A prospective randomized controlled study on the treatment outcome of SpineCor brace versus rigid brace for adolescent idiopathic scoliosis with follow-up according to the SRS standardized criteria

Cross-cultural adaptation, reliability and validity of the Greek version of the Spinal Appearance Questionnaire (SAQ) in patients with adolescent idiopathic scoliosis

PURPOSE

The Spinal Appearance Questionnaire (SAQ) is a widely validated tool for assessing perceptions of spinal deformity in adolescent idiopathic scoliosis (AIS) patients. This study aimed to develop and validate a Greek version of the SAQ (GR-SAQ).

METHODS

A cross-cultural adaptation of the SAQ following international guidelines was performed. Internal consistency and test-retest reliability were evaluated. Convergent validity was assessed by correlating the GR-SAQ with the Appearance domain of Scoliosis Research Society-22 (SRS-22) and the Cobb angle with the Trunk Shift domain of GR-SAQ. Divergent validity was examined through the relationship between GR-SAQ, patient characteristics, and clinical measures including Cobb angle, DIERS Formetric 4D angle, and scoliometer readings.

RESULTS

The study included 61 AIS patients (52 females, 13.91 ± 2.57 years, 25.33 ± 10.14° Cobb angle). GR-SAQ exhibited good internal consistency (Cronbach's α = 0.794) and excellent test-retest reliability (ICC = 0.931, 95%CI: 0.880-0.960). Correlations between GR-SAQ and SRS-22 showed a low-to-moderate negative correlation (r = -0.351, p = 0.006). The Trunk Shift domain moderately correlated with the Cobb Angle (r = 0.393, p = 0.002). Divergent validity analyses did not demonstrate statistical significance (p > 0.05).

CONCLUSION

The GR-SAQ is a valid and reliable tool for evaluating spinal deformity perception in Greek AIS patients.

The New Modular Sforzesco Brace (Modular Italian Brace) Is as Effective as the Classical One: A Retrospective Controlled Study from a Prospective Cohort

Background: The Sforzesco brace is a very rigid push-up brace effective in adolescent idiopathic scoliosis (AIS). We recently developed a new Sforzesco brace based on modularity (the Modular Italian brace-MI brace) that could allow standardization, facilitating global expertise diffusion, increased modifiability and adaptability, and cost savings due to longer brace life. We aimed to compare the short-term results of the two braces. Methods: The retrospective study included 231 consecutive AIS treated with a MI brace (N = 53) or Sforzesco brace (N = 178). The main outcome was the first 6-month follow-up out-of-brace radiograph Cobb angle change. Secondary outcomes included the in-brace Cobb degrees and aesthetics (TRACE), prominence (angle of trunk rotation and mm), kyphosis, and lordosis changes. Results: The two groups were similar at baseline, apart from more immature patients in MI brace. Both braces reduced the Cobb angle (-6° out-of-brace; -16° in-brace) without differences between groups. All secondary outcomes improved, apart from a statistically and clinically insignificant 3° kyphosis reduction. The MI brace participants were 4.9 times more likely to improve the Cobb angle than the Sforzesco brace (OR = 4.92; 95%CI 1.91-12.64; p = 0.001). Conclusions: These findings suggest that the MI-brace can be safely used instead of the classical Sforzesco brace. However, further studies of different designs and longer follow-ups are needed to confirm these findings.

Effectiveness of bracing to achieve curve regression in adolescent idiopathic scoliosis

Aims

To systematically evaluate whether bracing can effectively achieve curve regression in patients with adolescent idiopathic scoliosis (AIS), and to identify any predictors of curve regression after bracing.

Methods

Two independent reviewers performed a comprehensive literature search in PubMed, Ovid, Web of Science, Scopus, and Cochrane Library to obtain all published information about the effectiveness of bracing in achieving curve regression in AIS patients. Search terms included "brace treatment" or "bracing," "idiopathic scoliosis," and "curve regression" or "curve reduction." Inclusion criteria were studies recruiting patients with AIS undergoing brace treatment and one of the study outcomes must be curve regression or reduction, defined as > 5° reduction in coronal Cobb angle of a major curve upon bracing completion. Exclusion criteria were studies including non-AIS patients, studies not reporting p-value or confidence interval, animal studies, case reports, case series, and systematic reviews. The GRADE approach to assessing quality of evidence was used to evaluate each publication.

Results

After abstract and full-text screening, 205 out of 216 articles were excluded. The 11 included studies all reported occurrence of curve regression among AIS patients who were braced. Regression rate ranged from 16.7% to 100%. We found evidence that bracing is effective in achieving curve regression among compliant AIS patients eligible for bracing, i.e. curves of 25° to 40°. A similar effect was also found in patients with major curve sizes ranging from 40° to 60° when combined with scoliosis-specific exercises. There was also evidence showing that a low apical vertebral body height ratio, in-brace correction, smaller pre-brace Cobb angle, and daily pattern of brace-wear compliance predict curve regression after bracing.

Conclusion

Bracing provides a corrective effect on scoliotic curves of AIS patients to achieve curve regression, given there is high compliance rate and the incorporation of exercises.

A comparison between Boston brace and European braces in the treatment of adolescent idiopathic scoliosis (AIS) patients: a systematic review based on the standardised Scoliosis Research Society (SRS) inclusion criteria for brace treatment

PURPOSE

To compare the Boston brace and European braces using a standardised Scoliosis Research Society (SRS) inclusion criteria for brace treatment as well as consensus recommendations for treatment outcome.

METHODS

This was a systematic review that was carried out using MeSH terminology in our search protocol in PubMed, Cochrane Library, Scopus, Clinicaltrials.gov and Web of Science database between 1976 and 29th of Jan 2023. All studies that were included in this review had applied fully/partially the SRS inclusion criteria for brace wear. Outcome measures were divided into primary and secondary outcome measures.

RESULTS

3830 literatures were found in which 176 literatures were deemed relevant to the study once duplicates were removed and titles and abstracts were screened. Of these literatures, only 15 had fulfilled the eligibility criteria and were included in the study. 8 of the studies were Level IV studies, 5 were Level III studies and 2 studies were Level I studies (1 prospective randomised controlled trial (RCT) and 1 Quasi-RCT). The percentage of patients who avoided surgery for European braces ranged from 88 to 100%, whereas for Boston brace ranged from 70 to 94%. When treatment success was assessed based on the final Cobb angle > 45°, approximately 15% of patients treated with European braces had treatment failure. In contrast, 20-63% of patients treated with Boston brace had curves > 45° at skeletal maturity. The BrAIST study used a cut-off point of 50° to define failure of treatment and the rate of treatment failure was 28%. Curve correction was not achieved in most patients (24-51% of patients) who were treated with the Chêneau brace and its derivatives. However, none of the patients treated with Boston brace achieved curve correction.

CONCLUSION

Boston brace and European braces were effective in the prevention of surgery. In addition, curve stabilisation was achieved in most studies. Limitation in current literature included lack of studies providing high level of evidence and lack of standardisation in terms of compliance to brace as well as multidisciplinary management of brace wear.

Global research hotspots and trends in non-surgical treatment of adolescent idiopathic scoliosis over the past three decades: a bibliometric and visualization study

Background

In recent years, research on the non-surgical treatment of AIS has been increasingly conducted. To the best of our knowledge, this field doesn't yet have a comprehensive and structured pulse combing analysis. In order to provide inspiration and resources for subsequent researchers, we thus reviewed the literature studies on the non-surgical treatment of AIS from the previous thirty years and highlighted the hotspots and frontiers of research in this field.

Methods

Main using Citespace 6.1 software, the data from the core dataset of the WOS database pertaining to the non-surgical management of AIS from 1990 to 2022 was gathered, displayed, and analyzed.

Results

839 papers in all were included in the literature. With 215 papers, the USA came in first place. Chinese Univ Hong Kong ranked first with 32 papers. Research hotspots are adolescent idiopathic spondylitis, Schroth-based physiotherapy-specific exercise efficacy, curve development, Cobb angle, TLSO brace-based clinical efficacy, quality of life, reliability, health-related quality of life questionnaires, finite element biomechanical models, follow-up, and clinical guidelines.

Conclusion

There aren't many studies that compare the clinical effectiveness of various non-surgical treatments, and because of variations in inclusion eligibility standards and outcome measures, these studies cannot be directly compared. In addition, the inconsistency of existing growth potential and progression risk assessment systems further affects comparative studies of clinical efficacy; it is recommended to establish primary assessment indicators centered on patient treatment outcomes (including appearance, disability, pain, and quality of life), as well as standardized scoliosis progression risk assessment criteria.

Spine Bracing: When to Utilize-A Narrative Review

Spinal bracing is a common non-surgical technique that allows clinicians to prevent and correct malformations or injuries of a patient's spinal column. This review will explore the current standards of practice on spinal brace utilization. Specifically, it will highlight bracing usage in traumatic injuries, pregnancy, pediatrics, osteoporosis, and hyperkyphosis; address radiological findings concurrent with brace usage; and provide an overview of the braces currently available and advancements in the field. In doing so, we aim to improve clinicians' understanding and knowledge of bracing in common spinal pathologies to promote their appropriate use and improve patient outcomes.

Defining "successful" treatment outcomes in adolescent idiopathic scoliosis: a scoping review

PURPOSE

Adolescent idiopathic scoliosis (AIS) is the most common type of scoliosis that affects children aged 10-18 years old, manifesting in a three-dimensional spinal deformity. This study aimed to explore outcome measures used in defining AIS treatment success. Particularly, analyzing the extent of qualitative and quantitative (radiographic and quality of life domains) measures to evaluate AIS and whether AIS treatment approaches (surgical, bracing and physiotherapy) influences outcomes used as proxies of treatment success.

METHODS

EMBASE and MEDLINE databases were used to conduct a systematic scoping review with 654 search queries. 158 papers met the inclusion criteria and were screened for data extraction. Extractable variables included: study characteristics, study participant characteristics, type of study, type of intervention approach and outcome measures.

RESULTS

All 158 studies measured quantitative outcomes. 61.38% of papers used radiographic outcomes whilst 38.62% of papers used quantitative quality of life outcomes to evaluate treatment success. Irrespective of treatment intervention utilized, the type of quantitative outcome measure recorded were similar in proportion. Moreover, of the radiographic outcome measures, the subcategory Cobb angle was predominantly used across all intervention approaches. For quantitative quality of life measures, questionnaires investigating multiple domains such as SRS were primarily used as proxies of AIS treatment success across all intervention approaches.

CONCLUSION

This study identified that no articles employed qualitative measures of describing the psychosocial implications of AIS in defining treatment success. Although quantitative measures have merit in clinical diagnoses and management, there is increasing value in using qualitative methods such as thematic analysis in guiding clinicians to develop a biopsychosocial approach for patient care.

The natural history of curve behavior after brace removal in adolescent idiopathic scoliosis: a literature review

PURPOSE

Brace treatment is the most common nonoperative treatment to prevent curve progression in adolescent idiopathic scoliosis (AIS). The goal of this review and analysis is to characterize curve behavior after completion of brace treatment and to identify factors that may facilitate the estimation of long-term curve progression.

METHOD

A review of the English language literature was completed using the MEDLINE (PUBMED) database of publications after 1990 until September 2020. Studies were included if they detailed a minimum of 1 year post-brace removal follow-up of AIS patients. Data retrieved from the articles included Cobb angle measurements of the major curves at "in-brace," weaning, and follow-up visit(s) for all patients described and for subset populations.

RESULTS

From 75 articles, 18 relevant studies describing a follow-up period of 1-25 years following brace removal were included in the analyses. The reviewed literature demonstrates that curves continue to progress after brace treatment is completed with three main phases of progression: (i) immediate (upon brace removal) where a mean curve progression of 7° occurs; (ii) short term (within five years of brace removal) where a relatively high progression rate is evident (0.8°/year); and (iii) long term (more than five years after brace removal) where the progression rate slows (0.2°/year). The magnitude and rate of curve progression is mainly dependent on the degree of curve at weaning as curves weaned at < 25° progress substantially less than curves weaned at ≥ 25° at 25 years.

CONCLUSION

Curves continue to progress after brace removal and the rate and magnitude of progression are associated with the curve size at weaning, with larger curves typically exhibiting more rapid and severe progression. This analysis provides physicians and patients the ability to estimate long-term curve size based on the curve size at the time of weaning.

LEVEL OF EVIDENCE

IV.

Which interventions may improve bracing compliance in adolescent idiopathic scoliosis? A systematic review and meta-analysis

This review aimed to systematically review and meta-analyze the effects of interventions in improving bracing compliance among adolescent idiopathic scoliosis (AIS) patients. Eight databases were searched from their inception to April 2022. The eligibility criteria included controlled studies that used any type of intervention to enhance bracing compliance in braced AIS patients. Two researchers independently screened articles and extracted data based on the PICO (participant, intervention, comparator, and outcome) framework. Quality appraisal of included studies was performed using GRADE (overall assessment), and the risk of bias was assessed with Cochrane RoB Tool 2 for randomized controlled trials (RCT) and ROBINS-I for non-RCT studies. The primary outcome was bracing compliance and secondary outcomes included Cobb Angle and measurements for quality of life. Six eligible studies involving 523 participants were included. All studies were evaluated as low or very low quality with a high risk of bias. Four types of interventions were identified, including sensor monitoring (n = 2, RCTs), auto-adjusted brace (n = 1, RCT), more intensive or collaborated medical care (n = 2), and psychosocial intervention (n = 1). A meta-analysis of 215 patients from the three RCTs suggested that the compliance-enhancing intervention group had 2.92 more bracing hours per day than the usual care control (95%CI [1.12, 4.72], P = 0.001). In subgroup analysis, sensor monitoring significantly improved bracing wearing quantity compared to usual care (3.47 hours/day, 95%CI [1.48, 5.47], P = 0.001), while other aforementioned interventions did not show a significant superiority. Compliance-enhancing interventions may be favorable in preventing curve progression and promoting quality of life, but the improvements cannot be clarified according to limited evidence. In conclusion, although the results of this study suggested that sensor monitoring may be the most promising approach, limited high-quality evidence precludes reliable conclusions. Future well-designed RCTs are required to confirm the actual benefit of compliance-improving interventions in clinical practice.

A Randomized Controlled Trial to Evaluate the Clinical Effectiveness of 3D-Printed Orthosis in the Management of Adolescent Idiopathic Scoliosis

STUDY DESIGN

Prospective randomized controlled trial.

OBJECTIVE

To compare clinical effectiveness and quality of life (QoL) of the 3D-printed orthosis (3O) and conventional orthosis (CO) for adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Using 3D printing technology to design and fabricate orthoses to manage AIS aiming to improve in-orthosis correction and patients' compliance that are considered essential factors of effective treatment. Clinical evaluation was conducted to study the effectiveness of this innovative method.

METHODS

Thirty females with AIS who met the criteria (age 10-14, Cobb 20-40°, Risser sign 0-2, ≤12 months after menarche) were recruited. Subjects were randomly allocated to the 3O group (n = 15, age 12.4, Cobb 31.8°) and CO group (n = 15, age 12.0, Cobb 29.3°). All patients were prescribed for full-time wearing (23 hours/d) and follow-up every 4 to 6 months until bone maturity. Compliance was monitored by thermosensors, while QoL was assessed using three validated questionnaires.

RESULTS

Comparable immediate in-orthosis correction was observed between 3O (-11.6°, P < 0.001) and CO groups (-12.9°, P < 0.001). In the QoL study via SRS-22r, the 3O group got worse results after 3 months in aspects of function, self-image, and mental health (-0.5, -0.6, -0.7, P < 0.05) while the CO group had worse results in aspects of self-image and mental health (-0.3, -0.3, P < 0.05). No significant difference was found in QoL assessments between groups. After 2 years of follow-up, 22 patients were analyzed with 4 dropouts in each group. Comparable angle reduction was observed in both groups (3O: -2.2°, P = 0.364; CO: -3.5°, P = 0.193). There was one subject (9.1%) in the 3O group while two subjects (18.2%) in the CO group had curve progression >5°. Daily wearing hours were 1.9 hours longer in the 3O group than the CO group (17.1 vs. 15.2 hours, P = 0.934).

CONCLUSION

The 3O group could provide comparable clinical effects as compared with the CO group while patients with 3O showed similar compliance and QoL compared to those with CO.Level of Evidence: 1.

Brace treatment for patients with scoliosis: State of the art

Background

Physiotherapy, brace applications or surgery are the treatment options utilised to manage patients with scoliosis. Many different brace applications are used, and the success rates of orthoses vary.

Objectives

Brace applications can have detrimental impacts on the patient leading to physical discomfort, psychological discomfort, and in some instance the use of braces may even be painful. Therefore, future developments in this field should be aimed at improving the success rate and reducing physical distress experienced by the patient while using brace applications. The purpose of this article is to provide recommendations with respect to the most appropriate bracing approach in general.

Method

A narrative review of the scientific literature was carried out to substantiate the statements made in this article.

Results

The most important braces provided for the treatment of patients with scoliosis and the treatment results that can be achieved are presented and discussed, taking into account the most recent systematic reviews. A wide range of success rates have been found for the different brace applications.

Conclusion

Given that brace application may impact the patient leading to physical discomfort and psychological distress, good quality management in brace application for patients with scoliosis is needed to ensure the best possible outcome and the least stressful management.

Clinical implications

Safety in brace application for patients with scoliosis needs improvement. The use of standardised and reliable computer aided design (CAD) libraries and appropriate patient information based on published guidelines is suggested.

Risk factors for persistent coronal imbalance or revision surgery following L3 LIV selection in adolescent idiopathic scoliosis (AIS)

STUDY DESIGN

Retrospective case-control.

OBJECTIVE

To identify a cohort of patients with persistent coronal imbalance (CIB) or revision surgery 5 years following fusion to an L3 lowest-instrumented-vertebra (LIV) and determine factors that make an L3 LIV high-risk. In surgical planning for AIS, L3 is chosen over L4 whenever possible to maximize motion segments below the LIV. Though fusion to an L3 LIV is common, the rate of failure and its risk factors have not been described.

METHODS

In this analysis of prospectively-collected multi-center data of AIS patients who underwent posterior spinal fusion (PSF) to an L3 LIV, we identified patients with CIB at 5 years and/or those who required revision surgery attributable to LIV selection. Patients who were balanced at 5 years and did not require revision surgery served as controls. Pre-operative patient and radiographic variables were compared between cases and controls to identify risk factors for CIB/revision surgery.

RESULTS

We identified 646 patients with 2-year follow-up and 225 patients with 5-year follow-up, of which 11 were found to have CIB and/or revision surgery attributable to selecting L3 as the LIV. There were statistically significant differences between cases and controls with respect to several pre-operative factors, including BMI (24.5 in cases vs. 20.1 in controls; p = 0.01), Lenke curve type (81.8% Lenke 5/6 vs. 44.4%; p = 0.03), lumbar curve magnitude (56 vs. 45°; p < 0.01), TL/L apical vertebral translation (AVT) (6.2 vs. 4.1 cm; p < 0.01), L3 angulation (30° vs. 22°; p < 0.01), L3 translation (4.3 vs. 2.9 cm; p < 0.01), thoracic rib hump (7° vs. 12°; p = 0.02), lumbar rib hump (16° vs. 10°; p < 0.01), and thoracolumbar (T10-L2) kyphosis (10.5° vs. 2°; p = 0.006). Multivariate logistic regression showed that pre-operative BMI, TL/L AVT, L3 angulation, L3 translation, lumbar rib hump, and thoracolumbar kyphosis were independent predictors of CIB/revision surgery.

CONCLUSIONS

An L3 LIV is frequently successful at 5 years post-operatively. Consider an L4 LIV when: pre-operative BMI ≥ 28, L3 angulation ≥ 25°, L3 translation ≥ 4 cm, TL/L AVT ≥ 6 cm, or the lumbar curve is large (≥ 55°) and rotated (≥ 10°).

LEVEL OF EVIDENCE

Level III.

[Is it possible to improve treatment safety in the brace treatment of scoliosis patients by using standardized CAD algorithms?]

Hintergrund

Die Versorgung von Skoliosepatienten mit korrigierenden Rumpforthesen führt auch heutzutage noch zu recht unterschiedlichen Ergebnissen. Publizierte Erfolgsquoten zwischen 50 und 90 % führen zwangsläufig zu der Frage, wie sich die Erfolgsquoten der Korsettversorgung steigern und vereinheitlichen lassen. Die Ergebnisse einer mit dieser Zielsetzung weiterentwickelten computerunterstützen (CAD/„Computer Aided Design“) Chêneau-Versorgung werden dargestellt.

Methodik

Am Stichtag (08.12.2019) wurde die prospektiv angelegte Datenbank unserer Abteilung retrospektiv ausgewertet. Es waren ausschließlich unreife Mädchen mit einer Adoleszentenskoliose, Alter 10–14 Jahre, Risser 0–2 in die Datenbank aufgenommen worden.

Ergebnisse

Sowohl die Gesamtgruppe mit einem Beobachtungszeitraum von mindestens 18 Monaten als auch die Patientinnengruppen mit bereits erreichtem Behandlungsabschluss zeigten Erfolgsraten zwischen 86 und 88 %. Die Ergebnisse insgesamt waren signifikant besser als die Erfolgsrate der Boston-Brace-Kontrollgruppe (BRAIST) von 72 %. Auch im Vergleich mit den Ergebnissen anderer Chêneau-Derivate war die Erfolgsrate unserer Serie teils deutlich besser.

Schlussfolgerungen

Die Behandlungssicherheit für die Patienten mit Skoliosen sollte verbessert werden. Ein Ansatz hierzu kann die Verwendung standardisierter CAD-Bibliotheken sein. Weitere Untersuchungen mit Studiendesigns höherer Evidenz sind notwendig, um die in unserer Untersuchung gefundenen Ergebnisse zu untermauern.

The Effectiveness of Different Concepts of Bracing in Adolescent Idiopathic Scoliosis (AIS): A Systematic Review and Meta-Analysis

Brace treatment is the most common noninvasive treatment in adolescent idiopathic scoliosis (AIS); however it is currently not fully known whether there is a difference in effectiveness between brace types/concepts. All studies on brace treatment for AIS were searched for in PubMed and EMBASE up to January 2021. Articles that did not report on maturity of the study population were excluded. Critical appraisal was performed using the Methodological Index for Non-Randomized Studies tool (MINORS). Brace concepts were distinguished in prescribed wearing time and rigidity of the brace: full-time, part-time, and night-time, rigid braces and soft braces. In the meta-analysis, success was defined as ≤5° curve progression during follow-up. Of the 33 selected studies, 11 papers showed high risk of bias. The rigid full-time brace had on average a success rate of 73.2% (95% CI 61-86%), night-time of 78.7% (72-85%), soft braces of 62.4% (55-70%), observation only of 50% (44-56%). There was insufficient evidence on part-time wear for the meta-analysis. The majority of brace studies have significant risk of bias. No significant difference in outcome between the night-time or full-time concepts could be identified. Soft braces have a lower success rate compared to rigid braces. Bracing for scoliosis in Risser 0-2 and 0-3 stage of maturation appeared most effective.

Quality of life of adolescent idiopathic scoliosis patients under brace treatment: a brief communication of literature review

PURPOSE

To identify the life domains that are most frequently reported to be affected in scoliosis patients undergoing brace treatment.

METHODS

A search within the PubMed database was conducted and a total of 60 publications were selected. We classified the studies based on the methods used to measure patients' quality of life (QoL) and categorized the life domains reported to be affected.

RESULTS

Self-image/body configuration was the most reported affected domain of patients' QoL, identified in 32 papers, whilst mental health/stress was the second most reported affected domain. Mental health was identified in 11 papers, and 11 papers using the BSSQ questionnaire reported medium stress amongst their participants. Vitality was the third most reported affected domain, identified in 12 papers.

CONCLUSIONS

Our review indicates that scoliotic adolescents treated with bracing suffer in their quality of life most from psychological burdens. To improve these patients' life quality, more attention should be focussed on supporting their mental health.

Braces Designed Using CAD/CAM Combined or Not With Finite Element Modeling Lead to Effective Treatment and Quality of Life After 2 Years: A Randomized Controlled Trial

STUDY DESIGN

Single-center prospective randomized controlled trial.

OBJECTIVE

The aim of this study was to assess the computer-aided design/manufacturing (CAD/CAM) brace design approach, with and without added finite element modeling (FEM) simulations, after 2 years in terms of clinical outcomes, 3D correction, compliance, and quality of life (QoL).

SUMMARY OF BACKGROUND DATA

.: Previous studies demonstrated that braces designed using a combination of CAD/CAM and FEM induced promising in-brace corrections, were lighter, thinner, and covered less trunk surface. Yet, their long-term impact on treatment quality has not been evaluated.

METHODS

One-hundred twenty adolescent idiopathic scoliosis patients were recruited following Scoliosis Research Society standardized criteria for brace treatment; 61 patients in the first subgroup (CAD) were given braces designed using CAD/CAM; 59 in the second subgroup (CAD-FEM) received braces additionally simulated and refined using a patient-specific FEM built from 3D reconstructions of the spine, rib cage and pelvis. Main thoracic (MT) and thoraco-lumbar/lumbar (TL/L) Cobb angles, sagittal curves, and apical rotations were compared at the initial visit and after 2 years. Patient compliance and QoL were tracked respectively by using embedded temperature sensors and SRS-22r questionnaires.

RESULTS

Forty-four patients with CAD-FEM braces and 50 with CAD braces completed the study. Average in-brace correction was 9° MT (8° CAD-FEM, 10° CAD, P = 0.054) and 12° TL/L (same for both subgroups, P = 0.91). Out-of-brace 2-year progression from initial deformity was <4° for all 3D measurements. Sixty-six percent of all cases (30 CAD-FEM, 35 CAD) met the ≤5° curve progression criterion, 83% (38 CAD-FEM, 43 CAD) stayed <45°, and 6% (5 CAD-FEM, 1 CAD) underwent fusion surgery. 3D correction, compliance, and QoL were not significantly different between both subgroups (P > 0.05).

CONCLUSION

After 2 years, patients with braces designed using CAD/CAM with/without FEM had satisfying clinical outcomes (compared to the BrAIST study), 3D corrections, compliance and QoL. A more comprehensive optimization of brace treatment remains to be accomplished.

LEVEL OF EVIDENCE

2.

Severe persistent coronal imbalance following instrumented posterior spinal fusion for adolescent idiopathic scoliosis

STUDY DESIGN

Retrospective case-control study.

OBJECTIVE

The aim of this study was to identify the risk factors and health-related quality of life (HRQoL) impact of severe (> 4 cm) post-operative coronal imbalance at 2 years following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Coronal imbalance is an unfavorable outcome following PSF for AIS, though the degree of imbalance in such patients is typically mild. We hypothesize that a small number of patients become and remain severely imbalanced post-operatively, though this phenomenon has not been well studied.

METHODS

Prospectively collected data from a large multicenter registry were reviewed. Patients with severe coronal imbalance (SCIB; > 4 cm) 2 years after PSF were included. Matched controls without SCIB at 2 years were included at a 3:1 ratio. Comparisons were made between demographics, pre-operative radiographic measures, surgical factors, residual post-operative radiographic measures, and 2-year SRS-22 scores.

RESULTS

Nine of 954 (0.9%) patients (88.9% females; mean age 14.8 ± 2.3 years) were found to be severely imbalanced at 2 years. These patients had significantly greater pre-operative bending thoracic curve magnitude (45° vs. 33°; p = 0.013), curve flexibility (22.9% vs. 63.3%; p = 0.004), and kyphosis (41° vs. 26.5°; p = 0.034) compared to matched controls. Pre-operative curve flexibility of < 20% was associated with a 23.8 times greater odds of SCIB (95% CI 2.1-250; p = 0.008). With respect to HRQoL, median SRS-22 pain (4.1 vs. 4.8; p = 0.041), self-image (3.9 vs. 4.6; p = 0.013), general function (4.5 vs. 5; p = 0.022), and total (4.1 vs. 4.7; p = 0.012) scores at 2 years were significantly lower in cases compared to controls.

CONCLUSIONS

In the present study, thoracic curve stiffness was a strong risk factor for severe post-operative coronal imbalance, which was associated with poor HRQoL measures. Increased pre-operative thoracic curve stiffness (< 20% flexibility) should raise surgeon awareness for altering surgical approach to minimize the risk of severe post-operative coronal imbalance.

LEVEL OF EVIDENCE

Level III.

Bracing In The Treatment Of Adolescent Idiopathic Scoliosis: Evidence To Date

Brace effectiveness for adolescent idiopathic scoliosis was controversial until recent studies provided high quality of evidence that bracing can decrease likelihood of progression and need for operative treatment. Very low evidence exists regarding bracing over 40^ο and adult degenerative scoliosis. Initial in-brace correction and compliance seem to be the most important predictive factors for successful treatment outcome. However, the amount of correction and adherence to wearing hours have not been established yet. Moderate evidence suggests that thoracic and double curves, and curves over 30^ο at an early growth stage have more risk for failure. High and low body mass index scores are also associated with low successful rates. CAD/CAM braces have shown better initial correction and are more comfortable than conventional plaster cast braces. For a curve at high risk of progression, rigid and day-time braces are significantly more effective than soft or night-time braces. No safe conclusion on effectiveness can be drawn while comparing symmetrical and asymmetrical brace designs. The addition of physiotherapeutic scoliosis-specific exercises in brace treatment can provide better outcomes and is recommended, when possible. Despite the growing evidence for brace effectiveness, there is still an imperative need for future high methodological quality studies to be conducted.

Vertebra-disc ratio as a new predictor for curve progression in early thoracic AIS with bracing treatment

OBJECTIVES

Previous studies have reported various predictors for curve progression in braced adolescent idiopathic scoliosis (AIS) patients. However, the reported predictors might be insufficient for patients with early AIS. The aim was to investigate whether the initial vertebra-disc ratio (VDR) could serve as an effective predictor for curve progression in early thoracic AIS (premenarchal and Risser 0) undergoing brace treatment.

PATIENTS AND METHODS

This study reviewed a consecutive series of early thoracic AIS girls with thoracic curve. All patients had accepted brace treatment and had regular follow-up. According to the bracing outcomes, patients were divided into two groups: Group P (progressed, curve progressed over six degrees or indicated for surgery) and Group NP (non-progressed).

RESULTS

Totally 203 girls were included. There were 73 and 130 patients in Groups P and NP, respectively. The patients in Group P had greater initial VDR (1.9 ± 0.5 vs. 0.8 ± 0.4, P < 0.01) than Group NP. During the follow-up, it showed continuous higher values in Group P than Group NP. The logistic regression analysis revealed that initial VDR had an effective value for predicting curve progression in the braced early AIS girls. The ideal cut-off point of initial VDR was 1.5 for the prediction of curve progression.

CONCLUSION

The initial VDR could serve as an effective predictor for curve progression in braced early AIS girls. Evaluation of this new parameter should be carefully performed at the bracing initiation.

Specific exercises reduce the need for bracing in adolescents with idiopathic scoliosis: A practical clinical trial

BACKGROUND

In an ideal experimental setting, 2 randomized controlled trials recently showed the efficacy of physiotherapeutic scoliosis-specific exercises (PSSEs) for adolescents with idiopathic scoliosis (AIS). Now large observational studies are needed to check the generalizability of these results to everyday clinical life.

OBJECTIVE

To explore the effectiveness of PSSEs for avoiding bracing or progression of AIS in everyday clinics.

METHODS

This was a longitudinal comparative observational multicenter study, nested in a prospective database of outpatient tertiary referral clinics, including 327 consecutive patients. Inclusion criteria were AIS, age≥10 years old at first evaluation, Risser sign 0-2, and 11-20°Cobbangle. Exclusion criteria were consultations only and brace prescription at baseline. Groups performed PSSE according to the SEAS (Scientific Exercise Approach to Scoliosis) School, usual physiotherapy (UP) and no therapy (controls [CON]). End of treatment was medical discharge, Risser sign 3, or failure (defined by the need for bracing before the end of growth or Cobb angle>29°). The probability of failure was estimated by the risk ratio (RR) and 95% confidence interval (CI). The number needed to treat was estimated. Statistical analysis included intent-to-treat analysis, considering all participants (dropouts as failures), and efficacy analysis, considering only end-of-treatment participants. Propensity scores were used to reduce the potential effects of confounders related to the observational design.

RESULTS

We included 293 eligible subjects after propensity score matching (SEAS, n=145; UP, n=95; controls, n=53). The risk of success was increased 1.7-fold (P=0.007) and 1.5-fold (P=0.006) with SEAS versus controls in the efficacy and intent-to-treat analyses, respectively, and the number needed to treat for testing SEAS versus controls was 3.5 (95% CI 3.2-3.7) and 1.8 (95% CI 1.5-2.0), respectively. The success rate was higher with SEAS than UP in the efficacy analysis.

CONCLUSIONS

SEAS reduced the bracing rate in AIS and was more effective than UP. PSSEs are additional tools that can be included in the therapeutic toolbox for AIS treatment.

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.

A Prospective Cohort Study of AIS Patients with 40° and More Treated with a Gensingen Brace (GBW): Preliminary Results

Introduction:

There is a growing resistance from patients and their families to spinal fusion surgery for scoliosis. Due to inconclusive evidence that surgery has a long-term effect on scoliosis and/or improves the quality of life for patients with scoliosis, there is a need to extend the conservative perspective of treatment to patients with curvatures greater than 40 degrees. For that reason, a prospective cohort study was initiated to determine the effectiveness of the Gensingen brace (a Cheneau-style TLSO) in preventing progression in skeletally immature patients.

Materials and Methods:

Since 2011, fifty-five patients have been enrolled in this prospective cohort study. This report includes the mid-term results of twenty-five of these patients, who have a minimum follow-up of 18 months and an average follow-up of 30.4 months (SD 9.2). The twenty-five patients had the following characteristics at the start of treatment: Cobb angle: 49° (SD 8.4; 40º-71º); 12.4 years old (SD 0.82); Risser: 0.84 (SD 0.94; 0-2). A z-test was used to compare the success rate in this cohort to the success rate in the prospective braced cohort from BrAIST.

Results:

After follow-up, the average Cobb angle was 44.2° (SD 12.9). Two patients progressed, 12 patients were able to achieve halted progression, and eleven patients improved. Angle of trunk rotation (ATR) decreased from 12.2 to 10.1 degrees in the thoracic spine (p = 0.11) while the ATR decreased from 4.7 to 3.6 degrees in the lumbar spine (p = 0.0074). When comparing the success rate of the BrAIST cohort with the success rate of patients in this cohort, the difference was statistically significant (z = -3.041; p = 0.01).

Conclusion:

Conservative brace treatment using the Gensingen brace was successful in 92% of cases of patients with AIS of 40 degrees and higher. This is a significant improvement compared to the results attained in the BrAIST study (72%). Reduction of the ATR shows that postural improvement is also possible.

Braces for Idiopathic Scoliosis in Adolescents

STUDY DESIGN

A Cochrane systematic review.

OBJECTIVE

To evaluate the efficacy of bracing for adolescents with AIS versus no treatment or other treatments, on quality of life, disability, pulmonary disorders, progression of the curve, psychological, and cosmetic issues.

SUMMARY OF BACKGROUND DATA

Idiopathic scoliosis is a three-dimensional deformity of the spine. The most common form is diagnosed in adolescence. Although adolescent idiopathic scoliosis (AIS) can progress during growth and cause a surface deformity, it is usually not symptomatic.

METHODS

We searched CENTRAL, MEDLINE, EMBASE, five other databases, and two trials registers up to February 2015. We also checked reference lists and hand searched grey literature. Randomized controlled trials (RCTs) and prospective controlled cohort studies comparing braces with no treatment, other treatment, surgery, and different types of braces for adolescent with AIS. We used standard methodological procedures expected by the Cochrane Collaboration.

RESULTS

We included seven studies. Five were planned as RCTs, two as prospective controlled clinical trials. One RCT failed completely, another was continued as an observational study. There was very low quality evidence from one small RCT that quality of life (QoL) during treatment did not differ significantly between rigid bracing and observation.

CONCLUSION

Two studies showed that bracing did not change QoL during treatment, and QoL, back pain psychological and cosmetic issues in the long term (16 years.) All articles showed that bracing prevented curve progression. The high rate of failure of RCTs demonstrates the huge difficulties in performing RCTs in a field where parents reject randomization of their children.

LEVEL OF EVIDENCE

1.

Nonsurgical Management of Adolescent Idiopathic Scoliosis

Pediatric patient visits for spinal deformity are common. Most of these visits are for nonsurgical management of scoliosis, with approximately 600,000 visits for adolescent idiopathic scoliosis (AIS) annually. Appropriate management of scoliotic curves that do not meet surgical indication parameters is essential. Renewed enthusiasm for nonsurgical management of AIS (eg, bracing, physical therapy) exists in part because of the results of the Bracing in Adolescent Idiopathic Scoliosis Trial, which is the only randomized controlled trial available on the use of bracing for AIS. Bracing is appropriate for idiopathic curves between 20° and 40°, with successful control of these curves reported in >70% of patients. Patient adherence to the prescribed duration of wear is essential to maximize the effectiveness of the brace. The choice of brace type must be individualized according to the deformity and the patient's personality as well as the practice setting and brace availability.

A neglected point in surgical treatment of adolescent idiopathic scoliosis: Variations in the number of vertebrae

Inaccurate identification of vertebral levels is the main cause of wrong-site spine surgery which is performed by nearly half of the spine surgeons. Unusual anatomy and failure to verify the surgical level on radiographs have been commonly reported. We aimed at investigating the variations in vertebral number in adolescent idiopathic scoliosis (AIS) patients and thus to raise awareness of the possibility for wrong-level spinal surgery and to make a comparison with normal adolescents. A cohort of 657 AIS patients and 248 normal adolescents, presented to our center from June 2008 to February 2013, who met the inclusion criteria, were recruited. Radiographs were reviewed to identify the number of thoracic or lumbar vertebrae and the presence of a lumbosacral transitional vertebra. In the AIS group, 70 (10.6%) patients had variations in the number of thoracic and/or lumbar vertebrae. Remarkably, the prevalence of variations in male subjects was significantly higher than that in female subjects (P < 0.05). Thirty-seven patients (5.6%) had an atypical number of thoracic vertebrae, with 33 having 11 thoracic vertebrae and 4 patients having 13. Forty-eight patients (7.3%) had an atypical number of lumbar vertebrae, with 14 having 4 lumbar vertebrae and 34 patients having 6. Multilevel vertebral anomalies were present in 2.3% of the patients (15 of 657). A variation in the number of vertebrae had been identified in 1.7% (11) of the reports by the radiologist. In the normal group, 27 (10.9%) subjects showed variations in the vertebral number. There was no significant difference in the prevalence of atypical numbers of vertebral number between the AIS and normal groups (P > 0.05). Therefore, we concluded that variations in the number of thoracic-lumbar vertebrae were found in up to10.6% of AIS patients. Identification of variations in the number of vertebrae is crucial to serve to decrease the risk of wrong-level surgery.

A validation study on the traditional Chinese version of Spinal Appearance Questionnaire for adolescent idiopathic scoliosis

PURPOSE

"Simplified Chinese" version of Spinal Appearance Questionnaire (SC-SAQ) for patients with adolescent idiopathic scoliosis (AIS) was available but did not fit for communities using "Traditional Chinese" as their primary language. We developed a traditional Chinese version of SAQ (TC-SAQ) and evaluated its reliability and validity.

METHODS

TC-SAQ was administered to 112 AIS patients, of which 101 bilingual (English and Chinese) patients completed E-SAQ and the traditional Chinese version of Scoliosis Research Society-22 questionnaire (TC-SRS-22). Internal consistency and test-retest reliability were evaluated. Concurrent validity was evaluated by comparing TC-SAQ score with E-SAQ score, and convergent validity by comparing TC-SAQ score with TC-SRS-22 self-image domain score, and discriminant validity by analyzing the relationship between TC-SAQ score and patients' characteristics.

RESULTS

Internal consistency of individual TC-SAQ domain was high (Cronbach's α = 0.785 to 0.940), except for general (Cronbach's α = 0.665) and shoulders (Cronbach's α = 0.421) domain. Test-retest reliability of TC-SAQ was good (ICCs of each domain from 0.798 to 0.865). Concurrent validity demonstrated an excellent correlation between TC-SAQ and E-SAQ scores (r = 0.820 to 0.954, P < 0.0001 for all domains). Correlation between TC-SAQ domains and TC-SRS-22 self-image domain was weak to moderate. TC-SAQ total score and individual domain scores (except waist and chest domains) were positively correlated to major curve magnitude.

CONCLUSIONS

TC-SAQ had good internal consistency and test-retest reliability. Concurrent validity evaluated against the original English version was excellent. TC-SAQ was both reliable and valid for clinical use for AIS patients using traditional Chinese as their primary language.

Curve Progression in Adolescent Idiopathic Scoliosis With a Minimum of 2 Years' Follow-up After Completed Brace Weaning With Reference to the SRS Standardized Criteria

STUDY DESIGN

A retrospective study.

OBJECTIVES

To investigate curve evolution after brace weaning in adolescent idiopathic scoliosis (AIS) with reference to the Scoliosis Research Society (SRS) criteria.

SUMMARY OF BACKGROUND DATA

Previous studies mainly focused on curve evolution during bracing in AIS. However, curve progression after brace weaning was not well addressed.

METHODS

Braced AIS girls followed up for at least 2 years after brace weaning were reviewed. All patients had radiographs at initial visit, brace weaning, 6 months, 1 year, and 2 years after brace weaning, and last follow-up. Curve progression after brace weaning was separately defined as increase in Cobb angle >5 degrees and curve magnitude >45 degrees. The predictors for curve progression were identified using the independent t test.

RESULTS

200 AIS girls were reviewed. The average duration of follow-up after brace weaning was 51.4 ± 25.6 months. Compared with brace weaning, at 6 months, 1 year, 2 years and last follow-up after brace weaning, 50 (25.0%), 60 (30.0%), 93 (46.5%), and 87 (43.5%) patients, respectively, had curve progression >5 degrees; 0 (0%), 0 (0%), 2 (1%), and 2 (1%) patients, respectively, had surgery recommended; among those with Cobb angle ≤40 degrees at brace weaning, 7 (4.0%), 11 (6.3%), 16 (9.2%), and 18 (10.3%) patients, respectively, had Cobb angle >45 degrees; the mean progression magnitudes were 2.6 ± 5.8, 3.5 ± 5.8, 5.1 ± 6.5, and 5.4 ± 7.4 degrees, respectively; and the mean progression rates were 0.34 ± 0.83, 0.16 ± 0.56, 0.13 ± 0.39, and 0.006 ± 0.28 degrees/month, respectively. Cobb angle at brace weaning was associated with increase in Cobb angle >5 degrees (p = .033) and curve magnitude >45 degrees (p < .001) after brace weaning.

CONCLUSIONS

Curve progression after brace weaning is observed in 43.5% AIS patients. The highest risk occurs within 6 months after brace weaning whereas Cobb angle remains stable after 2 years' follow-up. High Cobb angle at brace weaning indicates high risk of curve progression after brace weaning.

LEVEL OF EVIDENCE

Level III.

The effectiveness of the SpineCor brace for the conservative treatment of adolescent idiopathic scoliosis. Comparison with the Boston brace

BACKGROUND CONTEXT

The Boston brace (Bb) is the most widely used brace design to treat adolescent idiopathic scoliosis (AIS). The dynamic SpineCor (SC) brace is prescribed in several scoliosis clinics worldwide, but its effectiveness remains controversial.

PURPOSE

The study aimed to compare the treatment effectiveness of SC in patients with AIS treated by the developers of the brace with that of the Bb at a single institution.

STUDY DESIGN/SETTING

This is a retrospective comparison between a cohort of AIS patients treated using the SC brace and a cohort treated using the Bb.

PATIENT SAMPLE

We assessed 243 patients treated with either Bb or SC brace to prevent the progression of AIS.

OUTCOME MEASURES

The primary outcome was the progression in main Cobb angle when reaching one of the following end point criteria: (1) progression in Cobb angle of ≥6°, (2) main Cobb angle of ≥45°, (3) surgery undertaken, or (4) reaching skeletal maturity (Risser sign of 5 or growth of <1 cm in the previous 6 months).

METHODS

Patients were identified at a single institution between 2000 and 2012 following the Scoliosis Research Society criteria for brace treatment: (1) diagnosis of AIS, (2) Risser sign of ≤2, (3) curve magnitude between 25° and 40°, and (4) age ≥10 years. A total of 97 patients treated with SC by the developers of the brace and 146 patients treated with Bb were identified. Data collection and radiograph measurements were performed by a single experienced nurse not involved in the decision-making for brace treatment or in the data analysis. Age and Risser sign at onset of treatment, initialmain Cobb angle, curve type, and duration of follow-up were similar in both cohorts. Statistical analysis was done using chi-square and logistic regression models, with a level of significance of .05.

RESULTS

The average progression was 14.7°±11.9° in the SC cohort compared with 9.6°±13.7° in the Bb cohort (p=.003). The average Cobb angle at the end point of the study reached 47°±13° in the SC cohort and 41.7°±14.2° in the Bb cohort (p=.005), whereas at the onset of bracing it was 32.2°±4.9° and 32.2°±4.4°, respectively, for the SC and Bb cohorts. The percentage of patients with a progression of ≥6° was 76% in the SC cohort and 55% in the Bb cohort (p=.001). The proportion of patients reaching 45° in the SC and Bb cohorts was, respectively, 51% and 37% (p=.03), whereas the proportion of patients referred to surgery was 39% and 30%, respectively, for the SC and Bb cohorts (p=.2). The odds of progressing ≥6° and of reaching ≥45° were 2.67 and 2.07 times greater, respectively, when using the SC brace.

CONCLUSIONS

The SC brace did not prevent curve progression as effectively as the Bb. Although it has the potential benefit of increasing mobility during brace wear, the SC brace was associated with increased curve progression in comparison with the Bb. There is also a trend for increased risk of requiring surgery when the SC brace is worn.

Braces for idiopathic scoliosis in adolescents

BACKGROUND

Idiopathic scoliosis is a three-dimensional deformity of the spine. The most common form is diagnosed in adolescence. While adolescent idiopathic scoliosis (AIS) can progress during growth and cause a surface deformity, it is usually not symptomatic. However, in adulthood, if the final spinal curvature surpasses a certain critical threshold, the risk of health problems and curve progression is increased.

OBJECTIVES

To evaluate the efficacy of bracing for adolescents with AIS versus no treatment or other treatments, on quality of life, disability, pulmonary disorders, progression of the curve, and psychological and cosmetic issues.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, five other databases, and two trials registers up to February 2015 for relevant clinical trials. We also checked the reference lists of relevant articles and conducted an extensive handsearch of grey literature.

SELECTION CRITERIA

Randomized controlled trials (RCTs) and prospective controlled cohort studies comparing braces with no treatment, other treatment, surgery, and different types of braces for adolescent with AIS.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included seven studies (662 participants). Five were planned as RCTs and two as prospective controlled trials. One RCT failed completely, another was continued as an observational study, reporting also the results of the participants that had been randomized.There was very low quality evidence from one small RCT (111 participants) that quality of life (QoL) during treatment did not differ significantly between rigid bracing and observation (mean difference (MD) -2.10, 95% confidence interval (CI) -7.69 to 3.49). There was very low quality evidence from a subgroup of 77 adolescents from one prospective cohort study showing that QoL, back pain, psychological, and cosmetic issues did not differ significantly between rigid bracing and observation in the long term (16 years).Results of the secondary outcomes showed that there was low quality evidence that rigid bracing compared with observation significantly increased the success rate in 20° to 40° curves at two years' follow-up (one RCT, 116 participants; risk ratio (RR) 1.79, 95% CI 1.29 to 2.50). There was low quality evidence that elastic bracing increased the success rate in 15° to 30° curves at three years' follow-up (one RCT, 47 participants; RR 1.88, 95% CI 1.11 to 3.20).There is very low quality evidence from two prospective cohort studies with a control group that rigid bracing increases the success rate (curves not evolving to 50° or above) at two years' follow-up (one study, 242 participants; RR 1.50, 95% CI 1.19 to 1.89) and at three years' follow-up (one study, 240 participants; RR 1.75, 95% CI 1.42 to 2.16). There was very low quality evidence from a prospective cohort study (57 participants) that very rigid bracing increased the success rate (no progression of 5° or more, fusion, or waiting list for fusion) in adolescents with high degree curves (above 45°) (one study, 57 adolescents; RR 1.79, 95% CI 1.04 to 3.07 in the intention-to-treat (ITT) analysis).There was low quality evidence from one RCT that a rigid brace was more successful than an elastic brace at curbing curve progression when measured in Cobb degrees in low degree curves (20° to 30°), with no significant differences between the two groups in the subjective perception of daily difficulties associated with wearing the brace (43 girls; risk of success at four years' follow-up: RR 1.40, 1.03 to 1.89). Finally, there was very low quality evidence from one RCT (12 participants) that a rigid brace with a pad pressure control system is no better than a standard brace in reducing the risk of progression.Only one prospective cohort study (236 participants) assessed adverse events: neither the percentage of adolescents with any adverse event (RR 1.27, 95% CI 0.96 to 1.67) nor the percentage of adolescents reporting back pain, the most common adverse event, were different between the groups (RR 0.72, 95% CI 0.47 to 1.10).

AUTHORS' CONCLUSIONS

Due to the important clinical differences among the studies, it was not possible to perform a meta-analysis. Two studies showed that bracing did not change QoL during treatment (low quality), and QoL, back pain, and psychological and cosmetic issues in the long term (16 years) (very low quality). All included papers consistently showed that bracing prevented curve progression (secondary outcome). However, due to the strength of evidence (from low to very low quality), further research is very likely to have an impact on our confidence in the estimate of effect. The high rate of failure of RCTs demonstrates the huge difficulties in performing RCTs in a field where parents reject randomization of their children. This challenge may prevent us from seeing increases in the quality of the evidence over time. Other designs need to be implemented and included in future reviews, including 'expertise-based' trials, prospective controlled cohort studies, prospective studies conducted according to pre-defined criteria such as the Scoliosis Research Society (SRS) and the international Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) criteria. Future studies should increase their focus on participant outcomes, adverse effects, methods to increase compliance, and usefulness of physiotherapeutic scoliosis specific exercises added to bracing.

Recommendations for research studies on treatment of idiopathic scoliosis: Consensus 2014 between SOSORT and SRS non-operative management committee

The two main societies clinically dealing with idiopathic scoliosis are the Scoliosis Research Society (SRS), founded in 1966, and the international Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT), started in 2004. Inside the SRS, the Non-Operative Management Committee (SRS-NOC) has the same clinical interest of SOSORT, that is the Orthopaedic and Rehabilitation (or Non-Operative, or conservative) Management of idiopathic scoliosis patients. The aim of this paper is to present the results of a Consensus among the best experts of non-operative treatment of Idiopathic Scoliosis, as represented by SOSORT and SRS, on the recommendation for research studies on treatment of Idiopathic Scoliosis. The goal of the consensus statement is to establish a framework for research with clearly delineated inclusion criteria, methodologies, and outcome measures so that future meta- analysis or comparative studies could occur. A Delphi method was used to generate a consensus to develop a set of recommendations for clinical studies on treatment of Idiopathic Scoliosis. It included the development of a reference scheme, which was judged during two Delphi Rounds; after this first phase, it was decided to develop the recommendations and 4 other Delphi Rounds followed. The process finished with a Consensus Meeting, that was held during the SOSORT Meeting in Wiesbaden, 8-10 May 2014, moderated by the Presidents of SOSORT (JP O'Brien) and SRS (SD Glassman) and by the Chairs of the involved Committees (SOSORT Consensus Committee: S Negrini; SRS Non-Operative Committee: MT Hresko). The Boards of the SRS and SOSORT formally accepted the final recommendations. The 18 Recommendations focused: Research needs (3), Clinically significant outcomes (4), Radiographic outcomes (3), Other key outcomes (Quality of Life, adherence to treatment) (2), Standardization of methods of non-operative research (6).