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Indications for conservative management of scoliosis (guidelines)
- SOSORT guideline committee,
- Hans-Rudolf Weiss†1Email author,
- Stefano Negrini†2,
- Manuel Rigo3,
- Tomasz Kotwicki4,
- Martha C Hawes†5,
- Theodoros B Grivas6,
- Toru Maruyama7 and
- Franz Landauer8
© Weiss et al; licensee BioMed Central Ltd. 2006
- Received: 15 December 2005
- Accepted: 08 May 2006
- Published: 08 May 2006
This guideline has been discussed by the SOSORT guideline committee prior to the SOSORT consensus meeting in Milan, January 2005 and published in its first version on the SOSORT homepage: http://www.sosort.org/meetings.php. After the meeting it again has been discussed by the members of the SOSORT guideline committee to establish the final 2005 version submitted to Scoliosis, the official Journal of the society, in December 2005.
- Adolescent Idiopathic Scoliosis
- Idiopathic Scoliosis
- Cobb Angle
- Congenital Scoliosis
- Neuromuscular Scoliosis
Scoliosis is defined as a lateral curvature of the spine with torsion of the spine and chest as well as a disturbance of the sagittal profile .
Idiopathic scoliosis is the most common of all forms of lateral deviation of the spine. By definition, it is a lateral curvature of the spine in an otherwise healthy child, for which a currently recognizable cause has not been found. Less common but better defined etiologies of the disorder include scoliosis of neuromuscular origin, congenital scoliosis, scoliosis in neurofibromatosis, and mesenchymal disorders like Marfan's syndrome .
The prevalence of adolescent idiopathic scoliosis (AIS), when defined as a curvature greater than 10° according to Cobb, is 2–3%. The prevalence of curvatures greater than 20° is between 0.3 and 0.5%, while curvatures greater than 40° Cobb are found in less than 0.1% of the population. All etiologies of scoliosis other than AIS are encountered more rarely .
The anatomical level of the deformity has received attention from clinicians as a basis for scoliosis classification. The level of the apex vertebra (i.e., thoracic, thoracolumbar, lumbar or double major) forms a simple basis for description. In 1983, King and colleagues  classified different curvature patterns by the extent of spinal fusion required; however, recent reports have suggested that these classifications lack reliability. Recently, a new description has been developed by Lenke and colleagues . This approach calls for clinical assessment of scoliosis and kyphosis with respect to sagittal profile and curvature components. Systems designed for conservative management include the classifications by Lehnert-Schroth  (functional three-curve and functional four-curve scoliosis) and by Rigo  (brace construction and application).
The primary aim of scoliosis management is to stop curvature progression . Improvement of pulmonary function (vital capacity) and treatment of pain are also of major importance. The first of three modes of conservative scoliosis management is based on physical therapy, including Méthode Lyonaise , Side-Shift , Dobosiewicz , Schroth and others . Although discussed from contrasting viewpoints in the international literature, there is some evidence for the effectiveness of scoliosis treatment by physical therapy alone .
It has to be emphasized that (1) physical therapy for scoliosis is not just general exercises but rather one of the cited methods designed to address the particular nuances of spinal deformity, and (2) application of such methods requires therapists and clinicians specifically trained and certified in those scoliosis specific conservative intervention methods.
The second mode of conservative management is scoliosis intensive rehabilitation (SIR), which appears to be effective with respect to many signs and symptoms of scoliosis and with respect to impeding curvature progression . The third mode of conservative management is brace treatment, which has been found to be effective in preventing curvature progression and thus in altering the natural history of IS [15, 16]. It appears that brace treatment may reduce the prevalence of surgery , restore the sagittal profile  and influence vertebral rotation . There are also indications that the end result of brace treatment can be predicted .
Systematic application of the modes of conservative treatment with respect to Cobb angle and maturity
I. Children (no signs of maturity) 
a. < 15° Cobb: Observation (6 – 12 month intervals)
b. Cobb angle 15–20°: Outpatient physical therapy with treatment-free intervals (6–12 weeks without physical therapy for those patients at that time have low risk for curve progression). In this context, 'Outpatient physical therapy' is defined here as exercise sessions initiated at the physical therapist's office, plus a home exercise program (two to seven sessions per week according to the physical therapy method being applied). After three months, one exercise session every two weeks may be sufficient.
c. Cobb angle 20–25°: Out patient physiotherapy, scoliosis intensive rehabilitation program (SIR) where available.). SIR, currently available at clinics in Germany and Spain, includes a 3- to 5- week intensive program (4 – 6 hour training sessions per day) for patients with poor prognosis (brace indication, adult with Cobb angle of > 40°, presence of chronic pain).
d. > 25° Cobb: Outpatient physical therapy, scoliosis intensive rehabilitation program (SIR) where available and brace wear (part-time, 12–16 hours)
II. Children and adolescents, Risser 0–3, first signs of maturation, less than 98% of mature height
The following section is based on progression risk rather than on Cobb angle measurement because of the changing risk profiles for deformityas theskeleton matures. For our purposes, progression risk is calculated by the formula shown in figure 1.
a. Progression risk less than 40%: Observation (3-month intervals)
b. Progression risk 40%: Out patient physiotherapy
c. Progression risk 50%: Out patient physiotherapy, scoliosis intensive rehabilitation program (SIR) where available
d. Progression risk 60%: Out patient physiotherapy, scoliosis intensive rehabilitation program (SIR) where available + part-time brace indication (16 – 23 hours [low risk]).
e. Progression risk 80%: Out patient physiotherapy, scoliosis intensive rehabilitation program (SIR) where available + full-time brace indication (23 hours [high risk])
III. Children and adolescents presenting with Risser 4 (more than 98% of mature height)
a. < 20° according to Cobb: Observation (6 – 12 Months intervals)
b. 20 – 25° according to Cobb: Outpatient physical therapy
c. > 25° according to Cobb: Outpatient physical therapy, scoliosis intensive rehabilitation programme (SIR) where available
d. > 35° according to Cobb: Outpatient physical therapy, scoliosis intensive rehabilitation programme (SIR) where available + brace (part time, about 16 hours are sufficient)
e. For brace weaning: Outpatient physical therapy, scoliosis intensive rehabilitation programme (SIR) where available + brace with reduced wearing time.
IV. First presentation with Risser 4–5 (more than 99.5% of mature height before growth is completed)
a. > 25° Cobb: Outpatient physical therapy
b. > 30° Cobb: Outpatient physical therapy, scoliosis intensive rehabilitation program (SIR) where available.
V. Adults with Cobb angles > 30°
Outpatient physical therapy, scoliosis intensive rehabilitation program (SIR), where available
VI. Adolescents and adults with scoliosis (of any degree) and chronic pain
Outpatient physical therapy, scoliosis intensive rehabilitation program (SIR) where available, with a special pain program (multimodal pain concept/behavioral + physical concept), brace treatment when a positive effect has been proven .
Severe sagittal deviations with structural lumbar kyphosis ('flatback')
Lumbar, thoracolumbar and caudal component of double curvatures with a disproportionate rotation compared to the Cobb angle and with high risk for future instability at the caudal junctional zone
Severe contractures and muscles shortening
Reduced mobility of the spine especially in the sagittal plane
others to be individually considered 
- Stokes IAF: Die Biomechanik des Rumpfes. Wirbelsäulendeformitäten – Konservatives Management. Edited by: Weiss HR. 2003, München, Pflaum, 59-77.Google Scholar
- Winter RB: Classification and Terminology. Moe's Textbook of Scoliosis and Other Spinal Deformities. 1995, Philadelphia Saunders, 39-43. 2Google Scholar
- Weinstein SL: Natural history. Spine. 1999, 24: 2592-2600. 10.1097/00007632-199912150-00006.View ArticlePubMedGoogle Scholar
- King HA, Moe JHY, Bradford DS, Winter RB: The selection of fusion levels in thoracic IS. Journal of Bone and Joint Surgery. 1983, 65-A: 1302-1313.Google Scholar
- Dangerfield PH: Klassifikation von Wirbelsäulendeformitäten. Wirbelsäulendeformitäten – Konservatives Management. Edited by: Weiss HR. 2003, München, Pflaum, 78-83.Google Scholar
- Lehnert-Schroth C: Dreidimensionale Skoliosebehandlung. 2000, Urban/Fischer, München, 6Google Scholar
- Rigo M: Intraobserver reliability of a new classification correlating with brace treatment. Pediatric Rehabilitation. 2004, 7: 63-10.1080/13638490310001654736.View ArticleGoogle Scholar
- Landauer F, Wimmer C: Therapieziel der Korsettbehandlung bei idiopathischer Adoleszentenskoliose. MOT. 2003, 123: 33-37.Google Scholar
- Mollon G, Rodot JC: Scolioses structurales mineures and kinesitherapie. Etude statistique comparative des resultats. Kinesitherapie Scientifique. 1986, 244: 47-56.Google Scholar
- Mehta MH: Active auto-correction for early AIS. Journal of Bone and Joint Surgery. 1986, 68: 682-Google Scholar
- Weiss HR, Negrini S, Hawes MC, Rigo M, Kotwicki T, Grivas TB, Maruyama and members of the SOSORT: Physical Exercises in the Treatment of Idiopathic Scoliosis at Risk of brace treatment – SOSORT Consensus paper 2005. Scoliosis. 2005Google Scholar
- Negrini S, Antoninni GI, Carabalona R, Minozzi S: Physical exercises as a treatment for adolescent idiopathic scoliosis. A systematic review. Pediatric Rehabilitation. 2003, 6: 227-235. 10.1080/13638490310001636781.View ArticlePubMedGoogle Scholar
- Weiss HR, Weiss G, Petermann F: Incidence of curvature progression in idiopathic scoliosis patients treated with scoliosis in-patient rehabilitation (SIR): an age- and sex-matched cotrolled study. Pediatric Rehabilitation. 2003, 6: 23-30. 10.1080/1363849031000095288.View ArticlePubMedGoogle Scholar
- Nachemson AL, Peterson LE, Members of Brace Study Group of the Scoliosis Research Society: Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. J Bone Joint Surg. 1995, 77: 815-822.PubMedGoogle Scholar
- Grivas TB, Vasiliadis E, Chatziargiropoulos T, Polyzois VD, Gatos K: The effect of a modified Boston brace with anti-rotatory blades on the progression of curves in idiopathic scoliosis: aetiologic implications. Pediatric Rehabilitation. 2003, 6: 237-242. 10.1080/13638490310001636808.View ArticlePubMedGoogle Scholar
- Rigo M, Reiter C, Weiss HR: Effect of conservative management on the prevalence of surgery in patients with adolescent idiopathic scoliosis. Pediatric Rehabilitation. 2003, 6: 209-214. 10.1080/13638490310001642054.View ArticlePubMedGoogle Scholar
- Rigo M: 3 D Correction of Trunk Deformity in Patients with Idiopathic Scoliosis Using Chêneau Brace. Research into Spinal Deformities 2. Studies in Health Technology and Informatics. Edited by: Stokes IAF. 1999, Amsterdam: IOS Press, 362-365.Google Scholar
- Kotwicki T, Pietrzak S, Szulc A: Three-dimensional action of Cheneau brace on thoracolumbar scoliosis. Research into Spinal Deformities 3. Studies in Health Technology and Informatics. Edited by: Tanguy A, Peuchot B. 2002, Amsterdam: IOS Press, 226-229.Google Scholar
- Landauer F, Wimmer C, Behensky H: Estimating the final outcome of brace treatment for idiopathic thoracic scoliosis at 6-month follow-up. Pediatric Rehabilitation. 2003, 6: 201-207. 10.1080/13638490310001636817.View ArticlePubMedGoogle Scholar
- Lonstein JE: Patient Evaluation. Moe's Textbook of Scoliosis and Other Spinal Deformities. 1995, Philadelphia, Saunders, 45-86. 2Google Scholar
- Ascani E, Bartolozzi P, Logroscino CA, Marchetti PG, Ponte A, Savini R, Travaglini F, Binazzi F, Di Silvestre M: Natural history of untreated IS after skeletal maturity. Spine. 1986, 11: 784-789.View ArticlePubMedGoogle Scholar
- Bjerkreim R, Hassan I: Progression in untreated IS after the end of growth. Acta orthop scand. 1982, 53: 897-900.View ArticlePubMedGoogle Scholar
- Brooks HL, Azen SP, Gerberg E, Brooks R, Chan L: Scoliosis: a prospective epidemiological study. Journal of Bone and Joint Surgery. 1975, 57: 968-72.PubMedGoogle Scholar
- Bunnell WP: The natural history of IS before skeletal maturity. Spine. 1986, 11: 773-776.View ArticlePubMedGoogle Scholar
- Clarisse P: Pronostic evolutif des scolioses idiopathiques mineures de 10–29 degrees, en periode de croissance. Thesis. 1974, Lyon FranceGoogle Scholar
- Collis DK, Ponseti IV: Long-term followup of patients with idiopathic scoliosis not treated surgically. Journal of Bone and Joint Surgery. 1969, 51-A: 425-445.Google Scholar
- Duval-Beaupere G: Rib hump and supine angle as prognostic factors for mild scoliosis. Spine. 1992, 17: 103-107.View ArticlePubMedGoogle Scholar
- Duval-Beaupere G: Threshold values for supine and standing Cobb angles and rib hump measurements: prognostic factors for scoliosis. European Spine Journal. 1996, 5: 79-84. 10.1007/BF00298385.View ArticlePubMedGoogle Scholar
- Karol LA, Johnston CE, Browne RH, Madison M: Progression of the curve in boys who have IS. Journal of Bone and Joint Surgery. 1993, 75: 1804-1810.PubMedGoogle Scholar
- Kindsfater K, Lowe T, Lawellin D, Weinstein D, Akmakjian A: Levels of platelet calmodulin for the prediction of progression and severity of AIS. Journal of Bone and Joint Surgery. 1994, 76-A: 1186-1192.Google Scholar
- Korovessis P, Piperos G, Sidiropoulos P, Dimas A: Adult idiopathic lumbar scoliosis: a formula for prediction of progression and review of the literature. Spine. 1994, 19: 1926-1932.View ArticlePubMedGoogle Scholar
- Lonstein JE, Carlson JM: The prediction of curve progression in untreated idiopathic scoliosis during growth. Journal of Bone and Joint Surgery. 1984, 66-A: 1061-1071.Google Scholar
- Masso PD, Meeropol E, Lennon E: Juvenile onset scoliosis followed up to adulthood: orthopedic and functional outcomes. Journal of Pediatric Orthopedics. 2002, 22: 279-284. 10.1097/00004694-200205000-00002.PubMedGoogle Scholar
- Meade KP, Bunch W, Vanderby R, Patwardhan AG, Knight G: Progression of unsupported curves in AIS. Spine. 1987, 12: 520-526.View ArticlePubMedGoogle Scholar
- Mehta M: The rib-vertebra angle in the early diagnosis between resolving and progressive infantile scoliosis. Journal of Bone and Joint Surgery. 1972, 54B: 230-243.Google Scholar
- Nachemson A: A long term followup study of nontreated scoliosis. Acta Orthop Scand. 1968, 39: 466-476.View ArticlePubMedGoogle Scholar
- Picault C, deMauroy JC, Mouilleseaux B, Diana G: Natural history of idiopathic scoliosis in girls and boys. Spine. 1986, 11: 777-778.View ArticlePubMedGoogle Scholar
- Robinson CM, McMaster MJ, Juvenile IS: Curve patterns and prognosis in 109 patients. Journal of Bone and Joint Surgery. 1996, 78-A: 1140-1148.Google Scholar
- Soucacas PN, Zacharis K, Loultanis K, Gelalis J, Xenakis T, Beris AE: Risk factors for IS: review of a 6-year prospective study. Orthopedics. 2000, 23: 833-838.Google Scholar
- Soucacos PN, Zacharis K, Soultanis K, Gelalis J, Kalos N, Beris A, Xenakis T, Johnson EO: Assessment of curve progression in IS. European Spine Journal. 1998, 7: 270-277. 10.1007/s005860050074.View ArticlePubMedPubMed CentralGoogle Scholar
- Villemure I, Aubin CE, Grimard G, Dansereau J, Labelle H: Progression of vertebral and spinal 3-D deformities in AIS. A longitudinal study. Spine. 2001, 26: 2244-2250. 10.1097/00007632-200110150-00016.View ArticlePubMedGoogle Scholar
- Wever DJ, Tonseth KA, Veldhuizen AG, Cool JC, vanHorn JR: Curve progression and spinal growth in brace treated IS. Clinical Orthopaedics and Related Research. 2000, 337: 169-179.View ArticleGoogle Scholar
- Yamauchi Y, Yamaguchi T, Asaka Y: Prediction of curve progression in IS based on initial roentgenograms; proposal of an equation. Spine. 1988, 13: 1258-1261.View ArticlePubMedGoogle Scholar
- Weiss HR: Das „Sagittal Realignment Brace" (physio-logic® brace) in der Behandlung von erwachsenen Skoliosepatienten mit chronifiziertem Rückenschmerz – erste vorläufige Ergebnisse. Medizinisch Orthopädische Technik. 2005, 125: 45-54.Google Scholar
- Negrini S, Aulisa L, Ferraro C, Fraschini P, Masiero S, Simonazzi P, Tedeschi C, Venturin A: Italian guidelines on rehabilitation treatment of adolescents with scoliosis or other spinal deformities. Eura Medicophys. 2005, 41: 183-201.PubMedGoogle Scholar
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