Scoliosis Blog

Well, as hinted at the end of the last blog.. another flight. Malcolm Gladwell writes in his book outliers that it takes 10 thousand hours to become a leader in any particular endeavour.  I am back on the way to Europe, back to Barcelona. All my trips over the last few years have been to attend conference or courses but this time its different. Dr Rigo's clinic treats patients in groups and every July they run a program in English for international patients. I discussed this with his head physio in Milan in May and hence my journey now.  I am off to spend time in the clinic to watch and learn, to discuss and hopefully contribute.  

The last few weeks have been busy as usual. We have had some patients who first went through treatment years ago return.  Some have stabilised and have weaned out of their braces not needing to have surgery. Some have not held in brace and some have elected to go straight for surgery.  We are beginning to get a clearer picture of all peripheral stuff around scoliosis. All the decisions are hard and EVERYONE has an agenda.

We had a few adults come through, most of the cases report significant pain. It is really rewarding working with them to problem solve the pain. One patient with a long history of unsuccessfully treated pain and difficulty sleeping reported last week that she is sleeping much  better (with no pain medication) and for the first time in many years felt comfortable to swim a kilometre. She was heading off to Germany to spend time with family. She questioned whether she should try to attend the Schroth clinic for an opinion. I thought this would be a great idea and I would love to get their thoughts on her case.

Last month I enrolled in a physiotherapy association webinar on scoliosis. It was a web-based seminar run by a physiotherapist who is part of a scoliosis surgical unit in Queensland. The seminar provided good background to scoliosis and argued the standard case that only bracing and surgery have been shown to halt the progression of the curve.   I agree that this is the case but think that there is a group of patients whom we can positively impact. The physio who gave the seminar displayed what she said was a very good article confirming that exercise has no role in scoliosis treatment. The article was published by Dr Weiss in the journal Scoliosis. Unfortunately it appears that the physio doesn't know that Dr Weiss is the grandson of Katarina Schroth and he teaches exercises to address scoliotic curves. The journal Scoliosis is a publication of SOSORT whose aim to research conservative management of scoliosis. This really confirmed my belief that in order to learn, one needs to seek out and spend time with the experts in the field. Its also a lesson that maybe the internet is not developed enough yet to facilitate real group learning. If it was a public discussion forum then I am sure the audience would have found the question and answer discourse very interesting.

Its the afternoon of the 5th day of my visit to the clinic. I'm sitting in a police station waiting for an interpreter to make a statement regarding the  dodgy character who was supposed to rent me an apartment but never showed up after payment. Life sure is interesting.

I have  spent time in all areas of the clinic and they have  been very  welcoming. Dr Rigo is as always amazing. He has 2 therapists  in the clinic, Monica Viillegrassa who has been doing Schroth  for 11 years and  Elena Pou for 7 years. Monica speaks English and therefore takes the English  group classes.  There were 2 English language classes this week. The  one is  a 5 x 2 hour day refresher class for those who had done the intensive month long  course before and the other  is the standard 4 week (3 hours per day) course which  has 3 participants. 2 of these had done Schroth therapy  already, 1 in England for a month  and one in Canada (weekly  treatment). It is interesting to see the  different styles of application of  Schroth and to discuss the experiences with the  patients.

Elena takes the  classes in Spanish  and Catalan. There  is a concept called the  song of Schroth which is almost a mantra to facilitate the exercises. Hearing Elena's powerfully deep and lyrical voice and seeing the way  she  verbally controls the class  is  an enlightening experience.

Dr Rigo doesn’t, himself, seem to do any  exercise prescription anymore. I spent the day  with him in his consulting office. The first case was of a young girl who originally  presented at age 11 with  a 25 degree curve (risser 0) and hence  a strong chance of progression. She  was braced by  Dr Rigo and  returned for follow up after weaning  out  of the  brace (she was in brace for 4 years). Her  curves are  now 14 degrees with hardly any rotation humps and  great balance.  

My  subsequent thoughts of how  simple conservative management is were short lived when the next patient walked in. She  had been managed in a Milwaukee brace and then a Cheneau  brace and eventually landed up with Dr Rigo as relatively mature girl with a decompensated rigid 75 degree curve.  Dr Rigo reluctantly agreed to brace her  and as expected was unsuccessful in changing her curve.  Dr Rigo recommended that  she  is a candidate for surgery but  the  patient  and family have decided to wait and have surgery  only when they feel it is  appropriate. She has no pain and is comfortable with her aesthetic appearance; pulmonary function is good so they will wait. They advised that they had seen a surgeon who was supportive of their decision to delay surgery.     

Dr Rigo conducts a lecture with the families of the kids at the end of the second week. It lasted a few hours and was presented in English and Catalan. The language was different but the questions were the same. He repeatedly stressed that scoliosis is a condition which should not develop into  a life destroying event. It is not a terminal condition and the truth is that we don't know many  aspects about it. It was refreshing to note that he is asked the same questions that I am. One father recounted the story of his two daughters. One is braced and going through Schroth and one is not. Dr Rigo was asked to 'guarantee' the brace, exercise treatment option.  He said he couldn't do that and said that there was no proof that the daughter who exercises will  avoid progression, neither was  there proof that the  daughter who doesn't exercise will progress.  Just as we don't know if surgically fused spine will not continue to have problems or progress. The general assumption is that EVERYONE needs to exercise whether they are scoliotic or not. However if you have scoliosis then your exercises should be specific for scoliosis.  There is the added benefit in that in some cases the exercises can be beneficial in managing the scoliosis.

Over the last few years I would hear a term called 'rectification' regarding Schroth. I spent some time with  Dr Rigo in the bracing workshop and got to see first hand what rectification is.  Dr Rigo makes his own braces by hand according to Cheneau principles. A mould is created in plaster and then he shapes it by hand by removing some areas of plaster and applying plaster to other areas. Its an art blending sculpting, medical and anatomical knowledge and an immense awareness of the subtleties required to rectify the postural asymmetries of the growing spines.  The brace does the work from the outside and Schroth  exercises do the work from the inside. Luckily Dr Rigo's bracing knowledge is available through a German firm called Ortholutions who  work with Jeb.  However Dr Rigo did qualify  that some braces still need to made by  him by hand as some curves are complicated and he needs to feel the subtleties of the curve and patient.

I'm on a  plane back to Sydney, back to work and my family. in 3 weeks I am attending a workshop on spinal deformity surgery. Its run by a spinal instrumentation company for orthopaedic and neurosurgeons. I would love to say that I can attend the seminar positing that we can offer a non-surgical alternative scoliosis, which is not the case.  In May I attended a  spinal surgery conference and often heard a term 'in my hands'. The surgeons were describing their technical skill and competence and confidence with certain procedures. I think that I now have a sense of 'in my hands' I can do something for   some of my scoliosis patients. The surgeons, the patients, and even I would like proof that these treatments work but I suspect that it's almost impossible  to prove this on a wide enough scale to validate the science.  I will have to work out how to implement some the nuances I saw in Barcelona into my practice.

I often underestimate the lack of free time when attending these overseas trips. I however did spend Sunday touring Barcelona seeing some of the sights I missed out on last year at SOSORT 2011.  It is an incredible city with a long history and interesting architectural character. The most notable architect was Antonio Gaudi whose designs are perfect for a city  housing a specialist scoliosis clinic. Some of his  buildings have absolutely  no  straight  lines and anatomical harmonic curves are seen throughout. I joked with Dr Rigo that  he  is like anti Gaudi. I  also managed to go for a daily swim at a gym nearby my hotel which also allowed me experience a new yoga  'fad' style called anti-gravity yoga which  is very interesting and I am sure with some tweaking  will open up a spinal pathology treatment protocol. I often joke with my osteoporosis class group that they need to swim in the sea and I will be able to tell them that I made it into the Mediterranean.