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Experimental and Molecular Pathology 74 (2003) 326 –335 www.elsevier.com/locate/yexmp

Regression of juvenile idiopathic scoliosis

William E. Stehbens* and Rachel L. Cooper
Department of Pathology and Molecular Medicine, Wellington School of Medicine and Health Sciences, Wellington, New Zealand

Received 21 August 2002

Abstract
For a young scoliotic boy the customary “wait and watch” management program for rapidly progressive juvenile idiopathic scoliosis was
considered unsatisfactory in view of the poor prognosis. The management program devised was based on the congenital postural induction
concept of scoliosis with progression accruing from mechanically induced bioengineering fatigue, cumulative molecular scissions, laxity of
ligaments, and secondary bone deformation. A coexisting pelvic tilt with restricted movement of the hip and shoulder joints was overlooked
initially. Possibly induced simultaneously with the scoliosis, it is considered a contributory factor in scoliosis progression and requires early
diagnosis and correction. The rapid improvement in this child’s spinal status achieved by physiological traction and specifically designed
exercises was such that as a preventive measure the technique warrants further clinical assessment on young scoliotics.
© 2003 Elsevier Science (USA). All rights reserved.

Keywords: Idiopathic scoliosis; Congenital postural scoliosis; Conservative exercise program; Vertebral traction; Scoliosis regression

Introduction clinically manifest from 3 to 10 years of age. This arbitrary

Despite a poor prognosis, juveniles with early idiopathic
scoliosis currently receive only periodic surveillance in the
hope that the spinal curvature will spontaneously regress,
there being no effective nonoperative therapy available to
reverse or stabilize the deformity. This analysis of the man-
agement is aimed at improving the prognosis and hopefully
at preventing the development and progression of this tragic
deformity.
Scoliosis and posture
In approximately 15–20% of cases of scoliosis the initial
cause is known and in the remainder the so-called idiopathic
scoliosis is likely to be postural in nature (Stehbens, 2002).
Like hallux valgus, scoliosis should be regarded as a bio-
mechanical deformity highly prone to further progression.
By convention, idiopathic scoliosis is of the infantile type
when detected before 3 years of age and juvenile when
* Corresponding author. Department of Pathology and Molecular Med-
icine, Wellington School of Medicine and Health Sciences, P.O. Box 7343,
Wellington South, New Zealand. Fax: ⫹64-4-389-5725.
E-mail address: wstehbens@wnmeds.ac.nz (W.E. Stehbens).
classification does not preclude the possibility that juvenile
scoliosis commences earlier or even in utero. The need to
separate juvenile from infantile scoliosis has been ques-
tioned (James, 1965; Mehta, 1992; Stehbens, 2002) as the
former seems to accrue from undetected curvatures in in-
fancy (Dickson, 1985).
The little known congenital postural scoliosis (Browne,
1956, 1965; Dunn, 1976a, 1976b) has been attributed to
compression deformity in utero as a result of rapid fetal
growth in late pregnancy, diminishing amniotic fluid, and
impaired mobility, the latter indicated by diminished kick-
ing and fetal inability to change position (Dunn, 1976a).
While mobile the body appears to grow normally in utero.
When comparatively immobile in a cramped and curved
position, the relatively fixed spine and ligaments maintain
growth in this incipient scoliotic position with muscles
probably underdeveloped rather than atrophic from little
use. After birth, when unrecognized and uncorrected, the
small curvature is perpetuated as a “position of comfort”
and ever so slowly and insidiously progresses to severe
scoliosis especially as the upright position is assumed. Most
of these curves are said to undergo spontaneous resolution
(Dunn, 1976a; James, 1954a) with an undefined number

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 W. E. Stehbens, R. L. Cooper / Experimental and Molecular Pathology 74 (2003) 326 –335
passing unnoticed and presenting later as juvenile or ado-
lescent scoliosis. The current practice of ignoring curves
with Cobb angles under 10° masks an uncertain number of
more slowly growing deformities (Stehbens, 2002). Other
idiopathic scoliotics may develop habitual, undesirable pos-
tures in which the spine becomes relatively fixed due to
growth of spinal ligaments in a scoliotic posture with later
progression during a growth spurt or ligament failure.
Congenital postural deformity initially defined by
Browne (1936, 1956) may be more important in idiopathic
scoliosis than currently believed. Infantile “idiopathic” sco-
liosis has been associated with plagiocephaly and dysplasia
of the hip (Browne, 1965; Dunn, 1976b; Lloyd-Roberts and
Pilcher, 1965; Wynne-Davies, 1968, 1975) which like hip
dislocation, bat ears, and torticollis can be produced by fetal
compression in utero, the posture perpetuated postnatally as
a position of comfort. With the femoral head held in its
proper position, hip joints develop normally whereas intra-
uterine pressure on the limbs in an atypical position can lead
to dysplasia or hip joint dislocation. Thus a thigh held in
abduction or adduction for too long late in gestation pre-
cedes limited mobility of hip joints and eventual pelvic
asymmetry (Cozen, 1968). Salter et al. (1963) reported that
in newborn piglets hip joints maintained in extension for 8
weeks developed progressive femoral head dysplasia and
slight subluxation. This was reversed after the piglets ran
freely for 12 weeks. The authors concluded that in humans
dysplastic hip instability and even subluxation may result
from compression in utero or develop postnatally when a
tightly wrapped baby is unable to move the legs freely (e.g.,
Navajo infants) (Coleman, 1968).
When one hip is dislocated, the other may exhibit vary-
ing degrees of dysplasia. Karski (2000) attributes most cases
of idiopathic scoliosis to abduction contracture of the right
hip. Unilateral congenital hip dislocation is more commonly
left-sided (Watson, 1971) and varying degrees of hip joint
subluxation or instability are frequent. Weissman (1954)
contended that in infants with abduction contracture, the
contralateral hip was often accompanied by hip dysplasia (a
forerunner of dislocation) with adduction contracture. Co-
existing changes in the two hips were considered to be
interrelated as both thighs are directed to the same side and
associated with pelvic obliquity, the abducted leg appearing
to be longer (Wiseman, 1954) as the unstable head of the
opposite femur slips out from under the cartilagenous rim of
the acetabulum. Unless treated this readily missed joint
instability can lead to pelvic asymmetry (Hart, 1942).
Lloyd-Roberts and Pilcher (1965) reported that 10% of their
infants with compression scoliosis had pelvic obliquity, the
pelvis following the curve of the trunk and being higher on
the concave side. Limited hip abduction was usually found
on the convex side, the authors believing this to be a man-
ifestation of the compressed fetal syndrome.
Dickson (1983, 1984) reported a pelvic tilt in 40 to 50%
of adolescent scoliotics. Although the spine would be de-
stabilized, he regarded the deformity as inconsequential
327
with no propensity to progression. Previously Dickson et al.
(1980) had attributed the pelvic tilt to unequal leg length, a
concomitant of the spinal curvature or pelvic asymmetry per
se whereas the latter is more likely to be secondary to severe
scoliosis or to develop simultaneously under the same pres-
sure. They also postulated that a substantial proportion of
scolioses is entirely or partially secondary to the sacral tilt,
that scoliosis did not progress in children with curves solely
due to a sacral tilt, and that compensatory lumbar scoliosis
(commonly produced by a sacral tilt secondarily to inequal-
ity of leg length) is never progressive.
The pelvic tilt in scoliotics is deserving of more atten-
tion. It is greatest in small curves and mostly associated with
lumbar and thoracolumbar curvatures (Dickson, 1983). Re-
garding it as inconsequential is unwarranted for whatever
the cause, the result is spinal instability unless the L5 ver-
tebra is wedge shaped to compensate. Its frequent associa-
tion with hip dysplasia and the apparent but not true in-
equality of leg length correlate with the compressed fetus
syndrome as Browne (1965) and Dunn (1976a, 1976b)
reported. The pelvic tilt, hip dysplasia, and fetal postural
scoliosis seem to develop concomitantly. Although abduc-
tion contracture of one hip can self-correct in physically
active children, the contralateral dysplastic hip on the con-
vex side would take longer to rectify. A little known com-
ponent of the fetal compression syndrome is the involve-
ment of the shoulders for they too are likely to be
compressed and immobile in late pregnancy (Tönnis, 1968).
Prognosis and progression
James (1951) divided infantile scoliosis into resolving
(36%) and progressive (64%) types conceding inability to
differentiate the two with any certainty (James et al., 1959).
Nor do all in the resolving group resolve permanently. Of 86
cases of infantile scoliosis attending a clinic in the first three
years of life, 24 were considered to be resolving, and 19
(curves ranging from 10 to 50°) were stable at that time. The
remaining 43 infants (50%) with single or double curves all
progressed substantially (33 requiring surgery) during sur-
veillance (Thompson and Bentley, 1980). Browne (1965)
contended that congenital postural scoliosis, if not treated
early after birth, progressed to severe intractable deformity
with dwarfism.
Most juvenile scoliotics progress and have a bad prog-
nosis (James, 1954a, 1954b). Nash (1980) said that rapidly
growing prepubertal scoliotic children have a 60% chance
of progression. Tolo and Gillespie (1978) reported progres-
sion in 71% of juvenile scoliotics, although lack of progres-
sion does not equate with regression. Untreated, scoliotic
juveniles progressed at a median rate of 6° per annum. In
another 98 juvenile scoliotics 7 resolved during the follow-
up, 8 remained stationary, and the remainder (85%) pro-
gressed, 56% requiring spinal fusion (Figueiredo and James,
1981). In another 109 juveniles (Robinson and McMaster,
328 W. E. Stehbens, R. L. Cooper / Experimental and Molecular Pathology 74 (2003) 326 –335
1996) with idiopathic scoliosis, 95.4% were progressive.
The remaining five received brace therapy and the curves
regressed to less than 10°, one with an original angle of 40°.
The ominous prognosis and the widely recognized propen-
sity for severe deformity (Dobbs and Weinstein, 1999; Ep-
stein, 1976; Morin, 1999) justify concern over the absence
of a satisfactory therapeutic program for juvenile scoliotics
who remain vulnerable to progression during the pubertal
growth spurt. Curve regression to below 10° does not ensure
lack of progression at puberty or later.
The pathogenesis of the progression, irrespective of the
initial cause, can be attributed to the unavoidable repetitive
biomechanical stresses of daily living applied unremittingly
and asymmetrically to the spinal deformity with its mala-
ligned vertebrae and discs. As with joints elsewhere the
spinal constituents of bone, cartilage, and ligaments mani-
fest increased vulnerability to fatigue-induced degenerative
osteoarthrosis involving cumulative, molecular scissions of
macromolecules and polymers rather than assumed enzy-
matic self-destruction (Stehbens, 2002). Molecular disinte-
gration accounts for the degenerative changes, laxity (and
tears) of ligaments, and augmentation of the architectural
deformity as in blood vessels (Stehbens, 1997).
Current management of scoliosis
Although conservative management of scoliosis has en-
compassed physiotherapy, electrical muscle stimulation,
traction, and bracing, the aim here is not to appraise the use
of orthotics. It is to consider conservative management in
the early stages of the deformity in young pediatric subjects.
Waiting for scoliosis progression to attain a specified degree
of severity has to be an undesirable management procedure.
Dickson (1985, 1999) maintains that if a deformity is ac-
ceptable at presentation, then preservation of this degree of
acceptability is the aim. Acceptability to those resigned to
severe progressive deformity and spinal osteoarthrosis with
greatly restricted employment and a shortened lifespan from
cardiopulmonary disease is far from optimal management
which should be based on an understanding of the patho-
genesis of the progression (Stehbens, 2002).
Boachie-Adjei and Lonner (1996) recommend close
monitoring of pediatric scoliotics at 4 to 6 monthly intervals
for curvatures up to 20°. Orthoses are considered for those
in the range of 20 to 29° with progression of 5° and for any
curvature of 30° or more in the skeletally immature with
surgery proposed for deformities of at least 40°. In the
absence of any therapy for children with curves up to 20°,
school screening programs have fallen by the way side.
Galasko (1998) recommends that in general terms, idio-
pathic adolescent scoliosis is “treated” by regular observa-
tion until skeletal maturity if the curve is less than 25 to 30°.
Moderate curves of 30 to 45° are frequently treated by
bracing until skeletal maturity, whereas in a growing ado-
lescent curves greater than 40 – 45° often require surgical
correction and spinal fusion (Lonstein, 1994). For pediatric
scoliosis the management generally advocated is periodic
surveillance at variable intervals with radiological assess-
ment until curves are sufficiently large to warrant bracing.
No other effective nonoperative treatment is available
(Dickson, 1996).
Exercise programs recommended for juvenile scoliotics
with large curves have, in general, proved ineffective (Nash,
1980). Hungerford (1975) vigorously condemned exercises
alone. With few exceptions description of the physical ex-
ercises is not provided. Whether the exercises are directed at
reducing the curve, or compensating for inactivity of the
relatively fixed trunk in the brace for most of the day, is
unstated. Bjure et al. (1969) had recommended exercise on
a bicycle ergometer, jumping up and down, throwing med-
icine balls, running on the spot, skipping, Indian jump, and
bicycling, the purpose being to enhance a subject’s general
physique and vital capacity. However because it is impos-
sible to prevent young children from running and playing, it
is of the utmost importance that parents maintain close
surveillance with avoidance of repetitive jumping up and
down movements which are detrimental and cumulatively
aggravate scoliosis. They are akin to impact loading the
vertebrae and disks vertically and asymmetrically, thereby
increasing the flexure and shortening the fatigue life of
spinal constituents (Stehbens, 2002).
The Schroth technique is an intensive course of in-pa-
tient physiotherapy (4 – 6 weeks) for those 8 to 70 years of
age. For 6 – 8 h/day patients are taught specific breathing
exercises and asymmetrical postural exercises promoting
body symmetry to correct the scoliosis and visible deformi-
ties (Lehnert-Schroth, 1992; Weiss, 1991, 1992). Mirrors
monitor the correction and posture and physiotherapists
monitor compliance and progress. Some patients receive
electrical muscle stimulation and orthoses. In a 31-month
follow-up, scoliosis was stabilized in two-thirds, progressed
in 16.1% and in 15.2% had improved more than 5° with
long-term effects uncertain. The prime benefit seems to
derive from the improved vital capacity of 18% and stretch-
ing exercises (Weiss, 1991). Ferraro et al. (1998) also re-
ported improvement and less progression in scoliotics given
active postural correction exercises of different types over
an average of 2 years. Sustained patient compliance was a
major problem and long-term benefit uncertain. The con-
sensus is that exercise programs have not provided signifi-
cant benefit (Rowe et al., 1997; Stone et al., 1979) and the
exercises are often detrimental. Nor has chiropraxis any-
thing expedient to offer (Lantz, 2001).
Longitudinal traction (as on a rack) has been used in
scoliosis since the times of Hippocrates (Roaf, 1966). On
current evidence it has proven to be a successful temporary
maneuver in severe deformities prior to bracing or surgical
fixation (Wilkins and MacEwen, 1977). It has been applied
by means of halotraction (halo-femoral or halo-pelvic) par-
ticularly in severe scoliosis (Bradford et al., 1975), the halo
being fixed to the skull and femoral or pelvic traction at the
 W. E. Stehbens, R. L. Cooper / Experimental and Molecular Pathology 74 (2003) 326 –335
lower end with the traction effected by weights. Given the
serious and at times fatal complications (lesions of cranial
nerves and brachial plexus, respiratory problems, abnormal-
ities of swallowing), all traction must be applied with cau-
tion particularly in the presence of neurological disease.
Cotrel traction (Cotrel et al., 1980; Hancox, 1981) con-
sists of horizontal stretching of the child’s body day and
night by means of a pelvic corset attached to scales at the
bottom of the bed and a head halter with a 2-kg weight
attached to the bed top through a pulley system. Additional
self-imposed dynamic traction is achieved by means of a
handle bar and stirrups attached to the static traction appa-
ratus, self-elongation by arm pressure proving more effec-
tive than foot pressure on stirrups. Intermittent pressure is
gradually increased in frequency up to 30 times per hour for
9 –10 h per day with unspecified exercise sessions and time
for schooling. The regimen continues for 7 to 10 days with
radiological assessment of improvement. In 19 cases cor-
rection was over 40% and used preoperatively, the proce-
dure obtains maximum possible correction. Cotrel (1965)
achieved a curve reduction from 73° at 3 years 10 months to
54° at 5 and a half years prior to surgery. The technique
induces some vertebral derotation and disadvantages are the
prolonged periods of immobilization and ensuing muscle
atrophy.
Vertical gravitational traction has been achieved by sus-
pending children upside down by the feet while a pelvic
brace with bars is held by the hands (Majoch, 1981). Treat-
ment duration was increased from 12 min to 1 h daily and
the loading on the head was increased up to 25% of the body
weight for 4 weeks preoperatively and combined with mus-
cle massage, manual curve correction, and swimming to
improve lung capacity. The program was not applied to
children with hypertension or a spinal or neurological dis-
order. A curve of 117° in a 12-year-old boy was reduced to
57° in 4 weeks and results were considered better than with
horizontal traction. Tabjan and Majoch (1980) used vertical
traction 6 times per week for 3 to 6 weeks preoperatively,
the patient hanging from parallel bars by the legs and feet
with additional weight or traction applied to the neck. This
method improved respiratory capacity and allowed better
corrective force on the spine despite its discomfort to the
feet and legs. Thus, despite its hazardous and unphysiolog-
ical application, traction remains the only technique known
to reduce the curvature.
Rationale of management
Management of juvenile scoliosis should be based on the
concept that it is not a specific disease but a mechanical
deformity of the spine complicating many diseases and that
the most common idiopathic group comprises instances of
an habitual posture established in utero or postnatally and
perpetuated biomechanically (Stehbens, 2002). Irrespective
of the cause, progression of scoliotic curves results from
329
bioengineering fatigue-induced severe accelerated osteoar-
throsis (Stehbens, 2002). The acquired laxity of the weak-
ened ligaments and degeneration and deformity of the discs
and vertebrae associated with biomechanical fatigue poten-
tiate further curve progression. In essence pediatric idio-
pathic scoliosis management aims to (i) detect the deformity
at its earliest stage to initiate regression as soon as possible,
(ii) be aware of and to minimize underlying mechanical
stresses responsible for progression and limit the develop-
ment of osteoarthrotic degenerative changes, (iii) strengthen
bones, ligaments, and surrounding muscles symmetrically
by exercise using the spine in the manner for which it was
designed, and (iv) encourage and sustain patient persever-
ance with the ameliorative program.
Bones are living tissues and readily reshaped, indented,
or even eroded mechanically by pulsating arteries or aneu-
rysms. Skull shape can be mechanically modified in utero or
postnatally e.g., by plagiocephaly or hydrocephalus, and
elongated by infant head bandaging by Chinook Indians
(Dunn, 1969a, b). Tight bandaging of the feet of Chinese
women produced gross distortion. Giraffe-necked Padang
women (Roaf, 1966) were subjected to deforming pressure
(up to 30 pounds weight) on the shoulder girdle to incor-
porate thoracic vertebrae into the neck. Valgus deformity of
big toes with eventual deformation (bunions and osteoar-
throsis) can result from poor shoe design. Once established,
correction of joint deformities by physiological means be-
comes increasingly difficult. However, plagiocephaly can
be modified or induced postnatally and in neonates some
congenital postural and compressive deformities of the feet
and hip dislocations can be rectified or improved by non-
surgical orthopedic methods. Similarly in orthodontics
thumb sucking deforms the palatine arch and the position of
teeth is dependent on the balance of opposing tongue and lip
pressures (Proffit, 2000). Permanent teeth are more easily
moved by continuous direct pressure from a dental brace to
improve the alignment and bite in young children whereas
long-established anatomical deformities are less amenable
to correction. The recommendations borne out by amelio-
ration of dental malalignment at an early age are relevant to
scoliosis. The pressures exerted in orthodontics are gradual,
persistent, and directly applied, whereas orthotic pressures
brought to bear in scoliosis are of necessity indirect, not
applied directly to the spine itself, and can cause secondary
defomity of the rib cage. The spine and its ligaments con-
tinue to respond to prevailing stresses and mesenchymal
cells are dependent on and respond to mechanical stresses,
advantageous or otherwise, during growth and develop-
ment. Thus the aim should be to detect scoliosis early while
the spine is growing and maturing and more readily re-
shaped to a near normal configuration before the develop-
ment of serious spinal deformation and osteoarthrosis.
In an indefinite number of young subjects, scoliosis re-
gresses spontaneously, with both the incidence of and the
explanation for regression as yet unknown. The need to
determine the factors responsible for such regression and to
330 W. E. Stehbens, R. L. Cooper / Experimental and Molecular Pathology 74 (2003) 326 –335
assess the extent of residual curvature and the nature of
long-term clinical sequelae in such subjects is obvious.
Unrecognized physical activity seems to potentiate early
regression and males with idiopathic scoliosis are more
inclined to regression than females. This suggests that the
unidentified physical activity is advantageous although me-
chanical stresses in males are likely to be greater.
Increased awareness of congenital postural scoliosis
(Browne, 1956, 1965) and the need for its early detection
and treatment with a splint similar to Browne’s design
permitting continued mobility while correcting the curve
would seem worthwhile even if some curves regress spon-
taneously. Browne’s success rate for treatment in the first 6
months was 100%. Conversely Walker (1965), assessing
Browne’s splint for infantile scoliosis, concluded that treat-
ment benefit did not differ from that of untreated cases.
However, neither his therapy nor patient group were com-
parable to Browne’s. Even if 90% of early congenital pos-
tural scoliotics self-correct, when and how they were man-
aged are unknown. The problem of treating young children
with “intractable scoliosis,” if spontaneous regression does
not eventuate, is such that it would be wiser to treat all
affected babies within the first 6 months of life as Browne
recommended. There is also a need to search for dysplasia
and abduction and adduction contractures of the hip and
stiff shoulder joints and to treat the infants by early postural
correction (Green and Griffin, 1982). Ceballos et al. (1980)
were of the opinion that treatment is imperative as soon as
the diagnosis of progressive scoliosis is made. They used a
plaster “shell” to overcorrect the lateral spinal curvature
rather than Browne’s padded metallic splint. The plaster
shell was extended to maintain flexure and moderate abduc-
tion of the thighs for hip dysplasia.
For older infants and juveniles traction can be applied by
holding and gently swinging the child by the arms as if
playing. This activity could be useful until a jungle gym is
available and manageable by the child. As Browne (1956,
1965, 1969) emphasized, it is important to induce the child
to use its back in the manner appropriate for its design (i.e.,
with symmetrical movements) and to discourage move-
ments or postures perpetuating the curvature. Passive but
gentle manipulation to slowly overcome the resistance to
turn and bend toward the convexity could be useful. Like-
wise infants with a pelvic tilt, dysplasia of the hip joint, and
adduction or abduction contracture of a hip could undergo
gentle passive manipulation of the thigh to overcome the
joint stiffness. Browne’s curved splint (1956, 1965) would
also benefit both dysplastic hips. Hip dysplasia in infants
usually disappears after use of an abduction splint for 6
months (Weissman, 1954). Long-term follow-up of un-
treated hip dysplasia in the Navajo reveals spontaneous
improvement by the time of skeletal maturity with only
subtle radiological changes in 40% of the hips (Schwend et
al., 1999).
Therapeutic trial
The boy, the youngest of three children, was induced at
38 weeks due to toxemia of pregnancy, associated with
oligohydramnios and diminished frequency of kicking. He
grew, developed well, and was active with no family history
of scoliosis. At the end of winter when aged 4 years 10
months his asymmetrical stature in the bath was noticed. It
became more obvious within 2 weeks and attempts to in-
duce him to stand straight were unsuccessful. His chest was
asymmetrical with the left scapula higher and more prom-
inent than the right. A prominent gap was noticeable be-
tween his left arm and hip. His chest protruded slightly on
the left side and appeared slightly twisted. Thick clothing in
the colder months of the year had apparently masked the
abnormality and rapidity of the vertebral change. The
child’s grumpiness and lethargy had been attributed to a
growth spurt in excess of his peers. He had occasional pain
over the lower left thorax. Scoliosis was confirmed by X-ray
(Fig. 1). During the 3 weeks wait to see an orthopedic
surgeon, his deformed stance became even more pro-
nounced. The two orthopedic surgeons consulted found no
neurological abnormality or underlying disease. They found
equal leg lengths and normal flexibility and movement of
his head and neck. Radiologically there was mild thoraco-
lumbar scoliosis, convex to the left (within the range of
15°–20°). The apex was at the T12-L1 level and no abnor-
mality was detected by magnetic resonance imaging. An-
ticipating that the curvature would regress spontaneously,
one surgeon recommended surveillance at 6 monthly inter-
vals and the other at 12 monthly intervals. This was at
variance with the progression over previous weeks and the
proven adage “as the wind blows, so the tree grows.”
One of us (W.E.S.) recalled that in the late 1940s, trac-
tion, a body cast, and physiotherapy were utilized. Because
of concern that the curve would continue to progress and
become increasingly difficult to correct during prolonged
surveillance, it was reasoned that traction was the only way
abnormal spinal curvatures (with rotation and whether sin-
gle or double) could be corrected. We conceived of exer-
cising the child on a jungle gym (monkey bars). This me-
tallic frame resembles a horizontal ladder suspended well
off the ground with steps at either end for access; the child
hanging by his hands from the cylindrical rungs swings
from rung to rung (back and forth). Soon adept at this, he
played on the bars several times per day with alacrity, the
activity proving to be enjoyable for him and his siblings.
The swinging motion applied the stresses equally to both
sides of his body, the weight of his lower body providing the
traction. Improvement was rapid and noticeable within 10
weeks (Fig. 2). To reinforce the regression already
achieved, further exercises were introduced from time to
time. The rationale was that physiological traction and care-
fully selected exercises would potentiate regression of the
curvature, strengthen the muscles and ligaments about the
spine simultaneously increasing vertebral bone strength and
 W. E. Stehbens, R. L. Cooper / Experimental and Molecular Pathology 74 (2003) 326 –335
Fig. 1. This X-ray, taken 2 days after his fifth birthday, demonstrates the
left thorocolumbar scoliosis. Another X-ray demonstrated that the 12th rib
was deflected downward more so than the right. The pelvic tilt to the left
and the narrowing of the nonossified cartilaginous gap in the left sacroiliac
joint were overlooked.
mineral density. The visual improvement prompted a com-
prehensive analysis of conservative therapy and additional
reinforcing exercises.
This subject, a tall child with a left scoliosis and a pelvic
tilt, conforms to the previously undetected congenital pos-
tural scoliotic profile. The overlooked pelvic tilt (Fig. 1)
represents a component of congenital postural scoliosis.
Mehta (1992) considered scoliosis in most juveniles to be of
this infantile type. The curvature concave to the right is
associated with pelvic obliquity (Lloyd-Roberts and Pilcher,
1965) and abduction contracture of the hip in at least 10%.
When this possibility was perceived in the present case, no
331
such contracture was detected and the pelvic tilt, although
still present in an X-ray one year later, was less pronounced
(Fig. 3). Plagiocephaly, also associated with the syndrome
(Ceballos et al., 1980; Wynne-Davies, 1975), was absent.
Even after improvement in the scoliosis, on standing upright
the child suddenly and subconsciously assumes the pelvic
tilt with a sudden jerk reminiscent of Coleman’s description
(1968) as the femoral head slips over the posterior acetab-
ular ring (the “jerk” of exit and entry). Significantly this is
now not nearly so pronounced. The observation is consis-
tent with hip dysplasia which seems to be more important
than the contralateral abduction contraction emphasized by
Karski (2000). The limited mobility of the child’s left arm
(possibly adduction contracture) became obvious when he
attempted to swim freestyle. Unequal mobility of all limbs
had already been recognized as a component of the fetal
compression phenomenon (Tönnis, 1968).
The pelvic tilt drew attention to the difference in the
sacroiliac (SI) joints which had been overlooked and the
possibility of left hip dysplasia. On consultation with a
radiologist, computerized tomography was performed 5
months after the X-ray in Fig. 3 because it was thought that
rotation might be responsible for the difference in the SI
joints. This revealed that the legs were of equal length and
the nonossified cartilaginous gap in the anterior portion of
the right joint was 2 mm wider than that of the left. The
more posterior portions were symmetrical. Overall the im-
provements in the pelvic tilt, the SI joints, and rib displace-
ment with a reduced list of the torso and loss of the gap
between the left hip and the elbow indicate that they oc-
curred simultaneously with reduction in the scoliosis. The
boy can now stand on his left leg unassisted. The narrowing
of the left SI joint, which has not previously been observed
in the fetal compression syndrome, is likely to be due to
asymmetrical pressures on the hips.
Little information could be found on therapy for juve-
niles although physiotherapy combining passive manipula-
tion and exercises emphasizing lateral abduction of the hip
and shoulder is currently meeting with some success in this
juvenile. In view of the absence of an abnormal gait in this
child and the radiological and visual improvements
achieved, the present management policy will continue. The
improvement obtained by traction postoperatively in sub-
jects with severe scoliosis provides support for his contin-
ued use of the more acceptable jungle gym. Daily exercises
on a jungle gym over a longer time span can only be
beneficial and prophylactic in such children.
The X-ray in Fig. 3 was taken 1 year after that in Fig. 1,
both parents being pleased with the visual and radiological
improvement. The lateral spinal deviation was so reduced
that the radiological report indicated no “scoliosis” and hip
joints were normal. His chest expansion is now equal and
symmetrical, his left scapula is less prominent with the
overall cosmetic appearance vastly improved and with no
recurrence of chest pain. Whether the displaced left 12th rib
(Fig. 3) will resume a more normal position is unknown at
332 W. E. Stehbens, R. L. Cooper / Experimental and Molecular Pathology 74 (2003) 326 –335

Fig. 2. Photographs taken 10 weeks after purchase and regular use of a jungle gym. (A) The distinct list to the left and asymmetrical stance with a prominent
gap between the elbow and hip on the left side. (B) Black ink dots indicate the tips of the vertebral spine. The list is still clearly visible whereas the back
demonstrates improvement of the curvature. The left scapula is still elevated and more prominent than the right.

this stage. It is anticipated that sustained monitoring and
further exercises with symmetrical stresses on the spine and
hips will improve his habitual stance.
Recommended exercises
The child, now aged 6 years 8 months, is probably an
example of congenital postural scoliosis and was therefore
destined to severe deformity. The historic concepts of pro-
longed traction outlined above were drastic. The exercise
program and frequent use of the jungle gym led to cessation
of progression and distinct improvement within 10 weeks.
This physiological, more natural use of traction, where the
lower half of the body provides the traction, is preferable to
a vertical or horizontal rack with immobilization. It is ac-
ceptable to the child and has benefited the hip joints and
pelvic tilt. Good nutrition being essential, this child is given
a traditional high protein diet with meat, eggs, milk, and a
variety of fruit and vegetables (Stehbens, 1993).
Other regular and varied short periods of daily exercises
include (i) push-ups, (ii) repeated lateral flexion of the trunk
to the left (convex side) when sitting, standing, or supine
which tends to reverse vertebral torsion and reduce the
primary curve with no bending to the concave side, (iii)
lying supine with hips and knees flexed and abducting and
adducting both hips against moderate resistance provided by
a parent, (iv) touching the toes of the left foot with legs wide
apart in sitting and standing position, (v) lying supine while
peddling in the air, and (vi) deep breathing exercises with
and without slight restrictive parental hand pressure over the
lower right side of the chest to facilitate maximum left side
expansion of the thorax.
Lying supine on a firm surface while simultaneously
performing exercises tends to exert pressure on the promi-
nent ribs on the convex side posteriorly. As subjects be-
comes older and stronger, chin-ups should be included and
some simple gymnastic exercises on parallel bars or rings to
manipulate the legs always omitting the final jarring jump
off the apparatus. Scoliotics under treatment should avoid
all strenuous exercises such as jogging, jumping, hopping,
skipping, marching, tramping, weight lifting, and any vibra-
tional exposure (tractors, bumpy roads, horse riding, pogo
sticks, trampolines) likely to result in vertical impacts trans-
missable to the spine. Habitual use of a sponge rubber
cushion when in a car is also recommended.
The angle of curvature diminishes by a mean of 9° in the
supine position, the difference in 93% of subjects so exam-
 W. E. Stehbens, R. L. Cooper / Experimental and Molecular Pathology 74 (2003) 326 –335
Fig. 3. X-ray taken two weeks prior to his 6th birthday. The radiology
report stated that no scoliosis was present. A very slight residual curve is
centered at approximately T11. The 12th left rib is clearly deflected
downward and a slight pelvic tilt remains. The difference in width of the
cartilaginous gaps in the SI joints is less pronounced.
ined (Torell et al., 1986) ranging from 0 to 20°. Therefore
lateral flexing to the convex side may be best performed
when supine. With the added buoyancy of the body swim-
ming exercises to strengthen the limbs and trunk muscles
equally on both sides would be beneficial. Breast stroke
swimming and sitting cross-legged on the floor while
watching television may be of particular benefit for this
child. Continued monitoring of the subject to maintain an
exercise program during adolescence and after bone matu-
ration is indicated, although older children are more able to
understand the need for self-correction.
This analysis and the proposed exercise program are
primarily concerned with young pediatric subjects whose
333
idiopathic scoliosis is likely to be postural in nature. Older
infants, juveniles, and even adolescents with scoliosis could
be candidates for similar management in hopeful anticipa-
tion of benefit at the earliest stage rather than waiting until
bracing or surgery is mandatory. For patients with advanced
scoliosis (severe angulation or double curves) exercises
should probably be limited or avoided until the angle is
much reduced by the mild persistent traction effected by a
jungle gym or parallel bars.
Discussion and conclusion
Routine examination of neonates and young infants for
compressive postural spinal deformities and appropriate
treatment should be routine. Obstetricians, midwives, pedi-
atricians, and general practitioners should be trained in their
early detection. School screening could be reintroduced and
appropriately trained personnel could detect early curva-
tures, advising teachers and parents to routinely encourage
children to spend time on the jungle gym which should be
standard playground equipment in primary schools with
such traction activity also of benefit to those with lordosis or
kyphosis.
Since mechanical stresses of everyday life are the dom-
inant force responsible for progression, it is logical to de-
duce that as in orthodontics, counteracting forces can in-
hibit, ameliorate or cause curvature regression. Longitudinal
traction must be the mainstay of management and is the
only mechanism known to regularly reduce scoliotic curva-
tures. The logic of this exercise program is consistent with
the pathogenesis of the deformity (Stehbens, 2002) and the
evidence provided indicates that it is likely to benefit those
with early scoliosis. The overall aim of pediatric scoliosis
management should be (1) to detect the deformity at its
earliest stage because geometrical abnormalities predispose
to osteoarthrosis (Stehbens, 2002), (2) to induce regression
of any deformity, to prevent or limit progression to obviate
the need for orthotics or surgery, (3) to prevent relapse and
ensure good compliance, (4) to prevent development of
scoliosis in the community, and (5) to increase awareness of
this deformity in the community and perinatal and pediatric
health services. This proposed management program will
hopefully restore the vertebrae and intervertebral discs to a
more appropriate anatomical position, shape, and more bal-
anced mechanics and should then consolidate their retention
of the normal status.
Acknowledgments
The Wellington Medical Research Foundation provided
financial support and Dr. G.T. Jones assisted with the print-
ing of Fig. 3.
334 W. E. Stehbens, R. L. Cooper / Experimental and Molecular Pathology 74 (2003) 326 –335
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