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Scoliosis X-rays: Why We No Longer Use Old Protections

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The use of protective devices intended to shield the foetus and gonads of the patient during X-ray imaging should be discontinued as a routine practice since it can compromise its benefits. This recommendation, published in April 2019 by the American Association of Physicists in Medicine AAPM represents a historic change.

Why, after more than 70 years of gonadal protection, have we reached this conclusion?
Let’s take a closer look. At ISICO, this topic is particularly important to us because we need to visualise the spine to offer the best therapies for scoliosis and assess its progress properly. Thus, while we reduce requests as much as possible, it’s almost always necessary to prescribe complete spine X-rays in one projection (either frontal or lateral) at least once a year.

Why This Change? There Are Two Reasons:

  1. Minimal or No Benefits from Protections
    Current scientific evidence shows that these protections provide minimal or no health benefits to patients. In the past, it was believed that radiation could damage reproductive cells, potentially harming future offspring. However, it has been discovered that reproductive cells are much less sensitive to radiation than previously thought, and there is no evidence that the very low doses currently used in diagnostic imaging can harm reproductive cells or the foetus. Radiation is not harmful to the foetus, even when a radiographic exam on a pregnant patient is necessary and indispensable.
  2. Negative Impact on Exam Effectiveness
    The protective equipment can obscure anatomy or significant pathologies or produce artefacts that require repeating the exam, thereby substantially increasing the dose. Additionally, most modern X-ray equipment can automatically adjust the amount of radiation used based on the body region being examined. Lead-equivalent individual protection in the field of view could lead to a significant and unjustified increase in the patient’s dose. These technological advancements have made patient shielding a practice that introduces more risks than benefits.

In line with this evidence, at ISICO, we discourage using these protections as they could potentially be harmful.

Gym workouts and scoliosis: can the two go hand in hand?

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In recent years, fitness has become a booming industry, driven by a growing interest among young people and on social media. This trend has resulted in the emergence of better-qualified fitness professionals, triggering a virtuous circle in terms of improving the quality and safety of training.

From our perspective, it is worth remembering that physical activity, if performed correctly, can have a protective role in the management of scoliosis.
We are often asked whether patients with scoliosis, particularly those undergoing bracing treatment, can work out in the gym.
Before answering this question, let’s make two things clear:

● the literature contains nothing specific on this topic;

● “working out in the gym” means more than one thing (i.e., not all training is the same).

The importance of goals
Before embarking on a training programme, it is crucial to establish your personal goals. Among adolescents, the main reasons for working out are often the desire to build muscle (boys) or tone up (girls). However, in adolescence, learning the correct training techniques and improving your physical abilities, such as coordination, balance, strength, and resistance, are more important than immediately seeking to bulk up your muscles.
Young people will find that efforts to gain muscle mass give more gratifying results once they have finished growing (i.e. after reaching 16-18 years of age).
The best approach, then, is to try to focus on what you actually do in the gym, striving to do it better and more effectively and thinking less about what you see in the mirror.

The benefits of training in the gym

Training in the gym offers you the chance to monitor your body and safely regulate training stimuli, unlike when practising many competitive sports, during which you are more likely to sustain an injury. Several studies show that the gym is associated with a lower injury rate than other sports.

Advice for those with scoliosis

We should first point out that young people with scoliosis (boys and girls) are, in most cases, no different from their peers who do not have scoliosis. Having said this, we do have some advice.

  1. Find a professional. A properly qualified trainer can help you do the exercises correctly and adapt the training programme to your individual requirements. It might also be a good idea to put your doctor/physiotherapist and trainer in contact with each other, so that the training programme can be refined and any doubts addressed.
  2. Don’t be in a hurry. Targeted warm-up exercises can improve flexibility and reduce stiffness in the spine.
  3. Choose your exercises. It is important to start with simple and controlled exercises, then gradually increase the difficulty level.
  4. Take care with axial loads. Axial loading exercises must be performed carefully to avoid sudden or compensatory movements. When it comes to the squat, for example, the goblet squat may be the best option as it is performed with the weight (dumbbell/plate/kettlebell) held in your hands, at chest height, in front of you. By facilitating load management, this version guarantees greater stability and makes it easier to control the movement.
  5. Learn to “dose” self-correction. When you are working out in the gym, the amount of self-correction you apply (i.e., the extent to which you adopt the position designed to counteract the scoliotic curves and therefore keep your spine more aligned) will depend on the type of exercise you are doing and the level of fatigue you are experiencing. The objective of exercises done in the gym differs from that of the specific exercises taught you by your physiotherapist, where self-correction is the key element, and determines how the exercises are performed. When you are using weights, the priority is to focus on the specific training stimulus, while at the same time trying to keep your spine properly supported.

Should a brace be worn in the gym?

Individuals who are being treated with a brace can consider doing their physical activity during their brace-on hours, so as to take full advantage of the support provided by the brace itself. However, if they prefer to train during their brace-off window, they should make sure they do a longer warm up, so as to prepare their back for the training session.

So, finally

Working out in the gym is possible for those with scoliosis and can indeed be beneficial if the necessary precautions are taken. Be sure to find a professional trainer, keep your doctor in the loop, and listen to your body because these are the keys to safe and effective training.

Your brace, an “accessory” that makes you unique

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Every era has its own fashion corset, you might say, if you think of the various ways, in which this particular garment has been used over the years.

First created in the sixteenth century, it has always been intended to enhance the female silhouette by the aesthetic canons of the times. Worn under clothes, it modified the shape of the body. It has undergone a continuous process of evolution to the point of becoming, nowadays, an actual item of clothing—a fashion garment that, again for aesthetic reasons, is deliberately left visible.

The well-known TV series Bridgerton, which features women in Regency-style corsets, has brought them back into vogue, so much so that, in the name of gender equality, male models are now even wearing them on catwalks. And, as we saw on the red carpet at the Oscars, corsets appeal both to Gen Z and over-60s celebrities, with Halle Bailey and Jamie Lee Curtis both appearing in Dolce & Gabbana ones.

Although the orthopaedic braces used in the rehabilitation treatment of scoliosis are created with a completely different function in mind, they, too, are worn to achieve a better silhouette. Indeed, one of their purposes is undoubtedly to improve the appearance of the patient’s back, as well as its health, of course.

Whenever we mention corrective braces, the initial response is always one of fear and dismay because the first image that springs to mind is that of some object that is impossible to disguise under clothes. We might think, for example, of the Milwaukee brace (now hardly ever used anywhere in the world), which even has a kind of chin rest that clearly can’t be concealed under clothing. However, thanks to research and continuous efforts to develop treatments that are the least invasive possible, the braces being produced nowadays are not only more and more effective as corrective devices, but also increasingly close-fitting and therefore impossible to see under clothes. One example is the Sforzesco brace, developed by ISICO, which is just as effective as casting.

Familiarity with these somewhat “awkward accessories” has grown in recent years as people are encouraged to regard them (whatever type they are) as objects that are just a part of everyday life and don’t need to be covered up. Actually, plastic braces now even exist that can be customized with different Thermo adhesive designs.

It’s a bit like the situation with glasses: frames have increasingly evolved, following fashion, and today the variety available is so great that there is something for all tastes, particularly eccentric styles. In this way, a person’s glasses are now a fundamental part of their style and identity. Their purely medical function has been combined with a strong aesthetic component, turning them into true accessories.

Similarly, dental braces have become increasingly customisable, and limb prosthetics, in part thanks to athletes, are now part of everyday life too. Indeed, many of those who wear them are happy to show them off as they are part of what makes them unique.

All these are examples of “awkward accessories” that are now a part of everyday life. And why shouldn’t this also be true of the corrective braces worn by young scoliosis patients?  

My next comments are aimed directly at those who wear braces or are about to start doing so.

Just like glasses, dental braces or limb prosthetics, a scoliosis brace should be seen, and treated, as something that sets you apart, but in a positive way, as something that is peculiar to you — something that makes you special, stronger and more self-confident, while also caring for your back. Although this might initially sound impossible, over time you really will come to see it as a strength.

You might think, “it’s easy for the physiotherapist to talk. They haven’t actually gone through this. We patients are the ones who have to wear these things, and only we can really know what it feels like.” 

Well, this is where, as a physiotherapist, I am able to draw on my own experience as a former patient. I lived with a brace for 7 years, wearing it full-time to begin with. And on the basis of that experience, I feel compelled to urge all youngsters who are embarking on, or about to embark on, this journey to use their brace and see it as a distinguishing feature, something to joke about with friends, something that makes you unique and will help you in your adult life (even though I realise that when you’re young it’s hard to think that far ahead).

Erica, former ISICO patient and now ISICO therapist

Isico Alliance, excellence in spine

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Isico’s goal has always been to promote the best therapies for the treatment of scoliosis in the world, and it is precisely from this idea and to give proper answers to the requests we periodically receive that we founded the Isico Alliance.

“ISICO stands alongside the ISICO Alliance Centres to support applying proper braces, organising new activities, and providing better care to their patients—explains Fabio Zaina, physiatrist and one of the project coordinators — taking advantage of the experience and ongoing innovations ISICO realises day by day. In fact, ISICO services mean excellent care for patients and an excellent approach for the centre.” 

There are several advantages from which an Isico Alliance centre can choose, from brace delivery, ISICO takes care of the entire production cycle of the prescribed brace in the workshops in Italy, to brace design, ISICO gives its assistance in designing the brace that will be produced on-site, from the training of a local orthotist to equip them with the skills necessary to manage the entire process of SPoRT (Symmetric, Patient-oriented, Rigid, Three-dimensional, active) braces production, to the opportunity to organise periodically SEAS courses in the local area, up to the use of the best technology for best care thanks to ScoliosisManager, the software developed by ISICO providing a uniform data collection protocol. Other optional services available are the ISICO iOS-Android app featuring specific functions for patients and ISICO practitioners, and Telemedicine services delivered to local patients directly by ISICO for complex or particular cases.

Do you wish to join the Alliance, or do you want to ask for more information? Please visit the website: https://isicoalliance.com

Margherita, sport, and scoliosis: a possible pairing

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What distinguishes ISICO in the treatment of scoliosis is a therapeutic approach that allows you to combine treatment with exercises and brace with sporting passions, even high-level competitive ones. This happened to Margherita, 14 years old, from the Marche region in Italy, who is an aerobic gymnastics champion.
We asked our young patient to share her experience while she prepares for an important sporting event: the Aerobic Gymnastics World Championships, scheduled for Pesaro, Italy, in September. Let’s discover with her how it is possible to reconcile sport and a brace.

How did your passion for aerobic gymnastics arise? 
It all started as a game with physical gymnastics. I was only 4 years old. Then my coach suggested the aerobics course to me, and from then on I became passionate about this sport.

When were you diagnosed with scoliosis?
I was 8 years old, it was in 2018…

What has been the impact of scoliosis on your daily life, at school and with friends?
At the beginning, I was monitored periodically and did specific exercises with my physiotherapists, who were special people for me, helping me to understand my condition better. As I grew up, my curve got worse, so I started the journey with ISICO and I found myself very well.

Do you wear a brace? For how many hours a day?
I started wearing the brace one year ago; it wasn’t easy because initially I had to wear it 20 hours a day; after a few months, it was decreased to 18 hours.

How do you reconcile the brace with sporting activity? How many hours do you train?
When I wore the brace for 20 hours, I only took it off for workouts. Now, my ISICO physiatrist, Fabio Zaina, has reduced the hours I wear it. I generally train between three and four hours a day, six days a week. In the summer, however, the hours increase. There are also double workouts.

What would you recommend to a peer who is starting corset therapy and playing sports?
Sport, like brace wearing, requires consistency, continuity, and tenacity. The first few weeks in a brace are not easy, but then everything improves, and you get used to it. My back has improved, and that’s the most important thing.


What are your next goals and competitions?
During this period, I am training for the World Championships, which will be held in Pesaro, Italy, in September.

Good luck, Margherita!

We remind you that ISICO’s innovative approach includes:

•  SEAS: specific exercises for scoliosis

•  Personalized Therapy: each patient receives a tailor-made treatment plan, which takes into account specific individual needs and conditions

•  Multidisciplinary Approach: the therapeutic team consists of physiotherapists, spine specialists and orthotist, who work together to offer a complete physical and psychological approach to treating scoliosis.

Sanders staging: the pros and cons?

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The progression of idiopathic scoliosis is related to skeletal growth, peaking during the adolescent growth spurt. Subsequently, once skeletal maturity has been reached, the pathology usually stabilises or slows down.

Knowing the predictors of skeletal maturity allows physicians to predict the risk and timing of curve progression, and therefore choose the most suitable treatment for their patient’s scoliosis.

Several indicators of skeletal maturity are closely linked to the progression of scoliosis. They include chronological age, height and weight, development of secondary sexual characteristics, and menarche.
However, skeletal maturity is known to be the most sensitive indicator of both the speed of skeletal growth and its completion. (1)

Numerous staging systems for evaluating skeletal maturity, in addition to the Risser sign, have been developed and used in patients with scoliosis. In the scientific community, particularly in the USA, the Sanders staging system is becoming increasingly popular.

Unlike the Risser method, which evaluates the degree of ossification of the iliac crests, the Sanders approach is based on the assessment of the ossification of the epiphyses of the wrist and hand bones, and it divides bone growth into 8 stages. Stage 3 corresponds to the pubertal growth peak when the risk of scoliosis worsening is greatest, while stage 8 corresponds to full skeletal maturity, and thus to the absence of a risk of worsening (in the case of curves measuring less than 50°) (2).

So, what are the pros and cons of this method of assessing skeletal maturity?

PROS:

1. It accurately predicts the skeletal growth peak: the Sanders classification system offers the possibility of dividing the relevant growth periods of patients who are still skeletally immature into multiple categories and would all be grouped as stage 0 using the Risser system. Essentially, some Risser stage 0 patients are at higher risk and more developmentally immature than others who are more skeletally mature but still classified as Risser 0 (1). 

2. It more reliably predicts residual growth: the Sanders classification can help doctors to predict residual growth in scoliosis patients more accurately than is possible with other assessment methods, and this allows them to plan better treatment (such as when to “wean” patients off their braces) and better monitor the evolution of the disease. (1)

3. It is a support tool: like other methods, the Sanders staging system, combined with clinical and radiographic parameters, allows doctors to make more informed decisions on the treatment of scoliosis, such as the decision to opt for a conservative approach (based on specific physiotherapeutic exercises and bracing) as opposed surgery, and vice versa (3).

CONS:

1. Its ability to predict skeletal growth may be limited: the Sanders staging system estimates skeletal maturity and residual growth, but it is not 100% accurate and may be limited in its ability to predict this type of growth.

2. It involves radiation exposure: to perform Sanders staging, radiographs have to be taken of the wrist, but this would mean increasing the radiation exposure of young patients, an aspect we always pay close attention to, and something we try to avoid as much as possible. as much as possible. In some places they experimented performing the classical spinal x-rays with specific hand positions to be able to see also the Sanders, but this is still experimental, and we don’t know yet if and how it changes the spinal posture. It could be a solution. In fact, we recommend that our patients have X-rays taken using EOS, a tool that allows their radiation exposure to be reduced. Of course, modern X-rays are nothing like the X-rays of the past, but it is nevertheless always better to have as few as possible.

3. Issues of cost and availability of resources: Sanders staging requires radiographic/logistical resources and specific expertise to interpret the images, which may not always be available in all healthcare settings. Furthermore, using the Sanders system can result in additional costs for patients or for the healthcare system.

Finally, our scientific director, Prof. Stefano Negrini, has explained an important reason why Sanders staging is not currently used at Isico: “We have a very pragmatic approach to the problem, that is based on adding further radiation only if necessary and if it would change our clinical behaviour. The reality is that scoliosis is still highly unpredictable: it can progress unexpectedly at any bone staging or it can stay stable at the highest risk phases. Consequently, the only clinical change when we are at a high-risk phase is seeing the patients more often, and intervening if needed because of progression. Would that change with more precise knowledge of bone maturity? Bone age is correlated with the risk, but not precise enough to rely on that alone – there are too many other unknowns… To explain all this, I often tell my patients that scoliosis treatment is rather like driving a car on a foggy night. We have some significant landmarks, but we never know exactly where we are. Increasing the precision of external reference points may perhaps help us, but it does not take away the fog or the night, which are the two factors that most determine our risk of having an accident, more than the road signs. In other words, we might well manage to obtain a more accurate assessment of the patient’s skeletal growth. Still, if the disease ends up following this indication only partially and behaving in a way we can’t control, then in reality we have not actually obtained any extra information that is really useful for treating our patient. For this reason, we don’t ask patients to have an additional X-ray if it is not really going to change their treatment significantly”.

References

1 – Prediction of Curve Progression in Idiopathic Scoliosis

2 – Maturity Indicators and Adolescent Idiopathic Scoliosis: Evaluation of the Sanders Maturity Scale

3 – Managing the Pediatric Spine: Growth Assessment

4 – Is there a skeletal age index that can predict accurate curve progression in adolescent idiopathic scoliosis? A systematic review

ISSLS Milan: a success with 500 participants

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“It was a bit as if the world, that of research and clinics in the field of spinal pathologies, had gathered in Milan — this is the comment of Dr. Greta Jurenaite, physiatrist specialist at ISICO — on her first participation in the ISSLS international conference, held between the end of May and the beginning of June. The congress was huge, with around 500 participants, most foreigners, coming from everywhere from Japan to Australia to South America. The few Italians were mostly from our institute.”

We would like to remind you that on the occasion of the conference, the 50th anniversary of its foundation was also celebrated, and Prof. Stefano Negrini, ISICO scientific director, and Dr. Fabio Zaina, physiatrist at ISICO, acted as local guests.

Dr. Jurenaite continues: “The days often began at 7:30 and the presentations continued until dinner, a commitment that makes us understand how much new there is in this sector and how essential it is to keep up to date. I’ll give you an example. On the last day, we participated in a session dedicated exclusively to rehabilitation before back surgery. It was a moment of discussion and comparison, and we reflected on what is still missing to “educate and make the patient as aware as possible, concluding that it is necessary to provide as much information as possible. This is what we do at ISICO when we dedicate time to explaining what scoliosis is, the therapy steps, and the objectives, because every therapeutic choice must be shared with the patient. The discussion was so interesting that we proposed the topic as the subject of a possible scientific article, whose co-authors could be some of us ISICO doctors.” 

Green June: Arianna, a karate champion

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Since I was a child, I have always loved sports, so much so that I started practising karate at the age of 4. I certainly never imagined that just three years later I would find myself facing something bigger than myself: scoliosis.

I remember very well the first day I wore the brace; I wasn’t sad, I was just very confused. Initially, wearing a corset at school and in the gym didn’t bother me, but as I grew up, I started to feel the weight of other people’s judgement. Going to karate classes with a brace became increasingly difficult, especially because I felt limited and unable to give my all.

Despite this, my passion for karate was stronger than anything else, and despite being a child, I didn’t let scoliosis get me down.

The first satisfaction came from agonism competitions: at 12 years old, I won my first title as an Italian Karate champion, and, from that moment on, my motivation to train grew more and more. Shortly afterwards, however, as I entered adolescence, I began to feel embarrassed about having to wear the brace. I fell into a period of sadness that I couldn’t overcome: the races were going badly, and so was my mood. I got out of it thanks to my family and my karate teacher, who always supported me.

Karate was the strongest motivation that helped me overcome these difficulties and allowed me (and still allows me) to express myself. Once I got over that dark moment, I started winning again, but above all, I had fun during training and races. The results, in fact, did not take long to arrive, so much so that I won two more Italian championships in 2022 and 2024.

After seven years of sacrifices and sometimes difficult moments, my scoliosis has taught me how essential it is to get involved in life, not give up in the face of difficulties, and be tenacious and determined to achieve small and large goals.

Even if the path is not at all easy, I want to tell all the kids who, like me, are “braced” to never give up on their dreams.

I sincerely thank ISICO and, in particular, Dr. Zaina and my physiotherapist, Lorenza Vallini, who have taken care of me over the years. With their attention and professionalism, together with my sacrifices, today I can say that I am proud of my back.

Green June: Gaia, an artistic gymnastics champion

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Often, a diagnosis of scoliosis leads to despair and the fear of not being able to live one’s daily life as a “braced.” It is not so.
We don’t want to say that it is easy or doesn’t require many sacrifices, but that despite the brace or wearing it, you can continue, for example, to practice sports. Even at a high competitive level, even with champion results, as in the case of the three stories we offer you this month dedicated to scoliosis.

Will you also wear green in June and share it with the hashtag #weargreenforscoliosis!

Gaia, a passion for artistic gymnastics
In November 2023, Gaia was diagnosed with scoliosis with primary right thoracic and left thoracic lumbar curves. A diagnosis that sounds like a condemnation of her passions. In fact, Gaia loves sports; she is very competitive and has been practicing artistic gymnastics since she was 5 years old. She trains for several hours, three times a week.
There’s no denying that her first thought was: Will I be able to practice gymnastics again? Will I be able to keep my habits the same? At the ISICO Centre, where she is being treated, the doctor who looks after her reassures her, telling her that she shouldn’t have to give up anything, especially gymnastics.

So it was: she continued to practice gymnastics, wearing her now faithful friend for 20 hours a day and training in the 4 hours of freedom, so much so that she won gold on the balance beam and placed second on the trampoline and third on floor exercise. “Our doctor was right—says Gaia—nothing has changed; sports, friends, habits… determination, perseverance, and sacrifice are needed, and, in a few years, I will be able to enjoy a healthy back, better posture, and bearing without having to give up my passions at the same time!”.

Modular Italian Brace works just as well as the Sforzesco

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A modular brace that has the same practicality and comfort of wearing and the same proven effectiveness, even on the most severe curves, of the Sforzesco corset but with significantly reduced costs. It is the Modular Italian Brace (MIB), the latest corset developed by our institute, after the Sforzesco and the Sforzesco Free Plevis.
Its effectiveness is demonstrated by the data of one of our studies recently published in the Journal of Clinical Medicine, The New Modular Sforzesco Brace (Modular Italian Brace) Is as Effective as the Classical One: A Retrospective Controlled Study from a Prospective Cohort. “A research of considerable importance,” comments Dr. Francesco Negrini, physiatrist and author of the study. “We recently developed a new Sforzesco brace based on modularity (the Modular Italian Brace—MI brace) that could allow standardisation, facilitating global expertise diffusion, increased modifiability and adaptability, and cost savings due to longer brace life”.

We remind you that the Sforzesco brace is a very rigid push-up brace effective in adolescent idiopathic scoliosis (AIS), which revolutionised rehabilitation treatment years ago by replacing the cast but guaranteeing the same results. Recently, the “Free Pelvis” (FP) innovation has been introduced. It consists of semi-rigid material on the pelvis connected to the main rigid body of the brace on the trunk.
It was found that it does not change the in-brace and short-term results of classical very rigid braces and, consequently, can be safely applied.

The MI brace, even if built in a different way, keeps the main characteristic of the Sf brace, that is, the overall symmetry (with some asymmetries inserted in specific areas). In fact, it is the symmetry that allowed the development of the MI brace, where it is possible to recreate the asymmetrical needs of the SF brace through internal pads.

The MIB can be built and fully personalised directly for the patient, modifying the classical procedures of brace construction through CAD-CAM or casting. Moreover, the MIB can be continuously adapted during treatment, giving full adaptability to the patient during changes due to growth or treatment.

The MIB is an evolution of the SF-FP. The two braces share the semi-rigid material on the pelvis, a novelty that improves comfort and patient acceptability. On the other hand, Sf FP is built in a more traditional way, without the MIB modularity and the possibility to adapt the brace during treatment. With Sf FP, if the patient changes due to growth, the brace must be changed altogether.

“The braces considered in this paper share the same action; the question is if they also share the same results. We aimed to compare the short-term results of the two braces,” explains Dr. Negrini. “We compared in this retrospective study 231 patients with scoliosis, between 10 and 16 years old, 53 treated with a MI brace, and 178 treated with a Sforzesco brace. Both braces reduced the Cobb angle (−6◦ out-of-brace; −16◦ in-brace) without differences between groups. The results of the present study suggest that the SfB and MIB can have similar positive short-term results on moderate-to-moderate, moderate-to-severe, and severe curve brace treatment with modular braces. that could lead to easier diffusion worldwide, even where there are reduced economic means and expertise in brace treatment. Before suggesting a generalised use of the MIB as a first-line rigid brace treatment, the results should be confirmed in studies with longer follow-ups”.