The importance of physiotherapeutic scoliosis-specific exercise (PSSE) training
Adolescent idiopathic scoliosis (AIS) is the most common type of spinal deformity in the pediatric population, accounting for 80-90% of the total population with scoliosis,1 with a reported prevalence of about 5.2%.2 With AIS, morphological changes in the bony structure of the vertebrae create a cascade of rotational and torsional forces that contribute to a three-dimensional deformity of the adolescent spine.3 The standard of care for AIS is highly dependent on Cobb angle but varies internationally. The Scoliosis Research Society (SRS) guidelines are widely accepted in North America, recommending observation for curves between 10˚-25˚, bracing for curves between 25˚-45˚and surgical intervention for curves greater than 45˚.4 Recent evidence suggesting the effectiveness of physiotherapeutic scoliosis-specific exercise (PSSE) has influenced the International Society of Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) to alter their standard of care as follows: PSSE and observation for curves between 15˚-25˚, PSSE and bracing for curves between 25-45˚, and PSSE and spinal fusion surgery for curves greater than 45˚.5 The revised SOSORT standards, integrating PSSE into the standard of care for almost all patients with AIS, will likely contribute to higher representations of this population in outpatient orthopedic clinics. All Physical Therapists must be prepared to treat them.
I was one of the unprepared Physical Therapists. Several years ago, there were three adolescent girls with AIS at once on my caseload. All three girls were active and athletic – two dancers and a runner – and the lack of progress with all three was frustrating for me and my colleagues. I usually anticipate an excellent prognosis for a strong, active, young athlete, but these girls with AIS were different. No matter how much my colleagues and I studied their spinal deformities, looked for weakness to target with strengthening, and tweaked their exercises, my patients were not improving. Worse, they would come for Physical Therapy for one to two weeks at a time, see no improvement, give up on rehab, then return a month or so later in a worsened condition. I felt I was truly letting these patients down, and it was especially disappointing because I was a dancer and cheerleader at their age. Most of the, albeit minor, injuries I sustained at that time in my life were what motivated me to this career path; I strongly relate to this patient population. After those girls gave up on Physical Therapy, I knew something needed to change. I knew I needed to do more to help all of my future patients with AIS. Research led me to become certified in The Schroth Method.
Schroth therapy is a specialized treatment technique performed by extensively trained and certified Physical Therapists that aims at treating scoliosis from three planes of motion. Since scoliosis is a three-dimensional spinal deformity, treatment in all three planes is essential in order to slow curve progression. Unlike general Physical Therapy, Schroth therapy provides PSSE, focusing on elongating and derotating the scoliotic spine, in order to improve posture. The Schroth Method includes passive correction, manual techniques, postural education, and active breathing exercises in order activate weakened/collapsed areas in the spine and contract prominences. While it is generally accepted that PSSE cannot reverse a scoliotic curvature, scoliosis remains a progressive deformity therefore slowing that progression and improving a patient’s postural awareness remain the primary goals of Schroth therapy.
Without proper training in PSSE, it is difficult for a Physical Therapist to successfully treat AIS. Physical Therapy treatment for AIS is not directed by pain. This poses a problem for clinicians like me, who use pain as a guide during evaluations and treatment sessions. When I am treating most nonsurgical patients in the clinic, I use a “test-retest” technique. For example, a patient tells me he has knee pain when he squats, so I have him squat and then have him assign the pain a number out of ten. After examination, I target an observed impairment with a manual technique or exercise, and then have him squat again post-treatment. Further treatment is dictated based on whether the pain increased or decreased.
Patients with scoliosis are different. Many adolescents with scoliosis are completely pain-free. The patient may feel nothing after an initial treatment, or even after several treatments. Furthermore, an exercise that a patient says “feels good” might actually be detrimental. A certain stretch may feel relieving to a patient with AIS because it is stretching contracted tissue, but it is actually aggravating a secondary curve or not addressing the two other planes of deformity involved. Natural and comfortable posture for these patients will be in positions that foster the curve and, therefore, promote progression. It is crucial to break bad habits and direct skilled treatment based on each patient’s individual scoliotic classification (which is more accurate than merely a “C” or an “S” curve), rather than pain.
Patience is paramount when treating scoliosis. There is not always instant gratification or reinforcement when treating AIS – not for the clinician, the patient or the parents. Two recent randomized controlled trials4,6 suggested 27 hours of PSSE to be effective. In the 2016 study, by Kuru et al., these 27 hours were completed over the course of six weeks6 and in another 2016 study, by Schreiber et al., 27 hours were completed over the course of six months.4 Regardless, both are a significant commitment and allowing sufficient time for observable results to manifest is needed. In addition, follow-up X-rays for an adolescent being tracked by an orthopedic for their scoliotic progression are only done every four to six months.7 Patients are going to be asked to work very hard without seeing obvious results. In order to keep the patient engaged, education is required, as well as a substantial amount of trust and communication between the therapist, the patient and the patient’s family. If the patient and family are not properly educated on the expectations, it will be easy for the patient to become bored, frustrated and disengaged.
Since radiological monitoring is not readily available during a course a Physical Therapy care, other objective measures can supplement education and communication, in order to motivate patients and their families. These include, but are not limited to, regular photos of patients standing with their learned corrective posture, scoliometer measurements to track changes in maximum vertebral rotation, and chest expansion measurements as patients’ lung capacity improves. Measuring regularly provides reinforcement to not only the patient and the parents, but to the insurance companies, of course!
Another difference between treating AIS versus other orthopedic conditions, and initially, most difficult for me to accept was that many referring physicians do not necessarily buy into the treatment. Immediately after I was certified in Schroth therapy, I was bursting with excitement to get my hands on as many patients with AIS as I could. That just did not happen as quickly as I thought it would. Some physicians called PSSE “hocus pocus” and I was deflated. However, I quickly realized that the research is not as robust as it needs to be in terms of effectiveness. If SRS and SOSORT cannot agree, and the standard of practice in North America and Europe differs considerably 5 how could I expect all of the local physicians to veer from SRS guidelines? In the last year, I spent a substantial amount of time cold-calling local physicians, walking into their offices, and providing them with all the literature that is out there. It is slowly becoming more successful, but it is not enough. The randomized controlled trials discussed earlier are a great start, but the sample sizes are relatively small and they lack sufficient follow-up and tracking over time.4,6 This is an exciting opportunity to proliferate research and understand much more about this very prevalent diagnosis. Negrini et al. provided a consensus between SRS and SOSORT on recommendations for future research studies,8 so I hope to both see this happen in the near future and to be a part of it.
As soon as I began treating scoliosis patients using The Schroth Method, I became fascinated and inspired. I finally felt I had identified and remedied my previous weaknesses regarding effective AIS treatment options. Although I am only just reaching the end of my first full year as a Schroth-certified clinician, I am cognizant of the differences between treating a scoliosis versus treating most other orthopedic and spinal conditions that Physical Therapists encounter in an outpatient clinic. There is much more to learn, and a far way to go, in order to successfully manage the AIS population. The Schroth Method is not the sole treatment technique; there are other methods being utilized internationally, including the DoboMed approach, side-shift therapy and the Lyon method.7 While every patient should be treated with individualized care, the uniqueness of AIS demands a proportionally unique type of care that may not come naturally for outpatient orthopedic Physical Therapists – it certainly did not for me.
- Weiss HR, Turnbull D, Tournavitis, Borysov M. Treatment of scoliosis-evidence and management: Review of the literature. Middle East J Rehabil Health. 2016; 3(2): 1-8.
- Schreiber S, Parent EC, Moez EK, et al. The effect of Schroth exercises added to the standard of care on the quality 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): 1-12.
- Dubosset J: Importance of the three-dimensional concept in the treatment of scoliotic deformities. Dansereau J ed. International Symposium on 3D Scoliotic Deformities joined with the VIIth International Symposium on Spinal Deformity and Surface Topography Edited in Germany. 1992, 302-311.
- Schreiber S, Parent EC, Moez EK, et al. Schroth physiotherapeutic scoliosis-specific exercises added to the standard of care lead to a better cobb angle outcomes in adolescents with idiopathic scoliosis – an assessor and statistician blinded randomized controlled trial. PLoS ONE. 2016; 11(12): 1-17.
- Negrini S, Aulisa AG, Circo AB, et al. 2011 SOSORT guidelines: Orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. 2012; 7(1): 3.
- Kuru T, Yeldan I, Dereli EE, Ozdincler AR, Dikici F, Colak I. The efficacy of three-dimensional Schroth exercises in adolescent idiopathic scoliosis: a randomized controlled clinical trial. Clinical Rehabilitation. 2016; 30(2): 181-190.
- Gomez JA, Hresko TM, Glotzbecker MP. Nonsurgical management of adolescent idiopathic scoliosis. J of the American Academy of Ortho Surg. 2016; 24(8): 555-564.
- Negrini S, Hresko TM, O’Brien JP, Price N, SOSORT Boards and SRS Non-Operative Committee. Scoliosis. 2015; 10(8): 1-12.