Recommendations for research studies on treatment of idiopathic scoliosis: Consensus 2014 between SOSORT and SRS non-operative management committee

Puberty changes the natural history of idiopathic scoliosis: three prediction models for future radiographic curve severity from 1563 consecutive patients

PURPOSE

Understanding idiopathic scoliosis (IS) natural history during growth is essential for shared decision-making between patients and physicians. We developed a retrospective model with the largest available sample in the literature and we aimed to investigate if using three peri-pubertal growth periods provides better prediction than a unique model.

METHODS

Secondary analysis of a previous study on IS natural history data from radiographs before and at the first consult. Three groups: BEFORE (age 6-10), AT (age 11-Risser 2) and AFTER (from Risser 3) the pubertal growth spurt. Available predictors: Cobb angle, curve type, sex, observation time, and Risser score. We used linear mixed-effects models to predict future Cobb angles in each group. We internally validated prediction accuracy with over 100 patients per group (3 to 5-fold cross-validation).

RESULTS

We included 1563 participants (275 BEFORE, 316 AFTER, 782 females and 190 males AT). Curves increased over time mostly in AT, importantly in BEFORE, but also in AFTER. All models performed better than the general one. In BEFORE, 74.2% of the predictions were within ± 5o, 71.8% in AFTER, 68.2% in AT females, and 60.4% in males. The predictors (baseline curve, observation time also squared and cubic, and Risser score) were similar in all the models, with sex influencing only AFTER.

CONCLUSION

IS curve severities increase differently during growth with puberty stages. Model accuracy increases when tailored by growth spurt periods. Our models may help patients and clinicians share decisions, identify the risk of progression and inform treatment planning.

Prognostic model development for risk of curve progression in adolescent idiopathic scoliosis: a prospective cohort study of 127 patients

BACKGROUND AND PURPOSE

 The study's purpose was to develop and internally validate a prognostic survival model exploring baseline variables for adolescent idiopathic scoliosis curve progression.

METHODS

 A longitudinal prognostic cohort analysis was performed on trial data (n = 135) including girls and boys, Cobb angle 25-40°, aged 9-17 years, remaining growth > 1 year, and previously untreated. Prognostic outcome was defined as curve progression of Cobb angle of > 6° prior to skeletal maturity. 34 candidate prognostic variables were tested. Time-to-event was measured with 6-month intervals. Cox proportional hazards regression survival model (CoxPH) was used for model development and validation in comparison with machine learning models (66.6/33.3 train/test data set). The models were adjusted for treatment exposure.

RESULTS

 The final primary prognostic model included 127 patients, predicting progress with acceptable discriminative ability (concordance = 0.79, 95% confidence interval [CI] 0.72-0.86). Significant prognostic risk factors were Risser stage of 0 (HR 4.6, CI 2.1-10.1, P < 0.001), larger major curve Cobb angle (HRstandardized 1.5, CI 1.1-2.0, P = 0.005), and higher score on patient-reported pictorial Spinal Appearance Questionnaire (pSAQ) (HRstandardized 1.4, CI 1.0-1.9, P = 0.04). Treatment exposure, entered as a covariate adjustment, contributed significantly to the final model (HR 3.1, CI 1.5-6.0, P = 0.001). Sensitivity analysis displayed that CoxPH maintained acceptable discriminative ability (AUC 0.79, CI 0.65-0.93) in comparison with machine learning algorithms.

CONCLUSION

 The prognostic model (Risser stage, Cobb angle, pSAQ, and menarche) predicted curve progression of > 6° Cobb angle with acceptable discriminative ability. Adding patient report of the pSAQ may be of clinical importance for the prognosis of curve progression.

Reliability and accuracy of scoliotic parameters on using a wireless handheld 3D ultrasound for children with adolescent idiopathic scoliosis: a pilot study

PURPOSE

To report the accuracy and reliability of Cobb angle (CA), axial vertebral rotation (AVR), kyphotic and lordotic angles (KA and LA) measurements on using a new 3D ultrasound (US) system.

METHODS

Forty participants (34 F, 6 M, aged 14.0 ± 2.3 years) were recruited. The first 20 participants were scanned by the validated US system and the new US system. The other 20 participants were scanned with the new US system only. Two raters (R1 and R2) performed the measurements: R1 has 10 years of experience in radiology but is new in ultrasound scoliosis, while R2 has 30 years of scoliosis experience. All US images were measured twice by R1, and once by R2. Forty posteroanterior and 30 lateral standing radiographs were obtained and measured once by R1. Statistical analysis consisted of mean absolute difference (MAD), intraclass correlation coefficient (ICC (2,1)), and Bland-Altman plots.

RESULTS

R1 showed excellent intra-rater and inter-rater reliability for US measurements with ICCs(2,1) ≥ 0.91. The inter-method reliability was good between the two US systems for all parameters with ICCs(2,1) ≥ 0.85 and maximum MAD of 3.4°. The new US showed good reliability and accuracy compared to radiographs for CA, AVR and KA with ICCs(2,1) ≥ 0.81 and maximum MAD of 5.8°, but poor results for LA with ICCs(2,1) of 0.27-0.35 and MADs of 14.0°-15.4°.

CONCLUSION

The new 3D US system showed good reliability and accuracy for CA, AVR and KA measurements, but a large measurement discrepancy on LA. A new measurement method for US LA may need to investigate.

Pelvic rotation correction combined with Schroth exercises for pelvic and spinal deformities in mild adolescent idiopathic scoliosis: A randomized controlled trial

INTRODUCTION

Individualized treatment of spinal deformity is needed for adolescent idiopathic scoliosis (AIS), and the integration of pelvic rotation correction based on proprioceptive neuromuscular facilitation (PNF) into regular physiotherapy may be a promising approach. However, few high-quality studies have investigated its effects. This study aimed to evaluate the efficacy of pelvic rotation correction combined with Schroth exercises in the treatment of mild AIS.

METHODS

This was a randomized controlled trial. Forty-two AIS patients were randomly divided into experimental and control groups. Both groups underwent 20 therapeutic sessions over 24 weeks. All patients (n = 42) performed Schroth exercises at each session. In addition, the experimental group (n = 21) also participated in a pelvic rotation correction program based on PNF at each session. The primary outcome was the concave/convex ratio of hipbone widths, and the secondary outcomes included the Cobb angle, trunk rotation angle, self-perception, apical vertebral translation, and apical vertebral rotation. Patients were evaluated before and after 24 weeks of intervention.

RESULTS

There was a significant between-group difference in the change from baseline between the experimental and control groups for the following parameters: concave/convex ratio 2.89% (95% confidence interval [CI], 1.58 to 4.20, P<0.001), trunk rotation angle -1.26° (95% CI, -2.20 to -0.32; P = 0.01), and apical vertebral rotation improved by at least one class from baseline in 3 patients (14.3%) in the control group and 9 patients (42.9%) in the experimental group (P = 0.04). While Cobb angle -1.60° (95% CI, -7.75 to 0.54; P = 0.14), self-image 0.149 (95% CI, 0.001 to 0.297; P = 0.049), apical vertebral translation -0.58 mm (95% CI, -3.83 to 2.67; P = 0.72), and pelvic obliquity 0.10° (95% CI, -0.21 to 0.41; P = 0.52) did not differ significantly.

CONCLUSIONS

Pelvic rotation correction combined with Schroth exercises more effectively improved pelvic axial rotation and other spinal deformities, including trunk rotation and apical vertebral rotation, than Schroth exercises alone in the treatment of mild AIS.

Incidence and Importance of Peripheral Vestibular Dysfunction in Adolescent Idiopathic Scoliosis

Adolescent idiopathic scoliosis (AIS) is a common form of scoliosis. As the name suggests, etiopathogenesis is not clearly defined, so treatment is still anchored in the musculoskeletal theory and correction/prevention of high Cobb angle values. This study aimed to determine whether there is any connection between developing scoliotic curvature and a positive history of motion sickness as a symptom of a peripheral vestibular dysfunction/deficit, and if vestibular rehabilitation exercises could be integrated into the treatment plan. The study was conducted over 12 months on a selected population of 159 patients to evaluate or treat scoliotic curvatures in a private clinic. The collected data were analyzed using IBM SPSS Statistics 25 and illustrated using Microsoft Office Excel/Word 2021. Patients with peripheral vestibular dysfunction had significantly higher Cobb angle values when compared to patients with a negative result in an instrumental test for peripheral vestibular dysfunction. Motion sickness was considerably more associated with peripheral vestibular dysfunction, and a positive Fukuda stepping test was associated with a positive history of motion sickness. Adolescent idiopathic scoliosis with higher Cobb angles is related to positive motion sickness history as part of peripheral vestibular dysfunction. Conservative treatment for scoliosis could incorporate sensory integration techniques, and a positive history of motion sickness could be an indicator of a higher risk of progression in adolescent idiopathic scoliosis.

Bracing in severe skeletally immature adolescent idiopathic scoliosis: does a holding strategy change the surgical plan?

PURPOSE

The purpose of the study was to assess the changes in flexibility during night-time bracing in skeletally immature adolescent idiopathic scoliosis (AIS) with curves in the surgical range.

MATERIALS AND METHODS

We included a consecutive cohort of 89 AIS patients with curves ≥ 45° and an estimated growth potential. All patients were eventually treated with fusion surgery, and all patients had side-bending radiographs prior to both bracing and surgery. Curves were classified as structural or non-structural curves according to Lenke at both timepoints.

RESULTS

The main curve progressed by a mean of 12 ± 10° and the secondary curve by 8 ± 8°. Flexibility of the main curve decreased from 50 ± 19% to 44 ± 19% (p = 0.001) and the underlying curve from 85 ± 21% to 77 ± 22% (p = 0.005). In 69 patients (79%), the Lenke category did not progress during bracing. In 14 patients (15%), the progression in Lenke type occurred in the thoracic region (i.e., Lenke type 1 to type 2), while six patients (7%) progressed in the lumbar region (i.e., type 1 to type 3). In the 69 patients that did not progress, we found that the last touched vertebra moved distally by one or two levels in 26 patients.

CONCLUSIONS

This is the first study to describe that curve flexibility decreases during bracing in severe AIS. However, this had only a modest impact on the surgical strategy. Bracing as a holding strategy can be applied, but the risk of losing flexibility in the lumbar spine should be outweighed against the risks of premature fusion surgery.

Effectiveness of Physiotherapeutic Scoliosis-Specific Exercises on 3-Dimensional Spinal Deformities in Patients With Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate the effects of physiotherapeutic scoliosis-specific exercises (PSSE) on coronal, horizontal, and sagittal deformities of the spine in adolescent idiopathic scoliosis (AIS) as well as how curve severity, intervention duration, and intervention type could modify these effects.

DATA SOURCES

Data sources included PubMed, Web of Science, Embase, Cochrane Library, and Scopus databases, which were searched from their inception to September 5, 2023.

STUDY SELECTION

Clinical controlled trials reporting the effects of PSSE on the Cobb angle, angle of trunk rotation (ATR), thoracic kyphosis (TK), or lumbar lordosis in patients with AIS aged 10-18 years. The experimental groups received PSSE; the control groups received standard care (observation or bracing) or conventional exercise such as core stabilization exercise, Pilates, proprioceptive neuromuscular facilitation, and other nonspecific exercises.

DATA EXTRACTION

Two researchers independently extracted key information from eligible studies. The quality of the studies was assessed using the Cochrane Handbook version 5.1.0 risk of bias assessment and the JBI Center for Evidence-Based Health Care (2016) of quasi-experimental research authenticity assessment tool. The level and certainty of evidence were rated according to the Grading of Recommendations, Assessment, Development, and Evaluation framework. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The protocol for this study was registered in PROSPERO (CRD42023404996).

DATA SYNTHESIS

Twelve randomized controlled trials (RCTs) and 5 non-RCTs were meta-analyzed separately. The results indicated that compared with other nonsurgical management, PSSE significantly improved the Cobb angle, ATR, and TK, whereas the lumbar lordosis improvement was not statistically significant. Additionally, the efficacy of PSSE on Cobb angle was not significant in patients with curve severity ≥30° compared with controls. Nevertheless, the pooled effect of PSSE on Cobb angle was not significantly modified by intervention duration and intervention type and that on ATR was not significantly modified by intervention duration. The overall quality of evidence according to Grading of Recommendations, Assessment, Development, and Evaluation was moderate to low for RCT and very low for non-RCT.

CONCLUSIONS

PSSE exhibited positive benefits on the Cobb angle, ATR, and TK in patients with AIS compared with other nonsurgical therapies. In addition, the effectiveness of PSSE may be independent of intervention duration and intervention type but may be influenced by the initial Cobb angle. However, more RCTs are needed in the future to validate the efficacy of PSSE in moderate AIS with a mean Cobb angle ≥30°. Current evidence is limited by inconsistent control group interventions and small sample size of the studies.

Deep learning-based identification of spine growth potential on EOS radiographs

OBJECTIVES

To develop an automatic computer-based method that can help clinicians in assessing spine growth potential based on EOS radiographs.

METHODS

We developed a deep learning-based (DL) algorithm that can mimic the human judgment process to automatically determine spine growth potential and the Risser sign based on full-length spine EOS radiographs. A total of 3383 EOS cases were collected and used for the training and test of the algorithm. Subsequently, the completed DL algorithm underwent clinical validation on an additional 440 cases and was compared to the evaluations of four clinicians.

RESULTS

Regarding the Risser sign, the weighted kappa value of our DL algorithm was 0.933, while that of the four clinicians ranged from 0.909 to 0.930. In the assessment of spine growth potential, the kappa value of our DL algorithm was 0.944, while the kappa values of the four clinicians were 0.916, 0.934, 0.911, and 0.920, respectively. Furthermore, our DL algorithm obtained a slightly higher accuracy (0.973) and Youden index (0.952) compared to the best values achieved by the four clinicians. In addition, the speed of our DL algorithm was 15.2 ± 0.3 s/40 cases, much faster than the inference speeds of the clinicians, ranging from 177.2 ± 28.0 s/40 cases to 241.2 ± 64.1 s/40 cases.

CONCLUSIONS

Our algorithm demonstrated comparable or even better performance compared to clinicians in assessing spine growth potential. This stable, efficient, and convenient algorithm seems to be a promising approach to assist doctors in clinical practice and deserves further study.

CLINICAL RELEVANCE STATEMENT

This method has the ability to quickly ascertain the spine growth potential based on EOS radiographs, and it holds promise to provide assistance to busy doctors in certain clinical scenarios.

KEY POINTS

• In the clinic, there is no available computer-based method that can automatically assess spine growth potential. • We developed a deep learning-based method that could automatically ascertain spine growth potential. • Compared with the results of the clinicians, our algorithm got comparable results.

Effect of adding Schroth physiotherapeutic scoliosis specific exercises to standard care in adolescents with idiopathic scoliosis on posture assessed using surface topography: A secondary analysis of a Randomized Controlled Trial (RCT)

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is a three-dimensional structural asymmetry of the spine and trunk affecting 2-4% of adolescents. Standard treatment is observation, bracing, and surgery for small, moderate, and large curves, respectively. Schroth exercises aim to correct posture and reduce curve progression.

PURPOSE

This study aimed to determine the effect of Schroth exercises added to the standard care compared to standard care alone on torso asymmetry in AIS.

METHODS

In a randomized controlled trial (NCT01610908), 124 participants with AIS (age: 10-18, Cobb: 10°-45°, Risser: ≤3) were randomly assigned to the control (Standard care only) or Schroth (Standard care + Schroth treatment) group. Schroth treatment consisted of 1-hour weekly supervised sessions and 30-45 minutes of daily home exercises for six months. The control group received Schroth exercises in the last six months of the 1-year monitoring period. Markerless 3D surface topography assessed torso asymmetry measured by maximum deviation (MaxDev) and root mean square (RMS). Intention to treat linear mixed effects model analysis was compared to the per protocol analysis.

RESULTS

In the intention to treat analysis, the Schroth group (n = 63) had significantly larger decreased RMS (-1.2 mm, 95%CI [-1.5,-0.9]mm, p = 0.012) and MaxDev (-1.9mm, 95%CI [-2.4,-1.5]mm, p = 0.025) measurements compared to controls (n = 57) after six months of intervention. In the per protocol analysis (Schroth n = 39, control n = 36), the Schroth group also had a significantly larger decrease compared to the control in both the RMS (-1.0mm, 95%CI [-1.9, -0.2]mm, p = 0.013) and MaxDev measurements (-2.0mm, 95%CI [-3.3,-0.5]mm, p = 0.037). For the control group, both the intention to treat and per protocol analysis showed no difference in RMS and MaxDev in the last six months of Schroth intervention (p>0.5).

CONCLUSION

Schroth Exercise treatment added to standard care (observation or bracing) reduced asymmetry measurements in AIS. As expected, a greater effect was observed for participants who followed the prescribed exercise treatment per protocol.

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

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

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

BACKGROUND

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

AIM

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

DESIGN

Prospective control study.

SETTING

Outpatient treatment.

POPULATION

Adolescents with scoliosis.

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL REHABILITATION IMPACT

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

Therapeutic exercises for idiopathic scoliosis in adolescents

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

The Improvement of Trunk Muscle Endurance in Adolescents with Idiopathic Scoliosis Treated with ScoliBrace® and the ScoliBalance® Exercise Approach

The impact of scoliosis bracing combined with physiotherapeutic scoliosis-specific exercises (PSSE) on trunk muscle endurance in adolescents with idiopathic scoliosis is unknown. ScoliBrace®, a rigid, three-dimensional, over-corrective thoraco-lumbar-sacral orthosis (TLSO), and ScoliBalance®, a PSSE program, were used to treat adolescent idiopathic scoliosis (AIS) patients. A retrospective study of the trunk muscle endurance of 33 AIS patients who received ScoliBrace® and ScoliBalance® was conducted. The patients were treated with ScoliBrace® and an individualized ScoliBalance® program. Trunk extensor muscle endurance (TE) and abdominal muscle endurance (AE) tests were performed at initial assessment and then at averages of 6.6 and 24.4 weeks of treatment. The data were analyzed using the Wilcoxon signed-rank test, Stata version 15.1. The participants were aged 13.24 years (SD = 1.64) with a mean Cobb angle of 38.97° (SD = 9.49°). TE improved significantly (p < 0.001) at both short- and medium-term intervals using ScoliBalance® and ScoliBrace® in the AIS patients. AE also showed significant improvement between baseline and short-term follow-up, with non-significant improvement at medium-term follow-up. Overall, trunk muscle endurance showed improvement in the AIS patients using ScoliBrace® and ScoliBalance®. Future research is required to determine the individual and combined effects of each treatment. However, it seems likely that trunk muscle endurance will not deteriorate in AIS patients with this combined treatment.

Reliability of the Risser+ grade for assessment of bone maturity in pediatric scoliosis cases: Investigation using standing and supine whole-spine radiograph

BACKGROUND

Although several radiography-based systems for assessing skeletal maturity are available to clinicians, the classical Risser grading system remains a clinical gold standard. For scoliosis follow-up, a standing whole-spine radiograph is usually used. However, in our clinical practice, we have occasionally encountered cases in which ossification of the iliac crest is seen differently in the standing and supine whole-spine radiography. Here, we aimed to clarify the reliability of the Risser+ grading system for supine versus standing position radiographs.

METHODS

This study recruited patients with all types of scoliosis who had been radiographed in both the standing and supine positions. We retrospectively evaluated the Risser+ grade of standing and supine whole-spine radiographs taken consecutively. Kappa statistics were computed to investigate the agreement between standing and supine Risser+ grades for this study.

RESULTS

We evaluated 111 patients (age: 12.6 ± 2.0; male-to-female = 23:88). The Kappa value for the standing and supine Risser+ grade systems was 0.74. The degree of agreement between the two positions for each Risser+ grade revealed high agreement for grades 0 and 5 in all cases, whereas grades 2 and 3 had low agreement.

CONCLUSIONS

Overall, there was substantial agreement between the Risser+ grades assigned to standing and supine position radiographs. However, disagreement was observed between standing and supine position radiographs assigned Risser+ grades of 2 or 3. Therefore, we have found a wide range in the visibility of iliac apophysis ossification of the iliac depending on the posture, and there are limitations in assessing bone maturity using the Risser+ grade alone. Clinicians should use other evaluation systems, in addition to the Risser+ system, to achieve a more accurate bone maturity assessment, especially for cases with standing position radiographs assigned Risser grades of 2 or 3.

Associations between spinal flexibility and bracing outcomes in adolescent idiopathic scoliosis: a literature review

OBJECTIVES

To identify the existing assessment methods used to measure the spinal flexibility of adolescents with idiopathic scoliosis before bracing and to evaluate the predictive effect of spinal flexibility on bracing outcomes.

METHODS

A broad literature search was performed in the PubMed, Web of Science, EMBASE, CINAHL, Scopus, and Cochrane Library databases to obtain relevant information about spinal flexibility and bracing outcomes. All literature was retrieved by October 14, 2023. The inclusion and exclusion criteria were meticulously determined. The quality of each included study and the level of evidence were evaluated by the Quality in Prognosis Studies (QUIPS) method and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system, respectively.

RESULTS

After screening 1863 articles retrieved from databases, a total of 14 studies with 2261 subjects were eligible for the final analysis in this review. Overall, nine methods of flexibility assessment were identified, including supine radiographs, supine lateral bending radiographs, lateral bending radiographs but without clear positions, hanging radiographs, fulcrum bending physical method, and ultrasound imaging in the positions of supine, prone, sitting with side bending and prone with side bending. In addition, five studies demonstrated that flexibility had a strong correlation with in-brace correction, and eleven studies illustrated that spinal flexibility was a predictive factor of the bracing outcomes of initial in-brace Cobb angle, initial in-brace correction rate, curve progression, and curve regression. The results of GRADE demonstrated a moderate-evidence rating for the predictive value of spinal flexibility.

CONCLUSION

Supine radiography was the most prevalent method for measuring spinal flexibility at the pre-brace stage. Spinal flexibility was strongly correlated with the in-brace Cobb angle or correction rate, and moderate evidence supported that spinal flexibility could predict bracing outcomes.

Effectiveness of Orthotic Treatment on Clinical Outcomes of the Patients with Adolescent Idiopathic Scoliosis Under Different Wearing Compliance Levels: A Systematic Review

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.

A feasibility study of applying two-dimensional photogrammetry for screening and monitoring of patients with adolescent idiopathic scoliosis in clinical practice

Standing posteroanterior radiographs have been the golden standard to quantify the severity of scoliosis deformity. However, it exposes ionizing radiation to scoliosis patients, and cannot be used for routine screening and monitoring. This study aimed to develop a protocol of measuring postural indexes by using the noninvasive and radiation-free two-dimensional (2D) photogrammetry method and identify its clinical value in scoliosis screening and monitoring. The five postural indexes were measured from the posterior view of 110 participants. One-way ANOVA with post hoc Tukey HSD/Games-Howell analysis was used to compare the differences between the participants in the scoliosis group and the non-scoliosis group. Pearson coefficients of correlation were analyzed to identify the relationships between Cobb angles and each of the five quantitative postural indexes. Based on 2D photogrammetry, the postural indexes of C7 deviation (p = 0.02), shoulder alignment (p < 0.001), scapula alignment (p < 0.001), waist angle discrepancy (p < 0.001), and PSIS alignment (p < 0.001) could significantly differentiate scoliosis and non-scoliosis patients during screening. The waist angle discrepancy (r = 0.4, p = 0.01; r = 0.8, p = 0.03; r = 0.7, p = 0.01) and shoulder alignment (r = 0.6, p = 0.03) had moderate to strong positive correlations with the Cobb angles, which supported their clinical values in monitoring scoliotic curvature changes of adolescent idiopathic scoliosis (AIS) patients.

Prediction of future curve angle using prior radiographs in previously untreated idiopathic scoliosis: natural history from age 6 to after the end of growth (SOSORT 2022 award winner)

PURPOSE

Treatment selection for idiopathic scoliosis is informed by the risk of curve progression. Previous models predicting curve progression lacked validation, did not include the full growth/severity spectrum or included treated patients. The objective was to develop and validate models to predict future curve angles using clinical data collected only at, or both at and prior to, an initial specialist consultation in idiopathic scoliosis.

METHODS

This is an analysis of 2317 patients with idiopathic scoliosis between 6 and 25 years old. Patients were previously untreated and provided at least one prior radiograph prospectively collected at first consult. Radiographs were re-measured blinded to the predicted outcome: the maximum Cobb angle on the last radiograph while untreated. Linear mixed-effect models were used to examine the effect of data from the first available visit (age, sex, maximum Cobb angle, Risser, and curve type) and from other visits while untreated (maximum Cobb angle) and time (from the first available radiograph to prediction) on the Cobb angle outcome. Interactions of the first available angle with time, of time with sex, and time with Risser were also tested.

RESULTS

We included 2317 patients (83% of females) with 3255 prior X-rays where 71% had 1, 21.1% had 2, and 7.5% had 3 or more. Mean age was 13.9 ± 2.2yrs and 81% had AIS. Curve types were: 50% double, 26% lumbar/thoracolumbar-lumbar, 16% thoracic, and 8% other. Cobb angle at the first available X-ray was 20 ± 10° (0-80) vs 29 ± 13° (6-122) at the outcome visit separated by 28 ± 22mths. In the model using data at and prior to the specialist consult, larger values of the following variables predicted larger future curves: first available Cobb angle, Cobb angle on other previous X-ray, and time (with Time2 and Time3) to the target prediction. Larger values on the following variables predicted a smaller future Cobb angle: Risser and age at the first available X-ray, time*Risser and time*female sex interactions. Cross-validation found a median error of 4.5o with 84% predicted within 10°. Similarly, the model using only data from the first specialist consult had a median error of 5.5o with 80% of cases within 10° and included: maximum Cobb angle at first specialist consult, Time, Time2, age, curve type, and both interactions.

CONCLUSIONS

The models can help clinicians predict how much curves would progress without treatment at future timepoints of their choice using simple variables. Predictions can inform treatment prescription or show families why no treatment is recommended. The nonlinear effects of time account for the rapid increase in curve angle at the beginning of growth and the slowed progression after maturity. These validated models predicted future Cobb angle with good accuracy in untreated idiopathic scoliosis over the full growth spectrum.

Schroth Physiotherapeutic Scoliosis-Specific Exercise (PSSE) Trials-Systematic Review of Methods and Recommendations for Future Research

The Schroth method is a non-operative treatment for scoliosis and kyphosis, used standalone or as an adjunct to bracing. While supporting evidence for its effectiveness is emerging, methodologic standardization and rigor are equivocal. Thus, we aimed to systematically review methods of published Schroth physiotherapeutic scoliosis-specific exercise (PSSE) trials and provide guidance for future research. We searched six databases for randomized controlled trials (RCT) and non-randomized studies of interventions (NRSIs) investigating the effect of Schroth in children and adults with scoliosis or kyphosis. General characteristics, methodological approaches, treatment protocols, and outcomes reporting were analyzed. Risk of bias (RoB) was assessed using an adapted Cochrane RoB2 tool for RCTs and ROBINS-I for NRSI. Eligible studies (n = 7) were conducted in six countries and included patients with Scheuermann's kyphosis (n = 1) and adolescent idiopathic scoliosis (n = 6). Though all seven studies used the term Schroth to describe their interventions, the Schroth method was used in four of seven studies, of which only one used Schroth classification, three used Schroth therapists, and none prospectively registered the study protocol. Overall, methodological rigor was suboptimal, potentially invalidating evidence synthesis. Authors should follow minimum standards for reporting, including prospectively registering detailed protocols; using appropriate exercise labeling, Schroth classification and certified therapists; naming and describing exercises per classification; and providing therapy dosages, prescription methods, and adherence.

Can Computer-Aided Design and Computer-Aided Manufacturing Integrating with/without Biomechanical Simulation Improve the Effectiveness of Spinal Braces on Adolescent Idiopathic Scoliosis?

The CAD/CAM technology has been increasingly popular in manufacturing spinal braces for patients with adolescent idiopathic scoliosis (AIS) in clinics. However, whether the CAD/CAM-manufactured braces or the CAD/CAM-manufactured braces integrating with biomechanical simulation could improve the in-brace correction angle of spinal braces in AIS patients, compared to the manually manufactured braces, has remained unclear. The purpose of this systematic review and meta-analysis was to compare the in-brace correction angle of (1) computer-aided design and computer-aided manufacturing (CAD/CAM)-manufactured braces or (2) the CAD/CAM-manufactured braces integrating with biomechanical simulation with that of (3) manually manufactured braces. The Web of Science, OVID, EBSCO, PUBMED, and Cochrane Library databases were searched for relevant studies published up to March 2023. Five randomized controlled trials (RCTs) or randomized controlled crossover trials were included for qualitative synthesis, and four of them were included for meta-analysis. The meta-analysis effect sizes of the in-brace correction angle for CAD/CAM versus manual method, and CAD/CAM integrating with biomechanical simulation versus the manual method in the thoracic curve group and the thoracolumbar/lumbar curve group were 0.6° (mean difference [MD], 95% confidence intervals [CI]: -1.06° to 2.25°), 1.12° (MD, 95% CI: -8.43° to 10.67°), and 3.96° (MD, 95% CI: 1.16° to 6.76°), respectively. This review identified that the braces manufactured by CAD/CAM integrating with biomechanical simulation did not show sufficient advantages over the manually manufactured braces, and the CAD/CAM-manufactured braces may not be considered as more worthwhile than the manually manufactured braces, based on the in-brace correction angle. More high-quality clinical studies that strictly follow the Scoliosis Research Society (SRS) guidelines with long-term follow-ups are still needed to draw more solid conclusions and recommendations for clinical practice in the future.

Bridging Motor Learning Principles with Physiotherapy Specific Scoliosis Exercises: a Perspective Article

AIM

This perspective paper illustrates the usefulness of explicitly integrating motor learning terminology with evolving therapeutic approaches. Physiotherapy specific scoliosis exercises (PSSEs) include a growing number of approaches to scoliosis management and serve as an example of this integration.

METHODS

Three quintessential patient cases (a young hypermobile adolescent, a post-pubescent teen, and an adult with childhood diagnosis of scoliosis) serve to contrast the clinical decision-making process for a PSSE plan of care when organized within a motor learning framework.

CONCLUSIONS AND IMPLICATIONS

As intervention approaches evolve, aligning the unique terminologies from different schools of thought with motor learning constructs would provide a common language for clinicians, academics and researchers to facilitate comparison of approaches and organize intervention care plans. Linking a motor learning framework and terminology to PSSE may facilitate comparison of PSSE treatment approaches by clinicians, academics, and researchers, as well as advance the global quality of care for patients with scoliosis.

Inventory of Patient-Reported Outcome Measures Used in the Non-Operative Care of Scoliosis: A Scoping Review

It is unclear which patient-reported outcome measures (PROMs) can assess non-operative care for scoliosis. Most existing tools aim to assess the effects of surgery. This scoping review aimed to inventory the PROMs used to assess non-operative scoliosis treatment by population and languages. We searched Medline (OVID) as per COSMIN guidelines. Studies were included if patients were diagnosed with idiopathic scoliosis or adult degenerative scoliosis and used PROMs. Studies without quantitative data or reporting on fewer than 10 participants were excluded. Nine reviewers extracted the PROMs used, the population(s), language(s), and study setting(s). We screened 3724 titles and abstracts. Of these, the full texts of 900 articles were assessed. Data were extracted from 488 studies, in which 145 PROMs were identified across 22 languages and 5 populations (Adolescent Idiopathic Scoliosis, Adult Degenerative Scoliosis, Adult Idiopathic Scoliosis, Adult Spine Deformity, and an Unclear category). Overall, the most used PROMs were the Oswestry Disability Index (ODI, 37.3%), Scoliosis Research Society-22 (SRS-22, 34.8%), and the Short Form-36 (SF-36, 20.1%), but the frequency varied by population. It is now necessary to determine the PROMs that demonstrate the best measurement properties in the non-operative treatment of scoliosis to include in a core set of outcomes.

Spinal Manual Therapy for Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective

We conducted this meta-analysis to provide better evidence of the efficacy of manual therapy (MT) on adolescent idiopathic scoliosis (AIS).

Methods

All RCTs of MT for the management of patients with AIS were included in the present study. The treatment difference between the experimental and control group was mainly MT. The outcomes consisted of the total effective rate, the Cobb angle, and Scoliosis Research Society-22 (SRS-22) questionnaire score. Electronic database searches were conducted from database inception to July 2022, including the Cochrane Library, PubMed, Web of Science, Embase, Wanfang Data, CNKI, and VIP. The pooled data were analyzed using RevMan 5.4 software.

Results

Four RCTs with 213 patients in the experimental group were finally included. There are 2 studies of standalone MT in the experimental group and 3 studies of MT with identical conservative treatments in the control group. Three trials reported total effective rate, and a statistically significant difference was found (P = 0.004). Three trials reported Cobb angle, and a statistical difference was found (P = 0.01). Then, sensitivity analysis showed that there was a significant difference in the additional MT subgroup (P < 0.00001) while not in the standalone MT subgroup (P = 0.41). Three trials reported SRS-22 scores (P = 0.55) without significant differences.

Conclusion

There is insufficient data to determine the effectiveness of spinal manipulation limited by the very low quality of included studies. High-quality studies with appropriate design and follow-up periods are warranted to determine if MT may be beneficial as an adjunct therapy for AIS. Currently, there is no evidence to support spinal manipulation.

Material sensitivity of patient-specific finite element models in the brace treatment of scoliosis

Objectives: To study the mechanical sensitivity of different intervertebral disc and bone material parameters and ligaments under different force configurations and magnitudes in the scoliosis model. Methods: The finite element model of a 21-year-old female is built using computed tomography. Local range of motion testing and global bending simulations are performed for the model verification. Subsequently, Five force of different directions and configurations were applied to the finite element model applying the brace pad position. The material parameters of the model were related to different spinal flexibilities and included different material parameters of cortical bone, cancellous bone, nucleus and annulus. The virtual X-ray technique measured Cobb angle, thoracic Lordosis, and lumbar Kyphosis. Results: The difference in peak displacement is 9.28 mm, 19.99 mm, 27.06 mm, 43.99 mm, and 50.1 mm under five force configurations. The maximum Cobb angle difference due to material parameters are 4.7° and 6.2°, which are converted to thoracic and lumbar in-brace correction difference of 18% and 15.5%. The maximum difference in Kyphosis and Lordosis angle is 4.4° and 5.8°. The average thoracic and lumbar Cobb angle variation difference in intervertebral disc control group is larger than that in bone control group, while the average Kyphosis and Lordosis angle is inverse. The displacement distribution of models with or without ligaments is similar, with a peak displacement difference of 1.3 mm in C5. The peak stress occurred at the junction of the cortical bone and ribs. Conclusion: Spinal flexibility largely influences the treatment effect of the brace. The intervertebral disc has a greater effect on the Cobb angle, the bone has a greater effect on the Kyphosis and Lordosis angles, and the rotation is affected by both. Patient-specific material is the key to increasing accuracy in the personalized finite element model. This study provides a scientific basis for using controllable brace treatment for scoliosis.

Effects of Schroth method and core stabilization exercises on idiopathic scoliosis: a systematic review and meta-analysis

PURPOSE

Conservative approaches such as Schroth exercises and core stabilization exercises showed effective results in the treatment of idiopathic scoliosis. This study aimed to critically evaluate the magnitude effect of Schroth and core stabilization exercises using a systematic review and meta-analysis.

METHODS

This study has been developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. The following three databases were searched for articles collection: Web of Science, PubMed, and Google Scholar. The key search terms were: Schroth exercise, core exercise, idiopathic scoliosis, Cobb angle, angle of trunk rotation, and quality of life. The articles included in our study was limited to original articles written only in English that met the following inclusion criteria: (1) Participants with idiopathic scoliosis; (2) Schroth exercises and core stabilization exercises used as interventions; (3) Cobb angle or angle of trunk rotation or quality of life used as outcome measures.

RESULTS

Thirteen studies were included. Depending on the outcome measured, the magnitude effect of Schroth and core stabilization exercises ranged from small to almost large as follows: Cobb angle (SMD = - 0.376, p ˂ 0.001); angle of trunk rotation (SMD = - 0.268, p = 0.104); quality of life (SMD = 0.774, p = 0.002). By subgroup analysis, Schroth method showed a larger effect size than core stabilization exercises.

CONCLUSION

The current systematic review and meta-analysis indicates that both Schroth method and core stabilization exercises have a positive effect in subjects with idiopathic scoliosis. Subgroup analysis showed that the Schroth method had a larger effect size than the core stabilization exercises.

Predicting final results of brace treatment of adolescents with idiopathic scoliosis: first out-of-brace radiograph is better than in-brace radiograph-SOSORT 2020 award winner

PURPOSE

In-brace radiograph of adolescents with idiopathic scoliosis (AIS) has been shown to reflect brace efficacy and the possibility of achieving curve correction. Conversely, the first out-of-brace radiograph could demonstrate the patient's ability to maintain the correction. We aimed to determine which of the two radiographs is the best predictor of the Cobb angle at the end of treatment (final radiograph).

DESIGN

Retrospective cohort study of a prospective dataset.

METHODS

The population was selected based on the following inclusion criteria: AIS, age 10-18 years; Risser score 0-2; Cobb angle 25-40°; brace treatment; availability of all radiographs.

STATISTICS

Pearson correlations provide a first exploration of data. The univariate and multivariate logistic regression model tested the predictors. Finally ROC curve provided a check of model accuracy.

RESULTS

A total of 131 patients were included (mean age 13.0 ± 1.3, Cobb angle 33.2 ± 5.5°; 78% females). At the end of treatment, 56% had stabilised, 9% had progressed, and 44% had improved. The difference between the in-brace and final radiographs was 8.0 ± 6.0°, while the difference between the first out-of-brace and final radiographs was 1.8 ± 5.2°. The best predictor of final outcome was the first out-of-brace radiograph (0.80), compared to in-brace (0.68) and baseline (0.59) radiographs. The best cut-offs to predict avoidance of progression were 30% and 10% of the correction rates for the in-brace and first out-of-brace radiographs, respectively.

CONCLUSION

The first out-of-brace radiograph predicts end results better than the in-brace radiograph. It offers an excellent clinical reference for clinicians and patients. The first out-of-brace radiograph should be considered an essential element of future predictive models. LEVEL OF EVIDENCE 1: Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

Brace and Physiotherapeutic Scoliosis Specific Exercises (PSSE) for Adolescent Idiopathic Scoliosis (AIS) treatment: a prospective study following Scoliosis Research Society (SRS) criteria

BACKGROUND

A growing scientific evidence for conservative treatment of AIS has recently proved that bracing is superior to natural history. Our aim was to investigate the effectiveness of a combined treatment with brace and PSSE for AIS.

METHODS

Prospective study, following SRS research inclusion criteria (> 10 years, 25^ο - 40^ο, Risser 0-2, < 1-year post-menarche, no prior treatment). 102 consecutive patients (87 females-15 males, mean age 12.8 years, Risser 0.48, Cobb Thoracic 29.2^ο, Lumbar 27.8^ο) received treatment with Cheneau brace and PSSE. Average follow-up time was 26.4 months. A scale from A to C was used to evaluate compliance with brace and PSSE (A: full-compliant, B: partially compliant, C: non-compliant). 7 subjects dropped-out (6.8%), so finally 95 patients included for statistical analysis, using paired t-test.

RESULTS

Sixty-two patients (65.3%) remained stable, 22 improved > 5^ο (23.2%) and 11 progressed (11.5%). In-brace correction (IBC) was 49.7% for thoracic and 61.7% for lumbar curves. Analysis of progressed cases revealed that IBC (31.7% for thoracic and 34.4% for lumbar curves) and compliance (81.8% C for brace, 63.6% C for PSSE) was lower than average. Group A for treatment compliance (65.3%), showed significantly better results (70.9% stable, 29.1% improved, 0% progressed).

CONCLUSION

A combination of bracing and PSSE can effectively treat AIS, according to SRS inclusion criteria. 88.5% of patients avoided progression > 5^ο and only 6.4% overpassed 40^ο. IBC and compliance are the most important prognostic factors for successful treatment result. Early detection of AIS is also necessary for increased possibilities of effective conservative treatment.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Bracing Interventions Can Help Adolescents with Idiopathic Scoliosis with Surgical Indication: A Systematic Review

There is a common agreement that bracing is appropriate for curves between 20 and 40° for the Cobb angle during growth, but for larger curves, the experts' opinions are not consistent. We designed this systematic review to report the updated evidence about the effectiveness of bracing in scoliosis patients with curves ≥40° and a residual growth period. We included randomized controlled trials, non-randomized controlled trials, prospective and retrospective observational studies, and case series addressing the effect of bracing in patients with idiopathic scoliosis during growth with curves ≥40° for the Cobb angle, published from 2000 onwards. Outcome: The percentage of patients with surgery, curves above 45° or 50°, and a Cobb angle change are all included in the study. Nine papers (563 patients, average worst curve of 44.8°) are included: four are retrospective case series, two are retrospective and two are prospective cohort studies, and one is a prospective controlled study. The overall quality was good, with respect to the type of design. A total of 32% of the patients improved, 26% were stable, and 42% worsened. The rate of improvement ranged from 11% to 78%; the rate of worsening ranged from 4% to 64%. There are some studies suggesting the use of bracing even in the case of severe curves when patients are motivated by trying to avoid surgery. More and better-quality research with coherent outcome criteria is needed.

Nonoperative management of adolescent idiopathic scoliosis (AIS) using braces

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

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

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

Short-Term Outcomes of the Boston Brace 3D Program Based on SRS and SOSORT Criteria: A Retrospective Study

Background: Adolescent idiopathic scoliosis (AIS) is characterized by a lateral curvature of the spine with a Cobb angle greater than 10 degrees, accompanied by rotation of the vertebral body. Bracing has been shown to be effective in halting the progression of at-risk curves, and, in some cases, even improving the Cobb angle by 6° or more. The Boston Brace 3D is part of the Boston Orthotics and Prosthetics standardized scoliosis program. The orthosis is custom-fabricated from scans, computer-aided design (CAD), and computer-aided manufactured (CAM) thoracolumbosacral orthosis used in the non-operative management of AIS. Aim: To evaluate the outcomes of a scoliosis program utilizing the Boston Brace 3D orthosis for patients with AIS, based on SRS and SOSORT criteria. Design: Retrospective study. Methods: An electronic medical records search was conducted to identify first-time brace wearers fitted between 1 January 2018, and 30 June 2019, at Boston Orthotics and Prosthetics Boston area clinics that met the SRS/SOSORT research guidelines. The initial out-of-brace, in-brace, and last follow-up X-rays (taken at least 12 months after fitting) were compared. Results: 84% of patients presenting with a single curve and 69% of patients with a double curve saw their curves improve (reduced 6° or more) or remain unchanged (±5°). Thirty-one patients started with a single curve between 25° and 30°, and thirty-two presented at 30° or below. Fifty-nine patients started with a double curve between 25° and 30°, and 59 patients presented at 30° or below. In general, the patients who wore their brace for more hours per day saw improved results. Conclusion: The Boston Brace 3D program is effective in controlling (and in some cases improving) curve progression in the non-operative management of adolescent idiopathic scoliosis. The approach is a repeatable system, as shown in this cohort of thirteen clinicians across six area clinics following the Boston Brace 3D clinical guidelines.

Does Risser Casting for Adolescent Idiopathic Scoliosis Still Have a Role in the Treatment of Curves Larger Than 40°? A Case Control Study with Bracing

Background: The most common conservative treatment for Adolescent Idiopathic Scoliosis (AIS) is bracing. However, several papers questioned the effectiveness of bracing for curves between 40° and 50° Cobb: the effectiveness in preventing curve progression could be as low as 35%. Seriate casting is considered a standard approach in early onset scoliosis; however, in the setting of AIS, cast treatment is seldom utilized, with only few studies reporting on its effectiveness. Aim of the study: The main aim of the study is to determine whether a seriate casting with Risser casts associated with bracing is more effective in preventing curve progression than bracing alone in curves larger than 40°. Furthermore, the secondary endpoints were: (1) is there a difference in effectiveness of casting between Thoracic (T) and Thoracolumbar/Lumbar (TL/L) curves? (2) Does the ‘in cast’ correction predicts the treatment outcome? (3) What is the effect on thoracic kyphosis of casting? Methods: This is a retrospective monocentric case−control study; through an Institutional Database search we identified all the patients treated at our institution between 1 January 2017 and 31 December 2020, with a diagnosis of AIS, Risser grade between 0 and 4 at the beginning of the treatment, at least one curve above 40° Cobb and treatment with either seriate Risser casting and bracing (Study Group, SG) or bracing alone (Control Group, CG). Standing full spine X-rays in AP and LL are obtained before and after the cast treatment; only AP standing full spine X-rays ‘in-cast’ are obtained for each cast made. Patients were stratified according to the curve behavior at the end of treatment (Risser 5): progression was defined as ≥6° increase in the curve magnitude or fusion needed; stabilization is defined as a change in curve by ±5°; and improvement was defined as ≥6° reduction in the curve. Results: For the final analysis, 55 compliant patients (12 M, 43 F, mean age 13.5 ± 1.6) were included in the SG and 27 (4 M, 23 F, mean age 13.6 ± 1.6) in the CG. Eight (14.5%) patients in the SG failed the conservative treatment while 14 (51.3%) failed in the CG. Consequently, the Relative Risk for progression in the Efficacy Analysis was 1.8 (95% CI 1, 3−2.6, p = 0.001), and the Number Needed to Treat was 2,4. No significant difference was found between the T and TL/L curves concerning the ‘progressive’ endpoint (z-score 0.263, p = 0.79). The mean percentage of ‘in cast’ curve reduction was 40.1 ± 15.2%; no significant correlation was found between the percentage of correction and the outcome (Spearman Correlation Coefficient 0.18). Finally, no significant differences between baseline and end of FU TK were found (32° ± 16.2 vs. 29.6 ± 15.8, p = ns). Discussion: Seriate Risser casting for AIS with larger curves (>40° Cobb) is effective in reducing curve progression when compared with full time bracing alone in treatment compliant patients. The treatment is equally effective in controlling T and TL/L curves; furthermore, a slight but non-significant decrease in TK was observed in patients treated with casting. This type of treatment should be considered for AIS patients who present with large curves to potentially reduce the percentage of surgical cases. Short Abstract: The aim of the study is to determine whether seriate Risser casting associated with bracing is more effective in preventing curve progression than bracing alone in curves larger than 40°. This is a retrospective monocentric case−control study; we identified all the patients treated at our institution with a diagnosis of AIS, Risser grade 0−4 at the beginning of the treatment, at least one curve above 40° Cobb (35° if treated with bracing alone) and treatment with either seriate Risser casting and bracing (Study Group, SG) or bracing alone (Control Group, CG). Fifty-five patients (12 M, 43 F, mean age 13.5 ± 1.6) were included in the SG and 30 (5 M, 25 F, mean age 13.9 ± 1.7) in the CG. Eight (14,5%) patients in the SG failed the conservative treatment while fifteen (50%) failed in the CG. Consequently, the Relative Risk for progression in the Efficacy Analysis was 1.8 (95% CI 1.3−2.6, p = 0.001), and the Number Needed to Treat was 2,4. Seriate Risser casting for AIS with larger curves (>40°) is effective in reducing curve progression when compared with full time bracing alone. This type of treatment should be considered for AIS patients who present with large curves.

Alternative methods for skeletal maturity estimation with the EOS scanner—Experience from 934 patients

Background

Hand-wrist bone age assessment methods are not possible on typical EOS 2D/3D images without body position modifications that may affect spinal position. We aimed to identify and assess lesser known bone age assessment alternatives that may be applied retrospectively and without the need for extra imaging.

Materials and methods

After review of 2857 articles, nine bone age methods were selected and applied retrospectively in pilot study (thirteen individuals), followed by evaluation of EOS images of 934 4-24-year-olds. Difficulty of assessment and time taken were recorded, and reliability calculated.

Results

Five methods proved promising after pilot study. Risser ‘plus’ could be applied with no difficulty in 89.5% of scans (836/934) followed by the Oxford hip method (78.6%, 734/934), cervical (79.0%, 738/934), calcaneus (70.8%, 669/934) and the knee (68.2%, 667/934). Calcaneus and cervical methods proved to be fastest at 17.7s (95% confidence interval, 16.0s to 19.38s & 26.5s (95% CI, 22.16s to 30.75s), respectively, with Oxford hip the slowest at 82.0 s (95% CI, 76.12 to 87.88s). Difficulties included: regions lying outside of the image—assessment was difficult or impossible in upper cervical vertebrae (46/934 images 4.9%) and calcaneus methods (144/934 images, 15.4%); position: lower step length was associated with difficult lateral knee assessment & head/hand position with cervical evaluation; and resolution: in the higher stages of the hip, calcaneal and knee methods.

Conclusions

Hip, iliac crest and cervical regions can be assessed on the majority of EOS scans and may be useful for retrospective application. Calcaneus evaluation is a simple and rapidly applicable method that may be appropriate if consideration is given to include full imaging of the foot.

Improvement of Adolescent Idiopathic Scoliosis Primary Correction by Brace Design Optimization

(1) Background: Primary in-brace correction has been shown to be related to conservative adolescent idiopathic scoliosis (AIS) treatment outcome. The purpose of the study was to evaluate TLSO brace design changes over eight years regarding primary Cobb correction and de-rotation of the (major) curve. (2) Methods: This retrospective analysis included AIS patients treated with a full-time TLSO-brace in a single Orthopedic University hospital in 2012–2014 and 2017–2019. Brace design changes resulted from an evolutionary process, from a 3-point bending to a 3D TLSO. The brace parameters (presence of an anterior shoulder pad, posterior high-thoracic pad, thoracic space, and angle of the lumbar and thoracic pressure points) were analyzed regarding the primary (major) Cobb angle and apex rotation correction with a multivariate analysis. (3) Results: A total of 74 (63 female) patients were included in the study. The Cobb angle primary correction was significantly improved over the timeframe. The primary correction was significantly influenced by all design parameters and partially by its interactions with (curve specific) different effects on the Cobb correction and apex de-rotation. (4) Conclusions: Knowledge about the effects of brace design parameters on the curve’s angle and rotation correction enables improvements in individualized brace design and the brace optimization process.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Effect of the Schroth Rehabilitation Exercise Program on Spinal and Feet Alignment in Adolescent Patients with Idiopathic Scoliosis: A Pilot Study

Background: This study investigated the therapeutic effects of 12-week Schroth rehabilitation exercises (SRE) in improving Cobb’s angle, scoliometer readings, lumbar lordosis, and the calcaneal valgus angle of patients with idiopathic scoliosis. Methods: This pilot study included 60 adolescent patients diagnosed with idiopathic scoliosis by a rehabilitation physician based on a Cobb’s angle of ≥10° using total anteroposterior plain radiography. Patients were classified into groups with a Cobb’s angle of 10–19° (G1), 20–29° (G2), and ≥30° (G3). Cobb’s angle, scoliometer readings, lumbar lordosis, and calcaneal valgus angles were analyzed before and after the 12-week SRE. Results: SRE improved Cobb’s angle (−6.85), scoliometer readings (−2.80), lumbar lordosis (4.23), and calcaneal valgus angles (left, −3.76; right, −2.83) regardless of the initial scoliosis angle, and within-group changes were significant (p < 0.001). In this study, participants in all three groups had undergone SRE, regardless of initial scoliosis severity, and the findings were significant. Conclusion: SRE can be used for patients with idiopathic scoliosis to improve asymmetric musculoskeletal morphology and the patient’s quality of life.

Three-dimensional corrective exercise therapy for idiopathic scoliosis: study protocol for a prospective non-randomized trial

Background

Although physiotherapeutic scoliosis-specific exercises (PSSEs) with or without other conservative treatments may improve scoliotic deformities, the evidence is insufficient. Three-dimensional corrective exercises (TDCEs) for scoliosis are based on the theory of PSSEs and are characterized by a combination of outpatient treatment and home-based exercise. This study aims to evaluate the effectiveness of TDCEs for idiopathic scoliosis (IS).

Methods

The participants will be divided into two age- and sex-matched groups: an experimental group (EG) treated with three-dimensional corrective exercise therapy (TDCET) and a control group (CG) receiving generalized exercise therapy. In each arm, mild and moderate IS cases will be reclassified based on the Cobb angle and biopsy results. The primary endpoint is the change in the largest Cobb angle; the secondary endpoints are the sagittal index, forced vital capacity, peak oxygen uptake, and peak oxygen uptake. Sixty-six patients with mild IS and 78 patients with moderate IS will be included.

Discussion

This study is the first controlled trial to systematically assess the effectiveness of TDCEs for IS. In addition to TDCET including three-dimensional corrective exercises, family rehabilitation and basic body awareness therapy may help patients adopt supportive attitudes and appropriate behaviours, thus enhancing their compliance with exercises and achieving better outcomes.

Trial registration

The study protocol was registered at www.clinicaltrials.gov (number identifier: NCT04539522). Registered on August 27, 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05057-7.

Benefits on pain and mental health of manual therapy for idiopathic scoliosis: A meta-analysis

BACKGROUND

Idiopathic scoliosis (IS) is a common spinal disorder. Although several studies have reported the benefits of manual therapy for patients with IS in improving pain, anxiety, depression, and spinal disorders, the efficacy of manual therapy in the management of IS remain controversial. Therefore, this review was conducted to assess effects of manual therapy in the management of IS, primarily on pain and mental health of the patients and secondarily on their spinal disorders.

METHODS

Six electronic databases were searched for randomized controlled trials of manual therapy in the management of IS. The methodological quality of the included studies was assessed using the Physiotherapy Evidence Database (PEDro) Scale. The meta-analysis was conducted depending on different outcomes and control therapies using Review Manager version 5.3 software.

RESULTS

Seventeen studies were included in the present review. The PEDro scores of the included studies ranged from 5-7 points. The aggregated results indicated that Tuina (a traditional Chinese manipulation technique) had valuable improvement effects on pain (standardized mean difference (SMD), 0.92; 95% confidence interval (CI), 0.59 to 1.25; P<0.00001), negative emotions (SMD, 0.82; 95% CI, 0.51 to 1.13; P<0.00001), and disability (SMD, 1.29; 95% CI, 0.39 to 2.19; P=0.005). For the radiographic outcomes including the Cobb angle and vertebral rotation, Tuina, especially when combined with other conservative therapies, showed potential complementary effects for patients with IS.

CONCLUSIONS

Tuina, as a complementary and alternative therapy, should be considered for the effective management of patients with IS, especially for the improvement of their pain and mental health. More randomized controlled trials are recommended to validate the current evidence.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier CRD42020165220.

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

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

Are trunk muscles weaker in adolescent females with adolescent idiopathic scoliosis compared with their healthy counterparts?

BACKGROUND: Adolescent Idiopathic Scoliosis (AIS) requires complex medical care because of multiple consequences especially on daily activities. Muscular involvement is part of the problem and may be treatable. OBJECTIVE: To analyze trunk muscle strength using an isokinetic dynamometer in female adolescents with AIS one year after orthopedic treatment by brace and compare the findings to a matched group of an asymptomatic cohort. METHODS: The trunk flexors and extensors strength was measured using an isokinetic dynamometer at 60, 90 and 120∘/s. Peak Moment (PM), Mean Power (MP) and the flexor/extensor ratio in 100 patients aged 14 to 18 years old were compared to a control group (N= 32) of asymptomatic age-matched females. In the AIS group, correlation analyses were computed to search for contributing factors to isokinetic performances, including morphological characteristics of patients, as well as clinical and radiological characteristics of the scoliosis. RESULTS: The trunk flexors in the AIS group were significantly but moderately (15%) weaker across speeds compared to their control counterparts at all speeds. No parallel weakness was noted for the extensors. While the MP of AIS patients was significantly weaker than that of the controls, 33% for flexors and by 31% for extensors, no significant differences were observed for the F/E ratios. The correlational analyses has indicated that weight and BMI were contributing factors at all speeds. CONCLUSION: Adolescents with AIS had weaker trunk extensors and mostly flexors compared to healthy females. Within this AIS population, weight and BMI seem to have a negative impact on muscular performances, whereas clinical and radiological characteristics of the scoliosis do not seem to contribute.

Schroth exercises improve health-related quality of life and radiographic parameters in adolescent idiopathic scoliosis patients

Background:

Finding an optimal treatment strategy for adolescent idiopathic scoliosis (AIS) patients remains challenging because of its intrinsic complexity. For mild to moderate scoliosis patients with lower skeletal growth potential (Risser 3–5), most clinicians agree with observation treatment; however, the curve progression that occurs during puberty, the adolescent period, and even in adulthood, remains a challenging issue for clinicians. The aim of the study is to investigate the efficacy of Schroth exercise in AIS patients with lower skeletal growth potential (Risser 3–5) and moderate scoliosis (Cobb angle 20°–40°).

Methods:

From 2015 to 2017, data of 64 patients diagnosed with AIS in Peking University Third Hospital were reviewed. Forty-three patients underwent Schroth exercise were classified as Schroth group, and 21 patients underwent observation were classified as observation group. Outcomes were measured by health-related quality of life (HRQOL) and radiographic parameters. HRQOL was assessed using the visual analog scale (VAS) scores for back, Scoliosis Research Society-22 (SRS-22) patient questionnaire. Radiographic spinopelvic parameters were obtained from anteroposterior and lateral X-rays. The pre-treatment and post-treatment HRQOL and radiographic parameters were tested to validate Schroth exercise efficacy. The inter-rater reliability of the radiographic parameters was tested using the interclass correlation coefficient (ICC). The paired t test was used to examine HRQOL and radiographic parameters. Clinical relevance between C2-C7 sagittal vertical axis (SVA) and thoracic kyphosis was analyzed using Spearman correlation.

Results:

In Schroth group, VAS back score, SRS-22 pain, and SRS-22 self-image domain were significantly improved from pre-treatment 3.0 ± 0.8, 3.6 ± 0.5, and 3.5 ± 0.7 to post-treatment 1.6 ± 0.6 (t = 5.578, P = 0.013), 4.0 ± 0.3 (t = −3.918, P = 0.001), and 3.7 ± 0.4 (t = −6.468, P < 0.001), respectively. No significant improvements of SRS-22 function domain (t = −2.825, P = 0.088) and mental health domain (t = −3.174, P = 0.061) were observed. The mean Cobb angle decreased from 28.9 ± 5.5° to 26.3 ± 5.2° at the final follow-up, despite no statistical significance was observed (t = 1.853, P = 0.102). The mean C2-C7 SVA value decreased from 21.7 ± 8.4 mm to 17.0 ± 8.0 mm (t = −1.224 P = 0.049) and mean T1 tilt decreased from 4.9 ± 4.2 ° to 3.5 ± 3.1° (t = 2.913, P = 0.011). No significant improvement of radiographic parameters and HRQOL were observed in observation group.

Conclusions:

For AIS patients with a Risser 3–5 and a Cobb angle 20°–40°, Schroth exercises improved HRQOL and halted curve progression during the follow-up period. Both cervical spine alignment and shoulder balance were also significantly improved after Schroth exercises. We recommend Schroth exercises for patients with AIS.

Reliability and validity of Chinese version of brace questionnaire for adolescent idiopathic scoliosis: A cross-sectional study

There is an increasing concern about the impact of bracing on the quality of life (QoL) of patients with adolescent idiopathic scoliosis (AIS). However, up to now, few multidimensional questionnaires on this impact are available in China. This study aimed to evaluate the reliability and validity of the Chinese version of Brace Questionnaire (C-BrQ).The BrQ was translated from Greek into Chinese with proper cross-cultural adaptation.An observational, cross-sectional study in Chinese patients with AIS was conducted to measure the temporal stability of C-BrQ using the intraclass correlation coefficient (ICC). The effects of ceiling and floor were evaluated and the reliability was verified by examining the internal consistency. The C-BrQ domains were compared with the domains in Chinese version of Scoliosis Research Society-22 Outcomes Questionnaire (C-SRS-22) using Pearson correlation coefficient to assess the concurrent validity.A total of 208 patients were included in the study. The results of test-retest reliability for each dimension of C-BrQ were desirable. The floor or ceiling effects were not demonstrated in the C-BrQ and C-SRS-22. Satisfactory internal consistency was found in all the C-BrQ domains. Most C-BrQ and C-SRS-22 domains showed satisfactory correlation coefficients, except when vitality and school activity in C-BrQ were compared with self-image, mental health, and management satisfaction in C-SRS -22, respectively.C-BrQ is reliable in evaluating the QoL of AIS patients receiving brace treatment.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Reliability of measurements of a reflection coefficient index to indicate spinal bone strength on adolescents with idiopathic scoliosis (AIS): a pilot study

PURPOSE

To investigate the test-retest, intra- and inter-rater reliabilities of an ultrasound (US) reflection coefficient (RC) index measured in a lumbar vertebra to reflect bone strength on children with AIS.

METHODS

Fifty-eight participants (47F; 11M) were scanned by an US imager in standing position. Twenty-four were scanned twice for a test-retest study. The RC index measures the US signal reflected from L5 to indicate bone strength. Five measurements were obtained using three different methods: (i) the maximum RC (MRC) values on the left and right sides, (ii) the average RC (ARC) values on left and right sides, and (iii) the combined average RC (CARC) from both sides. Only rater 1 measured the 24 repeated US scans once. Raters 1 and 2 measured the RC index twice on all 58 images in 1 week apart. The intraclass correlation coefficient ICC [3, 1] for test-retest and ICC [2, 1] for intra- and inter-rater reliabilities as well as the standard error of measurements (SEM) were reported.

RESULTS

The means of scan 1 versus scan 2 were 0.16 ± 0.08 versus 0.16 ± 0.07 for left-MRC, 0.17 ± 0.11 versus 0.18 ± 0.11 for right-MRC, 0.08 ± 0.04 versus 0.09 ± 0.04 for left-ARC, 0.09 ± 0.04 versus 0.09 ± 0.05 for right-ARC and 0.08 ± 0.04 versus 0.09 ± 0.03 for CARC and all ICC[3, 1] ≥ 0.77. Among these 5 approaches, the CARC provided the best intra-rater and inter-rater reliabilities with ICC [2, 1] ≥ 0.84 and SEM ≤ 0.01.

CONCLUSIONS

The RC index could be measured repeatably and reliably. The high RC value may reduce the risk of progression of scoliosis.

Influence of Chêneau-Brace Therapy on Lumbar and Thoracic Spine and Its Interdependency with Cervical Spine Alignment in Patients with Adolescent Idiopathic Scoliosis (AIS)

Chêneau-brace is an effective therapy tool for treatment in adolescent idiopathic scoliosis (AIS). Data on potential interdependent changes of the sagittal profile including the cervical spine are still sparse. The purpose of this study was to evaluate in-brace changes of the thoracic and lumbar spine and their influence on the pelvis and the cervical spine and apical vertebral rotation was reported. Ninety-three patients with AIS undergoing Chêneau-bracing were included. Patients were stratified by lumbar, thoracic and global spine alignment into normolordotic vs. hyperlordotic or normokyphotic vs. hypokyphotic or anteriorly aligned vs. posteriorly aligned groups. The coronal Cobb angle was significantly decreased in all groups indicating good correction while in-brace therapy. Sagittally, in-brace treatment led to significant flattening of lumbar lordosis (LL) in all stratified groups. Thoracic kyphosis (TK) was significantly flattened in the normokyphotic group, but no TK changes were noticed in the hypokyphotic group. Pelvic tilt (PT) stayed unchanged during the in-brace therapy. Chêneau-brace showed marginal changes in the lower cervical spine but had no influence on the upper cervical spine. The apical vertebral axis in primary and secondary curves was unchanged during the first radiological follow-up. Results from this study contribute to better understanding of initial spine behavior in sagittal and axial plane in the context of bracing.

Influence of curve morphology and location on the efficacy of rigid conservative treatment in patients with adolescent idiopathic scoliosis

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.