Scoliosis is defined as a lateral curvature found either in the lower lumbar, middle thoracic, and/or upper cervical spinal column regions. Curvatures are generally described as either conforming to an “S” or “C” shape . Spinal deformities can result in pain when performing relatively simple tasks such as standing, walking, or lifting objects and is often accompanied by a decreased range of motion. Uncontrolled disease progression may further result in severe pain, to the point of immobility, or even osteoporosis. Adolescent idiopathic scoliosis (AIS) is the usual diagnosis made in healthy children with a spinal curvature of unknown cause of least 10 degrees but less than 50 degrees. It represents the most common scoliosis type affecting 1-3% of adolescents in the United States . Worldwide prevalence of AIS has been more difficult to estimate. Factors such as “varying definitions of scoliosis, study protocols, and age-groups, missing standards for comparison and inclusion of curves <10°” have impacted a true estimate. However, several studies examined by Konieczny et. al.  indicated a prevalence of 0.47–5.2 % for AIS.Scoliosis treatment can be separated into either conservative or surgical methods, being based upon patient age, curvature size, and the risk of disease progression. The primary aim of scoliosis management is to stop curvature progression. Non-conservative treatment usually involves surgery to correct spinal deformities but these procedures are not without risk. Conservative therapies such as physiotherapy scoliosis-specific exercise (PSSE), with or without concurrent external bracing, are used as an alternative for patients presenting less than a 50-degree curvature. Due to the lack of higher quality studies, systematic reviews in 2014 and 2016 concluded that there was insufficient evidence to make a judgement as to whether conservative treatments were effective in managing this population [4, 5]. Anecdotally, the American Academy of Orthopedic Surgeons agree that PSSEs are often considered to produce just as successful of a patient outcome as does surgery .
There are a number of specific types of PSSEs referenced in the literature, but some techniques appear to be prescribed more often than others [7,8,9,10]. The four exercise approaches initially considered in this review included the Schroth method, the Scientific Exercise Approach to Scoliosis (SEAS), the Dobosiewicz technique, and the Side-shift program.
The Schroth method was developed by Katharina Schroth in Germany in 1921. This particular method uses a physiotherapeutic approach in strengthening and lengthening any uneven muscle groups. Treatments consists largely of a combination of scoliotic posture correction along with a modification of a patient’s breathing pattern through mirror self-monitoring [11, 12]. Schroth breathing techniques are described as a “rotational breathing”, which aims to lengthen the trunk and correct spinal imbalances . The primary goal is to improve both the patient’s posture and spine alignment mediated by a clinician maintaining proper positioning and utilizing exercise repetition. Using a mirror, the patient is taught to visualize his/her collapsed area(s) needing to be lengthened or contracted. Over time, exercise promotes spinal muscle correction to help stabilize curve(s), mobilize stiff body regions, correct postural alignment, and increase muscle strength/endurance. This process is largely accomplished through axial lengthening, asymmetric sagittal straightening, rotational breathing, and developing frontal sagittal straightening and muscle activation .
Based upon the Lyon methodology, the Scientific Exercise Approach to Scoliosis (SEAS) began in the 1960s . SEAS has been described as a “scoliosis-specific active self-correction technique performed without any external aids and incorporated into functional exercises” . The primary goals of SEAS include enhanced posture control, posture rehabilitation, muscle endurance, spinal stability, self-correction, and development of balance stability . Treatment sessions are conducted at least twice a week for 40 minutes each. Unlike the Schroth method these treatments are mostly performed at home. Additionally, SEAS utilizes a teamwork approach involving both clinicians (physician, physiotherapist, orthotist) and family members in generating successful patient outcomes .
The Dobosiewicz method, or DoboMed, was established in 1979. It has been described as a “3D auto-correction” technique. This particular technique utilizes a combination of instructional elements including mirrors, photographs, and video all to promote the correct execution of treatment exercises. There are three main objectives. First, a symmetrically positioned pelvis and shoulder girdle. Second, a primary curve mobilization towards a normal posture with a special emphasis on kyphotization or backward displacement of the thoracic spine along with a “lordotization” of the lumbar spine, as required . Third, to achieve stabilization of the corrected spinal position and make it a postural habit of the patient. The DoboMed can be used by itself, in conjunction with bracing, or even prior to surgical correction [7, 16, 17].Mehta first reported on the Side-shift exercise program in 1985, a year after its development. This method involves active correction of the spinal curve through frequent lateral shifting of the trunk relative to the concavity of the curve. The primary objective of the program is to effectively reduce AIS patient spinal deviation by gradually correcting it towards the body midline. The Side Shift method uses similar breathing techniques to the Schroth and DoboMed methods . Exercises are independently performed, which means that patients must be old enough to understand how to properly accomplish prescribed exercises. It may hold its greatest promise as an additional treatment for AIS patients demonstrating an initial Cobb angle between 20°- 32°. However, it has also been suggested that the Side-shift method should only be considered as a secondary treatment method for AIS .
These four PSSE methods have shown some promise for improving outcomes in patients with AIS [9, 18, 20, 21, 24]. To the author’s knowledge, three systematic reviews have exclusively investigated the effects of PSSE’s on individuals with AIS and these were published in 2008, 2011, 2013 [9, 18, 19]. Based on these reviews, recommendations were made in favor of PSSE’s for reducing scoliosis curve progression (Cobb angles) in patients with AIS, but several studies were noted to have weak methodological rigor and the heterogeneity of the studies did not allow the author’s to perform additional quantitative analyses, like effect size calculations. The authors of these reviews recommended a continuation of clinical trials with similar outcome measures and full data sets so that comparisons of PSSEs to no interventions and other types of exercises can be made. To that end, the authors have noted that updates to the literature have been made since 2013.Therefore, the purposes of the current review is to 1) determine if there is quantitative evidence that common PSSE’s (Schroth, SEAS, DoboMed, Side-shift methods) are effective at improving Cobb angles in patients with AIS compared to no treatment, 2). determine if there is quantitative evidence that common PSSE’s are effective at improving Cobb angles in patients with AIS compared to standard exercise prescription and if possible, 3) to explore if one PSSE method is more effective at improving Cobb angles compared to other PSSEs in patients with AIS. The author’s hypothesize that all PSSEs will demonstrate objective improvement in Cobb angles in patients with AIS, and based on clinical observation, the Schroth method provides superior results compared to the other methods.