Scoliosis Blog
Medtronic spinal deformity seminar August 2012
At least this is not being written in an airplane!! In May this year I discussed the work I do with the Medtronic training manager at the Spine Society meeting. I explained that I need to work closer with the surgeons and need to better understand what they do from the surgical side of treatment. So, thanks to Medtronic I spent one and a half days with a group of surgeons in Sydney. The surgeons were from Denmark, Australia, Korea, Japan and America. The seminar was run by the Medtronic "faculty" and consisted of a general session and then either a paediatric or degenerative stream. I wish I could have attended all the streams but landed up at the one session of adult degenerative and one session of paediatric deformity.
They seemed open to my being a physiotherapist with a special interest in spinal deformity (more on this below) and I sat with interest through the cases presented. I especially wanted to attend the talk on conservative management of scoliosis. It was presented by a surgeon from Queensland who reiterated that there is no evidence that exercises can be of benefit in adolescent scoliotic deformities and exhibited a slide with a few terms that he called "catchy names" including Schroth, SEAS, MED-X etc. I felt that his talk was derogatory in nature and quite dismissive of what we do but more from a lack of knowledge than from intent. He stated that some of the exercises programs seemed to force the kids to wear a brace, OF COURSE conservative management requires a brace, and there are very detailed guidelines on the SOSORT website. I wanted to jump on the table and shout it out but sat through the talk quietly until the end. I could not keep completely quiet and did announce to the surgeons that I was a physiotherapist who had certified in Schroth and SEAS and that I felt that some of my patients do need surgery and are reluctant to do so. I asked if any of the surgeons felt that bracing makes their surgical correction more difficult and they responded in the negative. They then had a show of hands of which of them "honestly" does recommend a trial of conservative management and it seems as if the majority of them do. Some of them appear unsure of whether kids actually do wear their braces and there was interesting debate about the SpineCore brace.
So... I took a peek into the void of knowledge between the two groups. I think it will still take a few years before there is any real knowledge transfer between the groups because we have not yet "done our time" and have not yet arranged ourselves to present our data in a way that can be openly reviewed and criticized. If not in a reputable journal then at least in a conference attended by our surgical colleagues. The Spinal Research Society (SRS) is the lead global scoliosis surgical treatment society and it takes 5 years for their own members to be accepted into the society so I don't think that this is any different. There were quite a few junior spinal surgeons who had not yet completed their training and they were telling me about the "difficult" journey they have to travel with large investments in time, finances and stress so I don't think my journey should be any different.
I spent the week with a very special lady from Melbourne, she is young in heart and older in body. She came up to Sydney with her husband and son and was a classic example of a decompensated posture. Her trunk was falling off her pelvis and her GP had advised her that nothing could be done. We spent the week going through some Schroth exercises and I hope that she will find it beneficial (or at least continue to do so). I also recommended that she see a spinal surgeon in Melbourne as she will need additional support to stabilise her postural schema. However I leave you with an email I received from her daughter....
Hi Larry,
Thank you VERY VERY much for treating my mum. It's a pity I can't be there with her and to meet you in person, but I'm so glad that you are able to help her in so many ways.
As soon as I booked her in to see you the other day, she told everyone "At last I'm seeing someone who knows what to do with my condition." I spoke to her on the phone every night when she was in Sydney and she told me "Larry is a very nice person and very easy to talk to."
When she got home this evening, I was actually in tears (happy tears) to see her noticeably straighter. And when she forgot to hold herself up, and when I reminded her, she knew exactly what to do to straighten herself up, She regained the confident to do a lot of things from what I understood, like got onto the floor on her own, got onto the cat & dog position, etc.
Larry, you have lifted up her spirit too. She is so much happier now. Mum did fill me in about the spine specialist.
Anyway, I just want to say a BIG thank you to you for helping my mum
and that is why the journey is worth it!!
August 2012 Scoliosis Ramble
xx Another flight, another trip. I went to a lecture last week by Lawrence Kelemen who suggested that all people should go for a daily walk, by themselves, for at least an hour. Without distractions, without iphones, ipods - just by themselves. He said that modern humanity has lost 'itself' and we need to reacquaint ourselves with ourselves. he explained that each individual consists of 2 parts, the I and the self. Eckhart Tolle writes in the introduction to his best selling book the 'Power on Now' that he realised, when the dark demons of his inner soul led him to say, that he 'didn't like himself' that this was the clue to his long journey to eventual happiness, bestselling books and global following.
The solitude of these flights gives me the space to spend time with myself and reflect on things. What is this thing called posture... why am I drawn to it. Do we choose our destinies or are they chosen for us. I suspect that when our 2 selves are consistent then we are balanced and comfortable. Does balance always mean comfort- not always, but I suspect we can endure a lot more when we are in balance.
A few weeks ago, a team of scientists from CERN revealed that they had found the G-d particle. I cannot claim to have a clue about what they are talking about but it has to do with the unifying force holding matter together which I suspect has something to do with gravity. I don’t know if you, reading this, are a religious person but many years ago I read in a textbook on muscle function by JANDA a quote from the book of Isaiah in the old testament. 'And G-d shall judge his people with a plumbline'. I think the passage is referring to sin, reward, punishment and prosperity. But the word plumbline didn’t need to be used.. it could have used scale or something else. The passage could be indicating that our structural position relative to gravity will have consequences. Nowadays with laser levels and optical scanners, I still use a plumbline. I even had to track down a plumbline is a small store in Milan because there are hardly any suitable plumblines available in Australia.
I had a call this week from an adult patient interstate who reported a long history of scoliosis with a curve in surgical range but had been stable for the last few years. She has been suffering from severe pain and wanted to know if Schroth could be of benefit and how it works and would it correct her curves and could I guarantee it working. She said that she had seen a surgeon who had recommended surgery but was reluctant to have surgery because of a possible 4% complication rate. I cannot comment on the complication rate because it might be minor complications and we need to be able to differentiate. Unfortunately she is also on a disability pension and was not sure if she could finance her Schroth therapy. I will always wonder that our government can spend 10's of thousands of dollars on surgical approaches without even trying conservative options. I am sure I would have been able to help her, and diplomatically informed her so. I asked if she had read my blog as I sensed that she was feeling that I would just show her some quick exercises and that would be it. She hadn't, which was kind of frustrating - but informative and confirmed Kelemen's other point in that modern humanity seeks, sometimes to its detriment, immediate solutions.
There is no easy way of learning postural correction and no easy way of teaching it. Dr Rigo only allows therapists to begin teaching other therapists after 5 years in the field because it takes time. Especially time to see the failures.
I saw a patient just after my return from Barcelona. He was booked in for 5 days for Schroth therapy and reported a relatively recent history of pain and that he had been diagnosed with kyphoscoliosis. I asked him to complete a Scoliosis Research Questionnaire which revealed severe pain and a very negative emotional and psychological state. I then put up his xrays and could find no trace of scoliosis. He did show signs of moderate scheurmans kyphosis. My patient reported seeing a rehabilitation specialist who told him that his back was in terrible state and that he would everlong suffer from debilitating pain. I went through his xrays with him and established that a few months ago he had picked up his girlfriend and then soon after picked up a ride-on mower and this precipitated his back pain. Since the discussion with the specialist his pain and outlook had deteriorated considerably. Prior to the specialist he had even enlisted in the Australian Army. He was rejected by the army.
Dr Rigo has an amazing approach to these cases. We know that there is evidence that some people with postural deformity experience more pain than the general population but it cannot be predicted in the demographic population. This kid was strong and content, volunteered for the army and had his future ripped from him unnecessarily. I went to great lengths to explain the different spinal deformities and we commenced a postural correction program. Scheurmann’s hyperkyphosis is treated in one plane and much more simple learn. I asked him to NOT come back the rest of the week and suggested he return to gym, sport and everything and anything that he wanted to do. He returned after a week of doing his exercises. His pain was easier but most importantly, his outlook was better. I don’t know if I agree with the army's approach but I told him that the army probably rejected him because they cannot take the risk of training him up and then possibly losing him IF his back does trouble him. He was OK with this we agreed that he would continue with his exercise program and return in few months.
A year or two ago I was interviewed by a well known journalist about posture and its effect or its cause on the emotions and psyche. There is some truth that depressed people have a particular posture (body language) and aggressive people have a different posture. There is a link between the two but it’s a lot more complicated. We need to differentiate between structural spinal deformities non structural deformities .ie.are the bones misshapen.
The Higgs Bosun or God particle might be the link between matter, gravity and energy. From the moment any structure is born or created it tries to conserve energy by finding the most efficient manner to withstand the negative effects of gravity. Our posture is a result of our constant interaction with gravity and this has ramifications on the physical and non-physical aspects of our bodies.
Early on in 1st year physiotherapy we did a course called anatomical terminology. We were shown a picture of the human body and were told that every movement was referenced to this starting position. Anatomical Man is a balanced symmetrical structure; and can be depicted as a stick figure. Every load joint is horizontally and vertically balanced with the load joint above and below. Egoscue has a cute description, calling this the 'design posture' although many of the postural treatment systems dismiss this ideal I think it’s a beneficial starting point.
I received an email from Lisa Horton who is a physiotherapist in Queensland who informs me she completed her Schroth training in Germany last year. I look forward to meeting up with her and learning together.
This week I will be attending the conference on surgical correction of spinal deformities. When we were training as physiotherapists I got to spend time in theatre watching knee replacements, fracture repairs and other orthopaedic surgery. Hopefully I can meet up with some spinal surgeons and travel on the surgical path for a while.
July 2012 Dr Rigo clinic visit
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.
SOSORT 2012
Once again i am sitting on a plane travelling overseas.. i have worked out that this is my 9th trip in 3 years. SOSORT is meeting in Milan this year. There is once again a 2 day pre-meeting course on 'all' the established conservative management techniques, followed by a 3 day conference, and then the level 2 SEAS course. Before I left, Chani (new receptionist) and Tim (physio) were joking that I should enjoy my holiday. This is certainly not the case... The emotional, financial and social expense is really quite significant. I have many friends who travel frequently for work and now appreciate what they go through. It will be an interesting conference as there will be a 'debate' with the head of the SRS about conservative vs. surgical treatment of scoliosis, which I guess is what it's all about. I am still concerned that some of the patients we are seeing should definitely be undergoing surgical management.
Well the SOSORT COURSE and conference is over. The course was a repeat of last year and although I had already attended most of the sessions it was good to see them again. It was also good to spend time with experts from around the world and these 2 days provided me with time to discuss cases with them. I got co-opted (coerced) into the SOSORT education committee. This committee deals with the pre-conference SOSORT course as well as the educational accreditation of the different SOSORT treatment methods. I have taken on the secretary roll and will have to see what this entails.
The conference was especially good. The standard seemed to be higher than last year and the discussions with the SRS representatives was enlightening. There were 2 'controversial sessions' scheduled. One with Dr Nigel Price (the current head of the conservative management committee of the SRS) who presented a talk confirming that there is a lack of good quality research validating the role of exercises in the management of scoliosis. There is no doubt that this evidence is lacking but the outcome from the conference is that good quality research will only be accepted when a large cohort prospective randomised controlled trial is conducted. These studies called RCTs involve some patients attending a therapist who randomly assigns them to a treatment or non treatment group which is almost impossible in a private clinical setting. I had some good talks with Dr Price who did part of his surgical training in Adelaide. He appeared very open to "not rushing" into surgery and although wasn't convinced that SSE's (scoliosis specific exercise) could play a huge roll in the management of scoliosis he was very open to what we do. I discussed quite a few of my more "difficult" cases with him and wish we had a surgeon like him in Sydney.
I had some very itense discussions with Steve Bunce who is the physiotherapy head of North Bristol hospital. Steve is involved as clinical advisor to a NHS project to try to set up a study like this. Prof Eric Parent of Alberta Canada is also trying to research this topic. However, and this is where a problem arises, it seems that scoliosis specific exercises need to be taught by expert therapists who not only have the theoretical knowledge, but also the practical experience and teaching abillity. I worry that the RCT programs will not have access to the quality of therapist to achieve a true outcome. Lindsay Dolan who is co-ordinating the very large BRAIST trial in America on bracing reported that the trial which was originally an RCT has changed as their patients want to choose their treatment options.
The second 'controversial topic' was with Dr. B Stephen Richards who is the current head of the SRS. A series of cases were presented to the conference and Dr's Richards and Negrini presented their management approaches. There was strong agreement with all the cases presented. I think that it was quite a relief to see that the two organisations could work so easily on these cases. I suspect that in a few years SRS and SOSORT will be even closer. There was also a presentation from an Eastern European country on the use of bracing for early onset scoliosis. Quite a few of us in the audience were concerned that these children were not getting the correct treatment and the SOSORT advisory board will take up the case with the presenter.
The last 2 days of the conference was devoted to the level 2 SEAS course. We spent this time with Micheli Romano and Alessandra Negrini who are the head physiotherapists of ISICO in Milan. I cannot say the that the educational component was very high but each participant was asked to present 2 cases for the group to discuss. Garikoitz Aristegui of Spain was very passionate about a method of treatment called global postural re-education (RPG) and how it can help with scoliosis. Its amazing how things turn around. After completing my Egoscue training I spent some time exploring a technique of postural correction developed by Mersiers in France. This later became RPG through the work of another Frenchman named Souchard. Anyway it was good to see someone blending techniques. Gary was looking at some of my case photo's and we immediately "clicked" on how I was trying to integrate some of the Egoscue pelvic positioning techniques into Scoliosis treatment.
I met another artist - Monica Vilegrasa in Dr Rigo's head physiotherapist in Barcelona. She is a sculptor. She was explaining that their unit now has a 4 week scoliosis program for English speakers (in a group) which runs every July. Although we have treated heaps of patients on an individual level I still haven't done groups yet..... I somehow sense another trip coming up.
Spine Society of Australia Meeting 2012
I really thought my next conference would be Milan in May 2012 but when I noticed that the Spine Society of Australia (SSA) would be having their conference in Sydney I felt it essential to attend. It was immensely interesting. The Spine Society is a group of specialists with an interest in the spine. The meeting seemed to be primarily attended by spinal orthopaedic and neurosurgeons with a (very) few other discipiplines as well. I met only one other physiotherapist (from Perth) and Jeb was there too.
I met quite a few of the surgeons and introduced myself as a physiotherapist from Sydney with a special interest in spine. I didn't go into discussion of conservative management of scoliosis as I dont think they or I are ready for this talk. I suspect that any discussion right now would be premature and I dont want to be viewed as some "nutcase" who is trying to convince their patients not to have surgery when it is required. I had an interesting chat to the technical team at Medtronics about surgical implants will hopefully be able to spend some time with them this year so I can more clearly understand the surgical side of things.
Spinal surgeons seem to differentiate themselves into either deformity surgeons or degenerative surgeons, but many will do both. They have many different approaches to conducting their surgery and this particular conference had a strong focus on minimally invasive surgery (MIS). This type of surgery is performed with small incisions and complex instrumentation to view and correct the pathology. There was strong debate on the merits of MIS and whether these outweighed the risks of this type of surgery. Howevery everyone seemed to agree that there is a steep learning curve to performing this type of surgery.
Failure of conservative (eg. physiotherapy) treatment was indicated as a reason for surgical intervention in degenerative spines but not mentioned in deformity cases. There was no mention of any specific physiotherapy treatment post -op for deformity or degenerative surgery; although we often see post-op degenerative spine patients.
Dr William Sears presented some very interesting work on saggital balance and the way the body compensates posturaly for these imbalances. I asked him if he thought it would be possible to train these beneficial compensatory mechanics or untrain the detrimental mechanics, which he said was a very good question. We agreed that I would call him in the next few weeks / months and meet up for a chat.
In the interim... next stop Milan 2012.
Advanced Schroth Scoliosis course
Just over 2 years ago I commenced this blog documenting what I termed was a "ramble" into the world of Scoliosis. I now find myself sitting in the adjacent hotel room in Stevens Point, Wisconsin, writing once again. I cannot even think how many patients I have seen since those first days or how my life and work has been impacted by the amazing experiences I have been privileged to share since those early days.
I ended off last blog voicing my concern about the weather. It has been cold and there is a reasonable amount of snow on the ground. Dr Len Markman whose wife (Dr Leslie Markman) I met at the last course has taken me snow shoeing, sledding, ice skating and hopefully tomorrow- cross country skiing. They are an amazing couple. Although its been cold, one of the patients on our course, who is a remarkable young man from Alaska has been joking around saying how mild the weather is. Its amusing to see the therapists in multi layer clothing and Devin in his shorts and bare chest. Devin, whom I shall write about later, has a double curve of which his major curve is approaching 60 degrees. He lives life to the full and has been telling me about his commercial fishing experiences in Alaska; ala- deadliest catch type stuff.
It was an interesting type of treatment course. We had 10 physio's from around the USA (including Rebecca Harding and myself) and 10 patients of various ages and cobb angles. The smallest curve we saw was just under 30 degrees and the larges curve just under 60 degrees. Most of the kids had or were being braced but some had not been. We spent the week rotating through treating each patient in different techniques under the watchful eye of Dr Rigo. He would explain a concept and we would try to refine the technique on our patients. I am glad to say that there was nothing massively new but we were able to refine our techniques and identify the nuances of the method.
One of the the great aspects was seeing all the patients interact together and some great friendships blossom. I also met up with Rachel who is a group leader at http://www.curvygirlsscoliosis.com/ .
It was interesting working with all the other physio's and the in-depth discussions with Dr Rigo who would often remark that his clinic had tried a "particular direction" of treatment 30 years ago and it had failed.
The next stop is SOSORT 2012 in Milan following which I will hopefully attend the next level SEAS course.
January 2012 Scoliosis Ramble
Happy 2012. 2011 was a life changing year. I hope that all readers of this blog have a happy and healthy 2012.
We recently received our first letter from a scoliosis surgeon. The letter was written in response to a patient that I had seen and although this particular case falls into the domain of possible conservative management, I still felt it essential that the scoliosis surgeon is involved in the early stages of the case.
Although the surgeon was not supportive of Schroth, at least he wrote back, which is a start. He wrote that although some early positive work had come out of the schroth clinic in Germany, it had not been able to be reproduced outside of Germany. I suspect it will take a long time to "convince" these surgeons of the work that we do. It also seems that the publications coming out of Italy regarding the effectiveness of SEAS is not filtering down to the local Australian scoliosis surgeons.
I did however receive the following email
"Just letting you know that the last x-ray that R had on 25th October 2010 showed that R's curve went from about 45 degrees to 25 degrees. Her hand x ray showed that she is nearly at the end of her growth, we will find out in February if she has stopped growing. We have been doing your exercises every day, but now that we are seeing R she changed exercises because her curve has changed. Her next appointment at the Royal Children's is at the end of February. I will keep you informed about her progress after her next scan. Thanks for you help this year, R really pushed herself to do the exercises and we can see an amazing change. Dr T couldn't believe the results. We told Dr T about the schroth method exercises and that we are seeing a Chiropractor weekly. He didn't seem keen on the idea but then told us to keep doing what we are doing."
I cannot push the scoliosis surgeons into believing what we do as sceptics cannot be convinced with pure information. (I am the same). Sceptics are only convinced through experience and hopefully as we continue with our work they will come around. There has also been some new conservative management clinics opening up in Sydney. I guess I am like the scoliosis surgeons who am very concerned that these people are treating scoliosis without the necessary scientific evidence and that they have the potential to create real damage.
We have also seen some Very large adult curves or post fusion curves in adults. These adults have been told that that although their curves are large, the surgeons are not yet willing to commence or re-do surgery. They present complaining of significant pain. It has been very interesting working with them and rewarding to be of help
I will be leaving in 3 weeks time to meet up with Dr Rigo again in Wisconsin. Scoliosis Rehab is hosting an advanced course in Scoliosis treatment and although I will not be looking forward to the weather will look forward to "drinking at the feet of the master". I have a pile of x-rays that I will be taking up with me to go through them with Dr Rigo.
July August Scoliosis Ramble
Hello again...
The lives of a group of physio's dealing with scoliosis continues to progress. These last few months have been quite busy, and the world, it seems, has gone mad. There is turmoil all over the place and everyone seems to be very unsettled. Quite a long time ago I was chatting to an elderly patient and happened to mention "that the world had gone mad", my patient who had survived WW2 looked up at me and clarified that the world had always been mad and that I was just lucky enough to be born at a time when things were quite stable. Schroth technique is underpinned by need for a stable base / pelvis.... may we all merit stability in our lives!!
Following our course in Milan in May we were told that we would be given an exam to complete. The exam was duly given and duly completed.Its funny how a few weeks of intensive reading and sleepless nights can be summerised into the one preceeding sentence. I now have my level 1 certification in SEAS (specific scientific exercises approach to scoliosis exercises) technique. As mentioned previously SEAS seems quite similar to Schroth and the ISICO group in Milan have recently published a very good article in the Spine Journal; (article here). I will try and locate the full article for the blog. I wonder why Schroth seems so much more popular than SEAS? We are presently using aspects of both techniques in our scoliosis treatments and they are very complimentary.
Shana-Lee has been seeing some of my old scoliosis patients as well as new patients. We sometimes get caught up with our own treatments and our own patients. Watching Shana-Lee work is very special. I can see the focus and caring attitude of Beth and Patty (the head physio's at Scoliosis Rehab Inc. who trained Shana-Lee in Wisconsin) coming through in her treatments.
Below is a patients' email about her treatment with Shana-Lee;
I am 47 years old and developed scoliosis in my teens. I have just learned that i have a four curve scoliosis, the biggest curve being 37 degrees.I have tried everything over the last 30 years to find pain relief and solutions to my scoliosis. I mean everything. I have been told all kinds of things, ranging from "it's just a beauty spot, don't worry about it" to "I'll give you a bikini figure in 6 weeks". By far the worst thing i have been repeatedly told is "I'm not going to try and straighten you up, i'm just going to make you comfortable". Embedded in these words is the whole idea that being curved is 'normal' for you, so we won't try and tamper with it. After 10 hours of Schroth, i realise just how misguided that idea is.I would urge anyone, at any age suffering from scoliosis to learn the Schroth Method. For the first time in my life i feel that i am in control of my scoliosis. People are saying to me, "You look different, you look really happy". I'm not saying it is a picnic. It's very challenging to go against the patterns of your body, but with a skilled teacher you can learn. More than anything it requires a high level of concentration, but every new day my body told me, "this is what i want." I am so grateful to Shana-Lee for her fantastic care, her encouragement and compassion as well as the sophisticated understanding of the Schroth Method that she was able to impart.
Last week I met up with Charles Smuts who is the chief radiographer at Dalecross Adventist Hospital. I was given an overview of their new EOS x-ray imager. The details of the machine are here. It is a very impressive machine and although its quite a trip from Bondi Junction I would definitely recommend my patients utilise it. During our meeting (Jeb joined me), we met up with a scoliosis surgeon by the name of Dr Davor Saravanja (website). We had a very productive talk about what we are trying to do with regard to conservative management and I look forward to working with Dr Saravanja.
June Scoliosis Ramble
Physiotherapy has no role in the management of scoliosis – Or does it ?
There is something comforting yet daunting in taking a long journey into the unknown. We hope that our past experiences and knowledge will prepare us for the task ahead. I initially embarked on a journey into the world of scoliosis a few years ago and now find myself sitting on a plane to attend the world meeting (conference) of conservative scoliosis practitioners (SOSORT).
The conference is in Barcelona, home of Dr Manuel Rigo – my first scoliosis teacher, and will be preceded by a course providing insight into the different “schools” of conservative scoliosis treatment (physiotherapy and bracing) and followed by a certification course (in Milan ) in the SEAS approach to conservative scoliosis management. The SEAS approach is conducted by ISICO (Italian Spine Scientific Institute).
The SOSORT meeting will be attended by the world’s leading experts in scoliosis and will be attended by exactly ONE Australian physiotherapist - myself. Australia is supposed to be one of the world’s leading physiotherapy countries and our physiotherapists are in demand globally. Yet, the question remains why we have no leading scoliotic practitioners who have entered into the world of Scoliosis.
The heading above might be reason... The prevalence of scoliotic curves above 20 degrees is about 0.29% of the population. Therefore; can there be 20 000 Australians who have been told that they should not attend physio as part of their management for their scoliotic curves? Am I embarking on a very expensive learning curve which is doomed to failure and are the surgeons in our country correct.? Are our patients destined to live an adolescent life waiting for their curves to finally progress sufficiently till they need surgery to correct their curves or should they be operated “in case their curves progress”. The answer to the question must be very complex.... I will try to be as objective as possible. Everyone has a conflict of interest!!! In the words of Tim Ferris, we need to be skeptical but need to differentiate between pro-active and defensive skepticism.
Once again I find myself sitting on a plane.. this time on the way home. I need to clarify the paragraph above in that although I was the only physiotherapist from Australia , the conference was also attended by an Australian sports physician by the name of Dr Mel Cusi with whom I have worked with in the past. Although never in the field of scoliosis. Additionally, Dr Jeb McAviney (chiropractor and Bracing specialist) attended the pre-conference course, the SOSORT meeting as well as the post conference certification course at ISICO in Milan.
Although SOSORT is supposedly a group of conservative scoliosis practitioners it was reassuring to meet up with many spinal surgeons who are highly regarded in the conservative management as well. The keynote address was by Dr. R. McCarthy who is the most recent past-president of the SRS (Spinal Research Society). Interestingly the SRS group in Australia state on their website that they do not endorse any “alternative” form of scoliosis treatment, apart from bracing and surgery.
Having Dr McCarthy and colleagues publicly discuss conservative management, bracing and surgery in an open forum with very good science and logic was paradigm shifting. I have always thought that Australia has been backward in its available treatment options with regard to scoliosis. However... just like unmodernised Africa has been able to “leapfrog” into modern technology I sincerely believe that we in Australia will be able to “leapfrog” into cutting edge scoliosis treatment.
Does physiotherapy have a place in scoliosis treatment... initially I would always answer it depends but now I am more confident in responding, Yes. However – it has to be the correct physiotherapy treatment. We know that most physiotherapy approaches are not able to positively affect scoliosis
There appears to be be 4 main approaches to scoliosis treatment accepted within SOSORT:
- Schroth therapy and its slight variation coming out the Barcelona school directed by Dr Rigo.
- Dobo method from Poland: based on a 4 point kneeling position
- FITS from Poland: fascinating in its integration of muscle energy, very specific massage and mobilisation and myofascial plane techniques
- Dr Weiss’s new “power schroth” and its variations
- SEAS from the ISICO clinic in Milan.
We were introduced to all the different methods in the pre-conference course and experienced the personalities behind the methods. The ISICO school ran a post conference course in the certification in SEAS which both Jeb and I completed.
ISICO is run by a physical medicine specialist by the name of Dr Stefano Negrini. I was able to have a great informal chat where he told me that he was introduced to scoliosis treatment by his physiotherapist father at the age of 10. Dr Negrini then spent many years with a specialist called Dr Sibilla and the foundation of his approach to scoliosis was based on the work on Dr Sibilla.
ISICO’s approach to scoliosis has similar “flavours” to Schroth and Schroth certification certainly helped in grasping the technique a lot quicker. Dr Negrini is the clinical director who decides on bracing options as well as physiotherapy directions however the real “craftsman” of the treatment is a physiotherapist, Michele Romano, who was the lead instructor on our course. We had many theoretical lectures as well as practical lectures. Watching Michele work is like watching a master craftsman work. Dr Rigo once told me that a good therapist is someone who can anticipate the response of the patient to any musculoskeletal movement and is able to respond the behaviour. Michaeli definitely shows this unique ability.
Dr Rigo has a hobby of playing the cello. When we did our course in Wisconsin he would take some time every afternoon to practice in one of the rooms. Michele’s hobby is drawing satirical cartoons. He has promised to email me some which I will put up on the blog.
ISICO is a unique clinic in that they are very active in the publishing their data and continually refine their approach according to their research results. They have a very un-Schrothlike treatment protocol. Only one or two 90 minute to 2 hour sessions and then again in 3-6 months. This seems very little treatment when compared to Schroth. We are currently using 5 sessions of 2 hours each whilst Germany and London use a full time month and Barcelona and Wisconsin use a protocol involving four hours daily for a fortnight. I think one of the major changes we will have in the clinic is that we will open opportunities for a more accelerated scoliotic correction program.
May Scoliosis Ramble
Hi All,
I am off to Barcelona and Milan for the SOSORT conference and to spend some time in the clinic of Stefano Negrini in Milan. Their group use a method called SEAS to treat scoliosis. I will write something from the course... however, in the interim...
I asked my colleague Shana-Lee to write something about her recent trip to Wisconsin...
After Larry returned from the USA in November 2009, I was intrigued and inspired at all he had learnt and wanted to hop on the next plane to do the Schroth course. Little did I know that after travelling with my husband for 5 months around the globe, I’d get an email from Larry in my last week of travels to say “don’t put your passport away” and I was to leave 2 weeks after returning from my relaxing time away.
I unpacked one bag, only to pack another but this time the bikinis were left behind and the warm winter coats, scarves and boots were packed. A snow storm hit the middle of the USA just in time for my and many other course participants arrival. So after a 50 hour journey with many itinerary changes and no sleep, I arrived in Wisconsin, USA….with no luggage. Due to the storm the first day of the course was cancelled and hence what was meant to be a 10 day course to learn the Schroth Based Method of treating Scoliosis, became 9 very long days.
Scoliosis was always one condition I questioned. Was there a cure? What treatments were best? Could you stop the progression of the curves? And could we help pain? None of which I knew how to answer fully until I attended the Schroth course. Learning about the Schroth method and the theory behind all the exercises was interesting and exciting knowing that now I could now finally answer most of the questions I had all along and most importantly…now I could truly help patients with a method that works!
The most amazing part of the course was seeing the patients performing the exercises and watching their faces glow as they realized their potential to improve not only their “curvy” posture, but their confidence and self esteem.
Like most physical conditions, scoliosis is coupled with many emotions from both the patients and their parents. We were lucky enough to have a physiotherapist attending the course who in fact had scoliosis herself, as well as 2 other physiotherapists who were mothers of teenage girls who both suffered with scoliosis. Seeing the emotions that came through from both the patients and the parents was amazing. The 4 teenage girls truly went from 4 shy girls with hunched shoulders to hide from their curves, to 4 confident and bubbly girls who stood up straight and proud.
Both the girls and the parents were inspired by each other and were so grateful to have others to talk to who knew what they were going through. It really made me realise the importance of having a support system for patients and their parents to be able to discuss their condition, the pain they feel both physically and mentally, and of course the big question for some is the possibility of surgery and possible outcomes.
In America there is a support group called “The Curvy Girls” which I think is an amazing idea and would be welcomed in Australia. For more information go to www.curvygirlsscoliosis.com.
March 2011 Scoliosis Blog
Happy 2011,
Where did December, January and February go??
School holidays resulted in a busy time in the clinic. We had quite a few local and interstate patients come in for Schroth treatment. The age and curve patterns varied considerably as well as a few post surgical patients came in for treatment.
I still get quite a few queries on who would be a reasonable candidate for conservative scoliosis treament. This is a slighly loaded question as Schroth scoliosis treatment is not an alternative to non-conservative (surgical) treatment but is part of the treatment. My general approach is that if the curves and posture can be stabilised within a reasonable range then conservative managment might be appropriate whilst surgery is delayed or offset. If not- and there is a strong chance of curve progression into "significant" ranges then surgery is definitely indicated and Shroth therapy is used as a preparatory phase leading towards surgery.
The International Society On Scoliosis Orthopaedic and Rehablitation Treatment (SOSORT) has published guidelines on conservative management of Scoliosis (available here) which provide an approach to management. A bigger question is one of bracing....
If curves are in surgical range then they are often in bracing range. Unfortunately, Australia has tended to be a bit behind the rest of the world with availability of bracing options. But this is beginning to change and we are beginning to see more Assymetric Rigid Bracing available. We are also seeing more options in dynamic bracing with the Spinecore brace.
Decisions to brace are not taken easily but once bracing is commenced we need to ensure that eventually the muscles of the body and it's spatial awareness systems are able to maintain the correction achieved by the brace. If not, then the body will return to unbraced positions - and that is why there is still a great deal of debate whether bracing is effective in the long term.
March was also a big month for one of my physio. colleagues and friends. Shana-Lee, whom I have worked with for quite a few years, went over to Wisconsin to do her Schroth training. I will ask her to write an article for the Blog.
I will be attending the SOSORT conference in May in Barcelona so if anyone out there has any questions please ask.... as I hope to be able to pick the brains of the delegates.