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Features Practice Technique
Research: winter 2006

Complex and diverse are two words that come to mind when considering the field of massage therapy. Diagnosis and treatment of “normal” dysfunctions can be a challenge.


September 28, 2009
By Terrance J. Giesbrecht graduate of the WCRMT Distance Education Program

Topics

Complex and diverse are two words that come to mind when considering the field of massage therapy. Diagnosis and treatment of “normal” dysfunctions can be a challenge.

The task is even more daunting when venturing into the uncharted waters of severe structural anomaly. Research data in this area tend to be quite limited. This case study of congenital scoliosis will attempt to fill a portion of that void.

Idiopathic scoliosis can have devastating effects on the human body. Although many sources have been implicated, root causes of this condition are still relatively unclear.

Contraction and/or fibrosis in various muscle groups during periods of rapid growth are known to cause spinal deformity. Surgical procedures and the resulting scar tissue will also contribute to abnormal spinal development. It has been established that 2-3 per cent of normal adolescents suffer from idiopathic scoliosis, compared with up to 19 per cent of congenital heart disease patients.1

A study by the Department of Physical Therapy, Santa Barbara Cottage Hospital, Santa Barbara, California even suggested that hearing impaired children may actually be protected from idiopathic scoliosis by a neural dysfunction. The research indicates a 4-10 per cent lower than national average rate of scoliosis in children with vestibular dysfunction.2

In light of these results, much research remains to be done on the root causes. Our focus in massage must, however, gravitate to treatment rather than etiology. Congenital scoliosis is not generally considered highly treatable. Bone development, in afflicted adults, has already been significantly altered. Any attempt to radically change joint angles or existing body mechanics could be met with painful resistance.

Normal spinal mechanics and posture are the result of many muscles acting as agonist, antagonist, and fixator simultaneously in a co-ordinated effort to maintain balance. A scoliotic spine functions in a similar manner, but many compensatory mechanisms come into effect to support the spine in a position which must be considered normal for that individual. Philip Greenman addresses this briefly in his Principles Of Manual Medicine.

Greenman is quoted as saying: “In the presence of a primary, structural scoliosis of the thoracic spine, structural diagnosis becomes quite difficult.

The group of segments involved in the primary scoliosis behave as a neutral, type I dysfunction. It is interesting that patients with this condition have minimal symptomatology until a minor traumatic event occurs. Then this vertebral area becomes extremely symptomatic.

What is frequently found in this situation is the presence of non-neutral, type II dysfunction(s) within the primary scoliotic curve. It is quite difficult to identify these non-neutral, type II dysfunctions but if the examiner makes a diligent search from one segment to the other, observing the behaviour of single vertebral motion units rather than the total curve, one can frequently identify the symptomatic and aggravating non-neutral dysfunction in the primary scoliotic curve.”3

My goal for this study was to clarify the role of massage in helping scoliosis victims maximize their mobility and sense of well-being. Treatment protocol followed was: “Treat what you find.” Three subjects with major scoliotic curvature were considered. Each subject had his or her own specific restrictions and limitations. Each had his or her own means of coping with the problems life dealt them. They represent up to 10 per cent of the adult population in North America according to the National Scoliosis Foundation.(4)

Subject #1 Penny
Penny is a 37-year-old female with a husband and two small children. Andrew is a 27-year-old unmarried farmer. Clayton is a 19-year-old trucker. Our first two subjects have unique medical histories in that both were born with congenital heart disease. The third participant was fortunately spared that type of trauma.

Penny was a “blue baby,” born with an interventricular septal defect measuring 12 mm. At age four, after several heart attacks, she was taken to the Mayo Clinic in Rochester, Minnesota, where she underwent open heart surgery. A dacron patch was sewn over the hole in a completely successful operation. Within days she was literally running down the hospital corridors, a totally new experience for her at that point. Having been given the gift of life, Penny’s problems were far from over. Fetal development is a fearfully complex and delicate balance. Congenital deformities rarely happen in only one area. Babies with such abnormal heart development are generally born with some degree of cerebral palsy.

Penny was not afflicted in the usual manner. She instead suffered extensive musculoskeletal wasting on the left side of her body from T12 to her foot. Later structural analysis will reveal a complete absence of the left quadratus lumborum, causing a major hip dysplasia.

Surgeries seem to have been an everyday occurrence in Penny’s life. At age two, a shunt was performed in an attempt to oxygenate her blood more thoroughly. A section of the radial artery was removed from her right arm to be spliced into the pulmonary circuit. Intention was for the blood to be circulated through the lungs twice before entering systemic circulation, thereby picking up more oxygen than normal. This experiment functioned approximately one day before failing completely. It did, however, leave her with no pulse in her right wrist – a fact not lost on many future doctors and nurses. There are those who, much to her amusement, still insist, “There has to be a pulse in that arm!”

Early childhood found Penny with very little strength and support in her left ankle. Doctors promptly fused it. Severe hammertoes have been straightened, and a clawfoot condition has been surgically rectified. When you add two caesarian sections and a knee dislocation requiring general anaesthetic to reset, you have a very medically experienced young lady.

Penny’s present state of health is excellent. She rarely falls ill with anything other than the common cold or ‘flu. She wears custom built orthopaedic shoes, which have helped her gait tremendously. Heart arrhythmia became a concern for a short time after the birth of her first child. This was remedied when she inadvertently discovered increasing her consumption of potassium (e.g. eating more bananas) completely eliminated the arrhythmia. Lots of scars and a wickedly loud heart murmur are the only lasting legacies of her delicate beginnings.

Penny’s capacity for work is phenomenal. Being a highly productive administrative secretary for 18 years, she has honed her typing skills to well over 110 words per minute. Shorthand is taken at 150 words per minute. Working half time for Community Health, keeping a spotless home, and raising two wonderful daughters keep her very busy.

Topping everything is her radiantly cheerful attitude toward life. A deeply rooted faith in God and compassion for others have empowered her to overcome any obstacle. Perhaps we could all take some notes.

• Students in their final year of training at the Western College of Remedial Massage Therapies in Regina, Saskatchewan, are required to complete research and study on topics related to the massage field. Student thesises can be viewed at www.westerncollege.ca
• References and data tables will not be included in this article, but they can be viewed on the WCRMT website.

Subject #2 Andrew
Andrew’s entry into the world was similar to Penny’s in that he suffered congenital heart disease. An aortic valve stenosis caused a great deal of concern to
parents and doctors alike.

Two surgeries to clean the valve were performed, one at age 6 and the other at age 20. Both surgeries provided only temporary relief of the problem. At age 26, a third heart surgery was performed at Saskatoon Royal University Hospital, Saskatoon, Saskatchewan. The defective valve was removed; and a 25 mm. stainless steel valve, implanted. Other surgeries included removal of all his baby teeth to prevent possible heart infection and a double hernia repair.

His mother reports an interesting observation that throughout Andrew’s many surgeries, not one blood transfusion was required.

Scoliosis was not immediately apparent at birth. Spinal deformity became noticeable at age 3. By age 13, deviation became so pronounced that a Herrington rod was implanted for spinal support. Doctors were very pleased with the results.

Andrew’s posture remained nearly normal for the next two years. Problems set in again as he reached puberty. Muscle imbalance in the presence of rapid musculoskeletal growth caused a severe lateral shift to the right, above the Herrington rods, dropping his right shoulder 10 cm. by the time he finished growing. Andrew’s present state of health is quite stable. He requires permanent anticoagulant therapy to prevent clotting around his heart valve. His physician reports, however: “Andrew is not like an eggshell. You would have to beat him with a two-by-four to get him to bleed.”

This is surprising, considering the relatively high dosage of Warfarin and Aspirin he consumes daily. He does have to treat any throat infections with an immediate course of antibiotic. Dental work also requires similar preventative measures to deal with potential infection introduced through the lymphatic system.

Lack of flexibility tends to limit Andrew’s activities. He prefers the computer to more vigorous activities but does enjoy shooting a recurve bow for recreation. His parents and several of his four brothers farm together, relying on Mom and Andrew to keep the books.

All things considered, Andrew has adapted very well to his condition.

Subject #3 Clayton
Clayton also started life with surgery, although not quite as dramatically as our first two patients. He suffered a blockage to the stomach at three weeks of age when his esophagus grew shut. 

When corrected, he immediately began to thrive. Eczema was a major problem, the cause being traced to food products containing vinegar. Clayton would break out in a severe rash, particularly in the mucus membranes of the face. According to Dr. Randall Radford of the Associate Family Physicians Clinic, Swift Current, Saskatchewan, children with eczema are considered high risk for developing asthma, which Clayton promptly did at age 11. It is quite likely that his asthma (along with possible hereditary factors) contributed to severe rib cage deformity, resulting in a rotary scoliosis of the thoracic spine.

Scoliosis was not a problem for Clayton as a child. Bone development began to be altered as he approached puberty. A family history of extreme kyphosis, bilateral and unilateral, exists. His mother is, and great-grandmother was, very much afflicted bilaterally. Clayton and his 22 year old cerebral palsied brother suffer the condition unilaterally. He recalls his back starting to “bulge out” on the right side about the same time he began developing asthma.

Sports, farming, team roping, and other physically demanding activities did not seem at all restricted by the progressive alteration in rib cage development. Today, however, he attributes much of his breathing difficulty to his spinal condition.

Clayton’s present state of health is good, as long as he avoids dust and/or extremely damp air.

 He is rarely sick but does need to carry a Vanceril inhaler. His main complaint would be an inability to straighten his back right up.

Pain is commonly presented in the upper thoracics, particularly on the right. He feels very restricted upon inspiration at these times. When breathing difficulties arise, he resorts to inhaling Vanceril. If relief is not almost immediate, he knows his back needs attention. This young man has not presented the problems of our first two subjects but still represents a fine example of coping with spinal anomaly.

Case Study #1
ASSESSMENT

Penny was the most difficult of the three subjects to assess. A complete absence of the quadratus lumborum and lumbar portion of the erector spinae on the left, coupled with hypertrophic development of the same muscles on the right, resulted in a massive hip dysplasia from birth.

This odd configuration tractioned her right innominate 6 cm. higher at the iliac crest than its mate to the left. Right rib #12 was being forced into the right iliac crest. Left tibia/fibula was anatomically shortened by 5 cm. compared contralaterally, compounding the dysplasia. Muscle structure in the left calf was 80 per cent atrophied due to a fused malleolus, and the left foot was 20 per cent smaller than the right. Spinal adaptation to the hip dysplasia was quite severe. (See Appendix #1.) The acute sacral angle drew L3-L5 sharply into a type I NSRTRLT. X-rays revealed a congenital fusion of L3 and L4. T10-L2 functioned as a type I NSLTRRT curve. T7-T9 remained neutral. Another type I NSRTRLT was found in the upper thoracics. Anteriorly, the sternum was surprisingly symmetrical considering her spinal adaptations. An extreme inferior subluxation was present at the pubis.

TREATMENT
Penny began receiving remedial massage regularly in 1991. She experienced great symptomatic relief when treatments were administered five times per month. To that point, pain could be alleviated four to six days at a time. In September of 1994, focus of treatment shifted from short-term relief of acute pain to structural realignment. Intrinsic treatments were unsuitable for Penny’s condition. Exercise and stretching were not regularly performed at home.

A tremendous amount of force was tractioning Penny’s pelvis superior on the right. Main priority was to loosen the quadratus lumborum/erector spinae group to the right of the lumbar spine. It had over the years become a heavily splinted, fibrous mass, which defied palpation. Deep transverse friction and much crossfibering were performed in the area, as well as the fascia overlying the sacrum. Splinting was found in all hip muscles and treated extrinsically. Tightness was treated extrinsically in the right abdominal obliques. Extensive crossfibering was also performed on the multifidi and erector spinae T1-T12.

OUTCOME
After one year of advanced remedial treatment, Penny began showing remarkable improvement in hip structure. The right erector spinae/quadratus lumborum became much more pliable, to the point of allowing the right innominate to drop inferiorly. Rib #12 no longer clashed with the innominate but had 1.5 cm. clearance.

Penny began developing extremely sharp sciatic pain from hip to ankle on the left side. Massage relieved the pain temporarily but would not eliminate it. After carefully considering the mechanics her body was exhibiting, a .4 cm. heel lift was placed in her left shoe. The sciatic pain immediately disappeared. Recurring pain necessitated three more heel lifts, for a total of 2.2 cm., as treatment continued. Relief was immediate with the addition of each lift. Range of motion was only marginally increased.

Penny is normally not very flexible. Standing flexion had the most dramatic increase after deep transverse friction over the right sacroiliac joint produced a major fascial release. A sudden “pop” surprised both the patient and the therapist. Instant relief was felt by the patient, and the area was completely pain free. She was then able to bend to the floor and touch her toes for the first time in years. This increased flexion has been maintained to date. Structurally, the spine did show some tangible change.

Two type II segmental dysfunctions found in the thoracic spine at T3 and T9 responded well to extrinsic treatment as predicted by Greenman. A larger neutral zone between the upper and middle curves from T4 to T7 became much less painful to oscillation. Her three type I curves also appeared more uniform.

Penny’s back is far less symptomatic than before the onset of regular therapy. She quite easily finds two weeks relief between treatments, a time frame unheard of before and steadily increasing. When she does develop pain, it tends to be less severe than before and is likely brought on by her hard work.
 
Penny’s case was a most interesting and rewarding study. She illustrates that changes, however small, are clinically significant. Thank you very much, Penny!

Case Study #2
ASSESSMENT

Andrew’s visual assessment began with plumbline, revealing a marked anterior shift of the head 5 cm. from midline resulting in cervical lordosis. The cranium also showed deviation from midline of 3 cm. with a slightly right sidebent resting position. His left shoulder was raised by 2 cm. in relation to the right, measured at the acromion process. Gross winging of the right scapula was obvious with the inferior angle projecting 3 cm. posterior. The inferior angle of the right scapula rested 2 cm. inferior to the left. Left ribs #1-2 projected posteriorly 1.5 cm. at the transverse articulations. Right ribs #3-6 projected posteriorly 3 cm. at the transverse articulations.

Structurally, the sternum showed alteration due to compensatory torsions of the rib articulations. Significant scarring was present at the sternum, remnants of being split during open heart surgery. X-ray photos clearly showed six wires holding the sternal structure together.

Andrew is a classic example of the tower system of spinal balance (or imbalance). A short left leg and congenital dysplasia of the hip dropped his left iliac crest 3 cm. inferior to the right. This induced a massive type I NSRTRLT compensation, T12-L5. T7-T10 formed an exaggerated type I NSLTRRT in response, with T11 being the neutral transition zone. T1-T5 reverted to type I NSRTRLT again, with T6 being another neutral transition zone. (See Appendix #2.)

The Herrington rod extended from L5 to T6, eliminating flexion/extension in the area. This motion was accomplished almost entirely from the hips. During standing flexion, Andrew’s hands would reach only to his knees. A limited degree of rotation was still possible below T6, as well as very slight sidebending. Initial ROM testing revealed left and right rotation at 30 each were very restricted. Left sidebending was greatly reduced at 5. Right sidebending was not much better at 10.

Tissue palpation revealed a number of splinted areas. Tightness was evident in the anterior portion of the left gluteus minimus. Tissues on the convex side of each major spinal group curve were very tight and fibrous at the apex, particularly T12-L5. Intercostal muscles were all quite tight as well. Fascia overlying L4 to the sacrum and laterally to the sacroiliac joints was extremely dense and heavy. An inferiorly subluxated pubis was found to be present on the right.

TREATMENT

Andrew’s most immediate need was a 5/8” heel lift under his left foot to level the innominates. He was referred to the Orthopaedics Department of Saskatchewan Abilities Council in Saskatoon, Saskatchewan. This was unfortunately not accomplished until late in the study. In the meantime, he inserted rubber shims in his left shoe to help him stand straighter.

Actual treatment protocol for Andrew was predominantly extrinsic, although one application of intrinsic manipulation did effectively treat his pubic subluxation. Some isometric/isotonic treatment was used for the appendicular skeleton. Extensive crossfibering was done on all splinted areas, such as the erector spinae and hip. Deep transverse friction was applied to the fascia and muscle tissue at the apex of each group curve. Intercostal raking and friction were applied to the intercostal muscles. Two type I segmental FRSLT dysfunctions were found near the apex of the two upper neutral curves at T8 and T4 (see Appendix #2) and treated extrinsically by stripping and cross-fibering.

In spite of the rigidity afforded by the Herrington rod, some vertebral movement was palpable in the lumbar spine. T12-L5 moved as a neutral group, rotating left in extension and right in flexion. L5 was painful to oscillation, indicating an area of higher stress. Dealing with contraction in the quadratus lumborum and high density of the lumbodorsal fascia was the main extrinsic goal in the lumbar. It took a considerable amount of energy in the form of deep transverse friction to break down fascial adhesion. Four such applications made a considerable difference to palpation in the area. Spinous processes L1-L4 at this point were much more palpable. More movement was also evident in sidebending and rotation.

Upper thoracic vertebrae were the least responsive to treatment. Extreme rib and sternal deformation locked the vertebrae solidly into the NSRTRLT formation T1-T3. Massage made the overlying tissues more pliable but, as expected, did not change upper rib positioning. Rib movement during the breathing cycle was almost nonexistent.

Scapular rhythm was another area of concern. Contraction in the serratus anterior caused excessive winging of the right scapula. Soft tissue techniques administered to the serratus anterior and pectoralis minor, plus some isometric stretches, helped considerably. Isotonic protocol was used on the elevating muscles of the right scapula, and isometric stretches were used on the right scapular depressors in a successful effort to bring the shoulder more cephalic.

OUTCOME
Twelve treatments were administered over a six week period. No exercise and stretching were performed at home. Other than an increased ROM in the cervicals, Andrew was not sure of what changes, if any, were occurring. His family observed him quite closely though and reported his posture to be noticeably improved.

Positionally, the vertebral bodies of the axial skeleton exhibited little or no structural change over the course of this study, but flexibility showed a positive increase. Sibebending of T1-L5 fully doubled to 10 left and 20 right. Rotation increased 10 bilaterally to 40 right and left. Standing flexion originally allowed his hands only to his knees. He was now able to reach midway down his shins. All type II segmental dysfunctions had disappeared by the final assessment. Three smooth neutral curves were all that remained. (See Appendix #2.) Rib motion was now occurring during deep inspiration. Both pump handle and bucket handle motions were restored, with some inhalation restriction remaining in the left mid thoracic.

The appendicular skeleton also showed some promising changes. Scapular rhythm was greatly improved. Winging on the right, although still slightly present at the end of the study, was much less obvious. Shoulders exhibited less anterior roll, and more mobility was apparent in all ranges. Innominates were nicely levelled with a heel lift in his left shoe, greatly reducing strain at the apex of the lumbar curve.

I was very pleased with Andrew’s progress over the course of this study. There were no radical changes, but improvement was tangible and measurable. With proper orthopaedic care and a good exercise program, I am sure this young man represents a great deal of potential. I very much appreciate his willingness to share in this study. Thank you, Andrew!

Case Study #3
ASSESSMENT
Clayton’s structural diagnosis began with a typical 10-step protocol. Plumb line revealed an 8 cm. anterior shift of the head, resulting in excessive lordotic cervical curvature. His right shoulder was slightly raised by 1.5 cm. Winging of the right scapula was obvious, with the inferior angle projecting 4 cm. posterior. Right ribs #2-7 projected posteriorly 4.5 cm. at the transverse articulations.

In forward flexion, the spine was very flat, T9-L2 indicating an extended condition. T1-T8 were in full flexion. A type I NSLTRRT condition existed T3-T12. (Please refer to Appendix #3 for structural data of the spine.) Structurally, the sternum showed alteration as well, due to compensatory torsions of the rib articulations. Sternal angle equalled 40, and the xiphoid process appeared to be completely missing. (Please refer to the chart found in Appendix #5 for data on relative anterior rib position.)

Initial range of motion tests revealed left and right rotation at 90 each were very acceptable. Left sidebending was somewhat reduced at 30. Right sidebending was quite restricted at 15. Flexion and extension were within normal expectations.

Anterior tissue palpation disclosed tightness in the rectus abdominous and left external oblique, as well as both pectoralis minors. Posterior palpation found splinting in the right erector spinae T2-T7 and very heavy fascia over the apex of the curve, making palpation of the multifidi quite difficult. When successfully accessed, they proved to be rather tender. Contraction was also found in the right serratus anterior. Weakness was found in the right rhomboids.

TREATMENT

Fascia was extremely dense and heavy between the spine and right scapula. Several sessions involved deep transverse friction in the area T2-T8. After three such treatments, the right multifidi were much more palpable; and the overlying erector spinae were much less cordlike. Clayton reported a corresponding reduction of tension in the area.

 The left spinalis thoracis also held a lot of tension, possibly contributing to the extreme sidebending T3-T12. Deep transverse friction proved very fruitful in this area as well. The right serratus anterior was treated for splinting, both extrinsicly and intrinsicly. Contraction in both pectoralis minors required several applications of extrinsic/intrinsic treatment. Right rhomboid major and minor were treated with isotonic protocol. Scapular winging showed immediate improvement.

A persistent left on left sacral torsion proved to be a difficulty, responding well to extrinsic and muscle energy treatment but returning every two or three sessions to irritate us. This may be attributable to the existence of a slight congenital hip dysplasia. Clayton’s left ASIS is shifted 1 cm. directly posterior in relation to the other, with no evidence of innominate rotation. This condition remained unaffected by any and all treatment given.

Spinal mechanics were somewhat difficult to determine due to each segment’s rotated resting position. The lumbar spine functioned in a basically normal manner, with exception of L1. (See Appendix #3). The first lumbar vertebra was the only segment to be rotated left. Its motion seemed fairly normal; and the segment was completely nonsymptomatic, in spite of its anomalous position.

Directly above at T3-T12, the type II NSLTRRT became very symptomatic at T4-T7. Clayton was found to have a type I ERSLT at T9 and T7. T9 and T7 were treated extrinsicly, as well as a type I FRSRT at T2. Intercostal muscles were treated extrinsicly at the same time. An immediate increase in lung capacity was noted by the patient.

OUTCOME
Sixteen treatments were administered in a period of two months. During this time, Clayton reported the most symptomatic relief in the first three weeks. Subsequent treatments helped to maintain his sense of well-being but had little apparent effect on biomechanics. Patient compliance to an exercise regimen was sporadic and minimal.

Clayton’s final assessment yielded some rather unexpected results. L1 was no longer rotated left but had returned to a neutral position. T3 and T11-T12, formerly the top and bottom of the type I NSLTRRT, were removed from the group curve and appeared to function in a normal manner. This reduced the problem area from 11 vertebrae to 8. At the apex, the vertebrae were showing less right rotation. All type II segmental dysfunctions had now disappeared.
Anterior examination of the sternum/rib cage confirmed the changes found in the thoracic spine. The majority of ribs exhibited less torsioning around the Y-axis, returning them to a more normal position. (See Appendix #5).

Some promising changes were found in the appendicular skeleton. Scapular rhythm was greatly improved. Winging on the right, although still slightly present to date, was much less obvious. Shoulders exhibited less anterior roll and more mobility in all ranges. A slight congenital hip dysplasia remained in the form of a posterior displacement of the left innominate on the Z-axis. This did not appear to alter apparent leg length. Clayton’s sacrum began functioning in a more normal manner but remained somewhat susceptible to left on left torsion when the body was subjected to overlifting.

The findings in this case could offer hope for many of the patients we may see in a clinical setting. Some structural changes in the vertebral column do seem possible. All aspects having been considered, I believe my therapeutic goal has been achieved with Clayton. He claims to breathe easier, sit straighter, and experience less pain and discomfort. What more can one ask? Thank you, Clayton, for your help!

I am well aware that a case study of three individuals hardly constitutes hard data to reshape commonly accepted views in any field of research. This study does raise some interesting speculation in regards to long-term care of scoliosis victims. What it also does is highlight the need for a longer, more in-depth study of the subject.

Based on my findings, success in treatment of congenital scoliosis seems highly dependant upon one’s therapeutic goal. The results of this study do indicate some hope for actual realignment of spinal structure, depending upon the degree of bone deformation present.

Two of the three subjects studied showed no appreciable change in structure of their type I group curves, although massage did eliminate the annoying type II dysfunctions. Our last subject did show positive change in structure but was also the least severe of the three cases. Clayton’s deformation began much later in life, allowing his vertebrae to become more fully developed before the advent of structural deviation. All three subjects did, however, show a general increase in most ranges of spinal motion, likely due to fascia becoming more pliable and elastic. Rib function, and as a consequence respiratory function, seemed to improve as well.
 
Relief from type II dysfunctions was evident as predicted by Greenman, easing acute symptoms.5 (He was right! “In the presence of a primary, structural scoliosis of the thoracic spine, structural diagnosis does become quite difficult.”6) Such relief was most welcomed by subject #3.

What I personally found most encouraging were the positive changes in the appendicular skeleton. Scapular rhythm showed significant improvement in our second two subjects. Winging, elevation, depression, and anterior tilt all responded well to both extrinsic and intrinsic treatment. Improvements of this nature could well be expected in most patients, regardless of spinal rigidity.

The presence of severe congenital hip dysplasia immediately signals loss of hope and low expectation for many practitioners. I believe the success evident in our first subject indicates perseverance, and a sound understanding of mechanical changes occurring can produce some very welcome results. It must be noted, however, that most progress made involved quite high levels of therapeutic discomfort during deep transverse friction. The fibrosis present in many of these special patients cannot be broken down with a half-hearted effort. In a clinical setting, it is likely that most patients would not tolerate such treatment, making progress difficult if not impossible.

Many questions came to mind as I worked with my three patients. What could have been done if proper treatment were given to these people as children, before bone development was so radically altered? Could controlling the contractile element of key muscle groups on the concave side of the curve have a positive effect? What if electrotherapy were used to strengthen the erector spinae on the convex side of the apex at the same time? Are these individuals being fit

with proper orthopaedic footwear soon enough? Physiotherapists have been putting such children in body braces for years now. Is neglecting the massage aspect skewing their results?

This study literally begs for more data. A good study of congenital scoliosis could well take years to compile, examining data from hundreds of patients. It remains a personal goal to pursue this area further as the scope of my practice expands. For the moment though, I am content knowing, “Yes, there is relief available!”



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