Some Considerations for Manual Treatment of Scoliosis, with particular reference to the thoracic spine

Notes made from a recording of the presentation made at the 2011 Soft Tissue Therapy Conference, Sydney.
©Colin Rossie, 2011. Not to be reproduced in any form without the express permission of Colin Rossie.
Contact:integratedbody@internode.on.net

There is much clinical anecdote about the effectiveness of manual treatment of scoliosis but minimal hard evidence or scientific research to validate manual therapy approaches.

Over the years the treatment of scoliosis by manual methods has received great attention in medical literature. From its inception in 1955 until the late 1980s, articles about the treatment of scoliosis often featured in the Australian Physiotherapists Association Journal. Individual physios still work with scoliosis, but exercise and manual therapy for scoliosis are now out of favour in physiotherapy. Recent physiotherapy journals and publications have become silent on the issue (with the possible exception of Josephine Key's and Shirley Sharmann's books.)

Many skilled Structural Integration practitioners offer courses on the manual treatment of scoliosis: Linda McClure, Robert Schleip, Til Luchau and Erik Dalton to name a few.

Various modalities, such as Alexander Technique, Orthobionomy, Visceral Manipulation, Onsen technique, Rolfing, Hellerwork and other forms of Structural Integration have protocols for working with scoliosis. In addition, books and DVDs on subjects like Yoga for Scoliosis and Pilates for Scoliosis have recently become big sellers on Amazon.

There has been a recent increase in journal articles discussing the manual therapy treatment of scoliosis, but still little solid research discussing methodologies or protocols or their effectiveness.

The Clinical Evidence Base

So …what does the current scientific evidence imply for manual treatment of scoliosis?

There have been two major recent systematic reviews discussing manual therapy treatment of scoliosis (Weiss, H. -R. and Goodall, D. 2008 and Romano, M. and Negrini, S. 2008).

Romano and Negrini had wide search criteria, including:

“in the term manual therapy all the manipulative and generally passive techniques performed by an external operator. In a more specific meaning, osteopathic, chiropractic and massage techniques have been considered as manipulative therapeutic methods.”

Romano and Negrini undertook a systematic search in Medline, Embassy, Canal, Cochrane Library and Pedro using the following terms: idiopathic scoliosis combined with chiropractic; manipulation; mobilisation; manual therapy; massage; osteopathy; and therapeutic manipulation. Inclusion criteria were any kind of research; diagnosis of AIS; patients treated exclusively by one of the treatment procedures accepted for the review (chiropractic manipulation, osteopathic techniques, massage); and outcome in Cobb degrees. Finding 145 texts, only 3 were considered relevant to the study. However, none of the 3 fitted all the inclusion criteria as they combined manual techniques with other treatment approaches. They concluded that there was a lack of serious scientific evidence for the efficacy of manual therapy treatment for idiopathic scoliosis.

In discussing the evidence, Weiss and Goodall noted that two distinct treatment approaches exist currently, each with their own cultures: a US/ UK/ Scandinavian one that emphasises surgery and bracing and a western and central European one which emphasises conservative treatment approaches such as manual therapy, exercise and monitoring.

They observed that no prospective controlled studies or RCT have been done on physiotherapy or manual therapy treatment for scoliosis but that several level III studies had been done, as well as two systematic reviews. The systematic reviews found little evidence for the use of physiotherapy whereas the level III studies described evidence for treatment. Several level II studies of bracing noted that, while there was some evidence for the effectiveness of bracing, the evidence had a wide and variable criteria, with weaknesses being the variability in brace type and the length of time worn each day and over what period of time.

Weiss and Goodall further observe that there are no prospective controlled study, RCT or meta-analysis comparing surgery to manual therapy or more conservative measures and note that “there is a substantial body of literature regarding complications following surgery”. They note that certain journals seem fixated on either surgical methods or bracing and publish poor quality papers advocating these, while ignoring or bypassing quality papers discussing more conservative measures. They conclude:

“there is evidence of a better scientific standard supporting conservative treatment for AIS, including in-patient rehabilitation and brace treatment. No evidence has been found in terms of prospective controlled studies to support surgical intervention. In the light of the unknown long-term effects of surgery, a RCT is long overdue, while to plan a RCT for conservative treatment options seems unethical when one considers the evidence for these treatment options already available. Even though there is evidence to support conservative treatments, this evidence is weak in number and length and further studies are warranted to extend the knowledge of such treatments.”

Their take away message is that surgery replaces one pathology (a rotated spine) with another (a stiff spine), with the possibility of increased complication and the need for further surgery, and that conservative treatment has well documented efficacy in both treatment outcomes and cost benefit.

Interestingly, the Scoliosis journal has since published a single case study that involves a massage therapist and an osteopath treating a single client over a number of years but the client has also concurrently tried physiotherapy and many different exercise systems during the same time period (Brooks et al. 2009.)

A recent paper (Weiss, 2012) discusses the current criteria for the physiotherapy approach to scoliosis------

(The scientifically validated evidence for this work is meagre, mainly because no one is doing the research. Research evidence for treatment of scoliosis by manual methods is almost non-existent. The several systematic reviews conclude that the anecdotal evidence is interesting and that further research needs to be done. Case studies are starting to be published outlining results but not methods.)


Other sources of research

Other sources of research include the online journal Scoliosis which publishes articles as they become available and the journal Spine, which is published fortnightly. The Journal of Bodywork and Movement Therapy, The Journal of Bone and Joint Surgery, The Annals of Internal Medicine and the Journal of Pediatric Orthopedics also occasionally feature relevant articles.

One particularly useful resource is the work of Katerina Schroth, a German physiotherapist active in the treatment of scoliosis since the 1920s. Her work has been continued by her daughter Kristina, also a physiotherapist, and has been described by her (Lehnert-Schroth The Schroth Method: Three-Dimensional Treatment for Scoliosis 2007.) While mainstream medicine and surgery was referring to scoliosis as a lateral curvature of the spine until the last 15 years, Schroth had been describing it as a 3 dimensional, body-wide, rotational pattern since the 1920s. Many of the manual therapy treatment protocols that are effective with scoliosis are based on principles that were first expounded by her, often many years in advance of mainstream thought on scoliosis: the idea of the pelvis having a profound effect on the measurement of Cobb angle and spinal rotation; the major concept of the trunk as a series of trapezoidal blocks stacked around the spine which become asymmetrical in 3 dimensions when in dysfunction; and the concepts of 3 and 4 rotations of the axial skeleton, among others, all owe their origin to her.


Absence of evidence or evidence of absence?

The hard evidence for the efficacy of manual therapy interventions for scoliosis is minimal. There is far more evidence for the efficacy of exercise interventions. Is this a classic instance of evidence of absence rather than absence of evidence, as Weiss and Goodall observed? Given the lack of evidence, how do manual practitioners formulate ideas regarding treatment? Anatomy is an imprecise science; most assessment techniques have limited efficacy; many of the techniques we use lack an evidence base and the reproducible techniques used in most studies for soft tissue and massage outcomes are effleurage, kneading, frictions, petrissage and tapotements.

However, we do get a lot of hints rather than direct indications for treatment methods - from that imprecise science of anatomy; from physiology; biomechanics; histology; extrapolation from various scientific laws; ideas and direction from some of the current pioneers outside the mainstream of science; extrapolating from journal articles (that possibly would stand up to rigourous scientific scrutiny) - some regarding conservative treatment (exercise) of scoliosis, others that discuss what impedes or enhances the results of spinal surgery for scoliosis; from published case studies and case series; from tradition; from clinical anecdote; and lastly and perhaps most profoundly, from the evidence of our clients’ responses. In this last respect, every clinician is a researcher.

Very little of the above is published in the reputable scientific journals. Most of it is what can be termed empirical evidence.

Perhaps it is worth noting the changing paradigms in medical science at this point: in the mid-20th century, the dominant medical paradigm, called either the authority-based or eminence-based medicine paradigm, was guided mainly by a patho-physiologic rationale and by knowledge provided by respected authorities in that field. Around 30 years ago this was replaced by the evidence-based practice paradigm. The evidence-based paradigm has met with considerable resistance from the clinical field. The main criticisms revolve around over-reliance on research evidence at the expense of clinical expertise and experience and disregard for social context. This has led currently to a new approach, the evidence informed paradigm. This is inclusive of the evidence, but also recognizes clinical expertise, patient values and other contextual factors in the clinical practice. In it, the clinician takes the evidence of research into account when making a clinical decision in regard to patient management, but the evidence does not dictate the decision.

Most of the interventionist surgery and orthotic bracing is not evidence based but is from the authority, eminence based model. In the last few years this has changed, with much research being published. Unfortunately, it doesn’t stand up to the scrutiny of the evidence-based paradigm. The journal Scoliosis has been publishing many evidence-based articles in the last 10 years and recently has published a few articles written in the evidence informed paradigm. These recent articles have begun to consider exercise approaches from the evidence based paradigm and have been favourable, and manual therapy and exercise approaches to scoliosis from the evidence informed paradigm. Both these approaches were dismissed by the authority/ eminence paradigm. Interestingly, bracing and surgery approaches do not fare as well in the evidence based or evidence informed paradigms.

One scientific law useful when considering soft tissue treatment protocols is Wolff’s Law, which states that systems such as hard and soft tissues remodel in response to the loads placed on them, distorting in direct correlation to the amount of stress imposed upon them. Wolff formulated this law to describe osseous structure, metabolism and behaviour:

“every change in the form and the function of a bone leads to changes in its internal architecture and in its external form.”

Expand this beyond bone to embrace most connective tissue that contains collagen. Healthy connective tissue adapts to the loads and stresses placed on it, which determines its form and function (this is almost Davis’s Law, though that was formulated specifically for muscle but is probably applicable to all soft tissue as well.)

“One of the hallmarks of connective tissue, including fascia, is its mutability and remodeling in response to mechanical stress.”

Fascia

Like bone, fascia is subject to Wolff’s Law. It changes and remodels in response to the forces placed on it. Muscle fibres can contract and relax, unless in spasm. Fascia, on the other hand, can’t relax as readily and will respond to poor usage by remodelling negatively. This can be quite rapid - it doesn’t take much to change its length. However, this plasticity is also a blessing because it doesn’t take much for it to remodel positively as well.

Fascia / connective tissue can respond to the stress of chronic postural change in various ways:

1. Thickening
2. Shortening
3. Calcifying
4. Eroding

Chronic muscle shortening can easily be treated by Swedish/relaxation massage, stretch and trigger point type work. Prolonged muscle tightness or shortening if not addressed will manifest in changes in the fascia, and is beyond treatment by simple massage. This, primarily, is what we are working with in scoliosis: a long-term pattern that has led to the fascia and connective tissue being affected and subsequently remodelling (or modelling) in a less than optimal manner.

The role of Myofascia:

- Transmission/lines of force
- Continuity in kinetic chains
- Neuro-myofascial web –proprioception, mechanoception.
- containment of muscular structures
- transportation
- structural homeostasis & repair (fibrinogen)

How it can affect scoliosis:

• Asymmetrical growth or localised pinning of the structure blocks congruent development and the body is forced to react at the “pinned” block. As soft tissue, it is the fascia that responds to long-term change first, before the bone.

• Soft tissue shortening goes hand in hand with the spinal curvature; therefore straighten initially by lengthening the fascia. Unknown whether it is cause or effect but possibly irrelevant so treat anyway as it has an affect.

• Consider the curvature continuing into the neck/cervical spine and through into the cranium. Shortened sub-occipitals, TMJ dysfunction, dural changes, vestibular dysfunction – all manifestations of fascial continuity – as well as autonomic/ parasympathetic responses.

Various patterns are possible – always respond to the client and their specific situation rather than rigidly seeking patterns and following treatment protocols.

Jan Sultan’s Internal/External model

The internal / external theoretical model of the body, developed by Jan Sultan, postulates two tendencies in bodily presentation. Based upon his observations of how femoral retro- and ante-version led to two consistently different body patterns, Sultan originally considered aspects of limb (especially femoral) rotation as part of what drives this process, thereby giving a name to the model. The concept of two possible, different responses of the body to gravity means two different lines of force transmission in the body. This results in different muscular and fascial loads and thus differing, characteristic patterns of tonus.

The internal/external model is an empirical model of the body, yet to be scientifically validated. However, it has been used as a cornerstone for observing the body and posture for 25 years in the Structural Integration / Rolfing paradigm and is a particularly useful observation tool. Given that a significant proportion of claims in manual therapy are yet to be validated (even in fields that pride themselves on their evidence base, such as physiotherapy), it should not be dismissed out of hand as currently unproven for lack of hard evidence but viewed as a useful, empirical contribution toward understanding the body.

Some correlation can be found in Vladmir Janda’s stratification syndrome, which postulates that in some dysfunctions there are alternating strata of hypertrophic and weak muscle groups throughout the body, that these alternating sections can be to differ at each layer and even side to side. Balance (or the lack of it) is related directly to the feet.

Sultan’s contention is that we tend toward one or the other pattern and in my observations this holds true for people without scoliosis - the body is normally congruent bilaterally. In scoliosis, especially idiopathic scoliosis, there is bilateral incongruence: the body will be the opposite tendencies on each side at the same level.

Thus you will find, looking at the posture from the ground up, the arch of one foot will be planus, the other cavus; one foot will be subtalar varus (calcaneal varum), the other valgus (calcaneal valgum); Tibial varum (a common congenital osseous deformity in which the distal one-third of the leg is angled medially) is often present in one leg but not the other; one knee will be a little more valgus, the other slightly varus, one will have genu recurvatum while the other will display a normal configuration; one femur will be externally rotated (and often retroverted in the joint) and the other internally rotated (and anteverted.) One ilium will be in anterior tilt, the other posterior, one in outflare and the other in inflare. The sacrum articulates with the ilium and sacral position and biomechanics directly affects the lumbar spine, which sits on the sacrum superiorly. Depending upon which source you use, there are between 9-11 axiis of sacral motion - like a keystone, the position of the whole spine is directly affected by the sacrum’s orientation. No one axis acts alone in the sacrum, so the multi directional altered sacral position will affect vertebral rotation accordingly. The rotation of the vertebrae and the pulls from the pelvic soft tissue upward will affect the structure of the thoracic cage. The shape of the thorax along with the lines of force transmitted by soft tissue originating in the pelvis will affect scapular position, in turn affecting humeral rotation, length of arm bones, tone of connective tissue in the upper and lower arm and on into the wrists. With regard to the cranial vault, the roof of the mouth, the palatine bones will asymmetrical, usually reflecting the asymmetry of the diaphragm. The TMJ will be asymmetrical in shape and function.

So far this has been about appendicular relationships one side to the other. From here, in the axial skeleton, osseous changes come into play. The sacrum, vertebrae and ribs can be asymmetrical in shape one side to another. This is the result of the prolonged force of soft tissue pulling on the bone. It doesn’t start out that way, but it will rapidly develop like that. Asymmetrical pulls in a juvenile body increase with the adolescent growth spurts that accompany puberty; at the same time the bone is increasing in ossification.

Keeping the above in mind, over a period of time appropriate manual therapy on any connective tissue with a collagenous component (bone, ligament, tendon, various types of fascia, adipose tissue) will see the structure of the body change and adapt. This is the whole basis of Structural Integration (Rolfing©, Hellerwork©, Tom Myers’ Kinesis©, etc), myofascial release, deep tissue massage and connective tissue massage. If done with skill and intelligence, this can profoundly affect scoliosis.


Scoliosis as a body wide pattern

Nothing occurs in isolation in the body: scoliosis is a body-wide pattern, not restricted purely to the thoracic spine, even though this is where it is most visibly obvious. It is also where many traditional textbook definitions of scoliosis stop - tending to refer to scoliosis purely in terms of lateral curvature of the spine, though in the last 5 years most of the literature has started referring to it more accurately as a 3-dimensional rotationary pattern in the spine. Rotations in the thoracic spine do not occur independently of the function of the rest of the trunk but are intimately related to what occurs above and below in the cervical and lumbar spines.

I would like to emphasise what is written above again: the body wide pattern manifests in the girdles and limbs and in the axial skeleton - not just the spine but also the jaw, face, dentition, roof of the mouth and cranial vault above. The shoulder girdle is affected directly by thoracic rotations, continuing out to affect rotation in the upper limbs. Because it is a body-wide pattern, there is a need to work with the whole body, not just the spine.

Spinal rotation also affects rib shape. Thoracic shape affects the pathomechanics of the pleural viscera, and thus the potential impairment of respiratory and circulatory function makes this one of the sites of great physiological impact. The heart and lungs are the two most constant, mobile viscera in the body, both housed in the thorax, thus affecting the whole physiology of the body. Because of the need to accommodate the constant motion of these two organs, the thorax needs to be able to deform quite markedly while still providing protection for its enclosed viscera. Most movement in the body can be related to the respiratory function; indeed, many disciplines utilise this interface between breathing and movement. To work with scoliosis you need to work with the whole body, the whole broad canvas, to be truly effective.


Anecdotal observations re structural scoliosis (mainly idiopathic scoliosis):

There are two types of functional scoliosis: one that is due to asymmetrical muscle usage, the other is a spinal manifestation secondary to structural anomalies elsewhere in the body. It is relatively easy to work with asymmetrical muscle usage, but if it is secondary to something like leg length inequality, hemi vertebra, hemi pelvis or has a congenital cause, then manual therapy only offers symptomatic relief. These types of functional scolioses are tricky, because you don’t want to work to change function if this does not support the best possible functional pattern for the person; what you do has to be a considered, supportive response to their altered biomechanics. Consider if there is the need for orthotics –

The rotationary pattern is at its most aggressive around the adolescent growth spurt. Females are the gender most affected (10:1). The rotationary changes are at their most extreme one year before and one year after the onset of menstruation. During this time work done is basically that of a holding pattern. You will usually get no reversal of the rotation during this period of aggressive growth, but you can slow down what is termed “the natural progression” so that it doesn’t worsen. After the period of aggressive growth, while the client is still in their early adolescence, soft tissue work can have the effect of reversing the curve in about 60% of cases and of stabilizing it and preventing further progression in about a further 20% of cases. In the other 20% of cases it will progress; half of these will be relatively minor, possibly less than the natural progression, and the other half will progress markedly (in the range of natural progression.)


Though the most dramatic worsening of the visible rotation of AIS is during early puberty, generally the child isn’t in that much pain or discomfort. PAIN IS NOT AN ISSUE OR CONCERN FOR THE CLIENT - at this stage it is often more a case of aesthetics; the parents and doctors are generally more concerned. This is the time that parents are at their most vulnerable and when doctors are at their most insistent regarding the need for surgery. The progression is generally at its worst, but it stabilises a year after the onset of the period and only progresses slightly after that time. Two-dimensional x-rays measuring Cobb angle are the tool doctors generally use in discussing the severity of the curve. This is a little misleading, as it is a 3 dimensional condition that is primarily driven by rotation in the transverse plane. Recently technology has become available to measure this aspect of the condition and this may change the thinking around scoliosis. Of greater importance, though not often done as a test, is a bone scan of the carpal and metacarpal bones to determine the stage of ossification which would indicate whether surgery would be effective or not. This is rarely done.

General considerations for working with scoliosis

• Scoliosis is a 3-dimensional body-wide pattern. Think 3 dimensionally.

• Scoliosis is a whole body pattern, so you need to work with the whole body, not just the spine.

• Rotation is the driver of scoliosis (not just in the thoracic spine but across the whole body.)

• The severity of thoracic rotation is determined by the position of the pelvis. Level the pelvis first every session! Before assessing or treating the spine for rotations, correct sacral position in relation to the two ilia, and level the ilia left to right.

• Create connections with and gain support from the ground. Work from the ground up – every time you work with the client, bring their awareness to the feet and lower limbs as the base of support for the body and the axial line. Reignite their relationship to the ground before they leave.

• In all scoliosis it is the core that is primarily affected, specifically as it relates to the centre of gravity. Relate the work you do to this axial core. Emphasise the core and the relationship to Anticipatory Postural Activity.

• There is asymmetry of form, function and proprioception on opposite sides of the body at the same level in idiopathic scoliosis. Imbalance is one side to the other – therefore work unilaterally to induce more order and organisation on the side that is less organised and ordered, more random.

• To increase proprioception, work with the client seated, standing and moving in addition to lying on the table. Encourage them to explore what they can’t readily sense somatically. Utilise novelty in the attempt to stimulate neuroplasticity. (Try having them walk on the table!)

• Work relationships within the body: limbs to girdles; girdle to opposite girdle; lower girdles to axial line from the pelvis; upper girdle to axial line in the thorax; upper girdle to neck; cranium to spine, cranium to upper girdle.

• Think of scoliosis as a disturbance of perception, as a body image disturbance, similar to anorexia. No matter how skinny or on death’s doorstep, anorexics can’t perceive of themselves as anything other than overweight. Similarly, someone with scoliosis cannot perceive themself as anything other than straight and aligned, no matter how rotated or disordered their body pattern.

Specific considerations for working the scoliotic thoracic spine

• Think 3 dimensionally.

• Work superficial to deep.

• Know the anatomy of the region and physiological joint function of respiration – the reciprocal relationship of structure and respiration. Be aware of the continuity and relationship of muscles in both micro and macro structure and subsequently function.

• In the spinal component of rotation, the trunk (including shoulders and neck) can be divided into three segments:
1. Lumbar spine with pelvis
2. Thoracic spine with rib cage
3. Cervical spine with shoulders and head.

• The upper and lower two ribs function differently to ribs 3-10 of the thorax. The upper two are overlayed by the shoulder girdle and neck; the weight of the head is cantilevered off the spine as low at T5/6 (mid/apex of thorax to the cranial vault- scalenes are also important here). The lower two are the interface with the pelvis through quadratus lumborum, the posterior spinal muscles, the psoas and the thoraco lumbar fascia.

• The aim is to introduce physiologic movement to create adaptive possibility- encourage full respiration in all 3 dimensions across the whole thorax. Specific sections of the lung will be under-functioning.

• Though the rotations in the thorax are more obvious visually and in assessment, rotations of the pelvis affect the thorax more than thoracic rotation affects the pelvis. This pelvis driven pattern is more common than a thoracic one. Therefore, to get a true sense of the amount of thoracic rotation, ensure the client has level ilia around a normal, physiologically optimal, functioning sacrum. When the sacrum and ilium are in optimal position the amount of thoracic rotation will be less, and what there is will be a truer reflection of the rotationally status of the thorax.

• Rotation is the driver; therefore work the rotatores and multifidi to counter this.

• Lumbar or Thoraco-lumbar rotations tend to be more profound and drive the rotations in the thoracic spine. Thoracic rotations tend to be counter rotations to the initial lower rotation.

• Maintenance of the correct lumbar lordosis encourages appropriate thoracic kyphosis. An asymmetrical lumbar lordosis will be present before any thoracic manifestations.

• There is often a loss of the thoracic kyphosis, which presents as an anterior/posterior flattening of the rib cage. Often the sternum is lower in relation to the thoracic spine than in non-scoliotic subjects. Work structurally to counter tissue restriction and functionally to enhance perception of the respiratory function.

• The Anatomy Trains arm lines, spiral lines and superficial back line directly affect the thoracic spine.

• Autonomic function is affected- between rib heads and transverse processes is a sympathetic nerve chain, therefore rib motion competence is vital to autonomic neural function.

• When working with the spine from skin to vertebra (surface to deep) there can be up to seven muscle layers that can affect the biomechanics of the spine and ribs. In functioning as a whole, these muscles can create different movements, opposite to each other, at the same level - each layer will need different things done to it.

• Each rib has four joints:
1. Sterno-chondral
2. Costo-chondral
3. Costo-transverse
4. Costo-vertebral

• Ribs 3-10 follow consistent rules

• R! -2

• R11-12


Relevant dissection observations (sample 7 bodies, 4 with scoliosis)

• 50% of serratus posterior muscle fibres continue to insert underneath the serratus anterior fibres. Serratus anterior could really be thought of as serratus anterior fibres interdigitating on top of serratus posterior fibres. It isn’t visually possible to discern where one starts and the other ends.

• There is no discernable difference where rhomboid minor ends and levator scapulae commences.

• The intertransversarii appear to be in three strips superior to inferior

• Levator costarum has superior and inferior portions. The superior portion is more tendinous and inserts into the rib at about 80˚, the inferior portion is more muscular and inserts primarily onto the muscle fibre of the external intercostals at the rib angles so that they seem like a continuation of the external intercostal fibres from the rib angle onto the transverse processes immediately superior to the intercostal region below the corresponding rib

• In subjects with scoliosis the levator costarum are hypertrophied and long on the convex side and hypertrophied and short on the concave side superior to the apex of the curve.


Spinal pathomechanics

- “very little is known about the details of how the loads are transmitted through the spine in three-dimensions.” (Stokes, 1996, 2000)

- “the vicious cycle hypothesis proposes that lateral spinal curvature produces asymmetrical loading of the skeletally immature spine, which in turn causes asymmetrical growth and hence progressive wedging deformity. Both discal and vertebral wedging contribute to a scoliosis curvature. The relative contributions of these two structures are not well-defined.” (Stokes, 2006)

There are currently several models posited for spinal pathomechanics. The experts are yet to achieve consensus on which is correct. This may be why there is so little validated research on manual therapy for scoliosis – no one seems entirely certain exactly what is going on.

Having said that, the model I tend to use is that of the transverse processes of the thoracic vertebrae rotating in the direction of the convexity of the curve. Thus, the spine side-bends to one side and rotates to the other. This means the anterior vertebral body rotates in the same direction as the TP. The ribs follow the transverse process: on the convex/ rotated side they present posteriorly, on the concave side they present anteriorly.


Technique Descriptions

Direct myofascial technique (myofascial release)

Direct myofasical technique is different to the slower, John Barnes-style MFR. It is the manual application of controlled mechanical stress to areas of restriction within the myofascia. This changes the mechanical properties of the fascia, allowing a new relationship between the previously restricted tissue and the surrounding tissue, in turn allowing new usage possibilities (i.e. lengthening; new, freer movement).

Choose appropriate tool: fingers, knuckles, soft fist, forearm. Then:
• Gently contact surface
• Sink to appropriate depth (INTENT)
• Contact appropriate level and apply gradual pressure to vector of force.
• Drift through tissue using bodyweight mindfully. Control by changing angle of application rather than amount of effort.
• Ask client for assisted movement.
• Be aware of your working posture; always maintain ease in your posture. This allows you to have greater responsiveness and sensitivity to your client. Don’t work with excessive pressure –your sensitivity decreases with too much force!

Active movement participation

Active motor learning is the fastest and most effective way for the nervous system to re-pattern. It involves the client more in the Rolfing process and increases proprioceptive input via kinetic activity and sensitivity. Active motor output decreases pain sensitivity and enhances the therapeutic effectiveness of interventions. As a movement education tool (i.e. homework), it educates the body to break habitual and limiting movement patterns by guiding it into new ones.

Indirect Myofascial Release (MFR)

Active Functional Technique (AFT)

Passive Functional Technique (PFT)

Dynamic Sensory Awareness (SA)

Muscle Energy Technique (MET)

Tri-Planar Fascial Loading (3PRFL) (AFL) (PFL)

Deep Transverse Frictions (DTF) and Cross Fibre Frictions (XFF)

Strain/ Counter-Strain (S/Cs)

C.R.A.C. & PNF Stretching

Trigger Point (TrP) and Direct Stretch

Acknowledgements

I would like to acknowledge the work of the many writers and teachers who have contributed to the knowledge I have and am able to present. Nothing I do is original; it is built on the shoulders of the giants who have preceded me. I would especially like to thank Dr Robert Schleip, Til Luchau, Jan Sultan, Judith Aston & Brian Linderoth, Ron Mariotti & Dee Ahern and for the classes of theirs I have attended; Robert Schlep, jan Sultan, Emmett Hutchins and Judith Aston for insights and several a-ha moments, and all the great trail-blazers - Ida Rolf, J.P. Barral & Katerina Schroth - whose original work has been the inspiration for this knowledge

References

Amat P. Occlusion, orthodontics and posture: are there evidences? The example of scoliosis International Journal of stromatology & Occlusion Medicine 2009 Volume, 2-10, DOI: 10.1007/s12548-009-0001-4

Barral, J.P. The Thorax 1991 Eastland Press, Seattle, WA.

Brooks WJ, Krupinski EA and Hawes, MC Reversal of childhood idiopathic scoliosis in an adult, without surgery: a case report and literature review Scoliosis 2009, 4:27 doi: 10.1186/1748-7161-4-

Calais-Germain, B. The Anatomy of Breathing 2006 Eastland Press Seattle WA

De Stefano, L. Greenman’s Principles of Manual Medicine 2010 4th Edition, Lippincott Williams & Wilkins, Baltimore

Fulgenzi, Miita Mazzali 
Scoliosis: what to do? 2000 Rolf Lines vol. XXVII, no.4

Key, J. Back Pain: A Movement Problem 2010 Elsevier Churchill Livingstone, Edinburgh.

Lee, D, The Thorax: an integrated approach 2003 OPTP Products

Lehnert-Schroth C, Mohr C, Reeves A and Smith D.A. The Schroth Method: Three-Dimensional Treatment for Scoliosis - A Physiotherapeutic Method for Deformities of the Spine 2007 Martindale Press

Lewit, K. Manipulative Therapy: Musculoskeletal Medicine 7th edition 2010, Churchill Livingstone/ Elsevier.

Liptan G. L. Fascia: A missing link in our understanding of the pathology of Fibromyalgia. Journal of Bodywork & Movement Therapies (2010) 14, 3e12

Lovejoy, C.O. Evolution of the human lumbopelvic region and its relationship to some clinical deficits of the spine and pelvis 2007 in Vleeming A, Mooney V, Stoeckart R. (eds) Movement, Stability and Lumbopelvic Pain 2nd edition, 2007, Churchill Livingstone, Edinburgh.

Negrini A, Parzini S, Negrini M.G., Romano M, Atanasio S, Zaina F and Negrini S Adult scoliosis can be reduced through specific SEAS exercises: a case report Scoliosis 2008, 3:20 doi:10.1186/1748-7161-3-20

Negrini S, Aulisa AG, Aulisa L, et al 2011 SOSORT Guidelines: Orthopaedic and Rehabilitation Treatment of Idiopathic Scoliosis During Growth Scoliosis 2012, 7:3 (20 January 2012

Newton, P., O’Brien, M., Shufflebarger, H. et al Idiopathic Scoliosis: The Harms Study Group Treatment Guide 2010 Thieme

Ni, Haijian MS; Zhu, Xiaodong MD; He, Shisheng MD; Yang, Changwei MD; Wang, Chuanfeng MS; Zhao, Yingchuan MS; Wu, Dajiang MS; Xu, Jin RN; Li, Ming MD An Increased Kyphosis of the Thoracolumbar Junction is Correlated to More Axial Vertebral Rotation in Thoracolumbar/Lumbar Adolescent Idiopathic Scoliosis Spine: 2010 - Volume 35 - Issue 23 - pp E1334-E1338

Pare, Stephen Internal/External: A Neglected Theory Rolf Lines/Structural Integration 2002 Vol 30 no 2 pp 18-19

Rolf I. P. Rolfing: Re-establishing the Natural Alignment and Structural Integration of the Human Body for Vitality and Well-being. 1977 Healing Arts Press, Rochester, VT

Rolf I. P. Rolfing and Physical Reality 1978 Healing Arts Press, Rochester, VT.

Saccucci M, Tettamanti L, Mummolo S, Polimeni A, Festa F, Salini V and Tecco S Scoliosis and dental occlusion: a review of the literature Scoliosis 2011 6:15 doi: 10.1186/1748-7161-6-15

Romano, M. and Negrini, S. 2008 Manual therapy as a conservative treatment for adolescent idiopathic scoliosis: a systematic review Scoliosis 3:2, 22 Jan 2008, available free online, through http://www.scoliosisjournal.com/ or via BioMed Central.)

Sahrmann, S. & Associates Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spine 2011Mosby/ Elsevier, St Louis, MO

Schleip, R. Scoliosis and Proprioception Rolf Lines, Vol.xxviii, no.4, Fall 2000. Available on the www.somatics.de website, along with many other good articles on scoliosis.

Smith, J. Structural Bodywork 2005 Churchill Livingstone/Elsevier Edinburgh

Standring, S. (Editor) Gray’s Anatomy: The Anatomical Basis of Clinical Practice 40th Edition 2008, Churchill Livingstone/ Elsevier, Edinburgh

Stokes IAF, Spence H, Aronsson DD, Kilmer N: Mechanical modulation of vertebral body growth: implications for scoliosis progression. Spine 1996, 21(10): 1162-1167.

Stokes IAF: Hueter-Volkmann effect. In Etiology of Adolescent Idiopathic Scoliosis. State of the Art Reviews. Spine 2000, Volume14: 349-357. 9 Edited by: Burwell RG, Dangerfield PH, Lowe TG, Margulies JY.

Stokes IAF, Burwell, RG & Dangerfield, PH Biomechanical spinal growth cent scoliosis – a test of the 'vicious cycle' pathogenetic hypothesis: Summary of an electronic focus group debate of the IBSE Scoliosis 2006, 1:16doi: 10.1186/1748-7161-1-16

Sultan, J Towards a Structural Logic Notes on Structural
Integration, May 1986

Ward, R.C. (editor) Foundations for Osteopathic Medicine 2003 2nd edition, Lippincott Williams & Wilkins

Wisby-Roth, T. 3 Dimensional Assessment & Treatment of Cervical/ Thoracic Spine 2005-2010 Wisby-Roth Consulting

Weiss, H. -R. and Goodall, D. 2008 The treatment of adolescent idiopathic scoliosis (AIS) according to present evidence: a systemic review (European Journal of Physical and Rehabilitation Medicine 2008 44:177-93

Weiss, H. The method of Katharina Schroth - history, principles and current development Scoliosis 2011, 6:17

Weiss, H. Physical Therapy Intervention Studies on Idiopathic Scoliosis - Review with the focus on Inclusion Criteria Scoliosis 2012, 7:4 (25 January 2012)