What is the recommended management for a 15-year-old patient with a 21° Cobb angle (scoliosis)?

From the Guidelines

For a 15-year-old patient with a 21° Cobb angle scoliosis, observation with regular follow-up is the recommended management approach. This patient should be monitored with clinical examinations and radiographs every 4-6 months to assess for curve progression until skeletal maturity is reached, as suggested by the SOSORT guidelines to limit spine radiographs to once every 12 months for those adolescent patients at Risser stages 0 to 3 and every 18 months for patients at Risser stages 4 to 5, unless there are objective clinical changes in the appearance of the scoliosis 1. No bracing is typically indicated at this time since the curve is below the conventional 25° threshold for brace treatment. During follow-up visits, the physician should evaluate for curve progression, which is more likely during periods of rapid growth, and the patient should be encouraged to maintain normal physical activities and sports participation, as exercise does not worsen scoliosis and may benefit overall health 1. Physical therapy focusing on core strengthening may be recommended, though it won't correct the curve. If the curve progresses to 25° or greater before skeletal maturity, brace treatment would then be considered to prevent further progression. The risk of progression is higher in this patient due to their young age and likely skeletal immaturity, making regular monitoring essential, as the likelihood of curve progression may exceed 70% in skeletally immature individuals with a Cobb angle of more than 20° 1. Parents and the patient should be educated about scoliosis, its natural history, and warning signs of progression such as noticeable changes in posture or trunk asymmetry.

Some key points to consider in the management of this patient include:

• The importance of regular follow-up to monitor for curve progression
• The role of radiographs in assessing curve severity and monitoring progression
• The potential benefits of physical therapy in maintaining overall health and strength
• The need for patient and parent education on scoliosis and its management
• The consideration of brace treatment if the curve progresses to 25° or greater before skeletal maturity.

It is also important to note that the diagnosis of idiopathic scoliosis is one of exclusion, and other potential causes of scoliosis, such as neuromuscular disorders or vertebral anomalies, should be considered and ruled out 1. However, in this case, the patient's presentation and radiographs suggest adolescent idiopathic scoliosis, and the recommended management approach is observation with regular follow-up.

From the Research

Management of Scoliosis

The management of scoliosis for a 15-year-old patient with a 21° Cobb angle involves several therapeutic interventions.

• Observation
• Physiotherapy Scoliosis Specific Exercises (PSSE)
• Bracing are all accepted by the 2011 International Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) for idiopathic scoliosis during growth 2.

Physiotherapy Scoliosis Specific Exercises (PSSE)

PSSE is part of a scoliosis care model that includes scoliosis specific education, scoliosis specific physical therapy exercises, observation or surveillance, psychological support and intervention, bracing and surgery 2.

• The model is oriented to the patient
• Diagnosis and patient evaluation is essential in this model
• Looking at a patient-oriented decision according to clinical experience, scientific evidence and patient's preference.

Effectiveness of PSSE

PSSE can temporarily stabilize progressive scoliosis curves during the secondary period of progression, more than a year after passing the peak of growth 2.

• In non-progressive scoliosis, the regular practice of PSSE could produce a temporary and significant reduction of the Cobb angle
• PSSE can also produce benefits in subjects with scoliosis other than reducing the Cobb angle, like improving back asymmetry, based on 3D self-correction and stabilization of a stable 3D corrected posture, as well as the secondary muscle imbalance and related pain.

Pattern-Specific Scoliosis Rehabilitation (PSSR)

Pattern-Specific Scoliosis Rehabilitation (PSSR) works to reduce the asymmetrical load caused by scoliosis 3.

• PSSR is effective in stabilizing Cobb angle, and can, in some cases, reduce Cobb angle in adolescents
• Patients recommended for surgery may be candidates for conservative treatment.

Conservative Treatment

Several studies have shown modest benefit from bracing and scoliosis-specific physical therapy to limit progression in mild to moderate scoliosis 4.

• Because no high-quality studies have proven that surgery is superior to bracing or observation, it should be reserved for severe cases
• There is little evidence that treatments improve patient-oriented outcomes.

Physiotherapeutic Scoliosis-Specific Exercise Methodologies

Physiotherapeutic scoliosis-specific exercise (PSSE) methods have lately gained popularity for the conservative treatment of scoliosis 5.

• The study revealed that inappropriate management of AIS could result in serious health problems
• Conservative interventions that aid in stabilizing spine curvature and improving esthetics are preferred for scoliosis treatment.

Current Research and Practice

Currently, there are several PSSE physiotherapy schools in Europe: Schroth, SEAS, BSPTS, FED, FITS, Lyon, Side Shift, and DoboMed 5.

• The methodologies of these schools are similar, in that they focus on applying corrective exercises in three planes, developing stability and balance, breathing exercises, and posture awareness
• Although high-quality research supporting the effectiveness of PSSE physiotherapy in the treatment of AIS is lacking, existing evidence indicates that PSSE physiotherapy helps to stabilize spinal deformity and improve patients' quality of life.