Physical exercises in the treatment of adolescent idiopathic scoliosis: An updated systematic review

Effect of adding Schroth physiotherapeutic scoliosis specific exercises to standard care in adolescents with idiopathic scoliosis on posture assessed using surface topography: A secondary analysis of a Randomized Controlled Trial (RCT)

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is a three-dimensional structural asymmetry of the spine and trunk affecting 2-4% of adolescents. Standard treatment is observation, bracing, and surgery for small, moderate, and large curves, respectively. Schroth exercises aim to correct posture and reduce curve progression.

PURPOSE

This study aimed to determine the effect of Schroth exercises added to the standard care compared to standard care alone on torso asymmetry in AIS.

METHODS

In a randomized controlled trial (NCT01610908), 124 participants with AIS (age: 10-18, Cobb: 10°-45°, Risser: ≤3) were randomly assigned to the control (Standard care only) or Schroth (Standard care + Schroth treatment) group. Schroth treatment consisted of 1-hour weekly supervised sessions and 30-45 minutes of daily home exercises for six months. The control group received Schroth exercises in the last six months of the 1-year monitoring period. Markerless 3D surface topography assessed torso asymmetry measured by maximum deviation (MaxDev) and root mean square (RMS). Intention to treat linear mixed effects model analysis was compared to the per protocol analysis.

RESULTS

In the intention to treat analysis, the Schroth group (n = 63) had significantly larger decreased RMS (-1.2 mm, 95%CI [-1.5,-0.9]mm, p = 0.012) and MaxDev (-1.9mm, 95%CI [-2.4,-1.5]mm, p = 0.025) measurements compared to controls (n = 57) after six months of intervention. In the per protocol analysis (Schroth n = 39, control n = 36), the Schroth group also had a significantly larger decrease compared to the control in both the RMS (-1.0mm, 95%CI [-1.9, -0.2]mm, p = 0.013) and MaxDev measurements (-2.0mm, 95%CI [-3.3,-0.5]mm, p = 0.037). For the control group, both the intention to treat and per protocol analysis showed no difference in RMS and MaxDev in the last six months of Schroth intervention (p>0.5).

CONCLUSION

Schroth Exercise treatment added to standard care (observation or bracing) reduced asymmetry measurements in AIS. As expected, a greater effect was observed for participants who followed the prescribed exercise treatment per protocol.

Therapeutic exercises for idiopathic scoliosis in adolescents

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is a pathology that changes the three-dimensional shape of the spine and trunk. While AIS can progress during growth and cause cosmetic issues, it is usually asymptomatic. However, a final spinal curvature above the critical threshold of 30° increases the risk of health problems and curve progression in adulthood. The use of therapeutic exercises (TEs) to reduce the progression of AIS and delay or avoid other, more invasive treatments is still controversial.

OBJECTIVES

To evaluate the effectiveness of TE, including generic therapeutic exercises (GTE) and physiotherapeutic scoliosis-specific exercises (PSSE) in treating AIS, compared to no treatment, other non-surgical treatments, or between treatments.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, four other databases, and two clinical trials registers to 17 November 2022. We also screened reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing TE with no treatment, other non-surgical treatments (braces, electrical stimulation, manual therapy), and different types of exercises. In the previous version of the review, we also included observational studies. We did not include observational studies in this update since we found sufficient RCTs to address our study aims.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology. Our major outcomes were progression of scoliosis (measured by Cobb angle, trunk rotation, progression, bracing, surgery), cosmetic issues (measured by surface measurements and perception), and quality of life (QoL). Our minor outcomes were back pain, mental health, and adverse effects.

MAIN RESULTS

We included 13 RCTs (583 participants). The percentage of females ranged from 50% to 100%; mean age ranged from 12 to 15 years. Studies included participants with Cobb angles from low to severe. We judged 61% of the studies at low risk for random sequence generation and 46% at low risk for allocation concealment. None of the studies could blind participants and personnel. We judged the subjective outcomes at high risk of performance and detection bias, and the objective outcomes at high risk of detection bias in six studies and at low risk of bias in the other six studies. One study did not assess any objective outcomes. Comparing TE versus no treatment, we are very uncertain whether TE reduces the Cobb angle (mean difference (MD) -3.6°, 95% confidence interval (CI) -5.6 to -1.7; 2 studies, 52 participants). Low-certainty evidence indicates PSSE makes little or no difference in the angle of trunk rotation (ATR) (MD -0.8°, 95% CI -3.8 to 2.1; 1 study, 45 participants), may reduce the waist asymmetry slightly (MD -0.5 cm, 95% CI -0.8 to -0.3; 1 study, 45 participants), and may result in little to no difference in the score of cosmetic issues measured by the Spinal Appearance Questionnaire (SAQ) General (MD 0.7 points, 95% CI -0.1 to 1.4; 1 study, 16 participants). PSSE may result in little to no difference in self-image measured by the Scoliosis Research Society - 22 Patient Questionnaire (SRS-22) (MD 0.3 points, 95% CI -0.3 to 0.9; 1 study, 16 participants) and improve QoL slightly measured by SRS-22 Total score (MD 0.3 points, 95% CI 0.1 to 0.4; 2 studies, 61 participants). Only Cobb angle results were clinically meaningful. Comparing PSSE plus bracing versus bracing, low-certainty evidence indicates PSSE plus bracing may reduce Cobb angle (-2.2°, 95% CI -3.8 to -0.7; 2 studies, 84 participants). Comparing GTE plus other non-surgical interventions versus other non-surgical interventions, low-certainty evidence indicates GTE plus other non-surgical interventions may reduce Cobb angle (MD -8.0°, 95% CI -11.5 to -4.5; 1 study, 80 participants). We are uncertain whether PSSE plus other non-surgical interventions versus other non-surgical interventions reduces Cobb angle (MD -7.8°, 95% CI -12.5 to -3.1; 1 study, 18 participants) and ATR (MD -8.0°, 95% CI -12.7 to -3.3; 1 study, 18 participants). PSSE plus bracing versus bracing alone may make little to no difference in subjective measurement of cosmetic issues as measured by SAQ General (-0.2 points, 95% CI -0.9 to 0.5; 1 study, 34 participants), self-image score as measured by SRS-22 Self-Image (MD 0.1 points, 95% CI -0.3 to 0.5; 1 study, 34 participants), and QoL measured by SRS-22 Total score (MD 0.2 points, 95% CI -0.1 to 0.5; 1 study, 34 participants). None of these results were clinically meaningful. Comparing TE versus bracing, we are very uncertain whether PSSE allows progression of Cobb angle (MD 2.7°, 95% CI 0.3 to 5.0; 1 study, 60 participants), changes self-image measured by SRS-22 Self-Image (MD 0.1 points, 95% CI -1.0 to 1.1; 1 study, 60 participants), and QoL measured by SRS-22 Total score (MD 3.2 points, 95% CI 2.1 to 4.2; 1 study, 60 participants). None of these results were clinically meaningful. Comparing PSSE with GTE, we are uncertain whether PSSE makes little or no difference in Cobb angle (MD -3.0°, 95% CI -8.2 to 2.1; 4 studies, 192 participants; very low-certainty evidence). PSSE probably reduces ATR (clinically meaningful) (MD -3.0°, 95% CI -3.4 to -2.5; 2 studies, 138 participants). We are uncertain about the effect of PSSE on QoL measured by SRS-22 Total score (MD 0.26 points, 95% CI 0.11 to 0.62; 3 studies, 168 participants) and on self-image measured by SRS-22 Self-Image and Walter Reed Visual Assessment Scale (standardised mean difference (SMD) 0.77, 95% CI -0.61 to 2.14; 3 studies, 168 participants). Further, low-certainty evidence indicates that 38/100 people receiving GTE may progress more than 5° Cobb versus 7/100 receiving PSSE (risk ratio (RR) 0.19, 95% CI -0.67 to 0.52; 1 study, 110 participants). None of the included studies assessed adverse effects.

AUTHORS' CONCLUSIONS

The evidence on the efficacy of TE is currently sparse due to heterogeneity, small sample size, and many different comparisons. We found only one study following participants to the end of growth showing the efficacy of PSSE over TE. This result was weakened by adding studies with short-term results and unclear preparation of treating physiotherapists. More RCTs are needed to strengthen the current evidence and study other highly clinically relevant outcomes such as QoL, psychological and cosmetic issues, and back pain.

Conservative Treatments of Adolescent Idiopathic Scoliosis: Physical Therapists' Perspectives

This study aimed to examine physical therapists' perspectives in conservative treatments of pediatric patients with adolescent idiopathic scoliosis (AIS). A cross-sectional survey design was used. A validated questionnaire was distributed to physical therapists, and the responses were analyzed. Preferred treatment frequency was 60 minutes (53.8%), twice weekly (41.5%), over 3 to 5 months (44.6%). Top 3 clinical interventions were core and trunk stability enhancement (90.8%), abdominal strengthening (83.1%), and postural correction (80.0%). Top 3 therapeutic goal-setting parameters were activity-based (78.5%), quality-of-life measure-based (56.9%), and participation-based (50.8%). The most common quality-of-life survey used was Oswestry low back pain disability questionnaire (15.6%) followed by Scoliosis Research Society-22 instrument (12.5%). According to our data, physical therapists believe that pediatric patients with AIS can benefit with addressing core and trunk stability, a 60-minute per session, twice weekly, over 3 to 5 months based on activity-based goal-setting and quality-of-life measures using Oswestry questionnaire.

Effectiveness of orthotic treatment for adolescent idiopathic scoliosis: a scoping review protocol of systematic reviews

INTRODUCTION

Spinal orthosis is a common conservative treatment for adolescent idiopathic scoliosis (AIS), and a large body of compelling evidence from systemic review studies strongly supports the use of spinal orthosis treatment in patients with this condition. To further improve our understanding of the available data, the aim of this study is to develop and propose a protocol for a scoping review of systematic reviews of studies that investigated the effectiveness of orthotic treatment in patients with AIS. Systematic synthesis and understanding of the data will improve the efficacy of spinal orthosis treatment in this patient population.

METHOD AND ANALYSIS

Using the scoping review methodological framework proposed by Arksey and O'Malley in 2005, we developed and herewith propose a scoping review protocol to evaluate systematic reviews of studies that investigated the effectiveness of orthotic treatment in AIS. Our proposed scoping review proposal is briefly described, as follows. A search of seven online databases will be conducted to identify systematic reviews published in English language from 1 January 2000 to 31 December 2023, and grey literature and reference lists of included articles will also be searched. A two-stage screening process consisting of a title and abstract screening and a full-text review will be used to determine articles' eligibility. All eligible articles will be extracted, charted and evaluated using Assessing the MeaSurement Tool to Assess systematic Reviews Version 2 (AMSTAR-2) critical appraisal tool. The charted data will be quantitatively analysed and summarised, and qualitatively analysed using narrative synthesis.

ETHICS AND DISSEMINATION

No primary data will be collected; therefore, ethics approval is not required. Findings will be disseminated through national and international conferences and publication in a peer-reviewed journal.

Predicting Progression in Adolescent Idiopathic Scoliosis at the First Visit by Integrating 2D Imaging and 1D Clinical Information

STUDY DESIGN

Retrospective observational study.

OBJECTIVES

The prediction of curve progression in patients with adolescent idiopathic scoliosis (AIS) remains an unresolved area in orthopedic surgery. To make a rapid meaningful prediction, easily accessible multi-dimensional data at the patient's first consultation should be used. Current studies use clinical growth parameters and numerical values extracted from radiographs to compile a predictive model, leaving out the radiographs themselves. Such practice inevitably wastes a lot of information. Thus, this study aims to create a neural network that can predict AIS progression among patients with curves indicated for bracing by integrating both one-dimensional (1D) clinical and two-dimensional (2D) radiological data collected at the patient's first visit in a fully automated manner.

METHODS

513 idiopathic scoliosis patients indicated for and managed with bracing orthosis were recruited. After exclusion, 463 patients were included in deep learning analysis. Processed first-visit growth parameters and posteroanterior radiographs are used as training inputs and the curve progression outcomes obtained in follow ups are used as binary training outputs. The CapsuleNet architecture was modified and trained accordingly to make a prediction.

RESULTS

The final model achieved 90% sensitivity with an overall accuracy of 73.9% in the prediction of AIS in-brace curve progression by using first-visit multi-dimensional data, outperforming conventional convolutional neural networks.

CONCLUSIONS

This first-ever multidimensional-input model shows promise in serving as a screening tool for AIS in-brace curve progression. The incorporation of such a model into routine AIS diagnostic pipeline can assist orthopedics clinicians in personalizing the most appropriate management for each patient.

Schroth Physiotherapeutic Scoliosis-Specific Exercise (PSSE) Trials-Systematic Review of Methods and Recommendations for Future Research

The Schroth method is a non-operative treatment for scoliosis and kyphosis, used standalone or as an adjunct to bracing. While supporting evidence for its effectiveness is emerging, methodologic standardization and rigor are equivocal. Thus, we aimed to systematically review methods of published Schroth physiotherapeutic scoliosis-specific exercise (PSSE) trials and provide guidance for future research. We searched six databases for randomized controlled trials (RCT) and non-randomized studies of interventions (NRSIs) investigating the effect of Schroth in children and adults with scoliosis or kyphosis. General characteristics, methodological approaches, treatment protocols, and outcomes reporting were analyzed. Risk of bias (RoB) was assessed using an adapted Cochrane RoB2 tool for RCTs and ROBINS-I for NRSI. Eligible studies (n = 7) were conducted in six countries and included patients with Scheuermann's kyphosis (n = 1) and adolescent idiopathic scoliosis (n = 6). Though all seven studies used the term Schroth to describe their interventions, the Schroth method was used in four of seven studies, of which only one used Schroth classification, three used Schroth therapists, and none prospectively registered the study protocol. Overall, methodological rigor was suboptimal, potentially invalidating evidence synthesis. Authors should follow minimum standards for reporting, including prospectively registering detailed protocols; using appropriate exercise labeling, Schroth classification and certified therapists; naming and describing exercises per classification; and providing therapy dosages, prescription methods, and adherence.

Effects of 3D Postural Correction and Abdominal Muscle Contraction on the Symmetry of the Transverse Abdominis and Spinal Alignment in Patients with Idiopathic Scoliosis

This study aimed to investigate the effectiveness of 3D postural correction (3DPC) using corrective cushions (CCs) and abdominal muscle contraction (AMC) on the thickness symmetry of the transversus abdominis (TrA) and spinal alignment in patients with idiopathic scoliosis (IS). In the first experiment, ultrasound measurements were taken of the TrA thickness on both the convex and concave sides of the lumbar curve in the supine position during AMC and non-AMC without 3DPC, and during AMC and non-AMC with 3DPC using CCs, in 11 IS patients. In the second experiment, 37 IS patients participated in a four-week 3DPC exercise program that aimed to maintain TrA thickness symmetry based on the results of the first experiment. The study found that TrA thickness symmetry significantly increased after 3DPC using CCs and combined with AMC (p < 0.05). Additionally, the Cobb angles and trunk rotation angles showed significant decreases, and trunk expansion showed a significant increase (p < 0.05). These results indicate that the simultaneous application of 3DPC and AMC is the most effective way to achieve TrA thickness symmetry in IS patients. Therefore, 3DPC and AMC should be considered as crucial elements in exercise interventions for IS patients.

Application of the Schroth Method in the Treatment of Idiopathic Scoliosis: A Systematic Review and Meta-Analysis

(1) Background: Idiopathic scoliosis can be defined as a complex three-dimensional deformity of the spine and trunk, which occurs in basically healthy children. Schroth scoliosis-specific exercises have shown good results in reducing idiopathic scoliosis progression. This study aimed to critically evaluate the effect size of Schroth's method through a systematic review and meta-analysis. (2) Methods: Four databases were included in the search: PubMed, Cochrane Library, Web of Science, and Google Scholar. The following keywords were used: "Schroth exercise", "idiopathic scoliosis", "Cobb angle", "angle of trunk rotation", and "quality of life". Only articles written in English that met the following criteria were included in our study: subjects who had idiopathic scoliosis, the Schroth method was applied, and Cobb angle or angle of trunk rotation or quality of life as outcomes. (3) Results: Ten randomized controlled trials were included in this study. The effect size of the Schroth exercise ranged from almost moderate to large, for the outcomes used: Cobb angle (ES = -0.492, p ˂ 0.005); ATR (ES = -0.471, p = 0.013); QoL (ES = 1.087, p ˂ 0.001). (4) Conclusions: The current meta-analysis indicates that the Schroth method has a positive effect on subjects with idiopathic scoliosis.

Physiotherapy Interventions for Preventing Spinal Curve Progression in Adolescent Idiopathic Scoliosis: A Systematic Review

Adolescent idiopathic scoliosis (AIS) is an abnormal curvature of the spine that appears in late childhood or adolescence. The aim of this systematic review was to present and synthesize the most relevant therapeutic advice and evidence on the efficacy of physiotherapy exercises for preventing the growth of spinal curvature caused by adolescent idiopathic scoliosis. "Adolescent idiopathic scoliosis," "exercise," "Cobb angle," and "physiotherapy" were the sole keywords used for the published research. Using these keywords and a combination of them, electronic resources such as PubMed, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database (PEDro), Elton B. Stephens Company (EBSCO) host, and ScienceDirect (Elsevier) were searched. The search was restricted to studies that were conducted in English between 2010 and 15 January 2022 that were controlled, randomized, and non-randomized. Studies were selected based on their titles and abstracts, with the exception of any that did not pertain to the study's goals. The Cobb angle was the important outcome measure. For each intervention, the Cobb angle's mean change score, the difference between the final and baseline scores, was determined. Nine studies were evaluated to be of outstanding quality out of a total of 20 studies that were reviewed for eligibility. With an exercise regimen of at least seven weeks, controls on lowering the Cobb angle in patients with AIS would provide encouraging outcomes. It also shows that bracing can strengthen the Cobb angle compared to exercise in the community. However, long-term orthotic activity ultimately results in trunk resistance and muscle loss in the center of the back. The combination of techniques and treatment methods seems to have better results in treating scoliosis, particularly using exercises involving the Schroth and scientific exercise approach to scoliosis (SEAS).

MPSI Manifestations and Treatment Outcome: Skeletal Focus

Mucopolysaccharidosis type I (MPSI) (OMIM #252800) is an autosomal recessive disorder caused by pathogenic variants in the IDUA gene encoding for the lysosomal alpha-L-iduronidase enzyme. The deficiency of this enzyme causes systemic accumulation of glycosaminoglycans (GAGs). Although disease manifestations are typically not apparent at birth, they can present early in life, are progressive, and include a wide spectrum of phenotypic findings. Among these, the storage of GAGs within the lysosomes disrupts cell function and metabolism in the cartilage, thus impairing normal bone development and ossification. Skeletal manifestations of MPSI are often refractory to treatment and severely affect patients’ quality of life. This review discusses the pathological and molecular processes leading to impaired endochondral ossification in MPSI patients and the limitations of current therapeutic approaches. Understanding the underlying mechanisms responsible for the skeletal phenotype in MPSI patients is crucial, as it could lead to the development of new therapeutic strategies targeting the skeletal abnormalities of MPSI in the early stages of the disease.

Prevalence of idiopathic scoliosis in athletes: a systematic review and meta-analysis

Objective

This study aimed to determine the prevalence of idiopathic scoliosis (IS) in child, adolescent and adult athletes of all sports activity levels.

Design

Systematic review with meta-analysis.

Data sources

Electronic databases (PubMed, Scopus, ProQuest, Sage journals, ScienceDirect, Google Scholar and Springer) were systematically searched up from inception to 28 September 2021.

Eligibility criteria for selecting studies

Observational investigations were included to evaluate the prevalence of IS in athletes (engaged in any type of individual and team sports). Congenital scoliosis, neuromuscular scoliosis, Scheuermann’s kyphosis and de novo scoliosis were not included. The risk of bias was assessed using the tool developed by Hoy et al.

Results

Twenty-two studies were included (N=57 470, range 15–46544, participants), thirteen studies were of high-quality. The estimated prevalence of IS in athletes was 27% (95% CI 20% to 35%, I²=98%), with a 95% prediction interval (1% to 69%). The prevalence of IS was significantly higher in female athletes (35%, 95% CI 27% to 34%, I²=98%). Ballet dancers showed a high IS prevalence (35%, 95% CI 24% to 47%, I²=98%). Recreational athletes showed a higher IS prevalence (33%, 95% CI 24% to 43%, I²=98%) than at competitive-level athletes (0.05%, 95% CI 0.03% to 0.08%, I²=98%), followed by elite (20%, 95% CI 13% to 27%, I²=98%).

Conclusions

The prevalence of IS in athletes was similar or higher to that as seen in other studies of the general population. IS prevalence may have a U-shaped relationship relative to level of competition. Further studies are required to determine which sports have the highest IS prevalence.

Conformity assessment of a computer vision-based posture analysis system for the screening of postural deformation

Background

This study evaluates the conformity of using a computer vision-based posture analysis system as a screening assessment for postural deformity detection in the spine that is easily applicable to clinical practice.

Methods

One hundred forty participants were enrolled for screening of the postural deformation. Factors that determine the presence or absence of spinal deformation, such as shoulder height difference (SHD), pelvic height difference (PHD), and leg length mismatch (LLD), were used as parameters for the clinical decision support system (CDSS) using a commercial computer vision-based posture analysis system. For conformity analysis, the probability of postural deformation provided by CDSS, the Cobb angle, the PHD, and the SHD was compared and analyzed between the system and radiographic parameters. A principal component analysis (PCA) of the CDSS and correlation analysis were conducted.

Results

The Cobb angles of the 140 participants ranged from 0° to 61°, with an average of 6.16° ± 8.50°. The postural deformation of CDSS showed 94% conformity correlated with radiographic assessment. The conformity assessment results were more accurate in the participants of postural deformation with normal (0–9°) and mild (10–25°) ranges of scoliosis. The referenced SHD and the SHD of the CDSS showed statistical significance (p < 0.001) on a paired t-test. SHD and PHD for PCA were the predominant factors (PC1 SHD for 79.97%, PC2 PHD for 19.86%).

Conclusion

The CDSS showed 94% conformity for the screening of postural spinal deformity. The main factors determining diagnostic suitability were two main variables: SHD and PHD. In conclusion, a computer vision-based posture analysis system can be utilized as a safe, efficient, and convenient CDSS for early diagnosis of spinal posture deformation, including scoliosis.

Coordination Between Trunk Muscles, Thoracolumbar Fascia, and Intra-Abdominal Pressure Toward Static Spine Stability

STUDY DESIGN

Numerical in-silico human spine stability finite element analysis.

OBJECTIVE

The purpose of this study was to investigate the contribution of major torso tissues toward static spine stability, mainly the thoracolumbar fascia (TLF), abdominal wall with its intra-abdominal pressure (IAP), and spinal muscles inclusive of their intramuscular pressure.

SUMMARY OF BACKGROUND DATA

Given the numerous redundancies involved in the spine, current methodologies for assessing static spinal stability are limited to specific tissues and could lead to inconclusive results. A three-dimensional finite element model of the spine, with structured analysis of major torso tissues, allows for objective investigation of static spine stability.

METHODS

A novel previously fully validated spine model was employed. Major torso tissues, mainly the muscles, TLF, and IAP were individually, and in combinations, activated under a 350N external spine perturbation. The stability contribution exerted by these tissues, or their ability to restore the spine to the unperturbed position, was assessed in different case-scenarios.

RESULTS

Individual activations recorded significantly different stability contributions, with the highest being the TLF at 75%. Combined or synergistic activations showed an increase of up to 93% stability contribution when all tissues were simultaneously activated with a corresponding decrease in the tensile load exerted by the tissues themselves.

CONCLUSION

This investigation demonstrated torso tissues exhibiting different roles toward static spine stability. The TLF appeared able to dissipate and absorb excessive loads, the muscles acted as antagonistic to external perturbations, and the IAP played a role limiting movement. Furthermore, the different combinations explored suggested an optimized engagement and coordination between different tissues to achieve a specific task, while minimizing individual work.Level of Evidence: N/A.

Non-cardiac Manifestations in Adult Patients With Mucopolysaccharidosis

Mucopolysaccharidoses (MPS) are a heterogeneous group of disorders that results in the absence or deficiency of lysosomal enzymes, leading to an inappropriate storage of glycosaminoglycans (GAGs) in various tissues of the body such as bones, cartilage, heart valves, arteries, upper airways, cornea, teeth, liver and nervous system. Clinical manifestations can become progressively exacerbated with age and affect their quality of life. Developments in advanced supportive treatment options such as enzyme replacement therapy (ERT), hematopoietic stem cell transplantation (HSCT) may have improved patients' life span. Adult MPS patients require specialist clinical surveillance long-term. In many cases, in addition to the MPS-related health problems, they may develop age-related complications. Considering the complexity of their clinical manifestations and lack of guidelines on the management of adult MPS disorders, multispecialty and multidisciplinary teams' care is essential to diagnose and treat health problems that are likely to be encountered. This review presents non-cardiac clinical manifestations, their pathophysiology, management and long-term outcomes in adult MPS patients.

Acute Effects of Self-Correction on Spine Deviation and Balance in Adolescent Girls with Idiopathic Scoliosis

Background: Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of spine and trunk with a higher incidence in girls. AIS alters and reduces postural control and balance. Self-correction movement (SCM) is a well-known non-invasive approach to ameliorate spine curve in AIS subjects. We aimed to evaluate the effects of SCM on the spine and on the balance of adolescents with AIS with a new non-invasive instrumentation. Methods: A total of 38 girls with AIS were recruited. To evaluate the acute effects of SCM and the oscillations of center of pressure (COP), we used LiDAR technology combined with a stabilometric platform to evaluate both changes in spinal curves and balance at the same time. Two tests were carried out simultaneously using the two instruments: before the execution of SCM, in the spontaneously assumed position of each subject (SP) and after the execution of SCM, during the achieved position (SC). Sway area, COP medio-lateral and antero-posterior directions, eccentricity of the ellipse and vertebral lateral deviation were recorded. The two conditions were compared with a Wilcoxon signed-rank test. Results: In general, all measures showed lower values in SC condition (p < 0.05), except the variation along the Y axis. Conclusions: Thanks to objective measured data, the therapists observed real-time changes during the performance of SCM, appreciating its efficacy on curve correction.

The Effect of the Schroth Rehabilitation Exercise Program on Spinal and Feet Alignment in Adolescent Patients with Idiopathic Scoliosis: A Pilot Study

Background: This study investigated the therapeutic effects of 12-week Schroth rehabilitation exercises (SRE) in improving Cobb’s angle, scoliometer readings, lumbar lordosis, and the calcaneal valgus angle of patients with idiopathic scoliosis. Methods: This pilot study included 60 adolescent patients diagnosed with idiopathic scoliosis by a rehabilitation physician based on a Cobb’s angle of ≥10° using total anteroposterior plain radiography. Patients were classified into groups with a Cobb’s angle of 10–19° (G1), 20–29° (G2), and ≥30° (G3). Cobb’s angle, scoliometer readings, lumbar lordosis, and calcaneal valgus angles were analyzed before and after the 12-week SRE. Results: SRE improved Cobb’s angle (−6.85), scoliometer readings (−2.80), lumbar lordosis (4.23), and calcaneal valgus angles (left, −3.76; right, −2.83) regardless of the initial scoliosis angle, and within-group changes were significant (p < 0.001). In this study, participants in all three groups had undergone SRE, regardless of initial scoliosis severity, and the findings were significant. Conclusion: SRE can be used for patients with idiopathic scoliosis to improve asymmetric musculoskeletal morphology and the patient’s quality of life.

Biofeedback Posture Training for Adolescents with Mild Scoliosis

Adolescent idiopathic scoliosis (AIS) is characterized by uneven shoulders, spinal curvature, and uneven hips, and asymmetry in paraspinal muscle activities is common in AIS. This pilot study was aimed at examining the use of a surface electromyography (sEMG) biofeedback posture training program in adolescents with mild scoliosis (Cobb′s angle < 30°) to attenuate asymmetry in paraspinal muscle activities and control the curve progression. Seven female adolescents (age, 12–14 years) with mild scoliosis (Cobb′s angle < 30°) were recruited. The participants received 30 tailor-made sessions of sEMG biofeedback posture training at a rate of one to two sessions per week for approximately 6 months. The activities of the paraspinal muscles (the trapezius, latissimus dorsi, thoracic erector spinae, and lumbar erector spinae) measured by sEMG during habitual sitting postures and spinal deformity evaluated by 3D ultrasound imaging were compared before and after training. The mean values of the root-mean-square sEMG ratio, an index of symmetry in paraspinal muscle activities of the muscle pairs between the concave and convex sides of the spinal curve, revealed significant asymmetry over the trapezius and lumbar erector spinae before the training (p <0.05). After the training, all seven adolescents achieved relatively more symmetrical paraspinal muscle activities over these two muscle pairs (p < 0.05). In two adolescents, the spinal curvature decreased by 5.7° and 5.6°, respectively, whereas the remaining adolescents showed a minimal curve progression with changes in the spinal curvature controlled under 5°. To conclude, sEMG biofeedback posture training can reduce asymmetry in paraspinal muscle activities and control curve progression in adolescents with mild scoliosis and can potentially be considered an alternative early intervention for muscle reeducation in this cohort.

A Pragmatic Benchmarking Study of an Evidence-Based Personalised Approach in 1938 Adolescents with High-Risk Idiopathic Scoliosis

Combining evidence-based medicine and shared decision making, current guidelines support an evidence-based personalised approach (EBPA) for idiopathic scoliosis in adolescents (AIS). EBPA is considered important for adolescents' compliance, which is particularly difficult in AIS. Benchmarking to existing Randomised Controlled Trials (RCTs) as paradigms of single treatments, we aimed to check the effectiveness and burden of care of an EBPA in high-risk AIS. This study's design features a retrospective observation of a prospective database including 25,361 spinal deformity patients < 18 years of age. Participants consisted of 1938 AIS, 11-45° Cobb, Risser stage 0-2, who were studied until the end of growth. EBPA included therapies classified for burdensomeness according to current guidelines. Using the same inclusion criteria of the RCTs on exercises, plastic, and elastic bracing, out of the 1938 included, we benchmarked 590, 687, and 884 participants, respectively. We checked clinically significant results and burden of care, calculating Relative Risk of success (RR) and Number Needed to Treat (NNT) for efficacy (EA) and intent-to-treat analyses. At the end of growth, 19% of EBPA participants progressed, while 33% improved. EBPA showed 2.0 (1.7-2.5) and 2.9 (1.7-4.9) RR of success versus Weinstein and Coillard's studies control groups, respectively. Benchmarked to plastic or elastic bracing, EBPA had 1.4 (1.2-1.5) and 1.7 (1.2-2.5) RR of success, respectively. The EBPA treatment burden was greater than RCTs in 48% of patients, and reduced for 24% and 42% versus plastic and elastic bracing, respectively. EBPA showed to be from 40% to 70% more effective than benchmarked individual treatments, with low NNT. The burden of treatment was frequently reduced, but it had to be increased even more frequently.

Morphology and epidemiological study of idiopathic scoliosis among primary school students in Chaozhou, China

BACKGROUND

Idiopathic scoliosis (IS) affects patients' quality of life, yet there have been few reports of its morphology and epidemiological study in the southeast region of China. The aim of this study is to access the curve characteristics, prevalence, and factors associated with IS in Chaozhou city.

METHODS

A cross-sectional study was performed in 2018, in which scoliosis screening was conducted among 5497 primary school students in Chaozhou city. Then, a case-control study based on the screening involving 2547 children was followed for the exploration of the associated factors. The questionnaires covering demographic characteristics, postural habits, cognition and self-sensation of scoliosis, and physical conditions were addressed for the investigation. ORs with 95%CIs were calculated based on logistic regression analysis to evaluate the factors associated with scoliosis.

RESULTS

The prevalence of IS among primary school students was 6.15% in Chaozhou city, with 4.04% for males and 8.71% for females. The average Cobb angle was 15° (range 8 to 37°). Multiple logistic regression analysis suggested that female (OR=2.45), BMI (OR=0.67), having myopia (OR=1.49), self-sensation of scoliosis with symptoms (OR=5.52), insufficient sleep time (OR=2.65, 3.33), and less exercise time (OR=7.09, 7.29) were significantly associated with IS.

CONCLUSIONS

The prevalence of IS among primary school students in Chaozhou was at an average level, and it was significantly higher in females than in males. Lower body mass, having myopia, insufficient sleep time, and lower physical activity were associated with IS.

Analysis of the scoliosis onset mechanisms for children and optimal rehabilitation interventions through aquatic activities

It is known, certainly, that it is much easier to form a correct attitude than to correct the vicious one, a reason that must determine the approach of prophylactic means of physical therapy and therapeutic swimming. The identification, at an early stage, of the etiological factors responsible for the installation of postural deficiencies, is a determining factor in the management of programs for their maintenance or recovery in children of prepubertal age. The study took place at the Constantinescu Mihai Physiotherapy Office of Suceava and at the Cornișa Botoșani Swimming Complex. It is known that the correct position is formed from childhood, and movement and exercise are the main factors of its construction. In this sense, the paper proposes kinetic recovery and therapeutic swimming programs in order to strengthen the postural status in children during growth and development. In this regard, we have set the following objectives: identification of children with vicious postural attitudes because of the overloads in the prepubertal period and analysis of the scoliosis mechanisms in children of prepubertal age on a vulnerable somato-functional status. Keywords: therapeutic swimming, evaluation, scoliosis, children, analysis,

An 18-month follow-up study on the effect of a neuromuscular stabilization technique on Cobb's angle in adolescent idiopathic scoliosis: A single-blind, age-matched controlled trial

BACKGROUND

The benefits of spinal realignment and stabilization in scoliosis need to be examined.

OBJECTIVE

We aimed to investigate the long-term effect of a neuromuscular stabilization technique (NST) on Cobb's angle in patients with adolescent idiopathic scoliosis.

METHODS

Twenty females recruited from two hospitals participated in this study. On the basis of convenience of location, participants were allocated to either the experimental group (EG) that underwent the NST, or the control group (CG) that received education for a home exercise program. The NST for the EG was performed for an average of 30 min per session, three times a week for six months, and consisted of spinal realignment and stabilization. Then, 12- and 18-month measurements for long-term follow-ups were conducted for the EG. The outcome measure was Cobb's angle.

RESULTS

Between-group comparison revealed a statistically significant difference at post-test (t=-3.26, p< 0.01) but not pre-test (t=-1.36, p= 0.19). Participants of the EG (-6.20 ± 2.49∘) showed greater differences between pre- and post-test scores compared to participants of the CG (-1.40 ± 0.52∘) (p< 0.05). Within-group comparisons showed a significant difference in both groups (p< 0.05). In the EG, Cobb's angle significantly changed across the follow-up sessions (p< 0.05), indicating more improvements by the 12-month (8.50 ± 4.03∘) and 18-month (6.60 ± 3.89∘) follow-ups.

CONCLUSION

This study shows that the NST may be a beneficial option to correct spinal alignments in patients with adolescent idiopathic scoliosis.

Completion of a formal physiotherapeutic scoliosis-specific exercise training program for adolescent idiopathic scoliosis increases patient compliance to home exercise programs

INTRODUCTION

Physiotherapeutic Scoliosis-Specific Exercise (PSSE) is a conservative approach for management of adolescent idiopathic scoliosis (AIS). Although there is Level I evidence for the efficacy of PSSE, compliance in the teenage population remains in question. The purpose of this study is to investigate the association between completion of formal PSSE training and compliance to prescribed home exercise programs (HEP).

METHODS

Patients with AIS evaluated at our institution between 2013 and 2015 with a minimum of one PSSE session were enrolled. A chart review and questionnaire completed by caregivers was utilized to assess HEP compliance following the final PSSE session at 1 week, 3 months, 1 year, and 2 years. Patients were divided into two groups, those completing formal training (10 or more PSSE sessions), and those who did not complete formal training (fewer than 10 sessions).

RESULTS

81 patients were identified (mean age of 13.1 years; major curve of 31.3°). Patients who completed training demonstrated 50% compliance at 1 week (vs. 25.6% for non-completers, Odds Ratio (OR): 2.9, p = 0.027), 41.2% at 3 months (vs. 18.9% for non-completers, OR: 3.0, p = 0.044), 23.5% at 1 year (vs. 13.5% for non-completers, OR: 2.0, p = 0.281), and 25.7% at 2 years (vs. 13.5% for non-completers, OR: 2.2, p = 0.197). The mean HEP duration (minutes) in patients who completed training was higher at 1 week (80.8 vs. 48, p = 0.010), 3 months (64.6 vs. 23.7, p ≤ 0.001), 1 year (35.3 vs. 22.7, p = 0.270), and 2 years (34.3 vs. 18.9, p = 0.140).

CONCLUSION

Patients who completed PSSE training maintained higher HEP compliance.

Clinical evaluation of the effectiveness of a new orthotic device for the non-operative treatment of scoliosis

BACKGROUND:

Bracing is one of the oldest non-operative treatments for patients with scoliosis. However, a wide variety of braces is used, and some show no effect, while others show conflicting results.

OBJECTIVE:

We aimed to evaluate the effectiveness of a new orthotic device for the treatment of adult scoliosis.

METHODS:

Twenty adult patients who were diagnosed with scoliosis and qualified for the study were selected and all participants were treated for 12 hours/day for 12 weeks using a new orthotic device. Various efficacy assessments (Cobb’s angle, spine length, pelvic angle, shoulder angle, thoracic angle, lumbar angle, pelvic sacral angle) were performed before and after the 12-week treatment. The values at each time point were compared.

RESULTS:

There were significant treatment effects in a time-dependent manner on every efficacy assessment (p< 0.05) after 12 weeks of bracing.

CONCLUSION:

In this clinical study, it was demonstrated that a new brace that is more comfortable for the wearer reduced scoliosis and may be a useful option for non-operative treatment of scoliosis.

The effects of exercise therapy on adolescent idiopathic scoliosis: An overview of systematic reviews and meta-analyses

BACKGROUND

Exercise therapy was suggested as an appealing treatment option for Adolescent Idiopathic Scoliosis (AIS) patients with less side effects, lower economic costs, and more psychological benefits. Nevertheless, no unanimous findings about the efficacy of exercise therapy have been obtained from previous systematic reviews and/or meta-analyses.

OBJECTIVE

To provide an overview of previous systematic reviews and/or meta-analyses on the effectiveness of exercise therapy on AIS treatment.

METHODS

Systematic searches in Medline, Eric, CINAHL, Embase, SPORTDiscus, PsycINFO, and the Cochrane Library for systematic reviews and/or meta-analyses of randomized controlled trials (RCTs), non-randomized comparison studies (NRS) or observational studies using exercise as an intervention, and with outcome measures including Cobb angle, angle of trunk rotation (ATR), and quality of life. The methodological quality of the review articles was evaluated by A Measurement Tool to Assess Systematic Reviews (AMSTAR) checklist.

RESULTS

Ten systematic reviews and meta-analyses were included. The quality of most of the review articles is moderate with a mean score of 6/11 on the AMSTAR scale. Overall, there is increasing evidence showing the efficacy of exercise therapy on reducing the Cobb angle and angle of trunk rotation, and improving perceived quality of life.

CONCLUSION

Exercise therapy was found to have potential benefits to treat physiological and psychological aspects of AIS patients. However, the findings were not conclusive given that some reviews relied on data from the trials with potential risk of bias and significant heterogeneity. More high-quality research is still needed to verify these findings.

Does the Aquatic Breathing Program Improve Lung Function in Adolescents with Scoliosis?

Aim: To determine pulmonary parameters in adolescents with scoliosis after three weeks of intensive physiotherapeutic scoliosis-specific exercises based on the Aquatic Breathing Program (ABP) compared to corrective swimming (CS).Methods: A pretest-posttest control group design was used. The ABP group comprised 13 adolescents (age 14.2 ± 1.4) and the CS group 10 adolescents (age 14.1 ± 1.5) with mild to moderate scoliosis. Both groups participated in a threeweek intervention consisted of three types of exercises: corrective, general and aquatic. ABP group participated in the Aquatic Breathing Program and CS group took part in corrective swimming. Spirometric measurements were taken before and after the intervention.Results: ABP group demonstrated a greater increase (p = .05) in the predicted percentage values of forced expiratory volume in 1 s (FEV₁) and maximal expiratory flow at 25% of forced vital capacity (MEF₂₅), both in absolute terms and in percentage values (MEF₂₅%pred) compared to the CS group. CS group exhibited lower values of all measured parameters in the second examination, and some of those differences were found to be statistically significant.Conclusions: The Aquatic Breathing Program can be used in adolescents with mild to moderate scoliosis to improve lung function.

Mucopolysaccharidoses I and II: Brief Review of Therapeutic Options and Supportive/Palliative Therapies

Purpose. Mucopolysaccharidoses (MPS) are group of inherited lysosomal storage diseases caused by mutations of enzymes involved in catalyzing different glycosaminoglycans (GAGs). MPS I and MPS II exhibit both somatic and neurological symptoms with a relatively high disease incidence. Hematopoietic stem cell therapy (HSCT) and intravenous enzyme replacement therapy (ERT) have had a significant impact on the treatment and comprehension of disease. This review is aimed at providing a comprehensive evaluation of the pros and cons of HSCT and ERT, as well as an up-to-date knowledge of new drugs under development. In addition, multiple disease management strategies for the uncontrollable manifestations of MPS I and MPS II to improve patients' quality of life are presented. Findings. Natural history of MPS I and MPS II shows that somatic and neurological symptoms occur earlier in severe forms of MPS I than in MPS II. ERT increases life expectancy and alleviates some of the somatic symptoms, but musculoskeletal, ophthalmological, and central nervous system (CNS) manifestations are not controlled. Additionally, life-long treatment burdens and immunogenicity restriction are unintended consequences of ERT application. HSCT, another treatment method, is effective in controlling the CNS symptoms and hence has been adopted as the standard treatment for severe types of MPS I. However, it is ineffective in MPS II, which can be explained by the relatively late diagnosis. In addition, several factors such as transplant age limits or graft-versus-host disease in HSCT have limited its application for patients. Novel therapies, including BBB-penetrable-ERT, gene therapy, and substrate reduction therapy, are under development to control currently unmanageable manifestations. BBB-penetrable-ERT is being studied comprehensively in the hopes of being used in the near future as a method to effectively control CNS symptoms. Gene therapy has the potential to “cure” the disease with a one-time treatment rather than just alleviate symptoms, which makes it an attractive treatment strategy. Several clinical studies on gene therapy reveal that delivering genes directly into the brain achieves better results than intravenous administration in patients with neurological symptoms. Considering new drugs are still in clinical stage, disease management with close monitoring and supportive/palliative therapy is of great importance for the time being. Proper rehabilitation therapy, including physical and occupational therapy, surgical intervention, or medications, can benefit patients with uncontrolled musculoskeletal, respiratory, ophthalmological, and neurological manifestations.

Standing in Schroth trained position significantly changes Cobb angle and leg length discrepancy: a pilot study

STUDY DESIGN

Retrospective.

OBJECTIVE

The aim of this study is to evaluate if standing in a Schroth trained position influences the radiographic assessment of Cobb angle and other radiographic parameters compared to a normal standing position. Schroth method has been associated with improved Cobb angle. This study aims to evaluate if standing in the Schroth trained position influences radiographic assessment of Cobb angle compared to a normal standing position.

METHODS

This is a retrospective review of patients with adolescent idiopathic scoliosis (AIS) who were participating in Schroth therapy at the time of radiographs. Ten pairs of radiographs were included in this study. Each pair consisted of two micro-dose biplanar PA thoracolumbar spine radiographs obtained on the same day, one with the patient standing in the Schroth trained position and one in their normal standing position. Each pair of radiographs was independently evaluated by three attending pediatric spine surgeons for Cobb angle, coronal balance, shoulder balance, and leg length discrepancy, for a total of 30 paired readings (3 readings for each of the 10 pairs of radiographs).

RESULTS

Major Cobb angle was a mean of 6° less (p = 0.02) and the compensatory curve was 5° less (p = 0.03) in the Schroth trained position compared to their normal standing position. Neither coronal balance (p = 0.40) nor shoulder balance (p = 0.16) was significantly different. Mean leg length discrepancy was 6.8 mm greater in the Schroth trained versus normal position (p < 0.001).

CONCLUSION

Standing in a Schroth trained position for a PA spine radiograph was associated with a mean change in major Cobb angle of 6° compared to a normal standing position. If bracing was recommended for curves > 25° and surgery for curves > 45°, different treatment recommendations would have been made in 33% (10/30) of attendings' readings for the Schroth versus normally paired radiographs taken on the same day on the same patient. Studies evaluating the effect of Schroth therapy on Cobb angle must report if patients are standing in a normal or Schroth trained position during radiographs for conclusions to be valid, or differences may be due to a temporary, voluntary change in posture.

LEVEL OF EVIDENCE

III.

Accelerometer based assessment of daily physical activity and sedentary time in adolescents with idiopathic scoliosis

BACKGROUND

Studies have shown a positive correlation between higher physical activity (PA) and health benefits. However, device-based assessment of PA and sedentary time (ST) in people with adolescent idiopathic scoliosis (AIS) has not been deeply investigated.

OBJECTIVE

Analysis and comparison of weekend and weekdays PA and ST using multiple accelerometers in people with AIS with different curvature severity compared to healthy controls.

METHODS

24 participants with AIS divided into 2 groups of 12 with Cobb angles < 40° and > 40°, along with 12 age and BMI matched healthy controls. Daily PA and ST during four consecutive days were measured using four tri-axial accelerometers. Clinical functional assessment was performed using the scoliosis research society (SRS-22) questionnaire.

RESULTS

The combined weekend and weekdays average daily step count was found to be 22% and 29% lower in the AIS groups with Cobb angle < 40° and > 40°, respectively, compared to the controls. The average ST was also reported to be 5% and 7% higher in the AIS groups with Cobb angle < 40° and > 40°, respectively, compared to the controls. The reported differences were significant in the AIS group with higher Cobb angle (p≤0.05). No significant differences in PA or ST were reported between the AIS groups based on curvature severity.

CONCLUSIONS

Decreased PA and increased ST observed in patients with AIS may have long term health implications and may play a role in the disease process. The device-based assessment of PA to understand potential benefits in clinical practice is recommended.

Outcome of 24 Weeks of Combined Schroth and Pilates Exercises on Cobb Angle, Angle of Trunk Rotation, Chest Expansion, Flexibility and Quality of Life in Adolescents with Idiopathic Scoliosis

Background

This study aimed to quantify the outcomes of combining Schroth and Pilates exercises on the Cobb angle, angle of trunk rotation (ATR), chest expansion, flexibility (trunk flexion), and quality of life (QoL) in adolescents with mild and moderate idiopathic scoliosis.

Material/Methods

Sixty-nine adolescents with idiopathic scoliosis aged 10–17 years, presenting with a Cobb angle of 10–45º were enrolled in this study. The treatment protocol, including selected exercises from Schroth and Pilates methods, was performed over 24 weeks and consisted of 2 periods of 2-week treatment regimens performed daily for 60 minutes. Each of treatment periods was then followed by the same home program treatment for 10 weeks. Cobb angle (x-rays), ATR (Scoliometer), chest expansion (cm), trunk flexion (cm, distance between C7 to S2 with measuring tape), and QoL (SRS-22r Scoliosis Research Society Questionnaire) were assessed pre-treatment, at 12 week, and at 24 weeks.

Results

Significant improvements (P<0.05) were found in both groups of patients wearing and not wearing a brace for Cobb angle (from 21.97±4.99° to 18.11±6.39°; from 14.19±3.11° to 11.66±2.73°), angle of trunk rotation (from 7.19±1.36° to 5.36±1.66°; from 4.72±1.04° to 3.58±0.94°), chest expansion (from 2.56±0.84 cm to 3.46±0.72 cm; from 2.57±0.87 cm to 3.52±0.72 cm), trunk flexion (from 9.55±1.95 cm to 14.33±2.40 cm; from 9.82±2.61 cm to 13.98±2.18 cm) and QoL (from 3.50±0.27 to 3.82±0.2; from 3.42±0.24 to 3.78±0.23) respectively.

Conclusions

This study showed that combined exercises provided benefit on the Cobb angle, ATR, chest expansion, trunk flexion and QoL in adolescents with mild and moderate idiopathic scoliosis.

The Effects of Active Self-correction on Postural Control in Girls with Adolescent Idiopathic Scoliosis: The Role of an Additional Mental Task

Due to balance deficits that accompany adolescent idiopathic scoliosis (AIS), the potential interaction between activities of daily living and active self-correction movements (ASC) on postural control deserves particular attention. Our purpose was to assess the effects of ASC movements with or without a secondary mental task on postural control in twenty-five girls with AIS. It is a quasi-experimental within-subject design with repeated measures ANOVA. They were measured in four 20-s quiet standing trials on a force plate: no task, ASC, Stroop test, and both. Based on the center-of-pressure (COP) recordings, the COP parameters were computed. The ASC alone had no effect on any of the postural sway measures. Stroop test alone decreased COP speed and increased COP entropy. Performing the ASC movements and Stroop test together increased the COP speed and decreased COP entropy as compared to the baseline data. In conclusion, our results indicate that AIS did not interfere with postural control. The effects of the Stroop test accounted for good capacity of subjects with AIS to take advantage of distracting attentional resources from the posture. However, performing both tasks together exhibited some deficits in postural control, which may suggest the need for therapeutic consultation while engaging in more demanding activities.

Surgeon Attitudes Toward Physiotherapeutic Scoliosis-Specific Exercises in Adult Patients With Spinal Deformities

Background

Physiotherapeutic scoliosis-specific exercise (PSSE) has proven to be an important treatment for patients with adolescent idiopathic scoliosis. However, there is a lack of understanding of the role of PSSE in older adults with spinal deformity.

Methods

An electronic, 14-question survey with questions regarding the use of physical therapy (PT) and PSSE for adult spinal deformity was administered to all Scoliosis Research Society members. Physician location, age, specialty, years in experience, and management preferences were quantified using descriptive analyses.

Results

Of the 98 surgeons who participated in this study, the majority of respondents were from North America (71.1%), and the mean age was 51.87 ± 10.93 years; approximately 98% of respondents were orthopedic surgeons, and 48.0% had been in practice for more than 21 years. Sixty-four percent reported they prescribed PT in their practice, with 52% of respondents often using PT as nonoperative treatment; 21.4%, preoperative; and 40.8% postoperative. The primary reason for PT referral was persistent pain (40.3%), followed by impairments to the patient's balance or gait (34.3%) and difficulty with daily living activities (25.4%). The primary indications for not referring postoperative patients to PT were lack of perceived value from PT (50%), lack of evidence supporting the benefits from PT (31.3%), and a lack of physical therapists appropriately trained for scoliosis (18.8%). Of the respondents, 74% were familiar with PSSE and 66% were comfortable prescribing PSSE postoperatively. In addition, 28% of respondents agreed that >12 weeks postoperation was the ideal time for PSSE referral, followed by 6 to 8 weeks postoperation (26.2%) and immediately postoperation (18%).

Conclusions

The results show that the majority of respondents prescribed PSSE solely for nonoperative treatment. Respondents who did not prescribe PSSE reported skepticism due to a lack of perceived value. This suggests the need for further research into the benefits of PSSE.

Level of Evidence

5.

Clinical Relevance

Physiotherapeutic Scoliosis Specific Exercises (PSSE) is an important non-operative treatment for patients with Adolescent Idiopathic Scoliosis (AIS) but is understudied in Adult Spinal Deformity (ASD) patients, suggesting further clinical research. This study demonstrates that only two-thirds of the respondents familiar with PSSE were comfortable prescribing PSSE postoperatively suggesting the need for further research into the effectiveness and benefits of PSSE in ASD patients.

Effect of exercise on static balance and Cobb angle during the weaning phase of brace management in idiopathic scoliosis and hyperkyphosis: A preliminary study

BACKGROUND

Exercises are usually prescribed in association with orthotic intervention for management of idiopathic scoliosis, however the role of these exercises on the efficacy of brace and/or balance is not clear yet.

OBJECTIVES

To investigate the role of exercise (the Blount and Moe protocol) on static balance and Cobb angle changes in adolescents with spinal deformities during weaning from brace.

METHODS

Seventeen brace users were allocated into 3 groups (good, moderate, and weak), according to their exercise quality and quantity static balance was evaluated on 4 conditions (standing on a platform/foam; with/without brace) using a force platform. Center of pressure displacement parameters were compared among the 3 groups. The mean Cobb angles of scoliosis and kyphosis at the beginning of brace use and at the start of the weaning phase were compared in general and among the 3 analogous groups.

RESULTS

No significant difference was found in the static balance parameters and also in Cobb angles among the 3 groups. However, scoliosis and kyphosis Cobb angles were improved significantly as a result of using the brace (p< 0.01).

CONCLUSIONS

The exercise quantity and quality in association with bracing, up to the weaning phase, has no effect on static balance and changes in scoliosis and kyphosis, but the curvature of scoliosis and kyphosis is reduced after wearing a brace.

Review of scoliosis-specific exercise methods used to correct adolescent idiopathic scoliosis

BACKGROUND

Adolescent idiopathic scoliosis (AIS) refers to a spinal curvature of an unknown origin diagnosed in otherwise healthy children. A conservative treatment approach includes physiotherapy scoliosis-specific exercises (PSSE) with or without corrective bracing in preventing further spinal column deviation. However, several PSSE types have been developed to facilitate a positive patient outcome and/or preclude surgical remediation. Based on other reviews, there has been insufficient evidence published on the efficacy of PSSEs. In addition, the superiority of PSSE over no intervention or compared to other exercise modes has yet to be determined.

METHODS

A comprehensive search of AIS literature, inception through February 2018, was conducted to reveal relevant PSSE articles. Only studies using commonly reported PSSEs were included. Examined databases included PubMed, Scopus, CINAHL Complete, and Physiotherapy Evidence Database (PEDro). Google Scholar search engine was also examined. Article types included randomized or clinical control trials. All articles were published in English or were of English translation. Search parameters were collectively defined by the reviewers and subsequently used to determine included studies. Individual PSSE study methodology quality was determined by the PEDro scale. Effect sizes (Hedge's g) and their 95% confidence intervals were calculated for Cobb angle between group changes.

RESULTS

Of the initial 24 articles recovered only eight (33%) met the established search criteria. Patient ages from these sources ranged from 11.4-16.2 including both males and females. Examined papers included two Schroth method and six specifying the Scientific Exercise Approach to Scoliosis (SEAS) method. All articles demonstrated positive between group effect sizes for PSSEs. There were no studies that compared one PSSE to another. Determined PEDro scores indicated an overall moderate quality of these studies.

CONCLUSIONS

There is insufficient evidence to suggest that both Schroth and SEAS methods can effectively improve Cobb angles in patients with AIS compared to no intervention. There is limited evidence that the SEAS method is more effective at reducing Cobb angles compared to traditional exercises in treating AIS. Overall, this review revealed a noticeable lack of contemporary studies that could be used in answering our questions. Evidence-based medicine (EBM) supplies clinicians with verifiable results from well-designed and managed research studies. Consequently, more and varied studies of higher quality are needed before any definitive determination can be made as to the effectiveness of any PSSE let alone the one offering better patient outcomes.

Patients with adolescent idiopathic scoliosis perceive positive improvements regardless of change in the Cobb angle - Results from a randomized controlled trial comparing a 6-month Schroth intervention added to standard care and standard care alone. SOSORT 2018 Award winner

Background

The Cobb angle is proposed as the “disease process” outcome for scoliosis research because therapies aim to correct or stop curve progression. While the Scoliosis Research Society recommends the Cobb angle as the primary outcome, the Society on Scoliosis Orthopaedic and Rehabilitation Treatment prioritises, as a general goal, patient related outcomes over Cobb angle progression.

Objective

To determine the threshold of change in the Cobb angle in adolescents with idiopathic scoliosis (AIS) who perceive improvement in a 6-months randomized controlled trial comparing a Schroth exercise intervention added to the standard of care to the standard of care alone.

Methods

This is a secondary analysis of data from a randomized controlled trial of 50 patients with AIS, with curves ranging from 10° to 45°, with or without a brace. Participants with diagnoses other than AIS, surgical candidates or patients who had scoliosis surgery were excluded. The 6-month interventions consisted of Schroth exercises added to standard-of-care (observation or bracing) with daily home exercises and weekly therapy sessions (Schroth) or standard-of-care alone (Control).

The anchor method for estimating the minimal important difference (MID) in the largest Cobb angles (LC) was used. Patient-reported change in back status over the 6-month treatment period was measured using the Global Rating of Change (GRC) scale as anchor varying from − 7 (“great deal worse”) to + 7 (“great deal better”). Participants were divided into two groups based on GRC scores: Improved (GRC ≥2) or Stable/Not Improved (GRC ≤1). MID was defined as the change in the LC that most accurately predicted the GRC classification as per the receiver operating characteristic curve (ROC).

Results

The average age was 13.4 ± 1.6 years and the average LC was 28.5 ± 8.8 °s. The average GRC in the control group was − 0.1 ± 1.6, compared to + 4.4 ± 2.2 in the Schroth group. The correlation between LC and GRC was adequate (r = − 0.34, p < 0.05). The MID for the LC was 1.0 °. The area under the ROC was 0.69 (0.52–0.86), suggesting a 70% chance to properly classify a patient as perceiving No Improvement/Stable or Improvement based on the change in the LC.

Conclusion

Patients undergoing Schroth treatment perceived improved status of their backs even if the Cobb angle did not improve beyond the conventionally accepted threshold of 5°. Standard of care aims to slow/stop progression while Schroth exercises aim to improve postural balance, signs and symptoms of scoliosis. Given the very small MID, perceived improvement in back status is likely due to something other than the Cobb angle. This study warrants investigating alternatives to the Cobb angle that might be more relevant to patients.

Trial registration

ClinicalTrials.gov, NCT01610908. Retrospectively registered on April 2, 2012 (first posted on June 4, 2012 - https://clinicaltrials.gov/ct2/keydates/NCT01610908)

Physical Therapy Scoliosis-Specific Exercises May Reduce Curve Progression in Mild Adolescent Idiopathic Scoliosis Curves

PURPOSE

To evaluate the curve magnitude in participants with mild adolescent idiopathic scoliosis (AIS) at high risk of progression who received outpatient physical therapy scoliosis-specific exercises (PSSEs).

METHODS

Participants with AIS curves 12° to 20° and Risser grade 0 chose either the PSSE or the control group. The PSSE group was instructed in the Barcelona Scoliosis Physical Therapy School. The control group was observed. Cobb angles were measured by one observer masked to group type at baseline, 6-month follow-up, and 1-year follow-up.

RESULTS

Forty-nine participants were enrolled (26 exercise vs 23 controls). Thirty-three participants (19 exercise vs 14 controls) were seen at 1-year follow-up. At 1-year follow-up, the exercise group had smaller curves than controls (16.3° vs 21.6°, P = .04) and less curve progression (0° vs 5.6°, P = .02). Bracing was performed similarly between groups at 1-year follow-up (37% vs 43%).

CONCLUSIONS

In this small prospective series, PSSE resulted in significantly less curve progression compared with controls.

The effectiveness of Schroth exercises in adolescents with idiopathic scoliosis: A systematic review and meta-analysis

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is one of the most common structural spinal deformities in adolescents, becoming apparent around the time of puberty. Schroth scoliosis-specific exercises have demonstrated promising results in reducing the progression of AIS.

OBJECTIVES

The aim of this study was to identify, critically appraise and establish the best available evidence for the effectiveness of Schroth exercises in comparison to non-surgical management to reduce the progression of AIS.

METHODOLOGY

Seven databases were searched in April 2018. Main key search terms included AIS, Schroth exercises, physiotherapy, exercise, electrical stimulation, yoga, Pilates, tai chi and bracing. The quality of the trials was critically appraised according to the PEDro scale. Revman© Review Manager Software was used to pool the quality of life (QOL) results.

RESULTS

Four randomised control trials with an average PEDro score of 6.75/10 were included in this study. Results indicated that Schroth exercises had a significant effect in decreasing the Cobb angle (p < 0.05) in comparison to non-surgical management. The pooled effect on QOL showed a significant result in favour of Schroth exercises at 12 weeks (p < 0.002) and at 24 weeks (p < 0.0004).

CONCLUSION

Level II evidence suggests that Schroth exercises have a significant effect on reducing the Cobb angle and improving QOL in adolescents with idiopathic scoliosis.

CLINICAL IMPLICATIONS

This review's findings should be considered with caution for physiotherapy practice because of the limited number of identified articles and their methodologic limitations. Based on the current available and limited evidence, clinicians could combine supervised Schroth exercises with conventional physiotherapy care (observation, exercise, bracing and manual therapy) when treating adolescents with idiopathic scoliosis.

Core stabilization exercises versus scoliosis-specific exercises in moderate idiopathic scoliosis treatment

BACKGROUND

There are several kinds of scoliosis-specific and general physiotherapeutic exercise methods used in scoliosis rehabilitation. But there is need for comparable studies on the effectiveness of different exercise approaches for the treatment of adolescent idiopathic scoliosis.

OBJECTIVES

Comparison of the effects of combined core stabilization exercise and bracing treatment with Scientific Exercises Approach to Scoliosis and bracing treatment in patients with moderate adolescent idiopathic scoliosis.

METHODS

Thirty females with adolescent idiopathic scoliosis, who have moderate curves (20°-45°), were randomly divided into two groups. In addition to brace wearing for 4 months, one group received core stabilization exercise therapy, while the other received scientific exercises approach to scoliosis exercise therapy. The outcome measures were based on Cobb angle, angle of trunk rotation, body symmetry, cosmetic trunk deformity, and quality of life.

RESULTS

Thoracic and lumbar Cobb angles and trunk rotation angles, body symmetry, and cosmetic trunk deformity improved for both groups. Quality of life did not change in either group. The pain domain of the Scoliosis Research Society-22 questionnaire improved in the core stabilization group only.

CONCLUSION

Both treatment conditions including core stabilization with bracing and scientific exercises approach to scoliosis with bracing had similar effects in the short-term treatment of moderate adolescent idiopathic scoliosis.

CLINICAL RELEVANCE

This study showed that when scientific exercises approach to scoliosis (SEAS) and core stabilization (CS) exercises were administered with equal intensity, the effects of the two treatment protocols including CS and bracing and SEAS and bracing were similar in the treatment of patients with moderate adolescent idiopathic scoliosis (AIS).

Effects of asymmetric loading on lateral spinal curvature in young adults with scoliosis: A preliminary study

BACKGROUND

Usual guidelines recommend symmetric load carriage over asymmetric load carriage. Whether this recommendation is valid for subjects with asymmetric body alignment, such as those with scoliosis, remains unclear. Scoliosis is both a subject-dependent and time-variant condition. Interventions are generally employed to prevent the abnormal spinal curvature from progressing.

OBJECTIVES

To investigate the effects of an asymmetric load carriage on lateral spinal deformity in participant with scoliosis.

STUDY DESIGN

Repeated measure and single-case experimental designs Methods: Photogrammetry was employed to measure the scoliotic curvature changes in thoracic and lumbar regions without a load (0%) and with a single-strap cross-chest bag loaded at 2.5%, 5%, 7.5%, 10% and 12.5% of body weight. Statistical tests and programming models were adopted to determine the loading conditions (placement and weight of the bag) with optimal and minimal corrections of the affected and unaffected scoliotic spinal regions, respectively.

RESULTS

Significant short-term postural correction of scoliosis was achieved through applying an asymmetric load on the ipsilateral shoulder relative to the apex location of the major scoliotic curve.

CONCLUSION

A subject-specific optimal loading configuration was determined using a programming model. The results suggest that the application of a properly controlled asymmetric load carriage might be possible for reducing scoliotic spinal curvature. Further study of the long-term effects of subject-specific optimal asymmetric load carriage on scoliotic spinal curvatures is warranted. Clinical relevance Short-term reduction of scoliotic spinal curvatures under asymmetric load carriage was demonstrated. Thoracic curvatures could be reduced when asymmetric loading was applied on the ipsilateral shoulder relative to the scoliotic apex. Multiobjective programming was applied to determine the optimal weight of asymmetric load for participant with scoliosis.

Global postural re-education in pediatric idiopathic scoliosis: a biomechanical modeling and analysis of curve reduction during active and assisted self-correction

Background

Global postural re-education (GPR) is a physiotherapy treatment approach for pediatric idiopathic scoliosis (IS), where the physiotherapist qualitatively assesses scoliotic curvature reduction potential (with a manual correction) and patient’s ability to self-correct (self-correction). To the author’s knowledge, there are no studies regarding GPR applied to IS, hence there is a need to better understand the biomechanics of GPR curve reduction postures. The objective was to biomechanically and quantitatively evaluate those two re-education corrections using a computer model combined with experimental testing.

Methods

Finite elements models of 16 patients with IS (10.5–15.4 years old, average Cobb angle of 33°) where built from surface scans and 3D radiographic reconstructions taken in normal standing and self-corrected postures. The forces applied with the therapist’s hands over the trunk during manual correction were recorded and used in the FEM to simulate this posture. Self-correction was simulated by moving the thoracic and lumbar apical vertebrae from their presenting position to their self-corrected position as seen on radiographs. A stiffness index was defined for each posture as the global force required to stay in the posture divided by the thoracic curve reduction (force/Cobb angle reduction).

Results

The average force applied by the therapist during manual correction was 31 N and resulted in a simulated average reduction of 26% (p < 0.05), while kyphosis slightly increased and lordosis remained unchanged. The actual self-correction reduced the thoracic curve by an average of 33% (p < 0.05), while the lumbar curve remained unchanged. The thoracic kyphosis and lumbar lordosis were reduced on average by 6° and 5° (p < 0.05). Self-correction simulations correlated with actual self-correction (r = 0.9).

Conclusions

This study allowed quantification of thoracic curve reducibility obtained by external forces applications as well as patient’s capacity to self-correct their posture, two corrections commonly used in the GPR approach.

2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth

BACKGROUND

The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) produced its first guidelines in 2005 and renewed them in 2011. Recently published high-quality clinical trials on the effect of conservative treatment approaches (braces and exercises) for idiopathic scoliosis prompted us to update the last guidelines' version. The objective was to align the guidelines with the new scientific evidence to assure faster knowledge transfer into clinical practice of conservative treatment for idiopathic scoliosis (CTIS).

METHODS

Physicians, researchers and allied health practitioners working in the area of CTIS were involved in the development of the 2016 guidelines. Multiple literature reviews reviewing the evidence on CTIS (assessment, bracing, physiotherapy, physiotherapeutic scoliosis-specific exercises (PSSE) and other CTIS) were conducted. Documents, recommendations and practical approach flow charts were developed using a Delphi procedure. The process was completed with the Consensus Session held during the first combined SOSORT/IRSSD Meeting held in Banff, Canada, in May 2016.

RESULTS

The contents of the new 2016 guidelines include the following: background on idiopathic scoliosis, description of CTIS approaches for various populations with flow-charts for clinical practice, as well as literature reviews and recommendations on assessment, bracing, PSSE and other CTIS. The present guidelines include a total of 68 recommendations divided into following topics: bracing (n = 25), PSSE to prevent scoliosis progression during growth (n = 12), PSSE during brace treatment and surgical therapy (n = 6), other conservative treatments (n = 2), respiratory function and exercises (n = 3), general sport activities (n = 6); and assessment (n = 14). According to the agreed strength and level of evidence rating scale, there were 2 recommendations on bracing and 1 recommendation on PSSE that reached level of recommendation "I" and level of evidence "II". Three recommendations reached strength of recommendation A based on the level of evidence I (2 for bracing and one for assessment); 39 recommendations reached strength of recommendation B (20 for bracing, 13 for PSSE, and 6 for assessment).The number of paper for each level of evidence for each treatment is shown in Table 8.

CONCLUSION

The 2016 SOSORT guidelines were developed based on the current evidence on CTIS. Over the last 5 years, high-quality evidence has started to emerge, particularly in the areas of efficacy of bracing (one large multicentre trial) and PSSE (three single-centre randomized controlled trials). Several grade A recommendations were presented. Despite the growing high-quality evidence, the heterogeneity of the study protocols limits generalizability of the recommendations. There is a need for standardization of research methods of conservative treatment effectiveness, as recognized by SOSORT and the Scoliosis Research Society (SRS) non-operative management Committee.

The effects of exercise on perception of verticality in adolescent idiopathic scoliosis

PURPOSE

Visual and proprioceptive cues are important for body orientation to maintain correct posture. This study investigated the effects of exercise training on subjective visual, postural, and haptic perception of verticality in patients with scoliosis.

SUBJECTS AND METHODS

Thirty-two female adolescents with moderate idiopathic scoliosis were randomly allocated to "Core Stabilization Exercise (CSE)," "Body Awareness," or "Traditional Exercise (TE)" groups. Each group completed a 1-hour supervised program, two days per week for 10 weeks while continuing to wear spinal braces. Perceptual visual, postural, and haptic estimates were assessed before and after treatment.

RESULTS

Subjective visual vertical perception only improved in the awareness group. Subjective visual horizontal perception, postural vertical perception, total postural perception scores, total haptic perception scores, and haptic perception 45° to the right were significantly improved in the stabilization and awareness groups. For the 60° right and 60° left postural perception parameters, as well as the 45° left haptic perception parameters, perception improved only in the stabilization group. No improvement was observed in the traditional group.

CONCLUSION

Improvements in visual, postural, and haptic verticality perception within the stabilization exercise training and Basic Body Awareness group treatment suggest the addition of these exercise methods for the treatment of idiopathic scoliosis to improve internal body orientation.

H-reflex changes in adolescents with idiopathic scoliosis: a randomized clinical trial

[Purpose] To detect H-reflex asymmetry and investigate the effect of direction sensitive exercise therapy protocol among patients with thoracolumbar and/or lumbar scoliosis. [Subjects and Methods] Fifty patients (10-17 years), Cobb's angle 10-20 degrees with thoracolumbar and lumbar scoliosis participated in the study. Soleus H-reflex was tested on both sides during prone lying position and standing position. Patients were randomly assigned into two groups. Group I received direction sensitive exercise therapy while the participants in group II received traditional exercise. Exercises were applied three times per week for twelve successive weeks. [Results] There were significant differences indicating asymmetry in the H-reflex amplitude on concave side. Cobb's angle significantly decreased and the H-reflex amplitude on concave side as well as H concave/convex ratios in both lying and standing significantly increased in both groups. Direction sensitive exercise therapy showed a more significant increase in the measured outcomes than traditional exercises therapy protocol. [Conclusion] H-reflex test was effective in discovering the asymmetry between concave and convex sides. Based on H-reflex test, direction-sensitive exercise therapy was more effective than traditional exercises in decreasing Cobb's angle and increasing H-reflex values as well as H/H percent in concave side in patients with adolescent idiopathic scoliosis.

A procedure to detect abnormal sensorimotor control in adolescents with idiopathic scoliosis

This work identifies, among adolescents with idiopathic scoliosis, those demonstrating impaired sensorimotor control through a classification procedure comparing the amplitude of their vestibular-evoked postural responses. The sensorimotor control of healthy adolescents (n=17) and adolescents with idiopathic scoliosis (n=52) with either mild (Cobb angle≥15° and ≤30°) or severe (Cobb angle >30°) spine deformation was assessed through galvanic vestibular stimulation. A classification procedure sorted out adolescents with idiopathic scoliosis whether the amplitude of their vestibular-evoked postural response was dissimilar or similar to controls. Compared to controls, galvanic vestibular stimulation evoked larger postural response in adolescents with idiopathic scoliosis. Nonetheless, the classification procedure revealed that only 42.5% of all patients showed impaired sensorimotor control. Consequently, identifying patients with sensorimotor control impairment would allow to apply personalized treatments, help clinicians to establish prognosis and hopefully improve the condition of patients with adolescent idiopathic scoliosis.

Physical Therapy for a Child With Infantile Idiopathic Scoliosis and Motor Delay

PURPOSE

The purpose of this case report is to describe physical therapy (PT) for a child with infantile idiopathic scoliosis and motor delay.

KEY POINTS

A 10-month-old boy with a 28° left thoracolumbar scoliosis was referred for PT and was seen weekly in his home over a 6-month period following a diagnosis of scoliosis and delayed gross motor milestones. Before the initiation of PT, the child was scheduled to undergo serial casting for correction of the spinal curve and was not yet rolling or transitioning in or out of sitting. By the end of the 6-month intervention period, the spinal curve had resolved to 12° without the need for serial casting and the child was walking independently.

CONCLUSION

PT appeared to have a positive effect on reduction of the spinal curve and achievement of gross motor milestones.