-- -r-

',eTrealmenlofSco/iO.fis TheConsen'alil'eScoliosisTrealmenl 191

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
_ ~ _ ----
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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
... --.'--' ,. '--'
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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
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I
lIJO ,.- ....__.. __ \_ .. _ I ..__-..t-
! I :
I :
;
:
:
,
-J------
r
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I I j
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-..-- - \ __ 1"'.,.
\ : I I ;
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15 .. - ..
--_..j---l-
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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.
_._.. _-_..... -------_._-- "-'--'--"-'- - - -_.-
-
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----'---,
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.
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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
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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.
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