Can we be sure that this brace works?

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A brace is a tool used to prevent the progression of scoliosis. They can be made of different materials: plastic (with metal parts), partly leather, or entirely elastic and fabric.

Finally, there exist numerous models with different names, such as the Cheneau, Sforzesco, PASB, Lapadula, Maguelone, and so on, not to mention variants of these different models.  

All this adds up to a real maze of terminology that the parents of a child or teenager recently diagnosed with scoliosis or a spinal disorder suddenly find themselves having to try and understand.

Why is it all so confusing?

It is not confusing, it is just that there exist different models, all designed to serve the same purpose, namely, to obtain the best possible alignment of the spine in order to counteract the evolution of the disease, which manifests itself as a progressive misalignment of the vertebrae.

Individual situations and cases vary, and braces are therefore chosen to meet the patient’s specific needs, which are determined by the severity, type and location of the curve.

The shape of the spine, viewed sideways on, is also a crucial aspect to consider when choosing a brace; this sagittal profile shows a series of physiological curves: cervical lordosis, dorsal kyphosis, lumbar lordosis and sacral kyphosis.

If these curves are correctly positioned and well balanced, your back will be strong; if not, it will be weak and vulnerable to the stresses of everyday life.

The type and construction features of the brace must be chosen by a medical specialist after a thorough assessment of the type of problem, the severity of the condition, the risk of progression, and the habit of using one brace compared with another.

One particular feature of the scoliotic spine, which we professionals must seek to address, is the presence of a deformity in the sagittal plane, in other words, a deformity of the spine as viewed from the side.

Indeed, the action of the disease can result in a reversal of the natural pattern of the curves described above. A dorsal scoliotic curve, for example, will have the effect of flattening the back, reducing or even reversing the direction of the natural dorsal kyphosis.

This makes the back look unnaturally “straight” or even causes the spine to curve inwards, creating a dorsal lordosis.

Such a deformity can seriously affect the health of the spine.

Indeed, conserving the physiological pattern of spinal curves in the sagittal plane means keeping the back strong, healthy and working efficiently.

When patients are diagnosed with dorsal scoliosis with this flattening of the back, their parents are often surprised because these youngsters, very erect, appear to have what is classically considered a “perfect” posture.

Most people associate scoliosis with a curved back and round shoulders. After all, as children, we are so often told: “Stand up straight or you’ll get scoliosis!” . Therefore, associating straightness with scoliosis seems something of a contradiction in terms.  But this is not the case at all.

A flat back, caused by dorsal scoliosis, is indeed one of the many forms that scoliosis can take: it is actually quite a frequent form and also one that can be difficult to treat using corrective tools.

Normally, a brace exerts a pushing action, but in these cases, to improve the shape of the back, the brace would need to act as a sort of suction cup, pulling the vertebrae back into position.

Obviously, this is not possible; therefore, in these cases, the brace will be shaped in such a way as to encourage the trunk and shoulders to assume a more “hunched” position so as to try and prevent the spine from becoming “too straight”.

The most worrying and upsetting aspect for parents is precisely this: to see their “straight backed” youngsters assuming, with their brace on, this rounded position with forward slumped shoulders – after all, their posture initially seems to look worse than before!

However, they soon understand the reason for it: these patients are not being asked to “stand up straight”; instead, what they need to do is learn to assist the corrective action of the brace, which is specially designed to promote kyphotic curvature of the upper spine.

In short, it isn’t easy to be sure that a brace is working, especially when, as in cases like these, its action seems to go against traditional aesthetic parameters.

However it is important to understand that, in many cases, certain construction features of the brace are the result of complex biomechanical reasoning.

What should you do if you are concerned? Ask, without hesitation, because exchanges with experts are always useful for learning about the corrective aspects of the treatment.

SRS research evaluates AIS brace management

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The research Scoliosis Research Society survey: brace management in adolescent idiopathic scoliosis has just been published by the journal Spine Deformities. While the Scoliosis Research Society (SRS) has established criteria for brace initiation in adolescent idiopathic scoliosis (AIS), there are no recommendations concerning other management issues. As the BrAIST study reinforced the utility of bracing, the SRS Non-Operative Management Committee decided to evaluate the consensus or discord in AIS brace management developing this research.

1200 SRS members were sent an online survey in 2017, which included 21 items concerning demographics, bracing indications, management, and monitoring.

218 SRS members participated in the survey: 207 regularly evaluate and manage patients with AIS, and 205 currently prescribe bracing.  99% of respondents use bracing for AIS and the majority (89%) use the published SRS criteria, or a modified version, to initiate bracing. 85% do not use brace monitoring and 66% use both Cobb correction and fit criteria to evaluate brace adequacy. 

“From the research it emerges that in practice the variability is very large – explains Dr Sabrina Donzelli, physiatrist and researcher at Isico – the treatment protocols, the hours of wearing, the time elapsed between visits, the radiographs required, with or without brace, with what times and after how many hours of break, the brace-weaning protocols, vary considerably from one specialist to another”.

In the United States, the use of braces is recent, it spread after the publication of the results of the BrAIST study: “The management of therapies and treatments is affected by the inexperience of specialists – continues Dr Donzelli – often the indications given to patients are not precise, they are not justified by the objectives of the treatment and they are not supported by strong motivations deriving from clinical experience. Or at least this is what emerges from the survey “.
What then is the conclusion of the research? 
This variability may impact the overall efficacy of brace treatment and may be decreased with more robust guidelines from the SRS. Furthermore, brace therapy must be personalised in a pathology so complex that it cannot be simplified: “The dosage with which the brace is prescribed must be correlated with the therapeutic goal to be achieved – states Dr Donzelli – Risser 0, 1 or 2 is characterised by different progression risks, the extent of the starting curve changes the treatment objectives: sometimes it is necessary to improve the curve, sometimes it is enough to stabilise. The type of brace to be used varies according to the type of curve, their localization and the estimated evolutionary risks of the curve correlated with the problems in adult life. I want to add to the research  – concludes Dr Donzelli – that they only considered the use of the brace, nothing is said about the role of exercises, of which several research studies have efficacy already proven, alone or in association with the brace itself as for example these articles https://pubmed.ncbi.nlm.nih.gov/25729406/ and https://pubmed.ncbi.nlm.nih.gov/30145241/ published by Isico”.

Brace competition 2020: winners awarded

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An online live show full of emotion was held on Saturday 13 March to reward the winners of the 2020 Brace competition – “Concorsetto”.

Prof Stefano Negrini, clinical and scientific director of Isico and Michele Romano, director of physiotherapy, conducted the appointment, while doctors and physiotherapists presented their winning patients showing a short extract of their work: a drawing, a video or a written text.

Different classified categories: awarded by the internal jury, by Facebook likes and the category of the youngest ones.

In this short video you can see all the more than 50 works arrived for this edition.

We look forward to seeing you next time!

Telephysiotherapy in Isico: the published research

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In this pandemic year a lot has changed in our daily habits, much in the way we work. Something also in the way we treat patients. We had to adapt to take opportunities from difficulties. In Isico, we have done this from the beginning, overcoming the first phase of closures thanks to the online mode of medical visits and physiotherapy treatments.

It was a way not to leave our patients alone and not to waste the efforts made, a way that after some time has become an integral part of our therapeutic proposal.

We learnt a lot and this also translated into the research, published recently by the Spine Journal, “Lessons learnt in two months of the exclusive application of telephysiotherapy instead of classical physiotherapy during the lockdown in Italy“. 

“Current evidence on telemedicine mostly refers to interventions not requiring hands-on approaches, based on either technology or oral/visual interactions – explains Michele Romano, director of Isico physiotherapy and author of the research –  In a way, the pandemic offered a sudden push to telemedicine. The question is which lessons can we learn on telephysiotherapy after a few months of extensive and mandatory experience?” 

For this reason, we want to share the experiences of exclusively telephysiotherapy treatments acquired by 38 physiotherapists working for Isico during the 2 months of lockdown from March 16th to May 11th.

It was crucial in the first phase that patients accept telephysiotherapy. Usually, the appointments are managed by the booking call-center, but after the first phone calls it was clear that this unusual and unexpected change proposed by a secretary was not well received by the patients.

Consequently, the new standard is that the appointment is made by phone call by the treating physiotherapist him/herself. That facilitates the interaction with the patient, and allows to professionally answer all eventual doubts.

How to organise to be able to carry out physiotherapy treatments online?  “An involvement of caregivers and families is necessary for the session. A free video-communication App is used (Skype or Meet) – explains Michele Romano  – Evaluation results autonomously collected by patients with the help of a caregiver, are sent before the session to fill the assessment form in advance. One caregiver is present during the session, with one camera to film the patient, to help correct mistakes and observe the right execution of specific exercises; a second device is used for the Institute App to record the exercises”.

During 2 months of lockdown, telephysiotherapy sessions have been 2,239 (100%). After the lockdown, when back to “normal” were face-to-face hands-on physiotherapy, 10% (532 out of a total of 5,091) remained telephysiotherapy sessions.

“The common feeling of patients and their caregivers was of not having been abandoned – explains Michele  Romano –  during these months we verified that the systems work properly, now this wide and sudden experience is available for the worldwide physiotherapy community. Telephysiotherapy is a not so difficult, readily available instrument.“

Obviously, limits and drawbacks referred by physiotherapists and patients included the impossibility to use hands-on, the need to simplify the approach, the limited attention of younger patients, the connection difficulties.  

Most physiotherapists and patients agreed that this type of approach is perfect in emergency, but it cannot substitute normal physiotherapy sessions in normal times.

“Yet we have found – concludes Michele Romano – that there is a group of patients who have discovered telemedicine and continue to use it even now, an additional opportunity that therefore in Isico we have decided to offer patients in the future, alongside the classical medical visits and physiotherapy treatments performed in-person.”

Natural History of Scoliosis: the development of a predictive model

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There are two abstracts on the natural history of scoliosis that Isico is going to present at the 56th SRS conference scheduled for next September in the United States: “Predicting Future Curve Severity for Juvenile Idiopathic Scoliosis: A Natural History Study” and “Predicting Future Curve Severity Requires Different Models for Adolescent and Juvenile Idiopathic Scoliosis “.
Abstracts which constitute research carried out by Isico in collaboration with the Canadian University of Alberta and Dr Erik Parent. The preliminary results of this research study will be presented by Prof Stefano Negrini at the Research Grant Outcome Symposium organized by SRS and scheduled for March 6 from 9 to 11 ET US.
Most models to predict future Scoliosis severity have not been validated; many previous samples included treated patients limiting our understanding of the natural history. 

“Our aim was to predict future curve severity at a time point of the clinician’s choice during adolescence using data from x-rays obtained before starting treatment in patients with a diagnosis of Juvenile Idiopathic Scoliosis (JIS) – explains dr Sabrina Donzelli, one of the authors of this research study – we included 2331 patients with a diagnosis of JIS, under age 26, previously untreated.
The data obtained through the radiographs confirm the factors involved in the severity of scoliosis: for juvenile scoliosis the age at onset and the extent of the curve, and for adolescent scoliosis the Risser stage and female gender. The idea is to optimize the use of this data for clinical purposes “.

That is, to be able to validate the model to verify  whether it works for another population with similar characteristics. “During the webinar to which I have been invited – says Prof. Negrini – I will present the preliminary data not only of the two abstracts but also of the other analyses developed by the Canadian university. As a team, we are continuing to validate one model with which we can create an algorithm to predict the cases with the highest development risk.”

Medicine: an entirely human reality

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As an old saying goes, “the tragedy of science is all the wonderful theories spoiled by a few bothersome facts”. The personal theories developed by individuals do not constitute science, because science is all about learning from the facts: this is one of the lessons we hope the COVID-19 experience will leave behind, not only for scientists, but for society as a whole, given that, over the years, people have allowed themselves to be drawn to theories with no scientific proof (the so-called anti-vaxxers being the prime example).
Because, in medicine and healthcare, failing to be led by science in our choices is the biggest mistake we can make, and this applies in the field of scoliosis, too.

Then, of course, there is the interpretation of scientific data, which creates further differences of opinion, in this case between medical practitioners. There are some areas in which these differences are only small, as the scientific evidence is strong and plentiful, and others in which, precisely because scientific evidence is still scarce, there are considerable differences of interpretation and numerous theories in circulation. The field of scoliosis and spinal deformities, particularly with regard to non-surgical treatment approaches, falls into the latter category.

Another aspect to consider is the, now fundamental, need for continuing medical education. It has been shown that scientific knowledge doubles in less than five years, which means that those who fail to stay abreast of developments can very quickly find themselves completely out of the loop.
How can a physician imagine that what he or she learned at university, perhaps many years before, will continue to be enough? This is why we should appreciate doctors who refer patients to another specialist whenever they feel poorly-equipped to deal with a particular clinical situation.
Doctors should not be drawing professional pride from attempting to deal with absolutely everything they encounter; the true mark of a good doctor is the ability to recognise when a patient’s needs are out of his or her sphere of competence and refer the patient to the right specialist.
Obviously, a doctor’s ability to deal optimally with every situation that arises within his/her own particular sphere of expertise is, also, the mark of a good professional and, rightly, a source of professional pride.

“Shared decision-making” (taking decisions together with the patient) and “personalised medicine” are cornerstones of modern medicine. Talking to patients and involving them in the decision-making process means reaching decisions that are also based on what the patient prefers and is willing to accept.
Really, patients can be satisfied with decisions only if they are adequately informed — in this regard, patients themselves must take on some of the responsibility —, as they will have been able to grasp the pros and cons of the treatments offered. Even though “Doctor Google” is often a poor source of information, consulting “him” can nevertheless help patients to formulate questions that a capable professional will then be able to answer fully (and authoritatively), thereby helping them to make the right choices for themselves and for a successful therapeutic outcome. And a successful outcome can never mean exactly the same thing for all patients since success depends on the clinical condition in question and the choices the patient is willing to make.

Finally, there is the question of trust. Doctor-patient interactions are human interactions that depend on the relationship between the two people involved. In the absence of this relationship, or if one of the two parties fails to engage, then the choices made will be purely technical ones, not weighed upon the basis of the needs of the person in question. 

If the current pandemic has taught us anything, it should be that medicine offers no guarantees and that highly important human factors come into play that simply cannot be overlooked.
Medicine is an entirely human reality.
While there are still many diseases we cannot “cure”, we certainly can “care” for all our patients, offering them the best available techniques and treating them with all the humanity they need.

Medicine today, of course, is not merely holding the patient’s hand and offering comfort and reassurance, but at the same time, we need to guard against returning to the depersonalised variety that we allowed to develop in the 1900s. 

These considerations are crucial when embarking on a long journey together, as we do when treating a scoliosis patient.

My brace: my friend ….my enemy!

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Aurora, 15 years old, shares with us her experience with the brace.

“I wasn’t born with scoliosis. My problems began when I was ten years old, and our doctor noticed that my back wasn’t quite as straight as other people’s.

On his suggestion, I had an X-ray that confirmed that I had a scoliotic posture, which corrective exercises could correct. So, I had a few sessions with a posturologist and learned how to do the necessary exercises. My posture improved, and that seemed to be the end of it.

Since I do artistic gymnastics at a competitive level, I often have checkups with a physical therapist, and on one occasion, it was noticed that I had a twisted hip.

We talked this over with my doctor — I was 12 by this time —, and it was decided that I should have another X-ray, which showed up a very mild scoliotic curve, measuring just a few degrees, that needed to be monitored.

I continued doing my sport as usual until, at the age of 13, I started getting a strong pain in my lower back, towards the hip area. It gave me a lot of trouble throughout that year’s artistic gymnastics championship. It was such a strong, searing pain that I had to wear an elastic sheath around my back for support when training and competing. But I never gave in!

I had various tests to try and get to the bottom of this pain, and it was discovered that my scoliosis had got a lot worse, with the curve increasing from just a few degrees to more than 30° in the space of just one year. My spine now had a marked “S” shape that started at hip level and even affected one shoulder blade. The scoliosis was so bad that I had to start wearing a brace without delay.

There were several tests and procedures to go through in order to get the brace, and I received my first one when I was 14 years old. I had to wear it for at least 18 hours a day.

To tell the truth, I wasn’t particularly concerned about the prospect of wearing a brace, partly because I didn’t really know what it entailed. My immediate concern was that I would have to give up my artistic gymnastics. I couldn’t bear that thought! However, as soon as I had been reassured and put this fear behind me, I was ready to start my bracing treatment.  

The first week I really hated it and regarded the brace as an enemy. I couldn’t do the simplest thing! I couldn’t stand comfortably, and it impeded me in everything: I couldn’t put my clothes on or tie my laces, or do so many of the everyday things you normally don’t think twice about. I was really mad! Mad about having scoliosis, about having to wear a brace, and about having to put up with all that pain and discomfort. Why did it have to be me?!

Before long, though, I calmed down and accepted the situation. I was going to have to wear the brace in any case, so there was no point getting mad about it.

My gymnastics helped me a lot in this sense, first of all, because this discipline had helped me, from a young age, to get used to coping with pain and having to make certain sacrifices, and second because it was my only outlet.

When I was training or doing competitions, I would take the brace off and then put it back on again as soon as I had finished.
I have to admit that, to begin with, I felt a bit uncomfortable and embarrassed about wearing it, but those feelings soon disappeared, because I tend not to worry too much about what other people think, and just try to feel good about myself.

I’m 15 years old now, and I have already been wearing a brace for more than a year.

I have had three braces so far, having had to change them frequently due to my growth. Apart from a little pain at the beginning each time as I get used to the new “shell”, it’s all pretty straightforward and easier than before. Now, I can get dressed by myself, do up my own shoes, and so on. Basically, I don’t need anyone’s help.

There is always a degree of discomfort, that doesn’t disappear completely, but now I see my brace as a friend, not an enemy: a friend that is there to help me to solve a problem, to prevent me from getting worse, and to try and make sure that I end up with a straighter back and more attractive silhouette.

So, basically, I have learned to get along with my brace. We are so close (literally!) that I have even given it a name: Dori. I am actually grateful to it because, together with my sport, it is helping me to develop a beautiful physique and a definite waistline (which I didn’t have before). Having said that, quite often I still fall out with it and really can’t stand it!

I have learned to dress in a way that hides my brace as far as possible. I have bought new, more suitable clothes and they help me feel good about myself too!

Nearly a year has gone by now, which is great!

I still don’t know how long I am going to have to wear my brace for, as I still have some growing to do. I guess it will still be some time before I’m done.  I hope that reading about my experience has helped and reassured you, and will encourage you to tackle your own long journey with commitment and determination, just as I am doing. I want to end on a positive note: there’s light at the end of every tunnel, so don’t despair!

All the best… hang in there!”

Aury Gymnastics

World Master open now!

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January saw the kick-off for the sixth edition of the World Online Master PPSCT – Principles and Practice of Scoliosis Conservative Treatment as well as for its second edition in the Chinese language. We are very proud to have collected a total of 63 participants from 24 different countries for both courses with the entry for the first time of countries like Nigeria, Syria and Ireland.

Waiting for the first Live lectures being given at the end of January and early February (for the Chinese edition), we are pleased to report the testimony of a young physiatrist coming from Sri Lanka. She participated in the last edition and sent us her best wishes for the new year.
Thank you Joan!

“I want to express my utmost gratitude to the Isico teaching staff. Thank you very much! I want to share how the scoliosis masterclass has impacted my practice and the whole hospital in managing scoliosis patients. I am a young physiatrist, just graduated last 2018, and am practising at the Philippine Orthopedic Center, which focuses on Orthopedics and Rehabilitation Cases including scoliosis. The master course provided the most in-depth, detailed, evidence-based and up-to-date discussion of all aspects of idiopathic scoliosis from diagnosis, monitoring to management. It has helped me to explain better to my patients and their parents their condition, the natural history, as well as the options for their informed decision-making. I appreciate that the course has even presented up-to-date knowledge on the field, even those preliminary findings on the ongoing studies that are not yet published. I m going to share all these learnings with residents in training on Rehabilitation Medicine. I now have a wider perspective of scoliosis, and one example of an important take-home learning is the importance of the sagittal profile and how to assess it. All these learnings from this course will ultimately lead to improved care of scoliosis patients. I would like to thank our mentors for being very accommodating in answering all our questions and guiding us even with our actual cases in the clinics via email. Thank you for all your research work in the advancement of knowledge on scoliosis. I am looking forward to the possibility of a SPORT brace course for physiatrist and orthotist, and I am looking forward to meeting you and my classmates in future conventions once it is safe to travel.  Happy happy New Year!“

WHO rehabilitation task force: Isico is also there

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Some of Isico’s are part of an international project promoted by WHO (World Health Organization) which aims to draw up rehabilitation guidelines for all countries, including those in the developing world, available to all Ministries of Health.
These rehabilitation guidelines need to be applicable in any context, taking into account the economic means and therapeutic possibilities that differ from country to country.

A large-scale and very ambitious project, involving Isico with three specialists, namely Dr Fabio Zaina, Dr Sabrina Donzelli and Dr Francesca Di Felice. 
The supervision is given by Prof Stefano Negrini, also involved as director of Cochrane Rehabilitation.
“In this process of developing guidelines, we were asked to deal specifically with back pain – explains Dr Zaina – in the first phase, already completed now, we dealt with the bibliographic research. In the second phase, we were asked to collect the scientific evidence in respect to the data collected so as to build the guidelines. At the moment we are working on the final phase: drawing up the guidelines, with great attention also to the sustainability of costs in different countries, and presenting them to the referents of the various countries for their application”.