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Schroth Scoliosis Therapy Everything You Want To Know, Andrea Lebel interviewed by Dr. Derek Lee

I’M dr. Derek Lee and I’m with Andrea LaBelle. It was a physiotherapist. Andrea, is very, very respected and established in her field. With all transparency, I my son actually sees a and Andrea for his scoliosis as well.

So I’ve been very impressed with her. As you can see, Andrea is which I was interesting too. It was actually to find out. It was the the first physiotherapist in Canada, they’d be certified with Shroff and the first clinic in Canada to be to have a full Tots program as well. Andrea, Andrea is also a member, a board member of so sort and has multiple certifications with BS pts.

As a certified instructor and with seas and in terms of certified at a second level and fully certified with Schroth, Andrea, Andrea, it’s all yours. Thank you. Thank you for your invitation am very pleased to present and I hope I can educate to whoever might be signing up to see this video and I think the goal is to have education and to be able to make educated consent for whatever treatment you might choose. In the future, so in I’m in Ottawa – and as you mentioned, I do operate the small clinic, which is focuses on Ernst courses and spinal disorders, and we also have a Scalia’s Resource Center. Where is anybody could come in and it’s open during weekdays and we do free screening for that, I’m trying to advance my slide.

Let me figure it out, yeah, okay, so I want to point out a couple other things during this presentation. I I used my course slides, which is the do no harm course slides, which I teach to practitioners who prescribe exercises for the general public and to make sure they know how to screen scoliosis, how to recognize, scoliosis or any other spinal conditions. Most of the presentations or most of the topics he touched today, you have recorded version on on scores and spine online learning, that’s a platform which is again open to the public and for very minor fees. You will be able to access present presentations, presenters recorded webinars from experts around the world and the farms which we we collect through these webinars and and speakers presentations. We support a couple of organizations, the masters courses, foundation and estates, and I confronted the Kenya scoliosis foundation.

So these are the places where we are continuing education and sending funds to help reach patients and professionals and do no harm, and this assess the well. The sources and spinal nerve learning is a proud sponsor of the e so sort which is on June 20th and then a.m.

Est and this year is all online, so you’re welcome to join and take part for for watching presenters and all the presentations which will be recorded and available for a whole year for you, if you sign up so I think excursus awareness walk and we won’t have It this year this will be the ninth year and we had families come from all across Ontario, some from here and Quebec. They join us for this walk and we are supporting the local hospitals to get equipment like AOS and some surgical monitoring equipment with the frontier is there, so you won’t have that walk this year.

We all know why and you can sponsor and donate directly to the hospital. So I want to point out her, since it was one of the questions where to go for evidence-based, good information when you’re researching and trying to choose the treatment options from treatment options out there. I used to say when you type in to Google Scholar osis, you have eight million link amat, but now actually I checked it is forty fourteen million. So if you wanted to go through those links, it’s gon na take you over a hundred years. So you must go to the most evidence-based platforms, which may not be what you want to read, but it is something which you can be sure that many experts standing behind those platforms and giving you information, up-to-date information on scoliosis, so scholars this research society Is mostly a surgical view society they have non-surgical the section as well.

So it’s important to know that many research has been funded by SRS and published, so it is something you can be trusting when you’re looking at information on the SRS SRS org under that is so sort where I’m a board. Member and secretary for a while now – and it is an international organization close to 40 countries presenting each year at the annual meeting, we have courses before the meetings and this year it’s gon na be online and doctors, physicians, orthotist, chiropractors, psychologists, physiotherapists are members here. Patients could be members as well, so you’re all welcome to join these conferences and take part or take part in the courses. There’S an open-door policy here. So everybody is welcome and this this is any presentations or any publications go through.

So short, it is going through a committee and assessed and checked for good quality information and good quality research. So it is another area where you can search for information as the school assistants find online journal is open access. Now we are in a process of joining another journal, but you can get many old publications from that website. We also in a transition of a website, so it’s gon na be any day now so sorg, okay, the last International Organization, is the research society of spinal disorders. This is where all the researchers get together every two years and present their very high quality.

Amazing research. We had a combined conference with IR SSD and we hope we have another one. So sought is Dean and a couple of years and the last one was in Canada in Banff, and we were amazed at how much we learned in a short period of time and then look for surgeons. You can look for surgeons with open mind. I just put in one surgeon here, dr

Michael Batali, who was one of the first ones with dr
Brachii, who was vice president back in 2009, who were open minded, and they were also interested in offering non-operative treatment methods, and this is new.

It’S not not very common that you see when you see a surgeon, they will offer other methods, but completely right surgery. They are surgeons, so they are more aware of all the information. What the surgery can do so, and you can see many surgeons who do not believe any of the non-operative treatment methods, and this is a presentation I gave at the hospital special surgery in a top orthopedic Department in United States. All the individuals in this room are spine surgeons, and as it is, you name it biggest names are sitting there and after this presentation there was not much of a consensus that this patient got better from 52 cop degrees to down to 16 and the surgeons saying That it is not doesn’t matter what you’ve done here. This patient will progress.

Some will need surgery, so you’re just wasting the time of the patient, so this presentation actually available also necessarily I’m going to present it on June 14th, 12-year follow-up of non-surgical management of a case, and it has been a very popular case. I’Ve been presenting it all around the world and now HSS also after this presentation actually created a non operative department and offering Shroud physiotherapy embraces. So this was back in that 2012. So it’s a long time ago, things have changed since then, and then I’m doing not just local courses at University of continuous it on the left side, but also international courses to teach professionals and physiotherapists whether it’s a do no harm course or the certification course for Treating physiotherapists, we have annual presentations from the clinic presenting our research at the so short conference and some other platforms and the resource center picture and up there you can see a picture of the walk which is not happening this year. So, just a little bit more where this all this information coming from and and what should we do when the child is diagnosed with scoliosis, and there are a lot of questions.

Millions of questions come to mind right after diagnosis. The families are searching for information. The teens are also asking many many questions of themselves of anyone they meet and it is and really why territory of known and unknown and depends on whom you talk to at home, you see and the teenagers they want to know. They can dance so they can do yoga, they can do weightlifting or what can they do in a gym? They are concerned about if they gon na progress, if they’re gon na get better, how do they sleep?

How did they sit? How do they walk? They are really thinking about worrying about every movement they may take if the curve will get worse by doing something and what can they do and what they should not do so gon na touch on that a little bit, and if I need surgery or when do I have the surgery now or later. These are all big big questions and the family needs to make it an educated decision for the for their loved ones. So it’s not so easy to to get that answer and before I give you answers for that, it’s important that we take a look at what is actually happening with their scoliosis condition.

What is it, what is the definition and why it is important for us to actually know all the three-dimensional aspect of the scoliosis, so this this definition is very well explains the structural component of the series of vertebra segments, in extension in lordosis, which, after that deflect, Which is lateral and axial rotate towards the same side, so once you’re responding your hand or you’re looking at your own spine, your spine, during that scoliosis deformity is moving out of the natural curvatures in extension, and lateral deviation and rotation and the same side. So when you were talking three dimensional, it is quite complex and when you’re talking multi factor causes it’s also quite complex. So I’m just gon na try to well move my my and speaker here good. So what what should we do? Should we get the patients or individuals more flexible, or should we increase the flexibility or should we decrease the flexibility?

That’S also a huge question: should we start doing yoga Pilates exercises anything you you might Google or take your you know you find there will be a lot Yoga for scoliosis Pilates for scoliosis any type of exercises for scoliosis. So what should we do? What should we keep in mind? These are very flexible people and I have a permission to show the yoga teacher natok, who was actually doing a yoga pose, but I want to show you that historic, his rib cage actually could not rotate, not because he has scoliosis is just a structural, individual limitation And you can see what it does with the spine to achieve that yoga pose and then you’re gon na see the ballet dancer here on the right side, which is a beautiful movement, and I don’t think she Ascanio sees. But you can definitely see what the spine is doing doing this during this movement, so if she would have scoliosis going to the right in a thoracic area, this movement probably going to increase that table angle, curvature and then down here.

Another yoga pose nothing against yoga. It could be done safely and we just had a new representation on ssoi, which was amazing, so a lot to learn on on poses and exercises, and this is a leg up on the side, and if this person would have an left lumbar curvature, it would be Keeping more force to that curvature to progress, so it would be very important to take apart some of the movements, some of the activities you may choose, and then you can see a whole lot out there on the Internet for magical exercises for scoliosis, which clearly does Not whoever prescribed these exercises never read the definition of scoliosis. When asked, or is this the first word they say it’s extension, adding more extension more backwards, bending it’s clearly going to not stop the scoliosis but keeping a little bit more chance, perhaps to progress it. So any of these movements – if you know the definition of the scoliosis in terms of extension, a lateral and rotational component of the same side, you will see that extension exercises passive, active. It’S not necessarily going to make the natural curvature easier to regain, also weight lifting on the right corner here, creating more rotational forces, and it is not necessarily the magical exercises.

Nevertheless, this little boy who’s struggling there to lift arms up and and hanging off, I’m not sure how he doing it, maybe standing. It is full of compensatory movements, so very important to look at what we give as an exercise and how they are performing the exercises. So these are no no’s. These are not something we would recommend for patients, and you can find these exercises everywhere on the internet, so don’t trust them because you know the definition of scoliosis. These are physiotherapists who are giving exercises, and these are regularly trained physiotherapists.

So they don’t action, learn was the right I’m wrong. In the physiotherapy school they learned that scholars is in one plane of deformity and lateral curvature of the spine, and they are thinking of that one plane of deformity. But if you know the definition of scoliosis, you know already that this person is not gon na get better. With these type of exercises, it will create compensatory curve, as you can see it on the lower-back curbing that away and the pelvis is pushed even further out of midline. So university of alberta made a lot of local research.

So since we have local research current Canadian research available, I feel that the professional community is listening a little bit more, so how to correct the position in a posture. This is a high level of soccer player, with a double major curve of 50 of each. That means the thoracic and the lumber, both fifty degrees and I’m asking everybody when they come and show me your your training moves. Show me our yoga move. Show me what you have to do for your training activities, so she’s a soccer goalie and showing me her side plank exercise.

Clearly not what we want to see and a trainer with the t-shirt on with the tank top whatever they wear. They don’t notice. That may be, but it’s not corrected, then I say well show me the other side how you would do it on the other side and again clearly is not a very stable pelvis, a very stable trunk. You can see the twisting and turning to perform. The exercise with this double major curve is not so easy, so I will have to adjust that I have to create a position where the pelvis the shoulders are leveled.

She has a little bit of support with an elastic band to maintain that and to not to harm herself during the training of the soccer practice, but actually maintain some kind of stability of the spine and the pelvis. This is not necessarily a shrub exercise or any kind of exercise. It’S made up on the spot. As we see it’s a combination of many things, but it is something which is helping this client to do so same with the planks. Many physiotherapists are giving planks for core and other trainers as well and pour and planks well.

It would be good if it’s done well, but we already know about the natural curvatures of the spine. When we looking at it from the side, we have a natural kyphotic, lordotic area. We cannot lose that we cannot lose the lumbar lordosis. That would be worse for the future. We really need to maintain November lordosis, so I’m not asking her to stop her activities, I’m trying to help her to do it better.

So you can see a little bit of here the lumber prominence because of the lumber curvature and you might see a little bit of more prominence of the thoracic right shoulder blades, but because of the upper thoracic curvature. But she isn’t a better sagittal, lateral view of the alignment so very important to not just pick an exercise because it says it’s from scoliosis, but you’d have to do it well for yourself, and you can see, all of these exercises are very individualized so because you Already know the definition of scoliosis, you know that we do not want to flatten the upper part of the spine where we have a curvature. Let’S say to the right closing the shoulder blades pushing the spine forward into more extension. So it is something often given to strengthen the muscles between the shoulder blades, and it is not necessarily at any effort for discovery of the patients, because that’s not the way that there is that the muscle is going to be exercised. It’S really no brainer for them and no effort because they show the place because it just already slides together, there’s no rib cage or no limitations for the muscles to just kind of close on that forward position spine.

What will why is it forward position that spine? So we know what happening when the scoliosis develops. We know that the birthday bra and the disc is growing a little bit faster on the anterior aspect of the vertebra of the bone. It is a gross failure. It’S a growth problem, as the children are growing.

It’S always a lot of research now out. Why is it happening? How it is happening? We know it’s happening. What started up is still a big question, because this is gon na, be the million dollar question to answer and take the idiopathic out of the diagnosis, so that will be refined at cost.

So a lot of things are happening in in in the nervous system. A lot of things happening during growth, hormone changes and the fast growth period, where there’s a mix, mixed information and some physical forces creating a larger growth of the frontal or the ventral part of the vertebra and limiting the growth in the posterior aspect of the vertebra. So there’s some compression and some tensions, so it is important to know that if it is severe like this, the spine moves forward so again. Exercises which are doing more and more extensions will not help the scoliotic patients and it is one of the possibility, more common mistakes. I see to strengthen the spine to strengthen the back to get more mobility.

Everybody goes into giving extension and strength exercises, so we can also see this during the screening process when they are doing the addams forward bending test. You can see it on even arc from the lateral view, and you can already know that, even though this child was only having a 30-degree curvature with this flattened and forward position, segments of the spine, multiple vertebra moving forward and going to move, lateral and and portioning. This is going to end up to be a big curve unless it’s very aggressively treated, so she already had this by no fusion. We already knew that if she’s not hundred percent compliant with bracing and scores a specific physiotherapy, which in fact she did beautifully this, both together, we’ll have a little chance to stop this curve. But if it is not 23 hours of very good quality bracing and not a very motivated individual, with compliance at home, we have other options non fusion and fusion surgeries.

So it’s not not always the goal of the family to avoid the surgery. I think that to be flexible and if it is causing more mental health issues and more fights at home, there is an option. There is a treatment option which is evidence-based to halt the curve progression to stop the curve is the spinal fusion or now the non fusion surgeries. So it’s important to know that this is what you can observe on a severe scoliosis before a very fast progression. As soon as this child is growing, it wasn’t in a brace as it was prescribed, the progression hit 50 degrees – I think in a few months, so it is something which which is visible.

So how do we check during atoms forward bending test? The patient’s? If you have asked oolitic posture, which you might even after surgery or before or anyways without any scoliosis you could have. This is my son on the left side and he was checked every day. He was screened on a daily basis before breakfast after breakfast, so you could see his posture is quite scoliotic and as he forward bending, you cannot see any elevation on either side.

So this is a non structural, functional, postural scoliosis, you name it any way. You like it this patient, like him, I taught him how to breathe into correctively opening the ribcage evenly. He he does it any time. I ask him or any time he wants to. He works out in a corrected posture, not in this posture and he does not have scoliosis.

So it is a fast rolls, a fast asymmetric, soft tissue development, but everyone who named it creating a scoliotic posture and also he prefers his left-handed. He prefers to use his left side. It refers to breathe into the left side, so it is something which we leave it like that, let’s say and never be consciously explained to him. What’S happening, we’re leaving it like that for 1020 years it could become structural, so it is not an adolescent, idiopathic, aggressive curvature, but by positioning by the forces of gravity and other vector forces. It could eventually create an isometric, wear and tear and become as scoliosis in the future, but for now he is completely straight.

So what do you see in a structural scoliosis during the atoms forward bending test? You would see a curve. You could see a curvature of the spinal processes. You can run your finger through it, it could be, very mad, could be almost unnoticeable, and you also see some prominences and the thoracic spine. You see the rib prominence of the rib cage and on a lumber spine, you see the lumber prominence of the vertebra rotation and the muscles which are sitting on the top of it creating a bump.

So these prominences are very visible during the atoms forward bending past. So, for that reason you can imagine if you’re giving bending exercises for scoliotic patients bending exercises, it will be aggravating or increasing these rotational forces. So, according to international guidelines, we will screen patients and over five degree is considered positive, but we are very careful of ordering x-rays if you’re really sure and the Scalia meters showing seven degrees. That’S probably the right time to order x-rays. That’S being said, there are large curls with less rotation and there’s small curve with large rotations, so the rotation of measurement not always represents the curvature inside.

If the kids look Scully, Oh dick, if the posture is scoliotic and schoola mater only measures 5 degree, you probably still have to order an x-ray, and this kid maybe already have a 2025 degree curve which needs to be treated if it is still a growing child. So recording x-ray, it has to be very carefully done because, if, let’s say the order next day for a 5 degree, not much rotated, not that scoliotic and you only see 11 degree of scoliosis the next x-ray you shouldn’t be ordering next month, you have to order It in six months now doing that six months and the fast growth combination, you can get 40 50 degree progression, it’s very fast if somebody growing fast. So it’s important to pick the x-ray timing the right time. Then you have some good baseline and if the child is in fact in a very fast growth, you might have to have one in three or four months and if you have an iOS machine in your city, then ask them that you know you see. This is fast progressing, get an early x-ray so and not to miss fast progression could be five degrees and mounted I’ve seen it even ten degrees.

So it’s very important to to catch the curve at the right time, not too early and not too late. When you are actually needing some treatment, okay, Scully a meter, you can use a phone accent and, and anything else you might want to use for that. There’S a water bottle method as well. So a lot of way to screen out scoliosis. It is important to start the early detection and early diagnosis.

Not too early. We don’t treat 10 degree curvatures, but it’s still called Colossus, but early means early enough that we can make a difference. So the treatment options, racing part-time, bracing full-time scores. The specific exercises there are many methods you can choose from and then always the goal of the early treatment is and any treatment really is prevention of curve progression. We have to count the curve if the curve is not stopped, the treatment doesn’t work, so we have to always pick the right treatment to be able to hold the curb progression, and we know the risk factors.

It is very well known that earlier the child is diagnosed, the risk factor or progression is much higher, more girls progress than boys just because they may be growing a little bit earlier. There’S some more research done on under hormonal and other aspect as well. The curve magnitude usually 25 degrees. An arc has a better chance of progressing growth potential. If somebody is really four feet, but all the parents are 6 feet tall, it might be a lot of growth left over.

So the growth potential is also very important to try to figure it out and we look at the research sign or some girls sign at hand actually now to see when the growth happening and when the growth is finishing progression happens during the rapid growth spurts. So there, in some months, there’s some almost years here and there when the kids don’t grow, that’s not the time to be worried about progression. When you see the feet grow. When you see the parents are getting short, that’s fast progression. You’Re gon na have to worry about that the the progression of the scoliosis.

Now we measure height, we measure the height even down to the millimeters, and we encourage everybody to measure the height even down to the millimeters. At the same time of the day, let’s say every Saturday and 10 a.m:

And see what happens now, you could have the child not growing, but you see progression. That means the growing happens in the curve and the major progression happens. So it’s not a hundred percent indicator but Lisa.

If you know, I see in kids every two weeks when they come a centimeter of growth, that’s a whole lot. So if you see any kind of increase in the height, even if it’s five millimeter, you could be such a put, it alert it and and checking closely what’s happening with the children. Where progression happens between age, eleven and fifteen boys and girls – and it happens fast, as you see it, this is a very famous slide from the International, so sort with the wobbly prey research-based information. So this is, these: are the ages when you are really alert and watching like a hawk these scoliotic kids, because they will progress if they are not treated properly. So it’s important few lucky ones percentage-wise, but if you reach 38 degrees by age 11, unlikely that this curve is going to stop and stay there unless you treat it very aggressively, sometimes okay, curve progressions, we have many objective charts you can plug in the Kabongo.

These are, this is an older one in 1982, based on census of many famous spine surgeons, and you can just as an example, 30 degrees, H. 10. You go into that age. Category 90 % of progression. That means out of 10 kids 9 will get worse.

There will be one lucky one if, if the curve, of course higher than 60, there are progress, so it’s important that you know that is the progression and we don’t call low risk 40 %. We try to call no risk like 25 %. But again, if you have a child, who’s has, let’s say 15 degree, cob angle, which is a smoker just iagnosed and it’s 11 years old, every fourth children. Fourth, child will progress with that kind of Kabongo, but if that person is already 14, only one out of ten will progress, and if that person is 16, almost nobody will progress. So it is important that you look at it.

It’S not. You know it’s not exact. For everybody, but it’s a major many many numbers are collected to create these charts and we need to make sure that we diagnose the children early. When we got an early diagnosis, then we have early treatment, we’re talking 25 degree or 20 degree. We can make a difference at many.

Many cases who who are straight now and – and it is not because you know score – is a specific physiotherapy magic is just because they were either compliant or they had the german mother or a russian father, and they had no choice of doing but doing exercises. But on the other hand, it is evidence-based, dr

Mcdreamy steam already produced evidence that small curves did the good prescribed for specific physiotherapy and compliance could be reduced. Now a little bit about bracing, you had a question about bracing. What kind of braces we use? We really want to be able to have the brace create a curve correction, ideally 3d.

So there are many many braces around and no matter how you call them the place could be a good place or not so good, brace so the just because the orthotist are trained and different bracing and you need the 3d view and a 3d knowledge to create A really good brace for that child, because the same brace may not work for the next child. So this is a brace concept developed by dr. rego. What we using at the clinic based on a 3d correction, according to the do be set concept. The preset was a very famous surgeon and very I should be highly valued of his work in a scoliosis field.

School is not just a scoliosis but the transverse plane deformity. We have to incorporate in the brace and inspired in a brace concept development by Jacques shano shano that the Chenault was the first orthopedic professional surgeon who developed a brace that created a three-dimensional option in there, and that was in 1979. Since not that long ago, so we dr

Rico developed this concept further and created the 3d brace concept by dr. Rico and yellow, which is an Serbian doctor who also works with dr. Rico.

Also is you can name it a new 3d brace generation, so we have many 3d braces available out there, but it is really, depending on the good assessment, the good hand and a good vision of the orthotist to create that perfect brace for the child. So doctor Rico makes the braces by hand it’s like an artwork when he was in New York. It’S very special surgery took two days to file the brace carefully to add the push pads carefully and running through every order. Is there how to make the brace perfect for a child with the high risk of progression, and then they had fitting and looking at how dr

Rico’S, adjusting the brace, the brace is not painful. The brace is not separate.

Limiting the brace is not limiting this child to do the somersault or do anything she wants. It is keeping stable the spine in the best possible 3d correction until she grows to change a little bit of the growth changes, great growth, modulation, let’s say so pssc. What is it physiotherapy, scoliosis specific exercises? This is how we call it an international platform and what it is and what is not, since you know already the definition of scoliosis and you seen already an atom’s forward bending test. This is from the internet.

I don’t know who put it up, sir cut it up, hopefully – and this says short method for scoliosis now you already know when a child bending forward and we checking the atoms for with bending test. This is where the thorax and the rib cage is the most rotated. There’S no way a schrott physiotherapist ever who is trained well, will give a forward bending type of exercise like that, so just because it’s called shroud or just because it’s called doesn’t matter how it’s called. Really you really have to check where knowledge came from and again this is what we teach at the be SPT of school in, according still do beset concepts. Courses correction looks for the best possible sagittal, which is very critical these days, the sagittal and frontal plane alignment through throughout combined the torsional forces not producing any, not even bad, but any compensate Tory or imbalance or disharmony.

So when we are doing a forward bending just this little picture here, yes you’re increasing the thoracic kyphosis. That may be good. Let’S say because we know it’s an extension deformity, but it’s also losing the lumber lordosis in a cervical lordosis that one movement and, if not not just how could it maybe have a little percent – could help there, but there’s a lot of high percentage of harm there. So it’s important that we do not create any compensation, any imbalance, any disharmony during the specific exercises, if you’re interested in further knowing about PSS, sees the most commonly use their research methods around the world. Myself and my daughter co-authored the Hoggett bearish axis paper here about the seven schools which are providing evidence-based scores, a specific physiotherapy.

It’S an open access and you can look at that. Publication are read it. It’S a full of pictures, very nice publication, it’s close to over 100,000 reads now and different platforms, so very popular publication, and it is also presented by the author on s Sol with a very long webinar. The recorded webinar is available and you can hear the explanation of different schools and you can see videos and so on what it is really methods from France, from Germany, from Italy, from Spain, from Poland, two different methods and from UK. These methods are work.

It’S not something we have to compare. Do they work, do they not work? They all work, because they all have three things in common, active self, elongation, active, 3-dimensional, correction of the body and exercising in these corrective movements, adding breathing and balance, and so on. They work in different ways. They work on the different philosophies.

It depends on what you should accuse. You go with that method. Basically, and this you can see some different movements here. Some some of the methods allow over corrections and some compensations. Some methods, like the BSB t is zero.

Compensations, may be slight of a correction in certain type of curves, so every method has their own philosophy, their own way of working with the patient. So I am aware of all the methods and I am certified in a few. I met crystal and it’s rotten in 2008. I believe, and we were penpals and we discussed cases and – and I miss her a lot, but I I first took my course in ask ApS Katherine our clinic in bars or behind. When I first was exposed to the Shroud method in detail and watch the large Institute every given time, there’s 200 patients in there doing exercises four to six hours a day in groups, some individuals as well, but mostly groups.

How did this method come about and how did it hit North America? I actually know so. First time the big deal was the yellow book, which probably somewhere here, but I can probably have a slide later on was published in English, I believe in 2007 or somewhere there. So the Shroud method book by Crystal and Herat was written as by a physiotherapist and published in in English. So it hit North America and many many who actually read the book were not sure what to do, because it’s a very detailed book and it’s a very deep book and if you don’t have hands on and you don’t have somebody teaching you.

I had many physiotherapists coming as patients in the day. Read it three times and they have no clue what to do so. It’S important that you actually understand the concept before you read the book and then it’s easier for you so once that book was published, one of the national conferences, I’ve been in 2009, when dr

Bochy was there was the head surgeon there at hospital, special surgery came to the so short meeting and with another physiotherapist in California. We had the book and we were shaking like that, but we gave it to him and he actually read on the plane back and gave it to hug. It baby shot ski the physiotherapist who, after the previous article and she went to study the shrug method in Germany and after that, brought more and more attention to North America, and many many courses have been taught by her, as well as her colleagues and other four Teachers in the United States, so now it’s very well known in North America.

What the Shroud method is, but you also know that there are many schools, be enough, bigshot methods, so there’s a not not all Shroud is the Shroud, but how did it really start? First? It was called orthopedic, breathing Catalina shrug herself had scoliosis and one day she she discovered if she’s starting to breathe into the concavity she’s, looking better and she’s feeling more balanced and based on that concept. Many patients coming to her in bad Zubin hang to to start learning the exercises because they wanted to get better spinal surgery wasn’t available those days, so bracing was very rare, and so these are always being very severe curves. She has been treating in their backyard here and giving the patients exercises.

I put this little boy down here, because I had a patient with the case study, which I was the 53 degree looking very similarly – and this was also very popular photo when this little boy, who had not really an idiopathic scoliosis more on polio type, was really Switched her his posture to within very short period of time to a corrective posture, so you can see that the shrug that that is really working on the corrective action so see the breathing. So this is this: is the breathing asymmetry based on many many components? The diaphragm being tighter on a concave side and more stressed on a calm backside. The rotational component of the ribcage, when the ribs are more open on a convex side, and it is pure physics. Air will go with the path of the least resistance they already open.

Ribs there there is no effort breed there and the concave side is getting more and more closed, the intercostal space and the diaphragm, because it’s not used as much so the orthopedic breathing. I was demonstrating that this this was the base of the Shroud method. This very specific rotational breathing technique and how it came about that one day, Katarina went out to his her back yard and found a half deflated ball. This is not her, apparently I don’t know. Actually, this is not her and she said what would happen if he blow air into this half deflated ball.

It looks exactly like my back. Let’S blow some air into that ball, so she started to blow air into that. Restricted left concave side and you can see on this patient who was one of the patients. We believe at the clinic very severe scoliosis, very severe asymmetries of the rib cage as well as looks like the left. Lung hardly ever function and be this very specific breathing technique and soft tissue work, you’re able to decode apps the concave side.

So this is a was the base of the shroud metal tree also see on when we are doing the posture assessment of our children here that the rotational component of the rib cage is really visible through the larger curves there’s always and reap hump backwards. That doesn’t mean the spine is there, the spine is still forward. Just the ribs are rounding backwards and creating this open space for the air to go there 10 to 20,000 times a day. Every time you inhale now, you can imagine I mean you see in water front, washing base creating holes in the rocks and all that through nature, you can, with 10 to 20,000 times of pressure, could create rotational force and it’s very difficult to change that during the Shroud physiotherapy, we try to change that breathing function and try to open the concavity and somewhat not restrict but creating a tension and a convexity to create the internal pressure balance. So the breathing would be a little bit more symmetrical.

So it’s just a little visual, very simple way. We start teaching the patient some breathing as well as just for you to see what the diaphragm looks like inside and how the doming and the muscle fibers might alter the bottom ribs as it’s attached and the spine. We do the same work made, the scoliotic patients who are fused and who are not fused, and it is important for, since you asked some questions about the surgery that we are creating, that stability, not just through the unfuse segments but also in the ribcage. The mobile increased mobility mobilization, mobilization of the ribcage to open up the rib cage, is still an issue afterwards, many patients actually come post operatively and they are not really pleased with the appearance because the rotation did not take place, they still breathe the same way. They still doing the same rotational breathing into the convexity.

So it’s important that we retrain the breathing patterns and improve the lung capacity on the concave side and improve the the rib expansion and change the balance and all the different things for post surgical. So BBT and narcotics patients, it’s the same thing really. We always work on a scoliotic posture, always tried to avoid compensation and always try to create a very symmetrical thorax with less and less rotation. I did seem probably about three or four patients. Three, maybe four, maybe maybe a little bit more because I do see some of them who come from New Jersey is about pre and post, pretty strong gone on doing pre and post so, and I just had one from stayin last week.

So it’s important that some surgeons actually map referring patients post surgically to scores a specific physiotherapy which hasn’t really been a routine before so please we have a little different approach. If they come pre, we be T – and we know they are going for the B BT or a perfect surgery. We will actually work on the mobility and more flexibility of the curve as much as we can to make the surgery a little bit easier. It doesn’t will alter any of our exercises other than we might add a couple of them, which we wouldn’t add. Otherwise, so the breathing function, the breathing education, the posture education is the same, whether you have pre or post surgical or non-surgical patients, the pulmonary function.

We always check, and we always want to make sure that the patient’s sagittal alignment during any activities during the day sitting, standing walking sleeping, is correct and we are basing that if we have the sagittal x-ray on the pelvic measurements, which are very, very personalized, it’s just Like everybody’s fingerprint, so we have to make sure that you know how much lordose is how much kyphosis this patient might need. See that so again I’ll just took the doctor regos the information here, because it’s the most comprehensive I know and the treatment plan is really not as simple as giving an exercise sheet and go home and practice or just give two exercises and do do it. You know just like let’s say if I have any problem and I can just do my leg raises and whether it’s 80 % correct or 50 % correct the leg will get stronger. But here, when you have a three-dimensional deformity, we really have to work with many. Many sense centers, so the treatment plan of registered cognitive but sensory motor and the kinesthetic training.

It’S a huge training for each patient. It takes many many hours and to treat the patient and to help to halt or improve his or her scoliosis in three dimensional posture and the thorax and the shape. That’S what we do, and this is an assumption that if we improve the scoliotic posture that will promote less curve progression or how to curb and according to the vicious cycle model which we’ll see in the next couple slides by the vicious cycle. So this is a very complex training. It is them often I have a phone call and say: well, I can book an assessment, and can you already teach my exercises on the same day?

Am I gon na leave me this sizes, and can you give me just this just fax me the exercise sheet and things like that? Well, there’s also saying when the physio type is finished, five o’clock, the work, the physiotherapist goes home and another five hours. The brain is going and going and going how to best approach that patient and create the treatment plan, because by then you know that patient is begging, the patient attention span is low or high. You know that they have done rhythmical gymnastics or never move. Just read a book all the time, so you have a lot of information of the individual and you have to alter the treatment plan for that individual to be successful.

It’S not so easy and it’s not so simple. Sometimes you overwhelm a patient and they run away. Sometimes you don’t give them enough and they say: well, that’s not doing anything for me. So, if you know is, as you know, I always start, we call it warm-up exercises, we don’t even call it short until I get to know the patients until they get the idea, what I’m trying to teach them eventually and if they stick around for the warm-up Exercises then later on, they’ll know more if they want to run their run in the first three sessions because it gets complicated. So we let me teach them, and it’s not so easy to get not just learning but integrating and living with the three dimensional postural self correction, and then they we learn how to do expansion of the collapses air collapse areas, as you showed you before, with the Ribs rib cage collapsed and then we should.

We learn muscle activation, not losing the three-dimensional achieved postures. So this is where we really have to be very stable. We can’t move because if you lose that extra, the three dimensional correction postures, we have either not made any difference or we have been compensations, so we have to make sure it’s very stable. So this is why it is so weird that we are kind of putting people in some position expect them to work as hard until they sweat and new, don’t even see anything moving. So that’s the goal, it’s very hard.

It’S just like plank. I think that the world record is four hours of plank or something like that, and even that is sinking down, because I watched at the end – there’s not this movement there. But if you want to hold that plank for a minute without any movement, it cannot be easy. It’S the same idea, just in another position. We have to hold and contract every muscle.

We can and then number four is very tricky. They either have very talented people who just come in the second visit. They say. Oh, I have to be honest with you. I didn’t do any of your exercises, but guess what I do it when I walk and when I sit when I sleep, I do it all the time I sing great you’re at number.

Four, you don’t have to do exercises you just keep doing what you’re doing, because you actually doing exercise 24/7. So when the exercise starts really when you learn what you have to do so once you have this integration into everyday life and everyday activity, you don’t need to go and do your exercises per se. You have the muscle activation and you using them. So you are already integrated into everyday activity and using them, so you are not going to be the one who will progress. We assume – and I see it who can do this.

Who can do this? They are really really doing. Well, then I have the patients. I have a very, very good. I think she also made it been one of my poster presentations, very good improvement, just the scores, a specific physiotherapy, very compliant doing it every day, beautifully doing exercises.

Everything is perfect and after four years we still don’t have integration. She it’s not from the math. She goes back into this kinetic posture, even though she improved 12 degrees. She still doesn’t know how to integrate it into everyday activities, so that integration sometimes is a talent or or some brain function. Some brain activity of memory, muscle memory, motor sensory skills, cognitive – I have no idea – are all above, but it is the most important part and it is not impossible to get the improvement be back without number four.

On x-ray, it’s not impossible to avoid surgery with number four but living with scoliosis for the rest of your of you need that. Okay, so that’s that’s the critical part, so we are reshaping the torso. This is a one-year Shroud, physiotherapy and bracing 456 cup degree individual. You can see that she entered into the program did not so fit. We like it.

We like it when they come not so fit because they don’t have to work against their own muscles. So much and she be shaped her torso, you can see the concavity opened. You can see the whole shape of the child is beautiful and she decreased it. I believe 10 degrees, she’s, 46, maybe right now, Jordie discharged two years ago, she’s stable for two years, stable, she’s living with this posture and a 46 degree curve. She did not want to have surgery.

She she wanted to try this first, why she was actually on a waiting list. We had those days two years waiting list so by the time they called her, they said actually you’re, not in the category to have a surgery anymore. So, even if you want one it’s 46, you actually don’t get one so she’s very happy very active now she’s in University. We removed the brace, I believe, after close to two years, even quite early, because I took the brace up. She was already standing like that.

So she integrated she couldn’t go back into her old posture, so she was very compliant too, and we do the same after surgery. This is fusion. This patient was fused on the backside on a selective, thoracic fusion. Actually, she was referred by the surgeon because the lumbar curve was increasing, I think she’s also a poster. Maybe it’s on a website somewhere and the lumbar curve was increasing after fusion to the level of possibly having a revision.

Extending the fusion and before that the surgeon said well, you go ahead and try – and I said that’s great, you know you gave me two reefers over the last five years and they both were the most challenging patients. I can see that you really want to test my skills, but nevertheless we did it and the lumbar curve decreased ten degrees. I think it was in the 40 range, but that was the side effect that she also looked postural II, more balanced and more. The patient was very happy with this posture, so it is something which we do work post surgically of the rib cage balance and the breathing function, as well as the symmetrical muscle activation to make sure that the spine and an unfused segments are more stable, not more Mobile but more stable and ready for the adult life. So you can see the concavity collapsing on the left side here with with the fusion, so that is quite a straight spine in there.

But the thorax was not altered during the surgery and you can also see the pelvis shifted, just like the first surgery to the left here. So that means that there’s a larger curvature here still coupled with the pelvis pulling her to the left and when she’s. This is just, I believe, after some camp she did photos and after she did the summer program, she has relaxed posture here. She could even breathe more into the left. Punkie, partly you can see the ribs and you can see a more balanced pelvis.

So it’s not an issue, and I have now probably about five five or six patient posts vbt, who is also working on posture. There are girls actually because they are really not expected to look scoliotic after surgery. They are quite surprised. They were not completely losing the scoliotic posture, so they working on it and not a problem. They actually doing really around so they’re motivated by making those changes.

So when do we see patients, we definitely see patients before and after surgery. We see patients during the called observation period when the mens, when they’re not ready for bracing, and they are having maybe 20 or 23 or not exactly 25 degree curvatures, and they are called back in six months and they put on a wait-and-see method. They are observing them if they get worse, so many parents don’t want to just sit and do nothing so they start scrolling to specific physiotherapy, and this is where we have those posters and x-rays showing straight spines, because they go back six months later and they automatically Ordered an x-ray, even if I could count only done, but they order an x-ray, so we have proof that they actually straighten their spine during this course. A specific physiotherapy – and I think I have a case series in I think it was in lean Leone. I believe when I, when that was presented on on three cases, who have the same waiting six months and veteran getting street signs – and you had another case earlier today – huh and then very bracing or surgery – refused many kids, don’t wan na wear brace.

So they can still try the school specific physiotherapy. As I mentioned earlier there, the girl, who was non-compliant with bracing, but did the two-hour physiotherapy for some reason she also decreased 12 degrees. It’S not something we guarantee, but it could happen. Every scoliosis has a postural component and a structural component. So this course is specific.

Physiotherapy could improve the posture component and then you, lastly, the structural component, so usually what I see 10 to 15 degrees could be postural components. So let’s say you have a 50 degree curvature, let’s make it more of a surgical or 60 degree curvature, and then you saying okay. This is clearly surgery, but you have a posture component of 15 degrees and then, once you finish with specific physiotherapy, you have a 45 degree curvature, which is your structural curvature and maybe that’s what you’ve got that little bit. But it is below the standard of of fusion criteria. So often happens, it will be the compliance and then there are families who just never want to have surgery, whether the child has 60 or 80 or 90 degree curvatures.

They don’t want to do surgery, so they are doing the physiotherapy with us when they embrace the always recommend physiotherapy and Mac Columbia University. Coming up with the standard of bracing eye care, and with this part of that you have to have prescribed grasing, then you have to add scores to specific physiotherapy and just a little bit of cutter inner and crystal and rich rods, drawing here or regional drawings, which I have a permission to use for presentations from Krista. You can see all the portions and all the muscle imbalances or the muscle length and strength changes which happens during scoliosis, so we have to normalize these muscles length wise and strength wise, to create a muscle brace during the scores, a specific physiotherapy based on short method. So this is delicious circle, ian stokes, very famous spine, surgeon and researcher, and he first presented the vicious circle model to understand more to see what’s happening in scoliosis, and we have this triggering event which we kind of not know. That’S why we call it idiopathic still and then slowly.

There is asymmetry, clothing, torso, deformity and progression, and it feeds into it and it is getting worse and that’s really. The progression made many many components. There are lots of references on the bottom if you’re interested. So when physiotherapists start to intervene or the or that they start to intervene or the surgeon wants to intervene into this vicious circle to stop it, we have different phases. We can make a difference.

So if it is right after a symmetric event and loading, we can change the loading we can change the muscle imbalance, it could possibly stop or slow down this vicious circle. Clearly, when, when surgeons intervene with the fusion or BBG again, they are changing the loading changing and halting the progression, so it is something which we all want to kind of take part and intervene. So how does this score is a specific physiotherapy exercise? Look like with all the components together. This is a gymnast who’s, doing gymnastics in this posture, 15 hours a day for so week, that’s a tumor a week, so she’s training and she’s a strong athlete.

She understands her body and she has about the 35 degree curvature here. She comes with this posture. Clearly she’s a right curve, lower, thoracic, Cooling, her to the right and the pelvis is compensating pulling her to the left. Her head position is a little bit altered and the shoulders as well. She also you can see that she’s, a very flat back very collapsed, very extended according to our definition of scoliosis, and when we do the physiotherapy in this pattern.

Only with this type of pattern, we can do a tiny bit of over correction, so she is not exactly midline with her exercise. She’S, going a little bit over to the left side, you can see those left ribs popping out and back from the concave side, opening them up with the breathing stabilizing the shoulder blades, you can see muscles working, sure sure they’re, maybe a little too high. We need a little bit more elongation, but this is her first session, so she was one of the fast learners, at least. Sometimes you just soak it in. She was also one of them who said well, I’m doing it all the time mom said she’s not doing any exercise.

I said, don’t worry she’s doing it all the time and she reduced her current for the next x-ray for eight degrees. I’M not saying it is a miracle anything like that. She actually got it. What is all that, on the right side mean she did her oxy elongation she’s not collapsed into her flat back anymore. She did her sagittal normalization she’s created a little bit of kyphosis little bit of lordosis of yours of her spine.

She definitely pushed her right curve a little bit to the left. She D rotated with the rotational breathing technique and she stabilized it she’s staying there and then she’s going to get muscle activation. So she did all that in in the one exercise. So this is one exercise I was able to a little bit over corrected pelvis a little bit over correct the trunk and making sure that her, hip and shoulders are able to manage the movement she had actually tight hips. So that’s why the leg is out there and then this is a slide from the German schrott Institute to to show you the goals.

Definitely the goal is reduction of the progression, always always always that’s the call, and then we have the cardiopulmonary function. We need to improve that. We know that even a 30 degree curvature. They noticing lower function in the lungs, it’s not affecting the quality of life, but it is a fact and then improving quality life, making sure that they are pain-free and improving their mobility of the extremities really and mobility into the correction to the in postural stability. After the surgery might be postponed or avoided, these are more information about.

You know how the plan for the treatment and how they do. The group exercises, let’s say in our clinic and everybody is doing the individual Corrections. These are small curves, which are responding well. For short, physiotherapy and the braces we use, you can see all kinds of braces here as long as they give you 30 to 50 percent, some of them embrace correction and and they look good postural e on the frontal and a sagittal plane. They are good braces.

So, depending on where they get the brace, if we have here braces from Spain from Toronto from the states and that one was, I think Toronto. So we have many braces here. Somebody even came with the spinecor brace marker, so we have no problem as long as they can maintain their posture correction, with the brace the same way as we have it without the brace and yes, the smaller kids who are treated longer and I’m changing the growth. This is a growth modulation, the bracing really as well as vbt as well as anything else. We try to do during growth.

We can make a difference. This is one of that case which are present for 32, 2008 and 9x 2020. So we have an eleven. You know follow-up of this child and again progression risk. We already talked about it, but many many different ways of checking the risk of progression based on the cop angle, based on bone maturity.

So once the risk is high, we must treat we have this little chart. What we do with patients, especially because maybe I’m going right over time here so too many slides – this is something which, which is in Canada. It’S very important to know that education is lacking. Detection is lacking. Freebasing period is very few because, when the kids are actually diagnosed, every third one is already in the red circle, so it is something which is which we’re working on and educating the public and also the patients were educating them on the vicious cycle.

Vicious circle for the postural Corrections of ADL what they have to do to change their learning posture and say when they do homework, to intervene in a vicious cycle at a symmetric loading and to create less opportunity. By for the curve. The progress just because of the vector forces of gravity and compression in this time we we spend a lot of time on education of how to sit, how to stand specially if they are not braced, if they braced, they are braced gon na do that for them. So we definitely learn more or spend more time with the unbraced individuals to make sure that they learn how to sit correctly, how not to do their favorite activities, and we explain that you know that posture does not cause the scoliosis. But if you are going on your right side there and go and isometrically spending 3-4 hours on the computer, like that, that curve is not going to be less pressure and we teach them standing postures.

This is not feeling straight. This is looking straight, so we cannot have mirrors to prove that for the patient’s, how to stand in the corrected posture, how to feel that it’s corrected, because it’s sure not feeling straight for them for a very long time how to sleep, depending on their curved pattern. Again, if they’re braced is not an issue, but if they’re not braced or just selective fusion or just selectively BT, it is important that we protect the lumbar area. So we have to make sure that the sleeping position is not affecting or not increasing, the curve progression. Again, just a little bit more explanation of the the sleeping position, you can see this right, thoracic curvature, sleeping on the right side, how the rotation increased and how the curvature is visible.

While when she’s on the left side, she is actually opening up the concavities just by pulling her shoulder up and she’s a little bit more balanced now, everybody’s sleeping position will be different, regular exercises. What do what do they do, and it’s not just me saying it: it’s very well respected. I think order of Canada was given to doctor sorry, McGill Kimmy Shailaja background who authored many books about back pain and saying that many exercises, however often prescribed, are not evidence-based. So he’s advising some of the exercises are really not doing what they supposed to do, so you have to really check the exercises, what you given and what you’re not supposed to do so this is Kat Krista’s poster of what not recommended what we really don’t encourage Patients to do – and we change this for them, and we explain every single one by one. What’S wrong with them, I mean you know ready from definition of scoliosis expansion is not the answer.

You know the rotational component of the scoliosis. The rotation is not the answer. If you have two curves, one of them will collapse with side bending. So that’s not the answer going upside down losing you know sagittal profiles, it’s really the loading curve may not be the answer. So I put in a hyper kyphotic situation, which is also could be changed as we diagnose it early.

It is also a big problem for teenagers, the Sherman condition and the pre Sherman condition when they are either having sway back or increased hypertrichosis, and if this may be postural, but could be also structural and the remodeling. The lumbar lordosis and any patients is very critical. This patient actually was horrified that she will not make it into the military everybody in the military in a family and he had a chaotic, lumbar region. You can see that it’s not not structural. He was able to change that and we prescribe exercise in this position and he did them and he’s in the military.

So it’s very happy and it is a remodeling. We measure these parameters. We create personalized exercises in a sagittal profile as well to make sure that the patients are improving and not losing their surgical profiles. Staying active is very important. Physical activity and having fun is good for you.

It’S not always going to be in a perfect position, but you doing one hour of physical activity of any kind. It’S not harmful. It’S a healthy thing to do. If you’re able to do it with some alterations of your postural Corrections towards the posture. Correction is great, but if you’re just having fun improving your lung capacity, doing some physical activity of any kind, we don’t stop patients from doing physical activity.

This is a video bomb on plate. It is also important where you spend many hours doing some of your favourite activities like doing playing cello here with the right thoracic curve had to control that during playing your instrument so again doing yoga or any other exercises. You can have to again think about what what is this exercise doing for us? How can we change it? How can we level up the pelvis?

I can remain there maintain the spine in a better position. How can we not add compositions or progressions running? Are we gon na run it lumber kyphosis? Are we gon na run with more stable pelvis with their lumbar lordosis? So all those things are very important.

Okay, so many many presentations are available as courses in spine online learning. If anybody wants to go deeper into yoga deeper into learning more about scoliosis, that’s there, it could be rented it’s very inexpensive. I already showed you with supporting lots of other organizations to make sure that they can learn in a very low fee. So when you pay something for $ 30, then someone else can watch it for free in another country when they can afford it. So it’s important that you join if you want to score some spine online learning, it’s not a charity.

It’S a new organization which I co-founded with my friend Hoggett birdie shares keys. So it’s a US and Canadian based online learning we’re reaching out right now, 59 countries. If you know anyone in the number 60 tell them, I’m 160 countries by tomorrow, but 59 countries is pretty impressive and then you can sign up for Easter sort. As I mentioned this June 20th, they also have a free webinar just before I so sort for scoliosis support as well. So you’re welcome to join us and if you know any physiotherapist who may want to learn all this and more, you can give them.

My email address right now. We cancelled all courses until October, but we hopefully gon na, add another level one course, and now we have three levels more or less, for that was of this education. It just changed, but local physiotherapist will get the certification in about two and a half to three years, full certification to do this method done. Thank you. So much for your attention I have to.

I should have told you. I have a slide. The problem. I always make too many slides, and so I used some of the do. No harm’ slides here, which I teach where our professionals are not to do harm, but so I couldn’t couldn’t help but putting in even more so hope you.

It will be helpful for you and and your followers or anyone who sees it to be safe when you’re doing exercises and to make decision, educated decision of the treatment method you might choose in the future until there was a exceptional presentation. Thank you very much. We went all the way from the history which I didn’t know and but I do know that yellow book you’re talking about so complicated the latest version. This is the latest version it’s in German danke and it has colorful pictures. But you know what I’m talking about.

If you have time to go over a couple, questions yeah we’re way over over the length – and I appreciate that now I’m glad you mentioned with the BB T and you have about four or five young, ladies who are post vbt and they were probably disappointed that They had didn’t have full correction right in terms of the posture. That’S the best. That’S the whole idea with bone modulation and they’ll grow. How important it is that to continue asymmetric exercises in terms and maintaining proper posture when you’re doing those exercises, I should say after vbt, so what I give them after we beat is actually more of a symmetrical exercises. They are achieving the symmetrical postures in the postural 3-d posture corrections when they do the correct standing, correct setting and we do the strengthening that way.

We don’t necessarily go into asymmetric poses we might go into a left-side line if there are bigness in the core of the lumber non touched. Scoliosis, let’s see left lumber, we might work on the right side of the quadratus lumborum, maybe up so as just to stabilize the lumber, but with with the positioning we achieve already the correction and already the vbt is done. So this cord inside is doing the correct as much as needed. What we work on, though, is the directional breeding, so the directional breeding is may be done in an asymmetric position because it helps the lips to open when it’s not touched, so that could be looking like and one-sided exercise, but I would say that would be only The left side line, all the other exercises would be in a symmetrical position, so just a follow-up to that. So if, if there’s still some rotation or pelvic shifting even after vbt, let’s say, there’s a 50 % correction, you still kind of focus on the symmetrical strength and exercises on only a couple of the asymmetric ones.

Yes, because we have to make sure that all the exercises are in a perfectly correct: it’s really postures. So if the pelvis is shifted, they won’t give them anything until we teach them not to go in the middle now, if it is an exercise in a position which will help them to do it like lying on the left side, then it looks like it’s an Asymmetric exercise because we only gon na do that on the left side, but otherwise it is really still working the muscles in in a balanced way. Okay, now I’m glad you brought up in the slides the the anterior vertebral overgrowth that causes the wedging at the front of the vertebra, which causes the loss of a curve, an increase of the hypothesis which drives the curve laterally into the coronal plane. When you have a patient, for instance, that gymnast that you highlighted in the in the slide – and you know they just – they – want to keep doing the gymnastics where there’s just lots of hyperextension what you say to those patients. So often I do have some high level of athletes and even ballet dancers you can talk to.

I asked them. Go explain to your coach. Go on. Explain of your choreographer was making a choreography what you want to do and what you want to avoid, and maybe they come up unless you go into the Olympics, there’s no, where you have to do it that way. So we have many times that I’ve talked to coaches right now have almost the whole team of the.

Can you both Olympic team, because they all have a little bit of asymmetry, our school nurses here in there. So we talk and we decide which side to sit, but to do we talk about it, how to find a way, if you, in fact, training for over 15 hours a week to make a little bit more harmony in the balance of the movements rather than expose The movement which is comes the easiest to do so they are always very tracking. They go over to the left side, let’s say a side bending, so the choreographers, oh well, let’s do that or or or yeah so it has been successful in some cases. Other cases, if the child is not so keen or the family is flexible, they don’t go competitive. They just go for a few hours a week and create a variety of activities and sign up for a variety of activities.

So it’s not just the same repetition of the let’s say choreography over and over and over again, but do a little bit of soccer. Do a little bit of swimming do a little bit of something else, and that way we don’t limit really the physical activities. It just suggests that you can think, and some kids are very good at thinking of what they can or cannot. I mean not like we don’t stop them to do it, but what is beneficial for them and what they have the coaches and no, no I’m not doing the split that way anymore. I don’t have to do the other way or I’m not going to hang on this way and under whatever bar I’m gon na.

Do it with that way. So it’s it is something which is which is a communication. It’S not a restriction for patients. Who’Ve already gone undergone DBT. How soon after surgery can they start going into those exercises?

Do they have to get clearance first and once it is, is fine, so we ask for clearance when the surgeon says and some surgeon says you next day you can do whatever you want, or some of them may say, come back for the six weeks and then You do what everyone we have very little restrictions coming from surgeons. They really go for the individuals quality of life, but he also had doctor Battalion one of the webinars here as well and you he said you know. We know. We know that the cord is not going to be there forever, so it is something which will get loose or snap or we know so it is for our physiotherapy point of view. We do educate the patient, maybe a little bit more on look.

This is where the cord is. This is when you stretch the cord. This is when you not stretching the cord, but we don’t limit them per say if the surgeon didn’t limit them, but it’s a. I think the education is very important. Okay – and I just have one last question since a lot of the well most of the exercises with straws and seeds, etc, are active traction?

How do you feel about past attraction? In terms of you know, just trying to lengthen out the spline without any active component, is that a benefit or not so much so depends on on on what the goal is? No passive traction has been around in the history for a very long time and with severe curbs you have here, no traction and passive traction. We use a lot of traction. We try to imagine it’s active because the kids are holding their hands on a wall bar traction using the gravity is a good force.

Let’S say passive traction without stabilizing afterwards could create some some issues. So if let’s say I’m just hooking up a lumber curb into a traction machine – and let’s say there are some stiff segments of L, one two, three and now four five is quite mobile. The traction is gon na pull L four five and not necessarily the apex or the curve, so it is a problem of knowing where distraction is happening. If it is happening in in fact in a segments, he actually want it or that’s the structure component of this curve, which is stiff and tight and no matter what you’re pulling it’s really gon na pull the other segments. So it’s a little bit tricky that way.

That’S my opinion: only it’s there’s no research, anything showing that, but it is just common sense. I think, because you’re gon na have our four five very mobile and and functional and and hyper mobile most cases. Then we know that 70 % of the lordosis is happening in that level, and we know that we try not confuse the patients all the way down to make sure they have all the mobility. So we know that a very mobile segment – it’s I’m sure, is research on that. But on the other hand, the curb and apex is very unlikely.

That’S there. It’S usually a number of apex is L, two one, maybe L three and those are not as easily accessible. Let’S say with the traction that you cannot really pick that level with attraction unless you are the surgeon and you know what you’re doing there, because it is really isolation when you have to do those segments. So that’s a that’s a little bit trickier and this is why adults we don’t and hang them and we don’t let them do the same exercises as the teenagers, because they are definitely have more stiffness in position and stenosis and whatnot calcium deposits, and by the time We hang them, we have no idea. Are we mobilizing some segments which should not be mobilized more or in fact, are we helping they’re curved?

So we don’t hang them, for example, the same way as teenagers in teenagers. We hope that they are flexible and they managing and maybe they’re getting a little bit of necessary structure, but a little bit of elongation mm-hmm capping. If anyone, okay, all right. Thank you so much you’re welcome. I learned a lot myself very much appreciate your time and I have to do this again sometime, but for adults as well says: that’s a long topic.

It’S this a very good, I would say: try it out. I mean, if you go, Tess Sol is the same thing. They’Re just talking and presenting the same way, it’s very easy access and we have a very good adult, a very good post, surgical presentation. There we have surgeons, I think they are much better than what I could say. Okay, great all, right so we’ll end it here.

Thank you very much again. You’Re welcome.

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