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DO YOUR EXERCISES........

The Importance of Attitude in doing your Exercises

By Marge Brannam

The first time I came to the St. Cloud Chiropractic Clinic, I noticed two signs on the wall.  One that said, "Be Nice or Go Away", which really impressed me, (as I knew then that this staff was kind and professional) and the other that said, "If you don't want to do your exercises, we'll cheerfully send you to a clinic where they don't care."  I made a mental note to always do my exercises if it was that important.  And it WAS, and IS. I've been asked to try to inspire young people to do their exercises and sometimes I wonder if I'm wasting my breath.  Ah yes, youth!  They're bullet proof, right?  Their bodies heal rapidly; therefore, they see no importance in a few exercises to be done at home.  WRONG!  Dr. Woggon, his staff, and the machines do a brilliant job of getting us on the right path to straightness but they can't do their miracles without us doing our part.  That is, our exercises at home.  One goes hand in hand with the other; you can't have one without the other. To me, it's very selfish of any one of us to not do our exercises and then expect Dr. Woggon and staff to perform miracles.  It's selfish also on our part to disregard the huge effort our families are putting forth on our behalf - so that we can be well.  

My first day at the Clinic was uncomfortable, to say the least.  I'm 73 and my scoliosis has been around since about age 12. (When I was little, no one gave any thought to whether a child had scoliosis and if we did, we lived with it.  It was post depression and no one had extra money.  And now, in the last few years, various chiropractors had said I was too old to rehab. (Thank God for Dr. Woggon)    My x rays showed a severe curvature and I knew then I'd have a lot of work to do.  My Dad, fiercely Irish to the core, said to us from the time we were little, “the Irish never ever give up"  and that attitude has been with me all my life.   So, in the first few days at the clinic, my muscles rebelled and caused pain.  I kept repeating to myself my mantra, "The Irish never ever give up."  When I came home so sore I could hardly move, same mantra. I even talked to my body, saying, "You're not going to get the best of me.  Remember I'm Irish."      And you need to straighten up.  (No answer from the body, just soreness. - which renewed my determination to get well)

So "never ever give up" on your exercises and the right attitude.  Keep your chin up and set your attitude to "I can do this."  You can't lose this way.  If you give up, you'll never know if you could have done it and you'll always wonder.  Especially when you are older and your body begins to fail you.  

Remember, you are in the best clinic on the planet and have THE VERY BEST in Dr. Woggon.  There's no one more caring and skilled in helping us all to wellness. 

Don't blow it!!!

TOO OLD TO REHAB........

“YOU’RE TOO OLD TO REHAB.”   

That’s what I was told by a number of chiropractors when I realized I had severe scoliosis and needed to do something about it. 

I was 73 at the time and was told over and over that I was too old to rehab and that a person needed to be young to “change” the spine.  So I want to give the over 50’s a heads up that they too can be successful in working toward a healthier, straight body.

 Thank God I was directed to Dr. Dennis Woggon at the St. Cloud Chiropractic Clinic & CLEAR Scoliosis Center.  He gave me back my life.   

I began rehab in January 2007, with Cobb angles of 79 lumbar, and 63 thoracic.  By May 2007, my Cobb angles were 67 lumbar, and 51 thoracic.  In October of that year, I was in a car accident and my neck had whiplash, which set me back in my rehab considerably.  I bought a vibe, and with the use of a traction device that goes along with it, I have used that almost every day (with the exception of travel).  In the past few months, I wear a backpack filled with weights as I do the vibe and traction, and the combination seems to work well. The backpack really makes you stand straight on the vibe.  

I do my exercises daily along with the vibe.  That’s the secret to rehab in “old age,” commitment – as in anything else at any age.  I was so thrilled in the beginning to know that someone out there could help me that I promised myself I “would never give up.”

 X-rays on March 21, 2011, show Cobb angles of 54 lumbar, and 39 thoracic.  I am thrilled to death. 

I do, however, credit not only Dr. Dennis (a one of a kind miracle worker) and Dr. Josh (with my vibe and lots of encouragement)  but also my Dad, who was “Irish to the core” and taught us from early on never, ever, ever to give up on anything.  He lived to 102 and he lived that principle all his life. 

In four years, I went from “really stooped over” to straight and it’s amazing that everything in the body works better now – imagine that!  Now that I have been given this gift of wellness from Dr. Dennis, I know that I can go into old age with a whole different body than was previously imagined.    We have talked about how long I will continue to do rehab and my answer is always “until I check out of this earth.”   I made Dr. Dennis promise me that he will not “check out” of this world until after I do…..he agreed. 

So, if I can do it, so can you all out there over 50 who have thought about beginning rehab but were hesitant about what changes you could make in your body.    

IT CAN BE DONE.  

And once you begin, don’t let anything or anyone stop you from doing your daily exercises or from getting to rehab – your commitment will literally save your life.    

ADULT SCOLIOSIS 2 WEEK PROTOCOL.........   

Case Series

Changes in clinical and radiographic parameters after a two-week regimen of chiropractic manipulation combined with soft tissue therapy and neuromuscular rehabilitation in 7 adult idiopathic scoliosis patients

 Woggon AJ1*, Martinez DA2

1Director of Research, CLEAR Institute of Texas; 2618 Electronic Lane, Suite 102; Dallas, Texas 75220;

2 Independent Researcher, Mesquite, Texas.

*Corresponding author

Email addresses:

AJW - jwoggon@clear-institute.org;

DAM – drdmart.fxneurology@hotmail.com

Background

The term Adult Idiopathic Scoliosis (Adult IS) is used to describe any lateral spinal curvature of unknown origin in a person greater than 18 years of age.  Some cases may arise in childhood or adolescence and go undiagnosed; others may develop spontaneously.1

The prevalence of scoliosis seems to increase with age.  Compared to 2-4% of adolescents,2 scoliosis was reported in 12-15% of college students.3,4  Scoliosis was found in 8.85% of adults over 40; in 19.9% of 1,299 adults with low-back pain; and, in 68% of healthy adults over 60.5-7

Although the majority of curvatures progress in adulthood, the rate generally slows and seldom increases as quickly as in early adolescence.  Spontaneous regression of adult IS is extremely rare, if it exists.  In a review of 587 cases of adult spinal deformity followed without treatment for up to 50 years, no case was reported to improve spontaneously (see Table 1.1).8 

The risk factors for progression of adult IS are Harrington Factor, Disc Index, and curve type.9,10  Curves greater than 30 degrees at the cessation of growth are more likely to progress in adulthood.11

Adolescents with idiopathic scoliosis may have impaired cardiopulmonary function upon exertion12,13, increased risk of pain14,15, and psychosocial disabilities related to their condition.16-18  An adult with idiopathic scoliosis is subject to the after-effects of living with these aforementioned symptoms in adolescence, and may have increased risk of pain, lower perception of their quality of life, and decreased social and emotional health.19,20  Severe scoliosis in adults is often accompanied by cardiopulmonary compromise.21-23

Adult IS is generally regarded as undeserving of treatment unless merited by pain, cosmetic reasons, pulmonary problems, and/or progression.24   Bracing is traditionally recommended only for skeletally immature patients; surgery is the sole recommended treatment for adults.  Regarding conservative care, according to Everett et al, “There is indeterminate Level III/IV evidence on the effectiveness of any conservative care option. There is insufficient research for a treatment recommendation beyond Level 2c very weak evidence, but the available literature is supportive of further clinical research in conservative care as a treatment in adult deformity. Basic clinical research at any level would be helpful to further clarify the options.”25  It is possible that one of the barriers in undertaking this research is a long-held belief that spinal deformity, in an adult, is irreversible.  While spontaneous improvement has never been reported in any study involving skeletally mature patients, this does not mean that scoliosis in an adult is permanent, or that their quality of life cannot improve.  Continued progression of scoliosis throughout adulthood has been documented, with more dramatic rates of progression possibly linked to more severe spinal imbalances; logically, if the curve can change for the worse in the presence of imbalanced forces, should it not be able to change for the better if the imbalances are corrected?  Previous case reports are suggestive of this possibility.26-30

Adding to this, we present a review of files chronicling the results of a novel two-week regimen of chiropractic manipulation combined with soft tissue therapy and neuromuscular rehabilitation in 7 patients with adult idiopathic scoliosis.

Methods (Case presentation)

Patient population

The authors conducted a retrospective review of 7 consecutive case files of patients with adult idiopathic scoliosis who presented for treatment between 1-1-2011 to 1-1-2012 at a private practice in Dallas, Texas.  The inclusion criteria for adult idiopathic scoliosis were defined as follows: previous orthopedic diagnosis of adolescent idiopathic scoliosis in an individual with a current chronological age greater than 18 and radiographic evidence of skeletal maturity (completed Risser sign).  All patients were negative for malignancy, fractures, arthrodesis, degenerative changes suggestive of de novo scoliosis, and neurological or congenital defects (including anatomical leg length inequality). 

There were 2 males and 5 females, median age 29 years (range 23 to 61).  Four patients presented with double thoracic and lumbar (“S”) curves; two presented with a single thoracolumbar (“C”) curve, and one presented with a single lumbar curve.  The mean Cobb angle was 46.4 (range 36 – 56.5) thoracic and 37.7 (range 9 - 60) lumbar. Family history for scoliosis was positive in 3 individuals.  All of the cases were diagnosed in adolescence.  Written informed consent to treatment, radiographic procedures, and the use of data for research purposes was obtained from each patient.  File numbers were changed to protect the identities of each patient.

Procedure

Standards of care and physical examinations were performed on all patients.  Each patient underwent twenty treatment sessions over a two week period (2 times daily/ten days) for an average length of 180 minutes/session.  

Treatment sessions were in three phases.  The first phase consisted of six parts: active spinal mobility exercises, passive vibration therapy, active cervical traction exercises, ­­massage therapy, passive flexion-distraction therapy, and mobilization therapy.

The second phase consisted of CMT.  Supine thoracic, prone lumbar, side-posture pelvic manual manipulations, and seated cervical instrument-assisted manipulations (ArthroStimTM – Impac, Inc.) were performed.

The third phase consisted of three parts: reactive body weighting therapy, isometric spinal exercises, and vibration therapy.

Patients were instructed to perform at-home exercises and therapies designed to correlate with their particular case for 30 - 60 minutes, 2/day.  Each patient was provided with equipment: a cervical traction device, foam rolls and wedges, an air-filled balance training disc, weighted headbands and belts, and a weighted cantilever.  Patients were also instructed to obtain a Scoliosis Traction Chair (Vibe For HealthTM - Madison Lake, MN) for use at home twice daily for 30 minutes.

Follow-up is pending as of the writing of this paper, and will be completed on or before December 31st, 2012. Follow-up will include a RAND SF-36 and SRS-22 to be filled out by the patient, and a standard scoliosis x-ray taken at an appropriate location and sent to the primary author for analysis.

Results

The mean, median, and range for the following primary outcome measures were recorded: Cobb angle changes: thoracic (-9.9o, -9.25o,  -4o  to  -15o), lumbar (-9.3o, -8o, -1o to -21o); apical vertebral rotation: thoracic (-3.33%, -2.65%, 0% to -11%), lumbar (-2.73%, -1.1%, -0.6% to -5.1%); apical vertebral deviation: thoracic (-7.83 mm, -4.5 mm, -1 mm to -12 mm), lumbar (-4.4 mm, -5.75 mm, 11 mm to -11.5 mm); digital spirometry: forced vital capacity (-78.6 cc, 50 cc, -490 – 180 cc), forced expiratory rate (2.1%, 2%, -2% to 13%), peak expiratory flow (540 cc, 700 cc, 550 – 1220 cc), forced expiratory volume in 1 second (42.9 cc, 20 cc, -110 to 200 cc); scoliometer readings: (-3.5o, -3o, 0o to -10o); TOLSWEC: left (10.1 seconds, 23 seconds, 0 to 25 seconds); right (11.4 seconds, 19 seconds, -8 to 22 seconds).  The greatest mean improvements in spinal ranges of motion (ROM) occurred in thoracic rotation, cervical lateral flexion, and lumbar lateral flexion (see Table 2.1).

Discussion

The goals of this therapeutic intervention were two-fold.  One goal was to address neuromuscular function, and another was to influence the biomechanical factors which may encourage curve progression.

Proprioceptive deficits and issues with balance have been reported to occur in scoliosis.38,39  A dysponesis between the sensory input and motor feedback systems (Central Pattern Generators and Proprioceptive Mismatch Correctors, or CPG’s and PMC’s) of the body could drive a neuromuscular imbalance that could lead to failures in the rotation-control systems; symmetrical function of neuromuscular mechanisms has been shown to be necessary for ideal spinal alignment.40-42  The hypothesis that vestibular asymmetry plays a role in the etiology of scoliosis has been supported in an animal model.43  However, treatment designed to affect the neuromuscular factors involved in scoliosis has not been specifically investigated.  Improving proprioceptive function could have benefit in reducing the risk factors involved in progression of scoliosis.44,45  This protocol utilized repeated exercise, whole-body vibration therapy, and gait therapy to influence neuromuscular function.46-49  This was combined with reactive body weighting (balance training exercises), in which the patient reacted to strategically positioned weights and cantilevers on the body while standing on an unstable surface, to rehabilitate the postural correction mechanisms. Changes were measured with the TOLSWEC test, with 6 of 7 patients demonstrating a mean increase in timed stability of 10.8 seconds.

The 3-dimensional involvement of the spine in scoliosis is generally accepted; what remains controversial is its role as a primary factor in the etiology of scoliosis.50,51  Neuromuscular factors have been suggested to contribute to the etiology of scoliosis, and biomechanical factors to its progression.52  Spinal imbalances and disruptions in the sagittal (and axial) plane have the capability of producing biomechanical imbalances which can influence curve progression in the coronal plane.53-61 Loss of the sagittal curves, resulting in a straightening of the spine, has been reported to contribute to scoliosis progression.62  Vertebral wedging occurs in scoliosis not only in the coronal plane, but in the sagittal dimension as well.63  The possibility of preventing scoliosis through treatment aimed at sagittal correction has been previously suggested.64    The applied protocol utilized a system of three-dimensional x-ray analysis to determine the applied CMT, with the goal of influencing spinal biomechanics and restoring optimal sagittal alignment.

According to a recent consensus of specialists in the conservative treatment of scoliosis, quality of life and cosmesis (personal appearance) were ranked as the two most important factors in scoliosis care.65  Radiographic measures alone are insufficient to determine the effect of scoliosis upon an individual’s quality of life; for this reason, functional outcome measures, such as spirometry and scoliometry, were included.  Long-term pulmonary impairment is one of the leading causes of disability in scoliosis.66 While only 1 of the patients in this study had spirometry readings below the predicted value (according to the reference values from Hankinson 1999),67 four were at the lower limits of normal; improvements in at least one of the four spirometric parameters were noted in every patient.

Aesthetics (cosmetic appearance) is not only important in the adolescent population but the adult population as well.  In fact, older patients may perceive their deformities as more severe than their younger counterparts.68  More severe cosmetic deformities are associated with lower health-related quality of life scores, and have a negative correlation with physical and psychological function.19,69  Many patients seek care due to concerns regarding their appearance rather than the underlying spinal deformity, and changes in radiographic indices do not always correlate with changes in cosmesis.69  For this reason, cosmesis was specifically investigated and quantified through scoliometry; improvements were noted in every patient in at least two of the three vertebral levels assessed.

Conclusion

Case studies on adult idiopathic scoliosis patients offer an advantage over similar studies on adolescent populations, as they allow spontaneous regression to be ruled out as a contributing factor.  While this study was a retrospective observational review lacking a control group, allowing no extrapolation beyond the involved subjects, the results support the premise that spinal deformity is NOT irreversible.

When treatment is indicated for adult scoliosis, the only currently-recognized orthopedic treatment option is surgery.  The results of this study add to the current body of case reports that indicate the need for further research into alternative methods.

Future studies could utilize a pragmatic design comparing the 2-years post-treatment results of surgical intervention to the 2-year post-treatment results of a similar adolescent or adult population undergoing an alternative treatment protocol (such as the one described in this article) to evaluate their comparative efficiency in a real-world scenario.

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  64. Dickson R: Spinal disorders and low back pain. JBJS 1999;81B:378-379.
  65. Negrini S, Grivas TB, Kotwicki T, Maruyama T, Rigo M, Weiss HR: Why do we treat adolescent idiopathic scoliosis? What we want to obtain and to avoid for our patients. SOSORT 2005 Consensus paper. Scoliosis 2006 Apr 10;1:4.
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  67. Hankinson et al: Spirometric reference values from a sample of the general U.S. population. Am J Respir Crit Care Med. Jan 1999;159(1):179-187.
  68. Tones MJ, Moss ND: The impact of patient self-assessment of deformity on HRQL in adults with scoliosis. Scoliosis  2007 Oct 15;2:14.
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Table 1.1. Incidence of Curvature Progression: After skeletal maturity8

Study                                                      # of Scoliosis Cases              Initial Cobb angle                 Incidence of Progression

Ascani et al., 1986                              187                              <20 - >60                                 100%

Bjerkrein and Hassan., 1982               70                                10-154                                     60%

Collis and Ponseti., 1968                     134                              <50 - >100                               69%

Korovessis et al., 1994                        91                                >10                                          67%

Weinstein and Ponseti., 1983             102                              15-135                                     68%

Totals and Averages                          584                              10 – 154                                  72.8%

Table 2.1 – Clinical and radiographic outcome measures, pre and post treatment

Radiographic Indices

Thoracic Cobb (o)

Thoracic Rotation (%)

Thoracic Deviation (mm)

Lumbar Cobb (o)

Lumbar Rotation (%)

Lumbar Deviation (mm)

∆ Mean

-9.92

-3.33

-7.83

-9.33

-2.73

-4.42

∆ Median

-9.25

-2.65

-4.5

-8

-1.1

-5.75

∆ Min

-4

0

-1

-1

-0.6

-11

∆ Max

-15

-11

-12

-21

-5.1

-11.5

Spirometric Indices

Timed One-Legged Stability with Eyes Closed

FVC (cc)

FER (%)

PEF (cc)

FEV1 (cc)

Left

Right

∆ Mean

-78.57

2.14%

540

42.86

10.14

11.43

∆ Median

50

2%

700

20

23

19

∆ Min

-180

-13%

-1470

-270

0

8

∆ Max

490

2%

-100

120

25

22

Spinal Ranges of Motion (o)

Cervical Flexion

Cervical Extension

Left Lateral Cervical Flexion

Right Lateral Cervical Flexion

Left Cervical Rotation

Right Cervical Rotation

∆ Mean

-8.86

1.71

5.14

8.71

-3.86

3.29

∆ Median

-9

8

12

1

-13

2

∆ Min

-6

-19

-16

-20

-12

-20

∆ Max

23

23

9

14

15

19

Spinal Ranges of Motion (continued)

Scoliometry (o)

Left Thoracic Rotation

Right Thoracic Rotation

Left Lateral Lumbar Flexion

Right Lateral Lumbar Flexion

T6

T12

L3

∆ Mean

2.86

6.86

-3.86

8.43

-3.43

-3.71

-3.43

∆ Median

0

6

-9

16

-5

0

-3

∆ Min

-18

-23

-18

-26

0

0

-2

∆ Max

9

8

23

13

-8

-10

-7

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