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Online Master: conclusion of edition 2020

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Our international online Master 2020 edition has reached its last session. It started as usual in January and for the first time in a double edition, English and Chinese. Thanks to the online formula consolidated over the time we have been able to proceed in the best possible way and absolute normality in this particular year. 
The last live lesson has been given together by the 3 teachers who perform the live lessons individually during the year, with the closing of prof Stefano Negrini, scientific director of Isico.
We remind you that registrations are open for the 2021 edition with lessons from January to November. The lectures are organised in modules self-administered by the participants except live lectures delivered two times a month.

Also the first Chinese edition of the online Master course closed its doors, with excellent prospects for the second edition in 2021.


For more infos please visit the website: www.scoliosismaster.org 

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

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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 “.

A perfectly straight back? That’s pretty rare!

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It is as rare to have a perfectly straight back and perfectly symmetrical body as it is to have scoliosis, a condition that affects no more than 5% of the population. Scoliosis is linked to different factors that influence the shape and development of the spine in the three planes of space.
What causes it? In most cases, we still don’t know.

On the other hand, we are very familiar with how the condition typically evolves. We know that scoliosis that is left untreated will worsen as an effect of bone growth. Therefore, to limit its effects, it is essential to obtain an early diagnosis and undertake an effective treatment, guided by experts in the field.  

  • When should scoliosis be treated? Let’s look at two key parameters  

There are two elements that tell us the seriousness of a case of scoliosis, namely, the amplitude of the curve (measured in Cobb degrees) and the individual’s bone age (Risser sign).

Briefly, with regard to the amplitude of the curve

  • 0 – 10 Cobb degrees → no scoliosis
  • 10 – 15 Cobb degrees → mild scoliosis
  • 16 – 34 Cobb degrees → moderate scoliosis
  • 35 – 44 Cobb degrees → moderately severe scoliosis
  • 45 Cobb degrees or more → severe scoliosis

Instead, to evaluate bone age we use a scale of 0 to 5 (where 5 corresponds to complete bone maturation).

The phase in a youngster’s development in which scoliosis is most likely to worsen is the pubertal growth spurt, a period in which their growth rate speeds up and they grow considerably. On average, this phase begins between the ages of 11 and 13 years in girls, and 12 and 14 years in boys, and this generally corresponds to the passage from level 0 to level 1 on the Risser scale.

The subsequent phases, of course, are not risk free, but in most cases the speed of growth progressively declines, and for this reason, so does the risk of progression of scoliosis.

  • 0-10 Cobb degrees: is it correct that even if there’s an asymmetry we don’t need to worry?

If a patient has an X-ray that shows a curve measuring less than 10 Cobb, he/she will not be diagnosed with scoliosis and no treatment will be prescribed, only further monitoring of the situation according to how much the patient is still expected to grow.

Nevertheless, the image will show some asymmetry of the spine, and on observing this, even slight, curvature, patients and parents quite often become alarmed.

No one likes to be told that their spine or their child’s spine is “asymmetrical”, and they can be sceptical or even disappointed to learn that nothing needs to be done.

  • “We don’t all come out of the same mould!”

It is probably as rare to have a perfectly straight spine and a perfectly symmetrical trunk as it is to have scoliosis.

We often tell our patients that “we don’t all come out of the same mould”, in order to explain, in simple terms, that everyone of us presents some (more or less visible) physical asymmetries. 

Think of the different parts of the body that we have two of. If we were to measure the precise length and size of our hands, feet, arms and legs, we would almost certainly find they show some minor differences.

In the presence of a difference in length of the lower limbs (typical during growth), for example, it is quite common to find a proportional inclination of the pelvis and, consequently, of the spine.

In this case, however, the scoliosis serves a “functional” purpose, as its contributes to the maintenance of the body’s balance and can thus be interpreted as a useful compensatory response and unlikely to worsen as the youngster grows.

Physical activity in adults with scoliosis: what and how much?

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Before we start talking about scoliosis and physical activity in adults, a few background considerations are called for.

It is important to remember that every patient has a unique history. Even though different patients can present similar scoliosis features, it should not be assumed that the same kind of physical exercise will suit all of them.  

It is also necessary to bear in mind certain thresholds of curvature: scoliosis curves measuring less than 25°-30°, especially if treated in adolescence, are extremely unlikely to worsen over time. Conversely, curves that exceed 45°-50° must be monitored, through specialist check-ups, throughout adulthood.

Then there is the “pain” factor. Scoliosis is not necessarily associated with pain. Nevertheless, pain is a factor that needs to be taken into account when choosing what physical activity or sport to do. As a rule, any kind of movement that does not worsen pain, or that alleviates it, can be considered a great help.

Exercise, in a general sense, helps to relieve pain, improve functionality and improve quality of life: and these are the real objectives. A healthy back, which does not necessarily mean a straight back, is one that is capable of withstanding the stresses of everyday life.
Furthermore, when you have scoliosis, it is especially important to train the muscles that support the spine, so as to stabilise it.

It is important that we distinguish clearly between sport and self-correction exercises i.e. active movements designed to lead to better positioning of the spine in the three planes of space, which the patient performs independently.
These exercises, prescribed specifically for scoliosis, with the aim of stabilising the condition, serve a therapeutic purpose. On the other hand, there is no sport or general physical activity of any kind that can be said to “treat” scoliosis.

It is also necessary to beware of certain old “beliefs” regarding scoliosis and sport. In the past, it has been claimed that certain sporting activities can “treat” or vice versa exacerbate scoliosis.

In reality, however, the literature contains no reliable data showing that certain sports activities might be harmful for adults with scoliosis.
The only question mark concerns activities (e.g. belly dancing) that demand considerable flexibility and mobility of the spine, since these could destabilise it and lead to a worsening of the condition.
To date, there are no sports that are specifically prohibited or recommended. Indeed, contrary to what some believe, swimming and Pilates cannot be guaranteed to be beneficial, while running and tennis do not need to be considered risky activities.
In adulthood, any sport, providing it is started gradually, practiced regularly, enjoyed and performed within your own limits, can only be good for you.

In conclusion, it is worth underlining that adults with scoliosis can and MUST do some form of physical activity, at least 2-3 times a week, choosing from the various disciplines. Those whose scoliosis causes them pain must make sure their chosen activity respects this limitation.

A Brace classification study

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The study Brace Classification Study Group (BCSG): part one – definitions and atlas, published by Scoliosis and Disorders,  represents the first part of the SOSORT consensus in addressing the definitions and providing a visual atlas of bracing.
Prof. Stefano Negrini, Scientific Director of Isico, is one of the authors who belong to a panel of professionals named the Brace Classification Study Group. 
Prof. Negrini explains: “The current increase in types of scoliosis braces defined by a surname or a town makes scientific classification essential. Currently, it is a challenge to compare braces and specify the indications of each brace. A precise definition of the characteristics of current braces is needed“. 
As such, the International Society for Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) mandated the Brace Classification Study Group (BCSG) to address the pertinent terminology and brace classification.
The BCSG introduced several pertinent domains to characterize bracing systems.
The domains are defined to allow for analysis of each brace system. The BCSG has reached a consensus on 139 terms related to bracing and has provided over 120 figures to serve as an atlas for educational purposes. 
During the annual meeting of the International Society for Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) in Athens in 2008, Prof. Negrini presented a new classification under the acronym BRACE MAP.
BRACE MAP derives from the following terms: Building, Rigidity, Anatomical classification, Construction of the Envelope, Mechanism of action, and Plane of action. Each item was composed of two to seven classificatory elements defined using one or two letters in order to refer specifically to the characteristics of the brace throughout the classification.  
“A visual atlas of various brace types is provided – ends prof. Negrini – This is the first clinical terminology tool for bracing related to scoliosis based on the current scientific evidence and formal multidisciplinary consensus”.

My kid is always slouching: bad posture or a medical problem?

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In today’s digital age, the incredible exponential curves of technological growth and innovation are increasingly reflected in curves of another kind, namely those affecting our spines, as we assume various odd and unnatural positions when using our electronic devices.  

Parents are the first to notice their youngsters’ tendency to adopt these awkward and unattractive positions. The most frequent is the hunched back position, where the upper spine, shoulders and head are bent forward in relation to the rest of the body.
Consequently, we now see countless humps like that of Quasimodo, the famous “Hunchback of Notre Dame”.

The tendency to slouch or adopt slumped postures is prevalent among the young. Youngsters (and adults too) often assume incorrect postures simply because it is easier and requires less effort.
As a result, they allow the force of gravity to take its toll on their backs without trying to counteract it. 
Some situations, however, require careful assessment, as incorrect postures can sometimes indicate a spinal disorder.

Initially, it is up to parents to check their children’s backs, and if they have any doubts at all, they should seek the opinion of expert medical spine specialists.

How do you tell the difference between incorrect posture and a spinal disorder?

If you have the youngster stand in front of you with his/her back exposed and look at him/her sideways on, you should immediately notice the classic shape of the back, created by two natural and opposing curves; starting from the base of the spine and moving upwards, you will see the first, lower curve.
Known as lumbar lordosis, this is a physiological curve in which the lumbar spine appears more anteriorly positioned and concave. Immediately above it, you will see that the dorsal spine instead shows a posterior convex curve.

In normal conditions, these two curves are harmonious and not too pronounced. However, if, on observing the youngster, you notice that one curve is more pronounced or protruding or that both are marked, then this could be a sign of a spinal disorder. In such cases, screening by a qualified professional or a consultation with a specialist spine doctor is strongly recommended.

In the same way, you might notice that the youngster’s back appears flat, with the physiological curves barely visible or not visible at all. This profile, too, can indicate the presence of a spinal disorder.

The spinal disorder most commonly associated with the rounded back or hunchback posture is hyperkyphosis, i.e. excessive curvature of the thoracic spine, evident on clinical examination as posterior protrusion of a section of the thoracic spine, often with the protruding vertebrae clearly visible under the skin.  

But how can a parent distinguish between incorrect posture and hyperkyphosis, a fairly frequent condition among youngsters?
Incorrect posture is always easily remedied simply by reminding the youngster to stand up straight: indeed, in this case, this action is enough to straighten his/her back completely.
In the presence of a spinal disorder, on the other hand, he/she will show more or less marked stiffness: even when he/she tries to stand up straight, part of the spine will remain curved due to the disease having stiffened his/her back.

Long kyphosis is another frequent vertebral alteration. In this case, the thoracic convexity extends down as far as the lumbar vertebrae, invading the space normally occupied by the upper part of the lumbar lordotic curve: the back, therefore, presents with a long convexity that reaches down to the base of the back.

Dorsal hyperkyphosis and long kyphosis are sometimes caused by Scheuermann disease, which is characterised by a wedge-shaped deformity of the vertebral bodies with anterior thinning of the vertebrae.
This makes it difficult and sometimes impossible for affected youngsters to hold their back straight: as a result, they become curled up like hedgehogs, and unfortunately, their growth exacerbates the vertebral deformity.

Conclusion

Like scoliosis, spinal deformities in the sagittal plane must be diagnosed early to allow timely and effective treatment. Families have the important task of trying to spot spinal disorders instead of simple cases of poor posture. Whenever they are in any doubt, they should always contact a specialist spine doctor for a proper diagnosis and necessary treatment. 

Now screening comes online!

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Isico launches online screening. Just connect to the dedicated screening website and you can perform a quick and simple assessment and check whether, with respect to pathologies such as scoliosis or curved back, it is appropriate to carry out a specialist medical visit that investigates further.
The idea, which has been in the works for some time, has had a further stimulus thanks to the departure of Telemedicine during the Covid-19 emergency period. We know how essential an early screening is to set up adequate rehabilitation therapy in case of vertebral deformities.
At Isico, screening has always been done, free of charge for the siblings of our patients. Now the novelty is given by an additional online tool that everyone can access as well in several languages; in addition to Italian and English, the German version is now available as well. 
How does the site work?
After viewing a short explanatory video of Michele Romano, head of physiotherapy in Isico, the evaluation begins either for scoliosis or for the curved back. 
The process is always guided by an introductory video given by Michele Romano. He explains how to make a part of these evaluations through observation only, others where you are asked to take measurements with a ruler and others again to be detected with the help of a simple bottle of water, the Torsion Bottle. 
On the basis of the data entered, it will be possible to know if it is appropriate to contact the evaluation of an expert in vertebral pathology or if there is nothing at the moment to worry about.


The next steps?
Translating the site into other languages ​​so that more people can use it easily. In this regard, we will be pleased to accept those who want to collaborate with us for the translation into other languages, in case you contact the email: isico@isico.it

SEAS: partial resumption of the courses

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Our SEAS courses have not yet been able to restart in full due to the Coronavirus emergency. At the end of August, however, we managed to be present in Slovenia where Michele Romano, director of physiotherapy in Isico, held a first-level course: about twenty participants were allowed to participate to keep the necessary distances and respect the safety protocols. Enthusiastic participation, despite having had to limit the interaction than usual.

After the Slovenian course, Romano was engaged in two SEAS online courses for a number of Russian participants.

A fundamentally important role in the success of this event was played by Dr Dmitry Gorkovsky, who, since 2016, has worked with us on the staging of eight previous courses in various Russian cities: Moscow, St. Petersburg and Novosibirsk.

Michele Romano gave practical demonstrations using a Dummy via Skype and Dr.Gorkovsky replicated these exercises with volunteers from among the participants.

How often should a brace be changed?

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Receiving their first brace is a key moment in the treatment of youngsters affected by spinal deformities.
This is the brace that shows them exactly what the treatment consists of. They learn about the pads, which are carefully positioned to correct their back; they become familiar with the fastener and how to adjust it to the right tightness, as well as how the brace sits under the armpits. They also have to get used to the shoulder pads and, quite simply, the weight of the plastic.

Surprising as it may seem, some youngsters even grow quite attached to their first brace as, over the weeks and months, it starts to become a part of their daily life and less of a problem. This “friend”, which they sometimes find irritating, especially early on, gradually feels less and less bulky, and in fact there will eventually come a point when it is too small. After all, while the brace stays the same, the youngster inside it grows of course!

For this reason, a new brace will be needed from time to time. It certainly isn’t possible to use the same one from the start to the end of the treatment. But there are also other reasons why a brace needs to be replaced, the first and most obvious being that, like any object used on a daily basis and for a number of hours each day, it starts to wear out. Indeed, after a time, it is subject to breaking, or some of its parts may no longer be intact.

A further reason, and this is perhaps the most important, is that the brace, especially the first one, moulds the youngster’s back so much that after a few months it becomes necessary to construct a new one adapted to its changing volumes. Unless braces are updated to take this aspect into account, they simply cannot work at full efficiency.

The young scoliosis patient’s back changes not only as an effect of the brace, but also because he/she is normally still growing.
In this stage of development, it is perfectly normal to get taller and heavier. A brace can usually tolerate slight increases in height and weight, but when these are more marked it will start to feel uncomfortable. Even just looking at the youngster in his/her brace can be enough to tell you that the time has come to start thinking about getting a new one made.  
From the second brace onwards, more time can usually elapse between braces. It may even be enough to get a new one about once a year.

Youngsters are often anxious at the prospect of changing their brace, fearing that the new one will be uncomfortable. Actually, however, they are unlikely to experience the same discomfort they had at the very start of the treatment.
In fact, in most cases they will find the new brace is more “comfortable”, given that it replaces one that had become too short and tight, and so no longer adequate. Furthermore, having already had to get used to wearing a brace, these “experienced” patients will be better able to recognise, quickly, any problems with the new one.
This will allow them to give the orthopaedic technician clear feedback, useful for making it fit better.  

A comparison of the Chêneau and Sforzesco braces

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Unfortunately, it has become common to think of braces in the same way as we do drugs. But before we go any further, we need to make one thing clear: whereas we all know that aspirin is not the same as paracetamol, in the case of a brace, the name doesn’t really mean anything specific.
A brace is a product that is made-to-measure for the individual patient, and therefore the success of bracing treatment depends not on the name of the brace, but on how correctly it has been constructed for the particular patient. If the pads are incorrectly positioned, or if the brace is constructed so that it sits too low or presses too much on one side, it may even contribute to worsening rather than improving the scoliosis. 

The names of the different braces, therefore, are meaningful only to those who prescribe them. 

Finally, adding to the confusion, Dr Chêneau gave his name to two completely different types of brace: the first Chêneau is much more symmetrical than the second one, which, on the other hand, is clearly asymmetrical. Although the second Chêneau brace is the one most commonly used worldwide, we prefer to use the first one, for two reasons: first of all, it is discreet (practically invisible under clothes) and second, in constructing it, we are able to apply the same principles that characterise the Sforzesco, which is the brace developed at our own centre. For this reason, the Chêneau that we use at Isico has been given a new name: we call it the Sibilla- Chêneau, in honour of Dr Sibilla, a pioneer of our school.

So, how do the Sibilla-Chêneau and the Sforzesco differ? They differ in several features, which determine the choice of one over the other on a case-by-case basis. The decision to prescribe one type of brace rather than another must always be taken by a medical specialist.

Let’s start with the material: the Sibilla-Chêneau, used at Isico, is of monovalve construction and it is made of polyethylene, whereas the Sforzesco has two valves and is made from a much more rigid material. Its two parts are linked to posterior fasteners, and there is sometimes an aluminium rod at the back, too. Being more rigid, the Sforzesco has shown the same efficacy as the old system of plaster casting, but with the huge advantage of being removable for bathing/showering.

The Sibilla-Chêneau tends to be used to treat milder cases with less rigid scoliotic curves; it is also preferred for pre-pubertal patients. The Sforzesco, on the other hand, is used for more severe scoliosis with more rigid curves (for example, in youngsters with greater bone maturation). 

In some cases, patients start off with a Sibilla-Chêneau brace but subsequently switch to a Sforzesco one if the scoliosis becomes too aggressive (a decision reflecting the concept that the treatment should evolve gradually): on a hypothetical treatment scale, we can say that the Sforzesco (a super-rigid brace) is one step up from the Sibilla-Chêneau (a rigid brace).

At Isico, both these braces are prepared in accordance with the SPoRT (Symmetrical, Patient-oriented, Rigid, Three-dimensional) concept of bracing.

 “Symmetrical” means that the brace, externally, appears almost perfectly symmetrical, which makes it unobtrusive and helps to replicate the natural shape of the human body. In other words, for aesthetic reasons, it is outwardly symmetrical. By contrast, internally the brace acts asymmetrically, exerting a three-dimensional corrective action on the deformity. 

The brace is defined “Patient-oriented” on account of its wearability, and therefore tolerability. Being very closely fitting, it moves with the patient, and it does not restrict arm and leg movements at all. Furthermore, since it is easy to conceal, patients accept it readily, rather than merely putting up with it.

The term “Rigid” refers to the type of material used.

Finally, “Three-dimensional” refers to the corrective action of this type of brace on the spine; technically speaking, the brace pushes in a down-up direction; overall, the transmission of the corrective forces to the spine is carefully balanced in such a way as to obtain optimal correction in all three planes of space, without any of the three being allowed to dominate.

As explained at the start, another type of Chêneau brace is also used worldwide; in Italy, we call this the Chêneau 2000: it is an asymmetrical brace that uses expansion chambers. It remains clearly asymmetrical, even externally.  We, on the other hand, prefer to use the symmetrical version of the Chêneau, in order to respect the SPoRT concept mentioned above and also because it favours compliance. Indeed, applying our school of thought, we have obtained, in our patients, the best bracing results recorded anywhere in the world, and this is thanks, in part, to the type of braces we use. Naturally, braces only work if patients actually wear them, and the easier they are to conceal under clothes, the more patients will wear them.