372- Improving Scoliosis with Spinal Manual Therapy

Welcome to the Evidence Based Chiropractor where each week we deliver the latest chiropractic research and marketing strategies all in the time it takes to get to your office. Now here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I am your host, Dr. Jeff Langme. Today we're talking research, brand new study 2023 all around spinal manual therapy for adolescent idiopathic scoliosis. This is a meta analysis of randomized controlled trials. A lot of clinical pearls and nuggets and it continues a conversation, I'm not going to say it ends the conversation on spinal manual therapy for scoliosis, but it continues the conversation end and continues to, I guess, build upon our understanding of how spinal manual therapy can positively impact the lives of people that struggle with scoliosis. We'll dive into that and much more in just a few moments. Before we get started, I wanna say a few words about patient pilot. If you have not scheduled a demo yet, it's 2023. What are you doing? You have to use email marketing. It's the highest ROI marketing channel that you have in and chances are you're listening to this podcast on what I call a gold mine, meaning your past patients. Whether you have 200, 2000 or 20,000 past patients. If you're not using email marketing to stay top of mind, to generate consistent reactivations and to build upon your retention, you're missing out. We call those holes in your bucket. You can schedule a demo at the smart chiropractor. Com. Again, that's the smart chiropractor.com schedule a demo for patient pilot. See what we have going on. We help over 300 practices around the world, say over a million emails per month. What does that result in? A 3x ROI guarantee. Yes, you heard that right, 3x ROI guarantee. I don't know too many people out there doing that. Why can we do it? Because we know the results that we get because we are the leaders in email marketing. So check out the smart cardback.com and book your demo. But as I said at the top, today we're talking research. This was a study that came out in Biomed research International in 2023 and the title of the article, I'll drop the link down in the show notes, is spinal manual therapy for Apple. Adolescent idiopathic scoliosis. We're going to call that AIs. A Systematic Review and Meta Analysis of Randomized Controlled Trials. So adolescent idiopathic scoliosis, it is complex, as with any scoliosis it's three dimensional, which adds to the complexity. It is considered a deformity when one or more segments of the spine, they bend laterally and there's a rotational component. And that usually occurs around puberty, which is why it's called adolescent idiopathic scoliosis. And idiopathic, of course, is that there's no direct cause. It sort of just happens. So idiopathic scoliosis. Adolescent scoliosis accounts for almost 80%. I did not know that 80% of confirmed scoliosis cases. So when people just say the word scoliosis, chances are they're talking about AIs. Adolescent idiopathic scoliosis, it also is the most rapid progress that coincides with adolescent growth spurt, which needs to be adequately managed. So it really rapidly progresses during that adolescent growth spurt. That's why it's so, so important. And I remember back in the day in school, you'd do the kind of bend over and they'd check out what's going on with your spine at the nurse's office one time. I don't know if they still do that or not, but it's a good idea to keep an eye on because when somebody hits that growth spurt, that is when this thing really takes off. So we're gonna talk about that age in those things in just a moment. So, of course, with the word idiopathic, as we talked about earlier, the underlying pathogenesis has not fully been evaluated. We don't really know. But it may be correlated with factors such as genetic components or bone dysplasia, endocrine dysfunction, and postural challenges. So those are sort of the buckets that the researchers have looked at and said it might have something that correlates with this. But there's not just one thing. The challenge with this is that when it becomes severe, and usually that's a Cobb angle of more than 40 degrees. When it's severe, there can be some really big challenges. It can lead to lopsided shoulders, bad posture, thoracic malformation, and, and ultimately can affect cardiopulmonary function and cause nerve damage, which is really what you're trying to ultimately avoid. When they go through surgical intervention, yes, there's a slight aesthetic component of it, but when the Cobb angle gets so great of over 40 degrees, the challenges really become cardiopulmonary issues. And I view that this is not in this paper, but I view that as a long term challenge. It's a decrease in oxygenation over a significant. Over a lifetime can really catch up with you as you age. So that's the crux of it. It's not that you're gonna stop breathing tomorrow, of course, but if there's cardiopulmonary functional impact over as weeks become months, become days, become years, become decades, that's a challenge. So early diagnosis, prevention and treatment are really, really essential. And again, over 40 degrees, surgical treatment is widely accepted as, you know, as being appropriate in that time. Now, with that being said, not every time that you're 40 degrees or more do you have to have surgery again. This is multidimensional. There's a lot of complexity. And if you can function at a good level without pain, without severe deformity, you can obviously avoid surgical intervention, which is what most people are trying to do. Because when you have Harrington rods placed in, and I think as chiropractors, we've all seen images of what that looks like, you really pay the piper. I mean, this is a significant, usually multi level, if not 10 plus levels, multi level surgical fusion, serious trauma, unbelievable changes to biomechanics. It is a big, big deal. Now, in the conservative realm, bracing has been used historically, but it comes with a lot of problems and challenges. One, poor compliance. You know, long term regular treatment, longer hours in braces. It's just something that, you know, it has poor compliance. Clearly it limits the range of motion and can impact, which I did not know this, the development of the shoulder and hip joints as well. This also has psychological challenges, social disorders, additional complications, pressure ulcers, back pain, decreased respiratory function, weird side effect there, which can greatly affect mental health and quality of life. So bracing is not a, you know, end all, be all and it comes with, you know, I just listed them off there. But we've all, again, probably seen patients in our practice that have had or are undergoing long term bracing. It is no joke. I mean, it is a serious, serious thing. So if you can avoid that, that, that would be a great thing. And that's where spinal manipulation and manual therapy come into play and what we'll be talking about over the course of the next few minutes here. But bracing has its own set of challenges. Super limited mobility over a long period of time. You're supposed to be wearing that brace a majority pret, all day, every day for years on end. This is a big time challenge. And I can empathize with the psychological challenges, which are real, the social challenges that come with that, which are real. The fact that it might not fix the problem, quote, unquote, that is real. And think about the disruption to range of motion, to ability from a proprioceptive standpoint, you just have no input to, to pretty much your whole entire thoracic spine for years on end. And the muscle degeneration. I'm super curious. I don't know this. I should look it up in the research, but to me this seems like you could almost proliferate the issue, which I think it might be controversial to say, but man, when you're not getting proprioceptive input, when you're diminishing muscle tone and quality. And I know bracing has helped a lot of people, so I'm not trying to say it's valueless, but, but there are trade offs with it. It is not perfect. So I think that is where, well, I know that's where we look towards manual therapy and say, is there a better way? Is there something that can help that doesn't require ridiculously interventional surgery or bracing which has all of these negative side effects? Thankfully, bracing's conservative by nature, but it doesn't mean it's not without side effects. So manual therapy has been recognized as a potential option. Now let's just define according to the International Federation of Orthopedic Manipulative Physical Therapists. Here's how they define it. I think this is a pretty good definition of manual therapy. Skilled hand movements intended to produce any or all of the following effects, improve tissue extensibility, increase range of motion of the joint complex, mobilize or manipulate soft tissues and joints, induce relaxation, change muscle function, modulate pain, and reduce soft tissue swelling, inflammation or, or movement restriction. I love, I mean that really encapsulates a lot of what we do with the hands on care we provide. Of course that's wider than what we do with spinal manipulation or chiropractic adjustments, but it touches on the holistic nature of manual therapy. And that's quite a laundry list. And it's a good one because those are all really positive effects that can be elicited through manual therapy and that don't require drugs or surgery or bracing. So in this study, this is again like kind of a meta analysis. They were looking at what's out there. At first they saw 105 studies that were confirmed. They whittled that down to four randomized control trials, including 213 patients in the experimental group and 177 in the control group. So these studies were published between 2019 and 2022. So you might say, gosh, you whittled down to four from 100. That's quite whittling down. Correct you know they, if they weren't, it wasn't a randomized controlled trial, if there weren't reviews, opinions, if there wasn't appropriate interventions, all those were exclud. But four trials in the last couple years is pretty good. And that also is fresh research, for lack of a better way to say it. So the treatment of adult idiopathic, excuse me, adolescent idiopathic scoliosis is aimed at stopping the curve, advancing, preventing respiratory dysfunction, relieving pain and improving the aesthetic appearance when possible. So what did they. And they found a few things that you're going to find interesting. A statistically significant difference was found in the Cobb angle in one study, especially with the addition of manual therap. However, here's the challenge with this study. The longest follow up was two months and you need a minimum of 12 months for non operative research according to a lot of the scoliosis guidelines. So super promising. A statistically significant difference found in Cobb angle is a big deal because there are differences and then there are statistically significant differences. Now it doesn't highlight whether it was clinically significant, but the fact that it's statistically significant is a great start. And I just think about that and it's wild to me and I'll take a step back and look at this from a high level. What we can do with our hands through manual therapy can literally impact the structure and function of the spine. I know we almost take that for granted, I believe when we see that all day, every day in our practices. But if you take a step back and think about that, the hands on care you can provide in 10 minutes, 5 minutes, 15 minutes, whatever that visit might be in your practice in terms of length can literally affect the structure and function of the spine and impact somebody's life for the rest of their lives. And somebody that has, you know, advancing scoliosis, that is a huge, huge deal. Imagine being able to avoid bracing. Imagine being able to theoretically in some cases avoid surgical intervention in Harrington rods that extend 10 plus 50% or more of your spine. This is dramatically life changing and it goes beyond low back pain and headache and it goes towards cardiorespiratory function. It goes towards aesthetics which matter, you know, the med spa business, billion dollar business probably trillion dollar business, aesthetics matter as well as the psychological benefits of that as well. So here's a couple things to keep in mind as we talk about this research. Patients, and I didn't know this, patients older than 16 had little growth activity or risk of progression. So this is something I often think of it, quite frankly, with teenagers, you know, 16, 17, 18 years old. But realistically, as they're highlighting here, this is something in early adolescence, we're talking, you know, 10, 11, 12, 13, 14. These are the ages where you really, it's probably more so 12 to 15, 12 to 16. That is really where you want to focus on identifying and providing proactive care before it drops to an advanced state. Because during those years, that is when there's, I guess, for lack of a better say it, that's the highest risk of advancement. That is when you see things go really off the rails. So between the ages of I'm going to loosely bucket it, you know, 10, 11 to up to 16 years old. That is really where you want to make a concerted effort. If there's any inkling of something going on, you, you wanna be as proactive as possible because you're going to be able to make the greatest impact and have the most gains. Which I did not put that together before. I love this research because it did that for me. So it is recommended that manual therapy was proposed only if associated with stabilization exercises and scoliosis specific exercises, which I think. And they're highlighting that in one of these studies here, makes sense to me. You know, clearly you want to also empower the patient to do things at home because as I always think of it, somebody's in your practice for 15 minutes every couple of days. What are they doing the other 23 hours and 45 minutes? Right. So providing exercises, providing postural tips, you know, very ergonomics. These are important things for everybody to take advantage of in a positive way when they're outside the four walls of your practice. Because you can only do so much in a 5 to 15 minute visit. You want to ensure that they're empowered to make great decisions for their overall health and benefit and to enhance the benefits of getting from your care when they're not in your practice. Now, a couple other things I thought were super interesting that I had never seen before, but were highlighted here from previous research. That intervertebral disc height in scoliosis patients was relatively larger than normal. I'd never heard that before. And it was strongly correlated with low muscle strength and reduced spinal axial loading. The longitudinal ligament with insufficient ligament adaptation to mechanical stretch may stop remodeling and growing, an interesting point there, resulting in a scoliotic curve and rotation. And it may also trigger a cytokine mediated cascade toward tissue repair, resulting in scar formation of the ligament. So that bit of science and research there, physiology I had never heard before. I thought it was absolutely fascinating. Such as the 80% of scoliosis cases being adolescent and 16 years old and older being difficult to turn around. So take home message from this study is the, the research that they looked at was as they defined it, low quality. And there weren't enough studies for them to plant their flag and say hey, spinal manipulation and manual therapy is what everybody needs to be doing. However, my take on it was it makes sense. And the early, even though there's not enough and the relatively low quality for what they were looking for, it was still positive to support manual therapy. And when the alternatives are do nothing, wear a brace or have surgery. Now you might not be deciding between those two three things. Excuse me, it's going to be depending upon the angle. But when those three are your choices, do nothing, bracing or surgery. Spinal manipulation and manual therapy are an absolute go to. Now they don't tell the aggregate number of individuals with adolescent scoliosis here, but I'm assuming it's going to be in the hundreds of thousands, if not millions of people. So is there an opportunity for you to help? Yes. Is there a market? Yes. Can you provide manual therapy which as we listed at the top of this has an innumerable practically amount of potential benefits with nearly no harms? Yes. Should you support what you do in your four walls with exercise and ergonomic recommendations? Yes, absolutely. So this study had some nuggets. I'm loving this study. As I said at the top, this is also a study that in my opinion starts and continues the conversation. It doesn't end the conversation, as they say, man, we just need some more research. So any of the researchers out there listening? If you want to do a study on adolescent scoliosis, I'd love to highlight it in the future and I think chiropractors around the world would love to hear about it as well because it certainly seems we've all seen the benefit that we can provide in our practice. So I don't think there's any question what we can do with manual therapy helps individuals with scoliosis. The question is how much and what criteria do we use to make the best decisions possible. So I'm looking forward to that as we continue on. Before we wrap up, I want to say a few words about Zingit. It's time to level up your patient experience with Zyngit. Zingit integrates with your EHR and has helped thousands of chiropractors. With Zyngit, you can expect an average of 23 Google reviews per month and a patient show rate of at least 94%. I love that. Zingit Solutions.com to schedule your demo today hit up Zingit Solutions.com to Schedule your demo today and if you have not picked up a pair of Power Step orthotics, head over there and do so. Pro.powerstep.com sample I'll drop that link down below. These are what I use, what my dad uses. They're developed by a podiatrist over 30 years ago. Love the product. Company supports this podcast. You should support them and they're willing to hook you up with a free sample pair. Why wouldn't you take advantage of that? Pro.powerstep.com sample use the code EBC for evidence based Chiropractor to pick up a free sample pair. Thank you so much for listening to this podcast. If you have not left us a rating or review, I'll ask you to do so. That helps more and more docs find out about this podcast. I hope you have an awesome week in practice and I will talk to you soon.

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