Salvatore Atanasio

Exercises reduce the progression rate of adolescent idiopathic scoliosis: Results of a comprehensive systematic review of the literature

Background. A previously published systematic review (Ped.Rehab.2003 – DARE 2004) documented the existence of the evidence of level 2a (Oxford EBM Centre) on the efficacy of specific exercises to reduce the progression of AIS (Adolescent Idiopathic Scoliosis). Aim. To confirm whether the indication for treatment with specific exercises for AIS has changed in recent years. Study design. Systematic review. Methods. A bibliographic search with strict inclusion criteria (patients treated exclusively with exercises, outcome Cobb degrees, all study designs) was performed on the main electronic databases and through extensive manual searching. We retrieved 19 studies, including one RCT and eight controlled studies; 12 studies were prospective. A methodological and clinical evaluation was performed. Results. The 19 papers considered included 1654 treated patients and 688 controls. The highest-quality study (RCT) compared two groups of 40 patients, showing an improvement of curvature in all treated patients after six months. We found three papers on Scoliosis Intensive Rehabilitation (Schroth), five on extrinsic autocorrection-based methods (Schroth, side-shift), four on intrinsic autocorrection-based approaches (Lyon and SEAS) and five with no autocorrection (three asymmetric, two symmetric exercises). Apart from one (no autocorrection, symmetric exercises, very low methodological quality), all studies confirmed the efficacy of exercises in reducing the progression rate (mainly in early puberty) and/or improving the Cobb angles (around the end of growth). Exercises were also shown to be effective in reducing brace prescription. Conclusion. In five years, eight more papers have been published to the indexed literature coming from throughout the world (Asia, the US, Eastern Europe) and proving that interest in exercises is not exclusive to Western Europe. This systematic review confirms and strengthens the previous ones. The actual evidence on exercises for AIS is of level 1b.

Physical exercises in the treatment of adolescent idiopathic scoliosis: An updated systematic review

Two years ago we published an update of another of our previous systematic reviews about the effectiveness of physical exercises (PEs), and we found that the evidence on exercises for AIS was of level 1b. Now we have updated these results in the field of exercises for AIS with the final aim to find the strongest evidence as possible about PEs. Our goal was to verify if treatment with specific exercises for AIS has changed in these years. The study design was a systematic review. A bibliographic search with strict inclusion criteria (patients treated exclusively with exercises, outcome Cobb degrees, all study designs) has been performed on the main electronic databases. We found a new paper about active autocorrection (Negrini et al, b), a prospective controlled cohort observational study on patients never treated before so the number of manuscripts considered in the systematic review was 20. The highest quality study (RCT) compared 2 groups of 40 patients, showing an improvement of the curve in all treated patients after 6 months. All studies confirmed the efficacy of exercises in reducing the progression rate (mainly in early puberty) and/or improving the Cobb angles (around the end of growth). Exercises were also shown to be effective in reducing brace prescription. Appendices of the popular exercise protocols that have been used in the research studies that are examined are included with detailed description and illustrations. This study (like the previously published systematic reviews) showed that PEs can improve the Cobb angles of individuals with AIS and can improve strength, mobility, and balance. The level of evidence remains 1b according to the Oxford Centre for Evidence-based Medicine, as previously documented.

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

BackgroundAesthetic appearance is of primary importance in the treatment of adolescent idiopathic scoliosis (AIS), but to date tools for routine clinical practice have not become available. The aim of the present study is to develop such a tool and to verify its repeatability.MethodsInstrumentation: At first we developed the Aesthetic Index (AI), based on a three-point scale for asymmetry of the shoulders, scapulae and waist that we tested for 5 years. From this experience we developed another tool we called TRACE, the acronym of Trunk Aesthetic Clinical Evaluation; TRACE is a 12-point scale based on four sub-scales, shoulders (0–3), scapulae (0–2), hemi-thorax (0–2) and waist (0–4).Population: Posterior-anterior (PA) photographs of one hundred-sixty AIS patientsProcedures: Each photograph was scored in two independent tests by four observers using AI, and subsequently TRACE.Data analysis: Kappa statistical analysis and 95% level of agreement were used; we also identified the minimum significant change (95% confidence level).ResultsWe found the intra- and inter-raters repeatability of AI to be fair. Three points out of seven was the minimum significant change between two different evaluations. For TRACE, intra-rater repeatability was fair and inter-raters poor; but the minimum significant change was three (intra-rater), or four (inter-raters) out of twelve points.ConclusionWidening the scale from 7 (AI) to 12 points (TRACE) increased the clinical sensitivity to changes of the aesthetic scale, even if TRACE has only a fair repeatability. TRACE is a no-cost tool for routine clinical practice in AIS patients. Due to the absence of other comparable validated tools, once the inherent measurement error is known and understood, its routine clinical use by physicians is advised.

Specific exercises performed in the period of brace weaning can avoid loss of correction in Adolescent Idiopathic Scoliosis (AIS) patients: Winner of SOSORT's 2008 Award for Best Clinical Paper

BackgroundExercises are frequently performed in order to improve the efficacy of bracing and avoid its collateral effects. Very frequently there is a loss of correction during brace weaning in AIS treatment.AimTo verify the efficacy of exercises in reducing correction loss during brace weaning.Study DesignRetrospective controlled study.PopulationSixty-eight consecutive patients (eight males), age 15 ± 1 and Cobb angle 22 ± 8° at start of brace weaning.MethodsThe start of brace weaning was defined as the first visit in which the wearing of brace for less than 18/24 hours was prescribed (according to our protocol, at Risser 3). Patients were divided into two groups according to whether or not exercises were performed: (1) EX (exercises), included 39 patients and was further divided into two sub-groups: SEAS (who performed exercises according to our institutes protocol, 14 patients) and OTH (other exercises, 25 patients) and (2) CON (controls, 29 patients) that was divided into two other sub-groups: DIS (discontinuous exercises, 19 patients) and NO (no exercises, 10 patients). Complete brace weaning was defined as the first visit in which the brace was no longer prescribed (ringapophysis closure or Risser 5, according to our protocol).ANOVA and Chi Square tests were performed.ResultsThere was no difference between groups at baseline. However, at the end of treatment, 2.7 years after the start of the weaning process, Cobb angle increased significantly in both the DIS and NO groups (3.9° and 3.1° Cobb, respectively). The SEAS and OTH groups did not change. Comparing single groups, OTH (with respect to DIS) had a significant difference (P < 0.05).ConclusionExercises can help reduce the correction loss in brace weaning for AIS.

Adult scoliosis can be reduced through specific SEAS exercises: a case report

BackgroundIt has been known since many years that scoliosis can continue to progress after skeletal maturity: the rate of progression has shown to be linear, and it can be used to establish an individual prognosis. Once there is progression there is an indication for treatment: usually it is proposed a surgical one. There are very few papers on an alternative rehabilitation approach; since many years we propose specific SEAS exercises and the aim of this study is to present one case report on this approach.Case presentationAll radiographs have been measured blindly twice using the same protractor by one expert physician whose repeatability error proved to be < 3° Cobb; the average measurement has been used. In this case a 25 years old female scoliosis patient, previously treated from 14 (Risser 1) to 19 years of age with a decrease of the curve from 46° to 37°, showed a progression of 10° Cobb in 6 years. The patient has then been treated with SEAS exercises only, and in one year progression has been reverted from 47° to 28.5°.ConclusionA scoliosis curve is made of different components: the structural bony and ligamentous components, and a postural one that counts up to 9° in children, while it has not been quantified in adults. This case shows that when adult scoliosis aggravates it is possible to intervene with specific exercises (SEAS) not just to get stability, but to recover last years collapse. The reduction of scoliotic curve through rehabilitation presumably does not indicate a reduction of the bone deformity, but rely on a recovery of the upright postural collapse. This reduction can decrease the chronic asymmetric load on the spine and, in the long run, reduce the risks of progression.

The Sforzesco brace can replace cast in the correction of adolescent idiopathic scoliosis: A controlled prospective cohort study

BackgroundThe conservative treatment of adolescent idiopathic scoliosis (AIS) has traditionally been divided into two phases–correction and stabilisation–and casts, even if less used today, can be considered the best standard in the correction phase. Till the present, however, no comparison between cast and brace efficacy has been proposed.MethodsThis is a prospective cohort study with a retrospective control group. The aim was to verify if it is possible to obtain with a specifically developed rigid brace results comparable to a cast. We considered fifty AIS patients who had refused surgery, aged 14.1 ± 1.5 years, with 46.7 ± 7.8° Cobb scoliosis. Thirty-two consecutive patients (with no drop-outs) were prospectively followed up with the Sforzesco brace (SBG), and compared against a retrospective group of eighteen patients treated with the Risser cast (RCG). The treatment time (the total correction phase) was 19 ± 3 months. Out-of-brace x-rays were compared, as well as clinical results.ResultsCompliance and hours of treatment were higher in the RCG while all the other parameters were not different. We observed a reduction of 6° Cobb and an important aesthetic gain in both groups (P<0.05). Three patients (6%) worsened, while 56% improved (36% at least 10°, and 14% 15° or more). The SBG did show results comparable to the RCG, with only minor differences in terms of scoliosis correction. On the contrary, straightening of the spine (decrease of the sagittal physiological curves) was much higher in the RCG but was not clinically significant in the SBG.ConclusionIn the corrective phase of AIS treatment it is possible with a specific rigid brace (Sforzesco – SPoRT concept) to obtain scoliosis correction similar to cast. Due to the human and social costs of casting, and worst sagittal profile results, Sforzesco brace should be the preferred method wherever possible.

Three-dimensional easy morphological (3-DEMO) classification of scoliosis, part I

BackgroundWhile scoliosis has, for a long time, been defined as a three-dimensional (3D) deformity, morphological classifications are confined to the two dimensions of radiographic assessments. The actually existing 3-D classification proposals have been developed in research laboratories and appear difficult to be understood by clinicians.Aim of the studyThe aim of this study was to use the results of a 3D evaluation to obtain a simple and clinically oriented morphological classification (3-DEMO) that might make it possible to distinguish among different populations of scoliotic patients.MethodWe used a large database of evaluations obtained through an optoelectronic system (AUSCAN) that gives a 3D reconstruction of the spine. The horizontal view was used, with a spinal reference system (Top View). An expert clinician evaluated the morphological reconstruction of 149 pathological spines in order to find parameters that could be used for classificatory ends. These were verified in a mathematical way and through computer simulations: some parameters had to be excluded. Pathological data were compared with those of 20 normal volunteers.ResultsWe found three classificatory parameters, which are fully described and discussed in this paper: Direction, the angle between spinal pathological and normal AP axis; Shift, the co-ordinates of the barycentre of the Top View ; Phase, the parameter describing the spatial evolution of the curve. Using these parameters it was possible to distinguish normal and pathological spines, to classify our population and to differentiate scoliotic patients with identical AP classification but different 3D behaviors.ConclusionThe 3-DEMO classification offers a new and simple way of viewing the spine through an auxiliary plane using a spinal reference system. Further studies are currently under way to compare this new system with the existing 3-D classifications, to obtain it using everyday clinical and x-rays data, and to develop a triage for clinical use.

Low back pain: state of art

Diagnosis of low back pain (LBP) is made by exclusion of secondary spinal diseases, identifiable in the first month of pain (acute LBP – ALBP) through the so-called “reds flags”, and only if pain persists over 4 weeks (sub-acute LBP – SALBP) using diagnostic exams. LBP classification is actually based on the localization (LBP and sciatica) and duration of pain: ALBP, SALBP, and chronic (CLBP) when it lasts over 6 months. ALBP prognosis is very good because it is auto-resolving in most of the cases; on the contrary, CLBP has a bad prognosis (very low rate of resolution even with treatment). The stage of most interest is SALBP, in which it is possible to identify risk factors (“yellow flags”) of chronicity and to avoid the development of a series of vicious cycles that, according to a bio-psycho-social model of illness, can lead the patient to CLBP. In CLBP its mandatory to make the patient able to manage his problem, so to increase his quality of life and decrease disability and pain. Treatment approach to ALBP consist of reassuring the patient and providing accurate preventive information, recommendations to remain as active as possible, to avoid bed rest. In SALBP and CLBP, a multidisciplinary team rehabilitation approach is the most important one, combining educational, cognitive-behavioural and physical exercise treatments according to the individual needs. Pain killer therapies can be proposed, but bearing in mind their short-term effects.

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

BackgroundAesthetics is a main goal of both conservative and surgical treatments in adolescent idiopathic scoliosis (AIS). Previously, we developed and validated a clinical scale - the Aesthetic Index (AI)--in order to measure aesthetic impairment and changes during treatment.AimTo verify the efficacy of bracing on aesthetics in AIS.Study DesignProspective Cohort Study.PopulationThirty-four consecutive patients, age 13.2 ± 3.7, initial Cobb Angle 32 ± 12°, ATR 10 ± 4° Bunnel, 11 males.MethodsPatients with AI scores of at least 5/6 were included. Each of them had a brace prescription (18 to 23 hours per day), according to the SPoRT concept. AI was measured again after six months and at the end of treatment, and then the pre- and post-treatment scores compared. The Wilcoxon test was performed.ResultsTwenty-nine patients out of the 34 included completed the treatment and had six-month and final results; four patients were lost during the treatment, and one was fused. At baseline, median AI was 6 (95% IC 5-6) but the score decreased to 3 (95% IC 0-5; p < 0.05) after six months with brace, and this value was maintained in the 29 who completed the treatment (95% IC 1-6; p < 0.05 with respect to the baseline).ConclusionAesthetics can be improved in a clinically significant way when the brace treatment is performed according to the SPoRT concept and by following the SOSORT management criteria. This is a relevant result for patients and a major goal of scoliosis treatment, be it conservative or surgical. The use of a more sensitive tool like TRACE could more easily detect the clinical changes; nevertheless, AI proved sensible enough that its use in everyday clinical practice can be suggested.

BRACE MAP, a proposal for a new classification of braces.

Braces today are named according to the authors name or town. The existing classification of braces considers only the anatomical spinal section involved (C: cervical; T: thoracic; L: lumbar; S: sacral; Orthosis). The absence of a more detailed classification do not allow to really distinguish between the different braces and to have a common language between the conservative treatment experts. Our aim was to propose and verify a new classification of braces. We developed the classification and applied it to 13 different braces (Boston, Charleston, Cheneau 2000, Lapadula, Lyonese, Maguelone, Milwaukee, PASB, Providence, Sforzesco, Sibilla, SpineCor, Triac). We considered the following items (acronym BRACE MAP): Building, Rigidity, Anatomical classification, Construction of the Envelope, Mechanism of Action, Plane of action. Each item is composed by 2 to 7 classificatory elements defined using one or maximum two letters, so that from the classification it is possible to come back to the brace characteristics. Out of the 13 braces considered, BRACE MAP did not allow to differentiate only two. This first proposal needs to be refined through Consensus and discussions that are already underway in the international Society On Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT); nevertheless, BRACE MAP appears to be useful in distinguishing between the existing braces.