The Role of Patient Specific Scoliosis Exercise (PSSE) in growing spines

By Belle Synnott, Exercise Physiologist

Adolescent Idiopathic Scoliosis (AIS) is a three dimensional spinal deformity that often emerges during the growth spurts of early adolescence. Without early intervention, scoliosis can progress rapidly, leading to functional limitations, pain, or even the need for surgical correction.

Conservative approaches like Physiotherapeutic

Scoliosis-Specific Exercises (PSSE) are gaining widespread recognition for their role in stabilsing curve progression in growing spines. PSSE exercises are designed to correct the spinal curve in all three planes: sagittal, frontal, and transverse. Unlike general physiotherapy, PSSE focuses on teaching patients postural correction techniques that they can integrate into daily life—while sitting, walking, or even integrated into their sport of choice. 

The goal of PSSE is threefold:

Auto-correction of spinal posture using active muscle control.

Stabilisation of the corrected posture through targeted strengthening and neuromuscular re-education.

Integration of the corrected posture into daily functional tasks.These exercises are typically tailored to the individual’s curve pattern (e.g., thoracic, lumbar, double major curves) and delivered by trained therapists using recognised methods such as Schroth, Rigo, SEAS, Scolibalance and others.

PSSE in Practice

PSSE programs often include:

Mirror feedback to enhance proprioception.

Elongation and rotational breathing (as emphasized in the Schroth method).

Isometric and dynamic stabilisation exercises

Functional integration, such as sitting or standing with corrected posture during routine activities.

The exercises may also involve props like wall bars, poles, or stability balls and are performed under supervision until the patient can perform them independently at home.

Exercise Prescription in PSSE

Evidence-based PSSE programs follow structured progressions tailored to the child’s curve pattern, developmental stage, and physical capability. Based on clinical practice and the protocols outlined by Schreiber et al. (2017) and Monticone et al. (2016)

A typical exercise progression might include:

Phase 1: Floor-Based Exercises 

Focus: Postural awareness, spinal elongation, core control

Functional breathing with posture reinforcement

Supine core activation exercises

Supine and side-lying elongation with breathing control

Modified planks (forearm or knee-based)

4-point kneeling (e.g., bird-dog with spinal alignment focus)Pelvic tilts and lumbar stabilisation drills

Phase 2: Stabilisation and Functional Correction

Focus: Maintaining correction during upright and functional tasks

Sit-to-stand (STS) with corrected posture

Seated postural correction with proprioceptive cues

Walking drills with active spinal self-correction

Step-ups and wall-supported balance tasks

Phase 3: Loaded and Sport-Specific Movements

Focus: Strengthening in corrected alignment, integration into daily and athletic tasks

Bodyweight squats with active spinal control

Weighted lunges using resistance bands or dumbbells

Overhead reaching and rotation tasks with resistance

Sport-specific drills with postural cueing 

Clinical Considerations and Contraindications

While PSSE is generally safe and effective when prescribed appropriately, there are several important considerations and potential contraindications to keep in mind when working with adolescents with scoliosis:

Thoracic Scoliosis:

Be cautious with chest flattening, especially in exercises involving thoracic rotation or extension.Rotational breathing exercises should promote rib cage expansion, not collapse.

Lumbar Scoliosis: 

In lumbar-dominant curves, patients may loose their natural lordosis, and compensate with lumbar-sacral extension increased pelvic tilt and upper back extension, leading to instability or discomfort. Cue for neutral pelvis and abdomen lengthening.

Pain and Fatigue

PSSE should not cause pain. If discomfort persists during or after sessions, reassess the technique and load.Watch for compensatory movements, such as trunk shifting or hip hiking, or spinal hyper-extension which may indicate fatigue or poor motor control.

Growth Phase Considerations

During rapid growth, patients may be more prone to curve progression and muscle imbalances. Regular reassessment is key.Be cautious with progressive loading (e.g., resistance or sport-based activities) and always ensure proper movement quality before advancing.

Psychological and Emotional Factors

Adolescents with scoliosis may experience body image concerns or anxiety around exercise. Encourage positive reinforcement, and foster autonomy in managing posture and movement.A thorough initial assessment and regular monitoring by a trained professional are critical for safe and effective PSSE programming.

Clinical Relevance

Numerous studies validate the effectiveness of PSSE. According to a randomised controlled trial by Schreiber et al. (2017), PSSE specifically the Schroth method can significantly reduce Cobb angle progression and improve quality of life in adolescents with scoliosis. Another review by Monticone et al. (2016) supports these findings, stating that PSSE, along with bracing, are the only conservative treatments with Level I evidence of efficacy in AIS management.

The SOSORT 2016 Guidelines advocate PSSE as the first line of treatment for mild curves (<25° Cobb angle) and as a co-treatment with bracing in moderate to severe curves. This is especially important for adolescents in their growth spurt phase, where the risk of progression is at its peak.

Why Early Intervention Matters

The earlier PSSE is introduced, ideally at the onset of curve detection the more effective it is in preventing progression. For growing spines, this is crucial. Delaying treatment can reduce the window for conservative management and increase the likelihood of surgical intervention.In conclusion, PSSE offers a structured, evidence-based approach to conservative scoliosis care. With consistent practice and professional supervision, these exercises empower young patients to take control of their posture, spinal health, and overall function—without relying solely on bracing or surgical options.

References

(APA 7th Edition) Monticone, M., Ambrosini, E., Cazzaniga, D., Rocca, B., & Ferrante, S. (2016). Exercise-based treatment for adolescent idiopathic scoliosis: A comprehensive review of the literature. Disability and Rehabilitation, 38(7), 628–636. https://doi.org/10.3109/09638288.2015.1055375Schreiber, S., Parent, E. C., Hill, D. L., Hedden, D. M., Moreau, M. J., & Southon, S. C. (2017). Schroth physiotherapeutic scoliosis-specific exercises for adolescent idiopathic scoliosis: How many patients require treatment to prevent one deterioration? Scoliosis and Spinal Disorders, 12, 26. https://doi.org/10.1186/s13013-017-0137-8Scoliosis SOS Clinic. (n.d.). Treating scoliosis with PSSEs. https://www.scoliosissos.com/blog/scoliosis-psse-treatmentSOSORT. (2022, September 9). Physiotherapeutic scoliosis-specific exercises (PSSE): The orthotist’s perspective [Video]. YouTube. https://www.youtube.com/watch?v=r-Z3AO5wCo4