Em Watkins

Schroth Physiotherapeutic Scoliosis-Specific Exercises Added to the Standard of Care Lead to Better Cobb Angle Outcomes in Adolescents with Idiopathic Scoliosis – an Assessor and Statistician Blinded Randomized Controlled Trial

Background The North American non-surgical standard of care for adolescent idiopathic scoliosis (AIS) includes observation and bracing, but not exercises. Schroth physiotherapeutic scoliosis-specific exercises (PSSE) showed promise in several studies of suboptimal methodology. The Scoliosis Research Society calls for rigorous studies supporting the role of exercises before including it as a treatment recommendation for scoliosis. Objectives To determine the effect of a six-month Schroth PSSE intervention added to standard of care (Experimental group) on the Cobb angle compared to standard of care alone (Control group) in patients with AIS. Methods Fifty patients with AIS aged 10–18 years, with curves of 10°-45° and Risser grade 0–5 were recruited from a single pediatric scoliosis clinic and randomized to the Experimental or Control group. Outcomes included the change in the Cobb angles of the Largest Curve and Sum of Curves from baseline to six months. The intervention consisted of a 30–45 minute daily home program and weekly supervised sessions. Intention-to-treat and per protocol linear mixed effects model analyses are reported. Results In the intention-to-treat analysis, after six months, the Schroth group had significantly smaller Largest Curve than controls (-3.5°, 95% CI -1.1° to -5.9°, p = 0.006). Likewise, the between-group difference in the square root of the Sum of Curves was -0.40°, (95% CI -0.03° to -0.8°, p = 0.046), suggesting that an average patient with 51.2° at baseline, will have a 49.3° Sum of Curves at six months in the Schroth group, and 55.1° in the control group with the difference between groups increasing with severity. Per protocol analyses produced similar, but larger differences: Largest Curve = -4.1° (95% CI -1.7° to -6.5°, p = 0.002) and Sum of Curves=−0.5° (95% CI -0.8 to 0.2, p = 0.006). Conclusion Schroth PSSE added to the standard of care were superior compared to standard of care alone for reducing the curve severity in patients with AIS. Trial Registration NCT01610908

Algorithms to prescribe Schroth exercises for each of four Schroth curve types

Background Systematic reviews have shown that most exercise studies for scoliosis treatment lacked standardization of exercise prescription. Schroth exercise prescription is based on scoliosis curve type with specific exercises designed to target different aspects of the spinal curve and different areas of the body. The intensity of exercises is increased based on patient capacity. There may be dose dependant and exercise specific effects, therefore it is important to adopt a standardized method of prescription, especially in clinical research trials. Goal: To describe prescription algorithms and a performance checklist for standardizing Schroth exercise treatment based on instructions in the Schroth training.

An algorithm for determining scoliosis curve type according to Schroth

Background Schroth exercises are scoliosis specific [1,2]. They are the most researched and have been shown to lead to good outcomes. The Schroth classification consists of four mutually exclusive curve type categories (3c, 3cp, 4c and 4cp). Patients with scoliosis are classified according to their clinical presentation by a certified Schroth therapist. Observing the alignment of the following body blocks guides the classification assessment: lumbar spine and pelvis, thoracic spine and rib cage, and the cervical spine, head and shoulder girdle. Classifying patients’ curve types within the four Schroth curve categories determines the appropriate exercise prescription for a patient. An algorithm is needed to minimize errors in classifying different scoliosis patterns and help standardize exercise prescription.

The effects of a 6-month Schroth intervention for Adolescent Idiopathic Scoliosis (AIS): preliminary analysis of an ongoing randomized controlled trial

Methods A total of 31 patients with AIS, aged 10-18, with curves from 10°-45°, wearing a brace or not, participated. Sixteen were randomized to Schroth with standard care, and 15 to standard care alone (monitoring or bracing) for six months. The Schroth intervention consisted of five individual visits to learn the exercises, followed by weekly supervised group sessions of one hour each, with daily home exercises prescribed using an algorithm [2] (45 minutes per day). Compliance was monitored with a logbook, and outcomes were recorded at baseline and six months. Effect sizes were estimated using Cohen’s d, which corresponds to the mean difference between the groups in the change observed from baseline to six months (Schroth – standard care), divided by the pooled standard deviation at baseline (Cohen’s d ≥0.8=large, 0.5-0.8=moderate, 0.2-0.5=small[3]). Results Two controls and one Schroth group participant dropped out. Mean age was 14.4±2.1yrs for Schroth and 13.7 ±1.7yrs for controls; mean Cobb angles were 32.6±7.9o and 28.8±10.0o, respectively. Schroth participants with complete follow-up attended 87±8% of the prescribed weekly exercise sessions and completed 86±5% of the prescribed home exercises. Intention-to-treat analysis lowered compliance to 83±19% and 81±17% for weekly sessions and home program, respectively. Effect sizes at six months for the SRS-22r were smaller than expected, but favored the Schroth group with Cohen’s d: pain=0.09, selfimage=0.09, function=0.00 and total=0.21. The effect sizes for self-efficacy (0.18) and for the Biering-Sorensen test (0.28) also favored Schroth. The perceived mean global rating of change in the Schroth group was 3.8±2.2, corresponding to moderate improvement, and -0.3±1.7 in the standard care group, corresponding to a small amount of deterioration.

Differences in measures of full-torso surface topography among healthy teenagers are independent of growth indicators

Surface topography (ST) has been proposed to monitor changes in spinal and rib cage deformity in adolescent with idiopathic scoliosis. The changes in ST parameters used to monitor scoliosis should be related to scoliosis progression and not to changes in torso shape occurring with growth. The objective was to determine the correlation between growth indicators and full-torso surface topography parameters in healthy teenagers.

The effect of a 6-month Schroth exercise program: a pilot study using subjects as their own controls

Methods We included patients with AIS, 10-18 years, with curves of 10-45o, wearing a brace or not, and randomized initially into the standard-care group (observation or bracing) of an ongoing RCT. After receiving standard care for 6 months, controls received the 6-month Schroth intervention. Patients completed five introductory individual visits followed by 1-hour weekly supervised group sessions combined with daily home exercises prescribed using an algorithm (45 minutes). Outcomes were recorded at baseline, 6 and 12 months. Effect sizes were estimated using Cohen’s d (≥0.2=small, 0.5-0.8=moderate, >0.8=large), which corresponds to the difference between groups divided by the pooled standard deviation of the individual differences[2]. Results Of 13 subjects, 2 dropped out while controls and 2 while in Schroth therapy. Of the nine subjects who completed all follow-ups, the mean age and Cobb angle at baseline were 14.0±1.8yrs and 31±10.5o (17-43o), respectively. The recruitment rate was 14% among eligible participants, with time constraints limiting participation. All effect sizes favored Schroth except the Spinal Appearance Questionnaire (SAQ) waist score (0.14). Effect sizes for the SRS-22r questionnaire were as follows: self-image=0.92, pain=0.60, function=0.18 and total=0.56. Pain, self-image and total scores improvements were statistically significant (repeated measures ANOVA). SAQ effect sizes were as follows: general=0.23, chest=0.96, kyphosis=1.43, shoulders=0.40, trunk shift=0.44, prominence=0.77 and curve=0.89. Effect sizes for curve measures were as follows: major Cobb angle=0.00 and combined Cobb angles=0.13. Global ratings of change were significantly higher after Schroth therapy (4.7±2.3, 15-point scale).

Test-retest standard error of measurements for full-torso surface topography parameters obtained with the arms at 30 and 90 degrees of elevation in healthy teenagers

The objective of this study was to report full-torso surface topography (ST) parameters and to determine test-retest standard error of measurement (SEM) in adolescents without spinal deformities. ST is used to quantify the external deformity of the torso due to scoliosis. A normative ST database is being developed to help interpret the ST parameters used to describe scoliosis. Test-retest SEM has not been estimated for most parameters in this population.

Asymmetry Assessment Using Surface Topography in Healthy Adolescents

The ability to assess geometric asymmetry in the torsos of individuals is important for detecting Adolescent Idiopathic Scoliosis (AIS). A markerless technique using Surface Topography (ST) has been introduced as a non-invasive alternative to standard diagnostic radiographs. The technique has been used to identify asymmetry patterns associated with AIS. However, the presence and nature of asymmetries in the healthy population has not been properly studied. The purpose of this study is therefore to identify asymmetries and potential relationships to development factors such as age, gender, hand dominance and unilateral physical activity in healthy adolescents. Full torso scans of 83 participants were analyzed. Using Geomagic, deviation contour maps (DCMs) were created by reflecting the torso along the best plane of sagittal symmetry with each spectrum normalized. Two classes of asymmetry were observed: twist and thickness each with subgroupings. Averaged interobserver and intraobserver Kappas for twist subgroupings were 0.84 and 0.84, respectively, and for thickness subgroupings were 0.53 and 0.63 respectively. Further significant relationships were observed between specific types of asymmetry and gender such as females displaying predominately twist asymmetry, and males with thickness asymmetry. However, no relationships were found between type of asymmetry and age, hand dominance or unilateral physical activity. Understanding asymmetries in healthy subjects will continue to enhance assessment ability of the markerless ST technique.

Feasibility and three months preliminary results of an RCT on the effect of Schroth exercises in adolescent idiopathic scoliosis (AIS)

Methods Fifteen patients with AIS, aged 10-18, with curves 10 – 45 degrees, braced or not, were randomized into Schroth, or standard care, groups. The six-month Schroth intervention consists of weekly one-hour long group exercise sessions, combined with a daily 45-minute long home program, consisting of 3-4 exercises prescribed using an algorithm. Compliance was monitored with a logbook. SRS-22r, Spinal Appearance Questionnaire, Sorensen back endurance, and Self-efficacy and Global Rating of Change (GRC) outcomes were measured. The effect sizes of the Schroth exercise treatment on key outcomes were estimated using Cohen’s d (≥0.8=large, 0.5-0.8=moderate, 0.2-0.5=small). Cohen’s d is defined as the difference in change between the group means, Schroth – Standard care, observed from baseline to 3 months, divided by the pooled standard deviation at baseline. Results Of 122 eligible patients, fifteen (12.3%) were enrolled between April and August 2011. Recruitment was 3 per month. Exercise subjects attended 89±9% of the prescribed weekly exercise sessions, and completed 76±8% of the prescribed home exercises. Only one Standardcare subject dropped out due to relocation. For SRS-22r domains, Cohen’s d effect sizes favored standard care: -0.31 for Self-image, -0.72 for Function, and -0.38 for Pain. For SAQ domains, some effect sizes favored standard care: 0.50 for General, 0.46 for Curve, 1.36 for Prominence, 0.57 for Shoulders and 0.35 for Chest. Other SAQ effect sizes favored Schroth: -0.14 for Trunk Shift, -0.31 for waist. The Sorensen test’s effect size was -0.14, and Self-efficacy’s was 0.5, both favoring standard care. The mean difference between groups in GRC was 3.4±1.7 in favor of the Schroth group.

Test-retest standard error of measurements for full-torso surface topography parameters in healthy teenagers

Methods Twenty-two healthy volunteers between 10-17 years old, with a body mass index of 19.1 ± 3.3 kg/m2, scoliometer measure of 3.6° ± 2.5°, and without pain were included. Four Minolta 910 Laser Scanners and a standard positioning frame were used to record ST scans. One evaluator positioned all subjects, marked 11 reference points, and scanned. Immediately after, reference points were erased, landmarking and scanning repeated. ST parameters were extracted with custom designed software in Matlab by one evaluator digitizing reference points. Nineteen previously published and 7 newly proposed ST parameters were extracted. Test-retest standard error of measurement was calculated for each parameter. SEM was estimated for the minimum, maximum and the range of within-subject values for parameters extracted. SEM < 4 mm, < 5° or < 0.2 for a ratio were considered adequate based on values in patients with scoliosis. (Figure 1) Conclusion Test-retest SEM of 15 of 26 ST parameters in healthy adolescents were found adequate for developing a normative database. Six of the 7 newly developed parameters had adequate SEM. from 6th International Conference on Conservative Management of Spinal Deformities Lyon, France. 21-23 May 2009