J Manipulative Physiol Ther. 2017 (Jul); 40 (6): 452–458 ~ FULL TEXT
Jean Théroux, DC, PhD, Norman Stomski, PhD,
Christine Dominique Losco, M(Chiro), PGCert(Ed),
Christelle Khadra, RN, Hubert Labelle, MD, Sylvie Le May, RN, PhD
School of Health Profession,
Murdoch, Western Australia, Australia
OBJECTIVE: The purpose of this study was to perform a systematic review of clinical trials of spinal manipulative therapy for adolescent idiopathic scoliosis.
METHODS: Search strategies were developed for PubMed, CINHAL, and CENTRAL databases. Studies were included through June 2016 if they were prospective trials that evaluated spinal manipulative therapy (eg, chiropractic, osteopathic, physical therapy) for adolescent idiopathic scoliosis. Data were extracted and assessed by 2 independent reviewers. Cochrane risk of bias tools were used to assess the quality of the included studies. Data were reported qualitatively because heterogeneity prevented statistical pooling.
RESULTS: Four studies satisfied the inclusion criteria and were critically appraised. The findings of the included studies indicated that spinal manipulative therapy might be effective for preventing curve progression or reducing Cobb angle. However, the lack of controls and small sample sizes precluded robust estimation of the interventions' effect sizes.
CONCLUSION: There is currently insufficient evidence to establish whether spinal manipulative therapy may be beneficial for adolescent idiopathic scoliosis. The results of the included studies suggest that spinal manipulative therapy may be a promising treatment, but these studies were all at substantial risk of bias. Further high-quality studies are warranted to conclusively determine if spinal manipulative therapy may be effective in the management of adolescent idiopathic scoliosis.
KEYWORDS: Adolescent; Cobb Angle; Scoliosis; Spinal Manipulation; Systematic Review
From the Full-Text Article:
Adolescent idiopathic scoliosis represents a >10° 3-dimensional spinal deviation occurring in adolescents 10 years or older.  The etiology of this condition remains unknown, and its documented prevalence ranges from 1% to 3%.  Although scoliosis can remain stable in some adolescents throughout their growth period, it can progress in others and needs to be adequately managed.
Management of adolescent idiopathic scoliosis is aimed at preventing curve progression and respiratory dysfunction, reducing spinal pain, and improving aesthetics.  Appropriate management usually comprises (1) observation for a small curve <25°, (2) bracing or special intensive inpatient rehabilitation for curves between 25° and 45°, and (3) surgical correction when the curve has progressed beyond 45°.  Observation usually encompasses 6 to 12 months’ in-clinic evaluation and, in some cases, radiologic assessment. 
Special inpatient rehabilitation comprises a combination of therapeutic intervention and exercises as an inpatient hospital program and is typically recommended for curvatures of 30° to 40°, with or without the addition of bracing.  This treatment approach, however, requires an extensive hospital stay, which may be unsuitable for some young people to undertake.
Bracing has been reported to significantly decrease the risk of progression in high-risk curves.  However, several issues can affect bracing compliance, including poor self-esteem and body image resulting from the brace’s unpleasant cosmetic appearance, discomfort associated with pressure points or inclement weather, and impeded range of movement.  Given the reluctance of substantial numbers of adolescents to use bracing, it is warranted to establish whether alternatives to bracing may be effective in the management of adolescent idiopathic scoliosis.
Guidelines developed by the Scoliosis Research Society suggest that spinal manipulative therapy may be beneficial in the management of adolescent idiopathic scoliosis.  Studies have reported that spinal manipulative therapy is commonly used by young people for the management of musculoskeletal disorders.  Whether adolescents with scoliosis use spinal manipulative therapy is unknown, but it would seem likely that it is the case. Hence, it is timely to systematically review the evidence regarding the effectiveness of spinal manipulative therapy for adolescent idiopathic scoliosis. The objective of this systematic review was to assess the effectiveness of spinal manipulative therapy for adolescent idiopathic scoliosis.
The results of the included studies suggest that spinal manipulative therapy may be promising for the management of adolescent idiopathic scoliosis. However, the small number of participants in 3 of the included studies [16, 22, 25] meant that there was insufficient power to achieve a robust estimation of the interventions’ effect size. In addition, the lack of control group in 2 of those studies [16, 22] also increases uncertainty around the interventions’ effect size. In the other included study,  which had an adequate sample size, the manner in which the outcomes were reported precluded the calculation of the intervention’s effect size. Hence, controlled, adequately powered studies are required to establish whether spinal manipulative therapy may be beneficial in the management of idiopathic adolescent scoliosis.
Authoritative recommendations for the assessment of scoliosis research outcomes have been recently developed.  These recommendations note that the following outcomes should be routinely evaluated: aesthetic concerns, curve progression, disability, pain, and quality of life. Of these, the only outcome reported in the studies included in this review was curve progression. Further studies therefore need to capture a broader of range of outcomes to ensure the development of a more complete understanding of the manner in which spinal manipulative therapy affects the lives of young people who experience adolescent idiopathic scoliosis. Moreover, to facilitate statistical pooling of data, researchers should use standardized outcome measures recommended by the Scoliosis Research Society and Society on Scoliosis Orthopaedic and Rehabilitation Treatment. 
In all but 1 of the studies included in this review,  spinal manipulative therapy was administered along with other adjunct therapies. Although the concurrent use of therapies may reflect pragmatic clinical practice, it does not allow for the isolation of the specific effect of spinal manipulative therapy in clinical trials. Hence, further studies should determine the specific effect of spinal manipulative therapy for adolescent idiopathic scoliosis through the use of a study design that involves only administering spinal manipulative therapy in 1 of the treatment arms.
The benefit of any therapy also needs to be considered in light of its adverse consequences.  Only 1 of the studies  included in this review reported adverse events. Therefore, additional studies that examine the effectiveness of spinal manipulative therapy for adolescent idiopathic scoliosis should routinely capture information about adverse events in order to weigh the benefit against the risk of treatment. 
Limitations associated with the search strategy need to be considered in the interpretation of the present study’s findings. The search strategy was limited to PubMed, CINHAL, and CENTRAL databases, and therefore relevant studies indexed only in other databases may have been omitted from this review. In addition, the nonindexed literature was not searched, which may also have resulted in the omission of relevant studies. Nonetheless, in our view the search strategy used in this review did not exclude a body of literature large enough to alter the conclusion that spinal manipulative therapy for idiopathic scoliosis remains an inadequately researched area
There is currently insufficient evidence to establish whether spinal manipulative therapy effectively reduces curve severity in adolescent idiopathic scoliosis. The results of the included studies suggest that spinal manipulative therapy may be a promising treatment for adolescent idiopathic scoliosis, but these studies were all at substantial risk of bias. High-quality studies are warranted to determine if spinal manipulative therapy may be beneficial in the management of adolescent idiopathic scoliosis.
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