Muscles move the joints, don't they???

[mamamax]

In re Martha Hawes, she exercised 4 hours a day for 4-5 years and got some reduction.

Please? Give me your source on this (i.e. 4 hours a day for 4-5 years). Thanks.

[Pooka1]

We KNOW that muscles effect bones (search rehab or muscle/bone physiology literature for details). Bones respond to strain imparted on them by contracting muscles, and new bone is constantly being formed in response to that. So it has more than "zip" to do with bone growth.

Okay I'll give you that but there is still no proof the scoliosis cycle can be broken by exercise.

I think that future research will start to show that a specifically applied set of exercises can in fact slow down curve progressions in certain scoliotic individuals, and/or help them maintain their status for a long time. It remains to be seen which subset of people would benefit MOST from such an approach.

Okay but then would you agree that the answer isn't Schroth or any of the present exercise regimes since some of these have had decades and decades to show some efficacy?

In re Martha Hawes, she exercised 4 hours a day for 4-5 years and got some reduction. She is one person who did a program that few other people would even attempt and we don't know where her curve is today.

If you have a brace on, it touches you and presses into your tissues. Some people find this tactile stimulation very effective, reporting that "now I can really feel those muscles are there and turn them on better". This is highly relevant to working muscle.

Yes but simply finding the muscles as through tactile stimulation doesn't mean you are working/building them. Statements like yours add to the general confusion that a brace can build muscle which is of course impossible. Braces do some or all of the work of muscle and(or) restrict muscle so muscles can only get smaller in brace. Yes/No?

[betty14]

Correct me if I'm wrong but the brace is designed to hold the spine such that the growth plates on the convex side physically cannot grow and allows room on the concave side so that the wedging doesn't occur. This is a mechanical mode of action that has zip to do with muscle.
...
What I thought is going on is some abnormality in the bone growth in the spine along the growth plates. Wedging occurs and the muscles adapt to it. The asymmetric muscling is a result of the spine wedging, not a cause.
...
I think the question is which provides more mechanical leverage to stop the wedging... muscle or a brace? I have no study to cite but my feeling is that a brace must be superior because it is constantly working when on. Muscle relaxes unless you are using it. So just from a duration standpoint, bracing has to be superior.

I'm not sure that your following comment is completely true: "(what) is going on is some abnormality in the bone growth in the spine along the growth plates. Wedging occurs and the muscles adapt to it. The asymmetric muscling is a result of the spine wedging, not a cause."

I believe you are referring to a recent study that suggested that vertebral body wedging may be due to a primary disturbance of growth involving asymmetrical growth plates?

While the above may be true, it is likely that the "vicious circle" mechanism is also at work. The growth disturbance causes wedging. That causes a small curve in that local area. That causes asymmetrical loading and abnormal muscle function. That in turn causes more abnormal bone modelling, which causes a greater deformity. Because the deformity is greater, the muscle function becomes even worse. More asymmetrical loading, the bones respond with asymmetrical growth, and on and on..... here's a (poor) diagram, you'll have to add the line and arrow going from 4 back to 1 in your mind:

1) wedging
V
V
2) curve
V
V
3) asymmetrical loading of the bones
V
V
4) asymmetrical bone growth
V
V
Back to 1)


As far as non-surgical options go, we can target point #2 with a brace or point#3 with exercise. Since point#3 is my specialty, I will speak about that.

We KNOW that muscles effect bones (search rehab or muscle/bone physiology literature for details). Bones respond to strain imparted on them by contracting muscles, and new bone is constantly being formed in reponse to that. So it has more than "zip" to do with bone growth.

I think that future research will start to show that a specifically applied set of exercises can in fact slow down curve progressions in certain scoliotic individuals, and/or help them maintain their status for a long time. It remains to be seen which subset of people would benefit MOST from such an approach.

Feeling your abs in a tight brace isn't really relevant to working/building muscle, yes?.

The above quote refers to standard back braces worn by some non-scoliotic people with back pain.

If you have a brace on, it touches you and presses into your tissues. Some people find this tactile stimilation very effective, reporting that "now I can really feel those muscles are there and turn them on better". This is highly relevent to working muscle.

[Pooka1]

A brace, if properly designed for the person's curves, could straighten and derotate the spinal segments within the limits of bony deformity and any hypo-mobile segments, if present. The patient would be passively held in a corrected alignment. This may offer pain relief due to reduced stretch and over-work in various areas. The wearer may get an improved awareness of alignment, and as he or she grew, would continue to be straighter. As you know, some people's curves hold, others' progress anyway, once the brace is removed.

Correct me if I'm wrong but the brace is designed to hold the spine such that the growth plates on the convex side physically cannot grow and allows room on the concave side so that the wedging doesn't occur. This is a mechanical mode of action that has zip to do with muscle. Indeed muscle mass must shrink with brace usage as movement is restricted and the brace takes over some support that the muscles/ligaments/tendons were doing before the brace.

In a normal body, the muscles work to hold the spine upright against gravity. This is clearly lost in a scoliotic spine. What we don't know is cause vs. effect. Are the messed up muscles a victim of the cause(s), or is there something abnormal with the muscles??? Don't really know.

What I thought is going on is some abnormality in the bone growth in the spine along the growth plates. Wedging occurs and the muscles adapt to it. The asymmetric muscling is a result of the spine wedging, not a cause.

In any case, having your muscles hold you straighter is much better that a passive support only. For one thing, the muscles, ligaments and joint capsules all contain tons of receptors for stretch/compression/level of tension etc.. They are constantly getting input from the environment, transmitting that to the CNS, and there is quick response in terms of minute postural corrections. I saw a lengthy post you made about horses where you spoke of that.

I think the question is which provides more mechanical leverage to stop the wedging... muscle or a brace? I have no study to cite but my feeling is that a brace must be superior because it is constantly working when on. Muscle relaxes unless you are using it. So just from a duration standpoint, bracing has to be superior.

The brain of the scoliotic person does not know what a good posture is, because they are never in a good posture. Because the various muscles have precise directions of pull, the goal of muscle training is to learn what good posture is, and activate those muscle patterns regularly, and get enough bulk and strength to maintain it. You know how when a person with a flexible scoliotic spine lays down and their curves are much smaller due to the gravity-eliminated position? Well, the goal is to train the muscles to hold that posture once the person stands up.

But we still don't know if muscle is ever enough to stop the bone wedging, even in body builders.

If a person was ONLY braced, he would get much less stimulation and chance for motor learning and strengthening. Perhaps a rigorous and specific exercise routine COMBINED with some static bracing will turn out to be a useful approach.

But I'm questioning the ability of any amount of stimulation of muscle to prevent bone wedging.

(snip)

The idea is that if a person is able to strengthen sufficiently to maintain improved posture, he may be able to effect the bony growth and remodelling to prevent some of the progression of deformity over the lifespan. (Obviously, there is no strong evidence of this at this time; however on a personal note, I tend to take a proactive approach, rather than watching and waiting to see if I'll get more pain and deformity)

I used to think braces and PT operate in opposite fashions but I am thinking twice about that. I think they are both trying to hold the spine to arrest the asymmetrical plate growth. This makes sense that we have little evidence either works if they are using the same mode of action.

There seems to be conflicting evidence and professional opinions on that. I have had some of my PT (non-scoliotis) patients come to me saying their doctor would not write a script for the back brace I recommeded because he or she was afraid they would get weak. I have also had patients who felt the brace made them "feel" their abdominals more because of the tactile stimulation.

Feeling your abs in a tight brace isn't really relevant to working/building muscle, yes?

The idea behind the Spinecor is totally different from other bracing products, because it is dynamic, not static. They are trying to overcome the obstacles of reduced activity and reduced opportunity to develop proprioception. A static brace just holds you. You can be lazy in it - no motor learning and strengthening would take place. A dynamic brace is postulated to coax you into aligment when you fall out it, and keep your muscles working. The ideas behind it are sound, and time will tell if those sound ideas translate to ongoing clinical success.

If you are able to move around more then you are possibly not arresting the right areas of the growth plates. That would explain the lack of evidence for efficacy to date.

[betty14]

Hi Pooka1:
I'll try to respond to each of your questions:

I don't know why this is so obvious to you. I would say OF COURSE a brace has to be superior to any amount of muscle training.

A brace, if properly designed for the person's curves, could straighten and derotate the spinal segments within the limits of bony deformity and any hypo-mobile segments, if present. The patient would be passively held in a corrected alignment. This may offer pain relief due to reduced stretch and over-work in various areas. The wearer may get an improved awareness of alignment, and as he or she grew, would continue to be straighter. As you know, some people's curves hold, others' progress anyway, once the brace is removed.

In a normal body, the muscles work to hold the spine upright against gravity. This is clearly lost in a scoliotic spine. What we don't know is cause vs. effect. Are the messed up muscles a victim of the cause(s), or is there something abnormal with the muscles??? Don't really know.

In any case, having your muscles hold you straighter is much better that a passive support only. For one thing, the muscles, ligaments and joint capsules all contain tons of receptors for stretch/compression/level of tension etc.. They are constantly getting input from the environment, transmitting that to the CNS, and there is quick response in terms of minute postural corrections. I saw a lengthy post you made about horses where you spoke of that.

The brain of the scoliotic person does not know what a good posture is, because they are never in a good posture. Because the various muscles have precice directions of pull, the goal of muscle training is to learn what good posture is, and activate those muscle patterns regularly, and get enough bulk and strength to maintain it. You know how when a person with a flexible scoliotic spine lays down and their curves are much smaller due to the gravity-eliminated position? Well, the goal is to train the muscles to hold that posture once the person stands up.

If a person was ONLY braced, he would get much less stimulation and chance for motor learning and strengthening. Perhaps a rigorous and specific exercise routine COMBINED with some static bracing will turn out to be a useful approach.

ETA: What we are talking about here is trying to stop the wedging of bone as far as I can tell. If braces haven't been able to hold the spine such that the growth plates on one side are not able to grow then I don't see how any amount of strength training with the same goal of holding the spine to arrest one side of the growth plate can work..

we know that bones require forces to be exerted on them to be healthy, and grow properly. It is well known that scoliotic spines show areas of low bone density; indeed we are at increased risk for osteoporosis. When a bone is immobolized and weight bearing is restricted, such as a leg in a cast, bone density declines. It comes back to normal once the person is able to load the bone via weight bearing and muscle forces. Spine and hip bone density has been shown to increase in people with osteoporosis by performing specific spine strengthening exercises.
The idea is that if a person is able to strengthen sufficiently to maintain improved posture, he may be able to effect the bony growth and remodelling to prevent some of the progression of deformity over the lifespan. (Obviously, there is no strong evidence of this at this time; however on a personal note, I tend to take a proactive approach, rather than watching and waiting to see if I'll get more pain and deformity)

So you are saying braces provide support that the muscles can't provide. Now if you continue to support the muscle through bracing, will the muscle get better or worse?.

There seems to be conflicting evidence and professional opinions on that. I have had some of my PT (non-scoliotis) patients come to me saying their doctor would not write a script for the back brace I recommeded because he or she was afraid they would get weak. I have also had patients who felt the brace made them "feel" their abdominals more because of the tactile stimulation.

I mean why wean people off braces when they build muscle as Spinecor claims? Why don't folks wear braces instead of exercise to build muscle if that claim is correct?

Can you please explain how braces work in terms of what happens to muscle so we can move on.

The idea behind the Spinecor is totally different from other bracing products, because it is dynamic, not static. They are trying to overcome the obstacles of reduced activity and reduced opportunity to develop proprioception. A static brace just holds you. You can be lazy in it - no motor learning and strengthening would take place. A dynamic brace is postulated to coax you into aligment when you fall out it, and keep your muscles working. The ideas behind it are sound, and time will tell if those sound ideas translate to ongoing clinical success.



B.

[Dingo]

Side flexion

Thanks for the info Betty!

Motion of the thorax ALWAYS involves a coupling of more than one motion, that is, side flexion always involves rotation, and rotation always involves side flexion.

Let me know if I understood this parrt correctly. If I bend to my side my spine rotates. If I rotate my spine my side will bend. Is that right?

The latest research on biomechanics shows that if you rotate first, the coupled motion is to the SAME side, but if you side bend first, the coupled motion is the the OPPOSITE side.

Ok, let me see if I can understand this one correctly.
If I rotate my spine in clockwise motion (towards my right) which side has the bend in it? My right side?

---

BTW I should add one more link. All kids with Scoliosis have a strong and weak side (left/right) on both their abs and their back. There are quite a few studies that address this but here is one of the more recent. The link includes the entire study.

2007 - Trunk rotational strength asymmetry in adolescents with idiopathic scoliosis: an observational study

Conclusion:
This preliminary study measured trunk rotational strength in a group of adolescent healthy females and a group of adolescent idiopathic scoliosis females. Scoliosis patients were significantly weaker when rotating towards the concavity of the spinal curve in the neutral position and when pre-rotated 18° and 36° toward the concavity and then contracting towards the concavity, i.e. away from neutral, termed "low force". In contrast, the healthy group did not show weakness in the low force arc. In addition, low force arc trunk strengths on the concave side in scoliotic individuals were also significantly lower than those on the left side in the healthy subjects. These findings may help future researchers develop effective new approaches for the management of idiopathic scoliosis.

[betty14]

Hello:

I just wanted to comment on the torso rotation questions that people have been asking.


Biomechanics of the thorax:

The thoracic spine is very complex, with ten or more joints per segment, once you count the anterior and posterior rib articulations. The orientation of the facet joints allows for quite a lot of rotation per segment; however the rib articualtions add bony stability that reduces that amount. At the bottom of the ribcage the last few ribs float (ie. don't attach to the sternum at the front). This allows the greatest amount of rotation to be at the junction of the thorax and upper lumbar spine.

Motion of the thorax ALWAYS involves a coupling of more than one motion, that is, side flexion always involves rotation, and rotation always involves side flexion. This next bit is complicated: The latest research on biomechanics shows that if you rotate first, the coupled motion is to the SAME side, but if you side bend first, the coupled motion is the the OPPOSITE side. Scoliosis appears to consistently involve side flexion with the ribcage moving posterior on the side of the convexity, which is opposite rotation.


This my understanding from my reading on Shroth therapy:

Derotatation is important, but it must be predeeded by elongation and correction of some of the side bend first, otherwise, one is rotating into a zone where there is no room, because the ribs in the concavity are literally in the way.

This Shroth concept has been around a long time, yet it is completely consistent with the most recent thoracic spine biomechanics research. I find this very exciting, how about you?

Regarding the torso rotation strengthening, I'll be checking out your links, Dingo, when I get a chance. Thanks for posting.

[Dingo]

Torso Rotation

Pooka1

And what about kids who have a curve and very little rotation like my one kid? Would they even be expected to benefit from torso rotation?

As you and LindaRacine have pointed out correctly there are no longterm studies to guide us. However one thing is for sure. Unless your daughter is an anomoly her abs and her back have a left/right strong side and a weak side.

As Dr. Mooney put it, "This is definitely abnormal."

One side of her back is pulling on her spine with 10 pounds of force and the other side is pulling with only 7 pounds. That's a simple explanation with imaginary numbers but that's what is going on inside of her body 24/7.

30 minutes of strength training per week can correct this completely. I would guess (and it's only a guess) that this would help just about any kid's spine stay straight or move to a straighter position. Adults with curves over 30 degrees tend to have slow curve progression as well. It makes sense that this could potentially slow or stop that progression. Of course if the curve gets bad enough gravity takes over and nothing can help but fusion.

[Dingo]

Torso rotation

mamamax
MissEmmyF

the information you post looks very very promising in certain cases ... what are those cases? The reason i ask is this: i have been told by my specialists (both past and present) to never do torso rotational exercises .. i don't know why, maybe something to do with double curves and the degree of magnitude. I don't know, but will ask.

Someone who I happen to like and respect very much wrote me a private message concerned about torso rotation. This person told me that certain well known people in Schroth forbid torso twists even if they are done in both directions.

It would be ironic if scientists ultimately prove beyond any doubt that an exercise that controls Scoliosis had been banned for decades.

Don't get me wrong, it makes logical sense that torso twists could be harmful. Like MissEmmyF pointed out 50% of a child's twists push the deformity further in the wrong direction. But Mooney's study (plus the other 2) show that the spine doesn't necessarily respond the way we'd expect. On page 4 you can see a list of all the different curves this therapy helped.

By comparison:
It makes logical sense that people with arthritis should avoid exercise. Driving a broken car will only wear it out faster. And yet arthritis doesn't work that way. Today doctors encourage their patients to get as much healthy exercise as they can. Study after study finds that exercise reduces pain and improves the longterm quality of life for people living with arthritis.

[Pooka1]

Also, keeping in line with that, I guess the part I don't fully understand is if you think about it, scoliosis has a rotational component to it...my scoliosis in particular rotates back toward the right...so if i'm doing any type of rotational stuff (whether it be strengthening or stretching) toward that back right side, wouldn't i be "feeding" into the rotation?

That's a very interesting point that I hadn't thought of at all.

I wonder how the curvature is addressed apart from the rotation?

And what about kids who have a curve and very little rotation like my one kid? Would they even be expected to benefit from torso rotation?

At base, I think the idea of torso rotation is to build muscle to prevent progression or, in kids, to correct curvature along with growth. But scoliosis is such a variable and complex three dimensional deformity that even if you had a bunch of kids with a right T curve doing a particular exercise, I don't think you would even expect the same outcome necessarily. Both my kids had a right T curve with apex at T9 but one was very rotated and the other hardly so.

[MissEmmyF]

Also, keeping in line with that, I guess the part I don't fully understand is if you think about it, scoliosis has a rotational component to it...my scoliosis in particular rotates back toward the right...so if i'm doing any type of rotational stuff (whether it be strengthening or stretching) toward that back right side, wouldn't i be "feeding" into the rotation?

[MissEmmyF]

I have also been told something to that effect actually - however, it was not in reference to strengthening but was in reference to stretching (i.e. sitting on a chair or the ground, rotating to either side, and holding it for a stretch - it's a common yoga pose that is even in Elise Browning's yoga for scoliosis DVD):

This is what I was told: "Spinal rotation will twist one part of the spine out of the scoliosis pattern but increase twist in the part of the spine above and below that area"

[LindaRacine]

i have been told by my specialists (both past and present) to never do torso rotational exercises .. i don't know why, maybe something to do with double curves and the degree of magnitude. I don't know, but will ask.

I've never heard a scoliosis specialist say anything about torso rotation exercises being bad for someone with scoliosis.

[LindaRacine]

Betty ~ i want to be a patient of yours!! Everything you have said makes perfect sense. At 59 this patient was quite weak and had lost several inches of height. My brace, a godsend in terms of postural rehabilitation and lessening of pain. This morning - standing 4 inches taller (out of brace) than when i began my treatment. The physical difference, quite dramatic. Muscles are being retrained and strengthened - it can be done :-) and i'm looking forward to adding Schroth (developed by a PT) to the program!

4"? Really? I hope you'll be able to post before and after pictures or xrays.

--Linda

[mamamax]

You know - there is no one size fits all. Dingo - the information you post looks very very promising in certain cases ... what are those cases? The reason i ask is this: i have been told by my specialists (both past and present) to never do torso rotational exercises .. i don't know why, maybe something to do with double curves and the degree of magnitude. I don't know, but will ask.

Bracing alone with Spinecor has some pretty impressive statistics w/5 year follow ups (SOSORT 2009). I do not know if these kids were also using PT specific for scoliosis or not. I suspect they were. I do know that for me, exercise is recommended because (i presume) the brace can provide a lot - but exercise will provide the stability.