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3 - The SEAS concept of exercises for scoliosis3.1
Why
and when to apply exercise treatment
Exercise treatment is the key to a good rehabilitation
approach to scoliosis. In fact, rehabilitation by definition is focused on
the entire person 1. It does not look only at the disease
or the impairments it causes but also (in particular) looks at the disabilities
and limitations of activities, with consideration for the limitations
of participation (in the past called handicap).1,160 Therefore, in a musculo-skeletal disease like
scoliosis, in whom impairments have been recognised beyond the mere state of
deformity, and in which all treatments (from bracing to surgery) cause
psychological as well as physical and functional disabilities (transient in
case of bracing, definitive in case of surgery), a good rehabilitation approach
requires the means to compensate, or prevent if possible, such secondary
damage: this is exercise treatment. Looking at scoliotic disease, when other therapies are not yet considered, exercise treatment is mainly the prevention of scoliosis progression and should be applied every time the risk of progression is significant. However, a brace could be avoided.106 As Sibilla used to say, “Scoliosis should be treated step by step, but the problem is starting with the right one”144,145 (Cap. 2 - Fig. 10). Exercises immediately follow observation alone, and come before bracing106. Several formulae in the literature have been
developed to calculate the risk of scoliosis progression, but they have all
been derived from populations with a high degree of scoliosis, with the
avoidance of surgery being the primary objective. Our aim with exercises is to
avoid or at least postpone bracing, and to arrive at the end of growth with
a presumably stable curvature (as much as possible far from 30°, so that a
value between 20° and 25° can be acceptable).74 Therefore, these formulae cannot be applied,
and the risk of progression is considered looking at a combination of factors,
including: - There is evidence of scoliosis progression coming from radiographs and/or clinical changes superior to the known measurement error (5° for radiographs, 2° for Bunnell, 3 mm for hump height);56,120 - The starting radiographic and clinical data are near to previously defined acceptable boundaries (i.e. around 15° Cobb, or 5° Bunnell, or 5 mm of hump);106 these points should be considered provisional and should be better understood in the future with new research; - There is a very high postural component, as evidenced by an important decompensation and/or by the Aesthetic Index;194 - There are high risks due to other known factors of progression, such as a family history of an important scoliosis, flat back, start of puberty, etc.16,74,169. On the other hand, i.e., when looking at the highest boundaries for
exercise treatment we must consider that as far as we know today, exercises
do not reduce the curvature105 (even if recently we ourselves raised some
doubts about this hypothesis)119 nor, importantly, change the cosmetic
appearance.119 So, exercises should never be proposed (in
favour of bracing) when 30° curves have been attained unless the
pubertal growth spurt is very far in the future and an important postural
component is presumed, with the only aim of postponing (possibly avoiding)
bracing.106 Moreover, exercises should be proposed when
there are uncertainties regarding the application of a brace, even in
curvatures exceeding 25°, and there is the possibility of stability due to the
absence of other progression factors and a relatively advanced age. In such
cases it is important to decide together with the patient and his/her family.
Regardless, due to the very short period of research in this field177 all these points will have to be thoroughly
studied and refined in the future. When a brace has already been prescribed, exercises are
mandatory in order to avoid all side effects of bracing, to increase its
function, and to allow the spine to be stable during the weaning period and
when the brace is abandoned.106,136 These points are thoroughly discussed
elsewhere in this chapter. 3.2
Theoretical
basis of the SEAS concept
SEAS is an acronym for “Scientific Exercises Approach to Scoliosis”118,119. As we are used to seeing with software
products, after the acronym there is a dot followed by a number, to indicate
the protocol version and the year in which substantial changes were introduced.
Today we have version “.06.” SEAS originated long ago (about 30 years)97,101,121, but it doesn’t really appear very old because
during this period it has continuously updated. Therefore, it’s with the times.
How can an exercise-based approach remain young? This can only happen if it
isn’t based on a rigid original idea but can update itself by following
acquisitions proposed by the scientific world. Among the best-known exercise treatments (Fig. 1) here are some, like the ones of
Mézières, Sohier and Klapp101,121 that
have remained almost unchanged over time, and other more dynamic ones, like the
Global Postural Rehabilitation
according to Souchard, or Schroth129,172,175,176, which
have changed over time with the stimulus of new proposals claimed by the
original authors and their followers (however, it must be said that today only
Schroth129,172,175,176 and
Dobosiewicz40,41,43,
together with SEAS118,119, have
results published in indexed literature).
Fig. 1. Some of the most known exercise treatments for scoliosis: Mézières, Sohier, Klapp, Global Postural Rehabilitation according to Souchard. Only Schroth129,172,175,176 and Dobosiewicz40,41,43, together with SEAS118,119, have results published in Indexed literature The difference from SEAS, however, is that these innovations are
directly suggested by the present leader’s intuition, and that some exercises
have remained basically unchanged since the beginning, contrary to SEAS, which
regulates its changes according to evidence coming from new developments
proposed by scientific research. For example, in the beginning the Active
Self-Correction movement (which is currently proposed as a methodological basis
within SEAS100 (Fig. 2 B) was a simple auto-elongation (Fig.
2
A) because scientific knowledge in the 1970s (in a consistent way with
Harrington’s fusion and Milwaukee brace techniques) saw in this solution the
best correction.89 Today, however, everything has radically
changed because of the knowledge about three-dimensional deformity,131 and auto-elongation has been almost completely
abandoned, having been replaced by Active Self-Correction on the three spatial
planes, according to what is reported below.100 So, by definition SEAS can radically improve
in accordance with new developments, regardless of the original ideas of the
person who first devised it.
Figure 2. SEAS originated long ago (about 30 years)97,101,121, but it doesn’t really appear very old because during this period it has continuously updated. Therefore, it’s with the times. The evolution of SEAS can be well represented by the passage from autoelongation (A) to active Self-Correction (B): in the beginning the Active Self-Correction movement (which is currently proposed as a methodological basis within SEAS100 (B) was a simple auto-elongation (A) because scientific knowledge in the 1970s (in a consistent way with Harrington’s fusion and Milwaukee brace techniques) saw in this solution the best correction.89 Today, however, everything has radically changed because of the knowledge about three-dimensional deformity,131 and auto-elongation has been almost completely abandoned, having been replaced by Active Self-Correction on the three spatial planes. Another distinctive element of SEAS
is that it acts outside the typical precepts of exercise-based techniques
and is founded upon the principle of a cognitive-behavioural approach typical
of ISICO, which in our view is an indispensable element in chronic disease
rehabilitation. In our field, this goal is pursued through regular moments of family counselling. Besides the possibility of
reassuring the patient and his/her family, and the ability to encourage
compliance, family counselling must let the patient feel that we are close to
him/her and that the entire team is working together to obtain the best
possible result. The team
concept is at the origin of the other important prerequisite of SEAS. We
believe that we can obtain the best results only if every single element of a
heterogeneous team contributes by giving the best of his/her specific
competencies, and if effective communication instruments are warranted. The
team that ISICO proposes is an extended group that in its “therapeutic” segment
includes the physician, the physiotherapist, trainer and orthotist along with
the patient and his/her family. 3.2.1
From a
biomechanical perspective, what are exercises for? Neurophysiology developments
indicate the role of Active Self-Correction
To fully understand the
biomechanical role of exercises in scoliosis treatment (which, as we will see
later, have other equally important roles),89,101,121,152,178 and to
understand why SEAS has certain unique characteristics relative to other
exercise treatments, an in-depth consideration is necessary. Every
biomechanical treatment for scoliosis tries to contrast the “vicious cycle”158 described by
Stokes (Cap. 2 - Fig. 9),
favouring a less pathological growth of affected vertebrae. In that sense, Active
Self-Correction is seen by all experts as the crucial moment of treatment, as
was confirmed by the SOSORT Consensus Conference.177 However, the point is: how can exercises influence
this “vicious cycle”? Consider
the following: - Correction obtained with exercises lasts only for the duration of exercise execution; - Even in more “aggressive” exercise methodologies, in which for certain periods patients are required to do an inpatient exercise treatment lasting up to eight hours per day,180,181 it would not be possible to hold the real correction for more than two or three hours, taking into consideration pauses and exercise intervals; - No one would ever think of proposing a corrective brace for such a short time. Given all the above, it is obvious
that exercises can work from the biomechanical point of view but only
through a permanent change in posture. So, the real question is: how can I
work better to modify my patient’s posture? Which is the best learning
method by which to obtain a new posture? Over the years, we have seen a
definite evolution from a purely mechanistic model--in which motor learning was
considered as related only to obsessive repetition--to a more complex
functional model in which repetition plays a role, but its execution in
confounding situations facilitates the creation of the correct cortical
engrams.14,64,66 Moreover, another question must be asked here: does
obtaining the maximum possible correction work better for learning a new
posture (passive auto-correction), or is it better to accept a smaller
correction but 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,14,64,66 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 can be replicated in a thousand different exercises with “distracting”
situations, thereby "strengthening" the neuromotor behaviour. The
SEAS answer specifically 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
exercises to learn behaviours) (Fig. 3).
Fig. 3. From a neurophysiological perspective,14,64,66 active movement is much better than passive one to learn neuro-motor behaviours, 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 behaviours). First line: normal posture. Second line: Active Self-Correction (ASC). Observe normalization of flanks, increase of thoracic kyphosis and better lumbar lordosis, radiographic results (C: Cobb; R: Raimondi rotation) Therefore, even if during the SOSORT
Consensus Conference177 the importance
of auto-correction has been underlined, we must notice that almost every school
of exercise, with the exception of SEAS,100 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 alignment (for example, contraction of
concavity psoas muscles in order to reduce lateral flexion component in a
lumbar scoliosis). 3.2.2
SEAS
therapeutic goals
Exercises do not have a strictly biomechanical role89,101,121,152,178. Before we explain the essential principles on
which SEAS is based, it is necessary to underline two other preliminary
remarks: - From a scientific point of view, we are still far from defining the cause of idiopathic scoliosis. - Regarding idiopathic scoliosis, we are certain of only a few elements regarding the functional impairments it causes or those with which it is associated. The research has chiefly served to clarify a series of dysfunctions that the scoliotic patient experiences and that exercise treatment based on the SEAS approach tries to reduce. The treatment schedule points to
the identification of a series of therapeutic goals that vary depending
on the phase of treatment and that must be pursued each time with the most
effective weapons available. The main dysfunctions experienced by a scoliotic
patient can be schematically described as follows. 3.2.2.1
Posture
and stability impairments
Increasing spinal stability is a primary therapeutic goal of the
SEAS approach. The importance of this rehabilitation aspect is derived from a
series of fundamental studies. Duval-Beaupère44 showed that scoliotic curve magnitude is not
only the result of a structural deformation but that there is also a postural
component signifying a difficulty of the stabilizing system in the spine to
counterbalance the alignment loss (Fig. 4). This component, which is always present, is particularly important in
the scolioses < 20° Cobb164 that are most targeted by exercises for
preventive purposes. From these observations, as well as Bunch and Patwardhan’s15 studies--which showed
how the load threshold beyond which the spine begins to get deformed (critical load) diminishes as
curvature increases--emerge the importance of improving spinal stabilisation in
order to reduce postural collapse and the consequent spinal structural
deformation potentials.
Fig. 4. Curve magnitude is not only the result of a structural deformation, (Cobb degrees in supine) but there is a postural component too (Difference in Cobb degrees between standing and supine radiographs), sign of a difficulty by the stabilizing system of the spine to counterbalance alignment loss.44
Fig. 5. The postural component has been measured,164 and corresponds to almost 10°, whose importance is obviously higher in scolioses < 20 °Cobb, that are the ones most targeted by exercises for preventive purposes. The importance of improving spinal stability derives not only
from scientific experiments but also from clinical evidence: a scoliotic spine can be seen as a structure whose
constituent elements, being subject to stimuli causing a loss of balance, are
no longer able to maintain their physiological alignment and primitive
stability. The natural history of a progressive scoliosis could therefore be a
postural collapse on several planes, which afterwards becomes a bone deformity
in accordance with the “vicious
cycle” theory ideated by Stokes158 (Fig. 5). Even during the SOSORT Consensus
Conference, which took place in Milan in
2005,177 in regard to defining the most important
therapeutic goals for scoliosis conservative treatment, the pursuit of
vertebral stabilisation was indicated as the second priority. The difficulty
probably lies in the practical way that such result can be obtained. The
therapeutic strategy proposed by the SEAS approach is based on improving
reactions to force of gravity and on enhancing the function of those muscles
that have a major stabilizing vocation (Fig.
6).68,153
Fig. 6. Load threshold beyond which the spine begins to get deformed (critical load) diminishes as curve increases.15 3.2.2.2
Neuromotor
impairments
High experts in scoliosis research, like Dubousset,42 Nachemson,94 and Stagnara150 and Herman (Fig.
7)65 have intuitively postulated the correlation
between postural deficits and spinal balance/stability. More recently, several
authors58,79,86 have also identified, among the aetiological
cofactors for scoliosis, balance dysfunctions. This is because a correlation
between idiopathic scoliosis and postural control proved to be evident, even if
the relationship between deficit magnitude and the progressive potential of
curvature has not yet been clarified. On the basis of these observations and
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 devote particular attention.
Fig. 7. Herman's theory, awarded with the Harrington Lecture by SRS, that considers scoliosis as a compensation to neuromotorial dysfunctions. 3.2.2.3
Sagittal
plan impairments
Several researches, among which those of Perdriolle131 and Graf54 in particular indicate that the evolution of
scoliotic curvature is characterised by a reduction of the curves on the
sagittal plane (flat or hollow back), a biomechanical condition that, according
to White and Panjabi,183 also facilitates axial rotation. In the
exercises proposed by the SEAS approach, the search and preservation of a
physiological sagittal orientation in the scoliotic spine is also a main
therapeutic goal. 3.2.2.4
Other
impairments
Finally, we cannot neglect the
impairments that scoliosis causes at an organic (aerobic) level, with a
reduction of both vital capacity and oxygen conduction ability (VO2max),37-39 the latter of which, among other
things, proves to be disproportionate to vital capacity reduction but related
to deficient physical conditioning. Furthermore, the psychological aspect is
a crucial one: it is partly due to the age at which the pathology appears but
also to the often iatrogenic influence on the psyche as determined by treatments
and healthcare operators. All these aspects are taken into consideration within
the SEAS approach. 3.2.3
SEAS
and brace treatment
The effects of an exercise regimen for a patient with adolescent
idiopathic scoliosis wearing corrective braces can be divided into two areas:9,20,33,89,101,121,152 general and specific. The former includes all
those beneficial modifications (obtained through the activation of muscles, the
stimulation of ventilatory exchanges and psychological help) that physical
activity induces in the patient, reducing impairments and disabilities due
to the orthosis. Let’s look at these one at a time: - Activation of muscles: In braced patients, it is normally thought that the supporting action of trunk muscles is reduced;9,50,87,89,97,101 exercises are proposed to avoid this effect, which could be more pronounced in adolescent patients using braces all day long. They have the effect of stabilizing the spine when the brace is removed; - Stimulation of ventilatory exchanges: Vital capacity and VO2 max are often reduced in patients, like ours, whose scoliosis exceeds 30o Cobb.26,39 VO2 max is usually reduced beyond a level that might be explained by a decrease in vital capacity alone. This reduction is usually due to a lack of physical exercise,67,69 and therefore exercises are proposed to increase vital capacity, train the patient so that both the cardiovascular and the musculo-skeletal systems have an increased capacity to use oxygen, and improve respiratory ability from a neuromuscular point of view; - Psychological help: Braces induce a “negative body image”46 in a growing child that could in turn lead to an immature personality in adulthood. Exercises are proposed to reduce the disability induced by the brace (the extent of which is not as great as that induced by the impairment itself) and the patient's feeling of inferiority with respect to his/her friends. The area of specific effects, on the other hand, relates to the
pressure that braces exert on the spine through the soft tissues. Specific
exercises have been proposed by Stagnara150,152 and many others9,20,33,50,87,89,146,166 with the rationale of increasing corrective
forces applied by the brace, somehow using movements as “dynamic tools” to
amplify the corrective “static” forces applied by the orthosis. Such movements
are obviously instantaneous, but the immobilisation of ribs and spine that they
induce (the former having modelling and the latter derotatory and deflective
effects) could in time and with repetition play a major role in bringing about
a positive effect of the brace.150,152 Moreover, it is necessary to consider that: - According to many aetiological theories, the central nervous system could play an important role in the origin of the deformity;65,73 - It has been supposed that soft tissues are not able to passively withstand the forces that should be applied by a brace in order to correct a scoliosis;191 - The brace corrective effect on Cobb angle reduction is strongly correlated to pad pressure;190 - Strap tension should be set as high as possible for right thoracic curves78; - Muscular contraction has been supposed to play a major role in the effect determined by braces5,191 and estero- and proprioceptive stimuli have also been considered important elements in causing a rearrangement of the postural system.65 On the basis of these assumptions, the forces applied during specific
exercises and physical activities are important not only from a biomechanical
perspective but also from a neurological one, helping the patient to develop a
new spinal behaviour. In this respect, exercises that are able to act on the
spine by increasing the forces of the brace and driving vertebrae in the
direction of the correction through the “escape from the pad” movement152,163 could be extremely useful. 3.3
Practical
application of SEAS concept
3.3.1
Goals
of exercises according to SEAS protocol
Scientific research showed that scoliosis causes functional impairments at a neuromotor, biomechanical,
organic and psychological level102,103,121. 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,91,118 while in braced ones this kind of
therapy is useful to increase the orthosis corrective action and avoid its side
effects. 3.3.2
Exercises
in low-degree scoliosis treatment
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 aerobic functioning and development
of a positive body image. 3.3.2.1
Postural control and spinal stability
Nachemson94 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 are postural rehabilitation, muscular
endurance strengthening in a correct posture, development of balance reactions
and neuromotor integration.28 Let’s take into consideration these modalities. 3.3.2.1.1
Postural rehabilitation
It 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. 3.3.2.1.2
Active Self-Correction
Active Self-Correction on the three spatial planes is the most important
individualised therapeutic moment directed towards one’s own deformity. It includes
several phases, as follows: - The first phase includes becoming aware of curve apex translation towards concavity on the frontal plane, and is done in several postures (Fig. 8). For example, 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.
Fig. 8. Active Self-Correction on the frontal plane. A - The therapist puts his/her fingers on the spinous processes correspondent to thoracic curve apex, while the patient lets the vertebrae shift towards concavity side. B - The therapist puts his/her fingers on the spinous processes correspondent to lumbar curve apex, while 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. - The phase immediately following includes becoming aware of correction on the sagittal plane. The studies of Perdriolle,131 Graf,54 White and Panjabi183 highlighted that idiopathic scoliosis, in the case of progression, reduces physiological curvatures on the sagittal plane, favouring 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 (Fig. 9). -
Fig. 9. Active Self-Correction on the sagittal plane A -By leaning against the upright, the patient then does a pelvis antiversion (to recreate lumbar lordosis) and a thoracic kyphotization (to recreate thoracic kyphosis). B- The patient does the same exercise without the help of the upright, at first looking at him/herself in the mirror. - Finally, we associate active Self-Correction movements on the frontal and sagittal planes. According to Dickson’s studies,34 an action done on two 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 performed by the patient in an independent manner and applied in every
standing exercise. 3.3.2.1.3
Muscular endurance strengthening in
the correct posture
Muscle endurance strengthening aims at developing paravertebral, abdominal, lower
limbs and scapulo-humeral girdle muscles through isometric 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 duration of isometric contraction of the
chosen muscles (Fig. 10). Panjabi and Abumi’s studies showed
that the spine needs good muscular support in order to guarantee greater
stability in a scoliotic spine.
Fig. 10. Muscular endurance strengthening in the correct posture. We ask the
patient to execute an active Self-Correction movement and to hold it for the
entire isometric contraction of the chosen muscles duration 3.3.2.1.4
Development of balance 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
(Fig. 11). Stagnara150 claims that the development of
balance reactions must be one of the main goals of rehabilitation because
scientific research has shown the presence of some impairments in cortical
centres that control balance in scoliotic patients.
Fig. 11. Development of
balance reactions Proposed exercises are always done in Active Self-Correction,
even on unstable planes, developed with growing difficulties 3.3.2.1.5
Neuromotor integration
This aims at integrating in everyday behaviours a more correct and better-balanced
spinal posture, progressively developing the ability to react with correct
functional 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 treatment, we give ergonomy
information so as to avoid spinal damage in
adulthood. 3.3.2.2
Aerobic functioning and development
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Fig. 12. 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
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Fig. 13. Modeling exercises in brace. A - The patient is in a relaxed position. B - The patient moves away from sternal upright to do a maximum thoracic kyphotization movement. C - The patient is in a relaxed position. D - The patient moves away from abdominal upright to maximally exert a pressure on the lumbar pressure pad
We require the execution of: modelling exercises in order to increase brace pressure on humps (Fig. 14); muscular endurance strengthening exercises, requiring lumbar lordosis and thoracic kyphosis preservation, while frontal and cross-sectional plane correction is guaranteed by brace pushes. We propose specific breathing activation exercises only when we detect some significant reductions of vital capacity.
Fig. 14. Muscular endurance strengthening exercises. We propose strengthening exercises, requiring lumbar lordosis and thoracic kyphosis preservation , while frontal and cross-sectional plans correction is guaranteed by brace pushes
- Complete brace weaning: We teach ergonomy elements aimed at avoiding spinal damage in adulthood.
During brace treatment, it is of fundamental importance to pursue
continuatively these other two goals: aerobic functioning and development of a
positive body image. For that reason, we recommend intensifying participation
in motor and sport activities, both agonistic and/or recreational, even
with a brace that must be worn full time (Fig. 15).
Fig. 15. Aerobic functioning and development of a positive body image
During brace treatment, we recommend to intensify participation in
motor and sport, both agonistic and/or recreational activities, even while
wearing a brace, like in the two cases presented.
The presence of the brace should never force any limitation upon the young patient’s personal and social life.
3.4
Results of SEAS
3.4.1
Scientific
results
3.4.1.1 SEAS treatment reduces the need for bracing
The main objective of exercise treatment is to
avoid that patient’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 controlled cohort study119 the results obtained in 69 patients
at risk of brace treatment; they were divided into two groups and were followed
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
follow-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 (Fig.
16). Further studies with longer
follow-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.
Fig. 16.
Percentage of braced patients in SEAS and control (CONT) group after 1 and 2
years of treatment119
3.4.1.2 SEAS treatment improves scoliosis parameters
In the study already mentioned119, we also documented exercises
results with traditional measures. In terms of Cobb degrees, the percentage of
patients who showed a radiographic 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 SEAS group (12% vs. 14%) (Fig. 17).
Fig. 17.
Patients improved, stable or worsened in terms of Cobb angle. After therapy,
the percentage of patients with improved Cobb angle in SEAS group is more than
twice that of control (CONT) group119
Upon a clinical evaluation of the largest curve
hump using Bunnell’s scoliometer, in the SEAS group we noticed a
stability/improvement in 73% of cases vs. 58% in the CONT groups (Fig.
18).
Fig. 18.
Patients improved, stable or worsened in terms of Bunnel angle. After therapy,
the percentage of patients with improved Bunnel angle in SEAS group in more
than twice that of control (CONT) group119
3.4.1.3 SEAS treatment normalizes balance and coordination in scoliosis patients
According to the SEAS protocol, exercises aim
at improving some specific impairments of the scoliotic patient so as to
normalize them and reduce the risk of progression of scoliosis. Among these, we
have equilibrium and coordination. In a controlled cross-sectional cohort
study,138 we evaluated 190 subjects divided
into two groups (forty Adolescent Idiopathic Scoliosis patients and 150
controls), and those patients were divided in two sub-groups (twenty treated
for one year with SEAS and twenty not treated). All participants were evaluated
through Unterberger (Fukuda), Romberg (sensitised and not sensitised) and
lower-limb oscillation tests. Patients treated with the SEAS protocol showed
results that were superimposable to the ones of control subjects, and on a
statistical basis both groups were definitely better than untreated scoliosis
patients.
3.4.1.4 Active Self-Correction according to SEAS principles reduces the radiographic curve
Autocorrection has been considered by SOSORT
experts as a key aim of exercises for idiopathic scoliosis: the Active
Self-Correction (ASC) is a kind of autocorrection actively performed by the
patient, without any external aid, that forms the base of SEAS (Fig. 3). 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 de-rotation: this
movement is very difficult and require some months to be learned. 27
consecutive patients under treatment that required x-ray examination for their
clinical follow-up have been included in the study100. All patients performed x-ray exam
both standard and in ASC; moreover, they all were photographed frontally and
laterally to have an evaluation of the quality of ASC. The statistically
significant percentage of reduction of scoliosis was 11.0±12.3%, with a reduction of rotation of
13.2±63.4%. This study proves that it is
possible to reduce actively the curvature with a selective action, without any
external aid, and that expert physiotherapists can teach ASC.
3.4.1.5 SEAS treatment improve results in case of bracing
Exercises play an important role in the preparation for brace treatment too, where they aim at facilitating orthosis function.
Fig. 19.
Effect of SEAS pre-brace treatment. Patients who
performed SEAS had a better result after bracing than controls118
To confirm whether the SEAS protocol,
mobilizing and preparatory to the brace, had this ability, we compared, with a
controlled prospective cohort study118 of the beginning of brace therapy,
the results obtained at the first radiographic follow-up at four months in 110
patients, divided into two groups. Data showed a higher efficacy of SEAS treatment,
compared to standard exercises (CONT group) in regard to cosmetic appearance
(Aesthetic Index) and Cobb degrees of the largest curve and hump (Fig. 19).
3.4.1.6 SEAS kyphotisation exercise is the most useful to help bracing push work
We performed a study136 in seventeen consecutive adolescents to
quantify and compare different exercises (kyphotisation, rotation and “escape from
the pad” in different positions – sitting, supine and on all fours) performed
in braced condition so as to increase their corrective forces. We verified that
in static and dynamic conditions the position adopted does not alter the total
pressure exerted by the brace. Kyphotisation and rotation exercises guarantee a
significant increase of pressure (+ 58.9% and 29.8% respectively), while the
“escape from the pad” exercise, despite its name, does not produce any
significant variation of pressure. We concluded that exercises in braced
condition allow the application of adjunctive forces on soft tissues and,
through those tissues, presumably on the spine. Different exercises can be
chosen in order to obtain different actions; physical exercises and sporting
activities are useful in mechanical terms, although other important actions are
not to be neglected (Fig. 20).
Fig. 20.
Forces of brace pushes can be incremented by specific
exercises. Kyphotisation can increment forces up to 60%136