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Indications for conservative management of scoliosis (SOSORT guidelines 2010)

SOSORT guideline committee , Hans-Rudolf Weiss* (1) , Stefano Negrini* (2) , Manuel Rigo (3) , Tomasz Kotwicki (4) , Martha C Hawes* (5) , Theodoros B Grivas (6) , Toru Maruyama (7)  and Franz Landauer (8)

1 Orthopedic Rehabilitation Services, „Gesundheitsforum Nahetal“ Gensingen, Germany
2 ISICO (Italian Scientific Spine Institute), Milan, Italy
3 Instituto Èlena Salvá, Barcelona, Spain
4 University of Medical Sciences, Poznan, Poland
5 University of Arizona, Tucson AZ 85721, USA
6 Orthopaedic Department "Thriasion" General Hospital, Magula, Athens, Greece
7 Department of Orthopaedic Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo 173-8605, Japan
8 Landesklinik für Orthopädie, Müllner Hauptstr. 48, A-5020 Salzburg, Austria
author email corresponding author email* Contributed equally

This guideline has been discussed by the SOSORT guideline committee prior to the SOSORT consensus meeting in Milan, January 2005 and published in its first version on the SOSORT homepage: webcite. After the meeting it again has been discussed by the members of the SOSORT guideline committee to establish the final 2005 version submitted to Scoliosis, the official Journal of the society, in December 2005. Recent publications made it necessary to adapt the guidelines to the actualized 2010 version.

Scoliosis is defined as a lateral curvature of the spine with torsion of the spine and chest as well as a disturbance of the sagittal profile [2].

Idiopathic scoliosis is the most common of all forms of lateral deviation of the spine. By definition, it is a lateral curvature of the spine in an otherwise healthy child, for which a currently recognizable cause has not been found. Recent investigations focus on a functional tethering of the spinal cord, or neuro-osseus disturbance [3, 4], which may result in a ventral overgrowth, however loss of lumbar lordosis has not yet been clearly explained [5]. Less common but better defined etiologies of the disorder include scoliosis of neuromuscular origin, congenital scoliosis, scoliosis in neurofibromatosis, Prader Willi syndrome and mesenchymal disorders like Marfan's syndrome [6-8].

The prevalence of adolescent idiopathic scoliosis (AIS), when defined as a curvature greater than 10° according to Cobb, is 0.9 -  12%. 
Nissinen M, Heliovaara M, Ylikoski M, Poussa M: Trunk asymmetry and screening for scoliosis: a longitudinal cohort study of pubertal schoolchildren. Acta Paediatr 1993, 82(1):77-82.
Willner S, Uden A: A prospective prevalence study of scoliosis in Southern Sweden. Acta Orthop Scand 1982, 53(2):233-7.
Laulund T, Sojbjerg JO, Horlyck E: Moire topography in school screening for structural scoliosis. Acta Orthop Scand 1982, 53(5):765-8.
Dickson RA et al 1983:  Scoliosis in the community. Br Med J 1983, 19(6365):615-8.
Strayer LM et al, 1973: The incidence of scoliosis in post-partum female on Cape Cod. J Bone Joint Surg Am 1973, 55A:436.
Brooks HL, Azen SP, Gerberg E, Brooks R, Chan L: Scoliosis: A prospective epidemiological study. J Bone Joint Surg Am 1975, 57(7):968-72.
Sugita K 2000: Epidemiological study on idiopathic scoliosis in high school students. Prevalence and relation to physique, physical strength and motor ability. Nippon Koshu Eisei Zasshi 2000, 47(4):320-5.
Wong HK, Hui JH, Rajan U, Chia HP2005: Idiopathic scoliosis in Singapore schoolchildren: a prevalence study 15 years into the screening program. Spine 2005, 30(10):1188-96.
Huang SC 1997: Cut-off point of the Scoliometer in school scoliosis screening. Spine 1997, 22(17):1985-9.
The prevalence of curvatures greater than 20° is between 0.3 and 0.5%, while curvatures greater than 40° Cobb are found in less than 0.1% of the population. All etiologies of scoliosis other than AIS are encountered more rarely [9,10].

The anatomical level of the deformity has received attention from clinicians as a basis for scoliosis classification. The level of the apex vertebra (i.e., thoracic, thoracolumbar, lumbar or double major) forms a simple basis for description. In 1983, King and colleagues [11] classified different curvature patterns by the extent of spinal fusion required; however, recent reports have suggested that these classifications lack reliability. Another description has been developed by Lenke and colleagues [12]. This approach calls for clinical assessment of scoliosis and kyphosis with respect to sagittal profile and curvature components. Systems designed for conservative management include the classifications by Lehnert-Schroth [13] (functional three-curve and functional four-curve scoliosis) and by Rigo [14] (brace construction and application).
Aims of conservative management
The primary aim of scoliosis management is to stop curvature progression [15]. Improvement of pulmonary function (vital capacity) and treatment of pain are also of major importance. The first of two modes of conservative scoliosis management is based on physical therapy, including Méthode Lyonaise [16], Side-Shift [17], Dobosiewicz [18], Schroth and others [19]. Although discussed from contrasting viewpoints in the international literature, today there is evidence for the effectiveness of scoliosis treatment by physical therapy alone [19-21]. It has been shown, that physiotherapy may reduce the risk for brace treatment [22] (Figure 1.).
It has to be emphasized that (1) physical therapy for scoliosis is not just general exercises but rather one of the cited methods designed to address the particular nuances of spinal deformity, and (2) application of such methods requires therapists and clinicians specifically trained and certified in those scoliosis specific conservative intervention methods.
Intensive rehabilitation (SIR), which appeared to be effective with respect to many signs and symptoms of scoliosis and with respect to impeding curvature progression [23] today seems outdated in view of the fact, that out-patient therapies may lead to the same results [24-26]. Initially a 6 week intensive in-patient program has been investigated, however the results achieved in this special ancient setting cannot be compared actually to the results with reduced rehabilitation times and modified programs [24]. More intensive out-patient programs are provided by Negrini, Rigo and Weiss and do not seem less effective than the actual inpatient program [24-26].
The second mode of conservative management is brace treatment, which has been found to be effective in preventing curvature progression and thus in altering the natural history of IS [27,28]. It appears that brace treatment may reduce the prevalence of surgery [29], restore the sagittal profile [30] and influence vertebral rotation [31]. There are also indications that the end result of brace treatment can be predicted [32].
Systematic application of the two modes of conservative treatment with respect to Cobb angle and maturity
Guidelines for conservative intervention are based on current information regarding the risk for significant curvature progression in a given period of time. Each case has its own natural history and must be considered on an individual basis, in the context of a thorough clinical evaluation and patient history [33]. Estimation of risk for progression is based on small (n < 1000) epidemiological surveys in which children were diagnosed with scoliosis, and radiographed periodically to quantify changes in curvature magnitude over time [34-56]. Such surveys support the premise that, among populations of children with a diagnosis of idiopathic scoliosis, risk for progression is highly correlated with potential for growth over the period of observation. In boys, prognosis for progression is more favorable, with relatively fewer individuals having curves that progress to >40 degrees. For SOSORT guidelines, prognostic risk estimation is based on the calculation of Lonstein and Carlson [45]. This calculation is based on curvature progression observed among 727 patients (575 female, 152 male) diagnosed between 1974–1979 in state of Minnesota (United States) school screening programs, and followed until they reached skeletal maturity. (See Figure 2).

I. Children (no signs of maturity)
a. < 15° Cobb: Observation (6 – 12 month intervals)
b. Cobb angle 15–20°: Physical therapy with treatment-free intervals (6–12 weeks without physical therapy for those patients at that time have low risk for curve progression).
c. Cobb angle 20–25°: Physical therapy
d. > 25° Cobb: Physical therapy and brace wear (part-time, 12–16 hours).

II. Children and adolescents, Risser 0–3, first signs of maturation, less than 98% of mature height
The following section is based on progression risk rather than on Cobb angle measurement because of the changing risk profiles for deformity as the skeleton matures. For our purposes, progression risk is calculated by the formula shown in figure 1.
a. Progression risk less than 40%: Observation (3-month intervals)
b. Progression risk 40%: Physical therapy
c. Progression risk 60%: Physical therapy + part-time brace indication (16 – 23 hours [low risk]).
d. Progression risk 80%: Physical therapy + full-time brace indication (23 hours [high risk]).

III. Children and adolescents presenting with Risser 4 (more than 98% of mature height)
a. < 20° according to Cobb: Observation (6 – 12 Months intervals)
b. 20 – 35° according to Cobb: Physical therapy .
c. > 35° according to Cobb: Physical therapy + brace (part time, about 16 hours are sufficient)
d. For brace weaning: Physical therapy + brace with reduced wearing time.

IV. First presentation with Risser 4–5 (more than 99.5% of mature height before growth is completed)
a. > 25° Cobb: Physical therapy.
b. > 35° according to Cobb: Physical therapy + brace (part time, about 16 hours are sufficient in cosmetic indication only, when surgery can be avoided).

V. Adults with Cobb angles > 30°: Physical therapy.

VI. Adolescents and adults with scoliosis (of any degree) and chronic pain
Physical therapy, scoliosis rehabilitation program (multimodal pain concept/behavioral + physical concept), brace treatment when a positive effect has been proven [5,57].

The prognostic estimation and corresponding indications for treatment apply to the most prevalent condition, idiopathic scoliosis. In other types of scoliosis a similar procedure can be applied. Exceptions include those cases where the prognosis is clearly worse, for example in neuromuscular scolioses where a wheelchair is necessary (early surgery for maintaining sitting capability may be required). Other reasons for the consideration of alternative treatments include:
- Severe decompensation
- Severe sagittal deviations with structural lumbar kyphosis ('flatback')
- Lumbar, thoracolumbar and caudal component of double curvatures with a disproportionate rotation compared to the Cobb angle and with high risk for future instability at the caudal junctional zone
- Severe contractures and muscles shortening
- Reduced mobility of the spine especially in the sagittal plane
- others to be individually considered [58]

Authors' contributions
*These authors contributed by reviewing, text editing and adding certain textfiles and references


[1] [] webcite
] Stokes IAF: Die Biomechanik des Rumpfes. In Wirbelsäulendeformitäten – Konservatives Management. Edited by: Weiss HR. München, Pflaum; 2003:59-77.

[3] Chu WCW, Lam WMW, Ng BKW, Tze-ping L, Lee K, Guo X, Cheng JCY, Burwell RG, Dangerfield PH, Jaspan T: Relative shortening and functional tethering of spinal cord in adolescent scoliosis – Result of asynchronous neuro-osseous growth, summary of an electronic focus group debate of the IBSE
Scoliosis 2008, 3:8 (27 June 2008)
[4] Burwell RG, Aujla RK, Grevitt MP, Dangerfield PH, Moulton A, Randell TL, Anderson SI: Pathogenesis of adolescent idiopathic scoliosis in girls - a double neuro-osseous theory involving disharmony between two nervous systems, somatic and autonomic expressed in the spine and trunk: possible dependency on sympathetic nervous system and hormones with implications for medical therapy
Scoliosis 2009, 4:24 (31 October 2009)

[5] Weiss HR, Werkmann M: Treatment of chronic low back pain in patients with spinal deformities using a sagittal re-alignment brace. Scoliosis. 2009 Mar 9;4:7.

[6] Weiss HR, Goodall D: Scoliosis in patients with Prader Willi Syndrome - comparisons of conservative and surgical treatment. Scoliosis. 2009 May 6;4:10.
[7] Kaspiris, Grivas, Weiss: Congenital.....
[8] Winter RB: Classification and Terminology. In Moe's Textbook of Scoliosis and Other Spinal Deformities. 2nd edition. Philadelphia Saunders; 1995:39-43.
[9] Weinstein SL: Natural history. Spine 1999, 24:2592-2600. PubMed Abstract | Publisher Full Text
[10] Asher M, Burton DC: Adolescent idiopathic scoliosis: natural history and long term treatment effects
Scoliosis 2006, 1:2 (31 March 2006)
[11] King HA, Moe JHY, Bradford DS, Winter RB: The selection of fusion levels in thoracic IS. Journal of Bone and Joint Surgery 1983, 65-A:1302-1313.
[12] Dangerfield PH: Klassifikation von Wirbelsäulendeformitäten. In Wirbelsäulendeformitäten – Konservatives Management. Edited by: Weiss HR. München, Pflaum; 2003:78-83.
[13] Lehnert-Schroth C: Dreidimensionale Skoliosebehandlung. 6th edition. Urban/Fischer, München; 2000.
[14] Rigo M: Intraobserver reliability of a new classification correlating with brace treatment. Pediatric Rehabilitation 2004, 7:63. Publisher Full Text
[15] Landauer F, Wimmer C: Therapieziel der Korsettbehandlung bei idiopathischer Adoleszentenskoliose. MOT 2003, 123:33-37.
[16] Mollon G, Rodot JC: Scolioses structurales mineures and kinesitherapie. Etude statistique comparative des resultats. Kinesitherapie Scientifique 1986, 244:47-56.
[17] Mehta MH: Active auto-correction for early AIS. Journal of Bone and Joint Surgery 1986, 68:682.
[18] Weiss HR, Negrini S, Hawes MC, Rigo M, Kotwicki T, Grivas TB, Maruyama and members of the SOSORT: Physical Exercises in the Treatment of Idiopathic Scoliosis at Risk of brace treatment – SOSORT Consensus paper 2005. Scoliosis 2005.
[19] Negrini S, Antoninni GI, Carabalona R, Minozzi S: Physical exercises as a treatment for adolescent idiopathic scoliosis. A systematic review. Pediatric Rehabilitation 2003, 6:227-235. PubMed Abstract | Publisher Full Text
[20] Negrini S, Fusco C, Minozzi S, Atanasio S, Zaina F, Romano M: Exercises reduce the progression rate of adolescent idiopathic scoliosis: results of a comprehensive systematic review of the literature. Disabil Rehabil. 2008;30(10):772-85.
[21] Weiss HR, Goodall D: The treatment of adolescent idiopathic scoliosis (AIS) according to present evidence. A systematic review. Eur J Phys Rehabil Med. 2008 Jun;44(2):177-93.
[22] Negrini S, Zaina F, Romano M, Negrini A, Parzini S: Specific exercises reduce brace prescription in adolescent idiopathic scoliosis: a prospective controlled cohort study with worst-case analysis. J Rehabil Med. 2008 Jun;40(6):451-5.
[23] Weiss HR, Weiss G, Petermann F: Incidence of curvature progression in idiopathic scoliosis patients treated with scoliosis in-patient rehabilitation (SIR): an age- and sex-matched cotrolled study. Pediatric Rehabilitation 2003, 6:23-30. PubMed Abstract | Publisher Full Text
[24] Weiss HR, Kozikogli LM, Goodall D: A systematic Pub Med review on in-patient rehabilitation. Proceedings of the 5th World congress of the International Society of Physical and Rehabilitation Medicine, Istanbul, Turkey, 13 – 17 June 2009, Edizioni Minerva Medica
[25] Maruyama T, Kitagawa T, Takeshita K, Mochizuki K, Nakamura K: Conservative treatment for adolescent idiopathic scoliosis: can it reduce the incidence of surgical treatment? Pediatr Rehabil. 2003 Jul-Dec;6(3-4):215-9.
[26] Negrini S, Atanasio S, Zaina F, Romano M, Parzini S, Negrini A: End-growth results of bracing and exercises for adolescent idiopathic scoliosis. Prospective worst-case analysis. Stud Health Technol Inform. 2008;135:395-408
[27] Nachemson AL, Peterson LE, Members of Brace Study Group of the Scoliosis Research Society: Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. J Bone Joint Surg 1995, 77:815-822. PubMed Abstract
[28] Grivas TB, Vasiliadis E, Chatziargiropoulos T, Polyzois VD, Gatos K: The effect of a modified Boston brace with anti-rotatory blades on the progression of curves in idiopathic scoliosis: aetiologic implications. Pediatric Rehabilitation 2003, 6:237-242. PubMed Abstract | Publisher Full Text
[29] Rigo M, Reiter C, Weiss HR: Effect of conservative management on the prevalence of surgery in patients with adolescent idiopathic scoliosis. Pediatric Rehabilitation 2003, 6:209-214. PubMed Abstract | Publisher Full Text
[30] Rigo M: 3 D Correction of Trunk Deformity in Patients with Idiopathic Scoliosis Using Chêneau Brace. In Research into Spinal Deformities 2. Studies in Health Technology and Informatics. Edited by: Stokes IAF. Amsterdam: IOS Press; 1999:362-365.
[31] Kotwicki T, Pietrzak S, Szulc A: Three-dimensional action of Cheneau brace on thoracolumbar scoliosis. In Research into Spinal Deformities 3. Studies in Health Technology and Informatics. Edited by: Tanguy A, Peuchot B. Amsterdam: IOS Press; 2002:226-229.
[32] Landauer F, Wimmer C, Behensky H: Estimating the final outcome of brace treatment for idiopathic thoracic scoliosis at 6-month follow-up. Pediatric Rehabilitation 2003, 6:201-207. PubMed Abstract | Publisher Full Text
[33] Lonstein JE: Patient Evaluation. In Moe's Textbook of Scoliosis and Other Spinal Deformities. 2nd edition. Philadelphia, Saunders; 1995:45-86.
[34] Ascani E, Bartolozzi P, Logroscino CA, Marchetti PG, Ponte A, Savini R, Travaglini F, Binazzi F, Di Silvestre M: Natural history of untreated IS after skeletal maturity. Spine 1986, 11:784-789. PubMed Abstract
[35] Bjerkreim R, Hassan I: Progression in untreated IS after the end of growth. Acta orthop scand 1982, 53:897-900. PubMed Abstract
[36] Brooks HL, Azen SP, Gerberg E, Brooks R, Chan L: Scoliosis: a prospective epidemiological study. Journal of Bone and Joint Surgery 1975, 57:968-72.
[37] Bunnell WP: The natural history of IS before skeletal maturity. Spine 1986, 11:773-776. PubMed Abstract
[38] Clarisse P: Pronostic evolutif des scolioses idiopathiques mineures de 10–29 degrees, en periode de croissance. In Thesis. Lyon France; 1974.
[39] Collis DK, Ponseti IV: Long-term followup of patients with idiopathic scoliosis not treated surgically. Journal of Bone and Joint Surgery 1969, 51-A:425-445.
[40] Duval-Beaupere G: Rib hump and supine angle as prognostic factors for mild scoliosis. Spine 1992, 17:103-107. PubMed Abstract
[41] Duval-Beaupere G: Threshold values for supine and standing Cobb angles and rib hump measurements: prognostic factors for scoliosis. European Spine Journal 1996, 5:79-84. PubMed Abstract | Publisher Full Text
[42] Karol LA, Johnston CE, Browne RH, Madison M: Progression of the curve in boys who have IS. Journal of Bone and Joint Surgery 1993, 75:1804-1810.
[43] Kindsfater K, Lowe T, Lawellin D, Weinstein D, Akmakjian A: Levels of platelet calmodulin for the prediction of progression and severity of AIS. Journal of Bone and Joint Surgery 1994, 76-A:1186-1192.
[44] Korovessis P, Piperos G, Sidiropoulos P, Dimas A: Adult idiopathic lumbar scoliosis: a formula for prediction of progression and review of the literature. Spine 1994, 19:1926-1932. PubMed Abstract
[45] Lonstein JE, Carlson JM: The prediction of curve progression in untreated idiopathic scoliosis during growth. Journal of Bone and Joint Surgery 1984, 66-A:1061-1071.
[46] Masso PD, Meeropol E, Lennon E: Juvenile onset scoliosis followed up to adulthood: orthopedic and functional outcomes. Journal of Pediatric Orthopedics 2002, 22:279-284. PubMed Abstract | Publisher Full Text
[47] Meade KP, Bunch W, Vanderby R, Patwardhan AG, Knight G: Progression of unsupported curves in AIS. Spine 1987, 12:520-526. PubMed Abstract
[48] Mehta M: The rib-vertebra angle in the early diagnosis between resolving and progressive infantile scoliosis. Journal of Bone and Joint Surgery 1972, 54B:230-243.
[49] Nachemson A: A long term followup study of nontreated scoliosis. Acta Orthop Scand 1968, 39:466-476. PubMed Abstract
[50] Picault C, deMauroy JC, Mouilleseaux B, Diana G: Natural history of idiopathic scoliosis in girls and boys. Spine 1986, 11:777-778. PubMed Abstract
[51] Robinson CM, McMaster MJ, Juvenile IS: Curve patterns and prognosis in 109 patients. Journal of Bone and Joint Surgery 1996, 78-A:1140-1148.
[52] Soucacas PN, Zacharis K, Loultanis K, Gelalis J, Xenakis T, Beris AE: Risk factors for IS: review of a 6-year prospective study. Orthopedics 2000, 23:833-838. PubMed Abstract
[53] Soucacos PN, Zacharis K, Soultanis K, Gelalis J, Kalos N, Beris A, Xenakis T, Johnson EO: Assessment of curve progression in IS. European Spine Journal 1998, 7:270-277. PubMed Abstract | Publisher Full Text
[54] Villemure I, Aubin CE, Grimard G, Dansereau J, Labelle H: Progression of vertebral and spinal 3-D deformities in AIS. A longitudinal study. Spine 2001, 26:2244-2250. PubMed Abstract | Publisher Full Text
[55] Wever DJ, Tonseth KA, Veldhuizen AG, Cool JC, vanHorn JR: Curve progression and spinal growth in brace treated IS. Clinical Orthopaedics and Related Research 2000, 337:169-179.
[56] Yamauchi Y, Yamaguchi T, Asaka Y: Prediction of curve progression in IS based on initial roentgenograms; proposal of an equation. Spine 1988, 13:1258-1261. PubMed Abstract
[57] Weiss HR: Das „Sagittal Realignment Brace" (physio-logic® brace) in der Behandlung von erwachsenen Skoliosepatienten mit chronifiziertem Rückenschmerz – erste vorläufige Ergebnisse. Medizinisch Orthopädische Technik 2005, 125:45-54.
[58] Negrini S, Aulisa L, Ferraro C, Fraschini P, Masiero S, Simonazzi P, Tedeschi C, Venturin A: Italian guidelines on rehabilitation treatment of adolescents with scoliosis or other spinal deformities. Eura Medicophys 2005, 41:183-201. PubMed Abstract | Publisher Full Text



Figure 1. 5-year old girl with infantile IS (onset at 3) and a good compliance for  PT presented for bracing after 6 month of out patient PT. The curvature (with clear structural changes) was reduced from 24° to 13° and a brace at that time was not prescribed.


Figure 2. The estimation of the prognostic risk to be used during pubertal growth spurt (modified from Lonstein and Carlson [33]). The numbers in the figure indicate the number of cases that each data point is based on. Note the small number of cases on which the upper margins of the graph are based. Lonstein and Carlson's progression estimation formula is based on curves between 20 and 29 degrees.