This presentation provides evidence on the effect of physiotherapeutic scoliosis specific exercises on scoliosis outcomes that is coming from methodologically stronger studies.
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Evidence Based Medicine on the Physiotherapeutic Scoliosis Specific Exercises
1. ™!
Results of Physiotherapeutic Scoliosis-
specific Exercises According to
Evidence Based Medicine
Sanja Schreiber Ph.D., Schroth therapist
Alberta Research Centre for Health Evidence - ARCHE
Department of Pediatrics, University of Alberta
SOSORT
Educational Pre-Meeting Course
3. ™!
Objective
• To present current evidence from 2011
onward on the effect of PSSE on scoliosis
outcomes
– Focus: the evidence from prospective
methodologically stronger primary studies
4. ™!
Definition of Physiotherapeutic
Scoliosis-specific Exercises (PSSE)
SOSORT defines PSSE as consisting of:
1. Auto-correction in 3D
2. Training in activities of daily living (ADL)
3. Stabilizing the corrected posture
4. Patient education
5. ™!
PSSE Schools
• DoboMed
• Global postural re-education
• Lyon
• Schroth (Asklepios & Barcelona Scoliosis
Physical Therapy School)
• Scientific Exercise Approach to Scoliosis (SEAS)
• Side shift
6. Reviews on exercise efficacy
- PICOS criteria -
Review Population Intervention Comparator Outcome Study
Negrini
20031
AIS, Risser<5 Any PE, no co-
intervention
Any Tx Cobb;
progression
All
designs
Lenssinck
20052
IS, <18 yrs Any
conservative Tx
Other Tx or
combination
Any defined
outcome
RCTs &
CCTs
Negrini
20083
AIS, Risser<5 Any PE, no co-
intervention
Any Tx Cobb;
progression
All
designs
Fusco 20114 AIS, Risser<5 Any PE, no co-
intervention
Any Tx Cobb;
progression
All
designs
Mordecai
20125
AIS Any PE Other Tx Any defined
outcome
All
designs
Romano
20126
(Cochrane
SR)
AIS, Risser<5 All types of
PSSE
No Tx; other
PSSE; usual
PT; conser-
vative Tx
Cobb;surface
deformity;
QOL;pain;adverse
events
RCTs &
CCTs
Anwer 20157 AIS, 10-19 yrs Any PE Any Tx Cobb;surface
deformity; QOL
RCTs &
CCTs
Legend: SR, systematic review; AIS, adolescent idiopathic scoliosis; IS, idiopathic scoliosis; PE, physical exercise;Tx, therapy;
QOL, quality of life; RCT, randomized controlled trial; CCT, controlled clinical trial;
7. Conclusions of reviews
Review Conclusions
Negrini 20031 “…studies demonstrated the efficacy of physical exercises in reducing
both the rate of progression or the magnitude of the Cobb angle... literature
failed to provide solid evidence for or against the efficacy of physical
exercises”
Lenssinck
20052
“The authors conclude that the effectiveness of bracing and exercises is not
yet established, but might be promising.”
Negrini 20083 “…exercises can be recommended according to level-1b evidence with the
aim of reducing scoliosis progression…solid data coming from RCTs and
long-term observational studies will be required.”
Fusco 20114 “PEs can improve the Cobb angles of individuals with AIS and can improve
strength, mobility, and balance.”
Mordecai
20125
“Well-designed randomised controlled studies are required to assess the
role of exercise therapy in AIS.”
Romano 20126 “…there appears to be no evidence for or against exercises...There is a
lack of high quality evidence to recommend the use of SSE for AIS.“
Anwer 20157 “…exercise program is superior to controls in reducing the Cobb angle,
angle of trunk rotation, thoracic kyphosis angle, and lumbar lordosis angle
and improving the quality of life…poor methodological quality limit the
validity of these results”
8. Conclusions of reviews
Review Conclusions
Negrini 20031 “…studies demonstrated the efficacy of physical exercises in reducing
both the rate of progression or the magnitude of the Cobb angle... literature
failed to provide solid evidence for or against the efficacy of physical
exercises”
Lenssinck
20052
“The authors conclude that the effectiveness of bracing and exercises is not
yet established, but might be promising.”
Negrini 20083 “…exercises can be recommended according to level-1b evidence with the
aim of reducing scoliosis progression…solid data coming from RCTs and
long-term observational studies will be required.”
Fusco 20114 “PEs can improve the Cobb angles of individuals with AIS and can improve
strength, mobility, and balance.”
Mordecai
20125
“Well-designed randomised controlled studies are required to assess the
role of exercise therapy in AIS.”
Romano 20126 “…there appears to be no evidence for or against exercises...There is a
lack of high quality evidence to recommend the use of SSE for AIS.“
Anwer 20157 “…exercise program is superior to controls in reducing the Cobb angle,
angle of trunk rotation, thoracic kyphosis angle, and lumbar lordosis angle
and improving the quality of life…poor methodological quality limit the
validity of these results””
9. ™!
PSSE Evidence Base Continuum
Before 2014 2014 2014 onward
Lowqualitystudies
2 RCT
Cohort
Retrospective
Non-
randomized
controlled
FirsthighqualityRCT
Monticone et
al (2014)8
• PSSE consistent
with SEAS
approach
LaterpublishedRCT
Kuru et al
(2015)9
• Schroth PSSE
Schreiber et
al (2015)10,11
• Schroth PSSE
10. ™!
PSSE Evidence Based Results
Monticone et al (2014)8
Population Immature girls with AIS, mean age of 12.5±1.1, Cobb angle of
19.3°±3.9°
Intervention PSSE consistent with SEAS approach
Comparison Usual physiotherapy
Design RCT
Main result • PSSE improved Cobb angles by 5.3° at skeletal maturity
• PSSE improved SRS-22r scored
• 1year post-treatment à patients stable
Follow-up Long term (at maturity)
Physiotherapy Evidence Database (PEDro) assessment: 7/10
11. ™!
PSSE Evidence Based Results
Schreiber et al (2015)10,11
Population Patients with AIS, mean age of 13.4±1.6, and Cobb of 28.5°±8.8°
Intervention Supervised PSSE consistent with Schroth approach + standard of
care (observation or brace)
Comparison Standard of care alone
Design RCT
Main results • Cobb angle improved by 1.2° in the supervised PSSE group
• Cobb angle deteriorated by 2.3° in the standard of care group
• Completers had even larger benefit
• Pain, back muscle endurance, and self-image improved in the
PSSE group
Follow-up Short term (6-month follow-up)
Physiotherapy Evidence Database (PEDro) assessment: 8/10
12. ™!
PSSE Evidence Based Results
Kuru et al (2015)9
Population Patients with AIS, mean age of 12.9, and Cobb of 31.3°
Intervention Supervised PSSE consistent with Schroth approach
Comparison • Unsupervised PSSE consistent with Schroth approach
• No treatment
Design RCT
Main results • Cobb angle improved by 2.5° in the supervised PSSE group
• Cobb angle deteriorated by 3.3° in the home exercise group
• Cobb angle deteriorated by 3.1° in the no treatment group
• PSSE improved all other outcomes in the experimental group
Follow-up Short term (6-month follow-up)
Physiotherapy Evidence Database (PEDro) assessment: 6/10
13. ™!
PSSE Evidence Based Results
Toledo et al (2011)12
Population Patients with AIS, mean age of 10, and Cobb 10° to 20°
Intervention PSSE consistent with Global postural re-education
Comparison No treatment
Design RCT
Main results • Cobb angle improved by 5.3° in the PSSE group
• Cobb angle deteriorated by 1.4° in the control group
Follow-up Short term (12-week follow-up)
14. ™!
PSSE Evidence Based Results
Choi et al (2013)13
Population Patients with AIS, mean age of 13.2, and Cobb angle of 14.5°
Intervention Theory of Planned Behaviour + posture exercises
Comparison Postural exercises
Design A prospective quasi-experimental study
Main results • Cobb angles improved by 1.67°±1.36° in the test group
• Cobb angles deteriorated by 0.56°±0.78° in the control group
• Other outcomes (posture management behaviour, muscle
strength, flexibility, also improved in the test group
Follow-up Short term (6-week follow-up)
• The Theory of Planned Behaviour management plan = continuous posture control behaviours.
• The posture management program included exercises to increase the flexibility and strength of
muscles around the spine & teaching the correct activities of daily living.
15. ™!
Other non-PSSE RCTs
Diab et al
201214
• 10-week forward head corrective exercises improved
forward head angle & 3D posture
Zapata et al
201515
• 8-week supervised stabilization exercises improved the
pain and function
Dos Santos
et al 201416
• 3-month aerobic exercises improved function, physical
health, pain, general health status, vitality, social and
emotional aspects and mental health
Hui et al
201517
• Long-term (at maturity) Chinese medicine - spinal balance
exercises, manual spinal manipulation and acupotomology
improved cobb angle & pulmonary function
16. Trials on PSSE underway
Multicentre Schroth Exercise Trial for Scoliosis (MultiSETS)
• EDM & CGY - Schroth PSSE + Standard of care vs.
standard of care
• Montreal - Schroth PSSE + Standard of care vs. Global
Postural Re-Education + standard of care
CONservative TReatment for Adolescent
Idiopathic Scoliosis: a randomised
controlled trial (CONTRAIS)
• active self-correction & spinal stability
Active Treatment for Idiopathic Adolescent Scoliosis
(ACTIvATeS)
• PSSE consistent with SEAS approach
17. ™!
Discussion and Conclusion
• The strong evidence on PSSE is rapidly emerging
• The interest in PSSE is also growing (ongoing
trials)
• The new survey of Scoliosis Research Society
(SRS) members (Marti et al, 2015):
– Of 262 surveyed members, 58 (22%) recommended
PSSE with braces or for smaller curves
– 88% supported funding of PSSE trials by SRS
