Letter to the editor concerning: "active self-correction and task-oriented exercises reduce spinal deformity and improve quality of life in subjects with mild adolescent idiopathic scoliosis. Results of a randomised controlled trial" by Monticone M, Ambrosini E, Cazzaniga D, Rocca B, Ferrante S (2014). Eur Spine J; DOI:10.1007/s00586-014-3241-y

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).

Schroth physiotherapeutic scoliosis-specific exercises for adolescent idiopathic scoliosis: how many patients require treatment to prevent one deterioration? - results from a randomized controlled trial - "SOSORT 2017 Award Winner"

BACKGROUND

Recent randomized controlled trials (RCTs) support using physiotherapeutic scoliosis-specific exercises (PSSE) for adolescents with idiopathic scoliosis (AIS). All RCTs reported statistically significant results favouring PSSE but none reported on clinical significance. The number needed to treat (NNT) helps determine if RCT results are clinically meaningful. The NNT is the number of patients that need to be treated to prevent one bad outcome in a given period. A low NNT suggests that a therapy has positive outcomes in most patients offered the therapy. The objective was to determine how many patients require Schroth PSSE added to standard care (observation or brace treatment) to prevent one progression (NNT) of the Largest Curve (LC) or Sum of Curves (SOC) beyond 5° and 10°, respectively over a 6-month interval.

METHODS

This was a secondary analysis of a RCT. Fifty consecutive participants from a scoliosis clinic were randomized to the Schroth PSSE + standard of care group (n = 25) or the standard of care group (n = 25).We included males and females with AIS, age 10-18 years, all curve types, with curves 10°- 45°, with or without brace, and all maturity levels. We excluded patients awaiting surgery, having had surgery, having completed brace treatment and with other scoliosis diagnoses. The local ethics review board approved the study (Pro00011552).The Schroth intervention consisted of weekly 1-h supervised Schroth PSSE sessions and a daily home program delivered over six months in addition to the standard of care. A prescription algorithm was used to determine which exercises patients were to perform. Controls received only standard of care.Cobb angles were measured using a semi-automatic system from posterior-anterior standing radiographs at baseline and 6 months.We calculated absolute risk reduction (ARR) and relative risk reduction (RRR). The NTT was calculated as: NNT = 1/ARR. Patients with missing values (PSSE group; n = 2 and controls; n = 4) were assumed to have had curve progression (worst case scenario). The RRR is calculated as RRR = ARR/CER.

RESULTS

For LC, NNT = 3.6 (95% CI 2.0-28.2), and for SOC, NNT = 3.1 (95% CI 1.9-14.2). The corresponding ARR was 28% for LC and 32% for the SOC. The RRR was 70% for LC and 73% for the SOC. Patients with complete follow-up attended 85% of prescribed visits and completed 82.5% of the home program. Assuming zero compliance after dropout, 76% of visits were attended and 73% of the prescribed home exercises were completed.

CONCLUSIONS

The short term of Schroth PSSE intervention added to standard care provided a large benefit as compared to standard care alone. Four (LC and SOC) patients require treatment for the additional benefit of a 6-month long Schroth intervention to be observed beyond the standard of care in at least one patient.

TRIAL REGISTRATION

NCT01610908 April 2, 2012.

Schroth Physiotherapeutic Scoliosis-Specific Exercises Added to the Standard of Care Lead to Better Cobb Angle Outcomes in Adolescents with Idiopathic Scoliosis - an Assessor and Statistician Blinded Randomized Controlled Trial

Background

The North American non-surgical standard of care for adolescent idiopathic scoliosis (AIS) includes observation and bracing, but not exercises. Schroth physiotherapeutic scoliosis-specific exercises (PSSE) showed promise in several studies of suboptimal methodology. The Scoliosis Research Society calls for rigorous studies supporting the role of exercises before including it as a treatment recommendation for scoliosis.

Objectives

To determine the effect of a six-month Schroth PSSE intervention added to standard of care (Experimental group) on the Cobb angle compared to standard of care alone (Control group) in patients with AIS.

Methods

Fifty patients with AIS aged 10–18 years, with curves of 10°-45° and Risser grade 0–5 were recruited from a single pediatric scoliosis clinic and randomized to the Experimental or Control group. Outcomes included the change in the Cobb angles of the Largest Curve and Sum of Curves from baseline to six months. The intervention consisted of a 30–45 minute daily home program and weekly supervised sessions. Intention-to-treat and per protocol linear mixed effects model analyses are reported.

Results

In the intention-to-treat analysis, after six months, the Schroth group had significantly smaller Largest Curve than controls (-3.5°, 95% CI -1.1° to -5.9°, p = 0.006). Likewise, the between-group difference in the square root of the Sum of Curves was -0.40°, (95% CI -0.03° to -0.8°, p = 0.046), suggesting that an average patient with 51.2° at baseline, will have a 49.3° Sum of Curves at six months in the Schroth group, and 55.1° in the control group with the difference between groups increasing with severity. Per protocol analyses produced similar, but larger differences: Largest Curve = -4.1° (95% CI -1.7° to -6.5°, p = 0.002) and Sum of Curves=−0.5° (95% CI -0.8 to 0.2, p = 0.006).

Conclusion

Schroth PSSE added to the standard of care were superior compared to standard of care alone for reducing the curve severity in patients with AIS.

Trial Registration

NCT01610908

Research quality in scoliosis conservative treatment: state of the art

The publication of research in the field of conservative treatment of scoliosis is increasing after a long period of progressive decline. In 2014, three high quality and scientifically sound papers gave new strength to the conservative scoliosis approach. The efficacy of treatment over observation was demonstrated by two RCTs for bracing, and one for scoliosis-specific exercises provided by a physical therapist. It is difficult to design strong studies in this field due to the long time needed for follow up and the challenge of recruiting patients and families willing to be involved in the decision process. Nevertheless, the main methodological errors are not related to the study design but rather on the way it is performed, which very frequently affects the reliability of results. The most common errors are: selection bias, with many studies including functional rather than a true structural scoliosis; inappropriate outcome measures, utilizing parameters not related to scoliosis progression or quality of life; inappropriate follow up, reporting only immediate results and not addressing end of growth results; an incorrect interpretation of findings, with an overestimation of results; and missing the evaluation of skeletal maturity, without which results cannot be considered stable. Being aware of these errors is extremely important both for authors and for readers in order to avoid questionable practices based on inconclusive studies that could harm patients.

Recommendations for research studies on treatment of idiopathic scoliosis: Consensus 2014 between SOSORT and SRS non-operative management committee

The two main societies clinically dealing with idiopathic scoliosis are the Scoliosis Research Society (SRS), founded in 1966, and the international Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT), started in 2004. Inside the SRS, the Non-Operative Management Committee (SRS-NOC) has the same clinical interest of SOSORT, that is the Orthopaedic and Rehabilitation (or Non-Operative, or conservative) Management of idiopathic scoliosis patients. The aim of this paper is to present the results of a Consensus among the best experts of non-operative treatment of Idiopathic Scoliosis, as represented by SOSORT and SRS, on the recommendation for research studies on treatment of Idiopathic Scoliosis. The goal of the consensus statement is to establish a framework for research with clearly delineated inclusion criteria, methodologies, and outcome measures so that future meta- analysis or comparative studies could occur. A Delphi method was used to generate a consensus to develop a set of recommendations for clinical studies on treatment of Idiopathic Scoliosis. It included the development of a reference scheme, which was judged during two Delphi Rounds; after this first phase, it was decided to develop the recommendations and 4 other Delphi Rounds followed. The process finished with a Consensus Meeting, that was held during the SOSORT Meeting in Wiesbaden, 8-10 May 2014, moderated by the Presidents of SOSORT (JP O'Brien) and SRS (SD Glassman) and by the Chairs of the involved Committees (SOSORT Consensus Committee: S Negrini; SRS Non-Operative Committee: MT Hresko). The Boards of the SRS and SOSORT formally accepted the final recommendations. The 18 Recommendations focused: Research needs (3), Clinically significant outcomes (4), Radiographic outcomes (3), Other key outcomes (Quality of Life, adherence to treatment) (2), Standardization of methods of non-operative research (6).

SEAS (Scientific Exercises Approach to Scoliosis): a modern and effective evidence based approach to physiotherapic specific scoliosis exercises

Background

SEAS is the acronym for “Scientific Exercise Approach to Scoliosis”, a name related to the continuous changes of the approach based on results published in the literature.

Rehabilitation program

SEAS is an individualized exercise program adapted to all situations of conservative treatment of scoliosis: stand-alone in low-medium degree curves during growth to reduce the risk of bracing; complimentary to bracing in medium-high degree curves during growth, with the aim to increase correction, prepare weaning, and avoid/reduce side-effects; for adults either progressing or fused, to help stabilising the curve and reduce disability.

SEAS is based on a specific active self-correction technique performed without external aid, and incorporated in functional exercises. Evaluation tests guide the choice of the exercises most appropriate to the individual patient.

Improvement of the stability of the spine in active self-correction is the primary objective of SEAS. SEAS exercises train neuromotor function so to stimulate by reflex a self-corrected posture during the activities of daily life.

SEAS can be performed as an outpatient (two/three times a week 45 for minutes) or as a home program to be performed 20 minutes daily. In the last case, expert physiotherapy sessions of 1.5 hours every three months are proposed.

Results

Different papers, including a randomized controlled trial (2014), published over the past several years, documented the efficacy of the SEAS approach applied in the various phases of scoliosis treatment in reducing Cobb angle progression and the need to wear a brace.

Conclusions

SEAS is an approach to scoliosis exercise treatment with a strong modern neurophysiological basis, to reduce requirements for patients and possibly the costs for families linked to the frequency and intensity of treatment and evaluations. Therefore, SEAS allows treating a large number of patients coming from far away. Even if SEAS appears simple by requiring less physiotherapist supervision and by using fewer home exercises prescribed at a lower dose than some of the other scoliosis-specific exercise approaches, real expertise in scoliosis, exercises, and patient and family management is required. The program has no copyrights, and teachers are being trained all over the world.