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Rapid response to:

Clinical Review

Adolescent idiopathic scoliosis

BMJ 2013; 346 doi: (Published 30 April 2013) Cite this as: BMJ 2013;346:f2508

Rapid Response:

Re: Adolescent idiopathic scoliosis

We compliment Altaf et al for their paper on Adolescent Idiopathic Scoliosis (AIS) [1]. However, it is important to note that this review does not include relevant evidence-based information on conservative treatment published in the last several years, which is also missing in other recent papers [2].

The most important lacking information concern physiotherapeutic specific exercises, that could represent adjuvant to braces [3, 4] and a first possible approach to AIS [4, 5]. Like bracing, this treatment modality is not usual in US and UK, but in other European Countries they are traditionally used and some results have been published [3, 5-13].

Research on conservative treatment of AIS had been decreasing for over 50 years (Figure 1), partly due to a shift of interest towards the more complicated surgical cases by many orthopaedic surgeons in the Scoliosis Research Society (SRS) [14]. This has been particularly relevant, as stated by Altaf [1], in the US and UK, while in most of the remaining European Countries the approach still remains more traditional. Consequently, in 2003 the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT), was formed to foster international research, define evidence and establish global Clinical Guidelines for conservative treatment. During the past five years, the collaboration between SOSORT and the SRS has steadily increased. Unfortunately this growth of research, evidence, and scientific relationships has not yet been reflected in the most important journals [1, 2, 15].

Examples of the important published papers on conservative treatment of adolescent idiopathic scoliosis usually missing [1, 2, 15] include:

• A Cochrane Review [16] published in 2010 which concluded that, even though the quality of the evidence is very low, it does support the use of braces [17] and the superiority of rigid versus elastic bracing [18]; although randomized controlled trials (RCTs) would provide the best evidence, so far the possibility of producing RCTs has been compromised due to parents not approving the randomization of their children in 70–80% of cases [19, 20].

• A more recent Cochrane Review [5] published in 2012 which concluded that high quality evidence is lacking on exercises: a low quality RCT [6] gives some evidence on their effectiveness in preventing the progression of AIS; an observational trial supports physiotherapeutic specific exercises versus usual physiotherapy [7].

• The SOSORT Clinical Guidelines [4] published in 2011, which provides 65 evidence-graded recommendations on braces, exercises, other conservative treatments, sports activities, and assessment. There was also a previous Clinical Guideline [21] published in 2009 which focused on team management of brace treatment and compliance, whose importance have been stressed by Altaf [1].

• Consensuses on conservative treatment of AIS produced by SOSORT to help cover the multiple grey areas of the non operative approach, and to start new research pathways [22-26].

• Finally, some other systematic reviews on conservative treatment [8-13, 27].
Stronger evidence for conservative treatment of AIS is needed, but some evidence does exist and should not be ignored.

1. Altaf F, Gibson A, Dannawi Z, Noordeen H: Adolescent idiopathic scoliosis. Bmj 2013, 346:f2508.
2. Hresko MT: Clinical practice. Idiopathic scoliosis in adolescents. N Engl J Med 2013, 368(9):834-841.
3. Zaina F, Negrini S, Atanasio S, Fusco C, Romano M, Negrini A: Specific exercises performed in the period of brace weaning can avoid loss of correction in Adolescent Idiopathic Scoliosis (AIS) patients: Winner of SOSORT's 2008 Award for Best Clinical Paper. Scoliosis 2009, 4(1):8.
4. Negrini S, Aulisa AG, Aulisa L, Circo AB, de Mauroy JC, Durmala J, Grivas TB, Knott P, Kotwicki T, Maruyama T et al: 2011 SOSORT guidelines: Orthopaedic and Rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis 2012, 7(1):3.
5. Romano M, Minozzi S, Bettany-Saltikov J, Zaina F, Chockalingam N, Kotwicki T, Maier-Hennes A, Negrini S: Exercises for adolescent idiopathic scoliosis. Cochrane Database Syst Rev 2012, 8:CD007837.
6. Wan L, Wang G-x, Bian R: Exercise therapy in treatment of essential S-shaped scoliosis: evaluation of Cobb angle in breast and lumbar segment through a follow-up of half a year. Zhongguo Linchuang Kangfu (Chinese Journal of Clinical Rehabilitation) 2005, 9(34):82-84.
7. Negrini S, Zaina F, Romano M, Negrini A, Parzini S: Specific exercises reduce brace prescription in adolescent idiopathic scoliosis: A prospective controlled cohort study with worst-case analysis. J Rehabil Med 2008, 40(6):451-455.
8. Negrini S, Fusco C, Minozzi S, Atanasio S, Zaina F, Romano M: Exercises reduce the progression rate of adolescent idiopathic scoliosis: results of a comprehensive systematic review of the literature. Disabil Rehabil 2008, 30(10):772-785.
9. Fusco C, Zaina F, Atanasio S, Romano M, Negrini A, Negrini S: Physical exercises in the treatment of adolescent idiopathic scoliosis: an updated systematic review. Physiother Theory Pract 2011, 27(1):80-114.
10. Negrini S, Antoninni G, Carabalona R, Minozzi S: Physical exercises as a treatment for adolescent idiopathic scoliosis. A systematic review. Pediatric Rehabilitation 2003, 6:227 - 235.
11. Lenssinck ML, Frijlink AC, Berger MY, Bierman-Zeinstra SM, Verkerk K, Verhagen AP: Effect of bracing and other conservative interventions in the treatment of idiopathic scoliosis in adolescents: a systematic review of clinical trials. Phys Ther 2005, 85(12):1329-1339.
12. Negrini S, Romano M: On "effect of bracing..." Lenssinck et al Phys Ther 2005;85:1329-1339. Phys Ther 2007, 87(1):112; author reply 112-113.
13. Mordecai SC, Dabke HV: Efficacy of exercise therapy for the treatment of adolescent idiopathic scoliosis: a review of the literature. Eur Spine J 2012.
14. Negrini S: Approach to scoliosis changed due to causes other than evidence: patients call for conservative (rehabilitation) experts to join in team orthopedic surgeons. Disabil Rehabil 2008, 30(10):731-741.
15. Weinstein SL, Dolan LA, Cheng JC, Danielsson A, Morcuende JA: Adolescent idiopathic scoliosis. Lancet 2008, 371(9623):1527-1537.
16. Negrini S, Minozzi S, Bettany-Saltikov J, Zaina F, Chockalingam N, Grivas TB, Kotwicki T, Maruyama T, Romano M, Vasiliadis ES: Braces for idiopathic scoliosis in adolescents. Cochrane Database Syst Rev 2010(1):CD006850.
17. Nachemson AL, Peterson LE: Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. A prospective, controlled study based on data from the Brace Study of the Scoliosis Research Society. J Bone Joint Surg Am 1995, 77(6):815-822.
18. Wong MS, Cheng JC, Lam TP, Ng BK, Sin SW, Lee-Shum SL, Chow DH, Tam SY: The effect of rigid versus flexible spinal orthosis on the clinical efficacy and acceptance of the patients with adolescent idiopathic scoliosis. Spine 2008, 33(12):1360-1365.
19. Dolan L, Weinstein S: To BrAIST or not to BrAIST: decisions and characteristics of 1131 patients eligible for the Bracing in Adolescent Idiopathic Scoliosis Trial. Scoliosis 2012, 7 Suppl 1:O23.
20. Bunge EM, Habbema JD, de Koning HJ: A randomised controlled trial on the effectiveness of bracing patients with idiopathic scoliosis: failure to include patients and lessons to be learnt. Eur Spine J 2010, 19(5):747-753.
21. Negrini S, Grivas TB, Kotwicki T, Rigo M, Zaina F: Guidelines on "Standards of management of idiopathic scoliosis with corrective braces in everyday clinics and in clinical research": SOSORT Consensus 2008. Scoliosis 2009, 4(1):2.
22. Kotwicki T, Negrini S, Grivas TB, Rigo M, Maruyama T, Durmala J, Zaina F: Methodology of evaluation of morphology of the spine and the trunk in idiopathic scoliosis and other spinal deformities - 6th SOSORT consensus paper. Scoliosis 2009, 4:26.
23. Grivas TB, Wade MH, Negrini S, O'Brien JP, Maruyama T, Hawes MC, Rigo M, Weiss HR, Kotwicki T, Vasiliadis ES et al: SOSORT consensus paper: school screening for scoliosis: Where are we today? Scoliosis 2007, 2(1):17.
24. Rigo M, Negrini S, Weiss H, Grivas T, Maruyama T, Kotwicki T: 'SOSORT consensus paper on brace action: TLSO biomechanics of correction (investigating the rationale for force vector selection)'. Scoliosis 2006, 1:11.
25. Why we treat adolescent idiopathic scoliosis? What we want to obtain and to avoid for our patients. SOSORT 2005 Consensus Paper – Topic 3 []
26. Weiss HR, Negrini S, Hawes MC, Rigo M, Kotwicki T, Grivas TB, Maruyama T: Physical exercises in the treatment of idiopathic scoliosis at risk of brace treatment - SOSORT consensus paper 2005. Scoliosis 2006, 1:6.
27. Romano M, Fusco C, Minozzi S, Atanasio S, Zaina F, Negrini S: Physical exercises and adolescent idiopathic scoliosis: results of a comprehensive systematic review of the literature. Stud Health Technol Inform 2008, 140:331.

Competing interests: SN: ISICO stock

17 May 2013
Stefano Negrini
Physical and Rehabilitation Medicine Physician
Fabio Zaina (ISICO - Italian Scientific Spine Institute Milan), Joe P O'Brien (National Scoliosis Foundation USA)
University of Brescia - IRCCS Don Gnocchi Foundation Milan (Italy)
Viale Europa 11, 25123 Brescia