The SPoRT concept of bracing for idiopathic scoliosis.

The SPoRT (acronym: Symmetrical, Patient-oriented, Rigid, Three-dimensional, active) concept of bracing is a new way to build braces based on our 20 years of experience and the biomechanical principles of scoliosis correction, inclusive of the Sibilla and Sforzesco braces. The concept always requires a custom brace, which is made according to the patient's individual requirements. New technologies such as CAD-CAM can be applied, and often for better results, without the customary use of prebuilt forms whose measurements are stored in databases. Once the initial draft brace is completed, a final test must be made on the patient to modify and adapt it, depending on his or her real interaction between the body and the brace. The results that are today available on the SPoRT concept relate to the Sforzesco brace and are necessarily short-term, because the first treated patients are now reaching the fourth-year follow-up examination and haven't yet completed their treatments. On the basis of the initial evaluations, we can state that the Sforzesco brace is more effective than the Lyon brace after 6 months of treatment and that the Sforzesco brace is equally effective as the Risser Plast brace.

How to improve aesthetics in patients with Adolescent Idiopathic Scoliosis (AIS): a SPoRT brace treatment according to SOSORT management criteria.

BACKGROUND: Aesthetics is a main goal of both conservative and surgical treatments in adolescent idiopathic scoliosis (AIS). Previously, we developed and validated a clinical scale - the Aesthetic Index (AI)--in order to measure aesthetic impairment and changes during treatment. AIM: To verify the efficacy of bracing on aesthetics in AIS. STUDY DESIGN: Prospective Cohort Study. POPULATION: Thirty-four consecutive patients, age 13.2 +/- 3.7, initial Cobb Angle 32 +/- 12 degrees , ATR 10 +/- 4 degrees Bunnel, 11 males. METHODS: Patients with AI scores of at least 5/6 were included. Each of them had a brace prescription (18 to 23 hours per day), according to the SPoRT concept. AI was measured again after six months and at the end of treatment, and then the pre- and post-treatment scores compared. The Wilcoxon test was performed. RESULTS: Twenty-nine patients out of the 34 included completed the treatment and had six-month and final results; four patients were lost during the treatment, and one was fused. At baseline, median AI was 6 (95% IC 5-6) but the score decreased to 3 (95% IC 0-5; p < 0.05) after six months with brace, and this value was maintained in the 29 who completed the treatment (95% IC 1-6; p < 0.05 with respect to the baseline). CONCLUSION: Aesthetics can be improved in a clinically significant way when the brace treatment is performed according to the SPoRT concept and by following the SOSORT management criteria. This is a relevant result for patients and a major goal of scoliosis treatment, be it conservative or surgical. The use of a more sensitive tool like TRACE could more easily detect the clinical changes; nevertheless, AI proved sensible enough that its use in everyday clinical practice can be suggested.

Effectiveness of complete conservative treatment for adolescent idiopathic scoliosis (bracing and exercises) based on SOSORT management criteria: results according to the SRS criteria for bracing studies - SOSORT Award 2009 Winner.

BACKGROUND: The SRS criteria give the methodological reference framework for the presentation of bracing results, while the SOSORT criteria give the clinical reference framework for an appropriate bracing treatment. The two have not been combined in a study until now. Our aim was to verify the efficacy of a complete, conservative treatment of Adolescent Idiopathic Scoliosis (AIS)according to the best methodological and management criteria defined in the literature. METHODS: Study Design. Retrospective study. Population. We included all AIS patients respecting the SRS inclusion criteria (age 10 years or older; Risser test 0-2; Cobb degrees 25-40 degrees ; no prior treatment; less than one year post-menarchal) who had reached the end of treatment since our institute database start in 2003. Thus we had 44 females and four males, with an age of 12.8 +/- 1.6 at the commencement of the study. Methods. According to individual needs, two patients have been treated with Risser casts followed by Lyon brace, 40 with Lyon or SPoRT braces (14 for 23 hours per day, 23 for 21 h/d, and seven for 18 h/d at start), and two with exercises only (1 male, 1 female): these were excluded from further analysis. Outcome criteria. SRS (unchanged; worsened 6 degrees or more; over 45 degrees at the end of treatment; surgically treated; two years' follow-up); clinical (ATR, Aesthetic Index, plumbline distances); radiographic (Cobb degrees); and ISICO (optimal; minimal). Statistics. Paired ANOVA and t-test, Tukey-Kramer and chi-square test. RESULTS: Median reported compliance during the 4.2 +/- 1.4 treatment years was 90% (range 5-106%). No patient progressed beyond 45 degrees , nor was any patient fused, and this remained true at the two-year follow-up for the 85% that reached it. Only two patients (4%) worsened, both with single thoracic curve, 25-30 degrees Cobb and Risser 0 at the start. We found statistically significant reductions of the scoliosis curvatures (-7.1 degrees ): thoracic (-7.3 degrees ), thoracolumbar (-8.4 degrees ) and lumbar (-7.8 degrees ), but not double major. Statistically significant improvements have also been found for aesthetics and ATR. CONCLUSION: Respecting also SOSORT management criteria and thus increasing compliance, the results of conservative treatment were much better than what had previously been reported in the literature using SRS criteria only.

Specific exercises performed in the period of brace weaning can avoid loss of correction in Adolescent Idiopathic Scoliosis (AIS) patients: Winner of SOSORT's 2008 Award for Best Clinical Paper.

BACKGROUND: Exercises are frequently performed in order to improve the efficacy of bracing and avoid its collateral effects. Very frequently there is a loss of correction during brace weaning in AIS treatment. AIM: To verify the efficacy of exercises in reducing correction loss during brace weaning. STUDY DESIGN: Retrospective controlled study. POPULATION: Sixty-eight consecutive patients (eight males), age 15 +/- 1 and Cobb angle 22 +/- 8 degrees at start of brace weaning. METHODS: The start of brace weaning was defined as the first visit in which the wearing of brace for less than 18/24 hours was prescribed (according to our protocol, at Risser 3). Patients were divided into two groups according to whether or not exercises were performed: (1) EX (exercises), included 39 patients and was further divided into two sub-groups: SEAS (who performed exercises according to our institute's protocol, 14 patients) and OTH (other exercises, 25 patients) and (2) CON (controls, 29 patients) that was divided into two other sub-groups: DIS (discontinuous exercises, 19 patients) and NO (no exercises, 10 patients). Complete brace weaning was defined as the first visit in which the brace was no longer prescribed (ringapophysis closure or Risser 5, according to our protocol). ANOVA and Chi Square tests were performed. RESULTS: There was no difference between groups at baseline. However, at the end of treatment, 2.7 years after the start of the weaning process, Cobb angle increased significantly in both the DIS and NO groups (3.9 degrees and 3.1 degrees Cobb, respectively). The SEAS and OTH groups did not change. Comparing single groups, OTH (with respect to DIS) had a significant difference (P < 0.05). CONCLUSION: Exercises can help reduce the correction loss in brace weaning for AIS.

TRACE (Trunk Aesthetic Clinical Evaluation), a routine clinical tool to evaluate aesthetics in scoliosis patients: development from the Aesthetic Index (AI) and repeatability.

BACKGROUND: Aesthetic appearance is of primary importance in the treatment of adolescent idiopathic scoliosis (AIS), but to date tools for routine clinical practice have not become available. The aim of the present study is to develop such a tool and to verify its repeatability. INSTRUMENTATION: At first we developed the Aesthetic Index (AI), based on a three-point scale for asymmetry of the shoulders, scapulae and waist that we tested for 5 years. From this experience we developed another tool we called TRACE, the acronym of Trunk Aesthetic Clinical Evaluation; TRACE is a 12-point scale based on four sub-scales, shoulders (0-3), scapulae (0-2), hemi-thorax (0-2) and waist (0-4). POPULATION: Posterior-anterior (PA) photographs of one hundred-sixty AIS patients. PROCEDURES: Each photograph was scored in two independent tests by four observers using AI, and subsequently TRACE. DATA ANALYSIS: Kappa statistical analysis and 95% level of agreement were used; we also identified the minimum significant change (95% confidence level). RESULTS: We found the intra- and inter-raters repeatability of AI to be fair. Three points out of seven was the minimum significant change between two different evaluations. For TRACE, intra-rater repeatability was fair and inter-raters poor; but the minimum significant change was three (intra-rater), or four (inter-raters) out of twelve points. CONCLUSION: Widening the scale from 7 (AI) to 12 points (TRACE) increased the clinical sensitivity to changes of the aesthetic scale, even if TRACE has only a fair repeatability. TRACE is a no-cost tool for routine clinical practice in AIS patients. Due to the absence of other comparable validated tools, once the inherent measurement error is known and understood, its routine clinical use by physicians is advised.

Adult scoliosis can be reduced through specific SEAS exercises: a case report.

BACKGROUND: It has been known since many years that scoliosis can continue to progress after skeletal maturity: the rate of progression has shown to be linear, and it can be used to establish an individual prognosis. Once there is progression there is an indication for treatment: usually it is proposed a surgical one. There are very few papers on an alternative rehabilitation approach; since many years we propose specific SEAS exercises and the aim of this study is to present one case report on this approach. CASE PRESENTATION: All radiographs have been measured blindly twice using the same protractor by one expert physician whose repeatability error proved to be < 3 degrees Cobb; the average measurement has been used. In this case a 25 years old female scoliosis patient, previously treated from 14 (Risser 1) to 19 years of age with a decrease of the curve from 46 degrees to 37 degrees , showed a progression of 10 degrees Cobb in 6 years. The patient has then been treated with SEAS exercises only, and in one year progression has been reverted from 47 degrees to 28.5 degrees . CONCLUSION: A scoliosis curve is made of different components: the structural bony and ligamentous components, and a postural one that counts up to 9 degrees in children, while it has not been quantified in adults. This case shows that when adult scoliosis aggravates it is possible to intervene with specific exercises (SEAS) not just to get stability, but to recover last years collapse. The reduction of scoliotic curve through rehabilitation presumably does not indicate a reduction of the bone deformity, but rely on a recovery of the upright postural collapse. This reduction can decrease the chronic asymmetric load on the spine and, in the long run, reduce the risks of progression.

The Sforzesco brace can replace cast in the correction of adolescent idiopathic scoliosis: A controlled prospective cohort study.

BACKGROUND: The conservative treatment of adolescent idiopathic scoliosis (AIS) has traditionally been divided into two phases-correction and stabilisation-and casts, even if less used today, can be considered the best standard in the correction phase. Till the present, however, no comparison between cast and brace efficacy has been proposed. METHODS: This is a prospective cohort study with a retrospective control group. The aim was to verify if it is possible to obtain with a specifically developed rigid brace results comparable to a cast. We considered fifty AIS patients who had refused surgery, aged 14.1 +/- 1.5 years, with 46.7 +/- 7.8 degrees Cobb scoliosis. Thirty-two consecutive patients (with no drop-outs) were prospectively followed up with the Sforzesco brace (SBG), and compared against a retrospective group of eighteen patients treated with the Risser cast (RCG). The treatment time (the total correction phase) was 19 +/- 3 months. Out-of-brace x-rays were compared, as well as clinical results. RESULTS: Compliance and hours of treatment were higher in the RCG while all the other parameters were not different. We observed a reduction of 6 degrees Cobb and an important aesthetic gain in both groups (P<0.05). Three patients (6%) worsened, while 56% improved (36% at least 10 degrees , and 14% 15 degrees or more). The SBG did show results comparable to the RCG, with only minor differences in terms of scoliosis correction. On the contrary, straightening of the spine (decrease of the sagittal physiological curves) was much higher in the RCG but was not clinically significant in the SBG. CONCLUSION: In the corrective phase of AIS treatment it is possible with a specific rigid brace (Sforzesco - SPoRT concept) to obtain scoliosis correction similar to cast. Due to the human and social costs of casting, and worst sagittal profile results, Sforzesco brace should be the preferred method wherever possible.

The Sforzesco brace and SPoRT concept: a brace to replace cast in worst curves.

PURPOSE: Bracing still remains the most important conservative treatment for scoliosis; approaches to bracing are really many and diverse. The aim of this paper of this paper, is the presentation of the brace we recently developed (the Sforzesco brace and SPoRT concept) to face worst scoliosis, in the past treated through casting. METHODS: The SPoRT concept was born while we were looking for a new brace; it means Symmetric, Patient oriented, Rigid, Three-dimensional and Active. Details of construction and the biomechanical principle of its corrective action are reported. This brace has been used widely in the last 3 years. RESULTS: The Sforzesco brace showed to be more effective than the Lyon brace and as effective as the Risser cast on different clinical and radiological outcome measures in 2 different prospective study of best clinical practice. CONCLUSION: When compared to the other braces, the Sforzesco can find its place in the most important curves, in which there are no alternatives to try avoiding surgery. The SPoRT Concept appear a useful tool to interpret what happens with this brace, even if in the future could be overcome by new theories according to new (and awaited) results in the literature.

Clinical evaluation of scoliosis during growth: description and reliability.

UNLABELLED: The clinical evaluation, even today, remains a central point in the diagnosis, prognostic definition and treatment prescription regarding scoliosis. The clinical evaluation of a scoliotic patient has been established for a long time, but it has not been standardized. The aim of the present work is to report the most common clinical measures for the assessment of scoliosis, explain the usefulness of each clinical measurement, and report the repeatability and limits in order to help the physician in making appropriate clinical choices. METHODS: The height of the hump, the angle of trunk rotation, the sagittal and frontal profiles, and the Trunk Aesthetic Clinical Evaluation (TRACE) have been fully described, and their reliability and repeatability have been assessed. RESULTS: The measures analyzed showed good reliability and repeatability on the intra-operator basis. The inter-operator repeatability is usually not that good. CONCLUSION: The main measures of the clinical assessment of scoliotic patients have been tested, and their reliability has been evaluated. The knowledge of measurement error, as well as intra- and inter-operator reliability, are essential for the clinical evaluation and treatment of scoliosis. This is an unavoidable basis for decision making in the assessment and the treatment of scoliosis.

3-DEMO classification of scoliosis: a useful understanding of the 3(rd) dimension of the deformity.

The third-dimension of scoliosis represent a great challenge for clinicians used to think in two dimensions due to the classical radiographic representation of the deformity. This caused problems in everyday clinical approaches, and led to the development of new bidimensional classifications (King, Lenke) who tried in different ways to face these problems, mainly in a surgical perspective. Recently, some three-dimensional classifications have been proposed, all developed in laboratory by bioengineers. In this paper we present the existing classifications of scoliosis, both bi-dimensional and three-dimensional and we thoroughly discuss the 3-DEMO (3-D Easy Morphological) that has been first presented years ago, and recently thoroughly published; this classification has been developed by clinicians with the main aim of being understandable and easily applicable to everyday clinical life.

The SPoRT (Symmetric, Patient-oriented, Rigid, Three-dimensional, active) concept for scoliosis bracing: principles and results.

The biomechanical action of an orthesis for the conservative treatment of AIS has two goals: correction and stabilization. These goals have been pursued through very well established principles of correction, developed over the years, divided in terms of efficacy (the correct positioning of pushes, as well as through escape ways and proper drivers of the forces and stops) and acceptability (compliance, perfect body design, maximal freedom in the ADL). To achieve all these goals, the Sforzesco brace has been developed through progressive changes and verification. Finally, we discovered we had something new, and summarised it in the SPoRT acronym: Symmetric, Patient-oriented, Rigid, Three-dimensional, active. The SPoRT concept always requires a customised construction of the brace according to the patient's individual requirements. It's possible to apply CAD-CAM technologies, which usually allow us to obtain the best results in this case, but without using pre-built forms stored in databases, as is usually done. Once done, a final test must be made on the patient so as to change the first theoretical project and adapt it in the best possible way, depending on the real interaction between the body and the brace. The results that are today available on the SPoRT concept relate to the Sforzesco brace and necessarily are short-term, because the first treated patients are now reaching the third-year follow-up examination and haven't yet completed their treatments. According to first studies we can state that: tte Sforzesco brace is more effective than the Lyon brace after six months of treatment; the Sforzesco brace is equally effective as Risser Plast brace.

End-growth results of bracing and exercises for adolescent idiopathic scoliosis. Prospective worst-case analysis.

BACKGROUND: In the literature the rate of surgery for AIS (Adolescent Idiopathic Scoliosis) of 30 degrees ranges from 22.4% to 31% when braces are used, versus the natural history rate of 28.1%. When a complete conservative approach is used (braces and exercises), this rate decreases to the range of 3.8% to 7.3%. All these studies are retrospective. AIM: The aim was to evaluate the final results of a prospective set of patients treated in a center fully dedicated to a complete conservative treatment (exercises and braces) of AIS. MATERIALS AND METHODS: This is an everyday clinical, retrospective study on a prospective data base. The population included 112 AIS patients, 13.2+/-1.8 years old, with 23.4+/-11.5 degrees Cobb degrees at the start of treatment. All the patients had been treated with a full set of conservative treatments, including exercises, according to their individual needs. We used the SEAS (Scientific Exercises Approach to Scoliosis) protocol and the ISICO approach, while the orthosis used included: Risser cast, and the Lyon, Sforzesco-SPoRT, Sibilla-Chêneau and Lapadula braces. The patients had been followed up by the same physician, braces had been made and exercises had been applied by the same team. The outcomes were established for each single patient: The absolute aim was to avoid surgery, while the minimal and optimal outcomes were defined according to the starting curve. An efficacy analysis and worst-case analysis had been performed. RESULTS: The rate of surgery was 0.9% (efficacy analysis), and 4.5% (worst case); the minimal outcomes had been obtained in 99% of patients and the optimal ones in 84%. Overall, the curves over 40 degrees , which numbered eleven at the start of observation, were reduced to three. In total, eight patients exited the presumable area of risk in adulthood (final curve over 30 degrees ). The treatment produced a statistically significant reduction in the worst curves, and the best results have been obtained in the curves over 40 degrees. CONCLUSION: Provided the use of a complete conservative approach, there is very little doubt that it is possible to reduce the rate of surgery in AIS treatment.

Three-dimensional easy morphological (3-DEMO) classification of scoliosis, part I.

BACKGROUND: While scoliosis has, for a long time, been defined as a three-dimensional (3D) deformity, morphological classifications are confined to the two dimensions of radiographic assessments. The actually existing 3-D classification proposals have been developed in research laboratories and appear difficult to be understood by clinicians. AIM OF THE STUDY: The aim of this study was to use the results of a 3D evaluation to obtain a simple and clinically oriented morphological classification (3-DEMO) that might make it possible to distinguish among different populations of scoliotic patients. METHOD: We used a large database of evaluations obtained through an optoelectronic system (AUSCAN) that gives a 3D reconstruction of the spine. The horizontal view was used, with a spinal reference system (Top View). An expert clinician evaluated the morphological reconstruction of 149 pathological spines in order to find parameters that could be used for classificatory ends. These were verified in a mathematical way and through computer simulations: some parameters had to be excluded. Pathological data were compared with those of 20 normal volunteers. RESULTS: We found three classificatory parameters, which are fully described and discussed in this paper: Direction, the angle between spinal pathological and normal AP axis; Shift, the co-ordinates of the barycentre of the Top View ; Phase, the parameter describing the spatial evolution of the curve. Using these parameters it was possible to distinguish normal and pathological spines, to classify our population and to differentiate scoliotic patients with identical AP classification but different 3D behaviors. CONCLUSION: The 3-DEMO classification offers a new and simple way of viewing the spine through an auxiliary plane using a spinal reference system. Further studies are currently under way to compare this new system with the existing 3-D classifications, to obtain it using everyday clinical and x-rays data, and to develop a triage for clinical use.