Exercise Approach To Scoliosis

MODULE 6: Spinal deformities - Scoliosis during growth & other deformities across the life course Exercise Approach to Scoliosis Karavidas Nikos, PT, MSc Certified Schroth BSPTS-Rigo Concept Teacher Certified Schroth ISST Therapist Certified Schroth Best Practice Therapist Certified SEAS Therapist Certified Lyon Therapist Certified McKenzie Therapist MSc Sports Physiotherapy

ADOLESCENT IDIOPATHIC SCOLIOSIS PATHOMECHANISM OF PROGRESSION Stokes IAF. Huetter-Volkmann effect. Spine (2000) Brace indications (Scoliosis Research Society) Cobb angle 25ο – 40ο, Risser 0-3 Factors, other than mechanical? Probably Yes

TREATMENT INDICATIONS Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) SOSORT GUIDELINES FOR SCOLIOSIS TREATMENT (2011) Observation Cobb angle 15ο , Risser 0-3 Cobb angle 20ο , Risser 4-5 Adults, Cobb angle 50ο , without pain PSSE Brace Cobb angle 25ο – 45ο , Risser 0-3 Adults with very progressive and painful scoliosis (?) Surgery Cobb angle 45ο , residual growth, fail of non-operative treatment Adults, Cobb angle 50ο , fail of non-operative treatment Cobb angle 15ο – 25ο , Risser 0-3 Braced patients, independent of curve magnitude Cobb angle 20ο – 40ο , Risser 4-5 Adults with any Cobb angle, with pain

SCOLIOSIS PROGNOSIS Example: 10 years, pre-menarche, Risser 0, Cobb angle 24ο : Progression factor 2.4 (90%) 14 years, Risser 3, Cobb angle 24ο : Progression factor 1.1 (25%) Other prognostic factors: Age of menarche, family history, curve type, vertebra rotation (AVR), hypokyphosis/flatback Lonstein JE and Carlson JM, The prediction of curve progression in untreated idiopathic scoliosis during growth. J Bone Joint Surg Am, 1984 Sep; 66 (7): 10611071

INTRODUCTION Physiotherapeutic Scoliosis Specific Exercises (PSSE): Curve pattern specific exercises - 3D Auto-correction - Self-Elongation - Activities of Daily Living (ADL) training Many different Schools / approaches: - Schroth ISST method (Germany) - BSPTS-Rigo concept method (Spain) - Schroth Best Practice (Germany) - SEAS method (Italy) - FITS method (Poland) - Side-Shift method (United Kingdom) - Lyon method (France) - Dobomed method (Poland) PSSE Concept of Correction 1) Diagnosis and classification of curve type 2) Self-correction, 3D balance and alignment 3) Expand/De-collapse the collapsed areas (concavities) in 3D (concavities) 4) Muscle activation by maintaining the correction in 3D 5) Stabilize the correction after exercises and train for ADL activities

GOALS OF PSSE Correct scoliotic posture Spine stabilization to avoid progression Patient and family education Improve breathing function ADL training Improve self-image and self-esteem Decrease pain

“Wait and See” Vs “Try and See” Vs “Brace” “Try and see” “Wait and see” Clinical and radiological observation every 3/6/9/12 months Generic or no exercises / sports No fatigue No cost PSSE, certified Therapist Individualized program Regular clinical observation, specific evaluation tools (scoliometer, photos, TRACE, POTSI/ATSI etc.) Full-time or part-time bracing Regular radiological evaluation every 6 or 12 months Reduce potential for progression, real More treatment than PSSE Predictable result by clinical Increased chances for halting - Potential overtreatment sometimes - Fatigue in long-term - Fatigue, risk for non- treatment - Not a real treatment - Unpredictable result “Brace” measurements, avoid significant progression Brace indications (Scoliosis Research Society) Cobb angle 25ο – 40ο, Risser 0-3 alone progression or even improve Cobb angle compliance in peak of growth - Increased cost - Psychosocial burden

Scientific Evidence for PSSE Growing evidence for PSSE in AIS

International Scientific Societies about PSSE SOSORT: Society on Scoliosis Orthopedic and Rehabilitation Treatment SRS: Scoliosis Research Society POSNA: Pediatric Orthopedic Society of North America AAP: American Academy of Pediatrics AAOS: American Association of Orthopedic Surgeons PSSE are the first step in scoliosis treatment, to halt progression and avoid bracing. Scientific evidence that PSSE are superior than non-specific, general or no exercises Recent high-quality studies have proven PSSE efficacy in reducing the likelihood of progression

SEAS METHOD Scientific Exercises Approach to Scoliosis Stefano Negrini Functional evaluation tests to determine patient’s deficits Active 3D self-correction Breathing mechanics ADL training From stable to unstable positions “In-brace” or “preparation for bracing” exercises /mobilisations Ponseti classification “Team approach” (Physician, PT, OT, patient’s family) Outpatient program, supervised sessions every 3 months Active 3D self-correction with “distracting” situations that place demand on neuromuscular connections to increase stability while performing movements (stairs, sit up /down, balance on one leg / closed eyes etc)

LYON METHOD Dr. Jean Claude de Mauroy Principles of the Lyon method 1. The Lyon approach to assessment. (age, Cobb angle, postural imbalance) 2. Awareness of trunk deformity (visualization with mirrors) 3. What to do: sample exercises. 4. What not to do and why (avoid extreme sagittal flexion/extension) 5. Sport or only physiotherapy? Lumbar mobilization for the lumbosacral curve Active thoracic shift on a gym ball Ponseti and Lenke classification Active lumbar correction promoting lordosis 3D segmental mobilization of the spine Mobilization of the ilio-lumbar angle (lumbar scoliosis) Enhance thoracic kyphosis – lumbar lordosis, frontal plane corrections Proprioception, balance, stabilization Breathing mechanics (RAB) Patient education and ADL training

SCHROTH ISST METHOD Axel Hennes Outpatient or intensive in-patient rehabilitation (Asklepios Katharina Schroth Clinic) Classification according to body blocks Pelvic corrections Rotational Angular Breathing (RAB) / Corrective breathing 3D stabilization exercises, from positioning to auto-correction Home exercise program Specific mobilisations In-brace exercises ADL training

SCHROTH BEST PRACTICE METHOD Dr.Hans Rudolf Weiss Augmented Lehnert- Schroth Classification 3D made-easy Physiological program (sagittal plane, walking exercise) Power Schroth exercises Emphasis on ADL training Highly corrective exercises, overcorrection for the main curve Mobilisations Rotational Breathing

BSPTS – RIGO CONCEPT Barcelona Scoliosis Physical Therapy School Dr. Manuel Rigo General Principles of BSPTS 3D Postural Correction Expansion Technique Muscle activation Integration Specific Principles of Correction Self-elongation from a 3D corrected/stable pelvis (Pelvic corrections) Asymmetrical Sagittal Straightening Frontal Plane Alignment Mobilisations in 3D correction ADL training Prone on knees exercise Side- lying exercise Standing tension with poles exercise

FITS METHOD Functional Individual Therapy for Scoliosis Marianna Bialek - Andrzej M’Hango 3 main stages - Patient examination and education - Preparation phase - 3D corrective phase Myofascial release (preparation phase) Sensory-motor balance training Lumbo-pelvic stabilization Facilitation of 3D corrective breathing in functional positions ADL training

DOBOMED METHOD Dr. Krystyna Dobosiewich (1913-2007) Jacek Durmala 3D auto-correction Focus on kyphotization of thoracic spine Lordotization of lumbar spine Breathing mechanics (phased-lock respiration), like Schroth Exercises in closed kinematic chains on a symmetrically positioned pelvis and shoulder girdle, followed by active stabilization of the corrected position Symmetric positions Asymmetrical active movements for 3D correction Transverse plane derotation, with specific treatment emphasis focused on the area of the curve apex Concave rib mobilization to expand and derotate the ribs

SIDE-SHIFT METHOD Tony Betts Active correction by side-shift movements to concavity (mainly frontal plane correction) Hitch exercise for single curves Hitch-shift exercise for double curves Breathing mechanics like Schroth Core stability exercises King and Lenke classification, but also based on flexibility Type I : very flexible curve Type II : moderately flexible curve Type III : extremely rigid curve

ADL training Activities of Daily Living Training

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Schroth Best Practice BSPTS-Rigo Concept SEAS

Case study 05/2015 02/2016 18o 25o 15 years old Female Th-Lu curve 25ο Risser 4 2 years post-menarche Angle Trunk Rotation 11ο (scoliometer) No family history

Case study

Schroth Scoliosis & Spine Clinic Adolescent Idiopathic Scoliosis Treatment result

Conclusions Ø Scoliosis Specific Exercises (PSSE) General Exercises Ø 3D auto-correction Ø Self-elongation Ø ADL training Ø Muscle activation in a 3D corrected position

Thank you for your attention Karavidas Nikos, PT, MSc www.skoliosi.com Contact information: info@skoliosi.com

TREATMENT INDICATIONS Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) SOSORT GUIDELINES FOR SCOLIOSIS TREATMENT (2011) Observation Cobb angle 15ο, Risser 0-3 Cobb angle 20ο,Risser 4-5 Adults, Cobb angle 50ο, without pain PSSE Cobb angle 15ο-25ο, Risser 0-3 Braced patients, independent of curve magnitude