The Influence of Body Habitus on Documented Brace Wear and Progression in Adolescents With Idiopathic Scoliosis

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.

The Sanders Classification and Obesity: Do Obese Kids With AIS Present With More Advanced Skeletal Maturity?

INTRODUCTION

Obese and overweight (OOW) patients with adolescent idiopathic scoliosis (AIS) have been shown to initially present with a more advanced Risser score compared to normal weight (NW) patients. The Sanders Maturity Scale (SMS) is now more commonly used by surgeons to assist with treatment decisions because it more reliably predicts skeletal maturity. However, the relationship between SMS and obesity has not been described. We hypothesize that in patients with AIS, OOW patients will have a higher SMS score on initial presentation when compared to NW patients.

METHODS

Billing data from 2 different institutions were used to identify patients with AIS presenting to a pediatric orthopaedic spine surgeon for an initial visit between July 2012 and March 2020. We excluded those without height/weight data, spine radiographs, or left-hand radiographs for measuring SMS stage. Body mass index-for-age percentiles were calculated and used to group patients into NW (<85th percentile) or OOW (85th percentile and above) per Centers for Disease Control guidelines. After collecting preliminary data, a power analysis was performed using average SMS scores between NW and OOW patients with an alpha of 0.5, determining a needed sample size of approximately 300 male and 300 female subjects.

RESULTS

Five hundred ninety patients (296 female, 294 male) were identified. The SMS stage at presentation was significantly greater in OOW compared to NW patients for both females (5.9±1.8 vs. 5.2±1.7; P =0.003) and males (4.9±1.9 vs. 4.1±1.8; P =0.002). The major curve magnitude for OOW females was significantly different from NW females (36±16 degrees vs. 30±16 degrees; P =0.004). The major curve magnitude was not different for OOW and NW males ( P =0.3).

CONCLUSION

At initial presentation, OOW patients present at a greater skeletal maturity as measured by the SMS compared with NW patients. OOW female patients present with a greater major curve magnitudes than NW female patients. These results highlight negative implications of the pediatric obesity epidemic as it relates to the AIS population. These findings can be used to counsel families and provide anticipatory guidance for the AIS treatment plan.

LEVEL OF EVIDENCE

Level III-cross-sectional study.

Influence of Specific Interventions on Bracing Compliance in Adolescents with Idiopathic Scoliosis-A Systematic Review of Papers Including Sensors' Monitoring

Adolescent idiopathic scoliosis (AIS) is a common disease that, in many cases, can be conservatively treated through bracing. High adherence to brace prescription is fundamental to gaining the maximum benefit from this treatment approach. Wearable sensors are available that objectively monitor the brace-wearing time, but their use, combined with other interventions, is poorly investigated. The aims of the current review are as follows: (i) to summarize the real compliance with bracing reported by studies using sensors; (ii) to find out the real brace wearing rate through objective electronic monitoring; (iii) to verify if interventions made to increase adherence to bracing can be effective according to the published literature. We conducted a systematic review of the literature published on Medline, EMBASE, CINAHL, Scopus, CENTRAL, and Web of Science. We identified 466 articles and included examples articles, which had a low to good methodological quality. We found that compliance a greatly varied between 21.8 and 93.9% (weighted average: 58.8%), real brace wearing time varied between 5.7 and 21 h per day (weighted average 13.3), and specific interventions seemed to improve both outcomes, with compliance increasing from 58.5 to 66% and brace wearing increasing from 11.9 to 15.1 h per day. Two comparative studies showed positive effects of stand-alone counseling and information on the sensors' presence when added to counseling. Sensors proved to be useful tools for objectively and continuously monitoring adherence to therapy in everyday clinical practice. Specific interventions, like the use of sensors, counseling, education, and exercises, could increase compliance. However, further studies using high-quality designs should be conducted in this field.

Association between body mass index and posterior spine fusion among patients with adolescent idiopathic scoliosis

INTRODUCTION

Previous studies have found mixed associations between body mass index (BMI) and adolescent idiopathic scoliosis (AIS) incidence and progression. The aim of this study was to examine the association between BMI and the incidence of posterior spine fusion (PSF) among pediatric patients with AIS.

METHODS

This was a retrospective cohort study of patients diagnosed with AIS at a single large tertiary care center between January 1, 2014 and December 31, 2020. BMI-for-age percentiles were used to categorize BMI into four categories: underweight (<5th percentile), healthy weight (≥5th to <85th percentile), overweight (≥85th to <95th percentile), and obese (≥95th percentile). Chi-square and t-tests were used to compare distributions of baseline characteristics by incident PSF outcome status. Multivariable logistic regression assessed the association between BMI category at baseline and incident PSF adjusting for sex, age at diagnosis, race/ethnicity, health insurance type, vitamin D supplementation, and low vitamin D levels.

RESULTS

A total of 2,258 patients met the inclusion criteria with 2,113 patients (93.6%) who did not undergo PSF during the study period and 145 patients (6.4%) who did undergo PSF. At baseline, 7.3% of patients were categorized as underweight, 73.2% were healthy weight, 10.2% were overweight, and 9.3% were obese. Compared to those in the healthy weight group, there was no significant association between PSF and being underweight (adjusted odds ratio [AOR] 1.64, 95% CI 0.90-2.99, p = 0.107), being overweight (AOR 1.25, 95% CI 0.71-2.20, p = 0.436), or being obese (AOR 1.19, 95% CI 0.63-2.27, p = 0.594).

CONCLUSIONS

This study did not find a statistically significant association between underweight, overweight, or obese BMI category and incident PSF among patients with AIS. These findings add to the current mixed evidence on the relationship between BMI and surgical risk and may support the recommendation of conservative treatment to patients regardless of BMI.

The Insidious Effects of Childhood Obesity on Orthopedic Injuries and Deformities

The current childhood obesity epidemic, affecting approximately 20% of American children and adolescents, is accompanied by unique orthopedic manifestations. The growing musculoskeletal system is susceptible to the endocrine effects of obesity, resulting in decreased bone mass and quality. As a result, obese children are at increased risk of musculoskeletal injury, fracture, and lower extremity deformities. The efficacy of nonoperative treatment such as casting or bracing may be limited by body habitus and surgical treatment is accompanied by increased risk of perioperative complications.

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.

Ethnic Disparity in the Incidence of Scoliosis Among Adolescents in Tianzhu Tibetan Autonomous County, China

Objectives

To determine the influence of ethnic disparities, socioeconomic status (SES) and hukou on the incidence of scoliosis.

Methods

We enrolled 2,445 junior high school students (Han: 1,153; ethnic minorities: 1,292) aged 12–16 years from two schools in Tianzhu Tibetan Autonomous County, Gansu Province from November 2020 to February 2021. We measured the angle of trunk rotation (ATR) using a scoliometer. Two-factor analysis of variance was used to comparatively analyze differences in the ATR according to ethnicity, age, sex, body mass index (BMI), and SES between the groups. Associations between risk factors and scoliosis were estimated using odds ratios and 95% confidence intervals with an unconditional multivariate logistic regression model for the two groups.

Results

Adolescents with Han ethnicity were more likely to have scoliosis than their ethnic minority counterparts (10.8% vs. 7.1%, P < 0.05). The ATR value in the Han group decreased with age whereas the minority group showed an upward trend (P < 0.05). The difference between ethnic groups was not significant, only at level 3. In particular, the ATR values among Han girls were significantly higher than those of ethnic minority girls (P < 0.05). Compared with Han adolescents, the BMI of ethnic minorities had a greater impact on the ATR. A statistically significant difference in SES was found between the two ethnic groups (P < 0.05). Hukou and parents' occupation had an important influence on the onset of scoliosis.

Conclusions

Han adolescents had higher ATR values and were more likely to have scoliosis than ethnic minority adolescents in our study. Growth and development indicators (height and BMI) and differences in SES between the two groups played an important role.

Supine correction index as a predictor for brace outcome in adolescent idiopathic scoliosis

Aims

The aim of this study was to assess the ability of morphological spinal parameters to predict the outcome of bracing in patients with adolescent idiopathic scoliosis (AIS) and to establish a novel supine correction index (SCI) for guiding bracing treatment.

Methods

Patients with AIS to be treated by bracing were prospectively recruited between December 2016 and 2018, and were followed until brace removal. In all, 207 patients with a mean age at recruitment of 12.8 years (SD 1.2) were enrolled. Cobb angles, supine flexibility, and the rate of in-brace correction were measured and used to predict curve progression at the end of follow-up. The SCI was defined as the ratio between correction rate and flexibility. Receiver operating characteristic (ROC) curve analysis was carried out to assess the optimal thresholds for flexibility, correction rate, and SCI in predicting a higher risk of progression, defined by a change in Cobb angle of ≥ 5° or the need for surgery.

Results

The baseline Cobb angles were similar (p = 0.374) in patients whose curves progressed (32.7° (SD 10.7)) and in those whose curves remained stable (31.4° (SD 6.1)). High supine flexibility (odds ratio (OR) 0.947 (95% CI 0.910 to 0.984); p = 0.006) and correction rate (OR 0.926 (95% CI 0.890 to 0.964); p < 0.001) predicted a lower incidence of progression after adjusting for Cobb angle, Risser sign, curve type, menarche status, distal radius and ulna grading, and brace compliance. ROC curve analysis identified a cut-off of 18.1% for flexibility (sensitivity 0.682, specificity 0.704) and a cut-off of 28.8% for correction rate (sensitivity 0.773, specificity 0.691) in predicting a lower risk of curve progression. A SCI of greater than 1.21 predicted a lower risk of progression (OR 0.4 (95% CI 0.251 to 0.955); sensitivity 0.583, specificity 0.591; p = 0.036).

Conclusion

A higher supine flexibility (18.1%) and correction rate (28.8%), and a SCI of greater than 1.21 predicted a lower risk of progression. These novel parameters can be used as a guide to optimize the outcome of bracing.

Cite this article: Bone Joint J 2022;104-B(4):495–503.

Impact of body mass index on the initial in-brace correction in patients with idiopathic scoliosis

Background/Aim: Many factors affect initial in-brace correction and treatment outcome in patients with idiopathic scoliosis. Previous studies have observed contradictory results on the role of BMI in orthotic treatment. The aim of this study was to examine whether BMI impacts in-brace correction, isolated and in relation to other predictive factors (curve magnitude, curve location and Risser sign). Methods: A retrospective study has been conducted on patients with idiopathic scoliosis treated with Cheneau-Sobernheim brace, that had no prior treatment. The collected and analysed data included patient demographics, BMI percentile and radiological parameters (curve magnitude in Cobb angle, curve location, Risser sign). The initial in-brace correction was expressed as a percentage of Cobb angle reduction in the brace as opposed to Cobb angle out of brace. Patients were categorised into groups according to their BMI, expressed in percentiles, ie: low BMI (< 5 percentiles), normal BMI (5-85 percentiles) and high BMI (> 85 percentiles). To determine the significant difference and correlation relationship between the examined variables, variance tests, t-test with unequal variance, and Pearson correlation coefficient have been used. Results: The cohort study comprised 213 patients (170 females and 43 males) with a mean age of 13.5 years at brace prescription. Low BMI has been detected in 10 % patients, normal BMI in 78 % and high BMI in 10 % patients. No significant difference in in-brace correction has been found between BMI groups, nor has there been any significant correlation between BMI and in-brace correction. Regarding other factors, significant difference within BMI groups was found between in-brace correction and curve location, as well as in-brace correction and Risser sign. Lumbar curves had significantly better in-brace correction than thoracic curves. Significant correlations between in-brace correction and curve magnitude, curve location and Risser sign were detected. Conclusion: The results of the present study show that, as an independent factor, BMI does not impact in-brace correction. Other factors, such as curve magnitude, curve location and Risser sign, play a more significant role in the orthotic treatment of patients with idiopathic scoliosis.

Supine flexibility predicts curve progression for patients with adolescent idiopathic scoliosis undergoing underarm bracing

Aims

The aim of this study was to assess whether supine flexibility predicts the likelihood of curve progression in patients with adolescent idiopathic scoliosis (AIS) undergoing brace treatment.

Methods

This was a retrospective analysis of patients with AIS prescribed with an underarm brace between September 2008 to April 2013 and followed up until 18 years of age or required surgery. Patients with structural proximal curves that preclude underarm bracing, those who were lost to follow-up, and those who had poor compliance to bracing (<16 hours a day) were excluded. The major curve Cobb angle, curve type, and location were measured on the pre-brace standing posteroanterior (PA) radiograph, supine whole spine radiograph, initial in-brace standing PA radiograph, and the post-brace weaning standing PA radiograph. Validation of the previous in-brace Cobb angle regression model was performed. The outcome of curve progression post-bracing was tested using a logistic regression model. The supine flexibility cut-off for curve progression was analyzed with receiver operating characteristic curve.

Results

A total of 586 patients with mean age of 12.6 years (SD 1.2) remained for analysis after exclusion. The baseline Cobb angle was similar for thoracic major curves (31.6° (SD 3.8°)) and lumbar major curves (30.3° (SD 3.7°)). Curve progression was more common in the thoracic curves than lumbar curves with mean final Cobb angles of 40.5° (SD 12.5°) and 31.8° (SD 9.8°) respectively. This dataset matched the prediction model for in-brace Cobb angle with less mean absolute error in thoracic curves (0.61) as compared to lumbar curves (1.04). Reduced age and Risser stage, thoracic curves, increased pre-brace Cobb angle, and reduced correction and flexibility rates predicted increased likelihood of curve progression. Flexibility rate of more than 28% has likelihood of preventing curve progression with bracing.

Conclusion

Supine radiographs provide satisfactory prediction for in-brace correction and post-bracing curve magnitude. The flexibility of the curve is a guide to determine the likelihood for brace success. Cite this article: Bone Joint J 2020;102-B(2):254–260.