Introduction
Adolescent idiopathic scoliosis (AIS) is a three-dimensional torsional condition of the spine and trunk, which varies in clinical presentation depending on the number and location of the curvatures [1,2,3,4]. AIS is identified in otherwise healthy children ages 10 and older, most commonly during the pubertal growth spurt, and is confirmed using radiographic imaging with a Cobb angle exceeding 10 degrees and axial rotation, as defined by the Scoliosis Research Society [1,5].
Scoliosis affects approximately 2 to 3% of the population, although the incidence can vary in different regions of the world [1]. Girls are more likely to develop progressive curvatures with Cobb angles exceeding 30 degrees at a ratio of 7:1 [6,7]. The etiology and pathogenesis of AIS are understood to be multifactorial and are influenced by both intrinsic and extrinsic alterations [8]. Asymmetrical bone growth is a key contributor to the pathogenesis of AIS and results in alterations in normal spinal geometry as a lateral curvature in the frontal plane and a flat back appearance in the sagittal plane [1,8]. If left untreated, progressive curvatures may cause significant trunk deformity, impacting general fitness, chest wall biomechanics, work capacity, and quality of life [9].
Treatment of AIS includes observation, scoliosis-specific physical therapy, bracing, and surgical interventions. Additional psychological support interventions may also be useful in addressing mental health needs due to these body changes [5]. The goals of conservative interventions, according to the 2016 SOSORT Guidelines, are to halt curve progression, prevent or treat respiratory dysfunction, reduce pain syndromes, improve aesthetics with postural correction, and avoid surgical fusion [1].
Bracing Treatment
Bracing is primarily indicated in patients with scoliosis who are still experiencing growth, as indicated by the Risser sign (0 to 3) or an open triradiate cartilage. It is most effective for curves between 25° to 40° [10]. Bracing shows potential efficacy for AIS curves ≥40°, though further high-quality research is needed to better understand risk factors and optimize treatment outcomes [11]. The goal is to manage scoliosis early to prevent progression to a severity where surgical intervention becomes necessary. The decision to begin bracing is typically made considering the growth potential and the scoliosis curve’s likelihood to progress [10].
The overarching goals of bracing are to prevent curve progression and maintain the spinal alignment during critical growth periods [10]. Beyond preventing surgery, effective bracing aims to maintain physical appearance, minimize pain or discomfort, and ensure balanced body posture. Psychological benefits, such as maintaining self-esteem and promoting a positive body image in adolescents, are also significant considerations [12]. Some evidence shows promise not only in preventing curve progression but also potentially in inducing regression [13]. High compliance with brace wear time is associated with both preventing progression and achieving regression [10]. In patients with curves exceeding 40 degrees, the combination of rigid bracing, PSSE, and extended daily brace wear may lead to curve regression [11].
Bracing can be categorized based on symmetry into symmetrical and asymmetrical braces, based on rigidity into soft and rigid braces, and based on wearing duration into night-time, part-time (12-16 hours), and full-time (20-23 hours) braces [14].
The effectiveness of a brace has been found to be correlated with the skill and expertise of the orthotist or practitioner fitting the brace, the type of correction the brace provides, and the amount of time it is worn [15]. Most studies show more effective results in favor of asymmetrical three-dimensional full-time rigid braces [16].
The recommended duration of brace wear varies between 16 and 23 hours per day to achieve optimal results, often depending on the specific curve’s risk of progression. Effective adherence is crucial; studies indicate higher success rates in patients who consistently wear their brace for the prescribed duration. The goal is to stabilize or reduce the curve as the patient approaches skeletal maturity, typically until they reach a Risser sign of 4 or 5 [10].
Weaning off a brace is a sensitive period often managed by reducing the hours the brace is worn incrementally, ensuring the spine remains stable as growth tapers off. This transition phase requires careful clinical evaluation to assess curve stability without bracing support. During this period, follow-up appointments are key to monitoring for any unexpected curve progression [17].
Bracing is contraindicated in patients with skin allergies or sensitivities, as they may experience adverse reactions to the materials used in braces [15]. Severe psychological impacts, such as depression or anxiety, directly tied to brace wear, can be a contraindication. It’s important to consider the mental well-being of the patient [14]. Other physical limitations that inhibit proper brace application, such as certain body shapes or sizes, can also be contraindications. Braces can cause skin irritation or pressure sores if not fitted or worn properly. Wearing a brace for extended periods can lead to discomfort or pain, particularly in the areas where the brace applies pressure [15].
Each patient should be individually assessed to identify any contraindications early and to accommodate their broader clinical and personal needs. This ensures that the treatment plan is tailored to the patient’s specific situation. Effective quality management in the application of braces is essential to achieve the best possible outcomes and minimize complications [14].
Physical Therapy Treatment
Physiotherapy scoliosis-specific exercises (PSSE) are a targeted approach to managing scoliosis and are widely regarded as an essential element of AIS care [18]. These specialized exercises enhance a patient’s neuromotor control and ability to maintain spinal stability in a corrected posture. PSSE aims to improve muscular strength and mobility, which are essential components in managing scoliosis effectively [19].
The primary objectives of PSSE are to enhance patient education regarding scoliosis and its anatomical impact, facilitate three-dimensional auto-correction through active spinal realignment, integrate posture maintenance into activities of daily living to ensure lasting postural corrections and implement stabilization exercises to uphold the corrected posture, thereby minimizing scoliosis progression and promoting consistent postural alignment [20].
PSSE may be prescribed as the primary treatment for AIS in growing children with curvatures under the bracing threshold [21]. In mild cases of AIS (Cobb angle below 20-25 degrees), studies have shown that scoliosis-specific exercises may help to reduce curve progression [22] and could reduce the need for bracing in adolescents with AIS [23]. PSSE has also been found to help improve muscle endurance, reduce spinal asymmetry, and improve quality of life [24,25].
Recent research consistently highlights the effectiveness of combining bracing with PSSE in managing moderate AIS curvatures (Cobb angles between 25-40 degrees) [26,27]. This approach aligns with findings that advocate for the broader integration of PSSE in AIS treatment protocols [28]. PSSE, when combined with nighttime bracing, has been shown to reduce curve progression [29]. Additionally, implementing PSSE in conjunction with full-time bracing may yield a greater chance of curve stabilization and improvement of progressive curvatures [27]. This combined treatment approach is part of a growing recognition of structured PSSE, validated as an evidence-based treatment tailored to scoliosis-specific needs [30]. The integration of PSSE with bracing thus offers a compelling, non-invasive treatment strategy that enhances physical outcomes and promotes overall patient well-being.
The current literature does not indicate significant differences in the effectiveness of different PSSE approaches. They are generally considered effective in managing adolescent idiopathic scoliosis (AIS), although outcomes vary depending on individual responses [30]. These exercises effectively target the three-dimensional asymmetry of the spine, offering comprehensive corrective benefits and promoting improved spinal alignment [32]. Most PSSE schools incorporate specific breathing techniques as a core component of their exercise regimens to aid in the de-rotation of the spine and correction of collapsed trunk areas. These techniques have been demonstrated to enhance breathing function and promote chest wall expansion. SOSORT experts strongly advocate for integrating respiratory exercises and patient education as part of scoliosis treatment, underscoring the importance of these practices in improving overall respiratory function and support [20]. A PSSE program consists of highly individualized exercises that can increase difficulty according to the patient’s abilities and specific curve patterns. These exercises must be performed regularly to achieve optimal results, with goals that can dynamically change based on the patient’s clinical status and response [20]. Currently, there is no specific, detailed dosage protocol; therapeutic sessions can vary widely, from once or twice a week to daily sessions, depending on various clinical factors and the risk of curve progression [19,20,24].
Aesthetic considerations also play a crucial role in the treatment goals for patients with scoliosis and are often regarded as the patient’s primary objective [20]. Patients who undergo PSSE treatment report noticeable improvements in their back appearance, even in cases where significant changes in the Cobb angle are not observed. While standard treatment approaches primarily aim to slow the progression of scoliosis, PSSE emphasizes enhancing postural balance and alleviating symptoms [33]. This approach underscores the importance of integrating patient-centered goals into clinical strategies, ensuring patients’ aesthetic and functional needs are addressed.
PSSE should be approached with caution in cases of severe pain, acute inflammatory conditions, new or worsening neurological symptoms, structural instability, non-compliance, and severe cardiopulmonary conditions. These factors may require re-evaluating the treatment plan or temporary cessation of exercises. Trained healthcare professionals must assess each patient individually to ensure PSSE is appropriate and safe for their specific condition.
Surgery
While curves less than 30 degrees at skeletal maturity have a lower tendency to progress, surgery for adolescent idiopathic scoliosis is typically considered for curves larger than 45-50 degrees that are more likely to increase with remaining adolescent growth and throughout adulthood [34,35]. The primary reasons patients and parents consider scoliosis surgery include worries of potential future consequences for cardiac and pulmonary changes, pain, and disability in adulthood, as well as curve progression over time. Cosmetic aspects, current pain level, and number of levels requiring surgery, including fusion, are additional concerns [36].
The University of Iowa studies of an untreated cohort of adolescent idiopathic scoliosis patients over a 50+ year time span serve as a reference for much of the current decision-making. Compared to matched controls, people with scoliosis were more likely to have pain; however, pain was moderate or less in most, and people functioned well. Additional complaints included shortness of breath, especially in those with curves greater than 80 degrees and in the thoracic region. Cosmetic and psychological concerns have also been identified [37]. As with long-term studies of outcomes of surgically treated patients, many patients were lost to follow-up over the years, and their status concerning their scoliosis is ultimately unknown.
Spinal fusion is the most common surgical intervention for scoliosis, with posterior spinal fusion being more typical than anterior. The structural curves and spine levels to be addressed are identified, and the placement of anchors to these segments is then followed with longitudinal rods connecting the anchors to straighten and stabilize the spine and bone graft to create a single solid bone under the rods. At the expense of motion, this method is highly effective in stopping the progression of the spinal curve and improving the patient’s appearance [38]. Selective thoracic fusion involves surgical correction of the major thoracic curve. Indirectly, improvement in the lumbar curve and overall spine balance may be achieved with maximal motion and function of the spine being retained. Following spinal fusion, patients usually stand and walk on the day of or the day following surgery, with hospital stays typically lasting 2 to 5 days. Recovery from posterior spinal fusion surgery typically spans approximately 6 months, with a gradual return to regular activities. Students generally return to school within two to four weeks. Despite the challenges of the surgical experience, most patients report satisfaction with their results and go on to lead productive lives similar to their peers [39].
Vertebral Body Tethering (VBT) is a more recent “fusionless” surgery, usually applied to growing children to achieve growth modulation. The procedure involves placing screws in the vertebral body on the convex side of the curve and connecting them with a flexible cord. The tension on the cord helps partially correct the spine’s curvature while allowing for movement. With subsequent growth, further correction of the curvature occurs. This procedure is particularly beneficial for growing children; however, there is a growth window during which the child is the best candidate for such surgery. If applied too young, overcorrection is a risk, and if too late, minimal to no growth modulation will occur [40]. Major lumbar curves may significantly benefit from tethering as flexibility of the spine can be maintained, and the degeneration and junctional problems that may occur over the years following spinal fusion may be limited. Given the potential complications of tethering, including higher re-operation rates compared to fusion, and the limited functional benefit of maintaining the motion of thoracic curves compared to lumbar, posterior thoracic fusion may be preferable. Hybrid approaches may be a favored option if selective thoracic fusion is not applicable: Hybrid surgeries involve fusion of the thoracic curve and Anterior VBT of the remaining lumbar curve [41]. Vertebral body tethering is typically utilized with curves in the 40 to 65-degree range with demonstrated bending flexibility to 30 degrees or less and no thoracolumbar or lumbar kyphosis. Children must have a minimum of 1 year of growth remaining [42].
Each of these surgical options has its benefits, considerations, and risks. The choice of procedure depends on factors such as the patient’s age, the severity and flexibility of the curve, and overall health. It is important to explore options and obtain additional opinions if needed. Contraindications for scoliosis surgery include poor general health, where significant comorbidities increase the surgical risk [43]. Non-progressive curves that are not causing symptoms do not typically warrant surgical intervention [35]. Psychological factors also play a role; patients who are not psychologically prepared for the surgery and its recovery process may not be suitable candidates [44]. Surgical intervention for scoliosis carries several potential complications. Postoperative infections are a significant risk and may require additional treatment [45]. There is also a risk of neurological injury, although this is relatively rare. Hardware failures, such as the breakage or loosening of rods, screws, or hooks, can occur and may necessitate further surgery, even in adulthood [45-48]. Non-union, where the bones fail to fuse properly, is another complication that might require additional surgical intervention [49].
The timing of surgery also merits significant consideration as skeletal maturity and growth potential impact which surgical options are appropriate. If pursued with significant growth remaining, posterior spinal fusion may lend to a “crankshaft” phenomenon, growth on the front of the spine after surgery contributing to increase of curve and change in chest shape, rotation, and trunk shift, possible “adding on” to the curve proximally and even distally, and less predictable outcome for lumbar curve with a selective thoracic fusion[50]. If delayed to adulthood, surgeries may be more involved as curves may be less flexible and require fusion of more levels [51,52]. However, while radiographic correction may be better if surgery is performed during adolescence, outcomes and complications are generally similar [53]. Conclusions from a 2011 critical review of surgery for adolescent idiopathic scoliosis note the following: 1) there is no medical necessity for surgery based on the current body of literature, 2) surgery may be beneficial, especially for cosmetic and psychological reasons, 3) it is not clear that the expectation of decreased future pain and disability is met, and 4) it is not conclusive that better radiographic alignment leads to enhanced function, self-image, or health [54].
The decision to undergo surgery should be made on a case-by-case basis, as additional reviews have found a lack of high-quality evidence supporting a general indication for spinal surgery based solely on Cobb angle measurements [55]. Surgery, while usually decreasing spinal motion, commonly improves spine shape and stops curve progression. Multiple studies have demonstrated improved patient quality of life outcomes with spinal fusion [56]. Fundamentally, most patients are happy with their surgery, especially in the near term. Those considering spinal surgery for AIS should seek more than one opinion to review surgical options and timing and make choices consistent with their own situation, goals, and priorities.
QOL and Other Assessment Tools
Numerous Quality of Life Assessment tools have been developed specifically to assess HRQoL for people with scoliosis. Many of these help to quantify a variety of different domains related to pain, functional status, self-image, psychological status, satisfaction with treatment, appearance, bracing, and mental health.
For children with early-onset scoliosis, the ideal questionnaire to evaluate their HRQoL is the Early-Onset Scoliosis Questionnaire-24. For adolescents with AIS who are potential candidates for surgical intervention, the use of Scoliosis Research Society-22, Scoliosis Japanese-27, and Quality of Life Profile Spinal Deformity questionnaires is appropriate. For patients who are under nonsurgical treatment, the Brace Questionnaire and Italian Spine Youth Quality of Life (ISYQOL) questionnaires can be utilized. Nonetheless, when the specific intent of a study is to evaluate the self-image perception of patients, the use of drawing-based questionnaires may be the optimal choice [57].
The SRS-22 was the most widely culturally adapted questionnaire, having been translated and modified for use in different languages. SRS-22 questionnaire, including five aspects of functional status, self-image, pain, psychological status, and satisfaction with treatment. In addition, the SRS-22 can be used to evaluate QoL in patients after surgery for scoliosis as well as QoL in patients receiving conservative treatment of scoliosis [58].
The Early Onset Scoliosis Questionnaire-24 (EOSQ-24) is a parent-reported tool to assess HRQoL of patients aged 0-18 years with EOS. The EOSQ-24 comprises 24 items distributed across four domains and 11 subdomains. The HRQoL domain collects data regarding general health (two items), pain/discomfort (two items), pulmonary function (two items), ease of transfer (one item), physical function (three items), daily living (two items), fatigue/energy level (two items), and emotion (two items) of patients with EOS. Parental burden (five items) and financial burden (one item) are additional domains that evaluate the strain placed on parents of their child’s condition, and the satisfaction (two items) domain evaluates the satisfaction level of the EOS patient and their parents [59].
The QoL profile for spine deformity (QLPSD) has 21 items, and its questions are distributed across five domains: psychosocial function (seven questions), sleep disturbance (four questions), back pain (three questions), body image (four questions), and back flexibility (three questions). The items of the QLPSD were rated on a five-point Likert scale, ranging from 1 to 5. Total scores, therefore, fall within a range of 21-105, with higher scores showing fewer QoL impairments, and lower scores indicating more QoL impairments [60].
The Italian Spine Youth Quality of Life (ISYQOL) is a specific self-reported tool comprising 20 items. These items are distributed across two domains: “spinal health” and “brace status.” Items 1-13 are related to the spinal health domain, and items 14-20 are related to the patient’s condition while using the brace. Thus, if the patient is being treated with a brace, they optimally need to complete the full questionnaire items [61].
The Scoliosis Japanese questionnaire-27 (SJ-27) is a gender-specific form that is composed of 27 items across five domains. In items 1-4, the patient is asked about their upper/lower back pain while lying down, following sitting or standing movement, or regarding neck/shoulder stiffness or soreness. In items 5-10 and 27, the questions are about patient discomfort while wearing clothes or lifting/holding bags. In items 11, 15, 16, and 19, the patients are then asked about any difficulties that they may have when participating in exercise, sport, and standing in front of a group of people. Items 12-14, 22, 25, and 26 are related to appearance-related self-consciousness during public situations. There are six items (items 17, 18, 20, 21, 23, and 24) regarding feelings of anxiety or depression resulting from the patient’s spinal deformity [62].
Other instruments include the Short Form-36 Health Survey (SF-36), the Pediatric Outcomes Data Collection Instrument (PODCI), and the Child Health Questionnaire (CHQ) to evaluate general health.
The SF-36 covers the 8 aspects of physiological functioning (PF), bodily pain (BP), physiological functioning (PF), general health (GH), social functioning (SF), vitality (VT), mental health (MH), and emotional functioning (EF). Evaluation of self-image, which is of particular significance in patients with AIS, is not included in SF-36 [63].
The Bad Sobernheim Stress Questionnaire (BSSQ) is a specific unidimensional questionnaire used to examine the stress levels of adolescents with idiopathic scoliosis. This tool is available in two versions: BSSQ-Brace (when wearing a brace) and BSSQ-Deformity, designed by Weiss et al. in Germany. Each version of this questionnaire has eight items. Based on the scores from this questionnaire, each patient is categorized into one of the following groups: high-stress level (with a score from 0 to 8), moderate stress level (from 9 to 16), and minimum stress level (from 17 to 24) [64].
The brace questionnaire (BrQ) is a tool for bracing patients. The BrQ is a self-reported tool aimed at assessing the QoL of adolescents with AIS treated with a brace. The BrQ comprises 34 items and eight domains that assess the HRQoL of adolescents aged between 9 and 18 years who have AIS. The domains of this questionnaire include the following: General health perception (items 1 and 2), Physical functioning (items 3-9), Emotional functioning (items 10-14), Self-esteem and esthetics (items 15 and 16), Vitality (items 17 and 18), School activity (items 19-21), Bodily pain (items 22-27), and Social functioning (items 28-34) [65].
The Body Image Disturbance Questionnaire-Scoliosis (BIDQ-S) is a self-administered, seven-item questionnaire that evaluates an AIS patient’s concerns regarding body image. This measure evaluates whether the scoliosis patient’s back shape causes feelings of unattractiveness or discomfort during social activities, such as at school, work, or with friends and family. The total score varies from 7 to 35. A higher score indicates more severe body image disturbance [66].
For the purpose of evaluating the self-image perception of patients with AIS, the use of drawing-based questionnaires such as WRVAS, SAQ, and TAPS may be the optimal choice.
The Walter Reed Visual Assessment Scale (WRVAS) consists of a visual test including seven items that deal with various aspects of the deformity. It includes a group of figures representing seven aspects of the deformity: item 1, spinal deformity; item 2, rib prominence; item 3, lumbar prominence; item 4, thoracic deformity; item 5, trunk imbalance; item 6, shoulder asymmetry; and item 7, scapular asymmetry. Each aspect is shown with five levels of increasing severity of the deformity, which are scored from minimum (1) to maximum (5). Results are presented as the sum of the seven questions. The figures present an image of the individual as seen from behind. Hence, the WRVAS measures the subjective perception of the deformity from this perspective, or, in other words, how the patient feels that others see his or her back [67].
The spinal appearance questionnaire (SAQ) is one of the specific tools designed to assess the self-image of patients with scoliosis. It has two versions: one aimed at the patient and another that is completed by the patient’s parent or guardian. Both SAQ questionnaires have two sections and nine subsections. The first section consists of drawing-based items that assess the perception of the severity of trunk deformity. The individual’s expectations regarding the symmetry of the shoulders, chest, and pelvis are assessed in the second section through textual-based questions. Subsections of this questionnaire include the following: General (items 9, 10, and 19), Curve (item 1), Prominence (items 2 and 3), Trunk shift (items 4 and 5), Waist (items 11, 12, and 13), Shoulders (items 6 and 16), Kyphosis (item 7), Chest (items 14 and 15), and Surgical scar (item 17). Lastly, there are three open-ended questions (items 8, 18, and 20) included in the questionnaire. The lowest total score for the SAQ is 17, and the highest is 85 [68].
The trunk appearance perception scale (TAPS) is a specific self-administered drawing-based tool aimed at the evaluation of a scoliosis patient’s perception of their trunk deformity. It comprises three sets of drawings that show the patient’s trunk from three viewpoints: (1) looking toward the back (SET 1), (2) looking toward the head when the patient is in an Adams forward bending test (SET 2), and (3) looking toward the front (SET 3). The front viewpoint comprises two sets of figures, that is, one for males and one for females. The instruction section of the TAPS contains a brief description: “Which of these drawings do you think best represents the appearance of your body?” The average total score can be calculated by summing the scores of three drawings and dividing them by 3. Thus, the maximum score will be 5, and the minimum score will be 1 [69].
For aesthetic assessment, there is a tool called TRACE. The acronym of Trunk Aesthetic Clinical Evaluation, TRACE, is a 12-point scale based on four sub-scales: shoulders (0–3), scapulae (0–2), hemi-thorax (0–2), and waist (0–4). TRACE is a no-cost tool for routine clinical practice in AIS patients. Its routine clinical use by physicians is advised [70].
There is also a tool for the evaluation of Truncal Anterior Asymmetry. The Truncal Anterior Asymmetry Scoliosis Questionnaire (TAASQ) contains 14 questions covering three domains: breast, appearance, and clothing. The subdomains of the TAASQ are clothing-general and clothing-specific for the clothing domain, and breast location, breast shape, and breast size for the breast domain. Scoring is based on a mean of these 22 items, where higher scores reflect greater asymmetry (as self-perceived), greater preoccupation, emotional distress, and impairment resulting from said asymmetry [71].
Clinicians and researchers should be careful before selecting a questionnaire to use in evaluating HRQoL and assessing children and adolescents with AIS.
Psychosocial Needs and Long-Term Implications
Patients with scoliosis face varying degrees of psychosocial and body image challenges, with better outcomes observed in those with good social or family support, regular exercise, or psychological health [72]. Anxiety and depression are the most common symptoms, but many parents (66%) are unaware of their child’s emotional or behavioral problems [74]. Females and individuals with moderate depression or who wear a brace are also more likely to experience back pain [74]. Pain catastrophizing, poor mental health, reduced thoracic kyphosis, and pelvic asymmetry are additional risk factors for back pain in adolescents with idiopathic scoliosis [75]. Adolescents and adults with scoliosis and pain often report higher levels of kinesiophobia, anxiety, depression, absenteeism from work or school, and a greater impact on their social and family environment [76].
Mental health, though desired by patients, is not discussed often enough by scoliosis providers, despite its positive association with clinical outcomes [77]. While research on psychosocial interventions for pediatric scoliosis patients is limited, frequent patient-provider interactions show promise [78]. Among the most recent interventions, a mindfulness-based intervention improved short-term bracing compliance for adolescents with idiopathic scoliosis [79] while an original interdisciplinary study, mixing art and nature connections, worked on adolescents’ body image [80].
References/Citations (in order of appearance)
Introduction:
1. Negrini, S., Donzelli, S., Aulisa, A.G. et al. 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis 13, 3 (2018). https://doi.org/10.1186/s13013-017-0145-8
2. Grivas TB, Burwell GR, Vasiliadis ES, Webb JK. A segmental radiological study of the spine and rib cage in children with progressive infantile idiopathic scoliosis. Scoliosis. 2006;1:17. Published 2006 Oct 18. doi:10.1186/1748-7161-1-17
3. Grivas TB, Vasiliadis ES, Rodopoulos G, Bardakos N: The role of the intervertebral disc in correction of scoliotic curves. A theoretical model of idiopathic scoliosis pathogenesis. Stud Health Technol Inform. 2008, 140: 33-36.
4. Grivas TB, Vasiliadis ES, Rodopoulos G: Aetiology of Idiopathic Scoliosis. What have we learned from school screening?. Stud Health Technol Inform. 2008*, 140: 240-244.
5. Negrini S, Aulisa AG, Aulisa L, Circo AB, Claude de Mauroy J, Durmala J, Grivas, TB, Knott P, Kotwicki T, Maruyama T, Minozzi S, O’Brien JP, Papadopoulos D, Rigo M, Rivard CH, Romano M, Wynne JH, Villagrasa M, Weiss HR, Zaina F. 2011 SOSORT guidelines: Orthopaedic and Rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis. 2012;7:3.
6. Parent S, Newton PO, Wenger DR: Adolescent idiopathic scoliosis: etiology, anatomy, natural history, and bracing. Instr Course Lect. 2005, 54: 529-536.
7. Lonstein JE: Scoliosis: surgical versus nonsurgical treatment. Clin Orthop Relat Res. 2006, 443: 248-259.
8. Peng Y, Wang SR, Qiu GX, Zhang JG, Zhuang QY. Research progress on the etiology and pathogenesis of adolescent idiopathic scoliosis. Chin Med J (Engl). 2020;133(4):483-493. doi:10.1097/CM9.0000000000000652
9. Berdishevsky, H., Lebel, V.A., Bettany-Saltikov, J. et al. Physiotherapy scoliosis-specific exercises – a comprehensive review of seven major schools. Scoliosis 11, 20 (2016). https://doi.org/10.1186/s13013-016-0076-9
Bracing:
10. Weinstein, Stuart L., et al. “Effects of bracing in adolescents with idiopathic scoliosis.” New England Journal of Medicine 369.16 (2013): 1512-1521.
11. Babaee, T., et al. “Does Bracing Control the Progression of Adolescent Idiopathic Scoliosis in Curves Higher Than 40°? A Systematic Review and Meta-analysis.” Asian Spine Journal, vol. 17, no. 1, 2023, pp. 203-212. doi:10.31616/asj.2022.0162. Epub 2022 Nov 16. PMID: 36382367; PMCID: PMC9977970.
12. Weiss, Hans-Rudolf, and Mario Werkmann. “Soft braces in the treatment of Adolescent Idiopathic Scoliosis (AIS) – Review of the literature and description of a new approach.” Scoliosis, vol. 7, no. 1, 2012, p. 11. DOI: 10.1186/1748-7161-7-11. PMID: 22640574; PMCID: PMC3479417.
13. Tang, S., J. P. Y. Cheung, and P. W. H. Cheung. “Effectiveness of Bracing to Achieve Curve Regression in Adolescent Idiopathic Scoliosis.” Bone & Joint Journal, vol. 106-B, no. 3, 2024, pp. 286-292. doi:10.1302/0301-620X.106B3.BJJ-2023-1105.R1.
14. Ng, Shu Yan, et al. “Brace Prescription for Adult Scoliosis – Literature Review.” The Open Orthopaedics Journal, vol. 16, 2022, pp. 1-12. DOI: 10.2174/18743250-v16-e2205270.
15. Benes, Gregory, et al. “Scoliosis Bracing: Details Make the Difference.” Journal of the Pediatric Orthopaedic Society of North America, vol. 5, no. 4, 2023, pp. 1-7. DOI: 10.55275/JPOSNA-2023-776.
16. Weiss HR, Çolak TK, Lay M, Borysov M. “Brace treatment for patients with scoliosis: State of the art.” S Afr J Physiother. 2021 Oct 26;77(2):1573. doi: 10.4102/sajp.v77i2.1573. PMID: 34859162; PMCID: PMC8603182.
17. Grivas TB, Negrini S, Negrini S, et al. “Nonoperative management of adolescent idiopathic scoliosis (AIS) using braces.” Prosthetics and Orthotics International. 2022 Aug;46(4):383-391. DOI: 10.1097/pxr.0000000000000117. PMID: 35320151.
Physical Therapy:
18. Berdishevsky, H., Lebel, V.A., Bettany-Saltikov, J. et al. Physiotherapy scoliosis-specific exercises – a comprehensive review of seven major schools. Scoliosis 11, 20 (2016). https://doi.org/10.1186/s13013-016-0076-9
19. Negrini, S., Donzelli, S., Aulisa, A.G. et al. 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis 13, 3 (2018). https://doi.org/10.1186/s13013-017-0145-8
20. Romano M, Minozzi S, Bettany-Saltikov J, Zaina F, Chockalingam N, Kotwicki T, Maier-Hennes A, Arienti C, Negrini S. Therapeutic exercises for idiopathic scoliosis in adolescents. Cochrane Database of Systematic Reviews 2024, Issue 2. Art. No.: CD007837. DOI: 10.1002/14651858.CD007837.pub3. Accessed 20 November 2024.
21. Zapata KA, McIntosh AL, Jo CH, Virostek D. The Addition of Daytime Physiotherapeutic Scoliosis-specific Exercises to Adolescent Idiopathic Scoliosis Nighttime Bracing Reduces Curve Progression. J Pediatr Orthop. 2023;43(6):368-372. doi:10.1097/BPO.0000000000002391
22. Romano M, Negrini A, Parzini S, et al. SEAS (Scientific Exercises Approach to Scoliosis): a modern and effective evidence based approach to physiotherapeutic specific scoliosis exercises. Scoliosis. 2015;10:3. Published 2015 Feb 5. doi:10.1186/s13013-014-0027-2
23. Zapata KA, Sucato DJ, Jo CH. Physical Therapy Scoliosis-Specific Exercises May Reduce Curve Progression in Mild Adolescent Idiopathic Scoliosis Curves. Pediatr Phys Ther. 2019;31(3):280-285. doi:10.1097/PEP.0000000000000621
24. Schreiber S., Parent E. C., Moez E. K., Hedden D. M., Hill D., Moreau M., J., Lou E., Watkins E. M., Southon S. C., The effect of Schroth exercises added to the standard of care on the quality of life and muscle endurance in adolescents with idiopathic scoliosis—an assessor and statistician blinded randomized controlled trial: SOSORT 2015 Award Winner. Scoliosis (2015) 10:24 https://scoliosisjournal.biomedcentral.com/articles/10.1186/s13013-015-0048-5
25. Monticone M, Ambrosini E, Cazzaniga D, Rocca B, Ferrante S. Active self-correction and task-oriented exercises reduce spinal deformity and improve quality of life in subjects with mild adolescent idiopathic scoliosis. Results of a randomised controlled trial. Eur Spine J. 2014;23(6):1204-1214. doi:10.1007/s00586-014-3241-y
26. Negrini S, Donzelli S, Negrini A, Parzini S, Romano M, Zaina F. Specific exercises reduce the need for bracing in adolescents with idiopathic scoliosis: A practical clinical trial. Ann Phys Rehabil Med. 2019;62(2):69-76. doi:10.1016/j.rehab.2018.07.010
27. Kocaman H, Bek N, Kaya MH, Büyükturan B, Yetiş M, Büyükturan Ö. The effectiveness of two different exercise approaches in adolescent idiopathic scoliosis: A single-blind, randomized-controlled trial. PLoS One. 2021;16(4):e0249492. Published 2021 Apr 15. doi:10.1371/journal.pone.0249492
28. Kwan KYH, Cheng ACS, Koh HY, Chiu AYY, Cheung KMC. Effectiveness of Schroth exercises during bracing in adolescent idiopathic scoliosis: results from a preliminary study-SOSORT Award 2017 Winner. Scoliosis Spinal Disord. 2017;12:32. Published 2017 Oct 16. doi:10.1186/s13013-017-0139-6
29. Karavidas N, Tzatzaliaris D. Brace and Physiotherapeutic Scoliosis Specific Exercises (PSSE) for Adolescent Idiopathic Scoliosis (AIS) treatment: a prospective study following Scoliosis Research Society (SRS) criteria. Arch Physiother. 2022;12(1):22. Published 2022 Nov 1. doi:10.1186/s40945-022-00150-5
30.Schreiber S, Whibley D, Somers EC. Schroth Physiotherapeutic Scoliosis-Specific Exercise (PSSE) Trials—Systematic Review of Methods and Recommendations for Future Research. Children. 2023; 10(6):954. https://doi.org/10.3390/children10060954
31.Dimitrijević V, Šćepanović T, Jevtić N, et al. Application of the Schroth Method in the Treatment of Idiopathic Scoliosis: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2022;19(24):16730. Published 2022 Dec 13. doi:10.3390/ijerph192416730
32.You MJ, Lu ZY, Xu QY, et al. Effectiveness of Physiotherapeutic Scoliosis-Specific Exercises on 3-Dimensional Spinal Deformities in Patients With Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-analysis. Arch Phys Med Rehabil. 2024;105(12):2375-2389. doi:10.1016/j.apmr.2024.04.011
33. Schreiber, S., Parent E. C., Hill D. L., Hedden D. M., Moreau M. J., Southon S. C., Patients with adolescent idiopathic scoliosis perceive positive improvements regardless of change in the Cobb angle – Results from a randomized controlled trial comparing a 6-month Schroth intervention added to standard care and standard care alone. SOSORT 2018 Award winner BMC Musculoskeletal Disorders (2019) 20:319
Surgery:
34. Weinstein SL, Ponseti IV, Curve progression in idiopathic scoliosis. J Bone Joint Surg Am. 1983;65(4):447–455.
35. Jada A, Mackel CE, Hwang SW, Samdani AF, Stephen JH, Bennett JT, Baaj AA. (2017). “Evaluation and management of adolescent idiopathic scoliosis: a review.” Neurosurg Focus, 43(4):E2. doi: 10.3171/2017.7.FOCUS17297. PMID: 28965447
36. Bridwell, K, et al, Parents’ and Patients’ Preferences and Concerns in Idiopathic Adolescent Scoliosis: A Cross-Sectional Preoperative Analysis. Spine 25(18):p 2392-2399, September 15, 2000
37. Weinstein SL, Dolan LA, Spratt KF, Peterson KK, Spoonamore MJ, Ponseti IV. Health and Function of Patients With Untreated Idiopathic Scoliosis: A 50-Year Natural History Study. JAMA. 2003;289(5):559–567. doi:10.1001/jama.289.5.559
38. Evaniew, N., Devji, T., Drew, B., Peterson, D., Ghert, M., & Bhandari, M. (2015). The surgical management of scoliosis: a scoping review of the literature. Scoliosis and Spinal Disorders, 10(1), 1-9.
39. Pishnamaz, M., et al, (2024). “Long-term outcomes of spinal fusion in adolescent idiopathic scoliosis: a literature review.” European Journal of Medical Research, 29:534.
40. Samdani, A. F., et al (2014). Anterior vertebral body tethering for idiopathic scoliosis: two-year results. Spine, 39(20), 1688-1693.
41. Cherian D, Samdani AF, Schüpper AJ, et al. Early outcomes in hybrid fixation for idiopathic scoliosis: posterior fusion combined with anterior vertebral body tethering. Patient series. J Neurosurg Case Lessons. 2023;6(15):CASE23331. Published 2023 Oct 9. doi:10.3171/CASE23331
42. Baker, C. et al. 2020. Anterior Lumbar Vertebral Body Tethering in Adolescent Idiopathic Scoliosis: Surgical/Technical Tips. Journal of the Pediatric Orthopaedic Society of North America. 2, 3 (Nov. 2020). DOI:https://doi.org/10.55275/JPOSNA-2020-145.
43. Wolpert, D. K. (2020). Scoliosis Surgery: The Definitive Patient’s Reference.
44. Moe, J. H. (2019). The Management of Spinal Deformities.
45. Epps Jr., C. H. (2018). Complications in Orthopaedic Surgery.
46. Burrows KR, et al, Long-term adjacent segment degeneration at average 21-year follow-up of posterior instrumented fusion for adolescent idiopathic scoliosis. Spine Deform. 2023;11(4):933-941. doi:10.1007/s43390-023-00652-7
47. Lander ST, Thirukumaran C, Saleh A, et al. Long-Term Health-Related Quality of Life After Harrington Instrumentation and Fusion for Adolescent Idiopathic Scoliosis: A Minimum40-Year Follow-up. J Bone Joint Surg Am. 2022;104(11):995-1003. doi:10.2106/JBJS.21.00763
48. Simony A, Hansen EJ, Carreon LY, Christensen SB, Andersen MO. Health-related quality-of-life in adolescent idiopathic scoliosis patients 25 years after treatment. Scoliosis. 2015;10:22. Published 2015 Jul 16. doi:10.1186/s13013-015-0045-8
49. Cobb, J. R. (2017). Scoliosis and Spinal Pain Syndrome.
50. Sponseller PD, Betz R, Newton PO, et al. Differences in curve behavior after fusion in adolescent idiopathic scoliosis patients with open triradiate cartilages. Spine (Phila Pa 1976). 2009;34(8):827-831. doi:10.1097/BRS.0b013e31819139ef
51. Zhu, Feng et al, Comparison of Surgical Outcome of Adolescent Idiopathic Scoliosis and Young Adult Idiopathic Scoliosis: A Match-Pair Analysis of 160 Patients. SPINE 42(19):p E1133-E1139, October 1, 2017. | DOI: 10.1097/BRS.0000000000002106
52. Lonner BS, Ren Y, Bess S, et al. Surgery for the Adolescent Idiopathic Scoliosis Patients After Skeletal Maturity: Early Versus Late Surgery. Spine Deform. 2019;7(1):84-92. doi:10.1016/j.jspd.2018.05.012
53. Chen JW, Chanbour H, Gupta R, et al. Adult versus adolescent idiopathic scoliosis surgery: a meta-analysis of clinical and radiographic outcomes. Eur Spine J.2024;33(4):1637-1643. doi:10.1007/s00586-024-08177-x
54. Westrick ER, Ward WT. Adolescent idiopathic scoliosis: 5-year to 20-year evidence-based surgical results. J Pediatr Orthop. 2011;31(1 Suppl):S61-S68. doi:10.1097/BPO.0b013e3181fd87d5
55. Weiss HR, Nan X, Potts MA. (2021). “Is there an indication for surgery in patients with spinal deformities? – A critical appraisal.” S Afr J Physiother, 77(2):1569. doi: 10.4102/sajp.v77i2.1569. PMID: 34859161; PMCID: PMC8603189.
56. Aghdasi, B. et al., Patient-reported Outcomes Following Surgical Intervention for Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-Analysis. Clinical Spine Surgery 33(1):p 24-34, February 2020. | DOI: 10.1097/BSD.0000000000000822
QOL and other Assessment Tools:
57. Taher Babaee, Vahideh Moradi, Ardalan Shariat, Albert T. Anastasio, Alireza Khani, Mahtab Bagheri, Naeimeh Rouhani, Disease-Specific Outcome Measures Evaluating the Health-Related Quality of Life of Children and Adolescents with Idiopathic Scoliosis and Scheuermann’s Kyphosis: A Literature Review, Spine Surgery and Related Research, 2022 Volume 6 Issue 3 Pages 197-223, DOI https://doi.org/10.22603/ssrr.2021-023 https://www.jstage.jst.go.jp/article/irdr/4/1/4_2014.01032/_article
58. Asher M, Min Lai S, Burton D, Manna B. The reliability and concurrent validity of the scoliosis research society-22 patient questionnaire for idiopathic scoliosis. Spine (Phila Pa 1976). 2003 Jan 1;28(1):63-9. doi: 10.1097/00007632-200301010-00015. PMID: 12544958. https://pubmed.ncbi.nlm.nih.gov/12544958/
59. Matsumoto H, Williams B, Park HY, Yoshimachi JY, Roye BD, Roye DP Jr, Akbarnia BA, Emans J, Skaggs D, Smith JT, Vitale MG. The Final 24-Item Early Onset Scoliosis Questionnaires (EOSQ-24): Validity, Reliability and Responsiveness. J Pediatr Orthop. 2018 Mar;38(3):144-151. doi: 10.1097/BPO.0000000000000799. PMID: 27299779; PMCID: PMC5562528. 44://pubmed.ncbi.nlm.nih.gov/27299779/
60. Climent JM, Reig A, Sánchez J, Roda C. Construction and validation of a specific quality of life instrument for adolescents with spine deformities. Spine (Phila Pa 1976). 1995 Sep 15;20(18):2006-11. doi: 10.1097/00007632-199509150-00011. PMID: 8578377. https://pubmed.ncbi.nlm.nih.gov/8578377/
61. Negrini S, Zaina F, Buyukaslan A, Fortin C, Karavidas N, Kotwicki T, Korbel K, Parent E, Sanchez-Raya J, Shearer K, Yilmaz HG, Donzelli S, Caronni A. Cross-cultural validation of the Italian Spine Youth Quality of Life questionnaire: the ISYQOL international. Eur J Phys Rehabil Med. 2023 Jun;59(3):364-376. doi: 10.23736/S1973-9087.23.07586-X. Epub 2023 May 17. PMID: 37195649; PMCID: PMC10272934. https://pubmed.ncbi.nlm.nih.gov/37195649/
62. Doi T, Inoue H, Arai Y, Shirado O, Doi T, Yamazaki K, Uno K, Yanagida H, Takeshita K. Reliability and validity of a novel quality of life questionnaire for female patients with adolescent idiopathic scoliosis: Scoliosis Japanese Questionnaire-27: a multicenter, cross-sectional study. BMC Musculoskelet Disord. 2018 Apr 3;19(1):99. doi: 10.1186/s12891-018-2025-7. PMID: 29615021; PMCID: PMC5883312. https://pubmed.ncbi.nlm.nih.gov/29615021/
63. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992 Jun;30(6):473-83. PMID: 1593914. https://pubmed.ncbi.nlm.nih.gov/1593914/
64. Botens-Helmus C, Klein R, Stephan C. The reliability of the Bad Sobernheim Stress Questionnaire (BSSQbrace) in adolescents with scoliosis during brace treatment. Scoliosis. 2006 Dec 19;1:22. doi: 10.1186/1748-7161-1-22. PMID: 17176483; PMCID: PMC1764899. https://pubmed.ncbi.nlm.nih.gov/17176483/
65. Vasiliadis E, Grivas TB, Gkoltsiou K. Development and preliminary validation of Brace Questionnaire (BrQ): a new instrument for measuring quality of life of brace treated scoliotics. Scoliosis. 2006 May 20;1:7. doi: 10.1186/1748-7161-1-7. PMID: 16759366; PMCID: PMC1481574.
66. Auerbach JD, Lonner BS, Crerand CE, Shah SA, Flynn JM, Bastrom T, Penn P, Ahn J, Toombs C, Bharucha N, Bowe WP, Newton PO. Body image in patients with adolescent idiopathic scoliosis: validation of the Body Image Disturbance Questionnaire–Scoliosis Version. J Bone Joint Surg Am. 2014 Apr 16;96(8):e61. doi: 10.2106/JBJS.L.00867. PMID: 24740669; PMCID: PMC6948793. https://pubmed.ncbi.nlm.nih.gov/24740669/
67. Pineda S, Bago J, Gilperez C, Climent JM. Validity of the Walter Reed Visual Assessment Scale to measure subjective perception of spine deformity in patients with idiopathic scoliosis. Scoliosis. 2006 Nov 8;1:18. doi: 10.1186/1748-7161-1-18. PMID: 17090338; PMCID: PMC1654183. https://pmc.ncbi.nlm.nih.gov/articles/PMC1654183/
68. Sanders JO, Harrast JJ, Kuklo TR, Polly DW, Bridwell KH, Diab M, Dormans JP, Drummond DS, Emans JB, Johnston CE 2nd, Lenke LG, McCarthy RE, Newton PO, Richards BS, Sucato DJ; Spinal Deformity Study Group. The Spinal Appearance Questionnaire: results of reliability, validity, and responsiveness testing in patients with idiopathic scoliosis. Spine (Phila Pa 1976). 2007 Nov 15;32(24):2719-22. doi: 10.1097/BRS.0b013e31815a5959. PMID: 18007251. https://pubmed.ncbi.nlm.nih.gov/18007251/
69. Bago J, Sanchez-Raya J, Perez-Grueso FJ, Climent JM. The Trunk Appearance Perception Scale (TAPS): a new tool to evaluate subjective impression of trunk deformity in patients with idiopathic scoliosis. Scoliosis. 2010 Mar 25;5:6. doi: 10.1186/1748-7161-5-6. PMID: 20338048; PMCID: PMC2852387. https://pubmed.ncbi.nlm.nih.gov/20338048/
70. Zaina, F., Negrini, S. & Atanasio, S. TRACE (Trunk Aesthetic Clinical Evaluation), a routine clinical tool to evaluate aesthetics in scoliosis patients: development from the Aesthetic Index (AI) and repeatability. Scoliosis 4, 3 (2009). https://doi.org/10.1186/1748-7161-4-3 https://scoliosisjournal.biomedcentral.com/articles/10.1186/1748-7161-4-3
71. Lonner, Baron S. MD; Toombs, Courtney S. MD; Shah, Suken A. MD; Bastrom, Tracey MA; Penn, Phedra MD; Bright, Kristin PhD; Stern, Carrie Scharf MD; Roy-Beaudry, Marjolaine PhD; Beausejour, Marie PhD; Neiss, Geraldine PhD; Castillo, Andrea BS; Parent, Stefan MD. What a Patient Sees in the Mirror: Validation of the Truncal Anterior Asymmetry Scoliosis Questionnaire. Journal of Prosthetics and Orthotics 35(3):p 172-179, July 2023. | DOI: 10.1097/JPO.0000000000000433 https://journals.lww.com/jpojournal/abstract/2023/07000/what_a_patient_sees_in_the_mirror__validation_of.7.aspx
Psycho-Social:
72. Tones M, Moss N, Polly DW Jr. A review of quality of life and psychosocial issues in scoliosis. Spine (Phila Pa 1976). 2006;31(26):3027-3038. doi:10.1097/01.brs.0000249555.87601.fc https://pubmed.ncbi.nlm.nih.gov/17173000/
73. Sanders AE, Andras LM, Iantorno SE, Hamilton A, Choi PD, Skaggs DL. Clinically Significant Psychological and Emotional Distress in 32% of Adolescent Idiopathic Scoliosis Patients. Spine Deform. 2018;6(4):435-440.
doi:10.1016/j.jspd.2017.12.014 https://pubmed.ncbi.nlm.nih.gov/29886916/
74. Wong AYL, Samartzis D, Cheung PWH, Cheung JPY. How Common Is Back Pain and What Biopsychosocial Factors Are Associated With Back Pain in Patients With Adolescent Idiopathic Scoliosis?. Clin Orthop Relat Res. 2019;477(4):676-686. doi:10.1097/CORR.0000000000000569 https://pubmed.ncbi.nlm.nih.gov/30516661/
75. Teles AR, St-Georges M, Abduljabbar F, et al. Back pain in adolescents with idiopathic scoliosis: the contribution of morphological and psychological factors. Eur Spine J. 2020;29(8):1959-1971.
doi:10.1007/s00586-020-06489-2 https://pubmed.ncbi.nlm.nih.gov/32519028/
76. Matamalas A, Figueras C, Pizones J, et al. How back pain intensity relates to clinical and psychosocial factors in patients with idiopathic scoliosis. Eur Spine J. 2022;31(4):1006-1012. doi:10.1007/s00586-022-07117-x https://pubmed.ncbi.nlm.nih.gov/35128586/
77. Zeck EJ, Glahn Castille ME. Clinician-led mental health conversations significantly associated with outcomes for scoliosis patients. Eur J Phys Rehabil Med. 2023;59(4):522-528. doi:10.23736/S1973-9087.23.08084-X https://pubmed.ncbi.nlm.nih.gov/37746784/
78. Van Niekerk M, Richey A, Vorhies J, Wong C, Tileston K. Effectiveness of psychosocial interventions for pediatric patients with scoliosis: a systematic review. World J Pediatr Surg. 2023;6(2):e000513. Published 2023 Mar 7. doi:10.1136/wjps-2022-000513 https://pubmed.ncbi.nlm.nih.gov/36919027/
79. Li, X., Lau, E.N.S., Chan, S.K.C. et al. Effects of Mindfulness-Based Intervention to Improve Bracing Compliance in Adolescent Idiopathic Scoliosis Patients: a Randomized Controlled Trial. Mindfulness 14, 322–334 (2023). https://doi.org/10.1007/s12671-022-02021-3
80. Baker C, Morris N, Tsirikos A, Fotakopoulou O, Parrott F. Adolescent idiopathic scoliosis: interdisciplinary creative art practice and nature connections. Med Humanit. 2024;50(1):41-51. Published 2024 Feb 22.
doi:10.1136/medhum-2023-012796 https://pubmed.ncbi.nlm.nih.gov/38164581/
