In the juvenile and adolescent forms, treatment depends on the degree of deformity: - 10 - 20°: serial observation. - 20-50°: thermoplastic corsets (Boston, Cheneau or Milwaukee, according to where the apex of the main curve is located). - 40-50°: with Risser less than 3, surgical arthrodesis would be indicated; with Risser greater than or equal to 3, the remaining growth potential of the curve is low and observation may be considered in case it tends to progress in adulthood.

An 11-year-old, 6-month-old, premenarchal girl with known idiopathic scoliosis. The spine x-ray performed 6 months ago showed a left thoracolumbar curve of 18º (Cobb angle). The current x-ray shows a Cobb angle of 28º, with an iliac crest maturation (Risser's sign) of 2. At this stage of evolution, what is the most appropriate treatment to try to stop the progression of the curve?

Surgical intervention by spinal arthrodesis.

Bracing can reduce high degree curves and improve aesthetics immediately after the end of growth. Final results of a retrospective case series.

Recently it has been shown that idiopathic scoliosis (IS) curves can be reduced with bracing, and it has been proposed that this could be useful in non-surgically treated high degree curves even after Risser 3. Moreover, bracing has been shown to be able to improve aesthetics, and this could be another reason to treat some patients with cosmetic needs. Our aim is to preliminary check if results can be obtained in IS patients after Risser 3. Design. Retrospective uncontrolled cohort study. Inclusion criteria. All IS patients treated on a voluntary basis for aesthetic reasons and/or for curve reduction; Risser 4-5 at start; end of treatment reached. Population. 34 females and 2 males, age 16.2±1.6 years, Cobb angle 27.6°±8.9°. Treatment. Lyon or SPoRT braces 18 to 24 hours/day, specific SEAS exercises, rapid weaning (2-3 hours every 6 months). Outcome criteria: SRS (unchanged; worsened over 6°; over 45° at the end of treatment; surgically treated), radiographic and clinical. Statistics. ANOVA and chi-test. The reported compliance during the 2.8 ± 1.1 treatment years was 95.1%, while residual growth was 0.9 ± 1.1 cm. Improvements were found in 39% of this cohort, (46% in curves over 30°). Only 1 patient progressed 6°. We found highly statistically significant reductions of maximal (-4.4°), thoracic (-6.0°) and thoracolumbar (-6.6°) curves. Statistically significant improvements were found for Aesthetic Index. Before 20 years of age, even in skeletally mature patients, it is possible to reach radiographic and aesthetic improvements, although not as good as during growth. Correction is based on bone growth, but ligaments and neuromuscular control of posture can also be involved.

Immediate effects of scoliosis-specific corrective exercises on the Cobb angle after one week and after one year of practice.

We are unaware of any studies describing the immediate effects of scoliosis-specific exercises on the Cobb angle measured by radiograph. This study aimed to describe the differences between radiographs obtained with and without corrective exercises after initial training and after one year. A female with adolescent idiopathic scoliosis was first seen at age 13 years, 0 months with a Risser 0. She had a 43<supo</sup left lumbar, 15<supo</sup right thoracic curve. She was seen again after 6, 18 and 30 months and performed exercises from 18 to 30 months. She performed Barcelona Scoliosis Physical Therapy School (BSPTS) exercises for a four-curve type (lumbar dominant with pelvis deviation to the lumbar concave side). At 18 and 30 months, x-rays were obtained with and without performing corrective exercises. At 6 months, her lumbar and thoracic curves measured 41<supo</sup and 28<supo</sup, respectively. At 18 months, her lumbar and thoracic curves measured 47 <supo</sup and 30<supo</sup, respectively. Also at 18 months, immediately after her x-ray in the relaxed standing position, she performed her corrective exercises in standing with arms lowered for a second x-ray. Her lumbar and thoracic curves remained similar and measured 43<supo</sup and 32<supo</sup, respectively. At 30 months, she performed unsolicited corrective exercises during the x-ray. Her lumbar and thoracic curves measured 26<supo</sup and 41<supo</sup, respectively. Another x-ray in the relaxed position revealed lumbar and thoracic curves measuring 39<supo</sup and 35<supo</sup, respectively. The immediate effect of corrective exercises after a year of training was a 33 % improvement at the lumbar spine compared to only a 9 % improvement the previous year. After initial training, corrective exercises during a standing x-ray did not significantly improve the Cobb angle for the major lumbar curve compared to the relaxed standing x-ray. However, a year after performing exercises, unsolicited corrective exercises resulted in a significantly improved Cobb angle compared to relaxed standing for the curve primarily targeted by the exercise program. Improved exercise ability and spinal flexibility may have contributed to the improved Cobb angle.

The natural history of idiopathic scoliosis.

Background. The natural history of idiopathic scoliosis is a crucial issue in the planning and assessment of different treatment methods. This article presents the evaluation of scoliotic deformity in immature patients who have been in observation without any treatment. Material and methods. 159 patients (128 girls, 31 boys) were examined between 1971 and 2002. Skoliosis was diagnosed at a mean age of 6 years 4 months (range 2.1-8.10), and observation was concluded at a mean age of 16 years 11 months (range 14.6-20.3). The mean follow-up was 10 years 5 months. The prognostic factors analyzed were: age, sex, Cobb angle, Mehta angle, apical vertebral rotation, specific rotation, Risser test. The progression and regression of curvature was analyzed in different biological age periods, and was measured by calculating the difference in the Cobb angle on successive x-rays divided by the interval between x-rays. Results. The mean progression of curvature before age 5 was 5.7 degrees per year; in the 6-10 age bracket, 2.3 degrees per year; in the 11-15 age bracket, 7.4 degrees per year; in the >15 age bracket, 0.3 degrees per year. The mean progression for patients with Risser 1 was 8.8 degrees per year; Risser 2, 7.3 degrees per year; Risser 3, 5.1 per year; Risser 4, 2.1 degrees per year; Risser 5, 0.3 degrees per year. Conclusions. The progression of curvature in idiopathic scoliosis is variable, and is influenced by age. Knowledge of the natural history of idiopathic scoliosis is a crucial tool in predicting the development of spinal curvature. The Risser test and biological age are the only effective predictors of progression.

Mild angle early onset idiopathic scoliosis children avoid progression under FITS method (Functional Individual Therapy of Scoliosis).

Physiotherapy for stabilization of idiopathic scoliosis angle in growing children remains controversial. Notably, little data on effectiveness of physiotherapy in children with Early Onset Idiopathic Scoliosis (EOIS) has been published.The aim of this study was to check results of FITS physiotherapy in a group of children with EOIS.The charts of the patients archived in a prospectively collected database were retrospectively reviewed. The inclusion criteria were:diagnosis of EOIS based on spine radiography, age below 10 years, both girls and boys, Cobb angle between 118 and 308, Risser zero, FITS therapy, no other treatment (bracing), and a follow-up at least 2 years from the initiation of the treatment. The criterion for curve progression were as follows: the Cobb angle increase of 68 or more, for curve stabilization; the Cobb angle was 58 comparing to the initial radiograph,for curve correction; and the Cobb angle decrease of 68 or more at the final follow-up radiograph.There were 41 children with EOIS, 36 girls and 5 boys, mean age 7.71.3 years (range 4 to 9 years) who started FITS therapy. The curve pattern was single thoracic (5 children), single thoracolumbar (22 children) or double thoracic/thoracolumbar (14 children), totally 55 structural curvatures. The minimum follow-up was 2 years after initiation of the FITS treatment, maximum was 16 years, mean 4.8 years). At follow-up the mean age was 12.53.4 years. Out of 41 children, 10 passed pubertal growth spurt at the final follow-up and 31 were still immature and continued FITS therapy. Out of 41 children, 27 improved, 13 were stable, and one progressed. Out of 55 structural curves, 32 improved, 22 were stable and one progressed. For the 55 structural curves, the Cobb angle significantly decreased from 18.085.48 at first assessment to 12.586.38 at last evaluation,p<0.0001, paired t-test. The angle of trunk rotation decreased significantly from 4.782.98 to 3.282.58 at last evaluation, p<0.0001,paired t-test.FITS physiotherapy was effective in preventing curve progression in children with EOIS. Final postpubertal follow-up data is needed.

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.

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. 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. 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). 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. 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. ClinicalTrials.gov , NCT01610908 . Retrospectively registered on April 2, 2012 (first posted on June 4, 2012 - https://clinicaltrials.gov/ct2/keydates/NCT01610908 ).

CONTRAIS: CONservative TReatment for Adolescent Idiopathic Scoliosis: a randomised controlled trial protocol.

Idiopathic scoliosis is a three-dimensional structural deformity of the spine that occurs in children and adolescents. Recent reviews on bracing and exercise treatment have provided some evidence for effect of these interventions. The purpose of this study is to improve the evidence base regarding the effectiveness of conservative treatments for preventing curve progression in idiopathic scoliosis.  Previously untreated girls and boys with idiopathic scoliosis, 9 to 17 years of age with at least one year of remaining growth and a curve Cobb angle of 25-40 degrees will be included. A total of 135 participants will be randomly allocated in groups of 45 patients each to receive one of the three interventions. All three groups will receive a physical activity prescription according to the World Health Organisation recommendations. One group will additionally wear a hyper-corrective night-time brace. One group will additionally perform postural scoliosis-specific exercises. Participation in the study will last until the curve has progressed, or until cessation of skeletal growth. OUTCOME variables will be measured every 6 months. The primary outcome variable, failure of treatment, is defined as progression of the Cobb angle more than 6 degrees, compared to the primary x-ray, seen on two consecutive spinal standing x-rays taken with 6 months interval. Secondary outcome measures include the SRS-22r and EQ5D-Y quality of life questionnaires, the International Physical Activity Questionnaire (IPAQ) short form, and Cobb angle at end of the study. This trial will evaluate which of the tested conservative treatment approaches that is the most effective for patients with adolescent idiopathic scoliosis. NCT01761305.

Prediction of curve progression in idiopathic scoliosis based on initial roentgenograms. A proposal of an equation.

A retrospective study was conducted in 122 patients with idiopathic scoliosis who were followed for more than 2 years. There were 58 patients who showed 5 degrees (Cobb) or more progression, and 41 patients who showed no progression. Only those who did not receive any treatment or who failed to comply with brace treatment were selected, to eliminate the effect of treatment. In the early phase of the study, 12 parameters were put into a multivariate analysis to observe the relative weight of each of them, which led the authors to eliminate the following five parameters: 1) Cobb angle, 2) rotation of the apical vertebra, 3) deviation of the apical vertebra, 4) Risser's expected correction: (standing angle--supine angle) X 3, and 5) maturation index of the iliac apophysis. Through a multiple regression analysis, an equation was obtained to correlate the predictive and the real progression within 10 degrees deviation.

Clinical improvement and radiological progression in a girl with early onset scoliosis (EOS) treated conservatively--a case report.

Chêneau-Brace treatment of a certain standard reduces the rate of surgery, prevents progression and in a certain patient population leads to marked improvement of Cobb angle and cosmetic appearance. During the last two years a patient refusing surgery with a double major curvature of initially 60 degrees showed a clear cosmetic improvement and a clear radiological progression at the same time. The findings of this patient have been reviewed in order to find out how cosmetic appearance and Cobb angle can develop differently. The patient entered conservative treatment at the age of 13 years, premenarchial with Tanner II and a Cobb angle of 60 degrees thoracic and 59 degrees lumbar. The angle of trunk rotation (ATR; Scoliometer) was 13 degrees thoracic and 13 degrees lumbar. We have documented the findings of this patient (Surface topography, ATR, Cobb angles and angles of vertebral rotation (according to Raimondi) during the treatment period (27 Month) until 2 years after the onset of menarche. After a treatment time of 27 Month the Cobb angle increased to 74 degrees thoracic and 65 degrees lumbar. The angles of vertebral rotation according to Raimondi increased slightly from 26 degrees thoracic and 28 degrees lumbar to 30 degrees thoracic and 28 degrees lumbar. The ATR improved to 12 degrees thoracic and 5 degrees lumbar while Lateral deviation improved from 22.4 mm to 4.6 mm and average surface rotation improved from 10.6 degrees to 6 degrees. In the X-rays a reduction of decompensation was visible. The patient felt comfortable with the cosmetic result. Conservative treatment may improve cosmetic appearance while the curve progresses radiologically. This could be explained by assuming that (1) the Rigo Chêneau brace is able to improve cosmetic appearance by changing the shape of the thorax when the curve itself is too stiff to be corrected by a brace, that (2) reduction of decompensation leads to significant cosmetical improvements or (3) that the patient gained weight and therefore the deformation is masked. However, the weight the patient gained cannot explain the cosmetical improvement in this case. Conservative treatment with a certain standard of quality seems a viable alternative for patients with Cobb angles of > 60 degrees when surgical treatment is refused. Specialists in scoliosis management should be aware of the fact that curve progression can occur even if the clinical measurements show an improvement.

A prospective randomized controlled trial of the natural history of idiopathic scoliosis versus treatment with the SpineCor brace. Sosort Award 2011 winner.

The purpose of this randomized controlled trial was to evaluate the efficacy of the Dynamic SpineCor brace for early idiopathic scoliosis (15°-30°) compared to the natural evolution of the disease. 68 patients participated in this study (32 treated and 36 controls) with at least 5 years follow-up. The inclusion criteria were: 1) high risk of evolution: family history and/or proven progressive; 2) no significant pathological malformation of the spine; 3) initial Cobb angle between 15° and 30°; 4) risser 0, 1 or 2. Assessment of brace efficacy included the percentage of patients who have 5º or less curve progression and the percentage of patients who have 6º or more progression at skeletal maturity. At five-year follow-up a correction was achieved in 50% of treated patient and only in 9.5% of controls, stabilization in 42.3% treated and 47.7% in controls and progression in 26.9% for the treated group and 42.8% for controls. For the control patients we considered as a failure if the Cobb angle worsened by more then 5° from the original angle and the patient then received treatment. The results 5 years after the treatment suggested that the SpineCor brace reduced the probability of the progression of early idiopathic scoliosis comparing with its natural history. Moreover, the positive outcome appears to be maintained in the long term.

Treatment of lumbar curves in scoliotic adolescent females with progressive action short brace: a case series based on the Scoliosis Research Society Committee Criteria.

A prospective interventional study. To determine the outcomes of adolescents affected by idiopathic lumbar scoliosis treated with a progressive action short brace (PASB). The efficacy of conservative treatment of scoliosis is still debated. In a recent study, we showed that the PASB was effective in correcting deformities in adolescents with idiopathic thoracolumbar scoliosis. The purpose of the present study was to extend our preliminary findings by determining the results of PASB treatment in scoliotic adolescents with lumbar curves. Patients were 40 adolescent girls (age [mean ± SD] = 11.6 ± 0.7 yr]) with lumbar curves and a pretreatment Risser score between 0 and 2. All patients were prescribed with a full-time PASB. The minimum duration of follow-up was 24 months (mean ± SD = 41.6 ± 34.5 mo). Anteroposterior radiographs were used to estimate the curve magnitude (CM) and the torsion of the apical vertebra (TA) at 5 time points: beginning of treatment (t1), 1 year after the beginning of treatment (t2), intermediate time between t1 and t4 (t3), end of weaning (t4), and 2-year minimum follow-up from t4 (t5). Three outcomes were distinguished: curve correction, curve stabilization, and curve progression. RESULTS.: A significant reduction in CM was achieved from t1 (Cobb angle [mean ± SD] = 26.4° ± 2.8) to t5 (Cobb angle [mean ± SD] = 13.8° ± 7.9; P < 0.001). Likewise, the PASB reduced TA from Perdriolle rotation angles of 10.8° (SD = 3.7) at t1 to 7.9° (SD = 4.2) at t5 (P < 0.05). Curve correction was accomplished in 82.5% of patients, whereas curve stabilization was obtained in 17.5% of patients. None of the patients experienced curve progression. The PASB allows a complete curve correction in most cases. No patients exhibited curve progression.

Cobb Angle Reduction in a Nearly Skeletally Mature Adolescent (Risser 4) After Pattern-Specific Scoliosis Rehabilitation (PSSR).

It has long been said that exercise-based rehabilitation for scoliosis is ineffective, however, these reports studied general exercises. This case report is a prospective one-year follow-up of a nearly skeletally mature adolescent female (Risser 4) with idiopathic scoliosis treated with Pattern-Specific-Scoliosis Rehabilitation (PSSR). The 15-year old patient recommended for surgery (initial Cobb angle of 45°) completed a 16-hour scoliosis-specific back school (according to Schroth Best Practice<sup®</sup), over the course of five weeks. She continued with her program at home, and followed up with the lead author after 6 months and 1 year. The patient achieved a 13° reduction in her primary thoracic Cobb angle. Postural improvement and reduction in trunk rotation (ATR) was also achieved (-4° in the thoracic spine, and -5° in the lumbar spine). Pattern-specific scoliosis rehabilitation (PSSR) works to reduce the asymmetrical load caused by scoliosis. PSSR is effective in stabilizing Cobb angle, and can, in some cases, reduce Cobb angle in adolescents. Patients recommended for surgery may be candidates for conservative treatment. This case suggests that the practice of discontinuing conservative treatment at Risser stage 4 should be re-evaluated.

Preliminary results and worst-case analysis of in patient scoliosis rehabilitation.

The purpose of this study was to assess the effectiveness of a scoliosis-specific rehabilitation programme as it is carried out in the Katharina Schroth Spinal Deformities Rehabilitation Center. Physiotherapy in the treatment of scoliosis patients is still regarded as ineffective since the study by the American Orthopedic Association in 1941, which showed that general exercises could not influence the natural history of scoliosis. However, specific exercise programmes were not known in the USA at that time. This preliminary study started in 1989 with the following inclusion criteria: (1) diagnosis of idiopathic scoliosis; (2) risser sign < 4; (3) no treatment other than physiotherapy; (4) first control after 1-3 years during repeated in patient treatment; (5) standing AP radiograph taken not more than 6 months before the first in patient treatment. A total of 181 scoliosis patients, with an average age of 12.7 years and an average angle of curvature of 27% according to Cobb, were included in this study. The average risser sign was 1.4, the average follow-up 33 months. The Cobb angle of the major curve was measured in a standardized way. The results of our preliminary study were compared to natural history as known from literature. For the worst-case analysis additionally a questionnaire was sent to the non-repeaters treated at our centre at the same time (1989 and 1990) as the patient sample described above, taking into account the same inclusion criteria for this patient sample except point 4. Results showed that progression as usually defined (increase in curvature of 5 degrees or more per year) has not been found in the preliminary study. The patient sample of this study was divided into different age groups and different groups of curve magnitude, for comparison with other studies. Additional to the patient sample of the preliminary study, 116 of the patients from the years 1989 and 1990 fulfilled the inclusion criteria of the preliminary study with the exception of point 4. These patients formed the questionnaire sample for the worst-case analysis showing that the progression rate of the 181 patients from the preliminary study and the 116 patients of the questionnaire sample together was still better than natural history even if all drop-outs were considered to be failures. The fact that there was no relative progression in our patients sample treated solely by physiotherapy (preliminary study), seems to show the effectiveness of the inpatient rehabilitation programme even in cases with a bad prognosis, severe angles of curvature and unfavourable curvature patterns. A worst-case analysis does not prevent this conclusion, even if all dropouts from the non-repeaters group were considered as failures.

Scoliosis

For example, a person who is still growing with a 17° Cobb angle and significant thoracic rotation or flatback could be considered for nighttime bracing. On the opposite end of the growth spectrum, a 29° Cobb angle and a Risser sign three or four might not need to be braced because the potential for progression is reduced. The Scoliosis Research Society's recommendations for bracing include curves progressing to larger than 25°, curves presenting between 30 and 45°, Risser sign 0, 1, or 2 (an X-ray measurement of a pelvic growth area), and less than six months from the onset of menses in girls. Scoliosis braces are usually comfortable, especially when well designed and well fitted, also after the 7- to 10-day break-in period. A well fitted and functioning scoliosis brace provides comfort when it is supporting the deformity and redirecting the body into a more corrected and normal physiological position.

SpineCor, exercise and SPoRT rigid brace: what is the best for Adolescent Idiopathic Scoliosis? Short term results from 2 retrospective studies.

SpineCor is a dynamic brace that showed good results in scoliosis treatment. But data suggest that its efficacy is reduced as curves magnitude increase, and no comparisons exist versus exercise alone. The objective of this double study is to compare the short term results of the SpineCor versus SEAS exercises and versus rigid SpoRT brace for AIS.  2 retrospective controlled studies. Population 1: 56 consecutive AIS patients (39 female; age 13±1, Cobb 21±4°; ATR 11±4°): 28 patients (19 females; age 13±1; TRACE 6; Cobb angle 22±4°; ATR 12±4°, Risser 0-3) treated by SpineCor 20/24 hours; 28 patients (20 females; age 13±1; TRACE 5; Cobb angle 20±4°; ATR 9±3°, Risser 0-3) treated by SEAS exercises. Population 2: 103 consecutive AIS patients from our prospective database (85 females; age 13±1, Cobb 24±5°; ATR 8±4°): 29 patients (19 females; age 13±1; TRACE 6; Cobb angle 22±5°; ATR 9±3°, Risser 0-3) treated by SpineCor 20/24 hours per day; 74 patients (66 females; age 13±1; TRACE 5; Cobb angle 25±4°; ATR 8±4°, Risser 0-3) treated by SPoRT Brace 18 to 23 hours per day. The short term results of treatment, both clinical and radiographic, were evaluated after 18 months. N° of rigid brace prescribed, TRACE, Cobb angle (changes > ±5), ATR (changes > ±2). Study 1: the N° of patients prescribed with a rigid brace was not significantly different in the 2 groups. TRACE was stable for SEAS while decreased for SpineCor (p<0.05). Considering the number of patients changed > ±5° Cobb in the SEAS Group we found 39.3% improved and 14.3% worsened vs 25% and 21.4% in SpineCor (NS); no differences for ATR. Study 2: Both the treatment showed to be effective in improving the TRACE. Considering the other parameters, the SPoRT brace seems to be slightly more effective than the SpineCor both for the Cobb angle and the ATR. Short term results showed the SpineCor's efficacy to be between rigid brace and exercise for treatment efficacy for AIS.

Management of scoliosis

Surgery is indicated by the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) at 45 degrees to 50 degrees and by the Scoliosis Research Society (SRS) at a Cobb angle of 45 degrees. SOSORT uses the 45-degree to 50-degree threshold as a result of the well-documented, plus or minus five degrees measurement error that can occur while measuring Cobb angles. Scoliosis braces are usually comfortable for the patient, especially when it is well designed and fit; also after the 7- to 10-day break-in period. A well fit and functioning scoliosis brace provides comfort when it is supporting the deformity and redirecting the body into a more corrected and normal physiological position. The Scoliosis Research Society's recommendations for bracing include curves progressing to larger than 25°, curves presenting between 30 and 45°, Risser sign 0, 1, or 2 (an X-ray measurement of a pelvic growth area), and less than six months from the onset of menses in girls.

Idiopathic scoliosis patients with curves more than 45 Cobb degrees refusing surgery can be effectively treated through bracing with curve improvements.

It is a broad consensus today that scoliosis curves cannot be improved through bracing, and the Scoliosis Research Society (SRS) methodological criteria for bracing have the avoidance of progression as their only objective. Consequently, in curves more than 45°, fusion is considered as basically the only possible treatment. The purpose of the study was to verify in a series of patients who utterly refused surgery if it was possible to achieve improvements of scoliosis of more than 45° through a complete conservative treatment (bracing and exercises). Retrospective cohort from a prospective database. Out of 1,148 idiopathic scoliosis (IS) patients at the end of treatment, the sample comprised 28 subjects older than 10 years, still growing, with at least one curve above 45°, who had continually refused fusion. The group comprised 24 females and four males, including 14 in which previous brace treatments had failed; at the start of treatment, the age was 14.2±1.8 years and Cobb degrees in the curve were 49.4° (range, 45°-58°). Subgroups considered were gender, bone age, type of scoliosis, treatment used, and previous failed treatment. Self-report measurement: SRS-22; physiological measures: Cobb degrees, Bunnell angle of trunk rotation (ATR), aesthetic index (AI), and sagittal plumb line distances. The methods comprised full-time treatment (23 or 24 hours per day) for 1 year with Risser cast, Lyon, or Sforzesco brace; weaning of 1 to 2 hours every 6 months; with strategies to maximize compliance through the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) management criteria applied and specific scientific exercises approach to scoliosis exercises (SEAS) performed. Reported compliance in the 4.10±1.2 treatment years was 94%, with satisfaction regarding treatment and excellent results at the SRS-22. Two patients (7%) remained above 50° Cobb but six patients (21%) finished between 30° and 35° Cobb and 12 patients (43%) finished between 36° and 40° Cobb. Improvements have been found in 71% of patients and a 5° Cobb progression in one patient. Statistically, we found highly significant reductions of the main (-9.25°), average (-6.6°), thoracic (-7.8°), and lumbar (-15.9°) curves. Statistically significant improvements have been found for the AI and ATR, with a general decrease in plumb line distances. Bracing can be successfully used in patients who do not want to undergo operations for IS with curves ranging between 45° and 60° Cobb, given sufficient clinical expertise to apply good braces and achieve great compliance. Future studies could demonstrate the percentages at which this result can be achieved.

Correction effects of the ScoliOlogiC "Chêneau light" brace in patients with scoliosis.

Different bracing concepts are used today for the treatment of scoliosis. The plaster cast method worldwide seems to be the most practiced technique at the moment. CAD (Computer Aided Design) systems are on the market which allow brace adjustments without plaster. The latest development however, is the use of the ScoliOlogiC off the shelf system enabling the orthopaedic technician to construct a light brace for scoliosis correction from a variety of pattern specific shells to be connected to an anterior and a posterior upright. This "Chêneau light" brace, developed according to the Chêneau principle, promises a reduced impediment of quality of life in the brace. However, material reduction should not result in reduced effectiveness. Therefore the primary correction effect in the "Chêneau light" brace has been evaluated and compared with that of other braces used today. The correction effects of the first 81 patients (main diagnosis Adolescent Idiopathic Scoliosis (AIS) [n = 64] or Early Onset Scoliosis (EOS) [n = 15]), treated according to the principle of the "Chêneau light" brace were evaluated after an average treatment time of 6 weeks by a full-body X-ray made in the standing position whilst wearing the brace and compared with the last X-ray before bracing. The average curvature angle of the whole group was 35,6 degrees , the average age was 12,9 years (SD 1,9), average Risser sign was 1,3 (SD 1,5), average Tanner rating 2,75 (SD 0,7). The Cobb angle in the whole group was reduced by an average of 16,4 degrees , which corresponds to a correction effect of 51%. The differences were highly significant in the T-test (T = 17,4; p < 0,001). The best correction effects reported in literature so far are about 40% in two different studies. The correction effect was highest in lumbar and thoracolumbar curve pattern (62 %; n = 18). In thoracic scoliosis the correction effect was 36 % (n = 41) and in double major curve pattern 50 % (n = 22). The correction effect correlated slightly negative with age (r = -0,24; p = 0,014), negatively with the Risser stage (-0,29; p = 0,0096) and correlated negatively with the Cobb angle measured before treatment (r = -0,43; p < 0,0001). The use of the "Chêneau light" brace leads to correction effects above average when compared to the correction effects of other braces described in literature. The reduction of material seems to affect the desired correction in a positive way.

Scoliosis-Specific exercises can reduce the progression of severe curves in adult idiopathic scoliosis: a long-term cohort study.

Scoliosis fusion surgery is generally considered the only means to stop the progression of adult idiopathic scoliosis (ADIS), but for patients refusing surgery there is lack of evidence in favour of conservative treatment. The aim of the present study was to verify the possible effectiveness of scoliosis-specific exercises when facing ADIS progression. We designed a retrospective cohort study. We included 34 ADIS patients in treatment at our Institute (5 males and 29 females, mean age was 38.0 ± 11.0), exclusively treated with specific Scoliosis Specific SEAS exercises. SEAS exercises are scoliosis-specific exercises. In adult patients they are aimed to recover postural collapse, postural control and vertebral stability through an active self-correction. Postural integration is a key element, including the neuromotor integration of correct postures and an ergonomic education program. Therapy includes at least two weekly exercise sessions each lasting 45 min. Radiographic progression was the main outcome and it was analysed as a continuous variable. One way ANOVA and paired t-test were applied for continuous data, while chi-square test was applied for categorical data. Alpha was set at 0.05. The mean Cobb angle of the patients included into the present study, was 55.8 ± 13.2 °. Fifteen patients had previous x-rays testifying scoliosis progression: the average curve progression (worsening) was 9.8 ± 6.6 ° at a median of 25 (range 17-48) years. The remaining were characterized by more severe curves, exceeding 40 ° Cobb (mean curvature 50.9 ± 13.6) but it was not possible to prove that the curves had progressed in these cases. After an average period of 2 years of treatment (range 1-18y), 68 % of the patients experienced an improvement in their scoliosis. However in one patient (3 %) the scoliosis worsened by 5 ° in 18 years (progression rate reduced from 0.5 ° to 0.27 ° per year). Patients improved 4.6 ± 5.0 ° Cobb (P < 0.05), with no differences based on the localization of the curve, gender, age, length of treatment, Cobb degrees at the start of observation or treatment. Scoliosis Specific SEAS Exercises proved to be superior to natural history in ADIS, at least in individual cases and should be considered as a first line treatment especially in patients refusing scoliosis surgery.

The conservative treatment of congenital scoliosis with hemivertebra: Report of three cases.

Scoliosis is the most common type of congenital vertebral disease. This spinal disorder may be due to a failure of formation, segmentation, or a combination thereof. Complete failure of formation causes hemivertebra which can lead to unbalanced growth and deformation. Statistically, 25% of congenital curves do not evolve, 25% progress slightly, while the remaining 50% develop quickly and require treatment. Hemivertebrae can be divided into three types: non-segmented, semi-segmented, and fully-segmented. The fully-segmented types are most likely to progress. Hemivertebra in the thoracolumbar region shows higher rates of progression compared with those in the lumbar area. The treatment may be either conservative or surgical. In general, bracing is not recommended in short and rigid curves, although it may help process secondary curves. To assess the effectiveness of bracing in congenital scoliosis due to hemivertebra. Searching in our database, we found three cases of patients with congenital scoliosis due to fully-segmented hemivertebra. The first of them was 6 years old at the time of diagnosis with a fully-segmented hemivertebra in L5, determining an L1-L5 (S1) lumbar curve. The second one was 10 years old at the time of diagnosis with a fully-segmented hemivertebra in L2 and a T11-L4 (L5 sacralized) thoracolumbar curve. The last one was 3 years old at the time of diagnosis with a fully-segmented hemivertebra in L3 (in six lumbar bodies), determining a thoracolumbar curve T12-L4. We utilized a Milwaukee brace for the first patient, a Boston brace for the second patient, and a Progressive Action Short Brace (PASB) for the third patient. At the beginning of the treatment, the Cobb angles measured 23°, 53°, and 25°, respectively. During treatment, the Cobb angles measured 22°, 35°, and 15°, respectively. At the end of treatment, the Cobb angles measured 18°, 45°, and 12°, respectively. At long-term follow-up, the curves measured 20°, 45°, and 12° Cobb angles, respectively. Comparing our cases with those found in the literature we can confirm the ability of conservative treatment to change the natural history of congenital lumbar scoliosis due to failure of formation. From our experience, in all cases of CS with hemivertebra, before considering a surgical approach, conservative treatment should be implemented as early as possible without waiting for the progressive deformation of the adjacent normal vertebrae.

PReventing Idiopathic SCOliosis PROgression (PRISCOPRO): A protocol for a quadruple-blinded, randomized controlled trial comparing 3D designed Boston brace to standard Boston brace.

Idiopathic scoliosis is the most common spinal deformity in children. Treatment strategies aim to halt progression of the curve. Patients are treated mainly with thoracolumbosacral orthosis (TLSO) if indicated. This form of brace treatment has been shown to be cumbersome and tough on growing individuals. However, computer aided design and manufactured (CAD/CAM) braces might increase comfortability and ultimately outcome if compliance is improved. In a multicenter, randomized controlled trial, we aim to compare CAD/CAM designed Boston 3D-brace to standard Boston brace. Subjects: 170 previously untreated and skeletally immature children diagnosed with idiopathic scoliosis, aged 9-17 years of age (curve magnitude Cobb 25-40 degrees) will be included. Interventions: Both groups will receive a physical activity prescription according to the World Health Organization recommendations. Randomization will be performed 1:1 to a 3D CAD/CAM designed Boston 3D-brace or a standard Boston brace, both with prescribed daily wear time of 20 hours. Outcome: The subjects will participate in the study until curve progression or until skeletal maturity. The primary outcome variable is failure of treatment, defined as progression of the Cobb angle more than 6 degrees compared to the baseline x-ray. The progression is confirmed if seen on two consecutive standing spinal x-rays. Radiographs will be taken at each six-month follow-up. Secondary outcome measures include patient and clinical reported outcomes, including number of individuals requiring surgical intervention. This study will show if efficacy in brace treatment can be improved with new brace designs. The protocol has been registered on ClinicalTrials.gov, identifier: NCT04805437.

Effectiveness of brace treatment for adolescent idiopathic scoliosis.

Effectiveness of brace treatment for adolescent idiopathic scoliosis (AIS) was demonstrated by the BrAIST study in 2013. Objectives of this study were to confirm its effectiveness by analyzing our results and to clarify the factors affecting the results of the treatment. According to the Scoliosis Research Society AIS brace studies standardization criteria, patients with age 10 years or older, Risser 0 to II, less than 1 year post-menarche, curve magnitude 25 to 40 degrees before brace treatment and who received no prior treatment were included in the study. At skeletal maturity, the rate of the patients whose curve was stabilized, exceeded 45 degrees, and who were recommended or underwent surgery were investigated. Additionally, initial correction rate by the brace and factors affecting the results were investigated. A total of 33 patients (27 females and 6 males) could be followed-up until their skeletal maturity and included in the analysis. An average age was 11.9 years, average Cobb angle was 30.8°, and Risser sign was 0 in 13 patients, I in 5, and II in 15 patients before treatment. There were 13 thoracic curves, 14 thoracolumbar or lumbar curves, and 6 double curves. Initial correction rate by the brace was 53.8% for the total curves. In terms of curve pattern, 34.4% for thoracic curve, 73.9% for thoracolumbar or lumbar curve, and 48.8% for double curve. After an average follow-up period of 33 months, 8 patients improved in more than 6 degrees, change of 17 patients were within 6 degrees, and 8 progressed in more than 6 degrees. Therefore, totally, 76% (25/33) of the curves were stabilized by the treatment. Four curves (12%) exceeded 45 degrees and one patient (3%) underwent surgery. Our results were better than the reported natural history. Factors that affected the results were hump degree before treatment and initial correction rate by the brace. 76% of the curve with AIS could be stabilized by brace treatment. Brace treatment was effective for treatment of AIS. Factors affecting the results were hump degrees and initial correction rate.

Radiological and cosmetic improvement 2 years after brace weaning--a case report.

In the early international literature, up to now only very few cases are reported with adolescent idiopathic scoliosis (AIS) and a significant improvement of Cobb angle after conservative management. In the recent literature the possibility of an improvement of Cobb angle at skeletal maturity after brace treatment is mentioned no more. The application of physiotherapy and braces is widely rejected while the standards of conservative measures differ greatly worldwide. So it seems necessary more than ever to present the possibility of successful conservative measures nowadays. More detailed case reports with long-term follow-up using defined protocols are needed to provide appropriate standards for replication by others. The purpose of this presentation is to demonstrate the possibility of significant improvement of curvature angle and cosmesis after the application of long-term physiotherapy and brace treatment in a girl with a curve of more than 50 degrees where spontaneous resolving is not usual. A pre-menarchial girl (although being Risser 2) with a Cobb angle of 53 degrees was treated by exercises and curve-specific bracing for more than 3 years. Two years after the start of the weaning period, the Cobb angle was 36 degrees with a marked and stable cosmetic improvement at the age of 18 years. This case report shows that conservative treatment can improve both cosmesis and curvature in immature patients with AIS. The results of such treatment is appreciated by the patients because of the significant reduction of the truncal deformity as documented by surface topography.

Success Rate of Brace Treatment for Juvenile-Onset Idiopathic Scoliosis up to Skeletal Maturity.

Natural history studies have reported that the progression rate of juvenile idiopathic scoliosis (JIS) curves larger than 20° is high and tends to progress. The aim of this study was to investigate the outcome of bracing on JIS and to determine the prognostic factors on the success rate of brace treatment. From March 1985 to February 2015, the clinical data of all JIS patients with referral age from 4 to 10 years who received brace treatment were reviewed. Those patients with a prebrace Cobb angle >20° and a Risser sign of 0 to 2 were included and followed up a minimum of 2 years after discontinuation of the brace or time of spinal fusion. The Cobb angle was recorded at the time of diagnosis, before initiation of bracing, weaning time, brace discontinuation, and final follow-up. From 297 patients with JIS, a total of 75 cases (18 boys, 57 girls) with an average curve magnitude of 31.9° at the time of diagnosis met the inclusion criteria of the study. For successfully treated patients, the average best in-brace correction was 55% for Lenke I curves, 59% for Lenke II curves, 41% for Lenke III curves, and 62% for Lenke V curves. For a total of 27 patients (36%), the brace treatment failed. Of these, 21 patients (78%) reached spinal fusion, and curves of 6 patients (22%) increased to ≥50°. The progression rate was highest in patients with Lenke type III curves (67%), and also in those with a curve magnitude of ≥46° (94%). Brace treatment is an effective strategy for controlling the curve progression and avoiding spinal fusion in JIS. 4.

Treatment of early adolescent idiopathic scoliosis using the SpineCor System.

The purpose of this prospective observational study was to evaluate the effectiveness of the Dynamic SpineCor System for adolescent idiopathic scoliosis in accordance with the standardized outcome criteria proposed by the Scoliosis Research Society Committee on Bracing and Nonoperative Management. The SpineCor System is the first and only truly dynamic brace, which provides a progressive correction of Idiopathic Scoliosis from 15 degrees Cobb angle and above. The new therapeutic approach is based on a new concept upon the etiology and pathogenesis of idiopathic scoliosis; a pathology of the neuro-musculoskeletal system in growth and maturation. This prospective observational study was carried out on a group of 639 patients (92.3% females) having idiopathic scoliosis treated with the SpineCor brace. Five hundred and eighty three patients met the criteria for inclusion, and 234 patients were still actively being treated. Overall, 349 patients have a definitive outcome. All girls were premenarchal or less than 1 year postmenarchal. Assessment of brace effectiveness included (1) percentage of patients who have 5 degrees or less curve progression, and percentage of patients who have 6 degrees or more progression; (2) percentage of patients who have been recommended/undergone surgery before skeletal maturity; (3) percentage of patients with curves exceeding 45 degrees at maturity (end of treatment); and (4) Two-year follow-up beyond maturity to determine the percentage of patients who subsequently underwent surgery. Successful treatment (correction, > 5 degrees, or stabilization, +/- 5 degrees) was achieved in 259 (74.2%) of the 349 patients from the time of the fitting of the SpineCor brace to the point in which it was discontinued (or at the time of the surgery). Fifty one immature patients (14.6%) required surgical fusion while receiving treatment. Eight mature patients out of 298 (2.7%) required surgery within 2 years of follow-up beyond skeletal maturity. The conclusion drawn from these findings is that the SpineCor brace is effective for the treatment of adolescent idiopathic scoliosis. Moreover, positive outcomes are maintained after 2 years because 151 (93.2%) of 162 patients stabilized or corrected their end of bracing Cobb angle up to 2 years after bracing.

Conservative treatment of a scoliosis patient after two heart surgeries in early childhood - A case report.

This is a case report of a juvenile female patient with scoliosis following two heart surgeries for congenital heart disease (CHD). Initially, the premenarchial female was 9 years old and had a Tanner stage 2-3 with a single thoracic curve of 65° Cobb. Because of the high risk for progression, immediate brace treatment was proposed as the father declined surgery. The patient received intensive treatment according to the Schroth Best Practice® programme and a Gensingen Brace® designed for large thoracic curves. Over the 18 months following the initial visit, she received two additional braces. As a result, the progression of the main curve was prevented. The patient continues to maintain an improved cosmetic result and is currently at a Risser 2. Surgery performed for CHD in rare cases may lead to stiff spinal deformity as a consequence of that surgery. Progression of a severe and stiff curve was prevented during the most vulnerable phase of the pubertal growth spurt with an improved clinical result. Therefore, we assume that the patient may have a normal life in adulthood with minor restrictions only. Supported by pattern-specific high correction exercises and braces, these typical single thoracic curves can be re-compensated to a more balanced appearance, less prone to progression in adulthood. Because of the relative high risks of spinal fusion and the long-term unknowns of such an intervention, high-impact conservative treatment should be implemented first before surgical correction is considered.

Significance of hanging total spine x-ray to estimate the indicative correction angle by brace wearing in idiopathic scoliosis patients.

Although most idiopathic scoliosis patients subject to conservative treatment in daily clinical practice, there have been no ideal methods to evaluate the spinal flexibility for the patients who are scheduled the brace treatment. The purpose of this study was to investigate the value of hanging total spine x-ray to estimate the indicative correction angle by brace wearing in idiopathic scoliosis patients. One hundred seventy-six consecutive patients with idiopathic scoliosis who were newly prescribed the Osaka Medical College (OMC) brace were studied. The study included 14 boys and 162 girls with a mean age of 13 years and 1 month. The type of curves consisted of 62 thoracic, 23 thoracolumbar, 22 lumbar, 42 double major, 14 double thoracic, and 13 triple curve pattern. We compared the Cobb angles on initial brace wearing (BA) and in hanging position (HA). Of those, 108 patients who had main thoracic curves were selected and evaluated the corrective ability of OMC brace. These subjects were divided into three groups according to the relation between BA and HA (BA < HA group, BA = HA group, and BA > HA group), and then, maturity was compared among them. The average Cobb angle in upright position (UA) of all cases was 31.0 ± 7.8°. The average BA and HA of all cases were 20.3 ± 9.5° and 21.1 ± 8.4°, respectively. The average chronological age was lowest in BA < HA group. And also, maturity in BA < HA group was the lowest among each of them. The rate of BA < HA cases were decreased as the Risser stage of the patients were progressed. The use of hanging total spine x-ray served as a useful tool to estimate the degree of correction possible curve within the OMC brace for main thoracic curve in idiopathic scoliosis. Maturity had some influence on the correlation between HA and BA. Namely, in immature patients, HA tended to be larger than BA. In contrast, in mature patients, HA had a tendency to be smaller than BA. With consideration for spinal flexibility based on maturity, in mature patients, larger BA than HA may be allowed. However, in immature patients, smaller BA than HA should be aimed.

Management of scoliosis

Indications for Scoliosis Bracing: Scoliosis professionals determine the proper bracing method for a patient after a complete clinical evaluation. The patient’s growth potential, age, maturity, and scoliosis (Cobb angle, rotation, and sagittal profile) are also considered. Immature patients who present with Cobb angles less than 20 degrees should be closely monitored and proactively treated based on their risk of progression as surgery can be prevented with early intervention of conservative treatment. Immature patients who present with Cobb angles of 20 degrees to 29 degrees should be braced according to the risk of progression by considering age, Cobb angle increase over a six-month period, Risser sign, and clinical presentation. Immature patients who present with Cobb angles greater than 30 degrees should be braced. However, these are guidelines and not every patient will fit into this table. For example, an immature patient with a 17-degree Cobb angle and significant thoracic

Conservative treatment for adolescent idiopathic scoliosis: can it reduce the incidence of surgical treatment?

Since 1986, the authors have been conducting conservative treatment for idiopathic scoliosis with the combination of brace treatment and physical treatment (side shift exercise and hitch exercise). A total of 328 female patients with adolescent idiopathic scoliosis who were at least 10 years of age at the first visit, with Cobb angle of 10 degrees at the minimum and followed until after 15 years of age or skeletal maturity were included. The average Cobb angle was 32.4 degrees and the average age was 13.8 years at the first visit. Surgery was recommended when curvature progressed to >50 degrees. Twenty of 328 patients (6.1%) with more severe curves to begin with (mean Cobb angle at admission of 48.5 +/- 9.3 degrees ) progressed to 62.2 +/- 8.5 degrees and were treated with spinal fusion by the age of 16.0 +/- 2.6 years. The remaining 308 patients, of comparable age at inception of treatment but with a smaller original mean Cobb angle (32.4 +/- 11.1 degrees ), showed no significant increase in magnitude of curvature (mean 33.6 +/- 11.5 degrees ) by the time of discharge (18.6 +/- 3.1 years). The fact that curvature magnitude was maintained at <35 degrees means that these patients will have a good prognosis for avoiding dramatic progression during adulthood.

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.

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. To verify the efficacy of exercises in reducing correction loss during brace weaning. Retrospective controlled study. Sixty-eight consecutive patients (eight males), age 15 +/- 1 and Cobb angle 22 +/- 8 degrees at start of brace weaning. 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. 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). Exercises can help reduce the correction loss in brace weaning for AIS.

Effect of an elongation bending derotation brace on the infantile or juvenile scoliosis.

A wide variety of braces are commercially available designed for the adolescent idiopathic scoliosis (AIS), but very few braces for infantile scoliosis (IS) or juvenile scoliosis (JS). The goals of this study were: 1) to briefly introduce an elongation bending derotation brace (EBDB) in the treatment of IS or JS; 2) to investigate changes of Cobb angles in the AP view of X-ray between in and out of the EBDB at 0, 3, 6, 9, and 12 months; 3) to compare differences of Cobb angles (out of brace) in 3, 6, 9, and12 month with the baseline; 4) to investigate changes (out of brace) in JS and IS groups separately. Thirty-eight patients with IS or JS were recruited retrospectively for this study. Spinal manipulation was performed using a stockinet. This was done simultaneously with a surface topography scan. The procedure was done in the operating room for IS, or in a clinical setting for JS. The brace was edited and fabricated using CAD/CAM method. Radiographs were recorded in and out of bracing approximately every 3 months from baseline to 12 months. A linear mixed effects model was used to compare in and out of bracing, and out of brace Cobb angle change over the 12 month period. Overall, 37.5% of curves are corrected and 37.5% stabilized after 12 months (Thoracic curves 48% correction, 19% stabilization; thoracolumbar curves 33% correction, 56% stabilization and lumbar curves 29% correction, 50% stabilization). The juvenile group had 25.7% correction and 42.9% stabilization, while the infantile group had 50% correction and 32.1% stabilization. There was a significant Cobb angle in-brace reduction in the thoracic (11°), thoracolumbar (12°), and lumbar (12°) (<ip</i < 0.001). There was no statistically significant change in out of brace Cobb angle from baseline to month 12 (<ip</i > 0.05). No patients required surgery within the 12 month span. This study describes a new clinical protocol in the development of the EBDB. Short-term results show brace is effective in preventing IS or JS curve progression over a 12 month span.

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

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. 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 . 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.

Management of scoliosis

"observation only" progressed to surgical range. Recent guidelines published by the Scientific Society of Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) in 2016 state that “the use of a brace is recommended in patients with evolutive idiopathic scoliosis above 25º during growth” based on a review of current scientific literature. Severe curvatures that rapidly progress may be treated surgically with spinal rod placement. Thus, early detection and early intervention prior to the pubertal growth spurt provides the greatest correction and prevention of progression to surgical range. In all cases, early intervention offers the best results. A growing body of scientific research testifies to the efficacy of specialized treatment programs of physical therapy, which may include bracing.