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Thread: A few comments on trunk rotational strength training

  1. #1
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    A few comments on trunk rotational strength training

    First off, Iíll tell you that my name is Kevin McIntire and our group did the work on trunk rotational strength asymmetry and strength training. I have been lurking on here from time to time over the last year or so and recently became a member and wanted to introduce myself and make a few comments on trunk rotational strength training. Especially because I have noticed that RST along with other exercise based therapies have been the topics of a lot of passion and debate.

    The RST study was my primary dissertation work. It was originally designed as an RCT. But due to recruitment problems we changed it to just a treatment group. That was lesson number 1 and should hopefully address some of the comments of ďwhy wonít doctors or therapists do a long term and/or randomized study.Ē About half of the patients that were somewhat interested in the study declined to participate due to the time commitment involved. Lesson number 2 was that it is extremely difficult to obtain a homogeneous sample. That is, to find one specific type of patient with a specific type of curve. 10-16 yrs old, female, riser 0-3, <=12 months post-menarchal, single thoracic curves >20į. This phenotype is supposed to have a large number of cases but reality is not as straight forward. By the end of the study we had opened up to allow just about everyone in.

    I donít believe RST is a panacea. Although I am extremely encouraged by some of the private conversations/results patientís families have shared with me over the last few years.

    I believe that at least 75% of people with scoliosis have a rotational strength asymmetry. I donít see this as causative but I do see it as a contributor to the vicious cycle of progression. I also believe that strength asymmetry will be made worse as the curve progresses. (A small cohort of patients with >50į curves had profound strength asymmetry. Not published) Thus, I think trunk strength should be addressed in every patient receiving any type of scoliosis therapy. This should be extended to curves 10į-20į. The "watch and wait" group. I am convinced we are missing a HUGE treatment window.

    If I could do the project over, I would follow two principles; strength and specificity. Strength is certainly important, but a more specific stimulus seems obvious to me. In essence, strength training wakes the muscles up (assuming they are asleep) and the specific exercises fine tune. Schroth, Side Shift, SEAS, CLEAR, directional breathing (Dobosiewicz Method)Ö there are probably othersÖ All of these use a specificity component and seek to re-train the neuromuscular system to control and stabilize the spine. The benefit of these therapies is that they are customized to each patient, whereas RST was using sort of the shotgun approach (strengthen everything). This was done intentionally because, from a scientific standpoint, you have to start somewhere. So we went with strength training based largely on the work of Vert Mooney. (BTW, I just read about his death yesterday here on the board. Iím in shock to say the least.) So we wanted to test strength training alone before we added anything else.

    I am currently doing a postdoctoral fellowship in a completely different field but am continuing my training in muscle physiology. So follow up studies were not possible for logistical reasons, not because we didnít see promise in the results. I hope to return to the field in some fashion in the future to pick-up where we left off.

    I have no monetary interest or investment in any product related to my project. In fact, we were aiming at the exact opposite. Money should not be a reason why someone canít get a treatment. As well, what good is a treatment if you have to come back on a weekly basis for it to be effective? This discriminates against people with no time or ability to make that effort. So we wanted to have a therapy that, after an initial learning/monitored exercise phase, the patient and families could be self-sufficient. We didnít quite accomplish that but we made good headway.

    Feel free to send me a message if you have any questions or comments. Iíd be glad to answer whatever I can or give you my opinion from a research perspective. I will say that I am not a clinician, although I have my background and previous work in physical therapy. So of course, donít take anything I say as official treatment advice . I think the NSF is a great foundation and I'm happy to be a part of this forum.

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    Thanks so much, Kevin. That's all very helpful.

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    Wow great contribution! Thank you.

    Can I ask if you agree with Dr. Mooney's claim in one of the papers that torso rotation is sufficient and bracing is unnecessary even during all growth spurts?

    Per other comments I have read, other PT modalities (e.g., Schroth and SEAS) use bracing through growth spurts.

    Also, as I am very sure you are aware, in certain connective tissue disorders that are associated with scoliosis, most exercise is contraindicated. An example would be Marfans. To the extent many people with these conditions may not be aware they have them, do you think it is dangerous for lay, untrained people to come on these fora and recommend specific PT modalities in a shotgun approach which is usually accompanied by claims that it works "every time?"
    Last edited by Pooka1; 01-13-2010 at 08:38 PM.
    Sharon, mother of identical twin girls with scoliosis

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    Greetings Kevin and welcome to forum. You really got my attention. I've been interested in torso rotation exercise and have wondered how this may improve chest wall/respiratory function and hope you will comment on that. Truly look forward to the contributions you may make to our discussions.

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    Quote Originally Posted by Pooka1 View Post
    Wow great contribution! Thank you.

    Can I ask if you agree with Dr. Mooney's claim in one of the papers that torso rotation is sufficient and bracing is unnecessary even during all growth spurts?

    Per other comments I have read, other PT modalities (e.g., Schroth and SEAS) use bracing through growth spurts.
    I am somewhat familiar with that comment from Mooney. I think it is an overstatement based how preliminary all of our results are and perhaps a bit reckless. These studies are really more like pre-pilot studies. Feasibility studies really. I would never be comfortable applying a blanket statement like that. But I'd also say that I think there is some unnecessary bracing. The trick is to find out exactly who needs what.

    Quote Originally Posted by Pooka1 View Post
    Also, as I am very sure you are aware, in certain connective tissue disorders that are associated with scoliosis, most exercise is contraindicated. An example would be Marfans. To the extent many people with these conditions may not be aware they have them, do you think it is dangerous for lay, untrained people to come on these fora and recommend specific PT modalities in a shotgun approach which is usually accompanied by claims that it works "every time?"
    My experience lies primarily within AIS, so scoliosis as a result of Marfan's syndrome, for example, wouldn't fit as it would not be idiopathic. Outside of that, I'm not going to comment on what is or isn't appropriate for people to tell other people. That is for the moderators to decide. I have stated that I don't see RST as being 100%.

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    Quote Originally Posted by mamamax View Post
    Greetings Kevin and welcome to forum. You really got my attention. I've been interested in torso rotation exercise and have wondered how this may improve chest wall/respiratory function and hope you will comment on that. Truly look forward to the contributions you may make to our discussions.
    Great question. Dr. Asher, one of my mentors, really wanted to test respiratory function. We didn't have access to the equipment until half way through the study. This is an outcome measure that is frequently overlooked (clinically and scientifically, everyone is so concerned with Cobb angle. Forrest... trees... ). Anyway, I could easily make the case that it would/could improve it. But it would all be theoretical.

    You should check out the Dobosiewicz Method. This is a group from Poland that works on 'directional breathing'. I spoke with them at a conference and they gave me one of their articles. It is written in polish so I can't read it but the pictures are pretty interesting. Do a Google Scholar search and see if anything pops up. I think I remember she presented some results at another conference and she had another younger guy working with her, i.e. someone to continue the work. They might have something published by now.

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    Quote Originally Posted by skevimc View Post
    My experience lies primarily within AIS, so scoliosis as a result of Marfan's syndrome, for example, wouldn't fit as it would not be idiopathic.

    Hi Kevin, thanks for posting, what you have to say is very interesting

    The trouble with Idiopathic Scoliosis is that there are plenty of people who could have undiagnosed connective tissue disorders. I'm 34 and have spent most of my life believing that I had Infantile Idiopathic Scoliosis, having been diagnosed at the age of 6 months with a 60+/40+ curve. Despite treatment throughout my childhood and several surgeries through my life I have only just been diagnosed as having Ehlers-Danlos Syndrome, which is almost certainly the cause of me developing so severe a scoliosis at such an early age. Given the number of people with scoliosis that I know who have joint hypermobility and other symptoms, I think it's entirely likely that there will be plenty of people diagnosed with AIS who actually have undiagnosed connective tissue disorders.

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    WHoops! Clicking on the link in the email to this thread response, I did not see Tonibunny's response which makes the same point about misdiagnosed causes of scoliosis (the "AIS" presumption if you will). It seems certain that some fraction of the subject patients in ALL AIS studies in fact do not have AIS but instead a connective tissue disorder of some type which may or may not react differently to PT and bracing. This seems like a potentially large confounder.

    Quote Originally Posted by skevimc View Post
    (snip) I would never be comfortable applying a blanket statement like that. But I'd also say that I think there is some unnecessary bracing. The trick is to find out exactly who needs what.
    "Some" unnecessary bracing is probably an understatement also.

    As you know, it is very hard to do a controlled study in this field. Braist is trying. Then there is the inherent variability of the condition.

    My experience lies primarily within AIS, so scoliosis as a result of Marfan's syndrome, for example, wouldn't fit as it would not be idiopathic.
    My point was that most, if not all, cases of emergent Marfans are diagnosed as AIS initially. A kid might have the condition yet not meet the diagnostic criteria until they reach adulthood. For example, my kids do not now meet the diagnostic criteria for Marfans and yet were recommend to get yearly aortic monitoring because they have enough indicators to warrant that. They presently have a diagnosis of "AIS." The incidence rate of Marfans, while very low in the general populace is of course much higher in the scoliosis crowd.

    I think people are in danger of taking random advice from fora like this to their detriment though agree with you that it is a moderator issue. And I think both the PT and bracing literature could be cleaner if researchers could somehow identify these connective tissue disorder (and potential) cases as some are known to be resistant to bracing and possibly to PT also. The result is to muddy the study and perhaps artificially skew the results towards apparent lower efficacy.
    Last edited by Pooka1; 01-14-2010 at 07:01 AM.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
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    Quote Originally Posted by skevimc View Post
    Great question. Dr. Asher, one of my mentors, really wanted to test respiratory function. We didn't have access to the equipment until half way through the study. This is an outcome measure that is frequently overlooked (clinically and scientifically, everyone is so concerned with Cobb angle. Forrest... trees... ). Anyway, I could easily make the case that it would/could improve it. But it would all be theoretical.

    You should check out the Dobosiewicz Method. This is a group from Poland that works on 'directional breathing'. I spoke with them at a conference and they gave me one of their articles. It is written in polish so I can't read it but the pictures are pretty interesting. Do a Google Scholar search and see if anything pops up. I think I remember she presented some results at another conference and she had another younger guy working with her, i.e. someone to continue the work. They might have something published by now.
    Thank you Kevin. Too bad the equipment was not available from the start of that project, though I dare say that if there was an improvement in respiratory function, that this improvement may have been observable in body changes to the chest area. I say this based upon the work of Martha Hawes in relation to her documented work which has focused on improved chest wall/respiratory function over the last 15 years. There is some argument that Martha has engaged many methods - however, her daily focus has been on chest wall/respiratory improvement.

    I'm only a tad familiar with the Schroth method of rotational breathing. I'm unfamiliar with the Dobosiewicz Method and would very much like to see the full text version of a paper I recently stumbled across: http://www.ncbi.nlm.nih.gov/pubmed/17108438

    I ponder that the literature suggests that most IS patients have some degree of respiratory impairment, along with Martha's documented work, and many anecdotal reports of those who find both spinal improvement along with methods they have used like Yoga, Pilates, Schroth .. all of which do in some fashion improve respiratory function. Something worth further documented investigation in my opinion. Makes me wonder if a focus on respiratory improvement may prove of (at least some) benefit for all.


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    2 studies

    Hi Dr. McIntire

    You may be interested to know that another study on what I believe is TRS has already been completed and is awaiting publication.

    The effect of asymmetrical weight training on paraspinal muscle activity in scoliosis

    You might also find this study interesting.

    2007: Decrease of electromyographic activity of concave paraspinal muscles in scoliotic girls after specific soft tissue therapy

    Conclusion: A single session of specific soft tissue therapy decreased the bioelectrical activity of the paraspinal back muscles at the concave side of thoraco-lumbar scoliosis.

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    Thanks for posting Kevin. Your discussion of your work and the subsequent questions posted are very helpful.

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    muscle mass

    Dr. McIntire do you have any comment on the conclusion from this study? It appears to offer further support for your work on TRS.

    Relation between adolescent idiopathic scoliosis and morphologic somatotypes.

    RESULTS: Patients with progressive adolescent idiopathic scoliosis showed significantly less mesomorphism (mean value of 0.88 +/- 0.51) than control girls (mean value of 1.72 +/- 0.52). CONCLUSION: Adolescent girls with progressive adolescent idiopathic scoliosis have a morphologic somatotype that is different from the normal adolescent population. Subjects with progressive adolescent idiopathic scoliosis are significantly less mesomorphic than control girls. This observation may be of value as a predictive factor for early identification of subjects with adolescent idiopathic scoliosis at greater risk of progression.

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    brilliant

    Dr. McIntire

    I have no monetary interest or investment in any product related to my project. In fact, we were aiming at the exact opposite. Money should not be a reason why someone canít get a treatment. As well, what good is a treatment if you have to come back on a weekly basis for it to be effective? This discriminates against people with no time or ability to make that effort. So we wanted to have a therapy that, after an initial learning/monitored exercise phase, the patient and families could be self-sufficient. We didnít quite accomplish that but we made good headway.
    I think your effort in this direction is brilliant.

    Would it be possible for you to film a short video that shows the "at home" exercise you developed for this study? Treatment of Adolescent Idiopathic Scoliosis With Quantified Trunk Rotational Strength Training: A Pilot Study

    Putting a video on YouTube costs nothing and it would help thousands of people around the world who don't have access to a MedX or similar machine. People are visual.
    Last edited by Dingo; 01-14-2010 at 10:04 AM.

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    Quote Originally Posted by tonibunny View Post

    The trouble with Idiopathic Scoliosis is that there are plenty of people who could have undiagnosed connective tissue disorders. ...
    Given the number of people with scoliosis that I know who have joint hypermobility and other symptoms, I think it's entirely likely that there will be plenty of people diagnosed with AIS who actually have undiagnosed connective tissue disorders.
    Quote Originally Posted by Pooka1 View Post
    ... It seems certain that some fraction of the subject patients in ALL AIS studies in fact do not have AIS but instead a connective tissue disorder of some type which may or may not react differently to PT and bracing. This seems like a potentially large confounder.
    ....

    My point was that most, if not all, cases of emergent Marfans are diagnosed as AIS initially. A kid might have the condition yet not meet the diagnostic criteria until they reach adulthood. ...

    The incidence rate of Marfans, while very low in the general populace is of course much higher in the scoliosis crowd.

    And I think both the PT and bracing literature could be cleaner if researchers could somehow identify these connective tissue disorder (and potential) cases as some are known to be resistant to bracing and possibly to PT also. The result is to muddy the study and perhaps artificially skew the results towards apparent lower efficacy.
    You both make very good points. A misdiagnosed connective tissue disorder seems dangerous for a number of reasons. I think it would be a worthy addition to the exercise studies. Mentioning connective tissue disorders as a screening criteria would be a good thing. As you all have mentioned, it's the undiagnosed cases that might cause problems. There's always room for more research. The more we learn the less we know.

    Quote Originally Posted by mamamax View Post

    I'm unfamiliar with the Dobosiewicz Method and would very much like to see the full text version of a paper I recently stumbled across: http://www.ncbi.nlm.nih.gov/pubmed/17108438

    I ponder that the literature suggests that most IS patients have some degree of respiratory impairment, along with Martha's documented work, and many anecdotal reports of those who find both spinal improvement along with methods they have used like Yoga, Pilates, Schroth .. all of which do in some fashion improve respiratory function. Something worth further documented investigation in my opinion. Makes me wonder if a focus on respiratory improvement may prove of (at least some) benefit for all.

    I have the Dobosiewicz paper. I tried to scan it earlier and it didn't turn out so well. I'll tinker around with it and try to send it to you. That abstract was the presentation I saw.

    Quote Originally Posted by Dingo View Post
    Hi Dr. McIntire

    You may be interested to know that another study on what I believe is TRS has already been completed and is awaiting publication.

    The effect of asymmetrical weight training on paraspinal muscle activity in scoliosis

    You might also find this study interesting.

    2007: Decrease of electromyographic activity of concave paraspinal muscles in scoliotic girls after specific soft tissue therapy
    The asymmetrical versus symmetrical exercise was probably one of the most asked questions I received when I would present my work. If they're weak on one side, why not strengthen just that side. The simple answer is that paraspinal muscles on both sides of the spine are active during rotations in either direction? Presumably, while one side is assisting with the movement the other side is assisting stabilization. So exercising in both directions allows the muscles to function in both roles. I have some EMG data but it is probably too messy to publish. EMG filtering and analysis can be pretty complex especially if you have a lot of noise, which I do in several of my trials.

    The EMG ratios are very interesting to me. It's hard to know if this change in ratio means anything though, just based on the abstract. There's an article by Cheung et al 2005 linking these ratios to progressive versus non-progressive curves. A significant difference between the ratios for progressive versus non-progressive curves at the lower end vertebral level was found in supine, sitting and standing positions.

    Quote Originally Posted by Dingo View Post
    Dr. McIntire do you have any comment on the conclusion from this study? It appears to offer further support for your work on TRS.

    Relation between adolescent idiopathic scoliosis and morphologic somatotypes.
    This study was the reason we measured the full somatotype. We didn't find the exact same thing, we found that non-scoliotic girls were more endomorphic. But I'm not confident about the statistical procedure we used. Their cohort was also much larger.

    Quote Originally Posted by Dingo View Post

    Would it be possible for you to film a short video that shows the "at home" exercise you developed for this study?

    Putting a video on YouTube costs nothing and it would help thousands of people around the world who don't have access to a MedX or similar machine. People are visual.
    That's an interesting suggestion. Researchers and clinicians should definitely begin to use the media outlets that are available. It's one of the reasons I decided to come on the forum here. My interests lie in translational research and I have a passion for scientific communication. Going to the public/patient population with information instead of waiting for it to filter down through changes in clinical dogma could have a pretty big impact on the way we do certain clinical trials. Although, there are also some inherent pitfalls with that as well. We're definitely in an era of major changes.

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    Quote Originally Posted by skevimc View Post
    The more we learn the less we know.
    If I didn't know you held a research doctorate before, I would have guessed you did just based on this comment. It's a common sentiment. Research is hard.

    And of course most published research results are false.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

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