Exercises for Scoliosis within the braces and Brace modifications for exercises

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 < 25 ο, Risser 0-3 Adolescents with Cobb angle 20 ο -29 ο, Risk of progression 40-60% (Lonstein formula) Adolescents with Cobb angle <35 ο, Risser 4-5 Adults with painful scoliosis Adults of any Cobb angle /Patients refused surgery Combined treatment Brace indication (adolescents with Cobb angle 25 ο 40 ο, 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 10 ο -25 ο, 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 3.5 ο, 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 (<25 ο ) 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 30 ο ), Risser 0-3 Results: Schroth supervised significant improvement in Cobb angle by 2.5 ο (p=0.005), ATR by 4.2 ο (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 10 ο -45 ο, 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 10 ο -45 ο, Risser 0-2 Schroth exercises for 6 months Results: Schroth group significantly less Cobb angle. Average initial Cobb angle 51.2 ο, final Schroth group 49.3 ο final control group 55.1 ο. 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 25 ο 40 ο, Risser 0-2 2 groups: 1 st Bracing, 2 nd 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 ScoliosisSpecificExercises

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 transversalplane for regional derotation Sagittal balance andphysiological 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) a b

Regional Derotation THORACIC (YELLOW) a 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

PSSE (out of brace)

Breathing mechanics in-brace (Dynamic effect) Pad/no movement Expansion room / move forward Right thoracic scoliosis Spine view from the top Expansion room / move backward -outward Pad/no movement 39

Breathing mechanics create an internal pairof-force for derotation and partial correction of the structural flat back Pad/no movement Expansion room / move forward Right thoracic scoliosis Spine view from the top Expansion room / move backward -outward Pad/no movement 40

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 Single Major High Thoracic (upper or proximal) Single Major Thoracic Single Major Thoracolumbar Single Major Lumbar Major Thoracic and Minor Lumbar Double Major Thoracic and Lumbar Double Major Thoracic and Thoracolumbar Double Major Thoracic Multiple /Triple structural Lonstein s Revision of the Moe & Ketleson (1970) Radiologic Criteria 1 Curve pattern compatibility Single Composite Double major = 2 structural curves with a Cobb angle not 5º + Thoracic: T2-T11 (Disc T11-12) Proximal Thoracic: T3-4-5 Main Th = T8; High Th: T6-7 Low Th T9-11 (Rigo) Thoracolumbar: T12-L1 Lumbar: L2-L4 (Disc L1-2) Lumbosacral: L5-S1 (Disc L4-5) Major lumbar or TL / Minor Thoracic Double Thoracic (not always double major, sometimes major-minor) (Rigo)

Brace Classification by Rigo Radiologic Criteria 2 Transitional Point and T1 CSL Offset UEV L LEV T 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) L1-L2 T12

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 Radiological Subtypes B1 and B2 Correction in Clinical N3N4 Curve Pattern 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 L1-2 T12

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