The Adult Degenerative Scoliosis Exercise Trial (Pilot Study)

1.1 Adult degenerative scoliosis. Scoliosis is a 3D spine deformity including frontal curves, vertebral rotations, and sagittal changes.1 A curve >10o after 18 years of age is called Adult Scoliosis (AS) and is the most common adult spinal deformity.2 Degenerative AS arises from asymmetric disc and facet degeneration or due to leg length discrepancy, hip pathology, and osteoporosis.3 Most AS curves are lumbar or thoracolumbar.4 The prevalence of degenerative AS is higher than adolescent scoliosis, but estimates range widely at 2.4% - 68%56. The prevalence of curves >20° is 24%.7

AS causes pain, curve progression, radiculopathy, or cosmetic deformity affecting quality of life and physical function8-10. Pain affects 90% of patients with AS9. Adults with degenerative scoliosis present more pain than with idiopathic scoliosis.3 Severe radiculopathy (47%), claudication (9%), weakness (8%), myelopathy, and bowel/bladder dysfunction(1%) are also more common in adults with scoliosis.11 Sagittal imbalance in AS is strongly correlated with disability and low quality of life.12 Curve progression is common in AS at 2-6o/yr.13 It is thus relevant to offer treatments to prevent curve progression and the signs and symptoms above.

1.2 What treatment is available? There is an important lack of evidence about non-operative treatments for AS despite the recommendation of non-operative treatments are the first line for treating AS.8,14,15 This suggestion arise mostly because of the high complications rates with surgery and poor bone quality8. However, exercise has generally not been offered in studies comparing non-operative to operative care.8,14,15 The main goal of rehabilitation in AS is to decrease pain, improve function and slow disease progression to avoid surgery.16,17 Our review on exercises for AS18 found only one study with high risk of bias showing that 20 weeks of scoliosis specific exercises compared to general physiotherapy led to significantly more improved pain (by 3.2/10 pts), SRS-22 quality of life (by 0.7/5 for function, 0.9 pain, 0.5 self-image, 0.7 mental health and 1.0 for satisfaction with care), and Oswestry disability (by 12%). Only adults with idiopathic scoliosis were included in this study19 and exercises have not yet been tested in adults with degenerative scoliosis.

1.3 Rationale for Schroth treatment: Our award winning work with adolescent idiopathic scoliosis suggests that pain, self-image and back muscle endurance improvements, as well as, reduced curve progression result from short exercise programs.20-22 Schroth is a 3D autocorrection exercise aiming to correct posture.23 Schroth exercises are not yet routinely used for adults in Edmonton, but surgeons and patients have expressed interest for evidence on exercise. Patients routinely seek treatment options for smaller curvatures and inquire about less invasive treatments than surgery.

1.4 Schroth treatment: Posture corrections are achieved with the use of pressure, mirror and therapist verbal and tactile feedback.24,25 Schroth exercises aim to improve the ability to maintain correct posture through endurance and strength training.22 Schroth exercises include de-rotation, side shifting, and stretching to establish vertebral alignment, torsion respiratory exercises, and strengthening for postural muscles.26