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Can bracing improve trunk asymmetries in young adults?

Scoliosis is a condition characterised by the presence of a vertebral deformity in the three planes of space. The extent to which this deformity is visible externally varies from case to case. As stated in the guidelines recently developed by SOSORT, one of the primary objectives of scoliosis rehabilitation treatment is to improve trunk asymmetries. Achieving this objective has important implications for quality of life — after all, having a positive self-image helps to ensure a good level of psychological wellbeing and this, in turn, translates into a better quality of life.

Not uncommonly, adolescents with scoliosis lack the willpower or motivation to undertake bracing treatment, or perhaps have never had a medical specialist recommend it to them; others, quite simply, may not even have realised that they had scoliosis.
Basically, many different factors can affect what scoliosis treatment a person received, or did not receive, in adolescence. But the fact is that some people reach adulthood before realising, for example, that they have one waist straighter than the other, that part of their rib cage protrudes, or that one breast is higher than the other.

What can be done to improve these asymmetries?

“Although there is no scientific evidence available to help us answer this question with precision, we at ISICO have performed some bracing treatments in young adults (up to 25 years of age)explains dr Fabio Zaina, physiatrist – In such cases, our doctors, during the consultation, are clear from the outset: this is a long and demanding course of treatment. For the first few months, the brace should be worn full time, i.e., for 23 hours a day, after which the brace-wearing time is reduced very gradually in an effort to maintain the results obtained”.

Patients wanting to start bracing must be absolutely convinced about it and highly motivated, too, because any sudden interruption of the treatment, without respecting the abovementioned weaning-off phase, can negatively affect the stability of the spine.

On the subject of stability, we should also point out that bracing treatment must always be combined with specific exercises based on self-correction. The purpose of these exercises is to keep the back muscles strong and teach the patient how to keep their trunk correctly positioned during the various activities of daily life.

Can adults obtain a radiographic improvement?

Unfortunately, radiographic improvements cannot be achieved in adulthood. In individuals who have reached full skeletal maturity, bracing is never proposed with this aim in mind.

In other words, bracing in adults can improve the external asymmetries related to the scoliotic curves, but it cannot reduce the Cobb degrees of the curves themselves.

Are there no other options available for adults who are reluctant to wear a brace?  

“Adults can always follow a specific physiotherapy programme based on self-correction exercises explains Valentina Premoli, physiotherapist- These exercises are a way to act on the postural component of scoliosis. They serve to counteract the spine’s tendency to collapse to one side, and can thus improve the functioning of the back generally. This type of treatment helps to limit the worsening of the asymmetries that accompanies the spine’s tendency to give way in the direction of the curves — a tendency that becomes increasingly marked as we get older”.

Scoliosis and pregnancy

For a woman, discovering she is pregnant is often one of the most memorable, most exciting and happiest moments in her life. Thinking about the baby, imagining it and talking about it, not to mention feeling it inside her, arouses a number of precious and positive emotions: hope, tenderness and love. However, at the same time, pregnancy leads to various changes, in her body, her self-image and her vision of the future.
Furthermore, she will need to make adjustments and seek new balances in her (often busy) daily life, her rhythms and her relations with others. 

All this can generate normal and entirely understandable fears, and these can be amplified in mothers-to-be who happen to be affected by a condition like scoliosis. Many such women will already have expressed anxiety over their ability to conceive, carry and give birth to a child.
Pregnancy and childbirth, on account of the physical demands they make, can indeed be quite a daunting prospect for these women.

An interesting recent review of the literature (Dewan MC, Mummareddy N, Bonfield C. The influence of pregnancy on women with adolescent idiopathic scoliosis. Eur Spine J. 2018 Feb;27(2):253-263. doi: 10.1007/s00586-017-5203-7. Epub 2017 Jun 29. PMID: 28664223.), focusing on the interaction between pregnancy and scoliosis, examines these very issues. Just to give an idea, in numerical terms, of the analysis carried out, this review included 134 articles and examined 22 studies, referring to a total of 3125 patients.

First of all, the review considered whether and how scoliosis affects the timing and outcomes of pregnancy. It would appear that women with idiopathic scoliosis need not worry about their possibility of having children, even though they have a slightly lower probability of becoming pregnant compared with age-matched women, and may be slightly more likely to receive fertility treatment. Furthermore, women with scoliosis, regardless of whether they underwent surgery or bracing treatment, can expect to have a similar number of children as healthy women. 

However, the studies considered have certain limitations: most of them failed to specify whether the women with scoliosis had been actively seeking or desired pregnancy. Similarly, it is not clear whether all the patients were followed up until menopause. Furthermore, marriage rates, often not even mentioned, were not uniform across the studies.
In the absence of indications on these aspects, the slightly higher rate among women with scoliosis who do not have children could be misinterpreted.

Isico at the SRS 56th Annual Meeting

The SRS 56th Annual Meeting, running from 22 to 25 September, 2021, was a hybrid event that included a robust in-person programme live in Missouri, USA and a virtual component, to allow delegates who were unable to attend in person to follow and enjoy the event. Isico took part with a podium presentation of its research “The natural history of adults with spinal deformities: results from a prospective collection of radiographic data”, given by dr. Sabrina Donzelli (Isico physiatrist) and a poster presentation, by Prof. Stefano Negrini (scientific director of Isico), entitled “Reducing Pelvis Constriction Changes the Sagittal Plane. A Retrospective Case-Control Study of 37 Free Pelvis vs 451 Classical Consecutive Very-Rigid Sforzesco Braces”. 

The Scoliosis Research Society (SRS) Annual Meeting is a forum for the realization of the Society’s mission and goals, the improvement of patient care for those with spinal deformities. Nine faculty-led instructional course lectures, case discussions, and 180 abstract papers were presented on an array of topics.

The Isico research started from current data telling us that scoliosis also affects adults and that patients with scoliosis treated during growth should have their backs regularly monitored in adulthood. This applies particularly to those with curves that measured more than 30 Cobb degrees when they finished growing. Curves measuring more than 50 degrees, on the other hand, are at high risk of worsening, and in these cases, therefore, surgical treatment is indicated. 

This is what we know, but do we know whether there are any particular times or ages at which the risk increases? Are there any conditions that might be associated with the risk of worsening?   

No one has ever investigated the factors that determine progression of the disease” explains Dr Donzelli, “because long-term monitoring of patients is a costly process. On the other hand, knowing when it is really necessary to increase the frequency of checks would allow timely interventions and therefore help to reduce costs. In our retrospective longitudinal study, we analysed the factors involved in the progression of scoliosis.”

The Isico researchers began by collecting data from radiographs the patients had undergone over the years. They measured these radiographs and, for each patient, plotted curves showing scoliosis worsening over time. In all, 767 patients (mean age 35 years, 85% women) met the inclusion criteria and were able to provide at least two X-rays taken in adulthood and at least 5 years apart. 

The authors then analysed which of the following factors influenced changes in Cobb degrees over time:    

  • Gender (F or M)
  • Idiopathic diagnosis (yes/no)
  • Menopause (yes/no)
  • Thoracic localisation (yes/no)
  • Comorbidities: bone metabolic diseases, bone and joint inflammatory disease, neurological associated disease (yes/no)
  • Brace during growth (yes/no)
  • Back pain (yes/no)
  • Family history of spine deformities (yes/no)
  • BMI at baseline (continuous)

The results of the research showed age to be one of the main predictors of worsening: after the age of 50, the risk of worsening increases, therefore from this age it is a good idea to start having more frequent check-ups; moreover, the forms of scoliosis seen in adults are different, and the period of time over which scoliosis appears and then progresses is much longer. 

“There are numerous factors involved, and research in this field is still in its infancy,” concludes Dr Donzelli. “The lengthy monitoring times and the very small variations occurring over time make it particularly complicated. Systematic data collection and regular monitoring over time are essential not only for research purposes, but above all to ensure timely preventive intervention.” 

Congress in Bulgaria: Michele Romano awarded

In Sofia/Bulgaria, September 11-12, 2021 the VIII National Congress of the Association of Physiotherapists in Bulgaria: “Interdisciplinary approach and current trends in practice” took place. 
Both the current trends in practice on a national and global scale, as well as the future development of the profession in Bulgaria were discussed during the Forum. The scientific program once again provided an opportunity for the exchange of information and innovations in the field of physiotherapy and rehabilitation – national experience and world achievements.
The congress had a special section for the treatment of scoliosis and Michele Romano, head of physiotherapy in Isico, gave two presentations.
One was titled “Scientific Exercises Approach to Scoliosis (SEAS)” and the second one focused on “Scoliosis Manager”: the Isico web tool for patients’ management available free for everyone. In its protected version adapted to Isico’s internal clinical and rehabilitation needs, it is the daily working tool for Isico’s expert professionals. 
Further to giving these two presentations, Michele Romano was awarded a commemorative plaque by the Bulgarian Association of Physiotherapy, who wanted to express with this recognition their gratitude for his ongoing commitment and dedication in the field of physiotherapy.

My brace has helped me to grow up!

I’m Ilaria, and I have spent the past 6 years wearing a scoliosis brace.

At last, on 28/6/2021, after countless sacrifices, many, many moments when it felt like everything was against me, and others when things seemed to be going better, I finally came to the end of my “journey” with ISICO.

In spite of the difficulties I had along the way, as time went by my check-ups became increasingly encouraging, my back stabilised, and I was able to leave my brace off more and more; also, thanks to the exercises, the cosmetic appearance of my trunk improved.

There have obviously been lots of ups and downs over these years, but these have helped me to grow up: I now know that the low points teach you the importance of persevering, of keeping your head held high and always looking for the positive side of things.

Through wearing a brace, I have come to realise that I was a rather superficial person before. However, over time I have matured, and in fact, I learned to really appreciate the true value of situations and times spent both in and out of my brace.

My brace also helped me to appreciate what people really thought of me, and how much they cared about me.

When I first started wearing a brace, in the 4th year of primary school, my classmates and teachers didn’t know at all what it was for or understand why I needed to wear it. For them, there was no point to it, whereas I realised that it represented my “salvation”.
Luckily, over time and in my next school I came across people (classmates and teachers) who knew more about it and were always very supportive.

One very important factor in getting me to the point I’ve reached today was the “brace camp” holiday, organised by ISICO, that I had on the island of Asinara in Italy in 2018. There, I made some lasting friendships and learned that wearing a brace on holiday was no big deal, even if I could only leave it off for a few hours a day.

During that holiday, the physiotherapists taught us that doing postural exercises for our backs could actually be fun. They encouraged us and helped us to “put up” with keeping our braces on for the prescribed number of hours. What’s more, even though we weren’t able to spend very much time with our braces off, we were still able to enjoy the sea and the natural surroundings. They even taught us how to go in the water in a brace.

In the course of this whole experience, I have met many different people, with different stories, and this has helped me to see that while everyone at ISICO is on the same journey, each person experiences and approaches it in their own way.

I want to thank Dr Monia Lusini, who has always been a great support, whatever the circumstances, but my most heartfelt thanks go to my parents, who have always been there for me through thick and thin, supporting me and encouraging me not to give up and always to be proud of myself and persevere.

My parents are amazing, always ready to do anything for me and give me whatever I need.

Finally, I hope the things I have said might be of help to lots of other young brace wearers out there!

My message to them is: stay strong and stay brave because in the end all your sacrifices and hard work will pay off. Before you know it, you will be seeing the light at the end of the tunnel!

And don’t forget! Go in the sea as often as you like… just slip on your brace undershirt, brace and swimming costume and go for it! After all, there’s nothing quite like a refreshing dip ❤️

Bracing + exercises + adherence to treatment = a recipe for successful treatment!

Idiopathic scoliosis is a disease that causes abnormal growth of the spine. Once a spinal curve has appeared, the vertebrae of a young patient are liable to become deformed in the three planes of space. This risk persists until he or she has finished growing.
Through conservative treatment, we aim to ensure that our patients, as adults, will have a strong back. In other words, we want them to reach adulthood with a healthy and functional spine, and that does not necessarily mean a perfectly straight one!

Therapy is therefore undertaken in order to try and limit the natural worsening of scoliosis curves through treatments proportionate to the severity of the condition.

To this end, there exist two main methods: specific physical exercises and bracing, and both need to be applied correctly and with the necessary adherence to treatment.

To decide whether a young patient needs to be prescribed a brace, the treating physician considers a series of factors, for example the size of the curve, the patient’s bone age, and whether or not he/she presents asymmetries (of hips, pelvis, scapulae, shoulders and so on).

When bracing is deemed warranted, we urge our youngsters to adhere scrupulously to the instructions given in order not to compromise the effectiveness of the treatment, and indeed to obtain the best possible correction.
This means that they must fasten and tighten their brace correctly, as shown by our doctors during the testing phase. If they do this, their brace will be less visible under their clothing; it will also be less prone to move about when they are walking, running and even sitting, and therefore more comfortable.

In addition to being more visible under clothes, a brace that is worn too loosely is less effective: it will not give the results that would have been achieved by wearing it properly.

According to data we have gathered, bracing treatment should produce its most marked results in the first months, and adhering to the prescribed number of brace-on hours is what makes the difference in this regard.

Bracing treatment is always prescribed together with specific physical exercises, i.e., 15-20 minutes per day of spinal self-correction and stabilisation exercises that help patients get into the habit of regularly correcting their posture themselves, even during the hours they are permitted to leave their brace off. 

We constantly remind our patients that whenever they remove their brace, self-correction becomes all important, and that “voluntary and active” self-correction works just like the brace itself does. Clearly, though, this demands good self-awareness on their part and a willingness to collaborate.

In “Specific exercises performed in the period of brace weaning can avoid loss of correction in Adolescent Idiopathic Scoliosis (AIS) patients: Winner of SOSORT’s 2008 Award for Best Clinical Paper”, we  showed that patients who regularly did specific exercises obtained a stable result when they finally stopped wearing their brace. Instead, those who did specific exercises discontinuously showed a worsening of a few degrees, while the curves of those who did no exercises at all worsened by an average of 10 Cobb degrees or more.

And it is important to remember that all these patients were prescribed the same type of brace, and the same number of bracing hours.

Brace weaning, which is carefully monitored by the physician, must be done extremely gradually, as the spine needs time to adapt to the absence of an external support. This is particularly true in the case of patients treated for very severe curves. During this delicate phase, self-correction exercises become even more important, helping to prevent the spine from once again collapsing in the direction of the curve. 

We often say that strength comes from within: a patient’s own determination to wear his/her brace consistently and do his/her exercises correctly will together help to ensure that conservative treatment is a success – and it is important to understand correction of the scoliotic curve is not the only measure of success. Success also means stabilising the curve and curbing its tendency to worsen as the patient grows.

Andrea’s story

Hi, I’m Andrea. It’s now been nearly two years, and I finally feel ready, and brave enough, to speak out.
Over time, I have come to realise that people are often judged for the way they look and not for who they really are. So, I may not have a six-pack with super-toned abs, and I haven’t got a straight back like other teenagers, but to be honest, none of that worries me anymore.
It is the people who can see your worth without bothering about your appearance who really love you for yourself. I am now half-way through a journey that seemed endless to begin with. I spent an entire year wearing this thing for 23 hours a day.
I had to cope with a whole summer when I couldn’t spend more than an hour a day by the sea, and holidays when I couldn’t do what everyone else was doing, and I was always finding excuses not to go out simply because I was too ashamed to admit that I had, and have, this “problem”.
Now, though, I am perfectly happy with who and what I am, and I know that the people who really care about me will continue to be there for me come what may.
I’d like to dedicate these few lines to myself, to acknowledge the fact that, after the initial tears and the anger at not being able to have a “normal” adolescence, I have finally grown self-confident enough not to feel ashamed.
This is not one of life’s real problems, it’s just an obstacle I need to overcome in order to become a better person. I am proud of who I am today. 

Scoliosis: why choose rehabilitation treatment?

I have scoliosis. What should I do? Do I absolutely have to follow a treatment, or is there no point? Will I need to be operated on? These are questions we often get asked by patients who have been diagnosed with scoliosis.

Therapeutic approaches to scoliosis fall into two categories: surgical treatment, indicated only in a limited number of cases, and conservative treatment, which we prefer to call rehabilitation treatment. This latter category comprises different approaches, which are based on the severity of scoliosis. 

First of all, there is simple clinical observation (for very mild cases), then treatment based on specific self-correction exercises (for mild scoliosis), and finally bracing (for the treatment of moderate forms). The braces used can be elastic, rigid or super-rigid. The choice of brace type and the number of prescribed brace-wearing hours (treatment dose) are always determined by two key factors: the severity of the curve(s) and the risk of worsening.

Even though surgical techniques have improved enormously over the years, surgery for scoliosis always entails vertebral fusion, and thus a complete loss of mobility (function) of the section of the spine involved, which is transformed into a single bone. It is the most difficult surgery in orthopaedics (apart from surgery for severe poly-trauma), and naturally it carries all the risks that derive from the fact that the spine encases and protects the spinal cord, which contains all the connections between the brain and the lower limbs.  

Rehabilitation treatment, therefore, must always be considered the first-choice treatment for scoliosis. This even applies to “surgical curves” (i.e., those with a Cobb angle greater than 45°–50°), if no attempt has ever been made to correct them through full-time bracing and specific exercises (1). In short, surgical treatment is used only when rehabilitation treatment has failed.

What are we aiming to achieve through rehabilitation treatment?

Basically, we are aiming to obtain a back that is not only strong and efficient but also aesthetically pleasing. This is, indeed, one of our main objectives, given that a person’s quality of life is strongly influenced by how they see themselves physically. Therefore, a brace needs to be built in such a way as to reduce the external deformity as well as the magnitude (i.e., the Cobb degrees) of the curve(s). In this regard, it is very important to underline the importance of preventing scoliosis from worsening, especially in puberty when it is at the greatest risk of doing so. Reducing the Cobb degrees of a scoliotic curve is always an objective, but given that scoliosis in puberty almost always worsens unless it is treated properly, simply blocking the evolution of the condition must, in itself, be considered a successful result.

Through rehabilitation treatment, we also try to prevent the onset of back pain in adulthood. To this end, as well as treating any pain that occurs in childhood and adolescence, we also do our best to preserve, as far as possible, the physiological curves present in the sagittal plane. Several studies have shown that back pain in adults with scoliosis is highly correlated with abnormalities in the sagittal plane, even more so than with scoliotic curve magnitude (2). And unfortunately, over the years, scoliosis that exceeds certain levels tends to progressively worsen; as a result, for purely mechanical reasons, the trunk progressively falls forwards.

Finally, rehabilitation treatment aims to prevent the respiratory system problems that can arise due to progressive deformation of the rib cage in the presence of a severe thoracic curve.

All these objectives were extensively discussed, and identified as therapeutic priorities, by international experts from the International Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) during the drafting of the SOSORT Guidelines (3). 

(1) Lusini M, Donzelli S, Minnella S, Zaina F, Negrini S. Brace treatment is effective in idiopathic scoliosis over 45°: an observational prospective cohort controlled study. Spine J. 2014 Sep 1;14(9):1951-6. doi: 10.1016/j.spinee.2013.11.040. Epub 2013 Dec 1. PMID: 24295798.

(2) Diebo BG, Shah NV, Boachie-Adjei O, Zhu F, Rothenfluh DA, Paulino CB, Schwab FJ, Lafage V. Adult spinal deformity. Lancet. 2019 Jul 13;394(10193):160-172. doi: 10.1016/S0140-6736(19)31125-0. Epub 2019 Jul 11. PMID: 31305254.

(3) Negrini S, Donzelli S, Aulisa AG, Czaprowski D, Schreiber S, de Mauroy JC, Diers H, Grivas TB, Knott P, Kotwicki T, Lebel A, Marti C, Maruyama T, O’Brien J, Price N, Parent E, Rigo M, Romano M, Stikeleather L, Wynne J, Zaina F. 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis Spinal Disord. 2018 Jan 10;13:3. doi: 10.1186/s13013-017-0145-8. PMID: 29435499; PMCID: PMC5795289.

ISYQOL: Polish adaptation study published

The study Polish Adaptation of the Italian Spine Youth Quality of Life Questionnaire has just been published (Edyta Kinel, Krzysztof Korbel, Piotr Janusz, Mateusz Kozinoga, Dariusz Czaprowski, Thomas Kotwicki), developed by the University of Medical Science of Poznan and from Olsztyn University, Bydgoska for the adaptation of our Italian Spine Youth Quality of Life Questionnaire (ISYQOL) into Polish (ISYQOL-PL).

Recall that ISYQOL is the questionnaire developed by Isico that measures the health-related quality of life of adolescents with spinal deformities and has proved particularly appropriate in patients with adolescent idiopathic scoliosis (AIS) not treated surgically.
The questionnaire is available for free online on a dedicated website, where you can also find the English and Polish versions of the questionnaire:   https://www.isyqol.org

The study aimed to carry on the process of the cultural adaptation of the Italian Spine Youth Quality of Life Questionnaire (ISYQOL) into Polish (ISYQOL-PL). The prior hypothesis was: the ISYQOL-PL questionnaire is reliable and appropriate for adolescents with a spinal deformity. Fifty-six adolescents (mean age 13.8 ± 1.9) were enrolled.
The ISYQOL questionnaire is based on patients’ concerns and has been shown to be particularly appropriate in AIS and SJK patients undergoing non-surgical management. The ISYQOL is a 20 items questionnaire. The process of the cross-cultural adaptation of the ISYQOL-PL was performed following the guidelines set up by the International Quality of Life Assessment (IQOLA). The implementation of this method includes the following steps: forward translation, back-translation and expert panel, pre-testing and cognitive interviewing, development of the final version. The total sample size was decided based on previous recommendations for validation studies.

What about study’s conclusions? “The ISYQOL-PL is a brief and practical tool for quantifying HRQoL in adolescents with a spine deformity – comments the coordinator of the study, the spine surgeon Dr. Tomasz Kotwicki from the Department of Spine Disorders and Pediatric Orthopedics –  Filling in the questionnaire takes less than 10 minutes to be completed. The ISYQOL-PL questionnaire is reliable and can be used in adolescents with spinal deformities”. 

Full text available here:  https://pubmed.ncbi.nlm.nih.gov/34066225/

Simona’s story

Hi, I’m Simona, and, like many of you, I wear a back brace. My “brace-wearing” journey began some years ago. To be precise, it was 26 October 2017 when I got my first Lyon brace. How could I forget it?!

I had discovered my scoliosis in May that year, after suddenly realising, during a PE lesson one day, that there was something wrong with me. During a run, I felt a very sharp pain in my shoulders, so I stopped and asked my PE teacher what might be the reason.

 She asked me to bend forwards, and after checking me over and getting me to do some movements, she said I had one shoulder higher than the other.

After talking over the problem at length with my parents, we went to a hospital to see an orthopaedic specialist. Needless to say, it was a disaster, partly due to the doctor’s lack of empathy: according to him, I needed to wear a Milwaukee brace for 18 hours a day!

The first time I saw an X-ray of my back, I was shocked, as I hadn’t seen anything like it before. I felt like a freak, also because up until that point, I had never even heard of scoliosis. I had no idea what it was. After realising that this doctor would not be at all interested in helping me cope with the considerable psychological impact of having to wear a brace (and I could already see that this was going to be considerable), my parents and I decided it would be better to consult another doctor.

That is what we did, and we couldn’t have found a better one! He turned out to be the best doctor ever: from our very first meeting, he always wanted to hear my opinion, even though I was still only young.

Thanks to him, I was able to embark on this bracing adventure with much more peace of mind. He prescribed me a Lyon brace with a removable neck support (8 hours of wear per day) to treat my cervical spine too and a right shoe-lift. Since then, I have had two new braces and two new shoe-lifts, and the treatment has reduced my degrees of curvature considerably. 

I can’t deny that having to wear a brace still had a strong psychological impact on me, but with the help of my family, my physiotherapist and my doctor, I managed to cope. And even though it’s not over yet, I know that the worst part is now behind me.

 I am very proud of all that I have achieved. My message to anyone else who wears a brace, or needs to start wearing one, is this: wear it as much as you can, and always for all the hours your doctor tells you to! The reason I have improved so much is that I have always worn mine even more than I had to. You’ll probably be really amazed to learn this, but I have actually decided that I want to train to be an orthopaedic specialist one day! 

Yesterday, I told my doctor this, and he was surprised. But it’s true! He has always been so kind and understanding with me. Thanks to him, I have even grown quite fond of my “condition”!  So, make sure you find a good doctor, and above all, one who treats you not as a laboratory animal but as a person who needs more than just physical attention. One day I want to be able to help other people get through what I have been through, and I’m still going through. If I succeed, I’ll be really proud of myself! 

I know this is rather a long message, but I have been a reader of this blog for so long now. The doctors who write it have often given me the answers I needed, and since it has often helped lift my spirits in blacker moments, I decided I should now share my story in the hope of encouraging others too!