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R E S E A R C H Open Access
Effectiveness of Schroth exercises during
bracing in adolescent idiopathic scoliosis:
results from a preliminary study—SOSORT
Award 2017 Winner
Kenny Yat Hong Kwan
1*
, Aldous C.S. Cheng
2
, Hui Yu Koh
1
, Alice Y.Y. Chiu
2
and Kenneth Man Chee Cheung
1
Abstract
Background: Bracing has been shown to decrease significantly the progression of high-risk curves to the threshold
for surgery in patients with adolescent idiopathic scoliosis (AIS), but the treatment failure rate remains high. There is
evidence to suggest that Schroth scoliosis-specific exercises can slow progression in mild scoliosis. The aim of this
study was to evaluate the efficacy of Schroth exercises in AIS patients with high-risk curves during bracing.
Methods: A prospective, historical cohort-matched study was carried out. Patients diagnosed with AIS who fulfilled
the Scoliosis Research Society (SRS) criteria for bracing were recruited to receive Schroth exercises during bracing.
An outpatient-based Schroth program was given. Data for these patients were compared with a 1:1 matched
historical control group who were treated with bracing alone. The assessor and statistician were blinded.
Radiographic progression, truncal shift, and SRS-22r scores were compared between cases and controls.
Results: Twenty-four patients (5 males and 19 females, mean age 12.3 ± 1.4 years) were included in the exercise
group, and 24 patients (mean age 11.8 ± 1.1 years) were matched in the control group. The mean follow-up period
for the exercise group was 18.1 ± 6.2 months. In the exercise group, spinal deformity improved in 17% of patients
(Cobb angle improvement of ≥6°), worsened in 21% (Cobb angle increases of ≥6°), and remained stable in 62%. In the
control group, 4% improved, 50% worsened, and 46% remained stable. In the subgroup analysis, 31% of patients who
were compliant (13 cases) improved, 69% remained static, and none had worsened, while in the non-compliant group
(11 cases), none had improved, 46% worsened, and 46% remained stable. Analysis of the secondary outcomes showed
improvement of the truncal shift, angle of trunk rotation, the SRS function domain, and total scores in favor of the
exercise group.
Conclusion: This is the first study to investigate the effects of Schroth exercises on AIS patients during bracing. Our
findings from this preliminary study showed that Schroth exercise during bracing was superior to bracing alone in
improving Cobb angles, trunk rotation, and QOL scores. Furthermore, those who were compliant with the exercise
program had a higher rate of Cobb angle improvement. The results of this study form the basis for a randomized
controlled trial to evaluate the effect of Schroth exercises during bracing in AIS.
Trial registration: HKUCTR-2226. Registered 22 June 2017 (retrospectively registered)
Keywords: Schroth, Scoliosis-specific exercise, Adolescent idiopathic scoliosis, Bracing, Curve progression, Conservative
management
* Correspondence: kyhkwan@hku.hk
1
Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of
Medicine, The University of Hong Kong, Pokfulam, Hong Kong
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Kwan et al. Scoliosis and Spinal Disorders (2017) 12:32
DOI 10.1186/s13013-017-0139-6
Background
The aim of treatment of adolescent idiopathic scoliosis
(AIS) is to prevent curve progression to 50°, beyond which
there is a risk of continued progression in adulthood.
Surgery is therefore usually recommended if the curve
reaches 50° during adolescence. Treatment with rigid bra-
cing has recently been shown in the Bracing in Adolescent
Idiopathic Scoliosis Trial (BRAIST) to decrease signifi-
cantly the progression of high-risk curves to the threshold
for surgery [1] and is the most widely accepted form of
treatment for the prevention of curve progression
worldwide. Nonetheless, the rate of treatment success was
reported to be 72%, suggesting a proportion of patients
will still need to undergo surgery despite bracing.
The standard of care for non-operative management
of scoliosis varies widely between North America and
Europe [2, 3], and the use of physiotherapy scoliosis-
specific exercises (PSSE) is not universally established or
accepted. Exercise therapy is well-received by patients
and parents [4], and several systematic reviews and
randomized controlled trials have reported the positive
effects of PSSE on slowing curve progression, improving
cosmetic appearance, and quality of life (QOL) outcomes
[5–7]. Nonetheless, these studies consisted of a hetero-
geneous population receiving mixed treatment regimens,
various stages of skeletal maturity, and non-standardized
outcome measures. Thus, the effect of PSSE on curve
progression in the clinical scenario where the curves are
at the highest risk of progression has remained unclear.
The Schroth method is the most widely studied and
used PSSE approach. It consists of three-dimensional
principles of correction, namely auto-elongation, deflec-
tion, derotation, rotational breathing, and stabilization
[8]. It uses specific rotational angular breathing for
vertebral and rib cage derotation, with muscle activation
and mobilization. It emphasizes postural corrections
throughout the day to change habitual postures and
improve alignment, pain, and progression. The Schroth
method exercises are curve pattern specific and can be
applied in ordinary daily activity, thereby allowing the
patients to spend more time in leisure activities and to
live a normal life [9].
The Society on Scoliosis Orthopaedic and Rehabilitation
Treatment (SOSORT) guidelines recommend the use of
PSSE as a stand-alone therapy, add-on to bracing, and
during the postoperative period [2]. Romano et al.
[10] found that exercises produced a significant
increase in the mechanical forces exerted at rest by
the fiberglass brace in AIS patients. The positive ef-
fects of PSSE can exert its maximal clinical benefit if
it improves the outcome of bracing in patients with
the highest risk for progression. An improvement of
the treatment success of bracing will decrease the
rate of surgical interventions in AIS patients.
Therefore, the aim of this study was to assess
prospectively the effect of Schroth exercise on curve
progression, appearance, and QOL in AIS patients with
high-risk curves during bracing.
Methods
Study design
A prospective, historical cohort-matched study was con-
ducted. The study was done in compliance with the prin-
ciples of Good Clinical Practice and the Declaration of
Helsinki. The local Institutional Review Board approved
the study protocol (Reference Number: UW 17-136). All
patients’parents or legal guardians gave written informed
consent.
Patient enrolment
Consecutive patients with AIS who met the Scoliosis
Research Society (SRS) criteria for bracing [11] and re-
ceived bracing were enrolled for the study. Inclusion cri-
teria were as follows: age of 10 to 15 years, skeletal
immaturity (defined on the Risser scale [12] as 0–2 in-
clusively or R6 U5 score or below on the Distal Radius
Ulna Classification [13]), a Cobb angle for the largest
curve of 25° to 40° [14], and ability to attend all the
physiotherapy sessions. Exclusion criteria were diagnoses
other than AIS, disabilities or systemic illnesses prevent-
ing exercise performance, and any other previous treat-
ment for AIS.
Study interventions
All patients received a rigid underarm orthosis (Fig. 1),
prescribed to be worn for a minimum of 18 h per
day. The SOSORT Management for bracing guidelines
for the physicians, orthotists, and physiotherapists
were followed [15].
Schroth-certified therapist was involved and provided all
the therapy sessions. No other treatments were advised
during the study period.
Experimental group
The Schroth exercise intervention consisted of an indi-
vidualized 8-week outpatient program that included four
initial private training sessions, once every 2 weeks,
where exercises were taught to the patient and their
caregivers. A home exercise program was instituted
thereafter, and patients were required to return for
supervised sessions once every 2 months. Exercises were
given in a pamphlet with a description of the corrective
movements required, the curve type for which they were
recommended, and digital photos of all the exercises
taken during their private sessions which they were
expected to perform at home. Figure 2 illustrates a case
example of a specific curve type and the exercises that
were prescribed.
Kwan et al. Scoliosis and Spinal Disorders (2017) 12:32 Page 2 of 7
Compliance was monitored and verified daily by their
caregivers and during the review sessions by the therapists.
During these sessions, adequate exercise performance was
assessed using a checklist. Attendance was calculated as a
percentage of the prescribed visits attended and com-
pliance as a percentage of the prescribed exercises
completed to the therapists’satisfaction. Compliance
was defined as > 80% of attendance of therapy ses-
sions and completion of the prescribed home exercise
program at least five out of 7 days per week.
Control group
A 1:1 historical cohort who was treated in the same in-
stitute with bracing only and matched for age, gender,
skeletal maturity, and curve magnitude was used as a
control group.
Outcome measures
The outcome measures were radiological deformities
(primary outcome), clinical deformities, and QOL scores
(secondary outcomes).
Cobb angles of all the major structural curves were mea-
sured on a standing posterior-anterior full-spine radio-
graph. Radiographic definitions of change were based on
the SOSORT and SRS non-operative committee consensus
Fig. 1 A typical underarm orthosis for curve whose apex is at T7 or
below, illustrating the view from the anterior (a) and posterior (b)
Fig. 2 An illustrative case demonstrating five sets of exercises prescribed to patients. aRadiograph pre-treatment showing a thoracolumbar major
curve from T11 to L3 with a Cobb angle of 40°. Exercises shown here include the following: bmuscle cylinder in standing, cshoulder counter-traction
in supine, dshoulder counter-traction in prone, eshoulder counter-traction in standing with two poles, and (f) shoulder counter-traction in side-lying.
gRadiograph at the completion of training showing an improvement of Cobb angle to 34.6°
Kwan et al. Scoliosis and Spinal Disorders (2017) 12:32 Page 3 of 7
[16]: improvement as 6° or more, unchanged as ± 5°, and
progressed as 6° or more.
Clinical deformity was recorded in terms of truncal
shift and angle of trunk rotation (ATR). The Bunnell
scoliometer was used to measure the ATR, i.e., the angle
between the horizontal plane and a plane across the pos-
terior aspect of the trunk, of the hump in the main
structural curve with the patient bending forward [17].
The SRS-22 questionnaire is a scoliosis-related QOL
questionnaire that assesses five domains: function, pain,
self-image, mental health (five questions each), and satis-
faction with care (two questions). Each question is
scored from 1 to 5, where 1 is the worst and 5 the best.
The Chinese version was administered, which had been
validated [18].
Adverse effects
Patients were asked to record any serious symptoms or
events they experienced during the study.
Statistics
Student’s paired ttest (p< 0.05) was made for each of
the outcome measures. Sub-analysis was performed
within the experimental group to study the effects of
compliance. The data were analyzed using SPSS 21.0
software.
Results
Subjects
Twenty-four (5 males and 19 females) were recruited
into the experimental group, and 24 patients were
matched in the control group. Both groups did not differ
at baseline for age, gender, Risser sign, and magnitude of
the main structural curves (Table 1). The mean age was
12.3 ± 1.4 years in the experimental group and
11.8 ± 1.1 years in the control group. The experimental
and control groups had a mean follow-up period of
18.1 ± 6.2 and 38.8 ± 11 months, respectively.
Effects of the interventions
After training, the spinal deformity improved in 17% of
the patients in the experimental group (Cobb angle de-
creases by 6° or more), worsened in 21% (Cobb angle in-
creases by 6° or more), and remained stable in 62% (Cobb
angle was ± 5°). In the control group, 4% improved, 50%
worsened, and 46% remained stable.
After training, the mean ATR improved from
9.43° ± 3.27° to 8.45° ± 3.45°, although it did not reach
statistical significance (p= 0.08), and it remained stable
in the control group. There was no statistical significant
difference in the mean truncal shift in the experimental
and the control groups.
For the SRS-22 domains, high scores were noted at
the baseline for both groups (mean of 4.25 ± 0.38 and
4.10 ± 0.52 out of 5). Statistical significant improvements
were found in the experimental group in the function
domain (4.60 ± 0.44 to 4.76 ± 0.33, p= 0.05) and the
total score (4.25 ± 0.38 to 4.45 ± 0.34, p= 0.04) whereas
changes in the other domains did not reach statistical
significance. No significant changes were noted for the
control group in any of the domains or the total score.
Effects of compliance
Brace compliance was rated as good in 70.8% in the
experimental group and 79.2% in the historical cohort
group. In the experimental group, 76.9% of patients who
were compliant to the Schroth exercises had good
bracing compliance, whereas only 63.6% of those who
were non-compliant to the exercises had good bracing
compliance.
In the experimental group, 13 patients were found to
be compliant to Schroth exercises according to our
definition above, and 11 patients did not meet this
criterion. Compliance was strongly associated with curve
improvement (31 vs 0%) and negatively associated with
curve progression (0 vs 46%). Compliance was also posi-
tively associated with improvements in truncal shift from
11.87 ± 8.16 to 7.09 ± 6.41 mm (p= 0.01) and ATR from
10.15° ± 3.65° to 8.69° ± 3.01° (p= 0.043).
Adverse effects
No adverse effects were noted during the study period.
Discussion
This is the first prospective study investigating the effect
of Schroth exercises on curve progression, topographical
Table 1 Baseline characteristics of the scoliosis-specific exercise
and the historical-matched cohort groups
SSE group cohort
group
Number of subjects 24 24
Age (mean/SD) 12.3 (10–14)/1.4 11.83 (10–14)/1.1
Gender (%)
Female 79.2 79.2
Male 20.8 20.8
Risser sign at the start of
treatment (%)
0–1 54.2 79.2
2 29.2 16.7
≥3 16.6 4.2
Region of largest curve (%)
Thoracic 20.8 33.3
Thoracolumbar/lumbar 79.2 66.7
Period of re-assessment/
months (mean/SD)
18.1/6.2 38.75/11
SSE scoliosis specific exercise, SD standard deviation
Kwan et al. Scoliosis and Spinal Disorders (2017) 12:32 Page 4 of 7
changes, and SRS-22 scores in AIS patients during
bracing. The findings of this study show that Schroth
exercises during bracing can increase the proportion of
patients with Cobb angle improvement ≥6° by 6%
compared with bracing alone. In addition, our results
suggest that 20% more patients have improved Cobb an-
gles of ≥6° if they are compliant with Schroth exercises
during bracing compared with bracing alone. However,
the outcomes of non-compliant patients were slight
worse than the historical cohort, which might partly due
to a worse compliance to brace treatment in this group.
Although previous studies have demonstrated the su-
periority of scoliosis-specific exercises in reducing curve
progression, they were performed in a population under-
going conservative treatment for mild AIS only [19–23].
Furthermore, their data cannot be generalized to
rehabilitation under other clinical scenarios, such as
during bracing or after surgical correction. This
preliminary study focused on a group of high-risk
patients who were all treated with bracing. The usual
intervention after treatment failure in these patients
would be surgical correction and fusion and was
recently reported in the BRAIST to be 25–28% [1].
Thus, any further treatment during bracing that can
improve the outcome can lower the surgical rate. We
show that the efficacy of bracing can be further
improved by the addition of Schroth exercises with a
strong compliance-response relationship.
Although there was a trend towards ATR reduction in
the experimental group, it did not reach statistical signifi-
cance in our study. All previous studies that reported ATR
showed a decrease after scoliosis-specific exercises ranging
from 0.33° to 4.23° [24, 25]. Schroth exercises have been
shown to improve the cosmetic appearance in children,
demonstrated in some studies to decrease the height of
the hump [26], and improving waist asymmetry [27]. Al-
though we cannot make a definite conclusion from our
results, a more reliable and valid measure of objective cos-
metic changes needs to be included in future studies.
The effect of the treatment on the SRS-22 scores shows
that Schroth exercises improve the overall QOL in AIS
patients during bracing. However, it is now increasingly
noted that the SRS-22 questionnaire was designed to
study the effects of surgery in AIS and suffers a ceiling
effect in conservative treatments [7, 28, 29]. The high
scores reported at the baseline therefore limit the ability
of this questionnaire to measure large improvements. Dif-
ferent tools, such as SRS-7, Trunk Appearance Perception
Scale (TAPS), Patient-Reported Outcomes Measurement
Information System (PROMIS), and computer adaptive
testing (CAT) instruments, may be administered together
in future studies to detect clinically significant differences
in their function and QOL. Currently, no alternative vali-
dated evaluating tools are available.
Our findings suggest that administering Schroth
exercise program as an outpatient is feasible and has a
reasonable compliance. These results are consistent with
earlier findings that a physiotherapist-supervised Schroth
exercise program is superior to a home-based program
or no treatment [25]. In their study, the supervised
program consisted of 18 sessions (1.5 h a day, 3 days a
week) for 6 weeks. However, this would be too deman-
ding for patients in this locality, and we predicted this
would have deleterious effects on the study enrolment,
the attendance, and compliance rate. We therefore
modified the protocol to four sessions (1 h per session
fortnightly) for 8 weeks. This was a compromise
between maintaining adequate supervision and minima-
lizing disruption to the patients’and their families’lives.
The study has several limitations. First, it was a his-
torical cohort comparison but every effort has been
made to ensure the two groups are compatible by
age, gender, and curve magnitude matching. However,
therewasadifferenceinthefollow-upperiod
between the two groups. At the time of analysis, all
patients in the experimental group had a minimum of
12 months of follow-up, but some patients in the his-
torical cohort had already completed treatment.
Nonetheless, we felt this cohort provided a reasonable
control since the only difference in intervention
between the groups was the addition of Schroth train-
ing. Secondly, exercise compliance and adherence to
treatment could not be fully assured, although the pa-
tients’diaries were checked, and full engagement of
the caregivers ensured accurate data collection.
Thirdly, although brace compliance between the two
groups was comparable, sub-analysis based on
exercise compliance found a difference in brace com-
pliance between the groups and historical control.
Hence, these results should be interpreted with
caution. Fourthly, the therapists could not be blinded
to the treatment group, although the analyses were
done by an independent assessor. Finally, the sample
size in the sub-analysis for compliance is small.
Conclusions
This is the first study to investigate the effects of Schroth
exercises during bracing in patients with a high risk of
curve progression. The findings from this preliminary
study suggest that Schroth exercises during bracing can
further improve the Cobb angle compared with bracing
alone and compliance is associated with greater benefit.
Based on the results of this study and using the current
protocol, appropriate sample size calculation and attrition
rate can be performed for a large-scale trial. Given the
promising findings, a prospective, randomized-controlled
trial to evaluate the effect of Schroth exercises during
brace treatment in AIS patients is now warranted.
Kwan et al. Scoliosis and Spinal Disorders (2017) 12:32 Page 5 of 7
Abbreviations
AIS: Adolescent idiopathic scoliosis; ATR: Angle trunk rotation;
BRAIST: Bracing in Adolescent Idiopathic Scoliosis Trial; CAT: Computer
adaptive testing; PROMIS: Patient-Reported Outcomes Measurement
Information System; PSSE: Physiotherapy scoliosis-specific exercises;
QOL: Quality of life; SOSORT: Society on Scoliosis Orthopaedic and
Rehabilitation Treatment; SRS: Scoliosis Research Society; TAPS: Trunk
Appearance Perception Scale
Acknowledgements
Not applicable.
Funding
None declared.
Availability of data and materials
Please contact author for data requests.
Authors’contributions
KK conceived of the study, participated in the study design, and drafted the
manuscript. ACSC performed the study and statistical analysis. HYK collected
the data and participated in its design and coordination. AYYC participated
in the study design and coordination. KC supervised the study and helped
to draft the manuscript. All authors read and approved the final manuscript.
Ethics approval and consent to participate
This study was approved by the Institutional Review Board of the University of
Hong Kong/Hospital Authority Hong Kong West Cluster (HKU/HA HKW IRB)—IRB
Reference Number: UW 17-136. Written informed consent was obtained from all
participants and/or their legal guardian.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.
Author details
1
Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of
Medicine, The University of Hong Kong, Pokfulam, Hong Kong.
2
Department
of Physiotherapy, Duchess of Kent Children’s Hospital, Sandy Bay, Hong
Kong.
Received: 22 June 2017 Accepted: 30 August 2017
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