Treatment: PT using MedX per Mooney & later, McIntire research

[AMom]

Progressive Resistance Torso Rotation Strength Training Case

QUESTIONS
i) Is anyone else trying progressive resistance torso rotation strength training? I would like to compare notes (positive & negative) and exchange research articles on related subjects.

ii) Will altering the seat height ½" to ¾" above or below current seat height distribute the intensity of the workout? (3 workouts per week = a possibility of up to 3 seat heights) I ask this question because her strength is not equal at the above referenced seat height variations. TRIED THIS, NO SUBSTANTIVE CHANGES TO PRIMARY CURVE NOTED ON X-RAYS. (Compensatory curve reduced in size.)

EQUIPMENT
We are using the MedX CTR and BackStrong VARC based on Mooney's initial research. We purchased both units, but then had to wait several years for our daughter to "grow into" the MedX at age 11. The length of her femur or lack thereof, is what kept her from safely using the leg restraint system.

New Info.: On January 1, 2013, MedX provided several modifications that allow the CTR to be used by most 9–11 yro if you add a footrest extension. They later added a notched seat that allows users with even shorter femurs to use the equipment. IMPORTANT: The modifications are not made for the older "overhead" MedX CTR versions.

PT
Note: Most research states the test subjects completed the exercises 2x per week until reaching a plateau & then reduced the workout to 1x per week. Initial research by McIntire suggests these PT benefits may wear off in 8-12 months if the workout is stopped altogether.

My daughter works out 3x per week as follows:
A) 10-15 minute walk or bike ride (hula-hoop on rainy days) to warm up
B) 20 reps on the VARC (see #1 DETAILS below to see how she progresses)
C) 20 reps Left & Right on the MedX (see #2 DETAILS below to see how she progresses)
CC) Added 2nd seat height (higher), alternating between the two every other workout
CCC) Added 10 eccentric reps Left & Right on MedX
CCCC) Added final seat height (lower), alternating between the three every week
D) Spirometer reading (best of 3 readings is recorded)
E) Large ice pack for back 15 minutes (still no back pain, but will reduce to 2x per week if it occurs)

CURVE & PLAN
Based on what little research I can find on the subject, we do not expect the PT to reduce her curvature; rather, we are hoping it will "hold" her curve. She has curves that made some frightening leaps--the last one BEFORE she was able to fit into the machine was an increase of 12 degrees (primary right thoracic) & 17 degrees (compensatory left lumbar) between x-rays. Her ortho said the PT would not do any good, but agreed that at least she would be in better health for the surgery he was anticipating. We began PT in February 2011. It is too soon to say if it will hold the curve for 5 years, but her initial readings show she is holding steady during a growth spurt.
33T & 27L on 02-10-11
32T & 23L on 06-16-11
34T & 20L on 10-10-11
31T & 25L on 04-16-12
31T & 28L on 10-15-12
31T & 30L on 04-11-13 Betz & Braun read x-rays (ended PT due to an unrelated accident)
31T & 30L on 10-13-14 Betz & Braun read x-rays
31T & 30L on 11-xx-15 Betz & Braun read x-rays--T/ primary curve bent out nicely!
34/5T & 30/2L on 08-xx-16 Newton (Newton read prior 3 x-rays slightly higher than Betz & Braun)

Maturation Levels
2010 R=0, T=1
2011 R=0, T=2 Began PT
2012 R=?, T=3 Continue PT
2013 R=4, T=3-4 End PT
2014 R=4, T=4
2015 R=5, T=5
2016 R=5, T=5

FYI: Her forward head thrust is gone, her spirometer readings are now above normal, she is less tired, & because her core strength is improved her posture is better & she is more comfortable while sitting, standing, & walking.

Our plan is to continue her PT until she is 16ish/ bone maturation occurs. Then, we will drop to 1x or 2x per week for another year. I don't know what will happen in the long run, but she likes that we made our plan together and that we can make changes based on what we see on the x-rays. In the meantime, her quality of life is great.

--Due to an accident, she stopped PT at roughly 26 months.

DETAILS
(This is NOT a suggestion that anyone else should try this workout, I am just telling you what she is doing. Many workouts can be dangerous if a child has anything else going on, so I always check with her ortho to R/O the possibilities of injuries before starting any new exercises!)

PROTOCOL PROGRESSION
BackStrong VARC (Variable Angle Roman Chair)
1) One set of 15-25 to fatigue on BackStrong (20 in a perfect world)
---Turn feet "in" (difficult to maintain)
---Back arch up, NOT flat back up (she loves to swim & calls the head movement a mermaid dip)
---We started at 75 degrees, hands behind back & continued this position until able to do 20
---We stayed at 75°, hands cross sternum & continued this position until able to do 20
---We stayed at 75°, genie arm cross & continued this position until able to do 20
---We stayed at 75°, fingers lightly behind ears & continued this position until able to do 20
---Then, we moved to 60°, 45°, 30°, 15°, & 0° and repeating the process

MedX Core Torso Rotation--(Unit fits 4’10” to 7’11” MALE, but not a 4’9 & ¾” female)
2) One set of 15-25 each direction to fatigue (20 in a perfect world)
Starting weight: 1/3 of body weight OR lift maximum weight and use 50 percent of that amount
ROM (range of motion) setting dependent on ability (#2 seems to work best)
Doctor suggested she increase weight in increments of 5% of current weight, but we increased as smaller percentages.

When she gets to 20 reps per side, then we are supposed to increase weight--not repetitions
Studies discuss exercising 2x per week (research suggests that for this group of muscles 2x - 3x per week provides maximum benefit, but is more likely to cause back pain & then the user will quit the PT)

Note: Conversations with clinics & gyms in the USA suggest 1x per week may be sufficient to achieve positive results. (No definition of “positive” results provided.) They stated they would prefer 2x per week, at least to get the weight lifted “up,” but acknowledged the results are pretty similar. This note is based on telephone conversations, nothing in writing, nothing published.

My Note Reply: Per my records, there was no change in results at the beginning of my daughter’s workout, low weight lifted=no increase/ decrease in curve AND later when a higher weight was lifted=no increase/decrease in curve.

Ongoing workout through puberty (No long term study, but there are some suggestions to be found in various articles that PT needs to be continued until toward the end of a Risser 4 or the beginning of a Risser level of 5 is reached/ bone maturation.

PLATEAU
When she plateaus we are considering the following for the MedX:
• She may add a 2-4 second count hold during full extension; (HAD BACK PAIN)
• Can change the ROM setting; (REVERTED TO #2 & STAYED THERE, NO CHANGE SEEN)
• Add minor seat height changes; (ONLY CHANGE SEEN WAS IN COMPENSATORY CURVE)
• Increase the weight and change angle of arms to 90°; (NO CHANGE SEEN)
• Reduce the frequency of the workout to 2x per week; (NO CHANGE SEEN)
• Consider eccentric workout. (HAD BACK PAIN)

The only ideas we have for the BackStrong VARC when she plateaus is to use an asymmetrical position. (SHE HAD A SMOOTH BACK WHEN USING ASYMMETRICAL POSTION IN THE ROMAN CHAIR—NO CHANGE SEEN ON NEXT X-RAY)

WORKOUT PROTOCOL
The workout she is doing is similar, but not the same, as the Mooney study. (20x BackStrong & 20x MedX portions are the same)

The McIntire protocol is different. They began their Warm up with a specified walk & workout on the MedX, move to Preparation/ Training on MedX, and end with a Burn-out on MedX.

PLEASE SHARE!
I don't know if this is written clearly. I am sure you see I do not have a background in biology or science. If you are trying something similar, please consider sharing your workout and results. I would love to be able to compare notes and exchange research articles on related subjects.

Thanks!

A Mom

[Pooka1]

I just saw this post today.

Don't know if this is written clearly.

Not only clear but well written and well-reasoned. Easily one of the best posts i have read in a long while.

I am sure you see I do not have a background in biology or science.

No actually I though you might have a background in research or something that requires analyzing a situation, taking onboard the literature implications and limitations, proposing a reasonable hypothesis, and keeping meticulous records to piece it all together. Clearly this can be learned outside of a graduate program.

This type of material seems amenable to being published as a case study because it is so good. I congratulate you.

It certainly appears the PT has stabilized her curves, especially in light of the surgeons remarks. Hard work pays off hopefully.

[TAMZTOM]

...she is holding steady during a substantial growth spurt.
33T & 27L on 02-10-11
32T & 23L on 06-16-11
34T & 20L on 10-10-11
She has grown SO MUCH (gained almost 20lbs and several inches) in the last year!

Incredible job, great to know of your daughter's success and excellently recorded. Do you know what her lumbar and thorax rotational measurements (scoliometer) were during this period?
Thanks
Tom

[Pooka1]

Incredible job, great to know of your daughter's success and excellently recorded. Do you know what her lumbar and thorax rotational measurements (scoliometer) were during this period?
Thanks
Tom

You're another person who is in a position to publish a case study in my opinion. There is some very meticulous documentation going on there.

Both cases are very interesting. It's very exciting to read these case study posts.

[TAMZTOM]

The stand-out data for me in Amon's post is the decrease in LC and stability of TC. Does TR primarily address core muscles around the lumbar area? Is that increase in core strength sufficient to stabilise statistically high TC progression rates? Does TR positively affect thoracic and lumbar vertebral rotation. And harking back to the other TR thread, would asymmetric TR towards the thoracic concavity more effectively correct than symmetric TR?

Possibly relevant is the SpineCor brace fitting procedure: the corrective movement principle applied while fitting the brace involves a locked pelvis, thoracic rotation towards the thoracic concavity (counter-clockwise in the transverse plane).

EDIT: from the SOSORT publication
Harrington established that postural imbalance alone can induce [ME: initiate the "vicious cycle" regardless of cause] severe scoliosis which resolves when the imbalance is removed before growth is complete.

It could be the case that Amon has reduced/is reducing her kid below the threshold for mechanical progression.

[AMom]

T vs. L curve and core torso rotation & Charting

Due to the movement of the spine, core torso rotation should theoretically focus on the thoracic rather than the lumbar curve. If you look at the Mooney article, you will see they did not even track the lower curve. The subjects with a right thoracolumbar curve “held” rather than reduced their T curves. The subjects with only a thoracic curve had better results: four curves reduced & 3 remained stable. –Yes, I know, they were tracking strength, but I am obviously interested in the “side effect”/ change in curvature.

If you look at the McIntire article, it shows the beginning readings and the readings AFTER they had stopped PT for a period of time. (I’d like to see the numbers at the end of the initial four month period, but do not want to wear out my welcome by requesting too many details in a short time span.) Moving on, after the subjects had stopped the workout they had eight T curves that increased & two that stayed the same/ increased by 2 degrees. The lumbar curves show five L curves that increased, two that remained the same, & three that decreased. Compared to Mooney’s study, the thoracic only curves did not do as well this time with four curves increasing & one remaining stable.

I can’t comment on whether the slightly different results were due to the two different prescribed workouts or the fact the sample size was too small.

I removed my opinions because I can’t back them with facts.

-------------------------------------------------------------------------------------------------------

My notes are likely of little interest to anyone other than myself—they are pretty basic. To make logging consistent, quick, & easy I created three simple tracking forms. Two are “tick sheets” w/ descriptions and photos of the stretches & exercises assigned by her PT. The third form tracks the VARC & MedX workout on a monthly basis. (*Sample Below—Sorry, no sample available, the table fell apart when pasted into the message. Do you know how to insert a table on this forum?) X-rays, ortho, & PT reports are retained along with my personal charting notes. Except for the prescribed changes on the VARC and MedX, her workout has become routine so we are able to focus on details.

I ran a few simple tests and found her strength is substantially different when seated in the MedX at slightly different heights. (Normal # of rotations = 20, however, she could only complete 7 rotations in a lower seat and 11 rotations in a higher seat.) After reviewing literature and discussing the possible cause with a variety of professionals we have decided to alternate seat heights (regular seat height & the higher seat height) during the interim between two x-ray’s. I will post her x-ray results.

FYI: It has been suggested that changing the height of her arms while in the MedX may have more of an impact than changing seat height.

[TAMZTOM]

Core torso rotation should theoretically focus on the thoracic rather than the lumbar curve.

The theory may not be fully fledged out, Amon. E.g., it would add to the theory if you were to isolate and establish a direct, corrective affect on the lumbar curve. I also, however, have experienced the incredible variation in measurement from 4 different physicians (e.g., we've been given measurements ranging 8 degrees on Tamzin's INITIAL TC).
I am neither sceptical nor assured about TR. I would like to be assured, hence my continuing thoughts on this exercise. We've been doing Schroth, which includes similar exercise, but asymmetrical; even there, we've--so far--avoided TR. I'm too ignorant to answer the Q about whether lumbar vertebrae are 'pressured' the contraindicated way even during asymmetrical rotations, so we've built up her strength using different exercises. Schroth is pretty static stuff though, so we've added "corrective ballet" to her program (i.e., basic ballet work-outs using corrective breathing and posture).

"isometric contraction"

Almost every exercise we've done has elements of isometric contraction involved. Tamzin has gained 8lbs of muscle since July, grown a few cms; her curves are stable (possibly improved), depending on who does the measuring). I am not assured; she's on the cusp of some mighty height and weight increases now, IMO, and, given her large curves, the prognosis isn't optimistic. We remain optimistic that we'll reduce the curves.

My notes are likely of little interest to anyone other than myself...I created three simple tracking forms.

Untrue! Your notes are of great interest to me and potentially many others. That you've actually made ticking forms puts me to shame (great idea, will be copied today by us).

From a purely subjective perspective, I can state that my daughters’ right shoulder has almost returned to normal while standing (rotation still noted during Adam’s Bend.)

Thanks for that. This is the area of TR regarding which I'm especially ignorant.

This means swim suits and summer clothes are once again a non-issue when shopping.

THEORY: my 10 yr old has for 5 months relentlessly dragged me into clothes stores. She suggests that "Stylish stuff stops scoliosis." Does a statistically significant forbidding of the propensity to 'shop till they drop' explain progression in 10 - 15 yr old girls?

[AMom]

The stand-out data for me in Amon's post is the decrease in LC and stability of TC. Does TR primarily address core muscles around the lumbar area? Is that increase in core strength sufficient to stabilise statistically high TC progression rates? Does TR positively affect thoracic and lumbar vertebral rotation. And harking back to the other TR thread, would asymmetric TR towards the thoracic concavity more effectively correct than symmetric TR?

Possibly relevant is the SpineCor brace fitting procedure: the corrective movement principle applied while fitting the brace involves a locked pelvis, thoracic rotation towards the thoracic concavity (counter-clockwise in the transverse plane).

EDIT: from the SOSORT publication
Harrington established that postural imbalance alone can induce [ME: initiate the "vicious cycle" regardless of cause] severe scoliosis which resolves when the imbalance is removed before growth is complete.

It could be the case that Amon has reduced/is reducing her kid below the threshold for mechanical progression.

Your first paragraph asks a lot of good questions, but there just isn't enough data to answer most of them one way or another with anything more than a guess on my part. And, I’m still concerned the x-rays only demonstrate 8 months of data. The fact that the curves are holding during PGV is a huge relief, but until the next x-rays (14 months) come back I won’t know if this is roughly the maximum “hold time” or if the PT can hold a curve stable longer than 8-12 months. The second and third x-ray from now will be more informative. Assuming things don’t change mid stride!

I'm not saying this with assurance, but I don’t think the lumbar region has any rotation--I'll double check that thought. --Okay, it has a tiny bit of rotation.

It is my understanding (second hand info) there is a group that are looking into asymmetric TR. Last I heard, they were putting the study together--no actual testing started. I think this has potential, but don't believe anyone knows enough to explain the dynamics yet and therefore they will not be able to choose a place to begin the testing with much more than an educated guess. I can't afford to be too experimental with the PT, so I am staying close to the original work (as good or bad as it may be, it is a place to start.) Conservative action may be boring to many, but my daughter is 12 so we don't have time to test the many, many variables before the process becomes useless for her.

I was also interested in the SpineCor Brace. I had presented my daughter with the following treatment choices: 1) watch & wait w/ PEs for general health, 2) rigid brace w/ PT to address some of the damage caused by the rigid brace, 3) flexible brace, 4) PT/ MedX rotation, or 5) flexible brace & PT/ MedX. It was just as well she didn’t choose #3 because by the time we had insurance and all of the options lined up; her curve had progressed so fast that her surgeon, both orthotists & a chiro discouraged its use due to the combination of her curve size, curve progression, & age. They all recommended a rigid brace. Your daughter is younger and more active than mine, so the Spinecor has a better chance of working well for her.

I think her T curve would need to be smaller than 32-34 to be below the threshold for mechanical progression. If her T curve were to magically reduce to 25-27 degrees (made up threshold) then I could consider your supposition as a possible explanation as to why the T curve is holding.

Lots of good questions. Thank you for wondering "outloud."

A Mom

[TAMZTOM]

...there just isn't enough data to answer most of them one way or another with anything more than a guess on my part.

Action after educated extrapolation is necessary--the clock ticks for us both. From different bases, we can modify programmes as we learn 'on the job'. Medical science is no different: e.g., current USA debate about premature surgery and a groundswell of renewed interest in conservative management after the arrogant dismissal by the surgical fraternity. We don't take 'leaps of faith' into any camp.

it has a tiny bit of rotation.

So, 8 months has not made lumbar rotation worse. That is important.

It is my understanding (second hand info) there is a group that are looking into asymmetric TR.

Excellent. I wonder is Dr McI knows about this?

I can't afford to be too experimental with the PT, so I am staying close to the original work (as good or bad as it may be, it is a place to start.) Conservative action may be boring to many, but my daughter is 12 so we don't have time to test the many, many variables before the process becomes useless for her.

Hitting one area that you've reasoned is likely to have some positive effects is wise. SEAS, for example, includes the TR 'area' as ONE of the factors to target: "The therapeutic modalities to obtain postural control and spinal stability are postural rehabilitation, muscular endurance strengthening in a correct posture, development of balance reactions and neuromotor integration."

They all recommended a rigid brace. Your daughter is younger and more active than mine, so the Spinecor has a better chance of working well for her.

With similar curves (I think), our daughters' respective medics recommend different equipment. This emphasises the lack of conviction from ANYONE, professionals alike, about the many ways to go. Actually, within 3 days of diagnosis, my wife and I reasoned that our best chance of success was to use an over-corrective night-time brace combined with a SpineCor during the day. (We had a night-time brace made, but the orthotist messed it up.) I'd like more immediate correction on Tamzin's lateral curves, but am wary about the intense pressure on a tiny wee body. For the moment, we'll use the SpineCor and exercise. (PS: doing asymmetric TR in her SpineCor brace, really would work her thoracic curve...possibly 20 - 30% more pressure on the TC apex working in brace.)

I think her T curve would need to be smaller than 32-34 to be below the threshold for mechanical progression. If her T curve were to magically reduce to 25-27 degrees (made up threshold) then I could consider your supposition as a possible explanation as to why the T curve is holding.

Consider this: 32 - 34 I agree is likely above the threshold, on it's own; but, with a stronger core and straighter/aligned vertebral stack above the LC, that TC curve progression threshold may be raised?
EDIT: my daughter has an L3 apex on her LC; this was originally measured at 37 - 40 degrees; 3 months later, it was measured at 27 (I think closer to 32 is accurate); regardless, the vertebral stack above from approx. L5 to T10 especially, but also all the way up to the cervical spine was far more perpendicular. The thoracic curve remains (somewhere between 32 & 37), but the vertebrae included in that curve are also more perpendicular. I am certain that the same degree curve in a more perpendicular alignment raises that threshold for progression.
This could explain your daughter's thoracic stability.

Just thinking...won't stop thinking and acting...and will deal with developments, good or bad, as they come.

[AMom]

How to question

How do I paste a table created in Word in this forum?

[TAMZTOM]

How do I paste a table created in Word in this forum?

I tried it, doesn't work (strips out the table). There is a table facility just above where you type posts; mine is greyed out, i.e., disabled.

[Pooka1]

Can you copy/paste to Word and save it as a .jpg?

[AMom]

Where is .jpeg?

Under "Save As" I see a variety of Word choices, Open Document, PDF, and an Other Formats setting (which does not seem to include .jpeg), but do not see a .jpeg choice when saving a document. If it isn't too time consuming, will you please tell me how to locate the .jpeg option?

Thanks,

A Mom

[Pooka1]

A Mom,

Sorry I took so long getting back to you. I wanted to take some time to figure this out. Word allows you to save a table as a .pdf. When you upload that file as an attachment, it uploads and converts it to a .jpg I htink. Anyway it works. See my test table.

Guinea pigs.pdf

[AMom]

Too large to insert

Pooka,

I had a few minutes until my next project so I tried to attach the .pdf, (simple process once I knew the steps.) The "blank" chart I use contains 186.9KB, which exceeds the 100.00KB allowed on this system. I removed the text preceding it, three of the five calendar rows, and the shading in the table and it remained too large to insert. Out of time, I really will have to try it on Monday.

A Mom