Chiropractic + Naturopathic Doctor • February 2018 • Research Review

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

I diopathic scoliosis (IS) is widely treated by chiropractors. The common goals 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 and Weiss et al.

The authors sought to determine whether 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. The goal of the study is to strengthen future outcome reporting in chiropractic research and improve inter- professional communication.

A total of only 27 studies that discussed chiropractic scoliosis treatments were identified – 15 case reports, 10 case series, one prospective cohort, and one randomized clinical trial. Only two 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.

One case study reviewed a seven-year-old patient with juvenile IS who underwent four visits of Pierce technique manipulation over one month. Post-treatment radiographs showed an eight-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 after five months of NUCCA upper cervical manipulation. The patient was managed for an additional four years; no additional Cobb angles were reported. Another case study reviewed a 10-year-old patient whose thoracolumbar scoliosis decreased by 10 degrees after 25 weeks of NUCCA manipulations. Unfortunately, no baseline Risser-stage or longterm 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 four years of physical therapy and spinal bracing.

A prospective cohort study including 42 patients receiving full spinal 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, apart from Cobb angle changes.

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

A separate case series reviewed Cobb angle changes after one year of scoliosis activity suit bracing in 62 adults with IS. The subjects were divided into two 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 out of 26 patients in the skeletally immature group. Meanwhile, six out of 26 remained within five degrees of baseline, while four patients’ curves advanced by > 6 degrees. Curves of 14 out of 36 skeletally mature patients corrected to some degree. Meanwhile, 20 skeletally mature patients’ curves remained unchanged during the study, while two progressed.

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

Unfortunately, the three studies included in this category did not follow skeletally immature patients to maturity. They also did not follow adult patients for five years, as previously recommended.

One RCT included six patients receiving combinations of different therapies. One of the six patients (Risser stage 1), improved her Cobb angle after six months of SMT and rigid bracing. IS progressed in four out of six 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 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 three-degree curve reduction.

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

The authors included multiple case reports in this category. Two case series followed seven patients between ages six and 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 three were not included there). The average Cobb angle after three 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 two years of treatment. However, it is unknown whether the patient had adolescent IS, or an adult degenerative scoliosis.

Another case report outlined the multimodal, six-year treatment of a four-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 2004 case series investigating the effect of multimodal therapy in 22 patients between the ages of 15 and 65 demonstrated an average 17-degree Cobb angle correction for the entire cohort. The lowest correction was eight degrees. One hundred per cent of the cohort achieved scoliosis correction. Patients were followed-up after six weeks of treatment, which is vastly shorter than the recommended fiveyear follow-up for skeletally mature patients.

The same multimodal treatment was provided for three 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 had a minimum scoliosis correction of eight degrees, alongside improvements in pain and functional status. Unfortunately, this too is well below the recommended five-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 eight weeks of rehabilitation. Results were maintained at sixth-month follow-up. The same authors later reported a four-week case study of a 20-year-old patient whose 35-degree thoracic scoliosis corrected by 15 degrees. At threeyear follow-up, radiographic examination revealed a continued 18-degree improvement.

A separate case report demonstrated a large decrease in thoracolumbar scoliosis after a two 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 six 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.

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. Only two 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.

DR. SHAWN THISTLE is the founder and CEO of RRS Education, providing weekly research reviews, online courses and seminars to help busy clinicians integrate current research evidence rationally into practice. For more information, visit: www.rrseducation.com. Shawn can be reached by email at [email protected]