Long-Term Management of Adolescent Idiopathic Scoliosis in Adulthood: Clinical Challenges and Progress During the Critical Period of Pregnancy

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Zhaomeng Hou, Jiaojiao Wu, Chaoqun Chen, Hua Lu, Jiali Yang, Tingliang Han 

PMID: 41975857 PMCID: PMC13073979 DOI: 10.3390/healthcare14070856

ABSTRACT

Adolescent idiopathic scoliosis (AIS) is the most common three-dimensional spinal misalignment, with its impact often extending into adulthood and presenting a range of long-term health challenges.
This review focuses on the long-term management strategies for adult patients with AIS and explores the unique physiological event of pregnancy and its influence on disease progression, clinical symptoms, and treatment decisions. We systematically analyze the natural history of adult AIS, the evolution of pain and functional impairment, and radiographic progression patterns. Special emphasis is placed on biomechanical changes of the spine and pelvis during pregnancy and postpartum, pain management approaches, delivery mode selection, and potential effects on offspring.
By integrating current evidence and recent research findings, this review synthesizes key insights: the progression of AIS in adulthood is typically slow but can be exacerbated by factors such as significant curve magnitude at skeletal maturity; pregnancy does not consistently accelerate curve progression but may intensify pain and functional limitations, necessitating tailored multidisciplinary management; and evidence supports that most women with AIS can undergo vaginal delivery without increased obstetric risk, while anesthetic and analgesic planning requires careful consideration of spinal anatomy.

This review aims to provide evidence-based guidance and clinical recommendations for comprehensive lifelong health management of this special patient population.

Keywords: adult patients; idiopathic scoliosis; long-term management; pain management; pregnancy; spine-pelvic biomechanics.

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Conflict of interest statement

The authors declare no conflicts of interest.

https://pubmed.ncbi.nlm.nih.gov/41975857/

SOSORT 2026 kicks off: ISICO contributes 23 studies and shares new research highlights

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The international SOSORT 2026 Congress opened on April 29 in Turin, Italy, and will run until May 2, bringing together experts from around the world in the field of conservative treatment of scoliosis and spinal deformities.

ISICO is contributing with a significant scientific output: 23 studies delivered as oral presentations and posters, confirming its ongoing commitment to research and clinical innovation. After presenting in our previous issue the two studies selected for the SOSORT Award, we are continuing here with four additional studies, most of which will be delivered as oral presentations.

Exercise adherence: understanding motivation to personalise care

A Rasch-Validated Questionnaire for Evaluating Adherence Predisposition to Scoliosis Specific Exercises in Adolescents with Idiopathic Scoliosis: Preliminary Results 
Vanossi M., Ferrario I., Leonelli B., Negrini S., Negrini A.

This study, presented as an oral presentation, introduces a Rasch-validated questionnaire designed to assess adolescents’ predisposition to adhere to scoliosis-specific exercises.

Findings show that adherence is multidimensional, driven by:

  • intrinsic motivation,
  • extrinsic motivation.

These components interact and influence patient behaviour differently, providing a foundation for more personalised and effective treatment strategies.

Video comment by Irene Ferrario

Brace quality: a checklist to standardise the brace check process 

The “Brace-Check List”: A New Tool for Scoliosis Brace Quality Control 
Febbo F., Zaina F., Lusini M., Zonta A., Ferrario I., Negrini S., ISICO physicians and I-SHAPE team

This study (an oral presentation at the conference) presents a structured checklist, developed through a consensus process, to improve the quality of brace evaluation.

It addresses four key domains:

  • brace fitting,
  • tolerability,
  • three-dimensional balance,
  • corrective effectiveness.

The goal is to make the brace check more systematic and reliable, ultimately improving both treatment outcomes and adherence.

Video comment by Francesca Febbo

Brace adherence: perspectives from patients, families, and professionals

Bracing for Success: Comparison of Patient, Family, and Professional Perspectives on Barriers and Facilitators from 3414 Messages in a Scoliosis Blog (poster)
Rebagliati G., Negrini A., Colombo M., Negrini F., Ferrario I., Negrini A., Zaina F., Negrini S.

Presented as a poster, this study analyses over 3,400 contributions to identify barriers and facilitators to brace adherence.

Key differences emerge across groups:

  • patients mainly report emotional impact and physical discomfort,
  • parents highlight informational needs,
  • professionals focus more on clinical aspects.

Facilitators include clinical support, effective communication, and perceived treatment results, highlighting the importance of a comprehensive, multidisciplinary approach.

Video comment by Giulia Rebagliati

Exercises and gender: minimal differences, beyond stereotypes

Gender differences in self-reported adherence to scoliosis-specific exercises: a cross-sectional study of 2,214 patients with adolescent idiopathic scoliosis
Romano M.

This study, presented as an oral presentation, investigates gender differences in exercise adherence in over 2,200 adolescents.

Males reported slightly higher exercise time than females; however, the difference is:

  • statistically significant,
  • but clinically negligible.

These findings challenge common assumptions and support the need for individualised approaches rather than gender-based expectations.

Video comment by Michele Romano

Ongoing updates

In the next updates, we will share more studies, along with insights and reflections emerging from the congress. The results of the SOSORT Award winners are also expected in the coming days.

Clinical, Psychological, and Social Determinants of Brace Compliance in Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-Analysis

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Marco Sapienza, Marco Simone Vaccalluzzo, Emanuele Perricone, Carmelo Giannone, Alessia Caldaci, Giuseppe Musumeci, Andrea Vescio, Gianluca Testa, Vito Pavone

Review.J Funct Morphol Kinesiol. 2026 Feb 8;11(1):68.doi: 10.3390/jfmk11010068

ABSTRACT

Background

Brace adherence is a key determinant of treatment success in adolescents with idiopathic scoliosis. However, adherence is influenced by multiple clinical, psychological, and social factors, and reported wear times vary widely across studies. This systematic review and meta-analysis aimed to identify determinants of brace adherence and assess their quantitative impact on real wear.

Methods

A comprehensive search was conducted in PubMed/MEDLINE, Scopus, Web of Science, Embase, and Google Scholar from database inception to November 2025. A total of 1040 records were identified, 620 were screened, and 45 full-text articles were assessed for eligibility. In total, 17 studies met the inclusion criteria and were included in the qualitative synthesis, and 10 provided extractable quantitative data and were included in the meta-analysis.

A random-effects model was used to calculate pooled mean differences for identified determinants, including sex, age, early adherence, and sensor-based monitoring.

Results

In total, 17 studies involving 1716 adolescents were included, and 10 provided extractable quantitative data for meta-analysis. Objective sensor-based monitoring was consistently associated with higher adherence, with a pooled mean difference of 25.6 percent compared with non-sensor methods.
Early adherence significantly predicted long-term compliance, with a mean difference of 9.6 percent. Younger adolescents demonstrated greater adherence than older patients, with a mean difference of 19.1 percent, while sex differences favored females but did not reach statistical significance. Psychosocial determinants such as body image perception, stress, family dynamics, and religious environment played an important role in modulating adherence.
Higher body mass index (BMI) and reduced quality of life were associated with poorer compliance. Overall, studies evaluating positive determinants reported a pooled mean adherence of 89.6 percent compared with 67.7 percent in studies characterized by negative determinants.

Conclusions

Brace adherence is determined by a combination of clinical and psychosocial factors.
Sensor-based monitoring, strong early adherence, and supportive environments consistently enhance compliance, whereas stress, poor body image, and higher BMI hinder wear. Targeted interventions, early counseling, and standardized adherence metrics are needed to improve outcomes in brace-treated scoliosis.

Keywords: adolescent; monitoring; orthotic devices; patient compliance; physiologic; quality of life; scoliosis.

https://pubmed.ncbi.nlm.nih.gov/41718196/

Ultrasonographic evaluation of diaphragmatic thickness in adolescents with thoracic hyperkyphosis: new horizons in diagnosis

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Deniz Oke, Zeynel Karakullukcuoglu, Meryem Guneser Gulec , Cansu Ozkan 

MC Musculoskelet Disord. 2026 Jan 2;27(1):92. doi: 10.1186/s12891-025-09462-6

ABSTRACT

Purpose: Thoracic hyperkyphosis (THK) is a prevalent spinal deformity in adolescents, which can impair respiratory function by affecting diaphragm morphology and thoracic mechanics. This study investigates the relationship between THK and diaphragmatic thickness using ultrasonography (USG) to explore its diagnostic and therapeutic implications.

Methods: This prospective study included 25 adolescents with THK and 29 healthy controls. Diaphragmatic thickness was measured using ultrasonography at the end of inspiration and expiration, and spirometry was conducted to assess respiratory function. Thoracic hyperkyphosis was diagnosed based on Cobb angle measurements. Statistical analysis included regression and ROC analyses to determine predictors of THK and evaluate diagnostic accuracy. The study was approved by the local Ethics Committee of the University of Healthy Science, Gaziosmanpasa Training and Research Hospital (IRB number: 109, date: 16 August 2023). The study protocol was registered to the clinicaltrial.gov.tr (NCT06418334 and initial release date: 01/11/2024).

Results: Adolescents with THK exhibited significantly higher Cobb angles (59.3 ± 7.9°) compared to controls (34.6 ± 3.7°, p < 0.001). Diaphragmatic thickness during inspiration (2.5 mm vs. 3.1 mm, p = 0.125) and expiration (1.50 mm vs. 1.56 mm, p = 0.965) was lower in the THK group, with significant reductions in thickening ratio (1.76 ± 0.29 vs. 1.98 ± 0.30, p = 0.008) and thickening fraction (DTf) (75.4% vs. 97.6%, p = 0.008). A negative correlation was observed between Cobb angle and diaphragmatic thickening (r=-0.378, p = 0.005). ROC analysis indicated that USG parameters, particularly thickening fraction (AUC = 0.72, p = 0.002), are reliable predictors of THK.

Conclusion: Adolescents with THK demonstrate reduced diaphragmatic thickness and impaired respiratory function. Ultrasonography emerges as a valuable, non-invasive tool for early diagnosis and monitoring of THK, offering potential for timely intervention to mitigate respiratory complications.

Keywords: Adolescents; Cobb angle; Diaphragmatic thickness; Spirometry; Thickening fraction; Thickening ratio; Thoracic hyperkyphosis; Ultrasonography.

https://pubmed.ncbi.nlm.nih.gov/41484972/

Impact of baseline HRQOL on brace-related stress in female patients with adolescent idiopathic scoliosis: a longitudinal retrospective study

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Tomoyuki Asada, Toshiaki Kotani, Tsuyoshi Sakuma, Yasushi Iijima, Kotaro Sakashita, Yosuke Ogata, Shohei Minami, Seiji Ohtori, 

Masao Koda, Masashi Yamazaki 

Spine Surg. Relat Res. 2025 Aug 9;9(6):682-689. doi: 10.22603/ssrr.2025-0088.eCollection 2025 Nov 27.

ABSTRACT

Introduction: Brace treatment is an essential nonoperative strategy to prevent curve progression in adolescent idiopathic scoliosis (AIS), yet it can cause substantial psychological stress. However, few studies have investigated factors associated with brace-related psychological stress. This study aimed to evaluate the association between pre-bracing health-related quality of life (HRQOL) and brace-related psychological stress during treatment.

Methods: This study retrospectively analyzed female patients with AIS aged 10-15 years who initiated brace treatment at a single center. Inclusion criteria were a baseline Cobb angle of 20-40°, initiation of full-time bracing, and completion of standardized questionnaires. Baseline assessments included demographic and radiographic data, as well as patient-reported outcomes: the Scoliosis Research Society-22r and the Scoliosis Japanese Questionnaire-27 (SJ-27). Brace-related psychological stress was assessed at multiple time points during the first year using the Japanese version of the Bad Sobernheim Stress Questionnaire-Brace (JBSSQ-brace). A linear mixed-effects model was used to identify baseline factors associated with higher stress levels over time.

Results: A total of 151 patients (mean age 12.4±1.1 years) were included. At one month, 32.5% of patients reported moderate to severe stress (JBSSQ-brace ≤16), and 11.8% of the total cohort experienced worsening stress during the first six months. In multivariable analysis, a higher baseline SJ-27 score was significantly associated with increased brace-related psychological stress over time (β=-0.15±0.04, p<0.001). Other factors, including age, skeletal maturity, pre-bracing Cobb angle, and in-brace correction rate, were not significant.

Conclusions: Lower pre-bracing HRQOL, as measured by the SJ-27, was independently associated with increased psychological stress during brace treatment. Early psychological screening using AIS-specific HRQOL tools may help identify high-risk patients and provide timely support to improve compliance and treatment outcomes.

Keywords: Adolescent Idiopathic Scoliosis (AIS); Brace Treatment; Brace-Related Stress; Health-Related Quality of Life (HRQOL); JBSSQ-brace; Psychological Stress; Scoliosis Japanese Questionnaire-27 (SJ-27).

https://pubmed.ncbi.nlm.nih.gov/41393780/

Agreement between the Sanders Maturity Scale and Pelvic Maturity Indicators in Children with Idiopathic Scoliosis: A Validation Study

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Vojtech Capek, Sara Brandt Knutsson, Per Wessberg, Helena Brisby, Olof Westin  

Spine (Phila Pa 1976). 2025 Dec 11. doi: 10.1097/BRS.0000000000005597. Online ahead of print.

ABSTRACT

Study design: Validation study on the agreement between the Sanders Maturity Scale (SMS) and the Pelvic Maturity Indicators (PMI) scale.

Objective: To validate the PMI concept and assess its reliability.

Summary of background data: Reliable assessment of skeletal maturity is essential for the management of adolescent idiopathic scoliosis (AIS). The pelvic maturity indicators system (PMI) was developed to link two most commonly used skeletal maturity scales, the Risser sign (RS) and SMS. This study aimed to validate the PMI using a blinded, multi-rater agreement design.

Methods: Sixty-seven consecutive AIS patients with both hand and pelvic radiographs obtained within a three-month interval were included and evenly distributed across SMS categories. The PMI comprises seven stages observable on pelvic radiographs. Radiographs were anonymized, randomized, and assessed by four raters in one SMS survey and two consecutive PMI surveys. Gold-standard ratings were established for each patient. Agreement between PMI and SMS was analyzed using Spearman’s rank correlation, Cohen’s κ, and Krippendorff’s α to evaluate correlation, pairwise, and multi-rater agreement, respectively.

Results: PMI and SMS demonstrated strong correlation (ρ=0.88; 95% CI, 0.77-0.93) and substantial agreement (κ=0.69; 95% CI, 0.60-0.79). Exact stage concordance was observed in 51% of cases. PMI stages 2, 3, 4, and 7 showed the highest concordance with SMS (100%, 64%, 50%, and 42%, respectively). Inter-rater agreement for SMS and PMI was near perfect (α=0.96; 95% CI, 0.95-0.97) and substantial (α=0.82; 95% CI, 0.78-0.86), respectively.

Conclusions: The PMI is a validated and reliable extension of the Risser sign, demonstrating substantial agreement with SMS. It provides a clinically useful framework linking triradiate cartilage, RS, and SMS grading systems in skeletal maturity assessment.

Level of evidence: II.

Keywords: Sanders maturity scale; agreement; idiopathic scoliosis; inter-rater reliability; intra-rater reliability; maturity assessment; pelvic maturity indicators; scoliosis; skeletal maturity; triradiate cartilage; validation.

https://pubmed.ncbi.nlm.nih.gov/41396364/

The Use of Proximal Femur Maturity Index in Guiding Brace Weaning for Adolescent Idiopathic Scoliosis

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Prudence Wing Hang Cheung, Federico Canavese, Janus Siu Him Wong, Keith Dip Kei Luk, Jason Pui Yin Cheung  

JB JS Open Access. 2025 Nov 12;10(4):e25.00191. doi: 10.2106/JBJS.OA.25.00191.eCollection 2025 Oct-Dec

ABSTRACT

Background: For adolescent idiopathic scoliosis, whether the Proximal Femur Maturity Index (PFMI) can guide brace-wear weaning remains unknown. The aim of this study was to investigate whether PFMI gradings at brace weaning were related to curve progression after brace treatment and to evaluate the postweaning curve progression risk associated with PFMI gradings.

Methods: This prospective study included 137 patients who were advised to wean from underarm bracing with adequate compliance. They were followed up for at least 2 years. Data collection included bodily growth parameters, curve magnitude, and skeletal maturity status at weaning as assessed by PFMI, distal radius and ulna classification, and Risser and Sanders staging. Curve progression was defined as >6° major curve increase at postweaning 2 years. Relationships between PFMI and other skeletal maturity gradings, and whether parameters at weaning were associated with curve progression were investigated.

Results: There were 59.1% (n = 81) of patients who weaned bracing at PFMI grade 5, 39.4% at grade 6, and 1.5% at grade 4. PFMI gradings correlated with radius (G = 0.596, p < 0.001), ulnar (G= 0.700, p < 0.001), and Sanders (G = 0.689, p < 0.001) stages. 11.7% of the patients experienced curve progression. Curve progression rate was 0% for those who weaned at PFMI grade 6, or PFMI grade 5 with Risser stage 5 or ≥ R10 U9 for <30° curves. Compared with PFMI grade 4 or 5, weaning at grade 6 reduced progression risk by 29.7% (95% Confidence Interval [CI] 13.3-43.0, p = 0.023) for curves ≥30°, while relative risk reduction was 10.9% (95% CI 1.4-19.4, p = 0.037) for <30° curves.

Conclusions: For patients who were prescribed bracing for their 25° to 40° curves with adequate compliance, PFMI grade 6 can serve as an independent indicator for guiding brace weaning with minimal curve progression risk.

https://pubmed.ncbi.nlm.nih.gov/41210905/

Evaluating the readability and quality of AI-generated scoliosis education materials: a comparative analysis of five language models

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Mengchu Zhao, Mi Zhou, Yexi Han, Xiaomei Song, Youbin Zhou, Haoning He 

Sci Rep. 2025 Oct 10;15(1):35454. doi: 10.1038/s41598-025-19370-3.

ABSTRACT

The complexity of scoliosis-related terminology and treatment options often hinders patients and caregivers from understanding their choices, making it difficult to make informed decisions. As a result, many patients seek guidance from artificial intelligence (AI) tools. However, AI-generated health content may suffer from low readability, inconsistency, and questionable quality, posing risks of misinformation.
This study evaluates the readability and informational quality of scoliosis-related content produced by AI. We evaluated five AI models-ChatGPT-4o, ChatGPT-o1, ChatGPT-o3 mini-high, DeepSeek-V3, and DeepSeek-R1-by querying each on three types of scoliosis: congenital, adolescent idiopathic, and neuromuscular.
Readability was assessed using the Flesch-Kincaid Grade Level (FKGL) and FleschKincaid Reading Ease (FKRE), while content quality was evaluated using the DISCERN score. Statistical analyses were performed in R-Studio. Inter-rater reliability was calculated using the Intraclass Correlation Coefficient (ICC). DeepSeek-R1 achieved the lowest FKGL (6.2) and the highest FKRE (64.5), indicating superior readability.
In contrast, ChatGPT-o1 and ChatGPT-o3 mini-high scored above FKGL 12.0, requiring college-level reading skills. Despite readability differences, DISCERN scores remained stable across models (~ 50.5/80) with high inter-rater agreement (ICC = 0.85-0.87), suggesting a fair level quality. However, all responses lacked citations, limiting reliability.
AI-generated scoliosis education materials vary significantly in readability, with DeepSeek-R1 being the most accessible. Future AI models should enhance readability without compromising information accuracy and integrate real-time citation mechanisms for improved trustworthiness.

Keywords: AI-generated health information; DISCERN score; Patient health literacy; Readability assessment; Scoliosis.

https://pubmed.ncbi.nlm.nih.gov/41073603/

Utilizing Mobile Health Technology to Enhance Brace Compliance: Feasibility and Effectiveness of an App-Based Monitoring System for Adolescents with Idiopathic Scoliosis

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Judith Sánchez-Raya, Judith Salat-Batlle, Diana Castilla, Irene Zaragozá, Azucena García-Palacios, Carlos Suso-Ribera 

Pers Med. 2025 Sep 1;15(9):405.doi: 10.3390/jpm15090405

ABSTRACT

Background/Objectives: Adolescent idiopathic scoliosis (AIS) often requires prolonged brace use to prevent curve progression. However, adherence is challenging due to discomfort, mobility restrictions, and psychosocial stressors. This study evaluated the feasibility and clinical utility of a mobile health (mHealth) system for real-time tracking of brace adherence and treatment-related experiences in adolescents with AIS. 

Methods: Thirty adolescents with AIS (mean age = 12.9, SD = 1.8) undergoing brace treatment at a tertiary care center used a custom app for 90 days. The app collected daily self-reports on brace wear duration, discomfort, movement limitations, emotional distress, and social challenges. A clinical alarm system alerted providers when patient input indicated potential concerns. Primary outcomes were feasibility (adherence to daily use and usability ratings) and brace adherence. Secondary outcomes included the app’s capacity to identify treatment-related challenges and its association with changes in stress, quality of life, anxiety, and depression. 

Results: Participants reported meeting recommended brace wear time (≥16 h/day) on 84.8% of days. The app triggered 186 clinical alarms, with the most frequent related to emotional distress (23.1%) and pain (15.6%). Alarm frequency declined over time. Improvements of ≥20% in psychological outcomes were observed in 20-26.7% of participants, while group-level changes were nonsignificant. 

Conclusions: mHealth-based monitoring appears feasible and acceptable for digitally engaged adolescents with AIS. The app supported early detection of treatment barriers and prompted timely clinical responses. Despite limitations, it shows promise as a tool to improve treatment engagement and address psychosocial challenges in scoliosis care.

Keywords: adolescent idiopathic scoliosis; brace adherence; digital health monitoring; mobile health (mHealth); patient-reported outcomes; personalized medicine.

https://pubmed.ncbi.nlm.nih.gov/41003108/

ISICO Online Master 2026: let’s start

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Registrations for the 11th edition of the ISICO Online Master “Principles and Practice of Scoliosis Conservative Treatment – PPSCT” will open on October 15th, 2025. The course will start in January 2026.

This training program has now become a well-established part of ISICO’s educational offer, alongside the Italian Master, the SEAS courses, and the course on Sforzesco brace construction.

A truly international training program

Since its launch in 2016, the Master has welcomed 334 participants from 66 different countries:

  • 126 European
  • 96 Asian
  • 74 from the Americas
  • 18 from Africa
  • 20 from Oceania

A genuine global learning event, giving professionals from different cultures the chance to meet, exchange ideas, and grow together.

“The organisation is very didactic, starting with the basic knowledge and evaluation techniques, evolving to more specific subjects, and finally, when the students already have some knowledge framework, focusing on the suggestion and discussion of clinical cases. The live lecture was a perfect conclusion for the discussion groups. Most of the recorded lectures had great quality content and very good visual presentation.”
— Leonardo, Brazil

Course structure

The Master is delivered entirely online and self-administered through a dedicated learning platform. It is organized into 16 modules lasting two or three weeks each, including:

  • three recorded lectures of about 45 minutes;
  • scientific papers for in-depth study;
  • a final assignment for each module;
  • discussion sessions for interaction and exchange among participants.

The experience of a global community

One of the most valued aspects is the opportunity to connect with colleagues from all over the world: a unique chance to discover treatment practices, expectations, and experiences in different countries.

“From this course, I hope to gain in-depth knowledge of scoliosis, learn from renowned experts, and connect with specialists from all over the world to understand how they manage it in their own countries.”
— Joy Igudia-Akumabor, Nigeria

Early bird registration is available until December 8th, 2025.