Sanja Schreiber

Effect of Schroth exercises on curve characteristics and clinical outcomes in adolescent idiopathic scoliosis: protocol for a multicentre randomised controlled trial

INTRODUCTION The promising results of Schroth scoliosis-specific exercises for adolescent idiopathic scoliosis found in low-quality studies will be strengthened by confirmation in a randomised controlled trial. RESEARCH QUESTIONS 1. Are Schroth exercises combined with standard care for 6 months more effective than standard care alone in improving radiographic and clinical outcomes for adolescents with idiopathic scoliosis? 2. Will the outcomes of the control group (who will be offered Schroth therapy delayed by 6 months) improve after 6 months of Schroth therapy? 3. Are the effects maintained 6 months after discontinuing the supervised intervention? DESIGN This is an assessor-blinded and statistician-blinded randomised controlled trial with transfer of the controls to the exercise group after 6 months. PARTICIPANTS AND SETTING Two hundred and fifty-eight consecutive adolescents with idiopathic scoliosis, aged 10 to 16 years, treated with or without a brace, with curves between 10 and 45 deg Cobb and Risser sign ≤ 3 will be recruited from three scoliosis clinics. INTERVENTION Combined with standard care, the Schroth group will receive five individual training sessions, followed by weekly group classes and daily home exercises for 6 months. CONTROL Controls will only receive standard care consisting of observation or bracing, and will be offered Schroth therapy 6 months later. MEASUREMENTS Curve severity (Cobb angle) and vertebral rotation will be assessed from radiographs at baseline, 6 and 12 months. Secondary clinical outcomes (back muscle endurance, surface topography measures of posture, and self-reported perceived spinal appearance and quality of life) will be assessed at baseline, and every 3 months until 1-year follow-up. ANALYSIS Data will be analysed using intention-to-treat linear mixed models. DISCUSSION The results will demonstrate whether Schroth exercises combined with standard of care can improve outcomes in adolescents with idiopathic scoliosis. This study has potential to influence clinical practice worldwide, where exercises are not routinely prescribed for adolescents with idiopathic scoliosis.

Inhaled short-acting bronchodilators for managing emergency childhood asthma: an overview of reviews

International guidelines provide conflicting recommendations on how to use bronchodilators to manage childhood acute wheezing conditions in the emergency department (ED), and there is variation within and among countries in how these conditions are managed. This may be reflective of uncertainty about the evidence. This overview of systematic reviews (SRs) aimed to synthesize, appraise, and present all SR evidence on the efficacy and safety of inhaled short‐acting bronchodilators to treat asthma and wheeze exacerbations in children 0–18 years presenting to the ED. Searching, review selection, data extraction and analysis, and quality assessments were conducted using methods recommended by The Cochrane Collaboration. Thirteen SRs containing 56 relevant trials and 5526 patients were included. Results demonstrate the efficacy of short‐acting beta‐agonist (SABA) delivered by metered‐dose inhaler as first‐line therapy for younger and older children (hospital admission decreased by 44% in younger children, and ED length of stay decreased by 33 min in older children). Short‐acting anticholinergic (SAAC) should be added to SABA for older children in severe cases (hospital admission decreased by 27% and 74% when compared to SABA and SAAC alone, respectively). Continuous nebulization, addition of magnesium sulfate to SABA, and levosalbutamol compared to salbutamol cannot be recommended in routine practice.

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

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.

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).

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.

Determining clinical significance independently from statistical significance? Implications for practice

Background In science, statistics are universally used for making an inference about a population from sample data. The purpose of statistical inference is to determine if a proposed null hypothesis can be rejected, by comparing the probability of an observation to occur under the null hypothesis (p-value) to a chosen alpha level of confidence. The null hypothesis is rejected if the p-value is smaller than alpha. The current focus on null hypothesis statistical significance testing in published work perpetuates confusion between statistical significance and clinical importance. Clinically, there are shortfalls to relying only on statistical inference.