children
Review
Schroth Physiotherapeutic Scoliosis-Specific Exercise (PSSE)
Trials—Systematic Review of Methods and Recommendations
for Future Research
Sanja Schreiber 1,2, * , Daniel Whibley 3 and Emily C Somers 4, *
Citation: Schreiber, S.; Whibley, D.;
Somers, E.C. Schroth
Physiotherapeutic Scoliosis-Specific
Exercise (PSSE) Trials—Systematic
Review of Methods and
Recommendations for Future
Research. Children 2023, 10, 954.
https://doi.org/10.3390/
children10060954
Academic Editors: Niels
Wedderkopp and Vito Pavone
Received: 30 January 2023
Revised: 18 May 2023
Accepted: 22 May 2023
Published: 27 May 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Children 2023, 10, 954. https://doi.org/10.3390/children10060954
1 Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta,
Edmonton, AB T6G 2G4, Canada
2 Curvy Spine—Specialized Scoliosis, Kyphosis and Other Spinal Disorders Centre,
Edmonton, AB T6E 1W7, Canada
3 Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI 48109, USA
4 Departments of Internal Medicine, Environmental Health Sciences and Obstetrics & Gynecology,
University of Michigan, Ann Arbor, MI 48109, USA
* Correspondence: sanja.schreiber@ualberta.ca (S.S.); emsomers@umich.edu (E.C.S.)
Abstract: The Schroth method is a non-operative treatment for scoliosis and kyphosis, used stan-
dalone or as an adjunct to bracing. While supporting evidence for its effectiveness is emerging,
methodologic standardization and rigor are equivocal. Thus, we aimed to systematically review
methods of published Schroth physiotherapeutic scoliosis-specific exercise (PSSE) trials and provide
guidance for future research. We searched six databases for randomized controlled trials (RCT) and
non-randomized studies of interventions (NRSIs) investigating the effect of Schroth in children and
adults with scoliosis or kyphosis. General characteristics, methodological approaches, treatment
protocols, and outcomes reporting were analyzed. Risk of bias (RoB) was assessed using an adapted
Cochrane RoB2 tool for RCTs and ROBINS-I for NRSI. Eligible studies (n = 7) were conducted in
six countries and included patients with Scheuermann’s kyphosis (n = 1) and adolescent idiopathic
scoliosis (n = 6). Though all seven studies used the term Schroth to describe their interventions, the
Schroth method was used in four of seven studies, of which only one used Schroth classification,
three used Schroth therapists, and none prospectively registered the study protocol. Overall, method-
ological rigor was suboptimal, potentially invalidating evidence synthesis. Authors should follow
minimum standards for reporting, including prospectively registering detailed protocols; using
appropriate exercise labeling, Schroth classification and certified therapists; naming and describing
exercises per classification; and providing therapy dosages, prescription methods, and adherence.
Keywords: Schroth method; physiotherapeutic scoliosis-specific exercises (PSSE); exercise therapy;
research design; data reporting; exercise trials
1. Introduction
Scoliosis is an abnormal curvature of the spine that displaces the spine in all three
planes of the body away from its natural position, creating morphological changes in
the trunk and intervertebral discs, leading to structural changes in the vertebrae that
can develop at any stage of life. Adolescent idiopathic scoliosis (AIS) has an unknown
etiology [1–4], and is the most common type of scoliosis, accounting for 90% of scoliosis
cases [5]. AIS is progressive, with onset typically during puberty in a healthy child [1]
affecting 0.47–5.2% of the population [5]. Females are more affected, and as curve severity
increases, the female to male ratio increases up to 10:1 [1,6,7]. Progression is associated
with pain, limitation in function, external deformities, and reduced self-image, pulmonary
function, and health-related quality of life (HRQL) [1,8–12]. Skeletally immature patients
have the highest risk of progression during the pubertal growth spurt [13], and early
treatment is paramount.
https://www.mdpi.com/journal/children
Children 2023, 10, 954 2 of 14

Adult spinal deformity (ASD) or adult scoliosis is a complex spinal disorder that can
broadly be categorized into a continuation of childhood scoliosis and degenerative (de novo)
scoliosis with an onset in adulthood [14]. Degenerative changes may also affect pre-existing
childhood scoliosis, which could lead to a progression and decreased HRQL [14–16]. The
prevalence of adult scoliosis in those above 18 years of age is estimated at 11.3%, and at 68%
in those over the age of 70 [17]. If symptomatic, ASD profoundly affects HRQL, including
debilitating pain, disability, and neurological problems [17–20]. Several classifications of
ASD have been developed based on etiology as well as correlation between radiological
and HRQL outcomes [14–16,21]. Biomechanically, ASD presents differently than adolescent
idiopathic scoliosis, and it has a higher rate of progression [17]. Appropriate clinical and
radiological assessment, as well as the risk of progression estimation of individuals with
ASD is paramount to ensure the optimal therapeutic intervention which should involve
multidisciplinary teamwork.
Contrary to scoliosis, hyperkyphosis is a deviation of the normal physiological spinal
alignment in the sagittal plane. Scheuermann’s kyphosis, also known as Scheuermann’s
disease, is a special type of hyperkyphosis in which the thoracic or thoracolumbar spine
becomes very rigid and fixed in excessive kyphosis due to the vertebral bodies being
wedged. Diagnosis is made based on lateral radiographs and is established if the thoracic
or thoracolumbar kyphosis measure >40◦ or <30◦ , respectively, and if at least three adjacent
vertebrae demonstrate wedging of ≥5◦ [22,23]. Similar to scoliosis, the etiology is not well
understood, and conversely, it is slightly more male predominant, with a roughly 2:1 male
to female ratio and affecting approximately 5% of population [22,23]. The onset of the
disease is typically between 12 and 17 years of age. Natural history of Scheuermann’s
disease demonstrates that the condition may lead to back pain, disability, cardiopulmonary
issues, psychological distress due to physical appearance, and decreased function [22–24].
The curves progress with longitudinal growth, and early treatment is essential.
The management of AIS and Scheuermann’s kyphosis is limited by our lack of under-
standing of their etiology and pathogenesis. To determine the etiology of scoliosis, some
authors have suggested that a generalized growth or functional defect within the skeletal
muscle could be one of the causes [2]. Evidence suggests that the distribution of the Type I
muscle fibers, responsible for postural control, of the erector spinae on the convex side is
significantly higher than that on the concave [25,26]. In addition, an extensive literature re-
view on the etiology of AIS reported that children with AIS show abnormalities in postural
balance, somatosensory function equilibrium, and proprioceptive function [27]. Moreover,
because children with AIS grow faster than typically developing children, it is postulated
that postural mechanisms of the somatic nervous system are incapable of controlling the
initiating deformity [27,28]. Due to these anatomical and physiological imbalances, the
length–force relationships can be altered in postural muscles due to muscle adaptation [29].
The asymmetrical loadings on the spine can cause further progression during skeletal
growth in a perpetual “vicious cycle” unless some counter force halts it [30–34]. Stokes
et al. conducted a biomechanical study on the progression of scoliosis and found that
curve progression depends on an individual’s neuromuscular control of the trunk muscles,
i.e., muscle activation strategy [33,35]. The authors concluded that to reverse the “vicious
cycle”, auto-correction must be at the maximum level [35]. Auto-correction is defined as
the ability to reduce the spinal deformity through the patient’s active postural realignment
of the spine in three dimensions [36].
Thus, it can be concluded that the effective exercise treatment for scoliosis and hyper-
kyphosis in children must (a) be introduced in the early stages of scoliosis development and
applied throughout the growing phase of adolescence [37–39]; (b) address auto-correction
in all three dimensions [40–44]; and (c) be applied in the direction opposite to the curve
pattern under loading for long periods of time [30,31,45]. In adults, treatment of spinal
deformity targets symptom management, including pain, HRQL, and disability. Operative
and non-operative scoliosis-specific treatment for adult spine deformity target decompres-
sion and stabilization of the spine [46,47].
Children 2023, 10, 954 3 of 14

The Schroth method is a physiotherapeutic scoliosis-specific exercise (PSSE) approach

consisting of neuromuscular, postural, and breathing exercises and education on adjusted
activities of daily living. The Schroth method capitalizes on auto-correction and principles
of motor learning and control, and is highly individualized [48,49]. This PSSE approach
uses a specific Schroth classification system to categorize patients with scoliosis into 16,
and those with sagittal plane deformity into 3 curve classifications [48,49]. The clinical and
radiological assessment starts with the Schroth classification, which determines treatment
prescription. The main goal of the Schroth treatment is recalibration of normal postural
alignment and static/dynamic postural control, as well as improving spinal stability [48,49].
Since 2015, when the first trials on the Schroth method were published [50,51], the
method has attracted interest among researchers, clinicians, patients, and their families. De-
spite increasing popularity, there is a lack of understanding of what constitutes the Schroth
method, its effects, and in which populations it should be used. A growing body of primary
studies on the Schroth method lacks methodological rigor, thus making collation of the
evidence into systematic reviews and meta-analyses challenging and potentially invalid.
Therefore, we aimed to systematically review methods of published Schroth PSSE
controlled trials for scoliosis and kyphosis and provide guidance for future research.

2. Materials and Methods

We included randomized (RCT) and non-randomized studies of intervention (NRSIs)
that investigated the effects of Schroth in pediatric and adult populations with scoliosis or
kyphosis. We excluded observational studies, uncontrolled studies or case series, reviews,
secondary studies, and trials that did not investigate the Schroth treatment or that used
Schroth as a control.
We searched six databases for the term “Schroth” (PubMed, Embase, Scopus, CINAHL,
SPORTDiscus, and PEDro) from inception to 24 January 2022. The full search strategy
for all databases is provided in Supplementary File S1. We augmented our search by
reviewing published abstracts, as well as the US National Institutes of Health Trials Registry
platform http://clinicaltrials.gov during the review period to identify published protocols
of completed, unpublished, and ongoing trials.
To streamline the production of our review, we used Covidence, a web-based sys-
tematic review collaboration software platform (Veritas Health Innovation, Melbourne,
Australia; available at www.covidence.org). We conducted all steps of the review, includ-
ing abstract and title review, full text review, risk of bias assessment, and data extraction
in Covidence.
Two independent reviewers screened titles/abstracts and full texts based on prede-
fined criteria. In case of conflicts, the reviewers discussed until consensus was reached.
General characteristics (9 domains), methodological approaches (14 domains), treat-
ment protocols (12 domains), and outcomes reporting (20 domains) were extracted into
55 domains and compared. The list of domains extracted for this review is provided in
Supplementary File S2.
Risk of bias (RoB) was assessed using an adapted Cochrane RoB 2 tool for RCTs [52],
and the Risk of Bias In Non-Randomized Studies–of Interventions (ROBINS-I) for NR-
SIs [53]. To assess the rigor of the trials more precisely, instead of using seven predetermined
risk of bias domains for RoB 2, we augmented the domains to include: Sequence gener-
ation, Allocation concealment, Blinding of participants, Blinding of the study therapists,
Blinding of outcome assessment—evaluator, Blinding of outcome assessment—statistician,
Incomplete outcome data, Attrition, Selective reporting, Baseline group characteristics,
Cointervention, Compliance, Outcome detection, Other sources of bias, and Overall as per
Cochrane Back and Neck group recommendations [54]. For ROBINS-I, we used the follow-
ing risk of bias domains: Bias due to confounding, Bias due to selection of participants, Bias
in classification of interventions, Bias due to deviations from intended interventions, Bias
due to missing data, Bias in measurement of outcomes, Bias in selection of the reported
result, and Overall. The description of domains for each risk of bias tool and signaling
Children 2023, 10, 954 4 of 14

questions that guided our decision making related to quality assessment are presented
in Supplementary File S3. We used the Risk-of-bias VISualization (robvis) tool to create
risk-of-bias plots and summary tables [55].
In surgical trials, the length of a follow-up is considered adequate if at least two
years duration [54], while consensus between two leading societies on non-operative and
operative management of scoliosis, the international Society on Scoliosis Orthopaedic
Rehabilitation Treatment (sosort.org) and Scoliosis Research Society (srs.org), respectively,
recommends a minimum of one-year follow-up for therapeutic trials [56]. Moreover,
many journals that publish articles on spinal deformities do not accept submissions of
manuscripts without at least 2-year follow-up on all patients. Surgery and physiotherapy
have different goals, and the nature of these treatments is substantially different. Therefore,
the outcome time points should be interpreted in a clinically meaningful way. In our review,
we adopted recommendations of the Cochrane Back and Neck group for exercise trials and
classified studies into short-term (≤4 weeks), intermediate (between 4 weeks and 1 year), and
long-term (≥1 year) [54].
We verified whether a study used Schroth-certified therapists through publicly avail-
able registers. If a treating therapist could not be verified, we directly contacted official
instructors and the authors.

3. Results
3.1. General Characteristics, Methodological Approaches, Treatment Protocols, and
Outcomes Reporting
3.1.1. General Characteristics of the Included Studies
Aside from identifying study information (lead author name, affiliation, contact, study
I.D., and title), we also extracted information on the country where the study was conducted,
setting, funding sources, and possible conflicts of interests for study authors. Detailed
information is available in Supplementary File S2.
Two studies were conducted in Turkey, and the others in Canada, Israel, Saudi Arabia,
the Republic of Korea, and the USA. Six studies were conducted in outpatient hospital
clinics, and for one the setting was not reported. Two studies received no funding, four
studies did not mention sources of funding, and one study received funding from multiple
non-profit and foundation sources. We did not identify any potential conflicts of interests
in any of the included trials.

3.1.2. Methodological Approaches of the Included Studies

To describe methodological aspects of the included studies, we extracted information
on the goal of the study, design, population, curve types, inclusion and exclusion criteria,
method of recruitment, protocol registration, usage of specific Schroth classification, bracing
information, primary and secondary outcomes, and information on questionnaires used.
Detailed information is available in Supplementary File S2.
Of the included studies, six were randomized and one was a non-randomized study
described by the authors as a prospective cohort study.
Four studies did not register protocols for their studies, two registered after the
completion of the study, and one registered after the start but before the end of the study.
Six studies assessed the effect of the intervention versus a control treatment, while one
assessed the effect of the supervised versus non-supervised and no treatment intervention.
The control treatment varied among studies, including standard of care in two, followed
by proprioceptive neuromuscular facilitation techniques (PNF), Pilates, antigravitation
exercises, core exercises, and no treatment. The standard of care in one study included
observation (no active treatment) and in the other observation or bracing depending on the
standard of care indication.
All studies included pediatric patients: two studies included adolescents aged from 10
to 17, three from 10 to 18, one from 14 to 16 years, and one did not specify a priori inclusion
by age, but the results suggest an average age of 15 to 16 years. Six studies focused on
Children 2023, 10, 954 5 of 14

AIS and one on Scheuermann’s kyphosis. Two studies included participants with smaller
curves ≤25◦ , three studies included curves from 10◦ to 30◦ and 10◦ to 45◦ , one from 10◦ to
60◦ , and one did not specify the inclusion based on the Cobb angles a priori.
Exclusion criteria varied. Most common exclusions were scoliosis type other than
AIS, previous spine surgery, comorbidities, mental or neurological deficits, and inability to
commit to the protocol. Six studies excluded patients who were currently or previously
braced, and one study included patients with a brace if it was indicated and prescribed but
excluded those who had completed brace treatment.
In six studies, patients were recruited based on their diagnosis from hospital out-
patient clinics. One study did not specify how the patients were recruited.
Three scoliosis studies reported including specific curve types ranging from all
curve types to only thoracolumbar; one included thoracic, double major, and thoracolum-
bar/lumbar, while others did not report on curve types. Only one study reported specifi-
cally using a Schroth classification and stratification according to the Schroth curve type.
The Cobb angle was the primary outcome in all included studies. Secondary outcomes
included objective measures of incidence of progression, brace prescription, angle of trunk
rotation, static plantar pressure distribution, functional capacity, muscle endurance, waist
asymmetry, weight distribution, surface topography measurements, spinal mobility, and
subjective measures on pain, body image perception, and quality of life. Patient-reported
outcomes included the Spinal Appearance Questionnaire, the Scoliosis Research Society
SRS-22r (three studies), and the SRS-23 (one study) questionnaires as well as the numeric
pain rating scale (NPRS). The study including participants with kyphosis included two
kyphosis-specific clinical outcomes: kyphotic deformity measured using inclinometer and
introduced a new outcome that the group named L5 kyphosis apex line (L5-KAL) which
has not been assessed for validity and reliability.

3.1.3. Treatment Protocols of the Included Studies

Treatment protocol information included titles of the Schroth exercises, number and
whether Schroth-certified treating therapists were used, description of the intervention
and control, start and end date, duration of the study period, intervention intensity, inten-
sity progression, adherence monitoring and calculation, as well as reporting on therapy
performance. Detailed information is available in Supplementary File S2.
Of seven included studies, six reported using Schroth exercises, of which four indeed
corresponded to the Schroth method, one to the Barcelona Scoliosis Physical Therapy School
(BSPTS) approach, and for one it was unclear what approach was used. One of the studies
reported to have used Schroth-based exercises that corresponded to the BSPTS approach.
Labeling of the exercises was performed in five studies, while appropriate description was
provided in three studies. For the remaining two studies that included the names of the
exercises, for one the exercise did not correspond to the Schroth method and for the other,
while the names of the exercises were correct, the descriptions were not. It was unclear how
many therapists were involved in the treatment for four studies, two reported to have used
one, and one study two therapists. Authors of the studies were included in the Schroth
(four studies) and BSPTS registrars (two studies). In one study, the authors or the study
personnel could not be verified as Schroth trained. Four studies explicitly stated to have
used either Schroth or BSPTS therapists.
Trial durations were intermediate to long-term, including 10 weeks in one study,
12 weeks in another, 6 months in three studies, and 1-year follow-up in two studies.
Protocol adherence was reportedly monitored in three studies, with only two quan-
tifying the adherence, but only one explicitly describing how adherence was calculated.
A single study explicitly monitored exercise performance using a predefined study per-
formance checklist, while one reported to have used a therapist’s non-specified subjective
observation. The exercises were progressed in two trials. One study used timed progres-
sion in three phases: early phase during the first 3 weeks, mid-phase from the 4th to 7th
week, and advanced phase occurring during the last 4 weeks. The other study used the
Children 2023, 10, 954 6 of 14

progression algorithms designed for each curve type, guiding the progression from easier
to more challenging exercises, and from start to target intensity, including less and more
sets and reps, respectively.

3.1.4. Outcomes Reporting of the Included Studies

Outcomes reporting included number of participants, baseline characteristics, age, sex,
race/ethnicity, Risser stage, scoliosis classification, and Cobb angles.
All studies included a relatively small sample, ranging from 24 to 50 participants. Two
studies included only females. Only one study specifically reported on race/ethnicity.
All but one study reported on the Risser stage. One included only Risser 0, two all
Risser stages, one Risser 0 to 3, one Risser 1 to 4, and one Risser 2 to 4.
The mean Cobb angle in the studies including participants with scoliosis ranged from
16◦ to 33.4◦ , with four studies including patients below the bracing threshold.
Two studies did not report on any type of curve classifications. Two studies included
only one curve type: one major lumbar and one major thoracic. Other studies did not limit
inclusion by the curve type. Only one study reported to have used the Schroth classification.
The table in Supplementary File S4 summarizes variables reported across the studies.

3.2. Risk of Bias Assessment

3.2.1. Risk of Bias of Included RCTs
Sequence generation was adequately reported for the most part, except for two studies.
For one study, there was a lack of information regarding envelope concealment, as well as
not mentioning who dealt with the envelopes; thus, the study was assessed with “some
concerns”. Another study stated that participants were randomized without providing any
details regarding how randomization was conducted, and was thus labeled “high risk” for
this domain.
Allocation concealment was adequate in three studies. Two studies were considered
to have “some concerns” due to a lack of information regarding envelope concealment
and the difficulty to appraise whether allocation could have been foreseen in advance or
during enrolment. Another study did not provide details regarding whether the allocation
sequence was generated and, if it was, how it was conducted, and was therefore assessed
as having a “high” risk of bias for this domain.
Blinding of participants and study therapists is not possible in physiotherapy trials
due to the nature of treatment delivery. Therefore, all included studies were assessed as
“high risk”. However, we considered detection bias (blinding of assessors and statistician)
a greater potential contributor to the systematic error in results of these trials. Thus, we did
not penalize the trials based solely on the blinding of participant and therapist domains.
Blinding of outcome assessment—evaluator and statistician is critical for avoiding
detection bias. All but two RCTs reported on blinding evaluators, and only one reported
on blinding the study statistician. Thus, two studies were considered to have “some
concerns” regarding the blinding of outcome assessors, and five regarding blinding of the
study statistician.
To assess the Incomplete outcome data domain, we considered whether the patients
were analyzed as randomized, and whether missing data were discussed and accounted for
regardless of participants’ reported adherence and potential cointervention. Two studies
were assessed as having “high risk” of bias because one did not use intention-to-treat
analysis and reported a 12% dropout rate, and another did not include a CONSORT
diagram, which made it difficult to assess if the sample size reflected everyone who was
recruited or if this represented participants with complete data. Other studies were labeled
as having a “low risk” of bias on this domain, with three reporting no data loss, and one
undertaking an intention-to-treat analysis.
Attrition was assessed with regard to trial duration and the reporting of the reasons for
drop-out. In a short-term study, a drop-out of >20% and in a long-term study, a drop-out of
>30% were considered unacceptable. Three studies reported no dropouts, two reported
Children 2023, 10, 954 7 of 14

a 12% dropout rate in an intermediate 6-month- and 1-year-long study, thus receiving a
“low” risk of bias for this domain. The remaining study was labeled as “high risk”, because
it did not report on the number of participants who were approached and who were finally
recruited in the study.
Selective reporting was “high risk” in two studies for which a protocol was not
available and the verification of planned compared to reported outcomes was impossible.
In addition, one of these studies mentioned pain as an outcome in the discussion but did
not report on that in the results section; the other excluded two participants from the
intervention group due to having “extremely high values of curves”, suggesting purposeful
selection of reports. Another study was assessed with “some concerns” due to the lack of
a protocol.
Baseline group characteristics were assessed as “high risk” in one study in which age,
height, and curve magnitude measured by inclinometer were different between the groups.
In addition, in the same study, the intervention group consisted primarily of boys, while
control consisted primarily of girls (64% vs. 20%, respectively).
Cointervention was considered as having “some concerns” for four studies because
cointervention and whether the authors controlled for possible cointervention were not
mentioned. The other two RCTs specifically addressed cointervention, and this domain
was assessed as “low risk” for these trials.
Compliance was adequately reported in one RCT, reporting on how the compliance
was monitored and calculated, including the report of adherence in both intention-to-treat
and per-protocol analyses. Two studies did not mention adherence and were scored with a
“high risk” of bias on this domain, while the remaining three RCTs were assessed as having
“some concerns” in this domain due to either not reporting on adherence or not reporting
on how the adherence was monitored.
Outcome detection or the timing of when the outcomes were measured was adequately
reported (“low risk”) in all but one RCT, for which it was unclear whether the outcomes
were measured concurrently in both groups, thus scoring “some concerns” on this domain.
Other sources of bias—This is a “catch-all” domain where additional potential sources
of bias could be listed. Additional sources of bias were found in three studies. Most
commonly, a source of bias included a lack of published protocol or a protocol that was
published after the study was completed, which was found for four studies. Two studies
published protocols after the completion of the trials, with one having an ethics approval
available and comparable to the protocol, while the protocol for the other study was judged
to be very poor and lacking detail, and was therefore rated as having a high risk of bias.
One study was conducted in Saudi Arabia, while both authors’ affiliations were at an
institution in Egypt, and the protocol was published in a Japanese registry and lacking
important information. We considered that a high risk of bias. For the same study, it was
not possible to verify whether qualified therapists were used, in addition to the exercise
descriptions not corresponding to the treatment they reported to have used, signaling a
possible incorrect use of the treatment. We considered that to be high risk of bias under
this domain.
Overall—We considered overall risk of bias as “high” or “some concerns” if at least
one domain was assessed as “high” or “some concerns”, except for the blinding of therapist
or participant domains. “Low” risk of bias was assigned to studies that had all but blinding
of therapists and participants domains judged as “low”. Therefore, three RCTs were
considered as “high”, two with “some concerns”, and one as “low” risk of bias.
The summary plot corresponding to the Modified RoB 2 for included RCTs is presented
in Figure 1.
 Overall—We considered overall risk of bias as “high” or “some concerns” if at least
one domain was assessed as “high” or “some concerns”, except for the blinding of ther-
apist or participant domains. “Low” risk of bias was assigned to studies that had all but
blinding of therapists and participants domains judged as “low”. Therefore, three RCTs
were considered as “high”, two with “some concerns”, and one as “low” risk of bias.
Children 2023, 10, 954 The summary plot corresponding to the Modified RoB 2 for included RCTs 8isofpre- 14
sented in Figure 1.

(a)

(b)

Figure1. 1.(a)(a)
Figure Modified
Modified RoBRoB 2 of
2 of included
included randomized
randomized controlledtrials
controlled trials(RCTs)
(RCTs) with
with corresponding
corresponding
domains;
domains; (b)(b) Risk
Risk ofof bias
bias summary
summary plot.
plot.

3.2.2. Risk of Bias in Non-Randomized Studies (ROBINS) of Included NRSIs

Bias due to confounding is an important aspect in designing NRSIs because some prog-
nostic variables could also predict the intervention received at baseline. For the included
NRSI study, this domain was assessed as “moderate risk” due to baseline characteristic
differences, including a discrepancy in sex and curve type between the groups that the
authors did not control for in the analysis.
Bias due to the selection of participants is another critical domain in NRSI conduct,
because exclusion of some eligible participants at the beginning of the trial may lead to a
systematic error. For the included NRSI, it was not possible to ascertain how the participants
were selected at baseline, if enrollment was consecutive or based on convenience, or if the
participants were naïve to the treatment, and this domain was scored as “serious” risk.
Bias in the classification of interventions and bias due to deviations from intended in-
terventions were considered as “low risk” because both intervention and control treatment
 systematic error. For the included NRSI, it was not possible to ascertain how the partici-
pants were selected at baseline, if enrollment was consecutive or based on convenience,
or if the participants were naïve to the treatment, and this domain was scored as “seri-
ous” risk.
Bias in the classification of interventions and bias due to deviations from intended
Children 2023, 10, 954 9 of 14
interventions were considered as “low risk” because both intervention and control
treatment are standard of care at the study institution, and it was assumed that both
would be carried out in their usual ways.
are standard
Bias dueoftocare at thedata
missing studycorresponded
institution, and it wastoassumed
closely that both
the “Attrition” would for
domain be carried
RCTs.
out in their usual ways.
The included NRSI reported a dropout rate of 32.7%, which is considered unacceptable
Bias due tostudy,
for a long-term missing
anddata corresponded
received a “Critical” closely
score. to the “Attrition” domain for RCTs.
The included NRSI reported a dropout rate of 32.7%,
Bias in the measurement of outcomes closely corresponded which is considered unacceptable
to Outcome detection for
in
a long-term study, and received a “Critical” score.
RCTs. The included NRSI scored “Moderate” risk because it was unclear what the actual
Bias in the measurement of outcomes closely corresponded to Outcome detection in
timing was compared with baseline visits since it varied for each participant and could
RCTs. The included NRSI scored “Moderate” risk because it was unclear what the actual
be every three to nine months, “depending on the treating orthopedic surgeon’s prefer-
timing was compared with baseline visits since it varied for each participant and could be
ence”.
every three to nine months, “depending on the treating orthopedic surgeon’s preference”.
Bias in the selection of the reported results corresponded closely to the “Selective
Bias in the selection of the reported results corresponded closely to the “Selective
reporting” domain for RCTs. The included NRSI was considered to be of “low risk” of
reporting” domain for RCTs. The included NRSI was considered to be of “low risk” of bias
bias in this domain.
in this domain.
Overall—The NRSI was assessed as “critical” due to a large amount of missing data
Overall—The NRSI was assessed as “critical” due to a large amount of missing data
and unclear selection of participants.
and unclear selection of participants.
The
The ROBINS-I
ROBINS-I risk
risk of
of bias
bias plot
plot is
is presented
presented inin Figure
Figure 2.
2.

Figure
Figure 2. Risk Of
2. Risk Of Bias
Bias In
In Non-Randomized
Non-RandomizedStudies
Studies- -ofofInterventions
Interventions(ROBINS-I)
(ROBINS-I) plot
plot ofof
thethe in-
included
cluded non-randomized study of intervention (NSRI), with corresponding domains.
non-randomized study of intervention (NSRI), with corresponding domains.

4. Discussion
4. Discussion
Randomized controlled trials (RCTs)
Randomized (RCTs) are
areconsidered
consideredthe
thegold
goldstandard
standardfor
forresearching
research-
therapeutic
ing interventions
therapeutic interventionsbecause
becausetheir design
their designminimizes
minimizesthe
thelikelihood
likelihoodofof systematic
systemat-
error (bias), and as such they provide the strongest evidence to guide clinical decision
making. Randomization protects against sampling bias, and any potential differences
between the groups at baseline are deemed to occur due to chance. RCTs also guard against
overenthusiastic conclusions, which is often the case with uncontrolled trials. However,
RCTs assume meticulous methodological design, conduct, and reporting, and not merely
the usage of randomized allocation. Deviation from the truth in results can stem from
various sources of bias. To appraise the risk of bias, Cochrane Collaboration proposed the
usage of the RoB 2 tool for appraisal of RCTs [52] and ROBINS-I for NRSIs [53]. These tools
help to differentiate the type of systematic errors that can occur at the beginning, during,
or in the reporting of trial results. Sources of bias can be broadly grouped into biases that
stem from the randomization process, deviations from intended interventions, missing
outcome data, measurement of the outcomes, and selection and reporting of the results.
Knowledge syntheses aim to collate the evidence on a specific research question to provide
valid information about the effectiveness of an intervention. Thus, rigor in RCT conduct
and reporting is essential.
The CONSORT statement is a set of guidelines for reporting on RCTs [57–59]. It
consists of a checklist of necessary information that should be included in RCT reporting
and a flow diagram that documents the movement of participants from screening through
reporting of the trial. The goal of CONSORT is to improve the transparency, completeness,
Children 2023, 10, 954 10 of 14

and quality of RCT reporting. Most reputable medical journals have adopted CONSORT
guidelines and require authors to use them.
Our analysis showed that overall, reporting of the Schroth PSSE trials was poor, and
they currently lack methodological rigor.
In summary, seven studies met inclusion criteria for this review. Five studies reported
to have used the Schroth method, and two the Barcelona-Scoliosis-Physical-Therapy-School
approach. One study included patients with Scheuermann’s kyphosis [60] and six with
adolescent idiopathic scoliosis [51,61–65]. All but one [64] were RCTs. The inclusion criteria
varied among studies.
All studies included pediatric populations. Using a search term “scoliosis” in the
clinicaltrials.gov database, we identified two registered clinical trials investigating the effect
of the Schroth method in adults, one being conducted in Canada and another in Pakistan.
However, our search did not yield any published RCTs or NRSIs including adults.
Studies included in this review were conducted in Turkey (n = 2), and one each in
Canada, Israel, the Republic of Korea, Saudi Arabia, and the USA. Intervention periods
were long-term for two studies (1-year follow-ups) and intermediate for five studies (range:
10 weeks to 6 months).
The Scoliosis Research Society (SRS) recommendation for standardizing non-operative
research identifies the Cobb angle as the primary outcome [66]. Consequently, the primary
outcome for all studies was the Cobb angle (measured via X-ray in all but one study,
which used surface topography). Other outcomes included: quality of life, incidence of
progression, brace prescription, angle of trunk rotation, static plantar pressure distribution,
functional capacity, muscle endurance, waist asymmetry, weight distribution, pain, body
image perception, surface topography measurements, and spinal mobility. The diversity
in the outcome selection and varied inclusion criteria makes it difficult to compare trial
results. A core set of outcome domains and measurements is critical for establishing the
effectiveness of an intervention and comparison across similar trials. In a four-round
Delphi study, The Nordic Spinal Deformity Society (NSDS), proposed 13 core outcomes
for surgically treated children with AIS, which prioritizes patient-reported outcomes and
lists only three clinical outcomes, including “re-operation”, “complications”, and “change
in deformity” [67]. Our group recently conducted a scoping review to inventory the tools
that measure patient-reported outcomes in persons with spinal deformities and identified
145 patient-reported outcome measures [68]. The creation of core outcome sets for non-
operatively treated children and adults with scoliosis has gained global attention. However,
consensus has not been reached. Currently, Close et al. are conducting a qualitative
investigation to establish a person-centered core set for adolescents and young adults with
spinal deformity who are undergoing treatment [69].
Adherence was explicitly monitored in three and exercise performance in two studies.
Exercise progression was reported in two studies. Exercise prescription according to the
Schroth curve type was reported in one trial. Stratifying randomization by curve type was
reported in one study.
Four studies did not register their protocols, two registered after study completion, and
one after the study commenced but before completion. Only one study provided sufficient
information in the published protocol to support replication. Insufficient information
for replication of the study or treatment protocols makes it difficult to judge the study’s
conduct, validity, and the intervention outcomes.
One study was determined to be of appropriate quality for risk of bias, while others
scored sub-optimally on multiple domains.
Authors typically do not report classifying participants into a specific Schroth classifi-
cation. Several classifications for scoliosis exist to guide the selection of surgical procedure,
and the most used among surgeons in North America is the Lenke classification developed
in 2001 [70]. Lenke classification distinguishes between six types of scoliosis patterns, each
of which can be subdivided according to the extent of lumbar deviation and sagittal plane
profile. Classification systems help clinicians to reliably compare among various procedures
Children 2023, 10, 954 11 of 14

and to assess outcomes in different curve types. While Lenke classification relies on the
radiological characteristics of the curve, the Schroth classification is based on the clinical
presentation, distinguishing between different compensatory patterns that guide therapy
decisions. Without a Schroth classification, a Schroth therapist cannot reliably prescribe
the exercise treatment. Thus, to ensure an appropriate Schroth therapy prescription, it is
essential to use the Schroth classification.
Three studies reported using certified Schroth therapists. Not using qualified Schroth
therapists challenges the trustworthiness of the intervention and, thus, the validity of the
results. The Schroth method, among other PSSE methods, is a specialized physiotherapeutic
treatment for scoliosis and hyperkyphosis that requires additional postgraduate training
beyond what a typical physical therapy curriculum offers. Schroth therapists undergo an
advanced theoretical and clinical postgraduate education to establish a broader depth of
knowledge and skills related to the treatment of patients with scoliosis and hyperkyphosis.
The certification process requires them to demonstrate competency in specialized knowl-
edge and advanced clinical proficiency on the topic. Moreover, the validity of knowledge
syntheses depends on reliable intervention administration. Administering medication in
pharmaceutical trials is far less complex than delivering a specialized physiotherapeutic
intervention. Thus, it is critical that Schroth therapists participate in the studies examining
the effect of Schroth intervention.
A limitation of this review is the inclusion of only Schroth PSSE trials. The Schroth
method was specifically developed to treat persons with adolescent idiopathic scoliosis
and was later extended to treat patients with hyperkyphosis and adult spine deformity.
To date, it remains the most researched method, despite the existence of other exercise
methods for scoliosis. Hence, in this study, we focused on Schroth trials. However, our
recommendations could be extrapolated to other physiotherapeutic trials, and particularly
to those that examine the effect of the PSSE more broadly. The evidence synthesis depends
on the quality of the primary studies, and high standards in trial design and conduct
are imperative.

5. Conclusions
We recommend minimum standards for the reporting of Schroth PSSE trials, including
prospectively registering detailed study protocols, providing appropriate PSSE labeling,
utilizing the Schroth classification system and qualified Schroth therapists, naming and
describing specific exercises per Schroth curve type, and providing therapy dosages, pre-
scription methods, and adherence. This will strengthen the evidence base for Schroth PSSE
and ensure that collation of evidence through systematic reviews is valid.

Supplementary Materials: The following supporting information can be downloaded at:

https://www.mdpi.com/article/10.3390/children10060954/s1, File S1: Search strategy; File S2:
Domains of interest; File S3: Risk of bias and study quality assessment; File S4: Reported variables
across included studies.
Author Contributions: Conceptualization, S.S.; methodology, S.S. and E.C.S.; validation, S.S., E.C.S.
and D.W.; formal analysis, S.S., E.C.S. and D.W.; investigation, S.S., E.C.S. and D.W.; resources, S.S.;
data curation, S.S., E.C.S. and D.W.; writing—original draft preparation, S.S.; writing—review and
editing, S.S., E.C.S. and D.W.; visualization, S.S. All authors have read and agreed to the published
version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Data Availability Statement: No new data were created or analyzed in this study. Data sharing is
not applicable to this article. However, all pertaining information to this review is available in the
Supplementary Materials or is contained within the article.
Children 2023, 10, 954 12 of 14

Acknowledgments: The authors thank Kathleen Santos for her help with data extraction verification
and Whitney Townsend, Health Sciences Informationist at the University of Michigan, for assistance
with the literature search strategy.
Conflicts of Interest: S.S. is an international Schroth instructor and is also trained in the BSPTS
method. S.S. owns a private specialty clinic for scoliosis, kyphosis, and other spinal disorders. S.S. is
an author of one of the included trials; however, all the data extraction and risk of bias assessment
pertaining to that study were conducted by the other two authors, which was consistent with publicly
available quality assessment provided through the PEDro database. D.W. and E.C.S. declare no
conflicts of interest related to this study.

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