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Open Access Highly Accessed Case report

Scoliosis treatment using a combination of manipulative and rehabilitative therapy: a retrospective case series

Mark W Morningstar*, Dennis Woggon and Gary Lawrence

BMC Musculoskeletal Disorders 2004, 5:32  doi:10.1186/1471-2474-5-32

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Incorrect Assumptions

Linda Racine   (2006-09-18 10:54)  Scoliosis Association of San Francisco email

Ms. O'Connell's comments are incorrect on several points.

Yes, I do have a website (http://www.scoliosislinks.com). It is not an ecommerce website, and I do not make a single dollar from it. In fact, my scoliosis "hobby" costs me in the neighborhood of $3,000 a year.

And, while I am listed as a moderator on the National Scoliosis Foundation Forums website (http://www.scoliosis.org/forum), I do not have the authority or ability to change or remove posts. You can contact the President of that organization to verify that fact.

Let's get back to commenting on the topic and not on one another.

Competing interests

None

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In response to earlier comments

Katie OConnell   (2006-02-28 13:46)  NV Me Design email

I wish to point out that Linda Racine does in fact have a competing

interest. She runs a scoliosis information site which is biased against

alternative therapies.

To quote from her website: "Before you check out any alternative

treatment, I'd like your attention for a minute. It might save you some time

and money. Are you listening? THERE ARE A LOT OF CHARLATANS ON THE

INTERNET! I admit it. I'm more than a little skeptical about alternative

treatments for scoliosis. I'd like to point out that, unlike alternative

practitioners who stand to make a lot of money if they can convince you

to try their treatments, I have absolutely nothing to gain by warning

you about such treatments. Structural scoliosis cannot be cured. No one

has ever published a single case study of structural scoliosis curves

being permanently reduced by an alternative treatment".

She points out the amount of money they "stand to make", never once

considering the compensation an average spine surgeon makes. Furthermore,

she is a moderator for scoliosis.org, supposedly an "open to the public

forum" where she has the right and ability to delete posts from people

who tout their success from alternative care, should she choose.

Her dislike of alternative practionioners is such that her comments

simply cannot be considered those of only an "interested consumer".

Competing interests

My boyfriend is a Chiropractor.

I am a patient of Dr. Woggon who has corrected 11 degrees so far, so I am admittedly biased in favor of this study.

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Deficient implementation and/or reporting

Ronald Feise   (2004-12-14 23:41)  Institute of Evidence-Based Chiropractic email

Dear Editor,

I read with disappointment the retrospective case series study by Morningstar (2004). The study contains numerous shortfalls which contribute to fatal implementation and/or reporting flaws.

The aim of the study was not clearly defined. The authors wrote, “The purpose of the present study is to investigate any possible benefits from combining manipulative and rehabilitative techniques from a randomized sample collected from various chiropractic facilities.” The term “randomized sample” means that a group of subjects all have an equal chance to be assigned to either a study intervention group or a control group(s). But this was an uncontrolled study, and no randomization could have occurred. I must assume that this was a mistake, and that the authors meant to write “a small convenience sample of patients,” because later in the paper the authors inappropriately use the word “nonrandomized” to describe the patient selection. This is confusing and misleading.

The inclusion and exclusion criteria are poorly described. Scoliosis has many different operational definitions. How was the scoliosis defined? The selection of patients is poorly described. What was the sample frame? Did every scoliosis patient have an equal chance of selection? How many subjects were excluded and for what reasons? Because this was a retrospective study, were patients selected because of their beneficial results? Selection bias is likely and has not been properly addressed.

The study population was not well described. What were the presenting primary and secondary complaints? Was the entry visit of the scoliosis patients confounded by pain? Injury? Comorbidities? What was the classification of scoliosis curve (Lenke)? What was the Risser sign? Without Lenke and Risser data, a reader does not know the probability of curve progression. Over what period of time was the data collected? Did the patients provide consent? Patients who failed to perform home exercise were excluded from this study. How did the authors collect this data? Did they trust patients to provide the response, or did they use an electronic monitoring device?

The outcome measure process is poorly described. Was the observer blinded to the dates on the x-rays and the purpose of the study? Did the authors calculate intra-reliability coefficient so that readers could know the measurement error? Intra-examiner measurement error has been reported to be between 5 and 10 degrees (Morrissy 1990, Carmen 1990, Loder 1995). Were the pre- and post-x-rays all taken the same time of day? Because there is a clinically important increase of curve severity (5 degrees) in severe idiopathic scoliosis between morning and evening, the comparative x-rays should be taken at approximately the same time of day ( + one hour) as the entry x-ray (Beauchamp 1993).

In the discussion section the authors make another error when they write, “Given that the average curvature progression in idiopathic scoliosis is 7.03° per year [38] . . .” This is misleading, because progression depends upon patient variables such as Risser, Cobb angle, and age. One cannot make a statement about mean progression without clearly defining the specific population (Roach 1999, Lonstein 1988, Lonstein 1984, Bunnell 1988, Little 2000).

In conclusion, this paper should not have been published in its present form and represents poor implementation and/or reporting.

Sincerely,

Ronald J. Feise, DC

Institute of Evidence-Based Chiropractic

References

Beauchamp M, Labelle H, Grimard G, Stanciu C, Poitras B, Dansereau J. Diurnal variation of Cobb angle measurement in adolescent idiopathic scoliosis. Spine 1993;18:1581-3.

Bunnell WP. The natural history of idiopathic scoliosis. Clin Orthop 1988;229:20-5.

Carmen DL, Browne RH, Birch JG. Measurement of scoliosis and kyphosis on radiographs: intra and inter-observer variation. J Bone Joint Surg 1990;72(A):328-33.

Morningstar MW, Woggon D, Lawrence G. Scoliosis treatment using a combination of manipulative and rehabilitative therapy: a retrospective case series. BMC Musculoskeletal Disorders 2004, 5:32

Morrissy RT, Goldsmith GS, Hall EC, Kehl D, Cowie H. Measurement of the Cobb angle on radiographs of patients who have scoliosis. J Bone Joint Surg 1990;72(A);320-7.

Little DG, Song KM, Katz D, Herring JA. Relationship of peak height velocity to other maturity indicators in idiopathic scoliosis in girls. J Bone Joint Surg [Am] 2000;82:685-93.

Loder RT, Urquhart A, Steen H, Graziano G, Hensinger RN, Schlesinger A, Schork MA, Shyr Y. Variability in Cobb angle measurements in children with congenital scoliosis.

J Bone Joint Surg Br. 1995 Sep;77(5):768-70

Lonstein JE, Carlson JM. The prediction of curve progression in untreated idiopathic scoliosis during growth. J Bone Joint Surg [Am] 1984;66:1061-71.

Lonstein JE. Natural history and school screening for scoliosis. Orthop Clin North Am 1988;19:227-37.

Roach JW. Adolescent idiopathic scoliosis. Orthop Clin North Am 1999;30:353-65.

Competing interests

None

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Consumer Responds

Linda Racine   (2004-11-05 05:11)  Just a Skeptical Consumer

Please call me Linda. May I call you Mark?

Regardless of the treatments you provide, there has never been a single treatment that has shown any promise to permanently reduce scoliosis curves. I agree that some amount of correction may be obtained from treatments such as yours, and even preserved, as long as the treatment is continued. But, as I mentioned in my original comment, just like a brace, when the treatment is discontinued, the curves will return.

Your comment that "your statement that a TLSO brace can do the same thing is not comparable" puzzles me. I did not compare your treatment to brace treatment. Your treatment might prove to be as effective as, or even more effective than, bracing. That doesn't mean that the patients in your cohort won't have their curves return once treatment is stopped.

I agree that the Weinstein study shows that the scoliosis patients in their cohort had pain more often than controls. It's not surprising to me, in that the mean age in the cohort was 66 years (range 54-80). (If I recall correctly, you did not mention the mean age in your study, but the age range was considerably younger.) Still, 23% of the scoliosis patients in the Weinstudy study reported no pain. Of those with pain, 68% reported only little to moderate back pain. To me, that's a fairly significant percent of people who are probably living fairly normal lives. (By the way, I'm sure you're famility with other studies that show that 80% of the entire adult population in the U.S. report at least occasional back pain.)

The bottom line in terms of this aspect of our little debate is that I believe the CONCLUSIONS section of the Weinstein study specifically supports my notion that many people with scoliosis live normal lives: "Untreated adults with LIS are productive and functional at a high level at 50-year follow-up. Untreated LIS causes little physical impairment other than back pain and cosmetic concerns."

Linda Racine

A Skeptical Consumer

Competing interests

None declared

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In Response

Mark Morningstar   (2004-11-02 22:27)  Spinal Technologies Company email

Ms. Racine,

I appreciate your interest in scoliosis and its multitude of proposed treatments. To reply specifically to your comment, there must first be clarification on some basic vocabulary. Your definition of chiropractic, as I infer it from your comment, is synonymous with spinal manipulation. The chiropractic profession at large contains many procedures, including spinal manipulation, along with several other common domain procedures. However, in our study, we performed the minimum amount of manipulation necessary to achieve the desired effect. We also used a bodyweighting system designed to change the global centers of gravity, so that predictable and corrective compensations are observed. This is not a commonly used procedure, and should only be considered chiropractic insofar as it is used by a chiropractor.

Furthermore, you mention that people with scoliosis can often lead a "normal" life, yet you did not define normal. Scoliosis has repeatedly shown to alter the quality of life in specific subsets of the general population. Recently Weinstein et al showed that people with scoliosis develop chronic back pain significantly more than controls. Other authors have shown connections with difficult labor, decrease of consortium, self-perception issues, decreased athletic performance, and others. Your notion that this population often leads "a normal life" is not strongly supported.

In terms of long-term prospects, you are correct. We are currently working on long-term follow-ups, but one has to start somewhere. However, your statement that a TLSO brace can do the same thing is not comparable. Braces must be worn the majority of the day every day to be clinically effective. There are significant psychological issues with brace treatment in terms of self-image. Our treatment only requires a total home care time of less than one hour per day. The purpose of this study was not to compare treatments. People with scoliosis must decide on their own which treatment they will undergo.

Mark W Morningstar, DC DAASP

Competing interests

See article

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Skeptical about Chiropractic Benefit on Scoliosis

Linda Racine   (2004-10-13 21:00)  Just a Skeptical Consumer email

While I applaud your effort to study the effectiveness of chiropractic on scoliosis, I see several problems with this study:

* Many of the references you used were not controlled for idiopathic scoliosis.

* Your cohort was 15-65 years of age, so your statement the the “average curvature progression in idiopathic scoliosis is 7.03 degrees per year” is useless. The vast majority of 15-65 year olds would be skeletally mature, so they would not be expected to have anywhere near 7.03 degrees of curvature per year, especially with average starting curves of 28 degrees.

(http://www.vh.org/pediatric/provider/orthopaedics/AIS/07CurveProgressionPM.html)

* There is no proof that the correction noted by the subjects in your study will hold over time. A simple TLSO brace could be applied and would probably get more than 17 degrees of reduction in a skeletally mature population. However, when that brace is removed, the curves will return to their original position over time.

While chiropractic may help some people with the pain associated with large scoliosis curves, there is no evidence that it can influence the natural history of the disease. Patients with small to moderate scoliosis curves can be expected to live a normal life without the need to try to reduce their curves.

Linda Racine

- a skeptical consumer

Competing interests

None declared

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