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

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

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

Personal and Clinical Determinants of Brace-Wearing Time in Adolescents with Idiopathic Scoliosis

Adolescent idiopathic scoliosis (AIS) is a three-dimensional spine and trunk deformity. Bracing is an effective treatment for medium-degree curves. Thermal sensors help monitor patients' adherence (compliance), a critical issue in bracing treatment. Some studies investigated adherence determinants but rarely through sensors or in highly adherent cohorts. We aimed to verify the influence of personal and clinical variables routinely registered by physicians on adherence to brace treatment in a large cohort of consecutive AIS patients from a highly adherent cohort. We performed a cross-sectional study of patients consecutively recruited in the last three years at a tertiary referral institute and treated with braces for one year. To ensure high adherence, for years, we have provided specific support to brace treatment through a series of cognitive-behavioural interventions for patients and parents. We used iButton thermal sensor systematic data collection to precisely analyse the real brace-wearing time. We included 514 adolescents, age 13.8 ± 1.6, with the worst scoliosis curve of 34.5 ± 10.3° Cobb. We found a 95% (95CI 60-101%) adherence to the brace prescription of 21.9 ± 1.7 h per day. Determinants included gender (91% vs. 84%; females vs. males) and age < 14 years (92% vs. 88%). Brace hours prescription, BMI, and all clinical variables (worst curve Cobb degrees, angle of trunk rotation, and TRACE index for aesthetics) did not influence adherence.

Spinal Orthosis in Adolescent Idiopathic Scoliosis: An Overview of the Braces Provided by the National Health Service in Italy

Adolescent idiopathic scoliosis (AIS) is a lateral, rotated curvature of the spine. It is a 3-dimensional deformity that arises in otherwise healthy children at or around puberty. AIS is the most common form of scoliosis in the pediatric population. The etiology is multifactorial, including genetic and environmental factors. The incidence is roughly equal between males and females, while there is a higher risk of progression in females. Guidelines for AIS treatment identify three levels of treatment: observation, physiotherapy scoliosis-specific exercises, and braces. In this paper, we carried out a review of the scientific literature about the indication and success rates of the braces provided for free by the National Health Service in Italy (SSN). Despite a general consensus on the efficacy of rigid bracing treatment and its use in AIS, an important heterogeneity about the treatment is present in the scientific literature, demonstrating a high degree of variability. The overall success rate of the braces provided by the SSN is high, suggesting an important therapeutic role in the treatment of AIS. Robust guidelines are needed to ensure uniform and effective treatments.

Predictors of Clinically Meaningful Results of Bracing in a Large Cohort of Adolescents with Idiopathic Scoliosis Reaching the End of Conservative Treatment

BACKGROUND

We need good outcome predictors to maximize the treatment efficiency of adolescents with idiopathic scoliosis (AIS). The in-brace correction has shown an important predictive effect on brace failure, while the influence of other variables is still debated. We aimed to identify new outcome predictors from a big prospective database of AIS.

METHODS

Design: Retrospective analysis of prospectively collected data.

INCLUSION CRITERIA

AIS between 21 and 45°, Risser 0-2, brace prescription during the observation, treatment conclusion. All of the participants followed a personalized conservative approach according to the SOSORT Guidelines.

OUTCOMES

End of growth below 30°-40°-50°. The regression model included age, BMI, Cobb angle, ATR, TRACE score, real brace wear (RBW), and in-brace correction (IBC).

RESULTS

A total of 1050 patients, 84% females, ages 12.1 ± 1.1, 28.2 ± 7.9° Cobb. IBC increased by 30%, 24%, and 23% the odds of ending treatment below 30°, 40°, and 50°, respectively. The OR did not change after the covariate adjustment. Cobb angle and ATR at the start also showed a predictive effect.

CONCLUSIONS

The systematic evaluation of IBC in clinics is useful for individuating the patient response to brace treatment more accurately, even in relation to the Cobb angle and ATR degrees at the start. Further studies are needed to increase the knowledge on predictors of AIS treatment results.

Sport improved medium-term results in a prospective cohort of 785 adolescents with idiopathic scoliosis braced full time. SOSORT 2018 award winner

PURPOSE

The association between idiopathic scoliosis (IS) and sports activities remains vague. We aimed to analyse their effect on full-time braced adolescents with IS.

METHODS

We retrospectively recruited all the consecutive patients of a tertiary referral Institute of age ≥ 10 (adolescents), with a juvenile (JIS) or adolescent (AIS) IS diagnosis, Risser 0-2, TLSO brace prescription and self-reported adherence ≥ 20 h per day, and follow-up out-of-brace X-rays 18 months after brace prescription. We divided participants into two groups: SPORT (sport twice or more per week) and CONTROL (sport once per week or less). We calculated odds ratio (OR) to compare the outcome of subjects performing to those not performing sport. We ran a logistic regression with covariate adjustment to assess if sports frequency affected the outcomes.

RESULTS

Out of 33,311 participants assessed for eligibility, 785 satisfied the inclusion criteria (693 females, age 12.7 ± 1.3 and 40 ± 11° Cobb). The SPORT group consisted of 290 participants and the CONTROL group of 495. The SPORT group showed higher odds of improvement (OR = 1.59, 95%CI = 1.17-2.16, p = 0.0018). The odds of improving increased with the frequency of sports activity (OR = 1.20, 95%CI 1.08-1.34).

CONCLUSION

This study shows that sports activities increase the odds of improvement at 18-month follow-up in adolescents with IS treated with a full-time brace. The odds of improvement increase with sports week frequency.

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.

Biomechanical Effects of Thoracolumbosacral Orthosis Design Features on 3D Correction in Adolescent Idiopathic Scoliosis: A Comprehensive Multicenter Study

STUDY DESIGN

Multicenter numerical study.

OBJECTIVE

To biomechanically analyze and compare various passive correction features of braces, designed by several centers with diverse practices, for three-dimensional (3D) correction of adolescent idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

A wide variety of brace designs exist, but their biomechanical effectiveness is not clearly understood. Many studies have reported brace treatment correction potential with various degrees of control, making the objective comparison of correction mechanisms difficult. A Finite Element Model simulating the immediate in-brace corrective effects has been developed and allows to comprehensively assess the biomechanics of different brace designs.

METHODS

Expert clinical teams (one orthotist and one orthopedist) from six centers in five countries participated in the study. For six scoliosis cases with different curve types respecting SRS criteria, the teams designed two braces according to their treatment protocol. Finite Element Model simulations were performed to compute immediate in-brace 3D correction and skin-to-brace pressures. All braces were randomized and labeled according to 21 design features derived from Society on Scoliosis Orthopaedic and Rehabilitation Treatment proposed descriptors, including positioning of pressure points, orientation of push vectors, and sagittal design. Simulated in brace 3D corrections were compared for each design feature class using ANOVAs and linear regressions (significance P ≤ 0.05).

RESULTS

Seventy-two braces were tested, with significant variety in the design approaches. Pressure points at the apical vertebra level corrected the main thoracic curve better than more caudal locations. Braces with ventral support flattened the lumbar lordosis. Lateral and ventral skin-to-brace pressures were correlated with changes in thoracolumbar/lumbar Cobb and lumbar lordosis (r =- 0.53, r = - 0.54). Upper straps positioned above T10 corrected the main thoracic Cobb better than those placed lower.

CONCLUSIONS

The corrective features of various scoliosis braces were objectively compared in a systematic approach with minimal biases and variability in test parameters, providing a better biomechanical understanding of individual passive mechanisms' contribution to 3D correction.

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.

The classification of scoliosis braces developed by SOSORT with SRS, ISPO, and POSNA and approved by ESPRM

PURPOSE

Studies have shown that bracing is an effective treatment for patients with idiopathic scoliosis. According to the current classification, almost all braces fall in the thoracolumbosacral orthosis (TLSO) category. Consequently, the generalization of scientific results is either impossible or misleading. This study aims to produce a classification of the brace types.

METHODS

Four scientific societies (SOSORT, SRS, ISPO, and POSNA) invited all their members to be part of the study. Six level 1 experts developed the initial classifications. At a consensus meeting with 26 other experts and societies' officials, thematic analysis and general discussion allowed to define the classification (minimum 80% agreement). The classification was applied to the braces published in the literature and officially approved by the 4 scientific societies and by ESPRM.

RESULTS

The classification is based on the following classificatory items: anatomy (CTLSO, TLSO, LSO), rigidity (very rigid, rigid, elastic), primary corrective plane (frontal, sagittal, transverse, frontal & sagittal, frontal & transverse, sagittal & transverse, three-dimensional), construction-valves (monocot, bivalve, multisegmented), construction-closure (dorsal, lateral, ventral), and primary action (bending, detorsion, elongation, movement, push-up, three points). The experts developed a definition for each item and were able to classify the 15 published braces into nine groups.

CONCLUSION

The classification is based on the best current expertise (the lowest level of evidence). Experts recognize that this is the first edition and will change with future understanding and research. The broad application of this classification could have value for brace research, education, clinical practice, and growth in this field.

A Pragmatic Benchmarking Study of an Evidence-Based Personalised Approach in 1938 Adolescents with High-Risk Idiopathic Scoliosis

Combining evidence-based medicine and shared decision making, current guidelines support an evidence-based personalised approach (EBPA) for idiopathic scoliosis in adolescents (AIS). EBPA is considered important for adolescents' compliance, which is particularly difficult in AIS. Benchmarking to existing Randomised Controlled Trials (RCTs) as paradigms of single treatments, we aimed to check the effectiveness and burden of care of an EBPA in high-risk AIS. This study's design features a retrospective observation of a prospective database including 25,361 spinal deformity patients < 18 years of age. Participants consisted of 1938 AIS, 11-45° Cobb, Risser stage 0-2, who were studied until the end of growth. EBPA included therapies classified for burdensomeness according to current guidelines. Using the same inclusion criteria of the RCTs on exercises, plastic, and elastic bracing, out of the 1938 included, we benchmarked 590, 687, and 884 participants, respectively. We checked clinically significant results and burden of care, calculating Relative Risk of success (RR) and Number Needed to Treat (NNT) for efficacy (EA) and intent-to-treat analyses. At the end of growth, 19% of EBPA participants progressed, while 33% improved. EBPA showed 2.0 (1.7-2.5) and 2.9 (1.7-4.9) RR of success versus Weinstein and Coillard's studies control groups, respectively. Benchmarked to plastic or elastic bracing, EBPA had 1.4 (1.2-1.5) and 1.7 (1.2-2.5) RR of success, respectively. The EBPA treatment burden was greater than RCTs in 48% of patients, and reduced for 24% and 42% versus plastic and elastic bracing, respectively. EBPA showed to be from 40% to 70% more effective than benchmarked individual treatments, with low NNT. The burden of treatment was frequently reduced, but it had to be increased even more frequently.

Efficacy of bracing in early infantile scoliosis: a 5-year prospective cohort shows that idiopathic respond better than secondary-2021 SOSORT award winner

PURPOSE

In conservative early onset scoliosis treatment, interest in bracing is growing because repeated general anaesthesia (required by casting) has been questioned for possible brain damages. We aimed to check the results in the medium term of bracing, comparing idiopathic (IIS) to secondary (SIS) infantile scoliosis.

METHODS

We performed a retrospective study in a consecutive prospective cohort. Inclusion criteria were: discovery of scoliosis and bracing below age 3; exclusion criteria: previous spine surgery, less than three consultations. We considered the following results: full (< 20° Cobb) and partial (< 30°) success; hold-up (progression < 5° but curve > 29°); partial (progression > 5°) and full (fusion) failure; statistics: ANOVA for repeated measures; linear mixed effect model with Cobb angle (dependent), time and diagnosis (independent) variables.

RESULTS

We included 34 infants (16 IIS and 18 SIS) of age 1·10 ± 0·10 (years·months), 44 ± 17° curves, 27 ± 10° rib vertebral angle difference, average observation 5·05 ± 3·03 years. We found progressive improvement of IIS and stability of SIS patients. Six IIS (37.5%) and one SIS (6%) reached brace weaning before puberty with 13 ± 5° (improvement 61 ± 15%, p < 0.001), after 4·11 ± 3·07 years of treatment. Three patients were fused, one IIS (6%) and two SIS (11%). Two IIS patients also reached end-of-growth with 18° (start 40° at 1·03 years) and 20° (start 32° at 2·12 years), respectively.

CONCLUSION

Bracing shows promising results in the medium term for high-degree IIS, with very few hold-ups (19%) and failures (12%). Conversely, failures prevail for SIS (full 11%), even if the partial failure (39%) is still a time-buying strategy.

Efficacy of Computer-Aided Design and Manufacturing Versus Computer-Aided Design and Finite Element Modeling Technologies in Brace Management of Idiopathic Scoliosis: A Narrative Review

The efficiency and design quality of scoliosis braces produced by the conventional casting method depends highly on the orthotist's experience. Recently, advanced engineering techniques have been used with the aim of improving the quality of brace design and associated clinical outcomes. Numerically controlled machine tools have provided enormous opportunities for reducing the manufacturing time and saving material. However, the effectiveness of computer-aided brace manufacturing for scoliosis curve improvement is controversial. This narrative review is aimed at comparing the efficacy of braces made by the conventional method with those made by two computer-aided methods: computer-aided design and manufacturing (CAD-CAM), and computer-aided design and finite element modeling (CAD-FEM). The comparison was performed on scoliosis parameters in coronal, sagittal, and transverse planes. Scientific databases were searched, and 11 studies were selected for this review. Because of the diversity of study designs, it was not possible to decisively conclude which brace-manufacturing method is most effective. Similar effectiveness in curve correction was found in the coronal plane for braces made by using advanced manufacturing and conventional methods. In the sagittal plane, modern braces seem to be more effective than traditional braces, but there is an ongoing debate among clinicians, about which CAD-CAM and CAD-FEM brace provides a better treatment outcome. The relative effectiveness of modern and conventional methods in correcting deformities in the transverse plane is also a controversial subject. Overall, advanced engineering design and production methods can be proposed as time- and cost-efficient approaches for scoliosis management. However, there is insufficient evidence yet to conclude that CAD-CAM, and CAD-FEM methods provide significantly better clinical outcomes than those of conventional methods in the treatment of scoliosis curve. Moreover, for some factors, such as molding and the patient's posture during the data acquisition, in brace curve-correction plan, the orthotist's experience and scoliosis curve flexibility should be explored to confidently compare the outcomes of conventional, CAD-CAM, and CAD-FEM methods.

Spinal Deformities and Advancement in Corrective Orthoses

Spinal deformity is an abnormality in the spinal curves and can seriously affect the activities of daily life. The conventional way to treat spinal deformities, such as scoliosis, kyphosis, and spondylolisthesis, is to use spinal orthoses (braces). Braces have been used for centuries to apply corrective forces to the spine to treat spinal deformities or to stabilize the spine during postoperative rehabilitation. Braces have not modernized with advancements in technology, and very few braces are equipped with smart sensory design and active actuation. There is a need to enable the orthotists, ergonomics practitioners, and developers to incorporate new technologies into the passive field of bracing. This article presents a review of the conventional passive braces and highlights the advancements in spinal orthoses in terms of improved sensory designs, active actuation mechanisms, and new construction methods (CAD/CAM, three-dimensional (3D) printing). This review includes 26 spinal orthoses, comprised of passive rigid/soft braces, active dynamics braces, and torso training devices for the rehabilitation of the spine.

Long-term results after brace treatment with Progressive Action Short Brace in adolescent idiopathic scoliosis

BACKGROUND

In the literature, there are few papers on long-term results after brace treatment and there is no consensus on whether scoliotic curves stop progressing at skeletal maturity. To date the factors that could influence curve behaviour following bracing have not been fully determined.

AIM

The aim of this study was to evaluate the results and the loss of the scoliotic curve correction in a cohort of patients treated with Progressive Action Short Brace (PASB) brace during adolescence and to compare patient outcomes of under and over 30 Cobb degrees 10 years after brace removal.

DESIGN

This is an observational controlled cohort study nested in a prospective clinical on-going database including 1536 patients with idiopathic scoliosis.

SETTING

Inpatients and outpatients in Rome.

POPULATION

The study enrolled 163 patients with idiopathic adolescent scoliosis who had been treated with the PASB brace at a 10 years minimum long-term follow-up examination.

METHODS

One hundred sixty-three (female) patients with adolescent idiopathic scoliosis (AIS) treated with the Progressive Action Short Brace (PASB) at a mean age of 13.4 years (range 10-34) had accepted to undergo long-term follow-up examination. All patients had clinical and radiological examinations, but only 62 replied to some simple questions (including work status, pregnancy and pain) the population was divided into two groups based on Cobb degrees (< 30° and ≥ 30°). Statistical analysis was applied to test the efficacy of our hypothesis.

RESULTS

The patients underwent a long-term follow-up after brace removal at a mean age of 13.46 years (±3.4). The prebrace mean curve was 28.98° (±7.918); after treatment, the mean was 13.88° and increased to a minimum of 15.35° in the 10 years following brace removal. However, there was no significant difference between the mean Cobb angle at the end of weaning and the mean Cobb angle at long-term follow-up. The curve angle at baseline of patients who were treated with a brace was reduced by 15° during the treatment, but at follow-up the curve size was found to have lost 2°. The over 30° group showed a prebrace scoliotic mean curve of 37.26°; at the end of weaning, the mean curve angle was 22.98° which increased to a mean of 25.07° at follow-up. The <30° group showed a prebrace scoliotic mean curve of 24.40° which, at the end of weaning, had reduced to a mean of 8.69°, increasing to 9.98° at follow-up. There was no significant difference in the mean progression of curve magnitude between the ˂ 30° and ≥ 30° groups at the long-term follow-up. Work status was 62% full-time and 11% part-time. 24% had given birth. Three percent presented back pain related to instability of the spine. No patients underwent surgery after maturity but one patient had indication to surgical treatment.

CONCLUSIONS

The PASB brace is effective for the treatment of lumbar and thoracolumbar scoliosis and is characterized by positive long-term outcomes, including in patients demonstrating moderate curves. In both groups, at 10-years minimum follow-up after bracing, scoliotic curves did not deteriorate beyond their original curve size after bracing in both groups at the 10-years minimum follow-ups.

CLINICAL REHABILITATION IMPACT

At 10 years follow-up after bracing, scoliotic curves had not deteriorated beyond their original curve size.

Adolescent Idiopathic Scoliosis Bracing Success Is Influenced by Time in Brace: Comparative Effectiveness Analysis of BrAIST and ISICO Cohorts

STUDY DESIGN

Comparative effectiveness study OBJECTIVE.: To evaluate factors leading to higher percentage of brace failures in a cohort of North American patients with adolescent idiopathic scoliosis relative to their peers in Italy.

SUMMARY OF BACKGROUND DATA

Studies of bracing in United States have shown worse outcomes than studies from European centers, possibly due to sample characteristics or treatment approaches.

METHODS

Sample: Braced patients, aged 10 to 15, Risser <3, Cobb 20°- to 40°, observed to Cobb ≥40° and/or ≥Risser 4 selected from prospective databases. Comparators: Bracing per Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) (TLSO) and Italian Scientific Spine Institute (ISICO) protocol (SPoRT braces with or without SEAS exercises). Baseline characteristics (sex, age, BMI, Risser, Cobb, curve type) and average hours of brace wear/day. Differences in programs (e.g., SEAS, type of brace, weaning protocol) were captured by a variable named "SITE."

OUTCOME

Treatment failure (Cobb ≥40 before Risser 4).

STATISTICS

Comparison of baseline characteristics, analyses of risk factors, treatment components, and outcomes within and between cohorts using logistic regression.

RESULTS

A total of 157 BrAIST and 81 ISICO subjects were included. Cohorts were similar at baseline but differed significantly in terms of average hours of brace wear: 18.31 in the ISICO versus 11.76 in the BrAIST cohort. Twelve percent of the ISICO and 39% of the BrAIST cohort had failed treatment. Age, Risser, Cobb, and a thoracic apex predicted failure in both groups. SITE was related to failure (odds ratio [OR] = 0.19), indicating lower odds of failure with ISICO versus BrAIST approach. With both SITE and wear time in the model, SITE loose significance. In the final model, the adjusted odds of failure were higher in boys (OR = 3.34), and those with lowest BMI (OR = 9.83); the odds increased with the Cobb angle (OR = 1.23), and decreased with age (OR = 0.41) and hours of wear (OR = 0.86).

CONCLUSION

Treatment at the ISICO resulted in a lower failure rate, primarily explained by longer average hours of brace wear.

LEVEL OF EVIDENCE

3.

Effect of exercise on static balance and Cobb angle during the weaning phase of brace management in idiopathic scoliosis and hyperkyphosis: A preliminary study

BACKGROUND

Exercises are usually prescribed in association with orthotic intervention for management of idiopathic scoliosis, however the role of these exercises on the efficacy of brace and/or balance is not clear yet.

OBJECTIVES

To investigate the role of exercise (the Blount and Moe protocol) on static balance and Cobb angle changes in adolescents with spinal deformities during weaning from brace.

METHODS

Seventeen brace users were allocated into 3 groups (good, moderate, and weak), according to their exercise quality and quantity static balance was evaluated on 4 conditions (standing on a platform/foam; with/without brace) using a force platform. Center of pressure displacement parameters were compared among the 3 groups. The mean Cobb angles of scoliosis and kyphosis at the beginning of brace use and at the start of the weaning phase were compared in general and among the 3 analogous groups.

RESULTS

No significant difference was found in the static balance parameters and also in Cobb angles among the 3 groups. However, scoliosis and kyphosis Cobb angles were improved significantly as a result of using the brace (p< 0.01).

CONCLUSIONS

The exercise quantity and quality in association with bracing, up to the weaning phase, has no effect on static balance and changes in scoliosis and kyphosis, but the curvature of scoliosis and kyphosis is reduced after wearing a brace.

Consistent and regular daily wearing improve bracing results: a case-control study

Background

In respect to the prescribed regimen and the regular daily pattern, investigate how short-term results are affected by wear time adherence in terms of hours per day.

Methods

This is a case-control study. The setting is outpatient clinic. There were 168 subjects, all of whom met the inclusion criteria: adolescent idiopathic scoliosis and Sforzesco brace prescription of 18 to 23 h/day. The minimum period of follow-up was 4 months, and the maximum was 6 months, which is the average time passing between the Thermobrace (TB) adoption and out-of-brace X-ray before treatment. The brace wear adherence rate, calculated from the ratio of brace wear time with the prescription, was considered in combination with the daily pattern compliance, classified as consistent (104 patients) or inconsistent according to the abnormal distribution of Thermobrace data. The short-term results were finally explored.

Results

Consistent brace wear is associated with a higher probability of improvement in curve magnitude (OR 1.96 CI 95% 1.22–3.14 chi-square 7.78 p = 0.0053). Inconsistent brace wear is more likely to progress (OR 0.14 CI 95% 0.30–0.75 chi-square 10.13 p = 0.0015). Results from the logistic regression show that the most influencing factor for improvement is Cobb degrees at the start.

Conclusions

In clinical everyday activity, patients must be encouraged to consistently follow their brace wear prescription, because this attitude is clearly associated with a higher probability of improvement.

Mechanical and Clinical Evaluation of a Shape Memory Alloy and Conventional Struts in a Flexible Scoliotic Brace

Smart materials have attracted considerable attention in the medical field. In particular, shape memory alloys (SMAs) are most commonly utilized for their superelasticity (SE) in orthopaedic treatment. In this study, the resin struts of a flexible brace for adolescent idiopathic scoliosis (AIS) are replaced with different conventional materials and an SMA. The corrective mechanism mainly depends on the compressive force applied by the brace at the desired location. Therefore, the mechanical properties of the materials used and the interface pressure are both critical factors that influence the treatment effectiveness. The results indicate that titanium is the most rigid among the five types of materials, whereas the brace with SMA struts presents the best recovery properties and the most stable interface pressure. A radiographic examination of two patients with AIS is then conducted to validate the results, which shows that the SMA struts can provide better correction of thoracic curvature. These findings suggest that SMAs can be applied in orthoses because their SE allows for continuous and controllable corrective forces.

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.

Curve progression after long-term brace treatment in adolescent idiopathic scoliosis: comparative results between over and under 30 Cobb degrees - SOSORT 2017 award winner

Background

The factors influencing curve behavior following bracing are incompletely understood and there is no agreement if scoliotic curves stop progressing with skeletal maturity. The aim of this study was to evaluate the loss of the scoliotic curve correction in patients treated with bracing during adolescence and to compare patient outcomes of under and over 30 Cobb degrees, 10 years after brace removal.

Methods

We reviewed 93 (87 female) of 200 and nine patients with adolescent idiopathic scoliosis (AIS) who were treated with the Lyon or PASB brace at a mean of 15 years (range 10–35). All patients answered a simple questionnaire (including work status, pregnancy, and pain) and underwent clinical and radiological examination. The population was divided into two groups based on Cobb degrees (< 30° and > 30°). Statistical analysis was performed to test the efficacy of our hypothesis.

Results

The patients underwent a long-term follow-up at a mean age of 184.1 months (±72.60) after brace removal. The pre-brace scoliotic mean curve was 32.28° (± 9.4°); after treatment, the mean was 19.35° and increased to a minimum of 22.12° in the 10 years following brace removal. However, there was no significant difference in the mean Cobb angle between the end of weaning and long term follow-up period (p = 0.105). The curve angle of patients who were treated with a brace from the beginning was reduced by 13° during the treatment, but the curve size lost 3° at the follow-up period.

The groups over 30° showed a pre-brace scoliotic mean curve of 41.15°; at the end of weaning, the mean curve angle was 25.85° and increased to a mean of 29.73° at follow-up; instead, the groups measuring ≤ 30° showed a pre-brace scoliotic mean curve of 25.58°; at the end of weaning, it was reduced to a mean of 14.24° and it increased to 16.38° at follow-up.

There was no significant difference in the mean progression of curve magnitude between the ≤ 30° and > 30° groups at the long-term follow-up.

Conclusions

Scoliotic curves did not deteriorate beyond their original curve size after bracing in both groups at the 15-year follow-ups. These results are in contrast with the history of this pathology that normally shows a progressive and lowly increment of the curve at skeletal maturity. Bracing is an effective treatment method characterized by positive long-term outcomes, including for patients demonstrating moderate curves.

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.

The three dimensional analysis of the Sforzesco brace correction

Background

Scoliosis is a three dimensional deformity, and brace correction should be 3D too. There is a lack of knowledge of the effect of braces, particularly in the sagittal and transverse plane. The aim of this study is to analyse the Sforzesco Brace correction, through all the parameters provided by Eos 3D imaging system.

Method

Design: This is a cross sectional study from a prospective database started in March 2003.

Participants: 16 AIS girls (mean age 14.01) in Sforzesco brace treatment, with EOS x-rays, at start, in brace after 1 month and out of brace after the first 4 months of treatment. Outcome measures: All the parameters and the Torsio-Index obtained from 3D Eos System, in and out of brace, in the three planes. Statistical analysis: the variability of the parameters and the mean differences were analyzed and compared using paired T test. ANOVA was used for multiple comparisons. Critical P value was set at 0.05.

Results

In the comparison of in-brace vs start of treatment, the mean Cobb angle changed significantly from 36.44 +/− 4 to 28.99 + −3.9° (p = 0.01). Significant changes in all the sagittal parameters were found (p = 0.02). In the axial plane, the Torsio Index changed significantly in-brace for thoracolumbar and lumbar curves (P < 0.05). The analysis of the single vertebral tilt demonstrated that the effect of the brace is mostly concentrated at specific segments: T4-T5, T10-T12, L1 and L5 in the axial plane and T3-T6 and T10-L1 in the frontal plane.

Conclusion

The Sforzesco brace mostly modifies the middle of the spine and preserves the sagittal balance. The single vertebral orientation in each plane should be considered together with the typically used values to assess brace effect.

Scoliosis curve analysis with Milwaukee orthosis based on Open SIMM modeling

BACKGROUND

Scoliosis is a three-dimensional spinal deformity characterized by lateral curvature and rotational deformity of the spine. Various methods have been used to investigate the performance of the subjects during walking with an orthosis, but nobody study the biomechanics of orthotic use by understanding the length of the muscles and the force produced by them. Therefore, the aim of this research is to test the effect of the orthosis on the muscular force, tendon length during walking with and without orthosis.

MATERIALS AND METHODS

A 12-year-old scoliosis subject was recruited in this study. The forces produced by trunk musculature, joint reaction force, length of trunk musculature were some parameters selected in this study. Open SIMM and Visual 3D software were used to model the subject.

RESULTS

The results of this research showed that the length of erector spine muscles increased follow the use of orthosis. Moreover, the force produced by trunk muscles differed during walking with and without orthosis and also between right and left sides.

DISCUSSION

It seems that Open SIMM software can be used to predict the length of muscles, active-passive forces produced by muscles in scoliotic subjects. Therefore, it is recommended this research be done on more number of subjects.

SOSORT Award Winner 2015: a multicentre study comparing the SPoRT and ART braces effectiveness according to the SOSORT-SRS recommendations

BACKGROUND

Data comparing different braces for adolescent idiopathic scoliosis (AIS) are scant. The SRS criteria represent some guidelines for comparing results from different studies, but controlled studies are much more reliable. Recently, super-rigid braces have been introduced in clinical practice with the aim of replacing Risser and EDF casts. The aim of the present study is to compare the short-term radiographic results of two super-rigid braces, the ART and the SPORT (Sforzesco) brace.

METHODS

A group of consecutive patients with Cobb >40°, Risser 0-4, age >10 treated with the ART brace for 6 months were matched with a group of similar patients taken from a prospective database of patients treated with the Sforzesco brace. Patients were matched according to Cobb severity, pattern and localization of the curve. All patients had a full-time brace prescription (23-24 hours per day) and an indication to perform scoliosis-specific exercises and were assessed radiographically both immediately in the brace and after 6 months of treatment out of brace. Curves were analyzed according to the pattern and localization taking into consideration both the in-brace correction and the 6-month out-of-brace results.

STATISTICAL ANALYSIS

t-test, ANOVA, linear regression, alpha set at 0.05.

RESULTS

Twenty-six patients were included in the ART brace group, and 26 in the Sforzesco brace group. At baseline, no differences were noted for gender (3 males for each group), age (14.1 ± 0.3 for ART vs 13.9 ± 0.3 for Sforzesco), ATR (11.8 ± 3.2 vs 11.5 ± 4.2 for thoracic curves and 7.8 ± 4.0 vs 7.1 ± 6.1 for lumbar/thoracolumbar), Cobb angle (44.8 ± 2 vs 45.5 ± 2 for thoracic; 43.8 ± 2 vs 46.0 ± 2 for lumbar/thoracolumbar) or Risser sign (median 2 for both groups). The in-brace correction was slightly better for the ART brace, but didn't reach statistical significance (24.3 ± 8.5 vs 28.0 ± 6.8 for thoracic; 23.7 ± 10.4 vs 29.9 ± 4.2 for lumbar/thoracolumbar). At 6 months, results were similar both for thoracic (34.4 ± 10.4 vs34.8 ± 6.8) and for lumbar/thoracolumbar (32.8 ± 10.8 vs 36.6 ± 5.2). Also, with regard to the pattern, results were similar for double major and for thoracic, while there were not enough data for single lumbar to make a comparison. No differences for ATR were found (7.8 ± 3.2 vs 8.6 ± 2.9 for thoracic; 4.3 ± 3.4 vs 4.3 ± 3.7 for lumbar/thoracolumbar).

CONCLUSION

These two super-rigid braces showed similar short-term results, despite the better in-brace correction for lumbar curves shown by the ART brace. According to our data, the asymmetric design showed results similar to the symmetric one. After these preliminary data, further studies are needed to check end growth results and the impact of compliance, rigidity of curve, exercise and assessing quality of life.

SEAS (Scientific Exercises Approach to Scoliosis): a modern and effective evidence based approach to physiotherapic specific scoliosis exercises

Background

SEAS is the acronym for “Scientific Exercise Approach to Scoliosis”, a name related to the continuous changes of the approach based on results published in the literature.

Rehabilitation program

SEAS is an individualized exercise program adapted to all situations of conservative treatment of scoliosis: stand-alone in low-medium degree curves during growth to reduce the risk of bracing; complimentary to bracing in medium-high degree curves during growth, with the aim to increase correction, prepare weaning, and avoid/reduce side-effects; for adults either progressing or fused, to help stabilising the curve and reduce disability.

SEAS is based on a specific active self-correction technique performed without external aid, and incorporated in functional exercises. Evaluation tests guide the choice of the exercises most appropriate to the individual patient.

Improvement of the stability of the spine in active self-correction is the primary objective of SEAS. SEAS exercises train neuromotor function so to stimulate by reflex a self-corrected posture during the activities of daily life.

SEAS can be performed as an outpatient (two/three times a week 45 for minutes) or as a home program to be performed 20 minutes daily. In the last case, expert physiotherapy sessions of 1.5 hours every three months are proposed.

Results

Different papers, including a randomized controlled trial (2014), published over the past several years, documented the efficacy of the SEAS approach applied in the various phases of scoliosis treatment in reducing Cobb angle progression and the need to wear a brace.

Conclusions

SEAS is an approach to scoliosis exercise treatment with a strong modern neurophysiological basis, to reduce requirements for patients and possibly the costs for families linked to the frequency and intensity of treatment and evaluations. Therefore, SEAS allows treating a large number of patients coming from far away. Even if SEAS appears simple by requiring less physiotherapist supervision and by using fewer home exercises prescribed at a lower dose than some of the other scoliosis-specific exercise approaches, real expertise in scoliosis, exercises, and patient and family management is required. The program has no copyrights, and teachers are being trained all over the world.

Prospective study and new concepts based on scoliosis detorsion of the first 225 early in-brace radiological results with the new Lyon brace: ARTbrace

Background

The symmetrical Lyon brace is a brace, usually used to maintain correction after a plaster cast reduction in the Cotrel’s EDF (Elongation-Derotation-Flexion) frame. The new Lyon brace or ARTbrace is an immediate corrective brace based on some of the principles of the plaster cast which are improved due to advances in CAD/CAM technology. The aim of this paper is to describe concepts of this new brace to be not only a replacement of the plaster cast, but also a definitive brace.

Methods

Instead of a plaster cast, three segmental CAD/CAM moulds are made with the instantaneous full 3D raster stereography digitizer (Orten):

In self axial elongation

In shift and lumbar lordosis

In shift and thoracic kyphosis

A specific software (OrtenShape) makes up the overlay of the three moulds. Mould 1 is used for the pelvis and the shoulders mould 2 for the lumbar segment and mould 3 for the thoracic segment.

The mathematical basis of the ARTbrace is the torso column which is a circled helicoid with horizontal circle generator. A torso column is reproduced in the opposite direction of the scoliosis.

Like the plaster cast, the ARTbrace is worn for a “total time” of 24 hours 7 days a week without modifying the standard protocol of the Lyon brace reduction.

The prospective controlled cohort observational study of the 225 first patients treated since May 2013 is reported below.

Results

The in-brace immediate reduction is: 0.7, i.e. 40% better with the ARTbrace than with a plaster cast. The correction of flat back is 9° (from 18°.4 to 28°.5 kyphosis Cobb angle). The improved aesthetic appearance is equal for rib hump and ATR.

Conclusion

This first paper is an introduction with very short results and does not prejudge the final outcome. The ARTbrace can be used not only to replace the plaster cast, but also as a definitive brace. The new segmental moulding with final detorsion is even more efficient and to this day the ARTbrace is the most effective to reduce the Cobb angle of scoliosis.

Electronic supplementary material

The online version of this article (doi:10.1186/1748-7161-9-19) 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.

The effectiveness of combined bracing and exercise in adolescent idiopathic scoliosis based on SRS and SOSORT criteria: a prospective study

BACKGROUND

Recently an RCT confirmed brace efficacy in adolescent idiopathic scoliosis (AIS) patients. Previously, a Cochrane review suggested also producing studies according to the Scoliosis Research Society (SRS) criteria on the effectiveness of bracing for AIS. Even if the SRS criteria propose a prospective design, until now only one out of 6 published studies was prospective. Our purpose was to evaluate the effects of bracing plus exercises following the SRS and the international Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) criteria for AIS conservative treatment.

METHODS

STUDY DESIGN/SETTING

prospective cohort study nested in a clinical database of all outpatients of a clinic specialized in scoliosis conservative treatment.

PATIENT SAMPLE

seventy-three patients (60 females), age 12 years 10 months ±17 months, 34.4±4.4 Cobb degrees, who satisfied SRS criteria were included out of 3,883 patients at first evaluation.

OUTCOME MEASURES

Cobb angle at the end of treatment according to SRS criteria : (unchanged; worsened 6° or more, over 45° and surgically treated, and rate of improvement of 6° or more).Braces were prescribed for 18-23 hours/day according to curves magnitude and actual international guidelines. Weaning was gradual after Risser 3. All patients performed exercises and were managed according to SOSORT criteria. Results in all patients were analyzed according to intent-to-treat at the end of the treatment. Funding and Conflict of Interest: no.

RESULTS

Overall 34 patients (52.3%) improved. Seven patients (9.6%) worsened, of which 1 patient progressed beyond 45° and was fused. Referred compliance was assessed during a mean period of 3 years 4 months ±20 months; the median adherence was 99.1% (range 22.2-109.2%). Employing intent-to-treat analysis, there were failures in 11 patients (15.1%). At start, these patients had statistically significant low BMI and kyphosis, high thoracic rotation and higher Cobb angles. Drop-outs showed reduced compliance and years of treatment; their average scoliosis at discontinuation was low: 22.7° (range 16-35°) at Risser 1.3 ± 1.

CONCLUSIONS

Bracing in patients with AIS who satisfy SRS criteria is effective. Combining bracing with exercise according to SOSORT criteria shows better results than the current literature.

In favour of the definition "adolescents with idiopathic scoliosis": juvenile and adolescent idiopathic scoliosis braced after ten years of age, do not show different end results. SOSORT award winner 2014

Background

The most important factor discriminating juvenile (JIS) from adolescent idiopathic scoliosis (AIS) is the risk of deformity progression. Brace treatment can change natural history, even when risk of progression is high. The aim of this study was to compare the end of growth results of JIS subjects, treated after 10 years of age, with final results of AIS.

Methods

Design: prospective observational controlled cohort study nested in a prospective database. Setting: outpatient tertiary referral clinic specialized in conservative treatment of spinal deformities. Inclusion criteria: idiopathic scoliosis; European Risser 0–2; 25 degrees to 45 degrees Cobb; start treatment age: 10 years or more, never treated before. Exclusion criteria: secondary scoliosis, neurological etiology, prior treatment for scoliosis (brace or surgery). Groups: 27 patients met the inclusion criteria for the AJIS, (Juvenile Idiopathic Scoliosis treated in adolescence), demonstrated by an x-ray before 10 year of age, and treatment start after 10 years of age. AIS group included 45 adolescents with a diagnostic x-ray made after the threshold of age 10 years. Results at the end of growth were analysed; the threshold of 5 Cobb degree to define worsened, improved and stabilized curves was considered. Statistics: Mean and SD were used for descriptive statistics of clinical and radiographic changes. Relative Risk of failure (RR), Chi-square and T-test of all data was calculated to find differences among the two groups. 95% Confidence Interval (CI) , and of radiographic changes have been calculated.

Results

We did not find any Cobb angle significant differences among groups at baseline and at the end of treatment. The only difference was in the number of patients progressed above 45 degrees, found in the JIS group. The RR of progression of AJIS was, 1.35 (IC95% 0.57-3.17) versus AIS, and it wasn't statistically significant in the AJIS group, in respect to AIS group (p = 0.5338).

Conclusion

There are no significant differences in the final results of AIS and JIS, treated with total respect of the SRS and SOSORT criteria, in adolescence. Brace efficacy can neutralize the risk of progression.

The current status of bracing for patients with adolescent idiopathic scoliosis

Adolescent idiopathic scoliosis affects about 3% of children. Non-operative measures are aimed at altering the natural history to maintain the size of the curve below 40° at skeletal maturity. The application of braces to treat spinal deformity pre-dates the era of evidence-based medicine, and there is a paucity of irrefutable prospective evidence in the literature to support their use and their effectiveness has been questioned. This review considers this evidence. The weight of the evidence is in favour of bracing over observation. The most recent literature has moved away from addressing this question, and instead focuses on developments in the design of braces and ways to improve compliance.

Optimal management of idiopathic scoliosis in adolescence

Idiopathic scoliosis is a three-dimensional deformity of the growing spine, affecting 2%-3% of adolescents. Although benign in the majority of patients, the natural course of the disease may result in significant disturbance of body morphology, reduced thoracic volume, impaired respiration, increased rates of back pain, and serious esthetic concerns. Risk of deterioration is highest during the pubertal growth spurt and increases the risk of pathologic spinal curvature, increasing angular value, trunk imbalance, and thoracic deformity. Early clinical detection of scoliosis relies on careful examination of trunk shape and is subject to screening programs in some regions. Treatment options are physiotherapy, corrective bracing, or surgery for mild, moderate, or severe scoliosis, respectively, with both the actual degree of deformity and prognosis being taken into account. Physiotherapy used in mild idiopathic scoliosis comprises general training of the trunk musculature and physical capacity, while specific physiotherapeutic techniques aim to address the spinal curvature itself, attempting to achieve self-correction with active trunk movements developed in a three-dimensional space by an instructed adolescent under visual and proprioceptive control. Moderate but progressive idiopathic scoliosis in skeletally immature adolescents can be successfully halted using a corrective brace which has to be worn full time for several months or until skeletal maturity, and is able to prevent more severe deformity and avoid the need for surgical treatment. Surgery is the treatment of choice for severe idiopathic scoliosis which is rapidly progressive, with early onset, late diagnosis, and neglected or failed conservative treatment. The psychologic impact of idiopathic scoliosis, a chronic disease occurring in the psychologically fragile period of adolescence, is important because of its body distorting character and the onerous treatment required, either conservative or surgical. Optimal management of idiopathic scoliosis requires cooperation within a professional team which includes the entire therapeutic spectrum, extending from simple watchful observation of nonprogressive mild deformities through to early surgery for rapidly deteriorating curvature. Probably most demanding is adequate management with regard to the individual course of the disease in a given patient, while avoiding overtreatment or undertreatment.

In defense of adolescents: They really do use braces for the hours prescribed, if good help is provided. Results from a prospective everyday clinic cohort using thermobrace

BACKGROUND

The effectiveness of bracing relies on the quality of the brace, compliance of the patient, and some disease factors. Patients and parents tend to overestimate adherence, so an objective assessment of compliance has been developed through the use of heat sensors. In 2010 we started the everyday clinical use of a temperature sensor, and the aim of this study is to present our initial results.

METHODS

POPULATION

A prospective cohort of 68 scoliosis patients that finished at least 4 months of brace treatment on March 31, 2011: 48 at their first evaluation (79% females, age 14.2±2.4) and 20 already in treatment.

TREATMENT

Bracing (SPoRT concept); physiotherapic specific exercises (SEAS School); team approach according to the SOSORT Bracing Management Guidelines.Methods. A heat sensor, "Thermobrace" (TB), has been validated and applied to the brace. The real (measured by TB) and referred (reported by the patient) compliances were calculated.Statistics. The distribution was not normal, hence median and 95% interval confidence (IC95) and non-parametric tests had to be used.

RESULTS

Average TB use: 5.5±1.5 months. Brace prescription was 23 hours/day (h/d) (IC95 18-23), with a referred compliance of 100% (IC95 70.7-100%) and a real one of 91.7% (IC95 56.6-101.7%), corresponding to 20 h/d (IC95 11-23). The more the brace was prescribed, the more compliant the patient was (94.8% in 23 h/d vs. 73.2% in 18 h/d, P < 0.05). Sixty percent of the patients had at least 90% compliance, and 45% remained within 1 hour of what had been prescribed. Non-wearing days were 0 (IC95 0-12.95), and involved 29% of patients.

CONCLUSION

This is the first study using a TB in a setting of respect for the SOSORT criteria for bracing, and it states that it is possible to achieve a very good compliance, even with a full time prescription, and better than what was previously reported (80% maximum). We hypothesize that the treating team (SOSORT criteria) plays a major role in our results. This study suggests that compliance is neither due to the type of treatment only nor to the patient alone. According to our experience, TB offers valuable insights and do not undermine the relationship with the patients.