Indications for conservative management of scoliosis (SOSORT guidelines 2010)

SOSORT guideline committee , Hans-Rudolf Weiss* (1) , Stefano Negrini* (2) , Manuel Rigo (3) , Tomasz Kotwicki (4) , Martha C Hawes* (5) , Theodoros B Grivas (6) , Toru Maruyama (7)  and Franz Landauer (8)

1 Orthopedic Rehabilitation Services, „Gesundheitsforum Nahetal“ Gensingen, Germany
2 ISICO (Italian Scientific Spine Institute), Milan, Italy
3 Instituto Èlena Salvá, Barcelona, Spain
4 University of Medical Sciences, Poznan, Poland
5 University of Arizona, Tucson AZ 85721, USA
6 Orthopaedic Department "Thriasion" General Hospital, Magula, Athens, Greece
7 Department of Orthopaedic Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo 173-8605, Japan
8 Landesklinik für Orthopädie, Müllner Hauptstr. 48, A-5020 Salzburg, Austria
author email corresponding author email* Contributed equally

This guideline has been discussed by the SOSORT guideline committee prior to the SOSORT consensus meeting in Milan, January 2005 and published in its first version on the SOSORT homepage: webcite. After the meeting it again has been discussed by the members of the SOSORT guideline committee to establish the final 2005 version submitted to Scoliosis, the official Journal of the society, in December 2005. Recent publications made it necessary to adapt the guidelines to the actualized 2010 version.

Scoliosis is defined as a lateral curvature of the spine with torsion of the spine and chest as well as a disturbance of the sagittal profile [2].

Idiopathic scoliosis is the most common of all forms of lateral deviation of the spine. By definition, it is a lateral curvature of the spine in an otherwise healthy child, for which a currently recognizable cause has not been found. Recent investigations focus on a functional tethering of the spinal cord, or neuro-osseus disturbance [3, 4], which may result in a ventral overgrowth, however loss of lumbar lordosis has not yet been clearly explained [5]. Less common but better defined etiologies of the disorder include scoliosis of neuromuscular origin, congenital scoliosis, scoliosis in neurofibromatosis, Prader Willi syndrome and mesenchymal disorders like Marfan's syndrome [6-8].

The prevalence of adolescent idiopathic scoliosis (AIS), when defined as a curvature greater than 10° according to Cobb, is 0.9 -  12%. 
Nissinen M, Heliovaara M, Ylikoski M, Poussa M: Trunk asymmetry and screening for scoliosis: a longitudinal cohort study of pubertal schoolchildren. Acta Paediatr 1993, 82(1):77-82.
Willner S, Uden A: A prospective prevalence study of scoliosis in Southern Sweden. Acta Orthop Scand 1982, 53(2):233-7.
Laulund T, Sojbjerg JO, Horlyck E: Moire topography in school screening for structural scoliosis. Acta Orthop Scand 1982, 53(5):765-8.
Dickson RA et al 1983:  Scoliosis in the community. Br Med J 1983, 19(6365):615-8.
Strayer LM et al, 1973: The incidence of scoliosis in post-partum female on Cape Cod. J Bone Joint Surg Am 1973, 55A:436.
Brooks HL, Azen SP, Gerberg E, Brooks R, Chan L: Scoliosis: A prospective epidemiological study. J Bone Joint Surg Am 1975, 57(7):968-72.
Sugita K 2000: Epidemiological study on idiopathic scoliosis in high school students. Prevalence and relation to physique, physical strength and motor ability. Nippon Koshu Eisei Zasshi 2000, 47(4):320-5.
Wong HK, Hui JH, Rajan U, Chia HP2005: Idiopathic scoliosis in Singapore schoolchildren: a prevalence study 15 years into the screening program. Spine 2005, 30(10):1188-96.
Huang SC 1997: Cut-off point of the Scoliometer in school scoliosis screening. Spine 1997, 22(17):1985-9.
The prevalence of curvatures greater than 20° is between 0.3 and 0.5%, while curvatures greater than 40° Cobb are found in less than 0.1% of the population. All etiologies of scoliosis other than AIS are encountered more rarely [9,10].

The anatomical level of the deformity has received attention from clinicians as a basis for scoliosis classification. The level of the apex vertebra (i.e., thoracic, thoracolumbar, lumbar or double major) forms a simple basis for description. In 1983, King and colleagues [11] classified different curvature patterns by the extent of spinal fusion required; however, recent reports have suggested that these classifications lack reliability. Another description has been developed by Lenke and colleagues [12]. This approach calls for clinical assessment of scoliosis and kyphosis with respect to sagittal profile and curvature components. Systems designed for conservative management include the classifications by Lehnert-Schroth [13] (functional three-curve and functional four-curve scoliosis) and by Rigo [14] (brace construction and application).
Aims of conservative management
The primary aim of scoliosis management is to stop curvature progression [15]. Improvement of pulmonary function (vital capacity) and treatment of pain are also of major importance. The first of two modes of conservative scoliosis management is based on physical therapy, including Méthode Lyonaise [16], Side-Shift [17], Dobosiewicz [18], Schroth and others [19]. Although discussed from contrasting viewpoints in the international literature, today there is evidence for the effectiveness of scoliosis treatment by physical therapy alone [19-21]. It has been shown, that physiotherapy may reduce the risk for brace treatment [22] (Figure 1.).
It has to be emphasized that (1) physical therapy for scoliosis is not just general exercises but rather one of the cited methods designed to address the particular nuances of spinal deformity, and (2) application of such methods requires therapists and clinicians specifically trained and certified in those scoliosis specific conservative intervention methods.
Intensive rehabilitation (SIR), which appeared to be effective with respect to many signs and symptoms of scoliosis and with respect to impeding curvature progression [23] today seems outdated in view of the fact, that out-patient therapies may lead to the same results [24-26]. Initially a 6 week intensive in-patient program has been investigated, however the results achieved in this special ancient setting cannot be compared actually to the results with reduced rehabilitation times and modified programs [24]. More intensive out-patient programs are provided by Negrini, Rigo and Weiss and do not seem less effective than the actual inpatient program [24-26].
The second mode of conservative management is brace treatment, which has been found to be effective in preventing curvature progression and thus in altering the natural history of IS [27,28]. It appears that brace treatment may reduce the prevalence of surgery [29], restore the sagittal profile [30] and influence vertebral rotation [31]. There are also indications that the end result of brace treatment can be predicted [32].
Systematic application of the two modes of conservative treatment with respect to Cobb angle and maturity
Guidelines for conservative intervention are based on current information regarding the risk for significant curvature progression in a given period of time. Each case has its own natural history and must be considered on an individual basis, in the context of a thorough clinical evaluation and patient history [33]. Estimation of risk for progression is based on small (n < 1000) epidemiological surveys in which children were diagnosed with scoliosis, and radiographed periodically to quantify changes in curvature magnitude over time [34-56]. Such surveys support the premise that, among populations of children with a diagnosis of idiopathic scoliosis, risk for progression is highly correlated with potential for growth over the period of observation. In boys, prognosis for progression is more favorable, with relatively fewer individuals having curves that progress to >40 degrees. For SOSORT guidelines, prognostic risk estimation is based on the calculation of Lonstein and Carlson [45]. This calculation is based on curvature progression observed among 727 patients (575 female, 152 male) diagnosed between 1974–1979 in state of Minnesota (United States) school screening programs, and followed until they reached skeletal maturity. (See Figure 2).

I. Children (no signs of maturity)
a. < 15° Cobb: Observation (6 – 12 month intervals)
b. Cobb angle 15–20°: Physical therapy with treatment-free intervals (6–12 weeks without physical therapy for those patients at that time have low risk for curve progression).
c. Cobb angle 20–25°: Physical therapy
d. > 25° Cobb: Physical therapy and brace wear (part-time, 12–16 hours).

II. Children and adolescents, Risser 0–3, first signs of maturation, less than 98% of mature height
The following section is based on progression risk rather than on Cobb angle measurement because of the changing risk profiles for deformity as the skeleton matures. For our purposes, progression risk is calculated by the formula shown in figure 1.
a. Progression risk less than 40%: Observation (3-month intervals)
b. Progression risk 40%: Physical therapy
c. Progression risk 60%: Physical therapy + part-time brace indication (16 – 23 hours [low risk]).
d. Progression risk 80%: Physical therapy + full-time brace indication (23 hours [high risk]).

III. Children and adolescents presenting with Risser 4 (more than 98% of mature height)
a. < 20° according to Cobb: Observation (6 – 12 Months intervals)
b. 20 – 35° according to Cobb: Physical therapy .
c. > 35° according to Cobb: Physical therapy + brace (part time, about 16 hours are sufficient)
d. For brace weaning: Physical therapy + brace with reduced wearing time.

IV. First presentation with Risser 4–5 (more than 99.5% of mature height before growth is completed)
a. > 25° Cobb: Physical therapy.
b. > 35° according to Cobb: Physical therapy + brace (part time, about 16 hours are sufficient in cosmetic indication only, when surgery can be avoided).

V. Adults with Cobb angles > 30°: Physical therapy.

VI. Adolescents and adults with scoliosis (of any degree) and chronic pain
Physical therapy, scoliosis rehabilitation program (multimodal pain concept/behavioral + physical concept), brace treatment when a positive effect has been proven [5,57].

The prognostic estimation and corresponding indications for treatment apply to the most prevalent condition, idiopathic scoliosis. In other types of scoliosis a similar procedure can be applied. Exceptions include those cases where the prognosis is clearly worse, for example in neuromuscular scolioses where a wheelchair is necessary (early surgery for maintaining sitting capability may be required). Other reasons for the consideration of alternative treatments include:
- Severe decompensation
- Severe sagittal deviations with structural lumbar kyphosis ('flatback')
- Lumbar, thoracolumbar and caudal component of double curvatures with a disproportionate rotation compared to the Cobb angle and with high risk for future instability at the caudal junctional zone
- Severe contractures and muscles shortening
- Reduced mobility of the spine especially in the sagittal plane
- others to be individually considered [58]

Authors' contributions
*These authors contributed by reviewing, text editing and adding certain textfiles and references


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Figure 1. 5-year old girl with infantile IS (onset at 3) and a good compliance for  PT presented for bracing after 6 month of out patient PT. The curvature (with clear structural changes) was reduced from 24° to 13° and a brace at that time was not prescribed.


Figure 2. The estimation of the prognostic risk to be used during pubertal growth spurt (modified from Lonstein and Carlson [33]). The numbers in the figure indicate the number of cases that each data point is based on. Note the small number of cases on which the upper margins of the graph are based. Lonstein and Carlson's progression estimation formula is based on curves between 20 and 29 degrees.