Selective screening for scoliosis

Comparison of the efficacy of Schroth and Lyon exercise treatment techniques in adolescent idiopathic scoliosis: A randomized controlled, assessor and statistician blinded study

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is the most common vertebral disorder in adolescence.

OBJECTIVES

The purpose of this study was to compare the effectiveness of Schroth and Lyon exercise methods on Cobb angle (CA), angle of trunk rotation (ATR), quality of life (QoL), and perceived trunk appearance in patients with AIS.

METHODS

The 31 participants diagnosed (diagnosis age = 12.2 ± 0.9) with AIS by a physician following the Lenke criteria and subsequently referred to the outpatient clinic were enrolled in the study. All participants were randomly assigned between the Schroth group (SG) and Lyon group (LG) for 6 months of supervised and home treatment. The participants' CA, ATR, Scoliosis Research Society-22 (SRS-22), and Walter-Reed Visual Assessment Scale (WRVAS) were assessed as a baseline, and again following the treatment by the same researcher who remained blinded to the study.

RESULTS

In 2-way mixed-design repeated-measures ANOVA analysis, when the change in time was analyzed between the groups (Group × Time [interaction]), a statistical difference was found more significant in SG for the CA-thoracic (F = 103.1, p < .01, 95% CI = 4.1; 2.0 to 6.2), CA-lumbar (F = 19.1, p < .01, 95% CI = 1.7; 1.0 to 2.4), ATR (F = 64.1, p < .01, 95% CI = 1.7; 1.2 to 2.3), and WRVAS (F = 169.5, p < .01, 95% CI = 6.5; 3.2 to 9.9) parameters. The LG was only more significantly improved in the SRS-22 total score (F = 15.7, p < .01, 95% CI = -0.9; -0.2 to -1.6).

CONCLUSION

In the study, The Schroth exercises gave more favorable results than Lyon exercises in terms of CA-T, CA-L, ATR and WRVAS in the conservative treatment of AIS, while Lyon exercises gave more favorable results in terms of QoL. Additionally, according to the results of this study, it was found that the QoL of participants in SG decreased after treatment compared to baseline.

Initial evaluation of the relationship between maximal axial vertebra rotation and the rotation deformity in adolescent idiopathic scoliosis

PURPOSE

This study evaluated the relationship between maximal axial vertebra rotation (maxAVR) and other clinical and radiological indexes, compared to apical vertebra rotation (AVR) in idiopathic adolescent scoliosis (AIS).

METHODS

Forty consecutive patients of AIS with Cobb angle of major curve > 40° were included. They were scanned by an EOS imaging system and had trunk rotational angle (TRA) measured by scoliometer. The correlation between variables was assessed using Pearson's correlation coefficient and loaded onto a meta-analysis model.

RESULTS

There were (34 girls and 6 boys) with an average age of 13.8 ± 1.6 years. AVR was maxAVR in only 47.5% (19/40) cases of the major curves and 42.3% (11/26) cases of the minor curves. The correlation between maxAVR and TRA was significantly higher than the correlation between AVR and TRA for the MT curves (p = 0.0001) and TL/L curves (p = 0.0001). On multivariate regression analysis, the magnitude of maxAVR showed a significant correlation with TRA (p = 0.0002), Cobb angle (p = 0.001), and coronal deformity angular ratio (C-DAR) (p = 0.027).

CONCLUSIONS

The apical vertebra was not the most rotated in most cases. The correlation between maxAVR and TRA was significantly higher than the correlation between AVR and TRA. Moreover, the maxAVR was multivariately related to TRA, Cobb angle, and C-DAR.

LEVEL OF EVIDENCE

Level II, diagnostic.

Timed rolling and rising tests in Duchenne muscular dystrophy ambulant boys: a feasibility study

BACKGROUND

Functional activities are extensively used in motor assessments of patients with Duchenne muscular dystrophy. The role of timed items has been reported as an early prognostic factor for disease progression. However, there are two functional activities that are not widely assessed in clinical practice among Duchenne muscular dystrophy patients: rolling and bed rising. This study aimed to investigate whether the 360-degree roll (roll) and supine to sit-to-edge (bed rise) measurements are feasible tools reflecting the functional status of ambulatory DMD children by establishing possible correlations between validated measures: the Vignos Scale (VS), timed rise from floor and the 6-Minute Walk Test (6MWT).

METHODS

A total of 32 ambulant boys with DMD were assessed using timed items, the 6MWT and VS.

RESULTS

The roll and bed rise are correlated with each other. The 6MWT, the floor rise and VS are correlated with the roll and with the bed rise.

CONCLUSIONS

Findings offer preliminary empirical evidence addressing feasibility and safety of roll and bed rise measurements. There is a potential clinical utility of these tests in assessing functional status of DMD ambulant patients.

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.

Application of machine learning standardized integral area algorithm in measuring the scoliosis

This study was to develop a computer vision evaluation method to automatically measure the degree of scoliosis based on the machine learning algorithm. For the X-ray images of 204 patients with idiopathic scoliosis who underwent full-spine radiography, histogram equalization of original image was performed before a flipping method was used to magnify asymmetric elements, search for the global maximum pixel value in each line, and scan local maximal pixel value, with the intersection set of two point sets being regarded as candidate anchor points. All fine anchors were fitted with cubic spline algorithm to obtain the approximate curve of the spine, and the degree of scoliosis was measured by the standardized integral area. All measured data were analyzed. In manual measurement, the Cobb angle was 11.70-25.00 (20.15 ± 3.60), 25.20-44.70 (33.89 ± 5.41), and 45.10-49.40 (46.98 ± 1.25) in the mild, moderate and severe scoliosis group, respectively, whereas the value for the standardized integral area algorithm was 0.072-0.298 (0.185 ± 0.040), 0.100-0.399 (0.245 ± 0.050), and 0.246-0.901 (0.349 ± 0.181) in the mild, moderate and severe scoliosis group, respectively. Correlation analysis between the manual measurement of the Cobb angle and the evaluation of the standardized integral area algorithm demonstrated the Spearman correlation coefficient r = 0.643 (P < 0.001). There was a positive correlation between the manual measurement of the Cobb angle and the measurement of the standardized integral area value. Two methods had good consistency in evaluating the degree of scoliosis. ROC curve analysis of the standardized integral area algorithm to measure the degree of scoliosis showed he cutoff value of the standardized integral area algorithm was 0.20 for the moderate scoliosis with an AUC of 0.865, sensitivity 0.907, specificity 0.635, accuracy 0.779, positive prediction value 0.737 and negative prediction value 0.859, and the cutoff value of the standardized integral area algorithm was 0.40 for the severe scoliosis with an AUC of 0.873, sensitivity 0.188, specificity 1.00, accuracy 0.936, positive prediction value 1 and a negative prediction value 0.935. Using the standardized integral area as an independent variable and the Cobb angle as a dependent variable, a linear regression equation was established as Cobb angle = 13.36 + 70.54 × Standardized area, the model has statistical significance. In conclusion, the integrated area algorithm method of machine learning can quickly and efficiently assess the degree of scoliosis and is suitable for screening the degree of scoliosis in a large dataset as a useful supplement to the fine measurement of scoliosis Cobb angle.

Predicting Progression in Adolescent Idiopathic Scoliosis at the First Visit by Integrating 2D Imaging and 1D Clinical Information

STUDY DESIGN

Retrospective observational study.

OBJECTIVES

The prediction of curve progression in patients with adolescent idiopathic scoliosis (AIS) remains an unresolved area in orthopedic surgery. To make a rapid meaningful prediction, easily accessible multi-dimensional data at the patient's first consultation should be used. Current studies use clinical growth parameters and numerical values extracted from radiographs to compile a predictive model, leaving out the radiographs themselves. Such practice inevitably wastes a lot of information. Thus, this study aims to create a neural network that can predict AIS progression among patients with curves indicated for bracing by integrating both one-dimensional (1D) clinical and two-dimensional (2D) radiological data collected at the patient's first visit in a fully automated manner.

METHODS

513 idiopathic scoliosis patients indicated for and managed with bracing orthosis were recruited. After exclusion, 463 patients were included in deep learning analysis. Processed first-visit growth parameters and posteroanterior radiographs are used as training inputs and the curve progression outcomes obtained in follow ups are used as binary training outputs. The CapsuleNet architecture was modified and trained accordingly to make a prediction.

RESULTS

The final model achieved 90% sensitivity with an overall accuracy of 73.9% in the prediction of AIS in-brace curve progression by using first-visit multi-dimensional data, outperforming conventional convolutional neural networks.

CONCLUSIONS

This first-ever multidimensional-input model shows promise in serving as a screening tool for AIS in-brace curve progression. The incorporation of such a model into routine AIS diagnostic pipeline can assist orthopedics clinicians in personalizing the most appropriate management for each patient.

Morphological differences in scoliosis curvatures as a cause of difficulties in its early detection based on angle of trunk inclination

INTRODUCTION

The three dimensional deformation of the spine in scoliosis is specific for a given child with regard to the number and length of curvatures, their degree of rotation and the size of the curvature angle. Early diagnosis of scoliosis in a clinical examination according to the Adams test depends on the correlation between the angle of trunk inclination (ATI) and the Cobb angle and the adopted diagnosis criterion. The aim of the study was to demonstrate the need to adopt different diagnostic criteria for ATI depending on the age and location of scoliosis. Moreover, the observed differences in the ATI/Cobb correlation became the basis for the proposal to introduce the concept of low, medium and high-rotated of curvature to the clinical description of scoliosis.

MATERIALS AND METHODS

The group consisted of 229 children who were first examined, aged 6 to 17 years, with an average age of -11.57 years (SD ± 3.26), with symptoms of idiopathic scoliosis. The correlation of the criteria for the diagnosis of scoliosis in the ATI 7° clinical trial with a Cobb angle of 10° three dimensional in the X-ray image was used to distinguish three types of curvature/scoliosis, i.e., low, medium and high rotation. The frequencies of each type were compiled for three age groups and three scoliosis locations. Moreover, the degree of vertebral rotation according to the Perdriolli (AVR) of curvature was correlated with the Cobb angle and ATI. A one-way logistic regression model was used to assess the effectiveness of scoliosis detection in children based on the measurement of the ATI angle alone and the measurement of both ATI and Cobb angles.

RESULTS

Low-rotated curves were most often found in the age groups of 6-9 and 10-12 years in 65.6% and 71.4% of patients, respectively (p < 0.05). Medium-rotated curvatures were most common in the age group of 13-17 years - 51.6%. With regard to the localization of scoliosis, the low-rotated curvatures were significantly more frequently (p < 0.05) found in the lumbar and thoracolumbar spine. Moreover, the univariate regression model for ATI showed that we could detect scoliosis best by taking the cut-off point of 5° and the mathematically determined Cobb angle was 9.5°. Patients with ATI ≥ 7° had significantly higher AVR values ​​than those with ATI < 7°, and the ATI/AVR correlation was of average strength.

CONCLUSION

The specific morphology of the scoliotic curvature of the child's spine may be manifested by the difference in the ATI/Cobb correlation depending on the location of the scoliosis and change with age. The curvatures of the scoliosis that form can be low, medium and high-rotated, and the low-rotated curvatures were most often found in the 6-9- and 10-12-year-old groups and in the lumbar and thoracolumbar section. To increase the rate of early diagnosis of scoliosis, the results suggest the need to adopt two ATI criteria for the diagnosis of scoliosis at screening, 5° for age of 6-12 years, and when asymmetry affects the lumbar and thoracolumbar section, and 7° for the remaining children.

Nonoperative management of adolescent idiopathic scoliosis (AIS) using braces

This review presents the state of the art according to the current evidence on nonoperative treatment for adolescent idiopathic scoliosis, focusing on bracing. The definition of braces for the treatment of adolescent idiopathic scoliosis and a short history are provided. The analysis includes biomechanics, types, existing classifications, indications for treatment, time of brace wear and weaning, adherence, three-dimensional modeling, use of ultrasound imaging for bracing, management of treatment, issue of immediate in-brace correction, and documentation of the outcomes usually assessed for brace treatment, including the quality-of-life issues. According to the current evidence, there are two randomized control trials in favor of bracing. There are insufficient data on the superiority of one brace over another, although it is possible to classify and grade braces for efficacy from nonrigid to rigid and very rigid. Nevertheless, there is consensus on patients' management on the need for teamwork focusing on adherence to treatment, acceptability, and family and patient involvement.

Systematic review of the association between isolated musculoskeletal hypermobility and adolescent idiopathic scoliosis

INTRODUCTION

Adolescent idiopathic scoliosis (AIS) affects 1-3% of the population, but its pathogenesis remains unclear. The coexistence of musculoskeletal hypermobility and scoliosis in many inherited syndromes raises the possibility that isolated musculoskeletal hypermobility may contribute to AIS development or progression.

METHODS

We performed a systematic review of the evidence for a relationship between isolated musculoskeletal hypermobility and AIS. A meta-analysis was planned, but if not possible, a narrative evidence synthesis was planned.

RESULTS

Nineteen studies met eligibility criteria for inclusion. One study was excluded due to insufficient quality. Substantial heterogeneity in study design and methodology negated meta-analysis, so a narrative review was performed. Of the 18 studies included, seven suggested a positive association and eight found no association. Three reported the prevalence of musculoskeletal hypermobility in individuals with AIS. Overall, there was no convincing population-based evidence for an association between musculoskeletal hypermobility and AIS, with only two case-control studies by the same authors presenting compelling evidence for an association. Although populations at extremes of hypermobility had a high prevalence of spinal curvature, these studies were at high risk of confounding. Wide variation in methods of measuring musculoskeletal hypermobility and the challenge of assessing AIS in population-based studies hinder study comparison.

CONCLUSIONS

There is a paucity of high-quality evidence examining the association between isolated musculoskeletal hypermobility and AIS. Large-scale prospective studies with adequate adjustment for potential confounding factors could clarify the relationship between musculoskeletal hypermobility and AIS to elucidate its role in the pathogenesis of AIS.

Cerebral White Matter Connectivity in Adolescent Idiopathic Scoliosis: A Diffusion Magnetic Resonance Imaging Study

Adolescent idiopathic scoliosis (AIS) is characterized by the radiographic presence of a frontal plane curve, with a magnitude greater than 10° (Cobb technique). Diffusion MRI can be employed to assess the cerebral white matter. The aim of this study was to analyze, by means of MRI, the presence of any alteration in the connectivity of cerebral white matter in AIS patients. In this study, 22 patients with AIS participated. The imaging protocol consisted in T1 and diffusion-weighted acquisitions. Based on the information from one of the diffusion acquisitions, a whole brain tractography was performed with the MRtrix tool. Tractography is a method to deduce the trajectory of fiber bundles through the white matter based on the diffusion MRI data. By combining cortical segmentation with tractography, a connectivity matrix of size 84 × 84 was constructed using FA (fractional anisotropy), and the number of streamlines as connectomics metrics. The results obtained support the hypothesis that alterations in cerebral white matter connectivity in patients with adolescent idiopathic scoliosis (AIS) exist. We consider that the application of diffusion MRI, together with transcranial magnetic stimulation neurophysiologically, is useful to search the etiology of AIS.

The importance of the size of the trunk inclination angle in the early detection of scoliosis in children

BACKGROUND

Early detection of idiopathic scoliosis is one factor in determining treatment effectiveness. Therefore, the aim of this study was to assess the importance of the size of the trunk inclination angle (ATI) for the early detection of scoliosis in preschool- and school-age children, taking into account the location and size of the spine curvature.

METHODS

The study included a group of 216 children (mean age 11.54 years, standard deviation ± 3.05), who had previously untreated idiopathic scoliosis and a Cobb angle of ≥ 10°. The ATI values were compared with the corresponding Cobb angle values. The results of the ATI-Cobb correlation were compared to the ATI thresholds of 5° and 7°.

RESULTS

In the age groups 6-9, 10-12 and 13-17 years, the method sensitivity for the ATI ≥ 7° criterion was low at 33.90%, 27.69% and 51.29% (p < 0.05), respectively, while for the ATI ≥ 5° criterion, it was 67.8%, 69.23% and 93.48% (p < 0.05), respectively. With respect to location, significantly more frequent misdiagnoses (p < 0.05) were related to the lumbar and thoracolumbar (regions) sections of the spine in the groups aged 6-9 and 10-12 for ATI ≥ 7°; while no significant relationship was found at ATI ≥ 5°. For both ATI levels, the most frequent cases of mis- or undiagnosed scoliosis were observed among children with a Cobb angle of 10°-14° (p = 0.004).

CONCLUSION

A low predictive ATI value was demonstrated regarding scoliosis detection for the ATI 7° criterion in children aged 6-9 and 10-12 years, particularly for the lumbar and thoracolumbar locations. Adoption of the threshold of ATI 5° in screening tests for children aged 6-12 years, as well as for lower locations of scoliosis, may be more effective in the early detection of scoliosis.

TRIAL REGISTRATION

This study was approved by the Jan Dlugosz University in Czestochowa Ethics Committee KE-U/7/2021, and conducted under the Declaration of Helsinki.

Effect of Chêneau style braces on vertebral wedging amongst individuals with adolescent idiopathic scoliosis

Background

It is generally accepted that braces can stop curve progression but little evidence exists regarding structural improvement in the spine using spinal bracing. Our study aimed to investigate the possible structural improvements of vertebral wedging with high correction bracing.

Objectives

The aim of our study was to assess whether spinal brace treatment may influence vertebral wedging in adolescent idiopathic scoliosis (AIS).

Method

We reviewed our database according to the following inclusion criteria: girls with a diagnosis of AIS, Risser 0–2, age 10–14 years with Cobb angles greater than 35°. Our study cohort consisted of 27 patients fulfilling the inclusion criteria with an average brace wearing time of 16.6 h per day and Cobb angles between 36° and 79°. The target value for our study was the apical vertebra wedging, measured twice before brace treatment commenced and twice after the average follow-up period of 20.5 months of treatment.

Results

The average apex wedging noted before brace wearing started was 9.8° (median: 9) and after a period of 20.5 months of brace wearing, it had reduced to an average of 5.8° (median: 4.9), (p < 0.001). This would indicate a structural correction of 44%.

Conclusions

Our study supports the hypothesis that spinal high correction braces improve the degree of vertebral wedging in skeletally immature girls with AIS.

Clinical implications

Structural corrections of the apical vertebra seem possible when high correction asymmetric braces are used in the treatment of patients with AIS.

Effectiveness of the FED Method in the Treatment of Idiopathic Scoliosis of Girls Aged 11-15 Years

(1) Background: The unknown etiology of idiopathic scoliosis and its three-dimensional nature make the cause-and-effect therapeutic management difficult. A tendency to progression of scoliosis and the failure of many methods of conservative treatment have prompted the search for new methods that would stop and correct deformations. One of them is the FED method, used in the conservative treatment of idiopathic scolioses, in which all scoliotic curves are corrected. The aim of this study was a comparative analysis of the effectiveness of idiopathic scoliosis treatment with the FED and FITS methods. (2) Methods: The study included 60 randomly selected girls, aged 11 to 15 years, treated with the FED and FITS methods. They were diagnosed with idiopathic scoliosis grade II according to Cobb and double-curve scoliosis type I and II according to King–Moe classification. The results of the therapy were assessed with the use of the Bunnell scoliometer. The examinations were performed before the start of the therapy—on the first day of the child’s stay—and 3 weeks after the therapy. The angle of trunk rotation and the sum of two rotations were assessed using a scoliometer. (3) Results: The performed statistical analysis demonstrated significant changes in the examined parameters in both therapeutic groups. (4) Conclusions: 1. The obtained results indicate that the FED therapy may prove to be an effective method of treating idiopathic scoliosis; however, it requires further research in a larger group of patients; 2. both methods significantly improved trunk rotation in primary and secondary scoliosis, but after using summing parameters (SDR parameter), the FED method appeared to be statistically more effective.

Conservative treatment of a scoliosis patient after two heart surgeries in early childhood - A case report

Introduction

This is a case report of a juvenile female patient with scoliosis following two heart surgeries for congenital heart disease (CHD).

Patient presentation, management and outcome

Initially, the premenarchial female was 9 years old and had a Tanner stage 2–3 with a single thoracic curve of 65° Cobb. Because of the high risk for progression, immediate brace treatment was proposed as the father declined surgery. The patient received intensive treatment according to the Schroth Best Practice® programme and a Gensingen Brace® designed for large thoracic curves. Over the 18 months following the initial visit, she received two additional braces. As a result, the progression of the main curve was prevented. The patient continues to maintain an improved cosmetic result and is currently at a Risser 2.

Conclusion

Surgery performed for CHD in rare cases may lead to stiff spinal deformity as a consequence of that surgery. Progression of a severe and stiff curve was prevented during the most vulnerable phase of the pubertal growth spurt with an improved clinical result. Therefore, we assume that the patient may have a normal life in adulthood with minor restrictions only. Supported by pattern-specific high correction exercises and braces, these typical single thoracic curves can be re-compensated to a more balanced appearance, less prone to progression in adulthood.

Clinical implications

Because of the relative high risks of spinal fusion and the long-term unknowns of such an intervention, high-impact conservative treatment should be implemented first before surgical correction is considered.

A Survey of Methods and Technologies Used for Diagnosis of Scoliosis

The purpose of this article is to present diagnostic methods used in the diagnosis of scoliosis in the form of a brief review. This article aims to point out the advantages of select methods. This article focuses on general issues without elaborating on problems strictly related to physiotherapy and treatment methods, which may be the subject of further discussions. By outlining and categorizing each method, we summarize relevant publications that may not only help introduce other researchers to the field but also be a valuable source for studying existing methods, developing new ones or choosing evaluation strategies.

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.

[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.

Associations between curve severity and revised Scoliosis Research Society-22 and scoliosis Japanese Questionnaire-27 scores in female patients with adolescent idiopathic scoliosis: a multicenter, cross-sectional study

Background

Patient-reported outcome measures are widely utilized to assess health-related quality of life (HRQOL) in patients with adolescent idiopathic scoliosis (AIS). However, the association between HRQOL and curve severity is mostly unknown. The aim of this study is to clarify the association between HRQOL and curve severity, and to determine the optimal cutoff values of patient-reported outcomes for major curve severity in female patients with AIS.

Methods

Female patients with AIS treated conservatively were recruited. The patients’ HRQOL outcomes were examined using the revised Scoliosis Research Society-22 (SRS-22r) and the Scoliosis Japanese Questionnaire-27 (SJ-27). The correlations of the SRS-22r and SJ-27 scores with the major Cobb angle were assessed using Spearman’s correlation coefficient analysis. The association between HRQOL issues in the SJ-27 and the major Cobb angle was evaluated by calculating Akaike’s Information Criterion (AIC). Furthermore, the optimal cutoff values of the SRS-22r and SJ-27 scores for the major Cobb angle were determined by AIC analysis.

Results

The study cohort comprised 306 female patients with AIS. The SRS-22r and SJ-27 scores were significantly correlated with the major Cobb angle. Questions in the SJ-27 regarding discomfort when wearing clothes showed a lower AIC value in patients with severe scoliosis. The optimal cutoff values were a SRS-22r score of 3.2 for the discrimination of severe scoliosis (Cobb angle ≥48°), and a SJ-27 score of 32 for the discrimination of moderate scoliosis (Cobb angle ≥33°).

Conclusion

Discomfort when wearing clothes was the most important HRQOL problem caused by severe scoliosis. The SRS-22r and SJ-27 scores are useful for the discrimination of clinical status in female patients with severe scoliosis or moderate scoliosis.

Relationship between postural changes and physical and functional variables in schoolchildren aged 6-12 years

Abstract The aim of this study was to evaluate the prevalence of postural changes and their relationship with BMI, pain, postures adopted in activities of the daily living (ADL), physical activity practice, gender and age (6 to 12 years). This study is characterized as cross-sectional, quantitative and descriptive. The convenience sample consisted of 840 schoolchildren. Regarding the sample characteristics, 477 (56.79%) were female aged 6-12 years (average=8.90±1.71years). Evaluations were carried out at the school premises and a questionnaire was used to collect data on gender, age, pain report, practice of out-of-school physical activities and postures adopted in ADLs. Body mass, height and posture were evaluated. Some schoolchildren (43.21%) reported not practicing physical activity outside of school, 544 (64.76%) correctly carried their backpack and 51.9% adopted correct postures to study and watch TV. Musculoskeletal pain was reported by 62.73%, and shoulders were the most affected. BMI indicated 55.6% of the sample with leanness/normal weight and 44.40% with overweight/obesity. Postural changes were present in 97.02% of students and the region with the highest number of alterations was the upper limbs. Girls presented greater number of trunk alterations (p=0.001), as well as those who did not practice physical activity (p=0.02) and alterations in the lower limbs for younger students (p=0.02) and female students (p=0.01). This study identified high prevalence of postural changes in schoolchildren.

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.

Prevalence of adolescent idiopathic scoliosis in Turkey: an epidemiological study

BACKGROUND CONTEXT

Studies have shown that adolescent idiopathic scoliosis (AIS) prevalence varies between 0.35% and 5.2% and it is generally accepted as an average of 2%-3% in children under age 16. There are a few narrow-scope studies based on school screening performed on the epidemiology of AIS in Turkey. Prevalence rates reported by these studies are lower than reported in neighboring countries. Of note, they were conducted in single cities, generally based on small sample size, and are different from each other in terms of methodology and age groups. The present study was conducted based on a large population in 85 schools of 40 provinces in Turkey.

PURPOSE

The aim of this study was to determine the prevalence of AIS in Turkey. Secondary outcomes were to determine age, gender, curve distribution, using standard tests, and radiological verification.

STUDY DESIGN

A cross-sectional epidemiological study.

PATIENT SAMPLE

The sample size was calculated to estimate the prevalence of AIS in children aged 10-15 years in Turkey.

OUTCOME MEASURES

Adams' forward bending test, angle of trunk rotation measurement, and posture analysis were used to screen. Students who had an angle of trunk rotation greater than or equal to five (≧5°) with scoliometer measurement or who had a positive forward bending test were referred to the mobile X-ray unit located in the school-yard on screening day. Their diagnosis was confirmed using Cobb angles of greater than or equal to 10 (≧10°).

METHODS

Medical personnel, mobile radiological tools, and logistical support needed during fieldwork were provided by the Directorate General for Health Research, Ministry of Health Republic of Turkey. Spine and posture were examined in upright standing position. Examiners looked for shoulder asymmetries, scapular prominence, unequal waist, and lower limb length discrepancy. Potential scoliosis diagnosis was verified with onsite radiographic examination. Cases with a Cobb angle of ≧10° detected in any region were accepted as scoliosis. The direction and location of scoliosis were determined according to the Scoliosis Research Society terminology criteria.

RESULTS

A total of 16,045 students were reached whose informed consent forms were signed by their parents. The prevalence of AIS was found to be 2.3% (female, 3.1%; male, 1.5%). Radiological confirmation rate was 98.8%; 256 (69.3%) of 369 adolescents with scoliosis had a single curvature and 108 (29.3%) had a double curvature. The most common single curve type was a lumbar curve. In all, 90.5% of cases with AIS had a mild (range of 10°-19°) Cobb angle.

CONCLUSIONS

The prevalence of AIS was 2.3% in Turkey. This prevalence rate was considerably higher than the values in previous regional studies conducted in Turkey; however, it was close to generally accepted averages in the literature. One of the strongest aspects of the study was that radiologic confirmation of each suspected case was made during the screening.

Spinal Coronal and Sagittal Balance in 584 Healthy Individuals During Growth: Normal Plumb Line Values and Their Correlation With Radiographic Measurements

BACKGROUND

Plumb line distances (PDs) are widely used in conservative clinical practice to evaluate the sagittal shape of the spine.

OBJECTIVE

The objective was to assess the normative values of PDs in a large, healthy population in an age range representative of the adolescent population with spinal deformities, and to correlate it with x-ray measurements.

DESIGN

This was a cross-sectional study.

METHODS

Participants were 584 healthy individuals (341 females) with x-rays showing no spine deformities. The whole sample (OVERALL) was divided into 5 groups: 6 to 9 years old (n = 106); >10 years, Risser 0 with triradiate cartilage open (n = 129) or closed (n = 104); Risser 1 to 2 (n = 126); and Risser 3 to 5 (n = 119).PDs were taken by maintaining a tangent to the thoracic kyphosis apex at C7, T12, L3, and S2. Sagittal index (C7 + L3), and sagittal and coronal balances (C7 related to S2) were calculated.

RESULTS

In OVERALL, PDs at C7, T12, L3, and S2 were 39.9 ± 16.7, 21.4 ± 15.3, 39.9 ± 15, 20.6 ± 17.0 mm, respectively. Sagittal index was 79.8 ± 26.8, sagittal balance was 19.3 ± 17 mm anterior to S2 plumb line; 13.5% had a coronal imbalance of 11.4 ± 5.4 mm to the right and 24.7% of 13.2 ± 6.0 mm to the left. C7 and L3 PDs, sagittal index, and sagittal balance were significantly lower in ages 6 to 9 compared to older patients in Risser 1 to 2 group. C7 and S2 PDs and sagittal index were significantly larger in males. Sagittal index correlated with thoracic kyphosis Cobb degrees (r = 0.47).

LIMITATIONS

The participants were not randomly chosen from the general population; and they had an x-ray because of spine pathology suspicion.

CONCLUSIONS

This study shows normative data to be used in clinical practice. Sagittal spinopelvic alignment has gained more and more importance in the last decades because of its high correlation to Health-Related Quality of Life scores in adults. 1.

The Angle of Trunk Rotation in School Children: A Study from an Idiopathic Scoliosis Screening. Prevalence and Optimal Age Screening Value

(1) Background: Idiopathic scoliosis is a deformity of the growing spine. It affects 2–3% of adolescents; yet its cause is still unknown. At the early stage of idiopathic scoliosis (IS), the signs are not very noticeable. That is why the primarily school-based screening for scoliosis is so important. (2) Methods: This was a cross-sectional analysis of 6850 respondents. Participants were elementary school students in the metropolitan area of Poland. The suspicion of IS was based on detection of three-dimensional deformity of the spine using scoliometer. (3) Results: Respondents were divided into two groups: Angle of trunk rotation (ATR) = 0–3º and ATR > 3º. Presented research using a referral criterion of 5º ATR showed that in the group of participants who had ATR > 3º the largest percentage of 5 degree values was recorded at the second and third measurement level of the spine (30.5%, 31.1%, respectively). Analyzing the differences between the two groups of girls (ATR = 0–3º, ATR > 3º), statistically significant differences were recorded between 9 and 11 years of age (p = 0.0388). Girls with ATR > 3º at all measuring levels are significantly slimmer than girls with ATR 0–3º; (4) Conclusions: Age; sex, and risk of developing angle of trunk rotation are very closely associated. The main thoracic (level 2) and thoraco-lumbar (level 3) level of measuring of the spine appears to be the most differentiating in the diagnosis of scoliosis. Girls with a lower degree of trunk deformity (4–6º trunk rotation), which can present mild scoliosis and those with a higher degree (7º trunk rotation) have lower body mass than girls within the norm.

The Effect of an Innovative Biofeedback SKOL-AS® Treatment on the Body Posture and Trunk Rotation in Children with Idiopathic Scoliosis—Preliminary Study

Background and Objectives: The deformity in idiopathic scoliosis (IS) is three dimensional and effective correction involves all three planes. Recently, the biofeedback method has been implemented in the treatment of scoliosis. The aim of this study was to evaluate the effectiveness of an innovative biofeedback SKOL-AS^® postural training among children with scoliosis. Materials and Methods: The target population for this study was 28 patients (25 girls and 3 boys) aged between 5 and 16 years old diagnosed and treated with progressing low-grade scoliosis. The postural diagnosis consisted of anthropometric measurements, posterior–anterior X-ray imaging, SpinalMeter^® postural assessment and the angle of trunk rotation (ATR) assessment. The SKOL-AS^® treatment comprised of 24 sessions conducted in lying and sitting positions, two times a week. Results: It has been shown that the postural training resulted in the decrease in the ATR value (pre- vs. post-exercise in younger: 5.55 vs. 3.0 and older patients: 5.2 vs. 3.0). The increase in height of the subjects seemed to confirm a positive effect of SKOL-AS^® elongation treatment. In the posterior view, a statistically significant decrease in shoulder asymmetry in the sitting position in younger children has been observed. In the anterior view, the changes in the head position (based on mouth and eye symmetry) have been observed. The statistically significant increase in acromion–heel, acromion–iliac crest and posterior superior iliac spine (PSIS)–heel length values has been shown in younger children on the left side of the body. After treatment, older subjects had higher acromion–iliac crest and PSIS–heel values on the left side of the body. On the right side only PSIS–heel length was higher. In a sitting position, only a small increase in acromion–iliac crest length value has been observed. Conclusions: The SKOL-AS^® biofeedback method could teach good postural habits and teach patients the auto-correction of the spine.

Effectiveness of school scoliosis screening and the importance of this method in measures to reduce morbidity in an Italian territory

Although several procedures for treating scoliosis have been developed, the most effective treatment is still based on early detection. For early diagnosis of idiopathic scoliosis, many authors have proposed methods of school screening; however, there is still no standardized screening program. The aim of this study was to evaluate a school screening method and the prevalence and distribution of scoliosis in Italian school children, aged 9-14 years, and to determine if the screening method can reduce morbidity in an Italian territory. The screening program consisted of three steps: the first step was a clinical examination carried out by the school physician and two specialists. In the second step, doubtful cases (presence of a hump between the two sides of the torso, in the thoracic or thoracolumbar region, measured using a hump meter) were evaluated by an orthopedic specialist and subsequently controlled every 6 months either clinically or by radiographic examination. The third step was the classification of the scoliosis and procedures for treatment. All patients were scheduled for a follow-up program and were evaluated during the subsequent 3 years. Statistical analyses were performed with GraphPad Prism 6. A total of 8995 children were screened for scoliosis. Of these, 487 showed clinical signs of scoliosis, and 181 were referred for anteroposterior radiographs because of a positive result on the forward-bending test (hump>5 mm). No significant statistical difference was observed by the three clinical examiners. Of the 181 patients who were referred, 69 were radiographed, and the clinical diagnosis was confirmed in 94.2% of the cases. The prevalence of scoliosis (defined as a curve of ≥10°) was 0.76% (65 of 8995 children), and most of the curves (44; prevalence 67.69%) were small (<20°). The overall ratio of boys to girls was 1 : 3.3, but varied according to the magnitude of the curve (1 : 3 for curves of <20°, 1 : 3.25 for curves of 20-29°, and 1 : 4 for curves of ≥30°). Double curves were the most common type identified, followed by thoracolumbar curves; specifically, of the 65 children who had a curve, 21 (32.30%) had a double curve, 18 (27.6%) had a thoracolumbar curve, 17 (26.1%) had a lumbar curve, and nine (13.84%) had a thoracic curve. In the following 3 years, only four patients were found to have curves more than 20° and none more than 30°. Our results show that the school screening program was accurate and repeatable. Moreover, screening children for scoliosis using a simple test appears to be an effective means of early detection. Above all, the screening process effectively decreased morbidity in the territory at a negligible cost.

Correlation of Radiographic and Patient Assessment of Spine Following Correction of Nonstructural Component in Juvenile Idiopathic Scoliosis

Objective

To evaluate the association between progression of curvature of scoliosis, and correction for functional component in patients with juvenile idiopathic scoliosis (JIS).

Methods

We retrospectively reviewed medical data of patients prescribed custom molded foot orthosis (FO) to correct inequality of RCSPA (resting calcaneal stance position angle), and chose 52 patients (26 females, 26 males) with Cobb angle ≥10° in radiology and uneven pelvic level at iliac crest by different RCSPA (≥3°) as a factor of functional scoliosis. They had different hump angle ≥5° in forward bending test, for idiopathic scoliosis component. Their mean age and mean period of wearing FO were 79.5±10.6 months and 18.6±0.70 months.

Results

Cobb angle was reduced from 22.03°±4.39° initially to 18.86°±7.53° after wearing FO. Pelvis height difference and RCSPA difference, were reduced from 1.07±0.25 cm initially to 0.60±0.36, and from 4.25°±0.71° initially to 1.71°±0.75° (p<0.01). Cobb angle improved most in 9 months. However, there was no significant improvement for those with more than 25° of Cobb angle initially. Mean Cobb angle improved in all age groups, but patients less than 6 years had clinically significant improvement of more than 5°.

Conclusion

JIS can have functional components, which should be identified and managed. Foot orthosis is useful in correcting functional factors, in the case of pelvic inequality caused by different RCSPA, for patients with juvenile idiopathic scoliosis.

The Duration of the correction loss after removing cheneau brace in patients with adolescent idiopathic scoliosis

OBJECTIVE

The aim of the study was to evaluate the loss of truncal rotation over 54 hours after removing Chêneau brace.

METHODS

The studied groups consisted of 39 girls aged 10-18 years old, diagnosed with adolescent idiopathic scoliosis (AIS) and treated with Chêneau brace (CAST) and 20 AIS girls aged 10-18 years old, not treated with bracing. Posterior-anterior radiographs were obtained from the clinical assessment of all subjects and were subsequently used to determine Cobb angles. The measurements of the angle of trunk rotation (ATR) were taken with the Scoliometer® and back-contour device during Adams forward bending test by the two evaluators. The changes in ATRs during 54 hours of observation were performed after the brace had been taken off (0, 2, 24, 30, 48 and 54 hours after debracing). This was described using VATR variable, defined as the change in the absolute Scoliometer® readings in the time intervals against the time interval Δt between the measurements. During back-contour assessment the differential factor (kra) has been used for the digital analysis. The changes in kra over 54 hours of observation were expressed as Vkra factor, defined as the difference in the absolute value of the amplitude differential factor (kra) in the time intervals against the time interval Δt between the measurements.

RESULTS

The highest changes were observed in the thoracic as well as in lumbar spine in patients with Cobb angle ≥30°, axial rotation of the apical vertebrae within 5-15°, Risser sign 0-2. The biggest change in the trunk rotation after Chêneau brace had been taken off was noted within the first two hours of observation.

CONCLUSION

The patients should be advised to take the brace off for a minimum of two hours before the scheduled x-ray, to allow full relaxation of the trunk in order to obtain reliable radiological images of the deformation.

LEVEL OF EVIDENCE

Level III Therapeutic study.

Incidence of scoliotic posture in school screening of urban children and adolescents: the case of Poznań, Poland

Postural defects including scoliotic posture constitute one of the most frequently observed health problems in school-aged children. The incidence of this multifactorial condition has been observed to increase recently. The aim of the study was to assess the incidence of scoliotic posture in primary and secondary school students living in a large city. The sample consisted of 1,325 boys and 1,355 girls, aged 6 to 18, living in the city of Poznań. Their postures were assessed through skilled visual inspection method based on the criteria delineated by Wiktor Dega. Additionally, measurements of scoliotic deformities were taken using the Bunnell’s scoliometer. It was found that the incidence of scoliosis assessed on the basis of Dega’s postural defect chart amounted in total to 14.6% in boys and 17% in girls. No substantial differences between boys and girls in particular age categories were found. Scoliometer examination appeared to be a more accurate method for screening scoliosis and revealed higher incidence of this condition in total and both in boys and girls as compared to the visual screening method. The contractures which may lead to scoliotic posture appeared most frequently in the knee joints, both in boys and in girls. The incidence of lateral spinal curvatures was related to age and increased with age. Scoliometer proved to be a more effective tool in detecting lateral spinal curvatures and should be more widely used in school healthcare.

Screening of scoliosis in school children in Tehran: The prevalence rate of idiopathic scoliosis

BACKGROUND

Scoliosis is the abnormal sideways curve of the spine. Screening for scoliosis is controversial, and there has been significant heterogeneity between studies. In Iran, there is still no suitable device to screen sideways curves in spine.

OBJECTIVE

To investigate the simple scolioscreen software for screening the students of elementary schools for detecting schoolchildren scoliosis. This students has been examined by trained medical student and data entered in scolioscreen application of an iPhone.

METHODS

One hundred forty-four 7-12 years old students from primary schools in the 17th district of Tehran were randomly invited to participate. Initial screening of the students was done in schools by health care provider or medical student who has been trained by a pediatrician to undergo a vertebral examination. Scoliometer for iPhone's smartphone has been used for measuring the angle of deviation.

RESULTS

1.4% of students had overt scoliosis and 10.4% were suspected to have a kind of mild abnormality in spine curve. These individuals were referred to clinic for radiologic evaluation and it was confirmed that relative frequency of this abnormality was defined as 4.86% in our population study. There was no significant correlation between sex and degree of spinal curve.

CONCLUSIONS

Regarding the high rate of scoliosis in our population and approval of this screening test in different studies, routine use of this screening method is highly recommended in schoolchildren. It is cost beneficial and can be effective in prevention and early treatment of scoliosis.

School scoliosis screening by Moiré topography - Overview for 33 years in Miyazaki Japan

BACKGROUND

Since 1981, we have performed school scoliosis screening (SSS) using Moiré topography in Miyazaki, Japan and attained a certain result in detecting scoliosis. However, this screening system was discontinued due to cessation of repair and production of Moiré topographic equipment. The purpose of this study was to make clear both the results and the problems of SSS by Moiré topography on the basis of our past 33 years' experiences.

METHODS

The subjects were 689,293 students (5th grade boys in 200,329, 5th grade girls in 191,919, 8th grade boys in 151,351, and 8th grade girls in 145,694) who were screened by Moiré topography between 1981 and 2013. The number of students received SSS, the positive rate of Moiré topography, the discovery rate of scoliosis greater than 20°, the reference rate to the second screening, and the positive predictive value of Moiré topography to detect scoliosis greater than 20° were investigated.

RESULTS

The number of students received SSS achieved a peak in 1992. The positive rate of Moiré topography and the discovery rate of scoliosis were highest in 8th grade girls. The reference rates to the second screening were 49.8% in 5th grade students and 41.4% in 8th grade students. The positive predictive values were 2.1% in 5th grade students and 7.6% in 8th grade students.

CONCLUSION

SSS by Moiré topography seemed to be effective in detecting scoliosis although both the positive predictive value and the reference rate to the second screening were low.

Brace Treatment for Adolescent Idiopathic Scoliosis

In the past, numerous non-operative treatments for adolescent idiopathic scoliosis (AIS), including exercise, physical therapy, electrical stimulation, and brace treatment, have been tried to delay or prevent the curve progression. Of these, brace treatment is the only option that is widely accepted and has demonstrated the efficacy to alter the natural history of AIS. Recently, the importance of brace treatment for AIS has been increasing since the efficacy was objectively established by the BrAIST (Bracing in Adolescent Idiopathic Scoliosis Trial) study in 2013. This editorial article summarizes the current status of brace treatment in patients with AIS and discusses future prospects on the basis of our clinical experiences.

Correlation Between Hump Dimensions and Curve Severity in Idiopathic Scoliosis Before and After Conservative Treatment

STUDY DESIGN

Prospective study in 150 consecutive outpatients affected by adolescent idiopathic scoliosis (AIS).

OBJECTIVES

The purposes were to (1) identify a correlation between hump dimensions and the severity of scoliotic curve, and (2) evaluate how the treatment influenced the main parameters of scoliosis.

SUMMARY OF BACKGROUND DATA

The existence of a relationship between clinical deformities and curve severity in AIS is still debated. Furthemore, only a few studies have investigated the effectiveness of conservative treatment for idiopathic scoliosis taking into account both clinical and radiologic factors.

METHODS

150 consecutive outpatients (mean age 12.8 ± 1.9 years) affected by AIS were subjected to conservative brace-based treatment. 134 participants completed the treatment protocol. Two parameters were considered to evaluate the treatment progress: the hump and the Cobb angle. Measurements were determined at the beginning and the end of treatment. Statistical analyses were performed in the whole sample and after dividing the study participants into 4 subgroups: patients with lumbar (n = 66) or thoracic curves (n = 68), patients ranging in age between 6 and 13 years (n = 89) and patients ≥ 14 years of age (n = 45).

RESULTS

A positive correlation was detected between the hump dimension and curve severity at the beginning and the end of treatment, except for lumbar curves at baseline. The deformity was effectively corrected by the orthotic treatment (Cobb angle: 29.4 ± 8.5° at baseline and 19.3 ± 9.8° at the end of treatment; hump severity: 11.6 ± 5.6 mm at baseline and 6.2 ± 4.6 mm at the end). In addition, our data indicate that the hump correction is more evident than that of the curve registered in Cobb degrees.

CONCLUSION

A significant correlation exists between the hump dimension and curve severity both at the beginning and the end of treatment, except for lumbar curves at baseline. The brace treatment confirmed its effectiveness in arresting the deformity progression and inducing a remodeling both of the scoliotic curve and the hump.

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.

Trunk and craniofacial asymmetry are not associated in the general population: a cross-sectional study of 1029 adolescents

Background

The literature did not show clearly if a correlation between trunk and facial asymmetry exists. The aim of this study was to verify the association between trunk and facial asymmetries, and trunk and facial sagittal configuration in adolescents.

Methods

This is a cross-sectional screening study. It was carried out in a small town in Northern Italy, from February to April 2014. Healthy children met the inclusion criteria. Exclusion criteria were subjects with physical and cognitive disability, genetic disease, and polymorphism. All subjects underwent a three phases for postural screening program.

Results

1029 healthy children were 491 females and 538 males with mean age: 12 (range 11–16) years. The association of facial and trunk asymmetry had a point prevalence rate around 1% for the various regions of the spine, the association on the sagittal plane of almost 1.3% for hyperkyphosis and hyperlordosis. Overall, results showed a very low sensitivity, specificity, and predictive values of facial anomalies for trunk asymmetry and sagittal spinal posture.

Conclusion

While correlations between jaw position and body posture for cervical spine can exist, our study denied association with trunk and back in a general population: postural compensatory mechanism may have minimized the effects of one area on the other, if any existed.

Systematic Review of School Scoliosis Screening

OBJECTIVES

The aim of this study was to review the literature on school screening and its reported effectiveness.

SUMMARY OF BACKGROUND DATA

There is no worldwide consensus concerning the mandating of school screening for scoliosis. This remains a controversial issue.

METHODS

The following databases were employed: Medline, Premedline, CINAHL, CENTRAL, AMED, Embase, SCOPUS, Ovid nursing, and Web of Science. These data were generated from the Forward Bend Test, the angle of trunk rotation and Moire topography. The first and second authors each independently screened titles and abstracts for potential studies. Fulltext papers of potential studies were also independently read by the first two authors to identify studies to be included based on strict inclusion/exclusion criteria. A heterogeneity test was performed by testing for the significance of the between-study variance. Publication bias was examined by a funnel plot.

RESULTS

We found 20 studies that met our inclusion criteria. The pooled estimate of prevalence of scoliosis curves in the population was 1.1% for curves greater than 10°, and 0.2% for curves greater than 20°. The pooled referral rate to radiography during the screening process was 6.6%. The pooled positive predictive values for detecting curves >10° and >20° were 32.3% and 6.5% respectively. Analysis of data demonstrated significant heterogeneity between studies but was not suggestive of the presence of publication bias.

CONCLUSIONS

We support the implementation of scoliosis screening as a means of detecting curves at an early treatable stage. The current available evidence in the literature for routine scoliosis screening is low to moderate. Challenges exist to the school scoliosis screening including a high referral rate to radiology.

The Risk of Curve Progression and Surgery in African Americans With Adolescent Idiopathic Scoliosis

STUDY DESIGN

Retrospective clinical cohort study.

OBJECTIVE

To determine if certain risk factors (age, curve magnitude, skeletal maturity, gender, and curve pattern) traditionally associated with curve progression and surgical intervention in the general population apply equally to African Americans.

SUMMARY OF BACKGROUND DATA

Currently, information is limited on the role that a patient's race plays in the risk of curve progression of adolescent idiopathic scoliosis (AIS), and existing studies have conflicting results.

METHODS

Retrospective search of records identified patients who were African American, had been diagnosed with AIS, had a major curve Cobb angle of 10 degrees or more, and had at least two clinical visits with spinal radiographs at least 90 days apart to determine the risk factors for surgical treatment, and 2 years apart to determine the risk factors for curve progression. Patients with a medical condition likely to cause scoliosis were excluded.

RESULTS

Of 738 African American patients with AIS, 223 were assessed for surgical risk factors, and 72 were assessed for curve progression risk factors. Fifty-six (29.17%) had progression of the major coronal curve, and 38 (17.04%) underwent surgery. Age at presentation and curve magnitude at presentation were significant risk factors for surgical intervention. Curve magnitude at presentation was a significant risk factor for curve progression. No significant relationships were found for gender or curve type as they relate to surgical intervention or curve progression.

CONCLUSION

Age and curve magnitude at presentation were significantly associated with surgery, as is true in other scoliosis populations. Curve magnitude at presentation was associated with curve progression. In contrast to studies in other populations, however, no significant association was observed between curve progression and age at presentation, curve type, or gender, or between surgery and curve type or gender.

LEVEL OF EVIDENCE

Level III, prognostic cohort study.

Body Mass Hides the Curve: Thoracic Scoliometer Readings Vary by Body Mass Index Value

BACKGROUND

Guidelines suggest referral for scoliosis when rib slope (scoliometer measurement, angle of trunk rotation) is ≥7 degrees. We hypothesized that overweight and obese patients would have lower scoliometer measurements compared with normal-weight and underweight patients for a given spinal curvature, causing overweight and obese patients with adolescent idiopathic scoliosis to present for treatment later and with larger curves. Our goal was to determine the association between scoliometer readings and major curve magnitudes in relation to body mass index (BMI).

METHODS

This retrospective cohort study at a tertiary referral center included 483 patients (420 girls) aged 10 to 18 years (mean age, 14±1.6 y) with thoracic adolescent idiopathic scoliosis who presented to 1 orthopaedic surgeon for initial evaluation of spinal deformity from 2010 to 2015. Records were reviewed for BMI percentile for age and sex (underweight, ≤fourth percentile; normal weight, fifth to 84th percentile; overweight, 85th to 94th percentile; obese, ≥95th percentile), patient characteristics, thoracic scoliometer measurements, and thoracic major curves.

RESULTS

Of the 483 patients, 23 were underweight, 372 were normal weight, 52 were overweight, and 36 were obese. Obese patients had a larger mean major curve (44 degrees) than normal-weight patients (34 degrees) (P=0.004). The odds of presenting with a major curve ≥20 degrees were 4.9 (95% confidence interval, 1.1-22; P=0.037) times higher for obese versus normal-weight patients. Receiver operating characteristic analysis of major curves (≥20 vs. <20 degrees) estimated the scoliometer values with the greatest sensitivity and specificity to be 8 degrees for underweight patients, 7 degrees for normal-weight patients, 6 degrees for overweight patients, and 5 degrees for obese patients.

CONCLUSIONS

Obese patients presented with larger thoracic curves versus normal-weight patients. Differences in chest-wall thickness in patients with different BMI values may alter scoliometer measurements for a given rotational deformity. Our data suggest new referral criteria for the scoliometer test based on BMI values. Specifically, obese patients should be referred at an angle of trunk rotation of 5 degrees.

LEVEL OF EVIDENCE

Level II.

Postural habits and weight of backpacks of Portuguese adolescents: Are they associated with scoliosis and low back pain?

BACKGROUND

The adoption of incorrect postures or carrying overweight backpacks may contribute to the development of musculoskeletal disorders in school children.

OBJECTIVE

This study evaluated the weight of backpacks and the postural habits adopted in schools by Portuguese adolescents, and their association with scoliosis and low back pain (LBP).

METHOD

The sample comprised 966 Portuguese students, aged between 10 and 16 years. The instruments included a questionnaire to characterize the presence of LBP and the postural habits adopted by students, the weighing of backpacks and a scoliometer to evaluate scoliosis.

RESULTS

No association was observed between assuming incorrect postures and carrying overweight backpacks, in students with scoliosis. Students who adopted incorrect sitting postures had 1.77 times the risk (95% CI: 1.32-2.36; p < 0.001) of developing LBP; those positioned incorrectly whilst watching TV and playing games had 1.44 times the risk (95% CI: 1.08-1.90; p = 0.012) of developing LBP; and those standing incorrectly had 2.39 the risk (95% CI: 1.52-3.78; p < 0.001) of developing LBP.

CONCLUSIONS

The results revealed that students who sat with the spine positioned wrongly, as well as those who were standing incorrectly, were more likely to present with LBP.

Clinical assessment of subacromial shoulder impingement - Which factors differ from the asymptomatic population?

BACKGROUND

To date, the significance of factors purported to be associated with subacromial shoulder impingement (SSI) and what differences, if any, are present in those with SSI compared to a matched asymptomatic population has not been identified. Gaining information about differences between people with SSI and asymptomatic people may direct clinicians towards treatments that impact upon these differences.

OBJECTIVE

Compare the assessment findings of factors suggested to be associated with SSI; passive posterior shoulder range, passive internal rotation range, resting cervical and thoracic postures, active thoracic range in standing and scapula positioning between cases experiencing SSI and a matched asymptomatic group (controls).

STUDY DESIGN

Case Control Study.

METHOD

Fifty one SSI cases and 51 asymptomatic controls were matched for age, gender, hand dominance and physical activity level. The suggested associated factors were measured bilaterally. Independent t-tests were used to compare each of these measurements between the groups. Any variables for which a significant difference was identified, were then included in a conditional logistic regression analysis to identify independent predictors of SSI.

RESULTS

The SSI group had significantly increased resting thoracic flexion and forward head posture, as well as significantly reduced upper thoracic active motion, passive internal rotation range and posterior shoulder range than the matched asymptomatic group. No independent predictors of SSI were identified in conditional logistic regression analysis.

CONCLUSION

Thoracic posture, passive internal rotation range and posterior shoulder range were significantly different between cases experiencing SSI and a matched asymptomatic group.

LEVEL OF EVIDENCE

Level 3a.

Scoliosis screening results of primary school students (11-15 years old group) in the west side of Istanbul

[Purpose] The present study aimed to find out the scoliosis prevalence 11–15 years old children and to create awareness about scoliosis. [Subjects and Methods] All of the children were assessed using the Adams Forward Bendings Test and a scoliometer. Sagittal plane changes such as kyphosis, lordosis, hypokyphosis, hypolordosis and anterior head tilt were screened. Children with trunk rotation angles (ATR) of 4 degrees or more were suspected of having scoliosis, and were evaluated for a second time for gibbosity height, arm-trunk distance, and ATR. [Results] A total of 2,207 children were screened and the evaluation revealed there were 11 girls (0.49%) with a Cobb angle of 10 degrees and more. The maximum Cobb angle was 43° (right thoracic-left lumbar) and the maximum ATR was 12°. Two children had kyphosis and lordosis, and one had hypokyphosis and was diagnosed as having idiopathic scoliosis. [Conclusion] Families should regularly check their children, even if they are not diagnosed as having scoliosis in school screenings. It is our opinion that our study increased the awareness of the families about scoliosis by screening, brochures and posters. In the future, if school screenings were performed as a routine procedure and scoliotic students were followed over the long term, the actual effectiveness of screening would be able to be detected.

To screen or not to screen for adolescent idiopathic scoliosis? A review of the literature

OBJECTIVES

Over the years, there has been much debate about the desirability and efficacy of screening for adolescent idiopathic scoliosis. To analyse the current evidence from a public health point of view a renewed evaluation of the literature was performed.

STUDY DESIGN

Literature review.

METHODS

We performed two literature searches: from January 2000 to April 2015 for systematic reviews or guidelines on screening for adolescent idiopathic scoliosis and from January 2009 to April 2015 for all studies on adolescent idiopathic scoliosis and screening methods. We evaluated if screening for adolescent idiopathic scoliosis fulfils the criteria of the UK National Screenings Committee for appraising a screening programme.

RESULTS

Adolescent idiopathic scoliosis is a condition with an unpredictable natural history. The optimal age and frequency of screening are unknown; it is not possible to predict which patients will need (conservative or surgical) treatment. The Forward Bending Test has a positive predictive value of 2.6% and a sensitivity of 56% (95% CI 23-88%) for (conservative or surgical) treatment, and is therefore not valid enough for use in a screening programme. There seems to be sufficient evidence that brace treatment is effective for preventing progression of adolescent idiopathic scoliosis. It is not clear if screening is cost effective.

CONCLUSIONS

Despite evidence that brace treatment is effective for preventing progression of adolescent idiopathic scoliosis, the benefits from the screening programme do not outweigh the harms. From a Public Health point of view, there is not enough evidence to support a screening programme for adolescent idiopathic scoliosis.

Evaluation of idiopathic scoliosis by anterior and posterior arthrodesis

<sec><title>OBJECTIVE:</title><p> To evaluate comparatively surgical treatment of adolescent idiopathic scoliosis type 5CN by anterior and posterior approach.</p></sec><sec><title>METHODS:</title><p> The study consists of a comparative retrospective study of two groups of patients with the thoracolumbar spine arthrodesis technique by anterior and posterior approach. Twenty and two patients were sequentially selected, 11 operated by anterior approach - called Group I - and 11 by posterior approach - Group II. Anamnesis and physical examination were performed, as well as length of hospital stay and ICU stay, degree of correction, comorbidities and pre and postoperative radiographic images data were gathered.</p></sec><sec><title>RESULTS:</title><p> The mean age was 13.7 years in Group I and 14 years in Group II. The average hospital stay was 5.81 days for Group I and 5 for Group II. The average ICU stay was 2.81 and 2 days, respectively. Considering the operated levels, Group I presented an average of 4.81 vertebrae (4-6 levels), and Group II presented an average of 6.36 vertebrae (5-11 levels). Complications did not show statistically significant difference.</p></sec><sec><title>CONCLUSION:</title><p> Despite the limited number of patients in groups, it was demonstrated that the posterior approach reduces the number of days of hospitalization and ICU stay. However, it was found increased levels included in the arthrodesis.</p></sec>

Idiopathic Scoliosis Prevalence Is 5 Times Less in Roma Than Greek Children and Adolescents

STUDY DESIGN

Serial screening of Roma children for idiopathic scoliosis.

OBJECTIVE

To confirm or reject the observation that the prevalence of scoliosis is reduced in the Roma population and possibly to explain it.

MATERIALS AND METHODS

The authors conducted serial screening for idiopathic scoliosis of 1,034 indigenous Roma children (542 boys and 492 girls), aged 4-18 years (857 children were aged 8-18 years) from 1997 to 2011. Age, height, weight, body mass index, years of schooling, and menarche for girls were recorded. Children were clinically examined for body asymmetries and a standing posteroanterior spinal radiograph was obtained in selected cases.

RESULTS

Sixty Roma children (6%) had clinical humps. Single humps, according to location, were mostly benign and not related to progressive scoliotic curves. In children with right thoracic humps a left lumbar component could be overlooked. Of 60 children, only 4 (3 girls and 1 boy) with right thoracic and left lumbar or thoracolumbar humps had true progressive scoliotic curves with greater than 10° Cobb angle (prevalence rate, 0.35%). This is 5 times less than the rate of 1.5% in Greek children. One of these 4 children was young and had possible congenital scoliosis; the other 3 were early adolescents.

CONCLUSIONS

A substantial difference in the prevalence of scoliosis between Roma and Greek children was documented. The usual percentage of adolescent scoliosis found in the Greek population (approximately 15-17 cases/1,000 children) was not seen in this sample of Roma children.

Validity and reliability of the iPhone to measure rib hump in scoliosis

STUDY DESIGN

This was a prospective blinded validity and reliability analysis.

OBJECTIVE

The aim of this study was validation and reliability evaluation of the Scoligauge iPhone app.

BACKGROUND

The scoliometer is used to clinically measure the rib hump in scoliosis as a means to evaluate the axial trunk rotation. The increasing availability of smartphone with built-in accelerometer led to the development of a vast number of applications to measure angles. Of these, the Scoligauge mimics a scoliometer. The aim of this study was to compare the validity of the Scoligauge iPhone application without an associated adapter with the traditional scoliometer and to test the reliability of the application in a clinical setting.

METHODS

Two observers measured the rib hump deformity on 34 consecutive patients with idiopathic scoliosis with an average Cobb angle of 24.2 ± 13.5 degrees (range, 4 to 65 degrees). Measurements were made with an iPhone without the adapter and with a scoliometer. The validity as well as the interobserver and intraobserver reliability were calculated using the intraclass coefficient (ICC) and the Bland-Altman test.

RESULTS

The mean difference between the scoliometer and the Scoligauge application was 0.4 degrees [95% confidence interval (CI) of ± 3.1 degrees] with an ICC of 0.947 (P < 0.001). The intraobserver and interobserver ICC were 0.961 (P < 0.001) and 0.901 (P < 0.001), respectively. The mean intraobserver difference was 0.0 degrees (95% CI of ± 2.7 degrees) and the mean interobserver difference was 0.1 degrees (95% CI of ± 4.4 degrees).

CONCLUSIONS

The intraobserver and interobserver reliability of the Scoligauge iPhone app, as well as its validity compared with the scoliometer, are excellent. The mean differences between measurements are small and clinically not significant. Thus, the Scoligauge application is valid for clinical evaluation even without special adapter.

LEVEL OF EVIDENCE

Level I (Diagnostic Study).