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.

Consensus statement on networks for high-quality rural anesthesia, surgery, and obstetric care in Canada.

OBJECTIVE: To describe the essential components of well-resourced and high-functioning multidisciplinary networks that support high-quality anesthesia, surgery, and maternity care for rural Canadians, delivered as close to home as possible. COMPOSITION OF THE COMMITTEE: A volunteer Writers' Group was drawn from the Society of Obstetricians and Gynaecologists of Canada, the Society of Rural Physicians of Canada, the Royal College of Physicians and Surgeons of Canada, the Canadian Association of General Surgeons, the College of Family Physicians of Canada, and the Association of Canadian University Departments of Anesthesia. METHODS: A collaborative effort over the past several years among the professional stakeholders has culminated in this consensus statement on networked care designed to integrate and support a specialist and non-specialist, urban and rural, anesthesia, surgery, and maternity work force into high-functioning networks based on the best available evidence. REPORT: Surgical and maternity triage needs to be embedded within networks to address the tensions between sustainable regional programs and local access to care. Safety and quality must be demonstrated to be equivalent across similar patients and procedures, regardless of network site. Triage of patients across multiple sites is a quality outcome metric requiring continuous iterative scrutiny. Clinical coaching between rural and regional centres can be helpful in building and sustaining high-functioning networks. Maintenance of quality and the provision of continuing professional development in low-volume settings represent a mutual value proposition. CONCLUSION: The trusting relationships that are foundational to successful networks are built through clinical coaching, continuing professional development, and quality improvement. Currently, a collaborative effort in British Columbia is delivering a provincial program-Rural Surgical Obstetrical Networks-built on the principles and supporting evidence described in this consensus statement.

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 ).

Factors influencing spinal curvature measurements on ultrasound images for children with adolescent idiopathic scoliosis (AIS).

The measurements of spinal curvatures using the ultrasound (US) imaging method on children with scoliosis have been comparable with radiography. However, factors influencing the reliability and accuracy of US measurement have not been studied. The purpose of this study is to investigate the effects of curve features and patients' demographics on US measurements and to determine which factors influence the reliability and accuracy. Two hundred children with scoliosis were recruited and scanned with US by one experienced operator and three trainees. One experienced rater measured the proxy Cobb angles from US images twice one week apart and compared the results with clinical radiographic records. The correlation and accuracy between the US and radiographic measurements were subdivided by different curve severities, curve types, subjects' weight status and US acquisition experiences. A total of 326 and 313 curves were recognized from radiographs and US images, respectively. The mean Cobb angles of the 13 missing curves were 17.4±7.4° and 11 at the thoracic region. Among the 16 curves showing large discrepancy (≥6°) between US and radiographic measurements, 7 were main thoracic and 6 were lumbar curves. Twelve had axial vertebral rotation (AVR) greater than 8°. The US scans performed by the experienced operator showed fewer large discrepancy curves, smaller difference and higher correlation than the scans from the trainees (3%, 1.7±1.5°, 0.95 vs 6%, 2.4±1.8°, 0.90). Only 4% missing and 5% large discrepancy curves were demonstrated for US measurements in comparison to radiography. The missing curves were mainly caused by small severity and in the upper spinal region. There was a higher chance of the large discrepancy curves in the main thoracic and lumbar regions with AVR>8°. A skilled operator acquired better US images and led to more accurate measurements especially for those subjects with larger curvatures, AVR and body mass index (BMI).

Assessment of curve progression on children with idiopathic scoliosis using ultrasound imaging method.

PURPOSE: To investigate the threshold of the curve difference on ultrasound measurement relative to the previous radiographic measurements to detect curves progression in children who have idiopathic scoliosis (IS). METHODS: Two hundred children with IS (F:170, M:30; mean age: 14.6 ± 1.9) were recruited from a single center. A retrospective study on comparing the current ultrasound measurements with the previous radiographic measurements with threshold values from 3° to 8° to detect curve progression was conducted. The receiver operating characteristic (ROC) analysis, accuracy (ACC), and odd ratio (OR) were calculated to determine the optimal threshold value of the curve differences between ultrasound and previous radiographic measurement. RESULTS: Both thresholds of 4° and 5° for curve difference from ultrasound scans presented the sensitivities ≥ 0.90 and specificities ≥ 0.85, and can reduce by 73 and 79% of radiographs on the studied subjects, respectively. Especially, for 4° threshold, the negative likelihood ratio (LR-) was only 0.08, which indicated that there is only 8% probability that the subject has progressed if the US measurement detected non-progression. CONCLUSIONS: The ultrasound imaging method can be applied to identify curve progression in children with IS. Four degree is the preferred threshold value to detect the curve which had progressed, since it also had the lower rate of undetected progressed cases (false negatives).

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.

Results of ultrasound-assisted brace casting for adolescent idiopathic scoliosis.

BACKGROUND: Four factors have been reported to affect brace treatment outcome: (1) growth or curve based risk, (2) the in-brace correction, (3) the brace wear quantity, and (4) the brace wear quality. The quality of brace design affects the in-brace correction and comfort which indirectly affects the brace wear quantity and quality. This paper reported the immediate benefits and results on using ultrasound (US) to aid orthotists to design braces for the treatment of scoliosis. METHODS: Thirty-four AIS subjects participated in this study with 17 (2 males, 15 females) in the control group and 17 (2 males, 15 females) in the intervention (US) group. All participants were prescribed full time TLSO, constructed by either of the 2 orthotists in fabrication of spinal braces. For the control group, the Providence brace design system was adopted to design full time braces. For the intervention group, the custom standing Providence brace design system, plus a medical ultrasound system, a custom pressure measurement system and an in-house software were used to assist brace casting. RESULTS: In the control group, 8 of 17 (47%) subjects needed a total of 11 brace adjustments after initial fabrication requiring a total of 28 in-brace radiographs. Three subjects (18%) required a second adjustment. For the US group, only 1 subject (6%) required adjustment. The total number of in-brace radiographs was 18. The p value of the chi-square for requiring brace adjustment was 0.006 which was a statistically significant difference between the two groups. In the intervention group, the immediate in-brace correction as measured from radiographs was 48 ± 17%, and in the control group the first and second in-brace correction was 33 ± 19% and 40 ± 20%, respectively. The unpaired 2 sided Student's t test of the in-brace correction was significantly different between the US and the first follow-up of the control group (p = 0.02), but was not significant after the second brace adjustment (p = 0.22). CONCLUSIONS: The use of the 3D ultrasound system provided a radiation-free method to determine the optimum pressure level and location to assist brace design, resulting in decreased radiation exposure during follow-up brace evaluation, increased the in-brace correction, reduced the patients' visits to both brace adjustment and scoliosis clinics. However, the final outcomes could not be reported yet as some of patients are still under brace treatment. TRIAL REGISTRATION: NCT02996643, retrospectively registered in 16 December 2016.

Assessment of Curve Flexibility on Scoliotic Surgical Candidates Using Ultrasound Imaging Method.

The ultrasound imaging method was implemented to assess the spinal curve flexibility of scoliotic surgical candidates, or how much correction it can achieve while patients are bending or lying down. Fifteen participants were recruited. Pre-operative radiographs and ultrasound images in both standing and bending positions were acquired. The post-operative standing radiographs were obtained 1 wk after surgery. Two raters (RZ, EL) measured the ultrasound images twice, 1 wk apart. A curve correction index (CI) was developed to estimate the curve flexibility. The CI from the pre-operative bending radiograph, ultrasound and post-operative radiograph were 0.51 ± 0.18; R1: 0.74 ± 0.08 vs R2: 0.72 ± 0.09 and 0.60 ± 0.10, respectively. The correlation of CI between ultrasound and post-operative radiography was slightly higher than the pre-operative bending and post-operative radiography. This pilot study demonstrated the bending ultrasound method is a promising supplemental tool to assess curve flexibility before surgical intervention for scoliotic surgical candidates.

Surface Topography Classification Trees for Assessing Severity and Monitoring Progression in Adolescent Idiopathic Scoliosis.

STUDY DESIGN: A validation study. OBJECTIVE: The aim of this study was to independently validate the diagnostic accuracy of surface topography (ST) classification trees to identify curve severity and progression using a new sample of data in participants with adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Radiographs for diagnosing and monitoring AIS involve harmful radiation exposure repeated at successive clinical visits. Classification trees using a novel ST technique have been proposed to determine curve severity and progression noninvasively that could be used to monitor scoliosis. METHODS: Forty-five adolescents with AIS treated nonoperatively, with ST scans and radiographs at baseline and follow-up (1 year later), were recruited from a scoliosis clinic. The Cobb angle (CA) from radiographs determined curve severity as mild (10° < CA < 25°) or moderate/severe (CA ≥ 25°) and progression as an increase >5°.ST scans were analyzed to calculate the best plane of symmetry and associated deviation color map. Root mean squares and maximum deviation were calculated for each area of asymmetry. ST measurements were analyzed using two published decision trees developed to maximize sensitivity and negative predictive value. Curves were classified as mild or moderate/severe and curve progression was predicted. Accuracy statistics were calculated to evaluate performance. RESULTS: For curve severity, sensitivity and specificity were 95% and 35%, respectively. Negative and positive predictive values were 90% and 53%, respectively, with an accuracy of 61%. For curve progression, sensitivity and specificity were 73% and 44%, respectively. Negative and positive predictive values were 83% and 30%, respectively, with an accuracy of 51%. Assuming that mild and nonprogressive curves would not require an x-ray, the use of ST decision trees could eliminate 31% of x-rays. CONCLUSION: Decision trees showed strong negative predictive values and sensitivity suggesting it may be possible to safely use ST asymmetry analysis with validated decision trees to reduce x-rays in patients with mild and nonprogressive curves. LEVEL OF EVIDENCE: 2.

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.

Improvement on the Accuracy and Reliability of Ultrasound Coronal Curvature Measurement on Adolescent Idiopathic Scoliosis With the Aid of Previous Radiographs.

STUDY DESIGN: Retrospective study of the coronal curvature measurement on ultrasound (US) images with the aid of previous radiographs. OBJECTIVE: To compare the reliability and accuracy of the coronal curvature measurements from US images on children who have adolescent idiopathic scoliosis (AIS) with and without the knowledge of previous radiographs. SUMMARY OF BACKGROUND DATA: Using US imaging technique to measure coronal curvature on children with AIS has demonstrated high intra- and interrater reliabilities. However, the selection of end-vertebrae and the measurement difference between radiography and the US method were only moderately reliable. METHODS: Two raters measured the coronal curvatures from 65 AIS standing US spine images, without (measured one time) and with the aid of previous standing radiographs (measured two times). The intra- and interrater reliability, the correlation and the difference between the radiographic and US measurements, and the error index of the end-vertebrae selection were assessed. RESULTS: Overall, 109 curves were investigated. The intraclass correlation coefficients (ICC) of intra- and interrater reliability of the US coronal curvature measurement with the aid of previous radiographs (AOR) were 0.95 and 0.91, respectively. In comparison with the radiographic measurements, the correlation of AOR method (R) was 0.90 and the MAD was 2.8°; the corresponding results of the US measurement without the AOR (blinded US method) were 0.73° and 4.8°, respectively. The average error index on end-vertebral selection improved 43% with the AOR. CONCLUSION: The AOR method significantly improved reliability and accuracy of the spinal curvature measurement on US images compared with the blinded US method (P<0.001). It indicates that US standing images with the AOR can be used as a reliable and accurate nonionizing imaging method to monitor children with AIS. LEVEL OF EVIDENCE: 3.

How quantity and quality of brace wear affect the brace treatment outcomes for AIS.

PURPOSE: To determine the reliability of a prognostic curve progression model and the role of the quantity and quality of brace wear for adolescent idiopathic scoliosis (AIS) brace treatment. METHODS: To develop a curve progression model for full-time AIS brace treatment, 20 AIS subjects (Group 1) prescribed full-time thoracolumbar sacral orthosis (TLSO) were monitored and followed for 2 years beyond maturity. The developed curve progression model was: curve progression (in degrees) = 33 + 0.11 × Peterson risk (%) - 0.07 in-brace correction (%) - 0.45 × quality (%) - 0.48 × quantity (%) + 0.0062 × quantity × quality. To validate the model, 40 new (test) subjects (Group 2) who met the same inclusion criteria and used the same type of monitors, were monitored and followed for 2 years after bracing. RESULTS: For the 40 test subjects (Group 2), the average in-brace correction was 40 ± 22 %. The average quantity and quality of the brace wear were 56 ± 19 and 55 ± 17 %, respectively. Twelve subjects (30 %) progressed of which 10 subjects (25 %) required surgery and 28 subjects (70 %) showed no progression. The accuracy of the model to determine which patients would progress was 88 % (35/40) which was better than the Peterson's risk model (68 %; 26/40) alone. Patients who had the combined quantity times the quality over a threshold 43 % had a success treatment rate of 95 %. CONCLUSIONS: This study showed the prognostic model of brace treatment outcome on AIS patients treated with full-time TLSO was reliable. Both the quantity and quality of the brace wear were important factors in achieving successful brace treatment.

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.

Intra- and Inter-rater Reliability of Coronal Curvature Measurement for Adolescent Idiopathic Scoliosis Using Ultrasonic Imaging Method-A Pilot Study.

STUDY DESIGN: Retrospective reliability study of the coronal curvature measurement on ultrasound (US) imaging in adolescent idiopathic scoliosis (AIS). OBJECTIVES: To determine the intra- and inter-rater reliability and validity of the coronal curvature measurements obtained from US images. SUMMARY OF BACKGROUND DATA: Cobb angle measurements on radiographs are the usual method to diagnose and monitor the progression of scoliosis. Repeated ionizing radiation exposure is a frequent concern of patients and their families. Use of US imaging method to measure coronal curvature in children who have idiopathic scoliosis has not been clinically validated. METHODS: The researchers scanned 26 subjects using a medical 3-dimensional US system. Spinal radiographs were obtained on the same day from the local scoliosis clinic. Three raters used the center of lamina method to measure the coronal curvature on the US images twice 1 week apart. The raters also measured the Cobb angle on the radiographs twice. Intra- and inter-rater reliability of the coronal curvature measurement from the US images was analyzed using intra-class correlation coefficients. The correlation coefficient of the US coronal curvature measurements was compared with the Cobb angles. RESULTS: The intra-class correlation coefficient (2,1) values of intra- and inter-rater reliability on the US method were greater than 0.80. Standard error of measurement on both of the intra- and inter-rater US methods was less than 2.8°. The correlation coefficient between the US and radiographic methods ranged between 0.78 and 0.84 among 3 raters. CONCLUSIONS: The US method illustrated substantial intra- and inter-rater reliability. The measurement difference between radiography and the US method was within the range of clinically acceptable error (5°). The US method may be considered a radiation-free alternative to assess children with scoliosis of mild to moderate severity.

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.