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Swaby L, Cui M, Cole A. Discontinuation of brace treatment in adolescent idiopathic scoliosis (AIS): a scoping review. Spine Deform 2024:10.1007/s43390-024-00882-3. [PMID: 38693334 DOI: 10.1007/s43390-024-00882-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 04/09/2024] [Indexed: 05/03/2024]
Abstract
PURPOSE Brace treatment for adolescent idiopathic scoliosis (AIS) is usually prescribed for 20-40° curves in patients with growth potential. The aim is to reduce the risk of curve progression during growth and to avoid the curve reaching a surgical threshold. Having as small a curve as possible at skeletal maturity will reduce the risk of curve progression during adult life. While evidence exists for brace treatment in AIS, there is disagreement on how and when to discontinue bracing. The purpose of this review was to investigate what criteria have been reported for initiating brace cessation and published weaning protocols and to look at estimates of the number of patients that may progress > 5 degrees after the end of growth. METHODS This scoping review summarizes existing knowledge on the best time to stop bracing in AIS patients, how to "wean," and what happens to spinal curves after bracing. Searches were carried out through MEDLINE, EMBASE, and PsycINFO in April 2022. A total of 1936 articles were reduced to 43 by 3 reviewers. Full papers were obtained, and data were extracted. RESULTS Weaning was most commonly determined by Risser 4 (girls) and 5 (boys). Other requirements included 2 years post-menarche and no growth in standing/sitting height for 6 months. Skeletal maturity assessed from hand and wrist radiographs, e.g., Sanders' stage; distal radius and ulnar physes, could determine the optimal weaning time to minimize curve progression. Complete discontinuation was the most common option at skeletal maturity; variations on weaning protocols involved gradual reduction of bracing over 6-12 months. Curve progression after weaning is common. The 12 studies reporting early curve progression after brace weaning found a mean Cobb angle progression of 3.8° (n = 1655). From the seven studies reporting early curve progression by > 5 degrees, there were 236/700 (34%) patients. There is limited information on risk factors to predict early curve progression after finishing brace treatment with larger curves, especially those over 40 degrees possibly having more chance of progression. CONCLUSION Curve progression after bracing cessation is a negative outcome for patients who have tolerated bracing for several years, especially if surgery is required. The literature shows that when to start brace cessation and weaning protocols vary. Approximately 34% of patients progressed by more than 5 degrees at 2-4 years after brace cessation or weaning. Larger curves seem more likely to progress. More research is needed to evaluate the risk factors for curve progression after brace treatment, defining the best time to stop bracing based on the lowest risk of curve progression and whether there is any benefit to weaning.
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Affiliation(s)
- Lizzie Swaby
- ScHARR, University of Sheffield, Sheffield, S1 4DA, UK.
| | - Mengwei Cui
- ScHARR, University of Sheffield, Sheffield, S1 4DA, UK
| | - Ashley Cole
- Department of Paediatric Orthopaedics, Sheffield Children's Hospital, Sheffield, UK
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Cheung PWH, Wong JSH, Luk KDK, Cheung JPY. Using the Proximal Femur Maturity Index at Brace Initiation for Adolescent Idiopathic Scoliosis Predicts Curve Progression Risk. J Bone Joint Surg Am 2024; 106:531-541. [PMID: 38261654 PMCID: PMC10939470 DOI: 10.2106/jbjs.23.00694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND The Proximal Femur Maturity Index (PFMI) can be used to assess skeletal maturity on existing whole-spine radiographs without additional radiation. However, the relationship between the PFMI at the initiation of bracing for adolescent idiopathic scoliosis (AIS) and subsequent curve progression remains unknown. This study aimed to investigate the relationship between the PFMI and curve progression, and the predictability of risks to adulthood curve progression and surgical thresholds based on the PFMI grade at brace initiation. METHODS This was a prospective study of 202 patients with AIS who were prescribed underarm bracing according to the Scoliosis Research Society criteria and had good brace-wear compliance. The patients were followed from brace initiation until complete skeletal maturity. Longitudinal data on the coronal Cobb angle and skeletal maturity assessments using Risser staging, Sanders staging, the distal radius and ulna classification, and the PFMI were collected. Each patient was assessed on whether the major curve progressed to ≥40° (adulthood deterioration) and ≥50° (the surgical threshold). Logistic regressions were used to predict probabilities of curve progression to the 2 thresholds, adjusted for factors that were significant in univariate analyses. RESULTS The PFMI correlated with the other skeletal maturity indices (r s [Spearman rank correlation] = 0.60 to 0.72, p < 0.001 for all). The pre-brace PFMI grade correlated with progression to ≥40° (r rb [rank-biserial correlation] = -0.30, p < 0.001) and to ≥50° (r rb = -0.20, p = 0.005). Based on regression models (p < 0.001) adjusted for the pre-brace major Cobb angle and curve type, brace initiation at PFMI grades 2 and 3 for a curve of ≥30° had predicted risks of 30% (95% confidence interval [CI], 4% to 55%) and 12% (95% CI, 7% to 17%), respectively, for progression to the surgical threshold. Brace initiation at PFMI grade 5 had 0% progression risk. CONCLUSIONS The PFMI can be used for predicting curve progression and prognosticating brace outcomes in AIS. Patients with brace initiation at PFMI grade 4 for a curve of <30° or at grade 5 were unlikely to progress to the adulthood deterioration or surgical threshold. In comparison, skeletally immature patients initiating bracing at a PFMI grade of ≤3 for a major curve of ≥30° had a higher risk of progression despite compliant brace wear. LEVEL OF EVIDENCE Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Prudence Wing Hang Cheung
- Department of Orthopaedics and Traumatology, University of Hong Kong, Pokfulam, Hong Kong SAR, People’s Republic of China
| | - Janus Siu Him Wong
- Department of Orthopaedics and Traumatology, University of Hong Kong, Pokfulam, Hong Kong SAR, People’s Republic of China
| | - Keith Dip Kei Luk
- Department of Orthopaedics and Traumatology, University of Hong Kong, Pokfulam, Hong Kong SAR, People’s Republic of China
| | - Jason Pui Yin Cheung
- Department of Orthopaedics and Traumatology, University of Hong Kong, Pokfulam, Hong Kong SAR, People’s Republic of China
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Tang S, Cheung JPY, Cheung PWH. Effectiveness of bracing to achieve curve regression in adolescent idiopathic scoliosis. Bone Joint J 2024; 106-B:286-292. [PMID: 38423123 DOI: 10.1302/0301-620x.106b3.bjj-2023-1105.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Aims To systematically evaluate whether bracing can effectively achieve curve regression in patients with adolescent idiopathic scoliosis (AIS), and to identify any predictors of curve regression after bracing. Methods Two independent reviewers performed a comprehensive literature search in PubMed, Ovid, Web of Science, Scopus, and Cochrane Library to obtain all published information about the effectiveness of bracing in achieving curve regression in AIS patients. Search terms included "brace treatment" or "bracing," "idiopathic scoliosis," and "curve regression" or "curve reduction." Inclusion criteria were studies recruiting patients with AIS undergoing brace treatment and one of the study outcomes must be curve regression or reduction, defined as > 5° reduction in coronal Cobb angle of a major curve upon bracing completion. Exclusion criteria were studies including non-AIS patients, studies not reporting p-value or confidence interval, animal studies, case reports, case series, and systematic reviews. The GRADE approach to assessing quality of evidence was used to evaluate each publication. Results After abstract and full-text screening, 205 out of 216 articles were excluded. The 11 included studies all reported occurrence of curve regression among AIS patients who were braced. Regression rate ranged from 16.7% to 100%. We found evidence that bracing is effective in achieving curve regression among compliant AIS patients eligible for bracing, i.e. curves of 25° to 40°. A similar effect was also found in patients with major curve sizes ranging from 40° to 60° when combined with scoliosis-specific exercises. There was also evidence showing that a low apical vertebral body height ratio, in-brace correction, smaller pre-brace Cobb angle, and daily pattern of brace-wear compliance predict curve regression after bracing. Conclusion Bracing provides a corrective effect on scoliotic curves of AIS patients to achieve curve regression, given there is high compliance rate and the incorporation of exercises.
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Affiliation(s)
- Shiyu Tang
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
| | - Jason P Y Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
| | - Prudence W H Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
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Duarte MP, Joncas J, Parent S, Duval M, Chémaly O, Brassard F, Mac-Thiong JM, Barchi S, Labelle H. A Dangerous Curve: Impact of the COVID-19 Pandemic on Brace Treatment in Adolescent Idiopathic Scoliosis. Global Spine J 2024; 14:513-518. [PMID: 35816368 PMCID: PMC9274152 DOI: 10.1177/21925682221113487] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Observational Cohort study. OBJECTIVES We aim to document the abandon and irregular compliance rate towards brace treatment during the COVID-19 pandemic and its impact on AIS progression. METHODS We reviewed a database of AIS patients recruited between March and September 2020. We included AIS patients under brace treatment according to SRS criteria. The patients were divided in 2 cohorts: those with self-reported Good-Compliance (GC) to treatment and those who had a Bad-Compliance (BC). Data analysis included biometric and radiographic data at first visit and last follow-up and percentage of progression. Unpaired student-t tests and Chi2 were used for comparison. RESULTS 152 patients met inclusion criteria. 89 patients (age:12.1y.o.±1.4) reported good adherence to treatment, while 63 patients (age:12.7y.o.±1.8) were not compliant. Within the BC group, 18 patients reported irregular brace wear, while 45 had completely abandoned treatment (abandon rate of 29%). The GC cohort started treatment with a mean main thoracic (MT) curve of 26° and finished with 27°. The mean difference between measurements was +.65°±7.5; mean progression rate was -4.6%. However, the BC cohort started with a mean MT curve of 27° and finished with 32°, with a mean increase of +5°±8 and a mean progression rate of -13%. The differences between the 2 cohorts were statistically significant (P = .0002). Six patients from the BC group progressed and were offered surgery. CONCLUSION The abandon rate of brace treatment in AIS significantly increased during the first wave of COVID-19 pandemic. Patients who voluntarily discontinued treatment had significant increases in curve progression and surgical indication rates. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Matias Pereira Duarte
- Orthopaedic Division, Sainte-Justine University Hospital Center, Montréal, QC, Canada
- University of Montreal, Surgery Department, Montréal, Québec, Canada
| | - Julie Joncas
- Orthopaedic Division, Sainte-Justine University Hospital Center, Montréal, QC, Canada
| | - Stefan Parent
- Orthopaedic Division, Sainte-Justine University Hospital Center, Montréal, QC, Canada
- University of Montreal, Surgery Department, Montréal, Québec, Canada
| | - Mylène Duval
- Orthopaedic Division, Sainte-Justine University Hospital Center, Montréal, QC, Canada
| | - Olivier Chémaly
- Orthopaedic Division, Sainte-Justine University Hospital Center, Montréal, QC, Canada
- University of Montreal, Surgery Department, Montréal, Québec, Canada
| | - Félix Brassard
- Orthopaedic Division, Sainte-Justine University Hospital Center, Montréal, QC, Canada
- University of Montreal, Surgery Department, Montréal, Québec, Canada
| | - Jean-Marc Mac-Thiong
- Orthopaedic Division, Sainte-Justine University Hospital Center, Montréal, QC, Canada
- University of Montreal, Surgery Department, Montréal, Québec, Canada
| | - Soraya Barchi
- Orthopaedic Division, Sainte-Justine University Hospital Center, Montréal, QC, Canada
| | - Hubert Labelle
- Orthopaedic Division, Sainte-Justine University Hospital Center, Montréal, QC, Canada
- University of Montreal, Surgery Department, Montréal, Québec, Canada
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Peuchot C, Cassoudesalle H, David R, Jourdan L, Glize B, de Seze M. Could trochanteric pelvic stabilization be removed from the adolescent idiopathic scoliosis brace? A prospective pilot study. Prosthet Orthot Int 2024; 48:55-62. [PMID: 37708334 DOI: 10.1097/pxr.0000000000000258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 06/09/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Idiopathic scoliosis is the most common musculoskeletal deformity in children. There is a dose-response relationship between compliance and improvement in scoliosis. The literature revealed that esthetic considerations have negative consequences on the quality of life (QOL) of patients and consequently on wearing time of the brace. To minimize esthetic problems and then increase QOL and wearing time, we proposed a new relay brace named "corset Collerette" without a pelvic-trochanteric base. METHODS A prospective cohort study was conducted in the rehabilitation department of Bordeaux University Hospital. Patients consulting for adolescent idiopathic scoliosis were registered in a prospective hospital database. The patients expressing unwillingness to wear the usual brace or who had decreased compliance were offered the corset Collerette and were included in a 3-month follow-up. Outcome measures assessed at baseline and at 3 months were Scoliosis Research Society Outcomes Questionnaire (SRS-22) and Brace Questionnaire scales and wearing time. Cobb's angle evolution since the start of bracing was also collected. The primary end point was the QOL assed by the SRS-22 scale at 3 months of follow-up. RESULTS The first 38 patients agreeing to wear the corset Collerette were included in the study. The QOL assessed by the SRS-22 was significantly improved with the corset Collerette ( p < 0.05). There was no significant increase in wearing time and thoracic Cobb's angles between baseline and follow-up ( p > 0.05). CONCLUSION The switch to the corset Collerette allowed an improvement in the QOL of the patients and avoid a decrease in compliance with wearing the brace and maintain the same in-brace Cobb's angles.
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Affiliation(s)
- Charline Peuchot
- Handicap Activity Cognition Health-HACS BPH Inserm U1219, University of Bordeaux, Bordeaux, France
- Department of Physical Medicine and Rehabilitation, CHU de Bordeaux, Bordeaux, France
- Department of Physical Medicine and Rehabilitation, Trois Marres Tampon, Ile de La Réunion, France
| | - Hélène Cassoudesalle
- Handicap Activity Cognition Health-HACS BPH Inserm U1219, University of Bordeaux, Bordeaux, France
- Department of Physical Medicine and Rehabilitation, CHU de Bordeaux, Bordeaux, France
| | - Romain David
- Department of Physical Medicine and Rehabilitation, CHU de Poitiers, Poitiers, France
| | - Louca Jourdan
- Handicap Activity Cognition Health-HACS BPH Inserm U1219, University of Bordeaux, Bordeaux, France
- Department of Physical Medicine and Rehabilitation, CHU de Bordeaux, Bordeaux, France
| | - Bertrand Glize
- Handicap Activity Cognition Health-HACS BPH Inserm U1219, University of Bordeaux, Bordeaux, France
- Department of Physical Medicine and Rehabilitation, CHU de Bordeaux, Bordeaux, France
| | - Mathieu de Seze
- Handicap Activity Cognition Health-HACS BPH Inserm U1219, University of Bordeaux, Bordeaux, France
- Department of Physical Medicine and Rehabilitation, CHU de Bordeaux, Bordeaux, France
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Capek V, Baranto A, Brisby H, Westin O. Nighttime versus Fulltime Brace Treatment for Adolescent Idiopathic Scoliosis: Which Brace to Choose? A Retrospective Study on 358 Patients. J Clin Med 2023; 12:7684. [PMID: 38137753 PMCID: PMC10743948 DOI: 10.3390/jcm12247684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/10/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023] Open
Abstract
The purpose of this study is to retrospectively compare the effectiveness of fulltime Boston Brace (BB) and Providence Nighttime Brace (PNB) treatments in moderate scoliotic curves (20-40°) at a single institution and to carry out analyses for different subgroups. Inclusion criteria: idiopathic scoliosis, age ≥ 10 years, curve 20-40°, Risser ≤ 3 or Sanders stage ≤ 6 and curve apex below T6 vertebra. Exclusion criteria: incomplete radiological or clinical follow-up and previous treatment. The primary outcome was failure according to the SRS outcome assessment: increase in main curve > 5° and/or increase in main curve beyond 45° and/or surgery. The subgroup analyses were secondary outcomes. In total, 249 patients in the PNB and 109 in the BB groups were included. The BB showed a higher success rate compared to the PNB (59% and 46%, respectively) in both crude and adjusted comparisons (p = 0.029 and p = 0.007, respectively). The subgroup analyses showed higher success rates in pre-menarchal females, thoracic curves and curves > 30° in the BB group compared to the PNB group. Based on the findings, fulltime braces should be the treatment of choice for more immature patients and patients with larger and thoracic curves while nighttime braces might be sufficient for post-menarchal females and patients with lumbar and smaller curves.
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Affiliation(s)
- Vojtech Capek
- Department of Orthopedics, Sahlgrenska University Hospital, SE413 45 Gothenburg, Sweden (O.W.)
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SE413 45 Gothenburg, Sweden
| | - Adad Baranto
- Department of Orthopedics, Sahlgrenska University Hospital, SE413 45 Gothenburg, Sweden (O.W.)
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SE413 45 Gothenburg, Sweden
| | - Helena Brisby
- Department of Orthopedics, Sahlgrenska University Hospital, SE413 45 Gothenburg, Sweden (O.W.)
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SE413 45 Gothenburg, Sweden
| | - Olof Westin
- Department of Orthopedics, Sahlgrenska University Hospital, SE413 45 Gothenburg, Sweden (O.W.)
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SE413 45 Gothenburg, Sweden
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Bae BH, Ham CH, Patel U, Suh Y. Psychosocial Effect of Brace Treatment in Adolescent Idiopathic Scoliosis: A Study Using EQ-5D. Clin Spine Surg 2023; 36:E488-E492. [PMID: 37482631 DOI: 10.1097/bsd.0000000000001489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 06/21/2023] [Indexed: 07/25/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To evaluate psychosocial effect of brace treatment in adolescent idiopathic scoliosis (AIS) using EuroQoL 5-dimension (EQ-5D) depression and anxiety category. BACKGROUND AIS is a structural abnormality of the spine often affecting patients during the puberty, a critical period of developing psychosocial problems. Many questionnaires had been adapted to evaluate mental health and health-related quality of life of AIS patients. However, these questionnaires are often time consuming and difficult to obtain. Therefore, a simpler substitute-EQ-5D-was evaluated. METHODS This is a single-center retrospective cohort analysis of adult idiopathic scoliosis patients aged between 8 and 19, visiting outpatient's clinic. Beck's depression inventory, EQ-5D and EuroQoL visual assessment scale, and Objectified Body Consciousness Scale for Youth were compared between brace group and non-brace group of AIS patients. Furthermore, difference between male and female were evaluated within brace group. RESULTS None of the questionnaire showed significant difference between brace and non-brace group. However, when male and female patients were compared within brace group, female patients were significantly more susceptible to depression and anxiety based on EQ-5D and body consciousness. Furthermore, depression and anxiety according to both BDI and EQ-5D were significantly correlated to health-related quality of life. CONCLUSION During brace treatment of female AIS patients, psychosocial status played a significant role in health-related quality of life. EQ-5D is a simple way to monitor the mental health status.
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Affiliation(s)
| | | | - Udit Patel
- Orthopedics, Korea University Guro Hospital, Korea University College of Medicine, Seoul
| | - Yunsun Suh
- Chadwick International School, Incheon, Republic of Korea
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Liu S, Ho LY, Hassan Beygi B, Wong MS. Effectiveness of Orthotic Treatment on Clinical Outcomes of the Patients with Adolescent Idiopathic Scoliosis Under Different Wearing Compliance Levels: A Systematic Review. JBJS Rev 2023; 11:01874474-202310000-00010. [PMID: 38079521 DOI: 10.2106/jbjs.rvw.23.00110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
BACKGROUND Wearing spinal orthosis for 16 to 23 hours a day during the teenage years could be challenging and stressful for patients with adolescent idiopathic scoliosis (AIS). The investigation of clinical outcomes under various orthosis-wearing compliances can provide helpful insight into orthotic treatment dosage. This systematic review aims to investigate actual orthosis-wearing compliance and evaluate the effectiveness of orthotic treatment in controlling scoliotic curvature and preventing surgery for patients with AIS under various levels of orthosis-wearing compliance. METHODS A literature search of 7 electronic databases, namely PubMed, MEDLINE, Cochrane Library, Scopus, CINAHL Complete, Web of Science, and Embase, was conducted on May 19, 2023. Participant characteristics, orthotic treatment protocols, compliance information, outcome measures, and key findings were extracted. The Newcastle-Ottawa Scales were used to evaluate the quality of included cohort and case-control studies. RESULTS This study systematically reviewed 17 of 1,799 identified studies, including 1,981 subjects. The actual compliance was inconsistent and ranged from 7.0 to 18.8 hours daily. The proportion of compliant subjects in each study varied from 16.0% to 78.6% due to the heterogeneity of calculation period, measurement methods, and orthosis prescription time. Thirteen studies were investigated to determine the effectiveness of orthotic treatment in controlling curve deformity under different compliance groups, and 2 studies compared the compliance under different treatment outcomes. The rate of curve progression, defined as surpassing the measurement error threshold of 5° or 6° after orthotic treatment, varied from 1.8% to 91.7% across the studies. Ten studies defined the treatment failure, surgery, or surgery indication as Cobb angle progressing to a certain degree (e.g., 40°, 45°, or 50°) and reported failure/surgery/surgery indication rates ranging from 0.0% to 91.7% among different compliance level groups. CONCLUSION This review found that the actual compliance with orthotic treatment was generally lower than the prescribed wearing time and exhibited wide variation among different studies. The electronic compliance monitors show promise in regular orthotic treatment practice. More importantly, the group with higher and consistent compliance has significantly less curve progression and lower surgery or failure rate than the group with lower and inconsistent compliance. Further studies are proposed to investigate the minimal orthosis-wearing compliance in patients with AIS treated with different types of orthoses. LEVEL OF EVIDENCE Level III, Systematic Review. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Shan Liu
- Department of Biomedical Engineering, Faculty of Engineering, The Hong Kong Polytechnic University, Hong Kong, China
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Heegaard M, Tøndevold N, Dahl B, Andersen TB, Gehrchen M, Ohrt-Nissen S. Does Risser stage accurately predict the risk of curve progression in patients with adolescent idiopathic scoliosis treated with night-time bracing? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3077-3083. [PMID: 37314578 DOI: 10.1007/s00586-023-07808-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 04/03/2023] [Accepted: 06/01/2023] [Indexed: 06/15/2023]
Abstract
PURPOSE Risser stage is widely used as a marker for skeletal maturity (SM) and thereby an indirect measure for the risk of progression of adolescent idiopathic scoliosis (AIS). The Scoliosis Research Society recommends bracing for Risser stages 0-2 as Risser stage 3 or above is considered low risk. Very few studies have assessed the risk of progression during bracing in Risser stages 3-4. The objective of the current study is to determine if Risser stages 3-4 provide a meaningful cutoff in terms of progression risk in patients with AIS treated with night-time bracing. METHODS AIS patients treated with night-time brace from 2005 to 2018 with a Cobb angle between 25 and 40 degrees and Risser stages 0-4 were retrospectively included. Curve progression (> 5 degrees increase) was monitored until surgery or SM. Skeletal maturity was defined as either 2 years postmenarchal, no height development or closed ulnar epiphyseal plates on radiographs. RESULTS One hundred and thirty-five patients were included (Risser stages 0-2: n = 86 and 3-4: n = 49). Overall, radiographic curve progression occurred in 52% while progression beyond 45 degrees was seen in 35%. The progression rate in the Risser 0-2 group was 60% and 37% in the Risser 3-4 group (p = 0.012). In multivariate logistic regression analysis, adjusted for Risser stages and age, only premenarchal status showed a statistically significant association with progression (OR: 2.68, 95%CI 1.08-6.67). CONCLUSION Risser stage does not provide a clinically meaningful differentiation of progression risk in AIS patients treated with a night-time brace. Risk assessment should include other more reliable measures of skeletal growth potential.
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Affiliation(s)
- Martin Heegaard
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark.
| | - Niklas Tøndevold
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Benny Dahl
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Thomas B Andersen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Søren Ohrt-Nissen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
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Asada T, Kotani T, Sakuma T, Iijima Y, Nakayama K, Inage K, Shiga Y, Akazawa T, Minami S, Ohtori S, Koda M, Yamazaki M. Impact of Brace-Related Stress on Brace Compliance in Adolescent Idiopathic Scoliosis: A Single-Center Comparative Study Using Objective Compliance Measurement and Brace-Related Stress. Spine Surg Relat Res 2023; 7:377-384. [PMID: 37636154 PMCID: PMC10447194 DOI: 10.22603/ssrr.2022-0246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/15/2023] [Indexed: 03/18/2023] Open
Abstract
Introduction This study aimed to investigate the brace compliance and clinical background of patients with adolescent idiopathic scoliosis (AIS) who demonstrate different degrees of psychological brace-related stress. Methods Forty-five patients initiating brace treatment with a Cobb angle between 25° and 45° were included. Patients receiving brace treatment for AIS were administered a questionnaire for brace-related stress (i.e., the Japanese version of the Bad Sobernheim Stress Questionnaire-Brace [JBSSQ-brace]). Based on their scores, we allocated the patients into two stress groups: mild-stress (≥16 points) and below-moderate-stress (<16 points). We investigated the character of brace compliance and brace-related psychological stress in all patients and compared the demographics and brace compliance between both groups. Results Forty-one of 45 patients completed the study. The mean JBSSQ-brace scores were 18.7±5.1, 19.1±5.2, and 18.7±5.0 points at the 1-month, 4-month, and 1-year follow-ups, respectively. There was no significant change in JBSSQ-brace scores over one year after the brace prescription (P=0.332). There was no difference in-brace compliance between seasons during the first month of brace prescription (P=0.252). Both groups' overall brace compliance was comparable (below-moderate: 17.1±7.1 h/day vs. mild: 20.4±3.0 h/day; P=0.078). The mild-stress group showed better compliance than the below-moderate-stress group on weekdays (below-moderate: 17.0±6.9 h/day vs. mild: 20.5±2.8 h/day; P=0.048) and at nighttime (below-moderate: 82.3%±27.0%/nighttime vs. mild: 93.8%±12.4%/nighttime; P=0.008). Conclusions Overall, brace compliance was comparable among patients with different brace-related stress, but brace compliance during weekdays and nighttime was significantly better in the mild-stress group.
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Affiliation(s)
- Tomoyuki Asada
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Toshiaki Kotani
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Tsuyoshi Sakuma
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Yasushi Iijima
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Keita Nakayama
- Department of Orthopedic Surgery, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Kazuhide Inage
- Department of Orthopedic Surgery, Chiba University, Graduate School of Medicine, Chiba, Japan
| | - Yasuhiro Shiga
- Department of Orthopedic Surgery, Chiba University, Graduate School of Medicine, Chiba, Japan
| | - Tsutomu Akazawa
- Department of Orthopedic Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Shohei Minami
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Seiji Ohtori
- Department of Orthopedic Surgery, Chiba University, Graduate School of Medicine, Chiba, Japan
| | - Masao Koda
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Masashi Yamazaki
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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11
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Khan F, Chinnery L, Loveridge J. Can physiotherapy alone reduce spinal curvature in patients with idiopathic scoliosis? Arch Dis Child 2023; 108:323-325. [PMID: 36717211 DOI: 10.1136/archdischild-2022-325101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 01/16/2023] [Indexed: 01/31/2023]
Affiliation(s)
- Faris Khan
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Lucy Chinnery
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Jacob Loveridge
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
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12
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Cho HE, Jang CW, Cho SR, Choi WA, Park JH. Mobile Apps to Improve Brace-Wearing Compliance in Patients with Idiopathic Scoliosis: A Quality Analysis, Functionality Review and Future Directions. J Clin Med 2023; 12:jcm12051972. [PMID: 36902759 PMCID: PMC10003789 DOI: 10.3390/jcm12051972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 03/06/2023] Open
Abstract
This study was performed to review which mHealth apps that improve brace-wearing compliance are currently available, and to carry out their quality assessments by listing their functionalities. We found ten mHealth apps in the literature review and commercial mHealth apps market (Google Play and App store). Then, the quality of these apps was evaluated by their transparency, health content, excellent technical content, security/privacy, issues of usability, and subjective ratings (THESIS) scale, and the functionalities of the included apps were reviewed. Regarding these functionalities, four categories (data acquisition, compliance enhancement, educational components, and additional functionalities) and twelve subcategories were identified. The mean overall quality of the apps was 3.00 out of 5. Although four of the apps achieved a score of 3.0 or more for their overall quality, indicating an acceptable quality, none of the apps scored higher than 4.0, which indicated a high or excellent quality. According to the sections, the transparency section had the highest rating (3.92) and the security/privacy section received the lowest rating (2.02). Given that the overall quality of current mHealth apps was not high, and their potential to motivate patients with idiopathic scoliosis to adhere to their bracing treatment, it is necessary to develop high-quality apps with appropriate functionalities for supporting brace treatment.
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Affiliation(s)
- Han Eol Cho
- Department of Rehabilitation Medicine, Rehabilitation Institute of Neuromuscular Disease, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06229, Republic of Korea
| | - Chan Woong Jang
- Department of Rehabilitation Medicine, Rehabilitation Institute of Neuromuscular Disease, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06229, Republic of Korea
| | - Sung Rae Cho
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
- Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
- Graduate Program of Biomedical Engineering, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Won Ah Choi
- Department of Rehabilitation Medicine, Rehabilitation Institute of Neuromuscular Disease, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06229, Republic of Korea
- Correspondence: (W.A.C.); (J.H.P.); Tel.: +82-2-2019-3698 (W.A.C.); +82-2-2019-3491 (J.H.P.)
| | - Jung Hyun Park
- Department of Rehabilitation Medicine, Rehabilitation Institute of Neuromuscular Disease, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06229, Republic of Korea
- Department of Integrative Medicine, Yonsei University College of Medicine, Seoul 06229, Republic of Korea
- Department of Medical Device Engineering and Management, Yonsei University College of Medicine, Seoul 06229, Republic of Korea
- Correspondence: (W.A.C.); (J.H.P.); Tel.: +82-2-2019-3698 (W.A.C.); +82-2-2019-3491 (J.H.P.)
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13
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The natural history of curve behavior after brace removal in adolescent idiopathic scoliosis: a literature review. Spine Deform 2023; 11:567-578. [PMID: 36715866 PMCID: PMC10147768 DOI: 10.1007/s43390-022-00638-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 12/26/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE Brace treatment is the most common nonoperative treatment to prevent curve progression in adolescent idiopathic scoliosis (AIS). The goal of this review and analysis is to characterize curve behavior after completion of brace treatment and to identify factors that may facilitate the estimation of long-term curve progression. METHOD A review of the English language literature was completed using the MEDLINE (PUBMED) database of publications after 1990 until September 2020. Studies were included if they detailed a minimum of 1 year post-brace removal follow-up of AIS patients. Data retrieved from the articles included Cobb angle measurements of the major curves at "in-brace," weaning, and follow-up visit(s) for all patients described and for subset populations. RESULTS From 75 articles, 18 relevant studies describing a follow-up period of 1-25 years following brace removal were included in the analyses. The reviewed literature demonstrates that curves continue to progress after brace treatment is completed with three main phases of progression: (i) immediate (upon brace removal) where a mean curve progression of 7° occurs; (ii) short term (within five years of brace removal) where a relatively high progression rate is evident (0.8°/year); and (iii) long term (more than five years after brace removal) where the progression rate slows (0.2°/year). The magnitude and rate of curve progression is mainly dependent on the degree of curve at weaning as curves weaned at < 25° progress substantially less than curves weaned at ≥ 25° at 25 years. CONCLUSION Curves continue to progress after brace removal and the rate and magnitude of progression are associated with the curve size at weaning, with larger curves typically exhibiting more rapid and severe progression. This analysis provides physicians and patients the ability to estimate long-term curve size based on the curve size at the time of weaning. LEVEL OF EVIDENCE IV.
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14
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Gornitzky AL, England P, Kiani SN, Yellin JL, Flynn JM. Why Don't Adolescents Wear Their Brace? A Prospective Study Investigating Psychosocial Characteristics That Predict Scoliosis Brace Wear. J Pediatr Orthop 2023; 43:51-60. [PMID: 36194756 DOI: 10.1097/bpo.0000000000002272] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although bracing for adolescent idiopathic scoliosis can prevent curve progression and reduce the risk for future surgery, children frequently do not wear their braces as prescribed. The purpose of this study is to investigate how a broad array of psychosocial characteristics predict future compliance with scoliosis brace wear. METHODS This was a single institution, prospective cohort study. All adolescents prescribed a first-time brace for adolescent idiopathic scoliosis were eligible. Patients and their parents completed a separate series of questionnaires that assessed baseline psychosocial characteristics across 6 domains: (1) brace-specific attitudes; (2) body image and self-esteem; (3) school performance and social relationships; (4) psychological health; (5) family functioning; and (6) demographics and scoliosis-specific details (242 total questions across 12 validated questionnaires). Objective brace compliance was collected using temperature-sensitive monitors. Defining compliance as percentage of brace prescription completed, comparative analyses were performed to identify baseline psychosocial characteristics that were associated with future wear. A composite measure (Bracing Fidelity Follow-Up Scale [BFFS]) of the 12 most predictive individual questions across all domains (both parent and adolescent) was constructed to help assess which adolescents were at highest risk of failure to wear their brace. Total BFFS score for each parent-adolescent dyad who completed all the included surveys was then determined by awarding one point for each factor that positively influenced future brace wear (maximum 12 points), and a correlation was calculated between total score and percent adherence to prescribed brace wear. RESULTS A total of 41 patients were included. On average, patients with high self-esteem, above average peer relationships and poor brace-specific attitudes had lower brace compliance, although patients with increased loneliness and parental religiousness had higher compliance. Body image, socioeconomic status, family dynamics, and school performance had no significant relationship with brace use. Total score on the Bracing Fidelity Follow-Up Scale (BFFS) was significantly associated with improved brace wear (r=0.687, P <0.001). Those with a score of 6 or above (n=15/33 [45%], median compliance 96%) were more reliable users (15/15 with compliance >75%), and those with a score of 5 or less (n=18/33 [55%], median compliance 50%) had less consistent brace wear (9/18 with compliance <50%). CONCLUSION This prospective study identifies numerous baseline psychosocial factors that are associated with future compliance with scoliosis brace wear. Although in need of further validation before widespread clinical application, the novel BFF scale offers a potential opportunity to partially discriminate between compliant and noncompliant scoliosis brace users such that supportive resources (eg, supportive counseling, peer-support groups, additional provider-based education, etc.) can be targeted to those patients most likely to benefit. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Alex L Gornitzky
- Division of Orthopaedics, The Children's Hospital of Philadelphia, Philadelphia, PA
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15
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Cantele F, Posanti E, Pittarello C, Masiero S. Is higher compliance to brace therapy associated with poorer quality of life and self-image? A 36-months follow-up study. J Back Musculoskelet Rehabil 2023; 36:1163-1169. [PMID: 37458018 DOI: 10.3233/bmr-220361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Brace treatment is the most effective tool for avoiding curve progression in moderate adolescent idiopathic scoliosis and high adherence is required to achieve therapeutic success. Despite this, the compliance often is impaired by the concern about the psychological well-being of adolescents. OBJECTIVE This 36-month follow-up study investigated if the patients most adherent to brace treatment could report a stronger impairment in the quality of life and body image. METHODS 64 adolescents with idiopathic scoliosis responded to the Scoliosis Research Society-22 revised Patient Questionnaire at 12, 24, and 36 months after prescription of a TLSO rigid brace. Retrospectively, participants who wore a brace for more than 75% of the prescribed time were assigned to the good-compliance group (GC); the others formed the poor-compliance group (PC). RESULTS At 12 months the GC group showed higher scores in treatment satisfaction and at 36 months they did not differ from the PC group in the overall SRS-22r score. Moreover, they achieved a statistically significant improvement in the scoliosis severity, although they showed lower scores in the self-image domain. CONCLUSION In our patient's cohort, increased brace adherence does not compromise QoL and provides better treatment outcomes. However, more attention is needed to maintain good self-perception.
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Affiliation(s)
- Francesca Cantele
- Physical Medicine and Rehabilitation School, University of Padua, Padova, Italy
| | - Elena Posanti
- Physical Medicine and Rehabilitation School, University of Padua, Padova, Italy
| | - Chiara Pittarello
- Physical Medicine and Rehabilitation School, University of Padua, Padova, Italy
| | - Stefano Masiero
- Physical Medicine and Rehabilitation School, University of Padua, Padova, Italy
- Department of Neurosciences, Section of Rehabilitation, University of Padua, Padova, Italy
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16
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Whitaker AT, Hresko MT, Miller PE, Verhofste BP, Beling A, Emans JB, Karlin LI, Hedequist DJ, Glotzbecker MP. Bracing for juvenile idiopathic scoliosis: retrospective review from bracing to skeletal maturity. Spine Deform 2022; 10:1349-1358. [PMID: 35852786 PMCID: PMC9579105 DOI: 10.1007/s43390-022-00544-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 06/11/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Juvenile idiopathic scoliosis (JIS) outcomes with brace treatment are limited with poorly described bracing protocols. Between 49 and 100% of children with JIS will progress to surgery, however, young age, long follow-up, and varying treatment methods make studying this population difficult. The purpose of this study is to report the outcomes of bracing in JIS treated with a Boston brace™ and identify risk factors for progression and surgical intervention. METHODS This is a single-center retrospective review of 175 patients with JIS who initiated brace treatment between the age of 4 and 9 years. A cohort of 140 children reached skeletal maturity; 91 children had surgery or at least 2 year follow-up after brace completion. Standard in-brace protocol for scoliosis 320° was a Boston brace for 18-20 h/day after MRI (n = 82). Family history, MRI abnormalities, comorbidities, curve type, curve magnitude, bracing duration, number of braces, compliance by report, and surgical interventions were recorded. RESULTS Children were average 7.9 years old (range 4.1-9.8) at the initiation of bracing. The Boston brace™ was prescribed in 82 patients and nine used night bending brace. Mid-thoracic curves (53%) was the most frequent deformity. Maximum curve at presentation was on average 30 ± 9 degrees, in-brace curve angle was 16 ± 8 degrees, and in-brace correction was 58 ± 24 percent. Patients were braced an average of 4.6 ± 1.9 years. 61/91 (67%) went on to posterior spinal fusion at 13.3 ± 2.1 (range 9.3-20.9) years and curve magnitude of 61 ± 12 degrees. Of those that underwent surgery, 49/55 (86%) progressed > 10°, 6/55 (11%) stabilized within 10°, and 0/55 (0%) improved > 10° with brace wear. No children underwent growth-friendly posterior instrumentation. Of the 28 who did not have surgical correction, 3 (11%) progressed > 10°, 13/28 (46%) stabilized within 10°, and 12/28 (43%) improved > 10° with brace wear. CONCLUSIONS This large series of JIS patients with bracing followed to skeletal maturity with long-term follow-up. Surgery was avoided in 33% of children with minimal to no progression, and no child underwent posterior growth-friendly constructs. Risk factors of needing surgery were noncompliance and larger curves at presentation.
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Affiliation(s)
- Amanda T Whitaker
- Department of Orthopaedic Surgery, Shriners Hospital for Children Northern California, 2425 Stockton Blvd, Sacramento, CA, 95817, USA.
- Department of Orthopaedic Surgery, University of California Davis, 4680 Y St, Sacramento, CA, 95817, USA.
| | - Michael Timothy Hresko
- Department of Orthopedic Surgery, Boston Children's Hospital, 300 Longwood Ave HU 221, Boston, MA, 02115, USA
| | - Patricia E Miller
- Department of Orthopedic Surgery, Boston Children's Hospital, 300 Longwood Ave HU 221, Boston, MA, 02115, USA
| | - Bram P Verhofste
- Department of Orthopedic Surgery, Boston Children's Hospital, 300 Longwood Ave HU 221, Boston, MA, 02115, USA
| | - Alexandra Beling
- Department of Orthopedic Surgery, Boston Children's Hospital, 300 Longwood Ave HU 221, Boston, MA, 02115, USA
| | - John B Emans
- Department of Orthopedic Surgery, Boston Children's Hospital, 300 Longwood Ave HU 221, Boston, MA, 02115, USA
| | - Lawrence I Karlin
- Department of Orthopedic Surgery, Boston Children's Hospital, 300 Longwood Ave HU 221, Boston, MA, 02115, USA
| | - Daniel J Hedequist
- Department of Orthopedic Surgery, Boston Children's Hospital, 300 Longwood Ave HU 221, Boston, MA, 02115, USA
| | - Michael P Glotzbecker
- Department of Orthopedic Surgery, Rainbow Babies and Children's Hospital, 11100 Euclid Ave, Cleveland, OH, 44106, USA
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17
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Nonoperative management of adolescent idiopathic scoliosis (AIS) using braces. Prosthet Orthot Int 2022; 46:383-391. [PMID: 35320151 DOI: 10.1097/pxr.0000000000000117] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 01/06/2022] [Indexed: 02/03/2023]
Abstract
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.
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18
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De Chelle G, Rampal V, Bentellis I, Fernandez A, Bertoncelli C, Clément JL, Solla F. Adolescent and Juvenile Idiopathic Scoliosis: Which Patients Obtain Good Results with 12 Hours of Cheneau–Toulouse–Munster Nighttime Bracing? CHILDREN 2022; 9:children9060909. [PMID: 35740846 PMCID: PMC9221823 DOI: 10.3390/children9060909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/27/2022] [Accepted: 06/09/2022] [Indexed: 11/24/2022]
Abstract
Background: The results of 12 h nighttime Cheneau–Toulouse–Munster (CTM) brace wear on adolescent idiopathic scoliosis are poorly described. Objective: The main objective was to analyze the efficiency of 12 h nighttime CTM brace wear on adolescent idiopathic scoliosis. The secondary objective was to identify the factors influencing good results. Methods: One hundred and fifty consecutive patients treated between 2006 and 2017 were retrospectively analyzed with subgroup analysis for the main curve pattern (main thoracic or main lumbar). The inclusion criteria were evolutive scoliosis, 12 h nighttime CTM brace wear, Risser stages 0-1-2 at the time of the prescription, and Cobb angle below 45 degrees. Success was defined as no surgery, and the main curve Cobb angle (CA) progression ≤5°. The overcurve was defined as the proximal thoracic curve above the main thoracic and mid-thoracic above the main lumbar curves. A logistic regression model was built to assess the predictors of success. RESULTS: Overall success was 70%: 60% for main thoracic (MT) and 84% for main lumbar scoliosis (ML) (p = 0.003). Efficacy was 62% at Risser stage 0 and 78% at Risser stage 1–2 (p = 0.054). For MT, failure was associated with high in-brace sagittal C7 tilt (Odds Ratio = 0.72, p = 0.014) and low initial overcurve CA (Odds Ratio = 0.42, p = 0.044). For ML, a high standing height was associated with success (OR = 1.42, p = 0.035), and frontal unbalanced C7 tilt was associated with failure (OR = 0.43, p = 0.02). Conclusion: Twelve-hour nighttime CTM brace wear provided good results for main lumbar curves with balanced frontal C7 tilt. For MT, this treatment is indicated if the in-brace sagittal C7 tilt is well balanced from Risser stage 2.
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Affiliation(s)
- Gautier De Chelle
- Paediatric Orthopaedic Unit, Lenval Foundation, 57, Avenue de la Californie, 06200 Nice, France; (G.D.C.); (V.R.); (C.B.); (J.-L.C.)
| | - Virginie Rampal
- Paediatric Orthopaedic Unit, Lenval Foundation, 57, Avenue de la Californie, 06200 Nice, France; (G.D.C.); (V.R.); (C.B.); (J.-L.C.)
| | | | - Arnaud Fernandez
- Children’s Psychiatry, Lenval Foundation, 57, Avenue de la Californie, 06200 Nice, France;
| | - Carlo Bertoncelli
- Paediatric Orthopaedic Unit, Lenval Foundation, 57, Avenue de la Californie, 06200 Nice, France; (G.D.C.); (V.R.); (C.B.); (J.-L.C.)
| | - Jean-Luc Clément
- Paediatric Orthopaedic Unit, Lenval Foundation, 57, Avenue de la Californie, 06200 Nice, France; (G.D.C.); (V.R.); (C.B.); (J.-L.C.)
| | - Federico Solla
- Paediatric Orthopaedic Unit, Lenval Foundation, 57, Avenue de la Californie, 06200 Nice, France; (G.D.C.); (V.R.); (C.B.); (J.-L.C.)
- Correspondence: ; Tel.: +33-4-9203-0491
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19
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Simhon ME, Fields MW, Grimes KE, Bakarania P, Matsumoto H, Boby AZ, Berdishevsky H, Roye BD, Roye DP, Vitale MG. Completion of a formal physiotherapeutic scoliosis-specific exercise training program for adolescent idiopathic scoliosis increases patient compliance to home exercise programs. Spine Deform 2021; 9:691-696. [PMID: 33230667 DOI: 10.1007/s43390-020-00253-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 11/03/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Physiotherapeutic Scoliosis-Specific Exercise (PSSE) is a conservative approach for management of adolescent idiopathic scoliosis (AIS). Although there is Level I evidence for the efficacy of PSSE, compliance in the teenage population remains in question. The purpose of this study is to investigate the association between completion of formal PSSE training and compliance to prescribed home exercise programs (HEP). METHODS Patients with AIS evaluated at our institution between 2013 and 2015 with a minimum of one PSSE session were enrolled. A chart review and questionnaire completed by caregivers was utilized to assess HEP compliance following the final PSSE session at 1 week, 3 months, 1 year, and 2 years. Patients were divided into two groups, those completing formal training (10 or more PSSE sessions), and those who did not complete formal training (fewer than 10 sessions). RESULTS 81 patients were identified (mean age of 13.1 years; major curve of 31.3°). Patients who completed training demonstrated 50% compliance at 1 week (vs. 25.6% for non-completers, Odds Ratio (OR): 2.9, p = 0.027), 41.2% at 3 months (vs. 18.9% for non-completers, OR: 3.0, p = 0.044), 23.5% at 1 year (vs. 13.5% for non-completers, OR: 2.0, p = 0.281), and 25.7% at 2 years (vs. 13.5% for non-completers, OR: 2.2, p = 0.197). The mean HEP duration (minutes) in patients who completed training was higher at 1 week (80.8 vs. 48, p = 0.010), 3 months (64.6 vs. 23.7, p ≤ 0.001), 1 year (35.3 vs. 22.7, p = 0.270), and 2 years (34.3 vs. 18.9, p = 0.140). CONCLUSION Patients who completed PSSE training maintained higher HEP compliance.
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Affiliation(s)
- Matthew E Simhon
- Columbia University Medical Center, 3959 Broadway-8 North, New York, NY, 10032, USA
| | - Michael W Fields
- Columbia University Medical Center, 3959 Broadway-8 North, New York, NY, 10032, USA
| | - Kelly E Grimes
- Columbia University Medical Center, 3959 Broadway-8 North, New York, NY, 10032, USA
| | - Prachi Bakarania
- Columbia University Medical Center, 3959 Broadway-8 North, New York, NY, 10032, USA
| | - Hiroko Matsumoto
- Columbia University Medical Center, 3959 Broadway-8 North, New York, NY, 10032, USA.
| | - Afrain Z Boby
- Columbia University Medical Center, 3959 Broadway-8 North, New York, NY, 10032, USA
| | - Hagit Berdishevsky
- Columbia University Medical Center, 3959 Broadway-8 North, New York, NY, 10032, USA
| | - Benjamin D Roye
- Columbia University Medical Center, 3959 Broadway-8 North, New York, NY, 10032, USA
| | - David P Roye
- Columbia University Medical Center, 3959 Broadway-8 North, New York, NY, 10032, USA
| | - Michael G Vitale
- Columbia University Medical Center, 3959 Broadway-8 North, New York, NY, 10032, USA
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20
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Strube P, Gunold M, Müller T, Leimert M, Sachse A, Pumberger M, Putzier M, Zippelius T. Influence of curve morphology and location on the efficacy of rigid conservative treatment in patients with adolescent idiopathic scoliosis. Bone Joint J 2021; 103-B:373-381. [PMID: 33517722 DOI: 10.1302/0301-620x.103b2.bjj-2020-1113.r2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of the present study was to answer the question whether curve morphology and location have an influence on rigid conservative treatment in patients with adolescent idiopathic scoliosis (AIS). METHODS We retrospectively analyzed AIS in 127 patients with single and double curves who had been treated with a Chêneau brace and physiotherapeutic specific exercises (B-PSE). The inclusion criteria were the presence of structural major curves ≥ 20° and < 50° (Risser stage 0 to 2) at the time when B-PSE was initiated. The patients were divided into two groups according to the outcome of treatment: failure (curve progression to ≥ 45° or surgery) and success (curve progression < 45° and no surgery). The main curve type (MCT), curve magnitude, and length (overall, above and below the apex), apical rotation, initial curve correction, flexibility, and derotation by the brace were compared between the two groups. RESULTS In univariate analysis treatment failure depended significantly on: 1) MCT (p = 0.008); 2) the apical rotation of the major curve before (p = 0.007) and during brace treatment (p < 0.001); 3) the initial and in-brace Cobb angles of the major (p = 0.001 and p < 0.001, respectively) and minor curves (p = 0.015 and p = 0.002); 4) major curve flexibility (p = 0.005) and the in-brace curve correction rates (major p = 0.008, minor p = 0.034); and 5) the length of the major curve (LoC) above (p < 0.001) and below (p = 0.002) the apex. Furthermore, MCT (p = 0.043, p = 0.129, and p = 0.017 in MCT comparisons), LoC (upper length p = 0.003, lower length p = 0.005), and in-brace Cobb angles (major p = 0.002, minor p = 0.027) were significant in binary logistic regression analysis. CONCLUSION Curve size, location, and morphology were found to influence the outcome of rigid conservative treatment of AIS. These findings may improve future brace design and patient selection for conservative treatment. Cite this article: Bone Joint J 2021;103-B(2):373-381.
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Affiliation(s)
- Patrick Strube
- Department of Orthopaedics at Waldkliniken Eisenberg, Jena University Hospital, Jena, Germany
| | - Maria Gunold
- Department of Orthopaedics at Waldkliniken Eisenberg, Jena University Hospital, Jena, Germany
| | - Tanja Müller
- Department of Orthopaedics at Waldkliniken Eisenberg, Jena University Hospital, Jena, Germany
| | - Mario Leimert
- Interdisciplinary Spine Center - Neurosurgical Spine Surgery, Asklepios Sächsische Schweiz Klinik Sebnitz, Sebnitz, Germany
| | - André Sachse
- Department of Orthopaedics at Waldkliniken Eisenberg, Jena University Hospital, Jena, Germany
| | - Matthias Pumberger
- Department of Orthopaedics, Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Putzier
- Department of Orthopaedics, Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Timo Zippelius
- Department of Orthopaedics at Waldkliniken Eisenberg, Jena University Hospital, Jena, Germany
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Can we predict the behavior of the scoliotic curve after bracing in adolescent idiopathic scoliosis? Τhe prognostic value of apical vertebra rotation. Spine Deform 2021; 9:91-98. [PMID: 32839925 DOI: 10.1007/s43390-020-00184-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 08/01/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE We aimed to recognize radiographic and clinical prognostic factors of scoliotic curve behaviour after bracing. METHODS Our prognostic study was based on the 25 years outcomes of a Boston braced AIS cohort between 1978 and 1993 that were previously reported. All patients were followed-up during bracing, at short term and 25 years post-bracing. We evaluated the impact of socio-demographic, clinical and radiological parameters on the loss of curve correction after bracing. RESULTS Seventy-seven patients were reevaluated at 25 years post-brace. The mean scoliotic curve was significantly increased after bracing until the 25 years follow-up (p < 0.001). The mean loss of curve correction between the end of bracing and long-term follow-up was independent on the curve type, apical vertebra, premenarcheal status at bracing, time and duration of bracing, Cobb angle before or after bracing. The mean apical vertebral rotation after bracing was significantly related to the loss of curve correction (Spearman ρ = 0.2, p = 0.049). Apical vertebral rotation (Perdriolle method) greater than 20° post-bracing had a three times higher chance of progression > 5° compared with lesser apical vertebral rotation (OR 3.071, CI 0.99-9.51). The rotation of the apical vertebra, type and magnitude of the scoliotic curve after bracing explained 27.4% of the variance in the loss of curve correction post-bracing (R square = 0.274, p < 0.001). CONCLUSION A scoliotic curve is expected to lose some correction after bracing. The apical vertebral rotation post-bracing mainly affected the long-term curve behaviour. Adolescents with apical vertebral rotation greater than 20° after bracing may need further attention. LEVEL OF EVIDENCE Prognostic study, Level II.
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22
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Aulisa AG, Toniolo RM, Falciglia F, Giordano M, Aulisa L. Long-term results after brace treatment with Progressive Action Short Brace in adolescent idiopathic scoliosis. Eur J Phys Rehabil Med 2020; 57:406-413. [PMID: 32990686 DOI: 10.23736/s1973-9087.20.06129-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Angelo G Aulisa
- Unit of Orthopedics and Traumatology, Institute of Scientific Research, Bambino Gesù Children's Hospital, Rome, Italy -
| | - Renato M Toniolo
- Unit of Orthopedics and Traumatology, Institute of Scientific Research, Bambino Gesù Children's Hospital, Rome, Italy
| | - Francesco Falciglia
- Unit of Orthopedics and Traumatology, Institute of Scientific Research, Bambino Gesù Children's Hospital, Rome, Italy
| | - Marco Giordano
- Unit of Orthopedics and Traumatology, Institute of Scientific Research, Bambino Gesù Children's Hospital, Rome, Italy
| | - Lorenzo Aulisa
- Department of Orthopedics, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
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Ohrt-Nissen S, Lastikka M, Andersen TB, Helenius I, Gehrchen M. Conservative treatment of main thoracic adolescent idiopathic scoliosis: Full-time or nighttime bracing? J Orthop Surg (Hong Kong) 2020; 27:2309499019860017. [PMID: 31284817 DOI: 10.1177/2309499019860017] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE To compare treatment efficacy between the Boston full-time brace and the Providence part-time brace in main thoracic adolescent idiopathic scoliosis (AIS). METHODS Patients were treated with either the Boston brace (n = 37) or the Providence brace (n = 40). Inclusion criteria were Risser grade ≤2, major curve between 25° and 40° with the apex of the curve between T7 and T11 vertebrae. Two-year follow-up was available in all patients unless brace treatment had reached endpoint. The primary outcome measure was main curve progression to ≥45°. RESULTS Median age was 12.6 years and median treatment length at follow-up was 25 months (interquartile range (IQR): 18-32)) with no difference between the groups (p ≥ 0.116). Initial median main Cobb angle was 29° (IQR: 27-33) and 36° (IQR: 33-38) in the Boston and Providence groups, respectively (p < 0.001). At follow-up, 13 patients (35%) had progressed to ≥45° in the Boston group versus 16 patients (40%) in the Providence group (p = 0.838). Twenty-three patients (62%) had progressed by more than 5° in the Boston group versus 22 patients (55%) in the Providence group (p = 0.685). The secondary thoracolumbar/lumbar curve progressed by more than 5° in 14 (38%) and 18 (45%) in the Boston and Providence groups, respectively (p = 0.548). CONCLUSIONS Despite a larger initial curve size in the Providence group, progression of more than 5° or to surgical indication area was similar in the Boston group. Our results indicate that nighttime bracing is a viable alternative to full-time bracing also in main thoracic AIS.
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Affiliation(s)
- Søren Ohrt-Nissen
- 1 Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Markus Lastikka
- 2 Department of Pediatric Orthopedic Surgery, Turku University Hospital, Turku, Finland
| | - Thomas Borbjerg Andersen
- 1 Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ilkka Helenius
- 2 Department of Pediatric Orthopedic Surgery, Turku University Hospital, Turku, Finland
| | - Martin Gehrchen
- 1 Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Hawary RE, Zaaroor-Regev D, Floman Y, Lonner BS, Alkhalife YI, Betz RR. Brace treatment in adolescent idiopathic scoliosis: risk factors for failure-a literature review. Spine J 2019; 19:1917-1925. [PMID: 31325626 DOI: 10.1016/j.spinee.2019.07.008] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 07/12/2019] [Accepted: 07/15/2019] [Indexed: 02/03/2023]
Abstract
Brace treatment is the most common nonoperative treatment for the prevention of curve progression in adolescent idiopathic scoliosis. The success reported in level 1 and 2 clinical trials is approximately 75%. The aim of this review was to identify the main risk factors that significantly reduce success rate of brace treatment. A literature search using the MEDLINE and Embase databases was conducted. Studies were included if they identified specific risk factor(s) for curve progression. Studies that looked at nighttime braces, superiority of one type of brace over another, the effect of physical therapy on brace performance, cadaver or nonhuman studies were excluded. A total of 1,022 articles were identified of which 25 met all of the inclusion criteria. Seven risk factors were identified: Poor brace compliance (eight studies), lack of skeletal maturity (six studies), Cobb angle over a certain threshold (six studies), poor in-brace correction (three studies), vertebral rotation (four studies), osteopenia (two studies), and thoracic curve type (two studies). Three risk factors were highly repeated in the literature which identified specific subgroups of patients who have a much higher risk to fail brace treatment and to progress to fusion. This data demonstrates that 60% to 70% of the patients referred to bracing are Risser 0 and 30% to 70% of this group will not wear the brace enough to ensure treatment efficacy. Furthermore, Risser 0 patients who reach the accelerated growth phase with a curve ≥40° are at 70% to 100% risk of curve progression to the fusion surgical threshold despite proper brace wear. Skeletally immature patients with relatively large magnitude scoliosis who are noncompliant are at a higher risk of failing brace treatment.
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Affiliation(s)
- Ron El Hawary
- Division of Orthopaedic Surgery, IWK Health Centre, PO Box 9700, 5850 University Ave, Halifax, Nova Scotia, B3K-6R8 Canada; Department of Biomedical Engineering, Dalhousie University, Halifax, Nova Scotia, Canada.
| | | | - Yizhar Floman
- Israel Spine Center, Assuta Medical Center, Tel Aviv, Israel
| | - Baron S Lonner
- Mount Sinai Hospital, 1468 Madison Ave, New York, NY 10029, USA
| | - Yasser Ibrahim Alkhalife
- Division of Orthopaedic Surgery, IWK Health Centre, PO Box 9700, 5850 University Ave, Halifax, Nova Scotia, B3K-6R8 Canada
| | - Randal R Betz
- Institute for Spine and Scoliosis, Lawrenceville, New Jersey
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Karavidas N. Bracing In The Treatment Of Adolescent Idiopathic Scoliosis: Evidence To Date. ADOLESCENT HEALTH MEDICINE AND THERAPEUTICS 2019; 10:153-172. [PMID: 31632169 PMCID: PMC6790111 DOI: 10.2147/ahmt.s190565] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 09/18/2019] [Indexed: 11/23/2022]
Abstract
Brace effectiveness for adolescent idiopathic scoliosis was controversial until recent studies provided high quality of evidence that bracing can decrease likelihood of progression and need for operative treatment. Very low evidence exists regarding bracing over 40ο and adult degenerative scoliosis. Initial in-brace correction and compliance seem to be the most important predictive factors for successful treatment outcome. However, the amount of correction and adherence to wearing hours have not been established yet. Moderate evidence suggests that thoracic and double curves, and curves over 30ο at an early growth stage have more risk for failure. High and low body mass index scores are also associated with low successful rates. CAD/CAM braces have shown better initial correction and are more comfortable than conventional plaster cast braces. For a curve at high risk of progression, rigid and day-time braces are significantly more effective than soft or night-time braces. No safe conclusion on effectiveness can be drawn while comparing symmetrical and asymmetrical brace designs. The addition of physiotherapeutic scoliosis-specific exercises in brace treatment can provide better outcomes and is recommended, when possible. Despite the growing evidence for brace effectiveness, there is still an imperative need for future high methodological quality studies to be conducted.
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Affiliation(s)
- Nikos Karavidas
- Schroth Scoliosis & Spine Clinic, Physiotherapy Department, Athens, Greece
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26
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Long-term Impacts of Brace Treatment for Adolescent Idiopathic Scoliosis on Body Composition, Paraspinal Muscle Morphology, and Bone Mineral Density. Spine (Phila Pa 1976) 2019; 44:E1075-E1082. [PMID: 31261269 DOI: 10.1097/brs.0000000000003069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective, long-term follow-up study. OBJECTIVE We aimed to investigate the long-term impacts of brace treatment for adolescent idiopathic scoliosis (AIS) on the musculoskeletal system. SUMMARY OF BACKGROUND DATA Although full-time brace treatment is the mainstay of conservative treatment for AIS, the restrictive nature of brace treatment for lumbosacral motion might negatively affect the musculoskeletal system. METHODS Of 319 patients treated nonoperatively for AIS, 80 patients completed clinical and imaging examinations. Body composition, including body fat mass, lean mass, fat percent, and muscle mass, was estimated via bioelectrical impedance analysis. Bone mineral density (BMD) was measured at the lumbar spine and left hip. In 73 patients, the measurement of cross-sectional area and fatty degeneration of paraspinal muscles at the superior endplate of L4 were performed using axial T2-weighted magnetic resonance imaging. Patients were divided into the full-time brace (FB; >13 hours per day) and nonfull-time brace (NFB; observation, part-time bracing, or drop out from FB within a year) groups. RESULTS There were 44 patients in the FB group and 36 in the NFB group. Patients in the FB group were significantly younger at the initial visit (12.7 ± 1.3 years) and older at the final follow-up (41.5 ± 5.6 years) than those in the NFB group (14.2 ± 3.2 and 37.4 ± 7.1 years, respectively; P < 0.01). The rate of patients engaging in mild or moderate sports activity in adulthood tended to be higher in the FB group (47.7%) than in the NFB group (25%) (P = 0.11). However, there were no significant differences in body composition, paraspinal muscle morphology, and BMD between the two groups both before and after adjusting for age. CONCLUSION Full-time brace wearing during adolescence did not have any negative impacts on the musculoskeletal system in adulthood. This information will be helpful for improving the compliance of full-time bracing. LEVEL OF EVIDENCE 4.
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Rahimi S, Kiaghadi A, Fallahian N. Effective factors on brace compliance in idiopathic scoliosis: a literature review. Disabil Rehabil Assist Technol 2019; 15:917-923. [PMID: 31248292 DOI: 10.1080/17483107.2019.1629117] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objectives: Compliance plays a major role in the success of brace treatment and is influenced by factors such as the kind of brace, measurements method, regimen for brace wear, pattern wearing at night/day or full/part time and another factor is also psychological condition of the wearer. The objective of this review is to assess affecting factors on compliance of spinal braces in idiopathic scoliosis.Materials and methods: The guideline of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) was used for conducting review and assessing the quality of evidence. The search in Pubmed databases had 175 results of which 17 articles met the inclusion criteria. Effective factors on compliance were extracted and categorized into six groups based on type of brace, measurement method, age, day/night time pattern wearing, full/part time wearing and psychological aspect that can improve the result of spinal brace treatment in idiopathic scoliosis.Results: The results demonstrated that the type of braces determines structure and appearance and affects compliance. Psychological aspects, age, brace wear pattern (daytime or nighttime or part-time versus fulltime) and the assessment method (using temperature versus pressure sensors) can affect recorded compliance.Conclusions: Compliance can be augmented by considering factors in the design and delivery of the brace. Superior appearance and comfortable within the brace can improve psychological acceptance and improve the compliance. Lower age, involving the patient in treatment procedure, considering the child habits, and improved family awareness of the treatment plan of idiopathic scoliosis can also improve overall compliance of the brace.Implications for rehabilitationThis article reviews factors that affect compliance with orthotic treatment in idiopathic scoiliosis.
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Affiliation(s)
- Sara Rahimi
- Department of Orthotics and Prosthetics, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Adele Kiaghadi
- Department of Orthotics and Prosthetics, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Nader Fallahian
- Pediatric Neurorehabilitation Research Centre, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
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Effectiveness of school scoliosis screening and the importance of this method in measures to reduce morbidity in an Italian territory. J Pediatr Orthop B 2019; 28:271-277. [PMID: 30807511 DOI: 10.1097/bpb.0000000000000611] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Although several procedures for treating scoliosis have been developed, the most effective treatment is still based on early detection. For early diagnosis of idiopathic scoliosis, many authors have proposed methods of school screening; however, there is still no standardized screening program. The aim of this study was to evaluate a school screening method and the prevalence and distribution of scoliosis in Italian school children, aged 9-14 years, and to determine if the screening method can reduce morbidity in an Italian territory. The screening program consisted of three steps: the first step was a clinical examination carried out by the school physician and two specialists. In the second step, doubtful cases (presence of a hump between the two sides of the torso, in the thoracic or thoracolumbar region, measured using a hump meter) were evaluated by an orthopedic specialist and subsequently controlled every 6 months either clinically or by radiographic examination. The third step was the classification of the scoliosis and procedures for treatment. All patients were scheduled for a follow-up program and were evaluated during the subsequent 3 years. Statistical analyses were performed with GraphPad Prism 6. A total of 8995 children were screened for scoliosis. Of these, 487 showed clinical signs of scoliosis, and 181 were referred for anteroposterior radiographs because of a positive result on the forward-bending test (hump>5 mm). No significant statistical difference was observed by the three clinical examiners. Of the 181 patients who were referred, 69 were radiographed, and the clinical diagnosis was confirmed in 94.2% of the cases. The prevalence of scoliosis (defined as a curve of ≥10°) was 0.76% (65 of 8995 children), and most of the curves (44; prevalence 67.69%) were small (<20°). The overall ratio of boys to girls was 1 : 3.3, but varied according to the magnitude of the curve (1 : 3 for curves of <20°, 1 : 3.25 for curves of 20-29°, and 1 : 4 for curves of ≥30°). Double curves were the most common type identified, followed by thoracolumbar curves; specifically, of the 65 children who had a curve, 21 (32.30%) had a double curve, 18 (27.6%) had a thoracolumbar curve, 17 (26.1%) had a lumbar curve, and nine (13.84%) had a thoracic curve. In the following 3 years, only four patients were found to have curves more than 20° and none more than 30°. Our results show that the school screening program was accurate and repeatable. Moreover, screening children for scoliosis using a simple test appears to be an effective means of early detection. Above all, the screening process effectively decreased morbidity in the territory at a negligible cost.
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Results of Bracing for Juvenile Idiopathic Scoliosis. Spine Deform 2019; 6:201-206. [PMID: 29735126 DOI: 10.1016/j.jspd.2017.10.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 10/06/2017] [Accepted: 10/12/2017] [Indexed: 11/22/2022]
Abstract
STUDY DESIGN Retrospective comparative therapeutic clinical study evaluating the results of bracing for juvenile idiopathic scoliosis (JIS). OBJECTIVES To evaluate if bracing has a role in treatment of JIS and, if so, to report its success rate and factors associated with successful bracing. SUMMARY OF BACKGROUND DATA Patients with JIS have higher mortality and morbidity in comparison to those with adolescent idiopathic scoliosis (AIS) or general population. Untreated JIS may cause severe cardiorespiratory compromise. METHODS All children treated at our institute and followed up until either skeletal maturity or surgeries between 1956 and 1999 with JIS were included. Those who had an incomplete set of radiographs or those treated by mere observation were excluded. RESULTS One hundred twenty-five patients, comprising of 93 who were braced as juveniles and 32 who were braced in adolescence, met the inclusion criteria. Fifty-six of them were successfully treated by bracing (32 juveniles and 24 adolescents) and 69 patients needed surgery despite bracing. When final curves greater than 45° were regarded as failure of bracing, the success rate was 41%. The braces used were Milwaukee brace (MB) and thoraco-lumbo-sacral orthosis (TLSO) and no statistically significant difference was found between the two. None of the patients had surgery of any kind during the juvenile phase (ie, at age <10 years). DISCUSSION The overall success rate with bracing was 41%. A third of them (ie, 18/56) could be safely weaned prior to skeletal maturity without risking curve progression. The odds of needing a surgery when braced as a juvenile was 2-in-3 (34% success), which fell to almost 1-in-4 for an adolescent (75% success) and was statistically significant (p = .001). Curves with Cobb angle ≤29° when braced progressed to a degree warranting surgery at a lower rate as compared to those ≥30°, this difference was not statistically significant (p = .22). CONCLUSION Bracing obviated the need for surgery during juvenile years in all patients and was a successful delaying strategy.
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Thometz J, Liu X, Rizza R, English I, Tarima S. Effect of an elongation bending derotation brace on the infantile or juvenile scoliosis. SCOLIOSIS AND SPINAL DISORDERS 2018; 13:13. [PMID: 30094340 PMCID: PMC6080392 DOI: 10.1186/s13013-018-0160-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 04/27/2018] [Indexed: 11/10/2022]
Abstract
Background A wide variety of braces are commercially available designed for the adolescent idiopathic scoliosis (AIS), but very few braces for infantile scoliosis (IS) or juvenile scoliosis (JS). The goals of this study were: 1) to briefly introduce an elongation bending derotation brace (EBDB) in the treatment of IS or JS; 2) to investigate changes of Cobb angles in the AP view of X-ray between in and out of the EBDB at 0, 3, 6, 9, and 12 months; 3) to compare differences of Cobb angles (out of brace) in 3, 6, 9, and12 month with the baseline; 4) to investigate changes (out of brace) in JS and IS groups separately. Methods Thirty-eight patients with IS or JS were recruited retrospectively for this study. Spinal manipulation was performed using a stockinet. This was done simultaneously with a surface topography scan. The procedure was done in the operating room for IS, or in a clinical setting for JS. The brace was edited and fabricated using CAD/CAM method. Radiographs were recorded in and out of bracing approximately every 3 months from baseline to 12 months. A linear mixed effects model was used to compare in and out of bracing, and out of brace Cobb angle change over the 12 month period. Results Overall, 37.5% of curves are corrected and 37.5% stabilized after 12 months (Thoracic curves 48% correction, 19% stabilization; thoracolumbar curves 33% correction, 56% stabilization and lumbar curves 29% correction, 50% stabilization). The juvenile group had 25.7% correction and 42.9% stabilization, while the infantile group had 50% correction and 32.1% stabilization. There was a significant Cobb angle in-brace reduction in the thoracic (11°), thoracolumbar (12°), and lumbar (12°) (p < 0.001). There was no statistically significant change in out of brace Cobb angle from baseline to month 12 (p > 0.05). No patients required surgery within the 12 month span. Conclusions This study describes a new clinical protocol in the development of the EBDB. Short-term results show brace is effective in preventing IS or JS curve progression over a 12 month span.
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Affiliation(s)
- John Thometz
- Department of Orthopedic Surgery, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI USA.,Musculoskeletal Functional Assessment Center, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI USA.,Pediatric Orthopaedics, 9000 W. Wisconsin Ave., Suite 360, PO Box 1997, Milwaukee, WI 53201 USA
| | - XueCheng Liu
- Department of Orthopedic Surgery, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI USA.,Musculoskeletal Functional Assessment Center, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI USA
| | - Robert Rizza
- 3Department of Mechanical Engineering, Milwaukee School of Engineering, Milwaukee, WI USA
| | - Ian English
- 3Department of Mechanical Engineering, Milwaukee School of Engineering, Milwaukee, WI USA
| | - Sergery Tarima
- 4Division of Biostatistics, Institution for Health & Society, Medical College of Wisconsin, Milwaukee, WI USA
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Mao SH, Sun X, Shi BL, Qiu Y, Qian BP, Cheng JCY. Association between braced curve behavior by pubertal growth peak and bracing effectiveness in female idiopathic scoliosis: a longitudinal cohort study. BMC Musculoskelet Disord 2018; 19:88. [PMID: 29580223 PMCID: PMC5870088 DOI: 10.1186/s12891-018-1987-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 02/22/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pre-pubertal idiopathic scoliosis (IS) is associated with high risk of bracing ineffectiveness. Integrated multidimensional maturity assessments are useful but complex to predict the high-risk occurrence of curve progression. This study is designed to provide a simple screening method for brace effectiveness by determining whether or not the braced curve behavior at growth spurt, being defined as variations in Cobb angle velocity (AV) at peak height velocity (PHV), can be a new factor predictive of brace outcome prescribed before PHV. METHODS This is a retrospective study of a series of 35 IS girls with simplified skeletal maturity score no more than 3 at initiation of bracing treatment and followed up through the growth spurt until brace weaning or surgery. Serial Cobb angle and maturity indicators involving height velocity, Risser sign, triradiate cartilage, simplified skeletal maturity score and distal radius and ulna classification were assessed and patients were stratified into either a positive or negative category based on a positive or negative value of AV at PHV. Comparisons were made between the positive and negative AV groups, as well as the failed and successful bracing groups, using independent sample T test and crosstab analysis. Logistic regression analysis was used to identify the predictive factors of failed brace treatment. RESULTS Brace treatment prescribed before PHV was found to have an overall failure rate of 57.1% and a surgical rate of 45.7%. Negative AV at PHV accounting for 54.3% of the recruited patients were associated with lower brace failure rate (36.8% vs. 81.2%, p = 0.016) and surgical rate (21.1% vs. 75.0%, p = 0.002). Patients in the failed bracing group showed higher ratio of thoracic curve (80.0% vs. 26.7%,p = 0.002) and higher AV at growth peak (2.3 ± 9.1 vs. -6.5 ± 11.4°/yrs., p = 0.016). The logistic regression analysis revealed that positive AV at PHV (OR = 9.268, 95% CI = 1.279-67.137, p = 0.028) and thoracic curve type (OR = 13.391, 95% CI = 2.006-89.412, p = 0.007) were strong predictive factors of ineffective brace treatment initiated before PHV. CONCLUSIONS Sustained curve correction following bracing despite early onset and rapid pubertal growth was strongly predictive of effective brace control of scoliosis.
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Affiliation(s)
- Sai-Hu Mao
- Spine Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China.,Joint Scoliosis Research Center of the Chinese University of Hong Kong & Nanjing University, Nanjing, China
| | - Xu Sun
- Spine Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China.,Joint Scoliosis Research Center of the Chinese University of Hong Kong & Nanjing University, Nanjing, China
| | - Ben-Long Shi
- Spine Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China.,Joint Scoliosis Research Center of the Chinese University of Hong Kong & Nanjing University, Nanjing, China
| | - Yong Qiu
- Spine Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China.,Joint Scoliosis Research Center of the Chinese University of Hong Kong & Nanjing University, Nanjing, China
| | - Bang-Ping Qian
- Spine Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China. .,Joint Scoliosis Research Center of the Chinese University of Hong Kong & Nanjing University, Nanjing, China.
| | - Jack C Y Cheng
- Joint Scoliosis Research Center of the Chinese University of Hong Kong & Nanjing University, Nanjing, China
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Negrini S, Donzelli S, Aulisa AG, Czaprowski D, Schreiber S, de Mauroy JC, Diers H, Grivas TB, Knott P, Kotwicki T, Lebel A, Marti C, Maruyama T, O’Brien J, Price N, Parent E, Rigo M, Romano M, Stikeleather L, Wynne J, Zaina F. 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. SCOLIOSIS AND SPINAL DISORDERS 2018; 13:3. [PMID: 29435499 PMCID: PMC5795289 DOI: 10.1186/s13013-017-0145-8] [Citation(s) in RCA: 412] [Impact Index Per Article: 68.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 11/06/2017] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Stefano Negrini
- Clinical and Experimental Sciences Department, University of Brescia Viale Europa 11, Brescia, Italy
- IRCCS Fondazione Don Gnocchi, Milan, Italy
| | - Sabrina Donzelli
- ISICO (Italian Scientific Spine Institute), Via R. Bellarmino 13/1, 20141 Milan, Italy
| | - Angelo Gabriele Aulisa
- U.O.C. of Orthopedics and Traumatology, Children’s Hospital Bambino Gesù, Institute of Scientific Research, 00165 Rome, Italy
| | - Dariusz Czaprowski
- Center of Body Posture, Olsztyn, Poland
- Department of Physiotherapy, Józef Rusiecki University College, Olsztyn, Poland
| | - Sanja Schreiber
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
- Alberta Health Services, Department of Surgery, Edmonton, Canada
| | | | - Helmut Diers
- Department of Orthopedics and Trauma Surgery, University Medical Center, Mainz, Germany
| | - Theodoros B. Grivas
- Department of Orthopaedics and Traumatology, “Tzaneio” General Hospital of Piraeus, Piraeus, Greece
| | - Patrick Knott
- Rosalind Franklin University of Medicine and Science, North Chicago, IL USA
| | - Tomasz Kotwicki
- Department of Spine Disorders and Pediatric Orthopedics, University of Medical Sciences, Poznan, Poland
| | - Andrea Lebel
- Scoliosis Physiotherapy & Posture Centre, 231 McLeod Street, Ottawa, Ontario K2P0Z8 Canada
| | - Cindy Marti
- Schroth-Barcelona Institute, LLC, Spinal Dynamics of Wisconsin, SC., Barcelona, Spain
| | - Toru Maruyama
- Saitama Prefectural Rehabilitation Center, Saitama, Japan
| | - Joe O’Brien
- National Scoliosis Foundation, Stoughton, MA USA
| | - Nigel Price
- Section of Spine Surgery, Children’s Mercy Hospitals and Clinics, UMKC Orthopedics, Kansas City, MO USA
| | - Eric Parent
- Department of Physical Therapy, 2-50 Corbett Hall, Edmonton, AB T6G 2G4 Canada
| | - Manuel Rigo
- Salvá SLP (E. Salvá Institute), Vía Augusta 185, 08021 Barcelona, Spain
| | - Michele Romano
- ISICO (Italian Scientific Spine Institute), Via R. Bellarmino 13/1, 20141 Milan, Italy
| | - Luke Stikeleather
- National Scoliosis Center, 3023 Hamaker Court, Suite LL-50, Fairfax, VA 22124 USA
| | - James Wynne
- Boston Orthotics & Prosthetics, Boston, MA USA
| | - Fabio Zaina
- ISICO (Italian Scientific Spine Institute), Via R. Bellarmino 13/1, 20141 Milan, Italy
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Aulisa AG, Guzzanti V, Falciglia F, Galli M, Pizzetti P, Aulisa L. Curve progression after long-term brace treatment in adolescent idiopathic scoliosis: comparative results between over and under 30 Cobb degrees - SOSORT 2017 award winner. SCOLIOSIS AND SPINAL DISORDERS 2017; 12:36. [PMID: 29094108 PMCID: PMC5662099 DOI: 10.1186/s13013-017-0142-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 10/18/2017] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Angelo G Aulisa
- U.O.C. of Orthopedics and Traumatology, Children's Hospital Bambino Gesù, Institute of Scientific Research, P.zza S. Onofrio 4, 00165 Rome, Italy
| | - Vincenzo Guzzanti
- U.O.C. of Orthopedics and Traumatology, Children's Hospital Bambino Gesù, Institute of Scientific Research, P.zza S. Onofrio 4, 00165 Rome, Italy.,University of Cassino, 03043 Cassino, FR Italy
| | - Francesco Falciglia
- U.O.C. of Orthopedics and Traumatology, Children's Hospital Bambino Gesù, Institute of Scientific Research, P.zza S. Onofrio 4, 00165 Rome, Italy
| | - Marco Galli
- Department of Orthopedics, University Hospital "Agostino Gemelli", Catholic University of the Sacred Heart School of Medicine, 00168 Rome, Italy
| | - Paolo Pizzetti
- U.O.C. of Orthopedics and Traumatology, Children's Hospital Bambino Gesù, Institute of Scientific Research, P.zza S. Onofrio 4, 00165 Rome, Italy
| | - Lorenzo Aulisa
- Department of Orthopedics, University Hospital "Agostino Gemelli", Catholic University of the Sacred Heart School of Medicine, 00168 Rome, Italy
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Cobetto N, Aubin CÉ, Parent S, Barchi S, Turgeon I, Labelle H. 3D correction of AIS in braces designed using CAD/CAM and FEM: a randomized controlled trial. SCOLIOSIS AND SPINAL DISORDERS 2017; 12:24. [PMID: 28770254 PMCID: PMC5525241 DOI: 10.1186/s13013-017-0128-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 06/16/2017] [Indexed: 11/13/2022]
Abstract
Background Recent studies showed that finite element model (FEM) combined to CAD/CAM improves the design of braces for the conservative treatment of adolescent idiopathic scoliosis (AIS), using 2D measurements from in-brace radiographs. We aim to assess the immediate effectiveness on curve correction in all three planes of braces designed using CAD/CAM and numerical simulation compared to braces designed with CAD/CAM only. Methods SRS standardized criteria for bracing were followed to recruit 48 AIS patients who were randomized into two groups. For both groups, 3D reconstructions of the spine and patient’s torso, respectively built from bi-planar radiographs and surface topography, were obtained and braces were designed using the CAD/CAM approach. For the test group, 3D reconstructions of the spine and patient’s torso were additionally used to generate a personalized FEM to simulate and iteratively improve the brace design with the objective of curve correction maximization in three planes and brace material minimization. Results For the control group (CtrlBraces), average Cobb angle prior to bracing was 29° (thoracic, T) and 25° (lumbar, L) with the planes of maximal curvature (PMC) respectively oriented at 63° and 57° on average with respect to the sagittal plane. Average apical axial rotation prior to bracing was 7° (T) and 9° (L). For the test group (FEMBraces), initial Cobb angles were 33° (T) and 28° (L) with the PMC at 68° (T) and 56° (L) and average apical axial rotation prior to bracing at 9° (T and L). On average, FEMBraces were 50% thinner and had 20% less covering surface than CtrlBraces while reducing T and L curves by 47 and 48%, respectively, compared to 25 and 26% for CtrlBraces. FEMBraces corrected apical axial rotation by 46% compared to 30% for CtrlBraces. Conclusion The combination of numerical simulation and CAD/CAM approach allowed designing more efficient braces in all three planes, with the advantages of being lighter than standard CAD/CAM braces. Bracing in AIS may be improved in 3D by the use of this simulation platform. This study is ongoing to recruit more cases and to analyze the long-term effect of bracing. Trial registration ClinicalTrials.gov, NCT02285621
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Affiliation(s)
- Nikita Cobetto
- Department of Mechanical Engineering, Polytechnique Montreal, P.O. Box 6079, Downtown Station, Montreal, Quebec H3C 3A7 Canada
| | - Carl-Éric Aubin
- Department of Mechanical Engineering, Polytechnique Montreal, P.O. Box 6079, Downtown Station, Montreal, Quebec H3C 3A7 Canada
| | - Stefan Parent
- Department of Mechanical Engineering, Polytechnique Montreal, P.O. Box 6079, Downtown Station, Montreal, Quebec H3C 3A7 Canada
| | - Soraya Barchi
- Department of Mechanical Engineering, Polytechnique Montreal, P.O. Box 6079, Downtown Station, Montreal, Quebec H3C 3A7 Canada
| | - Isabelle Turgeon
- Department of Mechanical Engineering, Polytechnique Montreal, P.O. Box 6079, Downtown Station, Montreal, Quebec H3C 3A7 Canada
| | - Hubert Labelle
- Department of Mechanical Engineering, Polytechnique Montreal, P.O. Box 6079, Downtown Station, Montreal, Quebec H3C 3A7 Canada
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Flexibility Predicts Curve Progression in Providence Nighttime Bracing of Patients With Adolescent Idiopathic Scoliosis. Spine (Phila Pa 1976) 2016; 41:1724-1730. [PMID: 27076435 DOI: 10.1097/brs.0000000000001634] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To determine treatment outcome with providence brace (PB) and to assess the ability of pretreatment supine lateral bending radiographs (SLBR) in predicting curve progression. SUMMARY OF BACKGROUND DATA Results from treatment with the PB for adolescent idiopathic ccoliosis (AIS) have been inconsistent and further research is needed. The association between flexibility, as determined by pretreatment SLBR, and curve progression has not previously been examined. METHODS All patients treated with the PB from 2006 to 2011 who met Scoliosis Research Society (SRS) bracing criteria were included. Flexibility of the curve was determined based on SLBR and radiographic variables were registered at beginning of treatment and at skeletal maturity (SM) or before surgery. An increase in standing Cobb angle by more than 5 degrees was considered progression. Follow-up SRS-22 scores were compared with a control group with minor AIS. Analysis included multiple linear and logistic regression. RESULTS A total of 63 patients were included. Mean age was 13.3 years (SD: 1.5) and mean standing Cobb angle was 34° (SD: 5°). Radiographic progression was observed in 43% of patients at SM and surgical rate was 27% and 37% at SM and 2-year follow up, respectively. SRS-22 total scores were similar but the mental health score was significantly better in the control group (P = 0.042). Multiple linear regression analysis showed that decreased flexibility adjusted for age, Cobb angle, and menarchal status was significantly associated with curve progression (P < 0.001). Multiple logistic regression analysis showed that a one percent increase in flexibility was associated with a decrease in risk of curve progression ≥6° (odds ratio = 0.95; 95% confidence interval 0.90-0.98; P = 0.013). CONCLUSION Progression was seen in 43% of AIS patients treated with the PB. Increase in flexibility was independently associated with a decreased risk of progression. LEVEL OF EVIDENCE 3.
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Supine Lateral Bending Radiographs Predict the Initial In-brace Correction of the Providence Brace in Patients With Adolescent Idiopathic Scoliosis. Spine (Phila Pa 1976) 2016; 41:798-802. [PMID: 26909835 DOI: 10.1097/brs.0000000000001519] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective, cross-sectional. OBJECTIVE To determine the initial curve correction of the providence brace (PB) and to determine to what extend the in-brace Cobb angle corresponds to the curve seen on supine lateral bending radiographs (SLBR). SUMMARY OF BACKGROUND DATA SLBR are used to assess curve flexibility in patients undergoing surgical treatment for adolescent idiopathic scoliosis (AIS). A low rate of in-brace correction (IBC) has been associated with a higher risk of curve progression, but to what extent SLBR can be used to predict IBC before initiating bracing treatment is unknown. METHODS All patients with AIS treated with the PB from January 1, 2006 to December 31, 2013 with a major curve of 25 to 45 degrees° were included. Cobb angle on SLBR before treatment and on initial standing, in-brace radiograph (IBR) were measured twice for each patient by one observer 30 days apart. Using a repeated measure mixed effect model, mean difference and 95% limits of agreement (LOA) between Cobb angles on each type of radiograph were estimated. Correction index (CI) was calculated as: curve flexibility (%)/curve correction (%). RESULTS A total of 127 patients were included. Mean long-standing Cobb angle was 35° (SD: 6°), which was reduced to mean 13° (SD: 8) on IBR (P < 0.05). No difference in curve correction between curve types was found when adjusting for flexibility using correction index (P = 0.77). Overall mean difference between SLBR and IBR was 0.2° (LOA ± 10°). Mean difference for thoracic curves was 0.2° (LOA ± 8°), for thoracolumbar/lumbar curves 0.9° (LOA ± 10°) and for double major curves 0.4° (LOA ± 16). CONCLUSION SLBR provide a close estimation to the expected in-brace correction with a mean difference of less than one degree. SLRB could potentially serve as prognostic parameter for curve progression before initiating brace treatment. LEVEL OF EVIDENCE 3.
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Pellios S, Kenanidis E, Potoupnis M, Tsiridis E, Sayegh FE, Kirkos J, Kapetanos GA. Curve progression 25 years after bracing for adolescent idiopathic scoliosis: long term comparative results between two matched groups of 18 versus 23 hours daily bracing. SCOLIOSIS AND SPINAL DISORDERS 2016; 11:3. [PMID: 27299156 PMCID: PMC4900243 DOI: 10.1186/s13013-016-0065-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 01/10/2016] [Indexed: 11/14/2022]
Abstract
Background Scoliotic curves do not necessarily stop progressing at skeletal maturity. The factors that influence curve behavior following bracing are not fully determined. Our objectives were to evaluate the loss of the scoliotic curve correction in a cohort of patients treated with bracing during adolescence and to compare the outcomes of 18 versus 23 h of bracing at a mean of 25 years post brace removal. Methods Seventy-seven patients, who were successfully treated for Adolescent Idiopathic Scoliosis with Βoston brace, were re-evaluated 25 years after the end of their treatment. Patients were further divided in 2 matched groups; those wearing the brace for 23 h and those not wearing the brace at school-time, limiting the application of the brace to 18 h. The mean scoliotic curve was compared between groups before, during, just after bracing and 25 years post bracing. Validated in patients’ native language forms of Short Form 36 and Oswestry Disability Index questionnaires were used to compare the quality of life between groups 25 years post bracing. Results The mean age of the cohort was 40.4 (±3.2) years. They underwent long term follow up at a mean of 25.16 (±2.69) years after brace removal. The mean cohort scoliotic curve increased by 3.9 (±6.69) at 25 years since brace removal. There was however no significant difference in the mean Cobb angle of the cohort between pre brace and long term follow up period (p = 0.307). The 18 and 23 h application groups were comparable according to demographics and several bracing and scoliotic curve parameters. There was no significant difference in the mean curve magnitude between 18 and 23 h application groups at brace removal (p = 0.512) and at 25 years follow-up (p = 0.878). There was also no significant difference in the mean score of Quality of Life questionnaires between groups at long term follow up. Conclusion Scoliotic curves do not necessarily stop progressing after bracing. Bracing is effective treatment method with good long term results in appropriate patients. Since compliance was not objectively measured, we don’t feel confident to give any indication about everyday dosage.
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Affiliation(s)
- Stavros Pellios
- Academic Orthopaedic Unit, Aristotle University Medical School, General Hospital Papageorgiou, Thessaloniki, Greece
| | - Eustathios Kenanidis
- Academic Orthopaedic Unit, Aristotle University Medical School, General Hospital Papageorgiou, Thessaloniki, Greece
| | - Michael Potoupnis
- Academic Orthopaedic Unit, Aristotle University Medical School, General Hospital Papageorgiou, Thessaloniki, Greece
| | - Eleftherios Tsiridis
- Academic Orthopaedic Unit, Aristotle University Medical School, General Hospital Papageorgiou, Thessaloniki, Greece
| | - Fares E Sayegh
- Academic Orthopaedic Unit, Aristotle University Medical School, General Hospital Papageorgiou, Thessaloniki, Greece
| | - John Kirkos
- Academic Orthopaedic Unit, Aristotle University Medical School, General Hospital Papageorgiou, Thessaloniki, Greece
| | - George A Kapetanos
- Academic Orthopaedic Unit, Aristotle University Medical School, General Hospital Papageorgiou, Thessaloniki, Greece
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Effectiveness of braces designed using computer-aided design and manufacturing (CAD/CAM) and finite element simulation compared to CAD/CAM only for the conservative treatment of adolescent idiopathic scoliosis: a prospective randomized controlled trial. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:3056-3064. [DOI: 10.1007/s00586-016-4434-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 01/05/2016] [Accepted: 01/28/2016] [Indexed: 11/25/2022]
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Aulisa AG, Guzzanti V, Falciglia F, Giordano M, Marzetti E, Aulisa L. Lyon bracing in adolescent females with thoracic idiopathic scoliosis: a prospective study based on SRS and SOSORT criteria. BMC Musculoskelet Disord 2015; 16:316. [PMID: 26497776 PMCID: PMC4619531 DOI: 10.1186/s12891-015-0782-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 10/17/2015] [Indexed: 11/11/2022] Open
Abstract
Background The Lyon brace is commonly prescribed in many European countries to patients with thoracic curves and is based on the three-point pressure system. The purpose of this study was to evaluate the efficacy of Lyon bracing for the conservative treatment of adolescent females with idiopathic thoracic curves in a case series selected on the basis of the Scoliosis Research Society (SRS) Committee on Bracing and Nonoperative Management Standardization Criteria and followed the guidelines on management of idiopathic scoliosis with corrective braces, proposed by the International Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT). Methods Prospective study based on an ongoing database. From 1297 patients treated for idiopathic scoliosis between 1995 and 2014 fulfill the inclusion criteria 102 patients treated with Lyon brace. Of these, 69 patients had a definite outcome, 17 have abandoned treatment e 16 are still in treatment. The 104 patients were adolescent females with curvatures in the thoracic spine and a pre-treatment Risser score ranging from 0 to 2. All patients were prescribed with full-time Lyon bracing. The minimum duration of follow-up was 24 months after the end of weaning (mean: 41.64 ± 31.45 months). Anteroposterior radiographs were used to estimate the curve magnitude (CM) at 5 time points: beginning of treatment (t1), one year after the beginning of treatment (t2), intermediate time between t1 and t4 (t3), end of weaning (t4), 2-year minimum follow-up from t4 (t5). Three outcomes were distinguished: curve correction, curve stabilization and curve progression. Results The results from our study showed that of the 69 patients with a definite outcome the CM mean value was 31.51° ± 4.34 SD at t1 and 20° ± 7.6 SD at t5. Curve correction was accomplished in 85.5 % of patients, curve stabilization was obtained in 13 % of patients and curve progression was evident in only 1.5 %. None of the patients were recommended surgery post-bracing. Of 17 patients who abandoned the treatment, at the time of abandonment (14.4 age) have achieved curve correction in 13 cases (77 %), stabilization in 53 cases (18 %) and progression in 1 case (5 %). Conclusion The Lyon brace, through its biomechanical action on vertebral modeling, is highly effective in correcting thoracic curves in particularly when the SOSORT guidelines were adopted in addition to the SRS criteria.
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Affiliation(s)
- Angelo G Aulisa
- U.O.C. of Orthopedics and Traumatology, Children's Hospital Bambino Gesù, Institute of Scientific Research, P.zza S. Onofrio 4, Rome, 00165, Italy.
| | - Vincenzo Guzzanti
- U.O.C. of Orthopedics and Traumatology, Children's Hospital Bambino Gesù, Institute of Scientific Research, P.zza S. Onofrio 4, Rome, 00165, Italy. .,University of Cassino, Cassino, FR, 03043, Italy.
| | - Francesco Falciglia
- U.O.C. of Orthopedics and Traumatology, Children's Hospital Bambino Gesù, Institute of Scientific Research, P.zza S. Onofrio 4, Rome, 00165, Italy.
| | - Marco Giordano
- U.O.C. of Orthopedics and Traumatology, Children's Hospital Bambino Gesù, Institute of Scientific Research, P.zza S. Onofrio 4, Rome, 00165, Italy.
| | - Emanuele Marzetti
- Department of Orthopedics, University Hospital "Agostino Gemelli", Catholic University of the Sacred Heart School of Medicine, Rome, 00168, Italy.
| | - Lorenzo Aulisa
- Department of Orthopedics, University Hospital "Agostino Gemelli", Catholic University of the Sacred Heart School of Medicine, Rome, 00168, Italy.
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Kuroki H, Inomata N, Hamanaka H, Higa K, Chosa E, Tajima N. Efficacy of the Osaka Medical College (OMC) brace in the treatment of adolescent idiopathic scoliosis following Scoliosis Research Society brace studies criteria. SCOLIOSIS 2015; 10:12. [PMID: 25932040 PMCID: PMC4415349 DOI: 10.1186/s13013-015-0036-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 03/19/2015] [Indexed: 11/10/2022]
Abstract
Background The efficacy of brace treatment for patients with adolescent idiopathic scoliosis (AIS) remains controversial. To make comparisons among studies more valid and reliable, the Scoliosis Research Society (SRS) has standardized criteria for brace studies in patients with AIS. The purpose of this study was to evaluate the efficacy of the Osaka Medical College (OMC) brace for AIS in accordance with the modified standardized criteria proposed by the SRS committee on bracing and non-operative management. Methods From 1999 through 2010, 31 consecutive patients with AIS who were newly prescribed the OMC brace and met the modified SRS criteria were studied. The study included 2 boys and 29 girls with a mean age of 12 years and 0 month. Patients were instructed to wear the brace for a minimum of 20 hours per day at the beginning of brace treatment. The mean duration of brace treatment was 4 years and 8 months. We examined the initial brace correction rate and the clinical outcomes of main curves evaluated by curve progression and surgical rate, and the compliance evaluated by the instruction adherence rate for all cases. The clinical course of the brace treatment was considered progression if ≥6° curvature increase occurred and improvement if ≥6° curvature decrease occurred according to SRS judgment criteria. Results The average initial brace correction rate was 46.8%. In 10 cases the curve progressed, 6 cases the curve improved, and 15 cases the curve remained unchanged (success rate: 67.7%). The mean instruction adherence rate, that was defined the percentage of the visits that patients declared they mostly followed our instruction to total visits, was 53.7%. The success rate was statistically higher in the patient group whose instruction adherence rate was greater than 50% (88.2%) as compared with in those 50% or less (42.8%). Conclusions OMC brace treatment for AIS patients could alter the natural history and significantly decreased the progression of curves to the threshold for surgical intervention. Better instruction adherence of brace wear associated with greater success.
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Affiliation(s)
- Hiroshi Kuroki
- Department of Orthopaedic Surgery, National Hospital Organization Miyazaki Higashi Hospital, 4374-1 Tayoshi Ooaza, Miyazaki, 880-0911 Japan
| | - Naoki Inomata
- Department of Orthopaedic Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Hideaki Hamanaka
- Department of Orthopaedic Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Kiyoshi Higa
- Department of Orthopaedic Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Etsuo Chosa
- Department of Orthopaedic Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Naoya Tajima
- Department of Orthopaedic Surgery, Nozaki Higashi Hospital, Miyazaki, Japan
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