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

2. United States
Surgery
Bracing
Observation

3. Europe
Surgery
Bracing
Physical Exercises

4. 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”

5. 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.

6. 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 curve threshold
Reduction of pain
Improvement of vital capacity

7. Team Members Physician Physical Therapist Orthotist Surgeon
Psychologist
Patient
Parents

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

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

10. 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

11. 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

12. 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

13. SOSORT 2011 Recommendations for Exercises
See handout

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

21. 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 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.

22. 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.

23. Otman et al (2005)
The Efficacy of Schroth’s 3-dimensional Exercise Therapy in the Treatment of Adolescent Idiopathic Scoliosis in Turkey
50 patients, , 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

24. 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)

25. 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 ± 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.

26. 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.

27. 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.

28. 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.

29. 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

33. 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).

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

37. 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

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

40. Schroth Evaluation
Body Blocks

41. 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

42. Lumbar Block
Waist lines
Lumbar prominence
Lordosis

43. 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

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

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

46. 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)

47. 3 c right

48. 3 cp Right

49. 4c Right

50. 4 cp Right

51. Schroth Postures Habitual Posture Resting Posture Conscious Posture
Correct Posture

52. 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

53. 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

54. 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.

55. Schroth Treatment
Manual Techniques

56. Side bending in sitting

57. 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

58. Side shift in sitting

59. 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)

60. Derotation of the rib hump in sitting and supine

61. 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

62. Derotation of the Ventral Prominence in Sitting and Supine

63. 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

64. Derotation of the lumbar prominence

65. 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

66. Stretching of thoracic concavity

67. 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

68. Stretching of lumbar concavity

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

70. 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

71. 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

72. Positioning Supports (towel roll, rice bag)
Positioning Supports (towel roll, rice bag). Positions maintained 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

73. 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)

74. 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

75. 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)

76. 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

77. 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.

78. 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

79. Positioning for elongation Right thoracic, Left lumbar curves
Incorrect
Correct

80. 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.

81. 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)

82. Standing with Poles

83. Side Hanging from ladder rungs

84. Pelvic Tilt (depression)

85. 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

86. Finding a Schroth-trained therapist

87. Thank You!!