Monia Lusini

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

BACKGROUND CONTEXT Recently, positive results in bracing patients with idiopathic scoliosis (IS) above 45° who refused surgery have been presented in a retrospective study. Obviously, this can give only an efficacy (EA) analysis, as there is neither a control group, nor it is possible to know failures because of dropouts. PURPOSE To present the prospective results of bracing patients affected by IS above 45° and still growing. STUDY DESIGN Prospective study including all IS patients with 45° or more, Risser stage 0 to 4, who had their first evaluation in our institute, an outpatient clinic specialized in scoliosis evaluation and conservative treatment, from March 1, 2003 to December 21, 2010 and utterly denied any surgical intervention. PATIENT SAMPLE Of 59 patients, we excluded 2 patients still in treatment and 57 (11 males) patients were included. At the beginning of the study, they were 15 years 3±22 months of age, had 52.5° Cobb (range, 45°-93°), and Risser 2 (0-4). Thirty-nine accepted a full-time brace treatment (BG) to try avoiding surgery, 18 refused any treatment and served as controls (CG). OUTCOME MEASURES Physiological measures: radiographic and clinical data. METHODS Treatment: A year of full-time Sforzesco brace (23 hours/day) or Risser cast (8-12 months) and gradual weaning after Risser 3; all patients performed exercises; and International Society on Scoliosis Orthopaedic and Rehabilitation TREATMENT management criteria were respected. Analyses: EA in patients who completed treatment/observation (34 in BG and 10 in CG) and intent-to-treat (ITT) with worst case analysis in the whole population. Relative risk (RR) and 95% confidence interval (CI) have been computed. RESULTS Efficacy: failures were 23.5% in BG and 100% in CG. Intent-to-treat: failures were 20.5% in BG and 55.6% in CG. Relative risks of failure in CG were 4.3 (95% CI, 3.6-4.9) in EA and 2.7 (95% CI, 2.0-3.5) in ITT (p<.05). Percentage of patients (53.8%) improved: RRs of improvement in BG were 1.6 (95% CI, 1.46-1.9) in EA and 1.9 (95% CI, 1.6-2.2) in ITT (p<.05). Patients who joined the treatment achieved a 10.4°±10.7° Cobb improvement, an ATR reduction of 4.2°±4.3°, and an esthetic improvement of 2.8±1.9 of 12 points (TRACE). At the end, in BG, 24 patients were below 45° and 6 patients below 35°. CONCLUSIONS Through this study we can conclude that the conservative brace plus exercises treatment (if correctly performed and managed) is a suitable alternative for those patients who reject any surgical intervention for IS above 45°. But we could also conclude that a good brace treatment should be considered as the first choice to try avoiding fusion because of the high sanitary and social costs of surgery.

How to measure kyphosis in everyday clinical practice: a reliability study on different methods.

INTRODUCTION The sagittal plane measures have a relevant role both in Idiopathic Scoliosis (AIS) and in Hyperkyphosis (HK) management. Nevertheless, clinical tools for everyday use are scarce and not adequately studied. AIM To assess the repeatability of different methods for the collection of the sagittal profile of patients with spinal deformities during everyday clinics. METHODS We performed 4 different studies in 4 different populations of AIS and HK patients. In the first study we reported the normative data and measurement error of the plumbline measures in a general population of 180 adolescents. In the second study we compared the sagittal distances from the plumbline of C7, T12, L3, and Sagittal Index (SI = C7+L3) with the measures of the Video Rasterstereography at the same levels and the angles of kyphosis and lordosis in 100 AIS patients. In the third study we evaluated the intra and inter-rater repeatability and the measurement error of kyphosis and lordosis angles measured with the Inclimed in 100 AIS patients. In the last study we evaluated the repeatability of the sagittal distances from the plumbline, by using a 1 mm change instead of 5 mm in a population of 40 patients. STATISTICAL ANALYSIS repeatability has been evaluated according to Bland and Altman, to identify the limits of variation that are clinically significant. Results. Study 1: the normative data were: females: 34 ± 11 mm for C7; 34 ± 15 mm for L3, males: 34 ± 10 mm for C7; 48 ± 10 mm for L3;. Study 2: a coefficient of correlation was calculated in order to compare measures. Study 3: the k value for Inclimed varied from fair to good. Study 4: the repeatability was fair for this measure. CONCLUSION Some clinical instruments are now available for sagittal plane assessment in AIS and hyperkyphosis. The results of the present study report the limits during measurements in a clinical setting of parameters that are routinely collected by some clinicians.

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

BackgroundRecently an RCT confirmed brace efficacy in adolescent idiopathic scoliosis (AIS) patients. Previously, a Cochrane review suggested also producing studies according to the Scoliosis Research Society (SRS) criteria on the effectiveness of bracing for AIS. Even if the SRS criteria propose a prospective design, until now only one out of 6 published studies was prospective. Our purpose was to evaluate the effects of bracing plus exercises following the SRS and the international Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) criteria for AIS conservative treatment.MethodsStudy design/setting: prospective cohort study nested in a clinical database of all outpatients of a clinic specialized in scoliosis conservative treatment.Patient sample: seventy-three patients (60 females), age 12 years 10 months ±17 months, 34.4±4.4 Cobb degrees, who satisfied SRS criteria were included out of 3,883 patients at first evaluation.Outcome measures: Cobb angle at the end of treatment according to SRS criteria : (unchanged; worsened 6° or more, over 45° and surgically treated, and rate of improvement of 6° or more).Braces were prescribed for 18–23 hours/day according to curves magnitude and actual international guidelines. Weaning was gradual after Risser 3. All patients performed exercises and were managed according to SOSORT criteria. Results in all patients were analyzed according to intent-to-treat at the end of the treatment. Funding and Conflict of Interest: no.ResultsOverall 34 patients (52.3%) improved. Seven patients (9.6%) worsened, of which 1 patient progressed beyond 45° and was fused. Referred compliance was assessed during a mean period of 3 years 4 months ±20 months; the median adherence was 99.1% (range 22.2-109.2%). Employing intent-to-treat analysis, there were failures in 11 patients (15.1%). At start, these patients had statistically significant low BMI and kyphosis, high thoracic rotation and higher Cobb angles. Drop-outs showed reduced compliance and years of treatment; their average scoliosis at discontinuation was low: 22.7° (range 16-35°) at Risser 1.3 ± 1.ConclusionsBracing in patients with AIS who satisfy SRS criteria is effective. Combining bracing with exercise according to SOSORT criteria shows better results than the current literature.

Swimming and spinal deformities: a cross-sectional study.

OBJECTIVE To compare the prevalence of spinal deformities and low back pain (LBP) in adolescent competitive swimmers and normal controls. STUDY DESIGN This was a cross-sectional study with convenience sample of 112 adolescent competitive swimmers (62 females) compared with 217 students (106 females) of the same age (12.5 years). We designed a questionnaire to collect data on LBP and measured the angle of trunk rotation with a Bunnell scoliometer to screen for scoliosis, along with the plumbline distances for kyphosis and lordosis. Clinical cutoffs defined in the literature for detection of spinal deformities were applied. Analyses were performed using the t test and χ(2) test, and ORs and 95% CIs were calculated. RESULTS Swimming was found to increase the risk of trunk asymmetries (OR, 1.86; 95% CI, 1.08-3.20). Swimming also increased the risk of hyperkyphosis (OR, 2.26; 95% CI, 1.35-3.77) and hyperlordosis (OR, 2.24; 95% CI, 1.06-4.73), and increased LBP in females by 2.1-fold (95% CI, 1.08-4.06). CONCLUSION Swimming is associated with an increased risk of trunk asymmetries and hyperkyphosis. Although swimming has been considered a complete sport and a treatment option for scoliosis, our data contradict that approach, and also show a higher prevalence of LBP in females.

Adolescent idiopathic scoliosis and eating disorders: is there a relation? Results of a cross-sectional study

UNLABELLED A recent study suggests a correlation between idiopathic scoliosis in adolescence and eating disorders. However, this does not correspond with our clinical experience in the same population. The aim of this study was to verify the correlation between scoliosis and eating disorders in adolescence. A cross-sectional study was designed including 187 consecutive adolescent girls with a diagnosis of idiopathic scoliosis (mean Cobb angle 26°, range 11-73°, age 15.2±2.5; 24% juveniles, 76% adolescent type) and 93 schoolgirls as controls (age 14.9±1.0). All of the participants answered the Italian validated questionnaire EAT-26 about eating habits in order to identify any eating disorders. Body mass index (BMI) was calculated for all participants and compared to reference data. STATISTICAL ANALYSIS chi-square test, Students t-test, Pearsons correlation coefficient. Only 3 (1.6%; 95% CI -0.2-3.4%) participants in the scoliosis group showed EAT-26 scores suggestive for eating disorders versus 7 (7.5%; 95% CI 2.2-12.9%) in the school population (p<0.05). The BMI was slightly lower (p<0.05) for scoliosis patients (19±0.2) than for school girls (21±0.3). EAT-26 is recognized among the most valid questionnaires for eating disorders and has been widely applied in various countries. By applying this questionnaire, a lower incidence of eating disorders in female scoliosis patients was found than in the general population (using both our own controls and Italian reference values). This contrasts with some expert opinions and a recent study performed in Italy. The low BMI already reported in the literature as being typical of scoliosis participants is confirmed by our data.

Characteristics of patients with more than 20° of improvement or worsening during conservative treatment of adolescent idiopathic scoliosis

INTRODUCTION Since the beginning of history of Medicine, it has been possible to learn from the worst and best results of treatments. Our aim was to verify which patients can reach the best and worst results during conservative treatment. METHODS All AIS patients with more than 2 visits included in a prospective clinical database started in September 2003 were reviewed on August 31st 2010. A cut-off of 20 degrees (improvement or worsening) from the first observation was used to select patients. Patients were analysed for diagnosis, morphology, Cobb degrees at start, curve improved/worsened, treatment, gender, Body Mass Index, clinical parameters. RESULTS Out of 1886 consecutive patients, 62 (3.3%) changed 20° or more: 26 (1.4%) improved (range 20-34°), 36 (1.9%) progressed (20-60°). Relative Risk of progression of 20° or more was increased more than 10 times in cases of thoracic curve or secondary scoliosis, 5 times for Moe scoliosis and BMI <15 kg/mq, 3 times for age <12 years, and congenital or juvenile scoliosis. Relative Risk of improvement of 20° statistically was increased more than 3 times in cases of previous exercises, female gender, thoracolumbar curve or scoliosis, ISICO treatment, and age <12 years. CONCLUSION Not all our results correspond to the usually reported prognostic factors in ample case series, but it must be taken into account that only wide variations (20° or more) have been considered here. In this population we had 1.9% of patients who improved at least 20° with conservative treatment, and this is notable as well. Finally, since these results are not similar to what would be expected according to the known natural history, conservative treatment appears able to change it.

Bracing can reduce high degree curves and improve aesthetics immediately after the end of growth. Final results of a retrospective case series

INTRODUCTION Recently it has been shown that idiopathic scoliosis (IS) curves can be reduced with bracing, and it has been proposed that this could be useful in non-surgically treated high degree curves even after Risser 3. Moreover, bracing has been shown to be able to improve aesthetics, and this could be another reason to treat some patients with cosmetic needs. Our aim is to preliminary check if results can be obtained in IS patients after Risser 3. METHODS Design. Retrospective uncontrolled cohort study. Inclusion criteria. All IS patients treated on a voluntary basis for aesthetic reasons and/or for curve reduction; Risser 4-5 at start; end of treatment reached. Population. 34 females and 2 males, age 16.2±1.6 years, Cobb angle 27.6°±8.9°. Treatment. Lyon or SPoRT braces 18 to 24 hours/day, specific SEAS exercises, rapid weaning (2-3 hours every 6 months). Outcome criteria: SRS (unchanged; worsened over 6°; over 45° at the end of treatment; surgically treated), radiographic and clinical. Statistics. ANOVA and chi-test. RESULTS The reported compliance during the 2.8 ± 1.1 treatment years was 95.1%, while residual growth was 0.9 ± 1.1 cm. Improvements were found in 39% of this cohort, (46% in curves over 30°). Only 1 patient progressed 6°. We found highly statistically significant reductions of maximal (-4.4°), thoracic (-6.0°) and thoracolumbar (-6.6°) curves. Statistically significant improvements were found for Aesthetic Index. CONCLUSION Before 20 years of age, even in skeletally mature patients, it is possible to reach radiographic and aesthetic improvements, although not as good as during growth. Correction is based on bone growth, but ligaments and neuromuscular control of posture can also be involved.

Correlation between in-brace radiographic correction and short time brace results

INTRODUCTION: In-brace radiographic correction is considered a reliable check of brace efficacy. The aim of this study was to correlate the in-brace correction with the short term results of treatment (6 months). DESIGN: pre-post study POPULATION: 41 consecutive adolescent girls with idiopathic scoliosis who were prescribed a brace treatment (39 thoracic curves, 37±12°; 16 thoracolumbar, 38±13°; 12 lumbar, 31±8°. Risser 0-3). In-brace radiographic correction and 6 months treatment out of brace X-ray results were correlated, according to curve localization. The in-brace/out-of-brace ratio was calculated, curves were grouped according to the Risser sign, the results ( 45°). STATISTICAL ANALYSIS: Correlation Coefficient. RESULTS: The in-brace/out-of-brace ratio varied according to localization of curve and Risser, achieving the best results for thoracic curves (38-45%). The groups of thoracolumbar and lumbar had higher variability (17-65% and 17-40%). The correlation coefficient between in-brace correction and out-of-brace results was statistically significant: 0.85 for thoracic curves, 0.64 thoracolumbar, 0.72 lumbar. Risser groups: 0.65-0.98 thoracic, 0,78-0.90 thoracolumbar, 0.94-0.98 lumbar. For Results groups, the correlation was better for the group with high degree of correction (High results) in lumbar and the group with low degree of correction (Low results) for thoracolumbar, no differences for thoracic. Low in-brace correction had a low correlation coefficient for thoracic and lumbar curves. No differences for Magnitude. CONCLUSION: The in-brace correction ranges from 17 to 47% of the curve magnitude. The correlation between in-brace correction and short time results of brace is significant, range 0.64-0.98. The in-brace correction seems able to predict the short time results of treatment.

Correlation between in-brace radiographic correction and short time brace results.

INTRODUCTION In-brace radiographic correction is considered a reliable check of brace efficacy. The aim of this study was to correlate the in-brace correction with the short term results of treatment (6 months). METHODS DESIGN pre-post study POPULATION 41 consecutive adolescent girls with idiopathic scoliosis who were prescribed a brace treatment (39 thoracic curves, 37±12°; 16 thoracolumbar, 38±13°; 12 lumbar, 31±8°. Risser 0-3). In-brace radiographic correction and 6 months treatment out of brace X-ray results were correlated, according to curve localization. The in-brace/out-of-brace ratio was calculated, curves were grouped according to the Risser sign, the results (<10°, ≥10° out-of-brace), in-brace correction (<10°, ≥10°), the magnitude (<30°, 30°-45°, >45°). STATISTICAL ANALYSIS Correlation Coefficient. RESULTS The in-brace/out-of-brace ratio varied according to localization of curve and Risser, achieving the best results for thoracic curves (38-45%). The groups of thoracolumbar and lumbar had higher variability (17-65% and 17-40%). The correlation coefficient between in-brace correction and out-of-brace results was statistically significant: 0.85 for thoracic curves, 0.64 thoracolumbar, 0.72 lumbar. Risser groups: 0.65-0.98 thoracic, 0,78-0.90 thoracolumbar, 0.94-0.98 lumbar. For Results groups, the correlation was better for the group with high degree of correction (High results) in lumbar and the group with low degree of correction (Low results) for thoracolumbar, no differences for thoracic. Low in-brace correction had a low correlation coefficient for thoracic and lumbar curves. No differences for Magnitude. CONCLUSION The in-brace correction ranges from 17 to 47% of the curve magnitude. The correlation between in-brace correction and short time results of brace is significant, range 0.64-0.98. The in-brace correction seems able to predict the short time results of treatment.

A cognitive behavioral approach allows improving brace wearing compliance: an observational controlled retrospective study with thermobrace

Methods Setting. Outpatient tertiary referral clinic. Population. Out of 778 patients, 246 fulfilled the inclusion criteria: Idiopathic Scoliosis; first brace prescription; regular use of Thermobrace heat sensor; two evaluations after bracing; age 36; European Risser 0-3. Evaluations. T0 (start of bracing), T1 (4 months), T2 (10 months). Measurements. Brace wearing compliance (BWC) T0 to T1 (T0-T1) and T1 to T2 (T1-T2). Treatment. CBA adjunctive sessions dispensed during PSSE (CBA-PSSE), after the standard CBA provided to all patients including: at prescription, 20’ by Medical Doctor (MD) and 30-45’ by Physiotherapist; at brace check, 10-15’ by MD and Orthopaedic Technician; at T1, 10-15’ by MD. Groups. According to CBA-PSSE in T0-T1 period: CBA1 (143 patients) 32 sessions; Poor-Adherence (PA1, 52) 1 session; Control (CON1, 51) 0 sessions . Similarly, according to CBA-PSSE in T1-T2 period: CBA2 (97), PA2 (78), CON2 (71). Combinations among the 6 groups in the two periods were checked. Statistics. ANOVA for group comparisons.