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Original Article

Reliability of the original Lehnert-Schroth (LS) scoliosis classification in physiotherapy practice

Maksym Borysov1), Xiaofeng Nan2), Hans-Rudolf Weiss, MD3)*, Deborah Turnbull, BSc4), Alexander Kleban, PhD5)

1) Orttech-plus Rehabilitation Service, Ukraine2) Nan Xiaofeng’s Spinal Orthopedic Workshop, China3) Orthopedic Rehabilitation Service: Alzeyer Str. 23, D-55457 Gensingen, Germany4) The London Orthotic Consultancy, UK5) Lomonosov Moscow State University, Russia

Abstract. [Purpose]The foundations of the scoliosis specific and evidence-based physiotherapyprogramac-cordingtoSchrothistheoriginaltheLehnert-Schroth(LS)classificationwhichisstillinusetoday.ThepurposeofthispaperistotestthereliabilityoftheLSclassificationsystem,usingclinicalandradiologicalimagesofscoliosispatientsasclassifiedbyspecialistexperiencedclinicians.[ParticipantsandMethods]Alistof40picturesofX-Raysandalistof40clinicalpictures(allposteriortrunkimages)ofpatientswithidiopathicscoliosiswereprovidedbythesecondauthor.ThreespecialistprofessionalphysiotherapistsororthotistsratedallclinicalandradiologicalpicturesaccordingtothesetwopatternsoftheLSclassification.[Results]Theintra-observerKappavaluewas0.90(clinical)and1.00(x-rays).Theinter-observerKappavaluesataveragewas0.65(clinical)and0.71(x-rays).[Conclusion]FortheapplicationofclassifyingthepatientswhenprescribingposturaladviceandexercisesfromtheSchrothprogramtheLS-classificationseemsaneasytouseandhighlyreliabletool.Thistestdemonstratedsufficientreliabilitywithrespecttothex-rays,butthetestsoftheclinicalpicturesalone,demonstratedfairlevelsofreliability,whichindi-catesthatitisanappropriatetoolforphysiotherapistswhenanx-rayisnotavailable.Key words:Scoliosis,Physiotherapy,Classification

(This article was submitted Feb. 1, 2020, and was accepted Jul. 17, 2020)

INTRODUCTION

Scoliosis—asathree-dimensionaldeformityofthespineandtrunk—isnotauniformconditionandmayhavedifferentcauses(e.g.congenital,neuromuscular,otherrarediseases).Themostcommoncauseistheadolescentidiopathicscoliosis(AIS)with80−90%ofallscoliosisconditions1–3).

Treatmentofscoliosisconsistsofphysiotherapy,bracetreatmentandspinalfusionsurgery.Whilethereishighqualityevi-denceforspecialistphysiotherapy4–7)andbracetreatment8–12)evidenceforsurgeryisstilllacking13–18).Duringthepubertalgrowthspurt,patientsathigherriskforthescoliosistoprogress,bracingistheprimarytreatmentsupportedbyphysiotherapy,whilstinpatientswithalowerriskofprogression,physiotherapycanbeconsideredtheprimarychoiceoftreatment3, 6).

Todaytherearemanydifferentapproachesofphysiotherapysuggestedforthetreatmentofsignsandsymptomsofsco-liosis6),however,highqualityevidencehasbeenobtainedfortheSchrothmethodonly,witharandomizedcontrolledstudyprovidingacomparativeuntreatedcontrolgroup7).Besidesitsimpactontheangleofcurvature(Cobbangle)theSchrothmethodmayimprovemanyothersignsandsymptomsofascoliosis.Vitalcapacity,rightcardiacstrain,muscleenduranceandpaincanbeimproved,besidesqualityoflifeandotherpsychologicalparameters6).

J. Phys. Ther. Sci. 32: 647–652, 2020

*Correspondingauthor.Hans-RudolfWeiss(E-mail:hr.weiss@skoliose-dr-weiss.com)©2020TheSocietyofPhysicalTherapyScience.PublishedbyIPECInc.

Thisisanopen-accessarticledistributedunderthetermsoftheCreativeCommonsAttributionNon-CommercialNoDeriva-tives(by-nc-nd)License.(CC-BY-NC-ND4.0:https://creativecommons.org/licenses/by-nc-nd/4.0/)

The Journal of Physical Therapy Science

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TheoriginalSchrothmethodfirststartedin1921onanin-patientbasisandhassincebeendevelopedfurther3,19).Whilethe original Schrothmethod programwasmainly used for large single thoracic curves (over 60 degreesCobb angle atdiagnosis)inthelate1970stheintermediatedevelopmentalsoincludedmajorlumbarcurvaturesandthiswasthebeginningofthepatternspecificphysiotherapytreatmentofscoliosisandtheseparationof3and4curveclassificationpatterns3,19).Lehnert-Schrothtermedthemajorthoraciccurves(functional)3-curvepatterns(3C)andthemajorlumbaranddoublemajorcurves(functional)4-curvepatterns(4C)3,19,20).

ThemostrecentdevelopmentoftheSchrothmethodtodayistheSchrothBestPracticeprogram3), also including correc-tionsofthesagittalplanedeformityaswellastheoriginalaugmentedcorrectivemovementsandpatternspecificactivitiesofdailyliving(ADLs)startingwiththefirstpublicationsin200621, 22).ThismorerecentdevelopmentalsoencompassesthesimpleLehnert-Schroth(LS)classificationdistinguishingbetween3Cand4Cpatterns3).

Someotherclassificationshavebeendevelopedsincethe1980ssupportingpatternspecificapproachesofsurgery23, 24) and bracetreatment3, 25–27),howeverforphysiotherapytreatmentofanidiopathicscoliosistheLSclassificationwiththesetwodistinctivepatternsisthemostsimplifiedversionandisstillusedworldwidetoday3,19).ThepurposeofthispaperistotestthereliabilityoftheLSclassificationwithrespecttotheclinicalandtheradiologicalaspectsofscoliosispatients.

PARTICIPANTS AND METHODS

DescriptionoftheLS-classification:AccordingtoSchrothterminology3,19),patternspecificphysiotherapyneedstodis-tinguishbetween‘functional3-curvescoliosis’and‘functional4-curvescoliosis’,foritbespecific(Fig.1).Withfunctional3-curvescoliosis, theshoulder-necksection, the thoracicsection,and the lumbo-pelvicsectionare twistedandaskewinfrontal,sagittal,andtransverseplanes(Fig.2).

Withfunctional4-curvescoliosis,thelumbo-pelvicsectionisfurthersubdividedintoalumbarsectionandapelvicsection,withthepelvisbeingseenasanadditionalfunctionalcurvaturethatservesasastartingpointforanindependentcorrectionprincipleinthecontextofthetailoredphysiotherapeutictreatment(Fig.3).Withfunctional3-curvescoliosiswedistinguishbetweenscoliosiswithalaterallyprominentpelvisonthethoracicconcaveside(=3CH)andfunctional3-curvescoliosisandacentredpelvis(=3C;Fig.2).

Functional4-curvescoliosisisdistinguishedbytheprominenceofthehiponthethoracicconvexside(=4C;Fig.3).Typi-cally,thereisastructurallumbarorthoracolumbarcurvatureandthelumbarspineproceedsfromthesacruminanobliquemovement,alsoknownas‘obliquetakeoff’28).

Methodology:40differentAISpatientswereselectedfromthedatabaseofthesecondauthor.Provisionof(a)theclinicalpicturesofallthepatients(posteriortrunkviews)and(b)theX-RaysofthesepatientsonaPDFwithoutanyidentifiablemarkingsandthesewerethennumberedconsecutively.Theparticipantswereselectedwiththefollowinginclusioncriteria:Adolescentidiopathicscoliosis(AIS),Age12−16years,Cobbanglebetween35and50°Cobb.

Bothlistsincludedbothcurvaturetypes.X-RaysandclinicalpictureswerenumberedinadifferentordertoavoidtheprofessionalsinvolveddrawingconclusionsfromtheX-Raywhenratingtheclinicalpictureorviceversa.

ClinicianMB(specialisedphysiotherapistandorthotist)ratedallclinicalandradiologicalpicturestwicewithoutaccesstothepreviousratingsinordertodeterminetheinter-raterreliabilityoftheclassification.

ClinicianXFN (specialisedorthotist) andclinicianDT (specialisedphysiotherapist) ratedall clinical and radiological

Fig. 1. TheLS-Classification.Ontheleftthetypical3Cscoliosiswiththreeblocksdeviatedandrotatedagainsteachother.Ontherightthetypical4Cscoliosis(doublemajor)withfourblocksdeviatedandrotatedagainsteachother.Thearrowsindicatethefrontalplanecorrectionoftheblocksagainsteachother(courtesyoftheSchrothBestPractiseacademywithkindpermission).SB:shoulderblock;TB:thoracicblock;LPB:lumbopelvicblock;LB:lumbarblock;PB:pelvicblock.

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picturesonce inorder todetermine the inter-rater reliabilityof theclassificationwithrespect toclinicalandradiologicalviews.TheirresultswerealsocomparedtothefirstratingofclinicianMB.

Intra-observer(performedbyMB)andinter-observerKappavalues(performedbyMB,XFN,DT)werecalculatedforthisclassificationwithrespecttotheclinicalanswers,aswellastheradiologicalanswers.

Fig. 2. Keyfeaturesofthefunctional3CpatternaccordingtoSchroth(courtesyoftheSchrothBestPracticeacademywithkindpermission).

Fig. 3. Keyfeaturesofthefunctional4CpatternaccordingtoSchroth(courtesyoftheSchrothBestPracticeacademywithkindpermis-sion).

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Anethics approval and consent toparticipatewasnot applicable.Noanimalswereused for studiesof this research.Writteninformedconsentforparticipationinthisstudyhasbeenobtainedfromboththepatientsandtheirparents;Consentforpublication:Writteninformedconsentforpublicationofthepatient’sinformation(X-rays,photos,records,etc.)hasbeenobtainedfromboththepatientsandtheirparents.

RESULTS

Theintra-observerKappavaluewas0.90(acceptance>0.60)fortheevaluationofthereliabilityoftheclinicalpicturesand1.00fortheevaluationofthex-raypictures.Theinter-observerKappavaluesfluctuatedfrom0.58to0.80(average0.65;acceptance>0.60)fortheevaluationofthereliabilityoftheclinicalpicturesandfluctuatedfrom0.58to0.80(average0.71)fortheevaluationofthereliabilityofthex-raypictures.

DISCUSSION

In this test the intrarater reliabilityof theLS-classificationwas excellentwith respect to clinicalpictures andx-rays.Interraterreliabilityataveragewasexceedingthelevelofacceptability.Theclassificationhasshowntohaveafairtogoodreliabilityclinicallyandradiologically29,30).Thiscurvepatternspecificclassificationisusedtoprescribeexercisetreatmentapproachesforindividualpatients3,6,19).Accordingtotheresultsfromthisstudytheuseofthisclassificationcanberecom-mendedforspecialistSchrothcertifiedphysiotherapists in thefunctional rehabilitationusing thepatternspecificSchrothmethod.Thistestdemonstratedsufficientreliabilitywithrespecttothex-rays,butthetestsoftheclinicalpicturesalonealsodemonstratedfairlevelsofreliability,whichindicatesthatitisanappropriatetoolforphysiotherapistswhenanx-rayisnotavailable.Althoughitisalwayswisetogainanimageofthex-raytoconfirmboththediagnosisandthepattern.

WithinthepatternspecificSchrothprogramitisnecessarytodistinguishbetweencertainpatternsofcurvature.Onlywithpatternspecificcorrectivemovementscanoneachieve thebestpossiblecorrectionandavoidan increaseofanycountercurvessametime3,19,20).

Whilethe3Cpatternofcorrectionincludesshiftingandde-rotationoftheshoulder-,thoracic-andlumbo-pelvicblockagainsteachother(Fig.4)withinthe4Ccorrectionthelumbopelvicblockissplitupintoalumbarandapelvicblockwhichareshiftedandde-rotatedagainsteachotherseparately(Fig.5).Thesebasicprinciplesofcorrectionhavealsobeenusedforpatternspecificbracinginitsearlierstages31)whiletodayforbracingslightlymorecomplexclassificationsareused3,27–29).

Physiotherapistscurrentlyhavenospecialiststandardisedtrainingintheirgeneralisedundergraduateordiplomacoursesworldwideregardingthetreatmentofscoliosiswhichmayhaveledtothelackofinvolvementoftherapistsintreatment,un-lessforadultsreportingpainorpost-operativerecovery.Foraconditionthatismusculoskeletalandorthopaedicatleastinitspresentationthisprofessionisnotwidelyorspeciallyeducatedinthemainstream.Orthotiststrainingalsovariesworldwideandtheprofessioncanbepoorlyregulatedincomparisontootherhealthprofessionsandorthoticsforscoliosisarerarelystandardisedorevenspecifiedwhenprescribing.

IfthestandardofconservativephysiotherapytreatmentisSchroth,thenareliablereferenceclassificationtoolisrequiredwhichisalsoreliablebetweenprofessionals,whichtheLSclassificationhasdemonstrated.Asalreadyoutlined,thereisagrowingbodyofevidenceforSchrothphysiotherapytreatment,asthisclassificationisnotonlysimplebutalsoreliableandstandardized,andthereforeshouldbeintegratedintophysiotherapyeducationalprograms.Itisonlythroughthesuccessfulidentificationofthespecificpattern,canaprofessionalthenidentifytheeffectivepattern-specificexercisesandposturestoprescribe.

Limitationofthisstudyisthesmallnumberofparticipants.Forfuturestudieswithinthistopicalargernumberofpar-ticipantsshouldbeinvestigated.Anotherlimitationisthatsomepatientshavebeenincludedwhowerealreadyunderbracetreatment(n=15),anintervention,whichmighthaveledtoachangeofthetrunkdeformity.Thismightbethereasonwhytheclinicalapplicationoftheclassificationwaslessreliablethantheradiologicapplication.Besidesthedorsalaspectofthetrunktheadditionalinformationinforwardbendingwouldalsopossiblyimprovethereliability,asthestructuraldeformityismorevisibleintheforwardbendingtest.Thisisthefirsttimethataclinicalandradiologicalreliabilitytestforascoliosisclassificationhasbeenmade.However,weactuallyhavenodataaboutthereliabilitycomparingtheclinicalvs.radiologicalclassification.Thisaspectshouldbeinvestigatedinfuturestudiesonthistopicaswell.

Inconclusion:FortheapplicationoftheexercisesfromtheSchrothprogramtheLS-classificationseemsaneasytouseandreliabletoolandshouldbeconsideredimportantintheeducationofprofessionalsprescribingexercisesforpatientwithscoliosis.

Conflict of interestHRWisreceivingfinancialsupportforattendingsymposiaandhasreceivedroyaltiesfromKoobGmbH&CoKG.The

companyisheldbythespouseofHRW.HRWhasheldapatentonasagittalrealignmentbrace(EP1604624A1).DTisemployedbyanorthotistcompanyprovidingspecialistphysiotherapyforspinalandchest/pectusdeformities.Noneoftheotherauthorsreportanycompetinginterestorpotentialconflictofinterest.

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ACKNOwLEDgEMENTS

HRWprovidedthefirstdraftandmadetheliteraturereviewandservedasthestudysupervisor.DTcontributedtotheim-provementofthefirstdraft,copyeditedthefinalpaperandprovidedtheindividualanalysisofthedata.XFNhasprovidedtheclinicalpicturesofthepatientsaswellastheirx-rays.AK(PhDinMathematics)wasinchargeofstatisticaltesting.MBsupervisedtheratings.XFN,MBandDTwhereperformingtheratingswithMBprovidingtheintratesterratings.

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