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

[Pooka1]

Can you tell me how to find Hey's blog on collapsing compensatory curves and the following two discussions mentioned on the NSF site? I am especially interested in the ones induced by PT.

No I doubt any collapse was ever due to PT. My mention of PT was in relation to a temporary DECREASE in a compensatory curve.

But here is one of Hey's cases - a collapsing compensatory curve (the second case - 55 yo woman)

http://www.scoliosis.org/forum/showt...ity&highlight=

I'll look for more.

[Pooka1]

The other cases are like this one where levels could have been saved had the fusion been done sooner. Not sure that is "collapsing" but the result is the same... loss of lower levels that might have been prevented...

http://drlloydhey.blogspot.com/2011/...in-review.html

[Pooka1]

Here's an "earlier" fusion to save levels.

http://www.scoliosis.org/forum/showt...ght=collapsing

[AMom]

How do you know things are backward in the UK and not in the US? Sometimes I wonder. There is no consistancy with PT, bracing, or surgery criteria here. It all depends on which doctor you go to. I know you aren't addressing me, but I don't think TR is commonly used here in the US as it is "believed" that NO physical therapy methods have any effect on scoliosis other than for pain relief. Refer to the information section of this website and see. You can also go to many other websites of big name places, such as Mayo Clinic and the Scoliosis Research Society, and I believe they say the same thing.

Sorry to say Rohrer is correct, PT is not considered an acceptable scoliosis treatment in the USA—though I haven’t found reputable research systematically disproving its usefulness…. Even the topic of research on the subject of PT as treatment for scoliosis isn't well received. I enthusiastically welcome research stating specific PT does/ does not hold or reduce a curve.

So far, there are some very poorly written articles in print that state PT doesn't work. I cringe when I read them and question how they made it through the peer review process. If you have a chance to read any of these articles AND read the research they site, you will quickly learn that 1) exercises were often chosen at random (not targeting any particular muscle group), 2) no one checked to see if the exercises actually recruited the targeted muscles, 3) instructions were usually given verbally during the ortho visit (no follow up by dr or pt OR written instructions with accompanying directions), 4) PT's were not utilized to start/ teach the exercises to the patient, 5) orthos all agreed the patients didn't do the exercises, 6) they further agreed most patients could not remember what exercises had been assigned, therefore they have now 7) proven PT doesn't work.

In reality, they’ve demonstrated the following points: A) People usually don’t do exercises if there isn’t a system of accountability in place and B) not doing exercises does not change the natural progression of the scoliotic curve.

I'd like to see everyone of these authors go back and demonstrate which of their exercises actually worked the muscles they were targeting, the rationale behind their choice of muscle groups, how the targeted muscle groups worked in concert, the reasonableness of their decision to include x-number of test subjects to prove their point, their plans to make sure the test subjects knew how & what to do (exercises), how frequently the exercises were to be completed, the period of time (number of months) the subjects would be required to complete the exercises, how they would confirm the exercises were completed (observation or tracking device), when & how the results would be checked, how frequently the results would be recorded, how long they would follow up after the exercises were stopped, and THEN write their results.

If they were to systematically work through the muscles and prove PT didn't work, I would enthusiastically thank them for the data presented. As it stands now, most (but not all) work on PT as a treatment for scoliosis, is shamefully lacking many of the components of the scientific method.


I know there are people who are trying PT in the USA, and some of them are trying core torso rotation (CTR.) I am hoping this thread will be a place where we can discuss CTR’s use & results. Negative results are every bit as useful as positive results. Pooling information is much more efficient than every single person and small group “recreating the wheel.” I believe that is the point of publishing.

[Pooka1]

I agree PT as a scoliosis treatment is very hard to study for all the reasons AMom stated. There is no evidence that PT can't work. It might.

It is possible Weiss's efforts for all those years to show Schroth works were consistently undermined by non-compliance. This is a very hard area of research.

[Pooka1]

Here's the case I was looking for... collapsed compensatory lumbar under a 30* structural T curve.

Age = 17, T 30*, L 18*
Age = 29, T 30*, L 39*

http://drlloydhey.blogspot.com/2007/...scoliosis.html

Could this collapse have been prevented? It is hard to say for sure, but it is possible that if the thoracic curve had been straightened and fixed when she was young, then the lumbar curve would have gone down to near zero degrees. This centering of the load may have prevented the asymmetric disc collapse in that mid-lumbar area. This possible prevention of later lumbar and/or thoracic collapse and degeneration is one of the benefits of early fixation of scoliosis in the adolescent or young adult.

Could a brace during adolescence or adulthood have prevented this collapse? No, unlikely. The brace in some growing adolescents can decrease the final curve at the time of skeletal maturity, but it does not have any protective effect thereafter for any collapse later in life that could cause ongoing progression and/or quality of life problems. Bracing typically does not improve the curve from the degree of curvature when the brace is applied — it may help to hold it closer to that number by the time they finish growing. However, if the child/adolescent is “out of alignment” at that point, as they are taken out of the brace, they still need life-long follow-up and may have later collapse of the upper or lower or both curves during adulthood — anywhere from college age, through senior citizen years.

Could earlier scoliosis have prevented this lumbar collapse? Probably yes. With modern current scoliosis techniques using pedicle screw fixation, and shorter constructs for thoracic curves (T5-L1 for example), 80-95% corrections are possible of the major curve, which results in nearly complete correction of the compensatory curves on either side, including the lumbar area. Although there can be an issue with adjacent level failure with lumbar fusions, it appears that the patients who have thoracic fusions down to L1 or L2, with most of the lumbar discs preserved actually wear their lower lumbar discs very well, especially when the top curve is well-corrected. Perhaps in the future we will have more longitudinal studies which will show that earlier short fusions can prevent the later collapse of the upper and / or lower curves that tend to affect quality of life a lot in the adult population. In this case, a “stitch in time may save nine”, in that a smaller operation can be performed on the adolescent or young adult which prevents the need for a longer instrumentation and fusion later in life to fuse across both the upper and lower curves. This younger age may also allow for a greater degree of correction, with subsequent improvement in load balance, and by fixing it at a younger age allow the discs to be subjected to more centered loads for the duration of the life of the person.

[TAMZTOM]

AMon

Been doing some experimentation on myself with a view to enhancing Tamzin's program. You mentioned trying to focus strength gain on the upper thoracic and/or cervical area by raising the arm and hand position (presumably this in addition to the regular positions used in your daughter's TR program). We have a multi-gym in the barn, swivel seat and "pec-dec" attachments, etc., similar arm levers to that on the MedX and similar machines (e.g., Cybex). It took me a few tries, but I managed to focus enough to distinctly feel more work on the upper paraspinals compared to the lower arm position. Performed symmetrically, the theory that this will increase the corrective possibilities on T curves seems sound.

Problem for us--or for Tamzin, rather--is that we cannot safely work symmetrically because of the potential syrinx harm. The potential, however, for symmetric TR users, remains extremely promising. I hope a few more TR users chime in here. (Wasn't there another recent thread with two other posters doing TR? I think one may have been a guy called "Gerbo" or maybe "Dingo"..."A Mom" another...not you, just someone with a similar NSF moniker.)

PS: during the first few tries with the higher arm position, I found it difficult to stop myself using shoulder strength...that may just be me though (e.g., I always found rowing problematic, using arm and shoulder strength to subconsciously substitute for awful technique).

[Kevin_Mc]

I can't confirm your mistake because I find the thing confusing. I am a little shocked he referred to compensatory curves at all when there is no evidence that I am aware of that addressing that addresses the structural curve. Maybe he was just throwing a wide net to see what he catches. And even though he does mention compensatory curves, I am not sure he is reporting out the data for anything other than the structural curves. Since we have anecdotal evidence that decreases in the compensatory curve through PT either does nothing to the structural curve or might make it slightly worse presumably if it is stiff, I would like to hear what McIntire was thinking.

We reported on the "main curve". In preparing to discuss this we/I realized that the definition of main/primary vs compensatory/secondary curve classification is fairly subjective. Generally, the larger curve is the main/primary curve with the other curves being compensatory/secondary. A double major is one that has two fairly equal curves that are well balanced. We showed data from both curves in our tables. The high T curves (5 reported in the study) were not considered to be the main curve. 2 of the 5 progressed >5° by the last follow-up. And in both of those cases the 'main' curve also progressed after 15 and 12 months follow-up. 2 of the 5 also progressed =5°. One of those curves started at 61° and the other 'main' curve progressed 7° at 15 months follow-up. I don't think we discussed it in the article but this certainly led to my general impression that TRS might not be as effective for HT curves. Whether primary or compensatory. It was not evident that we were able to strengthen the HT paraspinals with the protocol as written.

Please correct me if I've got this wrong, but I think this is how it works. The muscles work together (sometimes attached at several points) to contract (shorten if the movement is isotonic/ not shorten if there is no movement, called isometric.) Every time a muscle contracts, the muscle on the opposite side of the joint relaxes (allowing the contraction to occur). When you move in the opposite direction, the ACTIONS of the muscles (contracting & relaxing) switch sides. So, if you are twisting to the left, you are working the muscles on both sides of the spine—the right side is relaxing and the left side is contracting. Depending on which muscles you are working, there could also be other muscles (synergists) that are working to stabilize the action. AND, depending on the motion, you may be engaging multiple muscle groups to complete the action. It seems very complicated to me, so I hope I didn’t make the water muddier.

FYI: Remember, contrary to logic, the concave side has not been shown to have stronger muscles.

Muscle action on the trunk is very complicated indeed.

While we found a weakness while rotating towards the concavity in our preliminary study, it's difficult to say which muscles are stronger or weaker based on that. However, I maintain that the concave muscles are 'weaker' based on previously reported data on muscle histology and function.

From our study:

A spine without muscles cannot maintain an erect posture if an axial load of 10 kg or greater is applied.52 An important factor responsible for AIS progression may be disuse atrophy of trunk stabilizing muscles. The deep spinal muscles on the concave side of an AIS curve have been consistently found to have increased number of type II and decreased number of type I muscle fibers, reduced muscle cross-sectional area, and reduced low-level tonic activity.12,13,53–55 These changes suggest muscle disuse atrophy.56 Type I fibers are the slow twitch endurance muscles responsible for tonic activity in daily activities and tend to atrophy the most in disuse.57,58 Type II fibers are more resistant to disuse and might even increase in size.13 In contrast, on the convex side of the curve larger number of type I fibers are found.14,19,59 This is usually seen after endurance training or prolonged exposure to stretching59,60 and may help explain the paradox of shorter multifidus on the convex than the concave side.61

In reality, they’ve demonstrated the following points: A) People usually don’t do exercises if there isn’t a system of accountability in place and B) not doing exercises does not change the natural progression of the scoliotic curve.

That's funny stuff there. :> You're correct that as you go back through the decades of literature to see how the dogma developed against exercise, that 'exercise' was defined in the most general terms possible. E.g. "push-up, sit-ups, side bends and the like".

[Pooka1]

We reported on the "main curve". In preparing to discuss this we/I realized that the definition of main/primary vs compensatory/secondary curve classification is fairly subjective. Generally, the larger curve is the main/primary curve with the other curves being compensatory/secondary. A double major is one that has two fairly equal curves that are well balanced. We showed data from both curves in our tables.

Wait a minute please. Correct me if I'm wrong but:

1. a "main" curve is the largest curve and is almost always structural (excluding hysterical cases and such).

2. a "single curve pattern" has one structural curve and any number of compensatory curves.

3. all "non-single curves" are two or more structural curves to include the double major and triple curves. So-called "false doubles" can look like double majors (i.e., both curves about the same size) but structural curve does NOT bend out and the compensatory one does. This is a single curve pattern despite appearances and is fused as such with long-term success.

4. compensatory curves respond to straightening (through whatever means) of the structural curve but there is no evidence I am aware of for the converse - straightening a compensatory curve has not been shown to straighten a structural curve to my knowledge. If anyone has any evidence for this I hope they post it.

I do not understand how this research ball can be advanced down the field unless structural curves are rigorously identified and distinguished from compensatory curves. Otherwise folks might as well be singing in my opinion (no offense to Singer). :-)

[TAMZTOM]

Wait a minute please. Correct me if I'm wrong but:

1. a "main" curve is the largest curve and is almost always structural (excluding hysterical cases and such).

2. a "single curve pattern" has one structural curve and any number of compensatory curves.

3. all "non-single curves" are two or more structural curves to include the double major and triple curves. So-called "false doubles" can look like double majors (i.e., both curves about the same size) but structural curve does NOT bend out and the compensatory one does. This is a single curve pattern despite appearances and is fused as such with long-term success.

4. compensatory curves respond to straightening (through whatever means) of the structural curve but there is no evidence I am aware of for the converse - straightening a compensatory curve has not been shown to straighten a structural curve to my knowledge. If anyone has any evidence for this I hope they post it.

I do not understand how this research ball can be advanced down the field unless structural curves are rigorously identified and distinguished from compensatory curves. Otherwise folks might as well be singing in my opinion (no offense to Singer). :-)

Hi Sharon
Structural vs non-structural are not rigorously distinguished here in the UK (i.e., using bending films, etc). I agree about the bloke singing for his supper. Most US surgeons, I believe, do these films to classify curves to plan the surgery. There presumably is no 'surgical' evidence showing fusing comp. curves corrects structural (say, larger) curves from this camp because they don't do that!
In the exercise camp, things are different: a firmer base (legs, feet, pelvis and all associated muscles) all enable greater postural gain on the upper torso; a strong torso on a strong base has seen many kids straighten double curves. Tamzin for example, in a few months, corrected her TC by 5 - 9 degrees, her LC from 13 - 15 degrees. Most of the initial work emphasised correcting the LC and everything below. Chicken-and-egg really, did the TC exercises correct the LC greater or vice-versa.
PS: there are thousands of reports (as you mentioned, tons from Weiss) all reporting corrections. As AMon eloquently explained, much of the research is rubbish on both sides of the coin, surgery and exercise. There are quite a few pretty motivated parents in here all trying hard to save kids; as AMon again suggested, for THESE CURRENT KIDS to improve, a willingness of several to pool information of these live test cases and pool HOW they're doing could be revelatory...for many more kids than just ours.

E..g., I've been one step removed from the TR discussions (as we don't do them), but I only realised today that it's common knowledge that the upper paraspinals are relatively underused in the current protocols.

Strip all the exercises down to how they're done, how often, what changed, good or bad.

[Pooka1]

Tamzin for example, in a few months, corrected her TC by 5 - 9 degrees, her LC from 13 - 15 degrees.

What did they tell you Tamzin has? A T curve or double major? Judging from the L correction, it seems she just has a T curve. If the L curve was almost as large to begin with then maybe she has a false double like my one kid... still only one structural curve despite appearances.

It is beyond critical in surgical cases at least to RIGOROUSLY differentiate between a false double and a double major. (Single T curves are easy to spot.) There is long term evidence that selective fusion of the T portion of a false double is stable for at least two decades. Of course this is just following the rule of fusing ONLY the structural curve and NOT fusing the compensatory curve.

These are distinctions with real differences. They matter in research and in surgery.

[Pooka1]

There presumably is no 'surgical' evidence showing fusing comp. curves corrects structural (say, larger) curves from this camp because they don't do that!

Tom,

If there was evidence fusing a compensatory curve corrected a structural curve then not a single kid would ever need a lumbar fusion. If fusing a compensatory T curve above a structural L curve solved the L curve then it would be a crime not to do so. But we don't see that.

Rather we have a testimonial of a kid correcting a compensatory lumbar curve a bit through PT with no change in the structural T curve. And it may not count when talking about kids but we have seen radiographic evidence that correcting a lumbar curve quite a bit(!) in an adult makes the T curve slightly worse (eyeballing the radaiographs... I didn't measure). There is no symmetry here. A structural curve has a biological problem driving it that doesn't go away when correcting the compensatory curve. The compensatory curve only has the structural curve driving it. That's the difference in a nutshell and explains their different effect on the other curve when straightening.

Compensatory curves exist only when the structural curves exist. Structural curves exist for themselves. Some structural curves including pure thoracic curves don't appear to even have a compensatory curve.

[Pooka1]

Basically, this is how it appears...

- compensatory curves have a physical driver (the structural curve) which, when corrected, automatically removes the driver so the compensatory curve corrects.

- structural curves have a non-physical (biological, hormonal, metabolic, biochemical, neurological, etc.) driver so no matter what you do to the compensatory curve, that driver is still there. That is not to say bracing and PT aimed at straightening the structural curve can't work by physically forcing the structural curve straight or draining a syrinx or whatever. One does not rule out the other.

Because of this, if anyone has any evidence that straightening a compensatory curve helped a structural curve I would like to see it. I suggest the surgeons would like to see it also so they can stop fusing L curves in kids.

[Kevin_Mc]

Wait a minute please. Correct me if I'm wrong but:

1. a "main" curve is the largest curve and is almost always structural (excluding hysterical cases and such).

2. a "single curve pattern" has one structural curve and any number of compensatory curves.

3. all "non-single curves" are two or more structural curves to include the double major and triple curves. So-called "false doubles" can look like double majors (i.e., both curves about the same size) but structural curve does NOT bend out and the compensatory one does. This is a single curve pattern despite appearances and is fused as such with long-term success.

4. compensatory curves respond to straightening (through whatever means) of the structural curve but there is no evidence I am aware of for the converse - straightening a compensatory curve has not been shown to straighten a structural curve to my knowledge. If anyone has any evidence for this I hope they post it.

I do not understand how this research ball can be advanced down the field unless structural curves are rigorously identified and distinguished from compensatory curves. Otherwise folks might as well be singing in my opinion (no offense to Singer). :-)

For surgical cases this is undoubtedly true. And potentially for customized PT treatments and bracing, this would also be an important consideration. I have to consistently remind myself that our study was done to try and recreate Mooney's study with a few improvements. Moving forward with TRS might suggest that strict curve classification is important as well, e.g. HT curves. But since this type of training was aimed at the entire spine equally as well as meant only to stabilize the curve, reducing the curves did not play into the thinking.

[Pooka1]

For surgical cases this is undoubtedly true. And potentially for customized PT treatments and bracing, this would also be an important consideration. I have to consistently remind myself that our study was done to try and recreate Mooney's study with a few improvements. Moving forward with TRS might suggest that strict curve classification is important as well, e.g. HT curves. But since this type of training was aimed at the entire spine equally as well as meant only to stabilize the curve, reducing the curves did not play into the thinking.

Okay I see that. But given the known differences between structural and compensatory curves, their importance in surgical plans, and assuming the goal is to avoid surgery (I know you may not agree with that but patients and parents agree on that), I do not understand how it is possible to get a PT study published much less funded, even a whole spine one, where the two types of curves are not rigorously defined.

Do you know of any PT or brace study that discusses anything but structural curves? If not I can understand why not. As we have seen on the group, it is a lesser (and perhaps irrelevant) feat to stabilize or reduce a compensatory curve. The pay dirt in terms of avoiding surgery for life is stabilizing or reducing a structural curve.