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Interrater reliability of three-dimensional reconstruction of the spine : Low-dose stereoradiography for evaluating bracing in adolescent 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. 

Interrater reliability of three-dimensional reconstruction of the spine : Low-dose stereoradiography for evaluating bracing in adolescent idiopathic scoliosis.

Almansour H1, Pepke W1, Rehm J2, Bruckner T3, Spira D2, Akbar M4

Orthopade. 2020 Apr;49(4):350-358. doi: 10.1007/s00132-019-03712-x.

BACKGROUND 

Bracing constitutes the mainstay treatment for mild scoliosis. The 3D reconstruction of the spine using low-dose stereoradiographic imaging (LSI) is increasingly being used to determine the true shape of the deformity and to assess the success of bracing.

OBJECTIVE 

The aim of the study was to validate the measurement of 3D spinopelvic parameters and vertebral rotation in the setting of bracing treatment via a reliability study conducted in adherence to the guidelines for reporting reliability and agreement studies (GRRAS).

MATERIAL AND METHODS 

Full spine stereoradiographs of patients with adolescent idiopathic scoliosis (AIS) who underwent Chêneau bracing were retrospectively analyzed. The 3D reconstruction was performed by two experienced operators in a blinded manner and randomized order. Rotation of every vertebra was computed in the coronal, sagittal and axial planes. Sagittal spinopelvic parameters were evaluated. All measurements were statistically compared to determine agreement of the measurement of brace correction using the intraclass correlation coefficient (ICC).

RESULTS 

In this study, 45 patients (81% females) aged 12.5 ± 2 years were included. The mean absolute difference was less than 3.5° for all measured angles, less than 4 mm for sagittal vertical axis (SVA) and less than 1.5 mm for lateral pelvic shift. The ICC was high for all parameters (ICC >0.81). Despite the overall high reliability, the reliability of axial rotation was lower in the upper and middle thoracic spine and the lower lumbar spine.

CONCLUSION

Brace wearing during full spine LSI acquisition does not affect spinal measurements. The LSI under bracing treatment produces reliable measurements of spinopelvic parameters as well as vertebral rotation. These reproducible 3D data enable spine surgeons to assess the true shape of the deformity, to quantify rotation of each vertebra and enhance the understanding of the efficacy of bracing treatment.

 https://www.ncbi.nlm.nih.gov/pubmed/30899991

Prevalence of the thoracic scoliosis in children and adolescents candidates for strabismus surgery: results from a 1935-patient cross-sectional study in China.

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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. 

Prevalence of the thoracic scoliosis in children and adolescents candidates for strabismus surgery: results from a 1935-patient cross-sectional study in China.

Pan XX, Huang CA, Lin JL, Zhang ZJ, Shi YF, Chen BD, Zhang HW, Dai ZY, Yu XP, Wang XY.

Eur Spine J. 2020 Apr;29(4):786-793. doi: 10.1007/s00586-020-06341-7. Epub 2020 Feb 28.

PURPOSE 

No study so far has paid attention to strabismus-related spinal imbalance. This study aimed to determine the epidemiology of thoracic scoliosis in children and adolescents with strabismus and investigate the association of two diseases.

METHODS AND DESIGN

A cross-sectional study. Study group consists of 1935 consecutive candidates for strabismus surgery (4-18 years); Control group consists of the age- and sex-matched patients with respiratory diseases. All subjects underwent a screening program based on chest plain radiographs using the Cobb method. Their demographic information, clinical variables and results of Cobb angle were recorded and analyzed.

RESULTS 

A significantly higher prevalence of thoracic scoliosis (289/1935, 14.94% versus 58/1935, 3.00%) was found in study group compared with control group. Among strabismic patients, the coronal thoracic scoliosis curve mainly distributed in right and in main thoracic (198/289) and in the curves 10°-19° (224/289); Age range 7-9 years (103/1935), female (179/1935) and concomitant exotropia patients (159/851) were more likely to have thoracic scoliosis. According to the logistic regression, thoracic scoliosis had no significant association with age, BMI, duration of illness and onset age (p > 0.05). However, gender, BCVA, type of strabismus and degree of strabismus showed a significant relationship with the prevalence of thoracic scoliosis (p < 0.05).

CONCLUSIONS

With a pooled prevalence of 14.94%, strabismus patients showed a great higher risk of developing thoracic scoliosis. Screening for scoliosis in strabismus patients can be helpful to discover a high prevalence of potential coronal scoliosis. More attention should be paid to ophthalmological problems in patients with scoliosis. These slides can be retrieved under Electronic Supplementary Material.

Bracing works better in Italy

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Bracing treatment reduces the risk of needing surgery, but the proportion of patients who manage to avoid the scalpel differs between Europe and North America. The factor that makes the difference is patient compliance, i.e. a patient’s adherence to, and belief in, the course of bracing treatment prescribed. In this regard, Italian patients certainly come out on top. 
This is what emerged from a study conducted by ISICO entitled “AIS Bracing Success is Influenced by Time in Brace: Comparative Effectiveness Analysis of BrAIST and ISICO Cohorts”, which has just been published in the scientific journal Spine.

The study was based on a comparison of two populations of patients at high risk of surgery, which showed that, after bracing treatment, 39% of US patients go on to have surgery, as opposed to just 12% of patients treated by ISICO. The Italian institute sent clinical data referring to patients seen by its specialists to the University of Iowa, so that these data might be compared with those obtained in previous research published by the American group in 2014. 

“We worked in collaboration with the researchers at the University of Iowa” explains Dr Sabrina Donzelli, ISICO physician and author of the paper. “In 2014, our American colleagues published a randomized controlled multicentre trial called the “Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST)”. The resulting paper, by Lori Dolan and Stuart Weinstein, was published in the New England Journal of Medicine. Their study, the most important on this topic in the past 30 years, involved 383 patients from 25 US and Canadian institutes studied between March 2007 and February 2011. It showed that brace treatment reduced the percentage of patients requiring surgery. Given that surgeons and families in North America have always had a rather negative attitude towards bracing (unlike those in Europe, where it is well received), the authors were surprised by this finding. We took the results of the BrAIST study as the starting point for our research, comparing them with our own data. Working with our American colleagues, we selected patient subpopulations comparable for disease severity and risk of surgery”.

This comparison was a demanding task requiring clarity: the Italian researchers and the American surgeons from the Children’s Hospital of Iowa measured the radiographs of the patients from the BrAIST study and of 169 patients being treated at ISICO, in order to objectively verify the data. 
What did the comparison show? That bracing treatment at Isico works better, with the proportion of at-risk Italian patients who actually had surgery found to be just a third of the proportion recorded in the American population (12% vs 39%). It also emerged that the ISICO patients, respecting the treatment prescribed, wore their brace for a far greater number of hours than their American counterparts.

“Patient compliance is crucial,” Dr Donzelli continues “Our patients are careful to respect their doctor’s prescriptions, and the doctors and patients enjoy a good relationship based on mutual trust and faith in the proposed treatment. All this adds up to great teamwork between the patient, his/her family, the doctor, the orthopaedic technician and the physiotherapist”.

Telemedicine in response to Covid-19 emergency: the first results

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“I have appreciated being able to have continuity of treatment and the certainty that I can go on being supported by my doctor and therapist even in an emergency, like the one created by the coronavirus outbreak”. This is one of many anonymous comments collected by ISICO through quality assessment questionnaires that patients are filling in, voluntarily, to give us their personal feedback on our telemedicine service. 

The first results show a very high level of satisfaction among patients (mean overall satisfaction rating 2.8/3). Dozens of them clearly feel reassured by the fact that the telemedicine modality guarantees them continuity of care. As well as considering the modality worth recommending to others (mean satisfaction rating 2.8/3), they also feel that the information they have received is clear and exhaustive (mean satisfaction rating 2.99/3). 

As you know, on March 16th, after 13 days of constant and increasing cancellations due to travel restrictions (50% of bookings), ISICO launched its telemedicine initiative. 

It was clear to us, here at ISICO, that we needed to find a way of guaranteeing our patients ongoing care while at the same time removing the need for them to travel and physically access health facilities, thereby protecting them from possible contact with the virus.

Over the 12 days since the introduction of this new system, we have provided more than 1000 medical consultations or physiotherapy sessions in telemedicine mode, and cut face-to-face interventions to just 0.5% of the total. 

“This is a viable solution allowing us to continue providing services to patients, while eliminating the risk of infection associated with the need (both for patients and healthcare providers) to travel and access health facilities” explains Prof. Stefano Negrini, medical and scientific director of Isico. 

Organizing the service

The ISICO staff worked together, in teleconferences, to identify the tools necessary to conduct examinations remotely, i.e. via Skype or WhatsApp video call. The sensitive data are not recorded on these channels, but only in the internally used and protected file storage.

To be able to conduct examinations in telemedicine mode, we requested the collaboration of parents, sending them tutorials on how to photograph their children in a way that would allow us to do the measurements necessary to evaluate the state of their scoliosis.

We also had to explain to parents how the patient should be positioned in relation to the video camera. “Of course, measurements obtained in this way are slightly less reliable than those taken directly, but the photos/videos we are sent before the actual examination are generally of good quality” Prof. Negrini adds.

Parental support is also essential for delivering rehabilitation in telemedicine mode. “Fortunately, parents are always there in the gym, and so they are familiar with the work we do with their children” says Michele Romano, director of physiotherapy at ISICO. “We therapists have also sent written instructions and tutorials to explain how to perform simple tests of musculoskeletal function, and how to make their own simple measurement tools, which then help us to obtain reliable data. We are able to do, remotely, 70% of what we would normally do at the center”.

Consultations include adapted measurements and evaluations, which are done both “live” and from the photos/videos received. During physiotherapy sessions, new sets of exercises are defined and recorded. In both these settings, interviews and counselling are performed as usual.

It is worth recalling that treatments provided by ISICO are mostly based on home practice. Patients exercise at home 10/20 minutes per day, and individual physiotherapy sessions are provided every 30-90 (deformities) or 7-15 (pain) days.
During the sessions, physiotherapists perform evaluations, update and teach exercises (video recorded by parents), and provide patients with cognitive-behavioural therapy and counselling. An App, synchronised with the individual patient’s file, is used to manage treatment plans, provide exercise programmes and videos, promote compliance (with motivational tools) and encourage contact between patients and physiotherapists.

In conclusion, our early results are extremely positive. The telemedicine approach, which has been well received both by the patients and the professionals involved, has given us a means of providing uninterrupted outpatient services. In the current pandemic, this approach, reducing the need for travel and face-to-face contacts, can offer a viable alternative to closure for many outpatient services.

Predicting scoliosis progression: published an Isico review

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The scientific knowledge and the clinical competence of Isico experts recognized by Lancet’s EClinical Medicin Journal

One of the major challenges faced by clinicians is related to Idiopathic Scoliosis prognosis and to decision-making concerning which would be the best treatment for every single patient. 

Precisely on this topic, it has just been published by Isico in the journal EClinical Medicine the commentary Predicting scoliosis progression: a challenge for researchers and clinicians.  The editor invited to comment on the study  “A validated composite model to predict the risk of curve progression in adolescent idiopathic scoliosis”, following the review of the same conducted by Dr. Donzelli for the journal.

Idiopathic scoliosis has a multifactorial aetiology showing a wide range of different forms: anatomical (single or multiple curves and different localization), aesthetical (milder curves with visible changes and severe hiding perfectly), and prognostical (from highly to non-progressive).

Experts use some known clinical risk factors, the most important being residual growth: the more it is, the more the risk.

“It has been shown that ending growth below 30° allows preventing progression, disability and pain in adulthood – explains dr. Sabrina Donzelli, physiatrist in Isico and author of the review – the study of these colleagues developed a predictive model of the progression of scoliosis beyond 40 degrees, combining both clinical data and data from genetic tests. The idea of ​​combining clinical and genetic factors is interesting, but the results show that genetic testing does not play as significant a role as clinical data. The test of the accuracy of the model showed 80% of specificity and 92% of sensitivity, thus meaning that the model is good in discriminating patients at high risk for progression to 40°. According to the model, there is a 20% risk of overtreating patients with less aggressive IS. Is this enough? It depends on the treatment used to avoid progression”. 

The study therefore conducted is undoubtedly interesting, but the researchers showed a fundamentally surgical approach without any reference to the preventive role of the worsening and surgical risk shown by conservative treatments. Therefore we have been invited to process a comment to associate with the publication.

We would like to remind you that the SOSORT Guidelines recommend that ” for each patient, it is mandatory to choose the correct step of treatment, where the most efficacious is also the most demanding.” Expert clinicians should always choose the option they think is the most likely to reach the goals agreed with the patient but also the less invasive in the attempt to balance between undertreatment (that leads to little or no efficacy) and overtreatment.

“The introduction of a composite model, including genetic factors, is the novelty of this study, but some clinical questions remain open – continues dr Sabrina Donzelli – The type and quality of treatment applied, the compliance to treatment and the dosage of brace-wear have not been included in the model, although they are recognised as determinants of final results”.

From a clinical point of view, the 40° threshold is too low for surgery indication and too high for the best achievable result from patients’ perspective. Surgery is indicated for curves exceeding 50°.  

“A prognostic model should help clinicians in their choices after risks estimation – finalises dr Sabrina Donzelli – the currently developed composite prediction model for progression over 40° showed that the major predictor is Cobb degrees at start. The fact that Cobb at start is the major predictor, confirms the key-role played by screening and conservative care: exercises and bracing to prevent progression should be started at early stages of the deformity when it is early diagnosed“. 

What can parents do to help manage brace-wearing youngsters’ anger and outbursts?

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Fighting scoliosis is a team effort. It is also a long, difficult and sometimes exhausting battle in which the patient, who is in the front line of course, is ably supported by various team members: a specialist doctor, a physiotherapist, an orthopaedic technician and, if necessary, a psychologist.

Nevertheless, the people best placed to support patients are the members of their own family. Parents, who directly experience the everyday problems faced by their child, can play an active and crucial role in ensuring that the treatment runs smoothly.  

I would go so far as to say that their input is essential in order for the treatment even to begin.

A diagnosis of scoliosis always comes as a shock, and the course of action prescribed by the doctor is something no adolescent wants to hear. While they initially have little problem accepting the specific exercises they have to do, the prospect of wearing a brace is frightening. All they can think is that this is going to change everything, and they really don’t want that to happen!

In this situation, it is already clear that parents can play a crucial role. With their child probably completely overwrought, they need to inject a dose of rationality.

We, as a team of specialists, always try to address patients directly, striving, from the very outset, to involve them in every decision. We provide exhaustive explanations, as these are tools for interpreting and, above all, understanding the course that has been decided and prescribed.

However, on leaving our office or clinic, patients will inevitably take things out on their parents, and it will be up to them to find the best way of getting our words, and our message, across.

If you are reading this, you probably already appreciate that, in times of difficulty, we often find we have unexpected resources, and that, most of the time, it is possible to find a balance and follow doctor’s instructions properly. 

As with all long undertakings, however, obstacles are always just around the corner, and you need to have the strength to stay “on track”.  

Anger is a common and normal reaction in these patients, stemming from an understandable sense of injustice over the challenge they are facing.

In this circumstance, too, the whole team, but the parents primarily, must be ready to spring into action.

How can a parent best manage a child who is in difficulty with the treatment and gripped by a feeling of anger?

The first thing is to show empathy and understanding, remembering that things that are less important to us adults are not always viewed the same way by adolescents.
It is also important to remember that anger is a manifestation of distress, which can have various causes.

Parents must strive to be a point of reference and a channel through which their child can vent his or her feelings, in order to help him/her recognise and correctly express the anger he/she is feeling in the face of this difficult situation. The next step is to help the child to reason more clearly, reminding him/her of all the challenges he/she has thus far faced and overcome.

Parents must also be the first to believe in the course of treatment, and must continue to support it right through to its conclusion, having full confidence in the doctor and helping the child appreciate the importance of persevering. For these patients, this is perhaps the first time in their life that they have had to deal with a personal problem.

If they can learn to manage their anger and accept a compromise between what they want and what they can have (within the constraints of the treatment of course), then they will have learned, first hand, that, with a little patience and the support of those closest to you, difficult situations can always be overcome.

Note

This is one of the posts published in the Isico blog, www.scoliosi.org,  a dedicated space where patients can ask questions and swap experiences, but it is also a place where those involved in treating scoliosis can take a more in-depth look at a series of topics and also engage with patients.

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Scoliosis: dance and swimming. Yes or no?

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

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

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

Swimming and scoliosis

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

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

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

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

Dance and scoliosis

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

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

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

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

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

Back pain and scoliosis

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What causes back pain? Well, having a back and two legs to begin with! That’s right! As humans, we have one particular body part that is always going to be more exposed than the others to the risk of discomfort and overloading. And that body part is the spine.

You have probably sometimes wondered why certain people who do heavy jobs and spend their entire lives “mistreating their spine” don’t even know what it means to have back pain.

It is well established that “good” or “bad” loading of the spine is a result of its conformation in the sagittal (lateral) plane, in other words, on the distribution of its curves.
Unfortunately, the lateral profile of the spine, meaning the particular way in which the spine’s natural curves, called lordosis and kyphosis, are distributed, does not depend on the will of the individual, but on a genetic predisposition to one pattern or another.

Basically, whether or not we are predisposed to back problems is a matter of luck.

So, what should we do? Simply resign ourselves to the fact that, morphologically speaking, we are among the less fortunate? Simply accept that we are prone to back pain and put up with it, since there’s nothing that can be done?

No, absolutely not! Because back pain, affecting our work, mood and social activities, can really condition our lives!

Things to know

– You have to take care of your back because, for better or worse, it’s yours and it’s the only one you’re ever going to have.

– Taking care of your back means keeping it fit and knowing how to use it properly. So, make sure you do regular physical activity to keep your spinal muscles in shape, but also your leg and arm muscles. What kind of activity? There’s no “best” kind of physical activity; the important thing is to choose something you enjoy and do it at least twice a week, or better still three times. 

– Knowing how to use your back means making sure that you do not spend too long sitting down. You need to alternate sitting with spells of movement. Also learn to sit correctly, and if your work means you have to spend hours sitting at a desk, look at how to set everything (computer, seat, etc.) at the right height. Also, you need to think about how to correctly manage your body under stress, in other words when it is subjected to loads and also during physical effort.

– It is important to learn about the shape of your own spine and how forces are distributed over the body, and then to assess your particular limits and strengths. It can be helpful to do all this with the support of a specialist who can help to familiarise you with your own specific ergonomic and training needs.

What if I have scoliosis?

Even though there is still a lot to be discovered and learned in this field, we know that scoliosis, as it progresses, creates an abnormal alignment of the vertebrae, which is seen both in the frontal plane (as scoliotic curves) and in the sagittal plane (as changes in physiological lordosis and kyphosis).

Indeed, treatment of scoliosis aims to curb this progression and remodel the spine so that, by the time the individual finishes growing, it is as well aligned as possible.

According to scientific studies, if we can achieve good spinal balance in the sagittal plane (in particular, this means maintaining good lumbar lordosis), and if we can keep the scoliotic curves under 25-30°, the scoliosis outcome will not affect the proper functioning of the spine.

In such cases, the risk of back pain will be the same as that seen in people without scoliosis.

In the presence of more severe curves, it is necessary to be even more aware of the need to safeguard the spine. In the knowledge that it is a delicate and vulnerable part of the body, you must take good care of it and do physical activity to keep your back fit.

Dr Donzelli at Oxford University

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Dr Sabrina Donzelli, an Isico physician, participated some weeks ago in a joint programme in collaboration with the Centre for Evidence-Based Medicine in Oxford, together with other 15 students coming from Egypt, Brasil, Ireland, UK, USA, Ghana, Canada, Hong Kong, Malaysia, Lebano and Italia.

The topic of this demanding course was basic and advanced statistical methods for meta-analysis for health professionals designed to provide an overview of different meta-analysis methods and common problems encountered with extracting data. The module is part of the MSc degree in Medical Statistic provided by the department in  Evidence Based Health Care at Oxford University, Dr. Donzelli was admitted to the program in the Academic year 2019. 

Dr Donzelli is currently a teaching assistant for the online program in Principle and Practice in Clinical Research provided by the Harvard University gathering every year more than 400 students from all around the world.

Isis Navarro at Isico headquarter

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Could you tell us about your studies?

I am a PhD Student at Universidade Federal do Rio Grande do Sul. Since 2017, after I completed the SEAS course, I started to have only patients with scoliosis and work just with these patients. In my master’s degree I studied the surface topography as a possibility of easy and three-dimensional tool to evaluate scoliotic patients. I had some publications based on this primary subject.

https://www.sciencedirect.com/science/article/abs/pii/S0966636218303126

http://www.fortunejournals.com/articles/thoracic-idiopathic-scoliosis-establishing-the-diagnostic-accuracy-and-reference-values-of-surface-topography.html

And I have also some articles accepted for publication:

NAVARRO, ISIS J.R.L.; CANDOTTI, CLÁUDIA T. ; FURLANETTO, TÁSSIA S. ; DUTRA, V. H. ; AMARAL, M. A. ; LOSS, JEFFERSON F. . Validation of a mathematical procedure for the cobb angle assessment based on photogrammetry. Journal of Chiropractic Medicine (Print), 2019.

NAVARRO, I. J. R. L.; CANDOTTI, CLÁUDIA T. ; AMARAL, M. A. ; DUTRA, V. H. ; Gelain, G. ; LOSS, JEFFERSON F. . Validation of the measurement of the angle of trunk rotation in photogrammetry. JOURNAL OF MANIPULATIVE AND PHYSIOLOGICAL THERAPEUTICS, 2019.

What is your profession?

I am a physiotherapist.

Why did you register for the SEAS  course?

I was looking for the SEAS course, and my plan was to travel to Italy to attend the course, but fortunately Michele and Alessandra came to Brazil to teach for the first group in Brazil. I discovered the SEAS approach doing lots of researches on internet, searching for consistent methods of treatment to scoliotic patients to offer to them the best possibility of treatment and results.

What makes the SEAS learning course different from other educational courses and programs?

The more significant advantage of the SEAS course is the clarity of the reasoning behind the technic and the facility to apply what you learned. The SEAS approach allows doing physiotherapy with all type of scoliotic patients, independent of the type or classification of the curve. The teachers were always ready to answer all the questions and help with difficult cases I asked separately.

Are you satisfied with what you have learned? 

Yes. But when you start to practice more and more always news doubts arise. 

If you were asked to recommend the course, what would you say?

The SEAS course is an excellent way to understand the world of scoliosis, its characteristics and the reasoning to treat adequately and accurately. After the course, you will be able to evaluate and treat scoliotic patients based on a method easy to understand and to apply with a high level of scientific evidence.