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Chapter Summary
• Context: Non-surgical management of scoliosis encompasses strategies with distinct objectives depending on age, etiology, curve magnitude and behavior, and remaining growth potential. In early-onset scoliosis, serial casting can control deformity during a critical developmental window and, in selected cases, delay or avoid surgical procedures. In adolescent idiopathic scoliosis (AIS), bracing represents the primary conservative modality designed to reduce the risk of curve progression during growth, provided it is properly indicated and consistently worn. In neuromuscular, congenital, or adult scoliosis, treatment goals shift toward postural support, trunk balance, sitting comfort, or symptomatic relief. Physiotherapeutic Scoliosis-Specific Exercises (PSSE) expand this therapeutic armamentarium, although the chapter acknowledges heterogeneity and methodological limitations in the available evidence. Thus, conservative management is not a single, generic intervention, but an individualized strategy requiring precise patient selection, strict adherence, and continuous clinical and radiographic surveillance.
• Chapter Objective: To present the core principles guiding the selection, implementation, and follow-up of conservative management in scoliosis. The reader will understand the role of serial casting, recognize major brace categories and their distinct clinical indications across different scoliosis etiologies, and critically analyze the application of scoliosis-specific exercises, distinguishing potential functional benefits from the limitations of the current scientific evidence and appreciating the value of multimodal conservative protocols.
• Serial casting: controlling deformity while preserving growthSerial casting plays a pivotal role primarily in early-onset deformities. The chapter details the elongation, derotation, and flexion (EDF) principle, where corrective forces act three-dimensionally on the curve. This strategy involves successive cast applications tailored to patient growth and curve response, accompanied by regular radiographic monitoring to evaluate correction, progression, and the need for treatment modification. The literature summarized in the chapter indicates that early initiation can provide substantial deformity control and, in certain patients, reduce the need for surgery. However, the technique demands close vigilance for cutaneous complications and transient pulmonary repercussions. In select protocols, casting is followed by maintenance bracing to sustain the achieved correction.
• Bracing: indication and compliance go hand in handIn AIS, brace prescription depends on curve magnitude, documented progression, and, crucially, remaining skeletal growth. The chapter reviews various brace models selected according to curve apex, flexibility, and corrective objectives. The Milwaukee brace represents a cervicothoracolumbosacral orthosis traditionally used for high thoracic curves. The Boston brace is a compact thoracolumbosacral orthosis (TLSO). Charleston and Providence braces provide nighttime-only alternatives in selected patterns. The Rigo-Chêneau brace utilizes 3D corrective principles based on regional pressure and expansion chambers. Figure 1 illustrates the clinical and radiographic outcomes of a patient before and during Rigo-Chêneau wear. The chapter emphasizes that clinical efficacy does not depend solely on brace design; compliance, regular orthotic adjustments, patient education, and radiographic follow-up are indispensable determinants of success.
• Different etiologies, different therapeutic goalsBrace indications carry distinct meanings across etiologies. In adult scoliosis, orthoses are utilized primarily for mechanical support, trunk posture, and symptom relief, with less robust evidence for halting structural curve progression. In neuromuscular scoliosis, bracing focuses on postural trunk support, stable sitting balance, and skin protection. In congenital scoliosis, bracing plays a limited and typically adjuvant role. In infantile idiopathic scoliosis, it contributes to controlling curve progression and maintaining corrections achieved through prior conservative measures.
• Scoliosis-specific exercises: potential and evidence limitsPSSE protocols rely on principles of active 3D self-correction, integration of corrected posture into daily activities, trunk stabilization, and patient education. The chapter cites established schools such as Schroth, SEAS, and BSPTS. Systematic reviews and meta-analyses suggest potential benefits in curve parameters, trunk symmetry, and health-related quality of life. Nonetheless, the authors highlight methodological limitations, small sample sizes, and risk of bias across published trials, cautioning against overreaching conclusions. The evidence is particularly compelling when exercises are combined with bracing; cited studies demonstrate that this multimodal approach can yield superior functional outcomes and enhance curve control. Thus, specific exercises are presented as an integral part of a comprehensive strategy rather than an automatic substitute for bracing when an orthosis is strictly indicated.
• Clinical Application: In clinical practice, the first step is defining the specific goal of conservative treatment for the individual patient. In a young child with early-onset scoliosis, the objective may be progressive correction or curve control while preserving spinal and thoracic growth. In a skeletally immature adolescent with a progressive curve, the primary goal of bracing is preventing worsening and avoiding spinal fusion. In neuromuscular or adult patients, comfort, trunk stability, and functional mobility take precedence over radiographic correction. Method selection must integrate etiology, curve location and flexibility, skeletal maturity, progression velocity, and patient/family compliance. Prescribing a brace without ensuring proper fit, regular adjustments, and consistent daily wear substantially undermines therapeutic efficacy. Standardized serial radiographs evaluate treatment response and detect early failure. Serial casting monitors response across cast changes; bracing protocols assess curve containment and the need for pad modifications. PSSE can be incorporated, particularly when tailored individually and combined with orthotic therapy. However, the chapter advises cautious literature interpretation, underscoring that exercises alone cannot replace indicated bracing in patients at high risk of rapid progression.
