Dr. Lamantia presenting a report on the importance of vestibular rehabilitation at the 2007 International Conference on Conservative Management for Spinal Deformities at Northeastern University

A comprehensive neurological examination is recommended although it is not mandatory to be fitted with an orthosis. Our approach to the non-surgical management of scoliosis is focused on neuro-muscular re-education of the postural support systems. The evaluation may include a sensory/motor exam, vestibular screening/evaluation, oculomotor screening/evaluation, movement analysis, neurocognitive asseessment, neurophysiological evaluations.

Neurological patterns of dysfunction have been reported by researchers, however typical orthopedic management neglects most functional analyses and appropriate rehabilitation. In the event neurological imbalances are revealed, further testing, neuro-diagnostic imaging and appropriate therapy programs may be prescribed.    

Etiology of Idiopathic Scoliosis: Current Trends in Research. Click here

(Lowe et al 2000)

...A number of studies have shown an abnormal nystagmus
response to caloric testing in patients with idiopathic scoliosis, suggesting an oculovestibular abnormality. Herman et al.46 proposed that a dysfunction of the motor cortex that controls axial posture results from a sensory input deficiency concerning spatial orientation and that this effect probably results from central proprioceptive sources involving visual and vestibular function. Other reports have supported this concept. The clinical syndrome of symmetrical horizontal or lateral gaze palsy is associated with a high prevalence of scoliosis of the idiopathic type. The site of neurological abnormality is thought to be the paramedian pontine reticular formation, which links the preocular motor nuclei and the vestibular nuclei. It is reasonable to speculate that the site of neuropathy in idiopathic scoliosis could also be the paramedian pontine reticular formation.

Video Electronystagmography is the "gold standard" in the assessment of these systems as well as brain, brainstem and cerebellar control of eye movements. This non invasive diagnostic test can objectively diagnose cerebello-vestibular dysfunction and cortical imbalances which may be an underlying cause of spinal curvatures.

Vestibular Function in Adolescent Idiopathic Scoliosis

Abstract from Scoliosis Research Society (SRS) 2003 Meeting

Matthew T. Provencher M.D., Derin Wester, Ph.D., Bruce Gillingham M.D.; Naval Medical Center- San Diego, CA.  Orthopedic Research and Education Foundation- Resident Research Grant
Conclusion: A central vestibular deficit is present in scoliosis patients. Central vestibular function is worse with larger curves, and the dysfunction is opposite to the curve. Curves with location in the mid-thoracic region demonstrated less central deficit than low-thoracic and lumbar scoliosis curves. The data supports a central vestibular dysfunction in patients with scoliosis

A study of labyrinthine function in patients with adolescent idiopathic scoliosis. I. An electro-nystagmographic study.

Spontaneous nystagmus (SN) and positional nystagmus (PN) were found in 24 out of the 47 patients with single curvatures and in only one subject in the control group (P less than 0.001).

Significant differences were observed in the caloric response between right and left scoliotic patients (P less than 0.05). The right convex patients had a sensitivity dominance in the right labyrinth and the left convex patients in the left labyrinth (Acta Orthop Scand 1979 Dec;50(6 Pt 2):759-69 Sahlstrand T, Petruson B.)

Vestibular mechanisms involved in idiopathic scoliosis:

(Arch Ital Biol 2002 Jan;140(1):67-80 Manzoni D, Miele F.Dipartimento di Fisiologia e Biochimica, Universita di Pisa, Via S. Zeno 31, I-56127 Pisa, Italy)

...It appears, however, that, in children, a slight imbalance in the activity of vestibular complex of both sides escapes the neuronal mechanisms responsible for vestibular compensation and leads to the spinal curvature which characterizes Idiopathic Scoliosis.

...The recommendation was made that a neurological examination, including assessment of vestibular function, be incorporated into screening methods for scoliosis.
(Jensen GM, Wilson KB. Phys Ther 1979 Oct;59(10):1226-33)

...Significant differences were found between patients with right convex curves and those with left convex curves in the distribution of eye predominance and in labyrinthine sensitivity
(Spine 1980 Nov-Dec;5(6):512-8 Sahlstrand T.)

IS THERE A RELATIONSHIP BETWEEN THE RESULTS OF UNTERBERGER TEST AND CONVEXITY OF SCOLIOSIS MAJOR CURVE?
 

Romano Michele, Zaina Fabio
ISICO (Italian Scientific Spine Institute), Via Carlo Crivelli 20, 20122 Milan, Italy - michele. romano@isico. it
Objective: The Unterberger stepping test is normally used to identify vestibular dysfunction and not to detect central disorders of balance. However we already made a previous study where we found a significant statistical difference in a sample of 30 scoliotic patient compared with a healthy control group. Our aim was to study if there is a relationship between direction of rotation during the test performance and convexity of scoliosis major curve.
Study design: 59 patient with adolescent idiopathic scoliosis (range: 14-55° Cobb) performed an Unterberger test (50 steps on place with closed eyes) before physical therapy session. Patients were divided into two groups: single curves, 29 subjects with 11 left and 18 right curves; double curves, 30 patients.
 

Results: There was a statistically significant concordance between the side of the curve and patient displacement after test performance in the single curves group when compared with the double curves, even if not all patients performed in the same way. There was not a significant statistical difference among left and right curve behaviours. Conclusion: These results could be explained both with neuro-motorial changes primary or secondary to the pathology, and biomechanical ones due to vertebral displacements.

Dr. Lamantia and Dr. Romano at the 2007 SOSORT Convention