Shu Yan Ng, Ying Ling Ng, Ka Ping Cheng, Wing Yan Chan and Tsz Ki Ho. Intervention versus Observation in Mild Idiopathic Scoliosis in Skeletally Immature Patients

Introduction:Observation is the treatment of choice for idiopathic scoliosis with Cobb angles between 15 degrees – 20 degrees in growing children. This passive approach does not address the anxiety of the patient and the stress of the parents. In this paper, we attempt to identify skeletally immature patients with mild scoliosis curvatures that are more at risk of progression and propose possible intervention for this group of subjects.
Methods: The literature was searched in Pubmed, and additional references were searched manually in the literature.
Results: Many studies have shown that low serum 25[OH]D level, bone mineral density (BMD), and body mass index (BMI) are related to the curve severity or progression of the curve. We suggest that skeletally immature patients (< Risser 2) with mild curves be divided into two groups, viz. Group O (observation) with a lower risk of progression, and Group I (intervention) with a higher risk of curvature progression. We propose early intervention for the latter group. It is suggested that pre-menarcheal, skeletally immature patients with mild idiopathic scoliosis, and low vitamin D, BMD, and BMI should be treated. Also, asymmetric foot biomechanics should be addressed, although nutrition and foot orthoses are regarded to have no role in the management of idiopathic scoliosis. The outcome of early intervention may be utterly different from late treatment when the curvature becomes more structural, and the patient more skeletally mature.
Conclusion: Research is required to prove if the intervention is clinically indicated.

Diego Rothschild, Shu Yan Ng, Yin Ling Elaine Ng. Indications of sole lift and foot orthoses in the management of mild idiopathic scoliosis — a review

Introduction: Leg length discrepancy is common among patients with scoliosis. Some studies reported reduced functional scoliosis curves with correction of leg length discrepancy. Others, however, have shown that induced leg length discrepancy has little effects on spinal deformities. Also, small number of studies assessed the use of foot orthoses in patients with faulty foot biomechanics and their impact on idiopathic scoliosis. In this context, a review of the literature is needed to determine the current evidence for the appropriate use of sole lift and foot orthoses in a context of scoliosis.
Methods: A literature review was performed.
Results: It appeared that sole lifts are indicated for functional lumbar scoliosis when the level of the sacrum is parallel to that of the hips. Sole lifts may not be indicated for patients with structural scoliosis, seemingly inducing a compensatory curve. Custom foot orthoses were found to reduce spinal curves in juvenile patients with mild idiopathic scoliosis and concomitant abnormal foot biomechanics.

Conclusion: Sole lift appeared to be indicated in the presence of certain types of functional scoliosis. Custom foot orthoses can be considered in the management of mild idiopathic scoliosis in juvenile patients. Evidence, however, is low and quality studies are needed to validate these findings.

Shu Yan Ng, Tsz Ki Ho and Yin Ling Ng. Physical Rehabilitation in the Management of Symptomatic Adult Scoliosis

Scoliosis is prevalent in elderlies over the age of 60. Of the different curve types, the thoracolumbar curve is the most common curve type operated upon, as it is associated with marked trunk shift and disability. Current physiotherapy treatments consist of electrotherapy, aquatic exercises, core-strengthening exercises, and dry needling. Outcome of these treatments has not been satisfactory. Longterm successful rate of conservative treatment of symptomatic adult scoliosis is low, as the treatment addresses symptoms but not the biomechanics involved in adult scoliosis. Recent studies have shown that physiotherapeutic scoliosis-specific exercises (PSSE) and bracing stabilized the curves in 80% of the subjects. Thus PSSE and bracing should be added to the standard physiotherapy care in the management of symptomatic adult scoliosis. For asymptomatic patients with thoracolumbar curve that has an increased risk of progression, PSSE should be considered as preventative exercises. Patients who do not respond to conservative treatments and have significant spinal stenosis should be referred for surgery.

Shu Yan Ng, Wing Yan Chan, Tsz Ki Ho and Yin Ling Ng. A Pilot Study on the Effect of Outpatient Schroth Exercises on Thoracolumbar and Lumbar Curves in Adult Scoliosis Patients

Study design: This is a pilot prospective cohort study.
Objectives: To investigate if outpatient Schroth exercises (SBP) affect thoracolumbar or lumbar curves in adult scoliosis patients.
Background: Adult scoliosis tends to progress and is associated with an increased prevalence of low back pain. The outcome of conservative treatment is not satisfactory, as treatment is not directed towards spinal deformity. This study investigates if SBP influences the thoracolumbar and lumbar curves in patients with adult scoliosis.
Materials and methods: Adult patients with thoracolumbar and lumbar curves ≥ 20° were taught SBP exercises once weekly for 4 weeks. They then performed the exercises at home three times a week, for 9 months. Baseline measurements included Cobb angles, coronal offset, sagittal vertical axis (SVA), T4-12 kyphosis, L1-S1 lordosis, sacral slope, pelvic incidence and pelvic tilt. They were compared to post-intervention measurements, using paired t tests.
Results: SBP exercises statistically significantly decreased the Cobb angle (p = 0.0032) improved the ATR (p = 0.012), increased the sacral slope (p = 0.03), decreased the pelvic tilt (p = 0.0032) and the SVA (p = 0.032).
Conclusion: The SBP exercises improved the Cobb angles and SVA in adult scoliosis patients with thoracolumbar and lumbar curves.

Wing Yan Chan, Shu Yan Ng, Tsz Ki Ho, Yin Ling Ng. Bracing – Halting Progression or Improving Curves in Adolescent Idiopathic Scoliosis

The effectiveness of spinal bracing in the treatment of adolescent idiopathic scoliosis has been controversial. Some studies have shown that bracing is only as effective as observation, whilst others have shown that bracing is superior to observation, halting progression and effectively reducing progression to surgical threshold. Recently, some studies have even shown improvement of curves with bracing. Yet, many of these studies have been judged to be of low methodological quality. In 2005, the Scoliosis Research Society (SRS) attempted to standardize the inclusion criteria and outcome measurements for bracing studies, to enable comparison among studies. In the guidelines, progression of ≤ 5° is regarded as success. It is apparent that SRS did not regard improvement of curves probable. Improvement which is defined as a decrease of ≥ 6° was not proposed until 2009. This may reflect an improvement in outcome with bracing in the last one to two decades. The present review attempts to determine if there is a trend of improvement in outcome with bracing in the last 3 decades. Manual literature search was made in the PubMed using the keywords of brace, conservative treatment and adolescent idiopathic scoliosis. Relevant English articles on the outcome of wearing rigid braces from 1990-2016 were retrieved and reviewed to determine if there is a trend towards improvement in outcome with bracing and if bracing halts progression and improves curves. Results show that there has been an apparent improvement in the effectiveness of bracing in reducing surgical rate since 2005. Close inspection shows that the reduction in surgical rate is not due to an improvement over time, but is related to the types of brace. The effectiveness of Boston brace is not consistent over the years. The surgical rates vary and no consistent trend of improvement can be discerned in the last 2-3 decades. The surgical rate reported in 2007 for TLSO was as high at 79% and that in 2014 for Boston brace was 28%. The surgical rates with European braces (Progressive Action Short Brace (PASB), Cheneau derivatives and Lyon/Sforzesco braces), however, are consistently lower, at less than 8%. Similarly, the European braces have been found to be able to improve curves in over 50% of the at risk patients. Bracing does not therefore only halt progression of curves. Given a well-constructed brace, with good patient compliance, improvement of curves in over 50% of the patients is possible, particularly when used in conjunction with scoliosis specific exercises.