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29 January 2008

Traditional Scoliosis Treatment

The three medically-sanctioned methods of scoliosis treatment - observation, bracing, and surgery - have been around for decades, and a great deal of research has been done on the risks & benefits of each option. However, the general conclusion of this research suggests that a new paradigm is desperately needed, as there are many conflicts and inadequacies present in the current model.

Once an individual has been diagnosed with scoliosis, no treatment is initially prescribed, and no action is immediately taken, until the Cobb angle has progressed to 25 degrees (which is an arbitary figure; there is no clinical significance to this number), at which point bracing is typically prescribed. This period, which is termed "watch & wait," consists only of regular visits to an orthopedic surgeon, where full-spine x-rays are taken consistently to gauge the progress of the patient's condition.

Surprisingly enough, there are no reported cases of scoliosis being improved by observation alone. In addition, if there ever were a time when a patient could benefit most greatly from chiropractic, therapeutic exercise, or non-surgical intervention, it would undoubtedly be during the mild stages of the disease, before the muscles & tissues of the body have been deformed by months or even years of compensating for the abnormal twisting & bending of the spine.

There are also valid concerns regarding the value of the repeated x-rays necessary to monitor the scoliosis during this time. Some studies have found that rates of breast cancer almost doubled in scoliosis patients who had been subjected to "observation." This is especially disheartening when one considers that there is very little information of clinical significance obtained from these x-rays.

A full-spine x-ray requires a much stronger beam, and hence produces greater tissue damage, than a "spot" view of only one area of the spine. Chiropractors trained by CLEAR Institute take seven precise, small x-rays to evaluate the biomechanical integrity of the spine. With this information, they are able to apply scientific, specific adjustments and prescribe exercises & rehab protocols that are based upon that patient's specific posture, and the end result of this treatment is a measurable reduction in the severity of the patient's scoliosis. One full-spine x-ray exposes the patient to approximately 300 times more radiation than these seven precision x-rays and, unfortunately, the only information obtained from this x-ray is whether or not the patient is ready to move on to the next step in medical scoliosis management - bracing.

Bracing dates back to approximately 650 AD, when Paul of Aegina suggested bandaging scoliosis patients with wooden strips. The first metal brace was developed by Ambroise Pare in the 16th century. Today, there is a bewildering assortment of braces in use, ranging from the venerable and bulky Milwaukee brace, to the traditional TLSO (thoraco-lumbar-sacral orthosis) braces such as the Boston and the Wilmington brace. There are "part-time" braces, designed to be worn at night - the Providence brace, and the Charleston brace - and there are also "dynamic corrective braces," which may use soft, elastic materials, and claim to be able to do more than simply stabilize the progression of scoliosis. An example of a dynamic corrective brace would be the SpineCor brace, developed at the Sainte-Justine Hospital in 1992, or the Copes brace, developed by Arthur Copes to be used in conjunction with his STARS (Scoliosis Treatment Advanced Recovery System) rehabilitation protocol.

This dizzying variety is further complicated by the fact that not every doctor prescribes the braces to be used in the same manner, and not every patient may follow their doctor's recommendations to the same extent. As a result, research is often conflicting (to say the least) in regards to the true effectiveness of bracing in scoliosis treatment. Some studies have shown very little difference between patients who wore the brace for the prescribed time, and those who wore it barely, if at all. Others have demonstrated patients who have been successfully stabilized for years by wearing a bracing constantly; yet, there are also studies on patients who wore the brace for 23 hours out of every day, seven days a week, and continued to worsen. In every case, all corrective benefit is lost very quickly once the patient stops wearing the brace, and the general consensus is that bracing may prove helpful for some, but not for others.

This possible benefit must be weighed against the negative side-effects of bracing, which can include pain, skin & bone problems related to the constant pressure, adverse effects on the heart & lungs, and, perhaps most damaging of all, the psychological trauma that can result from having to wear a brace throughout adolescence. The authors of one study went so far as to conclude that the emotional damage inflicted by bracing was so severe that surgery might actually be considered a preferable alternative in some cases. In another research article, 60% of the patients treated with a brace stated that it handicapped their lives, and 14% considered the experience to have left a psychological scar.

Those patients for whom bracing fails to prevent the progression of their scoliosis are left with only one option: surgery. Those who are confronted with this choice may be told that having a metal rod fused to their spine will not impair their daily activities, and will reduce the rib arch & improve their cosmetic appearance. However, research has consistently shown that surgery - which primarily focuses upon the sideways bending, and does little to address the rotation of the spine (and hence the rib protrusion) - will actually cause the rib arch to worsen (Chen 2002, Goldberg 2003, Hill 2002, Pratt 2001, Weatherly 1980, Wood 1991, Wood 1997). Furthermore, the theory that unfused regions of the spine become more mobile to compensate for the lack of motion at fused regions is, in a word, incorrect. A study published in Spine in 2002 found that mobility was decreased not only in the fused area, but also in the unfused regions of the spine. The authors explicitly stated that, "the lack of compensatory increase at unfused regions contradicts current theory."

Spinal surgery, like most highly-invasive procedures, carries with it the ever-present risk of death. Although mortality rates of less than one percent are claimed, no surgeon can completely eliminate this possibility. There is also the danger of neurological damage, resulting in the loss of sensation or motor function to the arms & legs (paraplegia or quadraplegia). This has become a greater concern in recent years, as surgeons strive for greater corrections in their patients, and place more stress upon the nerves running through the spinal column.

The rate of hardware failure is virtually 100%; it may occur immediately after the surgery or several years later, but one or more components of the rod is highly likely to fail or break. The author of one study stated, "One would expect that if the patient lives long enough, rod breakage will be a virtual certainty." Another study found that amongst seventy-four patients who underwent the surgery, pseudoarthrosis (failed fusion) occurred in 27% of patients within a few years after the procedure.

The truth of the matter is that scoliosis is an abnormality of the spine which involves much more than merely a sideways curve. Yet the "effectiveness" of surgery is measured only by the degree to which it can reduce the lateral deviation through the application of brute force, and a fused spine is every bit as abnormal and dysfunctional as a scoliotic spine.

Since observation is not, technically, a method of treatment, it would be safe to say that the only options for treatment which are formally endorsed by orthopedic surgeons are orthoses (braces) and surgery; a classic example of the old adage, if the only tool you have is a hammer, every problem tends to resemble a nail. If you have a few more tools under your belt, however, new opportunities may arise.

In conclusion, it is not the intention of CLEAR Institute to disparage the efforts of medical professionals who have dedicated their lives to helping individuals with scoliosis. We would, however, like to add to the current list of options; to educate those who are personally involved with scoliosis about what the research says; and, to empower these individuals to make their own decision regarding their own spine, and their own life.

Credit is given to Martha C. Hawes, PhD, for her amazing & invaluable contribution to the body of scoliosis literature, "Scoliosis and the Human Spine," from which text much of the information under this heading received its inspiration and references. This book can be purchased at; it is perhaps the most comprehensive review of every piece of research ever done in regards to scoliosis.

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