J Child Orthop (2010) 4:219–226

DOI 10.1007/s11832-010-0258-6

ORIGINAL CLINICAL ARTICLE

No effect of osteopathic treatment on trunk morphology and spine

flexibility in young women with adolescent idiopathic scoliosis
Carol Hasler • Caius Schmid • Andreas Enggist •

Conny Neuhaus • Thomas Erb

Received: 17 March 2010 / Accepted: 31 March 2010 / Published online: 18 April 2010
Ó EPOS 2010

Abstract Methods This was a prospective, controlled trial of 20

Introduction Brace treatment is the gold standard for post-pubertal young women (20°–40° idiopathic scoliosis)
patients with mild adolescent idiopathic scoliosis (Cobb randomly allocated to an observation (group 0) or osteo-
angle 20°–40°). However, negative psychosocial impacts, pathic treatment (group 1). The latter comprised three
physical constraints and incompliance cause many patients sessions (5 weeks). Trunk morphology (clinical examina-
and parents to seek for so-called holistic and apparently tion, video rasterstereography) and spine flexibility
less harmful approaches within the field of complementary (MediMouseÒ) were assessed at a pre- and post-interven-
and alternative medicine (CAM). Osteopathy—manual tion with a 3-month interval (blinded examiner). We chose
interventions on the viscera and locomotor system—is scoliometer measurement (rib hump, lumbar prominence)
widely used for scoliosis. There is, however, a complete as the main outcome parameter.
lack of evidence regarding its efficacy. We, therefore, Results Two patients in the treatment group refused fur-
tested the hypothesis that osteopathy alters trunk mor- ther treatment and the final examination, as they felt no
phology, a prerequisite to unload the concave side of the benefit after two osteopathic treatments. Regression anal-
scoliosis, and that it halts curve progression. ysis for repeat measurements (independent statistician)
revealed no therapeutic effect on rib hump, lumbar prom-
inence, plumb line, sagittal profile and global spinal
C. Hasler (&)
flexibility.
Orthopaedic Department, University Children’s Hospital,
Roemergasse 8, 4005 Basel, Switzerland Conclusions We found no evidence to support osteopathy
e-mail: [email protected] in the treatment of mild adolescent idiopathic scoliosis.
Therefore, we caution against abandoning the conventional
C. Schmid
standard of care for mild idiopathic scoliosis. As for other
Corpo Sana, Training and Therapy,
Münchensteinerstrasse 220, 4053 Basel, Switzerland CAM therapies, the use of osteopathy as a treatment option
e-mail: [email protected] for scoliosis still needs to be clearly defined.

A. Enggist
Keywords Osteopathy
Adolescent idiopathic scoliosis

Enggist Medical Fitness, Bahnhofstrasse 43,
9470 Buchs, Switzerland Trunk morphology
Randomised trial
e-mail: [email protected]

C. Neuhaus
Introduction
Division of Physiotherapy, University Children’s Hospital,
Roemergasse 8, 4005 Basel, Switzerland
e-mail: [email protected] The treatment of mild idiopathic scoliotic curves (Cobb
angle 20°–40°) during growth to halt progression is a
T. Erb
classic conservative orthopaedic domain [1]. However,
Division of Anaesthesiology, University Children’s Hospital,
Roemergasse 8, 4005 Basel, Switzerland bracing as the cornerstone of this strategy remains con-
e-mail: [email protected] troversial, as its effect is limited by non-compliance and

123
220 J Child Orthop (2010) 4:219–226

potential negative psychosocial effects [2–9]. Intensive – At least 2 years post-menarchal status to exclude
scoliosis-specific rehabilitation regimens might alter the growth and ongoing brace treatment as confounding
curve’s natural history, but these programmes are time- factors
consuming and lack evidence regarding their effectiveness – Upper age limit: 20 years
[10–12]. Therefore, patients will often abandon these – No concomitant scoliosis therapy (e.g. physiotherapy,
traditional approaches in favour of so-called ‘‘holistic’’ brace treatment etc.) and no vigorous sporting activities
approaches, which are allegedly less harmful and more within 3 months before the start and during the study
efficient alternatives. As in other fields of medicine, com-
plementary and alternative medicine (CAM) methods are
Randomisation
increasingly promoted and utilised. Amongst these, oste-
opathy has gained widespread popularity, in particular for
Blocked randomisation (allocation ratio 1:1) of eligible
spinal disorders [13]. The term ‘‘osteopathy’’ was coined
patients was performed with a concealed envelope. It either
by Andrew Taylor Still, MD in the second half of the
contained a request to avoid any kind of therapy during the
nineteenth century. Education, licensing and practice rights
observation period (0, control group) or to contact
vary from country to country. The philosophy of osteo-
the osteopath (CS or AE) within 3 days (1, intervention
pathy emphasises the musculoskeletal system as the origin
group).
of health or disease and promotes the ‘‘integration’’ of
body, mind and spirit. However, there are no strict defini-
tions of this apparently comprehensive and drug-free Pre- and post-intervention assessment
approach. It is based on the belief that a range of manual
treatment interventions on the viscera and the locomotor All patients underwent two standardised assessments of
system will stimulate self-regulatory mechanisms, ulti- their trunk morphology and spine flexibility at a 3-month
mately restoring form and function, for example, in scoli- interval (measurement I, prior to randomization and II, 3 to
otic spines. To date, there is no scientific evidence 4 weeks after the last osteopathic intervention) between 5
supporting these assumptions [14]. Legal, medical, ethical and 7 pm by a blinded, experienced scoliosis physiother-
and economic implications and the increasing use of this apist (CN).
approach in children and adolescents which we have Clinical examination included body weight, standing
observed in our spinal practice have prompted us to per- height, body mass index, plumb line from C7 and pelvic
form a prospective randomised trial. obliquity. Trunk rotation—rib hump and lumbar promi-
The hypothesis of this study was ‘‘osteopathic treatment nence—was assessed with a Bunnell scoliometerTM
improves trunk morphology and spine flexibility in post- (Orthopedic Systems, Inc., Hayward, CA, USA) in a
pubertal young women with mild idiopathic scoliosis.’’ standing, bent-over position (arms dangling, palms pressed
together) with the pelvis horizontalised (wooden blocks)
and the subject standing on a foot template [15]. The
Methods scoliometer measurement is a reliable non-invasive method
when used by a single trained observer, with the best
Patient selection reproducibility in a standing, forward-bending position [16,
17]. The intrarater agreement is excellent (intraclass cor-
After approval of the local Ethical Committee (Ethi- relation coefficient Rho = 0.995 and Rho = 0.998 for the
kkommission beider Basel, Switzerland),1 informed thoracic and lumbar regions, respectively) and the accuracy
parental written consent and patient’s written assent was was 2° [15, 17–19]. There is a statistically significant
obtained from all participants. Twenty consecutive young correlation between scoliometer values and the radio-
women with adolescent idiopathic scoliosis were recruited graphic Cobb angles for each of the segments measured
from the spine clinic by the principal investigator (CH) (Pearson’s correlation coefficient r = 0.685, 0.572 and
according to the following inclusion criteria: 0.677 for thoracic, thoracolumbar and lumbar curves,
respectively) [20]. Therefore, the scoliometer provides a
– Idiopathic adolescent scoliosis
fairly reliable estimation of the Cobb angle at the initial
– Cobb angle 20°–40°
clinical examination of a scoliosis patient. However, if the
– No restrictions regarding curve type
initial Cobb angle is known and its relationship to the
– Standing PA spine radiograph within 3 months before
gibbosity calculated, longitudinal measures of the gibbosity
the start of the study
over time provide the clinician with a highly reliable
estimation of the Cobb angle and this is, therefore, a reli-
1
http://www.ekbb.ch. able tool to detect curve progression or improvement,

123
J Child Orthop (2010) 4:219–226 221

especially if further radiographs within a short time interval None of the patients had undergone osteopathic treatments
are not feasible [21]. previously.
Trunk morphology was also assessed without radiation
using a static video rasterstereographic surface analysis Statistical analysis
(FormetricÒ, DIERS International, Schlangenbad, Germany)
tool. When using this apparatus, the patient is standing The analyses were performed by an independent statisti-
upright, the feet are placed in a foot template and the cian (TE) who was blinded to the group assignments.
shoulders are in 10° of abduction. Stereography is a Sample size calculation was based on the variable of pri-
reproducible and reliable method for the three-dimensional mary interest (rib hump measurements) using the nQuery
surface measurement of idiopathic scoliosis with Cobb Advisor 4.0 software package (Statistical Solutions Ltd.,
angles of up to 50° [22–24]. Rotational standing surface Boston, MA, USA). Based on pilot data, a sample size of
values are smaller than actual vertebral rotation angles but 10 patients per group had an 80% power to detect a dif-
correlate well (r = 0.79). Adam’s forward-bending test ference in means of 2° between the rib hump measure-
combined with scoliometer measurements correlate badly ments, assuming a common standard deviation of 1.5°
with the standing stereographic examinations. As there is using a two-group t-test with a 0.05 two-sided significance
an individual correlation between stereographic and clini- level.
cal measurements of rib hump/lumbar prominence with Demographic and procedural data were analysed for
frontal plane Cobb angle, a given assessment of one patient normal distribution by the Shapiro–Wilk test, and the data
may be related to a wide range of possible Cobb angles. are reported as mean (standard deviation [SD]) or median
These methods are, therefore, often restricted to use as (interquartile range). Repeated measures were analysed
screening tools, but are suitable for longitudinal observa- with regression techniques using the PROC MIXED pro-
tions and evaluation of patients without direct reference to cedures in SAS software version 9.1 (SAS institute, Cary,
radiographs, as in this study [23, 25–29]. Significant Cobb NC, USA). The regression model used the patient’s group
angle changes would alter at least one associated topo- assignment (G), the repeated measures factor (I, indicated
graphic measurement [30]. the two measurements) and the interaction between the
Active global sagittal and coronal spine flexibility was two (G*I) as independent variables (Y = b0 ? b1(G) ?
objectively assessed with computerized non-invasive b2(I) ? b3(G*I)). Here, the interaction parameter b3 is of
scanning (SpinalMouseÒ, Idiag, Fehraltorf, Switzerland) of interest, because a statistically significant non-zero value
the trunk in maximal flexion, extension and bilateral side- for b3 indicates that the two patient groups reacted
bending. The device was found to be applicable for in vivo differently to the interventions.
studies of the sagittal profile and range of motion, as
consistently reliable results were found for the flexibility
measurements of global regions, e.g. the thoracic spine, but Results
not for individual segmental flexibility [31–33].
The demographic characteristics of the patients did not
Osteopathic intervention show significant differences (Table 1). Two patients mis-
sed an osteopathic session. They wanted to be excluded
The protocol comprised three standardised osteopathic from the study since they felt that they did not benefit from
sessions (90-, 30- and 60-min duration), with the 90-min the intervention. No intervention-related side-effects or
session at the start and the others at 1 and 4 weeks interval, complications were recorded.
respectively. They included patient education on osteo- The statistically non-significant interaction term of the
pathic principles, history taking, diagnostic osteopathic regression analysis for all parameters indicated that the
testing and osteopathic visceral and parietal manipulations change between the measurements levels was not different
by two experienced, certified osteopaths (CS, AE). Parietal between the two groups (Table 2).
interventions act directly on the locomotor system (mus- The hypothesis that osteopathy alters trunk morphology
cles, joints, ligaments, tendons) and, thereby, influence the in scoliotic post-pubertal girls was, therefore, rejected.
function of the inner organs, whereas, vice versa, visceral Because of the non-compliance of two patients in the
osteopathic treatment works on the inner organs, which, by osteopathy group, the planned sample size was missed in
their connective tissues, interact with the locomotor the treatment group. Based on the actual sample size and
system. measurements, the study has a power of 80% to detect a
The osteopaths defined the protocol according to their difference of 3.1° of the rib hump between the study
daily common osteopathic practice for scoliosis patients. groups.

123
222 J Child Orthop (2010) 4:219–226

Table 1 Patients and curve characteristics but the main issue is clinical efficacy and the raising of
Osteopathy (group 1) Control (group 0)
false expectations. Our own current systematic research
using scientific databases (Medline, Embase, Cinahl,
Age (years) 16.5 [15.2–18.5] 14.7 [12.3–18.1] Cochrane Library, Index to Chiropractic Literature,
Years post-menarche 3.6 [2–7] 2.8 [2–4.5] PEDro) and a former extensive literature survey conducted
Height (cm) 165.0 [152.4–175.1] 161.1 [147.5–175.0] by the Scoliosis Research Society [44] including over 30
Weight (kg) 54.1 [45.3–65.3] 51.8 [44.6–58.5] complementary and alternative approaches for the treat-
Body mass index (kg/m2) ment of scoliosis such as acupuncture, biofeedback, chi-
Measurement I 19.9 [17.2–22.8] 19.76 [17.3–22.3] ropractic, craniosacral therapy, Feldenkrais, Rolfing and
Measurement II 20.0 [17.8–23.0] 20.58 [17.2–23.5] Reiki—to name the most prominent—could not reveal any
Main curve Cobb 27.1 [20–40] 31.5 [22–40] scientific rationale to support their use. In particular, there
angle (°) is a complete lack of serious, high evidence level studies on
Thoracic curve 5 4 manual therapies such as osteopathic, chiropractic and
Lumbar curve 0 2 massage technique [14]. Nevertheless, their popularity
Thoracolumbar curve 4 2 continues to increase. The Internet offers access to more
Double curve 1 2 than 1.5 million sites on scoliosis, 130,000 on scoliosis and
Data are presented as mean [range] alternative medicine, and 60,000 on the osteopathic treat-
ment of scoliosis, most of them of limited quality and
poorly informative [45]. However, it is only human nature
Discussion that some parents and patients judge this information by
how well it agrees with ‘‘the way they want the world to
The primary goal of treating mild idiopathic scoliotic be’’ [46]. It is our duty to learn about existing and emerging
curves (20°–40°) is curve stabilisation by breaking the CAM options in our field of speciality and to educate and
vicious cycle of concave overload: growth inhibition– counsel our patients accordingly.
vertebral deformation–scoliosis progression and, subse- The major concerns are exposing the patient to the
quently, more asymmetric load on the vertebral growth natural history of the disease by delaying or—even
plates. The logical concept is, therefore, diminution of worse—abandoning the conventional standard of care and
these forces and breaking of the vicious circle. The current to burden the health care system with additional costs in
literature shows that only continuous wear of a well-fitted favour of unproven strategies. Moreover, with alternative
brace will be biomechanically effective [5, 9, 34, 35]. At health care professionals entering the mainstream of health
least 50% in-brace Cobb angle correction and adherence to care and an increasing number involved in scoliosis care,
a 20–23 h per day wear regimen are mandatory for success parents and patients seek their physician’s opinion about
[36–39]. However, the use of bracing is controversial: the risks and benefits of CAM or may ask for referral to or
compliance (hours in brace/prescribed brace regimen) has a prescription for CAM .
been found to be as low as 62–67.5% in rigid braces [6, 40, We aimed at exemplarily validating the effectiveness of
41] and pooled data in meta-analysis on observation, one of the most popular CAM representatives, osteopathy.
exercises and bracing did not provide evidence to recom- It is premised on the understanding of humans as units of
mend one approach over the other [42, 43]. This may body, mind and spirit, balanced by self-regulatory mecha-
reflect the physical and psychosocial impacts of a rigid, nisms and the interdependency of structure and function.
visible and warm orthosis. There may also be a conflict Different craniosacral, myofascial and visceral manual
between an otherwise healthy patient and a disease, which, techniques diagnose and relieve imbalances and restric-
to the patient, represents only a radiographic phantom but tions in the interconnections between the motion of all
otherwise does not cause pain or cardiopulmonary symp- organs and structures of the body. In contrast to bracing,
toms or major cosmetic upset in the early stages. this is effectuated smoothly and away from scrutiny by
Therefore, patients with adolescent idiopathic scoliosis peers, neighbours or relatives. As scoliosis is defined by an
are particularly liable to consulting non-MD practitioners inherent asymmetry which disturbs functionality and
who offer gentle, brace-free therapeutic pathways within structures on all levels, it is a logical target disease for
the wide and popular field of CAM. It is prudent not only to osteopathic treatment. The commonly accepted orthopae-
inquire as to a patient’s use of CAM therapy, but also to dic rationale relies on the ability to improve the three-
consider the medico-legal and economic implications, as dimensional morphology of the scoliotic trunk as a
the patient usually remains the responsibility of the MD, prerequisite to halt or slow down curve progression. Con-
most commonly an orthopaedic surgeon. The risk of pos- sequently, all parameters describing trunk morphology are
sible adverse reactions is small, since most CAM is safe, feasible endpoints to assess the effects of any scoliosis

123
J Child Orthop (2010) 4:219–226 223

Table 2 Results of clinical examination, video stereography and flexibility assessment

Measurements* Within group test (MI vs. MII) Change (MI vs. MII) between the groups
MI MII t value P value F value P value

Clinical examination
Plumb line C7 (mm)
Osteopathy 5.6 ± 11.2 6.9 ± 17.3 0.52 0.60 0.09 0.77
Control 6.2 ± 14.0 8.4 ± 13.8 1.02 0.32
Rib hump (°)
Osteopathy 6.4 ± 4.6 6.3 ± 5.3 0.15 0.88 0.63 0.44
Control 9.7 ± 4.1 8.7 ± 4.9 1.36 0.19
Lumbar prominence (°)
Osteopathy 2.0 ± 8.3 2.9 ± 8.7 0.93 0.36 0.59 0.45
Control 5.8 ± 4.1 5.7 ± 3.9 0.12 0.9
Video stereography
Trunk length (cm)
Osteopathy 43.1 ± 2.8 43.6 ± 2.6 1.55 0.14 1.09 0.31
Control 40.4 ± 4.3 40.4 ± 4.5 0.16 0.87
Plumb line C7 (mm)
Osteopathy 13.0 ± 6.3 14.0 ± 4.7 0.5 0.62 2.57 0.12
Control 16.2 ± 5.7 12.9 ± 8.1 1.84 0.08
Pelvic balance (mm)
Osteopathy 9.1 ± 12.7 7.6 ± 10.4 1.79 0.09 2.29 0.15
Control 5.8 ± 3.8 6.0 ± 4.1 0.27 0.79
Pelvic torsion (°)
Osteopathy -2.9 ± 10.7 -1.7 ± 9.9 2.69 0.02 4.70 0.046
Control -0.3 ± 3.1 -0.4 ± 3.0 0.24 0.81
Trunk rotation (°)
Osteopathy -5.3 ± 14.5 -5.6 ± 14.1 0.36 0.73 0.01 0.90
Control -10.1 ± 11.0 -10.3 ± 9.7 0.23 0.83
Sagittal balance (mm)
Osteopathy 21.4 ± 22.1 23.2 ± 25.6 0.30 0.77 0.17 0.68
Control 18.0 ± 23.6 23.3 ± 22.4 0.95 0.355
Thoracic kyphosis (°)
Osteopathy 49.9 ± 5.2 47.6 ± 7.0 1.81 0.9 3.02 0.102
Control 44.3 ± 7.9 45.5 ± 11.3 0.59 0.56
Lumbar lordosis (°)
Osteopathy 41.4 ± 5.5 40.1 ± 5.8 0.70 0.49 0.01 0.91
Control 42.4 ± 5.8 40.9 ± 7.9 0.94 0.36
Flexibility (°)
Sagittal flexion T1–11
Osteopathy 13.4 ± 11.7 8.0 ± 13.4 1.11 0.28 3.03 0.10
Control 10.2 ± 10.3 15.9 ± 8.7 1.39 0.18
Sagittal flexion T11–L2
Osteopathy 22.1 ± 9.0 20.6 ± 9.7 1.07 0.30 0.41 0.52
Control 20.9 ± 5.5 18.1 ± 5.2 2.28 0.037
Sagittal flexion L2–S1
Osteopathy 45.1 ± 5.7 45.7 ± 9.4 0.27 0.79 0.15 0.70
Control 43.7 ± 9.6 43.2 ± 10.1 0.28 0.78

123
224 J Child Orthop (2010) 4:219–226

Table 2 continued
Measurements* Within group test (MI vs. MII) Change (MI vs. MII) between the groups
MI MII t value P value F value P value

Side bending T1–11 L

Osteopathy 29.0 ± 6.8 31.3 ± 6.0 0.53 0.60 0.14 0.71
Control 20.1 ± 9.2 20.3 ± 13.3 0.06 0.95
Side bending T1–11 R
Osteopathy 14.3 ± 12.0 23.7 ± 8.0 2.07 0.056 2.47 0.13
Control 12.3 ± 3.5 12.4 ± 9.0 0.03 0.98
Side bending T11–L2 L
Osteopathy 9.9 ± 3.5 13.4 ± 5.4 1.38 0.18 1.76 0.20
Control 13.0 ± 4.2 12.1 ± 4.4 0.42 0.68
Side bending T11–L2 R
Osteopathy 14.3 ± 3.5 13.3 ± 3.3 0.64 0.53 1.88 0.19
Control 10.9 ± 5.4 12.7 ± 5.7 1.37 0.19
Side bending L2–S1 L
Osteopathy 25.3 ± 7.0 25.6 ± 3.3 0.11 0.91 0.77 0.39
Control 18.5 ± 6.4 21.8 ± 8.2 1.49 0.15
Side bending L2–S1 R
Osteopathy 25.4 ± 6.8 25.0 ± 3.9 0.14 0.89 0.00 0.99
Control 20.3 ± 8.4 19.9 ± 8.6 0.16 0.87

treatments, including instrumented fusions. Though the patients [50–52] and a pilot study on chiropractic treat-
gold standard to determine curve progression is Cobb angle ment which described six patients [49]. They all combine
measurement, ethical concerns would be raised in regard to manipulative cycles with concomitant, simultaneous other
repeat exposure to ionising radiation within a relatively treatments, such as electric stimulation, bracing or exer-
short study observation period [47]. Non-invasive three- cise programmes. Also, these studies lack control groups
dimensional analysis of trunk topography with a surface and evaluate outcomes only by visual assessments or
scanner is a reliable alternative [48]. The best documented palpation. These weak points render the objective evalu-
and most reliable clinical examination is scoliometer ation of the therapeutic effects of spinal manipulation on
measurement of trunk rotation, which was used for our pre- scoliosis impossible.
study power analysis and determination of group sizes. The lack of any osteopathic treatment effect in our study
Randomisation, blinding of observers and statisticians, might be ascribed to a dose–effect problem, but the fre-
as well as isolating osteopathy as the only parameter with quency and details of the three sessions over a 5-week
potential influence on trunk morphology during the period were proposed by experienced and certified osteo-
observation period are strengths of this study. Ongoing paths and coincides with that of a former case series [50].
growth and concomitant treatment as potential confound- In contrast, a pilot study on chiropractic manipulation
ing factors were removed by selecting post-pubertal young based on a survey among American chiropractors relied on
women, which is an advantage over former studies on a six-month protocol [49].
manual treatments [49]. Randomised controlled studies Our study does not exclude that osteopathy could
during the pubertal growth spurt including control groups, improve scoliotic trunks if applied earlier in the disease
brace groups and osteopathy groups would reach the process. However, this is unlikely, as accelerated spinal
highest evidence level, but would not match ethical stan- growth during the pubertal growth spurt represents the
dards, as the patients in two groups would be deprived from main driving force for curve progression and adds many
the common standard of care. more therapeutic challenges compared to the post-pubertal
Two relatively small groups of 10 patients each and setting, as is described here.
two drop-outs in the intervention group are identifiable In conclusion, CAM sees a widespread global applica-
weaknesses of this study. However, the only existing tion in the treatment of adolescent idiopathic scoliosis in
studies on the manipulative treatment of young patients clinical practice and increasingly gains legitimacy and
with scoliosis are case reports with one, two and three loyal followers, despite the lack of efficacy data from

123
J Child Orthop (2010) 4:219–226 225

rigorous clinical trials. No evidence of effectiveness was non-operative treatments for idiopathic scoliosis. J Bone Joint
shown in this trial, which emphasises the need to further Surg Am 79(5):664–674
10. Weiss HR, Klein R (2006) Improving excellence in scoliosis
investigate osteopathy and similar methods. Given the rehabilitation: a controlled study of matched pairs. Pediatr
well-established biomechanical understanding of increased Rehabil 9(3):190–200
concave loading and subsequent growth inhibition in pro- 11. Weiss HR, Weiss G (2002) Curvature progression in patients
gressively scoliotic growing spines, it is scientifically treated with scoliosis in-patient rehabilitation—a sex and age
matched controlled study. Stud Health Technol Inform 91:352–
implausible that a range of smooth manual treatments may 356
break this vicious cycle. The proposed effectiveness of 12. Stone B, Beekman C, Hall V, Guess V, Brooks HL (1979) The
other underlying mechanisms as suggested by CAM—yet effect of an exercise program on change in curve in adolescents
enigmatic—remain to be proven. Meanwhile, this approach with minimal idiopathic scoliosis. A preliminary study. Phys Ther
59(6):759–763
continues to constitute a belief system rather than science, 13. Birbaumer N, Flor H, Cevey B, Dworkin B, Miller NE (1994)
a complement but not an alternative to the current standard Behavioral treatment of scoliosis and kyphosis. J Psychosom Res
of scoliosis care and should, consequently, not replace 38(6):623–628
current established orthopaedic strategies [5, 9, 34, 35]. 14. Romano M, Negrini S (2008) Manual therapy as a conservative
treatment for adolescent idiopathic scoliosis: a systematic review.
The reimbursement of CAM for scoliosis treatment at a Scoliosis 3:2
time when public health system budgets are overstretched 15. Bunnell WP (1984) An objective criterion for scoliosis screening.
should be a matter for urgent debate. J Bone Joint Surg Am 66(9):1381–1387
16. Murrell GA, Coonrad RW, Moorman CT 3rd, Fitch RD (1993)
Acknowledgments Study approval was obtained from the local An assessment of the reliability of the Scoliometer. Spine (Phila
ethical committee (no. 114/05). Pa 1976) 18(6):709–712
17. Amendt LE, Ause-Ellias KL, Eybers JL, Wadsworth CT, Nielsen
Conflict of interest statement We have not received any funds for DH, Weinstein SL (1990) Validity and reliability testing of the
this study. Scoliometer. Phys Ther 70(2):108–117
18. Côté P, Cassidy JD (1999) Re: A study of the diagnostic accuracy
and reliability of the scoliometer and Adam’s forward bend test
(Spine 1999;23;796–802). Spine (Phila Pa 1976) 24(22):2411–2412
19. Côté P, Kreitz BG, Cassidy JD, Dzus AK, Martel J (1998) A
References study of the diagnostic accuracy and reliability of the Scoliometer
and Adam’s forward bend test. Spine (Phila Pa 1976) 23(7):796–
1. Danielsson AJ, Hasserius R, Ohlin A, Nachemson AL (2007) A 802
prospective study of brace treatment versus observation alone in 20. Sapkas G, Papagelopoulos PJ, Kateros K, Koundis GL, Boscainos
adolescent idiopathic scoliosis: a follow-up mean of 16 years PJ, Koukou UI, Katonis P (2003) Prediction of Cobb angle in
after maturity. Spine (Phila Pa 1976) 32(20):2198–2207 idiopathic adolescent scoliosis. Clin Orthop Relat Res 411:32–39
2. Climent JM, Sánchez J (1999) Impact of the type of brace on the 21. Griffet J, Leroux MA, Badeaux J, Coillard C, Zabjek KF, Rivard
quality of life of adolescents with spine deformities. Spine (Phila CH (2000) Relationship between gibbosity and Cobb angle dur-
Pa 1976) 24(18):1903–1908 ing treatment of idiopathic scoliosis with the SpineCor brace. Eur
3. Goldberg CJ, Dowling FE, Hall JE, Emans JB (1993) A statistical Spine J 9(6):516–522
comparison between natural history of idiopathic scoliosis and 22. Hackenberg L, Hierholzer E (2002) 3-D back surface analysis of
brace treatment in skeletally immature adolescent girls. Spine severe idiopathic scoliosis by rasterstereography: comparison of
(Phila Pa 1976) 18(7):902–908 rasterstereographic and digitized radiometric data. Stud Health
4. MacLean WE Jr, Green NE, Pierre CB, Ray DC (1989) Stress Technol Inform 88:86–89
and coping with scoliosis: psychological effects on adolescents 23. Hackenberg L, Hierholzer E, Bullmann V, Liljenqvist U, Götze C
and their families. J Pediatr Orthop 9(3):257–261 (2006) Rasterstereographic analysis of axial back surface rotation
5. Nachemson AL, Peterson LE (1995) Effectiveness of treatment in standing versus forward bending posture in idiopathic scolio-
with a brace in girls who have adolescent idiopathic scoliosis. A sis. Eur Spine J 15(7):1144–1149
prospective, controlled study based on data from the Brace Study 24. Lyon R, Liu XC, Thometz JG, Nelson ER, Logan B (2004)
of the Scoliosis Research Society. J Bone Joint Surg Am Reproducibility of spinal back-contour measurements taken with
77(6):815–822 raster stereography in adolescent idiopathic scoliosis. Am J Ort-
6. Nicholson GP, Ferguson-Pell MW, Smith K, Edgar M, Morley T hop 33(2):67–70
(2003) The objective measurement of spinal orthosis use for the 25. Stokes IA (1989) Axial rotation component of thoracic scoliosis.
treatment of adolescent idiopathic scoliosis. Spine (Phila Pa J Orthop Res 7(5):702–708
1976) 28(19):2243–2250 26. Stokes IA, Armstrong JG, Moreland MS (1988) Spinal deformity
7. Noonan KJ, Dolan LA, Jacobson WC, Weinstein SL (1997) and back surface asymmetry in idiopathic scoliosis. J Orthop Res
Long-term psychosocial characteristics of patients treated for 6(1):129–137
idiopathic scoliosis. J Pediatr Orthop 17(6):712–717 27. Stokes IA, Shuma-Hartswick D, Moreland MS (1988) Spine and
8. O’Neill PJ, Karol LA, Shindle MK, Elerson EE, Brin- back-shape changes in scoliosis. Acta Orthop Scand 59(2):128–
tzenhofeSzoc KM, Katz DE, Farmer KW, Sponseller PD (2005) 133
Decreased orthotic effectiveness in overweight patients with 28. Thulbourne T, Gillespie R (1976) The rib hump in idiopathic
adolescent idiopathic scoliosis. J Bone Joint Surg Am 87(5): scoliosis. Measurement, analysis and response to treatment.
1069–1074 J Bone Joint Surg Br 58(1):64–71
9. Rowe DE, Bernstein SM, Riddick MF, Adler F, Emans JB, 29. Liu XC, Thometz JG, Lyon RM, Klein J (2001) Functional clas-
Gardner-Bonneau D (1997) A meta-analysis of the efficacy of sification of patients with idiopathic scoliosis assessed by the

123
226 J Child Orthop (2010) 4:219–226

Quantec system: a discriminant functional analysis to determine 41. Lou E, Raso J, Hill D, Durdle N, Mahood J, Moreau M (2002)
patient curve magnitude. Spine (Phila Pa 1976) 26(11):1274–1278 Brace monitoring system for the treatment of scoliosis. Stud
30. Goldberg CJ, Kaliszer M, Moore DP, Fogarty EE, Dowling FE Health Technol Inform 88:218–221
(2001) Surface topography, Cobb angles, and cosmetic change in 42. Dolan LA, Weinstein SL (2007) Surgical rates after observation
scoliosis. Spine (Phila Pa 1976) 26(4):E55–E63 and bracing for adolescent idiopathic scoliosis: an evidence-based
31. Mannion AF, Knecht K, Balaban G, Dvorak J, Grob D (2004) A review. Spine (Phila Pa 1976) 32(19 Suppl):S91–S100
new skin-surface device for measuring the curvature and global 43. Lenssinck ML, Frijlink AC, Berger MY, Bierman-Zeinstra SM,
and segmental ranges of motion of the spine: reliability of mea- Verkerk K, Verhagen AP (2005) Effect of bracing and other
surements and comparison with data reviewed from the literature. conservative interventions in the treatment of idiopathic scoliosis
Eur Spine J 13(2):122–136 in adolescents: a systematic review of clinical trials. Phys Ther
32. Schulz S (1999) Measurement of shape and mobility of the spinal 85(12):1329–1339
column: validation of the SpinalMouse by comparison 44. Price CT, Abel MF, Richards BS, D’Amato C (2000) Report from
with functional radiographs. Dissertation, Ludwig-Maximilians the bracing and non-operative committee of the Scoliosis
University, Munich, Germany Research Society. 2000
33. Post RB, Leferink VJ (2004) Spinal mobility: sagittal range of 45. Mathur S, Shanti N, Brkaric M, Sood V, Kubeck J, Paulino C,
motion measured with the SpinalMouse, a new non-invasive Merola AA (2005) Surfing for scoliosis: the quality of informa-
device. Arch Orthop Trauma Surg 124(3):187–192 tion available on the Internet. Spine (Phila Pa 1976) 30(23):2695–
34. Emans JB, Kaelin A, Bancel P, Hall JE, Miller ME (1986) The 2700
Boston bracing system for idiopathic scoliosis. Follow-up results 46. Park RL (2001) Voodoo science. The road from foolishness to
in 295 patients. Spine Phila Pa 11(8):792–801 fraud. Oxford University Press, Oxford
35. Fernandez-Feliberti R, Flynn J, Ramirez N, Trautmann M, 47. Hoffman DA, Lonstein JE, Morin MM, Visscher W, Harris BS
Alegria M (1995) Effectiveness of TLSO bracing in the conser- 3rd, Boice JD Jr (1989) Breast cancer in women with scoliosis
vative treatment of idiopathic scoliosis. J Pediatr Orthop exposed to multiple diagnostic X rays. J Natl Cancer Inst
15(2):176–181 81(17):1307–1312
36. Richards BS, Bernstein RM, D’Amato CR, Thompson GH (2005) 48. Ovadia D, Bar-On E, Fragnière B, Rigo M, Dickman D, Leitner J,
Standardization of criteria for adolescent idiopathic scoliosis Wientroub S, Dubousset J (2007) Radiation-free quantitative
brace studies: SRS Committee on Bracing and Nonoperative assessment of scoliosis: a multi center prospective study. Eur
Management. Spine (Phila Pa 1976) 30(18):2068–2075 Spine J 16(1):97–105
37. Rahman T, Bowen JR, Takemitsu M, Scott C (2005) The asso- 49. Rowe DE, Feise RJ, Crowther ER, Grod JP, Menke JM, Gold-
ciation between brace compliance and outcome for patients with smith CH, Stoline MR, Souza TA, Kambach B (2006) Chiro-
idiopathic scoliosis. J Pediatr Orthop 25(4):420–422 practic manipulation in adolescent idiopathic scoliosis: a pilot
38. Lindeman M, Behm K (1999) Cognitive strategies and self- study. Chiropr Osteopat 14:15
esteem as predictors of brace-wear noncompliance in patients 50. Morningstar MW, Joy T (2006) Scoliosis treatment using spinal
with idiopathic scoliosis and kyphosis. J Pediatr Orthop manipulation and the Pettibon Weighting System: a summary of
19(4):493–499 3 atypical presentations. Chiropr Osteopat 14:1
39. Korovessis P, Zacharatos S, Koureas G, Megas P (2007) Com- 51. Niesluchowski W, Dabrowska A, Kedzior K, Zagrajek T (1999)
parative multifactorial analysis of the effects of idiopathic ado- The potential role of brain asymmetry in the development of
lescent scoliosis and Scheuermann kyphosis on the self-perceived adolescent idiopathic scoliosis: a hypothesis. J Manipulative
health status of adolescents treated with brace. Eur Spine J Physiol Ther 22(8):540–544
16(4):537–546 52. Aspegren DD, Cox JM (1987) Correction of progressive idiopathic
40. Helfenstein A, Lankes M, Ohlert K, Varoga D, Hahne HJ, Ulrich scoliosis utilizing neuromuscular stimulation and manipulation:
HW, Hassenpflug J (2006) The objective determination of com- a case report. J Manipulative Physiol Ther 10(4):147–156
pliance in treatment of adolescent idiopathic scoliosis with spinal
orthoses. Spine (Phila Pa 1976) 31(3):339–344

123