SCOLIOSIS : A NEW OSTEOPATHIC APPROACH

The Mechanical Link (in French, Lien Mécanique Ostéopathique or LMO)[1], as we have seen in the previous article, is an osteopathic diagnostic and treatment method that is characterized by the use of three particular techniques.

1. The tension test for a precise diagnosis of all the patient’s osteopathic lesions (concept of total lesion)
2. The inhibitory balance test to establish a hierarchy of priority among the different lesions found (concept of dominant lesions and of primary lesion)
3. The recoil for a precise adjustment of the lesions to be corrected (concept of specific treatment)

These three techniques, which could be termed “gentle tissue structural techniques”, have the advantage of being both efficient and applicable without contraindications to any structure of the human body: bones and articulation, organs, arteries, nerves, etc.

It is entirely possible to exclusively use these three techniques for a complete osteopathic treatment or to - very simply - integrate these techniques to a classical approach to practice.

The subject of this article, scoliosis, presents one of the many clinical applications of the LMO, knowing, of course, that the method is not limited to the treatment of spinal deviations.  Scoliosis illustrates very well the necessity of an approach that is both global (systematic examination) and specific (applied to precise points, generally seldom discussed or not mentioned at all in classical osteopathy).

 

[1] LMO is a concept originally developed in the 70’s and 80’s by Paul Chauffour DO (F) then further developed with the collaboration of Éric Prat DO (F) since the 90’s. Today, thanks to an entire team of dedicated practitioners, it is a world-renowned osteopathic method.

Idiopathic scoliosis[1] is a deviation of the spine, the cause of which is theoretically unknown.  The osteopathic approach to scoliosis that we propose focuses on the search for a possible « primitive osteopathic lesion[2] ». In our experience and from the results obtained in a number of cases, attention must be given to the following critical points[3].

 

1. Torsion of the dome of the cranium.

A horizontal rotation lesion of the dome of the cranium coupled with an asymmetry of the base of the cranium in the opposite direction may result in a torsion mechanism of the vertebral axis[4]. Most often, the calvaria presents a right frontal eminence more anterior than the left[5], possibly associated with right posterior occipital plagiocephaly.  This torsion of the cranial dome may also be accompanied by an asymmetry of the encephalon, the Yakovlevian Torque[6].

 

 

 

 

2. Vestibular imbalance.

Several posturography studies suggest that a dysregulation of the postural vestibular system, even minimal and subclinical, could be involved in the genesis of evolutive scolioses.  From an osteopathic point of view, we may find a positional asymmetry of the petrous parts of the temporal bones in most scolioses[7]. In this case, the specific treatment of the osteopathic lesions of the mastoid process of the temporal bone and the tympanic bone significantly improves the patient’s postural balance.

 

3. Craniocervical lesions.

Articular and particularly intraosseous osteopathic lesions of the different parts of the craniocervical junction constitute an essential, albeit unsuspected, cause of numerous scolioses.  In the case of a right thoracic scoliosis, we may describe the following fundamental pattern: a right anterior and inferior occiput (in relation to the odontoid process[8]), a right translation of the atlas (with or without rotation) and a left intraosseous torsion of the axis.

Along with the temporal bone and the craniocervical junction, the bones of the face must also be considered.  The fact that practically all our young patients presenting with scoliosis also have dental braces clearly illustrates how the asymmetry in growth affects the cranium as well as the spine.  With the potential risk that, in the absence of osteopathic care, the corrections that orthodontic treatment imposes to the maxillofacial area induce, by compensation, an accentuation of the scoliosis.

 

4. Spinal torsion.

Spinal curvature in the frontal plane presents at both of its extremities an end-vertebra (the most inclined) and at its apex an apical vertebra (the most lateral).  Scoliosis is characterized by a rotation of the vertebrae which is maximal in the apical zone and results in the appearance of gibbosity (rib protrusion) at the thoracic level on the side convex to the curvature.  It is important here to make a clear distinction between two different mechanisms: vertebral rotation and torsion.

       - Axial rotation of the vertebra.

The apical vertebra is subjected to a rotation movement which results in the vertebral body facing the convex side. The spinous process of the vertebra then logically deviates towards the concave side.

       - Intraosseous torsion of the vertebra.

The apical vertebra is subjected to a movement of torsion with the vertebral body facing the convex side and the spinous process turning to the same (convex) side.  According to some authors, this would be a « slippage » of the vertebra which, beyond a certain degree of rotation, would distort into torsion.  According to others, it would be a growth asymmetry of the neurocentral cartilage with early closing on the convex side.  Growth which continues on the concave side would then result in a longer pedicle (concave side) and would push the vertebra to deform into torsion[9].

Differential diagnosis between axial rotation and torsion is performed through analytic tests:

- in vertebral rotation, the spinous process is pointing to the side of the concavity,

- in vertebral torsion, the spinous process is pointing to the side of the convexity.

Treatment of the thoracic vertebral torsion using the recoil is performed with a point of contact on the side of the spinous process towards the convexity and a counter-pressure applied to the posterior tubercle of the corresponding rib.

 

5. Rib distortion.

Our reflexion on the possible role of an intraosseous lesion of the rib in the genesis of dysmorphoses of the thorax is based on several observations.

The gibbosity characterizing the scoliosis is not simply a rotation of the hemithorax but also a growth asymmetry: the rib on the convex side is longer by 1 to 2 cm than its counterpart on concave side[10].

The rib on the convex side is always more rigid than the one on the concave side and presents a positive compression test (lesion of the intraosseous line of force).

The correction of the line of force of a rib has, on several occasions, resulted in a significant decrease in the Cobb's angle (objectified by radiographic measurement of the scoliosis before and after treatment).

On the side of the thoracic gibbosity, one must also consider two commonly associated osteopathic lesions: the diastasis of the apex of the scapula (scapula alata) and tension of the corresponding intercostal nerve.

 

6. Fixation of the diaphragm.

Asymmetrical fixation of the diaphragm (crura, domes or phrenic centre) often accompany idiopathic scoliosis. The key point of the diaphragm located in the 7th intercostal space[11], incidentally almost always presents a positive test on the side of the thoracic gibbosity. It must be noted that, although they may be common, fixations of the diaphragm seldom prove to be primary to the scoliosis. Equilibration of the diaphragm however remains relevant in order to finalize the osteopathic treatment and promote proper integration of the corrections that have been performed.

 

7. Intraosseous coxal torsion.

The coxal bone is a flat bone comprised of the delayed fusion of three bones (the ilium, the ischium and the pubic bone), the junction of which (triradiate cartilage) is found at the acetabulum.  Closing of the triradiate cartilage thus occurs belatedly, after 20 years of age.  Before puberty, the coxal bone is therefore particularly exposed to intraosseous lesions between its three components[12]. Coxal distortion may then become the starting point of some scolioses, including those with a major lumbar or thoracolumbar curvature.  These coxal intraosseous lesions cannot be resolved using articular techniques (sacroiliac manipulations); they require specific treatment[13].

 

8. The filum terminale.

Excessive tension on the filum terminale may induce increased traction to the spinal cord and, during the growth period, accentuate vertebral curvatures in the frontal plane[14] with a reduction of thoracic kyphosis in the sagittal plane.  Our personal statistics show a filum terminale that is too tense and/or deviated in about 30% of idiopathic scolioses.  Albeit not necessarily dominant, an articular or intraosseous lesion of the coccyx often accompanies that of the filum terminale.

 

9. Leg length difference.

At this point we deviate from the stricto sensu topic of idiopathic scoliosis to discuss scolioses that present with an imbalance of the pelvis as a result of a difference in leg length.  Here, the key to treatment resides in the early testing of a difference in leg length and regular osteopathic care of young children before puberty[15].

 

The osteopathic treatment of scoliosis that we propose applies to all age groups.

In babies, one must pay great attention to asymmetries of the cranium (plagiocephaly, torticollis) and of the pelvis as well as to a « comma shaped » position of the body. These asymmetries, if they persist, may evolve into scoliosis.

In children, we must insist not only on screening for scoliosis but also on the importance of preventative osteopathic care.  In the beginning of a scoliosis, early treatment prior to puberty will always yield the best possibilities in terms of results. 

In adults, one must not underestimate the risks of degradation of a scoliosis where the lumbar spine is evolving towards kyphosis and rotation dislocation. Regular osteopathic care re-equilibrates the spine (decreasing the deviation of the occipital axis[16]), stabilises the scoliosis and gives relief to the patient[17].

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Osteopathic treatment:

 

Inferior R mastoid

Inferior R tympanic bone

C1 posterior L

C0-C2 R

… and miscellaneous others

 

6 consultations

over 2 years

 

 

 

 

 

 

07/03/2016

Boy, 12 you

 

Scoliosis:

Thoracic R 12,8°

Lombar L 11,2

 

History:

forceps delivery

 

Symptomatology:

orthodontia

low back pain

heartburn

15/03/2018

Boy, 14 yoa

 

Corrected scoliosis

 

No more low back pain

No more heartburn

 

 

To conclude, let us reiterate that the factors responsible for scoliosis may be multiple and variable from patient to patient.  The osteopathic approach to scoliosis always requires in each case a detailed general examination and a hierarchised specific treatment.  Furthermore, the osteopath must never work in isolation but rather, in close collaboration with other participants in physical and orthopaedic medicine.

 

 

 

[1] Also called primitive (primary) or essential scoliosis.

[2] In which case, the scoliosis is no longer primitive (primary)!

[3] This list of key points is not exhaustive. Other osteopathic lesions, such as a lesion of the arterial ligament, the aorta and certain visceral fixations should also be mentioned here.

[4] We have noticed this phenomenon in the case of severe juvenile scoliosis where our intervention was pivotal to the outcome (the different orthopaedic corsets/braces had given no results prior to the first osteopathic consultation).

[5] In cranial osteopathy, this horizontal torsion of the cranial dome unfortunately goes unnoticed since it is outside the scope of classically described sphenobasilar dysfunctions.

[6] The differential diagnosis between cranial torsion and torque of the encephalon requires a very specific inhibitory balance test.

[7] In the most common case, thoracic scoliosis with right convexity, we usually find an inferior left mastoid compared to the right with an asymmetrical torsion between the right and left tympanic parts of the temporal bones.

[8] We are not referring to the C0-C1 articulation, but rather, to the alignment between the occiput and the apex of the odontoid process (C0-C2 junction).

[9] In every case, regardless of the cause of the vertebral torsion, the osteopathic approach remains the same.

[10] This fact may be verified with a simple measuring tape.

[11] Neuromuscular point corresponding to the acupuncture point 46 Bladder (Ge Guan, door to the diaphragm).

[12] These coxal intraossous lesions may be acquired before birth (intrauterine malposition) or during childhood (trauma, falling on the buttocks).

[13] This is one of the reasons why one must be able to properly differentiate between, for example, an articular anterior ilium (in relation to the sacrum) and an intraosseous anterior ilium (in relation to the ischium or the pubis).  To correct intraosseous lesions of the coxal bone using the recoil, the points of contact on the ilium, ischium or pubic bone are determined through specific tests.

[14] Just like a string that is too tight will increase the curvature of an arc.

[15] This topic alone could be the subject of an entire article. In the presence of a leg length difference and a varus/valgus deviation in a child, the osteopathic treatment consists of regulating the growth of the femur and the tibia by neutralizing lesions of intraosseous lines of force, while stimulating the growth cartilage and normalizing tension on peripheral nerves.

[16] The occipital axis is defined as the vertical line passing through the spinous process of C7 and the intergluteal cleft.  A deviation of the occipital axis results in a lateral imbalance of the superior block (head and thoracic spine) in relation to the inferior block (lumbar spine and pelvis).  In our experience, these « off-centred scolioses » present in adults a risk of aggravation towards degenerative scoliosis.

[17] Many patients suffering from severe scoliosis were able to avoid surgery, as a result of the osteopathic treatment proposed in this article.