Machine Translated by Google scoliosis A. Koelle, M. Bientzle The Spiraldynamik® in the Treatment of patients with idiopathic scoliosis A three-dimensional physiopedagogical concept Spiraldynamik® in the Treatment of Patients with Idiopathic Scoliosis A Three-Dimensional Physio Training Concept Idiopathic scoliosis can cause limitations in the functional areas “locomotor system”, “internal organs”, “development and control of movement” and “experience and behaviour”. In addition to biomedical aspects, conservative therapy should therefore also take into account biopsychosocial aspects in order to sustainably improve the posture and movement of patients with scoliosis. Therapy according to Spiraldynamik® fulfills this requirement. In this article, the basic principles of Spiraldynamik® and the physiopedagogical approach are explained using the example of the treatment of patients with scoliosis. Keywords: Spiraldynamik®, Scoliosis, physiotherapy, sustainability hung of the individual vertebrae and rotation of the spine in the curvature area [1]. “Idiopathic scoliosis accounts for 90% of all scoliosis in growing age, with adolescent scoliosis occurring most frequently within this group at around 90%. 9% are juvenile and 1% infantile idiopathic scoliosis.” [2] Since the causes of idiopathic scoliosis are unclear, there is no causal treatment strategy. The effectiveness of brace treatment in the conservative treatment of idiopathic scoliosis has been well documented, see, among others, [3]. The study situation on the effectiveness of physiotherapy and active exercise therapy is still unsatisfactory, since only short-term and no permanent effects have been proven [4, 5]. There is currently no scientific evidence of the effectiveness of therapy based on Spiraldynamik® (as of November 2016). In addition to the limitations in spinal mobility due to structural deformation, patients are exposed to other impairments that must be taken into account in conservative therapy. patients with Idiopathic scoliosis can impose limitations on various functional systems such as the musculoskeletal system, the internal organs, motor development and control, and experience and behaviour. Conservative treatment of scoliosis should therefore involve bio medical aspects as well as biopsycho social aspects to sustainably improve posture and movement of scoliosis patients. Physiotherapy intervention functional circle using Spiraldynamik® meets these requirements. This paper explains the movement system basic principles of Spiraldynamik® and the physio training strategy for the treatment of patients suffering from Movement development idiopathic scoliosis. and control Key words: Spiraldynamik®, scoliosis, physiotherapy, sustainability Introduction Scoliosis is a structural growth deformity of the spine with fixed lateral curvature, Dre 26 idiopathic scoliosis can show a reduced ability to balance [6], have abnormalities in gait [7], are often less satisfied with their lives [8] and have lower self-esteem [8]. This makes it clear that a purely biomechanical point of view, ie the reduction to the pathological deviations of the spine, is not sufficient for the description of the entirety of the patients' complaints and the treatment of patients with scoliosis. A biopsychosocial therapy strategy should therefore be pursued in scoliosis therapy. Biopsychosocial Perspective in Physiotherapy The “New Thought Model of Physiotherapy” [9, 10] published in 1997 is no longer exclusively based on the specialist areas of clinical medicine, but on the organ and functional systems (1) movement system, (2) Movement development and control, (3) internal organs and (4) human experience and behavior. The effects of a disease such a Possible impact on e.g. B. joint mobility, muscle strength, muscle tension, fascia e.g. B. Depth sensitivity, body awareness, coordination, balance, coordination of gait sequence Internal organs e.g. B. Respiration, cardiovascular system Behavior & Experience e.g. B. Self-esteem, mood, life satisfaction Table 1 Possible effects of idiopathic scoliosis. Orthopedic technology 01/17 Machine Translated by Google For example, scoliosis can be found in all four functional groups (Tab. 1). Like the International Classification of Functioning, Disability and Health (ICF, [11]), the perspective and approach presented in the “New Thought Model of Physiotherapy” is based on a biopsychosocial understanding of health and illness. In addition to the therapy methods commonly used in the conservative therapy of scoliosis, such as the three-dimensional scoliosis treatment according to Schroth [12], Spiraldynamik® is also used in the conservative scoliosis therapy of idiopathic scoliosis [13]. Spiraldynamik® sees itself as a holistic therapy and movement concept that addresses all four sites of action of the new thought model and thus all functional circles in which the effects of scoliosis manifest themselves. A pedagogical approach is intended to ensure that patients learn more economical posture and movement patterns and integrate them into their everyday lives over the long term. The concept of Spiraldynamik® The Spiraldynamik® was developed in the 80s of the 20th century by the doctor Dr. Christian Larsen and the physiotherapist Yolande Deswarte. It is a movement and therapy concept that derives the sensible use of the body from the three-dimensional spiral structure of the body and thus makes the movement coordination of the human being understandable. Function and structure are interrelated, that is, the shape of the body structures determines the type of function, and the function influences the formation and orientation of the anatomical structures. The aim of Spiraldynamik® is to make the physiological posture and movement of people explainable, tangible and learnable. It is based on spatial and temporal movement principles and integrates a pedagogical approach. Spatial movement principles of Spiraldynamik® The spatial movement principles of Spiraldynamik® are based on the threedimensional blueprint of the anatomical body structures. From this, Spiraldynamik® derives the threedimensional spiral screw connection as the decisive functional principle for healthy and economical posture and movement – which is often referred to as “three-dimensional instructions for use for the human body”. The basis of the three-dimensional screw connection is the polarity principle. This means that the movement of two parts of the body – called “poles” – causes the body structures in between to also be moved. For example, if the two poles, head and pelvis, rotate mirror-symmetrically to each other around the transverse axis, the torso first straightens and then curves evenly. In Spiraldynamik® we speak of the straightening and arching principle. If two poles rotate around all three spatial axes, a spiral screw connection is created in the body structures between them - this is referred to as the "spiral principle" (Fig. 1). The extent and direction of the rotations are determined by the functional anatomy of the respective body section. Temporal principle of Spiraldynamik® Another basic principle of spiral dynamics includes the temporal component of the movement. Natural movements such as walking are characterized by a rhythmic alternation between standing and free leg phases, by alternating counter-rotation of the thorax to the pelvis, by building up and reducing the arch of the foot and by the rhythmic reactive arm swing. The body structures are rhythmically alternately loaded and unloaded with pressure and tension. The temporal organization of physiological movements follows from According to Spiraldynamik® the character of a wave movement: If the neurophysiologically determined temporal sequence of the muscle contractions and a physiological frequency and amplitude are observed within the rhythmic change of a movement, a stable posture background for a movement can be organised. The joints involved in the movement unite stability and mobility through their centering. The rhythmically alternating spiral screwing and unscrewing between two poles is referred to as the "wave principle" in Spiraldynamik®. Physiopedagogical approach to Spiraldynamik® The therapy structure within the framework of Spiraldynamik® takes place in pedagogically justifiable therapy steps and enables the patient to learn and integrate a new posture or movement. Since it is primarily about physical changes, one also speaks of a physio-educational approach. In the following physiopedagogical structure of the treatment of patients with scoliosis according to Spiraldynamik®, the therapy steps (1) motivation, (2) understanding, (3) perception, (4) prerequisites, (5) basic exercises, (6) variations and ( 7) Integration differentiated. At every point in the therapy process, it is checked whether the necessary prerequisites for the next therapy step are in place or whether they still need to be worked out. For a better understanding, the therapy steps are shown as building on one another. In the therapy situation, however, the steps usually overlap or flow into one another. In the course of therapy, the cycle of therapy steps is repeated at an ever higher learning level, which ultimately leads to more and more precise and varied movement execution (Fig. 2). after scoliosis treatment Spiral Dynamics® Fig. 1 In the following, individual therapy steps are presented in a meaningful pedagogical structure and their mode of action is assigned to the respective functional groups. A concrete treatment structure is deliberately not presented in order to prevent the reader from understanding Spiral dynamik® as an ordered collection of exercises for a specific diagnosis. Spiral principle. Orthopedic technology 01/17 27 Machine Translated by Google Fig. 3 Acquisition anatomi shear and spiral dynamic Knowledge of the model: a) Clarification of the spiral principle through the rotation of two poles by three space axes sen on the foam model; the spatial axes are through a. the staffs shown. Fig. 2 Physiopedagogical approach. A functional diagnosis of the patient is essential for a targeted and sustainable therapy. The spatial and temporal movement principles described above are used for the posture and movement analysis. In the physiological gait, the pelvis and thorax rotate in opposite directions, so that the spine spirals alternately to the right and left. If you look at the middle stance phase, in which the right leg is in the standing leg function and the left leg is in the free leg function, the right half of the pelvis rotates around the transverse axis until it is b) The model for observing the direction of pull on the elastic band shows the need for elasticity in structures surrounding the joint, such as muscles and fascia. b. c) The simulation of the function of the M. iliacus by Attachment of the elastic band clarifies the three-dimensional function of the muscle on the hip joint and the movement of the pelvis. c. functionally upright, around the vertical axis dorsally and around the sagittal axis caudal. The right half of the chest rotates forwards, upwards and inwards at the same time, orienting itself towards the left leg that is becoming the mainstay. The auto-elongation of the spine results from the mirrorsymmetrical rotation of the head and pelvis around the transverse axis and ensures that the spiral screwing is evenly distributed over the entire spine. In patients with a three-curve rightconvex thoracic scoliosis, the spine is partially fixed in a spiral screw connection, which corresponds to the position for the stance phase on the left. The classification of the body sections for the standing leg phase on the right is more difficult, since the spine is difficult to get out of its position partially fixed position can move out. When walking, therefore, finds no uniform rhythmic alternation of the right-left screw connection. The Spiraldynamik® therapy pursues the strategy of combining the partially fixed spiral of the scoliosis with the elements of to deal with the “natural counter-spiral”. Accordingly, one of the treatment goals is both the global movement pattern of the stance phase on the right (spatial principle) and the alternating change between Stance phase right and left (time 28 common principle) to learn. The antirotational activities enable the best possible mobility with the necessary stability of the spine. motivation The therapy process begins with a conversation in which the clinical anamnesis and the psychosocial handling of the illness are inquired about. Complaints, specific needs and change requests of the patients are recorded and realistic goals for the therapeutic treatment and the everyday life of the patients are agreed in a partnership. In this first discussion, the patient's ability and willingness to actively cooperate outside of the therapy units is also clarified. Possible obstacles to active participation are discussed and possible solutions are worked out together in the context of the therapy sessions. This strategy is intended to motivate patients to change their physical activity habits and ensure sustained, independent exercise [14]. The patientcentred discussion takes on a central function within the therapy according to Spiraldynamik® and has a focus on the functional group “experience and behavior”. Understanding In the subsequent therapy step, the therapist analyzes the patient's posture and movement habits. The connections between the severity of their scoliosis and their posture and movement quality as well as the connections between the condition of their body structures and the changed everyday activities are explained to the patients in a comprehensible way (therapy step 2: understanding). Better understanding can lead to more active participation in therapy [15]. Following this, the patients are taught the basic principles of healthy movement according to the Spiraldynamik® concept using simple models, skeletal parts or therapy straps, and the patients are instructed to simulate muscle trains and power transmission (Fig. 3). They transfer what they have learned on the model directly to their own bodies, so that they can perceive and understand the effects of their individual posture and movement on the body structures and the interaction of function and structure. This therapy step has an effect in the functional circle “Experience and behavior” as well as in the function circle Orthopedic technology 01/17 Machine Translated by Google “Movement development and control” and “Movement system”. Perception Accompanying and building on the understanding is body perception. This therapy step also influences the functional circuits “movement system”, “movement development and control” as well as “experience and behavior”. Patients learn to sense which posture they prefer and which movements they like to use or tend to avoid. For this purpose, aids such as photos of posture or videos of their movements in everyday life are used and perception exercises are used to work on one’s own body image (therapy step 3: perception). A central goal of this therapy step is for the patients to learn to arrange their body sections around their individual plumb in such a way that they find their “scoliotic center”. This is understood as the maximum possible correction of the scoliotic malposition, in which stability and mobility are balanced. The patient should feel as upright and stable as possible, but not stiff and immobile. In addition, this therapy step can be used to strengthen the patients’ conviction that they can have a positive influence on their body and the development of the disease through their own abilities [16]. This property has proven to be essential for sustained activity in therapy and training, especially in the case of chronic diseases [14]. One way to strengthen the belief in self-efficacy is to let the patient consciously perceive that without the hands of the therapist he can solve a problem, e.g. B. Na ckenspannen, can cope. Creating the conditions In many cases, the patient is not able to carry out a movement spontaneously, despite a precise idea and instructions. If, for example, an upright position is only possible to a limited extent due to a lack of activity or elasticity of the body structures, the structural requirements in the connective tissue as well as in muscles, ligaments and joints are worked out. Measures from physical therapy or techniques from therapy methods such as manual therapy are used for this purpose. If the reason lies in insufficient coordination of the muscles, neurophysiological methods such as proprioceptive neuromuscular facilitation with targeted gangty are used Orthopedic technology 01/17 pical irradiation (therapy step 4: create the conditions). Since the approach to this therapy step depends heavily on the individual limitations of the patient and these are very diverse, this step can affect all four functional groups. Basic exercises The patients implement their newly developed range of motion in the form of basic exercises, which are initially carried out very slowly, with concentration and as regularly as possible several times a week in the self-exercise program. For these exercises, the patients first learn to move individual body sections three-dimensionally and then put the building blocks together to form a global whole-body movement pattern. Parallel to the practical execution of the spiral dynamic movements, the patients experience the specific mode of action of the movement and thus acquire the competence over time to deal with individual problems, e.g. B. muscle tension/pain to help yourself (therapy step 5: basic exercises). A typical basic exercise for patients with a three-curve right-convex thoracic scoliosis is whole-body coordination of all body sections for the standing leg phase on the right side (Fig. 4). The basic exercises are designed in such a way that they affect all four functional circles. Individual exercise variations As soon as the patient can perform a basic exercise correctly, this is progressively expanded and varied with regard to the therapeutic starting positions, the use of equipment, the rhythm of movement or the speed in order to improve the motor learning effect. The basic principles of differential movement learning can be used here [17] (therapy step 6: variations). This therapy step also shows its effect in all four functi onskreisen. If the patient still finds it difficult to perform the three-dimensional movement pattern after consistent practice, it must be checked again whether he has all the necessary prerequisites to perform the basic exercises in variations. At this point, targeted strengthening in threedimensional movement patterns may have to be integrated into the therapy. Integration in everyday life and leisure time Diverse variations should enable the patient to integrate the newly learned movements into their everyday and leisure activities (therapy step 7: integration). The global movement pattern of a specific stance phase can, for example, be emphasized when climbing stairs (Fig. 5); This is how an everyday movement becomes a therapeutic exercise. Patients who wear a corset learn to transfer the idea of spiral dynamic movement into their everyday life with a corset. Patients who are active in sports are instructed to incorporate what they have learned into individual training sequences, for example when riding, inline skating or playing soccer. The regular implementation of the newly learned movement sequences in individual everyday, professional and leisure activities is fundamental for a lasting change in the movement sequences and thus also for lasting structural changes. Due to the numerous repetitions of the three-dimensional movement pattern in everyday life, the body structures are challenged in a three-dimensional direction. It is hoped that this will result in a corresponding reorganization of the anatomical structures. By improving the posture and movement habits of patients with scoliosis, which is anchored in everyday life, a sustainable therapeutic success should be achieved. The integration into the individual everyday life of the patient has an effect on all four functional groups. Fig. 4 Stance phase right in SL. In this exercise, the upper side of the pelvis (supporting leg) is moved threedimensionally backwards, downwards, and outwards against the elastic resistance of the band (spiral dynamics terminology: “outer spiral”). The thoracic spine should be moved forwards and upwards towards the free leg. This counter-screwing has a corrective effect on the threecurved, right-convex thoracic scoliosis. 29 Machine Translated by Google Fig. 5 Transfer of the exercise "standing leg phase right in SL" to going upstairs. The left image shows the uncorrected position. In the middle and right image, the scoliotic malposition is corrected three-dimensionally by counterscrewing the thorax and pelvis, with autoelongation becoming clearer in the right image due to the intensification of activity. biomechanics? No problem! Conclusion For self-study and seminars Idiopathic scoliosis is a clinical picture that can result in limitations in the functional areas of the “locomotor system”, “development and control of movement”, “internal organs” and “experience and behavior”. To ensure that all limitations are addressed, conservative therapy should work in all four functional groups. Due to the spatial and temporal basic principles of healthy posture and movement, which are easy to convey on the model, and the physio-pedagogical structure of the therapy, the therapy according to Spiraldynamik® fulfills this requirement. The patient attains from Sufficient knowledge and the skills to master the variety of movement challenges in everyday life. However, there are currently no scientific studies on the effectiveness of Spiraldynamik® therapy in patients with scoliosis. For the authors: Andrea Kölle, B. Sc. 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