Isico among the attendees of the November SRS webinar

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

Daytime versus night-time bracing: what to do when scientific evidence is of no help?

When we sit down in front of a doctor, we often expect him or her to have the solution to all our problems, but of course this is not the case. Unfortunately, that isn’t how evidence-based medicine (EBM) works!

EBM is defined as the explicit, conscientious and judicious use of the best current scientific evidence in decision making regarding the treatment of an individual patient or population. Indeed, the term “evidence” refers not to that which is “evident”, but rather to what has been discovered through specific research.

Evidence-based clinical practice is built on 3 key elements: 

– the best research evidence;

– the clinical experience of the treating physician;

– the patient’s values and expectations.

In other words, optimal clinical decision-making is based on knowledge of the best available scientific evidence, which must be combined with the values and preferences of the patient, who is involved directly in the process of choosing his or her treatment. 

But scientific evidence cannot answer all the questions that crop up in medicine. In the field of scoliosis treatment, for example, there are no studies showing that brace wearing is more effective during the day than at night. 

So, what are doctors meant to do when they are faced with situations like this? In the absence of available scientific evidence, the decision has to be based on the other two foundation stones of clinical practice (the doctor’s personal experience and the patient’s values), so as to achieve the best possible outcome. 

As far as bracing is concerned, there is an important study “Adolescent Idiopathic Scoliosis Bracing Success Is Influenced by Time in Brace: Comparative Effectiveness Analysis of BrAIST and ISICO Cohorts” which shows that the outcome, in terms of curve correction, depends on the number of hours the brace is worn: the longer it is worn the better the result will be.
On the basis of this knowledge, and also with the aim of increasing our patients’ compliance with the treatment, we at ISICO have decided that patients should always wear their brace at night, and enjoy their brace-off hours (as prescribed by their doctor) during the daytime.
After all, if patients sleep without their brace on, this means they lose 7-8 hours of correction every 24 hours. What is more, using brace-off hours during the daytime makes it easier for youngsters to take part in the daily activities they enjoy (sports, going out with friends, and so on), and this increases not only the level of compliance with the treatment, but also their quality of life.
Finally, we know that our spine does not remain passive during sleep; on the contrary, when we are in bed, swelling of the intervertebral discs (shock-absorbing “sponges” situated between our vertebrae) causes lengthening and tension of this entire structure, which is so important in growth.
This is one of the reasons why ISICO (and pretty much all practitioners worldwide) now recommend that, when the time comes to do so, bracing hours should be reduced during the daytime, until the point is finally reached when patients, in the last months of their treatment, are wearing their brace only at night. This, then, is an example of how the clinical experience of a specialist team and the particular needs of patients can together serve as the basis for making sound therapeutic choices in the absence of hard scientific evidence.

Best Practice Guidelines for bracing in AIS

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”.

Bracing works better in Italy

Bracing treatment reduces the risk of needing surgery, but the proportion of patients who manage to avoid the scalpel differs between Europe and North America. The factor that makes the difference is patient compliance, i.e. a patient’s adherence to, and belief in, the course of bracing treatment prescribed. In this regard, Italian patients certainly come out on top. 
This is what emerged from a study conducted by ISICO entitled “AIS Bracing Success is Influenced by Time in Brace: Comparative Effectiveness Analysis of BrAIST and ISICO Cohorts”, which has just been published in the scientific journal Spine.

The study was based on a comparison of two populations of patients at high risk of surgery, which showed that, after bracing treatment, 39% of US patients go on to have surgery, as opposed to just 12% of patients treated by ISICO. The Italian institute sent clinical data referring to patients seen by its specialists to the University of Iowa, so that these data might be compared with those obtained in previous research published by the American group in 2014. 

“We worked in collaboration with the researchers at the University of Iowa” explains Dr Sabrina Donzelli, ISICO physician and author of the paper. “In 2014, our American colleagues published a randomized controlled multicentre trial called the “Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST)”. The resulting paper, by Lori Dolan and Stuart Weinstein, was published in the New England Journal of Medicine. Their study, the most important on this topic in the past 30 years, involved 383 patients from 25 US and Canadian institutes studied between March 2007 and February 2011. It showed that brace treatment reduced the percentage of patients requiring surgery. Given that surgeons and families in North America have always had a rather negative attitude towards bracing (unlike those in Europe, where it is well received), the authors were surprised by this finding. We took the results of the BrAIST study as the starting point for our research, comparing them with our own data. Working with our American colleagues, we selected patient subpopulations comparable for disease severity and risk of surgery”.

This comparison was a demanding task requiring clarity: the Italian researchers and the American surgeons from the Children’s Hospital of Iowa measured the radiographs of the patients from the BrAIST study and of 169 patients being treated at ISICO, in order to objectively verify the data. 
What did the comparison show? That bracing treatment at Isico works better, with the proportion of at-risk Italian patients who actually had surgery found to be just a third of the proportion recorded in the American population (12% vs 39%). It also emerged that the ISICO patients, respecting the treatment prescribed, wore their brace for a far greater number of hours than their American counterparts.

“Patient compliance is crucial,” Dr Donzelli continues “Our patients are careful to respect their doctor’s prescriptions, and the doctors and patients enjoy a good relationship based on mutual trust and faith in the proposed treatment. All this adds up to great teamwork between the patient, his/her family, the doctor, the orthopaedic technician and the physiotherapist”.