2024

PSSE – Schroth
Physiotherapeutic Scoliosis Specific Exercises
Basic Online Course
22nd - 24th March 2024
Karavidas Nikos, PT, MSc
Schroth Scoliosis & Spine Clinic
Founder of PSSE - Schroth method

Certified BSPTS-Rigo Concept Therapist

Certified Schroth ISST Therapist
Certified Schroth Best Practice Therapist
Certified SEAS Therapist
Certified Lyon Therapist
Certified McKenzie Therapist
MSc Sports Physiotherapy, Cardiff University
info@skoliosi.com info@schrothpsse.com
www.skoliosi.com www.schrothpsse.com
nikoskaravidas Nikos Karavidas
schroth_scoliosis_spine_clinic Schroth Scoliosis & Spine Clinic
psse_schroth_method
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Physiotherapeutic Scoliosis Specific Exercises

PSSE – Schroth method

BSPTS-Rigo Concept Schroth ISST Schroth Best Practice Lyon SEAS

Dr. Manuel Rigo Axel Hennes Dr. Hans Rudolf Weiss Dr. Jean Claude de Mauroy Michelle Romano
Stefano Negrini

PSSE – Schroth method

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Schroth method history

Katharina Schroth Christa Schroth Hans Rudolf Weiss Axel Hennes Manuel Rigo Nikos Karavidas
“Original Schroth” “Original Schroth” Schroth Best Practice Schroth ISST BSPTS – Rigo Concept PSSE-Schroth

• The ”original Schroth method” does NOT exist anymore

• There are only “Schroth-based” methods
with different classifications & principles of corrections
2009
• Schroth ISST (Axel Hennes) 2022
• BSPTS-Rigo Concept (Manuel Rigo) • PSSE – Schroth (Nikos Karavidas)
• Schroth Best Practice (Hans Rudolf Weiss)

PSSE - Schroth method

Ø PSSE - Schroth method is a program of Physiotherapeutic Scoliosis Specific Exercises, working for Scoliosis
and Kyphosis treatment
Ø PSSE-Schroth concepts acquired by clinical experience, based on original Schroth principles, getting also
adaptations from other PSSE Schools, keeping their advantages and improving their limitations
Ø New curve type classification - Innovative ideas for 3D correction

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Other PSSE Schools

BSPTS-Rigo Concept Schroth ISST Schroth Best Practice Lyon SEAS

+ Theoretical education of + Easy practical application + Easy practical application from + Theoretical education of + Easy for practical
high quality from patients patients, less props high quality application from patients and
+ + Easy education for + Easy application for mild therapists
Simple Clinical classification + Mobilizations,
+ Accuracy of corrections, therapists curves lumbosacral area
+ Easy application for mild
+ Adequate overcorrection in + Max overcorrection in specific curves
avoiding compensations + Sagittal plane correction
+ specific types types + Dynamic exercises
Advantage in double and + ADL training
balanced curves + Mobilizations + ADL training + Clinical evaluation with
+ Radiological classification + ADL training + Practical education with real functional tests
(braces) + Variety of exercises patients + Good application for
kyphosis

- Too long educational plan (21 - Difficulties in classification - Short total education (5 + 3 - Short total education (3 - Short total education (3 + 3
days) of double curves and for days) days) days)
practical application -
- Complicated application of Risk of worsening secondary - Absence of practical - Difficulties for double
exercises, time-consuming - Lack of one curve type in curves by overcorrection of education curves
education for patients/therapists clinical classification main curve
- Difficulties in practical - Less scoliosis specific - Initial patient education in
- No variety of exercises, - Short theoretical education compared to other Schools sitting position, difficulties in
application in double and
especially in first levels - No variety of exercises (4-5 - No variety of exercises severe curves
- Low potential for overcorrection balanced curves in total) - Mobilisations
- Complicated educational plan - Risk of worsening secondary - Difficulties for double curves
curves by overcorrection of
- Online Basic course without main curve
Instructor

PSSE - Schroth method

+ Easy and Accurate Classification to describe all curve
types, just 3 simple questions need to be answered
+ Important to give the proper information to the
therapist on how to accordingly treat their patients
+ Concept of Overcorrection, the decision for + / - is
based on clinical, radiological and prognostic criteria and
is taken from the initial classification
+ Maximum correction for curve types when
recommended, avoidance when it is risky for creating
compensations (double and balanced curves)
+ Clinical, radiological and prognostic criteria are used
Advancements
Classification
+ Avoid dilemmas on how to classify and treat
curve types that are balanced (thoracic and
lumbar)
+ Avoid dilemmas on how to classify and treat
curve types when pelvis is almost balanced
+ Avoid dilemmas on how to classify and treat
curve types when you are not sure whether
thoracic is structural or not
+ Avoid dilemmas on how to treat Th-Lu curve
types with Apex T12/L1

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PSSE - Schroth method
Advancements
Educational Plan
+ Proper duration for education (9 days to start
applying the method in every type - 15 days for
final certification)
+ Basic course Online by live teaching on Zoom
with an Instructor
PSSE - Schroth method
Advancements
Practical Application
+ Treat your patient Precisely and Safely to get the
maximum effect of exercises based on their curve type
+ Innovative concepts of 3D correction
+ New Terminology with perfect accuracy on describing the
body blocks and the concepts of correction
+ New ideas for Corrective/Rotational Breathing
+ New techniques for Muscle Activation (Thoracic Counter
Traction on L-side, Shoulder Counter Traction on T-side)
+ New concepts of Activities of Daily Living (ADL) Training,
based on PSSE-Schroth classification
2024
+ High quality of theoretical education
(clinical assessment and evaluation tools,
prognosis, radiological measurements,
pathomechanism of progression etc.)
+ Unique Patient Evaluation Form for clinical
and radiological assessment of patients with
scoliosis and kyphosis
+ New exercises and different execution of already
existed Schroth exercises, based on curve type
classification
+ New ideas for Mobilisations by the therapist,
combination of Corrective Breathing with
mobilisations
+ Special emphasis on Proximal Thoracic Scoliosis and
new concepts of correction
+ Special emphasis on Thoracolumbar curves (Ventral
Flat Zone on L-side, new ideas of correction)
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PSSE – Schroth method

Educational plan

Basic Course Level 1 Course Level 2 Course Masters Course

• 3 days • 6 days • 6 days • 4 days (optional)

• In person or Online live by
Zoom
• Theoretical education,
epidemiology,
etiopathogenesis,
prognosis, treatment
indication for scoliosis and
kyphosis
• Clinical and radiological
evaluation of scoliosis and
kyphosis
• Scoliosis type classification
• Introduction in 3D
Principles of Correction for
PSSE - Schroth
• Practical education for
PSSE - Schroth exercises
for all scoliosis types
• Practical education for
PSSE - Schroth exercises
for kyphosis
• Practice of exercises
between therapists
• Observation of practice
with real patients
• Written exams
• Certification to start
application of PSSE-
Schroth method from
therapists to patients,
without time restriction to
attend Level 2
• Open for registration for BSPTS
Level 1 or Level 2 therapists
• Advanced exercises for kyphosis
and scoliosis
• Practice every day with real
patients under Instructor’s
supervision
• Special scoliosis cases
(congenital, neuromuscular,
syndromic, adult degenerative,
post-operative)
• Braces for scoliosis and kyphosis
• Practical exams with real
patients
• Final certification in PSSE -
Schroth method
• Practice every day with real
patients under Instructor’s
supervision
• Other PSSE Schools
• Advanced knowledge for
brace biomechanics
• Surgical options for scoliosis
and kyphosis (spinal fusion
and non-fusion techniques)
• Research methodology and
updated scientific data
• Modified exercises for
kyphosis and scoliosis based
on Pilates, yoga, TRX etc.

Adolescent Idiopathic Scoliosis

“Scoliosis is derived from the ancient Greek word “Skolios” , which means curved / crooked “

“The cause of Idiopathic Scoliosis has been not found yet, although efforts to correct this
deformity come from the antiquity .”

Scoliosis Research Society (SRS)

Lateral deviation of the spine with Cobb angle > 10ο with rotation,
of unknown reason

Society On Scoliosis Orthopedic Rehabilitation Treatment (SOSORT)

Idiopathic Scoliosis can be defined as a complex three-dimensional deformity of the spine and the trunk,
which appears in apparently healthy children, and can progress in relation to multiple factors during any
rapid period of growth, or later in life

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AIMS OF NON-OPERATIVE TREATMENT

OF IDIOPATHIC SCOLIOSIS
• 3D treatment of the deformity
• Halt progression or even partially correct
• Improve clinical appearance / aesthetics
• Train for Activities of Daily Living (ADL)
• Decrease pain
• Improve breathing function
• Improve Quality of Life

SOSORT 2005 Consensus Paper. S Negrini et al. Scoliosis, 2006 1:4 [3]

Aesthetics 100%; QL and disability >90%; Back pain, Psychological wellbeing,

Progression in adulthood, Breathing function, Scoliosis Cobb degrees, Needs
of further treatment in adulthood >80%

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INTERDISCIPLINARY APPROACH
Orthopedic Surgeon – Orthotist - Physiotherapist
Clinical and Radiological Evaluation Aims of treatment
Proper Information
Diagnosis - Prognosis Realistic expectations

Treatment recommendation based on Therapeutic plan

Clinical Experience + Scientific Evidence + Patient’s preferences
Evidence Based Medicine (EBM) Encouragement- Motivation
Psychological support

Conservative treatment

Observation PSSE Brace

Operative treatment

Spinal Fusion Non-Fusion Techniques

Quality control and Treatment Outcomes

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SCIENTIFIC EVIDENCE
Level of Evidence I

§ 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)

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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

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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 patients, 2 groups (1st PSSE, 2nd generic exercises), identical baseline
characteristics
Inclusion criteria: Cobb 10ο – 25ο ,Risser sign 0-1, Age >10 years
Follow-up 1 year post-treatment

Results
Cobb angle:
PSSE group: Improvement 69%, Progression 8%, Stable 23%
Control group: Improvement 6%, Progression 39%, Stable 55%
ATR: PSSE group Improvement 3.5ο, Control group Stable
SRS-22 (QoL): PSSE group Improvement >0,75 in all sub-categories (pain,
function, self-image and mental health)
Control group no statistically significant change

Conclusions: PSSE can reduce the risk of progression in

mild scoliosis (<25ο) and have significantly better results
than general exercises

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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

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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 to general
exercises

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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

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RCT – Schreiber et al 2016

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

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RCT – Schreiber et al 2017

Schroth physiotherapeutic scoliosis-specific exercises for
adolescent idiopathic scoliosis: how many patients require
treatment to prevent one deterioration? – results from a
randomized controlled trial - “SOSORT 2017 Award Winner”
Scoliosis and Spinal Disorders (2017) 12:26

• How many patients require treatment to prevent

on bad outcome in a pre-defined period of time.
(Number Needed to Treat – NNT). Index showing
clinical importance of an RCT.
• Schroth supervised program 1h/w, home program
35-40 min/day for 6 months.

Συμπεράσματα: Short-term results of

Schroth added to standard of care provided
better outcomes than standard care alone.
Therefore, RCT results proved to be
clinically significant, except from
statistically significant.

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Ongoing 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.

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RCT – Zheng et al 2017

Whether orthotic management and exercise are equally
effective to the patients with Adolescent Idiopathic
Scoliosis in Mainland China? A Randomized Controlled
Trial Study.
Spine (Phila Pa 1976). 2017 Sep 6

Comparative study Bracing and PSSE(SEAS)

SRS-SOSORT inclusion criteria
2 groups: 1)Brace only, 2) PSSE only
24 braced patients , 29 PSSE patients
12 months follow-up
ATR – Cobb angle, quality of life (SRS-22) statistically
improved in both groups, more in bracing group.
Shoulder balance improved only in bracing group.

Conclusions: Treatment results were

significantly better in both groups.
Bracing group improved more the
radiological parameters, while PSSE
improved more quality of life outcomes
(function and mental health, SRS-22)

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Prospective Control Study – Karavidas 2024

SOSORT 2023 Awards
Schroth – Physiotherapeutic Scoliosis Specific Exercises (PSSE - Schroth)
can reduce the risk for progression during the peak of growth in curves
below 25ο : Prospective control study
Prospective Control study
• 221 patients, 163 PSSE-Schroth exercises, 58 Control group general or no exercises
(largest sample in published literature)
• Inclusion criteria: Cobb 15ο -25ο , Risser 0-2, ATR> 5ο , < 1-year post-menarche

• Results:
Success rate (no progression > 5ο)
PSSE-Schroth group 87.1%, Control group 25.9 % (p=0.002)
103 (63.2%) stable, 39 (23.9%) improved, 21 (12.9%) progressed

Brace prescription
PSSE-Schroth group 9.8%, Control group 67.2% (p=0.001)

PSSE-Schroth group significantly improved aesthetics and Quality of Life (ATR, TRACE, TAPS, SRS-22 scores)

• Conclusions: Application of PSSE-Schroth exercises can be effective to reduce risk

of progression at peak of growth in mild scoliosis < 25ο. Significant improvement
of trunk rotation, body symmetry and QoL.

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Prospective study – Karavidas et al 2022

Brace and Physiotherapeutic Scoliosis Specific Exercises (PSSE) for
Adolescent Idiopathic Scoliosis (AIS) treatment: a prospective study
following Scoliosis Research Society (SRS) criteria
Arch Physiother. 2022 Nov 1;12(1):22. doi: 10.1186/s40945-022-00150-5.
PMID: 36316760; PMCID: PMC9624025.

Prospective study
• 102 patients, Cheneau brace + PSSE-Schroth exercises
• SRS Inclusion criteria: >10 years, Cobb 25ο -40ο , Risser 0-2,
< 1 year post-menarche, no prior treatment
• Results:
Success rate 88.5%, no progression > 5ο
(one of the highest in the published literature)
62 (65.3%) stable, 22 (23.2%) improved, 11 (11.5%) progressed
Only 6.4% passed 40ο

• Conclusions: Combination of brace and PSSE-Schroth

exercises can effectively treat AIS at the riskiest period
during peak of growth. Most important prognostic
factors are compliance and in-brace correction

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Systematic reviews with meta-analysis 2022

• Conclusions: PSSE had a positive medium effect size and can be used to reduce spinal deformity and
improve quality of life as isolated treatment for mild curves or combined with bracing in moderate curves

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SOSORT guidelines
(2011 -2016)
• PSSE are the first step to treat scoliosis and
prevent progression or bracing.
• PSSE based on 3D auto-correction, activities of
daily living training and stabilization of
corrected posture through patient education
• PSSE programs are designed only by Certified
Physiotherapists
• Individualized program according to curve type,
patient’s needs and treatment phase.
• A multi-professional therapeutic team,
consisted of MD, CPO and PT, is recommended
• Brace treatment should be accompanied by
PSSE
• Sport activities cannot be considered as
alternative treatment, but patients are
encouraged to participate in sports for their
general benefits.

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SRS statement (May 2014)

• A combination of brace and PSSE
seems to provide better results in
scoliosis treatment

• There is scientific evidence that

PSSE are superior to general or no
exercises

• SRS actively supports studies with

PSSE for scoliosis treatment

• SRS and SOSORT consensus

research guidelines

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Position Statement AAOS,SRS,POSNA,AAP

for Adolescent Idiopathic Scoliosis (2015)

• 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.

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57th SRS Annual Meeting

Stockholm, Sweden
14th – 17th September 2022

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SRS 2023 Workshop

• Session date: September 8th, 2023
• Session time: 12.05 - 13.35

• Session Title: Conservative Care for Adolescent Idiopathic Scoliosis : Brace and Scoliosis
Specific Exercises
• Nikos Karavidas Presentation Title: PSSE Indications, Protocols and Program Characteristics

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Physiotherapeutic Scoliosis Specific

Exercises (PSSE)
Curve pattern specific exercises

1) 3D Auto-correction

2) Patient education for activities of daily living

3) Stabilization of corrected posture

Italy France Germany Spain Poland United Greece

Kingdom

SEAS Lyon Schroth ISST BSPTS- DoboMed Side-Shift PSSE -

Schroth Best Rigo /FITS Schroth
Practice Concept

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SOSORT Board Official Message for PSSE-Schools

(SpineWeek 2023, Melbourne, Australia)

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PSSE – Schroth statements by Nikos Karavidas

• The name of a School or Brace does not guarantee a

successful treatment

Ø “Stop fighting about names”

Ø “There is no best School / Method / Brace , there are

different ways/concepts to treat the same condition,
SCOLIOSIS”

Ø “Learn as many as possible methods and develop your own

way of applying them to your patients”

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PSSE – Schroth statements by Nikos Karavidas

• PSSE cannot always prevent scoliosis progression, even if properly

applied, especially during the peak of growth

Ø “Be prepared to get frustrated with scoliosis treatment”

Ø “Stay humble, do not be arrogant”

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PSSE – Schroth statements by Nikos Karavidas

• Knowledge is not enough for successful treatment, you need

motivation of your patients

Ø “ Consider ourselves as part of the failure when the result is not

good and not only as part of the success when the result is good ”

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PATHOMECHANISM OF PROGRESSION

VIRTUOUS CYCLE THEORY

Reversing Reversing
Wedging of vertebra Asymmetrical growth

3D correction of Reversing
spinal curvature Asymmetrical loading
& ADL training

Multiple factors are related to etiopathogenesis

and Idiopathic Scoliosis progression
Stokes IAF. Huetter-Volkmann effect.
Spine (2000)

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3D PRINCIPLES OF CORRECTION
PSSE - SCHROTH

1. 3D AUTO-CORRECTION
Ø Self-elongation
Ø Pelvic Corrections
Ø Symmetrical / Asymmetrical Sagittal Straightening
Ø Frontal Plane Corrections
2. CORRECTIVE / ROTATIONAL BREATHING
Ø Inhalation: 3D Expansion technique for collapsed areas
Ø Exhalation: Maintain expansion / 3D correction
3. MUSCLE ACTIVATION
Ø Maintain expansion / 3D correction
Ø More activation in every exhalation
Ø Shoulder Traction / Thoracic Counter Traction / Shoulder Counter Traction
Ø Mobilisations
4. STABILISATION
Ø Activities of daily living training

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Scoliotic posture Corrective posture

3D Correction of scoliotic posture during exercises

Education for stabilization of correction during activities of daily living

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Treatment Indications
PSSE - Schroth
Other indications / restrictions
Main Indications
• Idiopathic scoliosis before puberty (<8 years)
• Adolescent Idiopathic Scoliosis • Congenital scoliosis
• Adolescent Kyphosis (Functional or Scheuermann) • Syndromic and Neuromuscular scoliosis with
• Adult Scoliosis “idiopathic-like curve type”
• Adult Kyphosis • Adult Degenerative Scoliosis
• Post-operative (after spinal fusion)

Contra-indications

• Reactive /Antalgic Scoliosis (e.g. Disc Hernia)

• Spinal Tumor
• Psychiatric problems (psychosis, hysteria) ?
• Anorexia nervosa ??

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Planes of movement

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Scoliosis: Curve magnitude (Cobb angle)

UEV: Upper End Vertebra (most

tilted vertebra on the upper part
of the curve)

LEV: Lower End Vertebra (most

tilted vertebra on the lower part
of the curve)

Apex = AV : Apical Vertebra

(most deviated vertebra from the
midline)

Complete curve: UEV and LEV both tilted to the horizontal plane

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Scoliotic angle (Cobb angle)

• Important for prognosis and treatment

decision
• Most tilted upper end vertebra – most
tilted lower end vertebra
• Objective measurement
Inter/intra observer error 2.8ο -7.2ο
Dependent on positioning, posture, time
• Cobb angle
10ο-24ο mild scoliosis
25ο-40ο moderate scoliosis
>40ο severe scoliosis

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Surgimap (free download)

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Smartphone applications

Immediate
measurement of
Cobb angle

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Curve type classification based on Apex

q Thoracic: T6-T11
(IVD T11-T12 και IVD T5-T6)

q Proximal Thoracic : T5 and higher

q Thoracolumbar : T12 – L1

q Lumbar : L2 and lower

(IVD L1-L2)

(SRS terminology)

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Cobb Angle Kyphosis - Lordosis

Normal values

1. Normal kyphosis and lordosis

2. Functional Kyphosis
3. Flatback/Inversion
4. Hollow back
5. Scheuermann Kyphosis
6. Thoracolumbar Kyphosis
Scoliosis Research Society (SRS)
Kyphosis = 20ο / 25ο – 40ο / 50ο (T4-T12)
Staffel classification (1889)
Lordosis = 30ο – 70ο (L1-S1)

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Kyphosis
Normal Spine Normal Spine • Functional Scheuermann
Lateral view Back view • Scheuermann Kyphosis
• Congenital Holger Scheuermann 1920
Cervical • Neuromuscular
• Etiology: Unknown
Spine • Myelomeningocele
• Incidence: 0.4 - 8.3%
• Traumatic (radiological and clinical criteria)
Thoracic
• Post-operative • Gender Distribution
Spine
Boys/Girls: 2/1
• Post-radiation
• Radiological signs :12-13 years
Lumbar • Metabolic
• Pain: 20%-60%
Spine • Dysplastic
• Frequently muscle tightness
• Collagen disease
(hamstrings, pectorals)
• Tumor
Sacrum
• Inflammatory
Coccyx • Infection (Tuberculosis)

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Differential Diagnosis– Clinical evaluation

Functional Scheuermann

• Poor posture • Poor posture

• Shoulders internal rotation, • Shoulders internal rotation,
often forward head position often forward head position
• Flexible spine • Spine rigidity
• No angular kyphotic hump • Angular kyphotic hump
(Adam’s test)

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Differential Diagnosis– Radiological evaluation

Functional Scheuermann

• Thoracic kyphosis (>40ο)

• Ventral vertebra wedging
(> 5ο - 3 consecutive vertebrae)
• End-plates irregularities
• Increased anterior-posterior
diameter
• Narrowing of intervertebral discs
• Schmörl nodes

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Differential diagnosis Scheuermann kyphosis

• Postural
• Infectious Spondylitis
• Post-fracture of the vertebral body
• Osteo-chondro-dystrophia (Morquio,
Hurler) Atypical Scheuermann Kyphosis
• Tumor Ø Some of the clinical or radiological
• Congenital criteria, but not all
• After laminectomy
• Ankylosing Spondylitis
• Atypical Scheuermann

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Thoracic Scheuermann Kyphosis

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Thoracic Scheuermann Kyphosis

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Thoracolumbar Scheuermann Kyphosis

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Lumbar Scheuermann Kyphosis

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Congenital
Kyphosis

57

PELVIC PARAMETERS

Ø Pelvic Incidence (PI) : defined as the angle between the line

perpendicular to the sacral plate at its midpoint and the line connecting
this point to the femoral heads' axis. Anatomical parameter,
independent from pelvic position. Low PI is related with reduced
lordosis, while high PI is related with increased lordosis.
Ø Pelvic Tilt (PT) : defined as the angle created by a line running from the
sacral end plate midpoint to the center of the bifemoral heads and the
vertical axis. Position-dependent parameter. Measures the tilt of the
pelvis (anteversion/retroversion).
Ø Sacral Slope (SS) : defined as the angle between the sacral plate and a
horizontal line. Measures the horizontalization of sacrum.

PI= PT + SS

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Type 1-2
Low PI / SS < 35ο

Type 3AP
Low PI / 35ο < SS < 45ο

Type 3
High PI / 35ο < SS < 45ο

Type 4
High PI / SS > 45ο

Sagittal plane morphology is

associated with pelvic parameters

People with Scheuermann Kyphosis

often have low PI

59

PELVIC PARAMETERS

Maximum Lumbar Lordosis (MLL): Angle

between upper plate of sacrum (S1 vertebra)
and the upper plate of the most tilted
vertebra (UEV)

Maximum Thoracic Kyphosis (MTK): Angle

between the lower plate of T12 vertebra and
the upper plate of the most tilted vertebra
MLL = PI + 9ο MLL = PI X 0.62 + 29ο
(UEV) Yilgor et al 2017, Eur Spine J

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Atypical Scheuermann Kyphosis

15 years, Risser 2
Cobb angle= 62Ο
SS = 46Ο
Type 4 (Rousoully)
No Scheuermann findings on x-ray
(just slight wedging)
High PI
Very rigid
Kyphotic hump

61

Scheuermann Kyphosis Treatment

Non-operative treatment Operative treatment

• Brace and Exercise (SRS – SOSORT guidelines) • Cobb angle > 80ο , painful (SRS guidelines)
• Fail of conservative treatment
• Brace indications (SRS recommendations): Cobb angle • Posterior spinal fusion
55ο – 80ο , Risser 0-3, Scheuermann findings on x-ray • In high rigidity, Smith-Peterson posterior osteotomies
• New techniques, combined anterior-posterior
• 16-22 hrs/day, in conjuction with exercises approach, less complications

62

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Scheuermann Kyphosis – SOSORT guidelines 2010

• Differential diagnosis Scheuermann
• Scheuermann, brace and exercises
• Exercises, even before brace initiation
• Auto-correction, Self-elongation, ADL
training
• Back school not recommended
• Sports allowed, but not as alternative
treatment option
• Cobb angle not so important, as
rigidity and pain
• Compliance with brace and exercises
main prognostic factor

63

Scoliosis
Structural or Functional Scoliosis
Forward Bending Test (FBT)
– Adam’s test
Clinical confirmation of
structural scoliosis
Types of structural
scoliosis
lIdiopathic (75%-80%)

lNeuromuscular (5%-7%)

lCongenital (10%)

lNeurofibromatosis (2%-
3%)
lOther types (syndromic)
• Lateral deviation of the
spinous processes Trunk asymmetry and
• Hump on one side lateral deviation of the
spine

64

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From Jean Dubousset. Reproduced with kind permission of the author

65

From Jean Dubousset. Reproduced with kind permission of the author

66

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From Jean Dubousset. Reproduced with kind permission of the author

67

From Jean Dubousset. Reproduced with kind permission of the author

68

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Vertebra Deformity – Axial Rotation

69

Radiological criteria to define a structural scoliosis

Scoliosis Research Society - SRS

• Functional Scoliosis • Structural Scoliosis

• No axial rotation • Cobb angle > 10ο +

axial rotation
False Positive Adam’s test False Negative Adam’s test

Scoliosis Research Society (SRS)

Lateral deviation of the spine with Cobb angle > 10ο with rotation,
of unknown cause

70

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PSSE – Schroth approach

(based on BSPTS-Rigo Concept)
• Positive FBT + Radiological confirmation (SRS) = Confirmed Structural Scoliosis

• Positive FBT + Fail of radiological confirmation= Hidden Structural Scoliosis

• Negative FBT + Fail of radiological confirmation = Non- Structural Scoliosis

• Negative FBT + Radiological confirmation (SRS) =

False Negative FBT/ Hidden Non-Structural Scoliosis
(radiological art effect?)

71

Failure in diagnosis by using SRS criteria

72

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Failure in diagnosis by using SRS criteria

19ο
8ο

30ο
6ο

11-2020 09-2022
73

Hidden Structural Scoliosis

7ο

74

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Structural Scoliosis ?

75

Structural Scoliosis ?

76

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Non-idiopathic Scoliosis ?

77

Non-idiopathic Scoliosis ?

78

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Axial Rotation / Vertebra Rotation

(Angle Vertebra Rotation – AVR)

Nash&Moe

Raimondi

Ñ Ñ Perdriolle

10º

79

Nash&Moe

Axial Rotation / Vertebra Rotation

(Angle Vertebra Rotation – AVR)

80

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Raimondi

Axial Rotation / Vertebra Rotation

(Angle Vertebra Rotation – AVR)

30º

Raimondi
81

Transitional Point (TP)

Frontal plane imbalance

Transitional Point (TP)

§ Point of change from thoracic to lumbar
curve
UEV
§ Lowest point of thoracic curve or
highest point of lumbar curve

Transitional 1. Th LEV
Point (TP)
LEV Lu UEV
Th LEV
2.

Lu UEV

Central Sacral Line - CSL

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Growth stage - Risser sign

Degree of formation or ossification of
iliac apophysis on the iliac crest
• Risser 0 : No signs of ossification
• Risser 1 : Iliac apophysis has covered
until 1/3 (1%-33%) of iliac crest, start
of ossification. Frequently coincides
with first menarche in girls
• Risser 2 : Apophysis ossification has
covered from 1/3 to 2/3 (33%-66%) of
iliac crest
• Risser 3 : Apophysis ossification has
covered until 2/3 (66%-100%) of iliac
crest. Still remaining growth, but
growth velocity is reduced
• Risser 4 : Fusion of iliac apophysis on
the iliac crest, but not completely
fused. Significant reduction of growth
velocity.
• Risser 5 : End of growth. Iliac
apophysis is completely fused on the
iliac crest.

83

Treatment result – Radiological measurements

84

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Treatment result – Clinical photos

85

3D Nature of Idiopathic Scoliosis

Torsion

86

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Relative Anterior Spinal Overgrowth (RASO)

Disruption of the normal arch of flexion

RASO seems to be secondary to the

mechanical phenomenon of Torsion

Normal Scoliosis suspicion

87

3D – Torsion

From René M Castelein. Reproduced with kind permission of the author

Lateral deviation, Axial Rotation and RASO occurs all together

88

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3D Vertebra Deformity

• First description of 3D vertebra

deformity
(John Adams 18th century)
• Torsional phenomenon
Perdriolle
(French Physiotherapist 20th century)

From René M Castelein. Reproduced with kind permission of the author

• Different orientation of the end plates (transversal plane)

• Lateral wedging on concave side (frontal plane)
• Dorsal wedging (sagittal plane)

89

3D Nature of Idiopathic Scoliosis

Mechanical Torsion Geometrical Torsion
Intervertebral Torsion Trunk Torsion
Intravertebral Torsion

Scoliosis is a Horizontal plane deformity, better representation from top view

R. Perdriolle J.Dubousset 1992

90

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Scoliosis progression with significant RASO

91

Scoliosis progression with significant RASO

92

46
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Scoliosis progression with significant RASO

93

Scoliosis progression with significant RASO

94

47
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Scoliosis progression with significant RASO

95

Scoliosis progression with significant RASO

96

48
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Scoliosis progression with significant RASO

97

Scoliosis progression with significant RASO

Paradoxical Kyphosis on x-ray

98

49
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Scoliosis progression without significant RASO

99

Scoliosis progression without significant RASO

100

50
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Scoliosis progression without significant RASO

101

Scoliosis progression without significant RASO

102

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Scoliosis progression Scoliosis progression

with significant RASO without significant RASO

Rib cage deformity Rib cage deformity

with significant RASO without significant RASO

The real Scoliotic Flatback comes from Torsion

and it does not properly appear on a profile x-ray

103

Gravity effect in scoliosis progression

From Jean Dubousset. Reproduced with kind permission of the author

104

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Scoliosis and Muscle system

Scoliosis creates a
secondary muscle
imbalance

105

Normal gait of a scoliotic patient

106

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King classification for Scoliosis

(Surgical treatment)

CLASSIFICATION
• (1) Be comprehensive and
include all types of curves
• (2) Emphasize consideration of
sagittal alignment
• (3) Help to define treatment that
could be standardized
• (4) Be based on objective criteria
for each curve type
• (5) Have good-to-excellent
intraobserver and interobserver
reliability
• (6) Be easily understood and of
practical value in the clinical
setting

Type I Type II Type III Type IV Type V

Double curve: Double curve: Double Thoracic
Thoracic curve Long thoracic
Lumbar is larger Thoracic is larger curve: T1 tilts
with fractional curve, L4 tilts
and more rigid and more rigid into concavity
lumbar into curve

107

Lenke classification for Scoliosis

(Surgical treatment)

Reliable but too complex for that purpose and questionable in

mild scoliosis:
• Definitions of structural curves using residual coronal curve on side-bending
radiographs of at least 25ο proximal thoracic, main thoracic, lumbar and
thoracolumbar; or +20ο of kyphosis in its specific region (sagittal radiograph)

108

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Scoliosis classification according to age

(Scoliosis Research Society - SRS)

Ø Congenital Scoliosis at birth

Ø Infantile Scoliosis 0-3 years
Ø Juvenile Scoliosis 3-10 years
Ø Adolescent Scoliosis 10-18 years
Ø Adult Scoliosis >18 years

Early Onset Scoliosis (EOS) : Infantile and Juvenile Idiopathic Scoliosis

Age of progression is more important than

Age of diagnosis

109

Congenital Scoliosis

• Scoliosis at birth
• Failure of vertebra formation or failure of vertebra segmentation
• Better prognosis in block and hemi-vertebra
• Bad prognosis in bar with hemi-vertebra

110

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Congenital Scoliosis

111

Congenital Scoliosis

112

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Infantile Scoliosis
• Age 0-3 years
• More often in boys, usually left
curves
• Relatively good prognosis
• Important parameter: Mehta RVAD
(Rib Vertebra Angle Difference)
• RVAD<20ο non-progressive

113

Juvenile Scoliosis

• Age 4-10 years

• More often in girls, usually right curves
• High risk of progression
• 18-25% neurological abnormalities
(Syringomyelia, Arnold-Chiari)
• 70% brace treatment

114

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Juvenile Scoliosis

115

Juvenile Scoliosis

116

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Adolescent Idiopathic Scoliosis

• Unknown etiology
• 80% of scoliosis, most common type
• At growth spurt, in apparently healthy children
• 2-3% of general population
• 7:1 females/males

117

Neuromuscular Scoliosis
• Neuropathic (Cerebral Palsy, Spinal Muscular Atrophy,
spinal cord trauma)
• Myopathic (Muscular Dystrophy, Polio, Arthrogryposis,
Spina Bifida)
• Long curves
• Balance and co-ordination disorders, pelvic obliquity
• Rapid progression, bad prognosis

118

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Neuromuscular Scoliosis
Spinal Muscle Atrophy (SMA)

119

Neuromuscular Scoliosis
Cerebral Palsy

120

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Syndromic Scoliosis
Marfan Syndrome

121

Syndromic Scoliosis
Di George Syndrome

122

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Neurofibromatosis

123

Clinical Evaluation Tools

Scoliometer Anthropometric Body symmetry indexes
(ATR) data (TRACE, POTSI)

Spirometry SRS-22 TAPS Brace

questionnaire questionnaire Clinical photos
(VC, FVC, FEV1.0) questionnaire

Data record: Proper treatment evaluation, Self-evaluation and future research

124

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Angle Trunk Rotation – ATR

Standing position Sitting position

Scoliometer
• ATR : Important progrnostic factor (>10ο)
• Max rotation at Apex
• Sitting and upright measurement
• Regular re-evaluation

125

Anthropometric data

• Standing height
• Sitting height
• Standing height with brace
• Arms span
• Body weight
• Thorax perimeter
• Thorax expansion
• Leg length (LLD suspicion)

126

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TRACE scale
(Trunk Appearance Clinical Evaluation)

• Asymmetry index:
Shoulders, Scapula, Thorax,
Pelvis
• Score 0-11

127

POTSI Index (Posterior Trunk Symmetry Index)

128

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Spirometry

• Estimates breathing function

• Reduced breathing function in
severe thoracic scoliosis
• Vital Capacity (VC) , Forced Vital
Capacity (FVC), FEV 1.0
• Re-evaluation every 6 months

129

TAPS (Trunk Appearance Perception

Scale)

• Self-image
questionnaire
• Re-evaluation every 6
months
• From 1 (severe
deformity) to 5 (minor
deformity)
• Total score: Average of 3
different sets scores

130

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SRS-22 Questionnaire

• Quality of Life
• 5 sub-categories (Pain, Mental Health,
Self-Image, Function, Treatment
Satisfaction)
• Score from 1 (worse) to 5 (best) for each
question
• Total score 20-100
• Re-evaluation every 6 months

131

Italian Spine Youth Quality of

Life (ISYQOL) Questionnaire
• Measures quality of life in adolescents with
scoliosis and kyphosis
• Rasch analysis
• 9 Spine-Health domain questions, 7
additional questions for bracing
• Score: 0 (best) to 2 (worst) για κάθε
ερώτηση
• Total score 0-32, conversion to percentage
by a table
• Re-evaluation after 6-12 months
• Validated in Greek

132

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Brace Questionnaire

• 34 questions regarding bracing

• At least 3 months after first fitting
• 8 sections: General Health, Physical
Activity, Emotional Function,
Clinical Appearance, Vitality, School
Activities, Pain, Social Function
• Each question, from 1 (worse) to 5
(best)
• Total score (%): Multiply total sum
by 20 and divide with 34

133

Clinical Photos

q In front of scoliogram
q Before exercises, neutral position
q Standardize position / camera
q Be aware of braced patients
q Proper clothing

134

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Formetric 4D – DIERS / Surface Topography

135

Treatment indications
Society on Scoliosis Orthopaedic and
Rehabilitation Treatment (SOSORT)
SOSORT GUIDELINES FOR SCOLIOSIS
TREATMENT (2011)
PSSE-Schroth
Observation • Cobb angle <15ο , Risser 0-3 recommendations
• Cobb angle <20ο , Risser 4-5
• Adults, Cobb angle <50ο , without pain • Cobb angle < 25ο, Risser 0-3 (sometimes
Cobb angle < 10ο with positive Adam’s
PSSE • Cobb angle 15ο – 25ο , Risser 0-3
test and vertebra rotation/deformity,
• Braced patients, independent of curve
potential for progression – hidden
magnitude
structural scoliosis)
• Cobb angle 20ο – 40ο , Risser 4-5 • Cobb angle 25ο – 40ο , at Risser 4-5
• Adults with any Cobb angle, with pain • Braced patients, independent of Cobb
Brace • Cobb angle 20ο – 45ο , Risser 0-3 angle
• Adults with very progressive and painful • Adults independent of Cobb angle, with
scoliosis (?) or without pain or aesthetic issues
Surgery • Cobb angle > 45ο , residual growth, fail of
non-operative treatment
• Adults, Cobb angle >50ο , fail of non-
operative treatment

136

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Treatment indications for bracing

SRS
Cobb angle 25ο – 40ο (Risser sign 0-3)

• Good treatment results with bracing

in curves > 45ο

137

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%)

Lonstein JE and Carlson JM, The prediction of curve progression in

untreated idiopathic scoliosis
Other prognostic factors: Age of menarche, family history, during growth. J Bone Joint Surg Am, 1984 Sep; 66 (7): 1061-1071
curve type, vertebra rotation (AVR), hypokyphosis/flatback

138

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Scoliosis prognosis

Difficult to define prognosis for curves < 20º

Evaluation of prognostic factors
“Spontaneous” improvement sometimes

139

“Wait and See” Vs “Try and

See”
“Wait and see” “Try and see”
• PSSE, certified Therapist
• Clinical and radiological observation every • Individualized program
3/6/9/12 months • Regular clinical observation, specific evaluation
• Generic or no exercises / sports tools (scoliometer, photos, TRACE, POTSI/ATSI etc.)

+ No fatigue + Reduce potential for progression, real treatment

+ No cost + Predictable result by clinical measurements, avoid
significant progression
- Not a real treatment
- Potential overtreatment sometimes
- Unpredictable result

Brace indications (Scoliosis Research Society)

Cobb angle 25ο – 40ο, Risser 0-3

140

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Growth velocity

141

Rapid progression during peak of growth

29ο 53ο

31-08-2016 21-10-2016

142

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Risk of progression

Period of stable or Period of

No progression Period of
Stable Progression
(PNP) Rapid Progression
(PSP)
(PRP)

143

Period of Rapid Progression

Infantile Scoliosis

Juvenile Scoliosis

Adolescent
Scoliosis

144

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Εarly Οnset Scoliosis (EOS) Late Οnset Scoliosis

145

BSPTS – Rigo Concept Classification Schroth ISST Classification

Schroth Best Practice Classification

146

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Limitations of other Schroth classifications

• BSPTS – Rigo Concept:

Ø Sometimes difficult to differentiate between 3C and N3N4 or 4C and N3N4,
when there is little pelvic imbalance
Ø Does not allow overcorrection in single curves, like N3N4 without lumbar
curve or G1-2 (single lumbar or thoracolumbar curves)
Ø No maximum of correction for some single curve types

• Schroth ISST:
Ø One clinical type is missing (THL type)
Ø Difficulties to classify balanced double curves, because overcorrection
always occurs for the main curve
Ø Difficulties in classifying the main curve (T or L type) based on Cobb angle,
flexibility, weight bearing, pelvic tilt etc.
Ø Always maximum of correction for the main curve

• Schroth Best Practice:

Ø Overcorrection in every type might result in worsening of a curve
Ø Difficulties in balanced curves, because of overcorrection in the main curve

147

PSSE - Schroth Classification by Nikos Karavidas

Advancements

+ Easy and Accurate Classification to describe all curve

+ Avoid dilemmas on how to classify and treat
types, just 3 simple questions need to be answered
curve types that are balanced (thoracic and
lumbar)
+ Important to give the proper information to the
therapist on how to accordingly treat their patients
+ Avoid dilemmas on how to classify and treat
curve types when pelvis is almost balanced
+ Concept of Overcorrection, the decision for + / - is
based on clinical, radiological and prognostic criteria and
+ Avoid dilemmas on how to classify and treat
is taken from the initial classification
curve types when you are not sure whether
thoracic is structural or not
+ Maximum correction for curve types when
recommended, avoidance when it is risky for creating
+ Avoid dilemmas on how to treat Th-Lu curve
compensations (double and balanced curves)
types with Apex T12/L1
+ Clinical, radiological and prognostic criteria are used

148

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PSSE - Schroth Classification by Nikos Karavidas

Questions for classification

PSSE - Schroth

I. Is there a structural thoracic curve?

II. Pelvis position in relation to the trunk? (frontal plane)

III.Is overcorrection allowed for the main curve?

149

Definition of Overcorrection + / -
PSSE - Schroth
Overcorrection for main curve in every or
in majority of exercises Overcorrective techniques Overcorrective exercises
Ø 3C + (3C without structural Lumbar) • Some Pelvic Corrections • Mermaid on the floor
• Mermaid on the ball
• Frontal/Transversal plane corrections
• Side-lying stretching WS / WP
Selective Overcorrection for main curve only in • Lateral flexion of the trunk is allowed for • Sitting overcorrection on ball
Overcorrective exercises, not in every exercise max of correction for the main curve (wallbar / poles)
Ø 3C + (3C with minor Lumbar)
Ø N3N4 + (N3N4 without Lumbar)
(Ν3Ν4 with minor Lumbar)
Ø 4C + (4C with minor Thoracic, 4C/STL – 4C/SL)
Ø SL / STL +

Overcorrection is not allowed in any exercise

Ø 3C - (3C with significant structural Lumbar)
Ø N3N4 - (N3N4 with significant structural Lumbar)
Ø 4C - (4C with significant structural Thoracic)
Ø SL/STL – (mainly adult degenerative scoliosis)

Overcorrective exercise, lateral flexion,

max correction for main curve

SELECTIVE OVERCORRECTION
In + curve types, the therapist decides how much overcorrection is needed
Normal exercise, no lateral flexion, 3D balance

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Clinical, Radiological & Prognostic Criteria

for Overcorrection or Not
CLINICAL CRITERIA RADIOLOGICAL CRITERIA PROGNOSTIC/OTHER CRITERIA

Trunk rotation Cobb angle Risk for progression

(short-term & long-term)
Frontal plane asymmetry Axial rotation Pain
(trunk-pelvis imbalance)
Pelvic tilt (for 3C+/3C-) Vertebra deformity Cosmetic issues
Significance of structural curves Risser sign
Rigidity Significance of structural curves
Frontal plane asymmetry (TP/CSL)
In-Brace correction

Data Analysis & Synthesis

Clinical Decision Making

151

PSSE - Schroth Classification by Nikos Karavidas

K type 3C type 4C type N3N4 type SL / STL type

KT 3C + 3C - 4C + 4C - N3N4 + N3N4 - SL/STL + SL/STL -

KTL 3C without Lu 3C with Lu 4C/STL or 4C/SL 4C N3N4 without Lu

N3N4 with Lu
SL/STL normal SL/STL
Major L/TL double major degenerative
3C with minor Lu N3N4 with
KL minor Lu
SL/4C STL/4C

Sagittal plane Structural Thoracic Scoliosis Structural Thoracic Scoliosis Structural Thoracic Scoliosis No Structural Thoracic Scoliosis
deformity Pelvis shifted to Pelvis shifted to Pelvis symmetrical Structural Lumbar or
thoracic concavity thoracic convexity Thoracolumbar Scoliosis

+ : Overcorrection of the main curve in some or all exercises

S : Structural Proximal Thoracic Scoliosis (Apex T5 and above)
- : No overcorrection for any curve in all exercises

152

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PSSE - Schroth Classification by Nikos Karavidas

153

PSSE - Schroth Classification by Nikos Karavidas

Structural Thoracic Structural Thoracic Structural Thoracic No Structural Thoracic

3C type 4C type N3N4 type SL / STL type

without Lu with Lu with Lu without Lu with Lu single Lu

3C + 3C + 3C - 4C + 4C - N3N4 + N3N4 + N3N4 - SL/STL + SL/STL -

154

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PSSE - Schroth Classification by Nikos Karavidas

Question 1: Is there a structural Thoracic curve? Question 1b: Is there a structural Lumbar
NO or Thoracolumbar curve?
YES

Question 2: Pelvis position in relation to the trunk? (frontal plane)

YES

Pelvis on Th concavity Pelvis on Th convexity Pelvis symmetric

3C type 4C type N3N4 type SL / STL type

Question 3: Is overcorrection allowed for the main curve?

YES NO YES NO YES NO YES NO

without with significant with with without with significant normal degenerative
Lu / Th-Lu Lu / Th-Lu minor Th significant Th Lu / Th-Lu Lu / Th-Lu Lu / Th-Lu
Lu / Th-Lu
with minor with minor
Lu / Th-Lu Lu / Th-Lu

3C + 3C - 4C + 4C - N3N4 + N3N4 - SL/STL + SL/STL -

155

3C +
3C without Lu
3C with minor Lu

Body blocks

Shoulder Shoulder
block block

Thoracic
Thoracic
block
block

Lumbar
block Lumbar
block

Pelvic Pelvic
block block

Structural Thoracic Scoliosis

Pelvis shifted to
thoracic concavity

156

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3C -
3C with Lu

Body blocks

Shoulder Shoulder
block block

Thoracic
block Thoracic
block

Lumbar
block Lumbar
block
Pelvic Pelvic
block block

Structural Thoracic Scoliosis

Pelvis shifted to
thoracic concavity

157

4C +
4C/STL ή 4C/SL
Major L/TL

Body blocks

Shoulder Shoulder
block block

Thoracic
Thoracic block
block

Lumbar
Lumbar
block
block

Pelvic
Pelvic
block
block

Structural Thoracic Scoliosis

Pelvis shifted to
thoracic convexity

158

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4C -
4C double major

Body blocks

Shoulder Shoulder
block block

Thoracic
Thoracic block
block

Lumbar
Lumbar
block
block

Pelvic
Pelvic
block
block

Structural Thoracic Scoliosis

Pelvis shifted to
thoracic convexity

159

N3N4 +
N3N4 without Lu
N3N4 with minor Lu

Body blocks

Shoulder Shoulder
block block

Thoracic
Thoracic
block
block

Lumbar Lumbar
block block

Pelvic Pelvic
block block

Structural Thoracic Scoliosis

Pelvis symmetrical

160

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N3N4 -
N3N4 with Lu

Body blocks

Shoulder Shoulder
block block

Thoracic
Thoracic
block
block

Lumbar
Lumbar
block
block

Pelvic Pelvic
block block

Structural Thoracic Scoliosis

Pelvis symmetrical

161

STL/SL +
STL normal
STL/4C – SL/4C

Body blocks

Shoulder Shoulder
block block

Thoracic Thoracic
block block

Lumbar
block Lumbar
block

Pelvic
block Pelvic
block

No Structural
Thoracic Scoliosis
Structural Lumbar
or Thoracolumbar
Scoliosis

162

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STL/SL -
STL/SL Degenerative

Body blocks

Shoulder Shoulder
block block

Thoracic Thoracic
block block

Lumbar
block Lumbar
block

Pelvic
block Pelvic
block

No Structural
Thoracic Scoliosis,
Structural Lu/Th-
Lu Scoliosis

163

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