Scoliosis: Degenerative &

Idiopathic

Dr. James Cox presents treatment of

scoliosis due to various causes,
latest published literature findings,
and in-office patient cases.
 Sciatic Scoliosis
 Sciatic scoliosis is due to irritation of the spinal neurons
in radiculopathic stimulation and its resultant muscle
activity.

 Hirayama et al in Spine 2001;26(6):602-9 reported on

the effects of electrical stimulation of the sciatic nerve
on background electromyography and static stretch
reflex activity of the trunk muscles in rats. They verified
the hypothesis that sciatic scoliosis is induced
reflexively by radiculopathic pain, and that scoliosis
might be maintained by prolonged asymmetric alteration
of the trunk muscle tonus caused by central
sensitization of the spinal neurons that constitute the
postural reflex pathways.
Sciatic Scoliosis
Sciatic scoliosis usually occurs with convexity to the
side of the herniated disc. The neuronal mechanism
of sciatic scoliosis has not been well clarified.

In spinalized rats (transection of the spinal cord), the

sciatic nerve was stimulated electrically as a
conditioning stimulus. Muscle stretch elicited by
bending of the lumbar spine was applied as a test
stimulus.
Sciatic Scoliosis
It was found that the pattern of electromyographic
activity of the trunk muscles evoked by sciatic nerve
stimulation coincided with the typical direction of
sciatic scoliosis in patients with lumbar disc
herniation. It was supposed that the prolonged
asymmetric alteration of the trunk muscle tonus was
caused by central sensitization, and that central
sensitization of spinal neurons may underlie the
neuronal mechanism of sciatic scoliosis.
Sciatic Scoliosis
As opposed to the work of Finneson and Herlin, the
sciatic scoliosis may not be, or not only be, the
mechanical embarrassment of the nerve root or
dorsal root ganglion by disc invasion of territory, but
the embarrassment of the neurological bed of the
nerve root resulting in the resultant muscle spasm
and scoliosis.

This is what we are discussing in this course. Let's

start with a patient case presentation and
treatment...
 Left Thoracolumbar Scoliosis
in a Young Male

Cox® Technic Flexion-Distraction and Decompression done to all

curves using all motions of the Cox® Table lying supine and side-lying.

Side Notes: This patient

moved to Fort Wayne from
another city where he was
treated by a chiropractic
physician with Cox®
Technic. He came to our
office seeking the same
care.
At the second visit, the
patient reports a drop in
his VAS score from a 7 to
a 1 with improvement
noted in his shoulder and
low back.
 Dr. Cox introduces this discussion of
degenerative scoliosis and its
management.

Fu KMG, Smith J, Sansur CA et

al: Standardized
measures of health
status and disability and
the decision to pursue
operative treatment in
elderly patients with
degenerative scoliosis.
Neurosurgery 2010;
66(1):42-47 Link to
Journal Abstract
Glassman SD, Carreon LY,
Shaffrey CI, Polly DW et al:
The costs and benefits of
nonoperative
management for adult
scoliosis. Spine 2010;
35(5):578-582 Link to
Journal Abstract
Dr. Cox shows imaging and
discusses scoliosis cases.
 Degenerative Scoliosis (cont.)
Bautmans I, Can Arken J, Van mackelenberg M, Mets
T: Rehabilitaiton using manual mobilization for
thoracic kyphosis in elderly postmenopausal
patients with osteoporosis. J of Rehabilitation
Medicine 2010; 42(2):129-135 Link to
Journal Abstract
Masharawi Y, Dar G, Peleg S, Steinberg N, Medlej B,
May J, Abbas J, Hershkovitz I: A morphological
adaptation of the thoracic and lumbar
vertebrae to lumbar hyperlordosis in young
adult females. European Spine Journal 2010;
19(5):768-773 Link to Journal Abstract
Upendra B, Meena D, Kandwal P, Ahmed A,
Chowdhury B, Jayaswal A: Pedicle
morphometry in patients with adolescent
idiopathic scoliosis. Indian Journal of
Orthopedics 2010; 44(2):169-176 Link to
Journal Abstract
Hee HT, Zhang JT, Wong HK:Effects of cyclic
dynamic tensile strain on previously
compressed inner annulus fibrosus and
nucleus pulposus cells of human intervertebral
disc. An in-vitro Study. J of Orthopaedic
Research 2010; 28(4):503-509 Link to Journal
Abstract
Beresford ZM, Kendall RW, Willick SE: Lumbar facet
syndromes. Current Sports Medicine Reports
2010; 9(1):50-56 Link to Abstract
Mayer JM, Haldeman S, Tricco AC, Dagenais S:
Management of chronic low back pain in active
individuals. Current Sports Medicine Reports
2010; 9(1):60-66 Link to Abstract
Motions of Treatment
 In the following videos, Dr. Cox demonstrates
treatment application options for specific conditions.
The caudal section of the flexion-distraction
instrument – The Cox®7 Table is used here - may
be used or the thoracic restraint or the automated
feature or the cervical spine headpiece or its
restraint. Any condition can be treated in any
number of ways. To clarify how Dr. Cox makes the
table move, please review the following images.
Foot Switch Strip
to Activate Long-Y-Axis while treating
the Thoracic Spine
Tiller Bar Handle Button (top)
to Activate Long-Y-Axis while treating the
Thoracic Spine
Table Handle Locks
 Treatment Demonstration:
Charite Disc Replacement/Dextrorotatory
Scoliosis

 This is a case of L4
Charite Disc
Replacement with and
L5 Disc herniation
and dextrorotatory
scoliosis.
 The Rule of 50% is
discussed in relation to
the treatment plan to
relieve S1 dermatome
pain.
Hyperkyphosis & Scheuermann's
Disease treated in the supine position.
 Hyperkyphosis / Scheuermann's Disease
/ Osteoporosis / Any Condition needing
thoracic adjusting

 Dr. Cox demonstrates

flexion-distraction long-y-
axis decompression spinal
adjusting (low-velocity, low-
amplitude adjusting) for
any condition needing
gentle thoracic spinal
adjusting. Patients working
on computers and carry
much stress really
appreciate this care.
 Hyperkyphosis / Scheuermann's Disease /
Upper Thoracic Spine Low-Velocity/Low-
Amplitude (LVLA) Adjusting using the Cervical
Headpiece

 Highlights:
 Use of the cervical spine
restraint to treat the
thoracic spine curvature.
 Long Y axis automated
distraction with cervical
headpiece restraint in
place.
 Goals:
 drop intradiscal pressures
 increase foraminal area
 restore physiological
ranges of motion
 Hyperkyphosis / Thoracic Spine
Adjusting in the Side-Lying Position

 For some patients, this

very gentle application
is preferred.
Compression Fracture Treated
in the Supine Position
 Case - Scheuermann's
Disease
 Here is a patient case of
Scheurmann's Disease treated
in the office.
 use of occipital restraint to
treat hyperkyphosis
 use of long y axis automated
to treat thoracic spine (LVLA
low velocity low amplitude)
 treatment without
occipital restraint
 use of foramen magnum
pump
 Initial Visit: 25 year old, post-
partum 8 months,
hyperkyphosis, extension
irritates low back pain
 Outcome of Case: At the
third visit, the patient reported
that the neck and shoulder
pain is gone and the low back
pain is over 50% gone.
 Demonstration of the Mehta
exercises with a male spine
 Exercises for scoliosis are for
strengthening the convex side of
the curve and ensuring its mobility,
the same goals for adjusting scoliosis.
We are not looking to necessarily
correct the curve or reverse it, but
rather ensure its mobility. Mehta
Exercises are excellent tools the
patient can do alone or, optimally, with
a helper. Both ways are
demonstrated, first alone in this video
and with a helper in the next.
 Source for Mehta Exercise: in
denBoer W, Anderson P, Limbeek J,
Kooljman M: Treatment of Idiopathic
Scoliosis with Side-Shift Therapy: An
initial comparison with a brace
treatment historical cohort. European
Spine Journal 1999; 8:406-410
(Reference #10 - Mehta MH in 1985
which is active correction by side shift
In Warner JO, Mehta MH on scoliosis
prevention from Proceedings of the P.
Zorab Scoliosis Symposium 1983,
Praeger, New York, p 126-40)
 Mehta Exercises for Scoliosis
Curve Strengthening

 Here is a
demonstration with a
helper assisting.
Latest Research On Scoliosis

 The following slide presentations are

discussions of the latest published articles
related to scoliosis, both idiopathic as well
as degenerative: bracing, exercise,
diagnosis strategies, causes, biomechanics,
potential solutions.
 Each slide has a list of the articles
discussed with a link to the abstract of the
article or book chapter for your later study.
 Scoliosis Literature –
Bracing Sources
 Negrini, S; Minozzi, S; Bettany-Saltikov, J; Zaina, F; Chockalingam, N; Grivas, TB; Kotwicki,
T; Maruyama, T; Romano, M; Vasiliadis, ES. Braces for Idiopathic Scoliosis in
Adolescents. Spine 2010; 35 (13): 1285-1293 Link to Abstract
 Danielsson, Aina J.; Hasserius, Ralph; Ohlin, Acke; Nachemson, Alf L. Health-Related
Quality of Life in Untreated Versus Brace-Treated Patients With Adolescent Idiopathic
Scoliosis: A Long-term Follow-up. Spine 2010; 35(2):199-205 Link to Abstract
 Lou, E; Hill, D; Raso, J: Brace Treatment for Adolescent Idiopathic Scoliosis.
Conservative Scoliosis Treatment: 1st SOSORT Instructional Course Lectures Book 135.
2009 Link to Book
 Scoliosis. Grivas, TB; Rodopoulos, GI; Bardakos, NV: Biomechanical and Clinical
Perspectives on Nighttime Bracing for Adolescent Idiopathic. Conservative Scoliosis
Treatment: 1ST SOSORT Instructional Course Lectures Book 135. Amsterdam: I O S
Press, 2009 Link to Book
 Katz, DE; Herring, JA; Browne, RH; Kelly, DM; Birch, JG. Brace Wear Control of Curve
Progression in Adolescent Idiopathic Scoliosis. Journal Of Bone And Joint Surgery-
American 2010; 92A (6):1343-1352 Link to Abstract
 Fayssoux, RS; Cho, RH; Herman, MJ. A History of Bracing for Idiopathic Scoliosis in
North America. Clinical Orthopaedics And Related Research 2010;468 (3): 654-664 Link
to Abstract
Scoliosis Literature –
Bracing Discussion
 Scoliosis Research II -
Sources
 Schiller, JR; Thakur, NA; Eberson, CP. Brace Management in Adolescent Idiopathic
Scoliosis. Clinical Orthopaedics And Related Research 2010;468 (3):670-678 Link to Abstract
 Burwell, RG; Dangerfield, PH; Moulton, A; Anderson, SI: Etiologic theories of idiopathic
scoliosis: autonomic nervous system and the leptin-sympathetic nervous system concept
for the pathogenesis of adolescent idiopathic scoliosis. Research Into Spinal Deformities 6
140. 2008. p.197-207 I O S PRESS, AMSTERDAM Link to Book
 Bettany-Saltikov, J; Warren, J; Stamp, M: Carrying a Rucksack on either Shoulder or the
Back, Does it matter? Load Induced Functional Scoliosis in "normal" young subjects.
Research Into Spinal Deformities 6 140. 2008. p.221-224 I O S PRESS, AMSTERDAM Link to
Book
 Domenech, J; Tormos, JM; Barrios, C; Pascual-Leone, A. Motor cortical hyperexcitability in
idiopathic scoliosis: could focal dystonia be a subclinical etiological factor?
 Kirby, AS; Moulton, A; Dangerfield, PH; Freeman, BJC; Cole, AA; Polak, FJ; Pratt, RK.
Ultrasound femoral anteversion (FAV) and tibial torsion (TT) after school screening for
adolescent idiopathic scoliosis (AIS). Research Into Spinal Deformities 6 140. 2008. p.225-
230 I O S PRESS, AMSTERDAM Link to Book
 Burwell, RG; Aujla, RK; Freeman, BJC; Dangerfield, PH; Cole, AA; Kirby, AS; Polak, FJ; Pratt,
RK; Moulton, A. The posterior skeletal thorax: rib-vertebral angle and axial vertebral
rotation asymmetries in adolescent idiopathic scoliosis. Research Into Spinal Deformities 6
140. 2008. p.263-268 I O S PRESS, AMSTERDAM Link to Book
 Stokes, IAF; McBride, CA; Aronsson, DD. Intervertebral disc changes in an animal model
representing altered mechanics in scoliosis. Research Into Spinal Deformities 6 140. 2008.
p.273-277 Link to Book
Scoliosis Research II -
Discussion
 Scoliosis Research III -
Sources
 Fong, Daniel Yee Tak; Lee, Chun Fan; Cheung, Kenneth Man Chee; Cheng, Jack Chun Yiu;
Ng, Bobby Kin Wah; Lam, Tsz Ping; Mak, Kwok Hang; Yip, Paul Siu Fai; Luk, Keith Dip Kei. A
Meta-Analysis of the Clinical Effectiveness of School Scoliosis Screening. Spine 2010;
35(10):1061-1071 Link to Abstract
 Ugras, AA; Yilmaz, M; Sungur, I; Kaya, I; Koyuncu, Y; Cetinus, ME. Prevalence of scoliosis
and cost-effectiveness of screening in schools in Turkey. Journal Of Back And
Musculoskeletal Rehabilitation 23 (1). 2010. p.45-48 Link to Abstract
 Wang, Chuanfeng; Xu, Weidong; He, Shisheng; Gu, Suxi; Zhao, Yingchuan; Zhang, Jingtao;
Zhu, Xiaodong; Li, Ming. Differences in Postoperative Quality of Life Between Adolescent
Patients With Idiopathic Scoliosis Residing in Urban and Rural Environments. Spine
2010. 35(6):652-656, March 15, 2010. Link
 Ogilvie, J. Adolescent idiopathic scoliosis and genetic testing. Current Opinion in
Pediatrics 2010; 22 (1):67-70 Link
 Akoume, MY; Azeddine, B; Turgeon, I; Franco, A; Labelle, H; Poitras, B; Rivard, CH; Grimard,
G; Ouellet, J; Parent, S; Moreau, A. Cell-Based Screening Test for Idiopathic Scoliosis
Using Cellular Dielectric Spectroscopy. Spine 2010;35 (13):E601-E608 Link
 Grivas, TB; Vasiliadis, ES; Rodopoulos, G. Aetiology of Idiopathic Scoliosis. What have we
learned from School Screening? Research Into Spinal Deformities 6 140. 2008. P.240-244 I
O S Press, Amsterdam Link
 Yong, F; Wong, HK; Chow, KY. Prevalence of Adolescent Idiopathic Scoliosis among
Female School Children in Singapore. Annals Academy Of Medicine Singapore 38 (12).
DEC 2009. p.1056-1063 Link
Scoliosis Research III -
Discussion
 Scoliosis Research IV -
Sources
 Ciazynski D, Czernicki K, Dumala J: Knowledge about idiopathic scoliosis among students of
physiotherapy. Research into Spinal Deformities 2008; 6(140):281-285 Link to Book Online
 Weiss H, Maier-Hennes A: Specific exercises in the treatment of scoliosis. Conservative
Scoliosis Treatment: 1st SOSORT Instructional Course Lectures Book 135; 2009 Link to Book
 Romano M, Negrini A, Parzini S et al: Scientific Exercises Approach to Scoliosis (SEAS):
Efficacy, Efficiency and Innovation. Conservative Scoliosis Treatment: 1st SOSORT Instructional
Course Lectures Book 135; 2009 Link to Book
 Rigo M, Quera-Salva F, Villagrasa M et al: Scoliosis intensive out-patient rehabilitation based on
Schroth Method. Conservative Scoliosis Treatment: 1st SOSORT Instructional Course Lectures
Book 135; 2009 Link to Book
 Dobosiewicz K, Drumala J, Kotwicki T: Dobosiewicz Method physiotherapy for idiopathic
scoliosis. Conservative Scoliosis Treatment: 1st SOSORT Instructional Course Lectures Book 135;
2009 Link to Book
 Weiss H, Rigo M: The Cheneau Concept of Bracing - Actual Standards. Conservative Scoliosis
Treatment: 1st SOSORT Instructional Course Lectures Book 135; 2009 Link to Book
 Durmala J, Tomalak W, Kotwicki T: Function of the respiratory system in patients with idiopathic
scoliosis reasons for impairment and methods of evaluation. Conservative Scoliosis Treatment:
1st SOSORT Instructional Course Lectures Book 135; 2009 Link to Book
 Rigo M, Weiss H: The Cheneau Concept of Bracing - Biomechanical Aspects. Conservative
Scoliosis Treatment: 1st SOSORT Instructional Course Lectures Book 135; 2009 Link to Book
 deMauroy J, Fender P, Tato B, Lusenti P, Ferracane G: Lyon Brace. Conservative Scoliosis
Treatment: 1st SOSORT Instructional Course Lectures Book 135; 2009 Link to Book
 Christine C, Alin C, Riward C: Treatment of early adolescent idiopathic scoliosis using teh
SpineCor System. Conservative Scoliosis Treatment: 1st SOSORT Instructional Course Lectures
Book 135; 2009 Link to Book
Scoliosis Research IV -
Discussion
 Scoliosis Research V – Sources
for Brace Types & Outcomes
 Sforzesco Brace - Ananasio, Saina, Negrini: The SPoRT (Symmetci, Patient-Oriented, Rigid, Three-
dimensional active) concept for scoliosis bracing: principles and results. Conservative Scoliosis Treatment:
1st SOSORT Instructional Course Lectures Book 135. 2009 Link
 Boston Brace - Wynne J: The Boston Brace System Philosophy, Biomechanics, Design & Fit. Conservative
Scoliosis Treatment: 1st SOSORT Instructional Course Lectures Book 135. 2009 Link
 Cosmetic Effect in IS Kids - Grivas T, Vasiliadis E: Cosmetic Outcome after Conservative Treatment of
Idiopathic Scoliosis with a Dynamic Derotation Brace. Conservative Scoliosis Treatment: 1st SOSORT
Instructional Course Lectures Book 135. 2009 Link
 Reduction in Surgical Intervention - Negrini S, Atanasio A, Zaina F, Romano M. et al: Endgrowth resluts of
bracing and exercises for adolescent idiopathic scoliosis. Prospective worst-case analysis. Conservative
Scoliosis Treatment: 1st SOSORT Instructional Course Lectures Book 135. 2009 Link
 Quality of Life - Vasiliadis E, Grivas T Quality of life after conservative treatment of adolescent idiopathic
scoliosis. Conservative Scoliosis Treatment: 1st SOSORT Instructional Course Lectures Book 135. 2009
Link
 Adult Scoiosis Surgery Effects - Yadla S, Maltenfort M, et al: Adult scoliosis surgery outcomes: a
systematic review. Neurosurgical Focus 2010; 28(3):NIL19-NIL25n Link to Yadla article
 Chromium from Scoliosis Rods - Cundy T, Delaney C, Rackham M, et al: Chromium Ion Release from
Stainless Steel Pediatci Scoliosis Instrumentation. Spine 2010; 35(9):967-974 Link to Abstract
 Cost of Scoliosis Treatment - Kamerlink J, Quirno M, Auerback J et al: Hospital costs analysis of
adolescent idiopathic scoliosis correction surgery in 125 consecutive cases. J of Bone and Joint Surgery -
American. 2010; 92A(5):1097-1104 Link to Abstract
 Scoliosis Research Subjects - Bunge E, Habbema J, deKoning H: A randomized controlled trial on the
effectiveness of bracing patients with idiopathic scoliosis. European Spine Journal 2010; 19(5):747-753 Link
to Issue to read article
 Kyphosis after Scoliosis Fusion - Wang J, Zhao Y, Shen B, Wang C, Li M: Risck facotr analysis of
proximal junctional kyphosis after posterior fusion in patients iwth idiopathic scoliosis. Injury-International
Journal of the Care of the Injured 2010; 41(4):415-420 Link to Issue to read abstract
Scoliosis Research V –
Discussion of Brace Types & Outcomes
Thank you.
 Thank you for studying with me degenerative and
idiopathic scoliosis: the latest in biomechanics,
diagnosis, and treatment. Scoliosis is a challenging
condition demanding confident, gentle care with a
realistic goal of maintaining mobility and flexibility
as well as building strength into a curve that may
not ever be straightened, but deserving of good
care.
James M. Cox, DC, DACBR
www.coxtechnic.com
info@coxtechnic.com