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ORIGINAL REPORT
J Rehabil Me 2008; 40: 451455
J Rehabil Med 40 2008 The Athors. oi: 10.2340/16501977-0195
Jornal Compilation 2008 Fonation of Rehabilitation Information.
ISSN 1650-1977
Objective: To compare the effect of Scientic Exercises Ap-
proach to Scoliosis (SEAS) exercises with usual care re-
habilitation programmes in terms of the avoidance of brace
prescription and prevention of curve progression in adoles-
cent idiopathic scoliosis.
Design: Prospective controlled cohort observational study.
Patients: Seventy-four consecutive outpatients with adoles-
cent idiopathic scoliosis, mean 15 (standard deviation 6)
Cobb angle, 12.4 (standard deviation 2.2) years old, at risk
of bracing who had not been treated previously.
Methods: Thirty-ve patients were included in the SEAS ex-
ercises group and 39 in the usual physiotherapy group. The
primary outcome included the number of braced patients,
Cobb angle and the angle of trunk rotation.
Results: There were 6.1% braced patients in the SEAS ex-
ercises group vs 25.0% in the usual physiotherapy group.
Failures of treatment in the worst-case analysis were 11.5%
and 30.8%, respectively. In both cases the differences were
statistically signicant. Cobb angle improved in the SEAS
exercises group, but worsened in the usual physiotherapy
group. In the SEAS exercises group, 23.5% of patients im-
proved and 11.8% worsened, while in the usual physiothera-
py group 11.1% improved and 13.9% worsened.
Conclusion:These data conrm the effectiveness of exercises
in patients with scoliosis who are at high risk of
progression.
Compared with non-adapted exercises, a specic and per-
sonalized treatment (SEAS) appears to be more effective.
Key words: iiopathic scoliosis, physical exercise, physical
therapy, brace.
J Rehabil Me 2008; 40: 451455
Correspondence address: Stefano Negrini, c/o ISICO, Via
Roberto Bellarmino 13/1, IT-20141 Milano, Italy. E-mail:
[email protected]
Sbmitte October 16, 2007; accepte Janary 9, 2008
INTROduCTION
The so-calle exercise-ogma, which states that exercise is
of no se in iiopathic scoliosis withot proof, is prevalent
in
certain contries (1). However, in other contries exercises
are wiely se to treat aolescent iiopathic scoliosis (AIS),
especially lower grae cases (2). A few recent systematic re-
views have shown the possible effects of exercise on
scoliosis
in terms of Cobb angle, base on concorant controlle sties,
which were mainly observational an partly prospective (24).
Sch reslts have le to the evience on exercises being jge
as efcacious for avoiding, or at least reducing, the
worsening
of crvatre with a level of evience of C(mltiple control-
le non-ranomize sties, whose reslts are consistent with
each other) by the Italian Gielines Committee (5), while
the international scientic Society On Scoliosis Orthopedican
Rehabilitation Treatment (SOSORT) has propose their
se an inications (6). Moreover, it has been shown that
physical exercises can have a positive inuence on breathing
fnction, strength an postral balance, an that they are sefl
in reducing specic impairments and disabilities of patients
with AIS (710).
Sties evalating exercises have, p to now, focse on
their efcacy in terms of Cobb angle (2, 4), but no study has
reporte their seflness in recing brace prescription. From
the patients perspective, avoiing bracing is a key goal, an
simply postponing its se for some months col also be
important (11). In fact, as treatment ens when growth stops,
postponing the start of bracing will rece the total length
ofthis type of treatment.
A sty focsing on brace prescription might look at exercise
treatment vs non-treatment, bt any active therapy shol be
compare with another one (or at least a placebo treatment)
in
orer to rece or eliminate bias. In rehabilitation this might
be
even more important, e to the key role of hman factors. In
this respect, Italy represents an ieal opportnity for
research
into exercise treatment, e to its wiesprea se, combining the
approaches an inpt of many ifferent schools (12, 13). Toay,
every rehabilitation centre has its own exercise protocol, as
oes
every physiotherapist. In most cases, the patients perform
the
same exercises in grops, which are sally not homogeneos
with respect to the scoliosis parameters an type of
treatment
se (e.g. bracing or not). Moreover, these stanar treatments
may be ifferent in terms of qality, the ration of each
session
an repetitions per week. Ths, it is evient that these
ifferences
may reslt in a highly variable otcome.
In a previous preliminary study we have shown the efcacy
of Scientic Exercises Approach to Scoliosis (SEAS) exercises
in recing the rate of progression of scoliosis compare with
sal care, while brace prescription was greatly rece bt
this last results was not statistically signicant(14). That
sty
incle patients who ha been treate previosly, which col
have affecte the reslts. The objective of the crrent
control-
SPECIFIC EXERCISES REDUCE BRACE PRESCRIPTION IN ADOLESCENT
IDIOPATHIC SCOLIOSIS: A PROSPECTIVE CONTROLLED COHORT STUDY
WITH WORST-CASE ANALYSIS
Stefano Negrini, MD1, Fabio Zaina, MD1, Michele Romano,
PT1,Alessandra Negrini, PT2 and Silvana Parzini2
From the1ISICO (Italian Scientifc Spine Institute), Milan
and2Centro Negrini-ISICO, Vigevano (PV), Italy
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452 S. Negrini et al.
le prospective sty was to compare the effect of this same
protocol of exercises vs sal-care rehabilitation programmes
in a grop of aolescent patients with low-egree iiopathic
scoliosis who ha not been treate previosly. The primary
otcome was to avoi braces, while seconarily we examine
the prevention of progression in crvatre. The reslts were
also compare with pblishe ata on the natral history ofAIS an its
treatment sing exercises (2).
MATERIAL AND METHODS
Patients
Between May 2003 and July 2005, 74 consecutive outpatients with
AIS
were enrolled in the study. Each patient was attending their rst
medical
evalation at or institte, none ha been treate previosly, an
all
were prescribe exercises to avoi bracing. All patients
provie
written informe consent to the blin research management of
their
clinical ata. Inclsion criteria were: aolescent iiopathic
scoliosis
not previosly treate, an iagnose as at risk of bracing
accor-
ing to the Italian Clinical Gielines an expert meical jgment
(5). The ata from the meical evalation incle history,
scoliosisand growth parameters, sagittal prole, posture, and
motor-neurone
control. These ata can be smmarize by the following clinical
pictres (which, nevertheless, are not totally inclsive of all
cases):
(i) proven raiographic progression; (ii) Cobb angle exceeing 15
or
Bunnell Angle of Trunk Rotation (ATR) exceeding 7, rst signs
of
pberty, pre-menarchal an Risser vale 01; ( iii) Cobb angle
excee-
ing 20 and Risser value of 2 or 3. Exclusion criteria were:
secondary
scoliosis an pathologies known as possible cases of scoliosis
(15),
neurological decits, a difference in inferior limb length
exceeding
10 mm, previos treatment for scoliosis (brace, exercises or
srgery)
an Risser vale exceeing 3.
The patients themselves ecie whether they preferre to be
treated according to our exercise protocol (the SEAS group) or
by
a rehabilitation centre or single physiotherapist of their
choice (the
sal physiotherapy (uP) grop). They were ths ivie into 2groups
through self-selection: 35 patients entered the SEAS group
(25 females, mean age 12.7 (stanar eviation (Sd 2.2) years)
an
39 entere the uP grop (27 females, mean age 12.1 (Sd 2.1)
years).
The mean Cobb angle at the start of treatment was 15 (Sd 6),
while
the mean ATR was 7 (Sd 2).
Study design
This was a prospective controlle cohort observational sty on
con-
sective otpatients. Moreover, it was a clinical everyay
practice
sty in which the physicians were netral observers becase
they
were not aware of the sty being performe an they were focse
only on the patients nees, althogh they were not bline to
the
treatment applie. de to the observational setting, ethical
approval
was not required. Each patient underwent a complete medical
evalua-
tion, ring which a physician with expertise in scoliosis
measrethe Bunnell ATR and radiographic Cobb angles. Clinical
evaluations
were performe every 6 months an raiographic measrement was
performe after 12 months of treatment, when the stie ene.
Treatment
The SEAS group performed SEAS exercises in its 2002 version
(2002:
SEAS.02) according to the Italian Scientic Spine Institute
(ISICO)
approach (14, 16). This consists of inivially aapte exercises
that
are taght to the patients in a strctre totally eicate to
scoliosis
treatment. The patients perform a single session of 1.5 h ration
every
23 months at or institte, in which they are evalate by a
physio-
therapist with expertise in scoliosis, learn a SEAS exercise
protocol that
is personalize accoring to meical an physiotherapic
evalations,
receive a vieo recor of their performance with
physiotherapists
sggestions, an participate in a family conselling meeting
with
regar to scoliosis. The patients contine treatment at a
rehabilitation
facility near their home (by themselves or with their parents)
twice a
week (40 min per session) pls one aily exercise at home (5
min).
The SEAS.02 exercises are based on Active Self-Correction
(ASC)
(17), which is an active movement performe in orer to
achieve
the maximm possible correction, the goal of which is to
activate
motor-neurone reex corrective response
(16, 17). The exercises areall performe with respect to ASC an
are aime at spinal stabiliza-
tion, strengthening of the tonic antigravity mscles,
improvement
of balance an co-orination, recovery an maintenance of
physio-
logical sagittal crves, an fll fnctional improvement accoring
to
physiotherapetic an meical evalations (16, 18). Therapists
avoi
increasing the spines range of motion (12, 16, 19, 20), bt
instea
focs mainly on spinal stability.
The uP grop participants performe many ifferent exercise
pro-
tocols at a local facility accoring to the preferences of their
single
therapist. In most cases the exercises were performe in a
grop
context, while in all cases they laste 4590 min an were
performe
2 or 3 times per week. In some cases, the patients were reqire
to
repeat their exercises aily at home.
All patients in both grops were also reqire to participate
in
sports as a complementary aspect of therapy, withot focsing on
any
particlar sports activity.
Outcome measures
The primary measres of otcome incle: the nmber of brace
patients, Cobb angle and ATR. Regarding Cobb angle, a
modication
of> 5 was considered signicant (5, 2123), while for ATR a
modi-
cation of> 2 was considered signicant (5, 23). In a previous
study
we fon a Cobb angel of 3 was the limit of etection of
otcome,
taking into accont intra-observer variations (17).
Accoringly,
progression was considered clinically signicant when it led to
a
change of treatment (brace prescription), while it was eeme
as
present when it was greater than the minimal etectable
change
accoring to the instrments se. Seconary otcome measres
included the sagittal prole, which was assessed by measuring
the
distance from the plumb-line at the C7 and L3 levels. The
method
applie has alreay been valiate, an its intra- an
inter-operator
repeatability measre (24). We also calclate the compliance rate
by
iviing the nmber of exercises sessions performe by the
expecte
freqency of 2 sessions per week.
Statistical analysis
The Cobb angle an the ATR were measre for each single crve,
an analysis was performe both for the single patients average
of
curves and worst curve. The distribution of variables was rst
evalua-
te, an then a fll set of paire sample comparisons employe,
sing
parametric or non-parametric tests, as appropriate. The t-test,
Mann-
Whitney U, Fishers exact an 2 tests were se. Ap-vale <
0.05
was considered statistically signicant.
RESULTS
No statistically signicant difference was found between the
2
grops at baseline for any of the scoliosis parameters. The
nmber
of sessions per week was 2.0, min per session 48, an
compliance
rate 95%. In aition, no ifference was fon between the 2
grops with respect to these parameters. There were 5
rop-ots:
2 females in the SEAS group and 3 (1 male) in the UP group.
Regaring the 11 brace patients, 81.8% were in the uP
grop, an the ifference between the grops was statistically
signicant (braced patients comprising 6.1% of the SEAS
grop vs 25.0% of the uP grop) (Fig. 1). A worst-case
analysis
J Rehabil Med 40
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453Exercises for adolescent idiopathic scoliosis
was performe, consiering all rop-ots as brace patients,
an the statistical ifference remaine, while the percentagesof
failures changed to 11.5% and 30.8% for the SEAS group
an uP grop, respectively.
The Cobb angle improved in the SEAS group but worsened in
the UP group. Even if they are statistically signicant (p
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454 S. Negrini et al.
an affecte by the prescribing physicians attite an the pa-
tients perception, brace prescription is a clear-ct change
of
treatment, implying increase hman an social costs; an, in
this respect, brace prescription can be consiere an otcome,
particlarly in a clinical everyay practice sty sch as this
one, where the physician is always the same an is focse on
the patients nees an not on the research reslts.There are no
pblishe ata on other exercise protocols that
might lea to a rection in the rate of brace prescription, bt
there are comparable ata on raiographic reslts in controlle
sties (Table II). In a similar poplation, bt sing retrospec-
tive grops (not incling rop-ots), Mollon & Root (27)
found, at the end of treatment with specic Lyon exercises,
that 63% of patients improve vs 20% in the control grop.
Such data was conrmed in similar studies by Ducong (28),
an by Klisic & Nicolic (29), who fon that 58% improve
with exercises vs 23% an 26%, respectively, in controls. In
all of these sties, a change of 3 in the Cobb angle was
considered signicant, which could explain why the authors
found only 5% of stable patients compared with our ndings.
In orer to compare or reslts with those pblishe previ-
osly, we consiere the proportion of patients who change
at least 3 in either irection (Table II): this limit was
chosen
to match that se in theprevios papers (2729), bt was also
in agreement with a sty we performe in which we fon,
in these small egree crves, an intra-observer variation of
3 was signicant to detect a change in either direction (17).
The rate of improvement in the uP grop was similar to that
of the control grops reporte above (28%), while the rate of
progression was slightly lower than that of the exercise
grops
(28% vs 3442%). This means that the uP grop also ha some
efcacy when compared with the literature. This holds trueeven
when taking into accont the fact that or reslts refer
to one year of treatment, while previos sties refer to the
entire treatment perio (34.7 years) (2527). The nmber of
improved patients in the SEAS group was only slightly lower
than reporte previosly, while it appears that the nmber of
worsene patients has been rece ramatically (to 13%). In
general, SEAS exercises have some reduction of efcacy (10%)
bt are mch safer (recing failre by a factor of 23). If,
in the future, this result of SEAS is conrmed at the end of
treatment, frther research will be reqire into the technical
explanations for the types of exercises performe.
The other controlle sties in the literatre, incling the
only one whose reslts were negative (bt which ha the weak-
est methoology) (2, 30), an the only one that was
prospective
an controlle (althogh it ha ifferent treatment teams) (31),
are not comparable becase of the ifferences in methoologyan
patient selection (2). Only one previos sty compare 2
treatment protocols (32), bt it fon no ifference accoring to
the protocol se. A mltiple linear regression analysis for
the
changes in Cobb angle as a fnction of compliance, physical
therapist an potentially confoning variables allows one to
etect that maximal participation in physical exercise
therapy
(> 30 min per ay), compare with minimal participation (
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455Exercises for adolescent idiopathic scoliosis
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