Teleprevention: a video

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If we analyse it, movement, in general, is part of different aspects of our lives: knowledge, therapies, human relationships… And, of course, we are also talking about physical activity: our body in motion! 

More than anything, movement promotes wellbeing, mental as well as physical, and above all, it helps to prevent conditions of the kind our specialists deal with, such as low back pain and neck pain. The more we move, the less susceptible we are to such ailments.

Our director of physiotherapy, Michele Romano, has prepared a video in which he explains how to prevent back pain and presents a series of simple exercises to be done at home.
They take up very little time and you don’t need any equipment to do them: preventive exercises in telehealth mode
Share our exercise programme using the hashtag #isicotelemedicine. 

Take a look at the video!

Bracing works better in Italy

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Bracing treatment reduces the risk of needing surgery, but the proportion of patients who manage to avoid the scalpel differs between Europe and North America. The factor that makes the difference is patient compliance, i.e. a patient’s adherence to, and belief in, the course of bracing treatment prescribed. In this regard, Italian patients certainly come out on top. 
This is what emerged from a study conducted by ISICO entitled “AIS Bracing Success is Influenced by Time in Brace: Comparative Effectiveness Analysis of BrAIST and ISICO Cohorts”, which has just been published in the scientific journal Spine.

The study was based on a comparison of two populations of patients at high risk of surgery, which showed that, after bracing treatment, 39% of US patients go on to have surgery, as opposed to just 12% of patients treated by ISICO. The Italian institute sent clinical data referring to patients seen by its specialists to the University of Iowa, so that these data might be compared with those obtained in previous research published by the American group in 2014. 

“We worked in collaboration with the researchers at the University of Iowa” explains Dr Sabrina Donzelli, ISICO physician and author of the paper. “In 2014, our American colleagues published a randomized controlled multicentre trial called the “Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST)”. The resulting paper, by Lori Dolan and Stuart Weinstein, was published in the New England Journal of Medicine. Their study, the most important on this topic in the past 30 years, involved 383 patients from 25 US and Canadian institutes studied between March 2007 and February 2011. It showed that brace treatment reduced the percentage of patients requiring surgery. Given that surgeons and families in North America have always had a rather negative attitude towards bracing (unlike those in Europe, where it is well received), the authors were surprised by this finding. We took the results of the BrAIST study as the starting point for our research, comparing them with our own data. Working with our American colleagues, we selected patient subpopulations comparable for disease severity and risk of surgery”.

This comparison was a demanding task requiring clarity: the Italian researchers and the American surgeons from the Children’s Hospital of Iowa measured the radiographs of the patients from the BrAIST study and of 169 patients being treated at ISICO, in order to objectively verify the data. 
What did the comparison show? That bracing treatment at Isico works better, with the proportion of at-risk Italian patients who actually had surgery found to be just a third of the proportion recorded in the American population (12% vs 39%). It also emerged that the ISICO patients, respecting the treatment prescribed, wore their brace for a far greater number of hours than their American counterparts.

“Patient compliance is crucial,” Dr Donzelli continues “Our patients are careful to respect their doctor’s prescriptions, and the doctors and patients enjoy a good relationship based on mutual trust and faith in the proposed treatment. All this adds up to great teamwork between the patient, his/her family, the doctor, the orthopaedic technician and the physiotherapist”.

Telemedicine in response to Covid-19 emergency: the first results

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“I have appreciated being able to have continuity of treatment and the certainty that I can go on being supported by my doctor and therapist even in an emergency, like the one created by the coronavirus outbreak”. This is one of many anonymous comments collected by ISICO through quality assessment questionnaires that patients are filling in, voluntarily, to give us their personal feedback on our telemedicine service. 

The first results show a very high level of satisfaction among patients (mean overall satisfaction rating 2.8/3). Dozens of them clearly feel reassured by the fact that the telemedicine modality guarantees them continuity of care. As well as considering the modality worth recommending to others (mean satisfaction rating 2.8/3), they also feel that the information they have received is clear and exhaustive (mean satisfaction rating 2.99/3). 

As you know, on March 16th, after 13 days of constant and increasing cancellations due to travel restrictions (50% of bookings), ISICO launched its telemedicine initiative. 

It was clear to us, here at ISICO, that we needed to find a way of guaranteeing our patients ongoing care while at the same time removing the need for them to travel and physically access health facilities, thereby protecting them from possible contact with the virus.

Over the 12 days since the introduction of this new system, we have provided more than 1000 medical consultations or physiotherapy sessions in telemedicine mode, and cut face-to-face interventions to just 0.5% of the total. 

“This is a viable solution allowing us to continue providing services to patients, while eliminating the risk of infection associated with the need (both for patients and healthcare providers) to travel and access health facilities” explains Prof. Stefano Negrini, medical and scientific director of Isico. 

Organizing the service

The ISICO staff worked together, in teleconferences, to identify the tools necessary to conduct examinations remotely, i.e. via Skype or WhatsApp video call. The sensitive data are not recorded on these channels, but only in the internally used and protected file storage.

To be able to conduct examinations in telemedicine mode, we requested the collaboration of parents, sending them tutorials on how to photograph their children in a way that would allow us to do the measurements necessary to evaluate the state of their scoliosis.

We also had to explain to parents how the patient should be positioned in relation to the video camera. “Of course, measurements obtained in this way are slightly less reliable than those taken directly, but the photos/videos we are sent before the actual examination are generally of good quality” Prof. Negrini adds.

Parental support is also essential for delivering rehabilitation in telemedicine mode. “Fortunately, parents are always there in the gym, and so they are familiar with the work we do with their children” says Michele Romano, director of physiotherapy at ISICO. “We therapists have also sent written instructions and tutorials to explain how to perform simple tests of musculoskeletal function, and how to make their own simple measurement tools, which then help us to obtain reliable data. We are able to do, remotely, 70% of what we would normally do at the center”.

Consultations include adapted measurements and evaluations, which are done both “live” and from the photos/videos received. During physiotherapy sessions, new sets of exercises are defined and recorded. In both these settings, interviews and counselling are performed as usual.

It is worth recalling that treatments provided by ISICO are mostly based on home practice. Patients exercise at home 10/20 minutes per day, and individual physiotherapy sessions are provided every 30-90 (deformities) or 7-15 (pain) days.
During the sessions, physiotherapists perform evaluations, update and teach exercises (video recorded by parents), and provide patients with cognitive-behavioural therapy and counselling. An App, synchronised with the individual patient’s file, is used to manage treatment plans, provide exercise programmes and videos, promote compliance (with motivational tools) and encourage contact between patients and physiotherapists.

In conclusion, our early results are extremely positive. The telemedicine approach, which has been well received both by the patients and the professionals involved, has given us a means of providing uninterrupted outpatient services. In the current pandemic, this approach, reducing the need for travel and face-to-face contacts, can offer a viable alternative to closure for many outpatient services.

Telemedicine: the video explaining

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Prof. Stefano Negrini, medical director of Isico explains how the examinations and treatments evolve during the Coronavirus epidemic.
Isico maintains its commitment and the trust that patients have given us by putting their health in our hands.

Isico launches Telemedicine: home treatment and care for the duration of the coronavirus emergency

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Dear Patients and Families,

The most difficult periods we face in life are the ones when we most need to be courageous and decisive, and look to the future.

We are living through a dramatic time, in which the health of every single one of us must take priority over every other consideration. And at a time like this, we, as a clinical institute, are acutely aware of our mission as doctors, therapists and specialists: a whole team working to support you, our patients. Because you have shown faith in us, by putting your health in our hands.

Over recent weeks, we have tried to keep all our outpatient clinics running, always in full compliance with the different regulations that have, progressively, been issued. Many of our patients in this period have had to go without examinations and treatments. 

Scoliosis, however, is a condition that goes on evolving all the time. Therefore, even in the midst of the present coronavirus emergency, it is crucial to ensure that treatments are not interrupted.

With the dual aim of guaranteeing our patients continuity of care while at the same time taking steps to drastically decrease the risk of infection, on Monday 16 March, we introduced a radically new way of operating. This has been done in order to limit the movements of our staff members, to limit the clinical activities performed in our dozens of centres throughout Italy, and thus to reduce, as far as possible, the risk of the virus being spread during examinations and treatments. However, for us, limiting does not mean not being there for our patients: we are still providing examinations, prescriptions and treatments, but we are adapting our activity to the rigorous restrictions imposed by our country. In recent days we have been working harder than ever, racing to find new approaches and solutions, in order to continue repaying your faith in us.

Isico is now ready to activate a new method for providing examinations and treatments, in all situations in which this is feasible. This approach, called Telemedicine, is a hugely important opportunity for patients. The patients we see are ones whose condition requires or can require

 a long and difficult course of treatment, and this is a way of preventing their hard work and sacrifices from going to waste. This new approach also reflects our determination to do all we can to reduce the burden on our National Health System, which is wrestling with the emergency, and also to do our bit for our country and for the many families facing unexpected economic hardship (we will be offering examinations and treatments at reduced rates). Obviously, these services will remain unchanged in terms of duration, timing and quality.

As one of our physiotherapists, Marta Tavernaro, wrote on the Facebook page aimed at our scoliosis patients: “I am not worried about this approach. We therapists already use it to follow young patients abroad, and for some time now our doctors have been studying an approach that might allow us to reach youngsters the world over. However, this emergency has hit everyone with catastrophic speed, and we have had to work day and night to come up with an adequate solution. Personally, in my 30-year career as a physiotherapist I have never experienced as many emotions, or had so many thoughts running round in my head as I have in recent days. Never before have I found it so hard to advise those who called me asking for advice, in this case on what they should do about their planned examinations and treatments. Now, however, with Isico Telemedicine, we have found the solution. And the fact that we have managed to do this is, believe me, yet another Isico miracle! At last, I have some peace of mind: in addition to being able, as a private citizen, to play my part in tackling this dreadful situation, I am now confident, as a professional, that I can go on giving our young patients the support they need without exposing them to the slightest risk”. 

Should we have been looking for further confirmation of the value of our approach, in recent days the New England Journal of Medicine published an editorial entitled Virtually Perfect? Telemedicine for Covid-19, which remarks that”disasters and pandemics pose unique challenges to health care delivery. Though telehealth will not solve them all, it’s well suited for scenarios in which infrastructure remains intact and clinicians are available to see patients”.

Isico has equipped itself to be, until the emergency ends, a digital institute.

Together we can get through this difficult time.

Isico launches a free psychological support service

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Recent weeks have seen Italy, and the world, plunged into an emergency that is quite naturally leaving people feeling fearful and anxious. Fear is a normal and useful reaction, because it helps us to prevent, and therefore avoid, danger. Sometimes, however, these emotions become overwhelming and prevent us from seeing things in the right perspective: anxiety can become unmanageable and turn into panic. That is why, in these difficult times, we need to look after our mental health, and not just our physical health.

Isico has launched a psychological support service available not only to its patients and their families, but to anyone in Italy who needs this kind of help.

The service consists of two free Skype sessions aimed at providing users with the tools they need to manage the current situation. Dr Irene Ferrario is a psychologist who already works with our therapeutic team. “To combat the spread of the virus, our government has ordered us to stay at home, allowing us to go out only when strictly necessary” she says. “But ‘doing our bit’ isn’t always easy. Our social contacts have been drastically reduced and the future is suddenly filled with uncertainty: all this naturally makes us feel isolated, lonely and unhappy. The aim of these Skype interviews is to help patients find ways of managing the emotions generated by this situation, and also to provide them with practical advice that might enable them to deal with this enormous upheaval in our daily lives more calmly”.

Online interviews are an easy and convenient way of getting direct help from a professional without having to leave the home. What is more, this method of delivery has no detrimental impact on the usual ethical and care standards. 

“The current scientific evidence also shows that psychological support and treatments provided online are just as effective as those provided face to face” Dr Ferrario adds. “In a review of the literature carried out in 2016, which considered data from 15 years of research, more than 100 randomized controlled trials showed online psychological and psychotherapeutic interventions to be effective in treating a very broad spectrum of medical and psychiatric conditions”.

Predicting scoliosis progression: published an Isico review

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The scientific knowledge and the clinical competence of Isico experts recognized by Lancet’s EClinical Medicin Journal

One of the major challenges faced by clinicians is related to Idiopathic Scoliosis prognosis and to decision-making concerning which would be the best treatment for every single patient. 

Precisely on this topic, it has just been published by Isico in the journal EClinical Medicine the commentary Predicting scoliosis progression: a challenge for researchers and clinicians.  The editor invited to comment on the study  “A validated composite model to predict the risk of curve progression in adolescent idiopathic scoliosis”, following the review of the same conducted by Dr. Donzelli for the journal.

Idiopathic scoliosis has a multifactorial aetiology showing a wide range of different forms: anatomical (single or multiple curves and different localization), aesthetical (milder curves with visible changes and severe hiding perfectly), and prognostical (from highly to non-progressive).

Experts use some known clinical risk factors, the most important being residual growth: the more it is, the more the risk.

“It has been shown that ending growth below 30° allows preventing progression, disability and pain in adulthood – explains dr. Sabrina Donzelli, physiatrist in Isico and author of the review – the study of these colleagues developed a predictive model of the progression of scoliosis beyond 40 degrees, combining both clinical data and data from genetic tests. The idea of ​​combining clinical and genetic factors is interesting, but the results show that genetic testing does not play as significant a role as clinical data. The test of the accuracy of the model showed 80% of specificity and 92% of sensitivity, thus meaning that the model is good in discriminating patients at high risk for progression to 40°. According to the model, there is a 20% risk of overtreating patients with less aggressive IS. Is this enough? It depends on the treatment used to avoid progression”. 

The study therefore conducted is undoubtedly interesting, but the researchers showed a fundamentally surgical approach without any reference to the preventive role of the worsening and surgical risk shown by conservative treatments. Therefore we have been invited to process a comment to associate with the publication.

We would like to remind you that the SOSORT Guidelines recommend that ” for each patient, it is mandatory to choose the correct step of treatment, where the most efficacious is also the most demanding.” Expert clinicians should always choose the option they think is the most likely to reach the goals agreed with the patient but also the less invasive in the attempt to balance between undertreatment (that leads to little or no efficacy) and overtreatment.

“The introduction of a composite model, including genetic factors, is the novelty of this study, but some clinical questions remain open – continues dr Sabrina Donzelli – The type and quality of treatment applied, the compliance to treatment and the dosage of brace-wear have not been included in the model, although they are recognised as determinants of final results”.

From a clinical point of view, the 40° threshold is too low for surgery indication and too high for the best achievable result from patients’ perspective. Surgery is indicated for curves exceeding 50°.  

“A prognostic model should help clinicians in their choices after risks estimation – finalises dr Sabrina Donzelli – the currently developed composite prediction model for progression over 40° showed that the major predictor is Cobb degrees at start. The fact that Cobb at start is the major predictor, confirms the key-role played by screening and conservative care: exercises and bracing to prevent progression should be started at early stages of the deformity when it is early diagnosed“. 

Rehabilitation: the comment of prof. Negrini on Lancet

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When discussing health care in disability, it is essential to talk about rehabilitation. Yet it is not always obvious. Precisely for this prof. Stefano Negrini, as director of the Group of Physical and Rehabilitation Medicine (Cochrane Rehabilitation), developed the comment “Prioritising people with disabilities implies furthering rehabilitation” to the editorial “Prioritising disability in universal health coverage“.
Both were published in the scientific journal Lancet.
“Unfortunately, it happens that even major magazines forget the central role of rehabilitation, which is why this comment had the aim of emphasising the theme. We fully agree with the Editors regarding the need to prioritise disability in universal health coverage – he commented Prof. Negrini –  but we want to emphasise that for the World Health Organization (WHO) this implies also strengthening the rehabilitation health strategy.
Because of changing health and demographic trends, an increase in the number of people living with permanent disabilities, but also of people experiencing disabilities with the potential of recovery, has been observed. 
1 billion people live with disabilities,  while 2·4 billion people experience disabilities.  
Rehabilitation serves both groups: by reducing the number of people transitioning from experiencing a disability to living with a disability, maximising the benefits of other health services, and reducing the overall costs“. 


The comment concludes with these words: “WHO has included rehabilitation in the universal health coverage mandate together with other public health strategies including promotion, prevention, treatment, and palliative care… Paradoxically, the fundamental struggle for the rights of people living with disabilities somehow drove the attention to those with permanent and stable disabilities and social rehabilitation, without including those with evolving and changing conditions, who are the target groups of the rehabilitation health strategy. Rehabilitation strengthening advocated by WHO is in line with disability prioritisation emphasised in the Editorial, but will also reduce the burden of disability on the population and the costs of health services worldwide“. 

What can parents do to help manage brace-wearing youngsters’ anger and outbursts?

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Fighting scoliosis is a team effort. It is also a long, difficult and sometimes exhausting battle in which the patient, who is in the front line of course, is ably supported by various team members: a specialist doctor, a physiotherapist, an orthopaedic technician and, if necessary, a psychologist.

Nevertheless, the people best placed to support patients are the members of their own family. Parents, who directly experience the everyday problems faced by their child, can play an active and crucial role in ensuring that the treatment runs smoothly.  

I would go so far as to say that their input is essential in order for the treatment even to begin.

A diagnosis of scoliosis always comes as a shock, and the course of action prescribed by the doctor is something no adolescent wants to hear. While they initially have little problem accepting the specific exercises they have to do, the prospect of wearing a brace is frightening. All they can think is that this is going to change everything, and they really don’t want that to happen!

In this situation, it is already clear that parents can play a crucial role. With their child probably completely overwrought, they need to inject a dose of rationality.

We, as a team of specialists, always try to address patients directly, striving, from the very outset, to involve them in every decision. We provide exhaustive explanations, as these are tools for interpreting and, above all, understanding the course that has been decided and prescribed.

However, on leaving our office or clinic, patients will inevitably take things out on their parents, and it will be up to them to find the best way of getting our words, and our message, across.

If you are reading this, you probably already appreciate that, in times of difficulty, we often find we have unexpected resources, and that, most of the time, it is possible to find a balance and follow doctor’s instructions properly. 

As with all long undertakings, however, obstacles are always just around the corner, and you need to have the strength to stay “on track”.  

Anger is a common and normal reaction in these patients, stemming from an understandable sense of injustice over the challenge they are facing.

In this circumstance, too, the whole team, but the parents primarily, must be ready to spring into action.

How can a parent best manage a child who is in difficulty with the treatment and gripped by a feeling of anger?

The first thing is to show empathy and understanding, remembering that things that are less important to us adults are not always viewed the same way by adolescents.
It is also important to remember that anger is a manifestation of distress, which can have various causes.

Parents must strive to be a point of reference and a channel through which their child can vent his or her feelings, in order to help him/her recognise and correctly express the anger he/she is feeling in the face of this difficult situation. The next step is to help the child to reason more clearly, reminding him/her of all the challenges he/she has thus far faced and overcome.

Parents must also be the first to believe in the course of treatment, and must continue to support it right through to its conclusion, having full confidence in the doctor and helping the child appreciate the importance of persevering. For these patients, this is perhaps the first time in their life that they have had to deal with a personal problem.

If they can learn to manage their anger and accept a compromise between what they want and what they can have (within the constraints of the treatment of course), then they will have learned, first hand, that, with a little patience and the support of those closest to you, difficult situations can always be overcome.

Note

This is one of the posts published in the Isico blog, www.scoliosi.org,  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 also engage with patients.

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