Digital neuromodulation in the rehabilitation of adolescent idiopathic scoliosis: A systematic review and comparative analysis of virtual reality and surface electromyography biofeedback versus conventional kinesitherapy

Adolescent idiopathic scoliosis is a complex three-dimensional spinal deformity with multifactorial
biomechanical and neurophysiological etiology, manifesting during periods of accelerated skeletal growth.
Despite the established clinical efficacy of scoliosis-specific physiotherapeutic exercises and orthotic
management, limitations persist, including the absence of objective biofeedback, variability in motor
performance, and suboptimal neuromotor re-education within conventional frameworks. Virtual reality and
surface electromyography biofeedback represent a promising technological extension aimed at addressing these
gaps through real-time sensorimotor feedback and adaptive motor training. The objective of this systematic
review was to evaluate the scientific evidence on the effectiveness of kinesitherapeutic interventions using
virtual reality and surface electromyography biofeedback compared with standard kinesitherapy in adolescents
with idiopathic scoliosis, and to assess the mechanisms underlying their potential clinical benefit.
Methodologically, the review followed the principles of evidence-based medicine, the 2020 Preferred Reporting
Items for Systematic Reviews and Meta-Analyses guidelines, the Oxford Centre for Evidence-Based Medicine
hierarchy of evidence, and the Grading of Recommendations Assessment, Development and Evaluation system
for certainty assessment; the literature was searched in major biomedical databases (2005–2026) using a
structured population, intervention, comparison, and outcomes framework, and included randomized controlled
trials, controlled clinical studies, and prospective cohort studies of adolescents aged 10–18 years with
radiographically confirmed idiopathic scoliosis who had not undergone spinal surgery; study quality was
assessed with the Physiotherapy Evidence Database scale, and risk of bias with the Cochrane Risk of Bias 2 tool
and the Risk Of Bias In Non-randomized Studies of Interventions tool. Results indicated that conventional
approaches, namely scoliosis-specific exercise methods such as the Schroth method and rigid
thoracolumbosacral orthotic bracing, retained the strongest evidence base for structural control, with moderate
to-high certainty of evidence for Cobb angle stabilization and prevention of progression. Studies of surface
electromyography documented asymmetric paraspinal muscle activity in idiopathic scoliosis, whereas evidence
for the effect of biofeedback training was limited to small and qualitative studies. Direct evidence for virtual
reality in adolescent idiopathic scoliosis was scarce, and evidence from neurological and orthopedic populations
was indirect and of low certainty. Combined digital protocols could not be evaluated formally because of the
small number of studies and methodological heterogeneity, so no meta-analysis was performed. In conclusion,
virtual reality and surface electromyography biofeedback do not replace established treatment standards for
idiopathic scoliosis, but they may serve as an adjuvant strategy targeting neuromotor re-education and therapy
adherence, which requires confirmation; future multicenter randomized controlled trials with long-term follow
up are recommended to confirm structural outcomes and cost-effectiveness.