Introduction
Adolescent idiopathic scoliosis (AIS) is a type of scoliosis defined by a lateral curvature of the lumbar, thoracic, or cervical regions of the spine in a prepubescent individual.1 AIS has a low prevalence rate, with approximately 3% of children showing cases of scoliosis,2,3 which is increased in females compared to males.4 The impact of AIS becomes a concern when lateral curvatures begin to progress. AIS, when left untreated, usually has benign long-term effects but can cause mid-back pain as well as emotional and social issues.
Wong et al.5 discussed origin possibilities such as genetic variant, neurological adaptation from development, hormonal inputs, and developmental errors. Burwell et al.6 extended research on a “multifactorial cascade” involving genetic, environmental, and lifestyle factors during development. Both studies lacked enough evidence to derive a definitive answer to the pathogenesis of AIS and settled on a multifactorial approach.
Scoliosis is primarily measured on x-rays using the Cobb angle. Thoracic curvatures beyond 40° can be considered severe.3 These curvatures are typically treated with surgical interventions such as a spinal fusion with Harrington Rods or Vertebral Body Tethering (VBT). Curvatures under 40 degrees fall under the conservative criteria for treatment. The “watch and wait” approach has been used for many years and has become more of an outdated approach when it comes to treatment. Scoliosis-specific exercises have gained traction in the field with increased utilization across multiple practitioners.1,7
Exercise interventions have become more prevalent amongst researchers seeking conservative care options for AIS. Multiple protocols have been accepted amongst professionals in the field, including that of ScoliSMART,7 the Schroth Method,8 and Scoliosis Boot Camp.9 All have shown clinically significant success rates in scoliotic treatment.
This case represents the protocols used in the treatment of a 12-year-old patient with minor lumbar and thoracic curvatures. The goal of the treatment was to see if chiropractic care and exercise could prevent the progression of the patient’s curvature.
CASE REPORT
Patient History
A 12-year-old male visited a chiropractic clinic to receive x-rays for a scoliosis screening. The patient’s mother started to notice postural changes while the son performed activities around the house. Postural changes included a minor right tilt in the thorax when performing chores, a consistent rightward lean when watching television, and a minor right hip elevation while standing.
The child was in a car accident with his family on more than 18 months earlier. The accident caused a fracture of the right femur, which was surgically repaired. After repair and rehabilitation, his orthopedic surgeon opted for a second surgery to insert a larger rod and bone grafting, based on the patient’s projected growth. This surgery was undergone in August of 2023. After this surgery, the patient’s mom noticed postural changes around the house, which prompted the request for scoliosis screening at the chiropractic clinic.
The original radiology impressions from November 6, 2024, revealed minimal left lumbar curvature not meeting the threshold for scoliosis and a left thoracic 12-degree curvature, T8-T12, consistent with minimal scoliosis. Based on these results, the patient’s mom had concerns about curvature progression. This concern is what initiated the beginning of this case report. Consent was given by the patient’s parent to begin care and publish a case report on the progression and outcome of the treatment.
His initial visit was for rehabilitative exercise after surgical implantation of intramedullary nailing. Postural discrepancies and a positive Adam’s Test warranted x-ray examination of the cervical, thoracic, and lumbar spine. His initial Cobb angle in the lumbar spine was measured at 5° and 12° in the thoracic spine (T8-T12), confirmed using standing PA radiographs.
Outcome assessment tools for initial encounter after radiography were as follows: Lower Extremity Functional Scale (LEFS): 73/80, Low risk for function, Yellow Flags (YF), 13/130, Visual Analog Scale (VAS), 0/10 No pain.
His postural analysis included mild anterior head carriage, right shoulder elevation, minor leftward pelvic rotation, right iliac spine discrepancy compared to the left.
His neurological and orthopedic examination was within normal limits except for mild right-sided paraspinal hypertonicity in the thoracic spine, visible right rib hump on Adams test, +1 patellar reflex on the right, left lateral pelvic tilt, and decreased left lateral flexion in the thoracic spine.
The patient performed bouts of different exercise programs throughout the coming weeks. These programs were divided into 3 different categories. The first category includes general strength exercises. Strength exercises measured included sled push and pull, deadlifts, shoulder press, kettlebell swings, and farmer carry. The second category included postural correction exercises, using banded rotations, unilateral balance, and active core engagement to create cognitive awareness. The third category focused on athletic improvement. These movements included running mechanics, agility drills, upper body and lower body plyometrics.
Radiograph Impressions
Initial cervical, thoracic and lumbar radiographs were taken on 11/6/2024. No scoliosis was evident in the cervical spine. A minimal left lumbar curvature was noted as not meeting the threshold for scoliosis. The thoracic radiograph revealed left 12° curvature T8-T12 consistent with minimal scoliosis. Follow-up images were taken almost 6 months later 4/30/2025. Cervical spine images showed no scoliosis was evident. Anterior head carriage. No substantive interval changes evident since previous examination. Follow-up lumbar images showed no scoliosis. Minimal left lumbar curvature unchanged from comparison examination. Left femur head 8mm lower than the right – correlate with the clinical history and presentation to include during radiographic examination. The follow-up thoracic image revealed left 12° curvature T8-T12 consistent with minimal scoliosis, unchanged from comparison examination.
Clinical Course
Over a 6-month treatment protocol where the patient was seen 2-3 times per week. This care consisted of chiropractic manipulative therapy to the cervical, thoracic, lumbar and pelvic regions as deemed medically necessary. The patient was mainly treated in the thoracic region with diversified chiropractic manipulative therapy and the low back region with side posture, high velocity low amplitude chiropractic manipulative therapy and Thompson drop technique (diversified, Palmer-Thompson, and Palmer Gonstead), corrective exercises, strength exercises, speed exercises, and neuromuscular control. In addition to the exercises listed in Table 1, the patient also walked backwards on the treadmill at a 10% incline for 10 minutes, performed single leg sit downs 3 rounds of 10 reps, eccentric step ups 3 rounds of 10 reps, single leg 2 second wall sits for 5-8 reps and 5 sets of weighted reverse sled pulls.
By week 12, the patient had an approximately 30% increase in strength, as shown in Table 1, by the increase in weight for prescribed exercises, approximately 50% visual improvement in lower extremity range of motion, and daily activity tolerance. At this point exercises were advanced to 3 sets of 8 reps of deadlifts, 3 sets of 12 sit-ups, 3 sets of 8 superman’s, 2 sets of 6 lateral raises, 2 sets of 10 pallof press with a resistance band.
By the 6-month mark, the patient had a total of 60% increase in strength, 50% increase in lower extremity range of motion, improved muscular tone, and improved postural awareness and daily activity tolerance. The thoracic and lumbar curves had no change. The exercises were then advanced to kettlebell dead lifts and bicep curls 4 sets of 8, and 2 rounds of a high intensity interval training consisting of shuttle runs, burpees, push-ups and body weight squats.
Strength measurements were calculated using the 1 rep max of the deadlift, and weight tolerance of other exercises performed in the trial. Lower extremity range of motion was measured using a visual scale of the patient’s sit and reach stretch.
Discussion
Adolescent idiopathic scoliosis (AIS) is a type of scoliosis defined as a lateral curvature of the spine in prepubescent individuals. Typically unexplained in its origin, AIS has been hypothesized to derive from a “multifactorial cascade”.5 In this case we were particularly interested in the developmental and postural components associated with AIS, and how traditional exercise in conjuncture with chiropractic care could influence the curvature in adolescence.
If in fact, a scoliosis could be derived from a postural adaptation, is it plausible that this patient’s history of multiple open reduction internal fixation (ORIF) of the femur proceeding with a car accident in the patient’s adolescence? No conclusion could be drawn from this question, based on a lack of evidence of previous imaging studies.
Many exercises have been shown to improve postural changes across multiple conditions. Examples of this can be seen from Bae et al.10 and Nitayarak et al.11 for upper cross syndrome. Both studies found that exercise programs focused on the scapular musculature, primarily the trapezius, resulted in improved biomechanical response. Scoliosis-specific programs have been researched as well, providing evidence that exercise can play a pivotal role in corrective care.
The patient underwent a traditional strength and conditioning regimen during this care plan and did not undergo any scoliosis-specific exercise programs like ScoliSMART,7 the Schroth Method,8 or Scoliosis Boot Camp.9 The purpose of following a traditional strength and conditioning program rather than implementing one of the other programs was to fill a gap in the research focusing on general exercise in an adolescent population as a treatment for scoliosis.
During the trial, the patient was adjusted once a week. A variety of Palmer Thompson and Palmer Gonstead adjustments were used to adjust the Sacrum with a left posterior rotational component. The patient was also adjusted in the Thoracic spine from T4-T8, using a cross bilateral pisiform, and reinforced pisiform HVLA (high-velocity, low-amplitude) adjustments. These segments were chosen based on radiographic interpretation, motion palpation, muscle tonicity, and skin texture or temperature variability.
The exercises chosen for the strength and conditioning program were selected based on postural and movement screenings performed at the beginning of the program. Programming included hip flexion and extension, core stability, deadlift variations, running progressions, unilateral and bilateral carries, multi-segmental extension, and lower to upper body transitional exercises. These exercise categories were chosen to improve proprioceptive awareness, neuromuscular control, and functional mobility.5,8,9 Scaling and progression were based on patient tolerance to previous modality.
By the end of the 6-month care plan, the patient and his mom expressed their concerns with fatigue during the programming. After final radiographic examination, a collective decision was made to decrease the overall volume of training to at home exercises only and once a week adjustment.
Conclusion
This case fills a gap in the research for exercise protocols and chiropractic manipulation and their effectiveness on scoliosis progression. More research is needed to provide conclusive evidence that general exercise protocols in association with chiropractic care are helpful for the treatment of adolescent idiopathic scoliosis.