Charles L. Blum,
DC Private practice of chiropractic, Santa Monica, Calif.
Received 11 March 1999; received in revised form 12 May 1999
Abstract
Objective:
To describe the use of Pilates therapy and sacro-occipital technique in the
management of a 39-year-old woman with scoliosis who had undergone spinal
fusion many years earlier. Clinical Features: The patient had progressive
severe low back pain that had worsened over the years after her surgery and had
prevented her from activities such as carrying her son or equipment necessary
for her job as a photographer. Intervention and Outcome: The patient was
provided a series of Pilates exercises used to overcome her chronic habituation
and muscle weakness. Although this therapy went on for some time, she did begin
to stabilize and increase physical activity. At present, she is no longer
limited in her physical activity, although she still exhibits some symptoms
from her scoliosis. Conclusion: The addition of Pilates therapy can be useful
to care for patients with chronic low back pain and deconditioning. (J
Manipulative Physiol Ther 2002;25:e3)
Introduction
Surgical
intervention for adult scoliosis carries risk.1, 2, 3 The obvious question is,
does the benefit outweigh the possible side effects of surgery? “The decision
to proceed with surgical treatment … must be based on a thorough understanding
of the anticipated benefits from surgical treatment and results that can be
less desirable than the original condition.”2 Complications of surgery on an
adult patient with scoliosis are relatively common, occurring from 30% to 53%
of the time.4, 5, 6, 7, 8, 9 Patients with scoliosis are at risk with epidural
anesthesia.1, 10 Complications as serious as a subdural hematoma have been
reported, which in one case resulted in paraplegia.1 Nonoperative treatment is
best suited to those adults with mild pain or older patients for whom surgery
is not prudent.11
Chiropractic
procedures have been shown to be helpful in the treatment of scoliosis.12, 13,
14, 15, 16, 17, 18, 19 In one study, it was determined that “chiropractic
spinal manipulation offers a possible treatment method for aiding in the
reduction and correction of scoliosis.”19 With chiropractic treatment,
mechanical stability is considered, applying engineering principals to
understand buckling and critical loading. By examining the factors of spine
slenderness and flexibility and strength of the trunk muscles and applying this
understanding to curve mechanics and the biomechanics of scoliosis, the
chiropractor has a rationale for the treatment of mild lateral curves.14
Another study suggested that chiropractic procedures may also have a favorable
long-term effect of preventing reoccurrence of back pain and on retarding curve
progression.12 Because of the serious sequelae associated with surgery,
conservative methods such as chiropractic, especially if they offer relief, are
viable and necessary options.
Case
report
A
39-year-old woman had sequelae caused by a long-term history of severe
scoliosis. The patient had a 2-year-old adopted son (she was not able to carry
a pregnancy because of her scoliosis), and the process of holding him and
trying to play with him caused excruciating pain. She had been working as a
photographer, but the carrying of cameras and the pain and discomfort that
followed made working prohibitive.
In
1974 the patient underwent a spinal fusion of T9 through L4. The surgeons
report noted that the incision was made from T9 down to L4. The spinous
processes from T9 down to L4 were identified and split with a knife.
Subperiosteal dissection of spinous process, lamina, and zygapophyseal joints
was performed involving 9 lumbar and dorsal segments. The spinous process was
split with the osteotome, and a facet fusion was performed with a gouge. An
initial cut was made into the superior facet, and cartilage was removed with a
small gouge. The second cut was made in the lamina just below this, and the
spicule of bone was brought up dorsally and imbricated into the facet. The
spinous process was cut with a gouge, and fish scale pieces were overlapped.
The identical procedure was performed from T9 to L4 so that the entire dorsal
lumbar spine was cut and imbricated. Bone grafts were removed from the right
posterior iliac crest, and strips of cortical cancellous bone were removed. The
bone was placed around the apex of the curve on the concave side to act as a
bone graft.
Twenty
years after her surgery, the patient's condition had continually worsened,
until the fear of being confined to a wheelchair directed her to pursue active
treatment. In early 1995 she began treatment and evaluation with a prominent
orthopedist because of significant pain she was experiencing in the cervical
and upper thoracic region. The orthopedist stated in his report on January 3,
1996, that he recommended a “strengthening program that is designed to produce
proper muscular control and support for her spine with her scoliosis and severe
radicular components which is the only hope that she has nonoperatively. The
alternative is a spinal fusion of her cervical and thoracic spine and there is
quite severe potential chance for complications. The estimated cost of the
spinal fusion is $150,000.00.” He recommended extensive testing, including a
scan, EMG, nerve conduction studies, and myelogram.
The
patient underwent all the all of the tests that were recommended but needed to
be hospitalized after the lumbar puncture for the myelogram for approximately
10 days. The tests essentially revealed that the patient's condition was
worsening. By October 1996, simple activities such as bending down to pick up
her son's toys were now prohibitive, and most of her activities were largely
limited. Because of her fear of surgery, she continued with the physical
therapy recommended by her orthopedist even though she was not seeing any
progress.
When
the patient came to my office in November 1996, she had essentially exhausted
what she considered all her possible options, and believed that she could do no
worse with chiropractic care. She was seen and evaluated, and a course of
treatment ensued. The treatments were spaced initially 1 to 2 times a week for
6 to 8 weeks. Although she was making progress, symptomatically, there would be
a gradual regression during the period between treatments. Specific exercises
were given to her to aid in her recovery; however, because of her chronic
habituation and facilitation, it was extremely difficult for her to isolate
specific muscle groups and stretch or strengthen the weakened or fixated
joints. As a result of these findings, the patient was referred to a Pilates
trainer specializing in exercises for patients with scoliosis.
As
treatment continued, the patient's ability to begin to use her body in a balance
manner allowed her to proceed with her Pilates exercises. Although her progress
was slow initially, 1 year after commencement of chiropractic treatment, she
was beginning to stabilize and increase her physical activity. By the beginning
of 1999 she was only being seen at the office for flare-ups, which consisted of
approximately 5 to 10 office visits per year. The patient was continuing with
her Pilates exercises and would see her Pilates trainer periodically to ensure
that she was exercising with proper placement.
She
now can infrequently carry her son, who is now 5 years old, and although she
still exhibits symptoms of her scoliosis, she is not limited by her condition
at this time. Her condition is consistently improving as of the last office visit.
Discussion
An
effective method of treating patients with scoliosis is sacro occipital
technique (SOT), which was developed by M.B. DeJarnette, a chiropractor and
osteopath.
SOT
orthopedic block placement
One
method, called “orthopedic block techniques,”20, 21 uses wedges or blocks
placed in specific positions to “derotate” the spine and rib cage of the
patient with scoliosis. DeJarnette noted that this type of orthopedic block
technique approach is extremely valuable in multiple rotations because it
permits proper muscle conformation as the correction is being made, and the
correction is made without force and therefore without trauma. Blocks can be
positioned under the pelvis, rib cage, and clavicles with the patient in either
the prone or supine position. With the patient lying supine or prone,
elevations of the pelvis, lumbar, thoracic spine, or rib cage is noted.
Placement of blocks or wedges is determined by SOT protocol, essentially
creating balance in the pelvis and rib cage by way of block placement as
specific reflex points are monitored. As the musculature and fascia relax as a
result of the block placement, reflex points and aspects of the body distal to
the block placement also relax.
Cranial
manipulation
Because
of the multiple interrelationships between the pelvis and cranium,22 it is
common to see cranial restriction in patients with scoliosis. An evaluation of
the cranial bone dynamics is often necessary. A good overview of the dural
membranes in the cranium can be obtained by performing sphenobasilar ranges of
motion.
Flexion/extension
With
the patient lying in a supine position, and the examiner at the head of the
table, the doctor will contact bilaterally the greater wings of the sphenoid
with his/her thumbs while the occiput rests in the fingertips of both hands. As
the head is held gently, a subtle force is initiated in the direction of
flexion. Flexion occurs when the doctor draws the greater wings of the sphenoid
and the occiput caudalward toward the patient's feet. The sphenobasilar
movement is monitored and allowed to return to a neutral position where at that
point the sphenoid and occiput are gently directed into an extension position.
Extension occurs when the doctor draws the greater wings of the sphenoid and
occiput toward the cranial vertex.
Side-bending
rotation
Side-bending
rotation in the sphenobasilar joint occurs when there is an approximation
between the greater wing of the sphenoid and the occiput on the ipsilateral
side. On the contralateral side, there is a lengthening between the greater
wing of the sphenoid and occiput. As this convexity or bulge occurs, inferior
rotation of the cranium will also occur on that side. The side-bending
disturbance of the sphenobasilar junction is named by the side of the convexity.
Therefore the lengthened distance between the sphenoid and occiput
ipsilaterally with its caudal rotation along an anteroposterior axis on the
right side would be termed a right side–bending distortion.
Trapezius
fibers
DeJarnette25
also found a relationship between the trapezius muscle and the thoracolumbar
spine. The trapezius muscle arises from the medial third of the superior nuchal
line at the external occipital protuberance and continues its attachment along
the nuchal ligament until the spinous process of C7/T1. The trapezius continues
along the spinous processes, also attaching to the supraspinous ligaments, of
all 12 thoracic vertebra. The lateral connections of the muscle insert at the
lateral third of the clavicle, medial border of the acromion, and the superior
lip of the crest of the scapular spine.26 DeJarnette25 found a group of 7
myofascial fibers along the trapezius muscles located bilaterally from T1 to
the acromion process. There is a direct relationship between one or more of these
fibers when swollen and specific thoracolumbar vertebra. DeJarnette25
postulated a relationship between the thoracolumbar vertebral pedicles, the
temperature-sensitive spinothalamic tract and the trapezius muscle fibers.
Correcting the malpositions of the specific vertebra balances and reduces
tension in the fiber that affects the entire trapezius muscle, specifically its
connection along the nuchal ligament with its attachment to the occiput.25
Pilates
exercise methods
A
complex method of exercise rehabilitation was developed by Joseph Pilates in
1923. “The Pilates Method of Physical and Mental Conditioning provides thorough
training to improve strength, flexibility, and postural awareness. Its
philosophy integrates the mind with the musculoskeletal system. Although
Pilates has traditionally been used by dancers, the method is becoming more
popular for use throughout general physical therapy practice.”37, 38, 39, 40,
41, 42, 43, 44, 45Exercise therapies have been shown to be effective tools in
combating the progression and sometimes improving the condition of idiopathic
scoliosis.46, 47 Pilates' focus of maintaining a balance in the use of the
musculoskeletal system throughout movements are the ideal physiotherapeutic
exercises for the patient with scoliosis.
It
is theorized that scoliosis-related injuries may cause, or may occur, as a
result of imbalances of the body and preferred patterns of movement. One weak
or misaligned area may result in a propensity to overcompensate or overdevelop
another area. Pilates conditioning works toward a rebalancing of
musculature.37, 38, 39, 40, 41, 42, 43, 44, 45 The symmetrical nature of the
Pilates exercise technique and apparatus (reformer)42 makes the Pilates method
an excellent rehabilitative therapeutic agent with patients who experience
imbalances in use as a result of scoliosis.
Practitioners
teaching Pilates therapy can be certified. The certification process is quite
extensive and involves years of study of anatomy and kinesiology along with at
least 2 years of apprenticeship and assistant instructing. There are also both
written and practical examinations required for the certification. One Pilates
teaching facility, “The Pilates Studio”, (New York, NY) has an extensive
teacher certification program that involves years of supervised teaching,
studies in anatomy and kinesiology, written, oral, and practical examinations,
as well as yearly recertification through continuing education courses.
Treatment
Treatment
for the patient discussed here consisted of sacro occipital technique and
“fascial unwinding” techniques. When patients with scoliosis are treated, a
balance between structure and function must be determined. Then a balance
between structure and function must be attained. Treatment focused on creating
a release of the patient's “fascial makeup,” which encased her spine, thoracic
cage, and cranium. Although I was concerned about her scoliosis and imbalance,
my focus was to unwind the 3-dimensional “scoliotic spiral” that her body
presented.
Lower
extremities and pelvis
The
patient exhibited a pattern that affected her from head to toes. Treatment was
focused on her whole body dynamics and fascial patterning. Initially it was
noted that her right lower extremity was externally rotated. This was initially
treated with SOT's iliofemoral technique, which is a method that is designed to
release a chronic contracture of the hip external rotators at their insertion
at the greater trochanter. When this condition persisted, evaluation of the
right knee, ankle, and foot revealed a continuation of the facial “twisting”
with a posterior fibula and lateralization of the talus with the calcaneus
presenting medially and in “hyper” inversion. The fibula and talus were
adjusted to correct their position and the foot and ankle were taped in a
neutral position, to decrease the persistent ankle inversion.
Lumbar/cervical
relationship
With
regard to her spine, the patient had a longstanding rotation of the L2 spinous
to the left and T8/9 to the right, creating a significant rib cage distortion.
This was present even though the patient had fusion from T9 to L4. Her lumbar
paravertebral musculature was notably decreased on the right with increased
height of the paravertebral musculature noted on the left in the prone and
standing postures.
With
SOT's R+C therapy, sensitivity was noted at the patient's left C4 transverse
process, and an orthopedic block was placed under her right ilium, between the
anterior superior iliac spineand greater trochanter. This placement restricts
pelvic bone rotation and elevates the right side of the pelvis and engages the
right paravertebral musculature. As the right paravertebral muscles contract as
a result of this block position, the fascia and musculature (iliopsoas and
quadratus lumborum muscles) surrounding the rotated L2 “unwinds,” and
sensitivity at the C4 transverse process decreases or is eliminated. Pressure
to the left of the L2 spinous process rotating to the right assists the process
of relaxation and neutralization of the reflex at the C4 transverse process.
The procedure can take anywhere from 2 minutes to 20 minutes depending on the
chronicity of the patient's condition.
Cervical
relaxation
With
specific “sutural technique”48 cervical preparatory procedures, the cervical
fascia is relaxed, with various techniques used to release any platysma,
scalenus, sternocleidomastoid fixation, and the deeper posterior vertebral
musculature of the cervicothoracic, cervical and suboccipital regions. After
relaxation of the cervical myofascial a procedure called “cervical stairstep”
was used. This procedure will localize and correct “loosened motor units” of
the cervical vertebra. DeJarnette recommends using a treatment called the
“figure eight,” which he described as the “ideal cervical technique as it
involves no violent motions or thrusting forces, rather a gentle controlled
motion to reset the processes of the loosened cervical motor units.” The
“resetting of the vertebra” involves a mechanical repositioning of the
vertebra, normalizing any limitations in ranges of motion during stairstep
range of motion testing.49
Cranial
bone/meningeal “unwinding”
Often,
in patients with scoliosis who have had surgery fixating parts of their spine,
a “build up” of tension can be palpated in the cranial aponeurosis and
meningeal structures. Sutural technique involves a step-by-step method of
analyzing myofascial and cranial sutural fixation with procedures to gently
relax and unwind any sutural or meningeal restrictions. Often, when the
patient's cranial base is affected, a procedure entitled “sphenobasilar range
of motion technique” is used to effectively determine the magnitude of cranial
base fixation and subsequently can be used to release this fixation.
Pilates
rehabilitative exercises: Precision of alignment, breath, and body placement
Although
various Pilates exercises were used, the following gives an example of the
exercise methodology and relationship to a patient with scoliosis. Only 2 of
the many exercises are described: (1) the prone latissimus dorsi pulls with
twist and (2) the side leg lift.
The
patient had significant spinous vertebral rotation in her mid thoracic region,
convexity of the curve toward the right with apex of the curve at T8/9. The
prone latissimus dorsi pulls with twist exercise was modified for the patient
to create an exercise to address this asymmetry. In the lumbar region the
patient had significant spinous vertebral rotation with convexity of the curve
to the left and apex of the curve at L2/3. The side leg lift was modified
regarding repetitions to address the decreased muscle mass of the right lumbar
paravertebral musculature.
Prone
latissimus dorsi pulls with twist
This
exercise was modified for this patient and was not performed the same on both
sides because of the vertebral spinous rotation in the mid thoracic region. To
address the asymmetry a “twist” or upper body rotation to the right was added
when the ipsilateral right arm was used, whereas no “twist” when using on the
left arm. This exercise is performed on alternating sides through 3 to 5
repetitions.
The
exercise begins with the patient lying on his or her stomach with a small
pillow under the abdomen to reduce any lumbar lordosis. Both arms are
straightened and extended above the head.
Right
side
Keeping
the neck relaxed, have the patient lift the head and arms approximately 10
degrees off the floor. The patient breathes in and then while slowly exhaling,
reaches, extending outward, with the right arm and in unison rotates the neck
90 degrees toward the right while slowly describing a semicircular arc toward
the right hip with the right arm. The patient then slowly returns the arm and
head to the starting position (held 10 degrees off floor) as they inhale. Then
have the patient lower their head and arms, so that the forehead and arms touch
the floor.
Left
side
The
exercise varies on the left side because the head and arm do not lift off the
floor. The patient breathes in and then while slowly exhaling, she reaches,
extending outward, with the left arm, while slowly describing a semicircular
arc toward the left hip with the left arm. At a few inches from the left hip
the arm makes a pulsing action (3 times), abducting and adducting, to activate
the left latissimus dorsi, trapezius muscles, and adjacent musculature to
encourage strengthening of the left mid thoracic paravertebral muscles. After
the 3 pulses the left arm is replaced in a semicircular arc to its starting
position, extended over the head. Sometimes a light weight (3 pounds) can be
used on this left side procedure.
Side
leg lift
This
exercise relieved tension in the patient's upper trapezius musculature and was
modified by performing greater repetitions (5 repetitions on “weaker” side
versus 3 repetitions on “stronger” side) on the side of weaker or less muscle
development in the lumbar paravertebral musculature.
Side
leg lifts are performed with the patient on their side with a pillow under
their head in a neutral position, without any lateral flexion. Alignment of the
body is essential, keeping the head, shoulders, hips, knees, and feet in a
“perfect” line. (1) Initially have the patient breath in and then exhale,
engaging the abdominal muscles without altering pelvic position. (2) Then have
the patient reach the superior leg “out” of the hip without contracting the
ipsilateral quadratus lumborum muscle nor having the superior hip and costal
margins approximate themselves. (3) The superior leg is then lifted
approximately 10 to 20 degrees and held for 3 seconds before gradually replaced
to the starting position as the patient breaths in. All motions are fluid,
gradual, with emphasis on precise body placement.
Conclusion
Pilates-type
exercises are essential whether the patient chooses a surgical or conservative
route of care. It appears from the research performed at the Katharina Schroth
Hospital that exercises focused on balancing spinal curvatures and the
associated muscles in conjunction with chiropractic/cranial therapy have been
successful options to surgical intervention.
Much
of the research in scoliosis intervention is focused on whether the curves are
reduced and whether the spine appears to be “straighter.” What is difficult to
measure, to some degree, is the ability of the fascia to allow for motion in
various positions. Sometimes there will be a “freeness” in the fascia but that
will not be found by increases of range of motion. This means that the skeletal
structure might still have a fixed anatomic structure, but the fascia and
musculature will not. Wolfe's law notes that as stress is applied to osseous
structure the trabecular pattern will modify or reconfigure itself to the
amount, direction, and location of the stress by increased localized bone mass.
Because osseous structure is constantly responding to stress, a balanced
nonfixated myofascial structure is theorized to create a 3-dimensional template
by which a scoliosis might reconfigure over time, measured in years.
Another
theory regarding releasing of the myofascial structure in patients with
scoliosis relates to Hiltons law. Hilton's law states that the motor nerve to a
muscle tends to give a branch of supply to the joint, which the muscle moves
and another branch to the skin over the joint.26 The neural intercommunication
might also help the osseous reorganization of the patient with scoliosis as
their muscles act in a more “balanced” manner.
The
ultimate result of treatment is to determine whether the patient has decreased
pain and increased function. It is imperative that chiropractic, in conjunction
with exercise modalities such as Pilates, team together to formulate studies on
the efficacy of cotreatment for patients with scoliosis. Greater communication
and education of our fellow health care practitioners is necessary, so that
many forms of care are available for patients with scoliosis, and surgery is
the last resort after other conservative methods have been exhausted.
http://www.jmptonline.org/article/S0161-4754(02)93254-9/fulltext
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