Exercises for Scoliosis within the braces

and Brace modifications for exercises

Karavidas Nikos, MSc, PT

Certified Schroth BSPTS Instructor

Certified Schroth ISST Therapist
Certified Schroth Best Practice Therapist
Certified SEAS Therapist
Certified McKenzie Therapist
MSc Sports Physiotherapy
 Introduction
• Physiotherapeutic Scoliosis Specific Exercises (PSSE):
Curve pattern specific exercises
- 3D Auto-correction
- Self-Elongation
- Activities of Daily Living (ADL) training

• 7 different Schools:
- Schroth ISST method (Germany)
- Schroth BSPTS method (Spain)
- SEAS method (Italy)
- FITS method (Poland)
- Side-Shift method (United Kingdom)
- Lyon method (France)
- Dobomed method (Poland)
 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
 PSSE-Brace indications (SOSORT guidelines)

Exclusive treatment
• Adolescents with Cobb angle < 25ο , Risser 0-3

• Adolescents with Cobb angle 20ο-29ο , Risk of

progression 40-60% (Lonstein formula)
• Adolescents with Cobb angle <35ο , Risser 4-5

• Adults with painful scoliosis

• Adults of any Cobb angle /Patients refused
surgery

Combined treatment
• Brace indication (adolescents with Cobb angle
25ο – 40ο , Risser 0-3)
• After spinal fusion (modified program) The prediction of curve progression in untreated idiopathic scoliosis during
growth.
Lonstein and Carlson, 1984
 Scientific Evidence

§ Systematic review with meta-analyses– Level of Evidence I

§ Randomized Control Trials (RCT) – Level of Evidence I
§ Prospective studies – Level of evidence II
§ Retrospective studies – Level of Evidence III
§ Case-studies – Level of Evidence IV
 Scientific Evidence (until 2012)

ØCochrane Review (Romano et al 2012)

Some evidence for PSSE, mostly based on a RCT (Wan et al 2005) with many
limitations. Lack of good quality studies.

ØSystematic Review (Weiss 2012)

No safe conclusions about PSSE, due to inadequate inclusion criteria in most studies

ØSystematic Review (Mordecai and Dabke 2012)

Previous Systematic Reviews showed some effectiveness of PSSE, but based on poor
methodological quality researches
 RCT - Monticone et al 2014
Active self-correction and task-oriented exercises reduce spinal deformity
and improve quality of life in subjects with mild adolescent idiopathic
scoliosis. Results of a randomized controlled trial. European Spine Journal
2014 Jun;23(6):1204-14

• 110 subjects, 2 groups (1st PSSE, 2nd general exercise), identical

baseline characteristics, 12 months follow-up
• Inclusion criteria: Cobb 10ο -25ο , Risser 0-1, Age>10 years

• Results
- Cobb angle: PSSE Improvement 69%, Progression 8%, Stable 23%
Control group Improvement 6%, Progression 39%, Stable 55%

- ATR: PSSE Improvement by 3.5ο , Control group stable

- SRS-22 (QoL) : PSSE improvement > 0.75 all domains (pain,

function, self- image, mental health), Control group no significant
changes

• Conclusions:
PSSE can reduce the risk of progression in mild scoliosis (<25ο) and
have significantly better results than general exercises
 RCT – Kuru et al 2015
The efficacy of three-dimensional Schroth exercises in adolescent
idiopathic scoliosis: A randomized controlled clinical trial. Clinical
Rehabilitation, 2015 Mar 16, 1-10

• 45 patients, 3 groups (1st supervised Schroth, 2nd home

Schroth, 3rd observation), identical baseline characteristics, 6
months follow-up
• Inclusion criteria: 10-18 years, Cobb 10ο – 60ο (mean 30ο),
Risser 0-3

• Results:
Schroth supervised significant improvement in Cobb angle by 2.5ο
(p=0.005), ATR by 4.2ο (p=0.001), hump height by 68.66 mm and
waist asymmetry
Control group no improvement in any parameter

• Conclusions:
Schroth method seems to be effective in scoliosis treatment, at
least better than observation
 RCT – Schreiber et al 2015
The effect of Schroth exercises added to the standard of care on the
quallity of life and muscle endurance in adolescents with idiopathic
scoliosis – an assessor and statistician blinded randomized controlled
trial : “SOSORT 2015 Award Winner”. Scoliosis 2015, 10:24

Schroth method added to standard care (observation or brace)

• 50 patients, 2 groups (1st standard care + Schroth, 2nd

standard care- control), identical baseline characteristics, 6
months period
• Inclusion criteria: 10-18 years, Cobb 10ο -45ο , Risser 0-2

• Results:
Schroth group Improvement of muscle endurance and ability to
keep an upright posture by 27.5 sec more than control
Schroth group significant improvement of pain and self-image on
SRS-22 questionnaire

• Conclusions:
Adding Schroth method to standard care offers significantly
better results than standard care alone
 Systematic Review – Anwer et al 2015

Review article: Effects of Exercise on Spinal Deformities and Quality of

Life in Patients with Adolescent Idiopathic Scoliosis. BioMed Research
International ,Vol 2015, Article ID 123848

The most recent SR, including the latest RCT’s on PSSE

• Literature review: Pubmed, CINAHL, Embase, Scopus, Cochrane

Register of Controlled Trials, PEDro, Web of Science
• Outcomes evaluated: Cobb angle, ATR, QoL
• 30 studies, 9 fulfilled the inclusion criteria, 6 had high
methodological quality on PEDro scale, 3 RCT’s
• Meta-analysis revealed moderate-quality evidence that PSSE
can reduce Cobb angle and ATR and improve QoL in scoliotic
patients

• Conclusions:
Now there is scientific evidence that PSSE are effective in scoliosis
treatment and superior than general exercises
 RCT – Schreiber et al 2017
Schroth Physiotherapeutic Scoliosis-Specific Exercises added to
the standard of care lead to better Cobb angle outcomes in
Adolescents with Idiopathic Scoliosis – an assessor and
statistician blinded Randomized Controlled Trial.
PLoS One. 2016 Dec 29;11(12):e0168746

Schroth method added to standard care (observation or

brace)
• 50 patients, 2 groups (1st standard care + Schroth, 2nd
standard care- control), identical baseline characteristics,
6 months period
• Inclusion criteria: 10-18 years, Cobb 10ο -45ο , Risser 0-2
Schroth exercises for 6 months

• Results:
Schroth group significantly less Cobb angle. Average initial
Cobb angle 51.2ο , final Schroth group 49.3ο final control
group 55.1ο.

• Conclusions:
Schroth method added to the standard of care for scoliosis
can reduce the Cobb angle and the severity of the curve
 RCT – Kwan et al 2017
Effectiveness of Schroth exercises during bracing in adolescent idiopathic
scoliosis: results from a preliminary study – SOSORT Award 2017 Winner.
Scoliosis Spinal Disord. 2017 Oct 16;12:32

• Prospective matched-cohort study

SRS inclusion criteria
24 patients, 2 groups: «Schroth + brace» and «brace alone»
Same baseline characteristics

• Results:
Cobb angle:
Schroth group 17% improvement, 61% stable, 21% progression.
Control group: 4% improvement, 46% stable, 50% progression.

Compliant patients Schroth group: 31% improvement, 69% stable

Schroth group improved Truncal shift, ATR, SRS function and total
scores.

Conclusions:
Schroth method together with bracing provides better treatment
result than bracing alone. Cobb angle, ATR and SRS-22 improved.
 BrAIST study RCT – Weinstein et al 2013

• Multicenter RCT in USA

• 242 patients, SRS inclusion criteria

Cobb angle 25ο – 40ο , Risser 0-2
2 groups: 1st Bracing, 2nd Observation

• Results:
Bracing success rate 72%, Observation success rate 48%

Ø The trial stopped early for ethical reasons, owing to the efficacy of bracing
Ø Significant positive association between hours of brace wear and
treatment success

• Conclusions:
Bracing significantly decreased the risk of progression and is superior
than natural history
More studies on bracing and PSSE
 SOSORT guidelines (2011)

• SOSORT: Society on Scoliosis Orthopedic and

Rehabilitation Treatment

• PSSE can be the first step of treatment for

mild scoliosis, in order to avoid bracing
• Multi-professional therapeutic team is
needed, consisted of MD, CPO, PT
• Brace treatment should be accompanied
with Scoliosis Specific Exercises
 SRS statement (May 2014)

• Scoliosis Research Society (SRS)

• The combination of brace and PSSE

can provide better results than
bracing alone

• PSSE are superior to general or no

exercises
 Position Statement AAOS,SRS,POSNA,AAP for
Adolescent Idiopathic Scoliosis (2015)

• AAOS: American Association of Orthopedic Surgeons

• SRS: Scoliosis Research Society
• POSNA: Pediatric Orthopedic Society of North
America
• AAP: American Academy of Pediatrics

• AAOS, SRS, POSNA and AAP believe that recent high

quality studies demonstrate that non-operative
interventions such as bracing and scoliosis specific
exercises can decrease the likelihood of curve
progression to the point of requiring surgical
treatment.
 Brace - 3D Correction

• Three-points systems in the frontal plane. Alignment in the

frontal plane

• Pair of forces in the transversal plane for regional derotation

• Sagittal balance and physiological alignment

• Cheneau type braces more compatible with PSSE

Frontal plane Correction – 3 points systems

’
Frontal plane Correction – Press zones and expansion rooms
Regional Derotation
LUMBAR (RED)

b
Regional Derotation
THORACIC (YELLOW)

b
 Regional Derotation

Local Derotation
a

a’
The pads for derotation, acting on the dorsal and
ventral rib humps should be at the same level
The pads for derotation, acting on the dorsal and
ventral rib humps should be at the same level

b a b
a’

Mirror effect
Frontal plane: Reduction of the Cobb angle

44º 13º

26
Transversal plane: Reduction of the axial rotation
Sagittal plane alignment
Boston with upper thoracic extension
Principle supported by Perie D et al. Spine 2003
 Scoliosis Specific Exercises and bracing

• Preparation for bracing

Ø Pattern specific mobilisations (open collapses, mobilize the prominences)
Ø Range of motion exercises in all planes

• During brace treatment (without the brace)

Ø The most important treatment with PSSE
Ø Curve pattern specific exercises, based on 3D auto-correction, self-elongation, ADL training

• During brace treatment (in-brace)

Ø Breathing mechanics in a Cheneau type brace
Ø Restore thoracic kyphosis and lumbar lordosis
Ø Shoulder balance
Ø Proximal thoracic scoliosis exercises in-brace

• Brace weaning time

Ø Avoid loss of correction
Ø Stabilize the correction in the long-term
Preparation for bracing
Preparation for bracing
Preparation for bracing
Preparation for bracing
PSSE (out of brace)
PSSE (out of brace)
 Breathing mechanics in-brace (Dynamic effect)

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 Breathing mechanics create an internal pair-
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of the structural flat back

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 Breathing mechanics create an internal pair-
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 In-brace exercises
Breathing exercises in Cheneau brace
 In-brace exercises

Opening of the lumbar concavity Opening of the thoracic concavity Rekyphosation exercises

Rekyphosation exercises with balance Psoas muscle activation

In-brace exercises
 In-brace exercises

Expansion of the thoracic concavity Expansion of the lumbar concavity

Proprioception and co-ordination exercises

In-brace exercises

Exercises to decrease kyphosis

(mostly for single thoracolumbar curves)
 Exercises at brace weaning phase

Active self-correction exercises

ADL training
Schroth BSPTS clinical classification, by Dr. Manuel Rigo

• 3C: Structural thoracic curve, pelvis on the opposite side

• 4C: Structural thoracic curve, pelvis on the same side
• N3N4: Structural thoracic curve, pelvis centered
• SL/STL: No thoracic curve, structural Lu/Th-Lu curve
 Brace Classification by Rigo
Radiologic Criteria 1
Curve pattern compatibility
• Single Major High Thoracic
(upper or proximal) Single • Thoracic: T2-T11 (Disc T11-12)
• Single Major Thoracic Composite • Proximal Thoracic: T3-4-5
• Single Major Thoracolumbar • Main Th = T8; High Th: T6-7
• Single Major Lumbar • Low Th T9-11 (Rigo)
• Major Thoracic and Minor Lumbar • Thoracolumbar: T12-L1
• Double Major Thoracic and Lumbar • Lumbar: L2-L4 (Disc L1-2)
• Double Major Thoracic and Thoracolumbar • Lumbosacral: L5-S1 (Disc L4-5)
• Double Major Thoracic
• Multiple /Triple structural
+ Major lumbar or TL / Minor Thoracic
Double Thoracic (not always double major,
Lonstein’s Revision of the Moe & Ketleson (1970) sometimes major-minor) (Rigo)

Double major = 2 structural curves with a Cobb angle not ≠ 5º

Brace Classification by Rigo
Radiologic Criteria 2
Transitional Point and T1
CSL Offset

LEV T

UEV L

LEV T UEV L
Brace Classification by Rigo
Radiologic Criteria 3
L5-L4 Counter-tilting
3C type 4C type N3N4 type SL/STL type

D-modifier
Radiological Criteria for Clinical 3 Curve Pattern (Scoliosis 2010, 5:1)
A1 Type design
A1 Type design, Apex T11
Classic 3C design for Types A2 and A3
(Closed Pelvis)
A2/A3 Type Design
Radiological Criteria for Clinical 4 Curve Pattern (Scoliosis 2010, 5:1)

T12

L1-L2
Classic 4C Design for Type B1
‘Closed Pelvis’
4C Design for Type B1 ‘Open Pelvis’. Most of
4C braces have ‘open `pelvis’ design
B1 Type Design (open)
4C Design for Type B2 type with TL pad. Pelvis closed
or open
 4C Design for Type B2 type with TL pad. Pelvis closed
or open

34º

19º

53º

12 y 10 m
Radiological Criteria for Clinical N3N4 Curve Pattern (Scoliosis 2010, 5:1)
Correction in Clinical 4 Curve Pattern Correction in Clinical N3N4 Curve Pattern
Radiological Subtypes B1 and B2 Radiological Subtypes C1 and C2

TP CSL TP= Transitional Point

CSL= Central Sacral Line TP and CSL
Classical design for C1
C 1-2 type
Radiologic Criteria: Lumbar/Thoracolumbar Patterns

It is like B type but with NO

structural curve

T12

L1-2
E1-2 type E1-2 Type Design
 Conclusions and Recommendations

• Level of Evidence I for PSSE and bracing for scoliosis

• Brace and PSSE can give better results than brace alone
• PSSE can be used before, during and after bracing
• PSSE and brace must be curve pattern specific
• Cheneau type braces are more compatible with PSSE
• Multi-professional therapeutic team is needed : MD, CPO, PT
Thank you for your attention!!!

Karavidas Nikos, MSc, PT

• Certified Schroth BSPTS Instructor
• Certified Schroth ISST Therapist
• Certified Schroth Best Practice Therapist
• Certified SEAS Therapist
• Certified McKenzie Therapist
• MSc Sports Physiotherapy www.skoliosi.com