The Oswestry Disability Index is reflective of pain interference and mobility in children.

PURPOSE: The 9-item Oswestry Disability Index version 2.1a (ODI-9) has never been formally validated in children. Our primary purpose was to evaluate the ODI-9 using the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Pain Interference (PI) and Mobility Computer Adapted Test (CAT) and Pain Catastrophizing Scale for Children (PCS-C) as anchors to determine concurrent validity in children. METHODS: We retrospectively reviewed cross-sectional patient-reported outcomes data using a convenience sample of children referred to a tertiary pediatric orthopedic institution for any spine condition from April 2021 to April 2022. The ODI-9, PI, and Mobility were completed at clinic intake in 2,097 children (1453 girls, 644 boys) aged 14.2 ± 2.6 years (range 5-18 years) during the same visit. The ODI-9 was administered when children or caregivers responded "yes" to the presence of back pain. The PCS-C was administered only when pain intensity was rated as "very severe" or "the worst imaginable" on Item 1 of the ODI-9 (n = 51). RESULTS: Average ODI-9 scores were 18.3% ± 14.8%, indicating minimal disability (ODI-9 ≤ 20%). Moderate, statistically and clinically significant associations were seen between the ODI-9 and PI (r = 0.68, p < 0.001), the ODI-9 and Mobility (r = - 0.68, p < 0.001), and the ODI-9 and PCS-C (r = 0.59, p < 0.001). CONCLUSION: Worse ODI-9 scores correlate with worse PROMIS PI scores, worse PROMIS Mobility scores, and worse PCS-C scores. The associations were moderate (PROMIS PI [r = 0.68], PROMIS Mobility [r = - 0.68], PCS-C [r = 0.59]).

Back pain and disability according to early onset scoliosis etiology in children younger than 10 years.

PURPOSE: To determine caregiver-reported back pain prevalence, disability, pain interference, and associations with curve magnitude in early onset scoliosis (EOS) using the Oswestry Disability Index (ODI) and Patient Reported Outcome Measurement Information Systems (PROMIS) measures. METHODS: A single-center, retrospective review was performed in children below 10 years of age according to EOS etiology. Caregiver-reported back pain prevalence, ODI, PROMIS Pain Interference, Mobility, and Anxiety measures, and curve magnitude were recorded as part of routine clinic appointments. RESULTS: A total of 1212 patients with EOS (588 idiopathic, 295 congenital, 217 neuromuscular, 112 syndromic) ages 6.6 ± 2.7 were included; 23% had caregiver-reported back pain. Neuromuscular EOS patients had the highest prevalence of back pain (29%). ODI scores were higher in neuromuscular (48%) and syndromic (35%) patients than congenital (20%, p < 0.05) and idiopathic (16%, p < 0.01) patients. Neuromuscular patients also had higher PROMIS Pain Interference scores (53.3) compared to idiopathic (41.6, p < 0.001) and syndromic (45.0, p = 0.016) patients. A higher curve was associated with the presence of back pain (39° vs. 30°, p < 0.001) and had positive correlations with ODI scores (r = 0.38, p < 0.001) and PROMIS Pain Interference scores (r = 0.34, p < 0.001). CONCLUSION: Approximately one in five children with EOS under the age of 10 have caregiver-reported back pain, with the neuromuscular EOS type exhibiting higher pain prevalence, interference, and disability scores. Larger curve magnitude is associated with an increased prevalence of caregiver-reported back pain, increased disability, and increased pain interference. LEVEL OF EVIDENCE: 3 - case-control study.

Early brace treatment for idiopathic scoliosis may change the paradigm to improve curves.

PURPOSE: This study evaluated whether early brace treatment of curves < 25° decreased the prevalence of curve progression and surgery. METHODS: In a retrospective review, patients with idiopathic scoliosis Risser stages 0 to 2 braced at < 25° were followed until brace discontinuation, skeletal maturity, or surgery. Patients with predominantly primary thoracolumbar/lumbar curves were prescribed nighttime braces (NTB) and thoracic curves were prescribed fulltime braces (FTB). Comparisons were made for TLSO type (NTB vs. FTB) and triradiate cartilage (TRC) status (open vs. closed) at brace prescription. RESULTS: 283 patients were included, 81% who were Risser stage 0 with curves averaging 21.8° ± 2.1° at brace prescription. The average curve change was 2.4° ± 11.2°. Curves improved ≥ 6° in 23% of patients. Patients who were not skeletally mature at brace discontinuation (n = 39) had lower Cobb angles (16.7° vs. 23.9°, p < 0.001), better curve improvement (- 4.7° vs. 2.1°, p < 0.001), and were braced for a shorter period of time (1.8 years vs. 2.3 years, p = 0.011) than those who were skeletally mature at brace discontinuation (n = 239). Only 7% of patients in NTB and 8% of patients in FTB with open TRC required surgery. The numbers needed to treat to prevent surgery in patients in FTB with open TRC was calculated to be 4. CONCLUSION: Early brace treatment (Cobb < 25° and open TRC) may not only reduce curve progression and the need for surgical treatment but may also result in curve improvement, thus challenging the paradigm that the goal of bracing is merely to stop curve progression. LEVEL OF EVIDENCE: 3-retrospective cohort study.

The Addition of Daytime Physiotherapeutic Scoliosis-specific Exercises to Adolescent Idiopathic Scoliosis Nighttime Bracing Reduces Curve Progression.

BACKGROUND: The effectiveness of physiotherapeutic scoliosis-specific exercises (PSSE) in addition to nighttime bracing compared with nighttime bracing alone is unknown. The purpose of this prospective comparative study was to evaluate the effectiveness of PSSE in skeletally immature patients with adolescent idiopathic scoliosis treated with nighttime bracing (PSSE group) compared with the standard of care of nighttime bracing alone (control group). METHODS: Patients with adolescent idiopathic scoliosis thoracolumbar or lumbar primary curves <35 degrees at Risser stage 0 who wore a Providence brace were prospectively enrolled into the PSSE or control group. A temperature sensor recorded the number of hours of brace wear. The PSSE group was instructed in the Schroth-based physical therapy method and a home exercise program for at least 15 minutes per day, 5 days per week, for 1 year. RESULTS: Seventy-four patients (37 PSSE, 37 controls) were followed until the final visit of skeletal maturity or surgery. The PSSE and control groups had similar baseline Cobb angles (24 vs. 25 degrees) and average hours of brace wear (8.0 vs. 7.3 h). The PSSE group had no change in curve magnitude at the final visit compared with curve progression in the control group (1 vs. 7 degrees, P <0.01). Furthermore, the PSSE group had a lower rate of curve progression >5 degrees at the final visit (14% vs. 43%, P <0.01). The PSSE group also had less conversion to full-time bracing after 1 year (5% vs. 24%, P =0.046), but differences were no longer significant at the final visit (14% vs. 27%). CONCLUSIONS: In this prospective series of patients in nighttime Providence braces, the addition of Schroth-based physical therapy reduced curve progression after 1 year and at skeletal maturity. These findings can educate motivated families interested in PSSE. LEVEL OF EVIDENCE: Level II.

Adherence to serial casting protocols for idiopathic toe walking: A quality improvement initiative.

PURPOSE: This initiative aimed to assess adherence to Scottish Rite for Children's serial casting protocol for children with idiopathic toe walking (ITW), factors related to adherence, and outcomes after education regarding the protocol. METHODS: 60 patients aged 7.1±2.7 years who completed serial casting were examined at baseline phase (n = 30) and post-education phase (n = 30). Protocols include weekly serial casting for 4 to 6 weeks to achieve 10° of ankle dorsiflexion (ADF) passive range of motion (PROM) with knees extended (KE), assessing the foot posture index (FPI-6) and single leg stance (SLS). Baseline phase evaluated adherence to protocols. Education phase evaluated factors related to adherence and education regarding serial casting findings. Post-education phase evaluated the impact of the education phase. RESULTS: Serial casting averaged 4.8±1.5 weeks (n = 60). ADF PROM was measured with 100% adherence. ADF PROM KE averaged -10.7° pre-cast and significantly improved to +6.5° post-cast (n = 60), and it significantly improved post-cast post-education (p = 0.04). FPI-6 and SLS adherence significantly improved post-cast post-education. FPI-6 total score averaged +5.3 at baseline and +5.8 post-cast (n = 35). CONCLUSION: Education of staff in serial casting protocols improved adherence and patient outcomes. Patients with ITW and ADF PROM KE -10° benefit from serial casting to improve PROM and to allow for orthotic use post-casting.

The Observational Gait Scale Can Help Determine the GMFCS Level in Children With Cerebral Palsy.

PURPOSE: To evaluate the association between the Observational Gait Scale (OGS) and the Gross Motor Function Classification System (GMFCS) in walking children with cerebral palsy (CP). METHODS: The charts of 512 children with CP GMFCS levels I to IV were reviewed for the OGS score and GMFCS level at their initial visit. RESULTS: The OGS score decreased with increasing GMFCS levels. The average OGS for GMFCS level I was 13.1 (2.8), level II was 11.3 (2.7), level III was 7.7 (2.7), and level IV was 6.1 (2.0). A significant negative relationship was seen between the OGS and the GMFCS. In particular, each GMFCS level was different across all levels in a pairwise comparison. In addition, multivariate modeling analysis confirmed that the association between the OGS and the GMFCS was still valid, after adjusting for age and gender. CONCLUSIONS: The OGS is a quick tool to rate gait and help confirm a child's GMFCS level.

Reliability and validity of a kyphosis-specific spinal appearance questionnaire.

PURPOSE: Hyperkyphosis, including Scheuermann and postural kyphosis, is associated with decreased perceived cosmesis and well being. No patient reported outcome questionnaire specific to kyphosis exists. We sought to assess the internal consistency, test-retest reliability and concurrent validity of a new Kyphosis-specific Spinal Appearance Questionnaire (K-SAQ). METHODS: A K-SAQ was developed from a modified SAQ to measure kyphosis-specific aspects of appearance. Patients with hyperkyphosis (ages 10-20 years) curves ≥ 50° completed the K-SAQ and SRS-22R at baseline and the K-SAQ 2 weeks later. RESULTS: 55 patients completed the K-SAQ and SRS-22R. 28 patients completed the K-SAQ 2 weeks later. The K-SAQ total averages showed excellent internal consistency (Cronbach's α = 0.91) and test-retest reliability (ICC = 0.84). Moderate associations were seen between the SRS-22R subtotal average score and K-SAQ total average score and (r = - 0.62, p < 0.001) and the SRS-22R self-image domain with the K-SAQ total average score (r = - 0.57, p < 0.001). Higher BMI and increased age scored worse on the K-SAQ total average, whereas only higher BMI scored worse on the SRS-22R subtotal average. CONCLUSION: The K-SAQ is a reliable patient reported outcome measure of kyphosis-specific aspects of appearance.

Skeletally Immature Patients With Adolescent Idiopathic Scoliosis Curves 15°-24° Are at High Risk for Progression.

STUDY DESIGN: Retrospective review. OBJECTIVES: To evaluate the incidence of adolescent idiopathic scoliosis (AIS) curve progression and brace prescription in skeletally immature patients (Risser 0 to Risser 1) with curves 15°-24°. SUMMARY OF BACKGROUND DATA: Many skeletally immature patients with mild AIS ask about the likelihood of curve progression. No studies have answered these questions. METHODS: The charts and radiographs of 302 consecutive patients with curves 15°-24° at initial visit, Risser 0 to Risser 1, were reviewed until skeletal maturity (≥Risser 4) or surgery. Curves averaged 19.1° ± 2.9° at initial visit. The Risser grade was 0 in 247 patients (82%) and 1 in 55 patients (18%). Patients who were Risser 0 were compared with those who were Risser 1, curves 15°-19° were compared with curves 20°-24°. RESULTS: The majority of patients demonstrated curve progression ≥5° (65%). Patients who were Risser 0 did not progress significantly more than patients who were Risser 1 (10° vs. 8°) (p = .22). Patients with curves 20°-24° did not progress significantly more than patients with curves 15°-19° (10° vs. 9°) (p = .65). CONCLUSIONS: Curve progression for small curves (15°-19°) is similar to curves between 20° and 24°. Close observation or perhaps early intervention for these patients is necessary. These data may suggest a paradigm shift to earlier brace initiation and call for early treatment in small curves. LEVEL OF EVIDENCE: Level II.

Physical Therapy Scoliosis-Specific Exercises May Reduce Curve Progression in Mild Adolescent Idiopathic Scoliosis Curves.

PURPOSE: To evaluate the curve magnitude in participants with mild adolescent idiopathic scoliosis (AIS) at high risk of progression who received outpatient physical therapy scoliosis-specific exercises (PSSEs). METHODS: Participants with AIS curves 12° to 20° and Risser grade 0 chose either the PSSE or the control group. The PSSE group was instructed in the Barcelona Scoliosis Physical Therapy School. The control group was observed. Cobb angles were measured by one observer masked to group type at baseline, 6-month follow-up, and 1-year follow-up. RESULTS: Forty-nine participants were enrolled (26 exercise vs 23 controls). Thirty-three participants (19 exercise vs 14 controls) were seen at 1-year follow-up. At 1-year follow-up, the exercise group had smaller curves than controls (16.3° vs 21.6°, P = .04) and less curve progression (0° vs 5.6°, P = .02). Bracing was performed similarly between groups at 1-year follow-up (37% vs 43%). CONCLUSIONS: In this small prospective series, PSSE resulted in significantly less curve progression compared with controls.

Factors influencing adherence to an app-based exercise program in adolescents with painful hyperkyphosis.

BACKGROUND: Software applications (apps) could potentially promote exercise adherence. However, it is unclear whether adolescents with painful hyperkyphosis will use an app designed for a home exercise program. The purpose of this study is to assess factors regarding adherence to an app-based home exercise program in adolescents with hyperkyphosis and back pain who were provided a one-time exercise treatment. METHODS: Twenty-one participants were instructed in a one-time exercise treatment and asked to complete a home exercise program 3 times a week for 6 months using an app called PT PAL. At a 6-month follow-up, 14 participants completed a survey assessing factors related to their experiences using the app and their treatment engagement. RESULTS: Although most participants did not use the app, they reported performing their exercises a few times per week. The adolescent participants considered the app to be more of a barrier than a supportive measure for promoting exercise adherence. Most participants still reported bothersome back pain. CONCLUSIONS: Although adherence to the 6-month app-based home exercise program was not successful, adolescents still viewed technology support such as text reminders as a potential solution. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03212664. Registered 11 July 2017. Retrospectively registered.

Gross Motor Function at 10 Years of Age in Children With Clubfoot Following the French Physical Therapy Method and the Ponseti Technique.

PURPOSE: To evaluate gross motor skills [Bruininks-Oseretsky Test of Motor Proficiency, 2nd ed (BOT-2)] of patients with idiopathic clubfoot initially treated nonoperatively with either the French functional physical therapy (PT) method or the Ponseti technique, at age 10 years. METHODS: The BOT-2 was administered by trained physical therapists on patients with idiopathic clubfoot at age 10 years. The cohort was divided by initial treatment method (PT or Ponseti), and compared. Subsequent analyses included comparisons of: initial clubfoot severity (Dimeglio scores: ≤13 vs. >13), laterality (unilateral vs. bilateral), and surgical versus nonoperative outcome. RESULTS: Of the 183 patients tested, 172 were included. The Ponseti and PT groups did not significantly differ according to age, height, weight, body mass index, ankle dorsiflexion, sex, average initial Dimeglio score, laterality, or surgical versus nonsurgical outcome. Overall, patients with treated clubfoot had average gross motor BOT-2 scores compared with age-matched peers. Patients in the PT group scored higher on Running Speed/Agility (P=0.019), Body Coordination percentile rank (P=0.038), and Strength and Agility percentile rank (P=0.007) than patients treated by the Ponseti technique. Patients with bilateral clubfoot scored significantly lower on the Balance subtest (P<0.01), and Body Coordination percentile rank (P<0.01), than those with unilateral clubfoot. Patients who required surgery scored significantly lower on the Balance subtest (P=0.04) than those who did not require surgery. CONCLUSIONS: Clubfoot may impair balance in 10 year olds with bilateral involvement and those requiring surgery. Future research should evaluate whether components of the PT method may improve gross motor outcomes as a supplement to the Ponseti technique. LEVELS OF EVIDENCE: Level II.

Clubfoot Does Not Impair Gross Motor Development in 5-Year-Olds.

PURPOSE: To evaluate the gross motor development of 5-year-olds using the Peabody Developmental Motor Scales, 2nd Edition (PDMS-2), test after initial nonoperative management of clubfoot as infants. METHODS: The PDMS-2 Stationary, Locomotion, and Object Manipulation subtests were assessed on 128 children with idiopathic clubfeet at the age of 5 years. Children were categorized by their initial clubfoot severity as greater than 13, unilateral or bilateral involvement, and required surgery. RESULTS: Children with treated clubfeet had average gross motor scores (99 Gross Motor Quotient) compared with age-matched normative scores. Children with more severe clubfeet required surgery significantly more than children with less severe scores (P < .01). Peabody scores were not significantly different according to initial clubfoot severity, unilateral versus bilateral involvement, and surgical versus nonsurgical outcomes. CONCLUSIONS: Clubfoot does not significantly impair gross motor development in 5-year-olds.

Six-Month Follow-up of Supervised Spinal Stabilization Exercises for Low Back Pain in Adolescent Idiopathic Scoliosis.

PURPOSE: To evaluate the effectiveness of 8 weeks of weekly spinal stabilization exercises compared with 1-time treatment in participants with adolescent idiopathic scoliosis and low back pain at a 6-month follow-up. METHODS: Thirty-two participants were evaluated at a 6-month follow-up. The supervised group received weekly spinal stabilization exercises. The unsupervised group received a 1-time treatment and home exercise program. RESULTS: Both groups improved in all outcome measures. The supervised group had significantly reduced Numeric Pain Rating Scale and Improved Global Rating of Change scores, but had no differences in the revised Oswestry Back Pain Disability Questionnaire, or Patient-Specific Functional Scale scores in comparison with the unsupervised group.

Ultrasonographic measurements of paraspinal muscle thickness in adolescent idiopathic scoliosis: a comparison and reliability study.

PURPOSE: To examine paraspinal muscle asymmetries in patients with mild adolescent idiopathic scoliosis (AIS) compared with controls using ultrasound (US) imaging and to determine reliability of the US imaging. METHODS: Twenty adolescents (10 with and 10 without AIS) whose muscle thickness of the deep paraspinals at T8 and the multifidus at L1 and L4 vertebral levels was determined using US imaging. RESULTS: Ultrasound imaging had good intrarater reliability (ICC3,3 = 0.83-0.99) and interrater reliability (ICC2,3 = 0.93-0.99). Significantly greater muscle thicknesses were found on the concave side at T8 and L1 compared with the corresponding convex side. Significantly greater normalized muscle thickness values were found on the concave side at T8, L1, and L4 in patients with mild AIS compared with controls. CONCLUSIONS: Ultrasound imaging is reliable for measuring the deep thoracic paraspinals and lumbar multifidus in adolescents with and without idiopathic scoliosis. Significant paraspinal muscle asymmetries were found in mild AIS. VIDEO ABSTRACT: For more insights from the authors, access Supplemental Digital Content 1, at http://links.lww.com/PPT/A76.