Volume 11 Supplement 2
Immediate effects of scoliosis-specific corrective exercises on the Cobb angle after one week and after one year of practice
© The Author(s). 2016
Published: 17 October 2016
We are unaware of any studies describing the immediate effects of scoliosis-specific exercises on the Cobb angle measured by radiograph. This study aimed to describe the differences between radiographs obtained with and without corrective exercises after initial training and after one year.
A female with adolescent idiopathic scoliosis was first seen at age 13 years, 0 months with a Risser 0. She had a 43o left lumbar, 15o right thoracic curve. She was seen again after 6, 18 and 30 months and performed exercises from 18 to 30 months. She performed Barcelona Scoliosis Physical Therapy School (BSPTS) exercises for a four-curve type (lumbar dominant with pelvis deviation to the lumbar concave side). At 18 and 30 months, x-rays were obtained with and without performing corrective exercises.
At 6 months, her lumbar and thoracic curves measured 41o and 28o, respectively. At 18 months, her lumbar and thoracic curves measured 47 o and 30o, respectively. Also at 18 months, immediately after her x-ray in the relaxed standing position, she performed her corrective exercises in standing with arms lowered for a second x-ray. Her lumbar and thoracic curves remained similar and measured 43o and 32o, respectively. At 30 months, she performed unsolicited corrective exercises during the x-ray. Her lumbar and thoracic curves measured 26o and 41o, respectively. Another x-ray in the relaxed position revealed lumbar and thoracic curves measuring 39o and 35o, respectively. The immediate effect of corrective exercises after a year of training was a 33 % improvement at the lumbar spine compared to only a 9 % improvement the previous year.
After initial training, corrective exercises during a standing x-ray did not significantly improve the Cobb angle for the major lumbar curve compared to the relaxed standing x-ray. However, a year after performing exercises, unsolicited corrective exercises resulted in a significantly improved Cobb angle compared to relaxed standing for the curve primarily targeted by the exercise program. Improved exercise ability and spinal flexibility may have contributed to the improved Cobb angle.
Auto-corrective exercises are integral to scoliosis-specific exercises [1–4]. The Cobb angle measured by radiograph is the most commonly used outcome measure to assess curve magnitude . However, it is unclear whether and how corrective exercises affect the Cobb angle. A number of promising studies showed that Schroth corrective exercises for patients with scoliosis can slow curve progression or help patients achieve some curve correction [2, 3, 6–9]. We are also unaware of any studies describing the immediate effects of scoliosis-specific exercises on the Cobb angle. In an article on the Scientific Exercise Approach to Scoliosis (SEAS) method, Romano et al.  demonstrated x-ray images of one patient in a relaxed position and during corrective exercises . However, no details were provided including the time frame of the x-rays and measurements of the exact Cobb angles. The aim of this study is to describe the differences between radiographs obtained with and without corrective exercises after initial training and after one year.
Since this is a de-identified case study, IRB approval was not required.
The patient’s thoracic curve worsened slightly from her 18 month visit to her 30 month visit although she approached skeletal maturity (Risser 4, 1 cm growth). She was treated as a 4C curve type (dominant lumbar curve with a nondominant thoracic curve), but the focus of the corrections were at the main curve (lumbar spine). It is difficult to say whether the corrective exercises had a negative effect on the nondominant thoracic curve, since clinically the patient appeared more balanced. Auto-corrrective exercises should improve alignment throughout the spine in three dimensions . However, it can be challenging to improve each aspect of spinal deformity with multiple and even opposing body blocks. Perhaps a bigger focus should have been placed on the thoracic curve. The thoracic spine is stiffer than the lumbar spine due to the ribs attaching to the lumbar spine. Future studies should investigate whether other patients have experienced curve progression at the nondominant curves despite approaching skeletal maturity. Other Schroth studies only reported curve magnitude at the main curves [6, 7, 9] or did not report data specifically about the secondary curves .
Since patients are able to improve their Cobb angle for radiographs, we emphasize that patients should stand in their relaxed posture for x-rays at all visits to follow proper standardized radiographic procedures. However, it is possible that patients that utilize scoliosis-specific exercises perform their corrective exercises during radiographs which may result in overestimated exercise effects. However, one could also argue that radiographs displaying exercise corrections despite requesting that patients stand in a relaxed natural position can capture patients’ ability to hold a corrected position throughout their daily life. Future exercise studies should clarify instructions given to patients during radiographic acquisition. Also, with an increasing availability of EOS imaging which includes significantly lower radiation effects,  facilities could consider imaging patients in both their relaxed and corrected postures. EOS imaging may monitor the ability of patients to perform their corrective exercises, to understand the relative effect of various corrective instructions, and to determine the effect of the three-dimensional nature of the exercises (planes of maximum deformity or angles of rotation).
After initial training, corrective exercises during a standing x-ray did not significantly improve the Cobb angle for the major lumbar curve compared to the relaxed standing x-ray. However, a year after performing exercises, unsolicited corrective exercises resulted in a significantly improved Cobb angle compared to relaxed standing for the curve primarily targeted by the exercise program. Improved exercise ability and spinal flexibility may have contributed to the improved Cobb angle. Wearable technology is needed to better understand how much time patients are spending in their corrected versus relaxed postures.
This article has been published as part of Scoliosis and Spinal Disorders Volume 11 Supplement 2, 2016. Research into Conservative Management of Spinal Deformities: Short Articles from the SOSORT 2015 Meeting. The full contents of the supplement are available online http://scoliosisjournal.biomedcentral.com/articles/supplements/volume-11-supplement-2.
Availability of data and materials
All the data pertinent to this case is in the manuscript.
KZ was the treating physical therapist. DS was the patient’s orthopaedic surgeon. KZ, DS, and EP helped draft the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Consent for publication was received by the parent; assent was received by the patient.
Ethics approval and consent to participate
This study received a letter of exemption from Texas Scottish Rite Hospital’s Institutional Review Board.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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