Which is more "cost effective"?  Scoliosis brace treatment, scoliosis surgery, or CLEAR Institute scoliosis treatment?

When you look at the cost of the CLEAR Institute scoliosis treatment^TM program, it certainly seems like a lot of money. If you call some of the CLEAR Institute^TM clinics, you’ll find out that the exact prices will vary, because each clinic sets their own prices. If you’re traveling from out of town for the intensive treatment (which is two visits each day, each visit lasting about 3 hours), most clinics charge around $3,000 for one week of care – not including the cost of travel, lodging, and food. Patients who live near a CLEAR Institute^TM clinic and receive care on a regular basis pay less, although the total cost will vary from person to person, depending upon the severity of the curvature and what treatment is required.

However, it’s not just about cost – it’s also about value. In order to understand why the treatment costs so much, you have to compare it to the other treatment options available.

With a mild case of scoliosis, the treatment fees for the CLEAR Institute method^TM are generally less than with a severe case of scoliosis. The other option besides CLEAR is doing nothing; observation only. However, even observation only has its costs – the cost of doctor visits, x-rays, and exams. According to research, the average cost of simply monitoring a mild curve for one year is $3,386.25, and the only benefit to observation is that you know what’s happening.¹ There are no recorded cases of scoliosis being cured by observation.

Comparing one year of doing nothing to one week of intensive treatment, the cost of one week of intensive treatment is less. The potential benefits are walking away with a Cobb Angle that is less than what it was before (sometimes even less than 10 degrees, thus technically no longer considered a scoliosis), and knowing what exercises & therapies to do at home to maintain and improve upon the correction. If the patient does their exercises faithfully and the correction can be maintained until skeletal maturity, research has shown that the chance that the scoliosis will worsen in adulthood is drastically reduced.² The real benefit of CLEAR Institute scoliosis treatment^TM, then, is that a person with a mild scoliosis may never need to worry about wearing a brace or undergoing surgery, or suffering pain or limitations because of their scoliosis later in life.

In this light, it really doesn’t make much sense why someone would choose to merely observe and do nothing about their scoliosis, when they could instead actually reduce the chances of their scoliosis getting worse – and pay less than if they chose to do nothing.

With a moderate case of scoliosis, scoliosis brace treatment is introduced as a treatment option. It must be recognized that the goal of scoliosis bracing is merely to stabilize a curve that is progressing; back bracing does not offer any long-term benefit or hope of correction. The cost of a scoliosis brace varies widely depending upon the design, but generally ranges from $5,000 to $10,000. This does not include the cost of the doctor fitting the brace, x-rays taken in the brace, or other associated fees – which, according to research, average around $10,836 annually.¹ So a patient being orthopedically braced faces an initial investment of $5,000 or more, plus $10,000 each year they wear the scoliosis brace. If, at the end of the back bracing period, their curve has progressed 5 degrees, this is then considered a success???

It’s important also to consider the ramifications of wearing a scoliosis brace – the time involved, and the emotional impact. Back Bracing is typically recommended for 23 hours out of the day; compliance, understandably, has been shown to be very poor.³ The psychological trauma of wearing a scoliosis brace during the formative middle school or high school years can also be very real, and can leave invisible scars that last for a lifetime.⁴

The CLEAR Institute^TM method for scoliosis recommends that someone with a moderate case of scoliosis purchase a Scoliosis Traction Chair^TM to use at home; this costs about $4,000. Generally they will use this chair twice a day for 30 minutes each time; one hour a day, instead of 23 hours. There’s no risk of emotional trauma; the chair is only used for a short time, not in a public setting but in the privacy of your own home, and you can watch television or play video games to help the time pass faster. If the scoliosis is corrected to the point where the Scoliosis Traction Chair^TM is no longer needed, it can be sold back to the company and a portion of the initial cost is returned to you. This isn't possible with a scoliosis brace, where each back brace is custom designed and fitted for one individual patient. Compliance with the chair tends to be much greater than it is with an orthopedic brace, because the time required is much less, and there is no shame or social isolation associated with using it.

A moderate case of scoliosis that travels to a CLEAR Institute^TM clinic from out of town may require two weeks of intensive treatment; this treatment regimen might be repeated again later on. The cost of two weeks of treatment averages around $5,000 (the initial examination is more expensive than later visits, so the cost is front-loaded). So, someone with a moderate case of scoliosis might be spending $10,000 a year on CLEAR Institute scoliosis treatment^TM – generally what they would be paying to undergo scoliosis brace treatment. They’ll be spending a little bit less on the Scoliosis Traction Chair^TM than they would for a back brace.

The value of CLEAR Institute^TM scoliosis treatment in this case is as obvious as it is with a mild case of scoliosis. Instead of hoping for the curve to stay the same, you’re hoping for the curve to get better. The financial costs are similar, but the emotional costs are much less. Instead of being motivated by the fear that if you don’t wear your back brace, your curve will get worse, you’re motivated by the hope that if you use the chair every day, your curve will be much better. If you do, and it does, you are rewarded by being able to reclaim some of the money you spent on the Scoliosis Traction Chair^TM.

With a severe case of scoliosis, surgery enters the picture. The cost of scoliosis surgery varies from region to region, but can be as high as $152,637.⁵ This does not include the cost of recovery time in the hospital, time lost from school or work – or the cost of revision surgery or treating any unforeseen complications. It should be expected that, when a healthcare procedure costs as much as a modest home, it has been thoroughly researched and proven to be effective. Unfortunately, only the first is true. There is no definitive long-term research that proves living with a fused, straight spine is superior to living with a flexible, curved spine. Each generation of new spinal implants evolved because of problems with the previous systems; these new systems allow better correction, but also result in a higher rate of complications. Whether it’s Harrington, Colorado, Cotrel-Dubousset, TSRH, or Universal Spine System, regardless of the type of instrumentation used, the underlying premise behind every spinal fusion surgery for scoliosis is identical; immobilization and solid bony fusion of the spine, resulting in a permanent loss of spinal flexibility and range of motion. There are never any guarantees that additional surgeries will not be needed, or that pain levels will be reduced or that cosmetic appearance will be improved by scoliosis surgery.

One of the primary goals of CLEAR Institute^TM scoliosis treatment is to ensure that the patient achieves the best possible quality of life and functions at the highest possible level. With scoliosis surgery, this is considered of secondary importance; the main goal is to make the spine look straighter on an x-ray. There is no correlation between this outcome and reductions in pain, improvements in lung function, increases in quality of life, or better physical function.

When an individual with severe scoliosis presents for CLEAR Institute^TM scoliosis treatment, it’s highly likely that the patient will be making a long-term commitment to care. Again, fees vary, but let’s imagine a hypothetical situation where a patient spends about $200 per visit, and comes in 50 times in one year. That patient would have spent around $10,000. If each visit is three hours, the hourly fee is just over $60 per hour – roughly the same fee that many massage therapists charge for an hour-long massage. This is a perfect example of how costs may mislead, but comparing the cost of one treatment to another – and what you should expect to receive for your money – leads to a better understanding of the real value of each therapy.

So while $10,000 may seem like a high cost, its value compared to surgical intervention is significant. One study found that 16.7 years after spinal fusion, 40% of patients were legally defined as permanently handicapped (it is rather ironic that scoliosis surgery is often presented as a patient’s only option to avoid permanent disability). Imagine you had a check for $150,000 that you had to spend only on healthcare, and ask yourself if you would choose to undergo an operation that may leave you worse off fifteen years from now, or spend your money on fifteen years of you & a CLEAR Institute^TM doctor working together to correct your scoliosis naturally.

Before anyone can fully accept this comparison, it’s reasonable at this point to ask, where is the long-term research on CLEAR’s methods? The cold hard truth is that, if there was any real interest on the part of the orthopedic community of finding a more cost-effective, less invasive method of helping people with scoliosis to lead active, pain-free lives without back bracing or scoliosis surgery, there would be extensive resources devoted to publishing this research. However, the vast majority of all scoliosis research done today is on the topic of surgical intervention; less than 5% of the articles published focus on finding alternatives or providing non-surgical alternatives. In the absence of the infrastructure & funding to implement a well-designed, independent study comparing CLEAR Institute scoliosis treatment^TM to scoliosis surgery, it is the responsibility of the patient to be their own advocate, and rely upon their own judgment, until such a time as when someone decides to put surgery to the test, and compare the long-term outcomes between surgically-treated patients with CLEAR Institute^TM-treated patients.

References

1)     Yawn et al: The estimated cost of school scoliosis screening, Spine 2000 Sep 15;25(18):2387-91.
2)     Weinstein et al: Curve progression in idiopathic scoliosis. J Bone Joint Surg Am 1983;65:447-55.
3)     Vandal S, Rivard C-H, Bradet R: Measuring the compliance behaviour of adolescents wearing orthopedic braces. Issues Compr Pediatr Nurs 1999, 22(2–3):59-73.
4)     Saccomani L, Vercellino F, Rizzo P, Becchetti S: Adolescents with scoliosis, psychological and psychopathological aspects. Minerva Pediatrica 1998, 50(1–2):9-14.
5)     Daffner et al: Geographic and demographic variability of cost and surgical treatment of idiopathic scoliosis. Spine 2010 May 15;35(11):1165-9.
6)     Gotze et al: Long-term results of quality of life in patients with idiopathic scoliosis after Harrington instrumentation and their relevance for expert evidence. Z Orthop Ihre Grenzgeb 2002 Sep-Oct;140(5):492-8.

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“How to fix scoliosis” doesn’t seem like it would be that difficult of a question to answer, yet, for 3,500 years of recorded human history no one has been able to answer, “how to fix scoliosis”.  Even with today’s genetic testing, computer data bases, and scoliosis blood test the question of “how to fix scoliosis” still remains.

Perhaps the reason the “how to fix scoliosis” questions hasn’t been answered is because no one has thoroughly examined the “why does scoliosis occur” question.  While there are many scoliosis theories abound, virtually all of them cite a neurological deficient in the automatic postural control centers of the brain as the root cause.  This means, idiopathic scoliosis is really primarily a neurological condition and secondarily a spine condition.  In other words, almost 500 year’s worth of scoliosis brace treatment attempts where doomed from the start, because it only attempt to treat idiopathic scoliosis as a spinal condition and not a neurological condition.  I guess scoliosis brace treatment only further proves “there’s no right way to do the wrong thing”.

In 1865 the French orthopedic community attempted to answer the “how to fix scoliosis” question with the first scoliosis surgery, which was shortly followed by the first orthopedic medical malpractice lawsuit (no kidding, it’s true).  Once again, scoliosis surgery is based on the premise that scoliosis is solely a spine condition with no neurologic root problem in the automatic postural control centers of the brain. 

The rate of complications during or shortly after scoliosis surgery is an alarming 68% (whist in all fairness includes things like bacterial infections that are present in all surgeries), which as very high number that should make everyone stand up and take notice.   Unfortunately, the long-term prognosis for scoliosis surgery treated scoliosis patients is even more bleak with one 2002 long-term study finding 40% of all scoliosis surgery treated patients qualifying as “severely disabled persons.”

So back to the question, “how to fix scoliosis”; Well scoliosis brace treatment appears to be worthless and scoliosis surgery may be worse than doing nothing, so now what.

Armed with the fundamental understanding the idiopathic scoliosis much be treated like it is a neurological condition first and a scoliosis spine condition second, a team of dedicated team of doctors across the United States began work on a scoliosis exercise based scoliosis treatment program that focused on re-training the automatic postural control centers in the brain, so the scoliosis spine would “learn” how to hold the spine in a straighter position automatically.

Over the course of several years this group morphed into what is now the CLEAR Institute non-profit organization.    

The Scoliscore genetic test was release and brought into wide spread use in 2010 and for the first time in human history, allowed doctors to identify the most “at risk” idiopathic scoliosis patients before the scoliosis spine began rapid progression towards scoliosis surgery.  This “scoliosis warning in alarm bell” in terms of genetic pre-disposition for a severe scoliosis condition has now created a demand for an Early Stage Scoliosis Intervention program that focuses on the environmental factors which trigger the genetics and create the condition known as idiopathic scoliosis. 

It appears that a “cure for scoliosis” may not be possible, but a combination of Scoliscore genetic testing and Early Stage Scoliosis Intervention may prove an effective “scoliosis prevention” approach to non-invasive scoliosis treatment.

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The current medical management of idiopathic scoliosis is fairly straight forward with 3: main recommendations:

~Smaller curves below 25 degrees monitor with no scoliosis treatment.

• ~Medium curves over 25 and less than 40 degrees, scoliosis brace treatment.

~Large curves over 40 degrees, multiple level scoliosis surgery.

The problem arises with parents of children who have entered the 40 degree zone when the typical orthopedic response is your child needs scoliosis surgery and many of these parents simply don’t want scoliosis surgery and feel that it is too invasive a procedure at this point. So what are the options? Is there a nonsurgical management plan for scoliosis? What are the real consequences of choosing not to do a multiple level scoliosis fusion surgery on a child with a 40 degree, 50 degree, 60 degree scoliosis?

The answer to these questions is going to be different based on the facts of the individual child’s clinical picture. If we look at options for nonsurgical management of larger curvatures we won’t find a whole lot of current literature or choices. Some of the more common but rather generic options are exercises, chiropractic, massage, and other alternative back care choices that don’t offer much in terms of addressing some of the more important aspects of larger scoliosis curvature. Many parents and children feel that addressing posture, function levels, breathing capacity, rib deformity, and pain are the major concerns with managing a larger scoliosis curvature.

The other concerns are often regarding the future health of their child. Will the scoliosis continue to progress? Are their cardiovascular or respiratory risks not just a shallower breathing pattern, but real tangible health concerns with a larger curvature? Can my daughter have children? What about sports?

As you can see there certainly is a plethora of questions facing a nonsurgical choice when it comes to scoliosis and probably why tens of thousands of scoliosis fusion surgeries are performed annually. It’s easier to swim downstream then to swim upstream especially when you have some of the most respected surgeons advising you to do the surgery.

Shedding light in regards to nonsurgical management of larger scoliosis curvature generally above 40 degrees is something that needs to be done and I hope the following information will help do this. Statistically the chances of cardiopulmonary or cardiac dysfunction that will actually affect the health of the individual with scoliosis are rare. Most experts feel that only in grossly severe curves over 100 degrees is the heart actually in danger of being affected. Pulmonary changes are more common but only occur in thoracic primary curves above 60 degrees in addition the thoracic kyphosis also must demonstrate significant losses in order for more noticeable changes in respiratory capacity to be measurable. The ability to have children both carry and deliver a baby to term without complications is often unaffected by larger scoliosis and in some reports more of a problem with multiple level spinal fusion surgeries. Most patients with a larger scoliosis remain fully functional and continue to live normal lives and other than some visual body asymmetry really are at no increased health risks.

It would be interesting to argue that there are potentially more health risks and complications with surgically treated scoliosis versus non surgically treated. Experts could argue that nonsurgical leaves you at risk for progression, pulmonary deficiencies pain whereas surgical intervention yields no improvement in pulmonary deficiencies or pain and adds functional losses in movement ability, stiffness, scarring, and host of other reported health issues. One thing surgery definitely provides is 250 billion dollars of revenue annually.

Moving forward a new nonsurgical treatment option created by a group of doctors known as CLEAR scoliosis treatment provides the best opportunity to manage a larger curvature. The main premise of CLEAR treatment is to decrease soft tissue resistance and then rehabilitate the neuromuscular system using advanced cantilever body weighting that helps the spine adapt and learn a new straighter position without creating immobility. Soft tissue adaptations that are present with larger curves involve muscle, tendons, ligaments, and discs. These tissues become more rigid and asymmetrical in larger curve formation. Advanced biomechanical equipment used produces cyclical loading and unloading combined with low frequency vibration to stimulate collagen elongation thus increasing spinal flexibility. Once the spine is unlocked where soft tissue has disengaged the neuromuscular retraining begins. A series of engineering measurements are taken to allow the doctor to create the appropriate weight leverage needed to cause the bodies neurological righting mechanism to shift the spine to a more stable balanced position when the weight is placed on the patient. This shift in spinal position used to rebalance and redistribute the bodies center of mass causes the spine to become straighter. When used repetitively for approximately 90 days follow up x-rays will demonstrate average scoliosis curve reductions between 30-50% with doctors that have clinical experience and advanced training so it is important who you choose for this type of care program.

Unlike physical therapy or chiropractic care this group of doctors are specifically trained in scoliosis bioengineering, require additional training, specific clinical equipment, and are required to take multiple exams to become eligible to provide CLEAR scoliosis treatment . So if I were a parent choosing a nonsurgical scoliosis management system I would choose these guys hands down. I would also consider for those parents who are planning on multiple level scoliosis fusion surgery to get a consultation with a CLEAR practitioner prior to undergoing surgery for scoliosis you may in fact see more benefit in a nonsurgical approach. When it comes to risks versus benefits the tide is turning in regards to nonsurgical versus surgical management for scoliosis.

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I consider myself to be analytical by nature, and I have always respected those who prefer hard data over personal stories. In my opinion, it is unfortunate that, in the realm of marketing, anecdotes and testimonials sometimes hold more appeal than facts and numbers.

Research is indeed an integral part of validating the efficacy of new treatment options as they become available. The new standard of Evidence-Based Medicine highlights the importance of utilizing the best available data from published, peer-reviewed articles, combined with the doctor’s clinical judgment and the specific needs of the patient. Since 2004, publishing research in scientific journals has always been a top priority of CLEAR Institute, and we maintain this commitment as our organization continues to evolve to meet the needs of our patients.

The article, “Scoliosis treatment using a combination of manipulative and rehabilitative therapy: a retrospective case series,” published by Drs. Morningstar, Woggon, & Lawrence in BMC Musculoskeletal Disorders, on September 14th, 2004, was a landmark in the realm of conservative scoliosis treatment. Within two years of its publication, it achieved the status of Most-Highly Accessed Article of All-Time in this journal, and continues to hold this title as of 2009, with over 36,000 views (number two has just under 24,000).

Limitations of this study have been recognized by the authors. Firstly, the design of the study is a Case Report, which essentially means that it was a retrospective review of how individual patients responded to 4-6 weeks of care. This study design limits the conclusions that can be made by the authors, and indeed, the only conclusion made was that the results of the study warrant further testing & research into the protocols. Another limitation is that there was no long-term follow-up demonstrating the permanence of the achieved results. It is important to state that CLEAR Institute has identified the need for continued research to address the short-comings of the first study, as well as the obstacles which need to be overcome in order to do so.

Our second study shares many of these limitations. Despite having a broader and more diverse sample size, it is also retrospective. A retrospective study looks back at the results of a certain number of individuals who fit the study criteria (such as having idiopathic scoliosis). A prospective study is probably what you would like to see the study criteria is expanded to include a time requirement (for example, every patient that started treatment from January 2010 until April 2010). In this manner, the rate of noncompliance ("drop-outs") can be included, and also the researcher has less control over the ability to self-select or "cherry-pick" the best results.

One of the greatest hurdles facing CLEAR Institute in the coming years is obtaining the necessary funding to pursue the long-term research into our technique, which is so desperately needed to establish confidence in the solidity & permanence of the achieved correction. It is an interesting side-note to point out at this time that, while the first spinal fusion surgery for scoliosis was conducted in 1911, and bracing has been around since the 17th century, many research reviews still consider the scientific evidence on these techniques to be inconclusive at best, despite the considerable resources wielded by the organizations advancing these techniques. CLEAR Institute, by contrast, was established less than a decade ago, in 2000, and did not begin working with scoliosis specifically until 2003. Coupled with the fact that CLEAR Institute is an organization primarily staffed by volunteers, most of them being clinicians who also maintain active private practices, it should be obvious that our financial & temporal resources are constrained to a much more significant degree.

CLEAR Institute has made an effort to ameliorate this difficulty by applying for Non-Profit Status in December of 2008, which will allow us to apply for & receive grant funding for proposed research endeavors. Unfortunately, like many bureaucratic processes, achieving formal recognition from the IRS as a Non-Profit Organization can take years even in the best of times. As of May of 2010, CLEAR Institute has not encountered any difficulties with its application; and has been granted provisional acceptance. Once this is formally & firmly in place, though, we will be able to submit research proposals & grant requests through a number of different organizations, including the Research Department of Parker College of Chiropractic, which is literally right next door to the CLEAR Scoliosis Treatment and Research (STAR) Clinic.

Please humor me by allowing me to expand briefly on some of various research study designs, and the benefits & limitations of each. I'll do my best to keep it as succinct as possible.

There may be considered three tiers of scientific articles. The first type, a Case Report, is merely observational. If a doctor or group of doctors notice an interesting case, or experience unusually good results in treating a common condition, they may draw up a Case Report to describe what they saw in their clinical practice. While relatively easy & inexpensive to produce, they allow the authors the least freedom to draw conclusions regarding the interpretation of the results, and are the most vulnerable to criticism regarding the validity of the results.

The second type is the Case Control or Cohort study, which can be prospective (designed in advance) rather than retrospective, but is still considered observational. In this type of study, two groups – one undergoing treatment, one not – are matched as closely as possible in terms of age, gender, severity of their condition, and similar factors. One group – the control – does not undergo any treatment, but are merely observed for how the condition progresses in the absence of care. The next group - the treatment or variable group – is the one which receives treatment, and at the end of the study, the two groups are compared. This allows for more specific data on the true effectiveness of the prescribed intervention, and thus the authors have more leeway to define the outcomes, but a Controlled study is subject to additional difficulties in its implementation. The first is the selection process; members of each group are self-selected (meaning they decide for themselves whether or not they would like to receive treatment), and screened for their eligibility. This process can take many months to refine the two groups into similarly-matched, and dozens of patients which may otherwise be ideal candidates for the study could be excluded for the simple reason that another patient matching their demographical profile cannot be found. Another limitation, common to all prospective studies, is the difficulty of maintaining patient compliance. It is inevitable that certain patients will drop out during the course of the study; if enough patients in the treatment group fail to keep their appointments, or if members of the control group do not come in for regularly scheduled check-ups, the entire study can be rendered invalid, and the results will be tossed.

The study design which is considered to be the most scientifically-sound is the Randomized Control Trial, or RCT. With the prospective design of a RCT, the patients in the treatment group & control group are not self-selected, but rather are randomly assigned to one of the two groups. Typically, the patients are not told (blinded) which group they will be in, and in a double-blind study (the most advanced form of RCT), even the doctors performing the study are kept ignorant of which patients are receiving the intervention and which are receiving a sham treatment or placebo, and even which patients have a disease and which do not (in conditions which are self-evident, such as scoliosis, these types of studies can be near impossible to design, however; doctors working with patients on a daily basis will soon be able to ascertain which ones have spinal deformities and which do not). To this day, a RCT has never been conducted on scoliosis bracing or scoliosis surgery.

Interesting sidenote: one of the only published RCT's to even involve scoliosis patients was published by Leatherman & Dickson in 1979, and showed that just eight days of exercises can improve the flexibility of the spine in scoliotic patients, converting a rigid, structural scoliosis, into a mobile, functional scoliosis - very encouraging news for alternative methods of treatment! I often wonder why, in the face of such powerful evidence, patients are not told to perform spinal mobilization exercises pre-surgery to improve the flexibility of the spine and hence the degree of obtainable correction, but I digress...

Obviously, a RCT suffers from the strictest limitations, one of which could be considered ethical in nature. Patients do not have a right to choose if they would like to receive treatment or not; if you would be reluctant to waive your right to choose your own treatment option for yourself (or your child), then you can understand why many patients are reluctant to participate in a RCT. In addition, those patients who were selected to be in the control group may experience deterioration of their condition while they are receiving sham treatment (and, due to the blinded nature of a RCT, they may be deliberately, albeit voluntarily, misled into believing that they are receiving effective treatment for their condition). Or, you may find yourself receiving treatment which is not delivering optimal results; should you elect to switch treatments or drop out, your participation in the study will be invalidated.

In consideration of the limited resources at our disposal, and the ethical considerations of designing a RCT, our agenda is to publish as many Case Reports of the individuals who have undergone treatment as possible; then, using this data then as evidence to help us achieve grant funding, we will be able to pursue prospective multicenter cohort studies. If you've never published a research article, please believe me when I say that it's a far more challenging endeavor than one might suspect! It's not as simple as just writing data down and sending it in to a journal, and it can be quite costly - even more so if the researcher gets paid. Right now the best we have to offer is Case Reports. We readily recognize the limitations of this tier of research, and cede the point to those who would desire a higher level of evidence immediately – so would we. Unfortunately, until such time as when bracing & surgery can stand up to the rigors of a RCT and validate their efficacy, there is no need to subject patients to the uncertainties of mere observation, the psychological trauma of bracing, or the physical scars of surgery; currently, we put forward data that is of no less significance that what other treatment options have provided to date.

One of the goals I am currently pursuing is the establishment of an online network that would allow CLEAR doctors to upload the case histories & x-rays of their patients (minus all confidential information, of course). In addition to providing us with the data we need to publish multicenter research studies, this would also empower CLEAR Institute to further refine its techniques.

You see, the techniques that CLEAR Institute is using to treat scoliosis are continually changing. One of my favorite sayings is, "We always reserve the right to get smarter." Unlike bracing & surgery, whose basic principles underlying the goal of their treatment have not changed since their inception, CLEAR's method has an entirely different focus. Traditional medical science views the spine as a bridge connecting the head and the hips; if a bridge starts to buckle, the correct thing to do is fuse it or brace it. However, chiropractic science views the spine as an engine, one that requires motion and feedback from its environment to function. If you have a six-cylinder engine that is not running correctly, and you fuse three cylinders, would you expect it to run better or worse? Similarly, there are mechanoreceptors in the spine that participate in a motor-sensory feedback loop with the brain and the body's other righting reflexes, such as the ears & eyes - much like the temperature, oxygen, & fuel sensors in your car help your engine to run optimally. An impairment of this loop could influence the development or progression of scoliosis, so one of the goals of our treatment focuses around re-training the patterns that the body uses to orient itself in time & space (proprioception). Scoliosis Bracing & scoliosis surgery, as passive therapies, do not influence the active & re-active neurological systems of the body.

The point I am making with this is that what scoliosis bracing & scoliosis surgery are trying to do is very simple & straightforward, and they've been trying this same approach for centuries. CLEAR is trying an entirely new approach, one that no one else has done before, and to be honest, we readily admit that we don't have it all figured out yet; neither does anyone else! If there were any scoliosis experts, there would be no scoliosis. We don't yet know what therapies are the most beneficial, or which ones could be left out of the treatment plan without adversely affecting the patient. We have made, and continue to make, a great deal of progress in refining our approach - using new digital motion x-ray technology, we were able to determine exactly which exercises were most effective, eliminate some that were less than ideal, and combine others to help our patients save time. Today, a CLEAR patient performs exercises that take up one-third of the time that they use to, yet on average experiences better results. The same goes for our equipment, our adjustments, and every other modality - the more we learn & refine, the better results we achieve. We don't want to rush it and publish results using unrefined protocols that present our methods as less effective than they truly are today. Writing research takes time - the study you publish today is always on yesterday's results. In our first study, three patients out of 22 dropped out; in the second, seven out of 140. It's reasonable to conjecture that, had we used the minimized exercise approach we are utilizing today, some of these patients might have continued with care, and thus influenced the results of the research. The same goes for the reduction in the Cobb Angle - we know that we can achieve a much better correction in a much shorter amount of time than we once could. But why do some corrections hold, why do some worsen, and why do some continue to improve? Obviously patient compliance & follow-up is a large part, but what else influences the permanence of the results? We're still trying to understand.

Working with scoliosis is a very challenging endeavor; one that exposes you to a great deal of criticism from individuals who are comfortable with the status quo, many of whom personally contribute very little in terms of actual progress, prefering instead the easy moral lassitude of taking shots at those who dare to try. I wouldn't be in this field unless I believed with all my heart that scoliosis patient deserve more options, not less, and that CLEAR's method is viable, scientific, and will withstand the test of time in comparison with the barbarism of fusing spines to treat one symptom of a condition while we readily admit our ignorance in knowing its cause. Lacking knowledge of a cause, all treatment must by nature be incomplete, aimed only at relieving the associated signs & symptoms of a deformity which continues to be driven by the cause, which we are blind to in our ignorance. CLEAR's treatment is based upon the premises that Dr. Clayton Stitzel outlined perfectly in an earlier post (Cause of Scoliosis, Initiating and Progressive Factors, posted on 5-18). We believe these to be the causes of scoliosis, and through our treatment we aim to treat the cause, because in doing so, the associated signs & symptoms will improve concurrently. This just makes more sense to me than fusing an engine together because we don't understand why it's functioning differently.

Returning to the original question, as I mentioned earlier, the triangle of Evidence-Based Medicine consists of three key points: the best available research, the clinical experience of the doctor, and the personal needs of the patient. It's important to note that research is only one factor; if a patient adamantly refuses to undergo surgery, all the evidence in the world in favor of surgery is irrelevant.

One of the little idiosyncrasies I have noted in the world of researchers is that many of us like to pretend we exist in a separate bubble, and that only published findings matter; if you can't prove it through research, it might as well not exist. This attitude is often exemplified by the "Parachute Study" - if you haven't heard of it, it can be acccessed here: http://www.bmj.com/cgi/content/abstract/327/7429/1459. short, I encourage you to make the best possible decision with all of the information you have on hand; just as you shouldn't make a decision based upon one testimonial, don't let research be your only deciding factor as well. Research is an inductive science - analyzing a small piece of the puzzle and trying to figure out how it fits into the big picture - and it doesn't always apply well to the real world, or to the realm of clinical science, where meeting the needs of the patient is paramount, as opposed to research, where the gold standard of a RCT by its very nature considers the needs of the patient irrelevant.

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How is CLEAR Institute different from scoliosis brace treatment and scoliosis surgery anyway?

I hope this can inform and/or clear (no pun intended) up any misconceptions.

Check out the 5 min introduction to CLEAR scoliosis treatment on www.clear-institute.org/freeinfo

The work we (CLEAR Institute) are doing is based on the fact that scoliosis is not just a spinal curvature, but involves abnormal spinal curves in the neck, as well as hip rotation. Active scoliosis patients always present with forward head posture and loss of cervical lordosis (side view of the neck)(seen on x-ray). There is also abnormal biomechanical malposition of the head and neck. Therefore before the lateral scoliotic curvature can be corrected the cervical lordosis in the saggital plane must be re-established. After which the lateral curve (Cobb angle) is reduced.. These results are achieved with a combination of specific spinal adjustments done with instruments, specific rehabilitative procedures including proprioceptive neuromuscular re-education, muscle and ligament rehab and vibration therapy. The scoliotic spine compresses and rotates three dimensionally; therefore it must be de-rotated, and de-compressed in order to correct. We use, among other things, vibration platforms and a vibration scoliosis traction chair as well as specific bracing to pull the Cobb angle back into proper alignment.

Scoliosis is the body's natural and innate response to the loss of mechanical
function provided by the normal curves of the spine. When these curves disappear, the
body re-inserts them in another dimension. If scoliosis has a "cause," then it can only be
described as the laws of physics!

1.) Scoliosis is caused by a dysponesis (miscommunication) between the motor-
sensory input/output from the upper trunk to the lower. This is in turn caused by a
unilateral (one-sided) impairment of the spino-cerebellar loop, which is located in the
area between the occiput and the first cervical vertebra. Supporting this theory is the fact
that 100% of scoliosis patients have a problem with proprioception (orientation of the
body in time and space), and 100% of scoliosis patients have a loss of the curve in their
neck, resulting in forward head posture.

2.) Exercise rehabilitation therapy is mandatory to reverse the scoliosis. Without
patient compliance, no amount of care can help. It is necessary to retrain the postural
muscles of the body. Vibratory stimulation overrides the body's proprioceptive signals
and mechanoreceptors, thus facilitating retraining of the postural muscles.

3.) Cobb angles over 30 degrees cannot be reduced in the same manner as Cobb
angles under 30 degrees. The muscles contract more on the convexity of the curve, rather
than the concavity, as is the case with angles under 30 degrees. Normal laws of
biomechanics do not apply in patients with Cobb angles of more than 30 degrees!

4.) One component is universally lacking in nearly all
forms of scoliosis treatment today: the effect of the cervical
spine in determining spinal pathology, gait, stance, and overall
posture. The head controls all components of the spine below
it, much like how the engine controls the direction of a train.
Without regard for which direction the locomotive is heading
in, how is it possible to control the boxcars behind it? The very
first aspect that must be addressed in scoliosis correction is the
cervical spine; specifically, correcting the forward head posture
by restoring the curve and the normal ranges of motion in the
neck, especially between the occiput (C0) and the atlas (C1).
This is why lateral cervical views in neutral, flexion, and
extension are necessary. Follow-up x-rays should be performed roughly every three
months as objective proof of improvement; should the patient's progress plateau or
regress, additional rehabilitation or alterations to the protocol may be required.
Obviously thoracic views are necessary to measure the Cobb angle, but stay away from
full-spine views! The rate of distortion is too high to allow for consistency and accuracy
when comparing measurements between pre-and post-x-rays. It is also important to
evaluate the curve in the low back, and rotation in the hips with lateral and A-P lumbar x-
rays, and correct any deviation from normal that is found.

The CLEAR Institute scoliosis treatment system is a completely new and revolutionary system of scoliosis treatment that achieves scoliosis reduction and stabilization by "unlocking" the curvature from the original position, mobilizing the spinal joints back ot a normal range-of-motion, and then "re-locking" the new, straighter spinal curvature by re-training the brain to learn the new spinal position.

Here is one way of thinking about it......

MIX FIX SET – the computer analogy

 
Mix – Format the hard drive.

Erase and brake down the soft tissue resistance in your scoliotic spine, is like clearing the errors and bugs on your hard drive formatting it.

Fix – Hit the power reset button.

Adjusting the misaligned spine spinal units, that were measured of your x-rays with spinal manipulation, is like hitting the power reset button on your formatted computer. This will force the body to recalibrate adjusted spinal segments, like your computer will have to reboot again.

Set – Install the new software.

Scoliosis Traction Chair (STC) and Spinal Weighting system is like installing the new operating software on your hard drive, retraining your brainstems ‘Body Set Point’ or ‘Body Scheme’ to adapt to its new alignment.

Personally, I like using the "making bread" type analogy......

Throw eggs, flour, yeast, oil, ect into a bowl and toss it in the oven and you won't get bread.....you'll get warm goo. However, if you knead the ingredients into dough, let it rise in the fridge, cook it in a pre-heated oven for the prescribed amount of time you will most likely get bread. Same ingredients, different protocols, dramatically different outcomes.

And that is how the CLEAR Institute Scoliosis Treatment program works.

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An Interview with Dr. James Ogilvie, Past President of the Scoliosis Research Society, and Founder & Chief Medical Advisor for Axial BioTech, the Creators of the ScoliScore™ Genetic Prognostic Test for Scoliosis

Dr. James Ogilvie is a board-certified orthopaedic surgeon. In addition to private practice, Dr. Ogilvie is adjunct Professor, Department of Orthopaedic Surgery, at the University of Utah in Salt Lake City and Professor Emeritus, Department of Orthopaedic Surgery, at the University of Minnesota in Minneapolis, MN. He is Staff Surgeon / Attending Staff at Shriners Hospital Intermountain Unit in Salt Lake City.
Dr. Ogilvie earned his Medical Degree at Yale Medical School in New Haven, CT and completed a surgical internship at the University of California, San Francisco. His residency education in orthopaedic surgery was performed at the University of Utah. Dr. Ogilvie advanced his skills and experience through a Spine Fellowship at Rush Presbyterian / St. Luke's Medical Center in Chicago, IL.

He is an active member of many prestigious organizations including the Academic Orthopaedic Society, American Academy of Orthopaedic Surgeons, Scoliosis Research Society, and Society of Military Orthopaedic Surgeons. Dr. Ogilvie served as a Commander in the United States Naval Reserve.
As researcher and prolific author, Dr. Ogilvie's editorship roles are recognized by journals including Spine Journal, Journal of Bone and Joint Surgery, Journal of Military Medicine, and Journal of the American Academy of Orthopaedic Surgeons.

CLEAR Institute:Today we welcome Dr. James Ogilvie, who has generously agreed to share his insight with our readers about genetic prognostic testing for scoliosis, bracing, and innovative approaches to scoliosis treatment. Dr. James, thank you very much for your time!

CI: Please tell us about the ScoliScore™ prognostic test for scoliosis. What led you to create this test, and how do you feel it will impact the way scoliosis is managed today?

James Ogilvie MD: Our initial goal was to identify the 85% of children with mild adolescent idiopathic scoliosis (AIS) who would not progress to the surgical range untreated. The current standard is to monitor everyone with multiple clinic visits and x-rays which are both expensive and present the danger of radiation exposure to growing children.

CI: Is the ScoliScore™ test expensive? Does it hurt? How accurate is it?

JO: The DNA-based test is less expensive than other comparable genetic tests and costs $2950. Our patient assistance program means that unless someone is wealthy they seldom have an out of pocket expense. It is less expensive than unnecessary years of doctor visits and x-rays. It’s a saliva-based test (no blood drawing required), and has been clinically validated to be 98% accurate. For those with a risk score of less than 50 there is less than 1% probability of progression. We have no cases of progression with scores less than 30. There is a caveat that sometimes a misdiagnosis is present and a patient's curve may progress. An MRI is then indicated and we have instances of syringomyelia or other conditions that cause progressive spine deformity.

CI: One of the reasons we at CLEAR Institute are so excited about the ScoliScore™ test is because of the potential it offers for a more efficient, personalized system of scoliosis treatment. What do you feel are some of the problems with the current system of how scoliosis is managed?

JO: The current clinical guidelines cannot identify progressive from non-progressive AIS. DNA testing allows a personalized risk of progression that is unique to each patient.

CI: You’ve published dozens of important research articles in very well-recognized journals. In one of your recent scientific articles, you utilized the potential of the ScoliScore™ test to determine which patients were at a high risk for progression, and compared two groups of patients - braced & non-braced. Your conclusion was that there is no significant difference in the natural history of scoliosis between the two groups. Could you share with us your thoughts about how this study is different than any other study which has been done on bracing in the past? Did the results of this study surprise you?

JO: Rigid bracing has been commonly practiced by spine surgeons for more than 100 years. Unfortunately those studies were unable to risk stratify the enrolled patients. Therefore they observed some that had a high risk of progression and braced some that had less than 1% risk of progression. No definitive answers have come from the current brace studies. Many surgeons have suspected this was the case, but bracing had become the “standard of care” and it was too threatening not to brace young patients.

CI: We’ve heard a great deal about the Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) study that is currently being led by Stuart Weinstein, MD, at the University of Iowa, which is the largest NIH-funded clinical trial in the history of orthopaedic pediatrics, and is scheduled for completion this August. What are your thoughts about this study? Do you think patients benefit from bracing?

JO: Without a knowledge of an individual patient’s risk of progression, some patients with little risk are being braced unnecessarily and some who have a very high risk are assigned to the observation arm. In effect, there is one equation with two unknowns, treatment assignment and genetic risk of progression. A single equation with two unknowns cannot be answered.

CI: The roots of bracing as a treatment for scoliosis go back a long ways (as early as 650 AD, Paul of Aegina was bracing scoliosis patients with wooden strips & bandages). What do you see happening in the future for scoliosis braces?

JO: With an understanding of the genetic factors that influence AIS progression and identify an individual’s risk, future spine therapists can challenge the current ineffective treatment routines and innovate on new therapies.

CI: If bracing is found not to be effective, do you think school scoliosis screening programs for scoliosis should be eliminated? How do you think ScoliScore™ will affect the potential benefit of scoliosis screening programs?

JO: Current school screening is not effective. However, early screening in school or a doctor’s visit is necessary to diagnosis AIS in its early stages when non-surgical treatments are more effective.

CI: Many people believe there are barriers to integrated medicine – that is, traditional medicine working hand-in-hand with alternative treatments such as chiropractic. Your presence here today is proof that hope exists for doctors of all specialties to work together for the common good of the patient, and it is greatly appreciated! What do you recognize as the major obstacles that prevent orthopedic surgeons from referring patients with mild scoliosis to a chiropractor?

JO: Health science is not the province of only one discipline. Allopathic medicine is ideally evidence-based. Surgeons will refer appropriate patients to the chiropractic profession, much as we refer patients to orthotists, as scientific evidence is generated that validates non-surgical treatment.

CI: Last March, some of the members of CLEAR Institute, including the founder, Dr. Dennis Woggon, were invited to the headquarters of Axial BioTech in Salt Lake City, Utah, for an opportunity to learn more about the ScoliScore™ test and tour the $19-million dollar facility in person. It made a very positive impression on everyone from CLEAR, and we would like to thank you again for Axial’s warm hospitality at that meeting. It was also an occasion for you to learn more about the methods & protocols developed by CLEAR Institute. What did you think about this new system of scoliosis treatment? Did anything in particular about CLEAR Institute impress you?

JO: I was impressed with two items, first the innovative approach that CLEAR has taken to non-operative AIS treatment is needed. With a realization that bracing is at best not very successful and at worst, not useful at all, innovative physiologic treatment regimes are needed. Secondly, CLEAR has made a commitment to evaluate these new therapies in a manner that will pass scientific scrutiny.

CI: The potential of the ScoliScore™ test to revolutionize research into scoliosis is amazing. For the first time in history, we have a method of identifying which patients are most likely to progress to surgical levels. In your opinion, is it possible that an individual at high risk could undergo a treatment which reduces their chance of progression? In other words, could it be possible to re-test someone after treatment and see a lower ScoliScore™ test result?

JO: It would be unlikely that the human genome will be changed by physical treatments. However, the expression of those genes can be modified.

CI: Dr. Ogilvie, thank you again for donating your time to share your knowledge & wisdom. Do you have any final words for our readers?

JO: DNA prognostic testing is only the beginning of our understanding of AIS genetics. As we learn what those causative genes do we may have even more effective interventions. Thank you for your generosity in letting me introduce genetic science into the treatment of a disorder in which we all have a great interest.

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Unfortunately, the lowest common denominator that all non-surgical scoliosis treatments have in common is the hope of preventing the "need" for scoliosis surgery......standing at approximately 38,000 per year in the US right now.

I say that it is "unfortunate", because this seems like it should be a rather low bar to hurdle, but to date no one has been able to effectively demonstrate the ability to do this on a large scale. The advent of genetic testing (Scoliscore) will provide the necessary genetic predisposition data to determine if a given non-surgical treatment has actually altered the natural course of the condition, so hope is on the horizon, but to simply boil down all treatment effort to avoiding surgery is abandoning a much loftier and noble goal of finding a cure. I would rather fail attempting to achieve high expectations, than succeed achieving low standards.

The current review of scoliosis brace data clearly demostrates that brace treatment does NOT reduce the rate of scoliosis surgery (Weinstein, 2007 and Oglivie, 2009); and rehab based programs like Schroth, CLEAR Institute, FITS, SEAS, Yoga, Pilates, ect haven't produced any large scale data to determine effectiveness in reducing surgical rates at this time, so we're in a bit of a tough spot here.

It has always been stated that one of the greatest challenges the scoliosis practioner has had was determining which cases would progress and how far, but in reality bracing's known and proven inability to alter the natural course of the condition made that a moot point anyway, and essentially there is nothing standing between the adolescent idiopathic scoliosis (AIS) patient and surgical intervention except genetic predisposition and luck. This is simply unacceptable.

The gap between prognostic testing for AIS and the ability to alter the natural course that prognostic testing can help predict is wide and widening further by the day. We have entered a realm in which we can tell a patient they are essentially a ticking time bomb for severe scoliosis, but there is no way to de-fuse it, so sit back, watch it get worse and we'll perform a highly invasive surgical procedure that very often results in long-term chronic pain and disability once the curve gets bad enough. Again, this is simply unacceptable.

So what can be done to lower the rate of spinal fusion rates for scoliosis in the future?

1. Earlier detection of small curves. This allows for genetic testing to determine genetic predisposition and the opportunity for early stage scoliosis intervention for the patients whom are at elevated risk for severe curve progression.

2. Early Stage Scoliosis Intervention. A neuro-muscular re-education based rehab program that targets the involuntary postural control centers of the brain stem that will "re-train" the brain to hold the spine in a straighter position automatically....when the spinal curvature is still relatively small and flexible for maximum benefit to the patient.

3. Vertebral Body Stapling (VBS). This is a relatively new, minimally invasive non-fusion surgical procedure which provides a "guided bone growth" type mechanism. It is mostly indicated for juvenile scoliosis cases, but could be used in certain "high genetic risk predisposition" AIS cases if the curve is discovered at an early enough age and the patient fails to respond to the early stage scoliosis intervention program.

4. Improved spinal rehab techniques for patients with larger spinal curvatures. As effective any any screening program could be and as well as any early stage scoliosis intervention program is, there will always be some patients whom "fall through the cracks" and need an effective rehab based program that is specifically designed and targets the unique biomechanical needs of patients with large spinal curves. To date, it appears that only CLEAR and Schroth are making in roads into this area.

5. Increased patient education in the risk/benefit and long-term consequences to chosing surgical intervention for scoliosis. Scoliosis surgery is not medically necessary...even in very severe cases....and is almost entirely based on improving the cosmetic deformity of the condition. However, trading deformity for dysfunction comes with a very steep price......chronic pain, hardware failure, rapid degeneration around the non-fused areas, ect. In short, many scoliosis patients would be far better off doing nothing than choosing spinal fusion surgery. They should be more aware and better educated on the fact that they indeed do have a "choice".

This is certainly not an exhaustive list, nor is it beyond debate, so please feel free to dispute, comment, or add to this discussion as you see fit.

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I am not Schroth certified, but I can offer some distinct treatment advantages that are unique only to the CLEAR Institute scoliosis exercises treatment system......

It has been well-documented that patients with scoliosis demonstrate a significant increase in neuroanatomical abnormalities of the corticospinal tract, as well as neurophysiological abnormalities, especially in the areas of vestibular function, proprioception, vibratory sensation, postural reflex mechanisms, abnormal reflex processing, and disordered postural equilibrium.50-60 Lateralization of neurophysiology also occurs more frequently in patients with idiopathic scoliosis (IS), and this can be correlated to the convexity of curvature.61-63 However, it has been suggested that this laterality is a result, rather than a cause, of scoliosis.64 While many authors have suggested that brain asymmetry may play a role in the etiology of scoliosis, one recent study did “not support the concept of a generalized brain asymmetry in idiopathic scoliosis,” but noted instead that the trend towards asymmetrical neurophysiology was “probably representing subclinical involvement of the corticospinal tracts secondary to mechanical compression.”65 The goal of the chiropractic manipulative therapy provided by CLEAR Institute doctors is to reduce this mechanical compression and thus restore normality.
Neurophysiological compensations may develop as a mal-adaptation to disordered spinal structure; similarly, disordered spinal structure may create muscle imbalances & exacerbate existing neuromuscular imbalances.66
Scoliosis has been induced in an animal model following unilateral vestibular compromise (when one part of the balance system of the body was disrupted).67 However, scoliosis only developed when the animals were subjected to gravity, thus lending further credence to the statement made by Stokes, Burwell & Dangerfield that, “independent of whether a scoliosis is congenital, neuromuscular, or idiopathic, mechanical factors become predominant relative to initiating factors during rapid adolescent growth, when the risk of curve progression is greatest” or, as expressed succinctly by Hawes & O’Brien, “no matter what you believe to be the cause of AIS, ultimately the problem can be reduced to the production of an imbalance of forces along the spine.”31,68 The simplest explanation for the cause of scoliosis is a biophysical adaptation to gravity. Understanding why this adaptation occurs is paramount to designing an effective treatment regimen.

Using innovative concepts such as whole-body vibration and advanced spinal weighting techniques to improve the body’s posture & balance and re-train how the brain activates different muscles in response to gravity, we are able to address the neuromuscular compensations that occur in scoliosis.69-72

References:

50) Mihaila D, Calancie B: Is corticospinal tract organization different in idiopathic scoliosis? Stud Health Technol Inform. 2008;140:350.
51) Woods LA et al: Decreased incidence of scoliosis in hearing-impaired children: implications for a neurological basis for idiopathic scoliosis. Spine, 1995;20:776.
52) Goldberg C J et al: Adolescent idiopathic scoliosis and cerebral asymmetry. An examination of a non spinal perceptual system. Spine, 1995;20:1685-1691.
53) Geiselle A E et al: Magnetic resonance imaging of the brain stem in adolescent idiopathic scoliosis. Spine, 1991;16:761-763.
54) Stevens et al: MRI of the posterior fossa and evoked potential analysis in adolescent idiopathic scoliosis. In: Proceedings of the Scoliosis Research Society, 27th Annual Meeting, Kansas City, Missouri, USA, September 23-26, 1992, p. 89-90
55) Maguire J: Intraoperative long-latency reflex activity in idiopathic scoliosis demonstrates abnormal central processing. A possible cause of idiopathic scoliosis. Spine, 1993;18:1621-1626.
56) McGovern A et al: Reflexes induced by vibration in the superficial paraspinal muscles of girls with adolescent idiopathic scoliosis. In: Proceedings of the British Scoliosis Society, 21st Annual Meeting, London 20-22 March 1996. Journal of Bone and Joint Surgery Orthopaedic Proceedings, British Volume, In Press.
57) Arai S et al: Scoliosis associated with syringomyelia. In: Proceedings of the Scoliosis Research Society, 27th Annual Meeting, Kansas City, Missouri, USA, September 23-26, 1992, p. 139.
58) Barnes PD et al: Atypical idiopathic scoliosis: MR imaging evaluation. Radiology, 1993;186:247-253.
59) Evans SC et al: MRI of ‘idiopathic’ Juvenile scoliosis. A prospective study. Journal of Bone and Joint Surgery, 1996;78B:314-317.
60) Lewonowski K et al: Routine use of magnetic resonance imaging in idiopathic scoliosis patients less than eleven years of age. Spine, 1992;17:S109-116.
61) Sahlstrand T: An analysis of lateral predominance in adolescent idiopathic scoliosis with special reference to the convexity of the curve. Spine, 1980;5(6):512-8.
62) Grivas TB, Vasiliadis ES, Polyzois VD, Mouzakis V: Trunk asymmetry and handedness in 8,245 school children. Developmental Neurorehabilitation, 2006;9(3):259-266.
63) Goldberg C, Dowling FE: Handedness and scoliosis convexity: a reappraisal. Spine 1990;15(2):61-4.
64) Goldberg CJ, Moore DP, Fogarty EE, Dowling FE: Handedness and spinal deformity. Stud Health Technol Inform. 2006;123:442-8.
65) Kimiskidis VK, Potoupnis M, Papagiannopoulos SK, Dimopoulos G, Kazis DA, Markou K, Zara F, Kapetanos G, Kazis AD: Idiopathic scoliosis: a transcranial magnetic stimulation study. J Musculoskelet Neuronal Interact. 2007;7(2):155-60.
66) Chu W, Lam W, Ng B, Tze-Ping L, Lee K, Guo X, Cheng J, Burwell R, Dangerfield P, Jaspan T: Relative shortening and functional tethering of spinal cord in adolescent scoliosis - Result of asynchronous neuro-osseous growth, summary of an electronic focus group debate of the IBSE. Scoliosis, 2008;3:8.
67) Lambert FM, Malinvaud D, Glaunès J, Bergot C, Straka H, Vidal PP: Vestibular asymmetry as the cause of idiopathic scoliosis: a possible answer from Xenopus. J Neurosci 2009 Oct 7;29(40):12477-83.
68) Hawes MC, O’Brien JP: The transformation of spinal curvature into spinal deformity: pathological processes and implications for treatment. Scoliosis, 2006;1(1):3.
69) Tjernström F, Fransson P, Hafström A, Magnusson M: Adaptation of postural control to perturbations – a process that initiates long-term motor memory. Gait & Posture 2002;15(1):75-82.
70) Fontana T, Richardson C, Stanton W: The effect of weight-bearing exercise with low frequency, whole body vibration on lumbosacral proprioception: a pilot study on normal subjects. Aust J Physiother., 2005;51(4):259-63.
71) Issurin V: Vibrations and their applications in sport: a review. J Sports Med Phys Fitness, 2005;45(3):324-336.
72) Kluzik J, Peterka R, Horak F: Adaptation of postural orientation to changes in surface inclination. Exp Brain Res. 2007;178:1-17.

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Having plenty of experience with both I am seeing little difference statistically between the expanded care version or the Intensive Version (scoliosis bootcamp) in overall reduction and stability, although recently I am seeing overall reduction levels with Intensive care starting to outperform expanded care mainly due to improved equipment and NMR technique.

Intensive Care has some advantages as well as some disadvantages from a clinical perspective:
advantages -
*turn things around quickly in a progressive case
*longer agressive mix phase for more rigid curvatures
*rapid increase in curve flexibility
*gives the doctor instant feedback as to progress and potential corrrection levels

disadvantages
*limited time and access to patient which can be crucial for the NMR component and dealing with cervical spine ligament instability
*rapid increases in curve flexibility

You will notice rapid increase in curve flexibility can work both ways and will depend on the neuromuscular retraining component which I feel has been significantly improved and I think in the future we will see CLEAR Institute Intensive Care out perform everything else.