Scientific Exercises Approach to Scoliosis

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',e Trealmenl ofSco/iO.fis The Consen'alil'e Scoliosis Trealmenl 191 T.B. Grims (Ed.)

:he TherapieanSal2e. In: Weiss fiR: art, 63-64, 1992

/OS Press. 2008 © 2008 Tile aulhors and /OS Press. All righls resen'etL

scoliotic curve. Ilalian Journal of

ninary results and worsH:ase analysis 5·40. 1997. ression in idiopathic scoliosis patients sex-matched controlled study. Pedialr

'ativeIy treated patients with scoliosis.

~ment on the prevalence of surgery in ion. 6 209-214. 2003. It., Pflaum, Munich, 2007 n the treatment of idiopathic scoliosis:

or the spine in girls with idiopathic :/mol Inform. 2006;123 904. tation: a controlled study of matched

italion--the key 10 an improvement of

-what do we know? A review of the

nities. ISICO Milano, 2007

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Scientific Exercises Approach to Scoliosis (SEAS): Efficacy, Efficiency and

Innovation

Michele ROMANO I , Alessandra NEGRINe, Silvana PARZINe, and Stefano NEGRINI I,2

IISICO (Ilaliall Scientific Spine Illstitllte), Via Carlo Crivelli 20, 20122 Milan, Italy[email protected]

2Centro NegrinilSICO, Vigevano, Italy

Abstract. SEAS is an acronym for "Scicntific Exercises Approach to Scoliosis", Main characteristics of SEAS are team approach and cognitive-behavioural approach because in our view these are two indispensable elements in chronic disease rehabilitation. In this article we describe the main differences between SEAS approach and other exercise techniques as well as theoretical bases and therapeutic goals. We illustrate practical application of SEAS concept and scientific results in order to reduce the patient's progress of scoliosis so that a brace would be needed. When compared to usual care, improvement of scoliosis parameters and balance normalization in scoliosis patients.

KC)"1\"urds. Idiopathic scoliosis, physical exercises, conservative treatment

1. The Scientific Exercises Approach to Scoliosis

SEAS is an acronym for "Scientific Exercises Approach to Scoliosis" [3, 4]. As we are used to see in software products, after the acronym there is a dot followed by a number, to indicate the protocol version and the year in which substantial changes were introduced. We now use version ".06". Although SEAS originated long ago (about 30 years)[8,9, 10], it has been continuously updated so to meet contemporary needs, An exercise-based approach remains updated only if it isn't based on a rigid original idea but can update itselfby following acquisitions proposed by the scientific world.

Among the more well-known exercise treatments are the ones ofMezieres, Sohier and Klapp [II, 12] that have remained almost unchanged over time, while others, more dynamic,like the Global Postural Rehabilitation according to Souchard, or Schroth [13, 14, IS, 16], have changed over time with the stimulus of new proposals claimed by the original authors and their followers (however, it must be said that today only Schroth [IS, 16, 13, 14] and Dobosiewicz [17, 18, 19], together with SEAS[3, 4], have results published in indexed literature). Hhowever, these innovations are directly suggested by the present leader's intuition, and that some exercises remained basically unchanged since the beginning, contrary to SEAS, which regulates its changes according to evidence coming from new

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192 M. Romano e/ a/.fSEAS: Efficacy, Efficiency and [nnom/ion

dcvelopments proposed by scientific research. For example, in the beginning, Active Self-Corrcction movement (which is currcntly proposed as a methodological basis within SEAS [I]) was a simple auto-elongation that was considered to be the best correction solution due to the scientific knowlcdge in the 1970s (in a consistent way with Harrington's fusion and Milwaukee brace techniques) [20]. Today, however, everything has radically changed because of the knowledge considering threedimensional deformitY,[21] and auto-elongation has been almost completely abandoned, having been replaced by Active Self-Correction on the three spatial planes, according to what is reported below.[22] So, by dcfinition SEAS can radically improve in accordance with new developments, regardless of the original ideas of the person who first devised it.

The tcam concept is an important prerequisite of SEAS. We believe that we can obtain the bcst results only if every single elemcnt of a heterogeneous team contributes by giving the best of hislher specific competencies, and if effective communication instruments arc warranted. The ideal team is an extcnded group that in its "therapeutic" segment includes the physician, the physiotherapist, trainer and orthotist along with the patient and hislher family.

1.1. From a biomechanicalperspective, what are exercises/or? Neurophysiology developments indicate the role 0/Active Self-Correction

To fully understand the biomechanical role of exercises in scoliosis treatment (which, as we will scc later, have other equally important roles),[ll, 12, 20, 23, 24] and to understand why SEAS has certain unique characteristics relative to other exercise treatments, an in-depth consideration is necessary. Evcry biomechanical treatment for scoliosis tries to contrast the "vicious cyclc" [25] describcd by Stokes, favouring a less pathological growth of affectcd vcrtebrae. In that sense, Active Sclf-Correction is seen by all experts as the crucial moment of treatment, as was confirmed by the SOSORT Conscnsus Conference.[24] Howevcr, the point is: how can exercises innuence this "vicious cycle"? Consider the following:

• Correction obtaincd with exercises lasts only for thc duration of exercise execution;

• Even in more "aggressive" exercise methodologies, in which for certain periods patients are required to do an inpatient exercise treatment lasting up to eight hours per day, [26, 27]it would not be possible to hold the real correction for more than two or three hours, taking into consideration pauses and exercise intervals. ' '

• No one would ever think ofproposing a corrective brace for such a short time. Given all the above, it is obvious that exercises can work from the biomcchanical

point of view but only through a permanent change in posture. So, the real question is: how can I 'work better to modify my patient's posture? Which is the best learning mcthod by which to obtain a 'new posturc? Over the years, we have seen a dcfinitc evolution from a purely mechanistic modcl--in which motor learning was considered as related only to obsessive repetition--to a more complcx functional model in which repetition plays a role, but its execution in confounding situations facilitates the creation of the correct cortical engrams [5, 6, 7]. Moreover, another question must be asked here: does obtaining the maximum possible correction work better for learning a new posture (passive auto-correction), or is it better to accept a smaller correction but

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Figure. 1. From a neurophY' one 10 Jearn neuro-mOlor autocorreclion, goes toward corrective exercises) to "nel normal posture. Second line: thoracic kyphosis and better I

actively obtained without not pcculiar to the spine t 6, 7] and from a neuroph the passive one to lean: accepted that posture is behaviour). Moreover, thi thousand different exerci: neuromotor bchaviour. 11 conceptual passage havill from "correction" (passiv1

exercises to learn behavio Therefore, even if dUJ

of auto-correction has be exercise, with the excep approach. From our poinl should be done by the musculature, without extl without using muscular

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lple, in the beginning, Active ~d as a methodological basis vas considered to be the best le 1970s (in a consistent way ques) [20]. Today, however, nowledge considering threealmost compldely abandoned,

.hree spatial planes, according !\.S can radically improve in [ginal ideas of the person who

EAS. We believe that we can eterogeneous team contributes .d if effective communication group that in its "therapeutic" er and orthotist along with the

?sfor? Neurophysiology

in scoliosis treatment (which, ,),[11, 12,20, 23,24] and to ics relative to other exercise y biomechanical treatment for led by Stokes, favoming a less Active Self-Correction is seen is confirmed by the SOSORT i can exercises influence this

tor the duration of exercise

llogies, in which for certain xercise treatment lasting up to :ible to hold the real correction lto consideration pauses and

ve brace for such a short time. work from the biomechanical lsture. So, the real question is: :'1 Which is the best learning ears, we have seen a definite tor learning was considered as x functional model in which ling situations facilitates the ,ver, another question must be tion work better for learning a :ept a smaller correction bw

M. Romano er al. / SEAS: Efficacy, Efficiency arid lnllOYClrion 193

Figure. 1. From a neurophysiological perspective,[5, 6, 7] active movement is much better than passive one to learn ncuro-motor behaviuurs, like posture. Active Self-Correction instead of passive autocorrection, goes towards this direction, with a conceptual passage from "correction" (passive corrective exercises) to "neuromotor rehabilitation" (active exercises to learn behuviours). First line: normal posture. Second line: Active Self-Correction (ASC). Observe nomuli7.ation of flanks, increase of thoracic kyphosis and better lumbar lordosis, radiographic results (C: Cobb; R: Raimondi rotation

actively obtained without external aids, i.e. limb attitudes, supports or muscles that are not peculiar to the spine (Active Self-Correction)? According to the same literature,[5, 6, 7] and from a neurophysiological perspective, active movement is much better than the passive one to learn neuro-motor behaviours such as posture (obviously once accepted that posture is not only a matter of anatomy but also of neuro-motorial behaviour). Moreover, this Active Self-Correction (see Figure I) can be replicated in a thousand different exercises with "distracting" situations, thereby "strengthening" the neuromotor behavioLlf. The SEAS answer specifical1y addresses this direction, with a conceptual passage having a precise neurophysiological basis that brings the patient from "correction" (passive corrective exercises) to "neuromotor rehabilitation" (active cxercises to learn behaviours).

Therefore, even if during the SOSORT Consensus Conference [241 the importance of auto-correction has been underlined, we must notice that almost every school of exercise, with the exception of SEAS,[22] is based on a passive auto-correction approach, From our point of view, auto-correction to become Active Self-Correction should be done by the patient exclusively through the spinal deep paravertebral musculature, without external help, thus pursuing the precise control of movement without using muscular contractions strategies that drive the spine into a passive


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Cobb [2) that are most observations, as well as I load threshold beyond whi as curvature increases-el order to reduce postural potentials. The importance experiments but also from whose constituent elemen longer able to maintain natural history of a prog several plancs, which aftl "vicious eycle" theory ide Consensus Conference, w the most important therapl vertebral stabilisation was in the practical way that SI

by the SEAS approach is enhancing the function of (see Figure 3).

2.2. Neuromotor ;mpa;mle

High experts in scoliosis I

[32] and Herman (see Figu postural deficits and spina identified, among the aetic because a correlation bet" evident, even if the rela potential of curvature has I

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Figure. 2. The postural component has been measurcd,[2] and corresponds to almost 10·•. whose importance is obviously higher in scolioses < 20 ·Cobb, \hat arc the ones most targeted by exercises for pre"entive purposes.

alignment (for example, contraction of concavity psoas muscles in ordcr to reduce lateral flexion component in a lumbar scoliosis).

2. SEAS therapeutic goals

Exercises do not havc a strictly biomechanical role[ll, 12,20, 23, 24]. Before we explain the essential principles on which SEAS is based, it is necessary to underline two other preliminary remarks: From a scientific point of view, we are still far from defining Ihe cause of idiopathic scoliosis. Regarding idiopathic scoliosis, we are cert~in

of only a few elements regarding the functional impairments it causes or those with which it is associated. The research has chiefly served to clarify a series of dysfunctions that the scoliotic patient experiences and that exe~cise treat~ent ~ased.on

the SEAS approach tries to reduce. The treatment schedule pomts to the IdentificatIOn of a scries of therapeutic goals that vary depending on the phase of treatment and that must bc pursued each time with the most effective weapons available. The main dysfunctions experienced by a scoliotic patient can be schematically described as follows.

2. J. Postllre alld stability ;mpa;nllents

Increasing spinal stability is a primary therapeutic goal of the SEAS approach. The importance of this rehabilitation aspect is derived from a series of fundamental studies. Duval-Beaupere [28] showed that scoliotic curve magnitude is not only the result of a structural deformation but that there is also a postural component signifying a difficulty of the stabilizing system in the spine to counterbalance the alignment loss. This component, which is always present, is particularly important in the scoliosis < 200

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orresponds to almosi 10°. whose Dnes most targeted by exercises for

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, 12, 20, 23, 24]. Before we J, it is necessary to underline of view, we are still far from lathic scoliosis, we are certain ments it causes or those with ·rved to clarify a series of 1t exercise treatment based on Jle points to the identification Ie phase of treatment and that veapons available. The main e schematically described as

. of the SEAS approach. The series of fundamental studies. ude is not only thc rcsult of a nponcnt signifying a difficulty lCC the alignment loss. This portant in the scoliosis < 20°

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Figure. 3. Load threshold beyond which the spine begins to get defonncd (criticallood) diminishes as cun'e increases.[ll

Cobb [2] that are most targctcd by exercises for preventive purposes. From these observations, as well as Bunch and Patwardhan's[l] studies-which showcd how the load threshold beyond which thc spine begins to get defonned (critical load) diminishes as curvature increases--emergc thc importance of improving spinal stabilisation in ordcr to reduce postural collapse and thc consequent spinal structural defonnation potcntials. The importance of improving spinal stability derives not only from scientific experiments but also from clinical evidence: a scoliotic spine can be seen as a structure whose constituent elements, being subject to stimuli causing a loss of balance, are no longer able to maintain their physiological alignment and primitive stability. The natural history of a progrcssive scoliosis could therefore be a postural collapse on sevcral planes, which afterwards becomcs a bone defonnity in accordance with the "vicious cyelc" theory ideated by Stokes[25] (sce Figure 2). Even during the SOSORT Consensus Conference, which took place in Milan in 2005,[24] in regard to defining the most important therapcutic goals for scoliosis conservative treatmcnt, the pursuit of vertebral stabilisation \WS indicated as the sccond priority. The difficulty probably lies in the practical way that such rcsult can be obtained. The therapcutic stratcgy proposed by the SEAS approach is bascd on improving rcactions to force of gravity and on cnhancing the function of those musclcs that have a major stabilizing vocation [29, 2] (see Figurc 3).

2.2. Neuromotor impairmellls

High experts in scoliosis research, like Duboussct [30] Nachemson,[31] and Stagnara [32] and Hennan (see Figure 4) [33] have intuitively postulated the correlation between postural deficits and spinal balance/stability. More recently, scvernl authors have also identified, among the actiological cofactors for scoliosis, balance dysfunctions. This is bccause a correlation between idiopathic scoliosis and postural control proved to be evidcnt, even if the relationship bctween deficit magnitude and the progressive potcntial of curvature has not yet been clarified. On the basis of these observations and

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concavity. B - The thcrapist p apex, while the patient lets the therapist's hand on the hemitor.

Figure 4. Hennan's theory, awarded with the Harrington Lecture by SRS that considcrs scoliosis as compensation to ncuromotorial dysfunctions. 3. Practical application 0

the research results, we can say that the development of balance reactions is a fundamental therapeutic goal to which the treatment schemes proposed by SEAS Scientific research sh0\1 devote particular attention. neuromotor, biomechanica

knowledge of these impai exercises in order to pre12.3. Sagillal plan impairments scoliosis and progressive altow us to slow down andSeveral researches, among which those of Perdriolle[21] and Graf [34] in particular 4] while in braced ones thiindicate that the evolution of scoliotic curvature is characterised by a reduction of the action and avoid its side ef curves on the sagittal plane (flat or hollow back), a biomechanical condition that,

according to White and Panjabi,[35] also facilitates axial rotation. In the exercises 3.1. Exercises in Jow-degrl proposed by the SEAS approach, the search and preservation of a physiological sagittal

orientation in the scoliotic spine is also a main therapeutic goal. Goals at the neuromotor aJ

and spinal stability, while 2.4. Otller impairmellls towards aerobic functionin

Finally, we cannot neglect the impairments that scoliosis causes at an organic (aerobic) 3.2. PoslllraJ COlllroJ and.s level, with a reduction of both vital capacity and oxygen conduction ability (VQ2max), [36, 37]the latter of which, among other things, proves to be disproportionate to vital Nachemson[31] claimed tl capacity reduction but related to deficient physical conditioning. Furthermore, the thereby stop the progressil psychological aspect is a crucial one: it is partly due to the age at which the pathology postural control and spin;appears but also to the often iatrogenic influence on the psyche as determined by strengthening in a correct treatments and healthcare operators. All these aspects are taken into consideration integration. [41] Let's takl within the SEAS approach.

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'y SRS thal comiders scoliosis as

t of balance reactions is a ~chemes proposed by SEAS

] and Graf [34'1 in particular cterised by a reduction of the tiomechanical condition ,hat, ial rotation, In the exercises ion of a physiological sagittal goal.

causes at an organic (aerobic) conduction ability (V02max), o be disproportionate tu vital nditioning. furthermore, the Ie age at which the pathology he psyche as determined by arc takcn into consideration

A B

Figure. 5. Active Self-Correction on the frontal plane. A - The therapist puts his/her fingers OIl the spinous processes correspondent to thoracic curve apex, whi Ie the patient lets the vertebrae shift towards

concavity, B - The therapist puts his/her fingers on the spinous processes correspondent to lumbar curve apex, wnile the patient lets the vertebrae shift towards concavity side. The counter-support of the therapist's hand on the hemitorax and hemipelvis opposed to curve convexity avoids imbalances.

3. Practical application of SEAS concept

Scientific research showed that scoliosis causes functional impairments at a neuromotor, biomeehanical, organic and psychologicallevel[38, 39, 12] Based on the knowledge of these impairments, we derive therapeutic goals to be pursued through exercises in order to prevent and reduce them in the treatment of both low-degree scoliosis and progressive forms in association with bracing. Furthermore, exercises allow us to slow down and in some cases stop progression in low-degree scoliosis, [40, 4] while in braced ones this kind of therapy is useful to increase the orthosis corrective action and avoid its side effects.

3.1. Exercises in low-degree scoliosis trealment

Goals at the neuromotor and biomechanical levels are directed towards postural control and spinal stability, while the goals at the bodily and psychological levels are directed towards aerobit: functioning and development of a positive body image.

3.2. Postural control and spinal stability

Nachemson[31] claimed that good spinal stability could neutralize postural deficits and thereby stop the progression of an initial scoliosis. The therapeutic modalities to obtain postural control and spinal stability arc postural rehabilitation, muscular endurance strengthening in a correct posture, development of balance reactions and neuromotor integration. [41] Let's take into consideration these modalities.


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M. Romano er al. / SEAS: Efficacy. Efficiency and lnnovtltion M.Rom.

A B

Figure 6. Active Self-Correction on the sagittal plane A -By leaning against the upright, lbe patient then docs a pelvis antiversion (to recreate lumbar lordosis) and a thoracic kyphotization (to recreate thoracic kyphosis). B- The putient does the same exercise without the help of the upright, at first looking at hirnlherself in the mirror.

3.3. Poslural rehabilitution

lt includes becoming aware of body posture, becoming aware of defects of posture and Active Self-Correction on the three spatial planes. Becoming aware of body posture and defects of posture is obtained through visual (mirror) and tactile (contacts in the various postures) biofeedback and rehabilitator guidance.

3.4. Active Self-Correction

Active Self-Correction on the three spatial planes is the most important individualized therapeutic moment directed towards one's own defonnity. It includes several phases, as f(Jllows:

• The first phase includes becoming aware of curve apex translation towards concavity on the frontal plane, and is done in several postures (see Figure 5). For exampic, in the case of a double-curve scoliosis, first we teach how to execute thoracic curve translation and then lumbar curve one; subsequently, we associate the two movements, beginning with lumbar translation.

• The phase immediately following includes becoming aware of correction on the sagittal plane. The studies of Perdriollc,[21] Graf,[34] White and Panjabi[3S] highlighted that idiopathic scoliosis, in the case of progression, reduces physiological curvatures on the sagittal plane, favoring vertebral rotation. Exercises must ensure thoracic kyphosis and lumbar lordosis. At the lumbar level, we ask the patient to do pelvis anteversion and a kyphotisation movement at the thoracic level (see Figure 6).

• finally, we associate active Self-Correction movements on the frontal and sagittal planes. According to Dickson's studies,[42] an action done on two

Fig

spinal planes (fror lordosis) causes all

Following the end 0

perfonned by the patient exercise.

3.5. Muscular endurance stl

Muscle endurance strength, limbs and scapulo-humeral that are one-third to two-thi patient to execute an Acti\! duration of isometric contn Abumi's studies showed tJ guarantee greater stability it Self-Correction movement ; chosen muscles duration (SCI

3.6. Development a/balance

This is aimed at improving exercises arc always done developed with growing d development of balance re~

because scientific research t centers that control balance ii


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M. Romano el al. / SEAS: Efficacy, Efficiency and Innovalionnd lnnovalion

against the upright, the patient then . kyphotintion (to recreate thoracic

of the upright, at lirst looki~.g at

ware of defects of posture and Jming aware uf body posture Ir) and tactile (contacts in the

most important individualized ty. It includes several phases,

lrve apex translation towards :veral postures (see Figme 5). Jliosis, first we teach how to lbar curve one; subsl:qucntly, I lumbar translation. Jming aware of correction on e,[21] Graf,[341 White and s, in the case of progression, tal plane, favoring vertebral is and lumbar lordosis. At the tteversion and a kyphotisation

lovements on the frontal and ;,[42] an action done on two

Figure 7. Muscular elldunmce strengthening in the correct posture.

spinal planes (frontal translation and kyphotisation and/or lumbar increase of lordosis) causes an involvement of the third plane (cross-sectional derotation).

Following the end of the initial learning phase, Active Self-Correction is perfonned by the patient in an independent manner and applied in every standing exercise.

3.5. Muscular endurance strengthening in the correct posture

Muscle endurance strengthening aims at developing paravertebral, abdominal, lower limbs and scapula-humeral girdle muscles through isomctric contractions. It uses loads that are one-third to two-thirds of maximal load in Active Self-Correction. We ask the patient to execute an Active Self-Correction movement and to hold it for the entire dmation of isometric contraction of the chosen muscles (see Figure 7). Panjabi and Abumi's studies showed that the spine needs good muscular support in order to guarantee greater stability in a scoliotic spine. We ask the patient to execute an active Self-Correction movement and to hold it for the entire isometric contraction of the chosen muscles dmation (scc Figure 7).

3.6. Development ofbalance reactions

This is aimed at improving axial, static and dynamic balance of the trunk. Proposed exercises are always done in Active Self-Correction, even on unstable planes, developed with growing difficulties (see Figure 8). Stagnara[43] claims that the development of balance reactions must be one of the main goals of rehabilitation because scientific research has shown thc presence of some impairments in cortical centers that control balance in scoliotic patients.


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200 M. Romano er al. / SEAS: E[JiCCIcy. Efficiency lind Innovaliol!

Figure 8. Devclopmcnt of balance reactions Proposed exercises are always done in Active SelfCorr,,~lion, even on unstable planes, developed with growing difficulties

3.7. Neuromotor integration

This aims at integrating in everyday behaviors a more correct and better-balanced spinal posture, progressively developing the ability to react with correct functional

Figure 9. Preparation to bracing. Exercises aimed at increasing range of motion of the spine on all planes, in order to allow the brace to exert the maximum possible correction

attitudes (Active Self-Correction) to the different requirements of social life. We propose exercises that associate Active Self-Correction with global movements, e.g., walking with a simple gait and oculo-manual education exercises, even on unstable planes. In this conclusive phase of treatmcnt, we give ergonomic information so as to avoid spinal damage in adulthood.

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3.8. Aerobicjunctjonin~

These goals are reached we are discussing, in· functioning (vital and positive body image. ' competitive sports that t maximum thoracic exte scoliotic patient every ] activities, for their limit changes but offer huge ~

3.9. Exercises in brace t

The main goals of exei effects caused by immo sagittal curves, mainly ~

corrective pushes. [44, modalities, subdivided it

3.9.1. Preparationjor bl

We request the executio spine on all planes, so a (see Figure 9). We also brace wearing, when it i!

3.9.2. Brace wearing pel

We initially propose ext lower limbs so as to fac: of hours. We propose st kyphosis preservation, \>

by brace pushes. DurinE continuatively these othe body image. For that re, sport activities, both agol full time (see Figure participation in motor a while wearing a brace, . should nevcr force any Iii


201 M. Romallo et al. / SEAS: Efficac)'. Efficiellc)' Gild lllllomtiolllid III//Om/ioll

3.8. Aerobicfimctioning and development oja positive body image

•• These goals are reached through modalities that aren't specific to the therapeutic field: we arc discussing, in particular, motor and sport activities that stimulate aerobic functioning (vital and oxygen uptake and consume capacity) and help develop a positive body image. When the patient does not wear a brace, we advise against competitive sports that require an increased range of motion of the spine, particularly in maximum thoracic extension and/or lumbar flexion. According to Stagnara,[23] for a scoliotic patient every motor activity done at a recreational level is beneficial. Such activities, for their limited duration and intensity over time, cannot determine structural changes but offer huge benefits at the bodily and psychological levels.

3.9. Exercises ill brace treatment

The main goals of exercises in brace treatment are: elimination or reduction of side effects caused by immobility (muscular hypotrophy), or the brace itself (reduction of sagittal curves, mainly kyphosis, and breathing impairment) and accentuation of brace corrective pushes. [44, 45, 23] Such goals are pursued through specific therapeutic modalities, subdivided into treatment phases:

are always done in Active Selfties 3.9.1. Preparationjor bracing

We request the execution of exercises aimed at increasing the range of motion of the spine on all planes, so as to allow the brace to exert the maximum possible correction (see Figure 9). We also continue proposing mobilisation exercises in the first phase of

e correct and better-balanced brace wearing, when it is worn for at least 21 hours per day. react with correct functional

3.9.2. Brace wearing period

We initially propose exercises of "wriggling out of supports" by using the upper and lower limbs so as to facilitate adaptation to brace usage for the recommended number of hours. We propose strengthening exercises, requiring lumbar lordosis and thoracic kyphosis preservation. while frontal and cross-sectional plans corrcction is guaranteed by brace pushes. During brace treatment, it is of fundamental importance to pursue continuativcly these other two goals: aerobic functioning and development ofa positive body image. For that reason, we recommend intensifying participation in motor and sport activities, both agonistic and/or rccreational, even with a brace that must be worn full time (see Figure IO).During brace treatment, we rccommend to intensify participation in motor and sport, both agonistic and/or recreational activities, even while wearing a brace, like in the two cases presented. The presence of the brace

ange of motion of the spine on all should never force any limitation upon the young patient's personal and social life. :arreetian

uirements of social life. We with global movements, e.g., 1 exercises, even on unstablc 'gonomic information so as to

•


;vI. Romano er al. I SEAS: Efficacy, E.JJiciency and lnnuvarion 202

3.10. Cognitive-behavioural approach and counselling: compliance and acceptability through humanisation

Chronic pathology tends to cause a change in behaviour and relationships with the omer world[46]. Scoliosis can fall within the group of chronic pathologies because of the long time period required for its therapy, and due to the fact that treatment outcome will not be a complete patient recovery but the best possible control of the deviation[9]. The correct management of this disease is not always easy, because it usually appears in a frail period oflife, i.e., the stage of pubertal growth spurt. When treatment includes a brace as well, the young patient's reaction is rarely good. [47,48] The brace causes a sudden shock and modifies the adolescent's human relationships during a period of dramatic physical change, when he/she is grappling with the acceptation of his/ber rapidly changing body, this being the period involving the development of his/her personality and in which the young person is concentrated on weaving the first complex plot of relationships with the other sex. For the parents, it is also a difficult situation. Their natural ambition is to seck the utmost happiness for their children, but they are forced to struggle with the difficult problem of whether to ask the person they love most to make a big sacrifice that is necessary for the child's health, or to try and find a different path with a doubtful efficacy that could be dangerous and create even bigger problems.

In the treatment of chronic pain, the importance of formulating the treatment on the basis of a far less mechanistic nature than before is shared internationally [49]. Chronic back pain is described as a bio-psycho-social problem, i.e., a disorder that has a biOlogic origin, causes psychological implications of non-acceptance, growing fear and distmst towards problem resolution, until it finally results in depressive behaviours that eventually have repercussions even on relationship dynamics with the outer world. Thanks to this new awareness, we consider every facet of a condition that is much more complex than what we used to think. [50J This has suggested the use of integrated treatment techniques that draw on the experience of other medical disciplines as well. It is the case of cognitive-behavioural approach that originated from experiences developed in psychology field halfway through the past century. [51, 52] The transposition of a cognitive-behavioural approach to scoliosis treatment is aimed at

Figure to. Aerobic functioning and development of a positive body image

iY!. Ru

simplifying treatment : problems and stimulatin

The essential condi of the clear and effecti patient[54] and family a

• Carefully listen • Let the patient! • Solve practical

For the practical appli( include a family coum meeting sees the partie who has taught the De, follows the patient ea importance to reach the contract" agreed upon\'< therapeutic team. lt is a outcome

4. Scientific results of ~

4.1. SEAS treatment red

The main objective of e so that a brace would I protocol, we compared obtained in 69 patients and were followed up protocol (SEAS group), in those treated with stf out of four cases (25%). it demonstrates how co most cases, thus avoidil two years of treatment i

one year (10% SEAS vs the two treatments. FUI populations will offer correct exercises we Cal

prescription. Because th growth, this delay at thf point of view.

4.2. SEAS treatment im[

In the study already , traditional measures. In' a radiographic improver while the number of we


203 ,and bmol'Qlion

,compliance and acceptability

iour and relationships with the 'chronic pathologies because of I the fact that treatment outcome ,ible control of the deviation[9]. ~asy, because it usual1y appears spurt. When treatment includes

lod. [47,48] The brace causes a clationships during a period of with the acceptation of his/ller ng the developmcnt of hislher :entrated on weaving the first ,he parents, it is also a difficult lappiness for their children, but , whether to ask the person they the child's health, or to try and i be dangerous and create even

If formulating the treatment on is shared internationally [49].

'roblem, i.e., a disorder that has f non-acceptance, growing fear :esults in depressive behaviours dynamics with the outer world. et of a condition that is much ,suggested the use of integrated :r medical disciplines as well. It originated from expcriences

: past century. [51, 52] The ;coliosis treatment is aimed at

I positive body image

M. Romano el a/.ISEAS: EjficaC)~ EjficienC)' and lnnOl'Qlion

simplifying treatment acceptance, reassurance, looking for a solution to practical problems and stimulating faith towards the outcome. [53]

The essential condition for an effective development of treatment is the definition of the clear and effective two-way communication necessary to win the trust of the patient[54] and family alike. This al10ws us to:

• Careful1y listen to doubts and explanation requests; • Let the patient/family feel that we understand hislher/their distress; • Solve practical problems that might arise.

For the practical application of these principles, treatment protocols used at ISICO include a family counselling meeting to be held at the end of each session. This meeting sees the participation of the patient, hislher family, the ISICO rehabilitator who has taught the new exercise plan and, if present, the therapist who in practice ' fol1ows the patient each time he/she docs exercises. It is a moment of utmost importance to reach the described objectives, to regularly consolidate the "therapeutic contract" agreed upon with the patient and hislher family, and to cement the "extended" therapeutic team. It is an indispensable element for an optimal attainment of the final outcome

4. Scientific results of SEAS

4.1. SEAS treatment reduces the need/or bracing

The main objective of exercise treatment is to avoid that paticnt's progress of scoliosis so that a brace would be needed. To verify the efficacy in this respect of the SEAS protocol, we compared in a prospective and control1ed cohort study[3] the results obtained in 69 patients at risk of brace treatment; they were divided into two groups and were follO\vea up for a period of one year. Among patients treated with our protocol (SEAS group), bracing was prescribed in one out of twenty cases (6%), while in those treated with standard exercises (CONT group) bracing was prescribed in one out of four cases (25%). This result is statistically significant, and it is relevant because it demonstrates how correctly designed exercises can guarantee scoliosis stability in most cases, thus avoiding more invasive treatments. The fol1ow-up examination after two years of treatment in 38 patients confirmed the differences already highlighted at one year (10% SEAS vs. 27% other group), even if with a reduction of the gap between the two treatments. Further studies with longer fol1ow-up periods and larger study populations will offer more definite results, but already today we know that with correct exercises we can reduce the number of prescribed braces or at least delay their prescription. Because the end of brace treatment always coincides with the end of bone growth, this delay at the start of therapy is another significant result from the patient's point ofview.

4.2. SEAS treatment improves scoliosis parameters

In the study already mentioned[3], we also documented exercises results with traditional measures. In terms of Cobb degrees, the percentage of patients who showed a rad,iographic improvement was 24% in the SEAS group vs. 11 % in the CONT group, while'the number of worsened cases was superimposable even if slightly lower in the

-


i

204 M. Romano et al.ISEAS: EjJicac}; EjJiciency and Tll/lomtion

SEAS group (12% vs. 14%). Upon a clinical evaluation of the largest curve hump using Bunnell's scoliometer, in the SEAS group we noticed a stability/improvement in 73% ofcases vs. 58% in the CONT groups.

4.3. SEAS treatment normalizes balance and coordination in scoliosis patients

According to the SEAS protocol, exercises aim at improving some specific impairments of the scoliotic patient so as to normalize them and reduce the risk of progression of scoliosis. Among these, we have equilibrium and coordination. In a controlled cross-sectional cohort study,[55] we evaluated 190 subjects divided into two groups (forty Adolescent Idiopathic Scoliosis patients and 150 controls), and those patients were divided in two sub-groups (twenty treated for one year with SEAS and twenty not treated). All participants were evaluated through Unterberger (Fukuda), Romberg (sensitised and not sensitised) and lower-limb oscillation tests. Patients treated with the SEAS protocol showed results that were superimposable to the ones of control subjects, and on a statistical basis both groups were definitely better than untreated scoliosis patients.

4.4. Active Self-Correction according to SEAS principles reduces tlte radiographic ! ;

curve

Auto-correction has been considered by SOSORT experts as a key aim of exercises for idiopathic scoliosis: the Active Self-Correction (ASC) is a kind of auto-correction actively performed by the patient, without any external aid, that forms the base of SEAS. ASC is a selective (i.e. only on the vertebrae involved) lateral de-flexion, sagittal correction (usually increase of kyphosis and preservation of lordosis) and horizontal dc-rotation: this movement is. very difficult and require some months to be learned. 27 consecutive patients under treatment that required x-ray examination for their clinical follow-up have been included in the study[22]. All patients performed x

I"I. ray exam both standard and in ASC; moreover, they all were photographed frontally ,: and laterally to have an evaluation of the quality of ASC. The statistically significant

percentage of reduction of scoliosis WiiS 11.0±l2.3%, with a reduction of rotation of .. 13.2±63.4%. This study proves that it is possible to reduce actively the curvature with a

selective action, without any external aid, and that expert physiotherapists can teach ASC.

, 4.5. SEAS treatment improve results in case ofbracingi

!,

To confirm whether the SEAS protocol, mobilizing and preparatory to the brace, had this ability, we compared, with a controlled prospective cohort study[4] of the beginning of brace therapy, the results obtained at the first radiographic follow-up at four months.in 110 patients, divided into two groups. Data showed a higher efficacy of SEAS treatment, compared to standard exercises (CONT group) in regard to cosmetic appearance (Aesthetic Index) and Cobb degrees of the largest curve and hump.

-------------,.~- - ------._. ...•_--._.__ ._-_ .. _-_.~ .. _~- - ------- ~ -------

M.

4.5.1. SEAS /':yplzotisi.

We performed a stU compare different e~ different positions - : as to increase their cc the position adopte; Kyphotisation and rc 58.9% and 29.8% re~

name, does not prot exercises in braced c( and, through those tis in order to obtain diO in mechanical terms, I

References

[I] W. Bunch and A. Patv 1989. .

[2] G. Torell, A. Nacherr, girls "ilh idiopathic 9

[3] S. Negrini, A. Negrir efficacy of SEAS.02 , Health Technollnfon.

[4] S. Negrini, A. Negrin efficacy of SEAS.02 Inform 123 (2006), 51

[5] V. B. Brooks, Motor c [6] H. D. Henalsch and H

Med6 (1985), 2-14. [7] M. E. loffe, Brain me

classical concepts, Ne; [8] E. Ascani, P. Bartolc

Binazzi and M. Di S Spine II (1986), 784-!

[9] M. A. Asher and D. ( effects, Scoliosis 1 (2(

[ 10] C. E. Aubin, J. Danse brace treatment ofadc

[II] A. Negrini, P. Sibilla; metodologici, Riabi/it,

[12] S. Negrini, A. Negri International Society 1996, pp. 68-71.

[13] S. Gtmlln, N. Kose a treatment ofadoJescet

[14] H. R. Weiss, Rehabili literature, Pediatr Reh

[15] H. R. Weiss, M. H, improYement of time...

[16] H. R. Weiss and R. matched pairs, Pediall

[17] K. Dobosiewicz, J. D treatment of progressi evaluation, SlIId Hea/t,


--------------- -

205 md bmol'Qtioll

ion of the largest curve hump iced a stability/improvement in

)Jl ill scoliosis patients

at improving some specific e them and reduce the risk of librium and coordination. In a d 190 subjects divided into two and 150 controls), and those

d for one year with SEAS and .hrough Unterberger (Fukuda). imb oscillation tests. Patients ~ superimposable to the ones of ps were definitely better than

i reduces the radiographic

:ts as a key aim of exercises for :) is a kind of auto-correction lal aid. that forms the base of .e involved) lateral de-flexion, preservation of lordosis) and

and require some months to be required x-ray examination for '[22]. All patients performed xIII were photographed frontally SC. The statistically significant with a reduction of rotation of tce actively the curvature with a pert physiotherapists can teach

d preparatory to the brace, had ective cohort study[4] of the first radiographic follow-up at

lata showed a higher efficacy of IT group) in regard to cosmetic ngest curve and hump.

(

II ...

M. Romano et al. / SEAS: EjJicaC}; EjJiciency alld Innomtioll

4.5.1. SEAS kyphotisation exercise is the most lIseful to help bracblgpllsh work

We performed a study [45] in seventeen consecutive adolescents to quantify and compare different exercises (kyphotisation. rotation and "escape from the pad" in different positions - sitting. supine and on all fours) performed in braced condition so as to increase their corrective forces. We verified that in static and dynamic conditions the position adopted does not alter the total pressure exerted by the brace. Kyphotisation and rotation exercises guarantee a significant increase of pressure (+ 58.9% and 29.8% respectively). while the "escape from the pad" exercise, despite its name. does not produce any significant variation of pressure. We concluded that exercises in braced condition allow the application of adjunctive forces on soft tissues and, through those tissues, presumably on the spine. Different exercises can be chosen in order to obtain different actions; physical exercises and sporting activities are useful in mechanical terms, although other important actions are not to be neglected.

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I

]nd Innomrion

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Scientific Exercises Approach to Scoliosis

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