TRACE (Trunk Aesthetic Clinical Evaluation), a routine clinical tool to evaluate aesthetics in scoliosis patients: development from the Aesthetic Index (AI) and repeatability

Physiotherapeutic Scoliosis-Specific Exercises (PSSE-Schroth) can reduce the risk for progression during early growth in curves below 25°: prospective control study

BACKGROUND

The main treatment aim in mild scoliosis is to prevent progression and if possible, to avoid bracing. Physiotherapeutic Scoliosis Specific Exercises (PSSE) are curve pattern specific exercises, based on 3D self-correction and activities of daily living training.

AIM

The objective of this study was to evaluate the efficacy of PSSE - Schroth, as an exclusive treatment, during the riskiest period of rapid growth.

DESIGN

Prospective control study.

SETTING

Outpatient treatment.

POPULATION

Adolescents with scoliosis.

METHODS

One hundred and sixty-three patients (148 girls,15 boys; mean age 12.6 years, Risser sign 1.1, thoracic (Th) Cobb angle 20.8° and lumbar/thoracolumbar (L/TL) Cobb angle 20.7°) performed PSSE - Schroth exercises in our clinic. They were asked to regularly attend supervised sessions and to follow a home-program at least 5 times per week. Our inclusion criteria were Cobb angle 15°-25°, Risser 0-2 and angle trunk rotation (ATR) >5°, measured by scoliometer. The outcome parameters were the Cobb angle before and after the intervention (improvement or progression were defined as angle difference more than 5°) and the number of patients that finally needed a brace. Average follow-up time was 29.4 months. Control group was consisted of 58 patients (54 girls, 4 boys; mean age 13.1 years, Risser sign 0-2, Th Cobb 19.4°, L/TL Cobb 19.2°), that were retrospectively analyzed and performed general or no exercises. Compliance was self-reported. Statistical analysis was performed by paired t-test.

RESULTS

For PSSE - Schroth group, 103 patients (63.2%) remained stable, 39 (23.9%) improved and 21 (12.9%) worsened. The success rate (87.1%) was significantly higher compared to Control group (P=0.002), where 15 subjects (25.9%) were stable and 43 (74.1%) worsened. Similarly, 16 patients (9.8%) from PSSE - Schroth group finally needed a brace, while 39 (67.2%) from control group (P=0.01).

CONCLUSIONS

PSSE - Schroth reduced the risk of progression in Adolescent Idiopathic Scoliosis (AIS) patients, during early growth. Our results are in accordance with the recently published literature, showing the effectiveness of PSSE and their superiority compared to general exercises or natural history.

CLINICAL REHABILITATION IMPACT

Scoliosis specific exercises can be the first step of scoliosis treatment in mild curves, to avoid progression and bracing.

Therapeutic exercises for idiopathic scoliosis in adolescents

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is a pathology that changes the three-dimensional shape of the spine and trunk. While AIS can progress during growth and cause cosmetic issues, it is usually asymptomatic. However, a final spinal curvature above the critical threshold of 30° increases the risk of health problems and curve progression in adulthood. The use of therapeutic exercises (TEs) to reduce the progression of AIS and delay or avoid other, more invasive treatments is still controversial.

OBJECTIVES

To evaluate the effectiveness of TE, including generic therapeutic exercises (GTE) and physiotherapeutic scoliosis-specific exercises (PSSE) in treating AIS, compared to no treatment, other non-surgical treatments, or between treatments.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, four other databases, and two clinical trials registers to 17 November 2022. We also screened reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing TE with no treatment, other non-surgical treatments (braces, electrical stimulation, manual therapy), and different types of exercises. In the previous version of the review, we also included observational studies. We did not include observational studies in this update since we found sufficient RCTs to address our study aims.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology. Our major outcomes were progression of scoliosis (measured by Cobb angle, trunk rotation, progression, bracing, surgery), cosmetic issues (measured by surface measurements and perception), and quality of life (QoL). Our minor outcomes were back pain, mental health, and adverse effects.

MAIN RESULTS

We included 13 RCTs (583 participants). The percentage of females ranged from 50% to 100%; mean age ranged from 12 to 15 years. Studies included participants with Cobb angles from low to severe. We judged 61% of the studies at low risk for random sequence generation and 46% at low risk for allocation concealment. None of the studies could blind participants and personnel. We judged the subjective outcomes at high risk of performance and detection bias, and the objective outcomes at high risk of detection bias in six studies and at low risk of bias in the other six studies. One study did not assess any objective outcomes. Comparing TE versus no treatment, we are very uncertain whether TE reduces the Cobb angle (mean difference (MD) -3.6°, 95% confidence interval (CI) -5.6 to -1.7; 2 studies, 52 participants). Low-certainty evidence indicates PSSE makes little or no difference in the angle of trunk rotation (ATR) (MD -0.8°, 95% CI -3.8 to 2.1; 1 study, 45 participants), may reduce the waist asymmetry slightly (MD -0.5 cm, 95% CI -0.8 to -0.3; 1 study, 45 participants), and may result in little to no difference in the score of cosmetic issues measured by the Spinal Appearance Questionnaire (SAQ) General (MD 0.7 points, 95% CI -0.1 to 1.4; 1 study, 16 participants). PSSE may result in little to no difference in self-image measured by the Scoliosis Research Society - 22 Patient Questionnaire (SRS-22) (MD 0.3 points, 95% CI -0.3 to 0.9; 1 study, 16 participants) and improve QoL slightly measured by SRS-22 Total score (MD 0.3 points, 95% CI 0.1 to 0.4; 2 studies, 61 participants). Only Cobb angle results were clinically meaningful. Comparing PSSE plus bracing versus bracing, low-certainty evidence indicates PSSE plus bracing may reduce Cobb angle (-2.2°, 95% CI -3.8 to -0.7; 2 studies, 84 participants). Comparing GTE plus other non-surgical interventions versus other non-surgical interventions, low-certainty evidence indicates GTE plus other non-surgical interventions may reduce Cobb angle (MD -8.0°, 95% CI -11.5 to -4.5; 1 study, 80 participants). We are uncertain whether PSSE plus other non-surgical interventions versus other non-surgical interventions reduces Cobb angle (MD -7.8°, 95% CI -12.5 to -3.1; 1 study, 18 participants) and ATR (MD -8.0°, 95% CI -12.7 to -3.3; 1 study, 18 participants). PSSE plus bracing versus bracing alone may make little to no difference in subjective measurement of cosmetic issues as measured by SAQ General (-0.2 points, 95% CI -0.9 to 0.5; 1 study, 34 participants), self-image score as measured by SRS-22 Self-Image (MD 0.1 points, 95% CI -0.3 to 0.5; 1 study, 34 participants), and QoL measured by SRS-22 Total score (MD 0.2 points, 95% CI -0.1 to 0.5; 1 study, 34 participants). None of these results were clinically meaningful. Comparing TE versus bracing, we are very uncertain whether PSSE allows progression of Cobb angle (MD 2.7°, 95% CI 0.3 to 5.0; 1 study, 60 participants), changes self-image measured by SRS-22 Self-Image (MD 0.1 points, 95% CI -1.0 to 1.1; 1 study, 60 participants), and QoL measured by SRS-22 Total score (MD 3.2 points, 95% CI 2.1 to 4.2; 1 study, 60 participants). None of these results were clinically meaningful. Comparing PSSE with GTE, we are uncertain whether PSSE makes little or no difference in Cobb angle (MD -3.0°, 95% CI -8.2 to 2.1; 4 studies, 192 participants; very low-certainty evidence). PSSE probably reduces ATR (clinically meaningful) (MD -3.0°, 95% CI -3.4 to -2.5; 2 studies, 138 participants). We are uncertain about the effect of PSSE on QoL measured by SRS-22 Total score (MD 0.26 points, 95% CI 0.11 to 0.62; 3 studies, 168 participants) and on self-image measured by SRS-22 Self-Image and Walter Reed Visual Assessment Scale (standardised mean difference (SMD) 0.77, 95% CI -0.61 to 2.14; 3 studies, 168 participants). Further, low-certainty evidence indicates that 38/100 people receiving GTE may progress more than 5° Cobb versus 7/100 receiving PSSE (risk ratio (RR) 0.19, 95% CI -0.67 to 0.52; 1 study, 110 participants). None of the included studies assessed adverse effects.

AUTHORS' CONCLUSIONS

The evidence on the efficacy of TE is currently sparse due to heterogeneity, small sample size, and many different comparisons. We found only one study following participants to the end of growth showing the efficacy of PSSE over TE. This result was weakened by adding studies with short-term results and unclear preparation of treating physiotherapists. More RCTs are needed to strengthen the current evidence and study other highly clinically relevant outcomes such as QoL, psychological and cosmetic issues, and back pain.

A New Clinical Tool for Scoliosis Risk Analysis: Scoliosis Tele-Screening Test

STUDY DESIGN

Methodological, observational clinical study.

PURPOSE

This study aimed to develop a virtual screening test to detect scoliosis risk initially by parents without the need for medical visit during the coronavirus disease 2019 pandemic.

OVERVIEW OF LITERATURE

The scoliosis screening program has been implemented to early detect scoliosis. Unfortunately, access to health professionals was limited during the pandemic. However, during this time, interest in telemedicine has increased remarkably. Recently, mobile applications related to postural analysis were developed, but none permits evaluation by parents.

METHODS

Researchers developed the Scoliosis Tele-Screening Test (STS-Test), which included drawing-based images of body asymmetries, to assess the scoliosis-associated risk factors. The STS-Test was shared on social networks, allowing the parents to evaluate their children. After test completion, the risk score was generated automatically, and children with medium and high risks were then advised for medical consultation for further evaluation. The test accuracy and consistency between the clinician and parents were also analyzed.

RESULTS

Of the 865 tested children, 358 (41.4%) consulted clinicians to confirm their STS-Test results. Scoliosis was then confirmed in 91 children (25.4%). The parents were able to detect asymmetry in 50% of the lumbar/thoracolumbar curvatures and 82% of the thoracic curvatures. In addition, the forward bend test revealed favorable agreement between parents and clinicians (r =0.809, p<0.0005). Internal consistency of the esthetic deformities domain in the STS-Test was also excellent (α=0.901). This tool was 94.97% accurate, 83.51% sensitive, and 98.87% specific.

CONCLUSIONS

The STS-Test is a new parent-friendly, virtual, cost-effective, result-oriented, and reliable tool for scoliosis screening. It allows parents to actively participate in the early detection of scoliosis by screening their children for the risk of scoliosis periodically without the need to visit the health institution.

Development and validation of a semi-automated measurement tool for calculating consistent and reliable surface metrics describing cosmesis in Adolescent Idiopathic Scoliosis

Adolescent Idiopathic Scoliosis (AIS) is a 3D spine deformity that also causes ribcage and torso distortion. While clinical metrics are important for monitoring disorder progression, patients are often most concerned about their cosmesis. The aim of this study was to automate the quantification of AIS cosmesis metrics, which can be measured reliably from patient-specific 3D surface scans (3DSS). An existing database of 3DSS for pre-operative AIS patients treated at the Queensland Children's Hospital was used to create 30 calibrated 3D virtual models. A modular generative design algorithm was developed on the Rhino-Grasshopper software to measure five key AIS cosmesis metrics from these models-shoulder, scapula and hip asymmetry, torso rotation and head-pelvis shift. Repeat cosmetic measurements were calculated from user-selected input on the Grasshopper graphical interface. InterClass-correlation (ICC) was used to determine intra- and inter-user reliability. Torso rotation and head-pelvis shift measurements showed excellent reliability (> 0.9), shoulder asymmetry measurements showed good to excellent reliability (> 0.7) and scapula and hip asymmetry measurements showed good to moderate reliability (> 0.5). The ICC results indicated that experience with AIS was not required to reliably measure shoulder asymmetry, torso rotation and head-pelvis shift, but was necessary for the other metrics. This new semi-automated workflow reliably characterises external torso deformity, reduces the dependence on manual anatomical landmarking, and does not require bulky/expensive equipment.

Reliability and Validity of Scoliosis Measurements Obtained with Surface Topography Techniques: A Systematic Review

BACKGROUND

Surface topography (ST) is one of the methods in scoliosis assessment. This study aimed to systematically review the reliability and validity of the ST measurements for assessing scoliosis.

METHODS

A literature search of four databases was performed and is reported following PRISMA guidelines. The methodological quality was evaluated using Brink and Louw appraisal tool and data extraction was performed. The results were analyzed and synthesized qualitatively using the level of evidence method.

RESULTS

Eighteen studies were included and analyzed. Four were evaluated for reliability, six for validity, and eight for reliability and validity. The methodological quality of fourteen studies was high. Good to excellent intra-investigator reliability was shown on asymmetry, sagittal, horizontal, and most frontal ST measurements (evidence level: strong). Asymmetry and most frontal, sagittal, horizontal ST measurements showed good to excellent inter-investigator reliability (evidence level: moderate). When comparing corresponding ST and radiological measurements, good to strong validity was shown on most frontal, sagittal, and asymmetry measurements (evidence level: strong). Formetric measurements had good intra-investigator reliability and validity (evidence level: strong).

CONCLUSIONS

Most asymmetry, sagittal, and frontal ST measurements showed satisfactory reliability and validity. Horizontal ST measurements showed good reliability and poor validity. The ST technique may have great potential in assessing scoliosis, especially in reducing radiation exposure and performing cosmetic assessments.

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.

Impact of the Free-Pelvis Innovation in Very Rigid Braces for Adolescents with Idiopathic Scoliosis: Short-Term Results of a Matched Case-Control Study

We introduced pelvis semi-rigid material (ethylene vinyl acetate) (Free-Pelvis) to improve the comfort and adaptability of very rigid braces (VRBs) for adolescents with idiopathic scoliosis (AIS), but this can also negatively impact the corrective forces on the trunk. Study Design: This was a matched retrospective cohort study. The inclusion criteria were AIS, age 10–16, VRB 23 h/day, X-rays available, primary curve 36°–65°, and angle of trunk rotation 7–23°. The cases were Sforzesco VRB with Free-Pelvis (FPB). The controls included classical Sforzesco VRB matched for Risser (range 0/4), menarche age (10/15), weight (33.5/83 kg), height (140/180 cm), BMI (13.5/29 kg/sqm), aesthetics (TRACE 4/12), plumbline distances (S1: −60/35; C7 + L3: −10/115 mm), and referred brace use (22/24 h/day). Statistics: predictors of the results have been tested with linear and logistic regression according to the outcome variable type. We performed logistic regression for improved vs. worsened. The explanatory variable was brace type. We included 777 VRB and 25 FPB, age 13 ± 1, 47° ± 8° Cobb, and 11% men. The few baseline statistical differences were not clinically relevant. We achieved in-brace corrections of 15.2° ± 7.7° and 17.4° ± 6.5° for VRB and FPB, respectively (p = 0.21); out-of-brace corrections at 5 ± 2 months were 7.8° ± 0.2° for VRB and 8.1° ± 1.3° for FPB (p = 0.83). The type of brace did not influence the Cobb angle at either time interval or affect the odds of improvement. Free-Pelvis innovation, introduced to improve comfort and adaptability, does not change the in-brace or short-term results of classical VRB and consequently can be safely applied.

Adolescent idiopathic scoliosis screening: Could a school-based assessment protocol be useful for an early diagnosis?

BACKGROUND

Adolescent idiopathic scoliosis screening still needs a considerable implementation, particularly throughout a school-based assessment protocol.

OBJECTIVE

This study aims to evaluate the effectiveness of clinical examinations currently in use for the diagnosis of adolescent idiopathic scoliosis, through a survey carried out in secondary schools to standardize a screening protocol that could be generalized.

METHODS

In their classrooms, the adolescents underwent an idiopathic scoliosis screening through three examinations: Adam's test, axial trunk rotation (ATR) and plumb line. In case of single positivity to one of the three examinations, a column X-ray examination was recommended.

RESULTS

The sensitivity and diagnostic specificity of Adam's test or ATR were 56.3% and 92.7%, respectively. The positivity to at least one between ATR or plumb line showed that sensitivity was higher than specificity: 91.3% versus 80.8%; the positivity to at least one between Adams's test or plumb line showed a sensitivity of 95.2% and a specificity of 81.5%. Finally, the positivity to all three examinations showed an increase in specificity (99.7%).

CONCLUSIONS

Taken together, our findings show that this school-based screening protocol had a very high specificity in early diagnosis of adolescent idiopathic scoliosis.

Assessment of the reliability of hand-held surface scanner in the evaluation of adolescent idiopathic scoliosis

PURPOSE

Spinal deformities due to adolescent idiopathic scoliosis (AIS) result in impairment in the back surface topography. Sophisticated interventions are needed that address different aspects of deformity. The purpose of our study is to test the reliability of hand-held 3D scanners on the assessment of AIS.

METHODS

Forty-two AIS patients were included in our study. The back surfaces of the patients were scanned with the hand-held 3D scanner, while the patients were in the standing position with the arms hanging at the sides (P1), with the arms extended (P2), and forward bending position (P3). The acquired original image was superimposed with the mirror image. Root mean square (RMS) of the point-to-point distance was calculated, and the differences between the surfaces were determined. Correlation between RMS, Cobb, POTSI, scoliometer, radiographic rotations, TRACE results was calculated.

RESULTS

A significant correlation coefficency (r) was found between the RMS and Cobb values in the thoracic (P1 = 0.80, P2 = 0.76, P3 = 0.71) and lumbal region (P1 = 0.56, P2 = 0.65, P3 = 0.63); between RMS and Raimondi in the thoracic (r, P1 = 0.80, P2 = 0.81, P3 = 0.78) and lumbar regions (P1 = 0.54, P2 = 0.64, P3 = 0.59); between RMS and scoliometer measurements in the thoracic (r, P1 = 0.58, P2 = 0.50, P3 = 0.41) and lumbar regions (P1 = 0.35, P2 = 0.41, P3 = 0.59); in thoracolumbar region between RMS and POTSI (P1 = 0.50, P2 = 0.25, P3= 0.36), between RMS and TRACE (P1 = 0.68, P2 = 0.5, P3 = 0.52), CONCLUSION: The hand-held scanners may contribute to gaining new insight into diagnosis and follow-up of AIS by its mobility that enables the acquisition of data in desired body position and place such as bedside or our patient clinics.

LEVEL OF EVIDENCE IV

Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

Construct validity of the Trunk Aesthetic Clinical Evaluation (TRACE) in young people with idiopathic scoliosis

BACKGROUND

Aesthetics is recognized as a main outcome in idiopathic scoliosis (IS) treatment, but to date, there is no criterion standard for physicians' evaluation. Trunk Aesthetic Clinical Evaluation (TRACE) is a simple 12-point ordinal scale to quantify symmetry as a proxy of aesthetics. TRACE is already diffused worldwide and has been used in clinical research.

OBJECTIVE

We aimed to validate TRACE and improve it with Rasch analysis.

MATERIAL AND METHODS

This study involved an observational Rasch analysis validation of an evaluation tool in outpatient rehabilitation centres. From a clinical database, we randomly selected patients who had IS, were age 10 to 18, had brace prescription at first evaluation, and had at least 2 consultations. Rasch analysis (partial credit model) was used. Differential item functioning (DIF) was assessed for age, sex, disease severity, bracing and treatment. The median was chosen to dichotomize disease severity and bracing. We removed 64 outlier participants (4%).

RESULTS

We included 1553 participants (1334 females; mean [SD] age 13 [1.7] years old). TRACE items showed ordered thresholds and proper fit to the Rasch model. The score-to-measure conversion table showed proper length (range -4.55 to 4.79 logit) with a mean (SE) measure of -0.52 (0.04) logit. The principal component analysis supported the TRACE unidimensionality. The TRACE was free from DIF for age, sex and bracing.

CONCLUSIONS

The TRACE ordinal scale has been converted into a Rasch-consistent, interval-level measure of trunk aesthetics in IS patients and can be used to compare different populations. Its main flaw is low reliability, likely because of the small number of items. TRACE can be used as an outcome measure and in everyday clinical evaluation of IS, even if new developments of the scale are advised.

Actigraphy-based Sleep Parameters and Rest-activity Circadian Rhythm in a Young Scoliotic Patient Treated with Rigid Bracing: A Case Study

The correct expression of circadian rhythmicity, together with a good sleep behavior, are key factors for the body homeostasis. Rest-activity circadian rhythms (RARs) are involved in the control of the sleep-wake cycle and altered RARs could lead to a compromised health status. Therefore, we aimed to investigate the existence of RAR and to study actigraphy-based sleep behavior in a 14-year-old male patient affected by severe idiopathic scoliosis and treated with a rigid brace 23 hours per day. RAR and sleep parameters were studied through actigraphy for seven consecutive days in July 2018. The mean cosinor analysis revealed the presence of a significant RAR (p < 0.001), specifically: the percentage of rhythm was 23.4%, the mean MESOR was 84.6 Activity Count (AC), the amplitude registered a mean value of 74.4 AC's, and the acrophase occurred at 17:56 h. The subject reached a good sleep quantity: 507.9 ± 30.2 minutes of Time in Bed with a mean Total Sleep Time of 450.7 ± 20.1 minutes; Similarly, Sleep Efficiency was equal to 83.3 ± 7.2% and the Fragmentation Index was 27.3 ± 12.8%. We observed that both RAR and sleep behavior had normal trends in a 14-year-old patient treated with a rigid brace for a severe adolescent idiopathic scoliosis (AIS). Improved assessment of sleep in routine clinical practice can help to identify and manage health-related problems that could potentially affect some clinical outcomes, such as pain, mood state, and recovery process.

The Italian Spine Youth Quality of Life questionnaire measures health-related quality of life of adolescents with spinal deformities better than the reference standard, the Scoliosis Research Society 22 questionnaire

OBJECTIVE

To compare the validity of the Italian Spine Youth Quality of Life (ISYQOL) questionnaire with that of the Scoliosis Research Society 22 (SRS22) questionnaire, the criterion standard for health-related quality of life (HRQOL) measurement in adolescents with spinal deformities.

DESIGN

Cross-sectional study.

SETTING

Outpatient clinic.

SUBJECTS

Consecutive adolescents (10-18 years; 541 wearing brace) affected by idiopathic scoliosis (642 females, 100 males) or hyperkyphosis (87 females, 109 males).

INTERVENTIONS

NA.

MAIN MEASURES

The Spearman's correlation coefficient (rho) between ISYQOL and SRS22 was used to assess ISYQOL concurrent validity. Sex, age, severity, bracing, trunk appearance and deformity type were assessed for known-groups validity. Cohen's d quantified between-groups differences. Multiple linear regression exploring the effect of sex, age, body mass index (BMI), severity, bone age, trunk appearance, physiotherapy, bracing and sport on HRQOL of scoliosis patients was used to assess concurrent validity further.

RESULTS

Satisfactory correlations were found between ISYQOL and SRS22 (scoliosis, rho = 0.71; kyphosis, rho = 0.56). Known-groups validity analysis showed that ISYQOL detects all the between-groups differences detected by SRS22 and a males-females difference undetected by SRS22. ISYQOL Cohen's d was larger than SRS22 Cohen's d in three between-groups comparisons and similar in the others. Brace, sport and scoliosis severity were independently related to ISYQOL (linear regression: R² = 0.23; p < 0.001). Brace, sport and physiotherapy were related to SRS22 (R² = 0.17).

CONCLUSIONS

ISYQOL showed high validity when used to measure HRQOL in adolescents with spinal deformities. Moreover, ISYQOL performs better than SRS22, having better known-groups validity and (contrary to SRS22) detecting the impact of disease severity on HRQOL.

A Description of Three-Dimensional Shape of the Posterior Torso Comparing Those with and without Scoliosis

Scoliosis results in a 3D asymmetry of the spine and torso. It is not clear what the variability in 3D shape is in a non-scoliotic population, how much that is altered by scoliosis and what surgery does to that. This study is a 3D analysis of the shape of the torso in a cohort of non-scoliotic children that is then compared with a cohort of those with scoliosis both pre- and post-operatively. Procrustes analysis is used to examine the mean 3D shape. There is variability in shape in the non-scoliotic cohort. Scoliosis increases this asymmetry, particularly around the most prominent areas of the torso. Surgery alters the torso asymmetry but increases the difference in height between the right and the left with regard to the most prominent points on the torso. There is a degree of asymmetry seen in a non-scoliotic cohort of children. Scoliosis increases that asymmetry. Surgery alters the asymmetry but causes an increase in some of the 3D elements of the most prominent areas of the torso.

Effects of spinal mobilization techniques in the management of adolescent idiopathic scoliosis - A meta-analysis

OBJECTIVES

The aim of this study is to examine the effectiveness of diverse exercise regimes used in multiple Randomized Control Trials as the only conservative management strategy for increased Cobb angle among Adolescent Idiopathic Scoliosis.

METHODS

Database such as Google Scholar, Medline, and BioMed Central was reconnoitered for the purpose of research articles of interest. Studies in which the effects of conservative management of scoliosis on the magnitude of Cobb angle were calculated were scrutinized procedurally, studies fulfilling the inclusion criteria were retrieved and encompassed in the present study.

RESULT

A total of 698 cases of AIS that were included in 17 controlled trials are part of this meta-analysis. The pool effects were measured using a standardized mean difference between the experimental and control group at 95% of confidence interval using Hedges'g statistics. Outcomes analyzed, reveals favorable for exercises based experimental group in term of standardized mean difference with an impact of 0.42° on random effect model, according to a Cohen's rule of thumb that depicts a near to moderate effects of exercises based interventions on Cobb angle.

CONCLUSION

The present study concludes that therapeutic exercise regimes alone have a pivotal role in both decelerating the progression of the curve and reducing the already increased magnitude of the curve.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Perspective review on applications of optics in spinal surgery

Optical technologies may be applied to multiple facets of spinal surgery from diagnostics to intraoperative image guidance to therapeutics. In diagnostics, the current standard remains cross-sectional static imaging. Optical surface scanning tools may have an important role; however, significant work is required to clearly correlate surface metrics to radiographic and clinically relevant spinal anatomy and alignment. In the realm of intraoperative image guidance, optical tracking is widely developed as the current standard of instrument tracking, however remains compromised by line-of-sight issues and more globally cumbersome registration workflows. Surface scanning registration tools are being refined to address concerns over workflow and learning curves, and allow real-time update of tissue deformation; however, the line-of-sight issues plaguing instrument tracking remain to be addressed. In therapeutics, optical applications exist in both visualization, in the form of endoscopes, and ablation, in the form of lasers. Further work is required to extend the feasibility of laser ablation to multiple tissues, including disc, bone, and tumor, in a safe and time-efficient manner. Finally, we postulate some of the short- and long-term opportunities for future growth of optical techniques in the context of spinal surgery. Particular emphasis is placed on intraoperative image guidance, the area of the authors' primary expertise.

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.

ISYQOL: a Rasch-consistent questionnaire for measuring health-related quality of life in adolescents with spinal deformities

BACKGROUND CONTEXT

Spinal deformities are commonly associated with poor health-related quality of life (HRQOL). Several questionnaires (eg, Scoliosis Research Society-24 [SRS-24] and Scoliosis Research Society-22 [SRS-22]) have been developed to evaluate HRQOL in these conditions. In adults as well as during growth, the HRQOL is considered one of the most relevant outcomes of both conservative and surgical treatments. Rasch analysis is a powerful statistical technique for developing high-quality and valid questionnaires. The SRS-24 and SRS-22 have been evaluated using the Rasch analysis but showed poor measurement properties. Thus, a proper measure of HRQOL in people with a spine condition is still missing.

PURPOSE

This study aimed to develop a new questionnaire that is totally Rasch consistent for measuring the HRQOL in young people with a spine condition.

STUDY DESIGN

This is a cross-sectional study for developing a new HRQOL measure.

PATIENT SAMPLE

A total of 402 participants with adolescent idiopathic scoliosis or Scheuermann juvenile kyphosis were included in the study.

OUTCOME MEASURE

The outcome measure used was the Italian Spine Youth Quality of Life (ISYQOL) questionnaire.

MATERIALS AND METHODS

The study consisted of different stages: a conventional approach content analysis, an opinion poll among clinicians trained in spine deformities, and the Rasch analysis (partial credit model).

RESULTS

The Rasch analysis showed that all items of the ISYQOL questionnaire had ordered thresholds and a good fit to the model. Differential item functioning was present for Item 1, with bracing only, and was solved with a conventional items splitting procedure. The ISYQOL item map spans an adequate range of HRQOL. The principal component analysis for Rasch residuals showed, in practical terms, the ISYQOL unidimensionality. The reliability of ISYQOL was high enough so that approximately three significantly different levels of HRQOL could be discerned. Two questionnaire versions were provided for patients with and without the brace, respectively.

CONCLUSIONS

ISYQOL is the first HRQOL questionnaire developed according to the Rasch analysis. It was developed in a conservative treatment setting for all types of spinal deformities, including also patients with surgical curves. Validation in many languages is already under way.

What is the variability in shoulder, axillae and waist position in a group of adolescents?

The clinical assessment of scoliosis is based on the recognition of asymmetry. It is not clear what the degree of asymmetry is in a population without scoliosis, which could make the differentiation between abnormal and normal uncertain. This study defines the range of normality in certain parameters of torso shape that are also associated with the clinical assessment of scoliosis. This was done by analysing the surface topography of a group of 195 children serially measured over a 5-year period. The analysis considered both the spinal curvature and the relative position of shoulders, axillae and waist on each side. The bivariate relationships were examined using 95% confidence interval data ellipses. Our results showed that a degree of spinal curvature was seen, either as a main thoracic or main thoracolumbar curve. The distribution of the data about a mean point is illustrated by 95% confidence interval (CI) data ellipses with shoulder, axilla and waist data plotted against spinal curvature. The mean values were close to zero (exact symmetry) for all of the measured parameters, with the ellipses showing little differences in the distributions. We conclude that mild asymmetry of the measured torso parameters is normal. These results define what is normal and beyond what point asymmetry becomes abnormal. This information is of use for those managing and counselling patients with scoliosis both before and after surgery.

Axial Plane Deformity of the Shoulder in Adolescent Idiopathic Scoliosis

STUDY DESIGN

Prospective observational study.

OBJECTIVE

To study axial plane deformation of the shoulder in adolescent idiopathic scoliosis (AIS) and try to correlate it with curve type and surgical correction.

SUMMARY OF BACKGROUND DATA

It is established that AIS is a 3-dimensional deformity. The rib hump is the most common manifestation of axial plane deformations; the least common manifestation seems to be upper trunk and shoulder rotation, which has been hitherto undescribed.

METHODS

Fourteen consecutive, operated cases of AIS were analyzed prospectively. Preoperative and postoperative x-rays of the spine and clinical photographs were studied. Clinical photographs (top view) were taken with patients in the sitting position, to show shoulder level in relation to the axis of the head and pelvis. Chest computed tomography scans were also studied to determine the direction of apical vertebra and trunk torsion.

RESULTS

All 14 patients in this series had their right shoulders anteriorly rotated preoperatively (anticlockwise). The direction of rotation seemed unrelated to the curve type and shoulder elevation, although most had rib humps on the right. This shoulder rotation was corrected postoperatively by routine maneuvers done for scoliosis correction. Minor residual rotation was seen in 6 patients who also had minimal persisting rib hump. In 1 case the axial plane rotation worsened, although the shoulder level and trunk symmetry improved significantly. The apical vertebral rotation on computed tomography had little bearing on the direction of shoulder rotation.

CONCLUSIONS

Axial plane rotation of the shoulder is a hitherto un-described dimension of AIS deformity complex. Much of it corrects spontaneously with correction of the thoracic spinal deformity.

Overweight is not predictive of bracing failure in adolescent idiopathic scoliosis: results from a retrospective cohort study

PURPOSE

Overweight was found to be a negative predictor of brace effectiveness for adolescent idiopathic scoliosis (AIS), with a threefold higher risk of progression than in normal weight patients. The aim of this study is to investigate overweight, as a predictor of brace results in AIS patients.

METHODS

Design: retrospective cohort study.

POPULATION

351 AIS patients (306 females), mean age 12.9 ± 1.4, mean Cobb 35.6 ± 11.4°, mean ATR 11 ± 4.3°, BMI 19.7 ± 3, median Risser: 2.

INCLUSION CRITERIA

no previous treatment, full-time prescription of brace at first visit (18-23 h per day), scoliosis physiotherapeutic exercise according to the SEAS protocol associated.

OUTCOME

improved, progressed, and stable according to the 5° Cobb agreed threshold.

STATISTICS

a stepwise linear regression was used to look for the effect of BMI as a predictor of result. A Chi-square test and logistic regression were used for the overweight category (BMI ≥ 85th percentile). Control for possible confounders was applied.

RESULTS

BMI is poorly correlated with final results. Confounders' adjustment did not change the correlation, and the predictive model explained about 10% of the result. Brace results were not statistically different in overweight and normal weight: 44 vs 52% improved, 52 vs 41% stable, and 3 vs 7% worsened, respectively.

DISCUSSION

Brace results were similar in overweight and normal weight subjects. These findings subvert the previous results and disprove the role of overweight as a negative predictor. Treatment management, brace type and effectiveness may play a major role in reducing the risks of scoliosis progression.

Reliability and concurrent validity of postural asymmetry measurement in adolescent idiopathic scoliosis

AIM

To investigate the reliability and concurrent validity of the Baseline^® Body Level/Scoliosis meter for adolescent idiopathic scoliosis postural assessment in three anatomical planes.

METHODS

This is an observational reliability and concurrent validity study of adolescent referrals to the Orthopaedic department for scoliosis screening at Karolinska University Hospital, Stockholm, Sweden between March-May 2012. A total of 31 adolescents with idiopathic scoliosis (13.6 ± 0.6 years old) of mild-moderate curvatures (25°± 12°) were consecutively recruited. Measurement of cervical, thoracic and lumbar curvatures, pelvic and shoulder tilt, and axial thoracic rotation (ATR) were performed by two trained physiotherapists in one day. The intraclass correlation coefficient (ICC) was used to determine the inter-examiner reliability (ICC2,1) and the intra-rater reliability (ICC3,3) of the Baseline^® Body Level/Scoliosis meter. Spearman’s correlation analyses were used to estimate concurrent validity between the Baseline^® Body Level/Scoliosis meter and Gold Standard Cobb angles from radiographs and the Orthopaedic Systems Inc. Scoliometer.

RESULTS

There was excellent reliability between examiners for thoracic kyphosis (ICC2,1 = 0.94), ATR (ICC2,1 = 0.92) and lumbar lordosis (ICC2,1 = 0.79). There was adequate reliability between examiners for cervical lordosis (ICC2,1 = 0.51), however poor reliability for pelvic and shoulder tilt. Both devices were reproducible in the measurement of ATR when repeated by one examiner (ICC3,3 0.98-1.00). The device had a good correlation with the Scoliometer (rho = 0.78). When compared with Cobb angle from radiographs, there was a moderate correlation for ATR (rho = 0.627).

CONCLUSION

The Baseline^® Body Level/Scoliosis meter provides reliable transverse and sagittal cervical, thoracic and lumbar measurements and valid transverse plan measurements of mild-moderate scoliosis deformity.

Trunk appearance perception scale for physicians (TAPS-Phy) - a valid and reliable tool to rate trunk deformity in idiopathic scoliosis

Background

Evaluation of trunk deformity by physicians in patients with idiopathic scoliosis (IS) has been considered an important part of clinical practice. Different methods to quantify the severity of trunk deformity by external observation have been reported. A valid tool to evaluate patients’ perception of trunk deformity, the Trunk Appearance Perception Scale (TAPS), is hereby validated for use by physicians (TAPS-Phy).

Methods

Cross-sectional study of patients with non-surgically treated IS. Patients were prospectively recruited. On the day of the visit, a posterior-anterior radiograph in standard position and clinical photographs in three different views (anterior, posterior and forward bending position) were obtained. Patients also completed a TAPS questionnaire (TAPS-Pat). Three different observers scored the TAPS questionnaire (TAPS-Phy), based on the digital photographs previously obtained, twice a week. The angle of trunk inclination (ATRI) was also measured on digital photographs. Inter and intra-rater reliability was calculated through weighted kappa coefficient. External validity was tested by the Spearman correlation coefficient between the TAPS-Phy score and the scoliosis magnitude determined using the magnitude of the largest curve (MLC), ATRI, and TAPS-Pat.

Results

Fifty two patients (46 women; mean age 16.6 years) were included. The average curve magnitude of the major curve was 44°. Mean scores of TAPS-Phy for the three evaluators ranged from 3.4 to 3.5. No differences between the three means were found. TAPS-Phy showed good internal consistency (Cronbach’s alpha coefficient 0.84). Inter-observer reliability ranged from slight to substantial (0.14 to 0.63); intra-observer reliability ranged from 0.35 to 0.99. Correlation between TAPS-Phy and ATRI (r = −0.54 to −0.75), MLC (r = −0.47 to −0.6) and TAPS-Pat (r = 0.29 to 0.34) were statistically significant (p < 0.01).

Conclusions

TAPS-Phy is a valid and reliable scale to rate a physician’s impression of the severity of the deformity in patients with idiopathic scoliosis and can be useful in routine clinical records.

Electronic supplementary material

The online version of this article (doi:10.1186/s13013-016-0085-8) contains supplementary material, which is available to authorized users.

IDIOPATHIC ADOLESCENT SCOLIOSIS: LIVING WITH A PHYSICAL DEFORMITY

ABSTRACT A qualitative, phenomenological, hermeneutical study with the aim of explaining the experience of having a body deformity diagnosed as idiopathic adolescent scoliosis. A semistructured interview conducted with scoliosis patients admitted to the unit of spinal cord at the Vall d'Hebron Hospital was used. The youth defined their scoliosis based on how they perceived their deformity. They spoke of pain and deformity as characteristic symptoms of suffering, and explained how this symptom affected their social relationships. Their deformity was associated with words such as "horrible", "shame", "complex" and "problem." It is concluded that the symptommost referred is pain and the biggest concern of the of the youth was their body aesthetic and feelings associated with it. They attempt to solve this problem by adapting the way they dress and through surgery. Surgery can resolve the body deformity but not self-perception of their body image.

Post-operative shoulder imbalance in adolescent idiopathic scoliosis: a study of clinical photographs

Study design

Retrospective observational study.

Objective

To assess what features determine post-operative shoulder asymmetry in Adolescent Idiopathic Scoliosis (AIS).

Summary of background data

Shoulder balance is one of the major determinants of the cosmetic outcomes of AIS surgery. Yet, other than level of the shoulders we are not clear what parameters are to be measured to assess torso symmetry. This study looks at the various features that might affect the appearance of the shoulder region.

Methods

The records of 157 operated cases of AIS were retrospectively reviewed. Eight patients with documented post-operative shoulder asymmetry and were dissatisfied with their cosmetic outcomes were selected for the study. Their clinical photographs alone were studied. Three regions- the base of the neck, the shoulder and upper arm region- were analysed separately. Four measures each for the neck and shoulder and two for the arms were documented. No statistical tools were employed since the numbers were quite small but consensus was obtained between two Consultant Orthopaedic surgeons regarding the cosmetic impact of each parameter.

Results

The neck and the shoulder appeared independent determinants of cosmesis of the proximal trunk. The base of neck symmetry seemed to be dependent on four features viz. centralization of the neck, neck tilt, trapezius angle and base of neck angle. The appearance of the shoulder itself depended on its level, axillary fold level, scapular level and the scapular prominence. The upper arm parameters appeared less critical in determining the cosmetic impact.

Conclusions

Proximal trunk symmetry in AIS depends on the symmetry of the base of the neck and shoulder regions. The level of the shoulders, axillary folds along with the base of neck angle, Trapezius angle appear to be key determinants of symmetry.

The effect of Schroth exercises added to the standard of care on the quality of life and muscle endurance in adolescents with idiopathic scoliosis-an assessor and statistician blinded randomized controlled trial: "SOSORT 2015 Award Winner"

Background

In North America, care recommendations for adolescents with small idiopathic scoliosis (AIS) curves include observation or bracing. Schroth scoliosis-specific exercises have demonstrated promising results on various outcomes in uncontrolled studies. This randomized controlled trial (RCT) aimed to determine the effect of Schroth exercises combined with the standard of care on quality-of-life (QOL) outcomes and back muscle endurance (BME) compared to standard of care alone in patients with AIS.

Material and Methods

Fifty patients with AIS, aged 10–18 years, with curves 10–45 °, recruited from a scoliosis clinic were randomized to receive standard of care or supervised Schroth exercises plus standard of care for 6 months. Schroth exercises were taught over five sessions in the first two weeks. A daily home program was adjusted during weekly supervised sessions. The assessor and the statistician were blinded. Outcomes included the Biering-Sorensen (BME) test, Scoliosis Research Society (SRS-22r) and Spinal Appearance Questionnaires (SAQ) scores. Intention-to-treat (ITT) and per protocol (PP) linear mixed effects models were analyzed. Because ITT and PP analyses produced similar results, only ITT is reported.

Results

After 3 months, BME in the Schroth group improved by 32.3 s, and in the control by 4.8 s. This 27.5 s difference in change between groups was statically significant (95 % CI 1.1 to 53.8 s, p = 0.04). From 3 to 6 months, the self-image improved in the Schroth group by 0.13 and deteriorated in the control by 0.17 (0.3, 95 % CI 0.01 to 0.59, p = 0.049). A difference between groups for the change in the SRS-22r pain score transformed to its power of four was observed from 3 to 6 months (85.3, 95 % CI 8.1 to 162.5, p = 0.03), where (SRS-22 pain score)⁴ increased by 65.3 in the Schroth and decreased by 20.0 in the control group. Covariates: age, self-efficacy, brace-wear, Schroth classification, and height had significant main effects on some outcomes. Baseline ceiling effects were high: SRS-22r (pain = 18.4 %, function = 28.6 %), and SAQ (prominence = 26.5 %, waist = 29.2 %, chest = 46.9 %, trunk shift = 12.2 % and shoulders = 18.4 %).

Conclusions

Supervised Schroth exercises provided added benefit to the standard of care by improving SRS-22r pain, self-image scores and BME. Given the high prevalence of ceiling effects on SRS-22r and SAQ questionnaires’ domains, we hypothesize that in the AIS population receiving conservative treatments, different QOL questionnaires with adequate responsiveness are needed.

Trial registration

Schroth Exercise Trial for Scoliosis NCT01610908.

Electronic supplementary material

The online version of this article (doi:10.1186/s13013-015-0048-5) contains supplementary material, which is available to authorized users.

The Level of Self-Esteem and Sexual Functioning in Women with Idiopathic Scoliosis: A Preliminary Study

A person’s image, which is determined through physical appearance, considerably affects self-esteem developed from early childhood. Scoliosis causes multiple trunk deformations that can affect a person’s perception of the body. The aim of the study was to analyze the impact of scoliosis dimension and the degree of trunk deformation on the level of self-esteem and sexual functioning in women with idiopathic scoliosis. Thirty-six women diagnosed with idiopathic scoliosis were recruited to a prospective, double-blind, randomized controlled trial. The subjects were divided into two groups depending on the value of the Cobb angle. The level of self-esteem was determined by means of the Rosenberg Self-Esteem Scale (SES), whereas the sexual functioning was assessed via the Female Sexual Function Index (FSFI). The trunk deformations were specified with the Posterior Trunk Symmetry Index (POTSI). A statistically significant correlation was proved between the amount of points received in the Rosenberg scale evaluation and the POTSI index in Group A (R = −0.56, p = 0.04). Subjects with smaller deformations within the coronal plane had a higher level of self-confidence. The trunk asymmetries in the coronal plane may have a negative effect on women with scoliosis and their self-appraisal.

Reliability and validity of inexpensive and easily administered anthropometric clinical evaluation methods of postural asymmetry measurement in adolescent idiopathic scoliosis: a systematic review

PURPOSE

As accurate and reproducible measurements of spinal curvature are crucial in the examination of patients with adolescent idiopathic scoliosis (AIS), this systematic review aims to report on the reliability and validity of a range of inexpensive and easily administered anthropometric methods of postural asymmetry measurement in an AIS population, to inform practice in a clinical setting.

METHODS

A systematic search of health research databases located studies assessing reliability and validity of inexpensive and easily administered anthropometric measures.

RESULTS

Fourteen studies satisfied eligibility criteria. The methodological quality of included studies ranged from low to high. Validity studies were of moderate to high quality. In total, nine clinically applicable, inexpensive and easily administered anthropometric methods were identified, for assessing AIS curvature. All methods demonstrated high to very high inter-observer and intra-observer reliability. Reported criterion validity of the scoliometer and 2D photographs, when compared to Cobb angle assessed from radiographs, ranged from low to very high. iPhone measurements correlated well with scoliometer measurements. 2D photography results had a moderate to high correlation with 3D topography results.

CONCLUSIONS

Overall, strong levels of evidence exist for iPhone and scoliometer measurements, with a high to very high reliability and moderate to very high validity. Moderate levels of evidence exist for scoliometer with mathematical formula and clinical examination with moderate and low validity, respectively. Limited evidence exists for aesthetic tools TRACE and AI and 2D photography. These results indicate there are accurate and reproducible anthropometric measures that are inexpensive and applicable in therapy settings to assess postural asymmetry; however, these only exist for measurement in the transverse plane, despite 3D characteristics of AIS. Further research is required into an inexpensive and easily administered method that can assess postural asymmetry in all anatomical planes.

[Perceived self-image in adolescent idiopathic scoliosis: an integrative review of the literature]

OBJECTIVE

To learn about the experiences of adolescents diagnosed with idiopathic scoliosis.

METHOD

Integrative review of the literature published within a specified time frame.

RESULTS

For both sexes, the predominant clinical symptom of this condition appears to be the negative effect that the deformity exerts on perceived self-image. Quantitative studies used numerical scores to assess perceptions of body image but did not analyse emotional aspects. Patients treated surgically were found to have a better self-image than patients treated with a brace. Quality of life was improved by a reduction in the magnitude of the curve.

CONCLUSION

Spinal deformity exerts a psychological effect on adolescent girls.

Reliability and validity study of measurements on digital photography to evaluate shoulder balance in idiopathic scoliosis

Objective

To determine the validity of digital photography as an evaluation method for shoulder balance (ShB) in patients with idiopathic scoliosis.

Material and methods

A total of 80 patients were included (mean age 20.3 years; 85% women). We obtained a full x-ray of the vertebral column and front and back clinical photography for all patients. For antero-posterior x-rays we measured the proximal thoracic curve angles (CPT). To evaluate radiological shoulder balance we calculated the clavicle-rib intersection angle (CRIA) and T1-tilt. For clinical photography we measured shoulder height angle (SHA), axilla height angle (AHA) and the left right trapezium angle (LRTA). We analyzed the reliability of the different photographic measurements and the correlation between these and the radiological parameters.

Results

The mean magnitude of PTC, CRIA and T1-tilt were 19°, −0.6° and 1.4° respectively. Mean SHA from the front was −1.7°. All photographic measurements revealed an excellent-near perfect intra and inter-observer reliability in both photographic projections. No correlation was found between the ShB and the magnitude of the PTC. A statistically significant correlation was found between clinical balance of the shoulders and radiological balance (r between 0.37 and 0.51).

Conclusions

Digital clinical photography appears to be a reliable method for objective clinical measurement of ShB. The correlation between clinical and radiological balance is statistically significant although moderate/weak.

Electronic supplementary material

The online version of this article (doi:10.1186/s13013-014-0023-6) contains supplementary material, which is available to authorized users.

Brace treatment is effective in idiopathic scoliosis over 45°: an observational prospective cohort controlled study

BACKGROUND CONTEXT

Recently, positive results in bracing patients with idiopathic scoliosis (IS) above 45° who refused surgery have been presented in a retrospective study. Obviously, this can give only an efficacy (EA) analysis, as there is neither a control group, nor it is possible to know failures because of dropouts.

PURPOSE

To present the prospective results of bracing patients affected by IS above 45° and still growing.

STUDY DESIGN

Prospective study including all IS patients with 45° or more, Risser stage 0 to 4, who had their first evaluation in our institute, an outpatient clinic specialized in scoliosis evaluation and conservative treatment, from March 1, 2003 to December 21, 2010 and utterly denied any surgical intervention.

PATIENT SAMPLE

Of 59 patients, we excluded 2 patients still in treatment and 57 (11 males) patients were included. At the beginning of the study, they were 15 years 3±22 months of age, had 52.5° Cobb (range, 45°-93°), and Risser 2 (0-4). Thirty-nine accepted a full-time brace treatment (BG) to try avoiding surgery, 18 refused any treatment and served as controls (CG).

OUTCOME MEASURES

Physiological measures: radiographic and clinical data.

METHODS

Treatment: A year of full-time Sforzesco brace (23 hours/day) or Risser cast (8-12 months) and gradual weaning after Risser 3; all patients performed exercises; and International Society on Scoliosis Orthopaedic and Rehabilitation TREATMENT management criteria were respected. Analyses: EA in patients who completed treatment/observation (34 in BG and 10 in CG) and intent-to-treat (ITT) with worst case analysis in the whole population. Relative risk (RR) and 95% confidence interval (CI) have been computed.

RESULTS

Efficacy: failures were 23.5% in BG and 100% in CG. Intent-to-treat: failures were 20.5% in BG and 55.6% in CG. Relative risks of failure in CG were 4.3 (95% CI, 3.6-4.9) in EA and 2.7 (95% CI, 2.0-3.5) in ITT (p<.05). Percentage of patients (53.8%) improved: RRs of improvement in BG were 1.6 (95% CI, 1.46-1.9) in EA and 1.9 (95% CI, 1.6-2.2) in ITT (p<.05). Patients who joined the treatment achieved a 10.4°±10.7° Cobb improvement, an ATR reduction of 4.2°±4.3°, and an esthetic improvement of 2.8±1.9 of 12 points (TRACE). At the end, in BG, 24 patients were below 45° and 6 patients below 35°.

CONCLUSIONS

Through this study we can conclude that the conservative brace plus exercises treatment (if correctly performed and managed) is a suitable alternative for those patients who reject any surgical intervention for IS above 45°. But we could also conclude that a good brace treatment should be considered as the first choice to try avoiding fusion because of the high sanitary and social costs of surgery.

Low rate of surgery in juvenile idiopathic scoliosis treated with a complete and tailored conservative approach: end-growth results from a retrospective cohort

BACKGROUND CONTEXT

The main distinctive aspect of Juvenile Idiopathic Scoliosis (JIS) with respect to Adolescent Idiopathic Scoliosis (AIS) is the high risk of severe deformity and surgery. Approximately 70% of curves in patients with JIS progress and ultimately require surgery. There are presently very few studies with long-term follow-up of JIS and even fewer looking specifically at bracing Purpose To verify the effectiveness of a complete conservative treatment, including bracing and exercises, for JIS.

STUDY DESIGN/SETTING

Retrospective cohort observational study nested in a clinical prospective database of consecutive outpatients. Patient Sample Inclusion criteria: JIS, no previous treatment, all consecutive radiographies available from treatment start to end of growth (Risser sign 3). We found 30 patients, 27 females, 10 JIS type 1; mean age at first diagnosis was 7.8 +/-1.5 and mean treatment lasted 5.8 years. Cobb degrees 24.4+/-10 degrees, with 7 cases >30 degrees, and 2 > 45degrees. Outcome Measures Physiological measures. Radiographic and clinical data.

METHODS

Treatment (exercises alone, or elastic-rigid-highly rigid braces plus exercises) was tailored and continuously changed according to Cobb degrees, individual preferences, anthropometric characteristics, pubertal spurt, remaining growth, rotation, hump, lumbar curve take-off, and imbalance. The SOSORT Guidelines for patients' management have been followed. Funding and Conflict of Interest: no.

RESULTS

33.3% (95% Confidence Interval 16.4-50.2%) of patients worsened over the years. At the end of growth, 6.6% (0-15.5%) had surgical deformities (>45degrees). We observed a good correction in the first years of treatment until pubertal growth spurt, when progression was usually noted and treatment changed increasing corrective forces (hours or rigidity of bracing). 23 cases were followed up until they had two consecutive radiographies showing Risser sign 5 and showed stability.

CONCLUSIONS

Conservative treatment initiated already in childhood may favorably change the natural history of JIS with the aim of reaching a curve as far as possible from surgical thresholds. Observation, physical exercises, braces can be useful tools in the hand of physicians, but they must be carefully utilized by a deep knowledge of JIS.

Scoliosis in musicians and dancers

Scoliosis, although often considered a condition of athletes, is very common as a cause of symptoms in performing artists. Three typical case histories are presented with a physiotherapy review. Surprisingly, scoliosis is often more of a problem in musicians than in dancers.

Gamma knife treatment for refractory epilepsy in seizure focus localized by positron emission tomography/CT

A total of 80 patients with refractory epilepsy were recruited from the Inner Mongolia Medical College Affiliated Hospital. The foci of 60% of the patients could be positioned using a combined positron emission tomography/CT imaging modality. Hyper- and hypometabolism foci were examined as part of this study. Patients who had abnormal metabolism in positron emission tomography/CT imaging were divided into intermittent-phase group and the seizure-phase group. The intermittent-phase group was further divided into a single-focus group and a multiple-foci group according to the number of seizure foci detected by imaging. Following gamma knife treatment, seizure frequency was significantly lower in the intermittent-phase group and the seizure-phase group. Wieser's classification reached Grade I or II in nearly 40% of patients. Seizure frequency was significantly lower following treatment, but Wieser's classification score was significantly higher in the seizure-phase group compared with the intermittent-phase group. Seizure frequency was significantly lower following treatment in the single-focus group, but Wieser's classification score was significantly higher in the single-focus group as compared with the multiple-foci group.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Brace technology thematic series - The Sforzesco and Sibilla braces, and the SPoRT (Symmetric, Patient oriented, Rigid, Three-dimensional, active) concept

BACKGROUND

Bracing is an effective strategy for scoliosis treatment, but there is no consensus on the best type of brace, nor on the way in which it should act on the spine to achieve good correction. The aim of this paper is to present the family of SPoRT (Symmetric, Patient-oriented, Rigid, Three-dimensional, active) braces: Sforzesco (the first introduced), Sibilla and Lapadula.

METHODS

The Sforzesco brace was developed following specific principles of correction. Due to its overall symmetry, the brace provides space over pathological depressions and pushes over elevations. Correction is reached through construction of the envelope, pushes, escapes, stops, and drivers. The real novelty is the drivers, introduced for the first time with the Sforzesco brace; they allow to achieve the main action of the brace: a three-dimensional elongation pushing the spine in a down-up direction.Brace prescription is made plane by plane: frontal (on the "slopes", another novelty of this concept, i.e. the laterally flexed sections of the spine), horizontal, and sagittal. The brace is built modelling the trunk shape obtained either by a plaster cast mould or by CAD-CAM construction. Brace checking is essential, since SPoRT braces are adjustable and customisable according to each individual curve pattern.Treatment time and duration is individually tailored (18-23 hours per day until Risser 3, then gradual reduction). SEAS (Scientific Exercises Approach to Scoliosis) exercises are a key factor to achieve success.

RESULTS

The Sforzesco brace has shown to be more effective than the Lyon brace (matched case/control), equally effective as the Risser plaster cast (prospective cohort with retrospective controls), more effective than the Risser cast + Lyon brace in treating curves over 45 degrees Cobb (prospective cohort), and is able to improve aesthetic appearance (prospective cohort).

CONCLUSIONS

The SPoRT concept of bracing (three-dimensional elongation pushing in a down-up direction) is different from the other corrective systems: 3-point, traction, postural, and movement-based. The Sforzesco brace, being comparable to casting, may be the best brace for the worst cases.

Idiopathic scoliosis patients with curves more than 45 Cobb degrees refusing surgery can be effectively treated through bracing with curve improvements

BACKGROUND CONTEXT

It is a broad consensus today that scoliosis curves cannot be improved through bracing, and the Scoliosis Research Society (SRS) methodological criteria for bracing have the avoidance of progression as their only objective. Consequently, in curves more than 45°, fusion is considered as basically the only possible treatment.

PURPOSE

The purpose of the study was to verify in a series of patients who utterly refused surgery if it was possible to achieve improvements of scoliosis of more than 45° through a complete conservative treatment (bracing and exercises).

STUDY DESIGN/SETTING

Retrospective cohort from a prospective database.

PATIENT SAMPLE

Out of 1,148 idiopathic scoliosis (IS) patients at the end of treatment, the sample comprised 28 subjects older than 10 years, still growing, with at least one curve above 45°, who had continually refused fusion. The group comprised 24 females and four males, including 14 in which previous brace treatments had failed; at the start of treatment, the age was 14.2±1.8 years and Cobb degrees in the curve were 49.4° (range, 45°-58°). Subgroups considered were gender, bone age, type of scoliosis, treatment used, and previous failed treatment.

OUTCOME MEASURES

Self-report measurement: SRS-22; physiological measures: Cobb degrees, Bunnell angle of trunk rotation (ATR), aesthetic index (AI), and sagittal plumb line distances.

METHODS

The methods comprised full-time treatment (23 or 24 hours per day) for 1 year with Risser cast, Lyon, or Sforzesco brace; weaning of 1 to 2 hours every 6 months; with strategies to maximize compliance through the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) management criteria applied and specific scientific exercises approach to scoliosis exercises (SEAS) performed.

RESULTS

Reported compliance in the 4.10±1.2 treatment years was 94%, with satisfaction regarding treatment and excellent results at the SRS-22. Two patients (7%) remained above 50° Cobb but six patients (21%) finished between 30° and 35° Cobb and 12 patients (43%) finished between 36° and 40° Cobb. Improvements have been found in 71% of patients and a 5° Cobb progression in one patient. Statistically, we found highly significant reductions of the main (-9.25°), average (-6.6°), thoracic (-7.8°), and lumbar (-15.9°) curves. Statistically significant improvements have been found for the AI and ATR, with a general decrease in plumb line distances.

CONCLUSIONS

Bracing can be successfully used in patients who do not want to undergo operations for IS with curves ranging between 45° and 60° Cobb, given sufficient clinical expertise to apply good braces and achieve great compliance. Future studies could demonstrate the percentages at which this result can be achieved.

Right adolescent idiopathic thoracic curve (Lenke 1 A and B): does cost of instrumentation and implant density improve radiographic and cosmetic parameters?

In adolescent idiopathic scoliosis (AIS) there has been a shift towards increasing the number of implants and pedicle screws, which has not been proven to improve cosmetic correction. To evaluate if increasing cost of instrumentation correlates with cosmetic correction using clinical photographs. 58 Lenke 1A and B cases from a multicenter AIS database with at least 3 months follow-up of clinical photographs were used for analysis. Cosmetic parameters on PA and forward bending photographs included angular measurements of trunk shift, shoulder balance, rib hump, and ratio measurements of waist line asymmetry. Pre-op and follow-up X-rays were measured for coronal and sagittal deformity parameters. Cost density was calculated by dividing the total cost of instrumentation by the number of vertebrae being fused. Linear regression and spearman's correlation were used to correlate cost density to X-ray and photo outcomes. Three independent observers verified radiographic and cosmetic parameters for inter/interobserver variability analysis. Average pre-op Cobb angle and instrumented correction were 54° (SD 12.5) and 59% (SD 25) respectively. The average number of vertebrae fused was 10 (SD 1.9). The total cost of spinal instrumentation ranged from $6,769 to $21,274 (Mean $12,662, SD $3,858). There was a weak positive and statistically significant correlation between Cobb angle correction and cost density (r = 0.33, p = 0.01), and no correlation between Cobb angle correction of the uninstrumented lumbar spine and cost density (r = 0.15, p = 0.26). There was no significant correlation between all sagittal X-ray measurements or any of the photo parameters and cost density. There was good to excellent inter/intraobserver variability of all photographic parameters based on the intraclass correlation coefficient (ICC 0.74-0.98). Our method used to measure cosmesis had good to excellent inter/intraobserver variability, and may be an effective tool to objectively assess cosmesis from photographs. Since increasing cost density only improves mildly the Cobb angle correction of the main thoracic curve and not the correction of the uninstrumented spine or any of the cosmetic parameters, one should consider the cost of increasing implant density in Lenke 1A and B curves. In the area of rationalization of health care expenses, this study demonstrates that increasing the number of implants does not improve any relevant cosmetic or radiographic outcomes.

Patient evaluation in idiopathic scoliosis: Radiographic assessment, trunk deformity and back asymmetry

Progressive adolescent idiopathic scoliosis (AIS) produces specific signs and symptoms, including trunk and spinal deformity and imbalance, impairment of breathing function, pain, progression during adult life, and psychological problems, as a whole resulting in an alteration of the health-related quality of life. A scoliosis-specific rehabilitation program attempts to prevent, improve, or minimize these signs and symptoms by using exercises and braces as the main tools in the rehabilitation treatment. Patient evaluation is an essential point in the decision-making process and determines the selection of the specific exercises and the specifications of the brace design. However, this article is not addressed to scoliosis management. In this present article, a complete definition and discussion of radiological aspects, such as the Cobb angle, axial rotation, curve pattern classifications, and sagittal configuration, follow a short description of the three-dimensional nature of AIS. The relationship between AIS and growth is also discussed. There is also a section dedicated to the assessment of trunk deformity and back asymmetry. Other important clinical aspects, such as pain and disability, changes in other regions of the body, muscular balance, breathing function, and health-related quality of life, are not discussed in this present article.

A review of the trunk surface metrics used as Scoliosis and other deformities evaluation indices

BACKGROUND

Although scoliosis is characterized by lateral deviation of the spine, a 3D deformation actually is responsible for geometric and morphologic changes in the trunk and rib cage. In a vast related medical literature, one can find quite a few scoliosis evaluation indices, which are based on back surface data and are generally measured along three planes. Regardless the large number of such indices, the literature is lacking a coherent presentation of the underlying metrics, the involved anatomic surface landmarks, the definition of planes and the definition of the related body axes. In addition, the long list of proposed scoliotic indices is rarely presented in cross-reference to each other. This creates a possibility of misunderstandings and sometimes irrational or even wrong use of these indices by the medical society.

MATERIALS AND METHODS

It is hoped that the current work contributes in clearing up the issue and gives rise to innovative ideas on how to assess the surface metrics in scoliosis. In particular, this paper presents a thorough study on the scoliosis evaluation indices, proposed by the medical society.

RESULTS

More specifically, the referred indices are classified, according to the type of asymmetry they measure, according to the plane they refer to, according to the importance, and relevance or the level of scientific consensus they enjoy.

CONCLUSIONS

Surface metrics have very little correlation to Cobb angle measurements. Indices measured on different planes do not correlate to each other. Different indices exhibit quite diverging characteristics in terms of observer-induced errors, accuracy, sensitivity and specificity. Complicated positioning of the patient and ambiguous anatomical landmarks are the major error sources, which cause observer variations. Principles that should be followed when an index is proposed are presented.

The Trunk Appearance Perception Scale (TAPS): a new tool to evaluate subjective impression of trunk deformity in patients with idiopathic scoliosis

Background

Outcome assessment in idiopathic scoliosis should probably include patients' perception of their trunk deformity in addition to self-image. This can be accomplished with the Walter Reed Visual Assessment Scale (WRVAS). Nevertheless, this instrument has some shortcomings: the drawings are abstract and some figures do not relate to the corresponding radiological deformity. These considerations prompted us to design the Trunk Appearance Perception Scale (TAPS).

Methods

Patients with idiopathic scoliosis and no prior surgical treatment were included. Each patient completed the TAPS and SRS-22 questionnaire and underwent a complete radiographic study of the spine. The magnitude of the upper thoracic, main thoracic, and thoracolumbar/lumbar structural curves were recorded. The TAPS includes 3 sets of figures that depict the trunk from 3 viewpoints: looking toward the back, looking toward the head with the patient bending over and looking toward the front. Drawings are scored from 1 (greatest deformity) to 5 (smallest deformity), and a mean score is obtained.

Results

A total of 186 patients (86% females), with a mean age of 17.8 years participated. The mean of the largest curve (CMAX) was 40.2°. The median of TAPS sum score was 3.6. The floor effect was 1.6% and ceiling effect 3.8%. Cronbach's alpha coefficient was 0.89; the ICC for the mean sum score was 0.92. Correlation coefficient of the TAPS mean sum and CMAX was -0.55 (P < 0.01). Correlation coefficients between TAPS mean sum score and SRS-22 scales were all statistically significant, ranging from 0.45 to 0.52 (P < 0.05).

Conclusions

The TAPS is a valid instrument for evaluating the perception patients have of their trunk deformity. It shows excellent distribution of scores, internal consistency, and test-retest reliability, and has good capacity to differentiate the severity of the disease. It is simple and easy to complete and score, the figures are natural, and a new frontal view is included.

Methodology of evaluation of morphology of the spine and the trunk in idiopathic scoliosis and other spinal deformities - 6th SOSORT consensus paper

BACKGROUND

Comprehensive evaluation of the morphology of the spine and of the whole body is essential in order to correctly manage patients suffering from progressive idiopathic scoliosis. Although methodology of clinical and radiological examination is well described in manuals of orthopaedics, there is deficit of data which clinical and radiological parameters are considered in everyday practise. Recently, an increasing tendency to extend scoliosis examination beyond the measure of the Cobb angle can be observed, reflecting a more patient-oriented approach. Such evaluation often involves surface parameters, aesthetics, function and quality of life.

AIM OF THE STUDY

To investigate current recommendations of experts on methodology of evaluation of the patient with spinal deformity, essentially idiopathic scoliosis.

METHODS

Structured Delphi procedure for collecting and processing knowledge from a group of experts with a series of questionnaires and controlled opinion feedback was performed. Experience and opinions of the professionals - physicians and physiotherapists managing scoliosis patients - were studied. According to Delphi method a Meeting Questionnaire (MQ) has been developed, resulting from a preliminary Pre-Meeting Questionnaire (PMQ) which had been previously discussed and approved on line. The MQ was circulated among the SOSORT experts during Consensus Session on "Measurements" which took place at the Annual Meeting of the Society, totally 23 panellists being engaged. Clinical, radiological and surface topography parameters were checked for agreement.

RESULTS

90% agreement or more was reached in 35 items and superior than 75% agreement was reached in further 25 items. An evaluation form was proposed to be used by clinicians and researchers.

CONCLUSION

The consensus was reached on evaluation of the morphology of the patient with idiopathic scoliosis, comprising clinical, radiological and, to less extend, surface topography assessment. Considering the variety of parameters indicated by the panellists, the Cobb angle, yet the gold standard, can be seen neither as the unique nor the only decisive parameter in the management of patients with idiopathic scoliosis.

Effectiveness of complete conservative treatment for adolescent idiopathic scoliosis (bracing and exercises) based on SOSORT management criteria: results according to the SRS criteria for bracing studies - SOSORT Award 2009 Winner

Background

The SRS criteria give the methodological reference framework for the presentation of bracing results, while the SOSORT criteria give the clinical reference framework for an appropriate bracing treatment. The two have not been combined in a study until now. Our aim was to verify the efficacy of a complete, conservative treatment of Adolescent Idiopathic Scoliosis (AIS)according to the best methodological and management criteria defined in the literature.

Methods

Study Design. Retrospective study. Population. We included all AIS patients respecting the SRS inclusion criteria (age 10 years or older; Risser test 0-2; Cobb degrees 25-40°; no prior treatment; less than one year post-menarchal) who had reached the end of treatment since our institute database start in 2003. Thus we had 44 females and four males, with an age of 12.8 ± 1.6 at the commencement of the study. Methods. According to individual needs, two patients have been treated with Risser casts followed by Lyon brace, 40 with Lyon or SPoRT braces (14 for 23 hours per day, 23 for 21 h/d, and seven for 18 h/d at start), and two with exercises only (1 male, 1 female): these were excluded from further analysis. Outcome criteria. SRS (unchanged; worsened 6° or more; over 45° at the end of treatment; surgically treated; two years' follow-up); clinical (ATR, Aesthetic Index, plumbline distances); radiographic (Cobb degrees); and ISICO (optimal; minimal). Statistics. Paired ANOVA and t-test, Tukey-Kramer and chi-square test.

Results

Median reported compliance during the 4.2 ± 1.4 treatment years was 90% (range 5-106%). No patient progressed beyond 45°, nor was any patient fused, and this remained true at the two-year follow-up for the 85% that reached it. Only two patients (4%) worsened, both with single thoracic curve, 25-30° Cobb and Risser 0 at the start. We found statistically significant reductions of the scoliosis curvatures (-7.1°): thoracic (-7.3°), thoracolumbar (-8.4°) and lumbar (-7.8°), but not double major. Statistically significant improvements have also been found for aesthetics and ATR.

Conclusion

Respecting also SOSORT management criteria and thus increasing compliance, the results of conservative treatment were much better than what had previously been reported in the literature using SRS criteria only.

How to improve aesthetics in patients with Adolescent Idiopathic Scoliosis (AIS): a SPoRT brace treatment according to SOSORT management criteria

BACKGROUND

Aesthetics is a main goal of both conservative and surgical treatments in adolescent idiopathic scoliosis (AIS). Previously, we developed and validated a clinical scale - the Aesthetic Index (AI)--in order to measure aesthetic impairment and changes during treatment.

AIM

To verify the efficacy of bracing on aesthetics in AIS.

STUDY DESIGN

Prospective Cohort Study.

POPULATION

Thirty-four consecutive patients, age 13.2 +/- 3.7, initial Cobb Angle 32 +/- 12 degrees , ATR 10 +/- 4 degrees Bunnel, 11 males.

METHODS

Patients with AI scores of at least 5/6 were included. Each of them had a brace prescription (18 to 23 hours per day), according to the SPoRT concept. AI was measured again after six months and at the end of treatment, and then the pre- and post-treatment scores compared. The Wilcoxon test was performed.

RESULTS

Twenty-nine patients out of the 34 included completed the treatment and had six-month and final results; four patients were lost during the treatment, and one was fused. At baseline, median AI was 6 (95% IC 5-6) but the score decreased to 3 (95% IC 0-5; p < 0.05) after six months with brace, and this value was maintained in the 29 who completed the treatment (95% IC 1-6; p < 0.05 with respect to the baseline).

CONCLUSION

Aesthetics can be improved in a clinically significant way when the brace treatment is performed according to the SPoRT concept and by following the SOSORT management criteria. This is a relevant result for patients and a major goal of scoliosis treatment, be it conservative or surgical. The use of a more sensitive tool like TRACE could more easily detect the clinical changes; nevertheless, AI proved sensible enough that its use in everyday clinical practice can be suggested.