Scoliosis - straightening is possible

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Table of Content Introduction a) Natural history & prognosis b) Deformations c) Complications d) Radiographs e) Conventional treatments A 59 cases study Method Patients Results Detailed analysis A new explanation and an efficient treatment for Scoliosis Expected progression Anatomy Scoliosis no longer idiopathic ? Conclusion Appendix 1 - Muscle contractures Functions of muscles The stretch reflex Two types of muscle fibers Muscle spasm Compensations Appendix 2: What is Brachy-Myotherapy ? What are the characteristics of BMT ? Some other specificities of BMT How can the action of BMT be explained ? References Useful addresses

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Introduction Idiopathic scolioses (IS) are those of which conventional medicine does not know the origin: they represent more than 90 % of scolioses. Scolioses have been described for the first time by Galen in the second century AD, and it is interesting that this was done in his book “De moto musculorum”. Oddly however, the role of muscles is totally neglected nowadays in the etiology of scoliosis. Only a few researchers have considered the possibility of muscle involvement, seeing it as a simple local reaction hypertonia to the curvature, without specifying the cause of scoliosis itself. Thus scoliosis remains idiopathic, meaning that its cause is unknown, and obviously treatment can then only be symptomatic, acting only on the consequence and not on the cause. For this reason current treatments cannot be effective to correct scolioses, or even to stop their progression seriously. It might be useful to first summarize what is conventionally known about IS ; after that we will suggest a nontraumatic therapeutic method that allows a recovery of most Idiopathic Scolioses, without braces or surgery, as well as a new etiological hypothesis.

a) Natural history & prognosis Idiopathic scoliosis concerns 1.4 ‰ to 7% of the population, 80 % of them girls. Scoliosis over 20 ° is rather scarce: 0.5 to 0.8% of the population. Only 30 to 60% of IS do really worsen. However at the beginning of puberty the risk increases to 80% for a Cobb angle of 20 °, and 100% for an angle of 30 ° with Risser 0. And this risk is only slightly diminished by the wearing of braces. From 10 to 40% of patients with an angle of 20 ° to 30 ° will undergo surgery. This risk is further increased if the Cobb angle is between 30 and 40 °. The periods of greater progression correspond to periods of rapid growth, thus especially during puberty. Girls are growing faster than during puberty boys. This may be the reason for increased frequency of scoliosis in girls. IS, however, is not only related to growth, since progression continues, albeit slowly, after after growth has ceased. IS is not supposed to be caused by an inequality of the lower limbs, which would only result in a habit scoliosis (HS) (in which there is an absence of rotation and above all a moderate side bending, of less than 10°, which is normalized when lying down). However, one may wonder whether there is a real difference between HS and IS: since the latter is as supposed to have an angle of more than 10°, HS could simply be the first step, often slowly evolving, to an IS: for to achieve more than 10 °, scoliosis must begin with less ...

b) Deformations IS develops in three dimensions: it is a twisting of the spine. . 1 / There are one or two curves of thoracic, lumbar or thoracolumbar side bending. One can often distinguish a principal curvature and a secondary compensation curvature, which allows the skull to be above the pelvis and the feet. Beyond 30 ° the deformation tends to get worse by itself, as a result of growth and muscle contraction.

. 2 / The vertebral spinous processes turn into the concavity. Beyond 20 ° of rotation IS also tends to worsen by itself. This rotation of the dorsal vertebrae causes a deformation of the chest, called gibbosity, which is observed when the patient leans forward: one side of the thorax is then higher than the other. This is also the main component of the clinical diagnosis of scoliosis. Moreover the lateral inclination of the spine causes the ribs to come closer on the side of the concavity. . 3 / Finally, the dorsal spine is extended, which means that the spinous processes of the vertebrae come closer, paradoxically causing a hollow back: thoracic kyphosis is reversed. .

c) Complications The main complications are on the one hand lumbar or back pain, which continues into adulthood; on the other hand the consequences of chest deflection can, beyond 80 °, lead to respiratory and/or cardiovascular complications. The main risk is actually aesthetic, but even advanced scolioses can pass almost unnoticed. In this respect it is questionable whether the current lengthy treatments, with all their discomfort and stress, for very poor results, are well adapted to the disease. .

d) Radiographs Confirmation of the diagnosis is made by radiological images of the whole spine. Thus the lateral inclination can be measured according to the Cobb method, which has a margin of error of + / - 5 (Fergusson‟s method is rarely used). The rotation is measured by the position of the spinous pedicles. A profile radiograph may be used to evaluate the extension of the dorsal vertebrae. (In practice these parameters are rarely mentioned.) For prognosis, bone age is often measured with the Risser method (ossification of the iliac crest), whose interest is disputed by many authors, who prefer chronological age. Radiographs also eliminate another pathology, and are used to monitor the development of the scoliosis, and finally to decide the possible therapeutic indications: no brace before 30 ° (or 20 ° according to some authors), and if so then only if the scoliosis is progressive (this criteria is often neglected), no surgery (arthrodesis) before 40 to 50 °. .

e) Conventional treatments As long as the etiology of scoliosis is not known, treatments, whatever they are, will only be palliative and symptomatic; none will cure the scoliosis itself. Current treatments are extremely restrictive and aggressive.

1 / Braces make life difficult for children and adolescents over many years; the many different forms show that there is no consensus on this issue. The Boston brace is even less effective than Milwaukee brace. The purpose of a brace is not to diminish the scoliosis but simply to avoid a worsening of more than 5 to 10°, a goal that is actually achieved in only 45 to 88% of cases (these figures, which vary in a ratio of one to two according to sources, are of course questionable), a result which differs significantly from the natural evolution only if the brace is worn 23 hours a day… which is seldom done. Conventionally a brace should only be recommended in case of a progressive scoliosis over 30 degrees (20 ° according to some authors: here too there is a clear lack of consensus). Many braces are prescribed improperly, and any apparent effect may be due only to the natural evolution of scoliosis... 30% of patients abandon their brace or do not wear it properly, and they rarely dare admit it to the therapist: this percentage is thus probably underestimated, and the effects of the braces overestimated: a total of more than 60% (!) of patients with brace goes on worsening, which represents no significant difference with the spontaneous evolution without treatment... In fact 1 in 3 patients with a brace will sooner or later have an indication for surgery, despite this conservative treatment. . 2 / physiotherapy or rehabilitation alone is not able to stop or even slow down significantly the evolution of a progressive scoliosis. The multitude of proposed techniques shows that there is no consensus at all on which method to use. Electrostimulation is considered ineffective, results being not different from the natural evolution. . 3 / After surgery there are a 25% relapses. Arthrodesis does not always change deformations. There are about 10% postoperative infections and 17% of patients will have to have another operation. Pseudarthrosis, fractures, and neurological sequelae are the other major complications of arthrodesis. Over 75% of patients operated with Harrington rod will present low back pain, and over 60% back pain. Arthrodesis in adults increases the risk of osteoarthritis and multiple arthralgias. The aim of surgery is to block the angle of the spine with metal rods. The main approaches being those of Harington and Cotrel-Dubousset. . 4 / For scoliosis of low amplitude, doing nothing is not always a bad solution ...: the initial curvatures of less than 10 degrees rarely worsen, the curvatures of 10 to 20 ° will deteriorate in only 10 to 20 % of cases. All in all about one third of IS of more than 10 ° worsen by more than 10 ° in less than a year. But those over 20 ° worsen in 60 to 80% of cases. Beyond 30%, there will be worsening in more than 90% of cases. The rate of spontaneous improvement (straightening) is only 10%, and applies only to IS under 15 ° and in prepubertal period. The patient's age and growth rate also affect prognosis: at Risser 0 the risk of progression of a scoliosis, even moderate, would be 60% on average (more or less, depending on the angle). . . An effective and non-traumatic treatment of IS would thus be welcome. We would like to show hereafter that there is indeed a non-traumatic and effective approach to this disease, a therapeutic approach based on an etiological hypothesis consistent with all current data published on the so-

called idiopathic scoliosis, a treatment which can not only stop the evolution this disease, but also straighten it in most cases.

A 59 cases study Method 17 GPs, 3 specialists in rehabilitation medicine, 1 pediatrician, and 9 physiotherapists have treated, with BrachyMyotherapy only, 59 children and adolescents before the end of growth, having scolioses with Cobb angle ranging between 11° and 52°. Brachy-Myotherapy (BMT) is a manual rehabilitation therapy that does not use thrust. It aims to treat lasting post-traumatic muscle spasms (contractures), which appear to be the basis of many joint diseases, whether acute or chronic. Only the musculoskeletal system is treated. A practitioner of BMT works by placing joints in positions that allow the shortening of the contractured muscles. The method is purely passive, i.e. without participation of the patient, and since the therapist never uses force, the physiological amplitude of joints is never exceeded. The effects of BMT have been shown by electromyographic measurements and numerous clinical studies. (For more details please refer to Appendix 2.) Contractures (i.e. lasting muscle spasms) are easy to diagnose, since they have specific symptoms: spontaneous pain (constant or intermittent) ; or pain triggered by movement, especially active movement, or by palpation, which on a stretched subject finds a hard muscle that is painful to pressure; the spasmed muscle resists its passive stretching. Furthermore the muscle contracture may distort the joint it governs to bend into its direction. Diagnosis also takes into account the spontaneous compensations of the body in relation to some contractures. Indeed, since a contraction distorts joint positions, it causes a chain reaction of hypertonic compensating muscles, neighboring or more remote, with the same consequences as for each contracture.

By treating the initial spasms, which are practically always located in the neck or the ankles, hypertonic compensations and their consequences (pain, stiffness, or deformation) disappear, since they have become irrelevant. Scoliosis seems to be a typical example of this process. That is why in this study only the muscles of the neck and / or ankle were treated; no treatment was done at back or lumbar level.

Patients Only patients without a brace were treated. The only therapy was therefore Brachy-Myotherapy, to the exclusion of any other approach, be it manual (manipulation, stretching, contractions, etc.) or by medication (oral or infiltration). Inclusion criteria were idiopathic scoliosis of over 10 °. Exclusion criteria were habit scolioses, scolioses of less than or equal to 10 ° (which are in fact often habit scolioses), non-idiopathic scoliosis (very rare in practice), and scoliosis with brace treatment.   

4 cases had an initial angle greater than or equal to 30 ° (expected worsening in 90% of cases). 15 cases had an initial angle between 20 and 29 ° (expected worsening in 68% of cases). The remaining 40 patients had an angle between 11 and 19 ° (expected worsening in 22% of cases).

. There were 17 boys and 42 girls.   

2 cases were under 10 years (Risser 0, therefore poor prognosis). 44 cases were between 10 and 15 years, a period of greater evolution. 12 cases were between 16 and 18 years old.

Recruitment: all patients included in this study were treated in town or country practices, never in a hospital. They were not selected. In general practice scoliosis patients are relatively rare, especially those over 20° without a brace, firstly because of their low prevalence, and partly because patients are often sent to a hospital or to specialized centers, and finally because a brace is often prescribed before 20 ° (wrongly it seems, as we have seen). For these reasons each therapist could not produce the results of many cases. On the other hand the number of therapists who participated in this study shows the reproducibility of results.

So this is an open multicenter study, representative of what is seen in the GP‟s or physiotherapist‟s practices in city or country. A comparative study would only have been conducted in a specialized center, where conservatism is unfortunately the rule. Its interest would anyway be limited, since there is no other treatment that is intended to straighten scoliosis. As for braces, their worsening limiting effects do not even reach unanimity. Anyway, most published studies of idiopathic scoliosis are not comparative. . A positive spontaneous evolution of Idiopathic Scoliosis is extremely rare, as we have seen, especially at the levels and ages that we have included in this study. Positive results are therefore sufficient to prove the effectiveness of the studied method, and will tend to prove the plausibility of the etiological hypothesis underlying it. A session of BMT was held on average about every 10 days. An average of 12 sessions was performed (range 240). The BMT treatment has been continued, unless otherwise stated by the patient, until the end of improvement (or the lack of it at the first control radiograph) and the final assessment made at that time. The treatment was generally quite short: 2 weeks to 13 months, on average 6 months.

Results

Details:

Patients were followed by x-rays, one before treatment and then every 2 or 4 months. Almost all radiologists gave only the Cobb angle of inclination, without mentioning the degree of rotation, nor the angle of kyphosis or the Risser sign. Therefore, we could not mention these. However, one should relativize these absences: several authors believe that the Risser sign is less accurate than the chronological age. A recent meta-analysis made at the request of the 'Scoliosis Research Society' on 20 publications confirm that the Risser sign is rarely noted in publications on scoliosis, which think chronological age is more relevant. The curve of Ms. Duval-Beaupère seems to be a universally recognized substitute, valid and more realistic. It shows a very much greater progression between 10 and 15 years than before and after.

It is worth recalling that most patients in our study were aged between 10 and 17.

Detailed analysis Conventionally prognosis depends on the Cobb angle: 70% of 20-29 ° curves and nearly 100% of those over 30 ° worsen spontaneously, against only 10-20% of those of less than 20 °, (which usually do not improve spontaneously, however very rarely this may happen). For this reason we will distinguish three groups in this study : initial scoliosis over 30 °, those between 20 and 30 °, and those of 11 to 20 °. a) In the first group of four scolioses, initially of 30 ° or more, traditionally the worst prognosis (aggravation expected in nearly all cases), the average recovery was 18 ° (extremes: 25 and 9°). No worsening nor even status quo was observed. b) In the second group of 14 scolioses, initially of 20° to 29 °, thus traditionally of unfavorable prognosis (worsening expected in about 70% of cases), the average recovery was 9° (maximum: 23 °). No deterioration was observed, one single case simply remained stable (neither worsening nor improving, which in itself is already a rather good result). c) In the third group of 40 scolioses, initially between 11 and 19 ° (expected worsening in 20% of cases ; straightening in a few cases possible if less than 15°, but only if before puberty, which was rarely the case in this study). The average recovery was of 6 ° (maximum: 17 °).

One aggravation was observed (6° only in one year, the same would have been considered a success with a brace), two cases remained stable, neither improving nor worsening, which in itself is not so bad a result. Among the total 59 cases treated, there was therefore only 1 aggravation, three nil effects (neither improving nor worsening), and 55 scolioses had straightened (93% of cases) which allowed a diminishment of the side bending angle, with an average gain of 7 °, up to 25 °. The more advanced scoliosis was, the more important the average gain was.

This was ascertained without any local treatment (dorsal and / or lumbar), by BMT or by another method. An example: • Miss T.M., 6 years, Risser 0, bad prognosis [photos A. Jamot]

A new explanation and an efficient treatment for Scoliosis Expected progression Despite the conventionally recommended treatments, the majority of IS tends to worsen, with or without a brace. Only 10% of children may have a spontaneous improvement of curvature of at least 5 °, but then only during pre-puberty period , never during or after puberty, and only for IS under 15 ° (almost no child in the study group matched these criteria). On the contrary our study shows 93% of straightenings of the curvature, with Brachy- Myotherapy as sole treatment. . If we only keep the 44 cases with a recovery greater than or equal to 5°, the average gain is 9 °. These cases represent 74% of the treated children, with an average age of 13, thus during puberty, when the risk of aggravation is the greatest, and having an average initial angle of 19 °. Improvement was nearly 50%. The rate and extent of the improvement with BMT is the opposite of what might be expected with or without a brace. . And the more advanced the state of the scoliosis, the better the results, which is normal if we consider that treatment acts directly on the cause of IS: the more important the angle was, the more important recovery could be.

It is worth recalling that the risk is greater for scolioses that began before the age of 10 years. Now if we only keep the two cases in our study included in this age group (6 and 9 years, angles 18 and 19°), for which the prognosis typically is very poor, we find an average recovery of 12 ° (thus well above the average of all ages in this study). . At Risser sign 0, the risk is four times larger than at Risser 3 or 4. In the absence of Risser, the interest of which is subject to debate, and which radiologists have rarely mentioned, we can use the curve of Ms. Duval-Beaupère: this well-known chart shows that worsening of scoliosis is much more significant between 10 and 15 calendar years of age, than before or after (this should not be confused with the age of onset of scoliosis). Now if we only keep the 45 cases included in our study this range of age (average 13 years),whose prognosis is very unfavorable, we find instead a recovery of 8 ° (which is above the average of all ages in this study). Age does thus not affect the results of the Brachy-Myotherapy. . All authors seem to emphasize that the risk of worsening is especially important beyond 20 ° (aggravation expected in more than 70% of cases). Now if we only keep the 18 cases in our study with an initial angle greater than 20 ° we see instead an average recovery of 10 ° (thus higher than all the initial angles taken together). . All authors seem to emphasize that the IS systematically worsens beyond 30 °. Now if we only keep the 4 cases of our study with an initial angle greater than 30 °, we see instead an average recovery of 18 ° (thus well above the average of all angles combined). Altogether, the worse the initial conventional prognosis, the better the results of Brachy-Myotherapy. .

Anatomy Let us try to understand the reasons behind these results. At the level of thoracic vertebrae there are no anterior muscles. All muscles are on the back-side, commonly grouped under the term transverso-spinal muscles. These are 5 kinds of short muscles, present on the whole spine, linking spinous processes together, transverse processes together, and spinous processes to transverse processes of a lower level: the Intertransversarius, Rotator, Multifidus, Spinalis, and Semispinalis muscles, all of them having only vertebral insertions. Their onesided contraction causes simultaneous side bending, rotation of the spinous processes into the concavity, and extension of the thoracic spine - that is to say exactly the same deformation as scoliosis.

Scoliosis no longer idiopathic ? Idiopathic means that the cause is unknown (that is, for conventional medicine). Since we were able to straighten more than 90% of idiopathic scolioses, some of them very advanced, without any local treatment, when only 10% of scolioses and only among those of low amplitude and very young age, are supposed to recover spontaneously, this means that the cause is probably not at the level of the back. . 1] Postural imbalance disorders and proprioceptive dysfunction have been noticed in several studies about IS, related to disturbance of oculomotor and/or vestibular reflexes. Over 80% of children with IS have a disorder of proprioception and oculomotor dysfunction reflexes.

Over 60% have a balance disorder related to vestibular dysfunction. Now the vertical position of the head is related to the vestibulo-labyrinthine system, which controls all tonic postural muscles. In other words, the horizontality of ears is necessary for reflex equilibration. Just look at a running animal: whatever the position of the rest of the body, both ears remain on the same level, and the position of the head is that of a horizontal gaze.

The conservation of these two factors seems to be a priority for the body, at all costs. Now an asymmetric position of the skull on the spine is found in 60% of scolioses (in our opinion those that are not well enough compensated by the following mechanism). This can only be due to a persistent post-traumatic muscle spasm (contracture), which can follow often in a remote way an excessive obstetric traction on the skull, or a fall or a blow on the head, etc. Any cervical muscle may be involved. Asymmetries of the position of the neck muscles, and resulting defects of the head position, may require the person to permanently tip his shoulders to rebalance, and therefore to bend his spine. This is in our opinion what is probably happening in all cases. . Post-traumatic persistent neck contractures, especially if they are lateral, generate an abnormal head position; this will have to be counterbalanced by a permanent contralateral muscle tension, which aims to restore the natural horizontality of the ears. The scoliotic child gives priority to the labyrinth over the spine. The compensation tension can occur at the same contralateral cervical level, or at an underlying one. In the latter case abnormal cervical muscle tone will cause compensation contractures at the thoracic level of the spine, and since there are no anterior muscles there, but only of the posterior muscles, the Transversospinalis,

the compensation distortion will be in the direction of the resultant force vector: lateral bending, ipsilateral rotation, and extension. An opposite side bending may then occur at the lumbar level (for instance by the Iliocostalis and Quadratus Lumborum muscles, which will also further spread the ribs located in the convexity), in order for the skull to remain vertically above the pelvis and the feet, for stability‟s sake. . The persistent dorsal contracture acts as a spinal bowstring during pubertal growth, which explains the increases of angle commonly observed during growth spurts.

Mechanism of scoliosis of cervical origin

. 2] We have just described the scoliosis of cervical origin. But the origin can also be located in the lower limbs, more specifically at the ankles. This will usually be a remote consequence of sprains or other ankle traumas. A tilt of the pelvis, which is an unstable structure laid on two spheres, the femoral heads, seems to be always due to increase of muscle tone at the hip and the knee, which makes up for post-traumatic contractures of an ankle.

An inequality of leg length seems almost always to be only apparent. It is usually a simple artifact on radiographs: a small flexion of joints of a leg due to increased tone of the flexor muscles of the hip and knee, which adapt to a primary lasting contracture of the flexor muscles of the ankle (e.g. Tibialis Anterior), often a sequela of an ankle sprain , will cause a tilt of the pelvis, that will however be reversible with the treatment of the muscles involved, especially those of the ankle .

Another mechanism of muscular pelvic tilt can be a varus or valgus of the knee, again necessarily due to lasting contractures, which by increasing or decreasing the angle of the physiological valgus of the knee, raise or lower the hip on the same side.

It should be noted that a so-called inequality of legs is often only inferred from a simple radiologically observed pelvic tilt, without the legs even appearing on the plate. The latter are rarely measured, which is rather unscientific. But even in case of a more or less accurate measurement of the lower limbs on a teleradiography, the slight joint tilts we have just mentioned will rarely be observable. On top of all these reactions one has to take into consideration that the same contractures will compress the joint cartilage, which will further decrease the apparent length of the concerned limb.

. If the inequality is only apparent in the lower limbs, the pelvic tilt itself is real. It inclines the spine, and so the skull, and to compensate this causes one-sided permanent increase of back muscle tone, and this necessarily with the same spinal muscles as mentioned above (since there are no other ...), always in order to able to keep (despite the tilted pelvis, spine and skull) the benchmarks necessary for equilibrium, i.e. the horizontality of the ears. The permanent contraction of the thoracic Transversospinal muscles will therefore, in the same way as for a cervical primary cause, create a local side bending, with rotation and extension - in other words, the exact deformation seen in scoliosis. . 3] To summarize, in case of scoliosis, spinal compensation curves, that can only be created by muscles (what else could mechanically act on the skeleton ?), restore the head-pelvis verticality , and, above all, keep the cranial vestibular landmarks necessary for equilibrium (that is to say the horizontality of the labyrinths thus of the ears). The deformity of scoliosis is due to the torsional orientation of the effector muscles. .

Conclusion How could one bend a spine without applying and maintaining some force ? And what could apply this force and keep it, apart from muscles ? It would seem that only an unbalanced functioning of the thoracic spinal muscular system can cause scoliosis. What else could do so ? . Contractures (lasting muscle spasms) of spinal muscles fully explain idiopathic scoliosis. And if there is pain, the contractures are also the only cause of it. They are a simple compensation of abnormal muscle tension located in the neck or sometimes at the ankles. These initial post-traumatic muscle contractures have created a side-bending of the neck, resulting in a vestibular dysfunction by non-horizontality of the ears, causing equilibrium impairment, which the body will have to compensate by tilting the spine, whilst keeping the head straight above the pelvis and the feet. . Brachy- Myotherapy will only address the first cause, at the neck or the ankles, without any local dorsal treatment - as opposed to the conventional treatments, which will of course be disappointing as long as scoliosis will be considered as idiopathic. At best they slow the worsening of scoliosis, and even that remains controversial. BMT can almost always straighten idiopathic scolioses of children and adolescents, a fact which tends to confirm our hypothesis, also consistent with various observations published to date on so-called „idiopathic‟ scoliosis.

Appendix 1 - Muscle contractures Muscles account for about half the mass of the human body! Yet they are the great forgotten ones of modern medicine, which likes to ignore them completely.

However, without muscles, there would be no movements; and, equally importantly, no standing up or maintaining positions would be possible. What would be the use of joints without their animation by the muscular system? And like all that constitutes our body, muscles may not function as they should, their behavior can be distorted. Can we reasonably afford to ignore half of the body? .

Functions of muscles Skeletal muscles (those that fit on the bones, as opposed to visceral muscles), those that cross the joints and move them, have actually four roles: 1) 2) 3) 4)

They create movements They maintain positions and postures They maintain the cohesion of the joint (coaptation) They protect the joint from dislocation in case of trauma

The first function is the one that comes to mind right away when it comes to muscles. But the second is equally important: by keeping the joint positions, only the muscles allow us to stand up, or to carry objects, etc. The only difference is that the first function requires only a brief contraction, the second a lasting one. We will see that this does not imply the same muscles. The third feature stems somewhat from the second: only muscle contraction maintains the cohesion of the joint, regardless of the position of the latter, for since ligaments are loose enough to allow movement, they cannot have this function. At best they are safeguards in extreme joint positions. Their role appears to be primarily to indicate the position of the joint to the central nervous system by means of mechanoreceptors. The fourth function is that the muscles, by their reflex contraction, protect the joint against dislocation in case of trauma or an unbalanced movement. To understand this we must briefly consider the basic reflex of skeletal muscles. .

The stretch reflex This is the main reaction to which every muscle is submitted: when it is stretched, it contracts. And the more quickly it is stretched, the stronger it contracts. Among others this is what keeps a position, in a reflex way: as soon as gravity tends to change it, a muscle is stretched, and it will contract with a force in direct ratio with the force that stretches it, in order to maintain the position. How does this happen ? In the muscle, scattered among the fibers that allow the contraction, special muscle fibers are grouped in spindles. These fibers have a central portion (the annulospiral endings) that is sensitive to stretch, its amplitude as well as its velocity. Ia afferent fibers wind around this middle portion of the intrafusal muscle fibers. These long nerve fibers will stimulate the motor neurons in the anterior horn of the spinal cord when the muscle is stretched.

When the motor neurons are stimulated they induce muscle contraction, leading to its shortening. Once achieved, the stretch reflex stops itself, the muscle spindle being no longer stretched. We have said that the intensity of the reflex contraction is proportional to the intensity of the muscle stretch. This also allows the muscles to protect the joints they cross in case of injury. What happens on impact ? A bone is suddenly deviated from the other bone with which it forms the joint: it is suddenly mobilized and some muscles will abruptly be stretched. That is where the stretch reflex comes in: the stretched muscles will contract to withstand the trauma, and this proportionally to the latter‟s intensity. In much the same way as when we fall we contract every muscle of the body. And the more intense the shock is, the stronger the reflex contraction will be: being perfectly adapted, it is effective (unless of course the shock is of an intensity exceeding the capacity of muscle contraction, which is fortunately rather seldom seen).

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Two types of muscle fibers Muscles are composed of 2 types of fibers that are very different in several respects. In the current state of knowledge, and to summarize and simplify the various classifications and subdivisions, there are two main groups of muscle fibers: a) Type I fibers have a slow but lasting twitch b) Type II fibers have a fast but short twitch Fiber properties are derived from their different structure, which allows their function: that is to maintain a position (I slow fibers) or create a movement (II fast fibers). The most important characteristics that differentiate them are: a) type I slow twitch fibers are red because they are richly vascularized. Their contraction mainly uses oxygen provided by blood. b) type II fast fibers are quickly fatigable; they are paler because they are less vascularized : they primarily use glucose for energy for their contraction, which does not need to last. (For the sake of completeness it should be noted that there are intermediate IIa fibers, fast and rather resistant to fatigue, whose metabolism is both aerobic and anaerobic, which allows a contraction that is both fast and durable.) It is found in practice that in every muscle one of the two fiber types is clearly predominant (this fact is generally ignored, though it is long known that there are red and pale muscles, which corresponds to this distinction). Just as there are two kinds of fibers, so there are two kinds of muscles: those composed mainly of type II fibers are those that create movements, up to a certain position which will then be maintained as long as necessary by the muscles that are composed primarily of type I fibers. For each joint the two types of muscles have to be present: one that creates the movement of this joint (called dynamic) ; another that will hold the position thus obtained, as long as necessary( this muscle is called tonic). This means that for any joint there are two muscles that seem to have the same action, if one makes the common mistake of forgetting that muscles may have other functions than to create movements. For example at the elbow, two muscles appear to have a seemingly identical flexing action, the Brachialis and the Biceps. Why two muscles for the same action ? In fact one creates the flexion, that is the Biceps, and the other keeps it, that will be the Brachialis, more deeply located, but with a stackable course, thus a seemingly identical function.

If we wanted to keep a position with a dynamic muscle, it would swiftly become tetanized, which would result in trembling. A prolonged contraction of a dynamic muscle is indeed not possible, partly because the motor neurons (the neurons that cause the contraction of the muscle fibers they innervate) have a kind of integrated circuit-breaker, the Renshaw cell, located in the spinal cord near the motor neuron itself, and stimulated via a collateral branch of it. This cell will almost instantaneously inhibit the motorneuron itself as soon as it sends impulses to the muscle fibers. The motorneuron will thus stop very quickly stimulating the muscle fibers, which have thus received only a short impulse, but sufficient to create a movement. Which is anyway quickly limited by the range of the joint, so a sustained movement would be of no use (the fact that all the fibers of a muscle are not stimulated at the same time, but on a rotational basis, however allows a long enough contraction to make the motion).

All this is important to understand what is by far the most common acquired muscle disease : the lasting muscle spasm or contracture, which explains most of the joint pains and dysfunctions. .

Muscle spasm A contracture is an involuntary but permanent muscle contraction, self-sustaining in a reflex way, of traumatic origin, which has no tendency to heal by itself, and tends to cause secondary contractures of the surrounding muscles. Since it lasts, it can only concern tonic muscles. How is a contracture created ? We have seen that in case of an impact that might injure a joint, a muscle contracts in a reflexive way to protect it. The intensity of muscle contraction is proportional to the intensity of the shock. Once this has passed, the protection contraction ceases. It has been quite short. But if the shock was violent, it will have led to a sudden stretch and a significant reflexive contraction of at least one muscle. It can be noticed in practice that, beyond a certain intensity of shock, the reactive contraction will

tend not to stop, even after the trauma: this is the lasting spasm, an involuntarily and continuous contraction, that can remain so for months or years, as if the initial stretching persisted. In fact, this contracture can last a lifetime, as long as it is left untreated.

Because once it has started, a contracture will not heal spontaneously. It is very easy to find on palpation, even long after the initial shock. The observation of this is fundamental for the understanding of the cause and mechanism of almost every joint pain or distortion. For this persisting contracture will not be without consequences, as one can suspect. . 1) The muscle that is reflexively contracted for far too long will sooner or later become painful. But this muscle, by definition, crosses a joint. It is here that his pain will be felt. This means that joint pain is almost always a pain of the muscles surrounding and crossing the joint. It is not due to the bone (not innervated), much less to cartilage (not innervated at all), but to the muscles, which are rich in pain receptors (nociceptors). Fortunately knowing this allows to stop the pain by removing the muscle contracture. What can only be done manually, not with a drug: for a mechanical cause, a mechanical treatment. . 2) The range of the joint is limited by the contracture. This is because a voluntary contraction of a spasmed muscle will trigger or exacerbate its pain, thus hindering the movements. (The pain is not caused by the movement muscles, as we have seen, but by those who maintain the position, the toning muscles, which will contract automatically together with the dynamic muscles, in order to maintain any position created by them. A tonic contraction that would start only when a position is obtained, would let weight change that position before the tonic muscle can take over, because of the short time lag required for tonic fibers to contract.) The second reason for painful and/or limited movements is that spasmed muscles, being in permanent involuntary contraction, resist their stretching, limiting in this way certain movements created by other muscles. And stretching causes a stretch reflex which increases the painful contracture. . 3) The muscle that is contractured, thus shortened, will pull the two bones of the joint on which it is inserted one toward the other. This may cause a joint deformation (or when the spine is concerned, a distortion of a group of vertebrae).

This alteration is seen frequently, especially on a radiograph, for instance in the neck globally, or at the knee locally, but it can affect any joint. (In a baby, it's what causes congenital torticollis or wryneck.) . 4) And this lasting muscle spasm will of course excessively compress the joint on its side. This causes a decrease in joint space that can be seen on a radiograph, but should not be confused, at this stage anyway , with the vanishing of joint space due to the destruction of cartilage in osteoarthritis (even if the cause is in fact the same, the lasting muscle spasm). . 5) On palpation of a muscle a contracture is painful. Thus it makes the diagnosis easy. Passive movements in the direction of muscle contractures are easy, but in the opposite direction they are limited, often painful or even impossible: the joint is more or less blocked, the contraction resisting to any attempt of stretch. .

Compensations Observation shows that only the already strained muscles in normal life can primarily become contractured after a violent shock. In practice these are those of the neck and those of the ankles, due to the greater usage and instability in these two regions. However, because the contractures cause pain, stiffness and even distortions, and because these two areas of the body must remain functional because of their importance for the standing and walking positions (the ankles) and global equilibrium (the neck), it is as though the body seeks to relieve the muscles in these areas as much as possible by spreading the abnormal tone around the entire muscular system. Contractures due to the first shock may then very well go unnoticed for years or even decades. It is not until the occurrence of a trigger that the increased muscle tone will show up in one or more locations. A new shock or repetitive strain, or any other trigger, can then bring down the whole system of compensation that was in place for years, creating pain, stiffness, or deformation. Nevertheless, it is obvious that in order to stop the compensation contractions, the primary contractures will have to be treated.

Appendix 2: What is Brachy-Myotherapy ? Brachy-Myotherapy (BMT, not to be confused with Myotherapy, which is quite different) is a purely manual therapy; it is soft, without any rough handling (thrust). As its name suggests, it is designed to deal specifically with post-traumatic lasting muscle contractures, which appear to be at the basis of joint pain, whether acute or chronic, joint stiffness, joint deformation, neuralgia, and many other diseases. A practitioner of BMT will work by placing joints during a few moments in positions allowing an increased shortening of the contractured muscles. The method is purely passive, i.e. without participation of the patient. It does not require force. Its action never goes beyond the physiological threshold of a joint, safety is thus absolute. The effects of BMT have been shown by electromyographic measurements, and by many clinical trials, like the one we have detailed here. Muscle contractures are easy to diagnose, since they have characteristic signs: spontaneous pain, whether lasting or intermittent, often caused or increased by an active movement, or by palpation, which on a lying subject will also find a hard muscle, which should normally not be the case. Finally the muscle resists its stretching, which may even be painful. Diagnosis takes also into account the spontaneous compensations of the body induced by primary contractures. Indeed, since contracture puts the joint out of alignments (the shortened muscle pulls the bones in its direction), it automatically leads to compensation hypertension of antagonist muscles, locally and more remote. By treating the initial contractures compensation contractures and their consequences (pain, stiffness, and deformation) will subside, as they are no longer necessary. .

What are the characteristics of BMT ? The muscle contracture has no tendency to heal by itself (contrary to what is sometimes claimed in literature – but one just has to examine a patient to see the evidence of the persistence of the lasting muscle spasm). However, since contracture is only a self-sustaining reflex loop (or beta loop), to cut this reflex is sufficient to stop the contracture and all the symptoms caused by it. This is what BMT allows, by passive muscle shortening (according to a very specific protocol). With this simple approach, disorders of the musculoskeletal system, that is to say of the muscles and of the skeleton, that would persist otherwise without any tendency to improve, on the contrary, are rather simple to heal in an average 10 sessions in general, often even less. In summary, contractures, the cause of so many diseases, are spontaneously irreversible (even though their intensity may vary), but are reversible with BMT. BMT is simple, using the same procedure for any contractured muscle, since the mechanism of contracture is unique and the only reason for pain, stiffness, or deformation, is always and only the lasting post-traumatic contracture. To stop the self-sustaining reflex loop that keeps the contracture, it will be necessary to put the affected muscle in a shortening position (not a stretching one, stretching causes a stretch reflex which tends to aggravate a contracture). Hence the name of the method: Brachy-Myotherapy. Brachy from the Greek word for short : the spasmed muscle is shortened, and the treatment is done by shortening it passively even more. .

Some other specificities of BMT Other important elements contribute to the originality of BMT, besides the fact that shortening is used as the only treatment method of contractured muscles. The two other main specificities are: 1) The primary origin of the symptoms causing the patient trouble is generally at a certain distance in the body. In practice, and this finding has never been found to be false, only the muscles of the neck or the ankles can be primarily contractured after a shock. These are actually two parts of the body where the muscles are constantly working as soon as sitting (the neck muscles will have to offset the anterior imbalance of the skull, among others) or standing (the muscles of the ankles have to offset the anterior imbalance of the body, among others). These muscles are most in demand, quite overworked, much more than the other muscles of the body, that ultimately will contract only occasionally. However we said that all joint pains are due to contractures. In practice, the body seems to relieve the primary contractures, at the neck or the ankles, by spreading hypertonia out to the whole body, and this by different mechanisms, to reduce the muscle tone of the primary location, thus causing latent hypertonia in many of the muscles of the body, which will manifest clinically at any given place in response to a trigger - which is not the cause, because it only adds to a tone that is already abnormally high. The same kind of compensation mechanism will be implemented, however less randomly, when equilibrium of the body is threatened by the primary contractures, as it is the case in Scoliosis. Possible triggers are many and varied: however, as it is often shock, strain, repetitive movements, sustained or awkward positions, they are too often taken for the cause, which results in treatment failure or relapses.

The only real cause is to be found in post-traumatic contractures (often long-standing, often asymptomatic since well compensated) at the neck or the ankles. To treat them is always necessary, and often sufficient. It is therefore common not to deal with the painful, stiff, or deformed area ... precisely to deal with it – because it is just a compensation. While a purely local treatment would be at best unstable, and at worst ineffective, and in any a case could simply move the compensation , leading eventually to pain felt elsewhere. 2) The second important factor specific to BMT is as follows. We have seen that there are two kinds of muscles, dynamic and tonic, and that only the latter can have contractures - because the dynamic muscles cannot contract in a sustainable manner. Yet there are always as many muscles to create movement as there are muscles to hold the positions thus obtained. So only more or less half of the muscles of the body may be contractured and cause the various already mentioned symptoms, and only these have to be treated. It is therefore necessary to know which the tonic muscles are. We were able to establish the precise list of tonic muscles, particularly through clinical observation, as there is no complete histological classification of muscles (the fragmentary data that are available, however, always confirm observation). Our list can help target the best treatment, and allows for greater efficiency.

How can the action of BMT be explained ? A contracture persists because of the permanent stretch of the muscle spindle‟s annulospiral receptors, in a selfsustaining reflex loop. If we want to stop a contracture, the easiest way is thus to stop this stretching by shortening the whole muscle passively – active contraction to shorten the muscle would only worsen things. (There are more complex methods - but simplicity is a guarantee of efficiency, and avoids the risk of adverse reactions). To shorten the concerned muscle, a therapist using BMT will passively put the joint governed by the concerned muscle in a position that allows a maximum shortening it.

So that's what is done in Brachy-Myotherapy: after an accurate diagnosis every pathological muscle, shortened by the contracture, is shortened a bit more, for a specific time, and according to a specific way to proceed. The muscle spindle receptor that maintained the abnormal contraction being no longer elongated, immediately ceases to stimulate the motorneurons, and the permanent contraction that is the contracture ceases at once. It's as simple and logical as that. However, this process will usually have to be repeated several times, for it is usual that antagonistic muscles be contractured: since a hypertonic muscle will resist stretching, it prevents maximum shortening of the antagonist one. Therefore, most of the time it is not possible to deal perfectly with every contractured muscle the first time. But generally less than ten sessions are required, often 4 to 6 if the problem is not too old. But only if the root cause that is located in the neck or ankle is addressed, as we have explained. . More information about BMT : http://www.brachy-myotherapie.com/english/

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BMT has been taught for more than 20 years in France. Practical training courses can be organized in English-speaking countries for physicians, physiotherapists, osteopaths and chiropractors. Groups of 20 are required.

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