Introduction to the Schroth Method for Scoliosis Treatment Laura Dobrich, PT, PCS, Schroth Therapist PPTA Pediatric SIG October 25, 2013

United States Surgery Bracing Observation

Europe Surgery Bracing Physical Exercises

Possible explanations for treatment differences Literature published in languages other than English not cited by US researchers Research typically with pts with mild AIS (< 30⁰) – which is generally not treated in US Lack of support/interest promoting research in this area in US All conservative methods often considered together as “alternative treatment”

History of the Schroth Method First developed in 1921 in Germany After WWII, East Germany ordered a 3-year investigation of the method Resulted in the Schroth House being “nationalized” to allow access to more people In 1955, moved to West Germany In 1961, Schroth Klinic opened in Bad Sobernheim.

Schroth 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 progression Avoidance of braces or surgery Support for decision-making process @ curve threshold Reduction of pain Improvement of vital capacity

Team Members Physician Physical Therapist Orthotist Surgeon Psychologist Patient Parents

Proprioceptive and visual stimuli Passive corrective forces Schroth Elements Guiding resistance Facilitation Proprioceptive and visual stimuli Passive corrective forces

Specific mobilization Self-correction Treatment Components Positioning Specific mobilization Self-correction Breathing Correction Active mobilization Stabilization (exercises) Schroth in ADL

Review of the Literature 2005: SOSORT (International Society on Scoliosis Orthopaedic and Rehabilitation Treatment) Established to verify the scientific basis and efficacy of exercises & bracing Scoliosis New journal launched to promote new research on this topic

SOSORT 2005 Consensus agreement for standard features in rehab for scoliosis: 3-D Autocorrection exercises ADL training Stabilization of the correct posture Patient education Multidisciplinary team – MD, PT, Orthotist

3-D active correction of curve Autocorrection 3-D active correction of curve SEAS (Scientific Exercises Approach to Scoliosis) Schroth Method Dobomed Program Other programs approved – see SOSORT 2011 Recommendations

SOSORT 2011 Recommendations for Exercises See handout

Scoliosis Journal 2010 “Rehabilitation Schools for Scoliosis” series To investigate efficacy of exercise on scoliosis with clearly defined guidelines for research Studies to include specifics of treatment including description and pictures of exercises Studies should follow SOSORT recommendations

Weiss (2010) - Scoliosis Review of conservative approaches: Outcome of brace treatment determined primarily by in-brace correction and patient compliance Some evidence that correct bracing can stop curve progression OP treatment sufficient for patients with spinal deformity without other limitations IP rehab recommended for patients with pain or restrictive ventilatory disorder

Fusco et al (2011) Updated systematic review 20 studies showing: Detailed Appendix describing several exercise methods with pictures 20 studies showing: Efficacy of exercise in reducing rate of progression &/or improving Cobb angle Exercise effective in reducing brace prescription Exercise improves strength, mobility, and balance

Fusco et al (cont) Physical exercises, if administered correctly, can prevent curve progression and prevent need for bracing PTs need to use specific exercises chosen according to strong scientific sources Literature using unsound methodology and interventions can suggest that physical exercises are not effective, while scientifically-based physical exercises appear to be efficacious

PE Efficacy Summary Need for further studies, esp RCTs, following SOSORT criteria, to improve level of evidence Present evidence is sufficient to consider PEs as an appropriate intervention for AIS 3-D Autocorrection exercises appear to be best, but cannot yet support a specific program Not yet clear if inpatient vs outpatient or intrinsic vs extrinsic exercises most effective

Recently 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

Weiss HR, Cherdron J (1994) Effects of Schroth's rehabilitation program on the self concept of scoliosis patients 37 scoliotic patients (33 female, 4 male), aged 20-57 years pre-/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 scales general 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.

Weiss et al (2003) Incidence of Curvature Progression in Idiopathic Scoliosis Patients Treated with Scoliosis In-patient Rehabilitation (SIR): an age- and sex-matched controlled study Two independent patient groups matched by age and sex at diagnosis One 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.

Otman et al (2005) The Efficacy of Schroth’s 3-dimensional Exercise Therapy in the Treatment of Adolescent Idiopathic Scoliosis in Turkey 50 patients, 1999- 2004, average age 14.15±1.69 years Outpatient 5 days/wk, 4 hr/day x 6 wk then home program Evaluated Cobb angle, vital capacity and muscle strength of the patients before treatment, and after 6 weeks, 6 months and one year Schroth technique positively influenced the Cobb angle, vital capacity, strength and postural defects

Otman 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)

Jelacic et al (2011) Barcelona Scoliosis Physical Therapy School–BSPTS–based on classical Schroth principles: short-term effects on back asymmetry in idiopathic scoliosis Retrospective, 47 pts treated exclusively with exercises. Mean age 18.64 ± 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.

Schreiber et al (2013) The effects of a 6-month Schroth intervention for Adolescent Idiopathic Scoliosis (AIS): preliminary analysis of an ongoing randomized controlled trial 31 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.

Schroth Terms Rib 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.

Schroth Terms Lumbar 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.

Schroth Terms Protracted 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

Schroth Terms Ventral 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).

Schroth Evaluation Medical History Age/gender/age at first menses X-rays? Cobb Angle Brace? Type/schedule/compliance Previous treatment?

Risser 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

Cobb angle – (3 x Risser sign) Chronological Age Progression Factor Cobb angle – (3 x Risser sign) Chronological Age

Schroth Evaluation Body Blocks

Pelvic block (includes LEs) Iliac crest height/rotation pelvic shift/tilt/rotation, PSIS/ASIS height/rotation Lateral shift LE positioning, abd/add, hip rotation, knee position (recurvatum, patellar position, patellar height) foot arches/pronation/supination Shoe lift/LLD? Weight bearing symmetry

Lumbar Block Waist lines Lumbar prominence Lordosis

Thoracic Block Scapular position (height, orientation, symmetry) Angle of inferior border Rib hump Space between arm and body Rib position (widened, narrowed, elevated) Breast height/size

Shoulder Block Level of shoulders Protraction/retraction Head position Upper thoracic/cervical curve

Schroth Evaluation Forward Bend Test Flexibility – side shift, side bend, finger-to-floor measurement (lateral flexion), active rotation

Schroth 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 curve 4c = primary lumbar curve p = pelvic involvement (lateral shift, elevation away from primary convexity)

3 c right

3 cp Right

4c Right

4 cp Right

Schroth Postures Habitual Posture Resting Posture Conscious Posture Correct Posture

Schroth Postural Terms Habitual Posture – Resting scoliotic position Relaxed 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 flexed For primary lumbar curves with small or no thoracic curve, on the lumbar concave side For double major curves, on thoracic concave side with lower leg flexed and upper leg extended to stretch the lumbar concavity Add slide on positioning with supports

Schroth 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 life Symmetrical 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

Schroth 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 lengthening Visual feedback provided with mirrors in front and back Therapist provides specific resistances and facilitation/elongation, instructions, and feedback.

Schroth Treatment Manual Techniques

Side bending in sitting

Side Bending Used to test flexibility of curve and for mobilization Pt sitting on table, arms crossed, bring to neutral, upright spine as able Test thoracic and lumbar curves bilaterally Mobilize by placing one hand on apex, other on opposite shoulder Ventral, medial, cranial mobilization to passively correct rib hump

Side shift in sitting

Side Shift Pt sitting in chair with UEs supported on table PT standing on thoracic concave side One 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)

Derotation of the rib hump in sitting and supine

Derotation of Rib Hump In sitting, passively retract shoulder. Mobilize rib hump ventral, medial, cranial. Pt can do this actively by bringing shoulder back, down, and externally rotating In supine, ER protracted shoulder, place support under retracted shoulder. Stabilize pelvis in posterior direction while mobilizing rib hump forward and medial Pt can hold corrected position

Derotation of the Ventral Prominence in Sitting and Supine

Derotation of ventral prominence Pt sitting on chair with UEs supported on table Bring retracted shoulder forward Mobilize ventral prominence (thoracic concave side) posterior, lateral, cranial In supine, ER protracted shoulder Therapist stands on opposite side. “Iron” prominence laterally and dorsally Can use other hand to bring lumbar prominence forward

Derotation of the lumbar prominence

Derotation of the lumbar prominence In sitting, stabilize rib hump in anterior/medial direction Mobilize lumbar prominence anteriorly and medially In prone, place thumb over apical transverse process (most rotated/prominent TP) Place other hand on top of thumb and derotate anteriorly and medially Can also specifically mobilize segments to increase extension, rotation as needed

Stretching of thoracic concavity

Stretching of thoracic concavity Lie on thoracic convex side with support under rib hump Do not lie on convexity if curve is severe or non-flexible Stretch soft tissue at least 20 sec Can also provide massage, ribcage mobilization, fascial techniques Pt can actively pull top arm up on inhalation while therapist fixes rib downward with exhalation and holds; move segmentally up rib cage

Stretching of lumbar concavity

Stretching of lumbar concavity Side lying on lumbar convexity over support Passive mobilization and stretching of concavity

PNF Posterior Depression Side lying on thoracic concavity with support under lumbar convexity Provide forward/diagonal resistance to upper ischial tuberosity Pt actively pushes into the resistance in posterior depression

Facilitated 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 able Palpate breathing and sync your breathing with patient Begin to provide resistance during inspiration in medial, forward direction Ask patient to breathe “out, back, and up” into your hands

Positioning Supports (towel roll, rice bag) Positioning Supports (towel roll, rice bag). Positions maintained 10-15 min Supine Under retracted shoulder Under rib hump Under lumbar prominence Under 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

Positioning Supports Prone Under forehead Under protracted shoulder Under ventral prominence Under pelvis to derotate in a primary thoracic curve with pelvic involvement (not in primary lumbar curve; can worsen lumbar rotation)

Positioning Supports Side lying Lie on side of thoracic concavity Roll support under lumbar convexity Bottom arm above head; head rests on arm Active exercise – Depress upper leg caudally, lift off surface Add slide for opposite side

Positioning 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)

Positioning 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 hump UE on thoracic concave side Positioned diagonally to stretch the concavity

Positioning Corrections Positioning for lumbar curve: Active depression of pelvis in caudal direction on lumbar concave side to stretch lumbar concavity Pelvic shift away from the prominent hip in curves with pelvic involvement. Body weight should be transferred to side of prominent hip.

Conscious Posture Goal is to teach the conscious posture so that it can be maintained without supports throughout the day Can use breathing corrections as self-facilitation of conscious posture Pelvic symmetry, equalize WB, bring convexities medial and anterior Change postural habits – overhead reach with UE of thoracic concave side, WB on UE of thoracic concave side in sitting for elongation

Positioning for elongation Right thoracic, Left lumbar curves Incorrect Correct

Pelvic Corrections Feet 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.

Exercise Sequencing Positioning Elongation of spine with normal breathing Corrective 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)

Standing with Poles

Side Hanging from ladder rungs

Pelvic Tilt (depression)

Schroth 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 certification Schroth (Asklepios) courses Bad 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

Finding a Schroth-trained therapist http://www.hunter.cuny.edu/pt/the-schroth-method-of-management-of-scoliosis http://www.bspts.net/bsptspts.html

Thank You!!