Scoliosis is a complex and three-dimensional structural change of the spine. It is characterised by lateral curvature, vertebral rotation and sagittal plane deviations. Thoracic curves cause variable degrees of deformity to the ribs and rib cage and this is closely related to the severity of the curve. Adolescent idiopathic scoliosis (AIS), which represents most idiopathic cases, is generally accepted to affect two to three per cent of the general population and girls are four times more likely to develop AIS than boys. While only 10 per cent of AIS cases progress to severe scoliosis, up to two-thirds of AIS cases experience curve progression during puberty.

Many factors affect the development of AIS including biomechanical factors, paraspinal muscle factors and genetic factors. Curve types are classified using the Lenke system (which has replaced the previously used King’s system) and this classification is used to guide surgical decision-making. Other classification systems include the Schroth classification, which guides Schroth exercise prescriptions, and Rigo/Rigo-Weiss classifications, which build on the Schroth classification and are used to guide selection of the brace design.

Intervention and management strategies are based on the Cobb angle, which measures the degree of lateral curvature; the rate of progression; and remaining skeletal growth potential. Observation is recommended for Cobb angles less than 20 degrees, while bracing is typically used for Cobb angles of 20–45 degrees. For Cobb angles above 45 degrees, surgery may be recommended.

Increasing evidence supports the use of therapeutic exercises to reduce spinal curvature, delay progression and avoid more invasive treatments including bracing and surgery. Exercises may modify spinal neuromuscular control, stabilise the spine in corrected posture and induce mechanical change in soft tissues, with generic therapeutic exercises addressing at least one component and physiotherapy scoliosis-specific exercises, including the Schroth exercises, targeting all components.

In their Journal of Physiotherapy Invited Topical Review, Arnold Wong and Tony Chiu outline and evaluate the evidence for different therapeutic exercises for AIS, both on their own and in combination with bracing, noting that the certainty of evidence regarding the effectiveness is still low to very low, mostly due to small sample sizes, heterogeneous interventions, very short-term follow-up of patients and more. They write that despite the very low certainty of evidence, therapeutic exercises—in particular, physiotherapy scoliosis-specific exercises—appear to be effective in delaying the need for bracing and should be considered as first-line interventions. They also look at bracing and surgical interventions, noting that while rigid braces have good success rates, compliance and discomfort are issues and that using enhanced recovery after surgery protocols appears beneficial.

The authors suggest that larger, more robust randomised clinical trials comparing interventions across different curve types are needed to confirm the impact of exercise, bracing and surgical interventions. They also recommend that psychosocial interventions be explored to improve psychological wellbeing and quality of life in teenagers with AIS.

Read the entire Invited Topical Review here.

Professor Arnold YL Wong leads the Bachelor of Science (Honours) in Physiotherapy program in the Department of Rehabilitation Sciences and serves as the associate director of the Research Institute for Smart Ageing at the Hong Kong Polytechnic University. A registered physiotherapist in Hong Kong, he earned his MPhil in orthopaedics from the University of Hong Kong and his PhD in rehabilitation sciences from the University of Alberta, Canada.

Tony SH Chiu is affiliated with the Department of Rehabilitation Sciences, the Hong Kong Polytechnic University.