Articles of Interest

Conservative treatment has no role in the management of scoliosis - or does it ? (Part 1)

Scoliosis is defined as a lateral deviation of the spine, however the true definition of scoliosis is slightly

wider. Scoliosis is a three dimensional deviation of the spine: the involved vertebrae of the spine shift

laterally (sideways), rotate backward on the convex side (creating a rib or lumbar hump) and change their

saggital (front to back) position. The diagnosis of scoliosis is made when the angle between the most

tilted vertebrae (Cobb angle) involved in the curve is more than 10 degrees. There can be many curve

profiles in scoliosis and there is no known cure. Scoliosis can often be progressive and affected by many

factors; however the chance of progression is increased relative to degree of the curve and earlier age of

onset.

There are different types of scoliosis (commonly defined by age of onset) and the most common is

Adolescent Idiopathic Scoliosis (AIS). The remainder of this article will primarily address AIS and provide

some insight into the decision making process around conservative management of AIS.

There is no doubt that there continues to be controversy with regard to the role of conservative (non-

surgical) management in scoliosis. There is a dearth of quality information as seen in Figure 1.

Figure 1 (Negrini et al): A Medline search of all papers on

scoliosis shows that there is a massive difference in the

amount of good quality research into conservative

management when compared to surgical management of

scoliosis.

There are however many groups who are beginning to publish good research into conservative

management. Additionally, there are currently 2 international groups conducting a randomised trial of

Schroth treatment in scoliosis. One group in Canada in a dual SRS, NIH funded trial under the auspices

of Dr Eric Parent and one Group in England in a NHS funded trial under Warwick University.

Therefore, although there is no published evidence proving that Schroth works there must be some

benefit which has convinced these independent bodies to contribute funds to these trials.

SOSORT (Society on Scoliosis Orthopaedic and Rehabilitation Treatment)

SOSORT (Society on Scoliosis Orthopaedic and Rehabilitation Treatment) is an international group

whose members include surgeons, doctors, physiotherapists, chiropractors and bracing specialists

who have a special interest in treating scoliosis. SOSORT members believe in a team approach to the

management of scoliosis using all available techniques, including surgery, bracing and in some cases;

specific exercise therapy. SOSORT decision guidelines1 are assisted by the following graph (Figure 2)

which is based on Lonstein and Carlson's progression estimation formula.

Progression factor = Cobb angle – (3 X Risser Sign) / Chronological age

Figure 2: Progression risk above 40% is an indication for

intervention. If conservative management is unsuitable or

fails then surgery is indicated. The formula was originally

based on curves 20-29 degrees so this needs to be take into

account with larger curves.

Eg. A 12 year old girl with a 30 degree cobb angle and Risser 0 results in a progression factor of 2.5

(30 degrees – (3 X 0) divided by 12. The risk of progression is 90%. The treatment recommendation is

bracing with exercises with close monitoring and surgery if required.

Curves below 40% risk of progression are initially managed by observation alone however curves at

greater risk of progression require intervention. The intervention can be specialised exercises, bracing

or surgery. There are many type of braces available but it is important to note that the person fitting the

brace needs expert knowledge of scoliosis and tracks the brace effectiveness with in-brace as well as

out-of brace x-rays. The patient will need to exercises to reinforce the brace action and strengthen their

musculature to ensure that there is no collapse upon brace weaning. Furthermore the patient needs to be

taught to internalise new body image awareness and reflex curve correction. The curve correction is a

highly specialised specifically choreographed order of movements encompassing all thee dimensions of

the curve.

How does scoliosis occur?

Stokes in 1996, 2000 and 20062 continued to expand on his resurrected ‘vicious cycle’ concept. The idea

is that a triggering event to precipitate the assymetrical loading of the spine will result in assymetrical

growth of the vertebrae, wedging of the vertebrae and hence an ever-increasing spinal curvature.

Simplistically; a small curve can eventually reach a threshold whereby gravity and mechanics alone can

cause the curve to progress. This is especially relevant during the growth phase.

Figure 3: The vicious cycle of scoliosis progression

Logic dictates that reduction in the assymetrical loading will reduce some of the inherent load of this

viscous cycle. Schroth therapy is one of the ways of restoring balance and symmetry to the spine.

How does Schroth therapy work

The asymmetry of the curve needs to, identified and deconstructed. The deconstruction of the curve

profile is analysed according to the principles of Katarina Schroth who was noted for scoliosis treatment

in 1925 founded her clinic in Germany in 1961. The method has been refined over the years but the

principles have remained pretty steady.

Once the curve is analysed, the patient is taught a choreographed sequence of movements, breathing

action and muscle contraction to lead to greater symmetry of the body.

Summary:

Conservative management has a role in scoliosis treatment.

Conservative management does not replace surgery.

Bracing is effective in scoliosis treatment but needs to be applied, monitored and weaned

correctly.

Exercise therapy is highly specialised and needs to take into account the 3 dimensions of the

curve.

Saggital curve profile is an essential component of scoliosis and incorrect self correction can lead

to detrimental loading of the curve.

Scoliosis is best managed and treated by a team of specialist bracing, surgical and exercise

practitioners.

•

References

http://www.sosort.mobi/pdf/OldSOSORTGuidelines.pdf

Biomechanical spinal growth modulation and progressive adolescent scoliosis – a test of the 'vicious cycle' pathogenetic hypothesis: Summary of an electronic

focus group debate of the IBSE

Ian AF Stokes, R Geoffrey Burwell, and Peter H Dangerfield

Scoliosis 2006, 1:16doi:10.1186/1748-7161-1-16 http://www.biomedcentral.com/content/pdf/1748-7161-1-16.pdf

Self-Correction of posture: Assessemnt of the quality of the movement accomplished by non-instructed school children. Stolinski L & Kotwicki T. Proceedings of

the Annual meeting of the SOSORT, Barcelona 2011.

Conservative treatment has no role in the management of scoliosis - or does it ?

Scoliosis is defined as a lateral deviation of the spine, however the true definition of

scoliosis is slightly wider. Scoliosis is a three dimensional deviation of the spine:

the involved vertebrae of the spine shift laterally (sideways), rotate backward on the

convex side (creating a rib or lumbar hump) and change their saggital (front to back)

position. The diagnosis of scoliosis is made when the angle between the most

tilted vertebrae (Cobb angle) involved in the curve is more than 10 degrees. There

can be many curve profiles in scoliosis and there is no known cure. Scoliosis can

often be progressive and affected by many factors; however the chance of progression

is increased relative to degree of the curve and earlier age of onset.

There are different types of scoliosis (commonly defined by age of onset) and the

most common is Adolescent Idiopathic Scoliosis (AIS). The remainder of this article

will primarily address AIS and provide some insight into the decision making process

around conservative management of AIS.

There is no doubt that there continues to be controversy with regard to the role of

conservative (non- surgical) management in scoliosis. There is a dearth of quality

information as seen in Figure 1.