Predictive factors for brace treatment outcome in adolescent idiopathic scoliosis: a best-evidence synthesis

Spinal ultrasound to quantify in-brace correction before nighttime brace fabrication in adolescent idiopathic scoliosis

PURPOSE

Initial in-brace curve correction is an important predictor of brace treatment success in adolescent idiopathic scoliosis (AIS). After brace measurement and fabrication, in-brace correction is sometimes not perfect and needs further optimization. Ideally, in-brace correction is known before fabrication without using ionizing radiation. This study investigates the use of spinal ultrasounds during Providence nighttime brace measurement, and tests the correlation between spinal ultrasound angles in corrected position and radiographic in-brace Cobb angles.

METHODS

Twenty-four consecutive AIS patients underwent full-spine radiographs and spinal ultrasounds in standing position before Providence brace measurement on the board in supine position. Immediately afterwards, they underwent spinal ultrasound in corrected position, prone on the mirrored measurement board. Four weeks after brace treatment initiation, supine in-brace radiographs were obtained. Coronal ultrasound angle and Cobb angle were measured for the primary curve. Curve correction was defined as percentage of change of the ultrasound angle and Cobb angle. Pearson's correlation coefficient was used to evaluate correlations between both angles and between correction percentages.

RESULTS

The initial Cobb angle was 30.0°±7.8 (mean ± sd), and corrected to 8.9°±5.9 in-brace, a correction of 71%±16. The ultrasound angle (based on posterior spinal elements) corrected from 18.6°±5.8 standing to 5.2°±3.1 on the measurement board, a correction of 72%±15%. Ultrasound angle in corrected position and in-brace Cobb angle were linearly correlated (r = 0.878 p < 0.001), as well as the correction percentages (r = 0.827, p < 0.001).

CONCLUSION

The in-brace correction of the Providence brace can be accurately assessed with spinal ultrasound and potentially improved while measuring the brace, without the need for ionizing radiation.

Bracing effectiveness in idiopathic early onset scoliosis followed to skeletal maturity: a systematic review and meta-analysis

PURPOSE

Treating idiopathic Early Onset Scoliosis (idiopathic EOS) is challenging due to ongoing growth and extensive follow-ups. While bracing is effective for Adolescent Idiopathic Scoliosis (AIS), its value for children under 10 remains debated. This systematic review and meta-analysis evaluates the effectiveness of spinal bracing in idiopathic EOS, followed to skeletal maturity.

METHODS

We searched Ovid Medline and Web of Science until November 1st, 2023. Studies included idiopathic EOS patients between the ages of 3 and 10 (corresponding to Juvenile Idiopathic Scoliosis), followed to skeletal maturity, with no more than 25% initiating bracing after age 11. The primary outcome was the percentage undergoing scoliosis surgery. Pooled outcomes were calculated using a random effects model and 95% confidence intervals.

RESULTS

Out of 417 studies, 15 met the inclusion criteria, encompassing 868 patients. All were observational with a high risk of bias. The pooled percentage of patients undergoing surgery was 40% (95% CI 27-55%). The percentage of patients with a 5-degree progression or more and those progressing beyond 45 degrees were 44% (95% CI 24-66%) and 33% (95% CI 17-54%), respectively. Factors including larger initial Cobb angles, younger age, smaller in-brace correction, and poor compliance were identified as progression risk factors.

CONCLUSIONS

Bracing may prevent progression to surgery in idiopathic EOS when initiated early, but progression and surgery are still more common compared to adolescents. This is the first systematic review and meta-analysis looking at the success of bracing in idiopathic EOS, followed up to skeletal maturity. The high bias and variability of included studies limit the strength of these conclusions, highlighting the need for high-quality research with innovative trial designs.

LEVEL OF EVIDENCE

IV (systematic review of level IV studies).

Identifying predictors of brace treatment outcomes for adolescents or adults with idiopathic scoliosis: a systematic review

PURPOSE

This systematic review aimed to identify predictors of brace treatment outcomes for adolescents or adults with idiopathic scoliosis.

METHODS

Four databases including MEDLINE, EMBASE, Web of Science, and CINAHL were searched. Free text and indexed terms identifying the populations, predictions analyses and key outcomes were combined to search the literature. Pairs from eight independent reviewers conducted abstracts and full-text screening, and data extraction. The Quality in Prognostic Studies (QUIPS) tool was used to assess the risk of bias (ROB). Strength of evidence summary statements were formulated based on the risk of bias and the consistency of the research findings.

RESULTS

The search found 2224 articles. After screening, seven articles were included. Only one article showed low ROB, while the others showed moderate ROB. All articles reported on patient-related outcome measurements (PROMS) of quality of life (QOL). Only one parameter achieved limited strength of evidence; shorter treatment time from one study predicted better long-term SRS-22 total scores. For other predictors, the level of evidence was unclear. Other predictors of long-term outcomes (> 1 year follow-up), from only 1 study on each outcome, were: larger Cobb angle predicted worse Spinal Appearance Questionnaire (SAQ) chest scores and worse depression; higher age predicted better SAQ curve scores, larger apical translations predicted worse SAQ shoulders and chest scores; a passive introverted personality or an active outgoing (MPI) character type predicted worse SRS-22 satisfaction; higher BMI predicted better SAQ curve, Rolland-Morris questionnaire (RMQ) lumbosacral pain, Quebec Back Pain Disability Scale (QDS) moving scores, and worse SRS-22 total; larger vital capacity predicted better QDS score; longer bracing (total) predicted worse depression; negative parental attitudes predicted worse depression; higher Strengths and Difficulties Questionnaire emotional symptoms, peer problems, prosocial behavior, and total scores predicted worse depression. Poor compliance from one short-term follow-up study predicted worse change of brace questionnaire (BRQ) for health perception, pain, physical and emotional functioning, and total scores. Moderate evidence from two studies with low and moderate RoB showed that age and Cobb angle did not predict long-term total SRS-22 score for prediction.

CONCLUSION

Eleven parameters predicted bracing outcomes, but most studies presented moderate risk of bias. Only one parameter, longer treatment time, with limited strength of evidence was predictive of better long-term SRS-22 total scores. Since most findings still present an unclear level of evidence, common weaknesses were identified to encourage design of high-quality studies predicting bracing outcomes.

Digitalized 3D Spinal Decompression and Correction Device Improved Initial Brace Corrections and Patients' Comfort Among Adolescents with Idiopathic Scoliosis: A Single-Centre, Single-Blinded Randomized Controlled Trial

This study aimed to evaluate the efficacy of a novel three-dimensional (3D) spinal decompression and correction device in improving the in-brace correction and patient comfort level for adolescents with idiopathic scoliosis (AIS), and to assess the impact of the number of vertebrae involved in the scoliotic curve on the correction's effectiveness. A single-centre, single-blinded randomized controlled trial (RCT) was conducted in 110 AIS patients aged 10-18 years who were randomly allocated into four groups receiving 0-3 days of device intervention. Each session lasted for 30 min and was conducted twice daily. Significant improvements were observed in both the in-brace correction ratio and patient comfort level, particularly in the 2- and 3-day intervention groups (p < 0.001). The number of involved vertebrae for a scoliotic curve was positively correlated with the in-brace correction ratio in the no intervention (or 0-day) and 1-day intervention groups, while this correlation varied in the 2- and 3-day intervention groups. These findings suggested that the prolonged use of the 3D device could improve the correction ratios and patient comfort, while the role of vertebrae involvement in predicting the initial correction may require further exploration to optimize personalized treatment strategies in future clinical practice.

The Biomechanics of Spinal Orthoses for Adolescent Idiopathic Scoliosis: A Systematic Review of the Controlling Forces

BACKGROUND

Orthotic treatment is a well-acknowledged conservative treatment for moderate adolescent idiopathic scoliosis (AIS). The efficacy of this treatment is significantly determined by the forces applied to the bodies of patients. However, there is uncertainty regarding the optimal force levels that should be applied to the patient's torso by spinal orthosis. This study aims to identify reference values for the controlling forces in AIS management.

METHODS

A comprehensive literature search was performed in five databases (PubMed, Scopus, Cochrane Library, CINAHL, and Web of Science). Only studies written in English and covering the force/pressure measurements of spinal orthosis for the treatment of AIS were included, without publication date restrictions. The methodological index for non-randomized studies (MINORS) was employed for the methodological quality assessment, and force measurements were standardized to pressure in kilopascals (kPa) for comparison.

RESULTS

From the initial 10,452 records, 10 studies were admitted for the final analysis. All the included studies reported the interface pressure between the thoracic (T) pad and patient's trunk, and seven studies evaluated the pressure from the thoracolumbar/lumbar (TL/L) pad. These studies used different pressure sensors or transducers with the range from 5.6 to 82.5 kPa for the T pads, and 4.8 to 85.1 kPa for the TL/L pads. Four studies reported strap tensions of 26.8 to 60.4 N. Higher strap tension was correlated with increased interface pressure (r = 0.84).

CONCLUSION

The mean strap tension was 42.5 N, the median interface pressure of the T pads was 8.75 kPa, and the median pressure of TL/L regions was 7.11 kPa without the outliers. The findings provide a baseline value for designing adjustable straps and strategically distributing pressure in orthoses.

Results of bracing adolescent idiopathic scoliosis in the context of clinical practice and the Scoliosis Research Society's criteria: 5-year observational study from a German orthopaedic university hospital

BACKGROUND

Brace therapy's influence on adolescent idiopathic scoliosis's (AIS) natural course is inconclusive.

METHODS

Brace-treated AIS patients from 2016 to 2020 were examined regarding four endpoints at brace weaning: surgery need, curve progress ≥ 6° and > 45°, and curve improvement ≥ 6°. Prediction variables' influence was computed for the all-patients group and three subgroups (Subgroup 1: fulfilling the Scoliosis Research Society's [SRS] criteria, Subgroup 2: initial Cobb angle < 25°, Subgroup 3: initial Cobb angle > 40°). According to the data characteristics, parametric and non-parametric tests and binary logistic regression were performed.

RESULTS

The research included 69 patients. Overall, after brace weaning surgery was recommended for 20.3% of them, curve progression was ≥ 6° in 23.2%, the Cobb angle was beyond 45° in 11.6%, and the Cobb angle improved by ≥ 6° in 20.3%. Patients needing surgery had a significantly higher initial Cobb angle (38.8° ± 9.8° vs 27.8° ± 7.6°, p < 0.001), lower Risser stages (p = 0.010), and higher Nash and Moe degrees (p = 0.030). Patients with curve progress ≥ 6° were younger at first curve notification (12.4 ± 1.5 vs 13.7 ± 1.7 years, p = 0.011) and older at menarche (13.4 ± 1.1 vs 12.6 ± 1.2 years, p = 0.037). Furthermore, 21.6% of all Risser 3 and 4 patients had still curve progress ≥ 6°. In-brace correction was significantly higher in patients with curve improvement ≥ 6° vs < 6° (54.0% ± 31.2% vs 31.9% ± 30.7%; p = 0.019). Nine patients fulfilled the SRS criteria, 22 had initial Cobb angles < 25°, and 11 had > 40°. Real brace wear (RBW) in all groups had no significant effect on outcome. Two significant subgroup differences were found: Surgery recommendation and curve progression beyond 45° were significantly more frequent in the initial Cobb angle > 40° subgroup.

CONCLUSIONS

Brace effectiveness can be assumed because curve improvement was achieved in nearly one-fifth with sufficient in-brace correction. However, no significant influence of RBW on the outcome endpoints was demonstrated. To clarify conflicting results, big data management, including untreated patients, must be employed to further research AIS's multifactorial influenced aetiology and course. Meanwhile, it is worth starting bracing in AIS in practice also beyond the SRS's criteria.

Lessons from the pandemic era: do we need new strategies to improve conservative treatment adherence in adolescent idiopathic scoliosis? A retrospective analysis

This study aims to examine whether the COVID-19 pandemic affected the adherence to conservative AIS treatment. Adolescent Idiopathic Scoliosis (AIS) is characterized by a lateral curvature of the spine of at least 10 degrees. Compliance rates in conservative treatments are influenced by various factors. From a database of AIS patients, we selected 30 AIS patients who were assessed before, during, and after the COVID-19 pandemic. Data regarding Cobb's angle, brace prescription, prescribed brace wear time, brace wear compliance, and time dedicated to sports activities were collected over a six-year period from January 2018 to December 2023, divided into three 2-year time periods (before, during, and after COVID-19). There was an increased percentage of AIS patients prescribed with a brace during the pandemic. However, no significant differences in Cobb's angle were observed. Additionally, the prescribed wear time showed a significant decrease from the pre-COVID period to the post-COVID period (p-value = 0.03). Wear compliance exhibited a decreasing trend from pre- to during- and post-COVID-19 periods without reaching statistically significant differences, and the time dedicated to sports statistically significantly decreased. These differences were statistically significant when comparing the pre- vs. post- and pre- vs. during-COVID-19 periods (p-values 0.01, 0.04, respectively). Our study highlights changes in AIS conservative treatment during and after the COVID-19 pandemic. The increase in the number of patients prescribed with a brace during the pandemic, although not supported by an increase in Cobb's angle, may be attributed to the concerns about regular monitoring during the reduction of rehabilitation services. The observed decreases in brace compliance and involvement in sport activities, which persisted even in the post-pandemic period, emphasizes the lasting impact of the pandemic on AIS management, necessitating innovative approaches to address these ongoing concerns.

Brace compliance process in adolescents with spinal deformities: A qualitative study

BACKGROUND

Adolescent idiopathic scoliosis affects 2-4% of adolescents aged 10-16, while Scheuermann's kyphosis affects 0.4-10% of adolescents aged 11 to 16. Over the past 50 years, brace treatment has been recommended as the most common non-surgical intervention for treating these spinal deformities. The effectiveness of brace treatment depends on the duration of brace wearing. This study aimed to understand the brace compliance process for adolescents with spinal deformities through a qualitative approach.

METHOD

This study applied multicenter exploratory qualitative research with an interpretative framework and enlisted the participation of as many individuals as possible involved in brace-wearing in adolescents with spinal deformities. Semi-structured, in-depth, and face-to-face interviews and telephone conversations from September 2020 to May 2021 were conducted. The recorded audio of each interview was typed into Word software with each personal code. The content analysis method was used to analyze the data.

RESULTS

Seventy-four participants were interviewed, including 32 adolescents treated with braces and their parents (27 mothers, five fathers), six orthotists, two physiotherapists, and two spine surgeons. Following data analysis, four main categories, 14 categories, and 69 subcategories of 2403 related codes were discovered.

CONCLUSION

Based on the analysis of the current qualitative research, adolescents with spinal deformities experience extensive challenges in the treatment process, which can affect the results and brace intervention efficacy. The current research findings showed that every adolescent goes through similar but unique conditions during the treatment. The importance of considering each adolescent's specific conditions and characteristics and providing functional solutions and support was understood to help them navigate critical situations more quickly and achieve effective treatment outcomes.

The Efficacy of Night Bracing in the Treatment of Adolescent İdiopathic Scoliosis: A Systematic Review

Background/Objectives: The effectiveness of night braces alone or in combination with other treatments for adolescent idiopathic scoliosis remains unclear. This systematic review study aimed to review and analyze the available literature to determine whether night braces are an effective treatment for idiopathic scoliosis. Methods: A total of 162 databases, including Cochrane Library (reviews, protocols, trials), Web of Science, PubMed, Medline, Scopus, PEDro, CINAHL (EBSCO), Ovid and Google Scholar, were searched for published articles from inception to February 2024. The available literature was screened by the following terms: "scoliosis and night-time brace", "scoliosis and night brace", "scoliosis and part-time bracing", "scoliosis and Providence" and "scoliosis and Charleston". Results: Twenty studies were included; only one study was a randomized controlled trial, and most of the studies were retrospectively designed. Providence, Charleston and Boston braces were used as night braces. The Cobb angle was evaluated in all studies, and Cobb angle change after treatment and surgical treatment rates were the parameters that were evaluated the most. In one study, the angle of trunk rotation, quality of life, perception of spinal appearance, and physical activity level were measured. In one study, sagittal plane assessments were performed in addition to the Cobb angle. Conclusions: The results of this review suggest that there is no evidence to support the use of night braces in the treatment of adolescent idiopathic scoliosis. Randomized controlled trials with a well-designed methodology are needed to determine the efficacy of night braces.

The effect of stretching exercises before orthotic treatment on the immediate in-orthosis correction of the patients with adolescent idiopathic scoliosis: A pilot study

BACKGROUND

Stretching exercise is generally used for improving flexibility. However, its application to promote orthotic treatment for patients with adolescent idiopathic scoliosis (AIS) remains unknown.

OBJECTIVE

This study was to explore the effect of pre-orthosis stretching exercises on spinal flexibility and initial in-orthosis correction for the patients with AIS.

STUDY DESIGN

A pilot-controlled study.

METHODS

An experimental group (EG) of 13 subjects (10 girls and 3 boys) with AIS allocating to self-stretching exercises and a control group (CG) of 19 AIS subjects (14 girls and 5 boys) with no stretching before orthosis fitting were recruited. The spinal flexibility of the EG was evaluated with an ultrasound imaging system and physical measurements. The initial in-orthosis correction rates between the 2 groups were compared with the independent t test, and the correlation analysis between the spinal flexibility measured from ultrasound images and physical measurement was performed with the Pearson correlation test.

RESULTS

The initial Cobb angle of EG and CG were 25.70° ± 7.30° and 28.09° ± 5.58°, respectively. No significant difference was observed between the initial in-orthosis Cobb angle of EG (11.13° ± 6.80°) and CG (15.65° ± 9.10°) (p = 0.06). However, the spinal flexibility after stretching exercises was improved (p < 0.001), and the spinal flexibility changes measured with ultrasound and physical forward-bending method were significantly correlated (r = 0.57, p < 0.05).

CONCLUSION

Stretching exercises before orthotic treatment could improve the spinal flexibility but did not cause a better in-orthosis correction. A study with a larger sample size and longer follow-up period should be conducted to investigate the long-term effect of stretching exercises.

Predictive Parameters for Chêneau Brace Efficacy in Patients with Adolescent Idiopathic Scoliosis

STUDY DESIGN

Retrospective consecutive cohort study.

OBJECTIVE

For patients with mild to moderate adolescent idiopathic scoliosis (AIS), bracing is the standard therapy to prevent progression of deformity. Still, not all patients benefit from treatment in the same way. Therefore, predictive parameters are needed to determine if patients are likely to benefit from brace therapy.

METHODS

Fourty-five AIS patients treated with a Chêneau brace were evaluated retrospectively. Inclusion criteria were based on SRS-criteria. Whole spine X-rays were performed pre-brace, in-brace, and at least 6 months after termination of brace treatment. Gender, age, Risser's sign, vertebral rotation determined by Nash and Moe grading system, in-brace correction and in-brace time per day were parameters evaluated. Treatment success and failure groups were compared to determine possible predictive parameters for successful brace treatment.

RESULTS

Chêneau brace treatment was successful preventing curve progression in 69%. We found significant differences between success and failure group concerning age (14 ± .22 vs 12.4 ± .4; P < .001) and Risser's sign (1.71 ± .16 vs .5 ± .17; P < .001) at beginning of brace treatment. Most significantly, initial in-brace curve correction was correlated with successful outcome after brace treatment (r = .64 (P < .001)).

CONCLUSIONS

As one of few studies adhering to the criteria defined by the Scoliosis Research Society our study shows reliable predictive parameters for Chêneau brace treatment success in patients with AIS. Data shown in this paper will help to differentiate AIS patients who are likely to benefit from adequate bracing therapy from those who could rather benefit from early surgical treatment.

The influence of night-time bracing on curve progression is not affected by curve magnitude in adolescent idiopathic scoliosis: a study of 299 patients

BACKGROUND AND PURPOSE

The efficacy of bracing larger curves in adolescent idiopathic scoliosis (AIS) patients is uncertain. We aimed to assess the influence of night-time bracing in AIS patients with main curves exceeding 40° Cobb angle at brace initiation.

METHODS

We reviewed AIS patients treated with nighttime braces between 2005 and 2018. Patients with curves ≥ 25° and estimated growth potential were included. Patients were monitored with radiographs from brace initiation until brace weaning at skeletal maturity. Patients were grouped based on curve magnitude at initial evaluation: a control group (25-39°) and a large-curves group (≥ 40°). Progression was defined as > 5° increase.

RESULTS

We included 299 patients (control group, n = 125; large-curves group, n = 174). In the control group, 65 (52%) patients progressed compared with 101 (58%) in the large-curves group (P = 0.3). The lower-end vertebra (LEV) shifted distally post-bracing in 41 (23%) patients in the largecurves group. Patients with progressive large curves were younger (age 13.2 [SD 1.5] vs. 13.9 [SD 1.1], P = 0.009) and more premenarchal (n = 36 [42%] vs. n = 6 [9%], P < 0.001) compared with non-progressive large curves.

CONCLUSION

Progression risk in patients with curves exceeding 40° treated with night-time bracing is similar to smaller curves. The LEV moved distally in almost one-fourth of the larger curves, possibly affecting fusion levels in cases of surgery.

Results of Gensingen Bracing in Patients With Adolescent Idiopathic Scoliosis: Retrospective Cross-Sectional Feasibility Study

BACKGROUND

Bracing is an essential part of scoliosis treatment. The standard of brace treatment for patients with scoliosis today is still very variable in terms of brace quality and outcome. The Gensingen brace is a further developed Chêneau brace derivative with individual design, which can be adapted through computer-aided design.

OBJECTIVE

This study aims to generate a template to obtain a database for prospective multicenter studies study to analyze the results of high-corrective asymmetric Gensingen brace treatment for patients with adolescent idiopathic scoliosis (AIS).

METHODS

A template for the database was created, which contains the patients' basic data (age, menarcheal status, Risser Sign, curve pattern, and daily brace wearing time), the Cobb angles of curvature, and the cosmetically relevant angles of trunk rotation (ATR). A retrospective review of medical records of patients with AIS, who met the Scoliosis Research Society's inclusion criteria for brace studies, was performed to test the feasibility of the template. Template items were filled in by the researchers.

RESULTS

Out of 115 patients between 2014 and 2018, the complete data of 33 patients followed up at least 3 months after complete Gensingen brace weaning could be analyzed. The mean age was 12 years, the mean Cobb angle was 33.6°, and the mean Risser value was 0.7 at the beginning of the treatment. The mean improvement in the Cobb angle on in-brace x-ray imaging was -26.1० (80% of in-brace correction). The Cobb angle of the major curvature changed as follows: curve stabilization was achieved in 7 (21.2%) cases, and curve improvement was achieved in 26 (78.8%) cases. None of the patients showed a curve progression. The Cobb angle was significantly reduced in the brace at the end of treatment and at follow-up evaluation (P<.001). ATR improved significantly for thoracic (P<.001) and lumbar curves (P<.001).

CONCLUSIONS

The database proved to be informative in the assessment of radiological and clinical outcome parameters. The example data set we have generated can be a helpful tool for professionals who work in clinics but do not store regular patient data. Especially with regard to different patient collectives worldwide, different results may be achieved with the same standards of care. In addition, the results of this study suggest that above-average correction effects with a full-time brace application lead to significant improvements in the Cobb angle after brace treatment has been completed.

Global research hotspots and trends in non-surgical treatment of adolescent idiopathic scoliosis over the past three decades: a bibliometric and visualization study

Background

In recent years, research on the non-surgical treatment of AIS has been increasingly conducted. To the best of our knowledge, this field doesn't yet have a comprehensive and structured pulse combing analysis. In order to provide inspiration and resources for subsequent researchers, we thus reviewed the literature studies on the non-surgical treatment of AIS from the previous thirty years and highlighted the hotspots and frontiers of research in this field.

Methods

Main using Citespace 6.1 software, the data from the core dataset of the WOS database pertaining to the non-surgical management of AIS from 1990 to 2022 was gathered, displayed, and analyzed.

Results

839 papers in all were included in the literature. With 215 papers, the USA came in first place. Chinese Univ Hong Kong ranked first with 32 papers. Research hotspots are adolescent idiopathic spondylitis, Schroth-based physiotherapy-specific exercise efficacy, curve development, Cobb angle, TLSO brace-based clinical efficacy, quality of life, reliability, health-related quality of life questionnaires, finite element biomechanical models, follow-up, and clinical guidelines.

Conclusion

There aren't many studies that compare the clinical effectiveness of various non-surgical treatments, and because of variations in inclusion eligibility standards and outcome measures, these studies cannot be directly compared. In addition, the inconsistency of existing growth potential and progression risk assessment systems further affects comparative studies of clinical efficacy; it is recommended to establish primary assessment indicators centered on patient treatment outcomes (including appearance, disability, pain, and quality of life), as well as standardized scoliosis progression risk assessment criteria.

Spinal Orthosis in Adolescent Idiopathic Scoliosis: An Overview of the Braces Provided by the National Health Service in Italy

Adolescent idiopathic scoliosis (AIS) is a lateral, rotated curvature of the spine. It is a 3-dimensional deformity that arises in otherwise healthy children at or around puberty. AIS is the most common form of scoliosis in the pediatric population. The etiology is multifactorial, including genetic and environmental factors. The incidence is roughly equal between males and females, while there is a higher risk of progression in females. Guidelines for AIS treatment identify three levels of treatment: observation, physiotherapy scoliosis-specific exercises, and braces. In this paper, we carried out a review of the scientific literature about the indication and success rates of the braces provided for free by the National Health Service in Italy (SSN). Despite a general consensus on the efficacy of rigid bracing treatment and its use in AIS, an important heterogeneity about the treatment is present in the scientific literature, demonstrating a high degree of variability. The overall success rate of the braces provided by the SSN is high, suggesting an important therapeutic role in the treatment of AIS. Robust guidelines are needed to ensure uniform and effective treatments.

Associations between spinal flexibility and bracing outcomes in adolescent idiopathic scoliosis: a literature review

OBJECTIVES

To identify the existing assessment methods used to measure the spinal flexibility of adolescents with idiopathic scoliosis before bracing and to evaluate the predictive effect of spinal flexibility on bracing outcomes.

METHODS

A broad literature search was performed in the PubMed, Web of Science, EMBASE, CINAHL, Scopus, and Cochrane Library databases to obtain relevant information about spinal flexibility and bracing outcomes. All literature was retrieved by October 14, 2023. The inclusion and exclusion criteria were meticulously determined. The quality of each included study and the level of evidence were evaluated by the Quality in Prognosis Studies (QUIPS) method and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system, respectively.

RESULTS

After screening 1863 articles retrieved from databases, a total of 14 studies with 2261 subjects were eligible for the final analysis in this review. Overall, nine methods of flexibility assessment were identified, including supine radiographs, supine lateral bending radiographs, lateral bending radiographs but without clear positions, hanging radiographs, fulcrum bending physical method, and ultrasound imaging in the positions of supine, prone, sitting with side bending and prone with side bending. In addition, five studies demonstrated that flexibility had a strong correlation with in-brace correction, and eleven studies illustrated that spinal flexibility was a predictive factor of the bracing outcomes of initial in-brace Cobb angle, initial in-brace correction rate, curve progression, and curve regression. The results of GRADE demonstrated a moderate-evidence rating for the predictive value of spinal flexibility.

CONCLUSION

Supine radiography was the most prevalent method for measuring spinal flexibility at the pre-brace stage. Spinal flexibility was strongly correlated with the in-brace Cobb angle or correction rate, and moderate evidence supported that spinal flexibility could predict bracing outcomes.

Bracing Adolescent Idiopathic Scoliosis (BASIS) study - night-time versus full-time bracing in adolescent idiopathic scoliosis: study protocol for a multicentre, randomized controlled trial

Aims

Scoliosis is a lateral curvature of the spine with associated rotation, often causing distress due to appearance. For some curves, there is good evidence to support the use of a spinal brace, worn for 20 to 24 hours a day to minimize the curve, making it as straight as possible during growth, preventing progression. Compliance can be poor due to appearance and comfort. A night-time brace, worn for eight to 12 hours, can achieve higher levels of curve correction while patients are supine, and could be preferable for patients, but evidence of efficacy is limited. This is the protocol for a randomized controlled trial of 'full-time bracing' versus 'night-time bracing' in adolescent idiopathic scoliosis (AIS).

Methods

UK paediatric spine clinics will recruit 780 participants aged ten to 15 years-old with AIS, Risser stage 0, 1, or 2, and curve size (Cobb angle) 20° to 40° with apex at or below T7. Patients are randomly allocated 1:1, to either full-time or night-time bracing. A qualitative sub-study will explore communication and experiences of families in terms of bracing and research. Patient and Public Involvement & Engagement informed study design and will assist with aspects of trial delivery and dissemination.

Discussion

The primary outcome is 'treatment failure' (Cobb angle progression to 50° or more before skeletal maturity); skeletal maturity is at Risser stage 4 in females and 5 in males, or 'treatment success' (Cobb angle less than 50° at skeletal maturity). The comparison is on a non-inferiority basis (non-inferiority margin 11%). Participants are followed up every six months while in brace, and at one and two years after skeletal maturity. Secondary outcomes include the Scoliosis Research Society 22 questionnaire and measures of quality of life, psychological effects of bracing, adherence, anxiety and depression, sleep, satisfaction, and educational attainment. All data will be collected through the British Spine Registry.

Effectiveness of orthotic treatment for adolescent idiopathic scoliosis: a scoping review protocol of systematic reviews

INTRODUCTION

Spinal orthosis is a common conservative treatment for adolescent idiopathic scoliosis (AIS), and a large body of compelling evidence from systemic review studies strongly supports the use of spinal orthosis treatment in patients with this condition. To further improve our understanding of the available data, the aim of this study is to develop and propose a protocol for a scoping review of systematic reviews of studies that investigated the effectiveness of orthotic treatment in patients with AIS. Systematic synthesis and understanding of the data will improve the efficacy of spinal orthosis treatment in this patient population.

METHOD AND ANALYSIS

Using the scoping review methodological framework proposed by Arksey and O'Malley in 2005, we developed and herewith propose a scoping review protocol to evaluate systematic reviews of studies that investigated the effectiveness of orthotic treatment in AIS. Our proposed scoping review proposal is briefly described, as follows. A search of seven online databases will be conducted to identify systematic reviews published in English language from 1 January 2000 to 31 December 2023, and grey literature and reference lists of included articles will also be searched. A two-stage screening process consisting of a title and abstract screening and a full-text review will be used to determine articles' eligibility. All eligible articles will be extracted, charted and evaluated using Assessing the MeaSurement Tool to Assess systematic Reviews Version 2 (AMSTAR-2) critical appraisal tool. The charted data will be quantitatively analysed and summarised, and qualitatively analysed using narrative synthesis.

ETHICS AND DISSEMINATION

No primary data will be collected; therefore, ethics approval is not required. Findings will be disseminated through national and international conferences and publication in a peer-reviewed journal.

Influence of Lateral Sitting Wedges on the Rasterstereographically Measured Scoliosis Angle in Patients Aged 10-18 Years with Adolescent Idiopathic Scoliosis

Adolescent idiopathic scoliosis (AIS) is a three-dimensional axial deviation of the spine diagnosed in adolescence. Despite a long daily sitting duration, there are no studies on whether scoliosis can be positively influenced by sitting on a seat wedge. For the prospective study, 99 patients with AIS were measured with the DIERS formetric III 4D average, in a standing position, on a level seat and with three differently inclined seat wedges (3°, 6° and 9°). The rasterstereographic parameters 'scoliosis angle' and 'lateral deviation RMS' were analysed. The side (ipsilateral/contralateral) on which the optimal correcting wedge was located in relation to the lumbar/thoraco-lumbar convexity was investigated. It was found that the greatest possible correction of scoliosis occurred with a clustering in wedges with an elevation on the ipsilateral side of the convexity. This clustering was significantly different from a uniform distribution (p < 0.001; chi-square = 35.697 (scoliosis angle); chi-square = 54.727 (lateral deviation RMS)). It should be taken into account that the effect of lateral seat wedges differs for individual types of scoliosis and degrees of severity. The possibility of having a positive effect on scoliosis while sitting holds great potential, which is worth investigating in follow-up studies.

Effect of the type of brace on head to pelvis sagittal alignment of adolescents with Scheuermann's kyphosis

The aim of this study was to determine the effects of the Milwaukee brace and thoracolumbosacral orthosis (TLSO) on head to pelvis sagittal alignment in adolescents with Scheuermann's kyphosis (SK). A total of 52 adolescents with SK who were under brace treatment were studied. They underwent biplanar radiography of the head to pelvis (EOS Imaging, Paris, France) before and 6 months after the beginning of bracing. We measured T1 slope, neck tilt (NT), cervical sagittal vertical axis (cSVA), thoracic inlet angle (TIA), C0-C2 lordosis, C2-C7 lordosis, thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), sagittal vertical axis (SVA) and T1 spinopelvic inclination (T1SPi). There were no significant differences in baseline values of TIA, PT, SS, PI, SVA, TK, cSVA, NT and T1 slope between the two groups (p > 0.05). There were significant differences between the baseline and final measurements of T1 slope, cSVA, TK, LL, T1SPi and TIA in both groups (p < 0.05). The results imply that brace treatment can significantly affect head to pelvis sagittal parameters of adolescents with SK. However, there are no significant differences in the values of head to pelvis sagittal parameters when comparing short-term effect of TLSO and the Milwaukee brace.

Does Risser stage accurately predict the risk of curve progression in patients with adolescent idiopathic scoliosis treated with night-time bracing?

PURPOSE

Risser stage is widely used as a marker for skeletal maturity (SM) and thereby an indirect measure for the risk of progression of adolescent idiopathic scoliosis (AIS). The Scoliosis Research Society recommends bracing for Risser stages 0-2 as Risser stage 3 or above is considered low risk. Very few studies have assessed the risk of progression during bracing in Risser stages 3-4. The objective of the current study is to determine if Risser stages 3-4 provide a meaningful cutoff in terms of progression risk in patients with AIS treated with night-time bracing.

METHODS

AIS patients treated with night-time brace from 2005 to 2018 with a Cobb angle between 25 and 40 degrees and Risser stages 0-4 were retrospectively included. Curve progression (> 5 degrees increase) was monitored until surgery or SM. Skeletal maturity was defined as either 2 years postmenarchal, no height development or closed ulnar epiphyseal plates on radiographs.

RESULTS

One hundred and thirty-five patients were included (Risser stages 0-2: n = 86 and 3-4: n = 49). Overall, radiographic curve progression occurred in 52% while progression beyond 45 degrees was seen in 35%. The progression rate in the Risser 0-2 group was 60% and 37% in the Risser 3-4 group (p = 0.012). In multivariate logistic regression analysis, adjusted for Risser stages and age, only premenarchal status showed a statistically significant association with progression (OR: 2.68, 95%CI 1.08-6.67).

CONCLUSION

Risser stage does not provide a clinically meaningful differentiation of progression risk in AIS patients treated with a night-time brace. Risk assessment should include other more reliable measures of skeletal growth potential.

Does in-brace correction affect coronal spinal and thoracic cage parameters in individuals with idiopathic scoliosis? A retrospective cohort study

The aim of the study is to identify the effects of in-brace correction on coronal spinal and thoracic cage parameters in individuals with idiopathic scoliosis (IS). The coronal spinal parameters [Cobb angle, apical vertebral rotation (AVR), lateral trunk shift, coronal alignment, biacromial slope and pelvic asymmetry] and the thoracic cage parameters [T1- 12 height, T1-S1 height, thoracic transverse diameter, and apical vertebral body-rib ratio (AVB-R)] of 89 child and adolescent patients were measured on posterior-anterior full-spine radiographs at pre-brace and in-brace conditions using Surgimap software. The initial in-brace correction (IBC) was calculated as a percentage decrease in the Cobb angle on the in-brace radiographs. The mean IBC rate for the primary curve was 37% (range = 10-100%). In the in- brace condition, the Cobb angle (p<0.001), AVR (p<0.001) and lateral trunk shift (p<0.001) decreased significantly; no statistically significant difference was found in the biacromial slope (p=0.713) and the coronal alignment (p=0.074). The T1-12 height and the T1-S1 height increased significantly (p<0.001) whereas the thoracic transverse diameter and the AVB-R decreased significantly (p<0.001). Unlike IBC rate was below 30% as IBC rate was above 30%, the T1-12 height (p<0.001) increased and the AVB-R decreased (p<0.001). The bracing improved the lateral trunk shift, the AVB-R, the thoracic and spine heights, but decreased the thoracic transverse diameter. The thoracic cage parameters may be better when the IBC rate is above 30%.

A new scoliosis brace padding method based on trunk asymmetry for scoliosis treatment

BACKGROUND

Pressure pads are used with scoliosis braces to adjust the magnitude and location of corrective forces that mechanically support the torso to correct the spine deformity. In the conventional brace (C.B.) design approaches, the location and shape of pads are determined based on the visual assessment of the clinician. The accuracy of this approach could be improved because it is limited to the clinician's expertise. The present study aimed to develop a new brace (N.B.) padding method based on trunk asymmetry for adolescents with idiopathic scoliosis and compare the efficacy of the developed method with C.B. in improving the Cobb angle and body posture symmetricity.

METHODS

The trunk surface geometry was scanned using a 3-dimensional scanner. The best plane of symmetry was determined, and the original trunk was reflected in the plane of symmetry, creating the reflected trunk. The difference between the reflected and original trunks was computed and color-coded using deviation contour maps. The boundary of deformed regions, with a minimum of 6-mm deviation contour maps, was identified as the trim lines for brace pads. Eight participants were recruited and divided into conventional and new padding groups. The variation of Cobb angle and torso asymmetry parameters, including the trunk rotation and back surface rotation, as well as the brace satisfaction and trunk appearance perception of the 2 groups, were compared after 3 months of treatment.

RESULTS

Cobb angle improved equally in the N.B. and C.B. groups. However, back surface rotation improved in the N.B. group (+49.6%) and worsened in the C.B. group (-6.8%). The mean trunk rotation was improved by 30% in the N.B. and further exacerbated by -2.2% in the C.B. group. The brace satisfaction and trunk appearance perception scores were higher in the N.B. than in the C.B. group, however not statistically significant.

CONCLUSIONS

The present study showed that the proposed brace padding system improved the trunk appearance without negatively affecting the Cobb angle correction.

Are torso asymmetry and torso displacements in a computer brace model associated with initial in-brace correction in adolescent idiopathic scoliosis?

BACKGROUND

Lack of initial in-brace correction is strongly predictive for brace treatment failure in adolescent idiopathic scoliosis (AIS) patients. Computer-aided design (CAD) technology could be useful in quantifying the trunk in 3D and brace characteristics in order to further investigate the effect of brace modifications on initial in-brace correction and subsequently long-term brace treatment success. The purpose of this pilot study was to identify parameters obtained from 3D surface scans which influence the initial in-brace correction (IBC) in a Boston brace in patients with AIS.

METHODS

Twenty-five AIS patients receiving a CAD-based Boston brace were included in this pilot study consisting of 11 patients with Lenke classification type 1 and 14 with type 5 curves. The degree of torso asymmetry and segmental peak positive and negative torso displacements were analyzed with the use of patients' 3D surface scans and brace models for potential correlations with IBC.

RESULTS

The mean IBC of the major curve on AP view was 15.9% (SD = 9.1%) for the Lenke type 1 curves, and 20.1% (SD = 13.9%) for the type 5 curves. The degree of torso asymmetry was weakly correlated with patient's pre-brace major curve Cobb angle and negligible correlated with major curve IBC. Mostly weak or negligible correlations were observed between IBC and the twelve segmental peak displacements for both Lenke type 1 and 5 curves.

CONCLUSION

Based on the results of this pilot study, the degree of torso asymmetry and segmental peak torso displacements in the brace model alone are not clearly associated with IBC.

Predictors of Clinically Meaningful Results of Bracing in a Large Cohort of Adolescents with Idiopathic Scoliosis Reaching the End of Conservative Treatment

BACKGROUND

We need good outcome predictors to maximize the treatment efficiency of adolescents with idiopathic scoliosis (AIS). The in-brace correction has shown an important predictive effect on brace failure, while the influence of other variables is still debated. We aimed to identify new outcome predictors from a big prospective database of AIS.

METHODS

Design: Retrospective analysis of prospectively collected data.

INCLUSION CRITERIA

AIS between 21 and 45°, Risser 0-2, brace prescription during the observation, treatment conclusion. All of the participants followed a personalized conservative approach according to the SOSORT Guidelines.

OUTCOMES

End of growth below 30°-40°-50°. The regression model included age, BMI, Cobb angle, ATR, TRACE score, real brace wear (RBW), and in-brace correction (IBC).

RESULTS

A total of 1050 patients, 84% females, ages 12.1 ± 1.1, 28.2 ± 7.9° Cobb. IBC increased by 30%, 24%, and 23% the odds of ending treatment below 30°, 40°, and 50°, respectively. The OR did not change after the covariate adjustment. Cobb angle and ATR at the start also showed a predictive effect.

CONCLUSIONS

The systematic evaluation of IBC in clinics is useful for individuating the patient response to brace treatment more accurately, even in relation to the Cobb angle and ATR degrees at the start. Further studies are needed to increase the knowledge on predictors of AIS treatment results.

Does Bracing Control the Progression of Adolescent Idiopathic Scoliosis in Curves Higher Than 40°? A Systematic Review and Meta-analysis

Routinely, adolescent idiopathic scoliosis (AIS) curves that progress beyond 40° in skeletally immature adolescents require surgery. However, some adolescents with AIS and their parents utterly refuse surgery and insist on wearing a brace. Debate continues regarding the appropriateness of bracing for AIS curves exceeding 40° in patients who have rejected surgical intervention. This systematic review and meta-analysis was conducted to review the literature on the effectiveness of bracing and its predictive factors in largermagnitude AIS curves ≥40°. This study replicated the search strategy used by the PICOS system for formulating study questions, which include consideration of the patient/population (P), intervention (I), comparison (C), outcome (O), and study design (S). The search was conducted up to January 2022 in the following bibliographic online databases only in the English language: PubMed, Google Scholar, Scopus, and Web of Science. Two assessors reviewed the articles for qualification. Eligible studies were assessed for risk of bias at the study level using the Newcastle-Ottawa Scale. The effect size across the studies was determined using standardized mean differences (Cohen's d) and 95% confidence intervals for the meta-analysis. Among the eight included moderate quality studies, evidence of potential publication bias (p <0.05) for the trials included was found in the Cobb angle outcome. Results obtained through meta-analysis indicated that the effectiveness of bracing in controlling Cobb angle progression in curves ≥40° is significantly positive. Additionally, initial curve severity, Risser stage, in-brace curve correction, curve type, and apical vertebral rotation were considered risk factors associated with brace effectiveness. This systematic review revealed that bracing could alter the normal course of AIS curves ≥40° in patients refusing posterior spinal fusion (PSF). However, the suggested course for patients refusing PSF remains unclear because of the significant heterogeneity in the risk factors associated with bracing failure.

The efficacy of trunk bracing with an instrumented corrective exercise on spinal deformity, pulmonary function, trunk muscle endurance and quality of life in adolescent idiopathic scoliosis: Protocol for a parallel-groups clinical study (Preprint)

BACKGROUND

Adolescent idiopathic scoliosis is a 3D spine distortion with an unidentified etiology. It results in noticeable trunk deformity, decreased muscle strength and endurance at the trunk, changes in chest volume, breathing issues, and ultimately a decline in the quality of life. Trunk bracing and corrective exercises make up most of the treatment of patients with scoliosis when their deformity is between 20° and 45°, and they have not yet attained skeletal maturity. Evidence suggests that spinal deformity in people with scoliosis may result from improper motor control. Automatic response training is an exercise therapy technique that can modify the pattern of trunk muscle control for supporting the spinal column in normal alignment. An apparatus called a cantilever device is required for this type of exercise, which facilitates training at home. In spite of research showing the benefit of braces and therapeutic exercise in adolescents with scoliosis, less emphasis has been given to the impact of home-based training, especially when this intervention is paired with braces.

OBJECTIVE

We aim to compare the efficacy of bracing and a conventional exercise program to a combination treatment that includes trunk bracing and exercises with a cantilever device performed at home on the degree of spine curvature, pulmonary function, trunk muscular endurance, and quality of life.

METHODS

This study was a 2-arms parallel-group clinical study. A total of 16 adolescents with idiopathic scoliosis and single lumbar and thoracolumbar curves of 20°-45° were recruited and randomly assigned into 2 groups. Group A received a combination of trunk bracing and exercise using an instrument known as a "cantilever." Group B (controls) received trunk bracing and a conventional exercise program (without a tool). The study outcomes were the Cobb angle of the scoliotic curve, pulmonary function, the endurance of the trunk muscles, and quality of life. The study outcomes were measured at 2 time points: before the intervention (T1) and 12 weeks following the start of the intervention (T2; at this time, the intervention period has been completed). Multivariate analysis of variance was used to test between- and within-group differences.

RESULTS

Recruitment for this study began in fall 2022 and is expected to be completed by the end of summer 2023.

CONCLUSIONS

We studied the efficacy of a combined trunk bracing program and postural response exercises using a cantilever device in treating adolescent idiopathic scoliosis and compared it with trunk bracing and conventional home exercises. Exercises performed at home using a cantilever device are anticipated to raise the endurance of trunk muscles, which will help reduce trunk deformity, enhance pulmonary function, and improve the quality of life of participants.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials IRCT20220330054371N1; https://www.irct.ir/trial/62811.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/43265.

Scoliosis: Brace treatment - from the past 50 years to the future

OBJECTIVE

This paper deals with scoliosis treatment over the past 50 years. The review of the literature from the point of view of the current formation of opinion. From conservative forms of treatment, the pendulum has swung to surgical measures. To visualize this temporarily rejection of conservative treatment is the goal of this article.

MATERIALS AND METHODS

A review of the literature over the last 50 years was performed from the perspective of current opinion, this with a pinch of personal experience in bracing and scoliosis surgery since 1972. The MESH terms (scoliosis, idiopathic scoliosis, adolescent idiopathic scoliosis) are presented in their number in a flow diagram and the publications on conservative therapies (brace, physiotherapy) are compared to surgical therapies (surgery).Opinions of "eminences" in the 1980s have been replaced by the rules of evidence-based medicine (EBM) at end of the 1990s. This transition will be visualized in the graph of PubMed statistics. In a statement, the future scoliosis treatment is derived from history.

RESULTS

The total number of publications shows a ratio of brace to surgery of 13.9% and physiotherapy to surgery of 6.7% for the MESH terms "scoliosis". When "scoliosis" is supplemented with "idiopathic", the brace to surgery ratio changes from 24.5% and physiotherapy to surgery 8.2%. Focusing on adolescent scoliosis the addition of "adolescent" changes the brace to surgery ratio from 24.8% and physiotherapy to surgery 8.1%. In the total number of publications, "adolescent idiopathic scoliosis" is treated by 25.26%. The patient numbers of our own scoliosis outpatient clinic (1482 patients) over the last 15 years show a ratio of brace (Cobb angle 20°-50° brace-indication) to surgery (Cobb angle >50° indication to surgery) of 1 to 0.06. The scientific focus on surgical therapy is evident from the figures of PubMed mentioned. The number of conservative publications shows a depression in the 1990s. In the remainder of this article, opinion-forming developments are outlined and supported by literature citations, responsible for the recovery of publications on conservative scoliosis treatment. New technologies provide additional treatment options.

CONCLUSIONS

In this sense, brace therapy is a success story with a future in the digital world of AI (artificial intelligence), mathematical model calculations, and production perhaps from the 3D printer. The central message from the history of the last 50 years is: "The scientific review of treatment results is essential for the further acceptance of brace treatment."

Clinical significance of concomitant pectus deformity and adolescent idiopathic scoliosis: systematic review with best evidence synthesis

BACKGROUND

A misbalance in forces is proposed for causing adolescent idiopathic scoliosis (AIS). AIS is therefore correlated to adjacent musculoskeletal pathologies. Its concomitance with idiopathic pectus deformities (PD) is underexposed. This systematic review analyzes the clinical significance and predictive factors of PD-associated AIS.

METHODS

A search was performed in PubMed, UpToDate, Embase, and Cochrane. A study was included if it: assessed the association between PD and scoliosis (category I), reported a prevalence of scoliosis in PD patients (category II), or addressed other topics about PD-associated AIS (category III). Studies in category I discussing predictive factors were appraised using the Quality in Prognosis Studies tool. Because of heterogeneity among the studies, predictive factors were analyzed according to a best evidence synthesis. A mean prevalence of scoliosis in PD patients was calculated using category I and II. Category III was narratively reviewed.

RESULTS

Forty-eight studies were included (I:19, II:21, III:8). Category I comprised 512 patients with PD-concomitant scoliosis. Thirteen studies reported predictive factors, of which 15 concerned the prevalence of scoliosis in PD patients and 12 Cobb Angle (CA) change after PD correction. Compared with AIS, PD seems to develop earlier in adolescence, and PD with concomitant AIS was more frequently reported in older patients. Evidence remained conflicting regarding the association between the severity of PD and that of scoliosis. As opposed to at a younger age, late PD correction is not associated with a postoperative increase of CA. Limited evidence showed that patients with a high CA undergoing PD correction do not experience an increase in CA, though, strong evidence indicated that it would not lead to a decrease in CA. The mean probable prevalence of AIS in PD patients was 13.1%.

CONCLUSION

Current literature confirms the association between PD and AIS in patients with an indication for PD correction.Level of evidence: III.

Evaluation of In-brace Correction in Individuals with Adolescent Idiopathic Scoliosis: A Retrospective and Descriptive Study

Introductions: Achieving maximum correction at the beginning of brace treatment in AIS is the only factor that can be controlled by the bracing provider if we have a better understanding of the prognostics and factors associated with achieving in-brace correction. The aim of this present study was to evaluate in-brace correction in a cohort of AIS patients who were treated by full-time bracing with plastic moulded thoraco-lumbo-sacral spinal orthosis (TLSO). Methods: This study was a retrospective descriptive study. We collected data from medical records of individuals with AIS who receiving full-time braces treatment from Orthotic Clinic, King Chulalongkorn Memorial Hospital. Demographic data included age, gender, weight, height, and body mass index (BMI). Cobb angle, Risser sign, and curve type were determined using pre and post-brace standing posteroanterior (PA) radiographs. Correlation analysis was performed to investigate in-brace correction with associated factors.  Results: We included 91 patients' data and radiographic images with AIS, with seven (7.69%) boys and 84 (92.31%). The overall mean Cobb angle was 32.9 ± 8.5º, and during brace treatment, it was 22.5 ± 11.5º. There was a significant mean difference in the mean Cobb angle before and in-brace (p < 0.001). The overall mean in-brace correction in the study was 34.1 ± 22.7%. Initial Cobb angle and BMI were found to be significantly negatively associated with in-brace correction with a Pearson coefficient of -0.49 and -0.24, respectively. Conclusion: The mean of first in-brace correction TLSO was 34.1% from the initial Cobb angle. No difference in in-brace correction across curve types in our study. There was a significant Cobb angle changed before and in-brace radiograph. We found that in-brace correction was significantly associated with initial Cobb angle and BMI. Keywords: Adolescent Idiopathic Scoliosis, in-brace correction, bracing

Do the three-dimensional parameters of brace-wearing patients with AIS change when transitioning from standing to sitting position? A preliminary study on Lenke I

Background

Bracing is the most common conservative treatment for preventing the progression of adolescent idiopathic scoliosis (AIS) in patients with a curve of 25°–40°. X-ray examinations are traditionally performed in the standing position. However, school-age teenagers may take more time to sit. Thus far, little is known about three-dimensional (3D) correction in the sitting position. Hence, this study aimed to determine the effects of standing and sitting positions on 3D parameters during brace correction.

Methods

We evaluated a single-center cohort of patients receiving conservative treatment for thoracic curvature (32 patients with AIS with a Lenke I curve). The 3D parameters of their standing and sitting positions were analyzed using the EOS imaging system during their first visit and after bracing.

Results

At the patients’ first visit, sagittal plane parameters such as thoracic kyphosis (TK), lumbar lordosis (LL), and sacral slope decreased when transitioning from the standing position to the sitting position (standing 29° ± 6°, 42° ± 8°, and 42° ± 8° vs. sitting 22° ± 5°, 27° ± 6°, and 24° ± 4°; p < 0.001), whereas pelvic tilt (PT) increased and sagittal vertical axis shifted forward (standing 9° ± 6° and 1.6 ± 2.7 cm vs. sitting 24° ± 4° and 3.8 ± 2.3 cm; p < 0.001). After bracing, TK and LL decreased slightly (from 29° ± 6° and 42° ± 8° to 23° ± 3° and 38° ± 6°; p < 0.001), whereas the thoracolumbar junction (TLJ) value increased (from 3° ± 3° to 11° ± 3°; p < 0.001). When transitioning to the sitting position, similar characteristics were observed during the first visit, except for a subtle increase in the TLJ and PT values (standing 11° ± 3° and 9° ± 4° vs. sitting 14° ± 3° and 28° ± 4°; p < 0.001). Moreover, the coronal and axial parameters at different positions measured at the same time showed no significant change.

Conclusions

In brace-wearing patients with thoracic scoliosis, compensatory sagittal plane straightening may be observed with a slight increase in thoracolumbar kyphosis, particularly when transitioning from the standing position to the sitting position, due to posterior rotation of the pelvis. Our results highlight that sagittal alignment in AIS with brace treatment is not completely analyzed with only standing X-Ray.

Trial registration

The study protocol was registered with the Chinese Clinical Trial Registry (ChiCTR1800018310).

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV.

Predictive Factors on Initial in-brace Correction in Idiopathic Scoliosis: A Systematic Review

STUDY DESIGN

Systematic literature review.

OBJECTIVE

The aim of this study was to systematically review the literature and provide an overview of reported predictive factors on initial in-brace correction in patients with idiopathic scoliosis (IS).

SUMMARY OF BACKGROUND DATA

Brace therapy is the best proven non-surgical treatment for IS. There is strong evidence that lack of initial in-brace correction is associated with brace treatment failure. To improve initial in-brace corrections and subsequently long-term brace treatment success, knowledge about factors influencing initial in-brace correction is a prerequisite.

METHODS

A systematic literature search was performed in Pubmed, Embase, Web-of-Science, Scopus, Cinahl, and Cochrane in November 2020. Studies which reported factors influencing initial in-brace correction in IS patients treated with brace therapy were considered eligible for inclusion.

RESULTS

Of the 4562 potentially eligible articles identified, 28 studies fulfilled the inclusion criteria and were included in this systematic review. Nine studies (32%) were classified as high quality studies and the remaining 19 studies (68%) as low quality. Thirty-four different reported factors were collected from the included studies. Strong evidence was found for increased curve flexibility as favorable predictive factor for initial in-brace correction. Moderate evidence was found for thoracolumbar or lumbar curve pattern as favourable predictive factor, and double major curve pattern as unfavourable predictive factor for initial in-brace correction. Also moderate evidence was found that there is no significant difference on initial in-brace correction between computer-aided design and manufacturing systems (CAD/CAM) braces with or without finite element models (FEM) simulation, and braces fabricated using the conventional plaster-cast.

CONCLUSION

The results of this systematic review indicate that increased curve flexibility is strongly associated with increased initial in-brace correction.Level of Evidence: 1.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Supine correction index as a predictor for brace outcome in adolescent idiopathic scoliosis

Aims

The aim of this study was to assess the ability of morphological spinal parameters to predict the outcome of bracing in patients with adolescent idiopathic scoliosis (AIS) and to establish a novel supine correction index (SCI) for guiding bracing treatment.

Methods

Patients with AIS to be treated by bracing were prospectively recruited between December 2016 and 2018, and were followed until brace removal. In all, 207 patients with a mean age at recruitment of 12.8 years (SD 1.2) were enrolled. Cobb angles, supine flexibility, and the rate of in-brace correction were measured and used to predict curve progression at the end of follow-up. The SCI was defined as the ratio between correction rate and flexibility. Receiver operating characteristic (ROC) curve analysis was carried out to assess the optimal thresholds for flexibility, correction rate, and SCI in predicting a higher risk of progression, defined by a change in Cobb angle of ≥ 5° or the need for surgery.

Results

The baseline Cobb angles were similar (p = 0.374) in patients whose curves progressed (32.7° (SD 10.7)) and in those whose curves remained stable (31.4° (SD 6.1)). High supine flexibility (odds ratio (OR) 0.947 (95% CI 0.910 to 0.984); p = 0.006) and correction rate (OR 0.926 (95% CI 0.890 to 0.964); p < 0.001) predicted a lower incidence of progression after adjusting for Cobb angle, Risser sign, curve type, menarche status, distal radius and ulna grading, and brace compliance. ROC curve analysis identified a cut-off of 18.1% for flexibility (sensitivity 0.682, specificity 0.704) and a cut-off of 28.8% for correction rate (sensitivity 0.773, specificity 0.691) in predicting a lower risk of curve progression. A SCI of greater than 1.21 predicted a lower risk of progression (OR 0.4 (95% CI 0.251 to 0.955); sensitivity 0.583, specificity 0.591; p = 0.036).

Conclusion

A higher supine flexibility (18.1%) and correction rate (28.8%), and a SCI of greater than 1.21 predicted a lower risk of progression. These novel parameters can be used as a guide to optimize the outcome of bracing.

Cite this article: Bone Joint J 2022;104-B(4):495–503.

In-Brace versus Out-of-Brace Protocol for Radiographic Follow-Up of Patients with Idiopathic Scoliosis: A Retrospective Study

The purpose of this retrospective study was to compare two standardized protocols for radiological follow-up (in-brace versus out-of-brace radiographs) to study the rate of curve progression over time in surgically treated idiopathic scoliosis (IS) patients after failed brace treatment. In-brace radiographs have the advantage that proper fit of the brace and in-brace correction can be evaluated. However, detection of progression might theoretically be more difficult. Fifty-one IS patients that underwent surgical treatment after failed brace treatment were included. For 25 patients, follow-up radiographs were taken in-brace. For the other 26 patients, brace treatment was temporarily stopped before out-of-brace follow-up radiographs were taken. Both groups showed significant curve progression compared to baseline after a mean follow-up period of 3.4 years. The protocol with in-brace radiographs was noninferior regarding curve progression rate over time. The estimated monthly Cobb angle progression based on the mixed-effect model was 0.5 degrees in both groups. No interaction effect was found for time, and patients’ baseline Cobb angle (p = 0.98), and for time and patients’ initial in-brace correction (p = 0.32). The results of this study indicate that with both in-brace and out-of-brace protocols for radiographic follow-up, a similar rate of curve progression can be expected over time in IS patients with failed brace treatment.

Initial In-Brace Correction: Can the Evaluation of Cobb Angle Be the Only Parameter Predictive of the Outcome of Brace Treatment in Patients with Adolescent Idiopathic Scoliosis?

Background: Patients with a better initial in-brace correction could show a higher probability of a successful outcome. However, no one has investigated whether parameters can affect the outcomes. The aim of this retrospective study was to evaluate if the initial correction rate (ICR) could be predictive of the bracing outcome and to determine the role of some mechanical and biological parameters in ICR. Methods: The study population comprised 449 patients who met the inclusion criteria. Curve correction > 10° Cobb defines brace treatment success. Success and failure groups were compared in terms of the Risser sign, initial Cobb angle, initial Perdriolle value and ICR. Results: ICR significantly correlates with initial Perdriolle. The success group had a significantly lower value of Pedriolle and initial Cobb angles, Risser sign and ICR than the failure group. The ICR and lower Risser were significantly associated with the brace treatment outcome. This seems particularly suitable for positivity prediction (Predicting value VP+: 87%). Conclusions: This study confirms that immediate in-brace correction can foretell the brace treatment outcome. Patients with a low Risser sign and a high rate of in-brace correction showed a bracing success of 87%. A correlation between rotation and in-brace correction confirms that rotation is among the parameters that influence the deformed spine reaction to corrective actions the most.

Optimized scheme for paired transverse corrective forces in S-shaped scoliosis via ultrasound and application in Chêneau brace: a pilot study

BACKGROUND

There is currently no consensus on the optimal positions of the transverse corrective forces (TCFs) for scoliosis braces.

OBJECTIVES

This study aimed to explore an optimal scheme of placing paired TCF for S-shaped adolescent idiopathic scoliosis and its feasibility in Chêneau brace (CB) treatment.

STUDY DESIGN

Cross-over feasibility pilot trial.

METHODS

Ten S-shaped adolescent idiopathic scoliosis participants were invited to receive four tests with different paired TCF positions under ultrasound. The positions of the paired TCF were test 1: thoracic apical vertebra (AV), lumbar AV; test 2: 2 cm inferior to thoracic AV, lumbar AV; test 3: thoracic AV, 2 cm superior to lumbar AV; and test 4: 2 cm inferior to thoracic AV, 2 cm superior to lumbar AV. The test scheme with the highest mean in-force correction rate (IFCR) for the thoracic spinous process angle (SPA) was further applied in the CB fabrication of 4 additional participants.

RESULTS

A significant higher mean IFCR of the thoracic SPA of 63.6% was found in test 2 (P < 0.001), which also contributed to its higher overall IFCR of the SPA of 64.6% (P = 0.001). Moreover, the mean in-brace correction rates for the thoracic and overall curves in CB were 46.4% and 51.8%, respectively. No adverse events were reported.

CONCLUSIONS

Placing paired TCF at the lumbar AV and 2 cm inferior to the thoracic AV achieved better treatment efficacy than other schemes. The practical application of this scheme on the CB was feasible.

Comment on Costa et al. The Effectiveness of Different Concepts of Bracing in Adolescent Idiopathic Scoliosis (AIS): A Systematic Review and Meta-Analysis. J. Clin. Med. 2021, 10, 2145

I read the above-mentioned work with great interest, and I would like to thank the authors for considering two papers from our working group [...]

Brace treatment for patients with scoliosis: State of the art

BACKGROUND

Physiotherapy, brace applications or surgery are the treatment options utilised to manage patients with scoliosis. Many different brace applications are used, and the success rates of orthoses vary.

OBJECTIVES

Brace applications can have detrimental impacts on the patient leading to physical discomfort, psychological discomfort, and in some instance the use of braces may even be painful. Therefore, future developments in this field should be aimed at improving the success rate and reducing physical distress experienced by the patient while using brace applications. The purpose of this article is to provide recommendations with respect to the most appropriate bracing approach in general.

METHOD

A narrative review of the scientific literature was carried out to substantiate the statements made in this article.

RESULTS

The most important braces provided for the treatment of patients with scoliosis and the treatment results that can be achieved are presented and discussed, taking into account the most recent systematic reviews. A wide range of success rates have been found for the different brace applications.

CONCLUSION

Given that brace application may impact the patient leading to physical discomfort and psychological distress, good quality management in brace application for patients with scoliosis is needed to ensure the best possible outcome and the least stressful management.

CLINICAL IMPLICATIONS

Safety in brace application for patients with scoliosis needs improvement. The use of standardised and reliable computer aided design (CAD) libraries and appropriate patient information based on published guidelines is suggested.

The Effect of Brace Treatment on Large Curves of 40° to 55° in Adolescents With Idiopathic Scoliosis Who Have Avoided Surgery: A Retrospective Cohort Study

Objective

To evaluate the effect of Milwaukee brace treatment on adolescents with idiopathic scoliosis (AIS) with large curves (40° to 55°) who refuse to do surgery.

Methods

In this retrospective cohort study, we gathered the clinical records of all adolescents with AIS with an initial curve of 40° to 55°. They had been referred to our center from December 1990 to January 2017. Although they had been advised to do surgery, they had all refused to do it. Their clinical data were recorded, such as sex, age, Risser sign, scoliosis, and kyphosis curve magnitude (at the beginning of brace treatment, weaning time, brace discontinuation, and minimum of 2 years after the treatment). Based on treatment success, the patients were divided into 2 groups: progressed and nonprogressed.

Results

Sixty patients with an average initial Cobb angle of 44.93°±4.86° were included. The curve progressed in 57%, stabilized in 25%, and improved in 18% of the patients. In the progressed group (34 patients), 31 patients had undergone surgery. There was no significant association between the age of beginning the brace treatment and the final Cobb angle of nonprogressed group (p>0.05). However, in-brace correction and initial Risser sign had a significant correlation with curve magnitude at the final follow-up (p<0.05).

Conclusion

Brace treatment seems to be effective in controlling the further curve progression in AIS with 40° and 55° curves. Our results can help physicians make sound decisions about the patients with larger curves who refuse to do surgery.

Predictive Factors for Outcomes of Overcorrection Nighttime Bracing in Adolescent Idiopathic Scoliosis: A Systematic Review

Predictive clinical and radiological factors can potentially identify adolescent idiopathic scoliosis (AIS) most likely to benefit from overcorrection nighttime bracing. These factors can provide helpful information in clinical decision making. However, the relationship between these factors and outcomes of overcorrection nighttime bracing is unclear. This systematic review determined the predictive factors for identifying outcomes of overcorrection nighttime bracing in AIS. A systematic search was conducted on PubMed, MEDLINE, Scopus, and Embase from January 1986 to January 2021. Studies on AIS patients, aged 10–18 years, with a Risser sign of 0–2 and an initial Cobb angle of 20°–45°, who were treated with overcorrection nighttime bracing and for whom at least one predictive factor of treatment outcome (failure and/or success) was assessed were included. Two blinded reviewers independently evaluated the studies using a quality assessment tool. To determine predictive factors, the level of evidence was rated through best-evidence synthesis. A total of nine studies met the inclusion criteria. A Providence brace was used in six of the included studies, while a Charleston bending brace was used in three. Findings from two high-quality studies provided strong evidence of the association between curve flexibility and brace treatment success. In terms of the Risser sign, this evidence was obtained from three high-quality studies. Moderate evidence indicated a positive association between premenarchal status and nighttime bracing failure. Inconclusive evidence indicated that poor brace compliance is associated with treatment failure. Conflicting evidence of treatment failure was indicated for initial curve magnitude, curve type, in-brace correction, age, Risser sign, curve apex, and sex. These findings show that greater curve flexibility and a higher Risser sign are associated with overcorrection nighttime bracing success.

Network meta-analysis of short-term effects of different strategies in the conservative treatment of AIS

PURPOSE

To evaluate the short-term effects of different conservative treatments on in adolescent idiopathic scoliosis.

METHODS

By searching the relevant literature of adolescent idiopathic scoliosis, the curative effects of the three regimens of bracing therapy combined with scoliosis-specific exercises, simple treatment with brace and simple scoliosis-specific exercises were compared. Review manager 5.3, Stata MP16 and Network software packages were used for Reticular Meta-analysis of Cobb's angles before and after treatment.

RESULTS

A total of 364 patients were included in four clinical studies. Reticular meta-analysis showed that the short-term effect of bracing treatment combined with scoliosis-specific exercises was better than that of treatment with brace and scoliosis-specific exercises, with effects of 2.71(95% CI 0.83-4.58) and 3.67(95% CI 1.21-6.14), respectively. There was no statistical difference between simple bracing therapy and scoliosis-specific exercises.

CONCLUSION

Among the three common conservative treatments of adolescent idiopathic scoliosis, the short-term effect of bracing treatment combined with scoliosis-specific exercises is better than that of bracing treatment or scoliosis-specific exercises.

[Is it possible to improve treatment safety in the brace treatment of scoliosis patients by using standardized CAD algorithms?]

Hintergrund

Die Versorgung von Skoliosepatienten mit korrigierenden Rumpforthesen führt auch heutzutage noch zu recht unterschiedlichen Ergebnissen. Publizierte Erfolgsquoten zwischen 50 und 90 % führen zwangsläufig zu der Frage, wie sich die Erfolgsquoten der Korsettversorgung steigern und vereinheitlichen lassen. Die Ergebnisse einer mit dieser Zielsetzung weiterentwickelten computerunterstützen (CAD/„Computer Aided Design“) Chêneau-Versorgung werden dargestellt.

Methodik

Am Stichtag (08.12.2019) wurde die prospektiv angelegte Datenbank unserer Abteilung retrospektiv ausgewertet. Es waren ausschließlich unreife Mädchen mit einer Adoleszentenskoliose, Alter 10–14 Jahre, Risser 0–2 in die Datenbank aufgenommen worden.

Ergebnisse

Sowohl die Gesamtgruppe mit einem Beobachtungszeitraum von mindestens 18 Monaten als auch die Patientinnengruppen mit bereits erreichtem Behandlungsabschluss zeigten Erfolgsraten zwischen 86 und 88 %. Die Ergebnisse insgesamt waren signifikant besser als die Erfolgsrate der Boston-Brace-Kontrollgruppe (BRAIST) von 72 %. Auch im Vergleich mit den Ergebnissen anderer Chêneau-Derivate war die Erfolgsrate unserer Serie teils deutlich besser.

Schlussfolgerungen

Die Behandlungssicherheit für die Patienten mit Skoliosen sollte verbessert werden. Ein Ansatz hierzu kann die Verwendung standardisierter CAD-Bibliotheken sein. Weitere Untersuchungen mit Studiendesigns höherer Evidenz sind notwendig, um die in unserer Untersuchung gefundenen Ergebnisse zu untermauern.

Influence of Chêneau-Brace Therapy on Lumbar and Thoracic Spine and Its Interdependency with Cervical Spine Alignment in Patients with Adolescent Idiopathic Scoliosis (AIS)

Chêneau-brace is an effective therapy tool for treatment in adolescent idiopathic scoliosis (AIS). Data on potential interdependent changes of the sagittal profile including the cervical spine are still sparse. The purpose of this study was to evaluate in-brace changes of the thoracic and lumbar spine and their influence on the pelvis and the cervical spine and apical vertebral rotation was reported. Ninety-three patients with AIS undergoing Chêneau-bracing were included. Patients were stratified by lumbar, thoracic and global spine alignment into normolordotic vs. hyperlordotic or normokyphotic vs. hypokyphotic or anteriorly aligned vs. posteriorly aligned groups. The coronal Cobb angle was significantly decreased in all groups indicating good correction while in-brace therapy. Sagittally, in-brace treatment led to significant flattening of lumbar lordosis (LL) in all stratified groups. Thoracic kyphosis (TK) was significantly flattened in the normokyphotic group, but no TK changes were noticed in the hypokyphotic group. Pelvic tilt (PT) stayed unchanged during the in-brace therapy. Chêneau-brace showed marginal changes in the lower cervical spine but had no influence on the upper cervical spine. The apical vertebral axis in primary and secondary curves was unchanged during the first radiological follow-up. Results from this study contribute to better understanding of initial spine behavior in sagittal and axial plane in the context of bracing.

Impact of body mass index on the initial in-brace correction in patients with idiopathic scoliosis

Background/Aim: Many factors affect initial in-brace correction and treatment outcome in patients with idiopathic scoliosis. Previous studies have observed contradictory results on the role of BMI in orthotic treatment. The aim of this study was to examine whether BMI impacts in-brace correction, isolated and in relation to other predictive factors (curve magnitude, curve location and Risser sign). Methods: A retrospective study has been conducted on patients with idiopathic scoliosis treated with Cheneau-Sobernheim brace, that had no prior treatment. The collected and analysed data included patient demographics, BMI percentile and radiological parameters (curve magnitude in Cobb angle, curve location, Risser sign). The initial in-brace correction was expressed as a percentage of Cobb angle reduction in the brace as opposed to Cobb angle out of brace. Patients were categorised into groups according to their BMI, expressed in percentiles, ie: low BMI (< 5 percentiles), normal BMI (5-85 percentiles) and high BMI (> 85 percentiles). To determine the significant difference and correlation relationship between the examined variables, variance tests, t-test with unequal variance, and Pearson correlation coefficient have been used. Results: The cohort study comprised 213 patients (170 females and 43 males) with a mean age of 13.5 years at brace prescription. Low BMI has been detected in 10 % patients, normal BMI in 78 % and high BMI in 10 % patients. No significant difference in in-brace correction has been found between BMI groups, nor has there been any significant correlation between BMI and in-brace correction. Regarding other factors, significant difference within BMI groups was found between in-brace correction and curve location, as well as in-brace correction and Risser sign. Lumbar curves had significantly better in-brace correction than thoracic curves. Significant correlations between in-brace correction and curve magnitude, curve location and Risser sign were detected. Conclusion: The results of the present study show that, as an independent factor, BMI does not impact in-brace correction. Other factors, such as curve magnitude, curve location and Risser sign, play a more significant role in the orthotic treatment of patients with idiopathic scoliosis.

Towards a predictive simulation of brace action in adolescent idiopathic scoliosis

Bracing is the most common treatment to stop the progression of adolescent idiopathic scoliosis. Finite element modeling could help improve brace design, but model validation is still a challenge. In this work, the clinical relevance of a predictive and subject-specific model for bracing was evaluated in forty-six AIS patients. The model reproduces brace action and the patient's spinopelvic adjustments to keep balance. The model simulated 70% or more patients with geometrical parameters within a preselected tolerance level. Although the model simulation of the sagittal plane could be improved, the approach is promising for a realistic and predictive simulation of brace action.

Pelvic rotation parameters related to in-brace correction in patients with idiopathic scoliosis

Background

To identify the pelvic parameters affecting in-brace correction (IBC) in patients with idiopathic scoliosis (IS).

Methods

Patients with IS receiving Chêneau brace treatment in our scoliosis center from January 2019 to November 2019 were retrospectively analyzed. Pelvic rotation parameters, including pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), L/R ratio, were collected. Other radiographic data, such as Risser sign, coronal and sagittal balance, curve location, kyphosis, lordosis of each patient were also recorded to analyze their correlations with IBC. Correlation analyses were performed to identify the classified variables influencing IBC. The principal component analysis was used to extract common factors of radiographic parameters to eliminate interaction effects. The linear regression equation was established using principal components, the variables influencing IBC were identified.

Results

A cohort of 44 patients with IS (36 girls and 8 boys) were included in the present study. The mean IBC was 49.87% (range, 3%–100%). IBC of lumbar IS was negatively correlated with apical rotate factor (ARF, B = –0.385), mainly consisted of pelvic coronal plane rotation (PCPR, 0.449), Cobb angle (CA, 0.575), apical vertebral rotation (AVR, 0.918), and pelvic rotate factor (PRF, B = –0.387), mainly consisted of PT (0.861), PI (0.728), PCPR (–0.570). The regression equation of lumbar IS had statistical significance (F = 6.500, P = 0.005, R2 = 0.317), whereas statistically significance was not found in the regression equation of thoracic IS (F = 2.913, P = 0.106). The remaining parameters were not related to IBC.

Conclusions

For lumbar IS, ARF and PRF have negative effects on IBC, coronal and sagittal rotation of the pelvis is related to IBC.

Effectiveness of scoliosis-specific exercises for alleviating adolescent idiopathic scoliosis: a systematic review

Background

Adolescent idiopathic scoliosis (AIS) is the most common pediatric spinal deformity with reported complications including pain, mental health concern and respiratory dysfunction. The scoliosis-specific exercise (SSE) is prescribed throughout pubertal growth to slow progression although effects are unclear. This review aims to establish the effectiveness of SSE for alleviating AIS in terms of reducing Cobb angle, improving trunk asymmetry and quality of life (QoL). Additionally, it aims to define the effects of age, skeletal maturity, curve magnitude and exercise compliance on the outcomes of SSE.

Methods

A systematic reviewed was conducted to net SSE articles. Searched databases included PubMed, MEDLINE, Cochrane Library, Scopus, CINAHL and Google scholar. The quality of study was critically appraised according to the PEDro scale.

Results

A total of ten trials with an average PEDro score of 6.9/10 were examined in this study. Two randomized controlled trials (RCTs) and two clinical controlled trials suggested that SSE alone and with bracing or traditional exercise had clinical significance in reducing Cobb angle more than 5°. One RCT specifically implicated no comparable effects between bracing and SSE in prevention of curve progression for moderate scoliosis. There was insufficient evidence to support the positive effects of SSE on improving truck asymmetry (n = 4) and QoL (n = 3). Five studies evaluated the interaction effects of age (n = 2), skeletal maturity (n = 1) and curve magnitude (n = 2) with SSE in reducing Cobb angle yet without drawing any firm conclusions.

Conclusions

Insufficient evidence is available to prove that SSE with or without other conservative treatments can reduce Cobb angle, improve trunk balance and QoL. The interaction effects of age, skeletal maturity, curve magnitude, and exercise compliance with SSE in reducing Cobb angle are not proven. Future studies should investigate the relationship of influencing factors and SSE in treating AIS but not only testing its effectiveness.

Trial registration

INPLASY202050100.