Scoliosis: situations to beware of in adulthood

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The importance of keeping scoliosis under control through regular specialist check-ups is well known, and this is also true in adulthood when the condition can continue to evolve, albeit slowly and gradually (by half/one degree per year according to the literature).

Although curves measuring less than 30° are unlikely to progress (and a progression becomes less and less likely the further below this threshold the measurement is), curves greater than 50° will often worsen in adulthood. Accordingly, the frequency of medical check-ups is decided by the specialist on the basis of the individual patient’s clinical situation.

Idiopathic scoliosis – the form most frequently found in children and adolescents – affects females in particular. It is important to remember that there are certain times in the life of an adult woman when her body undergoes major transformations that make it necessary for her to take particular care of her back.

The first is pregnancy: it was once thought that scoliosis was most at risk of worsening during pregnancy, due to the body’s production of the hormone relaxin in preparation for childbirth; it was thought that this hormone, in addition to softening the ligaments of the pelvis ready for delivery, also had the same effect on the ligaments that help to support the spine, thereby temporarily reducing the level of trunk support.
Now, however, it is understood that the postnatal period and early months in the child’s life are the trickiest time for the mother. Indeed, in the first year of life, babies often need to be held or carried, and in the space of just a few months, they become considerably heavier. Furthermore, as they learn to walk, the mother often finds herself having to adopt a forward bent position. Obviously, all this can have a negative effect on the back, affecting posture and giving rise to pain. At the first sign of back support problems (pain, difficulty getting through the day, frequently needing to lie down), women with scoliosis, particularly if it is a severe form, would be well advised to do specific self-correction exercises prescribed by an expert physiotherapist; these exercises strengthen the back and help it to support the spine.

Finally, in menopause and beyond, the clinical situation is at increased risk of sudden worsening.
The body changes and the aging process, which accelerates with the onset of the menopause, can cause a worsening of existing curves and even the appearance of new ones, so-called de novo scoliosis. 

Although men are less often affected by idiopathic scoliosis and are of course spared the major physical and hormonal changes that women go through, they are just as likely as women to experience aging-related scoliosis.
This form can cause postural imbalances severe enough to leave the affected individual with marked forward and/or lateral flexion of the trunk.
In this stage of life, a specialist medical examination is warranted in the presence of the following: onset of pain, an increasingly bent posture, worsening of postural asymmetries, loss of height, and difficulty supporting the trunk, relieved only when lying down.

And the Sosort Award winner is… Isico!

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At the International Sosort Meeting in June, this year held for the first time ever entirely online, Isico recorded another great success.

Dr Sabrina Donzelli, Isico physiatrist, won the Sosort Award, the event’s top prize, for her research entitled: “Predicting final results of Brace Treatment of Adolescents with Idiopathic Scoliosis: First Out-of-Brace are Better than In-Brace-radiographs”. Her study was chosen over the work of 7 other researchers in the running for the award.

Among eight studies selected as oral presentations, the Scientific Committee picked out, as the two finalists, Dr Donzelli’s research study and a study on the genetics of scoliosis by the Montreal-based research group led by Prof A Moreau. “After the initial selection we were asked to submit a complete article to be entered for the Sosort Award” explains Dr Donzelli. “The prize, for the winning study, is a sum of money allowing it to be published in any magazine, as an open-access article, in other words in a format accessible, free of charge, to anyone who might be interested in reading it”.

The other studies running for the award included a long-term follow up of patients with scoliosis, presented by Dr AG Aulisa, a cost analysis of conservative versus surgical treatment, and two studies on Scolioscan©, the ultrasound equipment present as well at Isico’s Milan clinic. 

“Our winning research underlines how important patients’ first out-of-brace radiographs are for predicting the results at the end of their course of treatment,” Dr Donzelli goes on. “The accuracy of the model we developed and tested, is the key factor that won us this prestigious award, which will allow us to publish our work in the coming months.” 

In the course of the online meeting, several of our specialists gave presentations: Alessandra Negrini, Isico physiotherapist, asked “Is swimming helpful or harmful in adolescents with idiopathic scoliosis?”, Dr Fabio Zaina, Isico physiatrist, gave a presentation entitled “ISYQOL, a Rasch consistent tool for quality of life evaluation in scoliosis patients during adulthood: comparison with the gold standard”, while our director of physiotherapy, Michele Romano, spoke about “The effect of dance performance on idiopathic scoliosis progression in adolescents”.

This is the second year running that Isico has not only been among the finalists but also gone on to win the award. 

In 2019, Isico also won an award with a study concerning scoliosis and sport. “The quality of our research has increased not only as a result of our acquisition of increasingly high-level methodological skills, but also thanks to the growing availability of systematically collected data,” explains Dr Donzelli. “In recent years, the data we routinely collect from patients visiting our facilities have allowed us to develop so-called predictive models. In other words, we consider the characteristics of large groups of patients to try and understand whether they allow us to predict their final results, or whether certain risk factors are more important to consider than others when deciding what type of therapy to prescribe. Our growing clinical and research expertise has led to international collaborations. Many others now look to us to provide expert support. We are also seeing an increase in our collaborations with international partners that want to analyse and compare their clinical and radiographic data with our database”.

Summer in a brace

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Summer is here at last and it is finally time to go on your long-awaited summer holidays. The problem is, you have to take a particularly annoying friend with you – your back brace, which is particularly difficult to put up with at this time of year. Yes, spending summer in a brace is another challenge you are about to face, and one that perhaps had not occurred to you until now.

Prospecting to spend your summer in a brace, you are probably starting to think that this piece of plastic can turn, what should be a fun-filled time, into a nightmare!  

So, what can you do about it?

First of all, it is important to understand that this is a challenge that you need to tackle head on, with the vital support of your family, but also drawing on your own resources. In the end, everyone finds themselves having to rise to challenges of some kind in their teenage years. Whatever these consist of, extreme sports or expeditions in the great outdoors, letting someone know how you feel about them, or working out how to respond to a first declaration of love, you, as adolescents, are probably already realising that now is the time to show just what you are made of!

The best thing is to draw on all your reserves of determination and self-discipline. It is also important to listen to good advice. For example, make sure you make the most of your brace-off time each day, and if you are a full-time brace wearer, why not consider spending your holidays somewhere cooler, such as up in the mountains?  

How can I stick to my prescribed brace-wearing time and still enjoy my holidays?  

Unfortunately, when your scoliosis is still “evolving” and liable to worsen spontaneously, deciding to reduce your brace-on time is very risky. Stopping scoliosis from progressing is already very difficult, and if it does worsen it is very difficult to reverse the trend and “correct” the damage.
We understand that the summer is a particularly difficult time if you wear a brace, and that you have to make many sacrifices. However, if you don’t take your treatment seriously, you could end up in the same position as many adults who have your same problem: they avoid going to the swimming pool or seaside because they feel embarrassed being seen in a swimming costume, and in their case, it’s too late to do anything about it.
So, try to stay determined in your battle against scoliosis, also in the summertime, because in the end, the results will make all your efforts worth it.

How can I best manage my brace-wearing time?

The main thing is to make the most of the hours when you can leave your brace off, and it might also be worth choosing to spend your holidays somewhere cooler, such as up in the mountains, especially if you have to wear your brace round the clock. If you are travelling by plane, we recommend that you take your medical prescription with you, translated into other languages as necessary.

In hot weather, there are some simple things you can do to prevent minor problems and discomfort: wash frequently and change your t-shirt often (do this quickly so as not to be out of your brace for too long). You may also want to apply thin panty liners to the brace where it fits under the armpits; these can be changed frequently, especially in the summer, when you sweat more.

In most cases, it is fine to keep your brace on when you go in the sea or in the swimming pool. In other words, these activities don’t have to be concentrated in your hours of “freedom”: you can simply bathe in your brace. Before you do, though, just bear in mind the following rules, take care, and remember that unfortunately not all braces allow you to do this.

Six rules for bathing if you wear a brace:

  • If you wear a Thermobrace device, this must be removed before you enter the water. Do not leave it in the sun, and put it back in place when you have finished bathing. 
  • If you have been in the sea, you will need to rinse the brace well in freshwater to get rid of the saltiness.
  • Dry the brace thoroughly.
  • Do not use hot air from a hairdryer to dry the brace pads and do not expose your brace to the summer sun, because the sun can overheat the metal parts and, as well as making them hot, will cause them to dilate. Basically, as the brace heats up, the holes where the hinges are attached to the plastic shells will expand and become deformed. The danger is that this can ruin the brace, because as the brace subsequently cools down, the metal part will return to its original size while the plastic will remain permanently enlarged and deformed.
  • If the brace pads are covered in Alcantara®, let them dry out thoroughly, as this material is easily spoiled.
  • As an extra precaution, you could use a stretchy seamless fabric tube to “line” your brace before going in the water (SOFT-TUBE or a similar product).

WARNING!

  • You cannot bathe or swim with your brace on if the strip protecting your abdomen is made from leather (another material that will be spoiled if it is allowed to get wet: you must first replace it with a plastic one (talk to your orthopaedic technician about this);
  • If you are trying out your brace, or just about to do so, contact the orthopaedic laboratory for more information, and to find out about the procedures to follow for your type of brace;
  • It is important to follow the above precautions carefully: a brace is a medical device and you should not let it get damaged through negligence.

Do not go in water where you are out of your depth, even if you can swim!

Don’t forget you can find lots more information and instructions in our handbook “Do you wear a brace? Here is Isico’s advice”:

you can download it from the Isico website.

My treatment hasn’t had the desired effect: why?

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Sometimes, even when a patient has followed the prescribed course of treatment (bracing and exercises), the final outcome isn’t what they expected and there are no marked improvements. Why is this?

Let’s start by reiterating something we all know to be a fact.

Scoliosis is a disease that can strike with varying degrees of severity and, as we have said many times, its origin is not known. However, although we don’t know what causes it, thanks to scientific research we are learning more and more about how it evolves and how to treat it.

The vast body of scientific literature now available on this topic has shown us the importance of monitoring scoliosis and its evolution during skeletal growth, in particular during the pubertal growth spurt, which is known to be the most critical phase in the course of this disease.

The aim of conservative treatment, which includes specific exercises and bracing, is to limit the progression of scoliosis during growth, so as to prevent problems from arising in adulthood, and to try and avoid the need to perform highly invasive surgery.

The risk of the disease worsening differs from patient to patient and from curve to curve. Unfortunately, there are no elements that allow us to predict this risk; all we have are indicators that can tell us how likely it is that the condition will worsen and, even then, we are only talking in terms of probabilities. Therefore, the task of the medical team responsible for making the diagnosis and treating the patient is to constantly monitor the situation and adjust the treatment as necessary. After all, we do not want to be too aggressive, but at the same time we need to avoid the risk of underestimating the case and prescribing an ineffective treatment.

The other key factor for a successful outcome is the patient’s “adherence” to the prescribed treatment, in other words his/her ability to follow it constantly and with precision.

How much do these two factors influence the result?

A few years ago, we did a study of “extreme” cases (less than 3% of the total), i.e. those patients showing the best and worst treatment outcomes, defined respectively as a greater than 20° improvement or a greater than 20° worsening of the curve. 

We found that all the patients (100%) who obtained exceptional results were treated with both bracing and exercises. But we also found that 50% of the patients with the poorest outcomes had nevertheless followed the treatment perfectly. In these cases, while the treatment had failed to arrest the course of particularly aggressive forms of scoliosis, the patients’ adherence to it had undoubtedly slowed down the worsening of the curve and prevented it from being as marked as it would have been without any treatment at all. And this brings us back to what we said at the start: although some cases show no apparent improvements, scoliosis that has worsened a little at the end of treatment must be considered a great success if the outcome of no treatment would have been a far more severe deterioration.

So, what do we ask of our patients? To collaborate, adhering to the treatment fully and regularly attending check-ups, so as not to run the risk of obtaining disappointing results, despite being treated.

Sforzesco in-brace corrections visible with EOS images

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The aim of our study “The three-dimensional analysis of the Sforzesco brace correction ”, published by Scoliosis and Spinal Disorders, is to analyse the Sforzesco Brace correction, through all the parameters provided by Eos 3D imaging system. This is a cross-sectional study from a prospective database started in March 2003.
The study took into account 16 AIS girls (mean age 14.01) in Sforzesco brace treatment, with EOS x-rays, at start, in brace after one month and out of brace after the first four months of treatment
“One of the major revolutions in the field of adolescent idiopathic scoliosis during the past 10 years is the development of 3D imaging devices in standing position, such as EOS Imaging – explains dr. Sabrina Donzelli, physiatrist of Isico and one of the authors of the study –  Through the 3D reconstructions produced by dedicated user-friendly software, it is possible to calculate and visualise a series of regional and local parameters characterising the spinal deformity. This new technology allows the clinician to deepen the direct effect of braces in all three spatial planes”.
Brace efficacy can play a role in determining the final outcome of a treatment. In recent years, braces have become really three dimensional, adding a detorsion action and addressing the whole shape of the trunk and its deformity. 
Different braces can act in different ways and may act in one plane more than in the other. Therefore, personalised prescription of the brace can optimise treatment.
According to the results, the Sforzesco brace has its strongest influence on the middle of the spine in the axial plane, while the Torsion Index cannot be considered an index of brace correction.
The three-dimensional elongation effect, which is typical of the Sforzesco brace, can be responsible for the main effect focused on the middle part of the spine and seen in the axial plane.
The main limitation of this study is a very small sample size, associated with a large heterogeneity of data which threaten the internal validity of the study. The lack of distinction in curve types, magnitude, bone maturity and age is a threaten for the external validity too, but “of course this preliminary study gives some interesting insight into the mechanism of the Sforzesco brace action and it suggests that EOS imaging could be very useful also to improve the immediate in-brace correction“.

Scoliosis: can it harm the lungs?

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Can scoliosis harm the respiratory system? Patients often ask us this question, as it is an aspect that particularly worries them.

The main purpose of the rib cage – we have 12 ribs – is to protect vital organs such as the heart and lungs.

Scoliosis, as we know, takes the form of spinal abnormalities in the three planes of space: the spine presents lateral curvature in the frontal plane, rotates on itself in the horizontal plane, and is shifted forward or back in the sagittal plane, increasing or decreasing lordosis and kyphosis (the spine’s natural curves).
The ribs, being closely linked to the spine, adapt to these abnormalities, and develop changes of their own. This explains why people can be concerned that scoliosis may impair the respiratory function or vital capacity of the lungs.

Let us try and clear up some of these issues, drawing on relevant scientific research data.  

First of all, the latest studies have shown a correlation between impaired lung function and scoliosis only in very severe cases (i.e. curves greater than 80°).

Let us clarify a further point: the alterations of the trunk and rib cage caused by the spinal deformity should not be considered solely from the perspective of the size (in degrees) of the curve; indeed, although this is certainly a significant parameter, it is not the only one. A patient who, despite having severe scoliosis, retains a well-balanced back with regard to other parameters, such as thoracic kyphosis, could have better function than one with less severe curvature of the spine.
As we know, “flat back” (a posture characterised by markedly reduced kyphosis) is a negative consequence of scoliotic curvature of the thoracic spine; this is why, in daily clinical practice and in the construction of braces, we try to avoid this phenomenon, which is also related to reduced lung capacity.

Other important factors that should be evaluated, and not underestimated, are lifestyle and quality of life. Keeping active and doing physical activity designed to improve respiratory fitness can undoubtedly make the difference in terms of maintaining adequate respiratory capacity.
Essentially, the risk of mild or medium scoliosis harming the respiratory system is very low. Meanwhile, in the presence of very severe scoliosis, the size of the curve may not be the only factor determining the correlation with decreased respiratory capacity, since other factors, both anatomical and lifestyle related, can also come into play.  

Studies along these lines are ongoing, their aim being to shed as much light as possible on these aspects, so as to be able to offer patients the best possible treatments, both preventive and conservative.

Telemedicine: patients’ feedback

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While Isico has organized to reopen in total safety its clinics throughout Italy (the reopening was on May 11th ), our work never stopped thanks to the Telemedicine, started two months ago. Weeks later, we are sure that it was the best choice for this specific moment we are experiencing because it allowed us to stay close to our patients and carry out the therapies. We have passed 3000 consultations, and many patients not only from Italy but also from abroad declared that they are fully satisfied with the solution proposed.
Like Simone from Germany and Laurie from Switzerland, both of them having their daughters treated in Isico. 

Here is their feedback.

The Telemedicine visit with Isico was fantastic. Isico was perfectly prepared and communicated to us exactly what we needed to do far in advance of the visit. Their videos explained everything very clearly in Italian and English and the upload of the requested data was easy to accomplish. We wouldn’t hesitate to do this again in the future, if needed. Thank you, Isico, for ensuring continued patient care, even during this challenging time!
Laurie, Swizterland

I always wanted to have the possibility to use telemedicine. Even if the current circumstances are not the circumstances I wished for, I was very happy for the offer from ISICO to try Telemedicine. I knew that it would require some hours of preparation at least for the first time, so I procrastinated for at least two or three weeks. But then I decided to force myself through the whole process. I was very astonished about the tool “weTransfer”, it is possible to send huge data. It took me about 20 minutes to send the x-rays and I just made sure that my computer didn’t turn off during the transmission. ISICO helped me before to find the right documents on the CD. Taking pictures was very easy with the explanations from ISICO. For the video I bought a scoliometer through Amazon. The cheapest one costs 20 € and a very professional one 98 €. My husband took the video and I made the measurements with the scoliometer. The consultation with the doctor and afterwords with the therapist were more than great. It was above our expectations. Our doctor could fully assess the current brace and we spoke about the further treatment. Our therapist gave my daughter a full set of new exercises. He really saw even the tiniest movements to correct. This kind of consultation is much more comfortable for us than the long travel with flights and train and metro from Munich to Milan. We definitely want to proceed this way and we are very thankful that we got the chance to use Telemedicine.
Simone, Germany



	Will the Covid emergency finally teach us the importance of scientific evidence?				
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Many people are saying that the present coronavirus epidemic will change our whole way of being: our relations with others and the way we see things. Indeed, this health emergency has forced practically all of us to change our habits and our way of life.





Perhaps we should therefore also be asking ourselves whether, in the post-Covid age, there will be greater recognition of the health sector and a greater understanding of the importance of the scientific community, research and evidence-based investigations.





Just think about it. Today, we are all anxiously waiting for an anti-Covid vaccine, whereas not so long ago (although it feels like a lifetime) there were parents who were choosing not to vaccinate their children with drugs that have been available on the market for many years and that countless studies have shown to be effective.





It is to be hoped that, in the wake of this emergency, it will be clear to everyone that infectious diseases (i.e. diseases that are passed from person to person) are only truly brought under control when most of the population is immune to them, in other words when there is so-called herd immunity. This situation is reached when a large section of the population has either been vaccinated against the disease or exposed to the virus and developed antibodies against it.





Unfortunately, there is plenty of incorrect information circulating at the moment. This includes, on a medical level, numerous false beliefs and myths that are difficult to eliminate. These ideas are spread in different ways: via media channels, by word of mouth or even, in some cases, by poorly informed healthcare workers. Some of the ideas going around might raise a smile, but what is less amusing is that they are sometimes heeded and applied by people without the necessary education and expertise to recognise them for what they are.





The Italian Health Ministry has warned people to beware of the various fake news currently circulating about novel coronavirus infection, debunking myths concerning Ayurvedic therapies, yoga and breathing exercises — these are claimed to offer protection against the virus —, the idea that it can be sweated out of the body during physical exercise, and even the claim that honey exerts a useful antibacterial and disinfectant action.





There is a common saying used in science: “In God we trust, all others must bring evidence”. Because what assumes scientific validity must first be proven. 
The basis of all evidence-based medicine is the same: scientific studies in which data have been collected and methods and results rigorously compared and analysed by the various experts on the topic in question. A good doctor must always seek to integrate the best scientific evidence from research with the patient’s clinical experience and values. Patients, in turn, must be fully informed about the treatments they are about to undertake.





But the trouble is, many people today tend to lack scientific culture, and few really appreciate the value of “scientific evidence”. Simply trusting in the views of a certain doctor, or the experiences of someone we know, is really no way to drive advances in medicine.





In rehabilitation, as in other branches of medicine, there exist various methods and techniques whose efficacy has been little explored, and others that have no valid medical basis and are quite often administered by people without proper qualifications, who therefore lack the right approach.





For example, numerous studies have shown that simply telling patients “what a terrible back you have!” will only aggravate their tendency to catastrophise and increase their fear of movement, two factors that contribute to the chronification of back pain. 





Similarly, reading on an MRI report that your spine has several protrusions or thinned discs is no more significant than being told that you have lots of grey hairs: the fact that you have a hernia is meaningless unless this information is correctly set within the overall clinical context. What we are saying is that it is the medical specialist’s job to make the diagnosis and prescribe a course of rehabilitation, which the therapist then decides how best to implement in the individual patient.





In the literature, there are various studies showing that some subjects with spinal hernias are completely asymptomatic. Unfortunately, however, we still have patients who come to us either alarmed to have learned they have a hernia or convinced that their osteopath, by manipulating their spine, has managed to “put back” a decades-old hernia.





At ISICO, we treat disorders of the spine, a field closely related to the concept of posture. Postural problems, too, are frequently addressed using approaches whose effectiveness may not have been properly demonstrated.





While this does not always create problems, in some cases, it costs patients valuable time and money, delaying the reaching of a correct diagnosis and proper planning of their care.





Take scoliosis, for example, a condition that tends to worsen with growth: it is one thing starting the treatment when the patient has a curve measuring 20°, quite another waiting until it has reached 40°. The treatment options, by this stage, are drastically reduced, and there is the risk of having to resort to more invasive therapies. Clearly, it is a shame for this situation to have been reached simply because an appropriate treatment was not proposed sooner.





At the courses we run, we are often asked, both by patients and colleagues, whether there is any link between scoliosis and mastication, dental occlusion, and foot and/or knee position/alignment. For the moment, all these ideas are theories with no scientific basis. It could be that, in the future, data will be collected that confirm these correlations and we will be prompted to review our position, but as things stand, it is not ethical to propose treatments based on these theories.





As regards the treatment of scoliosis, the current scientific literature tells us that we have different avenues that we can pursue: observation, exercises, bracing (with different types of brace, for different numbers of hours per day) and, in the most severe cases, surgery.





It is crucially important to offer the patient the right treatment, where “right” means that it is supported by scientific evidence of its effectiveness. Specific exercises for the back, including self-correction ones, are an active and important part of scoliosis treatment, as well as scientifically proven to be effective (“Specific exercises reduce the need for bracing in adolescents with idiopathic scoliosis: a practical clinical trial“). Instead, gymnastics generally, like other physical activity, has no therapeutic value, even though it can have positive effects (“Sport activity reduces the risk of progression and bracing: an observational study of 511 JIS and AIS Risser 0-2 adolescents“).


	Conservative or surgical treatment in adults? Two steps of therapy				
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Is there an alternative treatment to another in adults with scoliosis who suffer from back pain? The answer is no, simply because therapy is made up of several steps. 





It just has been published by the scientific journal Annals of Translational Medicine the editorial comment of Isico “Symptomatic adult spinal deformity: implications for treatment“. A comment to another editorial, namely “Operative Versus Nonoperative Treatment for Adult Symptomatic Lumbar Scoliosis” which compared the treatment for adults with conservative asymptomatic scoliosis with that for surgical scoliosis.





Let’s start with a premise.





Lumbar scoliosis is particularly relevant for its significant correlation with back pain. There are two main common etiologies for this pattern, degenerative scoliosis and idiopathic. Degenerative curves, also called “de novo” scoliosis, derives from pathological changes at the level of the facet joints and discs in the lumbar spine. Usually, they are not very large but frequently very painful and rapidly progressive. The other type is idiopathic scoliosis appeared during growth that starts its progression in adulthood, usually depending on the size of the curve as previously stated. There is a further type of adult scoliosis called metabolic, which is less frequent.





The most common treatment for scoliosis patients with chronic low back pain, according to current practice, is the surgical one. This has the aim of both preventing progression and improving pain and quality of life. Unfortunately, surgery in such patients is associated with a relevant number of complications, so that it cannot be considered appropriate for every patient. Moreover, some patients don’t want to be operated.





“The study we considered – explains Dr Francesca di Felice, physician of Isico – presents a mixed design, with a randomized and an observational arm. In both arms, conservative treatment was compared to surgery. The general conclusions were driven from the observational arm, since in the randomized one the rate of crossover was dramatically high (64%): this led to similar results for both the approaches in the intent to treat analysis (ITT). For the observational arm, the success of surgery in improving pain and reducing disability was clearly higher than for the conservative approach as supported by the as-treated analysis. We think that this study raises a number of interesting points that should be discussed in the scientific community. The authors tried to apply the best possible design, which is the randomized control trial, but its results were not really informative for the high crossover rate. Hence our comment.”





The ITT is considered more conservative in such cases, and this could be an advantage in case some efficacy is equally demonstrated, but it also underestimates the side effects, and this is a significant shortcoming. We think it’s thus evident that the RCT design cannot be applied to the comparison of surgery and conservative treatment at least in this specific field of spine care. When patients have to face big issues like painful scoliosis, and/or very invasive treatments like fusion for scoliosis, they want to choose their treatment. Some of them want to be operated in case the conservative treatment is not effective, and others are scared of surgery and decide to avoid it. 





Another limitation of the study is that there was no distinction between degenerative and idiopathic scoliosis. We know that the progression rate of the two is different, and also the association with pain. Degenerative scoliosis is more challenging for the conservative treatment, and focusing on this would have been more informative.





Furthermore, the most severe surgical complications for the patient compared to conservative exercise and brace treatment were not considered in the study.





“We are convinced that the choice between one treatment or another cannot be an alternative and thus dichotomous – concludes Dr Di Felice – both treatments must be considered as a step of therapy, if conservative treatment is not sufficient, it is necessary to resort to surgery.





 Surgical complications are a big challenge in adult patients with scoliosis, so we cannot consider surgery as the best option for a problem that can affect QoL but is not life-threatening. We strongly believe that surgery can be a good option for very selected and motivated patients, but we need more data about the advantages of a surgery over the conservative treatment, and hopefully a further improvement of the surgical approach. On the other side, the conservative treatment protocol applied in this study doesn’t rely on the Guidelines on the conservative treatment currently available, we need an appropriately conservative approach to be studied, based on the current guidelines and evidence and managed by experts in the field.”


	Seas: how it evolves to move forward				
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Due to the Coronavirus emergency and the consequent restrictive measures, our SEAS courses, foreseen in different countries of the world in the next period, cannot be done: we are ready to reschedule them as soon as possible. 
In some cases, however, SEAS has been able to evolve in online mode in order not to stop completely.
After the four-handed course in Moscow when Michele Romano, director of physical therapy in Isico, was connected online from Milan, we were invited to hold a theoretical Webinar in Turkey, a few days ago, on April 22nd.
In both cases it was a success beyond expectations, considering that the Webinar had 600 participants. During the Webinar, Dr Michele Romano explained what SEAS is, the scientific evidence of this type of approach to the treatment of idiopathic scoliosis and how it will evolve after the epidemic.





About Seas Course in Moscow, the lessons were given by our director of physiotherapy, Michele Romano, who linked up with 21 participants in Moscow, together with the course organiser Dr Dimitri Gorkovsky, who is a sports physician and specialist in physical and rehabilitation medicine.





“As the current situation prevented me from going to Moscow in person, as originally planned, we took a last-minute decision to switch from a residential to an online course” Romano explained. “A fundamentally important role in the success of this event was played by Dr Gorkovsky, who, since 2016, has worked with us on the staging of eight previous courses in various Russian cities: Moscow, St. Petersburg and Novosibirsk.”





On all these previous occasions, Dr Gorkovsky flanked Romano, translating from English into Russian. 
“Those past experiences certainly helped me this time, as I am now familiar with the topic” he said. “Michele gave practical demonstrations using a dummy, which we watched via Skype, and I then replicated these exercises with volunteers from among the participants. Instead, Michele was able to answer the participants’ questions and clarify their doubts directly, as though he were here with us. The course was excellent, as usual, and the participants were very satisfied with what they learned. This remote modality could certainly represent an important opportunity for the future.”