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SRS research evaluates AIS brace management

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”.

Telephysiotherapy in Isico: the published research

In this pandemic year a lot has changed in our daily habits, much in the way we work. Something also in the way we treat patients. We had to adapt to take opportunities from difficulties. In Isico, we have done this from the beginning, overcoming the first phase of closures thanks to the online mode of medical visits and physiotherapy treatments.

It was a way not to leave our patients alone and not to waste the efforts made, a way that after some time has become an integral part of our therapeutic proposal.

We learnt a lot and this also translated into the research, published recently by the Spine Journal,Lessons learnt in two months of the exclusive application of telephysiotherapy instead of classical physiotherapy during the lockdown in Italy“. 

“Current evidence on telemedicine mostly refers to interventions not requiring hands-on approaches, based on either technology or oral/visual interactions – explains Michele Romano, director of Isico physiotherapy and author of the research –  In a way, the pandemic offered a sudden push to telemedicine. The question is which lessons can we learn on telephysiotherapy after a few months of extensive and mandatory experience?” 

For this reason, we want to share the experiences of exclusively telephysiotherapy treatments acquired by 38 physiotherapists working for Isico during the 2 months of lockdown from March 16th to May 11th.

It was crucial in the first phase that patients accept telephysiotherapy. Usually, the appointments are managed by the booking call-center, but after the first phone calls it was clear that this unusual and unexpected change proposed by a secretary was not well received by the patients.

Consequently, the new standard is that the appointment is made by phone call by the treating physiotherapist him/herself. That facilitates the interaction with the patient, and allows to professionally answer all eventual doubts.

How to organise to be able to carry out physiotherapy treatments online?  “An involvement of caregivers and families is necessary for the session. A free video-communication App is used (Skype or Meet) – explains Michele Romano  – Evaluation results autonomously collected by patients with the help of a caregiver, are sent before the session to fill the assessment form in advance. One caregiver is present during the session, with one camera to film the patient, to help correct mistakes and observe the right execution of specific exercises; a second device is used for the Institute App to record the exercises”.

During 2 months of lockdown, telephysiotherapy sessions have been 2,239 (100%). After the lockdown, when back to “normal” were face-to-face hands-on physiotherapy, 10% (532 out of a total of 5,091) remained telephysiotherapy sessions.

The common feeling of patients and their caregivers was of not having been abandoned – explains Michele  Romano –  during these months we verified that the systems work properly, now this wide and sudden experience is available for the worldwide physiotherapy community. Telephysiotherapy is a not so difficult, readily available instrument.

Obviously, limits and drawbacks referred by physiotherapists and patients included the impossibility to use hands-on, the need to simplify the approach, the limited attention of younger patients, the connection difficulties.  

Most physiotherapists and patients agreed that this type of approach is perfect in emergency, but it cannot substitute normal physiotherapy sessions in normal times.

“Yet we have found – concludes Michele Romano – that there is a group of patients who have discovered telemedicine and continue to use it even now, an additional opportunity that therefore in Isico we have decided to offer patients in the future, alongside the classical medical visits and physiotherapy treatments performed in-person.”

Scoliosis: is aesthetics measurable?

When it comes to scoliosis therapy, aesthetics is one of the goals along with a healthy back.

Aesthetic deformity due to scoliosis and its impact on the patient is considered by the members of SOSORT (International Society On Scoliosis Orthopaedic and Rehabilitation Treatment) as the most important reason for treating AIS; unfortunately, only a few of scoliosis studies were found in PubMed on this topic. 

But can a goal, apparently so subjective, be measurable in a repeatable way to become objectiveYes,according to the data collected by the study Reliability, repeatability and comparison to normal of a set of new stereophotogrammetric parameters to detect trunk asymmetries, recently published by the Journal of BIOLOGICAL REGULATORS & Homeostatic Agents

“Aesthetic impairment is a crucial issue in Adolescent Idiopathic Scoliosis (AIS), but to date no objective measurements are available – states Dr Francesco Negrini, Isico physiatrist – for our research, we used the Formetric®, which we usually use to measure sagittal planes. We have established parameters for evaluating symmetries in patients, such as those of the shoulder blades or hips, to obtain objective data related to the aesthetic aspect. In order to validate this instrument for clinical practice, the first step and aim of this study are to evaluate the repeatability of the parameters measured by surface topography in a group of AIS subjects and to test if they can distinguish healthy subjects from AIS patients to develop an objective tool for deformity evaluation of the trunk in AIS patients. For our evaluations, we used a device for surface topography based on the principles of rasterstereography. This device (Formetric®, Diers Biomedical Solutions) can reconstruct digitally in three dimensions the back of any person”.

The study evaluated 15 selected parameters that could be good predictors of scoliosis’ impact on the patients’ trunk.
“We analysed short-term (30 seconds, 38 subjects) and medium-term (90 minutes, 14 subjects) repeatability of surface topography measures and their diagnostic validity in AIS (74 subjects, 33 AIS patients and 41 healthy subjects) – proceeds Dr Negrini – All examined parameters were highly correlated as far as short, and medium-term repeatability is concerned”. 

When it comes to aesthetics we cannot stop at Cobb degrees alone, believing that there is no objective measure: “Symmetries can be measured repetitively, as we did in our study – concludes Dr Negrini – so we can offer an objective measurement of aesthetics in patients with idiopathic scoliosis. The surface topography showed good repeatability. Moreover, some of its parameters are correlated with scoliosis, showing that it could very well evaluate deformity due to this pathology. Thanks to these findings, it will be possible to develop a tool that can objectively evaluate aesthetics in AIS patients.”.

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

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 “.

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”.

Scoliosis: dance and swimming. Yes or no?

Is there any particular sport, rather than others, that individuals with scoliosis should choose? 

Two Isico studies have addressed this question, and in so doing they have dispelled the misconception that dance and swimming have a negative impact on scoliosis curves.

The studies in question will be presented in Melbourne, Australia, at the next SOSORT meeting, this year being held from April 27th to May 1st, 2020, during Spine Week.
As their titles show, these studies — Is swimming helpful or harmful in adolescents with idiopathic scoliosis? and The effect of dance on idiopathic scoliosis progression in adolescents — explore the relationship between scoliosis and two types of physical activity: swimming and dance. 

Swimming and scoliosis

A few years ago, a previous Isico study, Swimming and spinal deformities: a cross-sectional study, exploded another myth.
It showed that swimming has no therapeutic benefit; in fact, the swimmers presented greater asymmetry and hyperkyphosis than the individuals who did not swim.
On this basis, it was concluded that swimming has a negative impact on posture and consequently is not an effective form of prevention. 

The aim of our latest study on swimming was to verify the safety of recreational versus competitive swimming in adolescents with idiopathic scoliosis. 

Of 780 patients fulfilling the inclusion criteria, 529 (68%, 420 females, age 12.3 ± 1.3, 16.0 ± 3.6 Cobb degrees) regularly performed sports activities. 63 (12%) were swimmers, and 15 of these were competitive swimmers. 

“Compared with our 2013 study, in this latest research we did not consider healthy subjects” says Alessandra Negrini, Isico physiotherapist.
“We studied a sample of subjects with mild scoliosis (10-25°, mean Cobb angle 16°), not being treated with braces, and therefore only a clinical population. Our aim was to evaluate, on the basis of radiological findings at 12 months, the effect of swimming in individuals who already have a diagnosis of scoliosis and are going through a growth spurt (Risser-0-2, over 10 years of age). The effect of swimming was found to be comparable to that of other sports, and it was also similar in the competitive and the non-competitive swimmers. Age and hump size were the only factors found to influence the risk of worsening. These findings show that there is no reason to demonise swimming, be it recreational or competitive”.
In other words, they show that swimming is no better or worse than other sports.

Dance and scoliosis

Many spine specialists advise their idiopathic scoliosis (IS) patients to stop dancing on account of the risks (increased spinal mobility and flat back) that are potentially associated with the movements typically involved in this form of physical activity.
“The current literature reports a higher prevalence of scoliosis in subjects who practice dance than in their peers who do not dance” says Michele Romano, director of physiotherapy at Isico. ”In this research, we set out to assess the impact, in terms of the progression of idiopathic scoliosis, of dance compared with other sports in a group of adolescents (545 consecutive scoliosis patients)”.

The patients were divided into two groups: a Sport Activity group (SA – 461 participants), whose members performed any kind of sport, and a group of dancers, the Dance Activity group (DA – 84 patients).

“According to the results, the dancers showed a similar risk of progression as the patients performing other types of sport” Romano concluded. “The small sample size is one limit of the study; larger studies are needed in order to verify the effect of practising dance”.

Scoliosis: there is no particular sport that is more recommended than others 

So, what conclusions can be drawn from the two studies? According to the two Isico specialists, at present there is no evidence to suggest that any particular sport should be preferred over others, or that there is any sport that people with scoliosis should avoid.
Given that neither swimming nor dance, two of the activities most often discouraged for those affected by scoliosis, showed negative effects when compared with other sports, it seems unlikely that other types of sport might have a negative impact.
“The scientific evidence tells us that sport is good for us, and while it may not constitute a treatment as such (unlike specific exercises), it may have a positive effect, supporting the improvements recorded by those with scoliosis” says Alessandra Negrini, “as already shown by my study Effect of sport activity added to full-time bracing in 785 Risser 0-2 adolescents with high degree idiopathic scoliosis (which won the Sosort Award 2019). We at Isico have always believed that it is crucial for our patients to carry on doing sport, especially since their treatment can already be an uphill battle for them. In short, being able to carry on doing sport, something many of these youngsters are passionate about, can make it easier for them to accept the treatment.»

The criteria for evaluation of aesthetics in scoliosis

Our study “Construct validity of the Trunk Aesthetic Clinical Evaluation (TRACE) in young people with idiopathic scoliosis” has recently been published by the journal Annals of Physical and Rehabilitation Medicine.

The aim of this study? Scientifically validate the criteria of evaluation of aesthetics in scoliosis.

Indeed, we recall that aesthetics is recognized as a main outcome in idiopathic scoliosis (IS) treatment, but to date, there are no standard criteria for physicians’ evaluation.

Trunk Aesthetic Clinical Evaluation (TRACE) is a simple 12-point ordinal scale to quantify symmetry as a proxy of aesthetics. TRACE is already diffused worldwide and has been used in clinical research.

” In our study, that included 1553 participants (1334 females, mean age 13 years old), we aimed to validate TRACE and improve it with Rasch analysis – explains prof. Stefano Negrini, Scientific Director of Isico – the statistical technique allows to make more precise measurements.
Let’s take the temperature measurement as an example: is it hot, warm, medium, or a little cold? With this type of analysis we develop a real thermometer, obtaining a numerical data. The same criterion is applied to the measurement of the aesthetics, reliably and effectively, as well as objective because it derives from external observation and not simply from what the patient reports “.


The TRACE ordinal scale has been converted into a Rasch-consistent, interval-level measure of trunk aesthetics in IS patients and can be used to compare different populations.

TRACE can be used as an outcome measure and in everyday clinical evaluation of IS, even if new developments of the scale are advised – ends prof. Negrini – It is an objective tool, the only one up to now in the literature. The benchmark for the aesthetics in scoliosis which we want to improve more and more with use”