Scoliosis

Importance of body alignment – with special thanks to John Rutherford MCSP DC HCPC

John Rutherford is my physiotherapist. Twelve years ago I was in dreadful pain and a surgeon referred me to John. He realigned my hips and right shoulder and his method of working continues to relieve any pains I sometimes get. John is not called ‘the miracle worker’ by his patients for nothing (as overheard many times in the waiting room at his clinic).
Caroline Brower

Introduction

I have known and treated Caroline for many years following her spinal fusion. I’m delighted I have been able to provide treatment which has made a positive contribution to her health and life. Having reviewed her book on Exercise for scoliosis, I was delighted to be asked to contribute the forward. The book will be a useful and practical guide for those who are able to use exercise to alleviate their scoliosis curves and also, for those who need a more radical solution, and need detailed exercise guidance following surgery.

Scoliosis

Scoliosis is a three-dimensional spinal deformity, focal in the middle and lower spine. The normal curves of the spine are distorted from front to back, side to side and rotated. There is a genetic factor involved in many cases of scoliosis. A scoliosis curve is commonly ‘S’ shaped, with a rib hump lifting the shoulder blade, uneven shoulder height and frontal rib and waist folds.

Parents with scoliosis, or a family history, should carefully observe their children for developing curves.

In idiopathic scoliosis, a genetic factor alone does not cause scoliosis. Current research has identified contributory factors. Imbalance of growth hormones may affect bone density and cartilage development. Oestrogen blood levels have an influence on normal bone formation. Calmodulin, a calcium-binding receptor protein, regulates the contractile properties of muscles and platelets. Altered levels in platelets have been observed. Collagen and elastin fibres are the base elements of the supporting ligaments and discs of the spine. Structural abnormalities have been observed in discs and ligaments in individuals with progressive spinal curves.

Neurotransmitters are messages from the brain, via the nerves, to muscles, prompting the spine to make adjustments in response to external changes. Postural control centres are in the hind brain and are not under voluntary control. Epinephrine, formed in the adrenal glands on top of the kidney, and serotonin, are neurotransmitters, formed from the essential amino acids tyrosine and tryptophan. The B vitamins assist the synthesis of numerous neurochemical and signalling molecules. These hormones assist neural transmission and help the body to adjust to new and sudden changes in position. Folic acid (B9) helps maintain normal levels of serotonin. Vitamins B6 and B12 contribute to the myelin sheath around nerve cells, which speeds signals through the brain. Studies indicate that niacin (B3) helps in the synthesis and repair of DNA, and that it plays a role in signalling between nerve cells.

Current research indicates that diet and nutrition can contribute to developing scoliosis. Calcium and vitamin D levels need to be adequate for correct bone density. Correct blood iron levels are essential for normal bone formation and synthesis of connective tissue. The heme protein in animal based foods binds larger quantities of iron, aiding absorption in the gut Vegetable based food lacks the heme binding iron protein, rendering iron absorption in the gut less efficient. Poor teenage diets or unmonitored vegan or vegetarian diets can have an impact on normal blood chemistry, affecting bone density in adolescents. Phytate, a substance found in high levels in soy and other foods with a high fibre content, is a strong inhibitor of iron absorption. Research suggests a possible 30% loss of bone density in adolescents with progressive spinal curves. Some statistics indicate increasing numbers of teenagers and young adults demonstrate thyroid dysfunction. Correct thyroid levels are essential for adequate bone formation and density.

Adolescent idiopathic scoliosis (AIS) forms the bulk of conditions seen in our clinics. ‘Idiopathic’ scoliosis describes a spinal curve of unknown cause. This occurs in 2–3% of both sexes between the ages of 10 and 16 years. However, it is up to 10 times more likely that the curve will progress in girls than in boys. Curve progression may be rapid during growth spurts in adolescence. A curve can be easily identified by the trained eye. X-ray or MRI imaging can be helpful. Bone maturity can be observed in the pelvic bones using the Reiser grading observed in the ilium: grade 1 indicates immature bone, while grade 5 confirms growth plate fusion. The Cobb angle is used to determine the degree of spinal curve. If the Cobb angle is below 30° at bone maturity, the curve should remain stable. If it is above 30°, the curve may gradually progress through adult life. If the Cobb angle is measured manually, there can be a 5° discrepancy in accuracy. Modern software advances should eliminate this. A scoliotic curve is often painless. Pain may come from stress on affected structures. Rapid curve development can be painful, and cause organ compression. Breathing function can be impaired if rib distortion impacts on the lungs.

Scoliosis in a newborn child or observed in a child under the age of 10 years may have a genetic origin such as -Spinae Bifida- or may develop in association with a neuromuscular disorder such as muscular dystrophy or cerebral palsy. Immediate review by a paediatrician is essential.

Idiopathic scoliosis accounts for 70–90% of all scoliosis. A structural scoliosis is fixed and cannot be altered by position or manipulation. Clinical examination will often reveal that a scoliosis that appears to be idiopathic and structural is, in fact, a functional curve. A structural curve will not release with forward bending of the body. However, a functional curve often corrects when testing body positions. Functional curves can be caused by altered spine, pelvic and sacrum alignment, leg length differences, poor posture, muscle tightness, weakness and altered head and neck position. Defective position of head alignment with the neck or subluxed position of the neck vertebrae, particularly the 1st and 2nd segments, are contributory factors.

A degenerative curve in adults is caused by progressive joint damage to the spinal segments, falling bone density and weakening of muscle. It presents as a C-shaped curve. It usually affects those above the age of 50. Falling hormone levels, i.e. oestrogen in women, and nutritional deficiencies contribute to lower bone density. A number of people lose the ability to synthesise vitamin B12 and folate. Flat feet, decreased levels of exercise and less effective body balance contribute.

Any treatment for scoliosis requires a full and precise understanding of the type of scoliosis you are observing. When a spine is tested in a neutral position, vertebrae with a concave bend to the left will bend to the left but rotate to the right. In a non-neutral spine, such as forward bending with a concavity to the left, vertebrae will bend to the left and rotate to the left also. The alternative occurs if the concavity exits to the right.

It is essential to understand the joint and muscle positions to deliver correct manual corrections. Muscle on one aspect of a curve will be contracted and weak, the opposite stretched and weak. The decisions to be made are which to strengthen and which to stretch.

Treatment of scoliosis in a child pre-puberty requires a paediatrician.

Functional and degenerative scoliosis can be treated with manual techniques derived from physiotherapy, osteopathy. This would include correction of vertebral position, stretching and strengthening of muscles, and functional exercise to retrain and reinforce body balance through the brain–nerve–muscle pathways.

Surgical intervention may be required if exercise and bracing can’t modify curve progression. Bracing and activity suits can be most useful in curves below 30° in an adolescent approaching bone maturity (Reiser grade 4–5). It is possible to correct any unfused segments following surgery to improve body alignment.

It is relatively easy and inexpensive to train parents, care workers and GPs to observe potential scoliosis. Observation is key to early intervention and early treatment is more effective.

Parents can observe a curve in a small child with minimal prompting. A teacher may notice a curve in PE. A GP may observe during an exam for another issue. It is feasible to test for scoliosis, particularly AIS, in less than 1 minute. There is a simple forward bending test.

Correct levels of exercise, tailored to the age group, are essential in dealing with any spinal curve. In adolescents, too much exercise can often be as detrimental as too little. Poor posture must be corrected. Diet and blood chemistry need to be evaluated and adjusted if indicated. Any exercise program should address correct body balance.