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Can we be sure that this brace works?

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A brace is a tool used to prevent the progression of scoliosis. They can be made of different materials: plastic (with metal parts), partly leather, or entirely elastic and fabric.

Finally, there exist numerous models with different names, such as the Cheneau, Sforzesco, PASB, Lapadula, Maguelone, and so on, not to mention variants of these different models.  

All this adds up to a real maze of terminology that the parents of a child or teenager recently diagnosed with scoliosis or a spinal disorder suddenly find themselves having to try and understand.

Why is it all so confusing?

It is not confusing, it is just that there exist different models, all designed to serve the same purpose, namely, to obtain the best possible alignment of the spine in order to counteract the evolution of the disease, which manifests itself as a progressive misalignment of the vertebrae.

Individual situations and cases vary, and braces are therefore chosen to meet the patient’s specific needs, which are determined by the severity, type and location of the curve.

The shape of the spine, viewed sideways on, is also a crucial aspect to consider when choosing a brace; this sagittal profile shows a series of physiological curves: cervical lordosis, dorsal kyphosis, lumbar lordosis and sacral kyphosis.

If these curves are correctly positioned and well balanced, your back will be strong; if not, it will be weak and vulnerable to the stresses of everyday life.

The type and construction features of the brace must be chosen by a medical specialist after a thorough assessment of the type of problem, the severity of the condition, the risk of progression, and the habit of using one brace compared with another.

One particular feature of the scoliotic spine, which we professionals must seek to address, is the presence of a deformity in the sagittal plane, in other words, a deformity of the spine as viewed from the side.

Indeed, the action of the disease can result in a reversal of the natural pattern of the curves described above. A dorsal scoliotic curve, for example, will have the effect of flattening the back, reducing or even reversing the direction of the natural dorsal kyphosis.

This makes the back look unnaturally “straight” or even causes the spine to curve inwards, creating a dorsal lordosis.

Such a deformity can seriously affect the health of the spine.

Indeed, conserving the physiological pattern of spinal curves in the sagittal plane means keeping the back strong, healthy and working efficiently.

When patients are diagnosed with dorsal scoliosis with this flattening of the back, their parents are often surprised because these youngsters, very erect, appear to have what is classically considered a “perfect” posture.

Most people associate scoliosis with a curved back and round shoulders. After all, as children, we are so often told: “Stand up straight or you’ll get scoliosis!” . Therefore, associating straightness with scoliosis seems something of a contradiction in terms.  But this is not the case at all.

A flat back, caused by dorsal scoliosis, is indeed one of the many forms that scoliosis can take: it is actually quite a frequent form and also one that can be difficult to treat using corrective tools.

Normally, a brace exerts a pushing action, but in these cases, to improve the shape of the back, the brace would need to act as a sort of suction cup, pulling the vertebrae back into position.

Obviously, this is not possible; therefore, in these cases, the brace will be shaped in such a way as to encourage the trunk and shoulders to assume a more “hunched” position so as to try and prevent the spine from becoming “too straight”.

The most worrying and upsetting aspect for parents is precisely this: to see their “straight backed” youngsters assuming, with their brace on, this rounded position with forward slumped shoulders – after all, their posture initially seems to look worse than before!

However, they soon understand the reason for it: these patients are not being asked to “stand up straight”; instead, what they need to do is learn to assist the corrective action of the brace, which is specially designed to promote kyphotic curvature of the upper spine.

In short, it isn’t easy to be sure that a brace is working, especially when, as in cases like these, its action seems to go against traditional aesthetic parameters.

However it is important to understand that, in many cases, certain construction features of the brace are the result of complex biomechanical reasoning.

What should you do if you are concerned? Ask, without hesitation, because exchanges with experts are always useful for learning about the corrective aspects of the treatment.

SRS research evaluates AIS brace management

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The research Scoliosis Research Society survey: brace management in adolescent idiopathic scoliosis has just been published by the journal Spine Deformities. While the Scoliosis Research Society (SRS) has established criteria for brace initiation in adolescent idiopathic scoliosis (AIS), there are no recommendations concerning other management issues. As the BrAIST study reinforced the utility of bracing, the SRS Non-Operative Management Committee decided to evaluate the consensus or discord in AIS brace management developing this research.

1200 SRS members were sent an online survey in 2017, which included 21 items concerning demographics, bracing indications, management, and monitoring.

218 SRS members participated in the survey: 207 regularly evaluate and manage patients with AIS, and 205 currently prescribe bracing.  99% of respondents use bracing for AIS and the majority (89%) use the published SRS criteria, or a modified version, to initiate bracing. 85% do not use brace monitoring and 66% use both Cobb correction and fit criteria to evaluate brace adequacy. 

“From the research it emerges that in practice the variability is very large – explains Dr Sabrina Donzelli, physiatrist and researcher at Isico – the treatment protocols, the hours of wearing, the time elapsed between visits, the radiographs required, with or without brace, with what times and after how many hours of break, the brace-weaning protocols, vary considerably from one specialist to another”.

In the United States, the use of braces is recent, it spread after the publication of the results of the BrAIST study: “The management of therapies and treatments is affected by the inexperience of specialists – continues Dr Donzelli – often the indications given to patients are not precise, they are not justified by the objectives of the treatment and they are not supported by strong motivations deriving from clinical experience. Or at least this is what emerges from the survey “.
What then is the conclusion of the research? 
This variability may impact the overall efficacy of brace treatment and may be decreased with more robust guidelines from the SRS. Furthermore, brace therapy must be personalised in a pathology so complex that it cannot be simplified: “The dosage with which the brace is prescribed must be correlated with the therapeutic goal to be achieved – states Dr Donzelli – Risser 0, 1 or 2 is characterised by different progression risks, the extent of the starting curve changes the treatment objectives: sometimes it is necessary to improve the curve, sometimes it is enough to stabilise. The type of brace to be used varies according to the type of curve, their localization and the estimated evolutionary risks of the curve correlated with the problems in adult life. I want to add to the research  – concludes Dr Donzelli – that they only considered the use of the brace, nothing is said about the role of exercises, of which several research studies have efficacy already proven, alone or in association with the brace itself as for example these articles https://pubmed.ncbi.nlm.nih.gov/25729406/ and https://pubmed.ncbi.nlm.nih.gov/30145241/ published by Isico”.

Brace competition 2020: winners awarded

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An online live show full of emotion was held on Saturday 13 March to reward the winners of the 2020 Brace competition – “Concorsetto”.

Prof Stefano Negrini, clinical and scientific director of Isico and Michele Romano, director of physiotherapy, conducted the appointment, while doctors and physiotherapists presented their winning patients showing a short extract of their work: a drawing, a video or a written text.

Different classified categories: awarded by the internal jury, by Facebook likes and the category of the youngest ones.

In this short video you can see all the more than 50 works arrived for this edition.

We look forward to seeing you next time!

Scoliosis: what positions to sleep in?

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The determination of parents, and patients, to find ways of counteracting the progression of scoliosis often leads them to come up with questions, and to look for as many new strategies as they can.

One of the issues they raise concerns the awkward and “twisted” positions that children and adolescents tend to adopt when relaxing on the sofa or bed, or when they are writing, and so on. 
Do these positions affect scoliosis in any way, and can they even cause it?  

To answer these questions, let’s start by making a few key points clear. First of all, scoliosis is a disorder that causes deviation of the spine in the three dimensions of space, and it shows a natural progression; in most cases, it first appears in the early phases of growth. Posture, like the positions a person assumes in daily life, may affect the condition, but only to an extent, and they do not trigger or cause it.

This deviation of the spine, which throws it out of line, results in non-uniform loading of the spine and can therefore drive what is known as Stokes’s vicious cycle (asymmetrical loading causes asymmetrical growth leading to progression of the deformity…).

Conservative therapeutic approaches, consisting of specific self-correction exercises or brace wearing, aim to reduce this misalignment of the spine, counteracting the natural worsening of scoliosis and allowing more physiological growth of the anatomical structures of the spine.

When we are seated or standing, spinal loading is an important issue: in these positions, the force of gravity acts vertically on the whole of the spine, causing it to be more compressed and therefore more susceptible to developing an asymmetry.
Instead, when we are lying down, be it on our back, on our front or on our side, there is much less loading of the back, as the force of gravity is no longer pushing down on the spine, but distributed horizontally over the entire body. 

During the night, precisely because we spend a number of hours lying in bed, with our backs unloaded and no longer subject to the stresses generated by loading and movements, our spine is able to “recover”: the discs situated between the vertebrae are rehydrated, and the entire spine lengthens.   

You may well remember your parents remarking of a morning, “Goodness, you’re so tall! You seem to have grown overnight!” .
Well, as it happens, there is a physiological reason for this. Some studies suggest that we can gain up to 1-2 cm in height as an effect of these nocturnal regenerative phenomena. However, this extra height is lost in the course of the day, and with the passing of the years.   

In conclusion, in the light of what has been said above, and also bearing in mind that we have no control over the positions we adopt when sleeping, our advice to patients is to carry on sleeping in the positions they find most comfortable, because there is no such thing as more or less correct positions during sleep.
Just make sure that the surface supporting your mattress (usually slats, metal bedsprings or a flat platform) ensures that it remains parallel with the ground, and that the central part does not sag. If you sleep in a brace, this isn’t even an issue, as your spine will remain correctly aligned whatever position you sleep in.

It is important to have an active lifestyle, do sport and, for those doing rehabilitation treatment, to follow the prescribed programme of physiotherapy exercises and/or brace wearing.
A final piece of advice: try not to spend too much time lying on your bed or on the sofa, unless it is to rest or watch something on TV! 

My brace: my friend ….my enemy!

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Aurora, 15 years old, shares with us her experience with the brace.

“I wasn’t born with scoliosis. My problems began when I was ten years old, and our doctor noticed that my back wasn’t quite as straight as other people’s.

On his suggestion, I had an X-ray that confirmed that I had a scoliotic posture, which corrective exercises could correct. So, I had a few sessions with a posturologist and learned how to do the necessary exercises. My posture improved, and that seemed to be the end of it.

Since I do artistic gymnastics at a competitive level, I often have checkups with a physical therapist, and on one occasion, it was noticed that I had a twisted hip.

We talked this over with my doctor — I was 12 by this time —, and it was decided that I should have another X-ray, which showed up a very mild scoliotic curve, measuring just a few degrees, that needed to be monitored.

I continued doing my sport as usual until, at the age of 13, I started getting a strong pain in my lower back, towards the hip area. It gave me a lot of trouble throughout that year’s artistic gymnastics championship. It was such a strong, searing pain that I had to wear an elastic sheath around my back for support when training and competing. But I never gave in!

I had various tests to try and get to the bottom of this pain, and it was discovered that my scoliosis had got a lot worse, with the curve increasing from just a few degrees to more than 30° in the space of just one year. My spine now had a marked “S” shape that started at hip level and even affected one shoulder blade. The scoliosis was so bad that I had to start wearing a brace without delay.

There were several tests and procedures to go through in order to get the brace, and I received my first one when I was 14 years old. I had to wear it for at least 18 hours a day.

To tell the truth, I wasn’t particularly concerned about the prospect of wearing a brace, partly because I didn’t really know what it entailed. My immediate concern was that I would have to give up my artistic gymnastics. I couldn’t bear that thought! However, as soon as I had been reassured and put this fear behind me, I was ready to start my bracing treatment.  

The first week I really hated it and regarded the brace as an enemy. I couldn’t do the simplest thing! I couldn’t stand comfortably, and it impeded me in everything: I couldn’t put my clothes on or tie my laces, or do so many of the everyday things you normally don’t think twice about. I was really mad! Mad about having scoliosis, about having to wear a brace, and about having to put up with all that pain and discomfort. Why did it have to be me?!

Before long, though, I calmed down and accepted the situation. I was going to have to wear the brace in any case, so there was no point getting mad about it.

My gymnastics helped me a lot in this sense, first of all, because this discipline had helped me, from a young age, to get used to coping with pain and having to make certain sacrifices, and second because it was my only outlet.

When I was training or doing competitions, I would take the brace off and then put it back on again as soon as I had finished.
I have to admit that, to begin with, I felt a bit uncomfortable and embarrassed about wearing it, but those feelings soon disappeared, because I tend not to worry too much about what other people think, and just try to feel good about myself.

I’m 15 years old now, and I have already been wearing a brace for more than a year.

I have had three braces so far, having had to change them frequently due to my growth. Apart from a little pain at the beginning each time as I get used to the new “shell”, it’s all pretty straightforward and easier than before. Now, I can get dressed by myself, do up my own shoes, and so on. Basically, I don’t need anyone’s help.

There is always a degree of discomfort, that doesn’t disappear completely, but now I see my brace as a friend, not an enemy: a friend that is there to help me to solve a problem, to prevent me from getting worse, and to try and make sure that I end up with a straighter back and more attractive silhouette.

So, basically, I have learned to get along with my brace. We are so close (literally!) that I have even given it a name: Dori. I am actually grateful to it because, together with my sport, it is helping me to develop a beautiful physique and a definite waistline (which I didn’t have before). Having said that, quite often I still fall out with it and really can’t stand it!

I have learned to dress in a way that hides my brace as far as possible. I have bought new, more suitable clothes and they help me feel good about myself too!

Nearly a year has gone by now, which is great!

I still don’t know how long I am going to have to wear my brace for, as I still have some growing to do. I guess it will still be some time before I’m done.  I hope that reading about my experience has helped and reassured you, and will encourage you to tackle your own long journey with commitment and determination, just as I am doing. I want to end on a positive note: there’s light at the end of every tunnel, so don’t despair!

All the best… hang in there!”

Aury Gymnastics

Scoliosis and posture: the two go hand in hand

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Let us start with one thing we know for sure: idiopathic scoliosis is not a postural complaint, but rather a progressive spinal disorder that causes three-dimensional deformation of the vertebrae.

Although it is still not clear exactly why scoliosis occurs, its progression is known to be due, in part, to the force of gravity (i.e., the force of gravity does not cause the disorder, it simply helps it to progress).

Let us try to explain this in simple terms: our spine is like a tower of building bricks that serves to support us, and the bricks distribute evenly the weight it has to bear. If we have scoliosis, some of our bricks are not correctly shaped.
As a result, they are not properly aligned and our tower (spine) may have curve(s) in it. A spine with curve(s) is no longer able to distribute evenly the weight it has to bear; indeed, this presses down harder on the inside of the scoliotic curve, and less on its outside. 

If our spine is well supported, this effect can be lessened, because the support allows the blocks to realign, and this, in turn, reduces the extent of the curve(s). Conversely, without support, the bricks will slide even further to one side, increasing the angle of curvature and shortening the trunk even more.

What does all this mean? That our scoliotic curve will worsen more rapidly unless we continually correct it.

This is why the exercise-based treatment method used at Isico is based on the principle of SELF-CORRECTION: affected youngsters learn to intervene independently to control and align their spine as correctly as possible, thereby countering its tendency to collapse in the direction of the scoliotic curve.

Let us consider another aspect. On a spinal X-ray, we can measure the degrees of curvature present. The angle of curvature is actually the sum of two components: the deformity itself and the effect of postural sagging in the direction of the curve. The contribution of this second component is largely dependent on our capacity for “self-correction”.

How can we distinguish between these two components, i.e., actual bone deformity and postural sagging, so as to be able to intervene effectively on each of them? Again, on an X-ray, but in this case, it must be taken with the patient lying down, so that the degrees of curvature caused by postural sagging disappear, and all that can be seen, and measured, are those due to the deformity itself.

One study, now rather old but still valid, published in Spine in 1976 (Standing and supine Cobb measures in girls with idiopathic scoliosis, G Torell, A Nachemson, K Haderspeck-Grib, A Schultz), showed that postural sagging in scoliosis causes, on average, 9 degrees of curvature (ranging from 0 to a maximum of 20), and that the degrees attributable to postural failure are independent of the severity of the curve. Another interesting study published in Spine, in this case in 1993 (Diurnal variation of Cobb angle measurement in adolescent idiopathic scoliosis, M Beauchamp, H Labelle, G Grimard, C Stanciu, B Poitras, J Dansereau), shows that back “fatigue” can also affect the Cobb angle. In this study, youngsters with moderate to severe scoliosis (an average of 60 Cobb degrees) were X-rayed in the morning and then in the evening. The X-ray taken in the evening showed an average 5-degree increase in curve severity.

What should we do in treatment terms? Clearly, exercises alone cannot alter the actual bone deformity resulting from the scoliosis, which needs to be treated with a combination of exercises and brace wearing.
Nevertheless, specific exercises and self-correction can do a lot to address the problem of postural sagging. And if this “sagging” is responsible for an increased Cobb angle, we need to work hard at our exercises in order to “eat away” at (reduce) the part of the curve that is due to this component.

Merry Christmas and Happy New 2021

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It is going to be a strange Christmas and New Year, different from any other. So, as we reach the end of 2020, we send you not only our sincerest greetings, but also a story of hope, trust and new life. Here Rossella, a former patient recalls the end of her treatment. 

“You can never really forget something that was, in effect, a part of you for a very long time. Sometimes I feel like I have forgotten all about it, and yet it only takes a passing thought to take me back to four years ago. 

To say that I remember it with pleasure, that I miss it, and that with hindsight the whole thing was actually quite easy, would be both untruthful and hypocritical. It was difficult, painful and a real burden, and the reality of this is something I can only appreciate fully now that it is all behind me.  

There is nothing unusual about my experience, quite the opposite. Like countless other Isico patients, I was just a normal adolescent, albeit one who had to live her everyday life in a brace.

Every so often, I still find myself thinking back what life was like in a brace. 

When I curl up in bed, for example, I suddenly remember all those nights when I simply couldn’t do that, because in a brace you have to lie straight, and turning your head to one side on the pillow is literally the only movement that you do with ease. 

Now, if a pen falls off my desk when I’m working, I just bend down and pick it up, without having to think twice about it. But this sometimes makes remember how picking up a pen used to be quite a performance! Back then, I would have to get up from the chair, bend my knees to lower myself to the ground, and then reach out at full stretch, scrabbling for the pen, before then standing up again and returning to my chair. 

I also remember that when we went on our summer holidays, I would only go on the beach in the mornings, because in the afternoons I had to wear my brace, and it was so hot I would end up spending the whole time in my hotel room. 

Another thing, how could I possibly forget the way my entire day (going out with friends, going to school, doing sport and so on) had to be planned around when I was meant to be wearing my brace? I used to think of my brace-off time as my “hours of freedom”, because it was then that I was able to behave just like any other girl. 

As I say, it would be wrong to claim that brace wearing wasn’t difficult for me. But, in the same way, it would be dishonest of me if I didn’t make it clear that I have absolutely no regrets about any of it.

Even though they are now relegated to the cellar, I have kept my braces, all five of them, each stored in its grey bag with “Isico” written on it in big blue letters. I have never put them on since my treatment came to an end, but occasionally I go and get them out. 

Had it not been for them, I might now have a curve measuring more than 30°, and would probably be in much more pain than I ever experienced during the treatment

I well remember going to see Prof. Negrini for my very last visit.  Inside my head, a voice was crying out: “Please, tell me it’s all over!”. Well, it was! With the help and support of Prof. Negrini and all the Isico doctors and physiotherapists, I really had done it!

I left his office and burst into tears. I went on crying all afternoon, but they were tears of great joy. 

I was elated. It was over. I had won my battle“.

SEAS in adults

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Over the past 13 years or more, we have published dozens of posts and thousands of comments on our blog dedicated to scoliosis.
The Isico blog is a dedicated space where patients can ask questions and swap experiences, but it is also a place where those involved in treating scoliosis can take a more in-depth look at a series of topics and engage with patients.


SEAS in adults

“You’re too old now”, “Your scoliosis has stopped now that you’ve finished growing”, “If you want to, do some exercise”… How often do adults with vertebral deformities like scoliosis or hyperkyphosis hear things like this?
Our patients often tell us that on reaching adulthood they become aware of physical changes, in their back, balance and height, and they therefore start looking for answers and treatments.
The natural ageing process does not spare our back and changes are quite normal and to be expected: when they occur, it is important to get active in order to restore elasticity and strength to joints and muscles. But ageing is an entirely different situation compared with the occurrence of spine deviations in young people, in whom we seek to modify the bone structures and consequently reduce the degrees of curvature.
 
Scientific studies in recent years have clarified several aspects, that are worth bearing in mind:

1. Scoliosis exceeding 30 degrees at bone maturity, generally reached between 17 and 19 years of age, is at risk of progressing over the years, resulting in a worsening of the existing curves: and the higher the measurement, the greater the risk of worsening.
2. Will scoliosis inevitably lead to back pain? Absolutely NOT!
3. Does having a correct lateral spinal profile (lordosis-kyphosis) protect us against the reduction of our quality of life due to disability and pain? YES, it does.

In light of all this, it is important to know that in adults, too, it is possible to intervene to correct postural abnormalities and prevent and/or slow down the worsening of scoliosis over time: our approach (SEAS) aims to do just this.
As an effect of the force of gravity, and also the curves that are already present, a scoliotic back will tend to drop down in the direction of the curve, and in many cases, there will also be a forward shift of the trunk. Simple physical activity alone, however useful and beneficial, is insufficient to counteract this phenomenon.
This can only be achieved through specific exercises designed to provide support for the structures of the spine in the opposite direction, and these reinforcement exercises must have precise and individual characteristics, in other words, they must be tailored to the individual patient.

The movements to be carried out must be chosen according to very specific priorities, and this is why it is necessary to turn to qualified professionals who have expertise in dealing with these conditions in adults, using effective approaches.
The SEAS method requires constant collaboration on the part of the patient and seeks to make him “responsible for himself”.
The exercises are carefully worked out for each patient. They are initially performed under the therapist’s guidance and then performed independently, with the patient doing daily repetitions, at home.
Sessions with the therapist are initially scheduled monthly, although this frequency is subsequently reduced, possibly even to only once every three months, and patients are given exercise sheets to follow at home.
It takes at least six months to obtain appreciable results, sufficient to motivate patients to continue and thereby ensure they remain fit well into old age.

Best Practice Guidelines for bracing in AIS

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Which are the guidelines for using a brace in idiopathic scoliosis treatment? The study “Establishing consensus on the best practice guidelines for the use of bracing in adolescent idiopathic scoliosis”, just published by the journal Spine Deformity, collected 38 experts who developed a consensus on 67 items across ten domains of bracing which were consolidated into the final best practice recommendations.
Among the experts, from surgeons to physiatrists and physiotherapists, prof. Stefano Negrini, scientific director of Isico: “Bracing is the mainstay of conservative treatment in Adolescent Idiopathic Scoliosis (AIS), but currently there is significant variability in the practice of brace treatment for AIS and, therefore, there is a strong need to develop best practice guidelines (BPG) for bracing in AIS“.
How did you go about developing a common consensus?
Following a review of the literature, three iterative surveys were administered. Topics included bracing goals, indications for starting and discontinuing bracing, brace types, brace prescription, radiographs, physical activities, and physiotherapeutic scoliosis-specific exercises. A face-to-face meeting was then conducted that allowed participants to vote for or against the inclusion of each item. Agreement of 80% throughout the surveys and face-to-face meeting was considered consensus. Items that did not reach consensus were discussed and revised, and repeat voting for consensus was performed.
 “A common adherence to these BPGs is fundamental for developing common protocols on an international level – ends prof. Negrini – furthermore, this consensus on the guidelines will lead to fewer sub-optimal outcomes in patients with AIS by reducing the variability in AIS bracing practices, and provide a framework for future research”.

Isico involved in an international research project: brace versus plaster cast

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An international project involving clinical centres in 40 countries in the US, Canada, Europe and Asia has just started. Target? A comparison between the use of plaster casts and braces in the treatment of infantile scoliosis.
Isico is one of the centres involved, thus representing Italy, expressly invited given the clinical and research experience gained over the years.

The project manager is Prof. Stuart L. Weinstein, referent Dr Lori A. Dolan, both from the American University of Iowa. The target enrollment is 440 subjects (220 patients and 220 parents). For Isico, the head researcher is Prof. Negrini, while Dr Donzelli is involved as the research referent.

We recall that infantile (early-onset) idiopathic scoliosis (IEOS) is a relatively rare disease affecting 40 out of 100,000 children. Defined as an idiopathic curve measuring > 20 degrees in those less than three years of age, the natural history of IEOS is variable with some curves resolving spontaneously and others quickly progressing to such a degree that severe pulmonary disease and shortened life span may occur. Casting, and less frequently bracing, have been used to treat this condition in hopes of resolving the curve or at least delaying surgical interventions.

The plaster cast is widely used for these early forms of scoliosis, but a plaster requires hospitalization, sedation, and daily handling is much less comfortable for hygiene than a removable brace.

“During the two-year duration of the project, funded by the University of Iowa and The Orthopedic Research and Education Foundation, – explains Dr Donzelli – we will bring between 5 and 10 cases treated at our Institute to research purposes. Isico has several years of experience in the use of braces; our participation will not involve the application of plaster casts; our results will be compared with those of other centres that apply these casts “.