Isico’s research wins the SOSORT Award

/0 Comments/in /by

For the fourth consecutive year, Isico has obtained the most prestigious award for those involved in rehabilitative treatment of the spine, winning the SOSORT Award with the study Prediction of Future Curve Angle using Prior Visit Information in Previously Untreated Idiopathic Scoliosis: Natural History in Patients under 26 Years Old with Prior Radiographs.

The research, which involved 2317 patients with idiopathic scoliosis between 6 and 25 years old, was developed by our researchers (the Isico authors are Prof. Stefano Negrini, together with Dr Giulia Rebagliati, Dr Fabio Zaina, Dr Sabrina Donzelli and Dr Alberto Negrini) in collaboration with Dr Erik Parent of the University of Alberta, Canada. This project was funded by a Standard Research Grant from the Scoliosis Research Society.

“Understanding natural history helps inform the treatment selection for modifying the course of the disease or to avoid overtreatment – explains prof. Stefano Negrini, Isico Scientific Director- Previous models predicting curve progression lacked validation, did not include the full growth spectrum or included treated patients. Our aim was to develop and validate models to predict future curve angles using clinical data collected only at, or both at and prior to, an initial specialist consultation in idiopathic scoliosis”. 

Scoliosis-specific exercises are recommended in small curves in skeletally immature patients, exercises and progressively more aggressive brace treatments are recommended for moderate and severe curves in 10% of growing children and adolescents and invasive corrective surgery is recommended in severe curves at risk of continued progression in adulthood for 0.1-0.3% of cases. 

“Patients were previously untreated and provided at least one prior radiograph prospectively collected at first consult – continues prof. Negrini – We excluded those previously treated”.

 Radiographs were remeasured blinded to the predicted outcome: the maximum Cobb angle on the last radiograph while untreated. Linear mixed-effects models with random effects and maximum likelihood estimate were used to examine the effect of data from the oldest visit (age, sex, maximum Cobb angle, Risser, and curve type) and from other visits while untreated (Max Cobb angle), and time (from oldest radiograph to prediction) on the Cobb angle outcome.

“Predictions models were proposed which can help clinicians predict future curve severity expected in patients not receiving treatment –ends prof. Negrini – Predictions can inform treatment prescription or show families why no treatment is recommended. Our models offer the flexibility to predict at a future timepoints over the full growth period. These validated models predicted future Cobb angle with 80% of predictions within 100 in non-treated idiopathic scoliosis over the full growth spectrum. Improved prediction ability may help clinicians inform treatment prescription or show families why no treatment is recommended”.

SOSORT 2022: the AWARD winners and a fourth ISICO President

/0 Comments/in /by

This year’s SOSORT meeting, held in San Sebastian, Spain in the wake of two editions forced online by the pandemic, was a double success for ISICO, which had two studies shortlisted for the SOSORT Award.
One of them, Prediction of Future Curve Angle using Prior Visit Information in Previously Untreated Idiopathic Scoliosis: Natural History in Patients under 26 Years Old with Prior Radiograph, conducted in collaboration with the University of Alberta in Canada, came first, making this the fourth consecutive year that ISICO has taken home the prestigious award. But this was not the only high point. Our Dr Sabrina Donzelli, physiatrist, was named as the next President of the International Society. This is the fourth time that ISICO has had this has honour since SOSORT was founded in 2004,  and it is the first time a woman has been appointed to the role.

“This prestigious appointment is an acknowledgement of Dr Donzelli’s scientific standing, hard work and commitment, as well as a recognition of our institute, which now provides a benchmark for clinical and research activity worldwide” remarked Prof. Stefano Negrini, Scientific Director of ISICO as well as one of the ISICO authors — the others being De Giulia Rebagliati, Dr Fabio Zaina and Dr Alberto Negrini — who collaborated with Dr Eric  Parent, first author of the study that won the SOSORT AWARD. The congress was hugely stimulating and we can’t wait for 2023 and next year’s meeting in Melbourne, Australia”.

Scoliosis: why prevention matters

/in , /by

About spinal disorders like scoliosis, it is often said that prevention is just as important as treatment.

Before we go any further, let’s clarify a few things, starting with the definitions of screening and scoliosis. Screening is an activity involving rapid tests, examinations or other procedures, and its purpose is to detect the possible presence of a disease or defect that the patient didn’t know they had.

Scoliosis, on the other hand, is a three-dimensional spine deformity.There are different forms, depending on the age at which it was first diagnosed: infantile (diagnosed between 0 and 3 years), juvenile (between 3 years of age and puberty), adolescent (between puberty and the completion of bone growth), and adult-onset. Scoliosis affects 3% of the population, prevalently females; 80% of cases are diagnosed in adolescence.

Two aspects in particular make scoliosis an insidious disease: first, it causes no symptoms of any kind during childhood and adolescence, which makes it difficult to identify young people who are at increased risk of developing spinal deformities; second, in most cases, it is idiopathic, which means we don’t know what causes it. 

Therefore, early diagnosis of scoliosis, i.e., at an age when there is a considerable risk of the condition progressing, allows the patient to receive adequate, less invasive and more effective treatment. This, as far as possible, will prevent it from worsening to the point of causing, in adulthood, pain, progressive deformity and sometimes cardiorespiratory problems that will negatively impact their quality of life.  

Screening: when and by whom?

Scoliosis screening’s importance is widely recognised, also by the scientific community (ref. Screening for adolescent idiopathic scoliosis: an information statement by the Scoliosis Research Society international task force). 

Scoliosis screening should target all girls in their last year of primary school/first year of secondary school and all boys in their second year of secondary education. This is the age at which they reach puberty and are therefore most at risk of progression of scoliosis, if affected by the disease. 

Youngsters should be screened by a spine expert who, through specific tests, can identify those at risk of a spinal deformity.

Screening results are given to the patient directly so that they can decide how to proceed with their doctor. In this way, if necessary, a diagnostic-therapeutic pathway can be planned.

What does Screening involve?

The first thing to do when evaluating whether or not a youngster may have scoliosis is to observe their bare back. The presence of more or less obvious asymmetries at trunk level, such as a difference in the height of the shoulders, or the hips, or a difference between the two shoulder blades, is the first sign of a possible case of scoliosis.

Then, the Adams test is performed, which is crucial: standing with their knees straight, the patient has to bend their trunk forwards, keeping their head down and letting their arms hang limply. This position has the effect of emphasising any hump due to scoliosis. If a hump is observed, it will be measured at the point where the height difference between the two sides of the patient’s back is greatest.

This measurement is taken using the Bunnell method, using a scoliometer to determine the angle of trunk rotation. If this angle measures 5° +/- 2° or more, it is advisable to have a specialist consultation. 

A patient with an angle of 3° or more should be checked every six months if they are approaching or have entered puberty, otherwise at yearly intervals. If a patient’s measurement is below this threshold (between 0 and 2°), but they have one hip or one shoulder higher than the other, or a protruding shoulder blade, then they need to be seen after six months and referred to a specialist if the asymmetries persist; otherwise, they can be referred back to their general practitioner/paediatrician.

How to screen a child online

Visit https://screening.isico.it to carry out a rapid screening for scoliosis or a curved spine, free of charge.
After watching the brief explanatory video, follow the steps and carry out the assessment. This will involve taking a few measurements. Depending on the data you provide us, we can tell you whether it would be a good idea to consult a spine specialist or whether there is currently no reason for concern.

Different specialists, different prescriptions: how should we choose?

/0 Comments/in , /by

Most parents of a child with scoliosis embark on a similar journey: once they have received the initial diagnosis, they start consulting other specialists, seeking second or third opinions that might provide them with the confirmation and reassurance they need, and/or simply answers to further questions and doubts that have cropped up in the meantime. 

Often, though, parents who do this find themselves left with more questions than answers. This is because different specialists, faced with the same scoliosis case, can make different diagnoses and prescribe different courses of treatment.

Why is this? There may be different reasons. Before going any further, though, it is important to remember that only a specialist with specific training in vertebral pathologies can treat scoliosis. Once a timely and correct diagnosis has been made, it is necessary to decide how to treat the condition. 

The SOSORT guidelines on conservative treatment of scoliosis are an important resource in this regard. Taking into account the best current scientific evidence, as well as the extent of the curves and the degree of bone maturation, they provide suggestions on the most effective treatment. 

What the guidelines offer is not a single, specific course of treatment, but rather a series of options, ranging from the most conservative to the most aggressive, that could conceivably be prescribed in a given patient. 

However, science alone cannot meet all the needs of a long and complex course of treatment of the kind required in scoliosis. The evidence-based medicine approach brings together and combines scientific knowledge, the expertise and experience of the specialist, and the values and desires of the patient, and therefore makes it possible to formulate the most appropriate prescription for the individual case. 

Bearing all this in mind, then, it may well be that one doctor, considering the data collected during the examination and the discussion with the patient and the patient’s family, decides to prescribe a brace where another doctor might instead recommend only specific physiotherapy or even a wait-and-see approach, which consists of monitoring the situation for a few months to see how the scoliosis evolves.
These are very different prescriptions, but they are all valid. The patient will in any case be monitored following the prescription in order to make sure that the type of treatment, and the dose, are correct.
In this way, it is also possible to make any changes needed to avoid under-treatment (insufficient to contain the progression of the disease) or over-treatment (too taxing for the patient).

The big question remains: how do we parents go about choosing? There’s no easy answer. Given that our children will need to be on this therapeutic journey until they have finished growing, the important thing is to find someone we feel we can trust. In other words, we need to choose the specialist — and it must be someone with expertise in the conservative treatment of scoliosis — who we, and our child, felt to be the most reassuring and empathetic.

Once we have made our choice, we need to place our child’s care in the doctor’s hands. It is important to follow the instructions we are given, and not to change anything without the doctor’s agreement, as to do so could undermine the success of the treatment. 

Ready for SOSORT

/0 Comments/in /by

There are just a few days and the SOSORT  International Conference finally, after two years from the start of the pandemic, is back in person in San Sebastian, Spain from the 4th to the 7th of May.
It will be the usual pre-course, scheduled for May 4, to kick off the event: three of our specialists will participate in the round table, Dr Fabio Zaina, with a session on Overview of Adult Spinal Deformity classification, and how it is differing from AIS, Dr Sabrina Donzelli with  ASD prevalence and Dr Michele Romano, director of Isico Physiotherapy, with Standardized presentations describing assessment, clinical decision making process and treatment.

In the following days, Isico will be present again with three presentations: Dr Fabio Zaina will present on May 6th “Night-time bracing improves back pain in patients with painful scoliosis: six months results of a retrospective controlled study“, Dr Michele Romano on May 7th “Exercises for adolescent idiopathic scoliosis: Updated Cochrane Review”  and finally, Prof. Stefano Negrini, scientific director of Isico, will compete for the SOSORT Award with his research “Splitting Growth into 3 Phases with Cut-offs at Pubertal Spurt and Risser 3 Facilitates Prediction of Progression. A Study of Natural History of Idiopathic Scoliosis Patients from age 6 to End of Growth”.

For more info: https://sansebastian2022.sosort.org

The winning study of the SOSORT Award 2020 has been published

/0 Comments/in /by

Two years after winning the SOSORT AWARD, the study “Predicting final results of Brace Treatment of Adolescents with Idiopathic Scoliosis: First Out-of-Brace are Better than In-Brace-radiographs” has finally been published in the European Spine Journal.

 A total of 131 patients were included in the study, the researchers aimed to determine which of the two radiographs is the best predictor of the Cobb angle at the end of treatment (final radiograph). In fact, the in-brace radiograph of adolescents with idiopathic scoliosis (AIS) has been shown to reflect brace efficacy and the possibility of achieving curve correction. Conversely, the first out-of-brace radiograph could demonstrate the patient’s ability to maintain the correction.

The first out-of-brace radiograph predicts end results better than the in-brace radiograph.

“Our research has highlighted – explains Dr. Sabrina Donzelli, author of the research – how important the first x-ray taken without the brace is in predicting end-of-care results. The first out-of-brace radiograph should be considered an essential element of future predictive models and offers an excellent clinical reference for clinicians and patients. The collection of clinical data that occurs routinely during all visits to ISICO has allowed in recent years to be able to develop the so-called predictive models, i.e. we can use the characteristics of the patient to understand how the final results can be predicted or to understand if there are risk factors more important than others to consider when deciding what type of therapy to prescribe “.

Curves measuring less than 10 degrees: should we treat them?

/0 Comments/in , /by

As suggested by the Scoliosis Research Society (SRS), a scoliosis diagnosis is confirmed when a patient presents a Cobb angle measuring 10° or more and axial vertebral rotation. Maximum axial rotation is measured at the apical vertebra. (1) The SRS established this threshold in 1977, replacing the previous one of 7°. Ever since, 10 ° has conventionally been accepted, worldwide, as the threshold for diagnosing scoliosis.
However, structural scoliosis, with a potential for progression, can also be observed in the presence of Cobb angles measuring less than 10°. In fact, initial wedging of the vertebral bodies and disks can sometimes be registered with curves of 4°–7°. (2)

Idiopathic scoliosis, being a developmental disorder, most commonly arises and progresses during periods of accelerated growth (growth spurts).

The first such period occurs in infancy/early childhood, generally between 6 and 24 months of age, and the second between the ages of 5 and 8 years; finally, there is the pubertal growth spurt, which generally occurs at 11–14 years of age. (1)

Although the later stages of development are obviously not risk free, after puberty the rate of growth usually slows down, reducing the risk of progression of scoliosis. 

Can the risk of scoliosis progression be predicted in the case of curves measuring less than 10°?
There is, of course, always a chance that these curves will become more pronounced as the youngster grows, even, in some cases, to the point of requiring the use of a brace. But it is also true that most of them will remain stable over time without reaching the minimum criteria for a diagnosis of scoliosis. Certain factors may possibly be associated with an increased risk of scoliosis progression: a positive family history of scoliosis, laxity of ligaments, flattening of physiological thoracic kyphosis, a greater than 10° angle of trunk rotation (ATR), and growth spurts. All these factors should be evaluated by the attending physician. 

So, should we be treating these youngsters? In short, no. First of all, it is worth remembering, that the main aim of conservative treatment of scoliosis is to improve the patient’s appearance, but curves as mild as this rarely have an aesthetic impact; at most there may be some slight asymmetry of the trunk, but nothing that can be considered to exceed physiological parameters. With very rare exceptions, the only advice necessary in these cases is to opt for clinical monitoring of the patient, which can be considered to all intents and purposes a treatment, in the sense that it allows us to overcome the critical phases of development (which also correspond to the periods of greatest risk of progression of scoliosis) and also to intervene if any progression does occur. Monitoring is the first step in an active approach to idiopathic scoliosis, and it consists of clinical evaluations performed at regular intervals, ranging from every 2-3 months to every 36-60 months depending on the single case. 

In conclusion, any active treatment in this population of patients is actually overtreatment. Even just specific exercises, whose prescription constitutes first therapeutic step after monitoring alone, would cost these youngsters in time and effort, as well as being an economic cost.

A further aspect, not to be underestimated, is the psychological impact: starting a treatment amounts to confirming that the individual has a disease that needs to be treated, and this can lead them to start thinking of themselves as “sick”.

Furthermore, even though an exercise programme is not a particularly arduous undertaking, starting a treatment when there is no real need for one could compromise the youngster’s collaboration and commitment should a treatment be needed later on. This is an important consideration, because if their scoliosis does progress as they grow, specific exercises, rather than being useful, could become crucial, in order to avoid bracing for example.  

1 – 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth

https://pubmed.ncbi.nlm.nih.gov/29435499/

2 – Radiographic Changes at the Coronal Plane in Early Scoliosis. Xiong, B., Sevastik, J. A., Hedlund, R., & Sevastik, B. (1994). Spine, 19(Supplement), 159–164. doi:10.1097/00007632-199401001-00008

https://pubmed.ncbi.nlm.nih.gov/8153824/

The experts’ brace-classification : a newly pusblished study with video-commentary

/0 Comments/in /by

Studies have shown that brace treatment for AIS is effective but not all braces are the same. The classification of scoliosis braces developed by SOSORT with SRS, ISPO, and POSNA and approved by ESPRM, a study just published by The European Spine Journal, aims to produce a classification of the brace types.Studies have shown that brace treatment for AIS is effective but not all braces are the same. The classification of scoliosis braces developed by SOSORT with SRS, ISPO, and POSNA and approved by ESPRM, a study just published by The European Spine Journal, aims to produce a classification of the brace types.
Four scientific societies (SOSORT, SRS, ISPO, and POSNA) invited all their members to be part of the study. Six level 1 experts developed the initial classifications. At a consensus meeting with 26 other experts and societies’ officials, thematic analysis and general discussion allowed to define the classification (minimum 80% agreement).
The classification was applied to the braces published in the literature and officially approved by the 4 scientific societies and by ESPRM.
There are substantial differences in results published in the literature: one of the factors impairing research and leading to clinical confusion in the field is the absence of a classification to understand differences and commonalities among braces.
The only existing classification is common to all other orthoses, which is to classify braces according to the anatomical joints held underneath the brace—in the spine, these are the trunk regions. Unfortunately, according to this classification, almost all braces for spinal deformities fall in the thoracolumbosacral orthosis (TLSO) category, without other differentiations included.
As a result, clinicians cannot generalize research results on one brace to another with the same biomechanical action. Even worse, we could be inaccurately generalizing data on one brace to another brace with different biomechanical actions.
In this study the experts developed a definition for each item and were able to classify the 15 published braces into nine groups.
“This is the first edition of a brace classification that we expect to evolve further in future due to better understanding and more research – explains prof. Stefano Negrini, Scientific Director of Isico and first author of the article – It is based on expertise more than evidence, but we also must recognize that expertise is the first step of the pyramid of evidence when no better research data are available. Moreover, this expertise is shared worldwide among some of the best brace experts. The involvement and support of the leading scientific societies in the field should guarantee its dissemination”.
Watch the short video commentary of Prof. Stefano Negrini about the published study for our Isico Science corner video column

That hated hump!

/0 Comments/in , /by

In a person with scoliosis, forward bending of the trunk will cause a protuberance to appear on their back, at the level of the scoliotic curve: this anomaly is commonly referred to as a hump.

Scoliosis alters the alignment of the spine, and this alteration can be seen in the three dimensions of space: the affected vertebrae move sideways, taking on a different shape when viewed from the side; they also rotate, and this, especially if they are dorsal vertebrae, also causes a rotation of the rib cage. 

This hump is an aesthetic problem for people with scoliosis, as they fear that it is obvious to everyone else. But that is not the case at all. There is often a world of difference between the problem itself and how it appears in everyday life. 

During a thorough postural analysis or a medical examination, the doctor or examiner will position the patient’s body to emphasise any asymmetries present precisely so that they can be identified and measured.

Nobody is perfectly symmetrical in daily life: when we move, we frequently twist our bodies and bend and rotate our joints, our movements involving different segments of our body in various combinations. As a result, we constantly develop asymmetries, humps, and combinations of bent and straight segments without even being aware of it.

Let’s take an example. A doctor examining a patient’s hump will have the youngster stand with his knees straight and body bent forwards so as to emphasise the protuberance on the side of the curve. Is it visible? Yes, if the patient’s scoliosis is sufficiently marked, it will be visible even to the untrained eye. 

Now, what if we ask someone with a healthy back to tie up their shoelace? To do this, most people will push their foot forward, bend their knees asymmetrically, and lean forwards, with their trunk deviating to one side (the side of the shoe needing to be tied). As they do this, their spine will be turned to one side, and a hump can be seen on their back, on the side of the leg, with the shoe needing to be tied. Does that hump mean they have scoliosis? Of course not! It is caused by them twisting their spine in order to reach their shoe.  

We can explain the scoliosis-induced asymmetry of the hips in a similar way. If we stand still with our feet parallel, our knees straight and our trunk aligned, our side and our hips will look symmetrical; in people with scoliosis, on the other hand, one hip will appear straighter in respect to the other. 

Now, let’s imagine how we normally stand. Do we ever actually stand with our feet positioned symmetrically and our bodyweight perfectly distributed between them? No! We usually stand with our weight on one foot and one hip thrust out. How do we look in this position? It is completely asymmetrical, but this asymmetrical appearance is due to our natural posture; it is not caused by scoliosis! 

Nobody ever notices these natural asymmetries because our bodies repeatedly assume them throughout the day. For this reason, even asymmetries caused by scoliosis are never really noticed by others. 

Going back to our “hump”: is it really such a bad thing, to the point that we should do everything in our power to get rid of it?

The back brace sometimes worn by youngsters with scoliosis, seeks to optimise the alignment of the vertebrae involved in the scoliosis curve, but how? It works by pushing “from the outside” directly on the affected portion to restore its symmetry. The force it exerts on the rib cage or on the soft tissues of the hips also affects the spine. 

 What is meant by an optimal alignment of the spine? The straightest possible? 

This isn’t an easy question to answer. Equally, it is not easy for the doctor to identify the correct balance of forces to be exerted on the spine by the brace pads. 

The best alignment will enable the treated spine to remain as stable as possible and to withstand the forces to which it is subjected in daily life. 

The strength of the spine depends to a large extent on its shape, as seen from the side. From this perspective, our spine is characterized by two curves, called lordosis and kyphosis. These curves must be well balanced: neither too pronounced nor too slight. 

Unfortunately, in scoliosis, and this applies particularly to dorsal scoliosis, the kyphotic curve is reduced, causing the back to appear flat or even hollow. In other words, the normal direction of spinal curvature is reversed, and the spine is weaker as a result. 

Unfortunately, the brace has no way of counteracting this problem, as all it can do is push. In fact, its corrective forces, which are applied to the hump to help align the vertebrae involved in the curve, have a flattening effect on the back’s upper part (dorsal section). 

Therefore, the doctor’s task is to find and maintain the best possible balance, considering the importance of all the planes of the spine.

What this means in practice is that it is sometimes necessary not to “go too far” in trying to eliminate the hump. Because if this objective can be achieved only by excessively reducing the dorsal kyphosis angle, the result will be a weaker and less healthy spine.  

Brace wearing: tenacity is rewarded with improvements

/0 Comments/in /by

It is not just a question of how many hours the brace is worn but also patient compliance with the prescription. Take, for example, Marco and Ginevra. Both have idiopathic scoliosis, are followed by Isico specialists, and wear a Sforzesco brace for 20 and 23 hours a day, respectively. Marco complies with the prescription for wearing the brace, but he is inconsistent with the prescribed hours: sometimes he wears it for the 20 hours prescribed, others for 10, and others for 22. Ginevra instead regularly respects the prescription of 23 hours daily; this allows her to attain better results and avoid worsening.

Our study demonstrates this, Consistent and regular daily wearing improves bracing results: a case-control study published in the journal Scoliosis and Spinal Disorders some years ago. The study considered 168 patients who wore a brace for between 18 and 23 hours per day, divided according to high, medium, or low compliance and classified according to consistency or inconsistency in wearing.
The data were collected using Thermobrace, a temperature sensor applied to the brace to monitor its actual wearing.

Isico was the first organization to introduce Thermobrace into the daily clinical routine in 2010, and since then, its use has become commonplace. It has been verified that the relationship between doctor and patient is strengthened through Thermobrace, since the therapeutic choices are based on real data; therefore, the data obtained from the sensor can be used to facilitate the use of the brace.

“The data confirmed that the brace should be worn consistently, which means that wearing the brace for a constant number of hours allows the achievement of good results,” explains Dr Sabrina Donzelli, physiatrist and author of the publication, “also for those who are not completely compliant to the prescribed hours”.
This confirms what we always recommend to patients who undergo brace therapy: the break must always be constant; fewer hours one day and then recovering the lost hours in the following days is not ideal!

In addition to not adhering to the prescribed treatment, patients who are also not consistent in wearing the brace are at greater risk of worsening. Patients who have worn the brace for less than 70% of the prescribed duration are considered non-compliant.
“The study shows that to achieve the best results, the brace must be worn for a consistent number of hours. The attempt to recover lost hours is useless,” concludes Dr Donzelli “While tenacity together with compliance, i.e., the adherence of the patient to the prescription, is rewarded”.