664151

research-article2016
POI0010.1177/0309364616664151Prosthetics and Orthotics InternationalGür et al.

INTERNATIONAL
SOCIETY FOR PROSTHETICS
AND ORTHOTICS

Original Research Report

Prosthetics and Orthotics International

The effectiveness of core stabilization 2017, Vol. 41(3) 303­–310

© The International Society for
Prosthetics and Orthotics 2016
exercise in adolescent idiopathic scoliosis: Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
A randomized controlled trial DOI: 10.1177/0309364616664151
journals.sagepub.com/home/poi

Gözde Gür, Cigdem Ayhan and Yavuz Yakut

Abstract
Background: Core stabilization training is used to improve postural balance in musculoskeletal problems.
Objectives: The purpose of this study was to investigate the effectiveness of stabilization training in adolescent idiopathic
scoliosis.
Study design: A randomized controlled trial, pretest–posttest design.
Methods: In total, 25 subjects with adolescent idiopathic scoliosis were randomly divided into two groups: stabilization
group (n = 12) and control group (n = 13). The stabilization group received core stabilization in addition to traditional
rehabilitation, and the control group received traditional rehabilitation for 10 weeks. Assessment included Cobb’s angle
on radiograph, apical vertebral rotation in Adam’s test, trunk asymmetry (Posterior Trunk Symmetry Index), cosmetic
trunk deformity (Trunk Appearance Perception Scale), and quality of life (Scoliosis Research Society-22 questionnaire).
Results: Inter-group comparisons showed significantly greater improvements in the mean change in lumbar apical vertebral
rotation degree and the pain domain of Scoliosis Research Society-22 in the stabilization group than those in the control
group (p < 0.05). No significant differences were observed for other measurements between the groups; however,
trends toward greater improvement were observed in the stabilization group.
Conclusion: Core stabilization training in addition to traditional exercises was more effective than traditional exercises
alone in the correction of vertebral rotation and reduction of pain in adolescent idiopathic scoliosis.

Clinical relevance
Stabilization exercises are more effective in reducing rotation deformity and pain than traditional exercises in the
conservative rehabilitation of adolescent idiopathic scoliosis. These improvements suggest that stabilization training
should be added to rehabilitation programs in adolescent idiopathic scoliosis.

Keywords
Adolescent idiopathic scoliosis, core stabilization, curve magnitude, posture, rehabilitation, scoliosis

Date received: 28 January 2016; accepted: 25 May 2016

Background
Adolescent idiopathic scoliosis (AIS) is present in 2%–4%
of children and occurs in 10-year-old children to maturity.
In AIS, improper mechanical forces acting on the spine
lead to biomechanical and physiological alterations along
the trunk segment.1 The trunk is the core segment of the
body that controls the center of gravity and maintains pos-
tural stability.2 Impaired neuromuscular control of the
trunk segment and the postural asymmetry observed in
patients with AIS may alter the motor control of the trunk
segment leading to decreased postural stability during
movement.3
Poor balance, decreased postural control, and increased
body sway have been recorded in AIS.3 The deep trunk
muscles (transversus abdominis and multifidus) play an
essential role in maintaining postural stability.4 Activation
Faculty of Health Sciences, Hacettepe University, Ankara, Turkey
Corresponding author:
Gözde Gür, Faculty of Health Sciences, Physiotherapy and Rehabilitation
Department, Hacettepe University, Samanpazari, Ankara, 06100, Turkey.
Email: gosdegr@hotmail.com
304
of these muscles in a feed-forward mechanism minimizes
changes in the center of gravity. Therefore, pathological
muscle alterations may lead to impaired postural control
changes in AIS. Many studies have confirmed the altered
muscle properties in AIS. Muscle imbalance in the lumbar
multifidus and deep paraspinal muscles has been recorded.5
Muscle atrophy and alterations in muscle fiber composi-
tion have been demonstrated to be leading to these muscle
imbalances. Paravertebral muscle atrophy has been char-
acterized with increased fatty infiltration.6 Alterations in
fiber composition of the spinal muscles have been shown
to include reduced type I fibers and increased type IIB and
IIC fiber compositions in both the convex and concave
sides of the curve.7 Weiss8 hypothesized that a decrease in
the type I fibers in the postural muscles causes inability to
maintain tonic contraction for long periods of time, lead-
ing to postural deficits in AIS. In addition, Zoabli et al.9
reported imbalance in the electromyography (EMG) activ-
ity with muscle volume differences between the left and
right sides of the spine in scoliosis.
Rehabilitation exercises involving deep trunk muscles
may increase postural stability and decrease postural
asymmetries. Core stabilization (CS) is a recently devel-
oped exercise approach aimed at improving postural
balance and preventing compensatory movements by con-
trolling the position of the trunk in static postures and
functional activities.2,4,10 CS has been reported to improve
muscle imbalance, particularly between the multifidus and
paraspinal muscles, thus enhancing local and global spinal
stability.11 CS has been found to be more effective than
general fitness exercises for improving spinal stabilization.12
Shin et al.13 found that CS exercises increased sitting bal-
ance in AIS. Alves de Araujo et al.14 reported improve-
ments in Cobb’s angle and pain scores.
There are several scoliosis-specific exercise methods
including Schroth, scientific exercise approach to scoliosis
(SEAS), and general exercise programs such as yoga and
pilates. A recent Cochrane review reported that a very low-
quality evidence supports that scoliosis-specific exercises
could reduce curve progression and brace prescription
compared to traditional physiotherapy.15
CS increases the recruitment efficiency of the stabiliz-
ing muscles around the spine, thereby improving the abil-
ity of the core muscles to correct and maintain the
alignment of the spine.16 However, there are limited stud-
ies demonstrating the effectiveness of CS in patients with
AIS. The objective of this study was to investigate the
effect of CS on curve magnitude, posture, trunk deformity,
and quality of life in patients with AIS.
Methods
Participants
The study participants comprised patients who were diag-
nosed with AIS and referred by their physician to receive a
Prosthetics and Orthotics International 41(3)
spinal brace and exercise treatment at the School of
Physiotherapy and Rehabilitation of Hacettepe University.
Inclusion criteria were adolescents with idiopathic scolio-
sis between the ages of 10 and 16 years who were referred
for a spinal brace. Patients with a history of rheumatologi-
cal, neuromuscular, cardiovascular, pulmonary, or renal
diseases were excluded. In addition, those with congenital
scoliosis or spinal deformity, those who had undergone
surgical correction of the spine, who had a tumor, who
were unable to participate in the supervised sessions, or
those who refused to follow treatment were excluded.
This study proposal was approved by the Research
Ethics Board of Hacettepe University. On their first visit,
patients with AIS were informed about the study. All
patients and their families signed informed consent prior to
the study. Patients were blinded to the type of exercise
intervention that they were going to receive.
Study design
Patients were randomly divided (using simple randomiza-
tion) into either a stabilization group or a control group.
Patients in both groups received 20 sessions of a 1 h super-
vised treatment program two times per week for 10 weeks.
For supervised exercises, the stabilization group received
CS exercises, and the control group received traditional
exercises. Both groups also performed daily home exer-
cises. In addition to these interventions, custom-made spi-
nal braces were designed for all the patients, and they were
instructed to wear them 22 h daily.
Intervention
Traditional and stabilization exercises were performed by
a trained physical therapist (first author (G.G.)). The con-
trol group received a traditional treatment program that
included exercise training and bracing. Traditional exer-
cise programs for scoliosis include breathing exercises,
posture training, spinal flexibility exercises, stretching
exercises for the involved muscles (especially for the con-
cave side of the curve), and general strengthening exer-
cises for the main muscle groups of trunk, pelvis, and
shoulder girdle muscles (especially for the convex side of
the curve).17 The program progressed in accordance with
the functional improvement of each patient. Spinal bracing
is one of the most important components of traditional
treatment in patients with AIS who have a curve of above
20°.18 In this study, custom-made spinal braces were
designed for the patients in order to correct the lateral
deviation and rotational components of the scoliotic
deformity.19 A thoraco-lumbo-sacral brace was designed
based on the symmetric, patient-oriented, rigid, three-
dimensional, active (SPoRT) concept.20 The brace-wear-
ing protocol involved 22 h of brace wearing and 2 h of
removal for hygienic activities and exercise.
Gür et al.
The stabilization group received CS exercises in addi-
tion to the traditional treatment program. The CS training
principles comprise respiratory control, neutral spinal
position, rib cage placement, scapular position, and neck–
head position. The CS training program included local
muscle stability training (transversus abdominis, multifi-
dus, and diaphragm), global muscle stability training
(oblique abdominal muscles, psoas major, quadratus lum-
borum, and pelvic floor muscles), global muscle mobility
training (rectus abdominis, back extensors, and hamstring
muscles), and strength training of the core muscles through
the thoracolumbar fascia by maintaining the neutral spine
position. Diaphragmatic breathing technique was used
during exercises. Exercises gradually progressed from the
training of the core muscles in static body positions to the
training of activation of the core muscles during functional
tasks in dynamic body positions. The patients proceeded to
the next level when they successfully completed the
weekly program. Patients who could not manage to com-
plete the program continued with the same exercises and
performed a few simple exercises from the next level with
fewer repetitions.
Assessments
Demographic data and patient characteristics, including
age, gender, height, body mass, Risser sign, and curve pat-
tern, were collected. Skeletal immaturity based on the Risser
stages was recorded for each patient at the first visit.
Curvatures were classified according to the King classifica-
tion system. The following outcome measures were per-
formed before and after 10 weeks of intervention in both
groups: curve magnitude with the measurement of the Cobb
angle on antero-posterior radiograph, apical vertebral rota-
tion (AVR) with a scoliometer in Adam’s test, trunk asym-
metry with the Posterior Trunk Symmetry Index (POTSI),
cosmetic trunk deformity with the Trunk Appearance
Perception Scale (TAPS), and quality of life with the
Scoliosis Research Society-22 questionnaire (SRS-22).
The Risser sign provides information about the skeletal
maturity and spinal growth. It is based on the ossification
of the iliac apophysis, which is evaluated with a four-grade
scale from 0 (no ossification) to 5 (fused ossified
apophysis).21
King classification system includes five types of curve
definitions based on the location of the curve apex and
flexibility on X-ray as follows: Type 1: double curve, lum-
bar curve larger and stiffer than the thoracic curve; Type 2:
double curve, thoracic curve larger and stiffer than the
lumbar curve; Type 3: single thoracic curve; Type 4: long
thoracic curve with L4 tilted into the curve; and Type 5:
double thoracic curve.22
Lateral curvature of the spine was measured with the
Cobb method on the antero-posterior radiograph in
degrees. The rotation of the apical vertebrae of the curve
305
was measured in degrees using a scoliometer in the Adam’s
forward-bending test.23 The change in AVR was reported
to be ⩾5° in order to have clinical significance.24
TAPS was used to assess the perceived body image and
to evaluate the outcome of the interventions on cosmetic
deformity. TAPS comprises three sets of figures. Each fig-
ure is scored from 1 (greatest deformity) to 5 (smallest
deformity). The mean score expresses the average of three
drawings.25 POTSI was used to quantify trunk asymmetry
with photographic assessment of posture. It is a two-
dimensional surface topography system, which is based on
the measurements taken from the patient’s back with a
tapeline. The total POTSI score is calculated as the sum of
six indices, that is, three frontal asymmetry indices and
three height difference indices.26
The SRS-22 questionnaire has been used to evaluate
quality of life. It consists of 22 questions covering five
domains: pain, self-image, function/activity, mental health,
and management satisfaction. Each item is scored from 1
(worst) to 5 (best). Each domain has its own scoring sys-
tem. A total score is calculated from the average of the five
domains. This tool has good to excellent internal consist-
ency and test–retest reliability.27
Compliance with the treatment was assessed using
patients’ self-reports. For exercises, the question was “Did
you perform your exercise for 1 h daily?” For the braces, the
question was “Did you wear your spinal brace 22 h daily?”
Patients were requested to rate themselves out of a score of
100%, and the results were recorded as a percentage.
Statistical analysis
Statistical power analyses based on the information from
previous studies (for our primary outcome measurement
method of Cobb’s angle)13,28 were used to determine the
optimum sample size. The number of subjects required for
the final analysis was calculated to be 10 for each treat-
ment group with a 20% missing rate. The α-level used in
determining the sample size was 0.05, and the ideal power
was considered to be 80%. Descriptive statistics were
expressed as means and standard deviations (SDs). Fisher’s
exact test was used to determine whether patients were
equally distributed across the two groups in terms of gen-
der and King classification categories. Differences
observed with interventions were analyzed with the
Wilcoxon signed-rank test. Between the groups, differ-
ences were compared using the Mann–Whitney U test. A
level of significance of p < 0.05 was accepted for the study.
All analyses were performed using SPSS for Windows
version 11.0 (SPSS Inc.).
Results
Among the 44 patients admitted to the department, 25 ful-
filled the inclusion criteria. In all, 19 patients could not
306 Prosthetics and Orthotics International 41(3)

Figure 1. Flow diagram for participant enrollment, allocation, follow-up, and analysis.

participate in the study because of the following reasons: five Table 1. General characteristics of the patients.
patients refused to participate, six had a history of previous
Subject Stabilization Control p-value
conservative treatment, and eight were unable to attend the
characteristics
supervised sessions. The study was completed with 25
patients (12 in the stabilization group and 13 in the control Gender 0.480
group) with 100% attendance compliance (Figure 1). Male (n) 1 –
There were no between-group differences regarding the Female (n) 11 13
baseline characteristics (p > 0.05) (Table 1). Compliance Age (years) 14.2 (1.8) 14 (1.6) 0.978
Height (cm) 160.9 (8.7) 155.1 (9) 0.199
with home exercises (82.25 ± 15.33 for the stabilization
Mass (kg) 46.8 (6.1) 44.2 (9) 0.511
group, 88.05 ± 15.08 for the control group, p = 0.216) and
BMI (kg/m2) 18 (1.6) 18.2 (2.3) 0.913
brace wearing (86.92 ± 9.88 for the stabilization group,
Risser grade 2 (0.6) 2 (0.6) 0.750
88.8 ± 13.03 for the control group, p = 0.586) did not differ
King 0.080
between the groups. 1 (n) 1 7
On comparing all the parameters, the baseline values 2 (n) 8 5
did not differ between the groups (p > 0.05) (Tables 1 and 3 (n) – –
2). An inter-group comparison revealed significantly 4 (n) 3 1
greater improvements in lumbar rotation and the pain
BMI: body mass index.
domain of SRS-22 (p < 0.05) (Table 2). The mean change Values are frequency or mean (standard deviation).
(SD) in the degree of lumbar rotation between pre- and
post-treatment was a reduction of −3.89 (2.09) in the stabi-
lization group and −2.09 (2.02) in the control group. In 0.27 (0.40) in the stabilization group and a worsening of
addition, the mean change in the pain domain of SRS-22 −0.05 (0.59) in the control group (p < 0.05) (Table 2). No
between pre- and post-treatment was an improvement of significant differences were observed for Cobb’s angle,
Gür et al. 307

Table 2. Main outcome measures by group at the pre- and post-treatment assessments.

Pre-treatment Post-treatment Actual mean difference

Stabilization Control Stabilization Control Stabilization Control

X (SD) X (SD) X (SD) X (SD) X (SD) X (SD)
Cobb’s angle (°)
Thoracic 35 (11.82) 31.42 (6.97) 28.45 (11.86)a 33.88 (7.34) −6.73 (2.69) 0.63 (4.34)
Lumbar 29 (8.35) 34.33 (9.2) 23.63 (10.39)a 32.63 (10.2)a −5.13 (5.49) −1.75 (3.45)
Total 56.75 (25.70) 60.69 (17.75) 45.64 (25.44)a 59.11 (19.99) −9.82 (6.13) −2.11 (6.31)
Rotation (°)
Thoracic 11.75 (5.23) 9 (5.15) 9.5 (5.6)a 8.09 (4.23) −2.25 (2.38) −1.55 (2.38)
Lumbar 7.67 (3) 12.08 (6.43) 3.78 (3.23)a 8.18 (4.77)a −3.89 (2.09)b −2.09 (2.02)
Total 17.5 (6.86) 19.31 (6.86) 12.33 (6.27)a 15 (6)a −5.17 (1.90) −3.92 (4.27)
TAPS 3.03 (0.49) 2.83 (0.6) 3.53 (0.45)a 3.45 (0.62)a 0.50 (0.45) 0.62 (0.42)
POTSI 29.84 (11.11) 32.41 (12.28) 21.87 (9.2)a 27.14 (16.74) −7.98 (6.07) −4.90 (9.78)
SRS-22
Pain 4.47 (0.4) 4.1 (0.53) 4.73 (0.36)a 4.02 (0.51) 0.27 (0.40)b −0.05 (0.59)
Self image 3.62 (0.63) 3.65 (0.6) 3.65 (0.55) 3.62 (0.68) 0.56 (2.08) 0.00 (0.53)
Function 4.48 (0.37) 4.43 (0.48) 4.67 (0.38) 4.56 (0.44) 0.18 (0.31) 0.12 (0.52)
Mental health 3.42 (1.06) 3.83 (0.71) 3.56 (0.96) 3.93 (0.84) 0.14 (0.49) 0.00 (0.31)
Total 3.98 (0.5) 3.98 (0.48) 4.26 (0.35)a 3.96 (0.46) 0.33 (0.28) −0.06 (0.38)

Rotation: apical vertebral rotation; TAPS: Trunk Appearance Perception Scale; POTSI: Posterior Trunk Symmetry Index; SRS-22: Scoliosis Research
Society-22 questionnaire.
Change values are expressed for mean (standard deviation).
ap < 0.05 within-group differences.
bp < 0.05 between-group differences.

rotation, trunk asymmetry, cosmetic trunk deformity, and
quality of life between the two groups; however, trends
toward improvement were observed in all measures for the
patients in the stabilization group (Table 2).
Discussion
The results of this study showed that CS training is effec-
tive in reducing AVR and pain in patients with AIS. In
addition, stabilization exercises are more effective than
traditional exercises in reducing lumbar rotation deformity
as measured by scoliometer. This is the first study investi-
gating the effects of conservative treatment, including CS
training and spinal bracing using outcomes of scoliosis as
parameters, such as body posture, trunk deformity, pain,
and quality of life in AIS.
Treatment strategies, which trigger the prevention of sco-
liosis progression and reduce the rate of surgery, are crucial
in patients with AIS.29 Measurement of the curve magnitude
with the Cobb method and AVR is decisive in determining
scoliosis progression.30 In this study, CS training was more
effective in the reduction of AVR of the lumbar region. For
the chaos theory of scoliosis, the scoliotic curve repre-
sents a discontinuous system. For a rotation below 25°,
the lever arms of the muscles on the concave and convex
sides are around the instant rotation center of the vertebral
body and enable the stability of the spine; for this move-
ment, all the spinal muscles attempt to correct the scoliosis.
If the rotation exceeds 25°, the lever arms of the concave
and convex muscles are on the same side with relation to the
instant rotation center of the vertebral body. Therefore, con-
traction of the stabilization muscles creates a rotator effect
which causes worsening of scoliosis.31 We think that reduc-
tion in vertebral rotation is associated with neuromuscular
retraining around the spine and re-education of the spinal
muscles’ ability to stabilize the curve against rotation with
core training.4 Previous studies mainly investigated the
effect of intervention on Cobb’s angle. Authors obtained a
reduction in Cobb’s angle with pilates-based exercises14 and
reported a greater correction of Cobb’s angle in scoliosis
with the core muscle release technique than with general
exercise and electrotherapy.32 Negrini et al. found that
SEAS exercise was more effective than traditional physio-
therapy for reducing curve progression. The average Cobb
angle was reduced 3° in SEAS group, whereas it stayed
unchanged in traditional physiotherapy group.33
Weiss et al.34 reported better results with 35 months of
treatment in scoliosis-intensive rehabilitation (Schroth
method) group (53%–70% improvement) versus control
group (29%–44% improvement). In this study, we did not
find any significant improvement in Cobb’s angle in the
stabilization group. However, the trend toward better
results in the thoracic and total Cobb angle in the stabiliza-
tion group suggests that further research should be con-
ducted. The total Cobb angle reduced on average 9° and 2°
in the CS and control groups, respectively.
308
The treatment of AIS has been reported to be aimed at
improving cosmetic appearance and trunk balance.35 TAPS
is used to assess trunk deformity and self-image. TAPS has
excellent internal consistency, test–retest reliability, and a
good capacity for differentiating the severity of the disease
in AIS.25 We used TAPS to assess the treatment effects
on visible aspects of the patients’ spinal deformity.
Furthermore, while traditional methods like the Cobb
angle focus on evaluating internal deformity of the spine,
POTSI assesses the external shape of the trunk in terms of
asymmetry.26 In this study, stabilization training did not
result in significant improvement in cosmetic deformity
and trunk symmetry. However, in the POTSI measure-
ments, the trend toward improved body symmetry within
the stabilization group could be related to a previous
review, which indicated that pilates-based spinal stabiliza-
tion exercises produced postural facilitation and straight-
ening of the spine by assisting the reactivation of spinal
muscles.36 Shin et al.13 demonstrated that CS exercises
could improve sitting balance in AIS and suggested that
this was caused by improvement in trunk muscle strength
and trunk symmetry. Emery et al.16 reported that pilates
therapy improved core strength, scapulae kinematics, and
spine posture by facilitating postural symmetry. Our initial
results showed that traditional exercise training is not suf-
ficient to reduce body asymmetry.
It has been suggested that quality of life should be taken
into account during treatment because scoliosis affects
quality of life.37 SRS-22 is a commonly used self-report
scale for assessing the quality of life in scoliosis. A pre-
liminary study reported a higher complaint rate of back
pain in patients with scoliosis than in healthy individuals.38
In the natural course of scoliosis, due to asymmetrical
loading on the spine, intervertebral disc and facet joint
degeneration and differences in spinal muscle length
occur, leading to chronic pain. Therefore, for the conserva-
tive treatment of AIS, pain relief is considered to be
important.38 In this study, CS training was found to
improve the pain domain of SRS-22. This suggests that
stabilization training improved the global musculature and
its ability to balance the loads on the body. In addition, it
improved the local musculature and its ability to maintain
force control within the spine. This increase in the spinal
stability may provide painless movements in the routine
functional tasks. A review has reported the effectiveness of
stabilization exercises in reducing pain in a heterogeneous
group of patients with lower back pain.39 Using the pilates
method, Alves de Araujo et al.14 observed reduction in
back pain in scoliosis. In addition, a trend toward improve-
ment in the quality of life with stabilization training was
observed. We propose that with pain-free movements, CS
training provides confidence to individuals to use their
spine for physical activities, and this improves their
quality of life. Traditional exercises were insufficient in
Prosthetics and Orthotics International 41(3)
improving quality of life and pain. These results are not
comparable with previous studies because in the literature,
these studies mostly compared quality of life and pain
between patients who were surgically treated and/or
treated with braces.35 Few studies have investigated the
effects of exercise on quality of life in AIS, and they all
differ in terms of patient characteristics, procedures, and
study settings. Monticone et al.17 reported that active self-
correction and task-oriented exercises were superior to tra-
ditional exercises in improving quality of life in mild
scoliosis. Unlike our study, Vasiliadis and Grivas37 reported
that quality of life in patients with AIS was negatively
affected by conservative treatment, including braces and
exercises. It has been previously reported that stabilization
training improves quality of life in patients with lower
back pain;40 however, there has been no comparable study
in scoliosis. In addition, there is no study which reported
on the efficacy of scoliosis-specific exercises to improve
cosmetic problems, quality of life, disability, pain, and
physiological issues in recent Cochrane review.15
This study included an AIS population which was close
to skeletal maturity (Average 14 years and Risser 2). The
CS training intervention might be more significant in
younger patients (lower Risser sign) with AIS who have
high risk of curve progression. However, there were some
limitations in this study. We did not objectively measure
the patients’ ability to contract the core muscles properly.
In addition, compliance to home exercises and wearing of
braces was subjective. Although change in lumbar AVR
was statistically significant, the clinical significance was
questionable (small magnitude of rotational change < 5°).
However, positive change in lumbar AVR with stabiliza-
tion training showed that CS training is a promising
approach especially to treat lumbar AVR in patients with
idiopathic scoliosis.
Conclusion
Our study indicated that CS exercises are more effective in
reducing AVR and pain than traditional exercises for the
conservative treatment of AIS. In addition, CS training
was helpful in improving curve magnitude, trunk deform-
ity, postural symmetry, and quality of life with trends
toward better outcomes in AIS. The improvements
obtained are valid for the 10 weeks of treatment (for short
treatment time), and further studies are warranted with
long time follow-up.
Acknowledgements
This study was approved by ClinicalTrials.gov (A service of the
US National Institutes of Health) with the identifier NCT02552615.
Author contribution
All authors contributed equally in the preparation of this article.
Gür et al.
Declaration of conflicting interests
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) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
This work was supported by the Scientific Research Coordination
Unit of Hacettepe University (project no. 014 T11 102 002).
References
1. Wever D, Veldhuizen A, Klein J, et al. A biomechanical
analysis of the vertebral and rib deformities in structural
scoliosis. Eur Spine J 1999; 8(4): 252–260.
2. Ayhan C, Unal E and Yakut Y. Core stabilisation reduces
compensatory movement patterns in patients with injury to
the arm: a randomized controlled trial. Clin Rehabil 2014;
28(1): 36–47.
3. Herman R, Mixon J, Fisher A, et al. Idiopathic scoliosis and
the central nervous system: a motor control problem. The
Harrington lecture, 1983. Scoliosis-Research-Society. Spine
1985; 10(1): 1–14.
4. Akuthota V and Nadler SF. Core strengthening. Arch Phys
Med Rehabil 2004; 85(3 Suppl. 1): S86–S92.
5. Chan Y-L, Cheng JC, Guo X, et al. MRI evaluation of mul-
tifidus muscles in adolescent idiopathic scoliosis. Pediatr
Radiol 1999; 29(5): 360–363.
6. Kim H, Lee C-K, Yeom JS, et al. Asymmetry of the cross-
sectional area of paravertebral and psoas muscle in patients
with degenerative scoliosis. Eur Spine J 2013; 22(6): 1332–
1338.
7. Mannion A, Meier M, Grob D, et al. Paraspinal muscle fibre
type alterations associated with scoliosis: an old problem
revisited with new evidence. Eur Spine J 1998; 7(4): 289–
293.
8. Weiss H. Imbalance of electromyographic activity and
physical rehabilitation of patients with idiopathic scoliosis.
Eur Spine J 1993; 1(4): 240–243.
9. Zoabli G, Mathieu PA and Aubin C-É. Back muscles biom-
etry in adolescent idiopathic scoliosis. Spine J 2007; 7(3):
338–344.
10. Muthukrishnan R, Shenoy SD, Jaspal SS, et al. The dif-
ferential effects of core stabilization exercise regime and
conventional physiotherapy regime on postural control
parameters during perturbation in patients with movement
and control impairment chronic low back pain. Sports Med
Arthrosc Rehabil Ther Technol 2010; 2: 13.
11. Hides J, Wilson S, Stanton W, et al. An MRI investigation
into the function of the transversus abdominis muscle dur-
ing “drawing-in” of the abdominal wall. Spine 2006; 31(6):
E175–E178.
12. Koumantakis GA, Watson PJ and Oldham JA.
Supplementation of general endurance exercise with stabi-
lisation training versus general exercise only: physiological
and functional outcomes of a randomised controlled trial of
patients with recurrent low back pain. Clin Biomech 2005;
20(5): 474–482.
309
13. Shin SS, Lee YW and Song CH. Effects of lumbar stabiliza-
tion exercise on postural sway of patients with adolescent
idiopathic scoliosis during quiet sitting. J Phys Ther Sci.
2012; 24(2): 211–215.
14. Alves de Araujo ME, Bezerra da 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.
15. Romano M, Minozzi S, Bettany-Saltikov J, et al. Exercises
for adolescent idiopathic scoliosis. Cochrane Database
Syst Rev. Epub ahead of print 15 April 2009. DOI:
10.1002/14651858.CD007837.
16. Emery K, De Serres SJ, McMillan A, et al. The effects of
a Pilates training program on arm–trunk posture and move-
ment. Clin Biomech 2010; 25(2): 124–130.
17. Monticone M, Ambrosini E, Cazzaniga D, 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(6): 1204–1214.
18. Seifert J, Selle A, Flieger C, et al. Compliance as a prognos-
tic factor in the treatment of idiopathic scoliosis. Orthopade
2009; 38(2): 151–158 (in German).
19. Gur G, Dilek B, Ayhan C, et al. Effect of a spinal brace
on postural control in different sensory conditions in ado-
lescent idiopathic scoliosis: a preliminary analysis. Gait
Posture 2015; 41(1): 93–99.
20. Zaina F, Fusco C, Atanasio S, et al. The SPoRT concept
of bracing for idiopathic scoliosis. Physiother Theory Pract
2011; 27(1): 54–60.
21. Risser J. The Iliac apophysis; an invaluable sign in the man-
agement of scoliosis. Clin Orthop 1957; 11: 111–119.
22. King HA, Moe JH, Bradford DS, et al. The selection of
fusion levels in thoracic idiopathic scoliosis. J Bone Joint
Surg Am 1983; 65(9): 1302–1313.
23. Bunnell WP. Outcome of spinal screening. Spine 1993;
18(12): 1572–1580.
24. Amendt LE, Ause-Ellias KL, Eybers JL, et al. Validity and
reliability testing of the Scoliometer. Phys Ther 1990; 70(2):
108–117.
25. Bago J, Sanchez-Raya J, Perez-Grueso F, et al. The Trunk
Appearance Perception Scale (TAPS): a new tool to evalu-
ate subjective impression of trunk deformity in patients with
idiopathic scoliosis. Scoliosis 2010; 5(6): 1–9.
26. 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.
27. Asher M, Lai SM, 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.
28. Aulisa AG, Guzzanti V, Falciglia F, et al. Lyon bracing in
adolescent females with thoracic idiopathic scoliosis: a pro-
spective study based on SRS and SOSORT criteria. BMC
Musculoskelet Disord 2015; 16(1): 316.
29. Nachemson AL and Peterson L-E. Effectiveness of treat-
ment with a brace in girls who have adolescent idiopathic
310
scoliosis. A prospective, controlled study based on data
from the Brace Study of the Scoliosis Research Society. J
Bone Joint Surg Am 1995; 77(6): 815–822.
30. Soucacos P, Zacharis K, Gelalis J, et al. Assessment of
curve progression in idiopathic scoliosis. Eur Spine J 1998;
7(4): 270–277.
31. De Mauroy JC. Idiopathic scoliosis and chaos. Stud Health
Technol Inform 2008; 135: 53.
32. Lee M, Hwang J, Seo B, et al. The effects of the core muscle
release technique on scoliosis. J Phys Ther Sci. 2013; 25(4):
445–448.
33. 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.
34. Weiss H-R, Weiss G and Petermann F. Incidence of cur-
vature progression in idiopathic scoliosis patients treated
with scoliosis in-patient rehabilitation (SIR): an age- and
sex-matched controlled study. Pediatr Rehabil 2003; 6(1):
23–30.
Prosthetics and Orthotics International 41(3)
35. 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.
36. Wells C, Kolt GS and Bialocerkowski A. Defining Pilates
exercise: a systematic review. Complement Ther Med 2012;
20(4): 253–262.
37. Vasiliadis E and Grivas TB. Quality of life after conserva-
tive treatment of adolescent idiopathic scoliosis. Stud Health
Technol Inform 2008; 135: 409–413.
38. Gotfryd AO, Franzin FJ, Poletto PR, et al. Pain assessment in
patients with adolescent idiopathic scoliosis at different stages
of disease evolution. MedicalExpress 2014; 1(4): 170–173.
39. Standaert CJ, Weinstein SM and Rumpeltes J. Evidence-
informed management of chronic low back pain with lum-
bar stabilization exercises. Spine J 2008; 8(1): 114–120.
40. Shaughnessy M and Caulfield B. A pilot study to investigate
the effect of lumbar stabilisation exercise training on func-
tional ability and quality of life in patients with chronic low
back pain. Int J Rehabil Res 2004; 27(4): 297–301.