Cobb Degrees Research Articles

Control of juvenile idiopathic scoliosis during pubertal growth spurt through conservative treatment: a retrospective observational study

Materials and methods Observational retrospective study. We enrolled 76 patients (65 females and 11 males) present in our database since 2003, with diagnosis of JIS. Mean age at first diagnosis was 6.37± 1.4. We considered as main indirect clinical sign of PGS the quick height growth (more than 5 cm in six months) while Risser test 1, menarche and sharp growth slowing down (2 cm in six months) were considered signs of the end of PGS. According to individual needs patients were already in treatment with physical exercises alone or with brace and physical exercises. We also clustered Risser test 0 patients in 3 groups based on Cobb degrees (under 20° , from 20° to 30° and over 30° ) and we observed radiographic modification during PGS. Outcome criteria: radiographic (Cobb degrees) and clinical (Bunnel, ATR, TRACE) parameters in PGS period; need to increase treatment load.

Spinecor vs sport brace for adolescent idiopathic scoliosis: short term results

SpineCor and rigid braces have both results testifying their effectiveness in Adolescent Idiopathic Scoliosis (AIS) treatment: an RCT recently compared the two showing the superiority of rigid braces. Since some years we introduced SpineCor as a treatment for patients at curves between 20 and 30 Cobb degrees to improve the quality of life and reduce rigid bracing. The objective of this study is to compare the short term results of the Spinecor vs SPoRT brace for AIS in this selected population.

Idiopathic Scoliosis Patients with Curves over 45 Cobb Degrees Refusing Surgery Can Be Effectively Treated through Bracing with Curve Improvements

It is a broad consensus today that scoliosis curves can't 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 over 45° fusion is considered as basically the only possible treatment.

Braces for Idiopathic Scoliosis in Adolescents

Cochrane systematic review. To evaluate the efficacy of bracing in adolescent patients with adolescent idiopathic scoliosis (AIS). AIS is a 3-dimensional deformity of the spine. Although AIS can progress during growth and cause a surface deformity, it is usually not symptomatic. However, in adulthood, if the final spinal curvature surpasses a certain critical threshold, the risk of health problems and curve progression is increased. Braces are traditionally recommended to stop curvature progression in some countries and criticized in others. They generally need to be worn full time, with treatment extending over years. The following databases (up to July 2008) were searched with no language limitations: the Cochrane Central Register of Controlled Trials, MEDLINE (from January 1966), EMBASE (from January 1980), and CINHAL (from January 1982), and reference lists of the articles. An extensive handsearch of the gray literature was also conducted. Randomized controlled trials (RCTs) and prospective cohort studies were searched for comparing braces with no treatment, other treatment, surgery, and different types of braces. Two review authors independently assessed trial quality and extracted data. We included 2 studies. There was very low quality evidence from 1 prospective cohort study with 286 girls that a brace curbed curve progression at the end of growth (success rate, 74% [95% confidence interval {CI}: 52%-84%]), better than observation (success rate, 34% [95% CI: 16%-49%]) and electrical stimulation (success rate, 33% [95% CI: 12%-60%]). There is low-quality evidence from 1 RCT with 43 girls that a rigid brace is more successful than an elastic one (SpineCor) at curbing curve progression when measured in Cobb degrees, but there were no significant differences between the 2 groups in the subjective perception of daily difficulties associated with wearing the brace. There is very low quality evidence in favor of using braces, making generalization very difficult. Further research could change the actual results and our confidence in them; in the meantime, patients' choices should be informed by multidisciplinary discussion. Future research should focus on short- and long-term patient-centered outcomes, in addition to measures such as Cobb angles. RCTs and prospective cohort studies should follow both the Scoliosis Research Society and Society on Scoliosis Orthopedic and Rehabilitation Treatment criteria for bracing studies.

Efficacy of bracing immediately after the end of growth: final results of a retrospective case series

Methods In this retrospective study, the population included all AIS patients with Risser 4-5 at start that reached the end of treatment since our database started in 2003. We had 23 females and 2 males, average age of 16.5 ± 1.6 years, and an average Cobb angle measurement of 27.4° ± 8.4°. Patients received bracing treatment with Lyon or SPoRT braces for 18 to 24 hours per day, in addition to specific exercises, respecting SOSORT criteria, with a rapid weaning (2-3 hours every 6 months). Outcome criteria included the following parameters: SRS (unchanged; worsened over 6°; over 45° at the end of treatment; surgically treated; 2 years follow-up); clinical (ATR, hump, Aesthetic Index, plumbline distances); radiographic (Cobb degrees); and ISICO (optimum; minimum). ANOVA and chi-test were used for data analysis. Results The reported compliance during the 2.6 ± 0.6 treatment years was 95.1 ± 7.8%, while residual growth was 0.9 ± 1.1 cm. No patients progressed over 45°, no one was fused, and this remained true at the 2 years follow-up for the 25% that reached it. Improvements were found in 48% and 36% of worst and average curves, and in 45%, 58% and 36% of Thoracic, Thoracolumbar and Lumbar curves respectively. We found highly statistically significant reductions of maximal (-4.4°), average (-4.2°), thoracic (6.0°) and thoracolumbar (-6.6°) curves. Statistically significant improvements were found for Aesthetic Index, but not for ATR or plumbline distances. Clinically, 30% of patients improved over the measurement error for Aesthetic Index. According to ISICO criteria, 50% of patients had minimum and 35% optimal results.

Efficacy of conservative treatment of adolescent idiopathic scoliosis: end-growth results respecting SRS and SOSORT criteria

Methods In this retrospective study, the population included all AIS patients meeting the SRS inclusion criteria (age 10 years or older, Risser test 0-2, Cobb degrees 25-40°, no prior treatment, less than 1 year post menarche) that reached the end of treatment since our database started in 2003. We had 44 females and 4 males, average age at the start of 12.8 years ± 1.6 years. According to individual needs, 2 patients were treated with Risser casts followed by Lyon brace, 40 with Lyon or SPoRT braces (14 for 23 hours per day, 23 for 21 hours per day, and 7 for 18 hours per day), and 2 with exercises only. Outcome criteria included the following: SRS (unchanged; worsened over 6°; over 45° at the end of treatment; surgically treated; 2 years followup); clinical (ATR, hump, Aesthetic Index, plumbline distances); radiographic (Cobb degrees); and ISICO (optimum; minimum). ANOVA and chi-test were used for statistical analysis.

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

BackgroundThe 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.MethodsStudy 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°; 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° or more; over 45° 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.ResultsMedian reported compliance during the 4.2 ± 1.4 treatment years was 90% (range 5-106%). No patient progressed beyond 45°, 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° Cobb and Risser 0 at the start. We found statistically significant reductions of the scoliosis curvatures (-7.1°): thoracic (-7.3°), thoracolumbar (-8.4°) and lumbar (-7.8°), but not double major. Statistically significant improvements have also been found for aesthetics and ATR.ConclusionRespecting 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.

Exercises reduce the progression rate of adolescent idiopathic scoliosis: Results of a comprehensive systematic review of the literature

Background. A previously published systematic review (Ped.Rehab.2003 – DARE 2004) documented the existence of the evidence of level 2a (Oxford EBM Centre) on the efficacy of specific exercises to reduce the progression of AIS (Adolescent Idiopathic Scoliosis).Aim. To confirm whether the indication for treatment with specific exercises for AIS has changed in recent years.Study design. Systematic review.Methods. A bibliographic search with strict inclusion criteria (patients treated exclusively with exercises, outcome Cobb degrees, all study designs) was performed on the main electronic databases and through extensive manual searching. We retrieved 19 studies, including one RCT and eight controlled studies; 12 studies were prospective. A methodological and clinical evaluation was performed.Results. The 19 papers considered included 1654 treated patients and 688 controls. The highest-quality study (RCT) compared two groups of 40 patients, showing an improvement of curvature in all treated patients after six months. We found three papers on Scoliosis Intensive Rehabilitation (Schroth), five on extrinsic autocorrection-based methods (Schroth, side-shift), four on intrinsic autocorrection-based approaches (Lyon and SEAS) and five with no autocorrection (three asymmetric, two symmetric exercises). Apart from one (no autocorrection, symmetric exercises, very low methodological quality), all studies confirmed the efficacy of exercises in reducing the progression rate (mainly in early puberty) and/or improving the Cobb angles (around the end of growth). Exercises were also shown to be effective in reducing brace prescription.Conclusion. In five years, eight more papers have been published to the indexed literature coming from throughout the world (Asia, the US, Eastern Europe) and proving that interest in exercises is not exclusive to Western Europe. This systematic review confirms and strengthens the previous ones. The actual evidence on exercises for AIS is of level 1b.

The three-dimensional easy morphological (3-DEMO) classification of scoliosis - Part III, correlation with clinical classification and parameters.

BackgroundIn the first part of this study we proposed a new classification approach for spinal deformities (3-DEMO classification). To be valid, a classification needs to describe adequately the phenomenon considered (construct validity): a way to verify this issue is comparison with already existing classifications (concurrent and criterion validity).AimTo compare the 3-DEMO classification and the numerical results of its classificatory parameters with the existing clinical classifications and the Cobb degrees on the frontal and sagittal planes respectively.Methods118 subjects (96 females) with adolescent idiopathic scoliosis (age 15.9 ± 3.1, 37.4 ± 12.5° Cobb) have been classified according to 3-DEMO, SRS-Ponseti, King and Lenke classifications as well as according to sagittal configuration. For all patients we computed the values of the 3-DEMO parameters and the classical Cobb degrees measurements in the frontal and sagittal planes. Statistical analysis comprised Chi Square and Regression analysis, including a multivariate stepwise regression.ResultsThree of the four 3-DEMO parameters (Direction, Sagittal and Frontal Shift) correlated with SRS-Ponseti, King and sagittal configuration classifications, but not with Lenke's one. Feeble correlations have been found among numerical parameters, while the stepwise regression allowed us to develop almost satisfactory models to obtain 3-DEMO parameters from classical Cobb degrees measurements.DiscussionThese results support the hypothesis of a possible clinical significance of the 3-DEMO classification, even if follow-up studies are needed to better understand these possible correlations and ultimately the classification usefulness. The most interesting 3D parameters appear to be Direction and mainly Phase, the latter being not at all correlated with currently existing classifications. Nevertheless, Shift cannot be easily appreciated on classical frontal and sagittal radiographs, even if it could presumably be calculated.

End-growth final results of an effective conservative treatment: a retrospective case series

Study design All fifty-eight patients (17% male, 83% female) who finished their treatment in the Centre of Vigevano of our Institute were included. Mean Cobb angle at the start of treatment was 22.6 ± 10.6 degrees (see Table 1), and mean age was 13.4 ± 2.4 years. Treatment groups considered included exercises, bracing+exercises, cast+exercises. Starting Cobb degrees, by groups, were: 11–20, 21–30, 31–40, over 40 degrees (see Table 2).

Health-related quality of life in patients with adolescent idiopathic scoliosis after treatment: short-term effects after brace or surgical treatment, a comment

We have read with great interest the article published by Bunge EM and colleagues [1] about short-term effects regarding health-related quality of life (HRQoL) in patients affected by adolescent idiopathic scoliosis (AIS) after a brace or surgical treatment. Recently, we performed a similar study about long-term effects on HRQoL in surgically or conservatively treated patients affected by scoliosis between 45°–60° Cobb and we believe we can provide a further contribution to this important topic. We have reviewed 840 clinical histories of patients treated for scoliosis (between 45°–60° Cobb) from 1975 to 1985 at the Fondazione Don C. Gnocchi (Rome). Of the initial population (840 patients), 98 showed a scoliosis with 45°–60° Cobb, 13 out of these 98 refused to participate in this study, 64 were untraceable, and the remaining 21 patients agreed to participate in this study giving their informed consent. Ten patients were surgically treated (SURG) and 11 received a conservative treatment (CONS). In terms of gender, 20 of the patients were women and 1 was man; and the mean age at follow-up was 36.7 ± 4.7 years (range 20–31 years). The conservative treatment consisted of the use of: plaster cast in one patient; plaster cast and Lyonnais in three patients; plaster cast, Lyonnais and Milwaukee brace in five; plaster cast and Milwaukee in one; Lyonnais in two patients; Milwaukee brace in one; and all treatments presented in eight patients. All the patients were instructed to wear their braces for about 20 h per day. In addition, all CONS patients underwent a rehabilitation program based on a postural re-education method. Wearing over was initiated when the patient’s curve had not progressed on two successive visits and the patient was judged skeletally mature. The brace period was mean 5.2 years (range ±3.4). With regard to SURG cases, after surgery, all patients wore a plaster brace and performed a rehabilitation program based on a postural re-educational method. Note that, the surgical treatment was always indicated in patients with a documented progression (Cobb angle between 45° and 60°) and expected remaining skeletal growth. Our 11 CONS patients had refused the surgical treatment and they chose the conservative management. At follow-up each patient underwent a multidimensional protocol including an anamnestic evaluation (school abandonment, current employment, sport practices, occurrence of pregnancy, menarche and abortions, cervicalgy and headache) physical examination (rib-hump measuring, sagittal and coronal alignment), radiological evaluation (using the Cobb technique), disability evaluation (Barthel Index and Deambulation Index), HRQoL and back pain evaluation (the Short Form-36 Health Survey [SF-36], NASS scale, Backill Scale and Visual Analogue Scale). As expected, comparing the two groups, we have observed: (1) an higher brace period in CONS group (P = 0.005); (2) a more severe pre-therapy scoliosis degree in SURG group (mean value 59.2° in SURG group versus 50.4° in CONS group, P = 0.005) and (3) a more severe post-therapy scoliosis degree in CONS group (mean value: 54.4° in CONS group versus 37.5° in SURG group, P = 0.005). Moreover, we recorded an higher school abandonment in SURG group (P = 0.04) since the global treatment duration (about 25 years ago) resulted to be longer in SURG group. Regarding HRQoL, disability and pain, the comparison of the two groups at follow-up did not show statistical differences. Table 1 shows mean, SD and statistical results of disability and patient-oriented measures recorded in the two groups. Table 1 Mean, SD and statistical results of disability and patient-oriented measures recorded in the CONS and SURG groups With respect to the Bunge’s study we have reported a long-term follow-up. We have studied HRQoL aspects using the SF-36 showing significant correlation with the Scoliosis Research Society-22 Patient Questionnaire [2], adopted by Bunge in his study. Bunge and colleagues enrolled a larger sample of patients including also patients with scoliosis lower of 45° Cobb, and they divided their surgery patients into two subgroups: brace before surgery and only surgery (not possible in our for small sample). Our study, even if on a little sample, focuses the attention on patients with 45–60 Cobb degree. As Bunge observed in short-term follow-up, we did not found in long-term follow-up any significant differences in disability, HRQoL and pain in patients undergoing conservative or surgical treatment. In scoliosis patients, the curve between 40° and 50° is a issue still discussed during the therapy decision (bracing or surgery) and Bunge’s and our results can not support the preference of surgical treatment above the conservative treatment and viceversa.

Why do we treat adolescent idiopathic scoliosis? What we want to obtain and to avoid for our patients. SOSORT 2005 Consensus paper

BackgroundMedicine is a scientific art: once science is not clear, choices are made according to individual and collective beliefs that should be better understood. This is particularly true in a field like adolescent idiopathic scoliosis, where currently does not exist definitive scientific evidence on the efficacy either of conservative or of surgical treatments.Aim of the studyTo verify the philosophical choices on the final outcome of a group of people believing and engaged in a conservative treatment of idiopathic scoliosis.MethodsWe performed a multifaceted study that included a bibliometric analysis, a questionnaire, and a careful Consensus reaching procedure between experts in the conservative treatment of scoliosis (SOSORT members).ResultsThe Consensus reaching procedure has shown to be useful: answers changed in a statistically significant way, and 9 new outcome criteria were included. The most important final outcomes were considered Aesthetics (100%), Quality of life and Disability (more than 90%), while more than 80% of preferences went to Back Pain, Psychological well-being, Progression in adulthood, Breathing function, Scoliosis Cobb degrees (radiographic lateral flexion), Needs of further treatments in adulthood.DiscussionIn the literature prevail outcome criteria driven by the contingent treatment needs or the possibility to have measurement systems (even if it seems that usual clinical and radiographic methods are given much more importance than more complex Disability or Quality of Life instruments). SOSORT members give importance to a wide range of outcome criteria, in which clinical and radiographic issues have the lowest importance.ConclusionWe treat our patients for what they need for their future (Breathing function, Needs of further treatments in adulthood, Progression in adulthood), and their present too (Aesthetics, Disability, Quality of life). Technical matters, such as rib hump or radiographic lateral alignment and rotation, but not lateral flexion, are secondary outcomes and only instrumental to previously reported primary outcomes. We advocate a multidimensional, comprehensive evaluation of scoliosis patients, to gather all necessary data for a complete therapeutic approach, that goes beyond x-rays to reach the person and the family.

Peak skeletal mass assessment in young adults with idiopathic scoliosis.

In 52 adult women with ages ranging from 20 to 35 years (mean age, 26.5 +/- 4.9 years) with scoliosis of the idiopathic type (mean, 44.7 +/- 17.4 Cobb degrees), bone density was assessed by conventional grading of the relative vertebral density (RVD) and the Singh trabecular index (STI). In vivo determinations of the bone mineral content (BMC) were performed in the radius, femur, and lumbar vertebrae by new noninvasive techniques of single (SPA)- and dual (DPA)-photon absorptiometry. Frequency distributions of scoliosis vs. control subjects with respect to RVD and STI grades showed interdependence to the P less than 0.01 level of significance. The mean BMC determinations of the radius (0.685 +/- 0.061 gm/sq cm) of the femur (0.947 +/- 0.110 gm/BA/sq cm) and of the vertebrae (1.091 +/- 0.105 gm/BA/sq cm) were markedly reduced compared with published control values (P less than 0.001). In comparison with the authors' institutional controls, mean BMC measurements were significantly lower for the radius (P less than 0.05) and for the femur (P less than 0.001). These results conclusively demonstrated that assessment of peak skeletal mass in a population of adult premenopausal women with idiopathic scoliosis showed significant decrease in average BMC measurements compared with control values. Maximal bone accretion was best evaluated at locations unaffected by deformity such as the radial diaphysis and the femoral neck.