Physiotherapeutic scoliosis-specific exercises (PSSEs) are an increasingly popular non-surgical method for treating scoliosis. PSSEs – so named to differentiate them from non-specific physiotherapy programmes – aim to provide a more functional approach to scoliosis management and improve the patient’s quality of life.
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The Schroth method
The Schroth method is a particularly well-known type of non-surgical scoliosis treatment. Devised by a German woman named Katharina Schroth, it uses tailored exercises for each individual to help their curved spine return to a straighter, more natural position.
Schroth realised that 3D postural correction could only be achieved through a series of corrective exercises designed to support a corrected posture and alter the postural perception of the individual suffering from scoliosis. Focusing on a number of objectives – including de-rotating, elongating and stabilising the spine on a three-dimensional plane – Schroth exercises focus on restoring muscular symmetry and alignment of posture whilst teaching patients to be more aware of their posture on a day-to-day basis.
Learn more about the Schroth method >>
Physiotherapeutic scoliosis-specific exercises
Scoliosis is, of course, a very complex condition. From the rear, it looks like a sideways curve in either a ‘C’ or an ‘S’ shape. However, what you can’t see are the ways in which the vertebrae in the spine rotate as that curve develops. Spaces between the vertebrae may also become stretched in some areas and compressed in others. For this reason, scoliosis-specific physiotherapy requires a 3D approach to address the curve from all angles and directions.
The extent of the rotation in the spine differs widely from one case to the next; therefore, when treating scoliosis with PSSEs, the exercises need to be tailored to the unique condition of the patient’s spine. Exercises can be performed whilst sitting, laying down or standing up, with several props being used to assist such as gym balls and wall bars. Take a look at our video below to see some simple versions of these exercises in action!
These exercises help to promote:
- Muscular symmetry – The muscles in your back are affected by changes in the curvature of your spine. One side may see muscles weaken, whereas on the other side muscles may be overworked. Therapeutic exercises should seek to address both problems and achieve symmetry between the two sides.
- Rotational breathing – The Schroth method utilises a unique breathing technique known as ‘rotational breathing’, where the idea is to use breathing to assist in the de-rotation of the spine, thereby reshaping the rib cage and the surrounding soft tissue.
- Postural awareness – Being aware of the position of your spine is the first step towards correcting it. Postural awareness is particularly important when it comes to performing day-to-day activities.
Treating scoliosis with PSSEs
The Schroth method forms the foundation of the scoliosis treatment courses we provide here at the Scoliosis SOS Clinic. However, we understand that there are elements of postural correction that Schroth is unable to address on its own. Therefore, all of our treatment plans are enhanced and complemented by an assortment of other well-established physiotherapeutic techniques from all around the world, ensuring that all aspects of each patient’s condition can be addressed effectively.
The result is our internationally-renowned ScolioGold treatment method. Use the links below to view before/after photos or book your initial consultation with Scoliosis SOS.
Photos: Before & After Treatment > Book an Initial Consultation >
Erika Maude, our Clinic Principal, delivered a scientific presentation to the 2019 SOSORT conference in San Francisco last week.
Watch the video below to see her presentation in full.
Video Transcript
Erika Maude: Hello everybody, and thank you for having me along today. This is a continuation of the research that my colleague Jason Black first presented in Lyon two years ago looking at the cost-effectiveness of exercise therapy for adults with scoliosis.
Introduction – Health Economics
Adult patients with idiopathic scoliosis have been shown to present with impaired health-related quality of life. Therefore, in health systems globally, a key objective of treatment is to improve quality of life whilst maintaining cost-effectiveness. The cost-effectiveness of PSSEs [physiotherapeutic scoliosis-specific exercises] has not been researched, and thus conclusions about whether or not they are a viable economic alternative to surgery or bracing for healthcare systems cannot be made.
In the UK, the National Health Service offers spinal fusion surgery as the only treatment for adults with idiopathic scoliosis. They treat about 360 cases per year, each costing £24,853. Under cost-utility analysis, cost-effective analysis estimates the cost of treatment. It is used to inform funding decisions based on the benefit of treatment versus how much it costs. It requires extrapolation of data because it estimates the lifetime benefits of treatment.
Introduction – QALYs
The primary outcome of cost-utility analysis is the cost per quality-adjusted life year, or ‘QALY’ for short – otherwise known as the incremental cost-effectiveness ratio, which I’ll come onto a bit more in a moment. QALYs analyse both the quality and the quantity of life years, where (rather morbidly) 0 equals death and 1 equals perfect health. QALY are accumulative, and thus a 0.2 QALY improvement lasting for 5 years equals 1 QALY for the patient.
The ICER [incremental cost-effectiveness ratio] is calculated as the difference in the expected cost of Intervention A compared to Intervention B divided by the difference in the expected QALYs produced by Intervention A and Intervention B. Generally, it is considered that the interventions costing the UK’s National Health Service less than £30,000 per QALY gained are deemed to be cost-effective.
Introduction – EQ-5D
The EQ-5D is the measure preferred by the UK’s National Institute of Clinical Excellence [NICE] for comparing cost-effectiveness. It’s a descriptive system, and it defines health-related quality of life in terms of five dimensions:
- Mobility
- Self-care
- Usual activities
- Pain and discomfort
- Anxiety and depression
Responses to each of these dimensions are divided into three levels (1st, no problems; 2nd, some to moderate problems; and 3rd, severe to extreme problems), thus generating a total of 243 possible health states. On the left is an example EQ-5D form, which can only be used with licensed permission.
Objectives
The aim of this study was to explore the cost-effectiveness of physiotherapeutic scoliosis-specific exercises for adult patients with idiopathic scoliosis using an intensive, group-based therapy approach.
Method
183 consecutively-recruited UK-based adult patients (with an average age of 38.5 years at the start of treatment) attending the Scoliosis SOS Clinic in London for intensive ScolioGold treatment filled out the EQ5D5L questionnaire at 5 different time points:
- Before treatment
- After treatment
- 6 months check-up
- 12 months check-up
- 18 months check-up
The EQ-5D results were then converted into QALYs using assumptions about the duration of treatment effect. A linear regression model was then used to statistically analyse the results.
Results – Response Rate
Due to the method of data collection, consecutive nature of patient recruitment, and time limitations imposed by the 3-year EQ5D5L licence, 100% of the participants completed the questionnaire pre-treatment, 91% immediately post-treatment, 68% at their 6-month check-up, with 51% at both 12- and 18-month check-ups.
Results – EQ5D5L Scores
Before treatment, the average EQ-5D score was 0.773, and immediately after treatment, this increased to an average of 0.881. At 6 months, the average was 0.862, and at both 12 and 18 months check-up, the average was maintained at 0.863. All of these changes were statistically significant.
Results – Calculation of QALYs
Although patient scores were statistically much improved at 12 and 18 months post-treatment, due to the fewer number of patients who reached the later time points, reliable data was only available up to 6 months following treatment, and therefore an assumption on the persistence of the treatment effect is required for later time points. To look at both extremes: assuming that the treatment benefit ended after just six months, additional QALYs were 0.045, which means that the ICER would be £90,000 per QALY. However, assuming that the treatment effect continued for 43.8 years (the average life expectancy of the patients in this study), then additional QALYs were 3.899, meaning the ICER would fall to just £1,000 per QALY.
Therefore, to meet NICE’s requirements for health economics, the effects of treatment would need to persist for 1.5 years.
Conclusion
In conclusion, EQ-5D results improved with PSSE in adult patients with idiopathic scoliosis. If the treatment effect of the PSSEs persists for only 1.5 years, it is expected to be cost-effective in UK-based adults. Further long-term research is required to start planning for PSSE to become available within national healthcare services; with publication of these results, we hope to highlight that the input of physiotherapy in this patient group should warrant funding.
Limitations
We are aware that there are several limitations to this study, namely lack of a control group, limited long-term follow-up, and no data on cost savings from exercise therapy.
Thank you for listening.
More Scoliosis Research > About Erika and the Team >
Idiopathic scoliosis (which usually arises during puberty, when the body is going through a period of rapid growth) is often treated using a rigid back brace that prevents the spinal curve from progressing as the patient grows. It’s important to note that the aim of this bracing treatment is not to correct / reverse the sideways curvature of the spine, but simply to stop it from getting worse until the body has finished growing.
And while bracing can be very effective in that respect, it does very little to assist in building up the muscle strength that will be needed to ensure spinal stability once the brace comes off.
In fact, bracing tends to have a negative effect on muscle strength.
Scoliosis braces typically have to be worn for over 20 hours a day in order to achieve the best treatment outcome. During the bracing period, the muscles around the spine are likely to become inactive because the brace is doing their job (i.e. supporting the spine) for them.
This often results in a weakening of the spinal muscles, which may lead to the patient becoming reliant on the support of the brace.
But physical therapy can help with this problem.
There is a lot of clinical evidence to suggest that bracing delivers better outcomes for the patient when combined with scoliosis-specific physiotherapy. A 2011 study1 found that combining these two approaches reduces the risk of future curve progression and thus the likelihood that spinal fusion surgery will eventually be required. It has also been shown2 that completing a scoliosis-specific exercise programme limits the reversal of spinal correction when bracing ends.
Not only are scoliosis-specific exercises recommended in the SOSORT 2011 guidelines for people with adolescent idiopathic scoliosis who are undergoing brace treatment, but several authors who developed scoliosis braces (such as the Milwaukee, Boston, Lyon and Chêneau braces) have proposed that scoliosis-specific exercises should be used to complement brace treatment. Indeed, the newly-developed Sforzesco and Gensingen braces are specifically designed to be worn in conjunction with exercise-based therapy.
In short: it’s good to receive physiotherapy for your scoliosis even if it’s also being treated with a brace. Integrating scoliosis-specific exercises with a bracing treatment helps to provide a more complete rehabilitation programme for growing patients with idiopathic scoliosis.
Our Treatment Methods > Book a Consultation >
Links & References
- ScolioGold Therapy – The Scoliosis SOS Clinic’s own combination of proven exercise-based scoliosis treatment techniques
- Contact Scoliosis SOS – Arrange an initial consultation (to be conducted at our clinic in London or via Skype / telephone)
1. Negrini S, Aulisa AG, Aulisa L, Circo AB, de Mauroy JC, Durmala J, Grivas TB, Knott P, Kotwicki T, Maruyama T, Minozzi S, O’Brien JP, Papadopoulos D, Rigo M, Rivard CH, Romano M, Wynne JH, Villagrasa M, Weiss HR, Zaina F: 2011 SOSORT guidelines: Orthopaedic and Rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis 2012, 7:3
2. Zaina F, Negrini S, Atanasio S, Fusco C, Romano M, Negrini A: Specific exercises performed in the period of brace weaning can avoid loss of correction in Adolescent Idiopathic Scoliosis (AIS) patients: Winner of SOSORT’s 2008 Award for Best Clinical Paper. Scoliosis 2009, 4(1):8.
