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12 Current Pediatric Reviews, 2016, 12, 12-16

Postural Re-Education of Scoliosis - State of the Art (Mini-review)

Maksym Borysov1, Marc Moramarco2, Ng SY*,3 and Sang G. Lee4

1
Orttech-plus Rehabilitation Services, Kharkov, Ukraine; 2Scoliosis 3DC, Woburn, MA, USA;
3
Wanchai Chiropractic Clinic, Wanchai, Hong Kong; 3Power Schroth Corrective Exercise Center,
Seoul, South Korea

Abstract: A new development of correcting exercises has been derived from the original Schroth pro-
gram in 2010 and the preliminary results have been published that year. Since then the program has
been applied in some centers worldwide.
As the original Schroth program was the only program so far to improve many signs and symptoms of
scoliosis besides the angle of curvature (Cobb angle) it was interesting to look for the preliminary re- Ng SY
sults of the recent development of scoliosis pattern specific corrective exercises derived from the
original program, to see if similar effects can be achieved with this less complicated method.
Methods: A manual search in Pubmed was conducted, using the key words, Schroth, rehabilitation, and idiopathic scolio-
sis. Three papers have been found describing the short-term results of this new development today called Schroth Best
Practice program (SBP). The papers were reviewed and analyzed with respect to the outcome parameters used.
Results: Outcome parameters were Angle of Trunk Rotation (ATR), Vital Capacity (VC), surface topography, electromy-
ography, stabilometry and Cobb angle before and after a course of treatment. There was a significant improvement of all
parameters after the application of this new program in all the three papers in the short- to mid-term.
Conclusions: Scoliosis corrective exercises are supported by two randomized controlled trials (RCT) and should regularly
be applied in mild scoliosis at risk for progression. Unspecific exercises such as Yoga, Dobomed cannot be regarded as ef-
fective as exercises using a well defined scoliosis pattern specific corrective routine.
Keywords: Activities of daily living, rehabilitation, scoliosis, specific exercises.

INTRODUCTION
Scoliosis is a three dimensional deformity of the spine
and trunk. Although many rare causes are known, most of
the patients affected are suffering from Adolescent Idio-
pathic Scoliosis (AIS) [1, 2]. AIS is also known as late onset
scoliosis as it appears during the pubertal growth spurt,
mainly in girls [3].
Conservative management of scoliosis is applied for
more that 2000 years [4]. The recent history and the latest
developments are described in a textbook [5].
Treatment consists of (1) physical rehabilitation, (2)
brace treatment and (3) spinal fusion surgery [1].
Physical rehabilitation as the sole form of treatment in
mild scoliosis is supported by a Cochrane review, a prospec-
tive controlled trial and three RCTs [6-10]. Although many
papers have shown that physical rehabilitation / physiother-
apy is effective in the treatment of AIS, the validity of con-
clusion of majority of the papers has to be accepted with
some reservation, as the the treatment indications in many of
*Address correspondence to this author at the Wanchai Chiropractic Centre,
11/fl China Hong Kong Tower, 8 Hennessy Road, Wanchai, Hong Kong;
Tel: 852-39983208; Fax: 852-39983222; E-mail: ngshuyanhcc@gmail.com
the papers were improper [11]. Out of the 19 published pa-
pers examined, only 7 studies (38%) consisted of patients
samples having a risk of progression exceeding 40% and
requiring treatment [11]. Some studies investigated imma-
ture patient samples with curvatures of less than 15° not yet
in the range of requiring treatment. Also, some had patients
sample who were already mature at the start of the study, and
did not need any treatment at all [11].
Many different approaches are promoted. Most of these
are not supported by high level of evidence. Some treatment
protocols mainly aim at specific curvature correction (Side-
shift, Self Correction Exercises (SCE), SEAS, Schroth,
Schroth Best Practice), the others use general exercises
without a defined correction procedure (Yoga, Dobomed)
[5]. Exercises that correct specific curvature aim at reducing
specific scoliotic curves during the exercises ; the corrective
movements are dictated by the level of the curvatures, shift
of the pelvis and whether the curves are single or double
(Table 1).
In brace treatment the corrective effect of a brace deter-
mines the outcome [12]. Therefore we can assume that also
with exercises the corrective effect plays an important role, a
claim supported by a RCT comparing correcting exercises
vs. unspecific exercises [9].

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Postural Re-Education of Scoliosis Current Pediatric Reviews, 2016, Vol. 12, No. 1 13

Table 1. The principles of different physiotherapeutic scoliosis specific exercises.

Types of Scoliosis Pat-

Principle of the Exercises Remarks
Exercises tern Specific

Active self Yes Based on Ponseti classification of scoliosis. Corrective movements depend on Predominantly to neutral position
correction the types of scoliosis curve and sagittal profile; out patient treatment

Schroth Yes Based on Lehert Schroth augmented classification. Scoliosis curves are divided Predominantly to neutral position
into two types viz. types 3 and 4 for exercises; uses rotational breathing; in
patient treatment.

Schroth Best Yes Based on Lehert Schroth augmented classification. Scoliosis curves are divided Depending on the flexibility of
Practice into two types, viz. types 3 and 4 for exercises; out patient treatment patient, over-correction is possible

Side shift Yes Based on types of curves. Exercises differ in thoracic, thoracolumbar/lumbar Depending on the flexibility of
and double curves patient, over-correction is possible

Dobomed No Address sagittal profile, with stable shoulder and pelvis girdle; uses rotational Do not correct the coronal curve
breathing; out patient treatment

SEAS No Exercises not defined on the basis of a curve pattern. No specific exercises for Predominantly to neutral position
lumbar or thoracic scoliosis; out patient treatment

Side-shift [13, 14], Self Correction Exercises (SCE)
[9] and the old Schroth program (Barcelona school or
original Schroth) [7, 15] implement specific correction to
some extent. In these schools the exercises are meant to
finally produce the result. Without a doubt it has been
shown that these approaches are efficient, but mostly time
consuming [5].
A new development of corrective exercises has been de-
rived from the original Schroth program in 2010 and the pre-
liminary results have been published that year [16]. Since
then the program has been applied in some centers world-
wide.
As the original Schroth program was the only program so
far to improve many signs and symptoms of scoliosis besides
the angle of curvature (Cobb angle) [5] it was interesting to
look for the preliminary results of the recent development of
pattern specific corrective exercises derived from the original
to see if similar effects can be achieved.
METHODS
A manual search in Pubmed was conducted, using the
key words, Schroth, rehabilitation, and idiopathic scoliosis.
This generated 36 papers. Key words search using idiopathic
scoliosis and specific exercises generated another 35 papers.
These were reviewed. Three independent papers [17-19]
describing the short-term results of this new development
today called Schroth Best Practice program (SBP) [17-19]
were found and reviewed.
The papers were analyzed with respect to the outcome
parameters used.
RESULTS
Outcome parameters included Angle of Trunk Rotation
(ATR), Vital Capacity (VC), surface topography, electromy-
ography, stabilometry and Cobb angle before and after a
course of treatment.
There was a significant improvement of all parameters
after the application of this new program in all the three pa-
pers in the short- to mid-term [17-19].
DISCUSSION
The results presented here demonstrate that comparable
or even better results are achievable with this short program
when compared to the original Schroth method [17-19]. All
parameters in the three independent studies made on an out-
patient basis have been improved to the same or even a better
extent than that found after an in-patient program lasting 4 –
6 weeks. In the study by Lee the subgroup of patients with
larger curvatures (exceeding 30°) the Cobb angle corrected
about twice as much as during in-patient rehabilitation in a
comparable sample of patients [19].
We now have high level evidence (RCT) that pattern
specific corrective exercises have a better effect than unspe-
cific exercises and observation [9, 10]. One randomized con-
trolled study compared the effect of active self correction
and task-oriented spinal exercises with traditional spinal ex-
ercises in patients with mild adolescent idiopathic scoliosis,
with Cobb’s angle less than 25o [9]. Outcome measures one
year later showed that the training in the intervention group
led to a significant improvement (decrease in Cobb angle of
5o), whereas the control group remained stable [9]. Thus
scoliosis pattern specific exercises are superior to traditional
exercises which are unspecific exercises in reducing spinal
deformities in patients with mild AIS [9]. The other random-
ized controlled study evaluated the effectiveness of Schroth
exercises in the treatment of AIS [10]. 45 patients with AIS
were randomized into three groups, each with 15 patients.
The intervention group performed Schroth exercises under
physiotherapist supervision for 6 weeks and continued to do
the exercises at home. The second group did the Schroth
exercises at home, after they were taught the exercises by a
physiotherapist. The third group was treated by observation
[10]. At the conclusion of the study at 24 weeks, evaluation
showed that the Cobb angle and angle of trunk rotation im-
14 Current Pediatric Reviews, 2016, Vol. 12, No. 1 Borysov et al.

proved significantly in the intervention group, when com-
pared with the other two groups [10]. This suggested that
scoliosis pattern specific exercises are superior to observa-
tion in the treatment of adolescent idiopathic scoliosis.
Also in bracing we do know that correction in the brace
is crucial to the outcome [12]. Therefore we should adopt
corrective exercises that address specific curvature patterns
and reduce scoliotic curves, rather than general exercises,
such as Yoga and Dobomed that do not address the scoliotic
curves directly [5].
Scoliosis patients should only be taught efficient methods
and these are clearly the ones with a well defined corrective
routine [5, 7, 9, 14]. More than that, within the Schroth Best
Practice program [5, 16-19] (Figs. 1, 2) the patients learn to
correct their activities of daily living (ADLs) which allows a
full day prevention of curvature stimulating behavior. Cor-
rect postures can be adopted during sitting, standing, sleep-
ing and when performing daily activities such as brushing
the teeth. These corrective postures are also scoliosis pattern
specific, taking into account the pelvic shift and the types of
scoliosis curve (Table 2).
The average scoliosis patient does not suffer from distur-
bace of equilibrium and other neurological side effects other
than a functional tethering of the spinal cord [20, 21]. There-
fore we should focus on the best possible pattern specific
correction, an improved mobility of the spine and the neural
structures and what seems most important, on a pattern spe-
cific ADL training. Because what value could be an exercise
performed for 20 min/ day when the patients slumps into his
deformity for the rest of the day?

Fig. (1). Patient with right thoracic scoliosis (functional 3-curve pattern as seen on the left) performing the correction of ADL in sitting posi-
tion (right)[taken from 17].

Fig. (2). Patient with right thoracic scoliosis (functional 3-curve pattern as seen on the left) performing the‚ Door handle exercise' according
to the new‚ Power Schroth' principles (right). The corrected head alignment is not yet achieved but correction of the sagittal profile is already
visible [taken from 17].
Postural Re-Education of Scoliosis Current Pediatric Reviews, 2016, Vol. 12, No. 1 15

Table 2. Some of the corrective postures that should be adopted during daily activities in patients with idiopathic scoliosis.

Types of Curves (Basing on

Activities of Daily
Lehnert Schroth Augmented Position of the Pelvis
Corrective Movement

Living

Classification)

Sitting
4 curve
Pelvis shifts to the side of Lower the shifted pelvis (the side of thoracic convexity)
thoracic convexity
and translate the thoracic spine to side of concavity

3 curve
Pelvis shifts to the side of Lower the shifted pelvis (the side of thoracic concavity)
thoracic concavity
and translate the thoracic spine to side of concavity

Standing
4 curve
Pelvis shifts to the side of Lower the shifted pelvis (the side of thoracic convexity)
thoracic convexity
and translate the thoracic spine to side of concavity

3 curve
Pelvis shifts to the side of Lower the shifted pelvis (the side of thoracic concavity)
thoracic concavity
and translate the thoracic spine to side of concavity

Though the initial outcome of the Schroth Best Practice
Program is encouraging, the three independent studies have
their limitations. Two of the papers [17, 19] were a prospec-
tive short term cohort studies. The studies included patients
who were relatively skeletally mature. The average age of
patients in one study [17] was 13.7 years of age and that of
another [19] was 16 years of age. Also, the period of inter-
vention was short. One study involved exercising for 7 days
[17] and another for 2.9 months [19]. Also, there was no
follow up of the patients until 5 years after skeletal maturity.
The third study [18] evaluated patients before and after 6
weeks of the exercises using optical topography, electromy-
ography and stabilometry. Whether the improvement in out-
come can be maintained over a longer period of time, how-
ever, has not been studied. Also, whether adoption of cor-
rected postures in daily activities does reduce the asymmetri-
cal loading of the scoliotic spines and the resultant deformi-
ties remain to be studied. Thus whilst Schroth Best Practice
Program should be incorporated in clinical practice, further
studies are required to determine its effectiveness and effi-
cacy. Also, studies should be conducted to determine the
effectiveness of different physiotherapeutic scoliosis specific
exercises.
CONCLUSIONS
Corrective exercises are supported by two RCTs and
should regularly be applied in mild scoliosis at risk for pro-
gression.
Unspecific exercises like Yoga, Dobomed cannot be re-
garded as effective as exercises using a well defined pattern
specific corrective routine.
Scoliosis pattern specific corrective exercises in combi-
nation with corrected ADLs should be adopted in the treat-
ment of scoliosis.
CONFLICT OF INTEREST
The authors confirm that this article content has no con-
flict of interest.
ACKNOWLEDGEMENTS
Declared none.
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Received: February 25, 2015 Revised: July 22, 2015 Accepted: July 24, 2015