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Scoliosis Deformity—Etiological Aspects, Management and Rehabilitation

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A special issue of Healthcare (ISSN 2227-9032).

Deadline for manuscript submissions: 31 May 2026 | Viewed by 13762

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Special Issue Editor

Dr. Theodoros B. Grivas

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Department of Orthopaedics and Traumatology, "Tzaneio" General Hospital of Piraeus, Zanni and Afendouli 1, GR-185 36 Piraeus, Greece
Interests: spinal deformity; idiopathic scoliosis; diagnosis; school screening; bracing; physiotherapeutic specific scoliosis exercises (PSSEs); growth modulation; operative treatment
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Special Issue Information

Dear Colleagues,

The unclear understanding of the etiology of idiopathic scoliosis (IS) is the main reason for study of this deformity within the wider scope of its management. This management includes prevention, including school scoliosis screening, non-surgical treatment in the form of physiotherapeutic specific scoliosis exercises (PSSEs), bracing or a combination of these two, and finally surgical treatment. All these areas of study are relevant to this Special Issue, and any progress experienced within the above areas is useful for individuals with scoliosis. The quality of life of children and adolescents with IS has recently resulted in a number of publications based on its management. Due to the advancements mentioned above, it is expected that new articles based on the most sophisticated types of treatment will be submitted, as well as new relevant questionnaires to assess the QoL.In all publications, IS is described as a three-dimensional deformity. In reality, it is four-dimensional if the survival time parameter is considered, as individuals with the deformity will have the deformity until death. The importance of this comment is particularly pertinent in operated patients, as this group—treated with the current very powerful posterior spinal fusion systems—show a significant percentage of the so called “adjacent level disease” in long term follow-up, often leading to a revision of these operations. Furthermore, the reported complications, using any other modern surgical technique, may encourage the study of IS etiology of so that the treatment will eventually be etiological rather than symptomatic as it is today, minimizing complications, procedures, hospitalizations, and the burden on families.

In this Special Issue entitled “Scoliosis Deformity—Etiological Aspects, Management and Rehabilitation”, we welcome the submission of articles pertinent to the above topics.

I look forward to receiving your contributions.

Dr. Theodoros B. Grivas
Guest Editor

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Keywords

idiopathic scoliosis
spinal deformity
diagnosis
physiotherapeutic specific scoliosis exercises (PSSEs)
surgical treatment
non-surgical treatment

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Published Papers (11 papers)

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Research

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14 pages, 258 KB

Open AccessArticle

The Effectiveness of Currently Recommended Questionnaires in Identifying Scoliosis Among Chronic Back Pain Patients: A Cross-Sectional Study

by Fabio Zaina, Tito Bassani, René Castelein, Carmelo Pulici and Stefano Negrini

Healthcare 2025, 13(24), 3196; https://doi.org/10.3390/healthcare13243196 - 5 Dec 2025

Viewed by 342

Abstract

Background/Objectives: Low back pain (LBP) is the most prevalent musculoskeletal condition, significantly impacting quality of life and incurring high social costs. Although non-specific (without anatomical abnormalities) LBP accounts for nearly 80% of cases, LBP due to adult spinal deformities (ASDs), including scoliosis, remains a major concern. Several patient-reported outcome measures (PROMs)—notably the Oswestry Disability Index (ODI), Scoliosis Research Society-22 questionnaire (SRS-22), and Core Outcome Measure Instrument (COMI)—are recommended for assessment in these populations. This study aims to verify if these PROMs can effectively distinguish between adults with scoliosis-associated LBP (SLBP) and those with non-specific LBP (LBP). Methods: subjects were categorised as either having idiopathic/degenerative scoliosis (>10° Cobb angle in the coronal plane) with LBP, or non-specific LBP. Statistical comparisons applied non-parametric tests (Wilcoxon rank-sum, Mood’s median, chi-square), Spearman’s correlation, and generalised linear regression analyses. Results: Among 1092 subjects (552 SLBP; 540 LBP), median ODI scores were similar between groups, while SRS-22 scores were modestly higher in the SLBP cohort. Females consistently reported higher ODI and lower SRS-22 scores. Significant correlations arose between ODI and COMI, with moderate inverse associations with SRS-22. Regression analysis demonstrated that pathology group, gender, age, and BMI weakly predicted PROM scores. Conclusions: ODI and SRS-22 perform comparably in assessing disability in adults with LBP regardless of scoliosis, suggesting they cannot discriminate different pathologies. These findings underscore the importance of employing multiple PROMs to capture clinical dimensions. Full article

(This article belongs to the Special Issue Scoliosis Deformity—Etiological Aspects, Management and Rehabilitation)

10 pages, 230 KB

Open AccessArticle

Surgical Site Infection After Posterior Spinal Fusion for Paediatric Spinal Deformities: A Single-Centre Retrospective Observational Study

by Dimitrios P. Christakos, Ioannis S. Benetos, Elias Vasiliadis, Panagiotis Karampinas, Angelos Kaspiris, Patra Koletsi, Ioanna Paspati and Spyridon G. Pneumaticos

Healthcare 2025, 13(23), 3043; https://doi.org/10.3390/healthcare13233043 - 25 Nov 2025

Viewed by 275

Abstract

Background/Objectives: Surgical Site Infections (SSIs) are among the most common complications of Posterior Spinal Fusion (PSF) in children and adolescents. The rate of SSIs after PSF varies from 0.9% to 3% for idiopathic scoliosis and can be as high as 8.7% for neuromuscular scoliosis due to cerebral palsy. Major factors associated with SSIs include patient’s underlying pathology and comorbidities, the complexity of the procedure, and many extrinsic factors such as the expertise of the surgeon, perioperative antibiotic prophylaxis, length of hospitalisation, and perhaps environmental factors in the operating theatre and the hospital infections rates of the centre at which the procedure is being performed. We sought to identify the overall rate of SSI and possible modifiable risk factors for SSI in children and adolescents treated with PSF in Penteli Children’s Hospital. Methods: A total of 46 consecutive patients accounting for 67 surgeries performed between 2019 and 2024 were included in this retrospective observational study. Inclusion criteria were as follows: patient’s age at the time of surgery less than 22 years, patients treated with PSF only, and more than 9 months postoperative observation. SSI was defined as infection occurring within 90 days of the index procedure. Results: The rate of deep SSI in our department was 6.0%. Older age at the time of surgery and a history of previous spine surgery were risk factors for developing an SSI. Conclusions: Between 2019 and 2024 four cases of deep SSI occurred in our institution, leading to a rate of 6.0% among all PSF cases for this specific time period. Higher age and a history of previous spine surgery were risk factors for SSI in this cohort of patients. Full article

(This article belongs to the Special Issue Scoliosis Deformity—Etiological Aspects, Management and Rehabilitation)

14 pages, 276 KB

Open AccessArticle

Prevalence and Classification of Scoliosis Among Female University Students in Saudi Arabia

by Marwan M. A. Aljohani, Yasir S. Alshehri and Reda S. Eweda

Healthcare 2025, 13(22), 2894; https://doi.org/10.3390/healthcare13222894 - 13 Nov 2025

Viewed by 699

Abstract

Background/Objectives: Although screening for scoliosis is common among adolescents, little is known about its subtypes and their correlations in young adults. This study aimed to investigate the prevalence and classification of scoliosis (functional vs. structural) among female university students in Saudi Arabia and to examine associated factors. Methods: A cross-sectional study was conducted with 263 female students at Taibah University. Screening was performed using Adam’s forward bending test and a scoliometer. Data on age, body mass index, academic year, hand dominance, habitual sitting posture, backpack carriage method, leg-length discrepancy, painful conditions, and family history of scoliosis were collected. The association between scoliosis subtypes and contributing factors was analyzed using descriptive statistics, chi-square test, and Spearman’s correlation. Results: Scoliosis was identified in 94 students (prevalence, 35.7%). Of these, 26.2% had functional scoliosis, whereas 9.5% had structural scoliosis. Functional scoliosis was significantly associated with sitting posture, leg-length discrepancy, and age (p < 0.05), whereas structural scoliosis was associated with family history, habitual sitting posture, and painful conditions (p < 0.05). Conclusions: The high prevalence and differing profiles of scoliosis subtypes underscore the need for routine postural screening in universities. Early identification and ergonomic education may help in selecting appropriate targeted interventions for individuals with functional or structural scoliosis. Full article

(This article belongs to the Special Issue Scoliosis Deformity—Etiological Aspects, Management and Rehabilitation)

11 pages, 505 KB

Open AccessArticle

by Eddie Geagea, Anna Rambo, Kylie Krombholz, Ali Siddiqui and Kevin M. Neal

Healthcare 2025, 13(22), 2857; https://doi.org/10.3390/healthcare13222857 - 11 Nov 2025

Viewed by 800

Abstract

Background/Objectives: 45–50° is typically considered a threshold to offer surgical intervention for adolescent idiopathic scoliosis (AIS) patients. Larger curves may continue to progress even after skeletal maturity (SM), but the risk of this progression remains poorly defined. This study aimed to quantify the risk factors for continued curve progression in skeletally mature females with moderate curves (25° to 45°). Methods: We reviewed a Non-Operative AIS Database of >2300 patients with curves of 25° to 45° at radiographic SM (defined as United States Risser 4 and Sanders 7, or Risser 5) and follow-up >24 months after SM. Progression of >5° and progression to 50° were analyzed using chi-squared tests and Mann-Whitney U tests to detect differences in factors at SM. Results: 90 patients met the inclusion criteria. For various starting curve sizes at SM, progression > 5° was 7.1% (25°), 26.7% (30°), 22.2% (35°), 42.3% (40°), and 33.3% (45°), respectively. Progression to 50° was 0% (25°), 0% (30°), 11.1% (35°), 42.3% (40°), and 55.6% (45°). Progression > 5° was higher in patients with Risser 4 at SM versus Risser 5 (p = 0.04), when curves were >35° at SM (p = 0.04), and onset of menarche was <16 months before SM (p = 0.03). Progression to 50° was higher for curves > 40° at SM (p < 0.00001) and when the onset of menarche was <15 months before SM (p = 0.02). Conclusions: Curves of 25° to 45° at SM can still progress > 5°, and curves of 35° to 45° can still progress to 50°. Patients should be counseled regarding these risks so they can make informed decisions about appropriate monitoring and treatment. Full article

(This article belongs to the Special Issue Scoliosis Deformity—Etiological Aspects, Management and Rehabilitation)

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18 pages, 27727 KB

Open AccessArticle

Adolescent Idiopathic Scoliosis in the Adult Patient: New Classification with a Treatment-Oriented Guideline

by Giovanni Viroli, Alberto Ruffilli, Matteo Traversari, Antonio Mazzotti, Marco Manzetti, Simone Ottavio Zielli, Alberto Arceri and Cesare Faldini

Healthcare 2025, 13(19), 2418; https://doi.org/10.3390/healthcare13192418 - 24 Sep 2025

Viewed by 1976

Abstract

Background/Objectives: Adolescent Idiopathic Scoliosis persisting into adulthood (AAIS) presents progressive stiffening and degenerative changes that are not fully captured by existing classifications. This heterogeneity complicates clinical decision-making and surgical planning. The aim of this study was to propose a novel, treatment-oriented classification system for AAIS. Methods: A retrospective review was performed on patients with AAIS who underwent surgical correction between 2018 and 2022. Pre- and postoperative radiographs, CT scans, and MRI were analyzed to define curve characteristics and evaluate surgical outcomes. Subgroups were identified according to age and deformity features, and corresponding surgical strategies were outlined. Results: AAIS was stratified into Young Adult Idiopathic Scoliosis (YAdIS, 19–30 years) and Adult Idiopathic Scoliosis (AdIS, >30 years). YAdIS was divided into mild, flexible curves (YAdIS 1) and severe/stiff curves (YAdIS 2). AdIS was classified into three categories: AdIS 1 (isolated coronal deformity), AdIS 2 (combined coronal and sagittal deformity), and AdIS 3 (revision cases). Within AdIS 1, additional refinement by age (30–45, 45–60, >60 years) reflected increasing stiffness and degenerative changes. Tailored surgical strategies included selective fusions, posterior releases, high-density constructs, three-column osteotomies, and combined anterior–posterior approaches, depending on curve type and age group. Conclusions: This classification provides a comprehensive, treatment-oriented framework to support surgical decision-making in AAIS, enabling optimized planning and improved outcomes for adult patients with scoliosis of adolescent onset. Full article

(This article belongs to the Special Issue Scoliosis Deformity—Etiological Aspects, Management and Rehabilitation)

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11 pages, 839 KB

Open AccessArticle

Quantification of Thoracic Volume and Spinal Length of Pediatric Scoliosis Patients on Chest MRI Using a 3D U-Net Segmentation

by Romy E. Buijs, Dingina M. Cornelissen, Dimo Devetzis, Peter P. G. Lafranca, Daniel Le, Jiaxin Zhang, Mitko Veta, Koen L. Vincken and Tom P. C. Schlösser

Healthcare 2025, 13(18), 2327; https://doi.org/10.3390/healthcare13182327 - 17 Sep 2025

Viewed by 1002

Abstract

Background/Objectives: Adolescent idiopathic scoliosis (AIS) can lead to significant chest deformations. The quantification of chest deformity and spinal length could provide additional insights for monitoring during follow-up and treatment. This study proposes a 3D U-Net convolutional neural network (CNN) for automatic thoracic and spinal segmentations of chest MRI scans. Methods: In this proof-of-concept study, axial chest MRI scans from 19 girls aged 8–10 years at risk for AIS development and 19 asymptomatic young adults were acquired (n = 38). The thoracic volume and spine were manually segmented as the ground truth (GT). A 3D U-Net CNN was trained on 31 MRI scans. The seven remaining MRI scans were used for validation, reported by the Dice similarity coefficient (DSC), the Hausdorff distance (HD), precision, and recall. From these segmentations, the thoracic volume and 3D spinal length were calculated. Results: Automatic chest segmentation was possible for all chest MRIs. For the chest volume segmentations, the average DSC was 0.91, HD was 51.89, precision was 0.90, and recall 0.99. For the spinal segmentation, the average DSC was 0.85, HD was 25.98, precision was 0.74, and recall 0.99. Chest volumes and 3D spinal lengths differed by on average 11% and 12% between automatic and GT, respectively. Qualitative analysis showed agreement between the automatic and manual segmentations in most cases. Conclusions: The proposed 3D U-Net CNN shows a high accuracy and good predictions in terms of HD, DSC, precision, and recall. This suggested 3D U-Net CNN could potentially be used to monitor the progression of chest deformation in scoliosis patients in a radiation-free manner. Improvement can be made by training the 3D U-net with more data and improving the GT data. Full article

(This article belongs to the Special Issue Scoliosis Deformity—Etiological Aspects, Management and Rehabilitation)

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20 pages, 3523 KB

Open AccessArticle

Telerehabilitation After Surgery in Adolescent Idiopathic Scoliosis: A Randomized Controlled Trial

by İrem Çetinkaya, Tuğba Kuru Çolak, Mehmet Fatih Korkmaz and Mehmet Aydoğan

Healthcare 2025, 13(16), 2063; https://doi.org/10.3390/healthcare13162063 - 20 Aug 2025

Cited by 1 | Viewed by 2345

Abstract

Background: Structured postoperative rehabilitation is not routinely provided for individuals with adolescent idiopathic scoliosis (AIS) after surgery, with physiotherapy typically limited to the immediate inpatient period. Telerehabilitation offers an accessible and supervised option to address persistent functional limitations, pain, and quality-of-life concerns in this population. Objectives: This study aimed to evaluate the effects of a synchronous telerehabilitation program—designed to support post-surgical recovery in individuals with adolescent idiopathic scoliosis (AIS)—on trunk muscle endurance, trunk flexibility, functional capacity, pain severity, perception of appearance, and quality of life. Methods: Thirty-two individuals with AIS, who had undergone surgery 6 months to 2 years prior, were randomly assigned to either an intervention group or a control group. The intervention group participated in a supervised telerehabilitation program twice weekly for eight weeks, while the control group received no exercise intervention. All outcome measures were assessed before and after the intervention. Results: The telerehabilitation group demonstrated significant improvements across all outcome measures compared with the control group (p < 0.05). Post-intervention, the telerehabilitation group had superior trunk muscle endurance, flexibility, and quality-of-life scores, as well as reduced pain intensity (p < 0.05). However, no significant differences were observed between the groups in functional capacity or perception of appearance (p > 0.05). Conclusions: A supervised telerehabilitation program initiated six months after surgery can effectively improve trunk muscle endurance, flexibility, pain intensity, and quality of life in individuals with AIS. These findings emphasize the value of structured post-surgical rehabilitation and raise awareness of the potential benefits of remotely delivered exercise programs in this population. Full article

(This article belongs to the Special Issue Scoliosis Deformity—Etiological Aspects, Management and Rehabilitation)

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12 pages, 622 KB

Open AccessArticle

Improving the Effectiveness of Conservative Treatment of Idiopathic Scoliosis Through Active Parental Participation During Inpatient Rehabilitation

by Marianna Białek, Justyna Pękala, Ewelina Białek-Kucharska, Małgorzata Poczynek, Paulina Poświata and Tomasz Kotwicki

Healthcare 2025, 13(13), 1551; https://doi.org/10.3390/healthcare13131551 - 29 Jun 2025

Viewed by 1415

Abstract

Background/Objectives: This is a study of adolescents with idiopathic scoliosis (IS), treated by the Functional Individual Therapy of Scoliosis (FITS) method. The hypothesis was that active parental involvement in the treatment process enhances the outcomes of therapy. Materials and Methods: A total of 208 adolescent girls with IS were examined and divided into two groups. Only in Group I were the parents present. Trunk morphology before and after was evaluated by measuring change of the Anterior Trunk Symmetry Index (ATSI), Posterior Trunk Symmetry Index (POTSI), Posterior Trunk Symmetry Index in Correction (POTSI COR), and the angle of trunk rotation (ATR). Results: Statistically significant improvements in ATSI values were observed in both groups (Group I: p < 0.001; Group II: p = 0.001). POTSI values showed improvement only in Group I (p < 0.001). Similarly, POTSI COR values improved significantly in Group I (p < 0.001). ATR improved significantly better in Group I. Conclusion and Significance: Children with IS who underwent specific physiotherapy demonstrated better outcomes when their parents actively participated in the therapy. Full article

(This article belongs to the Special Issue Scoliosis Deformity—Etiological Aspects, Management and Rehabilitation)

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Review

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14 pages, 740 KB

Open AccessReview

The Effects of the Schroth Method on the Cobb Angle, Angle of Trunk Rotation, Pulmonary Function, and Health-Related Quality of Life in Adolescent Idiopathic Scoliosis: A Narrative Review

by Ana Belén Jiménez-Jiménez, Elena Gámez-Centeno, Javier Muñoz-Paz, María Nieves Muñoz-Alcaraz and Fernando Jesús Mayordomo-Riera

Healthcare 2025, 13(20), 2631; https://doi.org/10.3390/healthcare13202631 - 20 Oct 2025

Viewed by 2070

Abstract

Background/Objectives: Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of the spine that can negatively impact on quality of life, pulmonary function, and body image. Its conservative management includes various interventions, among which the Schroth method stands out. This approach is based on three-dimensional corrective exercises and rotational breathing. This review aimed to analyze the effectiveness of the Schroth method, applied either alone or in combination with other conservative therapies, on variables such as Cobb angle, angle of trunk rotation (ATR), pulmonary function, and health-related quality of life in patients with AIS. Methods: A scientific literature search was conducted using the PubMed database. We searched for randomized controlling trials (RCTs), systematic reviews, and meta-analyses reported in English from 2020 to 2025. Different combinations of the terms and MeSH terms “adolescent”, “idiopathic”, “scoliosis”, and “Schroth” connected with various Boolean operators. Results: Overall, 82 articles were reviewed from the selected database. After removing duplicated papers and title/abstract screening, 13 studies were included in our review. The results showed that the Schroth method proved effective in reducing the Cobb angle and ATR, particularly in patients with mild curves and in early stages of skeletal growth. Improvements were also observed in health-related quality of life and aesthetic perception, and to a lesser extent, in pulmonary function. Moreover, therapeutic adherence and treatment continuity were important to maintaining long-term benefits. Conclusions: The Schroth method could be an effective treatment associated with orthopedic treatment, yielding satisfactory results. Its implementation requires structured programs, professional supervision, and strategies to enhance therapeutic adherence. Nevertheless, to validate its long-term effectiveness, we need more homogeneous studies with longer follow-up durations. Full article

(This article belongs to the Special Issue Scoliosis Deformity—Etiological Aspects, Management and Rehabilitation)

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17 pages, 543 KB

Open AccessReview

The Application of Biologic and Synthetic Bone Grafts in Scoliosis Surgery: A Scoping Review of Emerging Technologies

by Nikolaos Trygonis, Ioannis I. Daskalakis and Christos Tsagkaris

Healthcare 2025, 13(18), 2359; https://doi.org/10.3390/healthcare13182359 - 19 Sep 2025

Viewed by 1012

Abstract

Background: Spinal deformity correction surgery, particularly in scoliosis, often necessitates long fusion constructs and complex osteotomies that create significant structural bone defects. These defects threaten the integrity of spinal fusion, potentially compromising surgical outcomes. Bone grafting remains the cornerstone of addressing these defects, traditionally relying on autologous bone. However, limitations such as donor site morbidity and insufficient graft volume have made urgent the development and adoption of biologic substitutes and synthetic alternatives. Additionally, innovations in three-dimensional (3D) printing offer emerging solutions for graft customization and improved osseointegration. Objective: This scoping review maps the evidence of the effectiveness of the use of biologic and synthetic bone grafts in scoliosis surgery. It focusses on the role of novel technologies, particularly osteobiologics in combination with 3D-printed scaffolds, in enhancing graft performance and surgical outcomes. Methods: A comprehensive literature search was conducted using PubMed, Scopus, and the Cochrane Library to identify studies published within the last 15 years. Inclusion criteria focused on clinical and preclinical research involving biologic grafts (e.g., allografts, demineralized bone matrix-DBM, bone morphogenetic proteins-BMPs), synthetic substitutes (e.g., ceramics, polymers), and 3D-printed grafts in the context of scoliosis surgery. Data were extracted on graft type, clinical application, outcome measures, and complications. The review followed PRISMA-ScR guidelines and employed the Arksey and O’Malley methodological framework. Results: The included studies revealed diverse grafting strategies across pediatric and adult populations, with varying degrees of fusion success, incorporation rates, and complication profiles. It also included some anime studies. Emerging 3D technologies demonstrated promising preliminary results but require further validation. Conclusions: Osteobiologic and synthetic bone grafts, including those enhanced with 3D technologies, represent a growing area of interest in scoliosis surgery. Despite promising outcomes, more high-quality comparative clinical studies are needed to guide clinical decision-making and standardize practice. Full article

(This article belongs to the Special Issue Scoliosis Deformity—Etiological Aspects, Management and Rehabilitation)

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Other

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11 pages, 1681 KB

Open AccessOpinion

The Contribution of the Double Rib Contour Sign and the Rib Index to the Study of Scoliogeny, Thoracic Deformity, Progression, Outcome of Treatments and Costoplasty for Idiopathic Scoliosis

by Theodoros B. Grivas, Anastasios G. Christodoulou, Evangelos A. Christodoulou, Galateia Katzouraki, Marios G. Lykissas, Panayiotis J. Papagelopoulos, Elias C. Papadopoulos, Sotirios Papastefanou, Nikolaos Sekouris, Panayotis N. Soucacos, Konstantinos C. Soultanis and Elias Vasiliadis

Healthcare 2025, 13(9), 1014; https://doi.org/10.3390/healthcare13091014 - 28 Apr 2025

Viewed by 776

Abstract

This opinion article refers to the “double rib contour sign” and to the rib index (DRCS and RI), to their reliability study results in the chest radiographs of a control group and to their validity study results. These two parameters were introduced by the first author in this report. The introduction of the Segmental Rib Index (SRI) and its relation to spinal deformity is also discussed. The RI has been confirmed to be a strong surrogate for scoliometric readings in idiopathic scoliosis (IS). The clinical applications of the RI are analyzed for the following: (a) the documentation of deformity; (b) the assessment of physiotherapy outcomes (PSSEs); (c) the documentation of the outcomes of brace treatment; (d) the documentation of the pre- and post-operative assessment of thoracic deformity correction in different types of instrumentation; (e) its usage in prognosticating accelerated deterioration in skeletally mature adolescent idiopathic scoliosis (AIS) curves of 40–50 degrees; and (f) its usage in the recognition of the proper rib level for thoracoplasty/costoplasty. The emerging etiological–scoliogenic implications from the use of the DRCS and RI are described. The rotation of the trunk and vertebral bodies as interrelated, but distinct parameters are finally analyzed. Full article

(This article belongs to the Special Issue Scoliosis Deformity—Etiological Aspects, Management and Rehabilitation)

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