Table 6. Evidence from systematic reviews on non-surgical interventions in AIS, in the order of descending levels of evidence.
| reference, year | findings/conclusions | level of evidence [OCEBM/JBI]1 | AMSTAR score2/overall quality |
| EXERCISE TREATMENTS: | |||
| Exercises for adolescent idiopathic scoliosis. 2012; [33]; Cochrane review | “due to a lack of high quality RCTs in this area, there is no evidence for or against exercises, so hardly any recommendations can be given”; “no major risks of the intervention have been reported (…), and no side effects were cited in the considered studies” | 1/1a | 9/high3 |
| Exercises reduce the progression rate of adolescent idiopathic scoliosis: results of a comprehensive systematic review of the literature. 2008; [52]; (SR 2 of 3)4 | “Exercises can be recommended according to level-1b [OCEBM]4 evidence with the aim of reducing scoliosis progression”; “it is impossible to state anything regarding the kind of exercises. [or].kind of auto-correction to be performed” | 3/1b | 5/moderate |
| Physical exercises as a treatment for adolescent idiopathic scoliosis. A systematic review. 2003; [51]; (SR 1 of 3)4 | “the efficacy of physical exercises in the treatment of AIS to reduce progression of the curve remains to be demonstrated”; “their utility to reduce specific impairments and disabilities [breathing function, strength, postural balance] (…) cannot be neglected” | 3/1b | 4/low |
| Efficacy of exercise therapy for the treatment of adolescent idiopathic scoliosis: a review of the literature. 2012; [54] | methodological flaws of included studies; majority of evidence from studies performed in centres specialising in exercise treatment; “the current literature review failed to find robust evidence in support of exercise therapy in the treatment of AIS” | 3/1b | 1/low |
| Physical exercises in the treatment of adolescent idiopathic scoliosis: an updated systematic review. 2011; [53]; (SR 3 of 3)4 | conclusions from the preceding review [52] maintained | 45/3b | 1/low |
| MANUAL THERAPY: | |||
| Osteopathic manipulative treatment for pediatric conditions: a systematic review. 2013; [7] | findings from the AIS RCT: no evidence to support OMT as an effective treatment of mild AIS; the study assessed as high quality RCT; “more robust RCTs are needed (…). Until such data are available, OMT cannot be regarded as effective therapy for paediatric conditions, and osteopaths should not claim otherwise” | 1/1a | 7/moderate |
| The use of spinal manipulative therapy for pediatric health conditions: a systematic review of the literature. 2012; [55] | no conclusions regarding treatment effectiveness formulated both in the SR, and – as reported in the SR – in the included feasibility study | 26/1a | 3/low |
| Myofascial release as a treatment for orthopaedic conditions: a systematic review. 2013; [56] | findings from the IS case study: at the end of treatment the patient showed improvement in the outcomes measured; the study considered “lower quality in design”, but the results are “very promising and give the foundations for future RCTs” | 47/1b | 4/low |
| Manual therapy as a conservative treatment for adolescent idiopathic scoliosis. 2008; [6] | no evidence to draw any conclusions, complete lack of studies of acceptable quality, in opposition to brace and exercise therapy studies; urgent need for research | 4/3b | 2/low |
| BRACING: | |||
| Braces for idiopathic scoliosis in adolescents. 2010; [16]; Cochrane review | very low quality of evidence in favour of bracing in terms of curve progression; low evidence in favour of hard bracing vs elastic bracing; serious side effects not documented in the included studies | 1/1a | 9/high3 |
| Efficacy of bracing versus observation in the treatment of idiopathic scoliosis. 2011; [43] | “Findings with respect to surgical rates, quality of life, and change in curve angle demonstrate either no significant differences or inconsistent findings favouring one treatment or the other [bracing or observation].”; “If bracing does not cause a positive treatment effect, then its rejection will lead to significant savings for healthcare providers and purchasers.” | 3/2a | 2/low8 |
| Effectiveness and outcomes of brace treatment: A systematic review. 2011; [57] | limited evidence suggests that bracing can prevent curve progression (compared to observation), may not negatively influence quality of life, may be more effective than ES; it is not known if bracing is better than Side-Shift therapy and casting; bracing and surgery cannot be compared due to differences in study groups | 3/2b | 3/low |
| Surgical rates after observation and bracing for adolescent idiopathic scoliosis: an evidence -based review. 2007; [25] | “Inconclusive and inconsistent evidence concerning the risk of surgery in AIS”; the review “did not demonstrate any advantage to bracing over surgery in terms of surgical rates” | 4/3b | 2/low |
| Bracing in adolescent idiopathic scoliosis, surrogate outcomes, and the number needed to treat. 2012; [36] | The NNT is about 9 braced patients for 1 surgery, but about 4 for patients highly compliant; however the NNTs are derived from nonrandomised cohorts and should be treated with caution; bracing may reduce the need for surgery; there is no evidence for one brace over another, but rigid bracing seems better than soft braces (SpineCor) | CA/1b9 | 0/low |
| DIFFERENT COMBINATIONS OF NON-SURGICAL INTERVENTIONS: | |||
| Effect of bracing and other conservative interventions in the treatment of idiopathic scoliosis in adolescents: a systematic review of clinical trials. 2005; [37] | “Effectiveness of bracing and exercises is promising but not yet established’; limited evidence for the effectiveness of braces vs no treatment and vs electrical stimulation (ES); bracing, exercises or ES as add-on treatment – additional effect cannot be justified; no difference for: ES vs no treatment, bracing vs exercises, different types of bracing | 1/1b | 5/moderate |
| The treatment of adolescent idiopathic scoliosis (AIS) according to present evidence. A systematic review. 2008; [17] | “weak evidence (level III and IV) to support outpatient physiotherapy”; “evidence for the application of scoliosis inpatient rehabilitation”; various types, working mechanisms of braces, outcome measures in analysed studies, and “no definite or collective meaning for brace as such”, prevent from drawing conclusions on effectiveness of bracing | CA/2b10 | 1/low |
| Effectiveness of non-surgical treatment for idiopathic scoliosis. Overview of available evidence. 1991; [58] | early brace treatment may prevent severe progression and surgery in considerable proportion of patients, but controlled studies are needed | 3/2b | 4/low |
| A meta-analysis of the efficacy of non-operative treatments for idiopathic scoliosis. 1997; [26] | bracing more effective than LESS or observation; LESS not more effective than observation; bracing for 23 hours/day effective; skeletal maturity and criterion for failure significantly influence outcomes | CA (4?)/CA11 | 2/low |
| USUAL PHYSICAL ACTIVITY: | |||
| Is physical activity contraindicated for individuals with scoliosis? A systematic literature review.2009; [59] | recommendations: observed and brace treated patients encouraged to participate in sports and physical activities (with or without braces on) – grade D of recommendations (OCEBM)12 | 4/4a10 | 4/low |
| ADVERSE EFFECTS: | |||
| Low bone mineral status in adolescent idiopathic scoliosis. 2008; [60] | included studies do not support the presumption that bracing for AIS results in permanent loss of mineral bone mass; however, study findings are of limited value due to lack of data on compliance | CA/CA13 | 3/low |
| Scoliosis and dental occlusion: a review of the literature. 2011; [61] | the only relevant information from the review is that Milwaukee brace has undergone technical improvements; other orthoses described, but not regarding dental occlusion or any other side-effects | CA/CA13 | 2/low |
CA – cannot apply: LoE impossible to establish due to poor reporting and/or missing data; JBI – Joanna Briggs Institute [49], [50]; ES – electrical stimulation; LESS – lateral electrical surface stimulation; NA – not addressed: such types of SRs are not listed in the OCEBM hierarchy; NNT – number needed to treat; OCEBM – Oxford Centre for Evidence Based Medicine [47], [48]; OMT – osteopathic manipulative treatment;
1
for details of the designs of included studies see Table 3; 2the detailed appraisal, with an elaboration, is in Table 1; 3Cochrane review; 4subsequent updates, as explained with Tables 1, 2, 3 and S1; 5one prospective controlled study included; therefore the OCEBM level was graded down one level, according to the classification rules; 6one pilot RCT on 6 IS patients included in the review; therefore the OCEBM level was graded down one level; 7one case study on AIS included in the review; therefore the OCEBM level was graded down one level; 8for details regarding AMSTAR score of this SR see Table 1; 9scored 1b in the JBI classification, but the review was difficult to classify, as it included experimental, observational studies, and SRs; 10various study designs included, see Table 3; 11it was impossible to classify this review, as the authors did not report which specific study designs (except that the included studies were prospective or retrospective) were included or excluded; 12first (former) OCEBM classification; 13no study designs of included studies provided.