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ISPRM 2023: keynote lecture by Stefano Negrini

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Isico will also be present at the ISPRM Congress in Cartagena, Colombia, from June 4th to 8th. The motto of the international conference will be “New perspectives in Physical Medicine and Rehabilitation for global health challenges” thus representing the intention of focusing on the current and future rehabilitation health needs of people around the world.

Prof. Stefano Negrini, scientific director of Isico, will give one of the 8 keynote lectures in the Plenary session on New Perspectives on Evidence in Rehabilitation: from history to future. “The lecture will report on all Cochrane Rehabilitation contributions during these years, how they changed our understanding of evidence in rehabilitation and offer a way to reduce the burden of evidence on our shoulders – explains prof. Stefano Negrini – We will also look at the future, starting from the evidence-production ecosystem we will develop during the 5th Cochrane Rehabilitation Methodology Meeting in the next few months.”

Please visit the site for more info or to register for the event: https://isprm2023.org

Scoliosis: why choose rehabilitation treatment?

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I have scoliosis. What should I do? Do I absolutely have to follow a treatment, or is there no point? Will I need to be operated on? These are questions we often get asked by patients who have been diagnosed with scoliosis.

Therapeutic approaches to scoliosis fall into two categories: surgical treatment, indicated only in a limited number of cases, and conservative treatment, which we prefer to call rehabilitation treatment. This latter category comprises different approaches, which are based on the severity of scoliosis. 

First of all, there is simple clinical observation (for very mild cases), then treatment based on specific self-correction exercises (for mild scoliosis), and finally bracing (for the treatment of moderate forms). The braces used can be elastic, rigid or super-rigid. The choice of brace type and the number of prescribed brace-wearing hours (treatment dose) are always determined by two key factors: the severity of the curve(s) and the risk of worsening.

Even though surgical techniques have improved enormously over the years, surgery for scoliosis always entails vertebral fusion, and thus a complete loss of mobility (function) of the section of the spine involved, which is transformed into a single bone. It is the most difficult surgery in orthopaedics (apart from surgery for severe poly-trauma), and naturally it carries all the risks that derive from the fact that the spine encases and protects the spinal cord, which contains all the connections between the brain and the lower limbs.  

Rehabilitation treatment, therefore, must always be considered the first-choice treatment for scoliosis. This even applies to “surgical curves” (i.e., those with a Cobb angle greater than 45°–50°), if no attempt has ever been made to correct them through full-time bracing and specific exercises (1). In short, surgical treatment is used only when rehabilitation treatment has failed.

What are we aiming to achieve through rehabilitation treatment?

Basically, we are aiming to obtain a back that is not only strong and efficient but also aesthetically pleasing. This is, indeed, one of our main objectives, given that a person’s quality of life is strongly influenced by how they see themselves physically. Therefore, a brace needs to be built in such a way as to reduce the external deformity as well as the magnitude (i.e., the Cobb degrees) of the curve(s). In this regard, it is very important to underline the importance of preventing scoliosis from worsening, especially in puberty when it is at the greatest risk of doing so. Reducing the Cobb degrees of a scoliotic curve is always an objective, but given that scoliosis in puberty almost always worsens unless it is treated properly, simply blocking the evolution of the condition must, in itself, be considered a successful result.

Through rehabilitation treatment, we also try to prevent the onset of back pain in adulthood. To this end, as well as treating any pain that occurs in childhood and adolescence, we also do our best to preserve, as far as possible, the physiological curves present in the sagittal plane. Several studies have shown that back pain in adults with scoliosis is highly correlated with abnormalities in the sagittal plane, even more so than with scoliotic curve magnitude (2). And unfortunately, over the years, scoliosis that exceeds certain levels tends to progressively worsen; as a result, for purely mechanical reasons, the trunk progressively falls forwards.

Finally, rehabilitation treatment aims to prevent the respiratory system problems that can arise due to progressive deformation of the rib cage in the presence of a severe thoracic curve.

All these objectives were extensively discussed, and identified as therapeutic priorities, by international experts from the International Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) during the drafting of the SOSORT Guidelines (3). 

(1) Lusini M, Donzelli S, Minnella S, Zaina F, Negrini S. Brace treatment is effective in idiopathic scoliosis over 45°: an observational prospective cohort controlled study. Spine J. 2014 Sep 1;14(9):1951-6. doi: 10.1016/j.spinee.2013.11.040. Epub 2013 Dec 1. PMID: 24295798.

(2) Diebo BG, Shah NV, Boachie-Adjei O, Zhu F, Rothenfluh DA, Paulino CB, Schwab FJ, Lafage V. Adult spinal deformity. Lancet. 2019 Jul 13;394(10193):160-172. doi: 10.1016/S0140-6736(19)31125-0. Epub 2019 Jul 11. PMID: 31305254.

(3) Negrini S, Donzelli S, Aulisa AG, Czaprowski D, Schreiber S, de Mauroy JC, Diers H, Grivas TB, Knott P, Kotwicki T, Lebel A, Marti C, Maruyama T, O’Brien J, Price N, Parent E, Rigo M, Romano M, Stikeleather L, Wynne J, Zaina F. 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis Spinal Disord. 2018 Jan 10;13:3. doi: 10.1186/s13013-017-0145-8. PMID: 29435499; PMCID: PMC5795289.

Scoliosis: why appearance matters

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To treat scoliosis solely on the basis of radiological images, assessing only the patient’s skeletal conditions, would be a huge mistake.

The evolution of scoliosis typically leads to spinal changes in the three planes of space, and it therefore causes a modification of the ribcage. Indeed, as scoliosis progresses, it also changes the appearance of the torso, and this, depending on the severity of the curve, can impact more or less markedly the patient’s appearance.
According to the international guidelines on the conservative approach to scoliosis drawn up by Sosort, improving the patient’s appearance is the second most important goal of treatment.
If the condition is not adequately treated, or the treatment is ineffective, the above-mentioned changes will become more and more marked, even to the point of severely impairing the patient’s quality of life.

The way we see our body is highly subjective. People with asymmetries of the hips or shoulder blades, or a hump, react differently to the problem, in the sense that a defect that one person hardly thinks about, may be quite unbearable to another.
“In treating scoliosis, we must be careful not to overlook this question of aesthetics, precisely because we can never assume that our patients see things the same way as we do: any asymmetry, be it major or minor, can have a considerable psychological impact – says dr Irene Ferrario, Isico Psychologist – It is also important to remember that these changes occur in a period – adolescence – that is already full of challenges, and can sometimes see youngsters struggling to build, and accept, their own body image”.

For all these reasons, addressing patients’ aesthetic concerns should not be seen as indulging them; indeed, correcting aesthetic defects is not of secondary importance compared with correcting the curve: it is a therapeutic necessity. When a patient has, for example, one flank straighter than the other, a misaligned shoulder blade, or a hump that alters the line of the upper body, these changes may be perceived as more or less visible, depending both on the individual’s relationship with his/her body, and on his/her own (entirely subjective) aesthetic parameters. Over time, however, if the disease progresses, these changes can become objectively visible and psychologically damaging.
Obviously, we are referring here to the most severe cases, but these remarks nevertheless serve to illustrate that a scoliosis treatment plan cannot exclude the issue of aesthetics. Addressing this aspect is a necessary part of the treatment.

In short, good conservative practice absolutely must take into account aesthetic considerations. Regardless of whether or not the patient highlights this aspect, considering it to be of primary importance, the physician should in any case include it as a key objective of the treatment, which may contribute to its success.
In our care pathway, it is often the parents who first “raise the alarm”, alerting the therapeutic team to these concerns. This is because they are often the first to notice changes in the child’s body, especially if he or she is still too young to have a real awareness of his/her body and body shape.
Sometimes, these “alarm bells” are justified, and sometimes not, given that mild bodily asymmetries are normal, and do not always indicate an underlying problem. Purely aesthetic concerns, especially when raised by our young patients, should never be dismissed. Identifying and acknowledging a patient’s experiences and feelings is crucial to their all-round care. 

“Another aspect that should be underlined is brace wearing, as this treatment (when required) also has aesthetic implications –explains Lorenza Vallini, Isico PT – Many patients worry that their brace can be seen under their clothing, and addressing this concern is an important part of increasing the acceptability of the treatment: fitting patients with increasingly thin braces, moulded to their shape and therefore “almost invisible” to the onlooker, has proved to be a key factor in reducing and containing the deformity. Moreover, a good brace produces a truly remarkable aesthetic correction, not only immediately but also in the long term“.
Indeed, the brace wearer is rewarded with an improvement that lasts into adulthood. But arguments based on the long-term advantages are often lost on youngsters, and therefore an “invisible” brace is still crucial.
The main objective of the treatment will always be a well-balanced and harmonious body, which is as symmetrical as possible. After all, no one is perfect, not even Botticelli’s Venus. Indeed, her imperfections are part of her beauty!

WHO rehabilitation task force: Isico is also there

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Some of Isico’s are part of an international project promoted by WHO (World Health Organization) which aims to draw up rehabilitation guidelines for all countries, including those in the developing world, available to all Ministries of Health.
These rehabilitation guidelines need to be applicable in any context, taking into account the economic means and therapeutic possibilities that differ from country to country.

A large-scale and very ambitious project, involving Isico with three specialists, namely Dr Fabio Zaina, Dr Sabrina Donzelli and Dr Francesca Di Felice. 
The supervision is given by Prof Stefano Negrini, also involved as director of Cochrane Rehabilitation.
“In this process of developing guidelines, we were asked to deal specifically with back pain – explains Dr Zaina – in the first phase, already completed now, we dealt with the bibliographic research. In the second phase, we were asked to collect the scientific evidence in respect to the data collected so as to build the guidelines. At the moment we are working on the final phase: drawing up the guidelines, with great attention also to the sustainability of costs in different countries, and presenting them to the referents of the various countries for their application”.

Rehabilitation: the comment of prof. Negrini on Lancet

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When discussing health care in disability, it is essential to talk about rehabilitation. Yet it is not always obvious. Precisely for this prof. Stefano Negrini, as director of the Group of Physical and Rehabilitation Medicine (Cochrane Rehabilitation), developed the comment “Prioritising people with disabilities implies furthering rehabilitation” to the editorial “Prioritising disability in universal health coverage“.
Both were published in the scientific journal Lancet.
“Unfortunately, it happens that even major magazines forget the central role of rehabilitation, which is why this comment had the aim of emphasising the theme. We fully agree with the Editors regarding the need to prioritise disability in universal health coverage – he commented Prof. Negrini –  but we want to emphasise that for the World Health Organization (WHO) this implies also strengthening the rehabilitation health strategy.
Because of changing health and demographic trends, an increase in the number of people living with permanent disabilities, but also of people experiencing disabilities with the potential of recovery, has been observed. 
1 billion people live with disabilities,  while 2·4 billion people experience disabilities.  
Rehabilitation serves both groups: by reducing the number of people transitioning from experiencing a disability to living with a disability, maximising the benefits of other health services, and reducing the overall costs“. 


The comment concludes with these words: “WHO has included rehabilitation in the universal health coverage mandate together with other public health strategies including promotion, prevention, treatment, and palliative care… Paradoxically, the fundamental struggle for the rights of people living with disabilities somehow drove the attention to those with permanent and stable disabilities and social rehabilitation, without including those with evolving and changing conditions, who are the target groups of the rehabilitation health strategy. Rehabilitation strengthening advocated by WHO is in line with disability prioritisation emphasised in the Editorial, but will also reduce the burden of disability on the population and the costs of health services worldwide“.