View
223
Download
3
Category
Preview:
Citation preview
Improving excellence in scoliosis rehabilitation: A controlled study ofmatched pairs
H.-R. WEISS, & R. KLEIN
Asklepios Katharina Schroth Spinal Deformities Rehabilitation Centre, Bad Sobernheim, Germany
AbstractObjectives: Physiotherapy programmes so far mainly address the lateral deformity of scoliosis, a few aim at the correction ofrotation and only very few address the sagittal profile. Meanwhile, there is evidence that correction forces applied in thesagittal plane are also able to correct the scoliotic deformity in the coronal and frontal planes. So it should be possible toimprove excellence in scoliosis rehabilitation by the implementation of exercises to correct the sagittal deformity in scoliosispatients. An exercise programme (physio-logic� exercises) aiming at a physiologic sagittal profile was developed to add to theprogramme applied at the centre or to replace certain exercises or exercising positions.Material and methods: To test the hypothesis that physio-logic� exercises improve the outcome of Scoliosis IntensiveRehabilitation (SIR), the following study design was chosen: Prospective controlled trial of pairs of patients with idiopathicscoliosis matched by sex, age, Cobb angle and curve pattern. There were 18 patients in the treatment group (SIRþ physio-logic� (exercises) and 18 patients in the control group (SIR only), all in matched pairs. Average Cobb angle in the treatmentgroup was 34.5� (SD 7.8) Cobb angle in the control group was 31.6� (SD 5.8). Age in the treatment group was at average15.3 years (SD 1.1) and in the control group 14.7 years (SD 1.3). Thirteen of the 18 patients in either group had a brace.Outcome parameter: average lateral deviation (mm), average surface rotation (�) and maximum Kyphosis angle (�) asevaluated with the help of surface topography (Formetric�-system).Results: Lateral deviation (mm) decreased significantly after the performance of the physio-logic� programme and highlysignificantly in the physio-logic� ADL posture; however, it was not significant after completion of the whole rehabilitationprogramme (2.3 vs 0.3 mm in the controls). Surface rotation improved at average 1.2� in the treatment group and 0.8� in thecontrols while Kyphosis angle did not improve in both groups.Discussion: The physio-logic� programme has to be regarded as a useful ‘add on’ to Scoliosis Rehabilitation with regardsto the lateral deviation of the scoliotic trunk. A longitudinal controlled study is necessary to evaluate the long-term effectof the physio-logic� programme also with the help of x-rays.
Keywords: Idiopathic scoliosis, rehabilitation, physiotherapy, schroth programme, physio-logic� programme
Introduction
Thoracic flatback has been assumed to be the
triggering factor for thoracic Idiopathic Scoliosis
[1–5]. So, if coupled rotation and lateral deviation of
the spine are secondary patterns of deformity in the
development of Idiopathic Scoliosis (IS), it should
be possible to correct or improve scoliosis by the
application of sagittal forces.
Flatback seems to be a major problem in the
treatment of patients with idiopathic scoliosis using
braces. It has been demonstrated that flatback may
be increased instead of corrected using several brac-
ing concepts [6]. There are also other studies to
support especially the Boston brace to reduce sagittal
curvatures of the spine and in a Pub Med search no
study has been found to support the opposite.
Boston braces, the Charleston bending brace and
most of the other types of scoliosis braces up to now
have no pressure points to address the sagittal profile
while in the last modifications of the original
Cheneau brace pressure points for the correction of
thoracic hypokyphosis were introduced [7].
Physiotherapy programmes so far mainly address
the lateral deformity of scoliosis [8–11], a few aim at
the correction of rotation [12–15] and only very
few address the sagittal profile [16–18], although
already before 1992 Negrini stated that the sagittal
deformation is also important to correct with the help
of exercises [19]. In some programmes, flatback is
addressed in extent; however, those programmes
failed to show good results [20]. All patients
Correspondence: Hans-Rudolf Weiss, MD, Asklepios Katharina Schroth Spinal Deformities Rehabilitation Centre, Korczakstr. 2, D-55566 Bad Sobernheim,
Germany. Tel: 0049 6751 874 151. Fax: 0049 6751 874 171. E-mail: weiss.scolio.aksk@t-online.de
Received 16 September 2004; accepted 1 February 2005
Pediatric Rehabilitation, Month?? 2005; 0(0): 1–11
ISSN 1363–8491 print/ISSN 1464–5270 online/??/???1–011 � Taylor & Francis Group Ltd
DOI: 10.1080/13638490500079583
+ 2005 style [10.3.2005–12:07pm] [1–11] [Page No. 1] First Proof {TandF}Tpdr/TPDR-107491.3d (TPDR) Paper: TPDR-107491 Keyword
in the treatment programme described got worse
within 1 year of regular treatment. So it seems not
reasonable to mobilize the scoliotic spine into a global
kyphosis.
In the Schroth programme, thoracic kyphosis is
addressed performing a special breathing technique
(Figure 1); however, in the exercising position the
flatback is clearly visible (Figure 2). The results of
the Schroth concept seem to be quite good and show
that progression can be prevented in many cases
[21–25]. So, the Schroth programme has developed
to be the gold standard of physiotherapy for the
treatment of scoliosis in many countries as well as for
Scoliosis Intensive Rehabilitation (SIR) [18].
Meanwhile, there is evidence that correction forces
applied in the sagittal plane are also able to correct
the scoliotic deformity in the coronal and frontal
planes [6]. In an experimental study comparing the
short time effect of two different braces it could be
shown that sagittal correction forces lead to similar
short-term corrections as can be measured with the
help of surface topography, as the 3D correction
brace at the moment gold standard in many
European countries.
Although the Schroth method addresses also the
sagittal plane in the long-term [17], the results
achieved in the experimental study lead to the idea
to improve excellence in scoliosis rehabilitation by
the implementation of exercises to correct the sagittal
deformity in scoliosis patients more powerfully. An
exercise programme was developed aiming at a
physiologic sagittal profile to add it to the pro-
gramme applied at the centre or to replace certain
exercises or exercising positions. The exercises of
this programme all have the same basic principle to
increase and so improve lumbar lordosis at L2 level
and lower thoracic kyphosis and are called physio-
logic� exercises. However, to finally implement it to
SIR it should first be shown to be effective in the
short-term.
Figure 1. Rotational breathing demonstrated in forward bending position. Breathing is directed dorsally and laterally as can be seen on the
right picture.
Figure 2. Typical Schroth exercise in standing position on the left, flatback clearly visible and is only corrected by rotational breathing
in this position, right in prone position with a roll underneath the ribs to correct flatback.
2 H.-R. Weiss and R. Klein
+ 2005 style [10.3.2005–12:07pm] [1–11] [Page No. 2] First Proof {TandF}Tpdr/TPDR-107491.3d (TPDR) Paper: TPDR-107491 Keyword
Materials and methods
To test the hypothesis that physio-logic� exercises
improve the outcome of SIR, the following study
design was chosen: Prospective controlled trial of
pairs of patients with idiopathic scoliosis matched by
sex, age, Cobb angle and curve pattern. Outcome
parameter: average lateral deviation (mm), average
surface rotation (�) and maximum Kyphosis angle (�)
as evaluated with the help of surface topography
(Formetric�-system).
Treatment group
In July 2004, 20 consecutive patients with adolescent
idiopathic scoliosis between 13–17 years old were
asked to take part in the study. They were all females
and were admitted regularly for an inpatient rehabi-
litation programme of minimum 4 weeks. All 20
patients and their parents agreed to take part in the
study. Curve magnitude (Cobb angle) and curve
pattern (King classification) were recorded.
The patients of this group had a regular inpatient
rehabilitation programme as prescribed and addi-
tionally in the second or third week of their 4-week-
programme five times 90 minutes of the new exercise
programme called physio-logic�. The experimental
design was arranged in a fashion that all the subjects
in either subject group had similar exercise hours/
day. There might have been different responses
among the subjects in the physio-logic� group as the
subjects had different periods of the intervention of
the physio-logic exercises (either at the 2nd or 3rd
week of the programme); however, as is needed
20 subjects with certain inclusion criteria given to be
treated during the same time as the control group
saw no other way to perform this study.
For this study group, surface topography was
performed before and after the 4-week-programme
as usual and additionally directly after the perfor-
mance of the 1-week physio-logic� programme.
Additionally to that, the physio-logic� ADL posture
trained at that week was tested with the help of the
Formetric surface topography system as well.
Control group
To be able to establish a control group of biggest
homogeneity possible, one chose to take the matched
pair technique. One was looking for another 20
patients having inpatient rehabilitation at the same
time before applying physio-logic� exercises for the
treatment group. The patients of the control group
were matched by age, curve magnitude and curve
pattern in a way that in the end for every patient
from the treatment group had another patient in
the control group of similar curve pattern, curve
magnitude (�5�) and age (�1 year). All patients in
either group were female.
While the treatment group had the Schroth
inpatient rehabilitation programme as routinely
performed at the centre and an additional week
with 90 minutes of physio-logic exercises per day,
the control group only had the Schroth inpatient
rehabilitation programme as described in literature
[18]. As usual, the control group was investigated
by use of surface topography before and after
rehabilitation.
During the first 2 days performing the physio-
logic� programme two of the patients from the
treatment group cancelled their attendance.
Therefore, the patients were also removed from the
control group matched individually. In the end, there
were 18 patients in the treatment group and 18
patients in the control group as well all in matched
pairs. Average Cobb angle in the treatment group
was 34.5� (SD 7.8) Cobb angle in the control group
was 31.6� (SD 5.8). Age in the treatment group was
at average 15.3 years (SD 1.1) and in the control
group 14.7 years (SD 1.3). Thirteen of the 18
patients in either group had a brace.
Scoliosis intensive rehabilitation (SIR)
SIR employs an individualized exercise programme
combining corrective behavioural patterns with
physiotherapeutic methods, following principles
described by Lehnert-Schroth [12]. The three-
dimensional scoliosis treatment is based on senso-
motor and kinesthetic principles and its goals are
(1) to facilitate correction of the asymmetric posture
and (2) to teach the patient to maintain the corrected
posture in daily activities.
Referrals are from spine centres, general ortho-
paedic surgeons, paediatric physicians and general
practitioners. A 4-week minimum stay is required
for the first treatment and may be up to 6 weeks,
depending on prognosis; return treatments are 3–6
weeks in length, depending on symptoms and
prognosis. Patients are admitted in groups, with
the first day of the programme devoted to diagnosis
and evaluation of the three dimensional deformity,
supervized by seven staff physicians (one orthopaedic
surgeon and six general practitioners or specialists
for Physical Medicine and Rehabilitation) who also
provide oversight for each patient’s programme. On
the second day, instruction in basic human anatomy,
spinal deformity and principles of postural balancing
therapy is provided to the group. Each patient
receives a detailed summary of his/her own con-
dition and those with matching diagnoses (based
on age, degree and pattern of curvature) work
together in groups. Evening and weekend social
activities provide a sense of community and foster
A controlled study of matched pairs 3
+ 2005 style [10.3.2005–12:07pm] [1–11] [Page No. 3] First Proof {TandF}Tpdr/TPDR-107491.3d (TPDR) Paper: TPDR-107491 Keyword
development of psychological support systems that
can be maintained after treatment is complete.
The treatment programme consists of correction
of the scoliotic posture with the help of proprio-
ceptive and exteroceptive stimulation and begins on
the third day after admission. Each weekday, after a
20-minute group warm-up session, the patients exer-
cise in matched groups for 2 hours in the morning
and 2 hours in the afternoon and receive shorter
more individual training sessions in between. Central
to the individual and group exercise programmes
is therapist assistance, by a staff of 20 physical
therapists and sports therapists who supervize all
exercises and provide exteroceptive stimulation
needed to obtain desired correction. Depending on
individual curve patterns, the patients are assigned
to special exercise groups for an additional 2 hours
daily. Development and maintenance of the cor-
rected posture is facilitated using asymmetric stand-
ing exercises designed to employ targeted traction
to restore torso balance and mobility.
The correction is supported by ‘rotational breath-
ing’ exercises, an integral part of the regime: By
selective contraction of convex areas of the trunk, the
inspired air is directed to the concave areas of the
chest and the ribs to lengthen and mobilize soft
tissues in these regions. Female patients wear bikini
tops during all sessions and ceiling and wall mirrors
enable the patients to self-monitor progress at all
times during standing and floor exercises; this
practice facilitates optimum correction during exer-
cises and fosters patient proprioception of a balanced
posture. Four full time massage therapists provide
bi-weekly mobilization therapy for each patient,
using myofascial release, manual traction, ischemic
pressure and pressure point therapy. Two full-time
respiratory therapists meet weekly with each patient
to monitor vital capacity and to provide training in
corrected breathing patterns. Psychological counsel-
ling is provided by two staff psychologists to help
patients cope with feelings about the diagnosis of
deformity as well as the impact of treatment, as
needed; patients can request individual psycho-
therapy in response to anxiety, depression or other
psychological distress. Optional evening group ses-
sions devoted to relaxation therapies including
meditation and visualization approaches are also
available. Osteopathic manipulation and acupunc-
ture by staff therapists are available to treat pain as
needed, upon request by the patient.
At the end of in-patient treatment, the primary
goal is for patients to be able to assume their personal
corrected postural stereotype, independent of the
therapist and without mirror control and to maintain
this position in their daily activities. Recommended
at-home follow-up treatment includes three to four
exercises for 30 minutes daily in order to maintain
the improved postural balance. Therapists through-
out Germany receive training in the Schroth Clinic
approaches so that local outpatient resources are
available to patients after discharge. In case of pain,
curvature progression or pulmonary symptom devel-
opment repeat SIR treatment is available by referral
from primary care physicians.
The physio-logic� exercise programme
Within the physio-logic� exercise programme, one
provides
1. Symmetric mobilizing exercises to improve lor-
dosing mobility of the lumbar spine and kyphos-
ing mobility of the thoracic spine;
2. Asymmetric exercises to improve postural correc-
tions also in frontal and coronal plane; and
3. The physio-logic� ADL posture
The symmetric mobilizing exercises are performed
repeatedly. Those exercises can only be performed
with the help of postural reflexes. First, lumbar
lordosis is empowered actively and the pelvis is tilted
forward while the upper trunk is reclined backwards
to improve thoracic kyphosis reflectorily.
It is not the aim of the exercises to increase lumbar
lordosis at the L5/S1 level for this region is
responding with unspecified low back pain when
stressed. Therefore, one aims at a lordosis at the L2
level. One can enforce the exactness of the exercise
by ventralizing the lower ribbows (Figure 3).
For the asymmetric postural correction in 3D, one
can use exercises from the Schroth programme
modified due to the principles of the physio-logic�
exercise programme (Figure 4).
Activities of daily living (ADL) are very important
to change postural stereotype and for this reason the
physio-logic� ADL posture is trained in standing and
walking (Figures 5 and 6). Therefore, the patients
are trained to perform the ‘Catwalk’ which includes
the basic principles of the physio-logic� programme
addressing the sagittal plane (Figure 5) and the ADL
(Activities of daily living) posture called ‘Nuba’-
position. This position is derived from the normal
upright standing and walking position the Nuba
(people from North Africa) perform usually.
Actually there is no angle and possible range of
thoracic kyphosis and lumbar lordosis defined to
perform or maintain in the physio-logic� exercises.
Muscle groups involved for the exercise action are
not identified yet. This might be subject to further
investigation.
Surface topography system used for this study
The print-out of the Formetric�-system itself
gives a lot of values, the most important are the
4 H.-R. Weiss and R. Klein
Figure 3. Left: Lordosing exercise with the risk of low back pain due to L5/S1 stress. Right: Ventralization of the lower ventral ribs
to improve Lordosis at L2 level, where it naturally belongs [http:\\www.leni-riefenstahl.de\eng\dienubav\1.html]. In this position L5\S1 stress
is reduced.
Figure 4. Schroth exercise (see also Figure 2) changed to physio-logic� style. Lumbar lordosing and thoracic with increased kyphosis.
A controlled study of matched pairs 5
Figure 5. Physio-logic� ADL posture in standing position. Lumbar lordosis is increased, pelvis is corrected to the opposite side of
deformity while the hand on the lumbar hump helps to redress the lumbar curve. It is also possible to redress the ventral ribhump with the
other hand (right).
Figure 6. Catwalk’ with the patients from the treatment group. Ventralizing the lower ribs is important to reduce L5/S1 stress and
so the possibility of low back pain.
6 H.-R. Weiss and R. Klein
following: Lateral asymmetry, surface rotation and
kyphotic angle.
In the video rasterstereography (Formetric�-
system), the whole object is illuminated by a pattern
of parallel lines, recorded in a single frame and
needing only a short measurement time (40 milli-
seconds). The automatic image processing consists
of the identification of the raster lines and automatic
3-D reconstruction of the back; shape analysis is
performed by a mini computer. The computer helps
to evaluate the spine with the assistance of trian-
gulation [26, 27]. The video rasterstereography
(Formetric�-system) has a point discrimination of
0.15 mm and in a typical case of measurement
25 000 surface points are calculated (Figure 7).
Parameters used to compare the short-term effects
of the different treatment concepts described were
average lateral deformation (root mean square, rms)
with a technical error of 3 mm, average surface
rotation (rms) with a technical error of 1.5� and
average kyphosis angle with a technical error of
2.5� as measured and calculated by the Formetric�
surface topography system [28–30].
The surface topography values for the treatment
group were compared as follows: The values after
the treatment were compared with respect to the first
value before treatment as were the values directly
after performing the physio-logic� programme and
in the physio-logic� ADL position. In the control
group, the pre-treatment values were compared to
the post-treatment values in the same way. The
surface topography values were compared statisti-
cally using Winstart� Software.
Results
The Formetric� values Lateral Deviation in mm,
Surface Rotation in � and Kyphosis Angle in � before
Scoliosis Intensive Rehabilitation (SIR), after SIR,
after 5� 90 minutes performing the physio-logic�
programme (PL) and in the physio-logic� ADL
position (ADL) for the treatment group as well as
for the control group can be seen in Table I.
The difference between Lateral Deviation before/
after SIR, before SIR/after performing the physio-
logic� programme (PL) and before SIR/in the
Figure 7. Printout of the Formetric�-system (left: frontal view with lateral deviation of the trunk, right: lateral view showing a flatback
without a sign of thoracic kyphosis or lumbar lordosis).
A controlled study of matched pairs 7
physio-logic� ADL position (ADL) for the treatment
and the control group is documented in Table II and
Figure 8.
The only significant change in the control group
was the improvement of Surface Rotation (�0.75�,
p¼ 0.015) compared to the improvement before/
after SIR (�1.2�, p¼ 0.1) which, however, was not
significant (Figure 9).
Interestingly, the physio-logic� programme itself
did not have an impact on Surface Rotation directly
after the programme was applied in the physio-logic�
ADL position. However, Lateral Deviation was
changed significantly in the treatment group com-
pared to the control group. Kyphosis Angle was only
changed slightly with a tendency to decrease instead
of the expected increase (Figure 10).
Discussion
Video rasterstereography (Formetric�-system) has
been used for the evaluation of brace and physio-
therapy effects [31–35]. Although there are certain
limitations to respect, it has been demonstrated that
certain exercises tend to improve scoliosis as well
as kyphosis in the short-term [32–35]. While in
Scheuermann’s kyphosis the degree of curvature
decreased significantly after in patient rehabilitation
[34], there is no evidence for the short-term effect of
exercises on the flatback related to IS [32, 33, 35].
However, there is evidence that the Schroth phy-
siotherapy programme as well as the Cheneau brace
are able to correct thoracic flatback in the long-term
[17, 31].
Table I. Lateral deviation in mm, surface rotation in � and Kyphosis angle in � before Scoliosis Intensive
Rehabilitation (SIR), after SIR, after 5� 90 minutes performing the physio-logic� programme (PL) and in the
physio-logic� ADL position (ADL) for the treatment group as well as for the control group.
Before SIR After PL ADL After SIR
Treatment group
Lateral deviation (mm) 15.4 (SD 5.1) 13.1 (SD 5.9) 11.0 (SD 5.1) 13.1 (SD 5.0)
Surface rotation (�) 7.4 (SD 2.7) 7.0 (SD 2.5) 7.1 (SD 3.1) 6.2 (SD 1.8)
Kyphosis angle (�) 46.5 (SD 8.0) 42.1 (SD 8.2) 39.0 (SD 9.3) 45.8 (SD 7.7)
Control group
Lateral deviation (mm) 13.5 (SD 6.8) 13.1 (SD 6.2)
Surface rotation (�) 7.3 (SD 2.4) 6.5 (SD 2.3)
Kyphosis angle (�) 48.8 (SD 11.0) 46.8 (SD 10.2)
Before SIR/after PL
Before SIR/inADL
Before SIR/after SIR
Before SIR/after SIR
0
2
4
6
Average LateralDeviation in mm
Figure 8. Average lateral deviation changes in the treatment group
(first three columns) compared to the control group (solid
column). The improvements are better for the SIRþphysio-
logic� group and significant.
Before SIR/after PL
Before SIR/inADL
Before SIR/after SIR
Before SIR/after SIR
0
0.5
1
1.5
Average surfaceRotation in °
Figure 9. Average surface rotation changes in the treatment group
(first three columns) compared to the control group (solid
column). The improvements are better for the SIRþ physio-
logic� group after SIR; however, not significant.
Table II. Difference between lateral deviation before/after SIR,
before SIR/after performing the physio-logic� programme (PL)
and before SIR/in the physio-logic� ADL position (ADL) for the
treatment and the control group.
Lateral deviation
(mm)
Average
difference T-value p
Treatment
group
Before SIR/
after PL
2.32 (SD 3.8) 2.6 0.02
Before SIR/
in ADL
4.38 (SD 4.7) 3.9 0.001
Before SIR/
after SIR
2.31 (SD 5.6) 1.8 0.1
Control
group
Before SIR/
after SIR
0.32 (SD 2.5) 0.54 0.6
8 H.-R. Weiss and R. Klein
In this study, Lateral Deviation was significantly
improved in the treatment group (SIRþ physio-
logic�), especially directly after the performance of
the physio-logic� programme and in the physio-
logic� ADL position. The control group (SIR)
showed no significant changes.
In the preceding studies, Surface Rotation did not
change significantly [32, 33]; however, in the control
group significant improvements were found which,
however, were lower than in the treatment group
but in this group not significant.
Kyphosis Angle decreased in both groups, sig-
nificantly in the treatment group and not significant
in the control group although the physio-logic�
programme aims at an increase of thoracic kyphosis,
as can be seen in Figures 3–6. The hypothesis is that
in the development of IS the sagittal deformity comes
first and though is the stiffest component of the 3D
deformity. Secondly, trunk torsion appears which is
also more stiff than lateral deformation that seems to
be the least stiff part of the 3D deformity and so in
the short-term the best correctable. This theory is
supported in a controlled study by the fact that it is
possible to correct flatback by the exercises of the
SIR programme in the long-term [17]. Another
theory is that the measured value may not fully reflect
the actual skeletal curvatures. It seems that the
measured thoracic kyphosis is relatively normal but
not having hypo-kyphosis because the Formetric�-
system measures kyphosis not in the standard range
(T4; most tilted vertebra in the lower end of the
curve).
Of course, one has to take into account the
technical error of the Formetric�-system, which is
bigger than the average changes provided by the
exercise programmes. Only in the physio-logic�
ADL position the improvement of lateral
Deformity exceeded 3 mm (regarded as the technical
error due to postural sway of the patients [28]).
However, differences are found that are at least in
part statistically significant comparing the two groups
and also medically relevant differences justifying
conclusions. One has, of course, to accept that
there are limitations of this study due to the relatively
big technical error of the measuring system (15–20%
for Lateral Deviation and Surface Rotation; 5% for
Kyphosis Angle [28–30]); however, postural sway
cannot be regarded as a systematic error and,
therefore, one would expect small changes not to
be registered with the help of this device, whereas
clear tendencies or significant changes erase from the
general variability and so are medically relevant. On
the other hand, there is no other device to measure
the effects of exercises in short-term objectively other
than x-rays not suitable for a study of this design
because of the exposition to radiation.
Either subject group itself was not totally homo-
genous. Some subjects were under a mixture of brace
treatment and physical exercise treatment but some
were with physical exercise treatment only. During
SIR, the braces are worn in the evening and during
night time, while during daytime there are exercises
to be performed for �6 hours.
As the proportion of patients with a brace was the
same in both groups, brace wearing should not have
an influence on the results. Rigo et al. [35]
recognized that brace treatment does not affect the
results of the 4 weeks exercise programme obtained
with the Formetric�-system.
It has been emphasized that brace loads are not
applied in an optimal way to correct the 3-D
deformities associated with thoracic idiopathic sco-
liosis and that loads applied on the posterior rib
hump should be re-equilibrated to reduce anterior
displacement of the trunk [36]. This is what has been
found in an experimental study as well where it has
been demonstrated that a brace designed to correct
sagittal profile may only also correct scoliosis in 3D
[6]. So the same principles seem reasonable to be
applied in postural re-education and correction using
exercises as well.
From experience, one has no explanation for the
fact that hypokyphosis in the short-term could not
be corrected by the physiotherapy programmes
described, although both apply a 3-point pressure
in the sagittal plane. The same applies for braces
correcting the sagittal planes directly [6]. The
hypothesis is that in IS the sagittal deformity is the
primary problem. This theory is supported by quite
a number of studies [1–4, 37]. The deformity in the
sagittal plane, though, may be the stiffest and,
therefore, not as easy to correct as the deformities
in the other planes.
Before SIR/after PL
Before SIR/inADL
Before SIR/after SIR
Before SIR/after SIR
0
5
10
Max. KyphosisAngle in °
Figure 10. Max. Kyphosis angle changes in the treatment group
(first three columns) compared to the control group (solid
column). The decreases are bigger for the SIRþphysio-logic�
group (significant) than for the SIR group (not significant).
Interestingly, the mobilization into a thoracic Kyphosis seems to
increase flatback reflectorily in short-term. Treatment and control
group showed changes in the same direction.
A controlled study of matched pairs 9
Conclusions
The physio-logic� programme has to be regarded as
a useful ‘add on’ to Scoliosis Intensive Rehabilitation
(SIR) with regards to the lateral deviation of the
scoliotic trunk. The physio-logic� ADL position
corrects lateral deviation of the scoliotic trunk not
only highly significant but also on average more than
the technical error of the measuring system and so
should be trained regularly during SIR.
A longitudinal controlled study is necessary to
evaluate the long-term effect of the the physio-logic�
programme also with the help of x-rays.
References
[1] Deacon P, Flood BM, Dickson RA. Idiopathic scoliosis in
three dimensions: a radiographic and morphometric analysis.
Journal of Bone and Joint Surgery 1984;66-B:509–512.
[2] Tomaschewski R. Die funktionelle Behandlung der begin-
nenden idiopathischen Skoliose. Habilitation thesis, Halle,
1987.
[3] Weiss HR, Lauf R. Impairment of forward flexion—
physiological or the precursor of spinal deformity In:
D’Amico M, Merolli A, Santambrogio GC, editors Three
dimensional analysis of spinal deformities. Amsterdam: IOS
Press; 1995. p 307–312.
[4] Burwell RG. Aetiology of idiopathic scoliosis: Current
concepts. Pediatric Rehabilitation 2 22 2;6:137–170.
[5] Raso VJ. Biomechanical factors in the etiology of idiopathic
scoliosis. Spine: State of the Art Reviews 2000;14:335–338.
[6] Weiss HR, Dallmayer R, Gallo D. Sagittal counter forces
(SCF) in the treatment of idiopathic scoliosis: a preliminary
report. Pediatric Rehabilitation; in press.
[7] Rigo M, Weiss HR. Korsettversorgungsstrategien in der
Skoliosebehandlung. In: Weiss HR, editor. Wirbelsaulende-
formitaten, konservatives management. Munchen: Pflaum;
2003. p 251–287.
[8] Klapp R. Funktionelle behandlung der skoliose. Jena:
Fischer; 1907.
[9] Niederhoffer L. Die behandlung von ruckgratverkrummun-
gen (Skoliose) nach dem system niederhoffer. Berlin:
Osterwieck; 1942.
[10] Ozarcuk L. Grundlagen der skoliosebehandlung mit der
propriozeptiven Neuromuskularen fazilitation. In: Weiss HR,
editor. Wirbelsaulendeformitaten. Vol. 3. Stuttgart: Gustav
Fischer Verlag; 1994. p 11–30.
[11] Weiss HR. Peripher evozierte haltungsreaktionen: Erste
erfahrungen. In: Weiss HR, editor. Wirbelsaulendeformita-
ten. Vol. 3. Stuttgart: Gustav Fischer Verlag; 1994. p 53–58.
[12] Lehnert-Schroth C. Dreidimensionale skoliosebehandlung.
5. Auflage. Stuttgart: Fischer; 1998.
[13] Klisic P, Nikolic Z. Attitudes scoliotiques et scolioses
idiopathiques: prevention a l’ecole. Personal communication.
Journees Internationales sur la prevention des scolioses a
l’age scolaire. Rome; 1982.
[14] Mollon G, Rodot JC. Scolioses structurales mineures et
kinesitherapie. Etude statistique comparative et resultats.
Kinesither Scient 1986;244:47–56.
[15] Rigo M, Quera-Salva G, Puigdevall N. Effect of the exclusive
employment of physiotherapy in patients with idiopathic
scoliosis. Retrospective study. In: Proceedings of the
11th International Congress of the World Confederation
For Physical Therapy. London, 28 July–2 August 1991.
p 1319–1321.
[16] Tomaschewski R. Die fruhbehandlung der beginnenden
idiopathischen skoliose. In: Weiss HR, editor.
Wirbelsaulendeformitaten. Vol. 2. Stuttgart: Gustav Fischer
Verlag; 1992. p 51–58.
[17] Rigo M, Quera-Salva G, Puigdevall N. Auswirkungen der
schrothschen dreh-winkel atmung auf die dreidimensionale
verformung bei idiopathische thorakalskoliose. In: Weiss HR,
editor. Wirbelsaulendeformitaten. Vol. 3. Stuttgart: Gustav
Fischer Verlag; 1994. p 87–92.
[18] Weiss HR, Rigo M. Befundgerechte physiotherapie bei
sSkoliose. Munchen: Pflaum; 2001.
[19] Negrini A. Forschungsdaten und ihre konsequenzen fur die
krankengymnastik. In: Weiss HR, editor. Wirbelsaulendefor-
mitaten. Vol. 2. Stuttgart: Gustav Fischer Verlag; 1992.
p 85–88.
[20] Duconge P. Der skoliotische flachrucken. Krankengymnas-
tische therapieansatze. In: Weiss HR, editor. Wirbelsaulen-
deformitaten. Vol. 2. Stuttgart: Gustav Fischer Verlag; 1992.
p 63–64.
[21] Weiss HR. Influence of an in-patient exercise program on
scoliotic curve. Italian Journal of Orthopaedics and
Traumatology 1992;3:2 2––2 2.
[22] Weiss HR, Lohschmidt K, El Obeidi N, Verres Ch.
Preliminary results and worst-case analysis of in-
patient scoliosis rehabilitation. Pediatric Rehabilitation
1997;1:35–40.
[23] Weiss HR, Weiss G, Petermann F. Incidence of curvature
progression in idiopathic scoliosis patients treated with
scoliosis in-patient rehabilitation (SIR): an age- and sex-
matched controlled study. Pediatric Rehabilitation
2003;6:23–30.
[24] Weiss HR, Weiss G, Schaar HJ. Incidence of surgery in
conservatively treated patients with scoliosis. Pediatric
Rehabilitation 2003;6:111–118.
[25] Rigo M, Reiter Ch, Weiss HR. Effect of conservative
management on the prevalence of surgery in patients with
adolescent idiopathic scoliosis. Pediatric Rehabilitation
2003;6:209–214.
[26] Drerup B. Die form der skoliotischen wirbelsaule.
Vermessung und mathematische von standard-rontgenauf-
nahmen. Stuttgart: Fischer; 1993.
[27] Liljenqvist U, Halm H, Hierholzer E, Weiland M. 3-dimen-
sional surface measurement of spinal deformities with
video rasterstereography. Z Orthop Ihre Grenzgeb
1998;136:57–64.
[28] Weiss HR, Lohschmidt K, El Obeidi N. The automated
surface measurement of the trunk—technical error. In:
Sevastik JA, Diab KM, editors. Research into spinal
deformities 1. Amsterdam: IOS Press; 1997. p 305–308.
[29] Weiss HR, Lohschmidt K, El Obeidi N. Trunk deformity in
relation to breathing—a comparative analysis with the
formetric system. In: Sevastik JA, Diab KM, editors.
Research into spinal deformities 1. Amsterdam: IOS Press;
1997. p 323–326.
[30] Weiss HR, Verres C. Der einsatz von oberflachenvermes-
sungssystemen zur beurteilung von haltungsstorungen und
kyphosen. Orthopadische Praxis 1998;34:765–769.
[31] Rigo M. 3D correction of trunk deformity in patients with
idiopathic scoliosis using Cheneau brace. In: Stokes IAF,
editor. Research into spinal deformities 2. Amsterdam: IOS
Press; 1999. p 362–365.
[32] Weiss HR. Ergebnisqualitatsanalyse der rehabilitation von
patienten mit wirbelsaulendeformitaten durch objektive
analyse der ruckenform. Orthop Prax 1998;34:770–775.
[33] Weiss HR. Ermittlung der ergebnisqualitat der rehabilitation
von patienten mit wirbelsaulendeformitaten durch
objektive analyse der ruckenform. Phys Rehab Kur Med
1999;9:41–4799.
10 H.-R. Weiss and R. Klein
[34] Weiss HR, Dieckmann J, Gerner J. The practical use of sur-
face topography: following up patients with Scheuermann’s
disease. Pediatric Rehabilitation 2003;6:39–45.
[35] Rigo M, Quera G, Puigdevall N, Corbella C, Gil MJ,
Martinez S, Villagrasa M. Biomechanics of specific exercises
to correct scoliosis in 3D. Pediatric Rehabilitation 2004;
7:53–54.
[36] Aubin CE, Dansereau J, de Guise JA, Labelle H.
Rib cage-spine coupling patterns involved in brace treatment
of adolescent idiopathic scoliosis. Spine 1997;22:629–635.
[37] Millner PA, Dickson RA. Idiopathic scoliosis: bio-
mechanics and biology. European Spine Journal 1996;
5:362–373.
A controlled study of matched pairs 11
AUTHOR QUERIES Journal id: TPDR-107491
Query number Query
111111
1 Please provide year of publication 2 Please update 3 Please provide Journal title in full 4 Please provide page numbers
Recommended