Most types of scoliosis are classified as idiopathic scoliosis which means that the reasons for this type of rotational deformity of the spine are as vet unknown. Nevertheless, there are all kinds of assumptions, beliefs and anecdotal reports available in the alternative health community concerning the main cans,: and driving factors. For example, the following factors have been suggested as causes: traumatic events (if birth trauma, then scoliosis is believed to start at the cranial end it sexual trauma, usually at the caudal end); unilateral psoas shortening: nutrition; the Coriolis force (which causes hurricanes and bath lap water to spiral in a counter clockwise direction in the Northern Hemisphere1): visceral tensions (incomplete embryological rotational movement of organs) and psychological problems not facing the world, making yourself -smaller): etc. Yet when applying the usual scientific research standards most of these claims have not been substantiated, and this despite the fact that every year impressive amounts of money and research are devoted to improving our understanding of the causes of this dysfunction.
In preparation for my recent talk on Working with Scoliosis at the Annual Rolfing Conference 2000, I did a MEDLINE search of published scientific research papers on the subject. While most of the papers are still on surgical and measuring techniques, there have also been a few hundred published studies in the last decade which concern the etiology and causative factors of this deformity. I will try to summarize some of the themes and findings here:
.Among identical twins the concordance rare for idiopathic scoliosis is about twice as high as among non identical twins. This is seen as strong evidence for a genetic predisposition, although environmental factors to be involved, too2.
.Chickens whose pineal glands are cut away develop scoliosis with very similar features to that of an idiopathic scoliosis in humans. Since the pineal gland produces only one hormone, melatonin, it has been suggested that melotonin deficiency could be a primary factor for scoliosis in humans (as well as in chickens). In January of this Year a study was published that showed hi fact a lower melotonin serum level in scoliosis patients than in a matched control group.3 Yet just a few months later a more careful study was published, which had been measuring the serum level throughout the whole day; and this study did not show any significant differences in the melotonin level of scoliosis patients compared with others.4 Also, more recent studies with chickens showed that the induced scoliosis after pinealectomy has probably more to do with a secondary lack of serotonin (which has been known to influence general muscle toms).
.Attempts to link idiopathic scoliosis with, changes in genetic collagen morphology, or with zinc or potassium level in the body have tailed.
.No correlation could be found with the position or functioning of visceral organs, either, except that in high degree scoliosis the position of the aorta is changed. Yet this has been shown to be a secondary effect of the scoliosis not related to a primary causative factor.
.Attempts to decrease the degree of scoliosis by cutting the psoas on the suspected “short side” have failed5. This is also consist my own experience, in testing the myofascial length of the iliopsoas in the “Thomas Test” maneuver6. My scoliotic clients scent to have “on average” a similar mvofascial length of the iliopsoas similar to other people.
.Histochemical analysis of the paravertebral muscles has shown no myopathic changes. Flexibility studies of the lumbar spine, shoulder and hip joints showed no significant changes compared to a control group. This finding points to idiopathic scoliosis being an organic rather than a systemic disease.7
.A computer-aided biomechanical three-dimensional osseo ligamentous model of the human thorax was constructed to explore how asymmetric growth of the thorax might initiate spinal lateral curvature and axial rotation as seen in idiopathic scoliosis. In fact, the model showed that slightly larger rills on one side could result both in a side bending convexity towards that side plus an axial rotation of the spine similar to that observed clinically. “The model supports the idea that growth asymmetric could initiate a small scoliosis during adolescence.8
.An anatomical study of muscle biomechanics found that the “spatial displacement of vertebrae in idiopathic scoliosis is not explicable by forces created by the muscles which act upon the spine only (Intrinsic muscles). The trapezius and latissimus muscles are attached to the spinous processes and the upper limb” “The peculiarity of the vertebral anatomy, together with the direction of pull of these muscles, permits an explanation of the biomechanics of the development of ‘idiopathic” scoliosis9.
.A ten-fold higher incidence of scoliosis was found in rhythmic gymnastic trainees (12 %) than in their normal coevals Delay in menarche and generalized joint laxity are common In rhythmic gymnastic trainees. The study observed “a significant physical loading with the persistently repeated asymmetric stress on the growing spine” in these young gymnasts. A “dangerous triad” is attributed for the etiology of this type of idiopathic scoliosis: “generalized joint Laxity, delayed maturity, and asymmetric spinal loading”10.
.In general the morphology of scoliosis clients has fewer mesomorphic features. This seems to be also a predictive factor: if the mesomorphic values are low in the Sheldon typology, the scoliosis has a high probability of increasing with age.
.The multifidus, fibers tend to be more last-twitch than normal on the concave side of the apex. Myofascial release work on the (shortened) concave side tissues yielded significant improvements in one study.
.Trunk rotation against resistance is usually weaker in one direction. A systematic strength training, using a MedX Torso Rotation exercise machine, seemed to improve the degree of scoliosis in a recent stunt11.
.MRI studies have shown a significant proportion of abnormalities in the brain stem area (as well as in the spinal cord) among idiopathic scoliosis clients as compared with other types of spinal asymmetries or with normal people.
.A significant correlation with otolith vestibular dysfunction could be shown.12 Ann interesting newer finding (which needs to be confirmed by others) is that people with hearing problems seem to be ‘immunized’ against idiopathic scoliosis; i.e., idiopathic scoliosis seems to be much more ram among them than among normal people. This is seen as another indication for a strong neural factor in the etiology of scoliosis.
.Previous attempts to show a correlation between handedness and the direction of the primary curve have failed. Yet a newer study looked at the dirt of convexity of the low thoracic spine regardless of the primary curvature. Their result: “the correlation between scoliosis configuration and handedness was statistically significant. This is in contrast to the findings of previous studies, which have considered convexity only, without reference to the configuration of the whole spine. The implication of this finding is that scoliosis is associated with cortical functions.13
This seems to be the general trend in scoliosis research: compared with previous years most of the newer research seems to explore the central nervous system as a primary causative factor. The study by Maguire, et al., on ‘Abnormal Central Processing’ (see discussion about it in this issue of Rolf Lilies) is a typical example of it. It fits very nicely with another study, which I found even more intriguing, and which I will therefore choose for a more detailed description here. The study is called ‘Proprioceptive” Accuracy in Idiopathic Scoliosis and was done by W. Keesen ,and others in the Netherlands.” With the publisher’s permission, let me quote from the original text” and also add soon commentaries from my side.
The article starts with: “Defects in proprioceptive postural control have been linked to the etiology of idiopathic scoliosis”. Actually this ha: been found in several studies ahead since the early 1980s: that postural control -e.g.. walking on a high beam – lends to be less accurate in these people. Also, the amplitude of their ‘postural sway’ – i.e., the balancing movements of the body in standing has been found to be lightly larger than normal)” Yet it was unclear whether that is the result or the cause of the spinal deformation.
The article goes on: “In particular a rearrangement of the internal representation of the body has been proposed in these cases.” Now this sentence caught my personal interest, as lam quite fascinated by the correlation of outer body changes with specific dysfunction in cortical body representation”. In other words, there is sonic evidence that the diminished postural control in these clients does not come front a less accurate motor execution bill from a perceptual weakness based on an inaccurate ‘body image’ in their brain. Rolf Movement Practitioners, Feldenkrais Teachers, and other somatic practitioners invoked with the internal body organization, this is your field!
The researchers then describe the following experiment: 200 patients were asked individually to sit in front of a table. The table had a visible grid consisting of 24 points on its upper surface. Those 24 points corresponded with dome-shaped holes in the undersurface of the table plate form. The experimenter would then place one index, finger (‘target finger’) into one of the holes on the undersurface and asks the person to bring the index linger of the other hand (‘searching finger’) as close as possible to the target finger on the upper surface of the table, without being able to look under the table (see Fig 1).
If you are sitting on a desk right now, try this out yourself. You will find out even without a measuring grid as used in this experiment that the accuracy of your searching finger is not perfect, i.e. it deviates from the position of the target finger by a few millimeters or even more. If you do this a couple a dozen times, you will quite likely find that when your right index finger is the ‘searching finger’ it tends to point too much towards the left, and vice versa. This phenomenon is described as ‘overlap effect’. If you have a chance to compare Your accuracy with that of a child or a teenager, you will also quite likely find that you are slightly better Than they are. ‘I his indicates that proprioception usually improves in life and might therefore he open for further improvement, e.g. through active facilitated learning.
How would you guess the finger accuracy in this test was among the patients with scoliosis? The result of the study by Keesen, et al., was that there was a significant difference in the average accuracy between scoliosis patients and others. In the language of the authors: “In the present study, all inaccurate proprioceptive performance was … established in patients with idiopathic scoliosis.”
Now one could speculate that maybe the spinal asymmetry was the cause of the inaccurate proprioception, rather than the other way around. Yet the study reports that “no correlation could he found between the degree of scoliosis and the magnitude of inaccuracy in our view, it is not likely that the ability to bring both index fingers together is influenced to a great extent by a spinal deformity. If this were the case, we would be al the root of a new adverse effect of scoliosis, as yet unrecognized. However, because the inaccuracy also is observed in subjects with a non progressive spinal asymmetry, which is often found in adolescence, the cybernetic defects in these subjects is more likely to be at the origin of a postural instability, which may, but not always, lead to idiopathic scoliosis.
How can a proprioceptive accuracy lead to a spinal deformation? Let me quote again the author’s explanation: “Hermann et aI18 postulated that…a sensory (proprioceptive) rearrangement or recalibration of the internal representation of the body in space is present,and that a non erect vertebral alignment may be erroneously perceived as straight.” So when standing or moving in the upright position my body makes constant adjustments and oscillations in order to keep organized around a vertical axis, in order not to lose balance. To do so I rely to a large degree on my internal perception of the alignment of my body in space (also called proprioception). If my thorax leans too far forward, for example, or to the right, my body will correct this automatically; i.e without my hawing to pay conscious attention to these adjustments all the time. What happens in people with idiopathic scoliosis is that they perceive and accept their body position as straight, when it is already slightly off center and when other people would continue to adjust and correct their balance. Over tine especially if this happens during the years of most skeletal growth this could load to an uneven usage a id development of the osseo ligamentous and muscular components of the spine and ribcage, such that their habitual off-center position becomes the ‘neutral position’ and a straight position of the spine becomes difficult or strainful.
FIG.1 The experimental setup. The blindfolded subject is seated at the fable. The left index linger (large; finger) is placed in one of eight holes in the undersurface. The subject is then instructed to bring the right irdex finger (searching finger) as close as possible to the target.
Now this reminds me of similar distortions of the internal body representation which influence the outer shape of the body. For example, in anorexia it seems clear that many of these skinny persons feel ‘too fat’ in their internal body perception. And therapeutic experience often shows that unless one succeeds in altering the internal body perception, the success of curative attempts will he limited.
Another similar pattern has been discribed as ‘anterior pelvic shift19 or ‘banana posture by Hans Flury. When standing, these clients have their pelvis shifted (not necessarily tilted) anteriorly in relation to the thorax above. Flury attributes this to a chronic primary shortness’ of the conned ice tissue on the posterior side. Yet in my experience I also find maw clients in which this seems to be purely a ‘postural habit’ without any corresponding chronic tissue shortness as a cause. When lying on the table (on the side or any other position) or when floating in water there is no more banana posture. And when testing the overall myofascial length of the erector spinae according to janda20 (in asking them to bend the head forward and downwards passively In sitting on a chair without changing pelvic position), some of these people bring their tore head even closer towards their knees than their average non banana competitors. In other words, then only stand in such a banana posture not because in their internal perception this feels straight. A temporary shift into a more straight posture by a therapist from the outside feels to them as bent forward’; and even it I ask them to concentrate consciously to carry the thorax snore vertically over the pelvis, as soon as they shift postural control back to the unconscious self regulation of everyday life, they will return to the previous banana posture not because of any tissues pulling them there, but because this feels ‘straight’ in their internal body organization.
Looked at this way; at least some of the cases of idiopathic scoliosis could have started the same way. Except that there it is not the sagittally oriented inaccurate proprioception that is the problem, but the lateral ‘banana deviation’ of the spine which is inaccurately perceived as straight.
Now this is where I suggest that Rolf Movement comes in handy. Try to correct a pure habitual banana posture with myofascial manipulation alone, without any postural education training, and you will most likely find only very limited or short lived results. Yet of treated with the wisdom and various trick, of Rolf Movement towards altering the internal body representation it is often possible to achieve lasting results in as little as one session.
Let me therefore share with you how the research article by Keesen, et al influenced my current work with idiopathic scoliosis.21 Besides myofascial work on the shortened tissues, besides encouraging them to build tip a more healthy tonus in the trunk by an active healthy lifestyle, besides helping them to become ‘a bigger person physically and psychologically, and besides cooperating actively with their other health care providers, including their orthopedic – besides all of this, I involve them now more and more in exercises which facilitate refinement in proprioception.
One way to do so is to use active micro movements of the client m the area of the body that I am working on. With proper coaching, they learn to bring small undulations to even one single rib or vertebra at a time, without any spurious cu-contractions somewhere else. Later, even without my touching them with a hand or elbow, they learn to keep that sensory and motor refinement in sitting and standing.
Another direction is via all kinds of moderated balancing refinements in gravity. I usually start by using Darrel Sachez’ “Tuning Board” in standing, with open eyes, and having them notice their balancing habits plus various alternatives to that, with facilitated finer and finer perceptions. Then, if they are ready, owe can increase the level of complexity and stimulation, e.g. by having them close their eyes, by balancing a small cushion simultaneously on their head, by giving moderated ‘earthquakes’ to the board or gentle perturbations to their body with my hand from the outside, etc. Later they learn to balance, sitting on a large hall without their feet touching the ground and by constantly adjusting their relative upper bud y position to the movements of the ball. Or they learn to squat like a downhill ski racer on Iwo ‘wobble hoards’ (each foot on one half hemisphere platform). Additionally I encourage them to take up inline skating, snowboarding or similar hobby activities between sessions. Since most of the patients who come for scoliosis treatments are teenagers, this is often not that difficult, once a good rapport has been established. Often I give them the choice (I phrase it actually more as a ‘requirement ‘ to accompany my session either by weekly Pilates or Gyrotonics sessions, or by taking up some kind of balancing sports activity like inline skating, etc. Some even start doing both, as these patients often have a high motivation and compliance.
If this sounds like fun and creative playful work’ that is partly true. Yet no solid scoliosis (of 30 degrees Cobb angle and more) will be ‘cured’ by movement work and proprioception enhancement alone. At the most those can be powerful adjuncts for the much-needed mvofascial work. And as much as I don’t like it myself, the use of a corset or even a surgical operation is often indicated in strongly developed cases;22 if their history and situation slow signs of further progression.
1.This seems rather unlikely, as patients in the Southern Hemisphere exhibit the same preference for right-convex thoracic curves in idiopathic scoliosis as those in the Northen Hemisphere.
2.Hartvigsen J. et al: J.Bone Joint Surg. Br.; 82 (2): p.308.
3. Sadat-Ili M., et al: Joint.Bone Spine; 67 (1): p.62-64.
4. Brodner W., et al: J.Bone Joint Surg. Br.; 82 (3): p.399-403.
5.Woodcock B. Scoliosis ? A Practical Approach to Treatment, Standford University Press.
6.Schleip R.:?Lecture Notes one Psoas & Aductors,? Rolf Lines, Nov. 1998.
7.Maffulli N., Ital J: Orthop. Traumatol., 16(1): pp.61-71.
8.Stokes I.A, et al.: J.Biomech.,23(6): pp 589-595.
9.Nudelman W., et al.: Acta Anat., 139(3): pp.220-225.
10.Tanchev P.I.: Spine;25(11): pp.1367-1372.
11.Mooney V.,et al: J.Spinal Disord.,13(2): pp.102-107.
12.Wiener-Vacher S.R.,et al: J.Pediatr.,132(6): pp.1028-1032.
13.Goldberg C.,et al: Spine,15(2): pp.61-64.
14.Keesen W.et al: Spine, 17(2), pp.149-155. The author of this Rolf Lines article took the liberty to bold-mark certain pieces within the quotation, for emphasis.
15.For interested practitioners, I recommend ordering the full text version of
this article via MEDLINE (or ?Paper Chase?) on the internet and/or your library. Or directly for the journal Spine (publisher is Lippincott, Williams and Wilkins (http://www.spinejournal.com) wich is a highly respected scientific journal in the field of manual medicine. Many thanks to the publisher for the permission to quote extensively from this paper and to use the illustration (Fig.1). Copyright for both remains with the publisher.
16.Postural control of scoliotic people is clearly weaker in standing when the subjects are ´sensorially challenged´ as well ? e.g., when the eyes are closed. Yet there is nevertheless a debate as to whether this is also the case in regular standing, as studies have come to different results. Many thanks to the publisher for the permission to quote extensively from this paper and to use the illustration (Fig.1). Copyright for both remains with the publisher.
17.See ?The man who had lost his head? and other articles on my webpage, www.somatics.de
18.Hermann R.,et al:Spine, 10(1),pp: 1-14.
19.Flury,H., Notes on Structural Integration, 1989(1)
20.Janda, V.,Manuelle Muskelfunktionsdiagnostik, Berlin, 1994.
21.More details and working tips are on the audiotape lecture ?Working with Scoliosis ? A Rolfer?s Heaven?.(I.D.No.ROLF 00,024; includes illustrated script) from me; avaible from ?On-Site-Recording Productions, Phone/Fax(510)9850335; e-mail: [email protected]. Plus, the Rolf Institute sells na older video lecture from me on scoliosis, wich does not include these newer research findings, yet is helpful for understanding the three-dimensional biomechanics involved.
22.If progressive, a corset is usually indicateds at 40 degrees Cobb angle, surgery at 60 degrees.
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