ISSLS 2022: Fabio Zaina’s take

Finished SOSORT Meeting, ISICO physiatrist Fabio Zaina headed to Boston where the 48th ISSLS Annual Meeting, another international event that, following the hiatus due to the pandemic, could finally be staged in the normal way again.

Dr Zaina represented ISICO by giving a presentation which was one of the 8 selected for presentation to the general assembly at the ISSLS, the fourth in order of importance (in fact, the reports have been presented in order of choice of the scientific committee). Further to this great achievement, Dr Zaina also presented a poster.

We asked him three questions, to get his brief take on the event.

1) How did it feel to finally get together with so many colleagues from all over the world?

It felt absolutely great, because it is three years since the last time, and they have been difficult for everyone. Added to that, ISSLS is like a big family and the aim of its members is not just to do research, but to work together and nurture the good human relations that are essential if you want to produce quality scientific work.

2) What were the major scientific developments at this 48th Annual Meeting?

A number of the studies presented focused on type 1 and 2 Modic changes. Efforts were made to interpret this sign, which seems to be related to low back pain, and also to consider the possible causes, which might be mechanical, autoimmune or infectious. All this seems to suggest that although Modic 1 and 2 are two separate entities, there could exist intermediate and nuanced forms lying somewhere between the two.

3) In five lines, which would you say was the study of most relevance to your daily clinical and scientific work?  

I would say it was the AWARD-  winning “Progression of spinal degenerative changes in a group of chronic low back pain patients and patients 11-14 years after discography evaluation” by Swedish authors Hanna Hebelka, K. Lagerstrand, V. Gunterberg, and H. Brisby.
I say this because it threw into question the findings of a previous paper published in 2009, which took an ISSLS Prize that year, namely, “Does discography cause accelerated progression of degeneration changes in the lumbar disc: a ten-year matched cohort study reached the opposite conclusion to the previous study, which had found that discography techniques resulted in accelerated disc degeneration, disc herniation, loss of disc height and signal, and the development of reactive endplate changes compared with the findings in matched controls.

Even though the two study populations are not perfectly overlapping, the result is interesting and a starting point for further studies.

SOSORT 2022: a feedback by dr Sabrina Donzelli, the next president of SOSORT

We asked physiatrist Dr Sabrina Donzelli, one of our doctors at ISICO, to tell us about the highlights and significance of SOSORT, the international conference held at the start of May in San Sabastian.
We knew that the event would be an important occasion for the specialists in attendance, as they had not been able to meet in person for two years. Little did we imagine, though, when we approached Dr Donzelli, that we were asking the very person who, in the course of the event, would be named as the next President of SOSORT. The presidency of this association is a highly prestigious role. This is the fourth time an ISICO member has been chosen for the position, and Dr Donzelli is the first woman to have the honour.

We therefore begin this interview by extending our congratulations to Dr Donzelli.

1) Wow! Well, this was great news on two levels: first, because the position will once again be held by an ISICO member, and second, because this is the first time a woman has been chosen. The International Society has grown considerably over the years and now has a large membership with a good balance of men and women, even though this is not so true of the single professions. There aren’t many doctors in SOSORT; most of its members are physiotherapists. If you aspire to be President of SOSORT, you have to serve the organisation, putting in years of voluntary work. For some years now, I have been committed to doing all I can for SOSORT because I share its vision and its mission: to ensure that patients with scoliosis always receive the best treatment based on the scientific evidence. It is therefore important to be committed to research and to spreading knowledge. In other words, the mission is also to educate. My commitment and willingness have helped me become widely appreciated within the society, allowing me to join the executive board in 2019, and to be made President Elect this year. 

2) What did it mean, after three years, to finally be meeting in person, with colleagues all in one place rather than scattered around the world?

SOSORT, which dates back to as long ago as 2004, was created to bring together the world’s leading experts in the field of rehabilitation treatment for spinal disorders, to allow them to “compare notes” and increase the level of scientific evidence in the field, as well as improve the treatments available to patients. Over time, its missions and aims have been and continue to be updated, because medicine is a constantly evolving science. The last proper congress was held in San Francisco in 2019, after which the event moved online for a couple of years. It was therefore fantastic finally being able to get together in person again. We were able to talk face to face and really share, all together, our passion for what we do and our everyday challenges. All this is reflected in the slogan that was used to announce and promote the event: SOSORT 2022 – More than a congress: an experience in San Sebastian. You will never forget it! 

3) What are the main scientific developments you were able to take away with you? 

Epigenetics appears to be the future when it comes to improving understanding of scoliosis and trying to identify individuals at risk of developing it. Obviously, there is still a huge amount of work to be done, but at present this seems to be the way to go. 

Second, ultrasound is the future of radiation-free diagnostics, albeit perhaps not so much when applied to the spine as when used to estimate residual growth. In this regard, I should mention an interesting study by  Sanders based on ultrasound of the hand, Bracing outcomes in end-of-growth patients. Evidence to support the use of braces even towards the end of growth: it’s not too late to wear a brace.
Indeed, other studies similar to ours have shown that good results can be obtained even at the end of growth. There is also promising scientific evidence in patients who have finished growing: we at ISICO were the first to present these findings, and now other groups, too, are showing that good results are possible even in individuals with advanced bone growth. 

It is worth considering that three of the six studies in the running for the SOSORT Award dealt with outcome prediction: they ranged from Dr Lori Dolan’s study with 10-year follow up after the end of bracing treatment to our research conducted in collaboration Dr Eric Parent of the University of Alberta, in Canada, in which we attempted, in patients observed over time, to predict future curves solely on the basis of X-rays performed before they started treatment with braces or exercises. 

4) SOSORT Award: were there any surprises?

Not at all. The winning study was the strongest methodologically. The paper, on which we collaborated with the University of Alberta, illustrated a prediction model developed on the whole sample: it has some limits related to the heterogeneity of the data, which reflects that of scoliosis itself. Each patient has their own clinical history and this makes it difficult to predict how the disease will evolve in relation to age, time since onset, and residual bone growth estimated using the Risser classification. 

The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST), on the other hand, is a fundamentally important study: it has demonstrated the therapeutic effectiveness of braces and shown that follow up over time is essential in order to advance the study of scoliosis. The monitoring of the patients observed and treated by these researchers will continue to give us important information, while the methodological rigour of their study is a guarantee of very reliable scientific evidence.  

Pictured, Sabrina Donzelli, together with organiser (SOSORT 2022 local host) Garikoitz Aristegui, and Judith Sanchez Raya, co-Chair of the SOSORT 2022 Scientific Committee

Sforzesco course: starting with participants from 12 countries around the world!

It is a bit as if an appointment had been made from all over the world for the launch of the Sforzesco online course, which started last May 18 with the first module, given that there are 12 countries from which the various participants are coming.
From Brazil to Cambodia, from Singapore to Malaysia passing through Morocco, Syria, Turkey, Japan, United States, Italy, Latvia and Bosnia-Herzegovina: a world of multi-layered experiences.
The starting point of the Course is the presentation of the Sforzesco brace in its evolution from the first years of application to the current relevant innovations, accompanied and supported by the results of research in ISICO, published in indexed international literature.
These lectures are presented by Isico physiatrists Prof Stefano Negrini and Dr Fabio Zaina, in addition to the orthopaedic Isico doctor, dr Monia Lusini accompanied by several lectures held directly by CPOs who collaborate with ISICO in the realization of the Sforzesco braces, on the various technical and practical aspects to be taken into account during the design and the fabrication.
The course is divided into 3 modules, each module ends with a live session to make the point on what has been shown and explained.
The first live lecture will be held on June 8th.

Isico’s research wins the SOSORT Award

For the fourth consecutive year, Isico has obtained the most prestigious award for those involved in rehabilitative treatment of the spine, winning the SOSORT Award with the study Prediction of Future Curve Angle using Prior Visit Information in Previously Untreated Idiopathic Scoliosis: Natural History in Patients under 26 Years Old with Prior Radiographs.

The research, which involved 2317 patients with idiopathic scoliosis between 6 and 25 years old, was developed by our researchers (the Isico authors are Prof. Stefano Negrini, together with Dr Giulia Rebagliati, Dr Fabio Zaina, Dr Sabrina Donzelli and Dr Alberto Negrini) in collaboration with Dr Erik Parent of the University of Alberta, Canada. This project was funded by a Standard Research Grant from the Scoliosis Research Society.

“Understanding natural history helps inform the treatment selection for modifying the course of the disease or to avoid overtreatment – explains prof. Stefano Negrini, Isico Scientific Director- Previous models predicting curve progression lacked validation, did not include the full growth spectrum or included treated patients. Our aim 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”. 

Scoliosis-specific exercises are recommended in small curves in skeletally immature patients, exercises and progressively more aggressive brace treatments are recommended for moderate and severe curves in 10% of growing children and adolescents and invasive corrective surgery is recommended in severe curves at risk of continued progression in adulthood for 0.1-0.3% of cases. 

“Patients were previously untreated and provided at least one prior radiograph prospectively collected at first consult – continues prof. Negrini – We excluded those previously treated”.

 Radiographs were remeasured blinded to the predicted outcome: the maximum Cobb angle on the last radiograph while untreated. Linear mixed-effects models with random effects and maximum likelihood estimate were used to examine the effect of data from the oldest visit (age, sex, maximum Cobb angle, Risser, and curve type) and from other visits while untreated (Max Cobb angle), and time (from oldest radiograph to prediction) on the Cobb angle outcome.

“Predictions models were proposed which can help clinicians predict future curve severity expected in patients not receiving treatment –ends prof. Negrini – Predictions can inform treatment prescription or show families why no treatment is recommended. Our models offer the flexibility to predict at a future timepoints over the full growth period. These validated models predicted future Cobb angle with 80% of predictions within 100 in non-treated idiopathic scoliosis over the full growth spectrum. Improved prediction ability may help clinicians inform treatment prescription or show families why no treatment is recommended”.

SOSORT 2022: the AWARD winners and a fourth ISICO President

This year’s SOSORT meeting, held in San Sebastian, Spain in the wake of two editions forced online by the pandemic, was a double success for ISICO, which had two studies shortlisted for the SOSORT Award.
One of them, Prediction of Future Curve Angle using Prior Visit Information in Previously Untreated Idiopathic Scoliosis: Natural History in Patients under 26 Years Old with Prior Radiograph, conducted in collaboration with the University of Alberta in Canada, came first, making this the fourth consecutive year that ISICO has taken home the prestigious award. But this was not the only high point. Our Dr Sabrina Donzelli, physiatrist, was named as the next President of the International Society. This is the fourth time that ISICO has had this has honour since SOSORT was founded in 2004,  and it is the first time a woman has been appointed to the role.

“This prestigious appointment is an acknowledgement of Dr Donzelli’s scientific standing, hard work and commitment, as well as a recognition of our institute, which now provides a benchmark for clinical and research activity worldwide” remarked Prof. Stefano Negrini, Scientific Director of ISICO as well as one of the ISICO authors — the others being De Giulia Rebagliati, Dr Fabio Zaina and Dr Alberto Negrini — who collaborated with Dr Eric  Parent, first author of the study that won the SOSORT AWARD. The congress was hugely stimulating and we can’t wait for 2023 and next year’s meeting in Melbourne, Australia”.

Scoliosis: why prevention matters

It is often said, in reference to spinal disorders like scoliosis, that prevention is just as important as treatment.

Before we go any further, let’s get a few things clear, starting with the definitions of screening and scoliosis. Screening is an activity involving the use of rapid tests, examinations or other procedures, and its purpose is to detect the possible presence of a disease or defect that the patient didn’t know they had.

Scoliosis, on the other hand, is a three-dimensional deformity of the spine.There are different forms, depending on the age at which it was first diagnosed: infantile (diagnosed between 0 and 3 years), juvenile (between 3 years of age and puberty), adolescent (between puberty and the completion of bone growth), and adult-onset. Scoliosis affects 3% of the population, prevalently females; 80% of cases are diagnosed in adolescence.

There are two aspects in particular that make scoliosis an insidious disease: first, it causes no symptoms of any kind during childhood and adolescence, which makes it difficult to identify young people who are at increased risk of developing spinal deformities; second, in most cases it is idiopathic, which means we don’t really know what causes it. 

Therefore, early diagnosis of scoliosis, i.e., at an age when there is a considerable risk of the condition progressing, allows the patient to receive adequate, less invasive and more effective treatment, which, as far as possible, will prevent it from worsening to the point of causing, in adulthood, pain, progressive deformity and sometimes cardiorespiratory problems that will negatively impact their quality of life.  

Screening: when and by whom?

Scoliosis screening ‘s importance is widely recognised, also by the scientific community (ref. Screening for adolescent idiopathic scoliosis: an information statement by the Scoliosis Research Society international task force). 

Scoliosis screening should target all girls in their last year of primary school/first year of secondary school, and all boys in their second year of secondary education. This is the age at which they reach puberty, and are therefore most at risk of progression of scoliosis, if affected by the disease. 

Youngsters should be screened by a spine expert who, by means of specific tests, is able to identify those at risk of a spinal deformity.

Screening results are given to the patient directly so that they can decide, together with their doctor, how to proceed. In this way, if necessary, a diagnostic-therapeutic pathway can be planned.

What does screening involve?

The first thing to do when evaluating whether or not a youngster may have scoliosis is to observe their bare back. The presence of more or less obvious asymmetries at trunk level, such as a difference in the height of the shoulders, or of the hips, or a difference between the two shoulder blades, is the first sign of a possible case of scoliosis.

Then, the Adams test is performed, which is crucial: standing with their knees straight, the patient has to bend their trunk forwards, keeping their head down and letting their arms hang limply. This position has the effect of emphasising any hump due to scoliosis. If a hump is observed, it will be measured at the point where there the difference in height between the two sides of the patient’s back is greatest.

This measurement is taken using the Bunnell method, in other words using a scoliometer to determine the angle of trunk rotation. If this angle measures 5° +/- 2° or more, it is advisable to have a specialist consultation. 

A patient with an angle of 3° or more should be checked every six months if they are approaching or have entered puberty, otherwise at yearly intervals. If a patient’s measurement is below this threshold (between 0 and 2°), but they have one hip or one shoulder higher than the other, or a protruding shoulder blade, then they need to be seen after six months and referred to a specialist if the asymmetries persist; otherwise, they can be referred back to their general practitioner/paediatrician.

How to screen a child online

Visit https://screening.isico.it to carry out a rapid screening for scoliosis or a curved spine, free of charge.
After watching the brief explanatory video, follow the steps and carry out the assessment. This will involve taking a few measurements. Depending on the data you provide us, we will be able to tell you whether it would be a good idea to consult a spine specialist, or whether there is, at present, no reason for concern.

Different specialists, different prescriptions: how should we choose?

Most parents of a child with scoliosis embark on a similar journey: once they have received the initial diagnosis, they start consulting other specialists, seeking second or third opinions that might provide them with the confirmation and reassurance they need, and/or simply answers to further questions and doubts that have cropped up in the meantime. 

Often, though, parents who do this find themselves left with more questions than answers. This is because different specialists, faced with the same scoliosis case, can make different diagnoses and prescribe different courses of treatment.

Why is this? There may be different reasons. Before going any further, though, it is important to remember that only a specialist with specific training in vertebral pathologies can treat scoliosis. Once a timely and correct diagnosis has been made, it is necessary to decide how to treat the condition. 

The SOSORT guidelines on conservative treatment of scoliosis are an important resource in this regard. Taking into account the best current scientific evidence, as well as the extent of the curves and the degree of bone maturation, they provide suggestions on the most effective treatment. 

What the guidelines offer is not a single, specific course of treatment, but rather a series of options, ranging from the most conservative to the most aggressive, that could conceivably be prescribed in a given patient. 

However, science alone cannot meet all the needs of a long and complex course of treatment of the kind required in scoliosis. The evidence-based medicine approach brings together and combines scientific knowledge, the expertise and experience of the specialist, and the values and desires of the patient, and therefore makes it possible to formulate the most appropriate prescription for the individual case. 

Bearing all this in mind, then, it may well be that one doctor, considering the data collected during the examination and the discussion with the patient and the patient’s family, decides to prescribe a brace where another doctor might instead recommend only specific physiotherapy or even a wait-and-see approach, which consists of monitoring the situation for a few months to see how the scoliosis evolves.
These are very different prescriptions, but they are all valid. The patient will in any case be monitored following the prescription in order to make sure that the type of treatment, and the dose, are correct.
In this way, it is also possible to make any changes needed to avoid under-treatment (insufficient to contain the progression of the disease) or over-treatment (too taxing for the patient).

The big question remains: how do we parents go about choosing? There’s no easy answer. Given that our children will need to be on this therapeutic journey until they have finished growing, the important thing is to find someone we feel we can trust. In other words, we need to choose the specialist — and it must be someone with expertise in the conservative treatment of scoliosis — who we, and our child, felt to be the most reassuring and empathetic.

Once we have made our choice, we need to place our child’s care in the doctor’s hands. It is important to follow the instructions we are given, and not to change anything without the doctor’s agreement, as to do so could undermine the success of the treatment. 

Ready for SOSORT

There are just a few days and the SOSORT  International Conference finally, after two years from the start of the pandemic, is back in person in San Sebastian, Spain from the 4th to the 7th of May.
It will be the usual pre-course, scheduled for May 4, to kick off the event: three of our specialists will participate in the round table, Dr Fabio Zaina, with a session on Overview of Adult Spinal Deformity classification, and how it is differing from AIS, Dr Sabrina Donzelli with  ASD prevalence and Dr Michele Romano, director of Isico Physiotherapy, with Standardized presentations describing assessment, clinical decision making process and treatment.

In the following days, Isico will be present again with three presentations: Dr Fabio Zaina will present on May 6th “Night-time bracing improves back pain in patients with painful scoliosis: six months results of a retrospective controlled study“, Dr Michele Romano on May 7th “Exercises for adolescent idiopathic scoliosis: Updated Cochrane Review”  and finally, Prof. Stefano Negrini, scientific director of Isico, will compete for the SOSORT Award with his research Splitting Growth into 3 Phases with Cut-offs at Pubertal Spurt and Risser 3 Facilitates Prediction of Progression. A Study of Natural History of Idiopathic Scoliosis Patients from age 6 to End of Growth”.

For more info: https://sansebastian2022.sosort.org

The winning study of the SOSORT Award 2020 has been published

Two years after winning the SOSORT AWARD, the study “Predicting final results of Brace Treatment of Adolescents with Idiopathic Scoliosis: First Out-of-Brace are Better than In-Brace-radiographs” has finally been published in the European Spine Journal.

 A total of 131 patients were included in the study, the researchers aimed to determine which of the two radiographs is the best predictor of the Cobb angle at the end of treatment (final radiograph). In fact, the 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.

The first out-of-brace radiograph predicts end results better than the in-brace radiograph.

“Our research has highlighted – explains Dr. Sabrina Donzelli, author of the research – how important the first x-ray taken without the brace is in predicting end-of-care results. The first out-of-brace radiograph should be considered an essential element of future predictive models and offers an excellent clinical reference for clinicians and patients. The collection of clinical data that occurs routinely during all visits to ISICO has allowed in recent years to be able to develop the so-called predictive models, i.e. we can use the characteristics of the patient to understand how the final results can be predicted or to understand if there are risk factors more important than others to consider when deciding what type of therapy to prescribe “.

Curves measuring less than 10 degrees: should we treat them?

As suggested by the Scoliosis Research Society (SRS), a scoliosis diagnosis is confirmed when a patient presents a Cobb angle measuring 10° or more and axial vertebral rotation. Maximum axial rotation is measured at the apical vertebra. (1) The SRS established this threshold in 1977, replacing the previous one of 7°. Ever since, 10 ° has conventionally been accepted, worldwide, as the threshold for diagnosing scoliosis.
However, structural scoliosis, with a potential for progression, can also be observed in the presence of Cobb angles measuring less than 10°. In fact, initial wedging of the vertebral bodies and disks can sometimes be registered with curves of 4°–7°. (2)

Idiopathic scoliosis, being a developmental disorder, most commonly arises and progresses during periods of accelerated growth (growth spurts).

The first such period occurs in infancy/early childhood, generally between 6 and 24 months of age, and the second between the ages of 5 and 8 years; finally, there is the pubertal growth spurt, which generally occurs at 11–14 years of age. (1)

Although the later stages of development are obviously not risk free, after puberty the rate of growth usually slows down, reducing the risk of progression of scoliosis. 

Can the risk of scoliosis progression be predicted in the case of curves measuring less than 10°?
There is, of course, always a chance that these curves will become more pronounced as the youngster grows, even, in some cases, to the point of requiring the use of a brace. But it is also true that most of them will remain stable over time without reaching the minimum criteria for a diagnosis of scoliosis. Certain factors may possibly be associated with an increased risk of scoliosis progression: a positive family history of scoliosis, laxity of ligaments, flattening of physiological thoracic kyphosis, a greater than 10° angle of trunk rotation (ATR), and growth spurts. All these factors should be evaluated by the attending physician. 

So, should we be treating these youngsters? In short, no. First of all, it is worth remembering, that the main aim of conservative treatment of scoliosis is to improve the patient’s appearance, but curves as mild as this rarely have an aesthetic impact; at most there may be some slight asymmetry of the trunk, but nothing that can be considered to exceed physiological parameters. With very rare exceptions, the only advice necessary in these cases is to opt for clinical monitoring of the patient, which can be considered to all intents and purposes a treatment, in the sense that it allows us to overcome the critical phases of development (which also correspond to the periods of greatest risk of progression of scoliosis) and also to intervene if any progression does occur. Monitoring is the first step in an active approach to idiopathic scoliosis, and it consists of clinical evaluations performed at regular intervals, ranging from every 2-3 months to every 36-60 months depending on the single case. 

In conclusion, any active treatment in this population of patients is actually overtreatment. Even just specific exercises, whose prescription constitutes first therapeutic step after monitoring alone, would cost these youngsters in time and effort, as well as being an economic cost.

A further aspect, not to be underestimated, is the psychological impact: starting a treatment amounts to confirming that the individual has a disease that needs to be treated, and this can lead them to start thinking of themselves as “sick”.

Furthermore, even though an exercise programme is not a particularly arduous undertaking, starting a treatment when there is no real need for one could compromise the youngster’s collaboration and commitment should a treatment be needed later on. This is an important consideration, because if their scoliosis does progress as they grow, specific exercises, rather than being useful, could become crucial, in order to avoid bracing for example.  

1 – 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth

https://pubmed.ncbi.nlm.nih.gov/29435499/

2 – Radiographic Changes at the Coronal Plane in Early Scoliosis. Xiong, B., Sevastik, J. A., Hedlund, R., & Sevastik, B. (1994). Spine, 19(Supplement), 159–164. doi:10.1097/00007632-199401001-00008

https://pubmed.ncbi.nlm.nih.gov/8153824/