Physiotherapy Scoliosis Specific Exercises (PSSE) - … PSSE - SOSORT 2015... · 2017-05-15Physiotherapy Scoliosis Specific Exercises (PSSE) - SOSORT Lyon

Physiotherapy Scoliosis Specific Exercises

(PSSE)

Scoliosis Schools Around the World

Hagit Berdishevsky PT, DPT, Cert. MDT, Schroth & BSPTS Scoliosis Therapist and Teacher Trainer

Ghana mission, 2008

The Schools:

1. Barcelona Scoliosis Physical Therapy School (BSPTS)

2. Schroth asklepios (Germany)

3. Scientific Exercise Approach to Scoliosis - SEAS (Italy)

4. Functional individual therapy of scoliosis - FITS (Poland)

5. Side shift (UK)

6. The Lyon approach (Franch)

7. Dobomed (Poland)

Acknowledgements

Dr. Manuel Rigo

Josette Bettany-Saltikov

Monica Villagrasa

Jean Claude De Mauroy

Axel Hennes

Michele Romano

Marianna Bialek

Tony Betts

Jacek Durmala

Columbia University

Objectives

Objectives are for all schools presented here:

1. History

2. General definition of the treatment

3. Classification system

4. Treatment indications and goals

5. Treatment according to age

6. Principles of the method

7. Treatment tools active and passive (mobilization, US, tissue release,

mirror, computer, video…)

8. Description of the best exercises and their mechanics

9. ADL integration

10. Scientific support

The mission is one: not to straighten the spine

but to treat the patient. The journey

may be slightly different - depending on the

school.

School’s Mission #1 Treating the Patient

School’s Mission #2

The Team Approach” (Rehabilitation)

Doctor

Family

Physical

Therapist

Orthotist Speak the same language, involve the

patient and family

Physiotherapy Scoliosis Specific Exercises

(PSSE)

- SOSORT uses the term PSSE in connection with all of the

schools represented within the organization.

- The differences between the schools relate to the specific

exercises used by each school.

Evolution of Change

All schools report to use 3D active

correction to treat the scoliosis deformity.

A true 3D corrections in the sagittal,

frontal and transversal plane done

simultaneously.

Three Dimensional Active correction

BARCELONA SCOLIOSIS

PHYSICAL THERAPY SCHOOL

(BSPTS)

SPAIN

http://www.bspts.net

ALSO USED IN:

USA

ISRAEL

HOLLAND

History

BSPTS fully approved by Christa Lehnert Schroth

“3-D Treatment of Scoliosis According

to the Principles from K.Schroth and

C.L.Schroth”

109

In 4C we will be able to correct pelvis translation and trunk imbalance but not to overcorrect.

The third pelvis correction in 4C It is about centering the pelvis on the polygon of sustentation (translation of the pelvis from the packet side to the center) in combination with the best possible correction of the frontal plane imbalance from the correction to medial of the lumbar/tl curve. From a biomechanical point of view, the lumbar/tl curve should be first derotated before being brought to the midline (from convexities detorsion is produced first with derotation and then with deflection). Thus, 3rd pelvis correction has to performed with some degree of self-elongation and correction of the lumbar/tl curve forward and inwards. At the same time pelvis is centered with the third pelvis correction, it has to be derotated and leveled. This would be the equivalent of the 4 th and 5th pelvis corrections but from a practical point of view we do not use here the terms 4th and 5th pelvis correction during training but we just say ‘third pelvis correction’ meaning that centering the pelvis goes always coupled with derotation until 0º and level. It is easier than it resembles, it is about bring the pelvis ‘centered, non-rotated, non-tilted’.

When performing the 3rd pelvis correction the subject must avoid the main thoracic block to translate to the packet side. The main thoracic block has to be re-centered on the lumbar/tl block.

1968

History

Elena Salvá PT

- Elena Salva, PT

- Friends with Schroths – trained with

them

- Initiated Schroth in Barcelona - 1968

- Continued by Dr. Gloria Quera-Salva

(Daughter of Elena) MD/DO

Manuel Rigo, MD

- Dr. Manuel Rigo, MD

- Current Director – ‘Institute Elena Salva’

- Husband of Dr. Gloria Quera-Salva

- Trained in Sobernheim with Schroths

- Continued Schroth in Barcelona - 1989

- Initiated Schroth PT courses in English

- Training in Spain, Israel, Netherlands and USA

Definition of Treatment

Active Therapeutic Exercises:

Cognitive, sensory-motor and kinesthetic training is

used to teach the patient to improve her/his

posture based on the assumption that scoliosis

posture promotes curve progression.

According to the literature and from a neurophysiological perspective, active movement is much better than passive one to learn neuro-motor behaviours such as posture.

Obviously, once accepted that posture is not only a matter of anatomy but also of neuro-motorialbehaviour)

Classification System

SRS definition of curves. SRS classification by age

of onset. Curve Apex

Upper Thoracic T3-4-5

Thoracic T2-11 or

(Disc T11-12)

Lumbar L2-4 or

(Disc L1-2)

Thoracolumbar T12-L1

Lumbosacral L5-S1 or

(Disc L4-5)

classification Age of onset

IIS <3y

JIS 3-10y

AIS > 10y


Schroth groups: Schroth blocks

Deformity in sagittal plane onlyGroup 1 (G1):

- Hyper-kyphosis (Schuermann)

- Lordosis (Inverted back)

Deformity in 3 planes: scoliosis

Group 1-2 (G1-2):- Thoraco-lumbar/Lumbar

Group 2 (G2):- 3 curve

- 4 curve

- Non-3 Non-4 (w/ or w/o lumbar)

80

Group 2: From clinical observation to Schroth-theory (3C, 4C, N3N4)

When a primary structural thoracic scoliosis develops in the main thoracic region (right

convex in the example), two secondary curves appears to compensate caudal and cranially. The compensatory curves can be functional or become rapidly structural. Both

caudal and cranial curves could be even primary, so appearing at the same time than the

main thoracic curve, but in the case of the lumbar curve it will remain always the minor

curve in comparison with the major main thoracic curve, and coupled to the pelvis. The Main Thoracic Region appears translated and rotated to right whilst in opposition the

lumbo-pelvic region appears translated and rotates to the left (observing the whole body

pelvis looks translated and rotated to the left according the polygon of sustentation). Thus, the main and upper trunk looks imbalanced to the right according to the lower trunk and

pelvis, although the proximal thoracic region is also rotated and translated to the left in relationship to the main thoracic region. The body is collapsed in the correspondent concavities and expanded in the convexities. As a whole, the trunk, including the pelvis,

could be virtually divided in three blocks or sections, which are translated and rotated one

against the other, collapsed in the concavities and expanded in the convexities. The three

blocks or sections are called, from caudal to cranial:

a) Pelvic girdle block: It includes the lumbar curve so it can be also called ‘lumbo-

pelvic block’. It appears translated and rotated to the left in a right thoracic scoliosis. It appears collapsed on the right side - floating ribs are affected by the collapse- and

prominent on the left.

b) Ribs’ block: It includes the main thoracic curve and region so it can be also called ‘main thoracic block’. It appears translated and rotated to the right in a right thoracic scoliosis. It appears collapsed on the left ad prominent on the right. This affects the

scapular angles.

c) Shoulder girdle block: It includes the proximal thoracic region - with most part of the scapulae- coupled to the cervical spine when this compensation is just functional

and T1 appears tilted to the left or horizontal. When there is a structural proximal

curve the block includes only the proximal thoracic region, uncoupled from the cervical spine.

80









pelvis, although the proximal thoracic region is also rotated and translated to the left in

relationship to the main thoracic region. The body is collapsed in the correspondent concavities and expanded in the convexities. As a whole, the trunk, including the pelvis,






prominent on the left. b) Ribs’ block: It includes the main thoracic curve and region so it can be also called

‘main thoracic block’. It appears translated and rotated to the right in a right thoracic scoliosis. It appears collapsed on the left ad prominent on the right. This affects the

scapular angles.


and T1 appears tilted to the left or horizontal. When there is a structural proximal curve the block includes only the proximal thoracic region, uncoupled from the cervical spine.


Schroth blocks for 3D deformities

3C 4C N3N4 STL/SL

81

When a primary composite scoliosis develops in the lumbar/low thoracolumbar (L1) region (left in the example) and the main thoracic region (right), two compensations appears

caudal as well as cranially. The caudal compensation is defined as a lumbo-sacral curve. It

produces a functional separation between the lumbar/low thoracolumbar region and the

pelvis, something that will be later noticed on the X-ray (L4 and L5 shows a clear different degree of inclination – L4-L5 Counter-tilting. Sometimes the counter-tilting is observed

between L3 and L4). In this case the trunk is imbalanced to the left but pelvis is translated

to the right on the polygon of sustentation, becoming prominent on that side. Thus, the trunk is here divided in four virtual blocks or sections, also translated and rotated one

against the other, collapsing in the concavities and protruding on the convexities. The

blocks correspond, from caudal to cranial:

a) Pelvic girdle block: The pelvis region including L5 forms it. It appears translated and

rotated to the right in a right thoracic/left lumbar or thoracolumbar scoliosis, collapsing on the left side and protruding on the right.

b) Lumbar/low thoracolumbar block: It includes the lumbar or low thoracolumbar

regions with the floating or sometimes more ribs (depending on the extension of the curve and the level of the apical vertebra). It appears translated and rotated to the

left, collapsing on the right and protruding on the left.

c) Ribs’ block: It includes the main thoracic curve and region so it can be also called ‘main thoracic block’, like in 3C, but it uses to be shorter and higher than in 3C pattern. It appears translated and rotated to the right, always for the same example. It appears collapsed on the left ad prominent on the right. This affects the scapular

angles too. d) Shoulder girdle block: It includes the proximal thoracic region - with a big part of the

scapulae- coupled to the cervical spine when this compensation is just functional and T1 appears tilted to the left or horizontal. When there is a structural proximal curve the block includes only the proximal thoracic region and it is uncoupled from the cervical spine.

80









pelvis, although the proximal thoracic region is also rotated and translated to the left in relationship to the main thoracic region. The body is collapsed in the correspondent concavities and expanded in the convexities. As a whole, the trunk, including the pelvis,






prominent on the left.

b) Ribs’ block: It includes the main thoracic curve and region so it can be also called ‘main thoracic block’. It appears translated and rotated to the right in a right thoracic scoliosis. It appears collapsed on the left ad prominent on the right. This affects the

scapular angles.


and T1 appears tilted to the left or horizontal. When there is a structural proximal

curve the block includes only the proximal thoracic region, uncoupled from the cervical spine.

83

Group 2: other functional types What happen when we notice a significant dorsal rib hump (structural thoracic curve – Group 2), but pelvis looks well centered and trunk well balance?

When we are not sure about diagnose, when there is no chance to classify with conviction

3C or 4C, then the best is to classify preliminary as N3-N4 type.

Non3 – Non4 functional type corresponds also to a structural thoracic curve (right convex in the example), with minimal translation of the main thoracic block, which does not need

translation from the adjacent blocks to keep a correct balance. In other words, the

Transitional Point and T1 are acceptably balance on the Central Sacral Line in a way that, visually, pelvis looks centered on the polygon of sustentation. This functional type can be

associated to a structural lumbar curve or not (lumbar spine can be strictly rectilinear).

Pelvis block is more or less symmetric and translated. Sometimes it is mildly rotated, in the

opposite direction of the main thoracic block, like in 3C, because in any case, pelvis is coupled to the lumbar region. Lumbar block is more or less deformed and rotated (collapse-

prominence), but not translated. Main thoracic block is also deformed and rotated (collapse-

prominence) but just mildly translated.

3C and 4C are easier to diagnose in moderate and major scoliosis, but also in mild it is possible to establish an accurate diagnose with a minimum experience (In the figure above, left is 3C and right is 4C). In N3-N4, especially when there is a lumbar structural curve, diagnose can be more difficult. The case in the middle looks well balanced and although pelvis could

be observed like a little bit prominent on the right side in the upright position, the forward bending test shows a perfectly centered pelvis. The presence of a lumbar prominence allows us to diagnose a N3-N4 with lumbar structural curve in this case.

84

A special type of scoliosis is the double thoracic/ high thoracolumbar curve (Th 12). This curve pattern belongs functionally to the 4C type, although the high thoracolumbar prominence could be taken in some border cases like a low thoracic rib hump. The figure below shows one of these cases where a high thoracic curve is associated to a high thoracolumbar curve. No matters both curve are primary or the thoracolumbar develops first and thoracic becomes structural later, the schema of blocks works like in 4C scoliosis. The figure on the right corresponds to a primary left single high thoracolumbar curve with a ‘quasi’ rectilinear main and proximal thoracic spine. This last case will not give signs of structuration in the main thoracic region and should be diagnosed as Group 1-2 (Single High Thoracolumbar curve). The example in the middle would represent a primary single high thoracolumbar curve progressing with a compensatory functional thoracic curve. While giving no signs of structuration in the forward bending test it shall continue diagnosed as Group 1-2. Once we can recognize a structural curve in the main thoracic region the diagnose changes to 4C. In any case, this figure shows the proximity between G1-2 and 4C functional types. In fact G1-2 is like 4C without structural thoracic curve.

Group 1-2 is subdivided in Single High Thoracolumbar curve (Th12) and Single Lumbar or Low Thoracolumbar curve (L1). In Group 1-2 exists, like in 4C, two caudal uncoupled blocks, the pelvis block and the lumbar or low thoracolumbar or high thoracolumbar. Figure below shows a case where a left single high thoracolumbar curve (Group 1-2 or right 4C) could be confused with a low thoracic scoliosis (left 3C).

Clinical diagnose is essential for physiotherapy because PTs use the external clinical aspect of the subject as a monitor of the correction. In other words, PT

83














84

A special type of scoliosis is the double thoracic/ high thoracolumbar curve (Th 12). This curve pattern belongs functionally to the 4C type, although the high thoracolumbar prominence could be taken in some border cases like a low thoracic rib hump. The figure below shows one of these cases where a high thoracic curve is associated to a high thoracolumbar curve. No matters both curve are primary or the thoracolumbar develops first and thoracic becomes structural later, the schema of blocks works like in 4C scoliosis. The figure on the right corresponds to a primary left single high thoracolumbar curve with a ‘quasi’ rectilinear main and proximal thoracic spine. This last case will not give signs of structuration in the main thoracic region and should be diagnosed as Group 1-2 (Single High Thoracolumbar curve). The example in the middle would represent a primary single high thoracolumbar curve progressing with a compensatory functional thoracic curve. While giving no signs of structuration in the forward bending test it shall continue diagnosed as Group 1-2. Once we can recognize a structural curve in the main thoracic region the diagnose changes to 4C. In any case, this figure shows the proximity between G1-2 and 4C functional types. In fact G1-2 is like 4C without structural thoracic curve.

Group 1-2 is subdivided in Single High Thoracolumbar curve (Th12) and Single Lumbar or Low Thoracolumbar curve (L1). In Group 1-2 exists, like in 4C, two caudal uncoupled blocks, the pelvis block and the lumbar or low thoracolumbar or high thoracolumbar. Figure below shows a case where a left single high thoracolumbar curve (Group 1-2 or right 4C) could be confused with a low thoracic scoliosis (left 3C).

Clinical diagnose is essential for physiotherapy because PTs use the external clinical aspect of the subject as a monitor of the correction. In other words, PT

83















Schroth blocks for sagittal plane deformities

Hyperkyphosis Lumbar kyphosis Spinal inversion

c

b

a

.<

<

c

b

a

.<


Rigo and Weiss radiological classification for bracing

oror

2010

Relates to physical therapists more than any

other radiological classification

Treatment Indications, Goals and Age

SpecificsTreatment indication:

• SOSORT 2011 guidelines.

Other indication

• Juvenile and Adolescent Idiopathic Scoliosis (JIS, AIS).

• Sagittal plane deformities (Schueurmann, inverted back).

• Modified Schroth program for:

• Painful/degenerative adult scoliosis.

• Post-op.

Goals:

• Correction of the ‘scoliotic posture’.

• Stabilize the spine and arrest the progression.

• Patient and family education.

• Improved respiration.

• Improve function, ADL, self-image, and pain.

Treatment Indication, Goals and Age

Specifics

• Juvenile

o Activities of daily living.

o Modified Schroth (less intense, games).

• Adolescent

o Strict Schroth principles.

• Adult

o Considering number/s of modifiers.

o Modified Schroth (auto elongation and trunk

expansion NO derotation or detortion with older

adult).

Pain

Severity of deformity


Specifics

Minimal Correction and 3D stable pelvis

(Starting Position + Pelvic Corrections) =

Minimal Correction and 3D stable pelvis.

3D Principles of Correction

Maximum Correction

1. Auto/axial/self Elongation:

Deflection and Derotation.

2. Asymmetrical Sagittal Straightening.

3. Frontal Plane Correction.

4. Rotational Angular Breathing.

5. Stabilization.

Principles of Correction

1. Minimum Correction – before the maximum correction

• Postural Balance and 3D alignment of the lower extremities,

pelvic, trunk and head - low tension.

a. Translation

b. Rotation

92

Specific Nomenclature:

1. Packet 2. Weak Side 3. Weak Point 4. Lumbar prominence 5. Prominent Pelvis 6. Weak Side Shoulder 7. Packet Side Shoulder 8. Upper Concavity 9. Anterior rib hump 10. Anterior flat zone

109

In 4C we will be able to correct pelvis translation and trunk imbalance but not to overcorrect.

The third pelvis correction in 4C It is about centering the pelvis on the polygon of sustentation (translation of the pelvis from the packet side to the center) in combination with the best possible correction of the frontal plane imbalance from the correction to medial of the lumbar/tl curve. From a biomechanical point of view, the lumbar/tl curve should be first derotated before being brought to the midline (from convexities detorsion is produced first with derotation and then with deflection). Thus, 3rd pelvis correction has to performed with some degree of self-elongation and correction of the lumbar/tl curve forward and inwards. At the same time pelvis is centered with the third pelvis correction, it has to be derotated and leveled. This would be the equivalent of the 4 th and 5th pelvis corrections but from a practical point of view we do not use here the terms 4th and 5th pelvis correction during training but we just say ‘third pelvis correction’ meaning that centering the pelvis goes always coupled with derotation until 0º and level. It is easier than it resembles, it is about bring the pelvis ‘centered, non-rotated, non-tilted’.

When performing the 3rd pelvis correction the subject must avoid the main thoracic block to translate to the packet side. The main thoracic block has to be re-centered on the lumbar/tl block.

Major thoracic Major lumbar


2. Maximum Possible Correction = THE 5 PRINCIPLES

Specific Principles of Correction; High Tension; Hyper-

correction/over-correction to stabilize the spine.

1. Auto/axial/self Elongation (increase trunkal volume in all

directions; tension and expansion throughout.

a. Deflection

b. Derotation

2. Asymmetrical/Symmetrical

Sagittal Straightening.

3. Frontal Plane Correction.

4. Rotational Angular Breathing.

5. Stabilization/facilitation/muscle

activation.


Rotation Angular Breathing

• Into concavities, in direction that

promotes corrections: “outwards,

backwards”.

Muscle Activation

• Global trunk tension and expansion

• And local:

o In the prominences: “forwards,

inwards”.

o Iliopsoas, QL and others.

The Use of Breathing Mechanics, Muscle

Activation, and Mobilization



Mobilization and Flexibility

• To release tension and assist with the correction.

Release tense lumbosacral soft tissues

(A) will facilitate lumbar correction (B)

Treatment Tools

Active and Passive

Wall bar, Pads, poles, belt, strap, mirror,

thera-band, dowel, ball, yoga blocks, stool.

foam roller

Treatment Tools

Active and Passive

Soft tissue mobilization, rib mobilization, diaphragm release, flexibility.

Description of Most Relevant Exercise Mechanics1. Supine – for all Curves

In this example patient is a

4C (major lumbar).

Basic exercise in a gravity elimination

position where the patient can focus on

preciseness of the corrections and feel

them.

Convexities SCT

(forward - inward)

Elongation

Concavities

(outward – backward)

ST

Pelvic correction

Description of Most Relevant Exercise Mechanics2. Side-lying – for All Curves

In the example to the

left patients is a 4C

(major lumbar).

At the Bottom patient

is a 3C (major

thoracic).

Basic exercise with

increase deflexion in the

frontal plan:

Focus on Lumbar

facilitation and thorax

deflexion with increase

preciseness.



Description of Most Relevant Exercise Mechanics3. Muscle-Cylinder – Best for 4C (Major Lumbar)

In these examples (right

and bottom) patients are

4C (major lumbar).

Advance exercise with

extreme muscle

activation against

gravity.

Activities of Daily Living (ADL)Neutral Spine/Conscious Posture

Sleeping posture Resting/standing

++ ++

Carrying a bag

Exercises in brace

Neutral spine

and body

mechanics

Activity of Daily Living (ADL)Neutral Spine / Conscious Posture

Sitting posture

Scientific EvidencePEDIATRIC REHABILI TATION , 2003, VOL . 6, NO. 3–4, 209–214

Effect of conservative management onthe prevalence of surgery in patientswith adolescent idiopathic scoliosis

M . RIGO, CH. REITER and H.-R. WEISS

Accepted for publication: October 2003

Keywords Adolescent idiopathic scoliosis, physical therapy,brace treatment, Rigo-System Cheneau brace, scoliosissurgery

Summary

Study design: Retrospective analysis of outcome in terms ofprevalence of surgery for adolescent idiopathic scoliosis inpatients receiving conservative management.Objectives: To determine whether a centre with an activepolicy of conservative management has fewer patients whoeventually undergo surgery for adolescent idiopathic scoliosisthan a centre where the practice is non-intervention.Background data: The efficacy of orthoses for the treatmentof idiopathic scoliosis was called into question in a recentpublication. Because the prevalence of surgery in an untreatedgroup of patients (28.1%) was not significantly different fromthat in a braced group (22.4%), the authors concluded thatbracing appears to make no difference. Based on prior experi-ence, this conclusion is questioned.M ethods: Since 1991, bracing and physical therapy have beenrecommended for children with adolescent idiopathic scoliosisat a centre in Barcelona, Spain. The scoliosis database wassearched for patients with adolescent idiopathic scoliosiswho were at least 15 years of age at last review and whohad adequate documentation of the Cobb angle. The preva-lence of surgery was compared with that of published datafrom a centre where the practice is non-intervention.Results: From a total of 106 braced cases out of which 97 werefollowed up, six cases (5.6%) ultimately underwent spinalfusion. A worst case analysis, which assumes that all ninecases that were lost to follow-up had operations, bringsthe uppermost number of cases that could have undergonespinal fusion to 15 (14.1%). Either percentage is significantstatistically when compared to the 28.1% reported surgeriesfrom the centre with the policy of non-intervention.

Conclusions: I f conservative management does reduce theproportion of children with adolescent idiopathic scoliosisthat require surgery, it can be said to provide a real and mean-ingful advantage to both the patients and the community. I t iscontended that conservative methods of treatment shouldnever be ruled out from scoliosis management, because theycan and do offer a viable alternative to those patients whocannot or will not opt for surgical treatment.

Introduction

How effective is the conservative management of

scoliosis? Whether the treatment provided is physical

therapy (figure 1) or bracing, the problem has been

investigated continually. As early as 1958, Blount et al.

[1] appeared to provide a solution and the M ilwaukee

brace soon became the standard treatment of scoliosis

worldwide. Other brace designs introduced in the US,

e.g. the Boston [2] and the Wilmington braces [3], were

reported in the literature to have been effective treat-

ments [4–7]. A study by Nachemson and Peterson [9]

corroborated the effectiveness of bracing. Despite this

and other documented support for the efficacy of

certain orthoses [8, 9], their validity has generally been

Pediatric Rehabilitation ISSN 1363–8491 print/ISSN 1464–5270 online # 2003 Taylor & Francis Ltdhttp://www.tandf.co. uk/journals

DOI: 10.1080/13638490310001642054

Authors: M . Rigo, M D (author for correspondence), InstitutoElena Salva, Via Augusta 185 entlo. D, Esquina Amigo 78-80,E-08021 Barcelona, Spain. e-mail: [email protected]; Ch. Reiter and H.-R. Weiss, M D, Asklepios K atharina-Schroth Spinal DeformitiesRehabilitation Centre, K orczakstr.2, D-55566 Bad Sobernheim, Germany.

Figure 1 Asymmetric exercise for an asymmetric condition. Patientwith lumbar hump on the left side and pelvic prominence on the rightboth corrected in the ‘Schroth’ exercise.

Material and method: Retrospective analysis of outcome in terms of prevalence of surgery

for AIS in patients receiving conservative management.

Conclusion:

Conservative methods of treatment with outpatient physical therapy on an intensive basis

and the application of high-correction braces are effective in reducing the prevalence of

surgery in patients with AIS .

Brace & therapy

No intervention

Brace only

Scientific Evidence

Material and Methods:

• Retrospective. N=47 with IS. Mean age 18.64; Treated exclusively (outpatient) with

Schroth principles. 3 hours/day x 5 days/week x 4 weeks.

• Surface topography to measure trunk imbalance, surface rotation and lateral deviation

before and after treatment period.

Results:

• Trunk imbalance improved from 10.16 mm to 8.53 mm (p<0.05)

• Lateral deviation improved from 13.92 mm to 11.96 mm (p<0.05)

• Surface rotation improved from 6.880 to 6.520 (p<0.05)

Conclusion:

Current results suggest that exercises according to Schroth principles, following BSPTS

protocol, are able to improve back asymmetry, spinal imbalance in the frontal plane and

virtual spinal geometry in a short term, confirming specificity in its mechanics of action.

Scientific Evidence

Study: To determine the effectiveness of 3-dimensional therapy in the treatment of

adolescent idiopathic scoliosis.


• N=50 with AIS (1999-2004). Average age 14.15; Treated with Schroth (outpatient).

• 5 days a week, 4 hours/day x 6 weeks with continuation of HEP.

• Cobb angle, vital capacity and muscle strength after 6 weeks, 6 months and one year.

Results:

Conclusion:

Schroth’s technique positively influenced the Cobb angle, vital capacity, strength and postural

defects in outpatient adolescents.

Before 6 weeks 6 months 1 year

Cobb (0) 26.1 23.45 19.25 17.85

VC (ml) 2795 2956 3125 3215

SCHROTH ASKLEPIOS

GERMANY

www.asklepios.com/badsobernheim

History

Katherina Schroth, 1921 – Active exercises

Originally called “orthopedic breathing”

ACTIVE POSTURAL

CORRECTION

History

1920’s – Meissen, Germany

- Orthopedic breathing to reshape the body

- 3D postural corrections done first

1960’s Sobernheim, Germany

Daughter - Christa Lehnert-Schroth

P.T.

Grandson - H. R. Weiss, M.D.

research


“The Schroth method aims to reverse all of the abnormal

curvatures with a variety of means, based upon the

therapist's analysis of a patient's muscle imbalances.”

(Lehnert-Schroth Christa, 2015)


SRS definition of curves. SRS classification by age

of onset. Curve Apex

Upper Thoracic T3-4-5

Thoracic T2-11or

(Disc T11-12)

Lumbar L2-4 or

(Disc L1-2)

Thoracolumbar T12-L1

Lumbosacral L5-S1 or

(Disc L4-5)

classification Age of onset

IIS <3y

JIS 3-10y

AIS > 10y


Schroth scoliosis body blocks

+

Anatomical Schematical Scoliosis - specific

Shoulder block

S

Thoracic block

T

Lumbar block

L

Hip - pelvic

block H

The altered form

of the blocks desribes

the trunk deformity:

long side = convex

short side = concave

The blocks are

defined by the

neutral vertebrae


Schroth scoliosis body blocks

(3CP) (3C) (4C) (4CP)


KT KT + KT - KL

K = Kyphosis; T = Thoracic; L = Lumbar

Schroth sagittal plane deformities body blocks

Treatment indication:


Goals:


Specifics

1. Stop curve progression at puberty

(or possibly even reduce it).

2. Prevent or treat respiratory

dysfunction.

3. Prevent or treat spinal pain

syndromes.

4. Improve aesthetics via postural

correction.

Lehnert-Schroth C. 2007

8 weeks post

therapy5-year-old

boy

• Juvenile

o Activities of daily living.

o Modified Schroth (less intense,

games).

• Adolescent

o Strict Schroth principles.

• Adult

o Considering number/s of

modifiers.

o Modified Schroth respecting

pain and the stiffness of the

deformity.


Specifics


1. Auto-elongation (detorsion).

2. Deflection.

3. Derotation.

4. Rotational Breathing.

5. Stabilization.

Rotation Angular Breathing

• Into concavities in direction

that promotes corrections:

“outwards, backwards”.

Muscle activation

• In the prominences: “forwards,

inwards”.

• Iliopsoas, QL and others.





Mobilization and flexibility

• To release tension and assist with the correction.

Treatment Tools

Active and Passive

Wall bar, Pads, poles, belt, strap, mirror,

thera-band, dowel, ball, yoga blocks, stool,

foam roller.

Promotes challenges

Description of Most Relevant Exercise Mechanics

1. 50 x Pezziball

For all curves

• Auto/self elongation, convexities

activation “forward-inward” and

concavities opening “outward-

backward”.

Convexities SCT

(forward - inward)

Elongation

Concavities


ST


2. Prone

For all curves:

• “Specific for the thoracic corrections via

Shoulder Traction/Shoulder Counter Traction

(cervicothoracic, main thoracic).”

(Hennes Axel, 2015)

• For lumbar curve via Iliopsoas activation.

Convexities SCT

(forward - inward)

Elongation

Concavities


ST


3. The Sail

Best for thoracic curve

• “A very effective stretching exercise for

the thoracic concavity.”

(Hennes Axel, 2015)


4. Musclecylinder

For all curves

• Lumbar facilitation against gravity with the use of QL

activation.

• Cervicothoracic activation via ST – for upper thoracic curve

Activities of Daily Living (ADL)Postural Training

Scientific Evidence

Schroth and BSPTS were combined for evidence support and

presented at the BSPTS section.

SCIENTIFIC EXERCISE APPROACH

TO SCOLIOSIS (SEAS)

ITALY

http://en.isico.it/scoliosis

History

• Originates from the Lyon approach

• In the early 1960s Antonio Negrini and

Nevia Verzini founded a scoliosis

center that later became the Centro

Scoliosis Negrini (CSN).

• 2002: Instituto Scientifico Italiani

Colonna Vertebrale (ISICO)

SEAS is the acronym for “Scientific Exercise Approach to

Scoliosis,” a name related to the continuous changes of the

approach based on results published in the literature.


A therapeutic modality to obtain postural control

and spinal stability.

The self correction component can be defined as the

search for the best possible alignment within three

dimensional spatial planes that are obtained autonomously

by the patient.

This Active Self-Correction can be replicated

in a thousand different exercises with

“distracting” situations, thereby

"strengthening" the neuromotor behaviour.

The SEAS specifically addresses this direction.


Ponseti Classification, 1950 - First to classify IS.

Curve Type

Single curve

Double curves (higher chance to progress)

Triple curves

Curve Type

Cervico - Thoracic

Thoracic (apex above thoracolumbar)

Thoracolumbar (apex T12-L1 higher chance to progress)

Lumbar (apex below thoracolumbar and higher chance to

progress)



Goals:

• Increasing spinal stability.

• Development of spinal balance.

• Preservation of a physiological sagittal

orientation.

• Contrast the Stokes vicious cycle.

• Improved vital capacity and psychological aspect.

Age:

• Very young adolescent and adult patients.


Specifics

The overall aim is the same: contrast the evolution of the

misalignment.

• Kids and adolescents

o Self correction movements are the priority – to reduce the

progressive deformation of the vertebrae while spine is

growing.

• Adults

o Improvement of the stabilization of the spine.


Specifics

Treatment Indication and Goals

• Preparation for bracing.

• Brace wearing period.

• Complete brace weaning.

Sibilla brace (<300 Cobb). Sforzesco brace (300-450/500).

1. Start from where the spine is in a position of basic support

1. “Is my spine supported and not relaxed?”

2. Self correction (first with assistance of mirror, later without)

2. “Is my body more symmetrical than before?”

3. Maintaining correction

3. “While doing the exercise, am I able to maintain the

correction?”

4. Returning to original position before the self correction

4. “Am I able to recognize that my body returns to the original

position that it was in before performing the self correction?”

3D Principles of CorrectionThe Four Questions


ExamplesActive self-correction in sitting

Active self-correction in sitting

leaning forwardMaintaining self-correction

sit <> stand

Maintaining self-correction landing on a wall



Breathing Mechanics

• To help with the corrective movements.

Muscle activation

• To help with the stabilization of the trunk and maintaining the

alignment.


• To the spine and other body

parts if there is a real alteration

of joint mobility.

Treatment Tools

Active and Passive

Assistive equipment (balance board, rice bag) is used only at the

start of the treatment and later removed. The mirror is the only

tool that helps the patient.

Description of Most Relevant Exercise MechanicsPostural Rehabilitation

“…The most important exercises for each patient are the

exercises that “challenge” the patient and improve the

patient’s ability to maintain the active self-correction.”


Exercises and the Brace

Preparation for bracing: Exercises

aimed at increasing range of motion of

the spine.

Exercises in brace

A B C D

A - The patient is in a relaxed position. B - The patient moves away from sternal upright to do a maximum thoracic kyphotization movement. C - The patient is in a relaxed position. D - The patient moves away from abdominal upright to maximally exert a pressure on the lumbar pressure pad


.

• The first phase includes

becoming aware of curve apex

translation towards concavity on

the frontal plane.

• The second phase, immediately

after, includes exercises

ensuring thoracic kyphosis

and lumbar lordosis.

• Finally, we associate active Self-

Correction movements on the frontal

and sagittal planes.


Beyond the Basics

.

• Muscular endurance strengthening in the correct posture.

• Development of balance reactions.

• Neuromotor integration

o Integrating in everyday behaviors

o The exercises associate active

self-correction with global

movements, e.g., walking with a

simple gait and oculo-manual

education exercises.

Activities of Daily Living (ADL)

“We ‘challenge’ the patient to maintain the self correction

during their daily activities.”

(Romano, M et al. 2011)

Scientific Evidence

Exercises reduce the progression rate of adolescent idiopathic scoliosis:Results of a comprehensive systematic review of the li terature

S. NEGRINI, C. FUSCO, S. M INOZZI, S. ATANASIO, F. ZAINA & M . ROM ANO

ISICO (Italian Scientific Spine Institute), M ilan, I taly

AbstractBackground. A previously published systematic review (Ped.Rehab.2003 –DARE 2004) documented the existence of theevidence of level 2a (Oxford EBM Centre) on the efficacy of specific exercises to reduce the progression of AIS (AdolescentIdiopathic Scoliosis).Aim. To confirm whether the indication for treatment with specific exercises for AIS has changed in recent years.Study design. Systematic review.Methods. A bibliographic search with strict inclusion criteria (patients treated exclusively with exercises, outcome Cobbdegrees, all study designs) was performed on the main electronic databases and through extensive manual searching. Weretrieved 19 studies, including one RCT and eight controlled studies; 12 studies were prospective. A methodological andclinical evaluation was performed.Results. T he 19 papers considered included 1654 treated patients and 688 controls. T he highest-quality study(RCT) compared two groups of 40 patients, showing an improvement of curvature in all treated patients after six months.We found three papers on Scoliosis Intensive Rehabilitation (Schroth), five on extrinsic autocorrection-based methods(Schroth, side-shift), four on intrinsic autocorrection-based approaches (Lyon and SEAS) and five with no autocorrection(three asymmetric, two symmetric exercises). Apart from one (no autocorrection, symmetric exercises, very lowmethodological quality), all studies confirmed the efficacy of exercises in reducing the progression rate (mainly in earlypuberty) and/or improving the Cobb angles (around the end of growth). Exerciseswere also shown to be effective in reducingbrace prescription.Conclusion. In five years, eight more papers have been published to the indexed literature coming fromthroughout the world (Asia, the US, Eastern Europe) and proving that interest in exercises is not exclusive to WesternEurope. This systematic review confirms and strengthens the previous ones. The actual evidence on exercises for AIS is oflevel 1b.

Keywords: Physical exercises, adolescent idiopathic scoliosis, conservative treatment, physiotherapy, rehabilitation

Intr oduction

Various types of treatments for AIS (Adolescent

Idiopathic Scoliosis), whether conservative or surgi-

cal, have been reported. The majority of adolescents

with AIS have been treated with conservative care

that included bracing, simple observation and/or

physical exercises (PEs) [1]. PEs for the treatment of

AIS have been used since 500 BC, when Hippocrates

[2] , followed by Galenus [3], introduced their usage

as means to maintain the flexibility of the chest wall.

During the past centuries there was a considerable

flowering of different approaches to PEs, but only at

the beginning of the previous century, mainly in

Germany with K lapp and Von Niederhofer, was it

possible to verify the first methods through deep

scientific observation [4] . During the same period

Katharina Schroth described her method [5]. Later,

in many parts of Europe, authors described different

methods: Between 1930 and 1950 the ‘IOP’ method

was introduced in Italy, and the ‘Psoas’ method was

produced in the Soviet Union [4] . The ‘Lyon’

method [6,7] and that of M ezieres [8] were

described in France during the 1960s. Later,

Souchard derived its treatment from M ezieres [9] ,

and in Poland Dobosiewics proposed its approach

Correspondence: Stefano Negrini, D irettore, Scientifico ISICO (Istituto Scientifico I taliano Colonna vertebrale), M ilano, Italy. E-mail: [email protected]

Disabili ty and Rehabilitation, 2008; 30(10): 772 –785

ISSN 0963-8288 print/ISSN 1464-5165 online ª 2008 Informa UK Ltd.

DOI: 10.1080/09638280801889568

Dis

abil

Reh

abil

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by

Dr

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Fo

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use

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.

Exercises reduce the progression rate of adolescent idiopathic scoliosis:Results of a comprehensive systematic review of the li terature

S. NEGRINI, C. FUSCO, S. M INOZZI, S. ATANASIO, F. ZAINA & M . ROM ANO

ISICO (Italian Scientific Spine Institute), M ilan, I taly

AbstractBackground. A previously published systematic review (Ped.Rehab.2003 –DARE 2004) documented the existence of theevidence of level 2a (Oxford EBM Centre) on the efficacy of specific exercises to reduce the progression of AIS (AdolescentIdiopathic Scoliosis).Aim. To confirm whether the indication for treatment with specific exercises for AIS has changed in recent years.Study design. Systematic review.Methods. A bibliographic search with strict inclusion criteria (patients treated exclusively with exercises, outcome Cobbdegrees, all study designs) was performed on the main electronic databases and through extensive manual searching. Weretrieved 19 studies, including one RCT and eight controlled studies; 12 studies were prospective. A methodological andclinical evaluation was performed.Results. T he 19 papers considered included 1654 treated patients and 688 controls. T he highest-quality study(RCT) compared two groups of 40 patients, showing an improvement of curvature in all treated patients after six months.We found three papers on Scoliosis Intensive Rehabilitation (Schroth), five on extrinsic autocorrection-based methods(Schroth, side-shift), four on intrinsic autocorrection-based approaches (Lyon and SEAS) and five with no autocorrection(three asymmetric, two symmetric exercises). Apart from one (no autocorrection, symmetric exercises, very lowmethodological quality), all studies confirmed the efficacy of exercises in reducing the progression rate (mainly in earlypuberty) and/or improving the Cobb angles (around the end of growth). Exerciseswere also shown to be effective in reducingbrace prescription.Conclusion. In five years, eight more papers have been published to the indexed literature coming fromthroughout the world (Asia, the US, Eastern Europe) and proving that interest in exercises is not exclusive to WesternEurope. This systematic review confirms and strengthens the previous ones. The actual evidence on exercises for AIS is oflevel 1b.

Keywords: Physical exercises, adolescent idiopathic scoliosis, conservative treatment, physiotherapy, rehabilitation

Intr oduction

Various types of treatments for AIS (Adolescent

Idiopathic Scoliosis), whether conservative or surgi-

cal, have been reported. The majority of adolescents

with AIS have been treated with conservative care

that included bracing, simple observation and/or

physical exercises (PEs) [1]. PEs for the treatment of

AIS have been used since 500 BC, when Hippocrates

[2] , followed by Galenus [3], introduced their usage

as means to maintain the flexibility of the chest wall.

During the past centuries there was a considerable

flowering of different approaches to PEs, but only at

the beginning of the previous century, mainly in

Germany with K lapp and Von Niederhofer, was it

possible to verify the first methods through deep

scientific observation [4] . During the same period

Katharina Schroth described her method [5]. Later,

in many parts of Europe, authors described different

methods: Between 1930 and 1950 the ‘IOP’ method

was introduced in Italy, and the ‘Psoas’ method was

produced in the Soviet Union [4] . The ‘Lyon’

method [6,7] and that of M ezieres [8] were

described in France during the 1960s. Later,

Souchard derived its treatment from M ezieres [9] ,

and in Poland Dobosiewics proposed its approach

Correspondence: Stefano Negrini, D irettore, Scientifico ISICO (Istituto Scientifico I taliano Colonna vertebrale), M ilano, Italy. E-mail: [email protected]

Disabili ty and Rehabilitation, 2008; 30(10): 772 –785

ISSN 0963-8288 print/ISSN 1464-5165 online ª 2008 Informa UK Ltd.

DOI: 10.1080/09638280801889568

Dis

abil

Reh

abil

Do

wn

load

ed f

rom

in

form

ahea

lth

care

.com

by

Dr

Ste

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o N

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ni

on

03

/30

/11

Fo

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sonal

use

only

.

Study: To confirm whether the indication for treatment with specific exercises for AIS

has changed in recent years - a systemic review.


• 19 studies, one RCT (included 1654 treated patients and 688 controls) with strict

inclusion criteria: patients treated exclusively with exercises. Cobb degrees was

evaluated.

Results and conclusion:

• One RCT showed improvement of curvature in all treated patients after 6 months.

• Apart from one, all studies confirmed the efficacy of exercises in reducing the

progression rate (mainly in early puberty) and/or improving the Cobb angles

(around the end of growth).

• Exercises were also shown to be effective in reducing brace prescription.

Scientific Evidence

Study:

To compare the effect of SEAS exercises with “usual care” rehabilitation programs i

n terms of the avoidance of brace prescription and prevention of curve progression i

n adolescent idiopathic scoliosis.


• SEAS group n=35, “usual” PT n=39.

• Number of braced patients, Cobb angle and angle of trunk rotation was observed.

Results and conclusion:

• Braced patients: 6.1% in SEAS vs 25.0% in usual PT.

• Cobb (improved) SEAS 23.5% vs 11.1% in usual PT.

Conclusion:

These data confirm the effectiveness of exercises in patients with scoliosis who

are at high risk of progression. Compared with non--

adapted exercises, a specific and personalized treatment (SEAS) appears to

Scientific Evidence

Rehabilitation program:

• Based on scientific active and individualized self correction. The exercises train

neuromotor function stimulating by reflex a self-corrected posture during the activities of

daily life.

• SEAS can be performed as an outpatient (two/three times a week 45 for minutes) or as a

home program to be performed 20 minutes daily.

Results:

Different papers documented the efficacy of the SEAS approach in reducing Cobb angle

progression and the need to wear a brace.

Conclusions:

SEAS has a strong modern neurophysiological basis, to reduce requirements for patients and

possibly the costs for families linked to the frequency and intensity of treatment and

evaluations. Therefore, SEAS allows treating a large number of patients coming from far

away.

Scientific Evidence

Study: Retrospective controlled study to verify the efficacy of exercises in reducing correction

loss during brace weaning.


• Group (1) Exercise group n=39 (14 SEAS, 25 other exercises).

• Group (2) control n=29 (19 discontinuous exercises, 10 no exercises).

• Cobb angle and angle of trunk rotation (ATR) compered pre brace, start of weaning

(Risser 3) and post intervention.

Results:

• At the end of treatment (2.7 years after the start of brace weaning) Cobb angle and ATR

significantly increased in group 2.

• In group 1 Cobb and ATR didn’t change.

Conclusion: Exercises can help reduce the correction loss in brace weaning for AIS.

Scientific Evidence

Pre brace Start of weaning End of Rx Pre brace Start of weaning End of Rx

FUNCTIONAL INDIVIDUAL

THERAPY OF SCOLIOSIS (FITS)

POLAND

http://en.ortokursy.pl/fits-concept

History

• 2004 – Marianna Białek PT, PhD and Andrzej

M'hango PT, MSc, D.O. created a program to

improve postural problems and scoliosis.

• Has scientific contribution from Cracow

University.

• Used alone or combined with Cheneau

bracing.

• 2004 – the first FITS course for PTs.

• 2006 – cooperation with Dr. Tomasz Kotwicki. Marianna Białek

Andrzej M’hango

Definition of Treatment3D Treatment

Treatment based upon the inclusion of many elements

selected from a variety of other therapeutic approaches

that have been adopted and adapted to form a different

concept.

.

• A separate system for scoliosis correction.• A supportive therapy for bracing.• Preparation of children for surgery.• For the correction of the shoulder and pelvic girdles after surgical intervention.


No classification system is used: “Each child is covered

by an individual treatment program.” (Marianna Bialek, 2015)

“Each patient’s scoliosis is classified as low, moderate,

or severe. It is difficult to assign the patient to a

particular classification.”

(Marianna Bialek, 2015


• SOSORT 2011 guidelines in general with modification:

Juvenile:

o No observation, all children have FITS therapy.

o No soft bracing.

o Part time rigid bracing in scoliosis 210-250.

o Full time rigid bracing in scoliosis over 260.

Adolescent

o No soft bracing.

o In scoliosis over 150 no observation, all children have FITS therapy.

o FITS therapy independently of Cobb angle.

o In scoliosis over 300, Risser 0-2, additionally Full time rigid bracing .


Specifics

Goals:

Short term:o Patient awareness (psychological goal).

o Improved shoulder and pelvic girdle (esthetics goal).

o Teaching of 3D breathing and improving its function.

o Myofascial release.

o Teaching the correct shift, etc.

Long term:o Decrease scoliosis.

o Stabilize scoliosis (stop curve progression).

o Improve clinical body for children who do not undergo surgery or who are post-surgery.

Age Specifics:Same protocol for children, adolescents and adults regardless of Cobb angle (recommended to work with an orthopedist and a psychologist.)


Specifics

Main goals of FITS concept:

1. To make the child aware of existing deformation of the spine and the trunk as well as

indicate a direction of scoliosis correction.

2. To release myofascial structures which limit three-plane corrective movement.

3. To increase thoracic kyphosis through myofascial release and joint mobilization.

4. To teach correct foot loading to improve position of pelvis and to realign scoliosis.

5. To strengthen pelvis floor muscles and short rotator muscles of the spine in order to

improve stability in the lower trunk.

6. To teach the correct shift of the spine in frontal plane in order to correct the primary

curve while stabilizing (or maintaining in correction) the secondary curve.

7. To facilitate three-plane corrective breathing in functional positions (breathing with

concavities).

8. To indicate correct patterns of scoliosis correction and any secondary trunk deformation

related to curvature (asymmetry of head position, asymmetry of shoulders' lines, waist

triangles and pelvis).

9. To teach balance exercises and improvement of neuro-muscular coordination with

scoliosis correction.

10. To teach correct pelvis weight bearing in sitting and correction of other spine segments

in gait and ADL.


Specifics

Stage I - Patient examination and making the child aware of the

trunk deformity:

Examination of child with scoliosis using classical assessment but also

in terms of FITS method.

Stage II - Preparation for correction:

Preparation for correction-examination, detection and elimination

of myofascial restriction which limits three-plane corrective

movement by using different techniques of myofascial relaxation.

Stage III - Three-plane correction:

Three-dimensional correction-building and fixation of new corrective

patterns in functional positions.

3D Principles of Corrections

The Three Stages


Stage I

Patient examination and education: making the child

aware of the trunk deformity.

Examination of child with scoliosis using classical assessment but also

in terms of FITS method.

Examination of flexibility of the scoliotic spine in functional positions. And making the child

aware of trunk deformity due to scoliosis.


Stage II

Preparation for the correction:

Detection and elimination of myofascial restriction, which limits three-

plane corrective movement, by using different techniques of myofascial

relaxation.

Active myofascial

relaxation for hamstrings

and erector spine.

Active myofascial

relaxation for erector spine.Active relaxation for rectus

femoris with scoliosis

derotation maneuver.


Stage III

Three-plane correction:

3D correction and maintenance of the new corrective patterns in functional

positions.

Sensory-motor control training on the balance trainer.

Sensory-motor control training on one leg.

Stabilization of lower trunk with pillows sensorimotor and the ball.

Stabilization of lower trunk with 3-dimensional correction of scoliosis


Summery

1. Sensorimotor balance training.

2. Mobilization and flexibility techniques.

3. Muscles activation and corrective patterns.

4. Neuromuscular re-education.

5. Auto-correction.


Stage III – The Exercises

An example of corrective

patterns.



Breathing mechanics

• Breathing into the concavities using

scoliometer in supine progressing to

functional position (sitting and standing).

Muscle activation

• To create corrective tension.


• Myogascial release to release tension and assist with

the correction.

Treatment Tools

Active and Passive

• Initially - Biofeedback – video camera and screen, mirror,

rolls, sensorimotor pillows, balls, balance trainers.

• The final step - according the rules of motor learning the

child make auto-correction by her/his self.


Training in stages:

Performing auto correction in different positions :

1. Auto correction in sitting position (brushing hair,

wear/take off a shirt, sit to stand, don/doff socks.)

2. Auto correction in standing position (as above)

3. Auto correction in standing position on unsteady

surface.

Scientific Evidence


• N=115

o Group A - FITS only: 98 AIS >10y/o, Cobb between 10-25, Risser 0-2.

A1 - single thoracic (Th) or thoracolumbar (Th/L) or L curve (L) (52 children).

A2 - double scoliosis: thoracic (Th) and thoracolumbar (Th/L) or lumbar (L)

curves (26 children).

o Group B - FITS + bracing: 37 AIS >10y/o, Cobb between 26-40, Risser 0-2.

B1 - single thoracic (Th) or thoracolumbar (Th/L), (5 children).

B2 - double scoliosis: thoracic (Th) and thoracolumbar (Th/L) or lumbar (L)

curves (32 children).

o Cobb and Risser pre and post (2.8 years) treatment.

o Improvement=Cobb by ≥50; stabilization=Cobb ±50; progression=Cobb by ≥50.

Scientific Evidence

Results:

Conclusion:

1. Preliminary results suggest that FITS could be an effective treatment, capable to alter the

natural history of mild idiopathic scoliosis.

2. FITS therapy improved the external morphology (esthetics) of the patients.

3. Radiological progression was more common in double scoliosis than in single curves.

Single curve

Double curve

Single curve

Double curve

SIDE SHIFT

ROYAL NATIONAL ORTHOPAEDIC HOSPITAL

UNITED KINGDOM (RNOHT)

https://www.rnoh.nhs.ukFIGURE 3 A patient with left thoracolumbar curve (A), standing in the neutral (B), and hitch (C) position. She is instructed to lift

her heel on the convexity of the curve while keeping her hip and knee straight. Note that asymmetry of the waistline reduced in the

hitch position.

FIGURE 4 For double curve, hitch shift exercise is indicated. A patient is instructed to lift her heel on the convex side of the lower

curve as the hitch exercise, to immobilize the lower curve by her hand, and shift her trunk to the concavity of the upper curve.

108 Maruyama et al.

Copyright & Informa Healthcare USA, Inc.

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History

• Side Shift approach for correction of scoliosis curves has

been used by therapists at the Royal National

Orthopaedic Hospital for over 35 years.

• Used by Dr. Min Mehta to help treat congenital scoliosis

curves in children.

Definition of Treatment3D Treatment

Excessive side trunk movements to correct the lateral shift

of the trunk in the coronal plane which is based on the

theory that a flexible curve can be stabilized with lateral

movements.

“These lateral movements promote a

reduction in the postural forces which

affect a structural curve.” (Tony Betts, 2015)

A patient with left thoracolumbar curve (A), standing in the

neutral (B), and hitch (C) position. She is instructed to lift her

heel on the convexity of the curve while keeping her hip and

knee straight. Note that asymmetry of the waistline reduced in

the hitch position.A B


The Consultants of the Royal National Orthopaedic use the King

and Lenke systems for surgical classifications.

The therapy method is based upon the king’s classification and

the ability of an individual to auto-correct the spine during a

side shift movement:

The Side-shift classification: flexibilty of curvature:Type I:

• Any pattern curve which can be corrected by shifting the trunk to

beyond the coronal midline (extremely flexible curves).

Type II:• Any pattern of curvature which can be corrected to the mid line of the

coronal plane.

Type III:

• Any pattern of curvature which cannot correct to the midline, and the

vertebrae do not de-rotate, but remain prominent. (These curves are

extremely rigid and may represent a severe structural curve).

Indications:


Goals

• Stabilization of the spine through exercises for AIS.

• Correction of postural deviation from the midline, pre or post

operatively.

• Reduction of mechanical pain in Adults or Adolescents through

the correction of pain provoking postural deviation.

• Exercises to promotes: elongation of the spine, rib expansion

and derotation, improved vital capacity, core strengthening,

improved sagittal plan, proprioception and balance, “trunk shift”

in ADL.


Specifics

Age and treatment protocol:

• Adolescents = Overcorrection of exercise movements

beyond the midline. Never overcorrect into pain.

• Adults = Correction to physiological postural midline

(neutral) or pain free position.


Specifics

The Side Shift approach has been modified with practice,

experience and clinical re-evaluation. It includes principles

from the Schroth method:

• Active 3D auto-correction (transverse, frontal and sagittal planes).

• Overcorrection movements beyond the midline.

• Taught to shift the trunk sideways in the direction opposite to the

convexity of the primary curve.

• Patient has to be old enough to understand instructions and

perform exercise independently.

• Repetition of a corrective movement during growth (these

movements can influence the direction of the spine during growth).



FIGURE 3 A patient with left thoracolumbar curve (A), standing in the neutral (B), and hitch (C) position. She is instructed to lift


hitch position.



108 Maruyama et al.


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. FIGURE 3 A patient with left thoracolumbar curve (A), standing in the neutral (B), and hitch (C) position. She is instructed to lift


hitch position.



108 Maruyama et al.


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Hitch exercise

A patient with left thoracolumbar curve (A), standing

in the neutral (B), and hitch (C) position. She is

instructed to lift her heel on the convexity of the curve

while keeping her hip and knee straight. Note that

asymmetry of the waistline reduced in the hitch

position.

Hitch - Shift exercise

For double curve, hitch-shift exercise is indicated. A

patient is instructed to lift her heel on the convex side

of the lower curve as the hitch exercise, to immobilize

the lower curve by her hand, and shift her trunk to the

concavity of the upper curve.

A B C



Breathing mechanics:

• Using Schroth rotation angular breathing principles and DoboMed.

Muscle activation

• Isometric muscle bracing (via plank or ‘bird-dog’) to provide

dynamic correction to the side shift corrective movement

(incorporating Pilates and core).

• To prevent atrophy and provide greater

forces to the corrective movements.




• Principles of Maitland for joint tissues and Myofascial release

techniques for soft tissues.

Treatment Tools

Active and Passive

• Mirrors, photographs and videos.


• Standing upright, Side shift and holding position for ten

seconds, away from the convexity of curve.

Wall and balance stabilization in standing with thoracic curveAssistive correction of right thoracic curve in standing

(A)

Here the patient have left thoracolumbar (A) and performing in brace side

shift to the right


• Sit upright, Side Shift (B) and hold

for ten seconds, away from the

convexity of the spine (A).

• Sit to stand, to encourage

transition control of everyday

movements, while maintaining the

curve away from the convexity of

the curve.

A B


“We encourage the mantra of “think Shift” with

everyday activities.” (Tony Betts, 2015)

Here the patient (with right thoracolumbar) is performing side shift to the left in sit-to-stand (A) and standing (B) as part of ADL’s

A B

Scientific EvidenceAPPENDIX 4

Side shift exercise and hitch exercise

Toru M aruyama, M D, PhD,1 Katsushi Takeshita, M D, PhD,2 Tomoaki K itagawa, M D, PhD,3

and Yusuke Nakao, M D4

1

Associate Professor, Department of Orthopaedic Surgery, Saitama M edical Centre, Saitama M edical University,

Kawagoe, Saitama, Japan2

Assistant Professor, Department of Orthopaedic Surgery, Faculty of M edicine, University of Tokyo, Bunkyo-ku,

Tokyo, Japan3

Department of Orthopaedic Surgery, Faculty of M edicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan4

Department of Orthopaedic Surgery, Saitama M edical Centre, Saitama M edical University, Kawagoe, Saitama, Japan

ABSTRACT

We use side shift exercise and hitch exercise for treatment of idiopathic scoliosis. These physical therapies can

be indicated regardless of the curve magnitude or patients’ skeletal maturity. Results of side shift exercise used

in combination with part-time brace-wearing treatment or used for the curves after skeletal maturity are better

than natural history. Side shift exercise and hitch exercise are useful treatment options for idiopathic scoliosis.

INTRODUCTION

Side shift exercise was first described by M ehta

(1985), who reported the results of side shift exercise

of 35 patients (33 girls and 2 boys) whose average age

was 14.1 years and average Cobb angle was 23.88at

the beginning of the treatment. After a mean

treatment period of 1.9 years, their average Cobb

angle changed to 24.88. Of 42 curves in 35 patients,

nine curves (21.4%) improved of 58 or more and

change of 21 curves (50%) were less than 48.

We learned side shift exercise and another specific

exercise, hitch exercise, directly from Dr. M ehta and

have adopted these exercises as physical therapy for

idiopathic scoliosis since 1986.

As we prescribe part-time wearing of brace for

most of the patients who have an indication for

bracing (e.g., Cobb angle. 258, Risser sign 0–IV),

physical therapy is conducted in combination with

part-time bracing in such patients. Other indications

for physical therapy are patients whose curve is too

small for bracing (e.g., Cobb angle, 258) or patients

after skeletal maturity that include after weaning

of the brace (e.g., Risser sign IV or V, postmenarche

. 2 years).

METHODS OF TREATMENT

Side shift exercise

Side shift exercise consists of the lateral trunk shift to

the concavity of the curve. Lateral tilt at the inferior

end vertebra is reduced or reversed, and the curve is

corrected in the side shift position (Figure 1). In the

standing position, patients are instructed to shift their

trunk to the concavity of the curve, to hold the side

shift position for 10 seconds, to return to the neutral

position, and to repeat this exercise at least 30 times a

day. Attention should be paid that patients shift their

trunk properly, not to bend nor rotate it (Figure 2).

I f C7 plumb line lies to the convexity of the curve at

the level of the sacrum, large shift is indicated.

Conversely, if C7 plumb line lies to the concavity of

the curve at the level of the sacrum, small shift is

indicated. In addition, in the sitting posit ion, patients

are instructed to maintain the side shift posit ion for as

long as they can. Side shift is indicated for any single

curve at any location (i.e., thoracic, thoracolumbar,

Address correspondence to Toru M aruyama, M D, PhD, Depar tment

of Orthopaedic Surgery, Saitama M edical Centre, Saitama M edical

University, 1981 Kamoda, K awagoe, Saitama, 350-8550 Japan.

E-mail: [email protected]

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N=39 girls with AIS; Mean age 12.8; Mean Cobb 37.180 (progressive scoliosis);

Risser 0-3 at start; perform either side shift or hitch or both exercises; 2.8 years

follow up (average) or to at least Risser 4.

Results:

• Cobb increased to (only) to 45.480 (mean).

• 28 (72%) were classified as unchanged (Cobb angle was within 100).

• 11 (28%) progressed (Cobb angle increased by 100 or more).

Conclusion:

Side shift exercise and hitch exercise are useful options for progressive idiopathic

scoliosis.

Stud Health Technol Inform. 2008;135:246-9.

Scientific Evidence

Mehta M.H. Active Correction by Side-Shift : An alternative

treatment for early idiopathic scoliosis. Scoliosis prevention.

Praeger, New York. 1985:126 -140.


This study was part of an un-blinded retrospective study presenting observational

and radiological results of over 2530 patients.

N=35 with AIS mean age 14.1; Average Cobb 23.880; Treatment duration: 1.9

years (mean).

Results:

• Cobb changed to 24.880 (mean).

• Of 42 curves in 35 patients, 9 curves (21.4%) improved by 50 or more.

Conclusion:

Single and multiple case reports to demonstrate positive clinical and radiological

corrections of scoliosis by Side Shifts

THE LYON APPROACH

FRANCE

History

Pierre Stagnara was the first medical director (60 years ago).

It was very specialized in the treatment of vertebral deviations,

at that time often from Polio origin.

Gabriel Pravaz was not only the inventor of the syringe,

but he also created a great pneumatic Orthopaedic

approach.

The Lyon method is not intended to provide the physiotherapist

with an original technique and specific exercises, but rather it

is intended to be a way of approaching and understanding

scoliosis

Lyon school of physiotherapy for scoliosis is one of the oldest in France

and one of the first to be integrated in the Faculty of Medicine of Lyon.

“The Lyon method combines physiotherapy and the Lyon

brace. The Lyon brace is always preceded by a plaster cast

that allows a real lengthening of the concavity beyond the

simple mobilization.”


(De Mauroy 2011).

22

+ 3D mobilization of the spine + Mobilization of the ilio+lumbar angle (lumbar scoliosis) + Therapeutic patient education (food control to avoid cast syndrome, skin care ...) + Sitting position check

Fig. 17. AutoB3D correction of scoliosis with Lyon plaster cast

The advantage of the plaster cast for scoliosis under 30 degrees is that the brace is worn only during the night. Physical therapy will continue at least once a week. When the scoliosis curve exceeds 30°, the brace must be worn during part of the day. The physiotherapist will perform physical therapy with or without brace. (figure 18)

Fig. 18. Group physiotherapy in Lyon brace

5.5 Research Results

Psychologically group physiotherapy is better because the child feels less alone in her treatment. Unfortunately, the Lyon physiotherapy method for scoliosis is not a universal

Auto 3D correction of scoliosis with Lyon plaster cast

General indications:


Specific Lyon indications = The 2 phases:

• Chaotic scoliosis: Cobb <200

• Fluctuation

• Linear scoliosis: Cobb >200

• Vicious cycle


Specifics

SCOLIOSIS

Linear

Chaotic

Specific Lyon indications = The 3 stages:

• Before bracing.

• In plaster cast.

• In Lyon brace.


Specifics

Lumbar mobilization Shoulder balance

Goals

• Improve patient motivation with bracing.

• Patient education including awareness of postural defects.

• Improve range of motion, neuromotor control of the spine,

coordination, trunk stabilization, muscular strength,

respiration and ergonomics.


Specifics

Age and treatment protocol: the exercises will adapt to the

child’s age

• Juvenile: no stretching.

• Adolescents: whole program.

• Adults: pain and disc protection.


Specifics


For physiotherapy: Ponseti.

For bracing: the Lenke.

Stage I: Lyon approach to Assessment:• The patient’s age, the postural imbalance and the Cobb angle.

Stage II: Awareness of trunk deformity:• Using visualization via mirrors and camcorder and screen.

Stage III: What to do: Example exercises:• Avoiding spinal extension – is the basis of the Lyon method.

Stage IV: What not to do and why? • Avoid: sagittal plane extreme movements (flexion/extension), shortness

of breath.

Stage V: Sport or only physiotherapy: • How to practice sport at different ages. Best and worst sport for scoliosis.

Principles of the MethodThe Five Stages

Breathing mechanics

• Rotational angular breathing,

• Synergy with diaphragm.

Muscle activation

• Endurance of the deep paraspinal and core musculature.






Pelvic mobilization

Slow reversal, hold, relax.

Derotation exercise on Swiss ball

In thoracic kyphosis.

Treatment Tools

Active and Passive

Mirrors, videos, etc., but not mandatory.

Awareness of postural defects

with camcorder.

Developing perception of the

spine with the video feed back.

Description of Most Relevant Exercise Mechanics1. Lying

1st position:

Kyphotisation with cushion.

Description of Most Relevant Exercise Mechanics2. Rolling

2nd position: Fetal position with cushion.

Description of Most Relevant Exercise MechanicsRolling

Derotation exercise on Swiss ball in kyphosis.

Description of Most Relevant Exercise Mechanics3. Sitting

Adjustment of the

lumbar lordosis in

sitting position.

Positioning of the

upper limbs. Lumbar side shift.

Description of Most Relevant Exercise MechanicsSitting

Mobilization on Swiss ball.

Balance of the shoulder girdle.

Description of Most Relevant Exercise Mechanics4. Standing


Usual sitting position for writing

and using the computer.Sports is mandatory.

Scientific Evidence

“Unfortunately, the Lyon physiotherapy method for scoliosis is

not a universal standard protocol, but has to adapt to each

child and develop during growth. It is therefore very difficult to

quantify results in terms of angular correction for scoliosis,

but it is essential when the Lyon brace is prescribed.“

(Dr Jean Claude De Mauroy)

“No scientific evidence for scoliosis under 20°, and above 20°

we always use bracing + physiotherapy. In fact it’s more Lyon

experience that Lyon method.” (Dr Jean Claude De Mauroy)

DOBOMED

POLAND

Before treatment After treatment

History

• The method was developed in 1979 by

Prof. Krystyna Dobosiewicz (died in

2007).

• Used routinely in Poland since 1982.

• It was later used (regularly since 2000)

in the Department of Rehabilitation of

the Medical University of Katowice,

Poland.

• Used alone or in combination with

bracing (Cheneau brace).


Active 3D correction involving mobilization of the primary

curve towards curve correction, with special emphasis on

`kyphotization’ of the thoracic spine and/or `lordotization’

of the lumbar spine.

It is a conservative management that

addresses both the trunk deformity as

well as respiratory function

impairment. The Dobomed approach

has incorporated both Klapp`s position

for kyphotization of the thoracic spine

as well as Lehnert-Schroth’s approach

for active asymmetrical breathing into

its method.

Indication:


• Small, moderate and large curves (IS) can all be treated with

DoboMed.

• Method is dedicated for patients with and without brace

(Cheneau).

Goals:

1. Stabilization and correction of spine deformity / prevent

progression and or decrease the curvature of scoliosis.

2. Improve improve functionally status of patient (respiratory

function.)


Specifics

Age specific:

• “Cooperation is the basic requirement for using DoboMed.

Therefore DoboMed is not recommended for small

children.“

• Older patients: stabilization exercises NOT 3D correction


Specifics


“We don’t use own classification system. Every patient is

analyzed individually. During exercises planning we

consider the number of primary and secondary curves and

the location of the deformity.”

(Durmala Jacek, 2015)


1. Symmetrical positions for exercising.

2. Asymmetrical active movements to accomplish

3D scoliosis correction.

3. Thoracic spine mobilization to increase thoracic

flexion.

5. Transverse plane derotation. Specific treatment

emphasis is focused on the area of the curve

apex.

6. Concave rib mobilization to expand and

derotate the ribs.

7. External facilitation.

8. Respiration - directed movements of the thorax and spine to improv respiratory

function.

9. 3D displacement of vertebrae to obtain 3D scoliosis correction.

‘Phased-lock’ respiration

• A strong local pressure is applied

on the concave side during

inspiration, and a subtle

facilitation is applied on the

convex side during expiration and

the correction is stabilized.



Muscle activation

• Isometric contraction during expiration to stabilize the

correction/hypercorrection.



Beginning of

treatment session

End of treatment

session

1

9

Treatment Tools

Active and Passive

Yes – will be described by the school

The main corrective technique – forward bending:

The exercises are designed in closed kinematic chains in order to

enhance their effectiveness.

This is obtained by a strict fixation of

the pelvis and the shoulder girdle with

the upper and lower limbs.


The preparatory phase:

At the beginning of the session, after

warming up, exercises in low

positions are performed.

These positions free the back musclesfrom the influence of gravitation. Probablybecause of that, the largest correction ofscoliosis was observed in low positions.

Between exercises in low positions a very

difficult intermittent exercise – a break was

performed. The break consists of active

maximum kyphotization of the thoracic spine

and lordotization of the lumbar spine with

simultaneous 3D correction of the spine

deformation.


Later active 3D auto-correction exercises in

upright

positions:

• Active 3-dimensional auto-correction exercises

are performed in high positions (the spine is

placed vertically) and gravitation affects fully the

back muscles.


• The course of action focuses on the vicinity of the apicalvertebra.

• On the concave side of the curvature a strong local pressure isapplied, and on the convex side a subtle facilitation is applied.

• The correction and facilitation are phase-locked with theparticular phases of the respiratory cycle.

– In details, during inspiration a strong local pressure is appliedon the concave side,

– and during expiration a subtle facilitation is applied on theconvex side.

– During expiration, achieved correction or hipercorrection isbeing stabilized by an isometric contraction .


Summery

Physical Therapy for Adolescents with Idiopathic ScoliosisBy Josette Bettany-Saltikov, Tim Cook, Manuel Rigo, Jean Claude De Mauroy, Michele Romano, Stefano Negrini, Jacek Durmala, Ana del Campo, Christine Colliard, Andrejz M'hango and Marianna BialekDOI: 10.5772/33296

Scientific Evidence


N=25 girls with progressive AIS; Mean Cobb 26.10; Full time (mean 11 hours)

Cheneau brace and DoboMed daily therapy x 2 weeks and follow-ups of mean

53 months therapy; Radiograph once a year and upon d/c from brace.

Results:

56% of patients achieved stabilization of curve; 3 patients (12% ) exceeded 500

Cobb.

Conclusion:

Stabilization of progressive thoracic scoliosis was achieved in girls using the

Cheneau brace and specific DoboMed physiotherapy

Scientific Evidence


N=28 girls with progressive AIS (mean age 12); Thoracic Cobb was 300 with Perdiolle

angle of axial rotation of apical vertebra 8.70 (mean). In the lumbar Cobb was 29.10 with

apical rotation of 11.90 (mean); Full time Cheneau (12.9 hours mean) with daily DoboMed;

duration of therapy was 43 months (mean); 11 patients completed therapy. Radiograph

every year.

Results:

Final radiograph: Thoracic Cobb was 340 and rotation of 10.50 (mean); in the lumbar

Cobb was 29.20 with rotation of 13.40 (mean); 3 patients (11% ) exceeded 500 Cobb.

Conclusion:

Stabilization of progressive thoracic scoliosis during the period of rapid adolescent growth

was achieved in 89% of girls using the brace and specific DoboMed physiotherapy

THANK YOU!

ANY QUESTIONS?

Additional References

Bettany-Saltikov. J et al. Physical Therapy for Adolescent with Idiopathic Scoliosis.

ISBN 978-953-51-0459-9, Published: April 5, 2012.

Fusco. C., Zaina. F., atanasio. S., Romano. M., Negrini. A., Negrini. S. Physical

Exercises in the Treatment of Adolescent Idiopathic Scoliosis: An Updated

Systematic Review. Physiother Theory Pract. 2011 Jan; 27(1):80-114.

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