Adolescent Idiopathic Scoliosis: A New Approach
It is proposed that Adolescent Idiopathic Scoliosis (AIS) is a condition created by several environmental factors including emotional stress, and that spinal fusion surgery can be avoided. Evidence is presented that unresolved physical and emotional stress can cause unbalanced tensions in the fascia and growing muscles that gradually deform the spinal column.
Introduction
This article is a result of a personal journey to understand the causes of AIS. My wish is for parents to understand scoliosis better, and for the medical community to look for methods other than bracing and spinal fusion for its treatment and possible prevention.
This article suggests a hypothesis as to why AIS occurs and proposes ways to avoid spinal fusion surgery based on that understanding.
My experience with Idiopathic Scoliosis began when I was diagnosed with it at the age of 9 in a regular check-up at school. I later underwent a spinal fusion surgery at the age of 17 and have been living in a “pain management mode” ever since. (I am sure most scoliosis patients would understand what that means). For the following 17 years, pain has been a constant part of my life as well as other different forms of anxiety that I later discovered were related to PTSD induced from the spinal fusion surgery that I underwent.
Since my surgery I have tried many different treatment methods to ease the discomfort, pain and other symptoms associated with my scoliosis. While some were more successful than others, improvement only commenced when I started looking for the origin of my scoliosis.
After meeting and interviewing many different scoliosis patients, as well as therapists using different methods of treatment, I feel I have now enough information to share my understanding of scoliosis, and to suggest ways to treat it in order to prevent it from progressing and perhaps avoiding surgery altogether. In addition, it may help people with scoliosis alleviate the pain and discomfort that I have undergone.
Thanks to the approach I am sharing with you in this article I have decided to take the metal implants out of my spine after 19 years, and nowadays, 2 months post op. My body feels better than ever. Many things changed for the better thanks to the removal of the rods, lung capacity, sleeping, breathing and digestion became so much better.
This article is not intended as a substitute for medical advice, but rather as a means to share my own thoughts and experiences. Perhaps the suggestions here can help others to try a similar method of preventative treatment and obtain a better understanding of AIS.
I believe that with the connectivity of the internet, scoliosis patients can find each other more easily, and with the power of community wisdom, we will be able to understand more about the causes and treatment of AIS. It is hoped that it will help others to avoid surgery and manage scoliosis to prevent it from becoming a severe problem.
What is Scoliosis?
Adolescent Idiopathic Scoliosis is a three-dimensional, generally lateral curvature and rotation of the spine and trunk that occurs during puberty (Fig.1A). It affects approximately 1–4% of the population with varying degrees of severity (Cheng et al., 2015). A curve is defined as scoliotic when the so-called Cobb angle of curvature is greater than 10º. It is measured in the coronal plane at the intersection between a line drawn parallel from the surface of the top vertebra in the spinal curve and a line drawn from the lower surface of the bottom vertebra in the curve (Cheng et al., 2015). A gravity-induced torque has been proposed as the cause of the rotation once the spine has developed a lateral curve (Adam et al., 2008). The origin and cause of AIS still remains unknown but it is generally accepted that it is multifactorial (Machida, 1999), in contrast with other kinds of congenital and neuromuscular scoliosis (Cheng et al., 2015; Allan and Schwabe, 2013; Konieczny et al., 2013).
There is evidence for a genetic component in AIS. It has been known for some time that AIS is, to some extent, a familial condition that it is expressed through either dominant or multiple gene inheritance (Wynn-Davies, 1968). If both parents have idiopathic scoliosis, then the probability of their children have it is some 50 times that of the general population (MacEwen and Cowell, 1970; Lonstein, 1994). This could express itself as a connective tissue disorder (Stehbens, 2003) or by differences in the growth rates between the spinal cord and the spinal column (Roth, 1968; Porter, 2001; Yang et al., 2009). Scoliosis is best thought of having its origin from many causes and is the result of imbalanced mechanical stresses on the spine. The progressive spinal deformation that is observed in scoliosis is the cumulative result of long-standing asymmetrical stresses on the growing spine (Stehbens, 2003; Adam et al., 2008).
One method of treatment for AIS is the use of stiff plastic braces that fit around the torso (Fayssoux et al., 2009). They do not reverse the scoliosis, but prevent the spinal curvature from worsening and so can prevent the need for surgery (Weinstein et al., 2013). Their use is somewhat controversial, there being side-effects such as skin irritation, body pain, physical limitations, anxiety, and depression (Kuznia et al., 2020). Nonetheless they find their use in those cases where the patient rejects any surgical alternative for curves above 45º (Lusini et al., 2014).
Some 38,000 patients in the USA undergo spinal fusion surgery every year because of AIS (American Assoc. Neurological Surgeons, 2007; Agulnick, 2017) The operation to straighten, or partially straighten the spine involves some spinal fusion that irreversibly damages the tissues and bones of the spine (Imrie et al. 2011). It is a painful and high-risk operation, and in some cases further surgery is required. In addition to the risks of undergoing large scale invasive surgery, there are symptoms of stress and postoperative pain (Rullander et al., 2016). A recent study has found that one-fifth of the patients who underwent spinal fusion develop PTSD symptoms (Hart et al., 2013).
The Scoliosis Enigma
At present, the method of managing AIS consists of rigid braces to prevent the scoliosis from progressing and invasive surgery when the scoliosis curvature becomes too severe. These methods haven’t changed substantially over the past decades, despite much progress in the medical methodology. In fact, the current ways of dealing with scoliosis seem to resemble working with wrought iron; using force to shape the spine into a desired shape and position.
The body has its own, complex compensatory mechanisms to maintain posture and balance known as proprioception (Deliagina et al., 2012). People with scoliosis are usually healthy. I was sporty as a child, and I have met other patients who were dancers or athletes as they developed idiopathic scoliosis.
What if AIS is actually a mechanism of natural response in which the spine is doing what it is designed to do — to adopt a shape or form that provides a structurally balanced condition? That whatever shape the spine adopts, it is a result of what it is supposed to do by nature — to provide the structural support and balance necessary in order to maintain an upright posture. Perhaps the scoliotic curvature is merely a symptom of a problem in a different part of the body? Perhaps the deformation and twisting of the spine is the first visible and measurable symptom in a chain of events that began before the scoliosis became visible? In order to heal or prevent scoliosis we need to look at the possible origin of the chain of events that caused the spine to deform.
A different perspective
Adolescent Idiopathic Scoliosis is a condition that develops at different rates over the years of growth. In fact, there is a correlation between a patient’s growth rate and the speed of the spinal curve progression (Buscher et al. 2010).
Since AIS is related to growth, this suggests that there is a constant force causing the curvature to deviate as a result of the lack of equilibrium in the overall structure and balance of forces in the body. This unbalanced state would not be easily noticeable or affect the day to day functioning of an individual, but over the years of growth, it will slowly force a change in the structure of the spine, just as a tree would bend from a constant wind. If the origin of this force can be found and put back into balance, the spine may have the conditions to correct itself or at least stop the spinal curvature from worsening.
The spine is normally a flexible and curved structure. It supports and is supported by most of the major muscles in the body. The curvature of the lumbar spine for example, brings the centre of gravity over the pelvis so that body can stand upright and balance the strong forces that are necessary for a correct posture. That different cultures have developed some form of skeletal deformity as part of their traditions, such as neck rings and leg bindings, shows that the body can adapt to circumstances forced upon it. The ability to straighten teeth demonstrates that the body can change its structure if a constant force is applied (Roye et al., 2020).
Just as bones grow and are shaped by the tensions and pressures that they are subjected to, it can also be assumed that the internal structures of the body are also flexible depending on the internal pressures inside the body (Levin at al., 2017). Over time, unbalanced tensions in the muscles and fibrous connective tissues could cause changes in the internal positioning of organs in the body, and in the same way, affect the curvature of the spine.
If one side of the body has more resistance to deformation than the other, or if antagonistic muscle pairs are not balanced or if a certain muscle is overly tense compared to its lateral pair, then over time, the muscles on the other side of the body will have to compensate. The bones will then adjust their shape and position to balance the stronger side.
In Fig. 2 we can see that the spine is doing exactly what it is designed to do; reposition itself in the conformation that will maintain a balance between the forces acting upon it.
These ideas have already discussed in the Functional Matrix hypothesis as well as by Davis’ and Wolff’s laws regarding bones and soft tissue growth (Moss, 1997a). In particular, the principle that function will define structure rather than genetics (Moss, 1997b, c; Esteve-Altava and Rasskin-Gutman, 2014; Wolff, 2010).
The idea that scoliosis is caused by asymmetric muscle tightness was first suggested by Nicholas Andry in 18th century who coined the term ‘Orthopaedics’ from the words “straight” (orthos) and “child” (pais) (LeVay, 1990). Andry fostered the theory of “convulsive muscular contraction” as the cause of spinal deformity. He stated, “It is well worth while to remark that the crookedness of the spine does not always proceed from a fault of the spine itself, but is sometimes owing to muscles of the forepart of the body being too short, whereby the spine is rendered crooked, just in the same manner as a bow is made more crooked by tying its cord tighter.” Andry used rest, suspension, postural approaches, and padded corsets in his treatment of scoliosis.
Origins of muscle tension
What Andry did not explain however, was the cause of the asymmetric muscle tightness, and how it deformed the spine. There are many possible causes of asymmetric muscle tension including injury, sports, overuse of one side of the body, neurological disorders, birth defects, a problem with a specific organ, emotional stress and so on. This is the reason why scoliosis is still considered idiopathic. There are simply too many possible causes to establish a reproducible regime in order to generate statistical data. Furthermore, almost every scoliosis case is unique, the curve never looks exactly the same because each individual has their own set of circumstances that caused the imbalance to manifest itself.
An interesting development over the past two or three decades has been the revival of interest in the importance of the fibrous connective tissue known as fascia in musculoskeletal development (Stecco and Schleip, 2016; Adstrum et al., 2017; Stecco et al., 2018), and its role in chronic stress (Schmitter et al., 2010).
Fascia is not an inert structural component of the body, but forms a network throughout the body playing a role in proprioception, pain perception and to mechanically connect the muscles and transmit forces (Wilke et al., 2018). The fascia are well innervated with mechanoreceptors and free nerve endings (Yahia et al., 1992) and are rich in contractile cells so much so that the muscles and fascia can be considered to act as a myofascial unit (Stecco et al., 2009). The muscles of the body are linked by the fascia forming the so-called myofascial chains that extend the length and breadth of the body and can transmit mechanical forces of stress and strain (Wilke et al., 2016).
It is these myofascial chains that stabilize the lumbar vertebrae on the sacral base without which the lumbar spine would be incapable of bearing the normal loads it has to carry (Willard et al., 2012). It has been suggested that these chains can provide new methods for understanding referred pain and a rationale for the developments of more holistic treatments (Langevin, 2006).
Most people nowadays hold some form of chronic muscle tension in parts of their body. For example, it is estimated that 16% of the population in Europe suffer from migraine (Olesen et al., 2009). It has been proposed that migraine attacks have their origin in myofascial trigger points that are hyperirritable regions which develop in skeletal muscle (Do et al., 2018). In fact, the existence of unbalanced stress as such is common to almost everyone. Statistically, some 70% of people have some significant form of spinal deformity (Schwab et al. 2005). Yet why do some develop a significant spinal deformation while others do not?
The myofibroblasts present in tissue fascia are capable of long-term tissue contractions that can cause tissue remodelling (Hintz, 2013). Their incremental minute cellular contractions are strong enough to generate tissue contractures of ~1 cm per month (Follonier Castella et al., 2010; Schleip et al., 2019). Fascial contractility may be strong and persistent enough to affect the spine continuously over long periods of time from several days to months (Schleip and Klinger, 2019).
The link between emotions and the physiological response is well documented (Damasio and Carvalho 2013; Russell 2003). The brain can generate sensorimotor activation patterns that can change the state of the individual (Toivonen et al. 2012). Suppressed emotions stored as embodied memories can manifest themselves as overly tense fascia and over time create a chronic contraction in the area relative to the specific emotion being suppressed (Nummenmaa, 2018; Iani 2019). It is proposed that these activation patterns working through the fascia generate tensions in the muscles over long periods of time. When they are spread in a certain configuration and intensity (Fig 3.), the spine can change its orientation and scoliosis develops. This will be especially critical during periods of emotional stress and extensive growth as occurs during adolescence.
Irritation of the fascia can trigger a number of both local and global responses, such as connective tissue remodelling, inflammation, nervous system sensitization, eventually followed by an adaptive response of the whole organism (Langevin and Sherman, 2007). Under certain dysfunctional conditions, a neuro-fascial interaction may be responsible for the setting of a local tissue “memory” or peripheral sensitisation followed by a corresponding structural change (Tozzi, 2014).
Unresolved emotions during childhood can be internalized and stored as trauma in the body (Ruchkin and Schwab-Stone, 2014). The somatization of trauma amongst children and adolescents is complex and can be seen in children who suffer from some kind of emotional distress in general (Kealy et al., 2018; Luoni et al., 2018; Finn et al., 2018), and who survive cancer in particular (Erickson and Steiner, 1999). Children that grow up in an environment of high emotional stress and who are not supported to express and resolve those emotions, will store those emotions as hypertension in the fascia. The body stores these memories as myofascial trigger points in the fascicular tissue, in different locations according to the type of emotion. These fascicular contractions can affect the normal or pathological function of tissues and organs (Langevin, 2006), or appear as structural tensions that can lead to scoliotic deformations (Whyte Ferguson, 2014).
Anxiety disorders are the most common mental health disorders of childhood and adolescence. affecting almost a third of the adolescent population in the USA (Merikangas et al., 2010). Low back pain has been associated with psychosocial stress (Erne and Elfering, 2011), and unexplained chest pains with depression and impaired emotional and social functioning (Eliacik et al., 2019). Anxiety and depression have an effect on kyphosis (Moslehi et al., 2011), and psychological distress in AIS patients have been shown to play an important role in the occurrence of back pain (Makino et al., 2019). Females statistically tend to be more sensitive emotionally than males, and therefore the greater the sensitivity and the amount of stress the body has to deal with (Chen et al., 2018).
The primary age for the onset of scoliosis is 10–15 years old, occurring equally among both sexes. However, females are eight times more likely to progress to a curve magnitude that requires treatment (Raggio, 2006; National Scoliosis Foundation, 2020). An explanation for this is that the female spine grows more than the male spine from 9 to 13 years of age (Taylor and Twomey, 1984). Throughout the growing period to maturity, the transverse diameter of the thoracic and lumbar vertebrae increase more in males than in females, and this horizontal growth is accompanied by increased muscle bulk and strength that occurs during male puberty (Feik and Storey, 1983; Twomey et al. 1983). The female spine will tend therefore to be longer, and more slender at least in the early stages. It will therefore be more likely to deform, as AIS is characterized by smaller vertebral cross-sectional area and taller intervertebral disc heights (Schultz and Cisewski,1978; Ponrartana et al., 2016).
An explanation for the prevalence of severe scoliosis amongst girls is that they enter their skeletal adolescent growth spurt with immature postural mechanisms. If they have a predisposition to develop a scoliosis curve, then the spine will deform. This is seen in the prevalence for young female ballet dancers (Warren et al., 1986) and rhythmic gymnasts (Tanchev et al., 2000) to develop scoliosis and fractures. In fact, adolescent girl ballet dancers are up to twelve times more likely to develop scoliosis than non-dancers of their age (Longworth et al., 2014).
In contrast, boys enter their adolescent growth spurt with more mature postural mechanisms so they are relatively more protected from developing a scoliosis curve (Nachemson, 1966). Other research has found that during and after the growth spurt the spines of girls are more posteriorly inclined and therefore have more rotational freedom compared to boys at the same stage of development. It also explains why the initiation and progression of AIS is more common in girls around puberty (Schlösser et al., 2015; Sanders et al., 2006).
Another theory for the prevalence in girls over boys is based on the function of leptin, known as the “appetite suppression” hormone. Leptin has far-reaching effects on the human body. It has been implicated in asthma, cardiovascular disease, and rheumatoid arthritis. In mice, leptin affects bone growth acting via the sympathetic nervous system, and girls with AIS have been found to have higher sympathetic functions and to be thinner. Females are known to respond very differently to leptin in general, and so the non-genetic component of AIS may be related to leptin levels (Burwell et al., 2009).
How to treat Adolescent Idiopathic Scoliosis?
It is the basis of the theory proposed here, that scoliosis is misunderstood and is wrongly categorised in western medicine if not in its origin, then in its progression. The critical influence of the fascia in the support and shape of the spine, and the effects that emotions and physical activities have on the muscles (Pleuss et al., 2009) and fascia (Bordoni and Marelli, 2017), suggests that AIS is not an orthopaedic problem per se, but has psychogenic and environmental origins. It is therefore important to understand that AIS took a long time to form and will take time and effort to correct. The earlier it is detected, the better are the chances of reversing it.
Fortunately, AIS is easy to detect at an early stage. During a child’s growth spurt, the signs of idiopathic scoliosis often become more noticeable. These include uneven shoulders, one shoulder blade protruding more than the other, ribs more prominent on one side, uneven waistline and a difference in hip height (Boston Children’s Hospital, 2020). Uneven tension of the muscles on the back of the child can be an early indicator of developing scoliosis. If the child rests on the stomach and the area around the left kidney feels stiffer than the right kidney, or if the muscular tension in the upper back is different from side to side, then that could be an early sign of developing scoliosis. The Cox sign is an early diagnostic test that will detect scoliosis before the appearance of the spinal curve (Janzen and Woggan, 2020).
It is important to remember at this stage that AIS is regarded as having both a postural and a structural component. The non-structural element is the result of postural imbalance that occurs because of pain, muscle spasms or other factors, whereas structural scoliosis is seen as being genetically based and will be unaffected by environmental influences as it is an inherent abnormality in the vertebral column or its supporting mechanisms (Hawes and O’Brien, 2006). However, it has been found that over time postural scoliosis can become structural if the causes are not identified and corrected (Ogilvie, 1995).
A simple test, known as the Adam’s forward bend test will detect an abnormal curvature of the spine. The child bends forward from the waist, hangs their arms loosely in front of them, and reaches for the floor. If your child has a structural scoliosis, one side of their rib cage will be more prominent than the other because of the rotation of the spinal vertebrae. With a purely postural scoliosis the back will appear to be normal (Physiopedia, 2020).
The possibility of a genetic component to AIS means that parents should screen their children to detect it as early as possible. In the event that your child has been diagnosed with AIS, the most important action you can take is to prevent the scoliosis from progressing. You therefore need to proceed in three different ways:
A. Relieving the stress suppression mechanism
To identify if there is emotional stress and limiting it if possible, by helping the child to process the emotion, instead of suppressing it.
The main cause of childhood stress is the relationships within the family. This may be difficult to accept if you are a parent of a child with AIS and you are already doing the best you can. Perhaps you may be doing something to the child that you are unaware of as yet that is causing excessive stress. This can be related to multi-generational trauma that you inherited from your parents (Guided Pathways Support, 2020). As AIS is considered to be in part genetic, it suggests that multi-generational trauma can contribute to AIS.
B. Softening the fascial tissues storing the suppressed emotion
Some of the contractions in the fascia contributing to the form of scoliosis may be from a different source than emotional suppression, such as blunt trauma from a car accident or a strong fall in which an organ or vertebra may be forced out of alignment or position and cause a chain of compensations in the fascia as a result. Myofascial release treatments serve to release the trigger points and to soften the tight tissues pulling the spine (Whyte Ferguson, 2017).
The suggested techniques for relieving stress are: hands on Cranio-Sacral Osteopathy which is extremely effective in identifying the root cause of fascial contraction and releasing it. Yin-yoga, Rolfing, as well as massages that the child finds agreeable. For choosing the right therapist I would recommend those who work with the concept of myofascial trains (Myers, 1997; Wilke et al., 2016; Wilke et al., 2018).
Just as with people who practice yoga for the first time, opening the fascial tissue, can cause deep emotions to surface as the emotional tension is processed and released, and the fascia becomes softer and more flexible.
The right kind of touch can be a key in relieving stress, but if it is not the right one, it can cause stress. It is best to check with your child what makes them feel comfortable and at ease. The principle is to constantly promote the feeling of safety and comfort of the child with their body.
The fascia opens up the easiest when the body feels safe. Therefore, any environment or activity that promotes relaxation is extremely helpful in supporting the process.
C. Strengthening the core muscles to come back to balance.
It is important to use restorative yoga, physiotherapy, hydrotherapy, and posture experts to examine the body. It is essential to strengthen the muscles only when they are in alignment, otherwise the tendency for the body would be to tilt to the stronger side. The aim is not to grow stronger, but to achieve equal strength and alignment between the left and right sides of the body (Fishman et al., 2014).
The body is capable of making adjustments. In cases where spinal corrections have been made to the dorsal spine, the body was capable of correcting the curve in the lumbar spine (Imrie et al. 2001; Chang et al., 2007; Patel et al., 2008; Whyte Ferguson, 2017).
Proposal for a pilot study
If girls taking ballet lessons or taking rhythmic gymnastics classes are indeed susceptible to developing scoliosis, then I would suggest the Cox test be included as part of the curriculum in order to detect and document any changes to their posture. This would be a preliminary trial for a larger survey of children, particularly young girls, to test the utility of early detection of AIS. The appropriate treatment methods as described earlier would then be applied in consultation with parents and medical authorities.
Conclusion
A summary of the points raised in this essay are summarized graphically below:
The inevitable consequence of spinal fusion is that it creates tensions in the soft tissues. Therefore, even if you undergo spinal fusion, the actual pain and chronic tension of the muscles can simply get worse. The scoliosis of the spine will stop increasing, but the original cause of the scoliosis will still remain in the body. The body will lose its flexibility further limiting circulation and pushing the problem to other parts of the body.
I hope that this essay into the cause of scoliosis will encourage a different way of treating AIS other than braces and surgery.
If you find this information useful, please let me know. If you have anything to contribute to this subject, or if you find any errors or have suggestions how to improve this article, I will be glad to hear from you here: healing.scoliosis@gmail.com
Much love and gratitude to my father, Philip who helped me in editing this article and all my friends, colleagues and AIS patients who contributed from their time to answer the many questions I had for them.
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