The Impact of SEAS Approach on the Spinal Alignment of Patients in Their 20s with Idiopathic Scoliosis: A case report

Abstract

Purpose : The purpose of this study was to assess the effect of the scientific exercise approach to scoliosis (SEAS) approach on spinal morphological assessments of the spine in patients with idiopathic scoliosis in their 20s. Methods : This study is a case report examining the effects of an 8 week scientific exercise approach to scoliosis (SEAS) program on a 20-year-old female diagnosed with adolescent idiopathic scoliosis (AIS). The intervention consisted of one session per week, lasting two hours. To assess morphological changes associated with scoliosis, coronal imbalance (CI), the Lennie test (LT), and trunk aesthetic clinical evaluation (TRACE) were measured before and after the intervention using the same methodology. The intervention included 30 minutes of electrotherapy followed by 90 minutes of SEAS exercises. Results : In the seated position, the CI decreased from 22 to 0. For LT measurements, superior angle (SA) decreased from 78 to 55 on the left and from 80 to 49 on the right. Root of spine (RS) decreased from 80 to 55 on the left and from 80 to 50 on the right. Inferior angle (IA) decreased from 90 to 48 on the left and from 75 to 45 on the right. Regarding TRACE measurements, scapular decreased from 2 to 0, hemi thoracic (HT) from 1 to 0, and waist from 3 to 2. In the seated position with arms raised, the CI decreased from 24 to 0. For LT measurements, scapular decreased from 80 to 62 on the left and from 80 to 57 on the right. RS decreased from 65 to 45 on the left and from 72 to 52 on the right. IA decreased from 82 to 65 on the left. In TRACE measurements, SH decreased from 1 to 0, SC from 1 to 0, HT from 1 to 0, and WA from 3 to 2. Conclusion : Based on the results of this study, the SEAS exercise method appears to be effective in improving morphological outcomes in adults with idiopathic scoliosis. However, as this study is a single-case report, further in-depth research with a larger sample size is necessary to validate these findings.

Ⅰ. Introduction

Idiopathic scoliosis is characterized by a spinal curvature of more than 10 ˚ in the coronal plane, accompanied by vertebral rotation, and it can be defined as a three dimensional deformity of the spine and torso involving the coronal, sagittal, and transverse planes (Berdishevsky et al., 2016; Weinstein, 2019). Scoliosis can be categorized into functional scoliosis, which is caused by identifiable factors such as leg length discrepancy or differences in the tension of the erector spinae muscles, and idiopathic scoliosis, where the cause is unknown. Approximately 80 % of scoliosis cases are idiopathic, and while the exact cause remains unclear, it is believed to develop due to various factors during the rapid growth phase of otherwise healthy children (Negrini et al., 2018).

Treatment methods for idiopathic scoliosis consist of conservative and surgical approaches. Conservative treatment includes physical therapy, exercise, and bracing (Berdishevsky et al., 2016; Kaelin, 2020; Seleviciene et al., 2022). The primary objectives of conservative treatment for scoliosis are to improve aesthetic appearance as the top priority, followed by quality of life, and then functional disability. Respiratory function ranks as the seventh priority, and the Cobb angle is the eighth (Romano & Mastrantonio, 2018). Yagci and Yagut (2019) reported that applying core stabilization exercises to patients with idiopathic scoliosis resulted in a reduction in Cobb angle and an improvement in quality of life. Similarly, Schreiber et al. (2019) found that although there was no change in Cobb angle after six months of Schroth therapy, participants perceived positive changes in their appearance.

Among the conservative treatments for idiopathic scoliosis, there are seven key schools of physiotherapy scoliosis specific exercises (PSSE), all of which share common approaches such as three dimensional self correction, daily living training, stabilization of corrected posture, and patient education (Negrini et al., 2018). These seven schools include Italy's scientific exercise approach to scoliosis (SEAS), France's Lyon method, Germany's Schroth method, Spain's BSPTS, Poland's Dobomed and FITS, and the UK's Sideshift method (Berdishevsky et al., 2016).

Among these, SEAS focuses on educating patients and helping them recognize the areas of their spine that need correction. This process enables patients to consciously control their posture, allowing them to find the optimal spinal alignment within a three dimensional spatial plane (Romano et al., 2015). Negrini et al. (2008) conducted a case study on a 25-year-old female with scoliosis and reported that after one year of SEAS exercises, the Cobb angle decreased from 47 degrees to 28.5 degrees. Negrini et al. (2019b) observed that in the experimental group undergoing SEAS for 25 months, the Cobb angle decreased by approximately 1.7 degrees. Additionally, a study involving 52 with mild juvenile scoliosis demonstrated that after applying the SEAS method, both the Cobb angle and angle of trunk rotation (ATR) significantly decreased (Yuan et al., 2022). Kwan et al. (2017) study found that, similar to the Schroth method, SEAS is effective in preventing scoliosis progression. Additionally, a study comparing bracing and SEAS revealed that while the 23-hour bracing group showed greater improvements in spinal curvature and body symmetry, the SEAS group demonstrated significantly better outcomes, particularly in functional aspects, including quality of life (Zheng et al., 2018).

Stokes et al. (1996) described a phenomenon known as Stokes' vicious cycle, where spinal curvature leads to asymmetric loading, which in turn causes asymmetric growth of the spine, further exacerbating the deformity. The primary goal of SEAS, therefore, is to break this vicious cycle by promoting symmetrical loading and symmetrical growth of the spine (Berdishevsky et al., 2016; Romano et al., 2015). Patients with scoliosis often experience psychological issues related to their appearance, particularly when it comes to purchasing clothing (Weinstein, 2019). Self perception of aesthetic appearance in scoliosis patients significantly affects their quality of life, making aesthetic correction an important aspect of conservative treatment (Negrini et al., 2018). The limitations of using the Cobb angle as the sole method of scoliosis assessment can lead to misunderstandings in the analysis of scoliosis, as morphological perspectives alone cannot fully evaluate functional impairment or quality of life (Grivas et al., 2021).

Many studies on the application of conservative treatments for idiopathic scoliosis continue to focus on radiographic assessments, primarily the Cobb angle. Even among studies that address external evaluations, a significant number primarily discuss the ATR. Therefore, the purpose of this study was to investigate the effects of SEAS exercises on spinal morphological assessments in a 20-year-old female diagnosed with idiopathic scoliosis.

Ⅱ. Methods

1. Participants

The subject of this study was a 29 year old woman with a height of 165.92 ㎝ and a weight of 60.31 ㎏. The Cobb angle of her lumbar curve was 27 ˚, with the apex of the lumbar curvature located between the L2 and L3 vertebrae. The Cobb angle of her thoracic curve was 24.5 ˚, with the apex of the thoracic curvature at T9. The Adams forward bending test results were 10 ˚ for the lumbar curve and 5 ˚ for the thoracic curve. The subject was diagnosed with idiopathic scoliosis during her teenage years and had not undergone any related treatments. She was selected based on the absence of musculoskeletal disorders or surgeries within the last 6 months (Fig 1). This study was approved by the Daegu university institutional review board (1040621-202110-HR-085).

Fig 1. Radiographic images

2. Measurement

1) Coronal imbalance (CI)

To measure the lateral deviation of the torso in the coronal plane of the spine, the CI test was conducted (Fig 2). CI was assessed by positioning a vertical line along the mid sacral crest and measuring the horizontal distance between this vertical line and the spinous process of the 7th cervical vertebra. This method evaluates the weight shift in the coronal plane, with a 20 ㎜ deviation indicating a distortion in the coronal plane (Karami et al., 2016; Negrini et al., 2019a). Intra-rater variability was within 1 ㎝, while 1.5 ㎝ represented the minimum discrepancy observed between measurements recorded by two different raters (Karpiel et al., 2021). The test was performed three times, and the average of these measurements was used as the result for this study.

Fig 2. Coronal imbalance

2) Lennie test (LT)

To evaluate the alignment of the scapular, the LT was conducted (Fig 3). Stickers were placed on the superior angle (SA), root of the spine (RS), and inferior angle (IA) of the scapular, and horizontal lines were drawn on each sticker. The distance between these horizontal lines and the nearest thoracic spinous process was then measured (Sobush et al., 1996). The test was performed three times, and the average of these measurements was used as the result for this study. The LT test has demonstrated moderate to high inter-rater reliability (0.64~0.86) and provides an accurate assessment of scapular positioning compared to X-ray readings (Sobush et al., 1996).

Fig 3. Lennie test

3) Trunk aesthetic clinical evaluation (TRACE)

To assess the external appearance of the subject’s torso, the TRACE was performed (Fig 4). TRACE consists of four categories: shoulder joints (0~3), scapulae (0~2), thoracic (0~2), and lumbar region (0~4), and is evaluated through visual inspection by the examiner. Higher scores are assigned to more asymmetric appearances in each of the four categories (Zaina et al., 2009). To enhance the objectivity of the evaluation, all assessments in this study were conducted by a physical therapist with over 7 years of experience in treating idiopathic scoliosis, who was not involved in this research. The average of these measurements was used as the result for this study. Through the expansion of the TRACE scale, intra-rater reliability was found to be moderate, while inter-rater reliability was low (Kappa values: 0.16~0.24 and 0.09~0.14, respectively). However, TRACE is widely used because it is sensitive enough to detect changes induced by brace treatment, is cost free, and can be easily and quickly applied during clinical assessments.

Fig 4. Trunk aesthetic clinical evaluation (Zaina et al., 2009)

3. Intervention

This study was conducted over an 8 week period following the initial evaluation, with sessions held once a week, each lasting 2 hours. The 2 hour exercise sessions were structured as follows: 30 minutes of basic electrotherapy, 1 hour and 30 minutes of active self correction (ASC) exercises including maintaining symmetrical torso posture and task oriented exercises in various positions, and 30 minutes of stretching and home program activities. Additionally, exercises related to scoliosis, including ASC, utilized visual information to enhance the subject’s understanding and cognitive aspects. Evaluations were conducted at three time points: the initial assessment, after 4 weeks of SEAS ASC, and after 8 weeks of SEAS exercise. The assessments were performed in two positions: sitting and sitting with arms extended forward.

The definition of SEAS ASC involves the patient performing the best possible alignment actively in three dimensions. "Active" means that the patient corrects the alignment without external assistance, which includes avoiding the use of arms, legs, cushions, or any other supports designed to reduce the curvature. SEAS exercises are performed as challenging tasks to stabilize and maintain the corrected spine. These challenging tasks are tailored to the individual patient’s motor abilities and daily activities, involving different postures and movements based on personal needs.

The goal of ASC is to restore as much normal alignment as possible. During ASC, immediate improvements should be observed in torso symmetry, coronal balance, and weight distribution, as well as in other body alignments. The direction and areas for ASC vary based on the patient’s morphological and postural assessments, with the sequence of application progressing in the direction opposing gravity (Romano et al., 2015).

The SEAS exercises are as follows (Fig 5).

Fig 5. SEAS active self correction and scapular movement

1) ASC involves maintaining maximal abdominal pressure in the left, right, front, and back directions while keeping the pelvis in a neutral, stabilized position. The lumbar spine is rotated to the right, with correction directed toward the 10 o'clock position of the thoracic spine, maintaining a feeling of elongation in the torso, and breathing is performed comfortably. Practice in a sitting position helps the patient maintain the corrected posture effectively.

2) While maintaining ASC, the right scapula is moved toward the 8 o'clock position and the left scapula toward the 10 o'clock position, aiming to achieve symmetrical positioning of both scapulae.

3) With the torso actively self-corrected and both scapulae positioned symmetrically, the subject, based on reported pain during a bench press position, performs forward arm extension from a sitting position (90 ˚ flexion at the shoulder joint and 0 ˚ extension at the elbow joint).

Ⅲ. Results

1. Comparative analysis of external spinal changes in sitting position

In the seated position, the CI decreased from 22 to 0. For LT measurements, superior angle (SA) decreased from 78 to 55 on the left and from 80 to 49 on the right. Root of spine (RS) decreased from 80 to 55 on the left and from 80 to 50 on the right. Inferior angle (IA) decreased from 90 to 48 on the left and from 75 to 45 on the right. Regarding TRACE measurements, scapular decreased from 2 to 0, hemi thoracic (HT) from 1 to 0, and waist from 3 to 2. However, the shoulder (SH) measurement remained at 1 throughout the 8-week period (Table 1).

Table 1. Comparative analysis of external spinal changes in sitting position

CI; coronal imbalance, LT; lennie test, SA; superior angle, Lt; left, Rt; right, RS; root of spine, IA; inferior angle, TRACE; trunk aesthetic clinical evaluation, SH; shoulder, SC; scapular, HT; hemi thoracic, WA; waist

2. Comparative analysis of external spinal changes in a sitting position with arms extended forward

In the seated position with arms raised, the CI decreased from 24 to 0. For LT measurements, scapular decreased from 80 to 62 on the left and from 80 to 57 on the right. RS decreased from 65 to 45 on the left and from 72 to 52 on the right. IA decreased from 82 to 65 on the left. In TRACE measurements, SH decreased from 1 to 0, SC from 1 to 0, HT from 1 to 0, and WA from 3 to 2. However, the IA on the right increased from 56 to 65 (Table 2).

Table 2. Comparative analysis of external spinal changes in a sitting position with arms extended forward

CI; coronal imbalance, LT; lennie test, SA; superior angle, Lt; left, Rt; right, RS; root of spine, IA; inferior angle, TRACE; trunk aesthetic clinical evaluation, SH; shoulder, SC; scapular, HT; hemi thoracic, WA; waist

Ⅳ. Discussion

This study was conducted as a single subject case study to investigate the impact of the Italian conservative treatment method, the SEAS approach, on spinal aesthetic evaluation in patients with idiopathic scoliosis in their 20s.

According to the scoliosis research society, a CI distance of 15 ㎜ or less is considered compensatory (Lowe, 2006). In this study, the CI of the subject decreased from 22 ㎜ at the initial assessment to 5 ㎜ at the 4 week assessment and further to 0 ㎜ at the 8 week assessment when sitting. In the sitting position with arms extended forward, the CI decreased from 24 ㎜ at the initial assessment to 5 ㎜ at the 4 week assessment and then to 0 ㎜ at the 8 week assessment. Initially, both positions showed a CI exceeding 20 ㎜, indicating a coronal plane distortion. However, after 4 weeks, the CI reduced to 5 ㎜ in both positions, and after 8 weeks, it reduced to 0 ㎜, indicating that the coronal balance of the spine was achieved. Dong et al. (2022) reported a reduction in CI after applying PSSE to patients with moderate idiopathic scoliosis. Physical training that focuses on core strength has been shown to improve alignment and balance in the coronal plane in adults with degenerative scoliosis (Akeda et al., 2023). Similarly, in this study, the application of SEAS, a type of PSSE, resulted in a reduction in CI. This suggests that the improvement in spinal curvature angles influenced the alignment in the coronal plane. Furthermore, the ASC emphasized in SEAS is a three dimensional self correction training method that patients can independently apply without external assistance. This aligns with findings suggesting that it enhances the use of intrinsic spinal muscles as much as possible (Romano et al., 2015).

The LT is an assessment method used to evaluate the positioning of the scapular, and in this study, it was conducted to assess scapular alignment. At the initial assessment in the sitting position, the left IA was 15 ㎜ longer than the right IA, and when sitting with arms extended forward, the left IA was 26 ㎜ longer than the right IA. The longer left IA compared to the right IA is attributed to the measurement of horizontal distance from adjacent vertebrae, reflecting the right sided scoliosis of the subject. Additionally, the difference in IA between the left and right sides was 11 ㎜ greater in the position with arms extended forward compared to the sitting position. This larger difference is likely due to the scapular movements resulting from the rhythm between the scapula and the humeral head during the forward arm extension. Four weeks after the initial assessment, the right IA was 5 ㎜ longer than the left IA in the sitting position, and the left SA was 12 ㎜ longer than the right SA. In the position with arms extended forward, the right IA was 28 ㎜ longer than the left IA, and the right RS was 17 ㎜ longer than the left RS. The reversal in IA measurements observed at the 4 week assessment, where the right IA became longer than the left IA in both sitting positions, compared to the initial assessment, is thought to result from a reduction in thoracic curvature due to SEAS ASC over the 4 weeks. This suggests that the left scapula underwent more downward rotation compared to the right scapula when arms were extended forward.

In the study by Turgut et al. (2017), it was observed that in patients with idiopathic scoliosis, the convex side scapula exhibits internal rotation and anterior tilting in a stable posture, while the concave side scapula shows external rotation and posterior tilting. During arm elevation, the convex side scapula demonstrates reduced posterior tilting, and the concave side scapula shows reduced upward rotation. In this study, the SEAS intervention, specifically the initial ASC exercises involving moving the right scapula to the 8 o'clock position and the left scapular to the 10 o'clock position, resulted in increased upward rotation of the left scapular and a more neutral position of the right scapular after 8 weeks compared to the 4 week assessment, achieving a more symmetrical alignment of the scapular. Rapp van Roden et al. (2018) noted that scapular asymmetry in patients with idiopathic scoliosis is more closely related to spinal alignment than to arm and leg positioning. The symmetrical scapular alignment observed at the 8 week assessment in both sitting and sitting with arms extended forward positions indicates that the SEAS ASC likely improved spinal alignment, which, in turn, enhanced the activation of the serratus anterior and the middle and lower trapezius muscles involved in scapular positioning. Similarly, as observed in a case study where a one-year SEAS intervention reduced the thoracic angle from 35.5 degrees to 32 degrees, this aligns with biomechanical changes in the spinal soft tissues that facilitate maintaining proper posture before achieving primary skeletal deformity correction (Romano et al., 2015). The SEAS exercises, which include scapular movements and arm extension, appear to have achieved the goal of enhancing spinal stability and improving the functional alignment of the arms and legs (Seleviciene et al., 2022; Yagci & Yakut, 2019). However, it should be noted that the LT used in this study focuses solely on evaluating scapular upward and downward rotation, and may have limitations in assessing anterior and posterior tilting, as well as medial and lateral rotation.

In the TRACE assessment, both in the sitting position and the sitting position with arms extended forward, scores for the thoracic and lumbar sections decreased at the 4 week evaluation compared to the initial assessment. However, the score for the shoulder joint increased by 1 point in the sitting position, and the score for the scapula increased by 0.34 points when the arms were extended. The decrease in scores for the thoracic and lumbar sections at the 4 week evaluation can be attributed to improvements in spinal alignment due to SEAS ASC. The increase in scores for the shoulder joint and scapula sections at 4 weeks likely reflects an increase in downward rotation of the left scapula, despite the overall improvement in spinal alignment. At the 8 week evaluation, scores for the shoulder joint and scapula sections decreased in both the sitting and the sitting with arms extended positions, while there was no change in the lumbar section score. The decrease in scores for the shoulder joint and scapula sections indicates improved scapular symmetry and stability due to the SEAS exercises involving scapular movements and arm extension. The subject's Cobb angles were 27 ˚ for the lumbar and 24.5 ˚ for the thoracic spine, but the Adams test showed 10 ˚ for the lumbar and 5 ˚ for the thoracic spine.

Negrini et al. (2018) reported a positive criterion of 7 ˚ for the Adams test. In this study, the lumbar Adams test result exceeded the positive criterion, which led to applying clockwise rotation for the lumbar spine during SEAS ASC. Despite this, the reduction in the lumbar section of the TRACE assessment was relatively small. Naglič et al. (2019) applied a comprehensive treatment program, including SEAS approach, physical therapy, hydrotherapy, and occupational therapy, to adolescent idiopathic scoliosis patients over 5 days. Although the TRACE total score decreased by 0.33 points, the result was not statistically significant. In this study, the application of SEAS approach over 8 weeks led to a decrease of 4 points in the TRACE score in the sitting position and 4.66 points when arms were extended forward. The significant reduction in TRACE scores in this study compared to Naglič et al. (2019)'s research is attributed to the longer duration of the intervention. Negrini et al. (2019a) demonstrated a significant difference in the TRACE scores before and after treatment between a group receiving SEAS intervention and a non-intervention group. Similarly, this study showed a reduction in TRACE scores with the SEAS approach, suggesting that the SEAS approach positively impacts the external appearance improvement in scoliosis.

This study focused on spinal morphological assessments after applying the SEAS approach for 8 weeks to a patient with idiopathic scoliosis in their 20s. The advantage of spinal morphological assessments is that it does not require additional costs for assessment and can be conducted immediately with the patient, without constraints of time and location. However, as this study is a single-case report without a control group, its findings cannot be generalized. Furthermore, as it focused solely on spinal morphological assessments, future research should incorporate a variety of assessment methods to provide a more comprehensive evaluation of scoliosis.

Ⅴ. Conclusion

SEAS is a therapeutic approach that emphasizes ASC to improve three dimensional spinal alignment in individuals with scoliosis. This study aimed to evaluate the effects of SEAS on morphological assessments in a 20-year-old female with adolescent idiopathic scoliosis. The results of this study indicate that an 8 week SEAS intervention had a positive impact on the patient’s spinal morphology. However, as this study is a single case report, further in-depth research is necessary to address its limitations and validate these findings.