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SEAS Therapy: 20 Minutes of Daily Exercises at Home – Too Much or Too Little?

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The International Society for Conservative Scoliosis Treatment (SOSORT) recommends exercises based on self-correction, which involves movement aimed at counteracting spinal curves, stabilising this position, and integrating it into daily life【1.

At ISICO, we have developed and use the SEAS approach. These exercises involve actively achieving the self-corrected position and working to maintain it despite various challenges. The exercises are designed to test the stability of the correction, requiring the patient to stabilise their spine and recover the correction if control is lost【2.
Gradually, as therapy progresses and through continuous practice, patients become more adept at incorporating self-correction into their daily lives—for example, while eating, walking, or doing homework.

How much time should be dedicated to practising the exercises each day?
Typically, 20 minutes daily is a significant commitment, especially as this therapy can last for a long time—sometimes several years. Patients are given one rest day per week, making the total weekly commitment about two hours.

Some parents, particularly at the beginning, ask whether more than the prescribed amount can be done. We usually respond that it is important to train without overwhelming the patient. For example, consider marathon training: a young person should not exhaust all their energy at the start and then abandon therapy, but instead maintain endurance and continue until skeletal maturity. At this point, we can say that the risk of scoliosis progression has decreased.
Conversely, reducing the duration would result in an insufficient period of practice. When we think about how much time young people spend on their phones daily, 20 minutes is not much.

How much time is needed for exercises in other scoliosis treatment approaches?
According to current data, the other most widely used approach globally is the Schroth therapy, developed in Germany.
This method involves hospitalisation in a specialised clinic for 3–4 weeks, during which patients undergo daily two-hour sessions to learn the exercises properly. After the training period, patients are instructed to continue the exercises at home and visit the clinic one to four times a month to ensure proper execution【3.
Alternatively, patients can learn the exercises through closely spaced individual sessions with a therapist, lasting 60–90 minutes, followed by weekly group sessions of 60 minutes, combined with a daily home exercise programme lasting 30–45 minutes【4.
This represents a significantly greater commitment than the 20 minutes required for SEAS therapy.

1. Negrini S, Donzelli S, Aulisa AG, Czaprowski D, Schreiber S, de Mauroy JC, Diers H, Grivas TB, Knott P, Kotwicki T, Lebel A, Marti C, Maruyama T, O’Brien J, Price N, Parent E, Rigo M, Romano M, Stikeleather L, Wynne J, Zaina F. 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis Spinal Disord. 2018 Jan 10;13:3. doi: 10.1186/s13013-017-0145-8. PMID: 29435499; PMCID: PMC5795289.

2. Romano M, Negrini A, Parzini S, Tavernaro M, Zaina F, Donzelli S, Negrini S. SEAS (Scientific Exercises Approach to Scoliosis): a modern and effective evidence based approach to physiotherapic specific scoliosis exercises. Scoliosis. 2015 Feb 5;10:3. doi: 10.1186/s13013-014-0027-2. PMID: 25729406; PMCID: PMC4344739.

3. Rigo M, Reiter C, Weiss H-R. Effect of conservative management on the prevalence of surgery in patients with adolescent idiopathic scoliosis. Pediatr Rehabil. 2003;6(3–4):209–14.

4. Burger M, Coetzee W, du Plessis LZ, Geldenhuys L, Joubert F, Myburgh E, van Rooyen C, Vermeulen N. The effectiveness of Schroth exercises in adolescents with idiopathic scoliosis: A systematic review and meta-analysis. S Afr J Physiother. 2019 Jun 3;75(1):904. doi: 10.4102/sajp.v75i1.904. PMID: 31206094; PMCID: PMC6556933.

Full-time treatment: no stress!

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We talk of “full-time treatment” whenever a brace needs to be worn round (or almost round) the clock, i.e., for 23 or 24 hours a day.  When patients with scoliosis are treated using a brace, it is not unusual to have to wear the device full time in order to effectively address severe curves (those measuring more than 40 Cobb degrees) or high-risk situations (a pubertal growth spurt).  

Full-time treatment is a tough challenge, especially if you consider that it usually begins at between 11 and 15 years of age, in other words, just before or during adolescence, which is a notoriously tricky time that already brings plenty of changes. Youngsters of this age no longer see the world through children’s eyes. Instead, they begin to experience all kinds of doubts and insecurities, and sometimes they are unhappy about the changes in their appearance, or about having to wear dental braces or glasses. It is therefore entirely understandable that being prescribed bracing treatment can be upsetting for them, and also for their parents who would do anything to spare their child any suffering.

In the literature, it is suggested that the start of bracing treatment (the first 6 months) can negatively affect the patient’s quality of life.
Even though there is no scientific proof of this — on the contrary, research tells us that treatment, ultimately, does not negatively impact quality of life —, there can be no denying that the early stage of bracing is hard and must be overcome. In particular, it is crucial to avoid poor adherence to the treatment that might potentially lead to its early and total abandonment and thus expose the patient to all the risks, in terms of progression and consequent severity of the condition, that are associated with scoliosis in childhood and adolescence. 

“This is a very important issue for us at Isico”, remarks physiotherapist Lorenza Vallini. “We have long been aware of the difficulties youngsters face at the start of this experience, which we liken to a marathon rather than a sprint: our youngsters have to get to the finish line on their own two feet, but we healthcare professionals are alongside them all the way, guiding and helping them and their families.”

And what about friends? Well, friends are like fans on the terraces; if they feel involved, they will cheer the patient on.

All this is perhaps easy for us to say because the fact is that when full-time bracing is prescribed, which means 23 or even 24 hours a day, the patient can feel like their world is falling apart. That is why we at Isico like to make sure we always have a chat with the family and the youngster after their appointment.

“We know very well that this is a key moment, a watershed moment that needs to be addressed together”, Vallini continues. “Our therapists are trained to listen to doubts, answer a thousand questions, and provide all the necessary explanations. We try to get the youngsters involved, showing them videos of other young “brace wearers” doing all kinds of everyday activities, including sports, with their brace on. They are often visibly surprised to see their counterparts happily taking a dip in the sea or swimming pool.”

It is also important not to overlook the aesthetics of brace-wearing!

We at Isico are always careful never to overlook the aesthetic aspect. Many of our patients are girls who are of an age at which comparing yourself with others is a normal part of growing up: “We always stress that braces are hardly visible under clothes, and we give patients tips and advice about their appearance”, Vallini says. “This moment is an opportunity to start building an alliance with the patient. Obviously, our work and involvement don’t end with that one chat, which on the contrary is the starting point for a process that will continue over the monthly sessions we have with these youngsters thereafter. The first session after delivery of the brace is particularly important, as it is when we try to present this “intruder” as a friend, not the easiest to be sure, but a friend nonetheless.”

That is why this particular session is designed to be motivating as well as technical, an opportunity to tackle any issues or doubts that have arisen and gather the patient’s reactions – both the tears and the laughter. 

As soon as the brace arrives, it is tested by an Isico doctor, who provides a series of explanations in order to get the treatment off to a good start. As a rule, whenever possible, a meeting with the therapist is also arranged so that youngsters are not left to face their fears and doubts alone. When this is not possible, a telephone contact is offered and, after the first session, the patient is also contacted by email to find out if there have been any difficulties.

Availability, care and assistance are the cornerstones of our approach: “We never underestimate any request, from the simplest to the most complicated”, Vallini says. “We make sure patients realise we are always there for them, as we want them to be reassured that there is always someone available for them.”

The importance of listening
The Isico team includes all the specialists necessary to support and monitor young brace wearers, so not only doctors and orthopaedic technicians, but also therapists and a psychologist (who sees patients directly on the rare occasions when this is felt to be necessary, but usually intervenes through the other professionals). All the team members will accompany the patient for a part of their journey, to support them and ensure that the therapy is going as it should, particularly at the start.

Will there be any other particular crisis moments? Undoubtedly! In the course of a long and demanding treatment process, undertaken in the midst of a thousand other emotional interferences from the outside, this is only to be expected: “The main thing for us is to remain vigilant so that we know when a family might be needing extra help”, Vallini says. “Everyone is ready to add the right input at the right time to help patients reach the finish line. And when they do, the smiles and hugs we get from them are quite wonderful, as is their tangible sense of pride”.

How often should a brace be changed?

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Receiving their first brace is a key moment in the treatment of youngsters affected by spinal deformities.
This is the brace that shows them exactly what the treatment consists of. They learn about the pads, which are carefully positioned to correct their back; they become familiar with the fastener and how to adjust it to the right tightness, as well as how the brace sits under the armpits. They also have to get used to the shoulder pads and, quite simply, the weight of the plastic.

Surprising as it may seem, some youngsters even grow quite attached to their first brace as, over the weeks and months, it starts to become a part of their daily life and less of a problem. This “friend”, which they sometimes find irritating, especially early on, gradually feels less and less bulky, and in fact there will eventually come a point when it is too small. After all, while the brace stays the same, the youngster inside it grows of course!

For this reason, a new brace will be needed from time to time. It certainly isn’t possible to use the same one from the start to the end of the treatment. But there are also other reasons why a brace needs to be replaced, the first and most obvious being that, like any object used on a daily basis and for a number of hours each day, it starts to wear out. Indeed, after a time, it is subject to breaking, or some of its parts may no longer be intact.

A further reason, and this is perhaps the most important, is that the brace, especially the first one, moulds the youngster’s back so much that after a few months it becomes necessary to construct a new one adapted to its changing volumes. Unless braces are updated to take this aspect into account, they simply cannot work at full efficiency.

The young scoliosis patient’s back changes not only as an effect of the brace, but also because he/she is normally still growing.
In this stage of development, it is perfectly normal to get taller and heavier. A brace can usually tolerate slight increases in height and weight, but when these are more marked it will start to feel uncomfortable. Even just looking at the youngster in his/her brace can be enough to tell you that the time has come to start thinking about getting a new one made.  
From the second brace onwards, more time can usually elapse between braces. It may even be enough to get a new one about once a year.

Youngsters are often anxious at the prospect of changing their brace, fearing that the new one will be uncomfortable. Actually, however, they are unlikely to experience the same discomfort they had at the very start of the treatment.
In fact, in most cases they will find the new brace is more “comfortable”, given that it replaces one that had become too short and tight, and so no longer adequate. Furthermore, having already had to get used to wearing a brace, these “experienced” patients will be better able to recognise, quickly, any problems with the new one.
This will allow them to give the orthopaedic technician clear feedback, useful for making it fit better.  

My treatment hasn’t had the desired effect: why?

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Sometimes, even when a patient has followed the prescribed course of treatment (bracing and exercises), the final outcome isn’t what they expected and there are no marked improvements. Why is this?

Let’s start by reiterating something we all know to be a fact.

Scoliosis is a disease that can strike with varying degrees of severity and, as we have said many times, its origin is not known. However, although we don’t know what causes it, thanks to scientific research we are learning more and more about how it evolves and how to treat it.

The vast body of scientific literature now available on this topic has shown us the importance of monitoring scoliosis and its evolution during skeletal growth, in particular during the pubertal growth spurt, which is known to be the most critical phase in the course of this disease.

The aim of conservative treatment, which includes specific exercises and bracing, is to limit the progression of scoliosis during growth, so as to prevent problems from arising in adulthood, and to try and avoid the need to perform highly invasive surgery.

The risk of the disease worsening differs from patient to patient and from curve to curve. Unfortunately, there are no elements that allow us to predict this risk; all we have are indicators that can tell us how likely it is that the condition will worsen and, even then, we are only talking in terms of probabilities. Therefore, the task of the medical team responsible for making the diagnosis and treating the patient is to constantly monitor the situation and adjust the treatment as necessary. After all, we do not want to be too aggressive, but at the same time we need to avoid the risk of underestimating the case and prescribing an ineffective treatment.

The other key factor for a successful outcome is the patient’s “adherence” to the prescribed treatment, in other words his/her ability to follow it constantly and with precision.

How much do these two factors influence the result?

A few years ago, we did a study of “extreme” cases (less than 3% of the total), i.e. those patients showing the best and worst treatment outcomes, defined respectively as a greater than 20° improvement or a greater than 20° worsening of the curve. 

We found that all the patients (100%) who obtained exceptional results were treated with both bracing and exercises. But we also found that 50% of the patients with the poorest outcomes had nevertheless followed the treatment perfectly. In these cases, while the treatment had failed to arrest the course of particularly aggressive forms of scoliosis, the patients’ adherence to it had undoubtedly slowed down the worsening of the curve and prevented it from being as marked as it would have been without any treatment at all. And this brings us back to what we said at the start: although some cases show no apparent improvements, scoliosis that has worsened a little at the end of treatment must be considered a great success if the outcome of no treatment would have been a far more severe deterioration.

So, what do we ask of our patients? To collaborate, adhering to the treatment fully and regularly attending check-ups, so as not to run the risk of obtaining disappointing results, despite being treated.