Physiotherapy Scoliosis Specific Exercises

(PSSE)
Scoliosis Schools Around the World

Ghana mission, 2008

Hagit Berdishevsky PT, DPT, Cert. MDT, Schroth &

BSPTS Scoliosis Therapist and Teacher Trainer
 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
 School’s Mission #1
Treating the Patient
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 #2
The Team Approach” (Rehabilitation)
Orthotist Speak the same language, involve the
patient and family

Family

Physical Doctor
Therapist
 Evolution of Change

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.
 Three Dimensional Active correction

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.
 BARCELONA SCOLIOSIS
PHYSICAL THERAPY SCHOOL
(BSPTS)
SPAIN
http://www.bspts.net

ALSO USED IN:

USA
ISRAEL
HOLLAND
 History
The third pelvis correction in 4C
1968
It is about centering the pelvis on the polygon of su
pelvis from the packet side to the center) in combi
BSPTS fully approved by Christa Lehnert Schroth
correction of the frontal plane imbalance from the
lumbar/tl curve. From a biomechanical point of vie
first derotated before being brought to the midline
produced first with derotation and then with deflec
“3-D Treatment of Scoliosis According
has to performed with some degree of self-elonga
curve forward and inwards. At the same time pelvi
correction, it has to be derotated and leveled. This
and 5th pelvis corrections but from a practical poin
to the Principles from K.Schroth and
terms 4th and 5th pelvis correction during training b
correction’ meaning that centering the pelvis goes
until 0º and level. It is easier than it resembles, it is
C.L.Schroth” non-rotated, non-tilted’.
 History

- 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
Elena Salvá PT
- 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
Manuel Rigo, MD
 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-motorial
behaviour)
 Classification System

SRS definition of curves. SRS classification by age

of onset.
Curve Apex
classification Age of onset
Upper Thoracic T3-4-5
IIS <3y
Thoracic T2-11 or
(Disc T11-12) JIS 3-10y
Lumbar L2-4 or AIS > 10y
(Disc L1-2)
Thoracolumbar T12-L1
Lumbosacral L5-S1 or
(Disc L4-5)
 Classification System
Group 2: From clinical observation to Schroth-theory (3C, 4C
Schroth groups: Schroth blocks

Deformity in sagittal plane only

Group 1 (G1):
- Hyper-kyphosis (Schuermann)
- Lordosis (Inverted back)

Deformity in 3 planes: scoliosis

Group 2: From clinical observation to Schroth-theory (3C, 4C, N3N4)
Group 1-2 (G1-2):
- Thoraco-lumbar/Lumbar

Group 2 (G2):
- 3 curve
- 4 curve
- Non-3 Non-4 (w/ or w/o lumbar)
 thoracolumbar thoracolumbar prominence prominence could becould takenbe in taken
some in border
som
rib hump.ribThe hump. figure The below figure shows
belowone shows of these one of cases these whe ca
associated associated
to a highto thoracolumbar
a high thoracolumbar curve. No curve. matters No bothmat
Classification System
thoracolumbar
blocks works
thoracolumbar
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developsdevelops
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in 4Clike
first and first
scoliosis.
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thoracic
The figure
and thoracic becomesbecome
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structu
on the co
left single lefthighsingle thoracolumbar
high thoracolumbar curve with curve a ‘quasi’ with arectilinea ‘quasi’
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signs of
region and region should andbe should
diagnosed be diagnosed as Groupas1-2 Group (Single 1-2High(Sin
Group 2: other functional types
Schroth blocks for 3D deformities
What happen when we notice
The example
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The example
progressing
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progressing
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sewould pyt lanrepresent
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ecnbalance?
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(right type corresponds d alsontotoanstructural thoracic curve (right convex in
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o secondary composite
curves appears scoliosis develops
to compensate caudal ni xevnothoracolumbar
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and c thgir( evru(L1) Group 1-2
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ry curves can be functional or become rapidly structural. Both region (right), two dcompensations
e e n t o n s e oappears
d h c i h
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Lumbar , k c o l
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or Low Thoracolumbar c a r
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at the same from
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Sometimes
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rs between
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Pelvis block is more or less symmetric and s translated.
i Sometimes it is mildly rotated, in the
rotated to the left according the polygon of sustentation).
to the right on the polygon of sustentation, becoming prominent
ooks imbalanced to the right according to the lower
Thus,
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trunk is here divided in four virtual blocks or sections, also translated - e block,
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al thoracic region is also rotated and translated to the left in
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 Classification System

Schroth blocks for sagittal plane deformities

Hyperkyphosis Lumbar kyphosis Spinal inversion

< .
.
<
c < c

b b

a a
 Classification System
2010
Rigo and Weiss radiological classification for bracing
Relates to physical therapists more than any
other radiological classification

or
or
 Treatment Indications, Goals and Age
Specifics
Treatment 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.
 Treatment Indication, Goals and Age
Specifics
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
 3D Principles of Correction

Minimal Correction and 3D stable pelvis

(Starting Position + Pelvic Corrections) =
Minimal Correction and 3D stable pelvis.

Maximum Correction
1. Auto/axial/self Elongation:
Deflection and Derotation.
2. Asymmetrical Sagittal Straightening.
3. Frontal Plane Correction.
4. Rotational Angular Breathing.
5. Stabilization.
 It is about centering the pelvis on the polygon of sus
Principles of Correction
pelvis from the packet side to the center) in combina
correction of the frontal plane imbalance from the co
lumbar/tl curve. From a biomechanical point of view,
first derotated before being brought to the midline (fr
1. Minimum Correction – before the maximum
produced correction
first with derotation and then with deflectio
has to performed with some degree of self-elongatio
• Postural Balance and 3D alignment
curve forwardofand theinwards.
lowerAtextremities,
the same time pelvis
pelvic, trunk and head - lowcorrection,
tension.
th
it has to be derotated and leveled. This w
and 5 pelvis corrections but from a practical point o
a. Translation terms 4th and 5th pelvis correction during training but
b. Rotation correction’ meaning that centering the pelvis goes al
until 0º and level. It is easier than it resembles, it is a
Specific Nomenclature: non-rotated, non-tilted’.
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
 The Use of Breathing Mechanics, Muscle
Activation, and Mobilization
Rotation Angular Breathing
• Into concavities, in direction that
promotes corrections: “outwards,
backwards”.

Muscle Activation
• Global trunk tension and expansion
• And local:
o In the prominences: “forwards,
inwards”.
o Iliopsoas, QL and others.
 The Use of Breathing Mechanics, Muscle
Activation, and Mobilization
Mobilization and Flexibility
• To release tension and assist with the correction.

Release tense lumbosacral soft tissues

(A) will facilitate lumbar correction (B)
 Treatment Tools
Active and Passive

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

thera-band, dowel, ball, yoga blocks, stool.
foam roller
 Treatment Tools
Active and Passive
Soft tissue mobilization, rib mobilization, diaphragm release, flexibility.
Description of Most Relevant Exercise Mechanics
1. Supine – for all Curves
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
In this example patient is a
4C (major lumbar).
 Description of Most Relevant Exercise Mechanics
2. Side-lying – for All Curves
Basic exercise with
increase deflexion in the
frontal plan:
Focus on Lumbar
facilitation and thorax
deflexion with increase
preciseness.

In the example to the

left patients is a 4C
(major lumbar).

At the Bottom patient

is a 3C (major
thoracic).
Description of Most Relevant Exercise Mechanics
2. Side-lying – for All Curves
Description of Most Relevant Exercise Mechanics
2. Side-lying – for All Curves
 Description of Most Relevant Exercise Mechanics
3. Muscle-Cylinder – Best for 4C (Major Lumbar)
Advance exercise with
extreme muscle
activation against
gravity.

In these examples (right

and bottom) patients are
4C (major lumbar).
 Activities of Daily Living (ADL)
Neutral Spine/Conscious Posture
Sleeping posture Exercises in brace Resting/standing

Carrying a bag

Neutral spine
and body
mechanics

++ ++
 Activity of Daily Living (ADL)
Neutral Spine / Conscious Posture
Sitting posture
 Scientific Evidence
PED I A TRI C REH A BI L I TA TI ON , 2003, VOL . 6, N O. 3–4, 209–214

Effect of conservative management on

the prevalence of surgery in patients
with adolescent idiopathic scoliosis
M . RI GO, CH . REI TER and H .-R. WEI SS

Material and method: Retrospective analysis of outcomeConclusions:

Accepted for publication: October 2003 in termsI fofconservative
prevalence of surgery
management does reduce
proportion of children with adolescent idiopathic scol
for AIS in Keywords
patients
brace receiving
treatment, conservative
Rigo-System management.
A dolescent idiopathic scoliosis, physical therapy,
Chêneau brace, scoliosis
that require surgery, it can be said to provide a real and m
ingful advantage to both the patients and the community.
surgery contended that conservative methods of treatment sh
never be ruled out from scoliosis management, because
Summary can and do offer a viable alternative to those patients
cannot or will not opt for surgical treatment.
Study design: Retrospective analysis of outcome in terms of
prevalence of surgery for adolescent idiopathic scoliosis in
patients receiving conservative management.
Objectives: To determine whether a centre with an active I ntr oduction
policy of conservative management has fewer patients who
eventually undergo surgery for adolescent idiopathic scoliosis H ow effective is the conservative management
than a centre where the practice is non-intervention. scoliosis? Whether the treatment provided is phys
Background data: The efficacy of orthoses for the treatment therapy (figure 1) or bracing, the problem has b
Brace & therapyof idiopathic scoliosis was called into question in a recent
publication. Because the prevalence of surgery in an untreated
invest igated continually. A s early as 1958, Blount e
group of patients (28.1% ) was not significantly different from [1] appeared to provide a solution and the M ilwau
that in a braced group (22.4% ), the authors concluded that brace soon became the standar d treatment of scoli
bracing appears to make no difference. Based on prior experi- worl dwide. Other brace designs introduced in the
No interventionence, this conclusion is questioned. e.g. the Boston [2] and the Wilmington braces [3], w
M ethods: Since 1991, bracing and physical therapy have been reported in the literat ure to have been effective tr
recommended for children with adolescent idiopathic scoliosis
at a centre in Barcelona, Spain. The scoliosis database was ments [4–7]. A study by N achemson and Peterson
Brace onlysearched for patients with adolescent idiopathic scoliosis corroborat ed the effectiveness of bracing. D espi te
who were at least 15 years of age at last review and who and other documented support for the efficacy
had adequate documentation of the Cobb angle. The preva- certain orthoses [8, 9], their validity has generally b
lence of surgery was compared with that of published data
from a centre where the practice is non-intervention.
Conclusion: Results: From a total of 106 braced cases out of which 97 were
followed up, six cases (5.6% ) ultimately underwent spinal
fusion. A worst case analysis, which assumes that all nine
Conservative methods of treatment with outpatient physical therapy on an intensive basis
cases that were lost to follow-up had operations, brings
the uppermost number of cases that could have undergone
spinal fusion to 15 (14.1% ). Either percentage is significant
and the application of high-correction braces are effective in reducing the prevalence of
statistically when compared to the 28.1% reported surgeries
from the centre with the policy of non-intervention.

surgery in patients with AIS .

 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:
Before 6 weeks 6 months 1 year
Cobb (0) 26.1 23.45 19.25 17.85
VC (ml) 2795 2956 3125 3215
Conclusion:
Schroth’s technique positively influenced the Cobb angle, vital capacity, strength and postural
defects in outpatient adolescents.
 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
classification Age of onset
Upper Thoracic T3-4-5
IIS <3y
Thoracic T2-11or
(Disc T11-12) JIS 3-10y
Lumbar L2-4 or AIS > 10y
(Disc L1-2)
Thoracolumbar T12-L1
Lumbosacral L5-S1 or
(Disc L4-5)
 Classification System
Schroth scoliosis body blocks

Shoulder block The altered form

of the blocks desribes
S the trunk deformity:
Thoracic block
T long side = convex

Lumbar block short side = concave

L
The blocks are
Hip - pelvic defined by the
block H neutral vertebrae

+
Anatomical Schematical Scoliosis - specific
 Classification System
Schroth scoliosis body blocks
(3CP) (3C) (4C) (4CP)
 Classification System
Schroth sagittal plane deformities body blocks

K = Kyphosis; T = Thoracic; L = Lumbar

KT KT + KT - KL
 Treatment Indication, Goals and Age
Specifics
Treatment indication:
• SOSORT 2011 guidelines.
Goals:
1. Stop curve progression at puberty
(or possibly even reduce it).
2. Prevent or treat respiratory 8 weeks post
5-year-old therapy
dysfunction. boy
3. Prevent or treat spinal pain
syndromes.
4. Improve aesthetics via postural
correction.

Lehnert-Schroth C. 2007
 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 respecting
pain and the stiffness of the
deformity.
 3D Principles of Correction

1. Auto-elongation (detorsion).
2. Deflection.
3. Derotation.
4. Rotational Breathing.
5. Stabilization.
 The Use of Breathing Mechanics, Muscle
Activation, and Mobilization

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
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, Goals and Age
Specifics
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 and Goals

• Preparation for bracing.

• Brace wearing period.
• Complete brace weaning.

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

 3D Principles of Correction
The Four Questions

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 Correction
Examples
Active self-correction in sitting
Active self-correction in sitting
leaning forward
Maintaining 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 Mechanics
Postural 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)
 Disability and Rehabilitation, 2008; 30(10): 772 – 785
Scientific Evidence
Disability and Rehabilitation, 2008; 30(10): 772 – 785

Exer ci ses r educe t he pr ogr essi on r at e of adolescent i di opat hi c scoli osi s:

Result s of a com pr ehensi ve syst em at i c r evi ew of t he li t er at ur e

Exer ci ses r educe t he pr ogr essi on r at e of adolescent i di opat hi c scoli osi s:

S. N EGRIN I, C. FU SCO, S. M IN OZZI, S. AT AN ASIO, F. ZAIN A & M . ROM AN O
Result s of a com pr ehensi ve syst em at i c r evi ew of t he li t er at ur e
ISICO ( Italian Scientific Spine Institute), M ilan, Italy
Disabil Rehabil Downloaded from informahealthcare.com by Dr Stefano Negrini on 03/30/11

Study: ToS.confirm
N EGRIN I, C. FU SCO, S. M IN OZZI, S. AT AN ASIO, F. ZAIN A & M . ROM AN O
whether the indication for treatment with specific exercises for AIS
ISICO ( Italian Scientific Spine Institute), M ilan, Italy
has changed inactrecent years - a systemic review.
A bstr
Background. A previously published systematic review (Ped.Rehab.2003 – D ARE 2004) documented the existence of the
ehabil Downloaded from informahealthcare.com by Dr Stefano Negrini on 03/30/11

evidence of level 2a (Oxford EBM Centre) on the efficacy of specific exercises to reduce the progression of AIS (Adolescent
Idiopathic Scoliosis).
Material and Methods: Aim. T o confirm whether the indication for treatment with specific exercises for AI S has changed in recent years.
Study design. Systematic review.
A bstr act
• 19 studies, one RCT (included 1654 treated patients and 688 controls) with strict M ethods. A bibliographic search with strict inclusion criteria (patients treated exclusively with exercises, outcome Cobb
Background. A previously published systematic review (Ped.Rehab.2003 – D ARE 2004) documented the existence of the
For personal use only.

degrees, all study designs) was performed on the main electronic databases and through extensive manual searching. We
evidence of level 2a (Oxford EBM Centre) on the efficacy of specific exercises to reduce the progression of AIS (Adolescent
retrieved 19 studies, including one RCT and eight controlled studies; 12 studies were prospective. A methodological and
Idiopathic Scoliosis).
inclusion criteria: patients treated exclusively with exercises. Cobb degrees was clinical evaluation was performed.
Aim. T o confirm whether the indication for treatment with specific exercises for AI S has changed in recent years.
Results. T he 19 papers considered included 1654 treated patients and 688 controls. T he highest-quality study
Study design. Systematic review.
(RCT ) compared two groups of 40 patients, showing an improvement of curvature in all treated patients after six months.
evaluated. M ethods. A bibliographic search with strict inclusion criteria (patients treated exclusively with exercises, outcome Cobb
We found three papers on Scoliosis Intensive Rehabilitation (Schroth), five on extrinsic autocorrection-based methods
For personal use only.

degrees, all study designs) was performed on the main electronic databases and through extensive manual searching. We
(Schroth, side-shift), four on intrinsic autocorrection-based approaches (L yon and SEAS) and five with no autocorrection
retrieved 19 studies, including one RCT and eight controlled studies; 12 studies were prospective. A methodological and
(three asymmetric, two symmetric exercises). Apart from one (no autocorrection, symmetric exercises, very low
clinical evaluation was performed.
methodological quality), all studies confirmed the efficacy of exercises in reducing the progression rate (mainly in early
Results and conclusion: Results. T he 19 papers considered included 1654 treated patients and 688 controls. T he highest-quality study
puberty) and/or improving the Cobb angles (around the end of growth). Exercises were also shown to be effective in reducing
(RCT ) compared two groups of 40 patients, showing an improvement of curvature in all treated patients after six months.
brace prescription.
• One RCT showed improvement of curvature in all treated patients after 6 months. We found three papers on Scoliosis Intensive Rehabilitation (Schroth), five on extrinsic autocorrection-based methods
Conclusion. I n five years, eight more papers have been published to the indexed literature coming from
(Schroth, side-shift), four on intrinsic autocorrection-based approaches (L yon and SEAS) and five with no autocorrection
throughout the world (Asia, the U S, Eastern Europe) and proving that interest in exercises is not exclusive to Western
• Apart from one, all studies confirmed the efficacy of exercises in reducing the (three asymmetric, two symmetric exercises). Apart from one (no autocorrection, symmetric exercises, very low
Europe. T his systematic review confirms and strengthens the previous ones. T he actual evidence on exercises for AIS is of
methodological quality), all studies confirmed the efficacy of exercises in reducing the progression rate (mainly in early
level 1b.
puberty) and/or improving the Cobb angles (around the end of growth). Exercises were also shown to be effective in reducing
progression rate (mainly in early puberty) and/or improving the Cobb angles brace prescription.
K eywor ds: Physical exercises, adolescent idiopathic scoliosis, conservative treatment, physiotherapy, rehabilitation
Conclusion. I n five years, eight more papers have been published to the indexed literature coming from
(around the end of growth). throughout the world (Asia, the U S, Eastern Europe) and proving that interest in exercises is not exclusive to Western
Europe. T his systematic review confirms and strengthens the previous ones. T he actual evidence on exercises for AIS is of
• ExercisesI ntrwere also shown to be effective in reducing brace prescription.
oduction
level 1b. the beginning of the previous century, mainly in
 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--
 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
Andrzej M’hango
University.
• Used alone or combined with Cheneau
bracing.
• 2004 – the first FITS course for PTs.
• 2006 – cooperation with Dr. Tomasz Kotwicki. Marianna Białek
 Definition of Treatment
3D 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, Goals and Age
Specifics
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
Goals: Specifics
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.
 3D Principles of Corrections
The Three Stages
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.
 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 Active myofascial Active relaxation for rectus

relaxation for hamstrings relaxation for erector spine. femoris with scoliosis
and erector spine. derotation maneuver.
 Principles of Correction
Stage III
Three-plane correction:
3D correction and maintenance of the new corrective patterns in functional
positions.

Stabilization of
lower trunk with 3-
dimensional
correction of
Sensory-motor Sensory-motor scoliosis
control control Stabilization of lower trunk
training on training on the with pillows sensorimotor
one leg. balance and the ball.
trainer.
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:

Single curve
Double curve
Single curve
Double curve

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.
Physiother Theory Pract Downloaded from informahealthcare.com by KU Leuven - Tijdschriften on 01/21/11

SIDE SHIFT
ROYAL NATIONAL ORTHOPAEDIC HOSPITAL
For personal use only.

UNITED KINGDOM (RNOHT)

FIGU RE 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. N ote that asymmetr y of the waistline reduced in the
hitch position.
https://www.rnoh.nhs.uk

FIGU RE 4 For double curve, hitch shift exercise is indicated. A patient is instructed to lift her heel on the convex side of the lower
 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 Treatment
3D 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
A B
the hitch position.
 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).
 Treatment Indication, Goals and Age
Specifics
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.
 3D Principles of Correction

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).
yama et al.

uyama et al.
3D Principles of Correction

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

A B C
n the convexity of the curve while keeping her hip and knee straight. N ote that asymmetr y of the waistline reduced in the
ion.
position.
3 A patient with left thoracolumbar curve (A), standing in the neutral (B), and hitch (C) position. She is instr ucted to lift
on the convexity of the cur ve while keeping her hip and knee straight. N ote that asymmetr y of the waistline reduced in the
tion.

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.
 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.

(A) Wall and balance stabilization in standing with thoracic curve

Here the Assistive
patient have left thoracolumbar
correction (A) and
of right thoracic performing
curve in brace side
in standing
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).

A B

• Sit to stand, to encourage

transition control of everyday
movements, while maintaining the
curve away from the convexity of
the curve.
 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
 APPENDIX 4
Scientific Evidence
Side shift exercise and hitch exercise
Stud Health Technol Inform. 2008;135:246-9.
Toru M aruyama, M D, PhD,1 K atsushi Takeshita, M D, PhD,2 Tomoaki K itagawa, M D, PhD,3
and Yusuke N akao, M D 4
1
Associate Professor, Department of Orthopaedic Surgery, Saitama M edical Centre, Saitama M edical University,
K awagoe, Saitama, Japan
2
Assistant Professor, Department of Orthopaedic Surgery, Faculty of M edicine, University of Tokyo, Bunkyo-ku,
Physiother Theory Pract Downloaded from informahealthcare.com by KU Leuven - Tijdschriften on 01/21/11

Tokyo, Japan
3
Department of Orthopaedic Surgery, Faculty of M edicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
4
Department of Orthopaedic Surgery, Saitama M edical Centre, Saitama M edical University, K awagoe, Saitama, Japan

Material and Methods:

ABSTRACT

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
For personal use only.
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.

follow up (average) or to at least Risser 4.after skeletal maturity that include after weaning
INTRODUCTION
of the brace (e.g., Risser sign IV or V, postmenarche
Side shift exercise was first described by M ehta . 2 years).
Results: (1985), who repor ted 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 23.88 at
• Cobb increased to (only) to 45.48 (mean).
METHODS OF TREATMENT the beginning of the treatment. After a mean
treatment period of 1.9 years, their average Cobb
0
Side shift exercise
• 28 (72%) were classified as unchangedSide(Cobb
angle changed to 24.88. Of 42 curves in 35 patients,
angle was within 100).
shift exercise consists of the lateral trunk shift to
nine curves (21.4%) improved of 58 or more and
change of 21 curves (50%) were less than 48.
the concavity of the curve. L ateral tilt at the inferior
• 11 (28%) progressed (Cobb angle increased
We learned side shift exercise and another specific
by
end vertebra is 10or0reversed,
reduced or more).and the curve is
corrected in the side shift position (Figure 1). In the
exercise, hitch exercise, directly from D r. M ehta and
have adopted these exercises as physical therapy for
idiopathic scoliosis since 1986. standing position, patient s are instructed to shift their
As we prescribe part-time wearing of brace for trunk to the concavity of the curve, to hold the side
Conclusion: most of the patients who have an indication for
bracing (e.g., Cobb angle. 258, Risser sign 0–IV),
shift position for 10 seconds, to return to the neutral
position, and to repeat this exercise at least 30 times a
physical therapy is conducted in combination with day. Attention should be paid that patients shift their
Side shift exercise and hitch exercise are useful options for progressive idiopathic part-time bracing in such patients. Other indications trunk properly, not to bend nor rotate it (Figure 2).
If C7 plumb line lies to the convexity of the curve at
for physical therapy are patient s whose curve is too
scoliosis. small for bracing (e.g., Cobb angle, 258) or patients the level of the sacrum, large shift is indicated.
 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

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.

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
 Definition of Treatment

“The Lyon method combines physiotherapy and the Lyon

brace. The Lyon brace is always preceded by a plaster cast
that++3D mobilization of the spine
allows a real lengthening of the concavity beyond the
Mobilization of the ilio+lumbar angle (lumbar scoliosis)
+Therapeutic patient education (food control to avoid cast syndrome, skin care ...)
+Sitting position check simple mobilization.”
(De Mauroy 2011).

Auto
Fig. 17. AutoB 3D correction
3D correction ofwith
of scoliosis scoliosis with
Lyon plaster cast Lyon plaster cast
 Treatment Indication, Goals and Age
Specifics

General indications:
• SOSORT 2011 guidelines.

Specific Lyon indications = The 2 phases:

• Chaotic scoliosis: Cobb <200 SCOLIOSIS
• Fluctuation

• Linear scoliosis: Cobb >200 Linear

• Vicious cycle Chaotic

 Treatment Indication, Goals and Age
Specifics

Specific Lyon indications = The 3 stages:

• Before bracing.

• In plaster cast.

• In Lyon brace.
Lumbar mobilization Shoulder balance
 Treatment Indication, Goals and Age
Specifics
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.

 Classification System

For physiotherapy: Ponseti.

For bracing: the Lenke.
 Principles of the Method
The Five Stages

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.
 The Use of Breathing Mechanics, Muscle
Activation, and Mobilization
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
Mobilization and flexibility

Pelvic mobilization Derotation exercise on Swiss ball

Slow reversal, hold, relax. 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 Mechanics
1. Lying

1st position:
Kyphotisation with cushion.
Description of Most Relevant Exercise Mechanics
2. Rolling

2nd position: Fetal position with cushion.

Description of Most Relevant Exercise Mechanics
Rolling

Derotation exercise on Swiss ball in kyphosis.

Description of Most Relevant Exercise Mechanics
3. Sitting
Adjustment of the
lumbar lordosis in
sitting position.

Positioning of the
upper limbs. Lumbar side shift.
Description of Most Relevant Exercise Mechanics
Sitting
Balance of the shoulder girdle.

Mobilization on Swiss ball.

Description of Most Relevant Exercise Mechanics
4. 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.
 Treatment Indication, Goals and Age
Specifics
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

 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.
 The Use of Breathing Mechanics, Muscle
Activation, and Mobilization

‘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.
1
Beginning of
treatment session

9
End of treatment
session
 Treatment Tools
Active and Passive

Yes – will be described by the school

Description of Most Relevant Exercise Mechanics
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 muscles

from the influence of gravitation. Probably
because of that, the largest correction of
scoliosis 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
Summery
• The course of action focuses on the vicinity of the apical
vertebra.
• On the concave side of the curvature a strong local pressure is
applied, and on the convex side a subtle facilitation is applied.
• The correction and facilitation are phase-locked with the
particular phases of the respiratory cycle.
– In details, during inspiration a strong local pressure is applied
on the concave side,
– and during expiration a subtle facilitation is applied on the
convex side.
– During expiration, achieved correction or hipercorrection is
being stabilized by an isometric contraction .
Physical Therapy for Adolescents with Idiopathic Scoliosis
By 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 Bialek
DOI: 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.