Research Review By Dr. Demetry Assimakopoulos©

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Date Posted:

December 2017

Study Title:

Chiropractic Treatments for Idiopathic Scoliosis: A Narrative Review Based on the SOSORT Outcome Criteria

Authors:

Morningstar MW, Stitzel CJ, Siddiqui A et al.

Author's Affiliations:

Natural Wellness & Pain Relief Center, Grand Blanc, MI, USA; Lancaster Spinal Health Center, Lititz, PA, USA; Esprit Wellness Center, New York, NY, USA; Posture & Spine Care Center, Green Bay, WI, USA.

Publication Information:

Journal of Chiropractic Medicine 2017; 16(1): 64-71.

Background Information:

Idiopathic scoliosis (IS) is widely treated by chiropractors. The common goal(s) of treatment include correction or stabilization of the Cobb angle (i.e. curve severity) and/or to provide pain relief. It is uncertain whether the body of chiropractic literature fits the criteria for reporting of results as outlined by the 2015 Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) and the Scoliosis Research Society (SRS) consensus paper (1) and Weiss et al. (2).

The 2015 SOSORT/SRS consensus paper recommended that studies examining the effects of treatment on idiopathic scoliosis report the following outcomes:
  • Initial patient age and baseline Risser stage
  • Initial Cobb angle (between 10-30 degrees; > 30 degrees; > 50 degrees)
  • Cobb angle at Risser stage 5 (i.e. skeletal maturity)
  • Percentage of patients whose Cobb angle improved by ≥ 6 degrees
  • Percentage of patients whose Cobb angle stabilized within ± 5 degrees
  • Percentage of patents whose Cobb angle progressed by ≥ 6 degrees
  • Percentage of patients whose curve progressed beyond 50 degrees
  • Skeletally immature patients managed to skeletal maturity
  • Skeletally mature patients managed for at least 5 years.
The authors sought to determine whether or not the peer-reviewed literature examining the effect of chiropractic treatments on idiopathic scoliosis report results according to the recommended standard of the SOSORT/SRS consensus paper (1, 2). The goal of the study is to strengthen future outcome reporting in chiropractic research and improve inter-professional communication.

Pertinent Results:

Literature Search Results:

A total of only 27 studies that discussed chiropractic scoliosis treatments were identified – 15 case reports, 10 case series, 1 prospective cohort, and 1 randomized clinical trial. Only 2 studies described their outcomes as recommended in the 2015 SOSORT and SRS Non-Operative Management Committee consensus paper. The papers will be discussed below based on the intervention utilized.

Manipulation Only:

Case Studies:
One case study reviewed a 7-year-old patient with juvenile idiopathic scoliosis (IS), who underwent 4 visits of Pierce technique manipulation over a one month period. Post-treatment radiographs showed an 8 degree curve reduction. Additional Cobb measurements were not reported. A second case study reviewed a 15-year-old patient whose curve decreased by 12 degrees (from 44 to 32 degrees) after 5 months of NUCCA upper cervical manipulation. The patient was managed for an additional 4 years; no additional Cobb angles were reported. Another case study reviewed a 10-year-old patient whose thoracolumbar (TL) scoliosis decreased by 10 degrees (from 35 to 25 degrees) after 25 weeks of NUCCA manipulations. Unfortunately, no baseline Risser-stage or long-term Cobb angle measurements were reported. A separate case study reported a 16 degree curve correction after 18 months of full spine manipulation. Interestingly, this patient’s curve reportedly progressed significantly prior to initiation of SMT, in spite of 4 years of physical therapy and spinal bracing.

Prospective Cohort:
A prospective cohort study including 42 patients receiving full spine manipulation, postural training and heel lifts showed no change in curve measurements after 14-months.

Many of the studies falling into this category failed to follow patients into skeletal maturity. Also, many of the studies did not report outcomes consistent with the SOSORT criteria (listed above), apart from Cobb angle changes.

Bracing Only (as performed by chiropractors):

One case report described full resolution of IS in a 10-year-old after 8 months of SpineCor bracing. Results were maintained at 1-year follow-up.

A separate case series reviewed Cobb angle changes after 1 year of scoliosis activity suit bracing in 62 adults with IS. The subjects were divided into 2 groups: one group who were < stage 5 on the Risser scale (skeletally immature) and a second group who were > 5 (skeletally mature). The results were highly variable. There was a > 6 degree curve correction in 16/26 patients in the skeletally immature group. Meanwhile, 6/26 remained within 5 degrees of baseline, while 4 patients’ curves advanced by > 6 degrees. Curves of 14/36 skeletally mature patients corrected to some degree. Meanwhile, 20 skeletally mature patients’ curves remained unchanged during the study, while 2 progressed.

Another study of 53 adult patients demonstrated that 79% of subjects achieved curve correction after 18 months of scoliosis activity suit bracing. Seventeen percent of subjects remained unchanged.

Unfortunately, the 3 studies included in this category did not follow skeletally immature patients to maturity. They also did not follow adult patients for 5 years, as previously recommended (1).

Exercises Only:

One study evaluated use of isometric hip flexor endurance exercise to reduce adult lumbar scoliosis. No outcomes were reported beyond stress radiography during exercise. It is therefore impossible to know if the exercise could provide a lasting correction. A second case report of a 55-year-old female with IS who performed multisite isometric exercise, failed to demonstrate any change in Cobb angle.

Manipulation Plus Bracing:

One RCT included 6 patients receiving combinations of different therapies. One of the 6 patients (Risser stage 1), improved her Cobb angle after 6 months of SMT and rigid bracing. IS progressed in 4/6 patients in spite of management. The study reported the baseline Risser staging for each patient, but did not report on patient outcomes at, or after, skeletal maturity.

A small case series reported on 4 patients with IS who participated in a 3-month rehabilitation program while concurrently wearing a rigid brace. The average Cobb angle reduction was 13.5 degrees. Interestingly, 3 of 4 patients had baseline curvatures that were greater than the usual standard of care (> 60 and > 80 degrees), yet still achieved a correction of > 6 degrees. Unfortunately, the case series only reported 3 month outcomes, which is below the recommended follow-up time. Also, 4/6 patients weren’t followed to Risser stage 5.

Manipulation Plus Traction:

A case study reviewed an 11-year-old patient with a 22 degree left TL scoliosis, who underwent 31 visits of chiropractic manipulation and positional traction. Post-treatment radiographs demonstrated a 3 degree curve reduction.

Another retrospective case series evaluated 15 patients utilizing a proprietary traction chair for IS treatment over 6 months. The study demonstrated insignificant Cobb angle decreases in patients whose apical rotation improved while sitting in the chair.

Manipulation Plus Exercises:

The authors included multiple case reports in this category. Two case series followed 7 patients between ages 6-17 undergoing 38 Chiropractic BioPhysics (CBP) treatments. Four of the patients had an average Cobb angle of 16.2 degrees (not sure why the other 3 were not included there?). The average Cobb angle after 3 months of care was 11.6 degrees. This is considered to be a valid stabilization according to the SOSORT criteria. Unfortunately, Risser or Sanders staging were not reported.

Another case study reviewed a 14-year-old patient (Risser 1) with a baseline Cobb angle of 17.2 degrees; Cobb angle changed by < 4 degrees over 15 visits. Additional improvements in posture were also visualized, however.

Another case report described the use of Network Spinal Analysis treatment for a 75-year-old patient with a 10 degree lumbar scoliosis. The authors reported on surface electromyography, paraspinal thermography and Cobb angle. The Cobb angle completely resolved after 2 years of treatment. However, it is unknown whether the patient had adolescent IS, or an adult degenerative scoliosis.

Another case report outlined the multimodal, 6-year treatment of a 4-year-old patient with 25 degree juvenile IS, craniosynostosis and type-1 Arnold-Chiari malformation. The patient underwent upper cervical SMT, craniosacral therapy, raindrop therapy and cranial manipulation. Cobb angle in this patient stabilized post-treatment. The patient was not followed to skeletal maturity.

A case report reviewing a 39-year-old woman with a history of spinal fusion for adolescent IS who underwent sacro-occipital technique and Pilates demonstrated improvements in pain and function after 1 year of treatment. Unfortunately, Cobb angle measurements were not reported. The patient was followed for the requisite time (1).

A 2004 case series investigating the effect of multimodal therapy in 22 patients between the ages of 15-65 demonstrated an average 17 degree Cobb angle correction for the entire cohort (5). The lowest correction was 8 degrees. 100% of the cohort achieved scoliosis correction. Patients were followed-up after 6 weeks of treatment, which is vastly shorter than the recommended 5 year follow-up for skeletally mature patients.

The same multimodal treatment was provided for 3 patients with unique scoliosis presentations: a patient who was post-Harrington instrumentation; another who had concomitant Scheuermann’s kyphosis; and a third with a left thoracic scoliosis. All 3 subjects had a minimum scoliosis correction of 8 degrees, alongside improvements in pain and functional status. Unfortunately, this too is well below the recommended 5 year follow-up.

Another case study showed a significant reduction in pain and disability in a 59-year-old patient with adult degenerative scoliosis. The patient underwent manipulation under anaesthesia and subsequently performed 8 weeks of rehabilitation. Results were maintained at 6-month follow-up. The same authors later reported a 4 week case study of a 20-year-old patient whose 35 degree thoracic scoliosis corrected by 15 degrees. At 3-year follow-up, radiographic examination revealed a continued 18 degree improvement.

A separate case report demonstrated a large decrease in thoracolumbar scoliosis after a 2 week trial of chiropractic treatment and rehabilitation of identical twins that were scheduled for spinal fusion.

One final case report demonstrated a significant reduction in severe double-curve scoliosis after 6 months of SMT and exercise administered by a physiotherapist. They also reported additional improvements in the SRS-22, the Bad Sobernheim Stress Questionnaire and Brace Questionnaire.

Clinical Application & Conclusions:

The authors examined the peer-reviewed literature regarding chiropractic treatment of IS. They compared the included studies’ reporting of results to the recommended reporting criteria set by the SOSORT/SRS consensus paper (2015) and Weiss et al. (1, 2). Only 2 studies reported outcomes consistent with consensus criteria. Interestingly, many of the studies documented improvements in pain, regardless of the treatments employed. This finding is important, as many scoliotic patients seek treatment for spinal pain. Unfortunately, the majority of these treatments failed to demonstrate Cobb angle changes.

Additionally, the body of chiropractic research related to scoliosis treatment is generally low quality. Higher quality research designs and reporting of outcomes as per the SOSORT/SRS criteria are required to develop future guidelines for the chiropractic management of scoliosis.

Study Methods:

The authors searched for studies detailing chiropractic treatment and outcomes for idiopathic scoliosis, published between January 2000 – February 2016. The authors included English-language studies which reported at least one outcome measure (outline in Background Information above). A total of 15 case reports, 10 case series, 1 prospective cohort and 1 RCT were included.

Study Strengths / Weaknesses:

Weaknesses:
  • The primary limitation of this paper is the general lack of high-quality evidence on this topic (which is no fault of the authors, of course).
  • The authors limited the use of their search terms. Expanding their search terms may have yielded more results to review.
  • This study is not a qualitative review, and did not comment on study quality (which was generally low – consisting of mainly case reports/series).
  • The SOSORT/SRS consensus paper was published in 2015, after the vast majority of the included articles were published. Therefore, it is unlikely that the included studies purposefully attempted to follow their criteria (which did not yet exist!).
  • Multiple included studies were published by one or more of the authors.
Strengths:
  • The authors accessed multiple large article indexes.
  • No conflicts of interest were reported.

Additional References:

  1. Negrini S, Hresko TM, O’Brien JP, et al. Recommendations for research studies on treatment of idiopathic scoliosis: Consensus 2014 between SOSORT and SRS Non–Operative Management Committee. Scoliosis 2015; 10:8.
  2. Weiss HR. Physical therapy intervention studies on idiopathic scoliosis: review with the focus on inclusion criteria. Scoliosis 2012; 7(1): 4.
  3. Morningstar MW, Woggon D, Lawrence G. Scoliosis treatment using a combination of manipulative and rehabilitative therapy: a retrospective case series. BMC Musculoskelet Disord 2004; 5: 32.