Should we go for the straight back goal?

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Paola has scoliosis: her back is twisted on itself. Therefore, she has been given a brace to wear — a nice plastic “jacket” that she is actually going to have to wear for some years to come. But why? Well, to straighten her back, of course!

This, of course, is the logical answer, but unfortunately logic and medicine don’t always go hand in hand.

Many people also think, again quite logically, that surgery can eliminate the problem of scoliosis, but the reality is that surgery simply fixes a section of the spine with screws and bolts, blocking the curve in order to stop it from worsening. And even in those instances when the surgeon manages to almost straighten the patient’s back, we have to ask ourselves whether a surgically treated scoliotic spine can ever possibly be the same as before? 

The answer is that, obviously, it can’t – the fixation devices (screws and bolts) used to arrest the progression of the curve are constraints that will prevent single segments of the spine from moving.

In reality, many, if not all, treatments used in medicine don’t solve, erase or even fix the problem they are addressing. Therapy gives us the instruments we need to manage, as well as possible, our condition and all the problems it brings.

Take diabetes, for example. You have diabetes? No problem, just take a drug before each meal: it will control your blood sugar level. What it won’t do, however, is get rid of your diabetes.

The same goes for scoliosis. Scoliosis can’t be erased; it can’t be eliminated. If you have it, the first thing you have to do is accept that you have a totally manageable health problem. Then you simply have to roll up your sleeves and get on with the business of “taming” it. Try thinking of it like a wild horse, but one that we can certainly tame and keep under control. Just don’t expect to able to transform it into a fluffy little pet — it will always retain some of its wild spirit!

Receiving a diagnosis is always a difficult moment: it doesn’t matter what disease you are being told you have. Therefore, accepting the presence of an imperfection is hard, both for patients and for their parents.

Sometimes it seems easier to pretend that the problem is not there, and with scoliosis it is certainly easy to do this: first of all, being “behind us”, it is harder to see. Also, at the outset it is not particularly noticeable, or may even be almost invisible externally. Unfortunately, however, scoliosis, is sneaky and very insidious, and sooner or later it forces us to face reality. That’s when we find ourselves, once again, weighing up the treatment options. There will always be more than one treatment option, but as time goes by the possible outcomes change, and therefore so, too, do the objectives of the treatment!

The ultimate objective in scoliosis treatment is to ensure that the patient has a healthy and functional back by the time they have  finished growing, and that does not mean a straight back! A healthy back is one capable of withstanding the stresses and strains of daily life for the 70 or so years that we can, on average, expect to live once we have finished growing. It is also a back that will do its job without giving us pain, and without, over time, developing a major worsening of the curves.

Science has taught us that this objective is realistic, providing the curves are still under 30°-35° at the end of growth, which is hardly straight!

In pursuit of this ultimate objective, strongly supported by the SOSORT guidelines, medical prescriptions can differ between patients, even ones whose situation is apparently similar.

In some families, there will be more than one sibling affected by scoliosis, and even though these youngsters have the same disorder, its morphology may well vary. For example, one might have a dorsal curve and another a lumbar one. Similarly, the severity of the curves can differ: you might find one girl who can be treated with exercises alone, while her older sister has to wear a brace full time.

In these situations, misunderstandings can often arise! Let’s take an example.

Laura has scoliosis, an approximately 30° curve that was discovered when she was 14 years old. After examining her, the physician prescribed a rigid brace, to be worn 23 hours out of 24. By the end of the treatment her curves had improved considerably, her trunk was perfectly modelled and symmetrical, and her scoliotic curve had decreased to under 20°!

Laura has a sister, four years younger. From the time of Laura’s first examination, the physician caring for her began monitoring her sister, too. When she was 11 years old, the younger sister began treatment involving exercises alone. By the time she finished growing, however, her curve measured between 25 and 30 degrees!

At the end of the treatment, the mother was disappointed and worried about the younger according to the physicians’ instructions, for years bringing both daughters along for examinations and exercise sessions, only to end up with one daughter with worse curves than her sister.

In these situations, comparisons are inevitably made and the straight back misunderstanding arises! Nowadays braces aren’t as alarming as they once were and patients, providing they are properly informed, might well be tempted to think, why not wear one anyway, if it means I will end up with a good level of correction? 

Because the fact is that someone whose back is slightly curved (under 30º) at the end of growth will enjoy the same level of function and the same quality of life as a person whose back is straight. That’s why, as patients start out on their long and tiring therapeutic journey, we urge them to remember the motto: “let’s focus on function and not straightening up!”

Scoliosis and back pain: physical activity is the best prevention

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In the world’s richest countries, low back pain is so common that it has become one of the leading causes of disability and healthcare expenditure. Back pain in children should be taken seriously as it can reduce the amount of physical exercise they get, result in absences from school, and limit them in their everyday activities.

These brief opening remarks prompt a series of questions that our physiotherapist, Martina Poggio, here tries to answer in the light of the latest published data regarding a possible link with adolescent scoliosis.

How prevalent is low back pain in children and adolescents? 

In recent decades, a high prevalence (39.9%) of low back pain has been found in children and adolescents: one study found back pain to be associated with age (>12 years), a family history of the condition, spending more than two hours a day studying or watching TV, having an uncomfortable desk at school, suffering from generalised pain, and sleep problems. Evidence on the impact of heavy backpacks is conflicting.2

How common is idiopathic scoliosis among adolescents with back pain? 

Aetiologically speaking (in other words, when examining the possible causes of the condition), one retrospective study, conducted in almost 2000 patients under the age of 21 years, found the following underlying conditions: scoliosis, followed by Scheuermann’s disease and spondylolisthesis.1 However, since the role of spinal deformities in back pain is unclear, we reviewed recent literature on the association between pain and the most common adolescent spinal deformity, i.e., idiopathic scoliosis, which affects 1 to 3% of adolescents. Although idiopathic scoliosis was considered painless condition until a few decades ago, more recently patients seem to show a higher prevalence of back pain. What is not clear, however, is whether there is a marked association between this symptom and the spinal deformity. In studies specifically exploring its prevalence in adolescents with scoliosis, the rates range considerably: from 23% to 85%.

Does the severity of the curve correlate with pain intensity? 

One of main reasons for scepticism over a possible association between pain and scoliosis is the current debate in the literature on the link between the severity of the deformity and the intensity of the pain, and the association, more convincing, between pain and psychological factors (such as self-image and mental health status). Indeed, some patients with less pronounced curves showed more intense pain and vice versa, suggesting that spinal morphology is not the only factor at play.4

Some evidence from the literature suggests that the association between pain and scoliosis is not strongly linked to a biomechanical problem. Indeed, in most studies, pain did not correlate strongly with the magnitude of the curve (Cobb angle); untreated cases did reasonably well from a back pain perspective; epidemiological data revealed a much greater gender difference in scoliosis as opposed to back pain incidence; and patients’ self-image was found to be related to their pain. All these findings argue against a strong aetiological role of idiopathic scoliotic deformity in adolescent back pain.1 

Does back pain in adolescents with idiopathic scoliosis predispose them to pain in adulthood? What factors predispose adolescents with scoliosis to developing back pain?

In adolescents, early onset and persistence of back pain appear to be predictors of future back pain. A retrospective study showed that patients with thoracic scoliosis noted in their medical records were four times more likely to experience thoracic pain than those with no thoracic curve.5 Patients with scoliosis and back pain, compared with asymptomatic scoliosis patients, showed poorer physical function and sleep problems. Given that back pain has multiple causes, it is necessary to take into account depression, anxiety, catastrophising (i.e., having an exaggeratedly negative mindset towards actual or anticipated pain), and level of physical activity: all these factors can influence the perception and perpetuation of pain. 4,5 

In conclusion

“What recent studies show is that it is crucial to evaluated the youngster’s overall health in order to correctly evaluate back pain or possible risk factors,” explains Martina Poggio. “That means not just performing a physical assessment and encouraging the patient to get regular physical exercise, but also a psychological one, evaluating their self-perception and looking for anxiety, depression and drowsiness. These factors, although they may seem secondary in a case of scoliosis, could predispose the individual to the onset of back pain. Finally, it’s important to remind youngsters and their families that current data show no clear correlation between the deformity and pain, only that some people are more predisposed to pain”.

  1. “Prevalence of low back pain in adolescents with idiopathic scoliosis: a systematic review” Jean Théroux, Norman Stomski, Christopher J. Hodgetts, Ariane Ballard, Christelle Khadra, Sylvie Le May  and Hubert Labelle Chiropractic & Manual Therapies (2017)
  2. “Adolescent idiopathic scoliosis and back pain” Federico Balagué and Ferran Pellisé Scoliosis and Spinal Disorders (2016)
  3. “Back Pain in Children and Adolescents” Suraj Achar, Jarrod Yamanaka. Am Fam Physician (2020).
  4. “Back pain in adolescents with idiopathic scoliosis: the contribution of morphological and psychological factors” Alisson R. Teles, · Maxime St‐Georges, · Fahad Abduljabbar, · Leonardo Simões, · Fan Jiang, Neil Saran, · Jean A. Ouellet, · Catherine E. Ferland. European Spine Journal (2020)
  5. “How Common Is Back Pain and What Biopsychosocial Factors Are Associated With Back Pain in Patients With Adolescent Idiopathic Scoliosis?” Arnold Y. L. Wong , MPhil, Dino Samartzis , Prudence W. H. Cheung, Jason Pui Yin Cheung  Clin Orthop Relat Res (2019)
  6. “Prevalence of low back pain in adolescents with idiopathic scoliosis: a systematic review” Jean Théroux, Norman Stomski, Christopher J. Hodgetts, Ariane Ballard, Christelle Khadra, Sylvie Le May and Hubert Labelle. Chiropractic & Manual Therapies (2017)
  7. “Adolescent idiopathic scoliosis and back pain” Federico Balagué and Ferran Pellisé. Scoliosis and Spinal Disorders (2016)
  8. “Back pain in children and adolescents” Suraj Achar, Jarrod Yamanaka. American Family Physician (2020)
  9. “Back pain in adolescents with idiopathic scoliosis: the contribution of morphological and psychological factors” Alisson R. Teles, Maxime St‐Georges, Fahad Abduljabbar, Leonardo Simões, Fan Jiang, Neil Saran, Jean A. Ouellet, Catherine E. Ferland. European Spine Journal (2020)
  10. “How Common Is Back Pain and What Biopsychosocial Factors Are Associated With Back Pain in Patients With Adolescent Idiopathic Scoliosis?” Arnold Y. L. Wong, Dino Samartzis, Prudence W. H. Cheung, Jason Pui Yin Cheung. Clinical Orthopaedics and Related Research (2019)

SEAS: a year of enthusiastic recovery, ready for 2023!

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2022 was a year of exciting recovery for our international training courses after the pause due to the pandemic. It was not easy to start walking again with still so many unknowns, but the requests and the desire to be able to offer opportunities to learn about our approach to scoliosis with exercises (SEAS) were the march that prompted us to organize thirty courses around the world with hundreds of participants.
From Turkey to Brazil, from the United States to Israel, and from Serbia to Egypt to Hungary, we have organized 23 SEAS Level I courses for 450 participants and 6 SEAS Level II courses for 119 participants.
Many enthusiastic comments and experiences gathered worldwide: “The course was AMAZING!!! I really appreciate the structure and flow. SEAS has made a very complicated spinal dysfunction easier to understand. All the research really validates how we should treat our patients. I am so grateful for the generosity in sharing your knowledge with the rest of the world. Alessandra is a master instructor and I would be honoured to take another one of her classes!!!!!” and again, “WOW!! Can’t say enough good things about the class and instructor!! I learned so much new important information and techniques in the few days of this course even though I have prior training with PSSE and several years of experience with it. I am already putting this to work with my patients (and myself who also has scoliosis) on return from the course and seeing fantastic results“. And also “This information will be such a tremendous addition to my clinical practice! I have several teens who will be so relieved to have their programs modified to incorporate these accessible and simple SEAS exercises”.

SEAS doesn’t stop, though! In January, we start again with Brazil and the United States, from January 13 to 15, respectively in Porto Alegre and Austin, Texas.

Reliability of rasterstereography as an alternative to X-rays in the diagnosis of scoliosis and its monitoring over time

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To date, scoliosis continues to be diagnosed through clinical evaluation and confirmation by radiological examination. Monitoring its progression often entails frequent radiological assessments, which carry risks associated with radiological exposure, especially in growing patients.

Even though a low-dose radiation radiological investigation (using the EOS Imaging System, also offered to our patients) has recently been developed, it would still be an advantage to have at our disposal radiation-free methods for monitoring scoliosis and its progression.

“Numerous systems that explore the topography of the posterior surface of the trunk (i.e., surface topography, ST) have been developed as alternatives to normal radiography, with the aim of reducing patient exposure to ionising radiation. And these systems can accurately reproduce the Cobb angle” explains ISICO physiatrist Carmelo Pulici. “One of them, Formetric rasterstereography, which involves surface detection and rasterstereography, has become an increasingly widespread radiation-free option in evaluating vertebral deformity. Thanks to structured light, this technique allows us to recreate an approximate 3D image of the spine’s shape”.

How does it work? The rasterographic projects parallel lines of white light onto the patient’s back.
The three- dimensional shape of the spine distorts these lines, producing a curved light pattern which is captured by a camera. A three-dimensional model of the back and spine is then constructed. ST “photographs” patients in their normal and habitual postures, avoiding some of the unnatural postural changes induced when they are positioned in front of an X-ray machine.
Unfortunately, however, research has failed to show a reliable correlation of diagnostic measurements between radiography (Cobb angle) and ST (1; 2).

“Cobb angle measurement is still the basis for the clinical treatment of scoliosis, and ST has not been shown to be an effective diagnostic substitute for traditional radiography”, Dr Pulici continues. “Specifically, recent studies have shown that ST does not meet the accuracy thresholds it needs to reach in order to be a useful primary diagnostic tool (it shows moderate accuracy) or a valid means of monitoring the progression of the curve (in this case its accuracy is low)”.

It is even less reliable in bracing therapy, where trunk remodelling means no longer a correspondence between what is observed from the outside and what is happening in the body.

Conversely, rasterstereography has demonstrated greater reliability in the measurement and monitoring, over time, of changes in the sagittal curves of the spine (lordosis and kyphosis). “We should also add that, as some research suggests, ST could be considered for use in early scoliosis screening of large populations (e.g., in schools)” Pulici says. In fact, it has been shown to be able to detect the presence of spinal deformity (but it is not accurate enough to quantify this) (2).

Is rasterstereography a valid noninvasive method for the screening of juvenile and adolescent idiopathic scoliosis?  DOI: 10.1007/s00586-018-05876-0

First night in a brace? Stick with it! 

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For some young scoliosis patients, there is a particular watershed they have to face, one of those moments that separate the ‘before’ from the ‘after’. I am talking about the start of bracing therapy.
It isn’t always easy to get used to a brace, and difficult as it may seem wearing it during the day, that is nothing compared with what it is like trying to wear it at night.
When a patient goes to bed in a brace for the first time, it feels like there’s an unwelcome extra person in the bed with whom they are forced to share their mattress (whose softness and comfort they had never really appreciated, until now!).
The first night will be the hardest and the longest, but providing the patient manages to put up with the brace and resist the temptation to take it off, the second night will be easier, not least because they will be ready to catch up on the previous night’s missed sleep. After that, they will stop noticing the brace.
To begin with it’s quite normal to spend the night tossing and turning, trying to lie on your front, then your back, then on one side and then the other, before starting round again. The first minutes will drag and feel like hours and sleep will seem completely out of reach. 

On top of these initial difficulties, the unluckiest patients, meaning those who start their treatment in the summer, will also have to deal with heat and sweatiness, but these problems are not insurmountable.
Obviously, if the new brace wearer is going to have a sleepless night, it is only fair that the rest of the family endure one too! And if there seems to be absolutely no way to get some rest, it might be an idea to spend some time chatting or playing together to pass the time. If, in the dead of night, the patient still hasn’t managed to fall asleep, the temptation to take off the brace and fling it aside will be great, but they must stick with it, because at a certain point, the position that currently feels impossibly uncomfortable will gradually start to feel more sustainable. And, eventually, sleep will come, finally showing the patient the best position, for them, in which to sleep.

Adult Scoliosis: look after yourself!

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Adults with scoliosis are often convinced there is nothing more that can be done for their problem, partly because it has long been thought that scoliosis, in any case, doesn’t get any worse once you have finished growing. Unfortunately, now it has been shown not to be the case. We at ISICO, as well as monitoring patients through periodic checks, know that there is treatment available that may improve these patients’ conditions.

We frequently tell our patients that they will only be able to effectively manage their back and their scoliosis if they have a clear understanding of their condition and how to address it, which means: keeping fit, regularly doing appropriate exercises, and implementing strategies to avoid overstraining their back in everyday life. 

“Scoliosis in adults, treated or otherwise, may be one of three types: scoliosis that was discovered in adolescence, scoliosis that came to light in adulthood, and so-called de novo scoliosis. This latter form, typically seen in old age, is associated with often significant clinical symptoms, says our orthopaedic specialist, Dr Monia Lusini. For adolescent-onset scoliosis (which may have been discovered either in adolescence or in adulthood), the severity threshold beyond which the condition may worsen in adulthood is 30°, while curves greater than 50° are obviously much more likely to go on evolving, so much so that 50° is considered the cut-off point for surgery. Scoliosis worsens much more gradually in adulthood (by around 0.5-1 degree per year on average) often leading to the lateral and forward bending of the trunk typically seen in old age. The severity of de novo scoliosis, on the other hand, is generally mild to moderate, with the curve not normally exceeding the 30° threshold; nevertheless, this form can be associated with quite marked clinical symptoms.”

According to the data we have, mild curves (measuring less than 30°) are generally stable, whereas more severe scoliosis needs to be monitored, as a precautionary measure, through regular checks every 1-5 years.

And what happens if these checks show that the condition is worsening? “In that case, it may be useful to have a specific exercise programme drawn up by experienced and expert professionals in order to keep the situation stable” replies ISICO physiotherapist Alessandra Negrini. “Scoliosis is associated with several problems: a risk of back pain, aesthetic issues, progressive deformity, and problems with the internal organs (these are usually significant only in patients with curves greater than 70° and those with childhood-onset scoliosis)”.

This is why we at ISICO encourage our patients to do as much physical activity as they can, and to work out with their physiotherapist, a programme of specific exercises designed to strengthen the muscles that support the spine and combat the pain.

It has been scientifically proven (in two studies published by our group: Adult scoliosis can be reduced through specific SEAS exercises: a case report and Scoliosis-Specific exercises can reduce the progression of severe curves in adult idiopathic scoliosis exercises: a long-term cohort study) that appropriate and specific exercises tend to slow down or arrest the evolution of scoliosis.

Alongside physiotherapy, we at ISICO are currently trying out, in patients with scoliosis pain and ascertained progression of the condition, an elastic brace called Spinecor: when patients feel their back “giving way”, this device, even though it cannot be expected to lead to an improvement visible on X-rays, provides extra external support and can give them a few hours relief.

Two Isico patients among the final selection for Miss Italia

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We present two young women who hope to be chosen in the next Miss Italia contest finals as “the fairest of them all”. Lavinia and Cecilia, as well as being beautiful girls who have reached the final of Miss Italia, also have another thing in common: both have had to overcome many hurdles from a very young age, when they were diagnosed with curvature of the spine at our centre and had to embark on a lengthy course of bracing treatment. Looking at their smiling faces today, it is hard to imagine the struggle of those long years spent “braced up” and the determination they had to show in order to get where they are now. 

We spoke to both girls just after they won their place in the final. We were keen to know how Miss Lazio (Lavinia) and Miss Umbria (Cecilia) felt. 

Cecilia, 22, wore a brace for nine years, while Lavinia, 18, is still undergoing treatment that began five years ago when she was diagnosed with a 53° scoliosis curve. This has since been reduced to 35°. 

For both of them, their treatment, from the outset, involved wearing a brace for most of the day: “I had just turned 12 when it all began” Cecilia recalls. “I found it really hard to accept that I would have to spend years encased in plastic. Daily life was a real struggle and I well remember how upset I got every day, because I felt so awkward and stiff inside that kind of case. I remember the tight belts and the sound of the Velcro being pulled open when I took the brace off. I remember the sore patches and how anxious I was that I wouldn’t be loved or accepted in my new “shell” and wouldn’t receive all the attention, affection and hugs I had before. And yet, if it weren’t for my brace and all the self-correction exercises I did, I wouldn’t be the girl I am today”.

As for Lavinia, she turned to us in the hope of being able to avoid surgery for her scoliosis: “Of all the spine centres I consulted, Isico was the only one willing to try bracing treatment, despite the severity of my curve. I have to admit that those were difficult years for me, but I never stopped doing the things I love, like dancing, singing and going out with friends. Thanks to Isico and also to my own determination, I have made a considerable improvement. My curve has been reduced by almost 20°, and even though I don’t have a perfectly straight back, I have learned to love and accept my body the way it is.” 

Both girls firmly believe nothing can stop you from doing what you want and dream of doing. Obviously, you have to show loads of determination and perseverance, the two qualities that have enabled them to win places in the final of Miss Italia and, above all, get through years of treatment, during which they learned to treat their brace as that “friend” you love to hate, who has been by their side throughout their journey and helped them to become stronger people. “There will always be times when you don’t like yourself, with or without your brace, and if you happen to come across someone who doesn’t accept you because of it, you need to remember that it certainly isn’t your fault” Lavinia goes on. “This competition has shown me beyond doubt that my back hasn’t affected my appearance, and that it has actually made me more self-confident!”.

Because, in the end, a brace is also an ally. Both girls stress that “if you are patient, you will get results” and that a limitation, in this case in the form of a tricky condition like scoliosis, can turn out to be an unexpected opportunity: “We must all learn to love ourselves, have the courage to rise to the challenge, and fight prejudice without letting go of our dreams” Cecilia says. “I would like to be a voice encouraging acceptance of our limitations, because in an inclusive world we need to show ourselves the way we are and draw attention to the sacrifices that have made us strong. It is like we are all on a river in full flow and our brace is the boat that can help us make it to the open sea, where new lands and new horizons are just waiting to be explored”.  

This isn’t the first time we have had Miss Italia finalists; it is simply the first time we have had two together. “And it won’t be the last!” says Prof. Stefano Negrini, scientific director of Isico. “I am starting to wonder whether this phenomenon might be linked to the determination that people who face the difficulties in life manage to acquire in part thanks to the help of those around them. The effort you have to put in with a brace is a major investment in your future that gives fantastic results, also in an aesthetic sense. Could it perhaps be that these girls are keen for the world to see how they are not only because of the beauty Mother Nature has given them, but also because it represents the fruit of years of sacrifice and hard work? I’m not sure if we’ll ever get the answer to this question, but I like to think that there is something in this — that we are able to give our patients not just healthy and attractive backs, but also all the strength, pride and determination they need to fight for their goals. All hugely important values in life. So, well done Cecilia and Lavinia. Whatever the result of the competition, you are already winners!”.

“I have had scoliosis surgery. Do I face any risks with pregnancy?”

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Let’s imagine the case of a healthy, active young woman who, as a teenager, had challenging scoliosis treatment, to the point of requiring surgery. Now, a few years on, she faces a new challenge: she wishes to become pregnant in order to fulfil her dreams of becoming a mother. 

Pregnancy is a period that naturally brings worries as well as lots of new information that needs to absorbed in order to be able to enjoy this special time. Those with scoliosis might start wondering “Will I have problems in pregnancy because of my scoliosis and the surgery I had? Or the reverse: “Could pregnancy aggravate my back condition?”.

Let’s try and help this mother-to-be, by providing answers based on the best available scientific evidence.

Several studies in the literature have investigated the topic “Pregnancy and surgery”, examining how one might influence the other.
Let us begin by underlining one reassuring aspect: as far as has been demonstrated so far, pregnancy (be it one pregnancy or more) has no consequences (in terms of a progression or deterioration of the curve) either on the surgically fused portion of the spine or on the vertebrae that were left free (https://pubmed.ncbi.nlm.nih.gov/32272267/;  https://pubmed.ncbi.nlm.nih.gov/2948962/). 

Nevertheless, it is always a good idea, when possible, to seek the opinion of the surgeon who performed the surgery, in order to have answers to your queries and precise instructions to follow.

Moreover, if the patient chooses epidural pain relief and/or chooses or requires to deliver by caesarean section with epidural anaesthesia, the anaesthetist might wish to avoid the surgically-treated portion of the spine (https://pubmed.ncbi.nlm.nih.gov/32578160/ ; https://pubmed.ncbi.nlm.nih.gov/30610987/ ), even though this decision by the medical team, made in agreement with the patient, seems to be taken more as a precaution.

In general, the use of epidurals in women with previous scoliosis surgery is comparable to what is observed in scoliosis patients who have not had operative treatment. Furthermore, according to the available data, anaesthesiologists seem reluctant to perform an epidural if the surgically treated portion of the column is below the third lumbar vertebra, preferring instead to opt for general anaesthesia (https://pubmed.ncbi.nlm.nih.gov/26131384/ ; https://pubmed.ncbi.nlm.nih.gov/32578160/ ; https://pubmed.ncbi.nlm.nih.gov/30610987/ ).

With regard to possible pain or complications during pregnancy and delivery, some studies have shown that there are no differences between women who have and those who have not had scoliosis surgery (https://pubmed.ncbi.nlm.nih.gov/9391799/ ).
On the other hand, low back pain during pregnancy seems to be more frequent in surgically treated patients, although it disappears relatively quickly after delivery. ( https://pubmed.ncbi.nlm.nih.gov/30610987/ ).
All in all, then, a mother-to-be can face this exciting new chapter in her life with complete peace of mind, even though she should not forget to seek the opinion, regarding her back, of both her family doctor and a spine specialist. In this way, it is possible to prevent any pain and have the best possible experience of pregnancy and childbirth

Master On Line Course: registration now open!

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Since 2016 it is the international online Master for those involved in the rehabilitation treatment of vertebral pathologies: 300 participants since then from all five continents engaged in an ongoing learning process.
The English course was flanked in 2020 by the Chinese edition and in 2021 the Spanish one was added.
Participants have the privilege of attending the lessons of dozens of teachers among the leading international experts in rehabilitation treatment.
A learning opportunity that continues to be successful, in fact, we just opened the registration for the VIII Edition of the Online Master Course “Principles and Practice of Scoliosis Conservative Treatment – PPSCT“.
The Early bird registration deadline is December 18th, the course starts on January 2023.

Isico is keen to share its extensive clinical and scientific experience with the course participants, in the hope that this will result, worldwide, in increased availability of good quality conservative treatment with a high success rate.
Those who have already participated say that “This course has broadened my knowledge in scoliosis treatment. It gave me theoretical as well as practical point of view” (Sicca from Indonesia) and also “The course is great, it really covers a broad array of topics pertinent to the conservative management of Scoliosis. This should be a must for anyone involved in Scoliosis management” (Juan from Australia); and also “Thanks to all my colleagues who made this an intellectual adventure!” (Andrew from the USA).


How the course is organized
The PPSCT course is delivered entirely online and self-administered through a dedicated online learning platform. It is divided into 16 modules, each lasting two or three weeks. 
Every single module generally includes three recorded theoretical lectures (each about 45 minutes long), which participants can listen to at a time to suit themselves, enriched by scientific papers as in-depth material to complete the module task.
Discussion Group sessions complement the learning and the exchange with other students focusing on specific aspects of the topic dealt with, within that module.
If you want to know more about the course and know how to register please visit the Online Master website and try a lesson for free.

The online learning experience is narrated by the participants themselves, please watch the video

How long before having an X-ray should I remove my brace?

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During bracing for scoliosis, doctors want to see X-rays every 6-12 months in order to check how well the treatment is working and also verify the patient’s growth stage in order, over time, to adapt the prescription accordingly. 

This obviously begs the question: “How long before having an X-ray should I remove my brace?”

Let’s see what the scientific literature has to say. 

According to one study, it takes around 2 hours to reach the maximum correction that can be obtained using a brace; after removing, it the correction obtained is gradually lost over around 2 hours, after which the curve/spine stabilizes (https://pubmed.ncbi.nlm.nih.gov/24859575/). 

Another study suggested that subjects who leave their brace off for longer than they would normally do are more prone to this loss of correction (https://pubmed.ncbi.nlm.nih.gov/18810041). 

Because the patients in these studies were not assessed on the basis of repeat X-rays — it would not be ethical to expose patients to so much radiation —, but rather using other (less reliable) examinations, and the patient samples investigated were small, these data are only able to show a trend, which will need to be confirmed by more robust studies.  

So, what happens when you remove your brace? Does the spine remain corrected? And, if it does, for how long? In other words, when you need to have an X-ray, how long beforehand should you remove your brace?

Given the absence of reliable data to rely on, what we find, if we look at what happens worldwide, is that there exists no universally accepted criterion to guide this choice. This means that doctors can decide according to their own beliefs. Accordingly, some doctors ask their patients to remove their brace up to 2 days before having an X-ray, in order to get, even in those who normally wear it full time, a picture that can be considered to reflect the “real” situation, independent of the effect of the brace. Some instead want their patients to be X-rayed immediately after removing it, while others do not give precise instructions.

In our view, it is important to ensure consistency between X-rays taken in the course of bracing treatment, so that they can be compared and the effects properly understood. For this reason, whatever the doctor decides, it is a good idea to apply the same criterion for all X-rays performed during the treatment.

The approach of our doctors at ISICO is to ask patients to do X-rays after they have been out of their brace for the same number of hours they leave it off in real life. So, if a patient is prescribed 20 hours of brace wearing per day and 4 hours of brace-off time, then they will have their X-ray 4 hours after removing their brace.

Why this choice? Because the ISICO doctor wants an X-ray that shows the “worst” scenario, so as to be able to establish how well the spine is holding up during the hours of freedom and, on this basis, whether the brace-off period needs to be shortened.

There are two ways you can achieve optimal maintenance of the correction and, therefore, good results on follow-up X-rays. The first is to adhere scrupulously to the doctor’s prescription every day, rather than some days keeping the brace on for more hours than prescribed, and others for fewer; this constancy allows gradual and targeted strengthening of the muscles that support the spine. The second is to do specific physical exercises designed to increase your ability to practice self-correction of the spine during your everyday activities. 

If you can do this, you will end up with a kind of natural muscular brace that can be activated as necessary during your brace-off hours. This ability to support the spine can be further enhanced by regular sporting activity. 

In short, while there is no clear answer to the question asked at the start, we have here offered some considerations to help you to interpret your specialist’s requests, and also some tips on how to get good results from your treatment.