Scoliosis and posture: the two go hand in hand

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Let us start with one thing we know for sure: idiopathic scoliosis is not a postural complaint, but rather a progressive spinal disorder that causes three-dimensional deformation of the vertebrae.

Although it is still not clear exactly why scoliosis occurs, its progression is known to be due, in part, to the force of gravity (i.e., the force of gravity does not cause the disorder, it simply helps it to progress).

Let us try to explain this in simple terms: our spine is like a tower of building bricks that serves to support us, and the bricks distribute evenly the weight it has to bear. If we have scoliosis, some of our bricks are not correctly shaped.
As a result, they are not properly aligned and our tower (spine) may have curve(s) in it. A spine with curve(s) is no longer able to distribute evenly the weight it has to bear; indeed, this presses down harder on the inside of the scoliotic curve, and less on its outside. 

If our spine is well supported, this effect can be lessened, because the support allows the blocks to realign, and this, in turn, reduces the extent of the curve(s). Conversely, without support, the bricks will slide even further to one side, increasing the angle of curvature and shortening the trunk even more.

What does all this mean? That our scoliotic curve will worsen more rapidly unless we continually correct it.

This is why the exercise-based treatment method used at Isico is based on the principle of SELF-CORRECTION: affected youngsters learn to intervene independently to control and align their spine as correctly as possible, thereby countering its tendency to collapse in the direction of the scoliotic curve.

Let us consider another aspect. On a spinal X-ray, we can measure the degrees of curvature present. The angle of curvature is actually the sum of two components: the deformity itself and the effect of postural sagging in the direction of the curve. The contribution of this second component is largely dependent on our capacity for “self-correction”.

How can we distinguish between these two components, i.e., actual bone deformity and postural sagging, so as to be able to intervene effectively on each of them? Again, on an X-ray, but in this case, it must be taken with the patient lying down, so that the degrees of curvature caused by postural sagging disappear, and all that can be seen, and measured, are those due to the deformity itself.

One study, now rather old but still valid, published in Spine in 1976 (Standing and supine Cobb measures in girls with idiopathic scoliosis, G Torell, A Nachemson, K Haderspeck-Grib, A Schultz), showed that postural sagging in scoliosis causes, on average, 9 degrees of curvature (ranging from 0 to a maximum of 20), and that the degrees attributable to postural failure are independent of the severity of the curve. Another interesting study published in Spine, in this case in 1993 (Diurnal variation of Cobb angle measurement in adolescent idiopathic scoliosis, M Beauchamp, H Labelle, G Grimard, C Stanciu, B Poitras, J Dansereau), shows that back “fatigue” can also affect the Cobb angle. In this study, youngsters with moderate to severe scoliosis (an average of 60 Cobb degrees) were X-rayed in the morning and then in the evening. The X-ray taken in the evening showed an average 5-degree increase in curve severity.

What should we do in treatment terms? Clearly, exercises alone cannot alter the actual bone deformity resulting from the scoliosis, which needs to be treated with a combination of exercises and brace wearing.
Nevertheless, specific exercises and self-correction can do a lot to address the problem of postural sagging. And if this “sagging” is responsible for an increased Cobb angle, we need to work hard at our exercises in order to “eat away” at (reduce) the part of the curve that is due to this component.

Scoliosis: is aesthetics measurable?

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When it comes to scoliosis therapy, aesthetics is one of the goals along with a healthy back.

Aesthetic deformity due to scoliosis and its impact on the patient is considered by the members of SOSORT (International Society On Scoliosis Orthopaedic and Rehabilitation Treatment) as the most important reason for treating AIS; unfortunately, only a few of scoliosis studies were found in PubMed on this topic. 

But can a goal, apparently so subjective, be measurable in a repeatable way to become objective? Yes,according to the data collected by the study Reliability, repeatability and comparison to normal of a set of new stereophotogrammetric parameters to detect trunk asymmetries, recently published by the Journal of BIOLOGICAL REGULATORS & Homeostatic Agents. 

“Aesthetic impairment is a crucial issue in Adolescent Idiopathic Scoliosis (AIS), but to date no objective measurements are available – states Dr Francesco Negrini, Isico physiatrist – for our research, we used the Formetric®, which we usually use to measure sagittal planes. We have established parameters for evaluating symmetries in patients, such as those of the shoulder blades or hips, to obtain objective data related to the aesthetic aspect. In order to validate this instrument for clinical practice, the first step and aim of this study are to evaluate the repeatability of the parameters measured by surface topography in a group of AIS subjects and to test if they can distinguish healthy subjects from AIS patients to develop an objective tool for deformity evaluation of the trunk in AIS patients. For our evaluations, we used a device for surface topography based on the principles of rasterstereography. This device (Formetric®, Diers Biomedical Solutions) can reconstruct digitally in three dimensions the back of any person”.

The study evaluated 15 selected parameters that could be good predictors of scoliosis’ impact on the patients’ trunk.
“We analysed short-term (30 seconds, 38 subjects) and medium-term (90 minutes, 14 subjects) repeatability of surface topography measures and their diagnostic validity in AIS (74 subjects, 33 AIS patients and 41 healthy subjects) – proceeds Dr Negrini – All examined parameters were highly correlated as far as short, and medium-term repeatability is concerned”. 

When it comes to aesthetics we cannot stop at Cobb degrees alone, believing that there is no objective measure: “Symmetries can be measured repetitively, as we did in our study – concludes Dr Negrini – so we can offer an objective measurement of aesthetics in patients with idiopathic scoliosis. The surface topography showed good repeatability. Moreover, some of its parameters are correlated with scoliosis, showing that it could very well evaluate deformity due to this pathology. Thanks to these findings, it will be possible to develop a tool that can objectively evaluate aesthetics in AIS patients.”.

Merry Christmas and Happy New 2021

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It is going to be a strange Christmas and New Year, different from any other. So, as we reach the end of 2020, we send you not only our sincerest greetings, but also a story of hope, trust and new life. Here Rossella, a former patient recalls the end of her treatment. 

“You can never really forget something that was, in effect, a part of you for a very long time. Sometimes I feel like I have forgotten all about it, and yet it only takes a passing thought to take me back to four years ago. 

To say that I remember it with pleasure, that I miss it, and that with hindsight the whole thing was actually quite easy, would be both untruthful and hypocritical. It was difficult, painful and a real burden, and the reality of this is something I can only appreciate fully now that it is all behind me.  

There is nothing unusual about my experience, quite the opposite. Like countless other Isico patients, I was just a normal adolescent, albeit one who had to live her everyday life in a brace.

Every so often, I still find myself thinking back what life was like in a brace. 

When I curl up in bed, for example, I suddenly remember all those nights when I simply couldn’t do that, because in a brace you have to lie straight, and turning your head to one side on the pillow is literally the only movement that you do with ease. 

Now, if a pen falls off my desk when I’m working, I just bend down and pick it up, without having to think twice about it. But this sometimes makes remember how picking up a pen used to be quite a performance! Back then, I would have to get up from the chair, bend my knees to lower myself to the ground, and then reach out at full stretch, scrabbling for the pen, before then standing up again and returning to my chair. 

I also remember that when we went on our summer holidays, I would only go on the beach in the mornings, because in the afternoons I had to wear my brace, and it was so hot I would end up spending the whole time in my hotel room. 

Another thing, how could I possibly forget the way my entire day (going out with friends, going to school, doing sport and so on) had to be planned around when I was meant to be wearing my brace? I used to think of my brace-off time as my “hours of freedom”, because it was then that I was able to behave just like any other girl. 

As I say, it would be wrong to claim that brace wearing wasn’t difficult for me. But, in the same way, it would be dishonest of me if I didn’t make it clear that I have absolutely no regrets about any of it.

Even though they are now relegated to the cellar, I have kept my braces, all five of them, each stored in its grey bag with “Isico” written on it in big blue letters. I have never put them on since my treatment came to an end, but occasionally I go and get them out. 

Had it not been for them, I might now have a curve measuring more than 30°, and would probably be in much more pain than I ever experienced during the treatment

I well remember going to see Prof. Negrini for my very last visit.  Inside my head, a voice was crying out: “Please, tell me it’s all over!”. Well, it was! With the help and support of Prof. Negrini and all the Isico doctors and physiotherapists, I really had done it!

I left his office and burst into tears. I went on crying all afternoon, but they were tears of great joy. 

I was elated. It was over. I had won my battle“.

SEAS in adults

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Over the past 13 years or more, we have published dozens of posts and thousands of comments on our blog dedicated to scoliosis.
The Isico blog is a dedicated space where patients can ask questions and swap experiences, but it is also a place where those involved in treating scoliosis can take a more in-depth look at a series of topics and engage with patients.


SEAS in adults

“You’re too old now”, “Your scoliosis has stopped now that you’ve finished growing”, “If you want to, do some exercise”… How often do adults with vertebral deformities like scoliosis or hyperkyphosis hear things like this?
Our patients often tell us that on reaching adulthood they become aware of physical changes, in their back, balance and height, and they therefore start looking for answers and treatments.
The natural ageing process does not spare our back and changes are quite normal and to be expected: when they occur, it is important to get active in order to restore elasticity and strength to joints and muscles. But ageing is an entirely different situation compared with the occurrence of spine deviations in young people, in whom we seek to modify the bone structures and consequently reduce the degrees of curvature.
 
Scientific studies in recent years have clarified several aspects, that are worth bearing in mind:

1. Scoliosis exceeding 30 degrees at bone maturity, generally reached between 17 and 19 years of age, is at risk of progressing over the years, resulting in a worsening of the existing curves: and the higher the measurement, the greater the risk of worsening.
2. Will scoliosis inevitably lead to back pain? Absolutely NOT!
3. Does having a correct lateral spinal profile (lordosis-kyphosis) protect us against the reduction of our quality of life due to disability and pain? YES, it does.

In light of all this, it is important to know that in adults, too, it is possible to intervene to correct postural abnormalities and prevent and/or slow down the worsening of scoliosis over time: our approach (SEAS) aims to do just this.
As an effect of the force of gravity, and also the curves that are already present, a scoliotic back will tend to drop down in the direction of the curve, and in many cases, there will also be a forward shift of the trunk. Simple physical activity alone, however useful and beneficial, is insufficient to counteract this phenomenon.
This can only be achieved through specific exercises designed to provide support for the structures of the spine in the opposite direction, and these reinforcement exercises must have precise and individual characteristics, in other words, they must be tailored to the individual patient.

The movements to be carried out must be chosen according to very specific priorities, and this is why it is necessary to turn to qualified professionals who have expertise in dealing with these conditions in adults, using effective approaches.
The SEAS method requires constant collaboration on the part of the patient and seeks to make him “responsible for himself”.
The exercises are carefully worked out for each patient. They are initially performed under the therapist’s guidance and then performed independently, with the patient doing daily repetitions, at home.
Sessions with the therapist are initially scheduled monthly, although this frequency is subsequently reduced, possibly even to only once every three months, and patients are given exercise sheets to follow at home.
It takes at least six months to obtain appreciable results, sufficient to motivate patients to continue and thereby ensure they remain fit well into old age.

What is secondary scoliosis?

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Scoliosis: idiopathic or secondary? Let’s look at the difference.

Scoliosis, defined as a “three-dimensional deformity of the spine”, affects 3% of the population overall, and in 80% of cases its origin is not known.  In these cases, it is therefore termed idiopathic.

In the other 20% of cases, on the other hand, the cause of the scoliosis is known; in these cases, it is secondary to another condition. 

In particular, scoliosis can be the manifestation of congenital defects, i.e. abnormalities that originate before birth, such as abnormalities of vertebral formation like rib or vertebra fusions. It can also occur in inherited genetic syndromes, involving the nervous and/or musculoskeletal systems, and in diseases such as neurofibromatosis, Marfan’s disease, Willi-Prader syndrome and syringomyelia. 

In a further subgroup of cases, scoliosis can be secondary to iatrogenic causes, i.e. a “side effect” of medical treatments such as radiotherapy, or surgical procedures such as laminectomy or thoracotomy.

Finally, scoliosis can also have other causes, such as burns or retracted scars, post-traumatic paraplegia, spinal tumours, or bacterial or parasitic spinal infections.

The specific features of secondary scoliosis, including the mean age at onset, closely depend on the disease with which it is associated. Overall, these forms are more aggressive and less treatment responsive than idiopathic scoliosis.

In all these cases, whether secondary scoliosis is suspected or has already been diagnosed, it is crucial to consult a medical spine specialist. 

If the cause of the scoliosis is not clear the specialist, after performing an in-depth clinical and instrumental evaluation, will refer the patient for further investigations and tests, necessary to confirm or exclude the presence of primary conditions “masked” by the scoliosis. 

Once secondary scoliosis is confirmed, the proposed treatment and its management over time will be planned and adjusted taking into account the patient’s overall condition and its complexities.

Precisely because these forms are often particularly aggressive, it is crucial to contact extremely competent specialists in the field of spinal disorders, in order to start monitoring the evolution of the disease. Only in this way can the best therapeutic and rehabilitation options be identified, on the basis of the patient’s overall conditions and the opportunities, benefits and objectives identified. 

The spine specialist will thus intervene with the agreement of, and in collaboration with, the various healthcare professionals involved in the patient’s care. This multidisciplinary approach is necessary to ensure that every aspect of the patient’s condition is considered in the effort to optimise his/her health.

Best Practice Guidelines for bracing in AIS

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Which are the guidelines for using a brace in idiopathic scoliosis treatment? The study “Establishing consensus on the best practice guidelines for the use of bracing in adolescent idiopathic scoliosis”, just published by the journal Spine Deformity, collected 38 experts who developed a consensus on 67 items across ten domains of bracing which were consolidated into the final best practice recommendations.
Among the experts, from surgeons to physiatrists and physiotherapists, prof. Stefano Negrini, scientific director of Isico: “Bracing is the mainstay of conservative treatment in Adolescent Idiopathic Scoliosis (AIS), but currently there is significant variability in the practice of brace treatment for AIS and, therefore, there is a strong need to develop best practice guidelines (BPG) for bracing in AIS“.
How did you go about developing a common consensus?
Following a review of the literature, three iterative surveys were administered. Topics included bracing goals, indications for starting and discontinuing bracing, brace types, brace prescription, radiographs, physical activities, and physiotherapeutic scoliosis-specific exercises. A face-to-face meeting was then conducted that allowed participants to vote for or against the inclusion of each item. Agreement of 80% throughout the surveys and face-to-face meeting was considered consensus. Items that did not reach consensus were discussed and revised, and repeat voting for consensus was performed.
 “A common adherence to these BPGs is fundamental for developing common protocols on an international level – ends prof. Negrini – furthermore, this consensus on the guidelines will lead to fewer sub-optimal outcomes in patients with AIS by reducing the variability in AIS bracing practices, and provide a framework for future research”.

Message in a bottle: an Isico research

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Isico’s study, “Torsion bottle, a very simple, reliable, and cheap tool for a basic scoliosis screening“, published by Scoliosis and Spinal Disorders, demonstrates how and why scoliosis can be identified using a bottle of water. 

“One of the reasons that make scoliosis a disease that scares so much the parents, is its specific characteristic of being difficult to detect on its onset – explains Michele Romano, director of physiotherapists in Isico – A scoliometer is a professional medical instrument used by specialists such as doctors and physiotherapists to detect the pathology. In the absence of this instrument, is there a simple test for scoliosis that we can do in our own homes? Yes, the Torsion Bottle. Our paper aimed to check the possible usefulness of a simple tool (the Torsion Bottle) developed to offer an instrument for home-use by parents but also for screening purposes in low-income countries”.

The study was divided into two parts. The main purpose was to compare the measurements collected with the torsion bottle and the same measurements collected with the scoliometer in a population of patients accessing our clinic for the rehabilitation treatment following Isico standard evaluation protocols.

The secondary aim was to verify the reliability of blinded inter-operator assessments, performed with the torsion bottle on the same patients by two physiotherapists. These double-blinded measurements were taken periodically for a short-time-interval in our clinic to verify measurement accuracy in the everyday clinical activities.

The conclusion? The torsion bottle is useful to perform a pre-investigation of the presence of a prominence, permitting a simplified assessment of its value, thus referring to a specialist for a medical assessment.

We remind you that you can perform a quick and simple assessment/check for scoliosis or curved back on the website screening.isico.it,where you are simply asked to take some measurements with easily procurable tools like a ruler and others again to be detected with the help of a simple bottle of water, the Torsion Bottle. 

Online Master: conclusion of edition 2020

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Our international online Master 2020 edition has reached its last session. It started as usual in January and for the first time in a double edition, English and Chinese. Thanks to the online formula consolidated over the time we have been able to proceed in the best possible way and absolute normality in this particular year. 
The last live lesson has been given together by the 3 teachers who perform the live lessons individually during the year, with the closing of prof Stefano Negrini, scientific director of Isico.
We remind you that registrations are open for the 2021 edition with lessons from January to November. The lectures are organised in modules self-administered by the participants except live lectures delivered two times a month.

Also the first Chinese edition of the online Master course closed its doors, with excellent prospects for the second edition in 2021.


For more infos please visit the website: www.scoliosismaster.org 

Isico involved in an international research project: brace versus plaster cast

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An international project involving clinical centres in 40 countries in the US, Canada, Europe and Asia has just started. Target? A comparison between the use of plaster casts and braces in the treatment of infantile scoliosis.
Isico is one of the centres involved, thus representing Italy, expressly invited given the clinical and research experience gained over the years.

The project manager is Prof. Stuart L. Weinstein, referent Dr Lori A. Dolan, both from the American University of Iowa. The target enrollment is 440 subjects (220 patients and 220 parents). For Isico, the head researcher is Prof. Negrini, while Dr Donzelli is involved as the research referent.

We recall that infantile (early-onset) idiopathic scoliosis (IEOS) is a relatively rare disease affecting 40 out of 100,000 children. Defined as an idiopathic curve measuring > 20 degrees in those less than three years of age, the natural history of IEOS is variable with some curves resolving spontaneously and others quickly progressing to such a degree that severe pulmonary disease and shortened life span may occur. Casting, and less frequently bracing, have been used to treat this condition in hopes of resolving the curve or at least delaying surgical interventions.

The plaster cast is widely used for these early forms of scoliosis, but a plaster requires hospitalization, sedation, and daily handling is much less comfortable for hygiene than a removable brace.

“During the two-year duration of the project, funded by the University of Iowa and The Orthopedic Research and Education Foundation, – explains Dr Donzelli – we will bring between 5 and 10 cases treated at our Institute to research purposes. Isico has several years of experience in the use of braces; our participation will not involve the application of plaster casts; our results will be compared with those of other centres that apply these casts “.

A perfectly straight back? That’s pretty rare!

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It is as rare to have a perfectly straight back and perfectly symmetrical body as it is to have scoliosis, a condition that affects no more than 5% of the population. Scoliosis is linked to different factors that influence the shape and development of the spine in the three planes of space.
What causes it? In most cases, we still don’t know.

On the other hand, we are very familiar with how the condition typically evolves. We know that scoliosis that is left untreated will worsen as an effect of bone growth. Therefore, to limit its effects, it is essential to obtain an early diagnosis and undertake an effective treatment, guided by experts in the field.  

  • When should scoliosis be treated? Let’s look at two key parameters  

There are two elements that tell us the seriousness of a case of scoliosis, namely, the amplitude of the curve (measured in Cobb degrees) and the individual’s bone age (Risser sign).

Briefly, with regard to the amplitude of the curve

  • 0 – 10 Cobb degrees → no scoliosis
  • 10 – 15 Cobb degrees → mild scoliosis
  • 16 – 34 Cobb degrees → moderate scoliosis
  • 35 – 44 Cobb degrees → moderately severe scoliosis
  • 45 Cobb degrees or more → severe scoliosis

Instead, to evaluate bone age we use a scale of 0 to 5 (where 5 corresponds to complete bone maturation).

The phase in a youngster’s development in which scoliosis is most likely to worsen is the pubertal growth spurt, a period in which their growth rate speeds up and they grow considerably. On average, this phase begins between the ages of 11 and 13 years in girls, and 12 and 14 years in boys, and this generally corresponds to the passage from level 0 to level 1 on the Risser scale.

The subsequent phases, of course, are not risk free, but in most cases the speed of growth progressively declines, and for this reason, so does the risk of progression of scoliosis.

  • 0-10 Cobb degrees: is it correct that even if there’s an asymmetry we don’t need to worry?

If a patient has an X-ray that shows a curve measuring less than 10 Cobb, he/she will not be diagnosed with scoliosis and no treatment will be prescribed, only further monitoring of the situation according to how much the patient is still expected to grow.

Nevertheless, the image will show some asymmetry of the spine, and on observing this, even slight, curvature, patients and parents quite often become alarmed.

No one likes to be told that their spine or their child’s spine is “asymmetrical”, and they can be sceptical or even disappointed to learn that nothing needs to be done.

  • “We don’t all come out of the same mould!”

It is probably as rare to have a perfectly straight spine and a perfectly symmetrical trunk as it is to have scoliosis.

We often tell our patients that “we don’t all come out of the same mould”, in order to explain, in simple terms, that everyone of us presents some (more or less visible) physical asymmetries. 

Think of the different parts of the body that we have two of. If we were to measure the precise length and size of our hands, feet, arms and legs, we would almost certainly find they show some minor differences.

In the presence of a difference in length of the lower limbs (typical during growth), for example, it is quite common to find a proportional inclination of the pelvis and, consequently, of the spine.

In this case, however, the scoliosis serves a “functional” purpose, as its contributes to the maintenance of the body’s balance and can thus be interpreted as a useful compensatory response and unlikely to worsen as the youngster grows.