Efficacy of Scoliosis Specific Exercise in Patients With Adolescent Idiopathic Scoliosis During Bracing
Efficacy of Scoliosis Specific Exercise in Patients With Adolescent Idiopathic Scoliosis During Bracing
The purpose of this study is to examine the effectiveness of Schroth scoliosis-specific
 exercises (SSE) on patients with adolescent idiopathic scoliosis (AIS) during bracing. The
 goal is to determine if Schroth SSE combined with bracing can is superior in controlling
 curve progression when compared with bracing alone. Curve progression is defined as worsening
 of coronal Cobb angle of 6 degrees or more.
Adolescent Idiopathic scoliosis (AIS) is a three-dimensional deformity of the spine,
 characterized by a lateral curvature and vertebral rotation. Its prevalence is estimated to
 be 2.5% in children between aged 10 and 16 in Hong Kong. Curve progression occurs during
 pubertal growth spurt. If the primary curve does not exceed 40 degree at skeletal maturity,
 it is unlikely to continue to progress, and there are little or no long-term clinical
 consequences. However, if the curve progresses beyond 50 degree during adolescence, it may
 cause functional limitation, accelerated disc degeneration with potential neurological
 deficit, cosmetic concerns, decreased quality of life, and possible progression in adulthood.
 Thus, surgical correction of the deformity with instrumented spinal fusion is usually
 recommended if the curve reaches 50 degree during adolescence.

 Currently, spinal bracing is the only the only non-operative treatment supported with
 high-quality evidence that can prevent curve progression. In a randomized controlled trial,
 Weinstein et al. recently reported in the New England Journal of Medicine that bracing was
 effective in preventing curve progression to threshold for surgery in 72% of cases. The trial
 was terminated early due to the treatment benefit in favor of bracing. Nonetheless, the
 authors reported a treatment failure rate of 25% in the randomized cohort, which was similar
 to previous published studies. Hence, despite the best available non-operative treatment, the
 number of adolescents ultimately requiring surgery remains substantial. Surgery is associated
 with medical comorbidities, can cause psychosocial stress to the children and their families,
 and has significant financial impact on healthcare, with the total costs of spinal surgery to
 correct AIS ranked second only to appendicitis among children 10 to 17 years of age.
 Consequently, further effective strategies to prevent scoliosis progression in children are
 needed.

 Scoliosis-specific exercise (SSE) has been proposed as an additional non-operative
 intervention that may reduce curve progression during the adolescent growth spurt. However,
 the standard of care for non-operative treatment of AIS varies widely between North America
 and Europe, and the use of SSE is not universally accepted. SSE is a potentially low-cost
 intervention that will be of substantial benefit even if a relative risk reduction in curve
 progression or reaching the threshold for surgery is reduced in a modest proportion of those
 participating.

 SSE, as opposed to generalized physiotherapy, consists of individually-adapted exercises that
 aim to promote spinal realignment through self-correction and stabilization, as well as
 modulating patterns of trunk muscles recruitment. Electromyography (EMG) of paraspinal and
 abdominal muscles in AIS patients revealed disrupted patterns of muscles recruitment, which
 are associated with a disparity in trunk isometric rotation strength between sides. AIS
 patients demonstrate proprioceptive and balance control problems, along with a distorted body
 schema, resulting in a mismatch between the actual spinal alignment and the patients'
 internal representation of the body. SSE aims to reverse the anomalous patterns of muscle
 recruitment through training, and modify the body schema with visual and somatosensory
 feedback. This forms the theoretical neurophysiological basis for using this treatment
 strategy for AIS.

 Schroth SSE is one of the most studied and widely-used schools of SSE. It is a technique
 tailored to the type of scoliosis and the curve magnitude of each patient. It is based on
 vertebrae deflections and sagittal corrections that result in horizontal vertebrae
 de-rotation. It uses rotational breathing and postural auto-correction to reverse the
 underlying impairments in spinal muscle function, postural control and proprioception which
 contribute to the development of curvature in AIS. Patients will also be given cognitive
 behavioral strategies to empower them to self-manage their conditions.
Inclusion Criteria:

 -  Diagnosis of AIS

 -  Male or female from 10 to 15 year-old, inclusive, at the time of consent provided

 -  Skeletal immaturity, defined as a Risser grade (amount of ossification and eventual
 fusion of the iliac apophysis) of 0, 1, or 2

 -  Cobb angle of 25-40

 -  No prior conservative or surgical treatment for AIS

 Exclusion Criteria:

 -  An underlying cause or association that may cause scoliosis

 -  Leg length discrepancies or lower limb deformities that may interfere with spinal
 posture

 -  Previous spinal surgery

 -  Cognitive impairment

 -  Those receiving any other forms of treatment including alternative medicine for the
 treatment of their scoliosis

 -  Those who are unable to return for follow-up to complete the trial.