Protocols for the application of the SEAS exercises
The keywords for SEAS application include:
Control, as stated above with the four questions
Learning: the entire process is a neuro-motor improvement based on new motor experiences; accordingly, difficulties must be increased and feedback reduced, with learning.
Training: repetition is the basis for learning;
Individualization: both active self-correction and exercises are totally individualized according to patients’ physical abilities and needs;
Self-care and autonomy: patients learn through involvement and individual application; this is true in all protocols, in either outpatient or home-program regimens: in the first one patients never performed the same exercises all together, in the second independency and self-care are mandatory;
Cognitive behavioural approach: SEAS exercise learning includes furthermore the time for a regular family counseling at the end of each session
Many different protocols can be applied. In the past, the SEAS exercises were applied only as an outpatient group approach, with two/three sessions per week performed by an expert physical therapist. Every two-three months a specific evaluation was performed together with a counselling session. Today, this protocol has improved in some specific clinical situations to a more cost-effective home program. Nevertheless, it is still possible to find in Italy, where the SEAS program is well established among physiotherapists and rehabilitation professionals since many years, the classical outpatient application ; sometimes, this unfortunately does not include the individual regular evaluation and counselling sessions.
The typical actual expert application of the SEAS protocol starts with the evaluation of the patient, followed by individual teaching of the exercise program, and ends with a family counseling session based on a cognitive-behavioural approach, to obtain the better compliance of the patient. The SEAS approach attributes a fundamental relevance to this counseling session, because it considers the patient’s family to be a highly important representative member of the therapeutic team. Family support is mandatory to obtain the necessary compliance to achieve the optimum final result.
The modern SEAS approach requires a session that lasts about 1.5 hours. Usually, each session takes place every three months (so, there are four - five sessions a year) and it is carried out by an expert physical therapist. Exercises are recorded on a USB memory media while the patient is learning them, to help the patient remember every detail and repeat the exercises properly either at home with the help of a family member or at a nearby gym, with the assistance of another physiotherapist or personal trainer. If the patient comes from very far away (more than one hour by plane), or in specific situations, it is also possible to have two sessions with the physical therapist every six months thus preparing two treatment plans for the following six months. The patient will start the second exercise session (after three months), usually after a phone contact or a short Internet tele-medicine evaluation.
In either the outpatient or the home program regimen, the patient repeats his exercise program with two or three 45-minute sessions per week or with a daily session of 20 minutes, according to the preferences of the patient and his family. In outpatient settings it is possible to perform the exercises in little groups with a single trainer following up with six to eight patients (usually four to five). In this situation, the exercises are all changed, with one individual session every three to four months.
The progression of the exercise difficulty is based on the improvement of the ability of the patient to keep the correction. The modification of the exercises is the tool for the progressively more difficult training to achieve the ultimate target of the treatment: to be able to maintain the correction throughout daily life”..
Characteristics of the SEAS exercises
The exercises aren’t strictly defined on the basis of a curve pattern. Unlike other therapeutic approaches, there are no specific exercises for lumbar or thoracic scoliosis. This means that the specificity of the exercise does not depend on its use in a given situation but on its proper integration with the self-correction exercise.
In order to train the patient to reach the correct position of vertebral alignment and maintain it for a sufficient period of time, the level of difficulty created by the exercise must be measured carefully. The variables to be considered are the intensity of the challenge (how many seconds the patient must hold the position, how much overload should be imposed, how much the patient should lean over, etc.) and the typology of the postural challenge, namely imbalance, coordination difficulties or muscular effort etc.
For example, if the patient should manifest difficulty with respect to single leg balance or hand-to-eye coordination, the option of introducing exercises that challenge those functions would have a dual purpose: not only to improve the deficit, but also to improve the specific ability of maintaining self-correction.
The exercises are chosen on the basis of the results of the evaluation and in consideration of the patient’s characteristics, exploiting the weaknesses of his functional capabilities in order to adequately train the reinforcement of the stability of the spine.
To explain it better: the muscle response that the corrective exercises should elicit is of a tonic type, that is, the ability to maintain over time a muscle contraction. This is important because trained and strengthened muscles support the spine . Thus the exercises are mainly designed to provide and influence the ability of control. This does not imply that they should be static but that the exercises should be characterized by an optimal control of the alignment of the spine, which in turn is requested by the self- corrected posture.
The exercises should be able to allow an experimentation of very different positions. Daily life requires a wide range of postural combinations, consequently with these exercises we aim to train the reflexive response in self-correction posture, using postural challenges determined by the patient’s needs in daily life.
We need not emphasize the importance of varying one’s practice during the training. We have to plan the inclusion of increasingly more complex dynamic components. Everyday life is made up of actions, so, after a natural learning period that is facilitated by simple and generally static positions, the self-corrected posture should be exercised during the course of actions that simulates the difficulty of real life.
It is necessary to gradually abandon the visual aid as a control channel. Of the three neurological afferent channels concerning the position of the spine in space (visual, vestibular, somatosensory), sight is not the privileged one. This is because a portion of the body is hidden from sight and located in the central part of the spine The somatosensory system is the channel most responsible for the perception of the body in space . For this reason, and as soon as possible, one must encourage the patient to perform these exercises without the support of the mirror.
Individualization of exercises
One of the distinguishing elements of this approach, as compared to other treatment methods, is the absolute attention to the patient’s individual characteristics in defining the treatment program. Three-dimensional self-correction is determined not only by the scoliotic pattern deviation but also by the patient’s performance capacity. Initially, the patient performs simple exercises while keeping a simplified self correction. Progressively, with the refinement of performance capacity and control, self-correction will become increasingly more complex until the optimal execution is achieved.
The choice of exercises follows the same pattern. Exercises become more and more difficult. The level of difficulty must always be adapted to the patient’s ability, and it must increase proportionally with the improvement of his ability.
Another characteristic of the SEAS protocol is that exercises change according to the different treatment phases. For example, if the patient is wearing a brace, the exercises are aimed to increase the mobility and plasticity of the torso and the spine, while allowing the brace to achieve the best possible corrective result.
According to SOSORT Guidelines treatment lasts until the risk of progression is eliminated. Typically in medium degree curves (below 20-25°), that are the scoliosis treated with SEAS exercises alone, treatment stops at European Risser 3. In patients wearing a brace, usually treatment lasts longer: in this case SEAS exercises are stopped 3 months after weaning definitively the brace, to help the final spinal stabilization in the first months without the brace.
Patient evaluation to choose exercises
To prepare a physioterapic exercises plan for the rehabilitation of a patient who has suffered a trauma or surgery intervention is definitely important to evaluate muscle strength and joint flexibility because the patient has probably made a period of immobility and the re-education program will aim to improve these basic functions. In case of conservative treatment for scoliosis the situation is not the same.
The function we want improve with SEAS is the ability to self-correct the spine: this function simply does not exist without scoliosis, and it is also completely the opposite of what the pathology is creating in the patient. Consequently, this function does not need to be tested at the beginning, while during treatment it is tested simply checking how the patient is able to perform it.
Similar is the situation with the training of the ability to preserve self-correction in time. This too is a totally new function, and we need to train the neuromotorial control and the coordination of the spine, together with the stability function in general.
Nevertheless, to apply the SEAS protocol, an accurate evaluation of the patient is needed and this will be the basis for the choice of the exercises. Scheduled tests aim:
to collect useful information that helps to choose the treatment plan in order to improve the subject’s morphology;
to identify those functions that might eventually be deficient (i.e. muscular elasticity, neuromotor control, muscle resistance, etc.) and to integrate the program with specific exercises;
to be able to re-evaluate every function, to verify whether the deficit is improving and to adapt specific exercises;
to highlight deficient functions, to be able to choose accordingly the best stability training exercises for that specific patient. The complete evaluation is repeated each year. If the first evaluation emphasizes specific impairments, tests to evaluate these abilities should be performed more often, at least once every three months.
In any case, these evaluation test of the strength and mobility are not the most important assessment for the SEAS approach and they don’t particularly affect the treatment. These tests are simple means to discover any deficit that will try to recover while aiming to improve and build up a good self-correction ability. They represent only a complement of the treatment and not the real goal. An example: there are treatment methods that assume that the muscle retraction of some muscles are the causes of spinal misalignment. For this reason, the specific aim of this treatment is the resolution of the shortening of these muscles. Also in our assessment we evaluate the muscle stiffness and if patients show this, we use some exercises to improve it. In this case, the aim is simple: the improvement of the general condition of the patient.
During treatment we need difficulties to challenge the maintainance of self-correction, to improve its performance, and to build new neuromotorial strategies in the patient. The evaluation allow to focus these training difficulties to be used for self-correction; in this way, in the meantime the exercises improve the slight functional problems of strength, or balance, or shortening of muscles of the patient. But this is not the ultimate goal.