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:

  1. Before treatment
  2. After treatment
  3. 6 months check-up
  4. 12 months check-up
  5. 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 >

Schroth Best Practice Method

Developed by Dr Hans-Rudolf Weiss, the grandson of Katharina Schroth, the Schroth Best Practice Method® is a form of non-surgical scoliosis treatment that aims to reduce the patient's Cobb angle. This is achieved via a carefully-chosen set of stretches and other exercises.

Schroth Best Practice therapy is effectively a simplified version of the acclaimed Schroth method, which was developed by Weiss's grandmother. The new method was developed based on more recent research, and it adds a number of easy-to-perform exercises to Katharina Schroth's original programme.

Many clinics, both in the UK and elsewhere, use the Schroth Best Practice Method® to treat scoliosis patients who do not wish to undergo spinal fusion surgery. The Best Practice programme is often used in conjunction with a Gensingen brace (also developed by Dr Weiss) to achieve the best possible results for the patient.

Do Scoliosis SOS use the Schroth Best Practice Method® to treat scoliosis?

If you're familiar with the work we do here at the Scoliosis SOS Clinic, you probably know that the principles of the Schroth method are a huge influence on our own approach to scoliosis treatment; for a time, we were actually the UK's only provider of Schroth-based scoliosis therapy. We believe that Schroth's exercises can be massively beneficial, and we've seen first-hand how effective they can be when it comes to reducing a patient's Cobb angle.

However, we decided some time ago that we shouldn't restrict ourselves to only treating patients using the Schroth method. Scoliosis is a complex condition that can manifest itself in many different ways, and we feel that the Schroth programme only addresses a portion of the overall problem.

So instead of continuing to treat patients using the Schroth method alone, we developed our very own therapeutic programme with a view to treating every aspect of scoliosis. We call it the ScolioGold method, and in addition to Schroth exercises, it consists of...

...and a wide variety of other proven non-surgical treatment techniques. The entire programme is specifically tailored to the needs of scoliosis sufferers, and if our patient testimonials are anything to go by, it's an extremely effective approach that gets real results.

Do you (or a loved one) suffer from scoliosis? Contact Scoliosis SOS now to book an initial consultation.

Pilates is a system of exercises devised by a German physical trainer named Joseph Pilates. It has become incredibly popular in the Western world, with countless Pilates classes available throughout the UK.

But is Pilates beneficial for scoliosis sufferers? It certainly can be - there is evidence that Pilates can help to improve balance and muscle conditioning, and some scoliosis patients also find that Pilates helps to relieve tension, improve posture and increase joint mobility.

This method of exercising is usually very safe, and while it's no substitute for an intensive ScolioGold treatment course, you may find that Pilates goes some way towards helping you cope with your spinal curvature. Today we will be looking at some helpful Pilates techniques for scoliosis sufferers and how you can perform them at home.

Pilates for Scoliosis - Seated Pelvic Tilt

Seated Pelvic Tilt on a Stability Ball

To perform this exercise:

  • Sit up straight on a stability ball with your feet flat on the floor and hold a support in front of you.

  • Slowly tuck your tailbone under, curving your pelvis beneath you. You should feel the ball roll forward slightly.

  • Release, then start again.

 

Pilates for Scoliosis - Side Bend

Side Bend

The side bend exercise focuses on the upper half of your back. Here's how to do it:

  • Raise one hand up over your head, towards the ceiling, then bend your knees.

  • Once you're in a bending position, take your other hand and rest it on the side of your hip.

  • Lengthen your body to one side, rest, and then bend to the other side. Repeat.

 

Pilates for Scoliosis - Neutral Pelvis

Core Activation

This exercise is very gentle and can be conducted by patients of all ages. Lie flat on your back on a soft mat to begin with, then follows these steps:

  • With your knees bent and feet flat on the floor (hip-width apart), find your 'neutral pelvis' as shown in the photos above. First, move your lower back as far as you can away from the mat...

  • ...and then press it as far as you can towards the mat. The midpoint between these two positions is your 'neutral pelvis'.
  • To engage your core, place your finger tips on the inside of your hip bone. Try to tighten your stomach muscles in towards the spine - your tummy should move away from your fingers.

  • Hold for six seconds, and then repeat.

Pilates for Scoliosis - Core Activation

These are just a few gentle Pilates exercises that can be completed every morning. Regularly completing this routine can help relieve tension and other symptoms of scoliosis, but if you're looking for a more specialised exercise routine to prevent long-term progression of your condition, we can provide this here at the Scoliosis SOS Clinic.

Contact us today for details, or click here to learn more about our ScolioGold treatment method.

Scoliosis SOS Physical Therapists

We at the Scoliosis SOS Clinic are very proud to announce that we recently had our first piece of research published in a peer-reviewed scientific journal. The article, Current knowledge of scoliosis in physiotherapy students trained in the United Kingdom (Black et al, Scoliosis and Spinal Disorders 2017) was published online on the 27th September and can be read in full here.

What were we researching?

Put simply, we wanted to know how much UK physiotherapists know about scoliosis. In both Poland and the USA, it has been recognised that physiotherapy students have relatively little knowledge of idiopathic scoliosis, how it affects the human body, and how to factor a spinal curve into a patient's treatment regime; with that in mind, we wanted to measure UK students' familiarity with this condition.

To do this, we composed a 10-question survey and distributed it (via course leaders) to students at all UK universities that offer physiotherapy degrees. Questions on the survey included:

  • What is the definition of idiopathic scoliosis?
  • What causes idiopathic scoliosis?
  • When does idiopathic scoliosis commonly develop?
  • What percentage of scoliosis cases are idiopathic?
  • What physical activities are most/least beneficial for patients with scoliosis? (multiple choice question - options included yoga, swimming, martial arts, etc.)

In the end, a total of 206 students at 12 different institutions in England, Wales, Scotland and Northern Ireland completed our survey, giving us a good sample size to analyse.

What were our findings?

Of the students who responded to our survey:

  • 79% successfully identified when idiopathic scoliosis commonly develops
  • 54% knew when bracing is recommended
  • 52% correctly identified that the causes of idiopathic scoliosis are not known
  • 24% recognised that scoliosis is idiopathic in approximately 80% of cases
  • 12% knew the criteria for diagnosing idiopathic scoliosis
  • 7% were able to recognise the best treatment approach through physical therapy

Overall, just 7% of students surveyed were able to answer more than half of the questionnaire correctly. Based on this, our conclusion was that there is a clear lack of scoliosis knowledge among UK physiotherapy students - a lack of knowledge that has the potential to impact patients who receive information and treatment from physiotherapists in this country.

Click here to view more scoliosis research, or visit our ScolioGold page to learn about the exercise-based scoliosis treatment we provide here at the Scoliosis SOS Clinic.

Specialised scoliosis physiotherapy

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.