A brace? Nothing to fear!

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Unfortunately, scoliosis has to be treated in adolescence, which is already a very tricky and delicate phase in which youngsters often feel torn between wanting to be independent and wanting to fit in and belong.
We have all been through it and know how difficult this period of growing up can be. It’s not easy being the parent of an adolescent either. Sometimes we struggle to understand our children’s problems as they seem so far removed from our own. We might also struggle because we would like to be able to solve all their problems for them. This particular challenge, though, is one they need to overcome by themselves. What we, as adults, can do is be supportive, helping them to think things through and analyse situations, being careful never to minimise their problems or difficulties. 
For adolescents, it is very important to feel part of a group, and so anything that makes them feel “different” is scary. Years ago, youngsters worried about wearing braces on their teeth for this very reason, whereas nowadays so many have orthodontic treatment that no one bats an eye.   

Friendships are also important for teenagers, who will open up to one another, sharing their problems, feelings, insecurities and worries. True friends are the ones who support their brace-wearing peer (helping them to accept the device as a part of their daily life), and certainly not those who mock or tease another person for a health problem.

Also, as we all know, whenever we have what we consider to be a defect or flaw, we tend to see it as a far bigger problem than it really is. If, for example, we have a pimple on our face, however tiny, we become convinced that it’s the only thing everyone else notices about us!
In the same way, for some patients, a brace peeping out from under a t-shirt is an absolute disaster!
Compared with the braces of the past, today’s ones are made to be almost invisible under a vest or shirt. This is partly thanks to the orthopaedic technician’s skill and expertise and the specialist doctor who chooses the model. 

Over the years, we have seen that our patients can do seemingly impossible things with their brace on. Just take a look at the photos and videos published on our website, www.concorsetto.it, where you can find patients offering tips on how to conceal a brace under clothes, and others who do dance shows, go to the mountains or seaside, or do sport in their brace (even athletics, skiing and gymnastics).
Seeing other brace-wearing youngsters who have accepted the need to treat their condition and managed to deal with the situation in a positive way helps to normalise the whole experience!  Indeed, the key, basically, is to try and focus not on the inconvenience of a brace, but rather on the fact that spinal disorders have to be treated in order to prevent problems from arising in adulthood. It’s far better to pour your energies into fighting your scoliosis, rather than your brace. While you can’t change your brace, you can change your perception of it and how you approach it! In some cases, a patient might find it useful to talk to an expert, such as a psychologist, in order to overcome any difficulties in accepting the treatment.

Recently, one young patient even sent us a photo showing the rock band Måneskin wearing corsets, which are not so different, in the end, from braces! Who knows, this could be the start of a new trend!
The last thing to remember is to take things step by step. Start by telling just a few close friends that you have started wearing a brace. That way, later on, with their help perhaps, you should find it easier to talk about it with others. Also, give yourself time to get used to it, as it is a whole new thing for you. In this way, slowly but surely, you will soon find you are getting on OK with your initially unwelcome new “friend”!

Can leg length discrepancy cause or worsen scoliosis?

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Leg length discrepancy (LLD) is a common orthopaedic condition among children and adults, with a prevalence of 90% in the general population and 40% among athletes. LLD occurs when the lower limbs are of unequal length; the discrepancy is typically less than 10 mm and asymptomatic.
Individuals easily compensate for it through small adaptations of which they are very often unaware (such as bending or extending one leg more than the other). Some children are born with LLD; in other cases, the condition is acquired due to causes such as tumours, radiation, infections or injuries.

LLD can be classified as functional or structural depending on the aetiology, i.e., the underlying cause.

Functional LLD refers to an apparent asymmetry, in the absence of real shortening or elongation of the osseous components of the lower limb. It is typically a result of pelvic obliquity related to adaptive soft-tissue shortening, joint or muscle contractures, ligamentous laxity, or axial misalignment. As the pelvis rotates, the legs are pulled into apparent different lengths.

Structural LLD, on the other hand, is a primary disorder causing actual physical shortening or lengthening of a limb, with the osseous change occurring between the ilium and the foot. The causes of shortening are more common than those of lengthening, and they may be congenital or acquired: shortening is most often due to fractures along the physis (Salter-Harris fractures), which can stop bone growth and lead to LLD.

LLD can be associated with several musculoskeletal disorders, including scoliosis and resultant degenerative spinal changes. However, the degree of LLD required to cause such disorders is still debated. LLD has been shown to cause pelvic obliquity in the frontal plane. In order to maintain shoulder balance and compensate for the pelvic obliquity, the condition that most frequently occurs is lumbar scoliosis with convexity directed towards the shorter limb. Scoliosis caused by LLD is not true scoliosis.

Should scoliosis due to LLD be treated?

This type of scoliosis, termed functional scoliosis, is non-progressive and involves a structurally normal spine with an apparent lateral curvature: it is evident in the erect position, but reduced when the subject is seated, supine or prone. The greater the degree of LLD, the more apparent the functional scoliosis may be. 

This type of scoliosis regresses fully or partially when its cause (i.e., the LLD) is removed. 

A simple remedy is to use shoe lifts, which may be internal or external depending on the degree of LLD.

If, after clinical evaluation, the functional scoliosis is found to be reducible (in part or totally) with a shoe lift, this solution will also be useful for reducing the overloading of the spinal joints and for reducing the structural and disc changes that occur over the years in the presence of scoliosis due to LLD (particularly when the difference between the two limbs is greater than 9 mm), as various studies have shown.

In a patient with structural and functional (LDD-related) scoliosis, it is appropriate to carry out tests to evaluate the usefulness or otherwise of a shoe lift. A shoe lift does not treat true scoliosis and the decision on whether or not to use it is a complex and individual one that should be made by the specialist.

Applebaum A, Nessim A, Cho W. Overview and spinal implications of leg length discrepancy: narrative review.  Clin Orthop Surg. 2021;13(2):127-34.

Giles LG, Taylor JR. Lumbar spine structural changes associated with leg length inequality. Spine (Phila Pa 1976). 1982;7(2):159-62.

Adams MA, Hutton WC. The effect of posture on the role of the apophyseal joints in resisting intervertebral compressive forces. J Bone Joint Surg Br. 1980;62(3):358-62. 

Murray KJ, Azari MF. Leg length discrepancy and osteoarthritis in the knee, hip and lumbar spine. J Can Chiropr Assoc. 2015;59(3):226-37.

Are bracing and exercises really still the only way to “solve” the problem?

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This is a question many parents ask us when scoliosis is diagnosed. Perhaps their child has a particularly tricky curve, or maybe they themselves can remember dealing with the same condition when they were young. It is the same question we were recently asked by the mother of a five-year-old girl who, at this tender age, already has to reckon with a challenging treatment, “trapped” in a brace.

 Unfortunately, despite huge strides made in the formulation of less invasive and more effective braces (such as the Sforzesco type that we at ISICO, have long used as a valid substitute for plaster casts), bracing and specific exercises remain the only conservative treatments available for scoliosis.  

No parent wants their child to suffer the same negative experiences that they themselves remember, and it is perfectly understandable to be concerned about the possibility of them living the “nightmares” we did, and to want to protect them as far as possible. On the other hand, if this is something you have gone through yourself, you will actually be ideally placed to really understand all the difficulties your child is likely to face, and to help them find the best way to cope. It is not being complaining to ask whether other options exist and whether your child really does have to wear that uncomfortable piece of plastic — these are, after all, questions that any parent would ask.

 So, to return to the question, are there any other effective and less difficult treatments? Unfortunately, as explained in a recent study, manipulation and osteopathy, like all manual treatments, have not yet been shown to be effective (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9833903/).

Given the questions we so often get asked, we feel it is essential to properly explain the reason for certain aspects of the treatment, such as the need to ensure that brace-off hours are consecutive, the importance of performing specific exercises, and the duration and dosing of the treatment.

When deciding how long the treatment will last and how aggressive it needs to be in terms of the dose (i.e., number of brace-on hours per day), the factor we consider is the potential risk of the condition worsening. This risk is assessed based on the extent of the scoliotic curve and how much growing the patient still has to do (residual growth). Scoliosis worsens with growth, therefore the earlier it arises, the more likely it is to get worse, especially during growth spurts, when the youngster gains height rapidly (these usually happen at 6/7 years of age and in puberty).

Based on this information, the treatment can be adjusted, reducing or increasing the dosage according to the period of risk.

It also follows that the earlier scoliosis arises, the longer the treatment will need to be, given that bone growth has to be complete to reach a stable situation. Then there is the question of the “brace-on” hours. It has been demonstrated that after putting on a brace, it takes at least two hours for the spine to achieve the desired correction. 
This means that, when the brace is repeatedly taken off and put back on, we have to consider, and count, not only the brace-off hours, but also the hours needed for the spine to return to its correct position inside the brace. In the same way, every time the brace is removed the back tends to spring back to its starting condition (rather like a spring that has been pulled and then reverts to its original shape).

Then, the more frequently the brace is taken off to give the patient a break, the less effective the treatment will be compared with wearing it for the same number of hours but with fewer and longer breaks. For this reason, it is essential to try and establish and maintain a regular brace-wearing schedule.

We know that bracing treatment is very challenging and also that managing the brace-off hours can be difficult, especially during the summer. For this reason, we advise families, as far as possible, to choose somewhere cooler for their holidays, and also to talk to their specialist to see whether, on some days during the summer, the brace-on hours can be reduced or the brace-off time can be split into two blocks. Obviously, these decisions have to be taken on a case-by-case basis.

As for the specific exercises for scoliosis, these are designed to help support the back when the brace is not being worn, and also to prevent loss of muscle tone (otherwise an inevitable consequence of bracing). In the case of very young children (like the little girl whose mother prompted us to write this post), we recommend lots of sport to keep the muscles in shape, because children aged 4 to 6 years often don’t yet have the concentration necessary to be able to cope with exercise sessions.

Finally, in answer to the question, yes, at present, bracing and exercises are the only conservative therapy options that have been shown to work. This kind of treatment is certainly difficult and demanding, but we have to remember that it aims to help our children reach adulthood with healthy backs, and fortunately, we do at least have these “instruments” to offer them. 

ISPRM 2023: keynote lecture by Stefano Negrini

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Isico will also be present at the ISPRM Congress in Cartagena, Colombia, from June 4th to 8th. The motto of the international conference will be “New perspectives in Physical Medicine and Rehabilitation for global health challenges” thus representing the intention of focusing on the current and future rehabilitation health needs of people around the world.

Prof. Stefano Negrini, scientific director of Isico, will give one of the 8 keynote lectures in the Plenary session on New Perspectives on Evidence in Rehabilitation: from history to future. “The lecture will report on all Cochrane Rehabilitation contributions during these years, how they changed our understanding of evidence in rehabilitation and offer a way to reduce the burden of evidence on our shoulders – explains prof. Stefano Negrini – We will also look at the future, starting from the evidence-production ecosystem we will develop during the 5th Cochrane Rehabilitation Methodology Meeting in the next few months.”

Please visit the site for more info or to register for the event: https://isprm2023.org

Prof. Stefano Negrini at the World Health Assembly as Cochrane representative

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From May 23 to 26, Stefano Negrini, scientific director of Isico, participated as a Cochrane representative in an event of the World Health Assembly, the main decision-making body of WHO. The event is co-organised by missions to WHO from five countries and several scientific, professional, and patient organisations in the field of rehabilitation.

The theme of this year’s Health Assembly was WHO at 75: Saving lives, driving health for all.

On May 25, the event “Strengthening Rehabilitation in Health Systems: What’s at Stake?” took place on the sidelines of the World Health Assembly to discuss advances and challenges in integrating rehabilitation into health systems.

After the approval of the resolution on rehabilitation by the General Assembly of all Ministers of Health in the world, Prof. Negrini was one of the speakers at the workshop organised by the World Rehabilitation Alliance, in which Negrini represents Cochrane, a global independent network of researchers, professionals, patients, carers, and people interested in health.

“It is the first time that there is a resolution on rehabilitation by the World Health Assembly – comments Prof. Negrini – Rehabilitation is an essential component of universal health coverage. The lack of access to rehabilitation may expose persons with rehabilitation needs to higher risks of marginalisation in society, poverty, vulnerability, complications and comorbidities, and impact on functioning, participation and inclusion in society. The negative impact on people’s lives also causes an important economic burden on societies””.

SOSORT Award: Isico is back on the podium!

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And once again, the winner is… Isico! For the fifth consecutive year, our institute has been awarded the prestigious SOSORT Award, recognising our innovative and cutting-edge research focused on Artificial Intelligence in the rehabilitation treatment of the spine. The winning research, titled “Developing a new tool for scoliosis screening in a tertiary specialist setting using artificial intelligence: a retrospective study on 10,813 patients,” was one of the eight Isico studies presented at the Sosort conference held in Melbourne, Australia, a few weeks ago.

This prize shows the quality of research conducted at Isico, combining scientific evidence with daily clinical practise to enhance rehabilitation treatment for patients worldwide. Dr. Francesco Negrini, a physiatrist and author of the study, explains the motivation behind the research: “We sought to explore ways to reduce the need for radiographs while ensuring accurate and timely scoliosis screening. Through collaboration with engineers in Zurich, we employed advanced analysis methods using artificial intelligence to develop a model that accurately identifies cases warranting X-rays.”

This international collaboration enabled Isico to harness innovative technologies and present research able to achieve this prestigious recognition. Dr. Negrini further emphasises the significance of the prize, stating, “I am immensely satisfied with this achievement. It reaffirms the validity and excellence of Isico’s scientific dedication, paving the way for a reduction in the number of X-rays prescribed to patients while maintaining optimal care.”

https://en.isico.it/isico/ricerca/pdf/ID00665.pdf

Dr. Sabrina Donzelli, the next president, tells us about the SOSORT conference

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Once again, the international SOSORT conference was one of the most important appointments for our institute (eight abstracts were presented), and with a cherry on top, the fifth SOSORT Award was won!
We asked Dr Sabrina Donzelli, physiatrist and president of SOSORT in 2024, the first woman to hold this position, to tell us something more about the event, given that she was one of the three Isico specialists present in Melbourne (the others were Dr Fabio Zaina and our director of physiotherapy, Michele Romano).

1) What did participating in this event mean to you?
For the first time, SOSORT participated in Spineweek. Spineweek is an event that occurs every four years and brings together many societies dedicated to various aspects of the spine. This event allows participants to follow different companies by participating in a single event. It provides the other companies involved greater visibility or the possibility of being known and attracting new members.
The event was a success for SOSORT thanks to the number of participants and presentations. SOSORT is growing, and this experience was another opportunity for growth for the company, which is preparing to organize its first annual congress with total autonomy.

2) What were the major scientific innovations?
Dr Angelo Aulisa presented a remarkable study on the efficacy of braces in patients with Scheuermann with a 10-year follow-up. It is the first study to explore this area with such an extended follow-up.
Comparison studies are starting to emerge, for example, between braces at different dosages or nighttime bracing compared with exercises only; unfortunately, the quality of these studies is limited, and the results still need to be evaluated with caution.
We are also witnessing an increasing collaboration between surgery and rehabilitation treatment in a great communication effort to learn how to manage better patients who have surgical indications and those who would like a surgical approach but could benefit from conservative treatment. The president of the SRS (Scoliosis Research Society), Dr Serena Hu, showed the innovations in the surgical field; indeed, there are still many challenges to reducing invasiveness with the same effectiveness.

3) The SRS also has a female president for the first time, and your successor in the SOSORT presidency is the Croatian doctor Suncica Bulat Wuerching. There are more and more women, so how are you experiencing this moment of transition to your presidency?
We women play a fundamental role in the scientific world, like our colleagues, and this can only fill me with satisfaction for the work we carry out with great determination and professionalism. In terms of my position, it will be a great responsibility to lead the company through this transition. Still, I am delighted to work with a fantastic team of professionals, starting with the current president, James Wynne.

Scoliosis screening: the ISICO study on artificial intelligence in the running for the SOSORT Award

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Developing a new tool for scoliosis screening in a tertiary specialist setting using artificial intelligence: a retrospective study on 10,813 patients is one of the ISICO studies due to be presented at the next SOSORT conference, which will take place in Melbourne, Australia. The fact that the study is also a candidate for the SOSORT Award consolidates the standing of ISICO, which in recent years has not only participated with its research but also been awarded this prestigious prize on several occasions. 

In recent years, we have seen an increasing body of evidence supporting the efficacy of conservative treatment (e.g., exercises, soft and rigid braces) for adolescent idiopathic scoliosis (AIS), because treating a skeletally immature spine conservatively is certainly more effective and gives better results. The use of the conservative approach, however, has to be based on accurate and sensitive early screening for the condition, which often involves the use of X-rays.

What can be done to continue screening patients while at the same time making less use of X-rays? “Although technological improvements have, in recent years, made it possible to reduce the radiation dose in radiographic examinations, it is not possible to completely eliminate the long-term risk of cancer due to the stochastic effect of even low doses of radiation,” explains Dr Francesco Negrini, ISICO physiatrist and author of the research. “This is why we set out to analyse whether adding other rapid and reliable clinical parameters to the angle of trunk rotation (ATR°) might improve scoliosis screening in terms of sensitivity and specificity, making it possible to limit the use of X-rays to cases in which it is indispensable.”

How was the research conducted? The researchers looked at 10,813 patients between the ages of 4 and 18 who underwent clinical and radiological evaluation for scoliosis at a tertiary clinic specialising in spinal deformities. After excluding patients who wore a brace, had secondary scoliosis, or had no hump, 7,378 cases remained and were included in the analysis. In these cases, the following information was collected: ATR°, hump (mm), visible asymmetry of the waist, scapulae and shoulders, family history, sex, BMI, age, menarche (yes/no), and location of the curve. “At this point, we applied advanced analysis methods involving the use of artificial intelligence to try and create a model that would allow us to accurately select the cases needing to be X-rayed,” Dr Negrini goes on, “and we identified ATR°, hump (mm) and visible waist asymmetry as the clinical parameters best able to accurately classify Cobb angle measurements.”

On the basis of this conclusion, the researchers were able to affirm that classification models obtained through artificial intelligence may effectively improve non-invasive screening for AIS, thereby making it possible to reduce the X-ray exposure of healthy young individuals. “On the basis of the positive results obtained in the study, we may, in the near future, be able to develop a very flexible and user-friendly tool” says Dr Negrini. “This would allow doctors working in this specialised field to decide to prescribe radiographic imaging only when it is strictly necessary.”

https://en.isico.it/isico/ricerca/pdf/ID00665.pdf

Isico: our first 20 years

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2003-2023: 20 years of activity, two decades of steady growth, from a small clinic in Milan staffed by a handful of specialists to our current network of centres in 37 cities and a team of 101 medical/health professionals and administrative staff. Over the past 20 years, we have looked after over 51,000 patients and created a Clinical and Scientific Institute, recording a number of achievements. We have set up and established a national congress and an ISICO Master course, offered both nationally and internationally, that now runs into several editions; replaced plaster casting with the “Sforzesco” brace, widely shown to be effective; created a blog and a customised app for patients as well as Scoliosis Manager, a software package for specialists; diffused our exercise-based approach to scoliosis (SEAS)  through hundreds of courses worldwide; and launched a telemedicine service to support patients during the difficult months of the pandemic. A series of “stories” that, together, add up to an “incredible” two decades.

“These are results that we ourselves find rather remarkable, looking back,” says the director of Isico, Alberto Negrini. “They leave us feeling hugely proud and also grateful to the patients who have entrusted us with their care. We started out with a precise objective, which was also our mission for the first 10 years: to promote, in Italy, a scientific evidence-based approach to the conservative treatment of vertebral disorders. Building on the experience of the Scoliosis Centre in Vigevano, which has been active in the field since the 1960s, we built a working group able to export our approach and treatment model.

This mission allowed us to clearly define our purpose — the rehabilitation of vertebral pathologies —, our method — an approach based on treatments validated in the scientific literature —, and our geographical horizons — the whole of Italy. Into all this, we weaved some fundamental elements, such as a humane and person-centred approach, the formation of therapeutic teams, and continuous staff training.

On the clinical side, it was immediately clear that our work should be built around two main areas: vertebral deformities (scoliosis, kyphosis, etc.) and pain (particularly low back pain, and neck pain).

From the very early years, we found that the real demand on the ground was in the first of these areas: patients with vertebral deformities were clearly struggling to find valid and effective answers. Consequently, this area of our activity grew far more quickly than the other, to the point that it now accounts for 85% of all the clinical work we do.

Our scientific approach led us to start continuously monitoring developments in the scientific literature, something we do in constant collaboration with the Gruppo di Studio della Scoliosi e delle patologie vertebrali (GSS) — scoliosis and spinal disorders study group, and forerunner of ISICO, which was set up in 1978 —, but also to play an active part on the global scientific stage, thus entering a world in which, when we started out, little was known or said about the non-surgical treatment of spinal deformities. This was the start of our extensive scientific activity, which quickly earned recognition abroad and has led to the publication of numerous works (over 230 to date), most with immediate clinical applicability. Another important aspect is the support we lent to the creation of what was about to become the sector’s international scientific society of reference (SOSORT), which, with the help of our specialists, was founded in Milan during the 2005 international congress organised by ISICO at the Palazzo delle Stelline.

And so on to our aim to cover the whole of Italy. This was a highly ambitious target, which led us to adopt, from the outset, an organisational model that, based on an information system developed internally, was designed to allow us to grow beyond our initial (few) clinics,” Alberto Negrini explains. “These investments of time and resources left us in considerable difficulty in the first years, when our economic performance was very poor, but they also sustained our growth once the work done at the start began to bear fruit, allowing us to launch an expansion that has been constant, with the result that we are now present in 37 cities and 16 regions.

Indeed, 10 years in, when the goal that had initially seemed so ambitious was gradually being reached, our horizons expanded. Thanks to the growth of SOSORT, our participation in European research projects, and the growing demand for training from other countries, the international side of our activity took on an increasingly important role. Hundreds of patients from abroad have come to be treated in our clinics, and we have trained thousands of health professionals abroad through courses including our ISICO Master course.

Looking back, we can certainly say that this has been a success story, and I would say that the key to this success lies, more than anything, in the people that have worked at ISICO over these past 20 years, building and guaranteeing its reputation” Negrini says. “Thanks to their approach, which is both caring and professional, patients trust us and believe in us, which translates into very high approval ratings and has a positive “word of mouth” effect. At the same time, the rigorous way in which we work and record data has given us credibility in the eyes of other professionals. And our name has spread both in Italy and abroad, though numerous visits to and internships at our clinics, and also through our published scientific work.” 

What do the next 20 years hold for ISICO? “Starting from where we are today, and bearing in mind that, as the pandemic has taught us, you never know what might be just around the corner, there are two things we have in mind,” Negrini concludes. “On the one hand, to go on expanding in Italy by developing spaces that will allow us to diversify what we do, and on the other, to keep expanding our activities abroad, through research projects and new opportunities for collaboration. Another 20 years in which we will go on always striving to offer patients the best possible care, based on scientific evidence but also on medical and human experience, because the therapeutic team must always focus on the whole person.”

SOSORT Melbourne: 8 Isico abstracts

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There are 8 abstracts, which will be presented by Isico at the annual Sosort international conference, held from May 1–5 in Melbourne, Australia.

Once again, Isico will be in the front row at the International SOSORT meeting, and one of the abstracts, entitled “Developing a new tool for scoliosis screening in a tertiary specialist setting using artificial intelligence: a retrospective study on 10,813 patients,” is also competing for this edition of the Sosort Award, which, as we recall, Isico won for several consecutive years. 
The other abstracts that will be presented by our expert physiatrists, Dr Sabrina Donzelli, and Dr Fabio Zaina, and by Michele Romano, Director of Physiotherapy at Isico, are:
– Adherence to physiotherapeutic scoliosis-specific exercises during adolescence: voices from patients and their families: a qualitative content analysis;
– Bracing interventions can help adolescents with idiopathic scoliosis with surgical indications:
– A systematic review; SOSORT Guidelines for scoliosis conservative treatment: an update
– It is worth treating an adolescent with idiopathic scoliosis when bone maturity has passed US Risser 2: Bracing can improve curves and aesthetics
– Outcome measures in scoliosis treatment: Is the Cobb angle enough?
– The apex vertebrae of the scoliotic curves; a study of their frequency in 11758 cases
– Evaluation of thoracic flexibility in the sagittal plane with the Thoracic Stiffness Test: intra- and inter-operator reliability

Therefore, a reconfirmation for Isico with full marks among the best researchers in the world in the rehabilitation treatment of spinal pathologies.