Chiropractic care and treatment for scoliosis

Oh the joys of spam!  It’s usually very annoying, but just occasionally it provides a useful stimulus for a bit of investigation.  This turned out to be the case when a link to an article (oddly) on the Weight Loss Health Ways … Healthy Ways to Loose Weight website advocating Chiropractic care and treatment for Scoliosis popped into my spam filter.

According to the UK NHS Choices website: 

“Scoliosis is an abnormal curvature of the spine to one side. In those who have the condition, the spine bends either to the left or to the right. 

The bend can occur at any point along the spine from the top to the bottom. The curvature also varies from slight to severe. However, the chest area (thoracic scoliosis) and the lower part of the back (lumbar scoliosis) are the most common regions to be affected. 

[…]Scoliosis affects three to four children out of every 1,000 in the UK. In 90% of cases of scoliosis, treatment is not required because the condition corrects itself as the child grows. 

Most of the remaining 10% of cases can be successfully treated by using a back brace to prevent further curvature. Three out of every 1,000 children with scoliosis will need surgical treatment.” 

Now, what does the chiropractic promoting article have to say?  First, it describes the condition and two conventional approaches – bracing and Spinal Fusion Surgery  – before launching into a wholly unjustified promotion of Chiropractic.

“Using Chiropractic Approach

Nowadays, chiropractic care is recognized as a valid solution to scoliosis. Since chiropractors follow a standard procedure of initial examination and assessment of patients health history, most scoliotic patients undergo the Adam’s Forward Bending Test to see if chiropractic care is really for you. On top of that are a variety of range [sic] of motion studies to see if you should be referred to a specialist.” 

No mention here that most childhood cases do not require treatment, as it corrects itself as the child grows.  It does make a bold claim that, “chiropractic care is recognized as a valid solution to scoliosis”.  Outside the peculiar world of this chirophile, this statement would appear to be false. 

For instance, the NHS choices website comments on alternative therapies.  It mentions a number, “that may be helpful in correcting scoliosis”, namely: osteopathy, reflexology, acupuncture and the electronic stimulation of nerves in the back.   Chiropractic is not mentioned at all.  The “may” in the introductory sentence is nothing more than a weasel word, as the final pronouncement on these therapies reveals: 

“However, there is no definite evidence that any of these alternative therapies are effective. Physiotherapy can be effective, but only when used in combination with a back brace.”

It seems a bit odd to lump physiotherapy in with ‘alternative therapies’.  Perhaps, this is to lend a bit of credibility to the nonsensical approaches in the list.  One thing is clear: although the NHS information is quite CAM-friendly there is no real evidence that any of these approaches work.  Chiropractic is not even mentioned. 

The UK Scoliosis Association website contains this statement on ‘Alternative treatment’: 

“There is no reliable evidence that other techniques such as osteopathy, chiropractic, physiotherapy, reflexology, acupuncture, neurostimulation, and so on can make any difference to a potentially increasing spinal curvature. However, these complimentary techniques can be useful if backache or pain is present. Most spinal curvatures are relatively painless. If you are told that an established spinal curvature can be cured by any of these techniques, do not accept that as true. It is certainly true that many mild curvatures will not increase whatever is done, since the natural history (what would happen if a curve were left untreated) is very variable. Only surgery and sometimes bracing can substantially affect the natural history of the curvature.”

They are willing to accept that some of these approaches may lessen back pain, but the message is clear: there is no reliable evidence that chiropractic can make any difference to spinal curvature.  So “chiropractic care” is not “recognized as a valid solution to scoliosis” by reputable healthcare providers or patient support groups. 

Next, the article describes the, “Chiropractic Treatment Options”:

“Chiropractic treatment for scoliosis utilize [sic] a variety of treatment methods including spinal manipulation, shoe lifts, electric stimulation, and isotonic or active exercise methods. The idea behind employing chiropractic for scoliotic treatment is to arrive at a combination treatment that is both manipulative and rehabilitative.”

As is usual for chiropractic advocates the emphasis is on spinal manipulation, but other approaches are also co-opted into the ‘chiropractic’ treatment package.  

So, let’s look at the evidence^* for spinal manipulation being able to provide a solution for scoliosis. 

No surprise: no good evidence for chiropractic

Given that this is a condition that can resolve itself with time, I am not interested in case studies, case series or trials without control groups.  Unfortunately, most of the published articles fall into these categories. For instance, Lantz and Chen (2001) reported on a, “Cohort time-series trial”. Fourty-two children between the ages of six and twelve apparantly chose to have chiropractic care. The main intervention used was, “Full-spine osseous adjustments […] but heel lifts and postural and lifestyle counseling were used as well.” The authors concluded, after a year of treatment, “Full-spine chiropractic adjustments with heel lifts and postural and lifestyle counseling are not effective in reducing the severity of scoliotic curves.”

For all its limitations, this negative trial is certainly more suggestive of the efficacy of chiropractic than the single ‘positive’ case studies published by Chen and Chiu (2008) along with Hawes and Brooks (2002). The same is true of the three “atypical presentations” discussed by Morningstar and Joy (2006) or the retrospective case series of nineteen patients presented by Morningstar, Woggon and Lawrence (2004).

Rowe et al. (2006) reported on a six month pilot study of adolescent idiopathic scoliosis (AIS), which compared usual medical care, usual medical care plus sham chiropractic and usual medical care plus chiropractic interventions.  However, this very small study (n=6) was only focussed on assessing the viability of conducting a meaningful trial.  As the authors concluded, “our pilot study showed the viability for a larger randomized trial.”

More worryingly, these authors noted that:

“Chiropractors are using manipulation and other chiropractic approaches with these patients based largely on historical and anecdotal information, and without any scientific evidence.”

Little seems to have changed since. A review by Romano and Negrini (2008) identified, “145 texts, but only three papers were relevant”. None of the three (Morningstar, Woggon and Lawrence, 2004; Lantz and Chen, 2001; Rowe et al., 2006) were ultimately considered to have matched the inclusion criteria for the review as they mixed manual and other therapeutic therapies. The authors concluded that:

“The lack of any kind of serious scientific data does not allow us to draw any conclusion on the efficacy of manual therapy as an efficacious technique for the treatment of Adolescent idiopathic scoliosis.”

The authors also identified several flaws in Morningstar, Woggon and Lawrence (2004), namely:

“The recruited group of subjects presented an excessively wide age range, but no control group was designed and no follow-up observation was performed after treatment. Some doubts also arise as to the results, which seem so extraordinary to suggest a deep reflection to all health workers engaged in the conservative treatment of scoliosis throughout the world.”

Aside from children and adolescents, Everett and Patel (2007) conducted a, “A Systematic Literature Review of Nonsurgical Treatment in Adult Scoliosis”.  They determined that, “there is Level IV evidence on the role of physical therapy, chiropractic care, and bracing” for the treatment of adults.  If this scale is consistent with the Oxford Centre for Evidence-based Medicine definitions then this appears to mean that there is no evidence beyond “Case-series (and poor quality cohort and case-control studies)”.  There was better evidence (Level III – Systematic review of case-control studies) “for injections in the conservative treatment of adult deformity.” 

They concluded that: 

“Conservative [non-surgical] care in general may be a helpful option in the care of adult deformity, but evidence for this is lacking. Unfortunately, no treatment option within conservative care has support within the literature as a preferred solution. Basic clinical research at any level would be helpful to further clarify the options.”

And that is all the evidence that I could find.  For the treatment of children it amounts to a pilot study, with no reliable clinical outcomes, which warns that chiropractors treating this condition were relying on customary practise and anecdotes – not scientific evidence.  It doesn’t look like this position has changed.  In the case of adults it would appear that evidence is lacking for non-surgical interventions in general. 

What about the other non-manipulative approaches referred to in the article; is there any evidence to support their use? 

A little lift?

Beaudoin et al. (1999) reported some initial promising postural adaptations in a trial of shoe lifts on twenty young women (mean age 21), which led the authors to conclude that, “the global impact of a shoe lift on a patient’s posture should also be considered during treatment. This study provides a basis for comparison of future research involving pathological populations.” 

Zabjek et al. (2001) invesitagted the use of shoe lifts in a group of 46 patients with idiopathic scoliosis (mean age: 12 +/- 2 years).  The use of shoe lifts, “significantly decreased the Cobb angle.” 

So, it looks like shoe lifts might help; however, the evidence is sparse.  This single small study could not really be relied upon to guide clinical practise.  It is an interesting but limited study: it makes no comment on whether this might reduce the degree of spinal curvature over time, delay the need for other interventions, or even improve the quality of life of the children in the short-term. 

Evidence for electric stimulation melts away

We have already seen that the UK’s Scoliosis Association says that there is no reliable evidence that electric stimulation (neurostimulation) can slow the progression of scoliosis.  The available research shows why this is a reasonable view.

Farady (1983) cites three apparently uncontrolled studies of electric stimulation for the treatment of scoliosis.  Bobechko et al. (1979) treated, “55 children with progressive idiopathic scoliosis. They implanted stimulators that were activated at night only. The investigators subsequently reported that for the children with curves measuring ≤45 degrees, 38 percent improved, 45 percent were unchanged, and 17 percent worsened. The percentage of the success was inversely related to the severity of the curvature.”

Axelgaard and co-workers (1980) are credited with “A preliminary report of 23 patients undergoing LESS for six months indicated that 17 percent improved, 74 percent were unchanged, and 9 percent worsened.”  I cannot find any other references to this paper, but a publication with a very similar title appeared later (Axelgaard, 1984).  This claimed that, “Long-term treatment of 107 patients with progressive idiopathic scoliosis shows a 93% success rate in preventing further progression for curves below 30 degrees while the rate drops to 73% for curves above 30 degrees.”

McCollough and colleagues are said to have published a, “two-and-a-half-year follow-up [which] reported that 50 percent of those treated with surface electrical stimulation improved, 31 percent were unchanged, and 19 percent worsened.” (McCollough, 1980)  Again, I can find no other reference to this article.

These trials appear to suggest some promise, but Farady (1983) cautioned:

“[…] more information about the effect of prolonged electrical stimulation on growing children  […] and about the long-term effectiveness and the optimal treatment protocol is needed.”

To which I would add that these trials, from the scant descriptions I can find, appear to have been uncontrolled.  Given that many children show improvement with time in any event, then these results may not be that impressive.

Rinsky and Gamble (1988) reflected the initial optimistic view of this approach, but still cautioned that the true effect of this technique remained unknown.

“[…] there is no universally accepted nonoperative treatment that has been proved to alter the natural history. Orthotic bracing and electrical muscle stimulation programs are now widely prescribed and accepted by the general medical community, but unequivocal, nonbiased proof of efficacy of the treatment of scoliosis by nonoperative means is lacking.”

“[…] Despite an initial enthusiasm for electrical stimulation, many uncertainties remain. Typical reports have an average follow-up of only two to three years. Despite reports of success with curves of more than 30 degrees, our own experience is not as favorable with curves greater than 35 degrees at the onset of an electrical stimulation: most have progressed and required surgical treatment. The effect of the electrical stimulation on the natural history of scoliosis is still not resolved.  Stimulation is accepted better by patients than is external bracing, but further study and follow-up will be required to accurately judge its true efficacy.”

Keller (1989) offered a more cautious assessment:

“[…]The role of electrical spinal stimulation is uncertain at present, and further research is necessary […] We have learned that only appropriate orthotic treatment of scoliosis produces long-term stabilization of deformity. Impressive initial curve correction does not signify the end result […]”

A meta-analysis by Rowe et al. (1997) “of 1910 patients who had been managed with bracing (1459 patients), lateral electrical surface stimulation (322 patients), or observation (129 patients) because of idiopathic scoliosis” found that:

“The weighted mean proportion of success was 0.39 for lateral electrical surface stimulation, 0.49 for observation only […] Although lateral electrical surface stimulation was associated with a lower weighted mean proportion of success than observation only, the difference was not significant, with the numbers available.”

In other words the effect of “lateral electrical surface stimulation” was indistinguishable from “observation only”.  Ebenbichler, Liederer and Lack (1994) commented that, “[…] Electrotherapy was promising, but failed to alter natural history of IS [idiopathic scoliosis].”  Finally, a review by Lenssinck et al. (2005), “found no evidence of the effectiveness of electrical stimulation.”

In common with many novel approaches, it seems that initial promise melted away as it was subjected to closer scrutiny. 

Can exercise help?

There appears to be some evidence that particular exercise programmes might be helpful, though this is far from convincing.  For instance, Negrini et al. (2003) published a review that concluded there was no reliable evidence either for or against the use of exercises.  The main problem appears to have been the poor quality of the published evidence.  However, since this review the results of several trials have been published.

Mooney and Brigham (2003) published the results of a small trial in the same year.  Twenty adolescent patients with, “scoliosis ranging from 15 degrees to 41 degrees in their major curve were treated with a progressive resistive training program for torso rotation” with the result that, “Sixteen […] patients demonstrated curve reduction, and no patient showed an increase in curve.”  Again, this trial suffers from the lack of any kind of control group.

Negrini et al. (2006) observed that there was, “low evidence on the possible efficacy of exercises to treat idiopathic scoliosis”.  This article then went on to describe a trial that aimed to, “verify if exercises quality [sic] has an effect on results.”  This was a, “Prospective controlled study on idiopathic scoliosis patients” who only used exercises to avoid progression of the condition.  One group (n=48) used the SEAS.02 (Scientific Exercises Approach to Scoliosis, version 2002) protocol the other used, “different protocols preferred by the treating therapists”.  The result was that, “Cobb degrees improved with treatment (P<0.05) only in the SEAS group”.  The author felt that this study proved, “the short term efficacy of SEAS.02 when compared to usual care.”

In the same year Weiss et al. (2006) reported on a, “new ADL (Activities of Daily Living) approach in scoliosis rehabilitation.”  However, this was a small trial comparing thirteen patients given a two-week programme with an equal number of, “age-, sex-, Cobb-angle and curve pattern-matched controls” who received a, “4 weeks [sic] programme of exercise based rehabilitation (EBR) only.”  The results indicated that, “ABR seems to provide a better time efficiency, however a prospective controlled study with a larger sample of patients is desirable before final conclusions can be drawn.”

Weiss and Klein (2006) looked at, “An exercise programme (physio-logic exercises) aiming at a physiologic sagittal profile”.  Their approach was to conduct a, “Prospective controlled trial of pairs of patients with idiopathic scoliosis matched by sex, age, Cobb angle and curve pattern.”  This small study had, “18 patients in the treatment group (SIR + physio-logic exercises) and 18 patients in the control group (SIR only), all in matched pairs.”  They found that, “Lateral deviation (mm) decreased significantly after the performance of the physio-logic programme and highly significantly in the physio-logic ADL posture; however, it was not significant after completion of the whole rehabilitation programme.”

Zaina et al. (2009) concluded that some, “[e]xercises can help reduce the correction loss in brace weaning for AIS.”

Since 2003 a number of reviews have been published.  Lenssinck et al. (2005) concluded that the effectiveness of bracing and exercises was not yet established, but might be promising.

Updating their earlier review Negrini, Fusco and Minozzi et al. (2008) concluded, “In five years, eight more papers have been published to the indexed literature coming from throughout the world (Asia, the US, Eastern Europe) and proving that interest in exercises is not exclusive to Western Europe. This systematic review confirms and strengthens the previous ones. The actual evidence on exercises for AIS is of level 1b.”

Many of the same authors also commented that, “Results show that in literature there is proof of level 1b on exercises but no studies on manual therapy. High quality exercises like Scientific Exercises Approach to Scoliosis (SEAS) have more efficacy than usual physiotherapy, significantly reducing brace prescription in one year from 25% of cases to 6%. Moreover, such exercises help to obtain the best results in bracing first correction. The Sforzesco brace has proved to have more efficacy than the Lyon brace, whereas it has the same efficacy–but reduced side effects and impact on quality of life–than the Risser brace.” (Negrini, Atanasio and Zaina et al., 2008)

The claim of level 1b evidence appears to refer to an individual RCT (Negrini et al., 2006).

So, there might be something in the use of exercises.  It’s clear that there is much better evidence to support the use of some specific forms of exercise than there is for Chiropractic.  Then again, that’s not saying very much.

Alarmingly, the chiropractic propaganda piece continues, asserting the superiority of chiropractic over conventional treatments:

Chiropractic Care vs Spinal Surgery

Chiropractic care is gaining popularity as a treatment for scoliotic patients since it has been proven to be just as effective, if not more, than the existing treatment options for scoliosis. Chiropractic does not only treat any existing problems but also prevents further progression of the curves that is causing the problem. Those patients who’ve undergone chiropractic care for scoliosis have shown momentous improvement in size of the curves and this include [sic] 70 percent of them. This is important since any relief from scoliosis means that a patient won’t have to undergo surgery, take medications, and suffer from the effects of scoliosis.

No reference is provided to back up the claims.  From what I have read, this looks like selling false hope.

That is not to say, however, that conventional treatment is beyond criticism.  Negrini (2008) argues that, in treating AIS, “[…] in clinics exercises are generally ignored; braces are used with some criticism, while fusion is generally considered the only reliable treatment.”  And this despite evidence of efficacy for exercises and bracing being, in her opinion, better than that for surgical fusion (“grade B, B and C recommendations, respectively”)  She continues, making the point that, “The interest of the AIS treatment community (composed almost exclusively by orthopedic surgeons) has shifted toward fusion […] while conservative treatment is suffering a decrease in professional interest.” 

The views of this author could be coloured by a commitment to exercise as a treatment, however, it is an interesting view backed up by evidence – in contrast to the propaganda offered by this pro-chiropractic piece.

Weiss and Goodall (2008) take an even less favourable view of the evidence supporting surgical interventions in AIS (see also Weiss, 2008):

“No controlled study, neither short, mid nor long-term, was found to reveal any substantial evidence to support surgery as a treatment for this condition. There is some evidence supporting the conservative treatment for AIS. No substantial evidence has been found in terms of prospective controlled studies to support surgical intervention. In light of the unknown long-term effects of surgery, a randomised controlled trial (RCT) seems necessary. Due to the presence of evidence to support conservative treatments, a plan to compose a RCT for conservative treatment options seems unethical. But it is also important to conclude that the evidence for conservative treatments is weak in number and length.”

Given this, it is odd that UK’s Scoliosis Association are very positive about appropriate surgery; as are the UK’s NHS and support4scoliosis.  This apparent dichotomy may indicate that the evidence base for conventional treatments could do with improving.  However, it does not provide a justification for the use of chiropractic. 

Concluding thoughts

Having looked at what evidence I can find, it’s clear that it isn’t decisive for any conservative intervention.  However, it seems to be pretty reasonable to think that bracing (Rowe, et al, 1997) and exercise have merit.

It’s also clear that surgery is widely recommended by credible authorities, although the evidence base would seem to be sparse.  This makes me wonder: is this because it’s not as effective as people think, or is it because RCTs are hard to justify ethically and conduct for surgical interventions?  I don’t know and would be interested to hear from people who do. 

So, what of the ‘package’ of potential treatments listed in this article?  One thing is very clear: there is absolutely no good reason to suppose that chiropractic spinal manipulation offers anything beyond making some people feel better if they are in pain.

Shoe lifts might have some merit, but they have been insufficiently researched for anyone to say.

Electrical stimulation is a treatment whose time has passed.  For a while it looked like it might be effective, now the best available evidence says otherwise.

The most truthful claim in the article is the implication that, “isotonic or active exercise methods” might be useful.  I am not sure that these specific exercises have much merit, but there are examples of exercise regimes in the literature that look like they do. 

At the end of the day, AIS is a condition that mostly resolves itself over time.  For the 10% of children who need treatment, braces and exercise look like the only conservative options.  For those whose condition is the most severe, the decision to try the surgical option must be a difficult one.

The combination of a large number of cases that will get better anyway and limited –as well as intimidating – conventional options provides the classic environment for marketing CAM ‘treatments’.  The kind of opportunistic plugging of un-evidenced and disproven therapies seen in this article can only serve the financial interests of those who make a living from selling these treatments: it cannot serve the interests of patients and their families.  Neither does it help the broader challenge of bringing cost-effective medical care to communities as a whole.

Unless and until advocates for alternative therapies can provide decent evidence for the interventions they espouse, or at least discuss the evidence in a truthful and balanced way, I would really like to see them showing some modesty and limiting their claims to helping people to feel better; as opposed to actually making people better.

Links

These are potentially useful sources of information.

support4scoliosis

Teens First For Health

The British Scoliosis Research Foundation (BSRF)

The Scoliosis Association (UK) (SAUK)

Disclaimer

I am not a medical doctor and this article does not constitute medical advice.  If you need that please consult a properly registered medical practitioner. 

I would like to be clear that where I am critical, I am criticising particular therapies and those who advocate them without good reason.  I am not criticising patients or those who care for them.  In the end, we are all free to make our choices (or should be). 

Furthermore, this post is just my opinion.  I have tried to be fair and accurate.  If you think that I have missed anything or got anything wrong, please let me know.  If you are right I will correct my piece.  I am here to learn. 

Notes

*The evidence considered here has been obtained by searching two online databases on 11^th July 2009.  

The following searches were performed on The Cochrane Library.  Scoliosis AND chiropractic: 3 clinical trials, only one relevant (Rowe et al., 2006).  Scoliosis AND spinal manipulation: a single RCT with no abstract available (Spanos, 2002).  Scoliosis AND shoe lifts: No results.  Scoliosis AND “electric stimulation”: A single review (Rowe et al., 1997).  Scoliosis AND exercise: one protocol, one review (Negrini et al, 2003).  21 clinical trials.  Only trials published in English after the review have been considered (Zaina et al., 2009; Negrini et al., 2006; Weiss et al., 2006; Weiss and Klein, 2006; Mooney and Brigham, 2003)

The following searches were performed on PubMed.  Scoliosis AND chiropractic:

Only Reviews considered in this earch.  Four were identified, of which only one was relevant (Everett and Patel, 2007).  Scoliosis AND “spinal manipulation”: Eleven results – two case studies (Chen and Chiu, 2008; Hawes and Brooks, 2002), two case series (Morningstar and Joy, 2006; Morningstar, Woggon and Lawrence, 2004) and a single RCT with no abstract available (Spanos, 2002).  Scoliosis AND “shoe lifts”:  Two items were located, one of which was relevant (Zabjek et al., 2001).  One reference was extracted from this article (Beaudoin et al, 1999).  Scoliosis AND “electric stimulation”: Eight reviews, of which six were relevant (Wong and Liu, 2003; Nowakowski and Labaziewicz, 1996; Ebenbichler, Liederer and Lack, 1994; Keller, 1989; Rinsky and Gamble, 1988; Farady, 1983).  However, insufficient details were available to make use of two of them (Nowakowski and Labaziewicz, 1996; Wong and Liu, 2003). Scoliosis AND exercise: 35 reviews, of which only the most recent have been considered (Negrini et al, 2008; Negrini, 2008; Weiss and Goodall ,2008; Negrini et al, 2008; Lenssinck et al, 2005) 

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Edits

1^st August 2009. Re-write of the section, “No surprise: no good evidence for chiropractic” to include Lantz and Chen (2001) and Romano and Negrini (2008).

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