One of the most fascinating things about chiropractic care for older adults is the examination of what we accept as normal aging. Is it normal to lose, for example, fitness, balance, and memory, or for the spine to degenerate? Or is this merely common? Postural displacements are one such area of interest. A recent case series has shown some interesting similarities when it came to correcting such postural displacements in five patients in their sixth and seventh decades of life.
Postural displacements can be categorised as translations or rotation of the head, thorax, and/or pelvis. When we look at a normal spine from the side, it should adopt a gentle s-shape, with a straight line dropping through from the ears to the shoulders and then through the hips. However, the ageing spine is often associated with generative changes, including in those with degenerative scoliosis.
So, what’s the problem with this? An aged spine with a lateral translation posture may not be as flexible and may not manifest as the typical ‘s-shaped’ spinal coupling – and instead present as a left or right ‘lean’ in the coronal plane. Coronal balance (or imbalance) is well studied in those with scoliosis where lateral malalignment to certain degrees is associated with a significantly greater negative clinical impact. Similarly, it has also been correlated with poorer vitality on the short form-36 Health-Related Quality of Life questionnaire in adult degenerative scoliosis patients.
The Case Series
This particular case series included five cases featuring a reduction of coronal plane, lateral thoracolumbar spine translational offset postures (subluxations) in older patients with degenerative disc disease. To be included in the case series, all cases had to include a diagnosis of degenerative disc disease, a lateral translational offset of the thoracolumbar spine (measured from either T1 or C3 as compared to S1 or L5), chronic back symptoms (of greater than 3 months duration to ensure lateral subluxation was not a temporary acute antalgic posture – a posture people develop in response to pain or injury – that classic lean to the side), age older than 50, and all were patients who underwent treatment for their coronal misalignment.
That said, it was still a retrospective case series. This means this was simply a means of sorting for similarity to decide whether or not the cases would be included in the paper.
In each case, patient anterior-posterior (AP) radiographs were assessed using the modified Risser-Ferguson method. The authors remarked that, “This method was chosen as these patients did not exclusively have scoliosis warranting the Cobb angle of measurement. Although some had moderate scoliosis, most simply had a ‘lean’ to the left or right not due to muscle spasm (not an antalgic posture). This measurement method has good to very good inter and intra-rater reliability”
All five patients underwent chiropractic care for the correction of subluxations and to correct the coronal plane deformity. Chiropractic BioPhysics (CBP) methods that incorporate opposite lateral translational exercises, spinal adjustments, and spinal traction exercises were used to reduce the deformities.
For this series an opposite lateral displacement of the spine and torso was the corrective approach used. All patients performed exercises, adjustments, and traction in the office as well as home exercises. The exercises involved left or right thoracic translation on a platform that vibrated. Each repetition was held for 5 seconds with a 1 second rest. Patients were instructed to complete these exercises at a frequency of 100 per day.
When at the practice, patients received manual adjustments of the thoracic lumbar spine and also the application of a hand-held instrument to the paraspinal muscles. During the sessions patients were placed in the Meyer’s wall traction unit which stressed the spine to the left or right relative to the pelvis in a standing or seated position.
Here’s What Happened
Case 1 was a 51-year-old with low back pain and secondary complaints of numbness in the feet, cold feet, ankle pain, mid-back cramping, heartburn, neck pain and stiffness, and allergies. While specific subluxations for this patient and all others can be found at the reference below, it should be noted that the thoraco-lumbar X-ray showed a right whole spine translation and lean of 33.7mm. The patient also had a mild degenerative left lumbar scoliosis in the lower lumbar spine with a compensatory right curve. Patient received 24 chiropractic care sessions over 12 weeks.
- Re-assessment revealed notable improvements in the physical functioning and bodily pain
- Reduction on the Oswestry low back pain disability index
- The patient reported improvement in cold feet, low back and ankle pain, mid-back cramping, and most particularly in foot numbness, heartburn, and migraines.
- Post-assessment, static palpation showed hypertonicity, point tenderness, and motion restriction similar to that seen pre-care. However, post-care X-rays showed a reduction in coronal imbalance and a reduction of the lower lumbar scoliosis.
Case 2 was a 63-year-old male with right rib pain and secondary complaints of neck pain, constipation, pain at base of skull, and left thumb pain. His AP thoraco-lumbar x-ray showed a T1-S1 translation of 17.7mm to the left. There was visible degeneration of multiple intervertebral levels. The patient received 24 treatments over 22 weeks.
- When reassessed, visual posture looked symmetrical in the frontal plane
- Palpation revealed hypertonicity, point tenderness, and motion restriction similar to prior to chiropractic care for the condition.
- However, there was a significant improvement in bodily pain, improvement in the Oswestry low back pain disability index, and decreased average pain.
- The patient reported improvement in right rib pain, neck and base of skull pain, constipation and left thumb pain.
- Post-care x-ray showed a reduction of the left translation (4.8mm)
Case 3 was a 50-year-old female with left sacroiliac joint pain and secondary complaints of low back pain, numbness in the right 3rd/4th toes, plantar fasciitis, right-sided neck pain, and a tingling in both hands. Initial x-rays showed a right shifted coronal imbalance of 44.8mm. She also had a right thoracolumbar scoliosis curve of 19.5 degrees with degenerative changes at levels L3 to S1. She received 24 treatments over 15 weeks.
- Her re-assessment showed visual coronal symmetry of posture.
- Palpation revealed hypertonicity, point tenderness, and motion restriction similar to pre-chiropractic care, as with the others. However, the patient reported 100% improvement in plantar fasciitis and improvement in the tingling of the hands, numbness in the right toes, low back pain, and right-sided neck pain.
- Post-care x-rays showed a reduction in coronal imbalance and a reduction of the thoracolumbar scoliosis.
Case 4 was that of a 52-year-old male with who suffered an acute episode of chronic low back pain and described secondary complaints of cramping in the right inner thigh, pain radiating into the left leg, cold feet and handles, right mid back pain, occasional neck pain, tinnitus, and double vision. He originally presented with an antalgic posture (an unnatural movement or sway) that was treated until non-antalgic, at which point corrective care was given to reduce the chronic asymmetric lean.
He had an observable thoracic translation to the left. Radiographic assessment showed a thoracic translation of 27.4mm to the left, a left thoracic scoliosis of 21.8 degrees and a right lumbar scoliosis of 19.5 degrees. It was also noted that he had a shorter right leg by 16.5mm.
After addressing the initial antalgic posture, the patient received 6 sessions of chiropractic care before a reassessment was done.
- At reassessment, the patient’s posture looked significantly more symmetrical.
- Similar to the others, palpation revealed hypertonicity, point tenderness, and motion restriction similar to pre-chiropractic care.
- His average pain intensity remained the same, but ‘worst’ pain rating improved significantly (initially 8/10, now 3/10).
- There were notable improvements in physical wellbeing, social functioning, and bodily pain.
- The patient reported improvements in low back pain, left leg sciatica, double vision, right inner thigh cramping, right mid-back and neck pain, cold feet and hands, and a small improvement in tinnitus.
- Post-care x-ray showed a reduction of the coronal deviation and reduction of the thoracic and lumbar scoliosis curves.
The final case was that of a 60-year-old male with left sacroiliac joint pain and secondary complaints of neck pain and stiffness, numbness in the hands at night, weakness in grip, ringing in ears, allergies, weakened immune system, left rib pain, acid reflux, lower back pain, cramps in legs and feet. Patient had a right thoracic translation posture. Some orthopedic tests were positive. Muscle testing showed weakness in many areas of the body, cervical ROM was restricted in all directions but without pain, lumbar ROM was restricted in all directions with pain in all but flexion movement.
AP thoracolumbar x-ray showed a 40mm right thoracic translation shift and a severe unleveling of the pelvis (23.7mm lower on the right). A lift was prescribed which helped reduce the pelvic angle and coronal imbalance, although the coronal imbalance remained significant. He received 42 chiropractic care sessions over 19 weeks
- When reassessed (again) the patient’s coronal imbalance was visually improved
- All Range of Motion measurements, orthopedic, muscle, reflexes, and dermatome testing were within normal limits.
- There was a notable improvement in the Oswestry low back pain disability index
- He also noted improvements in health perception, emotional wellbeing, social functioning, mental health, energy/fatigue.
- Thoracic translation was reduced (originally 40mm, now only 7mm)
While we are still limited in our ability to generalise these findings to an entire population, it is interesting to note the similarities in these cases. This case series supports the ability of coronal plane lateral translational postures to be reduced in older patients with degenerative disc disease. All five patients experienced a reduction in symptoms, and notably, all tolerated the protocol well. This is especially important for older patients. It is also interesting to note that, while similar hypertonicity and sensitivity remained when they were re-assessed, significant health improvements had been seen.
This case series is especially interesting in that all cases had objective findings such as x-ray and questionnaire data to compare at beginning and ending. While certainly, these are atypical presentations of spinal disc degeneration, it is nice to see positive indications for chiropractic care for such postural concerns in older adulthood.
- Woodham, T., Fortner, M., Oakley, P., & Harrison, D. REDUCING ‘CROOKED’ LATERAL SPINE SUBLUXATION (GLOBAL CORONAL IMBALANCE) IN 5 PATIENTS WITH DEGENERATIVE DISC DISEASE IN THEIR 6TH AND 7TH DECADE OF LIFE: A CASE SERIES INVOLVING CHIROPRACTIC BIOPHYSICS© TECHNIQUE. Journal of Contemporary Chiropractic. 2021. 4(1), 128–137