Brace adherence Influenced by geographic and personal factors: ISICO study published in children

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The ISICO study entitled “Geographic, Personal and Clinical Factors Influencing Brace Adherence in Adolescents with Idiopathic Scoliosis” has just been published in the journal Children (MDPI). The research also competed for the SOSORT Award 2025.
Brace therapy is an effective treatment for adolescents with idiopathic scoliosis (AIS), provided that adherence is high. While previous studies have objectively measured compliance using thermal sensors, the influence of geographic and socioeconomic variables—such as living in mountain versus seaside areas, in large cities versus small towns, or differences in income level—had not previously been investigated.

The study, led by Alessandra Negrini, physiotherapist at ISICO and author of the research, analyzed 1,904 adolescents(mean age 13 years; mean curve 35° Cobb). Adherence was measured using a thermal sensor (iButton) applied to the brace. The variables examined included age, prescribed brace-wearing hours, geographic area (Northern, Central, Southern Italy), gender, skeletal maturity (Risser), curve type, presence of back pain, income level, altitude above sea level, and distance from the sea.

Key Findings

  • 90% of patients demonstrated good adherence (wearing the brace for more than 75% of the prescribed hours).
  • Higher adherence was associated with:
    • Younger age
    • Female gender
    • A prescription of more than 20 hours per day
    • Residence in Northern Italy

The results suggest that climatic and social factors may influence treatment adherence.

As Alessandra Negrini comments:

“Through this study, we aimed to verify the influence of geographic, personal, and clinical variables — routinely recorded by doctors — on adherence to brace treatment. Understanding that certain factors can reduce adherence allows us to identify patients who may benefit from targeted strategies to improve compliance. Thanks to this type of research, we can enhance the personalization of therapeutic interventions, adapting them to patient characteristics to maximize treatment effectiveness.”

📖 The full article is available here

Returning to sport after scoliosis surgery: when and why physical activity is part of the treatment

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For an adolescent, the prospect of undergoing spinal surgery inevitably raises a fundamental question: “Will I be able to go back to the sport I love?”
In the past, an extremely cautious approach often prevailed. Today, however, scientific evidence clearly shows that returning to physical activity is not only possible but an integral part of the recovery process.

The importance of staying active
Remaining physically active during adolescence is one of the best investments in long-term health. Young patients who stop practicing sport after surgery have a higher risk of developing chronic pain and functional limitations in adulthood.
Unfortunately, studies show that around 30–40% of patients do not return to their previous level of sporting activity. In most cases, this is not due to real physical limitations, but rather to fear (on the part of the patient or parents) or overly strict restrictions imposed by healthcare professionals.
One of the main challenges today for specialists dealing with spinal disorders is to break this vicious circle: a surgically treated body is a body that can — and should — move again.

A few words on surgical techniques
Several surgical techniques are currently available. The most commonly used include:
• Spinal fusion (arthrodesis): This is the standard technique. Although it involves immobilising certain segments of the spine, in the vast majority of cases, it allows a full return to most sporting activities.
• Vertebral Body Tethering (VBT): a more recent technique that does not “fuse” the vertebrae but uses a flexible cord. Available data indicate that patients undergoing VBT tend to return to school and sport slightly earlier, although these are often adolescents who were already very physically active before surgery.

The “roadmap” back to sport
Every patient is unique and follows a therapeutic and personal pathway that cannot be identical to that of another patient, even with the same diagnosis. However, the Scoliosis Research Society (SRS) — the oldest scientific society dedicated to this condition — has defined time-based guidelines that reflect the period needed for tissues and instrumentation to stabilise.

In general:

  • first 3 months: in most cases, it is possible to resume light sporting activities such as swimming, stationary cycling or gentle jogging, with the aim of rebuilding strength, coordination and confidence in movement.
  • around 6 months: many adolescents can return to more demanding dynamic sports such as football and basketball, provided there is no direct contact, gradually increasing intensity and duration.
  • 9–12 months: if recovery is smooth and clinical follow-ups confirm good progress, a return to high-impact sports such as rugby, judo and karate is generally allowed.

These indications are not rigid rules, but a reference framework designed to support a safe and gradual return to sport.
Many parents fear that an impact could damage the rods or compromise the nerves. The reality is reassuring: serious complications related to sporting activity are extremely rare.
The most common — though still infrequent — issues involve loosening of a screw or minor damage to the rods, and they tend to occur when recovery stages are rushed (for example, returning to snowboarding after only two weeks).
By respecting healing times and following a gradual progression, the risk remains very low. Surgeons and physiotherapists work together to build a genuine bridge back to normal life, based on trust and collaboration.

The real question is not whether to return to sport, but how and when to do so. Because movement is the medicine that protects the spine over time: returning to sport is not a risk to avoid, but the ultimate goal of every surgical intervention.

SEAS in France: Training Where We Once Went to Learn

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For the first time, at the end of January, SEAS — our exercise-based approach for the treatment of scoliosis — arrived in Marseille, involving 20 physiotherapists and one rheumatologist in an intense and highly engaging educational experience.

Hosted at the University School of Physiotherapy, the course represented a particularly significant moment for several reasons: it was the first SEAS edition in the region; it brought together a substantial number of professionals from an area historically distant from the most recent developments in conservative scoliosis treatment; and it combined theoretical lectures with practical applications.

Our Director of Physiotherapy, Michele Romano, who led the course, wished to share a brief personal reflection on this experience, describing its meaning and value also in light of the historical role France has played in scoliosis treatment.

“The treatment of scoliosis through exercises has undergone a fairly steady process of evolution in most parts of the world over the past twenty years.

During the same period, in France, there has been an unexpected and progressive decline — difficult to understand unless one considers political decisions related to public healthcare management.

France has long been considered a kind of international beacon in the treatment of this condition, thanks to the continuous development of casts, braces, and exercise methods that were, at the time, regarded as current and innovative.

Anyone who wanted to learn how to treat scoliosis or stay updated on new trends would go to France, making a kind of pilgrimage to the “Massues” Hospital in Lyon, and between a Camembert and a baguette, would return to their home countries with the latest developments.

Then, evolution slowly but inexorably came to a halt, and the trend moved in the opposite direction.
Thus, in recent years, with considerable ISICO pride, we have received requests to organize training courses in the very country where, in the past, we had all gone to learn.
Previous courses were delivered in Lyon and Paris. This latest training, however, took place in Marseille, responding to requests from professionals working in this region and in Corsica.

The course was held at the University School of Physiotherapy and generated great enthusiasm among the 20 participating physiotherapists and the rheumatologist, who attended the theoretical lectures and directly experienced the practical application of what they had learned on a group of real patients — adolescents and adults — who had been invited for the occasion.
While waiting to confirm the dates for the next course, already scheduled in Bordeaux, we left the transalpine country after visiting the wonderful MUCEM museum and filling a colorful bag with jars of Moutarde de Dijon.

Au revoir”.

From Patient to Physiotherapist: Simone’s Story

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Turning a difficulty into a resource, and a vulnerability into a life choice.
This is the story of Simone Priano, a former ISICO patient, who has recently graduated in Physiotherapy from the University of Novara, in north-western Italy, with a final mark of 108/110, defending a thesis focused on scoliosis and scoliosis-specific exercises for its treatment.

A topic that was anything but coincidental.

“It is often said that one should turn weaknesses into strengths. Fortunately, I have turned mine into my profession,” Simone explains. “Today I celebrate my graduation in Physiotherapy with a thesis on scoliosis. This subject is deeply personal to me because it is thanks to my experience as a former patient that I am here today. Bringing it to my final thesis was my way of honouring that journey and closing the circle.”

Simone began his therapeutic journey as an adolescent, while attending the ISICO centre in Turin and playing volleyball. He was diagnosed with scoliosis with a significant curve, requiring a demanding course of conservative treatment: 23 hours a day wearing a brace, combined with specific exercises. His treatment lasted five years, from September 2016 to June 2021.

Initially, however, his experience was not positive. Treated elsewhere, he had been told that conservative therapy would be ineffective and that surgery was the only possible option — a prospect that could have discouraged anyone. Instead, Simone encountered a different approach, based on consistent, structured work and a strong therapeutic relationship.

“He was already a serious and determined young man during his treatment,” recalls his ISICO physiotherapist, Martina Poggio. “Being able to support him later during his thesis work was an immense pleasure for me. Through therapy, we accompany young patients throughout their growth, often for many years, and inevitably form a bond with them. Seeing them again as adults — confident, aware and fulfilled — is truly special.”

The relationship did not end with the conclusion of treatment. On the contrary, it evolved into professional dialogue and scientific collaboration.

“The fact that he chose the same professional path and career means that, despite the evident challenges of therapy, he was able to go beyond them, finding motivation and support to overcome the condition. He is the second former patient whom I have met again, years later, as a colleague.”

Today, Simone is a young physiotherapist whose training combines academic study with direct personal experience — a valuable perspective that enriches both his clinical practice and his human approach to patients.

“I wish Simone a brilliant future,” his former physiotherapist concludes, “with the certainty that he will be able to pass on to other young people what he himself has experienced: that even a difficult journey can become a source of strength.”

Scoliosis and height: how much does spinal curvature affect stature?

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One of the most frequently asked questions regarding scoliosis concerns loss of height:
“My daughter has a 40° scoliosis… does that mean she is shorter than she would otherwise be?”

The answer is not straightforward. Reduction in stature associated with scoliosis does not depend solely on the angle of the curve; it is influenced by a range of structural and morphological characteristics of the spine.

The Cobb angle—commonly referred to as the curve angle—is the standard measure used to quantify the degree of lateral deviation in scoliosis. Over the years, several computational models have been proposed to estimate height loss attributable to scoliosis. However, formulae relying exclusively on the Cobb angle—such as the historical Stokes equation—have proved to be imprecise.

A study by Gardner et al. (2016) demonstrated that the original formula contained an error and emphasised that scoliosis is a three-dimensional deformity that cannot be summarised by a single parameter to estimate height loss. Similarly, Lonner et al. (2016) reported that the Cobb angle alone is insufficient to predict accurately the loss of stature: the true length of the deformed vertebral arc, the number of vertebrae involved and the degree of vertebral rotation all contribute. In other words, two patients with identical Cobb angles may nonetheless exhibit markedly different statures.

Stature is also relevant from a functional and respiratory perspective. Two recent studies from K Politarczyk et al. (2021) have shown that, in individuals with severe scoliosis, measured height may not reflect true body length, thereby affecting the interpretation of pulmonary function tests. In particular, height influences assessment of parameters such as forced vital capacity (FVC)—the total volume of air forcefully and completely exhaled after a full inspiration—and forced expiratory volume in one second (FEV₁). Consequently, in patients with severe scoliosis, it is necessary to correct the recorded height to avoid underestimating actual respiratory capacity.

In summary:

  • height loss in scoliosis is non-linear and cannot be estimated solely from the Cobb angle;
  • simple formulae, such as the Stokes equation, are now regarded as approximate;
  • a more accurate appraisal should incorporate morphological parameters of the curve and trunk, in addition to the Cobb angle;
  • for respiratory function testing, consideration of a corrected stature is particularly important in severe cases.

These studies underline that scoliosis is a complex three-dimensional deformity that affects not only appearance and stature but also clinical and functional outcomes. For this reason, assessment and treatment must be individualised and based on a thorough analysis of the curve and the patient’s growth.

Bibliographic references:

Medications and Low Back Pain: an ISICO commentary of a Cochrane review

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The Cochrane review “Pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews” has recently been published. This extensive and methodologically robust work significantly updates our understanding of the effectiveness—and the limitations—of the medications most commonly used for low back pain: from paracetamol to NSAIDs, as well as muscle relaxants, opioids, antidepressants, and antiepileptics.

Alongside the review, an editorial commentary by Prof. Stefano Negrini, ISICO Scientific Director, and Dr. Carlotte Kiekens, physiatrist, has also been published.
Their contribution offers a valuable interpretative perspective, helping to clarify what these findings really mean for clinicians working daily with spinal disorders and rehabilitation.

What the review shows

The central message is clear: medications alone play a very limited role in the management of low back pain.

Paracetamol is no more effective than placebo; NSAIDs provide only mild and short-term relief; muscle relaxants may help in the immediate phase but come with relevant adverse effects; and opioids show an unfavorable risk–benefit profile. For many other drug classes, the evidence remains insufficient.

The review does not deny the usefulness of medications in acute phases, but it highlights how they do not represent a long-term solution nor a first-line treatment.

“Low back pain is not a condition that can be treated with a pill. Medications may have a role, but they do not address what truly generates pain,” explains Negrini. “They do not improve function, they do not modify motor behavior, they do not change movement quality.
The real risk is prolonging the search for quick relief while postponing the interventions that actually work: exercise, rehabilitation, and education”.

Kiekens emphasizes the complexity of low back pain, particularly when it overlaps with structural conditions such as adult scoliosis: “Low back pain is generally multifactorial. It is the result of an interaction between muscles, joints, posture, degeneration, and lifestyle. This is why it is unrealistic to expect medication to resolve it. In clinical practice, what truly works is a multimodal approach: movement, awareness, load-management strategies, and active rehabilitation pathways.”

Medications may therefore have a role as a support, but they cannot guide the treatment: rehabilitation is what truly enables patients to get better. An active, multidisciplinary approach—combining medical care, rehabilitation, and lifestyle strategies—is essential for restoring function and achieving long-term improvement. This is exactly what patients can expect at ISICO.

Chronic Pain: diet also may play a significant role

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What we eat can influence not only our overall health, but also the way we perceive pain. A recent Australian study has revealed a surprising connection between a balanced diet and the reduction of chronic pain, extending beyond the simple association with obesity.

Chronic Pain: A Multidimensional Challenge

Chronic pain is a complex condition affecting millions of people worldwide. Although it is often associated with specific injuries or diseases, scientific evidence shows that less obvious factors — such as lifestyle and diet — can modulate the perception of pain.

Recent studies, Pain trends among American Adults e Increases in BMI and chronic pain for US adults in midlife, 1992 to 2016 conducted in the United States have demonstrated that an increase in body mass index (BMI) is associated with chronic pain, with prevalence rates ranging from 10% to 32%.
However, the relationship between adiposity and pain is not unidirectional:
“Pain itself can contribute to weight gain,” explains Dr Irene Ferrario, clinical psychologist at ISICO, “as many individuals tend to reduce physical activity or develop an increasing fear of movement.”

Within this context, another study conducted at the University of South Australia examined how diet influences bodily pain levels. The most noteworthy finding? The benefits of a healthy diet are not limited to individuals who are overweight but also extend to those with a normal BMI.

“It is important to understand that there is no single cause of chronic pain. Factors such as diet, physical activity and stress management should be viewed as components of an integrated care approach,” says Francesco Saveri, physiotherapist at ISICO.

Diet and Pain: More Than a Matter of Weight

Traditionally, body weight has been considered the main link between diet and chronic pain. Excessive weight can overload joints and promote inflammation, thereby worsening pain.
However, the Australian study showed that diet may play an independent role. Participants who followed a diet rich in fruit, vegetables, whole grains, lean meats and dairy products reported significantly lower pain levels, regardless of their BMI. This suggests that a balanced diet may positively influence inflammatory and oxidative processes that heighten pain perception.

“Educating patients to improve their diet is essential — not only to reduce pain, but also to promote a healthier long-term lifestyle. It is an investment in their quality of life,” adds Saveri.

Key Components of a “Pain-Reducing” Diet

Which foods should be included in a diet aimed at alleviating pain? According to experts, it is essential to prioritise:

  • Fruit and vegetables: rich in antioxidants and anti-inflammatory compounds.
  • Whole grains: due to their lower glycaemic impact, they help regulate blood sugar levels and reduce inflammation.
  • Lean proteins: fish and poultry provide essential amino acids for tissue repair.
  • Healthy fats: such as olive oil and nuts, which support the nervous system and reduce oxidative stress.

Why Diet Matters

The key lies in inflammatory processes. A diet high in simple sugars, saturated fats and ultra-processed foods increases oxidative stress and pro-inflammatory cytokines, thereby it may exacerbate pain.
Conversely, a balanced diet helps maintain an appropriate inflammatory equilibrium, improving not only general health but also overall quality of life.

“Further high-quality research is needed. Although the findings of the Australian study are of significant interest, the lack of temporal precedence due to the cross-sectional nature of the research prevents the exclusion of reverse causality or the influence of unmeasured confounding factors,” concludes Saveri.

Long-term stability in PWS scoliosis without surgery

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It is rare for a single case to so clearly demonstrate the power of a conservative approach. This is what emerges from the article published in the Journal of Clinical Medicine (Effective Conservative Management of Severe Scoliosis in a Girl with Prader–Willi Syndrome: A 20-Year Case Study Follow-Up, MDPI, 2024).

Prader–Willi syndrome (PWS) is a rare genetic disorder characterized by muscle hypotonia, obesity, and cognitive difficulties, often associated with severe scoliosis.
“In many of these cases, surgery is considered the only possible solution,” explains Dr. Francesco Negrini, author of the study. “In contrast, we present the clinical case of a young patient followed for twenty years with a conservative approach, based on scoliosis-specific exercises and customized braces, from Milwaukee to Sforzesco.”

Despite an initial curve exceeding 50° Cobb, the patient avoided surgery, maintaining long-term stability of the deformity and a good quality of life.

“This case highlights the potential of a well-organized, long-term conservative approach to managing scoliosis in PWS,” adds Negrini. “It suggests that, under specific conditions, surgery may be avoided or postponed. Most importantly, it underscores the need for further research to establish standardized protocols and to support clinical decision-making in the conservative treatment of scoliosis in PWS patients. We are already working on specific protocols for ambulatory patients with scoliosis secondary to neurological diseases,” concludes Negrini. “These protocols are urgently needed, as at present they do not yet exist.”

Scoliosis in children and teenagers: could dental problems be the cause?

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During a patient’s first medical visit, the parents were concerned after taking their twelve-year-old daughter to the dentist. During the dental check-up, a problem of malocclusion and swallowing emerged. The dentist suggested that this combination of factors might have contributed to the development of scoliosis.
But is it really possible that a problem in the mouth could lead to scoliosis? Let’s clear things up.

Malocclusion is a problem of how the teeth fit together: the upper and lower teeth do not align properly. It may mean crooked or crowded teeth or a jaw that protrudes or recedes. Sometimes it can affect chewing, the posture of the neck, or cause discomfort such as cervical pain.

Scoliosis. The majority of scoliosis cases in young people (around 80%) are defined as idiopathic, meaning without an identifiable cause. Despite decades of research, we still do not have a clear understanding of its origin.
What we do know, however, is that idiopathic scoliosis tends to appear in individuals with a genetic predisposition: it is often found to run in families. It is not a condition caused by bad habits, poor posture, injuries, or factors such as malocclusion.

It is important to stress this point to avoid attributing unnecessary blame or choosing therapeutic approaches that are not supported by scientific evidence.

At present, according to the data available, we know that malocclusion can influence the posture of the head and neck. In fact, malocclusion may cause the head to tilt forward or backwards and, in some cases, may even be associated with increased cervical pain. Nevertheless, while malocclusion can directly affect head position, it does not seem to have any effect on the risk of developing scoliosis, nor on the potential worsening of spinal curvature.

The same is true the other way around: a worsening scoliosis does not seem to influence malocclusion.

In patients with scoliosis, slight asymmetries are often seen in other parts of the body, including the face: this also involves the teeth and jaw. Studies have shown that people with scoliosis are about twice as likely to present with malocclusion (Class II or crossbite).
The correlation between malocclusion and scoliosis, although without a proven causal link and still not fully understood, highlights the importance of a multidisciplinary approach. Teamwork is essential in these cases.

How? Dentists and orthodontists may be among the first to detect possible postural changes that require attention. In the same way, the rehabilitation team managing conservative treatment for scoliosis can recommend a preventive orthodontic consultation.

Working as a team makes it possible to:

• monitor both conditions during growth;
• optimise the timing and therapeutic pathways;
• avoid false expectations: not assuming that one treatment will automatically affect the other, whether positively or negatively.

How should treatment proceed?
There are no contraindications to treating scoliosis and malocclusion at the same time: both orthodontic treatment and rehabilitation based on specific exercises can run in parallel, even when a brace is being worn, without fears of negative interference. No orthodontic treatment worsens scoliosis, and vice versa.

As far as we know today, no orthodontic treatment can worsen or improve scoliosis, just as no scoliosis treatment can worsen or improve malocclusion.

Dental treatment is essential for oral health and aesthetics, while scoliosis treatment is crucial for managing and controlling the curve over time.

Even though each specialist works on a different area, and there is no definite cause-and-effect relationship between malocclusion and scoliosis, working as part of a team made up of medical specialists, physiotherapists, and psychologists ensures higher-quality care.
This allows families to receive clear, timely, and reliable answers and enables professionals to share expertise in order to optimise timing and offer a clear, comprehensive, and highly personalised care pathway, tailored to each child.

Back to school with a brace

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Going back to school is not always easy for adolescents with scoliosis who wear a brace.—-> with scoliosis, and who need to wear a brace
Some are able to talk about it and share their difficulties, while others keep everything inside — and often they are the ones who suffer the most.

Of course, not all of our adolescent patients will struggle, but we need to pay particular attention to those who are changing schools: moving from primary to middle school, from middle to high school, or even simply to a new class.

Facing new teachers, new subjects, and above all new classmates is always an exciting challenge, full of curiosity… but no one knows  is aware about the brace!

It is natural, when entering a new environment, to want to give our best and show the best version of ourselves. It’s natural to want to give your best and show the best version of yourself when entering a new environment.But then comes the question: what about the brace?

“What will they think of me?”
“I can’t let them see me with the brace! Please, Mom, Dad, just the first few days without it and then I promise I’ll wear it again!”
“I’ll take it off at school and I promise I’ll put it back on afterward. In the afternoon I just do homework, I never go out anyway!”

Who could blame them? And above all, when this happens, how can we really help? It’s difficult — for the teenagers, for you the parents, and also for us professionals who care for them.

How to deal with it

If the prescribed “brace-free” hours allow it , it’s fine to leave the brace at home in the very first days. But if the free hours are limited (at least 3–4 in addition to school hours), then after a short initial adjustment it becomes important to face the class with the brace on. No adolescent will spend every afternoon locked indoors: there will be sports, birthdays, parties, get-togethers…

If, on the other hand, many hours of therapy are still required and free time is very limited, then it’s better to tackle the challenge right away. We know it’s tough, but once the “wall” is broken down, the path becomes much easier.

What we usually tell our patients

First of all, we remind them that they cannot live in seclusion. They have done nothing wrong to deserve a sort of “house arrest”: wearing the brace is already challenging enough, they shouldn’t also give up their social life.

Then we propose a kind of exercise: imagine it isn’t you with the brace, but one of your classmates. This classmate, afraid of being judged, chooses not to follow the treatment properly and doesn’t wear the brace the required hours. Nobody will ever know, because this classmate never had the courage to show up with the brace. But meanwhile, their spine is getting worse.

And then we ask: what would you want for this classmate? That they trusted you and asked for help, or that they considered you incapable of supporting them — so much so that they gave up their own health?

As always, when we put ourselves in someone else’s shoes, the answer becomes clear.

A special wish

Good luck to all the adolescents who are about to return to school wearing a brace — and good luck also to all their parents!