children

Article
Algorithm for Schroth-Curve-Type Classification of Adolescent
Idiopathic Scoliosis: An Intra- and Inter-Rater
Reliability Study †
Sanja Schreiber 1 , Eric C. Parent 1, * , Gregory N. Kawchuk 1 and Douglas M. Hedden 2

1 Department of Physical Therapy, University of Alberta, 8205 114 Street, 2-50 Corbett Hall,
Edmonton, AB T6G 2G4, Canada
2 Department of Surgery, University of Alberta, 8440 112 Street, 2D2.24 WMC, Edmonton, AB T6G 2R7, Canada
* Correspondence: [email protected]; Tel.: +1-780-492-8889
† This is a part of the Ph.D. Thesis of Sanja Schreiber.

Abstract: Schroth exercises for scoliosis are prescribed based on curve types. This study aimed to
determine the reliability of an algorithm for classifying Schroth curve types. Forty-four consecutive
volunteers with adolescent idiopathic scoliosis, 10 to 18 years old, with curves 10◦ to 50◦ , were
recruited from a scoliosis clinic. Their standing posture and Adam’s bending test were videotaped.
Ten consecutive Schroth therapist volunteers from an international registry independently classified
the curve types using the proposed classification algorithm. Videos were rated twice at least seven
days apart. Reliability was calculated using the Gwet’s AC1 agreement coefficient for all the raters
and for subgroups reporting full understanding (well-trained) and with prior algorithm experience.
The intra-rater and weighted agreement coefficients for all the raters were 0.64 (95% CI: 0.53–0.73)
and 0.75 (0.63–0.84), respectively. For the well-trained raters, they were 0.70 (0.60–0.78) and 0.82
(0.73–0.88), respectively; for the experienced raters, they were 0.81 (0.77–0.85) and 0.89 (0.80–0.94),
respectively. The inter-rater versus weighted agreement coefficients for all the raters were 0.43
(0.28–0.58) versus 0.48 (0.29–0.67). For the well-trained raters, they were 0.50 (0.38–0.61) versus 0.61
(0.49–0.72), and for the experienced raters, they were 0.67 (0.50–0.85) versus 0.79 (0.64–0.94). Full
Citation: Schreiber, S.; Parent, E.C.;
understanding and experience led to higher reliability. Use of the algorithm can help standardize
Kawchuk, G.N.; Hedden, D.M.
Schroth exercise treatment.
Algorithm for Schroth-Curve-Type
Classification of Adolescent
Idiopathic Scoliosis: An Intra- and
Keywords: scoliosis; algorithms; classification; posture; reliability; reproducibility of results; Schroth;
Inter-Rater Reliability Study. Children adolescent
2023, 10, 523. https://doi.org/
10.3390/children10030523

Academic Editor: Luigi 1. Introduction

Aurelio Nasto
Adolescent idiopathic scoliosis is a three-dimensional deformity of the spine affecting
Received: 23 December 2022 2–3% of teenagers who are mostly female [1]. Scoliosis can lead to chronic consequences,
Revised: 9 February 2023 including external torso deformity, pain, limited function, and poor self-image [2]. Pre-
Accepted: 26 February 2023 venting curves from progressing before maturity is important to: (1) reduce the risk of
Published: 8 March 2023 consequences described above, which typically manifest once curves exceed 50 degrees;
and (2) limit or fully prevent progression during adulthood.
Schroth exercises are physiotherapeutic scoliosis-specific exercises that aim to correct
Copyright: © 2023 by the authors.
posture and curvatures by improving the endurance and control of the muscles affected
Licensee MDPI, Basel, Switzerland.
by scoliosis [3]. Recent systematic reviews have demonstrated that Schroth exercises can
This article is an open access article improve scoliosis curves [4–6], self-image [5,7], and back muscle endurance [5,7], while also
distributed under the terms and decreasing pain [5,7]. A recent survey of Scoliosis Research Society members indicated that
conditions of the Creative Commons 88% support funding scoliosis-specific exercise research, and a growing number prescribe
Attribution (CC BY) license (https:// such exercises [8]. In fact, the use of Schroth exercises has increased over the past decade
creativecommons.org/licenses/by/ due to the greater interest of patients and families [8].
4.0/).

Children 2023, 10, 523. https://doi.org/10.3390/children10030523 https://www.mdpi.com/journal/children

Children 2023, 10, 523 2 of 11

Schroth therapists use a classification system [9] to prescribe exercise treatment for
patients with scoliosis that is adapted to each patient’s curve type. During a clinical assess-
ment, the influence of scoliosis on the alignment and posture of each of the four body blocks
is visually appraised to determine the curve pattern. The four blocks are: (a) hip-pelvic
block, representing pelvis and lower extremities; (b) lumbar block, representing the part
of the spine where the lumbar curve appears; (c) thoracic block, where the thoracic curve
appears; and (d) shoulder block, including the shoulders and the neck (Figure 1). Scoliosis
presentation can be classified into four Schroth curve types (Figure 1), two thoracic (3c and
3cp) and two thoracolumbar/lumbar (4c and 4cp) patterns. The reliability of the Schroth
classification system is unknown.

Figure 1. Schroth classification illustrated based on the most common right-convex thoracic or left
lumbar curve direction.

From left to right, the first illustration shows a body without scoliosis; 3c is a major
thoracic curve, with a small or no lumbar curve and a balanced pelvis; 3cp is a single
long thoracic curve with the unbalanced pelvis deviated in the opposite direction of the
thoracic convexity; 4c is a major lumbar curve compensated by a thoracic curve of similar
importance (not necessarily in terms of Cobb angles) and a balanced pelvis; 4cp presents
a major thoraco-lumbar or lumbar curve, with or without a thoracic curve, and with
the unbalanced pelvis shifted in a direction opposite to the lumbar convexity. The plus
underneath each curve representation signifies the side on which the major curve convexity
appears [10].
Rigo et al. developed a classification to guide the design of the Cheneau rigid
braces [11]. Rigo’s classification is based on the Schroth classification, but it distinguishes
five curve types based on the location of external features and the position of the pelvis.
Radiological assessment is used to further subclassify the curves. The Rigo classification
has acceptable intra- and inter-rater reliability, with a kappa of 0.87 and ranging from 0.61
to 0.81, respectively [11]. Weiss also developed a classification to guide the Cheneau Light
bracing, which, similarly, relies on the Schroth classification [12]. Weiss further differenti-
ated between the curve patterns where the pelvis is imbalanced to create two additional
categories, but the reliability is unknown. Several other classifications to guide treatment
for scoliosis exist, including King’s [13], Lenke’s [14], and Peking Union Medical College’s
classifications [15]. All aim to help plan surgery, with King’s also used to guide bracing.
Although the Peking Union Medical College’s classification was found to be more reliable
(kappa = 0.90) [15] than King’s (0.64) and Lenke’s classifications (0.73) [16], Lenke’s has
been endorsed by the Scoliosis Research Society and is used most widely.
Although these reliable scoliosis classifications exist, they are used to inform bracing
or surgical treatments rather than exercise therapy, and they rely on radiographs. Con-
Children 2023, 10, 523 3 of 11

versely, the Schroth classification mainly relies on clinical assessment to guide exercise
treatment. This is consistent with most Schroth therapists not having direct access to
radiographs. A reliable curve classification strategy is needed to help standardize Schroth
exercise treatment delivery. Therefore, for the Multicenter Schroth exercise trial for scol-
iosis (NCT01610908) [6,7,17], we proposed a rule-based algorithm to assist therapists in
classifying patients. Algorithms have previously been used successfully to maximize the
reliability of the Cobb angle measurements and the King’s classification of patients with
scoliosis, for surgery purposes [18].
To demonstrate the generalizability of the novel classification algorithm, it was im-
portant to involve varied therapists, representative of the population of certified Schroth
therapists worldwide. Although Schroth therapists are spread internationally, the majority
were trained by the same instructor in Germany and could, thus, be contacted from the
institution’s registry. It was not feasible to have many raters test the same patients in person
due to travel requirements and patient fatigue. However, because the curve classification
assessment is simple, a reliability study was conducted by presenting videos of the same
patients. The benefits of video recordings are that they allow for (1) blinded ratings, (2) a
larger sample of widely distributed raters to be involved to maximize generalizability, and
(3) minimizing the patients’ burden due to repeated evaluations.
Given these considerations, the purposes of this study were to: (1) propose a Schroth
classification algorithm; and (2) determine the intra- and inter-rater reliability of Schroth thera-
pists in classifying adolescents with idiopathic scoliosis using the algorithm. We hypothesized
that therapists experienced with the algorithm and those reporting that they fully understood
the classification algorithm training material would achieve adequate reliability.

2. Methods
2.1. Research Design
In this intra- and inter-rater reliability study, therapists independently rated videos
twice, with at least one week in between assessments.

2.2. Study Participants and Raters

Forty-four volunteers with scoliosis were consecutively recruited from a specialized
scoliosis clinic within a university hospital. The inclusion criteria were: (1) diagnosis of
adolescent idiopathic scoliosis; (2) all curve types; (3) 10 to 18 years old; and (4) curves
between 10 and 50◦ . Other scoliosis diagnoses and/or a history of scoliosis surgery were
ineligible. All therapists trained by the German Schroth clinic and fluent in English were
invited to participate as raters in this study. The first 10 therapists to volunteer were
enrolled. All participants and raters gave informed consent to participate. The study
was approved by the Health Research Ethics Board—Health Panel at the University of
Alberta (Pro00019547).

2.3. Physical Examination

Participants were videotaped while standing in habitual posture presenting their front,
left, right, and back sides for 10 s each, and while performing the Adam’s forward bending
test (≈20 s). Maximal thoracic and lumbar rotation measurements were obtained using a
scoliometer. High intra- (ICC = 0.92) and inter-rater (0.89) reliability were reported for these
measurements [19]. Video capture was standardized using drapes and a frame holding a
posture assessment grid to ensure consistent lighting and to aid the visualizing of postural
features. A plumb line was aligned with the umbilicus in the front, the gluteal cleft for the
back, or the lateral malleoli for the side views. The participants’ identity was hidden using
iMovie (v8.0.6 Apple, Cupertino, CA, USA), and the scoliometer measurements were overlaid
in the videos. Edited videos lasted about 60 s. Figure 2 presents a representative 3cp curve
type. Other curve types are presented online (Supplementary Materials S1: Figures S1–S3
Presentation of a representative case with 3c, 4c, and 4cp curve types, respectively).
Children 2023, 10, 523 4 of 11

Figure 2. Snapshots from the video assessment of a 3cp curve type. The plumb line was aligned
with the umbilicus, left malleolus, right malleolus, and the gluteal cleft in the front, left, right, and
back views, respectively. The Adam’s bending test video clip displayed scoliometer readings for the
largest rotation to the right and left, measured over the trunk.

2.4. Classification Algorithm

The Schroth classification algorithm and operational definitions were designed based
on the 2011 Schroth training manual by the consensus of two experienced Schroth therapists
with research experience [9]. The international Schroth instructor reviewed the material
before testing. The algorithm guides therapists in detecting key postural features to
determine the Schroth curve type (Figure 3). Each algorithm step leads to a “yes/no”
decision, with the final step resulting, unambiguously, in selecting one Schroth curve type.
To assist therapists in classifying, operational definitions and instructions were provided
(Supplementary Materials S2: Operational definitions for Schroth Classification Algorithm).
The algorithm starts with the evaluation of the pelvis displacement relative to midline,
with a displaced pelvis being considered unbalanced (Figure 3). If the pelvis is found
unbalanced, the relationship between the pelvis and lumbar spine is assessed. If the
lumbar spine and the pelvis block deviate in the same direction (i.e., are “coupled”), the
classification is 3cp. If the lumbar and pelvis blocks deviate in opposite directions (i.e.,
are “uncoupled”), the classification is 4cp. If the pelvis is balanced, therapists determine
whether it is uncoupled from the lumbar spine and if a prominent hip is observed. In this
case, therapists assess the relative importance of the thoracic prominence (rib hump) and
of the lumbar prominence. If the thoracic prominence is judged to be more significant, the
classification is 3c. Otherwise, the classification is 4c.
Children 2023, 10, 523 5 of 11

Figure 3. Schroth-curve-type classification algorithm.

2.5. Rater Training

Each therapist-rater was given secure access to a website, where the algorithm, user’s
guide, and operational definitions could be downloaded. After reviewing this material,
raters streamed four videos from the website representing each of the Schroth curve types.
After viewing each video, therapists provided decisions for each algorithm branch and the
final classification and were encouraged to note any comments. The primary author of this
study reviewed the comments and prepared explanatory videos to highlight the algorithm
decisions for each of the four Schroth curve types in reference to the relevant section of
the instructions.

2.6. Rating Procedures

After training, 44 patient videos were streamed in a random order on the website.
Therapists could view the videos as often as needed. After the first round of rating was
completed, access was blocked for a week. Subsequently, the same 44 videos were streamed
again in a different random order. Therapists were blinded to their first ratings, the
participants’ identity, and other therapists’ ratings.

2.7. Analyses
2.7.1. Gwet’s Agreement Coefficient
Because of kappa’s well-documented limitations [20,21], we used Gwet’s agreement
coefficient (AC1) [20] to determine intra- and inter-rater reliability as well as weighted relia-
bility [20]. Percentage of agreement is also reported with 95% confidence intervals [20]. Reli-
ability estimates were obtained for: the entire sample of raters; a subgroup of two therapists
who conceptualized and had used the algorithm in an ongoing trial (labeled “experienced”);
and a subgroup of six therapists who self-reported full understanding of the algorithm
(labeled “well-trained”). Calculations were performed using AgreeStat 2013.1 for Excel
Windows (Advanced Analytics, Gaithersburg, Maryland, USA).
Children 2023, 10, 523 6 of 11

We used Gwet’s benchmarking method, which focuses only on the part of the esti-
mated agreement coefficient that confidently reflects genuine and not chance agreement [20].
This “significant part” was obtained by subtracting Gwet’s “critical value”, determined
based on the number of participants, raters, and rating categories, from the estimated
agreement coefficient [20]. With 44 participants, 10 raters, and 4 classification options,
the critical value was 0.08 [20]. Reliability estimates between 0.61 and 0.80 were, thus,
considered substantial. Adequate reliability to recommend clinical use was set a priori at
≥0.61. Mean reliability coefficients were calculated using Fisher’s transformation.

2.7.2. Weighted Agreement

A weighted analysis was justified because differences in Schroth therapies have greater
significance when misclassifying between some categories than others. Because the 3c and
4c curve patterns have a balanced pelvis, the exercise prescription will not differ as much
as between the 3cp versus 4cp (major thoracic versus major lumbar with imbalanced pelvis
compensating for different major curves directions), 4cp versus 3c (major lumbar with
imbalanced pelvis versus thoracic major curve with balanced pelvis), or the 3cp versus 4c
curve patterns (major single thoracic curve with imbalanced pelvis versus major lumbar
curve with thoracic curve compensation and balanced pelvis). For 3c versus 3cp and for 4c
versus 4cp patterns, the differences in therapy would be only in the prescription of exercises
related to the imbalanced pelvis.
Pairings involving classifications where the treatment would occur in opposite direc-
tions (e.g., pelvis correction in 3cp versus 4cp) or focus on a different part of the posture
(e.g., in 3c versus 4cp) were assigned no agreement (0.00). Full agreement weighting
(1.00) was assigned to same-group ratings. The weights for each pairing, including those
representing partial agreement determined a priori, are summarized in Table 1.

Table 1. Partial agreement weights.

3c 3cp 4c 4cp
3c 1.00 0.75 0.50 0.00
3cp 0.75 1.00 0.00 0.00
4c 0.50 0.00 1.00 0.75
4cp 0.00 0.00 0.75 1.00

2.7.3. Sample Size

Based on Gwet’s recommendations [20] of tolerating ≤15% error margin on the co-
efficient of variation of the percent agreement (standard error/percent agreement) and
20% relative error on the percent agreement (width of 95% confidence interval around the
percent agreement), 44 volunteers with scoliosis and 10 raters were required for 2 repeated
evaluations with 4 classification options [20].

3. Results
3.1. Participants and Therapists
The participants’ characteristics are shown in Table 2. Based on the first experienced
rater’s ratings, there were nine 3c, twelve 3cp, six 4c, and seventeen 4cp Schroth curve
types. Sixty-five international therapists were invited to participate, sixteen consented,
and the first six to complete the ratings, in addition to the three research therapists and
the Schroth instructor, were included. The age of the six female and four male therapists
(mean ± standard deviation) was 46.7 ± 12.3 years old. At the time of rating, they had
worked for 6.6 ± 6.4 years as Schroth therapists (range: 3 to 23 years). Five of the therapists
had treated more than 75 patients in their career, two between 26 and 75, two between 11
and 25, and one between 4 and 10 patients. The therapists’ self-reported understanding
of the classification algorithm ranged from 50% to 100%. Six therapists reported 100%
understanding. All therapists found the algorithm useful and user-friendly, and 7 out of 10
stated they would continue using it clinically.
Children 2023, 10, 523 7 of 11

Table 2. Description of the participants with adolescent idiopathic scoliosis.

Standard
N Mean Minimum Maximum
Deviation
Age (years) 44 14.2 2.0 10.0 18.0
Upper thoracic Cobb angle (◦ ) 8 25.0 7.1 15.0 38.0
Major thoracic Cobb angle (◦ ) 36 26.7 10.3 10.0 49.0
Thoracolumbar/lumbar Cobb angle (◦ ) 37 25.8 10.0 10.0 48.0

3.2. Intra-Rater and Weighted AC1 Agreement Coefficients

The overall mean intra-rater agreement coefficient was 0.64 (95% confidence interval:
0.53–0.73), and the mean weighted intra-rater coefficient was 0.75 (0.63–0.84).(Table 3) Experi-
enced raters reached higher estimates with a mean agreement coefficient of 0.81 (0.77–0.85) and
weighted coefficients of 0.89 (0.80–0.94). The six well-trained therapists reached a mean intra-
rater coefficient of 0.70 (0.60–0.78) and a weighted intra-rater coefficient of 0.82 (0.73–0.88).

Table 3. Intra-rater AC1 and weighted AC1 coefficients and percent agreement with 95% confidence intervals.

Weighted Percent
AC1 Percent Agreement Weighted AC1
Agreement
(95% CI) (95% CI) (95% CI)
(95% CI)
Experienced 1 0.79 (0.64–0.94) 84.1 (73.0–95.2) 0.92 (0.87–0.98) 96.0 (93.2–98.9)
Experienced 2 0.83 (0.69–0.96) 86.3 (75.9–96.8) 0.85 (0.71–0.99) 91.5 (83.7–99.2)
Rater 1 0.47 (0.27–0.67) 59.1 (44.1–74.0) 0.60 (0.41–0.79) 78.4 (68.5–88.3)
Rater 2 0.52 (0.32–0.71) 63.6 (49.0–78.3) 0.58 (0.36–0.79) 78.4 (67.5–89.4)
Rater 3 0.73 (0.57–0.89) 79.5 (67.3–91.8) 0.89 (0.82–0.96) 94.3 (90.7–97.9)
Rater 4 0.51 (0.30–0.71) 61.5 (45.8–77.2) 0.57 (0.35–0.80) 76.3 (64.2–88.4)
Rater 5 0.61 (0.43–0.80) 70.5 (56.6–84.3) 0.68 (0.50–0.87) 83.0 (73.1–92.8)
Rater 6 0.34 (0.14–0.54) 48.8 (33.5–64.2) 0.41 (0.18–0.64) 67.4 (54.8–80.1)
Rater 7 0.72 (0.55–0.88) 77.2 (64.5–90.0) 0.80 (0.66–0.95) 88.0 (79.9–96.2)
Rater 8 0.64 (0.46–0.82) 72.7 (59.2–86.3) 0.83 (0.72–0.94) 90.9 (85.3–96.5)
Mean (overall) 0.64 (0.53–0.73) 72.0 (63.9–78.6) 0.75 (0.63–0.84) 86.7 (79.9–91.3)
Mean (experienced) 0.81 (0.77–0.85) 85.0 (82.9–86.9) 0.89 (0.80–0.94 94.0 (86.8–97.3)
Mean (well-trained) 0.70 (0.60–0.78) 76.6 (69.4–82.3) 0.82 (0.73–0.88) 90.1 (84.8–93.6)

3.3. Inter-Rater and Weighted AC1 Agreement Coefficients

The overall mean inter-rater agreement coefficient was 0.43 (95% confidence interval
0.28–0.58). (Table 4) The corresponding value for the experienced raters was 0.67 (0.50–0.85).
The well-trained therapists’ inter-rater coefficient was 0.50 (0.38–0.61). Overall, the weighted
coefficient was 0.48 (0.29–0.67). The experienced and well-trained raters had weighted
coefficients of 0.79 (0.64–0.94) and 0.61 (0.49–0.72), respectively.

Table 4. Inter-rater AC1 and weighted AC1 coefficients and percent agreement with 95% confidence intervals.

Percent Weighted Weighted Percent

AC1
Agreement AC1 Agreement
(95% CI)
(95% CI) (95% CI) (95% CI)
All raters (N = 10) 0.43 (0.28–0.58) 56 (45–67) 0.48 (0.29–0.67) 73 (63–82)
Experienced raters (N = 2) 0.67 (0.50–0.85) 75 (62–88) 0.79 (0.64–0.94) 89 (81–96)
Well-trained raters (N = 6) 0.50 (0.38–0.61) 61 (53–70) 0.61 (0.49–0.72) 79 (73–85)

4. Discussion
In this study, we proposed a standardized algorithm to achieve adequate rater’s relia-
bility in classifying the Schroth curve type. This algorithm was developed to assist with
standardizing exercise prescription as part of the Multicentre Schroth Exercise Trial for Sco-
liosis [6,7,17]. For the first time, we presented the intra- and inter-rater reliability of Schroth
Children 2023, 10, 523 8 of 11

exercise therapists in classifying patients with idiopathic scoliosis treated conservatively.

The overall weighted intra-rater, intra-rater, and weighted agreement coefficients for the
experienced and well-trained therapists, as well as the weighted inter-rater coefficients for
the experienced therapists, met our a priori threshold (≥0.61) for recommending clinical
use. Note that the weighted reliability analysis is the most relevant one for Schroth clinical
practice because some categories share similar postural defects and, thus, similar exercises,
whereas others do not share such postural or exercise prescription similarities.
Rigo’s [11] and Weiss’ [12] classifications were derived from the Schroth curve classifi-
cation to guide brace design. The King’s [13], Lenke [14], and Peking University Medical
Center [15] classifications were proposed to guide surgical procedures and, hence, are rather
tailored to more or significant deformities. Therefore, comparisons with other reliability
classification studies are difficult because the Schroth classification tested for reliability
in the present study is tailored for the classification of patients with small curves for a
different purpose: selecting exercises.
With the usage of an algorithm, the intra-rater reliability of King’s classification im-
proved from a previously published kappa of 0.64 [21] to 0.85[17] and the inter-rater reliabil-
ity from 0.44 [22] to 0.82 [18]. Similarly, when compared with the gold standard—software
automatically classifying Lenke curve types according to radiographic measurements of
Cobb angles—the accuracy of Lenke’s classification improved from 0.77 to 0.93 by using an
algorithm [23].
To minimize differences in therapists’ interpretation of the rating procedure, we
proposed a standardized Schroth classification algorithm with operational definitions and
instructions. Still, the two therapists experienced in using the algorithm had the highest
reliability. Overall, the self-reported comprehension of the algorithm ranged between
50% and 100% and significantly correlated with the intra-rater reliability coefficient in
this sample of 10 therapists (Spearman’s rho = 0.68, p = 0.03). Additional training may be
needed for therapists with a lower level of understanding. Furthermore, modifications of
the algorithm could be considered to improve its reliability.
To avoid sampling bias and maximize generalizability, study participants were con-
secutively selected from our specialized scoliosis clinic. However, Lenke 1, 2, and 5 curve
types that partially correspond to the 3c, 3cp, and 4cp curve types, according to Schroth,
reportedly account for 83% of all scoliosis patterns [24]. Thus, underrepresentation of the
4c Schroth curve type might have been observed.
After training, a professional photographer helped improve the quality of the videos
by minimizing shadows affecting the three-dimensional perception of the postural charac-
teristics of scoliosis. Most therapists reported that the quality of the videos was adequate.
During treatment, a therapist, over time, could confirm or change classification and adjust
the treatment if needed. Our results may therefore reflect a lower limit of the reliability
because therapists were shown only one assessment over which they had no control.
Although video assessments have been successfully used in reliability studies [25–27],
the inability to rate scoliotic presentation in person might have influenced the estimates.
Reliability may be overestimated by using a video presentation that removed the errors that
could be caused by therapists providing different instructions during the evaluation. On
the other hand, reliability may be underestimated if issues related to observing evaluation
videos caused more difficulty in classifying than if the exams were conducted in person.
Difficult-to-rate patients may be better assessed if therapists could evaluate them while
using different postures or while performing movements other than forward bending.
Reliability may be improved if this flexibility in the testing procedure led to a better
classification accuracy; however, it could also lead to poorer reliability if it increased the
variability in the testing procedures. Typically, a therapist observes a patient from each side
and performs the Adam’s bending test to assess asymmetries. As such, we think that the
current standardized video assessment adequately reflects the typical assessment of most
practicing Schroth therapists.
Children 2023, 10, 523 9 of 11

Limitations and Future Work

While adequate to meet our power calculations a priori, the samples of 44 patients, and
10 raters (including 2 experienced and 6 well-trained raters) is relatively small to ensure
generalizability for all other raters and patients. Replicating this study with additional
patients and raters would help demonstrate generalizability. To assess the true value of the
algorithm, reliability should be compared with the classification reliability observed before
therapists are trained in using the algorithm. In the future, the sources of disagreements
should be determined by calculating the reliability at each decision step and identifying
the decision steps most responsible for the classification error. If there are some patients
who are difficult to rate, their characteristics could be assessed. The algorithm could also be
tested with therapists assessing patients in person. Finally, it would be important to assess
whether the reliability changes with the severity of the scoliosis.

5. Conclusions
We proposed a simple algorithm to maximize the therapists’ reliability in classifying
Schroth curve type and assist in the prevention of treatment errors due to misclassification.
The algorithm was well accepted, and most raters reported that they were planning to use
it clinically. Experienced and well-trained raters achieved adequate reliability. Our results
suggest that the algorithm can be used clinically with sufficient training [28].

Supplementary Materials: The following supporting information can be downloaded at: https://www.
mdpi.com/article/10.3390/children10030523/s1, Supplementary Materials S1: Figures S1–S3 Presenta-
tion of a representative case with 3c, 4c, and 4cp curve types, respectively. Supplementary Materials S2:
Operational definitions for Schroth classification algorithm. Supplementary Material S3: Data file.
Author Contributions: Conceptualization, S.S. and E.C.P.; methodology, S.S. and E.C.P.; formal
analysis, S.S.; investigation, S.S.; data curation, S.S.; writing—original draft preparation, S.S.; writing—
review and editing, E.C.P., D.M.H. and G.N.K.; visualization, S.S.; supervision, E.C.P., D.M.H. and
G.N.K.; project administration, E.C.P.; funding acquisition, E.C.P., S.S. and D.M.H. All authors have
read and agreed to the published version of the manuscript.
Funding: This research was funded by a Clinical Research Grant from the Glenrose Rehabilitation
Hospital Foundation. Sanja Schreiber was supported by the Interfaculty Graduate Studentship
awarded jointly by the Faculty of Rehabilitation Medicine and the Faculty of Medicine and Dentistry,
University of Alberta.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki and approved by the Health Research Ethics Board—Health Panel at University of Alberta
(Pro00019547 4 October 2011).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the
study. Written informed consent was obtained from the patients appearing in the figures to publish
this paper.
Data Availability Statement: The data presented in this study are available in Supplementary Material S3:
Data file.
Acknowledgments: The authors wish to thank: Kathleen Shearer for research coordination; the
Rehabilitation Medicine Technology Group for website development and information technology
support; Axel Hennes, international Schroth instructor for reviewing the algorithm and operational
definitions prior to the start of the study; and the patients and therapists for participating in our study.
Conflicts of Interest: Sanja Schreiber is now owner of Curvy Spine, a clinic offering Schroth exercise
treatment in Edmonton, and an instructor for International Schroth Three-Dimensional Scoliosis
Therapy. She was not involved with these institutions while conducting the research. No potential
conflict of interest is reported by the other authors. The funders had no role in the design of the
study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the
decision to publish the results.
Children 2023, 10, 523 10 of 11

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