In North America, care recommendations for adolescents with small idiopathic scoliosis (AIS) curves include observation or bracing. Schroth scoliosis-specific exercises have demonstrated promising results on various outcomes in uncontrolled studies. This randomized controlled trial (RCT) aimed to determine the effect of Schroth exercises combined with the standard of care on quality-of-life (QOL) outcomes and back muscle endurance (BME) compared to standard of care alone in patients with AIS. Fifty patients with AIS, aged 10–18 years, with curves 10–45 °, recruited from a scoliosis clinic were randomized to receive standard of care or supervised Schroth exercises plus standard of care for 6 months. Schroth exercises were taught over five sessions in the first two weeks. A daily home program was adjusted during weekly supervised sessions. The assessor and the statistician were blinded. Outcomes included the Biering-Sorensen (BME) test, Scoliosis Research Society (SRS-22r) and Spinal Appearance Questionnaires (SAQ) scores. Intention-to-treat (ITT) and per protocol (PP) linear mixed effects models were analyzed. Because ITT and PP analyses produced similar results, only ITT is reported. After 3 months, BME in the Schroth group improved by 32.3 s, and in the control by 4.8 s. This 27.5 s difference in change between groups was statically significant (95 % CI 1.1 to 53.8 s, p = 0.04). From 3 to 6 months, the self-image improved in the Schroth group by 0.13 and deteriorated in the control by 0.17 (0.3, 95 % CI 0.01 to 0.59, p = 0.049). A difference between groups for the change in the SRS-22r pain score transformed to its power of four was observed from 3 to 6 months (85.3, 95 % CI 8.1 to 162.5, p = 0.03), where (SRS-22 pain score)4 increased by 65.3 in the Schroth and decreased by 20.0 in the control group. Covariates: age, self-efficacy, brace-wear, Schroth classification, and height had significant main effects on some outcomes. Baseline ceiling effects were high: SRS-22r (pain = 18.4 %, function = 28.6 %), and SAQ (prominence = 26.5 %, waist = 29.2 %, chest = 46.9 %, trunk shift = 12.2 % and shoulders = 18.4 %). Supervised Schroth exercises provided added benefit to the standard of care by improving SRS-22r pain, self-image scores and BME. Given the high prevalence of ceiling effects on SRS-22r and SAQ questionnaires’ domains, we hypothesize that in the AIS population receiving conservative treatments, different QOL questionnaires with adequate responsiveness are needed. Schroth Exercise Trial for Scoliosis NCT01610908
 .

/pdf/the-effect-of-schroth-exercises-added-to-the-standard-of-2abcy3o1va.pdf

The effect of Schroth exercises added to the standard of care on the quality of life and muscle endurance in adolescents with idiopathic scoliosis—an assessor and statistician blinded randomized controlled trial: “SOSORT 2015 Award Winner”

The Cobb angle is proposed as the “disease process” outcome for scoliosis research because therapies aim to correct or stop curve progression. While the Scoliosis Research Society recommends the Cobb angle as the primary outcome, the Society on Scoliosis Orthopaedic and Rehabilitation Treatment prioritises, as a general goal, patient related outcomes over Cobb angle progression. To determine the threshold of change in the Cobb angle in adolescents with idiopathic scoliosis (AIS) who perceive improvement in a 6-months randomized controlled trial comparing a Schroth exercise intervention added to the standard of care to the standard of care alone. This is a secondary analysis of data from a randomized controlled trial of 50 patients with AIS, with curves ranging from 10° to 45°, with or without a brace. Participants with diagnoses other than AIS, surgical candidates or patients who had scoliosis surgery were excluded. The 6-month interventions consisted of Schroth exercises added to standard-of-care (observation or bracing) with daily home exercises and weekly therapy sessions (Schroth) or standard-of-care alone (Control). The anchor method for estimating the minimal important difference (MID) in the largest Cobb angles (LC) was used. Patient-reported change in back status over the 6-month treatment period was measured using the Global Rating of Change (GRC) scale as anchor varying from − 7 (“great deal worse”) to + 7 (“great deal better”). Participants were divided into two groups based on GRC scores: Improved (GRC ≥2) or Stable/Not Improved (GRC ≤1). MID was defined as the change in the LC that most accurately predicted the GRC classification as per the receiver operating characteristic curve (ROC). The average age was 13.4 ± 1.6 years and the average LC was 28.5 ± 8.8 °s. The average GRC in the control group was − 0.1 ± 1.6, compared to + 4.4 ± 2.2 in the Schroth group. The correlation between LC and GRC was adequate (r = − 0.34, p < 0.05). The MID for the LC was 1.0 °. The area under the ROC was 0.69 (0.52–0.86), suggesting a 70% chance to properly classify a patient as perceiving No Improvement/Stable or Improvement based on the change in the LC. Patients undergoing Schroth treatment perceived improved status of their backs even if the Cobb angle did not improve beyond the conventionally accepted threshold of 5°. Standard of care aims to slow/stop progression while Schroth exercises aim to improve postural balance, signs and symptoms of scoliosis. Given the very small MID, perceived improvement in back status is likely due to something other than the Cobb angle. This study warrants investigating alternatives to the Cobb angle that might be more relevant to patients. ClinicalTrials.gov
 , NCT01610908
 . Retrospectively registered on April 2, 2012 (first posted on June 4, 2012 - https://clinicaltrials.gov/ct2/keydates/NCT01610908
 )

/pdf/patients-with-adolescent-idiopathic-scoliosis-perceive-4br3gck641.pdf

Patients with adolescent idiopathic scoliosis perceive positive improvements regardless of change in the Cobb angle - Results from a randomized controlled trial comparing a 6-month Schroth intervention added to standard care and standard care alone. SOSORT 2018 Award winner.

Study design Review and statistical analysis of studies evaluating the effect of surgery on the health-related quality of life of adolescents with adolescent idiopathic scoliosis, using Scoliosis Research Society (SRS) outcomes. Objective Apply published minimum clinical important differences (MCID) values for the SRS22r questionnaire to the literature to identify what areas of health-related quality of life are consistently affected by surgery and whether changes are clinically meaningful. Summary of background data The interpretation of published studies using the SRS outcomes has been limited by the lack of MCID values for the questionnaire domains. The recent publication of these data allows the clinical importance of any changes in these studies to be examined for the first time. Methods A literature search was undertaken to locate suitable studies that were then analyzed. Statistically significant differences from baseline to 2 years postoperatively were ascertained by narratively reporting the analyses within included studies. When possible, clinically significant changes were assessed using 95% confidence intervals for the change in mean domain score. If the lower bound of the confidence intervals for the change exceeded the MCID for that domain, the change was considered clinically significant. Results The numbers of cohorts available for the different analyses varied (5-16). Eighty-one percent and 94% of included cohorts experienced statistically significant improvements in pain and self-image domains. In terms of clinical significance, it was only self-image that regularly improved by more than MCID, doing so in 4 of 5 included cohorts (80%) compared with 1 of 12 cohorts (8%) for pain. No clinically relevant changes occurred in mental health or activity domains. Conclusion Evidence suggests that surgery can lead to clinically important improvement in patient self-image. Surgeons and patients should be aware of the limited evidence for improvements in domains other than self-image after surgery. Surgical decision-making will also be influenced by the natural history of adolescent idiopathic scoliosis.

What is the effect of surgery on the quality of life of the adolescent with adolescent idiopathic scoliosis? A review and statistical analysis of the literature.

Objectives The purpose of this study was to compare the efficacy of two different types of exercise methods in patients with adolescent idiopathic scoliosis. Methods In total, 28 subjects with adolescent idiopathic scoliosis with a mild curve magnitude (10°–26°) were randomly divided into two groups: the Schroth group (n = 14) and the core group (n = 14). The patients in the Schroth group were treated with supervised Schroth exercises, and the patients in the core group were treated with supervised core stabilization exercises; both groups performed the exercises for three days per week for a total of 10 weeks, and both were given additional traditional exercises to perform. Assessment included Cobb angle (Radiography), trunk rotation (Adam’s test), cosmetic trunk deformity (Walter Reed Visual Assessment Scale), spinal mobility (Spinal Mouse), peripheral muscle strength (Biodex System 4-Pro), and quality of life (Scoliosis Research Society-22 questionnaire). Results It was found that patients in the Schroth group showed greater improvement in Cobb angles, thoracic trunk rotation angle, cosmetic trunk deformity, spinal mobility, and quality of life than those in the core group (p<0.05), except for in lumbar trunk rotation angle. Peripheral muscle strength improvement was greater in the core group than in the Schroth group (p<0.05). Conclusion Schroth exercises are more effective than core stabilization exercises in the correction of scoliosis and related problems in mild adolescent idiopathic scoliosis, and core stabilization exercises are more effective than Schroth exercises in the improvement of peripheral muscle strength. Trial registration NCT04421157

/pdf/the-effectiveness-of-two-different-exercise-approaches-in-147vj7p3mz.pdf

The effectiveness of two different exercise approaches in adolescent idiopathic scoliosis: A single-blind, randomized-controlled trial

Four patient-reported outcome (PRO) instruments are commonly used to assess body image in idiopathic scoliosis (IS): the Quality of Life Profile for Spinal Deformities (QLPSD), SRS-22 Self-Image scale, Spinal Appearance Questionnaire (SAQ), and Trunk Appearance Perception Scale (TAPS). The aim of this study is to compare the psychometric properties of these instruments in patients with IS and report the translational/cultural adaptation of the SAQ to Spanish. The four instruments in a Spanish version were administered to 80 patients with IS aged 10 to 40 years old. The sample was stratified according to scoliosis magnitude (less and more than 45o). Analysis was also conducted for age groups. The psychometric properties studied included convergent and divergent construct validity, as well as internal consistency. Convergent validity was evaluated by correlation analysis between the self-image instruments and Cobb angle. Divergent validity was assessed with correlation analysis between PRO scores and SRS-22 dimensions scores such as Function, Pain and Mental Health. In the overall sample, each of the PRO instruments demonstrated high internal consistency (QLPSD Body Image, α = 0.80; SRS-22 Self Image, α = 0.78; SAQ, α = 0.89; TAPS, α = 0.87), also both for younger and adult patients subgroups. Correlation with curve magnitude was significant for each of the four scales. However, the correlation was higher for the pictorial scales (SAQ Appearance r = 0.61, TAPS r = - 0.62) than for the textual scales (QLPSD-bi r = 0.36, SRS-22 Self-Image scale r = - 0.41). In the younger group, correlation between Cobb angle and textual scales (QLPSD-bi and SRS-22 Self-Image Scale) was not significant. Body Image scales showed significant correlations with SRS-22 Pain, Function and Mental Health dimensions. All four instruments tested have good psychometric properties. Pictorial scales (SAQ Appearance and TAPS) correlated better with the radiological magnitude of the curve and this correlation is independent of age. Unexpectedly, all four scales demonstrated significant correlations with non-body image dimensions and the divergent hypothesis was not confirmed. Globally, pictorial scales showed slightly better construct validity to test body image perception than textual scales.

/pdf/body-image-in-idiopathic-scoliosis-a-comparison-study-of-3wx7tnu9en.pdf

Body image in idiopathic scoliosis: a comparison study of psychometric properties between four patient-reported outcome instruments.

STUDY DESIGN Cross-sectional correlation study. OBJECTIVE To determine the threshold in spinal deformity severity measurements beyond which there is a progressive decline in health-related quality-of-life (HRQOL). SUMMARY OF BACKGROUND DATA The associations between HRQOL and scoliosis deformity measures are at best moderate when assessed using linear regressions. This may be because HRQOL is not affected until a severity threshold is reached. Identifying the thresholds in deformity beyond which HRQOL deteriorates could assist in treatment recommendations. METHODS The Scoliosis Research Society-22 (SRS-22) questionnaire was completed by 101 females with adolescent idiopathic scoliosis (age, 15.0 +/- 1.8; largest Cobb angle, 36.9 degrees +/- 14.6 degrees). Radiographs and surface topography were used to quantify the severity of the internal (largest Cobb angle) and external deformity (cosmetic score, decompensation, trunk twist), respectively. Segmented linear regression models were estimated to determine the association between SRS-22 domains and spinal deformity measures. This analysis also identifies deformity thresholds beyond which HRQOL is more affected. The percentage of variance explained (R2) by linear and segmented models were compared (alpha = 0.05) to identify the best models. RESULTS Cobb angle predicted significantly more variance in all SRS-22 domains except mental health using segmented models (R2: 0.09-0.30) than linear models (R2: 0.02-0.21). Segmented models with a single threshold estimated at a Cobb angle between 43 degrees and 48 degrees predicted between 3% and 11% more variance compared to corresponding linear model using the same variables. Surface topography parameters were not strongly associated with SRS-22 variables with linear and segmented models explaining less than 10% of the variance. CONCLUSION Deterioration in SRS-22 scores is mildly associated with increases in the severity of the internal deformity. HRQOL is stable until the curve reaches a maximal Cobb angle threshold at approximately 45 degrees where HRQOL declines linearly with increasing internal deformity. The association between HRQOL and scoliosis severity is low, but is better explained by segmented rather than linear models.

The association between Scoliosis Research Society-22 scores and scoliosis severity changes at a clinically relevant threshold.

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The association between Scoliosis Research Society-22 scores and scoliosis severity changes at a clinically relevant threshold.