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
Classification System
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
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.
Classification System
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
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.
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
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
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.
Classification System
Schroth blocks for sagittal plane deformities
Hyperkyphosis Lumbar kyphosis Spinal inversion
c
b
a
.<
<
c
b
a
.<
Classification System
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
Treatment Indication, Goals and Age
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
Principles of Correction
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.
Principles of Correction
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
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 Mechanics2. Side-lying – for All Curves
Description of Most Relevant Exercise Mechanics2. Side-lying – for All Curves
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.
Material and Methods:
• 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
Definition of Treatment
“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)
Classification System
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
Classification System
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
Classification System
Schroth scoliosis body blocks
(3CP) (3C) (4C) (4CP)
Classification System
KT KT + KT - KL
K = Kyphosis; T = Thoracic; L = Lumbar
Schroth sagittal plane deformities body blocks
Treatment indication:
• SOSORT 2011 guidelines.
Goals:
Treatment Indication, Goals and Age
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.
Treatment Indication, Goals and Age
Specifics
3D Principles of Correction
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.
The Use of Breathing Mechanics, Muscle
Activation, and Mobilization
The Use of Breathing Mechanics, Muscle
Activation, and Mobilization
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
(outward – backward)
ST
Description of Most Relevant Exercise Mechanics
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
(outward – backward)
ST
Description of Most Relevant Exercise Mechanics
3. The Sail
Best for thoracic curve
• “A very effective stretching exercise for
the thoracic concavity.”
(Hennes Axel, 2015)
Description of Most Relevant Exercise Mechanics
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.
Definition of Treatment
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.
Classification System
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)
Treatment indication:
• SOSORT 2011 guidelines.
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.
Treatment Indication, Goals and Age
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.
Treatment Indication, Goals and Age
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
3D Principles of Correction
ExamplesActive self-correction in sitting
Active self-correction in sitting
leaning forwardMaintaining self-correction
sit <> stand
Maintaining self-correction landing on a wall
The Use of Breathing Mechanics, Muscle
Activation, and Mobilization
Breathing Mechanics
• To help with the corrective movements.
Muscle activation
• To help with the stabilization of the trunk and maintaining the
alignment.
Mobilization and flexibility
• 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.”
Description of Most Relevant Exercise Mechanics
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
Description of Most Relevant Exercise Mechanics
.
• 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.
Description of Most Relevant Exercise Mechanics
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
Do
wn
load
ed f
rom
in
form
ahea
lth
care
.com
by
Dr
Ste
fan
o N
egri
ni
on
03
/30
/11
Fo
r per
sonal
use
only
.
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
fan
o N
egri
ni
on
03
/30
/11
Fo
r per
sonal
use
only
.
Study: To confirm whether the indication for treatment with specific exercises for AIS
has changed in recent years - a systemic review.
Material and Methods:
• 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.
Material and Methods:
• 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.
Material and Methods:
• 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.
Classification System
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
Treatment indication:
• 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 .
Treatment Indication, Goals and Age
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.)
Treatment Indication, Goals and Age
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.
Treatment Indication, Goals and Age
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
Principles of Correction
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.
Principles of Correction
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.
Principles of Correction
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
Description of Most Relevant Exercise Mechanics
Summery
1. Sensorimotor balance training.
2. Mobilization and flexibility techniques.
3. Muscles activation and corrective patterns.
4. Neuromuscular re-education.
5. Auto-correction.
Principles of Correction
Stage III – The Exercises
An example of corrective
patterns.
The Use of Breathing Mechanics, Muscle
Activation, and Mobilization
Breathing mechanics
• Breathing into the concavities using
scoliometer in supine progressing to
functional position (sitting and standing).
Muscle activation
• To create corrective tension.
Mobilization and flexibility
• 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.
Activities of Daily Living (ADL)
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
Material and Methods:
• 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.
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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
Classification System
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:
• SOSORT 2011 guidelines.
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.
Treatment Indication, Goals and Age
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.
Treatment Indication, Goals and Age
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).
3D Principles of Correction
3D Principles of Correction
FIGURE 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.
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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
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.
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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
The Use of Breathing Mechanics, Muscle
Activation, and Mobilization
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.
The Use of Breathing Mechanics, Muscle
Activation, and Mobilization
Mobilization and flexibility
• Principles of Maitland for joint tissues and Myofascial release
techniques for soft tissues.
Treatment Tools
Active and Passive
• Mirrors, photographs and videos.
Description of Most Relevant Exercise Mechanics
• 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
Description of Most Relevant Exercise Mechanics
• 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
Activities of Daily Living (ADL)
“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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Material and Methods:
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.
Material and Methods:
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.”
Definition of Treatment
(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:
• SOSORT 2011 guidelines.
Specific Lyon indications = The 2 phases:
• Chaotic scoliosis: Cobb <200
• Fluctuation
• Linear scoliosis: Cobb >200
• Vicious cycle
Treatment Indication, Goals and Age
Specifics
SCOLIOSIS
Linear
Chaotic
Specific Lyon indications = The 3 stages:
• Before bracing.
• In plaster cast.
• In Lyon brace.
Treatment Indication, Goals and Age
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.
Treatment Indication, Goals and Age
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.
Treatment Indication, Goals and Age
Specifics
Classification System
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.
The Use of Breathing Mechanics, Muscle
Activation, and Mobilization
The Use of Breathing Mechanics, Muscle
Activation, and Mobilization
Mobilization and flexibility
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
Activities of Daily Living (ADL)
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).
Definition of Treatment
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:
• SOSORT 2011 guidelines.
• 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.)
Treatment Indication, Goals and Age
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
Treatment Indication, Goals and Age
Specifics
Classification System
“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)
3D Principles of Correction
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.
The Use of Breathing Mechanics, Muscle
Activation, and Mobilization
Muscle activation
• Isometric contraction during expiration to stabilize the
correction/hypercorrection.
The Use of Breathing Mechanics, Muscle
Activation, and Mobilization
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.
Description of Most Relevant Exercise Mechanics
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.
Description of Most Relevant Exercise Mechanics
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.
Description of Most Relevant Exercise Mechanics
• 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 .
Description of Most Relevant Exercise Mechanics
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
Material and Methods:
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
Material and Methods:
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.