Die Compliance als Prognosefaktor bei der konservativen Behandlung idiopathischer Skoliosen

Predictors for long-term curve progression after Boston brace treatment of idiopathic scoliosis

BACKGROUND

Identifying factors that predict successful bracing in patients with idiopathic scoliosis may help planning treatment.

AIM

To assess predictors for long-term curve progression and health-related quality of life after Boston brace treatment.

DESIGN

Observational retrospective cohort study with analysis of brace treated patients followed from start until at least 10 years after treatment.

SETTING

Patients recruited from the country's entire population consecutively treated at the National Hospital.

POPULATION

365 patients (339 girls/26 boys) with idiopathic scoliosis. Mean (SD) chronological age/bone age at start bracing was 13.2 (1.9)/12.6 (1.9) years. The primary major curve measured 33.2 (7.4°), and the major levels were thoracic (N.=248), thoracolumbar (N.=78) and lumbar (N.=39). Mean bracing time was 2.8 (1.5) years. Long-term follow-up was in average 23.3 (4.1) years after weaning with a mean major curve of 33.0 (13.1°). Successful treatment was defined as a stable primary curve with progression ≤5°, and secondary the SRS-22 questionnaire assessed quality of life.

METHODS

We applied linear or logistic regression with backward elimination. Internal validation was assessed by bootstrapping. Twelve variables were included in the prediction models: age, bone age, scoliosis in close family, major curve size, level, shape, flexibility and in-brace redressement, compliance, curve magnitude after 1 year, treatment time and quality of life (SRS-22).

RESULTS

290 patients (79%) had rated good compliance using the brace >20 hours daily. Treatment failure was observed in 65 patients (18%), and 27 of them were operated. The best baseline predictors were age and brace redressement. During treatment compliance, major curve after 1 year, and treatment time were the best predictors, while thoracic major curve, curve size at start bracing and scoliosis in close family also contributed to the final model. The model's ability to predict quality of life was low.

CONCLUSIONS

The best predictors for a long-term success were good redressement and compliance, unchanged or reduced major curve after one year and short treatment time.

CLINICAL REHABILITATION IMPACT

Predictors at baseline and during early treatment can help identifying patients who benefit from bracing.

Effect of the Chêneau Brace in the Natural History of Moderate Adolescent Idiopathic Scoliosis in Girls: Cohort Analysis of a Selected Homogenous Population of 100 Consecutive Skeletally Immature Patients

STUDY DESIGN

Α series study.

OBJECTIVES

To evaluate the relationships between the effectiveness of brace in reduction of scoliosis angle, axial trunk rotation (ATR), and patients' compliance, in skeletally immature females with moderate adolescent idiopathic scoliosis (AIS), treated with Chêneau brace for a minimum of three years.

SUMMARY OF BACKGROUND DATA

According to some authors, braces are ineffective, whereas others find that braces stop scoliosis progression and that the outcome has been related to patient's compliance.

METHODS

From the 100 patients who were initially recruited, 88 patients were included in the final analysis. The average ± SD primary scoliosis angle before brace application was 36.8° ± 9.9°, 32.7° ± 6.3°, and 33.5° ± 11.5° for major thoracic, thoracolumbar, and lumbar curvatures, respectively. All patients were aged ≥10 years at treatment initiation, and their Risser index varied from 0 to II. Eighty-eight patients were followed for at least three years with brace treatment, whereas 43 patients were reevaluated 31 ± 7 months after brace weaning. In baseline and while in brace, the scoliosis Cobb angle, Risser index, menarche age, ATR, and patient's compliance were recorded.

RESULTS

In the 88 patients, the brace reduced the major thoracic, thoracolumbar, and lumbar scoliosis one month after brace onset while "in brace" to 26° ± 11° (29% ± 18%, p = .0006), 23° ± 8° (31% ± 20%, p = .00001), and 24° ± 11° (34% ± 21%, p = .00043), respectively; thereafter, no significant decrease of the curves was recorded. Total bracing time averaged at 45 ± 19 months (range 36-96) and brace weaning averaged at 17 ± 2 years (range 15-19). Six of the 88 (6.8%) individuals underwent surgery for scoliosis progression. In the 43 patients who were reevaluated 31 ± 7 months after brace weaning, scoliosis angle and ATR increased insignificantly, compared to the three years' values.

CONCLUSIONS

Chêneau orthosis reduced while "in brace" AIS in girls with sufficient compliance, with a low rate (6.8%) of patients who underwent surgery.

LEVEL OF EVIDENCE

Level 3.

Quality of life and patient satisfaction in bracing treatment of adolescent idiopathic scoliosis

BACKGROUND

Bracing is used as a valid non-surgical treatment for adolescent idiopathic scoliosis (AIS) to avoid progression of the deformity and thereby surgery. The effect of bracing treatment on quality of life of patients with AIS has been a topic of interest in the international literature. The aim of this study was to evaluate the quality of life and patient satisfaction during bracing treatment for AIS of a pediatric hospital.

MATERIAL AND METHOD

We assessed a total of 43 non-consecutive female patients (mean age at questionnaire, 13 years and 1 month and 10 years and 8 months to 14 years and 5 months; mean period of usage of brace, 1 year and 7 months), with adolescent idiopathic scoliosis (AIS), older than 10 years of age until skeletal maturity, with a Risser sign less than 3 and scoliosis between 20 and 45°, treated with thoracolumbosacral orthosis (TLSO) for a period longer than 6 months, and without other comorbidities or previous surgeries, were evaluated. The patients were administered a previously validated to Spanish questionnaire on quality of life (Brace Questionnaire (BrQ); Grivas TB et al.). BrQ is a validated tool and is considered a disease-specific instrument; its score ranges from 20 to 100 points, and higher BrQ scores are associated with better quality of life.

RESULTS

The patients reported using the brace for a mean of 17.6 h daily and for a mean period of 1 year and 7 months at the time of the study. Overall, 72% of the study population reported to be in some way psychologically affected by the brace wearing, 56% felt their basic motor activities were affected, 54% felt socialization with their environment was affected, 46% considered their quality of life deteriorated due to pain, and 40% reported conflicts in the school environment.

CONCLUSION

Patients with AIS treated with bracing reported a negative impact (53.5% overall) on quality of life and treatment satisfaction in terms of psychological, motor, social, and school environment aspects. An interdisciplinary approach would be important for the integrated psychosocial care of these patients.

Effectiveness of basic body awareness therapy in adolescents with idiopathic scoliosis: A randomized controlled study1

BACKGROUND

In scoliosis, curve progresses due to muscle imbalance and poor posture. Basic body awareness therapy (BBAT) aims to improve posture, coordination, and balance by increasing body awareness, which may help decrease deformities.

OBJECTIVE

This study aimed to investigate effects of Basic body awareness therapy (BBAT) on curve magnitude, trunk asymmetry, cosmetic deformity, and quality of life in adolescent idiopathic scoliosis (AIS) patients.

METHODS

Twenty female AIS patients were randomly assigned to BBAT and traditional exercises (TEs) groups. The BBAT group received BBAT and traditional exercises (TEs), while the TEs group received only TEs. The following assessments were included: Cobb angles using X-ray, angle of trunk rotation (ATR) using scoliometer, trunk asymmetry using the Posterior Trunk Symmetry Index (POTSI), cosmetic deformity using the Walter Reed Visual Assessment Scale (WRVAS), and quality of life using the SRS-22 test. Measurements were conducted at baseline examination and ten weeks later. Patients were instructed to wear their brace 23 h daily. Results were analyzed using the Wilcoxon rank-sum test to compare repeated measurements and Mann-Whitney U test to compare the groups.

RESULTS

The BBAT group had greater improvement in the thoracic Cobb angle than the TEs group. Cosmetic deformity improved in both groups, whereas body asymmetry improved in only the BBAT group. SRS-22 scores were unchanged in both groups.

CONCLUSIONS

BBAT as an additive to bracing and TEs improve curve magnitude, body symmetry and trunk deformity.

The novel three-way variant t(6;17;15)(p21;q21;q22) in acute promyelocytic leukemia with an FLT3-ITD mutation: A case report

Acute promyelocytic leukemia (APL) is characterized by the reciprocal translocation t(15;17)(q22;q21), resulting in the fusion of the promyelocytic leukemia gene at 15q22 with the retinoic acid receptor α at 17q21. Additionally, all patients with APL who have additional chromosome abnormalities (ACA) and gene mutations are resistant to all-trans retinoic acid (ATRA), the drug that causes disease regression specifically in patients with APL globally. The present study describes a case of a 19-year-old female with APL carrying a novel complex variant translocation t(6;17;15)(p21;q21;q22), add(7)(q32) and an FMS-related tyrosine kinase 3 internal tandem duplication (FLT3-ITD) mutation. Complete remission was attained following a course of chemotherapy with ATRA and arsenic trioxide. To the best of our knowledge, this is the first report of a novel three-way translocation of 6p21 and a FLT3-ITD mutation involved with APL.

2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth

BACKGROUND

The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) produced its first guidelines in 2005 and renewed them in 2011. Recently published high-quality clinical trials on the effect of conservative treatment approaches (braces and exercises) for idiopathic scoliosis prompted us to update the last guidelines' version. The objective was to align the guidelines with the new scientific evidence to assure faster knowledge transfer into clinical practice of conservative treatment for idiopathic scoliosis (CTIS).

METHODS

Physicians, researchers and allied health practitioners working in the area of CTIS were involved in the development of the 2016 guidelines. Multiple literature reviews reviewing the evidence on CTIS (assessment, bracing, physiotherapy, physiotherapeutic scoliosis-specific exercises (PSSE) and other CTIS) were conducted. Documents, recommendations and practical approach flow charts were developed using a Delphi procedure. The process was completed with the Consensus Session held during the first combined SOSORT/IRSSD Meeting held in Banff, Canada, in May 2016.

RESULTS

The contents of the new 2016 guidelines include the following: background on idiopathic scoliosis, description of CTIS approaches for various populations with flow-charts for clinical practice, as well as literature reviews and recommendations on assessment, bracing, PSSE and other CTIS. The present guidelines include a total of 68 recommendations divided into following topics: bracing (n = 25), PSSE to prevent scoliosis progression during growth (n = 12), PSSE during brace treatment and surgical therapy (n = 6), other conservative treatments (n = 2), respiratory function and exercises (n = 3), general sport activities (n = 6); and assessment (n = 14). According to the agreed strength and level of evidence rating scale, there were 2 recommendations on bracing and 1 recommendation on PSSE that reached level of recommendation "I" and level of evidence "II". Three recommendations reached strength of recommendation A based on the level of evidence I (2 for bracing and one for assessment); 39 recommendations reached strength of recommendation B (20 for bracing, 13 for PSSE, and 6 for assessment).The number of paper for each level of evidence for each treatment is shown in Table 8.

CONCLUSION

The 2016 SOSORT guidelines were developed based on the current evidence on CTIS. Over the last 5 years, high-quality evidence has started to emerge, particularly in the areas of efficacy of bracing (one large multicentre trial) and PSSE (three single-centre randomized controlled trials). Several grade A recommendations were presented. Despite the growing high-quality evidence, the heterogeneity of the study protocols limits generalizability of the recommendations. There is a need for standardization of research methods of conservative treatment effectiveness, as recognized by SOSORT and the Scoliosis Research Society (SRS) non-operative management Committee.

Correlation between compliance and brace treatment in juvenile and adolescent idiopathic scoliosis: SOSORT 2014 award winner

Background

Over the last years, evidence has accumulated in support of bracing as an effective treatment option in patients with idiopathic scoliosis. Yet, little information is available on the impact of compliance on the outcome of conservative treatment in scoliotic subjects. The aim of the present study was to prospectively evaluate the association between compliance to brace treatment and the progression of scoliotic curve in patients with idiopathic adolescent (AIS) or juvenile scoliosis (JIS).

Methods

Among 1.424 patients treated for idiopathic scoliosis, 645 were eligible for inclusion criteria. Three outcomes were distinguished in agreement with the SRS criteria: curve correction, curve stabilization and curve progression. Brace wearing was assessed by one orthopaedic surgeon (LA) and scored on a standardized form. Compliance to treatment was categorized as complete (brace worn as prescribed), incomplete A (brace removed for 1 month), incomplete B (brace removed for 2 months), incomplete C (brace removed during school hours), and incomplete D (brace worn overnight only). Chi square test, T test or ANOVA and ANOVA for repeated measures tests were used as statistical tests.

Results

The results from our study showed that at follow-up the compliance was: Complete 61.1%; Incomplete A 5.2%; Incomplete B 10.7%; Incomplete C 14.2%; Incomplete D 8.8%. Curve correction was accomplished in 301/319 of Complete, 19/27 Incomplete A, 25/56 Incomplete B, 52/74 Incomplete C, 27/46 Incomplete D. Cobb mean value was 29.8 ± 7.5 SD at beginning and 17.1 ± 10.9 SD at follow-up. Both Cobb and Perdriolle degree amelioration was significantly higher in patients with complete compliance over all other groups, both in juvenile, both in adolescent scoliosis. In the intention-to-treat analysis, the rate of surgical treatment was 2.1% among patients with definite outcome and 12.1% among those with drop-out. Treatment compliance showed significant interactions with time.

Conclusion

Curve progression and referral to surgery are lower in patients with high brace compliance. Bracing discontinuation up to 1 month does not impact on the treatment outcome. Conversely, wearing the brace only overnight is associated with a high rate of curve progression.

Good brace compliance reduced curve progression and surgical rates in patients with idiopathic scoliosis

PURPOSE

To examine the association between brace compliance and outcome.

PATIENTS AND METHODS

495 (457 females) patients with late onset juvenile and adolescent idiopathic scoliosis were examined prospectively before bracing and at least 2 years after brace weaning. One spine surgeon examined all patients. 381 (353 females) answered a standardised questionnaire and 355 had radiological examination after median 24 years. Compliance was defined as brace wear >20 h daily until weaning. Main outcomes were curve progression and surgery.

RESULTS

At weaning, 76/389 compliers and 59/106 non-compliers had curve progression ≥6° (OR 5.2, 95 % CI 3.3-8.2). At long-term the numbers were 68/284 and 46/71 (OR 5.8, 95 % CI 3.3-10.2), 10/284 versus 17/71 had been operated (OR 8.6, 95 % CI 3.7-19.9).

CONCLUSION

We conclude that the risk for curve progression and surgery are reduced in patients with good brace compliance.

2011 SOSORT guidelines: Orthopaedic and Rehabilitation treatment of idiopathic scoliosis during growth

BACKGROUND

The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT), that produced its first Guidelines in 2005, felt the need to revise them and increase their scientific quality. The aim is to offer to all professionals and their patients an evidence-based updated review of the actual evidence on conservative treatment of idiopathic scoliosis (CTIS).

METHODS

All types of professionals (specialty physicians, and allied health professionals) engaged in CTIS have been involved together with a methodologist and a patient representative. A review of all the relevant literature and of the existing Guidelines have been performed. Documents, recommendations, and practical approach flow charts have been developed according to a Delphi procedure. A methodological and practical review has been made, and a final Consensus Session was held during the 2011 Barcelona SOSORT Meeting.

RESULTS

The contents of the document are: methodology; generalities on idiopathic scoliosis; approach to CTIS in different patients, with practical flow-charts; literature review and recommendations on assessment, bracing, physiotherapy, Physiotherapeutic Specific Exercises (PSE) and other CTIS. Sixty-five recommendations have been given, divided in the following topics: Bracing (20 recommendations), PSE to prevent scoliosis progression during growth (8), PSE during brace treatment and surgical therapy (5), Other conservative treatments (3), Respiratory function and exercises (3), Sports activities (6), Assessment (20). No recommendations reached a Strength of Evidence level I; 2 were level II; 7 level III; and 20 level IV; through the Consensus procedure 26 reached level V and 10 level VI. The Strength of Recommendations was Grade A for 13, B for 49 and C for 3; none had grade D.

CONCLUSION

These Guidelines have been a big effort of SOSORT to paint the actual situation of CTIS, starting from the evidence, and filling all the gray areas using a scientific method. According to results, it is possible to understand the lack of research in general on CTIS. SOSORT invites researchers to join, and clinicians to develop good research strategies to allow in the future to support or refute these recommendations according to new and stronger evidence.

[Scoliosis: the bent spine]

Scoliosis, a permanent abnormal curvature of the spine to the side, is divided into four forms: idiopathic (infantile, juvenile and adolescent, accounting for 80% of cases), neurogenic, congenital and adult scoliosis. Most patients with adolescent idiopathic scoliosis initially have mainly cosmetic problems. However, neurogenic, congenital and adult scoliosis can lead to severe clinical symptoms. The leading symptom is back pain caused by secondary changes. In recent years the Lenke classification has been proven to be a reliable tool for disease classification. Non-progressive scoliosis is usually treated conservatively. In the case of Cobb angles of greater than 50°, surgical therapy is recommended in patients presenting before adulthood. Technical improvements in implants and the optimisation of surgical methods have set a trend in the direction of surgical therapy.