|Satisfaction with management||10||5.0|
|General health perception||10||5.0|
|Self-esteem and aesthetics||2||1.0|
|Total = little stress||27||3.37|
Scoliosis is a structural 3-dimensional deformity of the spine and trunk that occurs during puberty because of several factors. [2, 3] In general, the larger the scoliotic curve, the higher is the risk of progression. Similarly, thoracic and thoracolumbar double curves have greater chances of progression than single curves. Moreover, patients with less skeletal maturity have a worse prognosis than adults. [2, 3] Small variations in curvatures are sometimes viewed as normal, as they have little potential for progression [2, 3] and, in some cases, will correct by themselves over time.
This case demonstrated the effects of 9 months of physiotherapy and 6 months of follow-up on double curve in a patient with idiopathic scoliosis. These results suggest that the intervention had an immediate effect on mechanical standardization of double curve. Moreover, physiotherapy treatment did not affect quality of living with idiopathic scoliosis.
The effectiveness of the brace treatment in adolescent idiopathic scoliosis is widely acknowledged. [7, 9, 11, 12, 25] However, brace treatments have some disadvantages. Patients, usually young, have to wear the brace for 18 to 23 hours a day for several years; the brace is often visible and can be uncomfortable to wear.  This type of treatment can be rather bothersome  and may significantly impact patients’ psychological well-being and negatively affect their QoL. [9, 21] Bracing may have psychological impacts at the beginning of treatment, including reduced self-esteem. [3, 9, 13, 27] Because of psychological issues alone, a 9% rate of brace-treatment distress and discontinuation among girls has been reported. [9, 12] Poor compliance with a brace protocol is associated with even poorer QoL. In addition, noncompliant patients have decreased vitality, combined with physical-emotional and social deterioration.  Moreover, noncompliance with brace wear is often an issue and varies from refusal to wear the orthosis to premature discontinuation of the use of that brace and to less than full-time use of the brace. 
Others have found that spinal manipulation alone does not appear to alter spinal structure when administered as a sole treatment modality.  Therefore, we hypothesized that treatment of adolescent idiopathic scoliosis should include the use of both manipulative and rehabilitative procedures so that structural changes can be accomplished. Consequently, a careful choice of specific and personalized exercises and therapies may be more effective than conventional care; and such treatment may avoid brace prescription in countering scoliosis.  However, more research needs to be done in a controlled setting to test these hypotheses.
A retrospective analysis of 24 months, 28 patients with scoliosis receiving chiropractic rehabilitation was reported. The authors demonstrated sustained radiographic, self-rated, and psychological benefits after treatment ceased.  Chiropractic treatment was also associated with a reduction in a severe case of adolescent idiopathic scoliosis (46° Cobb angle) in a young female after she had previously received conservative medical treatment that failed to stop curve progression. 
Currently, nonsurgically treated patients are encouraged to participate in sports and physical activity; and scoliosis is not a contraindication to participation in most sports ; therefore, this could also increase the QoL of the patients. In addition, manipulation of the spine under anesthesia is an outpatient procedure performed to restore normal joint kinematics and musculoskeletal function.  Pain, functional, and radiographic outcomes demonstrated improvements immediately following treatment for this patient.  Taken together, these therapeutic alternatives should also be considered depending on the patient's case.
Body image and health-related QoL are significant issues for patients with scoliosis because of cosmetic deformity and physical and psychological symptoms.  Increased severity of structural spine deformation correlates with a greater likelihood of social and psychological complications. 
Although the treatment was successful, the fundamental explanations of our results are unknown. The mechanisms underlying our outcomes might be related to increased spine movement and ligamentous lengthening of the concavities of the scoliotic curvatures. Therefore, it is possible that the addition of manipulative and rehabilitative techniques allowed us to mobilize regions of the spine that were not successfully mobilized by other means. In addition, the present case introduces a possible alternative conservative therapy and does not appear to induce a detrimental effect in the patient's psychological development. It is suggested that the decision to perform a given treatment of adolescent idiopathic scoliosis should not be based solely on a health practitioner's opinion; it should also include the opinions and guidance of the psychology staff.
There are limitations to this case report. This report demonstrates only a single case; and therefore, the management protocol cannot be generalized to all cases of adolescent idiopathic scoliosis. A single case report does not prove cause and effect. Because of the nature of the case and the lack of a placebo, it is possible that there were other influences and that this patient may have improved without treatment.
The management protocol used in this case seemed to produce clinical improvements for this patient. In addition, the patient did not show psychological sequel after the treatment. These results confirm the urgent need of large, high-quality, randomized controlled studies of such techniques to demonstrate their validity. We recommend that outcome measures of these studies should include psychological and social effects.
Funding sources and potential conflicts of interest
This work was supported by personal funds of J.H.V. and in part by a grant from the J. Robert Cade Foundation to G.B.S.
G.B.S. is also a member of the Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET) Argentina. No conflicts of interest were reported for this study.
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