Conduct an in-depth evaluation of your scoliosis patients to determine exercises and gait training rehabilitation

Lateral curvatures of the spine are often overlooked, and their proper treatment is problematic. Many times, nonstructural and nonidiopathic causes of spinal curvatures can be resolved or at least substantially decreased. Otherwise, they can result in persisting postural distortions and recurring subluxations. Over time, asymmetric degenerative changes and vertebral deformities may develop.¹ Many of the lateral spinal curvatures seen in both children and adults can be correctly identified and effectively managed with conservative chiropractic care.

A lateral deviation of the spine that exceeds 10° is called scoliosis, which is defined as “any lateral deviation of the spine from the mid-sagittal plane.”² There are four major types of scoliosis that must be considered in practice: idiopathic, congenital, neuromuscular, and functional curvatures.

Congenital causes may be due to either osseous or nonosseous anomalies, while the source of a neuromuscular curvature might be a condition such as muscular dystrophy or syringomyelia. These two conditions are not candidates for a corrective rehabilitation exercise program, except to improve flexibility and maintain function. A functional scoliosis is likely to be secondary to either postural habits or leg-length inequality.

Idiopathic scoliosis. In spite of much speculation and ongoing research, there is still no accepted theory for the cause of idiopathic scoliosis. This lateral curvature of the spine is accompanied by vertebral rotation and rib cage deformity and becomes more apparent as the spine grows during childhood.

Idiopathic scoliosis can be progressive, worsening significantly during periods of rapid growth. In more severe cases, bracing or even surgery is commonly performed to prevent substantial deformity. After skeletal maturity, most curvatures progress only slowly, if at all.

Recent scientific research has focused on hormonal and neurological causes for idiopathic scoliosis, with some promising early results, but no definitive conclusions. The pineal gland appears to have some influence on the development of a balanced spine, at least in chickens and rats. Surgical removal of the pineal gland in young chickens³ and more recently in bipedal rats⁴ has produced spinal curvatures very similar to human idiopathic scoliosis, including vertebral rotation and rib humps. Unfortunately, chiropractic care has not been found to significantly affect the progression of adolescent idiopathic scoliosis.⁵

Functional scoliosis. The classification of functional scoliosis has been summarized as compensatory (due to leg length inequality or pelvic unleveling), postural (caused by habits and muscle imbalance), and transient (often an antalgic response to a disc herniation).⁶

The key factor in all of these conditions is the reversibility of the abnormal curvature with various positions and movements, as is seen in the Adam’s test. During this clinical maneuver, the patient flexes forward from the waist, with the arms hanging down and the hands together (in the prayer position). If the spinal curvature straightens out and there is no evidence of rib humping, then the test is considered to be negative and is indicative of a functional scoliosis.⁷ A similar phenomenon may be noted when the patient lies prone on the examination table. If the curvature is functional, it will disappear as the muscles relax and the spine no longer depends on the lower extremities and pelvis for support. This is most obvious in younger patients, since the spine becomes less flexible with age, and functional curves become stiffer and more fixed.

Rehab for Scoliosis
While no studies have found a significant corrective effect from exercises in patients with any type of scoliosis, there are indicators that rehabilitation may be beneficial. Several studies over the years have shown that humans with scoliosis have various defects in muscle coordination and standing balance. The source of these difficulties with fine motor control is unknown, and many theories have been developed and then discarded. The gait of children with scoliosis has been found to be somewhat abnormal, but there is controversy about whether this causes a curvature to develop or is simply the result of walking with a curved spine. Researchers have observed that the “differences between the scoliosis and the control group, together with previously reported abnormalities of torsion in the tibia and femur and the hypothesis of pelvic rotation, suggests these are primary mechanisms of the cause of idiopathic scoliosis.”⁸

Postural assessment. The first step in examining a patient with a spinal curvature is to carefully inspect the alignment of the entire body during relaxed, upright stance. Head position in relation to the body, relative heights of the shoulders, and any spinal list or rotation should be noted, since specific corrective exercises may be needed. The lower extremities must be evaluated for any asymmetry, since functional scolioses are commonly associated with leg-length inequality.⁹ Most commonly seen is pronation of one or both of the feet.

Hyperpronation. The loss of arch height that occurs with excessive pronation allows the pelvis to drop to the more pronated side during stance and gait.¹⁰ The resulting lateral pelvic tilt lowers the sacral base and drops the lowest freely moveable vertebra to the side of the shorter leg. A lateral spinal curvature develops in the lumbar spine due to lack of balanced support from the lower extremities. If the functional curvature progresses to involve the thoracic region, it may demonstrate a mild rib hump, which disappears upon correction of the leg discrepancy.¹¹

Researchers have also verified that posterior rotation of the innominate is often found on the side of a longer leg.¹² In persons with asymmetrical pronation, the accentuated medial rotation movement of one leg is transmitted to the pelvis and sacroiliac joints. In response, various compensatory pelvic lists and sacroiliac subluxation complexes have been seen.¹³

When presented with a patient with scoliosis, an in-depth evaluation must determine the classification of the curvature and the potential for progression. Exercises to develop fine control of balance and posture, as well as gait training is helpful. Custom-made stabilizing orthotics should be provided early in treatment of all patients with scoliosis, to improve bilateral balance and gait symmetry.

Kim D. Christensen, DC, DACRB, CCSP, CSCS, founded the SportsMedicine & Rehab Clinics of Washington. He is a team doctor to high school and university athletic programs, a postgraduate faculty member at numerous chiropractic colleges, president of the ACA Rehab Council, and a lecturer and the author of many musculoskeletal rehabilitation and nutrition texts. He can be reached at PeaceHealth Hospital via e-mail:kchristensen@peacehealth.org.

References
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