Review article
Volume 6, No. 1, 2014, 23-30
UDC 616.711-007.5-085
Nikola Jevtić*
Faculty of Sports and Physical Education - University of Novi Sad
Idiopathic scoliosis is a deformity of the spinal column and is found among healthy chil-
dren. Etiology of idiopathic scoliosis is unknown. Spinal shift occurs in all three planes followed
by muscle disfunction and reduced vital capacity of the lungs. Asymmetric loading on the spine
can be listed as one of the factors of rapid progression of scoliosis, whereby large pressure is put on
the concave side of the scoliotic curvature due to the shift of standing balance of the body. Reha-
bilitation is based upon improvement of functionality, ability and capacity of the patient with sco-
liosis. The initial stage of rehabilitation rests on correct diagnosis and estimation of patient’s con-
dition in order to commence the treatment in the best possible manner. The Schroth method has a
long-standing tradition and is primarily applied in correction of scoliosis. It is based on three-di-
mensional breathing, proper pelvic correction and specific exercises and education of patients in
order to continue the treatment at home.
Keywords: the Schroth method, scoliosis, asymmetric loading, muscle disbalance
Idiopathic scoliosis may be defined as a complex three-dimensional deformity of the spine
and trunk. It occurs in healthy persons and its etiology is unknown (Rigo, M., & Grivas, T. 2010).
With the aim to detect scoliosis easier, its specific name can be obtained according to the localiza-
tion of the principal curvatures (thoracic, lumbar, thoracolumbar, double major, double thoracic);
however, there are numerous classifications by means of which it is easier to recognize the type of
idiopathic scoliosis (Weiss, H.R. et al, 2013). In addition to idiopathic scoliosis, scoliosis can be
classified into two more groups according to the etiology: congenital and neuromuscular. Congen-
ital scoliosis is gained by nurture and the process of deformation can occur even in the embryonic
conception, while the other type of scoliosis comprises of neuromuscular scoliosis, whereby neu-
romuscular diseases occur as a result of deformity. Many authors dealt with etiology of idiopath-
ic scoliosis and did not wind up with a concrete answer. They suggest various causes as the rea-
* Corresponding author. Avgusta Cesarca 11/9, 21 000 Novi Sad, Serbia, e-mail: njevticns@gmail.com
© 2014 Faculty of Sport and Physical Education, University of Novi Sad, Serbia
Nikola Jevtić
sons of occurrence of this type of scoliosis; nevertheless, it is assumed that genetics and asymmet-
ric loading represent the greatest cause. The difference in rehabilitation from congenital and neuro-
muscular scoliosis in comparison to idiopathic scoliosis lies in the fact that the first two deal with
the causes of the deformity, while in idiopathic scoliosis consequences are ones that are addressed.
Biomechanical factors may have a significant role during the rapid progression of scolio-
sis in adolescence (Stokes, I. 2007). Asymmetric loading of the body, as well as the shift of stand-
ing balance of the body, may have serious consequences on the deformity of the lumbar spine.
Mechanical factor becomes predominant, as compared to the initial factor, in the period of rapid
growth during adolescence (Stokes, I. et al, 2006). Muscle disbalance occurs as a result of spinal
column shift, thus the muscles on one side of the spinal column are less active, whereby rotation
of the spinal column can be listed as the cause (Fidler, M.W. & Jowett, R.L. 1976). Patients who
suffer from this condition often have problems with reduced function of respiratory muscles, and
even reduced vital capacity of the lungs (Martinez-Liorens J. et al, 2010).
The Schroth method is a longstanding, traditional method applied in rehabilitation from
scoliosis and it is used around the globe. It originates from Germany and it rapidly spread to oth-
er countries in Europe and worldwide due to its results. The method was launched by Katharina
Schroth; later, her daughter Christa Lehnert Schroth joined her and gave a large contribution to the
development of this method (Weiss, H.R. 2010). The Schroth method corrects scoliosis in all three
planes, which is actually its advantage as compared to certain methods.
The history of Schroth method
The Schroth method is a non-operative treatment applied in the correction of scoliosis and
has a very long tradition. One may suggest that it is a conservative type of treatment that reminds
of Hippocrates’ original method. Although it has been more than 2,000 years since Hippocrates’
era, the conservative type of scoliotic correction retained the same approach to the problem. The
fact that three therapists used to work with one patient in order to prevent mistakes during the cor-
rection shows how seriously this problem used to be approached two centuries ago. Corrective
treatment based on the principles of the Schroth method is nowadays applied worldwide, precise-
ly because of its approach to the problem, primarily based on three-dimensional breathing, which
has the most significant role in treatment of scoliosis.
Development of the Schroth method rests upon professional work of three generations.
The first steps were recorded back in 1921, by Katharina Schroth, who suffered from scoliosis
herself. Dissatisfaction, caused by the treatment she had received in particular institutions, made
her to look for the solution to her problem by herself. She started to explore her body and apply a
new type of treatment. She was a teacher, so she did not know anything about anatomy, physiolo-
gy and biomechanics; however, her inspiring spirit contributed to the development of something
completely new, something that gave amazing results in the following years. She came to the con-
clusion that it is possible to achieve postural control exclusively by changing of postural percep-
tion. She was trying to make the correction of the rib cage by performing deep inhalations on the
concave side. She used to do that in front of a mirror in order to be able to control the movements
of the rib cage. Her primary inspiration was a balloon. While observing the balloon being inflat-
ed, she concluded that there is a possibility to make a correction of the deformity by following the
same principle. She started to develop the method in Meissen, Eastern Germany, where she had
her first small institute. During the 1930s and 1940s, Katharina received support in work and de-
velopment of the method from her daughter Christa, who was born in 1924. Katharina moved with
her daughter Christa to Bad Sobernhein in 1961. This is the town where they founded their insti-
Scoliosis and treating scoliosis with Schroth method
tute which gradually developed into a well-established clinic, officially opened in 1983 under the
name “Katharina Schroth Klinik”. After Katharina’s death in 1985, her daughter Christa Lehnert-
Schroth, therapist, continued with the development of the method. Later on, her son, Hans Ru-
dolf Weiss, orthopedic surgeon, joined her. Dr. Weiss was the director of the clinic during the peri-
od from 1995 to 2008. German health care provider, Asklepios, bought the clinic in 1995 with all
rights and liabilities to use the name “the Schroth Method”, thus today, the clinic bears the name
“Asklepios Katharina-Schroth-Klinik”.
In order to assess the influence of the Schroth method, the first research with patients was
conducted in the period 1989-1991, and it was published in German in 1995 and in English in
1997. The next research also included the division of patients according to their age and gender,
which brought about more valid results. Studies included the improvement of cardio-pulmonary
capacity, vital capacity, muscle function monitoring, electromyography and changes in pain dur-
ing the treatment. It was determined by EKG tests that there is a statistically significant reduction
of cardiac exertion during the intensive treatment of 6 weeks in 794 patients. The improvement of
vital capacity of the lungs and mobility of the ribs were recorded in more than 800 patients. Activ-
ity of the muscles was reduced in more than 300 patients after intensive treatment. The correction
of thoracolumbar curvature, including derotation by means of muscle psoas was improved during
the 1920s. The program of correction according to the principles of the Schroth method was de-
signed so that patients continue to practice at home after being provided with proper education su-
pervised by a Schroth therapist.
Etiology of scoliosis
Idiopathic scoliosis is a complex deformity of unknown etiology which includes morpho-
logical changes and transformation of the spinal column in all three planes. Scoliosis is a term that
describes lateral deviation of the vertebrae, axillar rotation of which stimulates three-dimension-
al deformity of the trunk. Therapists and doctors, who deal with this problem, understand what the
term “idiopathic scoliosis” is, but are speechless when etiology is concerned. Various studies who
deal with etiology of the idiopathic scoliosis have not come to a direct response, but they have
made certain conclusions. Thomas et al. (2008) listed several factors which cause the development
of scoliosis, the first of which is genetics.
Genetic or hereditary factors are widely accepted in the development of idiopathic scolio-
sis (Thomas et al., 2000). Harrington’s research with women who had scoliotic curvatures of more
than 15 degrees, ended with a result that showed that 27 percent of these women’s daughters have
scoliosis. It was determined that 11 percent of patients (first-degree relatives are affected), 2,4 per-
cent second-degree and 1,4 percent third-degree relatives suffer from scoliosis (Harrington, P.R.
1977). The research conducted with identical and fraternal twins who had scoliosis showed that
genetics has a large infuence on the developement of scoliosis. The group of autors obtained the
results which indicated that 73 percent of scoliosis developed in both identical twins when one of
them initially had scoliosis, while the percentage was slightly less in fraternal twins, so that scoli-
osis developed in both of them in 36 percent of cases (Kesling, K. L., i Reinker, K.A. 2009).
Other studies show that a hormon called melatonin also has a large influence on the de-
velopement of idiopathic scoliosis. In consequence, certain authors conducted numerous studies
in order to prove that fact. Dubousset et al. (1998) controlled the level of melatonin in thirty ad-
olescents in his study who had severe curvature, between 57 and 75 degrees. Patients who expe-
rienced the deterioration of the curvature of more than 10 degree had 35 percent- reduced secre-
tion of melatonin during the night, while in the group of patients with stable scoliosis, during the
Nikola Jevtić
same year, melatonin secreted without any problems. Lafortune et al. (2007) conducted an exper-
iment in which he did a research of the influence of melatonin on scoliosis in chickens. He divid-
ed the chickens into three groups. He removed the pineal gland, which secrets melatonin, from the
first group, made an incision on the second group in order to simulate the removal of the gland,
and the third group was the control group. All three groups had the same treatment during the ex-
periment, 12 hours of light, 12 hours of dark, 26 degree Celsius and 78% humidity. Scoliotic cur-
vature occurred in 55% of the chickens in the first group after two weeks and developed into a se-
vere condition during the third and fourth week. Cases of scoliosis were not recorded in the sec-
ond and third group.
Besides genetics and melatonin, some other factors, mentioned by various authors, can be
listed as the cause of idiopathic scoliosis. One of these factors can be effects of connective tissue.
Collagen and elastic fibers are crucial elements of the supporting structure of the spinal column
and have a significant role, according to many authors who deal with the pathophysiology of idio-
pathic scoliosis (Thomas, L. et al. 2000). Skeletal muscle abnormalities are also one of the factors
that can be claimed to have a significant role in the development of idiopathic scoliosis, as well as
the Role of Growth and Development.
Nevertheless, Manuel Rigo (2010) stated that there are two types of pathogenetic factors
for idiopathic scoliosis. The first group comprises the initial stage of scoliosis, where the main fac-
tors are biological, morphological, neuromuscular and biomechanical, while the main cause of
rapid progression of scoliosis lies in the biomechanical factors, i.e. asymmetric loading on the spi-
nal column.
Biomechanics of scoliosis
Understanding the etiology of scoliosis is a great challenge, but it is well known that me-
chanical factors have a significant role in the development of deformity. Geometry and anatomy
are fundamental for understanding mechanical part of deformity. It is mentioned that scoliosis is
a three-dimensional deformity; however, the entire process may include the fourth dimension as
well (Bagnall et al. 2009). Deformity shifts over time and, consequently, this is the time when the
fourth dimension is very important for patients because they can follow and control their own con-
The shifting process of deformity occurs due to the shifted standing balance of the body
which causes altered pressure on the spinal column (Rigo, M., Grivas, T. 2010). The concave side
of the spinal column suffers a lot more pressure than the convex side, which leads to certain conse-
quences. One of them is that vertebral body loses its natural geometry and becomes wedging ver-
tebrae over time (Stokes, I. 2007). Scoliosis progresses rapidly during the adolescent growth. That
period is considered the most critical for the development of scoliosis. Spinal column tissue and
trunk tissue also suffer from the loading during everyday activities, precisely because of the asym-
metric loading. In 2006, Professor Stokes introduced biomechanical modulation of spinal growth
and development of scoliosis in adolescents. In the illustrated scenario of loading, he explains to
what extent altered pressure actually affects the progress of scoliosis. He calculated that vertebral
body suffers the pressure of 1.3 MPa on the concave side on the verge of the curvature, whereas
the convex side suffers the loading of 0.7 MPa, with annual spinal growth of 3 percent (30 mm).
Growth of the vertebral body at the center of the curvature on the concave side amounts 0.5 mm
and 1.3 mm on the convex side, which would lead to the increase of the curvature of 6.7 degrees
and forming the wedging vertebrae. The influence of gravity can be listed as one of the crucial
factors in producing axial force that leads to asymmetry and torsion, because standing balance of
Scoliosis and treating scoliosis with Schroth method
the body is shifted to the side of convexity of the primary curvature. In that manner, the increase
of loading on the concave side, and consequently the increase of deformity, occurs (Stokes, I., et
al. 2006). Scoliosis research society explains that torsion of the spinal column may be defined in
two manners. The first is a mechanical torsion that influences the intervertebral disc in the verte-
bral body. The second type of torsion is explained as geometric and represents the movement of
the spinal column in space, i.e. the change in its physiological shape in all three planes (Rigo, M.,
Grivas, T., 2010).
Scoliosis also has significant influence on movement. Mahaudens et al. (2008) conducted a
research in which, besides muscle activation, he wanted to examine the difference in mobility of
certain parts of the body during movement. Between participants with formed scoliotic curvature
(exclusively lumbar and thoracolumbar) and healthy participants, those with scoliosis were divid-
ed into three groups in respect to the degree of the curvature. They concluded that statistically sig-
nificant reduced mobility of certain parts of the body, as well as length of a step, in comparison to
the control group, alterations mainly occurred during the movement of body segments in the fron-
tal plane. Participants with scoliosis had shorter steps as compared to the control group. Reduction
of pelvic and hip movement in the frontal plane, as well as hip movement reduction in the trans-
versal plane occurred. Differences between the experimental groups were not recorded, regardless
of the difference in the degree of the deformity.
Muscle disfunction
Besides the changes in bone structure, changes also occur in the muscles. In 1976, Fiddler
and Jowett conducted a research on corpses with large scoliotic curvatures in order to determine
the disbalance of the deep back muscles. They came to a conclusion that the muscle multifidus on
the verge of scoliotic curvature is shorter on the convex side. That was the consequence of the ro-
tation of the spinal column, while the erector spinae was longer on the convex side than on the con-
cave side, which is the cause of movement in the spinal column in the frontal plane.
Long-term use of braces may have a significant role in the change of muscle structure since,
due to muscular inactivity, transformation of muscle fibers may occur. In a research, during biop-
sy, Meier et al. (1997) discovered the transformation of muscle fibers in the muscle multifidus in
patients with scoliosis who had worn braces. Considering the fact that multifidus mainly compris-
es of slow muscle fibers, the other author came to the conclusion that, after long use of braces, the
muscles change their structure due to inactivity and slow muscle fibers become fast. The role of
braces is very significant in prevention of the progression of scoliosis; however, patients have to be
engaged in corrective activities in order to prevent transformation of the muscle fibers.
It can be noticed that numerous consequences occur on muscles in patients with scolio-
sis. Therefore, Dr. Weiss (1933) wanted to determine the effect of the Schroth treatment on mus-
cle activation. The study included 316 scoliotic persons who were tested before and after treat-
ment. Muscle activation was tested by electromyography having a patient extend the trunk from
the prone position. Overall results indicated significant improvement in postural capacity. Results
also showed significant reduction of muscle activation on the convex side of thoracic and lumbar
curvatures after the treatment. Major reduction in muscle activation was recorded on lumbar sco-
liotic curvature in comparison to thoracic scoliotic curvature.
Nikola Jevtić
Idiopathic scoliosis is a deformity that most often occurs among adolescents and its etiolo-
gy is unknown. However, rapid progression of scoliosis is assigned to biomechanical factors such
as asymmetric loading where the crucial role belongs to gravity. Due to this three-dimensional de-
formity, numerous side effects, such as disfunction of the respiratory system, muscle disbalance,
pelvic shift and shoulder girdle shift, come into play. All of them have an influence on the move-
ment disorder. The Schroth method is applied in correction of scoliosis and it influences the defor-
mity in all three planes. It impacts the improvement of vital capacity of the lungs and derotation of
the rib cage. This method appeared to be very effective in correction of scoliotic curvature by us-
ing gravity as an aid in rehabilitation. Therefore, it can be assumed that more rapid rehabilitation
from scoliosis would be achieved exactly with the increase of gravity.
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