# Exercise as it relates to Disease/Effects of scoliosis specific exercise (SEAs) on Adult Idiopathic Scoliosis?

This Wikibook page presents a critical appraisal of a research article: “Scoliosis-Specific exercises (SEAs) can reduce the progression of severe curves in adult idiopathic scoliosis: a long-term cohort study”.

## What is the background to this research?

* Adult idiopathic scoliosis (ADIS) is a type of spinal disorder, in which the spine curves sideways in a C or S shape in skeletally mature patients with unknown cause.
* It progresses slowly and affects both the appearance and function of the body, for example, worsening the degree of pain on spine, radicular pain. Once asymmetric load and degeneration of spine starts, it probably results a chronic degeneration and deformity. In extreme cases, it may affect the shape of the rib cage, hence, respiratory system.
* Surgery is generally considered to be the only intervention that can stop curve progression. Some studies state that scoliosis-specific exercise other than SEAs and/or combined with therapy treatment, which are likely to stop or slow down curve progression of a patient with ADIS. There is, however, lack of evidence of SEAs for ADIS patients who refuse surgery treatment.
* The aim of this research was to find out the effectiveness of scoliosis-specific exercise-SEAs that might limit the progression of curves in ADIS patients.

## Where is the research from?

* The research was conducted in Italian Scientific Spine Institute (ISICO), that was founded in Italy in 2003. ISICO promotes and develops an innovative approach to the rehabilitation treatment of non-surgical diseases of the spine in individuals of all ages, from children to the elderly.
* All seven authors of this study are leading experts in the area of physical and scoliosis rehabilitation, and are consultants in ISICO.
* The researchers are Stefano Negrini, Fabio Zaina, Michele Romano, Sabrina Donzelli, Alessandra Negrini and Maria Gabriella Negrini. They have published combinedly over 900 articles, with much of their research devoted to scoliosis rehabilitation and medicine.
* This research article is published in a journal named Scoliosis and Spinal Disorders (ISSN 2397-1789). It is an online, open access and peer reviewed scientific journal, which encompasses all aspects of research on prevention, diagnosis, treatment, outcomes and cost-analyses of conservative and surgical management of all spinal conditions. It has been part of BioMed Central publications since 2006 and indexed in dozens of online search engines, such as PubMed and Scopus.

## What kind of research was this?

* Retrospective cohort study (also known as a historic study) is an observational study where the participants already have a known disease or outcome.
* Retrospective cohort study is easier, cheaper and quicker than prospective cohort study. It can address rare diseases and identify potential risk factors. It aims to generate premises or associations for future studies rather than focusing on the result itself

## What did the research involve?

* Retrospective study is designed to analyse pre-existing data, and is subject to numerous biases as a result. When the observation period spans many years, it can be difficult to track subjects for the entire study. Subjects may disappear as a result of death, relocation, or loss of interest in the study.
* There are two selection biases. First, subjects will probably be selected if they have the outcome of interest. Second, there is frequently an absence of data on the potential confounding factors if the data was recorded in the past. This may weaken the level of evidence collected. For example, if these patients have treatments with other professional practitioners at the same time that may affect the outcome.
* There are two enrollment biases. First, there is a sex bias between men and women ratio. Often, this ratio does not match the real population of ADIS which may weaken the level of evidence collected. Second, there is an age bias which excludes of elderly aged above 50 years old. Convenience sampling may weaken the level of evidence further. Increasing in the recruitment of participants will reduce the standard deviation of results, thereby produce more reliable outcomes for subsequent studies.

## What were the basic results?

$_{TableTwo:Theresultsafteranaverageperiodof2yearsoftreatment(range1–18years)}$ :
| Patients | Condition | Cobb angle | Progression rate |
| 33 | Improved | 4.6 ± 5.0 ° Cobb | Nil |
| 1 | Progressed | 5.0 ° Cobb in 18 years | reduced from 0.5 ° to 0.27 ° per year |
* Averaging of data makes evidence less valuable to patient, for example, telling a patient regarding the time necessary for stabilization of their spine which ranges from 1–18 years makes prognosis prediction irrelevant. For future studies, all patients of the study should be measured in a more accurate and objective manner.
* Data shown in the article does not exactly correspond with the tables & figures, e.g., table 1 doesn’t show some types of scoliosis (5 thoracolumbar curves, and 2 proximal thoracic), and figure 1 only shows the results of 15, but not that of all 34 patients, this probably makes the reader confused. For future studies, all supplementary data have to be precise and consistence with the essay.
* Additional information shown at the end of the result also makes the reader confused. For future studies, all information should be well-structured to increase the level of evidence.

## What conclusions can we take from this research?

Positive:
* Scoliosis Specific SEAS Exercises may be an effective treatment for ADIS patients who refuse surgery.
* Retrospective cohort study is a good tool to start an initial study for preparing future expensive one.
Negative:
* This study shows a low level of evidence, as convenience sampling and selection biases (sex, age and confounding factors).
* Averaging of data (e.g., the results of SEAs treatment differentiate from 1–18 years) makes the outcome of SEAs imprecise.
* Data (e.g. graphs & tables) shown in the research does not totally correspond to the text.

## Practical advice

* Retrospective study should be used for an initial study.
* A prospective cohort study prescribing SEAs exercise to patients with ADIS should be carried out after an initial study.

## Further information/resources

* Scoliosis information
* Scoliosis Causes, Symptoms, Diagnosis and Treatment
* Glossary of spinal disorder

## References

* 1 2 3 4 5 6 Negrini, Alessandra et al. “Scoliosis-Specific exercises can reduce the progression of severe curves in adult idiopathic scoliosis: a long-term cohort study.” Scoliosis vol. 10 20. 11 Jul. 2015, doi:10.1186/s13013-015-0044-9. Accessed from: https://link.springer.com/article/10.1186/s13013-015-0044-9
* ↑ Collis, Dennis K., and Ignacio V. Ponseti. "Long-term follow-up of patients with idiopathic scoliosis not treated surgically." JBJS 51.3 (1969): 425-445. Accessed from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.896.8430&rep=rep1&type=pdf
* 1 2 Aebi, Max. "The adult scoliosis." European spine journal 14.10 (2005): 925-948. Accessed from: https://link.springer.com/article/10.1007/s00586-005-1053-9
* ↑ Kafer, Enid R. "Respiratory and cardiovascular functions in scoliosis and the principles of anesthetic management." Anesthesiology: The Journal of the American Society of Anesthesiologists 52.4 (1980): 339-351. Accessed from: https://pubs.asahq.org/anesthesiology/article/52/4/339/26890/Respiratory-and-Cardiovascular-Functions-in
* ↑ Brooks, William J., Elizabeth A. Krupinski, and Martha C. Hawes. "Reversal of childhood idiopathic scoliosis in an adult, without surgery: a case report and literature review." Scoliosis 4.1 (2009): 27. Accessed from: https://link.springer.com/article/10.1186/1748-7161-4-27
* ↑ Negrini, Alessandra, et al. "Adult scoliosis can be reduced through specific SEAS exercises: a case report." Scoliosis 3.1 (2008): 20. Accessed from: https://scoliosisjournal.biomedcentral.com/articles/10.1186/1748-7161-3-20?optIn=false
* 1 2 3 4 5 Nickson, Chris. “Retrospective Studies and Chart Reviews.” Life in the Fast Lane, Life in the Fast Lane, 9 Apr. 2019. Accessed from: http://litfl.com/retrospective-studies-and-chart-review