What the Schroth method is

Short answer: Schroth is the oldest and most widely known school of practice under the heading of scoliosis-specific physiotherapy exercise. It is built on an active correction set up around the child's own curve pattern, on breathing directed into the collapsed regions of the rib cage, and on holding the corrected position through muscle work. There are randomised trials indicating that the method may contribute to slowing the progression of a curve. Those trials are small and the certainty of the evidence is low, which means no outcome can be predicted in advance for one particular child. In a child who needs a brace, exercise is added alongside the brace and does not stand in for it.

What scoliosis-specific exercise means

Not every exercise recommended for a child's back has the same aim. General back and trunk exercise works on strength, flexibility and stamina, and it looks much the same for every child who does it. Scoliosis-specific exercise is built instead around where the child's curve sits, which way it points and which part of the trunk has shifted sideways. Two children working in the same room at the same hour will not be doing the same movements.

In the international literature this group of methods goes by the abbreviation PSSE, meaning physiotherapeutic scoliosis-specific exercises. The 2016 SOSORT guideline defines the heading so as to cover those forms of outpatient physiotherapy shown to have an effect on scoliosis outcomes, and states that such programmes must rest on four principles. In the order the guideline gives them:

• Three-dimensional self-correction, meaning that the person brings their own trunk into the corrected position through their own muscle work
• Training in the activities of daily living
• Stabilisation of the corrected posture, so that the position learned can be held
• Patient education

Schroth is the oldest and best known of the schools of practice that fall under that definition. The two terms should not be treated as synonyms. PSSE is a heading, and Schroth is one of the routes beneath it. The guideline also reports that session frequency ranges from two to seven days a week depending on the complexity of the technique and on how quickly the person learns, and that long-term programmes typically run two to four sessions a week. How a programme is put together in practice is described separately on the what happens in a session page.

From Katharina Schroth to the present

The method was developed in Germany in the 1920s by Katharina Schroth, who had scoliosis herself. Standing in front of a mirror, she tried moving the shifted part of her trunk towards the opposite side and directing her breath into the part of the rib cage that had stayed flattened. The two ideas now described as the core of the method came out of that.

Her daughter, Christa Lehnert-Schroth, turned her mother's trial-and-error work into a classified approach and applied it for decades at the clinic in Bad Sobernheim. Her book, the written foundation of the method, sets out how curve patterns are grouped and in which direction correction is worked in each group. Weiss's 2011 history paper examines how the method developed from its earliest form to the present, and how the training lines that later diverged from one another came about.

The method was born of clinical observation and was practised for decades without randomised trials. Controlled research began to be published much later, in the 2010s. The age of the method is therefore not the same as the age of its evidence, and being long-established is not on its own an indicator of effectiveness.

Whether Schroth is a single school

A family that has spent an evening reading about the method online will usually have found three sites that do not describe it in the same way. The Schroth name covers a tradition descended from Katharina Schroth's work, and no single institution owns it. As the method spread beyond Germany, separate training lines formed, and over time these developed their own curricula, their own detail of classification and their own levels of certification. One of the subjects Weiss's history paper takes up is precisely this divergence.

In practice this matters for one reason. Two physiotherapists trained on two different lines may work with the same child on similar principles but differ in the detail of how they do it. A family cannot rank those lines by quality, because no study compares them with one another. This page does not rank them either.

The common ground is the four principles listed above. Whichever line a programme comes from, if it does not teach a correction built around the child's own pattern, if it leaves out carrying what has been learned into daily life, and if it does not inform the family, then whatever name is attached to it, it does not count as a scoliosis-specific programme.

What ISST means

ISST, in full International Schroth 3-Dimensional Scoliosis Therapy, is the name of an international training programme in the Bad Sobernheim tradition, run for physiotherapists. The training covers the classification of curve patterns, the principles of three-dimensional correction, the breathing technique and working with children who wear a brace. Therapists who complete the programme appear in the training organisation's own therapist directory, grouped by country.

This is a training certificate. It carries no official title and gives its holder no medical authority. A certified therapist does not make a diagnosis, does not order X-rays and does not prescribe a brace. What the document says is that the person has completed a particular curriculum. The two sections at the end of this page deal at greater length with what such a document does and does not establish, and with how a family can check it.

Self-correction specific to the curve pattern

This is where the method parts company with every other exercise programme. The assessment first establishes where in the trunk the curve sits, how many curves there are, which way each of them points and how the pelvis stands in that picture. The exercises are then built around that pattern.

Self-correction, or autocorrection, means the child bringing her own trunk into the corrected position with her own muscles rather than being pushed and pulled there by somebody else. It usually begins with positioning the pelvis, continues with lengthening the trunk along its long axis, and is completed by carrying the segment that has shifted sideways towards the other side. The child learns this by watching in a mirror, by feeling the tactile cue the therapist's hand gives, and by counting along. In the first sessions the movement usually looks rough. Over the following weeks it tends to become more precise, and how quickly that happens differs from one child to the next.

The practical consequence is this: a movement that is right for one child is applied in the opposite direction in another child whose pattern differs. That is why a video watched online, or a memorised list of exercises, does not serve the purpose. For the same reason, following several children who are each working in a different direction, and catching a wrong direction the moment it appears, is harder the more people there are in the room. That is a practical observation about supervision, and the trials have not compared it. What supervision is for is taken up separately below.

Learning the correction also takes time. The child builds it first lying down or in a supported position, then sitting, and only last of all standing and while moving. If that order is skipped, the child imitates the correction but cannot construct it on her own.

Rotational breathing

In scoliosis the vertebrae rotate about their own axis and the rib cage joins in that rotation. On one side the ribs come closer together. On the other they open out. Breath by its nature goes where expansion is easiest, so the region that is already open ends up being used still more.

Rotational breathing teaches the child to direct the breath deliberately into the narrowed region. A child does not feel that region at first. The therapist's hand, the light resistance of a belt, or a support placed under the back while lying down let him feel where the breath ought to go. Holding the lengthened position of the trunk while breathing out is part of the work as well, because most children collapse again as the breath leaves.

The aim is to contribute to the expansion of the collapsed part of the rib cage and to support the corrected position from the inside. The limit of the method sits at exactly this point. The randomised trials of scoliosis-specific exercise mostly measured the degree of curvature, trunk rotation (how far the trunk is twisted about its own long axis, measured over the back with a small angle-measuring instrument) and quality of life. No numerical promise about breathing capacity can be drawn out of their results.

Stabilising the corrected posture

Building the correction once and being able to hold it are two different skills. Stabilisation work means keeping the position that has been built through contraction of the trunk muscles. To somebody watching from outside the movement is almost invisible, because the child stays where she is instead of going anywhere. The work is hard all the same, and she tires quickly.

The hold is kept short, the number of repetitions is raised, and a break is given when fatigue starts to break the correction down. Pushing a correction that fatigue is already pulling apart leads to a faulty pattern being learned. This is exactly the third of the four principles the guideline lists.

Carrying what is learned into daily life

A child comes to a session for an hour a week. All the time that is left is spent at school, at home, at a desk and in bed. The second of the four principles is the carrying of the learned correction into those hours.

In practice this runs through very ordinary details: how the trunk is placed while sitting at a desk, how a bag is carried, which side not to collapse towards while looking at a phone, and which support to use in bed. Telling a child to hold the corrected position at every moment of the day does not work, because nobody manages that. Instead a few fixed moments in the day are chosen and the correction is tied to them. Whether the school bag is being carried on one shoulder belongs under this heading too.

This principle earns its place. In the randomised trials the children were given a home programme to be done every day alongside the supervised session, and the results that were reported rest on that daily load. How a home programme is set up, how long it takes and why the real work happens at home are described in detail on the what happens in a session page.

The fourth principle: informing the child and the family

The last of the four principles is patient education, and it is the heading that gets the least space in most descriptions. What is meant by it is that the child and the family understand what the curve is, why particular measurements are taken, what the programme is aiming at, and in which circumstances they go back to the physician. A programme can only be kept up for months on end when the person doing it knows what she is doing and why.

There is a side of this information that has to be honest. As a family learns what the method aims at, it should also learn what the method does not promise. A programme begun without knowing that the certainty of the evidence is low leaves a family disproportionately disappointed when the measured angle fails to come down as expected at the first X-ray check. The physician is also the one who makes the decision and follows it, and a family should hear that at the outset.

This paragraph speaks directly to the teenager. Nobody else can do this programme for you. The therapist teaches you the movement and your family will remind you about it, but the muscles that build the correction are your muscles. Asking about a movement you have not understood costs you less time than pretending you have. If a movement hurts, or if you find you have to hold your breath to manage it, say so, because unpicking a pattern that has been learned wrongly is harder than learning it properly the first time.

The difference between supervised work and working alone at home

One randomised controlled trial, run in Turkey, addressed this question head on. Adolescents were divided into three groups: those doing Schroth in a clinic under the supervision of a physiotherapist, those doing the same programme alone at home, and a group receiving no treatment. The improvement measured in the curve and in trunk rotation reached significance only in the supervised group. The children who followed the same programme alone at home did not show it, and neither did the untreated group. The trial is small and its follow-up short, so on its own it does not produce a firm rule. It still stands as direct evidence that starting at home with a video watched online does not give the same result.

A distinction has to be drawn plainly here. The comparison ran between a programme under a physiotherapist's supervision and the same programme done by the child alone, rather than between one-to-one work and group work. No comparison exists showing how the number of people in the room affects the result, so no evidence-based claim of superiority can be built on the format of a session.

In concrete terms, supervision means spotting the moment a correction starts sliding the wrong way and putting it right there and then, renewing the movements as the child grows and the programme advances, updating the home programme, and repeating the trunk measurements by the same method each time. None of that can be done through a video.

Where it comes into the picture and where it does not

This method is not the answer to every complaint about a back. The table below summarises where it stands in which situation. The degree values in the table refer to the Cobb angle, which is the degree of curvature measured on an X-ray, and how that measurement is taken is described on the diagnosis and follow-up page. In every row of the table, the decision itself belongs to the physician.

A family who has not used this health system before will not know the route to that physician, so here it is. The first step is the family physician at a family health centre (aile sağlığı merkezi) or a paediatrician, who examines the child and refers her onward. The referral goes to orthopaedics and traumatology (ortopedi ve travmatoloji) or to physical medicine and rehabilitation (fiziksel tıp ve rehabilitasyon, usually shortened to FTR), and imaging follows only if the physician asks for it. The state route and the private route end at the same two specialties — what mainly differs is how long the wait is. Which of the two suits a particular household is not something a guide can decide.

Why the threshold in the third row sits where it does, how the number of hours a day a brace is worn determines the outcome, and what role exercise takes on alongside a brace are taken up on the bracing and exercise page. What the findings in the last row mean is explained on the noticing the signs at home page, and why the aim is set differently in adults is explained on the scoliosis in adults page.

What the evidence says

The evidence position of the method is dealt with at length in one place in this cluster, on the bracing and exercise page. The names of the trials, their numbers, their confidence intervals and their limitations sit there. Only the summary is given here.

There are randomised trials indicating that scoliosis-specific exercise may contribute to slowing the progression of a curve, and to trunk symmetry and quality of life. Those trials are small, their follow-up is short and the certainty of the evidence is low. Reviews that pool the results of trials on the same question into a single calculation also report that the benefit is uncertain, and the change seen in the averages stays within the natural margin of error of the X-ray measurement itself. Exercise may still do useful work. What cannot be done is turning a change in a group average into a promised outcome for one child.

How long it takes before a measurable change is expected, and which measurements are used to follow progress, are set out on the what happens in a session page. How a curve is behaving is judged by the physician, working from an X-ray check.

What the method cannot do

The following lie outside the scope of the method.

• It does not take over the function of a brace. In a child for whom a brace is indicated, exercise is added alongside it.
• It offers no alternative to surgery. In a curve that has come close to the surgical threshold, the person to see is the spine surgeon.
• It carries no promise of undoing a curve that is already there. The average change seen in randomised trials stays below the threshold accepted as clinically meaningful.
• It does not make a diagnosis. A diagnosis is made by a physician, from a standing X-ray and an examination.
• A physiotherapist does not order X-rays, does not prescribe a brace and does not recommend medication.
• How an operation goes, how long it takes, what its risks are and what changes afterwards are not questions this page is able to answer. They are put to the spine surgeon, and the surgical decision page shows which questions can be prepared in advance.

What a Schroth certificate establishes and what it does not

Families get stuck on one distinction more than any other. The appearance of the Schroth name somewhere does not in itself show that the person using it has completed Schroth training. A sentence saying that Schroth principles are drawn on says nothing about a document. The only way to learn the difference is to ask, and it is the family who has to ask.

The certificate establishes the following:

• That the person has completed the curriculum of a particular organisation
• That the person passed the assessment at the end of that curriculum
• At what level and on what date the training was taken

The certificate does not establish the following:

• How many people the therapist has worked with to date, or how experienced the therapist is
• What the outcome will be in any particular child
• That the person has kept up to date since the training, or practises the method regularly
• That the person has been granted any medical authority

The line the training came from is written on the document as well. As described above, more than one training line exists under the Schroth name and their programmes are not identical. A family can do something simpler and more reliable instead: check that the document exists and read what it covers.

How a family can verify the document

The questions below can be put to any therapist, and no therapist should find them odd. Asking them is an ordinary piece of verification in health care.

1. Which organisation did you take your Schroth training from, and what is that organisation's full name?
2. In which year did you complete the training, and what level are you at?
3. May I see the certificate?
4. Is your name listed in the therapist directory of the organisation that gave the training?
5. Which university is your physiotherapy degree from, and from which year?

The fourth question is the most practical one in most cases. Some of the organisations that give Schroth training publish their certified therapists on their own websites, grouped by country, and ISST is one of them. Where such a directory exists, a family can look up the therapist's name there and check the statement against an independent source. Training taken from an organisation that publishes no directory remains valid all the same. In that case it is enough to see the document itself and to note down the name of the organisation.

The fifth question is a separate matter. A Schroth certificate sits on top of a physiotherapy degree and cannot stand in for one.

For a family that does not speak Turkish, one practical point matters here. All of the questions above can be asked in English, and consultations at this practice can be held in English, including the short introductory call that comes before a first appointment.

Where verification ends, there are other questions left to ask. On what measurements is the programme being built, how often is it reviewed, what information is sent in writing to the physician who follows the child, and does the child work with the same therapist each time he comes in. The answers to those are not printed on any document, and a family learns them by asking. A wider list of the questions a family can put to a physician and to a therapist has been gathered on the parents' questions page.

A certificate shows what the person in front of you has learned. It does not alter the evidence position of the method. The limitations described above apply in exactly the same way to a programme run by a therapist who has completed training at the highest available level. Giving a family both of those pieces of information together is more useful than giving only one of them.