Salvatore Minnella

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.

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.

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.

A retrospective controlled study comparing Spinecor vs exercises for Adolescent Idiopathic Scoliosis

Methods Study design: retrospective controlled study. Population: Exercise Group (EG): 28 consecutive scoliosis patients (26 females), age 13±2, TRACE 4.5, Cobb angle 18±3°, ATR 7±3°, Risset 0-3. SpineCor Group (SG): 41 patients (33 females), age 13±1, TRACE score 6, Cobb angle 24±5°; ATR 8±3°, Risser 0-3. EG patients performed specific exercises twice per week according to the SEAS protocol. SG patients wore the SpineCor brace 20 hours per day. Patients were evaluated both clinically and radiographically before and after the treatment. Main outcome measured TRACE (changes ≥3), Cobb angle (changes > ±5) and ATR.

Sagittal balance in the conservative treatment of pathological kyphosis: a retrospective observational study

Methods Study Design: Retrospective observational study. Population: A total of 23 patients (15 males; 8 females), aged 11 to 17 years were included. Each patient had at least two clinical evaluations and spinal X rays (lateral projection) at the time of therapy start (T0) and stop (T1). Methods: 20 patients presented thoracic hyperkyphosis and three presented thoracolumbar kyphosis. All of the patients were treated conservatively; specifically, 17 were treated with brace plus specific exercises and 6 were treated with only specific exercises. For all of the patients we measured the sagittal parameters of thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS) and spinosacral angle (SSA). Statistical analysis: paired Wilcoxon test and correlation (Pearson). Results Mean and standard deviation for each parameter were measured in T0: TK, LL, PI 43.83± 7.95, PT 4.83± 6.96, SS 38.91± 7.67, SSA; and in T1: TK, LL, PI 41.87± 9.62, PT 5.48± 7.04, SS 36.39± 7.80, SSA. Highly significant improvements were found for the main spinal parameters from T0 to T1: TK reduced from 54.22± 13.58 to 44.48± 12.80 (p= 0.0006), LL from 57.43± 11.16 to 51.13± 10.28 (p= 0.0077) and SSA from 132.87± 9.80 to 127.09± 9.24 (p= 0.0036); no significant differences were found for the other parameters. Looking at sagittal parameter correlations,very few were found at the start of treatment: SS correlated with LL (R=0.651; p=0,007), SSA (R=0.600; p=0.0025) and PI (R=0.596; p=0.0027) which also correlated with PT (R=0.515; p=0.0119). Contrarily, at the end of treatment, most parameters were correlated: LL with PI ( R=0.514; p=0.0122), SS (R=0.499; p=0.0152), and SSA (R=0.743; p<0.0001), PI with PT(R=0.600; p=0.0024), SS (R= 0.691; p=0.0003) and SSA (R=0.628; p=0.0013) and SS with SSA (R=0.650; p=0.0008).

Low reliability of the Risser sign in consecutive radiographs: a case series

Conclusions and discussion At this stage, the following explanatory hypotheses can be drawn: Technical radiological differences (exposure, machine) Variation of pelvis positioning Postural changes influencing the pelvis Brace compression on the pelvis According to our study results, all of the hypotheses include data both in favor and against the reliability of the Risser sign. Since the Risser sign is a 2D evaluation of a 3D phenomenon, pelvis repositioning could perhaps be the most plausible explanation. This case series is open to the possibility that the Risser sign is even less reliable than originally considered. Unfortunately, this result cannot be checked experimentally due to ethical reasons. Nevertheless, observational designs could be considered in the future.

Risser stages, menarche and their correlations with other growth parameters in a cohort of 3,553 Italian adolescent idiopathic scoliosis patients

4.7 years; and an average growth in height from R1 (158.8 ±6.9) to R5 (164.7±6.2) or 5.9 cm; as regard to weight, there was an increase of 6.3 kg from average value in R1 (47.9±8.7) to R5 (54.2±7.5); the percentage of patients who had menarche was 27% in R0, 79% in R1, 90% in R2, 97% in R3, 99% in R4, and 100% in R5; but, it’s important to point out that 3% in R1, 13% in R2, 53% in R3 and 87% in R4 were two years after menarche. In males, the average growth period from R1 to R5 was also 4.7 years; but average height increased 7.2 cm; and weight increased by an average of 11.7 kg. Conclusion According to our results, it’s important to relate all the parameters examined for timing the stop of conservative treatment in AIS patients. Our results also show that the parameter of two years after menarche cannot be considered to determine skeletal maturity.

Conservative treatment with brace and exercise for hyperkyphosis: a retrospective observational cohort study

Participants In December 2013, among all the patients below 18 years of age at first evaluation, present in the database, we selected those respecting the following inclusion criteria: • diagnosis of idiopathic or Scheuermann’s kyphosis • at least two clinical evaluations at the time of therapy start (T0) and stop (T1) • spinal X-rays (lateral projection) at the time T0 and T1 Treatments All patients underwent conservative treatment with rigid braces, specific for hyperkiphosis, associated with specific exercises. The brace was prescribed for at least 18 hours a day at the beginning of therapy.

Previously treated versus untreated scoliosis: are results different?

Outcome measure The threshold of 5° Cobb to define worsened, improved and stabilized curves was considered, average Cobb angle, ATR, TRACE (for aesthetic evaluation) Statistical analyses: Mean and SD were used for descriptive statistics of clinical and radiographic changes. Relative Risk of failure (RR), 95% Confidence Interval (CI), Student’s t, Kruskall Wallis, and chi square test were applied. Results 268 patients were included (226 females), age 13.3 (±1). BRACE Group: 108 (96 females), age 13.2 (±1), Cobb Angle 34±12°, ATR 9.6±0.4, TRACE 5.7. UNTREATED Group: 160 (130 females), age 13.2 (±1), Cobb Angle 33±11° ATR 10.3±0.2°, TRACE 5. No differences among groups at first visit but for TRACE (p<0.05). 49.38% of patients improved in UNTREATED, 43.13 stable, 7.50 worsened vs 35.19, 52.78 and 12.04 for BRACE (p=0.06). The Cobb angle was 28.9 vs 30.1 (p=0.06). The RR of failure for BRACE was 1.6 (IC95%0.86-2.35). No differences among groups for TRACE and ATR. Drop out had results similar to the completers (NS).