Idiopathic Scoliosis

 Search Strategy

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- Search Databases : PubMed, Web of knowledge,
- Books

Keywords :
• Idiopathic scoliosis treatment
• Idiopathic scoliosis physical therapy
• Idiopathic scoliosis exercises
• Idiopathic scoliosis non operative treatment
• Idiopathic scoliosis bracing
• Idiopathic scoliosis brace

Physical Therapy Management

Without Brace

The role of exercise in the nonoperative management of adolescent idiopathic scoliosis is controversial. Most experts agree that exercise alone will not affect the progression of structural scoliosis. There is agreement, however, that a selective exercise program in conjunction with bracing treatment is beneficial. Moreover, it has been shown that physical exercises can have a positive influence on breathing function, strength and postural balance, and that they are useful
in reducing specific impairments and disabilities of patients with idiopathic scoliosis.

It is stated that exercises, based on the ‘Scientific Exercises Approach to Scoliosis’, compared with non-adapted exercises even reduce brace prescription. SEAS exercises should be performed with respect to active self-correction and are aimed at spinal stabilization, strengthening of the tonic muscles, improvement of balance and coordination, recovery and maintenance of physiological sagittal curves. Therapists avoid increasing the spine’s range of motion but instead focus mainly on spinal stability., , 
Likewise the global postural rehabilitation according to Schroth has results published in indexed literature. The Schroth treatment programme consists of correction of the scoliotic posture and breathing pattern with the help of proprioceptive and exteroceptive stimulation and mirror control. Schroth tries to achieve this correction using only active trunk muscle force. Thus the patients learn to raise themselves as far as possible from a position of solely passive support by spinal ligaments, which is thought to promote curve progression, and then to maintain the corrected posture in activities of daily living.,

Among other well-known excersise treatments are the ones of Mézières, Sohier and Klapp, unlike the previously mentioned treatments these have been remained almost unchanged over time.

With Brace

According to the generally accepted indications for conservative management of idiopathic scoliosis, the brace treatment is considered a standard management for progressive curvatures of moderate Cobb angle; it is usually recommended for angles of 25 to 40 degrees and if residual growth of the spine is expected. Adolescent girls with idiopathic scoliosis having the Cobb angle above 45 degrees and subjected to brace treatment for more than one year revealed smaller clinical deformity of their back comparing to non-treated girls having similar Cobb angle. 
Recently a Cochrane review has been published about the present evidence of bracing in idiopathic scoliosis. They found very low quality evidence in favor of using braces, making generalization very difficult. The Cochrane review concluded that further research is necessary; in the meantime, patient choices should be informed by multidisciplinary discussion.

The SOHORT guidelines summation:
- High variability among results of bracing is confirmed.
- It is clearly evident that other factors beyond the instrument (brace) influence the final results. These factors can include dosage, quality of bracing, compliance to treatment , family history, type of scoliosis and even a geographical distribution, but also team approach.
-Today it is not possible to state with any certainty which brace is better than the other.

Recommendations of the SOHORT guidelines:
1.Bracing is recommended to treat adolescent idiopathic scoliosis.
2. Bracing is recommended to treat juvenile and infantile idiopathic scoliosis as the first step in an attempt to avoid or at least postpone surgery to a more adequate age.
3. Casting is recommended to treat infantile idiopathic scoliosis to try stabilizing the curve.
4. It is recommended not to apply bracing to treat patients with curves below 15 ± 5° Cobb, unless otherwise justified in the opinion of a clinician specialized in conservative treatment of spinal deformities.

Brace types:
A lot of different braces can be considered when speaking about brace management in Idiopathic Scoliosis: soft braces, hard braces, full time braces, night time braces, TriaC, Spinecor, Wilmington brace, Rosenberg brace, Night time bending brace, Boston brace, LA brace, Chêneau brace and many others.  We only discuss the different bracing types mentioned by Schiller et al. (2010), because these are the most commonly used.

	Material	Treatment of	Hours/day
Milwaukee brace (3)	Plastic pelvic section with  an anterior and two posterior uprights connected superiorly by a neck ring	Thoracic and double curves	Full time wear, unless sports and extracurriular activities
Wilmington brace	Custom-made plastic underarm TLSO. Designed as a body jacket.	Thoracic and double curves	Full-time wear (23 hours/dag)
Boston brace	Prefabricated polypylene pelvic module with a soft foam plyethylene lining	All scoliosis	Full-time brace
Dynamic Spine-Cor brace	Applied according to definitions contained in the Spine-Cor Assistant software	Uses a specific corrective movement dpendent on the type of the curve	20 hours a day for a minimum of 18 months
Charleston brace	Custom-molded spinal orthosis	All scoliosis	At night
Providence brace (4)	Polypropylene plastic from measurements or a plaster impression	All single and double curves	At night

The great variation of braces applied today implies that RCT on brace treatment will never be able to illustrate what really can be achieved with braces. The only possibility would be to test braces of different standards one against each other in controlled trials. As there are prospective controlled trials showing the Boston brace is effective, to leave a control group of a future RCT in braces without treatment clearly is unethical.
Schiller et al. investigated the efficacy of the different bracing types listed above. The goal of bracing idiopathic curves remained consistent in the different studies: control the curve, prevent progression, and avoid surgical intervention. They concluded that despite success with the Boston, Spine-cor, Milkauwee and Wilminghton braces, non of them is superior to the others with regard to the main gaols of bracing. Future research also will be needed to compare full-time versus part-time bracing. 

Surgery

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Literature showed that thoracic curves of 50°-75° progress 0,73°/year. Thus, most surgeons indicate surgery above this angle. The knowledge on what happens to the patient without treatment (natural history) is needed to support the decision whether to operate or not. The aim is to give the patient an acceptable quality of life.
Patients have to be aware that scoliosis surgery is still stigmatized with a rather archaic way of sacrificing function in young and otherwise healthy individuals.
The Pain associated with scoliosis is underestimated, there is poor agreement between surgeons and patients regarding the presence of pain. About ¾ of the patients report pain before surgery which is reduced after operation. 1/3 of the patients showed no change in pain. 1/5 showed an increase.