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RESEARCH REPORTS

Physical Therapy Scoliosis-Specific Exercises May Reduce Curve Progression in Mild Adolescent Idiopathic Scoliosis Curves

Zapata, Karina A. DPT, PhD; Sucato, Daniel J. MD, MS; Jo, Chan-Hee PhD

Author Information
doi: 10.1097/PEP.0000000000000621
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INTRODUCTION

Adolescents with adolescent idiopathic scoliosis (AIS) have the highest risk of curve progression during the period of rapid growth prior to achieving skeletal maturity.1,2 Curve magnitude measured by the Cobb angle is the most important outcome measure in determining medical management of AIS.3

The Cobb angle is determined on radiograph by measuring the angle formed at the intersection of 2 perpendicular lines drawn at the end vertebrae. The end vertebrae, or top and bottom of the curve, have the greatest amount of tilt. To account for measurement error, a curve must increase at least 5° before it is considered a true change and to have progressed.1 The standard medical management for AIS is observation for skeletally immature mild curves (10°-25°), bracing for skeletally immature moderate curves (25°-45°), and surgery for severe curves (>45°).1 Risser grades, triradiate cartilage status, and menarche status provide useful clinical estimations of skeletal immaturity and the resulting risk of curve progression.4 Risser grades and triradiate cartilage status are collected from radiographs. The Risser grade rates a participant's skeletal maturity based on the ossification of the iliac apophysis from 0 (no ossification; skeletally immature) to 5 (fused ossified apophysis; skeletally mature).5 The triradiate cartilage status of the acetabulum is another radiographic index of skeletal maturity and typically closes before Risser grade 1 and menarche.4,6 Participants with mild curves who are Risser grade 0 are at a high risk of curve progression7 and may demonstrate muscle asymmetries.8

In the United States, physical therapy (PT) is not widely prescribed by physicians to manage AIS due to a lack of evidence supporting the concept that exercise alters the natural history of scoliosis.2,9,10 However, little research from the United States has evaluated the effectiveness of physical therapy scoliosis-specific exercises (PSSEs) in reducing curve progression. Other countries use PSSE to reduce curve progression and brace prescription, to enhance brace wear, and to improve quality of life.3,10,11 The various types of PSSE focus on autocorrection in 3 dimensions, stabilizing the corrected posture, and maintaining the corrected posture with daily activities.12,13 PSSEs are viewed as effective conservative treatments of scoliosis that could be offered to people with AIS.3,14 The PSSE method with the longest history is the Schroth method.15–17 The Barcelona Scoliosis Physical Therapy School (BSPTS), widely referred to as the Schroth-based method, teaches the original principles of Schroth.17 The Schroth and BSPTS methods both use corrective movements and breathing to open concave areas and contain prominences.18

Since current clinical practice does not typically include PT, implementing PSSE to manage AIS is controversial, but shows promise.11,19 Systematic reviews conclude that exercises may be effective in reducing curve progression and reducing brace prescription.11,14 The evidence quality in the systematic reviews is low, with only 1 randomized controlled trial (RCT) included. Since the latest systematic reviews, results from 3 RCTs supported that PSSEs were effective in reducing curve progression.13,20,21

Skeletally immature adolescents with mild AIS curves are at the highest risk of curve progression and have a greater potential for a meaningful effect with early intervention before the growth spurt and curve acceleration phase.4 A smaller curve is more flexible22 and may be more amenable to changes from exercise before spinal growth is complete. Increasing efforts are being made to prevent a scoliotic curve from progressing past 30° at skeletal maturity. Curves less than 30° are less likely to progress into adulthood than curves greater than 30°, and mechanical wedging of the immature disc and vertebral body may be reversible.23 The primary aim of this study is to assess whether the Schroth-based method is effective in skeletally immature participants with mild AIS curves at high risk of progression, compared with the standard of care of observation (control) in reducing curve magnitude, curve progression, and brace prescription after 1 year of intervention. The secondary aim is to assess whether the Schroth-based method is more effective than observation in improving participant perception of spinal appearance and quality of life after 1 year.

MATERIALS AND METHODS

This study is a prospective cohort study to compare 2 groups (exercise group and control group).

Participants

A power analysis indicated that 14 participants per group were needed to detect a 1.11 standard deviation of the difference in Cobb angles (1 year minus baseline) to achieve 80% power at the .05 significance level. We assumed the standard deviation of the difference to be 5.6 for each group and expected a 70% follow-up rate. Girls and boys between 10 and 17 years with AIS major curve Cobb angles 12° to 20°, Risser grade 0, and no current or previous brace wear were recruited from all scoliosis clinics at this institution. Participants were excluded if they had developmental disorders that prevented understanding and compliance with an exercise schedule, current or previous brace wear, previous spine surgery, and inability to commit to attend at least 8 hours of PT within 6 months. The curve magnitude range was chosen, as it represented true scoliosis curves that did not require bracing, so a bias was avoided from brace wear.

A written informed assent was obtained from adolescent participants and legal guardians. This study was approved by the Institutional Review Board at University of Kentucky. The primary outcome measures were collected by approved research personnel masked to group assignment.

Outcome Measures

The primary outcome measures were curve magnitude of the primary curve according to the Cobb angle,2 the incidence of curve progression, and brace prescription. One research assistant masked to group type measured the Cobb angle at baseline, 6-month, and 1-year follow-up. The secondary outcome measures were the Spinal Appearance Questionnaire (SAQ)24 and the Scoliosis Research Society-22r Health-Related Quality-of-Life Questionnaire (SRS-22r).25

Procedures

Exercise Group

Participants in this group had at least 8 hours of PT sessions within 6 months with a physical therapist certified in BSPTS at this institution. The Schroth-based exercises were prescribed according to participants' curve patterns and abilities to perform the exercises. Participants committed to a home exercise program (HEP) for 15 minutes a day, 3 days a week. Participants performed 5 Schroth-based exercises in a variety of positions (supine, sitting, side-lying, prone, and standing positions). Each participant met successful independent exercise execution before being discharged to an HEP. Participants saw a physical therapist again if they requested a “refresher” of their HEP. Their responsible orthopedic surgeon followed up participants every 3 to 9 months, depending on the treating orthopedic surgeon's preference.

A secure web application and browser-based research database, Research Electronic Data Capture (REDCap) was used to monitor exercise adherence. A weekly 2-question survey e-mail asked how many days and minutes total participants performed their exercises the previous week. Participants or caregivers responded to the weekly e-mails. Treating physical therapists had administrator access to monitor exercise adherence at any time. Exercise adherence for a given participant was calculated by the percentage of completed exercises from the prescribed exercises from baseline to the end points at 6-month and 1-year follow-up.

Control Group

Participants in this group continued receiving the standard of care (observation). Observation included clinical assessment by an orthopedic surgeon every 3 to 9 months to detect curve progression before deciding whether bracing was required.

Statistical Analysis

Statistical analysis was done using SAS software (version 9.4) and SPSS (version 24). Baseline characteristics were calculated with means and standard deviations, and ranges for continuous variables and frequency distributions for categorical variables. We compared categorical variables using a Fisher exact test. For continuous variables, transformations of variables ensured that normality assumptions were satisfied. If necessary, a nonparametric test such as the Mann-Whitney test was used. In addition, paired t tests were used for within-group changes (P < .05).

RESULTS

Participants

Forty-nine participants (26 in exercise group and 23 in control group) with AIS curves 12° to 20° and Risser grade 0 were seen at baseline. The baseline curve magnitude was 16.2° ± 3.2° in the exercise group and 14.7° ± 3.6° in the control group. A gender imbalance was found between participants in the exercise and control groups, but a comparison between genders within the exercise group did not show significant differences in curve progression at 1-year follow-up (P = .34).

Thirty-six participants (20 exercise and 16 controls) were seen at 6-month follow-up. Curves in the exercise group averaged 16.7° ± 4.9° and in the control group 17.5° ± 5.3° (P = .64). Participants in the exercise group averaged 2.4 ± 0.7 days (80%), 34 ± 12 minutes (77%) per week of exercise adherence from baseline to 6 months.

Thirty-three participants (19 exercise and 14 controls) were seen at 1-year follow-up. No between-group differences were seen in baseline age, Risser grade, status of the triradiate cartilage, or the amount of growth over the 1-year period. Participant characteristics at baseline are in Table 1, and Table 2 has participant characteristics at 1-year follow-up. Participants in the exercise group averaged 1.8 ± 1.0 days (60%), 26 ± 19 minutes (58%) per week of exercise adherence from 6-month to 1-year follow-up. At 1-year follow-up, the dropout rate was 27% in the exercise group, and 39% in the control group.

TABLE 1 - Characteristics of Participants at Baseline Who Were Seen at 1-Year Follow-upa
Control Group (n = 14) Exercise Group (n = 19) P Value
Age 11.8 ± 0.9 12.5 ± 1.5 .18
Curve magnitude 16.0° ± 3.2° 16.3° ± 3.4° .94
Gender
Female 14 12 .03
Male 0 7
Ethnicity
Caucasian 11 16 .65
Hispanic 1 2
Asian 2 1
Body mass index, kg/m2 19.0 ± 4.9 17.1 ± 2.0 .32
Physical activity, h/wk 4.5 ± 4.1 4.2 ± 3.3 .90
Menarche
Pre 13 11 >.99
Post 1 1
n/a 0 7
Triradiate cartilage
Open 12 16 >.99
Closed 2 3
Curve pattern classification
Thoracic 5 3 .29
Double major 4 6
TL/L 5 10
Abbreviations: L, lumbar; n/a, non-applicable; TL, thoracolumbar.
aData are mean ± standard deviation.

TABLE 2 - Characteristics of Participants at 1-Year Follow-upa
Control Group (n = 14) Exercise Group (n = 19) P Value
Curve magnitude 21.6° ± 6.1° 16.3° ± 5.8° .04
Body mass index, kg/m2 19.8 ± 5.2 18.2 ± 2.2 .53
Growth, % height, cm 6.6 (6.3% ± 2.6%) 8 (8.0% ± 4.0%) .52
Menarche
Pre 6 4 .70
Post 8 8
n/a 0 7
Triradiate cartilage
Open 2 5 .86
Closed 12 14
Risser grade 1.4 ± 1.4 1.3 ± 1.4 .44
Abbreviation: n/a, non-applicable.
aData are mean ± standard deviation.

Primary

Curve Magnitude in Participants With 1-Year Follow-up

Curve magnitude outcomes were evaluated at baseline (n = 33), 6-month follow-up (n = 29), and 1-year follow-up (n = 33) in participants who returned for 1-year follow-up to ensure that curve magnitude comparisons applied to the same individuals (Table 3). After 6 months, there was no significant curve difference between the exercise and control groups (16.6° vs 19.3°). However, the control group's curve magnitudes significantly increased at 6 months (3.6°, P = .02). The exercise group's curve magnitude did not significantly increase at 6 months (0.4°).

TABLE 3 - Curve Magnitude (°) of Exercise Group and Control Group According to Mean ± Standard Deviation at Baseline, 6-Month Follow-up, and 1-Year Follow-upa
Exercise Group Control Group P Value P Value Within Exercise Group P Value Within Control Group
Baseline 16.3 ± 3.4 (n = 19) 16.0 ± 3.2 (n = 14) .94
6-mo follow-up 16.6 ± 5.2 (n = 17) 19.3 ± 4.9 (n = 12) .15
1-y follow-up 16.3 ± 5.8 (n = 19) 21.6 ± 6.1 (n = 14) .04b
Change from baseline to 6 mo 0.4 ± 5.5 (n = 17) 3.6 ± 4.0 (n = 12) .09 .76 .02b
Change from baseline to 1 y 0.0 ± 5.6 (n = 19) 5.6 ± 5.5 (n = 14) .02b .97 <.01b
Change from 6 mo to 1 y −0.4 ± 3.8 (n = 17) 0.7 ± 4.4 (n = 12) .58 .71 .55
aData are mean ± standard deviation.
bStatistical significance (P < .05).

At 1-year follow-up, the exercise group had significantly smaller curves than the control group (16.3° vs 21.6°, P = .04). The control group's curve magnitude significantly increased from baseline to 1-year follow-up (5.6°, P < .01), but did not significantly increase from 6 months to 1 year (0.7°). The exercise group's curve magnitude did not change from baseline to 1 year (0.0°) and from 6 months to 1 year (−0.4°). The control group's curve magnitude significantly increased compared with the exercise group from baseline to 1 year (P = .02), but did not significantly increase compared with the exercise group from baseline to 6 months and from 6 months to 1 year.

Curve Progression

At 1-year follow-up, 3 of 19 curves (16%) progressed more than 5° in the exercise group, averaging 7° ± 2° of curve progression. Seven of 14 curves (50%) progressed more than 5° in the control group, averaging 10° ± 4° of curve progression. Eleven curves (58%) remained stable (ie, had 0°-5° of change) in the exercise group, and 7 curves (50%) remained stable in the control group. Five curves (25%) improved more than 5° in the exercise group, averaging 7° ± 2° of improvement (Figure). The curve types that improved included 4 thoracolumbar curves (2 right and 2 left) and 1 right thoracic curve. No curves improved more than 5° in the control group.

Fig.
Fig.:
X-rays of participant in PSSE group at baseline (left) and at 1-year follow-up (right).

Brace Prescription

At 1-year follow-up, 7 participants in the exercise group (37%) and 6 participants in the control group (43%) were braced. In the exercise group, 3 participants were prescribed night-time braces and 4 participants were prescribed full-time braces. In the control group, 4 participants were prescribed night-time braces and 2 participants were prescribed full-time braces. Bracing was initiated in curves smaller than 25° in 6 of 7 participants in the exercise group and 4 of 6 participants in the control group. One participant met the SRS bracing criteria in the exercise group (5%) and 3 participants met the SRS bracing criteria in the control group (21%), which was not significantly different (P = .28).

Curve magnitude outcomes were evaluated in participants who were not prescribed a brace to avoid potential effects of brace wear on curve magnitude (Table 4). Although the exercise group did not have significantly smaller curves than the control group at 1-year follow-up (14.3° vs 20.1°), the control group's curve magnitude significantly increased compared with the exercise group from baseline to 1 year (P = .04).

TABLE 4 - Curve Magnitude (°) of Exercise Group and Control Group in Nonbraced Patients According to Mean ± Standard Deviation at Baseline, 6–Month Follow-up, and 1-Year Follow-upa
Exercise Group Control Group P Value P Value Within Exercise Group P Value Within Control Group
Baseline 16.5 ± 3.4 (n = 12) 16.3 ± 3.1 (n = 8) .78
6-mo follow-up 14.8 ± 4.1 (n = 11) 17.1 ± 3.8 (n = 7) .27
1-y follow-up 14.3 ± 5.4 (n = 12) 20.1 ± 7.1 (n = 8) .10
Change from baseline to 6 mo −1.5 ± 4.6 (n = 11) 1.1 ± 2.2 (n = 7) .16 .33 .28
Change from baseline to 1 y −2.2 ± 5.0 (n = 12) 3.9 ± 3.0 (n = 8) .04b .20 .11
Change from 6 mo to 1 y −0.2 ± 2.9 (n = 11) 0.7 ± 1.0 (n = 7) .68 .86 .61
aData are mean ± standard deviation.
bStatistical significance (P < .05).

Secondary

Perception of Spinal Appearance

Participants averaged 1.7 ± 0.4 in both groups on the SAQ subtotal at baseline. At 1-year follow-up, participants averaged 1.8 ± 0.7 in the exercise group and 1.6 ± 0.4 in the control group on the SAQ subtotal, which was not significantly different.

We analyzed Question #9 individually, which states “I want to be more even,” with 1 = not true, and 5 = very true. At baseline, participants in the exercise group averaged significantly worse (higher) scores than the control group on the SAQ Question #9 (3.5 ± 1.6 vs 2.2 ± 1.4, P = .04). At 1 year, participants in the exercise group did not average better (lower) scores on the SAQ Question #9 than the control group (1.8 ± 0.7 vs 3.0 ± 0.5, P = .05). The exercise group averaged significantly better (lower) scores on the SAQ Question #9 than the exercise group from baseline to 1-year follow-up (−1.4 ± 1.7 vs 0.9 ± 1.5, P = .02). Participants in the control group wanted to be more even than participants in the exercise group.

Quality of Life (SRS-22r)

Participants averaged 4.5 ± 0.3 in the exercise group and 4.4 ± 0.4 in the control group on the SRS-22r at baseline. At 1-year follow-up, participants averaged 4.5 ± 0.3 in the exercise group and 4.4 ± 0.4 on the SRS-22r, which was not significantly different.

DISCUSSION

Curves in the exercise group overall remained stable. Curves in the control group progressed at least 5°, which is considered a true change, as 5° is greater than the average measurement error1 and considered clinically important.26 Our results strengthen the evidence supporting PSSE for AIS, and in particular an outpatient model using the Schroth-based method in skeletally immature AIS participants with mild curves.

Two recent RCTs implementing outpatient-based PSSE for AIS also found improved Cobb angle outcomes in the PSSE groups. Schreiber et al13 reported that participants' curves averaging 28° to 29° at baseline improved 1.2° in the PSSE group and worsened 2.3° in the control group after 6 months. Kuru et al21 reported that curves averaging 30° to 33° at baseline improved 2.5° in the supervised PSSE group, worsened 3.3° in the unsupervised PSSE group, and worsened 3.1° in the control group after 6 months. Participants in both studies were more skeletally mature (Risser 0-5 and Risser 0-3, respectively) and had larger curve magnitudes (10°-45° and 10°-60°, respectively) than our participants (Risser 0, curves 12°-20°). Schreiber and Kuru provided 27 hours of exercise supervision over 6 months, whereas we provided 8 hours. We had adequate time to instruct participants in corrective exercises, since their mild curves had less significant structural deformity, making self-corrective exercises in these participants clinically easier than larger curve types. However, a higher level of supervision may improve exercise adherence, and we noted that more involved parents kept participants more accountable to achieving their recommended exercise adherence.

Although Schreiber and Kuru did not evaluate outcomes at 1-year follow-up, Negrini et al did.27 Negrini performed a prospective cohort study implementing PSSE in Risser 0 to 3 smaller curves (averaging 15°). Negrini found curve magnitude improvements averaging 0.3° in the PSSE group and worsening 1.1° in the non-PSSE group, as well as a significantly lower incidence of brace prescription in the PSSE group (6%) compared with the non-PSSE group (25%) at 1-year follow-up. Our results demonstrated increased curve progression and brace wear compared with Negrini (0° change in the exercise group and 5.6° worse in the control group, and 37% vs 43% brace wear, respectively). Negrini's therapy intensity was higher than ours, with the PSSE group receiving 1.5-hour sessions every 2 to 3 months, twice a week exercise sessions near home for 40 minutes, and 1 exercise daily for 5 minutes. However, our participants were at higher risk of curve progression than Negrini, as we only included participants who were Risser grade 0.

Exercise adherence in our study was lower after 6 months (77%) than Schreiber (82.5%).13 Schreiber also had a more frequent and longer exercise routine (daily exercise, 30-45 minutes). However, we emphasized that participants should perform their autocorrective exercises throughout the day, which we were unable to objectively measure. There is nearable technology to capture slight movements. Due to the relatively low number of minutes of exercises performed per week, we now ask participants to perform their exercises 15 minutes a day, 5 days a week.

A major limitation of this study is that we do not have follow-up results until skeletal maturity, participants were not randomized, and compliance in the treatment group is difficult to measure. We plan on evaluating radiographs at skeletal maturity to evaluate whether results still favor the PSSE group. Future research should evaluate which curve types respond best to PSSE. Although we do not expect curves to improve, an improvement of 29% in the mild curve group warrants further investigation.

ACKNOWLEDGMENTS

The authors wish to acknowledge Rebecca Bernhardt and Charter Rushing for providing physical therapeutic scoliosis-specific exercises and Kiley Poppino for performing masked radiographic measurements.

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Keywords:

adolescent idiopathic scoliosis; spine deformity

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