Rehabilitation of adolescent patients with scoliosis—what do we know?

[foofer]

and I was really intrigued with your mediation efforts. I was learning a lot and may have to hit you up another time, another place for some more info on these methods!

Getting off topic and gonna get off!

[Pooka1]

Yes, it is strange to read random postings in response to no one, but not nearly as bizarre as watching 3 pages disappear before my very eyes while I was rubbernecking from afar...

dhugger's stuff is pretty good. Mine stuff was largely penetrating glimpses into the obvious. You missed nothing you probably didn't already know.

[Ballet Mom]

"Mine stuff was largely penetrating glimpses into the obvious"

ROFL!

[mamamax]

Going to the Source

Kudos mamamax! I vaguely remember you suggesting that...lol! How nice of Lori Dolan to respond to you. That was very kind of her to take the time.

Ballet Mom - It never ceases to amaze me how many people Like Lori Dolan are more than eager to share their knowledge with just about anybody who has a genuine thirst for such things. I think hdugger has also written to the SEAS authors and requested some info which proved valuable here in forum. I wrote one of those authors also and was gifted with a ton of information. So really this kind of info is not that hard to get. At one point Lori was trying to join the forum to help keep us informed of the BrAist Study - but somehow that never came through :-(

[mamamax]

Terms and Definitions

Thanks to Dr. Weiss and Lori Dolan we have some definitions of terms used in the literature that may prove useful as this thread evolves (thanks to both).

• Deterioration - when signs of osteoarthritis of the little spinal joints are visible (on x-ray). This does not correlate with pain. (Source: Hans Weiss)

• In-Brace Study - I’m not aware of any studies where all the x-rays are taken with the brace on – usually in-brace x-rays are taken within a few weeks after the brace is delivered to check on pad placement, trimlines, decompensation, and the amount of curve correction. Otherwise, x-rays are taken out-of-brace.
  Sometimes people will use the term “study” as they would radiograph, xray, film, etc. But usually it means what you’d think it does – i.e. a research study. (Source: Lori Dolan)
  
  
• Decompensation, or decomp - basically when the head isn't centered over the pelvis- this is why double curves are sometimes less noticable than single curves, because balance is maintained (Source: Lori Dolan)

[mamamax]

The problem I have with this is that Weiss does not seem to be applying the same critiques of other studies to his own.

Why would we expect him to? Really, I would like to know about your thoughts on that. I don't recall seeing authors heavily critiquing their own methods in the literature? I don't know how common that practice is.

He is pretty harsh on Negrini and the SEAS approach with one critique being that the studies lack any type of control group (I skimmed, but I think I'm reading that correctly). However, the main study he cites won an award for best clinical paper at SOSORT in 2008. I am not aware of any controlled trial using Schroth. As well he cites an RCT in China that evidently had good results (didn't present them) and good level of evidence (level Ib) but he criticized it because it lacked specific descriptions of exercises.....

I think Weiss has an eye for bracing technique and can see things on x-rays that many cannot - there may be more in the Negrini paper (Negrini S, Atanasio S, Negrini F, Zaina F, Marchini G. 2008. The Sforzesco brace can replace cast in the correction of adolescent idiopathic scoliosis: A controlled prospective cohort study. Scoliosis 3:1) that would support his opinions. Weiss states:

The only result as demonstrated in this paper as a figure seems to show an alleged correction after brace wearing. In clinically critising the spine as shown on the X-Rays it actually seems more immature after treatment than before, the Risser sign is more mature before treatment and pelvic width is bigger before treatment than after (http://www.scoliosisjournal.com/cont...1/15/Figure/F3). Therefore this result cannot be regarded as being credible.

Could be a justifiable critique along with the statement that Considering the fact, that the average patient from this sample according to the SOSORT guidelines would not need any treatment at all, the study would not seem worthwhile performing (Figure 10).

The China thing ... seems there was also translation problems with the submission.

Oddly, his introduction says that the medical literature dismisses exercise as an option. But then he doesn't do a good job of presenting the convincing evidence.

Figure 4 is pretty convincing to me! Attached.

I don't know... Lots of Weiss references and details and, unfortunately, not much else. Now, I think Schroth has validity based on proposed physiology, but I doubt this posted article would make it past the peer review process.

I think Schroth is going through some generational upgrading. And maybe this article we are discussing is already obsolete. It was written in 2009 but shows up as 2010 at the university web site for some reason. From the article:

As has been shown, Scoliosis Intensive Rehabilitation (SIR), in its original form can no more be regarded as being effective when rehabilitation times have been reduced to 3-4 weeks, only (Weiss and Goodall 2009). The incidence of surgery for the patients receiving this in-patient program (Weiss, Weiss and Schaar 2003) is comparable to out-patient approaches (Maruyama et al. 2003, Rigo, Reiter and Weiss 2003), although the different studies have patient samples which are not necessarily comparable. The development of such research means that more intensive out-patient approaches seem more appropriate when one considers; time efficiency and new teaching approaches including experiential learning (ISR), as described within the book on "Best Practice" treatment (Weiss 2007a). Therefore an in-patient program, such as SIR is today regarded as outdated. Actually three day intensive programs based on the "experiential learning" approach of ISR are provided in the US, UK and in Germany at the first authors centre.

So actually - this article includes an author critique of SIR? Is that how you read it?

The newest method (developed by Weiss) is: SSTR (Scoliosis Short-Term Rehabilitation). A study on this now in review - available in a few months.

[mamamax]

SSTR & The Best Practice Method

So what the heck is SSTR (Scoliosis Short Term Rehabilitation) relative to Adolescent Rehabilitation?

As you might have guessed, I asked the best source. Whom, I'm not going to quote verbatim, because I have not asked permission to do so. But my take on it is this:

It is a method of short term rehabilitation with long term results which uses exercises specific to all the various curvature patterns along with bracing which results in cosmetic results arguably similar to surgery (when braces are worn appropriately during growth). The aim is not to do the exercises over the course of a lifetime - the aim of the exercise is the acquisition of a postural monitoring system allowing posture control along with corrected activities of daily living. One analogy could be like learning anew language, once fluent - no need to think about it, it is automatic. Once this has become automated - there is no longer any need to exercise. Short term rehab, or patient orientation is a matter of days vs weeks. The method is based upon the book: The Best Practice Method (HR Weiss).

The beauty of all this being that it could be implemented in US physical therapy departments. Older folks like myself would only require the PT exercise (bracing in some cases where pain is an issue), and some post surgical patients could also benefit from the PT exercise when pain remains an unresolved issue.

Looks win-win to me. Very much looking forward to upcoming publications.

[hdugger]

It is a method of short term rehabilitation with long term results which uses exercises specific to all the various curvature patterns along with bracing which results in cosmetic results arguably similar to surgery (when braces are worn appropriately during growth).

But no effect on the natural progression of the curve?

My son has actually managed to greatly improve the cosmetic look of his scoliosis/kyphosis through a mixture of PT and massage, so it's really holding the curve in place that we're interested in.

[skevimc]

Why would we expect him to? Really, I would like to know about your thoughts on that. I don't recall seeing authors heavily critiquing their own methods in the literature? I don't know how common that practice is.

What sticks out to me is that he is apparently discounting studies for things like not having a good control group, but ignores the same fault in his own studies. Unless I'm unaware of a randomized study that he has published.

A good study will highlight the obvious faults in their own study and a good peer review process will ensure that the faults are well identified and discussed. It's a very important process in publishing. It shows that you have really thought seriously about your study and understand its limitations.

I think Weiss has an eye for bracing technique and can see things on x-rays that many cannot - there may be more in the Negrini paper (Negrini S, Atanasio S, Negrini F, Zaina F, Marchini G. 2008. The Sforzesco brace can replace cast in the correction of adolescent idiopathic scoliosis: A controlled prospective cohort study. Scoliosis 3:1) that would support his opinions. Weiss states:

The only result as demonstrated in this paper as a figure seems to show an alleged correction after brace wearing. In clinically critising the spine as shown on the X-Rays it actually seems more immature after treatment than before, the Risser sign is more mature before treatment and pelvic width is bigger before treatment than after (http://www.scoliosisjournal.com/cont...1/15/Figure/F3). Therefore this result cannot be regarded as being credible.

Could be a justifiable critique along with the statement that Considering the fact, that the average patient from this sample according to the SOSORT guidelines would not need any treatment at all, the study would not seem worthwhile performing (Figure 10).

Could be justified. Could also be an incorrect assessment. What exactly is he suggesting with that comment? That Negrini is presenting false data or that the skeletal age actually regressed? If he's just saying that the x-rays look funny, that alone doesn't discount the study as he is suggesting.

The China thing ... seems there was also translation problems with the submission.

Ok. But was there a problem or not? Was it a good study or not? It was an RCT with positive results. If you're going to present a 'review' and possibly critique the paper, it would be appropriate to make sure you're getting the story correct. Present the data and then describe why it is not as convincing.

Figure 4 is pretty convincing to me! Attached.

If that is the standard then it should be easy to present lots more data like that. Data collected in a randomized design and with all exercises fully described, as he has critiqued.

I think Schroth is going through some generational upgrading. And maybe this article we are discussing is already obsolete. It was written in 2009 but shows up as 2010 at the university web site for some reason. From the article:

As has been shown, Scoliosis Intensive Rehabilitation (SIR), in its original form can no more be regarded as being effective when rehabilitation times have been reduced to 3-4 weeks, only (Weiss and Goodall 2009). The incidence of surgery for the patients receiving this in-patient program (Weiss, Weiss and Schaar 2003) is comparable to out-patient approaches (Maruyama et al. 2003, Rigo, Reiter and Weiss 2003), although the different studies have patient samples which are not necessarily comparable. The development of such research means that more intensive out-patient approaches seem more appropriate when one considers; time efficiency and new teaching approaches including experiential learning (ISR), as described within the book on "Best Practice" treatment (Weiss 2007a). Therefore an in-patient program, such as SIR is today regarded as outdated. Actually three day intensive programs based on the "experiential learning" approach of ISR are provided in the US, UK and in Germany at the first authors centre.

[COLOR="Navy"]So actually - this article includes an author critique of SIR? Is that how you read it?

You could read that as a critique. But when are his exercises fully described like the critique he gave to the China RCT? They're described in his book. Why not the article? I don't mind someone wanting to publish this stuff in a book, but then you can't discount another study for omitting their exercise descriptions.

To be honest, I haven't read Weiss' recent work in the last ~ 3 years. He might do a better job of addressing the weaknesses of his studies than before. In fact, it's been a while since I've read anything of his. I'd be interested to read his up coming work.

[Pooka1]

To be honest, I haven't read Weiss' recent work in the last ~ 3 years. He might do a better job of addressing the weaknesses of his studies than before. In fact, it's been a while since I've read anything of his. I'd be interested to read his up coming work.

Not sure you have missed much. I brought Weiss's pubs to the attention of Quackwatch a bit ago...

http://www.scoliosis.org/forum/showthread.php?t=8179

N.B. This was the state of affairs as of the end of 2008.

[Pooka1]

But no effect on the natural progression of the curve?

You know, last I recall, I can't find where Schroth clearly claims to affect the natural progression. I see them making some noises that might be construed as affecting the natural progression but I don't think it is clear. I think they might only claim better appearance through posture modification and some correction/holding through lifelong PT.

Anyone know?

If they don't claim to permanently halt progression or permanently improve a curve then we can't gig them on not doing those things.

If they claim permanent halting or improvement and hide the fact hat life long PT is required then we can gig them on that.

[Ballet Mom]

There is an absolutely gorgeous ballerina at my daughter's studio who's dad has a noticeable kyphosis of his back. Also a handsome man. The ballerina's upper back had started to develop a noticeable kyphotic roundness last year as she was going through a growth spurt. Her shoulder blades were very noticeably winging out too. I told her mom that there were braces available that could help modify the kyphosis through her growth, especially suitable since the girl is home-schooled.

Apparently, they never looked into the orthopedists in order to get the brace. But the same ballet teacher who has worked with my daughter with her scoliosis and posture also gives privates to this girl. Over the past year, the ballet teacher has worked with this girl on her posture continuously. Amazingly, I can't even tell anymore that she has kyphosis. A couple of times when she's tired and not paying attention, I've seen her scapulas winging out recently. But the improvement is dramatic. I wouldn't even realize she had anything going on with her back most of the time.

There is certainly something going on with the ability to improve people's cosmetic outcome with exercises, stretches and posture. There is no doubt in my mind. I'm sure it's probably difficult to quantify in terms of scientific data. But to the people it helps, it has to improve their psyches immeasurably.

The fact that the Schroth program has lasted eighty years is a testament to the fact that it's providing people something worthwhile and isn't a bogus scam. Of course, ballet doesn't avoid rotations, they make huge rotational movements, so maybe not all of what Schroth does is required, but it's probably pretty hard to pin down exactly what it is that helps.

[Ballet Mom]

But no effect on the natural progression of the curve?

My son has actually managed to greatly improve the cosmetic look of his scoliosis/kyphosis through a mixture of PT and massage, so it's really holding the curve in place that we're interested in.

It would be nice to know if Schroth actually prevents the curves from progressing as an adult. I would send my daughter to Germany in a heartbeat if it could be shown to do that. My daughter already has a good cosmetic result from bracing and ballet and I too would like to help her prevent any possible progression.

I know there are professional ballet dancers that apparently use Schroth-type exercises to keep their curves from progressing. Obviously I have no idea what their x-rays look like, but they continue to dance so they couldn't have progressed much. Although most curves under 50 degrees won't progress anyway. But I suppose I could also have her do pilates in the future. I don't think my daughter is ready at this point to add more exercises to her daily routine! Not enough time in the day!

Let's hope that Weiss is able to do a study to show that it prevents future curvature. Most likely, though, it will be like all other things related to scoliosis and will help some people and not others.

I think most kids going through their growth spurt would be happy to have a good cosmetic result with their bracing. I really believe that those kids in their braces should be in some type of stretching and exercise program in order to help make their bracing a success.

[hdugger]

The fact that the Schroth program has lasted eighty years is a testament to the fact that it's providing people something worthwhile and isn't a bogus scam. Of course, ballet doesn't avoid rotations, they make huge rotational movements, so maybe not all of what Schroth does is required, but it's probably pretty hard to pin down exactly what it is that helps.

Yes, I think that's exactly true - many of the exercise methods have some parts that work and some that don't. If we could have someone with the background but without the financial motivation go through and figure out what pieces of each of them worked and what pieces were just fluff, it would be really great.

The SEAS people claim to be doing that, btw - they don't have an over-arching theory of exercise, they're just doing everything that has some evidence that it works.

[Pooka1]

Homeopathy has been around for over 200 years and is demonstrably patent nonsense.

Evolution denial has been around for over 100 years and is widely subscribed in the US at least but is demonstrably false.

Etc. etc. etc.

Thus you can't conclude from the length of time something has been around that it is not nonsense. And sometimes, the less evidence, the more nonsensical, the longer it sticks around.