Schroth Exercises Improve Health-Related Quality of Life and Radiographic Parameters in Adolescent Idiopathic Scoliosis Patients
Adolescent idiopathic scoliosis (AIS) is the most common type of scoliosis, characterized by a lateral curvature of the spine with no identifiable cause. The condition often emerges during puberty and can progress during adolescence and even into adulthood. Finding an optimal treatment strategy for AIS remains challenging due to its intrinsic complexity. Factors such as age, sex, skeletal maturity, Cobb angle, and menarche status must be considered during clinical evaluation. For patients with mild to moderate scoliosis (Cobb angle 20°–40°) and lower skeletal growth potential (Risser sign 3–5), observation is commonly recommended. However, curve progression during puberty and adulthood, along with a decline in health-related quality of life (HRQOL), remain significant concerns. This study investigates the efficacy of Schroth exercises in improving HRQOL and radiographic parameters in AIS patients with moderate scoliosis and lower skeletal growth potential.
Background and Rationale
AIS is a complex condition that requires a multifaceted approach to treatment. Non-operative treatment is typically recommended for patients with a major curve less than 45°, according to the Scoliosis Research Society (SRS) criteria. Bracing is strongly recommended for patients with a Risser sign of 0–2 and moderate scoliosis due to their rapid skeletal growth. However, for patients with a Risser sign of 3–5, observation is often the preferred approach. Despite this, curve progression and HRQOL decline remain significant issues, necessitating a long-term sustainable treatment strategy.
Physical therapy, particularly Schroth exercises, has been shown to improve HRQOL and halt curve progression in patients with mild scoliosis. However, its effectiveness in patients with lower skeletal growth potential and larger curvatures remains unclear. This study aims to validate the efficacy of Schroth exercises in improving HRQOL and radiographic parameters in AIS patients with a Risser sign of 3–5 and a Cobb angle of 20°–40°.
Methods
This retrospective study reviewed data from 64 patients diagnosed with AIS at Peking University Third Hospital between 2015 and 2017. Patients were divided into two groups: the Schroth group (n=43), which underwent Schroth exercises, and the observation group (n=21), which received no active treatment. The inclusion criteria for the Schroth group were: a primary diagnosis of AIS, age between 10 and 17 years, Risser sign of 3–5, Cobb angle between 20° and 40°, completion of a minimum 2-year follow-up, and availability of complete radiographs. Exclusion criteria included prior brace treatment, physical exercise history, surgical treatment, cardiac or respiratory dysfunction, other types of scoliosis, and psychiatric diseases.
The Schroth exercises were performed according to the Barcelona Scoliosis Physical Therapy School protocol, focusing on auto elongation, asymmetrical sagittal straightening, frontal plane correction, rotational angular breathing, and stabilization variations. Patients underwent a 14-day intensive training program supervised by certified physical therapists, followed by a home exercise program supervised by parents. The training frequency was set to two or three times per week for 1 hour.
HRQOL was assessed using the Scoliosis Research Society-22 (SRS-22) patient questionnaire, which includes domains for function, pain, mental health, self-image, and satisfaction with management. Visual Analog Scale (VAS) scores for back pain were also recorded. Radiographic parameters, including Cobb angle, cervical spine alignment, thoracic kyphosis (TK), lumbar lordosis (LL), and shoulder balance, were measured from anteroposterior and lateral X-rays. The inter-rater reliability of the radiographic parameters was tested using the interclass correlation coefficient (ICC).
Results
Health-Related Quality of Life
In the Schroth group, significant improvements were observed in VAS back scores, SRS-22 pain domain, and SRS-22 self-image domain. The mean VAS back score decreased from 3.0 ± 0.8 pre-treatment to 1.6 ± 0.6 post-treatment. The SRS-22 pain domain improved from 3.6 ± 0.5 to 4.0 ± 0.3, and the self-image domain improved from 3.5 ± 0.7 to 3.7 ± 0.4. No significant improvements were observed in the SRS-22 function and mental health domains. In contrast, the observation group showed no significant improvements in HRQOL.
Radiographic Parameters
The mean Cobb angle in the Schroth group decreased from 28.9° ± 5.5° to 26.3° ± 5.2° at the final follow-up, although this change was not statistically significant. Six patients experienced curve progression, with a mean progression of 1.2° ± 1.1° per year. No patient required surgery during the follow-up period. Significant improvements were observed in cervical spine alignment and shoulder balance. The mean C2-C7 sagittal vertical axis (SVA) decreased from 21.7 ± 8.4 mm to 17.0 ± 8.0 mm, and the mean T1 tilt decreased from 4.9° ± 4.2° to 3.5° ± 3.1°. No significant improvements were observed in coronal vertical axis (CVA), TK, TLK, or LL. The observation group showed no significant changes in radiographic parameters.
Discussion
Health-Related Quality of Life
The decline in HRQOL and curve progression are major concerns in the conservative treatment of AIS. This study demonstrates that Schroth exercises significantly improve HRQOL in AIS patients with moderate scoliosis and lower skeletal growth potential. The improvements in VAS back scores and SRS-22 pain and self-image domains suggest that Schroth exercises are effective in reducing pain and enhancing self-perception in these patients. The lack of significant improvements in the function and mental health domains may be due to the relatively high baseline scores, indicating that these aspects were less affected by the condition.
Curve Progression
Bracing is not recommended for patients with a Risser sign of 3–5 due to their lower skeletal growth potential. However, curve progression remains a concern, even in adulthood. This study found that Schroth exercises halted curve progression in patients with moderate scoliosis, with a mean Cobb angle decrease from 28.9° to 26.3°. Although this change was not statistically significant, the stabilization of the curve suggests that Schroth exercises may be an effective long-term treatment strategy for these patients.
Cervical Spine Alignment and Shoulder Balance
Few studies have investigated the effects of physical therapy on cervical spine alignment and shoulder balance in AIS patients. This study found significant improvements in C2-C7 SVA and T1 tilt after Schroth exercises, indicating that these exercises may correct cervical spine malalignment and improve shoulder balance. The lack of significant improvements in CHD and Cla-A may be due to the intrinsic conformity of these parameters. Further studies are needed to clarify the relationship between physical therapy and shoulder balance in AIS patients.
Conclusion
For AIS patients with a Risser sign of 3–5 and a Cobb angle of 20°–40°, Schroth exercises improve HRQOL and halt curve progression. Significant improvements in cervical spine alignment and shoulder balance were also observed. These findings suggest that Schroth exercises are an effective long-term treatment strategy for AIS patients with moderate scoliosis and lower skeletal growth potential. Further studies with longer follow-up periods are needed to validate these findings and explore the potential benefits of other physical therapies.
doi.org/10.1097/CM9.0000000000001799
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