The Thinking Practitioner Podcast
w/ Til Luchau & Whitney Lowe
Episode 07: Scoliosis and Manual Therapy
Feb. 12, 2020 | Transcript | Subscribe | Comments | ⭑⭑⭑⭑⭑
07: Til and Whitney talk about hands-on work with scoliosis.
In this episode,
- What do we know about scoliosis' causes?
- What are some common scoliosis myths?
- When is scoliosis a problem?
- What are conventional treatments?
- What’s manual therapy’s role?
- And much more.
Join two of the leading educators in manual therapy, bodywork, and massage therapy, as they delve into the most intriguing issues, questions, research, and client conditions that hands-on practitioners face. Stimulate your thinking with imaginative conversations, tips, and interviews related to the somatic arts and sciences. With Whitney Lowe and Til Luchau.
Resources discussed in this episode:
- John P. Kostuik and John Bentivoglio, “The Incidence of Low-Back Pain in Adult Scoliosis,” Spine 6, no. 3 (May/June 1981): 268–73, https://doi.org/10.1097/00007632-198105000-00009 https://www.ncbi.nlm.nih.gov/pubmed/6455747
- Schwab et al., “Adult Scoliosis: Prevalence, SF-36, and Nutritional Parameters in an Elderly Volunteer Population,” Spine 30, no. 9 (May 2005): 1082–85, https://doi.org/10.1097/01.brs.0000160842.43482.cd. https://www.ncbi.nlm.nih.gov/pubmed/15864163
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Thanks for listening and subscribing to the podcast! Make sure to connect with us on Twitter, Instagram and Facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts!
(The Thinking Practitioner Podcast is intended for professional practitioners of manual and movement therapies: bodywork, massage therapy, structural integration, chiropractic, myofascial and myotherapy, orthopedic, sports massage, physical therapy, osteopathy, yoga, strength and conditioning, and similar professions. It is not medical or treatment advice.)
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The Thinking Practitioner Podcast:
Episode 07: Scoliosis and Manual Therapy
Broadcast date: 02/12/2020
©Copyright The Thinking Practitioner Podcast, Til Luchau & Whitney Lowe
Whitney Lowe: Welcome to The Thinking Practitioner Podcast.
Til Luchau: ... a podcast where we dig into the fascinating issues, conditions, and quandaries in the massage and manual therapy world today.
Whitney Lowe: I'm Whitney Lowe-
Til Luchau: ... and I'm Til Luchau. Welcome to The Thinking Practitioner.
Whitney Lowe: Welcome to the Thinking Practitioner.
Til Luchau: Hello. This episode is sponsored by Handspring Publishing. When I wrote my advanced myofascial techniques books, I was lucky enough to have two offers, one from a huge international media company, and the other from Handspring, a small publisher in Scotland run by four lovely people, and I'm so glad that I went with my gut and chose them, Handspring, as not only did they help me make the books I wanted to share, but their catalog has emerged as one of the leading collections of professional level books written especially for body workers, movement teachers, and all professionals who use movement or touch to help patients achieve wellness.
Whitney Lowe: Yes, indeed. Handspring has done a great job of expanding their offerings for the movement manual therapy professions. They're author list reads like a who's who for many of the leading thinkers in our fields. So, head on over to their website at handspringpublishing.com and browse their excellent catalog there. Once you find the gems that you've got to have, then use the code TTP, like The Thinking Practitioner, that's TTP at checkout for your discount.
Whitney Lowe: So, welcome everybody to this episode of The Thinking Practitioner. Til, how are you today?
Til Luchau: Doing great, Whitney. Thanks.
Whitney Lowe: Good. Well, we're going to be diving into some lateral curvatures today I think is our topic. I think we're going to be addressing some things with scoliosis. That's our plan, isn't it?
Til Luchau: Yeah. Well, the debate has already started. Is scoliosis a lateral curvature?
Whitney Lowe: Yes. Right. There we go.
Til Luchau: Scoliosis is our topic, is it a lateral curvature, and other questions. I'm excited about this one because it's one of my favorite topics, and I think it's one of the topics where there are the most, we could say, misconceptions or oversimplifications amongst body workers.
Whitney Lowe: Yeah. It is certainly one of those words that gets bandied about quite a bit without some good definitions and clarifications about what people are talking about. So, we're going to try to drill down into that a little bit today, I think, and see if we can nail some of those things down.
Til Luchau: Yeah. Well, can you tell us what it is, what do we know about its causes, that kind of things? Can you lay that out for us?
Whitney Lowe: Yes. Let's look a little bit at some of the basics of scoliosis. In a general category, we refer to scoliosis most commonly as a lateral curvature of the spine. So, this is if you're looking straight on at your client's back, this would be a curvature of the spine that goes to the left or the right. Now, it can curve in different directions. Again, the term scoliosis, we'll get into this a little bit later, there are some other times where you may run across it when it's talking about something that may seem not necessarily related to a lateral curvature, but for all practical purposes, that is the most common definition of that.
Whitney Lowe: You may periodically run into the terms level scoliosis or dextro scoliosis. This is just getting more specific about the way that the curve is going. So, for example, you might hear people talk about C curves or S curves. So, a C curve would be one smooth curve throughout the whole spinal region where the spine is curving just to one side only, and it looks like a thinned out letter C if you are looking at it straight on. An S curve would be one where it goes to one side and then it goes to another side in the spine, all throughout the length of the spinal region.
Whitney Lowe: A level of scoliosis would be one where the convex portion of the curve, that means the bumping out portion of the curve is going to the left. A dextro scoliosis being one where the curved or bumped out portion is going to the right. So, that is a referred to as a dextro scoliosis, and then there's also some-
Til Luchau: Far more common pattern, by the way.
Whitney Lowe: Yes, and I was going to ask you about that because I don't know about this. Any idea why that is?
Til Luchau: No, and there's some evidence that it's reversed in England.
Whitney Lowe: No way.
Til Luchau: Yeah. The left is more common in England, but not, here's the weird part.
Whitney Lowe: Because they drive on the wrong side of the road.
Til Luchau: That's the immediate conclusion, yes, right there, but it doesn't hold true in Australia, Japan, Wales, Scotland, Ireland, South Africa, other countries where they drive on the other side of the road. So, that's not the reason, but we don't have no idea why. There's a higher prevalence of left convex scoliosis in England.
Whitney Lowe: That is fascinating.
Til Luchau: Yeah. Most places it's right that's more dominant.
Whitney Lowe: Yeah. Well, we will have to dig into that, see if we can figure that out a little bit there. So, a couple of other terms I just want to scoot across here, too. You may run across the term AIS, which is the adolescent, the scoliosis, and now, I'm mind-blanking.
Til Luchau: Adolescent Idiopathic Scoliosis.
Whitney Lowe: Thank you. Yeah. I was mind-blanking on Adolescent Idiopathic Scoliosis. Idiopathic predominantly being the term we refers to something we don't really know the cause of, and there seems to be a moderate, frequent degree of occurrence with that Adolescent Idiopathic Scoliosis. My understanding Til, and correct me if I'm wrong about this, this is more frequent in females, correct?
Til Luchau: Yeah, and the more severe it is, the higher the female dominance in that. So, with the most severe curves of Adolescent Idiopathic Scoliosis is about seven to one girls to boys.
Whitney Lowe: Yeah, and do you have any idea why that is? I was trying to scratch against, scratch hidden and see if I could figure out a rationale or come across a rationale for what that was about.
Til Luchau: This is the second time you've asked me why.
Whitney Lowe: Yeah.
Til Luchau: They're both about idiopathic.
Whitney Lowe: Right. Yeah. I want to know why.
Til Luchau: We all want to know why.
Whitney Lowe: Somebody's got to know the answer.
Til Luchau: What does idiopathic mean again?
Whitney Lowe: Yes, that's right. Yeah, we have no idea.
Til Luchau: We don't know why.
Whitney Lowe: So, we're going to rest there. We'll rest our case there. So, then also, we've got the adult onset scoliosis, usually in adults where this is not related to something that's happening or let me back up also a minute, too, because we didn't clarify. Back to when we talked about those three main categories, we talked about the idiopathic being one where we don't really know the cause for it.
Whitney Lowe: Congenital scoliosis being that which is something having to do with the deformities that are generally present at birth, some type of genetic defect or something that is causing that spinal curvature to the neuromuscular-
Til Luchau: Yeah, developmental things in the utero. Yup.
Whitney Lowe: What's that?
Til Luchau: Developmental in utero, that kind of thing. Yeah.
Whitney Lowe: Yeah. Right, right. Then the neuromuscular branch being those that seem to be caused by various neuromuscular disorders, sometimes muscular diseases that cause either atrophy wasting or different poles on the spine causing the spine to be bent into these different positions. That would be the neuromuscular category.
Til Luchau: Yeah, I think. Sorry, I think traumatic scoliosis would be in that category, too. Some people will have a serious injury or a wound or a surgery that will disrupt the control of their movement, and position, and posture, and end up with scoliosis. I think that would be the neuromuscular category.
Whitney Lowe: Right. Yeah. So, the adult onset scoliosis is one that comes on without any of the early childhood indicators that this is going to be something that's a problem, and that can come from a number of different causes.
Whitney Lowe: I was curious when I was looking and reading a bunch about this as we were doing some preparation for this episode, interesting, the number of places, even on some of the official scoliosis sites that did not make the distinction that we frequently speak about in the manual therapy world of structural versus functional scoliosis. They were really leaning very heavily on the structural causes.
Whitney Lowe: We often make that distinction between structural being those that are about bone causes, the spinal curvature related to bone causes, and functional ones related to various different muscular or neuromuscular patterning causes. We'll delve into that in a good bit more detail as we track later down through here. So, those are some of the overall categories that you may hear when you're hearing about that.
Whitney Lowe: So, what do you think are some of the other things that we've seen or heard about? There's a lot of myths out there about scoliosis. What other kinds of things have you run across?
Til Luchau: Well, just continuing on your last comment about adult onset scoliosis, we often will think about idiopathic scoliosis as a teenage condition. You'll see statistics where they say about 80%, 85% of all scoliosis is AIS, Adolescent Idiopathic. Again, that's people that are seeking treatment, but there's been some other study, much less, but some more recent study into the adult onset type, and they're saying or seeing that it's even more common than the adolescent one.
Til Luchau: So, the idea that it is an adolescent issue might be one of the myths that up to 20% of all adults up to 40% of people at age 60, and then 68% at age 70, it's like the 70% of 70, 70% of all adults in this very large study had an observable scoliosis.
Whitney Lowe: Yeah, and I would wonder at that point as we begin talking about that how much of that is falling within the vision of structural versus functional scoliosis because my suspicion is we're going to see a lot of those adult onset scoliosis falling into the functional category, those that are the result of other adapted neuromuscular patterns versus structural.
Til Luchau: All right. You want to go there? Should we go to structural/functional?
Whitney Lowe: Let's talk about it a little bit.
Til Luchau: Okay. Say more about that. You would see adult onset is probably being in the functional?
Whitney Lowe: I would. I would. That would be my suspicion. Again, I don't have some good, hard evidence about that, but since we're talking about those adapted neuromuscular patterns, the functional, some examples of what we might be talking about-
Til Luchau: Yeah, what's the difference?
Whitney Lowe: Structural scoliosis, we've mentioned earlier, having to do with the bony deformities, but functional would be ones where, for example, a person, let's say has a leg length discrepancy, and one leg being longer than the other when they're in a standing position is going to tilt the pelvis to the other side.
Whitney Lowe: So, let's say the right leg is longer. Structurally, the bones of the leg are longer, so it's going to tilt the pelvis to the opposite side. So, they will consequently because of the lumbosacral junction having such a relatively strong and firm connections with the pelvis as the pelvis tilts, it's going to tilt the lumbar vertebra to that same side, and you would then with a long right leg have a functional scoliosis. That would be level scoliosis in the lumbar region bending out to that side on the left side.
Til Luchau: So, you're saying structural scoliosis has to do with the bones, functional has to do with the soft tissue?
Whitney Lowe: Well, yeah, or some other type of indicator that's not a bone disorder. I mean, that's been my interpretation of what that distinction is. So, that could get potential murky. How would he see that in terms of that distinction? Does that make sense?
Til Luchau: I reject the distinction.
Whitney Lowe: All right. Let's hear it.
Til Luchau: I understand it. No. It comes from a treatment strategizing placing. Are we going to treat this in a bony or ligamentous way? Structural scoliosis is thought to be related to the skeleton or the ligaments or are we going to treat this in a functional or muscular way with movements or things like that that'll help strengthen or work with the muscular control?
Til Luchau: So, it's a strategic ... Originally, it's probably the strategic distinction, and you can see it if you just have someone bend, side bend left, straight left and right. One way will often be more curved than the other. The side that stays straight is actually thought to be more structural.
Til Luchau: Well, let's start over. The side that doesn't bend as much is thought to be more of a structural thing. The side that bends a lot is thought to be functional. So, in other words, can I straighten out my scoliosis by just movement? Then it's thought to be functional. If I can't straighten out with movement, then it's thought to be structural. That's the way I'm built.
Whitney Lowe: Yeah.
Til Luchau: Now, the reason I ... Go ahead. You had a question?
Whitney Lowe: No. Go ahead. Go ahead and complete that thought there.
Til Luchau: The reason I'm saying I reject that, I'm not saying it's totally baloney, of course, there's something there, but as body workers, it doesn't help me determine how I'm going to work on it or if I'm going to work on it. I've heard other body workers say, "Well, Body work is mostly good for functional, and then Ida Rolf's position, the flag she raved as well, actually, we can change structure. So, it's for that, too.
Til Luchau: In my approach these days after 30 something years of pondering scoliosis and working with it, I don't know that it matters. I still work with both of them in the same way because my goal is applied to both.
Whitney Lowe: Yeah.
Til Luchau: So, I don't spend a lot of time trying to determine is it structural or functional. I do spend a lot of time determining does it move or not.
Whitney Lowe: Yeah. So, here's a place where I would see trying to make that distinction. Again, we may be playing with semantics a little bit around this, but if a person has, let's say, to go back to the example I gave a moment ago, the person who has a true bone leg length discrepancy and that produces a scoliosis, would you consider that a structural or functional scoliosis?
Til Luchau: I don't use the terms.
Whitney Lowe: Okay.
Til Luchau: Sorry not to play, but it's like ... No. I would say, classically, it's true. Obviously, it's structural. It's their bony length. I mean, in terms of something they could just relax a muscle and change, but what I'm saying is I still work with both of them, and we can help both of them.
Whitney Lowe: Yeah, and the reason, again, part of the reason why, just to extend on that example, why I think it's valuable to look at that distinction is going back to that same example of the person who has a leg length discrepancy with the bones being longer on the right side and that is going to tilt their pelvis to the left, okay?
Whitney Lowe: Now, the ideal in an orthopedic environment, the treatment strategy for that is going to focus on trying to level the legs and balance the pelvis most likely by putting a lift in the left shoe, right? Okay. All right. Now, that might've been evaluated. Let's say they were doing this possibly with a person's supine on the treatment table.
Whitney Lowe: Let's say they did that same thing. They looked at somebody on a treatment table and they said, "Oh, your right leg is longer than your left leg," by putting them supine on the treatment table and looking at their leg lengths and saying, "Okay. Your left leg is shorter than your right leg. So, we need to put a lift in your left shoe."
Whitney Lowe: In actuality, their bone lengths are identical. On the left side of their lumbar region, their quadratus lumborum is really tight and hiking that pelvis up when they get in that position. If you put a lift under that person's left shoe, you're actually going to aggravate the problem as opposed to alleviating it. That's where I was talking about the importance of making that structural versus functional discrepancy.
Til Luchau: Okay. Does that influence your hands on treatment?
Whitney Lowe: Well, I don't know that it would make a big difference in what we are actually doing with people-
Til Luchau: My point exactly.
Whitney Lowe: ... but it might make a difference in what we're recommending to people or what we're saying that they have. If they say they've had this done, they went to somebody and, "They told me to put this lift in my shoe," and you're thinking, "Oh, wait a minute. This could be actually making things worse if it's not evaluated correctly."
Til Luchau: Well, it's tricky to second guess or put opinions on someone else's recommendations, too. I'd probably try to avoid that.
Whitney Lowe: Yes, it is.
Til Luchau: No. My point being, it doesn't affect my treatment choices as a manual therapist. Now, there's other places where it certainly would, but whether they have femurs the same length or different lengths, my goals are still going to be refined proprioception and options for movement, and that helps people.
Til Luchau: So, we need to get to the myths because you asked about that, and some of that's in the background of what we're talking about here. I'm also going to, if I remember, I'm going to get back and refute, let's say, or challenge your idea that the quad, the QL on that side is pulling the pelvis up.
Whitney Lowe: Okay. Let's remember to do that.
Til Luchau: All right. Anyway, so some of the myths. First myth that we really got to talk about, that scoliosis is a problem because even so far in our conversation, we've been talking about treating it, maybe even correcting it. The big thing to keep in mind is most of the time, it's not a problem in that people with scoliosis do not have pain more often than people without scoliosis. Scoliosis is-
Whitney Lowe: I think that's a big one.
Til Luchau: That's huge.
Whitney Lowe: Yeah, because we've seen this as a structural thing and think we have to fix it or something.
Til Luchau: Yeah. So, I mean, maybe we should even go back and put this right at the beginning because that's the big thing. It's like just because someone has a curve in their spine doesn't mean you have to go in there and try to fix it. In fact, as we saw for many years in the Rolfing world, sometimes we can really work to align people and they feel much worse. They have more pain. They don't feel as balanced because they're a different shape.
Whitney Lowe: Yeah. Right.
Til Luchau: I'm biting my tongue about structural and functional, but there's more to say there. Basically, that first one, scoliosis is a problem. Back pain incidents. I'm just going to repeat that again because I love that fact, back pain incidents, and this is something you can share with your scoliosis clients. Back pain is not more common in people with scoliosis than people without scoliosis. Just because you have a curved spine doesn't mean you're going to hurt necessarily any more than anybody else is going to hurt.
Whitney Lowe: I think that is really fascinating because that really ... That also lets us extrapolate those ideas. Well, if let's say we want to take the chance and extrapolate those ideas into some other things and talking about other supposed structural challenges in the spine, it really makes us think twice about how much do we have to fix those other supposed structural challenges if people can get along with all kinds of scoliosis problems and not have pain with it.
Til Luchau: Yeah. That's right. That's exactly it. Footnote I should put in there is that if you have scoliosis and you have back pain, there is some evidence that it could be worse, that people with scoliosis, when they do get back pain, it tends to be worse. So, it's something to try to avoid and prevent, and the movement, and adaptability, and using your body seems to be the way to do that, but just because you're curved doesn't mean you're going to hurt.
Til Luchau: Now, the other footnote that I should stick in there is up to a point, and we're going to talk a little later about when scoliosis wouldn't really matter, but for the vast majority of people walking in your door, they're not more likely to have pain than people will have pain. So, you don't have to fix it.
Til Luchau: Second myth, scoliosis is an S or a C or you could say sometimes it's a triple major, an S with three curves. There's even documented four curved scoliosis, things like that. That comes from our legacy of photographs and X-rays, where we look at it, we take a picture or we take an X-ray that come out flat. We see the scoliosis in one plane, and we say it's a curve to the side, a lateral. That's by definition. A scoliosis is a lateral curvature that doesn't straighten out.
Til Luchau: Well, you mentioned in our trading notes back and forth beforehand for its laws, and there's a lot of other reasons why people say whenever it curves one way, it curves and always. So, you're not going to see in nature a spine that's just curved to the side and doesn't rotate or doesn't flex and extend a little bit, too.
Whitney Lowe: Yeah. So, you're saying at the same time that it's got curvature to the side, there is also motion in other planes of those vertebra that are not pure motion that it's supposed to be doing.
Til Luchau: Yup. That's right. There are some arguments about which of those motions are coupled, but everyone agrees that when you move in one plane, you can move in all planes. No one's saying the spine just moves in one plane, but yet our thinking that scoliosis is just a lateral curvature informs the ways we approach it. Then we think, "Okay. We got to straighten it out. We got to lie them on their side and stretch out the concave side or strengthen the convex side."
Til Luchau: The goal then becomes straightening people out in a single plane, and it's really helpful. It really helped my work when I really started realizing it's a helix, it's a three-dimensional spiral. It's not just an S curve.
Whitney Lowe: Yeah, and a good example for those who may have a little bit of challenge visualizing some of what you're talking about with the coupled motions, you see this moderately frequently in scoliosis, especially the Adolescent Idiopathic Scoliosis. You see that frequently in the thoracic region, something called the rib hump, which is if the person is in a prone position, they will have one side of their upper ribcage maybe more elevated than the other.
Whitney Lowe: That is often a relationship with the lateral curvature in the spine, so that as the vertebra curve to one side, they also rotate to the opposite side, which pushes the transverse processes in a posterior direction making that side of the back up here higher or lifted up compared to the other side.
Whitney Lowe: So, that's a an example, a clinical example of how you might see that idea of coupled motions of not only pure lateral curvature, but lateral curvature with rotational movements simultaneously.
Til Luchau: Yeah. That's right. In our approach, we use the coupled motion idea to get it moving in all three planes. That's one of the goals, that things move in all three planes and people feel great. People feel so much better when that's happening.
Whitney Lowe: Yes. Right.
Til Luchau: Next myth. Ready for the next myth?
Whitney Lowe: Yes, indeed.
Til Luchau: The myth here is scoliosis is a spinal condition. Now, this gets back maybe to my indoctrinations or Rolfer, where we really looked at everything big picture. We said it's never just the thing, it's always the whole, and scoliosis is one of those examples where you don't just see it curving the spine, you see the rib cage, of course, changing, you see the pelvis changing, and you see the upper girdle, the upper limbs being either affected or perhaps affecting the scoliosis.
Til Luchau: Sometimes scoliosis is talked about being their top down, that it's involving the cranium or shoulder girdle or bottom up involving the legs or pelvic girdle, but the whole body is affected. There were stories about Ida Rolf distributing a photograph of just somebody's armpit and saying, "Okay. So, is their left leg internally rotated or externally rotated from this photograph?"
Til Luchau: She could tell. The story goes, but her point was that the pattern of scoliosis is going to be reflected throughout the whole body. Yeah. So, then in our approach, our goals, my goals, more movement options and refined proprioception. That's going to involve the whole body. too. So, I really do start my scoliosis work with the limbs and girdles. We really check to see are the arms and legs adaptable.
Til Luchau: The extreme case, I remember a six-day scoliosis training I did at the Rolf Institute years ago as a student. I was a participant. We probably spent most of the first five days on the legs and pelvis, honestly.
Whitney Lowe: So, is the idea that if you are treating, for example, the extremities there, that you are then affecting some other aspects of the spinal structure by addressing the extremities or how does that or is there a ... What's the connected thought process there?
Til Luchau: We're thinking less linearly. It's not like if I do the legs, then I affect the spine. It's thinking we step back and we say, "Okay. We're seeing spinal curves. That's part of a whole body curve." To give someone more options for movement, our goal, then we need to look at the whole body. We need to see how the legs and arms are involved in that rotation when we see the spine.
Whitney Lowe: Yeah. I imagine, too, there's some other factors that we really would need to consider about function to look what kinds of things are people doing on a regular basis that may impact the way their body moves or is impacted by those positional challenges, if we call them something like that.
Til Luchau: Well, yeah. You'd wonder about asymmetrical activities like, "Is dextro scoliosis more common in right-handed people?" or something like that. Not a lot of evidence that asymmetrical activities are involved with scoliosis, but, for sure, bilateral activities, things that involve both sides of the body are helpful to get all those options for movement. That seems to be the helpful thing.
Whitney Lowe: Yeah. Okay.
Til Luchau: More myths?
Whitney Lowe: Yeah. You got some more?
Til Luchau: I got a couple.
Whitney Lowe: Oh, let's hear it.
Til Luchau: You stop me. You stop me when-
Whitney Lowe: Okay. These are good. I love this.
Til Luchau: While you're talking, this reminded me of these. I think I already talked about this one, body work can help with functional but not structural scoliosis. Body work helps with both, but let's redefine help because so many times, practitioners to help means straighten them out. That's not my goal. That's not my goal. It's not even a useful goal. I mean, sometimes it's the client's goal, but really, I mean, I got a note to talk about that when we talk about how to apply this. First step is really getting the client's goals. My goal-
Whitney Lowe: Yeah. So, what are frequently ... What would you see as the primary goals here? Is less pain, I'm not going to say pain-free, but less pain movement or more freedom of movement or ... I guess that's, of course, individual on what that client actually wants, but what do you see as most commonly?
Til Luchau: Yeah. I start with the client's goals, but then I do a conversation or reality check around what my goals are and they're based on what I am good at, what I think is realistic, and what I think is most effective, but it's only two. I only have two goals. One is more options for movement. So, I'm looking to find out where and how they don't move and helping them move more in those ways. That's both on a really small level of joint adjustment and on big range of motion ways. The other one is refined proprioception. Can they really feel their bodies in a more accurate way? Some of that is the whole, basically, increasing body awareness, refining body awareness. That helps a lot with pain, and so does movement options. Those two things help with pain.
Til Luchau: Often, the scoliosis person, like I said, they're probably not more likely to be in pain than anybody else, but if they do come in with pain, I work with them as I would back pain. If there's back pain, then I work with them as I do back pain. I got a lot of tools for back pain. If they have sciatic pain, I work with a sciatic pain.
Whitney Lowe: So, do you see, for example, when somebody comes in, would you talk with them and educate them about, "We're not going to try to change your spinal shape here. We're going to try to help you move more freely," or things like that? Do you talk with them along those lines of, "I'm not even going to begin to try to change your spinal structure. That's not even necessary"? How do you address that?
Til Luchau: Well, I mean a lot of clients will ... Let's put it this way. Probably in my practice, at least in my limited dataset, a lot of people have come because somebody else tells them they have scoliosis. They don't even have an internal experience of that. So, they've been told they have a problem and it should be addressed. Now, there are definitely times to do that. We're going to talk about when it really matters, but there's other times, if it's under 20 degrees or they're already an adult, et cetera, where they stay mobile, they stay engaged with their body, they're going to be fine. So, then it is reframing it.
Til Luchau: I remember one client who came to me. She said, "I want you to help with my scoliosis. I hear you're really good at that."
Til Luchau: My first question is, "Okay. So, why? Why do you want to address this now?"
Til Luchau: Her daughter was getting married and she wanted to look even in her daughter's wedding pictures. She had an address in mind that would really show her scoliosis. So, there was a case where, well, my usual conversation, like you said, it's like, "Well, my goal isn't going to try to get you straight. It's trying to get you comfortable and moveable and adaptable," but her goal really was to be straight.
Til Luchau: So, I had to have an honest conversation with her and say, "There are times that this helps people be really straight." I have photos in my old collection and we used to take photos before and after every session. There are dramatic changes as do a lot of other practitioners, but, honestly, if we're really honest, not everyone changes dramatically visually. Maybe most people don't change dramatically in a visual sense from any treatment even though-
Whitney Lowe: Yeah. The other question, of course, how long do those changes last?
Til Luchau: Then there's that question. That's right. That's right. So, in her case, because her goal was so much about looking straight, we worked in the mirror with her perception inside out of what straight felt like, so she could find it for the picture, basically. Then we did more work around her mobility and comfort, but she wasn't in any pain. So, once she felt comfortable being straight, she was done with me.
Til Luchau: Now, there's other people that I'll work with on a more ongoing basis in a maintenance sense to keep them mobile and keep them in their body in a way that helps them deal with the asymmetries they have in their body because they are in some ways more challenging.
Whitney Lowe: Yeah. Right. Huh. That's big challenges I think that really are important for us as practitioners to get a different perspective. So much of the way we tend to look at things does come from that kind of fix it mentality or fix it mindset. It's really so crucial a lot of times to step outside that box and say, "Well, let's talk about lifestyle and function and what are really realistic goals to be pursuing here."
Til Luchau: Lifestyle function, body image, acceptance, your own body. I mean, I'd say to myself, I don't say this to clients, but I say my goal is to help straighten out people's ideas, not their back.
Whitney Lowe: Oh, I like that. Yeah. That's a good bumper sticker or a T-shirt. Yeah.
Til Luchau: Oh, boy. I mean, I could go on forever, but I'm just wondering, is this a good time for our halftime thing?
Whitney Lowe: I think this is perfect time for that. So, let's hear from who's sponsoring us today at half time.
Til Luchau: Half time sponsor is ABMP, Associated Body Work and Massage Professionals. ABMP membership combines the insurance you need, they say, the free CE you want, that's for sure because both Whitney and I have things there, and the personalized service you deserve. They are featuring their new dynamic five-minute muscle review app with muscle-specific palpation and technique videos, and the award-winning massage and body work magazine where Whitney and I are both frequent contributors.
Whitney Lowe: Yes. It's certainly easy to see why all these members love ABMP. I personally have been a member for years, and it's clear the organization is driven to offer loads of key benefits to their members, and their primary focus is on delivering exceptional opportunities and services. Any of our listeners who join ABMP as new members can save $24 on their membership at abmp.com/thinking. So, with ABMP, you can expect more.
Whitney Lowe: All right. So, we drifted into a little bit of this before the halftime, but let's talk a little bit more about manual therapies in terms of what we want to be doing and what are some of the treatment strategies that are engaged for people with scoliosis. We already mentioned and we're talking about we're probably not wanting to be focusing so much attention on, "Hey, straighten this spine."
Whitney Lowe: Now, of course, many people, if they have, let's say, severe congenital scoliosis and they're going a traditional orthopedic route might be having surgery where that is the surgeon's goals, but so many, many people who have scoliosis issues and especially the adult onset things that probably isn't necessary or something ideally in their preferred treatment plans. So, what kind of things that we should be focusing on here? Let me know, Til.
Til Luchau: That's really the key question and to talk about that, we do need to talk about when it's a problem. Like I mentioned, under 20 degrees, adults unlikely to get progress, get more curves, but in a young person, like a kid, and especially adolescents, then it's probably not something or it's not something you want to just try to treat with manual therapy. You need to be assessed because the younger and the more severe, then the bigger the chance that it could keep getting more severe as they grow, and at some point, it is a problem, at some point.
Til Luchau: Classically, it says 30-40 degrees, you could have a breathing impairment, heart impairment, organ function impairment. So, at some point, it's a serious issue and there is a window of opportunity around adolescents, couple years before and after adolescents where bracing seems to be particularly effective to keep it from progressing more. Then at some point-
Whitney Lowe: Yeah. I want to pause just for a second here, Til.
Til Luchau: Please, yeah.
Whitney Lowe: Back track for our listeners here. You've made a couple of references to degree measurements here. So, are you referring to the Cobb angle when you're talking about those degree measurements?
Til Luchau: I am. Yeah, Cobb angle.
Whitney Lowe: Okay. Can you just briefly tap on that for our listeners to clarify what we're talking?
Til Luchau: Yeah. Thanks, Whitney. It's the difference in the greatest off vertical vertebrae. So, essentially, you take the two vertebrae that are the most tilted on an X-ray. You draw lines through them and you measure the angle between those lines and that's your Cobb angle. It's a measure of how side bent you are in that plane. It only does one plane, so it's not perfect at all.
Whitney Lowe: So, and note that's going to require an X-ray to really be able to do that appropriately. So, that's not something we're going to do clinically with people, but they may come in having been to some other medical professional who was looking at X-rays and giving them some indications of angles associated with that.
Til Luchau: That's right.
Whitney Lowe: So, just want to clarify that for everybody there.
Til Luchau: Thank you.
Whitney Lowe: Yeah.
Til Luchau: So, you're asking about body work.
Whitney Lowe: Yeah, and then we were wrapping up to saying the younger that that person was and the more potential there is for it to become problematic, they do definitely want to get that addressed, especially if that angle is pretty significant with them because-
Til Luchau: That's right.
Whitney Lowe: ... time can continue. If there is a curvature present, the continual progression of that curvature can keep going in the wrong direction as opposed to moving back into a natural straight position. Now, there are instances, of course, where scoliotic things will occur in adolescents and they will flush themselves out and straighten up a bit.
Til Luchau: Oh, lots, lots of times or even more common, scoliosis appears and doesn't turn into a problem. They continue their life and they got a little bit of curve and they're great.
Whitney Lowe: Yeah. I think I had read ... This was a popular news story, I don't know, a couple of years ago or something like that. The sprinter, world-class sprinter Usain Bolt has scoliosis, right?
Til Luchau: Yes.
Whitney Lowe: So, that's always a great example of, yeah, you can function pretty good under lots of conditions with scoliosis and does not necessarily have to be fixed.
Til Luchau: That's right. Yeah. Well, and then there's stories, too, about people with scoliosis with pain. There are times it's a problem. Again, from a manual therapy point of view, at least in my view, I work with pain as pain. I don't work with pain as scoliosis.
Whitney Lowe: Yeah. So, let me ask this question since we're going along that direction, and you had brought this up earlier. People look at this in terms of a simplistic picture about treatment strategies for addressing scoliosis. Let's just take something really simple like a C curvature of the spine, which is relatively simple to visualize. One side is shorter, the concave side is shortened, the convex side appears to be lengthened.
Whitney Lowe: So, the idea that we would have as manual therapists, "Hey, we should go in and work on that shortened side, so those things relax and straighten the spine out." So, what do you think about that?
Til Luchau: The bowstring model.
Whitney Lowe: Exactly.
Til Luchau: If see it bowed, then we're going to go work on the bowstring length in the bowstring because that's got to be pulling it tight.
Whitney Lowe: Exactly.
Til Luchau: Pulling it closed. Well, the research doesn't really back that up. I mean, it's what I learned and we get very intricate. You work one way below the apex of the curve, another way above the apex of the curve. You can get so involved in that about exactly which structure and looking at the limbs. The problem is when you measure the forces required to bend the spine, the muscles of the trunk aren't strong enough to do that.
Whitney Lowe: Yeah, especially with their anchoring location so close to the spine. The axis rotation is not powerful enough, yeah.
Til Luchau: It's pretty safe to say the spine is not being bent by the muscles.
Whitney Lowe: Yeah.
Til Luchau: Now, there are ways that the muscles could contribute to movement restrictions. In order to bend any direction, you have to be able to lengthen the muscles. If the muscles aren't used to lengthening or you don't let them LinkedIn, then it's going to be hard to bend that way. So, that's the role for soft tissue, in my view. I mean, it ends up being looking like we're lengthening the short side, but it's from this more modern model that says it's not a physical, passive quality of the tissues we're trying to change as much as tolerating movement in a direction that's unfamiliar.
Whitney Lowe: Yeah. So, would you say our goal is really more about creating new-
Til Luchau: Options for movement.
Whitney Lowe: ... neuromuscular patterning and, yeah, new options for proprioceptive patterning and things like that to occur in those areas that maybe are helped with reductions of pain through descending modulation, all those other magical things that happen from touching people.
Til Luchau: My goal is options for movement and refined proprioception. Pain, I put aside for now for another discussion. We will have one on pain, but when I get options for movement and I get refined proprioception, a lot of pain gets handled.
Whitney Lowe: That's what I was going to say. Yeah. That's like the result of process of us as focusing in those directions.
Til Luchau: Exactly. Exactly. So, manual therapy's role, really, I got to say it again. What's the client's goal? We've got to have a conversation early on about their context because it's something we're going to do together. Whatever we do, we're going to do together. I don't really think of manual therapy anymore as lying a client down and passively changing them in a way.
Til Luchau: There are some things I can do with my hands. They're pretty effective and they don't have to even know or participate, but especially the question of does it last and is it going to be available, that involves some level of participation, and it might be active movement, it might be them actually feeling or breathing with me or understanding. So, to get them to participate, I have to understand what their goals are.
Whitney Lowe: Right. So, while we are on this thing with the movement and manual therapy interventions, I just want to call back. You called me on something a little while ago with the quadratus lumborum thing. Is this a time that we would revisit that? I'm curious to hear your perspective on it.
Til Luchau: Well, it's a big discussion, but your statement, I think, I remember was, "Well, it could be functional in that the QL could be tight and pulling the right hip up." If the QL is tight, first of all, there's a whole discussion on what tight means. Is that a passive thing? Is it an active thing? Does it change? Is it a sensation of tightness? Is it a measurable thing? et cetera, but let's just leave that aside for a minute. Let's say somehow it is pulling. Is it going to pull the leg or the hip up? Are they going to pull the trunk over? Which is the fixed point?
Whitney Lowe: Well, that becomes a question that might depend on the position that the body is in. So, for example, let's say a person is standing. Maybe their righting reflex, their vestibular balance reflexes, let's say the quadratus is pulling in those directions. Maybe it would have a tendency to pull the spine to that side, but their vestibular righting reflexes make them want to stand up straight. Would that, and I'm asking the question because I don't know, would that possibly then cause the quadratus to lift and pull the pelvis up off of its resting on the greater trochanter to lift the pelvis a little bit higher?
Whitney Lowe: I mean, I've seen that clinically happen in people with extremely hypertonic spasming low back muscles and a hiked pelvis on that side when they're in a standing position, and the same thing happening once they get in a non-weightbearing position. It's a lot easier for that pelvis to get lifted up as opposed to the back being more the trunk being pulled to that side.
Til Luchau: I see the same pattern. I don't assume it's the erectors causing it. I don't think the erectors are the chicken. I think they may be the egg.
Whitney Lowe: Oh, I agree. I think it's not the erectors. I think it's more likely the quadratus. Do you think that it's-
Til Luchau: Oh, I don't think the quadratus is the chicken either. I think it's the egg.
Whitney Lowe: Really?
Til Luchau: Yeah.
Whitney Lowe: So, what's doing it?
Til Luchau: What's doing it? I don't think I need to know that even. I think I need to know how to work it, but I don't assume that it's tight muscles pulling something up, first of all, because tight is so debatable. Are we talking about resting tone? Yeah. That's a great thing for massage therapists to think about, for example, because you're thinking about relaxing.
Til Luchau: If we can get it to relax and we've helped, there's something to that, but it may not have a higher resting tone. You go palpate someone's tissue on their back who has scoliosis, the muscles in the concave side are not going to be necessarily more tight. You often won't feel more tones there.
Whitney Lowe: Yeah. I'm totally with you on that because I think in a lot of instances. We may be talking about two different things when we talk about a muscularly induced lateral pelvic tilt from severely significantly hypertonic muscles versus a person who's just got scoliosis, which appears to be maybe related to some muscular involvement.
Til Luchau: There you go. There you go. If I find severe hypertonus, really hard to the touch and they're obviously contracted, then definitely I'm going to work with that, but just because of the position, I don't assume that's what's happening because there are other things that could contribute or reinforce or perpetuate that position.
Whitney Lowe: Yeah. Okay. Are we done with that?
Til Luchau: Sure, sure.
Whitney Lowe: Okay. Yeah. I mean, we can, of course, probably spin off on this for a couple hours at a time.
Til Luchau: Well, maybe one more comment. In practice, what I do is I look to see how people can move or I feel how they can move. If they can move that way, good. I don't have to try to relax it, lengthen it, whatever, anymore. We got the movement.
Whitney Lowe: Yeah. Yeah, and I think we really have a lot of unlearning to do about looking at things from a pretty mechanistic viewpoint just because that's the way we're taught and that's the way a lot of musculoskeletal science has been taught for a long time. So, there's certainly interesting perspectives to blend about that. There's a lot of instances where that perspective is really viable and very pertinent, and there's a lot of other instances where it doesn't fit the model quite as easily.
Til Luchau: Scoliosis was my waterloo, you could say. It's the one where I kept dashing myself against the rocks of my clients with my theories that I'd learned so carefully and thoroughly, and it wasn't happen, it wasn't working. So, I really did have to go through and rethink it. You're getting my current formulation after I really, like you said, I'm having to unlearn a lot of what I knew and it seemed to be right to me, but I'm changing my mind.
Whitney Lowe: So, you, in essence, became the thinking practitioner then.
Til Luchau: Huh? Yeah. There you go. Let's not be the overthinking, but sometimes it's really simple.
Whitney Lowe: So, let me ask another question here in relation to what we're doing with manual therapy because there may be instances where you come upon clients who have had, let's say, a severe congenital scoliosis which has been surgically treated and they're having Harrington rods, which are the rods that they put in a person's spine to straighten it out when they have a surgical treatment of scoliosis. Concerns, cautions, thoughts about working with people who have rods and bracing in their spine.
Til Luchau: The usual surgical considerations apply. If it's a recent surgery, then no. You let it heal. That's about it, I mean, honestly. I mean, there's more. What typically happens, Harrington rods is an older form. I don't know if they're used much at all in North America anymore because they were straight. They were based on the X-ray view of scoliosis as a lateral curve. You could take an extra before and after and say, "Look, it's straight now."
Til Luchau: There's lots of those, but it didn't address the three-dimensional aspect. It didn't address the movement aspect. So, there were complications. Not everyone with Harrington road has complications. A lot of people still have them in their body, and do well with them.
Til Luchau: One of the complications was they would isolate the movement to the upper and lower into the rod, so that the joints at the two ends of the rod would be more demanded on them on movement and they would after a few decades be more likely to show arthritis than other joints in the spine.
Whitney Lowe: Yeah. Certainly, as we now know, there's lots of other functional biomechanical and physiological challenges that come along with fusing vertebra and stopping movement at those motion segments even if it's not the ideal type of movement. It certainly can cause some other kinds of things later on to be seriously problematic.
Til Luchau: Yeah. I'm careful about how I talk about that with, as I'm sure you are, with clients because it's also true that a lot of people have, like I said, have rods and have fusions and do just great. My approach then is let's get everything moving throughout the spine, including cervicals, including actually hip joints, SI joints, all that. If that's all moving, it does relieve the demands on those two ends of the rod.
Til Luchau: The other thing about rods is I'm not trying to bend them, by the way. I'm not trying to get them to curve, but I don't assume they're fixed. People will still have the experience of movement and sensation and proprioception even in the sections of their spine that have a rod. It's actually been my clients and some of our students who have really strongly come back and said, "Work the rods. Work the zones with the rods," and we're not trying to bend them. We're trying to bring back options for subtle movement, lots of refined proprioception, and bringing them, in some ways, back into the brain's map of what's happening in the body, and that seems to be really helpful.
Whitney Lowe: Yeah. So, these are important considerations if people have had some of those kinds of things and you may or may not know some of the other treatments that people have gone through when they have had this. So, these are some really key considerations for what we can contribute as manual therapists. This is one of those instances I see frequently where we may be working in conjunction with other health professionals who, let's say, somebody maybe going to their physician or orthopedist and trying to have some things done with the more structural aspects of that, and they're coming to see you at the same time.
Whitney Lowe: So, this an important time to take into consideration. You had called attention to this, and I think this is really important that we don't ever try to supersede anybody else's perspective or practice about the way they're trying to address this, but there's lots of different ways that we can approach the perspective of what we're doing with people.
Whitney Lowe: I really liked your ideas in talking about just refining proprioception and refining, encouraging movement and just freedom of movement, and reduction of those.
Til Luchau: Options for movement. Yeah. That's right. Yeah. One more thing about rods. You can help the rest of the body accommodate the rod. A lot of times you'll see a rod surgery. The spine is straight, the one shoulder is still a lot higher, one arm is still more internally rotated than the other legs are, and there I'm not trying to go straighten everything out. I'm trying to make sure that everything can move in every direction.
Whitney Lowe: Yeah. So, in doing that, do you run through a functional movement evaluation to see how a person's movement is impaired or limited or how do you make that determination?
Til Luchau: That's right. We have a series of assessments. I mean, we got a two-day training and it's really just the overview. We've got a series of assessments that are movement and hands-on assessments to feel for those things we described, and to help the client feel, too, the options for movement and their proprioception.
Whitney Lowe: Yeah. Great. So, how about some other resources or things like that? Any things that people might be aware of or wanting to know about there that would be helpful?
Til Luchau: Yeah. So, it's important to understand that you shouldn't be the only practitioner for someone with a moderate to severe scoliosis. Mild scoliosis is not necessarily a problem. Under 35 degrees, that's said to be the underserved population because they're not to the point where an orthopedist would want to brace them or surgery is not even till 60 degrees or so, but under 35, relatively mild scoliosis, lots of movement, lots of things you can do to help.
Til Luchau: They also should be doing things with their balance and proprioception. So, balanced sports or wobble boards or functional things they're doing where it does challenge their balance in all directions. There's some clear correlations between scoliosis and vestibular abnormalities, that there's more postural sway in people with scoliosis. So, if you can work with that proprioceptive sense of balance, it seems to help prevent scoliosis from becoming problematic.
Til Luchau: Strength and conditioning is the other category that there is statistically lower muscle tone and less strength in people with scoliosis. So, it helps people a lot to stay fit essentially to stay active, to be doing things they enjoy, and multi-directional, multi-movement activities that help the whole body to stay in shape, that seems to help people manage their scoliosis quite a bit.
Whitney Lowe: Yeah. I think when we talk about movement things and strengthening conditioning, too, letting people understand the composite of motions and things like that that are so important throughout the spine because some people would get this idea, "Well, I shouldn't do any movements where I'm bending to that side because that's the side that's short already and I don't want to overstrengthen those muscles because it'll pull my spine even further."
Til Luchau: That's right. That's right.
Whitney Lowe: Yeah. So, I think it's helpful to clarify with them that that's not really exactly how it works.
Til Luchau: That's not how I see it. That's how I phrase it because sometimes, I'm just thinking of a couple clients recently, they're told very explicitly by their physical therapist working say, scruff method or something, some of the other approaches, what movements are good and which movements are bad. I don't want to argue with them. I don't see it that way. I don't want to argue with them. I just encourage them to stay mobile and to explore all options to the extent that feels right.
Whitney Lowe: Yeah. Yeah. What else being other good resource thing?
Til Luchau: Well, I guess the other bullet point, other thing about resources, psychosocial, meaning saying body image or having support or normalizing the experience, especially adolescent idiopathic, typically affecting girls more than boys at a time that your body image is really a big thing that you're developing and getting to know and testing out and the social context is so important that the impact of, say, having to wear a brace, certainly, but even having a rib cage that's a little bumpy on one side can be really big for a kid or for anybody.
Til Luchau: So, there's lots of ways to get support for that. There's some really interesting online forums. One of them is curvygirls.com for adolescent, for teenage girls, where they learn about scoliosis and they have a social media platform and things like that.
Whitney Lowe: Great. Great. Those sound like some wonderful good resources here. Of course, this is a tremendously deep topic. We could go on and on and we'll probably revisit this with some other future episodes, but there's so much in there that I think the real key important takeaways I think are not feeling like have to change structure with people. There's lots of things that we can do that can be very beneficial for numerous individuals that are working with these challenges.
Til Luchau: Keep them moving, give them a great experience in your body and you're doing so much. That's the takeaway.
Whitney Lowe: Yeah. That sounds good. So, maybe we'll wrap it there for today. What do you think?
Til Luchau: Sounds good. Sounds good. Oh, I guess we should just also mention, yeah, don't forget that other medical issues could be there, too. So, if people aren't getting evaluated and they do have a scoliosis, especially if it's changing, go do a medical evaluation. That's always the prudent course, and age, too, if they're puberty or younger. Sometimes wait and see is not the right approach, that they really should also get some expert opinion at that stage.
Whitney Lowe: Yeah, again, those instances where we talked about if it's not addressed appropriately, things can continue to progress and get worse.
Til Luchau: That's the window where there's some interventions that can really make a difference.
Whitney Lowe: Yeah. That's the goal. Yeah.
Til Luchau: Okay. Time to wrap up.
Whitney Lowe: Great. Yeah. I think so.
Til Luchau: Well, thanks to our sponsors. They make this possible and we only pick sponsors that we really believe in and we do believe today with Handspring and ABMP, but all the sponsors that we have helping us out, thanks to all of them. Stop by the website for the show notes, for CE credit updates, for the extras that might come with this, for the references I mentioned. That would be thethinkingpractitioner.com. My site also has it. Our blog page also has those things, advanced-trainings.com, and your site has that, too. Whitney, what is your site?
Whitney Lowe: We do also, and we're over at theacademyofclinicalmassage.com, and also through social media on Facebook. You can find us there at Academy of Clinical Massage. If you've got questions or ideas, other input that you'd like to send to us, please feel free to send that over to us at infoatthethinkingpractitioner.com, and if you will also rate us on Apple podcasts or wherever else you listen, and please do tell a friend, share the words so we can help get this information out to as many people and share it with other people out there in the manual therapy worlds.
Til Luchau: Thanks, Whitney. Good to talk to you today. Thanks for keeping me on track.
Whitney Lowe: All right. Good. We'll do it again sometime soon. We'll see you all again in two weeks.
Til Luchau: Okay. Bye-bye.
Whitney Lowe: Okay. Bye-bye.
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