Effects of Body Awareness Therapy on Posture, Trunk Movement, Scoliosis & Body Awareness in Adolescents With Scoliosis

Adolescent idiopathic scoliosis (AIS) is a complex deformity of the spine, and its cause remains unknown. AIS can have negative physical, psychological, and social effects on an individual's health. There are two main treatment options for AIS: surgical and conservative approaches, including observation, exercise, and bracing. Scoliosis-specific exercises (SSE) refer to globally recognized, evidence-based exercise approaches.

In this study, the Scientific Exercise Approach to Scoliosis (SEAS), one of the SSE methods, will be used. SEAS consists of individualized active self-correction exercises combined with functional movements. Additionally, the Basic Body Awareness Therapy (BBAT) method will also be applied. BBAT is a body-focused, comprehensive approach that incorporates slow, rhythmic movements and breath control.

Both groups will attend supervised sessions in the clinic once a week, and home exercises will be assigned for the remaining days. Participants in the SEAS group will receive only SEAS treatment, while those in the BBAT group will receive both SEAS and additional BBAT exercises.

The goal of this clinical study is to investigate the effects of BBAT in addition to a rehabilitation program including SSE, on posture, spatial orientation, trunk proprioception, scoliosis-specific parameters, quality of life, and body in adolescents with IS aged between 10 and 17 years.

The research hypotheses for this study are as follows:

H1: Basic Body Awareness Therapy has an effect on posture in adolescents with idiopathic scoliosis.

H2: Basic Body Awareness Therapy has an effect on spatial orientation in adolescents with idiopathic scoliosis.

H3: Basic Body Awareness Therapy has an effect on trunk proprioception in adolescents with idiopathic scoliosis.

H4: Basic Body Awareness Therapy has an effect on scoliosis-specific clinical parameters in adolescents with idiopathic scoliosis.

H5: Basic Body Awareness Therapy has an effect on both general and scoliosis-specific quality of life in adolescents with idiopathic scoliosis.

H6: Basic Body Awareness Therapy has an effect on body awareness in adolescents with idiopathic scoliosis.

Adolescent idiopathic scoliosis (AIS) is a 3-dimensional complex deformity of the spine, involving lateral curvature, axial rotation, and altered sagittal physiological curves, that occurs in children between the ages of 10 and skeletal maturity. AIS is the most common type, accounting for 84-89% of all types of scoliosis. Although there are many studies in the literature on its aetiopathogenesis, the cause is still unknown. AIS causes chronic back pain, muscle imbalance in the trunk, limited spinal movement, weakening of the para spinal muscles, reduced respiratory capacity, and dissatisfaction with physical appearance due to distorted body image.The main concern about scoliosis is progression of the deformity. In the absence of treatment, scoliosis can lead to negative physical, psychological, and social effects on an individual's health Individuals with idiopathic scoliosis (IS) are known to have a lower quality of life than their healthy peers. The progressive nature of the disease can be considered a factor contributing to the decline in quality of life.

There are two main treatment options for IS: surgical and conservative (observation, exercise, brace) approaches. Because of its complex underlying mechanism, IS requires a comprehensive conservative treatment approach. The current preventive approach to scoliosis rehabilitation is scoliosis-specific exercises (SSE). SSE is the general term for globally recognized evidence-based exercise approaches. In this study, the Scientific Exercise Approach to Scoliosis (SEAS), a school of thought focused on active self-correction, will be used. SEAS is an exercise program designed to enhance spinal stability through individualized, active self-correction without external assistance, integrated into functional exercises.

The three-dimensional deformities in scoliosis lead to musculoskeletal problems such as postural changes, muscle imbalance, sensory disturbances, and deficits in balance and postural stability. As a result, postural control and trunk alignment awareness are impaired. Another factor affecting postural control, vertical perception, is also known to be disrupted in individuals with AIS however, no specific exercise model focuses on this issue.

Basic Body Awareness Therapy (BBAT) is a comprehensive approach that considers the physical, physiological, psychological, and existential aspects of human existence. It includes fundamental functions such as postural stability, relaxed breathing, and awareness. The therapy consists of daily movements like lying, sitting, standing, and walking, aiming to enhance body awareness and develop a more realistic body image by normalizing posture, balance, and muscle tension. The learning process involves gradually increasing awareness of grounding, the vertical axis, breathing, flow, and centering. Individuals are encouraged to focus not only on their movements but also on their experiences while performing them, fostering both physical and mental self-awareness. The slow movements in BBAT integrate postural alignment awareness with breathing, aiming to improve body awareness, movement quality, posture, coordination, balance, postural control, and physical-social functions. It is recommended in the literature that adding BBAT exercises to the rehabilitation program of individuals with AIS may help improve internal body orientation. BBAT's slow and rhythmic movements, which are focused on postural alignment and postural awareness, can help improve the postural control deficits commonly seen in AIS, by improving trunk alignment and proprioception.

The study will include voluntary participants with IS aged between 10 and 17. The individuals will be evaluated twice: at the beginning and at the end of the treatment.

The Cobb angle is the gold standard method for measuring the curve angle on frontal X-ray. Another indicator of scoliosis, trunk rotation, was measured using the forward bending test with a scoliometer. The scoliometer is designed to measure trunk asymmetry and axial trunk rotation. These two values give us the severity of the deformity. Concerns about aesthetic appearance in adolescents with IS lead to a decrease in quality of life and are a primary reason for seeking healthcare. Therefore, we will use the Spinal Appearance Questionnaire (SAQ) for assessing cosmetic appearance. With this questionnaire, we will evaluate the perception of the deformity by the individual, parent and physiotherapist. Posterior Trunk Symmetry Index (POTSI) and Anterior Trunk Symmetry Index (ATSI) are assessment methods used in the coronal plane that can be applied to all age groups and provide an objective measure of the effectiveness of the treatment on postural and body symmetry. For this purpose, we will take front and back photographs of the individual and make measurements based on ATSI and POTSI. It is accepted that increasing proprioceptive capacity can prevent the deterioration of proper posture and the progression of deformity, which is why it is important in individuals with AIS. The Joint Repositioning Test (JRPT) will be used to assess trunk proprioception. Literature reports that the most sensitive angles for assessment in this group are 15° and 30°, so trunk flexion will be measured at these angles. The Neutral Lumbar Positioning Test (LNP) will be used to assess the difficulty individuals experience in repositioning their spines. Spatial orientation was assessed using the Fukuda Stepping Test, which also evaluates dynamic balance. Two questionnaires will be used to assess individuals' body awareness. The first is the Body Awareness Questionnaire (VFA), which explores body responses, individuals' predictions about body processes, the disease process, and the sleep-wake cycle. The second is The Awareness Body Chart (ABC), which evaluates the level of perception and awareness regarding different body parts. The Japanese Scoliosis Questionnaire-27 (SJ-27) was used for scoliosis-related quality of life assessment, and the Pediatric Quality of Life Inventory (PedsQL) was used for general quality of life evaluation.

This study will include two groups. Both groups are required to perform their exercises individually with a physiotherapist in the clinic once a week and continue with a home exercise program on the remaining days of the week. Individuals in the SEAS group will receive 60 minutes of SEAS once a week in the clinic, while the BBAT group underwent the same SEAS program along with an additional 30-minute BBAT session, totaling 60 minutes per session for 16 weeks. Participants in the SEAS group will perform 40 minutes of SEAS exercises at home, while those in the BBAT group will practice 20 minutes of SEAS and 20 minutes of BBAT exercises.

Eligibility Criteria:
Inclusion Criteria:

* Being diagnosed with adolescent idiopathic scoliosis
* Being between the ages of 10 and 17
* Having scoliosis of 15° or greater
* Not having received previous treatment for scoliosis and not receiving any other treatment during this study
* Risser stage 0-4
* Willing to participate in the study

Exclusion Criteria:

* Having any spinal/bone deformity in addition to scoliosis (such as hyperkyphosis, pectus, etc.)
* Wearing a brace
* Having congenital scoliosis
* Having any rheumatological, neuromuscular, neurological, cardiovascular, or pulmonary pathology
* Having a regular history or habit of physical activity
* Having undergone scoliosis surgery