Physiotherapy Scoliosis-specific Exercises: The Orthotist’s Perspective

Idiopathic scoliosis is a 3D spinal deformity with a Cobb angle of more than 10 degrees and vertebral rotation. 1 Typical treatment includes observation, bracing, surgery, or physical therapy regimens. Conservative treatment goals for scoliosis are to stop the curve progression at puberty; prevent respiratory dysfunction; prevent or treat spinal pain syndromes; improve aesthetics via postural correction; avoid surgery; and improve quality of life of the patient with scoliosis. 1 One treatment option is physiotherapy scoliosis-specific exercises (PSSE). When PSSE is used along with brace treatment to treat idiopathic scoliosis, it has been shown to improve patient outcomes, therefore it is important to understand whether orthotists are discussing, educating, or referring their patients to PSSE as an additional treatment option. PSSE is a specific physical therapy regimen that must consist of autocorrection in three dimensions, training in activities of daily living (ADLs), stabilizing the correct posture, and patient education. 1 Seven schools of PSSE are currently accepted and are often named based on the region where they were founded: Lyon Approach (France), Schroth Method (Germany), Scientific Exercises Approach to Scoliosis (Italy), Barcelona Scoliosis Physical Therapy School (Spain), Dobomed Method (Poland), Side Shift (United Kingdom), and Functional Individual Therapy of Scoliosis (Poland). 2 Their regimens vary on the specific exercises, exercise time, in-patient or outpatient, and recommendations on what specific brace to prescribe. There has not been significant research conducted to determine if one regimen is more effective than another for scoliosis treatment. However, PSSE as a whole has been researched, and when comparing surgical rates of brace treatment, and brace treatment combined with PSSE, the surgical rate dropped from an average of 23 percent to 14 percent. 3 Brace treatment is effective at preventing curve progression, while PSSE in combination with bracing has shown to reduce Cobb angles. 3 Studies were found regarding surgeons’ attitudes about prescribing PSSE. PSSE was prescribed 22 percent of the time in one study, and in another study 65 percent felt comfortable prescribing the treatment, but it was not routinely prescribed. 4,5 PSSE was prescribed when the patient had a small curve, was post-surgery, or was currently undergoing brace treatment. 4,5 The reasons for prescribing PSSE were to treat pain, improve aesthetics, and improve post-operative outcomes. The main complaint against prescribing PSSE was a lack of supporting research, followed by a perception that there is no value in PSSE for treatment of idiopathic scoliosis. 4,5 No studies were found regarding orthotists’ attitudes regarding PSSE to treat idiopathic scoliosis. A project was conducted to begin to understand whether orthotists in the United States are knowledgeable about PSSE, are recommending it to their patients, or are educating their patients about the treatment option. Methods The research study was approved by Eastern Michigan University Human Subject Review. A 25-question survey was written based on published papers from a complete literature review that revealed the current research focuses on doctors’ perspectives and attitudes regarding PSSE and lacks the orthotist perspective. 4,5 The survey’s wording was reworked to target orthotists’ perspectives. Questions included basic demographics, PSSE background knowledge, PSSE availability, recommendations for PSSE, and interest in the role of PSSE. Subjects were recruited via email, LinkedIn, the OANDP-L listserv, and the survey was posted to multiple O&P-related websites. Participation involved completing an anonymous online survey. The inclusion criteria for the subjects were that they must be a certified orthotist, certified orthotist/prosthetist, an orthotic resident, or dual prosthetic and orthotic resident; must practice in the United States; and must treat idiopathic scoliosis. For data analysis, descriptive results summarized the survey responses. [caption id="attachment_264431" align="alignright" width="332"] Figure 1. Summary of responses for PSSE availability[/caption] Results Demographics The survey had 30 responses; 60 percent of respondents were certified prosthetists/orthotists, 30 percent were certified orthotists, and 10 percent were residents. Their educational levels were as follows: 53.3 percent earned a master’s level or above, and the remaining underwent a certification program. Experience levels were: more than 15 years of experience treating idiopathic scoliosis (43.3 percent), ten to 15 years (6.7 percent), five to 10 years (6.7 percent), three to five years (13.3 percent), and less than two years of experience (30 percent). PSSE Background Eighty-three percent of respondents reported being familiar with PSSE to treat idiopathic scoliosis. Of the various schools of PSSE, Schroth Method has the most familiarity, followed by Barcelona Scoliosis Physical Therapy School, and Lyon Approach; 18.5 percent of respondents reported not knowing the exact name of the method. Nearly 89 percent of the orthotists reported seeing a patient treated with PSSE. Breaking it down further, 48.1 percent had seen 20 or more patients, 14.8 percent had seen 15-20 patients, and 37.1 [caption id="attachment_264432" align="alignright" width="310"] Figure 2. Summary of responses for recommendation for PSSE[/caption] percent reported between one and 15 patients that had been treated with PSSE. The Schroth method was the most commonly observed PSSE method used, followed by Barcelona Scoliosis Physical Therapy School, Scientific Exercise Approach Therapy School, Side Shift, and Functional Individual Therapy of Scoliosis. No orthotists reported observing Lyon Approach nor the Dobomed Method. PSSE Recommendations Orthotists were asked about the availability of PSSE to see if that influenced their recommendation for PSSE. Figure 1 is a summary of responses regarding PSSE availability, and Figure 2 summarizes whether orthotists recommend PSSE or not. The results show the majority of respondents do recommend PSSE. Orthotists reported recommending PSSE prior to bracing, during bracing, after surgery, or only when the patient or family asks about PSSE treatment. Figure 3 outlines which methods orthotists are recommending to their patients. Reasons reported for recommending PSSE included to prevent curve progression, to improve posture, bracing is not prescribed due to small curve (less than 20 degrees), impaired balance/gait, persistent pain, patient not compliant with brace treatment, difficulty with ADLs, to postpone or prevent surgery, to work with current brace treatment, trunk weakness concerns, or when the patient had significant decompensation. The most reported reason for recommending PSSE was to prevent curve progression followed by improving posture. Orthotists that do not recommend PSSE cited the following reasons for not recommending: lack of evidence for the role of PSSE, lack of access to physical therapist with appropriate knowledge of PSSE, lack of personal knowledge about PSSE, leaving it up to referring doctor to discuss need for any physical therapy, PSSE recommendation is not a part of their role on a multidisciplinary team, or reluctance to overstep the referring physician’s preferences for scoliosis treatment. [caption id="attachment_264499" align="aligncenter" width="1000"] Figure 3. Summary of PSSE methods that orthotists recommend to their patient[/caption] Orthotists’ Current Practices Orthotists were asked a series of questions regarding their patients’ referring physicians, and 81.5 percent reported that physicians they work with directly prescribe PSSE to treat idiopathic scoliosis. Additionally, when orthotists were asked if they have a patient that they feel would benefit from PSSE, would they talk to the patient’s doctor about it, 52 percent reported no. Figure 5 outlines steps that orthotists take when directly asked about PSSE. [caption id="attachment_264436" align="alignright" width="800"] Figure 4. Summary of results for reasons orthotists recommend PSSE[/caption] Interest in the Role of PSSE Lastly, subjects were asked about the increased interest among various groups regarding PSSE. Orthotists were asked, have you observed an increased interest among orthotists regarding PSSE to treat idiopathic scoliosis? Almost 62 percent reported no. However, when the same question was asked about physicians’ interest, 61.5 percent reported yes, they do see an increased interest. The biggest increased interest was reported to be among patients, with 66.7 percent of orthotists reporting they see patients having an increased interest in PSSE to treat idiopathic scoliosis. Orthotists were also asked if they anticipated an increased role for PSSE in the future: 65.4 percent reported yes, 30.8 percent reported they were unsure, and 3.8 percent reported no. Discussion Orthotists reported that the referring physicians they work directly with are prescribing PSSE at a higher rate than previous research suggested. 4,5 Physicians and orthotists have cited similar reasons for and against recommending PSSE. 4,5 However, the majority of orthotists are not speaking to the referring physicians about PSSE. [caption id="attachment_264437" align="aligncenter" width="1000"] Figure 5. Responses regarding actions orthotists take when families ask about PSSE[/caption] This indicates that there could be a lack of communication between orthotists and physicians, and that orthotists rely on their patients to bring the recommendation of PSSE to their prescribing physicians. Limitations of this study include the small sample size, recruitment style, lack of knowledge of the setting in which subjects work, and the title of the survey. With 30 responses, generalizations cannot be made regarding orthotists’ attitudes and current practices of treating idiopathic scoliosis with PSSE. The survey was posted on the American Academy of Orthotists and Prosthetists’ website, LinkedIn, scoliosis research opportunities page, and emailed to clinicians that the faculty advisor and principal investigator knew personally. Therefore, people that are on these types of websites and people that received the email may be more up to date on current scoliosis research and treatment options. Also, because the respondents were not asked about their work settings (whether they worked in a hospital, private clinic, or public domain, or in a city or rural area), that may affect their knowledge and recommendation for PSSE. Additionally, this may affect the availability of additional resources and the availability to interprofessional care to treat idiopathic scoliosis. Completion rates for the survey may have been impacted by the survey title, which contained the acronym PSSE, as clinicians who were unfamiliar with the term may have been less likely to click on a survey. Conclusion Orthotists in the United States are familiar with PSSE and the various PSSE methods. The majority of the time orthotists are recommending PSSE to their patients with idiopathic scoliosis, with Schroth Method being the most recommended method. Orthotists reported that the physicians they work with are routinely prescribing PSSE, and when patients ask about PSSE, orthotists inform them about the need for a prescription for treatment. Due to the small sample size, more studies should be conducted to better understand orthotists’ perspectives regarding PSSE. Future directions of this research include more research regarding orthotists’ perspectives on PSSE, how the interprofessional team affects scoliosis treatment plan, and the impact work settings have on knowledge and resources of PSSE treatment. Molly Winget, MSOP, CO, is an orthotist and prosthetic resident, Boston Orthotics and Prosthetics, Ohio, and a member of the Academy’s Spinal Orthotics Scientific Society. Sun Hae (Sunny) Jang, PhD, CO, FAAOP, is chair of the Academy’s Spinal Orthotics Scientific Society and a professor at Eastern Michigan University. Academy Society Spotlight is a presentation of clinical content by the Scientific Societies of the Academy in partnership with The O&P EDGE. Image credit: dream@do/stock.adobe.com References Negrini, S., S. Donzelli, and A. G.Aulisa, et al. 2016. 2016 SOSORT guidelines: Orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis and spinal disorders. https://pubmed.ncbi.nlm.nih.gov/29435499/. Berdishevsky, H., V. A. Lebel, and J. Bettany-Saltikov, et al. 2016. Physiotherapy scoliosis-specific exercises–a comprehensive review of seven major schools. Scoliosis and Spinal Disorders 11(20). Seleviciene, V., A. Cesnaviciute, B. Strukcinskiene, L. Marcinowicz, N. Strazdiene, and A. Genowska. 2022. Physiotherapeutic scoliosis-specific exercise methodologies used for conservative treatment of adolescent idiopathic scoliosis, and their effectiveness: An extended literature review of current research and practice. International Journal of Environmental Research and Public Health 19(15):9240. Marti, C. L., S. D. Glassman, P. T. Knott, L. Y. Carreon, and M. T. Hresko. 2015. Scoliosis Research Society members attitudes towards physical therapy and physiotherapeutic scoliosis specific exercises for adolescent idiopathic scoliosis. Scoliosis . 10:16. Steinmetz, L., F. Segreto, and C. Varlotta, et al. 2019. Surgeon attitudes toward physiotherapeutic scoliosis-specific exercises in adult patients with spinal deformities. International Journal of Spine Surgery 13(6):568-74.

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