T.B. Grims(Ed.) :he TherapieanSal2e. In: Weiss fiR: art,63-64, 1992 /OS Press. 2008 2008Tileaulhorsand/OS Press.Allrighlsresen'etL scoliotic curve. Ilalian Journal of ninaryresults andworsH:aseanalysis 540. 1997. ression in idiopathic scoliosis patients sex-matchedcontrolledstudy.Pedialr 'ativeIytreated patientswithscoliosis. ~ m e n t on the prevalence ofsurgery in ion.6209-214.2003. It., Pflaum,Munich,2007 nthetreatmentofidiopathicscoliosis: or the spine in girls with idiopathic :/molInform. 2006;123904. tation: a controlled study ofmatched italion--the key 10 an improvementof -what do we know? A review ofthe nities. ISICOMilano,2007 --_... -..... ScientificExercisesApproachto Scoliosis (SEAS):Efficacy,Efficiencyand Innovation MicheleROMANO I , AlessandraNEGRINe,SilvanaPARZINe,and Stefano NEGRINI I ,2 IISICO(IlaliallScientificSpineIllstitllte), Via CarloCrivelli20, 20122Milan, Italy- michele.romano@isico.il 2CentroNegrinilSICO, Vigevano, Italy Abstract. SEAS isanacronym for "Scicntific Exercises Approach to Scoliosis", Main characteristics of SEAS are team approach and cognitive-behavioural approach because in our view these are two indispensable elements in chronic disease rehabilitation. In this article we describe the main differences between SEAS approach and other exercise techniques as well as theoretical bases and therapeutic goals. We illustrate practical application of SEAS concept and scientific results in order to reduce the patient's progress ofscoliosis so that a bracewould beneeded. Whencompared to usual care,improvement ofscoliosis parametersandbalance normalizationinscoliosispatients. KC)"1\"urds. Idiopathicscoliosis,physicalexercises,conservativetreatment 1.TheScientificExercisesApproachtoScoliosis SEAS isanacronymfor"ScientificExercisesApproachto Scoliosis"[3, 4].As weare used to seeinsoftwareproducts,aftertheacronymthereisadotfollowed byanumber, to indicate the protocol version and the year in which substantial changes were introduced. We nowuse version ".06". Although SEAS originated long ago (about30 years)[8,9, 10], it has beencontinuouslyupdated so to meet contemporaryneeds, An exercise-based approach remains updated onlyifit isn'tbasedon a rigid original idea butcanupdateitself byfollowingacquisitionsproposedbythescientificworld. Amongthe more well-known exercisetreatmentsare the onesofMezieres,Sohier andKlapp[II,12] thathaveremainedalmostunchangedovertime, whileothers, more dynamic,liketheGlobalPosturalRehabilitationaccordingtoSouchard,orSchroth[13, 14, IS, 16],havechangedovertimewiththestimulusofnewproposalsclaimedbythe original authors and their followers (however, it must be said that today onlySchroth [IS, 16, 13, 14] and Dobosiewicz [17, 18, 19], togetherwith SEAS[3, 4], have results publishedinindexed literature). Hhowever, these innovations are directly suggested by the present leader's intuition, and thatsomeexercises remainedbasicallyunchanged sincethebeginning, contraryto SEAS, which regulates its changes according to evidence coming from new _ ~ _ ---- Material may be protected by copyright law (Title 17, U.S. Code) -- I i : ! I' I I 192 M. Romano e/ a/.fSEAS: Efficacy, Efficiency and [nnom/ion dcvelopments proposed by scientific research. Forexample, in the beginning, Active Self-Corrcction movement (which is currcntly proposed as a methodological basis within SEAS [I]) was a simple auto-elongation that was considered to be the best correction solution due to the scientific knowlcdge in the 1970s (in a consistent way with Harrington's fusion and Milwaukee brace techniques) [20]. Today, however, everything has radically changed because of the knowledge considering three- dimensionaldeformitY,[21] andauto-elongationhasbeenalmostcompletelyabandoned, having been replaced byActive Self-Correction on the three spatial planes, according to what is reported below.[22] So, by dcfinition SEAS can radically improve in accordance with new developments, regardless oftheoriginal ideasofthe person who first devisedit. The tcam concept is an important prerequisite ofSEAS. We believe that we can obtainthe bcstresults onlyif everysingleelemcntof a heterogeneousteamcontributes by giving the best ofhislher specific competencies, and ifeffective communication instrumentsarcwarranted.Theidealteam is an extcndedgroupthat in its"therapeutic" segment includesthephysician, the physiotherapist,trainerand orthotistalong with the patientandhislherfamily. 1.1. From a biomechanical perspective, what are exercises/or? Neurophysiology developments indicate the role 0/Active Self-Correction To fully understand the biomechanical role ofexercises in scoliosis treatment (which, as we will scc later, have other equally important roles),[ll, 12, 20, 23, 24] and to understand why SEAS has certain unique characteristics relative to other exercise treatments, an in-depthconsideration is necessary. Evcry biomechanical treatment for scoliosis tries to contrastthe"viciouscyclc" [25] describcdbyStokes, favouring aless pathological growthofaffectcd vcrtebrae. In that sense, Active Sclf-Correction is seen by all experts as the crucial moment oftreatment, as was confirmed bythe SOSORT Conscnsus Conference.[24] Howevcr, the point is: how can exercises innuence this "viciouscycle"?Considerthe following: Correction obtaincd with exercises lasts only for thc duration of exercise execution; Even in more "aggressive" exercise methodologies, in which for certain periodspatientsare requiredto doan inpatientexercisetreatment lastingupto eighthoursperday, [26,27]itwouldnotbepossibletohold the realcorrection for more than two or three hours, taking into consideration pauses and exerciseintervals. ' ' No onewould everthinkof proposingacorrectivebraceforsuchashorttime. Given all theabove, it is obviousthatexercises can work from the biomcchanical pointofviewbutonlythroughapermanentchange in posture. So, the real question is: how can I'work better to modify my patient's posture? Which is the best learning mcthod by which to obtain a'new posturc? Over the years, we have seen a dcfinitc evolutionfrom apurelymechanisticmodcl--in whichmotorlearningwas consideredas related only to obsessive repetition--to a more complcx functional model in which repetition plays a role, but its execution in confounding situations facilitates the creation ofthe correct cortical engrams [5, 6, 7]. Moreover, anotherquestion must be asked here: does obtainingthe maximumpossiblecorrection work betterforlearninga newposture(passiveauto-correction),oris itbettertoacceptasmallercorrectionbut ~ ~ M.Rt Figure.1. FromaneurophY' one 10 Jearn neuro-mOlor autocorreclion, goes toward corrective exercises) to "nel normalposture.Secondline: thoracickyphosisandbetterI activelyobtained without not pcculiar to the spinet 6, 7] and from a neuroph the passive one to lean: accepted that posture is behaviour). Moreover,thi thousand different exerci: neuromotor bchaviour. 11 conceptual passage havill from "correction"(passiv1 exercisesto learnbehavio Therefore,evenifdUJ ofauto-correction has be exercise, with the excep approach. From our poinl should be done by the musculature, without extl without using muscular ... --.'--' ,. '--' Material may be protected by copyright law (Title 17, U.S. Code) I 'lulnnol'Qiion lple, in the beginning, Active as a methodological basis vas considered to be the best le 1970s (in a consistent way ques) [20]. Today, however, nowledge considering three- almost compldely abandoned, .hree spatial planes, according !\.S can radically improve in [ginal ideas of the person who EAS. We believe that we can eterogeneous team contributes .d if effective communication group that in its "therapeutic" er and orthotist along with the ?sfor? Neurophysiology in scoliosis treatment (which, ,),[11, 12,20, 23,24] and to ics relative to other exercise y biomechanical treatment for led by Stokes, favoming a less Active Self-Correction is seen is confirmed by the SOSORT i can exercises influence this tor the duration of exercise llogies, in which for certain xercise treatment lasting up to :ible to hold the real correction lto consideration pauses and ve brace for such a short time. work from the biomechanical lsture. So, the real question is: :'1 Which is the best learning ears, we have seen a definite tor learning was considered as x functional model in which ling situations facilitates the ,ver, another question must be tion work better for learning a :ept a smaller correction bw M. Romano er al. / SEAS: Efficacy, Efficiency arid lnllOYClrion 193 Figure. 1. From a neurophysiological perspective,[5, 6, 7] active movement is much better than passive one to learn ncuro-motor behaviuurs, like posture. Active Self-Correction instead of passive autocorrection, goes towards this direction, with a conceptual passage from "correction" (passive corrective exercises) to "neuromotor rehabilitation" (active exercises to learn behuviours). First line: normal posture. Second line: Active Self-Correction (ASC). Observe nomuli7.ation of flanks, increase of thoracic kyphosis and better lumbar lordosis, radiographic results (C: Cobb; R: Raimondi rotation actively obtained without external aids, i.e. limb attitudes, supports or muscles that are not peculiar to the spine (Active Self-Correction)? According to the same literature,[5, 6, 7] and from a neurophysiological perspective, active movement is much better than the passive one to learn neuro-motor behaviours such as posture (obviously once accepted that posture is not only a matter of anatomy but also of neuro-motorial behaviour). Moreover, this Active Self-Correction (see Figure I) can be replicated in a thousand different exercises with "distracting" situations, thereby "strengthening" the neuromotor behavioLlf. The SEAS answer specifical1y addresses this direction, with a conceptual passage having a precise neurophysiological basis that brings the patient from "correction" (passive corrective exercises) to "neuromotor rehabilitation" (active cxercises to learn behaviours). Therefore, even if during the SOSORT Consensus Conference [241 the importance of auto-correction has been underlined, we must notice that almost every school of exercise, with the exception of SEAS,[22] is based on a passive auto-correction approach, From our point of view, auto-correction to become Active Self-Correction should be done by the patient exclusively through the spinal deep paravertebral musculature, without external help, thus pursuing the precise control of movement without using muscular contractions strategies that drive the spine into a passive Material may be protected by copyright law (Title 17, U.S. Code) " ! 100
III 194 M. Romano 1'1 01. / SEAS: EfJicaC); EfJiciency and Innomlion
I I , I I .... I - I II I I I lIJO ,.- ....__.. __ \_ .. _ I ..__-..t- ! I : I : ; : : , -J------ r -----..!- I I i I I i I I j I I -..-- - \ __ 1"'.,. \ : I I ; I I : . I I i I I 15 .. - .. --_..j---l- I I .......... o S20 1130 -II-SO 6170 >70 SIlJ'inc (...,.....> o o Figure.3. Load threshold be curveincreases.[I] Cobb [2) that are most observations, as well as I loadthresholdbeyondwhi as curvature increases-el order to reduce postural potentials.Theimportance experiments butalsofrom whose constituentelemen longer able to maintain natural history ofa prog several plancs, which aftl "viciouseycle"theoryide Consensus Conference, w themostimportanttherapl vertebral stabilisationwas in the practical waythatSI by the SEAS approach is enhancing the function of (seeFigure3). 2.2. Neuromotor ;mpa;mle High experts in scoliosis I [32] and Herman(seeFigu postural deficits and spina identified, amongthe aetic because a correlation bet" evident, even if the rela potentialofcurvaturehasI , I ! I I' I :1 Figure. 2. The postural component has been measurcd,[2] and corresponds to almost 10.whose importanceisobviouslyhigherin scolioses<20Cobb,\hatarctheonesmost targetedbyexercisesfor pre"entivepurposes. alignment (for example, contraction ofconcavity psoas muscles in ordcr to reduce lateralflexioncomponentin alumbarscoliosis). 2.SEAStherapeuticgoals Exercises do not havc a strictly biomechanical role[ll, 12,20, 23, 24]. Before we explain the essential principles on which SEAS is based, it is necessary to underline two other preliminary remarks: From a scientific point ofview, we are still far from definingIhecauseofidiopathicscoliosis. Regardingidiopathicscoliosis,weare ofonly a few elements regarding the functional impairments it causes or those with which it is associated. The research has chiefly served to clarify a series of dysfunctions thatthe scolioticpatientexperiencesandthat the SEAS approach tries to reduce. The treatment schedule pomtsto the IdentificatIOn ofascriesoftherapeutic goals that varydepending on the phase oftreatment and that must bc pursued each time with the most effective weapons available. The main dysfunctions experienced by a scoliotic patient can be schematically described as follows. 2.J. Postllre alld stability ;mpa;nllents Increasing spinal stability is a primary therapeutic goal ofthe SEAS approach. The importanceofthis rehabilitationaspectisderivedfrom aseriesoffundamental studies. Duval-Beaupere [28] showed that scolioticcurve magnitude is not onlythe result ofa structuraldeformationbutthatthere isalsoaposturalcomponentsignifyingadifficulty of the stabilizing system in the spine to counterbalance the alignment loss. This component, which is always present, is particularly important in the scoliosis < 20 0 Materialmaybe protected bycopyrightlaw(Title 17, U.S:Code) 195 -c Id Inno\'Q/ion ....................1.-- , ---------.-! -_.'. , i _.. 1 . ! .i__. ..... ! ~ i ! j 6170 ,.70 lOS' orresponds to almosi 10. whose Dnes mosttargeted byexercises for ; muscles in ordcr to reduce , 12, 20, 23, 24]. Before we J, it is necessary to underline ofview, we are still far from lathicscoliosis,we arecertain ments it causes or those with rved to clarify a series of 1t exercise treatment basedon Jle points to the identification Ie phase oftreatment and that veapons available. The main e schematically described as .ofthe SEAS approach. The series offundamental studies. ude is not only thc rcsult ofa nponcnt signifyingadifficulty lCC the alignment loss. This portant in the scoliosis < 20 . .a+ M. Romano e/ al. / SEAS: Efficacy, Efficiency and ImlOm/ioll ------r------r----- 100....-=------:----1:-------.1-------, 50 j ! I -1----r--'-- ----T-- n-------r-------- I \ I I -----t---- f------r----- ! ' 1 ----t-----i------- j ---- --.. l : ~ = = ~ = : : : ~ l = = : t = ~ --_-_-t--_-i-- --1------- ----..--_._--- ,._---_......__. O+-----+-----i----+---=--i o IS 30 60 80 [)e1f"1orCU....1IlUrC Figure.3. Load threshold beyond which the spinebeginsto getdefonncd(criticallood)diminishesas cun'eincreases.[ll Cobb [2] that are most targctcd by exercises for preventive purposes. From these observations, as well as Bunch and Patwardhan's[l] studies-which showcd how the loadthresholdbeyondwhichthcspinebeginstogetdefonned(criticalload)diminishes as curvature increases--emergc thc importance of improving spinal stabilisation in ordcr to reduce postural collapse and thc consequent spinal structural defonnation potcntials.Theimportanceofimprovingspinal stabilityderivesnotonlyfrom scientific experimentsbutalso from clinicalevidence:ascolioticspinecan beseenas astructure whose constituent elements, being subject to stimuli causing a loss ofbalance, are no longer able to maintain their physiological alignment and primitive stability. The natural history ofa progrcssive scoliosis could therefore be a postural collapse on sevcral planes, which afterwards becomcs a bone defonnity in accordance with the "viciouscyelc"theoryideatedbyStokes[25] (sceFigure 2). Evenduringthe SOSORT Consensus Conference, which took place in Milan in 2005,[24] in regard to defining the most importanttherapcuticgoals for scoliosisconservativetreatmcnt, thepursuitof vertebral stabilisation\WS indicated as the sccondpriority. Thedifficultyprobablylies in thepracticalwaythatsuch rcsult can be obtained.Thetherapcutic stratcgyproposed by the SEAS approach is bascd on improving rcactions to force ofgravity and on cnhancing the function ofthose musclcs that have a major stabilizing vocation [29, 2] (seeFigurc3). 2.2. Neuromotor impairmellls High experts in scoliosis research, like Duboussct [30] Nachemson,[31] and Stagnara [32]andHennan(seeFigure4)[33] haveintuitivelypostulatedthecorrelationbetween postural deficits and spinal balance/stability. More recently, scvernl authors have also identified, amongthe actiological cofactors for scoliosis,balance dysfunctions. This is bccause a correlation between idiopathic scoliosis and postural control proved to be evidcnt, even if the relationship bctween deficit magnitude and the progressive potcntialofcurvaturehas not yetbeen clarified.Onthe basisoftheseobservationsand .__.__ Material may be protected by copyright law (Title 17, U.S. Code) 196 i' I, : ' i, I I' 1 \ M. Romano e/ 01./ SEAS: EfficoC); Efficiency and lImom/ioll M.Roma I ~ d body- spdIIDI orit1lJ \ <kulomolor collllOl I 1 Alia!moIor C<lft1r01 Molor adaplalion Alia!motor sySltm A Figure.S. Acti\'cSelf-Com:cti spinousprocessescorrespondCl concavity.B - Thethcrapistp apex,whilethepatientletsthe therapist'shandonthehemitor. Figure 4. Hennan's theory, awarded with the Harrington Lecture by SRS that considcrs scoliosis as compensationtoncuromotorialdysfunctions. 3.Practicalapplication0 the research results, we can say that the development of balance reactions is a fundamental therapeutic goal to which the treatment schemes proposed by SEAS Scientific research sh0\1 devoteparticularattention. neuromotor, biomechanica knowledge ofthese impai exercises in order to pre1 2.3. Sagillal plan impairments scoliosis and progressive altowus to slowdownand Several researches, among which those ofPerdriolle[21] and Graf[34] in particular 4] whileinbracedones thi indicate that the evolution ofscoliotic curvature is characterised bya reductionofthe actionandavoidits sideef curves on the sagittal plane (flat or hollow back), a biomechanical condition that, according to White and Panjabi,[35] also facilitates axial rotation. In the exercises 3.1. Exercises in Jow-degrl proposedbytheSEASapproach,thesearchandpreservationofaphysiologicalsagittal orientationinthescolioticspineisalsoamaintherapeuticgoal. GoalsattheneuromotoraJ and spinal stability, while 2.4. Otller impairmellls towardsaerobic functionin Finally, wecannotneglectthe impairmentsthatscoliosiscausesatan organic(aerobic) 3.2. PoslllraJ COlllroJ and.s level, witha reductionofboth vitalcapacityandoxygenconductionability(VQ 2 max), [36, 37]the latterofwhich, amongother things, proves to be disproportionate to vital Nachemson[31] claimedtl capacity reduction but related to deficient physical conditioning. Furthermore, the therebystoptheprogressil psychologicalaspect is acrucial one: it is partlydue to theage at which thepathology postural control and spin; appears but also to the often iatrogenic influence on the psyche as determined by strengthening in a correct treatments and healthcare operators. All these aspects are taken into consideration integration. [41] Let'stakl withintheSEASapproach. _._.. _-_..... -------_._-- "-'--'--"-'- - - -_.- - Materialmaybe protectedbycopyrightlaw(Title 17, U.S. Code) ----'---, 1d J'lnovation lH. Romano et at. / SEAS: Efficacy, Efficiency and Innovation 197 'y SRS thal comiders scoliosis as t of balance reactions is a ~ h m s proposed by SEAS ] and Graf [34'1 in particular cterised by a reduction of the tiomechanical condition ,hat, ial rotation, In the exercises ion of a physiological sagittal goal. causes at an organic (aerobic) conduction ability (V0 2 max), o be disproportionate tu vital nditioning. furthermore, the Ie age at which the pathology he psyche as determined by arc takcn into consideration A B Figure. 5. Active Self-Correction on the frontal plane. A - The therapist puts his/her fingers OIl the spinous processes correspondent to thoracic curve apex, whi Ie the patient lets the vertebrae shift towards concavity, B - The therapist puts his/her fingers on the spinous processes correspondent to lumbar curve apex, wnile the patient lets the vertebrae shift towards concavity side. The counter-support of the therapist's hand on the hemitorax and hemipelvis opposed to curve convexity avoids imbalances. 3. Practical application of SEAS concept Scientific research showed that scoliosis causes functional impairments at a neuromotor, biomeehanical, organic and psychologicallevel[38, 39, 12] Based on the knowledge of these impairments, we derive therapeutic goals to be pursued through exercises in order to prevent and reduce them in the treatment of both low-degree scoliosis and progressive forms in association with bracing. Furthermore, exercises allow us to slow down and in some cases stop progression in low-degree scoliosis, [40, 4] while in braced ones this kind of therapy is useful to increase the orthosis corrective action and avoid its side effects. 3.1. Exercises in low-degree scoliosis trealment Goals at the neuromotor and biomechanical levels are directed towards postural control and spinal stability, while the goals at the bodily and psychological levels are directed towards aerobit: functioning and development of a positive body image. 3.2. Postural control and spinal stability Nachemson[31] claimed that good spinal stability could neutralize postural deficits and thereby stop the progression of an initial scoliosis. The therapeutic modalities to obtain postural control and spinal stability arc postural rehabilitation, muscular endurance strengthening in a correct posture, development of balance reactions and neuromotor integration. [41] Let's take into consideration these modalities. Material maybe protectedbycopyrightlaw(Title 17, U.S. Code) 198 _L: M. Romano er al. / SEAS: Efficacy. Efficiency and lnnovtltion M.Rom. A B Figure 6. Active Self-Correction on the sagittal plane A -By leaning against the upright, lbe patient then docs a pelvis antiversion (to recreate lumbar lordosis) and a thoracic kyphotization (to recreate thoracic kyphosis). B- The putient does the same exercise without the help of the upright, at first looking at hirnlherself in the mirror. 3.3. Poslural rehabilitution lt includes becoming aware of body posture, becoming aware of defects of posture and Active Self-Correction on the three spatial planes. Becoming aware of body posture and defects of posture is obtained through visual (mirror) and tactile (contacts in the various postures) biofeedback and rehabilitator guidance. 3.4. Active Self-Correction Active Self-Correction on the three spatial planes is the most important individualized therapeutic moment directed towards one's own defonnity. It includes several phases, as f(Jllows: The first phase includes becoming aware of curve apex translation towards concavity on the frontal plane, and is done in several postures (see Figure 5). For exampic, in the case of a double-curve scoliosis, first we teach how to execute thoracic curve translation and then lumbar curve one; subsequently, we associate the two movements, beginning with lumbar translation. The phase immediately following includes becoming aware of correction on the sagittal plane. The studies of Perdriollc,[21] Graf,[34] White and Panjabi[3S] highlighted that idiopathic scoliosis, in the case of progression, reduces physiological curvatures on the sagittal plane, favoring vertebral rotation. Exercises must ensure thoracic kyphosis and lumbar lordosis. At the lumbar level, we ask the patient to do pelvis anteversion and a kyphotisation movement at the thoracic level (see Figure 6). finally, we associate active Self-Correction movements on the frontal and sagittal planes. According to Dickson's studies,[42] an action done on two Fig spinal planes (fror lordosis) causes all Following the end 0 perfonned by the patient exercise. 3.5. Muscular endurance stl Muscle endurance strength, limbs and scapulo-humeral that are one-third to two-thi patient to execute an Acti\! duration of isometric contn Abumi's studies showed tJ guarantee greater stability it Self-Correction movement ; chosen muscles duration (SCI 3.6. Development a/balance This is aimed at improving exercises arc always done developed with growing d development of balance ~ because scientific research t centers that control balance ii Material may be protected by copyright law (Title 17, U.S. Code) 199 I M. Romano el al. / SEAS: Efficacy, Efficiency and Innovalion nd lnnovalion against the upright, the patient then . kyphotintion (to recreate thoracic of the upright, at lirst l o o k i ~ at ware of defects of posture and Jming aware uf body posture Ir) and tactile (contacts in the most important individualized ty. It includes several phases, lrve apex translation towards :veral postures (see Figme 5). Jliosis, first we teach how to lbar curve one; subsl:qucntly, I lumbar translation. Jming aware of correction on e,[21] Graf,[341 White and s, in the case of progression, tal plane, favoring vertebral is and lumbar lordosis. At the tteversion and a kyphotisation lovements on the frontal and ;,[42] an action done on two Figure 7. Muscular elldunmce strengthening in the correct posture. spinal planes (frontal translation and kyphotisation and/or lumbar increase of lordosis) causes an involvement of the third plane (cross-sectional derotation). Following the end of the initial learning phase, Active Self-Correction is perfonned by the patient in an independent manner and applied in every standing exercise. 3.5. Muscular endurance strengthening in the correct posture Muscle endurance strengthening aims at developing paravertebral, abdominal, lower limbs and scapula-humeral girdle muscles through isomctric contractions. It uses loads that are one-third to two-thirds of maximal load in Active Self-Correction. We ask the patient to execute an Active Self-Correction movement and to hold it for the entire dmation of isometric contraction of the chosen muscles (see Figure 7). Panjabi and Abumi's studies showed that the spine needs good muscular support in order to guarantee greater stability in a scoliotic spine. We ask the patient to execute an active Self-Correction movement and to hold it for the entire isometric contraction of the chosen muscles dmation (scc Figure 7). 3.6. Development ofbalance reactions This is aimed at improving axial, static and dynamic balance of the trunk. Proposed exercises are always done in Active Self-Correction, even on unstable planes, developed with growing difficulties (see Figure 8). Stagnara[43] claims that the development of balance reactions must be one of the main goals of rehabilitation because scientific research has shown thc presence of some impairments in cortical centers that control balance in scoliotic patients. Material may be protected by copyright law (Title 17, U.S. Code) - 200 M. Romano er al. / SEAS: E[JiCCIcy. Efficiency lind Innovaliol! Figure 8. Devclopmcnt of balance reactions Proposed exercises are always done in Active Self- even on unstable planes, developed with growing difficulties 3.7. Neuromotor integration This aims at integrating in everyday behaviors a more correct and better-balanced spinal posture, progressively developing the ability to react with correct functional Figure 9. Preparation to bracing. Exercises aimed at increasing range of motion of the spine on all planes, in order to allow the brace to exert the maximum possible correction attitudes (Active Self-Correction) to the different requirements of social life. We propose exercises that associate Active Self-Correction with global movements, e.g., walking with a simple gait and oculo-manual education exercises, even on unstable planes. In this conclusive phase of treatmcnt, we give ergonomic information so as to avoid spinal damage in adulthood. -----------_.. _- M.Rt 3.8. These goals are reached we are discussing, in functioning (vital and positive body image. ' competitive sports that t maximum thoracic exte scoliotic patient every ] activities, for their limit changes but offer huge 3.9. Exercises in brace t The main goals of exei effects caused by immo sagittal curves, mainly corrective pushes. [44, modalities, subdivided it 3.9.1. Preparationjor bl We request the executio spine on all planes, so a (see Figure 9). We also brace wearing, when it i! 3.9.2. Brace wearing pel We initially propose ext lower limbs so as to fac: of hours. We propose st kyphosis preservation, \> by brace pushes. DurinE continuatively these othe body image. For that re, sport activities, both agol full time (see Figure participation in motor a while wearing a brace, . should nevcr force any Iii Material may be protected by copyright law (Title 17, U.S. Code) 201 M. Romallo et al. / SEAS: Efficac)'. Efficiellc)' Gild lllllomtioll lid III//Om/ioll 3.8. Aerobicfimctioning anddevelopment oja positive body image
Thesegoalsare reachedthrough modalitiesthataren'tspecific to thetherapeutic field:
we arc discussing, in particular, motor and sport activities that stimulate aerobic functioning (vital and oxygen uptake and consume capacity) and help develop a positive body image. When the patient does not wear a brace, we advise against competitivesportsthatrequirean increasedrangeofmotionofthespine,particularlyin maximum thoracic extension and/or lumbar flexion. According to Stagnara,[23] for a scoliotic patient every motor activity done at a recreational level is beneficial. Such activities, for theirlimiteddurationandintensityovertime, cannotdeterminestructural changesbutofferhuge benefitsatthe bodilyandpsychologicallevels. 3.9. Exercises illbrace treatment The main goals ofexercises in brace treatment are: elimination orreduction ofside effects caused by immobility (muscular hypotrophy), or the brace itself(reduction of sagittal curves, mainly kyphosis, and breathing impairment)and accentuation ofbrace corrective pushes. [44, 45, 23] Such goals are pursued through specific therapeutic modalities,subdividedintotreatmentphases: are always done in Active Self- ties 3.9.1. Preparationjor bracing We request the execution ofexercises aimed at increasing the range ofmotion ofthe spine on all planes, so as to allow the brace to exert the maximumpossible correction (seeFigure9). We also continueproposingmobilisation exercises in the first phaseof e correct and better-balanced bracewearing,whenitiswornforatleast21 hoursperday. react with correct functional 3.9.2. Brace wearing period We initially propose exercises of"wriggling out ofsupports" by using the upper and lowerlimbsso as to facilitate adaptationto brace usage for the recommendednumber ofhours. We propose strengthening exercises, requiring lumbar lordosis and thoracic kyphosis preservation.whilefrontal andcross-sectionalplanscorrcction is guaranteed by brace pushes. During brace treatment, it is offundamental importance to pursue continuativclytheseothertwogoals: aerobic functioninganddevelopmentofapositive body image. For that reason, we recommend intensifying participation in motor and sportactivities,bothagonisticand/orrccreational,evenwithabrace that mustbeworn full time (see Figure IO).During brace treatment, we rccommend to intensify participation in motor and sport, both agonistic and/or recreational activities, even while wearing a brace, like in the two cases presented. The presence ofthe brace angeofmotionofthespineonall shouldneverforce anylimitationupontheyoungpatient'spersonalandsociallife. :arreetian uirements ofsocial life. We with global movements, e.g., 1 exercises, even on unstablc 'gonomic information so as to
Material may be protected by copyright law (Title 17, U.S. Code) ;vI. Romano er al. I SEAS: Efficacy, E.JJiciency and lnnuvarion 202 3.10. Cognitive-behavioural approach and counselling: compliance and acceptability through humanisation Chronic pathology tends to cause a change in behaviour and relationships with the omer world[46]. Scoliosis can fall within the group of chronic pathologies because of the long time period required for its therapy, and due to the fact that treatment outcome will not be a complete patient recovery but the best possible control of the deviation[9]. The correct management of this disease is not always easy, because it usually appears in a frail period oflife, i.e., the stage of pubertal growth spurt. When treatment includes a brace as well, the young patient's reaction is rarely good. [47,48] The brace causes a sudden shock and modifies the adolescent's human relationships during a period of dramatic physical change, when he/she is grappling with the acceptation of his/ber rapidly changing body, this being the period involving the development of his/her personality and in which the young person is concentrated on weaving the first complex plot of relationships with the other sex. For the parents, it is also a difficult situation. Their natural ambition is to seck the utmost happiness for their children, but they are forced to struggle with the difficult problem of whether to ask the person they love most to make a big sacrifice that is necessary for the child's health, or to try and find a different path with a doubtful efficacy that could be dangerous and create even bigger problems. In the treatment of chronic pain, the importance of formulating the treatment on the basis of a far less mechanistic nature than before is shared internationally [49]. Chronic back pain is described as a bio-psycho-social problem, i.e., a disorder that has a biOlogic origin, causes psychological implications of non-acceptance, growing fear and distmst towards problem resolution, until it finally results in depressive behaviours that eventually have repercussions even on relationship dynamics with the outer world. Thanks to this new awareness, we consider every facet of a condition that is much more complex than what we used to think. [50J This has suggested the use of integrated treatment techniques that draw on the experience of other medical disciplines as well. It is the case of cognitive-behavioural approach that originated from experiences developed in psychology field halfway through the past century. [51, 52] The transposition of a cognitive-behavioural approach to scoliosis treatment is aimed at Figure to. Aerobic functioning and development of a positive body image iY!. Ru simplifying treatment : problems and stimulatin The essential condi of the clear and effecti patient[54] and family a Carefully listen Let the patient! Solve practical For the practical appli( include a family coum meeting sees the partie who has taught the De, follows the patient ea importance to reach the contract" agreed upon\'< therapeutic team. lt is a outcome 4. Scientific results of 4.1. SEAS treatment red The main objective of e so that a brace would I protocol, we compared obtained in 69 patients and were followed up protocol (SEAS group), in those treated with stf out of four cases (25%). it demonstrates how co most cases, thus avoidil two years of treatment i one year (10% SEAS vs the two treatments. FUI populations will offer correct exercises we Cal prescription. Because th growth, this delay at thf point of view. 4.2. SEAS treatment im[- In the study already , traditional measures. In' a radiographic improver while the number of we Material may be protected by copyright law (Title 17, U.S. Code) 203 ,and bmol'Qlion , compliance and acceptability iour and relationships with the 'chronic pathologies because of I the fact that treatment outcome ,ible control of the deviation[9]. because it usual1y appears spurt. When treatment includes lod. [47,48] The brace causes a clationships during a period of with the acceptation of his/ller ng the developmcnt of hislher :entrated on weaving the first ,he parents, it is also a difficult lappiness for their children, but , whether to ask the person they the child's health, or to try and i be dangerous and create even If formulating the treatment on is shared internationally [49]. 'roblem, i.e., a disorder that has f non-acceptance, growing fear :esults in depressive behaviours dynamics with the outer world. et of a condition that is much ,suggested the use of integrated :r medical disciplines as well. It originated from expcriences : past century. [51, 52] The ;coliosis treatment is aimed at I positive body image M. Romano el a/.I SEAS: EjficienC)' and lnnOl'Qlion simplifying treatment acceptance, reassurance, looking for a solution to practical problems and stimulating faith towards the outcome. [53] The essential condition for an effective development of treatment is the definition of the clear and effective two-way communication necessary to win the trust of the patient[54] and family alike. This al10ws us to: Careful1y listen to doubts and explanation requests; Let the patient/family feel that we understand hislher/their distress; Solve practical problems that might arise. For the practical application of these principles, treatment protocols used at ISICO include a family counselling meeting to be held at the end of each session. This meeting sees the participation of the patient, hislher family, the ISICO rehabilitator who has taught the new exercise plan and, if present, the therapist who in practice ' fol1ows the patient each time he/she docs exercises. It is a moment of utmost importance to reach the described objectives, to regularly consolidate the "therapeutic contract" agreed upon with the patient and hislher family, and to cement the "extended" therapeutic team. It is an indispensable element for an optimal attainment of the final outcome 4. Scientific results of SEAS 4.1. SEAS treatment reduces the need/or bracing The main objective of exercise treatment is to avoid that paticnt's progress of scoliosis so that a brace would be needed. To verify the efficacy in this respect of the SEAS protocol, we compared in a prospective and control1ed cohort study[3] the results obtained in 69 patients at risk of brace treatment; they were divided into two groups and were follO\vea up for a period of one year. Among patients treated with our protocol (SEAS group), bracing was prescribed in one out of twenty cases (6%), while in those treated with standard exercises (CONT group) bracing was prescribed in one out of four cases (25%). This result is statistically significant, and it is relevant because it demonstrates how correctly designed exercises can guarantee scoliosis stability in most cases, thus avoiding more invasive treatments. The fol1ow-up examination after two years of treatment in 38 patients confirmed the differences already highlighted at one year (10% SEAS vs. 27% other group), even if with a reduction of the gap between the two treatments. Further studies with longer fol1ow-up periods and larger study populations will offer more definite results, but already today we know that with correct exercises we can reduce the number of prescribed braces or at least delay their prescription. Because the end of brace treatment always coincides with the end of bone growth, this delay at the start of therapy is another significant result from the patient's point of view. 4.2. SEAS treatment improves scoliosis parameters In the study already mentioned[3], we also documented exercises results with traditional measures. In terms of Cobb degrees, the percentage of patients who showed a rad,iographic improvement was 24% in the SEAS group vs. 11 % in the CONT group, while'the number of worsened cases was superimposable even if slightly lower in the - Material may be protected by copyright law (Title 17, U.S. Code) i 204 M. Romano et al.I SEAS: EjJicac}; EjJiciency and Tll/lomtion SEAS group (12% vs. 14%). Upon a clinical evaluation ofthe largest curve hump usingBunnell's scoliometer, in the SEAS groupwe noticed a stability/improvement in 73%ofcasesvs. 58%intheCONTgroups. 4.3. SEAS treatment normalizes balance and coordination in scoliosis patients According to the SEAS protocol, exercises aim at improving some specific impairments ofthe scoliotic patient so as to normalize them and reduce the risk of progression ofscoliosis. Among these, we have equilibrium and coordination. In a controlledcross-sectionalcohortstudy,[55]we evaluated 190subjectsdivided into two groups (forty Adolescent Idiopathic Scoliosis patients and 150 controls), and those patients were divided in two sub-groups (twenty treated for one year with SEAS and twenty not treated). All participants were evaluated through Unterberger (Fukuda), Romberg (sensitised and not sensitised) and lower-limb oscillation tests. Patients treatedwiththeSEASprotocolshowedresultsthat weresuperimposableto theones of control subjects, and on a statistical basis both groups were definitely better than untreatedscoliosispatients. 4.4. Active Self-Correction according to SEAS principles reduces tlte radiographic ! ; curve Auto-correctionhas beenconsideredbySOSORTexpertsas a keyaimofexercises for idiopathic scoliosis: the Active Self-Correction (ASC) is a kind ofauto-correction actively performed by the patient, without any external aid, that forms the base of SEAS. ASC is a selective (i.e. only on the vertebrae involved) lateral de-flexion, sagittal correction (usually increase of kyphosis and preservation of lordosis) and horizontal dc-rotation: this movement is.verydifficult and require some months to be learned. 27 consecutive patients under treatment that required x-ray examination for theirclinical follow-up havebeen included in the study[22]. All patients performed x- I "I. ray exam both standard and in ASC; moreover, they all were photographed frontally ,: and laterally to have an evaluation ofthe quality ofASC. The statistically significant percentage ofreduction ofscoliosis WiiS 11.0l2.3%, with a reduction ofrotation of .. 13.263.4%.Thisstudyprovesthatitis possibleto reduceactivelythecurvaturewitha selective action, without any external aid, and that expert physiotherapists can teach ASC. , 4.5. SEAS treatment improve results in case ofbracing i !, To confirm whether the SEAS protocol, mobilizing and preparatory to the brace, had this ability, we compared, with a controlled prospective cohort study[4] of the beginning ofbrace therapy, the results obtained at the first radiographic follow-up at four months.in 110patients,dividedinto two groups. Datashowedahigherefficacyof SEAS treatment, compared to standard exercises (CONT group) in regard to cosmetic appearance(AestheticIndex)andCobbdegreesof the largestcurveandhump. . ~ - ------._. ... _--._.__._-_.. _ _ . ~ .._ ~ - ------- ~ -------- M. 4.5.1. SEAS /':yplzotisi. We performed a stU compare different e ~ different positions- : as to increasetheircc the position adopte; Kyphotisation and rc 58.9% and 29.8% r e ~ name, does not prot exercisesin bracedc( and, through those tis in ordertoobtaindiO in mechanicalterms,I References [I] W.BunchandA.Patv 1989. . [2] G. Torell, A. Nacherr, girls"ilhidiopathic9 [3] S. Negrini, A. Negrir efficacyofSEAS.02, Health Technollnfon. [4] S. Negrini, A. Negrin efficacyofSEAS.02 Inform 123(2006),51 [5] V. B.Brooks,Motorc [6] H.D.HenalschandH Med6 (1985),2-14. [7] M. E. loffe,Brainme classicalconcepts,Ne; [8] E. Ascani, P. Bartolc Binazzi and M. DiS Spine II(1986),784-! [9] M.A.AsherandD.( effects,Scoliosis 1(2( [10] C. E. Aubin,J. Danse bracetreatmentofadc [II]A. Negrini,P.Sibilla; metodologici,Riabi/it, [12] S. Negrini, A. Negri International Society 1996,pp.68-71. [13] S. Gtmlln, N. Kose a treatmentofadoJescet [14] H. R. Weiss, Rehabili literature,Pediatr Reh [15] H. R. Weiss, M. H, improYementof time... [16] H. R. Weiss and R. matchedpairs,Pediall [17] K. Dobosiewicz,J. D treatment ofprogressi evaluation,SlIId Hea/t, Material maybe protectedbycopyrightlaw(Title 17, U.S. Code) --------------- - 205 md bmol'Qtioll ion ofthe largest curve hump iced astability/improvement in )Jl ill scoliosis patients at improving some specific e them and reduce the risk of librium and coordination. In a d190subjectsdividedinto two and 150 controls), and those dfor one year with SEAS and .hrough Unterberger (Fukuda). imb oscillation tests. Patients superimposable to the onesof ps were definitely better than i reduces the radiographic :tsas akeyaimofexercisesfor :) is a kind ofauto-correction lal aid. that forms the base of .e involved) lateral de-flexion, preservation of lordosis) and and require some months to be required x-ray examination for '[22]. All patientsperformed x- III were photographed frontally SC. The statistically significant with a reduction ofrotation of tceactivelythecurvaturewith a pert physiotherapists can teach d preparatory to the brace, had ective cohort study[4] of the first radiographic follow-up at lata showedahigherefficacyof IT group) in regard to cosmetic ngestcurveandhump. ( I- I ... M. Romano et al. / SEAS: EjJicaC}; EjJiciency alld Innomtioll 4.5.1. SEAS kyphotisation exercise is the most lIseful to help bracblgpllsh work We performed a study [45] in seventeen consecutive adolescents to quantify and compare different exercises (kyphotisation. rotation and "escape from the pad" in different positions- sitting. supine andon all fours) performed in bracedconditionso as to increase theircorrective forces. We verifiedthat in staticanddynamicconditions the position adopted does not alter the total pressure exerted by the brace. Kyphotisation and rotation exercises guarantee a significant increase ofpressure (+ 58.9% and 29.8% respectively). while the "escape from the pad"exercise, despite its name. does not produce any significant variation of pressure. We concluded that exercises in bracedconditionallow the applicationofadjunctive forces onsofttissues and, through thosetissues,presumablyonthespine. Differentexercisescanbechosen inorderto obtain differentactions; physicalexercisesand sportingactivitiesareuseful inmechanicalterms,althoughotherimportantactionsarenotto beneglected. References [I] W. Bunchand A. Patwardhan,ScoliosisMakingClinicalDecisionsed,C.V.MosbyCompany,SI.Louis, 1989. [2] G. Torell, A. Nachemson,K. Haderspeck.GribandA. Schultz, StandingandsupineCobbmeasures in girls\\ithidiopathicscoliosis,Spine 10(1985),425-7. [3] S. Ncgrini, A. Negrini, M. Romano, N. Verzini and S. 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