Scoliosis as a natural attitude - Idiopathic scoliosis: old and new concepts, clinical case

Edited by Dr. Giovanni Chetta

INDEX

Premise
Scoliosis this unknown
Diagnosis of scoliosis

Limits of Cobb's angle, radiographs and scoliosometer

Prognosis of scoliosis
Treatment of scoliosis

Mild scoliosis
Severe scoliosis

From biochemistry to biomechanics

Extra-cellular matrix (MEC)

Connective tissue

Connective tissue band
Fascial mechanoreceptors
Myofibroblasts
Deep fascia biomechanics
Viscoelasticity of the fascia

Posture and tensegrity
The specific motion of man

Praise to the propeller

"Artificial" life

Breech support
Occlusal support (stomatognathic apparatus)

Myths about (idiopathic) scoliosis to dispel

Clinical case

Introduction
Materials and methods
Results
Discussion of the results

Conclusions
Bibliography

Premise

The aim of this work is to try to make a contribution of clarity, albeit necessarily partial, to the problem of idiopathic scoliosis and spinal and postural alterations in general, based on recent biomechanical and biochemical acquisitions.

After introducing the "canonical" concepts, commonly accepted, concerning scoliosis, I will move on to describe biochemical concepts that are the basis of biomechanical concepts that are now to be considered acquired. In turn, the description of the latter represents the foundations of the integrated treatment method, which I have in team with other professionals, used for the real clinical case given as an example.

Scoliosis this unknown

Scoliosis - from the Greek skolios which means crooked, twisted - represents a deformation of the spinal column that has always caught the attention, especially for its strong aesthetic impact. This alteration (previously considered two-dimensional) is usually three-dimensional and constant, and is highlighted in particular way on the frontal plane; characteristic signs of scoliosis are in fact the lateral convexities / concavities of the rachis.
Scoliosis affects about 3% of the population with female prevalence (5: 1) and in the childhood-adolescent period (over 80%). In most cases it occurs at the beginning of pubertal development and tends to evolve up to bone maturation.In important scoliosis, however, evolution can persist even if very slowly.
Normally scoliosis does not cause pain except in the adult if an important degree of spinal deformation is reached which can lead, in some cases, to significant organic dysfunctions such as cardio-respiratory ones. Scoliosis is severe in less than 0, 5 per thousand of cases (source: www.isico.it).

It must immediately be said that, despite the numerous study groups on scoliosis, there are still considerable shadow areas regarding the scoliotic problem; just think that in 80-85% of cases scoliosis is defined as idiopathic , that is with unknown origin, while only in a few cases are evident neurological, genetic, metabolic causes, etc. (neuromuscular syndromes such as cerebral palsy, muscular dystrophy, poliomyelitis, congenital hypotonia, musculo-spinal atrophy and Friedrich's ataxia; collagen diseases, such as Marfan's syndrome, neurofibromatosis, Down's syndrome, dysplasias, dwarfism, etc.). This is reflected, inevitably, in definitions and classifications at least "with poorly defined outlines" and with consequent programs and re-educational indications often, at least in part, without real proven scientific foundations.

The same differentiation between structural scoliosis (dysmorphism) and scoliotic attitude (paramorphism) it can often represent a diagnosis, therefore a poorly specific prognosis, and consequently entailing ineffective re-educational treatments. Structural scoliosis is defined as such if we are in the presence of a structural alteration of the vertebrae, that is, there is the detection of some deformed vertebrae. The abnormal curvatures of this scoliosis are therefore more persistent and more resistant to correction.
In reality, it must be considered that bone tissue, being part of the large family of connective tissues, has a specific peculiarity: viscoelasticity. In fact, bone tissue can be considered as a composite material consisting largely of rigid hydroxyapatite (HAP) particles inserted in a flexible (elastic) matrix made of collagen fibers. The anisotropic form of these mineral particles is one of the probable causes of the anisotropic mechanical properties (the "anisotropy represents the characteristic of a solid for which the physical properties assume different values depending on the direction in which they are measured) of the cortical bone tissue. L" evident viscoelastic behavior shown by the bone tissue is related to the viscoelasticity of the collagen fiber of the bone matrix (Clienti et al, 2007). Like all connective tissues, therefore, bone is also malleable. As demonstrated by J. Wolff as early as 1892 with his law, bone deformation occurs in the directions and on the basis of the mechanical stimuli (thrusts and / or tractions) that it undergoes in a preponderant way (both under the quantitative and temporal aspect). The mechanical load therefore represents the variable that conditions the architecture of the bone. Specifically, the lack of collagen fibers determines a greater fragility of the bone while the lack of calcium increases the flexibility of the bone. Therefore the malleability of the bone it is, as a rule, maximum in the growth phase and in the osteoporotic phase.
The probability that a scoliotic attitude (paramorphism) evolves over time into dysmorphism (structural scoliosis) is therefore to be considered high.

Wolff's law
The trabeculae are arranged according to the main directions of the stresses and their thickness and the spaces between them vary as the intensity of the load varies. Any change in function or shape in the bone is accompanied by variations in its internal architecture, as well as by alterations secondary to the external conformation, both linked to precise formulations

It is believed that the scoliotic process predominantly (70% of cases) starts with one or two primary curves (also called main or primitive) which can be followed by other minor compensation (Stagnara, 1985), such as to allow the subject to pursue the primary need to look towards the horizon while walking.

Flexion in the frontal plane of the spine is generally accompanied by a rotation in the transverse plane of the same. This torsion essentially depends on the positioning of the center of rotation in the various vertebral metamers involved in scoliotic curves. The center of rotation it can be imagined as the fulcrum around which the vertebrae making up the same metamer rotate. Depending on the position of the center of rotation (and the relative contact between the articular facets), the lateral bending of the spine may involve a right, left or neutral rotation of the vertebrae. This rotation mechanism, discussed later, allows rotation of the pelvis ( coupledmotion of the spine ), therefore a physiological walk that precisely requires the conversion of lateral flexion into axial rotation (Gracovetsky, 1988).

The scoliotic alteration, like all spinal deformations, involves, in addition to the vertebrae and the relative joints, the intervertebral discs, the ligaments, the myofascial system and the internal organs. All this is therefore capable of causing structural and functional problems , as well as aesthetic, which can evolve negatively over time unless appropriate action is taken.