Hawes 2003

PEDIATRIC REHABILITATION, 2003, VOL. 6, NO.
3–4, 171–182
The use of exercises in the treatment of

scoliosis: an evidence-based critical review
of the literature
MARTHA C. HAWES
Accepted for publication: August 2003 Physical Therapy Association (http://www.apta.org/

Dev Neurorehabil Downloaded from informahealthcare.com by Selcuk Universitesi on 01/03/15
Consumer/ptandyourbody/scoliosis) and the National

Keywords Spinal deformity, physical therapy, manipulation,
polio epidemics, scoliosis, posture Institutes of Health (http://www.niams.nih.gov/hi/
topics/scoliosis/scochild.htm), respectively: ‘Exercises
Summary are not a treatment and do not prevent or cure scoliosis’
and ‘Studies have shown that exercise alone will not
The loss of flexibility in a spinal curvature defines it as
stop progressive curves’. The purpose of this literature
a structural spinal deformity; a curvature sufficiently mobile
to resolve with a change in posture is a non-structural or survey was to identify studies in support of the premise
‘functional’ scoliosis which is within the normal limits of that studies have shown that exercises are not a
movement for a human spine. It, therefore, seems logical legitimate approach to use in the treatment of scoliosis.
that exercise-based therapies designed to improve and/or The scientific and medical literature of the English
For personal use only.
maintain flexibility and range of motion of the spine and

language were searched using Premedline and Medline
thorax would be useful in the treatment of scoliosis.
Recognition of the importance of maintaining flexibility (1966–2003); CINAHL (1982–2003); PubMed Central;
of the thoracic spinal column to avoid scoliosis-associated Science Citation Index (1945–2003); HealthStar (1975–
pulmonary dysfunction made the use of exercise-based thera- 2003); PsychInfo (1872–2003); Cochrane Central
pies a topic of clinical interest in ancient Greece. In recent Register of Controlled Trials; Cochrane Database of
years, successful prevention of polio epidemics has resulted
Systematic Reviews and Allied and Complementary
in a stable change in patient populations such that most
individuals diagnosed with scoliosis do not suffer from Medicine (AMED) (1985–2003). Key words were
irreversible central nervous system compromise. As a result, ‘scoliosis’ or ‘scoliosis and . . . treatment; therapy; exer-
realistic opportunities to examine the role of exercise in treat- cise; physical therapy; physical methods; osteopathy;
ment of scoliosis are available for the first time in history. chiropractic; manipulation; massage; non-surgical;
A growing body of evidence from independent sources is
conservative and early intervention’. Older literature
consistent with the hypothesis that exercise-based approaches
can be used effectively to reverse the signs and symptoms cited in articles obtained through electronic searches
of spinal deformity and to prevent progression in children was procured from the University of Arizona Health
and adults. Sciences Center Library collection in Tucson, Arizona
or through the AHSC interlibrary loan service.
Also surveyed were proceedings of meetings of the
Scoliosis Research Society, the International Research
Society for Spinal Deformity and the Phillip Zorab
The purpose of this review and methods for
Symposium; contemporary (1950s–present) physical
survey of the literature
therapy, pulmonary, orthopaedic and other medical
Information available to scoliosis patients and their textbooks including issues dedicated to scoliosis
families in the US is summarized by the following and other spinal deformities; popular and scholarly
statements from the web-sites of the American books on scoliosis available commercially through
Amazon.com or the University Library system, inclu-
ding English translations of the writings of ancient
Author: Martha C. Hawes, Professor, Department of Plant Greek physicians including Hippocrates. Over 10 000
Pathology, 204 Forbes Building, University of Arizona, original articles on ‘scoliosis’ were identified by this
Tucson, AZ 85721, USA. e-mail : mhawes@u.arizona.edu method and surveyed for information about research
Pediatric Rehabilitation ISSN 1363–8491 print/ISSN 1464–5270 online # 2003 Taylor & Francis Ltd
http://www.tandf.co.uk/journals
DOI: 10.1080/0963828032000159202
M. C. Hawes
Table 1 Published statements about the role of exercises in treatment every review of scoliosis treatment published in recent
of scoliosis decades either states explicitly that exercise is of no use
‘Exercise alone is to be vigorously condemned’ [18 (p. 1523)]; in the treatment of scoliosis or does not mention it at all
‘ . . . exercises only treat the psyches of the parents and help the [2–17]. With the exception of physical therapy, which
muscle coordination of certain poorly muscled children, who is occasionally mentioned in the peer-reviewed spine
are overweight and underexercised’ [19 (p. 153)];
literature as a way to help patients cope with the com-
‘From before the dawn of orthopaedics in the 18th century, physicians
and surgeons (as well as other members of the ‘‘healing arts’’) have
plications of brace and surgical treatment, avenues that
attempted to treat idiopathic scoliosis with exercises. There has involve physical methods of treatment by a professional
never been a single scientific article documenting the value of have been ignored almost entirely.
exercise. Conversely, there have been publications comparing the
results of exercise treatment with a simultaneous control group.
In the US, an uncritical acceptance of this ‘expert
No differences have been shown’ [20 (p. 239)]; opinion’ underlies a clinical impasse so bleak that
‘Today, most experts agree that exercise alone will not affect the some have argued that screening to diagnose scoliosis
progression of a structural scoliosis’ [21 (p. 903)]. in early stages might as well be eliminated [23–39].
‘Time and common sense prevent me from discussing any other In fact, the dogma that exercises are without potential
[conservative] treatment modality than bracing’ [22 (p. 2603)].

benefit is so entrenched that possible effects of such
therapies in patient outcomes are simply ignored.
Thus, ‘natural history’ surveys describing outcome
in purportedly ‘untreated’ populations generally have
(case reports, reviews, descriptive surveys, cohort series,
included patients who used exercises or received thera-
epidemiological surveys, controlled trials or basic
peutic treatment by professionals other than surgeons
science) examining the use of exercises as a treatment.
[16, 40–50]. These patients were presumed to exhibit
To identify research that may remain unpublished
the same disease course as an untreated patient and
to date, or may have been published in documents
were included within the ‘natural history’ populations.
unretrievable by standard methods, internet searches
For example, in Bunnell’s [44] study of 123 female
for ‘scoliosis’ were conducted. Finally, personal letters

patients, ‘the only forms of non-operative treatment
were sent to authors who have stated or implied in
prescribed were exercises or shoe lifts. For this reason,
articles published in peer reviewed journals that
all patients were regarded as demonstrating the natural
research has shown that exercises are ineffective in the
history of idiopathic scoliosis’ (p. 773). Shoe lifts and
treatment of scoliosis (e.g. table 1).
exercise might have improved the outcome [51, 52] and
some exercise programmes might have made the prob-
lem worse [53, 54]. However, in every situation where
The role of exercise in treatment of scoliosis:
the authors chose to ignore the potential impact of such
an unsupported consensus
therapies, it is impossible to rule out the possibility that
This article critically evaluates a long-standing bias divergent outcomes within patient populations were
regarding the use of exercise in the treatment of scolio- influenced by exercise regimens some individuals used
sis. The term ‘exercise’ is defined by the American [55, 56].
Medical Association [1] as ‘The performance of any In the following paragraphs, the historical back-
physical activity that improves health or that is used ground to this situation will be summarized and the
for recreation or correction of physical injury or defor- small number of original publications which have
mity. Different types of exercise affect the body in one been cited in support of the dogma that exercise-based
or more of the following ways: some improve flexibility, therapies have been proven ineffective will be critiqued.
some improve muscular strength, some improve Finally, evidence consistent with the hypothesis that
physical endurance and some improve the efficiency of active and passive exercise-based therapies can be
the cardiovascular and respiratory systems. Exercises used successfully to treat the signs and symptoms of
may be passive, in which a therapist moves parts of spinal deformity in children and adults will be outlined.
the patient’s body, or active, in which the patient is
taught to contract and to relax certain muscle groups
Historical perspective on scoliosis treatment in
or to perform specific movements’ (p. 425).
Western medicine
For many years, the English-language medical and
scientific literature of the spine community has dis- Scoliosis is a three-dimensional deformity in which
missed every type of exercise as a legitimate avenue to the spine deviates from its normal sagittal and coronal
employ in the treatment of scoliosis (table 1). Virtually positions in the upright human posture and becomes
172
Exercises in the treatment of scoliosis
fixed in this unbalanced posture [57–60]. The mechan- of curvatures during growth and worked on improved
ical imbalance inherent in scoliosis, irrespective of its corsets as a method to control it. In 1741, Nicholas
cause, results in asymmetric loading which constitutes Andre gave birth to the discipline of ‘orthopaedics’
a ‘vicious cycle’ with an inevitable tendency to worsen by way of his treatise on scoliosis, which he believed
with time [61–63]. In fact, most cases of scoliosis do to be a result of faulty posture leading to a muscular
continue to progress throughout the life of the patient imbalance.
[16, 40, 42, 45, 64–66]. Symptoms that occur in associ- From 500 BC, then, through the early 1900s, the
ation with scoliosis include pain [40, 45–47, 67–78] basic principles of scoliosis treatment remained the
and psychological distress [14, 16, 24, 49, 79–87]. In same as the common-sense approaches attempted by
curvatures involving the thoracic spine, reduced chest Hippocrates: Traction, manipulation and supportive
wall mobility and impaired excursion occur as a second- braces made of everything from iron to plaster were
ary effect of reduced spinal flexibility [88–90]. Reduced used to reverse the rigidity and push the torso back
chest excursion causes restrictive lung dysfunction into alignment in the absence of any knowledge of
which is proportional to magnitude of curvature and what caused the problem in the first place [61]. No
death by cardiac or respiratory failure can occur when one knows whether any of these treatments was effective
Cobb angle is > 70 [78, 91–95]. Even mild or moderate or not. Occasionally an effort was made to use drawings
cases that remain stable are associated with pulmonary or sculpture to illustrate treatment successes, but such
dysfunctions including reduced vital capacity, reduced reports are dismissed out of hand as exaggerations
exercise capacity and recurrent respiratory infection based on contemporary biases that nothing but bracing
[96–107]. Impaired respiratory function in scoliosis and surgery can influence spinal deformity [115].
generally develops gradually over time and, therefore,
is ‘symptomless’ because patients adapt to reduced
Changes in the modern era
function and remain unaware of their limitations; there-
fore, cardiopulmonary failure may occur unexpectedly Efforts to treat scoliosis with surgery were initiated
in response to onset of respiratory infection [91, 93, in the 19th century and, for more than a century now,
108–111]. orthopaedic surgeons have remained at the centre of
It is the loss of flexibility in a spinal curvature that protocols for screening, diagnosis, treatment, research
defines it as a spinal deformity [11]. A curvature that is and publication on every aspect of scoliosis [34]. With
sufficiently mobile to resolve when the patient lies down the exception of a short-lived and fruitless effort in
or bends sideways is a ‘functional’ or non-structural the 1980s to use ‘electrical stimulation’ of lateral spinal
curvature which is within the normal limits of move- musculature as a therapy [10, 21, 34, 115, 116], the prin-
ment for a human spine and does not qualify formally ciples underlying scoliosis treatment have undergone
as a spinal deformity. Moreover, the flexibility of the no significant changes since the time of Hippocrates:
spinal curvature is inversely correlated with progression Treatments including spinal fusion surgery are still
and pain: the more rigid the curve, the more likely it based on trying to force curvatures back into alignment
is that the curvature will worsen and the patient will in the absence of any scientific or practical understand-
suffer from symptoms [20, 112]. It, therefore, seems ing of what caused the curve in the first place and
logical to predict that exercise-based therapies designed what forces may still be at work holding it that way
to improve and/or maintain flexibility of the spine and [61, 62, 111].
thorax would be useful in the treatment of scoliosis. The only fundamental changes that have occurred
An awareness of the dangers of scoliosis-associated in the world of scoliosis treatment, notwithstanding
pulmonary dysfunction and the importance of main- continual efforts to develop surgical approaches that
taining flexibility of the chest wall made the use of exer- will address the signs and symptoms of spinal deformity
cise-based therapies a topic of long-term clinical interest in a meaningful way [117, 118], involve diagnosis and
by the time the Hippocratic Collection was assembled demographics. Throughout recorded history, cases
in 500 BC [113]. Galenus (AD 131–201), who first used of spinal deformity have comprised a heterogeneous
the term ‘scoliosis’ to define a lateral curvature in the mixture of aetiologies including everything from quad-
spine, followed up on this published body of work riplegia to catastrophic genetic mutations to leg-length
by using ambulatory corsets and jackets to control discrepancies to nutrient deficiencies. Not only was
spinal curves. He also advocated the use of respiratory there no mechanism to distinguish different kinds of
exercises including loud singing [114]. Ambrose Pare spinal deformity, but there was no reproducible means
(1510–1590) recognized the potential for progression to define the magnitude of the spinal curvature or to
173
M. C. Hawes
assess whether it was getting worse. In the early 1900s, surgery. Although such claims are made routinely in
X-ray technology was developed and suddenly it reviews, books and other surveys of the literature,
became possible to distinguish different categories of only a few original publications have been cited in sup-
scoliosis based on magnitude and also to distinguish port of the premise that early proactive treatments
among cases caused by congenital bone deformities, involving exercise-based interventions do not work.
arthritis, infections, tumours, rickets and other known These published papers which have been cited in
causes. support of statements that exercise cannot be used
A second major change has been in the makeup of effectively to treat idiopathic scoliosis are summarized
scoliosis populations who seek medical advice. This below.
has been in part a result of improvements in treating
infectious diseases that cause scoliosis. Throughout
Published evidence against exercises as
most of recorded history, people who had been infected
treatment for scoliosis
with polio and tuberculosis predominated among popu-
lations of patients seeking relief from spinal deformity The term ‘treatment’ is used in the same sense it is
[18, 61, 111]. For paralytic polio patients especially, used in these studies, to refer to effects on progression,
a drastic surgical intervention might offer the only stabilization or reversal of the spinal curvature and its
hope for survival, let alone a semblance of a normal associated deformities and dysfunctions.
social life. Thus, the likelihood that a traumatic surgical In 1941, a committee of orthopaedic surgeons com-
intervention might be fatal was a risk worth taking. piled results describing 425 case histories of patients
Over the course of this century, vaccinations and seen in 16 orthopaedic clinics throughout the US
antibiotics have narrowed scoliosis populations more [122]. Results from 185 patients ‘originally treated by
and more such that, in the current generation, for the exercises of all types’ were obtained through interviews
first time in history, the vast majority of cases are with clinicians. Curvature magnitude ranged from less
‘idiopathic’, meaning the cause is unknown and the than 20 to greater than 40 , age at diagnosis ranged
patient appears to be perfectly healthy except for the from 2–19 years and outcome ranged from progression
presence of a spinal curvature. of more than 20 in 27% of patients to improvement
A final important change resulting in a quantum of 10 in one patient. The authors reported that ‘most
shift in the makeup of patient populations has been the men believed a mild curve should be treated with
advent of widespread programmes for early diagnosis posture exercises’ and that ‘Most men agree that pos-
[28, 119, 120]. Thanks to school screening programmes, tural improvement can be expected from a regimen of
for the first time in history, most spinal curvatures exercises, but the curve itself cannot be decreased
are now detected in early stages. Before such pro- by this means’. No data or citations are provided in
grammes were initiated in the 1970s, curvatures were support of these statements. Similarly, the advice that
generally not detected until they already were at least ‘Strenuous exercises should be prescribed cautiously,
moderately severe and there was an obvious deformity since they may mobilize a rigid curve and allow further
which was apparent to family members or physicians collapse’ is offered, but it is not clear if this reflects
[111]. Thus, as recently as 30 years ago, a large per- a consensus opinion of the committee or the personal
centage of patients seeking help already suffered from opinion of one or more of the surveyed clinicians.
advanced cases of spinal deformity, many of which Because detailed information describing methods,
involved irreversible muscular and nervous system supervision, compliance, follow-up or duration of
damage. treatment is not provided, no conclusions about the
Unfortunately, screening programmes in the US have use of exercises to treat scoliosis can be drawn from
been of limited success in improving the outcome for this study.
those found to have mild curvatures, at least in part The paper most often cited in support of claims
because no effort is made to treat those found to have that exercises cannot be used to treat scoliosis is
a curvature. Instead, patients are advised to do nothing a small, well-planned pilot study by a group of physical
but wait till the curvature either stabilizes sponta- therapists [123]. This appears to be the only study ever
neously or progresses to a point of severity at which published in the US which documents efforts to use
bracing or surgery can be justified [121]. This clinical clinical research approaches to test the hypothesis that
approach is based on a presumption that therapies exercise alone can influence curvature progression. Over
other than bracing and surgery have no role in the the course of a 1-year period, children in two groups
treatment of scoliosis except in support of bracing and matched with respect to age, degree and shape of
174
curvature were treated with exercise (42 subjects) or no (p. 2644)’ [50]. Whether these patients were among the
exercise (57 subjects). At the end of the 1-year period ‘great number’ who originally were taught postural
of evaluation, there was no difference in curvature exercises and whether such routines were continued in
progression between the two groups. Unfortunately, adulthood is not addressed.
because only four of the 41 children in the test group Rinsky and Gamble [14] cite two papers [125, 126] in
even claimed to have done the exercises ‘daily or almost support of the following statement: ‘Exercise alone does
daily’, as prescribed, the authors acknowledged that not halt the advance of progressive scoliosis. . . Though
‘Based on this study, we cannot conclude that exercise there is a natural tendency to ‘‘do something’’ there is
has no effect on change in curvature in patients with no proof that prescribed exercises help, even if done on
minimal idiopathic scoliosis’ (p. 763). They proposed a regular supervised basis’. The paper by McCollough
a follow-up study that would include a longer-term, et al. [125] deals with the use of bracing in scoliosis
more intensive regime in which children were supervised therapy. Exercises were not a part of the treatment
to make sure the exercises were actually being carried regime, in keeping with their stated opinion: ‘The
out. authors do not believe that exercises influence the
Two papers from a long-term study by a spine clinic course of scoliotic spine deformity’ (p. 145). No refer-
in Iowa [45, 48] were cited by Dworkin et al. [124] in ences are offered in support of this belief and no claims
support of the following statement: ‘Intensive pro- are made for its being anything other than personal
grammes of exhortation, verbal instruction and exer- opinion. Carman et al. [126] also deal with the use of
cises have generally been recognized to be without any exercise in conjunction with brace therapy and have no
effect on the condition of the spine . . . On the question- bearing on the issue of whether exercise alone can influ-
able assumption that idiopathic scoliosis is at least par- ence outcome in scoliosis.
tially caused by muscular weakness, a variety of exercise In summary, an intensive review of the English-
programmes to treat scoliosis have been proposed and language scientific and medical literature pertaining to
tested. These programmes have met with little, if any scoliosis has been carried out. Based on that review,
success’ (p. 2497). Ponseti and Friedman [48], who it appears that there is not one single published
stated that ‘While conservative therapy may improve study, let alone a body of interpretable scientific
body posture, it has never been found—or claimed— research, which can be construed as evidence to support
to decrease the size of a spinal curvature’ (p. 381), actu- the hypothesis that scoliosis cannot be treated with
ally offer no references or data to support this statement exercise-based therapies.
and make no claims to have provided such supportive
information in the paper. Among 444 patients whose
Evidence consistent with the hypothesis that
case reports were analysed, it is stated that ‘a great
exercise-based therapies can improve the
number received conservative treatment consisting of
signs and symptoms of spinal deformity
exercises designed to increase muscle strength and to
correct postural imbalance’ . . . and ‘were taught to Not only is it inaccurate to claim that scientific
shift their thorax into proper alignment with the pelvis. studies have ruled out the use of exercise in the treat-
Braces were often given to help maintain body posture’ ment of scoliosis, but a small number of studies suggest
(p. 381). No details are provided, and the possibility that a range of physical methods can positively influ-
that a relationship might exist between the use of bra- ence the course of spinal deformity [127–133]. For
cing and exercise by some individuals and widely diver- example, Ferraro et al. [129] report stabilization of
gent outcomes within the population was ignored. spinal curvature and rib hump among 34 children
More recent follow-up studies of sub-sets of this with mild scoliosis over a 2-year period of treatment
original cohort [45, 48] have confirmed that long-term which included daily exercises taught by physical
outcome in adolescent idiopathic scoliosis ranges from therapists. Participation in an intensive 5-month daily
benign to lethal for unknown reasons [16, 49, 65, 66, exercise programme was correlated with improved
78]. The authors of the Iowa series have continued to appearance and reduced spinal curvature in 10 children
ignore the possible role of exercise-based treatments in with mild scoliosis [133]. A recent abstract [130] reports
these divergent outcomes, referring to the patients as intriguing results consistent with an older report [131]
‘untreated’ because they did not receive spinal fusion that side-shift exercises can stabilize curvature progres-
surgery [56]. This omission was justified based on the sion in adolescents. In that study [130], side-shift exer-
premise that ‘there is no evidence that exercise results in cises were correlated with reduced curvature magnitude
sustained flexibility and benefits over a 50-year period in young adults, with Cobb angle improvement of 10
175
M. C. Hawes
or more in some patients. In addition to such observa- also induces asymmetric moulding of the thorax, result-
tions, several important studies, summarized below, ing in development of a spinal curvature [135, 139].
constitute a strong conceptual and experimental basis Mild cases of infantile scoliosis may resolve sponta-
for the proposition that the signs and symptoms of neously, but 8–80% become progressive, a relentless
spinal deformity can be reversed without surgery. and potentially lethal course that, according to Lloyd-
Scientifically definitive evidence that scoliosis, in an Roberts and Pilcher [139] is ‘established by the age of
animal model system, can result entirely from move- 2, for by this time all resolving curves are improving (p.
ment and postural imbalance and can be corrected 521)’ [135, 136, 140–143]. A patient treated by
simply by removing the postural imbalance was pub- Harrington developed progressive scoliosis following
lished more than 20 years ago. Harrington [134] used abdominal surgery and by the age of 2.5, she had a
a population of inbred mice so closely related as to be severe structural scoliosis measuring 75 . In response,
functionally similar to identical twins. In one popula- Harrington treated her by ‘protection of her spine from
tion, he inhibited spinal mobility and induced constitu- gravity loading’. By the time she was 15 years old, the
tive postural imbalance by surgically tying the right scoliosis had resolved entirely. Similar results have been
hind- and fore-quarters together at the knee and obtained by using serial casting of the torso to restore a
elbow joints, at different periods during development. balanced posture [121, 144]. These results constitute a
At defined periods during growth, the imbalance was powerful argument in support of the hypothesis that
reversed by untying the front and hind legs and allow- postural imbalance can cause severe structural scoliosis
ing normal movement. A matched population was used which is reversible in humans, just as it is in mice.
as a control for all aspects of the study. The results Other data supporting the hypothesis that postural
indicated that severe structural scoliosis with a Cobb imbalance alone can cause structural scoliosis which
magnitude of up to 90 and with associated morpholo- can be reversed when postural balance is restored
gical changes including compressed intervertebral disc are provided by an important case report series which
space and wedged and rotated vertebrae could be followed the course of pain-provoked spinal deformity
induced within a defined period of growth and that all in five cases of structural scoliosis over a period of years
of these signs could be reversed completely when spinal [145]. This study yields several important conclusions:
mobility and postural balance were restored before If a painful lesion causing scoliosis heals or is treated
growth was complete. The implications of this import- within 1 year, the spinal deformity may resolve sponta-
ant paper are clear: Scoliosis is reversible, even when it is neously. On the other hand, if the pain and its associ-
severe and even when it is accompanied by deterioration ated scoliosis remain in place for longer than 1 year,
of the structures of the spinal column. It can occur in a the scoliosis is likely to remain even after the pain is
perfectly healthy population in the absence of any gone and can become progressive. Indeed, even when
genetic disorder and it can be prevented and it can be bone tumours are diagnosed, it is frequently only after
cured. Several recent studies using other model animal they first have been misdiagnosed as muscle strain,
systems have confirmed the essential thesis of herniated disc, idiopathic scoliosis, arthritis, infection,
Harrington’s work: Structural spinal deformity is rever- spinal cord tumour or hysteria [146]. If the painful
sible, if asymmetrical compression of vertebral struc- lesion is of a nature that never shows up on X-rays
tures is reversed before spinal growth is complete [62]. or if it heals leaving no trace or if the physician con-
In humans, the most definitive example of a postural tinues to dismiss and/or misinterpret the symptoms, an
aetiology for scoliosis (and, by implication, the like- accurate diagnosis would be impossible. Mehta [145]
lihood that correction will occur with exercises that cautiously points out that inducing forces parallel to
correct postural imbalance) occurs in infants in associ- those causing pain-provoked scoliosis may operate in
ation with a phenomenon called ‘plagiocephaly’ [121]. some cases of ‘idiopathic’ scoliosis and highlights
Plagiocephaly is a benign moulding of a child’s head the implications for healing of structural scoliosis,
which commonly develops after birth during the first irrespective of its primary trigger. Like Harrington’s
6 months of life, in response to lying on its back work, the results indicate that structural spinal defor-
(‘supine’) with the head to one side [135]. In surveys mity can stabilize or reverse given the right circum-
of several hundred babies under the age of three who stances and that, therefore, ‘The attainment of the
had scoliosis, 97–100% also had plagiocephaly which limited goal of preventing progressive scoliosis by a
matched to the sidedness of the curve [136–138]. This combined programme of early detection and early
remarkable correlation apparently occurs because the curve correction would appear to be entirely feasible
same asymmetric posture which leads to head moulding (p. 65)’ [145].
176
Perhaps the most convincing evidence of the power response to polio. More importantly, the improvement
of exercises to improve spinal deformity is a small in curvature was correlated with dramatically improved
randomized, controlled test by Dickson and signs of respiratory dysfunction, including a nearly
Leatherman [147], which demonstrated that flexibility 100% improvement in vital capacity, from 0.77 to 1.4
of fixed spinal curvatures can be increased by more litres (25% to nearly 50% of predicted). The symptoms
than 30% by an 8-day programme of supervised of respiratory failure also improved: Upon admission,
exercises. Flexibility of the spine is the factor which the patient reportedly ‘could barely breathe at rest’
defines whether or not it is a structural deformity and after treatment he reported relief from his short-
and is a parameter that plays an important role in ness of breath. The potential application of physical
deciding the type of surgery that can be performed methods in treatment of spinal deformity is obvious
and the degree of correction that can be obtained [11]. from these results [148]. Of most importance was the
Flexibility is assessed based on how much correction of demonstration that (1) even severe long-standing spinal
the Cobb angle can be obtained when the patient deformity was reversible by physical methods applied
lies down, bends to the side, or is placed in traction; for a few weeks; and (2) the corresponding long-
an extremely rigid curve does not change in response standing life-threatening cardiopulmonary dysfunctions
to this maneouvre, whereas a non-structural curvature were also rapidly reversible. The authors explicitly
will resolve completely. In a preliminary evaluation, expressed their hope ‘that this report may stimulate
10 patients (mean age 12.9 years) diagnosed with idio- similar attempts leading to a more meaningful evalua-
pathic scoliosis (mean curvature 43 ) took part in an tion of the long-term potential improvement (p. 1522)’
8-day inpatient programme in preparation for spinal to be achieved by such methods.
fusion surgery [147]. The programme included traction These papers [134, 144, 147–150] comprise a small
and exercises performed by the patients. The exercises yet compelling body of research consistent with the
were performed daily for two 1-hour periods, under most straightforward prediction of the ‘vicious cycle’
the supervision of a physical therapist. Each session model for spinal deformity development and progres-
included 20 exercises with 15 replicates and concen- sion [61, 62, 151]: Irrespective of the inciting trigger
trated on lateral bending to correct the curve and that causes a spinal curvature to develop, removing
pelvic tilting to mobilize the lumbar lordosis. Flexi- the resultant asymmetric gravity loading by restoring
bility of the curvature was assessed at the beginning postural balance can improve signs and symptoms of
and end of treatment. The results revealed that scoliosis even after it has progressed to being a
average flexibility was increased by 7 in only 8 days. fixed spinal deformity [134, 145, 149]. If the asymmetric
That is, the average curve on lateral bending was 20 to loading is removed before growth is complete, before
start and at the end was reduced to 13 . The differences too much time has passed, the spinal deformity can
were highly significant ( p<0.001) based on standard be completely eliminated [134, 144, 145, 148, 149]. In
statistical analyses. A follow-up study with a second moderately severe curvatures in the range which
group of patients yielded the same results: Traction warrants surgical intervention, the loss of spinal
had no measurable effect, but performance of an exer- flexibility which defines a curvature as a spinal defor-
cise regime for 8 days yielded a statistically significant mity can be reversed by more than 30% in response
improvement in flexibility of the curve. In this study, to treatment consisting of exercises performed daily
there was no improvement in the standing curvature for 8 days [147]. Even in long-standing, severe thoracic
and the data are derived from a small sample popula- scoliosis whose associated pulmonary dysfunctions
tion. Nevertheless, the results reveal that exercises have progressed to the point of near-lethality, a
designed and supervised by qualified clinicians can be dramatic reversal of the signs and symptoms can be
used to reverse the spinal rigidity which is the defining accomplished in a matter of weeks in response to
characteristic of a structural scoliosis, in a very short physical therapies which mobilize the curvature [148].
time. It is significant that the conclusions to be drawn from
A case report demonstrates that pulmonary dysfunc- these studies apply to spinal deformity ranging from
tion associated with structural spinal deformity also early mild cases to longstanding cases of catastrophic
can be alleviated quickly using physical methods to magnitude, in individuals ranging in age from babies to
mobilize a severe thoracic curve [148]. The study adults.
reported that a 3-week period of traction significantly In the past decade, the Schroth Clinic in Bad
reduced the magnitude of curvature in a 49-year-old Sobernheim, Germany, has published a series of studies
man who had developed severe scoliosis as a baby in exploring the use of exercise-based therapies in the
177
M. C. Hawes
treatment of scoliosis. The Schroth programme is based plinary research by physical therapists, physiatrists,
on the principle that spinal deformity, irrespective of exercise scientists, respiratory therapists and other qua-
its cause, by definition comprises a postural disorder lified professionals is long overdue. The need for
and that patients will benefit from correction of that research is especially urgent in the US, where a success-
disorder. Scoliosis inpatient rehabilitation (SIR) essen- ful campaign to reduce sudden infant death syndrome
tially accomplishes the goals proposed by Stone et al. (SIDS) by convincing parents to place their babies in
[123] following their preliminary survey: Those goals the supine position for sleeping has been underway for
include more intensive exercise-based treatment, super- the past decade [173]. Unfortunately, use of the supine
vised by physical therapists over a defined period, with position in the past almost certainly underlies the fact
subsequent long-term follow-up. Clinical studies with that infantile scoliosis was prevalent in Europe where
large populations of children and adults have examined babies traditionally slept in the supine position and
structure-function relationships between spinal curva- almost non-existent in the US where babies tradition-
ture and symptoms, including the dynamics of posture ally slept face-down (‘prone’) [139]. Infantile scoliosis
and breathing as they relate to the mechanics of spinal reportedly has almost disappeared from Europe with
deformity. Other studies have measured the impact adoption of the prone sleeping position for babies
of treatment by comparing the magnitude of scoliosis [135, 174]. As a result of a ‘back to sleep’ campaign
signs and symptoms before and after treatment. Papers which has failed to consider the known dangers of indu-
published in peer-reviewed English-language medical cing infantile scoliosis [121, 135], this potentially deadly
journals during the past decade report quantitative, disorder can be predicted to be on the rise in the US,
statistically significant improvement in pain [152–154] where it used to be extremely rare [140]. The children
stabilization or improvement in curvature magnitude who are victims of this policy are going to need reliable
and torso deformity [154–158], reduced psychological non-surgical therapeutic intervention to prevent tragic
distress [159–161] and measurably improved chest consequences [144, 150].
expansion and cardiopulmonary function [162, 163].
References
Conclusions 1. Clayman, CB.: American Medical Association Encyclopedia of
Medicine (New York: Random House), 1989.
After nearly 100 years of domination of scoliosis 2. Bleck, E.: AIS. Developmental Medicine in Child Neurology, 33:
research by the orthopaedic surgery community, one 167–176, 1991.
3. Boachie-Adjei, O. and Onner, B.: Spinal deformity (common
principle has been established without question: orthopedic problems I). Pediatric Clinics NA, 43: 883–897, 1996.
A structural deformity which is present at skeletal 4. Bunnell, W. P.: Nonoperative treatment of spinal deformity: the
maturity and remains untreated is a life sentence, at case for observation. Instructional Course Lectures, 34: 106–109,
1985.
best [66]. Like cancer, infections and other disorders 5. Dickson, R. A. and Weinstein, S. L.: Bracing (and screening)—
of the human condition, scoliosis develops at a parti- yes or no? Journal of Bone and Joint Surgery, 81-B: 193–198, 1999.
cular point in an individual’s development in response 6. Farady, J. A.: Current principles in the nonoperative manage-
ment of structural AIS. Physical Therapy, 63: 512–523, 1983.
to a particular combination of environmental and 7. Haasbeek, J. F.: AIS; recognizing patients who need treatment.
genetic influences and, as in other diseases and dysfunc- Postgraduate Medicine, 101: 207–216, 1997.
tions, early detection and early treatment in scoliosis 8. Kaelin, D. L., Oh, T. H., Lim, P. A. C. et al.: Rehabilitation
of orthopedic and rheumatologic disorders. 4. Musculoskeletal
can be predicted to be a key to successful outcomes. disorders. Archives of Physical Medicine Rehabilitation, 81:
A small body of clinical and basic research now S-73–77, 2000.
supports the hypothesis that exercise-based therapies 9. Killian, J. T., Mayberry, S. and Wilkinson, L.: Current
concepts in AIS. Pediatric Annals, 28: 755–761, 1999.
can be used to reverse the signs and symptoms of 10. Lonstein, J. E. : AIS. Lancet, 344: 1407–1412, 1994.
scoliosis in children and adults [100, 127–134, 145, 11. Lonstein, J. E.: Patient evaluation. In: J. Lonstein, D. Bradford,
147, 148, 154–163, 166–168]. Conversely, there does R. Winter et al. (editors) Moe’s Textbook of Scoliosis and
Other Spinal Deformities, 3rd edn (Philadelphia: WB Saunders),
not appear to be a single study supporting the dogma pp. 45–86, 1995.
that scoliosis will not respond to exercise-based 12. Reamy, B. V. and Slakey, J. B.: AIS: review and current
therapies applied early in the disease process. Given concepts. American Family Physician, 64: 111–116, 2001.
13. Rinsky, L. A.: Advances in management of IS. Hospital Practice,
the known risks of curvature progression, chronic 27: 49–55, 1992.
pain, psychological distress and reduced pulmonary 14. Rinsky, L. A. and Gamble, J. G.: AIS. Western Journal of
function [50, 73, 87, 164–165, 169–172] and the likeli- Medicine, 148: 182–191, 1988.
15. Roach, J. W.: 353 Disorders of the pediatric and adolescent
hood that early treatment can foster the long-term spine. Orthopedic Clinics NA, 30: 353–365, 1999.
health and productivity of scoliosis patients, multidisci- 16. Weinstein, S. L.: Natural history. Spine, 24: 2592–2600, 1999.
178
17. Winkel, D.: Diagnosis and Treatment of the Spine. Nonoperative 45. Collis, D. K. and Ponseti, I. V.: Long-term follow-up of
Orthopaedic Medicine and Manual Therapy (Gaithersburg, MD: patients with IS scoliosis not treated surgically. Journal of Bone
Aspen Publishers), 1996. and Joint Surgery, 51-A: 425–445, 1969.
18. Hungerford, D. S.: Spinal deformity in adolescence: early detec- 46. Fowles, J. V., Drummond, D. S., L’Ecuyer, S. et al.: Untreated
tion and nonoperative treatment. Medical Clinics of NA, 59: scoliosis in the adult. Clinical Orthopedic Related Research, 134:
1517–1525, 1975. 212–224, 1978.
19. Keim, H. A.: The Adolescent Spine, 2nd edn (New York, 47. Nachemson, A.: A long term follow-up study of nontreated
Heidelberg, Berlin: Springer-Verlag), 1987. scoliosis. Acta Orthopedica Scandinavica, 39: 466–476, 1968.
20. Lonstein, J. E. and Winter, R. B.: AIS; nonoperative treatment. 48. Ponseti, I. V. and Friedman, B.: Prognosis in IS. Journal of Bone
Orthopedic Clinics NA, 19: 239–245, 1988. and Joint Surgery, 32-A: 381–395, 1950.
21. Cassella, M. C. and Hall, J. E.: Current treatment approaches 49. Weinstein, S. L.: Long term follow-up of pediatric orthopedic
in the nonoperative and operative management of AIS. Physical conditions; natural history and outcomes of treatment. Journal of
Therapy, 71: 897–909, 1991. Bone and Joint Surgery, 82-A: 980–990, 2000.
22. Dickson, R. A.: Spinal deformity—AIS. Nonoperative treat- 50. Weinstein, S. L.: Letter to the editor, response, health and func-
ment. Spine, 24: 2601–2606, 1999. tion of patients with untreated IS (50). JAMA, 289: 2643, 2003.
23. Drummond, D. S., Rogala, E. and Gurr, J.: Spinal deformity: 51. Irvin, R. E.: Reduction of lumbar scoliosis by use of a heel lift
natural history and the role of screening. Orthopedic Clinics of to level the sacral base. Journal of the American Osteopathic
NA, 10: 751–759, 1979. Association, 91: 34–44, 1991.
24. Goldberg, M. S., Mayo, N. E., Poitras, B. et al.: The Ste. 52. Zabzek, K. F., Leroux, M. A., Moillard, C. et al.: Acute
Justine AIS cohort study: II. Perception of health, self and body postural adaptations induced by a shoe lift in IS patients.
image, and participation in physical activities. Spine, 19: 1562, European Spine Journal, 10: 107–113, 2001.
1994. 53. Ogon, M., Riedl-Huter, C., Sterzinger, W. et al.: Radiologic
25. Goldberg, C. J., Dowling, F. E., Fogarty, E. E. et al.: School abnormalities and low back pain in elite skiiers. Clinical
scoliosis screening and the United States Preventive Services Task Orthopedic Related Research, 390: 151–162, 2001.
Force. An examination of long-term results. Spine, 20: 1368–1374, 54. Tanchev, P. I., Dzerov, A. D., Parushev, A. D. et al.: Scoliosis
1995. in rhythmic gymnasts. Spine, 25: 1367–1371, 2000.
26. Hazebrook-Kampschreuer, A.: The effect of school screening 55. Hawes, M. C.: Scoliosis and the Human Spine: A critical review of
on surgery for AIS: a comment. European Journal of Public clinical approaches to the treatment of spinal deformity in the
Health, 9: 152–153, 1999. United States, and a proposal for change (Tucson, AZ: West
27. Kane, W. J.: A new challenge in scoliosis care. Journal of Bone Press), www.scoliosis.org, 2002.
and Joint Surgery, 64-A: 479–480, 1982. 56. Hawes, M. C.: Letter to the editor, Health and function of
28. Lonstein, J. E.: Natural history and school screening for patients with untreated IS. JAMA, 289: 2644, 2003.
scoliosis. Orthopedic Clinics of NA, 19: 227–237, 1988. 57. Jaremko, J. L., Poncet, P., Ronsky, J. et al.: Estimation of
29. Lonstein, J. E.: AIS. Lancet, 344: 1407–1412, 1994. spinal deformity in scoliosis from torso surface cross sections.
30. Montgomery, F., Pehrsson, U., Benoni, G. et al.: Screening Spine, 26: 1583–1591, 2001.
for scoliosis: a cost-effectiveness analysis. Spine, 15: 67–70, 1990. 58. Kojima, T. and Kurokawa, T.: Quantitation of three-
31. Morrissy, R. T.: School screening for scoliosis. Spine, 24:
dimensional deformity of IS. Spine, 17: S22–S29, 1992.
2584–2591, 1999.
59. Poncet, P., Dansereau, J. and Labelle, H.: Geometric torsion
32. Reijneveld, S. A. and Hirasing, R. A.: The effect of school
in IS; three-dimensional analysis and proposal for a new classifi-
screening on surgery for adolescent idiopathic scoliosis: reanalysis
cation. Spine, 26: 2235–2243, 2001.
is needed. European Journal of Public Health, 10: 153–155, 2000.
60. Villemure, I., Aubin, C. E., Grimard, G. et al.: Progression
33. Renshaw, T. S.: Screening school children for scoliosis. Clinical
of vertebral and spinal three-dimensional deformities in AIS.
Orthopedic Related Research, 229: 26–33, 1988.
A longitudinal study. Spine, 26: 2244–2250, 2001.
34. Rowe, D., Bernstein, S., Riddick, M. F. et al.: A meta-analysis
61. Roaf, R.: Scoliosis (Baltimore, MD: Williams and Wilkins), 1966.
of the efficacy of nonoperative treatments for IS. Journal of Bone
62. Stokes, I. A. F.: Hueter-Volkmann Effect; state of the art
and Joint Surgery, 79-A: 664–669, 1997.
reviews. Spine, 14: 349–357, 2000.
35. Weiss, H. R.: Letters. Spine, 26: 2058–2059, 2001.
63. Stokes, I. A. F. and Gardner-Morse, M.: The role of muscles
36. Wiegersma, P. A., Hofman, A. and Zielhuis, G. A.: The effect
of school screening on surgery for AIS. European Journal of Public and effects of load on growth. Research into Spinal Deformity, 4:
Health, 8: 237–240, 1998. 314–317, 2002.
37. Winter, R. B.: Adolescent idiopathic scoliosis. New England 64. Korovessis, P., Piperos, G., Sidiropoulos, P. et al.: Adult
Journal of Medicine, 314: 1379–1380, 1986. idiopathic lumbar scoliosis: a formula for prediction of progres-
38. Woolf, S. H.: Screening for AIS—policy statement. JAMA, 269: sion and review of the literature. Spine, 19: 1926–1932, 1994.
2664–2666, 1993. 65. Weinstein, S. L. and Ponseti, I. V.: Curve progression in IS.
39. Woolf, S. H.: Screening for AIS—review article. JAMA, 269: Journal of Bone and Joint Surgery, 65-A: 447–455, 1983.
2667–2672, 1993. 66. Weinstein, S. L., Dolan, L. A., Spratt, K. F. et al.: Health and
40. Ascani, E., Bartolozzi, P., Logroscino, C. A. et al.: Natural function of patients with untreated IS: a 50-year natural history
history of untreated IS after skeletal maturity. Spine, 11: 784–789, study. JAMA, 289: 559–567, 2003.
1986. 67. Brown, D.: The pain drawing in AIS. Proceedings of the Scoliosis
41. Bjure, J. and Nachemson, A.: Non-treated scoliosis. Clinical Research Society, 36th Annual Meeting, Cleveland, OH, 2001.
Orthopedic Related Research, 93: 44–52, 1973. 68. Balague, F., Dutoit, G. and Waldburger, M.: Low back pain
42. Bjerkreim, R. and Hassan, I.: Progression in untreated IS after in schoolchildren. An epidemiological study. Scandinavian Journal
the end of growth. Acta Orthopedica Scandinavica, 53: 897–900, of Rehabilitation Medicine, 20: 175–179, 1988.
1982. 69. Edgar, M. A.: Back pain assessment from a long term follow-up
43. Brooks, H. L., Azen, S. P., Gerberg, E. et al.: Scoliosis: a pros- of operated and unoperated patients with AIS. Spine, 4: 519–521,
pective epidemiological study. Journal of Bone and Joint Surgery, 1979.
57-A: 968–972, 1975. 70. Fairbank, J. C., Pynsent, P. B., Van Poortvliet, J. A. et al.:
44. Bunnell, W. P.: The natural history of IS before skeletal Influence of anthropometric factors and joint laxity in the
maturity. Spine, 11: 773–776, 1986. incidence of adolescent back pain. Spine, 9: 461–464. 1984.
179
M. C. Hawes
71. Kostuik, J. P. and Bentivoglio, J.: The incidence of low back 94. Pehrsson, K., Larsson, S., Oden, A. et al.: Long term follow-
pain in adult scoliosis. Spine, 6: 268–273, 1981. up of patients with untreated scoliosis. A study of mortality,
72. Jackson, R. P., Simmons, E. H. and Stripinis, D.: Incidence causes of death and symptoms. Spine, 17: 1091–1096, 1992.
and severity of back pain in adult idiopathic scoliosis. Spine, 8: 95. Schneerson, J. M., Sutton, G. C. and Zorab, P. A.: Causes of
749–756, 1983. death, right ventricular hypertrophy, and congenital heart dis-
73. Mayo, N. E., Goldberg, M. S., Poitras, B. et al.: The ease in scoliosis. Clinical Orthopedic Related Research, 135:
Ste-Justine AIS cohort study. Part III: Back pain. Spine, 14: 52–57, 1978.
1573–1581, 1994. 96. Boyer, J., Amin, N., Taddonio, R. et al.: Evidence of airway
74. Nastasi, A. J., Levine, D. B. and Veliskakis, K. P.: Pain obstruction in children with IS. Chest, 109: 1532–1535, 1996.
patterns in AIS. Journal of Bone and Joint Surgery, 54-A: 1575, 97. Chong, K. C., Letts, R. M. and Cumming, G. R.: Influence of
1972. spinal curvature on exercise capacity. Journal of Pediatric
75. Nilsonne, U. and Lundgren, K.: Long term prognosis in IS. Orthopedics, 1: 251–254, 1981.
Acta Orthopedica Scandinavica, 39: 456–465, 1968. 98. DiRocco, P., Breed, A. L., Carlin, J. I. et al.: Physical work
76. Ramirez, N., Johnston, C. E. and Browne, R. H.: The preva- capacity in adolescents with mild IS. Archives of Physical
lence of back pain in children who have IS. Journal of Bone and Medicine Rehabilitation, 64: 476–479, 1983.
Joint Surgery, 79-A: 364–368, 1997. 99. DiRocco, P. and Vaccaro, P.: Cardiopulmonary functioning in
77. Vitale, M. G., Levy, D. E., Johnson, M. G. et al.: Assessment of adolescent patients with mild IS. Archives of Physical Medicine
quality of life in adolescent patients with orthopedic problems: are Rehabilitation, 69: 198–199, 1988.
adult measures appropriate? Journal of Pediatric Orthopedics, 21: 100. Hawes, M. C. and Brooks, W. J.: Improved chest expansion
622–628, 2001. in IS after intensive, multiple modality, nonsurgical treatment in
78. Weinstein, S. L., Zavala, D. C. and Ponseti, I. V.: Idiopathic an adult. Chest, 120: 672–674, 2001.
scoliosis: long term follow-up and prognosis in untreated patients. 101. Kearon, C., Viviani, G. R. and Killian, K. J.: Factors influ-
Journal of Bone and Joint Surgery, 63-A: 702–712, 1981. encing work capacity in thoracic AIS. American Reviews in
79. Bengtsson, G., Fallstrom, K., Jansson, B. et al.: A psycholo- Respiratory Disease, 148: 295–303, 1993.
gical and psychiatric investigation of the adjustment of female 102. Kesten, S., Garfinkel, S. K., Wright, T. et al.: Impaired
scoliosis patients. Acta Psychiatrica Scandinavica, 50: 50–59, 1974. exercise capacity in adults with moderate scoliosis. Chest, 99:
80. Clayson, D. and Levine, D. B.: AIS: personality patterns and 663–666, 1991.
effects of corrective surgery. Clinical Orthopedic Related Research, 103. Olgiati, R., Levine, D., Smith, J. P. et al.: Diffusing capacity
116: 99–102, 1976. in IS and its interpretation regarding alveolar development.
81. Clayson, D., Luz-Alterman, S., Cataletto, M. M. et al.: American Reviews in Respiratory Disease, 126: 229–234, 1982.
Long-term psychological sequelae of surgically vs nonsurgically 104. Smyth, R. J., Chapman, K. R., Wright, T. A. et al.: Pulmonary
treated scoliosis. Spine, 12: 983–987, 1987. function in adolescents with mild IS. Thorax, 39: 901–904, 1984.
82. Edgar, M. A. and Mehta, M. H.: Long term follow-up of fused 105. Smyth, R. J., Chapman, K. R., Wright, T. A. et al.:
Ventilatory patterns during hypoxia, hypercapnia, and exercise
and unfused IS. Journal of Bone and Joint Surgery, 70-B: 712–716,
in adolescents with mild scoliosis. Pediatrics, 77: 692–696, 1986.
1988.
106. Szeinberg, A., Canny, G. J., Rashed, N. et al.: Forced VC
83. Fallstrom, K., Cochran, T. and Nachenson, A.: Long term
and maximal respiratory pressures in patients with mild and
effects on personality development in patients with AIS; influence
moderate scoliosis. Pediatric Pulmonaries, 4: 8–12, 1988.
of type of treatment. Spine, 11: 756–758, 1986.
107. Weber, B., Smith, J. P., Briscoe, W. A. et al.: Pulmonary
84. Heckman, L. A., Schatzinger, L. A., Nash, C. L. et al.:
function in asymptomatic adolescents with IS. American
Emotional adjustment in scoliosis. Clinical Orthopedic Related
Reviews in Respiratory Disease, 111: 389–397, 1975.
Research, 125: 145–150, 1977.
108. Branthwaite, M. A.: Cardiorespiratory conequences of
85. Kahanovitz, N. and Weiser, S.: The psychological impact of IS
unfused IS. British Journal of Diseases of the Chest, 80:
on the adolescent female; a preliminary multi center study. Spine, 360–369, 1986.
14: 483–487, 1989. 109. Davies, G. and Reid, L.: Effect of scoliosis on growth of alveoli
86. MacLean, W. E., Green, N. E., Pierre, C. B. et al.: Stress and and pulmonary arteries and on the right ventricle. Archives of
coping with scoliosis: psychological effects on adolescents and Disease in Childhood, 46: 623–632, 1971.
their families. Journal of Pediatric Orthopedics, 9: 257–260, 1989. 110. Drummond, D. S.: Spinal deformity: natural history and the role
87. Payne, W. K., Ogilvie, J. W., Resnick, M. D. et al.: Does of screening. In: D. S. Bradford and R. M. Densinger (editors)
scoliosis have a psychological impact and does gender make a The Pediatric Spine (Stuttgard, NY: Georg Thieme Verlag),
difference? Spine, 22: 1380–1384, 1997. pp. 167–180, 1985.
88. Bowen, R. M.: Respiratory management in scoliosis. In: 111. Leatherman, K. and Dickson, R.: The Management of Spinal
J. Lonstein, D. Bradford, R. Winter et al. (editors) Moe’s Deformities (London, Boston, Singapore, Sydney, Toronto,
Textbook of Scoliosis and Other Spinal Deformities, 3rd edn Wellington: Wright Press), 1988.
(Philadelphia: WB Saunders), pp. 572–581, 1995. 112. Deviren, V., Berven, S., Kleinstueck, F. et al.: Predictors
89. George, R. B., Light, R. W., Matthay, M. A. et al.: Chest of flexibility and pain patterns in thoracolumbar and lumbar
Medicine: Essentials of Pulmonary and Critical Care Medicine, IS. Spine, 27: 2346–2349, 2002.
3rd edn (Baltimore: Williams and Wilkins), 1995. 113. Adams, F.: Hippocrates. The Genuine Works of Hippocrates.
90. Seaton, A., Seaton, D. and Leitch, A. G.: Crofton and Translated by Francis Adams and L. L. D. Surgeon
Douglas’s Respiratory Diseases, 5th edn (Oxford: Blackwell (Baltimore, MD: The Williams and Wilkins Company), 1939.
Science), p. 90, 2000. 114. Moen, K. Y. and Nachemson, A. L.: Treatment of scoliosis: an
91. Fraser, R. S., Muller, N. L., Colman, N. et al.: Fraser and historical perspective. Spine, 24: 2570–2575, 1999.
Pare’s Diagnosis of Diseases of the Chest, 4th edn (Philadelphia: 115. Ogilvie, J. W.: Historical aspects of scoliosis. In: J. Lonstein, D.
W.B. Saunders Company), 1999. Bradford, R. Winter et al. (editors) Moe’s Textbook of Scoliosis
92. Hitosugi, M., Shigeta, A. and Takatsu, A.: An autopsy case of and Other Spinal Deformities, 3rd edn (Philadelphia: WB
sudden death in a patient with IS. Medicine Science and the Law, Saunders), pp. 1–5, 1995.
40: 175–178, 2000. 116. Focarile, F. A., Bonaldi, A., Giarolo, M. et al.: Effectiveness
93. Murray, J. F. and Nadel, J. A.: Textbook of Respiratory of nonsurgical treatment for IS; overview of available evidence.
Medicine, 3rd edn (Philadelphia: WB Saunders), 2000. Spine, 16: 395–401, 1991.
180
117. Bridwell, K. H.: Spine update—surgical treatment of AIS: 140. Ferreira, J. H. and James, J. I. P.: Progressive and resolving
the basics and the controversies. Spine, 19: 1095–1100, 1994. infantile IS. Journal of Bone and Joint Surgery, 54B: 648–655,
118. Bridwell, K. H.: Surgical treatment of idiopathic adolescent 1972.
scoliosis. Spine, 24: 2607–2616, 1999. 141. Mehta, M.: The rib-vertebra angle in the early diagnosis
119. Bunnell, W. P.: An objective criterion for school screening. between resolving and progressive infantile scoliosis. Journal of
Journal of Bone and Joint Surgery, 66: 1381–1387, 1984. Bone and Joint Surgery, 54B: 230–243, 1972.
120. Hensinger, R. N., Cowell, H. R. and MacEwen, G. D.: 142. James, J. I. P.: Idiopathic scoliosis. The prognosis, diagnosis,
Orthopedic screening of school age children. Review of a ten- and operative indications related to curve patterns and age of
year experience. Orthopedic Reviews, 4: 23–28, 1985. onset. Journal of Bone and Joint Surgery, 36B: 36–49, 1954.
121. Lonstein, J. E.: IS. In: J. Lonstein, D. Bradford, R. Winter et al. 143. Scott, J. C. and Morgan, T. H.: The natural history and
(editors) Moe’s Textbook of Scoliosis and Other Spinal prognosis of infantile IS. Journal of Bone and Joint Surgery,
Deformities, 3rd edn (Philadelphia: WB Saunders), pp. 219–256, 37B: 400–412, 1955.
1995. 144. Mehta, M. H.: Infantile idiopathic scoliosis. In: D. S. Bradford
122. Shands, A. R., Barr, J. S., Colonna, P. C. et al.: Research and R. Dickson (editors) Management of spinal deformities.
committee of the American Orthopedic Association: end-result (Boston, MA: Butterworths), pp. 101–120, 1984.
study of the treatment of idiopathic scoliosis. Journal of Bone and 145. Mehta, M. H.: Pain provoked scoliosis. Clinical Orthopedics and
Joint Surgery, 23: 963–977, 1941. Related Research, 135: 58–65, 1978.
123. Stone, B., Beekman, C., Hall, V. et al.: Physical effects of 146. Bradford, D. S. and Bueff, H. U.: Benign and malignant
an exercise program on change in curvature in adolescents tumors of the Spine. In: J. Lonstein, D. Bradford, R. Winter
with minimal idiopathic scoliosis: a preliminary study. et al. (editors) Moe’s Textbook of Scoliosis and Other Spinal
Therapy, 59: 760–763, 1979. Deformities, 3rd edn (Philadelphia: WB Saunders), pp. 483–501,
124. Dworkin, B., Miller, N. E., Sworkin, S. et al.: Behavioral 1995.
method for treatment of IS. Proceedings of the National Academy 147. Dickson, R. A. and Leatherman, K. D.: Cotrel traction,
of Sciences (USA), 82: 2493–2497, 1985. exercises, casting in the treatment of IS: a pilot study and pro-
125. McCullough, N. C., Schultz, M., Javech, N. et al.: Miami spective randomized controlled clinical trial. Acta Orthopedica
TLSO in the management of scoliosis: preliminary results in 100 Scandinavica, 49: 46–48, 1979.
cases. Journal of Pediatric Orthopedics, 1: 141–152, 1981. 148. Block, A. J., Waxler, J. and McDonnell, E. J.: Cardiopul-
126. Carman, D., Roach, J. W., Speck, G. et al.: Role of exercises monary failure of the hunchback: a possible therapeutic
in the Milwaukee brace treatment of scoliosis. Journal of approach. JAMA, 212: 1520–1522, 1970.
Pediatric Orthopedics, 5: 65–68, 1985. 149. Asher, M.: Harrington’s: the human spine. In: R. R. Joabobs
127. Athanasopoulos, S., Paxinos, T., Tsafantakis, E. et al.: The (editor) Pathogenesis of Idiopathic Scoliosis (Chicago, IL:
effect of aerobic training in girls with idiopathic scoliosis.

Scoliosis Research Society), pp. 1–10, 1984.
Scandinavian. Journal of Medical SciSports, 9: 36–40, 1999.
150. Mehta, M. H.: Preserving function in the treatment of IIS,
128. Carstens, T.: Exercise therapy in postural weakness. Zeitschrift
Orthopedic Transactions, 3: 59, 1979.
für Orthopädie und ihre Grenzgebiete, 135: 16–17, 1997.
151. Stokes, I. A. F.: ‘Stress-modulated growth’ and the progression
129. Ferraro, C., Masiero, S., Venturin, A. et al.: Effects of
of scoliosis. In: I. A. F. Stokes (editor) Research into Spinal
exercise therapy on mild idiopathic scoliosis. Preliminary results.
Deformities 2 (IOS Press), pp. 205–208, 1999.
Europa Medicophysica, 34: 25–31, 1998.
152. Weiss, H. R.: Scoliosis related pain in adults–treatment
130. Maruyama, T., Kitagawa, T., Takeshita, K. et al.: Side shift
influences. European Journal of Physical Medicine and
exercise for the treatment of IS after skeletal maturity. Research
Rehabilitation, 3: 91–94, 1993.
into Spinal Deformities, 5: 231, 2002.
153. Weiss, H. R., Verres, C., Lohschmidt, L. et al.: Pain and
131. Mehta, M. H.: Active auto-correction for early adolescent
idiopathic scoliosis. Journal of Bone and Joint Surgery, 68: 682, scoliosis—is there any relationship? Orthopadische Praxis, 34:
1986. 602–606, 1998.
132. Mooney, V., Gulick, J. and Pozos, R.: A preliminary report on 154. Weiss, H. R., Verres, Ch. and El-Obeidi, N.: Evaluation
the effect of measured strength training in adolescent idiopathic of the result quality in spinal deformities rehabilitation by
scoliosis. Journal of Bone and Joint Surgery, 68: 682, 2000. objective back shape analysis. Physikalische Medizin, 9: 41–47
133. Solberg, G.: Scoliosis: plastic changes in spinal function of 1999.
pre-pubescent scoliotic children engaged in an exercise therapy 155. Weiss, H. R.: Influence of an in-patient exercise program
programme. South African Journal of Physiotherapy, 52: 19–24, on scoliotic curve. Italian Journal of Orthopedic Trauma, 18:
1996. 394–406, 1992.
134. Harrington, P.: Is scoliosis reversible? In vivo observations of 156. Weiss, H. R.: The progression of idiopathic scoliosis under
reversible morphological changes in the production of scoliosis the influence of a physiotherapy rehabilitation programme.
in mice. Clinical Orthopedics and Related Research, 116: 103–111, Physiotherapy, 78: 815–821, 1992.
1979. 157. Weiss, H. R.: Particularities of rehabilitative physiotherapy in
135. McMaster, M. J.: Infantile IS. In: D. S. Bradford and R.M. adults with scoliosis. Rehabilitation, 31: 38–42, 1992.
Hensinger (editors) The Pediatric Spine (Stuttgart, NY: Georg 158. Weiss, H. R., Lohschmidt, K., El-Obeidi, N. et al.:
Thieme Verlag), pp. 218–232, 1985. Preliminary results and worst-case analysis of inpatient scoliosis
136. Ceballos, R., Ferrer-Torreles, M., Castillo, F. et al.: rehabilitation. Pediatric Rehabilitation, 1: 35–40, 1997.
Prognois in infantile IS. Journal of Bone and Joint Surgery, 159. Weiss, H. R. and Cherdron, J.: The psychical and physical
62A: 863–875, 1980. effect of physiotherapeutical rehabilitative inpatient treat-
137. McMaster, M. J.: Infantile IS: Can it be prevented? Journal of ment on patients with scoliosis. Orthopadische Praxis, 28:
Bone and Joint Surgery, 65B: 612–617, 1983. 87–90,1992.
138. Wynne-Davies, R.: Infantile IS: causative factors, particularly 160. Weiss, H. R. and Cherdron, J.: The impact of Schroth’s
in the first six months of life. Journal of Bone and Joint Surgery, rehabilitation programme on the self-concept of patients with
57B: 138–141, 1975. scoliosis. Rehabilitation, 33: 31–34, 1994.
139. Lloyd-Roberts, G. C. and Pilcher, M. F.: 1965 Structural IS 161. Weiss, H. R., Verres, C. and Neumann, S.: Scoliosis and
in infancy. A study of the natural history of 100 patients. Journal psyche: a study on juveniles and young adolescents.
of Bone and Joint Surgery, 47B: 520–523, 1965. Orthopädische Praxis, 34: 367–372, 1998.
181
M. C. Hawes
162. Weiss, H. R.: The effect of an exercise programme on VC and rib 168. Weiss, H. R., Verres, C. H., Lohschmidt, K. et al.: Pain
mobility in patients with IS. Spine, 16: 88–93, 1991. and scoliosis—is there any relationship? Orthopadische Praxis,
163. Weiss, H. R. and Bickert, W.: Improvement of the parameters 34: 602–606, 1998.
of right-heart stress evidenced by electrocardiographic examina- 169. Lonstein, J. E.: Scoliosis. In: R. T. Morrissy and A. L. Weinstein
tions by the in-patient rehabilitation program according to (editors) Winter’s Pediatric Orthopedics, 4th edn (Philadelphia:
Schroth in adult patients with scoliosis. Orthopädische Praxis, Lippincott-Raven Publishers), pp. 625–683, 1996.
32: 450–453, 1996. 170. Balady, G. F.: Survival of the fittest—more evidence. New
164. Bradford, D. S.: Adult scoliosis In: J. Lonstein, D. Bradford, England Journal of Medicine, 346: 852–854, 2002.
R. Winter et al. (editors) Moe’s Textbook of Scoliosis and Other 171. Karlson, B. W., Sjolin, M., Lindqvist, J. et al.: Ten-year
Spinal Deformities, 3rd edn (Philadelphia: WB Saunders), mortality rate in relation to observations of a bicycle exercise
pp. 369–386, 1995. test in patients with a suspected or confirmed ischemic event
165. Bradford, D. S., Tay, B. K. and Hu, S. S.: Adult scoliosis: but no or only minor myocardial damage. American Heart
surgical indications, operative management, complications, Journal, 141: 977–984, 2001.
and outcomes. Spine, 24: 2617–2629, 1999. 172. Myers, J., Prakash, M., Froelicher, V. et al.: Exercise
166. Metha, M. H.: Infantile idiopathic scoliosis. In: D. S. Bradford capacity and mortality among men referred for exercise testing.
and R. Dickson (editors) Management of Spinal Deformities New England Journal of Medicine, 346: 793–801, 2002.
(Boston, MA: Butterworths), p. 114, 1984. 173. Corwin, M. J., Lesko, S. M. and Heeren, T.: Secular changes
167. Weiss, H. R.: Scoliosis related pain in adults—treatment in sleep position during infancy, 1995–1998. Pediatrics, 111:
influences. European Journal of Physical Medicine and 52–60, 2003.

Rehabilitation, 3: 91–94, 1993. 174. Mau, H.: The changing concept of infantile scoliosis.
International Orthopedics, 5: 131–137, 1981.
182

Hawes 2003

Uploaded by

Copyright:

Available Formats

Hawes 2003

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Hawes 2003

Uploaded by

Copyright:

Available Formats

PEDIATRIC REHABILITATION, 2003, VOL. 6, NO.

The use of exercises in the treatment of

Accepted for publication: August 2003 Physical Therapy Association (http://www.apta.org/

Consumer/ptandyourbody/scoliosis) and the National

maintain ﬂexibility and range of motion of the spine and

[conservative] treatment modality than bracing’ [22 (p. 2603)].

for ‘scoliosis’ were conducted. Finally, personal letters

eﬀect of aerobic training in girls with idiopathic scoliosis.

inﬂuences. European Journal of Physical Medicine and 52–60, 2003.

You might also like