Physical Therapy Scoliosis-Specific Exercises May Reduce Curve Progression in Mild Adolescent Idiopathic Scoliosis Curves
Zapata KA, Sucato DJ, Jo CH. Physical therapy Scoliosis-Specific exercises may reduce curve progression in mild adolescent idiopathic scoliosis curves. Pediatric Physical Therapy. 2019;31(3):280-285. doi:10.1097/pep.0000000000000621Link to Original Article: https://pubmed.ncbi.nlm.nih.gov/31220013/
Introduction
Adolescent idiopathic scoliosis (AIS) is a condition where adolescents are at high risk of curve progression during rapid growth. The Cobb angle is used to measure the curve magnitude, and a minimum increase of 5° is needed to signify progression. The standard medical management for AIS includes observation for mild curves, bracing for moderate curves, and surgery for severe curves. Risser grades and triradiate cartilage status are used to assess skeletal immaturity and the risk of curve progression. Physical therapy scoliosis-specific exercises (PSSEs) are used in other countries to reduce curve progression and brace prescription, but they are not widely prescribed in the United States due to a lack of evidence supporting their effectiveness. The Schroth-based method is a type of PSSE that uses corrective movements and breathing techniques to address scoliosis. Previous systematic reviews have shown that exercises may be effective in reducing curve progression, and recent randomized controlled trials have further supported this finding. Skeletally immature participants with mild AIS curves are at the highest risk of progression and may benefit from early intervention. The primary aim of this study is to determine if the Schroth-based method is effective in reducing curve magnitude, curve progression, and brace prescription compared to observation alone. The secondary aim is to assess the impact on participant perception of spinal appearance and quality of life after one year of intervention.
Methods
Participants
The study aimed to recruit 28 participants (14 per group) to investigate the effectiveness of the Schroth-based method in skeletally immature participants with mild adolescent idiopathic scoliosis (AIS) at high risk of progression. The study included girls and boys between 10 and 17 years old with AIS major curve Cobb angles ranging from 12° to 20°, Risser grade 0, and no current or previous brace wear. Participants with developmental disorders, previous brace wear, previous spine surgery, and an inability to commit to attend at least 8 hours of physical therapy within 6 months were excluded. The chosen range of curve magnitudes ensured that true scoliosis curves not requiring bracing were included to avoid bias from brace wear. Written informed assent was obtained from the adolescent participants and legal guardians, and the study was approved by the Institutional Review Board at the University of Kentucky.
Outcome Measures
The primary outcome measures included the angle of the primary curve based on the Cobb angle, the incidence of curve progression, and the use of brace. In addition, the secondary outcome measures included SAQ24 and SRS-22r. The data were collected by research personnel who were unaware of the participants' group assignments at baseline, 6 month, and 1 year follow up.
Procedure
The study included an exercise group and a control group to investigate the effectiveness of the Schroth-based method in reducing curve magnitude, curve progression, and brace prescription in skeletally immature participants with mild adolescent idiopathic scoliosis (AIS) at high risk of progression. Participants in the exercise group received at least 8 hours of physical therapy sessions within 6 months with a certified physical therapist. The Schroth-based exercises were tailored to each participant's curve patterns and abilities, and participants were prescribed a 15-minute home exercise program (HEP) to be done 3 days a week. The exercises included various positions such as supine, sitting, sidelying, prone, and standing. Participants had to demonstrate successful independent exercise execution before being discharged to the HEP, and they could request a refresher session if needed. Adherence to the exercises was monitored using a secure web application, and participants or caregivers responded to a weekly survey on exercise duration. The control group received the standard of care, which involved regular clinical assessments by an orthopedic surgeon to check for curve progression and determine the need for bracing. The study aimed to assess the impact of the Schroth-based method on participant perception of spinal appearance and quality of life after 1 year of intervention.
Results
Participants
The study included 49 participants with mild adolescent idiopathic scoliosis (AIS) who were at high risk of progression. There were 26 participants in the exercise group and 23 in the control group. The baseline curve magnitude was 16.2°± 3.2°in the exercise group and 14.7°± 3.6°in the control group. There was a gender imbalance between the exercise and control groups, but no significant differences in curve progression were found between genders within the exercise group at the 1-year follow-up.
At the 6-month follow-up, 36 participants (20 exercise and 16 controls) were assessed. The average curve magnitude in the exercise group was 16.7°± 4.9°and in the control group was 17.5°± 5.3°. Participants in the exercise group showed good adherence to the exercise program, averaging 2.4 ± 0.7 days (80%) and 34 ± 12 minutes (77%) per week.
At the 1-year follow-up, 33 participants (19 exercise and 14 controls) were evaluated. There were no significant differences between the exercise and control groups in terms of baseline age, Risser grade, triradiate cartilage status, or amount of growth over the 1-year period. The exercise group had a dropout rate of 27%, while the control group had a dropout rate of 39%.
Primary Outcome
This research paper investigated the effectiveness of the Schroth-based method compared to standard observation in reducing curve magnitude, curve progression, and brace prescription in`skeletally immature participants with mild adolescent idiopathic scoliosis (AIS) at high risk of progression. The study also aimed to assess the impact on participant perception of spinal appearance and quality of life after 1 year of intervention.
The results showed that at 6 months, there was no significant difference in curve magnitude between the exercise group and the control group. However, the control group showed a significant increase in curve magnitude at this time point, while the exercise group did not. At 1-year follow-up, the exercise group had significantly smaller curves compared to the control group.
Regarding curve progression, at 1-year follow-up, 16% of curves in the exercise group progressed more than 5°, while 50% of curves in the control group progressed by the same amount. In terms of brace prescription, 37% of participants in the exercise group and 43% in the control group were prescribed braces. Most participants were prescribed night-time braces or full-time braces, and bracing was initiated in curves smaller than 25°.
When evaluating participants who were not prescribed a brace, the exercise group did not have significantly smaller curves than the control group at 1-year follow-up. However, the control group showed a significant increase in curve magnitude compared to the exercise group from baseline to 1 year.
Overall, the study suggests that the Schroth-based method may be effective in reducing curve magnitude and progression in skeletally immature participants with mild AIS who are at high risk of progression. However, further research is needed to determine the long-term effects and potential benefits for participants' perception of spinal appearance and quality of life.
Secondary Outcome
The perception of spinal appearance was assessed in a research study comparing the effectiveness of the Schroth-based method to standard observation in participants with mild adolescent idiopathic scoliosis (AIS) at high risk of progression. At baseline, both the exercise group and control group had similar scores on the Scoliosis Appearance Questionnaire (SAQ) subtotal, averaging 1.7 ± 0.4. After 1 year, there was no significant difference in the SAQ subtotal scores between the exercise group (averaging 1.8 ± 0.7) and the control group (averaging 1.6 ± 0.4).
The researchers also analyzed Question #9 of the SAQ individually, which assesses the desire for a more even appearance of the spine. At baseline, participants in the exercise group had significantly worse scores than the control group on Question #9 (averaging 3.5 ± 1.6 vs 2.2 ± 1.4, P = .04). However, after 1 year, there was no significant improvement in Question #9 scores for the exercise group compared to the control group (averaging 1.8 ± 0.7 vs 3.0 ± 0.5, P = .05). Importantly, there was a significant improvement in Question #9 scores from baseline to 1-year follow-up for the exercise group compared to the control group (-1.4 ± 1.7 vs 0.9 ± 1.5, P = .02). This finding suggests that participants in the control group desired a more even spinal appearance compared to those in the exercise group. Overall, the study found that the Schroth-based method did not significantly impact participants' perception of spinal appearance compared to the standard observation.
Discussion
The research paper discusses the effectiveness of the Schroth-based method in reducing curve magnitude, curve progression, and brace prescription in skeletally immature participants with mild adolescent idiopathic scoliosis (AIS) at high risk of progression, compared to the standard of care of observation. The study found that curves in the exercise group remained stable, while curves in the control group progressed at least 5 degrees, which is considered clinically important. The results support the use of PSSE (Physiotherapeutic Scoliosis Specific Exercises) for AIS, particularly in outpatient settings using the Schroth-based method for participants with mild curves.
Comparisons with previous studies showed improved Cobb angle outcomes in the PSSE groups. These studies involved participants with larger curve magnitudes and were more skeletally mature. More supervised PSSE sessions were associated with better exercise adherence. Another study demonstrated improvements in curve magnitude and a lower incidence of brace prescription in the PSSE group at 1-year follow-up. However, the current study showed increased curve progression and brace wear compared to that study, and follow-up until skeletal maturity is needed to confirm results.
Exercise adherence was lower in the current study compared to previous research, and a focus on performing autocorrective exercises throughout the day was emphasized. Future research should examine which curve types respond best to PSSE and investigate the potential for improvement in mild curve groups. However, the limitations of the current study include the lack of follow-up until skeletal maturity, non-randomized participants, and difficulty in measuring compliance in the treatment group.
Opportunities for Future Research
1. Investigate the long-term effects of physical therapy scoliosis-specific exercises (PSSEs) on curve progression in participants with mild adolescent idiopathic scoliosis (AIS).
2. Explore the potential benefits of PSSEs in reducing the need for bracing in individuals with AIS.
3. Determine the optimal duration and frequency of PSSEs for maximum effectiveness in reducing curve progression.
4. Compare the effectiveness of different PSSE methods, such as the Schroth-based method and other types, in reducing curve progression.
5. Examine the impact of PSSEs on participant perception of spinal appearance and quality of life.
6. Assess the effects of PSSEs on different curve types and determine which types may respond best to this type of intervention.
7. Investigate the factors that influence exercise adherence in participants undergoing PSSEs and develop strategies to improve adherence rates.
8. Compare the effectiveness of outpatient-based PSSEs to other treatment options, such as observation or bracing, in reducing curve progression in individuals with mild AIS.
9. Evaluate the long-term outcomes of PSSEs, including the stability of curve reductions and the impact on overall spinal health, in individuals with AIS.
