Adolescent Idiopathic Scoliosis: Is Sleep Position the Missing Link?
The Nighttime Perfect Storm Hypothesis
By Dr. Jarrett Grunstein, Chiropractic Physician
NOTE: The following hypothetical model was presented at the 2022 SOSORT (The International Society on Scoliosis Orthopaedic and Rehabilitation Treatment) conference in San Sebastián, Spain in May, 2022 by Dr. Jarrett Grunstein and was co-authored by the world-renowned scoliosis researcher, Dr. Theodoros Grivas, MD, PhD.
Spinal deformity, the oldest disease known to humankind, was first documented in an Indian religious mythological book between 3500 BC and 1800 BC.(1) Many years later, Hippocrates (460BC-375BC), the founder of modern medicine, reportedly revealed in his writings what he believed to be the cause of scoliosis (as we use the term today). He suggested two possible causes of the disease: 1) Due to 'gatherings' (probably tuberculous abscesses) in the spine and 2) The positions the children are accustomed to take in bed.(2) Sadly, to this day, the reality is that the majority of scoliosis cases in children remain idiopathic, meaning the disease arises spontaneously and the cause remains unknown.
The subject of sleep position and its potential involvement with Adolescent Idiopathic Scoliosis (AIS) was first explored by Dr. Cobb in the first half of the 20th century. As reported by Dr. Alvin Arkin in his 1949 paper (3), Dr. Cobb recruited over 30 children with AIS. He kept the children in bed for twenty-two hours per day for a full 3 months (so cruel!!!). Except in one
case, no progress in the children’s spinal curvatures were noted after the 3 month period. The conclusion from this experiment was that the scoliosis curve MUST develop while children are upright and NOT in bed. This view has been upheld by the scientific community ever since.
As a chiropractor for close to 20 years, I noticed the strong relationship between back and neck pain with how my patients slept at night. I was so intrigued by this risk factor that I eventually invented an ergonomic sleeping pillow that was in the marketplace for a few years called Dr. J’s Sleep Solution Pillow. In the spring of 2018, I had one of those classic “aha”
moments. I realized that if certain sleep positions can potentially cause so many problems with my back and neck pain patients, is it POSSIBLE that certain sleep positions are responsible for the curvature(s) that develops in AIS? And if so, how could we explain Dr. Cobb’s findings that keeping kids in bed PREVENTS curve development?
After much contemplation, I asked an obvious question. How the heck did Dr. Cobb keep those unlucky kids in bed for 22 hours per day??? Since the exact details of his study were never published, common sense was needed to solve this mystery. I finally concluded that the only way he could have ensured all the children remained in bed for so long each day
for a full 3 months was that he must have restrained them. Further, most likely, he restrained them while they were lying on their backs. In other words, he kept them from sleeping on their sides and on their stomachs, the very same sleep positions I saw contributing to back pain in my chiropractic patients.
This led me on a 3 year research journey of exploring all the scientific literature I could find on what we did know about the biology of children with AIS. As it turns out, we know quite a bit! Many different genetic mutations have been found in children with AIS. The involved genes often relate to bone density and other tissues such as the intervertebral discs that are found between the spinal vertebrae, the bones that make up the spine.
However, if the problem of AIS is purely genetic in nature, then we would find that identical twins would have identical spinal curvature(s). As it turns out, studies have shown that many identical twins have different spinal curves in terms of the shape and degree of their
scoliosis curvature. This has led scientists to the conclusion over the last decade or so that AIS must have an epigenetic component.(4) Simply put, epigenetics is the field of science that explores how the environment can alter how the genes express themselves.
Many scientists have tried to determine what environmental factor(s) may lead to the development of AIS. What these studies have shown is that lifestyle factors, diet, environmental factors such as industrialization, nor exercises can explain why a spinal curvature develops and progresses in an otherwise perfectly healthy child. However, there was one study performed in Brazil that did show a distinct relationship between one environmental factor and curve development; the more the AIS kids in their study slept in a hammock, the less they developed a spinal curvature. Notably, hammocks are primarily used for sleeping on one’s back and NOT on one’s sides or stomach.(5) Sounds a little like Dr. Cobb’s findings, no?
So, without further ado, let me introduce you to the Nighttime Perfect Storm Hypothesis that was presented to the global scientific community at the SOSORT 2022 conference in Spain in May of 2022.(6) A “perfect storm” implies that a combination of different factors all have to line up for the violent storm to occur. The 3 parts of the perfect storm are:
- Genetic abnormalities
- Adolescent growth spurt
- Sleep position during the REM stage of sleep
So, we have already discussed #1, the genetic abnormalities in those with AIS. In terms of #2 (Adolescent Growth Spurt), scientists have determined that this is the period when a child is most vulnerable to developing a spinal curvature, with the most rapid rate of curve progression occurring during the beginning of puberty.(7)
Now, for #3 (Sleep Position during the REM stage of sleep). According to our hypothesis, there are 2 sleep positions that might possibly be contributing to the spinal curves that develop in AIS. We refer to these 2 positions as the “Lateral Provocative Sleep Position” and the “Prone Provocative Sleep Position.” Provoke simply means something that “stimulates or gives rise to.”
Figure 1: The Lateral Provocative Sleep Position
Figure 2: The Prone Provocative Sleep Position
The Lateral Provocative Sleep Position may lead to a Lumbar (Low-back) Curve. As can be seen in Figure 1 above, one leg is hiked up. In a landmark book on the engineering of mattresses for sleep, Dr. Haex discusses how a pillow between the knees is recommended to keep the legs parallel. He notes that when one leg is hiked up (as in the picture above), a
twisting force is applied to the pelvis and that this may encourage a scoliosis in the low back. (8)
The Prone Provocative Sleep Position may lead to a Thoracic (Mid-back) Curve. As can be seen in Figure 2 above, one leg is hiked up, serving to prop the body in a tilted fashion in relation to the mattress. As the rib cage of the child presses against the mattress on an angle due to this tilt, a rotation pressure may lead to the ribs pressing into the vertebrae (spinal bones). Eventually, night after night, this may ultimately cause the vertebrae to rotate and bend, leading to the all too familiar mid-back spinal scoliosis with associated rib hump. Think about it this way: the ribs of children with AIS have been found to be abnormally bent when comparing side to side. Yet, during the typical day of a child, when is constant pressure applied to the ribs that could account for any type of bending to occur?
Finally, let’s discuss REM sleep. This is the stage of sleep at night where we actively dream. Scientists have discovered that our muscles are actually in a semi-paralyzed state during this stage of sleep, which arises on average about 5 times throughout the course of the night. While the first REM stage of the night is typically only about 10-15 minutes long, they progressively lengthen as the night goes on. During the last REM stage of the night, a child might be positioned in one sleep position up to an hour. Mother Nature was wise to ensure that we are paralyzed while in a dream state. Otherwise, we would act out our dreams, potentially harming ourself or others. On the downside, the muscles that normally stabilize and protect the spine throughout the day are completely helpless in supporting the spine during REM sleep. Therefore, a child with genes that soften their bones and surrounding structures MAY be vulnerable to developing a spinal curvature while spending each and every night in one (or both) of these 2 different sleep positions.
It is my sincere hope that those in the scientific community and families who have a child with AIS will come together so that we can at least test whether or not The Nighttime Perfect Storm Hypothesis has been the missing link in explaining why the scoliosis curve develops in AIS.
About the author: Dr. Jarrett Grunstein is the owner and operator of Grunstein Family Chiropractic Center in Livingston, New Jersey. He served as consulting chiropractor for The Toronto Blue Jays for 4 seasons (‘08-‘11) and formerly owned and operated Clearwater Chiropractic Center in Clearwater, Florida. He can be reached by email at JGspineez@gmail.com if you have questions, comments, or would like to read The Nighttime Perfect Storm Hypothesis paper in it’s entirety.
(1) RF Heary, K Madhavan. The history of spinal deformity. Neurosurgery. 2008 Sep; 63(3 Suppl):5-15.
(2) ES Vasiliadis, TB Grivas, A Kaspiris, Historical overview of spinal deformities in ancient Greece, Scoliosis 4 (6) (2009). doi: 10.1186-1748-7161-4-6. doi: 10.1186-1748-7161-4-6. (3) AM Arkin. The mechanism of the structural changes in scoliosis. J Bone Joint Surg Am 1949;31:519e28.
(4) RJ Burwell, PH Dangerfield, A Moulton, TB Grivas, Adolescent idiopathic scoliosis (AIS), environment, exposome and epigenetics: a molecular perspective of postnatal normal spinal growth and the etiopathogenesis of AIS with consideration of a network approach and possible implications for medical therapy, Scoliosis. 6 (1) (2011) 26. doi: 10.1186/1748-7161-6-26. (5) M Baroni, GJB Sanchis, SJC de Assis, R.G. dos Santos, S.A. Pereira, K.G. Sousa, J.M. Lopes, Factors associated with scoliosis in schoolchildren: a cross-sectional population-based study, J. of Epid., Japan Epid. Assoc. 25 (3) (2015) 212-220.
(6) JB Grunstein, TB Grivas, Sleep position and the aetiology of AIS? A New Hypothetical Model. SOSORT Congress May 4-7, 2022, San Sebastian Donostia, Spain, Program book and Abstracts Proceedings, page 152.
(7) TB Grivas, E Vasiliadis, V Mouzakis, C Mihas, G Koufopoulos, Association between adolescent idiopathic scoliosis prevalence and age at menarche in different geographic latitudes, Scoliosis. 1 (2006) 9. doi: 10.1186/1748-7161-1-9.
(8) B Haex, Back and bed: ergonomic aspects of sleeping, P.79. Boca Raton Press, 2005.