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Physical Functioning in Adolescents with Idiopathic Scoliosis: A Systematic Review of Outcome Measures and Their Measurement Properties

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Every year, the Italian Scoliosis Study Group selects the best published papers on conservative spine treatment from the global scientific literature.
Here is the abstract from one of these papers. 

Physical Functioning in Adolescents with Idiopathic Scoliosis: A Systematic Review of Outcome Measures and Their Measurement Properties

Samia Alamrani, Alison B Rushton, Adrian Gardner, Elena Bini, Deborah Falla, Nicola R Heneghan
PMID: 34033069 DOI: 10.1007/s43390-021-00365-9

Abstract

Study design: A systematic review.

Objective: To summarize evidence on measurement properties of Outcome Measures (OM) used to assess physical functioning in adolescents with idiopathic scoliosis (AIS).

Summary of background data: The AIS is a common spine deformity in those aged 10 to 18 years old. Associated health problems (e.g., back pain) significantly impact the quality of life (QoL). One important domain in QoL is physical functioning, which can be measured with patient-reported outcome measures (PROM), performance-based outcome measures (PBOM), and body structure and function OM. Adequate measurement properties of OM are important for precision in research and practice.

Methods: A two-staged search strategy was performed on electronic databases up to December 2019. Search one revealed a list of OM was used for physical functioning assessment in AIS. Search two identified studies that evaluated the measurement properties of OM in AIS; using the list identified in search one. Two independent reviewers determined study eligibility, risk of bias assessment (COnsensus-based Standards for the selection of health Measurement INstruments [COSMIN] checklist), and performed data extraction. The level of evidence was established using a modified GRADE approach.

Results: Search one yielded: 28 PROM, 20 PBOM, and 10 body structure and function OM. Search two revealed: 16 measurement properties studies for PROM, one for PBOM, and three for body structure and function measures. Construct validity, reliability, and responsiveness of most PROM has been established in AIS, but not content validity or internal consistency (moderate evidence). Construct validity was sufficient for the Timed Up and Go test and body structure and function measures (very low to low evidence).

Conclusion: Currently, physical functioning is evaluated with a variety of measures in AIS. The majority of measurement properties studies evaluated PROM with a paucity of information on measurement properties of PBOM and body structure and function OM. Based on COSMIN methodology, none of the OM identified in this review can be recommended with confidence in individuals with AIS.Level of Evidence: 2.

https://pubmed.ncbi.nlm.nih.gov/33496543/

Low back pain

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Every year, the Italian Scoliosis Study Group selects the best published papers on conservative spine treatment from the global scientific literature.
Here is the abstract from one of these papers. 

Long-term follow-up of untreated Scheuermann’s kyphosis
  Enrique Garrido, Simon B Roberts, Andrew Duckworth, Joseph Fournier 
PMID: 34212306 DOI: 10.1007/s43390-021-00354-y

Abstract

Study design: Long-term cross-sectional study.

Objectives: To investigate the long-term effects of untreated Scheuermann’s kyphosis on quality of life, and its relationship to radiographic parameters of spinal deformity. Previous studies reported reduced self-image, increased pain and impaired physical status. Little is known of the long-term impact of sagittal plane deformity in untreated SK.

Methods: One hundred and thirteen consecutive untreated patients with SK were identified from a national service database prior to 2000, when surgery was not offered at this unit. 81 of these patients were available for evaluation; 66 (81%) consented to questionnaire and clinical evaluation, and 47 (58%) consented to additional radiological evaluation. Health-related quality of life (HRQoL) was compared to normative population values. Mean age was 45.1 years (31-65), and mean follow-up was 27 years (16-36). 57 patients had thoracic kyphosis and 9 had thoracolumbar deformity.

Results: SRS-22 and SF-36 scores were lower, and ODI was greater in patients with untreated SK compared to normative population values. Kyphosis progressed from mean 66° at skeletal maturity to 78° (p < 0.001) after mean follow-up of 27 years. Long-term progression of untreated SK was 0.45°/year (n = 47). Multilinear regression showed good correlation between increasing SVA and worse ODI scores (r = 0.59; p = 0.001). Increasing SVA also correlated with worse function, pain and mental health scores reported by SRS-22, and with worse physical function and bodily pain scores reported by SF-36. Increasing CL correlated with worse SF-36 physical function scores. Increasing cSVA and increasing TK correlated with worse SRS-22 self-image scores.

Conclusion: SRS-22 and SF-36 scores were lower, and ODI was greater in patients with untreated SK compared to normative data. Long-term progression of untreated SK was 0.45°/year (n = 47). Increasing SVA correlated with worse SF-36 physical function, SRS-22 function, SRS-22 pain and higher ODI scores. Total kyphosis (TK) and cSVA were independent predictors of low SRS self-image.

Level of evidence: III.

Keywords: Disease; Kyphosis; Natural history; Outcome; Scheuermann’s.

https://pubmed.ncbi.nlm.nih.gov/34212306/

Low back pain

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Every year, the Italian Scoliosis Study Group selects the best published papers on conservative spine treatment from the global scientific literature.
Here is the abstract from one of these papers. 

Low back pain
 Nebojsa Nick Knezevic, Kenneth D Candido, Johan W S Vlaeyen, Jan Van Zundert, Steven P Cohen
PMID: 34115979 DOI: 10.1016/S0140-6736(21)00733-9

Abstract

Low back pain covers a spectrum of different types of pain (eg, nociceptive, neuropathic and nociplastic, or non-specific) that frequently overlap. The elements comprising the lumbar spine (eg, soft tissue, vertebrae, zygapophyseal and sacroiliac joints, intervertebral discs, and neurovascular structures) are prone to different stressors, and each of these, alone or in combination, can contribute to low back pain. Due to numerous factors related to low back pain, and the low specificity of imaging and diagnostic injections, diagnostic methods for this condition continue to be a subject of controversy.
The biopsychosocial model posits low back pain to be a dynamic interaction between social, psychological, and biological factors that can both predispose to and result from injury, and should be considered when devising interdisciplinary treatment plans.
Prevention of low back pain is recognised as a pivotal challenge in high-risk populations to help tackle high health-care costs related to therapy and rehabilitation. To a large extent, therapy depends on pain classification, and usually starts with self-care and pharmacotherapy in combination with non-pharmacological methods, such as physical therapies and psychological treatments in appropriate patients.
For refractory low back pain, a wide range of non-surgical (eg, epidural steroid injections and spinal cord stimulation for neuropathic pain, and radiofrequency ablation and intra-articular steroid injections for mechanical pain) and surgical (eg, decompression for neuropathic pain, disc replacement, and fusion for mechanical causes) treatment options are available in carefully selected patients.
Most treatment options address only single, solitary causes and given the complex nature of low back pain, a multimodal interdisciplinary approach is necessary. Although globally recognised as an important health and socioeconomic challenge with an expected increase in prevalence, low back pain continues to have tremendous potential for improvement in both diagnostic and therapeutic aspects.
Future research on low back pain should focus on improving the accuracy and objectivity of diagnostic assessments, and devising treatment algorithms that consider unique biological, psychological, and social factors.
High-quality comparative-effectiveness and randomised controlled trials with longer follow-up periods that aim to establish the efficacy and cost-effectiveness of low back pain management are warranted.

https://pubmed.ncbi.nlm.nih.gov/34115979/

Serum metal ion levels in adolescent idiopathic scoliosis (AIS) patients 25 years after treated with Harrington rod instrumentation or bracing

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Every year, the Italian Scoliosis Study Group selects the best published papers on conservative spine treatment from the global scientific literature.
Here is the abstract from one of these papers. 

Serum metal ion levels in adolescent idiopathic scoliosis (AIS) patients 25 years after treated with Harrington rod instrumentation or bracing

Simon Thorbjørn Sørensen, Anne Vibeke Schmedes, Mikkel Østerheden Andersen, Leah Carreon, Ane Simony 
PMID: 34033069 DOI: 10.1007/s43390-021-00365-9

Abstract

Introduction: Surgical instrumentation in children with adolescent idiopathic scoliosis (AIS) is performed early in life and the implants are left in situ for the rest of the patient’s life. Concern has been raised regarding persistent elevated levels of serum metal ions, but only a few studies on the topic have been published. The aim of this study was to compare the levels of serum metal ions in patients with AIS treated with either Harrington rod instrumentation or bracing.

Materials and methods: AIS patients treated with Boston brace (BB) or posterior spinal fusion with Harrington rod instrumentation (HR) from 1983 to 1990 were requested to return to clinic. One hundred fifty-nine (73%) of 219 patients were available for follow-up of whom 115 agreed to have a blood draw.

Results: The proportion of patients who agreed to have a blood draw were similar in the BB (48 of 100, 48%) and HR (67 of 115, 60%, p = 0.085) groups. None of the surgical patients had their implants removed; mean age at follow-up (BB: 43.2 years vs HR: 43.5 years, p = 0.566) and mean length of follow-up (BB: 26.5 years vs HR: 24.5 years). Mean chromium serum levels were similar between the BB (2.7 nmol/L) and the HR (2.9 nmol/L, p = 0.827). Mean Cobalt serum levels were also similar between the BB (2.6 nmol/L) and the HR (2.8 nmol/L, p = 0.200).

Conclusion: Serum metal ions were similar in AIS patients treated with bracing or Harrington rod instrumentation 25 years after initiation of treatment.

https://pubmed.ncbi.nlm.nih.gov/34033069/

Index radiographic measurements in the prediction of progression in infantile idiopathic scoliosis: a comparative analysis and description of a novel predictive model

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Every year, the Italian Scoliosis Study Group selects the best published papers on conservative spine treatment from the global scientific literature.
Here is the abstract from one of these papers. 


Index radiographic measurements in the prediction of progression in infantile idiopathic scoliosis:

a comparative analysis and description of a novel predictive model
Adam P Lloyd , Morgan E B Jones , Adrian Gardner , Matthew P Newton Ede 

Eur Spine J 2021 Mar 9. doi: 10.1007/s00586-021-06795-3

Abstract

Purpose: To assess the comparative accuracy of commonly utilised index radiological measurements in the prognosis of infantile idiopathic scoliosis (IIS) and build a parsimonious prognostic model utilising these measurements.

Methods: This was a retrospective analysis of a UK population of patients with IIS. Index radiological parameters –  Cobb angle, rib-vertebra angle difference (RVAD), and convex rib-vertebra angle (RVA) – were analysed  were analysed, and outcome of their condition was determined over long-term follow-up. Comparative accuracy of each radiological measurement category was determined by logistic regression analyses and the corresponding receiver operating characteristic (ROC) curve. A predictive model of IIS progression using these measurements was then created.

Results: All three radiological measurement categories were predictive of IIS progression. However, on pairwise comparison of ROC curves and multivariate analysis, the index Cobb angle proved the most significant predictor of curve progression. Using the index Cobb angle only, a predictive model of curve progression achieved an accuracy of 81.18% with a cut-off Cobb angle of 34.5° found to be the optimal threshold to discriminate a progressive from resolving curve.

Conclusion: Of the three analysed index radiological parameters commonly used by surgeons in the prognosis of IIS, we found that the Cobb angle is the most accurate predictive measure. Further, neither addition of the RVAD nor convex RVA provided significant further prognostic value in a multivariate model of progression. However, not even the Cobb angle model was accurate in all cases; emphasising caution should be applied when relying on index radiological measurements to predict IIS outcomes.

Keywords: Cobb; Infantile; Prognosis; RVAD; Scoliosis.

https://pubmed.ncbi.nlm.nih.gov/33687542/

Prospective investigation of Oswestry Disability Index and short form 36 subscale scores related to sagittal and coronal parameters in patients with degenerative lumbar scoliosis

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Every year, the Italian Scoliosis Study Group selects the best published papers on conservative spine treatment from the global scientific literature.
Here is the abstract from one of these papers. 

Prospective investigation of Oswestry Disability Index and short form 36 subscale scores related to sagittal and coronal parameters in patients with degenerative lumbar scoliosis
Chang-Hoon Jeon, Nam-Su Chung, Hee-Woong Chung, Ha Seung Yoon, Han-Dong Lee

European Spine Journal ( IF 2.458 ) Pub Date : 2021-03-14

Abstract

Purpose: This study investigated relationships of Oswestry Disability Index (ODI) and Short Form 36 (SF-36) total and subscale scores with global spinal parameters in patients with degenerative lumbar scoliosis (DLS).

Methods: This was a prospective single-center study of 126 consecutive patients with DLS. Disability was evaluated using the ODI and SF-36 total and subscale scores. Sagittal and coronal parameters were measured. Pearson’s correlation analysis was performed to determine relationships between disability and radiographic parameters.

Results: The study population included 76 women and 15 men (mean age, 70.2 ± 8.4 years). Mean Cobb angle was 18.9° ± 8.0°. The ODI total score and SF-36 physical component score were only correlated with coronal parameters. ODI pain intensity, personal care, lifting, sitting, and sex life domains were only correlated with coronal parameters. The walking, standing, social life, and traveling domain scores were correlated with coronal and sagittal parameters. The SF-36 bodily pain and vitality domain scores were only correlated with coronal parameters. The SF-36 physical function domain score was correlated with both coronal and sagittal parameters. Among the clinical and radiographic parameters, the personal care score and the coronal vertical-axis had the strongest correlation (r = 0.425), although the r2 value was only 0.18.

Conclusions: ODI total score and most of the subscale scores were significantly, but weakly correlated with coronal parameters. Sagittal parameters were only correlated with some of the ODI and SF-36 subscale scores. Analysis using ODI and SF-36 subscale scores may aid in understanding and treatment of disability in patients with DLS.

Keywords: Coronal parameter; Degenerative lumbar scoliosis; Oswestry Disability Index; Sagittal parameter; Short form 36.

https://pubmed.ncbi.nlm.nih.gov/33715073/

Does curve pattern impact on the effects of physiotherapeutic scoliosis specific exercises on Cobb angles of participants with adolescent idiopathic scoliosis: A prospective clinical trial with two years follow-up

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Every year, the Italian Scoliosis Study Group selects the best published papers on conservative spine treatment from the global scientific literature.
Here is the abstract from one of these papers. 

Does curve pattern impact on the effects of physiotherapeutic scoliosis specific exercises on Cobb angles of participants with adolescent idiopathic scoliosis: A prospective clinical trial with two years follow-upnders stage 7b: Using the appearance of the ulnar physis improves decision-making for brace weaning in patients with adolescent idiopathic scoliosis
Yunli Fan, Michael K T To, Eric H K Yeung, Jianbin Wu, Rong He, Zhuoman Xu, Ruiwen Zhang, Guangshuo Li, 
Kenneth M C Cheung, Jason P Y Cheung

PMID: 33493172 PMCID: PMC7833215 DOI: 10.1371/journal.pone.0245829

Abstract

Background: Current clinical evidence suggests that a well-planned physiotherapeutic scoliosis specific exercise (PSSE) program is effective for scoliosis regression.

Objectives: We investigated the effect of curve patterns on Cobb angles with PSSE.

Methods: This was a non-randomized prospective clinical trial that recruited participants with adolescent idiopathic scoliosis between January and June 2017. Participants were grouped by curve pattern into major thoracic and major lumbar groups. An outpatient-based PSSE program was conducted with the following schedule of intensive exercise: ≥ 1 session of supervised PSSE per month and > 30min of home exercise 5 days/week in the first 6 months, after which exercise frequency was reduced to 1 session of supervised PSSE every three months and > 30min of home exercise 5 days/week until 2 years after study initiation. Radiographic Cobb angle progressions were identified at the 1, 1.5 and 2-year follow-ups. A mixed model analysis of variance (ANOVA) was performed to examine the differences in Cobb angles between groups at four testing time points. The two-tailed significance level was set to 0.05.

Results: In total, 40 participants were recruited, including 22 with major thoracic curves (5 males and 17 females; mean age 13.5±1.8 years; Cobb angle 18-45 degrees) and 18 with major lumbar curves (7 males and 11 females; mean age 12.7±1.7 years; Cobb angle 15-48 degrees). Curve regressions, namely the reduction of Cobb angles between 7 to 10 degrees were noted in 9.1% of participants in the major thoracic group; reductions of 6 to 13 degrees were noted in 33.3% of participants in the major lumbar group at the 2-year follow-up. Repeated measurements revealed a significant time effect (F2.2,79.8 = 4.1, p = 0.02), but no group (F2.2,79.8 = 2.3, p = 0.1) or time × group (F1,37 = 0.97, p = 0.3) effects in reducing Cobb angles after 2 years of PSSE. A logistic regression analysis revealed that no correlation was observed between curve pattern and curve regression or stabilization (OR: 0.2, 95% CI: 0.31-1.1, p = 0.068) at the 2-year follow-up.

Conclusion: This was the first study to investigate the long-term effects of PSSE in reducing Cobb angles on the basis of major curve location. No significant differences in correction were observed between major thoracic and major lumbar curves. A regression effect and no curve deterioration were noted in both groups at the 2-year follow-up.

Trial registration: ChiCTR1900028073.

https://pubmed.ncbi.nlm.nih.gov/33493172/

Sanders stage 7b: Using the appearance of the ulnar physis improves decision-making for brace weaning in patients with adolescent idiopathic scoliosis

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Every year, the Italian Scoliosis Study Group selects the best published papers on conservative spine treatment from the global scientific literature.
Here is the abstract from one of these papers. 

Sanders stage 7b: Using the appearance of the ulnar physis improves decision-making for brace weaning in patients with adolescent idiopathic scoliosis
Prudence Wing Hang Cheung, Jason Pui Yin Cheung
PMID: 33380190 DOI: 10.1302/0301-620X.103B1.BJJ-2020-1240.R1

Abstract

Aims: The aim of this study was to investigate whether including the stages of ulnar physeal closure in Sanders stage 7 aids in a more accurate assessment for brace weaning in patients with adolescent idiopathic scoliosis (AIS).

Methods: This was a retrospective analysis of patients who were weaned from their brace and reviewed between June 2016 and December 2018. Patients who weaned from their brace at Risser stage ≥ 4, had static standing height and arm span for at least six months, and were ≥ two years post-menarche were included. Skeletal maturity at weaning was assessed using Sanders staging with stage 7 subclassified into 7a, in which all phalangeal physes are fused and only the distal radial physis is open, with narrowing of the medial physeal plate of the distal ulna, and 7b, in which fusion of > 50% of the medial growth plate of distal ulna exists, as well as the distal radius and ulna (DRU) classification, an established skeletal maturity index which assesses skeletal maturation using finer stages of the distal radial and ulnar physes, from open to complete fusion. The grade of maturity at the time of weaning and any progression of the curve were analyzed using Fisher’s exact test, with Cramer’s V, and Goodman and Kruskal’s tau.

Results: We studied a total of 179 patients with AIS, of whom 149 (83.2%) were female. Their mean age was 14.8 years (SD 1.1) and the mean Cobb angle was 34.6° (SD 7.7°) at the time of weaning. The mean follow-up was 3.4 years (SD 1.8). At six months after weaning, the rates of progression of the curve for patients weaning at Sanders stage 7a and 7b were 11.4% and 0%, respectively for those with curves of < 40°. Similarly, the rates of progression of the curve for those being weaned at ulnar grade 7 and 8 using the DRU classification were 13.5% and 0%, respectively. The use of Sanders stages 6, 7a, 7b, and 8 for the assessment of maturity at the time of weaning were strongly and significantly associated (Cramer’s V 0.326; p = 0.016) with whether the curve progressed at six months after weaning. Weaning at Sanders stage 7 with subclassification allowed 10.6% reduction of error in predicting the progression of the curve.

Conclusion: The use of Sanders stages 7a and 7b allows the accurate assessment of skeletal maturity for guiding brace weaning in patients with AIS. Weaning at Sanders stage 7b, or at ulnar grade 8 with the DRU classification, is more appropriate as the curve did not progress in any patient with a curve of < 40° immediately post-weaning. Thus, reaching full fusion in both distal radial and ulnar physes (as at Sanders stage 8) is not necessary and this allows weaning from a brace to be initiated about nine months earlier. Cite this article: Bone Joint J 2021;103-B(1):141-147.

Keywords: Brace weaning; Curve progression; DRU; Distal radius and ulna classification; Sanders classification; Sanders staging; Skeletal maturity.

https://pubmed.ncbi.nlm.nih.gov/33380190/

The Influence of Lumbar Modifiers on Functional and Radiological Outcomes in the Brace Treatment of Lenke Type 1 Adolescent Idiopathic Scoliosis

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Every year, the Italian Scoliosis Study Group selects the best published papers on conservative spine treatment from the global scientific literature.
Here is the abstract from one of these papers. 

The Influence of Lumbar Modifiers on Functional and Radiological Outcomes in the Brace Treatment of Lenke Type 1 Adolescent Idiopathic Scoliosis
Alkan Bayrak, Altug Duramaz, Alican Koluman, Burak Belen , Vedat Öztürk 
PMID: 33233010 DOI: 10.1055/a-1269-0000

Abstract

Background Brace treatment prevents the progression of scoliosis and reduces surgical treatment rates. However, the efficacy of brace treatment varies depending on the patientʼs age, gender, curve magnitude and type, structure of the curve, and patient compliance at the beginning of treatment.

Methods Between January 2009 and April 2015, 106 Lenke type 1 AIS consecutive patients (69 females, 37 males) who were treated with a brace were examined in three groups according to Lenke classification lumbar modifiers. The patients were evaluated at pre-bracing and 1 and 2 years after bracing. The Scoliosis Research Society 22 (SRS-22) and Oswestry Disability Index (ODI) were used for functional evaluation. Radiological evaluation revealed the Cobb angle, thoracic kyphosis angle, lumbar lordosis angle, trunk shift, shoulder asymmetry, and body height difference.

Results Functional and radiological evaluation showed a statistically significant improvement in Lenke 1A, 1B, and 1C at 1 and 2 years after bracing compared to the pre-bracing (p = 0.000, p = 0.000, and p = 0.000, respectively). Lenke 1C had the best ODI score and followed by decreasing values of 1B and 1A respectively (p = 0.009). Lenke 1B had the best SRS-22 score and the mean scores of 1A and 1C were equal (p = 0.017). There was no significant difference between the groups in the parameters other than the trunk shift in radiological evaluation (p = 0.043).

Conclusions Significant improvement was observed in all types of lumbar modifiers at the end of the 2nd year compared to pre-bracing. The best improvement in the ODI score was in the 1C modifier, whereas the best improvement in the SRS-22 score was in the 1B modifier. The type of lumbar modifier should be directly taken into consideration before starting brace treatment in Lenke type 1 AIS.

Level of evidence Level III, retrospective study

https://pubmed.ncbi.nlm.nih.gov/33233010/

Impact of growth hormone treatment on scoliosis development and progression: analysis of 1128 patients with idiopathic short stature

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Every year, the Italian Scoliosis Study Group selects the best published papers on conservative spine treatment from the global scientific literature.
Here is the abstract from one of these papers. 

Impact of growth hormone treatment on scoliosis development and progression: analysis of 1128 patients with idiopathic short stature
Se-Jun Park , Keun-Ho Lee , Chong-Suh Lee , Ki-Tack Kim , Jun Hyuk Jang , Dae Hun Shin , Min Sun Kim , Jiyeon Kim , Sung Yoon Cho , Dong-Kyu Jin 
PMID: 33180047DOI: 10.1515/jpem-2020-0393

Abstract

Objectives
The purpose of this study was to evaluate the impact of recombinant human growth hormone (rhGH) on the development and progression of scoliosis in patients with idiopathic short stature (ISS).
Methods
Patients with ISS who underwent rhGH treatment from 1997 to 2017 and were followed up for scoliosis screening with serial radiographic examination were included. For assessing scoliosis development, patients who did not have scoliosis at the time of rhGH treatment were included and followed up to determine whether de novo scoliosis developed during the treatment. For evaluating scoliosis progression, patients who already had scoliosis were analyzed. Univariate and multivariate Cox regression analyses of demographic and radiographic variables were performed to determine the related factors in the development and progression of scoliosis.
Results
For assessing scoliosis development, 1093 patients were included. The average duration of rhGH treatment was about 2 years. De novo scoliosis developed in 32 patients (3.7%). The analysis revealed that sex (p=0.016) and chronological age (p=0.048) were statistically significant factors associated with scoliosis development. However, no relationship was observed between scoliosis development and rhGH treatment types or duration. Among 67 patients who already had scoliosis at the time of rhGH treatment, 11 (16.4%) showed scoliosis progression. However, the rhGH types and duration also did not affect scoliosis progression.
Conclusions
De novo scoliosis developed in 3.7% and scoliosis progressed in 16.4% of the patients during rhGH treatment. However, scoliosis development or progression was not affected by the types or duration of rhGH treatment in patients with ISS.

https://pubmed.ncbi.nlm.nih.gov/33180047/