Progressive Infantile Scoliosis Managed With Osteopathic Manipulative Treatment
The Journal of the American Osteopathic Association, September 2017, Vol. 117, 595-599. doi:10.7556/jaoa.2017.114
Infantile idiopathic scoliosis is a compensatory result of cranial and sacral intraosseous dysfunction associated with asymmetric developmental deformation of the occiput, leading to dysfunction of the sphenobasilar synchondrosis. A female infant with progressive infantile idiopathic scoliosis diagnosed at age 12 months (46.9° left scoliotic curve) initially received standard orthopedic care, including casting. The patient presented for osteopathic evaluation at age 14 months, at which time her scoliotic curve was 52°. The patient wore a Risser cast extending from T1-L5 at her first osteopathic manipulative treatment (OMT) visit, which included osteopathic cranial manipulative medicine. Her parents chose to have the cast removed at age 17 months, with a 23° curve remaining. For approximately 12 months, OMT was the only continued, consistent treatment, which occurred once per month. By 28 months of age, radiographs measured 0° of scoliosis. This case demonstrates that OMT can dramatically improve infantile idiopathic scoliosis and prevent its progression.
Scoliosis is classified as congenital, neuromuscular, or idiopathic. Idiopathic scoliosis, the most prevalent type,1 is classified by age: infantile (<3 years), juvenile (3-10 years), and adolescent (11-17 years).1-5 Infantile idiopathic scoliosis (IIS) occurs in only 1% of idiopathic scoliosis cases,2 whereas adolescent idiopathic scoliosis is most prevalent.2,3
Measurement of the rib vertebral angle difference (RVAD) is used to diagnose and predict curve progression in IIS. Serial casting done with the patient receiving general anesthesia is commonly started in patients with greater than a 20° RVAD, as these cases are associated with the less common, progressive type of IIS, whereas RVADs less than 20° are associated with a nonprogressive, resolving curve.2 Serial casting is continued until correction is maintained at 10° or less, at which time full-time bracing is begun.1,2
Although infantile scoliosis is commonly idiopathic, it can result from perinatal causes, such as intrauterine compression,2-8 birth trauma,2,6,7,9-11 or postpartum causes, such as supine positioning2,11 or trauma.10 Infantile idiopathic scoliosis is a compensatory result of cranial and sacral intraosseous dysfunction associated with asymmetric developmental deformation of the occiput, leading to dysfunction of the sphenobasilar synchondrosis (SBS),3,5,6-9,11 called scoliosis capitis.6,9,10
This report documents a case of progressive IIS managed with osteopathic manipulative treatment (OMT) and specifically osteopathic cranial manipulative medicine (OCMM).
Report of Case
The patient was born 6 pounds, 5 ounces, and 19.7 inches at term by uncomplicated cesarean delivery to a gravida 2 para 2 Russian mother.4 The mother had received epidural anesthesia. Apgar scores were 8 and 9 at 1 and 5 minutes. No meconium was passed.
The mother first noticed the abnormal thoracolumbar curve when the patient was aged 6 months. The patient's medical history was noncontributory. Family history was positive for mild asymptomatic idiopathic scoliosis in the mother and maternal grandmother, untreated nonprogressive type scoliosis in the 10-year-old brother, and short-leg syndrome in the father.
Pediatric orthopedic specialists first saw the patient at age 12 months and noted a thoracic deformity, apex to the left, and no other abnormalities. Initial radiographic findings measured a 46.9° RVAD, and initial diagnosis was asymptomatic progressive IIS.
The initial treatment plan of serial casting to the thoracolumbar spine was made, and the patient underwent her first Risser casting with general anesthesia at age 12 months. At 14 months, a radiograph revealed that the RVAD had progressed to 52° (Figure 1), and Risser casting was repeated.
Standing radiograph shows 52° curve in a 14-month-old child before osteopathic manipulative treatment.
The patient presented for osteopathic evaluation for the first time at age 14 months, wearing the Risser cast spanning from T1-L5. The patient's mother had no complaints and reported no symptoms pertinent to the chief complaint of scoliosis in her child. Osteopathic structural examination (OSE) showed diminished cranial rhythmic impulse, left temporal bone locked in internal rotation, right temporal bone held in external rotation, C1 rotated right, left sacral torsion, left pelvis posterior, and right pelvis anterior. Initial osteopathic diagnosis was plagiocephaly, progressive IIS, and somatic dysfunction to head, cervical spine, sacrum, and pelvis. At this first visit, because of the Risser cast, OMT was applied only to the head, cervical spine, sacrum, and pelvis. The primary OCMM techniques used were the primary respiratory method and balanced membranous tension. Monthly OMT visits were recommended (Table).
The second cast was removed at age 17 months, with an RVAD of 40°, the first recorded improvement. The patient returned for her second OMT visit. Repeated radiograph revealed 23° RVAD. The patient underwent a third casting.
The patient's third OMT visit occurred at age 18 months. Three weeks earlier, the third cast was emergently removed because of 2 episodes of respiratory distress secondary to pneumonia. Owing to marked improvements since the start of OMT, the parents, against orthopedic recommendation, did not resume serial casting for their child. The patient was fitted with a thoracolumbosacral orthoses brace intended for continuous use, but the mother was noncompliant.
The patient's fourth OMT visit occurred at age 19 months. A week before the fifth visit, the patient was a passenger in a rear-end motor vehicle accident, and, according to the mother, the patient was not able to walk the day after the accident. The patient was 21 months old at the fifth visit. The radiograph showed a 12° RVAD, which indicated continuous improvement without casting or bracing.
After the fifth OMT visit, the patient continued to be evaluated and treated once per month. Cranial, cervical, L5, sacral, and pelvic OSE findings showed common patterns on subsequent visits, including left torsion or left lateral strain of SBS, C1 rotated right, C2-4 rotated left, sidebent left, L5 rotated left sidebent left, left sacral torsion, and right pelvis anterior. Thoracic OSE findings showed no consistent diagnoses of dysfunction.
At age 28 months, after 11 OMT visits, radiographic findings measured no scoliosis (Figure 2). After this resolution of curve, the patient received OMT 6 to 10 times per year until age 5 years. At that time, treatment continued on a less frequent basis because of the patient's school schedule. Annual radiographic imaging until age 7 years showed that the thoracic spine remained stable at less than 5° RVAD.
Standing radiograph shows no scoliosis in the child at age 28 months, after 12 months of osteopathic manipulative treatment.
In the osteopathic literature,3,5,6-8 IIS is described to result from structural deviation due to asymmetric compression of the developing occiput caused by intrauterine contractions and fetal position.3,5,6-8 The occipital dysfunction results in cranial obliquity and SBS strain.3,5,6-9 In a study of 97 patients with IIS at the Edinburgh Scoliosis Clinic, “plagiocephaly was present in all 97 infants, the ‘recessed’ side agreeing always with the side of the convexity of the curve.”12 This finding suggests an association of plagiocephaly and IIS, as well as supports the long-time documented osteopathic manifestation theory that a compensatory scoliosis capitis results in the occiput sitting asymmetrically on the atlas, leading to the compensatory spinal scoliosis.3,5,6-9
In comparison with standard orthopedic management of IIS, which targets just the secondary cause—compensatory spinal scoliosis—OCMM targets the primary dysfunction. When the primary structural dysfunction is also addressed, the body is capable of self-regulation of the compensatory dysfunctions, a principle tenet of osteopathic medicine; fixing just the secondary problem leaves the risk for recurrence, in this case spinal scoliosis, returning because of the presence of scoliosis capitis.13 This principle explains why OCMM was effective at the first treatment when the patient was in the Risser cast. The OSE findings exemplified a primary dural strain pattern of the SBS and sacrum, resulting in scoliosis capitis, and the thoracic findings demonstrated a changing scoliotic compensatory pattern in response to OMT.14-17 To our knowledge, no cases of progressive IIS in which OCMM played a significant role in the resolution of IIS have been published.
A 2006 randomized clinical trial18 of OMT for infantile postural asymmetry reported that OMT performed once per week for 4 weeks in term infants aged 6 to 12 weeks improved head, cervical, and thoracic asymmetry. The study did not report the specific diagnoses, prognoses, or resolution of disease in the infants.
Limitations of the current case report include the combination of OMT and OCMM with standard orthopedic treatment for 4 months. The scoliotic curvature dramatically improved with dual therapy and continued to significantly improve once orthopedic treatment was curtailed. Although unlikely, given progressive IIS curves tend to worsen, spontaneous resolution cannot be ruled. It is the majority of non-progressive IIS curves that resolve spontaneously. Furthmore, spontaneous resolution is even less likely when the etiology of this patient's progressive IIS was known to be scoliosis capitits, was treated directly, and results were immediate and continuous until resolution. Other confounding factors include the patient's history of a motor vehicle accident, which may have affected her balance and delayed speech development.
Future research should assess the treatment and outcomes of OCMM as the principle therapy in cases of IIS. Then, randomized controlled trials should be conducted to compare OMT and specifically OCMM with standard orthopedic treatment.
A patient with progressive IIS, which was unresponsive to standard orthopedic treatment alone, improved during the course of 11 OMT sessions over 14 months. Osteopathic cranial manipulative medicine directly addressed the key cranial structural component that leads to compensatory spinal scoliosis.
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