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Curve type, flexibility, correction, and rotation are predictors of curve progression in patients with adolescent idiopathic scoliosis undergoing conservative treatment: a systematic review

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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. 

Curve type, flexibility, correction, and rotation are predictors of curve progression in patients with adolescent idiopathic scoliosis undergoing conservative treatment : a systematic review

Lester P K Wong, Prudence W H Cheung, Jason P Y Cheung 

Bone Joint, 2022 Apr. PMID: 35360948 PMCID: PMC9020521DOI: 10.1302/0301-620X.104B4.BJJ-2021-1677.R1

Abstract

Aims: The aim of this study was to review the current evidence surrounding curve type and morphology on curve progression risk in adolescent idiopathic scoliosis (AIS).

Methods: A comprehensive search was conducted by two independent reviewers on PubMed, Embase, Medline, and Web of Science to obtain all published information on morphological predictors of AIS progression. Search items included ‘adolescent idiopathic scoliosis’, ‘progression’, and ‘imaging’. The inclusion and exclusion criteria were carefully defined. Risk of bias of studies was assessed with the Quality in Prognostic Studies tool, and level of evidence for each predictor was rated with the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. In all, 6,286 publications were identified with 3,598 being subjected to secondary scrutiny. Ultimately, 26 publications (25 datasets) were included in this review.

Results: For unbraced patients, high and moderate evidence was found for Cobb angle and curve type as predictors, respectively. Initial Cobb angle > 25° and thoracic curves were predictive of curve progression. For braced patients, flexibility < 28% and limited in-brace correction were factors predictive of progression with high and moderate evidence, respectively. Thoracic curves, high apical vertebral rotation, large rib vertebra angle difference, small rib vertebra angle on the convex side, and low pelvic tilt had weak evidence as predictors of curve progression.

Conclusion: For curve progression, strong and consistent evidence is found for Cobb angle, curve type, flexibility, and correction rate. Cobb angle > 25° and flexibility < 28% are found to be important thresholds to guide clinical prognostication. Despite the low evidence, apical vertebral rotation, rib morphology, and pelvic tilt may be promising factors. Cite this article: Bone Joint J 2022;104-B(4):424-432.

Keywords: Adolescent idiopathic scoliosis; Bracing; Cobb angle; Correction; Curve progression; Flexibility; Medline; Morphology; Prognostic Studies; Rib; Rotation; Systematic review; bone age; pelvic tilt; randomized controlled trials; thoracic kyphosis; univariate analysis; vertebrae.

https://pubmed.ncbi.nlm.nih.gov/35360948/

Isico’s research wins the SOSORT Award

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For the fourth consecutive year, Isico has obtained the most prestigious award for those involved in rehabilitative treatment of the spine, winning the SOSORT Award with the study Prediction of Future Curve Angle using Prior Visit Information in Previously Untreated Idiopathic Scoliosis: Natural History in Patients under 26 Years Old with Prior Radiographs.

The research, which involved 2317 patients with idiopathic scoliosis between 6 and 25 years old, was developed by our researchers (the Isico authors are Prof. Stefano Negrini, together with Dr Giulia Rebagliati, Dr Fabio Zaina, Dr Sabrina Donzelli and Dr Alberto Negrini) in collaboration with Dr Erik Parent of the University of Alberta, Canada. This project was funded by a Standard Research Grant from the Scoliosis Research Society.

“Understanding natural history helps inform the treatment selection for modifying the course of the disease or to avoid overtreatment – explains prof. Stefano Negrini, Isico Scientific Director- Previous models predicting curve progression lacked validation, did not include the full growth spectrum or included treated patients. Our aim was to develop and validate models to predict future curve angles using clinical data collected only at, or both at and prior to, an initial specialist consultation in idiopathic scoliosis”. 

Scoliosis-specific exercises are recommended in small curves in skeletally immature patients, exercises and progressively more aggressive brace treatments are recommended for moderate and severe curves in 10% of growing children and adolescents and invasive corrective surgery is recommended in severe curves at risk of continued progression in adulthood for 0.1-0.3% of cases. 

“Patients were previously untreated and provided at least one prior radiograph prospectively collected at first consult – continues prof. Negrini – We excluded those previously treated”.

 Radiographs were remeasured blinded to the predicted outcome: the maximum Cobb angle on the last radiograph while untreated. Linear mixed-effects models with random effects and maximum likelihood estimate were used to examine the effect of data from the oldest visit (age, sex, maximum Cobb angle, Risser, and curve type) and from other visits while untreated (Max Cobb angle), and time (from oldest radiograph to prediction) on the Cobb angle outcome.

“Predictions models were proposed which can help clinicians predict future curve severity expected in patients not receiving treatment –ends prof. Negrini – Predictions can inform treatment prescription or show families why no treatment is recommended. Our models offer the flexibility to predict at a future timepoints over the full growth period. These validated models predicted future Cobb angle with 80% of predictions within 100 in non-treated idiopathic scoliosis over the full growth spectrum. Improved prediction ability may help clinicians inform treatment prescription or show families why no treatment is recommended”.

The Hereditary Nature of Adolescent Spinal Deformities-A study of over 600,000 adolescents

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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 Hereditary Nature of Adolescent Spinal Deformities-A study of over 600,000 adolescents

Yair Zloof, Ran Ankory Amit Elbaz Braun, Maya Braun, Shlomi Abuhasira, Naama Schwartz, Dotan Yaari, Elon Glassberg, Amir Shlaifer

Spine, 2022 Apr. 21, PMID: 35472202, DOI: 10.1097/BRS.0000000000004355

Abstract

Study design: A cross-sectional study.

Objective: We designed this study to investigate the risk for spinal deformity among individuals whose parents had a spinal deformity.

Summary of background data: Adolescent idiopathic scoliosis and Scheuermann Kyphosis are common adolescent spinal deformities (ASD) with a significant impact on public health. Timely treatment with bracing is effective in halting or slowing the progression of these deformities. However, screening healthy adolescents for spinal deformities remains debatable. While the leading medical organizations endorse contradictory positions regarding the screening of the general population, there is a consensus that screening of targeted population should be considered. Due to their genetic predisposition, adolescents whose parents suffer from a spinal deformity may be candidates for targeted screening.

Methods: We conducted a nationwide, population-based study of 611,689 Israeli adolescents, aged 16-19 years old, who were screened for spinal deformities between the years 2000-2019. The data for this study were derived from a central database containing medical records of all adolescents who were examined preliminary to mandatory military service. In our study, ASD were strictly defined by plain X-ray.

Results: Compared with adolescents of whose parents did not have a spinal deformity, the odds ratios for ASD among adolescents whose father, mother or both parents had spinal deformity were 1.46, 1.74, and 2.58, respectively. These ratios were consistent in multivariate models.

Conclusion: We have found a considerable increased risk for adolescent spinal deformities among adolescents whose parents suffered from spinal deformities. We believe that our findings should serve the leading medical organizations when considering the screening of targeted populations.

https://pubmed.ncbi.nlm.nih.gov/35472202/

Spinal mobility and muscle function in middle-aged patients treated for early onset idiopathic scoliosis: compared with untreated and treated adolescent onset patients

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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. 

Spinal mobility and muscle function in middle-aged patients treated for early onset idiopathic scoliosis: compared with untreated and treated adolescent onset patients

Karin Romberg, Aina Danielsson, Monika Fagevik Olsén, Gunilla Kjellby-Wendt 

Spine Deform. 2022 Mar 23.PMID: 35091992 doi: 10.1007/s43390-021-00466-5

ABSTRACT

Purpose: To determine long-term outcome in terms of spinal range of motion (ROM) and trunk muscle endurance (TME) patients treated for idiopathic scoliosis, diagnosed before the age of ten, were evaluated and compared with untreated or treated patients with idiopathic scoliosis with adolescent onset (AIS).

Methods: Sixty-three braced and 53 operated patients underwent examination of spinal ROM and TME. Validated questionnaires were used for evaluation of back function.

Results: A total of 116 patients were examined 26.5 years after treatment. Braced EOS patients had longer bracing time and operated EOS patients had longer fusions compared to the respective AIS groups. Braced EOS patients had similar total ROM (thoracic ROM 40°, lumbar ROM 78°) and TME (trunk flexors 140 s, trunk extensors 255 s) as untreated AIS patients (thoracic ROM 34°, lumbar ROM 88°, trunk flexor endurance 158 s, trunk extensor endurance 234 s). Braced patients also had significantly better results than braced AIS patients. Operated EOS patients were slightly but significantly stronger and more mobile compared to AIS peers. The lumbar ROM was found to affect the back function in the operated EOS group (Oswestry Questionnaire, rs = 0.49, p < 0.001).

Conclusions: The braced EOS patients had mostly similar muscle strength and mobility as the untreated but younger AIS group, while the braced AIS group showed reductions of both strength and mobility. Similar significant, but small, differences were also found between operated EOS and AIS patients. Especially for muscle strength were findings at a level that would be of significant clinical importance.

Levels of evidence: III.

Keywords: Idiopathic scoliosis; Long term; Muscle function; Spinal mobility.

https://pubmed.ncbi.nlm.nih.gov/35320580/

Intra-and inter-rater reliabilities and differences of kyphotic angle measurements on ultrasound images versus radiographs for children with adolescent idiopathic scoliosis: a preliminary study

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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. 

Intra-and inter-rater reliabilities and differences of kyphotic angle measurements on ultrasound images versus radiographs for children with adolescent idiopathic scoliosis: a preliminary study

Tehzeeb Sayed, Mahdieh Khodaei, Doug Hill, Edmond Lou 

Spine Deform. 2022 Jan 29.PMID: 35091992 doi: 10.1007/s43390-021-00466-5

Abstract

Purpose: To develop a new method based on 3D ultrasound information to measure the kyphotic angle (KA) on ultrasound (US) images in adolescents with idiopathic scoliosis (AIS) and to evaluate the intra-rater and inter-rater reliabilities and accuracy of the US measurements.

Methods: Twenty subjects with AIS (17F, 3 M, aged 13.7 ± 2.2 years old) were recruited. One 20 + years experienced rater (R3) measured the KA on radiographs twice using the Cobb method. Two raters (R1, R2), both have at least 1-year experience measured US images twice using the new spinous processes method. The intraclass correlation coefficients (ICC[2,1]) of the intra-rater and inter-rater reliabilities of US KA measurements were calculated. An equation based on US KA measurements to calculate the radiographic KA was generated.

Results: The intra-rater reliability ICC[2,1] (R3) of the X-ray measurement was 0.92 and US KA measurements for R1 and R2 were 0.94 and 0.95, respectively. The inter-rater reliability ICC[2,1] for R1 versus R2 were 0.85 and 0.86, respectively. The mean absolute differences (MAD) of US versus radiography measurements were 4.2 ± 3.0° (R1 vs R3) and 5.0 ± 4.1° (R2 vs R3), respectively. The radiographic equivalent KA = 0.82 × US KA – 5.6°. When using this equation, the overall MAD between US and radiographic KA was 2.9 ± 1.6°.

Conclusions: The ultrasound spinous process method was reliable to measure the KA. Although there was a systematic bias on the US measurements, after the correction, the MAD of the US and radiographic KA was 2.9 ± 1.6°. Using US allows clinicians to monitor KA without exposing children to ionizing radiation.

Keywords: Accuracy; Adolescent idiopathic scoliosis; Kyphotic Angle; Reliability; Ultrasound.

https://pubmed.ncbi.nlm.nih.gov/35091992/

Coronal deformity angular ratio as a predictive factor for in-brace curve correction and long-term outcome of brace treatment in adolescents with 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. 

Coronal deformity angular ratio as a predictive factor for in-brace curve correction

and long-term outcome of brace treatment in adolescents with idiopathic scoliosis

Taher Babaee, Mojtaba Kamyab, Mohammad Saleh Ganjavian, Naeimeh Rouhani, Adel Khorramrouz , James G Jarvis 

Spine Deform. 2022 Jan 16. PMID: 35034344 DOI: 10.1007/s43390-021-00452-x

Abstract

Purpose: To investigate the relationship between coronal deformity angular ratio (C-DAR) and in-brace correction (IBC) and their role in predicting the long-term bracing outcome in adolescents with idiopathic scoliosis (AIS).

Methods: In this retrospective multicenter study, the patient’s sex, age, primary curve Cobb angle (at initiation of brace treatment, best in-brace, before spinal fusion, and final follow-up), curve pattern, duration of brace treatment, brace type, and C-DAR at initiation of bracing were recorded. The C-DAR values were classified as < 5, 5 ≤ to ≤ 6, and > 6. The IBC values were classified as ≥ 50%, 40% ≤ to ≤ 49%, and < 40%. We classified the patients into two groups of success and failure according to the Cobb angle at the final follow-up.

Results: A total of 164 patients (25 boys and 119 girls) were included. Bracing was successful in 60.4% of them. There was a significant association between C-DAR and bracing outcome (p < 0.0001). 63.9% of the patients with C-DAR < 5 had an IBC ≥ 50%. However, when C-DAR was 5 ≤ to ≤ 6 and > 6, 29.2% and 16.9% of the patients had an IBC of ≥ 50%, respectively. For patients with IBC ≥ 50%, the success rate of bracing was 89.2%. Results of logistic regression analysis revealed that the strongest predictor for brace treatment outcome was the C-DAR, with an odds ratio of 2.11.

Conclusion: C-DAR may be used as a predictive factor for the long-term outcome of brace treatment in AIS.

Level of evidence: IV.

Keywords: Adolescent idiopathic scoliosis; Brace; Coronal deformity angular ratio; In-brace correction; Predictive factor.

https://pubmed.ncbi.nlm.nih.gov/35034344/

Psychometric performance of proxy-reported EQ-5D youth version 5-level (EQ-5D-Y-5L) in comparison with three-level (EQ-5D-Y-3L) in children and adolescents with 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. 

Psychometric performance of proxy-reported EQ-5D youth version 5-level (EQ-5D-Y-5L) in comparison

with three-level (EQ-5D-Y-3L) in children and adolescents with scoliosis

Jiaer Lin, Carlos King Ho Wong, Jason Pui Yin Cheung, Prudence Wing Hang Cheung, Nan Luo 

Eur J Health Econ. 2022 Feb 4. PMID: 35122171 DOI: 10.1007/s10198-022-01435-z

Abstract

Objectives: To assess the psychometric performance of proxy-reported EQ-5D-Y-5L (Y-5L) in comparisons with EQ-5D-Y-3L (Y-3L) administered by caregivers of patients with juvenile (JIS) or adolescent idiopathic scoliosis (AIS).

Methods: A consecutive sample of caregivers of JIS or AIS patients were recruited. Redistribution property, ceiling effects, and discriminative power were examined. Known-group validity was determined by examining their ability to detect differences across clinical known groups. Test-retest reliability was assessed using intraclass correlation coefficient (ICC) for EQ-VAS score and Gwet’s agreement coefficient (GAC) and percentage agreement (PA) for dimension responses. Furthermore, subgroups were analyzed for comparing test-retest reliability.

Results: A total of 130 caregivers were involved in the study. Consistencies between proxy-reported Y-3L and Y-5L were very high for all dimensions (93.8-99.2%). The ceiling effect in the Y-5L was slightly reduced in four dimensions (AR: 0.8-2.3%) whereas increased in “Having pain/discomfort”. Greater informativity was found in the Y-5L than the Y-3L. In known-group comparisons of curvature magnitude, curvature type, and treatment modality, Y-5L and Y-3L dimension scales showed hypothesized results. For example, more full-health responses were found in the mild Cobb angle group (Y-5L: 63.1%; Y-3L: 62.2%) than the severe Cobb angle group (Y-5L: 55.6%, Y-3L: 55.6%). EQ-VAS score exhibited low test-retest reliability (ICC: 0.41), whereas dimension scales of both instruments showed satisfactory test-retest reliability (GAC ≥ 0.7 and PA ≥ 70% for all). In most known groups, hard-to-observe dimensions were more reliable for proxy-reported Y-5L than Y-3L.

Conclusion: Both the proxy-reported Y-5L and Y-3L are valid and reliable instruments for assessing the HRQoL of JIS or AIS patients.

Keywords: Adolescent idiopathic scoliosis; EQ-5D-Y-3L; EQ-5D-Y-5L; Proxy; Psychometric performance.

https://pubmed.ncbi.nlm.nih.gov/35122171/

Returning to physical activity after surgery for adolescent idiopathic scoliosis

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Sport and physical activity are essential for psychosocial and physical well-being in children and adolescents, and youngsters with scoliosis are not subject to any limitations in this regard: they can do sports and other physical activities just like their peers can.

In severe scoliosis, i.e., in individuals with curves measuring more than 50° and presenting significant aesthetic and developmental deformities despite undergoing orthotic/bracing treatment properly administered according to the SOSORT criteria, surgery is indicated. 

“In some cases, patients who undergo corrective surgery for scoliosis may reduce their level of physical activity postoperatively due to a loss of spinal flexibility and pain. This inevitably impacts negatively on their quality of life – says dr Carmelo Pulici, physiatrist – No guidelines have yet been published on the resumption of physical activity after surgery for adolescent idiopathic scoliosis, and “expert opinion” is therefore all we have to rely on. Consequently, different surgeons may give different indications, depending on their experience and the particular type of approach”.

There are also individual factors at play, and the decision to resume physical activity may therefore depend on: the type of surgery performed, how the body responds and adapts to the metal rods inserted to correct the spine, the extent of the fusion, how recently the surgery was carried out, the characteristics of the patient, and also the type of sport practised (non-contact, contact or collision).  

For example, while some surgeons allow contact sports to be resumed six months after surgery, others recommend waiting a year, and some even rule out the resumption of collision sports altogether (https://pubmed.ncbi.nlm.nih.gov/26920125/). 

“In one study, return to sport/physical activities after surgery was examined using a specially created questionnaire (https://pubmed.ncbi.nlm.nih.gov/28604495/). By six months, most patients had returned to the activities they did before the surgery” – explains Dr Pulici. “The authors found that patients returned to athletics much earlier than expected. Despite this, there were no cases of loss of correction, implant failure or complications among the 95 patients included in the study”. 

A new surgical technique

In recent years, there has been a growing interest in vertebral body tethering (VBT), a new surgical technique used only in children and in early adolescence and, even then, only in carefully selected patients, given that the method is still experimental. VBT is proposed as a possible alternative to spinal fusion (currently the most widely used technique for the surgical treatment of scoliosis). Unlike spinal fusion, it does not reduce the mobility of the spine. 

“According to a recent study, VBT allows daily activities and sports to be resumed within three months of the surgery” Dr Pulici goes on. “Furthermore, most of the patients examined in the study reported an improvement in their athletic performance, and some were found to be doing more sports than before undergoing VBT”.

Even though surgeons today tend to allow patients to return to sports (even high-intensity ones) earlier than in the past (https://pubmed.ncbi.nlm.nih.gov/34267153/), we are still a long way from seeing a common approach to the management of postoperative resumption of physical activity in this patient population.

In the absence of guidelines, we at Isico recommend that patients turn to an experienced therapist in the post-operative period to ensure a gradual and safe return to physical activity, obviously following the instructions received from their surgeon.

It is important to avoid falling into the vicious cycle of a sedentary lifestyle. The less active you are, the less you feel inclined to do physical activity and the greater the risks to your health due to your lack of movement.

Kinesiophobia and its association with treatment choice in individuals with 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. 

Kinesiophobia and its association with treatment choice in individuals with idiopathic scoliosis 

Gozde Yagci, Damlagul Aydin Ozcan, Cigdem Ayhan Kuru, Yavuz Yakut  

Back Musculoskelet Rehabil. 2021 Oct 29PMID: 34744071 DOI:10.3233/BMR-210111

Abstract

Background: Previous studies have reported increased kinesiophobia in adults with degenerative scoliosis or adolescents who have undergone spinal surgery. However, little is known about the phenomenon of kinesiophobia among adolescents with idiopathic scoliosis (IS).

Objectives: The aim of this study was to investigate levels of kinesiophobia and its association with treatment choice in IS.

Methods: The study included 98 IS patients with a mean age of 14 years and 20 healthy controls. Participants with IS were divided into groups based on treatment conditions, as follows: (1) untreated (n= 33); (2) treated with exercise (n= 32); and (3) treated with a brace (n= 33). Kinesiophobia was measured using the Tampa Scale for Kinesiophobia (TSK). Comparisons were made between four groups.

Results: Untreated participants with IS were found to have greater kinesiophobia than healthy controls (p< 0.001). Participants treated with a brace (p= 0.046) and exercise (p= 0.064) had similar kinesiophobia levels as the healthy control group.

Conclusions: Kinesiophobia was found to be higher in adolescents with IS compared to healthy peers. Brace or exercise treatment both had a positive impact on kinesiophobia. These findings should be considered when organizing rehabilitation programs to achieve the best results for adolescents with IS.

Keywords: Scoliosis; brace; exercise therapy; fear; movement.

https://pubmed.ncbi.nlm.nih.gov/34744071/