Three Dimensional Treatment for Scoliosis by Christa Lehnert-schroth Pt

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Christa Lehnert-Schroth, P.T.

-THREE= DIMENSIONAL TREATMENT FOR SCOLIOSIS

A PHYSIOTHERAPEUTIC METHOD FOR DEFORl\AITIES OF THE SPINE

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The 1\Iartindale Press Palo Alto, California

Copyright 2007 by Christa Lehnert-Schroth

All rights r~'"erved. Except for usc in reviews, no part. of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without written permission from the publisher.

Published by The Martindale Press Palo Alto, California

www.schrothmethod.com

Originally published in German asDreidimensionale Skofiose-Behandfung (Stuttgart: G. Fischer, 1973). 7th edition 2007 by Urban & Fischer Verlag, Elsevier GmbH, Munich, as Dreidimensi-onale Skoliosebelzandlung: Eine physiotherapeutische Spezialmethode zur Verbesserung ro11 Riickgratverkriimmungen. Atmungs-Ortlzopadie S);stem Schroth. The translation is based upon the 7th edition.

Lehnert-Schroth, Christa Three-Dimensional Treatment for Scoliosis:

A Physiotherapeutic Method for Deformities of the Spine

First edition in English. Translated by Christiane Mohr, Alistair Reeves, and Douglas A. Smith.

276 pages. 679 illustrations. Includes bibliographical references.

ISBN 978-0-914959-02-l I. Scoliosis. II. Physiotherapy.

Christa Lehnert -Schroth ( 1924- ) www.scoliosistreatment-schroth.com

Notice: The pictures presented in this book are amateur photographs taken over the past 60 years. They have been preserved to document this book.

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-Dedicated with admiration to my mother Katharina Schroth by

Katharina Schroth (22 Febmary 1894-19 February 19S5)

Katharina Schroth was awarded the Bundesrerdienst-kreuz ("Federal Cross of Merit'' of the Order of rvicrit of the Federal Republic of Gennany) for the intro-duction and development of her treatment for scoliosis, because this system was unique in its intensity, effect, and results.

from among all the people Whom you meet in the course of your lite You arc the only one Whom you will neither leave nor lose. You arc the only answer to That Question of the meaning of lite. You arc the only solution To the problem of life.

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1 (!~Jk 01 COlll(> S

D.::\'clopmcnt oi the S~hroth rotational breathing system .................................. 1

Sample of cnrly bwchurcs and booklets ........... 3

PART A Theoretical basis of the Schroth ~1cthod .......... 9

I. Division of the trunk (including shoulders and neck) into three segments .......... 11

II. Symmetrical postural deviation in the sagittal plane ..................... 12

Ill. Postural deviation in the frontal plane ..... 17 IV. The three torsions of the trunk in scoliosis .. 19 V. Breathing as a fonnati\'.:: factor .......... 20 VI. The scoliotic breathing pattern ........... 23 VII. Increase in cardiopulmonary capacity

during three-dimensional treatment ...... 24 VIII. Effect of sun and air .................. 24 IX. Evaluation of spinal length loss in scoliosis

in relation to vital capacity ............. 25

PARTB Evidence-based theory ....................... 27

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I. Influencing the scoliotic wedges with the aim of restoring rectangular blocks ...... 29 I. Planes and axes of the body .................... 29 2. Conceptual division of a three-curve

s:oliosis into three blocks ...................... 30 3. Principle of pelvic corrections in

three-cmYe scoliosis .............................. 30 4. Corrections of deviations in the sagittal plane:

postural improvement, firstandsecondpelvic correction ............................................... 30

5. Corrections of deviations in the frontal ph;ne: third pelvic correction and shoulder countertraction ....................................... 30

6. Derotation of trunk as part of the fourth pelvic correction and derotation of the shoulder girdle in three-curve scoliosis ................ 32

7. Horizontal positioning of the aleae of ilium: the fifth pelvic correction ....................... 32

S. Targeted rotational angular breathing (RAB) combined with counterrotation of the trunk segments ....................................... 33

9. Postural correction of neck and head ...... 36 10. Stabilizing isometric tension

after postural corrections ....................... 36 II. Appropriate starting positions and Oiihopaedic

aids for trunk derotation exercises (three-curve scoliosis) ................ 37 I. Flat supine position without a pillow ...... 3 7 2. Prone position .......................................... 3 7 3. Lateral position ........................................ 38 4. Sitting position ....................................... .40 5. Sitting on the heels ................................. .40 6. 'TV' position .......................................... .40

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-i. C,>irccti\c !'iHin-" po~,, ''-''1 wh,n tlic: concavity is extreme .............................. 41

3. On all fours .............................................. 4l 9. Low-sliding po~iti'm .............................. .4! 10. Kneeling position .................................. 4~ 11. Standing ................................................. 4~

Ill. The ~coliotically changed locomotor system a) Pathological clements .............. 4~ b) Individual muscles involved in a

scoliotic malpostur.: .................. 44 1. Abdominal muscles ................................. 44 .2. l\1. quadratus lumborum and deeper

holding musculature .............................. -!6 3. Erector trunci (!\I. longissimus dorsi,

l\1. iliocostalis), the back extensors ....... -lS 4. M. iliopsoas muscle ................................. 52 5. Intrinsic musculature ............................... 55 6. Jvl. latissimus dorsi .................................. 57 7 . .l\1m. scaleni ............................................. 5S 8. Pectoral muscles ...................................... 59 9. Coccyx and ischial tuberosities ............... 59 10. Floating ribs .......................................... 61

IV. Summary of physical corrections using the Schroth method for three-curve scoliosis .. 63

V. Theoretical reflections on four-curve scoliosis (with a lumbosacral CUIYature) and its correction ..................... 65

VI. Summary of ph)sical corrections using the Schroth method for four-curve scoliosis .. i2

VII. Feet and legs ........................ 75 VIII. Summary of theoretical considerations ... 76 IX. Objectives of Schroth treatment. ......... 17 X. Learning to observe in the Schroth manner . 7S

PARTC Exercise instructions ................ ; ........ 81

I. Breathing exercises .................... 83 II. Exercises at wall bars .................. S-+ Ill. Exercises using chair and table ........... 9-i IV. Floor exercises ....................... I 02 V. Neck exercises ....................... II-+ VI. Exercises with a resistance band ......... 119 VII. Exercises to correct lumbosacral

curvature & scoliotic pelvis (4th curve) .. 136 VIII. Problems in the treatment of scoliosis ... 14-i

I. Retroflexion (extension), lateral flexion and distorsion of the tnmk ....... 144

2. Problem cases ........................................ I 53 3. Validity of X-ray monitoring during

in-patient treatment.. ............................ 166 4. Accessory rotation in lateral flexion

of the upper trunk ................................ 170 5. Puberty .................................................. I 7 I 6. Correction of the shifted sternum .......... I 7 I 7. Correction of the shoulder on

the concave side ................................... I 73 8. Correction of the anterior rib hump ...... 173

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9. Correction of 11atback in combination with ~coliosis ....................................... 173

10. Correction ofthc scoliotic pelvis ........ 178

II. Multiple-curve scoliosis ...................... 180 12. Atypical scoliosis ........................... ." .... 183 13. Correction of nllse body statics ........... 183 14. Lumbar kyphosis ................................. 185 !5. Spondylolisthcsis ................................. l87 16. The hollow back .................................. 188 17. Rotational sl ippagc of vcrtebrac .......... 190 18. Thoracolumbar scoliosis ..................... 191 19. Double curvatures of the lumbar spine 198 20. Cervic

I nm very pleased tlnt 1:"~ !cxtbook is now avaih;blc in the English bngu:~gc. This means that English-speaking physiothcr:1pists who wish to treat patients suffering from scoliosis now hrm~ a very broad range of exercises at their disposal for all cases and shapes of scoliotic bodies. For fifty years I worked as a physiotherapist with pa-tients sutTering from scoliosis, introc: :cing the specific system of treatment that bears the name of my mother, Katharina Schroth, to therapists and patients. Because she suffered from scoliosis herself during her youth, she developed the program now known in Ger-many as 'The Three-Dimensional Scoliosis Treatment' or 'Three-Dimensional Scoliosis Physiotherapy'. This is a conservative method of treatment, which works among other things with exercises that elongate the trunk, correct the imbalance of the body, and fill the concavities of the trunk using a special breathing tech-nique which she called 'rotational breathing'. Katharina Schroth's app,oach to treatment was far ahead of her time. Many patient;; are helped by the treatment we give and by the courses we offer for physiothera-pists, who come from many countries, at our Katha-rina Schroth Spinal Deformities Rehabilitation Centre. In 1981, on the occasion of Katharina Schroth's 60th professional anni\ersary, Professor Friedrich Brussatis, J\1.D., said in his address:

"I am myself a member of the research society of the American 01ihopedic Society, which has designated itself specifically ns the 'Scoliosis Research Society'. The fact alone that such a society exists may indicate to you whnt extrnordinarily great, only partly solved prob-lems still exist today in the diagnosis and treatment of scoliosis. "Precisely because of so many failures and great at-tempts and disappointments over the centuries, it con-stitutes an extraordinarily important landmnrk to hnve recognized the three-dimensional flow of motion and

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dcfomi::Jtion of the spin(. and above all to L:-,. :;;plic,i it exknsivcly in pr:Ktic:. I believe the mo5! ;:::porlaili pan of your treatment method is the fact tb! you prt~cccd from a given !';

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Foreword

The problems of treating scoliosis have hitherto re-mained unsolved either by surgical or non-surgical methods. Years of research and the development of more and more complicated procedures have not changed the substance of this de\clopment. The goal is still correc-tion of the deformity and maintenance of the correction. This \\ould certainly be possible with an outrageously cl

Development of the Schroth Rotationai Breathing System

Katharina Schroth was born in Dresden, Germany, on fcbrmuy 22, 1894. In her youth, she had scoliosis her-self. She suffered mentally because of her deformity, and more so since she had to wear a brace. This ortho-paedic support device did not bring about the desired result because it hindered physical activity. At that time there was no adequate treatment for scoliosis. All she wanted was to be able to 'stand straight up' and live without the brace . . -\.rubber ball with a depression that could be pressed out by air gave her the original idea for self-treatment and the firm resol\e to work on her body according to this principle. The depression seemed to her like the concave side of her body. She started to breathe into her concave side in order to fill it with air. Creativity, methodical thinking, and continuous working at it soon brought the first successes. By practising between minors, she was able to follow visually what was happening to her body. In the middle of her right side was the rib hump, and she saw how it flattened out \vhcn she directed her breath into her left side. She realized: this is actually not a rib hump- the ribs arc just twist

Fig. 3: Mrs. Katharina Schroth at age cighty-fiw

The rotational breathing method was continuously im-proved. Each new case perfected her knowledge further. Soon she was called upon to speak at conferences. As early as 1925, the journal Medizilzalpolitische Rzmd-scluw commented that the Schroth method was epoch-making in the treatment of scoliosis. In 1927, Katharina Schroth completed training at the Erna Graf Klotz School for Functional Gymnastics and Movement in Dresden, where she earned her diploma with the highest marks. During her training, she had learned about all the different systems of gymnastics, such as Laban, Klapp, Medau, Hellerau-Lachsenburg, Surcn, Gindler, and Kallmeyer. She took dancing lessons with Mary Wigman and Palucca. She also studied Swe-dish Gymnastics at the 'Konigliches Palais' in Dresden. She became convinced that these methods represented a good basis, but that they were not specific enough for t,.;:ating scoliosis. None of these methods included tar-geted methods to help people specifically with spinal deformities. These circumstances forced her to observe closely her own body and those of her patients in order to discem principles behind the exercise effects. She sought the principles according to which a posture-dependent scoliosis developed, and she sought, in its turnaround by pertinent exercises, conditions that could influence a sco-liosis to traverse its same developmental path in reverse. The method had already enjoyed considerable success before World War II. After a large-scale comparison of various methods during a controlled experiment in Hin-denburg, a commission of experts noted that the Schroth system's results far outstripped other methods, The gap between Schroth treatment results and those of the other systems was so great that they began to retrain the in-structors at the other schools in the Schroth method. In 1934, Prof. Gebhardt ofHohenlychen and Prof. Wil-helm of Freiburg confirmed the success of the Schroth method. After the war, the Ministry of Internal Affairs in East Germany ordered a three-year investigation of the method. Afterwards the Schroth house was national-izect"on the grounds that "the method must be open to a larger circle of sick people". In 1955, Katharina Schroth moved to West Germany. In 1961 she founded her clinic

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li1 tL~!..! 0ULJ~rilll;,.~iill 1 \',Jil:l~ n 11,:."1 1.... '-"' ... treating patients from all OYer the wo

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Sample of c::1rly brochures' and booklets

Katharina Schroth\ flr~t bookie! was pubk;hcd in 1924: Die Arnurngskzn; f_cifadeli :11r Lungengymnastik (The !3rcathing Cure: a Guid..: to Exercises for the Lungs). It conuincd exerci~cs. for the breathing system and im-portant tips for patients with scoliosis. The third edition of this booklet wa:; issued in 1930, with an excellent

Fig. 4: 192X: The gard~n in whkh t':':c ~xerciscs were 1xrfonncd.

foreword by Dr. L. Grewers of Essen. A!fhat time, other systems were practiced in Germany and elsewhere on the Continent, often counterproductively. (Sec pages 144-152 for some of the faulty exercises they recommended.)

a) The grc1up is cxercisil'g io strengt'c~n the "cak lumbar musculature b

-Fi~. ()a: ScL"ond ph1~pcctu.:-: in 1920. \Vc han .. printed it in this h(~t1k hccausc the c\~ntcnt is still \'~lid totby.

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v ( Ttat~~latiot1(ab~revia~~~ fornl):. . :;;~~; ': Da~~ers in th~ tre~tll1.~~t of s~Wtiotic cti_i,Js~~ . . . . .. .. \

::;;, by Katharina Schroth, Mcissen, author of the NcwBreathing Orthopaedic System ,,.b.

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;;~~; . \vhichmost purely rcalizs tlJedivin.ecrcative tho.ti~l,!.~)s always the best, the one that allow~ all organs ,,,,io; and parts oft his body to. function rnostcompktcly:C: i;;. . . . > . . .\!ek CLirvaturc oft he spine, or scoliosis, is aprccariousformal dcr~ct in terms ofhealth,appearance, and the spiritual-psychological aspect, Whcnattcmpting tohqlp a scoliotic \Vith this defect, we mu~tnot vic\\: the matter primarily from the mechanical standpqi~t,~ namclythe ina! functioning body. F?t~\ve l1ave before us not a mechanical structure of bony levers ail# the muscles that move them, but rather an un-~::: fortunate person who has lost the form originally cr~ated for her and \Vho cannot restore it by herseif. i\n With all scoliotic people, the cause probably licspartly in the mental realm. Envision whattl1c expres~

sion "not ingood form" means. Imagine the mcntal,statc of a childscolded by his inothcr. The psychic depression and loss of equilibrium arc immediately visible in his abnormal bodily form. H()\~ \vonder~ ful the form of a little child's body is! What a victorious, natural, 111attcr-of-fact nature he has in the

!.'il !~presentation of his Self,,and,in cv:~ry movement atld in all ofhis life statements... _ , . . ,,,:1 However, let us observe a s~hool class three or fom years later. What has happened to these children?

Alrnost all arc missing their origillal sense of complete, untroubledcomfort w.ithin. Many children have pronounced signs 9fsufft::ring in their faces, angtheir deprcss(:d .mental stat::( Sttebe-~~- /',: ()f>.in~~;L !"!f)lJ' ;d,: Funl\\k.;;_~J:.!rh:tHni~,_~:\ .!L;(~ al:{

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The nornd, healthy condition of the living body has a natural, inner aspiration k) ensure that normal functional r.::ationships assume a normal form. Local assistance, namely goal-dir.:2:~d work on the body, _.. must support this natural striving for order, the drive to assume a nom1al structure-.

.J This constitutional therapy will not only induce inner bodily harmony, but ab:o 3 surplus of strength, which then directly serves rebuilding of the external pcn;on as well as the Jo:ld-r

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Fig. li c (lrnnslalcd captions) .........

s e i 11 c umncllba re V c r "cc, 'seaside'. anOr;.;..>~-JS how he c'xerciscs. kcted so much after you had given me no hope."

This young girl !wd an identical experi-ence nbroad. Five years ago she had only tirst-dcgrcc ~coliosis. !'rot: X. write's: "Before her orthopae-dic gymnasti

-pi\J~T A Theoretical basis of the Schroth 1nethod

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I. Division of the trunk (including shoulders and neck) into three segments (Figs. 7, 10)

Practical observation of persons with postural disorders showed that it was useful to divide the t111nk into three segments, from caudal to cranial:

a) lumbar spine with pelvis b) tl\01-;:~cic spine with rib cage c) cenical spine with shoulder girdle (and head)

In a healthy person, these three segments can be reprc-SCilted by rectangles.

a) The cattdalt'cctangle is formed by the pelvis, lumbar spine, hypogastric region including umbilicus, up to the lower ribs.

b) The next rectangle is formed by the chest and epigas-tric region. The lower border is the waist (12th rib) and the upper border the axilla (about the 3rd rib).

d The third rectangle is bordered caudally by the up-per border of the middle segment. The upper or cranial border is in the region of the acromion. The Fig. i: Fror.tal view. cenical lordosis lies outside of this upper segment. However, as the cervical spi:1c belongs functionaily to this third segment, it can be imagined as mtming cranially to the beginning of the occiput.

The three segments arc stacked vertically on top of each other. The body is balanced.

\"icwed laterally, however, they are trapezoidal as a result of the physiological curves of the spine. The caudal segment (trapezium a) has its lower border in an imaginaty line passing through the two ant

Symm~trical po~tur-1! deviation in the sagittal plane, or k:yr!': :::. rc~ults in the formation of three sagittal

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So far we ll:we b~cn describing the healthy locomotor system. In case of postural defects and even more in minor or major spinal deformities, these structural changes arc more pronounced. For example, juvenile or adolescent kyphosis (Scheuermann's disease) or kyphoscoliosis. ln these conditions, the physiological spinal curves show pathological changes in the sagit-tal plane. The spinal column appears compressed and shortened, giving ris~ to pathological vertebral defor-mations (Figs. 9 and 15-19) In the case of n13lposture, these three segments arc shifted against each other (sagittal plane), resulting in a line with two breaks (lateral view); beginning at the feet, running to the pelvis, from there to the back and continuing up to the head (Figs. 9, 14,15).

Due to the shifts of the three segments caused by the col-lapse of posture, the three segments appear as 'wedges' on top of one another- the short side of the trapezium becoming shorter and the long side of the trapezium increasing i;l height- and these really do have the ap-pearance of ,edges (Fig. 13). The more pronounced the deformity, the more extreme the wedging and the col-lapse of the back.

Lateral view (Figs. 15-17)

\Vedge 1: The lumbopelvic wedge has its vertex in the lumbar lordosis. The wide side (abdominal wall) is fom1ed by stretched abdominal muscles and the anterior iliac crest, sloping in the ventrocaudal direction forming the caudal border. The cranial border is an imaginary line beginning at 1h~ lumbar lordosis, passing the lower ribs and leading to the xyphoid process.

\\'edge 2: The chest-rib wedge has its vertex below the nipple. The wide side is formed by the thoracic kyphosis. The caudal border corresponds to the cranial border of the lumbopclvic wedge. The upper border is an imaginary line running from the narrow anterior area below the nipple, passing the armpits up to the lower third of the shoulder blade.

Wedge 3: the shoulder-neck wedge: Since the shoulders arc drawn forward, the anterior acromial processes form the wide side, while the exact position of t,he vertex is difficult to define. It lies in the region of the upper two ribs covered by the shoulder blades. The caudal border corresponds to the cranial border of the chest-rib wedge. The cranial border is formed by the

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Fig. 9: Pathological body shape: wrong- o\ercorrc.:tion - corre-.:t

Fig. 10: Latcrnl view: p:lthological and normal shape. c: neck-shoulder w~dg~ b: thorJx-rib wc'

fig. 13: Lateral view of a normal spine. Ka-pandji describes the lumbar lordosis of a dynamic type to be about 90; the spine shown in Fig. 14 belongs to a static type, which is more often found in children (spine without a scoliotic component).

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fig. 14: LatCr41 \itw ora kypho;:c spine with the postural defect c~.:ribcd above. The right angles marked sho.; the directions or the com:ction. Sec Figs. 9 ar.d 472.

-fig. 15: Double 'broken' axis showing postural collapse.

shoulder level. Since the cervical spine fom1s a func-tional part of this wedge, the vertex is in the cervical lordosis and the \\ide side is formed by the hypcrex-tcnded anterior neck portion. These two wedges may also overlap nnd in some cases can be seen as one large wedge theorel ica lly.

The above applies to symmetrical postural disorders in the sagittal plane.

In the scoliotic body, the trunk also shows wedge-like ddormities in the sagittnl plane.

This is only true for the lateral view of the 'rib hump side'. This is because of the torsion of the tnmk seg-ments against each other.

For idiopathic scoliosis at least, it has been assumed that the lumbar spine has decreased lordosis while the thoracic spine tends to present a lordotic postural de-formity (Dickson, Tomaschcwski: sec the sections on llatbaek).

Of course, there arc structural changes of this type that cannot be corrected acti\'dy, such as cases with a partly tlxcd deformity (Meister, Heine). In the presence of deformity, different parts of the body segments adapt their appcarancc;J.0.11tc spine, and functional three-curve scoliosis can exist even in the presence of only minor lumbar and cervical countercurvaturcs. Treatment is adapted to the individual situation.

Fig. 16: The resulting 'wt.:iges'.

Fig. 17: Lateral view.

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Fig. t8: 11-year-old girl with malposture and incipient kft con, ex scoliosis.

Fig. 19: The three blocks arc still almost rectangularly superposed.

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The 2nd, chest-rib wedge can be subdivided into f,\o parts in cases of major scoliosis and kyphoscoli.::sis (Fig. 17). The vertex of wedge 2a is ix:low the nir;cle and the wide side is bordered by the posterior rib hm::p; the vertex of wedge 2b is located in 1~e region of he subaxillary rib portions. The correspor:ding wide sic'~ is formed by the kyphotic cune which begins at the shcJI-der. It shows the most cranially located thoracic hu:-,p. These two wedges cnn merge into one ::.nother.

"'edge 4, the 'vedge of the anterior rib hump, is on the dorsal concave side (Fig. 21 ). The vertex lies ir the posterior concavity and the wide side is fonned by the anteriorly-orientated ribs of the dorsal concavity. The caudal border is an imaginary line wh:ch begins a: lhe concave posterior ribs and leads along the lowest ribs towards the umbilicus. The cranial border runs from the posterior concavity to a point below the nipple. This creates the scoliotic balance of the body and brings all body segments that deviate anteriorly or posteriorly above the centre of gravity. They balance each o:hcr out.

In the following. the terms 'concave' and 'convex' side always refer to the thoracic spinal cunature.

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Fig. 21: Frontal view.

IIL Postural deviation in the frontal plane

In scoliosis and kyphoscoliosis, the deviation in the frontal plane leads via a trapezoid to the formation of three lateral wedges (Figs. 20-23). While scoliosis is characterized more by btentl form deviations, in ky-phoscoliosis, the sagittal and frontal deviations arc pre-~cnt together. Looking at a scoliotic body from the back, \\"e can sec that the three tnmk segments (pelvic girdle, rib cage, shoulder girdle) are not aligned as rectangles as they arc in a healthy body. They have shifted against c~1ch other. These lateral deviations and the changed pressure ~md traction first twist the originally rectangu-lar segments into trapezoids and then wedge-like seg-ments (Fig. 23 ).

Dorsal view: \\'edge 5: lateral lumbar-pelvic wedge (figs. 20, 22 and 23) , The vertex of the wedge is below the lateral rib hump I I th and 12th rib). The wide side is formed by the pro-minent lumbar convex-sided hip and, vcty oncn, also by the upper lu~.s1r hump. Its caudal border is formed by the iliac crest sloping downwards on the side of the dorsal concavity due to the lateral shill. The cranial bor-der can be ::;cen as a line extending from the vertex of

Fig. 22: Posterior view.

the wedge leading to the ilia of the dorsal concave side, i.e., the highest point of the lumbar hump of this side.

Wedge 6: lateral chest-rib 'wdge (Figs. 22 and 23 j The vertex of the wedge is at the lowest point of the dorsal concave side. The wide side is formed by the lateral rib hump. The caudal border is also the cranial border of the 5th wedge, while the cranial border leads from the \ertex of the wedge obliquely across the upper thoracic vertebrae to the middle of the shoulder bbdc on the convex side.

Wedge 7: lateral shoulder-neck wedge (figs. 22 and 23) a) Most often the vertex is located above the thoracic

hump (covered by the shoulder blade). The wide side is formed by the shoulder on the side of the dorsal concavity, Its caudal border nms parallel with the cr~:nial border of wedge 6. The cranial border is tormcd by the shoulder levels on both sitks.

b) Functionally, the cervical spine lorms part of this. The \crtcx is therefore in the shortened ccrvic;il muscle:; of the dorsal convex side and the wide side

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Fig. 23: I. pehic girdle 2. Rib cage 3. Shoulder girdle

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-IV The three torsions of the trunk in three-curve scoliosis

Scoliosis is n

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The rnon::nc,'nt:' "~~,,:i::;;;d with breathing urc of major impor!

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Fig. JO: Distance bc'twccn the ribs on deep cxh3!::::on on the ten and right side. t 2th-! ! th 2.5 em. : 1 th-l Oth 2.5 em. 10th-9th 2.0 Clll.

Position of diaphragm, left T I 0; rig.ht T9; crcctsp:~,al column.

hme to be trained in a very precise and selective man-ncr. Costal or rib breathing is possible, s;nce the ribs are connected with the spine and move around an oblique axis. The rotational axes of each rib pair form an angle \\hich opens dorsally. This angle differs however, de-p~nding on the height of the segment. 1:1 the exhalation position, the ribs point obliquely downwards. Lifting the ribs means also enlarging the sagiital diameter of the rib cage. The oblique position of th~ rotational axes also enlarges the horizontal diameter of the thorax in its lower part during inhalation. Improvement of the shape of the thorax is therefore always accomr:micd by an im-provement in function, and vice versa. This can be demonstrated by measurements and the pcl\'imetcr. It is ncccssmy to differentiate between 'ex-ternal' breathing movement' (i.e. of the rib cage) and imcma/' breathing movement (i.e. lifting and lowering of the diaphrag111). This approach can also be applied in other postu1~1l and breathing disturbances. Contmc-t ion of the diaphragm during inhalation llattens the cranially con\c.x dome, thus increasing the volume of Jhc pleural cnvity. The lungs follow the movement of the diaphragm as well as that of the ribs - filling the complementary spaces. The flattening of the dome of ihe diaphragm is only possible by a simultaneous pres-sure and displacement of the intestines. When the pelvis i::: in a lorward-dG.l,\mward position, the abdominal walls retreat forwurd during inhalation because the abdominal

mu~c!cs yield to the pressure. This creates the imprcs-sil'll that breathing with the diaphragm equals abdomi-

Fig. 31: Dc~p inhalation on the right;:.::~. Distance of rib; on the !eli side, Same as Fig 30. Dis!

J )1C lO!lO\\"ilig n~iS O~~il 00:\~fV~O \ idl H..:b .. UU l\1 Ul>..: !Ji volvcmcnt of the spinal column dun;;g breathing mmc-ment: As Ion, ' scoliosis is not fixed by ankylosis. it is possible k : .,t]ucncc the spinal column positiv: \. Erecting the pchis leads to a reduction of the lur. .r lordosis and the erector spinae muscles arc activated. in addition, the patient is asked to visualize a straightened spine. This alonc brings about a straightening. The more pronounced the spinal curvature, the more the trunk may be elongated during corrective inhalation. This has been demonstrated by measurements. The combination of mechanical forces and mental co-operation is an essential requirement for the Schroth method and is decisive in success. Figs. 30 and 31 show the effect of intentional unilateral breathing in a normal 52-year-old woman. Fig. 30: spine verticaL Fig. 3!: maximum inhalation with unilaterally guided diaphragm on the right. It is clearly visible that the spine is being pulled to the right. Her shoulders are horizontal. The intercostal spaces have been widened distinctively (right side) and the diaphragm lowered about 8 em. It is, of course, possible to move the ribs without using breathing. Everybody can check it: inhaling, or exhal-ing, hold the air halfway (do not apply pressure). Now the ribs may be spread or contracted. This can be done several tirn~s; it is a purely muscular function. It has to be admittd, though, that spreading of the ribs is 100% better if the diaphragm is lowered intentionJily during inhalation. The effect of the contraction ofthe ribs can be increased if the exhalation and elevation of the dome of the diaphragm are perfonned at the same time. To improve shape, the muscles have to be activated, which brings back muscular as well as a static balance. This will result automatically in a better, i.e., more use-fi.il inflation of the lungs, because the hitherto unused . parts of the lungs are activated as well. Katharina Schroth observed the movement of the ribs 'at right angles' to lateral and cranial during inhalation and exhalation in her own body. It was not theory which made her believe that ribs move sideways and upwards during lowering of the diaphragm. In a healthy body, ribs not only move to the sides (lateral-ly) but also dorsally, ventrally and cranially during in-halation. Everybody can verifY this by placing their hands on the attachment positions of the diaphragm (rib arches, free ribs, upper lumbar spine) and feeling what happens to the body. The scoliotic patient may not be able to do this immediately, and has to be trained to use the breathing movements with simultaneous correction of the exterior shape. A di ffcrent body posture is there-fore needed, including the relieving and widening of the concavities. In this situation, the question of what fills the )loll ow body segments is not important: whether it is the d isplacemcnt of the intestines, or air, or the result of normal muscle activity. What matters is the fact that the visible recesses arc flattened out.

~-22 .. ,

easily be imagined since the diaphragm reaches dom1 to this area, but this 'right-angled brcathin{ (RAB) doc:' require a gr.::at deal of concentration, i, order to lower the dome of the di,;phragm, so evcryr::ag c:.n have ;1 corrective effect. Prof. Vogel, Drcsde::: wmrnc:nted on this 'fonnatin~ force of breathing' in 1937. See Appen-dix. At this point, it is appropriate to mention a specific phenomenon that Katharina Schroth noticed at the beginning of her professional career: if a scoliotic pa-tient only breathes deeper than usual (symmetrically and not in a certain direction), more air penetrates into the already stretched pulmonary half of the rib hump side. This worsens the scoliosis defom1ities, since breathing this way docs not incorporate the orthopaedic moment of straightening and derotation. Breathing movements have to be modified for the treatment of scoliosis. Breathing has to be targeted, and it has to straighten, derotate, and influence the thoracic segments positively from the very beginning. It is not difficult to conclude that three-dimensional breathing stimulates the inactive pulmonary alveoli. The positive result patients feel is that they become less susceptible to colds and that their physical pcrfonnance increases, while their pulse stays in the normal range. Even paradoxa! breathing, during which the ribs con-tract in the inhalation phase, can be normalized.

Investigations into breathing excursions with the seolio-meter (see Part D.II: Statistical evaluation of treatment results) show that RAB can bring about derotation. If we are successful in changing the scoliotic breath-ing pattern, each breath acts as a corrective exercise at the same time. By contracting the trunk musculature in the region of the protmding convex tmnk segments, the breathing excursion is restricted in these areas and makes possible an increase of breathing excursion in the concave, recessed tmnk segments. Patients can be trained only in RAB, but actually it fom1s the basis of the entire Schroth method.

.. ;__~~4--!?!fhr~

Vl. The scoliotic breathing pattern

In the resting po:>ition and, most of the time, when breathing deeply, the scoliotic patient has an asym-metric breathing pallem due to the scoliotic deformity (fig. 32). According to Schmitt ( 1985), the healthy patient shows till a\ially-oricntcd push of the ribs when contr

J\!ost ~:oii,~tic' pticnts arc atkctcd by pulmonary and c;1rdiac d..:ficicncy. We obscr\'cd that patients show a n::duct j,, in or elimination of lip cyanosis during in-patient ... dmcnt. We also registered an increased vital capacity -which even doubled in many patients (with baselines around 350 cc). Patients often state that they ted better in general. Jn 197"L ll1~ ln$titutc of Sports Medicine at the Univer-sity of\\',:stphalia, Gem1any examined cardiopulmona-ry cap:1city in l\\'O groups of patients at our clinic, with the followmg rcsulis: "At the beginning of the in-patient treatment, we did not note any pathological cardiopulmonary deficiency in the group (except in 2 patients). The spirocrgometric values at the end of the 4-week treatment had increased markedly in each patient, although to different degrees. Most striking was the positive influence on the circula-tOiy system. The pulse rate decreased with increasing effort, generally by 10-15 beats/min. The wattage of the effort threshold was able to be increased continuously. A highly significant improvement in PWC 170 was ano-ther result. The individual values for the physical work capacity (PWC at a rate of 170/min) in adolescent scoli-otics showed a highly significant increase in the !-test.

VIII. Effect of sun and air

Hippocrates pointed out: "Water, air, sun, conscientious nutrition, occasional fasting, the ability to relax and a joyful temper form the vital impulses which create health."

Tabel 1: Average amount of air in one exhalation

Adolescents lh1ys Age Girls

ccm ccm

J-100 9 1400 1650 10 1500 1800 II 1600 1900 12 1750 2050 13 1900 2300 14 2100 2400 15 2200

This also appli;:-d to the cdurancc Cfl .. JtfAA\%h::t'Wke -~tti'lf t:tii!!:!::mr22EP"~~:~tv-itw.tMitM".'f!!:1i'SUIi Ph i' t #

.:;..,;,.._ .. ,

26 . -"""'

-PA.RT B Evidence-based theory

?~ _,

-'1-

-

~~--~~--======~---~-------------

I. lnllucncing the scoliotic wedges with the aim of restoring rectangular blocks

1. Planes and axes of the body Fig. 35 outlines the tlm::c planes (three directions, three dimensions) which ddine the space within which the body can mo,e- as well as the axes around which the ''ody can rotate. I. The sagittal plane (sagitta= arrow) passes from pos-

terior to an>~rior through the body and divides it into two halves.

2. The frontal plane (front = forehead) passes through the body fro

'''''--'" J.J.a\.lll'l.:'.

In scoliosis, th~ r-xtangular blocks that ar~ normally superimposed vertically, shift and rotate against each other. In three-curve scoliosis, the shoulder and pelvic girdle blocks shift in the frontal plane to one side and the rib cage block to the other side. N ;lJc same time, the laterally shifted blocks rotate dorsa;.J, as shown in Fig. 37.

3. Principle of pchic corrections in three-cur\'c sco-liosis (Fig. 36)

The first two pelvic corrections are made in the sagit-tal plane. The pehis, pointing for.vard, is drawn back above the heels (a). The frontal pelvic rim is then raised (e). The third pelvic correction is a lateral movement in the frontal plane. Patients are instmcted to draw in the prominent hip (b). The fourth pelvic correction moves in the transverse plane. The convex-side hip is brought backwards (f). The fifth pelvic co:rection is, like the third, a movement in the frontal plane. Patients are instmcted to lower the hip below the convexity (d). Pelvic corrections for 4-cmve scoliosis a;,:pear in section C. VII.

4. Conection of deviations in the sagittal plane: postural improvement, first and serond pelvic

. conection The axis of the legs, which runs obliquely for.vards to the forefoot due to shifting of tl1e weight has to point obi iquely backwaHis for the purposes of correction, and

Fig.37

30 ;,.;;.._ .. ,

\\~;g;H J:-' r :\".!;nt onto li1(' i~~cb :.-~ lir~l plnJc Cl1;rt:.:-tion. Thi5 l' .n .:; the pchis backward~. The front~];- _-1\ic rim is rai: :d = scc(lnd pc; ;ic COIT :-... . . :.; ... :_,~;.,: .~ :.': .. ' .. ' ~:y:.

"::~: . ::-!,.,; .. -":

' I I i

r

'l. I

. -

i j

~:....

t~--------

Fi:.;. JR (right): 12.5-y~:Jr-old ~irl wi1h idillpalhic scoliosis. As one ..::111 s~t: on this n-p Xr~lY in th" ~t:mding position. she abll has C's ro-t:l!d pchis: the wing of the kt1 ilium sccms wider than the right. This cxpl~ins why the wing 1'fthc kit ilium has turned hadw:1rds and the

othc~. which uppcars n~rmwcr. h:J> rot:Jtcd ltlrwnnk

Exception While exercising upright between two poles or in a lying position, both arms arc at the same height, provided the shoulders arc horizontal. If the sh :ilders arc not at the same height, the hand of the side 011 which the shoulder countertraction is being applied gra:;ps higher. If the shoulder on the concave side is lower und the cur-vature start::; in the upper thoracic spine, the shoulder countertraction is applied on the opposite side. The arm on the concave side is pushed outwards and upwards, and the lumbar countercurvaturc is contracted forward inwards (Fig. 46). It is also possible to pull the same shoulder upwards and sideways, and to move the hip below the con\c:dty diagonally backwards and down-wards ('Oblique torsion', Figs. 187 and 204-205). \'cry important: aYoid purely lateral pressure. Due to rotation of the convex-side middle trunk segment, the lateral ribs and muscles also rotate backwards. The parts found laternlly are actually ribs and muscles of tl1e front. They must be neither pushed nor contracted, because they would push or rotate the rib hump even further dorsally, and this would exacerbate the rotation of \"Crtebrae. The goal is to rotate them into the correct position and widen the spaces between the ribs. Only then can the muscles of the protmding rib hump be con-tracted (intercostal muscles and M. latissimus dorsi). The diagonal lateral movement is created by the upper p:u1 of the M. serratus anterior (pars horizontal is) at1d the middle par1 (pars divergcns). Once this technique is mastered, the lateraUy protruding rib hump decreases, and in some cases disappears completely.

At the same time, the position of the hip has to be cotTected (outwards, backwards and downwards). (Figs.l87, 205) Note: in the case of four-curve scoliosis, do not lean towards the concave side, since this would move the hip below the con,vexity even further laterally.

Fi\!. 39 a, h, c, d Postural corr

Fi;:. ~0: Scolio:i-: lx"xly with pel , i.- nulpc>s!urc'. The' lx"xlyw~ight

n."$t~ t.11l th~ right kg.

fig. 41: Same patient exercis-ing the third pelvic correction. See explanation in text.

6. Dcrotation of the trunk as part of the fourth pel-,ic correction and derotation of the shoulder girdle in three-curve scoliosis

First, the patient must master the technique of derota-ti~'ll of the pelvic girdle. From this fixed point, leverage can then be used to correct the upper trunk segment (rib

ca~c). Once this has been mastered and the rib cage is dcrotatcd, this fonns a solid basis for dcrotation of the shl'ulder girdle.

The three kyphotic elevations of the tnmk: tnmk segment 1 is the hip and lumbar hump below the

~dNsal concavity; tnmk segment 2 is the dorsal rib hump; trunk segment 3 is the shoulder girdle of the dorsal con-

caw side; They have to be moved forward.

trunk segment l is the hip below the; :ump ir.clt;,l;;-; the lumb'll pari and llo:1ting ribs . ,;1;:,-; side::

trunk segment 2 is ihC'COI\CJ\ ity; tnmk segment 3 is the shoulder uboYc th,- rib hur.;p.

They must be rotated backwards.

Fourth pehic correction: the gluteal muscles slwuU be firmly contr.1ctcd. a) Contraction of these muscles on the dorsal concaw

side brings the hip forward b) Manual pressure on anterior thigh of the rib hun:r

side brings this hip backwards (Fig. 47) The derotated pelvis now forms a fim1 point ag3inst which the second tmnk segment can rotate. This derota:i-on also remains as a fixed point. Now the shoulder gircik has to rotate in the same direction as the pelvis: aboYc the rib hump backwards; above the concave side forwards.

7. Horizontal positioning of the aleae (crista iliaca) of the ilium: the fifth pelvic correction

In most cases, the pelvis moves out of its corrected hori-zontal position during the third pelvic correction, which means that a fifth correction is necessary. The leg on the convex side appears to be shorter. This fifth correction, however, consists only ofloweting the heel on the con-vex side, thus videning the space between the ribs and pelvic rim (Figs. 40, 41, 116-120 ). Bes\des achie\ing an improved clinical appearance, this correction causes the important deftcxion of the lumbar spine into the up-right position, a basic correction for the spinal segments located more cranially.

n~ .. c: s::oulder countertraction. Incorrect Fig. 43: Correct position of the shoulders and fig. 44: With manual assistance: rotation, lift-ing and pushing grip . p..'\Sition of the head and shoulders head.

.:;..;.._ .. ,

. ' ---==h""lt:'

-Fig. 45 Fig. 46

8. Targeted 'rotational-angular breathing' with countciTotation of dcrotatcd trunk segments (most important point in postural improvement for all patients!).

Rotational angular b!eathing (RAll) Aft~r pelvic corr.::ction has been established, breathing movements of the rib cage arc performed in a 'right an-gled' manner. This means that the breathing directions foil ow the sides of an imaginary right angle (the second sid~ of this angie always runs cranially). The RAB starts at the 'vertices of the wedges' and is combined during inh:Jlation with the mental image of lowering the dia-pl::agm. RAT3 is accompanied by a couniermovement of the body segments located above or below. Th:: procedure t~)r kyphosis and scoliosis is as follows.

A) Lt.:~llL\It HEGIO:'\ IL\CK\\'ARDS Acful: intestines backwards and along the spin;.;: upwards= right angle. The countcm1ovcment takes the fGnn of downward movement of the posterior iliac cr.:st, increased straightening up of the pelvis, and lean-ing foi>vard of the upper trunk to open the vertex of the \Vc\.:igc in the lumbar region.

11) 'FLAT ,\~TI:RIOH CJIEST' FORWAIU>S A:'\ll lJI'\\',\RilS (W!J>GE 2, fiG. 49, 52)

The p

Fig. 48

F) NAHRO\\' A:\lTRIOR Sl!) FORWARDS Ai\D UPWARDS (WEDGt: 2A, FIG. 52)

Similar to breathing movement b) unilateral at the convex side. It is important to visualize lowering the diaphragm at the same time to even the lumbar lordosis and create a sup-port from which the narrow front can be pushed out. Counter-movement: counterhold of ipsilateral hip and shoulder.

Fig. 50 Fig. 51

34 ~-.. ,

-

fig.49

G) NARROW A:'\TERIOR .SIDE FOHWAROS .-\:\0 UPWARDS (WEDGE 2, FtGS. 52 .-\:\[) 53)

If the tnmk is very rotated, (sternum has shifted to the convex side), an additional inward movement is r.eces-sary until the sternum is across the midline (Fig. 53). It is equally important to lower the diaphragm. The in-ward movement is lateral and may be done only after

Fig. 52

}>.-:Y ... Vv'L!.:~.dii\!4 t--~t;-.; &ZiJ!.'Siti '""'""!,c!~:,$.1&lii:.-~01Jtz.l!-:llil':!+:!!!N-~'t%~'imm==a::;:===-===.,...==="'~""""== ~

-Fin ~~ !8~~~~;-old girl at th~ b~ginning oftr~atmcnt.

fi~.-54: A!kr 3 months of tn:atmcnt.

Fig~ 55: Afkr 4Y, months (notice her fa-cial expr~-ssion). The part of the rib c:1gc which had deviated to the right, laterally and dorsally, has been moved forwards, up-wards and inwards with RAI3. The thrl:'c blocks arc now supcr-poscd vertically.

dcrotation. If the sternum lie;; in the middle, the dero-tational breathing is omitted. Instead, only the lateral intercostal mu~c!cs arc contracted during exhalation as for shoulder countertraction (fig. 44). Countermove-ment: hip and shoulder of the convex side outwards. If the sternum has twisted to the concave side (Fig. 52), s.::.:: section C. V!II.6, Correction of the shifted sternum.

H) Sl"ll.-\"li.L\RY HillS FOI

;~~---------

-

in corrected position lying ~upinc. In doing so the patient should 'think' the concave back sections wider and apply them to the floor. The c!Ycct of this imagining is high!y visible and occurs to an astonishing degree. Every exercise can be combined with these "Twclvc-Count-Tcnsings" and, depending upon the patient's strength, can be increased up to l 6-20 repetitions. It is nn excellent way of shortening over-stretched muscles and restoring a bet-ter posture. It can only be successful, however, if it is per-formed with the best possible (corrected) starting position. Any strong tensing of the muscles results in the forma-tion of new muscle fibres. Care must therefore be taken to ensure that not only the rib hump side is contracted, because this would only make it look bigger. After dcrcta-tion therefore, it is necessary to tense both sides during the exhalation phase- the concave side after lengthening,

nnd the conYcx side af\:r shortening. \\'hilc these Twdw-Count-Tcnsings can 1x performed at the cntl of any exer-cise, patients should r.01 imagine that because they haYc just cxeticd thcmsclYcs so much, they can sit or stand as they please in their leisure time (meals, watching televi sion, etc.). Those wh0 think this \\-~:y will surely'- Sc',111 fall back into their prc\ious malposn:rc. This means that they arc perf01111ing an incotTCct exercise that unfortu-nately reverse

Fig. 67: Unsuitable position. The convexities are increased. The thoracic convexity moves backwards.

on the hands; the chin is directed towards the sternum and the convex side (Figs. 65 and 66). If the pelvis is aligned, i.e. there is no prominent hip, the legs should lie straight. If the hip on the thoracal concave side is prominent, the legs should be about l0 to the concave side, thus open-ing the 'weak spot' underneath the dorsal convexity. This stretches and activates muscles in this area and enables the hip to move towards the convex side. Pay attention to the concave side- it must stay wide and open. Do not per-furm lateral flexion. Patients with a lumbosacral counter-curvature straddle the leg on this side (section C.VII).

3. Lateral position

Never lie on the side of the rib hump, even when sleep-ing! Spinal torsion and the rib hump will be exacerbated by lateral pressure. Even books or pillows placed under the lateral rib hump will further compress the narrow ribs and intercostal spaces on this side. This may pro-duce a fold in the ribs and a 'pointed rib hump'. The patient should ideally rest on the dorsal concave side, with that arm underneath the head, stretched up

fig. 69: The cushion underneath the hip leads to overcorrection and is not nec-essary in every case, since the floor pushes the pelvis inwards.

38

Fig.66

Fig. 68: Suitab:e position on the concave side. The spine is s:retched

or outward. The head lies on the upper arm or a pillow. If the hip on this side is prominent, place a cushion un-der it. If the hips are straight, lay the cushion somewhat higher to the side under the lumbar convexity, but not under the concave ribs. These must lie free so that at that rib rotation may be promcted there by means of corrective breathing. The weight of the rib hump nov: works correctively. RAB is now possible (Fig. 68-70).

Fig. 70: In the case ofprcnounccd la:eral shifting of the shoulder gird)e, put 3 corrective cush!on underneath it. ln the case of a large lur.1b2r hump and rotational wnebralslippagc, the lumbar hump is dero:a:ed man-ually forwards ~r:d then cushions are put underneath - as n:any as needed to bring the lumbar spine into a median position. Notefor sleepir.g: Patients with a lumbosacral curvature (see sectior:s C. VII and C. VIII) usually bve a high lumbar hump. When lying on the side this should be supported, even when sleeping, by a 20-cm-long, thin, sand-filled cushion, othcmisc it wells outwcrds. l f this happens, lying on the side is not only an unfavourable position, but is dangerous, since the lumbar curve b~nds outv:ardsandtwisB further. A sand-filled cushion does not usually slip so easily, and remains in the same position when the patient turns onto his b:1ck. Once the pa-tient has imprinted the Schroth philosophy on his mind, he develops a 'hygienic conscienee' that makes him wake up if he turns onto the 'wrong' side when slctping. In this way, sleeping at night also be-comes a corrective exercise.

Fig. 75:

Fig. 76: In the case of three-curve scoliosis, the lower leg is pushed a little backwards at the side of the convexity to derotate this hip.

4. Sitting position (Fig. 71)

Always sit on the ischial tuberosities, either on a chair-without leaning back- or cross-legged on the floor. The lower leg on the concave side is placed across the lower on. the convex side. If the lumbar curvature cannot be in-fluenced by exercise, we must put a cushion under the hip on this side (Fig. 73). The bodyweight then rests on

.....,.._

40

Fig. 77

this side. The hip on the convex side is now lowered until it has contact with the ground; it is also brought bJCk-wards to derotate the pelvis. Sometimes the patient feels it would be easier to place a cushion under the opp0site side to create better balance. This would narrow the ver-tex of the wedge even more and the lower wedge would be enlarged (Fig. 74). Additionally, this would support the scoliotic pelvis and make derotation impossible. The table at which one sits should be adjusted to body size to support the corrected upright posture during meals. We have tables of different heights at our clinic (Fig. 571).

5. Sitting on the heels (Figs. 75 and 76)

If a cushion is used, it should be on the heel of the lum-bar convexity. Do not use in cases of four-curve sco-liosis.

6. TV position (Fig. 77)

Straddled on a chair, femurs horizontal, feet point-ing slightly outwards; forearms resting on the back of

Fig. 78 Fig. 79

-

-

n~. sn: Ko cu-;hion under the knee in the case of lour-curve scoliosis.

fi:,:. :ll: :.,;,, ,u;)lionundcr the knee in the case oflour-curw scoliosis ..

the chair; pcl\'iS back as far as possible; if necessary, a cushion under the hip of the lumbar convexity. This position prc\-.::nts the trunk from'sinking in', and the p:Hicnt can !XlY close attention to other things. This is a \\:ry suitabk position for studying, listening, etc.

Fig. 82: i'L' cushion UIHkr the knee in the .:asc of l\1ur-.:u1Yc scoliosis.

Fig.83: No cushion under the foot in the case cf four-curve scol:osis.

7. Corrective sitting position when the conc2sity is extreme (Figs. 78 and 79)

Concave side towards the back of the chair: the hip on the convex side as much as possible to the side, down and back. Arm on the concave side rests on the back of the chair to support this side ar:d to widen it. The hip on the concave side carries the weight.

8. On all fours (Fig. 80)

The knees are held apart as wide as the hips, with the thighs in a YeJiical position; the anns are extended VClii-cally under the shoulders, with the fingers pointing in-wards. A cushion is placed under the knee of the conwx side; a second cushion under ;he hand of the same side accomplishes passive derotation of the shoulder girdle and pelvic girdle. Internal rotation of arms is used to create a better starting position for exerci~cs, which in-clude shoulder countcrtraetioT!. \\'l1

If a cu,:hion i~ n~cdcd (will not usually be the case), it should be unckr tk knee of the lumbar convcxiiy (s::c usitling cross-lc,::.gcdl').

11. Standing (Fig. 83) If one kg is shorter, the whole foot and not just the heel must be elevated (danger of pes cquinus- dropfoot). The following distinction should be made: trunk in up-right position -cushion under one foot moves the hip cranially and means the pelvis is no longer horizontal. Trunk leaning forwards (Fig. 84), the cushion pushes the hip dorsally and derotatcs the pelvis. Always think care-fully: what is achieved by using a cushion? In the case of three-curve scoliosis, a cushion must be placed under the foot on the convex side to bring the hip backwards while exercising with the trunk inclined forwards. The Fig. 8-l: Omit the cushion in L\e -ose of a four-curve scoliosis. hand grasps the next higher bar, for example, to dero-tatc the same-side shoulder girdle. When in doubt, omit cushions (section B.I.l, Planes and Axes).

III. The scoliotically changed locomotor system

Explications of muscular movement are always based on measurements taken from non-scoliotic persons. This means that it is sometimes difficult to explain the move-ments of the muscle and ligament apparatus in scoliosis. The scoliotic patient has a number of contractions of the soft parts and changes in hones with unilateral ankylo-sis, and the entire system reacts differently. A multitude of muscles arc involved in a scoliotic cur-vature. Thus, correction of a scoliotic curve cannot he limited to correction of one muscle only. If we only concentrated on individual muscles, important parts of the corrective process would be ignored. Additionally, many synergistic and antagonistic effects lead to a bal-anced corrective system. In the following, we shed light on the activity of some muscles.

a) Pathological clements

Scoliosis is characterised by a more or Jess pronounced change in the balance of forces, starting already in the feet, legs and hips, with inequality of muscles in terms of length and size. The greater the deviations from the midline, the longer the affected muscles become at1d the more volume is lost. They become flaccid and finally inactive. They lose their supportive function. Shape changes arc only possible because the muscles permit them to happen. They become longer or shorter depend-ing on the direction in which the trunk is moved and ro-tated. In other words, deviations oft he trunk to the side

supportive muscles give way and become elongated. Figure 113 shows that muscle inequality already starts in the lumbar segment and continues through as far as the cervical spine. Therefore, treatment must primarily improve posture so that the body can regain its original perpendicular axis. This can only happen by developing and training the corresponding muscle groups responsible for upright posture. To restore the balance of the body muscles, those that have grown longer must be shortened and those that have become shorter must be lengthened. In

or backwards can only develop if the cotTcsponding Fig. 85

42 ~;

-

a

t l

' ..

l

f ' ~

-~.

1-

Fi;!. 86: C. n.;cnilll sco!io;i; presenting ditlusc changes in vcrtcbmt bodies ;:-.: .:annot be alun.-d by our method. We coL\i, however, certainly

~:\ ~v.: impro,cme;us in breathing and posture.

Firg. 87 (right): S'lmc patient as in Fig. 86.

,,:der for these to be able to hold the spinal column and ~ibcage in their normal perpendicular position again, t:;cy need to be strengthened - and on both sides. It is absolutely essential that the inactive shortened muscles have to perform strength work in the lengthened state. In his thesis to become a university lecturer, Brussatis d~scribcd the difference between electrical activity in the muscles on the convex and concae sides (Brussatis 1962). l-Ie found that the activity in the muscles on the ~on vex side was greater. This can be explained by 111uscle mechanics. According to Schmidtrfhews (1976), there is a connection between pretension and contraction of a muscle. Investigations done with isolated frog muscles demonstrate that a muscle can only reach its maximal t.:nsion after a certain degree of prestrctching. The lat-ter correspond$ roughly with its resting position. Increased str~tching decreases the contractive capacity a$ much as further contraction would. .-\pplying this to scoliotic malposture. the only conclu-$ion that can be drawn is thut the strongly contmcted musdcs pn the concave side of iile curvature are as in-$ufficicnt as the over-stretched ones on the convex side. Strong myockctric activity of the muscles on the con-\cx side results tiom the n\ct that they alone have to bear the load ot:.Ulc parts of the body that lie cranially. They hypertrophy but do not increase in strength, as we

u~cd to believe. They arc in n much too severely pre-$trctched state. They cannot bear the stress alone and,

instead of strengthening, weaken continuvcisly until bony disposition has been reached to stop th~ progres-sion of the scoliosis. The electromyographieally 'silent' muscles in the con-cavity shorten and show decreasing function as the cur-vature increases. Pretension decre-ases here, and we can also assume that this results in an increase in insuf-ficiency. The corrective starting positions of the Schroth method ensure that near-physiological pre-tension is reached, in both the concavity and the convexity. This enables muscles to contract almost to the maximum extent.

Scoliosis is always preceded by an incongruity between maximum weight tolerance and actual workload of musculoskeletal system. Once the different parts of the skeleton are no longer propei-ly aligned, they gradually enforce the 'scoliotic balance' of the body, socallcd 'static decompensation'. This, however, is only possible because the defective ligamentous structures (overall connective tissue weakness) allow this to happen. The physiological function of the vertebral and costoverte-bral joints, and often also the sternocostal junctions, arc disturbed. Vertebral slippage combined v:ith rotation and even subluxation may result. This opens up the way to extensive deformities. The scoliotically changed locomotor system is held in place by sets of muscles, some of which ure overloaded

43

r.~mt:=.a:(a., :::Ji&iAWSilil..a~ .. >-1f!F',im;sn~:Usru W &~

Fig. 88 Fig.89

and stretched and others which are contracted and atro-phied. This allows multiple torsion of the spine to occur to an incredible degree. The greater the pathological ef-fects of pressure and traction, the greater the effect on the bones. Initially, intervertebral discs become wedge-shaped, and later they suffer pressure atrophy, with bony anky)of,iS in the most severe cases.

a

b

Fig. 91: Sch~matic representation of the length dillcrence of the abdominal musculature. The arrows show the direction of exercises.

44 ;..;;.." .. ,

fig. 90 (right)

b) Individual muscles involved in scoliotic mal posture

1. ABDO~tli\'AL 1\lVSCLES (FIGS. 88-91)

The pelvic girdle and ribcage (and shoulder girdle) are counter-rotated in scoliosis. All abdominal muscles are therefore involved. Our working hypothesis: in right-convex scoliosis, fibres of the M. obliquus abd.:,minis externus on 'the right (Fig. 91, a) and those of tl;e ~.1. obliquus abdominis intemus on the left (b), which run diagonally parallel in one line, are mer-stretched. Con-sequently, the rib hump can move laterally and dor:.J!ly. On the other side, the hip on the concave side shifts out-wards and backwards (b). The opposite muscles, c-d, are shorter and bring the front a 1 rib arch (so-called anterior rib hump) and the hip below the dorsal rib hump forwards and inwards. The exercise treatment has to restore muscular bala;;c-e by shortening the elongated diagonal a-b and clong ~~ing the shortened diagonal c-d. This principle applies to all exercises. Sho1i diagonals seem loriger than pre-viously overstretched diagonals on the other side. The remaining abdominal muscles which had also moved obliquely, normalize at the same time. The result is nor-malization ofthe entire tnmk.

First exercise to stretch line c-d (Fig. 92) Supine position with corrective cushions. With one hand, the patient pushes the hip below the convexity outwards (laterally), backwards (dorsally) and down-wards (caudally). The other hand brings the anterior rib hump outwards (laterally), upwards (cranially) and then backwards (dorsally). This is done gently and with accompanying corrective breathing. The patient should

Fit:. 92

fig. 9J (right) feel oblique traction inside (if necessary, the fingers can be hooked underneath the frontal rib arch to help). During exhalation, the patient relaxes and then repeats the exercises with a new breath. To intensify the exer-cise, corrected position may be held dunng the follow-ing breath.

Second exercise to stretch line c-d (Fig. 93) Supine position with corrective cushions. The therapist kneels on the convex side and holds the hip back, using the knee (or a sand-filled cushion). One hand moves the frontal rib arch laterally and cranially and, addition-ally, dorsally and cranially (derotating and lifting with manual aid). The patient supports this with RAB which spreads and widens hollow areas of the back. Now the dorsal ribs find room to mow and align. Lumbar spine and corrected hip stay on the floor.

Third exercise to untwist b--e (Fig. 94) Supine position with correctiYe cushions. The therapist kneels on the convex side, pulling the hip on the con-cave side forwards and inwards. The other hand pushes the frontal rib hump outward and upward (laterally and cranially) and backwards and upwards (dorsally and cranially) creating two 'right angles'. The patient in-hales during rotation and tries to maintain the position during exhalation for as long as possible. In the case of a lumbar bump above the hip on the concave side, it also has to be pulled forwards and inwards.

Fourth exercise to shotien line a-b (Figs. 95,93 and 101) Supine position with corrective cushions. At first, the patient may support manually on his own. He places one hand on the laterally deviated rib hump, moving it forward, upward and inward. The other hand moves the prominent hip on the concave side forward and in-ward. This movement is assisted manually only at the beginning, a!lcrward the hands 'glide' in the right direc-tions, and then visualization alone produces the desired results. :;.,;,.._

fig. 9-l

fig. 95

Fifth exercise for derotation a-d (Fig. 102) Supine position with corrective cushions. The therapist kneels at the patient's concave side and pushes the con-vex-sided hip to the outside, backward and downward. The patient assists with this movement. The other hand of the therapist moves the rib hump forward, upward and inward. The patient senses these corrective move-ments and tries to reproduce these: s:nsations later on

45

fig. 96: Start Fig. 97: After 8 weeks. Fig. 98: Exercising. Fig. 101 (below):

Fig. 99 (btlo" ): Start Fig. 100 (below): After & wed.;. Exerci:c:ng (note the facial expression).

while practising.

2. l\f. QUADRATUS LUJ\IBORUM AND THE DEEPER BOLDING 1\IUSCULATUR (FIG. 103, 104)

Together with erector tnmci, this muscle has the func-tion of keeping the lumbar spine in medial position. It is attached to the 12th rib as well as the transverse pro-

Fig.I02

~c 46 '

cesses of the Llmbar vertebrae. In scoliosis, this mm-cle works unilaterally, pulling transverse processes of lumbar spine to one side (see section B.III.3, Erector tnmci). Result: shifting of the lumbar spine and torsion, thus creating lumbar scoliosis. (See section C.VII.4, Accessory rotation.) In case of inactivity, this muscle no longer pu lis on the transverse processes (Fig. 1 04). It occurs on the convex side, where vertebrae glide over to the opposite side and create a compensating lumbar curvature. The upper body which has deviated to the convex side has to be kept in balance by Jv1. quadratus lumborum and erector trunci. These muscles are then forced into increased (supportive) activity. Due to continuous path-ological muscle tension and overall weakness of con-nective tissue, vertebral articulations deviate from the vertical axis in scoliosis. At times they even subluxate and create torsion of the lumbar spine, including a rota-tion of spinous processes towards the lumbar concavity. The transverse processes rotate- with the hip- forward on the convex side. The lumbar musculature- shortens while a muscular hump forms on the opposite side (it is possible to palpate the transverse processes -Fig. 104 ).

-"t\ laterally deviating spine is only 1ws~ible in connection ,,ith torsion. The spinal column doc:; not have a central point of rotation but an eccentric one, similar to th:1t of an ellipse. A vct1cbral body, without posterior arch and spinous process, has its centre in the middle. However, because of the posterior vertebral arch, spinous process and zygapophyscal joints with additional axes of rota-ti'-)11, a corresponding rotational centre is created, lor~:ted :1t the posterior margin of the actual vertebral body. This centre of rotation docs not lead to real rotation but to torsion. This can easily be demonstrated: Fix t\VO steel rulers of equal length next to each other (about I or 2 em apa11 and parallel) and try to bend them. Each ntlcr will show torsion, similar to the ctrect of scoliosis." (K. F. Schlegel, Prof. of Orthopaedics, Essen.) I3cforc starting the next exercise, the 'muscle cylinder', the patient should observe his lumbar spine carefully. Practising getting down into starting position as well as getting up has to be performed carefully. It is important to be aware of the leg that leads to getting up or down. Inattention at this point may lead to reversing the ex-ercise results. No problem arises when one gets up or down with both legs at the same time. I\,1ost often the patient will usc the 'comfortable' leg: the leg on the cpncave side, to go down, and the convex-sided leg to get up. This will increase the lumbar con-vexity. (Figs. l 05, 1 06). It is most impot1ant to practise between two mirrors. From standing position to kneeling: I. Kneeling: leg of convex side starts the movement. 2. Simultaneously leaning trunk to concave side and

extending leg on convex side. 3. Ending: first pull leg towards body and bring trunk

into upright position. 4. Standing up: foot (leg) on the concave side starts the

!1\0\"elllCII t.

Fig. 103: l'os!L'rior abduminalmu;de Uvt. quadratus lumborum).

-~-

,. . ! .

!:~:

Fig. I 04 (Drawing by Lehnert-Schroth)

Goal of exercise treatment is the activation of mu~culaturc below the convexity by forcing it to 'work' ino a corrective position.

Exercise to increase the tonus of l\1. quadra-tus lumborum and of deeper holding muscula-ture in three-curve scoliosis (muscle cylinder) (Figs. 107 and 108) Kneeling or standing position; hands on hips; pelvis up-right; trunk leaning over to concave side (do not tend over!). Leg on the convex side is stretched out, rolJtcd outwards and placed laterally. The leg and upper t-ody form one straight line. The hip on the concave side is contracted to the midline (:he 3rd pelvic correction) and rotated forwards (4th peL ic correction); extended leg pushes hipcaudally at the same time (5th pelvic correc-tion). These pelvic corrections force the M. quadr.ltus lumborum to work. The following is happening: I. The previously atrophic part of the lumbar muscula-

ture begins to work again and to develop power!i.llly. 2. The lumbar spine moves back to the midline again

because the concavity is released fr.Jm pressure. 3. The transverse processes of the lumbar vettebrae, from

47

!: !-'~"""""'""$1t"",.,l'""""""""~~i

Fig. 105: Fig. 106: Left kg kneeling (incorrect). Right leg kneeling (correct).

which the M. quadratus lumbontm originates, rotate sideways- in some cases even a little backwards.

4. This musculature and all other muscles wl1ich have atrophied due to scoliotic torsion are now forced to support the weight of the upper trunk. They are acti-vated and increase in length and strength.

The upper body, which is positioned diagonally, should now perfom1 very tiny up-and-down movements so as to stimulate the inactive lumbar muscles specifically. It is always better to perform tiny movements than large, inipressive-looking ones that are incorrect. A glance in the mirror will immediately indicate that the 'shoulder countermove' (Fig. 107) is now required in addition. However, what has been described above is just the starting position. Next come the rotational angular breathing movements with the deliberate lowering of the diaphragm in each case. Each strengthening exercise should be followed by a break to allow recovery.

fig. 107. ' -..;,.. .

...

48

Patients with four-curve scoliosis cxcr,:i~,~ these i;:c:::; c waist muscles differently (section C. VII, Excrci:

Fi!;. 109

The 'rib valley' may also appear due to insufficiency oi the lumbar part of the M. erector tmnci. Insertions of this muscle - the ribs on the concave side- can now shift ventrally. The insufficic;-;c thoracic part on the right side cannot wmpcnsatc in the long run (weight of the head, neck and shoulder girdle hanging over to the left), and gives

Fig. 111: .::: = m. ilioco~i~:::::

.~ = nt. spinali;: :--= n1. rot~ tor~

~=Ill. kvatcJ!" ~'.._"':::.:~ - = 111- quadr.1:c:; 'Jmborum

Fig. 110

way to the ribs on the convex side to move backwards. The situation is similar in the cervical region. Compen-satory bending of the cervical spine to the right over-stretches the left cervical part of this muscle. Weakened by pathological overstretching, this muscle will also not be able to uphold the weight of the head in th~ long run and it will not be able to counteract curvature of the cer-

Fig. 112:

I a= m. longissimus dorsi I b = m. k'ngissimus ccrvicis 3 = 111. ~pinal is 4 = 111. multilidus

49

Fig.ll3 The torsion rdationships of the scoliotic spine, with resultant strength-ening of the muscles on the convex side. These left lumbar spinal erector muscles are overly strong, thus the right thoracic group be-comes stronger as well, and finally the left cervical group, resulting in a typical three-curve scoliosis posture. (Drawing: Lehnert-Schroth).

vical spine. The goal of our exercises has to be reversal of the scoliotic balance of the body. We start with cor-rection of the lumbar and pelvic region, and strengthen the intrinsic part ofM. erector trunci because of its abil-ity to derotate the lumbar spine. This activates the left part of M. erector tnmci because it is now in an almost normal pre-stretched position. This allows corrective static changes to the posture. The right-sided thoracic part of this muscle can, with the help ofRAB, move the ribs on the convex side ventrally and thus the concavecsided ribs dorsally. Be careful not to enhance flatback, and always exercise into extension and elongation to make dcrotation possible. Shortened parts of this muscle on the left side arc stretched by spreading the ribs and then using RAB to make space for the ventrally sunken ribs and to enable the thoracic lordosis to move dorsally. Exercise treatment has the goal of creating muscular ,balance in all segments. We start with the lumbar region, then the cranial segments follow automatically. As mentioned above, exercise always statis with active elongation, which leads automatically to dcflcxion

50 ~~

:md creates room for dcrotation of the pchis, ribcage and shoulder girdle. All corrective measures arc th'cn stabilized by a final 'muscle mantle', a firm contrac-tion of all thoracic muscles. In the end, all muscles arc strengthened, those on the concave side and those on the convex. Continuous repetition facilitates corrected posture. The observation point may be the septum of the M. latissi-mus. It shows activation during the stabilization phase on both sides, and demonstrates that the overstretched and shortened lateral musculature is activated to achieve its physiological length. The left-sided lumbar part of the erector trunci holds the laterally shifted trunk and has a static holding function. The same muscle is shortened on the right side. Looking at the intrinsic lumbar parts of the M. erector spinae (Figs. 113, 127 and 128}, we sec that it is over-stretched in the right-sided lumbar region and shortened on the left because of its dorsoventral direction from pelvic crest to the transverse processes. One may con-tinue to theorise: it might be that the intrinsic muscula-ture does not show either shortening or overstretching because of the many ligaments. This seems logical be-cause of its dorsoventral direction. The fact is: the right sided lumbar part is shortened and needs to be elongated or stretched. The right-sided thoracic part of the erector trunci holds the shoulder girdle, which shifts over to the concave side. This is especially the case when weight is carried on one side. The same muscle on the right side is shortened. The left-sided cervical part of the erector trunci holds the head, which hangs over to the right. This muscle also has a static function in this overstretched position. On the right, these muscles have shortened. Reversal of these faulty static relationships must begin in the lower segment by creating opposite relationships. \Ve strengthen and activate the static function of the right-side lumbar part of the erector trunci. During the exercise, this muscle should activate more on one side than on the other. This means a correction across the midline, or overcorrection. The patient has to develop a strong 'muscle mantle'. Exercise treatment reproduces muscular balance in all segments, starting at the lumbar region. Other segments follow automatically.

Exercise influencing all segments correctively: "Ro-tational sitting" (Fig. 115) Omit in the case of four-curve scoliosis. Sit on a chair. Leg on the thoracal convex side is extended backwards and rotated so the instep of the foot touches the floor. This heel pushes backwards and downwards. The other leg in front, knee bent, forming a right angle. Upper body leaning (not bending!) forwards fonning one line with the extended leg. Bodywcight rests on the hip of the concave side. A cushion in front of the hip on the convex side (these arc all5 pelvic corTcctions!).

T -

-Fig. 114 1_.-y.:ar-old girl with right-sid .. "d do~s:1l kyphoscoEosis and a m::rk-.:dly twisted compFig. 115 Tht' 5amc patient p~rfonning rotc.tic':1ol sitting. Tnis exercise is not us.:d for four-curw scoliosi;;.

The upper body Jeans obliquely to the concave side with-out narrowing it (this slrcngth~ns inacti\e musculatme below the thoracic convexity). The head pulls into the same direction (a compcnsatil)il for ccf\ical scoliosis); the chin is turned to the com-ex side (acti\"

Fig. ll i: Very sewre scoliosis; 2'i-ycar-old patient.

Fig. 118: Same patient after three courses of treatment (3 months each).

fig. 119: The same p2ti

--

;!_

.':>)'Ienius capitis---

1erlcbra prominens ~~~

suina scapulae ' \

\

Rhomboideus

proccss11s spinosi------\'Crlcbr. lamb. I, /1

faric.;; dorsalis ___ _ ossis sacri

Fig. 121

---

p rol ubcra ul ia - --occipilalis l'Xlcma

..-- Sternoclcidomastvidcus

53

Longissiln!ts ti:pilis ..... Scmispiriiilis cDpi!is _,

Splmius ccnicis X',,

iliocostalis cerl'icis

Semisp~n.nlis . CCn'ICIS

Longissimus cenicis

1/iocosla/is / dorsi

Serratus anterior

!:>[!ilia/is dorsi/

Iliocostalis /umbomr/1

Longissimus dorsi' ' /

'-lmtlincs accessorii/ m. longissimi dorsi

il/u/tifidus /umbomm

Longissimus tflirsi +

lliocoslalis ~ lumborum

Fig. 122

54

/,\~:l:i:.:,. capitis ~:- ___ ~ ~jii.i:~tcri-:;r lninnr _ ~ _____ R:r!r:s capitis postnior n:ajM ----- -Ubliq1;;;s capitis supcrirr

-- ------Ob!iq;ms capitis infaior ----Semispinalis capitis X

- ,- _-Jful/Ifidus ccrl'icis

','Sacrospinalis X

'Lel'alores costarum hre1es

'Le1atM costae longus

;l!u!lifidus lumborum fascia /umbodorsalis,

/amiua a11ferior , lnlerfnnisvcrsarii ' lalerales - 1Jbliquus abclominis ext.

-fascia lumbodorsalis, lamina po:;feriorX

-Fi!:. 123: Scoliotic skeleton (dorsal vic\\') Fig. 124: Scoliotic skeleton (frontal \"iew) N~rY.:s for the autonomous muscles come directly from the spir:al cord :111d i1111,:rvatc directly: M. iliocostalis, M. longissimus, tvl. spi-1l:Jlis, iv1m. rot;Jtores, 1\lm. intc11ransversarii, and !\1. erector spincc. Comparing the cks must have been pulled and twisted in the scoliotic body, 2nd the nerves arl! irritat,d. Gymnastic exercises that dcrotatc the thor~x al!cinst the pelvic and shoulder girdks may well li.:e lhcsc stretched

0~ pinched nctYCS ami rclicYc the patient's pain.

5. 1:\TIU:\SIC ,\IUSCUL\TURE (FIGS. 127 A:\D 128)

!\lac intosh and !3ogduk (1987) found that theM. longis-simus dorsi and M. iliocostalis (erector spinae) have an intrinsic lumbar part. The intrinsic lumbar musculatme of i'd. erector spinae originates on the dorsal parts of the: iliac crests and the dorsal upper spina, attaching to transverse processes of the lumbar vertebrae. In lUi nbar scoliosis, the spin~_ processes rotate toward the interi-or side of the arch (concavity). The transverse processes move ventrally on the concave side, thus increasing the ' t 1 '1et tl1et 1 S\'''SCJ11'0 Fi,n.l25: Frontalvicw ,distance from pos cnor 1 me spu o n n 1,;1. -

55

LJ '''" 8 ""

0 B D ~"' ~ Tii12

) ..

trochanter minor

Fig. 126: frontal view (drawingS. Adler)

cess of the lumbar vertebra. This means stretching of this muscle group on the concave side and shortening on the convex side. We may draw the following conclusions for Schroth corrections from these biomechanical facts. It has been shown that lateral stabilization (as in lateral flexion, for example) is created significantly more by lateral pmis of the autonomous back musculature than by medial parts (M. multifidus and rotatores). Looking at the muscle cyl-inder exercise, we observe this when leaning over toward the concave side. Activity of intrinsic lumbar muscula-ture of the M. erector spinae increases more than that of M. multifidus at the same height on the convex side. Thus this muscle will untwist lumbar transverse process-es which have been twisted ventrally on the convex side and, in addition, straighten the lumbar curvature. We find no such an oblique direction of theM. erector spinae in the thoracic region, but rather a more parallel alignment to the axis organ. Increased activity on the thoracic con-vex side is visible here as well.

56 ~-

--------------------

Fig. 127: Intrinsic lumbar parts ofl'.c M. erector s;:'::ae. Schemari..: representation oft);,~ lumt>ar lilscicccfthe M. ilioccc;:Jiis lumbor.J:li. The broken lines mark the extensic:: of the areas of;

Fig. 129

According to biomcchanical facts, we find here a ten-dency to lateral straightening of the curvature and a straightening of the thoracic convexity, above which the 1\1. erector spinae is stretched. However, if torsion is too pronolll

rig. 131 Fig.l32

concave side. The patient's spine is straightened by con-tinuous small wriggling movements, since a derotation of individual rotated trunk segments is only possible after straightening the trunk. Maintaining the corrected position of shoulder girdle, the poles are pushed into the ground. The oscillatory movements upwards (straight-ening of the back) have to be slow and allow intense concentration on the concave areas of the trunk. Only after this can RAB exercises begin. During exhalation this result is stabilized by isometric tension and a muscle mantle. The position is then correct for the next inhala-tion. The second side of the 'right angle' always nms

Fig. 133

.;,.;;._ 58 .. ,

cranially to giYc the spinal column maximum length and elongation. Additionally, an occipital neck ehmga-tion musculature increases the straight~ning c!Tect. Having reached best possible height, the polcs arc pushed against the floor during exhalation. The pelvis might lift a bit from the floor. The corrected hip belO\v the convexity should push forcefully towards the floor as well. Once the margin of the 1vL latissimus dorsi ac-ti\ates on both sides, the concave side is sufficiently stretched and the laterally overhanging comcxity is tensed and contracted.

7. i\ht. SCALEi'\1 (FIG. 133)

The function of these muscles is to elevate the I st and 2nd ribs onto which they insert. In kyphosis of the upper thoracic spine, they are partly inactive. Consequently, the first two ribs have lowered anteriorly, narrowing the apices of the lungs. The back deviates dorsally and cra-nially. The head sinks forward. The same is present in scoliosis, but is often worse on one side.

Exercise treatment has to train the ll'1tn. scaleni to bring the upper chest forward and widen the apices of lungs again, Succeeding in this brings the protruding pmis of the upper back forwards and flattens the kyphosis (Figs. 280-287).

Isometric head aml neck elongation exercise Omit in case of cervical kyphosis or flatback (Fig. 295}. Supine position. Corrective cushions. The hollow parts of the back are brought in contact with the floor from caudal to cranial. This is done by perfonning small, os-cillatory movements with the spine in combination \Yith RAB. An additional occipital push elongates the cervical spine even further. During exhalation, the patient pushes the head and elbows against the floor. This contracts the upper back, and the shoulder girdle lifts slightly from the floor. At the same time, minimal contractions of the dor-sal intercostal musculature ("pulling it together") are per-fanned. A sho1i resting period follows, then the exercise is repeated.

Additional Exercise: Figs 288-290 Same starting position as before, except the head is turned alternately to left and right. The patient soon notices which rotation is more difficult. That side is then exercised more often. In the case of scoliosis, the head has to be bent in continuation of the main curvature to the concave side, with the chin pointing to convex side. -There arc exceptions. This is an essential exercise and has to be practised in the supine position. sitting up, standing, and with or without wall resistance. The section on exercises shows more neck exercises aimed at individual muscles. Dur-

. -

l r

! ! ~

ing all exercises,- the infonnation given here should be taken into consideration. It is very important, since the position of the head is an essential clement in good or bad posture. it makes the rib hump appear either larger or