Idiopathic scoliosis is a pathology that affects approximately 2% of adolescents 12. Various treatment procedures are proposed, according to severity of curvature, hump height, age at diagnosis, spinal stiffness and skeletal maturity. One of the major problems in the treatment of this pathology is the lack of a reliable prognostic tool for its possible evolution. There are scolioses that, once discovered, don't worsen anymore, whereas others are characterized by a rapid and dramatic worsening – especially during the pubertal growth spurt – or that continue to worsen in adulthood. This particular variety of behaviours allows us to employ two alternative methods of therapeutic approach:

1. The patients are not subjected to screening or to previous treatments. This forces the persons who are affected by serious scoliosis to begin treatment later, causing negative repercussions on the final results or the need to perform an important surgical intervention.

2. The patients are subjected to a screening (school, family, pediatrician); all risky scolioses are identified (namely those that exceed a certain degree according to age) and are referred to a program of conservative treatment, according to the potential risk of evolution. Furthermore, this procedure has a disadvantage in that it involves a long and expensive treatment even for the subject who is not affected by an progressive scoliosis.

The steps of non-surgical intervention can start with a simple observation, if no particularly important curvature is discovered and the subject is not at a particularly risky age. Alternatively, it is possible to adopt different therapeutic solutions, such as the use of braces 345678910111213, which are intended to correct spinal development when curvature evolution is not controlled through other techniques. Many studies have been conducted regarding the efficacy of such a therapeutic approach, whose validity is nevertheless confirmed by official medicine 58141516. Another common therapeutic approach is the use of physical exercises 1718192021222324252627 whose efficacy is not universally recognized, even if two systematic review 28 has been published during recent years. The results of these works do not allow us to state with reasonable certainty that this procedure will represent an efficacious treatment for idiopathic scoliosis, given that the studies on which the aforementioned review were based had been performed using different techniques. However, the possibility of comparing the best results from the various treated groups with the respective control groups encourages us to carry out new research with a better scientific design 2829. Besides the above-described treatments, it is possible to mention a range of alternative therapeutic proposals, such as the implantation of a dental bite or of podalic insoles. Their efficacy, however, has not been supported by published studies. A therapeutic approach that seems more and more common for the conservative treatment of adolescent idiopathic scoliosis includes manual techniques proposed by chiropractors and osteopaths. These techniques are favoured by their progressive popularity within the wider and wider panorama of alternative therapies 303132333435363738.

The purpose of this study is to present a systematic review of the international scientific literature in order to verify the therapeutic efficacy of these procedures, which include all the manipulative and generally passive techniques performed by an external operator to treat idiopathic scoliosis. In a more specific meaning, osteopathic, chiropractic and massage techniques have been considered manipulative therapeutic methods.

We conducted systematic research in the following databases: Medline, Embase, Cinhal, Cochrane Library and Pedro. The research was carried out in May of 2005 without time, meaning without fixing a starting date or imposing language restrictions. The key phrases were as follows: Idiopathic scoliosis (combined with chiropractic); manipulation; mobilization; manual therapy; massage; osteopathy; and therapeutic manipulation. The research was completed through the analysis of the other papers published and available, thanks to the following specialized databases: Index to Chiropractic Literature, Osteomed, Osteopathic Research Web, and N.C.C.A.M.

The criteria for inclusion were as follows:

• Subjects: Diagnosis of Adolescent idiopathic scoliosis;

• Type of treatment received: Exclusively one of the procedures fixed as a standard for this review (chiropractic manipulation, osteopathic techniques, massage);

• Outcome: Cobb degrees;

• Type of study: Any kind of research.

The decision not to apply highly restrictive selection criteria but to include studies conducted with different procedures was determined through the presumption that homogeneous trials are seldom performed.

None of the papers retrieved had the characteristics required for inclusion in our review. Indeed, we found only two research trials. Neither of the two had a control group, but each was characterized by a combination of manipulative procedures and other therapeutic approaches. The results of these two research studies are discordant. In the paper written by Morningstar et al 31the result seems extremely positive (an average improvement of 17° Cobb after four to six weeks of treatment), while the conclusions of the study conducted by Lantz et al. 32 show an absolute ineffectiveness of the applied treatment. It must be stated that the first study had certain flaws: The recruited group of subjects presented an excessively wide age range, but no control group was designed and no follow-up observation was performed after treatment. Some doubts also arise as to the results, which seem so extraordinary to suggest a deep reflection to all health workers engaged in the conservative treatment of scoliosis throughout the world.

Case reports are not a valuable aid. Even when summing up single results, in the absence of homogeneous studies the data is absolutely inadequate (only two cases related to young patients, always characterized by the association of manual treatment with other techniques). None of the other papers allowed us to obtain supplementary information that could be deemed useful.

Generally, for manual therapy we can underline that even if we were to extend our inclusion criteria, the available papers are completely inadequate for a review. We can compare these results with those obtained using different conservative techniques, such as physical therapy or braces. Regarding physical exercises, few trials have been conducted as to their efficacy. We can mention just two systematic reviews 2841. The quality of the retrieved papers is not very high, given the lack of randomized controlled studies. However, the results are very interesting for future research and suggest the possible usefulness of exercises. The most recent review 41 published in 2005, asserts that at this state of the art, physical therapy and the application of a brace have the same reliability value. Of course, in the scientific literature we can find a greater number of papers on treatment using a brace. However, for this technique we still lack the certainty that the brace is an absolutely reliable therapeutic technique.

In conclusion, the data reported above does not allow us to evaluate the efficacy of manual therapy techniques in adolescent idiopathic scoliosis. These results confirm the urgent needof scientific studies with at least one control group, to be performes by operators using such techniques, to demonstrate their validity.

Both authors participated in all phases of the study, excluding data collection, that was performed by MR alone.