Search Results: scoliosis

Scoliosis Massage1A

Scoliosis – Massage Therapy

Pain: The primary reason for massage therapy in scoliosis is to relieve pain.  Massage can be an integral part to relieving long term and chronic pain.  Our massage therapists are highly experienced in scoliosis and post-scoliosis surgery massage.

Who will benefit?

Anyone over the age of 10 with a diagnosis of scoliosis and is having pain. We recommend that you begin your treatment by having an assessment with one of our physiotherapists to help determine the source of the pain. However, if your primary goal is pain relief an appointment with our Registered Massage Therapist may help you to get immediate relief.

Service provided by: Juliette Woodruff RMT

More information:
https://orthophysio.com/?s=scoliosis

To Book an appointment call 416 925 4687 or email jwoodruff@orthophysio.com

Scoliosis Adults1A

 

Scoliosis Adults

Physiotherapy treatment is provided for adult, adolescent and post-surgical scoliosis.

Our treatment approach: The primary reason for treatment in adults with scoliosis is to relieve pain. Postural correction and/or prevention of curve
progression can also be addressed. Our approach uses a combination of manual therapy, modalities, core conditioning exercises and Schroth/Scoliologic
approaches to curve management. https://schrothbestpractice.com/north-america/

Pain: Just because you have scoliosis, does not mean that you have to have back pain. Our assessment helps to determine the source of the pain. Treatment may include a combination of manual therapy, modalities and/or exercises to help relieve and prevent pain reoccurring in the future.

Prevention of Curve Progression: In adults most curves will not progress unless the curve is over 35-50 degrees. Scoliologic/Schroth exercises can be used in adults to help with curve management.

Surgery: We provide exercises to assist in limiting the need for surgery as well as working with you to prepare and recover from surgery.

Who will benefit? Adults with a diagnosis of scoliosis who would like to develop a scoliosis specific exercise program. Anyone who has had scoliosis surgery or is having back or neck pain.

Service provided by:

Maureen Dwight RPT, Clinical Musculoskeletal Specialist, Advanced Practitioner ISAEC, Certified Scoliologic practitioner https://schrothbestpractice.com/north-america/

Juliette Woodruff RMT

More information:
https://orthophysio.com/?s=scoliosis

To Book an appointment call 416 925 4687 or email mdwight@orthophysio.com

 

Scoliosis Adolescents1A

 

Scoliosis Adolescents

Physiotherapy treatment is provided for adult, adolescent and post-surgical scoliosis.

For Scoliosis-Adults click here

For Scoliosis Massage click here

Our treatment approach: In adolescents our primary goal of treatment is prevention of curve progression.  We work together with you and your medical scoliosis team to optimize results.  Our approach uses a combination of core conditioning exercises and Schroth/Scoliologic approaches to curve management.   https://schrothbestpractice.com/north-america/

Bracing: We provide exercises to assist in preventing the need for bracing, as well as providing exercises to improve the results of bracing. Bracing is known to be more effective when combined with exercise.

https://www.srs.org/about-srs/quality-and-safety/position-statements/srs-statement-on-physiotherapy-scoliosis-specific-exercises

Pain control and prevention: Although pain is less frequent in adolescents, we provide direct treatment if pain is a key concern. Treatment may include a combination of manual therapy, modalities and/or exercises. Our approach is to teach you how to relieve and prevent pain.

Surgical rehabilitation: We provide exercises to assist in limiting the need for surgery as well as working with you to prepare and recover from surgery.

Who will benefit from our scoliosis approach? Anyone over the age of 10 with a diagnosis of scoliosis, with or without bracing.  Anyone who has had scoliosis surgery and lacks function, strength or is having ongoing pain.

Service provided by:

Maureen Dwight RPT, Clinical Musculoskeletal Specialist, Advanced Practitioner ISAEC, Certified Scoliologic practitioner, https://schrothbestpractice.com/north-america/

Juliette Woodruff RMT

More information:
https://orthophysio.com/?s=scoliosis

To Book an appointment call 416 925 4687 or email mdwight@orthophysio.com

Scoliosis

Scoliosis Physiotherapy treatment is provided for adult, adolescent and post-surgical scoliosis. 

 

Scoliosis Adolescents

Our treatment approach: In adolescents our primary goal of treatment is prevention of curve progression.  We work together with you and your medical scoliosis team to optimize results.  Our approach uses a combination of core conditioning exercises and Schroth/Scoliologic approaches to curve management https://schrothbestpractice.com/north-america/

 

Bracing – We provide exercises to assist in preventing the need for bracing, as well as providing exercises to improve the results of bracing.  Bracing is known to be more effective when combined with exercise. https://www.srs.org/about-srs/quality-and-safety/position-statements/srs-statement-on-physiotherapy-scoliosis-specific-exercises

 

Pain control and prevention– Although pain is less frequent in adolescents we provide direct treatment if pain is a key concern. Treatment may include a combination of manual therapy, modalities and/or exercises.  Our approach is to teach you how to relieve and prevent pain.

 

Surgical rehabilitation – We provide exercises to assist in preventing the need for surgery as well as working with you to prepare and recover from surgery.

 

Who will benefit from our scoliosis approach? Anyone over the age of 10 with a diagnosis of scoliosis, with or without bracing.  Anyone who has had scoliosis surgery and lacks function, strength or is having ongoing pain.  

 

Service provided by: Maureen Dwight RPT, Clinical Musculoskeletal Specialist, Advanced Practitioner ISAEC, Certified Scoliologic practitioner

More information: https://orthophysio.com/?s=scoliosis

 

Scoliosis Adults

Our treatment approach: The primary reason for treatment in adults with scoliosis is to relieve pain. Postural correction and/or prevention of curve progression can also be addressed.    Our approach uses a combination of manual therapy, modalities, core conditioning exercises and Schroth/Scoliologic approaches to curve management.

 

Pain – Just because you have scoliosis, does not mean that you have to have back pain.  Our assessment helps to determine the source of the pain. Treatment may include a combination of manual therapy, modalities and/or exercises to help relieve and prevent pain reoccurring in the future.

 

Prevention of Curve Progression – In adults most curves will not progress unless the curve is over 35-50 degrees.  Scoliologic/Schroth exercises can be used in adults to help with curve management.

 

SurgeryWe provide exercises to assist in preventing the need for surgery as well as working with you to prepare and recover from surgery.

 

Who will benefit? Adults with a diagnosis of scoliosis who would like to develop a scoliosis specific exercise programAnyone who has had scoliosis surgery or is having back or neck pain.  

 

Service provided by: Maureen Dwight RPT, Clinical Musculoskeletal Specialist, Advanced Practitioner ISAEC, Certified Scoliologic practitioner https://schrothbestpractice.com/north-america/

More information: https://orthophysio.com/?s=scoliosis

 

Scoliosis – Massage Therapy

Pain – The primary reason for massage therapy in scoliosis is to relieve pain.  Massage can be an integral part to relieving long term and chronic pain.  Our massage therapists are highly experienced in scoliosis and post-scoliosis surgery massage. 

 

Who will benefit? Anyone over the age of 10 with a diagnosis of scoliosis and is having pain.  We recommend that you begin your treatment by having an assessment with one of our physiotherapists to help determine the source of the pain. However, if your primary goal is pain relief an appointment with our Registered Massage Therapist may help you to get immediate relief.   

Service provided by: Juliette Woodruff RMT

More information: https://orthophysio.com/?s=scoliosis

Physiotherapy in the Treatment of Scoliosis

The Role of Physiotherapy in the Treatment of Scoliosis

(published Orthopaedic Division Review, CPA September 2017) 

Maureen Dwight[1], Dr. Josette Bettany-Saltikov[2], Dr. Eric Parent[3]

Introduction

The role of physiotherapists in the treatment of scoliosis can be somewhat unclear and sometimes controversial. Many therapists have little exposure to the treatment of this condition[4] [5] which is in part related to the lack of education on spinal deformities at university as well as the relatively low acceptance rate by scoliosis surgeons and specialists for the inclusion of physiotherapy in the comprehensive management of scoliosis.  Despite increasing research supporting treatment, the number one reason given for this lack of inclusion is limited evidence of efficacy.

This article seeks to review the diagnostic factors which influence physiotherapy treatment and to review the known efficacy and role of physiotherapy in the treatment of Adolescent Idiopathic Scoliosis.

Key Considerations in the Treatment of Scoliosis

1. Diagnosis

Scoliosis is a structural alteration to the normal curves in the spine. During active growth periods the spine develops curves in the frontal and sagittal planes however the scoliotic spine develops with axial rotation which alters the normal development of these curvatures.  These changes can result in a rib hump or a rotational lumbar prominence as well as altering the normal lordosis and kyphosis resulting in a kypho-scoliosis, thoracic lordosis, sway, flat back, etc.

For a patient to be diagnosed as having a scoliosis, the lateral curvature in the frontal plane must measure greater than 10 degrees.  Approximately 2-3%[6] of children under the age of 16 will have scoliosis however the majority will not progress.

Curves are commonly defined by the location of the apex and the Cobb angle.  The Cobb angle is a measurement of the angle in the frontal plane between the superior vertebral end plate of the most tilted vertebra above the curve apex and the lower endplate of the most tilted vertebra below the apex. Measures of vertebral rotation may also be quantified through imaging.

Curves may be classified as major and minor[7] which denotes the relationship of their magnitude to each other.  If more than one curve is present it may be described as a double major or a major with an associated minor curve(s).  The Lenke[8]  or SRS classifications are the most commonly used taxonomies of curve type.

The Lenke system, while widely used by surgeons to plan surgeries, is not widely used by physiotherapists as it requires side-bending radiographs and is meant for bigger curves. Scoliosis Research Society (SRS) definitions with reference to curve apex are as follows: Cervical (C1 to C6-6 disc), cervico-thoracic (C7 to t1), Thoracic (T2 to T11-12 disc), Thoraco-lumbar (T12 to L1), Lumbar (L1-2 to L4-5 discs), and Lumbosacral (L5 and below)[9].

For a physiotherapist the location of curve can be important when using Physiotherapeutic Specific Scoliosis Exercises (PSSE)[10] as these treatment techniques base their approach on the specificity of curve location.  This knowledge also determines the need and effectiveness of other types of treatment which can influence treatment planning i.e. bracing is less effective in a thoracic double major curve.

2. Idiopathic vs. Non-idiopathic scoliosis

Scoliosis is typically divided into two major categories: idiopathic and non-idiopathic. This division reflects the underlying causes with the term idiopathic identifying the lack of consensus on the cause of these curves. One of the key features of the idiopathic-type of scoliosis is that it is not associated with any other conditions.

a. Idiopathic scoliosis

Idiopathic scoliosis is typically divided into 4 categories based on age and risk for progression.  There is more difficulty determining risk for progression of the early onset types of scoliosis (<age 10) which justifies the need for closer monitoring in this age group. The risk for progression is more predictable in the adolescent age group and is sometimes described as linear, however each patient should be approached individually as not all curves progress as predicted.

I. Infantile idiopathic scoliosis is diagnosed when first seen in a child under age 3

II. Juvenile idiopathic scoliosis is diagnosed in children ages 4 to 9

III. Adolescent idiopathic scoliosis is diagnosed when the spine curvature changes during the growth spurts commonly occurring around puberty(between ages 10 and 18)[11]

IV. Adult idiopathic scoliosis occurs in patients older than 18. This condition can also be referred to as de Novo scoliosis.  Many of these new diagnoses are related to spinal degeneration however, when the onset is not coincident with periods of skeletal growth, other non-idiopathic causes should be considered.

b. Non-idiopathic scoliosis

The non-idiopathic type of scoliosis is associated with other conditions and/or underlying causes.  The causes are typically divided into two categories.

I. Neuromuscularscoliosis.  This type of scoliosis is associated with neuromuscular diseases i.e., Arnold-Chiari malformation/syrinx or trauma to the spinal cord.

II. Syndromicscoliosis is related to other diseases i.e. Marfans syndrome, spina bifida.

 3. Indications for additional monitoring

For a physiotherapist working with scoliosis a primary consideration is determining the type of scoliosis.  If the patient has been seen by a specialist or pediatrician this diagnosis may already be clear however when the physiotherapist is the first to diagnose the condition consideration should be given to the need for further investigation and/or referral.

Screening for further testing can be particularly important in the non-idiopathic patient as an undiagnosed Marfan’s syndrome, syrinx, Chiari Malformation, etc. can have serious health consequences[12].  These patients should be referred for monitoring/testing by the appropriate specialist.  The following considerations can assist in determining the need for additional testing[13]

1. Is the patient under age 10?

The most common scoliosis (AIS) occurs in the teens.  Earlier onset need to be monitored and/or investigated more closely both for the unpredictability of the progression and for the likelihood of non-idiopathic causes.

2. Is the patient still growing?

Bracing is only effective while the spine is still growing. There is typically a window of approximately 2 years, occurring around puberty, when this treatment can limit the likelihood of curve progression.  If the patient is under age 18 consideration should be given to referral for quantification of spinal maturity and degree of curvature.

3. How large is the curve?

The larger the curve the more likely it is to progress[14]. The younger/less skeletally mature the patient is the greater the risk for progression[15].   Younger children and adolescents, particularly with larger curves, are more likely to require additional monitoring and/or intervention.

4. Is the patient male or female?

Although the incidence of scoliosis in males and females is equal the presence of larger curves is more typical in females.  A significant curve in a male can be more indicative of non-idiopathic type of scoliosis and sometimes represents an indication for an MRI[16].

5. Are there other signs of concern?

The presence of upper motor neuron signs, connective tissue disorders, café au lait[17] spots, spinal hairy patch etc. all can be markers of non-idiopathic types of scoliosis These factors can be indicative of the need for additional investigation.

4. Treatment of AIS

Primary goal of treatment

As there is no consensus on causation, the prevention of scoliosis cannot be a goal at this    time.  The primary goal of treatment is prevention of curve progression.

Within this goal the first consideration is to keep the curve to less than 30-35 degrees.  This magnitude is often a threshold for other treatment as these curves are more at risk for progression.  Curves less than 30 degrees at skeletal maturity present a low risk of continued progression in adults. Untreated curves of 50 degrees and greater are predicted to progress at .5 degree per year[18].

The second threshold is 50 degrees.  When the curve exceeds this magnitude surgery is often recommended. Most studies[19] report the strongest predictive factors in determining the risk for progression of idiopathic scoliosis are age, magnitude of curve, and gender.

Currently the strongest acceptance for prevention of progression is for bracing and surgery.  Recently, the BrAISt randomized controlled trial demonstrated convincingly the ability of bracing to prevent progression to surgery indication thresholds with 72% success compared to only 48% in the group under observation[20]. This trial also demonstrated clearly the role of compliance in the brace treatment effect showing that when a rigid brace prescribed for full time wear (<18hr/day) is worn at least 13 hours a day the probability of success is high (<90%).

Despite the wide acceptance for surgery, a systematic review by the Cochrane Collaboration failed to find sufficient evidence to support its use in severe curve management.  Bettany-Saltikov et al[21] looked to compare surgical vs. non-surgical treatment of curves over 45 degrees but were unable to find any RCT’s or prospective studies that met the criteria.  They were unable to make any conclusions of the effectiveness of surgical vs. non-surgical management of severe adolescent idiopathic scoliosis of over 45 degrees.

Physiotherapy Goals of Treatment

In physiotherapy the goals of treatment are broader than strictly the prevention of curve progression. 

The SOSORT survey by Marti et al.[22] of SRS scoliosis specialists documented the key reasons for referral to physiotherapy. These referral patterns were separated into standard physiotherapy treatments and PSSE’s.   In Parent et al’s study the survey of the standard physiotherapy techniques listed the following approaches used in the treatment of AIS:

  1. stabilization exercises (76%)
  2. non-scoliosis specific postural approaches (73%)
  3. mobilizations (55%)

In the Marti study the most common specific PSSE used were:

  1. Schroth – Germany (57%)
  2. Side Shift – UK (22%)
  3. SEAS – Italy (21%)
  4. FITS – Poland (19%)

The top reasons for the surgeon’s prescribing standard physiotherapy were:

  1. in conjunction with brace treatment (58 %),
  2. small curves (48 %)
  3. improving post-operative outcomes (37 %)
  4. treatment of pain (25 %)[23]
  5. Improving aesthetics (40 %

The top reasons for the surgeon’s prescribing PSSE’s were:

  1. improve aesthetics (62 %)
  2. to prevent curve progression (60 %)
  3. improve quality of life (53 %).

Similarly, the SOSORT guidelines[24], from the international Society on Scoliosis Orthopedic and Rehabilitation Treatment identify the following four common objectives to be pursued when using PSSE’s:

  1. limit curve progression
  2. prevent respiratory dysfunction
  3. control pain
  4. improve postural appearance.

 Physiotherapy Role in Prevention of Curve Progression

Although one of the goals of physiotherapy may be to reduce curve progression, despite increasing research support, this goal remains controversial at this time.  Early support is seen in the 2012 Cochrane systematic review[25] for the use of PSSE’s in reducing curve progression.  The Negrini study[26] has shown value of the use of PSSE’s in reducing curve progression both with and without bracing.

Of note, in Monticone et al’s study[27], the percentages of patients presenting improvement >5o), stable curves (changes < 5o) or deterioration over 5o were 62%, 38% and 0% in the exercise group and 0%, 92% and 8% in the control group, respectively. In response to 6 weeks of supervised therapy, participants in Kuru et al’s trial[28] assessed after 24 weeks showed larger improvements in Cobb angles, Angle of trunk rotation, height of gibbosity and waist asymmetry but not SRS-23 scores than both controls under observation or having done unsupervised exercises. Other exercise trials[29] are ongoing and other results await publication which suggests the evidence base on PSSE effectiveness will continue to grow stronger in the near future.

With this increase in data, a shift in the acceptance of scoliosis treatment is starting to be seen in changes to the position statements of the Scoliosis Research Society (SRS) and other influential scoliosis-related associations.  The 2014 SRS Statement on Physiotherapeutic Scoliosis Specific Exercises Dr. Timothy Hresko, MD: Chair, SRS Non-operative committee includes the following statement:

Physiotherapy Scoliosis Specific Exercises have been used with spinal orthotic management in the treatment of progressive idiopathic scoliosis. The combination of the two modalities may offer advantages over more simplified treatment plans”. 

In the 2015 Screening for the Early Detection for Idiopathic Scoliosis in Adolescents SRSPOSNA/AAOS/AAP[30] position Statement Dr. Timonthy Hresko, MD included the following statement supporting PSSE’s in scoliosis management:

Other means for non-operative treatment of scoliosis have also been studied. Scoliosis specific exercises used to supplement brace wear or prevent progression in mild curves have been reported. A randomized clinical trial of patients with mild scoliosis of 10-20 degrees has shown that scoliosis specific exercises may prevent progression to the level of deformity that would result in brace treatment”.

4. Physiotherapy Role in Pain Management

In her review Marti noted that the most common concern of the specialists is the alleviation of pain (72%).  Despite this high level of concern only 25% of the specialists surveyed refer to physiotherapy for pain management.   This discrepancy may reflect the perception that pain in scoliosis is considered a relatively negligible factor and/or the lack of research in this area.

The 50 year longitudinal review by Dr. Weinstein et al[31] confirmed an increased prevalence of low back pain in untreated scoliosis. With an average age of 66 at the conclusion of the study, 61% of the scoliosis group reporting chronic low back pain vs. 35% of the age-matched control group.  However this study also determined that the intensity of the pain was no worse than controls. There was no impact on disability with the majority being gainfully employed or homemakers.

The following two concluding statements from this review on the relationship of low back pain to function have likely had strong influence on perceptions of pain and the requirement for treatment in this population.

“Although the prevalence of back pain in untreated scoliosis likely exceeds the general population it does not appear to cause excessive disability.” 

“Although scoliosis patients report more chronic back pain, those with pain have similar profiles in terms of duration and intensity of their peers and their ability to work and perform everyday activities is similar to their peers.  Additionally, back pain had no larger impact on work and activities for scoliosis patients than it did for controls.”

When reading Weinstein’s article the conclusions should be viewed in context with the reference that previous perceptions of scoliosis by health care professionals predicted a life of pain and disability.  These results support a better prognosis for function however based on this study the need for physiotherapy treatment for pain is at a minimum consistent with what is required in the general population and is likely to have a higher requirement.

While at this time there is limited research looking at the provision of physiotherapy for back pain in the scoliosis patient, recent evidence is promising. Of note, in Monticone et al’s[32] study, participants in the exercise group also showed larger improvements in the function, pain, self-image and mental health of the SRS-22 questionnaire.

Schreiber et al[33]  also found significantly larger benefits with Schroth exercises than in controls on SRS-22 pain and self-image domains. Further Zapata et al[34] showed in a RCT that spinal stabilization exercises helped reduce the numeric pain rating scores and the patient-specific functional scales scores in patients receiving supervised than unsupervised 8 week of therapy. 

5. Physiotherapy and Screening for Scoliosis

Although screening for scoliosis is no longer standard, there is increasing support for regular testing during growth periods.  A task force from the Scoliosis Research Society[35] recommends that females be screened twice, at age 10 and 12 years of age.  Males should be screened once at between ages 13-14.  This frequency reflects the increased risk in females for larger curves.

 

 

Observation of standing posture asymmetries followed by observation of the spine in forward flexion[36] are the norms for determining if further testing is required i.e. 3 foot standing view X-ray.

 

 

 

 

Physiotherapists are well suited through their education and training to perform these screening tests. The observation of posture for asymmetries should include the frontal alignment of the spine, the height of the shoulders, the hip and waist shapes and the forward bending test.

The forward bending test consists of checking if the spine is straight while the patient bends forward slowly beginning with the neck with the hands together while keeping the legs straight until the hand are between the knees. If a side to side back difference is noted and a spine deviation is noted it suggests a scoliosis is present.

 

 

The importance to emphasize screening for scoliosis is further supported by the fact that bracing and exercise treatments to be effective need to be applied to smaller curves before reaching skeletal maturity. Early detection of scoliosis is therefore important to identify adolescents at risk of progression and offer the chance to try non-operative therapies while they may be most effective[38].

 

 

 

6. PSSE’s vs. Standard Physiotherapy

Physiotherapeutic Scoliosis Specific Exercises, also known as Scoliosis Specific Exercises (SSE’s), differ from standard physiotherapy exercises.  In the 2014 European Journal of Physical Medicine and Rehab, Dr. Josette Bettany–Saltikov et al[39] listed the key features of PSSE as: 

  1. Individually adapted to a patient’s curve site, magnitude and characteristics
  2. Performed with the therapeutic aim of reducing the deformity and preventing its progression
  3. Aim to stabilize the improvements achieved with the ultimate goal of limiting the need for corrective bracing or the necessity of surgery

Additional elements may include:

  1. Auto-correction,
  2. Spinal elongation,
  3. Isometric exercise contraction,
  4. Individually taught
  5. Inserted into stabilizing exercises
  6. Rotational breathing

A review of the difference in the schools of thought are beyond the scope of this article however Dr Bettany-Saltikov’s[40] chapter in the text book Physical Therapy Perspectives in the 21st Century provides a substantial review of the differences and commonalities of the major schools of scoliosis treatment.  Similarly, a recent overview has been published in Scoliosis and Spinal Disorders[41].

In Parent et al’s survey of the highest ranked perceived useful treatment methods by Alberta physiotherapists, the top choices included:

  1. stabilization exercises (76%)
  2. non-scoliosis specific postural approaches (73%)
  3. mobilizations (55%)

No physiotherapist reported the use of PSSE’s in this review.  This likely demonstrates a need to educate Canadian physiotherapists on the most recent evidence supporting the use of PSSE in the management of scoliosis.

7. Additional Resources for Scoliosis

Patients

a. Curvy Girls

International scoliosis peer support group.  Providing support for adolescent girls both online and through meetings.  Looks to destigmatize the diagnosis and the wearing of braces through peer support.

Website address: http://www.curvygirlsscoliosis.com/

b. SOSORT – Society on Scoliosis Orthopaedic and Rehabilitation Treatment

An international multidisciplinary organization including scientists, healthcare professionals, patients and their families

Website address: http://www.sosort.mobi/index.php/en/

c. National Scoliosis Foundation

A patient led advocacy and support foundation.

Website address: http://www.scoliosis.org/

Therapists

a. SOSORT – Society on Scoliosis Orthopaedic and Rehabilitation Treatment

Founded in 2006, and brings together scientists and clinicians focused on the conservative treatment of spinal deformities. A multidisciplinary organization including scientists, healthcare professionals, patients and their families.

Website address: http://www.sosort.mobi/index.php/en/

b. SRS – Scoliosis Research Society

Founded in 1966 its membership includes spine surgeons, researchers, physician assistants, orthotists and welcomes other allied health professionals working with scoliosis.  It provides information for practitioners and families.

Website address: http://www.srs.org

c. Outcome measures

The core outcomes monitored to determine if scoliosis is progressive or if curves are improved by treatment is the Cobb angle obtained from radiographs of the full spine[42].

The degree of vertebral rotation in particular has been shown to be a useful predictor of progression[44]. The sagittal spinal alignment, especially in adults is closely related to pain and quality of life[45].

Depending on the domain of research several different types of outcome measures have been used including pain ratings, Roland Morris Questionaire, Oswestry, Euro-Qol D5.  In addition, the following two questionnaires are common outcome measures more specific to AIS.

  1. SAQ – Spinal Appearance Questionnaire[46]
  2. SRS 22 – Scoliosis-Research Society questionnaire[47]

However, in patients with small curves, these questionnaires originally designed for surgical cases have demonstrated high ceiling effects[48]. Since physiotherapists work with scoliosis is also focused on esthetics, a number of subjective[49] [50]  photographic [51] [52] and 3D sophisticated postural assessments[53] have also been recommended.

Conclusions

The role of physiotherapists in the treatment of scoliosis is evolving.  Increasingly, research is identifying the need for treatment as well as defining role of physiotherapist in the management of this condition.  Screening for early diagnosis, prevention of curve progression, bracing stabilization exercises, pain management are all roles that physiotherapy may assist in however awareness of the critical points, which require the involvement of other members of the team, are important to ensure comprehensive care.

Acceptance of the physiotherapist’s roles in the treatment of this condition requires further dissemination of the existing research within and beyond our profession.  Continued studies are also needed to further consolidate the role of the area of pain management and to further define optimum protocols for prevention of curve progression.

References

[1] Maureen Dwight, R.P.T., Co-founder Spine Therapy Network, Clinical Musculoskeletal Specialist, Adjunct Lecturer University of Toronto Dept. of Physical Therapy, Scoliologic Therapist

[2] Dr Josette Bettany-Saltikov PhD MSc MCSP PGCE-HE Senior lecturer in Research Methods, Chartered physiotherapist and Schroth Therapist, Doctorate of Health and Social Care TEESSIDE University, Institute of Health and Social Care

[3] Eric Parent, P.T., M.Sc., Ph.D., Schroth Therapist, Associate Professor Dept. of Physical Therapy, University of Alberta

[4] Parent EC, Buyks D, Clough J et al, Therapy objectives, treatments modalities and outcomes used by physiotherapists for adolescent idiopathic scoliosis in Alberta, Canada

[5] Cindy L. MartiSteven D. GlassmanPatrick T. KnottLeah Y. Carreon, and Michael T. Hresko, Scoliosis Research Society members attitudes towards physical therapy and physiotherapeutic scoliosis specific exercises for adolescent idiopathic scoliosis, Scoliosis. 2015; 10: 16.

[6] Weinstein SL, Dolan LA, Cheng JCY, Danielsson AJ, Morcuende JA. Adolescent idiopathic scoliosis. Lancet. 2008;371(9623):1527–1537.

[7] Revised Glossary of Terms SRS Terminology Committee and Working Group on Spinal Classification

[8] http://www.orthobullets.com/spine/2076/lenke-classification-of-ais

[9] SRS E-Text: The Primary Resource for Education in the Field of Spine Deformity Care http://etext.srs.org/

[10] See below

[11] http://www.srs.org/professionals/online-education-and-resources/srs-e-text

[12] Horn P, Scoliosis Early Identification of Affected Patients, Clinician Reviews August 2012;Vol 22;8: 16-22

[13] Janicki J. et al, Scoliosis: Review of diagnosis and treatment, Paediatr Child Health Vol 12 No 9 November 2007

[14] Weinstein Sl, Adolescent Idiopathic Scoliosis: Prevalence and Natural history. Instr Course Lect 1988:38:115-126

[15] Lonstein JE, Carlson JM. The Prediction of Curve Progression in Untreated Idiopathic Scoliois During Growth. J Bone Joint Surg Am. 1984:66;1061-1071

[16] http://www.srs.org/professionals/online-education-and-resources/srs-e-text

[17] http://www.srs.org/professionals/online-education-and-resources/srs-e-text

[18] Megan Raverty M, Mehbod A, Garvey T, Transfeldt E, Schwender J, Lonstein J, Winter R, Natural History of Adolescent Idiopathic Scoliosis of 50° or Greater at Maturity: Rate of Progression and Functional Outcomes, The Spine Journal 9(10), Supplement Page p.160S[19]http://www.boneandjointburden.org/docs/The%20Burden%20of%20Musculoskeletal%20Diseases%20in%20the%20United%20States%20%28BMUS%29%202nd%20Edition%20%282011%29.pdfhttp://www.boneandjointburden.org/docs/The%20Burden%20of%20Musculoskeletal%20Diseases%20in%20the%20United%20States%20%28BMUS%29%202nd%20Edition%20%282011%29.pdf

[20] N Engl J Med. 2013 Oct 17;369(16):1512-21. doi: 10.1056/NEJMoa1307337. Epub 2013 Sep 19.

Effects of Bracing in Adolescents With Idiopathic Scoliosis. Weinstein SL1Dolan LAWright JGDobbs MB

[21] Bettany-Saltikov, Weiss HR, Chockalingham N, Taranu S, Srinivas S, Hogg J, Whittaker V, Kalyan RV, Arnell T, Surgical vs. Non-Surgical Interventions for People with Adolescent Idiopathic Scoliosis, a Cochrane Systematic Review, 2015:Issue 4

[22] Cindy L. MartiSteven D. GlassmanPatrick T. KnottLeah Y. Carreon, and Michael T. Hresko, Scoliosis Research Society Members Attitudes Towards Physical Therapy and Physiotherapeutic Scoliosis Specific Exercises for Adolescent Idiopathic Scoliosis, Scoliosis. 2015; 10: 16.

[24] 2011 Sosort Guidelines: Orthopaedic and Rehabilitation Treatment of Idiopathic Scoliosis During Growth.

Negrini S, Aulisa AG, Aulisa L, Circo AB, de Mauroy JC, Durmala J, Grivas TB, Knott P, Kotwicki T, Maruyama T, Minozzi S, O’Brien JP, Papadopoulos D, Rigo M, Rivard CH, Romano M, Wynne JH, Villagrasa M, Weiss HR, Zaina F.

Scoliosis. 2012 Jan 20;7(1):3. doi: 10.1186/1748-7161-7-3.

[25] Romano M, et al, Exercises for Adolescent Idiopathic Scoliosis: A Cochrane Systematic Review, Spine 2013 Jun 15;38(14):E883-93.

[26] Negrini, S The Effectiveness of Combined Bracing and Exercise in Adolescent Idiopathic Scoliosis Based On SRS And SOSORT Criteria: A Prospective Study,. BMC Musculoskeletal Disorders 2014, 15:263

[27] Monticone M, Ambrosini E, Cazzaniga D, Rocca B, Ferrante S (2014) Active Self-Correction and Task-Oriented Exercises Reduce Spinal Deformity and Improve Quality Of Life In Subjects With Mild Adolescent Idiopathic Scoliosis. Results of a Randomised Controlled Trial. Eur Spine J 23(6):1204–1214

[28] Kuru T1Yeldan ?2Dereli EE3Özdinçler AR2Dikici F4Çolak ?, The Efficacy of Three-Dimensional Schroth Exercises in Adolescent Idiopathic Scoliosis: A Randomised Controlled Clinical Trial. 5Clin Rehabil. 2016 Feb;30(2):181-90.

[29] clinicaltrial.gov NCT01610908, NCT02807545

[30] SRS – Scoliosis Research Society, POSNA – Paediatic Orthopaedic Society North America, AAOS –American Academy of Orthopaedic Surgeons, AA_- American Academy of Paediatics

[31] Weinstein SL, Dolan La, Spratt KF, Peterson KK, Spoonamore MJ, Ponsetti IV, Health and Function of Patients with Untreated Idiopathic Scoliosis: A 50 Year Natural History Study, JAMA 2003:Vol 289:555

[32] Monticone M, Ambrosini E, Cazzaniga D, Rocca B, Ferrante S (2014) Active Self-correction and Task-oriented Exercises Reduce Spinal Deformity and Improve Quality of Life in Subjects with Mild Adolescent Idiopathic Scoliosis. Results of a Randomised Controlled Trial. Eur Spine J 23(6):1204–1214

[33] The Effect Of Schroth Exercises Added to the Standard of Care on the Quality of Life and Muscle Endurance in Adolescents With Idiopathic Scoliosis – An Assessor and Statistician Blinded Randomized Controlled Trial: “SOSORT 2015 Award Winner”.

Schreiber S, Parent EC, Moez EK, Hedden DM, Hill D, Moreau MJ, Lou E, Watkins EM, Southon SC. Scoliosis. 2015 Sep 18;10:24.

[34] Spinal Stabilization Exercise Effectiveness for Low Back Pain in Adolescent Idiopathic Scoliosis: A Randomized Trial.

Zapata KA1Wang-Price SSSucato DJThompson MTrudelle-Jackson ELovelace-Chandler V.

[35] https://www.srs.org/about-srs/news-and-announcements/position-statement—screening-for-the-early-detection-for-idiopathic-scoliosis-in-adolescents

[36] http://www.tsrhc.org/scoliosis-screening

[37] http://www.srs.org/about-srs/quality-and-safety/position-statements/screening-for-the-early-detection-for-idiopathic-scoliosis-in-adolescents

[38] http://www.srs.org/about-srs/quality-and-safety/position-statements/screening-for-the-early-detection-for-idiopathic-scoliosis-in-adolescent

[39] Bettany-Saltikov J, Parent EC, Romano M, Villagrassa M, Negrini S,  Physiotherapeutic Scoliosis-Specific exercises for Adolescents with Idiopathic Scoliosis, Eur J Phys Med Rehab 2014;50, 111-121

[40] Bettany-Saltikov J, et al, Physical Therapy For Adolescents With Idiopathic Scoliosis, Physical Therapy Perspectives In The 21st Century – Challenges And Possibilities, 2012.

[41] Hagit Berdishevsky H, Lebel VA, Bettany-Saltikov J, Rigo M, Lebel A, Hennes A, Romano M, Bia?ek M,  M’hango A, Betts T, de Mauroy JC, Jacek Durmala J, Physiotherapy Scoliosis-Specific Exercises – A Comprehensive Review of Seven Major Schools

Scoliosis and Spinal Disorders201611:20, August 2016

[42]http://www.srs.org/professionals/online-education-and-resources/srs-e-text

[43] http://www.oref.org/docs/default-source/default-document-library/sdsg-radiographic-measuremnt-manual.pdf?sfvrsn=2

[44] Nault ML1, Mac-Thiong JMRoy-Beaudry MTurgeon IDeguise JLabelle HParent S. Three-Dimensional Spinal Morphology Can Differentiate Between Progressive and Nonprogressive Patients With Adolescent Idiopathic Scoliosis at the Initial Presentation: A Prospective Study. Spine (Phila Pa 1976). 2014 May 1;39(10):E601-6

[45] Terran J1, Schwab FShaffrey CISmith JSDevos PAmes CPFu KMBurton DHostin RKlineberg EGupta MDeviren VMundis GHart RBess S,Lafage VThe SRS-Schwab Adult Spinal Deformity Classification: Assessment and Clinical Correlations Based on A Prospective Operative and Nonoperative Cohort.; International Spine Study Group.

[46] Carreon, Leah Y, Spinal Appearance Questionnaire: Factor Analysis, Scoring, Reliability, and Validity Testing Spine:

15 August 2011 – Volume 36 – Issue 18 – p E1240–E1244

[47] M.A. Asher, et al , Discrimination Validity Of The Scoliosis Research Society – 22 Patient Questionnaire: Relationship To Idiopathic Scoliosis Curve Pattern And Curve Size Orthopaedic Proceedings, March 2003

[48] Parent EC, Dang R, Hill D, Mahood J, Moreau M, Raso J, Lou E: Score distribution of the scoliosis research society-22 questionnaire in subgroups of patients of all ages with idiopathic scoliosis. Spine (Phila Pa 1976). 2010 Mar 1;35(5):568-77.

[49] . Zaina F, Negrini S, Atanasio S. TRACE (Trunk Aesthetic Clinical Evaluation), A Routine Clinical Tool to Evaluate Aesthetics In Scoliosis Patients: Development From the Aesthetic Index (Ai) And Repeatability. Scoliosis. 2009;4:3.

[50] Kotwicki T. Evaluation of Scoliosis Today: Examination, X-Rays and Beyond. Disabil Rehabil. 2008;30(10):742–51.

[51] Fortin C, Feldman DE, Cheriet F, Labelle H., Clinical Methods For Quantifying Body Segment Posture: A Literature Review. Disabil Rehabil. 2011;33(5):367-83.

[52] Fortin C, Feldman DE, Cheriet F, Gravel D, Gauthier F, Labelle H. Reliability of a Quantitative Clinical Posture Assessment Tool Among Persons With Idiopathic Scoliosis. Physiotherapy. 2012 Mar;98(1):64-75.

[53]Patias P, Grivas TB, Kaspiris A, Aggouris C, Drakoutos E., A Review of the Trunk Surface Metrics Used as Scoliosis and Other Deformities Evaluation Indices. Scoliosis. 2010 Jun 29;5:12

Scoliosis

Scoliosis back_5scoliosis

Scoliosis is a condition where the spine curves sideways rather than the more standard front to back curvatures. This change to the shape of the spine may be caused by genetics, underlying conditions or as we age – degeneration.

Adolescent idiopathic scoliosis is the most common type and is detected around puberty. Although this condition is often painless it is important to have it evaluated as untreated curve that may continue to progress.

You may not notice the changes in the spine at first. Scoliosis is often first noticed by a change in the angle of the waist or the observation of a higher shoulder. A physician or a physiotherapist with training in scoliosis can assess whether these changes are caused by the spine and are sufficient to warrant an X-ray. In adolescents early detection is best as there are more options for treatment if they are still growing.

Treatment is determined by the degree of curvature and the maturity of the bone. Options range from exercise, to bracing, or surgery.

Your therapist at The Orthopaedic Therapy Clinic will help you to understand the treatment options as well as provide exercises to improve your core and correct underlying muscle imbalances. We are experienced in the treatment of adult and adolescent, operative and non-operative scoliosis conditions. We work with you through all stages of treatment to ensure the best recovery and long-term plan for managing this condition.

Scoliosis-Teenage angst (book review)

Recommended reading for adolescents with Scoliosis

‘Deenie’, by Judy BlumeI have had a few young clients recommend a book titled ‘Deenie’, by Judy Blume, as being helpful in coping with their scoliosis. Deenie is a thirteen year old girl in high school, experiencing the physical and emotional changes of adolescence, while finding out she has scoliosis – a condition that causes the spine to curve abnormally as she grows. She feels frustrated that her clothes never fit her properly, insecure about people knowing she has scoliosis, or people seeing her brace. She worries constantly about what her cheerleading team will think of the brace, and will they think she is a freak or will they be supportive.  Read more…

We Are Hiring !

Experienced Orthopaedic Physiotherapist Required

The Orthopaedic Therapy Clinic Inc. is looking for an experienced Orthopaedic Physiotherapist for a Full Time or Part Time position. FCAMPT certified, pelvic floor qualifications and/or acupuncture certification is preferred.

You will be joining a physiotherapist-owned, multidisciplinary clinic. Our team includes highly qualified physiotherapists, massage therapists, chiropractor, kinesiologist and a yoga/pilates instructor. Our physiotherapy team includes: clinical musculoskeletal specialist, Scoliosis, FCAMPT and pelvic floor certifications.   Our clients are highly motivated with a wide variety of musculoskeletal injuries.

You must be Registered in the Province of Ontario enjoy a team approach to helping patients get well, show continuing education and a desire for learning,

This is the right position for you if you are looking to contribute to a strong team, enjoy collaborating and are looking to be challenged to grow. Send us your resume and show us what you’ve got, (references included please).

While you’re at it, look at our web site at www.orthophysio.com to get an understanding of why our practice has thrived for over 30 years. We are located at 1075 Bay Street in the heart of downtown Toronto.

Forward your resume to Maureen Dwight, Clinic Director at mdwight@orthophysio.com

We are Hiring!

Experienced Orthopaedic Physiotherapist Required

 

The Orthopaedic Therapy Clinic Inc. is looking for an experienced Orthopaedic Physiotherapist for a Full Time or Part Time position. FCAMPT certified, pelvic floor qualifications and/or acupuncture certification is preferred.

You will be joining a physiotherapist-owned, multidisciplinary clinic. Our team includes highly qualified physiotherapists, massage therapists, chiropractor, kinesiologist and a yoga/pilates instructor. Our physiotherapy team includes: clinical musculoskeletal specialist, Scoliosis, FCAMPT and pelvic floor certifications.   Our clients are highly motivated with a wide variety of musculoskeletal injuries.

You must be Registered in the Province of Ontario enjoy a team approach to helping patients get well, show continuing education and a desire for learning,

This is the right position for you if you are looking to contribute to a strong team, enjoy collaborating and are looking to be challenged to grow. Send us your resume and show us what you’ve got, (references included please).

While you’re at it, look at our web site at www.orthophysio.com to get an understanding of why our practice has thrived for over 30 years. We are located at 1075 Bay Street in the heart of downtown Toronto.

Forward your resume to Maureen Dwight, Clinic Director at mdwight@orthophysio.com

 

5 Signs that your Low Back will Attack

If you are reading this blog, you have probably experienced a low back-pain ATTACK and never want to experience another one.  Or you may have be lucky to have never experienced your first Attack but want to remain pain free.  No matter your goal, it is critical to recognize the warnings.  Many low back pain Attacks can be minimized or even completed avoided when  we recognize the warning signs, know what they mean and learn how to deal with them. here are the 5 signs of a low back pain attack:

5 Signs of a Low Back  Pain Attack

  1. Back pain when you cough or sneeze
  2. Back pain or stiffness when you get out of a chair
  3. Back pain or stiffness when you sit for less than 30 minutes
  4. Back stiffness in the morning when you haven’t worked out the day before
  5. A desperate need to sit down when you have been standing for less than 30 minute

1. Why does my back hurt when I cough or sneeze

This symptom is highly correlated with a bulging disc or extreme muscle tension in your hips or back.  No matter which one you have – heed the warning.  It is not normal for the back to hurt when you cough or sneeze.

What do I do about it? 

  • Sit less.  Too much sitting puts a strain on your disc and can cause excess back and hip muscle tension.
  • Walk more.  If you haven’t walked much recently then begin with shorter durations several times each day  to allow your body to adjust to the increased activity
    • John Gray’s,  (Reg. Kinesiologist), articles can help you find a balance on increasing activity safely.
  • Limit bending forward and don’t lift heavy loads.  These activities put more strain on the already strained structures. Wait until you feel better to start these movements again. 

2. Why does my back hurt when I get out of a chair?

Back pain getting out of a chair can be one of the earliest warnings of an impending low back pain attack.  This pain can be caused by a strain on your disc, tight hip flexors (psoas) or insufficient use of your buttock muscles (gluteus maximus).

What do I do about it? 

  • Walk more.  This is often the simplest and most effective strategy.
  • Stretch  your hip flexors.  The typical kneeling stretch with one foot forward in a lunge position is good. If you can’t get down to the floor or if you have had a total hip replacement you can put your front foot up on a chair and hold the chair’s arms as you stretch forward.
  • Put less tension in these muscles.  Most people don’t realize how tight their hips get with crossing their legs or sitting with their feet “en pointe” like a ballerina.   Make an effort to sit with both feet entirely flat on the floor.
  • Avoid perching.  Those low back bar stools may look good in your new kitchen design but too much perching can be disastrous for tight hip flexors.  A wider foot support is best, as is a higher back support.  If you really love a minimalist design, then admire them like a piece of art from the comfort of your more supportive dining room chair.
  • Use your buttock muscles.  Many people rely too much on their hip and thigh muscles to get out of a chair.  This means these muscles are working harder than they need to.  Using your buttock muscles reduces pain and minimizes how hard these muscles need to work.

3. Why do I get back pain when I sit too long?

The easy answer is that sitting is the new cancer, however it’s not that simple.  Sitting affects our circulation and metabolism.   There is no doubt that these effects have profound impact on our health however there is nothing wrong with sitting, we just sit too much.

When our back is healthy, we should be able to sit comfortably  for 1.5 – 2 hours.  A short break (10-15 minutes) and our back should be ready to repeat this all over again.  If you decide to sit through 2 movies or pull an all-nighter, studying without breaks, then expect your back to hurt as this is just too long to go without a good break.

When you can sit for less than 30 minutes, in a good chair, the pain is most often caused by:

  • strain on the disc
  • poor core support
  • tight hip and back muscles

What do I do about it? 

  • Walk.  Increasing  your walking can go a long way to correcting this problem.
  • Stretch:  Focus on your  hip flexors and quads
  • Strengthen your core.  Dead bugs, bridges and planks can all be useful.

4. Why is my back stiff in the morning?

20-year-olds tell me that they hurt in the morning because they are getting old while many 80-year olds have no morning stiffness. Unless you have radically increased your workout or suddenly decided to accomplish everything on your “Honey Do” list, don’t mistake a sudden onset of morning stiffness as age.

The two most common causes of morning stiffness are:

  1. Increased disc fluid – Discs drink at night.  When we lie down a negative pressure is created in the disc.  This attracts fluid and results in you being slightly taller in the morning.  It is also one of the reason astronauts have back pain while in space.  Astronauts counteract this problem by walking on treadmills using weights to simulate the effects of gravity.

      2. Inflammation in the back joints (facets) – When you irritate the back joints it’s almost  the same as spraining your ankle.  Both injuries cause swelling which results in the joints becoming stiff.  It’s harder to get going in the morning when you haven’t moved for several hours.  You may also feel worse at the end of the day as poor posture and insufficient muscle support puts more stress on the facet joints.

What do I do about it? 

  • Walk more.  When the problem is the excess fluid in the disc, like the astronauts, you need to walk.  Fortunately you don’t need to carry the extra weights they do.
  • Don’t lie down for long periods.  The more you lie down the more fluid there is in your disc.  When this is your problem, a walk before bed can help you to sleep longer, more comfortably.
  • Correct your posture.  Joint inflammation typically can’t be walked out.  Instead you need to focus on correcting your posture, lengthening tight leg muscles and restoring core support.

    5.  Why does my back hurt when I stand?

    Many people are not even aware they are limited in standing because they seldom challenge it.  Chairs are everywhere.  Take a moment to time yourself as you should be able to stand for at least 30 minutes.

    Some of the signs that you may be limited in standing are when you avoid or limit these activities:

    • cocktail parties
    • shopping
    • museums

    The most likely causes of standing back pain are poor posture (sway-back), tight muscles or poor core support.

    What do I do about it? 

    • Correct your posture. Reduce the sway in your back.
    • Stretch tight muscles.  Stretch your quads and hip flexors.
    • Activate your hip muscles.  The hip abductor muscles (gluteus medius and minimus) are your most important muscles for standing and balance.

    When should I see my spine therapist?

    Your spine therapist can be a resource to guide you through these symptoms and your recovery however it is more important to seek advice if:

    • Walking does not relieve the pain
    • You are ready to get back to fitness and feel at risk
    • You don’t know how to activate your core support muscles
    • Your low back pain increases when you try to get more active.

    If you need more advice call us to book an appointment at 416-925-4687 or email us at physio@orthophysio.com.  If you are still in the attack stage this article will help you to get to the next stage of Recovery – which is the subject of my next blog.

    Winning the War on Low Back Pain – Recovery or Recurrence?

    One of the biggest problems I see when you are recovering from low back pain is that you are tricked into thinking you are completely  better when the truth is that you still have a long way to go.  After weeks of intense, unrelenting pain you wake up one morning and there’s nothing.  No pain.  No stiffness.  It’s gone!  You are thankful for the lack of pain and vow to take your life back.  You immediately start doing everything you used to do.  You go to the gym, book a Yoga class, take up running, find core strength video’s on YouTube, etc.  only to begin to hurt again.

    Click here for the Video Winning the war on low back pain – Recovery or Recurrence

    Relief changes to despondency.  Not realizing that the problem is your lack of a rehab plan you start to worry that whatever is wrong with your back is serious and for life.  You go into an emotional tailspin – reinforcing your return to being a  Prisoner of the Pain.

    Avoiding mistakes in recovering from low back pain

    The most common mistake I see in the Recovery stage of winning the WAR on low back pain is trying to do too much too quickly. This happens because we equate the absence of pain to full recovery.  The reality is that pain often abates when strength is around 40% of normal.

    Whenever pain lasts for more than a few weeks most people are weaker than they realize.  If you have had a pinched nerve the weakness is compounded by loss in the strength in muscles supplied by the nerve. This weakness can be quite profound, causing;

    Even when the pressure comes off the nerve the muscle may not immediately regain strength.

    These are often the reasons your recovery fails.  Unless you understand these imbalances and look to correct the impact they are having on your body, your recovery can be very hit or miss.

    3 Stages of Low Back Pain Recovery

    The changes caused by low back pain and nerve pressure mean you need to make good decisions in your recovery from low back pain.  Your decisions need to build logically on each other until you return to your full and active lifestyle with a step-by-step plan.  These decisions start with the knowledge that recovery has 3 stages.

    1. Resolution
    2. Robust
    3. Resilience

    Most people go through each stage sequentially however the stages typically overlap.  Each stage requires a change in therapy and should become progressively more demanding as you regain your strength, stamina, flexibility and coordination.

    Recovery Stage 1 – Resolution

    The hallmark of this stage in your recovery is that the pain is intermittent. Typically, the pain is provoked by certain activities and feels better when you do other things.

    You may have trouble identifying the links between what makes the pain better or worse.  At this stage what is most likely happening is that your back is exhibiting what is called a “directional preference”. This technical jargon simply means that your back prefers certain positions and is made worse by other movements.

    Most commonly the back has one of two preferences – it either likes to flex (bend forward) or extend (bend backward).   The therapy goal of this stage is to control pain  through movement. This is often when you can reduce or eliminate medication.  Your exercises will make you stronger and more flexible but most importantly they should make you feel better or at least not worse.

    Flexion (bend forward) preference:

    Flexion preference typically achieves pain relief with sitting and is made worse by walking.  The most likely structures at fault are the facet joints or spinal stenosis.  If this is your pattern, exercises such as knees to chest, Figure 4 stretch and stationary bike are the places to start.

    It is  important to avoid/limit the direction you back doesn’t like.  In this case we term it an extension intolerance.  This means you should limit activities that put your back into an arch such as standing for too long, Yoga cobra poses or deciding this is the exact moment you need to paint your ceiling.

    Extension (bend backward) preference:

    Extension preference is often associated with pain relief from walking.  It is typically made worse by sitting. The most likely structures at fault are the discs or tight hip muscles (psoas, quads). Exercises such as Yoga cobras, sloppy push-ups, bridging and lots of walking can substantially reduce your pain.

    In this early recovery stage you should avoid activities that put your back into flexion such as toe touches, hamstring stretching or deciding that you finally have to beat your high school sit-up record.

    Recovery Stage 2 – Robust

    The marker that you are entering the next stage in recovery is that you have minimal pain with basic activities such as sitting, walking, standing etc. It is still relatively easy to aggravate your back with heavier or sustained activities.

    At this stage it may feel OK to bend forward to pick up a muffin or a Kleenex box but you still hurt if you go to the gym or lift the laundry basket.  You know you’ve overdone it when you pick up a case of beer for the long weekend and feel an immediate urge to crack open a bottle to relieve your back muscle tension.  In other words the intensity of the activity is the limiter, not the direction of the movement.

    Often at this stage your pain gets worse as the day goes on. The more tired you are, the more you hurt.

    These symptoms indicate that the intensity of the activity and fatigue are the irritating factors.  This tells us that it’s time to make a plan to resume cardio, strengthen your core and restore your flexibility.

    At the start of the robust stage you may be still be exhibiting a directional preference.  You can still exercise however the strengthening and flexibility must respect the preference i.e. strengthen in extension.  As you progress you should be able to restore some  degree of the opposite direction of movement.

    Recovery Stage 3 – Resilience

    Resilience is about our ability to recover from our mistakes.  We all do it.  The weather improves and we decide to go for a two hour walk when the longest walk we have done in the last 6 months is 20 minutes. We decide to clean up our garage or return to gardening when the heaviest thing we have lifted in the last month is our coffee cup.

    The problem with these decisions is that you have increased your physical demands too quickly.  However pat yourself on the back if you only experience mild discomfort or stiffness and recover from your low back pain within a day or two.  Mild symptoms and a quick recovery are indicators that you have restored some degree of resilience.

    To fully  restore resilience your recovery plan needs to uncover and correct compensatory patterns.  We need to identify those pockets of profound weakness that the pinched nerve left behind and bring these muscles back to normal strength and coordination.  The failure to restore normal movements and efficient, coordinated movement patterns is what I find is the most predictive of recurrence and of your recovery not resolving within the expected 3 months.

    How do you know you need to restore resilience?

    1. Exercise dependency. Your back exercises really help but whenever you stop them the pain returns.
    2. Inability to return to exercise, sports or household chores without provoking pain.
    3. Constant, low grade pain. The intense pain has lessened but now the pain never leaves.
    4. Your pain is still intense after 3 months

    To get to the truly resilient stage you may need to find a spine therapist who understands how to find and correct the weaknesses and compensatory patterns left behind by your injury.  If you have pinched a nerve and the symptoms have lasted for longer than 3 months I can almost guarantee that these imbalances will be there. You and your therapist need to determine what is missing in your recovery and specifically address these imbalances.

    Over the next few blogs I will explore each one of these stages more thoroughly and help you to find your own direction of recovery and to assist you in creating a dialogue with your spine therapist to partner in winning the WAR on low back pain.  Please contact us at 416-925-2687 or physio@orthophysio.com if you need assistance in putting your Recovery plan into place.

     

    Winning the WAR on Low Back Pain – Managing the attack

    One day it starts.  Your back hurts even though you did nothing to injure it.  The pain is intense.  You feel sharp pain shooting down your leg.  You bend forward and your muscles spasm.  It’s almost impossible to straighten up.   When you feel like this you have probably missed the warning signals and have entered the Attack stage in the WAR on low back pain. Watch the you tube video here:  https://www.youtube.com/watch?v=z75EFc9unHk

    man with low back pain

    Signs of the Attack 

    In may last blog I reviewed the stages of low back pain and gave you a guideline for recovery. Each stage has it’s own strategies and it’s important to know whether you are in the Warning, Attack or Recovery Stage (WAR).

    Although it may seem obvious, the symptoms of  the Attack stage can be confused with the initial stages of Recovery.  The key characteristics that tell you that you are in a full-blown Attack are:

    • Unrelenting pain. The pain may wax and wane but you are never pain free.
    • Short term relief with changing positions however the improvement doesn’t last.
    • Symptoms present less than 3 months.

    How long will the pain last?

    When you are in the Attack stage you need to be prepared that your symptoms are not going to disappear overnight.  They may last for a few weeks or even a few months.  Fortunately, the odds are in your favour as you have a 95% chance that within 3 months your pain will be better.

    Three months can feel like forever. I understand that no one wants to hear that they may be in pain for this long, but believe me it is comforting to know that, when the pain doesn’t immediately abate, time is truly a healer.

    You can also expect your pain to progressively lessen and become more intermittent over this period.  However if you want to avoid this hiatus of life – next time pay attention to the warnings!  Right now the most important thing you can do is avoid becoming a prisoner of the pain.

    Prisoner of pain

    This stage is caused by your emotions.  When the pain is intense you worry that something serious is wrong or whether this will be how you will feel for the rest of your life.

    The problem with these emotions is that it’s hard to heal when you are worried and it’s even harder to be logical when making decisions to manage the pain.  This can make the pain last even longer. Your job at this stage is to stay relaxed – despite the pain.

    The key to avoiding becoming a prisoner is to know that most causes of low back pain are not serious and that the pain will end.  Education, medication and relaxation strategies such as breathing can all help. It is important to keep reminding yourself that you will get better with time.

    Although it may take the full 90 days, many people will be much better within 2-3 weeks.  I often recommend you mark the days on a calendar as you can expect parole no later than 3 months, and it may be sooner for “good behavior”.

    What have I hurt?

    We all want to understand what is causing our pain. When we Google low back pain  it seems a diagnosis is critical to know how to get better.

    This perspective can be problematic, as at the beginning of the Attack stage it can be difficult to determine exactly which structure is hurt.  The difficulty in getting an exact diagnosis can be unsettling.  You may interpret this as meaning you have something unusual or unknown, when the real reason we can’t tell you what you’ve injured is that the cause of the pain is somewhat generic.  Irrespective of whether you have herniated a disc, sprained a facet or pulled a back muscle, most back pain initially has the same cause.

    Almost every injury starts with a stage that is variously referred to as nociceptive (pain), chemical or inflammatory.  These terms reflect that the pain you are experiencing is caused by the release of chemicals[1]. These chemicals irritate the surrounding tissues however they are not all bad as they also help you heal.  The most important thing to know is that as long as they are present you will be in pain.  Your rehab plan should include strategies to avoid prolonging this stage by limiting activities that provoke the tissues to release more chemicals.

    Do I move or do I rest?

    The pain makes you want to rest however the internet tells you to move.  Both are wrong!

    Second only to whether to use ice or heat, the decision to move or rest can be one of the most confusing decisions in back pain recovery.  When we look online, our research tells us that core is essential to recovery however during the Attack-stage strengthening your core will not cure the pain. Too much movement or exercise can cause more irritation and prolong our recovery.

    However don’t think this means you should take to your bed.  You need to move but you should also avoid substantial increases in pain from being too active before you’re ready. Movement is the key to flushing the chemicals out of your body by enhancing your circulation.

    Determining the right level of activity

    Start with gentle everyday movements like walking or light activities around the house i.e. dishes. As you transition out of this stage, exercise will become more valuable. Leave going to the gym until the basic movements are feeling better.

    As you get moving it is normal to feel a mild increase in pain however the increase should not be intense nor last for longer than 30 minutes.  I find this guideline helps to determine whether you are doing too much or too little.

    What about medication?

    Medication can be helpful during the Attack stage.  It can make  the pain more manageable.  This allows you to move more easily and worry less.

    Take what you need, but don’t make the mistake of thinking that intense pain needs intense medication.  Sometimes surprisingly low doses of over-the-counter medication can manage your pain.

    See your family physician and discuss whether pain medication is right for you. Recognize that most medication for low back pain does not cure the problem.  The main purpose is to allow you to move more comfortably and to get more sleep.

    What about Therapy?

    In the Attack stage the primary focus is pain control and staying active as tolerated.  Gentle hands-on treatments and pain-relieving modalities (ice, heat, acupuncture, laser etc.) can help you to get through this stage.

    If treatment doesn’t immediately relieve the pain, don’t despair.  Have your therapist help you to develop a treatment plan.  Discuss which home-based strategies are right for you i.e. heat, ice, etc.   Plan to come back for a review in a few weeks as the most value in winning the war of low back pain is to see your therapist for their guidance during the Resolution stage.

    If you need more advice on managing your low back pain or preventing another WAR, contact us to book an appointment at  physio@orthophysio.com or 416-925-4687.

    [1] One of these chemicals has the self-evident name of pain substance.  Many of the other chemicals are related to inflammation.

    Winning the WAR on Low Back Pain

    One morning you wake up, get out of bed and find it difficult to straighten up.  Your back is stiff.  It’s hard to bend forward to put on your shoes.  You sit down and find that your leg suddenly won’t bend enough to reach your foot.  You take a hot shower and within an hour you begin to feel better and go to work.  You forget about it until the next day the same thing happens.   Whether you are 25 or 65 you may decide that this is just a sign of age when what it is telling me is that you are going to W.A.R. with your body.  These are the early signs of low back pain and unless you recognize them you may go onto a full back pain attack.

    Stages of Low Back Pain

    View Video, WAR on low back pain https://youtu.be/7E0Tc0i-ZxQ

    W.A.R. is the acronym I chose to represent the struggle of the mind and body that is an integral part of this injury and because it is a helpful for understanding the 3 stages of recovery. Like with any war, there are stages of engagement.  Each stage has different characteristics and strategies.  Ultimately, winning this WAR will be determined by identifying which stage you are in and applying the treatments that work for that stage.

    3 Stages of Low back pain:

    1. W- Warning
    2. A – Attack
    3. R – Resolution

    Choosing your treatment

    The most common mistake I see made in the recovery or prevention of low back pain is when the wrong treatment is selected for your stage of recovery.  Well-meaning friends, therapists or Dr. Google tells you about some amazing recovery from a certain type of treatment.  Maybe it’s exercise, manipulation or strong stretching techniques like ART.  Testimonials will encourage you to try it, but what is often unclear is whether it’s right for you.

    While there is no doubt that each of these treatments can help reduce low back pain, if you want to win this WAR it’s critical to match the right treatment to where you are in your healing.  The wrong treatment at each stage can have a profound effect on both your speed and resilience of recovery.  The first step is to determine your stage of back pain recovery before you choose your treatment.

    Stage 1 – Warning

    Back pain often starts with subtle warnings. These warnings may go unrecognized or are ignored until suddenly you under Attack.  The result of missing these cues can be a full-blown episode of back pain which puts your entire life on hold for weeks or even months. To win this WAR your first goal should be to avoid the full-blown Attack.  This is best done by recognizing the Warnings and immediately making lifestyle changes.

    Warning Symptoms:

    Some of the most common symptoms of an impending back attack are:

    • Back stiffness in the morning
    • Back stiffness at the end of the day or after exercise
    • Back discomfort rising out of a chair
    • Back discomfort when standing. [1]
    • Muscle tightness in your hamstrings or calves when you haven’t worked-out

    When you feel any of these symptoms, recognize that they are warning you that your back pain may escalate and seek some help in managing this stage.  Most people don’t need much treatment at this stage and prevention can be quite simple.  The focus of therapy should be to identify your risk factors and to understand which modifications can make a difference.

    Correcting factors such as a sedentary lifestyle, tight muscles, poor core, etc. can go a long way to avoiding the Attack.  For many people preventing WAR can be as simple as reducing the length of time you are sitting and ensuring you are walking enough i.e. >8,000 steps per day. It can also be about ensuring you have a good ergonomic set-up for your computer and that you stop working on your laptop in bed or at the coffee table.

    Attack

    This is the stage that we all want to avoid however it is the one most people get to before they seek treatment.  It’s not surprising that this is what takes you in to your therapist, as the pain can be overwhelmingly intense.

    The intensity of the pain may make this stage seem quite obvious however it is important to determine whether you are really in a full-blown Attack or already in the first stage of Resolution. Some people skip the full Attack stage or progress into the Recovery stage very quickly.  I find that these two stages are often confused and the treatment strategies are very different depending on where you are in your WAR.

    Attack Symptoms:

    The key characteristics of the full-blown Attack are:

    • Unrelenting pain. The pain may wax and wane but you are never pain free.
    • Short term relief may be felt from shifting positions but doesn’t last.

    When you are in a full Attack the primary goal is to end it as quickly as possible.  Managing this stage is best addressed by never going to WAR in the first place, however if you find yourself in the middle of the Attack, the most important elements of treatment are management of the pain and avoidance of becoming mentally incarcerated as a prisoner of pain. This is when you should discuss medications with your physician, pain relieving strategies with your physiotherapist i.e. acupuncture, manual therapy and educate yourself on recovery strategies.

    I find that the most common mistake made is over-exercising  during this stage. Knowing that core exercise is good you choose this moment to start your return to fitness.  Remember you need to move but you should also avoid substantial increases in pain.  My rule is that the pain should not increase for more than 20 minutes after movement or exercises.

    Recovery

    Your final goal is to achieve full resolution. To do this you need a treatment plan which ensures your recovery is robust and resilient.  This is what will allow you to return to all your favourite activities and avoid future WAR’s.

    The most common mistake I see at this stage is a failure to recognize the early signs of recovery. Many of us use pain as our guide, expecting to get active once the pain stops.  However pain doesn’t always shut off like a tap. The early signs of recoverycan be subtle.  There are changes in the quality, location and in what provokes the pain.  These changes tell me when you are ready to enter the final stage in the battle and really participate in therapy.

    Signs of Resolution:

    1. Pain intensity lessening and/or becoming intermittent
    2. Pain localization (less leg or buttock pain)
    3. Pain improving with specific activities/directional preference i.e. walking or sitting
    4. Increasing function with no need to increase your medication

    The second most frequent mistake I see is that we don’t focus enough on ensuring full resolution.  This is the stage when you should really start to exercise.  Restoring your core, re-establishing coordinated movements and strength is critical. You should be able to start weaning off medication and therapy shifts from pain relief to restoration of lifestyle.

    Avoiding Future Wars

    Depending on how well we manage the resolution stage determines whether we will keep going to WAR or whether our life returns to full and pain free.  Many people come out of the Attack stage only to have it replaced with constant low-grade discomfort and stiffness.  When you try to return to full activity or resume sports the Attack returns. You see numerous practitioners and no one can give you a clear answer why you can’t get rid of your pain.  MRI’s, X-rays and other tests all fail to explain your ongoing symptoms.  This reinforces the prisoner of pain.  You begin to worry that something permanent is wrong with your back – which no one can find!

    If you are having repeated episodes of low back pain and all your tests are clear, this tells me that your back is structurally healthy.  If you are in the resolution stage you are ready to engage in therapy.  If there is no structural damage of significance i.e. herniated discs, stenosis, there are also no significant restrictions to recovery.  Even if you have structural changes your recovery can be good, it just takes a more thoughtful approach to planning your program.

    The Recovery phase often requires the guidance of a knowledgeable spine therapist. Someone who understands which factors are challenging your recovery and can guide you into starting your exercise at the right level.  Remember if your pain has lasted longer than 3 months you are now out of shape.  You have also begun to lay down permanent motor memories which impact on your ability to recover.  A solid approach to fitness and restoring coordination are critical at this time.

    Join me in the WAR on low back pain

    I would like you to help win the W.A.R. on back pain.  Over the next series of articles, my goal is to help you become educated about recognizing what your body is telling you. This will help you to find the right therapist to guide you in your recovery.  It will also help you to know when it’s time to make a change in approach.  Winning this W.A.R. is also about helping you, your friends and even your children to avoid your first episode.

    My next few blogs will explore each one of these stages more fully.  I will provide a more in-depth look at the symptoms and which treatments are likely to help. In the interim please contact us for more information or call 416-925-4687 to book an appointment if you need assistance in managing or preventing your own personal W.A.R. on back pain.

     

    [1] This one is harder to recognize as may people mask this symptom by avoiding standing activities such as cocktail parties, museums, shopping or cooking

    Pilates and Yoga now available at The Orthopaedic Therapy Clinic

    Aniela Amio – Pilates and Yoga Instructor, Reiki practitioner is joining our team at the Orthopaedic Therapy Clinic. Aniela brings extensive experience in injury rehabilitation through Yoga and Pilates. She is a certified instructor Pilates, Yoga and Reiki. Her focus is on spinal health and injury recovery as well as pre and post-natal care. https://orthophysio.com/pilates-and-yoga/

    Aniela will be an integral part of the therapeutic team, along with our registered kinesiologist, John Gray, in helping you to advance your recovery to return to fitness while reducing your risk of injury.

    Aniela’s passion is to empower people of all ages and abilities to improve how they to move and help them to take care for their own bodies.  She is interested in and continues to expand her studies with workshops on the mind body connection, chronic pain, scoliosis, fascia, pre and postnatal health and recovery as well as working with the aging population.  Aniela has had the opportunity to work with professional athletes, dancers, chronic pain suffers and those recovering from spinal injuries and surgeries.

    Aniela will be at our clinic on Tuesday’s starting February 19, 2019. Call us  at 416-925-4687 to book an appointment or chat with your therapist to determine when you are ready to benefit from working with her.

    PIlates and Yoga

    Aniela Amio

    Pilates, Yoga & movement teacher, Certified Reiki Practitioner level 2

    Aniela completed her yoga certification at The Yoga Sanctuary in 2011, adding courses in meditation, Yin Yoga and Restorative Yoga shortly after.  She then went on to become certified in Mat Pilates with Body Harmonics in 2013, Reformer Pilates with The Mindful Movement Centre and Leslie Parker. She is currently working towards her Comprehensive Pilates Diploma with Body Harmonics (2019) with a special focus on spinal health and injury recovery, as well as pre and post-natal care.

    Aniela  empowers people of all ages and abilities by teaching them how to move and care for their own bodies.  She hopes her students find joy, safety and strength in their sessions which translates into better quality and functional movement in their daily lives.  She is interested in and continues to expand her studies with workshops on the mind body connection, chronic pain, scoliosis, fascia, pre and postnatal health and recovery as well as working with the aging population. Aniela has had the opportunity to work with professional athletes, dancers, chronic pain suffers and those recovering from spinal injuries and surgeries.

    Aniela  is excited to learn from and work with the team at The Orthopaedic Therapy Clinic to further her education.  She looks forward to being an integral part of her client’s recovery and journey to health and vitality. To arrange an appointment please call 416-925-4687 or email: aamio@orthophysio.com

    When Aniela isn’t teaching or taking courses you can find her in the park with her dog, travelling, or in a plant store deciding which plant baby to add to her home.

    Aniela Amio – Bio

    Pilates, Yoga & movement teacher

    Certified Reiki Practitioner level 2

     

    Aniela completed her yoga certification at The Yoga Sanctuary in 2011, adding courses in meditation, Yin Yoga and Restorative Yoga shortly after.  She then went on to become certified in Mat Pilates with Body Harmonics in 2013, Reformer Pilates with The Mindful Movement Centre and Leslie Parker. She is currently working towards her Comprehensive Pilates Diploma with Body Harmonics (2019) with a special focus on spinal health and injury recovery, as well as pre and post-natal care.

     

    Aniela empowers people of all ages and abilities by teaching them how to move and care for their own bodies.  She hopes her students find joy, safety and strength in their sessions which translates into better quality and functional movement in their daily lives.  She is interested in and continues to expand her studies with workshops on the mind body connection, chronic pain, scoliosis, fascia, pre and postnatal health and recovery as well as working with the aging population.  Aniela has had the opportunity to work with professional athletes, dancers, chronic pain suffers and those recovering from spinal injuries and surgeries.

     

    Aniela is excited to learn from and work with the team at The Orthopaedic Therapy Clinic to further her education.  She looks forward to being an integral part of her client’s recovery and journey to health and vitality. To book an appointment please call 416-925-4687.

     

    When Aniela isn’t teaching or taking courses you can find her in the park with her dog, travelling, or in a plant store deciding which plant baby to add to her home.

    Post-surgical spinal care1A

     

    Post-surgical spinal care

    Physiotherapy has been shown to help reduce pain and improve your function after spinal surgery. We provide an individualized program of core exercise, general conditioning, posture correction, stretching and therapeutic modalities, once your initial healing is completed.

    Who will benefit?

    Our program is designed for anyone who is still experiencing back or leg pain after surgery. We have experience in neck, thoracic, lumbar and scoliosis surgeries. Contact us if you have had a spinal fusion, discotomy, decompression or kyphoplasty and are still experiencing symptoms or who would like guidance on safe and effective return to activity.  

    When should I start therapy?

    Therapy can begin as soon as your surgeon indicates that you can return to full activity.  We recommend most people wait a minimum of 6-12 weeks post-operatively to begin treatment if you have a fusion.  Therapy can begin sooner after a decompression or discotomy providing your surgeon does not have any concerns with you starting a gentle and individualized exercise program.

    Service provided by:

    Maureen Dwight RPT, Clinical Musculoskeletal Specialist, Advanced Practitioner ISAEC

    Gareth Sneath RPT

    Milad Bazaz Jazayeri RPT

    Svetlana Marianer RPT.

    More information: https://orthophysio.com/?s=spine+surgery

    To Book an appointment call 416 926 4687 or email physio@orthophysio.com

    Juliette Woodruff – Bio

    Juliette WoodruffJuliette Woodruff

    Registered Massage Therapist and Acupuncture Practitioner

    jwoodruff@orthophysio.com

    Juliette joined The Orthopaedic Therapy Clinic Team in 2004. She is a graduate of the Sutherland-Chan College of Massage Therapy. After graduating her ongoing commitment to professional development has led her to complete advanced studies in manual lymph drainage and she is currently pursuing certification in breast cancer treatment and myofascial release therapy. In 2012 she received her certification in acupuncture from McMaster University. Juliette is committed to collaboration.

    Juliette is an integral member of our treatment team working to find solutions to pain and helping to relieve the barriers limiting recovery. She has worked with a diverse range of people including athletes, expectant mothers, and business professionals. She is particularly interested in treating conditions such as scoliosis, lymphedema, and frozen shoulder. She believes in helping her clients to become an active participant in their own healing process through body awareness, postural education, and self-care exercises.

    Juliette has a personal as well as clinical experience with the different stages of cancer. She works towards creating improved quality of life for her clients through education, exercise, self-bandaging, acupuncture and manual lymph drainage techniques. She believes in implementing a variety of modalities and current knowledge to improve and personalize care.

    Juliette has a specific interest in the relief of pain and restoration of mobility in scoliosis. She has worked with clients following extensive reconstruction surgery as well as non-operative conditions. She has studied with Dr. Rudolph Weiss of Germany (Katerina Schroth’s grandson) and received a certification in his Scoliologic method. She has a developed an approach to the application of massage therapy in scoliosis which has been recently published by her professional alumni newsletter. SutherlandChan_FingerPrint

    Juliette implements knowledge and clinical techniques from a variety of post-graduate courses such as: treatment techniques for post-operative breast cancer, cervical joint mobilizations, Structural Integration for structural alignment (Nisa), Scoliologic method, myofascial techniques, and acupuncture. She utilizes and incorporates several different treatment approaches to develop an individualized approach for each client.

    Association Memberships

    Juliette is registered with the College of Massage therapist of Ontario. She is a member of the Canadian Massage Therapy Association and the Canadian Academy of Medical Acupuncture. Her interest in sports and movement led her to obtaining a level II theory/practice National Coaching Certification in swimming.

    Maureen Dwight – Bio

    MaureenDwightMaureen Dwight PT, B.Sc. PT

    Registered Physiotherapist, Clinical Musculoskeletal Specialist, Advanced Spine Practitioner ISAEC, Clinic Director

    mdwight@orthophysio.com

    Maureen founded The Orthopaedic Therapy Clinic Inc. in 1987. She is committed to excellence in her practice and to the advancement of the physiotherapy profession. She was one of the first physiotherapists in Ontario to receive a nationally recognized specialist designation as a Clinical Musculoskeletal Specialist.

    After graduating from the University of Alberta physiotherapy program with distinction in 1980 she has gone on to study with world recognized experts in the fields of physiotherapy and medicine. These studies have gone beyond the borders of Canada and taken her to the U.S., England, Australia and the Czech Republic. Her areas of interest include chronic neck, back and post-operative spinal conditions.

    She has extensive experience with adolescent and adult scoliosis, including both non-operative and post-operative rehabilitation. She has studied with Dr. Rudolph Weiss, grandson of Katerina Shroth, of Germany and received a certification in his Scoliologic method.  She has studied with renowned Czech neurologist, Dr. Vladimir Janda.

    She is committed to the understanding of underlying issues which impact chronicity and the non-traumatic causes of musculoskeletal pain. Her experience in complex post-surgical conditions has led her to recently expand her practice into the area of post-treatment cancer rehabilitation.

    Maureen’s commitment to the physiotherapy profession’s education has been recognized through her appointment as an Adjunct Lecturer with the University of Toronto, Department of Rehabilitation Medicine. In this capacity she provides clinical placements for Master level students in physiotherapy as well as assisting with the education of foreign trained physiotherapists who are transitioning their practice to Canada (OEIPB). These experiences have helped her to remain at the forefront of physiotherapy education both in Canada and in the world at large. She enjoys public speaking and is frequently requested as a guest lecturer at conferences and seminars. Her status as an expert in physiotherapy practice has been accepted in the Civil Courts of Ontario and by the College of Physiotherapists of Ontario.

    Association memberships and awards

    She is a member of the Canadian Physiotherapy Association (CPA) and the College of Physiotherapists of Ontario. She actively participates in the CPA oncology and orthopaedic divisions. She received the Recognition Award, Professional Contribution – External Support from the Ontario Physiotherapy Association. She has been recognized by the readers of NOW Magazine as the best physiotherapist in Toronto. For over 10 years her peers have recognized her leadership and she has received the designation of an ‘Educational Influential’ in Physiotherapy the Institute for Work and Health (IWH). She has been awarded an honorary membership in the Czech medical society.

    When did you lose it?

     

    When we are younger the question “when did you lose it” provokes a completely different response than later in life.  As grandchildren enter our life, or as we finally find time to get back to the activities we were always meaning to resume, we are struck by the change in our physicality.  Suddenly and without warning we are no longer able to:

    • Get off the floor
    • Go jogging
    • Run for the bus
    • Walk an hour on the beach
    • Stand in the mosh pit with our kids at the concert

    As we reflect on these changes we may also notice that other things have changed.  We’re stiff when we get up in the morning – even when we haven’t worked out the day before.  Its hard to straighten-up when we get out of a chair.  We find it easier to walk with our hands behind our back.   We avoid cocktail parties because the alcohol is insufficient to off-set our back pain.

    Should you accept physical aging?

    If you mention these changes to your health practitioner, they often bring up the “A” word.  When faced with the Age pejorative some give in and accept their fate.  Others rail against it, sometimes creating injuries as they are unable to accept the changes in their body.

    There is no doubt that physicality changes as we age, however there are some changes we should never accept.  Keeping or restoring these physical abilities will not only help your quality of life, but many of these activities are predictors of longevity and independence.  Here’s what the research is telling us:

    Can you still get off the floor?

    I prefer my clients do their exercises on the floor, not only because of the firmer surface, but also because I want them to be able to get off the floor for the rest of their life.  Researchers have realized that this basic physical ability is a predictor of longevity.   We now know that whether you can get yourself off the floor, and the technique you use, is predictive of how long you will live.

    When analyzed it becomes apparent why this simple movement would be so predictive.

    1. Falls are one of the most common problems as we age. Not only do we want to prevent falls we also need to be able to get off the floor when it happens.
    2. Getting off the floor requires balance, flexibility and strength. All these elements come together in this basic movement, making it a quick screen to determine your overall physical health.

    If you are playing on the ground with your grandchildren or can manage your exercises on the floor, then keep this up.  If you struggle to get off the ground and avoid picking anything up off the ground, it’s time to have your physiotherapist or kinesiologist assess the barriers and develop a program to restore this important life skill.

    Staying independent

    I may have given up any dreams of Wimbledon, but the one physical expectation I will never give up is staying independent.  Anyone who has worked with me knows that I am obsessed with posture.  A few years ago, a study out of Japan gave me even more reason to maintain my obsession.  It looked at the predictors of independence.  Over a 20+ year period it analyzed which physical measures were predictive of whether you would need to go to a nursing home and require help with everyday activities such as dressing. It concluded that one of the key factors predicting the need for assistance was your posture.  In a nut shell, if you cannot stand up straight, with your spine directly over your pelvis, you are more likely to need help as you age.

    You may have nagged at your teenagers to stand up straight, but it’s now time for your children to nag you.  Ask them what they have noticed.  Do you stand tall or are you bent forward when you walk? If you find it difficult to stand up straight, working on your flexibility and core strength should be on your list of exercises for the long term.

    How low should you go?

    In my youth the buzz was about Sebastian Coe breaking the 4-minute mile.  The headlines around the world read “How low can he go”? Usain Bolt and Andre De Grasse have taken over the headlines but the message remains the same.  Many of us have been brought up with the belief that faster is better however we now know that there is a range of speed which is ideal.  Throughout our lifetime we should target our running, and then our walking, for between 3.5 and 4.5 mph.  If you are metric it’s an 8-11 minute kilometer.

    These numbers should guide us, our children and our grandchildren on doing enough, but not too much. Whether it is speed or strength there is an optimum demand – do more and you cause injury, do less and you might as well eat bonbons by the pool.

    As we age, many people find they can’t walk.  The wear and tear on our spine has resulted in overgrowth of bone.  Spinal stenosis (narrowing of the spinal canal) gets in the way of our retirement. Instead of taking cruises and exploring the ports we take the bus tours or stay onboard – professing we prefer to read or play cards when the reality is that it hurts to walk.

    Maintaining your spinal health is paramount to enjoying an active retirement.  Target 8-10,000 steps per day but also time your walk.  Your goal is to manage 3 km in 30-33 minutes every day.  If that causes back pain, leg heaviness or other symptoms then seek advice from your spine therapist.

    Find me a chair!

    Many of my clients hurt when they stand or walk slowly. They avoid shopping, limit visiting art galleries and decline invitations to cocktail parties.  As it gets worse even standing to cook causes pain.  Often attributed to aging this change in physicality is more likely due to poor back posture, tight hip flexors and weak hip muscles.

    A protruding belly is often a marker that we have a sway back.  Many of my clients think they need to lose weight when a simple adjustment in their posture will not only relieve the pain in their back but it also looks better!  If you can’t stand for an hour consider seeing your spine therapist for an assessment of how to change your posture.

    When did you lose it?

    Although ageing is inevitable, the changes of physicality are not.  The one system that is not affected by age is our muscles.  Research is showing that we can build strength into our 80’s, and that limiter is only because we have yet to study the 90 year olds. If you are over 50, the only physical restriction on my list that you should consider accepting is jogging.  None of the other losses in physicality need to be attributed to age.

    To quote one of my colleagues, Dr. Adonis Makris, D.C. , you not only need a financial plan, you also need a physical plan to stay healthy and active.  Although it’s best to start this plan by age 60, even if you are older an exercise program can help to restore much of what you have lost.  If you need help with your physical plan our physiotherapists, chiropractor, massage therapists and therapeutic fitness team can help to target your program to change the dialogue around “when did you lose it?”

    Announcements

     

    Announcing Aneila Amio – Pilates and Yoga Instructor. Reiki practitioner

    We are excited to announce Aneila Amio is joining our team at the Orthopaedic Therapy Clinic. Aniela brings extensive experience in injury rehabilitation through Yoga and Pilates. She is certified in Pilates, Yoga and Reiki. Her focus is on spinal health and injury recovery as well as pre and post-natal care. Aniela will be an integral part of the team, along with our registered kinesiologist, John Gray, in helping you to advance your recovery to return to fitness while reducing your risk of injury.

     

    Aniela’s passion is to empower people of all ages and abilities to improve how they to move and help them to take care for their own bodies.  She is interested in and continues to expand her studies with workshops on the mind body connection, chronic pain, scoliosis, fascia, pre and postnatal health and recovery as well as working with the aging population.  Aniela has had the opportunity to work with professional athletes, dancers, chronic pain suffers and those recovering from spinal injuries and surgeries.

     

    Aneila will be at our clinic on Tuesday’s starting February 19, 2019. Call us  at 416 925 4687 to book an appointment or chat with your therapist to determine when you are ready to benefit from working with her.

    Pelvic Floor Rehabilitation

    Svetlana Marianer Registered Physiotherapist is continuing her advanced training in pelvic floor rehabilitation. She has recently worked with an advanced practitioner in a clinic setting to apply her skills and has completed the second section of a three part course.  Pelvic floor therapy is emerging as one of the strongest, evidence based areas of physiotherapy.  If you would like to know about what it can do for you, you can read about it in her article https://orthophysio.com/?s=pelvic or contact her directly at smarianer@orthophysio.com

    Scoliosis Presentation

    Maureen Dwight presented a paper on scoliosis at the National Orthopaedic Division Conference held  in London Ontario.  This will represent her third presentation to treatment professionals on managing and treating scoliosis.  These engagements have been based on the paper she  co-authored on scoliosis treatment.  Although primarily written for treating professionals, it is available on our website at https://orthophysio.com/?s=scoliosis. These efforts are helping to raise the awareness of treatment professionals on evidence-based treatments for scoliosis.  Maureen also attended the International scoliosis conference (SOSORT http://sosort2018.com/ ) in Dubrovnik Croatia.

    Herniated Discs and Sciatica

    herniated disc treatment in TorontoHerniated Discs are common causes of low back pain and neck pain treated at the Orthopaedic Therapy Clinic. The disc functions as an important biomechanical shock absorber between the spinal bones. If the outer layer (the annulus fibrosus) cracks, the inner portion (the nucleus pulposus) can push through and compress a nerve causing back pain and/or pain, tingling and numbness into the leg (sciatica). This is called a disc herniation.

    Physiotherapy treatment initially focuses on strategies for symptomatic relief followed by progression of flexibility and strengthening exercise once pain control has been achieved to maintain and restore physical function.Integrating a brisk walking routine can also make your discs healthier.  Education also plays an important role in treatment in order to give you the tools to manage these conditions.

     

    Publications

    1. Physiotherapy in the Treatment of Scoliosis

     

     

    How Brain Plasticity Causes Low Back Pain

    Maureen Dwight Registered Physiotherapist, Clinical Musculoskeletal Specialist, Advanced Spinal Practitioner ISAEC

    There is a common saying in our industry stating that nerves which fire together wire together. This principle is the basis of motor coordination and reflects our brain’s capacity for plasticity. Brain plasticity causes low back pain by making it harder to relearn how not to be injured. The key premise is that as we develop motor skills our nervous system is learning which muscles work together to produce a movement.  The more we practice, the smoother and more automatic the movement becomes until finally it is “grooved” and we no longer have to think about it.

    This principle applies to our early childhood, when we learned our basic motor skills of rolling over, sitting and walking.  It also applies to the sports we learn.  We see it at its best in the finest athletes.  Even when they are performing the seeming impossible, they look effortless.  Their refined coordination means they exert less energy, take longer to get tired and just plain look better than everyone else when they are working at maximum.

    Compensatory Movement Patterns

    Brain plasticity also applies to injury.  While we are injured many of us use compensatory movement patterns to keep going.  These adaptations allow us to stay active while avoiding strain on the damaged tissues. When a muscle is damaged the body innately shifts our movement to engage other muscles, limiting the demand on the weakened structure[1].

    Whether you sprain a ligament or hurt a joint, you will naturally splint the area, stiffening your muscles to avoid further damage. These changes are reflected in our movements.  We may limp, lock our knee or even hop on one foot to avoid putting weight on an injured leg.  During this period our brain and spinal cord (Central Nervous System) are “learning” these movement patterns.  Committed to efficiency the nervous system begins to re-wire these muscles to work together. Initially these adaptations can be useful however when we use compensatory movements too long the wiring becomes established.  We over-ride healthier movements, making it harder to go back to our original, more efficient movement patterns.

    Even though the injury may be short lived, the effect of compensatory movements can last long after our tissues have healed.

    Although compensatory motion can occur with any injury, these changes are more likely to be a problem when we hurt our back or neck.  Injuries to ankles or knees may involve the joint, ligament or muscle but when we hurt the spine it will often affect our nerves. Once nerves are involved the nature of the injury changes.  Nerves are exquisitely sensitive structures which directly affect pain.  Their involvement has a more direct impact on coordination as they are the communication pathway between our muscles, the brain and spinal cord.

    Brain plasticity causes low back pain

    I find the implications of brain plasticity on low back pain one of the most interesting research areas to emerge in my field.  At the forefront are researchers such as Dr. Paul Hodges, Dr. L. Danneels and Dr. Simon Brumagne, whose presentations I had the fortune of sitting in on at the North American Spine Society meeting last fall.  Their research uses highly sophisticated equipment, including Transcranial Magnetic stimulation and functional MRI (fMRI), to watch the brain function in real time. One aspect of these studies looks at which areas of the brain are used to coordinate certain movements.  This information is then compared to the brain of individuals who have low back pain.

    In fMRI the activity in the brain is represented by light.  The more areas that light up, the more energy we are using to perform the task.  The larger the area that lights up, the “harder” we are working to complete the task. What these studies confirm is that the activity in the brain is changed from back pain.  Whereas a non-back pain sufferer may “light up” only a few areas, the low back pain person recruits a much larger area to perform the same motor activity[4]. This finding is consistent with the theory my colleague John Gray wrote about in When Hamstrings Attac[5]:

    low back pain sufferers often use a high load strategy for low load activities

    This theory, along with this impressive quality of research to support it,  indicates that after back injuries some movement patterns are less efficient.  Too many muscles and/or too much thought process is being utilized to perform a simple task.

    This pattern is also consistent with another function studied with fMRI several years ago, [6].  Most of us understand that it is easier to learn a language when we are young.  Studies confirm that this is because we are more efficient at coordinating speech.  We use a relatively smaller number of areas of the brain to process and produce language.  If we add more languages later in life we access a larger number of areas of the brain, increasing the “work” and reducing the efficiency of speaking in another language.  This lower level of efficiency is one of the theories proposing why age, brain injury or stroke causes some people to revert to their first language.

    Brain smudging

    The current terminology describing the changes seen in the brain with low back pain is “smudging”[7].  Instead of seeing localized pockets of specific and efficient muscle activity, there is a broader area of involvement[8].  It’s as though someone has taken those points of light and smudged them all together into an indistinct pattern.

    The implication of this research for therapy is that it tells us to get better you need to un-smudge these movement patterns. The therapeutic research in this area is just beginning however in the interim this information provides us with important guidance.  We now know that in addition to improving strength and more flexibility, most people with chronic or recurrent low back pain need to re-establish muscle coordination (Symptoms of compensation.)

    All too often I see clients where their therapy has stopped once they learn how to tighten their abdominal muscles to brace their spine or clench their gluts when they lift. The problem with relying on “remembering” to tighten muscles before you move is that it is slow and takes too much thought process.  Movement needs to become easy, automatic and efficient, otherwise the moment you forget to activate these muscles you may get hurt.  For our everyday movements we need to strive to be like the athlete, effortless in our walking, sitting, standing etc.

    Fortunately brain plasticity and efficiency also work in our favour.  The body has been described as being indolently lazy which means we naturally gravitate to movement patterns requiring less energy.  Your therapy should take advantage of this innate laziness and focus on re-establishing your more efficient primary “language of movement”. Just as we never forget how to ride a bike, the re-establishment of these pre-injury movement patterns is recognized by your nervous system as requiring lower resources. This propensity helps us to re-establish these basic, more efficient movement choices.  Working on a daily program to “remember” how to move non-injured will help to restore your healthier movement patterns, improve your energy, reduce pain and lower your risk for re-injury.

    To learn to work less hard and to have less back pain requires an assessment by a therapist who understands the effects and knows where to look for compensatory muscle patterning after injury.  The therapists at the Orthopaedic Therapy Clinic are knowledgeable in this retraining.  Please contact us to book an assessment if you have chronic or persistent low back pain.

    The advice in this article is not meant to replace advice from your health care professional.

    [1] The compensatory relationship of muscles was understood by Leonardo da Vinci in the 1400’s

    [4] Changes in the fMRI have also been seen in scoliosis

    [6] http://www.ncbi.nlm.nih.gov/pubmed/14683721

    [7] http://www.ncbi.nlm.nih.gov/pubmed/21508892

    [8] http://www.ncbi.nlm.nih.gov/pubmed/27244113

    Back Pain: Spondylolisthesis and Andre Agassi

    Many of us who learned to play tennis in the ‘80’s and 90’s were taught to emulate Agassi’s mini-step style of movement. Small steps were believed to make you more adaptable, allowing you to adjust for the unexpected bounce of the ball. Then along came Pete Sampras with his long legs, loping gait and highly successful career. Almost overnight mini-steps were out and coaching focused on increasing the speed you could run to the ball. What a surprise for those of us who have lived through both of these style paradoxes to find out that Agassi’s movement was not a philosophy but rather the result of an impairment imposed on him by his back – spondylolisthesis.

    What is Spondylolisthesis

    Agassi and approximately 7% of the population suffer from a structural defect in the spine called spondylolisthesis. This condition is characterized by a fracture (lysis) that causes the front body of the vertebrae (spondylo) to separate (thesis) from the bone and joints located at the back of the spine. This defect allows the body of the vertebra to shift forward (thesis) in relation to the rest of the vertebral column, leaving this section of the spine inherently less stable than other areas of the spine.

    What Causes Spondylolisthesis

    When this conditions occurs in young people the cause has been attributed both to genetics and to injury. Injury has recently gained more support as it is well known that participants in certain sports are more at risk for this condition. Gymnasts, divers and football players all have a higher frequency of spondylolisthesis than what is typical for the rest of the population. It is speculated that immature bones cannot withstand the forces generated by these sports and the bone breaks under the stress. It is not known why the fracture never heals.

    How serious is Spondylolisthesis?

    Fortunately most spondylolistheses are stable, however when first diagnosed it is important to periodically monitor the condition to be sure that the shift is not increasing. The degree of instability can be quantified on X-ray by measuring the amount of shift in relation to the adjacent stable vertebra. The most common, and least unstable shift, is labelled as a grade 1 when the vertebral body shifts forward from 1-25% of its depth. There are a total of 5 grades with each level increasing by 25% until it reaches the extremely rare grade 5 where the front of the vertebrae has shifted completely forward of the spine.

    Symptoms of Spondylolythesis

    The age at which someone first experiences back pain can often be a marker for the presence of this condition. Whereas most people can expect to experience their first episode of back pain after age 30, the pain associated with a spondylolisthesis frequently manifests itself in our teens. The pain is often caused by certain movements straining the fracture site as it allows movement at the area commonly called a pseudoarthrosis (false joint). For example the sufferer may feel pain from the compression of the two surfaces while he or she is leaning back to serve the ball. It may also be caused by the increased stress on the disc. The firm attachment of the intervertebral disc to the margins of the adjacent bone is under more strain by the vertebra’s forward displacement.

    Treatment of Spondylolithesis

    The treatment for this condition depends on whether the condition is acute or chronic and the degree of instability. A highly unstable listheses will require surgery however most people with this condition do well with more conservative approaches. During the acute stage, the pain from the irritation of the pseudoarthrosis and/or the disc means that therapies which help to control pain are the priority. Ice, advice on modifying activity, rest, medication, acupuncture and/or a variety of electrical modalities can all be beneficial. Over the long term the goal shifts to strategies to prevent further strain on the weakened structure as this is what will ultimately limit future painful episodes and prevent additional damage.

    Rehabilitation and prevention programs’ primary focus should be on posture and adequate muscle strength. This approach will help to ensure that the stress of everyday movements can be absorbed by the muscles rather than being transmitted to the mechanically challenged vertebral-disc complex. As with all back pain the importance of having a strong core cannot be overemphasized however in this condition you may also need to broaden the scope of exercises as depending on where the defect is located you will be more prone to specific muscular weaknesses. For example the most common location for a spondylolisthesis is in one of the bottom two vertebrae of the low back, L4-5 or L5-S1. The problem with this location is that it houses the nerves that supply the muscles of the buttock and outer hip and is a possible cause of sciatica. Damage in this area can cause compression to the nerves and this means it is more likely that strength will be lost in the muscles they supply.

    Compensation and muscle weakness’

    Although Agassi does not reveal the location of his spondylolistheses he alludes to having these specific muscle weaknesses when he attributes his back to the cause of his pigeon-toe gait. Having a toed-in position is often an indicator that the buttock muscles (gluteus maximus) and outer hip muscles (gluteus medius and minimus) are relatively weak. A postural and gait mal-alignment results when the muscles which turn the legs outward do not ounteract the pull of the muscles turning the legs in. Unfortunately this over-reliance on the inner thigh and groin muscles causes tightness and compensatory movement patterns which increase the risk of injury, particularly in someone like Agassi who competed at such a high level. His biography shows the outcome of these imbalances as he was often unable to finish matches once his over-worked groin muscles started to spasm.

    Despite all of these anatomical stresses and strains many people who have a spondylolisthesis can be completely symptom free and may only find out that they have had this condition much later in life when they are being investigated for age related back pain. Having good core muscles is invaluable in counter-acting the effects of this condition and preventing pain.

    The effects of a good training program can be seen in this example of Andre Agassi, as not only was he able to play tennis with this condition he was able to excel at it.