Assessment of malalignment at early stage in adolescent idiopathic scoliosis: a longitudinal cohort study.

INTRODUCTION: Our objective was to assess abnormalities of the odontoid-hip axis (OD-HA) angle in a mild scoliotic population to determine whether screening for malalignment would help predict the distinction between progressive and stable adolescent idiopathic scoliosis (AIS) at early stage. MATERIALS AND METHODS: All patients (non-scoliotic and AIS) underwent a biplanar X-ray between 2013 and 2020. In AIS, inclusion criteria were Cobb angle between 10° and 25°; Risser sign lower than 3; age higher than 10 years; and no previous treatment. A 3D spine reconstruction was performed, and the OD-HA was computed automatically. A reference corridor for OD-HA values in non-scoliotic subjects was calculated as the range [5th-95th percentiles]. A severity index, helping to distinguish stable and progressive AIS, was calculated and weighted according to the OD-HA value. RESULTS: Eighty-three non-scoliotic and 205 AIS were included. The mean coronal and sagittal OD-HA angles in the non-scoliotic group were 0.2° and -2.5°, whereas in AIS values were 0.3° and -0.8°, respectively. For coronal and sagittal OD-HA, 27.5% and 26.8% of AIS were outside the reference corridor compared with 10.8% in non-scoliotic (OR = 3.1 and 3). Adding to the severity index a weighting factor based on coronal OD-HA, for thoracic scoliosis, improved the positive predictive value by 9% and the specificity by 13%. CONCLUSION: Analysis of OD-HA suggests that AIS patients are almost three times more likely to have malalignment compared with a non-scoliotic population. Furthermore, analysis of coronal OD-HA is promising to help the clinician distinguish between stable and progressive thoracic scoliosis.

Effect of curve location on the severity index for adolescent idiopathic scoliosis: a longitudinal cohort study.

OBJECTIVES: Adolescent idiopathic scoliosis (AIS) is the most common spinal disorder in children. A severity index was recently proposed to identify the stable from the progressive scoliosis at the first standardized biplanar radiographic exam. The aim of this work was to extend the validation of the severity index and to determine if curve location influences its predictive capabilities. METHODS: AIS patients with Cobb angle between 10° and 25°, Risser 0-2, and no previous treatment were included. They underwent standing biplanar radiography and 3D reconstruction of the spine and pelvis, which allowed to calculate their severity index. Patients were grouped by curve location (thoracic, thoracolumbar, lumbar). Patients were followed up until skeletal maturity (Risser ≥ 3) or brace prescription. Their outcome was compared to the prediction made by the severity index. RESULTS: In total, 205 AIS patients were included; 82% of them (155/189, 95% confidence interval [74-90%]) were correctly classified by the index, while 16 patients were unclassified. Positive predictive ratio was 78% and negative predictive ratio was 86%. Specificity (78%) was not significantly affected by curve location, while patients with thoracic and lumbar curves showed higher sensitivity (≥ 89%) than those with thoracolumbar curves (74%). CONCLUSIONS: In this multicentric cohort of 205 patients, the severity index was used to predict the risk of progression from mild to moderate scoliosis, with similar results of typical major curve types. This index represents a novel tool to aid the clinician and the patient in the modulation of the follow-up and, for progressive patients, their decision for brace treatment. KEY POINTS: • The severity index of adolescent idiopathic scoliosis has the potential to detect patients with progressive scoliosis as early as the first exam. • Out of 205 patients, 82% were correctly classified as either stable or progressive by the severity index. • The location of the main curve had small effect on the predictive capability of the index.

Pain coping strategies in children with cerebral palsy.

AIM: To describe coping strategies in children and adolescents with cerebral palsy (CP), relative to age. METHOD: Patients were prospectively recruited from two paediatric rehabilitation centres in France. The Pediatric Pain Coping Inventory - French and Structured Pain Questionnaire were completed by an experienced professional for each child. RESULTS: One hundred and forty-two children with CP were included (80 males, 62 females; median age 12y; IQR=8-15y). They generally used fewer coping strategies than typically developing children ('Seeks social support and action': 12.47 vs 12.85, p=0.477; 'Cognitive self-instruction': 9.28 vs 10.90, p<0.001; 'Distraction': 4.89 vs 7.00, p<0.001; 'Problem solving': 4.43 vs 5.19, p<0.001). In the CP group, 'Seeks social support and action' decreased with age (p=0.021) and 'Cognitive self-instruction' increased with age (p<0.001). 'Problem solving' and 'Distraction' did not change with age. Coping strategies were influenced by Gross Motor Function Classification System level (p=0.022) and history of surgery (p=0.002). INTERPRETATION: Children with CP generally used fewer coping strategies than typically developing children and tended to rely on social support. Use of active strategies increased with age; however, they appeared later than in typically developing children and were used to a lesser extent. WHAT THIS PAPER ADDS: Children with cerebral palsy (CP) use fewer pain-coping strategies than typically developing children. Children with CP tend to use social support to cope with pain. Children with CP learn more appropriate strategies from previous painful experiences. Active coping strategies appear later but remain underused in children with CP.

ESTRATEGIAS DE AFRONTAMIENTO DEL DOLOR EN NIÑOS CON PARÁLISIS CEREBRAL: OBJETIVO: Describir estrategias de afrontamiento en niños y adolescentes con parálisis cerebral (PC), en relación con la edad. MÉTODO: Los pacientes fueron reclutados prospectivamente de dos centros de rehabilitación pediátrica en Francia. El Inventario de Afrontamiento del Dolor Pediátrico - Cuestionario de Dolor Francés y Estructurado fue completado por un profesional con experiencia para cada niño. RESULTADOS: Se incluyeron 142 niños con PC (80 varones, 62 mujeres; mediana de edad de 12 años; IQR = 8-15 años). En general, los niños con PC utilizaron menos estrategias de afrontamiento que los niños con desarrollo típico ("Busca apoyo social y acción": 12,47 vs 12,85, p = 0,477; "Autoinstrucción cognitiva": 9,28 vs 10,90, p <0,001; "Distracción": 4,89 vs 7,00, p <0,001; "Resolución de problemas": 4,43 vs 5,19, p <0,001). En el grupo de PC, la búsqueda de apoyo y acción social disminuyó con la edad (p = 0,021) y la autoinstrucción cognitiva aumentó con la edad (p <0,001). La "resolución de problemas" y la "distracción" no cambiaron con la edad. Las estrategias de afrontamiento se vieron influenciadas por el nivel del Sistema de Clasificación de la Función Motora Gruesa (p = 0,022) y los antecedentes quirúrgicos (p = 0,002). INTERPRETACIÓN: Los niños con PC generalmente usaron menos estrategias de afrontamiento que los niños con un desarrollo típico y tendían a confiar en el apoyo social. El uso de estrategias activas aumenta con la edad; sin embargo, aparecieron más tarde que en los niños con un desarrollo típico y se utilizaron en menor medida.

ESTRATÉGIAS PARA LIDAR COM A DOR EM CRIANÇAS COM PARALISIA CEREBRAL: OBJETIVO: Descrever estratégias para lidar com a dor em crianças e adolescentes com paralisia cerebral (PC), com relação à sua idade. MÉTODO: Pacientes foram prospectivamente recrutados em dois centros de reabilitação pediátrica na França. O Inventário Pediátrico de Manejo da Dor - Francês e o Questionário Estruturado sobre dor foram completados para cada criança por um profissional com experiência. RESULTADOS: Cento e quarenta e duas crianças com PC foram incluídas (80 do sexo masculino, 62 do sexo feminino; idade mediana 12a; IIQ=8-15a). Elas geralmente usaram menos estratégias para lidar com a dor do que crianças com desenvolvimento típico ('Procura suporte e ação social': 12,47 vs 12,85, p=0=,477; 'Auto-instrução cognitiva': 9,28 vs 10,90, p<0,001; 'Distração: 4,89 vs 7,00, p<0,001; 'Resolução do problema': 4,43 vs 5,19, p<0,001). No grupo com PC, 'Procura suporte e ação social' diminuiu com a idade (p=0,021) e Auto-instrução cognitiva' aumentou com a idade (p<0,001). 'Resolução de problemas' e 'Distração' não mudaram com a idade. As estratégias de manejo da dor foram influenciadas pelo nível do Sistema de Classificação da Função Motora Grossa (p=0,022) e histórico de cirurgia (p=0,002). INTERPRETAÇÃO: Crianças com PC geralmente usam menos estratégias para lidar com a dor do que crianças com desenvolvimento típico, e tendem a depender de suporte social. O uso de estratégias efetivas aumentou com a idade; no entanto, elas aparecem mais tarde do que em crianças com desenvolvimento típico, e são utilizadas em menor escala.

The acceptance of the clinical photographic posture assessment tool (CPPAT).

BACKGROUND: There is a lack of evidence-based quantitative clinical methods to adequately assess posture. Our team developed a clinical photographic posture assessment tool (CPPAT) and implemented this tool in clinical practice to standardize posture assessment. The objectives were to determine the level of acceptance of the CPPAT and to document predictors as well as facilitators of and barriers to the acceptance of this tool by clinicians doing posture re-education. METHODS: This is a prospective study focussing on technology acceptance. Thirty-two clinician participants (physical therapists and sport therapists) received a 3-5 h training workshop explaining how to use the CPPAT. Over a three-month trial, they recorded time-on-task for a complete posture evaluation (photo - and photo-processing). Subsequently, participants rated their acceptance of the tool and commented on facilitators and barriers of the clinical method. RESULTS: Twenty-three clinician participants completed the trial. They took 22 (mean) ± 10 min (SD) for photo acquisition and 36 min ± 19 min for photo-processing. Acceptance of the CPPAT was high. Perceived ease of use was an indirect predictor of intention to use, mediated by perceived usefulness. Analysis time was an indirect predictor, mediated by perceived usefulness, and a marginally significant direct predictor. Principal facilitators were objective measurements, visualization, utility, and ease of use. Barriers were time to do a complete analysis of posture, quality of human-computer interaction, non-automation of posture index calculation and photo transfer, and lack of versatility. CONCLUSION: The CPPAT is perceived as useful and easy to use by clinicians and may facilitate the quantitative analysis of posture. Adapting the user-interface and functionality to quantify posture may facilitate a wider adoption of the tool.

The use of a photogrammetric method for the three-dimensional evaluation of spinal correction in scoliosis.

PURPOSE: Clinical parameters, characterizing the spinal deformations due to scoliosis, are still directly measured on the spinal curve plane projections. METHODS: A 3D spinal curve has been reconstructed from its two projections, using photogrammetric techniques. Each spinal curve is a compound of several plane regions, where it is purely flexed, and short zones of connection, where abduction and axial rotation components are concentrated. All spinal curves are represented as linear chains of regional planes articulated together. The regional plane is represented by a triangle, where one summit corresponds to the point of maximum offset. The set of weight forces, representing pelvis and spine, forms a bundle of vertical forces. The dispersion of the bundle illustrates the postural stability of patients. RESULTS AND CONCLUSIONS: The first objective was to numerically describe the changes of the 3D spinal feature, due to the correcting treatment. Changes are calculated from the comparison between 3D radiologic situations, between before and after treatment. The second objective was to determine the direction of the external force, which would be the most efficient for correcting the patient set spine/rib cage. A mild mechanical analysis is proposed, for representing the transit of the external force, from rib cage to thoracic regional plane.

Spine slenderness is not an early sign of progression in adolescent idiopathic scoliosis.

Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of the spine. Spine slenderness, which represents its potential instability to buckling under compressive loads, was shown to be higher in AIS patients than non-scoliotic subjects, but it is not clear at what stage of the progression this difference appeared, nor if slenderness could be used as an early sign of progression. In this study, we hypothesized that slenderness could be an early sign of progression. One-hundred thirty-eight patients and 93 non-scoliotic subjects were included. They underwent standing biplanar radiography and 3D reconstruction of the spine, which allowed computing vertebra and disc slenderness ratio. Then, patients were followed until progression of the deformity or skeletal maturity (stable patients). Vertebral slenderness ratio in AIS patients varied between 2.9 [2.7; 3.0] (T9) and 3.4 [3.2; 3.6] (T1), while disc slenderness ranged from 0.6 [0.6; 0.7] at T6-T7 to 1.2 [1.1; 1.3] at L4-L5. Slenderness ratio increased with age, while disc slenderness tended to decrease with age and Cobb angle. Slenderness was similar between progressive and stable patients, and also between patients and non-scoliotic subjects. In conclusion, spinal slenderness does not appear to be an early sign of progression. Further studies should analyse the development of slenderness during growth, and how it could be affected by non-operative treatment.

Benefits of Digital Smile Design (DSD) in the conception of a complex orthodontic treatment plan: A case report-proof of concept.

INTRODUCTION: Digital Smile Design (DSD) is a systematic protocol based on specific photographs and software analysis that is used worldwide. DSD aims to assist the practitioner in creating and planning a course of treatment, especially in a multidisciplinary approach, and provides a virtual simulation of the final result. Additionally, it is a tool that enables communication and discussion between all the dental team, including the dental laboratory, and also with the patient. Although widely described and used in prosthetic rehabilitation, this tool remains only anecdotally used in the world of orthodontics. The objective of this proof of concept was to describe the application of the Digital Smile Design protocol in the diagnosis of orthodontic treatment. MATERIALS AND METHODS: A teenage patient was referred to our university clinic by a private orthodontic practitioner for a second opinion on the treatment at that time. The patient had a self-ligating orthodontic appliance. According to the history of the case and the oral situation at that moment, the patient required an accurately calculated plan for orthodontic tooth movement that would permit the achievement of future rehabilitation. Therefore, the decision was taken to use a DSD protocol to potentially complete the classic orthodontic examination. RESULTS: From the classic orthodontic examination, the patient presented a molar class I, midline deviations, the #21 and #23 were missing, #12 was conoid (microdontic) and, finally, #22 was in the position of #21. From the DSD results, three different views simulated the final results and therefore provided additional and relevant information, such as the correct position of the upper midline and the correct position of #12, #13, #22 and #23. CONCLUSION: This proof of concept showed the clinical relevance of the Digital Smile Design protocol as a new tool for complex orthodontic treatment planning, especially in a multidisciplinary approach. Further publications will be necessary in order to define a specific DSD protocol for orthodontic treatment.

Impact of an ergonomic seat on the stand-to-sit strategy in healthy subjects: Spinal and lower limbs kinematics.

PURPOSE: To assess differences in spinal, pelvic and lower limb parameters in healthy individuals during a stand-to-sit task using three different seating conditions. METHODS: Ten healthy adults carried out three stand-to-sit movements on different stools: a high ergonomic stool with the seat tilted 10° forward; a standard stool (adjusted to the same height as the ergonomic stool) and a standard stool at a lower level (so their thighs were horizontal). Movements were recorded by an optoelectronic Vicon system. RESULTS: Hip flexion was altered by the height of the seat (significantly greater for the low standard stool in comparison to either the ergonomic stool or the high standard stool (p < 0.0001)). There was also significantly less knee flexion with the ergonomic stool in comparison to the low standard stool (p < 0.0001) and to the high standard stool (p = 0.0017). Lumbar lordosis was not significantly altered by seat height, although it was less pronounced with the ergonomic stool, with a significantly higher range of motion for the pelvis (p = 0.015). At the thoracic level, no differences were observed, except that the stand-to-sit movement on the lower stool produced greater flexion. CONCLUSION: Lumbar lordosis was not increased by the ergonomic stool and the range of lower limb motion was reduced by the high seat. These findings contrast with current opinion that ergonomic seats promote lumbar lordosis.

French validation of the Brace Questionnaire (BrQ).

BACKGROUND: Quality of Life (QoL) scales have to be introduced in the treatment evaluation of our patients with adolescent idiopathic scoliosis. Vasiliadis et. al. created the Brace Questionnaire (BrQ), which is specific for brace-treated adolescents. This tool was developed and validated in Greek. The aim of our study was to undertake the process of cultural adaptation of the Brace Questionnaire (BrQ) into French. METHODS: The BrQ is made of 34 items on Likert scale, divided in eight domains. The questionnaire was developed for self-completion by the children and is adapted for 9 to 18-year-old patients. The process of cultural adaptation of the questionnaire was in accordance with the International Quality of Life Assessment (IQOLA) guidelines. In the first place, descriptive statistics were used to calculate mean scores and standard deviations for a given question and a domain. The second level was comparative, concerning reliability and validity. RESULTS: The internal consistency was satisfactory; Cronbach's alpha coefficient was 0.85. There were no floor or ceiling effects. CONCLUSIONS: The French version of the BrQ (F-BrQ) is reliable and reproducible, and can therefore be used to evaluate the quality of life of children and adolescents treated with a brace for idiopathic scoliosis.

Use of videographic examination for analysis of efficacy of botulinum toxin in the lower limbs in children with cerebral palsy.

The objective of this study was to test the interobserver and intraobserver reproducibility of videographic gait analysis in paediatric cerebral palsy patients following botulinum toxin type-A injections. Standardized videos according to gait-specific functional criteria were assessed for 1 h. For intraobserver reproducibility, 13 of 17 items showed good/moderate correlation, one mediocre and three poor correlation. For interobserver reproducibility, 12 of 17 items showed excellent, good or moderate agreement, five items showed poor agreement. Overall, 9 of 17 items showed good intraobserver or interobserver reproducibility. Mean interobserver scores for sagittal plane items were slightly lower than mean intraobserver scores (kappa=0.509 and 0.536, respectively). In conclusion, video analysis of children with cerebral palsy based on functional criteria is useful.

Pelvic-Spinal Analysis and the Impact of Onabotulinum toxin A Injections on Spinal Balance in one Child With Cerebral Palsy.

BACKGROUND: In children with cerebral palsy, primary (eg, abnormal muscle tone and weakness) and secondary impairments (eg, contractures) can modify pelvic-spinal alignment. The main aim of this article was to establish a new approach to pelvic-spinal analysis in children with cerebral palsy, taking into account the whole pelvis-spine complex, illustrated by a case study. METHODS: This is a case study of an ambulatory child with cerebral palsy (spastic diplegia) who underwent analysis of the pelvic-spine complex from X-ray images taken in standing position from C2 to the proximal femur. Pelvic shape was characterized by the pelvic incidence angle, which is the sum of sacral slope and pelvic tilt, before and after the treatment by regular onabotulinumtoxinA injections into the hip flexors, and the use of soft lumbar brace over 5 years. RESULTS: The sagittal balance of the spine was improved following the treatment, with a reduction in lumbar lordosis and sacral slope. The reduction in lumbar hyperextension likely reduced the risk of spondylolysis, low back pain, and degenerative spondylolisthesis in adulthood. CONCLUSION: A biomechanical approach to the evaluation of the pelvic-spinal complex offers new perspectives to increase the understanding of spinal balance in children with cerebral palsy, providing more options for treatment, such as onabotulinumtoxinA.

Functional variants of POC5 identified in patients with idiopathic scoliosis.

Idiopathic scoliosis (IS) is a spine deformity that affects approximately 3% of the population. The underlying causes of IS are not well understood, although there is clear evidence that there is a genetic component to the disease. Genetic mapping studies suggest high genetic heterogeneity, but no IS disease-causing gene has yet been identified. Here, genetic linkage analyses combined with exome sequencing identified a rare missense variant (p.A446T) in the centriolar protein gene POC5 that cosegregated with the disease in a large family with multiple members affected with IS. Subsequently, the p.A446T variant was found in an additional set of families with IS and in an additional 3 cases of IS. Moreover, POC5 variant p.A455P was present and linked to IS in one family and another rare POC5 variant (p.A429V) was identified in an additional 5 cases of IS. In a zebrafish model, expression of any of the 3 human IS-associated POC5 variant mRNAs resulted in spine deformity, without affecting other skeletal structures. Together, these findings indicate that mutations in the POC5 gene contribute to the occurrence of IS.

The carbon brace.

BACKGROUND: The CMCR brace (Corset MonocoqueCarbone respectant la Respiration -which means Monoshell Carbon Brace respecting Breathing) is an innovative brace, used in orthopaedic treatment for progressive thoracic, thoraco-lumbar or combined scoliosis, whatever their etiology. It can be used at the very young age without disrupting the chest growth, but should be kept for reducible scoliosis in older teenagers. BRACE DESCRIPTION AND PRINCIPLES: The CMCR brace is monoshell while retaining the corrective principle of the polyvalve Lyon brace with one or two supports (brace "pads") located on hump(s).In contrast to Lyon brace made of plexidur and structured by metal reinforcement with adjustable but fixed localized supports, the CMCR brace is made of polyethylene and carbon with adjustable and mobile supports. This mobility provides a permanent pressure, which varies depending on ribs and spine movements.The correction is obtained without spinal extension so that each respiratory movement takes part in a gradual return to dorsal kyphosis. RESULTS: Results were presented in two published analysis:• In the first retrospective study about 115 patients, French-published in the Annals of Physical Medicine and Rehabilitation (2005), the CMCR brace stabilized moderate scoliosis, decreased the vital capacity (VC) of 13% compared to the VC without brace, and did not have sufficient impact on the hump reduction. Treatment had better results when started at Risser 3 or 4 than Risser 0, 1, 2. The brace was then modified to increase the dorsal pad pressure and the location of correction forces was defined more precisely through the use of 3D analysis.• The second study published in Scoliosis (2011) mainly focused on the impact on VC at brace setting up and followed a cohort of 90 patients treated with CMCR. Girls as well as boys increased VC during treatment, and at brace definitive removal, VC had increased of 21% from the initial value, whereas the theoretical VC at the same time rose by 18%.The difference between the time where the child actually wears its brace and the time asked by the clinician for the brace to be worn is only 1 hour, which means that this brace is accepted by teenagers. CONCLUSIONS: Orthopaedic treatment is still a heavy treatment for teenagers in growth period. This orthosis is designed to partly maintain spine and chest mobility. We hope so to have part in improving life conditions of these teenagers, compared to those treated with rigid braces.

Vital capacity evolution in patients treated with the CMCR brace: statistical analysis of 90 scoliotic patients treated with the CMCR brace.

OBJECTIVE: To study the evolution of pulmonary capacity during orthopaedic treatment of scoliosis with the CMCR brace. BACKGROUND: Investigating the impact of moderate scoliosis on respiratory capacity and its evolution during CMCR brace treatment with mobile pads. CONTEXT: Several studies demonstrate the impact of scoliosis on respiratory capacity but few of them focus on the impact of bracing treatment. We studied the evolution of the pulmonary capacity of a cohort of 90 scoliotic patients. METHODS: This retrospective study included 90 scoliotic patients treated since 1999 with a brace with mobile pads called CMCR (n = 90; mean age: 13 years; 10-16). These patients were diagnosed with an idiopathic scoliosis (mean angulation 20.6°). All patients underwent a radiographic and respiratory evaluation at the beginning, the middle and the end of treatment. RESULTS: Mean age at treatment start was 13. Before treatment, our patients did not have a normal pulmonary capacity: Forced Vital Capacity (FVC) was only 75% of the theoretical value. All curvature types (thoracic, thoraco-lumbar and combined scoliosis) involved this reduced pulmonary capacity, with moderate-angulated scoliosis having a negative impact. At the beginning of brace treatment, the loss of real vital capacity with brace (0.3 litres) was 10% lower than without brace.At CMCR removal, the FVC had increased by 0.4 litre (21% +/- 4.2% compared to the initial value). The theoretical value had increased by 3%. This positive evolution was most important in girls at a low Risser stage (0,1,2), and before 11 years of age. CONCLUSION: These results supported our approach of orthesis conception for adolescent idiopathic scoliosis which uses braces with mobile pads to preserve thorax and spine mobility.

New disease gene location and high genetic heterogeneity in idiopathic scoliosis.

Idiopathic scoliosis (IS) is a spine disorder of unknown origin with 1.5-3% prevalence in the general population. Besides the large multifactorial-form sample of IS, there is a good evidence for the existence of a monogenic subgroup in which the disease is inherited in a dominant manner. However, results from literature suggest a strong heterogeneity in the locations of the mutated genes. Using a high-resolution genome-wide scan, we performed linkage analyses in three large multigenerational IS families compatible with dominant inheritance including 9-12 affected members or obligate carriers. In two of these families, our results suggested intra-familial genetic heterogeneity, whereas, in the other, we observed a perfect marker disease co-segregation in two regions at 3q12.1 and 5q13.3. We can state that one of these two locations is a novel IS disease gene locus, as the probability of having this perfect co-segregation twice by chance in the genome is very low (P=0.001). Lastly, in all three families studied, linkage to the previously mapped dominant IS loci on chromosomes 19p13.3, 17p11.2, 9q34, 17q25 and 18q is unlikely, confirming that there is a high genetic heterogeneity within the subgroup of dominant forms of IS.