The best clinical decision I've made in my 23 years of practice as a physical therapist has been to specialize in the rehabilitation applications of Pilates. I use Pilates equipment as a tool to treat physical dysfunction, posture abnormalities and pain. Superior core activation and rapid results provide patient satisfaction and invaluable word-of-mouth recommendations to friends and physicians. The practice has helped me to tap into a level of creative therapy I didn't know I possessed. Applications for adolescent scoliosis reduction and de-rotation are particularly exciting.
Teenage patients love working out on the Reformer, Trapeze and Pilates Chair. Even though Pilates equipment can be cost prohibitive for home use, there are some great inexpensive options to use for a home exercise program. There are a multitude of free videos on YouTube that demonstrate how to use a mobile version of the Half Trapeze.
I often use my smart phone to take photos or record videos of a patient performing the exercises we learn in therapy. I e-mail the files to the patient so they have a unique and individualized home program. With this method, I find patients are generally more likely to be compliant with their home programs.
Foundational instruction in isolating the transverse abdominals is key to effective training. Providing my patients with instructions to exhale and simultaneously "cinch in the waist" is helpful. In some cases, I tie a resistive band around the waistline for tactile feedback to remind the patient to keep the waist cinched in. During this method, I have the patient use mirror feedback to check for accuracy, which paves the way for instruction in both lateral rib breathing and oblique rib (de-rotational) breathing.
The ability to affect a symmetrical posterior pelvic tilt is also important. Once the pelvic base is established, the obliques can be specifically fired to bring the rib cage into more balanced alignment.
Pediatric Orthopedic Background
Postural deformity, chronic pain and low self-esteem are frequently associated with the development of scoliosis in adolescents. Postural distortions can progress rapidly during adolescent growth spurts and often take the child and his family by surprise. Routine spine screenings by school nurses may miss the onset of the condition. Although parents may notice posture changes in their child (e.g., unusual slouching, holding one shoulder higher than the other or keeping the head tilted to one side), they may not attribute it to scoliosis.
Eventually, the child is referred to an orthopedic specialist for X-rays to determine the degree of scoliosis. Measurements are made to determine the degree of deviation from the midline of the spine by determining the radiographic Cobb angle for each major curve. Pediatric orthopedic guidelines typically state that curves under 30 degrees are "observed" via X-rays taken at six-month intervals, curves 30 to 40 degrees are routinely braced, and curves greater than 40 degrees are referred for surgical evaluation.1
Unfortunately, scoliosis doesn't exist exclusively in lateral planes; the condition almost always develops as a three-dimensional distortion. Abnormal spinal curves can occur in more than one of the body's planes. An optimal spine has no scoliotic dysfunction.
In a patient with 3-curve scoliosis, for example, the three trunk segments (the shoulder girdle, the rib cage and the pelvic girdle) rotate clockwise or counterclockwise around the longitudinal axis of the spine. This torsion (twisting) actually rotates the vertebral bodies of the spine toward the convexity of that particular curve and the spinous processes rotate toward the side of concavity. The rib cage itself becomes distorted and is oriented obliquely with rib compression and muscle atrophy on the side of concavity.
The Schroth Method
I have begun to study the work of Katharina Schroth, a German therapist who pioneered scoliosis rehabilitation more than 90 years ago. I'm convinced that a hybrid approach that combines Schroth's systematic approach of spine correction together with Pilates-based de-rotational exercises will provide even more exciting options for scoliosis reduction and management. It's interesting and ironic to note that these two German-born exercise pioneers (Joseph Pilates was also German) lived and worked in the same era; both of whom were so far ahead of their time that their methods are still considered "cutting edge."
Katharina Schroth became well known in Germany in the 1920s after developing a radical and effective treatment methodology for adolescent and adult scoliosis. Her daughter (Christa Lehnert-Schroth, a physical therapist) worked side by side with her mother at their clinic in Bad Sobernheim, Germany. Katharina's grandson, Hans-Rudolf Weiss, an MD and orthopedic specialist, is now the director of the clinic and continues to carry on the research and treatment established by his mother and grandmother.
The Schroths developed a surprisingly effective methodology for structural correction of the spine that included: 1) activation and stretching of muscles in the concavities of the spine, and 2) correction of vertebral rotation and scoliosis using specialized breathing that causes the ribs to work as levers to derotate the spine.
Christa Schroth's book Three Dimensional Treatment for Scoliosis: A Physiotherapeutic Method for Deformities of the Spine includes hundreds of photographs of children and teenagers whose bodies were transformed with the application of her exercise regimen.2 The photos are fascinating because they were taken in sequence during each patient's three-month stay at her clinic and document dramatic and visible skeletal and postural improvement. Until recently, training for physical therapists in Schroth Treatment Methodology was only available in Germany and Spain, but has since come to the United States. The method is much better known in the international community than in this country.
Release of Myofascial Restriction
Often stubborn to stretching, tight myofascial tissue on the side of the concavities can be lengthened using a technique called dynamic cupping. I invented a silicone cup with a flared rim called the "Cup and Release." I have found that cocoa butter is one of the best mediums to apply to the skin over muscle and fascia that needs stretching. Cocoa butter provides the best viscosity to hold a good vacuum seal that will withstand multi-directional pulling and stretching by the therapist.
Before I use dynamic cupping, I usually use high-speed vibration therapy over tight fascia and muscles to flush the region with increased localized blood flow. One of the amazing benefits of dynamic cupping is how it accelerates myofascial release; often achieving in a few sessions what previously took me weeks to achieve with manual release techniques. Furthermore, cupping provides lengthening release forces, where manual therapy release uses more compressive forces. For paralumbar and paracervical release, the patient is positioned in sidelying with the regions of concavities on top and with an appropriate sized bolster under the opposite side convexity to open the restriction as much as possible.
Adolescent spines are "plastic" and the most easily adaptable to change. For patients, learning is most effective with visual feedback such as watching themselves in the mirror and looking at photographs or videos taken of them as they exercise as well as tactile feedback from my hands, the patient's hands, and the use of therapeutic tape over a specific muscle we are trying to activate.
Once the patients have mastered the technique, it's a matter of repetition. As the patients internalize motor control strategies, we gradually wean away external feedback.
Current research doesn't support the efficacy of standard/generic forms of exercise to treat idiopathic adolescent scoliosis (i.e., non-scoliosis specific exercises) even if supervised by a PT. External bracing has its limitations; although it can slow or halt curve progression, bracing cannot reverse spinal deformity.
Furthermore, once out of the brace, curves can reappear because imbalances in strength and bulk of the paraspinal muscles were not addressed. The Schroth Institute found that incorrect application of exercise, or doing the wrong type of exercise, could increase the risk of worsening the scoliosis.1 And the reality is that teenagers are often non-compliant with exercises and bracing.
Recent international literature reviews reveal that the Schroth Method is one of the most effective and highly reproducible methods for scoliosis rehab. A Turkish PT clinic followed 50 13- to 15-year-olds for a year after discharge from a Schroth-based six-week program. At the end of one year, significant improvements were made in reduction of Cobb angle(s), increased respiratory capacity, improved posture and improved strength.3
I hope that more clinicians express interest in learning more about how to use Pilates equipment to perform corrective muscle energy exercise.
1. Negrini, S., Fusco, C., Minozzi, S., Atanasio, S., Zaina, F., & Romano, M. (2008). Exercises reduce the progression rate of adolescent idiopathic scoliosis: Results of a comprehensive systematic review of the literature. Disability and Rehabilitation, 30, 772-785.
2. Schroth, C. (2007). Three Dimensional Treatment for Scoliosis: A Physiotherapeutic Method for Deformities of the Spine. The Martindale Press.
3. Otman, S., Kose, N., & Yakut, Y. (2005). The efficacy of Schroth's 3-dimensional exercise therapy in the treatment of adolescent idiopathic scoliosis in Turkey. Saudi Medical Journal, 9, 1429-1435.
Susan King is a senior outpatient physical therapist at East Cooper Medical Center in Mt. Pleasant, SC. For more information, visit www.eastcooperrehab.com