SCOLIOSIS PLASTIC CHANGES IN SPINAL FUNCTION OF PRE-PUBESCENT SCOLIOTIC CHILDREN ENGAGED IN AN EXERCISE THERAPY PROGRAMME ABSTRACT ■ by Gill Solberg, M A - Rehabilitation Research Unit, Department o f H um an M ovem ent Studies, Rhodes University, South Africa INTRODUCTION Previous stud ies have tended to d em onstrate that in cases of functional scoliosis, postural m uscle "tig h tn ess" should be as­ sessed during m u sculo-skeletal exam inations, and that the treat­ m ent rationale shou ld inclu de appropriate m obilisation therapy along w ith im proving im balances betw een antagonistic m uscle gro u p s along the spine (Janda, 1983; A lter, 1988; N udelm an and R eis, 1990). H ow ever, no published data w ere found on the effect o f these treatm ents o n lateral d eviations o f the spine. T his stud y w as designed to determ ine w heth er or not it is possible to show red uction o f the lateral deviation in a group of functional scoliotic ch ild ren follow ing a 20 w eek period o f thera­ peutic exercises, and to exam ine the extent to w hich spinal func­ tion can be im proved. METHOD T en scoliotic school-children (m ean age 10.6 years) were exam ­ ined and m easured by on e trained observer via the follow ing stages: Subjective assessment T h e presence or absence o f the follow ing b od ily sym m etries w as recorded: • Shou lder height • Scapu lar level • C h est and hip prom inence • Lateral deviation of the spine. T he child w as then asked to bend forw ard looking at the floor, keeping the feet together, knees braced back, shoulders loose and h and s positioned b etw een the knees. A subjective assessm ent of asym m etry o f the up per chest, m id -chest and low er chest, the lum bar region and sacru m w as m ade in this position. The pres­ ence o f absence or a lateral spinal curvature (clinical evidence of scoliosis) w as recorded. Objective assessment A t this stage data w ere collected in the follow ing categories: D em ograp hic data: Includ in g age, m ass, stature and fam ily history o f scoliosis, as w ell as m edical, surgical and developm en­ tal history. A n th rop om etric m easu rem ents: The anthropom etric param e­ ters chosen w ere those that have a functional role in the general aim s o f the clinical exam ination, and w ere aim ed at observing any lateral sym m etries along the body. The follow ing m easurem ents w ere m ade, all w ithin tolerance lim its o f 5 mm: • H eight o f acrom ia: The vertical d istance from each acrom ion to the floor. • Scapu la-spine distance: m easured horizontally from the infe­ rior angle o f each scapula to the nearest vertebral thoracic spinous process. • Biacrom ial diam eter: The m axim um distance betw een right Previous studies (Stone et al., 1979) of the effect of exercise therapy on scoliosis have demonstrated progression of spinal curves despite vigorous exercise regimens. This study presents evidence to the contrary. Ten South African black school children with mild scoliosis and attendant upper thoracic asymmetries were analysed both before and after a specific exercise therapy programme, in order to determine the effect of the therapy on spinal functionality and the scoliotic curve. The effect of this intensive treatment, in which the subjects underwent a five-month exercise training programme with a total o[ 60 one-hour sessions, was investigated in a controlled clinical trial. A subjective and objective appraisal of posterior trunk asymmetry in school­ children aged 7 - 1 8 years is reported. Selected functional and anthropomet­ ric measurements were made before and after the treatment, and antero­ posterior X-rays were used to indicate changes in the scoliotic curve. New methods are described for quantifying the scoliotic curves in each child. Post-treatment tests showed a significant (p) decrease in Cobb’s angles as well as a significant reduction in all the spinal and thoracic functional asymmetries observed in the study. The findings suggest that selective exercise programmes can contribute to improvement in cases of functional scoliosis. The study sheds new light on problems related to scoliosis and the benefits of exercise rehabilitation. Data on the incidence of scoliosis amongst 1052 black children are presented and discussed too. V _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ J and left acrom ia, m easured from b ehind w ith the subject stand ­ ing. T he pointer w as b rou gh t d ow n onto each acrom ion from above. • S i - A crom ia distance: T he d istance b etw een right and left acrom ia to S i w ith the subject standing. • H eight o f anterior superior iliac spines (A SIS): T he vertical distance from each A SIS to the floor. • L ow er limb length: M easured from the A SIS to the m edial m alleolus, w ith subject lying supine. In order to be able to com pare d ifferent sym m etries at d ifferent sites on the sam e scale, an asym m etry ratio (AR) w as derived as follows: AR = H / L -l W here: H = higher shoulder height, and L = low er shoulder height. Thu s, all data w ere recorded as positive values. For each subject AR w as calculated for selected anthropom etric m easu re­ ments. Functional m easurem ents: • Trunk flexion (thoracolu m bar spine): T he d istance b etw een the spinous processes o f C 7 and S i in the start position w ith the subject standing, and at the lim it o f m otion w ith the subject flexing the trunk forw ard. • Lateral b end ing test: M easurem ent o f d istance b etw een C 7 and seating plane w ith the subject sitting erect and at lim it of m otion w ith the subject b end ing laterally to the right and left sides. The pelvis w as stabilised to the plane o f the seat. • Spinal rotation: R otation angle o f the spine (cervical spine excluded) w ith the subject sitting and at the lim it o f m otion w ith the subject rotating the spine to the right and left sides. SA J o u r n a l P h y s io th e r a p y , V o ! 5 2 N o I F e b r u a r y 1996 P a g e 19 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) The pelvis w as stabilised and a pointer w as connected to the sternum to m easure angular m ovem ent. • Shoulder flexibility: B oth shoulder jo in t and shoulder girdle flexibility w as exam ined. T est position: the right elbow w as raised and the rig ht hand reached dow n betw een the shoulders w ith the subject sitting erect. The left hand w as placed in the sm all o f the back with the fingers pointing upward a n d the palm facing aw ay from the back. The distance between the hands if not overlapped or the am ount of fingers overlap w as m easured. • H am string flexibility: M easurem ent o f the angle o f straight leg raising in a supine position, w ith the low er extrem ities ex­ tended. S ca p u la r asym m etry: The angle o f acrom ial plane scapular asym m etry w as d eterm ined using linear distance b etw een the acromia (h) and the vertical difference in acrom ial height m eas­ ured from the floor (o) as depicted in Figure 1. Thu s the angular asym m etry is given by: 9= Arc Sin o/h Several researchers have reported that the d evelopm ent o f a curvature is m ost likely d uring periods o f rapid grow th (Taylor, 1983; Loncar et al, 1991). Since the d evelopm ent of scoliosis is so intim ately related to the d evelopm en t and grow th of the skeleton, physical anthropom etry can b e an im portant m easurem ent tool. H ow ever, quantifying change o f shape, over time, especially as it related to scoliotic p rogression or response to treatm ent, is also an im portant clinical problem . The precision o f m easurem ent tech­ niques is crucial to accurate detection o f change, especially in the case o f back-surface m easurem ent w hose m agnitude is small com pared w ith the m agnitu de o f the underlying skeletal d eform ­ ity. O ne of the m ajor factors lim iting the understanding o f the relationship betw een therapeutic physical activity and scoliosis is the lack o f easily adm inistered valid and reliable m easures, w hich will obviate false conclusions (Figure 2). As Figure 2 show s, a taller subject (w ith presum ably broader chest), appears to exhibit a greater asym m etry in terms of dispa­ rate heights o f left (L) and right (R) acrom ia, w hile in fact this may be an artifact of body size. Even if stature is identical, an individ­ ual w ith larger bi-acrom ial axis m ay exh ibit an apparent (but not real) increase in asym m etry. Thus, in the present study, asym m e­ try w as viewed as an angular d eviation w hich is independent of size, and 0 in Figure 2 is identical, despite a considerable apparent difference in left and right acrom ial height. On the assum ption _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Figure 2 : Angle o f asym m etry t —R J: original measure L-R2: loler meosure. A2>A1 but 9 is constant L—R2(a): later measure. A 2(a)>Al and 9 is increased l-R 2 (b ): later measure. A 2(b)>Al but 9 is decreased. that a subject undergoing an adolescent grow th spurt could con ­ ceivably grow in stature and/or bi-acrom ial diam eter w ithout in fact changing the relative level o f asym m etry, this would convey a spurious impression that the asym m etry had increased when in fact it m ight even have dim inished. Thus the angle 9 expresses acrom ial height asym m etry better, as a size-independent m easure, and therapeutic interventions are then aim ed at reducing 9 to zero, w hile grow th changes are factored-out. This will also enable data from different age groups to be pooled for statistical analysis. M easu rem en ts on th e R ad io g rap hs: One anteroposterior roentgenogram w as taken o f each subject in a standing position, using a large 36 x 43 cm cassette and directing the central ray horizontally to the m id -point o f the film. The research protocol was approved by the appropriate sub-com - mittee on ethical standards w hich required, inter-alia, the direct personal involvem ent o f an orthopaedic surgeon during the X-ray phase, to ensure that only children deemed on m edical grounds to require X-ray screening would be subjected to this intervention. These radiographs w ere analysed using the follow ing m eas­ urem ents: All spinal curvatures were m easured in degrees as described by Cobb (1958.). M easurem ents of the general spinal d eviation w as developed, as follows: B la d s y 2 0 F e b r u a r ie 1996 SA T y d s k rif F is io te r a p ie , D e e l 5 2 N o 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ Figure 4 : M e asurem ent o f area under th e curve_ _ _ _ _ _ _ _ _ _ _ _ _ _ • A plum b-line w as draw n on the radiograph from the spinous process o f C 7. In cases o f a cervical curve, this line was drawn from the first sym m etrical vertebra. • Five anatom ical points w ere then identified on each vertebral body w ithin the curve (Figure 3), and used to find the middle point of the vertebra. • The distance betw een each vertebral centre and the plum b line was m easured to the nearest millim etre and the spinal devia­ tion relative to this vertical line w as then calculated using a sim ple ratio relationship: SD = S d / H W here SD is the extent of spinal deviation; d is the distance of each vertebrae from the plum b line; and H is the height o f the vertebral body of the tw elfth thoracic vertebra. This ratio relation­ ship ensures standardisation o f the m easurem ent if the child grew in size and/or if projected X-ray im age altered from test to test. The area under the curve w as m easured, as follows: • A straight line w as draw n betw een all the vertebral centra w ithin the curve. • The area under the curve (i.e. betw een the plum b line and the curve) w as measured in square centim etres using a com pen­ sating polar planim eter. • For standardisation of the m easurem ent, this result was di­ vided b y the area o f the b od y of T 12 as m easured on the same X-ray. Thus: SRD = C/A W here SRD is the size-relative curve am plitude encom passing spinal deviation, C is the area under the curve, and A is the area o f the tw elfth thoracic vertebra. This ratio relationship w as used to ensure standardisation of the m easurem ent. Treatment Follow ing exam inations and X-rays, the subjects w ere re­ quested to participate in a 60-treatm ent exercise therapy pro­ gram m e in w hich a graduated regim e w as provided to enhance each subject's m uscular strength, neurom u scu lar coordination and joint range o f m otion (RO M ) according to individual needs. The subjects w ere seen three times w eekly for 20 w eeks and a warm , w ell-lit room w as utilised throughout. Exercise procedures and programme The aim of the treatm ent w as to provide therapeutic regim ens differentiated by each patient's initial functional condition. The treatm ent w as specifically adjusted to the subjects, taking account o f the direction and extent o f the curve(s). The program m e was designed to release m uscle contractures on the concave side o f the spine, since soft tissue contracture in this area is one o f the m ain forces m aintaining the deform ity, resisting correction and reject­ ing im plants (N udelm an and Reis, 1990). The lateral d eviation o f the spine m ight also reduce the ability of the intervertebral disc to distribute w eight effectively and a decrease in the disc height m ight occur, causing abnorm al w eight­ bearing by the facet joints and an alteration in facet jo in t alignm ent (Cailliet, 1975). Therefore, one o f the general aim s o f treatm ent was to encourage aw areness o f the use o f the spine in everyday life, and teach the application o f m echanical principles of kinetic handling in activities of daily living. The exercise system and procedures w ere developed by the author. The exercises w ere taught to the subject during an orien­ tation session. Before the subjects w ere allow ed to participate in the study, they w ere required to perform the exercises correctly. Subjects were individually supervised during their exercises to ensure correct execution. A log was kept, recording exercise dos­ age date in the follow ing categories: intensity, repetition and frequency. Adjustm ents of exercise intensity w ere m ade for exer­ cise progression each m onth. T rea tment sessions were o f one hour duration each. D uring the first tw o w eeks, quality o f perform ance o f the exercises was em phasised. In addition to perform ing exer­ cises during the treatm ent sessions, the subjects w ere instructed to do these sam e exercises at hom e. The exercises were o f two types. The first consisted o f ten exercises and was a standard condi tioning routine to m aintain the strength of the trunk m uscles as w ell as its norm al range of m otion. Vigorous exercises included incidental m ovem ents that are translated to active correction of the m ajor curve. The second type com prised exercises involving specific m ovem ents designed to dim inish the curve o f the individual in question. After 20 w eeks (60 treatm ents) subjects w ere re-evaluated and the initial m easurem ents were com pared to post-program m e re­ sponses. Paired t tests w ere used to evaluate the effectiveness of the program m e in reducing bodily im balance, im proving spinal functionality and altering the Cobb angle as m easured on the X-rays. RESULTS AND DISCUSSION Pre-treatment Roentgenographic Findings The criteria for the existence o f scoliosis in this study included the presence of obvious truncal lateral sym m etries as well as c o n f ir m a tio n o f th o se s ig n s in the e r e c t a n te r o p o s te r io r roentgenogram of the spine using as the criterion a m inim um of 5", determ ined by C obb 's technique. Anthropometric measurements: The exercise program m e had a positive effect on all the sym ­ metries which w ere observed in the anthropom etric m easure- SA J o u r n a l P h y s io th e r a p y , V o ! 5 2 N o 1 F e b r u a r y 1996 P a g e 21 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) merits. T he general asym m etry scores (E H / L -l) w ere signifi­ cantly decreased (p) b y the treatm ent program m e. The p rogram m e-effects on A crom ial A ngle A sym m etry are presented in T able I. TABLE 1: Effects o f prog ram m e on acrom ioal angle asym m etry Condition Subject number Angle of asymmetiy Pre-treatment acromial 1 4,3 asymmetiy 2 1,0 3 3,1 4 1,9 5 2,0 6 2,8 7 0,1 8 2,4 9 4,2 10 3,1 x 2,4 SD 1,2 Post-treatment acromial 1 1,2 asymmetiy 2 0,0 3 0,6 4 0,0 5 0,0 6 0,0 7 0,0 8 0,0 9 0,0 10 0,0 x 0,1 SD 0 ,416 7 The angle o f acrom ial asym m etry appears to serve not only a good indicator o f the need for treatm ent, b u t as a quantitative m easurem ent o f realignm ent. A com parison betw een pre- and post-treatm ent results show a significant im provem ent after the exercise p rogram m e (Table I). Functional measurements: Functional tests w ere used in this stud y as a m eans o f the d eterm inating fu nctional lim itations o f the scoliotic spines and extent o f truncal sym m etries. The results o f the fu nctional m easurem ents concur w ith other studies o f lateral sym m etries, w h ich found that there is a relation betw een scolio sis and fu nctional im balances (N udelm an and Reis, 1990; K isner and C olby, 2985; Thom pson, 1989). The m ajor­ ity o f the subjects in this stu d y presented w ith tightness in pos­ tural m uscles, p red om inantly those m aintaining the locom otor posture, to correlate w ith the concept that these m uscles adap­ tively shorten and b eco m e tight (Janda, 1983). T he treatm ent ap p arently exerted a significant influence on all the observed functional sym m etries, over the 20-w eek period of the p rogram m e (p). Results of measurements on the X-ray films: In roentgenographic exam inations, m agnification o f the im age depends on the tube position. A m agnification factor w as taken into accou nt to stand ard ise this. Because all o f the geom etric inform ation w as com pressed onto a single film plane, the m agni­ fication varies w ith the position o f the part o f the skeleton being m easured, since it is also d epend ent o n the d istance from the film plane. This m ay p ro d u ce sm all differences on the radiograph and therefore all the m easurem ents on the X -rays in this stud y w ere standardised (using T 12 as a reference vertebra) b y the m ethod described earlier, before the data o n the spinal d eform ity could b e obtained w ith confidence. Cobb Angles: T he results o f pre- and post-treatm ent cu rves, as m easured on the X -rays, show significant reduction in C obb angles and are p resented in Table II. TABLE II: X-ray results p re /p o s t-tre a tm e n l curves (Cob ) angles) Number Pre-treatment Post-treatment % reduction 1 27,0 9,5 64,8 2 12,0 8,0 33,3 3 6,0 6,0 nil 4 • 7,5 3 ,0 60 ,0 5 9,5 5,0 4 7 ,3 6 8,0 4,0 50,0 7 7,0 4,0 42,8 8 9,0 5,0 44,4 9 .15,0 4,0 73,3 10 9,0 2,0 77,7 x 11,0 x 5,05 54,1 SD 6,2 SD 2,3 SIG The results o f this stud y show that the area under the cu rve as w ell as the general spinal d eviation scores w ere significantly low er in the post-treatm ent m easurem ents. The significant posi­ tive changes in these m easurem ents, and in the C obb angles give som e indication o f the success o f the training p ro g ram m e. The results seem to confirm the potential valu e o f an intensive and rigorous therapeutic exercise p ro gram m e in the treatm ent of scoliosis, and argue against the op inions postulated b y K isner and C olby (1985) and others (K eim , 1982; R oaf, 1958), w h o consider exercises beneficial only w h en perform ed b y patients w earing trunk orthoses. Measurement Procedures T he m easurem ent techniques used in this stu d y have been applied to studying the effects o f treatm ent, as w ell as to im prov­ ing ou r description o f the scoliosis d eform ity and ou r under­ standing o f its aetiology. T he test sequ ence p resen ted facilitated observation in an ordered w ay to avoid u n necessary changes in starting positions. This fu rther encou raged efficien cy d uring the tests and w as a practical m ethod o f evaluating the m u scu loskele­ tal system in children. To ensure valid conclu sions from the data, the reliability of all the m easurem ents w as determ ined. T he m easurem ents used yielded acceptable test-retest reliabil­ ity, and can im prove the therapist's ab ility to d ecid e the effective­ ness o f treatm ents. In this w ay m odifications o f the treatm ent plan can be initiated at an earlier phase o f therapy. T h e author believes that the m ethods w hich w ere developed in the stu d y are rigorous and w ould appear to reflect the m agnitu de o f the scoliotic curve. Thus, clinicians should consid er using the m ethods described w hen evaluating patients w ith suspected spinal problem s. Exercise programme and treatment procedures: Treatm ent o f scoliosis b y exercise therapy rem ains controv er­ sial, w ith m ost o f the investigators rep orting p o or results and questioning its effectiveness (C obb, 1958; K eim , 1982; Road , 1956; T arr, 1948; K isner and C olby, 1985; Stone et al, 1979). M o st o f these authors contend that exercise o f an y kind is n ot b eneficial in inhibiting scoliotic developm ent. In 1941, the A m erican O rtho­ p aed ic A ssociation's R esearch Com m ittee cam e to the conclusion, after a stu d y o f 425 cases o f end -resu lt idiopathic scoliosis, that exercise should b e avoided. This stud y found that approxim ately B la d s y 2 2 F e b r u a r ie 1996 SA T y d s k rif F is io te r a p ie , D e e l 5 2 N o 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) In order to get the most out o f your working holiday in Britain, you’ll want the expert care you can only gain from Corinth. With almost thirty years experience we’ve grown to be the leading specialist Employment Agency in our field by helping Physiotherapists from all over the world combine business with pleasure; giving them the opportunity to work with the U K ’ s leading hospitals and helping them take time out to enjoy the different cultures and sights. 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ENGLAND Tel: 09 44 181 207 0234 Fax: 09 44 181 207 6894 T H E P R O F E S S I O N A L S T A F F I N G A G E N C Y SA J o u r n a l P h y s io th e r a p y , V o l 5 2 N o I F e b r u a r y 1996 P a g e 2 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) ...c o n t i n u e d fro m p a g e 2 2 after a stu d y o f 425 cases o f end-result idiopathic scoliosis, that exercise shou ld be avoided. T his stud y found that approxim ately 60% o f the p atients treated w ith exercises had an increase in the deform ity, and 40% had no change. R ecent w ork d one b y Stone et al (1979), has included a nine- m onth exercise therapy p ro gram m e for 99 subjects w ith scoliosis and also reported p o o r results. H ow ever, the results o f this study show ed the extent to w hich, un der the optim al cond itions ou t­ lined, therapeutic exercises w ere capable o f correcting functional scoliosis and a sig nificant change in both body position and spinal fu nctionality w as show n after 20 w eeks o f treatm ent. The data revealed p ost-treatm ent valu es that suggested that som e positive changes had taken place due to the therapeutic program m e. It appears that in cases o f lateral sym m etries, you ng child ren have high potential for b alancing the trunk m uscles if the exercise intensity is w ell regulated and m onitored. This should encourage clinicians to consid er using exercise therapy as an im portant treatm ent for fu nctional scoliosis. E xtrem e care w as taken in the present study to control testing proced u res and the cond u ct o f the treatm ent program m e itself. It is adm issible, w h ere oth er ou tcom es are the focus, to be less rigorous w ith respect to the treatm ent itself. Thu s Stone et al (1979), had subjects p erfo rm an active exercise program m e at hom e w ith no superv ision, as op posed to the individual attention given to each su b ject in the present study. H ow ever, it is the au th or's op in ion that w ithout individual supervision, no valid inform ation on the effect o f exercise program m es on functional scoliosis can be achieved. T h e i n f o r m a t i o n p r e s e n t e d h e r e is a n a t t e m p t to s h o w th e r e s p o n s e s o f th e f u n c t i o n a l s c o l io t i c s p i n e to a n in d iv id u a l i s e d a n d c l o s e ly s u p e r v i s e d e x e r c i s e p r o g r a m m e . T h i s k n o w le d g e m a y p r o v i d e a u s e f u l b a s i s f o r b e t t e r u n d e r s t a n d i n g a n d m a n a g e m e n t o f f u n c t i o n a l s c o l io s i s , a n d m ig h t s h e d a d d i t i o n a l l ig h t o n th e e f f e c t i v e n e s s o f e x e r c i s e t h e r a p y in th e t r e a t m e n t o f t h is p r o b l e m . REFERENCES 1. A lter M J. S cience o f stretching. F irst Editio n, Illinois: C am p aig n ; 1988:17- 2 1 . 2. C ailliet R. Scoliosis. F irst Editio n, P h iladelp h ia. F A D avie; 1975:12-43. 3. C obb J R. Scoliosis, jou rn al o f B one a n d jo in t Surgery 1958;40(A ):510-512. 4. Jand a V. O n the co ncep t o f p o stu ral m u scles and p o stu re in man. A u stralian jou rn al o f P hysiotherapy 1 9 8 3 ;2 9 (l):8 3 -8 5 . 5. K eim H R. T he adolescent spine. F irst E dition, N ew Y ork: Sp ring er-V er- lag;1983:25-62. 6. K isner C , C olby L A. T herapeu tic exercise. Secon d E d itio n , P hiladelphia: D avis F A ;1 985:509-542. 7. L oncar D M , Pecina M , P reb erg Z. A lo n gitud inal stu d y o f grow th velocity and d ev elo p m ent o f second ary g e n d e r ch aracteristics versus on set o f idiop athic sco liosis. C linical O rthopaedics 1991 ;2 7 0 (l):2 7 8 -2 8 2 . 8. N u delm an W , R eis N D. A natom y o f the extrin sic spin al m u scles related to the deform ity o f scoliosis. A cta A n atom ica 1990;139(3):220-225. 9. R o a f R . P a r a l y t i c S c o l i o s i s . J o u r n a l o f B o n e a n d J o in t S u r g e r y 1956;38(b):640-659. 10. Sto n e B, B eekm an C , H all V et al. T he effect o f an exercise pro gram on ch ange in cu rve in ad olescen ts w ith m in im al idio p ath ic scolio sis. P hysi­ cal T herapy 1979;59(6):759-763. 1 1 . T a r r I. A n a ly s is o f n o r m a l a n d s c o l io t i c s p in e . P hysiotherapy 1948;28(1):6-10. 12. T ay lo r J R. Scoliosis and grow th. P attern s o f a sy m m etry in norm al vertebral grow th. A cta O rthopaedica S can din avica 1 9 8 3 ;5 4 (l):5 9 6 -6 0 2 . 13. T ho m p son C W . M an u al o f structu ral kin esiology. E lev en th Edition. Boston ; T im es M irro r,1989:51-83. THE SA JOURNAL OF PHYSIOTHERAPY IN THE INTERNATIONAL CONTEXT ■ by Lo-an Roux, Physiotherapy Publications In his last ed itorial after ed iting the New Zealand Journal o f Physiotherapy for n ine years, Bryan P aynter com m ents that on the occasion he "le ft ou t the editorial to see if anyone w ould notice, nobody said a w o rd ''. H e also com m ents that he is not certain that his w ish that the Jo u rn al w ould be a vehicle o f professional com m unication w as fu lfilled to the extent he desired. And yet the index o f articles in the D ecem ber issue o f the New Zealand Journal o f Physiotherapy looks interesting enough: • Study raises concern about concussion in rugby league gam es • N eural involvem ent in shou ld er pain • H ypertrophy and hyperplasia in skeletal m uscle follow ing end urance training • The effects o f ultrasound o n tum our grow th and m etastasis • Physiotherapists rated positively by parents • O verw eight nurses su ffer m ore back pain • C linical notes • W orking in the U SA - a K iw i perspective • N ew directions for p hysiotherap y research. K athy H end erson is the Scientific Editor o f the Australian Journal o f Physiotherapy, and in her D ecem ber editorial "C areful m an u scrip t p rep aration m axim ises publication p o ten tial" she com m ents that "th e m ajority o f m anuscripts are returned to the author(s) for rev isio n " and that "a num ber o f m anu scrip ts require revision on m ore than one occasion p rior to acceptance for p u bli­ cation ". A n d y e t the in d e x o f a r tic le s in d ic a te s th a t A u s tra lia n physiotherapists are w riting scientifically acceptab le articles: • Effect o f trunk flexion speed on flexion relaxation o f erector spinae • Effect of age, gender and speed o n three d im ensional lum bar spine kinem atics • G roup exercises for subjects w ith osteoarthritis o f the knee • Post stroke recovery o f balanced sittin g a n d am b ulation ability • D oes laser enhance bru ising in acute sporting injuries: • Physiotherapy m anagem ent o f obstructed defaecation • H ow to w rite a p aper for a scientific jo u rn al. T he South African Journal o f P hysiotherapy has the sam e mission, m ethods and requ irem ents as p hysiotherap y jo u rn als the world over. Even though it serves a relatively sm all local com m unity of physiotherapists, it is also our professional show case to the world. W e know that South African p hysiotherap ists are highly re­ spected for the quality o f papers presented at national and inter­ national congresses. The Journal is ou r vehicle for m aintaining that respect betw een congresses. The difficulties experienced by p hysiotherap ists in w riting for publication are universal. The difficulties experienced by journal editors in finding and shaping articles suitable for p u blication are universal. The "G u id elines for A u th o rs", published by every jo urnal in the w orld, invites and w elcom es contrib u tio ns. Y our Journal is no exception! B la d s y 2 4 F e b r u a r ie 1996 SA T y d s k rif F is io te r a p ie , D e e 1 5 2 N o 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )