Response to letter to editor regarding “Core stabilization exercises versus scoliosis-specific exercises in moderate idiopathic scoliosis treatment” by Yagci and Yakut (2019)

We would like to thank the author(s) for their inquiry and remarks regarding our recent study reporting the effects of core stabilization exercise versus scoliosis-specific exercises in the treatment of patients with moderate idiopathic scoliosis. ¹ Your comments highlight several important points that need to be clarified.

According to the review by International Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT)/Scoliosis Research Society (SRS), ² there have been studies that show benefits of conservative treatment (bracing and/or exercise) after periods of application up until 1 year (10 week, 4 months, 6 months, etc.). However, there is no consensus about the specific treatment period necessary for eliciting exercise effectiveness in scoliosis rehabilitation. Our study included a 4-month period of application, in which curve magnitude, body symmetry, and cosmetic deformity improved in both treatment groups.

We agree that our study showed short-term effects of the core stabilization and scoliosis-specific exercise interventions on moderate curves with idiopathic scoliosis. The issue has already been reported clearly in the article, where we state that

Both treatment conditions including core stabilization with bracing and scientific exercises approach to scoliosis with bracing had similar effects in the short-term treatment of moderate adolescent idiopathic scoliosis.

But we disagree that the treatment period is “very short-term (because it is less than 12 months of treatment)” as reported in the letter to the Editor. According to the SOSORT/SRS criteria, short term has been defined as several weeks, medium term as several months, and long term as several years of intervention. ² Additionally, we reported in the limitation section that

This study shows short-term effect of the two treatment protocols. Future studies are needed to compare long-term effects of CS and SEAS interventions in the conservative treatment of AIS. It is clear from this statement that we do not have long-term results and future studies are needed.

The letter raises the question “what can we expect from exercises as an add-on to bracing in the very short term?” We aimed in this study to compare different exercise methods when bracing is indicated. As we already know from the SOSORT/SRS consensus, ² for mild scoliosis, the primary treatment is exercise, while for moderate curves, the primary treatment is the combination of bracing and exercise. If we did not expect an effect from exercise when brace is indicated, we would not have added this intervention to the treatment. We believe that, in mild curves where bracing is not indicated, scoliosis-specific exercise may be superior to general exercise methods. But in this study, we aimed to compare the effects of scoliosis-specific exercise and general exercise (not specific for scoliosis) which includes a core stabilization component, as an add-on treatment to bracing of moderate curves. Of course, we cannot differentiate the effects of the two exercise methods from bracing and we stated this in the limitation section,

Traditionally, a “bracing only” group would be included in order to make a real comparison of two different exercise interventions, but this would have been difficult to implement for ethical reasons, given that it is necessary to combine bracing and exercise intervention for the improvement of moderate curves.

Therefore, our study reported comparison of one treatment method combining scoliosis-specific exercise with bracing to another treatment method combining core stabilization exercise with bracing.

Thank you for emphasizing the underlying reason why we chose to compare specifically these two exercise methods, Scientific exercise approach to scoliosis (SEAS) and core stabilization. The two exercise methods had a core stabilization component, while SEAS also had a scoliosis-specific correction component. We agree that stabilization is important during the brace wearing period.

It is recommended by the SOSORT/SRS committee that therapists implement a compliance system for exercise tracking and brace wearing. ² We followed this recommendation by recording and reporting how many hours patients wore their spinal brace daily (necessary for 23 h) and how long they spent on home exercises daily (20 min). We also reported sums of compliance scores as percentages in the results section. The two groups were similar on brace and home exercise compliance variables, with no statistically significant differences. We understand that a compliance monitor is suggested in bracing studies, but we could not use this technological method due to economic constraints and lack of facilities. We did state this issue in the limitations section and hope that the authors of the letter understand our choice.

We believe that the methodology of the study is clear. We reported that

Assessments were undertaken at baseline and after the 4-month treatment period for each patient by the second investigator, who was blind to the allocation of the participants, throughout the study. Final measurements were taken after the brace has been removed for 6 h.

This means that change in curve magnitude (by Cobb angle) with treatment was assessed at baseline and after 4 months of treatment in out-of-brace condition. In-brace correction was measured for the in-brace condition after fabrication of the brace and the amount of in-brace correction was noted. This was reported in the paragraph stating that

Furthermore, initial in-brace corrections were calculated for the primary curve, and the correction rate was reported in percentages in order to assess the clinical success of the brace as part of the bracing protocol.

In conclusion, we thank the authors of the letter to the editor for emphasizing that stabilization is the most important component of scoliosis-specific exercises in the first phase of bracing treatment and also for giving us the opportunity to clarify related issues in the study.