Christa Lehnert t-Schroth, P.T. - THREE-DIMENSIONAL u- TREATMI ENT FOR SCOLIOSIS A PHYSIOTHERAPEUTIC METHOD FOR DEFORMITIES OF THE SPINE The Martindale Press Palo Alto, CaliforniaCopyright © 2007 by Christa Lehnert-Schroth All tights reserved, Except for use in reviews, no part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without written permission from the publisher, Published by The Martindale Press Palo Alto, California www.schrothmethod.com Originally published in German as Dreidimensionale Skoliose-Behandlung (Stuttgart: G. Fischer, 1973). 7th edition 2007 by Urban & Fischer Verlag, Elsevier GmbH, Munich, as Dreidlimensi- onale Skoliosebehandlung: Eine physiotherapeutische Spezialmethode zur Verbesserung von Riickgratverkriimmungen. Atmungs-Orthopadie System Schroth. The translation is based upon the 7th edition Lehnert-Schroth, Christa ‘Three-Dimensional Treatment for Scoliosis: ‘A Physiotherapeutic Method for Deformities of the Spine First edition in English. ‘Translated by Christiane Mohr, Alistair Reeves, and Douglas A. Smith. 276 pages. 679 illustrations. Includes bibliographical references. ISBN 978-0-914959-02-1 I. Scoliosis. Il. Physiotherapy. Christa Lehnert-Schroth (1924- ) www-scoliosistreatment-schroth.com Notice: The pictures presented in this book are amateur photographs taken over the past 60 years. They have been preserved to document this book.- Dedicated with admiration to my mother Katharina Schroth by klude Uhort detrvete Katharina Stroth (22 February 1894 -19 February 1985) _ Katharina Schroth was awarded the Bundesverdienst- reuz ("Federal Cross of Merit” of the Order of Merit of the Federal Republic of Germany) for the intro- duction and development of her treatment for scoliosis, because this system was unique in its intensiry, effect, and results. 1 From among all the people Whom you meetin the course of your life i? . You ave the only one : Whom you will neither leave nor lose. You are the only answer 10 ‘That Question of the meaning of life You ate the only solution To the problem of life, MaynardJavte of conten 's Development of the Schroth rotational breathing system ; 1 Sample of early brochures and booklets... 3 PARTA ‘Theoretical basis ofthe Schroth Method 1. Division ofthe trunk (including shoulders and neck) into three segments «2.24 UT HL. Symmetricat postural deviation in the sagital plane. “2 11, Postural deviation in the frontal plane ..... 17 IV. The three torsions ofthe trunk in scoliosis. . 19 V. Breathing asa formative factor .......-.. 20 VI. The scoliotic breathing pattern........... 23 VIL Increase in cardiopulmonary capacity during three-dimensional treatment 24 VIL. Effect of sun and air. 224 TX. _ Evaluation of spinal length loss in scoliosis in relation to vital capacity... weve BS PARTB Evidence-based theory oo 1. Influencing the scoliotic wedges withthe sim of restoring rectangular blocks .......29 1. Planes and axes of the body 2. Conceptual division of a thres-curve sis into three BIOCKS wnneennne 30 3. Principle of pelvic corrections in three-curve scoliosis. 30 4. Corrections of deviationsinthesagitalplane: posturalimprovement,frstandsceondpelvic correction : 30 5. Convections of deviations in the frontal plese: third pelvie correction and shoulder counteraction 30 6.Derotationoftrunkas partofthefourthpelvie correction and derotation of the shoulder girdle in three-curve SCOLOSiS.rnnon32 7. Horizontal positioning ofthe aleae of ium: the fifth pelvic correction sesne 32 rgeted rotational angular breathing (RAB) trunk segments 9. Postural correction of neck and head 10, Stabilizing isometric tension after postural corrections son I. Appropriate starting positions and orthopaedic ‘ids for trunk derotation exercises (lne-curve scoliosis) ...... 237 1, Flat supine positon without a pillow ...37 2, Prone position. > 3. Lateral position. 4, Sitting position scrnnon 5. Sitting on the heels... 6.°TV" posit oa 7. Convetive sitting poss ava whew the concavity is extreme 41 8. Onall fours. ronment 9. Lowsliding pasition rmsd 10. Kneeling positon... 2 1. Standi os ' 2 Ml. The eof changed lorometor system 2) Pathological elements . 2 bb) Individual muscles involved ina scoliotic malposture: a 1. Abdominal muscles sat 2. M. quadratus lumbbonum and deeper holding musculature 48 3. Erector trunei(M. longissinns dorsi, 1M. ilfocostais), the back extensors nu A8 4M. iliopsoas muse... 5. Intrinsic musculature ‘6. M,latissimus dvs 7.Mm. scaleni.. 8, Pectoral muscles 9. Coceyx and ischial tuberosites 10, Floating rbs.. 1V, Summary of physical correetions using the Schroth method for three-curve scoliosis. . 63 V. Theoretical reflections on four-curve scoliosis (witha lumbosacral curvature) and its correction... 268 VI. Summary of physical corrections using the Schroth method for four-curve scoliosis VIL. Feet and legs VII. Sunnmary of theoretical considerations IX. Objectives of Schroth treatment, . X._ Learning to abserve in the Schroth manner. 78 PART C Exercise instructions. seen ees 1. Breathing exercises ....2..ecese0000-++ 83 H, Exercises at wall bars se St IIL. Exercises using chair and table. 94 IV. Floor exercises ceeeeeeees 10? V. Neck exercises... feeds VI. Exercises with a resistance band......... 119 VIL. Exercises to correct lumbosacral curvature & scoliotic pelvis (4th curve). . 136 IIL, Problems in the treatment of scoliosis ... 144 1. Retroffexion (extension), lateral flexion and distorsion ofthe trunk... 2. Problem cases.. 3. Validity of X-ray moni patient treatment onrnnnoneone 166 4, Accessory rotation in Tatra flexion | of the upper trunk . 170 5. Puberty rns see IT 6.Cortection of the shifted sternum... 171 7. Comrection of the shoulder on the concave sie... eI 8. Conection ofthe anterior rib hump... 173 144 so lS3 ao 9, Correction of fatback in combination with seoliosis, seo 4B 10, Correction ofthe scoliotic pelvis. 178 U1, Muttiple-curve se0H1088.oonsnnees 180 12, Atypical scoliosis... sono 183 13. Correction of false body staties.noun 183 14. Lumbar kyphosis 185 15, Spondylolisthesis 187 . The hallow back. 188 17. Rotational slippage of vertebra 190 18. Thoracolumbar seolios 191 19. Double curvatures of the lumbar spine 198 20. Cervical kyphosis 198 21, Final tensing of the muscle mantle,,...199 22. Diagnosis of eases of externally invisible minimal scoliosis... 1-200 IX. Therapeutic aids for correction ......... 201 PART D Documentation « 1. Xray monitoring and photographs - TH, Statistical evaluation of treatment results. . 238 1. Changes in vital eapacity 2 Changes in breathing movement vu. 240 3. Changes in length of exhalation phase and chest circumference in transverse plane 240 4, Changes in scoliometer values 5. Electromyographic changes... 6. Target muscle contol with surface EMG electrodes soesnnnnnsenn 243 7. Compatison of X-rays 244 8, Pulse measurements 248 9, Favourable side effets of three-dimrensional Schroth treatment...252 241 242 tT 253 1. Inpatient treatment in the Katharina Schroth-Klinik in Bad Sobernbicim .... 255 H. Orthopaedically-orientated daily life. .... . 256 II, Indications and contraindications ....... 258 Appendix... aero) ‘What is “rotational breathing"? 2-259 Excerpt from the Biologisch-Medizinisches Taschenbuch 1937... seseesee0+e1 262 Excerpt from Arembeilkunst, 1956, Dr. Johannes-Ludwig Schmitt... 262 6 courses of trcatment... : 1 Report by a 43-year-old female paticnt.263 2. Report by a 65-year-old female patient. 264 3. Course over 10 years. 265 4. Report by an Sl-yearold male patient..267 5. Aletter of an 84-year-old female patient... 267 6.A visit ofa 32-year-old patient... 268 Literature ces eeee 269 The Schroth book in German and Spanish .. .. 272 Index .... Pee vilthat eis textbaok is now availible in the English language. This means that English-speaking physiotherapists who wish to treat patients suffering fiom scoliosis now have a very broad range of exercises at their disposal for all eases and shapes of scoliotic bodies. For fifty years I worked as a physiotherapist with pa ents suffering from scoliosis, into" :cing the specific system of tecatmet that bears the name of my mother, atharina Selioth, to therapists and patients Because she suffered from scoliosis herself ding her south, she developed the program now known in Ger- rman a8 “The Three-Dimensional Scoliosis Treatment” oF “Three-Dimensional Scoliosis Physiotherapy". This is a conservative method of treatment, which works among other things with exercises thet elongate the trunk, correct the imbalance of the body, and fill the concavities ofthe trunk using a special breathing tech- nique which she called ‘rotational breathing’ Katharina Schroth's aprosch to treatment was farahead of her time. Many paticnts are helped by the treatment we give and by the courses we offer for physiothera- pists, who come from many countries, at our Katha- rina Schroth Spinal Deformities Rehabilitation Centre. In 1981, on the occasion of Katharina Schroth's 60th professional anniversary, Professor Friedrich Brussats, M.D, said in his address: “Lam myself a member of the research society of the American Orthopedic Society, which has designated itself specifically as the ‘Scoliosis Research Society’ ‘The fact alone that such a society exists may indicate to you what extraordinarily great, only partly solved prob~ lms still exist today in the diagnosis and treatment of scoliosi “Precisely because of so many failures and great at- tenipts and disappointments over the centuries, it con- stitutes an extraordinarily important landmark to have recognized the three-dimensional flow of motion and = vit od deformation of the spine, aad above all to hex. “plied it esteasively in prectice. I believe the most port part of your treatment matiod isthe fact that you pre- ceed froma given sitsstion of malposture, whose faulty form in itselfwee::: alter much, But we ean proceed into a-situation, in which you apply: everything, fune= tionally available for beiter conditioning of the body. particularly the breathing function, in order to help the patient and to motivate him psychologically despite 2 sometimes extraordinarily great handicap. “When we once again observe this combination of thought processes in connection with your life work passing before us, we know what we have to thank you for. And we also know exactly where the path in the future will lead us: precisely to the three-dimensional treatment of scolios ‘The book is a description of the techniques of the Schroth method, It describes almost all trunk é:vis- tions and their treatment, thus it is a wonderful source of information for therapists who wish to treat scoliotic patients, The book is strongly practice-related. It should be possible for therapists who treat their patients follow- ing the book’s guidelines to achieve successful results. ‘The Schroth method has long been regarded as the gold standard in German physiotherapy. Tam very pleased that this method of treatment has al- ready been the subject of repeated scientific investiga- tions and has now been described in several books at large, My mother’s basic three incorporated into the current brac Europe that has been shown tobe effective. ‘May this book help many physiotherapists and ease the burden of all young children, adolescents and adults suffering from scoliosis. Bad Sobernheim, Spring. 2007, Christa Lehner-Sehroth, PT. stForeword “The problems of treating scoliosis have hitherto mained unsolved cither by surgical or non-surgical inethods, Years of research and the development of more and more complicated procedures have not changed the substance of this development. The goal is still correc tion of the deformity and maintenance of the correction. This would certainly be possible with an outrageously claborate set of pre-operative, operative, and post-op- trative procedures, However, is fusion of a large part of the spine afier correction desirable? Do we know whether the satisfaction of scoliosis patients following, such surgery — beyond the very expensive, partly cos~ metic correction for the patient, who now has a reduced: scoliosis but also a stiff spine — is greater than it would have been if he had not been operated upon? Judging by the remarks afier successful surgery, We iknow this. Yet no large-scale and fong-term follow-up studies exist to prove whether it would be true in view of the patient's capacity to withstand future physical stress and cope with professional life ti the final analysis, not just the objective physical con- dition but rather motivation is the decisive factor, once the patient has returned from the Procrustean bed or sut- gery to his or her familiar environment. This is why any proposals for treatment that not only have a physical put also a psychological impact on the scoliotic patient should be weleomed Katharina Schroth, who suffered from scoliosis herself, developed exactly sixty years ago a treatment method that was unique both in terms of intensity and success rate, This admirable system is practiced nowhere else on the Continent in this manner, intensity, and with these successes. It consists of a logical series of exercises based upon fixing the pelvis, as the foundation of scoliosis, in an actively corrected position, and sub- sequently performing trunk-clongating exercises. This process also addresses derotation of the ribs and flat- tening the rib hump, which have a positive secondary cfiget on breathing. However, we are primarily dealing, swith a functional treatment method that helps patients to preserve their own well-being, Continuing the tradition of her mother, Christa Leh- niert-Sehroth has diteeted the clinic in Sobernhieim For the past twenty years and developed it into ain intr nationally recognized centre forthe conservative teat- tment of scoliosis. The first edition ofthis monograph was plished in 1973. Inthe meantime, the treatment has bbeon refined furthes.The method was initially relegated to the field of complementary medicine, primarily be- se it was labelled an ‘orthopaedic breathing method, but today is principles have long been recognized and ‘embraced by experts and authorities on scoliosis. The formula of “thee-dimensional treatment’ referred to the medico-mechanical aspect of the Schroth exercises, which was later incorporated into traditional medicine by the recognized expert Dr. Cotrel and his treatment based! on the, principle of EDF (extension, devotation, Aexion). Katharina Sehroth developed her method that could be suited to each patient using ative measures and corree- tions with simple aids, and Cote later continued with the help of straps on the extension table. Subsequently he fixed the correction using plaster cass, in which he left windows to enable breathing movements to assist in reversing the thoracie deformations. ‘Throughout its entire history, physicians have been intimately involved in the development of Katharina Schioth’s methods, curently Public Health Officer O10 Hindi, M.D., and Karl Gross, M.D. In his preface to tse first edition, De. Hundt expressed the wish that: “this book shall serve its purpose and give patients support in exercises and life, as well as providing medical experts ‘with ertical insight into a proven system”. ‘This new edition has been revised by the author and ‘expanded with new text and more illustrations. Som: ceases are documented not only photographically but also radiologically. ‘Naturally even the Schroth method is not the philoso- pher’s stone as far as treating scoliosis is concerned. However, again and again therapists observe that it creates a better feeling for posture and partially actively corrects the secondary factors which make a scoliosis appear larger. Of course the method has its limits. In a growing body, the maxinmumn that can be treated is « scoliosis of 50°. Yet even severe scoliosis in an older patient reacts positively to intensive treatment at the clinic, Group interaction and becoming familiar w the visual image of one’s own scoliosis result in a cooperative patient-partner, which is a prerequisite for the success of all further medical treatment, be it con- servative, physiotherapeutic with or without apparatus, for even surgical. In this regard, we wish for a broader adoption of the principle of three-dimensional treatment of scoliosis further success for this ingenious concept of Katharina Schroth and its intensive development by mother and ighter, and therefore for this book. March, 1981 K.F, Schlegel, M.D. Professor and Director of the Orthopaedic Clini University of Essen, GermanyTam detighted that this book has + interest that again a reprint is necess27 ‘This 6th edition has again been revised carefully and 4 number of important sections have been added. To compensate for this, [have deleted some of the X-ry ‘materia! and shortened some ofthe other chapters: ~ cally. The fact that the last edition sold out so qui y shows that a new edition is necessary. This book has become a real reference work and textbook for thera- pists treating scoliosis, Tamalso very pleased that we receive such positive fed ‘back fro participants in our physiotherapists" training program, who report that they are able to achieve im- provements in their patients that are demonstrable even bby X-rays. They are themselves delighted that they are able to teach their potients to help themselves. They have found enjoymen: and confidence in the treatment ‘of scoliosis, which is sry important. Very special, heartfelt thanks are due to my son, Hans- Rudolf Weiss, M.D,, orthopaedic specialist and eurrent ‘medical director of our clinic, for hisunrelenting efforts to consolidate the scientific basis for the Schroth meth- od. The results of the research he has published are given in the bibliography ofthis book. My greatest wish is that this book should serve as an aid and support for therapists and for ther patients. Bad Sobernheim, Winter, 1999 Christa Lehnert Schroth, PT. with such lively Foreword to the first edition ‘This book is about the practical experience of trating scoliosis for half a century. The author herself has thirty years of professional experience in the treatment of scoliosis. ‘The aim of this book is to explain the basies of the treatment method. However, it is often difficult 10 ex- plain detaits of the method in writing, since writen ‘explanations become complicated, whereas during ac- tual treatment the ideas flow together and are simplified, Participation in one of our training courses is therefore recommended T hope that this rotational breathing method will be spread with ine help of interested physicians and physiotherapists, since after itis leamed, the method is also a successful tool for patient selftreatment. I would bbe happy if this book became the basis for discussion, and motivation for a precise scientific corroboration of the metho. am grateful particularly to Hed Teirich-Leube, M.D, F. Baumann M.D., Otto Hundt, M.D., and all others who have supported this hoak project Bad Sobernheim, 1972 Christa Lehnert-Schroth, Physiotherapist ‘This boo’. explains notional treatment of scoliosis ws ing the nizthod developed by Katharina Schroth. Th's imcthod differs from previous therapies ins completely new appnach fo structural correction of f basie ec epts mark this principle inactive muscles of vertebral distortion and scoliosis using breathire movement, employing the ribs us levers. ‘The book serves as 2 guide to scoliosis treatment and 2s «stimulus for physiotherapists Spring, 1973 Baumann, M.D. spine, Two This new edition shows that the Schroth method has e+ ceived widespread acknowledgement that must be co sidered astonishing, since the method itself is not bei taught as part of physiotherapy training at our physical therapist schools. In spite ofthis, many physicians such as ourselves, especially orthopaedists, have recognized the often astounding effects of this treatment on their patients. In our years of work at the Schroth Clinic, we often found ita deeply moving experience to see how youn People who arrived frustrated and depressed because of their faulty posture, retumed after a few weeks for their final physician examination self-confident and radian, ‘with changed tacial expression, The feeling and know!- ‘edge that they could influence their faulty development with their own energy and effort gave them hope, which often made more positive the whole person in her tela- {ion to herself and her environment. This is a treatment method which has been developed and explained empirically. Some aspects sill remain to bbe prove scientifically. Documentation of success using X-rays is dificult, since X-rays from both before and af- ter in-patient treatment are seldom available to us. ‘The success of this conservative phy’ {treatment depends on duration and intensity of daily ap- plication at home. This is a non-controtlable risk fae- tor which is easly charged against the method, We are aware that scientific facts are still missing which would support our empirical practice. We would therefore be grateful for any help and comments, in particular any usable and comparable X-ray documentation The Schroth method will continue to forge ahead. The best evidence is the necessity for this now edition, ex panded with resistance-band exercises and exercises to correct lumbosacral curvature, This book is meant to be an advisor to physicians, physiotherapists and patients Its basic format has therefore been retained. We intend to remain active as medical advisors for the Schroth method. Spring 1981, . Hundt, M.D. Surgeon / K. Gross M.D. Orthopaedist a PaDevelopment of the Schroth Rotational Bre: Katharina Seheoth was born in Dresden, Germany, on February 22, 1894. In her youth, she had scoliosis her- self, She suffered mentally because of her deformity, and more so since she had to wear a brace. This ortho- paedie support device did not bring about the desized result because it hindered physieal activity. At tha ime there was no adequate treatment for scoliosis. All she wanted s95 10 be able fo ‘stand straight up" and live without the brace. A.nubber ball with a depression that could be pressed out by air gave her the original idea for self-trcatment and the firm resolve to work on her body according to this principle. The depression seemed to her ike the concave side of her body. She started to breathe into her eoncave ‘order to fil it with ai. Creativity, methodical ing, and continuous working at itsoon brought the first successes, By practising between mirrors, she was able to follow visually what was happening to her body. Tn the middle of her right side was the rib hump, and she saw how it flattened out when she directed her breath into her left side, She realized: this is actually not a rib hump — the ribs are just twisted! These twisted ribs could be turned back into their normal position. Sco sis ost is fatefl power and became simply a disorder to be comected, if not completely cured One realization le to another. For instance, there was & fat area on the front of the rib cage ~ exactly opposite ine rib hurnp on the back. She succeeded in pushing out this part by breathing into it She felt the vib hump Hat- System ‘ening accordingly: This meant that correcting the front simultancously resulted in correction of the back. The left front part of her rib cage also had a rib hump. She could not simply push it in. Bur it lowered and flat ‘ened when she breathed into the indentation of the left side of her back. In this way, the ‘rotational breathing” method was conceived. When correct changes were happening in one place, other body parts were forced to conrect themselves as wel ‘She then recognized that 1 trunk was formed of three body segments: palvic girdle, ib cage, and shoul- der girdle, and that in her body these three parts were rotated against each other (which she later noticed in hhor patients) It was necessary to derotate these three segmien's and to use the ribs as lever arms. What fol- Towed was elimination and flatening of the three high parts onthe back andthe frontal ib hump, while the low areas were built up. At the time, Katharina Schroth was a teacher at the Rackow Business School in Dresden. Her colleagues noticed the positive physical change. She was asked to deliver specches, and prepared for them by studying anatomy intensively. She was tested by Sentkowsky, MD., in Dresden. These speeches were followed by courses which she gave all over Germany. Jn 1921, she married and moved to Meissen on the Elbe, After a short while she was treating patients feom Germany and foreign countries. She worked hard on her patients with unceasing ideatism. Year after year, she‘Mes, Katarina Schroth cightyfve ‘The rotational breathing method was continuous! proved. Each new ease perfected her knowledge further. Soon she was ealled upon to speak at conferences. AS carly as 1925, the journal Medizinalpolitische Rund- schau commented thatthe Schroth method was epoch making in the treatment of scoliosis. In 1927, Katharina Schroth completed training at the Ema Graf Klotz School for Functional Gymnastics and Movement in Dresden, where she earned her diploma with the highest marks. During her training, she had learned about alt the different systems of gymnastics, such as Laban, Klapp, Medau, Hellerau-Lachsenburg, :n, Gindler, and Kallmeyer. She took dancing lessons with Mary Wigman and Palucea. She also studied Swe- dish Gymnastics a the “K@nigliches Palais’ in Dresden. ‘She became convinced that these methods represented cod basis, but that they were not specific enough for ating scoliosis. None of these methods included tar- ‘geted! methods to holp people specifically with spinal doformities. These cieumstances forced her to observe closely her own body and those of her patents in order to dliscem principles behind the exercise effects, She sought the prineiples according to which a posture-dependent scoliosis developed, and she sought, in its turnaround by pertinent exercises, conditions that could infiucnce a sco- Tiosis to traverse its same developmental pat in reverse ‘The method had already enjoyed considerable success before World War Il. After a large-scale comparison of various methods during a controlled experiment in Hin- denburg, a commission of experts noted that the Schroth system’s results far outstripped other methods. The gap between Schroth treatment results and those ofthe other systems was so great that they began to retrain the in- structors atthe other schools in the Schroth method. In 1934, Prof. Gebhardt of Hohenlychen and Prof. Wil- helm of Freiburg confirmed the success of the Schroth method. After the war, the Ministry of Internal Affairs in East Germany ordered a three-year investigation of the method. Afterwards the Schroth hiouse was national- ized on the grounds that “the method must be open to a larger eirele of sick people”. In 1955, Katharina Schroth moved to West Germany. In 1961 she founded her clinic treating patients from all over the wo: (Federal Cross of Meri) fiom the Federal Republic of Germany. Physicians and orthopaedic clinics, as well as insurance companies and the Social Security O: ‘were quite cooperative with our elinic, which was ansis Sruitfil for its further ds -iepment. The author is ful for their support as... -caurageme: In 1976, Johannes Heitans and Erhard Schulte waste ther diploma thesis on the following topic: “Soztalysy= chologische Beobachiungen an jugendlichen Skoliose- ptienten aus der Sicht des Sozialpidagogen” (Sccio- psychological observations of young scoliotic patients fiom the viewpoint of the social worker). Overt: ment period of four weeks at our clinie in Sobembzi, both men interviewed patient in groups and individually, and presented the essence ofthese discussions in desl In 1979, Andreas Prager completed his doctoral disser- tation in dentistry a the University of Mainz, writ ‘Untersuchungen diber die Zusammenhinge zwischen Deformitten der Wirbelsiule und Kieferanomalien” (Research into the correlation between deformities of the spine and anomalies ofthe jaw). The greater pert of his research was done at our elinic. Groups of 80, 100, 120 and 130 patients were examined, Results: almost all had pathological findings. There were malocelusions that suggested a connection between the spine and jaw. We also observed that children with anomalies of the jas usually breathe through the mouth Jn 1983, Angela Blume wrote her diploma at the Uni- versity of Brussels on “De Schroth Methode”. She hed also done measurements on patients during their exer- cises and demonstrated that these exercises corrected the position ofthe spine. On May 17, 1981, a ceremony honoured the 643 an- niversary of Katharina Schroth’s professional career. ‘The clinic's orthopaedist, Dr. Karl Gross, described the many attemps to treat scoliosis during the 19th Cen- tury: “Many exercise tools were developed, and there ‘were already orthopaedic gymnastics systems. Hos~ ‘ever, methods propagated in those days did not ad- quately consider the actio-pathological processes of spinal distortion. Despite great efforts, the success rate ‘was almost zero. This is the point where Frau Schroth and her secure intuition began when she included spinal derotation, which is always a consequence of sideways bending, in her physiotherapeutic efforts”. On this ovcasion, the designated president of the Ger- ‘man Society for Orthopacdics and Traumatology, Pro- fessor Brussatis, also a member of the American Scolio- sis Rescarch Society, gave the speech excerpted above in my Foreword to the English Edition, In February 1985, the clinic was named “Katharina Schroth Kiinik” in honour of the founder's method. Katharina Schroth died on February 19, 1985. m rlSample of carly brochures and booklets Katharina Schroth’ frst boo! published in 1924: Die Atmmngskur, Leitfaden zur Langengyonnastit (The are: a Guide to Exercises for the Lungs). He contained exercises for the breathing system and im- portant tips for paticns with scoliosis. The third edition Of this booklet was issued in 1930, with an excellent ig, ts 1928 The gard in which exes wen pertormed 2) The geoup is exer Bj very unsuitable Sus foreword by Dr. L, Grewers of Essen. Atthat time, other systems were practiced in Germany and elsewhere on the Continent, often counterproductively. (See pages 144-152 for some of the faulty exercises they recommended.) ' in weak lamar nse bow the um. ever for eversa of eure, 8 was practised in hose days. crsslegged.Frans 1 = op ros): fully, sig ty breathing exercises in 3 mths, Presi toate fafa LO yoats 3 photog ero): Six woeks of raion} brats, orginal Sch system, Msiven, LG gear pa oA): Ths degree Sol Frans IV and 12 (bottom row right: 2° mesths of rotational breathing, 33-yvarol patient. Treated by echopacdic spits rom the 25 ble wo resume work because major pain ceased for Sv years by 4 experi, with pevgressive die rit fa ehorthepadisehan titlein, (urchweg Original-Photos) Freiluftarbeit. Sonne an die kranken Knochen! von 4 Kapazitaten bohandolt, vor. Grade aus ‘ich verschlimmemé. 1 Meche or ‘9 Be Die neue Imonalleh ab 8 tk Atmungs-Orthopddie Original Schroth Meifen, Boselweg 52 ews and comment imprinted inthe fist prospects in 1925): ir approh gute every und Ute a tion. "Anyone with ees to see must inevitably reach the ‘here was 0 remedy al... "My pares were astonished that such sn son'scasciso splendid: it doe’ tjust met bt fir exceeds llespectation “Ws just the thing” Fsingpved? a bom doctr".has ean an immortal eps sin tha this a god thing fra condition for which previously roxerent was possible injust 3 month... "This succes in our "Absolutely amazodat the deelopmentaitl Kurt's body" < if i frge 6: Soc pospsctusin 1929, Weave print tin his ho Doane the tent til aid Gefahren - bei Behandlung seitlicer Ritckgratverkrimmungen. Von Frau Kathe Schroth-Meifen, a ites ring toe 7 i (abbreviated ors ee ia Dangers in the treatment of scoliotic curves by Katharina Schroth, Meissen, author of the New Breathing Orthopacdie System “The intrinsic growth enetgy inborn in every living plant, enimeal, or hurnan strives to eeate the har imonious form predestined for its every bodily organ, body part, and finally complete body. That formn - «| which mast purely realizes the divine creative thought is always the best, the one that allows all organs |: and parts ofthis body to function most completely. Curvature ofthe spine, or scoliosis, isa precarious formal defect in terms of health, appearance, and the spiritual-psychological aspect. When attempting to help a sclioti with this defect, we must not view the matter primarily from the mechanical standpoint, namely the malfunctioning body. For we have of hefore us not a mechanical structure of bony levers aid the miiscles that move them, but rather an un- fortunate person who has lost the form originally created for her and who cannot restore it by herself. “1 With all scoliotic pcople, the cause probably lis partly in the mental realm. Envision what the expres- 2] sion “not in good form’ means. Imagine the mental state ofs child scolded by his mother. The psychic ‘rel depression and loss of equilibrium are immediately visibe in his abnormal bodily form. How wonder~ 4} fal the form of a little child's body is! What a victorious, natural, matter-of-fact nature he has in the ‘epresentation of his Self, and in every movement and in all of his life statements. However, It us observe a school class three or four yeas Iter. What has happened to these children? 0 ‘Almost all are missing their original sense of complete, untroubled comfort within, Many children 3 have pronounced signs of suffering in their fces, and their depressed mental state finds expression in their bodies. i 4 ‘Why do gymnastic attempts to erect such a troubled child often fail completely? It is because they approach the child much too mechanically, much too much in'the form of exercises, without fst Js TA] becoming familiar with his life diffcultcs, his uifullled needs, which to the adult may scem trivial Sel Straightening of the external person will only succeed when we can erect the inner person, open an +} avenne of hope, and allow him to breathe a sigh of relief Extemally we can say that for those individuals who suffer from constitutional weakness, the loss of J), “1 sme balance necessarily leads to formal defects and thus to a defect in physical function. Exterior es- }., S5] sistance consists therefore in groat measure of constitutional weatment, which often must reverse the | mistakes ofedencrations, ind Pons SThessereng des delerisicney Wempers gail wenen, Der wornat-gestanle Zvatand de wenden Ket ik sh guy sow as dooce Steebea, 7e orien, noun iecevsthiltnis, a9 auc 3 ge inert SEEDS ESS TE I TE ET‘The norm. healthy condition of the living body has @ natural, inner aspiration to ensure that normal fanetional relationships assume a normal form. Local assistance, namely goal-irecid work on the body, ‘must support this natural striving for order, the drive to assume a normal strecture This constituional therapy will not only induce inner bodily harmony, but also 2 surplus of strength, which then directly serves rebuilding of the external person as well as the loaé-teating capacity, as it 2} were, of the person with regard {0 life's adversities and defeats. This latter clement is important, because the work on the inner person must go hand in hand with as- tance to the externals. We must readjust thet! ought life ofthe sufferer and kelp her give up wasting}. Lif time on useless protests against fate or making her ensironment responsible for ker condition. Our job is to help her orient herself such that difficulties disappear, that she is adaptable snd productive enough to work on turing her disability into an edvantage ~ on freeing her strength to ¥rk on improving her Lay fate oq Only when the therapist has helped the patient learn that she cannot avoid the consequences of her pos- ivi ture, “that she must bear the consequerices of flight from the consequences”, can local help ~ healing s°} gymnastics exercises = bear frit 3 ha Ne 3 5 wai, wen wort gar FBT Dow ten Kann, che Gar Hellen der Evobe Die neue Atmungs-Orthopadie Criginal Schroth-Meiften elgg Pats Correct posture Incorrect posture Mere we see 8 typical cae: It hip Lefsied scsi ao exists bot is ‘Schematic diggram Mastatng proper body posture raised, torso overhanging to the right, rarer sho] in 9 estes). ‘na “normal” person. Most curvatures of the spine and rib hump twisted to th right nd. The new sem of rotational breathing se 25 shown inthe next diagram: the upper torso backwards. The new syiem of roi naturals sve thie tors fo the right {stilted overto the rightand the ribs are twisted 19 tonal breathing achsves a let shift Outcore iar months the right and backerds, the tomo that as sunk down on the Fight side-The above photo shows the ‘oucome of 3 month” work to achieve a lenshi. Rule no. 1: Where the hump ion the right side, the torso overhangs to the right nceds tobe maved tothe lt, “Thinb-degre scoliosis IOgearol patent After Thinédepe sel Aer 4 mons" ‘Aller months? ‘Smontht rotational breathing. "Weeried with joy si, withextemsly rotation breath- patie wih goatonal reath> ver Lists success” sowrestlfening. ingwor'nal——simulsneose ing. Condon present Schroth sysem, — nowrope. : fin 20 yes, Meiscn Rate skeleton is dpc lke a line broken in several places, Mental postural contro is absent The rib Thump ft fr hack, The ew system of rotational breathing shifts forwards 4Fig 6 CUranaated captions) ua seine unnefbare Verantworilichkeit. Er mu den Leidenden aus der stheinbacen Unieciheit in dle er sich seelisch gefldehtet hat, heraustihren, thm eigen, daf dieser Selbstbeitug, und zum Gegenstand eines toten Naturgesclzes mah, als da er die V auf sich nisimt, thn nist von der Nétiqung entbinde), immer wieder die Denkens auf sidh 2u eehanen* Erst dann, wenn es dem Erticher gelungen i echaltons witht entaiehen ham baie Tokale Hille, die Heilgy. Rastile, Fre tragen, | 28 yes old, Seconds Afer2 months 23 years old Ate months" degree sco rotational bresth~ Pa ing. Original west continuously bret sh System. sine the azo : Thesamechild Afer3monts* tubsreulsis, sen fom behind. rata beating : eae Doctor's venict: Moder vent “dust be glad she “Thad tespected so can valk" mucha you had iver men bop” a This fs bow his 12 4 years’ This young gt had an identical expeis Scurold Iuy came tesiment using all ence abroad. Five yeas ago she had only ' for treatment to Prof, be rescursse of fistdepre ste, X. There he was pre the Resbequipped Prat, X. wiles “fre he ecthopoc- & scrived a piste cas, insctton, this dic gymnastics [a sjtem that preceded . race, ‘seasie', anasras how he Sehoth) she had no scolis Tooke 7 te na 4: The function ofthe body yields ts form, Wor it Under what circumstances? . : sity lieber die Willensireihelt abspricht iworlung far seine Handlungsweige voli~ Riidowirhungen eines eigenen falstien em Leidenden Kiarzumadien, daft er sith den Folgen seines Gall er audi die Folgen von der Fludt vor den Folgen agen mus lan ele eigen “The same gid seen AferS months’ fiom the font. rotor atin 3 Sehr ‘System, Mtsen Her parents “We were speehles” 3Oyears oll After 4 months? Ossited soos, tations bathing, present for20 Original Schroth years System, Meisen According wo his original ls of exer: fas the 12-year-boy had to perfor te exercise shown above, Botusn photo: eis working onthe seme exercise acconding t Sebo, i 0 the body can also be dangerous“This i how the boy looked (de view) afer the 4 years of ‘Parents? convents remarkble ht Schroth was able to bring abou a consigrabl improvement ven though, “This is bow he had execs, azar ing wo ie original cesersise Hist ight Sue backward fd sideband 10 eri In contrast, the ew system of rotational beeath- ing enabled. the ib np to be “ercathod” for wards is former exer How oven the now cise list had aso system ofroitional required him w9 do. breathing enabled forvardbends. the nb hump ‘be reduced in ine through testing ‘Afir 3 months" tosational breathing Ie looked tke this, ‘ase his body ms Have been more dicult o treat and this was nt scheved before when his contin was mil" Ne alo had to per However, the new According to his Tho more aihening exereiesadso- The new system of form is excrete sen of ional ad Ts he alo cated by two ober exp scoring to roaona reth- fevtrding. to hs eating actually tad to perorm the same pcp, published ina text ing. also asthe Tomer lis. sit “eae the ib Gis‘nightenig” book fo ovo, cre nure, welfare de. opposite eect ere fing sradiled (es. tmp fonwadsané_ exerci. partments ee This book epaine why t_ teense Ht hat to pan), et arn fo the Te side back tras in such common use 500 othopse- linn he "wt Sete eghtam eds te gyrmats instructor were Uained tingle” on the tehind. (Coppa eed. inva wayby single instiaton, ight side and the NES hip hee Role oS Like the camination of the execs 0 a0 the body shape that Isto be achleve by this exercise 5 “Posie ein clininaes he bad by puting sont 1 1 . “The boy in he pe- This is how the By contrast with *Normal® body The body centre fe The principles of iow fomes ko. young. git loos the poto‘above', shape: posure s+ ll income po- the new sytem of 5 feat do the seme when she doer the nw system of plored and wines, sioned. tos breathing q thers a is gil woking. Pls clan ready Lack of skeletal also apply in ar ‘ Coach bed) Tok esl a ing pescibes ths ining. mat bes sheofiherbbunp execs in he find. the mbar samecnse. reson ’ The result of 20 years of research. : (First tried out successfully on Katharina Schroth’s own body with its abnormal curvature). 8 ‘ z 1 ~ oe 4PARTA ~ Theoretical basis of the Schroth method 0asnprematne 1. Division of the trunk (including shoulders an Practical observation of persons with postural disorders showed that it was tsseful o divide the trunk into three segments, from caudal to cranial: 2) lumbar spine with pelvis by thoracie spine with rib cage ) cervical spine with shoulder girdle (and bead) Ina healthy person, these three sented by rectangles, ents ean be repre 4) The caidat rectangles formed by the pelvis, lbar spine, hypogastric region including umbilicus, wp t0 the lower ribs. 1) The next rectangle is formed by the chest and epiges- tie region. The lower border isthe waist (12th sb) tnd the upper border the axilla (about the 3rd). ‘© The third rectangle is bordered caudally by the up per border of the middle segment. The upper or Cranial border isin the region ofthe acromion. Tre cervical lordosis lies outside ofthis upper segment However, as the cervieal spine belongs funetionally to this thd segment, it ean be imagined as rans ceranially tothe beginning ofthe occiput. ‘The three segments are stacked vertically on top of each, ‘other. The body is balanced. Viewed! laterally, however, they are tapezoidal es a result ofthe physiologieal curves ofthe spine. ‘The caudal segment (trapezium a) has its lower bo=Ser in an imaginary line passing through the two antcror superior iliac erest, extending dorsally to LS. With the pelvis in an erect position, this fine runs horizontally. The upper border passes through the lower ribs end ends at TH ‘The middle seginent (tapezium b) includes the chest sind epigasitie region. The lower border is'the upper jorder of trapezium a) The upper border runs along an imaginary lie atthe level of the armpits, the Level of the eranial stemum between the clavcles and over one third of the shoulder blades dorsally up to T6. The up- por seqnent (trapezium ¢) is bordered caudally by the ‘rant Tine of the middle segment. The upper border is formed by the shoulder level. Since the cervical spines art of it functionally, one imagines trapezium c)clon- ted cranally {0 the occiput and mandible. This partis fore ealled the shoulder-ncek segment. These three nenis are blaneed over the centre of gravity: neck) into three segments (Figs. 7, 10) Fig. 7: Foal viewJL. symmewne: Symmictrieal posteral deviation in the sagittal plane, p for kypls-is, fesulis in the formation of three sagittal “wedge: So far we have been describing the healthy locomotor system, In case of postural defects and even more in minor or major spinal deformities, these structural changes are mare pronounced. For example, juvenile for adolescent kyphosis (Scheuermann’s disease) of yphoscoliosis. In these conditions. the physiological spinal curves show pathological changes in the sagit- {al plane. The spinal column appears compressed and shortened, giving rise to pathological vertebral defor mations (Figs. 9 and 15-19) In the case of melposture, these three segments are shifted against each other (sagittal plane), resulting in a fine with two breaks (lateral view); beginning at the feet, running to the pelvis, fom there to the back and continuing up tothe head (Figs 9, 14,15) Due to the shifis ofthe three segments caused by the col- lapse of posture, the three segments appear as ‘wedges" ‘on top of one another ~ the short side of the trapezium, becoming shorter and the long side of the trapezium, increasing isi height - and these really do have the ap- pearance of -vedges (Fig, 13). The more pronounced the deformity, the more extreme the wedging and the col- lapse of the back, Lateral view (Figs. 15-17) Wedge 1: The lumbopelvic wedge has its vertex i the lumbar lordosis. The wide side (abdominal wall) is formed by stretched abdominal muscles and the anterior iliac crest, sloping in the ventrocaudal direction forming, the caudal border, The cranial border is an imaginary line beginning at the lumbar lordosis, passing the lower ribs and leading to the xyphoid process. ‘Wedge 2: The chestrib wedge has its vertex below the nipple. The wide side is formed by the thoracic kyphosis. The caudal border corresponds to the cranial border of the lumbopelvie wedge. The upper border is an imaginary line running from the narrow anterior area below the nipple, passing the armpits up to the lower third of the shoulder blade, Wedge 3: the shoulder-neck wedge: Since the shoulders are drawn forward, the anterior acromial processes form the wide side, while the exact position ff the vertex i dtfcnlt to define. I ies inthe rexion of the upper two ribs eovered by the shoulder blades. The csadal border coresponds to the eranial border of the cchestrib wedge. The eranial border is formed by the 2 postural GEVEINOR ILE Agius esis B Fig. 9: Pathological body shape: wrong 0° Lateral view pathologies and normal shape. Fig 16 neck-shoulder wedge Bb: thorasa wedge 2 lumbarpelvie wedge a fa uLateral view fa kypho' spine with the pasta defect desctibed above. ‘The right angls marked sho the decios ofthe cometion. Seo Figs. 921 472 (spine without a solos eomponentFig. 18: Double “roken’ axis showing postural collapse ince the cervical spine forms a func tional part of this wedge, the vertex is in the cervical Tordosis and the ‘ide side is formed by the byperex- - tended anterior neck portion, These two wedges may also overlap and in some eases ean be seen as one large wedge theoretically. shoulder level. “The above applies to symmetrical postural disorders in the sagittal plane. In the seoliotie body, the trunk also shows wedge-like ‘deformities in the sagittal plane. ‘This is only true for the lateral view of the ‘rib hump, side’. This is because of the torsion of the trunk seg- rents against each other, a For iiopathie scoliosis at least it has beon assumed that the lunnbar spine has decreased lordasis while the thoracie spine tends to present a fordotic postural de- formity (Dickson, Tomaschewski: see the sections on flaback). Of course, there are structural changes of this type that cannot be corrected actively, such as cases with a partly fixed deformity (Meister, Heine). In the presence of deformity, different parts of the body segments adapt ‘ theirappearancedgthe spine, and functional thiee-curve scoliosis can exist even in the presence of only minor lumbar and cervieal countercurvatures. Treatment is L adapted to the individva! situation, Fig. 17: Lao vwFig: 1: H-yemnold gil with malpostre and incipient The thre blocks are stil almost rectangularly The 2nd, chestrib wedge can be subdivided into 5:0 parts in cases of major scoliosis end kyphoscolic: (Fig. 17). The vertex of wedge 2a is telow the 1 andthe wide side is bordered by the posterior rib hun; the vertex of wedge 2b is located in te region of subaxillay rib portions. The corresponcing wide sic is formed by the kyphotie curve which bezins atthe sheal- der. It shows the most eranially located thoracie hp. These two wedges ean merge into one enother. Wedge 4, the wedge of the anterior rib hump, is on the dorsal concave side (Fig. 21). The vertex lies i. posterior concavity and the wide side is formed by the anterirly-orientated ribs of the dorse! concavity. The caval border is an imaginary line which begins the concave posterior ribs and leads along the lowest sibs towards the umbilicus. The cranial border runs from: the posterior concavity 10 a point below the nipple. This creates the scoliotic balance of the body and brings all body segments that deviate anteriorly or posteriorly above the centre of gravity, They belance each o:her out. In the following. the terms ‘concave’ and “eonvex’ always refer tothe thoracic spinal curvature. aTIL. Postural deviation in the frontal plane In scoliosis and kyphoscoliosis, the deviation in the frontal plane leads via a trapezoid to the formation of three lateral wedges (Figs. 20-23). While scoliosis is characterized more by lateral form deviations, in ky- pphoscoliosis, the sagital and frontal deviations are pre- sent together Looking ata scoliotic body from the back, tee can sce tha the thrce rank segments (pelvie girdle, rib cage, shoulder girdle) are not aligned as rectangtes as they are ina healthy body. They have shifted against teach othr, These lateral deviations and the changed pressure and traction fist st the originally rectungu- Tar segments into trapezoids and then wedge-ike s iments (Fig. 23). Dorsal view: Wedge 5: lateral lumbar-pelvie wedge (Pigs. 20, 22 and 23), ‘The vertex of the wedge is below the laceral ib thump th andl 12th sib). The wide side is formed by the pro- iinent Iuinbar convex-sied hip an, very often, also by the upper Ingar hump. Its caudal border is formed boy the ifiae erest sloping downwanis on the side of the dorsal concavity duc tothe Tateral shift. The cranial bor 1 der ean be seen as a line extending from the vertex of Fig. 2: Posterior view the wedge leading to the ilia of the dorsal concave side, ice, the highest point of the lumbar hump of this side. Wedge 6: lateral chest-rib wedge (Figs, 22 and 23) ‘The vertex of the wedge is at the lowest point of the dorsal concave side. The wide side is formed by the lateral rib hump. The caudal border is also the eranial border of the Sth wedge, while the cranial border leads from the vertex of the wedge obliquely across the upper thoracie vertebrae to the middle of the shoulder blede fon the convex side. Wedge 7: lateral shoulder-neck wedge (Figs. 22 and 23) '8) Most often the vertex is located! above the thoracic Thump (covered by the shoulder blade). ‘The wide side is formed by the shoulder on the side of the dorsal concavity, Its eaudal border runs parallet with the eranial border of wedge 6. The eranial border is tonned by the shoulder levels on both sides. ) Functionally, the cervical spine forms part of this. ‘The vertex is therefore in the shortened cervical inuseles of the dorsal conves side and the wide sidetimes, aly one of these we booth, tey’ ean merge and are then named the shoul: det-neck “The three wodge vertices correspond 40 the three de pressions of the rib eng, These postural abnormalities correspond tothe three lordotic retractions 4) Hip with floating ibs (11th and 12th ribs) below the sib hump; 'b) Dorsal concavity: ©) Shoulder above the rib hump with narrow side of the neck, “The three wide sides correspond to the three thoracic clevations which represent the kyphotie bulzes: 2) Hip of dorsal concavity with lumbar hump (For es- ample lef), 1b) Rib hump of the opposite side (right); ©) Shoulder of the dorsal concavity (le). This very of ten scems to bea separate rib hump. Allwedge vertices are rotated forwards all wide sides ‘packwards within the lateral shifting, except wedge + ‘The laterally shifted trunk segments are grouped aroun the centre of gravity and keep each other in balance This is, however, a seoliatic and not a normal balance, that serves to keep the body upright, nevertheless. Fig. pelvic girdle 2, Ribeage 3. Shoulder girdle 18 El;1V, The three torsions of the unk in three- Scotiosis is nearly always a three-dimensional patho: Jogieal development. In alton tothe three patholo cally changed spinal curvatures and the three deviations fr the frontal plane, there is a threefold torsion of the trunk segments against each other around the longitu: tinal axis, Since the spinal column adapts 10 “he body, the various segments also show torsion of the vertebrae. ‘The spinous processes point tothe concave side within the curvature, Ina healthy person, the pelvic girdle, rib eage, shoulder tirdle and bisad are in one frontal plane (Fig. 24). In the case of thvee-curve scoliosis, the pelvie girdle and Shoulder gisdle are rotated in the same direction, and the rib cage in the opposite direction. This creates the posterior rib hump on the right and the frontal ib hump othe let side (Figs. 23 and 25). In detail, therefore the following is elements are present: 1. shifting in the sagital plane, resulting in exacerba- tion of lumbar lordosis, chest kyphosis, and cervicel ondosis, This results inthe above-mentioned wedges (Fig. 15). These wedges should be viewed from the convex side, They develop because of the rotation of the three trunk segments and have less impact on the spinal colunve on the entire trunk areas. 2, Shifting in the Frontal plane causing the wedges to deviate laterally (Fig. 23) 3, Shifting in the transverse plane resulting in ventral otation of the verlices of the wedges and dorsal ro- tation of the wide sides. 4, Sooner or later the shoulder girdle on the concave Side will come closer to the pelvic girdle on the Concave side (Fig, 22), as the ribs on the concave Side move ventrally, They eannot support the shoul- tier girdle. Due to the distortions and shifting in the planes mentioned, shortening of the upper body is inevitable. ‘Analysis ofthe exact defeets present in each patient is jp eomplex process. This isthe first step. Exercise treat neat is then tailored to the particular condition at hand, 24: From abe ple gins 2b cage shold gle curve scoliosis, concentrating on the most impo the body. A certain deflexion of t. ‘at the same time. The stabilization takes place in the form of isome' ‘exhalation phase (see PART B). at aim: to elongate tal plane ccc urs 7 the correction then sion during the Fig. Te pele irle - 2=sbeage ~ 3=steulderinle Fig 26 Schomati orzo section zag the chest o scoot: Frac sbows oon and toion «he wetebal bes & dorsal hump onthe convex se, font storm of the ib cage and a shiis sternum Fig, 21: Cranial view ofthe distorted snk sepments of 17-year-old si wth ight hori ess 19“The mov od with breathing ae of major imports s. Breathing is, also a mechanical problem, and thus we shall investi= gate the forees which become active during breathing movement On one hand, they are active forces working through the muscles in the lecometor system, On the other hand thoy are passive forces ~ partly the lungs = working through the elasticity of the soft tissue. Passive fore- es are always trying to reverse forced changes in the natural shape of the trunk. This is esp.cially the ease in exercises for scoliosis. The appro'sh therefore has to be selective, activating the weak n:.seles, especially the weak muscle fibres of the diaphragm, until they are strong enough to counterbalance the strong muscles, General physiological concepts distinguish between costostemal and ablominal breathing, It must fist of all, be stated that neither type of breathing is found excl sively on its own, Scoliosis cannot be treated with only thoracic or abdom- inal breathing. The scoliotic shape of the rib cage and the chest needs three-dimensional treatment to widen the concave parts ofthe trunk and to flatten out the pro- truding parts. This isthe concept of the Schroth breath- ing method: the diaphragm has to be active in each part of breathing movement. Ithas to be guided mentally to achieve acertain degree of deep or full’ breathing, This is a learning process which leads to automatic move- ments by using visualization. Deep breathing is only Side view front ba | is fp! “exhalation ‘short and Wide on exhalation Jong and narrow on inhelatios “from the front Fig. 28: Muscles of the posterior abdoninsl wall and diaphragm a5 Sce fom the sbdoninal envi possible with an upright body, with the pelsis straight and in an o:thopaedically corrected position. To under- stand the many different mechenical problems, patients ts Frontal view a rmtw. {h-91h 2.0m, Poston of diaphragm, le THO; igh 9; erst sa column, have to be trained in a very precise and selective man net, Costal or rib breathing is possible, since the ribs ere Connected with the spine and move around an oblique axis, The rotational axes of each rib pair form an angle ‘ehich opens dorsally. This angle differs however, de- ring on the height ofthe segment. Ja the exhalation postion, the sibs point obliquely downwards, Lifting The ribs means also enlarging the sogital diameter of the rib eage, The oblique position of tke rotational axes flso enlarges the horizontal diameter ofthe thorax in its ower part during inhalation. Improvement of the shape dof the thorax is therefore always accompanied by an im- provement in function, and vice versa. This can be demonstrated by measurements and the plsimeter, It necessary to differentiate between “ex- femal’ breathing movement’ (ic. of the rib cage) and siaeral” breathing movement (ie. lifting and Yowering cof the diaphragm). This approach can also be applied in other postural and breathing disturbances, Contrac- tion of the diaphragm during inhalation flattens the Crnially convex dome, thus inereasing the volume oF the pleural cavity. The lungs follow the movement of the diaphragm as Well as that of the ribs ~ filling the complementary spaces. The fattening of the dome of the diaphragm is only possible by a simultaneous pres sure and displacement ofthe intestines. When the pelvis ic ina forwand-dagyaward position, the abdominal walls tetreat forward during inhalation because the abdominal muscles yield to the pressure. This ereates the impres- that breathing with the diaphragm equals abdomt- Fig, Ss Desp inhalation on he right Tet sie, Some as Fig 30. Dis Tatktlin 40em = ithe tOih 3 Poston of aiaphragr, let LY; ight 712 Spinal elu pall 10 she right wi early onchange, Distance of ribs en she bs nthe ght sie: a. = OIh-9t42.5 cn nal breathing. When the pelvis is bought into an upright position during exercise, the abdeminal wall is relieved because the intestines move back into the pelvis. At the same time the lumbar lordosis decreases, which means that the spinal column receives en extension impulse. The latter may be enhanced veluntarily even more. Breathing using the diaphragm trings the abdominal svall lightly forward; atthe same time, the lateral thorax expands down unto the lumbar region. This breathing movement is of eritieal importsrce for improvement of the scoliotic form. Very often, to breathe in this way is nat possible because of thoracic otation and counter rotations, but it must be recaptures (Fig. 29). During es- halation, the diaphragm relaxes end moves back to the starting position, The shape of ths thorax ean also be in- flucneed by specific exhaling movements, ifthe anterior ifiae crest is raised, thas reducing the lumbar Jordosis, Tis very important for patients to maintain this upright position during exhalation, Afterwards they need (0 Tarn to maintain this better poste for 3, 5 and later 10 breaths. After the shaping resus have been imprinted ‘on the mind, all the muscles of the trunk are tensed as much as possible, by performing a so-called ‘muscle mane’ excrcise. This is of prizs importance to instil the feeling of *posture’, Due tothe attachment points of the diaphragm (origin in the ribs, sternum, lower ribs. ‘and Ist to 4th lumbar vertebrae - sec Schmidt and Koh- ratusch 1981), the diaphragm also has to change position ‘as well as the rib cage (see section A.VI, The Scotiotic [Breathing Pattern),Ane tottowing tas vscn ooserve + volvement of the spinal column durin breat iment: AS lon + scoliosis isnot fixed by ankylosis. itis possible to fluence the spinal column positv Erecting the pelvis leads to a reduction of the lun. 1 londosis and the ereetorspinae muscles are activated. in addition, the patient is asked to visualize a straightened spine. This alone brings about a straightening. The more pronounced the spinal curvature, the more the trunk nay be elongated during comectve inhalation. This has been demonstrated by measurements ‘The combination of mechanical forces and mental co- ‘operation is an essential requirement for the Schroth method and is decisive in success. Figs. 30 and 31 show the effect of intentional unilateral breathing in anormal $2-year-old woman, Fig. 30: spine vertical. Fig, 31: maximum inhalation with unilaterally guided diaphragm on the right It is clearly visible that the spine is being pulled tothe right. Her shoulders are horizontal. The intercostal spaces have been widened distinctively (Fight side) and the diaphragm lowered about 8 em. Itis, of course, possible to move the ribs without using breathing, Everybody can check it: inhaling, or exhal- ing, hold the air halfvay (do not apply pressure). Now the ribs may be spread or contracted. This can be done several ti2s; itis a purely muscular function. It has to be admitted, though, that spreading ofthe ribs is 100% botter if the diaphragm is lowered intentionally during inhalation. The effect of the contraction of the ribs can be increased ifthe exhalation and elevation ofthe dome of the diaphragm are performed atthe same time. To improve shape, the muscles have to be activated, which brings back muscular as well as a static balance. ‘This will result automatically ina bette, ic, more use- ful inflation of the lungs, because the hitherto unused parts of the lungs are activated as well. Katharina Schroth observed the movement of the ribs “at right angles? to lateral and cranial during inhalation and exhalation in her own body. It was not theory which ‘made her believe that ribs move sideways and upwards ‘during lowering of the diaphragm. Ina healthy body. ribs not only move tothe sides (lateral- |y) but also dorsally, ventrally and cranially during in- halation. Everybody can verify this by placing their hands on the attachment positions ofthe diaphragm arches, free ribs, upper lumbar spine) and feeling what happens to the body. The scoliotic patient may not be able to do this immediately, and has to be trained to use the breathing movements with simultaneous correction of the exterior shape. A different body posture is there- fore needed, including the relieving and widening ofthe concavities. In this situation, the question of what fills the hollow hory segments is not important: whether it is the displacement ofthe intestines, or air, or the result Cf normal muscle activity. What matters is the fact that the visible recesses are flattened out. Pa S easily be imagined sin ths ae, ba his require a gic the dome ofthe diaphnagin, 50 every comective effect. Prof. Vogel, Dresde this “formative foree of breathing* in 1237. dix, AC this point, itis appropriate to mention @ speci phenomenon that Katharina Schroth noticed at the boginning of her professional career: if a scoliotic pa tient only breathes deeper than usual (symmettically and not in certain direction), more air penctrates into the already stretched pulmonary half of the ib hump side. ‘This worsens the scoliosis deformities, since breath {his way doesnot incorporate the oxthopaedie moment of straightening and deroation. Breathing movements have to be modified forthe treatment of scoliosis. Breathing has to be targeted, and it has to straighten, derotate, and influence the thoracic segments positively from the very beginning 1Wis not difficult to conclude that threedimensional breathing stimulates the inactive pulmonary alve ‘The positive result patients felis that they become less susceptible to colds and that their physical performance increases, white their pulse stays inthe normal range. Even paradoxal breathing, during which the ribs eon- tract in the inhalation phase, can be normalized. oss Investigations into breathing excursions with the scolio- meter (sce Part DH: Statistical evaluation of treatment results) show that RAB can bring about derotation, If we are successful in changing the scoliotic breath: ing patter, each breath acts as a corrective exercise at the same time, By contracting the trunk musculature in the region of the protruding convex trunk segments, the breathing excursion is restricted in these areas and makes possible an increase of breathing excursion in the concave, recessed trunk segments. Patients can be trained only in RAB, but actually it forms the basis of the entire Schroth method. aVL. The scoliatic breathing pattem In the rest position and, most of the time, when u breathing deepl msiric br (Fig. 32), According to Schmitt (1985), the healthy patient shows fn axially-oriented push of the ribs when contractin the intereostal musculature, thus stabilizing the spine at the same tine by symmetrical breathing, the scoliotic patient has an asym pattern due t0 the scoliotic deformity In cae of asymmetric breathing oF scoliosis, this fresh acts unilaterally on the spine and increases the Toaton ofthe vertebrae because the shearing force of the corresponding ribs on the concave side is directed tsdominanls atthe body ofthe versbrae, and onthe u cave side via the costtransversl joint othe sp process, iaphragin is also impaired because its points of at- ment (ribs) are displaced. It has to work within the scoliotic distortion’ ‘Thus, in the ease of torsion of the thoracic vertebrae, symmetrical breathing inercases the deformity. Each eath contributes to and exacerbates the scoliotic mal- posture and deformation. Already widened areas of the rib cage are influenced, and the lung is ventilated in al- ready Well aited parts scoliotic has to learn to correct the breathing pat Consciously directed breathing into the concave pans of the rib cage mobilizes restricted ribs. Less von- {Cated parts of the lungs are filled with air and achieve- maat of the correct posture is also facilitated, Contract- ing the convey areas prevents them from expanding ‘and dirgets breathing to the relaxed musculature (cas, Seoliometer measurements (Weiss possible to alter the way a scoliotic ‘more beneficial pattern (see chap- in scoliometer values) fically deed thoras (Weks) The sous beating pater roses heise aon to Heke). The srows n> ne retin oY Breath noth seolisis “Se eves Breathing pati acconing to Schroth The a= sad indat the Cgcton of RAB, hi {Tee soolote eeaing patent onthe Kell, Transverse section of a RAB cannot be integrated into the corrective techniques of the Schroth exercises unless the trunk is elongised ‘as much as possible and the concavities are relieved of pressure. This means that the patient has to be able (0 straighten up first, come out of passive ligament-hoki- ing = within the existing range of spinal mobility ~ to achieve the desired effect We recorded the breathing movement values of several paticnts with the Heibrock-Scift Method (Figs. 33 and 34), Starting point was the beginning of a S-week course of in-patient treatment. At the point of deepest inhala- tion and exhalation with a with @ tape measure: a) subaxillary b) across the chest <) around the waist (atthe level of the floating ribs) ) across the stomach below the umbilicus Breathing movement was recorded in centimetres. Plots ‘were made on graph paper. Anja, 15 years, showed a major improvement in breath- ing under the axilla and around the waist (Fig. 34). Karin, 20 years, showed a negative value of 1 em. The intersecting lines across the waist show that her waist narrowed during inhalation. After S weeks, we recorded 2 positive value of 4 em at this point, This inerease can be attributed to daily breathing training including the diaphragm (Fig. 33). Karin, 20 years, start, Anja, 15 years, start 86-79 66-85 a4-8e 4 weeks later 2BMost scoliotic patients are affected cardiae deficioney. We obs pulmonary and red that patients show a This also applisd to the endurance eapucity: below pulse frequency of 130/min in the same patients. Ano reduetio: in or elimination of lip eyanosis during in- ther effect of training is the faster reeavery in terms of patient » iment, We also registered an increased vital pulse. All these factors are evidence that the circulation 7 capacity - which even doubled in many patients (with — system is being used more efficiently. As far as cardi: baselines around 350 ce). Patients often state that they circulatory capacity is concemed, the vial capacity feel better in general not be seen as a measute ofthis, but it ay'be seein a Jn 1974. the Insite of Sports Medicine atthe Univer measure of restrictive functional impairment”. sity of Westphalia, Gemany examined eardiopulmona- ry capacity in two groups of patients at our clinic, with According to more recent studies (Weiss, 1989) a hig! the following resus ly significant increase in vital capacity and rib mobitty “At the begimiing of the in-patient weatment, we did can be expected, even in adult patients not note any pathological eardiopulmonary deficiency in the group (except in 2 patients) The spirocrgometric Medical investigations in Bad Sobemaim confirmed values at the end of the 4-week treatment had increased that an intensive 4-week course of Schroth treatment markedly in each patient, although to different degrees, can increase the organic capacity considerably. This in- Most striking was the positive inflience on the circula- dicates tha the treatment isnot only of velue in termsof py tory system. The pulse rate decreased with increasing _its orthopaedic effects, but also with respect to intemal u cffor, generally by 10-15 beats/min. The watlage ofthe medicine. effort threshold was ble to be increased continuously. Ahighly significant improvement in PWC 170 was ano- Significant increases in cardiopulmonary eapacity can ther result. The individual values forthe physical work be attained by endurance traning or physical conditio: capacity (PWC ata rate of 170/min) in adolescent scoli- ning, but no significant increases in vital capacity (Biure ties showed a highly significant inerease inthe test, etal 1969, Gotze 1976), VIIL. Effect of sun and air ‘Hippocrates pointed out: “Water, air, sun, conscientious ‘This s something we must always bear in mind, We exsr nutrition, occasional fasting, the ability to relax and cise outside whenever possible. The famous physician a joyful temper form the vital impulses which create _ for alternative medicine, Dr. H. Bottenberg (see Litera- health.” ture), illastrated wonderfully the connection berveen “abel 1 Average smut far in oe exain "lessen naa ays ee ins Men Height women 1400 5 1400 a0 150 1650 © 1500 2.00 15s 200 1800 0 1600 | 20 160 2600 aa 1900 R 1950 | 200 16s 2400 q 250 b 1900 | s00 170 3o0 2300 4 2100 soo ns 200 2400 1s 2200 a0 180 2400 Avorge vals fr sprtnen , Comps shee so0 | poser 00 Foobalrs 4200 | soimmors om hess 4750 Rowers 50 : 4 SR ESSE J Sasun, air and health, He remarked: “The fresh air which sre inhale and which touches our skin gently is the most Tlementary vital need for our organism, Many people treed clean, living air more than nutsition, Next to nat Tal nutrition, ar, ight and sun ave the best physiological incans to stimulate and increase the body's defences.” ‘as early ats 1795, Hufeland pointed out that a deficiency of light and stn nny provoke serofuta and rickets, It is ‘ery important for seatioties to bear this ia min. Fresh air recharges the body and brings back lost muscle tone — therefore leads to health. It is recom- mended to sleep with an open window: H'should always tbe bome in mind that we spend a third of our lives (8 op) in out bedsoam. Leo Kofiritlusrated the sity for clean aie with the following experiment a sparrow locked under a glass bell was able t0 sur Nive alone for 3 hours, Then the oxygen was used up. IX. valuation of spinal length loss in scotiosi ‘To evaluate vital capacity in adults, we base our mea nts on body Fength. Table | shows the stendard values. “This mosi important point of reference to deicrine the theoretical value of lung content is different in Scoliotic. patients, The reasons are lateral shitting fof the spine accompanied by rotation or torsion and corresponding changes in the rib esse, They cause n loss. of height and restrict the pelimonary space. ‘Tuhte 2: Rough values for the wationship bewwcen the rule of sotioa and dhe shortening ofthe per boss met om om asdeyres 1am gsm BOadeyrees LS em Wodesree 9 em ASdogres 15 on mosdepess 986 degrees 2 em odegeos 10 emt aSdkyrees 2.5 em Heo 12 ow degrees 3 om sSdegioes 3S em Wodegeets 8 om 125em cSakgron AS om Mon 70d sem 15 om asdegiees FF em 16 on Sodegrst 6S em 1s SSdogrees 7m) “The sparrow may have Hived for 10 more minutes, An~ ‘other sparrows was aeded ~ it did immediately after in- hhaling the stale air, whereas the frst one stayed alive, Shoily before 3 hours had passed, it was set ee. One ‘may conclude that stale air From others is poisonous for us . Clean, fiesh living air has another physiological effect: it has the fragrance of nature. It stimulates all livin, beings to breathe deeply. Fritz Kahn describes viv~ idly the most subtle regulating healing effects. which influence a healing process. Permanent outdoor treatment should have priority be- ‘cause itis atype of air-bath which represents the mildest and most uncomplicated biological form of treatment. A nude body can enjy the air-bath thoroughly. ‘This is the reason why we have outdoor arcas in addition to our exercise halls at the Katharina Schroth Clinic. n relation to vital capacity ‘The diaphragm supports this defect functionally (sec scetion A.VT regarding the scoliotic breathing pattern). In order to gain a ‘heorctical value for the vital capacity that the patient should have in the upright position, we carvied out spinal measurements by X-ray. Rotation, torsion and rib deformities were not taken into account. ‘The course of the curvature was compassed at about the middle of the vertebrae and the vertical distance between caudal and cranial point ofthe curve was mea sured. The tape measure was then stretched to evalu ate the difference. The difference represented the Toss of eight. “These measurements were done separately on the tho= racic and lumbar spinal curves, since a single spinal curvature of about 100° Cobb shows a stronger contac- tion than two 50° Cobb curvatures. We then tooked for ‘a relationship between the angular values and the loss of body length. “The values in Table 2 refer only to the thoracie cur- ature (ie. shortening and restriction of the rib cage). “They are probable values. They should be added to the existing body length to evaluate the vital capacity. The theoretical body length is calculated by adding together the values for the thoracie and lumbar curvature. It is ‘obvious that the standard values in Table 1 ean hardly bbe reached in cases of major scoliosis. Less severe cases of scaliosis often execed the standard values, especially ‘when the patient is ative physically 2526 aa 1 PART B Evidence-based theory aca fia nl 1. Influencing the seoliotie wedges with the aim of restorin, we Fig, 35 ouilines the three planes (three directions, three dimensions) wich define the space within which the body can move ~ as well asthe axes around which the nes and axes of the body ody ean rotate al 1. Thes terior to ‘wo halves. 2. The fiontal plane (front = Forehead) passes through the body from one side to the other. 3. The transverse or horizontal plane passes horizon tally throug’ the body. 44. The sagittal axis runs through the body from poste- rior to anterior. The body rotates around this axis in the frontal plane (for example right upwards or left downwards) ‘The frontal axis runs through the body from one side to the othes. The body rotates around this axis in the sagittal plane (For example front upwards, back downwards) 6. The longitedinal axis runs from cranial to caudal. ‘The body sotates around this axis in the transverse plane (for example right backwards, left forwards) 1 (sagita= arrow) passes from pos jor through the body and divides it into In the case of mialposture and scoliosis, itis important to be aware of the changes in postural appearance caused by the shifting of individual body segments in the above entioned planes and rotating around the correspond- xxes. The iree-dimensional changes that ensue are especially evident in scoliosis. It is therefore necessary to correct thes: changes ina three-dimensional manner. We describe ths in the following chapters ‘The most impectant element in postoral correction isthe upward direction, ic, elongation cranially. This etonga- reotangular blocks Aangitadinal ais (6) | fro plen fom side ws] fromat axis) sagitat plane (1) {from back to Front) a rangverse plane ©) {torizonal tougl the body] Fig. 3s tion feads toa opening ofthe concavities, Space is also defined by length x height x width. Each deviation i shape to the side, back or front results automatically in a shortening of the trunk and there the angle of the deformity. Since the lifting forces of the intervertebral dses are being weongly directed, the scoliosis increases according to the devistion of exch of the body seginents from the midline. It i therefore of wast importance to actively elongate the trunk and the spine, Our method provides this by starting each exercise with small serpentine movements of the spine upwards and sideways like slow w ossibises of epasiining and trang the pels vette tice main aes sgt, tesvense, lginnl,In scoliosis, the rectangular blocks that are no:inally superimposed vertically, shift and rotate against each other, In three-curve scoliosis, the shoulder and palvie agitdle blocks shift in the frontal plane to one side and the rib eage block to the other side, A he same time, the laterally shifted blocks rotate dorsu:., 8 shown in Fig. 37, 43. Principle of pelvie corrections in three-curve sco- liosis (Fig. 36) ‘The first two pelvic corrections are made in the sagit- tal plane. The pelvis, pointing forward, is drawn back above the heels (3). The frontal pelvic im is then raised (e. ‘The third pelvic covrection is a lateral movement in the frontal plane, Patients are instructed to draw in the prominent hip (b) ‘The fourth pelvic correction moves in the transverse plane. The convex-side hip is brought backwards (A. the fifth pelvic ccrzeetion is like the third, a movement in the frontal plane. Patients are instructed to lower the hip below the convexity (4), Pelvie corrections for 4-curve scoliosis arpear in section C.VIL. 4. Correction of deviations in the sagittal plane: postural improvement, first and second pelvic correction he axis of the legs, which runs obliquely forwards to the forefoot due to shifting of the weight has to point obliquely backwards forthe purposes of core Hon. ‘this » ves the pelvis backwards, ‘he frontal civ rim is 1 son. This Fags the upper thank for reflex that activates bumber and dor tirst powne ence ic corres sading traction (Figs. 40-16) The polis, having shifted laterally, has to be moved back across the midline inthe opposite direction, exc ing an‘overcorection: third pelvie correction. It ist ‘enough to find only the vertical line, since we have to tate & nev postural image, We aim at overcorection to achieve this. This is not an overcor: rection of the spine, but of the body statics. The i tive muscles have to be activated and stimulated strengthened: When first performing this correction, there i the danger of increasing the cervical curvanure (shoulder or the concave side is pulled too far lateralis). Shoulder countertraction therefore has to be applied The shoulder on the convex side is moved diagonally sideways and upwards, aiming also to lift the cervical curve while the trank moves in the opposite direction, The shoulder blade should never be pressed towards the spine, bu pulled away fom it. The shoulder blade tums around its sagital avis, the lower angle pointing towards the spine, and the upper outer angle laterally. At this point, the shoulder girdle is held in position, andthe rib cage is derotated in a three-dimensional way: for vwards, upwards, and then intemally (sce section BLLS, ‘Rotational angular breathing’, below). Fig. 37 ma.(ugha): 12 &.ycarot il with optic tetas Aone rane ap Nosy in the aning poston, se a0 has 0 oe gah thon sens wider a the ght, This he et io tare ochvards ard he Whilecxcreising upright between two pales or ina lying poston, both ats area dhe same heiaht, provided the Tpoulders ave horizontal the shulders are not at dhe ame height, the hand of the side on which the shoulder ountertraetion i being applied grasps highe. {fikeshouder onthe concave side is lower and the eu Nature starts in the upper thoracic spine, the shoulder Countertraction is applied on the opposite sie. The arm Ghihe concave side is pushed outwards and upwards, gd the lumbar eountercurvatore is contracted forward inwards (Fig, 46). is also possible to pull the same Shoulder upwards and sideways, and to move the hip below the convesty diagonally backwards and down teards (‘Oblique torsion’, Figs. 187 and 204-208), Very tmportant: avoid purely lateral pressure. Due fo sotation of the convesside middle trunk segment, the lateral ribs and museles also rotate backwards. The parts found fateally are actully ibs and muscles of the front. They must be neither pushed nor contacted, pecance they would push or rotate the rib hump ever forher dorsally, nd this would exacerbate the rotation ff vertebrae, The goal ist rotate them ino the corect . foattion and siden the spaces between the ribs. Only L_TRanean the museles ofthe protruding rib hump be €0n- rected (intercostal muscles and M, latissimas dorsi ‘The diagonal Interal movement is created by the upper put ofthe M, serratus anterior (pars horizontals) and the middle part (pars divergens). Once this technique is thastered, the laterally protruding rib hump decreases, completely. [At the same time, the position of the hip has to be corrected (outwards, backwards and downwards), (Figs.181, 205) Note: in the case of four-curve scoliosis, do not lean towards the concave side, since this would move the hip ‘below the convexity even lly. b f Pes = ae ee eet) Tepe ete foal irs peasants i Se i nen) Tepisharn fee eee son OE Ne 3Fig. 0: ScolocBedy wih pe {ie malpostrs, The bodyweight iit. Fig. lz Same patent exercis- ing the thed pelvic conection Seeexplaation intext, 6. Derotation of the trunk as part of the fourth pel- vie correction and derotation of the shoulder girdle in three-curve scoliosis First, the patient must master the technique of derota- tion of the pelvic girdle. From this fixed point, leverage ccan then be used fo correct the upper trunk segment (rib ceage). Once this has been mastered and the rib cage is iderotated, this forms a solid basis for derotation of the shoulder girdle. ‘The three kyphotic elevations of the trunk: rank segment 1 is the hip and lumbar hump below the ‘dorsal concavity; trunk segment 2 is the dorsal rib hump; srunk segment 3 isthe shoulder girdle of the dorsal con- ccave sides ‘They have to be moved forward. tion ofthe hed and shoulders hea, trunk segment Lis the hip below the the lumbar part and floating ribs tnink segment 2is the concavity trunk segment 3 is the shoulder sbove the rib hump, ‘They must be rotated backwards. sump inclesing is side: Fourth pelvic correction: the gluteal muscles shout be firmly contracted. 2) Contraction of these muscles on the dorsal concave side brings the hip forward ') Manual pressure on anterior thigh of the rib hanip side brings this hip backwards (Fig. 47) ‘The derotated pelvis now forms a firm point agsinst which the second trnk segment can rotate, This deresi- con also remains as 8 fixed point. Now the shoulder gi has to rotate inthe same direction as the pelvis: above the rib hump backwards; above the conca 17. Horizontal positioning of the aleae (crists ilies) of the ilium: the fifth pelvie correction Inmost cases, he pelvis moves out of ts corrected he: zontal position during the third pelvic correction, which ‘cans that a fifth correction is necessary. The leg on the ‘convex side appears to be shorter. This fifth correction, however, conssis only of lowering the heel on the con- vex side, thus ~videning the space between the ribs and pelvic rim (Figs. 40, 41, 116-120 ). Besides achieving ‘an improved clinical appearance, this correction causes ‘the important deflexion ofthe lumbar spine into the up- right position, a basic correction forthe spinal segments located more cranally. rp ig. 48: Conc position of the shoulders and. Fig. 44 Wih mam asistance: rota, it~ ing and pushing grip. aa 8 Targeted ‘rotational-angutar breathing’ with counterrotation of derotated trunk segments important point in postural improven for all patients!). Rotational angular breathing (RAB) Afizr pelvie corsection has been established, breathing, ‘movements of the rib cage are performed in a ‘right an- ‘gled” manner. This means that the breathing directions follow the sides of an imaginary right angle (the second ‘siz of this angle always runs eranially). The RAB starts at the ‘vertices of the wedges’ and is combined during inkatation with the mental inage of lowering the dia- phregm, RAB is accompanied by a countermovement of the body segments located above or below. “The procedure for kyphosis and scoliosis is as follows. 14) Lew. REGION BACKWARDS AND UPWARDS (wenge 1, Fic. 49) With hands on the lumbar lordosis, the patient inhiales and checks whether the region flattens while lifting the anteri- or pelvic rim, Flattening of the lordosis relieves pressure from the abdominal wall, since the intestinesthen rest ly in the pelvis. This has to be reinforced by tight- the abdominal muscles during exhalation through the mouth (forming the letter *F* or *s"), Imagining the following is usefitl: intestines, backwards and along the spine upwards = tight angle. The countemovement takes the form of dawnward movement of the posterior ili crest, increased straightening up of the pelvis, and Tean- Forward of the upper trunk fo open the vertex of the swadlge in the humbar region, 8) Str aSrenion CHEST? FORWARDS AND UPWARDS (vince 2, Fic. 49, 52) ‘The patient’s hands. are now gently rested on the re cessed anterior side These ribs are then brought forward by breathing forwards and upwards into the area, Atthe me time, the diaphragm is lowered and sinks down to nestines. and the rib hump Mattens, ‘The patient ean Fig, 47: Foun povie eaecton {eel this v2ry easily. The countermovement is pushing the shoulder and hip backwards. ©) Cenvicat, Lonbosis acewanos aND vrwantos (separ 3, Fic. 49) During inhalation, theneck moves gently backwards and upwards oscillatory movements ofthe spine), giving the head a strong occipital push This decreases the lordosis. Countermoverent: upper trunk forwards, widening of the chest, The following breathing movements have to be performed additionally inthe case of scoliosis: 1) Fhostise mins (131TH 4x0 121#) seLow THE waB HU) sineways axb Urwaros (weDce 5, Fics. $0, 1) In the case of severe scoliosis, these ribs point almost vertically downwards, The patient puts his/her fingers tothe recessed arcaand pushes until the ribs are found. ‘Then they are moved sideways and upwards and back- wards and upwards by breathing and the diaphragm is lowered mentally (and physically). Countermovement: the lateral rib hump is pulled towards the centre. 8) Tue sate rosie mins nacanns-brwanns (WEDGE 1) ‘The thumb pushes strongly from the back against the last ribs, which arch towards the thumb during. inhala tion, Now the concavity below the rib hump is filled with air, because the diaphragm lowers and forces these ‘ibs outwards, Now the previously inactive ribs ean give support again, Countermovements: pelvis downwards, trunk forwards, contraction of the posterior rib hump. 33 es SEVERE EE I EE SITS OTTa #) Nankow ANTERIOR SIDE FORWARDS AND UPWARDS 6) NARROW ANTERIOR SIDE FORWARDS AND UPWARDS (ovence 24, Fro. 52) (WeDo 2, Fics. 52 ax $3) Similar to breathing movement b) unilateral at the convex If the trunk is very roteted, (stemum has shifted to the side. I is important to visualize lowering the diaphragm at convex side), an additional inward movement is neces the same time to even the lumbar lordosis and create a sup- sary until the sternum is across the midline (Fig. $3), port from which the narrow front canbe pushed out. Counter- It is equally important to lower the diaphragm. The in= ‘movement: counterhold of ipsilateral hip and shoulder ‘ward movement is lateral and may be done only after Fig 82 ofFig st ‘ter 3 mas of treatment, Fig ‘ier 46 mans (noice her f= ial expesion. The part of the fib cope which ad doviaed 10 he ight, nteraly and dorslly, tins been moved forwards, up wards and inwards with RAB, “The the blocks are now super posed vena derotation. If the stemum Ties in the middle, the dero- tauonal breathing is omitted, Instead, only the lateral Jntercostal muscles are contracted during exhalation as for shoulder countertraction (Fig. 44), Countermove~ tment: hip and shoulder of the convex side outwards. If the stornuim has twisted to the concave side (Fig. 52), sew section C.VHIL6, Corvoction of the shifted sternum. 4i) SEMANIEL.ARY RIMS FORISARDS AND COWARDS 1, FIG. 56) “This aca is especially narrow ifthe shoulder above the rib hump is rotted far forward. Widening and relief of presune is only possible with proper alignment of the Shoulder and scapula, with the later ina vertical pos tion, Here, too, we must make the connection dovn- Ntords to the diaphragm, Countenmovement: shoulder Jevel (exterior angle of scapula) backwards, inferior forwards, to ep push the ib hump forward. 1) Coxeave (werner: 6, Fies. 41 asp § (oe LATERALLY AND LW ates 8) ‘These very closobjespaced ribs are spread by inh ine sideways and upwards over the coneave-side hip {clieeking movement with the fingers). Lowering the iaphragm, the ribs ean be Fel fo move outwards one after the other. This phase is important, since only af- ter widening the intr-rib spaces can the ribs be moved ‘backwards and raised. Countermovenient: contraction of the concave-side lateral hip muscles (M. tensor fas- ciac lane, M. glutacus medius and mininws) from sige- ‘ways to inwards. The outer shoulder girdle on the same side should also be contracted. This is very difficult to ‘achieve, but shoulder countertraction an the convex side contributes to it x) CoNcAve SIDE BACKWARDS AND UPWARDS (wences 4 4x0 6, Fic. 58) “The ibs onthe concave side eannot be rotated immedi- ately because they then hinder each oer. Moving them backwards can only be achieved afier they have been lifted laterally. Afterwards there is an upward move- sont which causes the eoncave area to arch backwards. “This also evens out the thoracic Tordosis, Voluntarily contracting the diaphragm leads to 2 faster and more complete corrective movement. Countermovements are ‘concave-side glteal contraction to move the hip for ‘ward (fouth pelvie correction ) and forward rotation of the eoncave-side shoulder. is important to combine all countermovements with depression of the diaphragm and an occipital push. ‘With these eountermovemen, the kyphotie and lordo- i trunk segments are brought back into one plane. The trunk is visually balanced. 1b) RAB writ TRUNK HANGING FORWARD (Fics. 244, 250 anv 490-494) Asymmetry of the back is most visible in this position However it submits to good correction sinee the spineis ‘at maximum elongation. Fourkitos of head weight dravw it out, and the concave side is freed of the shoulder-gir dle pressure. Diaphragmatic breathing ean flow wnob- siructed, Ribs on the concave side are rotated laterally, 35Barts Fig. $7: The concede (left) is badly depressed rst ofthe time, The shoulder gidle on the same side eet Realy 00 the concave ribs, fen even on Fig. $8: The concave side is widened with simotencous elie conection snd RAB. ‘Now the bs onthe concave side can straight bral bodies ccranially and dorsally, Figs. 491-494 show ventral ro- tation of the convex side when the concavity is pushed ‘out dorsally by breathing. This action reverses thoracic, spinal lordsis. The patient should breathe inthis way for slong as possible and try to perfect the result with each, breath. As mentioned earlier, one characteristic of major scoliosis is lordotic spine inthe atea of the strongest ‘curvature. This means that itis not useful to concentrate exclusively onthe rib hump while exercising, Derotation- ‘al movement of the vertebrae is often mor ‘we see in Fig. 494, the rotational breath ‘more successful with added tactile si 9) Postural correction of the neck and head ‘The head should be held in a position that extends the median scoliotic curve. The larger this curve, the more the head is held towards the side of the convexity, thus By pressing the hands against dhe poles, the wpper bay ited fom he pst and the Interpol ofthe trunk are elongated, Air this, RAB i pple, sve side during exercise. The 6 chin to tins Fea towards the eo: fotlows ide and turn 61). The smaller wards the convex side 0 cavature, the straighter case. even with kyphos! thes is cervical hyperlordosis (see Part C). For cervical kyphosis, the head should only be held upright witzout extension of the cervical spine, Le., no eccipital pus 10) Isometric tension for stabilization following pos- tural correction Flattening out the raiseclareas using relaxing moversents can only be suecessfl if isometric tension is applied to the newly-obtained ‘norm!’ shape as an int cach exercise. Exercise: On inhalation, the best possible correction ofthe posture is adopted, whatever exercise is being perforred. On subsequent exhalation, all muscles of the trusk are tensed as much as possible (without movement), ans the patient should count to four mentally. steadily increas- ing the tension. The tension is held during the next i halation, and should be increased even more during the subsequent inhalation, until --according to individu! ca- pacity ~ reaching 2 count of twelve. The muscles then be allowed to relax a little, without the i of breathing, until the latte: has returned to normal. The tension should be applied from the lower to the vpper body, stating from the front of the thighs, via th ‘up to the ribs, and from there sideways and back ‘The exercise i then repeated. After three or four of “Twelve-Count-Tensing” exercises, the patient stould relax fora while until breathing has rerumed to its rhythm and the muscles heve recovered. This t \Welen coro the posting of ete: ie insne tothe concave sive, wie the hin is pointed tovards the conve side ‘These comectons a stabilized by Emily ‘pushing the poles gaint the prounein corrected position lying supine, In doing so the patient should “think” the eoneave back sctions wider and apply them t0 the Moor. The effect ofthis imagining is high!y visible and occurs toan astonishing degree. Everyexertiseean be combined with hese “Twelve-Count- “Tensings” and, depending upon the patient's strength, can be increased up to 16-20 repetitions tian excellent way of shortening over-stciched muscles and restoring a bet tor postare. I cat only be sucessful, however, if iis per formed with the Best pasibe (corrected) stating positon ‘Any stvong,tensing of the muscles results in the forma- tion of new amuse fibres, Care must therefore be taken to ensure that not only the rib hump side is contracted, beease this would only make it Took bigger. After derata- tion therefore, itis necessary to tense both sides during the exhalation phase the concave side afer lengthening, and the convex side aficr shortening, While these Twelve- ‘Count-Tensings en be performed atthe eth of any exer cise, patients should rot imagine that because they have just exerted themselves so much, they ean sit oF stand as they please in their leisure time (meals, watching televi- sion, ele). Those who think this way will surely’ soon fall back into their previous malpostte. This means that they are performing an incorrect exercise that unforti- nately reverses the corset results they just achieved. The outcome is as if they had never exercised. Patients umust make a great effort to ensure that their previous posture is a thing of the past. Whon all is said and done, their own bodies should tell them, so that they never again con: seiously think of re-sdopting their old habits. 1 they get tired, itis much better 1 simply ie down and rest, Patients need to increase their proprioception of the new postere. Il. Appropriate starting positions and orthopaedic aids for trunk derotation exercises (three-curve scoliosis) Four eushions re needed: postcard-sze filled with rice or ‘rain, weighing about 200 grams, preferably wedge-shaped (Fig, 574), They should be fim but also exible to adapt to body shape. They are used to derotate spscific trunk seg- iments, The cushions nat only serve passive correction, but also as 2 mnemonic device for everyday activities. “What ddo Thave wo bing forward? What has to go backwards?" 1. Flat supine position without pillow under the head Bont legs. One eushion under the concave-side hip; one ceushion under the shoulder blade on the same side (Fig, £62); one cushion sideways under the rib hump (Fig. 63), but not _undemeath or across the spine. The pressure should be applied where the rib hump begins to deviate ‘caudally to the bck and to the side. If there is a thick Tumbar hump uestcr the dorsal concave side, an additional cushion should be put under it (Fig. 64). Particularly in Four-curve eases, it must lie crossways sothat the concave Fibs are not pressed forwards, The upper trunk is inclined obliquely towards the concave side, If patients sleep on theirback, the position described above is good, otherwise aitach foam cushions tothe pyjama top. To avoid lateral deviation of the rib hump (Je. lumber hump), a wedge- shaped cushion may te put undemeathit Fig. 575). 2. Prone position Generally, the pelvis is elevated by 2 large cushion, a roll or alittle footstoot, Tose care that itis not too far up under the thighs, which eculd promote lumbar hyperlordosis. ‘An additional cushica under the hip on the convex side, a thick cushion unde: the shoulder joint of elbow on the convex side; one to tree cushions under the frontal rib Inump (concave side), tho size ofthese cushions depending. ‘on the size of footsicol or roll, The forehead should rest,positon. The convenities are increase. “The thoracic conveity moves backwards ‘on the hands; the chins directed towards the sterum and the convex side (Figs. 65 and 66). Ifthe pelvis is aligned, i.e. there i no prominent hip, the legs should le straight, If the hip on the thoracal concave side is prominent, the legs should be about 10° to the concave side, ths open- ing the “weak spot’ underneath the dorsal convexity. This stretches and activates muscles in this area and enables the hip to move towards the convex side. Pay attention to the concave side— it mus stay wide and open. Do not per ‘orm lateral flexion, Patients with a lumbosacral counter- ‘curvature straddle the leg on this side (section C.VI). 3. Lateral position ‘Never lic om the side ofthe rib hump, even when sleep- ing! Spinal torsion andthe ib hump will be exacerbated by lateral pressure. Even books or pillows placed under the lateral rib hump will further compress the nairow ribs and intercostal spaces on this side. This may pro- duce a fold in the ribs and a ‘pointed rib hump’. ‘The patient should ideally rest on the dorsal concave 38 table postion en the eoneave side. The spine is etched ‘or outward, The head les on the upper arm or 3 gillov:. Ifthe hip on this side is prominent, place a cushion un- der it. Ifthe hips are straight, lay the eushion somewhet higher to the side under the lumbar convexity, but not under the concave ribs. These must lie free so that at that rib rotation may be promcted there by means: of corrective breathing. The weight of the rib hump nox works corectively. RAB is now possible (Fig. 68-70). comective cushion undereshi Inthe ease of large lumber bump and rotational verbal stirrape, th hbar hump is deve’ man- ually forwards od then eesions ate put undercath ~ es any 3 ‘ewe to bring the lumbar spine into media position, ‘Noe for sleeping: Patents wih slunbosaerl crvatre(ée sections CAI and CV usually bave high Lambe ump, When lying oo the side this shouldbe supported, even when seeping, by # 20-c long. thin, sanéfiled cusion, oer it wells outwerds. I this happens, yng onthe side isnt only an unfvourabe poston, but is dangers, since the lumbar curve bends outwards and ts futher ‘A sane cushion does rt usualy sli sa easily, and rains in the sme positon wen the patent tums ont his Back. Once the pas "ent has impsnieg the Scscin pilosphy oa his mind, he eeveleps ‘hygienic conscience’ that makes him we up if he turs onto the “nog side when sleeping. In this way, sleeping at nigh elso he= Ps mcushions in aeeordance withthe Sth pelvic eorction or reserve seofess applied only ithe hp Blow the rib hp hos isinfibe and eanaotbe ie ovat the ght a fourth because would aerease the ture is present, his cushions it ! Tembosaera curate sar eonvexity splayed. This will ONE : the pls into a hoes postion. ‘ . 2»In the case of thre-cuve sealiss, th lower legis pushed isle backwards atthe side of the convent to droite thi hip. 4, Sitting position (Fig. 71) Always sit on the ischial tuberosties, ether on a chair — ‘without leaning back ~ or eross-legged on the floor. The ower leg on the concave side i placed across the lower ‘on the convex sid. IFthe lumbar curvature cannot be in- fiuenced by exercise, we must put a cushion under the hip on this side (Fig. 73). The bodyweight then rests on < 40 this side. The hip on the convex side isnow lowered until it has contact with the ground; itis also brought buck- wards to derotat the pelvis. Sometimes the patient feels it would be easier to place a cushion under the opposite side to create better balance. This would narrow the ver- tex of the wedge even more and the lower wedge weuld be enlarged (Fig. 74). Additionally this would support the scoliotic pelvis and make derotaton impossible. ‘The table at which one sits should be adjusted to body size to support the corrected upright posture during, meals. We have tables of different heights at our clinic (ig. 571). 5, Sitting on the heels (Figs. 75 and 76) Ifa cushion is used, it should be on the hecl of the lum- bar convexity. Do not use in cases of four-curve sco- Tiosis. 6. TY position (Fig. 77) Straddled on a chair, femurs horizontal, feet point= ing slightly outwards; forearms resting on the back of ia}co Fig 80: Scorhon andor dhe ke in te eas of ouseurve sco fips NE Siion under the ka inthe ess of fourcurve scoliosis the chair; pelvis back as far as possible; if necessary, 2 cushion under the hip of the lumbar convexity. This position prevents the trunk from ‘sinking in’, and the patient ean pay close attention to other things. This is ‘very suitable position for studying, listening, ete. Fig. 82 eeariion undee the knee nthe ease of Foursurve solos Fig. 83: ‘Noeushion wer the fot inthe ease of four-curve sets +. Corrective sitting position when the concavity is extreme (Figs. 78 and 79) ‘Concave side towards the back of the chs: the hip on the convex side as much as possible to the side, down and back. Arm on the concave sie ress onthe back of the chair to suppor this side z-d t widen it. The hip on the concave side caries the weight. 8, Onall fours (Fig. 80) “The knees are held apart as wide as the hips, with the thighs in a vertical position; the anns are extended vert cally under the shoulders, with the fingers point wards. A cushion is placed under the knee of the conse side; a second cushion under the hand of the same side accomplishes passive derotstion of the shoulder girdle and pelvic girdle, Intemal rotation of arms is used to create « better starting position for exercises, which in clude shoulder countertraction. When performing only breathing exercises (no change in body position along axes), the arms and fingers point straight ahead ‘As above; however, arms extended forwards and clay icles pointing towards floor. Cushion under wrist and knee on convex side. alIfa cushion is should be wn sitting cv ed (will not usually be the ease), it knee of the lumbar convenity (see ed") 11, Standing (Fig. 83) Ione legis shorer, the whole foot and nat just the heel rust be elevated (danger of pes equims ~ dropfoot). ‘The following distinction should be made: trunk in up- right position ~ cushion under one foot moves the hip cranially and means the pelvis is no longer horizontal Trunk leaning forwards (Fig. 84, the cushion pushes the hp dorsally and derotats the pelvis. Always think care- fully: what is achieved by using a cushion? In the case of three-curve scoliosis, a cushion must be placed under the foot on the convex side to bring the hip backwards while exercising with the trunk inclined forwards, The hhand grasps the next higher bar, for example, to devo tate the same-side shoulder girdle. When in doubt, omit cushions (section B.L.1, Planes and Axes). IIL. The scoliotically changed locomotor system Explications of muscular movement are always based ‘on measurements taken from non-scolioti persons. This ‘means that ts sometimes difficult to explain the move- ‘ments of the muscle and ligament apparatus in scoliosis, ‘The scoliotic patient has a number of contractions of the soft parts and changes in bones sis, and the entire system reacts ‘A multitude of muscles are involved in a scoliotic eur- vature. Thus, correction of a scoliotic curve cannot be limited to correction of one musele only. If we only concentrated on individuel muscles, important parts of the corrective process would be ignored. Additionally, many synergistic and antagonistic effects lead to a bal- anced corrective system. In the following, we shed light ‘on the activity of some museles. a) Pathological elements ‘Scoliosis is characterised by a more or less pronounced change in the balance of forces, starting already in the feet, legs and hips, with inequality of muscles in terms of length and size. The greater the deviations from the ‘midline, the longer the affected muscles become and the more volume is lost. They become flaccid and finally inactive, They lose their supportive function. Shape changes are only possible because the muscles permit them to happen. They become longer or shorter depend- {ng on the direction in which the trunk is moved and ro- tated. In other words, deviations of the trunk tothe side ‘or backwards can only develop if the corresponding ay eae nor ae Fig 8: Omit the cushion in be ease of fourcene scoliosis. supportive muscles give way and become elongated. Figure 113 shows that muscle inequality already starts in the lumbar segient and continues through as far as. the cervical spine. Therefore, treatment must primarily improve posture so that the body can tegain its original perpendicular axis. This can only happen by developing and training the corresponding muscle groups responsible for upright posture. To restore the balance of the body muscles, those that have grown longer must be shortened and. those that have become shorter must be lengthened, In maa cay tat seotioss presenting difge chanes in verbal bodies not be ahered by eur method. We cud however, certainly ‘ fouproevens in bathing and poste Some patont asin Fig 86. caler for these to be able to hold the spinal column and Soeage in their normal perpendicular position again, they need to be strengthened ~ and on borh sides. I is “bsolutely esseatial thatthe inactive shortened muscles jrave to perforin strength work inthe lengthened state Tn his thesis to become a university lecturer, Brossatis described the difference between electrical aetvity in the muscles on the convex and concave sides Brussatis 1962). He found thatthe activity in the museles on the conver side was greater. Thiscan be explained by muscle techanies, According to Schii/Thews (1976), there isa connection between pretension and contraction of huscfe, Investigations done with isolated frog muscles tlemonstrate that a usele ean only reach its maximal tension after a certain degrce of pre-stctching, The lat ter corresponds roughly with its testing position, Increased sticiching deereases the contraetive eapacity js much as further contraction would. plying this to scoliotic matpostue. the only concht- ‘don that can be draw is that the strongly contracted snscles on the concave side of rie curvature are as in- suifefont as the oversiretchied ones on the conver side. Strong myoelettc activity of the muscles on the con Nee side results from the fact that they alone have to tear the load ofabe parts of the body that lie erally “They hypertrophy but do not increase in strength, ws we used to believe, They are in a much 00 severely pre- __stetched stat, They eamot ear the stress alone and, instead of strengthening, weaken continucasly until bony disposition has been reached to stop the piogres- sion of the scoliosis The eleetromyographically “silent” muscles in the con- cavity shorten and show decreasing funetion as the eur ature increases. Pre-tension decreases here, and we ccan also assume that this results in an increase in insuf- ficiency. ‘The coneetive starting positions of the Schroth method ‘ensure that nearphysiological pre-tension is reached, jn both the concavity and the convexity. This enables iuseles to contract almost to the maximum extent. Scoliosis is always preceded by an incongruity between ‘maximum weight tolerance and actual workload of tmusculoskeletal system. Once the diferent parts of the skeleton are no longer properly aligned, they gradually cenorce the “scoliotic balance’ of the body, so-called “static decompensation’. This, however is only possible because the defective ligamentous structures (over ‘connective tissue weakness) allow this to happen. The physiological function of the vertebral and costoverte- bral joints, and often also the stemnocostal junctions, are distrbed. Vertebral slippage combined with rotation and even subluxation may result. This opens up the way to extensive deformities. “The scoliotically changed locomotor system is hetd in place by sets of muscles, some of which are overloaded 43‘and stretched and others which are contracted and atro- hied. This allows multiple torsion ofthe spine to occur ton incredible degree. The greater the pathological ef- fects of pressure and traction, the greater the effect on the bones. Initially, intervertebral dises become wedge- shaped, and later they suffer pressure atrophy, with bony ankylosis in the most severe cases. Fig. 91: Sehmate representation ofthe length eilfevence of the abdominal ‘musculature. The arrows show the dieetion of exercises, 44 Fig. 90 (ight) b) Individual malposture muscles 1, Anpowvat muscurs (Fics. 8-91) ‘The pelvic girdle and ribcage (and shoulder girdle) are counter-rotated in scoliosis. All abdominal muscles are therefore involved. Our working hypothesis: in right- convex scoliosis, fibres of the M. obliquuis abdminis ‘extermus on the right (Fig. 91, a) and those of the M. obliquus abdominis internus on the left (b), which run diagonally parallel in one line, are over-stretched. Con- sequently, the rib hump can mave laterally and dorsally. On the other side, the hip on the concave side shifis out- wards and backwards (b). ‘The opposite muscles, cd, are shorter and bring the frontal rib arch (so-called anterior rib hump) and the hip below the dorsal rib hump forwards and inwards ‘The exercise treatment has to restore muscular bala: by shortening the elongated diagonal a-b and elongs- ing the shortened diagonal e-d, This principle applies to all exercises. Short diagonals seem loriger than pre~ viously overstretched diagonals on the other side. The remaining abdominal muscles which had also moved obliquely, normalize at the same time. The result is nor- alization of the entire trunk, First exercise to streteh line e-d (Fig. 92) Supine position with corrective cushions, With éne hhand, the patient pushes the hip below the convexity outwards (laterally), backwards (dorsally) and down. wards (caudally). The other hand brings the anterior rib hump outwards (laterally), upwards (eranially) and then backwards (dorsally). This is done gently and with accompanying corrective breathing. The patient should oO aFig 93 (gh) feel oblique traction inside (iF necessary, the fingers ‘can be hooked underneath the frontal rib arch to help). Daring exhalation, the patient relaxes and then repeats the exercises with a new breath. To intensify the exer- cise, corrected positon may be eld durnn the follow- ing breath ‘Second exercise to stretel line e-d (Fig. 93) Supine position with corrective cushions. The therapist kneels on the convex side and holds the hip back, using the knee (ora sund-filled cushion). One hand moves the frontal rib arch laterally and cranially and, addition- ally, dorsally and eranially derotating and tifting with manual aid). The patient supports this with RAB which spreads and widens hollow areas ofthe back. Now the dorsal ribs find room to move and aig. Lumbar spine and corrected hip stay on the floor, “Third exercise to untwist b-e (Fig. 94) ‘Supine position with corrective cushions. The therapist kneels on the convex side, pulling the hip on the con- cave side forwards and invsards, The other hand pushes the frontal rib hump outward and upward (laterally and cranially) and backwards and upwards (dorsally and, cranially) creating to ‘right angle ales during rotation and tries to maintain the position during exhalation for as long as possible. In the case ‘of a lumbar hump above the hip on the eoncave side, it also has to be pulled forwards and inwards. Fourth exercise to shorten line a-b (Figs.95, 98 ana 101) Supine position with corrective cushions. At first, the patient may support manually on his own. He places fone hand on the laterally deviated rib hump, moving it forward, upward and inward, The other hand moves the prominent hip on the eoncave side forward and i card, This movement is assisted manually only at the beginning, afterward the hands glide” in the right direc- tions, and thea visualization alone produces the desired results Fig. 95, Fifth exercise for derotation a-d (Fig. 102) Supine positon with corrective cushions. The therapist kncels atthe patient's concave side end pushes the con ‘ver-sided hip to the outside, backward and downward. “The patient assists with this movement, The other hand of the therapist moves the rib hump forward, upward ‘and inward, The patient senses these corrective move- to reproduce these sensations later on 45Fig. 97: Aer wecks. while practising. 2. M. QUADRATUS LUMBORUM AND THE DEEPER HOLDING MUSCULATURE (FiG. 103, 104) ‘Together with erector trunci, this muscle has the func- tion of keeping the lumbar spine in medial position. 1t is attached to the 12th rib as well as the transverse pro- cesses of the lumbar vertebrae. In scoliosis, this mus- cle works unilaterally, pulling transverse processes of lumbar spine to one side (see section B.IIL3, Erector truncip. Result shifting of the lambar spine and torsion, thus creating lumbar scoliosis. (See section C.VIL4, ‘Accessory otstion) In case of inactivity, this muscle no longer palls on the transverse prozesses (Fig. 104). It occurs on the convex side, where vertebrae glide over to the opposite side and create a compensating lumbar curvature, ‘The upper body which has deviated to the convex side has 10 be Kept in balance by M. quadiatus umborum and erector trunci, These muscles are then forced into increased (supportive) activity. Due to continaous path- ological muscle tension and overall weakness of con- nective tissue, vertebral articulations deviate from the vertical axis in scoliosis. At times they even subluxate and create torsion of the lumbar spine, including a rota- tion of spinous processes towards the lumbar concavity “The transverse processes rotate ~ with the hip— forward on the convex side. The lumbar musculature shortens ‘hile a muscular hump forms on the opposite side (itis possible to palpate the transverse processes ~ Fig. 104) o ra_\ aterally deviating spine isonly possibte in connection swith torsion, The spinal colunm does not have @ eentral point of rotation but at cecentric one, similar 0 that of {in ellipse, A vertebral body, without posterior arch and spinous process, has is centre jn the middle, However, because of the posterior vertebral arch, spinous process and zygapophysea! joints with additional axes of rat tion, a corresponding rotational conte is ercated, located atthe posterior margin of the actual vertebral body. This nilte of rotation docs not fead (0 real rotation but to torsion. This can easily be demonstrated: Fix two steel rulers of equal length next to each ether (about 1 oF 2 fom apart and parallel) and try to bend them. Each ruler ill show torsion, similar to the effect of scoliosis.” (K.F Schlegel, Prof. of Orthopaedics, Essen.) Before starting the next exercise, the ‘muscle cylinder", the patient should observe his lumbar spine carefully. Practising getting down into starting position as well as ‘getting up has to be performed carey. Its important to be aware of the leg that leads to getting up or down, nattention at this point may lead fo reversing the ex reise results, No problem arises when one gets up or down with both legs at the same time, Most often the patient will use the ‘comfortable’ leg: the Jeg on the concave side, to go down, and the convex- sided leg to get up. This will increase the lumbar con- vexity. (Figs. 105, 106). It is most important to practise between two mirrors From standing position to knecling: 1. Kneeling: leg of convex side starts the movement. 2. Simultaneously leaning trunk to concave side and extending leg on convex side, 43, Ending: first pull leg towards body and bring trunk. into upright position, 44, Standing up: foot (leg) on the concave side starts the movement Fig, 104 (Drawing by Lebner-Sehoti) Goal of exercise treatment isthe activation of mu: lature below the convesity by forcing it to ‘work’ into a corrective position. Exercise to increase the tonus of M. quadr: tus lumborum and of deeper holding musect: ture in three-curve scoliosis (muscle eylinder) (Figs. 107 and 108) Kneeling or standing position; hands on hips; pelvis up- right; trunk leaning over to concave side (do not tend ‘over!). Leg on the convex side is stretched out, rotated. outwards and placed laterally. The leg and upper body form ont straight Tine, The hip on the concave side is contracted to the midline ("ke 3d pelvie correction) and rotated forwards (4th pelsie correction); extended pushes hip caudally a the same time (Sth pelvic correc: tion). These pelvie corrections force the M. quadratus Tumborum to work, The following is happening: 1. The previously atrophic part of the lumbar muscula- tute begins to work again and to develop powerfully 2. The fumbar spine moves back to the midline again because the concavity is released fram pressure, 3. Thetransverse processes ofthe lumbar vertebrae, from 4Fig, 106: Teitlcekoceting Gncorec), Right eg kneeling (come. which the M, quadratus lumborum originates, rotate sideways ~ in some eases even alittle backwards. 4, This musculature and all other muscles which have ‘arophied due to scoliotic torsion are now forced to support the weight ofthe upper trunk. They are acti- ‘ated and increase in length and strength. “The upper body, which is positioned diagonally, should now perform very tiny up-and-down movements so a to stimulate the inactive lumbar muscles specifically. It js always better to perform tiny movements than Targe, impressive-looking ones that are incorrect. ‘A glance in the mirror will immediately indicate that the ‘shoulder countermove" (Fig. 107) is now required in addition. However, what has been described above is just the starting position. Next come the rotational angular breathing movements with the deliberate lowering of the diaphragm in each case Each strengthening exercise should be followed by a break to allow recovery. Patients with four-curve scoliosis exescise these i waist muscles differenly (ection C. VII, Exerc correct the lumbosacral curvature and scoliotic y while still making the inactive waist muscles work “This exercise rapidly produces a good muscular bse ‘of the entire musculature below the thoracic conse In this corrected starting position, the differe paedic RAB techniques may be applic’, besi the vertices of the wedges. Simulizncously, the segments above and below are counter-held and ¢ éer counteraction is applied (Figs. 44, 107, an Exception: (Fig. 109). If the main curvature i= tow, extending into the lumbar region, there is no 2=0- phic musculature below the rib hump. Therefore ‘muscles donot have tobe activated. They ae suppested bya pole which the patient pushes with the hand che concave sie into the floor. Thus the concavit and space is created for eorective breathing. 3, ERECTOR TRUNCI (M. LONGISsINtS DORSI; M. 1:10 [COSTALIS), THE BACK EXTENSORS (FiG. UL Axo 112) ‘These are two overlapping longitudinal muscles, ocsted ‘on both sides of the spine. The M. iliocostalis is évided into lumbar, thoracic and cervical segments. T+ M. longissimus dorsi is divided into M. longissimus Zorsi, M. longissimus cevices, and M. longissimus ca Contracting the erector trunci bilaterally results is an clongation of the spine which pushes the ribs forsards (elongation of the thoracic spine). Unilateral contraction Of the M. iliocostalis can also produce lateral flexion of the rib cage. In the ease of scoliosis, these two are also out of balance. Their activity and length !on~ got fulfil its function and allows the lumbar curs increase and the Fibs to shift more and more ver: moma a ib valley’ may also appear due to insufficiency of the lumbar part of the M. erector trini, Insertions fof this muscle ~ the ribs onthe concave side ~ can now shift ventrally “Tee insufficiens thoracie parton the right side cannot compensate in the long run (weight of the head, neck and shoulder girdle hanging over tothe Fe), and gives way to the ribs on the convex side to move backwards ‘The situation is similar in the cervical region. Compen- satory bending of the cervical spine to the right over stretches the le cervical part of this muscle. Weakened by pathological overstretching, this muscle will also not ‘be able to uphold the weight ofthe head in the Tong run and it wil not be able to counteract curvature of the cer- Fig. a= mons dorsi Ibm. longissimus cerviis 49Fig. 13 “Tn torsion relationships ofthe solo spne, wlth rsulantsteength- ening ofthe muscles on the convex side. These left lumbar spinal ‘rector muscles are overly song, thus the righ thorcie group be- sronger es wel, and finaly the left cervical group resulting in 1 thres-cuve scoliosis posture. (Drawing: Lehnet‘Shrot) vical spine. The goal of our exercises has to be reversal of the scoliotic balance of the body. We start with cor- rection of the lumbar and pelvic region, and strengthen the intrinsic part of M. erectortrunci because of its abil- ity to derotate the lumbar spine. This activates the left part of M. erectortrunci because it is now in an almost novinal pre-streched position, This allows corrective static changes to the posture. ‘The right-sided thoracic part ofthis muscle can, with the help of RAB, move the ribs on the convex side ventrally andl thus the eoncave-sided ribs dorsally. Be careful not to enhance flatback, and always exercise into extension ‘and elongation to make derotation possible Shortened parts of this muscle on the left side ate stretched by spreading the ribs and then using RAB to make space for the ventrally sunken ribs and to enable the thoracie lordasis to move dorsally Exercise treatment has the goal of creating muscular balance inall segments. We start with the lumbar region, then the cranial segments follow automatically ‘As mentioned above, exercise always starts with active elongation, which leads automatically to deflexion Sy 50 and ercates room for derotation of the pelvis, ribeage and shoulder girdle, All corrective measures are then stabilized by a final ‘muscle mantle’, a firm contrac- tion of all thoracic muscles. In the end, all muscles are strengthened, those on the coneave side and those on the convex. Continuous repetition facilitates corrected posture. The ‘observation point may be the septum of the M. latissi- mus. It shows activation during the stabilization phase 6on both sides, and demonstrates that the overstretched. and shortened lateral musculature is activated to achieve its physiological length. The left-sided lumbar part of the erector trunci holds the laterally shifted trunk and has a static holding function. ‘The same muscle is shortened on the right side. Looking atthe intrinsic lambar parts of the M. erector spinae (Figs. 113, 127 and 128), we see that itis over stretched inthe right-sided lumbar region and shortened on the left because of its dorsoventral direction from pelvic crest to the transverse processes. One may eon tinue to theorise: it might be thatthe intrinsic muscula- ture does not show either shortening or overstretching because of the many ligaments. This seems logical be~ cause of ts dorsoventral direction. The fact is: the right sided lumbar partis shortened and needs to be elongated ‘or stretched. The right-sided thoracic part of the erector trunci holds the shoulder girdle, which shifts over to the concave side. Tis is especially the ease when weight is carried on one side. ‘The same muscle on the right side is shortened. ‘The left-sided cervical part of the erector trunci holds the head, which hangs over to the right. This muscle also has a static function in this overstretched position. ‘On the right, these muscles have shortened. Reversal of these faulty static relationships must begin in the lower segment by creating opposite relationships. We strengthen and activate the static function of the right- side lumbar part of the erectortrunci During the exercise, this muscle should activate more ‘on one side than on the other, This means a correction ‘across the midline, or overcorrection. The patient has to develop a strong ‘muscle mantle’. Exercise treatment reproduces muscular balance in all segments, starfing atthe lumbar region. Other segments follow automaticaly. Exercise influencing all segments correctively: “Ro- tational sitting” (Fig, 115) Omit in the case of four-curve scoliosis. Sit on a chair. Leg.on the thoracal convex side is extended backwards and rotated so the instep of the foot touches the floor. ‘This heel pushes backwards and downwards. The other {eg in fiont, knee bent, forming a right angle. Upper body leaning (not bending!) forwards forming one line with the extended leg. Bodyweight rests on the hip of the concave side. A cushion in front of the hip on the convex side (hese are all 5 pelvic corrections!) mocoro girl with sigh-sisd! dora kyphosctios and @ mark- cy twisted compensator lobar cure. Lambar surface ratio 1:2 ig. us “The same patie pesforing otis siting. This exercise i not sed for fourcure solos “The upper body Teans obliquely to the concave side with- ‘out narrowing it (this strengthens inactive musculature below the thoracic convexity), The head pulls into the same diteetion (a compensation for cervical scotiosis); the chin is turned 0 the convex sie (activating unilateral aveak neck musculature » intensified by vcight carying ivi). Gives derotation impulse tothe cervical spine 114 shows éfewrly how tir the lumbar spine has shifted from the midline, spine approaching the midline and 2) activation ofthe Tumbar segment of the ersetor tunci. Fig. 117 shows Fig. 16 “The same patient dong he same exercise viewed from bid. Lum bar surface ratio: 25:35, severe scoliosis in a 24-year-old female patient with very restricted movement and VC. Her left side is com- pletely atrophied anteriorly, laterally and posteriorly. The very pronounced rib hump depresses the lumbar musculature on the right as well as the false ribs, and creates deep furrow. ‘The sitting position described above is only a starting position for RAB, which always begins in the concave areas (vertices of wedges) and is combined with con- ‘scious depression of the diaphragm: 1. Convex side: floating ribs sideways and upward, and backward and upward (laterally and cranially, dorsally and craially).. 2. Concave side: sideways and upward and backward, and upward. 3. Convex side, ventral: forward and upward (ventrally and cranially). 4, Subaxillary ribs on the convex side: forward and up- ward with counterhold of aligned shoulder girdle in a horizontal direction — obliquely outward, upward and backward (Ihe shoulder countertraction, Fig. 44), Shoulder girdle is rotated en bloc agaist the rib cage. Attention: shoulder girdle During these exereises the trunk has to lean towards the ‘concave side at all times and to be widened or ‘opened’. ‘There isthe danger of pulling with the shoulder on the ‘coneave side. This is not necessary and in most cases even wrong. Forced lifting of the shoulder girdle will slig. 107s Very sever selisis, 2-year patent create a cervical curve automatically. The concavity is widened by breathing ito it and keeping the width by isometric tension: During rotational sitting, for ex- ample, the arm of the concave side pushes against the back of the seat or a table after correction of all three trunk segments. The shoulder is not lifted, but has to be brought forwards actively. RAB moves the concave ribs part and back'vards and upwards this Tift the shoulder ‘This way they Form a halding and supporting posterior wall (Figs. 98 and 120). 4, My aniorsoss (Fic. 125 ano 126) “The muscle consists ofthe M. psoas major, M. psoas mi- nor and the M.iiacus, We believe that these muscles are mainly responsible for derotating the lumbar vertebrae daring our exercises. Kapangji gives a vivid deseription ofthis muscle andits effect in healthy people: “As M, iliopsoas, i isthe strongest flexor in any posi- tion, ‘The M., psoas major's longitudinal fibres have @ reat lifting capacity. This muscle is positioned ventral- Iy to the M. quadeatus lumborum. It has two origins: deep portion at the transverse processes of the lumbar vertebrae, a superficial one atthe vertebral body of T12 ‘and the lumbar vertebrae; aimed at the upper and lower eadges of two neighbouring bodies of vertebrae, as well as the corresponding dis, which serves as the area of origin. The muscle pulls obliquely downward and later ally int the pelvis, It nestles against the inside of the hip bone. The ligament ofthe muscle fastens tothe tip ofthe trochanter minor (inside of the thigh). When the hip joint 4s fixed (the fxed point at the thigh), this muscle has a reat impact on the lumbar spine. It effects lateral move- rent tothe side of the contraction and at the same time rotation tothe opposite side. Since the muscle originates atthe apex of the lumbar lordosis, it also creates ventral flexion in relation to the pelvis. It creates hypertordosis inthe lumbar spine”, 2 Fig 18: Same paentar hee courses of Fig 118: The sam ‘weanent (3 months eae). i ied cours of Fig. 120: The above patient during exercise wing mor cont What good is allthis theory? Everything is different in a scolitie body. There are synergistic and antagonistic effects in the abdominal musculature and autonomous back musculature. Thus itis impossible to describe the effect of only one muscle during ourexercises. There isa derotational momentum duc to the muscle attachment st the frontal region of the vertebral body. Inthe following isometric exercises, this muscle does tremendous work ‘while being elongated (as inthe ‘muscle eyfinder” exer cise). This may neutralize the hyperlordatie effect in the lumbar convexity. The tain of thought deseribed here cannot completely explain the corrective effect. There is no better teacher than observed facts. (Figs. $48 - 565) 12o ___ protuberantia cceipilalis externa _- Slernocleidomastoideus splenius capitis Splenias capitis vertebra promincens spina seapulae Dettoidens + faseia alissinus dorsi Teres major ff fascia infraspinata / Rhowboidens wijor fetes thorae. 0 Eetete tan | taming posterior Obtiguus- “Jasciae lumbodorsalis abdominis externus trigonun twnbate” cristae ittace facies dorsuli vig. 21 33 sR SE ETE 1 PRSCTIcapitis apilis posterior reajor capitis superior =-Obligans capitis inferior Longissinins capitis Sesispi Splenins cervicis spinalis capitis Miocostatis cervicis Semispinatis Longissimas cme Rhomboidens Hiocostalis major X. ‘dorsi *Sacrospinalisx, Sispinatis dorsi Servatus anterior ‘Levatores costarum Spinalis dor » Levator costae longus Mallfidus tuncboram asia tumbodorealis, Fina auterior Hiocostatis tumboruti ntertransversarii Iederates ~Obtiquas abdominis ext. Longissimus dorsi Lendines accesso . am longissiné dorsi ‘Sacrospinalis x ‘fascia tumbodorsalis, vets famina posterior vara postions, Longiesines ia iiorostatis fimborom Fig. 2 43: Seatiatic skeleton (dorsal view) for tne avonamous muscles come directly from the spi hd innervate dirty: M, icostais,M. longissimus, Msi sere alm rtstorc, Min, inleransessai, and M. eretor spine. Conparing te above figures, one can visualise how these inne ceaapa must have bec pulled and twisted in the solotie body, snd Treacy av rated Gyrasticexeeises that dette the thorax wea the pelvic and shoulder gids may wall re these sted Te Nnebedd nerves ant relieve lepton’ pi 5, Irransie muscurarene: (Figs, 127 asp 128) intosh and Bogduk (1987) found that the M. longis+ 's dorsi andl M. iliocostalis (crector spinae) have an asic Ingnbar pat, The intrinsic lumbar musculature fof M. erector spinae originates on the dorsal parts of the iliac crests and the dorsal upper spi transverse processes ofthe humbair vertebrac, In Junnbar s, the spingus processes rotate toward the interi- or side of the arch (Concavity), The transverse processes move ventrally on the concave side, thus inereasing the sistance from posterior ite spine to the transwerse pro- 55‘wochenter minor Fig, 126: frontal view (drawing . Adler) cess of the lumbar vertebra. This means stretching of this muscle group on the concave side and shortening ‘on the convex side, ‘We may draw the following conclusions for Schroth corrections fiom these biomechanical facts. t has been shown that lateral stabilization (as in lateral flexion, for example) is created significantly more by lateral parts of the autonomous back musculature than by medial parts (M. multfidus and rotatores). Looking at the muscle ey!- inxder exercise, we observe this when leaning over toward the concave side. Activity of intrinsic lumbar muscula- ture of the M, erecior spinae inereases more than that ‘of M, multfidus at the same height on the convex side, ‘Ts this muscle will untwis lambar transverse process- 5 which have been twisted ventrally on the convex and, in adeition, straighen the lumbar eurvature. We find ro such an oblique direction ofthe M. erector spinac the thoracie region, but rather a more parallel alignment to the axis organ, Increased activity on the thoracic con- vex side is visible here as well 56 * Fig. 128 Schema epresenaton ofthe file of he Mi Tonge simus thoracis pars lanboro. FascclesI-4 have log endl tendons which form the lamba apoeross The Bcien lines show the cranial tachment, az La Fig 19 ‘Acconding to biomechanical faets, we find here a ten- ddoncy to lateral straightening of the curvature and a ‘straightening of the thoracic convexity, above which the M. ereetor spinac is stretched. However, if torsion is 100 pronounced, the opposite effect may take place, if the thoracic convex-sided M. erector spinae pushes ‘noross the arch vertex on the thoracic concave side. In this case, preliminary corrections have to be made so that the origin and insestion points of the autonomous musculature are brought closer so that the above effect does not occur, 6, Monarissiaes Dous! (Fics. 129 anv 130) “This musele originates from the spinous processes of “76-12, extends laterally and cranially, and has its point ‘of atiachment on the tuberculum minotis of the upper fim, It has a flat insertion at the lower inferior angle Of the scapula by which the latter is held to the ribs, Through inactivity of museutature, the lower angle of the seapuila does not receive pressure and can deviate backwards, A wing-shaped prominent scaputa results (Geaputa alata). Th scoliosis (Fig. 130), this muscle is active only nilatcrally or isshortened, On the side ofthe dorsal con Fig. 130 cavity, it may press the lower angle of the scapula against the ribs in a way that it forces thein to deviate forwards. “Then, the upper border ofthe scapula becomes prominent posteriorly beyond the normal position, On the convex: side, this musele is overstretched and allows the ribs to ‘sag backwards (Fig. 131). The lower angle of the scapula is lifted backwards and upwards, and the entire scape 4a tums in its upper part forwards. As the outer part of shoulder level has been brought forward, the rib hump increases in a way that its cranial part often lies hori zontally (Figs. 17, 23). Due to the three torsions of the nk, the septa of the M. latisinnus dorsi are no longs lateral, but have deviated in the middle and lower trunk segiients, The M.latissimus dorsi is short on the concave side and long on the convex side (Fig. 468). Exereise treatment has to elongate the muscle on the concave side first, then activate itt cofully. On the ‘convex side, it has to be forced to cont together with the M, serratus lateralis. Ths is only possible after cor- reeting the three torsions of the trun: Exercise: Small cranial oscillatory srovements upwards betiveen two poles (Figs. 69, 61) Sitting on the ischial uberosities. Corrective cushions, Upper body leaning forward and sideways towards theconcave side. The patient's spineis straightened by con- tinuous small wriggling movements, since a derotation of individual rotated trunk segments is only possible afier straightening the trunk. Maintaining the corrected position of shoulder girdle, the poles are pushed into the ‘ground. The oscillatory movements upwards (straight- ening of the back) have to be slow and allow intense concentration on the concave arcas of the trunk. Only ‘fier this can RAB exercises begin. During exhalation this result is stabilized by isometric tension and a muscle ‘mantle. The position is then correct for the next inhala~ tion. The second side of the ‘right angle" always runs cranially to give the spinal column maximum length and elongation. Additionally, an occipital neck clone tion musculature inereases the stisightening effect. Having reachod best possible height, the poles are pushed against the floor during exhalation. The pelvis, tmight lift bit from the floor. The corrected hip below the convexity should push forcefully towards the floor as well, Once the margin of the M. latissimus dorsi ac~ tivates on both sides, the concave side is sufficiently stretched and the Taterally overhanging convexity is tensed'and contracted. 7. Ma. Scauent (Fic. 133) ‘The function of these muscles is to elevate the Ist and ‘onto which they insert. In kyphosis of the upper thoracie spine, they are partly inactive, Consequently, first two ribs have lowered anteriorly, narrowing the ices of the lungs. The back deviates dorsally and cr tially. The head sinks forward. The same is present scoliosis, but is often worse on one side. Exercise treatment has to train the Mm. scaleni to bring, the upper chest forward and widen the apices of lungs. again, Succeeding in this brings the protruding parts of the upper back forwards and flattens the kyphosis (Figs. 280-287), Isometric head and neck elongation exercise Omit in case of cervical kyphosis or flatback (Fig. 295). Supine position, Corrective cushions. The hollow parts Of the back are brought in contact with the floor from caudal to cranial, This is done by performing small, os~ cillatory movements with the spine in combination with RAB. An additional occipital push elongates the cervical spine even further. During exhelation, the patient pushes the head and elbows against the floor. This eontracts the upper back, and the shoulder giedle lifts slightly from the floor, At the same time, minimal contractions of the dor~ sal intercostal musculature (“pulling it together") are per- formed. A short resting period follows, then the exerci is repeated, ‘Additional Exercise: Figs 288-290 Same starting position as before, except the head is turned alternately to loft and right. The patient soon notices which rotation is more difficult. That side is then ‘exereised more often. In the ease of scoliosis, the head hus to be bent in continuation ofthe main curvature to the concave side, with the chin pointing to convex side. = There are exceptions This isan essential exercise and has to be practised in the supine position. sitting up, standing, and with or ‘without wall resistance. The section on exercises shows tore neck exercises aimed at individual muscles. Dur ao o Fig, 134 ing all exercises, the information given here should be taken into consideration. It is very’ important, since the position of the head is an essential element in good or bad posture. It makes the rib hump appear either larger or smaller. Uninterrupted transition of the thoracie spine to the cervieal spine up to the occiput is of special im- portance, 8, Pecronat, susctes (Fras. 134, 589, 599) “The pectoral muscles pull shoulders forward, particu lay in scotios! gonists (M. trapezitis; Mim. rhomboidei) have lost their tone. The more the later are ‘weakened, the more the shoulder girdle is brought for- ward and the apices of lungs ure inhibited. Exercise treatment has fo counteract this process, Only after the pectoral muscles have been Tengthened sufficiently are the upper back muscles in a position to contract, beeause they are no longer restricted from the font (sce Part C). Exercise: ‘The starting position is the fow-sliding post tion (Fig, 81) Corrective cushions. Kneeling, thighs at right angles, trunk and arms in one fine, stretched for ‘wards, hands on the floor. In lumbar hyperlordosis, the pelvis is pulled back a litle towards the ect (caudally). Ta order to steeteh all pectoral muscle fibres, the ex tended arms glide gradually more and more sideways, reaching a diagonal position. The position of the arms svhich produces the strongest stretching effect is main- tained, The patient performs sinall oscillatory sos ments to elongate the spine tn scoliosis, the trunk leans towards the concave side, the hip below the-thoracic convexity pulls caudally Citeles ae performed with the narrow front (especially ‘by subaxillary ribs). Omit this exercise in case of fat- k. when ant Fig. 135: Setematic representa tion of the skeen: siting on the iehil eos, 9, Cocesx axo iscutaL Tuntnostries (Fic, 135 ~143) Tis not unimportant how someone with scoliosis or mal posture sits, because the visual impression they make ‘depends on this. The size of the rib hump may seem larger. Sitting on the coceyx might round the lumbar spine, but it also has an effect on the back, Its the same as bending over. The abdomen protrudes forwards, the chest sinks ventrally, and breathing is inhibited. Sitting ‘on the ischial tuberosities causes a more upright posi- tion, leading to elongation ofthe spine and fattening of the convenities. Sitting on the coccyx indicates fatigue of the body and Tack of support. Asking the patient to sit straight up will result in straightening fora short period only, and it w bee very tense. Sitting on the ischial tuberosities, on the contrary, is done without strain, asi isa natural position. Figs. 142 and 143 show sitting on the coceyx and ischial tulberosites in scoliosis, viewed from the back: 2) in the presence of a dorsally overhanging rib huinp, the spinal curvatures and torsions arc + creased by the spine in a more upright position w ith curvatures straightened “These ae reasons why the patient shouldbe careful about silting posture at table, in school, at work, or during Iei- sure time, Since we st for long periods, itis obvious that the sitting position is important for the back. Each min- tte of wrong siting or crouching may be compared with 9ig. Fig the coccyx produces ypbotictsnbar Spine abyss inthe thoracic reson. sine an inadequate exercise. Poor posture of many years can not be changed if one fall back into a ‘relie? position. 1 facilitates wrong movement and old postural patterns. “These pattems have to be changed immediately. It is “quite casy because there are “Tifting”fores within in- tervertebral dies which help straightening up. Once the patient has a clear picture ofthis, the wrong postre will be avoided at all times, Striving for an upright position wil Keg to better health and strength 60 Siting on the ischial tuberosi- ties produces straightening of the entire Fig. 1st: Correct. “The patient has to live with scoliosis. It is important to ‘overcome this handicap now and strive for an upright posture which will eventually influence the spinal ecl- tim, and this fs of mest importance while sitting maa U i ofthe ribs at thors veebra Viewed font hows the Hgamients. 10. FLostise nuns (Fics. 150, 152, 47) Ribs 11 and 12 end laterally in soft tissue musculature. Tay run almost horizontally, In severe scoliosis, these tsvo ribs reach vertically into the abdomen because the sofi tissue museulature docs not offer support and is rurophie. The weight of the overhanging rib hump pro- duces a deep fold, The lumbar spine is displaced and rrished over to the opposite side Fig, 148: Results ofehanged pressure ad pling in severe kyposso- Toss with ott bone tissue. Bxeretse treatment has to retum these two ribs to their designated place to enable them to fill the waist segment ‘below the rib hump and to support Bxercise: (Figs, 150 and 152) fingers push into the fold beneath rib hump until they feel ribs. They offer resistance, against which the patient breathes sideways ‘and upwards while lowering the diaphragm. Fig. 152 dlemonstrates how spinal curvatures straighten. The Thea touches the pote above it. Variation: splayed log and laterally eaning trunk (Fig. 181 Late :a LV, Summary of the physical corrections using the Schroth method for three-curve s “The term “thee-curve’ originates from the three shifted blocks of the trunk that each pull the spine to their sige “The basis of correction is always a properly aligned pelvis and correction of the body statics in all three planes. First pelvic correction “The entive pelvis is moved backwards, which consti- tutes a correction of statics in the sagittal plane, Second pelvic correction Lift anterior pelvie Fim; pelvis horizontal. This achieves delordosation of kumbar spine and correction in the s23~ ittal plane about the frontal ais ‘Third pelvic correction Patling in the prominent hip on the concave side con tracts the musculature in the area of the major trockant= cr The result is lateral shifting of pelvis and correction lof statics in the frontal plane. If there is no prominent hip, the third correction is omitted Fourth pelvic correction Pelvis on convex side moved backwards, hip on con- ‘cave side forwards. This corrects pelvic distortion and the twisted lumbar spine, and results in correction in the transverse plane around the longitudinal axis, Fifth pelvie correction Heel on the convex side is pushed against the ground ‘This lowers the pelvis on the convex side, defleses the umbar spine with accompanying derotation of lumbar spine, snd results in correction around the sagittal axis Standing, it is necessary to perform these pelvic cor rections with the weight of the body on the leg of the concave side. If the weight is not shifted to on¢ ie not possible to accomplish satisfactory correction of the scolidtie statics in the frontal plane, ‘nce the pelvie position has been corrected, attention is, paid to active elongation ofthe spine. Ths is achieved by lateral deflexion of the thoracic eurve towards the concave side. TTS is followed by active derotation of the thoracic spival region, supported by contraction of the intercostal museles on the convex side. RAB is then -oliosis performed: forwards and upwards on the conves side, and backwards and upwards on the concave side, Counterrotation {0 achieve correction has to be per formed with the shoulder girdle: the convex-sided shoulder is moved backwards and the coneave-sided ‘one forwards (exactly like the pelvis). Additional shift- ing of the entire shoulder girdle to the convex side is algo necessary (shoulder counteriraction). The correc- tive effect ison the upper spinal curve and also on body staties in the frontal plane. ‘The culmination of the corrective procedure lies in an orderly alignment ofthe head, which in logical sequ is inclined towards the thoracic concave side to defiex. the cervical spine, and the chin is turned to the thoracic convex side to derotate the cervical spine. Thus the tho- racic spinal curvature is further extended. ‘The optimal preconditions for RAB are not present un- til all of these corrections have been made. The pelvic ccoxrcetions therefore constitute the basis of the Schroth rotational breathing procedure. Using dircetional breathing inthis way, the floating ribs on the convex side are moved sideways and upwards and backwards and upwards (laterally and cranially and

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