820144

research-article2019
POI0010.1177/0309364618820144Prosthetics and Orthotics InternationalYagci and Yakut

INTERNATIONAL
SOCIETY FOR PROSTHETICS
AND ORTHOTICS

Original Research Reports

Prosthetics and Orthotics International

Core stabilization exercises 1­–8

© The International Society for
Prosthetics and Orthotics 2019
versus scoliosis-specific exercises in Article reuse guidelines:
sagepub.com/journals-permissions
moderate idiopathic scoliosis treatment DOI: 10.1177/0309364618820144
https://doi.org/10.1177/0309364618820144
journals.sagepub.com/home/poi

Gozde Yagci, PT, PhD1  and Yavuz Yakut, PT, PhD2

Abstract
Background: There are several kinds of scoliosis-specific and general physiotherapeutic exercise methods used in scoliosis
rehabilitation. But there is need for comparable studies on the effectiveness of different exercise approaches for the
treatment of adolescent idiopathic scoliosis.
Objectives: Comparison of the effects of combined core stabilization exercise and bracing treatment with Scientific
Exercises Approach to Scoliosis and bracing treatment in patients with moderate adolescent idiopathic scoliosis.
Methods: Thirty females with adolescent idiopathic scoliosis, who have moderate curves (20°–45°), were randomly
divided into two groups. In addition to brace wearing for 4 months, one group received core stabilization exercise
therapy, while the other received scientific exercises approach to scoliosis exercise therapy. The outcome measures
were based on Cobb angle, angle of trunk rotation, body symmetry, cosmetic trunk deformity, and quality of life.
Results: Thoracic and lumbar Cobb angles and trunk rotation angles, body symmetry, and cosmetic trunk deformity
improved for both groups. Quality of life did not change in either group. The pain domain of the Scoliosis Research
Society-22 questionnaire improved in the core stabilization group only.
Conclusion: Both treatment conditions including core stabilization with bracing and scientific exercises approach to
scoliosis with bracing had similar effects in the short-term treatment of moderate adolescent idiopathic scoliosis.

Clinical relevance
This study showed that when scientific exercises approach to scoliosis (SEAS) and core stabilization (CS) exercises were
administered with equal intensity, the effects of the two treatment protocols including CS and bracing and SEAS and
bracing were similar in the treatment of patients with moderate adolescent idiopathic scoliosis (AIS).

Keywords
Scoliosis, exercise, bracing

Date received: 9 April 2018; accepted: 15 November 2018

Background movement and posture through the use of different motor

AIS is a three-dimensional deformity of the spine and rib
cage. The aims of AIS rehabilitation are primarily to keep
the curve magnitude below 30° if possible and to avoid
progression1 and, secondarily, to prevent potential com-
plications, such as postural asymmetry, cosmetic trunk
deformity, back pain, and psychosocial effects.2
For moderate curves (Cobb angle 20°–45°)3, the con-
servative treatment is combined spinal braces and exercise
approaches with the aim of preventing curve progression.4
The mechanism of the spinal brace reducing curve magni-
tude is to change the patient’s posture by keeping the trunk
in a fixed (corrected) position, whereas the aim with exer-
cises is to create behavioral and automatic changes of
control strategies.5
Scoliosis-specific exercise approaches are commonly
used in scoliosis treatment, which consist of different active
1Faculty of Health Sciences, School of Physical Therapy and
Rehabilitation Sciences, Orthotics and Biomechanics Department,
Hacettepe University, Ankara, Turkey
2Physiotherapy and Rehabilitation Department, Hasan Kalyoncu
University, Gaziantep, Turkey
Corresponding author:
Gozde Yagci, PT, MSc, PhD, Asst Prof., Hacettepe University, Faculty
of Health Sciences, School of Physical Therapy and Rehabilitation
Sciences, 06100, Ankara, Turkey.
Email: gozdeygc8@gmail.com
2 Prosthetics and Orthotics International 00(0)
self-correction strategies of the spine (based on curve loca-
tion, pattern, and magnitude) and individually adapted
exercises. The scientific exercise approach to scoliosis
(SEAS) is one of these commonly used scoliosis-specific
exercise approaches in scoliosis rehabilitation.6 SEAS pro-
vides functional stimulation of muscle contraction for
search of the best realignment of the spine and spinal stabil-
ity in order to counteract curve progression. This muscle
contraction is provided by autocorrection of the patient.5
SEAS exercises are based on three-dimensional active self-
correction and stabilization of the correction in different
functional movements.7 The effectiveness of SEAS therapy
in AIS in preventing curve progression has been demon-
strated.7,8 Negrini et al.8 reported short-term efficacy of
SEAS exercises (for 5-month intervention) in subjects with
moderate curves. Reduced risk of progression for mild
curves with SEAS intervention is shown in the study by
Romano et al.9
On the other hand, there are general physiotherapeutic
exercises, like CS exercises, Pilates, and yoga, which have
recently been used in the conservative treatment of idio-
pathic scoliosis.10,11 These exercises focus on spinal stabil-
ity and core strength training.12 Increasing spinal stability
is one of the primary therapeutic goals of the CS approach
in scoliosis.11 CS exercise therapy includes training the
deep trunk muscles by controlling the position of the trunk
in static postures and in functional activities.13 Improvement
in curve magnitude, pain, and postural control due to CS
exercises has been shown in adult subjects with mild
scoliosis.10 We previously found that CS exercises are
more effective in reducing the angle of lumbar trunk rota-
tion and pain than traditional exercises in moderate AIS.11
The most effective exercise method for the treatment of
AIS remains controversial. There is a need for compara-
tive studies on different methods of exercise for recom-
mendation in clinical practice. In addition, there have been
no studies reporting on the efficacy of scoliosis-specific
exercises in the improvement of cosmetic issues, quality of
life, back pain, and psychological issues.14 After docu-
menting the efficacy of CS exercise training in AIS,11 with
this study we aimed to establish whether SEAS and brac-
ing intervention are more effective than CS and bracing
intervention for treating moderate AIS. The aim of the
study was to compare the effects of the combined CS and
bracing approach with the SEAS method of scoliosis-
specific exercise and bracing on curve magnitude, trunk
symmetry, cosmetic deformity, and health-related quality
of life in brace wearer individuals with AIS.
Methods
Study Design
This randomized prospective intervention study was
approved by the university ethics committee (GO 16/82
on 22 March 2016). All patients gave written informed
consent before the study. Eligible subjects were randomly
assigned using stratified block to one of two study arms:
CS group or SEAS group. Patients were stratified accord-
ing to age, skeletal maturity, and curve pattern including
single (thoracic, lumbar, or thoracolumbar) and double
(both thoracic and lumbar) curves. The randomization
schedule was known by only one investigator, who was
not involved in recruiting participants.
There were 124 females with AIS assessed for eligibil-
ity, of which 70 were excluded from the study for not
meeting the inclusion criteria, and 24 patients refused to
participate in the study. Familial economic problems and
patients’ intensive schoolwork were cited as reasons for
not participating. Thirty patients agreed to participate in
the study. All patients completed the 4-month intervention
process and attended the final assessments. The enrollment
process is shown in Figure 1.
Participants
Included patients were adolescents with idiopathic scolio-
sis seen in our department who were prescribed brace and
exercise treatment by the physician between November
2015 and October 2016. Additional inclusion criteria:
female sex; at least 12 years old; primary curve magnitude
20°–45° Cobb angle;3 double curve (right thoracic–left
lumbar) or single thoracolumbar curve having an apex in
the thoracic region; Risser 2–3;15 and no previous treat-
ment. Exclusion criteria for both groups: evidence of con-
genital curve; neuromuscular, rheumatologic, renal,
cardiovascular, pulmonary, or vestibular diseases; or surgi-
cal correction history.
Outcome measures
The patient general characteristics collected at baseline
included age, sex, body weight, height, body mass index,
curve pattern (double curves or single thoracolumbar
curves), and Risser grade for skeletal maturity.
Assessments were undertaken at baseline and after
the 4-month treatment period for each patient by the sec-
ond investigator, who was blind to the allocation of the
participants, throughout the study. Final measurements
were taken after the brace has been removed for 6 h. The
CS exercise and SEAS exercise intervention groups
were compared using the following measures for treat-
ment outcome: curve magnitude with Cobb angle on
anteroposterior standing radiograph,3 angle of trunk
rotation with scoliometer in forward bending,16 trunk
asymmetry with the Posterior Trunk Symmetry Index
(POTSI),17 cosmetic deformity with the Walter Reed
Visual Assessment Scale (WRVAS),18 and quality of life
with the SRS-22 questionnaire.19 Furthermore, initial in-
brace corrections were calculated for the primary curve,
and the correction rate was reported in percentages in
order to assess the clinical success of the brace as part of
Yagci and Yakut 3
Figure I.  Flow diagram for participant enrollment, allocation, follow-up, and analysis.
the bracing protocol. Initial mean in-brace correction
was recognized as at least 30%, or more as necessary, as
previously reported.20
The Risser grade for determining skeletal maturation
was obtained from a frontal-plane radiograph and an index
of maturity rated on a scale of 0–5 (where grade 0 indicates
no ossification center at the level of iliac crest apophysis
and grade 5 indicates complete ossification and fusion of
the iliac crest apophysis).15
Cobb angle is considered the gold standard for deter-
mining the magnitude of spinal curve on the frontal-plane
radiograph.3 All patients’ curves were measured, and the
score was recorded in degrees. Moderate curves (20°–45°)
based on the Cobb angle of the primary curve4 were
included in this study. Thoracolumbar and right thoracic-
left lumbar curves were included in this study.
The most common clinical approach used in the meas-
urement of the angle of trunk rotation is the scoliometer of
Bunnell measurement in the standing forward-bending
position.16 This method has been reported to have high
intraobserver reliability.21
The POTSI includes the sensitive assessment of the
frontal-plane asymmetry of trunk deformity as a two-
dimensional surface topographic method in scoliosis. The
index based on assessing trunk asymmetry with regard to
C7 plumb line, shoulder, and hip asymmetry based on back
surface photograph of patient. The ideal POTSI score is
zero, which represents full symmetry of the back surface.
Higher scores indicate an increasing asymmetry of the
trunk.17
The WRVAS assesses the patient’s cosmetic trunk
deformity with a set of figures representing seven visible
aspects of spinal deformity: spinal deformity, rib promi-
nence, lumbar prominence, thoracic deformity, trunk
imbalance, shoulder asymmetry, and scapular asymmetry.
Each item is scored from 1 to 5, with higher scores
4 Prosthetics and Orthotics International 00(0)
reflecting worsening deformity. Results are presented as
the sum of the seven items.18 WRVAS was completed by
the physiotherapist.
SRS-22 is widely used to evaluate the efficacy of sev-
eral treatment regimens for idiopathic scoliosis from the
patient’s perspective of his or her condition. It consists of
22 items exploring five domains related to psychophysical
wellbeing: function/activity level, pain, mental health,
self-image, and treatment satisfaction. For each item, the
score ranges from 0 (worst) to 5 (best). The summary score
is obtained by summing the score of each domain.22 The
Turkish transcultural adaptation of SRS-22 was found to
have good consistency and concurrent validity for indi-
viduals diagnosed with idiopathic scoliosis.19
Evaluation of patient compliance with the spinal brace-
wearing and home exercise program was done with a daily
follow-up diary that was given to patients, to be completed
by them, with help from the parent when needed. Patients
were required to keep a record of how many hours they
wore their spinal brace daily (necessary for 23 h) and how
many times they performed home exercises daily (20 min
daily). Sums of compliance scores are expressed as
percentages.
Interventions
Patients attended an individual exercise program consist-
ing of one 40-min individual session in the clinic per week
for 4 months. Patients were instructed to continue perform-
ing the same exercise approach for 20 min daily at home.
They were taught the exercises individually in the sessions
and advised of the intensity at which they should exercise
at home. Patients were also given a booklet outlining the
movements for visual reference. In this 4-month period,
the CS exercise group received CS exercise training, while
the SEAS group received SEAS exercises. Both exercise
programs were given by the first author, a certified pro-
vider of SEAS and CS training methods.
Along with exercises, a spinal brace was applied.23
Patients were instructed to wear the brace for 23 h daily23
and to take it off while exercising and during personal
hygienic activities for 1 h per day. The treatment was clas-
sified as a success or a failure, with failure defined as >5°
Cobb angle progression within a 4-month period.24
In this study, we used a custom-made thoracolumbosa-
cral spinal brace that was adapted according to the curve
patterns of the individual patients. The brace was pre-
scribed by the physician as a part of standard care of
patients with moderate scoliosis and then fabricated by the
same orthotist. The brace was based on the symmetric,
patient-oriented, rigid, three-dimensional, active concept
of bracing.23
SEAS consist of individually adapted exercises based
on active self-correction. Active self-correction is defined
as active movement performed to achieve the maximum
possible correction. The approach aims for the stabiliza-
tion of active self-correction in functional movements;
strengthening of the tonic antigravity muscles; and
improvement in balance, postural control, and coordina-
tion.8 Supervised SEAS exercise training lasted 40 min in
this study. Patients performed seven exercises at home for
20 min, with 3 min spent on each exercise. Exercises grad-
ually progressed based on the participant’s ability each
month.
The purpose of the CS method in scoliosis is to develop
the ability of the core muscles to restore the dynamic con-
trol of external and internal forces over the spine and
increase spinal stability. This approach integrates respira-
tory control, neutral spinal position, rib cage placement,
scapular position, and neck-head position.11 The CS exer-
cise supervised session lasted for 40 min. CS training grad-
ually progressed from the stability of local core muscles
(transversus muscles, multifidus, and diaphragm) in static
positions to global muscle stability training (internal and
external oblique abdominal muscles, psoas major, m.
quadratus lumborum, and pelvic floor muscles), global
muscle mobility, and strength training (m. rectus
abdominis, back extensor muscles, and hamstring mus-
cles) in dynamic body positions. Home exercises were
designed to be done for 20 min daily.
Statistical analysis
Sample size was determined based on a pilot study with
nine patients using a power of 0.80 and α = 0.05. It was
calculated at a minimum of 12 participants per group con-
sidering primary outcome of Cobb angle. After confirming
the normal distribution of data (using the Kolmogorov–
Smirnov test) and homogeneity of variances (using
Levene’s test), the effects of the interventions were com-
pared using an independent-sample t-test for continuous
variables and Pearson’s chi-square test for categorical
variables of outcome measures. The paired t-test was used
to test changes from baseline within each treatment group.
Data were expressed as means (X) and standard deviations
(SDs; 95% confidence intervals (CIs)). p values < 0.05
were considered statistically significant. Analyses were
done with SPSS for Windows, version 11.0 (SPSS Inc.,
Chicago, IL).
Results
The patient groups were similar at baseline in terms of
demographic and scoliotic characteristics (Table 1) and
outcome measures (Table 2). Right thoracic-left lumbar
curves and single thoracolumbar curves were present in
both groups.
Intergroup comparison revealed no significant differ-
ence between the groups in thoracic Cobb angle (p = 0.34);
lumbar Cobb angle (p = 0.49); thoracic angle of trunk
Yagci and Yakut 5
Table I.  Comparison of patient characteristics.
Age (years)
Height (cm)
Mass (kg)
BMI (kg/m2)
Risser grade
  2 (n)
  3 (n)
Curve pattern
  Right thoracic left lumbar (n)
  Single thoracolumbar (n)
BMI: body mass index; CS: core stabilization exercise; SEAS: scientific exercise approach to scoliosis.
Values are frequency or mean (standard deviation).
rotation (p = 0.23); lumbar angle of trunk rotation (p = 0.96);
WRVAS score (p = 0.39); POTSI score (p = 0.46); total
quality of life score (p = 0.83); pain domain (p = 0.09), self-
image domain (p = 0.24); function domain (p = −0.18);
mental health domain (p = 0.14); and satisfaction with
treatment domain (p = 0.20; Table 2). The pre- and post-
treatment data and the change in outcome measures are
shown in Table 2.
Initial mean in-brace correction for the primary curve
was −43.9% (13.1) for the CS group and −44.0% (7.4)
for the SEAS group. There was no significant difference
between groups in terms of providing initial in-brace
correction (mean difference, 0.1; 95% CI, −9.3 to 9.1,
p = 0.98).
The two groups were similar on brace and home exer-
cise-compliance variables, with no statistically significant
differences (p > 0.05). Compliance with the brace was
88% (11.9) and 79.6% (19.5) in the CS and the SEAS
groups, respectively (p = 0.17). Compliance with the home
exercise program was 61.6% (17.2) and 63.7% (22.9) in
the CS and the SEAS groups, respectively (p = 0.78).
Compliance was high with the brace and moderate with
the exercise, and patients displayed great care and atten-
tion in keeping the diary. They took notes every day on
brace use and exercise.
Discussion
The results of this study revealed that combined CS with
bracing and SEAS with bracing interventions have similar
effects on Cobb angle, angle of trunk rotation, body sym-
metry, and cosmetic trunk deformity during 4-month treat-
ment period in patients with AIS. These findings confirm
the benefits of combined bracing and exercise therapy,
whether or not the exercise approach is general spinal sta-
bilization training or scoliosis-specific exercise, in the
short-term treatment of moderate AIS.
CS group SEAS group p value
Mean (SD) Mean (SD)
14.0 (1.3) 14.2 (1.5) 0.71
159.6 (7.4) 159.6 (7.6) 0.97
46.0 (6.5) 49.3 (8.2) 0.26
18.0 (1.7) 19.1 (1.8) 0.10
7 7 1.00
8 8  
8 8 1.00
7 7  
The Cobb angle and angle of trunk rotation were con-
sidered to be important prognostic factors for AIS.2
Previous studies have focused on the clinical indication of
the curve progression, where progression has been defined
as a change in Cobb angles at least 5° and in the angle of
trunk rotation as 2° for primary curves.8 Overall, CS and
SEAS exercise training, in addition to bracing, had a statis-
tically significant impact on curve progression in this
study. In all participants, both thoracic and lumbar Cobb
angles of the scoliotic curve decreased. The mean decrease
of the Cobb angle of the primary curve was −5.6 (2.7) for
the CS group and −5.2 (2.8) for the SEAS group. In addi-
tion, there were no patients who had curve progression
clinically based on the Cobb angle and angle of trunk rota-
tion scores. Thoracic and lumbar angles of trunk rotation
reduced with both treatments as well. These data suggest
that both treatment protocols used in the study are effec-
tive in preventing curve progression in patients with AIS
with moderate curves; however, they have similar effects
on Cobb angle. Romano et al.25 also found SEAS exercises
to be effective therapy compared with classical physiother-
apy in patients with AIS who were prescribed exercise
only. Negrini et al. reported effective curve stabilization
with SEAS therapy in mild curves (defined as a Cobb
angle of 15.3° and an angle of trunk rotation of 8.9°). Of
all patients, 28.9% showed curve improvement clinically,
68.4% were stable, and 2.7% progressed after 1 year of
SEAS treatment in their study.8 In the literature, SEAS was
found to be more effective than the usual physiotherapy in
AIS.8,25 Task-oriented corrective spinal exercises26 were
other exercises, which also was found more effective than
general physiotherapeutic exercises in patients with mild
AIS. For moderate curves, SEAS was determined to be
helpful in reducing correction loss during brace weaning
period.27 Gur et al.11 showed that combined CS and brac-
ing protocol was effective than general physiotherapeutic
exercises and bracing protocol in patients with moderate
AIS.
6 Prosthetics and Orthotics International 00(0)

Table II.  Mean (SD) scores, mean (SD) differences within groups, and mean differences between groups (95% CI) for all outcomes.

Outcome Pretreatment Posttreatment Difference within group Difference between groups

Mean (SD) Mean (SD) Mean (SD) Mean 95% CI

Thoracic Cobb’s angle (°)
  CS group 30.0 (9.3) 24.7 (9.7)** −5.3 (2.2)  
  SEAS group 27.6 (8.0) 21.4 (7.1)** −4.8 (2.6) −3.3 −10.2 to 3.7
Lumbar Cobb’s angle (°)
  CS group 24.9 (9.0) 19.4 (9.3)* −4.1 (2.5)  
  SEAS group 25.9 (8.0) 22.4 (7.0)** −3.5 (3.0) 3.0 −6.2 to 12.1
Thoracic ATR (°)
  CS group 10.7 (5.4) 8.7 (5.6)* −2.0 (2.1)  
  SEAS group 9.6 (4.6) 6.4 (3.7)** −3.2 (2.0) −2.3 −6.2 to 1.6
Lumbar ATR (°)
  CS group 7.9 (3.0) 3.6 (3.1)* −4.3 (2.2)  
  SEAS group 8.0 (2.5) 3.5 (1.9)* −4.5 (1.9) −0.1 −3.2 to 3.1
WRVAS
  CS group 2.9 (0.5) 2.1 (0.5)** −0.8 (0.5)  
  SEAS group 3.1 (0.6) 2.2 (0.5)** −0.8 (0.4) 0.1 −0.2 to 0.5
POTSI
  CS group 32.9 (11.8) 23.2 (7.7)** −9.7 (8.1)  
  SEAS group 33.7 (13.5) 20.7 (10.1)** −13.0 (9.3) −2.5 −9.5 to 4.4
Components of SRS-22
 Pain
  CS group 4.5 (0.4) 4.7 (0.4)* 0.2 (0.3)  
  SEAS group 4.3 (0.7) 4.3 (0.6) 0.0 (0.6) −0.4 −0.8 to 0.1
 Self-image
  CS group 3.7 (0.6) 3.7 (0.5) 0.0 (0.5)  
  SEAS group 3.6 (0.8) 3.4 (0.5) −0.2 (0.8) −0.3 −0.7 to 0.2
 Function
  CS group 4.6 (0.4) 4.6 (0.4) 0.1 (0.4)  
  SEAS group 4.6 (0.3) 4.5 (0.4) −0.2 (0.4) −0.2 −0.5 to 0.1
  Mental health
  CS group 3.6 (0.9) 3.6 (0.8) 0.1 (0.5)  
  SEAS group 4.1 (0.7) 4.1 (0.8) 0.1 (0.6) 0.5 −0.2 to 1.6
  Treatment satisfaction
  CS group – 4.4 (0.6) –  
  SEAS group – 4.7 (0.6) – 0.3 −0.2 to 0.7
 Total
  CS group 4.0 (0.5) 4.1 (0.4) 0.1 (0.3)  
  SEAS group 4.1 (0.4) 4.1 (0.4) 0.0 (0.4) −0.0 −0.4 to 0.3

CI: confidence interval; CS: core stabilization exercise; SEAS: scientific exercise approach to scoliosis; ATR: apical trunk rotation; WRVAS: Walter
Reed Visual Assessment Scale; POTSI: Posterior Trunk Symmetry Index; SRS-22: Scoliosis Research Society 22 Questionnaire.
*p < 0.05.
**p < 0.001 within group differences.

The assessment of clinical components of scoliotic
deformity, such as torso asymmetry and cosmetic deform-
ity, is essential for describing and treating three-dimen-
sional scoliotic deformity. POTSI provides quantitative
data for detecting posture changes and reliably find differ-
ences that are clinically significant.17 Body symmetry
improved in both the CS and SEAS therapy groups, with
no difference in group mean values in this study.
Improvement in cosmetic appearance is the primary
objective of scoliosis treatment, which is clearly reported in
a consensus by SOSORT.28 WRVAS was found to have sen-
sitivity to the changes occurring regarding the worsening or
improving of the deformity of the scoliosis.29 Cosmetic
deformity improved considerably in all cases in both groups
in this study. The significant improvement in cosmetic
deformity in both groups after 4 months of exercise and
bracing therapy can be attributed to the reduced curve mag-
nitude and improved body symmetry. Both exercise meth-
ods used in this study mainly work on improving spinal
stability, poor posture, and postural habits.
Yagci and Yakut 7
The negative effects of scoliosis on quality of life and
related constructs such as psychosocial health have been
reported in the literature.30 As stated in the 2005 consen-
sus, only 5% of studies on scoliosis included a measure
of esthetic appearance and 1.4% a measure of health-
related quality of life.28 Quality of life is considered good
if patients had at least four points on SRS-22.31 But both
exercise methods adjunctive to bracing had no impact on
the quality of life of the patients with AIS. However in
the CS group, there was a trend toward reduction of pain
with an average of 0.2 points. 0.2 points was reported as
the minimal clinically important difference in pain out-
come measure of SRS-22 previously.32 This may be
explained by the fact that the patients increased their
back extensor and deep abdominal muscles’ endurance
and core stability with CS exercise training. Movements
in CS training are performed using all types of muscle
contraction (i.e. concentric, eccentric, and isometric),
establishing a progressive increase in muscular flexibil-
ity, recruitment, and strength.13 This trend toward reduced
pain with CS exercise training suggests further studies to
explore the long-term effects of exercise treatments on
pain in AIS. Alves de Araujo et al.10 found reduction in
back pain and a trend toward improvement in quality of
life with stabilization training in patients with scoliosis,
whereas Plaszewski et al. 33 reported that scoliosis-
specific exercise treatment in adolescents did not alter
adult quality of life in idiopathic scoliosis. The lack of
reported details about change in body symmetry, trunk
appearance, and quality of life with conservative treat-
ment in scoliosis makes a quantitative comparison impos-
sible with our study.
Psychological distress among patients is of major con-
cern to therapists, given its negative effect on patient com-
pliance.30 In this study, there was good compliance with
bracing and moderate compliance with home exercises in
both groups. There was no statistically significant differ-
ence between groups in terms of brace and exercise com-
pliance. In addition, patients in both the groups reported
satisfaction with treatments in the subdomains of SRS-22.
A limitation of the study is that compliance was not for-
mally measured and, therefore, it was not possible to eval-
uate fully the effect of compliance with daily home
exercises on outcome. The use of additional bracing may
have influenced outcome, but this was standardized in
both the groups in terms of curve pattern, initial in-brace
correction, skeletal maturity, and age. Traditionally, a
“bracing only” group would be included in order to make
a real comparison of two different exercise interventions,
but this would have been difficult to implement for ethical
reasons, given that it is necessary to combine bracing and
exercise intervention for the improvement of moderate
curves.34 But also a group, which consists of participants
who were less compliant with the exercise protocol, would
have been used to enlighten the exercise effect. This study
shows short-term effect of the two treatment protocols.
Future studies are needed to compare long-term effects of
CS and SEAS interventions in the conservative treatment
of AIS.
In conclusion, the results suggest that both treatment
conditions including CS exercise with bracing, or SEAS
exercise with bracing reduced curve progression, angle of
trunk rotation, improved body symmetry, and cosmetic
trunk deformity in the 4-month period. When SEAS and
CS exercises were administered with equal intensity in
addition to bracing, the results showed no difference
regarding the effects of the two different treatment proto-
cols in the 4-month treatment period for moderate AIS.
Authors’ Note
This study was approved by ClinicalTrials.gov (a service of the
US National Institutes of Health) with the identifier: NCT02978820
At the time this article was written, G.Y. was a researcher at
the Physiotherapy and rehabilitation Department, Hacettepe
University, Ankara Turkey.
Author contribution
All authors contributed equally in the preparation of this
manuscript.
Declaration of conflicting interest
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Gozde Yagci https://orcid.org/0000-0002-4603-7162
References
1. Negrini S, Aulisa AG, Aulisa L, et al. 2011 SOSORT
guidelines: Orthopaedic and Rehabilitation treatment of idi-
opathic scoliosis during growth. Scoliosis 2012; 7(1): 3. doi:
10.1186/1748-7161-7-3
2. Horne JP, Flannery R and Usman S. Adolescent idiopathic
scoliosis: diagnosis and management. Am Fam Physician
2014; 89(3): 193–198.
3. Cobb JR. Outline for the study of scoliosis. In Edited by
Edwards JW. AAOS, Instructional Course Lectures Volume
5. Ann Arbor, 1948, pp. 261-275.
4. Weinstein SL, Dolan LA, Wright JG, et al. Effects of brac-
ing in adolescents with idiopathic scoliosis. N Engl J Med
2013; 369(16): 1512–1521. doi: 10.1056/NEJMoa1307337
5. Smania N, Picelli A, Romano M, et al. Neurophysiological
basis of rehabilitation of adolescent idiopathic scoliosis.
Disabil Rehabil 2008; 30(10): 763–771. doi: 10.1080/174
83100801921311
8 Prosthetics and Orthotics International 00(0)
6. Fusco C, Zaina F, Atanasio S, et al. Physical exercises in
the treatment of adolescent idiopathic scoliosis: an updated
systematic review. Physiother Theory Pract 2011; 27(1):
80–114. doi: 10.3109/09593985.2010.533342
7. Romano M, Negrini A, Parzini S, et al. SEAS (Scientific
Exercises Approach to Scoliosis): a modern and effective
evidence based approach to physiotherapic specific scolio-
sis exercises. Scoliosis 2015; 10: 3. doi: 10.1186/s13013-
014-0027-2
8. Negrini S, Negrini A, Romano M, et al. A controlled pro-
spective study on the efficacy of SEAS. 02 exercises in
preparation to bracing for idiopathic scoliosis. Stud Health
Technol Inform 2006; 123: 519.
9. Romano M, Negrini A, Parzini S, et al. Adolescent with 10
to 20 Cobb scoliosis during growth: efficacy of conservative
treatments. A Prospective Controlled Cohort Observational
Study. Scoliosis 2012; 7(1): O50
10. Alves de Araujo ME, Bezerrada Silva E, Bragade Mello D,
et al. The effectiveness of the Pilates method: reducing the
degree of non-structural scoliosis, and improving flexibil-
ity and pain in female college students. J Bodyw Mov Ther
2012; 16(2): 191–198. doi: 10.1016/j.jbmt.2011.04.002
11. Gür G, Ayhan C and Yakut Y. The effectiveness of core sta-
bilization exercise in adolescent idiopathic scoliosis: A ran-
domized controlled trial. Prosthet Orthot Int 2017; 41(3):
303–310. doi: 10.1177/0309364616664151
12. Akuthota V, Ferreiro A, Moore T, et al. Core stability exer-
cise principles. Curr Sports Med Rep 2008; 7(1): 39–44.
doi: 10.1097/01.CSMR.0000308663.13278.69
13. Vasseljen O, Unsgaard-Tøndel M, Westad C, et al. Effect of
core stability exercises on feed-forward activation of deep
abdominal muscles in chronic low back pain: a randomized
controlled trial. Spine (Phila Pa 1976) 2012; 37(13): 1101–
1108. doi: 10.1097/BRS.0b013e318241377c
14. Romano M, Minozzi S, Zaina F, et al. Exercises for ado-
lescent idiopathic scoliosis: a Cochrane systematic review.
Spine (Phila Pa 1976) 2013; 38(14): E883–193. doi:
10.1097/BRS.0b013e31829459f8
15. Risser J. The Iliac apophysis; an invaluable sign in the man-
agement of scoliosis. Clin Orthop 1957; 11: 111–119.
16. Bunnell WP. An objective criterion for scoliosis screening.
J Bone Joint Surg Am 1984; 66(9): 1381–1387.
17. Inami K, Suzuki N, Ono T, et al. Analysis of posterior trunk
symmetry index (POTSI) in scoliosis. Part 2. In Stokes IAF
(eds.) Technology and Informatics, Research into Spinal
Deformities 2. Burke, VA: IOS Press, 1999, pp. 85-89.
18. Sanders JO, Polly DW Jr, Cats-Baril W, et al. Analysis of
patient and parent assessment of deformity in idiopathic sco-
liosis using the Walter Reed Visual Assessment Scale. Spine
(Phila Pa 1976) 2003; 28(18): 2158–2163. doi: 10.1097/01.
BRS.0000084629.97042.0B
19. Alanay A, Cil A, Berk H, et al. Reliability and validity of
adapted Turkish Version of Scoliosis Research Society-22
(SRS-22) questionnaire. Spine (Phila Pa 1976) 2005; 30(21):
2464–2468.
20. Katz DE, Richards BS, Browne RH, et al. A comparison
between the Boston brace and the Charleston bending brace
in adolescent idiopathic scoliosis. Spine (Phila Pa 1976)
1997; 22(12): 1302–1312.
21. Coelho DM, Bonagamba GH and Oliveira AS. Scoliometer
measurements of patients with idiopathic scoliosis. Braz
J Phys Ther 2013; 17(2): 179–184. doi: 10.1590/S1413-
35552012005000081
22. Asher M, Min Lai S, Burton D, et al. The reliability and con-
current validity of the scoliosis research society-22 patient
questionnaire for idiopathic scoliosis. Spine 2003; 28(1):
63–69. doi: 10.1097/01.BRS.0000047634.95839.67
23. Gur G, Dilek B, Ayhan C, et al. Effect of a spinal brace on
postural control in different sensory conditions in adolescent
idiopathic scoliosis: A preliminary analysis. Gait Posture
2015; 41(1): 93–99. doi: 10.1016/j.gaitpost.2014.09.001
24. Altaf F, Gibson A, Dannawi Z, et al. Adolescent idiopathic
scoliosis. Bmj 2013; 346(f2508): 1–7
25. Romano M, Negrini S, Zaina F, et al. Does quality of
exercises affect results in adolescent idiopathic scoliosis
treatment to avoid braces? SEAS. 02 results at two years.
Scoliosis 2007; 2(1): S8
26. Negrini S, Bettany-Saltikov J, DeMauroy JC, et al. Active
self-correction and task-oriented exercises reduce spinal
deformity and improve quality of life in subjects with mild
adolescent idiopathic scoliosis. Results of a randomised
controlled trial. Eur Spine J 2014; 23(10): 2218–2220. doi:
10.1007/s00586-014-3464-y
27. Zaina F, Negrini S, Atanasio S, et al. 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(null): 8. doi: 10.1186/1748-7161-4-8
28. Negrini S, Grivas TB, Kotwicki T, et al. Why do we treat
adolescent idiopathic scoliosis? What we want to obtain and
to avoid for our patients. SOSORT 2005 Consensus paper.
Scoliosis 2006; 1: 4. doi: 10.1186/1748-7161-1-4
29. Pineda S, Bago J, Gilperez C, et al. Validity of the Walter
Reed Visual Assessment Scale to measure subjective per-
ception of spine deformity in patients with idiopathic sco-
liosis. Scoliosis 2006; 1: 18. doi: 10.1186/1748-7161-1-18
30. Lonner B, Yoo A, Terran JS, et al. Effect of spinal deform-
ity on adolescent quality of life: comparison of operative
scheuermann kyphosis, adolescent idiopathic scoliosis,
and normal controls. Spine 2013; 38(12): 1049–1055. doi:
10.1097/BRS.0b013e3182893c01
31. Tavernaro M, Pellegrini A, Tessadri F, et al. Team care to
cure adolescents with braces (avoiding low quality of life,
pain and bad compliance): a case–control retrospective
study. 2011 SOSORT Award winner. Scoliosis 2012; 7(1):
17. doi: 10.1186/1748-7161-7-17
32. Carreon LY, Sanders JO, Diab M, et al. The minimum clini-
cally important difference in Scoliosis Research Society-22
Appearance, Activity, And Pain domains after surgical
correction of adolescent idiopathic scoliosis. Spine 2010;
35(23): 2079–2083. doi: 10.1097/BRS.0b013e3181c61fd7
33. Płaszewski M, Cieśliński I, Kowalski P, et al. Does scoli-
osis-specific exercise treatment in adolescence alter adult
quality of life? Sci. World J 2014; 2014: 539671.
34. Negrini S, Donzelli S, Aulisa AG, et al. 2016 SOSORT
guidelines: orthopaedic and rehabilitation treatment of idi-
opathic scoliosis during growth. Scoliosis Spinal Disord
2018; 13(null): 3. doi: 10.1186/s13013-017-0145-8