The importance of observational studies

Our study, Observational Studies: Specific Considerations for the Physical and Rehabilitation Medicine Physicianwas recently published in the American Journal of Physical Medicine & Rehabilitation

Experimental and non-experimental designs are used to investigate the effect or association of an intervention and clinical or surrogate outcome. These methods aim to improve knowledge and develop new strategies to manage a disease or condition. 

While experimental research studies entail scrutiny by the scientist and provide results that are less prone to systematic errors, their downside is that they are poorly generalisable. “What all this means in clinical terms,” explains Dr Sabrina Donzelli, physiatrist at Isico and first author of the published research,” is that a treatment that worked fine during a study may in the long term, following its prescription by a hospital or general practitioner, throw up problems that did not emerge in the experimental research”. 

Therefore, to verify what happens in the real world, non-experimental studies, called observational studies, can be carried out, of the kind dealt with by the research we have just published. 

Well-designed observational studies can provide valuable information regarding exposure factors and the event under investigation

“Basically, what the researcher does is simply observe data, without having the possibility to manipulate it”, Dr Donzelli goes on. “The researcher’s task is to interpret and contextualise the results, taking into account all potential errors introduced during the selection of the study sample. To eliminate, as far as possible, systematic errors that could lead to incorrect evaluations and interpretations, it is necessary to implement a series of methodological strategies that are not very widespread in the rehabilitation field.” 

In physical and rehabilitation medicine, where complex procedures and multiple risk factors can be involved in the same disease, the use of observational study must be planned in detail and a priori to avoid overestimations. 

“This is why we wrote this article, to offer clear suggestions to researchers in the rehabilitation field who are interested in planning an observational study”, concludes Dr Donzelli. “We give an overview of the methods used for observational design studies and describe when it is appropriate to use them and how to do so in different scenarios”. 

The Risser sign, growth and scoliosis: let’s clear a few things up

When patients come for medical consultations or physiotherapy sessions, numerous measurements get taken and recorded, often without less expert eyes even noticing.

On the other hand, other measurements are quickly seized upon, both by parents and youngsters. Take height, for example. The sliding piece barely has time to touch the patient’s head before the patient, hopeful, blurts out: “Have I grown? Can I leave off my brace now?”

Another milestone we are promptly informed of is menarche in girls, as parents are often convinced that when their daughters start their periods, they have finished growing, meaning that their treatment can come to an end. But this isn’t always the case. On the contrary, this delicate phase can sometimes coincide with the most marked progression of the disease, making it all the more important to act with caution.

Although these are two important examples of the many factors that need to be taken into account to work out what point a youngster’s growth has reached, it has been shown that increases in height and menarche do not necessarily coincide with the individual patient’s growth peak [1] and may therefore not be helpful and/or sufficient when it comes to deciding on the best course of treatment.

Since these manifestations are secondary growth characteristics, they can only be seen as an indication that the patient’s growth spurt has begun. What they do not tell us is precisely how far on it is. There is a scientific explanation for the traditionally held belief that girls “develop earlier” than boys. In fact, because testosterone starts to be released into the body after oestrogens, boys start their pubertal growth spurt later than girls.[1]

To manage scoliosis and optimise the treatment results of the condition, it is crucial to have a good idea of the patient’s residual growth potential and the time remaining until he/she reaches skeletal maturity. An accurate prediction of the growth rate is also required to know when the deformity is likely to be most at risk of progressing. On the other hand, once it has been established with certainty that the patient has finished growing, this is the time at which preventive measures can be stopped with only minimal risk of further deterioration of the curve. [1]

There are various methods we can use to evaluate bone growth in adolescence, and one of them is called the Risser sign.

An individual’s Risser grade can be determined from an anteroposterior X-ray of the spine. An advantage of this method is that the same X-ray can be used to measure both the number of Cobb degrees (necessary to diagnose scoliosis) and the degree of skeletal maturity, thereby limiting the patient’s radiation exposure.

From 0 to 5, Risser grades are assigned based on the amount of calcification present in the iliac apophysis, and the scale thus measures progressive ossification. A Risser grade 0 indicates a low degree of bone maturity: this status is present from birth through puberty.

A Risser grade 5 means that the iliac apophysis has fused to the iliac crest, and the structure is 100% ossified: this status is present in adults  [2]. 

It would be misleading to imagine the transition from Risser 0 to Risser 5 as a continuous and constant progression that occurs over a fixed time and at a set pace. This is because growth is not constant but proceeds at different rates in the different phases. There are times when it pauses, times when it speeds up considerably, and times when it slows down.

The crucial stage in a youngster’s growth, also vital for understanding the course of their scoliosis, is the pubertal growth spurt, during which the disease can alter the shape of the patient’s back in the space of just a few weeks. From the perspective of a Risser evaluation of skeletal maturity, this stage corresponds to the transition from Risser 0 to the complete acquisition of Risser 1.

Between Risser 2 skeletal maturity and the end of the Risser 3 stage, the growth spurt slows down, but as far as the scoliosis treatment is concerned, we still cannot lower our guard: the patient should continue to receive treatment.

Scoliosis treatment is brought to an end gradually as skeletal maturity increases. Once the patient has reached Risser grade 5 (complete skeletal maturity), the treatment can be terminated safely without fearing that some of the hard-won gains might be lost 

The Risser classification varies slightly in different parts of the world, with some differences found, in particular, between Europe and America. In Europe, the successive grades tend to be assigned more cautiously, in the sense that a patient is deemed to have passed from one stage to the next only in the presence of precise levels of bone maturation. On the other hand, the American tendency is to assign the successive grades sooner.

Another method for assessing skeletal maturity is the Sanders classification, whose eight grades are assigned based on the assessment of hand bone growth [3]. Some studies have found the Sanders classification more precise than the Risser sign. It shows higher staging sensitivity when growth is most rapid and is therefore more reliable during certain growth phases [4]. The problem with the Sanders classification is that it requires a separate X-ray of the hand, which therefore means that it could increase the patient’s radiation exposure.

All this information clearly shows that residual growth is essential to evaluate, but at the same time, difficult to establish and interpret.

Specialists can, of course, use the classification they prefer, which will be the one that, in their experience, works best for identifying and evaluating the growth peak in adolescence. It is essential that they can correctly interpret all the data they collect, including from radiographs and patients themselves, to optimise the timing and results of the treatment. 


[1] Cheung JPY, Luk KD. Managing the Pediatric Spine: Growth Assessment. Asian Spine J. 2017 Oct;11(5):804-816. doi: 10.4184/asj.2017.11.5.804. Epub 2017 Oct 11. PMID: 29093792; PMCID: PMC5662865.

[2] Greiner KA. Adolescent idiopathic scoliosis: radiologic decision-making. Am Fam Physician. 2002 May 1;65(9):1817-22. PMID: 12018804.

[3] Sanders JO, Khoury JG, Kishan S, Browne RH, Mooney JF 3rd, Arnold KD, McConnell SJ, Bauman JA, Finegold DN. Predicting scoliosis progression from skeletal maturity: a simplified classification during adolescence. J Bone Joint Surg Am. 2008 Mar;90(3):540-53. doi: 10.2106/JBJS.G.00004. PMID: 18310704.

[4] Minkara A, Bainton N, Tanaka M, Kung J, DeAllie C, Khaleel A, Matsumoto H, Vitale M, Roye B. High Risk of Mismatch Between Sanders and Risser Staging in Adolescent Idiopathic Scoliosis: Are We Guiding Treatment Using the Wrong Classification? J Pediatr Orthop. 2020 Feb;40(2):60-64. doi: 10.1097/BPO.0000000000001135. PMID: 31923164.

Isico science corner video column

At Isico we give great importance to research, an integral part of our clinical work.  
Our newsletters always dedicate a space to the presentation and a comment when a new Isico study is published. 
From this issue on, we will go one step further, enriching each presentation with the video commentary of the first author of the research paper. We are pleased that it is just our scientific director Stefano Negrini, the first author of the article, launching the new Isico Science corner video column with a study of such great importance.

Adults: can hyperkyphosis be improved?

With the passing years, many adults start to realise, when they look at themselves in the mirror, that they are getting increasingly stooped. Some people are unwilling to accept this situation and start wondering whether they can do anything to arrest this process. The question is, can this condition be improved or is it pointless even to try?

The condition we are talking about is HYPERKYPHOSIS. If you look at a person sideways on, you see that their back is not straight, but has natural curves, whose function is to cushion the forces that act on the spine. Following the back line from the top down, we see that first, at cervical level, there is a forward curvature, termed LORDOSIS, then a backward dorsal one, called KYPHOSIS, followed by another forward curve, at lumbar level, also called LORDOSIS. When the amplitude of the dorsal kyphotic curve, measured on an X-ray, exceeds the normal range, we speak of HYPERKYPHOSIS. Usually, this curve measures between 20 and 60 Cobb degrees.
Various factors explain this considerable range. Some are positional and related to the type of examination performed (for example the position of the arms), while others are linked to the associated disorder itself, which may be characterised by marked (e.g., scoliosis) or more prominent (e.g., idiopathic hyperkyphosis, Scheuermann’s disease) curves. Elderly people often present hyperkyphosis caused by the osteoporotic vertebral collapse. As the bones become more fragile, even minor movements can cause tiny fractures of the anterior portion of the vertebrae, resulting in progressive bending of the whole back

Everyone’s back bends forward more as the years go by, regardless of whether or not they have hyperkyphosis.
Why is this?  Most people spend much of their time, i.e., many hours of most days over many years, in a hunched position, with the head looking downwards. In fact, in our daily lives, we are often in the sitting position, which encourages forward flexion of the back; furthermore, many of the activities that require us to move around (cooking, cleaning, DIY, hobbies) also involve bending forwards. For all these reasons, dorsal kyphotic curves tend to get progressively worse over time, we become increasingly stiff, and the trunk extensor muscles grow weaker, resulting in postural collapse. In short, all these factors, combined, leave us “crushed” by the force of gravity.

What are the effects of hyperkyphosis? In adults and the elderly, hyperkyphosis can increase our risk of back pain and worsen our quality of life as we find it increasingly challenging to support our back, both when seated and when standing. Another effect is impaired balance and stability when walking.

So, to go back to our original question: is it possible to break this vicious cycle through physiotherapy and, in particular, through specific exercises? 

The answer is yes! The initial objectives of the treatment are to reduce the stiffness of the dorsal spine and strengthen the trunk muscles that oppose the force of gravity, so as to facilitate postural recovery, and to integrate the correction into daily life. Indeed, from the outset, the treatment approach based on specific exercises encourages patients to learn the crucial “self-correction” movement that allows them to achieve optimal realignment of the spine in the sagittal plane without compensating for this at other levels of the spine (reference: Exercise for improving age-related hyperkyphosis: a systematic review and meta-analysis with GRADE assessment. Ponzano M, Tibert N, Bansal S, Katzman W, Giangregorio L. Arch Osteoporos. 2021 Sep 21;16(1):140. doi: 10.1007/s11657-021-00998-3. PMID: 34546447)


Once the improvement has been obtained, it needs to be made stable and lasting. This involves reducing the frequency of the specific exercises and integrating them with other types of physical or sporting activity, all the time continuing to maintain the correction in daily life.  

Together, all this translates into less pain, better physical function and a more attractive back.

Giulia, the story of a record-breaking Paralympic champion

It was her smile that first made us want to hear her story.

Giulia Terzi, 26, recently came back from the Tokyo Aquatics Centre with five Olympic medals from five races (two golds, two silvers and a bronze) — a new Italian and European record. Within the space of just weeks, she was also awarded, with top marks, a degree in law, to add to a previous one in political science. All in all, she is a real wonder woman, blessed with truly enviable determination and perseverance.
“When I asked her how all this makes her feel,” says Isico physiotherapist Martina Poggio, who had the privilege of interviewing her, she said: “It’s like a dream that I am still struggling to take in. It is the culmination of countless sacrifices. Each time I pick up my medals and look at them, I am reminded that hard work, sacrifices and everything you have to give up really are worth it, and can take you to the top, even though it can be hard to believe it at the time.”

Giulia also explained: “I went through some very difficult years. I was diagnosed with congenital scoliosis at the age of just 3 years, and therefore embarked on an exercise-based treatment at a very young age. When I was 14 years old, I spent 9 months wearing a plaster cast and that was followed by 4 years of bracing. Between 2015 and 2018, I had three operations, and as a result of medullary complications that arose subsequently, I am now in a wheelchair. I have found that the secret is to have the right people around you, trust those who love you and, whenever you need it, ask for help.  No one is invincible and some days and periods are more difficult than others, but with the love and support of family, friends and the right people, you can overcome anything! My parents and siblings have been crucial in helping me get through the hard times, I owe them so much!”

Giulia has a great Instagram profile, full of content, where she writes: “In my case, scoliosis has meant casts, braces, three operations, and titanium rods in my back with all that that entails. But, more than all of this, the word scoliosis, to me, means lots of other things as well. It means a bond, that special bond created through the looks you exchange with those around you, who see how hard you have to fight every single day, fight back tears when you are being taken off for surgery, but also look at you with so much pride whenever, despite everything, you achieve an objective. Scoliosis means pain, sleepless nights spent trying to sleep on a table or the bedroom floor. It means resilience, because all of this has, after all, allowed me to develop into a much stronger person, teaching me to endure fatigue and to pour ever more determination into making my dreams come true, because nothing has been allowed to get in the way of those! It also means love, for the people who have been by my side since the start, and ice creams that could not be enjoyed outdoors, in a park, but had to be eaten in a hospital bed, laughing about it, like it was the normal thing to do. When you find yourself facing a difficult situation, it’s so easy to let yourself get dragged down by negative comments, words and fears, but in the end, it is the energy and determination with which you pick yourself up that shows you for the person you are and that, whatever your problems, that must always win through.”

I prefer to quote Giulia’s exact words because I really believe that only someone who has gone through this experience themselves can really understand what it is like for our youngsters having to wear a brace day after day, rising bravely to the challenges that scoliosis brings” Martina Poggio says. 

“I wanted to turn a spotlight on Giulia, because she is a great example and her story illustrates perfectly the importance of fighting every day and not giving up on your dreams.”

The scientific literature reports perioperative complication rates of between 5% and 20%, depending on the surgical approach and the type (severity) of the complications themselves (Weiss, HR., Bess, S., Wong, M.S. et al. Adolescent idiopathic scoliosis – to operate or not? A debate article. Patient Saf Surg 2, 25 (2008). The rate of neurological complications after posterior fusion is 0.32%.

Unfortunately, Giulia is part of that very small percentage, but her case is a crucial reminder of the fact that every difficulty can also bring new opportunities. This is a message aimed both at those youngsters who, through exercises, are trying to make sure their condition does not worsen to the point of needing bracing treatment, and also at those who are wearing a brace in the hope of managing to avoid surgery.

“Another important aspect of this story, worth underlining, is the important role played by sport,” Poggio points out. “As Giulia says, “sport is fundamental, because it helps you experience lots of different worlds and get to know loads of people. But it also presents you with many challenges and helps you overcome barriers. My particular scoliosis-related barrier was the idea that “I can’t…”.
Instead, what sport teaches you is that you can! And you also learn that this is partly thanks to the support you get from being part of a group that believes in the objective you have set yourself and helps you to achieve it.”

“It can certainly be difficult fitting in sports training, studying and physiotherapy” says Giulia, reflecting on a typical day in her life. “However, I think that health has to be the number one priority and that, to stay fit and well, you need to show the same level of commitment to your treatment as you do to your other pursuits. Studying is another key area that shouldn’t be neglected. Education is crucial when it comes to building your future and chosen career, and studying is clearly the key contributor to this objective. The trick is to be organized: I do two hours of swimming in the morning, followed by a gym or physiotherapy session. Then I go home to study. I do another couple of hours in the pool in the afternoon, and then in the evening it’s back to my books!  It’s a tough schedule, but this year I managed to win a gold medal at the Paralympic Games and graduate in law, earning top marks with honours, so all in all I would say that all my sacrifices have paid off!”

Many of our youngsters who do competitive sport are familiar with the challenges Giulia describes. When they are told that they need to wear a brace full time, their main concern is making sure they can go on practising the sporting activity they have dedicated so much to. The physicians at Isico agree that it is hugely important to ensure that wearing a brace does not interfere too much with these young people’s lives. Indeed, everything possible is done to make sure that they can go on training every day, in spite of the treatment they are receiving.

We asked Giulia what advice she has for youngsters dealing with scoliosis and its challenges on a daily basis, and she replied: “Don’t let barriers and prejudice stop you. Unfortunately, you are bound to meet some, but we all have hidden resources. If you can discover those, you can develop into a great man or woman. Learn from your sport, and on difficult days try and find at least one reason to be happy! Everything is easier with a smile on your face!”

We end with another valuable consideration taken from Giulia’s Instagram profile. She says: “I think that you really need to embrace pain fully. Don’t try and block it out: let it in and learn to live with it. It needs to take its time and work in its own way. It has to develop before it weakens. After that, the scars will fade, but only with time. It doesn’t make sense to try and hide them. People can’t always be invincible. Instead, I firmly believe that those who sometimes allow themselves to be fragile are actually stronger.”

Isico among the attendees of the November SRS webinar

A new webinar for professionals is scheduled for November 7, part of the cycle of those organized in recent months by the SRS (available on the pages of the society’s website).

Two specialists from Isico, our scientific director, Prof. Stefano Negrini and Dr. Fabio Zaina, Isico physiatrist will be taking part in this online event titled Current Status of Bracing in Adults and Adolescents:An SRS-SOSORT Collaboration.

Join the SRS Non-Operative Committee and the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) for a webinar analyzing the current evidence and practice guidelines for bracing for adolescent and adult patients with spinal deformity.

This webinar will provide a systematic analysis of the current evidence and best practice guidelines for bracing management of patients with spinal deformity in both adolescents and adults. With variations in brace design and documentation of long-term benefits, use the consensus discussed to clarify your current practice and brace selections.
There will be an update on the current training of Orthotists, including specialization, fabrication, fitting and deformity correction.

To register please visit the page of the SRS website

Digital Transformation at ISPO: Isico is there

The theme of the international online conference of the International Society for Prosthetics and Orthotics (ISPO), scheduled from 1 to 4 November will be “Digital Transformation in an Evolving World”: the World Congress will explore how digital transformation affects all aspects of using and working with assistive technology, from booking a clinic appointment and electronic health records to computer-aided design, microprocessor-controlled prostheses or orthoses, or video conferencing and social media.

 During the event, Prof.Stefano Negrini, Scientific Director of Isico, will present one poster, Modular Effective as Custom-Made. A Matched Case-Control Study of Modular Italian MI-brace vs Very-Rigid Sforzesco Brace in AIS” and two oral presentations “Introducing Pelvis Semi-Rigid Material does not change Short-Term Very-Rigid Sforzesco Brace Results. A Matched Case-Control Study in AIS” and “Reducing the Pelvis Constriction Changes the Sagittal Plane. A Retrospective Case-Control Study of Free Pelvis vs Classical Very-Rigid Sforzesco Braces”. 

Furthermore, Prof. Negrini will also hold a workshop on November 2nd on Innovations in the Design of Hard Rigid Braces for Adolescent Idiopathic Scoliosis Treatment in collaboration with Guerrino Rosellini and Fabrizio Tessadri of the orthotist’s shops ITOP and Orthotecnica.

Can bracing improve trunk asymmetries in young adults?

Scoliosis is a condition characterised by the presence of a vertebral deformity in the three planes of space. The extent to which this deformity is visible externally varies from case to case. As stated in the guidelines recently developed by SOSORT, one of the primary objectives of scoliosis rehabilitation treatment is to improve trunk asymmetries. Achieving this objective has important implications for quality of life — after all, having a positive self-image helps to ensure a good level of psychological wellbeing and this, in turn, translates into a better quality of life.

Not uncommonly, adolescents with scoliosis lack the willpower or motivation to undertake bracing treatment, or perhaps have never had a medical specialist recommend it to them; others, quite simply, may not even have realised that they had scoliosis.
Basically, many different factors can affect what scoliosis treatment a person received, or did not receive, in adolescence. But the fact is that some people reach adulthood before realising, for example, that they have one waist straighter than the other, that part of their rib cage protrudes, or that one breast is higher than the other.

What can be done to improve these asymmetries?

“Although there is no scientific evidence available to help us answer this question with precision, we at ISICO have performed some bracing treatments in young adults (up to 25 years of age)explains dr Fabio Zaina, physiatrist – In such cases, our doctors, during the consultation, are clear from the outset: this is a long and demanding course of treatment. For the first few months, the brace should be worn full time, i.e., for 23 hours a day, after which the brace-wearing time is reduced very gradually in an effort to maintain the results obtained”.

Patients wanting to start bracing must be absolutely convinced about it and highly motivated, too, because any sudden interruption of the treatment, without respecting the abovementioned weaning-off phase, can negatively affect the stability of the spine.

On the subject of stability, we should also point out that bracing treatment must always be combined with specific exercises based on self-correction. The purpose of these exercises is to keep the back muscles strong and teach the patient how to keep their trunk correctly positioned during the various activities of daily life.

Can adults obtain a radiographic improvement?

Unfortunately, radiographic improvements cannot be achieved in adulthood. In individuals who have reached full skeletal maturity, bracing is never proposed with this aim in mind.

In other words, bracing in adults can improve the external asymmetries related to the scoliotic curves, but it cannot reduce the Cobb degrees of the curves themselves.

Are there no other options available for adults who are reluctant to wear a brace?  

“Adults can always follow a specific physiotherapy programme based on self-correction exercises explains Valentina Premoli, physiotherapist- These exercises are a way to act on the postural component of scoliosis. They serve to counteract the spine’s tendency to collapse to one side, and can thus improve the functioning of the back generally. This type of treatment helps to limit the worsening of the asymmetries that accompanies the spine’s tendency to give way in the direction of the curves — a tendency that becomes increasingly marked as we get older”.

Scoliosis and pregnancy

For a woman, discovering she is pregnant is often one of the most memorable, most exciting and happiest moments in her life. Thinking about the baby, imagining it and talking about it, not to mention feeling it inside her, arouses a number of precious and positive emotions: hope, tenderness and love. However, at the same time, pregnancy leads to various changes, in her body, her self-image and her vision of the future.
Furthermore, she will need to make adjustments and seek new balances in her (often busy) daily life, her rhythms and her relations with others. 

All this can generate normal and entirely understandable fears, and these can be amplified in mothers-to-be who happen to be affected by a condition like scoliosis. Many such women will already have expressed anxiety over their ability to conceive, carry and give birth to a child.
Pregnancy and childbirth, on account of the physical demands they make, can indeed be quite a daunting prospect for these women.

An interesting recent review of the literature (Dewan MC, Mummareddy N, Bonfield C. The influence of pregnancy on women with adolescent idiopathic scoliosis. Eur Spine J. 2018 Feb;27(2):253-263. doi: 10.1007/s00586-017-5203-7. Epub 2017 Jun 29. PMID: 28664223.), focusing on the interaction between pregnancy and scoliosis, examines these very issues. Just to give an idea, in numerical terms, of the analysis carried out, this review included 134 articles and examined 22 studies, referring to a total of 3125 patients.

First of all, the review considered whether and how scoliosis affects the timing and outcomes of pregnancy. It would appear that women with idiopathic scoliosis need not worry about their possibility of having children, even though they have a slightly lower probability of becoming pregnant compared with age-matched women, and may be slightly more likely to receive fertility treatment. Furthermore, women with scoliosis, regardless of whether they underwent surgery or bracing treatment, can expect to have a similar number of children as healthy women. 

However, the studies considered have certain limitations: most of them failed to specify whether the women with scoliosis had been actively seeking or desired pregnancy. Similarly, it is not clear whether all the patients were followed up until menopause. Furthermore, marriage rates, often not even mentioned, were not uniform across the studies.
In the absence of indications on these aspects, the slightly higher rate among women with scoliosis who do not have children could be misinterpreted.

Isico at the SRS 56th Annual Meeting

The SRS 56th Annual Meeting, running from 22 to 25 September, 2021, was a hybrid event that included a robust in-person programme live in Missouri, USA and a virtual component, to allow delegates who were unable to attend in person to follow and enjoy the event. Isico took part with a podium presentation of its research “The natural history of adults with spinal deformities: results from a prospective collection of radiographic data”, given by dr. Sabrina Donzelli (Isico physiatrist) and a poster presentation, by Prof. Stefano Negrini (scientific director of Isico), entitled “Reducing Pelvis Constriction Changes the Sagittal Plane. A Retrospective Case-Control Study of 37 Free Pelvis vs 451 Classical Consecutive Very-Rigid Sforzesco Braces”. 

The Scoliosis Research Society (SRS) Annual Meeting is a forum for the realization of the Society’s mission and goals, the improvement of patient care for those with spinal deformities. Nine faculty-led instructional course lectures, case discussions, and 180 abstract papers were presented on an array of topics.

The Isico research started from current data telling us that scoliosis also affects adults and that patients with scoliosis treated during growth should have their backs regularly monitored in adulthood. This applies particularly to those with curves that measured more than 30 Cobb degrees when they finished growing. Curves measuring more than 50 degrees, on the other hand, are at high risk of worsening, and in these cases, therefore, surgical treatment is indicated. 

This is what we know, but do we know whether there are any particular times or ages at which the risk increases? Are there any conditions that might be associated with the risk of worsening?   

No one has ever investigated the factors that determine progression of the disease” explains Dr Donzelli, “because long-term monitoring of patients is a costly process. On the other hand, knowing when it is really necessary to increase the frequency of checks would allow timely interventions and therefore help to reduce costs. In our retrospective longitudinal study, we analysed the factors involved in the progression of scoliosis.”

The Isico researchers began by collecting data from radiographs the patients had undergone over the years. They measured these radiographs and, for each patient, plotted curves showing scoliosis worsening over time. In all, 767 patients (mean age 35 years, 85% women) met the inclusion criteria and were able to provide at least two X-rays taken in adulthood and at least 5 years apart. 

The authors then analysed which of the following factors influenced changes in Cobb degrees over time:    

  • Gender (F or M)
  • Idiopathic diagnosis (yes/no)
  • Menopause (yes/no)
  • Thoracic localisation (yes/no)
  • Comorbidities: bone metabolic diseases, bone and joint inflammatory disease, neurological associated disease (yes/no)
  • Brace during growth (yes/no)
  • Back pain (yes/no)
  • Family history of spine deformities (yes/no)
  • BMI at baseline (continuous)

The results of the research showed age to be one of the main predictors of worsening: after the age of 50, the risk of worsening increases, therefore from this age it is a good idea to start having more frequent check-ups; moreover, the forms of scoliosis seen in adults are different, and the period of time over which scoliosis appears and then progresses is much longer. 

“There are numerous factors involved, and research in this field is still in its infancy,” concludes Dr Donzelli. “The lengthy monitoring times and the very small variations occurring over time make it particularly complicated. Systematic data collection and regular monitoring over time are essential not only for research purposes, but above all to ensure timely preventive intervention.”