The natural history of adolescent idiopathic scoliosis

Assessment of age-dependent sexual dimorphism in paediatric vertebral size and density using a statistical shape and statistical appearance modelling approach

This work focuses on the growth patterns of the human fourth lumbar vertebra (L4) in a paediatric population, with specific attention to sexual dimorphism. The study aims to understand morphological and density changes in the vertebrae through age-dependent statistical shape and statistical appearance models, which can describe full three-dimensional anatomy. Results show that the main growth patterns are associated with isotropic volumetric vertebral growth, a decrease in the relative size of the vertebral foramen, and an increase in the length of the transverse processes. Moreover, significant sexual dimorphism was demonstrated during puberty. We observe significant age and sex interaction in the anterior vertebral body height (P = 0.005), where females exhibited an earlier increase in rates of vertebral height evolution. Moreover, we also observe an increase in cross-sectional area (CSA) with age (P = 0.020), where the CSA is smaller in females than in males (significant sex effect P = 0.042). Finally, although no significant increase in trabecular bone density with age is observed (P = 0.363), a trend in the statistical appearance model suggests an increase in density with age.

Gender Dysphoria and Scoliosis: Pediatric Orthopaedists Are Very Much Members of the Healthcare Team

Background

Adolescence is a pivotal time of change, and in treating adolescent idiopathic scoliosis (AIS), pediatric orthopaedists form lasting relationships with adolescents. Gender dysphoria (GD) also affects a significant number of adolescents, and with high rates of mental health disorders seen in both GD and AIS, the pediatric orthopaedic surgeons can play an important role in recognizing psychological challenges present in those patients with concurrent AIS and GD.

Methods

A national database investigation was performed using PearlDiver Technologies, Inc., queried for AIS and GD using the International Classification of Diseases codes in patients aged 10-18 years in the period of October 2015 through 2020. Psychological disorders of interest included anxiety, depression, suicidal ideation, and suicide attempt. Descriptive statistics and chi-squared analyses were performed comparing the prevalence of psychological disorders between cohorts of AIS ​+ ​GD patients, AIS-only patients, and GD-only patients. Additionally, mental health outcomes were compared based on the presence or absence of bracing and fusion interventions for AIS between the AIS ​+ ​GD and AIS-only cohorts.

Results

Over the 12-year study period, 820 adolescent patients were identified as having concurrent AIS and GD, representing 0.32% of adolescent AIS patients in the database. In the population with both AIS and GD, diagnoses of mental health issues were observed to be more common across the evaluated parameters. Depression was 7-fold more common (22.2% vs. 3.6%), anxiety 3-fold (79.0% vs. 25.9%), suicidal ideation 12-fold (36.2% vs. 3.8%), and suicidal attempt nearly 13-fold (5.1% vs. 0.4%, P ​< ​.01 for all, AIS ​+ ​GD and AIS only, respectively). Of all included parameters, only suicidal ideation was significantly different between the AIS ​+ ​GD and GD-only cohorts (36.2% vs. 41.7%). No significant differences in psychological disorders were present between AIS ​+ ​GD patients and AIS-only patients based on treatment interventions; however, significant differences were present between groups relative to presence or absence of GD.

Conclusion

While the overall occurrence of adolescents diagnosed with both GD and AIS is low, those with both conditions exhibit notably higher rates of psychological comorbidities than those with AIS alone. Comorbidities in AIS ​+ ​GD were not, however, significantly different from those in the GD-only population. The findings emphasize the importance of mental health awareness by pediatric orthopaedists, especially in the context of patients additionally struggling with GD-associated manifestations.

Key Concepts

(1)The frequency of mental health diagnosis is high in both the adolescent idiopathic scoliosis (AIS) and gender dysphoria (GD) populations. Mental health diagnoses range from 3- to 13-fold greater in the AIS ​+ ​GD compared with AIS-only patients.(2)Bracing can be challenging to the mental health of AIS patients and thus may present an even greater issue in patients with AIS ​+ ​GD.(3)Pediatric orthopaedists have a longitudinal relationship with AIS patients and therefore should have a heightened awareness of the complexities of patients with AIS ​+ ​GD.

Level of Evidence

III.

Association between incorrect postures and curve magnitude of adolescent idiopathic scoliosis in china

BACKGROUND

Despite advancements in school scoliosis screening (SSS), there are still no effective indicators to estimate the severity of spinal curvature. We aim to investigate the association between incorrect postures and curve magnitude of adolescent idiopathic scoliosis (AIS) among Chinese adolescents.

METHODS

In this SSS program, we examined the incorrect posture, Adam's forward bending test (FBT) results, and angle of trunk rotation (ATR) in adolescents. Those with suspected scoliosis were referred for a standing anteroposterior whole-spine radiography as outpatients. The radiographic data of 426 students with lateral Cobb angles were collected from 2016 to 2022 and the associations were studied using logistic regression (LR) models and receiver operating characteristic (ROC) curves.

RESULTS

Univariate LR revealed that female gender [odds ratio (OR) = 2.92, 95% confidence interval (CI) 1.67-5.09, P < 0.001], age 16-19y (OR = 2.83, 95%CI 1.10-7.28, P = 0.031), right shoulder height (OR = 2.15, 95%CI 1.23-3.75, P = 0.007), right scapula tilt (OR = 2.03, 95%CI 1.18-3.50, P = 0.010), right rib hump (OR = 1.88, 95%CI 1.23-2.85, P = 0.003), right thoracic rotation ≥ 5° (OR = 2.14, 95%CI 1.43-3.20, P < 0.001), and left thoracolumbar kyphosis (OR = 3.79, 95%CI 1.06-13.56, P = 0.041) were all significantly associated with the severity of the curve magnitude. Multivariate LR showed that female gender [adjusted OR (AOR) = 3.23, 95%CI 1.81-5.73, P < 0.001], those aged 16-19y (AOR = 5.08, 95%CI 1.86-13.91, P = 0.002), and with a right rib hump (AOR = 1.72, 95%CI 1.11-2.64, P = 0.015) presented with a higher risk of severe curve magnitude than men, those aged 7-12y, and without a rib hump, respectively. ROC curves further proved that sex, age, shoulder-height difference, scapula tilt, flat back, rib hump, angle of thoracic rotation were the risk predictors for curve magnitude.

CONCLUSION

Incorrect posture and ATR, especially the right rib hump, were significantly associated with the curve magnitude of AIS. Early screening for incorrect postures and ATR could be an effective and economical strategy to predict the severity of AIS through SSS in Chinese adolescents.

Investigating the Differential Circulating microRNA Expression in Adolescent Females with Severe Idiopathic Scoliosis: A Proof-of-Concept Observational Clinical Study

Adolescent Idiopathic Scoliosis (AIS) is the most common form of three-dimensional spinal disorder in adolescents between the ages of 10 and 18 years of age, most commonly diagnosed in young women when severe disease occurs. Patients with AIS are characterized by abnormal skeletal growth and reduced bone mineral density. The etiology of AIS is thought to be multifactorial, involving both environmental and genetic factors, but to date, it is still unknown. Therefore, it is crucial to further investigate the molecular pathogenesis of AIS and to identify biomarkers useful for predicting curve progression. In this perspective, the relative abundance of a panel of microRNAs (miRNAs) was analyzed in the plasma of 20 AIS patients and 10 healthy controls (HC). The data revealed a significant group of circulating miRNAs dysregulated in AIS patients compared to HC. Further bioinformatic analyses evidenced a more restricted expression of some miRNAs exclusively in severe AIS females. These include some members of the miR-30 family, which are considered promising regulators for treating bone diseases. We demonstrated circulating extracellular vesicles (EVs) from severe AIS females contained miR-30 family members and decreased the osteogenic differentiation of mesenchymal stem cells. Proteomic analysis of EVs highlighted the expression of proteins associated with orthopedic disease. This study provides preliminary evidence of a miRNAs signature potentially associated with severe female AIS and suggests the corresponding vesicular component may affect cellular mechanisms crucial in AIS, opening the scenario for in-depth studies on prognostic differences related to gender and grade.

A Risk Quantification Reference Table for Progressed Adolescent Idiopathic Scoliosis Surgery: An Exact Case Matched Outcomes Analysis

STUDY DESIGN

Retrospective Exact Matched case-control study.

OBJECTIVES

Surgical treatment delay in AIS due to family preferences is common. This study aims to quantify the increase in risks as the Cobb angle increases and provide a Quantifiable Risk Reference Table that can be utilized for counseling.

METHODOLOGY

AIS patients were divided into 3 groups: Group A: Cobb angle 50-60°, Group 61-70°, and Group CFinal ≥80°. Each patient in Group CFinal who had curve progression were then traced-back-in-time (TBIT) to review the clinical data at earlier presentations at 50-60° (C1), and 61-70° (C2). Patient demographics, radiological, operative, and outcomes data were compared between Group A vs C1 and Group B vs Group C2.

RESULTS

A total of 614 AIS surgeries were reviewed. Utilizing the EM technique, a total of 302 AIS patients were recruited. There were 147, 111, 31, and 32 patients matched in Groups A, B, C1, and C2, respectively. C2 Final patients had 34% curve pattern change, 23.2% higher incidence of requiring two surgeries, and 17.3% increase in complications. There was a statistically significant increase of 2.4 spinal levels fused, 12% increase in implant density, 35% increase in operative time, 97% increase in intra-operative blood loss, 10% loss of scoliosis correction, 40% longer hospitalization stay, and 36% increase in costs for patients who had curve progression.

CONCLUSION

This study is the first to use a homogenously matched AIS cohort to provide a Quantifiable Risk Reference Table. The Risk Table provides essential knowledge for treating physicians when counseling AIS patients.

Three-stage correction of severe idiopathic scoliosis with limited skeletal traction during a humanitarian surgical mission: illustrative case

BACKGROUND

Underprivileged and underserved patients from developing countries often present late with advanced, untreated spinal deformities. We report a three-stage all-posterior approach using limited skeletal traction with Gardner-Wells tongs (GWTs) for the management of severe idiopathic scoliosis during a humanitarian surgical mission trip.

OBSERVATIONS

A 17-year-old high-school female was previously diagnosed with juvenile idiopathic scoliosis (diagnosed at age 8) and progressed to a severe 135° kyphoscoliosis. Procedural stage 1 involved spinal instrumentation and posterior releases via posterior column osteotomies from T3 to L4. She then underwent 7 days of skeletal traction with GWTs in the intensive care unit as stage 2. In stage 3, rod engagement, posterior spinal fusion, and partial T10 vertebral column resection were performed. There were no changes in intraoperative neuromonitoring during either surgery and she woke up neurologically intact after both stages of the surgical procedure.

LESSONS

Skeletal traction with GWTs is a viable alternative to traditional halo-gravity traction in settings with limited resources. Three-stage spinal deformity correction using limited skeletal traction is a feasible and effective approach for managing severe scoliosis during humanitarian surgical mission trips.

An Examination of the Number of Adolescent Scoliotic Curves That Are Braceable at First Presentation to a Scoliosis Service

Adolescent idiopathic scoliosis (AIS) affects between 0.5% and 5.2% of adolescents and is progressive in two-thirds of cases. Bracing is an effective non-operative treatment for AIS and has been shown to prevent up to 72% of curves from requiring surgery. This paper explores the presentation of AIS in the UK and identifies who would be suitable for bracing, as per guidelines published by the Scoliosis Research Society (SRS) and British Scoliosis Society (BSS), through curve severity and skeletal maturity at presentation. There were 526 patients with AIS eligible for inclusion across three tertiary referral centres in the UK. The study period was individualised to each centre, between January 2012 and December 2021. Only 10% were appropriate for bracing via either SRS or BSS criteria. The rest were either too old, skeletally mature or had a curve size too large to benefit. By the end of data collection, 38% had undergone surgery for their scoliosis. In the UK, bracing for AIS is only suitable for a small number at presentation. Future efforts to minimise delays in specialist review and intervention will increase the number of those with AIS suitable for bracing and reduce the number and burden of operative interventions for AIS in the UK.

Efficacy of conservative treatment on exacerbation of adolescent idiopathic scoliosis

Scoliosis is defined as a deviation from the normal vertical line of the spine and consists of a lateral curvature in which the spine rotates within the curvature. Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis and the cause is unknown. In this study, it was investigated whether conservative treatment for adolescent idiopathic scoliosis (CONTRAIS) reduced the patient’s Cobb angle, and the effect of CONTRAIS according to the severity of idiopathic scoliosis and the efficacy of CONTRAIS by spinal region were also verified. Idiopathic scoliosis patients with a Cobb angle of 10° or more were recruited and classified into mild, moderate, and severe groups according to the Cobb angle (°). Cobb angle was measured radiographically before and after 10 weeks of treatment. A combination of CONTRAIS, including physical therapy, exercise therapy, manual therapy, and home exercise was prescribed for all patients. The patients visited the hospital 3 times a week for 10 weeks for treatment, and exercised at home for 20 min every day. In this study, the effect of reducing Cobb angle of CONTRAIS did not differ according to the spinal region. Also, the Cobb angle reduction effect of CONTRAIS was more effective in severe group. This study may suggest that early detection and treatment through CONTRAIS enables successful correction of AIS.

Prevalence and Predictors of Scoliosis and Back Pain in 591 Adolescents: A Randomized, Stratified, Cross-Sectional Study in Riyadh, Saudi Arabia

Purpose

Owing to the difficulty of establishing a screening program for scoliosis and back pain, along with their disabling consequences and the lack of local prevalence rates, we sought to study the prevalence of scoliosis and back pain in adolescents in Saudi Arabia and the burden reported by the affected age group on the health system.

Materials and methods

A school-based, cross-sectional pilot study covering all school districts in Riyadh, Saudi Arabia, was conducted. Students between 12 and 18 years of age were included. Students with any spinal or neurological disorders were excluded. Physical examinations to screen for scoliosis and student-filled questionnaires to assess back pain and health-related quality of life were performed.

Results

Of the 700 students, 591 met the inclusion criteria. High suspicion of adolescent idiopathic scoliosis (AIS) was considered in 174 students (29.44%). In addition, 45.42% of the students had a history of back pain. The Oswestry Disability Index showed that 87 students had disabilities. The average Scoliosis Research Society-22 score was 3 out of 5. A significant difference was found in the self-image and mental health domains for AIS (p = 0.04, p = 0.02, respectively). Age showed a significant increase in the odds ratio of a positive physical exam for every increase of one year in age (p < 0.01).

Conclusion

Identifying the prevalence rates and early associated factors during adolescence would help lower the burden on the health system and benefit public health in general. A nationwide study is required to identify the relationship between scoliosis and back pain.

Influence of curve morphology and location on the efficacy of rigid conservative treatment in patients with adolescent idiopathic scoliosis

AIMS

The aim of the present study was to answer the question whether curve morphology and location have an influence on rigid conservative treatment in patients with adolescent idiopathic scoliosis (AIS).

METHODS

We retrospectively analyzed AIS in 127 patients with single and double curves who had been treated with a Chêneau brace and physiotherapeutic specific exercises (B-PSE). The inclusion criteria were the presence of structural major curves ≥ 20° and < 50° (Risser stage 0 to 2) at the time when B-PSE was initiated. The patients were divided into two groups according to the outcome of treatment: failure (curve progression to ≥ 45° or surgery) and success (curve progression < 45° and no surgery). The main curve type (MCT), curve magnitude, and length (overall, above and below the apex), apical rotation, initial curve correction, flexibility, and derotation by the brace were compared between the two groups.

RESULTS

In univariate analysis treatment failure depended significantly on: 1) MCT (p = 0.008); 2) the apical rotation of the major curve before (p = 0.007) and during brace treatment (p < 0.001); 3) the initial and in-brace Cobb angles of the major (p = 0.001 and p < 0.001, respectively) and minor curves (p = 0.015 and p = 0.002); 4) major curve flexibility (p = 0.005) and the in-brace curve correction rates (major p = 0.008, minor p = 0.034); and 5) the length of the major curve (LoC) above (p < 0.001) and below (p = 0.002) the apex. Furthermore, MCT (p = 0.043, p = 0.129, and p = 0.017 in MCT comparisons), LoC (upper length p = 0.003, lower length p = 0.005), and in-brace Cobb angles (major p = 0.002, minor p = 0.027) were significant in binary logistic regression analysis.

CONCLUSION

Curve size, location, and morphology were found to influence the outcome of rigid conservative treatment of AIS. These findings may improve future brace design and patient selection for conservative treatment. Cite this article: Bone Joint J 2021;103-B(2):373-381.

Intraoperative neurophysiologic monitoring in idiopathic scoliosis surgery: a retrospective observational study of new neurologic deficits

PURPOSE

Patients with adolescent idiopathic scoliosis undergoing corrective surgery are at risk for iatrogenic spinal cord injury and subsequent new neurologic deficits (NNDs). Intraoperative neurophysiologic monitoring (IONM) has been used to identify spinal cord injury; however, available data showing that IONM leads to improved clinical outcomes are inconclusive. This exploratory study aimed to examine the incidence of NNDs after idiopathic scoliosis surgery in two pediatric institutions in Canada with a focus on IONM use.

METHODS

Charts of pediatric patients (10-18 yr) with adolescent idiopathic scoliosis who underwent scoliosis correction surgery were retrospectively identified from the operating room database. Data regarding incidence and severity (mild [isolated sensory deficit] vs severe [any motor deficit]) of NNDs as well as demographic and clinical characteristics were extracted.

RESULTS

Of 547 patients reviewed, 359 (66%) underwent IONM and 186 (34%) underwent wake-up test. Neuromonitoring data were missing in two patients. Total incidence of NNDs was 4.9% (95% confidence interval [CI], 3.1 to 6.8). Compared with the wake-up test, patients undergoing IONM were less likely to develop NNDs (unadjusted odds ratio, 0.39; 95% CI, 0.18 to 0.86; P = 0.02). Nevertheless, subgroup analysis did not reveal a statistical difference in severity of those deficits (mild vs severe) with IONM vs wake-up test. Combined anterior and posterior approach was also significantly associated with increased risk of such deficits.

CONCLUSION

This exploratory study revealed that IONM was associated with a reduced overall incidence of NNDs in idiopathic scoliosis correction; however, its impact on the severity of those deficits is questionable. As we were unable to adjust for confounding variables, further research is needed to determine the impact of IONM on NNDs.

Annual Observation of Changes in the Angle of Trunk Rotation. Trunk Asymmetry Predictors. A Study from a Scoliosis Screening in School Adolescents

Adolescent forms of idiopathic scoliosis are commonly encountered deformities of the thoracic and lumbar spine. They affect a significant number of adolescents, yet their cause is still unknown. The presented research is a cross-sectional analysis of 3933 volunteers (2131 girls and 1802 boys). The participants were primary school students aged 9 to 13 years old. This study determined a relationship between predictors such as: body mass, body height and body mass index (BMI) (independent variables) and angle of trunk rotation (ATR) value (dependent variable). Moreover, a stepwise multiple regression with backward selection was conducted to determine to what extent the dependent variable is explained by body mass, body height and BMI. In the group of 11,12,13-year-old girls, the analyzed results of multiple stepwise regression were statistically significant. Among the all studied predictors, it has been shown that body mass in the 11-year-old girls and body height in 12- and 13-year-old girls are major correlates of a 1-year ATR increase in proximal and main thoracic spine levels.

P, R. DV, Karthik L. The Influence of Smile Arc by Bracket Position Modification: A Prospective Clinical Study

Objective: The purpose of this study was to assess the effects of McLaughlin, Bennett, and Trevisi Bracket Positioning in patients with ideal smile arc and to assess the efficacy of McLaughlin, Bennett, and Trevisi by modifying anterior bracket position among patients with flat smile arc in pretreatment and postalignment phases.

Methodology: A total of 30 subjects divided into 2 groups (group A: 15 subjects with ideal smile arc, and group B: 15 subjects with flat smile arc) were made to participate in this study. A flat smile arc was converted to an ideal smile arc in group B subjects by bracket position modification, and an ideal smile arc was maintained in group A subjects. While paired student t test was performed to find the level of significance in tip and torque values, Mann–Whitney test was used to find the mean difference in intercanine width and visual analogue scale.

Results: Wilcoxon signed ranks test was used to determine the statistically significant changes observed in torque in relation to all the maxillary anteriors. The results showed that tip values in maxillary lateral incisors and torque values in maxillary canines of group B were statistically significant.

Conclusion: A good amount of intrusion was seen in maxillary canines, which helped in the correction of the smile arc.

GENETIC ASPECTS OF IDIOPATHIC ESCOLIOSIS - A LITERATURE REVIEW

ABSTRACT The idiopathic scoliosis (IS) is the most common form of spinal deformity. The pathogenesis of IS is still poorly understood. Several studies show evidence that the genetic component is determinant to the development of IS. In this setting, a crescent focus has been placed on the identification of genes, associated genetic polymorphisms, and multiple susceptibility loci. This review highlights the genes and genetic polymorphisms currently studied, identified as influential in the genesis of IS, such as MMP-3, IL-6, type I collagen, and vitamin D and estrogen receptors. We concluded that IS remains a complex disease with a polygenic background and that genetic polymorphisms are intrinsically related to this condition. Level of evidence III; Narrative Review.

Differences in Nonspecific Low Back Pain between Young Adult Females with and without Lumbar Scoliosis

Study design

Retrospective characterization of nonspecific low back pain (NSLBP) in young adult female patients with and without lumbar scoliosis.

Background

There is no consensus as to whether NSLBP in scoliosis patients is related to scoliosis per se or is just a normal symptom that could happen in anyone.

Objectives

The aim of this study was to compare the differences in NSLBP between young adult female patients with and without lumbar scoliosis and to provide a theoretical basis for differential treatment of NSLBP in patients with and without lumbar scoliosis.

Methods

Ninety female young adults with NSLBP were divided into scoliosis and nonscoliosis groups. Characteristics of pain, lumbar mobility, muscle strength, Cobb angle, axial trunk rotation (ATR) angle, and surface electromyography (SEMG) signal were compared between the two groups.

Results

The pain location in scoliotic patients was more concentrated on the left side of the lumbar spine (P ≤ 0.001). The area affected by pain (P=0.028) and the numerical pain rating scale (NPRS) scores (P=0.014) of scoliotic patients were less than those of nonscoliotic patients. The difference between side-bending in scoliotic patients was greater than that in nonscoliotic patients (P=0.001). Scoliotic patients exhibited a significantly better ability for flexion (P=0.001) and extension (P=0.017) than nonscoliotic patients. The posterior muscles in scoliotic patients were stronger than those in nonscoliotic patients (P=0.014). The ratio of root-mean-square (RMS) on paraspinal muscles in scoliotic patients was greater than that in nonscoliotic patients (P ≤ 0.001). Scoliotic patients exhibited greater relaxation time during the flexion-relaxation phenomenon (FRP) than nonscoliotic patients (P=0.024).

Conclusions

The characteristics of NSLBP experienced by patients with lumbar scoliosis were distinct from those of NSLBP experienced by nonscoliotic patients. The treatment of NSLBP in scoliotic patients should be different from that in nonscoliotic patients.

Effects of spinal mobilization techniques in the management of adolescent idiopathic scoliosis - A meta-analysis

OBJECTIVES

The aim of this study is to examine the effectiveness of diverse exercise regimes used in multiple Randomized Control Trials as the only conservative management strategy for increased Cobb angle among Adolescent Idiopathic Scoliosis.

METHODS

Database such as Google Scholar, Medline, and BioMed Central was reconnoitered for the purpose of research articles of interest. Studies in which the effects of conservative management of scoliosis on the magnitude of Cobb angle were calculated were scrutinized procedurally, studies fulfilling the inclusion criteria were retrieved and encompassed in the present study.

RESULT

A total of 698 cases of AIS that were included in 17 controlled trials are part of this meta-analysis. The pool effects were measured using a standardized mean difference between the experimental and control group at 95% of confidence interval using Hedges'g statistics. Outcomes analyzed, reveals favorable for exercises based experimental group in term of standardized mean difference with an impact of 0.42° on random effect model, according to a Cohen's rule of thumb that depicts a near to moderate effects of exercises based interventions on Cobb angle.

CONCLUSION

The present study concludes that therapeutic exercise regimes alone have a pivotal role in both decelerating the progression of the curve and reducing the already increased magnitude of the curve.

Tracking low back pain in adolescent idiopathic scoliosis: a prospective cohort study protocol

Background

Numerous methodological limitations have constrained the findings of previous studies that have examined the prevalence of low back pain in adolescents with idiopathic scoliosis. This article presents a study protocol that has been designed to address the shortcomings of prior research in this area. In addition, it will establish the level of disease burden associated with acute, recurrent, and chronic low back pain in adolescents with idiopathic scoliosis.

Methods

This study will involve a prospective cohort of adolescents with idiopathic scoliosis presenting to an outpatient department in a paediatric hospital. Potential participants will be eligible for inclusion if they are aged 10–17 years, experience adolescent idiopathic scoliosis, own a mobile phone, and are able to communicate in either French or English adequately. The primary outcome measure is the presence of low back pain. The secondary outcome will be measures with the Brief Pain Questionnaire and the PedsQL questionnaire. Participants will be followed over a 12-month period reporting weekly, via SMS-tracking.

Discussion

Previous studies frequently established the prevalence of low back pain through asking participants to recall whether they experienced low back pain over certain periods. These periods often extended beyond many months, and hence were subject to recall bias. Our study addresses such bias through gathering data on a weekly basis using SMS-tracking providing detailed information about the progression of low back pain, which allows researchers to establish the prevalence of acute, recurrent, and chronic low back pain with a better certainty. Furthermore, the previous studies failed to use a standardised definition of low back pain. As such, it is not possible to determine whether the reported low back pain was experienced at the following standardised defined location: “pain in the space between the lower posterior margin of the rib cage and the horizontal gluteal fold”.

Conclusion

This research protocol will be the first study to determine the proportion of adolescents with idiopathic scoliosis who experience acute, recurrent, and chronic low back pain, and establish the level of the burden associated with these subgroups of low back pain.

Lack of association between AKAP2 and the susceptibility of adolescent idiopathic scoliosis in the Chinese population

Background

Adolescent idiopathic scoliosis (AIS) is a well characterized spinal deformity that affects millions of children world-wide. The role of genetic factor in the development of AIS has been of great interest, since obvious hereditary trend has been observed in AIS families. In a recent study of Chinese population, a novel mutation of AKAP2 was observed in a family with AIS, which was believed to play a role in the aetiopathogenesis of AIS. The purpose of this study was to investigate whether genetic variants of AKAP2 are associated with the susceptibility of AIS in Chinese population.

Methods

SNV c.2645A > C of AKAP2 was genotyped in 1254 AIS patients and 1232 normal controls using allelic-specific multiple ligase detection reactions. SNPs located within 5′ untranslated regions (UTR) and 3′ UTR of AKAP2 gene were selected using Haploview (v2.6). The GWAS database composed of 961 AIS patients and 1499 controls was referred to for the genotyping information. Relative mRNA expression of AKAP2 in peripheral blood was analyzed for 33 patients and 18 age-matched controls. Comparison between the cases and controls were performed using the Student’s t test. PLINK (v1.90) was used to calculate the association of each SNP with the disease by Cochran-Armitage trend test.

Results

All the patients and the controls presented a genotype of AA in c.2645A > C of AKAP2, and there was no case of mutation in any subject. A total of 116 SNPs covering AKAP2 were analyzed, and none of these SNPs was found to have significantly different allele frequency between the cases and the controls. The mRNA expression of AKAP2 in patients was comparable with that in the controls (1.9 ± 0.8 vs. 1.8 ± 0.7, p = 0.66).

Conclusions

Our large-scale replication study of the variants in AKAP2 gene did not support its association with the susceptibility of AIS in the Chinese population. In future study, functional studies of the previously reported rare variant are warranted to clarify whether the variant can regulate the expression of AKAP2. The whole AKAP2 gene can be sequenced in larger AIS cohorts to identify potentially missing mutations.

Back Pain Prevalence Is Associated With Curve-type and Severity in Adolescents With Idiopathic Scoliosis: A Cross-sectional Study

STUDY DESIGN

A cross-sectional study.

OBJECTIVES

The aim of this study was to investigate spinal pain prevalence in adolescents with idiopathic scoliosis (AIS) and to explore associations between pain intensity and pain-related disability with scoliosis site, severity, and spinal bracing.

SUMMARY OF BACKGROUND DATA

The causal link between spinal pain and AIS remains unclear. Spinal asymmetry has been recognized as a back pain risk factor, which is a known cause of care-seeking in adolescents.

METHODS

Participants were recruited from an outpatient tertiary-care scoliosis clinic. Pain intensity and pain-related disability were measured by the Brief Pain Inventory questionnaire and the Roland-Morris Disability Questionnaire. Scoliosis severity estimation was performed using Cobb angles. Associations were explored using multiple linear regressions and reported with unstandardized beta coefficients (β) adjusted for age and sex.

RESULTS

We recruited 500 patients (85% female) with mean (SD) age of 14.2 (1.8) years. Means (SD) of thoracic and lumbar Cobb angle were 24.54(9.77) and 24.13 (12.40), respectively. Spinal pain prevalence was 68% [95% confidence interval (95% CI): 64.5-72.4] with a mean intensity of 1.63 (SD, 1.89). Spinal pain intensity was positively associated with scoliosis severity in the main thoracic (P = 0.003) and lumbar (P = 0.001) regions. The mean (SD) disability score was 1.73 (2.98). Disability was positively associated with scoliosis severity in the proximal thoracic (P = 0.035), main thoracic (P = 0.000), and lumbar (P = 0.000) regions.Spinal bracing was associated with lower spinal pain intensity in the thoracic (P = 0.000) and lumbar regions (P = 0.009). Bracing was also related with lower disability for all spinal areas (P < 0.045).

CONCLUSION

Spinal pain is common among patients with AIS, and greater spinal deformity was associated with higher pain intensity. These findings should inform clinical decision-making when caring for patients with AIS.

LEVEL OF EVIDENCE

3.

Spinal Manipulative Therapy for Adolescent Idiopathic Scoliosis: A Systematic Review

OBJECTIVE

The purpose of this study was to perform a systematic review of clinical trials of spinal manipulative therapy for adolescent idiopathic scoliosis.

METHODS

Search strategies were developed for PubMed, CINHAL, and CENTRAL databases. Studies were included through June 2016 if they were prospective trials that evaluated spinal manipulative therapy (eg, chiropractic, osteopathic, physical therapy) for adolescent idiopathic scoliosis. Data were extracted and assessed by 2 independent reviewers. Cochrane risk of bias tools were used to assess the quality of the included studies. Data were reported qualitatively because heterogeneity prevented statistical pooling.

RESULTS

Four studies satisfied the inclusion criteria and were critically appraised. The findings of the included studies indicated that spinal manipulative therapy might be effective for preventing curve progression or reducing Cobb angle. However, the lack of controls and small sample sizes precluded robust estimation of the interventions' effect sizes.

CONCLUSION

There is currently insufficient evidence to establish whether spinal manipulative therapy may be beneficial for adolescent idiopathic scoliosis. The results of the included studies suggest that spinal manipulative therapy may be a promising treatment, but these studies were all at substantial risk of bias. Further high-quality studies are warranted to conclusively determine if spinal manipulative therapy may be effective in the management of adolescent idiopathic scoliosis.

Prevalence of low back pain in adolescents with idiopathic scoliosis: a systematic review

Background

Adolescent idiopathic scoliosis is the most common spinal deformity occurring in adolescents and its established prevalence varies from 2 to 3%. Adolescent idiopathic scoliosis has been identified as a potential risk factor for the development of low back pain in adolescents. The purpose of this study was to systematically review studies of the prevalence of low back pain in adolescents with idiopathic scoliosis in order to establish the quality of the evidence and determine whether the prevalence estimates could be statistically pooled.

Methods

Systematic electronic searches were undertaken in PubMed, CINAHL, and CENTRAL without any restrictions. Studies were eligible for inclusion if they reported the prevalence of low back pain in adolescents with idiopathic scoliosis. Studies were excluded if they detailed the prevalence of pain in post-surgical subjects or were published in languages other than English or French. Data were reported qualitatively, since there was insufficient evidence for statistical pooling.

Results

The electronic search strategies yielded 1811 unique studies. Only two studies fulfilled the eligibility criteria. The prevalence of low back pain in adolescents with idiopathic scoliosis ranged from 34.7 to 42.0%. However, these prevalence estimates should be viewed cautiously as the included studies were at high risk of bias.

Conclusion

The results of this systematic review indicate that adolescents with idiopathic scoliosis frequently experience low back pain. However, there was insufficient evidence to confidently estimate low back pain prevalence in adolescents with idiopathic scoliosis and further studies are needed in this area.

Electronic supplementary material

The online version of this article (doi:10.1186/s12998-017-0143-1) contains supplementary material, which is available to authorized users.

Long-Term Effects of Untreated Adolescent Idiopathic Scoliosis: A Review of the Literature

Currently, adolescent idiopathic scoliosis (AIS) is principally regarded as benign, but some researchers have cited serious or extreme effects, including severe pain, cardiopulmonary compromise, social isolation, and even early death. Therefore, exploration of the long-term effects of AIS, the most common type of idiopathic scoliosis, is warranted. The purpose of this review was to examine the long-term studies on the natural history of AIS and/or reviews concerning the long-term effects of untreated AIS. A PubMed search was conducted using the key words idiopathic scoliosis, long-term effects and idiopathic scoliosis, natural history. For further analysis, references cited in those studies were reviewed for additional, related evidence not retrieved in the initial PubMed search. A review of the pertinent bibliography showed that older natural history studies did not distinguish between late-onset scoliosis (referred to in this paper as AIS) and early-onset scoliosis (EOS). The more recent studies offer such important distinction and reach to the general conclusion that untreated AIS does not lead to severe consequences with respect to signs and symptoms of scoliosis. It is possible that earlier studies may have included patient populations with EOS, leading to the perception of untreated scoliosis as having an unusually high morbidity rate. Studies on the long-term effects of AIS that specifically excluded EOS patients conclude that AIS is a benign disorder. This indicates that for research and reporting purposes, it is important to distinguishing between AIS and EOS. This will allow the practitioner and patient and their families to decide on an optimal treatment plan based on the most appropriate prognosis.

Effect of Surgical Approach on Pulmonary Function in Adolescent Idiopathic Scoliosis Patients: A Systemic Review and Meta-analysis

STUDY DESIGN

Systemic review and meta-analysis.

OBJECTIVE

To analyze the effect of spinal fusion and instrumentation for adolescent idiopathic scoliosis (AIS) on absolute pulmonary function test (PFTs).

SUMMARY OF BACKGROUND DATA

Pulmonary function is correlated with severity of deformity in AIS patients and studies that have analyzed the effect of spinal fusion and instrumentation on PFTs for AIS have reported inconsistent results. There is a need to analyze the effect of spinal fusion on PFTs with stratification by surgical approach.

METHODS

Our analysis included 22 studies. Cohen's d effect sizes were calculated for absolute PFT outcome measures with 95% confidence intervals (CI). Meta-analyses were performed at each postoperative time frame for six homogeneous surgical approaches: (i) combined anterior release and posterior fusion with instrumentation; (ii) combined video assisted anterior release and posterior fusion with instrumentation without thoracoplasty; (iii) posterior fusion with instrumentation without thoracoplasty; (iv) anterior fusion with instrumentation and without thoracoplasty; (v) video assisted anterior fusion with instrumentation without thoracoplasty; and (vi) any scoliosis surgery with additional thoracoplasty.

RESULTS

Anterior spinal fusion with instrumentation, any scoliosis surgery with concomitant thoracoplasty, or video-assisted anterior fusion with instrumentation for AIS had similar absolute PFTs at their 2 year postoperative follow up compared with their preoperative PFTs (effect sizes ranging from -0.2-0.2 with all CI crossing "0"). Posterior spinal fusion with instrumentation (with or without an anterior release) demonstrated small to moderate increases in PFTs 2 years postoperatively (effect sizes ranging from 0.35-0.65 with all CI not crossing "0").

CONCLUSION

Anterior fusion with instrumentation, regardless of the approach, and any scoliosis surgery with concomitant thoracoplasty do not lead to significant change in pulmonary functions 2 year after surgery. Posterior spinal fusion with instrumentation (with or without an anterior release) resulted in small to moderate increases in PFTs.

LEVEL OF EVIDENCE

N/A.

Adolescent Idiopathic Scoliosis

Background:

Scoliosis refers to deviation of spine greater than 10 degrees in the coronal plane. Idiopathic Scoliosis is the most common spinal deformity that develops in otherwise healthy children. The sub types of scoliosis are based on the age of the child at presentation. Adolescent idiopathic scoliosis (AIS) by definition occurs in children over the age of 10 years until skeletal maturity.

Objective:

The objective of this review is to outline the features of AIS to allow the physician to recognise this condition and commence early treatment, thereby optimizing patient outcome.

Method:

A thorough literature search was performed using available databases, including Pubmed and Embase, to cover important research published covering AIS.

Conclusion:

AIS results in higher incidence of back pain and discontent with body image. Curves greater than 50 degrees in thoracic region and greater than 30 degrees in lumbar region progress at a rate of 0.5 to 1 degree per year into adulthood. Curves greater than 60 degrees can lead to pulmonary functional deficit. Therefore once the disease is recognized, effective treatment should be instituted to address the deformity and prevention of its long-term sequelae.

Hypothesis about an existent biomechanical cause-effect relationship between Schëuermann's kyphosis and scoliosis

Schëuermanńs kyphosis is usually observed with a mild idiopathic scoliosis, and there is parity between these two diseases. The aim of this work is to establish a hypothesis about the existence of a biomechanical causal relationship between Schëuermann's kyphosis and scoliosis. To achieve this, a literature review was conducted. A simple mechanical model of the passive thoracolumbar subsystem was created to support part of the discussion. This mechanical model describes the passive thoracolumbar subsystem under ideal conditions of equilibrium. After giving consideration to the system under these conditions, some of the geometrical changes that may be found in Schëuermanńs kyphosis are considered. Next, this work discusses the evolution of the spine, taking into account its relationship with stable equilibrium, which the passive subsystem tends toward. We hypothesized about the postural response of the body to compensate for possible situations of imbalance. In conclusion, it can be found that a change in the alignment of the spine may occur due to the postural adaptation of the body to an inadequate mechanical situation that may lead to scoliotic deformity of the spine.

Prevalence and management of back pain in adolescent idiopathic scoliosis patients: A retrospective study

BACKGROUND

Back pain (BP) has often been associated with adolescent idiopathic scoliosis (AIS), which is a three-dimensional deviation of the vertebral column. In adolescents, chronic pain appears to be a predictor of health care utilization and has a negative impact on physical, psychological and family well-being. In this population, BP tends to be persistent and may be a predictor of BP in adulthood.

OBJECTIVE

To document the prevalence and management of BP in AIS patients.

METHODS

A retrospective chart review of AIS patients who were referred to Sainte-Justine University Teaching Hospital (Montreal, Quebec) from 2006 to 2011 was conducted.

RESULTS

A total of 310 randomly selected charts were reviewed. Nearly one-half of the patients (47.3%) mentioned that they experienced BP, most commonly in the lumbar (19.7%) and thoracic regions (7.7%). The type of BP was documented in only 36% (n=112) of the charts. Pain intensity was specified in only 21% (n=65) of the charts. In approximately 80% (n=248) of the charts, no pain management treatment plan was documented.

CONCLUSIONS

The prevalence of BP was moderately high among the present sample of adolescents with AIS. An improved system for documenting BP assessment, type, treatment plan and treatment effectiveness would improve pain management for these patients.

Factors relating to curve progression in female patients with adolescent idiopathic scoliosis treated with a brace

PURPOSE

One single factor cannot by itself predict curve progression accurately. The aim of this study is to determine multiple related factors in predicting the progression of scoliosis in girls with adolescent idiopathic scoliosis (AIS) treated with bracing.

METHODS

Eighty-nine female patients with AIS treated with a brace were reviewed. A series of parameters were consecutively measured and documented during the period of follow-up. Curve behavior between the first visit and final follow-up was analyzed. Several different parameters which may contribute to progression of curve were selected by a logistic regression analysis.

RESULTS

Mean age of patients at the first visit was 13.6 (10-16) years. The patients were followed for 12-72 months (mean 24.8 months). At the last visit, 21 patients (23.60 %) had curve progression more than 5°. After performing a logistic regression analysis, Risser sign less than two, the magnitude of the major curve at pre-brace greater than 35°, apical vertebral rotation beyond grade III, and the spinal length increasing larger than 20 mm in 1 year were found to be factors which predict the progression of more than 5°.

CONCLUSIONS

This study suggests that Risser sign, the magnitude of the major curve at pre-brace, apical vertebral rotation, and the spinal length increasing velocity are important factors to predict progression in the girls with AIS. Risser sign cannot predict the progression of scoliosis accurately unless combined with other related parameters.

Does delaying surgery in immature adolescent idiopathic scoliosis patients with progressive curve, lead to addition of fusion levels?

PURPOSE

To analyze the changes in the curve extent, pattern and the fusion level in adolescent idiopathic scoliosis (AIS) patients who undergo delayed surgery instead of early surgery.

METHODS

Thirty-five immature AIS patients whose radiographs demonstrated an initial primary curve of more than 40° with a subsequent increase of 10° before attaining skeletal maturity with brace were enrolled. The initial and the final radiographs taken before surgery were compared to assess the changes in curve extent, pattern and the fusion levels as recommended by King's, Lenke's and Suk's guidelines.

RESULTS

The average age of 35 AIS patients was 12.7 ± 1.6 years. The time interval between initial and final radiography was 39.3 ± 20.2 months and the degree of progress of the primary curve was 13 ± 9.7°. Fusion levels changed in 33 (94.2%), 33 (94.2%) and 32 (91.4%) patients according to King's, Lenke's and Suk's guidelines, respectively. Curve pattern was changed in 2 (5.7%), 12 (34.3%) and 10 (28.6) patients by King's, Lenke's and Suk's guidelines. The mean number of levels requiring fusion increased from 9.4 ± 2.1 at initial visit to 11.1 ± 1.8 at the final follow-up using King's guidelines, 9.7 ± 2.2-11.6 ± 2.0 as per Lenke's guidelines and 9.1 ± 2.0-11.5 ± 2.3 when fusion was planned using Suk's guidelines (p < 0.001 in all guidelines).

CONCLUSIONS

Delay of surgery in immature AIS patients whose Cobb's angle exceed 40° initially and showing subsequent progression of the curve, of more than 10° can lead to alterations in the curve pattern and the need for increase in fusion levels.

Ultrastructure of Intervertebral Disc and Vertebra-Disc Junctions Zones as a Link in Etiopathogenesis of Idiopathic Scoliosis

Background Context. There is no general accepted theory on the etiology of idiopathic scoliosis (IS). An important role of the vertebrae endplate physes (VEPh) and intervertebral discs (IVD) in spinal curve progression is acknowledged, but ultrastructural mechanisms are not well understood. Purpose. To analyze the current literature on ultrastructural characteristics of VEPh and IVD in the context of IS etiology. Study Design/Setting. A literature review. Results. There is strong evidence for multifactorial etiology of IS. Early wedging of vertebra bodies is likely due to laterally directed appositional bone growth at the concave side, caused by a combination of increased cell proliferation at the vertebrae endplate and altered mechanical properties of the outer annulus fibrosus of the adjacent IVD. Genetic defects in bending proteins necessary for IVD lamellar organization underlie altered mechanical properties. Asymmetrical ligaments, muscular stretch, and spine instability may also play roles in curve formation. Conclusions. Development of a reliable, cost effective method for identifying patients at high risk for curve progression is needed and could lead to a paradigm shift in treatment options. Unnecessary anxiety, bracing, and radiation could potentially be minimized and high risk patient could receive surgery earlier, rendering better outcomes with fewer fused segments needed to mitigate curve progression.

Knowledge and management of Adolescent Idiopathic Scoliosis among family physicians, pediatricians, chiropractors and physiotherapists in Québec, Canada: An exploratory study

BACKGROUND

Health professionals (HPs) are likely to encounter adolescent idiopathic scoliosis (AIS) patients. Best practice dictates that early detection leads to better decision making regarding optimal management. The aim of our study was to appraise the basic knowledge, evaluation and management skills concerning AIS care among family physicians, pediatricians, chiropractors, and physiotherapists.

METHODS

A semi-structured questionnaire including 3 clinical scenarios was developed. Telephone interviews were conducted with 51 HPs to assess their knowledge of the clinical signs, risk factors, and management options of AIS and their preferences in clinical guidelines for AIS care.

RESULTS

The majority of HPs (70-90%) would refer the patient who required prompt referral, but only 38-60% actually rated the case as requiring prompt referral. Forty percent of HPs (predominantly physiotherapists and family physicians) stated that they would not be comfortable providing AIS patient follow-up. Access to specialized care was considered a problem, and nearly all believed that establishment of clinical guidelines would be beneficial.

CONCLUSIONS

Considerable gaps exist regarding the knowledge of the clinical signs and risk factors of AIS. The importance of a patient in need of a prompt referral is recognized by the majority of the HPs, but they believe that there are problems regarding accessibility to a specialist. Interprofessional collaboration is discussed as a promising approach to improve the management of AIS.

Three-dimensional vertebral wedging in mild and moderate adolescent idiopathic scoliosis

Background

Vertebral wedging is associated with spinal deformity progression in adolescent idiopathic scoliosis. Reporting frontal and sagittal wedging separately could be misleading since these are projected values of a single three-dimensional deformation of the vertebral body. The objectives of this study were to determine if three-dimensional vertebral body wedging is present in mild scoliosis and if there are a preferential vertebral level, position and plane of deformation with increasing scoliotic severity.

Methodology

Twenty-seven adolescent idiopathic scoliotic girls with mild to moderate Cobb angles (10° to 50°) participated in this study. All subjects had at least one set of bi-planar radiographs taken with the EOS® X-ray imaging system prior to any treatment. Subjects were divided into two groups, separating the mild (under 20°) from the moderate (20° and over) spinal scoliotic deformities. Wedging was calculated in three different geometric planes with respect to the smallest edge of the vertebral body.

Results

Factorial analyses of variance revealed a main effect for the scoliosis severity but no main effect of vertebral Levels (apex and each of the three vertebrae above and below it) (F = 1.78, p = 0.101). Main effects of vertebral Positions (apex and above or below it) (F = 4.20, p = 0.015) and wedging Planes (F = 34.36, p<0.001) were also noted. Post-hoc analysis demonstrated a greater wedging in the inferior group of vertebrae (3.6°) than the superior group (2.9°, p = 0.019) and a significantly greater wedging (p≤0.03) along the sagittal plane (4.3°).

Conclusions

Vertebral wedging was present in mild scoliosis and increased as the scoliosis progressed. The greater wedging of the inferior group of vertebrae could be important in estimating the most distal vertebral segment to be restrained by bracing or to be fused in surgery. Largest vertebral body wedging values obtained in the sagittal plane support the claim that scoliosis could be initiated through a hypokyphosis.

Pelvis morphology, trunk posture and standing imbalance and their relations to the Cobb angle in moderate and severe untreated AIS

Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis and usually affects young girls. Studies mostly describe the differences between scoliotic and non-scoliotic girls and focus primarily on a single set of parameters derived from spinal and pelvis morphology, posture or standing imbalance. No study addressed all these three biomechanical aspects simultaneously in pre-braced AIS girls of different scoliosis severity but with similar curve type and their interaction with scoliosis progression. The first objective of this study was to test if there are differences in these parameters between pre-braced AIS girls with a right thoracic scoliosis of moderate (less than 27°) and severe (more than 27°) deformity. The second objective was to identify which of these parameters are related to the Cobb angle progression either individually or in combination of thereof. Forty-five scoliotic girls, randomly selected by an orthopedic surgeon from the hospital scoliosis clinic, participated in this study. Parameters related to pelvis morphology, pelvis orientation, trunk posture and quiet standing balance were measured. Generally moderate pre-brace idiopathic scoliosis patients displayed lower values than the severe group characterized by a Cobb angle greater than 27°. Only pelvis morphology and trunk posture were statistically different between the groups while pelvis orientation and standing imbalance were similar in both groups. Statistically significant Pearson coefficients of correlation between individual parameters and Cobb angle ranged between 0.32 and 0.53. Collectively trunk posture, pelvis morphology and standing balance parameters are correlated with Cobb angle at 0.82. The results suggest that spinal deformity progression is not only a question of trunk morphology distortion by itself but is also related to pelvis asymmetrical bone growth and standing neuromuscular imbalance.

Efficacy of exercise therapy for the treatment of adolescent idiopathic scoliosis: a review of the literature

PURPOSE

Current evidence regarding the use of exercise therapy in the treatment of adolescent idiopathic scoliosis (AIS) was assessed with a review of published literature.

METHODS

An extensive literature search was carried out with commonly used medical databases. A total of 155 papers were identified out of which only 12 papers were deemed to be relevant.

RESULTS

There were nine prospective cohort studies, two retrospective studies and one case series. All studies endorsed the role of exercise therapy in AIS but several shortcomings were identified--lack of clarity of patient recruitment and in the method of assessment of curve magnitude, poor record of compliance, and lack of outcome scores. Many studies reported "significant" changes in the Cobb angle after treatment, which were actually of small magnitude and did not take into account the reported inter or intra-observer error rate. All studies had poor statistical analysis and did not report whether the small improvements noted were maintained in the long term.

CONCLUSIONS

This unbiased literature review has revealed poor quality evidence supporting the use of exercise therapy in the treatment of AIS. Well-designed randomised controlled studies are required to assess the role of exercise therapy in AIS.