Scoliosis and evidence-based practice

This special issue on scoliosis contains the current knowledge of physical methods and brace applications designed for the treatment of scoliosis, a three-dimensional spinal deformity that even today seems a mystery for many clinicians. We have indeed many different etiologies, different curve patterns, and different prognoses, although most of the curves tend to progress during times of rapid growth, causing clinical deterioration and raising psychological issues as well. Therefore, one could easily address scoliosis as a deformity in five dimensions that, besides the three-dimensional deformity of the spine and trunk, contains a timing and a psychological dimension.

The right treatment at the right time may prevent major deformities that, in deterioration, might impact the psychosocial role of the patient in a negative way. The indications guideline established by members of the SOSORT (Weiss et al, 2006) may enable the professional to avoid overtreatment but also undertreatment as well. While there seems consensus among the conservative specialists on the indications for treatment, the conservative community of scoliosis specialists seems far from being clear about how to treat. What kind of exercise is the most appropriate or how to adjust braces best is still a matter of debate (Rigo et al, 2006).

This special issue, therefore, is meant to provide a synopsis of methods available today and by this, shall provide a baseline for future developments in this field. Unfortunately, many studies are not comparable to easily enable the practitioner to find the “Best Practice.” However, the reader may go deeper into the subject and find studies with comparable methods, yet different outcomes (Dobosiewicz, Durmala, Czernicki, and Piotrowski, 2006; Otman, Kose, and Yakut, 2005).

Today, evidence-based medicine (EBM) and evidence-based practice (EBP) are valuable instruments in the decision-making process of professionals in the medical field. Restrictions upon resources of social health care systems have led to calls for greater efficiency and cost-effectiveness of treatment programmes. Therefore, good-quality evidence studies providing the highest level of research are necessary to evaluate the effectiveness of treatments.

Grade B recommendations for conservative treatment of scoliosis are justified. There are prospective controlled studies (level II) (Danielsson, Hasserius, Ohlin, and Nachemson, 2007; Nachemson and Peterson, 1995; Weiss, Weiss, and Petermann, 2003) and enough data from level III or IV, which are generally consistent (Weiss, 2003), when taking into account studies from central Europe or Asia (Edelmann, 1992; Maruyama et al, 2003; Rigo, Reiter, and Weiss, 2003; Weiss, Weiss, and Schaar, 2003). These levels of evidence seem not to have been reached in the United States (Dolan and Weinstein, 2007; Goldberg, Moore, Fogarty, and Dowling, 2001).

Although randomised controlled trials (RCTs) provide the highest standard of evidence, the application of this study design is unrealistic for complex disorders like scoliosis. While pharmacological studies are the main field for RCTs, no RCTs have been performed on treatment outcomes for scoliosis. In pharmacological studies one can easily standardise the treatments (drugs) to be investigated. Body weight of the patients and dosage of drugs can easily be measured (Hernandez et al, 2007). Scoliosis, on the other hand, is not a uniform condition. Even the subset of patients suffering from adolescent idiopathic scoliosis (AIS) appears to include multiple variations in curve patterns, maturity, curve stiffness, and sexual differences all influencing the outcome of treatment (Weiss, Werkmann, and Stephan, 2007).

Recently, claims have been made for an RCT on bracing (Dolan, Donnelly, Spratt, and Weinstein, 2007; Dolan and Weinstein, 2007; Goldberg, Moore, Fogarty, and Dowling, 2007), but questions remain to be answered: what brace, with what set amount of time, should be monitored, and in which particular patient? It seems even difficult to define what exactly may be referred to as a “brace” because there is a wide variability of applications (Figure 1). Treatment and subjects treated are of such high variability that an RCT for bracing seems to be a very complex task. In addition, there is evidence on level II for the use of the Boston brace (Danielsson, Hasserius, Ohlin, and Nachemson, 2007; Nachemson and Peterson, 1995). In the SRS multicentre prospective controlled study (Nachemson and Peterson, 1995), the survival analysis clearly has shown that the Boston brace was superior to observation only and to electrical stimulation. A long-term controlled prospective follow-up has also provided evidence that the Boston brace effectively stops curvature progression (Danielsson, Hasserius, Ohlin, and Nachemson, 2007). A meta-analysis (Rowe et al, 1997) clearly unveils that brace wearing time is one determinant for a successful outcome. But if the brace could not influence the curvature, why would the amount of time spent wearing the brace be an important issue?

Figure 1.  There is a great variety of braces applied today. It is because of this great variation of applied braces that an RCT on brace treatment will never be able to illustrate what really can be achieved with braces. The only possibility would be to test braces of different standards one against each other in controlled trials. Because there are prospective controlled trials showing the Boston brace is effective, to leave a control group of a future RCT on braces without treatment clearly is unethical. Nevertheless, when the SRS inclusion criteria for studies on bracing are respected, there will be a good baseline for future studies on braces and a good comparability of different brace types.

In light of the evidence already available, an RCT is not only a complex task but an unethical one. To allow growing patients to continue without conservative treatment (a control group) until nothing except surgical intervention might help is unethical, especially when one considers the problems with surgery, such as primary risks; re-surgery rate, which might be higher than 40% in the long term (Asher and Burton, 2006; Dickson, Erwin, and Rossi, 1990; Sponseller et al, 1987); and future complications (Asher and Burton, 2006; Weiss and Goodall, 2008; Weiss et al, 2008). Therefore, this type of approach cannot be regarded as patient-oriented.

With respect to surgery, there are no level II or level I studies to support the use of surgery in the treatment of AIS and as previously stated by Hawes (Hawes, 2006; Hawes and O'Brien, 2008) signs and symptoms of AIS cannot be changed by surgery.

A midpoint RCT evaluating physiotherapy (Negrini et al, 2008) should encourage physical therapists to enter the field of spinal deformities, because this is what patients obviously benefit from, and physical therapy has the least side effects. This is why I have offered this special issue to this particular journal. It is about time that physical therapists worldwide consider spinal deformities as their own professional task.

I am very thankful that my friends and colleagues working in the field of conservative management have agreed to support this idea with their contributions.

Manuel Rigo, one of the most experienced clinicians in the field of conservative management of scoliosis, has offered a paper on patient evaluation to start the Special Issue. If someone wants to get involved with scoliosis management, a proper patient evaluation indeed is the key for proper treatment indications. From this point of view the investigation determines the individual prognosis, and this prognosis determines the best possible and most cost-effective treatment.

Stefano Negrini is one of the most reknown scientists in the field of conservative treatment of scoliosis, as easily can be seen by viewing his numerous Pub Med listings of publications on this topic. But more than that I personally want to thank him for his constant work on making the evidence visible to support conservative approaches with special respect to physiotherapy. So clearly he is the coauthor of the 2011 update of a systematic review on physical therapy in the treatment of scoliosis together with members of his wonderful team from Milano.

Toru Maruyama, founding member of the SOSORT and professor for orthopedic surgery in Tokyo, also is a very special fellow with many publications on physiotherapy with special focus on the “side shift” treatment. He has skills in bracing and surgery as well, and by this, unifies conservative and operative treatment. He has provided an update on the current bracing strategies with special respect to the end results already obtained.

Michele Romano is the senior physical therapist in the team of Stefano Negrini and has constantly given important input with respect to new developments in physiotherapy in the scientific literature and during his lectures at the SOSORT conferences, which besides the scientific content, achieved high levels of entertainment.

Jacek Durmala, specialist for physical therapy and rehabilitation and head of the Sliesian Institute in Kattowice, and Tomasz Kotwicki, pediatric orthopedic surgeon, head of the Pediatric Orthopedic Department of the University of Poznan, are presenting the work of Prof. Dobosiewicz, who passed away in 2007. The Dobosiewicz method represents the Polish approach of physiotherapy in the treatment of patients with scoliosis with special emphasis on breathing techniques and restoration of thoracic kyphosis, which is a major issue, especially for idiopathic scoliosis. Both authors are founding members of SOSORT and have skills in conservative treatment of scoliosis; like Professor Maruyama, Professor Kotwicki also can offer the best possible up-to-date operative treatment for patients with spinal deformities.

Axel Hennes and Deborah Turnbull (Goodall) both are physical therapists and specialists in the treatment of scoliosis. While Axel Hennes for more than one decade has been the senior physical therapist at the Katharina Schroth Institute in Bad Sobernheim, Deborah Goodall has quite a number of publications in the field of spinal deformities, besides her training in Schroth. I am very thankful for her support as a coauthor of quite a few of my papers! Together, they are presenting techniques derived from the Schroth method used for inpatient and outpatient physiotherapy. The Schroth method of treatment—the method of my Granny Katharina Schroth—can be regarded as the original German approach of scoliosis physical therapy and has gained supporters throughout the world. Today, as pointed out within the presentations of this special issue, the inpatient approach is necessary for adult patients with pain and pulmonary function limitations (Weiss, 1991). Short-term rehabilitation can be provided for children and adolescents with scoliosis, because the results for correction of the deformity within the setting of an inpatient rehabilitation program with today's methodology have been questionned (Yilmaz and Kozikoglu, 2010). First experiences with short-term outpatient programs have shown encouraging results of correction.

Theodoros B. Grivas is an orthopedic surgeon in Athens, member of all the most important scoliosis societies including the SRS, founding member of the SOSOR, editor in chief of Scoliosis, and reknown scientist and practitioner. He has dedicated most of his professional life to the treatment of spinal deformities. Theo agreed to present and represent the Boston brace within this special issue on scoliosis.

Dr. Stefano Negrini, besides his work in the field of physical therapy, has developed a symmetric brace that is described in the second paper he is coauthoring with his colleague Fabio Zaina, who also is a constant contributor at the yearly SOSORT conferences.

Professor Man Sang Wong, senior orthotist and lecturer at the PolyU in Hong Kong, is one of the very few specialists and reknown scientists in the world using the CAD/CAM technique to develop scoliosis braces. He is the first one to compare CAD/CAM applications to cast-based braces for time efficiency and amount of in-brace correction. My very special thanks to Man Sang for agreeing to present his work within this issue.

The LA Brace is an asymmetric CAD/CAM brace developed recently. Because the results achieved with this brace, which has many pressure points in common with the Chêneau brace, I thought it should have a place in this issue published in the United States. While many of the braces used in the United States are lacking correction effects, this brace with a home in Los Angeles, has demonstrated an outcome comparable to that of many bracing centres in Europe. Thanks to Gez Bowman, who is also the developer of the LA Brace presented in this special issue.

My friend Manuel Rigo and I demonstrate the asymmetric bracing standard, which is mainly used in central Europe. Recently, I gave a course on conservative treatment of scoliosis in the Ukraine and witnessed that with their plaster-based Chêneau braces they had comparable correction effects like ours in the modern Chêneau CAD/CAM applications. There are clearly some real artists in the world who are able to address scoliosis correctly (according to the individual curve pattern) and achieve the best possible results. However, this is not the case in the majority of orthotists. The more asymmetric scoliosis braces that are built the more mistakes that can be made. Therfore, the development of expert-driven Chêneau applications, as described in our paper using quality management programs as offered by the Chêneau light standard (Weiss and Werkmann, 2010a) and also for the Gensingen brace (Weiss and Werkmann, 2010b), the latest CAD/CAM Chêneau derivate, was the logical consequence.

As the editor of this special issue I want to familiarize the reader with current evidence-based practice, and I am very thankful to Scott Hasson, editor in chief for Physiotherapy Theory and Practice, for giving me this opportunity. I hope you will enjoy the result of our work, and I also hope this issue will encourage you to get involved with the treatment of scoliosis, which is a wonderful task with thankful patients!

Finally, I thank all of my friends and colleagues, specialists in the conservative management of spinal deformities, who have agreed to contribute to this very special issue. To me, the final result, even if due to the editors' suggestions, is different from what I initially had planned, is a very great synopsis of the latest developments in the field of conservative treatment of scoliosis. But even more than that, the most important thing to acknowledge is that there is more evidence for conservative treatment of scoliosis than there is for surgical management (Weiss, 2010).

Many thanks to the referees, who have made it possible to achieve a result of such high quality. The final structure of this synopsis has been made due to the reviewers' suggestions, which surely is the best way of presentation!

Lastly, I acknowledge that the editor in chief of this journal has made this special issue possible. In addition, he had much more work with this issue to have the papers reviewed, edited on time, and corresponding with the numerous authors and reviewers. Thank you so much Scott!