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Integrative Treatment Using Chiropractic and Conventional Techniques for Adolescent Idiopathic Scoliosis: Outcomes in Four Patients

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  • Natural Wellness & Pain Relief Center

Abstract and Figures

Background: Bracing treatment for adolescent idiopathic scoliosis is a commonly prescribed treatment for curvatures up to roughly 35°. Little data in the United States has been published concerning bracing treatment for larger curves, as surgical intervention is typically reserved for such cases. This study reports on the combined use of Boston bracing and a conservative manual therapy system for larger magnitude scoliosis. Methods: A total of 4 patients presented to a private spine clinic for treatment consisting of bracing, a patented weighting system, vibration therapy, and manual traction procedures. The evaluation process consisted of multiple outcomes, including radiographic, functional, respiratory, and postural assessments. Patients were evaluated at the onset of treatment and after 90 days. Results: All 4 patients saw their major curvatures reduced an average of 13.5°. Peak expiratory flow, computerized postural assessment, chest expansion, rib hump measurements, and functional rating index scores also improved for all patients. Two of the patients also reported an improvement in specific symptoms. Conclusion: Using this combined treatment for 90 days, the patients outlined here were able to achieve positive benefits in radiographic, functional, and physiological outcome measures. Limited conclusions can be made due to the study design, however. All patients will be monitored for moderate and long-term assessments.
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Integrative Treatment Using Chiropractic and Conventional
Techniques for Adolescent Idiopathic Scoliosis: Outcomes in
Four Patients
Mark Morningstar, D.C.1
__________________________________________________________________________________________
ABSTRACT
Background: Bracing treatment for adolescent idiopathic
scoliosis is a commonly prescribed treatment for curvatures up
to roughly 35°. Little data in the United States has been
published concerning bracing treatment for larger curves, as
surgical intervention is typically reserved for such cases. This
study reports on the combined use of Boston bracing and a
conservative manual therapy system for larger magnitude
scoliosis.
Methods: A total of 4 patients presented to a private spine clinic
for treatment consisting of bracing, a patented weighting system,
vibration therapy, and manual traction procedures. The
evaluation process consisted of multiple outcomes, including
radiographic, functional, respiratory, and postural assessments.
Patients were evaluated at the onset of treatment and after 90
days.
Results: All 4 patients saw their major curvatures reduced an
average of 13.5°. Peak expiratory flow, computerized postural
assessment, chest expansion, rib hump measurements, and
functional rating index scores also improved for all patients.
Two of the patients also reported an improvement in specific
symptoms.
Conclusion: Using this combined treatment for 90 days, the
patients outlined here were able to achieve positive benefits in
radiographic, functional, and physiological outcome measures.
Limited conclusions can be made due to the study design,
however. All patients will be monitored for moderate and long-
term assessments.
Key Words: Chiropractic, Scoliosis, Vertebral Subluxation,
Bracing, Pettibon Technique
____________________________________________________________________________________________________________
Background
Although idiopathic scoliosis is typically characterized as an
orthopedic deformity, its health consequences extend well
beyond the musculoskeletal system. A 50-year natural history
study by Weinstein et al1 suggests that people with untreated
scoliosis have “little physical impairment other than back pain
and cosmetic concerns.” However, it is also known that even
mild spinal curvatures beginning at 10º are associated with
reduced chest wall compliance and vital capacity,2 reduced
exercise capacity,3-5 recurrent respiratory infection,6,7 reduced
spinal flexibility,2 recurrent back pain,8,9 psychological
distress,10,11 and cardiac or respiratory failure for curvatures
greater than 70º.12,13 Therefore, any curvature beyond 10º
should be treated to minimize or prevent these symptoms.
In the United States, the Boston brace is one of the more
commonly used orthoses for the treatment of scoliosis. This
may be due to the extensive published data pertaining to both
its short and long-term outcomes. An earlier study by Emans
et al14 evaluated the results of 295 patients (mean age of 13.2
years) using the Boston brace for an average period of 2.9
years. They found an average best in-brace correction of 50%,
with a mean 15% correction after treatment and 11% mean
correction at 1.4 years follow-up. All patients in this study
have curvatures between 20-59º.
The Boston brace may also have increased effectiveness
compared to other bracing systems. When compared to the
Charleston Nighttime Bending brace, the Boston brace
demonstrated more effectiveness in preventing curvature
progression and reducing the incidence of surgical
intervention.15 More specifically, 43% of patients using the
Original Research
_______________________________________________
1. Director of Research , Pettibon Institute.
Gig Harbor, WA
Scoliosis Outcomes J. Vertebral Subluxation Res. July 9, 2007 1
Boston brace experienced curvature progression greater than
5º, versus 83% of patients using the Charleston brace. The
Wilmington brace has shown effectiveness in reducing the
amount of spinal decompensation in 70% of 372 scoliosis
patients with curvature magnitudes of 20-49°.16
Spinal decompensation is defined as the horizontal distance
between the vertical axes of the sacrum and occiput. This
distance should be less than 1cm, according to Rudicel and
Renshaw.17 A later study by Allington and Richard18 showed
that full-time and part time bracing in 188 patients produced
similar reductions in curvature progression (p < 0.18). These
patients had curvatures up to 40°.18 The Milwaukee brace
performed in a similar fashion to the Wilmington brace. In a
review of 1020 radiographs by Lonstein and Winter,19 the
Milwaukee brace demonstrated a failure rate of 23%. Failure
rate was defined as an increase in the curvature of more than
5°.19 A newer, dynamic brace, called a SpineCor, has recently
been reported. A study by Coillard et al20 followed a group of
195 patients treated with idiopathic scoliosis using the
SpineCor brace. The patients were divided into two groups:
those with curvatures above 30° and those below 30°. A total
of 29 patients were followed up after 2 years (avg. Cobb angle
of 30° ± 9). This group showed a 90-day mean Cobb angle
reduction of 10° ± 5, with a 2-yr follow-up of 5°.20 However,
the highest Cobb angle in the sample group was 41°. A larger
cohort of 365 patients using the SpineCor brace were followed
for 5 years post-treatment, showing that 65.4% of these
patients achieved a permanent correction, while only 3.8% had
worsened. Again, while this is good evidence of correction,
the mean curvature magnitude did not exceed 40°.21
Although bracing has shown good clinical success, it does
have specific limitations. Katz and Durrani22 performed a
retrospective analysis of 51 patients treated with the Boston
brace for curvatures ranging from 36-45º. They found that 31
of these patients were considered successes, while 16 patients
eventually required surgical intervention. There is little
available research that investigates bracing treatment at
curvatures higher than 45º. According to standardized criteria
outlined by the Scoliosis Research Society,23 optimal bracing
candidates share the following characteristics: 10 years of
age, Risser sign of 0-2, primary curvature of 25-40°, and
premenarchial to < 1 year postmenarchial if female.
Scoliosis treatment using the Pettibon System has previously
been reported.24-26 However, in all these reported cases, only
one of 23 total cases presented with an initial Cobb angle
above 40º (52º).24 Here we report 4 cases of adolescent
idiopathic scoliosis with moderate and severe curvatures,
ranging from 42°-89°. This report is a more extensive version
of a case report presented at the 3rd Annual International
Conference on Conservative Management of Spinal
Deformities (www.sosort.org).27 These patients were treated
using a combination of the Pettibon System and Boston
bracing. Their multi-factorial, collective outcomes after 90
days of treatment are reported.
Four patients reported to the Grand Blanc Spine Center in
Grand Blanc, MI USA for scoliosis treatment. All 4 patients
were female, ages 12,12,13, and 14. Prior to manuscript
preparation, the center’s HIPAA compliance officer obtained
written permission from the patients’ parents to report age,
gender, and treatment outcomes. Before beginning active
treatment, patients were fitted for a Boston thoraco-lumbo-
sacral orthosis (TLSO) brace. The patients then presented to
their initial visit with their respective brace and were evaluated
for treatment development. Radiographs of each patient while
wearing their brace were taken prior to manual therapy being
rendered. Patients were evaluated using functional,
radiographic, and physiological outcomes. Specifically, peak
expiratory flow, computerized posture analysis, chest
expansion, Cobb measurements, the functional rating index,
and rib hump measurements were recorded. Each patient was
tested before being accepted for treatment. Under the protocol
taught in the Pettibon System,28 patients are first tested to
predict whether or not they will respond to this treatment
method. If they don’t, they are not accepted for care and are
referred to the most appropriate provider. Examples of this
testing procedure have been previously published.29,30
This initial testing for scoliosis patients involves routine
warm-up stretches, autotraction, spinal manipulation, vibration
traction, posture corrective exercise, and post-treatment x-rays
were performed while wearing the brace and an external
weighting system simultaneously. The warm-up stretches and
autotraction are shown in Figure 1. Chiropractic adjustments
were employed for the purpose of mobilizing spinal joints so
that the following rehabilitative exercises are performed while
the joints have a temporary increase in mobility.
The vibration traction, shown in Figure 2, was performed
using a Pettibon Wobble Chair, a Soloflex variable-speed
motor, and a NeckPro traction system. For this procedure, the
patient puts on his/her individually prescribed weighting
system, which may include bilateral hipweights and a
shoulderweight, followed by the Boston brace. The patient is
then helped into the traction unit, and the right amount of
tension is applied. In order to find the right tension, the patient
is instructed to pull the rope until the neck feels stretched, but
the neck muscles are not activating. As the patient pulls the
rope, a series of clicks are heard. Each click increases the
traction force by approximately one pound. The vibration
motor is turned on and set for 45 Hz frequency, and the patient
performs this exercise for 20 minutes. At 5-minute intervals,
the patient is instructed to pull the rope one or two more
clicks. Following this 20-minute session, the patient is
instructed to take off the weighting system, after which the
straps on the posterior of the brace are pulled tighter. An
illustration of this can be seen in Figure 2. The patient then
adds the entire weighting system, and an anteroposterior
radiograph is taken to calculate in-brace correction. In these 4
cases, in-brace corrections met or exceeded 25%, with a high
of 58%. A sample of this radiographic process is shown in
Figure 3. Each patient was then prescribed a specific course
of treatment for 90 days. Post-treatment x-rays were taken an
average of 37 hours following the previous clinic visit.
Results
After 90 days of care, all patients were re-examined. Post-
treatment anteroposterior radiographs, peak expiratory flow, a
functional rating index, computerized posture analysis using
PosturePro software (www.posturepro.com), chest expansion,
and rib hump measurements using a scoliometer were
obtained. A physician independent from this study, to avoid
J. Vertebral Subluxation Res. July 9, 2007 2 Scoliosis Outcomes
examiner bias, analyzed all pre- and post-treatment
radiographs. The collective results of the four patients are
shown in Table 1.
Patient 1 initially presented with an 89° thoracic
dextroscoliosis and a 32° left levoscoliosis. The thoracic
curvature was reduced to 77°, while the lumbar scoliosis
remained at 32°. Her peak expiratory flow increased 11%,
chest expansion increased from.75” to 1.6”, her rib hump
decreased 5° at the T8 vertebral level, while her posture
improved 34%. Her functional rating index remained at a 4/40,
and she reported a complete resolution in her daily chest pain
and heart palpitations.
Patient 2 began treatment with a 63° right thoracolumbar
scoliosis. At re-examination, her peak expiratory flow
increased 29%, chest expansion increased from .75” to 3.25”,
rib hump with T8 apex reduced 7°, and her posture improved
51%. Her functional rating index decreased from 5/40 to 1/40,
while her scoliosis decreased to 44°. She did not report any
symptoms throughout the 90-day treatment period.
Patient 3 started her care with an 83° thoracolumbar scoliosis.
Following care, chest expansion increased from .25” to 1.25”,
rib hump reduced 3°, peak expiratory flow increased 27%,
posture improved 22%, her functional rating index reduced
from 12/40 to 7/40. Her curvature decreased to 73°. She also
did not report any subjective complaints throughout care.
Finally, patient 4 reported initially with a right thoracic
scoliosis of 42°, which reduced to 29° at re-evaluation. Her
functional rating index reduced from 2/40 to 0/40, chest
expansion increased from 1.0” to 1.5”, her posture improved
33%, peak expiratory flow increased 17%, and her rib hump
reduced 4°.
Discussion
In all cases, an initial in-brace correction of 25% or greater
was achieved. This finding is consistent with the observation
by Katz and Durrani3 that an in-brace correction of at least
25% significantly increases the likelihood of success with
bracing treatment. However, they also identify >18 hours of
brace use per day as a significant predictor of success. Here,
our patients were instructed to wear their braces only 6-10
hours per day. Previous studies report an average compliance
rate of 67.5% to 75% when full-time bracing is prescribed.31,32
Therefore, it is possible that these four patients did not wear
their brace for the entire 6-10 hours per day. All home care
and bracing could be performed in their own home. This may
also reduce the negative impact of bracing treatment on
psychological well being.33,34 We hypothesize that this may
increase compliance, since the patients did not have to wear
their braces to school. Although pulmonary restriction has
been a reported concern,35 Korovessis36 found no detrimental
effects of brace treatment on pulmonary function over a 2-year
period.
Studies of scoliosis patients have indicated that the long-term
health of the spine may be more related to the sagittal profile
rather than frontal alignment.37,38 Additionally, abnormal
sagittal alignment has also been associated with an increased
risk of frontal Cobb angle progression.39 This observation
forms the basis for the hypothesis that complementing the
bracing treatment with the Pettibon System may provide a
more complete treatment outcome. The Pettibon System
places a clinical priority on restoring sagittal alignment,28
especially in patients with scoliosis.24-26 Typically, bracing
treatment lasts about 2-3 years, or shortly after the onset of
menarche. However, in cases where the scoliotic curvature is
not completely corrected, asymmetric spinal loading will still
cause the curvature to progress over the remainder of the
patient’s lifetime,40, 41 even in cases of surgically-treated
scoliosis.42,43,44 Therefore, if patients continue to perform
rehabilitative procedures, designed to promote sagittal
alignment, after discontinuance of the bracing treatment, the
effects of the brace treatment may be maximized. This will be
the focus of future articles pertaining to the combination of
these treatments.
Traditionally, outcomes for scoliosis treatment have included
self-rated health assessment questionnaires, such as the SF-36,
and Cobb angle measurements taken from full-spine
radiographs. In our report, we decided to also outline the
physiological improvements achieved following 90 days of
this combined treatment regimen. These types of physiological
parameters are indeed important outcome goals, according to a
recent consensus opinion of physicians and therapists.45,46
It is important to note that the data illustrated in this study is
over a relatively short time frame. Because of that, it is
unknown what the intermediate and long-term effects of this
treatment are, especially since a curvature still remains in all 4
cases, which perpetuates asymmetric loading, growth, and
ultimately remodeling. Other factors, such as remaining
growth, compliance, and co-morbidities must be accounted
for. Achievement of results at 90 days does not guarantee
maintenance of results, especially if these others factors are
present. Consistent treatment must be maintained as long as
asymmetric gravitational loading exceeds spinal muscle
strength and endurance.40 Constant maintenance must be
performed in a life-long disorder such as scoliosis.47
Conclusion
Four cases of moderate to severe adolescent idiopathic
scoliosis achieved positive radiographic, respiratory,
functional, and symptomatic improvements following a 90-
day course of integrative scoliosis treatment using the Boston
brace and the Pettibon System. Integrative treatments such as
this may provide chiropractors with an opportunity for
interprofessional dialogue and cooperative management from
traditional providers. It is unknown how these improvements
are related to the treatment procedures. The present study
design limits any firm conclusions. Any proposed scoliosis
treatment should consider using physiological outcome
assessments, since scoliosis is associated with a variety of
non-musculoskeletal disorders.
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Competing Interests
MWM is the director of research for the Pettibon Institute. He
is not financially compensated for his position. However, he
does receive funding for statistician services, and is
compensated by the institute as a postgraduate instructor.
J. Vertebral Subluxation Res. July 9, 2007 5
Scoliosis Outcomes
Scoliosis Outcomes
Table 1
Patient Age Risser
Cobb
1
Cobb
2 PEF 1 PEF 2
RH
1
RH
2
CE
1
CE
2
Posture
1
Posture
2
FRI
1
FRI
2
(L/min) (L/min) N=0-5 N=0-5 x/40 x/40
1 12 1 89/32 77/32 340 390 20 15 0.8 1.6 35 23 4 4
2 14 4 63 44 210 270 18 11 0.8 3.3 35 17 5 1
3 13 4 83 73 310 390 21 16 0.3 1.3 24 19 12 7
4 12 2 42 29 290 340 12 8 1 1.5 18 12 2 0
"1" represents initial findings; "2" represents 90-day findings
Cobb = radiographic Cobb angle in degrees
PEF = Peak Expiratory Flow
RH = Rib Hump measurement in degrees
CE = Chest Expansion or Rib Cage Expansion in inches
Posture = Posture Rating Score on PosturePro software; normal = 0-5
FRI = Functional Rating Index score; score/40 = % disability
Figure 1
The wobble chair exercises and the auto-traction performed over a door.
J. Vertebral Subluxation Res. July 9, 2007 6 Scoliosis Outcomes
Figure 2
The picture on the left illustrates the vibration traction therapy for 20 minutes per visit. Following this, the patient’s brace
was tightened, and worn that way for the remainder of the day.
Figure 3
This figure provides a sample illustration of the radiographic testing process used in these cases. The radiograph on the left is
the initial view, the middle radiograph was taken prior to treatment intervention wearing the brace only. The right radiograph
was taken following the treatment intervention, using the tightened brace and weighting system combined. This is patient #4.
J. Vertebral Subluxation Res. July 9, 2007 7 Scoliosis Outcomes
... In a small case series, Morningstar reported on 4 patients with idiopathic scoliosis who participated in a rehabilitation program while concurrently wearing a rigid brace as well. 21 After 3 months of participating in the combined approach, the average Cobb angle reduction was 13.5°. Of note was that 3 of the 4 patients had baseline curvatures that were greater than the usual standard of care (N60°and N80°), yet still achieved an average correction N6°. ...
Article
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Objective: The purpose of this review was to evaluate the current body of literature on chiropractic treatment of idiopathic scoliosis against the 2014 consensus paper of the Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) and the Scoliosis Research Society (SRS) Non-Operative Management Committee for outcome reporting in nonoperative treatments. Methods: A search of the PubMed and Index to Chiropractic Literature databases for studies published from January 2000 through February 2016 detailing specific treatments and outcomes for idiopathic scoliosis was conducted. Results: A total of 27 studies that discussed chiropractic scoliosis treatments were identified. Of these, there were 15 case reports, 10 case series, 1 prospective cohort, and 1 randomized clinical trial. Of the 27 studies, only 2 described their outcomes as recommended in the 2014 SOSORT and SRS Non-Operative Management Committee consensus paper. Conclusion: The 2014 SOSORT and SRS Non-Operative Committee consensus paper details the format and types of outcomes they collectively believe are the most important and relevant to the patient. Among the chiropractic studies located in this review, 2 described outcomes consistent with how SOSORT recommends they be reported. Given that these consensus papers form the basis for nonoperative treatment recommendations and outcome reporting, future chiropractic studies should seek to report their outcomes as recommended by these papers. This will allow for better interprofessional collaboration and methodologic comparison.
... Within this system, a core component is the Pettibon Weighting System™, which is composed of a series of external head, torso, and pelvic weighting designed to elicit specific postural responses that are measurable both by visual posture and by comparative radiography. This external weighting system has been the focus of, or part of, several previous studies [15][16][17][18][19][20][21][22] . This weighting system works primarily by stimulating translational posture adaptations, which can be predicted based upon the patient's baseline posture and/or radiographs. ...
... Morningstar was able to accomplish 50% or greater in-brace correction in four patients, but only when TLSO bracing was combined with an external weighting system. 80 However, only three month results were reported for those patients. ...
... Other physiological outcome assessments are currently being explored, such as peak expiratory flow, rib cage expansion, and spirometry. 31,32 Conclusion Scoliosis is a multi-dimensional disorder. Biomechanically, scoliosis is a three-dimensional deformity of the spine. ...
... Ten studies provided psychometric data [8,[27][28][29][30][31][32][33][34][35], two gave prediction information [36,37], and fourteen employed FRI as an outcome measure in a clinical study [38][39][40][41][42][43][44][45][46][47][48][49][50][51]. FRI has been translated into three languages: Korean, Brazilian-Portuguese and Turkish [28,31,33]. ...
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Unlabelled: In 1999, a new self-report outcome measure, the Functional Rating Index (FRI), was developed and tested. This measure demonstrated reasonable reliability, validity and responsiveness. Since the publication of the original testing, numerous independent research teams have examined the psychometric qualities of the FRI and published their findings. The aim of this study is to review the psychometric properties of the FRI as reported by published studies. Researchers independently searched the literature for relevant studies using MEDLINE and Index to Chiropractic Literature from January 2001 to August 2009. Descriptive and outcome data was extracted using standardized forms. The psychometric properties of the FRI were analyzed with established criteria and compared head-to-head with other outcome measures. The search yielded ten studies that provided psychometric data. Reliability: Test-retest: Intraclass correlation coefficient and Cronbach's alpha were good, and FRI is equivalent to the other measures. Validity: the FRI has good convergent validity with pain and function self-report scales and a weaker correlation with items that measure different constructs. Responsiveness: FRI was similar to the comparative measures for standardized response mean, effect size and receiver operating curve statistics. Patient acceptability: time required by the patient and staff averaged 78 seconds per administration, and there were few missing responses. The FRI demonstrates favorable measurement properties of reliability, validity and responsiveness. It provides an alternative to other self-report measures, because it is quicker for a patient to complete and can be used for patients with neck and back pain.
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A retrospective study of 2442 patients who had idiopathic scoliosis was performed to determine the prevalence of back pain and its association with an underlying pathological condition. Five hundred and sixty (23 per cent) of the 2442 patients had back pain at the time of presentation, and an additional 210 (9 per cent) had back pain during the period of observation. There was a significant association between back pain and an age of more than fifteen years, skeletal maturity (a Risser sign of 2 or more), post-menarchal status, and a history of injury. There was no association with gender, family history of scoliosis, limb-length discrepancy, magnitude or type of curve, or spinal alignment. At the latest follow-up evaluation, 324 (58 per cent) of the 560 patients who had had back pain at presentation had no additional symptoms. Forty-eight (9 per cent) of the 560 patients who had back pain had an underlying pathological condition: twenty-nine patients had spondylolysis or spondylolisthesis, nine had Scheurmann kyphosis, five had a syrinx, two had a herniated disc, one had hydromyelia, one had a tethered cord, and one had an intraspinal tumor. A painful left thoracic curve or an abnormal neurological finding was most predictive of an underlying pathological condition, although only eight of the thirty-three patients who had such findings were found to have such a condition. When a patient with scoliosis has back pain, a careful history should be recorded, a thorough physical examination should be performed, and good-quality plain radiographs should be made. If this initial evaluation reveals normal findings, a diagnosis of idiopathic scoliosis can be made, the scoliosis can be treated appropriately, and non-operative treatment can be initiated for the back pain. It is not necessary to perform extensive diagnostic studies to evaluate every patient who has scoliosis and back pain.
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To evaluate the effectiveness of Pettibon spinal manipulation and anterior headweighting for correct cervical hypolordosis and forward head posture, quantified by measurements taken from pre and post intervention lateral cervical radiographs. A total of 15 subjects were selected for investigation at random. An initial seated lateral cervical radiograph was taken to evaluate forward head posture and the amount of cervical lordosis. A series of 3 manipulative procedures were performed, followed immediately by introduction of an anterior headweight device. This headweight device was worn for 5 minutes while walking on a treadmill. A post intervention seated lateral cervical radiograph was taken while each subject wore the headweight. Measurements of cervical lordosis and forward head posture were again quantified and compared to the initial radiographs. The average overall decrease in forward head posture among all subjects was 0.83 inches. The largest reduction in forward head posture was 1.25 inches. One subject failed to show any reduction. The largest and smallest improvements in the cervical lordosis were 23 degrees and 4 degrees , respectively. The average increase in cervical lordosis for all subjects was 9.9 degrees . This specific protocol was able to provide measurable improvement in cervical lordosis and reduction of forward head posture after only 1 session. However, it is not known which component, the spinal manipulation or the anterior headweighting, made the biggest impact. This study shows the immediate effects of spinal manipulation and headweighting combined. Future research should focus on the headweighting effects over a longer period of time. Additionally, anterior headweighting alone needs to be tested to evaluate its effectiveness as a sole treatment intervention.
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A survey is presented on the etiologic factors of scoliosis and spine deformities, and also on the general therapeutic surgical and bracing possibilities.