Evaluating exercise therapies in adolescent idiopathic scoliosis: a systematic review with Bayesian network meta-analysis

Abstract

Background: Exercise therapy represents a financially prudent and readily applicable intervention that has gained considerable traction in the treatment of adolescent idiopathic scoliosis (AIS) in recent years. Nevertheless, a definitive agreement on the superiority of one method over another remains elusive.

Methods: A comprehensive search was performed across the PubMed, Cochrane Library, Embase, and Web of Science databases for randomized controlled trials pertaining to exercise and AIS, concluding on August 20, 2024. Four independent researchers conducted a thorough review of the literature, engaged in meticulous data extraction, and assessed the risk of bias. A Bayesian network meta-analysis was performed utilizing the R programming language (version 4.3.4) and MetaInsight tool (version V6.0.1).

Results: A total of 23 studies were incorporated into the analysis, encompassing 1,289 participants with AIS. Compared to the control group, the primary meta-analysis showed that both SchrothCo and physiotherapeutic scoliosis-specific exercises (PSSE) modalities significantly improved Cobb angle (MD = -4.79, 95% CI [-8.56 to -1.11] MD = -3.11, 95% CI [-5.27 to -0.9]), axial trunk rotation (ATR) (MD = -3.03, 95% CI [-4.68 to -1.46]; MD = -2.37, 95% CI [-3.59 to -1.14]), and SRS-22 scores (MD = 0.66, 95% CI [0.39-0.94]; MD = 0.44, 95% CI [0.22-0.66]). The secondary meta-analysis showed that within the PSSE modality, Schroth therapy significantly reduced Cobb angle (MD = -2.3, 95% CI [-5.45 to -0.66]), while in the SchrothCo modality, both Schroth + Core and Schroth + Hippotherapy significantly improved Cobb angle (MD = -5.27, 95% CI [-14.15 to -3.5]). For ATR, Schroth therapy within PSSE (MD = -2.79, 95% CI [-6.4 to -0.1]), and Schroth + Core (MD = -4.03, 95% CI [-9.37 to -0.98]), Schroth + Sling (MD = -3.12, 95% CI [-10.05 to -2.94]), and Schroth + Hippotherapy (MD = -3.39, 95% CI [-10.29 to -2.84]) within the SchrothCo modality all showed significant reductions. Significant differences in SRS-22 scores were found only in the PSSE modality with Schroth therapy (MD = 0.48, 95% CI [0.02-0.9]) and in the SchrothCo modality with Schroth + Core (MD = 0.79, 95% CI [0.13-1.43]).

Conclusions: According to the latest findings, the integration of the Schroth method with core stabilization training (Schroth + Core) is regarded as the optimal strategy for addressing AIS. The integration of core stabilization training with the Schroth method reveals a markedly enhanced effectiveness. Future inquiries should encompass more rigorous studies to establish a more robust evidence foundation and facilitate progress in this domain.

Keywords: AIS; Adolescent Idiopathic Scoliosis; Exercise; Exercise therapies; Network meta-analysis; Scoliosis.

Figure 1. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow chart.

Figure 2. Risk of bias graph.

Note: Monticone et al., 2014; Kim & HwangBo, 2016; Kuru et al., 2016; Ko & Kang, 2017; Schreiber et al., 2019; Negrini et al., 2019; Yagci & Yakut, 2019; Yu, Yang & Park, 2019; Zapata, Sucato & Jo, 2019; Abdel-aziem et al., 2021; Gao et al., 2021; Kocaman et al., 2021; Mohamed & Yousef, 2021; Won, Oh & Shen, 2021; El et al., 2022; Qi et al., 2022; Shen et al., 2023; Zapata et al., 2023; Büyükturan et al., 2024; Karavidas et al., 2024; Khaledi et al., 2024; Manzak Dursun et al., 2024; Zhang et al., 2024.

Figure 3. Network plot for Cobb.

PSSE, PSSE modality: Physiotherapeutic Scoliosis-Specific Exercise; Strengthening, Strengthening training; SchrothCo, Schroth Combo modality: Schroth combined with other therapies; PNF, Proprioceptive Neuromuscular Facilitation techniques; Pilates, Pilates exercise.

Figure 4. Model fitting diagram.

(A) The fixed and random-effect models for Cobb angle utilize plots and Deviance Information Criterion (DIC). DIC, Deviance Information Criterion; Dres, Deviance Residuals; pD, Posterior Mean Deviance; Wik, Adjustments for Study and Group Normal Distributions. (B) Leverage plots and DIC for Cobb’s consistency and inconsistency models. (C) Posterior mean deviance plots for Cobb’s consistency versus inconsistency models. DIC, Deviance Information Criterion; Dres, Deviance Residuals; pD, Posterior Mean Deviance; Wik, Adjustments for Study and Group Normal Distributions.

Figure 5. SUCRA plot of Cobb angle.

PSSE, PSSE modality: Physiotherapeutic Scoliosis-Specific Exercise; Strengthening, Strengthening training; SchrothCo, Schroth Combo modality: Schroth combined with other therapies; PNF, Proprioceptive Neuromuscular Facilitation techniques; Pilates, Pilates exercise. Schroth, Schroth therapy.

Figure 6. Radial SUCRA plot for a secondary meta-analysis concerning the Cobb angle.

PSSE, PSSE modality: Physiotherapeutic Scoliosis-Specific Exercise; Strengthening, Strengthening training; PNF, Proprioceptive Neuromuscular Facilitation techniques; Pilates, Pilates exercise; Schroth, Schroth therapy; BSPTS, BSPTS therapy; SEAS, SEAS therapy; Lyon, Lyon therapy; Sch Co Sling, Schroth therapy + Sling training; Sch Co Balance, Schroth therapy + Balance training; Sch Co Hippo T, Schroth therapy + Hippotherapy; Sch Co Core, Schroth therapy + Core stability training; Core, Core stability training; Sling, Sling training.