**4.5. SRS-22**

lumbar lordosis [41]. The findings are not unexpected, in view of the fact that the spine of adult scoliosis patients is generally more rigid than that of AIS patients and improvement of

Yet, the present study found that SBP exercises increased the sacral slope, decreased the pelvic tilt, and improved the SVA significantly (**Table 4**). It is noteworthy that the improvement involved two of the three key radiographic parameters correlated with disabilities [40]. At baseline, the mean sacral slope was 25.3°, which is lower than the mean sacral slope of 39 and 40.9° reported in normal volunteers by Troyanovich et al. and Duval-Beaupere et al., respectively [43, 44]. Our results, however, compared well with the results reported by Iida et al. in adult scoliosis patients. They reported a sacral slope of 26.6° of the DLS patients group and 27.5° for the adult AIS group, respectively [9]. Yang et al. reported a mean sacral slope of 32° in the 99 adult patients with spinal deformities (ASD) with a median age of 67 years [45]. The difference between our data and that of other studies may be related to the magnitude of the scoliosis [9, 45], as progression of lumbar

Duval-Beaupere et al. suggested that a reduction in sacral slope reduced the stability of the pelvis [47]. At the conclusion of the study, the sacral slope increased significantly from a mean of 25.3–28.8°, suggesting that the intervention may improve the stability of the pelvis requir-

The pelvic tilt reduced from 20 to 16.2° post intervention. The difference was statistically significant. A study has shown that a pelvic tilt angle of above 22° correlated with disability [43]. Similarly, a number of studies have shown that a large pelvic tit is associated with increased pain and decreased function [35, 38]. A study which analyzed the pre and postoperative differences in spinopelvic parameters and their relationship to postoperative pain showed that patients with a larger postoperative pelvic tilt were likely to have postoperative residual pain than patients with a smaller postoperative pelvic tilt [38]. Similarly, Lafage et al. showed clear evidence that an increased pelvic tilt was associated with increased pain and decreased function [35]. Thus, the reduction of pelvic tilt after intervention may be associated

PI-LL mismatch has also been found to strongly correlate with disability [40]. A mismatch suggests that the lumbar lordosis does not compensate adequately [40]. The mismatch is clinically significant when it is in excess of 10°. At baseline, 5 had PI-LL mismatch, whereas after 9 months, only 2 had any significant PI-LL mismatch. Yet, the pre- and post-intervention

Positive sagittal spinal imbalance has also been found to correlate with the severity of symptoms and disability [29, 40]. Duval-Beaupere et al. showed that an anterior translation of the center of gravity in excess of 30 mm in front of the coxofemoral joints require the contraction of the hip extensors for balance [44]. This may be related to the increase in symptoms in patients with positive sagittal spinal imbalance. In the present study, it was shown that the SVA reduced significantly after intervention, suggesting that the patients had an improved global sagittal spinal balance. This may be clinically significant as Schwab et al.

showed that a SVA in excess of 47 mm correlated with disability [40].

scoliosis has been found to reduce the sacral slope [35, 46].

ing less hip extensor activity to maintain balance [47].

with a better clinical outcome.

differences were not statistically significant.

curves is less likely.

106 Innovations in Spinal Deformities and Postural Disorders

Glassman et al. showed that patients with thoracolumbar and lumbar curves tended to have a lower pain and function scores as compared to those with thoracic curves [12, 29]. The present study showed that the exercises tended to increase the SRS pain domain scores, but the pre- and post-intervention difference was not statistically significant. This might be due to the fact that most of the patients did not have marked pain at baseline. It was possible that most of the subjects had adult idiopathic scoliosis, which was not as disabling or painful as those with DLS [45].

The SRS-22 self-image (*p* = 0.001) and mental health (*p* = 0.04) scores, however significantly improved after the 9 months of scoliosis pattern specific exercises. The improvement in self-image is unlikely to be a result of the change of the subject's perspective [48] as the study spanned over a few months. The improvement in self-image is important as studies [48, 49] have shown that operated AIS patients and adult patients with thoracolumbar and lumbar curves had lower SRS-22 self-image scores, as compared to nonoperated group [48]. Pizones et al. found that the surgical cohort had worse SRS-22 scores in all domains with mean values under 3.1 points (range = 2.4–3.1), as compared to the conservatively treated cohort [4]. In our study, there was a significant improvement in the scores in the self-image domain. Seven subjects had scores below 3.1 points before the intervention, but after the program, only two had scores below 3.1 points. Also, the improvement of SRS-22 self-image and satisfaction scores exceeded 0.4, which is regarded as the minimal clinical important difference relating to SRS-22r (refined) in surgically treated adults with spinal deformity [50]. Improvement of the self-image may reduce the drive for surgical intervention.
