To understand the correction process of scoliosis, one must remember an understanding of kinematics, in that a vertebra in motion has 3 axis of motion and may translate or rotate about any of the 3. Until recent years, for clinical and experimental purposes, the motion has been measured in only two dimensions. This is explained fully in Clinical Biomechanics of the Spine, Augustus A. White III, MD, and Manohar M. Panjabi, PhD, Second Edition, 1990, J.B. Lippincott, page 129. In my correction procedures, I address all of these motions.
To effect a correction, I must rely on the patient's inherent ability for their body to correct itself. Sevastik, Aaro and Normelli, Scoliosis:experimental and clinical studies. Clin. Orthop., 191:27, 1984, emphasized that the vertebra undergoes deformation within that vertebra, in curves over 40 degrees. This, in part, is due to the Heuter-Volkmann's Law and Wolff's Law. Page 132, of the above mentioned Clinical Biomechanics of the Spine states, "When one finds a consistent unilateral alteration resulting in scoliosis, the assumption is that with a growing spine, the initial, functional scoliosis ultimately develops into a structural deformity. The theory suggests that increased pressure across an epiphyseal growth plate inhibits growth, whereas decreased pressure across the plate tends to accelerate growth (emphasis added). Page 143, same text, says about Wolff's Law, "Bone is thought to be laid down in regions of maximal stress. Of particular interest here is the observation of bone resorption .....(emphasis added)". Page 537, same reference, state that bone is laid down where stresses require its presence, and bone is absorbed where stresses do not require it. The very broad variety of experimental variables that have resulted in a "scoliotic" deformity suggests that a maintenance of a normal spine is dependent upon a delicately balanced, easily disrupted equilibrium. Attempts to compensate for or re-establish that delicate balance are sometimes successful and sometimes not. The type, degree, extent, and duration of the imbalance are also factors that influence the probability of return to a normal or new balance, either spontaneously or as a result of some intervention (page 133, Clinical Biomechanics).
In my bracing concept, I utilize the above information as a basis to effect corrections. We must also remember the concept of creep and relaxation. This phenomenon is due to the viscoelastic properties of the muscles, ligaments and bones. Creep is the deformation that follows the initial loading of a material and that occurs as a function of time without further increase in the load. When force is applied to correct spinal deformity, and the force continues to work after initial correction, the subsequent correction that occurs over a period of time as a result of the same load is due to creep. Chiropractic care adds mobility to the vertebral segments and the dynamic force vectors in the brace address this issue, thus allowing for more correction.
No one treatment protocol has shown the ability to stand alone in its' perported correction of scoliosis. The use of an orthotic appliance is only one area in scoliosis to be considered. We must also consider the neurological aspects. There has been considerable interest in a variety of neurophysiologic abnormalities associated with scoliosis. Pincott and Tafts, Experimental studies in primates: a neurological cause. J. Bone Joint Surg., 64B:503, 1982, state that in scoliotic cases, there is damage on the convex side of the spinal cord, particularly in the posterior horn and posterior central gray matter (Clark's column). Asymmetrical weakness of the paraspinal muscles can be due to a loss of proprioceptive innervation. Yamada and co-workers, :Etiology of idiopathic scoliosis, Clin. Orthop., 184:50, 1984, emphasized that virtually any disruption of the postural reflex system can result in scoliosis. The imbalance may be in the afferent system either primarily or secondarily. The authors also indicated that there is clinical and experimental evidence that brain stem dysfunction may contribute to the etiology of scoliosis. These studies show that subtle muscle imbalance can create scoliosis, and disruption of postural reflexes can produce scoliosis. Yamada and associates, A neurological approach to the etiology and treatment of scoliosis, J. Bone Joint Surg., 53A:197, 1971, found that of 100 patients with scoliosis, 99 had abnormal equilibrium. This malfunction increased with the severity of the scoliotic curve. The dysfunction was noted in the proprioceptive and optic reflex systems. I test and document the postural reflex abnormalities by use of a surface EMG of the paraspinal muscles. I treat the paraspinal weaknesses with active exercises while in the brace, and electrical stimulation of the muscles in the proposed corrected positions. This approach is supported by Schultz and colleagues, Mechanical analysis techniques for improved correction of idiopathic scoliosis, Clin. Orthop., 100:66, 1974. They stated that trunk muscle stimulation can be expected to effect substantial changes in spine configuration. This was thought possible even with contractions of modest intensity. This is further supported by Brown and associates, Multicenter trial of a non-invasive stimulation method for idiopathic scoliosis, A summary of early treatment results, Spine, 9:382, 1984. They concluded that the electrical stimulation was a viable alternative to orthotic treatment. They used surface stimulation and reported success in the treatment of single and double curves. Overall success was 84% in single curves and 83% in double curves. If only compliant patients are considered, the success rate goes up to 97% and 93%, respectively. Nerubay and associates, showed a statistically significant increase in osteoblastic activity with bone formation in the use of electrical stimulation. This is significant information when electrical stimulation is used in conjunction with a properly fitted TLSO.
I re-inforce the optic/ proprioceptive reflex by use of a stairstepper--while in the brace. The patient utilizes the stepper, with no balance-assisted handrails, while concentrating on perfectly vertical lines on the wall in front of them, thus creating a new blueprint in the brain. In other words, the brain remembers where the new body is in space rather than remembering where it was when it was uncorrected. Again, one treatment phase does not work independently, but is effective when used with other supporting methods.
At no time do any references referred to in Clinical Biomechanics of the Spine ever state that at a certain age range, all repair activity stops, yet, for some unknown reason, that is the accepted theory--growing children may be helped, but bone-matured adults can't. This theory is supported by the studies reported by the AMA in that geriatrics patients over 80 years old were found to have increased bone mass by 4% with the use of weight-bearing exercises.
