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Effectiveness of Schroth exercises during bracing in adolescent idiopathic scoliosis: Results from a preliminary study-SOSORT Award 2017 Winner

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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)
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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 studySOSORT
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
[57]. 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
patientsparents 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 02 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 therapistssatisfaction. 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.
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
Students 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 (1014)/1.4 11.83 (1014)/1.1
Gender (%)
Female 79.2 79.2
Male 20.8 20.8
Risser sign at the start of
treatment (%)
01 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 [1923].
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 2528% [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 patientsand their familieslives.
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-
tientsdiaries 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.
Authorscontributions
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.
PublishersNote
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 Childrens Hospital, Sandy Bay, Hong
Kong.
Received: 22 June 2017 Accepted: 30 August 2017
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Kwan et al. Scoliosis and Spinal Disorders (2017) 12:32 Page 7 of 7
... Although a recent meta-analysis suggests that Schroth programs longer than 6 months seem to be more effective than those shorter than 6 months [14], few studies implement programs lasting more than 6 months [10,14,15]. Furthermore, even in cases where the duration of Schroth exercise programs exceeds 6 months, the exercises are often given as home instructions after a few weeks of supervision rather than being conducted under continuous supervision by a physiotherapist [16,17]. However, Kwan et al. [16] found that a supervised Schroth exercise program resulted in statistically significant improvements in scoliosis severity parameters compared to both a home exercise group and a control group. ...
... Furthermore, even in cases where the duration of Schroth exercise programs exceeds 6 months, the exercises are often given as home instructions after a few weeks of supervision rather than being conducted under continuous supervision by a physiotherapist [16,17]. However, Kwan et al. [16] found that a supervised Schroth exercise program resulted in statistically significant improvements in scoliosis severity parameters compared to both a home exercise group and a control group. ...
... Sessions were held three times a week. The protocol was based on previous similar studies [16,20]. Exercises were performed at the clinic under the supervision of a trained physiotherapist, with each session lasting 60 min. ...
Article
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Background and Objectives: Adolescent Idiopathic Scoliosis (AIS) affects individuals aged 10–18 years and is characterized by spinal deformity, three-dimensional axis deformation, and vertebral rotation. Schroth method exercises and braces have been shown to reduce the Cobb angle and halt spinal deformity progression. The aim of this study was to investigate the impact of a 12-month, supervised Schroth exercise program on scoliosis severity and quality of life in adolescents with AIS. Materials and Methods: Eighty adolescents with AIS (aged 10–17 years) were prescribed a brace and were divided into two groups. The intervention group followed a supervised Schroth exercise program three times a week for 12 months in addition to wearing a brace. The control group used only the brace. Outcomes included the Cobb angle of the main curvature and the sum of curves using radiography, the maximum angle of trunk rotation (ATR maximum, using a scoliometer), and quality of life with the Scoliosis Research Society-22 (SRS-22) questionnaire. Evaluations were conducted at baseline, after 12 months, and 6 months post-intervention. A multivariate analysis of covariance (MANCOVA) was used for statistical analysis (p-Value < 0.05). Results: The intervention group showed statistically significant improvement compared to the control group in the 12th month in Cobb angle (mean differences, 95% CI: −3.65 (−5.81, −1.53), p-Value < 0.001, Cohen’s d = 0.30), ATR maximum (mean differences, 95% CI: −3.05 (−3.86, −2.23), p-Value < 0.001, Cohen’s d = 0.74), and SRS-22 score (mean differences, 95% CI: 0.87 (0.60, 1.13), p-Value < 0.001, Cohen’s d = 0.58). Differences in ATR maximum and SRS-22 score remained significant at the 18-month measurement. No significant differences were found between groups in the sum of curves (p-Value > 0.05). Conclusions: A 12-month supervised Schroth exercise program in AIS patients undergoing brace treatment significantly improves scoliosis severity (Cobb angle and ATR maximum) and quality of life. Improvements were greater than those in shorter-duration studies, suggesting a linear dose–response relationship. Further clinical studies are needed to clarify the impact of long-term Schroth programs.
... Schroth exercises are better for improving the overall quality of life of AIS cases, even during bracing. Therefore, these exercises positively impact treatment, especially on the QOL of patients [15]. The core and trunk are the focus of Schroth exercises and are specially targeted at positioning the entire body in such a manner to establish a stable, corrected posture. ...
... Patients were asked to do the correct pelvic alignment and then perform spinal extension exercises followed by rotational angular breathing (RAB) techniques to bring the spine and ribs into the best position. After completing it, patients were asked to stretch body muscles isometrically to strengthen weak muscles and maintain corrected posture [15]. B. scoliosis correction exercises-First, the patients were asked to perform active self-correction exercises in which strengthening exercises of the side flexors of the trunk (convex side of the curve) and stretching exercises of the side flexors of the trunk (Concave side of the curve) were practiced. ...
Article
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Background: The Adolescent Idiopathic Scoliosis deformity manifests itself during the adolescent development spurt. On the other hand, adolescent therapy aims to lessen curve growth, thus reducing the likelihood of back discomfort, weakness, aberrant pulmonary function, and cosmetic diseases and improving quality of life. Schroth exercises (Rotational breathing exercises) consider the positioning of the entire body to establish a stable, corrected posture. The study aimed to determine the impact of adding rotational angular breathing exercises on the 1-year outcome of mild adolescent idiopathic scoliosis. The study's objectives were to assess the effect on daily living activities using short form 36, assess the effect on respiratory functions using pulmonary function test, and find out the difference in respiratory functions. Methods: Participants in the study were between the ages of 10 and 15 years (19 Male and 17 Female), diagnosed with a specific type of AIS, characterized by Cobb’s angle measurements less than 20° for curves in the thoracic region and less than 15° for curves in the thoracolumbar area. Cases of group 1 had undergone the specific breathing exercise protocol, i.e., Rotational angular breathing exercises; however, other groups followed conventional exercise therapy. Results: A significant finding of this study is that parameters related to quality of life significantly improved in groups (p<0.01), with the test group showing more significant improvement than the conventional group. Following intervention, group 1 appeared with a significantly higher FVC (p=0.001*) of 2.63 ± 0.36 compared to the other group’s FVC of 2.19 ± 0.40. Also, group 1 showed significantly greater FEV1 (p=0.01*) and VC (p=0.002*) after intervention compared to group 2. Conclusion: It was observed that there was a notable improvement in HRQL parameters within the group 1 community. Significant variations in pulmonary function were also observed in this study between the groups, with group 1 showing a significant change in FVC, FEV1, and VC.
... These characteristics make comparison with our work difficult. Kwan's study is more closely related to ours [12]. It is a prospective controlled study, carried out on 48 patients with AIS aged between 10 and 15 years, with a Cobb angle between 25° and 40°, and a Risser test between 0 and 2. The average follow-up was 18.1 months. ...
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Purpose Adolescent Idiopathic Scoliosis (AIS) affects 3% of adolescents. Physiotherapeutic Scoliosis Specific Exercises (PSSE) are recommended to limit AIS progression, especially within intensive multidisciplinary programs. Our study evaluated the efficiency of these programs in AIS cases with a high progression risk. Methods We conducted a controlled retrospective observational study using data collected from a multicenter cohort that was prospectively collected. One hundred and forty-three major AIS cases with a high progression risk, treated with a corrective brace, were included and divided into two matched groups. In the PSSE group, 72 adolescents followed an intensive 4-week PSSE rehabilitation program; in the control group, 71 adolescents did not follow this program. Patient files were assessed at V0 (inclusion), V1 (6 to 12 months after V0) and V2 (≥ 6 months after V1). The evaluation criteria were: change in Cobb angle and percentage of patients reaching surgical stage at V2. Results At V1, 54.2% of patients in the PSSE group showed improvement compared to 16.9% in the control group (p < 0.001). In contrast, 38.9% of patients in the PSSE group were stabilized, compared to 53.3% in the control group (p = 0.2). At V2, 34.7% of patients in the PSSE group improved compared to 15.5.% in the control group (p <0.006). At V2, 55.6% of patients in the PSSE group were stabilised versus 40.8% in the control group (p < 0.05). At V2, 8.3% of patients in the PSSE group reached the surgical stage versus 21.1% in the control group (p = 0.005). Conclusion Our study is an additional argument in favor of using PSSE rehabilitation in AIS.
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Вступ. Неправильне лікування ідіопатичного сколіозу в підлітків може спричинити серйозні проб­леми в майбутньому. Консервативні методи втручання вважають найкращими для управління цим станом, оскільки вони сприяють стабілізації викривлень хребта і поліпшують зовнішній вигляд. Хоча основним методом залишається використання корсетів, нові дослідження вказують на те, що спеціалізовані фізіотерапевтичні вправи можуть бути ефективнішими у лікуванні ідіопатичного сколіозу в підлітковому віці. Через різноманітність наявних методик виникає питання щодо оцінки їх ефективності загалом і визначення переваг окремих методик. Мета роботи – визначити ефективність фізичної реабілітації у профілактиці прогресування сколіозу в підлітків. Основна частина. Аналіз наукової літератури свідчить про те, що ефективність фізіотерапії PSSE можна оцінити за різними показниками, такими, як зміна кута Кобба, кута ротації хребта, поліпшення якості життя (SRS-22), функціональні можливості й зменшення болю. Методику Шрот вважають найбільш дослідженою та ефективною. Вона демонструє статистично значуще зменшення кута Кобба та поліпшення функціональних можливостей пацієнтів. Інші методики, такі, як SEAS і BSPTS, також показують позитивні результати у стабілізації прогресування деформацій. Результати досліджень свідчать про те, що, незважаючи на брак доказів на користь деяких методик, специфічні фізіотерапевтичні вправи можуть значно покращити стан пацієнтів. Висновки. Дослідження підтверджують, що консервативні методи лікування, зокрема фізіотерапевтичні вправи, є пріоритетними, оскільки вони можуть допомогти уникнути або відтермінувати проведення хірургічного втручання. Методика Шрот виявилася найефективнішою у зменшенні кута Кобба і стабілізації деформацій, методики SEAS та BSPTS також продемонстрували позитивні результати. Це свідчить про важливість різноманітних підходів у лікуванні підліткового ідіопатичного сколіозу, що може покращити естетичний вигляд пацієнтів та їх фізичне самопочуття. Незважаючи на позитивні результати, існує брак достовірних наукових досліджень, що підтверджують ефективність усіх використовуваних методик. Подальші дослідження є необхідними для детального оцінювання ефективності альтернативних фізіотерапевтичних підходів.
Article
Background The Schroth method is the most commonly used patient scoliosis-specific exercise paradigm for treating pediatric scoliosis. The aim of this study is to systematically and critically examine the evidence for the Schroth method for pediatric scoliosis. Methods PubMed, MEDLINE, CINAHL, and Web of Science were searched through April 5, 2024, for articles examining the Schroth method for pediatric scoliosis (<18 years old). Thirteen review questions were created spanning the study aim. Each included article was independently assessed for the level of evidence (I-IV). Research questions were given a grade of recommendation (A, B, C, and I [insufficient]). Results A total of 29 articles (41.4% Level I, 31.0% Level II, 13.8% Level II, and 13.8% Level IV) met inclusion criteria out of 845 initially retrieved, describing 1,555 patients with scoliosis aged 4 to 18 years. There was grade A evidence that the Schroth method is most commonly used for adolescent idiopathic scoliosis (AIS), can improve the angle of trunk rotation, and is safe; grade B evidence for improvement in posture; and grade I evidence for improvement in Cobb angle, cosmetic deformity, quality of life, ideal treatment parameters, economic value, utility in delaying/preventing surgery, effectiveness in relation to patient characteristics (e.g., skeletal maturity or curve size), and comparative effectiveness to other conservative interventions. Conclusion While there is good evidence that the Schroth method is commonly and safely used in AIS and can minimally improve the angle of trunk rotation and fair evidence of improvement in posture, there is insufficient evidence regarding multiple important clinical and economic outcomes, such as comparative effectiveness to other conservative interventions and improvement of Cobb angle. Although clinicians may consider the Schroth method as 1 option of several conservative strategies, clinical benefit may be limited, and further high-quality research is needed to evaluate its performance in areas of insufficient evidence.
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Preoperative spine flexibility plays a key role in the intraoperative treatment course of severe scoliosis. In this cohort study, we examined the effects of 5 day inpatient scoliosis-specific exercise (SSE) on the spinal flexibility of patients with adolescent idiopathic scoliosis before surgery. A total of 65 patients were analyzed. These patients were divided into a prospective cohort (n = 43, age: 15 ± 1.6 years, 36 girls and 7 boys, Lenke class 1 and 2, Cobb angle: 64 ± 11°) who underwent spinal fusion in 2020, and a retrospective cohort (n = 22, age: 15 ± 1.5 years, 17 girls and 5 boys, Lenke class 1 or 2, Cobb angle: 63 ± 10°), who underwent surgery between 2018 and 2019 and did not receive preoperative SSE. Rigid scoliosis was defined as a reduction of less than 50% in Cobb angle between the preoperative fulcrum bending and initial standing curve magnitude. In the prospective cohort, 21 patients (Cobb angle: 65 ± 11°) presented with rigid thoracic scoliosis (pre-SSE fulcrum bending: 40 ± 9°, 39% reduction), and therefore received 5-day SSE to improve their preoperative spinal flexibility (SSE group), whereas 22 patients (Cobb angle: 63 ± 12°) presented with flexible thoracic scoliosis (pre-SSE fulcrum bending: 27 ± 8°, 58% reduction), and therefore underwent surgery without preoperative SSE (non-SSE group). For patients who received 5-day preoperative SSE for 4 h every day, the International Schroth Three-Dimensional Scoliosis Therapy technique was implemented with an inpatient model. After 5 days of SSE, improvements in Cobb angle with post-SSE fulcrum-bending radiography (23 ± 7°, 66% reduction) and pulmonary function (forced expiratory volume in 1 s/forced expiratory volume: 87% before SSE and 92% after SSE, p < 0.01) were observed. At the postoperative day 5, the degree of scoliosis had reduced from 44 ± 6.6° to 22 ± 6° in the SSE group, which is 1° less than the Cobb angle obtained on post-SSE fulcrum-bending radiography. In the non-SSE group, the degree of scoliosis decreased to 26 ± 5.7°. In the retrospective cohort, the degree of scoliosis decreased to 35 ± 5°, with the group also having higher postoperative pain (Visual Analog Scale score = 7, range = 5–10) and an extended hospitalization duration (11 ± 3 days). At 2-year follow-up, curve correction was found to be maintained without adding-on or proximal junctional kyphosis. Compared with the non-SSE group, the SSE group exhibited a greater curve correction (66%) with a shorter hospitalization duration (5 ± 1 days) and a lower degree of postoperative pain (Visual Analog Scale score = 4, range = 3–8). Taken together, our findings indicate that 5 day SSE improves preoperative spinal flexibility and facilitates curve correction.
Article
Дослідження та аналіз науково-методичної літератури показали зростання проблем і захворювань опорно-рухового апарату в дітей молодшого шкільного віку. У період стрімкого зросту важливо вчасно діагностувати захворювання і вжити заходів щодо лікування та реабілітації дитини. Проаналізувавши методики діагностики захворювань опорно-рухового апарату в дітей та корекцію порушень, ознайомились із найбільш ефективними методами та засобами фізичної терапії для корекції деформацій та з’ясували відмінності в підходах до проблеми і недосконалості в питаннях вибору методів корекції рухового стану дітей. Під час проведення дослідження було теоретично обґрунтовано та розроблено алгоритм застосування засобів фізичної терапії для відновлення дітей зі сколіозом. Розроблено та впроваджено комплексну програму фізичної терапії дітей молодшого шкільного віку із С-образним сколіозом грудного відділу хребта. Комплекс заходів базувався на поєднанні сучасних методів і засобів фізичної реабілітації та доведеній ефективності застосування вправ за методом Шрот для формування та закріплення навички правильної постави в повсякденному житті. Застосування методики Шрот допомагає фіксувати правильне положення спини, покращує поставу, усуває косметичні дефекти, зменшує больові відчуття, нормалізує дихання та покращує респіраторну функцію, зупиняє розвиток сколіозу, дає можливість підняти самооцінку і покращити психологічний стан пацієнта, навчає контролю над власним тілом, покращує якість життя. Результати, що були отримані після впровадження програми фізичної терапії, дозволили знизити ступінь прояву порушень постави, покращили фізичну підготовленість дітей та допомогли підтвердити, що порушення постави в дітей молодшого шкільного віку успішно коригуються за допомогою запропонованої програми фізичної терапії. Також результати дослідження можуть бути корисними під час подальшого вивчення даної теми та розроблення нових методів фізичної реабілітації в разі порушення постави в дітей та дорослих.
Article
The purpose of this study was to evaluate evidence on the effectiveness of combined bracing and exercise on adolescent idiopathic scoliosis (AIS). From inception to April 28, 2022, PubMed and Web of Science searched for randomized clinical and nonrandomized prospective studies reporting Cobb angle (CA), angle of trunk rotation (ATR), quality of life (QoL), and pulmonary function (PF) in AIS patients treated with exercise and braces (10 years-skeletal maturity). Two authors analyzed and extracted data for this review. The PEDro scale was used to assess the risk of bias (RoB). Therapy protocols and basic data have been collected. Each CA, ATR, QoL, and PF study’s evidence and strength were also included. A total of 12 studies with 714 patients with AIS were included. Five studies used a control group with exercises and 7 with braces. The results showed that exercise-brace can decrease CA and ATR and increase QoL and PF with AIS; however, the strength of conclusion for all outcomes was moderate. In this review, 4 studies were categorized as low RoB, 3 as moderate RoB, and 5 as high RoB. Level of evidence analysis revealed that 12 studies were classified as level of evidence B. The current studies do not sufficiently support the effects of exercise and brace therapy on CA, ATR, QoL, and PF in patients with AIS.
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Background Positive effects of brace treatments in adolescent idiopathic scoliosis patients on gait were proven. Aim Therefore, this study examined whether the influence of brace therapy in combination with Schroth therapy influencing the plantar pressure distribution, pre and post intensive rehabilitative inpatient treatment. Design Prospective cohort study, longitudinal. Setting Scoliosis rehabilitation clinic “Asklepios Katharina-Schroth-Klinik” (Bad Sobernheim, Germany). Population Twenty (14f/6m) patients (12–16 years) had a medically diagnosed moderate idiopathic scoliosis (Cobb angle 20–50°, Median 30°) and an indication for combined brace and Schroth therapy with an inpatient stay (4 weeks) at the Asklepios Katharina Schroth Clinic (Germany). Methods At the beginning (T1) and at the end of the stay (T2), the plantar pressure distribution with (A) and without wearing a brace (B) was recorded (walking distance 10 m). Results No significant differences between the left and right foot were found at baseline (T1). The T1 - T2 comparison of one foot revealed significant differences (p ≤ 0.05 − 0.001, respectively) for (A): mean pressure right midfoot, loaded area total left foot, left midfoot, left inner ball of foot, right midfoot, impulse total right foot, right midfoot and for (B): mean pressure right midfoot, right outer ball of foot, loaded area total right foot, right heel, right midfoot, impulse right heel, right midfoot, right outer ball of foot. Conclusions A combined brace and Schroth therapy maintains the initial symmetrical plantar pressure distribution over the duration of four weeks since the significant differences fall within the range of measurement error. Clinical rehabilitation impact The insole measuring system can be used to objectively support therapeutic gait training as part of rehabilitation and to assess insole fitting based on foot shape. Due to its convenient handling and rapid data acquisition, it may be a suitable method for interim or follow-up diagnostics in the treatment of idiopathic scoliosis.
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Abstract In recent decades, there has been a call for change among all stakeholders involved in scoliosis management. Parents of children with scoliosis have complained about the so-called “wait and see” approach that far too many doctors use when evaluating children’s scoliosis curves between 10° and 25°. Observation, Physiotherapy Scoliosis Specific Exercises (PSSE) and bracing for idiopathic scoliosis during growth are all therapeutic interventions accepted by the 2011 International Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT). The standard features of these interventions are: 1) 3-dimension self-correction; 2) Training activities of daily living (ADL); and 3) Stabilization of the corrected posture. PSSE is part of a scoliosis care model that includes scoliosis specific education, scoliosis specific physical therapy exercises, observation or surveillance, psychological support and intervention, bracing and surgery. The model is oriented to the patient. Diagnosis and patient evaluation is essential in this model looking at a patient-oriented decision according to clinical experience, scientific evidence and patient’s preference. Thus, specific exercises are not considered as an alternative to bracing or surgery but as a therapeutic intervention, which can be used alone or in combination with bracing or surgery according to individual indication. In the PSSE model it is recommended that the physical therapist work as part of a multidisciplinary team including the orthopeadic doctor, the orthotist, and the mental health care provider - all are according to the SOSORT guidelines and Scoliosis Research Society (SRS) philosophy. From clinical experiences, PSSE can temporarily stabilize progressive scoliosis curves during the secondary period of progression, more than a year after passing the peak of growth. In non-progressive scoliosis, the regular practice of PSSE could produce a temporary and significant reduction of the Cobb angle. PSSE can also produce benefits in subjects with scoliosis other than reducing the Cobb angle, like improving back asymmetry, based on 3D self-correction and stabilization of a stable 3D corrected posture, as well as the secondary muscle imbalance and related pain. In more severe cases of thoracic scoliosis, it can also improve breathing function. This paper will discuss in detail seven major scoliosis schools and their approaches to PSSE, including their bracing techniques and scientific evidence. The aim of this paper is to understand and learn about the different international treatment methods so that physical therapists can incorporate the best from each into their own practices, and in that way attempt to improve the conservative management of patients with idiopathic scoliosis. These schools are presented in the historical order in which they were developed. They include the Lyon approach from France, the Katharina Schroth Asklepios approach from Germany, the Scientific Exercise Approach to Scoliosis (SEAS) from Italy, the Barcelona Scoliosis Physical Therapy School approach (BSPTS) from Spain, the Dobomed approach from Poland, the Side Shift approach from the United Kingdom, and the Functional Individual Therapy of Scoliosis approach (FITS) from Poland.
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In North America, care recommendations for adolescents with small idiopathic scoliosis (AIS) curves include observation or bracing. Schroth scoliosis-specific exercises have demonstrated promising results on various outcomes in uncontrolled studies. This randomized controlled trial (RCT) aimed to determine the effect of Schroth exercises combined with the standard of care on quality-of-life (QOL) outcomes and back muscle endurance (BME) compared to standard of care alone in patients with AIS. Material and Methods Fifty patients with AIS, aged 10–18 years, with curves 10–45 °, recruited from a scoliosis clinic were randomized to receive standard of care or supervised Schroth exercises plus standard of care for 6 months. Schroth exercises were taught over five sessions in the first two weeks. A daily home program was adjusted during weekly supervised sessions. The assessor and the statistician were blinded. Outcomes included the Biering-Sorensen (BME) test, Scoliosis Research Society (SRS-22r) and Spinal Appearance Questionnaires (SAQ) scores. Intention-to-treat (ITT) and per protocol (PP) linear mixed effects models were analyzed. Because ITT and PP analyses produced similar results, only ITT is reported. After 3 months, BME in the Schroth group improved by 32.3 s, and in the control by 4.8 s. This 27.5 s difference in change between groups was statically significant (95 % CI 1.1 to 53.8 s, p = 0.04). From 3 to 6 months, the self-image improved in the Schroth group by 0.13 and deteriorated in the control by 0.17 (0.3, 95 % CI 0.01 to 0.59, p = 0.049). A difference between groups for the change in the SRS-22r pain score transformed to its power of four was observed from 3 to 6 months (85.3, 95 % CI 8.1 to 162.5, p = 0.03), where (SRS-22 pain score) 4 increased by 65.3 in the Schroth and decreased by 20.0 in the control group. Covariates: age, self-efficacy, brace-wear, Schroth classification, and height had significant main effects on some outcomes. Baseline ceiling effects were high: SRS-22r (pain = 18.4 %, function = 28.6 %), and SAQ (prominence = 26.5 %, waist = 29.2 %, chest = 46.9 %, trunk shift = 12.2 % and shoulders = 18.4 %). Supervised Schroth exercises provided added benefit to the standard of care by improving SRS-22r pain, self-image scores and BME. Given the high prevalence of ceiling effects on SRS-22r and SAQ questionnaires’ domains, we hypothesize that in the AIS population receiving conservative treatments, different QOL questionnaires with adequate responsiveness are needed. Trial registration Schroth Exercise Trial for Scoliosis NCT01610908.
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Objective: To determine the effectiveness of 3-dimensional therapy in the treatment of adolescent idiopathic scoliosis. Methods: We carried out this study with 50 patients whose average age was 14.15 +/-1.69 years at the Physical Therapy and Rehabilitation School, Hacettepe University, Ankara, Turkey, from 1999 to 2004. We treated them as outpatients, 5 days a week, in a 4-hour program for the first 6 weeks. After that, they continued with the same program at home. We evaluated the Cobb angle, vital capacity and muscle strength of the patients before treatment, and after 6 weeks, 6 months and one year, and compared all the results. Results: The average Cobb angle, which was 26.10 degrees on average before treatment, was 23.45 degrees after 6 weeks, 19.25 degrees after 6 months and 17.85 degrees after one year (p<0.01). The vital capacities, which were on average 2795 ml before treatment, reached 2956 ml after 6 weeks, 3125 ml after 6 months and 3215 ml after one year (p<0.01). Similarly, according to the results of evaluations after 6 weeks, 6 months and one year, we observed an increase in muscle strength and recovery of the postural defects in all patients (p<0.01). Conclusion: Schroth`s technique positively influenced the Cobb angle, vital capacity, strength and postural defects in outpatient adolescents.
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Objective To compare the efficacy of three-dimensional (3D) Schroth exercises in patients with adolescent idiopathic scoliosis. Design A randomised-controlled study. Setting An outpatient exercise-unit and in a home setting. Subjects Fifty-one patients with adolescent idiopathic scoliosis. Interventions Forty-five patients with adolescent idiopathic scoliosis meeting the inclusion criteria were divided into three groups. Schroth’s 3D exercises were applied to the first group in the clinic and were given as a home program for the second group; the third group was the control. Main Measures Scoliosis angle (Cobb method), angle of rotation (scoliometer), waist asymmetry (waist – elbow distance), maximum hump height of the patients and quality of life (QoL) (SRS-23) were assessed pre-treatment and, at the 6th, 12th and 24th weeks. Results The Cobb (-2.53°; P=0.003) and rotation angles (-4.23°; P=0.000) significantly decreased, which indicated an improvement in the clinic exercise group compared to the other groups. The gibbosity (-68.66mm; P=0.000) and waist asymmetry improved only in the clinic exercise group, whereas the results of the other groups worsened. QoL did not change significantly in either group. Conclusion According to the results of this study the Schroth exercise program applied in the clinic under physiotherapist supervision was superior to the home exercise and control groups; additionally, we observed that scoliosis progressed in the control group, which received no treatment.
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Background The role of bracing in patients with adolescent idiopathic scoliosis who are at risk for curve progression and eventual surgery is controversial. Methods We conducted a multicenter study that included patients with typical indications for bracing due to their age, skeletal immaturity, and degree of scoliosis. Both a randomized cohort and a preference cohort were enrolled. Of 242 patients included in the analysis, 116 were randomly assigned to bracing or observation, and 126 chose between bracing and observation. Patients in the bracing group were instructed to wear the brace at least 18 hours per day. The primary outcomes were curve progression to 50 degrees or more (treatment failure) and skeletal maturity without this degree of curve progression (treatment success). ResultsThe trial was stopped early owing to the efficacy of bracing. In an analysis that included both the randomized and preference cohorts, the rate of treatment success was 72% after bracing, as compared with 48% after observation (propensity-score-adjusted odds ratio for treatment success, 1.93; 95% confidence interval [CI], 1.08 to 3.46). In the intention-to-treat analysis, the rate of treatment success was 75% among patients randomly assigned to bracing, as compared with 42% among those randomly assigned to observation (odds ratio, 4.11; 95% CI, 1.85 to 9.16). There was a significant positive association between hours of brace wear and rate of treatment success (P<0.001). Conclusions Bracing significantly decreased the progression of high-risk curves to the threshold for surgery in patients with adolescent idiopathic scoliosis. The benefit increased with longer hours of brace wear. (Funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and others; BRAIST ClinicalTrials.gov number, NCT00448448.)
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