A predictive model of scoliosis: the research will be published in 2022

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During these months, Isico carried out the study funded by the SRS (Research Society on Scoliosis), aimed at identifying a predictive model on the evolution of scoliotic curves in untreated patients, in collaboration with the University of Alberta, in Canada. Collected the data, presented preliminarily in March by Prof. Stefano Negrini, scientific director of Isico, in a webinar during the Research Grant Outcome Symposium organized by SRS, we moved to the writing phase of the study that will be published in 2022.
The radiographic measurements collected (we recall that the research included 431 patients with a diagnosis of JIS, below age 26, previously untreated) were used to create a model that allows predicting the curve’s progression.
“Let’s take an example – explains Dr Sabrina Donzelli, a physiatrist who is following the research – with an 8-year-old patient and a 20-degree curve, the equation derived from the sample allows us to calculate how much it will evolve in the first year from diagnosis. Another equation instead will predict the curve at the end of growth. To refine the prediction, the sample was then divided into different risk categories to estimate the potential progression in groups of patients different for age and risk of progressivity, based on the Risser. The models developed were then validated through artificial intelligence “.
In the article that will be published, the researchers will provide the equation that allows calculating the evolutionary potential of scoliosis.

The Risser sign, growth and scoliosis: let’s clear a few things up

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When patients come for medical consultations or physiotherapy sessions, numerous measurements get taken and recorded, often without less expert eyes even noticing.

On the other hand, other measurements are quickly seized upon, both by parents and youngsters. Take height, for example. The sliding piece barely has time to touch the patient’s head before the patient, hopeful, blurts out: “Have I grown? Can I leave off my brace now?”

Another milestone we are promptly informed of is menarche in girls, as parents are often convinced that when their daughters start their periods, they have finished growing, meaning that their treatment can come to an end. But this isn’t always the case. On the contrary, this delicate phase can sometimes coincide with the most marked progression of the disease, making it all the more important to act with caution.

Although these are two important examples of the many factors that need to be taken into account to work out what point a youngster’s growth has reached, it has been shown that increases in height and menarche do not necessarily coincide with the individual patient’s growth peak [1] and may therefore not be helpful and/or sufficient when it comes to deciding on the best course of treatment.

Since these manifestations are secondary growth characteristics, they can only be seen as an indication that the patient’s growth spurt has begun. What they do not tell us is precisely how far on it is. There is a scientific explanation for the traditionally held belief that girls “develop earlier” than boys. In fact, because testosterone starts to be released into the body after oestrogens, boys start their pubertal growth spurt later than girls.[1]

To manage scoliosis and optimise the treatment results of the condition, it is crucial to have a good idea of the patient’s residual growth potential and the time remaining until he/she reaches skeletal maturity. An accurate prediction of the growth rate is also required to know when the deformity is likely to be most at risk of progressing. On the other hand, once it has been established with certainty that the patient has finished growing, this is the time at which preventive measures can be stopped with only minimal risk of further deterioration of the curve. [1]

There are various methods we can use to evaluate bone growth in adolescence, and one of them is called the Risser sign.

An individual’s Risser grade can be determined from an anteroposterior X-ray of the spine. An advantage of this method is that the same X-ray can be used to measure both the number of Cobb degrees (necessary to diagnose scoliosis) and the degree of skeletal maturity, thereby limiting the patient’s radiation exposure.

From 0 to 5, Risser grades are assigned based on the amount of calcification present in the iliac apophysis, and the scale thus measures progressive ossification. A Risser grade 0 indicates a low degree of bone maturity: this status is present from birth through puberty.

A Risser grade 5 means that the iliac apophysis has fused to the iliac crest, and the structure is 100% ossified: this status is present in adults  [2]. 

It would be misleading to imagine the transition from Risser 0 to Risser 5 as a continuous and constant progression that occurs over a fixed time and at a set pace. This is because growth is not constant but proceeds at different rates in the different phases. There are times when it pauses, times when it speeds up considerably, and times when it slows down.

The crucial stage in a youngster’s growth, also vital for understanding the course of their scoliosis, is the pubertal growth spurt, during which the disease can alter the shape of the patient’s back in the space of just a few weeks. From the perspective of a Risser evaluation of skeletal maturity, this stage corresponds to the transition from Risser 0 to the complete acquisition of Risser 1.

Between Risser 2 skeletal maturity and the end of the Risser 3 stage, the growth spurt slows down, but as far as the scoliosis treatment is concerned, we still cannot lower our guard: the patient should continue to receive treatment.

Scoliosis treatment is brought to an end gradually as skeletal maturity increases. Once the patient has reached Risser grade 5 (complete skeletal maturity), the treatment can be terminated safely without fearing that some of the hard-won gains might be lost.  

The Risser classification varies slightly in different parts of the world, with some differences found, in particular, between Europe and America. In Europe, the successive grades tend to be assigned more cautiously, in the sense that a patient is deemed to have passed from one stage to the next only in the presence of precise levels of bone maturation. On the other hand, the American tendency is to assign the successive grades sooner.

Another method for assessing skeletal maturity is the Sanders classification, whose eight grades are assigned based on the assessment of hand bone growth [3]. Some studies have found the Sanders classification more precise than the Risser sign. It shows higher staging sensitivity when growth is most rapid and is therefore more reliable during certain growth phases [4]. The problem with the Sanders classification is that it requires a separate X-ray of the hand, which therefore means that it could increase the patient’s radiation exposure.

All this information clearly shows that residual growth is essential to evaluate, but at the same time, difficult to establish and interpret.

Specialists can, of course, use the classification they prefer, which will be the one that, in their experience, works best for identifying and evaluating the growth peak in adolescence. It is essential that they can correctly interpret all the data they collect, including from radiographs and patients themselves, to optimise the timing and results of the treatment. 

References

[1] Cheung JPY, Luk KD. Managing the Pediatric Spine: Growth Assessment. Asian Spine J. 2017 Oct;11(5):804-816. doi: 10.4184/asj.2017.11.5.804. Epub 2017 Oct 11. PMID: 29093792; PMCID: PMC5662865.

[2] Greiner KA. Adolescent idiopathic scoliosis: radiologic decision-making. Am Fam Physician. 2002 May 1;65(9):1817-22. PMID: 12018804.

[3] Sanders JO, Khoury JG, Kishan S, Browne RH, Mooney JF 3rd, Arnold KD, McConnell SJ, Bauman JA, Finegold DN. Predicting scoliosis progression from skeletal maturity: a simplified classification during adolescence. J Bone Joint Surg Am. 2008 Mar;90(3):540-53. doi: 10.2106/JBJS.G.00004. PMID: 18310704.

[4] Minkara A, Bainton N, Tanaka M, Kung J, DeAllie C, Khaleel A, Matsumoto H, Vitale M, Roye B. High Risk of Mismatch Between Sanders and Risser Staging in Adolescent Idiopathic Scoliosis: Are We Guiding Treatment Using the Wrong Classification? J Pediatr Orthop. 2020 Feb;40(2):60-64. doi: 10.1097/BPO.0000000000001135. PMID: 31923164.

Isico science corner video column

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At Isico we give great importance to research, an integral part of our clinical work.  
Our newsletters always dedicate a space to the presentation and a comment when a new Isico study is published. 
From this issue on, we will go one step further, enriching each presentation with the video commentary of the first author of the research paper. We are pleased that it is just our scientific director Stefano Negrini, the first author of the article, launching the new Isico Science corner video column with a study of such great importance.

A closer look at the data

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The study just published, A Pragmatic Benchmarking Study of an Evidence-Based Personalised Approach in 1938 Adolescents with High-Risk Idiopathic Scoliosis, focused on 1938 participants with AIS, Cobb angles of 11–45°, and Risser stage 0–2, who were studied until the end of growth. 

Using the inclusion criteria reported in existing RCTs on physiotherapeutic scoliosis-specific exercises (PSSE), plastic bracing (PB), and elastic bracing (EB), we benchmarked 590, 687, and 884 members of our study population, respectively.
The study showed EBPA to be from 40% to 70% more effective than benchmarked individual treatments, with a low number needed to treat (NNT). 

“We evaluated clinically significant results and burdensomeness of care, calculating the relative risk of success and the NNT for efficacy”, explains Dr Sabrina Donzelli, Isico physiatrist who contributed to the data analysis. “In randomised studies, patients are randomly allocated to one treatment or another, to ensure that all patients have the same probability of being treated or observed. This randomisation process is necessary to rule out factors (such as physician choice of treatment) that could affect the outcome. We compared our PB, EB, and PSSE subgroups with the corresponding paired RCTs for benchmarking purposes. The probability of success in patients treated in EBPA is between 1.5 and 3.5 times that of natural history and between 1.2 and 2.9 when compared to per-protocol treated groups. Although surgery could not be avoided completely, only 2% of our patients ultimately needed it, compared with 28% of those belonging to the comparison studies’ untreated control groups”.

Patient compliance is the factor underlying the significant difference in these results. 

ISICO evidence-based treatment decided in agreement with patient and family: the best solution

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How effective is a personalised scoliosis treatment, which means a treatment supported by clinical experience combined with available scientific evidence on risk factors; based on the specific therapeutic objective; and adapted to the patient’s particular needs to encourage compliance? In other words, how effective is the treatment approach adopted by Isico compared with a simplified protocol based on a single, standardised type of brace and a set number of brace-wearing hours? 

According to our study A Pragmatic Benchmarking Study of an Evidence-Based Personalised Approach in 1938 Adolescents with High-Risk Idiopathic Scoliosis, just published in the Journal of Clinical Medicine (link), the answer is hugely effective! 

Our study, featuring a retrospective observation of a prospective database, includes nearly 2000 patients from our centre, recruited between 2004 and 2017, and is therefore the largest on conservative treatment of scoliosis in the current literature. 

The evidence-based personalised approach (EBPA) for idiopathic scoliosis in adolescents (AIS), routinely adopted in clinical practice by Isico, was compared with data from existing randomised controlled trials (RCTs), as paradigms of single treatments, to verify EBPA efficacy and burdensomeness in high-risk AIS.

“We compared the results recorded by Isico, in terms of the probability of avoiding surgery, with those of two randomised studies: one conducted using SpineCor® the other based on the use of a rigid brace”, explains Prof. Stefano Negrini, scientific director of Isico and first author of the study.
“We found that an evidence-based and personalised approach like ours yielded far better results than standardised treatments where strict protocols are followed. This is because it combines evidence with physician expertise and consideration of the patient’s preferences. At Isico, every patient follows a unique and personalised treatment pathway, both in terms of the brace chosen — other centres instead tend to offer only the one they are most familiar with —, but also in terms of the dosing of the treatment (brace-wearing time): in short, we offer an “à la carte” approach that allows us to find exactly the right balance, for the patient, between a series of factors and considerations: the degree of invasiveness, the risk of progression, and the mutually agreed goals of the treatment. In this way, in line with the great importance nowadays attached to patient-centred care, it might be decided that the treatment should be only as burdensome as is strictly necessary, or as burdensome as the patient is willing to accept. Throughout, the patient is involved in the therapeutic decision-making process and also made to feel he/she is actively contributing to the pursuit of the final goal of treatment. All this is achieved in a stepwise manner, in such a way as to ensure we provide the most effective treatment with the lowest impact.”

To ensure informed and shared decisions, the treating physician systematically informed the participants about their clinical and aesthetic condition, their progression risk, and the significance of Cobb angle thresholds (30° and 50°) and how these could influence their health and possible results. We discussed alternatives: to either reduce the burdensomeness of the treatment or increase the probability of success.

In short, greater patient involvement was found to lead to greater compliance and better results, which is exactly what was shown by another study published by our group several years ago entitled Adolescent Idiopathic Bracing Success Rates Influenced by Time in Brace: Comparative Effectiveness Analysis of the BrAIST and ISICO Cohorts. 

“Back then, in that study, which compared our findings with those of the “BrAIST” randomised multicentre study by Lori Dolan and Stuart Weinstein, we were already showing that Isico treatment works better”, Prof. Negrini goes on. “Indeed, it reduced the rate of recourse to surgery to a third of that recorded in the American study: this is because Isico patients, adhering to the prescribed treatment, wear their brace for a far greater number of hours. And now, this latest, pragmatic, observational study of a large prospective cohort benchmarked to published RCTs has shown higher efficacy of EBPA compared with standardised protocols, to the point that only 2 % of our patients had surgery, compared with 28% of those in groups receiving standardised treatment. In addition to being initiated early on and prolonged over time, the treatment delivered by Isico is also carefully personalised based on the severity of the current condition and its risk of progressing. Accordingly, the treatment offered ranges from simple exercises to bracing, with the number of brace-wearing hours per day varying according to need. It is thus a stepwise approach that progresses from observation, through exercises, SpineCor®, rigid and super rigid bracing (at Isico, instead of plaster casts, we use the equally effective Sforzesco brace), and finally to surgery as a last resort. What explains the success of this treatment? Well, the team of experts of course, but above all the trust and cooperation we receive from our young patients and their families”.

Adults: can hyperkyphosis be improved?

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With the passing years, many adults start to realise, when they look at themselves in the mirror, that they are getting increasingly stooped. Some people are unwilling to accept this situation and start wondering whether they can do anything to arrest this process. The question is, can this condition be improved or is it pointless even to try?

The condition we are talking about is HYPERKYPHOSIS. If you look at a person sideways on, you see that their back is not straight, but has natural curves, whose function is to cushion the forces that act on the spine. Following the back line from the top down, we see that first, at cervical level, there is a forward curvature, termed LORDOSIS, then a backward dorsal one, called KYPHOSIS, followed by another forward curve, at lumbar level, also called LORDOSIS. When the amplitude of the dorsal kyphotic curve, measured on an X-ray, exceeds the normal range, we speak of HYPERKYPHOSIS. Usually, this curve measures between 20 and 60 Cobb degrees.
Various factors explain this considerable range. Some are positional and related to the type of examination performed (for example the position of the arms), while others are linked to the associated disorder itself, which may be characterised by marked (e.g., scoliosis) or more prominent (e.g., idiopathic hyperkyphosis, Scheuermann’s disease) curves. Elderly people often present hyperkyphosis caused by the osteoporotic vertebral collapse. As the bones become more fragile, even minor movements can cause tiny fractures of the anterior portion of the vertebrae, resulting in progressive bending of the whole back. 

Everyone’s back bends forward more as the years go by, regardless of whether or not they have hyperkyphosis.
Why is this?  Most people spend much of their time, i.e., many hours of most days over many years, in a hunched position, with the head looking downwards. In fact, in our daily lives, we are often in the sitting position, which encourages forward flexion of the back; furthermore, many of the activities that require us to move around (cooking, cleaning, DIY, hobbies) also involve bending forwards. For all these reasons, dorsal kyphotic curves tend to get progressively worse over time, we become increasingly stiff, and the trunk extensor muscles grow weaker, resulting in postural collapse. In short, all these factors, combined, leave us “crushed” by the force of gravity.

What are the effects of hyperkyphosis? In adults and the elderly, hyperkyphosis can increase our risk of back pain and worsen our quality of life as we find it increasingly challenging to support our back, both when seated and when standing. Another effect is impaired balance and stability when walking.

So, to go back to our original question: is it possible to break this vicious cycle through physiotherapy and, in particular, through specific exercises? 

The answer is yes! The initial objectives of the treatment are to reduce the stiffness of the dorsal spine and strengthen the trunk muscles that oppose the force of gravity, so as to facilitate postural recovery, and to integrate the correction into daily life. Indeed, from the outset, the treatment approach based on specific exercises encourages patients to learn the crucial “self-correction” movement that allows them to achieve optimal realignment of the spine in the sagittal plane without compensating for this at other levels of the spine (reference: Exercise for improving age-related hyperkyphosis: a systematic review and meta-analysis with GRADE assessment. Ponzano M, Tibert N, Bansal S, Katzman W, Giangregorio L. Arch Osteoporos. 2021 Sep 21;16(1):140. doi: 10.1007/s11657-021-00998-3. PMID: 34546447)

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Once the improvement has been obtained, it needs to be made stable and lasting. This involves reducing the frequency of the specific exercises and integrating them with other types of physical or sporting activity, all the time continuing to maintain the correction in daily life.  

Together, all this translates into less pain, better physical function and a more attractive back.

Giulia, the story of a record-breaking Paralympic champion

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It was her smile that first made us want to hear her story.

Giulia Terzi, 26, recently came back from the Tokyo Aquatics Centre with five Olympic medals from five races (two golds, two silvers and a bronze) — a new Italian and European record. Within the space of just weeks, she was also awarded, with top marks, a degree in law, to add to a previous one in political science. All in all, she is a real wonder woman, blessed with truly enviable determination and perseverance.
“When I asked her how all this makes her feel,” says Isico physiotherapist Martina Poggio, who had the privilege of interviewing her, she said: “It’s like a dream that I am still struggling to take in. It is the culmination of countless sacrifices. Each time I pick up my medals and look at them, I am reminded that hard work, sacrifices and everything you have to give up really are worth it, and can take you to the top, even though it can be hard to believe it at the time.”

Giulia also explained: “I went through some very difficult years. I was diagnosed with congenital scoliosis at the age of just 3 years, and therefore embarked on an exercise-based treatment at a very young age. When I was 14 years old, I spent 9 months wearing a plaster cast and that was followed by 4 years of bracing. Between 2015 and 2018, I had three operations, and as a result of medullary complications that arose subsequently, I am now in a wheelchair. I have found that the secret is to have the right people around you, trust those who love you and, whenever you need it, ask for help.  No one is invincible and some days and periods are more difficult than others, but with the love and support of family, friends and the right people, you can overcome anything! My parents and siblings have been crucial in helping me get through the hard times, I owe them so much!”

Giulia has a great Instagram profile, full of content, where she writes: “In my case, scoliosis has meant casts, braces, three operations, and titanium rods in my back with all that that entails. But, more than all of this, the word scoliosis, to me, means lots of other things as well. It means a bond, that special bond created through the looks you exchange with those around you, who see how hard you have to fight every single day, fight back tears when you are being taken off for surgery, but also look at you with so much pride whenever, despite everything, you achieve an objective. Scoliosis means pain, sleepless nights spent trying to sleep on a table or the bedroom floor. It means resilience, because all of this has, after all, allowed me to develop into a much stronger person, teaching me to endure fatigue and to pour ever more determination into making my dreams come true, because nothing has been allowed to get in the way of those! It also means love, for the people who have been by my side since the start, and ice creams that could not be enjoyed outdoors, in a park, but had to be eaten in a hospital bed, laughing about it, like it was the normal thing to do. When you find yourself facing a difficult situation, it’s so easy to let yourself get dragged down by negative comments, words and fears, but in the end, it is the energy and determination with which you pick yourself up that shows you for the person you are and that, whatever your problems, that must always win through.”

I prefer to quote Giulia’s exact words because I really believe that only someone who has gone through this experience themselves can really understand what it is like for our youngsters having to wear a brace day after day, rising bravely to the challenges that scoliosis brings” Martina Poggio says. 

“I wanted to turn a spotlight on Giulia, because she is a great example and her story illustrates perfectly the importance of fighting every day and not giving up on your dreams.”

The scientific literature reports perioperative complication rates of between 5% and 20%, depending on the surgical approach and the type (severity) of the complications themselves (Weiss, HR., Bess, S., Wong, M.S. et al. Adolescent idiopathic scoliosis – to operate or not? A debate article. Patient Saf Surg 2, 25 (2008). https://doi.org/10.1186/1754-9493-2-25). The rate of neurological complications after posterior fusion is 0.32%.

Unfortunately, Giulia is part of that very small percentage, but her case is a crucial reminder of the fact that every difficulty can also bring new opportunities. This is a message aimed both at those youngsters who, through exercises, are trying to make sure their condition does not worsen to the point of needing bracing treatment, and also at those who are wearing a brace in the hope of managing to avoid surgery.

“Another important aspect of this story, worth underlining, is the important role played by sport,” Poggio points out. “As Giulia says, “sport is fundamental, because it helps you experience lots of different worlds and get to know loads of people. But it also presents you with many challenges and helps you overcome barriers. My particular scoliosis-related barrier was the idea that “I can’t…”.
Instead, what sport teaches you is that you can! And you also learn that this is partly thanks to the support you get from being part of a group that believes in the objective you have set yourself and helps you to achieve it.”

“It can certainly be difficult fitting in sports training, studying and physiotherapy” says Giulia, reflecting on a typical day in her life. “However, I think that health has to be the number one priority and that, to stay fit and well, you need to show the same level of commitment to your treatment as you do to your other pursuits. Studying is another key area that shouldn’t be neglected. Education is crucial when it comes to building your future and chosen career, and studying is clearly the key contributor to this objective. The trick is to be organized: I do two hours of swimming in the morning, followed by a gym or physiotherapy session. Then I go home to study. I do another couple of hours in the pool in the afternoon, and then in the evening it’s back to my books!  It’s a tough schedule, but this year I managed to win a gold medal at the Paralympic Games and graduate in law, earning top marks with honours, so all in all I would say that all my sacrifices have paid off!”

Many of our youngsters who do competitive sport are familiar with the challenges Giulia describes. When they are told that they need to wear a brace full time, their main concern is making sure they can go on practising the sporting activity they have dedicated so much to. The physicians at Isico agree that it is hugely important to ensure that wearing a brace does not interfere too much with these young people’s lives. Indeed, everything possible is done to make sure that they can go on training every day, in spite of the treatment they are receiving.

We asked Giulia what advice she has for youngsters dealing with scoliosis and its challenges on a daily basis, and she replied: “Don’t let barriers and prejudice stop you. Unfortunately, you are bound to meet some, but we all have hidden resources. If you can discover those, you can develop into a great man or woman. Learn from your sport, and on difficult days try and find at least one reason to be happy! Everything is easier with a smile on your face!”

We end with another valuable consideration taken from Giulia’s Instagram profile. She says: “I think that you really need to embrace pain fully. Don’t try and block it out: let it in and learn to live with it. It needs to take its time and work in its own way. It has to develop before it weakens. After that, the scars will fade, but only with time. It doesn’t make sense to try and hide them. People can’t always be invincible. Instead, I firmly believe that those who sometimes allow themselves to be fragile are actually stronger.”

Back and neck pain and smartphone: is there a correlation?

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Can being bent over the smartphone too often cause back- and neck pain in younger people? Data coming out of the study Posture and time spent using a smartphone are not correlated with neck pain and disability in young adults: A cross-sectional study, published some time ago by the Journal of Bodywork and Movement Therapies are not confirming this.

The cross-sectional correlational study was conducted in a sample of students selected through convenience sampling between September 2016 and March 2017: the inclusion criteria were university students at the School of Medicine and Surgery, routine/daily use of mobile devices with advanced computing and connectivity capability built on an operating system, and aged 18–30 years. A total of 238 volunteers were recruited.

“The objective of the study – explains Prof. Stefano Negrini, scientific director of Isico and one of the authors of the research – was to determine the impact of smartphone use on neck impairment and functional limitation in university students. Neck pain was assessed using a visual analogue pain score (VAS) and a pain drawing (PD); disability status was measured using the Neck Disability Index (NDI-I); cervical postures while using the phone were captured using the Deluxe Cervical Range of Motion (CROM) device”.

While half of the young medical students reported neck pain, the use of smartphones was not correlated with neck pain and disability. “While we wait for future prospective studies – ends Prof. Negrini – there is no reason to recommend a change in smartphone use habits among young adults in the meantime”.

Isico among the attendees of the November SRS webinar

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A new webinar for professionals is scheduled for November 7, part of the cycle of those organized in recent months by the SRS (available on the pages of the society’s website).

Two specialists from Isico, our scientific director, Prof. Stefano Negrini and Dr. Fabio Zaina, Isico physiatrist will be taking part in this online event titled Current Status of Bracing in Adults and Adolescents:An SRS-SOSORT Collaboration.

Join the SRS Non-Operative Committee and the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) for a webinar analyzing the current evidence and practice guidelines for bracing for adolescent and adult patients with spinal deformity.

This webinar will provide a systematic analysis of the current evidence and best practice guidelines for bracing management of patients with spinal deformity in both adolescents and adults. With variations in brace design and documentation of long-term benefits, use the consensus discussed to clarify your current practice and brace selections.
There will be an update on the current training of Orthotists, including specialization, fabrication, fitting and deformity correction.

To register please visit the page of the SRS website

Digital Transformation at ISPO: Isico is there

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The theme of the international online conference of the International Society for Prosthetics and Orthotics (ISPO), scheduled from 1 to 4 November will be “Digital Transformation in an Evolving World”: the World Congress will explore how digital transformation affects all aspects of using and working with assistive technology, from booking a clinic appointment and electronic health records to computer-aided design, microprocessor-controlled prostheses or orthoses, or video conferencing and social media.

 During the event, Prof.Stefano Negrini, Scientific Director of Isico, will present one poster, Modular Effective as Custom-Made. A Matched Case-Control Study of Modular Italian MI-brace vs Very-Rigid Sforzesco Brace in AIS” and two oral presentations “Introducing Pelvis Semi-Rigid Material does not change Short-Term Very-Rigid Sforzesco Brace Results. A Matched Case-Control Study in AIS” and “Reducing the Pelvis Constriction Changes the Sagittal Plane. A Retrospective Case-Control Study of Free Pelvis vs Classical Very-Rigid Sforzesco Braces”. 

Furthermore, Prof. Negrini will also hold a workshop on November 2nd on Innovations in the Design of Hard Rigid Braces for Adolescent Idiopathic Scoliosis Treatment in collaboration with Guerrino Rosellini and Fabrizio Tessadri of the orthotist’s shops ITOP and Orthotecnica.