Spontaneous movement therapy for a young adult with adolescent idiopathic scoliosis: a case report

Abstract

[Purpose] This case study explored the potential of Spontaneous Movement Therapy (SMT)—an active-modified form of Vojta therapy—in improving spinal alignment parameters in a young adult with a history of Adolescent Idiopathic Scoliosis (AIS). [Participant and Methods] A 21-year-old female with a prior diagnosis of AIS was assessed using full-spine radiographs, which revealed thoracic dextroscoliosis (35.6°) and lumbar levoscoliosis (28.8°). She reported no spinal pain or leg length discrepancy. The patient subsequently underwent an 8-week SMT intervention targeting both coronal and sagittal spinal alignment. [Results] Following the SMT intervention, the thoracic Cobb angle decreased by 4.6° (from 35.6° to 31°), and the angle of trunk rotation (ATR) decreased by 4.0° in the thoracic spine and 3.33° in the lumbar spine. The lumbar Cobb angle remained largely unchanged (28.8° to 29.1°). Although the Cobb angle and ATR were reduced, these changes did not exceed the minimal clinically important difference (MCID). [Conclusion] Although this case report presents promising preliminary observations, the reductions in spinal curvature parameters did not exceed the MCID, suggesting the need for cautious interpretation. Further studies with larger sample sizes and control groups are warranted to validate the clinical effectiveness of SMT in AIS management.

INTRODUCTION

Scoliosis (defined as a Cobb angle ≥10°) is a three-dimensional spinal deformity characterized by curvature in the sagittal (thoracic lordosis), transverse (vertebral rotation), and frontal (lateral curvature) planes¹⁾. Although the primary cause of AIS remains uncertain, factors such as genetic predisposition, hormonal dysfunction, abnormal platelet calmodulin levels, altered bone density, and central nervous system abnormalities have been associated with its development²⁾. Additionally, studies have reported that trunk asymmetries (e.g., in strength and thickness) and dysfunction of the abdominal muscles (transversus abdominis, external oblique, and internal oblique) are associated with spinal deformities^3,4,5,6,7). Exercise plays an important role in managing AIS, with the Schroth method being widely used. Although this method offers short-term benefits, evidence supporting its long-term effectiveness—particularly regarding significant improvements in the Cobb angle—remains limited⁸⁾. Research indicates that individuals with scoliosis exhibit asymmetric contraction of the transversus abdominis (TrA) relative to healthy individuals⁹⁾, with the most pronounced asymmetry observed at rest¹⁰⁾. Notably, combining three-dimensional postural correction with abdominal muscle contraction yields the greatest symmetry¹⁰⁾. Therefore, treatment should prioritize symmetrical exercises to re-store normal TrA function and promote structural spinal changes, given its key role in trunk stability⁹⁾.

Vojta therapy consists of two primary components: reflex turning and reflex creeping¹¹⁾. These techniques elicit innate motor responses through specific starting positions and peripheral stimulation, reflecting partial patterns of early motor ontogeny¹¹⁾. To adapt this approach for adults, Spontaneous Movement Therapy (SMT) was developed as a modified form of Vojta therapy to address its limitations—particularly in adults, where reduced flexibility, greater body mass, and increased resistance to stimulation may hinder the effectiveness of multi-zone reflex activation.

In SMT, reflex turning is applied with the patient positioned supine on an incline table with the hips and knees flexed. If tolerated, a gym ball is placed between the thighs, and the patient is instructed to press the ball during hip and knee flexion to promote deeper abdominal engagement. During this task, the therapist stimulates the reflex zone in caudal, medial, and dorsal directions—a modification of the traditional cranial-directed stimulation used in Vojta therapy. Clinical observations suggest that caudal stimulation elicits stronger abdominal contractions, indicating a potentially more effective approach for adult patients.

In SMT, reflex creeping is applied by positioning the patient in a final-phase or anticipated response posture, with an emphasis on active weight-bearing—particularly through the lower extremities. Spatial weighting strategies, such as pressing the feet against footrests on an incline table in the prone position, are employed to enhance proprioceptive input and facilitate lower limb responses. For the upper extremities, where passive weight-bearing is less feasible, the patient is supported on the elbows in a horizontal configuration to encourage active muscle contraction that simulates weight-bearing. Simultaneously, the therapist stimulates a targeted reflex zone to reinforce the neuromuscular response. By modifying both reflex turning and reflex creeping to accommodate adult biomechanics, SMT simplifies reflex stimulation, reduces physical burden on the therapist, and enhances patient participation. As a functionally adaptive extension of Vojta therapy, SMT may offer clinical utility in populations for whom conventional techniques are less effective.

This case report examines the effects of an 8-week SMT intervention on spinal curvature and trunk rotation in a young adult with a history of adolescent idiopathic scoliosis.

PARTICIPANT AND METHODS

On March 14, 2024, a 21-year-old female patient (165 cm, 50 kg) visited our institute for scoliosis, which had been diagnosed when she was 12. Currently a college junior, she expressed dissatisfaction with her cosmetic appearance and reported mild back pain when standing or sitting for long periods. She participates in sports, including basketball at least once a week, and experiences no significant pain or discomfort. Furthermore, no leg length discrepancy was observed. In her family history, both older sisters have severe scoliosis with Cobb angles of 35° to 40° or more; they received treatment with braces and hospital care. Although her symptoms are relatively milder than those of her sisters, she has not undergone special treatment due to financial reasons. Prior to participation, she was informed about the study’s purpose and provided written informed consent. This study was conducted in accordance with the ethical standards of the Declaration of Helsinki. Base-line measurements revealed a thoracic Cobb angle of 35.6° and a lumbar Cobb angle of 28.8°, with an angle of trunk rotation (ATR) of 5.0° in the thoracic region and 12.33° in the lumbar region. She was identified as having moderate scoliosis; however, both the therapist and the patient noted lumbar stiffness, particularly during palpation in the Adam’s test. The Cobb angle and ATR were measured as at baseline. The Cobb angle was determined by drawing perpendicular lines to the superior endplate of the upper vertebra and the inferior endplate of the lower vertebra of the curve, with the angle between these lines representing the curve magnitude. The ATR was evaluated using Bunnell’s scoliometer in conjunction with Adam’s forward bend test. The patient was asked to bend forward, and the trunk rotation angle (the angle between the horizontal plane and a plane across the posterior aspect of the trunk) was measured at the apical vertebra of the curve.

The Cobb angle and ATR were measured at baseline and after the intervention. The Cobb angle was determined by drawing perpendicular lines to the superior endplate of the upper vertebra and the inferior endplate of the lower vertebra of the curve, with the angle between these lines representing the curve magnitude. The ATR was evaluated using Bunnell’s scoliometer in conjunction with Adam’s forward bend test. The patient was asked to bend forward, and the trunk rotation angle (the angle between the horizontal plane and a plane across the posterior aspect of the trunk) was measured at the apical vertebra of the curve.

All measurements were performed by a physical therapist who was blinded to the intervention details to minimize assessment bias. Previous studies have reported that Bunnell’s scoliometer demonstrates very good to excellent reliability for detecting scoliosis^{12, 13)}. However, its validity has been primarily evaluated based on its ability to detect the presence of scoliosis rather than to precisely quantify the degree of curvature¹⁴⁾. Nonetheless, this supports its appropriate use for monitoring directional changes in trunk rotation over time.

The intervention plan was established during a pre-baseline interview, during which the patient requested 30-minute treatment sessions three times a week to avoid interference with her studies. The SMT protocol was designed to achieve both sagittal and coronal corrections (Fig. 1). The intervention was administered three times a week for 8 weeks, with each session lasting 30 minutes. Figure 1A was performed for 3 minutes on each side, while the remaining interventions were alternated within the 30-minute session based on the patient’s condition on the day. The patient changed positions between interventions, resting for approximately 5 seconds during each transition. Outcome measurements were taken at the 4- and 8-week marks following the baseline assessment. The SMT protocol is detailed in Fig. 1. The procedure was performed with the patient in a supine position on a tilt table (kept horizontal during the first week, with the angle gradually increased to a 45° incline after the fourth week). The side toward which the patient’s head was turned 30° was designated as the face side. The therapist applied stimulation to the 6th–7th inter-costal space in caudal, medial, and dorsal directions until the patient reached maximum fatigue. This stimulation was applied for 3 minutes on each side. During this period, the patient was instructed to place a gym ball between her legs and pull her knees toward her abdomen to strengthen the abdominal muscles and promote elongation of the spine along its longitudinal axis (Fig. 1A). With the patient in the right lateral recumbent position, the therapist stimulated the lower third of the left scapula’s medial border in cranial, medial, and ventral directions to encourage elbow support. Simultaneously, with the opposite hand, the therapist stimulated the anterior superior iliac spine (ASIS) in caudal, medial (or lateral), and dorsal directions to support the lower pelvis. The patient raised her head to stretch the left lumbar region by performing a sit-up-like movement aimed at reducing lumbar convexity (Fig. 1B). In the same position as in Fig. 1B, the therapist stimulated the scapula while simultaneously grasping the patient’s elevated foot and pulling it toward the ceiling to induce lateral flexion of the left lumbar region. The patient executed a sit-up motion with her head raised slightly obliquely to promote rotation of the concave side of the thoracic spine (left) and reduce the convexity of the left lumbar spine (Fig. 1C). With the patient in the quadruped position, the side toward which the head was turned 30° was designated as the face side and the opposite side as the occipital side. The face side arm was maintained at 120–135° flexion and 45° abduction, while the occipital arm was kept slightly extended with the hand placed on the floor. The face side lower limb was positioned with both hip and knee flexion, whereas the occipital leg was slightly extended. At this point, the heel and ischial tuberosity were aligned in a straight line. The therapist stimulated the trunk area (the intercostal space just below the inferior angle of the scapula) in cranial, medial, and ventral directions toward the sternum, and the patient pressed the floor with her elbow and foot. During this movement, she was in-structed to move forward and upward to avoid increasing kyphosis, thereby inducing elongation of the left thoracic concave region and the right lumbar concave region (Fig. 1D). In a modified posture similar to that in Fig. 1D, the face-side arm was supported while the occipital arm remained free. The left lower extremity was positioned with slight hip flexion, approximately 45° knee flexion, and the foot in a neutral position. The therapist combined stimulation of the heel zone, left ASIS, and right trunk zone as needed. Meanwhile, the patient pressed against the floor to support the face-side arm, and the leg on the floor was repeatedly bent and extended at the knee to enhance coronal correction of the lumbar region (Fig. 1E).

Fig. 1.

Spontaneous movement therapy protocol.

RESULTS

At baseline, the thoracic Cobb angle measured 35.6° and the lumbar Cobb angle 28.8°. After 4 weeks, these angles were 34.8° (thoracic) and 31.8° (lumbar); following 8 weeks, they measured 31° (thoracic) and 29.1° (lumbar), indicating a total reduction of 4.6° in the thoracic region (Fig. 2). At baseline, the ATR was 5.0° in the thoracic spine and 12.33° in the lumbar spine. After 4 weeks, the values were 1.17° (thoracic) and 9.33° (lumbar), and after 8 weeks, they were 1° (thoracic) and 9° (lumbar), corresponding to decreases of 4.0° and 3.33° in the thoracic and lumbar regions, respectively.

Fig. 2.

Cobb angle. (A) Baseline; (B) 4 weeks; (C) 8 weeks.

DISCUSSION

This case report describes the successful improvement of both the Cobb angle and ATR in a 21-year-old woman with AIS. Ng et al.¹⁵⁾ reported that while muscle activity asymmetry is not consistent in all AIS patients, there is a trend toward higher activity on the convex side. Since the autochthonous (intrinsic) back muscles responsible for spinal stabilization and extension cannot be voluntarily activated, targeted training is necessary to strengthen them¹⁶⁾. This underscores the potential of Vojta therapy in AIS, as its tactile stimulation activates brain regions involved in sensory processing, motor planning, and control, facilitating neuromuscular coordination¹⁷⁾. This mechanism not only promotes movement intention but also induces actual muscle contraction. Building on this concept, the present case study incorporated active patient participation into conventional Vojta therapy to promote the desired response. While Vojta therapy primarily relies on tactile stimulation to elicit reflexive movement patterns, SMT integrates active participation, encouraging voluntary movement alongside reflexive responses. Although Vojta therapy includes an active component, SMT further enhances neuromuscular coordination by combining tactile stimulation with conscious engagement. In particular, integrating active participation during both the anticipated and final contraction phases likely maximized muscle activation, extending the benefits of Vojta therapy through additional movement strategies unique to SMT. Although TrA thickness was not directly measured in this case, Ha and Sung reported that breast zone stimulation—similar to the intervention described in Fig. 1A—in healthy adults activated the TrA and diaphragm, thereby improving trunk stability¹⁸⁾. In our study, the patient was positioned on an inclined table, instructed to engage her abdominal muscles, and stimulated in the breast zone while squeezing a gym ball between her legs to enhance abdominal contraction. The stimulation was applied in a caudal direction, and the patient reported experiencing stronger abdominal contractions caudally than cranially. Studies assessing abdominal muscle thickness in AIS patients have demonstrated significant TrA asymmetry compared to healthy individuals⁹⁾. Another study that combined three-dimensional postural correction with cushions and abdominal muscle contraction found the greatest improvement in TrA symmetry on both the concave and convex sides of the lumbar curve¹⁰⁾. This improvement was accompanied by reductions in both the Cobb angle and ATR, as well as enhancements in trunk expansion. The Cobb angle and ATR are considered important prognostic indicators in AIS¹⁹⁾. In Vojta therapy, stimulation of the reflex zone at closed kinetic chain positions can induce differentiation of muscle function¹¹⁾. This differentiation occurs through coordinated muscle contractions facilitated by mechanical compression of joint surfaces, which in turn enhances muscle strength and endurance²⁰⁾. During the intervention depicted in Fig. 1D, muscle action was reversed by repositioning external support points, causing the direction of muscle contraction to change from the origin to the insertion. The patient was instructed to press her elbow (on the face side) and her heel (on the occipital side) firmly against the floor, resulting in elongation of the left thoracic concavity. Both the therapist and the patient consistently noted a “filling” sensation of the concavity during the intervention. Pressing the heel against the floor also reversed hamstring contraction, leading to dorsal pelvic extension and elongation of the right lumbar concavity. The patient was further directed to move forward (same as Fig. 1A, facilitating sagittal plane correction).

In this method for transverse plane correction (Fig. 1E), the patient supports her body with the left elbow while the therapist stimulates the left heel zone and both ASIS zones. Repeated facilitation of knee flexion and extension on the floor-side leg induces rightward spinal rotation, counteracting the patient’s left-sided lumbar rotation.

Figure 1B and 1C illustrate targeted coronal plane correction, with stimulation of the left ASIS used to encourage right pelvic support and correct left lumbar convexity. In Fig. 1C specifically, the patient supports her body with her lower arm while performing an oblique sit-up motion, promoting elongation of the right lumbar spine and ipsilateral rotation of the left thoracic vertebral body.

A recent study reported that combining Schroth and Pilates exercises, as well as Schroth and Vojta exercises, improved the Cobb angle, ATR, thoracic expansion, and quality of life in AIS patients²¹⁾. Notably, the combination of Schroth and Pilates demonstrated superior improvements in these parameters. Similarly, our case exhibited reductions of 4° in ATR and 4.6° in the primary thoracic Cobb angle. However, the change in the Cobb angle did not exceed the minimal clinically important difference (MCID). This discrepancy may be due to the relatively shorter intervention duration and session time in our case compared to the referenced study, which applied intensive exercise for 12 weeks, five times a week, for 80 minutes per session. A recent meta-analysis by Ceballos-Laita et al. supports our findings. The study reported that while the Schroth method alone can improve Cobb angle, trunk rotation, and quality of life in the short term, the reductions in Cobb angle did not exceed MCID⁸⁾. Hamazoglu et al.²²⁾ reported that while lumbar curves are more flexible in mild cases, they tend to become stiffer than thoracic curves in severe cases. In our study, the absence of change in the lumbar Cobb angle may be attributed to increased stiffness in the lumbar region relative to the thoracic region, despite the scoliosis not being classified as severe.

This case report highlights the application of SMT in a 21-year-old patient with AIS, demonstrating improvements in coronal balance and spinal alignment. Although reductions in the Cobb angle and ATR were observed, they did not exceed the MCID, and the findings should be interpreted with caution. As an exploratory investigation, this study provides preliminary evidence supporting the potential role of SMT in scoliosis management and underscores the need for validation through larger controlled studies.

Funding

This research received no external funding.

Conflict of interest

The author declares no conflicts of interest.