Physical exercises in the treatment of idiopathic scoliosis at risk of brace treatment – SOSORT consensus paper 2005

Most clinical outcome surveys have revealed that, by early adulthood, the majority of scoliosis patients suffer from pain [1‐15]. Only one large, controlled survey has been carried out, to date [16]. In that study, 1178 young adults, interviewed 10 years after diagnosis in adolescence, reported a significantly higher incidence of pain than 1217 control subjects. Of the scoliosis patients reporting pain, 23% (147/650) described it as 'horrible, excruciating, distressing' compared with 1% (6/416) of the control subjects who reported pain. Similar results were reported at >44 year followup [17]. Of a subset of 69 patients treated in adolescence (from an original population of 444), twice as many scoliosis patients (77% vs 35%) suffered from pain compared with a population of adults of comparable age (>55 years). Incidence of chronic pain was almost three fold higher in the scoliosis patients (61%) compared with the controls without scoliosis (22%). This is despite the fact that the 'control' popoulation was selected from hospital clinics, nursing homes, and senior citizens' centers where incidence of disability is exceptionally high [18, 19]. How scoliosis causes pain is not clear, but the magnitude of pain in adult scoliosis patients recently has been found to be inversely proportional to curvature flexibility [20]. Related factors linked with pain include regional balance, instability and pathological mechanical loads on spinal elements [21].

Thoracic scoliosis in children results in characteristic signs of pulmonary dysfunction including reduced vital capacity (VC) and impaired exercise capacity (EC) [22‐28]. Because the mechanism for impaired function is reduced mobility of the chest wall and such mobility deteriorates with age, pulmonary function deteriorates according to curvature magnitude even when the curvature itself does not progress [29‐33]. In severe cases death occurs by respiratory failure [30‐35]. The effects of reduced pulmonary function in patients with mild to moderate scoliosis are not known and have been dismissed as insignificant [e.g., [36, 37]]. Recent studies, however, have shown that VC and EC characteristic of patients with mild to moderate scoliosis (<85% predicted) are more reliable predictors of increased mortality than diabetes, high blood pressure, and heart disease [38‐40]. Patient-described pulmonary symptoms, in general, are not a reliable indicator because patients usually are unaware of their limitations even when documented signs are severe and respiratory failure is imminent [29‐33, 41‐43].

Once a flexible spinal curvature evolves into a spinal deformity, a 'vicious cycle' is initiated in which continuous asymmetric loading of the spinal elements fosters continued progression [44‐46]. Only a few small surveys have examined the epidemiology of progression and insufficient information is available to reliably predict outcome for any given patient [47, 48]. In general, the danger for dramatic progression is highest during periods of rapid growth, but most cases continue to progress throughout life [1, 15, 48‐50]. Some individuals with similar curves exhibit marked progression after skeletal maturity while others are relatively stable [41]. The bases for such differences are unknown, though some have suggested that the likelihood of progression is greater the more rigid the curvature [51].

Exercise based therapies, alone or in combination with orthopedic approaches, are a logical approach to improve and maintain flexibility and function in patients at risk for pain, pulmonary dysfunction, and progression. Data from the Schroth clinic in Bad Sobernheim, Germany reveal improved pulmonary function [52, 53] and reduced pain [54‐56] in response to an intensive scoliosis in-patient rehabilitation (SIR) regime. Among the small number of studies which have examined it formally [56‐63], progression was less in patient populations who were treated with exercise [reviewed in [64]]. When exercise was prescribed but was not carried out by the patients, progression was similar to untreated populations [60].

The role of exercise based therapies as discussed in the spine literature has been controversial, however, with often-repeated claims that research has shown that such approaches are ineffective in treating scoliosis [e.g. [65‐78]]. A systematic review of articles published in English throughout history produced no data in support of such claims [79]. As pointed out by Focarile et al., [80] in 1991, 'Experimental controlled studies of different therapies seem to be justified both on ethical and scientific grounds.'

SOSORT was established in 2004 to respond to a need for objective scientific information from independent sources. A meeting was held in Milan, Italy, to explore existing community perspectives regarding (1) the aims of physical exercises; (2) standards of treatment; and (3) the impact of such treatment performed by specialists in the field. The goal was to initiate a dialog for building a working consensus prior to initiation of multicenter research initiatives among members of SOSORT.

Questionnaires were prepared through consensus among the authors of the study. A first version was drafted by the second author, then critiqued and revised through electronic mail conference to produce a second edition. The second version was submitted to a pre-test by e-mail, to obtain the final form. The title of the questionnaire was "Therapeutic aims of physical exercise treatment in patients at risk of brace treatment."

The following clinical description was given:

The following questions were asked:

1. What are the therapeutic aims of the exercises you propose (i.e what do you want to improve?)

2. Which aims are more important ( priority : 1 high – 2 medium – 3 low) ?

3. Why do you choose these aims ?

4. How do you obtain these aims ?

During the preparation of the study, the possibly relevant therapeutic aims of the exercises for scoliosis treatment were proposed by the second author and submitted to a preliminary consensus among the authors of this study: The final list was provided in the questionnaire, with space to answer to questions 2, 3 and 4 for each therapeutic aim chosen. The possibly relevant therapeutic aims of the exercises for scoliosis treatment identified by the authors included:

Responders could add any relevant aim.

Questionnaires constituted the abstracts of the "SOSORT consensus meeting in Milan, January 2005." These were sent, together with the Preliminary Program, to all the attendees of the "1^st International Meeting on Conservative Management of Spinal Deformities" held January 2004 in Barcelona. The program also was distributed to all others with interest in conservative treatment of adolescent idiopathic scoliosis that it was possible to retrieve according to the indexed literature. To gather the maximum possible range of opinions, it was required to fill in the questionnaire independently by the participation to the Consensus Meeting, and to reply by e-mail 1.5 months before the Meeting. 20 persons or institutions responded to the premeeting questionnaire.

During the Milano consensus meeting the attendees were asked to fill in the questionnaires after formal discussion.

Thirty attendees took part and filled in the questionnaire to state their opinion about their aims when treating scoliosis patients by physiotherapy. The results can be seen on Table 2.

The results are summarized in Table 1. Data were incomplete for some responders and statistical treatment was not attempted.

This important issue, also classified at 'self perception' is integrated into the Lyonaise Method [84, 85] and the Schroth programme [82, 83, 86] as a component of diagnosis and education, as well as a baseline for 'before and after' evaluation.

The results of the postmeeting-test changed slightly compared to the premeeting values (Table 2). The choice for highest priority for treatment aims were: