Adolescent idiopathic scoliosis (AIS) is a three-dimensional structural deformation of the spine and trunk with lateral shift and rotation of the vertebrae . Idiopathic scoliosis with curvature over 10° affects around 3% of children and adolescents. Idiopathic scoliosis occurs in otherwise healthy children and is often diagnosed at the time of the pubertal growth spurt. About one tenth develop a more aggressive variant leading to a more severe deformity of the spine and thorax . By early adulthood, the majority of patients with scoliosis suffer from back pain and if the curve progresses to be very large, even pulmonary dysfunction and psychological distress can occur .
In its mild form, idiopathic scoliosis is common and is not treated. In Sweden, screening occurs in school grade 4 (age 10–11) and in grade 7 or 8 (ages 13–14), and it can be estimated that at least 200,000 children are screened yearly by school nurses and physicians. The aim is to find the children with moderate scoliosis. These are often treated with a brace to prevent progression to severe scoliosis. More severe curves are treated with spinal fusion surgery. Surgical complications are few but if they occur, may be devastating, such as paraplegia . The spinal curve is corrected and fused with limitation in mobility as a result.
Several theories propose that during the adolescent period of skeletal growth, bone deformation may occur in the event of vertebral body weakness or an imbalance of muscle forces and joint flexibility . A recent review of literature concerning the association of low bone mineral density and idiopathic scoliosis reported generalized osteopenia and an osteoporosis prevalence of 20–38 percent . Adequate levels of self-mediated physical activity and intake of calcium and vitamin-D is a requirement for normal skeletal growth and development during childhood and adolescence. It is well documented that physical exercise is associated with improvements in not only muscle strength, aerobic fitness and motor development but also bone density which may help decrease the risk of osteopenic related bone deformation [7, 8].
Current guidelines from the International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) recommend physical therapy from curve magnitudes >15° Cobb . Furthermore it is recommended that physical therapy and/or bracing of conservative treatment for AIS be implemented when curve magnitudes of 25-45° are apparent . Surgical intervention for AIS is generally first considered when curve magnitudes reach >50° . A recent systematic literature review of all available literature investigating the effectiveness of physical exercise in the treatment of AIS reported the results of 1 randomised controlled trial, 9 prospective cohort controlled trials, 8 prospective observational cohort studies and 2 retrospective cohort studies . Together, the studies provide an evidence base of limited scientific quality suggesting the efficacy of physical exercise in reducing the scoliosis progression. Improved scientific quality of future research will better define the evidence base effects of physical therapies .
A recent literature review investigating the effectiveness of brace treatment of AIS reported the results of two prospective cohort controlled trials and 18 longitudinal case control studies . Together, the existing studies provide an evidence base of limited scientific quality for the efficacy of bracing preventing the progression of scoliosis. Two randomised trials comparing brace treatment with observation only are currently being conducted; NCT00448448 and NCT01370057, registered at http://www.clinicaltrials.gov (accessed at March, 12th, 2013). Another trial from Holland has been terminated due to recruitment difficulties .
The on-going randomised trial use a thoracolumbar sacral orthosis worn during 20–23 hours per day as the active treatment. This brace is made of hard plastic and stretches from under the arms to the pelvis. It is custom made and corrects the scoliotic curvature of the spine when worn. The psychological impact when using the brace 20–23 hours per day should not be underestimated. In one study, 27% of the brace treated patients reported that the treatment had a major negative effect on their lives , and our clinical impression is that this is one of the reasons to the poor compliance that is often seen. Recently, preliminary data suggested that approximately eight hours of night-time bracing with an over-corrective brace was as effective as bracing during 23 hours per day .
Night-time bracing is attractive since you wear the brace a limited amount of time. The brace does not restrict activities during daytime. Our clinical impression is that the psychological concern for a teenager is much less when compared to brace treatment day and night-time, which increases the possibility of good compliance. There have been no controlled studies on night time bracing versus observation only. Several uncontrolled trials have been published, indicating an immediate corrective effect on the scoliosis by the brace .
Only one low quality study has compared bracing with physical exercise showing no statistical differences in the reduction or progression of scoliosis curves between the groups . To draw valid conclusions about the effectiveness of conservative treatments for AIS, a randomised controlled trial research design is needed to compare the interventions.
Aim of study
The primary objective of this study is to improve the evidence base regarding the effectiveness of conservative treatments for preventing the progression of AIS. Secondary aims include improving knowledge of clinical features that may predict a patient's response to each treatment.
That the use of a night-time brace and adequate levels of self-mediated physical activity is more effective in preventing curve progression than adequate levels of self-mediated physical activity alone.
That prescribing scoliosis specific exercise and adequate levels of self-mediated physical activity is more effective in preventing curve progression than adequate levels of self-mediated physical activity alone.