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

[Pooka1]

Using the Shroth position on the equipment, she had a perfectly smooth back. I never really asked questions about it, but I had a vague idea that the STRUCTURAL portion of the curve could not straighten out, flex, or de-rotate without surgery, so I thought I would never see a "flat" back in a bending position. Am I confusing two separate ideas here?

Structural curves can bend out some, just not mostly/completely like a compensatory curve. My kids did the following:

Kid 1: T55* bent out to T23*
Kid 2: T58* bent out to T31*

Because your daughter's curve is still relatively small, she can probably bend it out to an even smaller angle which would not necessarily be noticeable.

We have a guy on the group who "fails" the Adams forward bending test (i.e.,. indicates no structural curve) and yet he was told he has a structural curve. I think there is something unusual going on there and he should chase that down if the curve ever progresses and he is told he needs surgery. I am skeptical that he has a structural curve.

Also, Tom's girl has a flat back when seated and bending forward if I recall. Either this test is not useful or her Chiari/SM curve might be different than the great run of AIS curves. We would have to determine if AIS curves also have flat backs when doing that maneuver.

Last, I think Adams is claimed to help determine rotation (correct me if I'm wrong). But my daughters differed greatly on apparent rotation at least on similar-sized curves yet both had very large slopes on the Adams test. They were never measured so that's the best I can do. Apparently, the scoliometer readings are not of interest to our surgeon as he never did them with my kids during treatment nor to plan surgery.

[Kevin_Mc]

We tried Tom's "Shroth version" of the roman chair/ Shroth positioning instead of symmetrical positioning. (fingers lightly touching ear while the other hand rested on her opposing hip.) I was shocked. I can't remember the last time I saw my daughter bend over (think Adam's bend) and not see a bump immediately appear. Using the Shroth position on the equipment, she had a perfectly smooth back. I never really asked questions about it, but I had a vague idea that the STRUCTURAL portion of the curve could not straighten out, flex, or de-rotate without surgery, so I thought I would never see a "flat" back in a bending position. Am I confusing two separate ideas here?

She said it felt easier. It was my impression she could do another 7-10 reps, but I didn't want to push it the first time, just in case there was residual discomfort. I'll try it again tomorrow (second time for us) and let her do the extra set of 10 if she is up to it.

That's pretty interesting. I'll have to think about that a bit. I've mentioned somewhere before but I had a PT back in KC that talked to me after a seminar I gave and he had the suggestion/question if different arm positioning would activate different areas of the spine. It's a great idea and I can easily see that it would. Doing exercises in a Schroth position is clearly a good direction. At least from a 'specificity' point of view. That position is meant to derotate the top and bottom curves I think.

Last, I think Adams is claimed to help determine rotation (correct me if I'm wrong). But my daughters differed greatly on apparent rotation at least on similar-sized curves yet both had very large slopes on the Adams test. They were never measured so that's the best I can do. Apparently, the scoliometer readings are not of interest to our surgeon as he never did them with my kids during treatment nor to plan surgery.

That's correct. It just accentuates the rib hump, which is LOOSELY correlated with rotation. Some people have a positive Adam's but no scoliosis. I'd imagine some doctors wouldn't even bother doing an Adam's if surgery was most likely in their future. It can be a tool for progression measurement. But has obvious weaknesses.

[TAMZTOM]

She said it felt easier.

With the arms in this position, the relatively underused concavity muscles (top left and bottom right) share an increased portion of the load. The position therefore LIGHTENS the load on the already overloaded/overstretched/overused muscles (top right and bottom left).

=

"easier"

[TAMZTOM]

Structural curves can bend out some, just not mostly/completely like a compensatory curve.

"Structural curve" has no unanimously accepted definition; e.g., in the UK, a structural curve is one that doesn't flatten out! So-called "structural curves" can flatten out; I doubt it happens very often because the overwhelming majority of those with scoliotic curves are told that they don't flatten out...and believe it!

I am skeptical that he has a structural curve.

And that is an important point, Sharon. The medics are misinforming many people about the nature of their condition.

Also, Tom's girl has a flat back when seated and bending forward if I recall.

I'm glad someone noticed that post! It seemed very important when I made it. In the seated, bending position, the pelvis and leg muscles and ligaments DO NOT affect contribute to the rotational forces--therefore, when doing a standing Adam's test, they do!

Either this test is not useful or her Chiari/SM curve might be different than the great run of AIS curves.

There is no medical condition called a "Chiari/SM curve". According to the medical community (spine surgeons, neurosurgeons, orthotists, PTs, scientists), Tamzin has AIS. I've just slated many of that community, so it's hypocritical of me to know use their definition! Ach... As a hypothesis, it's far reaching to suggest that Chiari caused scoliosis which caused SM; or SM caused Chiari which caused scoliosis; or scoliosis caused Chiari which caused SM...etc.

We would have to determine if AIS curves also have flat backs when doing that maneuver.

Tamzin's back is derotated when doing that manoeuvre, therefore her AIS curves respond. AMon's AIS kid responds in that manner. 3sisters AIS kid's curves respond in that manner. 3SISTERS herself--and adult diagnosed with AIS as a kid--STILL NOW responds in that manner.
I think the determination has been made!

...the scoliometer readings are not of interest to our surgeon as he never did them with my kids during treatment nor to plan surgery.

Spine surgeons cannot easily correct rotation...they often perform costoplasty to remove the rear rib prominence. I.e., they cut the ribs off, big chunk out of them, then try to grow the ends back together, this because they never figured out how to fix the rotation.

[Pooka1]

I think the determination has been made!

Okay then! Case closed. :-)

Spine surgeons cannot easily correct rotation...they often perform costoplasty to remove the rear rib prominence. I.e., they cut the ribs off, big chunk out of them, then try to grow the ends back together, this because they never figured out how to fix the rotation.

Pedicle screws have solved derotation to the point that costoplasty is rarely done any more in the US to my knowledge. The screws have almost completely obviated costoplasty. Costoplasty is still done in the UK per my reading of SSO but I am not abundantly clear why given the screws.

There are videos of how surgeons de-rotate spines with special tools. It is exactly how it sounds... they move the vertebrae around the vertical axis until they are derotated.

My one kid was highly rotated pre-op and was about 90% de-rotated post-op because of pedicle screws. The two rods are almost completely superimposed for most of their length which is related to how most of the rotation was removed. She appears very close to normal in terms of rotation now whereas she was obviously highly rotated before. A naive person would not notice the residual rotation whereas they couldn't miss it before.

[TAMZTOM]

It just accentuates the rib hump, which is LOOSELY correlated with rotation. Some people have a positive Adam's but no scoliosis.

Interesting, never knew the emboldened bit. My understanding was that the rib prominence is often due to side ribs rotated around to the back near or under the scapula. With Tamzin, the side ribs were distinctly rotated around to the back. We derotated these (approx. 6 - 7 degrees correction). The back ribs can also buckle; we've HAD this with Tamzin. I've also heard reports that the ribs can straighten, buckle, straighten...etc...i.e., fixed once does not mean fixed for good.

[AMom]

I don't know much about Shroth

That's pretty interesting. I'll have to think about that a bit. I've mentioned somewhere before but I had a PT back in KC that talked to me after a seminar I gave and he had the suggestion/question if different arm positioning would activate different areas of the spine. It's a great idea and I can easily see that it would. Doing exercises in a Schroth position is clearly a good direction. At least from a 'specificity' point of view. That position is meant to derotate the top and bottom curves I think.
....

I'd be interested in speaking with the PT in Kansas, would you mind asking if it would be okay for me to contact her/him?

Emily, my daughter, Erin, and Tamzin, all have curves that respond in a similar manner to a Shroth position (finger tips lightly touching the ear, fingers on opposing hip) while using a roman chair, which might be telling us something. (So far, I've got nothing, but Shroth hasn't been my focus. Could it have any impact on the rotation of the spine? Or, do you think it just looks like this DURING the workout?)

She has been working hard to complete 20x at 45° with hand across the sternum, this evening she did 25x and stopped because she didn't want to do more--not because she couldn't do more. Based on what I saw, she could have completed 30x in the asymmetric position.

I'd be interested in speaking with the PT in Kansas, would you mind asking if it would be okay for me to contact her/him?

Emily, my daughter, Erin, and Tamzin, all have curves that respond in a similar manner to a Schroth position (finger tips lightly touching the ear, fingers on opposing hip) while using a roman chair, which might be telling us something. (So far, I've got nothing, but Schroth hasn't been my focus. Could it have any impact on the rotation of the spine? Or, do you think it just looks like this DURING the workout?)

She has been working hard to complete 20x at 45° with hand across the sternum, this evening she did 25x and stopped because she didn't want to do more--not because she couldn't do more. Based on what I saw, she could have completed 30x in the asymmetric position.

Listing everything in order of age Emily, my daughter, Erin, & Tamzin below:
AGE: Adult 49, and Girls 12, 12, & 10;
SCOLIOSIS: AIS, AIS, AIS & AIS with C&S;
CURVE MEASUREMENTS: 50T & 35L, 34T & 20L, 40T & 30L, and 34T & 25L;
CURVE DIRECTION: _____?, Right T & Left L, _____?, Right T & Left L:
(Emily will you please remind me of the directions of yours and your daughter’s curves?)
TREATEMENT (overly simplified): Schroth, CTR w/ additional PT, Schroth w/rigid brace, & Schroth w/ flexible brace:
FREQUENCY: _____?, 3x per week, _____?, 7x per week
(Emily will you please share the frequency of yours and your daughters’ workouts?
***Let me know if I don’t have the most updated info on anything above.***

[TAMZTOM]

Or, do you think it just looks like this DURING the workout?

AMom

Regular performance of particular corrective exercises help correct ribs and spine. Your endeavour to identify and isolate effective exercise is necessary and commendable.
And then we have the rest of life. Identifying efficacious methods or exercises is important but problematic given disparate postural, proprioceptive, nutritional, motivational, focused lives of the ‘patients’. Tamzin cannot be categorised as a SpineCor wearing Schroth patient. Schroth is grounded on proprioception improvements. ISICO, SEAS, several SOSORT conferences, a century of European corrective methods all emphasise the crucial importance of what patients do when they are NOT exercising. I and many others consider erasing the scoliotic subconscious with active self-correction throughout every day necessary to achieve lasting correction. To optimise, the patient should be healthy, fit, focused and determined to correct. General entire body aerobic conditioning and muscular strength are crucial. Then, particular exercise (e.g., Schroth, TR) can be added to achieve maximum results. Within Schroth exercising, there are 100s of exercises; we have a core of around 10 that we observe have the best effect.
Schroth rotational angular breathing (RAB) is designed to derotate the spine. Tamzin’s spine (before wearing a brace) derotated by approx. 6 – 7 degrees (thoracic). Tamzin uses RAB all day, every day. Schroth exercises build muscle and muscle endurance AFTER the patient has used RAB to align the body. Your question—“Or, do you think it just looks like this DURING the workout?”—I think entirely misses the point of physiotherapeutic exercise to correct scoliosis.

However convenient and simple it would be to isolate the ONE THING THAT WORKS, a better way to approach treatment would be to determine what type of daily life is the most likely to succeed, then fill that day accordingly. 3sister and her daughter are the same, i.e., cannot be categorised simply as Schroth patients w/ or w/o brace.

PS: Given your questions about rotation, perhaps your 'log sheet' should have space for detailing changes in rotation, thoracic and lumbar.

[Pooka1]

However convenient and simple it would be to isolate the ONE THING THAT WORKS, a better way to approach treatment would be to determine what type of daily life is the most likely to succeed, then fill that day accordingly.

This is an astute point that I haven't seen made before to my recollection... it may be there is no ONE thing in conservative treatment that works. It may be conservative treatment can work for many patients but several modalities are simultaneously required.

I understand why the paradigm of trying to figure out which "one" thing works... most people without an a priori interest in PT like Tom's entire family for example don't want to do so much PT or to wear a brace. So the hope is one thing will work and the quest is to find it. That may be an unobtainable chimera that has resulted in perennial doubt about the efficacy of conservative methods by professionals.

Unfortunately, apparently many kid will not get with the program with "one" thing. The odds of getting them to cooperate with more than one thing are obviously worse.

[AMom]

AMom
.... Your question—“Or, do you think it just looks like this DURING the workout?”—I think entirely misses the point of physiotherapeutic exercise to correct scoliosis.....

However convenient and simple it would be to isolate the ONE THING THAT WORKS, a better way to approach treatment would be to determine what type of daily life is the most likely to succeed, then fill that day accordingly. 3sister and her daughter are the same, i.e., cannot be categorised simply as Schroth patients w/ or w/o brace.

PS: Given your questions about rotation, perhaps your 'log sheet' should have space for detailing changes in rotation, thoracic and lumbar.

Everything we do doesn't automatically correlate with a change in the progression of scoliosis, so my question stands, but might be better phrased: How & how much does this alter the natural progression of the scoliotic curve. --You answered the, "How" part and I'm not sure anyone can answer the "How much" part, yet. (We have similar ideas with a different emphasis.)

You are right, I OVER-simplified what each family is focusing on and doing in their routine. We are each taking the best of what seems to fit our child’s needs and inserting it into their individualized program. Part of that means addressing their foundation: health and well-being. For the sake of convenience, I tried to name the easiest to recognize portions of the treatment so others would have a general idea of what our kids are doing. Those that are interested will know more as private communication expands. We also agree, but I may not have said it to you, whatever anyone does, it has to fit within the entire family’s life in order for it to be maintained.

I like your idea of tracking rotation, but I don’t know how to do that objectively (I don’t have much confidence as others do in scoliometer results.) What do you have in mind?

A Mom

[Pooka1]

I like your idea of tracking rotation, but I don’t know how to do that objectively (I don’t have much confidence as others do in scoliometer results.)

Linda posted about a scoliometer app...

http://www.scoliosis.org/forum/showt...in-Your-Pocket

You can get numbers and look for changes at least if you can do it precisely enough (i.e., not get swamped out by the noise of the measurements). Relating that to science/medicine will of course be more dicey.

[TAMZTOM]

Everything we do doesn't automatically correlate with a change in the progression of scoliosis, so my question stands, but might be better phrased: How & how much does this alter the natural progression of the scoliotic curve. --You answered the, "How" part and I'm not sure anyone can answer the "How much" part, yet. (We have similar ideas with a different emphasis.)

I admit to not having rested the brain for a week as I've observed and 'trained' three different sets of curves for almost a week. If I seem abrupt...it's probably because I am! :-)

I thought I did answer the "How much" part. If correction can be achieved--and it is difficult--but it's difficult to quantify how much 'entire being' training is necessary, rather than speculate, it's far safer to always do it. We always breathe, so breathe correctively all day; je pense parce-que je suis so think correctively all day, every day. ASC all day, breathing correctively all day. Focus on postural correction, all day. Coincidentally, Dingo just sent you and I research articles exploring the idea that focused exercise is far superior to 'just exercise' in terms of innervating neural pathways. I agree entirely with Dingo's enthusiasm for such research...so did Katerina Schroth who wanted her child scoliotic patients to be treated all day, every day for 6 months, this to erase the scoliotic subconscious. All that thought eventually becomes reflex action, doesn't require as much energy and enhances one's life, not interferes with it.

As for "How" to alter progression or the particular progression threshold, we're all on that trail. Roman Chair with adapted arms seems tremendous; asymm. TR for us seems great (Tamzin is up for a miserable 30° ROM to closer to 70°, upper left trapezius, lat, rhomboid and paraspinals firing excitingly); Schroth breathing and exercise saving us so far from the surgeon's knife (e.g., told that Tamzin would 100% progress rapidly since last June, but has corrected ever since); ballet and Pilates have been and is being fantastic for increasing flexibility and strength (legs looking great). Atop that, we cycle, RUN a little, swim, climb mountains...but still not doing enough to restore her formerly very high aerobic conditioning.

For the sake of convenience, I tried to name the easiest to recognize portions of the treatment so others would have a general idea of what our kids are doing. Those that are interested will know more as private communication expands.

Agree with the 2nd point, not with the first. E.g., I've read many posts from parents of kids who wore SpineCor braces and then had surgery. Without PRECISE detail, this suggests failure. Several of those kids actually did not comply. Same goes for TR, Schroth and other methods--the battle-field is strewn with failures. I look for the successes, look for what the successes are doing ALL THE TIME, not just at whether they do one thing.

I like your idea of tracking rotation, but I don’t know how to do that objectively (I don’t have much confidence as others do in scoliometer results.) What do you have in mind?

3sister and I have been noting it all week. We have some very particular ideas. It's been quite amazing tweaking many exercises and seeing during-exercise improvement. Rotation will be logged. Will detail this stuff in an email to you soon. Video will assist. The SpineCor procedure also involves tracking rotation and angle of each affected vertebrae (more in May!).

Cheers
Abrupt and knackered Tom

[TAMZTOM]

This is an astute point that I haven't seen made before to my recollection... it may be there is no ONE thing in conservative treatment that works. It may be conservative treatment can work for many patients but several modalities are simultaneously required.

I've just taken my meds (catharsis responding to posts from you and AMom) so can now be civil again. :-)
That was very astute of you to observe my astute point. You express what I meant with two neat little sentences. Thanks.

I understand why the paradigm of trying to figure out which "one" thing works... most people without an a priori interest in PT like Tom's entire family for example don't want to do so much PT or to wear a brace. So the hope is one thing will work and the quest is to find it. That may be an unobtainable chimera that has resulted in perennial doubt about the efficacy of conservative methods by professionals.

POST OF THE MONTH NOMINATION.

Unfortunately, apparently many kids will not get with the program with "one" thing. The odds of getting them to cooperate with more than one thing are obviously worse.

Agree.

[AMom]

Sturctural Curve Thread & Scoliometer

Linda posted about a scoliometer app...

http://www.scoliosis.org/forum/showt...in-Your-Pocket

You can get numbers and look for changes at least if you can do it precisely enough (i.e., not get swamped out by the noise of the measurements). Relating that to science/medicine will of course be more dicey.

So with this type of device, I would be looking at trends over time, not individual results, right? Do you think monthly recorded results are sufficient? I am curious how well my readings would correlate with reality, maybe I'll run the numbers just for the fun of it.

By the way, I appreciate the Structural Curve and the Scoliometer Accuracy, Precision, and Relative Usefulness threads you started. Thank you for pulling those pieces together into one place.

A Mom

[Pooka1]

So with this type of device, I would be looking at trends over time, not individual results, right?

Yes. Per that one citation about repeatability and intraobserver precision, I think you could do this the same way every time at the same point of the back (curve apex) such that you can see trends if they are there. Per that one paper, you should repeat the measurement with complete standing in-between until the different reading converge.

Do you think monthly recorded results are sufficient?

I think you have a better sense of changes in your daughter's back than I do! I would GUESS one a month is probably enough. More sounds like overkill based on my extremely limited understanding of this.

I am curious how well my readings would correlate with reality, maybe I'll run the numbers just for the fun of it.

I agree this is not obviously a waste of time if you stick with trends and not absolute values so much. :-)

It seems like scoliometers are used mainly to screen kids for treatment, not to monitor progression so much because of the tenuous association between rotation and lateral angle. That would explain why our surgeon never did a scoliometer measurement on my kids. I am coming to think that those, along with Adams tests on already diagnosed kids are just dog and pony shows for the parents. Because I made it clear with the surgeon that I was interested only in straight, rigorous science and nothing else, that may explain his not using the scoliometer. Or maybe he never uses it on any patient, who knows.