4Possible explanations for treatment differences Literature published in languages other than English not cited by US researchersResearch typically with pts with mild AIS (< 30⁰) – which is generally not treated in USLack of support/interest promoting research in this area in USAll conservative methods often considered together as “alternative treatment”
5History of the Schroth Method First developed in 1921 in GermanyAfter WWII, East Germany ordered a 3-year investigation of the methodResulted in the Schroth House being “nationalized” to allow access to more peopleIn 1955, moved to West GermanyIn 1961, Schroth Klinic opened in Bad Sobernheim.
6Schroth Objectives Improvement of posture and appearance Improvement of static/dynamic postural control and stability (achieve/maintain “conscious posture” in ADLs)Deceleration or prevention of curve progressionAvoidance of braces or surgerySupport for decision-making curve thresholdReduction of painImprovement of vital capacity
7Team Members Physician Physical Therapist Orthotist Surgeon PsychologistPatientParents
8Proprioceptive and visual stimuli Passive corrective forces Schroth ElementsGuiding resistanceFacilitationProprioceptive and visual stimuliPassive corrective forces
10Review of the Literature 2005:SOSORT (International Society on Scoliosis Orthopaedic and Rehabilitation Treatment)Established to verify the scientific basis and efficacy of exercises & bracingScoliosisNew journal launched to promote new research on this topic
11SOSORT 2005Consensus agreement for standard features in rehab for scoliosis:3-D Autocorrection exercisesADL trainingStabilization of the correct posturePatient educationMultidisciplinary team – MD, PT, Orthotist
123-D active correction of curve Autocorrection3-D active correction of curveSEAS (Scientific Exercises Approach to Scoliosis)Schroth MethodDobomed ProgramOther programs approved – see SOSORT 2011 Recommendations
13SOSORT 2011 Recommendations for Exercises See handout
14Scoliosis Journal 2010 “Rehabilitation Schools for Scoliosis” series To investigate efficacy of exercise on scoliosis with clearly defined guidelines for researchStudies to include specifics of treatment including description and pictures of exercisesStudies should follow SOSORT recommendations
15Weiss (2010) - Scoliosis Review of conservative approaches: Outcome of brace treatment determined primarily by in-brace correction and patient complianceSome evidence that correct bracing can stop curve progressionOP treatment sufficient for patients with spinal deformity without other limitationsIP rehab recommended for patients with pain or restrictive ventilatory disorder
16Fusco et al (2011) Updated systematic review 20 studies showing: Detailed Appendix describing several exercise methods with pictures20 studies showing:Efficacy of exercise in reducing rate of progression &/or improving Cobb angleExercise effective in reducing brace prescriptionExercise improves strength, mobility, and balance
17Fusco et al (cont)Physical exercises, if administered correctly, can prevent curve progression and prevent need for bracingPTs need to use specific exercises chosen according to strong scientific sourcesLiterature using unsound methodology and interventions can suggest that physical exercises are not effective, while scientifically-based physical exercises appear to be efficacious
18PE Efficacy SummaryNeed for further studies, esp RCTs, following SOSORT criteria, to improve level of evidencePresent evidence is sufficient to consider PEs as an appropriate intervention for AIS3-D Autocorrection exercises appear to be best, but cannot yet support a specific programNot yet clear if inpatient vs outpatient or intrinsic vs extrinsic exercises most effective
19Recently Published Research Physical exercises in the treatment of adolescent idiopathic scoliosis: an updated systematic review – Physiotherapy Theory and Practice (2011) - PEs can improve the Cobb angles of individuals with AIS and can improve strength, mobility, and balance.Scoliosis short-term rehabilitation (SSTR) according to 'Best Practice' standards-are the results repeatable? Scoliosis (2012) – angle of trunk rotation and VC improved and repeatable
21Weiss HR, Cherdron J (1994)Effects of Schroth's rehabilitation program on the self concept of scoliosis patients37 scoliotic patients (33 female, 4 male), aged yearspre-/post-interview study on the basis of the Frankfurt self-concept scales (FSKN)statistically significant changes in a positive direction found for 7 of 10 self-concept scalesgeneral coping ability; sensitivity and mood; self-assertion towards groups and significant others; perceived appreciation by others; feelings towards and relationship with others; self-worth; and ability to make contact and interact.
22Weiss et al (2003)Incidence of Curvature Progression in Idiopathic Scoliosis Patients Treated with Scoliosis In-patient Rehabilitation (SIR): an age- and sex-matched controlled studyTwo independent patient groups matched by age and sex at diagnosisOne group was untreated and the other received scoliosis in-patient rehabilitation (SIR) (Schroth)Incidence of progression in groups of untreated patients ranged from 1.5-fold to 2.9-fold higher than in groups of patients treated with SIR, even when SIR-treated groups included patients with more severe curvatures.
23Otman et al (2005)The Efficacy of Schroth’s 3-dimensional Exercise Therapy in the Treatment of Adolescent Idiopathic Scoliosis in Turkey50 patients, , average age 14.15±1.69 yearsOutpatient 5 days/wk, 4 hr/day x 6 wk then home programEvaluated Cobb angle, vital capacity and muscle strength of the patients before treatment, and after 6 weeks, 6 months and one yearSchroth technique positively influenced the Cobb angle, vital capacity, strength and postural defects
24Otman et al (2005)Cobb angle 26.1⁰ average before treatment, 23.45⁰ after 6 weeks, 19.25⁰ after 6 months and 17.85⁰ after one year (p<0.01)VC average 2795 ml before treatment, reached 2956 ml after 6 weeks, 3125 ml after 6 months and 3215 ml after one year (p<0.01)
25Jelacic et al (2011)Barcelona Scoliosis Physical Therapy School–BSPTS–based on classical Schroth principles: short-term effects on back asymmetry in idiopathic scoliosisRetrospective, 47 pts treated exclusively with exercises. Mean age ± 5.78 years.Surface topography (Formetric) was performed to measure trunk imbalance, surface rotation and lateral deviation before and after the treatment period.Improvements noted in mean trunk imbalance, lateral deviation mean and max, and surface rotation.
26Schreiber et al (2013)The effects of a 6-month Schroth intervention for Adolescent Idiopathic Scoliosis (AIS): preliminary analysis of an ongoing randomized controlled trial31 patients with AIS, aged 10-18, with curves from 10°-45°, wearing a brace or not. 16 randomized to Schroth with standard care, and 15 to standard care alone (monitoring or bracing) for six months.Schroth exercises showed a small but positive influence on self-efficacy, self-image, pain and back muscle endurance.
27Schroth TermsRib Hump – thoracic convexity. Most rotated, most prominent, and most posterior aspect at the apex. Ribs are rotated posteriorly and spread apart resembling the “inhalation position”Weak Side – ribs of the thoracic concavity are closer and lower, resembling the “exhalation position”. Ribs are rotated forward. Area appears flat and hollowed.
28Schroth TermsLumbar Prominence – Lumbar convexity. Extensor muscles become overstretched and are displaced posteriorly. Leads to asymmetric waistline, full on convex side and accentuated on concave side.Weak Point – Lumbar concavity. TPs rotated anteriorly and muscles/connective tissues shortened. Waist is accentuated and pelvis appears shifted to this side.
29Schroth TermsProtracted Shoulder – Shoulder on thoracic convex side is IR with inferior angle of scapula moved upward and tilted away from the ribcage.Retracted shoulder – Shoulder on thoracic concave side is ER and may sink into the thoracic cavity (scapula appears to wing, but this is really secondary to lack of rib support).May vary if a high thoracic or cervical compensatory curve is present
33Schroth TermsVentral Flat Zone – Ventral aspect of the rib hump. Ribcage appears compressed; apical ribs closer and rotated posteriorly. Breast looks smaller.Ventral Prominence – Lower ribs of thoracic concave side are ventrally more prominent due to spinal rotation. Creates a “ventral rib hump”Prominent Hip – Pelvis deviated laterally as compensation for either T or L curve; causes hip adduction and raised iliac crest on that side. Increased WB on side opposite of prominent hip. (Prominent hip usually opposite side of primary curve).
36Schroth Evaluation Medical History Age/gender/age at first menses X-rays?Cobb AngleBrace? Type/schedule/compliancePrevious treatment?
37Risser Sign*Radiographic measurement of skeletal maturity based on ossification of the iliac apophysis *Ossification begins laterally; progresses medially *Proceeds from 0 (no ossification) to 5 (ossified apophysis fused completely to ilium
43Thoracic Block Scapular position (height, orientation, symmetry) Angle of inferior borderRib humpSpace between arm and bodyRib position (widened, narrowed, elevated)Breast height/size
44Shoulder Block Level of shoulders Protraction/retraction Head position Upper thoracic/cervical curve
45Schroth EvaluationForward Bend TestFlexibility – side shift, side bend, finger-to-floor measurement (lateral flexion), active rotation
46Schroth Classification Named by position of thoracic convexity (right/left)Static standing posture determines primary curve (increased WB on side of primary curve)3c = primary thoracic curve4c = primary lumbar curvep = pelvic involvement (lateral shift, elevation away from primary convexity)
52Schroth Postural Terms Habitual Posture – Resting scoliotic positionRelaxed Posture – Gravity-eliminated, lying. Side lying on the concave side of the main curve is preferred.For primary thoracic curves, on the thoracic concave side with knees flexedFor primary lumbar curves with small or no thoracic curve, on the lumbar concave sideFor double major curves, on thoracic concave side with lower leg flexed and upper leg extended to stretch the lumbar concavityAdd slide on positioning with supports
53Schroth Postural Terms Conscious Posture - Postural correction as close to physiologically-typical posture as possible without requiring great physical or cognitive effort.Goal is to transfer this posture from exercise to dynamic alignment for daily lifeSymmetrical WB in sitting and standing (can depress the elevated side or raise the opposite side in sitting), correction of pelvic shift, shift of ribcage toward thoracic concave side
54Schroth Postural Terms “Correct Posture” – Exercise position that approaches the flexibility threshold of the curve; attempts to reverse the curve.Requires concentration and coordination, correct breathing, and specific muscle tension and lengtheningVisual feedback provided with mirrors in front and backTherapist provides specific resistances and facilitation/elongation, instructions, and feedback.
57Side Bending Used to test flexibility of curve and for mobilization Pt sitting on table, arms crossed, bring to neutral, upright spine as ableTest thoracic and lumbar curves bilaterallyMobilize by placing one hand on apex, other on opposite shoulderVentral, medial, cranial mobilization to passively correct rib hump
59Side Shift Pt sitting in chair with UEs supported on table PT standing on thoracic concave sideOne hand reaches across front of pt and grasps rib hump; other hand at transitional vertebra (do not allow movement past this point)Translation of rib hump toward concave side (medial translation with some anterior derotation)
60Derotation of the rib hump in sitting and supine
61Derotation of Rib HumpIn sitting, passively retract shoulder. Mobilize rib hump ventral, medial, cranial.Pt can do this actively by bringing shoulder back, down, and externally rotatingIn supine, ER protracted shoulder, place support under retracted shoulder. Stabilize pelvis in posterior direction while mobilizing rib hump forward and medialPt can hold corrected position
62Derotation of the Ventral Prominence in Sitting and Supine
63Derotation of ventral prominence Pt sitting on chair with UEs supported on tableBring retracted shoulder forwardMobilize ventral prominence (thoracic concave side) posterior, lateral, cranialIn supine, ER protracted shoulderTherapist stands on opposite side. “Iron” prominence laterally and dorsallyCan use other hand to bring lumbar prominence forward
65Derotation of the lumbar prominence In sitting, stabilize rib hump in anterior/medial directionMobilize lumbar prominence anteriorly and mediallyIn prone, place thumb over apical transverse process (most rotated/prominent TP)Place other hand on top of thumb and derotate anteriorly and mediallyCan also specifically mobilize segments to increase extension, rotation as needed
67Stretching of thoracic concavity Lie on thoracic convex side with support under rib humpDo not lie on convexity if curve is severe or non-flexibleStretch soft tissue at least 20 secCan also provide massage, ribcage mobilization, fascial techniquesPt can actively pull top arm up on inhalation while therapist fixes rib downward with exhalation and holds; move segmentally up rib cage
69Stretching of lumbar concavity Side lying on lumbar convexity over supportPassive mobilization and stretching of concavity
70PNF Posterior Depression Side lying on thoracic concavity with support under lumbar convexityProvide forward/diagonal resistance to upper ischial tuberosityPt actively pushes into the resistance in posterior depression
71Facilitated Breathing Hand placement on concavities (weak side, weak point, ventral flat zone)Can work in one area at a time or 2 simultaneously if patient is ablePalpate breathing and sync your breathing with patientBegin to provide resistance during inspiration in medial, forward directionAsk patient to breathe “out, back, and up” into your hands
72Positioning Supports (towel roll, rice bag) Positioning Supports (towel roll, rice bag). Positions maintained minSupineUnder retracted shoulderUnder rib humpUnder lumbar prominenceUnder pelvis to derotate in a primary thoracic curve with pelvic involvement (not in primary lumbar curve; can worsen lumbar rotation)UE position based on curve type
73Positioning Supports Prone Under forehead Under protracted shoulder Under ventral prominenceUnder pelvis to derotate in a primary thoracic curve with pelvic involvement (not in primary lumbar curve; can worsen lumbar rotation)
74Positioning Supports Side lying Lie on side of thoracic concavity Roll support under lumbar convexityBottom arm above head; head rests on armActive exercise – Depress upper leg caudally, lift off surfaceAdd slide for opposite side
75Positioning Corrections UE Positioning for Symmetrical thoracic spine:90 degree abduction with elbows flexed at 90 degrees.Isometric contraction of scapular adductor and serratus anterior corrects sagittal plane deformity (shoulders positioned back for kyphosis reduction, shoulders positioned forward for flat back correction)
76Positioning Corrections Positioning for thoracic curve:UE on thoracic convex side at 90 degree abduction/90 degree elbow flexion.Patient can actively ER and adduct scapula to self-mobilize rib humpUE on thoracic concave sidePositioned diagonally to stretch the concavity
77Positioning Corrections Positioning for lumbar curve:Active depression of pelvis in caudal direction on lumbar concave side to stretch lumbar concavityPelvic shift away from the prominent hip in curves with pelvic involvement. Body weight should be transferred to side of prominent hip.
78Conscious PostureGoal is to teach the conscious posture so that it can be maintained without supports throughout the dayCan use breathing corrections as self-facilitation of conscious posturePelvic symmetry, equalize WB, bring convexities medial and anteriorChange postural habits – overhead reach with UE of thoracic concave side, WB on UE of thoracic concave side in sitting for elongation
79Positioning for elongation Right thoracic, Left lumbar curves IncorrectCorrect
80Pelvic CorrectionsFeet parallel. Knees unlocked. Pelvis balanced over center of feet.Adjust anterior/posterior tilt to physiological position (about 30 degrees).Lateral shift of pelvis to correct prominent hip (Increase WB away from primary curve, shift pelvis toward primary curve).Derotate the pelvic block (but do not correct a primary lumbar curve with pelvic involvement – can increase the lumbar rotation)Depress elevated hip. In sitting, can elevate the opposite side with passive support.
81Exercise Sequencing Positioning Elongation of spine with normal breathingCorrective breathing. Use isometric tension to hold corrected posture on exhalation as able.Dynamic exercise performed during exhalation for predetermined # of reps.Rest between sets maintaining conscious posture.ie 4 sets of 6 reps (each repetition = 1 breathing cycle)
85Schroth Training Options Barcelona School (Dr. Manuel Rigo)Spain, Israel, or Wisconsin – 10-day course for part 1 certification AND 6-day course 1-3 years later for Part 2 certificationSchroth (Asklepios) coursesBad Sobernheim, Germany – 10-day certification, recommend 3-yr refresher (English courses available)New York, NY – 3 3-day course and testing for certification – Courses also offered in Latvia, Estonia, Hungary, S. Korea, Thailand