Idiopathic Scoliosis

Introduction[edit | edit source]

Scoliosis is a three-dimensional abnormality of the spine that causes an observable deformity. Scoliosis is defined by the Cobb's angle of spine curvature in the coronal plane, and is often accompanied by vertebral rotation in the transverse plane and hypokyphosis in the sagittal plane. Cases of scoliosis can be categorised as:

  • Congenital - present from birth due to defects of formation, segmentation or mixed ones.
  • Idiopathic - Develop during growth

Idiopathic Scoliosis accounts for approximately 85% of cases and can be described as infantile, juvenile or adolescent depending on the age the scoliosis presented.

  • Infantile - Infantile Scoliosis affects children between birth and the age of 3. This category represents about 1% of all idiopathic scoliosis in children with about 60% of those diagnosed being male[1].
  • Juvenile - affects children between the ages of 4 and 10 years and accounts for 10–15 % of all idiopathic scoliosis in children. If left untreated curves may cause secondary cardiopulmonary complications[1]. In those with curves of 30° or more it is more likely that the curve will progress, in 95 % of cases a surgical procedure is indicated.[2]
  • Adolescent - Adolescent idiopathic scoliosis (AIS) has the highest prevalence of the three categories. This type of scoliosis is present at age ten and lasts till the end of growth. Its prevalence is dependent on the curvature of the spine and gender of the patient.[3]

Epidemiological studies have demonstrated that Idiopathic Scoliosis in young people over the age of 10 is occurs more often in females than males reaching a ratio of 4:1[4]. Anwer et al. described a prevalence of 2,5% with a Cobb angle larger then 10 degrees. They also stated that a variety of risk factors may result in a higher curve progression. These factors include the following: female gender, age of 10–12 years, absence of menarche, presence of thoracic curves, curve size at presentation >25 degrees, Risser sign of 0-1, and residual growth potential.[5][6]

Physical Therapy Management[edit | edit source]

Without a Brace[edit | edit source]

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.[7] 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.[8]

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.[8], [9][10]
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.[11],[12]

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.[10]

With a Brace[edit | edit source]

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. [13]
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.[14]

The SOHORT Guidelines Summation[14][edit | edit source]

  • 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[14]:[edit | edit source]

  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.

Types of Brace[edit | edit source]

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. [10] 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. [9]

Surgical Management[edit | edit source]

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.[15]
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.[13]
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.[14]

  1. 1.0 1.1 Konieczny MR, Senyurt H, Krauspe R. Epidemiology of adolescent idiopathic scoliosis. Journal of children's orthopaedics. 2012 Dec 11;7(1):3-9.
  2. Coillard C, Circo AB, Rivard CH. SpineCor treatment for Juvenile Idiopathic Scoliosis: SOSORT award 2010 winner. Scoliosis. 2010 Dec;5(1):25.
  3. Johari J, Sharifudin MA, Ab Rahman A, Omar AS, Abdullah AT, Nor S, Lam WC, Yusof MI. Relationship between pulmonary function and degree of spinal deformity, location of apical vertebrae and age among adolescent idiopathic scoliosis patients. Singapore medical journal. 2016 Jan;57(1):33
  4. Patil CG, Santarelli J, Lad SP, Ho C, Tian W, Boakye M. Inpatient complications, mortality, and discharge disposition after surgical correction of idiopathic scoliosis: a national perspective. The Spine Journal. 2008 Nov 1;8(6):904-10.
  5. Anwer S, Alghadir A, Shaphe A, Anwar D. Effects of exercise on spinal deformities and quality of life in patients with adolescent idiopathic scoliosis. BioMed research international. 2015;2015.
  6. Hacquebord JH, Leopold SS. In brief: The Risser classification: a classic tool for the clinician treating adolescent idiopathic scoliosis. Clin Orthop Relat Res. 2012;470(8):2335–2338.
  7. Cassella, M.C., Hall, J.E. (1991). Current Treatment Approaches in the Nonoperative and Operative Management of Adolescent Idiopathic Scoliosis [electronic version]. Phys Ther, 71: 897-909. fckLRLevel of evidence: 3
  8. 8.0 8.1 Negrini, S., Zaina, F., Romano, M.,… , Parzini, S. (2008). Specific exercises reduce brace prescription in adolescent idiopathic scoliosis: a prospective controlled cohort study with worst-case analysis [electronic version]. J Rehabil Med, 40: 451-55.fckLRLevel of evidence: 1
  9. 9.0 9.1 Negrini, S., Zaina, F., Romano, M.,… , Parzini, S. (2006). A controlled prospective study on the efficacy of SEAS.02 exercises in preventing progression and bracing in mild idiopathic scoliosis [electronic version]. Stud Health Technol Inform., 123: 523-6.fckLRLevel of evidence: 1
  10. 10.0 10.1 10.2 Grivas, T.B. (2008). The conservative Scoliosis treatment. Amsterdam: Ios Press.
  11. Otman, S., Kose, N., Yakut, Y. (2005). The efficacy of Schroth s 3•dimensional exercise therapy in the treatment of adolescent idiopathic scoliosis in Turkey [electronic version]. Saudi MedJ, 26: 1429-35fckLRLevel of evidence: 1
  12. Weiss, H.R. (1992). The progression of idiopathic scoliosis under the influence of a physiotherapy rehabilitation programme [electronic version]. Physiotherapy, 78(11): 815-21.fckLRLevel of evidence: 1
  13. 13.0 13.1 Edyta Kinel,1 ,* Tomasz Kotwicki,2 Wanda Stryła,1 and Andrzej Szulc2. Corrective Bracing for Severe Idiopathic Scoliosis in Adolescence: Influence of Brace on Trunk Morphology. ScientificWorldJournal. 2012; 2012: 435158. fckLRPublished online 2012 April 30.fckLR Level of evidence: 2
  14. 14.0 14.1 14.2 14.3 Stefano Negrini, 1,2,3 Angelo G Aulisa,4 Lorenzo Aulisa,5 Alin B Circo,6 Jean Claude de Mauroy,7 Jacek Durmala,8 Theodoros B Grivas,9 Patrick Knott,10 Tomasz Kotwicki,11 Toru Maruyama,12 Silvia Minozzi,13 Joseph P O'Brien,14 Dimitris Papadopoulos,15 Manuel Rigo,16 Charles H Rivard,6 Michele Romano,3 James H Wynne,17 Monica Villagrasa,16 Hans-Rudolf Weiss,18 and Fabio Zaina3. 2011 SOSORT guidelines: Orthopaedic and Rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis. 2012; 7: 3. Published online 2012 January 20. doi: 10.1186/1748-7161-7-3. fckLRLevel of evidence: 1
  15. AINA DANIELSON, Natural history of adolescent idiopathic scoliosis: a tool for guidance in decision of surgery of curves above 50°, J Child Orthop 2013fckLRLevel of evidence: 1