Correlation between scoliosis deformity type and trunk symmetry before and after schroth physiotherapeutic exercises

Abstract

The variety of the scoliosis deformities is large. They can differ in type and severity. Our interest is the effectiveness of teaching in corrective exercises. Our aim is to follow the dynamics of the posterior (POTSI) and anterior trunk symmetry index (ATSI) in relation to the type of scoliosis deformity according to Rigo classification.
For a period of 2 years and 8 months (April 2014 ÷ November 2016) we accessed 128 children with adolescent idiopathic scoliosis with different severity – low 7.8%, low to moderate 20.3%, moderate 39.1%, moderate to severe 17.2%, severe 11.7% and very severe 3.9%. They were distributed in 4 groups according to Manuel Rigo: 3C (single thoracic or thoracolumbar) 29.6%, 4C (double major) 25%, N3N4 (scoliosis with good balance) 31.3% and G 1‑2 (single lumbar) 14.1%. We made photos from anterior and posterior for calculating POTSI and ATSI in the beginning of therapy and on the 5th day after exercises. All patients we taught to make exercises for correction according to Schroth method after the initial evaluation. Teaching the patients included 5 consecutive days of 120 min in small groups of 2 children.
The highest initial POTSI asymmetry was found in group 3C 42.14 ± 20, with lowest POTSI asymmetry in group N3N4 with 23.22±11.38. With ATSI the highest initial asymmetry was in 3C 29.09 ± 12.73 and 4C 30.11 ± 13.49, with lowest asymmetry in G 1‑2 20.41±12.86. We have statistically significant improvement in all patients as for POTSI from initial 31.27 ± 17.1 to the end value of 23.08 ± 14.38 (0.634, p < 0.001), as also for ATSI from initial 27.09 ± 12.37 to end value of 22.9±10.69 (0.501, p < 0.001). Statistically remarkable is the improvement of POTSI in group 3C from initial 42.14±19.98 to end value of 27.36 ± 17.63 (0.607, p < 0.001), which could be explained with the higher initial asymmetry. In the other groups improvement of POTSI is with similar values: 4C from initial 29.72 ± 14.17 to end 26.23 ± 15.04 (0.704, p < 0.001); N3N4 from initial 23.22 ± 11.38 to end 17.09 ± 8.85 (0.480,p < 0.01); G 1‑2 from initial 28.53 ± 14.49 to end 21.54 ± 10.71 (0.590, p < 0.1).
Improvement in the trunk symmetry does not depend on the severity and type of scoliosis, but only on the initial values. With PSSE we have statistically significant improvement in the symmetry indices (POTSI and ATSI) only for 5 days intensive training. Single thoracic and single thoracolumbar scoliosis leads to the most pronounced asymmetry in comparison to the scoliosis with good trunk balance.

Key words: scoliosis, POTSI, ATSI, Rigo classification, BSPTS, Schroth method

Full text

Доклади на Българската академия на науките
Comptes rendus de l’Acad´emie bulgare des Sciences
Tome 70, No 10, 2017
MEDECINE
M´edecine clinique
CORRELATION BETWEEN SCOLIOSIS DEFORMITY TYPE
AND TRUNK SYMMETRY BEFORE AND AFTER
SCHROTH PHYSIOTHERAPEUTIC EXERCISES
Borislav Chongov∗,∗∗ , Venelin Alexiev∗∗, Hristo Georgiev∗∗ ,
Krasimir Kalinov∗∗∗, Evgenia Dimitrova∗
(Submitted by Corresponding Member L. Traykov on February 15, 2017)
Abstract
The variety of the scoliosis deformities is large. They can differ in type
and severity. Our interest is the effectiveness of teaching in corrective exercises.
Our aim is to follow the dynamics of the posterior (POTSI) and anterior trunk
symmetry index (ATSI) in relation to the type of scoliosis deformity according
to Rigo classification.
For a period of 2 years and 8 months (April 2014 – November 2016) we
accessed 128 children with adolescent idiopathic scoliosis with different sever-
ity – low 7.8%, low to moderate 20.3%, moderate 39.1%, moderate to severe
17.2%, severe 11.7% and very severe 3.9%. They were distributed in 4 groups
according to Manuel Rigo: 3C (single thoracic or thoracolumbar) 29.6%, 4C
(double major) 25%, N3N4 (scoliosis with good balance) 31.3% and G 1–2
(single lumbar) 14.1%. We made photos from anterior and posterior for calcu-
lating POTSI and ATSI in the beginning of therapy and on the 5th day after
exercises. All patients we taught to make exercises for correction according to
Schroth method after the initial evaluation. Teaching the patients included 5
consecutive days of 120 min in small groups of 2 children.
The highest initial POTSI asymmetry was found in group 3C 42.14 ±20,
with lowest POTSI asymmetry in group N3N4 with 23.22 ±11.38. With ATSI
the highest initial asymmetry was in 3C 29.09 ±12.73 and 4C 30.11 ±13.49,
with lowest asymmetry in G 1–2 20.41 ±12.86. We have statistically significant
improvement in all patients as for POTSI from initial 31.27 ±17.1 to the end
value of 23.08 ±14.38 (0.634, p < 0.001), as also for ATSI from initial 27.09 ±
12.37 to end value of 22.9±10.69 (0.501, p < 0.001). Statistically remarkable is
the improvement of POTSI in group 3C from initial 42.14 ±19.98 to end value
of 27.36 ±17.63 (0.607, p < 0.001), which could be explained with the higher
initial asymmetry. In the other groups improvement of POTSI is with similar
values: 4C from initial 29.72 ±14.17 to end 26.23 ±15.04 (0.704, p < 0.001);
N3N4 from initial 23.22 ±11.38 to end 17.09 ±8.85 (0.480,p < 0.01); G 1–2
from initial 28.53 ±14.49 to end 21.54 ±10.71 (0.590, p < 0.1).
1455

Improvement in the trunk symmetry does not depend on the severity and
type of scoliosis, but only on the initial values. With PSSE we have statistically
significant improvement in the symmetry indices (POTSI and ATSI) only for 5
days intensive training. Single thoracic and single thoracolumbar scoliosis leads
to the most pronounced asymmetry in comparison to the scoliosis with good
trunk balance.
Key words: scoliosis, POTSI, ATSI, Rigo classification, BSPTS, Schroth
method
Introduction. Scoliosis is a three plane deformity of the spine with predom-
inance in frontal plane. There are different classifications for assessment type of
scoliotic deformity. The most detailed classification of Lenke [1] includes 6 basic
groups and 3 subgroups (A, B, C). It describes the model of the deformity, num-
ber of the curves and their severity, spine topography and saggital profile. This
classification is primary for surgical treatment indication. The classification of
Lehnert-Schroth [2] distributes the patients according to corrective exercises
and includes 2 major groups: a model with 3 curves and a model with 4 curves.
This classification was supplemented by Rigo [3], who describes 5 curves, dis-
tributed in 4 groups. They serve as a guide for the exercises according to Schroth
principles and are presented as a block scheme. Similar is the radiological classi-
fication that accesses treatment with braces type Rigo System Chˆeneau (RSCr)
[4]. In the present investigation Rigo classification is used for the first time in
Bulgaria.
Schroth physiotherapeutic method is developed in Germany by Katharina
Schroth in 20th century and is further improved by Lehnert-Schroth [5, 6].
The first randomized investigation for the period 1989–1991 was published in
1995 [7]. Rigo conducts many investigations that show good trunk correction
immediately after exercises in three planes [8–10 ]. Schroth method is introduced
for the first time in Bulgaria by our team in 2014.
The aim of the current investigation is to follow the dynamics of the posterior
(POTSI) and anterior trunk symmetry index (ATSI) in relation to the type of sco-
liosis deformity according to Rigo classification after Schroth exercises treatment
(Fig. 1).
Material and methods. From April 2014 to November 2016 (2 years 8
months) in Sofia Medical University Orthopaedic Hospital “Prof. Boicho Boichev”
and the National Sports Academy 128 children with adolescent idiopathic scolio-
sis (AIS) were investigated. In all cases the therapy was indicated by a paediatric
orthopaedic or spine surgeon according to severity of deformity: in curvature
10◦to 25◦Cobb angle – physiotherapeutic scoliosis-specific exercises (PSSE), in
curvature 25◦to 45◦Cobb angle – brace treatment and PSSE and in curvatures
>45◦according to Cobb – operative treatment. Patients, indicated for opera-
tive treatment, but with written consent refusal of surgery, were also included for
brace and PSSE treatment.
1456 B. Chongov, V. Alexiev, H. Georgiev et al.

Fig. 1. Patients, classified according to Rigo classification and their
Posterior trunk symmetry index (POTSI): 3C – 54.35; 4C – 66.85;
N3N4 – 44.53; G 1–2 – 39.24
Our patients were distributed in 4 groups according to Rigo classification:
3C (single thoracic or thoracolumbar) – 29.6%, 4C (double major) – 25%, N3N4
(scoliosis with a good balance) – 31.3% and G 1–2 (single lumbar) – 14.1%.
The therapy consists of teaching the patients to perform PSSE according
to Katharina Schroth method for 5 consecutive days with 120 min duration in
small groups of 2 children. The treatment plan includes the following steps.
First the patients are getting familiar with his/her scoliosis spine deformity and
trunk changes. Then the patients are educated in auto-distraction of torso and
corrective rotational breathing aiming transverse plane correction and muscular
activation. At the end patients are educated how to keep the correction in daily
activities. After treatment therapy consists of everyday home exercises and once
a week group exercises.
For calculating POTSI and ATSI in the beginning of therapy and at the end
after exercises we made digital camera photos from anterior and posterior
Statistical methods. We used descriptive methods for parameters, calcu-
lated by non metrical scales that are given absolute (number) and relative (%)
incidence. For parameters, calculated by metrical scales, were given: number of
cases, average arithmetical value and standard deviation. Basic method for hy-
pothesis validation was ANCOVA (co-variation analysis), including factors and co
variants of the following parameters: result at inclusion (baseline), severity of the
condition and group. Where possible Student t-test was applied for 2 correlated
groups.
9Compt. rend. Acad. bulg. Sci., 70, No 10, 2017 1457

T a b l e 1
Patients distributed in groups according to M. Rigo’s classification, severity of scoliosis
curve according to Cobb angle and SOSORT 2011 classification
Severity
Group Low Low-
moderate Moderate Moderate-
severe Severe Very
severe Total
3C N 3 6 14 7 7 1 38
% 7.9 15.8 36.8 18.4 18.4 2.6 100.0
4C N 1 4 12 11 1 3 32
% 3.1 12.5 37.5 34.4 3.1 9.4 100.0
N3N4 N 3 9 18 4 5 1 40
% 7.5 22.5 45.0 10.0 12.5 2.5 100.0
G 1–2 N 3 7 6 0 2 0 18
% 16.7 38.9 33.3 0.0 11.1 0.0 100.0
Total N 10 26 50 22 15 5 128
% 7.8 20.3 39.1 17.2 11.7 3.9 100.0
T a b l e 2
Posterior (POTSI) and anterior (ATSI) trunk symmetry index in the
beginning and at the end of treatment
Group POTSI before POTSI after ATSI before ATSI after
3C N 38 38 35 35
Mean 42.1368 27.3616 29.0951 22.9363
4C N 32 32 23 22
Mean 29.7178 26.2394 30.1122 25.8473
N3N4 N 40 40 26 25
Mean 23.2190 17.0868 24.5996 22.6832
G 1–2 N 18 15 16 14
Mean 26.5428 21.5367 20.4056 18.5821
Total N 128 125 100 96
Mean 30.9273 23.0874 26.7699 22.9025
Results. The patients are distributed according to severity of Cobb angle as
follows: low 7.8%, low to moderate 20.3%, moderate 39.1%, moderate to severe
17.2%, severe 11.7% and very severe 3.9%, calculated as in SOSORT 2011 manual
(Table 1).
The highest initial POTSI (Table 2) asymmetry was found in group 3C
42.14±20, with lowest POTSI asymmetry in group N3N4 with 23.22±11.38. With
ATSI the highest initial asymmetry was in 3C 29.09 ±12.73 and 4C 30.11±13.49,
with lowest asymmetry in G 1–2 20.41 ±12.86. We have statistically significant
improvement in all patients as for POTSI from initial 31.27±17.1 to the end value
of 23.08 ±14.38 (0.634, p < 0.001), as also for ATSI from initial 27.09 ±12.37
to end value of 22.9±10.69 (0.501, p < 0.001). Statistically remarkable is the
1458 B. Chongov, V. Alexiev, H. Georgiev et al.

Fig. 2. Clinical cases: 3C scoliotic curve with 30◦Cobb angle and improvement of POTSI from
65.63 to 20.52 with 5 days PSSE. 4C scoliotic curve with 42◦Cobb angle thoracic and 30◦Cobb
lumbar with improvement 66.85 to 64.2 POTSI
improvement of POTSI in group 3C from initial 42.14 ±19.98 to end value of
27.36 ±17.63 (0.607, p < 0.001), which could be explained with the higher initial
asymmetry (Fig. 2). In the other groups improvement of POTSI is with similar
values: 4C from initial 29.72 ±14.17 to end 26.23 ±15.04 (0.704, p < 0.001);
N3N4 from initial 23.22 ±11.38 to end 17.09 ±8.85 (0.480, p < 0.01); G 1–2 from
initial 28.53 ±14.49 to end 21.54 ±10.71 (0.590, p < 0.1).
Discussion. The application of different classifications for scoliosis defor-
mity allows more precision in the methodology of PSSE. All the above cited
classifications supplement each other. Lenert-Schroth classification, modified by
Rigo is based on external signs and shows deformity type in accordance with the
outer body contour. For higher clarification the body is presented as a scheme
of blocks. There are 4 basic blocks: shoulder girdle, thorax, lumbar region and
pelvic ring. With different curves these blocks move in a specific direction. In
a single thoracic and thoracolumbar scoliosis we observe a shift of the thorax
towards convexity of the deformity. The pelvic ring and lumbar region move
towards the concavity. The shoulders also shift to the concave side. The dis-
placement is on three levels and is called 3C (3 curvature scoliosis). We found
that the symmetry indices are highest in 3C, indicative of higher asymmetry.
Compt. rend. Acad. bulg. Sci., 70, No 10, 2017 1459

Our opinion is that this type of scoliosis is most easily detectable. In a double
curve scoliosis we observe shifting of the thoracic and pelvic blocks towards the
convex thoracic curve, while the shoulder and lumbar blocks move towards the
convex lumbar curve. Displacement is on 4 levels and is marked as 4C (4 cur-
vature scoliosis). The POTSI is lower than in 3C with a statistically significant
difference. We also found curvatures where we do not observe shifting of the
pelvic ring. In these curves photography proves good balance with coincidence
of the central sacral vertical line with Th 1. The other blocks move in direction
of the curvature. These curves are classified as N3N4 (non 3 non 4 curvature
scoliosis). Symmetry indices are best in this group. Presence of a single lumbar
curve is classified as G 1–2 (group 1–2 curvature scoliosis). In this group shoulder
and thoracic blocks remain nondisplaced, while lumbar block displaces towards
convexity and pelvic ring – towards concavity. The upper two blocks we treat by
symmetry exercises, while the lower two – asymmetrically. The aim of PSSE in
this group is keeping the physiological saggital profile in the thoracic region and
correction of the lumbar scoliotic curve. POTSI is better than in 4C, but worse
than in N3N4 group.
According to the manual of the Society on Scoliosis Orthopaedic and Reha-
bilitation Treatment (SOSORT) the aims of conservative scoliosis treatment are:
1. Stop of scoliosis deformity progression during the growth spurt of the child
in puberty; 2. Prophylaxis and treatment of respiratory dysfunction; 3. Prophy-
laxis and treatment of pain syndromes; 4. Improvement in symmetry and outer
outlook of the body; 5. Reducing necessity for surgical treatment [11].
There are different tests, based on body topography, to access symmetry
and to prognose eventual spine deformity without X-ray [12]. Photography is fre-
quently used for scoliosis monitoring and for a patient feedback. Using photogra-
phy the symmetry index of Suzuki [13] can be calculated, defined as POTSI. This
index utilizes the central sacral vertical line (CSVL) and is a sum of 6 subindices,
of which 3 horizontally and 3 vertically oriented. With photos from anterior ATSI
of Stolinski [14] is calculated, using the same principles.
In our material 15.6% of the cases are with scoliosis with Cobb angle above
45◦, i.e. out of scoliosis conservative treatment indications by the aforementioned
physiotherapeutic method. We explain this by several factors: 1. Refusal of the
family for a surgical scoliosis correction; 2. In children with flexible structure and
refusal for surgery postponing definitive treatment by 6 months with an aim to
reduce Cobb angle below 40◦; 3. Preoperative preparation for making the curve
flexible if possible and reducing it to some extent.
In our investigation we found statistically significant improvement in ATSI
and POTSI despite the short period of training of the patients. Improvement is
found only in connection with the initial indices values. It does not correlate with
the type and severity of scoliosis. This gives us confidence that physiotherapeutic
program, based on precise classification and principles can lead to future improve-
1460 B. Chongov, V. Alexiev, H. Georgiev et al.

ments in the Cobb angle, reported by various authors [15–18]. Fast improvement
in symmetry gives additional stimulus for performing the exercises at home and
regular attendance of the weekly group exercises. Symmetry indices can be used
on the one hand for a fast evaluation of the posture, and on the other – for a fast
feedback, estimating effectiveness of the manipulations and exercises. Stolinski
[19] finds improvement in symmetry after a single manipulation on the sacroiliac
joint in kids.
Conclusion. Scoliosis treatment is multidisciplinary [11 ]. The presented
method is a part of this complex treatment. The Schroth method is widely ac-
cepted in Europe and is for the first time applied in Bulgaria. According to us
an indication for its usage are scoliotic curves between 15◦and 50◦in children
below 10 years of age. Its application does not depend on the curve type and the
accompanied brace treatment. The method improves even the deformities in sag-
gital plane (hyperkyphosis, hyperlordosis). In severe grade scoliosis over 50◦Cobb
angle, preoperative Schroth method application makes easier the intraoperative
correction.
REFERENCES
[1]Lenke L. G., R. R. Betz, J. Harms, K. H. Bridwell, D. H. Clements et
al. (2001) Adolescent idiopathic scoliosis: a new classification to determine extent of
spinal arthrodesis, J. Bone Joint Surg. Am., 83-A(8), 1169–1181.
[2]Lehnert-Schroth C. (2000) Dreidimensionale Skoliosebehandlung. 6 Auflage,
Stuttgart, Urban and Schwarzer.
[3]Rigo M., G. Quera-Salv´
a, M. Villagrasa, M. Ferrer, A. Casas et al.(2008)
Scoliosis intensive out-patient rehabilitation based on Schroth method, Stud. Health
Technol. Inform., 135, 208–227.
[4]Rigo M., H. R. Weiss (2008) The Chˆeneau concept of bracing–biomechanical
aspects, Stud. Health Technol. Inform., 135, 303–319.
[5]Weiss H. R. (2011) The method of Katharina Schroth – history, principles and
current development, Scoliosis, 6, 17.
[6]Lehnert-Schroth C. (2007) Three-dimensional treatment for scoliosis. A physio-
therapeutic method to improve deformities of the spine, Palo Alto, CA, The Mar-
tindale Press.
[7]Weiss H. R. (1995) The Schroth scoliosis-specific back school – initial results of a
prospective follow-up study, Z. Orthop. Ihre Grenzgeb., 133(2), 114–117.
[8]Rigo M., G. Quera-Salv´
a, M. Villagrasa, M. Ferrer, A. Casas et al. (2008)
Scoliosis intensive out-patient rehabilitation based on Schroth method, Stud. Health
Technol. Inform., 135, 208–227.
[9]Rigo M., G. Quera-Salv´
a, M. Villagrasa, M. Ferrer, A. Casas (2007)
Effect of specific exercises on the sagittal profile of scoliotic spines, Scoliosis, 2(Suppl
1), 7.
[10]Bettany-Saltikov J., T. Cook, M. Rigo, C. D. Mauroy, M. Romano et al.
(2012) Physical therapy for adolescents with idiopathic scoliosis. In: Physical Ther-
Compt. rend. Acad. bulg. Sci., 70, No 10, 2017 1461

apy Perspectives in the 21st Century Challenges and Possibilities (Eds J. Bettany-
Saltikov, B. Paz-Lorido), Rijeka, Croatia, InTech, 3–40.
[11]Negrini S., A. G. Aulisa, L. Aulisa, A. B. Circo, J. C. de Mauroy et
al. (2012) 2011 SOSORT guidelines: Orthopaedic and Rehabilitation treatment of
idiopathic scoliosis during growth, Scoliosis, 7(1), 3.
[12]Patias P., T. B. Grivas, A. Kaspiris, C. Aggouris, E. Drakoutos (2010) A
review of the trunk surface metrics used as Scoliosis and other deformities evaluation
indices, Scoliosis, 5, 12.
[13]Suzuki N., K. Inami , T. Ono, K. Kohno, M. A. Asher (1999) In: Research into
Spinal Deformities 2. Stokes, I. A. F. Amsterdam, IOS Press; Analysis of posterior
trunk symmetry index (POTSI) in Scoliosis, Part 1, 81–84.
[14]Stolinski L., T. Kotwicki, D. Czaprowski, J. Chowanska, N. Suzuki (2012)
Analysis of the Anterior Trunk Symmetry Index (ATSI). Preliminary report, Stud.
Health Technol. Inform., 176, 242–246.
[15]Zapata K., E. Parent, D. Sucato (2016) Immediate effects of scoliosis-specific
corrective exercises on the Cobb angle after one week and after one year of practice,
Scoliosis Spinal Disord., 11(Suppl 2), 36.
[16]Schreiber S., E. C. Parent, E. K. Moez, D. M. Hedden, D. Hill et al.
(2015) The effect of Schroth exercises added to the standard of care on the quality of
life and muscle endurance in adolescents with idiopathic scoliosis – an assessor and
statistician blinded randomized controlled trial: “SOSORT 2015 Award Winner”,
Scoliosis, 10, 24.
[17]Schreiber S., E. C. Parent, D. M. Hedden, M. Moreau, D. Hill et al.
(2013) The effects of a 6-month Schroth intervention for Adolescent Idiopathic Scol-
iosis (AIS): preliminary analysis of an ongoing randomized controlled trial, Scoliosis,
8(Suppl 2), O44.
[18]Schreiber S., E. C. Parent, E. K. Moez, D. M. Hedden, D. L. Hill et al.
(2016) Schroth Physiotherapeutic Scoliosis-Specific Exercises Added to the Standard
of Care Lead to Better Cobb Angle Outcomes in Adolescents with Idiopathic Scoliosis
– an Assessor and Statistician Blinded Randomized Controlled Trial, PLoS One,
11(12), e0168746.
[19]Stolinski L., T. Kotwicki (2012) Change of the child’s posture after sacroiliac
joint manipulation: improved symmetry assessed with the POTSI index. 8th Interna-
tional Conference on Conservative Management of Spinal Deformities and SOSORT
2011 Annual Meeting, Scoliosis, 7(Suppl 1), O65.
∗National Sports Academy “V. Levski”
Department of Physiotherapy
∗∗ Sofia Medical University
Orthopaedic Hospital “Prof. B. Boichev”
and MC “Orthomed”
56, N. Petkov Blvd
1614 Sofia, Bulgaria
e-mail:bobychongov@gmail.com
∗∗∗ New Bulgarian University
Department of Informatics
21, Montevideo St
1618 Sofia, Bulgaria
1462 B. Chongov, V. Alexiev, H. Georgiev et al.