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

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

    The SEAS people claim to be doing that, btw - they don't have an over-arching theory of exercise, they're just doing everything that has some evidence that it works.
    Good luck with that, it's apparently very difficult to find a scientist with an open mind these days.

    I hope SEAS is successful finding out what IS successful with exercise. Unfortunately, I have low expectations that any good results will actually make it to the United States.

    Maybe skevimc could get funding...he seems like a reasonable guy, and already interested in this subject.
    Last edited by Ballet Mom; 08-10-2010, 05:33 PM.

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    • Typo

      Just noticed this typo in one of my posts...

      "Mine"stuff was largely penetrating glimpses into the obvious. You missed nothing you probably didn't already know.
      That should be...

      "Meine" stuff was largely penetrating glimpses into the obvious."
      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."

      Comment


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

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

        I'm not well versed in the publishing process. So please clarify if needed. As I understand it the levels are evidence based and progress from lowest to highest this way: (1) case studies (2) cohoert studies (3) prospective controlled studies (4) RCT and (5) Meta Analysis. I would like to know more about what each means in terms of the material presented. Maybe you could design a post outlining each for us. That would be valuable - and I think you would be a good source :-)

        Is a randomized study the same as a prospective controlled study? I was looking through my Weiss files on my computer and came across Incidence of curvature progression in idiopathic scoliosis patients treated with scoliosis in-patient rehabilitation (SIR): an age- and sex-matched controlled study. The full text is a good read! Sorry, I cannot upload the full text - our forum features are too limited. If anyone wants the full text PDF, just PM me and I'll get it to you.


        Abstract
        The goal of this study is to test the hypothesis that physiotherapy-based intervention can reduce incidence of progression in children with IS. Two independent patient groups matched by age and sex at diagnosis were analysed using the outcome parameter, incidence of progression (> or =5 degrees ). One group was untreated and the other received scoliosis in-patient rehabilitation (SIR). Incidence of progression in groups of untreated patients ranged from 1.5-fold (71.2% vs 46.7%) to 2.9-fold (55.8% vs 19.2%) higher than in groups of patients treated with SIR, even when SIR-treated groups included patients with more severe curvatures. Statistically, the differences were highly significant. Efforts to test the hypothesis that physical therapies addressing postural imbalance can be used effectively in the treatment of IS have been limited. The results of this study are consistent with the possibility that a supervized programme of exercise-based therapies can reduce incidence of progression in children with IS.


        Is this more like what you are looking for? I don't think the article we are discussing was meant to be a prospective controlled study in and of itself, but serves as in introduction only to SSTR and The Best Practice Method.

        Could be justified. Could also be an incorrect assessment. What exactly is he suggesting with that comment? That Negrini is presenting false data or that the skeletal age actually regressed? If he's just saying that the x-rays look funny, that alone doesn't discount the study as he is suggesting.
        I can't say what he is suggesting, lacking a personal conversation about it. But taking what he published literally, it looks like he is saying that from his experience, the illustration is not credible because (for one thing): the Risser sign is more mature before treatment and pelvic width is bigger before treatment than after. And he also states that: .... the average patient from this sample according to the SOSORT guidelines would not need any treatment at all, the study would not seem worthwhile performing. So I walk away from that as seeing a professional opinion stated. Which I seem to see all the time in various studies that I read. These things do seem odd - and maybe deserving of some questioning?

        Ok. But was there a problem or not? Was it a good study or not? It was an RCT with positive results. If you're going to present a 'review' and possibly critique the paper, it would be appropriate to make sure you're getting the story correct. Present the data and then describe why it is not as convincing.
        Without more information - I can only look at that as it was presented: that there were translation problems. Wouldn't it be better to wait for a better presentation before attempting any critique in depth? In the article, Weiss does acknowledge it and even further states: this issue should be investigated more closely in the near future. So I'm guessing we will hear more about that at some future point. Seems he felt it should certainly not be ignored.

        If that is the standard then it should be easy to present lots more data like that. Data collected in a randomized design and with all exercises fully described, as he has critiqued.
        That Figure 4 is impressive isn't it? I've seen other presentations like that - Like the above study I referenced. So much of these presentations are available in full text articles - as well as many which have not yet even been translated (appearing in German Journals). I have not read all the articles given by those like the SEAS folks, hdugger has a lot more experience with the reading of those papers than myself - and it seems she has alluded to the fact that SEAS may still be largely in the experimental stage. Whereas Weiss (in my opinion) has this nailed in three generations of work - in speaking of which exercises (PT) work for any given curvature pattern (for which there are many indeed). So if Weiss were to demonstrate this - it would take a book - or many case studies for each curvature presentation. Would you agree?

        You could read that as a critique. But when are his exercises fully described like the critique he gave to the China RCT? They're described in his book. Why not the article? I don't mind someone wanting to publish this stuff in a book, but then you can't discount another study for omitting their exercise descriptions.
        Thanks - that is how I read it also. Again, it would take a book (I think) to fully describe the many many exercises, specific to all the various curvature patterns, which also include up to four breathing techniques. Do you have a copy of The Best Practice Method? Kind of sounded like you did. Man, I am looking forward to my copy. I don't have access to the China RTC, but if they omitted even a brief overview - I guess that could be a justifiable criticism. I note Weiss does give a brief overview even in the university article from 2009. I don't know. I do know authors seem to criticize each other fairly consistently - and sometimes harshly.

        To be honest, I haven't read Weiss' recent work in the last ~ 3 years. He might do a better job of addressing the weaknesses of his studies than before. In fact, it's been a while since I've read anything of his. I'd be interested to read his up coming work.
        His writing is profoundly prolific - one would be hard pressed to keep up in one language let alone two :-) In trying to follow along, I find he is ever evolving and improving his method. I'm anxious to see the upcoming myself.

        I have some thoughts and questions about RTC studies. Firstly, it looks like Weiss is not a big fan of RTC studies in regards to bracing. He outlines why in an oral presentation given at SOSORT found Here. It is beneath Lori Dolan's presentation (also a good listen).

        What are your thoughts on that? I am truly interested on what your take is.

        As for RTC studies in general - I tried some quick Google searches, looking for RTC studies on scoliosis surgical techniques and could not find any. Why is that? Maye they exist but I don't know how to find them?

        I'm just a lay patient and know nothing about the politics of the game, but if it is lack of RTC studies that is keeping a method such as Weiss' from finding implementation into our established medical system - when there does exist evidence galore in Europe, then I suppose, as is said at the space center - Houston, we have a problem.

        Comment


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

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

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

          The fact that the Schroth program has lasted eighty years is a testament to the fact that it's providing people something worthwhile and isn't a bogus scam. Of course, ballet doesn't avoid rotations, they make huge rotational movements, so maybe not all of what Schroth does is required, but it's probably pretty hard to pin down exactly what it is that helps.
          This is all just ... to cool!!! That teacher - worth her weight in gold. Proving once again - such things, can be done :-)

          Comment


          • SSTR (Scoliosis Short Term Rehab) & Natural History

            Originally posted by hdugger View Post
            But no effect on the natural progression of the curve?

            My son has actually managed to greatly improve the cosmetic look of his scoliosis/kyphosis through a mixture of PT and massage, so it's really holding the curve in place that we're interested in.
            Figure 4 looks to have effected some natural history to me :-) And it seems this one example is typical of expected outcomes. The young woman in her 20's that I correspond with in Germany, who is bracing under someone trained by Weiss and using Schroth as was taught to her in the clinic while Weiss was there - has had astounding results. I'll write her and ask if it is ok to share her images.

            Like your son, I'm more interested in keeping things from progressing than I am cosmetics. I would like to do PT that is specifically designed for my curvature pattern, vs some generalized exercise that may in fact make matters worse for me unknowingly. Of course, a bit of improved cosmetics wouldn't suck :-) Congrats bty & may the future be one of continued success!
            Last edited by mamamax; 08-10-2010, 09:13 PM. Reason: typo - your son - not our son - late nite, no sleep all week!

            Comment


            • Originally posted by mamamax View Post
              This is all just ... to cool!!! That teacher - worth her weight in gold. Proving once again - such things, can be done :-)
              She is most definitely worth her weight in gold. Her students all think she's a miracle worker! And so do the moms... A very smart lady and she comes up with an exercise to improve anything that needs to be improved!

              This ballerina will definitely go pro too, if she continues with her successful control of her kyphosis. She was already asked this spring to attend a residential program at a European ballet school, but is waiting for a better offer in this coming year. I suspect she'll get it too because her improvement has been amazing. She has legs that go on forever!

              Comment


              • Originally posted by mamamax View Post
                Figure 4 looks to have effected some natural history to me :-) And it seems this one example is typical of expected outcomes.
                Amazing, Figure 4 looks almost exactly like the results my daughter has had. I think actually that my daughter's right scapula isn't quite as noticeable as this young lady's in the final picture, but it most definitely did look like the second picture at one point. It would be hard to say for sure unless my daughter had a picture in the exact same setting and lighting. I can absolutely vouch for the fact that those results can be obtained, in my daughter's case with nighttime bracing and ballet.

                Good news for a lot of kids.
                Last edited by Ballet Mom; 08-10-2010, 11:19 PM.

                Comment


                • Congratulations Ballet Mom .... your experience, makes my heart smile - big time! May the journey be of continued success :-)

                  Comment


                  • Originally posted by mamamax View Post
                    Congratulations Ballet Mom .... your experience, makes my heart smile - big time! May the journey be of continued success :-)
                    Thanks mamamax! I'm very happy too.

                    I looked at Figure 4 again, and I actually believe that when my daughter was first diagnosed, she may not have had quite as much decompensation as this girl (hard to remember), but my daughter had a much more "windswept" look to the right and her rib hump was more pronounced. Unfortunately, I never even thought to take pictures. Darn. But very similar, a 35 degree scoliosis reduced to 29 degrees and a big reduction in the rotation. And a huge improvement in the cosmesis.
                    Last edited by Ballet Mom; 08-11-2010, 07:02 AM.

                    Comment


                    • Originally posted by Ballet Mom View Post
                      Maybe skevimc could get funding...he seems like a reasonable guy, and already interested in this subject.
                      I'm glad you see me as reasonable. I'm definitely interested in this area of research. And specifically the science behind rehabilitation from a muscle stand point. We'll see how the next several years go. There's definitely room and need for the science. But we'll have to see what kind of money is there. Not for me personally, but to do the research.

                      Originally posted by mamamax View Post
                      Thank you skevimc, you make me think more :-)

                      [COLOR="Navy"]I'm not well versed in the publishing process. So please clarify if needed. As I understand it the levels are evidence based and progress from lowest to highest this way: (1) case studies (2) cohoert studies (3) prospective controlled studies (4) RCT and (5) Meta Analysis. I would like to know more about what each means in terms of the material presented. Maybe you could design a post outlining each for us. That would be valuable - and I think you would be a good source :-)
                      There are papers published on the rating levels of studies. A double or single blind prospective RCT is definitely the gold standard. This means you have a treatment and you take the next 1000 patients that walk through the door and randomly assign them to one of two or three groups. One group gets the experimental treatment and the other groups get either no treatment or a placebo or the currently accepted standard of care. The groups depend heavily on what is being studied.

                      Double blind means that neither the patient or the doctor/researcher knows what treatment group the patient is in. For some studies, like exercise studies, this can be understandably hard to do. But it's definitely possible to keep the physician in the dark. The blinding is important because it protects the study from bias. Even the most careful researcher can be influenced by bias. It's not even malicious or trying to be intentionally misleading. It can be done subconsciously. It can also be done overtly which is severely unethical.

                      I'll kick around the idea you suggested of posting a 'guide to research studies'. I'm actually working on a course on that very thing and it's specifically aimed at the lay population. to be continued.... ?


                      Originally posted by mamamax View Post
                      Is this more like what you are looking for? I don't think the article we are discussing was meant to be a prospective controlled study in and of itself, but serves as in introduction only to SSTR and The Best Practice Method.
                      That Weiss study is prospective in nature but might not be appropriately matched. Matching to age and gender is a start, but with scoliosis, matching for curve size and type is also extremely important.

                      I will think about the rest of your questions. I honestly haven't carefully read the articles from Weiss so I don't feel able to defend my overall point right now. My perception of the article was that it was full of his articles and his results but lacked results from other papers.

                      This is an example of what I see as being a good presentation of various studies.

                      Negrini S, Fusco C, Minozzi S, et al. Exercises reduce the
                      progression rate of adolescent idiopathic scoliosis: Results of a
                      comprehensive systematic review of the literature. Disabil Rehabil.
                      2008;30(10):772-785.
                      Last edited by skevimc; 08-11-2010, 04:01 PM.

                      Comment


                      • Kevin, can I ask you your overall impression of the SEAS folk? In general, their papers seem pretty sound to me, but I'm always suspicious of people who are running their own clinics with a proprietary protocol.

                        Do they have a decent reputation in the field? Or are they eyed with some suspicion?

                        Comment


                        • Originally posted by hdugger View Post
                          Kevin, can I ask you your overall impression of the SEAS folk? In general, their papers seem pretty sound to me, but I'm always suspicious of people who are running their own clinics with a proprietary protocol.

                          Do they have a decent reputation in the field? Or are they eyed with some suspicion?
                          I believe they have a very good reputation within the field. I am just starting to read some of their papers, like the one I linked to. He also published a landmark paper (for me at least) when he stated, that "while no evidence exists that exercise influences the natural history, there is also no good evidence to suggest it doesn't". This was a big statement because the dogma at the time was pretty set that exercise does no good. But that dogma wasn't based on solid evidence. For me, it clearly stated what I had felt for a while.

                          The perception I get is that, while there may be a proprietary clinic, they are trying to base it on documented studies. So at least their starting point is from "what has been reasonably tested and seems to work" instead of "let's prove our method works while discrediting all others". Again, I haven't read all of their stuff so I don't know if they are pushing one type of therapy over another. I mean the name alone makes me like it "Scientific Exercise Approach to Scoliosis". Love it!

                          Comment


                          • Originally posted by skevimc View Post
                            He also published a landmark paper (for me at least) when he stated, that "while no evidence exists that exercise influences the natural history, there is also no good evidence to suggest it doesn't". This was a big statement because the dogma at the time was pretty set that exercise does no good. But that dogma wasn't based on solid evidence. For me, it clearly stated what I had felt for a while.
                            This sounds very plausible. It may be that there was never enough folks with relevant research training (or those who booted themselves up on how to do research) who applied themselves to the problem. As for lack of progress on showing efficacy of other conservative treatments, I think this is just a result of how difficult medical research is, especially with such an intrinsically variable condition like scoliosis. The comment you posted about another researcher advising you not to go into scoliosis research seems well taken when reading some of these published papers. Critiquing some of them is like shooting ducks in a barrel until you realize how the researchers' hands are tied and how much variation they are dealing with. I admire the resolve of even starting one of these studies in the first place.

                            The field seems wide open to score big. And it would be a big score to obviate fusion surgery using PT. I think solid evidence of that would get folks to exercise who otherwise would never stick with it.

                            I think it would be a Nobel contender (in physiology or medicine) if not a winner if it happens.
                            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."

                            Comment


                            • Originally posted by Pooka1 View Post
                              This sounds very plausible. It may be that there was never enough folks with relevant research training (or those who booted themselves up on how to do research) who applied themselves to the problem.
                              This is certainly part of the reason. The other is that 'exercise' as we know it by today's standards is NOTHING like what it was when the original studies were done that set the dogma. The 'exercises' used were described as 'general calisthenics' 'push-up, sit-ups, side bends and the like'. No kidding exercise wasn't found to be effective. It's staggering what was unknown about muscle physiology that is now taken for granted. (And ten years from now I'll say the same thing about us today. I love science so much. )



                              Originally posted by Pooka1 View Post
                              As for lack of progress on showing efficacy of other conservative treatments, I think this is just a result of how difficult medical research is, especially with such an intrinsically variable condition like scoliosis. The comment you posted about another researcher advising you not to go into scoliosis research seems well taken when reading some of these published papers. Critiquing some of them is like shooting ducks in a barrel until you realize how the researchers' hands are tied and how much variation they are dealing with. I admire the resolve of even starting one of these studies in the first place.
                              I sincerely appreciate this comment.

                              Comment


                              • Treatment Reviews & Levels of Evidence

                                skevimc -

                                Thank you for that 2008 Negrini (et al) reference. An excellent review of the literature in terms of of specific exercises to reduce the progression of AIS. Who did the RCT study? I only have access to the Abstract at the moment but a few things really jumped out at me:
                                • 19 papers considered included 1654 treated patients and 688 controls.

                                • The highest-quality study (RCT) compared two groups of 40 patients, showing an improvement of curvature in all treated patients after six months.

                                • We found three papers on Scoliosis Intensive Rehabilitation (Schroth), five on extrinsic autocorrection-based methods (Schroth, side-shift), four on intrinsic autocorrection-based approaches (Lyon and SEAS) and five with no autocorrection (three asymmetric, two symmetric exercises).

                                • CONCLUSION: In five years, eight more papers have been published to the indexed literature coming from throughout the world (Asia, the US, Eastern Europe) and proving that interest in exercises is not exclusive to Western Europe. This systematic review confirms and strengthens the previous ones. The actual evidence on exercises for AIS is of level 1b..

                                • The previous level of evidence was 2a (2003/2004)


                                That is surely encouraging. Would like to read the full text.

                                I see Weiss/Goodal published a paper the same year The treatment of adolescent idiopathic scoliosis (AIS) according to present evidence - A systematic review. In this abstract are some interesting observations from the viewpoint of reviewing all available treatment options:
                                • The aim of this paper was to provide a synopsis of all treatment options in the light of evidence based practice (EBP). A systematic review was carried out using the most encompassing databases available. Literature has been searched for the outcome parameter ''rate of progression'' and only prospective controlled studies that have considered the treatment versus the natural history have been included.

                                • One prospective controlled study was found to support scoliosis in-patient rehabilitation (SIR). One prospective multi-centre study, a long-term prospective controlled study and a meta-analysis have been found to support bracing. No controlled study, neither short, mid nor long-term, was found to reveal any substantial evidence to support surgery as a treatment for this condition.

                                • In light of the unknown long-term effects of surgery, a randomised controlled trial (RCT) seems necessary.

                                • Due to the presence of evidence to support conservative treatments, a plan to compose a RCT for conservative treatment options seems unethical.

                                • But it is also important to conclude that the evidence for conservative treatments is weak in number and length.


                                Reading the full text of that this evening.

                                The SEAS study/Full Text proves promising from the adult point of view in regards to postural rehabilitaion which I know is possible because I personally experienced it with a bracing technique designed to serve as PT. From the SEAS study:

                                • This case opens the possibility that when adult scoliosis aggravates it is possible to intervene with specific exercises not just to get stability, but to recover last years collapse. We hypothesize that this reduction of Cobb degrees is due to a reduction of the postural collapse, that in turn can decrease the chronic asymmetric load on the spine and, in the long run, reduce the progression.

                                • In this case report, we hypothesize that the worsening before the beginning of exercise therapy was due to an inadequacy of antigravitary trunk muscles due to all the years B.I. used casts and braces. During those years, she unfortunately never exercised to maintain or to restore these muscles. The only sport she played was swimming, which doesn't stress such muscles. With exercises, she could completely recover the worsening of the last five years.

                                • Obviously exercises can lead to results other than stabilization of the curve, including pain, postural control, balance, strength, but in the indexed literature no data have been published on this topic. There are few works in literature showing it is possible improving the curvature in adult scoliosis with exercises, but no study has a long follow-up. The only case report with a long follow-up showed stability over time [25]. In our opinion, the recovery of the postural collapse we obtained in this case can possibly reduce the risk of future worsening, aside from the absolute decrease of the curves we had. In fact, the functional, cosmetic and psycho-social damages caused by scoliosis are directly proportional to curve magnitude [26,27], so any improvement over time must be considered a remarkable success in adult scoliosis therapy.


                                Coming full circle, I'm intrigued by The Best Practice Method because its aim is not to exercise over a course of a lifetime in order to maintain positive results.

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