Premise
Mandate
Committee
Content
Scope, purpose, and applications
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How should a patient be assessed?
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Which conservative treatment should be provided, and how?
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How and when should bracing be applied?
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How and when should exercises be used?
Development of the guidelines
Methods
Strength of evidence | Question | Meaning |
I | Effectiveness | Multiple Randomized Controlled Trials or Systematic Reviews of such studies |
Diagnosis | Multiple Randomized Controlled Trials, or Cross-sectional Studies with verification by reference (gold) standard, or Systematic Reviews of such studies | |
II | Effectiveness | One Randomized Controlled Trial |
Diagnosis | One Randomized Controlled Trial, or one Cross-sectional Study with verification by reference (gold) standard | |
III | Effectiveness | Multiple Controlled nonrandomized Studies or Systematic Reviews of such studies |
Diagnosis | Multiple Cross-sectional Studies with incomplete & unbalanced verification with reference (gold) standard | |
IV | Effectiveness | Other studies |
Diagnosis | ||
V | Effectiveness | SOSORT consensus with more than 90% of agreement |
Diagnosis | ||
VI | Effectiveness | SOSORT consensus with 70 to 89% of agreement |
Diagnosis |
Strength of recommendation | Meaning |
---|---|
A | It must be applied widely and to all patients with this specific need |
B | It is important, but does not have to be applied to all patients with this specific need |
C | Less important, it can be applied on a voluntary basis |
D | Very low importance |
Target users of the guidelines
Updates
Applicability
General information on idiopathic scoliosis
Definitions
Epidemiology
Etiology
Natural history
Classifications
Chronological (SoE: V) | Angular (SoE: VI) | Topographic (SoE: V) | ||||
---|---|---|---|---|---|---|
Age at diagnosis (years.months) | Cobb degrees | Apex | ||||
from | to | |||||
Infantile | 0–2. | Low | Up to 20 | Cervical | – | Disc C6–7 |
Juvenile | 3–9. | Moderate | 21–35 | Cervico-thoracic | C7 | T1 |
Adolescent | 10–17. | Moderate to severe | 36–40 | Thoracic | Disc T1–2 | Disc T11–12 |
Adult | 18+ | Severe | 41–50 | Thoraco-lumbar | T12 | L1 |
Severe to very severe | 51–55 | Lumbar | Disc L1–2 | |||
Very severe | 56 or more |
Chronological
Angular
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Over 30° of scoliosis, the risk of progression in adulthood increases, as well as the risk of health problems and reduction of quality of life.
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Over 50°, there is a consensus that it is almost certain that scoliosis is going to progress in adulthood and cause health problems and reduction of quality of life.
Topographic
Rigo classification
Evidence-based clinical practice approach to idiopathic scoliosis during growth
Goals of conservative treatment
General goals
Esthetics | |
Quality of life | |
Disability | |
Back pain | |
Psychological well-being | |
Progression in adulthood | |
Breathing function | |
Scoliosis Cobb degrees | |
Need of further treatments in adulthood |
Specific goals of conservative treatment during growth
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Absolute goal: these are the minimum expected goals of conservative treatment. If not anything else, at least these goals should be reached.
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Primary goals: these are the “best possible” goals for patients starting treatment in each specific clinical situation.
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Secondary goals: these are the compromise goals that come when it becomes clear that it is not possible to reach the primary goals
Absolute aim of treatments | Percentage | |
Avoid surgery | 90.70 | |
Improve aesthetics | 86.05 | |
Improve quality of life | 82.56 | |
Degree of curve | Primary aim | Secondary aim |
Low | Remain below 20° | Remain below 45° |
Moderate | Remain below 30° | Remain below 45° |
Severe | Remain below 45° | Postpone surgery |
Evidence-based clinical practice approach
1 | Obs 36 |
2 | Obs 12 |
3 | Obs 8 |
4 | Obs 6 |
5 | Obs 3 |
6 | PSSE |
7 | NTRB |
8 | SIR |
9 | SSB |
10 | HTRB |
11 | PTRB |
12 | FTRB |
13 | TTRB |
14 | Su |
Low | Moderate | Severe | |||||
---|---|---|---|---|---|---|---|
Min
|
Max
|
Min
|
Max
|
Min
|
Max
| ||
Infantile | Obs3 | Obs3 | Obs3 | TTRB | TTRB | Su | |
Juvenile | Obs3 | PSSE | PSSE | FTRB | HTRB | Su | |
Adolescent | Risser 0 | Obs6 | SSB | HTRB | FTRB | TTRB | Su |
Risser 1 | Obs6 | SSB | PSSE | FTRB | FTRB | Su | |
Risser 2 | Obs6 | SSB | PSSE | FTRB | FTRB | Su | |
Risser 3 | Obs6 | SSB | PSSE | FTRB | FTRB | Su | |
Risser 4 | Obs12 | SIR | PSSE | FTRB | FTRB | Su | |
Adult up to 25 y | Nothing | PSSE | Obs12 | SIR | Obs6 | Su | |
Adult | No Pain | Nothing | PSSE | PSSE | SIR | Obs12 | HTRB |
Pain | PSSE | SSB | PSSE | HTRB | PSSE | Su | |
Elderly | No Pain | Nothing | PSSE | Obs36 | PSSE | Obs12 | HTRB |
Pain | PSSE | SSB | PSSE | HTRB | PSSE | Su | |
trunk decompensation | Obs6 | SSB | PSSE | PTRB | PSSE | Su |
I | II | III | IV | V | VI | Total | |
---|---|---|---|---|---|---|---|
Bracing | 2 | 3 | 3 | 6 | 12 | 1 | 25 |
Specific exercises to prevent scoliosis progression during growth | 1 | 1 | 1 | 0 | 8 | 1 | 12 |
Specific exercises during brace treatment and surgical therapy | 0 | 3 | 0 | 0 | 3 | 0 | 6 |
Other conservative treatments | 0 | 0 | 0 | 0 | 2 | 0 | 2 |
Respiratory function and exercises | 0 | 0 | 0 | 0 | 3 | 0 | 3 |
Sports activities | 0 | 0 | 2 | 0 | 3 | 1 | 6 |
Assessment | 0 | 0 | 1 | 9 | 1 | 3 | 14 |
Total | 3 | 7 | 7 | 15 | 32 | 6 | 68 |
A | B | C | D | E | Total | |
---|---|---|---|---|---|---|
Bracing | 2 | 20 | 3 | 0 | 0 | 25 |
Specific exercises to prevent scoliosis progression during growth | 0 | 7 | 5 | 0 | 0 | 12 |
Specific exercises during brace treatment and surgical therapy | 0 | 2 | 4 | 0 | 0 | 6 |
Other conservative treatments | 0 | 0 | 2 | 0 | 0 | 2 |
Respiratory function and exercises | 0 | 1 | 2 | 0 | 0 | 3 |
Sports activities | 0 | 3 | 3 | 0 | 0 | 6 |
Assessment | 1 | 6 | 4 | 1 | 2 | 14 |
Total | 3 | 39 | 23 | 1 | 2 | 68 |
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PAS is proposed to resolve the differences in treatment decisions between different clinicians in their clinical practice. PAS guards against presumably wrong clinical decisions (above maximum: overtreatment, below minimum: undertreatment).
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It reports a real approach, since most clinicians usually choose a variety of treatments for a single patient; the final decision comes after discussion with the patient, and weighting the various risk factors involved in the clinical situation. In fact, the PAS has been developed according to the “Step by Step” Sibilla’s theory [92, 112‐115], which states that for each patient, it is mandatory to choose the correct step of treatment, where the most efficacious is also the most demanding. Accordingly, coming to a wrong decision means facing one of the two main mistakes in conservative treatment of idiopathic scoliosis, overtreatment (too much burden on the patient, without improved efficacy) or undertreatment (treatment that leads to little or no efficacy).
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Evidence-Based Clinical Practice is by definition the best integration between the knowledge offered by Evidence-Based Medicine, individual clinical expertise and patients’ preferences [116‐118]. Consequently, different clinicians will treat a patient with the same clinical problem differently; the variation can be due to the patient’s preferences or because of the specific expertise of the clinician. Therefore, proposing a definitive clinical approach for a certain clinical situation is problematic. Rather, a range of options should be considered.
Conservative treatments
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Night Time Rigid Bracing (8–12 h per day) (NTRB): wearing a brace mainly in bed.
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Part Time Rigid Bracing (12–20 h per day) (PTRB): wearing a rigid brace mainly outside school and in bed.
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Full Time Rigid Bracing (20–24 h per day) or cast (FTRB): wearing a rigid brace all the time (at school, at home, in bed, etc.). Casts have been included here as well. Casts are used by some schools as the first stage to achieve correction to be maintained afterwards with rigid brace [126‐128]; a cast is considered a standard approach in infantile scoliosis [129‐132]. Recently, a new brace has been developed that has been claimed to achieve same results as casting [91, 133, 134].
Prognostic factors
Brace treatment
Methods
Results
Efficacy in adolescents
Are there braces that are better than others?
Recommendation | Strength | Evidence | References |
---|---|---|---|
1. Bracing is recommended to treat adolescent idiopathic scoliosis | B | I | |
2. Bracing is recommended to treat juvenile and infantile idiopathic scoliosis as the first step in an attempt to avoid or at least postpone surgery to a more appropriate age | B | III | |
3. The use of brace is recommended in patients with evolutive idiopathic scoliosis above 25° during growth; in these cases PSSE alone (without bracing) should not be performed unless prescribed by a physicans expert in scoliosis. | B | I | |
4. Casting (or rigid bracing) is recommended to treat infantile idiopathic scoliosis to try stabilizing the curve | B | IV | |
5. It is recommended not to apply bracing to treat patients with curves below 15° ± 5° Cobb, unless otherwise justified in the opinion of a clinician specialized in conservative treatment of spinal deformities | B | V | |
6. Bracing is recommended to treat patients with curves above 20° ± 5° Cobb, still growing (Risser 0 to 3), and with demonstrated progression of deformity or elevated risk of worsening, unless otherwise justified in the opinion of a clinician specialized in conservative treatment of spinal deformities | B | I | |
7. Very hard rigid bracing (casting) is recommended to treat patients with curve between 45° and 60° to try avoiding surgery. | C | IV | |
8. It is recommended that each treating team provide the brace that they know best, which means the brace they are more experienced and with perceived outcomes. This is due to the actual knowledge; there is no brace that can be recommended over the others. | C | IV | |
9. It is recommended that braces are worn full time or no less than 18 h per day at the beginning of treatment, unless otherwise justified in the opinion of a clinician specialized in conservative treatment of spinal deformities | B | II | |
10. Since there is a “dose-response” to treatment, it is recommended that the hours of bracing per day are in proportion with the severity of deformity, the age of the patient, the stage, aim and overall results of treatment, and the achievable compliance | B | II | |
11. It is recommended that daily brace wear is proportionate to the deformity severity, age of patient, scoliosis stage, aim and overall results of treatment, and the expected compliance | B | II | [87] |
12. It is recommended that braces are worn until the end of vertebral bone growth and then the wearing time is gradually reduced, unless otherwise justified in the opinion of a clinician specialized in conservative treatment of spinal deformities | B | V | |
13. It is recommended that the wearing time of the brace is gradually reduced, while performing stabilizing exercises, to allow adaptation of the postural system and maintain results | B | IV | |
14. It is recommended that any mean is used to encourage compliance, including a careful adherence to the recommendations defined in the SOSORT Guidelines for Bracing Management | B | IV | |
15. It is recommended that compliance to bracing is regularly checked through compliance monitor devices. | B | V | |
16. It is recommended that quality of the brace is checked through an in-brace X-ray | B | IV | |
17. It is recommended that the prescribing physician and the constructing orthotist are experts according to the criteria defined in the SOSORT Guidelines for Bracing Management | C | VI | [135] |
18. It is recommended that bracing is applied by a well-trained therapeutic team, including a physician, an orthotist and a therapist, according to the criteria defined in the SOSORT Guidelines for Bracing Management | B | V | [135] |
19. It is recommended that all the phases of brace construction (prescription, construction, check, correction, follow-up) are carefully followed for each single brace according to the criteria defined in the SOSORT Guidelines for Bracing Management | B | V | [135] |
20. It is recommended that the brace is specifically designed for the type of the curve to be treated | B | V | |
21. It is recommended that the brace proposed for treating a scoliotic deformity on the frontal and horizontal planes should take into account the sagittal plane as much as possible | A | V | |
22. It is recommended to use the least invasive brace in relation to the clinical situation, provided the same effectiveness, to reduce the psychological impact and to ensure better patient compliance | A | V | |
23. It is recommended that braces do not so restrict thorax excursion in a way that reduces respiratory function | B | V | |
24. It is recommended that braces are prescribed, constructed and fitted in an out-patient setting | B | V | |
25. It is recommended that braces are regularly changed according to growth and/or specific pathological needs as judged by a scoliosis expert physician | B | V | |
26. It is recommended that out of brace X-rays are regularly performed to check the effectiveness of bracing treatment: the number of hours out of brace before x-ray taking should correspond to the daily weaning time | B | V |
Conservative treatments other than bracing
Physiotherapeutic scoliosis-specific exercises (PSSE) to prevent scoliosis progression during growth
Methods
Results
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Auto-correction in 3D
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Training in activities of daily living (ADL)
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Stabilizing the corrected posture
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Patient education
Recommendations on “physiotherapeutic scoliosis-specific exercises to prevent scoliosis progression during growth”
Recommendation | Strength | LoE | References |
---|---|---|---|
1. Physiotherapeutic scoliosis-specific exercises are recommended as the first step to treat idiopathic scoliosis to prevent/limit progression of the deformity and bracing | C | I | |
2. It is recommended that physiotherapeutic scoliosis-specific exercises follow SOSORT Consensus and are based on auto-correction in 3D, training in ADL, stabilizing the corrected posture, and patient education | B | II | [88] |
3. It is recommended that physiotherapeutic scoliosis-specific exercises follow one of the Schools that have shown the effectiveness of their approach with scientific studies | C | III | |
4. It is recommended that physiotherapeutic-scoliosis specific exercise programmes are designed by therapists specifically trained in the approach they use | B | V | |
5. It is recommended that physiotherapeutic scoliosis-specific exercises are proposed by therapists included in scoliosis treatment teams, with close cooperation between all members | C | V | [88] |
6. It is recommended that physiotherapeutic scoliosis-specific exercises are individualized according to patient needs, curve pattern, and treatment phase | B | V | |
7. It is recommended that physiotherapeutic scoliosis-specific exercises are always individualized even if performed in small groups | B | VI | |
8. It is recommended that physiotherapeutic scoliosis-specific exercises are performed regularly throughout treatment to achieve best results | B | V | |
9. It is recommended that therapists implement a compliance system for exercise tracking | C | V | |
10. It is recommended that therapists regularly assess patients’ quality of physiotherapeutic scoliosis-specific exercises performed by the patients. | B | V | |
11. It is recommended that physiotherapeutic scoliosis-specific exercises difficulty is progressively increased according to patient ability. | B | V | |
12. It is recommended that physiotherapeutic scoliosis-specific exercises are taught individually in a 1 to 1 relationship to assure individualized care, while regular performance could also be at home or in little groups | C | V |
Physiotherapeutic specific exercises during brace treatment and surgical therapy
Methods
Results
Recommendations on “physiotherapeutic scoliosis-specific exercises during brace treatment and surgical therapy”
Recommendation | Strength | Evidence | References |
---|---|---|---|
1. It is recommended that physiotherapeutic scoliosis-specific exercises are performed during brace treatment | B | II | |
2. It is recommended that, while treating with physiotherapeutic scoliosis-specific exercises, therapists work to increase compliance of the patient to brace treatment | B | II | |
3. It is recommended that spinal mobilization physiotherapeutic scoliosis specific exercises are used in preparation to bracing | C | V | |
4. It is recommended that stabilization physiotherapeutic scoliosis-specific Exercises in autocorrection are used during brace weaning period | C | V | [290] |
5. It is recommended that physiotherapeutic scoliosis-specific exercises in painful operated patients are used to reduce pain and increase function | C | V | [348] |
6. It is recommended that aerobic physiotherapy training be used prior to surgery. | C | II | [493] |
Other conservative treatments
Methods
Results
Recommendations on “other conservative treatments”
Recommendation | Strength | Evidence | References |
---|---|---|---|
1. It is recommended that manual therapy (gentle, short-term mobilization, or releasing soft tissues techniques) is proposed only if associated with stabilization physiotherapeutic scoliosis specific exercises, unless otherwise justified in the opinion of a clinician specialized in conservative treatment of spinal deformities | C | V | [331] |
2. It is recommended that correction of real leg length discrepancy, if needed, is decided by a clinician specialized in conservative treatment of spinal deformities | C | V |
Respiratory function and exercises
Methods
Results
Recommendations on “respiratory function and exercises”
Recommendation | Strength | Evidence | References |
---|---|---|---|
1. It is recommended that, when needed, exercises to improve respiratory function are used | B | V | |
2. It is recommended during brace treatment to use exercises to improve respiratory function | C | V | [352] |
3. It is recommended to use physiotherapeutic scoliosis-specific exercises to train regional respiratory strategies in order to promote the expansion and ventilation of specific lung compartments | C | V | [351] |
Sports activities
Methods
Results
Recommendations on “sports activities”
Recommendation | Strength | Evidence | References |
---|---|---|---|
1. It is recommended that sports is not prescribed as a treatment for idiopathic scoliosis | C | III | |
2. It is recommended that general sports activities are performed because of the specific benefits they offer to patients in terms of psychological, neuromotor and general organic well-being | B | V | |
3. It is recommended that, during all treatment phases, physical education at school is continued. Based on the severity of the curve and progression of the deformity and the opinion of a clinician specialized in conservative treatment of spinal deformities, restrictions may be placed on practicing certain types of sports activities | B | V | |
4. It is recommended that sports activities are continued also during brace treatment because of the physical (aerobic capacity) and psychological benefits these activities provide | B | V | [352] |
5. It is recommended that, during brace treatment, contact or highly dynamic sport activities are performed with caution | C | VI | |
6. It is recommended that competitive activities that greatly mobilize the spine are avoided in patients with scoliosis at high risk of progression | C | III |
Assessment
Clinical assessment
Screening
Radiological assessment
Surface assessment
Aesthetics
Surface topography
Other evaluation
Recommendations on “assessment”
Recommendation | Strength | Evidence | Reference |
---|---|---|---|
1. School screening programmes are recommended for the early diagnosis of idiopathic scoliosis | B | IV | |
2. The schools screening should be performed using the Scoliometer during trunk forward bend (Adam’s test) | B | IV | |
3. It is recommended that for scoliosis screening programmes 5° and 7° of angle of trunk rotation should be used as criteria for referral | B | V | |
4. It is recommended that, every time they evaluate children aged from 8 to 15 years, pediatricians, general practitioners and sports physicians perform the Adam’s test for scoliosis screening purposes, using the Scoliometer | B | VI | |
5. It is recommended for clinical follow-up to use validated assessment methods and standard clinical data collection forms | B | IV | |
6. It is recommended to take into account the measurement error for each method applied for the assessment of scoliosis patients | A | IV | |
7. It is recommended to clinically assess in scoliosis patients at least: angle of trunk rotation, aesthetics, and sagittal alignment of the spine. Other possible common evaluations include: pain, respiratory function, =spine and joint flexibility and strength, leg length discrepancy, balance and coordination, quality of life. | B | IV | |
8. The sagittal spine balance should be assessed with X-ray | E | III | |
9. It is recommended that clinical follow-up examinations are performed at least twice a year, a part periods of rapid growth (pubertal spurt, first 3 years of life) | D | IV | |
10. It is recommended that frontal radiographic studies are made postero-anteriorly, using digital films with a ratio X-rays, including visualization of the femoral heads and protection of the gonads, in any standing position without the use of support aids or indication of correct posture, unless otherwise justified in the opinion of a clinician specialized in spinal deformities | C | IV | |
11. It is recommended that curve magnitude is measured using the Cobb method | C | IV | [62] |
12. On radiographic lateral view, the patient’s upper extremities should be placed in a position to uncover the upper thoracic spine. The recommended positions comprise: (1) 45° angle flexion of the arms, elbows extended and hands resting on a support to preserve the sagittal curvature of the spine, (2) the arms crossed over the breasts, (3) the hand resting on the ipsilateral shoulder without pressing it | E | IV | |
13. To reduce the invasiveness of follow-up, it is recommended that the least number of projections is made on radiographic studies | C | VI | |
14. It is recommended that all idiopathic scoliosis patients, even if not treated, are regularly followed-up | C | VI |