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The development of high-quality research is desired in all healthcare fields. Experimental and nonexperimental designs are used to investigate the effect or association of an intervention and clinical or surrogate outcome. The aims of these methods are to improve knowledge and to develop new strategies to manage a disease or condition. Randomized clinical trials are considered one of the standard methods to test the efficacy of a new drug or intervention; however, they are costly, have reduced generalizability, and cannot be feasible in all scenarios. Well-designed observational studies can provide valuable information regarding exposure factor and the event under investigation. In physical and rehabilitation medicine, where complex procedures and multiple risk factors can be involved in the same disease, the use of observational study must be planned in detail and a priori to avoid overestimations. In this article, we will give an overview of the methods used for observational design studies in physical and rehabilitation medicine using clinical examples to illustrate each method. We will describe when it is appropriate and how to use the observational studies in different scenarios explaining how to deal with potential bias and confounders using the adequate design and statistical plan for the situation.

Adult scoliosis is sometimes associated with back pain and severe curves can progress over time. Despite scoliosis has been estimated to affect up to 68% of the population over 60, there is scant literature about conservative treatment for adult scoliosis. Recently, we tested a new brace designed to alleviate pain for adult patients with chronic pain secondary to scoliosis. The study aims to test the efficacy of a prefabricated brace in reducing pain in adult scoliosis patients.Twenty adults (age 67.8 ± 10.5, curve 61.9 ± 12.6° Cobb) with chronic low back pain (cLBP) secondary to Idiopathic Scoliosis (IS) were included. Patients were evaluated at baseline immediately before starting with the brace and after 6 months. Outcome measures were GRS, Oswestry Disability Index (ODI), Roland Morris Questionnaire (RM), COMI. The paired t test, ANOVA and Wilcoxon tests were used for statistical analysis RESULTS: At six months, worst pain, leg pain and back pain were significantly improved: from 7.15 to 5.60, from 5.65 to 4.35 and from 6.55 to 5.25 (p 0.05). Sixty-five percent of patients achieved the minimal clinically important difference of 2 points for worst pain and leg pain, 55% for back pain. RM and COMI improved (p 0.05), no differences for ODI.The prefabricated brace showed a significant improvement at 6 months of worst, leg and back pain in most patients in a group of adult women with IS and cLBP. The quality of life didn't change in a clinically significant way even if the patients reported satisfaction with the treatment. Trial registration number and date of registration: ClinicalTrials.gov Identifier: NCT02643290, December 31, 2015.

Objective To investigate the feasibility and acceptability of telemedicine as a substitute of outpatient services in emergency situations like by the sudden surge of the COVID-19 pandemic in Italy. Design Observational cohort study with historical control. Setting Tertiary referral outpatient Institute. Participants Consecutive services provided to patients with spinal disorders. Interventions Telemedicine services included teleconsultations and telephysiotherapy. They lasted as long as usual interventions. They were delivered using free teleconference Apps, caregivers were actively involved, interviews and counselling were performed as usual. Teleconsultations included standard, but adapted measurements and evaluations in video and from photos/videos sent in advance according to specific tutorials. During telephysiotherapy, new sets of exercises were defined and recorded as usual. Main Outcome Measure(s) We compared the number of services provided in three phases, among them and with corresponding periods in 2018 and 2019: during CONTROL (30 working days) and COVID surge (13 days) only usual consultations/physiotherapy were provided, while during TELEMED (15 days) only teleconsultations/telephysiotherapy. If a reliable medical decision was not possible during teleconsultations, usual face-to-face interventions were prescribed. Continuous quality improvement questionnaires were also evaluated. Results During TELEMED, 325 teleconsulations and 882 telephysiotherapy sessions were provided in 15 days. We found a rapid decrease (-39%) of outpatient services from CONTROL to COVID phase (R2=0.85), partially recovered in TELEMED for telephysiotherapy (from -37% to -21%; p, Highlights ● Due to COVID-19 pandemic outpatients care is difficult ● A progressive drop was found in Italy, even before the total lockdown ● The total conversion to telemedicine offered a unique experimental set-up ● We found a partial recover with satisfaction of patients and professionals ● Telemedicine is feasible and acceptable in emergency situation

Combining evidence-based medicine and shared decision making, current guidelines support an evidence-based personalised approach (EBPA) for idiopathic scoliosis in adolescents (AIS). EBPA is considered important for adolescents’ compliance, which is particularly difficult in AIS. Benchmarking to existing Randomised Controlled Trials (RCTs) as paradigms of single treatments, we aimed to check the effectiveness and burden of care of an EBPA in high-risk AIS. This study’s design features a retrospective observation of a prospective database including 25,361 spinal deformity patients &lt, 18 years of age. Participants consisted of 1938 AIS, 11–45° Cobb, Risser stage 0–2, who were studied until the end of growth. EBPA included therapies classified for burdensomeness according to current guidelines. Using the same inclusion criteria of the RCTs on exercises, plastic, and elastic bracing, out of the 1938 included, we benchmarked 590, 687, and 884 participants, respectively. We checked clinically significant results and burden of care, calculating Relative Risk of success (RR) and Number Needed to Treat (NNT) for efficacy (EA) and intent-to-treat analyses. At the end of growth, 19% of EBPA participants progressed, while 33% improved. EBPA showed 2.0 (1.7–2.5) and 2.9 (1.7–4.9) RR of success versus Weinstein and Coillard’s studies control groups, respectively. Benchmarked to plastic or elastic bracing, EBPA had 1.4 (1.2–1.5) and 1.7 (1.2–2.5) RR of success, respectively. The EBPA treatment burden was greater than RCTs in 48% of patients, and reduced for 24% and 42% versus plastic and elastic bracing, respectively. EBPA showed to be from 40% to 70% more effective than benchmarked individual treatments, with low NNT. The burden of treatment was frequently reduced, but it had to be increased even more frequently.

Several reports in the literature have suggested a causative association between oral occlusion and spinal deformity such as scoliosis and Scheuermann's disease or kyphosis. Based on these findings, a growing number of adolescents with spinal deformity receive orthodontic treatment, supposing a beneficial effect on the spine.The aim of this study was to verify the association between spinal deformity and malocclusion in the orthopedic population and potential effect of orthodontic treatment on the spinal deformity.The databases: MEDLINE, CINAHL, EMBASE, Cochrane Register, OTseeker and ScienceDirect were searched up to August 2017 for studies reporting on associations between spinal and occlusal conditions. Case series, cohort, case-control studies and randomized clinical trials were considered for analysis. Two reviewers independently selected studies, conducted quality assessment and extracted results. Methodological quality was assessed using MINORS score.Nine publications reporting on 1424 patients were included. Studies were two case series, five case-control studies, one cohort study and one randomized clinical trial. The methodological quality was poor in 8/9 studies.Evidence from three low-quality studies suggests an increased prevalence of occlusal dysfunction in patients with known spinal deformity, but the conclusions have a high risk of bias. No evidence of beneficial effects of orthodontic treatment on spinal deformity was found. These slides can be retrieved under Electronic Supplementary Material.

In conservative early onset scoliosis treatment, interest in bracing is growing because repeated general anaesthesia (required by casting) has been questioned for possible brain damages. We aimed to check the results in the medium term of bracing, comparing idiopathic (IIS) to secondary (SIS) infantile scoliosis.We performed a retrospective study in a consecutive prospective cohort. Inclusion criteria were: discovery of scoliosis and bracing below age 3; exclusion criteria: previous spine surgery, less than three consultations. We considered the following results: full ( 20° Cobb) and partial ( 30°) success; hold-up (progression 5° but curve 29°); partial (progression 5°) and full (fusion) failure; statistics: ANOVA for repeated measures; linear mixed effect model with Cobb angle (dependent), time and diagnosis (independent) variables.We included 34 infants (16 IIS and 18 SIS) of age 1·10 ± 0·10 (years·months), 44 ± 17° curves, 27 ± 10° rib vertebral angle difference, average observation 5·05 ± 3·03 years. We found progressive improvement of IIS and stability of SIS patients. Six IIS (37.5%) and one SIS (6%) reached brace weaning before puberty with 13 ± 5° (improvement 61 ± 15%, p 0.001), after 4·11 ± 3·07 years of treatment. Three patients were fused, one IIS (6%) and two SIS (11%). Two IIS patients also reached end-of-growth with 18° (start 40° at 1·03 years) and 20° (start 32° at 2·12 years), respectively.Bracing shows promising results in the medium term for high-degree IIS, with very few hold-ups (19%) and failures (12%). Conversely, failures prevail for SIS (full 11%), even if the partial failure (39%) is still a time-buying strategy.

The effectiveness of operative compared with nonoperative treatment at initial presentation (no prior fusion) for adult lumbar scoliosis has not, to our knowledge, been evaluated in controlled trials. The goals of this study were to evaluate the effects of operative and nonoperative treatment and to assess the benefits of these treatments to help treating physicians determine whether patients are better managed operatively or nonoperatively.Patients with adult symptomatic lumbar scoliosis (aged 40 to 80 years, with a coronal Cobb angle measurement of ≥30° and an Oswestry Disability Index [ODI] score of ≥20 or Scoliosis Research Society [SRS]-22 score of ≤4.0) from 9 North American centers were enrolled in concurrent randomized or observational cohorts to evaluate operative versus nonoperative treatment. The primary outcomes were differences in the mean change from baseline in the SRS-22 subscore and ODI at 2-year follow-up. For the randomized cohort, the initial sample-size calculation estimated that 41 patients per group (82 total) would provide 80% power with alpha equal to 0.05, anticipating 10% loss to follow-up and 20% nonadherence in the nonoperative arm. However, an interim sample-size calculation estimated that 18 patients per group would be sufficient.Sixty-three patients were enrolled in the randomized cohort: 30 in the operative group and 33 in the nonoperative group. Two hundred and twenty-three patients were enrolled in the observational cohort: 112 in the operative group and 111 in the nonoperative group. The intention-to-treat analysis of the randomized cohort found that, at 2 years of follow-up, outcomes did not differ between the groups. Nonadherence was high in the randomized cohort (64% nonoperative-to-operative crossover). In the as-treated analysis of the randomized cohort, operative treatment was associated with greater improvement at the 2-year follow-up in the SRS-22 subscore (adjusted mean difference, 0.7 [95% confidence interval (CI), 0.5 to 1.0]) and in the ODI (adjusted mean difference, -16 [95% CI, -22 to -10]) (p0.001 for both). Surgery was also superior to nonoperative care in the observational cohort at 2 years after treatment on the basis of SRS-22 subscore and ODI outcomes (p0.001). In an overall responder analysis, more operative patients achieved improvement meeting or exceeding the minimal clinically important difference (MCID) in the SRS-22 subscore (85.7% versus 38.7%; p0.001) and the ODI (77.4% versus 38.3%; p0.001). Thirty-four revision surgeries were performed in 24 (14%) of the operative patients.On the basis of as-treated and MCID analyses, if a patient with adult symptomatic lumbar scoliosis is satisfied with current spine-related health, nonoperative treatment is advised, with the understanding that improvement is unlikely. If a patient is not satisfied with current spine health and expects improvement, surgery is preferred.Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

STUDY DESIGN Comparative effectiveness study OBJECTIVE.: To evaluate factors leading to higher percentage of brace failures in a cohort of North American patients with adolescent idiopathic scoliosis relative to their peers in Italy. SUMMARY OF BACKGROUND DATA Studies of bracing in United States have shown worse outcomes than studies from European centers, possibly due to sample characteristics or treatment approaches. METHODS Sample: Braced patients, aged 10 to 15, Risser

This study aims to propose and validate a new unified “Risser+” grade that combines the North American (NA) and European (EU) variants of the classic Risser score. The “Risser+ ” grade can effectively combine the North American and European Risser Classifications for skeletal maturity with adequate intra-rater/inter-rater reliability and agreement. Agreement and reliability were evaluated for 6 raters (3-NA, 3-EU) who assessed 120 pelvic radiographs from the BrAIST trial, all female, average age 13.4 (range 10.1–16.5 years). Blinded raters reviewed x-rays at two time-points. Intra- and inter-rater agreement (RA) were established with Krippendorff’s alpha (k-alpha), while intra- and inter-rater reliability (RR) were established with intraclass correlation coefficients (ICC). Acceptable agreement and reliability were set a priori at 0.80. Inter-RA for the second reading met study requirements (k-alpha = 0.86 [0.81–0.90]) compared to the first reading (0.72 [0.63–0.79]) while combined readings was close to target agreement (0.79 [0.74–0.84]). Removal of 20 readings demonstrating outlier tendencies increased agreement for the first, second, and combined reads (k-alpha = 0.85, 0.89, 0.87, respectively). Intra-RA was sufficient for 4 out of 6 raters (k-alpha > 0.80) and one rater from EU and NA presented subpar intra-RA (k-alpha = 0.64 and 0.74, respectively). Inter-RR met study requirements overall reads (ICC = 0.96 [0.95–0.97]) including the first (0.94 [0.92–0.95]) and second (0.97 [0.97–0.98]) reads, independently. The Risser+ system showed excellent reliability across multiple reads and raters and demonstrated 79% agreement overall reads and ratings. Agreement increased to over 85% when raters could distinguish Risser 0 + from Risser 5. These slides can be retrieved from electronic supplementary material.

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The aim of the study was to provide a meta-analysis of current literature concerning the natural history of idiopathic scoliosis during growth.A comprehensive search of Medline, Embase, And Scopus databases was conducted up to November 2016. Eligible works were prospective or retrospective studies that enrolled patients with infantile idiopathic scoliosis, juvenile idiopathic scoliosis, or adolescent idiopathic scoliosis, followed up without any treatment from the time of detection. A meta-analysis for proportion was performed. The following studies were grouped per diagnosis: infantile idiopathic scoliosis, juvenile idiopathic scoliosis, and adolescent idiopathic scoliosis.Of the 1797 citations screened, we assessed 61 full-text articles and included 13 of these (2301 participants). Three studies included infantile idiopathic scoliosis patients (347 participants), five studies included a mixed population of juvenile idiopathic scoliosis and adolescent idiopathic scoliosis (1330 participants), and five studies included adolescent idiopathic scoliosis patients only (624 participants). The random pooled estimated progression rate was 49% (95% confidence interval = 1%-97%) for infantile idiopathic scoliosis, 49% in a mixed group of patients affected by juvenile idiopathic scoliosis or adolescent idiopathic scoliosis (95% confidence interval = 19%-79%), and 42% in adolescent idiopathic scoliosis (95% confidence interval = 11%-73%).During growth, idiopathic scoliosis tends to progress in a high percentage of cases. The progression rate varies according to the age at diagnosis, with infantile scoliosis being the most unpredictable. There are many confounders, such as age, Risser sign and baseline Cobb angles that were not consistent among studies, making the data very heterogeneous.

Background Context Spinal deformities are commonly associated with poor health-related quality of life (HRQOL). Several questionnaires (eg, Scoliosis Research Society-24 [SRS-24] and Scoliosis Research Society-22 [SRS-22]) have been developed to evaluate HRQOL in these conditions. In adults as well as during growth, the HRQOL is considered one of the most relevant outcomes of both conservative and surgical treatments. Rasch analysis is a powerful statistical technique for developing high-quality and valid questionnaires. The SRS-24 and SRS-22 have been evaluated using the Rasch analysis but showed poor measurement properties. Thus, a proper measure of HRQOL in people with a spine condition is still missing. Purpose This study aimed to develop a new questionnaire that is totally Rasch consistent for measuring the HRQOL in young people with a spine condition. Study Design This is a cross-sectional study for developing a new HRQOL measure. Patient Sample A total of 402 participants with adolescent idiopathic scoliosis or Scheuermann juvenile kyphosis were included in the study. Outcome Measure The outcome measure used was the Italian Spine Youth Quality of Life (ISYQOL) questionnaire. Materials and Methods The study consisted of different stages: a conventional approach content analysis, an opinion poll among clinicians trained in spine deformities, and the Rasch analysis (partial credit model). Results The Rasch analysis showed that all items of the ISYQOL questionnaire had ordered thresholds and a good fit to the model. Differential item functioning was present for Item 1, with bracing only, and was solved with a conventional items splitting procedure. The ISYQOL item map spans an adequate range of HRQOL. The principal component analysis for Rasch residuals showed, in practical terms, the ISYQOL unidimensionality. The reliability of ISYQOL was high enough so that approximately three significantly different levels of HRQOL could be discerned. Two questionnaire versions were provided for patients with and without the brace, respectively. Conclusions ISYQOL is the first HRQOL questionnaire developed according to the Rasch analysis. It was developed in a conservative treatment setting for all types of spinal deformities, including also patients with surgical curves. Validation in many languages is already under way.

Background Aesthetics is recognized as a main outcome in idiopathic scoliosis (IS) treatment, but to date, there is no criterion standard for physicians’ evaluation. Trunk Aesthetic Clinical Evaluation (TRACE) is a simple 12-point ordinal scale to quantify symmetry as a proxy of aesthetics. TRACE is already diffused worldwide and has been used in clinical research. Objective We aimed to validate TRACE and improve it with Rasch analysis. Material and methods This study involved an observational Rasch analysis validation of an evaluation tool in outpatient rehabilitation centres. From a clinical database, we randomly selected patients who had IS, were age 10 to 18, had brace prescription at first evaluation, and had at least 2 consultations. Rasch analysis (partial credit model) was used. Differential item functioning (DIF) was assessed for age, sex, disease severity, bracing and treatment. The median was chosen to dichotomize disease severity and bracing. We removed 64 outlier participants (4%). Results We included 1553 participants (1334 females; mean [SD] age 13 [1.7] years old). TRACE items showed ordered thresholds and proper fit to the Rasch model. The score-to-measure conversion table showed proper length (range −4.55 to 4.79 logit) with a mean (SE) measure of −0.52 (0.04) logit. The principal component analysis supported the TRACE unidimensionality. The TRACE was free from DIF for age, sex and bracing. Conclusions The TRACE ordinal scale has been converted into a Rasch-consistent, interval-level measure of trunk aesthetics in IS patients and can be used to compare different populations. Its main flaw is low reliability, likely because of the small number of items. TRACE can be used as an outcome measure and in everyday clinical evaluation of IS, even if new developments of the scale are advised.

Background Plumb line distances (PDs) are widely used in conservative clinical practice to evaluate the sagittal shape of the spine. Objective The objective was to assess the normative values of PDs in a large, healthy population in an age range representative of the adolescent population with spinal deformities, and to correlate it with x-ray measurements. Design This was a cross-sectional study. Methods Participants were 584 healthy individuals (341 females) with x-rays showing no spine deformities. The whole sample (OVERALL) was divided into 5 groups: 6 to 9 years old (n = 106); >10 years, Risser 0 with triradiate cartilage open (n = 129) or closed (n = 104); Risser 1 to 2 (n = 126); and Risser 3 to 5 (n = 119). PDs were taken by maintaining a tangent to the thoracic kyphosis apex at C7, T12, L3, and S2. Sagittal index (C7 + L3), and sagittal and coronal balances (C7 related to S2) were calculated. Results In OVERALL, PDs at C7, T12, L3, and S2 were 39.9 ± 16.7, 21.4 ± 15.3, 39.9 ± 15, 20.6 ± 17.0 mm, respectively. Sagittal index was 79.8 ± 26.8, sagittal balance was 19.3 ± 17 mm anterior to S2 plumb line; 13.5% had a coronal imbalance of 11.4 ± 5.4 mm to the right and 24.7% of 13.2 ± 6.0 mm to the left. C7 and L3 PDs, sagittal index, and sagittal balance were significantly lower in ages 6 to 9 compared to older patients in Risser 1 to 2 group. C7 and S2 PDs and sagittal index were significantly larger in males. Sagittal index correlated with thoracic kyphosis Cobb degrees (r = 0.47). Limitations The participants were not randomly chosen from the general population; and they had an x-ray because of spine pathology suspicion. Conclusions This study shows normative data to be used in clinical practice. Sagittal spinopelvic alignment has gained more and more importance in the last decades because of its high correlation to Health-Related Quality of Life scores in adults. 1

The aim of this study was to describe the association between scoliosis and sagittal balance parameters in Parkinson disease patients.This is a cross-sectional study.Fifty percent of the cohort presented a scoliosis larger than 11 degrees; 84% of the patients with scoliosis presented a thoracolumbar curve, 10% presented a thoracic one, and 6% presented a lumbar one. The group with scoliosis curves presented a lower spinosacral angle (111.6 [21.9] degrees vs. 121.7 [9.8] degrees, P0.05), whereas thoracic kyphosis, lumbar lordosis, and spinopelvic angle were similar. Pelvic incidence, pelvic tilt, and sacral slope were not statistically different. In the scoliosis group, the authors found negative correlations for lumbar lordosis/spinopelvic angle, sacral slope/spinosacral angle, and lumbar lordosis/pelvic tilt. Moreover, the sacral slope/pelvic tilt correlation was positive in patients without scoliosis and negative in others. The two groups did not present differences regarding age, years of disease, Hoehn-Yahr score, and Unified Parkinson Disease Rating Scale-motor section.Pelvic parameters were similar in the two groups, whereas spinosacral angle was lower in patients with scoliosis. The prevalence of scoliosis in Parkinson disease was higher than what was previously described and the thoracolumbar spine was the mostly affected.

BACKGROUND: In respect to the prescribed regimen and the regular daily pattern, investigate how short-term results are affected by wear time adherence in terms of hours per day. METHODS: This is a case-control study. The setting is outpatient clinic. There were 168 subjects, all of whom met the inclusion criteria: adolescent idiopathic scoliosis and Sforzesco brace prescription of 18 to 23 h/day. The minimum period of follow-up was 4 months, and the maximum was 6 months, which is the average time passing between the Thermobrace (TB) adoption and out-of-brace X-ray before treatment. The brace wear adherence rate, calculated from the ratio of brace wear time with the prescription, was considered in combination with the daily pattern compliance, classified as consistent (104 patients) or inconsistent according to the abnormal distribution of Thermobrace data. The short-term results were finally explored. RESULTS: Consistent brace wear is associated with a higher probability of improvement in curve magnitude (OR 1.96 CI 95% 1.22-3.14 chi-square 7.78 p = 0.0053). Inconsistent brace wear is more likely to progress (OR 0.14 CI 95% 0.30-0.75 chi-square 10.13 p = 0.0015). Results from the logistic regression show that the most influencing factor for improvement is Cobb degrees at the start. CONCLUSIONS: In clinical everyday activity, patients must be encouraged to consistently follow their brace wear prescription, because this attitude is clearly associated with a higher probability of improvement. ispartof: SCOLIOSIS AND SPINAL DISORDERS vol:13 ispartof: location:England status: published

Background In some studies, an association has been reported between laterality of the curve in scoliotic adolescents and hand dominance; however, additional studies have to be performed to confirm these findings. Objective The objective of this study is to evaluate the prevalence between trunk asymmetry and side dominance in hand, foot and visual laterality in adolescents. Methods This was a cross-sectional study secondary analysis. In total, 1029 children (491 females) were enrolled from the Secondary School of Brescia, Italy, with a mean age of 12 (SD = 0.9 years). All subjects underwent a screening program divided into three phases: Phase 1, collection of demographic and clinical characteristics; Phase 2, spine evaluation with a plumb line and Bunnell Scoliometer; and Phase 3, evaluation of side dominance of the eye, hand and foot with a 4-item survey. Results Our data showed a prevalence of 0.43%, 1.01% and 0.87% for thoracic, thoracolumbar and lumbar curves, respectively, with a right-side dominance and a prevalence of 2.72%, 2.54% and 0.65% for thoracic, thoracolumbar and lumbar curves, respectively, with a left-side dominance. Conclusion The left-side dominance could have a prevalence on trunk asymmetry in thoracic and thoraco-lumbar curves. Our study suggests that the clinical evaluation of trunk asymmetry should be associated with the evaluation of laterality.

Objective The aim of this study was to examine the association between trunk sagittal posture and nonspecific chronic low back pain (CLBP) by evaluating plumb-line distances in subjects recruited in an everyday clinical setting. Methods Of the 1364 subjects recruited, 63.1% were female (mean age ± SD: 56.2 ± 16.8 years). Subjects were categorized into CLBP and control groups and were prospectively assessed over a 3-month period. They provided information about their daily activities and their history of CLBP. Prognostic factors were analysed using univariate and multivariate logistic regression analyses. A physical examination was performed to record demographic (i.e. age, height and weight) and pain characteristics, and the intensity of pain was assessed using a numerical visual analogue scale. Disability was assessed using the Roland–Morris Disability Questionnaire (RMDQ). A simple measure generally used for sagittal plane screening purposes during growth was also utilized. Results Multivariate logistic regression analysis revealed that gender (OR = 1.70), RMDQ score (OR = 0.51) and thoracic hyperkyphosis (C7 + L3 at the plumb-line distance) (OR = 1.57) were associated with CLBP. The final regression model explained 85.6% (R 2 = 0.56; P Conclusions General practitioners can clinically and easily assess trunk posture in subjects with low back pain to identify subjects at higher risk of CLBP.

Background The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) produced its first guidelines in 2005 and renewed them in 2011. Recently published high-quality clinical trials on the effect of conservative treatment approaches (braces and exercises) for idiopathic scoliosis prompted us to update the last guidelines’ version. The objective was to align the guidelines with the new scientific evidence to assure faster knowledge transfer into clinical practice of conservative treatment for idiopathic scoliosis (CTIS). Methods Physicians, researchers and allied health practitioners working in the area of CTIS were involved in the development of the 2016 guidelines. Multiple literature reviews reviewing the evidence on CTIS (assessment, bracing, physiotherapy, physiotherapeutic scoliosis-specific exercises (PSSE) and other CTIS) were conducted. Documents, recommendations and practical approach flow charts were developed using a Delphi procedure. The process was completed with the Consensus Session held during the first combined SOSORT/IRSSD Meeting held in Banff, Canada, in May 2016. Results The contents of the new 2016 guidelines include the following: background on idiopathic scoliosis, description of CTIS approaches for various populations with flow-charts for clinical practice, as well as literature reviews and recommendations on assessment, bracing, PSSE and other CTIS. The present guidelines include a total of 68 recommendations divided into following topics: bracing (n = 25), PSSE to prevent scoliosis progression during growth (n = 12), PSSE during brace treatment and surgical therapy (n = 6), other conservative treatments (n = 2), respiratory function and exercises (n = 3), general sport activities (n = 6); and assessment (n = 14). According to the agreed strength and level of evidence rating scale, there were 2 recommendations on bracing and 1 recommendation on PSSE that reached level of recommendation “I” and level of evidence “II”. Three recommendations reached strength of recommendation A based on the level of evidence I (2 for bracing and one for assessment); 39 recommendations reached strength of recommendation B (20 for bracing, 13 for PSSE, and 6 for assessment).The number of paper for each level of evidence for each treatment is shown in Table 8. Conclusion The 2016 SOSORT guidelines were developed based on the current evidence on CTIS. Over the last 5 years, high-quality evidence has started to emerge, particularly in the areas of efficacy of bracing (one large multicentre trial) and PSSE (three single-centre randomized controlled trials). Several grade A recommendations were presented. Despite the growing high-quality evidence, the heterogeneity of the study protocols limits generalizability of the recommendations. There is a need for standardization of research methods of conservative treatment effectiveness, as recognized by SOSORT and the Scoliosis Research Society (SRS) non-operative management Committee. Electronic supplementary material The online version of this article (10.1186/s13013-017-0145-8) contains supplementary material, which is available to authorized users.

Adult scoliosis is sometimes associated with back pain. Recently, the PeakTo test the efficacy of the Peak Scoliosis Brace in reducing pain in adult scoliosis patients.Prospective experimental cohort study.A total of 20 adult females with back pain secondary to idiopathic scoliosis were included. Patients were evaluated at baseline immediately before starting bracing and after 1 month. The brace had to be worn for at least 2 h per day. The outcome measures used were Graphical Rating Scale, Roland-Morris Questionnaire, Core Outcome Measurement Index, and Oswestry Disability Index.Worst pain, back pain, and leg pain significantly improved from 7.15 to 5.85, from 6.55 to 5.25, and from 5.65 to 3.55, respectively ( p 0.05). A total of 75% of patients reported improved worst and leg pain, 65% improved back pain, 30% of patients achieved the minimal clinically significant difference of 2 points for worst pain, 60% for leg pain, and 25% for back pain. Roland-Morris Questionnaire and Core Outcome Measurement Index improved ( p 0.05) and no differences were observed for Oswestry Disability Index.The Peak Scoliosis Brace led to some improvement of pain at 1 month in a group of adult women with scoliosis and chronic low back pain. The quality of life did not change significantly. Clinical relevance According to our data, the Peak Brace is helpful to quickly improve pain in patients with chronic low back pain secondary to scoliosis. To achieve this goal, it should be applied for at least 2 h per day.

Background The literature did not show clearly if a correlation between trunk and facial asymmetry exists. The aim of this study was to verify the association between trunk and facial asymmetries, and trunk and facial sagittal configuration in adolescents. Methods This is a cross-sectional screening study. It was carried out in a small town in Northern Italy, from February to April 2014. Healthy children met the inclusion criteria. Exclusion criteria were subjects with physical and cognitive disability, genetic disease, and polymorphism. All subjects underwent a three phases for postural screening program. Results 1029 healthy children were 491 females and 538 males with mean age: 12 (range 11–16) years. The association of facial and trunk asymmetry had a point prevalence rate around 1% for the various regions of the spine, the association on the sagittal plane of almost 1.3% for hyperkyphosis and hyperlordosis. Overall, results showed a very low sensitivity, specificity, and predictive values of facial anomalies for trunk asymmetry and sagittal spinal posture. Conclusion While correlations between jaw position and body posture for cervical spine can exist, our study denied association with trunk and back in a general population: postural compensatory mechanism may have minimized the effects of one area on the other, if any existed.

Recently, positive results in bracing patients with idiopathic scoliosis (IS) above 45° who refused surgery have been presented in a retrospective study. Obviously, this can give only an efficacy (EA) analysis, as there is neither a control group, nor it is possible to know failures because of dropouts.To present the prospective results of bracing patients affected by IS above 45° and still growing.Prospective study including all IS patients with 45° or more, Risser stage 0 to 4, who had their first evaluation in our institute, an outpatient clinic specialized in scoliosis evaluation and conservative treatment, from March 1, 2003 to December 21, 2010 and utterly denied any surgical intervention.Of 59 patients, we excluded 2 patients still in treatment and 57 (11 males) patients were included. At the beginning of the study, they were 15 years 3±22 months of age, had 52.5° Cobb (range, 45°-93°), and Risser 2 (0-4). Thirty-nine accepted a full-time brace treatment (BG) to try avoiding surgery, 18 refused any treatment and served as controls (CG).Physiological measures: radiographic and clinical data.Treatment: A year of full-time Sforzesco brace (23 hours/day) or Risser cast (8-12 months) and gradual weaning after Risser 3; all patients performed exercises; and International Society on Scoliosis Orthopaedic and Rehabilitation TREATMENT management criteria were respected. Analyses: EA in patients who completed treatment/observation (34 in BG and 10 in CG) and intent-to-treat (ITT) with worst case analysis in the whole population. Relative risk (RR) and 95% confidence interval (CI) have been computed.Efficacy: failures were 23.5% in BG and 100% in CG. Intent-to-treat: failures were 20.5% in BG and 55.6% in CG. Relative risks of failure in CG were 4.3 (95% CI, 3.6-4.9) in EA and 2.7 (95% CI, 2.0-3.5) in ITT (p.05). Percentage of patients (53.8%) improved: RRs of improvement in BG were 1.6 (95% CI, 1.46-1.9) in EA and 1.9 (95% CI, 1.6-2.2) in ITT (p.05). Patients who joined the treatment achieved a 10.4°±10.7° Cobb improvement, an ATR reduction of 4.2°±4.3°, and an esthetic improvement of 2.8±1.9 of 12 points (TRACE). At the end, in BG, 24 patients were below 45° and 6 patients below 35°.Through this study we can conclude that the conservative brace plus exercises treatment (if correctly performed and managed) is a suitable alternative for those patients who reject any surgical intervention for IS above 45°. But we could also conclude that a good brace treatment should be considered as the first choice to try avoiding fusion because of the high sanitary and social costs of surgery.

Unfortunately, the affiliation of the author Negrini S has been incorrectly published in the original version. The complete correct affiliation of this author should read as follows.

The eosinophilic granuloma is a unifocal or multifocal Langerhans cell histiocytosis characterized by an expanding proliferation of Langerhans cells in bones. Skeletal LCH is a rare condition, and vertebral regeneration in cases of vertebral body collapse is even rarer. We report the case of a girl with spontaneous complete healing. A 3-year-old girl was referred for nighttime back pain, with no fever and no neurologic signs. Within a few days, she developed sudden painful restriction of all spine movements. X-ray and computed tomography (CT) of the spine showed reduced T7 vertebral body height (vertebra plana).The patient underwent T7 curettage and the histopathological exam was suggestive of LCH. Two additional skull lesions were found and therefore she underwent chemotherapy. After 7 years of follow-up, total vertebral reconstruction was observed. Despite the rarity of the condition and despite the rarity of vertebral body lesion resolution, total vertebral body reconstruction was observed over a 7-year period. Long-term follow-up is necessary for a better understanding of the final outcome of patients with EG.

Overweight was found to be a negative predictor of brace effectiveness for adolescent idiopathic scoliosis (AIS), with a threefold higher risk of progression than in normal weight patients. The aim of this study is to investigate overweight, as a predictor of brace results in AIS patients. Design: retrospective cohort study. Population: 351 AIS patients (306 females), mean age 12.9 ± 1.4, mean Cobb 35.6 ± 11.4°, mean ATR 11 ± 4.3°, BMI 19.7 ± 3, median Risser: 2. Inclusion criteria: no previous treatment, full-time prescription of brace at first visit (18–23 h per day), scoliosis physiotherapeutic exercise according to the SEAS protocol associated. Outcome: improved, progressed, and stable according to the 5° Cobb agreed threshold. Statistics: a stepwise linear regression was used to look for the effect of BMI as a predictor of result. A Chi-square test and logistic regression were used for the overweight category (BMI ≥ 85th percentile). Control for possible confounders was applied. BMI is poorly correlated with final results. Confounders’ adjustment did not change the correlation, and the predictive model explained about 10% of the result. Brace results were not statistically different in overweight and normal weight: 44 vs 52% improved, 52 vs 41% stable, and 3 vs 7% worsened, respectively. Brace results were similar in overweight and normal weight subjects. These findings subvert the previous results and disprove the role of overweight as a negative predictor. Treatment management, brace type and effectiveness may play a major role in reducing the risks of scoliosis progression.

Tennis is widely practiced by adolescents in many countries. Many spinal deformity experts consider this activity, together with other asymmetrical sports, as risk factors for scoliosis development even though scientific data are missing. The aim of the present study was to verify the prevalence of spinal deformities and LBP in adolescent competitive tennis players compared to healthy controls. We designed a cross-sectional study. A convenience sample of 102 adolescent tennis players (52 girls) was compared to 203 scholars (102 girls) of the same age (12 years). We used a questionnaire to collect data on LBP and we measured the ATR to screen for spinal deformities and the plumb line distances for kyphosis (C7 and C7 + L3) and lordosis (L3). We found similar spinal deformities in both groups: ATR female: 3.2° ± 1° (tennis) versus 2.8° ± 1° (school), NS; ATR males: 2.8° ± 1° (tennis) versus 2.6° ± 1° (school), p

Introduction/Background Back pain prevalence ranges from 7 to 58% of subjects aged between 13 and 15, equally distributed in males and females. Back pain is thought to be associated with spinal deformities but no studies investigated the prevalence of back pain in different spinal deformities like, spondylolisthesis, Scheuermann disease, hyperkyphosis, scoliosis. Aim To document the prevalence of back pain, in all its forms in a large population of adolescents with spine deformities and to investigate the association of back pain and different spine pathologies. Material and method All the patients visited in 2010–2015 were asked for pain at first clinical evaluation by a single expert physician. PAINGroup and NOPAINGroup were formed. Pain description was then classified into 4 subtypes (localized or generalized, limiting or occasional). Inclusion criteria: age between 10 and 18, spine deformity diagnosis, Exclusion criteria: secondary deformities and other associated pathologies. Descriptive statistics. t-test to check the difference in the two groups considered for SRS-22 score, age and BMI. Chi2 test to check the association between the presence of pain and diagnosis and pain subtypes; sports activities and previous treatment with brace. Results In total, 702 patients were included (males n = 468), mean age 13.3 ± 1.92. Subjects’ diagnosis: adolescent idiopathic scoliosis (n = 387; 55.1%), sagittal unbalance (idiopathic) (n = 134; 19.1%) Scheuermann deformities (n = 67; 9.55%); all other diagnosis (n = 114; 16.2%). In AIS 32% referred pain, 55% in sagittal unbalanced patients and 52% in Scheuermann disease. Only Scheuermann disease predispose to pain (Chi2 = 10.2, Fisher exact test = 0.002), Sagittal unbalance is slightly associated to pain with Chi2 = 3.65, Fisher exact test = 0.05. BMI, age, sports and brace were not associated with SRS-22. Conclusion This is the first study investigating the epidemiology of different type of back pain in a large adolescents population with spinal deformities, Scheuermann deformity resulted associated to pain.

Introduction/Background Current GUIDELINES propose PCA, but there are no large studies to check final results, and predict which patients will respond better. A personalised conservative approach (PCA) to adolescents with idiopathic scoliosis (AIS) is based on different treatment protocols according to risk groups (11–20, 21–30, 31–40, 41–45). The aim of the present research is to develop a model to predict end results of a PCA in adolescents with idiopathic scoliosis (AIS). Material and method Design: retrospective observational study nested into a prospective database. Inclusion criteria: AIS, 11–45°, Risser 0–2, age 10–16, first consultation, no previous bracing, at end of observation (Risser 3, medical prescription). Treatments followed a personalised conservative approach (PCA) following the step-by-step theory (Negrini, 2018): intensity increases with estimated risk factors. Outcomes: end Cobb angle Results In total, 1457 patients, 82.6% females, age 12.11 ± 1.05. End Conclusion Time of brace wearing is the strongest predictor of final results whether a

Background context The Scoliosis Research Society 22 Questionnaire (SRS-22) has shown to worsen with increasing deformity in adolescents with idiopathic scoliosis (AIS). However, all the studies have been performed on patients who have already been diagnosed and in relatively small samples. Purpose The purposes of this study were to evaluate a large sample of consecutive patients before diagnosis to develop reference values and check the discriminative validity and correlation with deformity of the SRS-22. Study design/setting This is a cross-sectional study, with patients referred to a specialized outpatient scoliosis rehabilitation institute. Patient sample The recruited subjects were 1,205 consecutive adolescents, 75% females (13.7±1.9 years), before their first scoliosis evaluation. Five subgroups were 0°–10° Cobb (normal) and 11° to 20°, 21° to 30°, 31° to 40°, and greater than 40° (AIS). Outcome measures The outcome measure is based on the SRS-22. Methods The SRS-22 was used to examine the differences between the domains of the five subgroups and total scores, and it was correlated with Cobb degrees and curve location. We used one-way analysis of variance and Spearman rho test. Results Apart from the self-image domain in both genders and all subgroups, all other scores were greater than 4 points with small standard deviations. Females showed significant differences among groups for all domains and total score (p .1). All differences found were less than the minimally clinically significant change (0.5 points). The correlations with the severity of deformity measures were very low (r s Conclusions According to our results, deformity is apparently not a real issue for AIS before diagnosis made, treatment planned, and/or specialists interfere with their everyday life. Scoliosis Research Society 22 Questionnaire demonstrated some discriminative validity between small and large curves, but the differences found were small.

Objective To compare the prevalence of spinal deformities and low back pain (LBP) in adolescent competitive swimmers and normal controls. Study design This was a cross-sectional study with convenience sample of 112 adolescent competitive swimmers (62 females) compared with 217 students (106 females) of the same age (12.5 years). We designed a questionnaire to collect data on LBP and measured the angle of trunk rotation with a Bunnell scoliometer to screen for scoliosis, along with the plumbline distances for kyphosis and lordosis. Clinical cutoffs defined in the literature for detection of spinal deformities were applied. Analyses were performed using the t test and χ2 test, and ORs and 95% CIs were calculated. Results Swimming was found to increase the risk of trunk asymmetries (OR, 1.86; 95% CI, 1.08-3.20). Swimming also increased the risk of hyperkyphosis (OR, 2.26; 95% CI, 1.35-3.77) and hyperlordosis (OR, 2.24; 95% CI, 1.06-4.73), and increased LBP in females by 2.1-fold (95% CI, 1.08-4.06). Conclusion Swimming is associated with an increased risk of trunk asymmetries and hyperkyphosis. Although swimming has been considered a complete sport and a treatment option for scoliosis, our data contradict that approach, and also show a higher prevalence of LBP in females.

Methods Setting: outpatient tertiary referral clinic specialized in conservative treatment of spinal deformities. Participants: Inclusion criteria: idiopathic scoliosis; European Risser 0-2; 25° to 45° Cobb; age 10 years or more at start of treatment. Exclusion criteria were for both groups: secondary scoliosis and pathologies known to be possible causes of scoliosis, neurological, previous treatment for scoliosis (brace or surgery).

We read with interest the paper entitled Clinical evaluation of the ability of a proprietary scoliosis traction chair to de-rotate the spine: 6-month results of Cobb angle and rotational measurements by Stitzel et al. (doi: 10.4081/cp.2014.642) published recently as a brief report in the Journal Clinics and Practice. [...]

We read with interest the paper by Rahman about compliance temperature monitors for scoliosis braces [1]. This study confirms our everyday clinical experience with compliance monitors for braced patients. In fact, since 2010, our institute has systematically applied this kind of monitoring in everyday clinical practice [2]. We already have 2,106 patients in brace treatment who allowed us to monitor them during therapy. Thanks to this large experience, we now know that the use of this tool can improve results for our patients. Today, when braced patients do not accept the use of sensors, treatment becomes more difficult and less accurate. Recently, we interviewed patients and parents who said they would recommend the use of these monitors to other families (unpublished data). The awareness of being monitored, if well managed by explaining to patients and parents its advantages, can increase compliance, as shown in a randomized clinical trial by Miller et al. [3]. We must also report that our results completely differ from those previously published, since the compliance we documented was dramatically higher than what is usually reported (91.7 % of prescription; IC95 56.6–101.7 %), with 60 % of patients wearing the brace as much or even more than required [2]. These results are also maintained in the long term [4], which is probably a result of team management [5] during treatment according to the current SOSORT guidelines [6], and of the application of an externally symmetric and patient-oriented brace (SPoRT Brace) [7]. In addition, we encourage patients to maintain their normal everyday activities, including sports [8–10]. Even though the reliability of compliance through temperature monitors has been demonstrated [11–13], some authors advocate that these devices cannot measure the quality of brace wear; therefore, patients can reach the ‘on’ temperature without wearing the brace at the correct tightness [14]. This could be true in some cases, even if, in our experience, a correct set up of the temperature thresholds could reduce this kind of error. It would have been interesting to know the point of view of the authors and their own experience with the Cricket sensor. In the current study, the authors reported some concerns related to the variability of brace prescriptions in the sample included in their study. Previous studies did not find a correlation between compliance and dosage, even though most clinicians would expect the highest compliance in night-time brace wear, as it can be considered the easiest dosage. On the contrary, we previously found that the number of hours of brace wearing prescribed (HBW) might positively affect compliance. In our cohort, patients with 23 HBW were more compliant than were those with 18 HBW [2]. This may be justified by the severity of the curve, which may scare patients and motivate them to be adherent, or the simplicity of the prescription. A 1-h break per day is easy to understand and manage as patients must do everything while wearing their brace. The sample considered in our study included only patients with a full-time brace wear prescription (18–23 h per day). The uniformity of the sample can strengthen the reliability of our data. On the contrary, we believe that the heterogeneity of the sample considered for this study can strongly affect the generalizability of their compliance results and lead to an overestimation of their results. In addition, the absence of correlation between prescribed time and compliance can be due to the smaller sample size considered with a greater variability of data, which exposes the study to a higher risk of type I error.

Background Recently an RCT confirmed brace efficacy in adolescent idiopathic scoliosis (AIS) patients. Previously, a Cochrane review suggested also producing studies according to the Scoliosis Research Society (SRS) criteria on the effectiveness of bracing for AIS. Even if the SRS criteria propose a prospective design, until now only one out of 6 published studies was prospective. Our purpose was to evaluate the effects of bracing plus exercises following the SRS and the international Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) criteria for AIS conservative treatment. Methods Study design/setting: prospective cohort study nested in a clinical database of all outpatients of a clinic specialized in scoliosis conservative treatment. Patient sample: seventy-three patients (60 females), age 12 years 10 months ±17 months, 34.4±4.4 Cobb degrees, who satisfied SRS criteria were included out of 3,883 patients at first evaluation. Outcome measures: Cobb angle at the end of treatment according to SRS criteria : (unchanged; worsened 6° or more, over 45° and surgically treated, and rate of improvement of 6° or more). Braces were prescribed for 18–23 hours/day according to curves magnitude and actual international guidelines. Weaning was gradual after Risser 3. All patients performed exercises and were managed according to SOSORT criteria. Results in all patients were analyzed according to intent-to-treat at the end of the treatment. Funding and Conflict of Interest: no. Results Overall 34 patients (52.3%) improved. Seven patients (9.6%) worsened, of which 1 patient progressed beyond 45° and was fused. Referred compliance was assessed during a mean period of 3 years 4 months ±20 months; the median adherence was 99.1% (range 22.2-109.2%). Employing intent-to-treat analysis, there were failures in 11 patients (15.1%). At start, these patients had statistically significant low BMI and kyphosis, high thoracic rotation and higher Cobb angles. Drop-outs showed reduced compliance and years of treatment; their average scoliosis at discontinuation was low: 22.7° (range 16-35°) at Risser 1.3 ± 1. Conclusions Bracing in patients with AIS who satisfy SRS criteria is effective. Combining bracing with exercise according to SOSORT criteria shows better results than the current literature.

Background The most important factor discriminating juvenile (JIS) from adolescent idiopathic scoliosis (AIS) is the risk of deformity progression. Brace treatment can change natural history, even when risk of progression is high. The aim of this study was to compare the end of growth results of JIS subjects, treated after 10 years of age, with final results of AIS. Methods Design: prospective observational controlled cohort study nested in a prospective database. Setting: outpatient tertiary referral clinic specialized in conservative treatment of spinal deformities. Inclusion criteria: idiopathic scoliosis; European Risser 0–2; 25 degrees to 45 degrees Cobb; start treatment age: 10 years or more, never treated before. Exclusion criteria: secondary scoliosis, neurological etiology, prior treatment for scoliosis (brace or surgery). Groups: 27 patients met the inclusion criteria for the AJIS, (Juvenile Idiopathic Scoliosis treated in adolescence), demonstrated by an x-ray before 10 year of age, and treatment start after 10 years of age. AIS group included 45 adolescents with a diagnostic x-ray made after the threshold of age 10 years. Results at the end of growth were analysed; the threshold of 5 Cobb degree to define worsened, improved and stabilized curves was considered. Statistics: Mean and SD were used for descriptive statistics of clinical and radiographic changes. Relative Risk of failure (RR), Chi-square and T-test of all data was calculated to find differences among the two groups. 95% Confidence Interval (CI) , and of radiographic changes have been calculated. Results We did not find any Cobb angle significant differences among groups at baseline and at the end of treatment. The only difference was in the number of patients progressed above 45 degrees, found in the JIS group. The RR of progression of AJIS was, 1.35 (IC95% 0.57-3.17) versus AIS, and it wasn't statistically significant in the AJIS group, in respect to AIS group (p = 0.5338). Conclusion There are no significant differences in the final results of AIS and JIS, treated with total respect of the SRS and SOSORT criteria, in adolescence. Brace efficacy can neutralize the risk of progression.

Background context: The main distinctive aspect of Juvenile Idiopathic Scoliosis (JIS) with respect to Adolescent Idiopathic Scoliosis (AIS) is the high risk of severe deformity and surgery. Approximately 70% of curves in patients with JIS progress and ultimately require surgery. There are presently very few studies with long-term follow-up of JIS and even fewer looking specifically at bracing Purpose To verify the effectiveness of a complete conservative treatment, including bracing and exercises, for JIS. Study design/setting: Retrospective cohort observational study nested in a clinical prospective database of consecutive outpatients. Patient Sample Inclusion criteria: JIS, no previous treatment, all consecutive radiographies available from treatment start to end of growth (Risser sign 3). We found 30 patients, 27 females, 10 JIS type 1; mean age at first diagnosis was 7.8 +/�1.5 and mean treatment lasted 5.8 years. Cobb degrees 24.4+/�10 degrees, with 7 cases >30 degrees, and 2 > 45degrees. Outcome Measures Physiological measures. Radiographic and clinical data. Methods: Treatment (exercises alone, or elastic-rigid-highly rigid braces plus exercises) was tailored and continuously changed according to Cobb degrees, individual preferences, anthropometric characteristics, pubertal spurt, remaining growth, rotation, hump, lumbar curve take-off, and imbalance. The SOSORT Guidelines for patients’ management have been followed. Funding and Conflict of Interest: no. Results: 33.3% (95% Confidence Interval 16.4-50.2%) of patients worsened over the years. At the end of growth, 6.6% (0–15.5%) had surgical deformities (>45degrees). We observed a good correction in the first years of treatment until pubertal growth spurt, when progression was usually noted and treatment changed increasing corrective forces (hours or rigidity of bracing). 23 ca ses were followed up until they had two consecutive radiographies showing Risser sign 5 and showed stability. Conclusions: Conservative treatment initiated already in childhood may favorably change the natural history of JIS with the aim of reaching a curve as far as possible from surgical thresholds. Observation, physical exercises, braces can be useful tools in the hand of physicians, but they must be carefully utilized by a deep knowledge of JIS.

Dear Editor, We read with interest the paper by Polak [1], showing incredible improvement of scoliosis with a manual therapy technique. Nevertheless, there are some methodological biases that greatly concern us: many details are missing, and the conclusions are far from supported by the data. First, the selection bias. Scoliosis is a three-dimensional deformity of the vertebrae and trunk, not just a postural matter, diagnosed through the presence of the hump, then confirmed by radiographs [2,3]. Most of the patients in the study had curves between 11° and 19° Cobb, where the presence of non-structural scoliosis is higher: no data were reported about the Adams test [2], while the author stated he excluded postural problems without saying how. Since the author supposes that neck contracture caused scoliosis (this is not supported by current knowledge about structural scoliosis etiology [4]), we can imagine that many of these were simply antalgic scoliosis. Moreover, information about the patients' selection, drop out, and failures is missing, so it's possible that non responders were excluded. These selection biases make the conclusions unreliable. Other biases typical of scoliosis treatment: The follow-up period is too short, and shows no end of growth results. This has been clearly stated recently as an important factor in scoliosis conservative treatment [5]. Some patients had their outcomes after 2 weeks, making it impossible to determine the stability of the result. Even accepting muscular imbalance as the cause, and this has never been proved, short-term realignment of the spine is not enough to remove the deformation since bones take a long time to recover. Improper use of the term adolescent idiopathic scoliosis. The author included juveniles, adolescents, and probably end of growth patients. Since they have very different short-term risks of progression [2,3,6], they must be studied separately. Juvenile scoliosis is not very aggressive in short time before the pubertal growth spurt; in the oldest group (>16 years), we expect the growth to be already concluded, so a short-term improvement doesn't really change the deformity. Large changes in Cobb angle can occur even during the same day: large curves in adults tend to be 6-7 degrees lower in the morning with respect to the evening [7], and specific exercises can improve posture up to 20° [8]. The Risser test, the gold standard for spinal growth evaluation, was ignored [3,5]. The only conclusion supported by the present data could be that the technique provided very short-term postural benefits. No conclusions about end of growth results and or structural scoliosis can be drawn. The etiological theory was not demonstrated: beyond the biases reported, successfully applying a treatment doesn't make its founding theory correct. The effect of the treatment is probably a provisional postural change, and not an improvement of any deformity. Proposing this technique alone as an alternative to bracing is not supported by data, and can be totally misleading for readers; moreover, bracing has been shown to be effective not just in stopping, but even in improving the condition [6,9,10].

Background A previous study reported that being overweight is predictive of decreased effectiveness of bracing for patients diagnosed with Adolescent Idiopathic Scoliosis (AIS), with the risk of worsening three times higher in overweight patients than in normal-weight scoliosis patients. Purpose The goal of this study was to verify if body mass index (BMI) and, specifically, obesity, are predictive for the effectiveness of bracing in a cohort of AIS patients. Methods Design: retrospective cohort study. Population: 351 AIS patients (306 females), age 10-15 years at first assessment (average 12.9±1.4), worst curve 35.6±11.4° Cobb, ATR 11±4.3°, median Risser 2, BMI 19.7±3. All subjects included were prescribed a brace treatment at first visit (initially 18-23 hours per day) accompanied by Scoliosis Physiotherapic Exercise according to the Scientific Exercises Approach to Scoliosis (SEAS) protocol. After the treatment, all patients were evaluated again and changes were analysed. Outcome: n° of patients improved/worsened (defined as patients with a change of more than 5° Cobb) or stable, average change of Cobb angle. Statistical analysis: a stepwise linear regression was used to look for the effect of BMI as a predictor of result. A chi-square test and a logistic were used for the category of overweight patients (BMI³85° percentile). During the statistical analysis, we controlled for possible confounders. Results The chi-square test showed similar results in overweight and normal weight 44% vs. 52% improved, 52% vs. 41% stable and 3% vs. 7% worsened, respectively. We found BMI to be poorly correlated with final results. Adjusting for confounders did not change this poor correlation, and the predictive model explained about 10% of the result.

Conclusions and discussion At this stage, the following explanatory hypotheses can be drawn: Technical radiological differences (exposure, machine) Variation of pelvis positioning Postural changes influencing the pelvis Brace compression on the pelvis According to our study results, all of the hypotheses include data both in favor and against the reliability of the Risser sign. Since the Risser sign is a 2D evaluation of a 3D phenomenon, pelvis repositioning could perhaps be the most plausible explanation. This case series is open to the possibility that the Risser sign is even less reliable than originally considered. Unfortunately, this result cannot be checked experimentally due to ethical reasons. Nevertheless, observational designs could be considered in the future.

Scoliosis with combined increase of the curves on the sagittal plane is 8.3%. In this subgroup, males are 24.4%. Radiographic signs of Scheuermann’s disease have been found in 45 patients (23.3% of the 201 subjects under study). Among those, 14 were male (31.1%) and 31 female. Comparing to the classification according to Lenke, 6 of them were of type 1, 31 of type 3, and 8 of type 5. Conclusion Among IS with combined hyperkyphosis, the prevalence of the male sex is greater than what is reported for the common form of IS. According to our results, in a significant number of idiopathic scoliosis, alterations related to Scheuermann’s disease have been reported in one or more vertebrae: in these cases the rate of males slightly increases. This could imply the exclusion of this subgroup from IS.

A recent study suggests a correlation between idiopathic scoliosis in adolescence and eating disorders. However, this does not correspond with our clinical experience in the same population. The aim of this study was to verify the correlation between scoliosis and eating disorders in adolescence. A cross-sectional study was designed including 187 consecutive adolescent girls with a diagnosis of idiopathic scoliosis (mean Cobb angle 26°, range 11-73°, age 15.2±2.5; 24% juveniles, 76% adolescent type) and 93 schoolgirls as controls (age 14.9±1.0). All of the participants answered the Italian validated questionnaire EAT-26 about eating habits in order to identify any eating disorders. Body mass index (BMI) was calculated for all participants and compared to reference data.chi-square test, Student's t-test, Pearson's correlation coefficient. Only 3 (1.6%; 95% CI -0.2-3.4%) participants in the scoliosis group showed EAT-26 scores suggestive for eating disorders versus 7 (7.5%; 95% CI 2.2-12.9%) in the school population (p0.05). The BMI was slightly lower (p0.05) for scoliosis patients (19±0.2) than for school girls (21±0.3). EAT-26 is recognized among the most valid questionnaires for eating disorders and has been widely applied in various countries. By applying this questionnaire, a lower incidence of eating disorders in female scoliosis patients was found than in the general population (using both our own controls and Italian reference values). This contrasts with some expert opinions and a recent study performed in Italy. The low BMI already reported in the literature as being typical of scoliosis participants is confirmed by our data.

Material and methods Sagittal parameters of the spine and pelvis were analysed in lateral standing radiographs of 256 adolescents (13.7±5 years, curve range 4-57) and compared with statistically normal values (NV) in adolescents found in the literature: thoracic kyphosis TK (NV 22–66), lumbar lordosis LL (NV 24-72), pelvic incidence PI (NV 27-71), sacral slope SS (NV 25-57) and pelvic tilt PT (NV –8-16). Lateral standing radiographs were matched with anteroposterior radiograph. Patients were classified according to the entity of scoliosis curves, age, gender and risser score.