Algorithm for Schroth-Curve-Type Classification of Adolescent Idiopathic Scoliosis: An Intra- and Inter-Rater Reliability Study.

Schroth exercises for scoliosis are prescribed based on curve types. This study aimed to determine the reliability of an algorithm for classifying Schroth curve types. Forty-four consecutive volunteers with adolescent idiopathic scoliosis, 10 to 18 years old, with curves 10° to 50°, were recruited from a scoliosis clinic. Their standing posture and Adam's bending test were videotaped. Ten consecutive Schroth therapist volunteers from an international registry independently classified the curve types using the proposed classification algorithm. Videos were rated twice at least seven days apart. Reliability was calculated using the Gwet's AC1 agreement coefficient for all the raters and for subgroups reporting full understanding (well-trained) and with prior algorithm experience. The intra-rater and weighted agreement coefficients for all the raters were 0.64 (95% CI: 0.53-0.73) and 0.75 (0.63-0.84), respectively. For the well-trained raters, they were 0.70 (0.60-0.78) and 0.82 (0.73-0.88), respectively; for the experienced raters, they were 0.81 (0.77-0.85) and 0.89 (0.80-0.94), respectively. The inter-rater versus weighted agreement coefficients for all the raters were 0.43 (0.28-0.58) versus 0.48 (0.29-0.67). For the well-trained raters, they were 0.50 (0.38-0.61) versus 0.61 (0.49-0.72), and for the experienced raters, they were 0.67 (0.50-0.85) versus 0.79 (0.64-0.94). Full understanding and experience led to higher reliability. Use of the algorithm can help standardize Schroth exercise treatment.

Patients with adolescent idiopathic scoliosis perceive positive improvements regardless of change in the Cobb angle - Results from a randomized controlled trial comparing a 6-month Schroth intervention added to standard care and standard care alone. SOSORT 2018 Award winner.

BACKGROUND: The Cobb angle is proposed as the "disease process" outcome for scoliosis research because therapies aim to correct or stop curve progression. While the Scoliosis Research Society recommends the Cobb angle as the primary outcome, the Society on Scoliosis Orthopaedic and Rehabilitation Treatment prioritises, as a general goal, patient related outcomes over Cobb angle progression. OBJECTIVE: To determine the threshold of change in the Cobb angle in adolescents with idiopathic scoliosis (AIS) who perceive improvement in a 6-months randomized controlled trial comparing a Schroth exercise intervention added to the standard of care to the standard of care alone. METHODS: This is a secondary analysis of data from a randomized controlled trial of 50 patients with AIS, with curves ranging from 10° to 45°, with or without a brace. Participants with diagnoses other than AIS, surgical candidates or patients who had scoliosis surgery were excluded. The 6-month interventions consisted of Schroth exercises added to standard-of-care (observation or bracing) with daily home exercises and weekly therapy sessions (Schroth) or standard-of-care alone (Control). The anchor method for estimating the minimal important difference (MID) in the largest Cobb angles (LC) was used. Patient-reported change in back status over the 6-month treatment period was measured using the Global Rating of Change (GRC) scale as anchor varying from - 7 ("great deal worse") to + 7 ("great deal better"). Participants were divided into two groups based on GRC scores: Improved (GRC ≥2) or Stable/Not Improved (GRC ≤1). MID was defined as the change in the LC that most accurately predicted the GRC classification as per the receiver operating characteristic curve (ROC). RESULTS: The average age was 13.4 ± 1.6 years and the average LC was 28.5 ± 8.8 °s. The average GRC in the control group was - 0.1 ± 1.6, compared to + 4.4 ± 2.2 in the Schroth group. The correlation between LC and GRC was adequate (r = - 0.34, p < 0.05). The MID for the LC was 1.0 °. The area under the ROC was 0.69 (0.52-0.86), suggesting a 70% chance to properly classify a patient as perceiving No Improvement/Stable or Improvement based on the change in the LC. CONCLUSION: Patients undergoing Schroth treatment perceived improved status of their backs even if the Cobb angle did not improve beyond the conventionally accepted threshold of 5°. Standard of care aims to slow/stop progression while Schroth exercises aim to improve postural balance, signs and symptoms of scoliosis. Given the very small MID, perceived improvement in back status is likely due to something other than the Cobb angle. This study warrants investigating alternatives to the Cobb angle that might be more relevant to patients. TRIAL REGISTRATION: ClinicalTrials.gov , NCT01610908 . Retrospectively registered on April 2, 2012 (first posted on June 4, 2012 - https://clinicaltrials.gov/ct2/keydates/NCT01610908 ).

Schroth physiotherapeutic scoliosis-specific exercises for adolescent idiopathic scoliosis: how many patients require treatment to prevent one deterioration? - results from a randomized controlled trial - "SOSORT 2017 Award Winner".

BACKGROUND: Recent randomized controlled trials (RCTs) support using physiotherapeutic scoliosis-specific exercises (PSSE) for adolescents with idiopathic scoliosis (AIS). All RCTs reported statistically significant results favouring PSSE but none reported on clinical significance. The number needed to treat (NNT) helps determine if RCT results are clinically meaningful. The NNT is the number of patients that need to be treated to prevent one bad outcome in a given period. A low NNT suggests that a therapy has positive outcomes in most patients offered the therapy. The objective was to determine how many patients require Schroth PSSE added to standard care (observation or brace treatment) to prevent one progression (NNT) of the Largest Curve (LC) or Sum of Curves (SOC) beyond 5° and 10°, respectively over a 6-month interval. METHODS: This was a secondary analysis of a RCT. Fifty consecutive participants from a scoliosis clinic were randomized to the Schroth PSSE + standard of care group (n = 25) or the standard of care group (n = 25).We included males and females with AIS, age 10-18 years, all curve types, with curves 10°- 45°, with or without brace, and all maturity levels. We excluded patients awaiting surgery, having had surgery, having completed brace treatment and with other scoliosis diagnoses. The local ethics review board approved the study (Pro00011552).The Schroth intervention consisted of weekly 1-h supervised Schroth PSSE sessions and a daily home program delivered over six months in addition to the standard of care. A prescription algorithm was used to determine which exercises patients were to perform. Controls received only standard of care.Cobb angles were measured using a semi-automatic system from posterior-anterior standing radiographs at baseline and 6 months.We calculated absolute risk reduction (ARR) and relative risk reduction (RRR). The NTT was calculated as: NNT = 1/ARR. Patients with missing values (PSSE group; n = 2 and controls; n = 4) were assumed to have had curve progression (worst case scenario). The RRR is calculated as RRR = ARR/CER. RESULTS: For LC, NNT = 3.6 (95% CI 2.0-28.2), and for SOC, NNT = 3.1 (95% CI 1.9-14.2). The corresponding ARR was 28% for LC and 32% for the SOC. The RRR was 70% for LC and 73% for the SOC. Patients with complete follow-up attended 85% of prescribed visits and completed 82.5% of the home program. Assuming zero compliance after dropout, 76% of visits were attended and 73% of the prescribed home exercises were completed. CONCLUSIONS: The short term of Schroth PSSE intervention added to standard care provided a large benefit as compared to standard care alone. Four (LC and SOC) patients require treatment for the additional benefit of a 6-month long Schroth intervention to be observed beyond the standard of care in at least one patient. TRIAL REGISTRATION: NCT01610908 April 2, 2012.

Schroth Physiotherapeutic Scoliosis-Specific Exercises Added to the Standard of Care Lead to Better Cobb Angle Outcomes in Adolescents with Idiopathic Scoliosis - an Assessor and Statistician Blinded Randomized Controlled Trial.

BACKGROUND: The North American non-surgical standard of care for adolescent idiopathic scoliosis (AIS) includes observation and bracing, but not exercises. Schroth physiotherapeutic scoliosis-specific exercises (PSSE) showed promise in several studies of suboptimal methodology. The Scoliosis Research Society calls for rigorous studies supporting the role of exercises before including it as a treatment recommendation for scoliosis. OBJECTIVES: To determine the effect of a six-month Schroth PSSE intervention added to standard of care (Experimental group) on the Cobb angle compared to standard of care alone (Control group) in patients with AIS. METHODS: Fifty patients with AIS aged 10-18 years, with curves of 10°-45° and Risser grade 0-5 were recruited from a single pediatric scoliosis clinic and randomized to the Experimental or Control group. Outcomes included the change in the Cobb angles of the Largest Curve and Sum of Curves from baseline to six months. The intervention consisted of a 30-45 minute daily home program and weekly supervised sessions. Intention-to-treat and per protocol linear mixed effects model analyses are reported. RESULTS: In the intention-to-treat analysis, after six months, the Schroth group had significantly smaller Largest Curve than controls (-3.5°, 95% CI -1.1° to -5.9°, p = 0.006). Likewise, the between-group difference in the square root of the Sum of Curves was -0.40°, (95% CI -0.03° to -0.8°, p = 0.046), suggesting that an average patient with 51.2° at baseline, will have a 49.3° Sum of Curves at six months in the Schroth group, and 55.1° in the control group with the difference between groups increasing with severity. Per protocol analyses produced similar, but larger differences: Largest Curve = -4.1° (95% CI -1.7° to -6.5°, p = 0.002) and [Formula: see text] (95% CI -0.8 to 0.2, p = 0.006). CONCLUSION: Schroth PSSE added to the standard of care were superior compared to standard of care alone for reducing the curve severity in patients with AIS. TRIAL REGISTRATION: NCT01610908.

Intraoperative spinal cord monitoring using low intensity transcranial stimulation to remove post-activation depression of the H-reflex.

OBJECTIVE: To investigate whether low intensity transcranial electrical stimulation (TES) can be used to condition post-activation depression of the H-reflex and simultaneously monitor the integrity of spinal motor pathways during spinal deformity correction surgery. METHODS: In 20 pediatric patients undergoing corrective surgery for spinal deformity, post-activation depression of the medial gastrocnemius H-reflex was initiated by delivering two pulses 50-125ms apart, and the second H-reflex was conditioned by TES. RESULTS: Low intensity TES caused no visible shoulder or trunk movements during 19/20 procedures and the stimulation reduced post-activation depression of the H-reflex. The interaction was present in 20/20 patients and did not diminish throughout the surgical period. In one case, the conditioning effect was lost within minutes of the disappearance of the lower extremity motor evoked potentials. CONCLUSION: Post-activation depression was used to detect the arrival of a subthreshold motor evoked potential at the lower motor neuron. The interaction produced minimal movement within the surgical field and remained stable throughout the surgical period. SIGNIFICANCE: This is the first use of post-activation depression during intraoperative neurophysiological monitoring to directly assess the integrity of descending spinal motor pathways.

Development of a Competence-Based Spine Surgery Fellowship Curriculum Set of Learning Objectives in Canada.

STUDY DESIGN: Modified-Delphi expert consensus method. OBJECTIVE: The aim of this study was to develop competence-based spine fellowship curricula as a set of learning goals through expert consensus methodology in order to provide an educational tool for surgical educators and trainees. Secondarily, we aimed to determine potential differences among specialties in their rating of learning objectives to defined curriculum documents. SUMMARY OF BACKGROUND DATA: There has been recent interest in competence-based education in the training of future surgeons. Current spine fellowships often work on a preceptor-based model, and recent studies have demonstrated that graduating spine fellows may not necessarily be exposed to key cognitive and procedural competencies throughout their training that are expected of a practicing spine surgeon. METHODS: A consensus group of 32 spine surgeons from across Canada was assembled. A modified-Delphi approach refined an initial fellowship-level curriculum set of learning objectives (108 cognitive and 84 procedural competencies obtained from open sources). A consensus threshold of 70% was chosen with up to 5 rounds of blinded voting performed. Members were asked to ratify objectives into either a general comprehensive or focused/advanced curriculum. RESULTS: Twenty-eight of 32 consultants (88%) responded and participated in voting rounds. Seventy-eight (72%) cognitive and 63 (75%) procedural competency objectives reached 70% consensus in the first round. This increased to 82 cognitive and 73 procedural objectives by round 4. The final curriculum document evolved to include a general comprehensive curriculum (91 cognitive and 53 procedural objectives), a focused/advanced curriculum (22 procedural objectives), and a pediatrics curriculum (22 cognitive and 9 procedural objectives). CONCLUSION: Through a consensus-building approach, the study authors have developed a competence-based curriculum set of learning objectives anticipated to be of educational value to spine surgery fellowship educators and trainees. To our knowledge, this is one of the first nationally based efforts of its kind that is also anticipated to be of interest by international colleagues.

The effect of Schroth exercises added to the standard of care on the quality of life and muscle endurance in adolescents with idiopathic scoliosis-an assessor and statistician blinded randomized controlled trial: "SOSORT 2015 Award Winner".

BACKGROUND: In North America, care recommendations for adolescents with small idiopathic scoliosis (AIS) curves include observation or bracing. Schroth scoliosis-specific exercises have demonstrated promising results on various outcomes in uncontrolled studies. This randomized controlled trial (RCT) aimed to determine the effect of Schroth exercises combined with the standard of care on quality-of-life (QOL) outcomes and back muscle endurance (BME) compared to standard of care alone in patients with AIS. MATERIAL AND METHODS: Fifty patients with AIS, aged 10-18 years, with curves 10-45 °, recruited from a scoliosis clinic were randomized to receive standard of care or supervised Schroth exercises plus standard of care for 6 months. Schroth exercises were taught over five sessions in the first two weeks. A daily home program was adjusted during weekly supervised sessions. The assessor and the statistician were blinded. Outcomes included the Biering-Sorensen (BME) test, Scoliosis Research Society (SRS-22r) and Spinal Appearance Questionnaires (SAQ) scores. Intention-to-treat (ITT) and per protocol (PP) linear mixed effects models were analyzed. Because ITT and PP analyses produced similar results, only ITT is reported. RESULTS: After 3 months, BME in the Schroth group improved by 32.3 s, and in the control by 4.8 s. This 27.5 s difference in change between groups was statically significant (95 % CI 1.1 to 53.8 s, p = 0.04). From 3 to 6 months, the self-image improved in the Schroth group by 0.13 and deteriorated in the control by 0.17 (0.3, 95 % CI 0.01 to 0.59, p = 0.049). A difference between groups for the change in the SRS-22r pain score transformed to its power of four was observed from 3 to 6 months (85.3, 95 % CI 8.1 to 162.5, p = 0.03), where (SRS-22 pain score)(4) increased by 65.3 in the Schroth and decreased by 20.0 in the control group. Covariates: age, self-efficacy, brace-wear, Schroth classification, and height had significant main effects on some outcomes. Baseline ceiling effects were high: SRS-22r (pain = 18.4 %, function = 28.6 %), and SAQ (prominence = 26.5 %, waist = 29.2 %, chest = 46.9 %, trunk shift = 12.2 % and shoulders = 18.4 %). CONCLUSIONS: Supervised Schroth exercises provided added benefit to the standard of care by improving SRS-22r pain, self-image scores and BME. Given the high prevalence of ceiling effects on SRS-22r and SAQ questionnaires' domains, we hypothesize that in the AIS population receiving conservative treatments, different QOL questionnaires with adequate responsiveness are needed. TRIAL REGISTRATION: Schroth Exercise Trial for Scoliosis NCT01610908.

Predicting success or failure of brace treatment for adolescents with idiopathic scoliosis.

Adolescent idiopathic scoliosis (AIS) is a three-dimensional spinal deformity. Brace treatment is a common non-surgical treatment, intended to prevent progression (worsening) of the condition during adolescence. Estimating a braced patient's risk of progression is an essential part of planning treatment, so method for predicting this risk would be a useful decision support tool for practitioners. This work attempts to discover whether failure of brace treatment (progression) can be predicted at the start of treatment. Records were obtained for 62 AIS patients who had completed brace treatment. Subjects were labeled as "progressive" if their condition had progressed despite brace treatment and "non-progressive" otherwise. Wrapper-based feature selection selected two useful predictor variables from a list of 14 clinical measurements taken from the records. A logistic regression model was trained to classify patients as "progressive" or "non-progressive" using these two variables. The logistic regression model's simplicity and interpretability should facilitate its clinical acceptance. The model was tested on data from an additional 28 patients and found to be 75 % accurate. This accuracy is sufficient to make the predictions clinically useful. It can be used online: http://www.ece.ualberta.ca/~dchalmer/SimpleBracePredictor.html .

Interpretation of surgical neuromonitoring data in Canada: a survey of practising surgeons.

Intraoperative neuromonitoring is a specialized skill set performed in the operating room to reduce the risk of neurologic injury. There appears to be a shortage of qualified personnel and a lack of Canadian guidelines on the performance of the task. We distributed a web-based survey on the attitude of the surgeons to the interpretation of intraoperative neuromonitoring data among surgeons who use the technique. At present, most of the interpretation is performed by either technologists or by the surgeons themselves. Most surgeons would prefer professional oversight from a neurologist or neurophysiologist at the doctoral level. There is a lack of personnel in Canada with the appropriate training and expertise to interpret intraoperative neuromonitoring data.

Effect of Schroth exercises on curve characteristics and clinical outcomes in adolescent idiopathic scoliosis: protocol for a multicentre randomised controlled trial.

INTRODUCTION: The promising results of Schroth scoliosis-specific exercises for adolescent idiopathic scoliosis found in low-quality studies will be strengthened by confirmation in a randomised controlled trial. RESEARCH QUESTIONS: 1. Are Schroth exercises combined with standard care for 6 months more effective than standard care alone in improving radiographic and clinical outcomes for adolescents with idiopathic scoliosis? 2. Will the outcomes of the control group (who will be offered Schroth therapy delayed by 6 months) improve after 6 months of Schroth therapy? 3. Are the effects maintained 6 months after discontinuing the supervised intervention? DESIGN: This is an assessor-blinded and statistician-blinded randomised controlled trial with transfer of the controls to the exercise group after 6 months. PARTICIPANTS AND SETTING: Two hundred and fifty-eight consecutive adolescents with idiopathic scoliosis, aged 10 to 16 years, treated with or without a brace, with curves between 10 and 45 deg Cobb and Risser sign ≤ 3 will be recruited from three scoliosis clinics. INTERVENTION: Combined with standard care, the Schroth group will receive five individual training sessions, followed by weekly group classes and daily home exercises for 6 months. CONTROL: Controls will only receive standard care consisting of observation or bracing, and will be offered Schroth therapy 6 months later. MEASUREMENTS: Curve severity (Cobb angle) and vertebral rotation will be assessed from radiographs at baseline, 6 and 12 months. Secondary clinical outcomes (back muscle endurance, surface topography measures of posture, and self-reported perceived spinal appearance and quality of life) will be assessed at baseline, and every 3 months until 1-year follow-up. ANALYSIS: Data will be analysed using intention-to-treat linear mixed models. DISCUSSION: The results will demonstrate whether Schroth exercises combined with standard of care can improve outcomes in adolescents with idiopathic scoliosis. This study has potential to influence clinical practice worldwide, where exercises are not routinely prescribed for adolescents with idiopathic scoliosis.

A comparison of a commercially made pedicle stimulating probe with a custom-made device: does the commercial device detect pedicle wall breaches more reliably?

STUDY DESIGN: Clinical trial. OBJECTIVE: To compare the efficacy of a commercially available stimulating pedicle probe with a custom-made probe for the detection of pedicle wall breaches during screw insertion for the surgical correction of scoliosis. SUMMARY OF BACKGROUND DATA: Stimulus triggered electromyography has been used to detect small breaches in the walls of the spinal pedicles during pedicle screw insertion. We routinely use a reusable, custom-made clip that can be attached to the screw, pedicle probe, or other instruments. Commercial systems are available in which the instrument is electrically instrumented to deliver current. METHODS: In five patients (173 pairs of tests), we compared the threshold current required to trigger an electromyographic response during testing of the pedicle. Each track or screw was tested with both the custom-made and the commercial probe and the threshold current recorded. RESULTS: Both systems were able to detect pedicle wall breaches using triggered electromyography. The threshold current recorded was not significantly different between the two systems (P > 0.1, paired t test) nor was the difference (0.16 mA) clinically significant. CONCLUSION: No difference was found between the thresholds detected with either system. There is however, a significant difference in the costs of the two probe systems.

Superior mesenteric artery syndrome following spinal deformity correction.

BACKGROUND: Superior mesenteric artery syndrome is a known complication associated with the correction of spinal deformity. Recent investigations of this disorder have focused on patient height and weight. We are not aware of any published study examining the degree of deformity, type of curve, or magnitude of correction, and to our knowledge all of the reported literature on this syndrome lacks control data. The purpose of this study was to examine the relationship between the correction of spinal deformity and the development of superior mesenteric artery syndrome in patients with scoliosis. Our hypothesis was that greater correction of spinal deformity would increase the risk of the development of superior mesenteric artery syndrome. METHODS: A case-control study was performed over a five-year period. The primary outcome measure was the development of superior mesenteric artery syndrome. The predictor variables that were considered included demographic characteristics; preoperative height, weight, and body mass index; aspects of the deformity, including curve magnitude, Lenke curve classification, and correction; and operative factors, including surgical approach, estimated blood loss, and the presence of operative hypotension. RESULTS: A review of the records on 364 surgical procedures for scoliosis identified seventeen cases of superior mesenteric artery syndrome. Thirty-four subjects who had had surgery for scoliosis but no superior mesenteric artery syndrome were randomly selected as controls. Eight of the seventeen subjects with superior mesenteric artery syndrome had undergone a two-stage procedure (compared with one of the thirty-four controls, p < 0.001), nine of the seventeen had had combined anterior and posterior procedures (compared with two of the thirty-four controls, p < 0.001), and seven of the seventeen had had a thoracoplasty (compared with two of the thirty-four controls, p < 0.001). No significant differences were noted between the groups with regard to demographic factors. Compared with the controls, the patients in whom superior mesenteric artery syndrome developed were shorter (by a mean of 7.1 cm, p = 0.03), weighed less (by a mean of 11.5 kg, p = 0.001), had a lower body mass index (p = 0.003), had a greater minimal thoracic curve magnitude achieved by bending (a mean of 12 degrees greater [45 degrees for subjects with superior mesenteric artery syndrome and 33 degrees for controls], p = 0.015), had a lower percent correction of the thoracic curve on bending (a mean of 11% lower, p = 0.025), and had more lumbar lateralization (88%, compared with 61% in the control group, had a Lenke lumbar modifier of B or C instead of A, p = 0.008). Multivariate logistic regression analysis identified a staged procedure (odds ratio, 31.0), the lumbar modifier (odds ratio, 9.06), body mass index (odds ratio, 7.75), and thoracic stiffness (odds ratio, 6.67) as the most predictive of the development of superior mesenteric artery syndrome. CONCLUSIONS: Preoperative identification of the risk factors described above in conjunction with preoperative nutritional maximization should be considered in order to limit the prevalence of superior mesenteric artery syndrome in patients undergoing surgical correction of spinal deformity.