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. 2024 Feb 28;2(2):CD007837.
doi: 10.1002/14651858.CD007837.pub3.

Therapeutic exercises for idiopathic scoliosis in adolescents

Michele Romano  1 , Silvia Minozzi  2 , Josette Bettany-Saltikov  3 , Fabio Zaina  1 , Nachiappan Chockalingam  4 , Tomasz Kotwicki  5 , Axel Maier-Hennes  6 , Chiara Arienti  7 , Stefano Negrini  8   9
Affiliations

Therapeutic exercises for idiopathic scoliosis in adolescents

Michele Romano et al. Cochrane Database Syst Rev. .

Abstract

Background: Adolescent idiopathic scoliosis (AIS) is a pathology that changes the three-dimensional shape of the spine and trunk. While AIS can progress during growth and cause cosmetic issues, it is usually asymptomatic. However, a final spinal curvature above the critical threshold of 30° increases the risk of health problems and curve progression in adulthood. The use of therapeutic exercises (TEs) to reduce the progression of AIS and delay or avoid other, more invasive treatments is still controversial.

Objectives: To evaluate the effectiveness of TE, including generic therapeutic exercises (GTE) and physiotherapeutic scoliosis-specific exercises (PSSE) in treating AIS, compared to no treatment, other non-surgical treatments, or between treatments.

Search methods: We searched CENTRAL, MEDLINE, Embase, four other databases, and two clinical trials registers to 17 November 2022. We also screened reference lists of articles.

Selection criteria: Randomised controlled trials (RCTs) comparing TE with no treatment, other non-surgical treatments (braces, electrical stimulation, manual therapy), and different types of exercises. In the previous version of the review, we also included observational studies. We did not include observational studies in this update since we found sufficient RCTs to address our study aims.

Data collection and analysis: We used standard Cochrane methodology. Our major outcomes were progression of scoliosis (measured by Cobb angle, trunk rotation, progression, bracing, surgery), cosmetic issues (measured by surface measurements and perception), and quality of life (QoL). Our minor outcomes were back pain, mental health, and adverse effects.

Main results: We included 13 RCTs (583 participants). The percentage of females ranged from 50% to 100%; mean age ranged from 12 to 15 years. Studies included participants with Cobb angles from low to severe. We judged 61% of the studies at low risk for random sequence generation and 46% at low risk for allocation concealment. None of the studies could blind participants and personnel. We judged the subjective outcomes at high risk of performance and detection bias, and the objective outcomes at high risk of detection bias in six studies and at low risk of bias in the other six studies. One study did not assess any objective outcomes. Comparing TE versus no treatment, we are very uncertain whether TE reduces the Cobb angle (mean difference (MD) -3.6°, 95% confidence interval (CI) -5.6 to -1.7; 2 studies, 52 participants). Low-certainty evidence indicates PSSE makes little or no difference in the angle of trunk rotation (ATR) (MD -0.8°, 95% CI -3.8 to 2.1; 1 study, 45 participants), may reduce the waist asymmetry slightly (MD -0.5 cm, 95% CI -0.8 to -0.3; 1 study, 45 participants), and may result in little to no difference in the score of cosmetic issues measured by the Spinal Appearance Questionnaire (SAQ) General (MD 0.7 points, 95% CI -0.1 to 1.4; 1 study, 16 participants). PSSE may result in little to no difference in self-image measured by the Scoliosis Research Society - 22 Patient Questionnaire (SRS-22) (MD 0.3 points, 95% CI -0.3 to 0.9; 1 study, 16 participants) and improve QoL slightly measured by SRS-22 Total score (MD 0.3 points, 95% CI 0.1 to 0.4; 2 studies, 61 participants). Only Cobb angle results were clinically meaningful. Comparing PSSE plus bracing versus bracing, low-certainty evidence indicates PSSE plus bracing may reduce Cobb angle (-2.2°, 95% CI -3.8 to -0.7; 2 studies, 84 participants). Comparing GTE plus other non-surgical interventions versus other non-surgical interventions, low-certainty evidence indicates GTE plus other non-surgical interventions may reduce Cobb angle (MD -8.0°, 95% CI -11.5 to -4.5; 1 study, 80 participants). We are uncertain whether PSSE plus other non-surgical interventions versus other non-surgical interventions reduces Cobb angle (MD -7.8°, 95% CI -12.5 to -3.1; 1 study, 18 participants) and ATR (MD -8.0°, 95% CI -12.7 to -3.3; 1 study, 18 participants). PSSE plus bracing versus bracing alone may make little to no difference in subjective measurement of cosmetic issues as measured by SAQ General (-0.2 points, 95% CI -0.9 to 0.5; 1 study, 34 participants), self-image score as measured by SRS-22 Self-Image (MD 0.1 points, 95% CI -0.3 to 0.5; 1 study, 34 participants), and QoL measured by SRS-22 Total score (MD 0.2 points, 95% CI -0.1 to 0.5; 1 study, 34 participants). None of these results were clinically meaningful. Comparing TE versus bracing, we are very uncertain whether PSSE allows progression of Cobb angle (MD 2.7°, 95% CI 0.3 to 5.0; 1 study, 60 participants), changes self-image measured by SRS-22 Self-Image (MD 0.1 points, 95% CI -1.0 to 1.1; 1 study, 60 participants), and QoL measured by SRS-22 Total score (MD 3.2 points, 95% CI 2.1 to 4.2; 1 study, 60 participants). None of these results were clinically meaningful. Comparing PSSE with GTE, we are uncertain whether PSSE makes little or no difference in Cobb angle (MD -3.0°, 95% CI -8.2 to 2.1; 4 studies, 192 participants; very low-certainty evidence). PSSE probably reduces ATR (clinically meaningful) (MD -3.0°, 95% CI -3.4 to -2.5; 2 studies, 138 participants). We are uncertain about the effect of PSSE on QoL measured by SRS-22 Total score (MD 0.26 points, 95% CI 0.11 to 0.62; 3 studies, 168 participants) and on self-image measured by SRS-22 Self-Image and Walter Reed Visual Assessment Scale (standardised mean difference (SMD) 0.77, 95% CI -0.61 to 2.14; 3 studies, 168 participants). Further, low-certainty evidence indicates that 38/100 people receiving GTE may progress more than 5° Cobb versus 7/100 receiving PSSE (risk ratio (RR) 0.19, 95% CI -0.67 to 0.52; 1 study, 110 participants). None of the included studies assessed adverse effects.

Authors' conclusions: The evidence on the efficacy of TE is currently sparse due to heterogeneity, small sample size, and many different comparisons. We found only one study following participants to the end of growth showing the efficacy of PSSE over TE. This result was weakened by adding studies with short-term results and unclear preparation of treating physiotherapists. More RCTs are needed to strengthen the current evidence and study other highly clinically relevant outcomes such as QoL, psychological and cosmetic issues, and back pain.

PubMed Disclaimer

Conflict of interest statement

MR: none.

SM: is the Joint‐Coordinating Editor of Cochrane Drugs and Alcohol Group. She was not involved in the editorial process of the present review.

JBS: none.

FZ: none.

NC: none.

TK: none.

AMH: none.

CA: none.

SN: none.

Many members of the review team have published widely in the field of scoliosis. Whenever a paper authored by a review author was considered, all decisions about the paper were made by the other review authors.

Figures

1
1
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1: Therapeutic exercise versus no treatment, Outcome 1: Cobb angle (°)
1.2
1.2. Analysis
Comparison 1: Therapeutic exercise versus no treatment, Outcome 2: Angle of trunk rotation (ATR) (°)
1.3
1.3. Analysis
Comparison 1: Therapeutic exercise versus no treatment, Outcome 3: Objective surface measurements (waist asymmetry) (cm)
1.4
1.4. Analysis
Comparison 1: Therapeutic exercise versus no treatment, Outcome 4: Subjective evaluation (Spinal Appearance Questionnaire – General) (points)
1.5
1.5. Analysis
Comparison 1: Therapeutic exercise versus no treatment, Outcome 5: Subjective evaluation (SRS‐22 Self‐Image) (points)
1.6
1.6. Analysis
Comparison 1: Therapeutic exercise versus no treatment, Outcome 6: Quality of life (SRS‐22 Total score) (points)
1.7
1.7. Analysis
Comparison 1: Therapeutic exercise versus no treatment, Outcome 7: Back pain (SRS‐22 Pain, SF‐36 Pain)
1.8
1.8. Analysis
Comparison 1: Therapeutic exercise versus no treatment, Outcome 8: Mental health (SRS‐22 Mental Health, SF‐36 Mental Health) (points)
2.1
2.1. Analysis
Comparison 2: Therapeutic exercise plus non‐surgical versus non‐surgical, Outcome 1: Cobb angle (°)
2.2
2.2. Analysis
Comparison 2: Therapeutic exercise plus non‐surgical versus non‐surgical, Outcome 2: Angle of trunk rotation (°)
2.3
2.3. Analysis
Comparison 2: Therapeutic exercise plus non‐surgical versus non‐surgical, Outcome 3: Subjective evaluation (Spinal Appearance Questionnaire – General) (points)
2.4
2.4. Analysis
Comparison 2: Therapeutic exercise plus non‐surgical versus non‐surgical, Outcome 4: Subjective evaluation (SRS‐22 Self‐Image) (points)
2.5
2.5. Analysis
Comparison 2: Therapeutic exercise plus non‐surgical versus non‐surgical, Outcome 5: Quality of life (SRS‐22 Total score) (points)
2.6
2.6. Analysis
Comparison 2: Therapeutic exercise plus non‐surgical versus non‐surgical, Outcome 6: Back pain (SRS‐22 Pain) (points)
2.7
2.7. Analysis
Comparison 2: Therapeutic exercise plus non‐surgical versus non‐surgical, Outcome 7: Back pain (Visual Analogue Scale 0–10 scale)
2.8
2.8. Analysis
Comparison 2: Therapeutic exercise plus non‐surgical versus non‐surgical, Outcome 8: Mental health (SRS‐22 Mental Health) (points)
3.1
3.1. Analysis
Comparison 3: Any therapeutic exercise versus bracing, Outcome 1: Cobb angle (°)
3.2
3.2. Analysis
Comparison 3: Any therapeutic exercise versus bracing, Outcome 2: Subjective evaluation (SRS‐22 Self‐Image) (points)
3.3
3.3. Analysis
Comparison 3: Any therapeutic exercise versus bracing, Outcome 3: Quality of life (SRS‐22 Total score) (points)
3.4
3.4. Analysis
Comparison 3: Any therapeutic exercise versus bracing, Outcome 4: Back pain (SRS‐22 Pain) (points)
3.5
3.5. Analysis
Comparison 3: Any therapeutic exercise versus bracing, Outcome 5: Mental health (SRS‐22 Mental Health) (points)
4.1
4.1. Analysis
Comparison 4: Physiotherapeutic scoliosis‐specific exercise (PSSE) versus generic therapeutic exercise (GTE), Outcome 1: Cobb angle (°)
4.2
4.2. Analysis
Comparison 4: Physiotherapeutic scoliosis‐specific exercise (PSSE) versus generic therapeutic exercise (GTE), Outcome 2: Angle of trunk rotation (°)
4.3
4.3. Analysis
Comparison 4: Physiotherapeutic scoliosis‐specific exercise (PSSE) versus generic therapeutic exercise (GTE), Outcome 3: Number progressed > 5° Cobb angle
4.4
4.4. Analysis
Comparison 4: Physiotherapeutic scoliosis‐specific exercise (PSSE) versus generic therapeutic exercise (GTE), Outcome 4: Subjective evaluation (SRS‐22 Self‐Image, WRVAS) (points)
4.5
4.5. Analysis
Comparison 4: Physiotherapeutic scoliosis‐specific exercise (PSSE) versus generic therapeutic exercise (GTE), Outcome 5: Quality of life (SRS‐22 Total score) (points)
4.6
4.6. Analysis
Comparison 4: Physiotherapeutic scoliosis‐specific exercise (PSSE) versus generic therapeutic exercise (GTE), Outcome 6: Back pain (SRS‐22 Pain) (points)
4.7
4.7. Analysis
Comparison 4: Physiotherapeutic scoliosis‐specific exercise (PSSE) versus generic therapeutic exercise (GTE), Outcome 7: Mental health (SRS‐22 Mental Health) (points)
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Dickson 1978 {published data only}
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Sun 2022 {published data only}
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Zheng 2018 {published data only}
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References to studies excluded from this review

Alves 2006 {published data only}
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Athanasopoulos 1999 {published data only}
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Atici 2017 {published data only}
    1. Atici Y, Aydin CG, Atici A, Buyukkuscu MO, Arikan Y, Balioglu MB. The effect of Kinesio taping on back pain in patients with Lenke Type 1 adolescent idiopathic scoliosis: a randomized controlled trial. Acta Orthopaedica et Traumatologica Turcica 2017;51:191-6. - PMC - PubMed
Carman 1985 {published data only}
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De Sousa Dantas 2017 {published data only}
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Diab 2012 {published data only}
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Durmala 2002 {published data only}
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Durmala 2003 {published data only}
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Dyner‐Jama 2000 {published data only}
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Gür 2017 {published data only}
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Kamel 2022 {published data only}
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Kowalski 2001 {published data only}
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Kumar 2017 {published data only}
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Mamyama 2002 {published data only}
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Maruyama 2003 {published data only}
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McIntire 2008 {published data only}
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Mooney 2003 {published data only}
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Negrini 2008a {published data only}
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Shah 2019 {published data only}
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Toledo 2011 {published data only}
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Trzcinska 2020 {published data only}
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Weiss 1991 {published data only}
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Weiss 1992 {published data only}
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Weiss 1995a {published data only}
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Weiss 1997 {published data only}
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Weiss 2003 {published data only}
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Zakaria 2012 {published data only}
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Zapata 2015 {published data only}
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References to studies awaiting assessment

Akyurek 2022 {published data only}
    1. Akyurek E, Zengin Alpozgen A, Akgul T. The preliminary results of physiotherapy scoliosis-specific exercises on spine joint position sense in adolescent idiopathic scoliosis: a randomized controlled trial. Prosthetics and Orthotics International 2022;46(5):510-7. [DOI: 10.1097/PXR.0000000000000136] - DOI - PubMed

References to ongoing studies

NCT04568759 {published data only}
    1. NCT04568759. Effect of a postural re-education intervention compared to standard care on scoliosis progression in adolescents [Randomized controlled trial to evaluate the effect of a postural re-education intervention compared to standard care on scoliosis progression in adolescents]. clinicaltrials.gov/study/NCT04568759 (first received 23 September 2020).
NCT04921813 {published data only}
    1. NCT04921813. Investigation of conservative treatment on adolescent idiopathic scoliosis patients [Investigation of the efficiency of three dimensional scoliosis exercises and balance-coordination exercises in the conservative treatment of adolescent idiopathic scoliosis patients]. clinicaltrials.gov/study/NCT04921813 (first received 7 February 2021).
NCT05138393 {published data only}
    1. NCT05138393. Scoliosis-specific exercises for mild idiopathic scoliosis [PREventing Mild Idiopathic SCOliosis PROgression (PREMISCOPRO): a randomized controlled trial comparing scoliosis-specific exercises to observation in mild idiopathic scoliosis]. clinicaltrials.gov/study/NCT05138393 (first received 5 November 2021).
NCT05259956 {published data only}
    1. NCT05259956. Trial on two treatments for adolescent idiopathic scoliosis [The impact of "3+1" multidimensional therapeutic exercises on the progression of adolescent idiopathic scoliosis]. clinicaltrials.gov/study/NCT05259956 (first received 16 February 2022).

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References to other published versions of this review

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