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British Journal of Healthcare and Medical Research (BJHMR) Vol 9, Issue 5, October - 2022

Services for Science and Education – United Kingdom

INTRODUCTION

Scoliosis is a three-dimensional structural deformity with a Cobb angle (lateral curvature) >

10° in the coronal plane. Its development and progression are often related to growth and are

accelerated during growth spurts. Scoliosis may be either structural or functional. Structural

scoliosis includes anatomical changes in the spine that persist in all positions. In contrast,

functional scoliosis is not an actual spinal deformity but an attempt to maintain an upright

stance in response to disorders elsewhere in the body, such as unequal leg length. Therefore,

treatment will be directed according to the primary abnormality, thus reducing the Cobb angle

[1].

Among the different types of scoliosis, adolescent idiopathic scoliosis (AIS) is the most common,

with an overall prevalence of 5.2% in the population [2]. AIS, characterized by lateral deviation,

axial rotation, and abnormal sagittal curvature of the spine, is the most common spinal

deformity [2]. Based on the Cobb angle, the current SOSORT (International Scientific Society on

Scoliosis Orthopedic and Rehabilitation Treatment) guidelines recommend practitioners to

watch and wait (< 25°), bracing with or without exercises (25–40°), and surgical intervention

(> 40 °) [3]. Risser sign (skeletal maturity), trunk deviation, quality of life, and prediction of

curve progression by measuring the infra-apex segment are standard measures used to

determine the therapeutic outcomes in AIS patients. Recently, multiple studies have shown the

inefficiency of bracing as a corrective measure. Schreiber et al. conducted a randomized

controlled study and concluded that adding specific exercises was superior to bracing alone in

improving Cobb angles and trunk rotation [4]. In addition, a cohort study conducted by Byun

and Hann [5] demonstrated that chiropractic techniques effectively reduce the spinal curvature

in AIS patients within as little as four weeks, thus reinforcing the efficiency of these techniques.

Current evidence shows that the risk of progression at the beginning of puberty is 20% in 10°

scoliosis, 60% in 20° scoliosis, and as much as 90% in 30° scoliosis [3]. Thus, it is vital to treat

scoliosis in the early stages of puberty before skeletal maturity. AIS typically develops between

10–18 years of age, and a genetic link is suggested, although studies have yet to confirm this

definitively. According to research conducted by the Journal of Pediatric Orthopaedics [6], the

female-to-male ratio ranges from 1.5:1 to 3:1 and increases substantially with age. In particular,

the prevalence of curves with higher Cobb angles was substantially higher in girls than in boys.

The female to male ratio rises from 1.4:1 for 10°- 20° curves to 7.2:1 for > 40° curves. Moreover,

the total number of scoliosis cases in the United States is estimated to be greater than 4 million.

Each year, 442,900 GP visits, 133,300 hospital visits, and 17,500 emergency room visits are

made by children with scoliosis. In addition, spinal deformities in children and adolescents

account for 48% of all musculoskeletal deformity healthcare visits over 857,280 every year

[6,7]. The impact of scoliosis on the overall health-related quality of life can be severe compared

to other medical conditions.

At present, there are no published articles that review the literature on chiropractic and

Schroth therapy as an alternative to bracing for AIS. This study reviews the available literature

to explore the possibilities and potential of chiropractic manipulation and scoliosis-specific

exercises (SSEs) in AIS patients.

METHODS

A systematic approach was adopted for the collection and appraisal of the data. Critical

appraisal skills program, appraisal notes, and checklists [8] were used for RCTs, cohort, and

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Kwok, R., Yau, K. H. Y., Leung, B. K. Y., & Cheong, B. K. C. (2022). Chiropractic Treatments and Scoliosis-specific Exercise Therapy as An Alternative

to Bracing for Adolescent Idiopathic Scoliosis: A Narrative Review. British Journal of Healthcare and Medical Research, 9(5). 157-174.

URL: http://dx.doi.org/10.14738/jbemi.95.13207

case-controlled studies, with CEBMa for case reports, SIGN for clinical trials, and HNLBI for

observational case series. These tools are good for evaluating each study's bias, validity, and

generalizability. The quality of the body of evidence was assigned as high, moderate, or low,

based on the adaptation Cochrane recommendation and CASP analysis. Randomized controlled

studies were considered high-quality evidence, whereas observational studies were low- quality studies due to the study design's limitations.

In addition, only papers published in English with free full text and evaluating chiropractic

manipulation, and SSE (Schroth), as the primary treatment or combined treatment were

reviewed. The participants in the included studies were adolescents (10-19 years old). Papers

investigating only the effectiveness of bracing for AIS or examining other manipulation

therapies and research without a clear goal or conclusion were excluded.

Papers published between 2017 and 2021, after the narrative review by Mark W. Morningstar

in 2017, were included to keep the information as updated as possible and reinforce the

efficiency of chiropractic scoliosis treatment.

A search on PubMed, Index to Chiropractic Literature, Spine Journal, BioMed Central, Google

Scholar, and Research gate was also performed using the keywords' Schroth therapy and

adolescent idiopathic scoliosis', 'chiropractic and adolescent idiopathic scoliosis,' scoliosis- specific exercise, and adolescent idiopathic scoliosis. The literature search included systematic

reviews, cohort studies, case reports, retrospective chart reviews, and randomized controlled

trials (RCTs). Only English literature with full text available was used.

This review aimed to investigate the efficacy of chiropractic treatments and Schroth therapy as

an alternative to bracing for AIS. Despite the relatively limited number of studies, the current

review provides insight into "therapy and AIS," "chiropractic and AIS," and "SSE and AIS."

RESULTS

The literature search yielded 156 papers. After reviewing the titles and abstracts, six papers

were finally included in the analysis, after excluding 149 that did not meet the inclusion criteria.

One additional paper (by Liu et al.) that fell outside the inclusion criteria (the subjects were <

10 to 15 years of age) was included in the analysis because it was considered significant and

worth discussing [11]. This cohort study by Liu et al. [11] showed the effectiveness of specific

exercises in controlling or improving curve progression. The authors also concluded that

younger patients with low-risk grades were most likely to respond.

Of the six papers, two demonstrated the effectiveness of SSE (Schroth, SEAS) in reducing curve

progression and improving quality of life. The other four studies demonstrated the

effectiveness of chiropractic manipulation alone and in combination with exercise. All reviewed

papers [9] were critically appraised and compiled into a general evidence table (Table 1).

Separate charts analyzing the possibilities of chiropractic and SSE for improving/stabilizing

curve progression are included in Appendix (1-7).

DISCUSSION

Negrini et al. [5] conducted a clinical trial to investigate whether SEAS reduced the need for

bracing in patients with AIS. The results are promising and show that the SEAS group had the