Why do we defend the status quo in scoliosis treatment

[DrStitzel]

Change is, at the least, an interesting little creature and, at the most, an amazing phenomenon. It is often resisted and rarely embraced....generally speaking one's reaction to change says more about their individual perspective/circumstance, than the purposed change idea itself.

Either way, it still makes for an interesting discussion topic, especially since I have observed repeated attempts protect/maintain the status quo in the field of idiopathic scoliosis treatment despite a growing body of testimonial and scientific evidence that clearly demonstrates drastic changes need to be made.

I often wonder if many people even know why they feel compelled to defend the status quo of current scoliosis treatment protocol or if they are simply re-acting to a group/mob mentality that demands obedience to the "this is the way we do things around here" syndrome. It reminds me of an example that I am almost certain Jim Collins referred to in one of his fantastic books........

Imagine there is a large monkey cage at a zoo and the monkeys in the cage are broken up into two groups, A & B. There is a long rope in the middle of the cage that extends from the bars across the top of the cage all the way to the floor of the cage and a HUGE bunch of bananas are located at the very top of the rope.

Unfortunately, this zoo has a very mean zoo keeper who stands on top of the monkey cage with a high powered water hose and he sprays any monkey who attempts to climb the rope to get the bananas.....in addition he also sprays all the other monkeys with the hose each time ANY monkey attempts to climb the rope as well. After a while, only the most ambitious monkeys attempt to climb the rope, but before the zoo keeper can spray him and the rest of the monkeys with the hose, all the other monkeys freak out and pull him down off the rope and beat him up for even attempting to climb the rope in the first place.

After a while, all of the monkeys in group A are replaced with a brand new group of monkeys, group C. The group C monkeys are thrilled to see the rope with bananas at the top and immediately begin attempting to climb it, but the group B monkeys (from the original group) intercept them and physically pull them of the rope and beat up the group C monkeys, so they won't be sprayed by the hose. The group C monkeys don't know why the group B monkeys reacted in such a way, but one thing is very clear...you don't even attempt to climb the rope to get the bananas or you will get beat up.

Eventually, the group B monkeys group gets replaced with a brand new group of monkeys, group D, so there are no more monkeys from the original group left in the cage. The brand new monkey group (group D) sees the rope leading to the bananas and immediately begin attempting to climb it. The group C monkey group springs into action and begins pulling the new monkeys from group D off the rope and beating them up. They don't actually know why this is the protocol since they have never been sprayed with the hose by the zoo keeper, but this is the status quo and the way things are done around here.

In only 2 generations of monkeys in this cage, they have learned to resist/self govern attempting to climb the rope to get the bananas they desperately want and none of them even know why anymore.

The most shocking part of the story. The mean zoo keeper was fired after the first group of monkeys (group A) was exchanged with group C and replaced with a kind and nurturing zoo keeper.....who now, can't figure out why in the world the monkeys at this zoo don't like bananas.......


Moral of the story: Don't be afraid to climb the rope for the prize you desire.....you may find that the zoo keeper isn't all that mean after all.

[Dr Kalla]

Here is a slightly easier way to understand your great example.



Start with a cage containing five monkeys.

Inside the cage, hang a banana on a string and place a set of stairs under it. Before long, a monkey will go to the stairs and start to climb towards the banana. As soon as he touches the stairs, spray all of the other monkeys with cold water.

After a while, another monkey makes an attempt with the same result - all the other monkeys are sprayed with cold water. Pretty soon, when another monkey tries to climb the stairs, the other monkeys will try to prevent it.

Now, put away the cold water. Remove one monkey from the cage and replace it with a new one. The new monkey sees the banana and wants to climb the stairs. To his surprise and horror, all of the other monkeys attack him.

After another attempt and attack, he knows that if he tries to climb the stairs, he will be assaulted.

Next, remove another of the original five monkeys and replace it with a new one. The newcomer goes to the stairs and is attacked. The previous newcomer takes part in the punishment with enthusiasm! Likewise, replace a third original monkey with a new one, then a fourth, then the fifth. Every time the newest monkey takes to the stairs, he is attacked.

Most of the monkeys that are beating him have no idea why they were not permitted to climb the stairs or why they are participating in the beating of the newest monkey.

After replacing all the original monkeys, none of the remaining monkeys have ever been sprayed with cold water. Nevertheless, no monkey ever again approaches the stairs to try for the banana. Why not? Because as far as they know that's the way it's always been done round here.

And that, my friends, is how company policies are made.


Above example is the very reason we started the FixScoliosis forum - to challenge the status quo and look for a better way.

[DrStitzel]

OMG we absolutely need a better way.....as soon as possible.

The first metal brace was created in 1575 and the first scoliosis surgery was performed in 1865, so just think of how many generations removed we are from those original thought processes......

Personally, this monkey doesn't mind the cold water......

[Dr Kalla]

If you are familiar with Covey's book: The 7 habits...... you may recall his reference to Thomas Kuhn's book "The structure of Scientific Revolutions" were Kuhn shows that almost every significant breakthrough in the field of scientific endeavor is first a break with tradition, with old ways of thinking, with old paradigms.


I believe that the treatment and the way we view adolescent idiopathic scoliosis needs a paradigm shift.

[sjmcphee]

Hi Dr. Stitzel, Dr. Kalla and anyone else subscribed to this thread.
I'm a new member, and this is my first post.

Every now and again I have a look on the web for articles relating to scoliosis biomechanics.
A google link directed me to a page named "Spinal Biomechanics and Thoracic Idiopathic Scoliosis" on this website submitted by Dr Kalla. Mostly all of the information was already known to me except for 1 small piece of information that I didn't know, and found particularly interesting.
Quote> "What Dr. Lovett proved in all his experiments was that if the spine was lordotic the spine rotated in the opposite direction; and if the spine was kyphotic the spine rotated in the same direction as the side bend."
I almost purchased a hand drawn sketch of what I think may have been Dr. Robert Lovett off a US seller on ebay several years ago. The seller had drawn it recently himself from an old picture, he said he like to draw weird and interesting things.
The sketch depicted Dr. Lovett (99% sure it was him) examining a semi-naked female scoliotic patient who hung beneath a large wooden tripod, with her hands bound above her head.
This sketch appealed to me in a weird kind of a way. Although it looked somewhat barbaric, and certainly uncomfortable for the naked female subject being examined it made me feel as if there was once a time when scoliosis researchers were truly trying to the absolute best of their ability to understand exactly how scoliosis works, from a biomechanical point of view.
Unfortunately, the ebay seller notified me soon after bidding that the sketch had been destroyed during the hurricane at the time, which was either Ivan or Katrina. I took copies of the sketch from the ebay listing, one of which can be seen below.


If Image doesn't work Go Here ->
https://cid-583521f9d77cc36f.photos....%5E_1%5E_b.jpg

Now this particular thread discusses "Why do we defend the Status Quo (existing state of affairs) in Scoliosis Treatment?"
(It's a big word for me - I understand myself better if I put the term status quo that way. Kind of funny in a way, since I've got some much bigger words coming up.)

Its a complicated issue, but the most simple answer being lack of any overwhelming evidence supporting anything better.
Now I know that the Dr's here are going to be quick to defend alternative scoliosis treatments and say that there is overwhelming evidence to support something better, and I agree, but here's what it comes down to.

Whether you lend yourself to the non-surgical or alternative scoliosis treatment side of things or whether you are in the more formal surgically inclined group of thinking and research side of things one fact remains.

The exact biomechanical systems responsible for progression of idiopathic scoliosis are not well understood.
- Which is a kind way of saying they don't know how the biomechanics of scoliosis works.
They do know however that scoliosis patients do have altered spinal biomechanics.

The problem, put simply is that scientists don't possess the equipment or technology yet to accurately test all the muscles in a scoliotic spinal column all at once in order to fully understand how the biomechanics of scoliosis works. I read somewhere once that these tests cannot be done accurately with a scoliotic spinal column specimen out of the body either (cant remember the word for that) due to the loss of water content in the intervertebral discs.

So basically it's seemingly impossible to get the data needed to gain a complete understanding of scoliosis biomechanics that would otherwise bring together the non-surgical / alternative scoliosis treatment thinkers with the more traditional and formal group of scoliosis thinkers... Seemingly...

If we go back to the early 1900's when scoliosis surgery was first performed and try to imagine what is was like at that time, I'm guessing that although significant efforts were made to understand scoliosis biomechanics, a complete answer was not found, and after successful scoliosis surgery was performed the surgeons became the leading scoliosis thinkers, formed their own research society and tended to focus more on the surgically related ideas that they could understand, research and improve.

This didn't mean that biomechanical related scoliosis research stopped, (although it may have slowed.) It's just that a conclusive answer never came, and always remained a mystery.

Formal researchers carry with them a standard position of scepticism on anything that is put forward unless it can be proven.
Maybe it's because if one researcher gets up and says "It works this way" another 100 will stand up and challenge him to prove his statements, and so if you cannot prove what you wish to put forward it might be better not to say anything at all.

Things to think about...

So you are all standing up and saying things need to be changed. Paradigm - another big word for me, meaning prototype or standard. Geez you can tell I never went to college or Uni. So you want a new standard or prototype for the treatment of scoliosis.

But where are you going without knowing the way?

Now from this point on I'm going to mention some things that I probably shouldn't.
You see just like the researchers - I've learned over the years that it is somewhat foolish to put forward what you cant prove.

Earlier, I mentioned that it is impossible for researchers to get the data they need to fully understand the biomechanical mechanisms responsible for idiopathic scoliosis, but I also used the word "Seemingly".

There is another way. Now before I put this forward I want to say I cannot yet prove what I'm about to say.
I don't really want to open myself up to a barrage of questions, but wish to say I am making efforts that I hope will allow me to someday put forward my ideas in a manner that will be accepted by researchers for review.

My aim, is to create the first completely accurate 3D spine buckling model of scoliosis progression that incorporates coupling.

Right now, I'm currently about halfway through a course in 3d Modelling and Animation, and I have a 3D spine model that can be used and modified for the project although right now it's without muscles, and does not accurately demonstrate Flexion /Extension, Lateral Flexion, and Rotation of the trunk, which I will need.

I need to take a normal spine, and simulate an injury to the workings of normal spinal biomechanics.
Now, you ask how the hell can I achieve this where so many others have already tried and failed to understand how coupling works.
Easy Answer - Inside information, I already know how the biomechanics of scoliosis works, specifically coupling.
How am I going to get this so-called "Impossible" data to base my model on?
Answer - I'm not. I intend to simulate and quantify it all within the model and I will derive my data from mathamatics and geometry.

So how did I get to this point? Why am I so sure of myself?

12 years ago I injured myself whilst working. It was a weird twisting motion that I placed on my trunk, which resulted in the misalignment of normal spinal biomechanics and created scoliosis. I know the exact biomechanical movement which I used to create this injury. I know the exact vertebral levels at which the injury occurred - (2 misalignments not 1, on semiadjacent vertebral levels with the rib facets - kind of loaded and locked in opposite diagonally on the rib facets - both intercostal and costal demifacets (Not sure if I have the terminology correct - I'm going years back - from memory) Normal loading through the thoracic region is misaligned through the injury and divided into 2 thoracic regions. The coupling occurs through the stretch and unstretch of connective tissue and systematically couples with verterbra in neighbouring regions of the spines natural curves. 16 vectors, 4 sets of 4 make up the true anterior / posterior loading vectors. Its extremely difficult to visualise or comprehend this level of complexity without a model. Think of an 4cl engine and the firing order. With thoracic divided equalling 2 sections, you now have 4 regions instead of 3. The loading can divide. Theres a lot of other factors too, Torsion, Spinal Rotation, Factors relating to growth, My intention here is to simulate the exact biomechanical model in a skeletally mature spine, and then use that data to look at factors relating to growth later.

Other info which has made understanding scoliosis biomechanics difficult is that I believe the original misalignments determine both the individual curve pattern and the "path" of the coupling process. I believe that original misalignments in Thoracic region will create an "S" curve, whilst original misalignments in Lumbar or Cervical regions will create "C" curves. The misalignments occur on the junctions of the spines natrual curves.

These points above are interesting because I think it relates in some way to the findings Dr. Robert Lovett concluded in the passage I quoted above.

Anyhow better go,
Thanks for letting me join the club
Scott

[Dr Kalla]

Hi Scott

Thanks for your post. I am looking forward to hear more news on your progress on animating the spine.
The thing that makes adolescent idiopathic scoliosis a big mystery, is the "Sensory Integration Hypothesis". It not merely a spinal biomechanical issue how it develops, but has a central processing problems that makes the spinal muscles to fire inappropriately.

[DrStitzel]

Hi Scott,

I'm thrilled to have you join us. Thanks and feel free to challenge me on anything......anytime. I can take it.

Your post covered a lot of ground, so I'll try to keep my comments focused and brief.

"Proof" is a subjective term based on the amount of evidence one requires to obtain the seal of approval deemed "proof". Evidence based medicine (EBM) has done a fairly good job of objectifying it, but grey areas still remain. So while no one has "proven" the biomechanics of idiopathic scoliosis, we do know an awful lot about it.

The main trust of my post centered around the buckets of cold water that are lobbed at anyone even suggesting a better way for treating scoliosis based on the most current and accepted understanding of the condition as a neurological disease first and a spinal disease second....Which means scoliosis spine treatment shouldn't revolve around the mis-guided efforts of attempting to influence vertebral growth patterns with a scoliosis brace or to circumvent the entire bio-mechanical process with scoliosis surgery.

I think your spinal modeling idea is great, but in the end, it will still only be a model of potentiality, not actuality.....Which doesn't mean it doesn't have value, but it's value will be limited.

I think you going to find the shift at the base of the rib cage in the lower region of the thoracic spine will determine whether the scoliosis pattern developes into an "S" or a "C". Shifting away from the L3 fulcrum vert gives you an "S" and shifting towards the L3 fulcrum vert will produce a "C" curve.

[sjmcphee]

Hi Dr Kalla and Dr Stitzel,
Thanks for your replies, and sorry for the slow response.
I guess I'm trying to resist the urge to go into depth with my own thoughts on some of the things you guys mentioned.
You see this here is one little monkey who did get sprayed with too much cold water.
I've learned not to become drawn into long and lenthy discussions if I'm not able to prove my point of view,
and so at some level I'm choosing not to get into these big discussions just yet.
But I will say this...
Take away all the complex things you know about scoliosis and bring it back to its simplicity.
What is the one thing we know about scoliosis?
It's that scoliosis comes in specific curve patterns.
What can we assume from that?
We can assume that there is some kind of biomechanical component relating to progression of the condition.
Why? Because otherwise there would be a seemingly unlimited number of different curve patterns.
One must relate to the other.
So if we accept that scoliosis does have a unknown biomechanical component and that scoliosis comes in specific curve patterns, then what can we assume from that?
That this unknown biomechanical component follows a set path for each individual curve pattern.
- And that this set path must follow the same unknown set of biomechanical rules as the set paths for the other curve patterns.
So where does it get confusing?
I won't deny that there is some kind of hereditary aspect to scoliosis, and I do not have the answers to explain this, nor will I deny or ignore the fact that the nervous system plays some kind of unknown part in relation to activation of muscles.
Also I will not deny that the whole scope of trying to understand whats going on in the scoliotic spine is complicated by factors relating to growth.
So where do we go now?
We leave the DNA research to those experts who are qualified to find the answers there, and we put the neurology to the side, just for now. Then, if we truly want to understand the biomechanical component which follows a set path for each curve pattern we need a way to isolate factors relating to growth - so we can truly see this biomechanical component for what it is.
So what do we look for.
The normal working movement of the spine consists of flexion / extention, lateral flexion and rotation.
We need to look closely at these components and try and determine whats going on.
Firstly scoliosis does not cause a great deal of pain during normal movement.
We can forget the articular facets, they are not responsible, if they were, patients would endure a great deal more pain.
We need to account for shearing force translations within the spinal column, and if not the articular facets, then what?
Rib facets. It has to be. If an unknown biomechanical component did exist, then that's where you would look.
There is no other way - if an unknown biomechanical component did exist as a set path for individual curve patterns; that distorts the ribs, whilst normal working motion of the articular facets remains relatively intact then the shearing force translation component must be the costal and intercostal demifacets. (proper name for rib facets if I recall correctly.)

Researchers will say they have looked at these things, but they havent looked properly.
The translations themselves arent caused by the force from adjacent vertebra,
- scoliosis cannot progress unless the configuration of the mucles allow it to.
The translations are caused by the combination of stretching and unstretching of connecting tissue from neighboring regions of the spine (the spines natural curves) - not the neighbouring vertebra, and thats where the true anterior / posterior loading vectors come in.

Now you see - I came to these conclusions, but not from thinking about it logically like the way I just wrote it, but rather I learned it from the other side. My specific scoliosis experience itself drew me towards these conclusions, because it was the only logical explanation for the specific conditions surrounding my particular scoliosis.

You see as I explained in my first post.
I know the particular forces I placed on my spinal column to compromise the normal working biomechanics of my spine and create scoliosis (and I can tell you that in relation to the degree values for determining a classification of scoliosis 10 degrees is in my opinion valid, and precisely correct even if it wasn't chosen that way)
This happened at a time when I was skeletally mature - age 25 - No factors relating to growth in my scoliosis.
I picked apart every single aspect of the biomechanics of my scoliosis as it progressed and I quantified it as entirely as is possible without creating a complete 3d Model. Compression, tension, shearing component, and torsion, the normal workings of the spine and how they tie in - flexion / extension, lateral flexion and rotation of the trunk. The true anterior posterior loading vectors of the curve pattern and the trigonometry type ways of calculating the translations and understanding how the spinal column reacted to all these things on a daily basis in relation to normal postural events - standing, sitting and laying down.
But thats where I got stuck. No amount of contacting people within scoliosis research circles eventuated in anyone being willing to go the distance to explore what I was trying to put forward and so I was not able to move forward unless I learned 3d modelling and animation myself. I learned that its in some ways foolish to discuss my ideas without being able to prove them,
and which is why I had some relectance in posting this.

You see though the first part I wrote is in my opinion basic logic trying to figure it all out, but my particular scoliosis experience itself stands for nothing less that the opposite side of the equation. I didn't ask for the answers any more than I asked to get scoliosis.

My opinions on things are going to be biased towards what I believe, but cannot yet and may never be able to prove.
This is also part of the reason why I think I should refrain from taking part in some complex discussions.
Because if I cannot prove what I believe then my opinions are based on nothing more than conjecture or heresay, and I just leave myself open to criticism and ridicule. And so, I need to focus on my 3d modelling.
Anyhow, just wanted you guys to know I wasn't being ignorant.


Thanks for your time,
Scott

[Dr Kalla]

Hi

Look up geometric torsion and scoliosis. With geometric torsion idiopathic scoliosis can be categorized in into 3 groups, that's it 3. It might even help you with your 3d modeling.

As for adult / de-novo / degenerative scoliosis we know that it follows a definite vicious cycle and gets progressively worse.

But what Dr Stitzel and myself are interested in is how to spot AIS in its early stages before it becomes a problem and that's when we have to dig into its neurological component.

Please do continue to share your thoughts on this forum. Remember that we learn from each other and it is good to look at this problems from different angles.

[DrStitzel]

Hi Scott,

Rib facets. It has to be. If an unknown biomechanical component did exist, then that's where you would look.
There is no other way - if an unknown biomechanical component did exist as a set path for individual curve patterns; that distorts the ribs, whilst normal working motion of the articular facets remains relatively intact then the shearing force translation component must be the costal and intercostal demifacets.

Hmm, rib facets are non-weight bearing, so how would they account for the rapid curve progression seen during growth spurts and how would that fit in with the 8:1 female to male ratio of idiopathic scoliosis seen in that same time period/age range?

Btw, no one things your being ignorant Scott. I'm just apprecative that your using you own brain to figure this stuff out instead of just taking "the guided tour" like most scoliosis patients.