 2009 Link to Book 
• Durmala J, Tomalak W, Kotwicki T Function of the
  respiratory system in patients with idiopathic
  scoliosis reasons for impairment and methods of
  evaluation. Conservative Scoliosis Treatment 1st
  SOSORT Instructional Course Lectures Book 135
  2009 Link to Book 
• Rigo M, Weiss H The Cheneau Concept of Bracing -
  Biomechanical Aspects. Conservative Scoliosis
  Treatment 1st SOSORT Instructional Course
  Lectures Book 135 2009 Link to Book 
• deMauroy J, Fender P, Tato B, Lusenti P,
  Ferracane G Lyon Brace. Conservative Scoliosis
  Treatment 1st SOSORT Instructional Course
  Lectures Book 135 2009 Link to Book 
• Christine C, Alin C, Riward C Treatment of early
  adolescent idiopathic scoliosis using teh
  SpineCor System. Conservative Scoliosis
  Treatment 1st SOSORT Instructional Course
  Lectures Book 135 2009 Link to Book 

31
Scoliosis Research IV - Discussion
32
Scoliosis Research V Sources for Brace Types
Outcomes

• Sforzesco Brace - Ananasio, Saina, Negrini The
  SPoRT (Symmetci, Patient-Oriented, Rigid,
  Three-dimensional active) concept for scoliosis
  bracing principles and results. Conservative
  Scoliosis Treatment 1st SOSORT Instructional
  Course Lectures Book 135. 2009 Link
• Boston Brace - Wynne J The Boston Brace System
  Philosophy, Biomechanics, Design  Fit.
  Conservative Scoliosis Treatment 1st SOSORT
  Instructional Course Lectures Book 135. 2009 Link
• Cosmetic Effect in IS Kids - Grivas T, Vasiliadis
  E Cosmetic Outcome after Conservative Treatment
  of Idiopathic Scoliosis with a Dynamic Derotation
  Brace. Conservative Scoliosis Treatment 1st
  SOSORT Instructional Course Lectures Book 135.
  2009 Link
• Reduction in Surgical Intervention - Negrini S,
  Atanasio A, Zaina F, Romano M. et al Endgrowth
  resluts of bracing and exercises for adolescent
  idiopathic scoliosis. Prospective worst-case
  analysis. Conservative Scoliosis Treatment 1st
  SOSORT Instructional Course Lectures Book 135.
  2009 Link
• Quality of Life - Vasiliadis E, Grivas T Quality
  of life after conservative treatment of
  adolescent idiopathic scoliosis. Conservative
  Scoliosis Treatment 1st SOSORT Instructional
  Course Lectures Book 135. 2009 Link
• Adult Scoiosis Surgery Effects - Yadla S,
  Maltenfort M, et al Adult scoliosis surgery
  outcomes a systematic review. Neurosurgical
  Focus 2010 28(3)NIL19-NIL25n  Link to Yadla
  article  
• Chromium from Scoliosis Rods - Cundy T, Delaney
  C, Rackham M, et al Chromium Ion Release from
  Stainless Steel Pediatci Scoliosis
  Instrumentation. Spine 2010 35(9)967-974 Link
  to Abstract
• Cost of Scoliosis Treatment - Kamerlink J, Quirno
  M, Auerback J et al Hospital costs analysis of
  adolescent idiopathic scoliosis correction
  surgery in 125 consecutive cases. J of Bone and
  Joint Surgery - American. 2010 92A(5)1097-1104 
  Link to Abstract
• Scoliosis Research Subjects - Bunge E, Habbema J,
  deKoning H A randomized controlled trial on the
  effectiveness of bracing patients with idiopathic
  scoliosis. European Spine Journal 2010
  19(5)747-753  Link to Issue to read article
• Kyphosis after Scoliosis Fusion - Wang J, Zhao Y,
  Shen B, Wang C, Li M Risck facotr analysis of
  proximal junctional kyphosis after posterior
  fusion in patients iwth idiopathic scoliosis.
  Injury-International Journal of the Care of the
  Injured 2010 41(4)415-420   Link to Issue to
  read abstract

33
Scoliosis Research V Discussion of Brace Types
Outcomes
34
Thank you.

• Thank you for studying with me degenerative and
  idiopathic scoliosis the latest in biomechanics,
  diagnosis, and treatment. Scoliosis is a
  challenging condition demanding confident, gentle
  care with a realistic goal of maintaining
  mobility and flexibility as well as building
  strength into a curve that may not ever be
  straightened, but deserving of good care.
• James M. Cox, DC, DACBR
• www.coxtechnic.com
• info_at_coxtechnic.com