ISICO (Italian Scientific Spine Institute), Milan, Italy.
Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
Cochrane Database Syst Rev. 2024 Feb 28;2(2):CD007837. doi: 10.1002/14651858.CD007837.pub3.
Adolescent idiopathic scoliosis (AIS) is a pathology that changes the three-dimensional shape of the spine and trunk. While AIS can progress during growth and cause cosmetic issues, it is usually asymptomatic. However, a final spinal curvature above the critical threshold of 30° increases the risk of health problems and curve progression in adulthood. The use of therapeutic exercises (TEs) to reduce the progression of AIS and delay or avoid other, more invasive treatments is still controversial.
To evaluate the effectiveness of TE, including generic therapeutic exercises (GTE) and physiotherapeutic scoliosis-specific exercises (PSSE) in treating AIS, compared to no treatment, other non-surgical treatments, or between treatments.
We searched CENTRAL, MEDLINE, Embase, four other databases, and two clinical trials registers to 17 November 2022. We also screened reference lists of articles.
Randomised controlled trials (RCTs) comparing TE with no treatment, other non-surgical treatments (braces, electrical stimulation, manual therapy), and different types of exercises. In the previous version of the review, we also included observational studies. We did not include observational studies in this update since we found sufficient RCTs to address our study aims.
We used standard Cochrane methodology. Our major outcomes were progression of scoliosis (measured by Cobb angle, trunk rotation, progression, bracing, surgery), cosmetic issues (measured by surface measurements and perception), and quality of life (QoL). Our minor outcomes were back pain, mental health, and adverse effects.
We included 13 RCTs (583 participants). The percentage of females ranged from 50% to 100%; mean age ranged from 12 to 15 years. Studies included participants with Cobb angles from low to severe. We judged 61% of the studies at low risk for random sequence generation and 46% at low risk for allocation concealment. None of the studies could blind participants and personnel. We judged the subjective outcomes at high risk of performance and detection bias, and the objective outcomes at high risk of detection bias in six studies and at low risk of bias in the other six studies. One study did not assess any objective outcomes. Comparing TE versus no treatment, we are very uncertain whether TE reduces the Cobb angle (mean difference (MD) -3.6°, 95% confidence interval (CI) -5.6 to -1.7; 2 studies, 52 participants). Low-certainty evidence indicates PSSE makes little or no difference in the angle of trunk rotation (ATR) (MD -0.8°, 95% CI -3.8 to 2.1; 1 study, 45 participants), may reduce the waist asymmetry slightly (MD -0.5 cm, 95% CI -0.8 to -0.3; 1 study, 45 participants), and may result in little to no difference in the score of cosmetic issues measured by the Spinal Appearance Questionnaire (SAQ) General (MD 0.7 points, 95% CI -0.1 to 1.4; 1 study, 16 participants). PSSE may result in little to no difference in self-image measured by the Scoliosis Research Society - 22 Patient Questionnaire (SRS-22) (MD 0.3 points, 95% CI -0.3 to 0.9; 1 study, 16 participants) and improve QoL slightly measured by SRS-22 Total score (MD 0.3 points, 95% CI 0.1 to 0.4; 2 studies, 61 participants). Only Cobb angle results were clinically meaningful. Comparing PSSE plus bracing versus bracing, low-certainty evidence indicates PSSE plus bracing may reduce Cobb angle (-2.2°, 95% CI -3.8 to -0.7; 2 studies, 84 participants). Comparing GTE plus other non-surgical interventions versus other non-surgical interventions, low-certainty evidence indicates GTE plus other non-surgical interventions may reduce Cobb angle (MD -8.0°, 95% CI -11.5 to -4.5; 1 study, 80 participants). We are uncertain whether PSSE plus other non-surgical interventions versus other non-surgical interventions reduces Cobb angle (MD -7.8°, 95% CI -12.5 to -3.1; 1 study, 18 participants) and ATR (MD -8.0°, 95% CI -12.7 to -3.3; 1 study, 18 participants). PSSE plus bracing versus bracing alone may make little to no difference in subjective measurement of cosmetic issues as measured by SAQ General (-0.2 points, 95% CI -0.9 to 0.5; 1 study, 34 participants), self-image score as measured by SRS-22 Self-Image (MD 0.1 points, 95% CI -0.3 to 0.5; 1 study, 34 participants), and QoL measured by SRS-22 Total score (MD 0.2 points, 95% CI -0.1 to 0.5; 1 study, 34 participants). None of these results were clinically meaningful. Comparing TE versus bracing, we are very uncertain whether PSSE allows progression of Cobb angle (MD 2.7°, 95% CI 0.3 to 5.0; 1 study, 60 participants), changes self-image measured by SRS-22 Self-Image (MD 0.1 points, 95% CI -1.0 to 1.1; 1 study, 60 participants), and QoL measured by SRS-22 Total score (MD 3.2 points, 95% CI 2.1 to 4.2; 1 study, 60 participants). None of these results were clinically meaningful. Comparing PSSE with GTE, we are uncertain whether PSSE makes little or no difference in Cobb angle (MD -3.0°, 95% CI -8.2 to 2.1; 4 studies, 192 participants; very low-certainty evidence). PSSE probably reduces ATR (clinically meaningful) (MD -3.0°, 95% CI -3.4 to -2.5; 2 studies, 138 participants). We are uncertain about the effect of PSSE on QoL measured by SRS-22 Total score (MD 0.26 points, 95% CI 0.11 to 0.62; 3 studies, 168 participants) and on self-image measured by SRS-22 Self-Image and Walter Reed Visual Assessment Scale (standardised mean difference (SMD) 0.77, 95% CI -0.61 to 2.14; 3 studies, 168 participants). Further, low-certainty evidence indicates that 38/100 people receiving GTE may progress more than 5° Cobb versus 7/100 receiving PSSE (risk ratio (RR) 0.19, 95% CI -0.67 to 0.52; 1 study, 110 participants). None of the included studies assessed adverse effects.
AUTHORS' CONCLUSIONS: The evidence on the efficacy of TE is currently sparse due to heterogeneity, small sample size, and many different comparisons. We found only one study following participants to the end of growth showing the efficacy of PSSE over TE. This result was weakened by adding studies with short-term results and unclear preparation of treating physiotherapists. More RCTs are needed to strengthen the current evidence and study other highly clinically relevant outcomes such as QoL, psychological and cosmetic issues, and back pain.
青少年特发性脊柱侧凸（AIS）是一种改变脊柱和躯干三维形状的病理。虽然 AIS 在生长过程中可能会进展并导致美容问题，但通常无症状。然而，脊柱曲率超过 30°的临界阈值的最终变化会增加健康问题和成年后曲线进展的风险。使用治疗性运动（TE）来减少 AIS 的进展并延迟或避免其他更具侵入性的治疗方法仍然存在争议。
评估 TE（包括通用治疗性运动（GTE）和物理治疗脊柱侧凸特异性运动（PSSE））在治疗 AIS 方面的有效性，与不治疗、其他非手术治疗或不同治疗方法相比。
我们检索了 CENTRAL、MEDLINE、Embase、其他四个数据库和两个临床试验注册库，截至 2022 年 11 月 17 日。我们还筛选了文章的参考文献列表。
比较 TE 与不治疗、其他非手术治疗（支具、电刺激、手动治疗）和不同类型运动的随机对照试验（RCT）。在之前的版本中，我们还包括了观察性研究。由于我们发现足够的 RCT 来解决我们的研究目标，因此在本次更新中我们没有包括观察性研究。
我们使用了标准的 Cochrane 方法。我们的主要结局是脊柱侧凸的进展（通过 Cobb 角、躯干旋转、进展、支具、手术来衡量）、美容问题（通过表面测量和感知来衡量）和生活质量（QoL）。我们的次要结局是背痛、心理健康和不良影响。
我们纳入了 13 项 RCT（583 名参与者）。女性比例从 50%到 100%不等；平均年龄从 12 岁到 15 岁不等。研究包括 Cobb 角从低到严重的参与者。我们判断 61%的研究在随机序列生成方面风险较低，46%的研究在分配隐藏方面风险较低。没有研究可以对参与者和人员进行盲法。我们判断主观结局的检测偏倚风险高，客观结局的检测偏倚风险在 6 项研究中高，在其他 6 项研究中低。一项研究没有评估任何客观结局。
与不治疗相比，我们非常不确定 TE 是否能减少 Cobb 角（平均差值（MD）-3.6°，95%置信区间（CI）-5.6 至-1.7；2 项研究，52 名参与者）。低确定性证据表明 PSSE 在躯干旋转角（ATR）方面的差异很小或没有（MD -0.8°，95%CI -3.8 至 2.1；1 项研究，45 名参与者），可能稍微减少腰侧不对称（MD -0.5cm，95%CI -0.8 至-0.3；1 项研究，45 名参与者），并且可能对 Spinal Appearance Questionnaire（SAQ）General（MD 0.7 分，95%CI -0.1 至 1.4；1 项研究，16 名参与者）测量的美容问题的评分没有影响。PSSE 可能对 Scoliosis Research Society-22 患者问卷（SRS-22）测量的自我形象（MD 0.3 分，95%CI -0.3 至 0.9；1 项研究，16 名参与者）和 SRS-22 总评分（MD 0.3 分，95%CI 0.1 至 0.4；2 项研究，61 名参与者）测量的 QoL 有轻微改善。只有 Cobb 角的结果才有临床意义。与 PSSE 加支具相比，低确定性证据表明 PSSE 加支具可能减少 Cobb 角（MD -2.2°，95%CI -3.8 至-0.7；2 项研究，84 名参与者）。与其他非手术干预加 PSSE 相比，低确定性证据表明 GTE 加其他非手术干预可能减少 Cobb 角（MD -8.0°，95%CI -11.5 至-4.5；1 项研究，80 名参与者）。我们不确定 PSSE 加其他非手术干预与其他非手术干预相比是否能减少 Cobb 角（MD -7.8°，95%CI -12.5 至-3.1；1 项研究，18 名参与者）和 ATR（MD -8.0°，95%CI -12.7 至-3.3；1 项研究，18 名参与者）。PSSE 加支具与支具单独治疗相比，在 SAQ General（MD -0.2 分，95%CI -0.9 至 0.5；1 项研究，34 名参与者）、SRS-22 Self-Image（MD 0.1 分，95%CI -0.3 至 0.5；1 项研究，34 名参与者）和 SRS-22 总评分（MD 0.2 分，95%CI -0.1 至 0.5；1 项研究，34 名参与者）测量的主观美容问题方面，PSSE 可能对自我形象没有影响，QoL 也没有影响。这些结果都没有临床意义。与支具相比，我们非常不确定 PSSE 是否允许 Cobb 角的进展（MD 2.7°，95%CI 0.3 至 5.0；1 项研究，60 名参与者），改变 SRS-22 Self-Image（MD 0.1 分，95%CI -1.0 至 1.1；1 项研究，60 名参与者）和 SRS-22 总评分（MD 3.2 分，95%CI 2.1 至 4.2；1 项研究，60 名参与者）测量的 QoL。这些结果都没有临床意义。与 GTE 相比，我们不确定 PSSE 是否能使 Cobb 角的差异小或无差异（MD -3.0°，95%CI -8.2 至 2.1；4 项研究，192 名参与者；非常低确定性证据）。PSSE 可能会减少 ATR（具有临床意义）（MD -3.0°，95%CI -3.4 至-2.5；2 项研究，138 名参与者）。我们不确定 PSSE 是否对 SRS-22 总评分（MD 0.26 分，95%CI 0.11 至 0.62；3 项研究，168 名参与者）和 SRS-22 Self-Image 和 Walter Reed Visual Assessment Scale（SMD 0.77，95%CI -0.61 至 2.14；3 项研究，168 名参与者）测量的 QoL 有影响。此外，低确定性证据表明，38/100 名接受 GTE 的人可能会比 7/100 名接受 PSSE 的人进展超过 5° Cobb（RR 0.19，95%CI -0.67 至 0.52；1 项研究，110 名参与者）。没有研究评估不良影响。
由于异质性、样本量小和许多不同的比较，目前 TE 疗效的证据非常有限。我们只发现了一项研究，该研究随访了接受 PSSE 治疗的参与者，直到生长结束，证明了 PSSE 比 TE 更有效。这一结果因加入了短期结果的研究和对治疗物理治疗师的准备情况不明确而减弱。需要更多的 RCT 来加强现有的证据，并研究其他高度临床相关的结果，如 QoL、心理和美容问题以及背痛。
