**2.2. Procedures**

**1. Introduction**

94 Innovations in Spinal Deformities and Postural Disorders

Scoliosis is a three-dimensional spinal deformity with a lateral curvature in excess of 10°. Adult scoliosis refers to scoliosis after skeletal maturity. It can arise from a wide range of conditions, including neuromuscular diseases, metabolic diseases, trauma, etc. Most commonly, the condition includes adult idiopathic scoliosis and degenerative lumbar scoliosis (DLS) [1–3], which are discrete conditions. Sometimes they coexist and are difficult to distinguish.

Adult scoliosis is increasing in importance in recent years, as its prevalence is increasing, as a result of increased life expectancy of the population [2, 3]. Adult scoliosis with thoracolumbar and lumbar curves is associated with a higher prevalence of low back pain. Also, they tend to progress. Many adult AIS patients consult because of the progression of their curves or of symptoms that decrease their quality of life inducing functional impairment [4]. Thoracolumbar curves receive the highest percentage of surgical treatment among adult coro-

Apart from causing low back pain, thoracolumbar and lumbar curves tend to progress. Weinstein and Ponseti showed that 68% of the AIS curves progressed after skeletal maturity, especially when the Cobb angle exceeds 30° [6, 7]. In a retrospective study on progression of adult scoliosis, Marty-Poumarat et al. found that curves in adult AIS as well as DLS patients' progress, irrespective of the initial Cobb angle [8]. The rate of progression for lumbar or thoracolumbar single curve was 0.82°/year (0.34–1.65°) for adult AIS patients and 1.64°/year (0.77–3.82°) for DLS patients, respectively. Similarly, Iida et al. reported that AIS patients with thoracolumbar and

lumbar curves (Lenke 5C) with a Cobb angle over 30° have a high risk of progression [9].

HRQOL (Health-Related Quality of Life) measure over 2-year follow-up [12].

affect thoracolumbar and lumbar curves in adult scoliosis patients.

**2. Materials and methods**

**2.1. Patient selection**

Symptomatic adult scoliosis patients are generally treated conservatively by NSAIDs, analgesics, manipulation, acupuncture, and electrotherapy [10]. These conservative treatments have not been found to be effective [11]. Everett and Patel found a low level of evidence in support of conservative treatment. They identified level IV evidence for physical therapy, chiropractic care, and bracing and level III evidence for steroid injections [11]. Similarly, Glassman et al. assessed the cost associated with nonsurgical treatment of adult scoliosis and found that despite the substantial mean cost of US\$10,815 per patient, there was no improvement in any

The unsatisfactory outcome of the treatment approach is possibly due to the fact that it targets at the symptoms of the adult scoliosis, but not the spinal deformities which are the one of the causes of the symptoms. The present study attempts to investigate whether Schroth best practice (SBP) exercises, which have been found to improve curves in AIS patients [13–18], do

Adult scoliosis patients with AIS and degenerative lumbar scoliosis of either sex, who were aged 20–70 years and were seen in the Wanchai Chiropractic Clinic were included. Patients

nal deformities; it accounted for 32.6% of all surgeries for adult scoliosis [5].

Consecutive adult scoliosis patients consulted for low back pain between January 2014 and October 2015 in the Wanchai Chiropractic Clinic, with signs of thoracolumbar or lumbar scoliosis were referred for standing postero-anterior (PA) full spine radiographs. When the Cobb angle was ≥20° and the apex of the curve lied in the thoracolumbar or lumbar area, the subject would be asked for consent to participate in the study and was then referred for standing full spine lateral radiograph.

The angle of trunk rotation (ATR) of the patients was measured. The subjects then completed the Chinese version of the SRS-22 which has been found to have satisfactory internal consistency and excellent reproducibility [19]. They were then instructed to perform the SBP exercises [20, 21], which essentially involve holding the lumbar spine in lordosis and horizontally translating the trunk to the side of the lumbar convexity, whilst simultaneously lowering the contralateral pelvis to deflex the lumbar spine. The subjects then breathed into the areas of concavities [22] and exhaled forcefully with isometric contraction of all the trunk muscles [22]. The breathing method is termed "rotational angular breathing (RAB)"and is an inherent part of the Schroth exercise approach [22]. Corrective postures to be undertaken during daily activities [21, 23, 24] were also taught by a certified SBP therapist.

The subjects took four weekly classes. They then performed the exercises at home for at least three times a week and adopted corrective postures basing on their curve types [21, 23] and the side of the curves during daily activities. They had to mark on their log book the dates they did the exercises. They returned quarterly for assessment to see if they had been performing the exercises correctly.

The subjects were advised not to take up any sports or activities that they did not do prior to the intervention nor engage in any therapy and/or treatments targeted to the spinal deformities, as these might confound the outcome.

After 9 months, PA and lateral full spine X-rays of the patients were again taken and the ATR measured. The patient filled in the Chinese version of SRS-22 again.
