LAURA DOBRICH, PT, PCS,SCHROTH THERAPIST

PPTA PEDIATRIC SIGOCTOBER 25, 2013

Introduction to the Schroth Method for Scoliosis Treatment

United States

Surgery

Bracing

Observation

Europe

Surgery

Bracing

Physical Exercises

Possible explanations for treatment differences

Literature published in languages other than English not cited by US researchers

Research typically with pts with mild AIS (< 30⁰) – which is generally not treated in US

Lack of support/interest promoting research in this area in US

All conservative methods often considered together as “alternative treatment”

History of the Schroth Method

First developed in 1921 in GermanyAfter WWII, East Germany ordered a 3-year

investigation of the methodResulted in the Schroth House being

“nationalized” to allow access to more peopleIn 1955, moved to West GermanyIn 1961, Schroth Klinic opened in Bad

Sobernheim.

Schroth Objectives

Improvement of posture and appearanceImprovement of static/dynamic postural control

and stability (achieve/maintain “conscious posture” in ADLs)

Deceleration or prevention of curve progressionAvoidance of braces or surgerySupport for decision-making process @ curve

thresholdReduction of painImprovement of vital capacity

Team Members

PhysicianPhysical TherapistOrthotistSurgeonPsychologistPatientParents

Schroth Elements

Guiding resistanceFacilitationProprioceptive and visual stimuliPassive corrective forces

Treatment Components

PositioningSpecific mobilizationSelf-correction

Breathing CorrectionActive mobilization Stabilization (exercises)Schroth in ADL

Review of the Literature

2005: SOSORT (International Society on Scoliosis

Orthopaedic and Rehabilitation Treatment) Established to verify the scientific basis and

efficacy of exercises & bracing Scoliosis

New journal launched to promote new research on this topic

SOSORT 2005

Consensus agreement for standard features in rehab for scoliosis:1. 3-D Autocorrection exercises2. ADL training3. Stabilization of the correct posture4. Patient education5. Multidisciplinary team – MD, PT, Orthotist

Autocorrection

3-D active correction of curveSEAS (Scientific Exercises Approach to Scoliosis)

Schroth MethodDobomed ProgramOther programs approved – see SOSORT 2011 Recommendations

SEE HANDOUT

SOSORT 2011Recommendations for

Exercises

Scoliosis Journal 2010

“Rehabilitation Schools for Scoliosis” seriesTo investigate efficacy of exercise on scoliosis

with clearly defined guidelines for researchStudies to include specifics of treatment

including description and pictures of exercises

Studies should follow SOSORT recommendations

Weiss (2010) - Scoliosis

Review of conservative approaches: Outcome of brace treatment determined primarily by

in-brace correction and patient compliance Some evidence that correct bracing can stop curve

progression OP treatment sufficient for patients with spinal

deformity without other limitations IP rehab recommended for patients with pain or

restrictive ventilatory disorder

Fusco et al (2011)

Updated systematic review• Detailed Appendix describing several exercise methods

with pictures20 studies showing:

Efficacy of exercise in reducing rate of progression &/or improving Cobb angle

Exercise effective in reducing brace prescription Exercise improves strength, mobility, and balance

Fusco et al (cont)

Physical exercises, if administered correctly, can prevent curve progression and prevent need for bracing

PTs need to use specific exercises chosen according to strong scientific sources

Literature using unsound methodology and interventions can suggest that physical exercises are not effective, while scientifically-based physical exercises appear to be efficacious

PE Efficacy Summary

Need for further studies, esp RCTs, following SOSORT criteria, to improve level of evidence

Present evidence is sufficient to consider PEs as an appropriate intervention for AIS

3-D Autocorrection exercises appear to be best, but cannot yet support a specific program

Not yet clear if inpatient vs outpatient or intrinsic vs extrinsic exercises most effective

Recently Published Research

Physical exercises in the treatment of adolescent idiopathic scoliosis: an updated systematic review – Physiotherapy Theory and Practice (2011) - PEs can improve the Cobb angles of individuals with AIS and can improve strength, mobility, and balance.

Scoliosis short-term rehabilitation (SSTR) according to 'Best Practice' standards-are the results repeatable? Scoliosis (2012) – angle of trunk rotation and VC improved and repeatable

Weiss HR, Cherdron J (1994)

Effects of Schroth's rehabilitation program on the self concept of scoliosis patients

37 scoliotic patients (33 female, 4 male), aged 20-57 years

pre-/post-interview study on the basis of the Frankfurt self-concept scales (FSKN)

statistically significant changes in a positive direction found for 7 of 10 self-concept scales

general coping ability; sensitivity and mood; self-assertion towards groups and significant others; perceived appreciation by others; feelings towards and relationship with others; self-worth; and ability to make contact and interact.

Weiss et al (2003)

Incidence of Curvature Progression in Idiopathic Scoliosis Patients Treated with Scoliosis In-patient Rehabilitation (SIR): an age- and sex-matched controlled study

Two independent patient groups matched by age and sex at diagnosis One group was untreated and the other received scoliosis in-patient

rehabilitation (SIR) (Schroth)Incidence of progression in groups of untreated patients ranged from 1.5-

fold to 2.9-fold higher than in groups of patients treated with SIR, even when SIR-treated groups included patients with more severe curvatures.

Otman et al (2005)

The Efficacy of Schroth’s 3-dimensional Exercise Therapy in the Treatment of Adolescent Idiopathic Scoliosis in Turkey

50 patients, 1999- 2004, average age 14.15±1.69 years

Outpatient 5 days/wk, 4 hr/day x 6 wk then home program

Evaluated Cobb angle, vital capacity and muscle strength of the patients before treatment, and after 6 weeks, 6 months and one year

Schroth technique positively influenced the Cobb angle, vital capacity, strength and postural defects

Otman et al (2005)

Cobb angle 26.1⁰ average before treatment, 23.45⁰ after 6 weeks, 19.25⁰ after 6 months and 17.85⁰ after one year (p<0.01)

VC average 2795 ml before treatment, reached 2956 ml after 6 weeks, 3125 ml after 6 months and 3215 ml after one year (p<0.01)

Jelacic et al (2011)

Barcelona Scoliosis Physical Therapy School–BSPTS–based on classical Schroth principles: short-term effects on back asymmetry in idiopathic scoliosis

Retrospective, 47 pts treated exclusively with exercises. Mean age 18.64 ± 5.78 years.

Surface topography (Formetric) was performed to measure trunk imbalance, surface rotation and lateral deviation before and after the treatment period.

Improvements noted in mean trunk imbalance, lateral deviation mean and max, and surface rotation.

Schreiber et al (2013)

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

31 patients with AIS, aged 10-18, with curves from 10°-45°, wearing a brace or not. 16 randomized to Schroth with standard care, and 15 to standard care alone (monitoring or bracing) for six months.

Schroth exercises showed a small but positive influence on self-efficacy, self-image, pain and back muscle endurance.

Schroth Terms

Rib Hump – thoracic convexity. Most rotated, most prominent, and most posterior aspect at the apex. Ribs are rotated posteriorly and spread apart resembling the “inhalation position”

Weak Side – ribs of the thoracic concavity are closer and lower, resembling the “exhalation position”. Ribs are rotated forward. Area appears flat and hollowed.

Schroth Terms

Lumbar Prominence – Lumbar convexity. Extensor muscles become overstretched and are displaced posteriorly. Leads to asymmetric waistline, full on convex side and accentuated on concave side.

Weak Point – Lumbar concavity. TPs rotated anteriorly and muscles/connective tissues shortened. Waist is accentuated and pelvis appears shifted to this side.

Schroth Terms

Protracted Shoulder – Shoulder on thoracic convex side is IR with inferior angle of scapula moved upward and tilted away from the ribcage.

Retracted shoulder – Shoulder on thoracic concave side is ER and may sink into the thoracic cavity (scapula appears to wing, but this is really secondary to lack of rib support).

May vary if a high thoracic or cervical compensatory curve is present

Schroth Terms

Ventral Flat Zone – Ventral aspect of the rib hump. Ribcage appears compressed; apical ribs closer and rotated posteriorly. Breast looks smaller.

Ventral Prominence – Lower ribs of thoracic concave side are ventrally more prominent due to spinal rotation. Creates a “ventral rib hump”

Prominent Hip – Pelvis deviated laterally as compensation for either T or L curve; causes hip adduction and raised iliac crest on that side. Increased WB on side opposite of prominent hip. (Prominent hip usually opposite side of primary curve).

Schroth Evaluation

Medical History

• Age/gender/age at first menses• X-rays?• Cobb Angle• Brace? Type/schedule/compliance• Previous treatment?

Risser Sign

*Radiographic measurement of skeletal maturity based on ossification of the iliac apophysis*Ossification begins laterally; progresses medially*Proceeds from 0 (no ossification) to 5 (ossified apophysis fused completely to ilium

Progression Factor

Cobb angle – (3 x Risser sign)Chronological Age

Body Blocks

Schroth Evaluation

Pelvic block (includes LEs)

Iliac crest height/rotationpelvic shift/tilt/rotation,PSIS/ASIS height/rotationLateral shiftLE positioning, abd/add, hip rotation, knee

position (recurvatum, patellar position, patellar height) foot arches/pronation/supination

Shoe lift/LLD?Weight bearing symmetry

Lumbar Block

Waist linesLumbar prominenceLordosis

Thoracic Block

Scapular position (height, orientation, symmetry)

Angle of inferior borderRib humpSpace between arm and bodyRib position (widened, narrowed,

elevated)Breast height/size

Shoulder Block

Level of shouldersProtraction/retractionHead positionUpper thoracic/cervical curve

Schroth Evaluation

Forward Bend TestFlexibility – side shift, side bend, finger-to-floor measurement (lateral flexion), active rotation

Schroth Classification

Named by position of thoracic convexity (right/left)

Static standing posture determines primary curve (increased WB on side of primary curve)

3c = primary thoracic curve4c = primary lumbar curvep = pelvic involvement (lateral shift,

elevation away from primary convexity)

3 c right

3 cp Right

4c Right

4 cp Right

Schroth Postures

Habitual PostureResting PostureConscious PostureCorrect Posture

Schroth Postural Terms

Habitual Posture – Resting scoliotic position

Relaxed Posture – Gravity-eliminated, lying. Side lying on the concave side of the main curve is preferred.

For primary thoracic curves, on the thoracic concave side with knees flexedFor primary lumbar curves with small or no thoracic curve, on the lumbar concave sideFor double major curves, on thoracic concave side with lower leg flexed and upper leg extended to stretch the lumbar concavity

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 lifeSymmetrical WB in sitting and standing (can depress the elevated side or raise the opposite side in sitting), correction of pelvic shift, shift of ribcage toward thoracic concave side

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 lengtheningVisual feedback provided with mirrors in front and backTherapist provides specific resistances and facilitation/elongation, instructions, and feedback.

MANUAL TECHNIQUES

Schroth Treatment

Side bending in sitting

Used to test flexibility of curve and for mobilization

Pt sitting on table, arms crossed, bring to neutral, upright spine as able

Test thoracic and lumbar curves bilaterally

Mobilize by placing one hand on apex, other on opposite shoulder

Ventral, medial, cranial mobilization to passively correct rib hump

Side Bending

Side shift in sitting

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)

Side Shift

Derotation of the rib hump in sitting and supine

Derotation of Rib Hump

In sitting, passively retract shoulder. Mobilize rib hump ventral, medial, cranial.

Pt can do this actively by bringing shoulder back, down, and externally rotating

In supine, ER protracted shoulder, place support under retracted shoulder. Stabilize pelvis in posterior direction while mobilizing rib hump forward and medial

Pt can hold corrected position

Derotation of the Ventral Prominence in Sitting and Supine

Derotation of ventral prominence

Pt sitting on chair with UEs supported on table

Bring retracted shoulder forwardMobilize ventral prominence (thoracic

concave side) posterior, lateral, cranialIn supine, ER protracted shoulderTherapist stands on opposite side. “Iron”

prominence laterally and dorsallyCan use other hand to bring lumbar

prominence forward

Derotation of the lumbar prominence

Derotation of the lumbar prominence

In sitting, stabilize rib hump in anterior/medial direction

Mobilize lumbar prominence anteriorly and medially

In prone, place thumb over apical transverse process (most rotated/prominent TP)

Place other hand on top of thumb and derotate anteriorly and medially

Can also specifically mobilize segments to increase extension, rotation as needed

Stretching of thoracic concavity

Lie on thoracic convex side with support under rib hump

Do not lie on convexity if curve is severe or non-flexible

Stretch soft tissue at least 20 sec

Can also provide massage, ribcage mobilization, fascial techniques

Pt can actively pull top arm up on inhalation while therapist fixes rib downward with exhalation and holds; move segmentally up rib cage

Stretching of thoracic concavity

Stretching of lumbar concavity

Side lying on lumbar convexity over support

Passive mobilization and stretching of concavity

Stretching of lumbar concavity

PNF Posterior Depression

Side lying on thoracic concavity with support under lumbar convexity

Provide forward/diagonal resistance to upper ischial tuberosity

Pt actively pushes into the resistance in posterior depression

• 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

Facilitated Breathing

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)

Positioning Supports (towel roll, rice bag). Positions maintained 10-

15 min

PRONE• UNDER FOREHEAD • UNDER PROTRACTED SHOULDER• UNDER VENTRAL PROMINENCE• UNDER PELVIS TO DEROTATE IN

A PRIMARY THORACIC CURVE WITH PELVIC INVOLVEMENT (NOT IN PRIMARY LUMBAR CURVE; CAN WORSEN LUMBAR ROTATION)

Positioning Supports

SIDE LYING

• LIE ON SIDE OF THORACIC CONCAVITY

• ROLL SUPPORT UNDER LUMBAR CONVEXITY

• BOTTOM ARM ABOVE HEAD; HEAD RESTS ON ARM

• ACTIVE EXERCISE – DEPRESS UPPER LEG CAUDALLY, LIFT OFF SURFACE

Positioning Supports

UE POSITIONING FOR SYMMETRICAL THORACIC SPINE:

90 DEGREE ABDUCTION WITH ELBOWS FLEXED AT 90 DEGREES.

ISOMETRIC CONTRACTION OF SCAPULAR ADDUCTOR AND SERRATUS ANTERIOR

CORRECTS SAGITTAL PLANE DEFORMITY (SHOULDERS POSITIONED BACK FOR KYPHOSIS REDUCTION, SHOULDERS

POSITIONED FORWARD FOR FLAT BACK CORRECTION)

Positioning Corrections

POSITIONING FOR THORACIC CURVE:

UE ON THORACIC CONVEX SIDE AT 90 DEGREE ABDUCTION/90 DEGREE ELBOW

FLEXION.PATIENT CAN ACTIVELY ER AND ADDUCT SCAPULA TO SELF-MOBILIZE RIB HUMP

UE ON THORACIC CONCAVE SIDEPOSITIONED DIAGONALLY TO STRETCH

THE CONCAVITY

Positioning Corrections

POSITIONING FOR LUMBAR CURVE:

ACTIVE DEPRESSION OF PELVIS IN CAUDAL DIRECTION ON LUMBAR

CONCAVE SIDE TO STRETCH LUMBAR CONCAVITY

PELVIC SHIFT AWAY FROM THE PROMINENT HIP IN CURVES WITH

PELVIC INVOLVEMENT. BODY WEIGHT SHOULD BE TRANSFERRED TO SIDE OF

PROMINENT HIP.

Positioning Corrections

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

IncorrectCorrect

Positioning for elongationRight thoracic, Left lumbar curves

Pelvic Corrections

1. Feet parallel. Knees unlocked. Pelvis balanced over center of feet.

2. Adjust anterior/posterior tilt to physiological position (about 30 degrees).

3. Lateral shift of pelvis to correct prominent hip (Increase WB away from primary curve, shift pelvis toward primary curve).

4. Derotate the pelvic block (but do not correct a primary lumbar curve with pelvic involvement – can increase the lumbar rotation)

5. Depress elevated hip. In sitting, can elevate the opposite side with passive support.

Exercise Sequencing

1. Positioning2. Elongation of spine with normal breathing3. Corrective breathing. Use isometric tension to

hold corrected posture on exhalation as able.4. Dynamic exercise performed during exhalation

for predetermined # of reps.5. Rest between sets maintaining conscious

posture.6. ie 4 sets of 6 reps (each repetition = 1

breathing cycle)

Standing with Poles

Side Hanging from ladder rungs

Pelvic Tilt (depression)

Schroth Training Options

Barcelona School (Dr. Manuel Rigo) Spain, Israel, or Wisconsin – 10-day course for part 1

certification AND 6-day course 1-3 years later for Part 2 certification

Schroth (Asklepios) courses Bad Sobernheim, Germany – 10-day certification,

recommend 3-yr refresher (English courses available)

New York, NY – 3 3-day course and testing for certification – Courses also offered in Latvia, Estonia, Hungary, S. Korea, Thailand

Finding a Schroth-trained therapist

http://www.hunter.cuny.edu/pt/the-schroth-method-of-management-of-scoliosis

http://www.bspts.net/bsptspts.html

Thank You!!