Search

Background: This study aimed to compare the effect of the ultrasound-guided bilateral and bilevel erector spinae plane block (ESPB) on pain scores, opioid requirement, intraoperative motor-evoked potentials (MEPs), and stress response to surgery expressed by the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) versus standard analgesia methods following idiopathic scoliosis surgery., Methods: This was a prospective, double-blinded, randomized controlled trial. Sixty patients aged 10 to 18 years and physical status ASA 1 or 2 were randomized into 2 equal groups, each receiving an ESPB or sham block. The primary outcome was the pain scores (Numerical Rating Scale, NRS) within 48 hours after spinal correction and fusion surgery for idiopathic thoracic scoliosis. The secondary outcomes were total opioid consumption, NLR, and PLR levels at 12 and 24 hours postoperatively and intraoperative MEPs., Results: ESPB patients presented lower NRS scores, signifying less pain, at all time points (30, 60, 90, 120 min; and 6, 12, 24, and 48 h after surgery), all P <0.0001. The total opioid consumption, the incidence of nausea or vomiting, and the need for remifentanil and propofol during surgery were significantly lower in the ESPB group. The surgery-induced stress response expressed by NLR and PLR was considerably lower in the ESPB group. ESPB did not affect the intraoperative MEP's amplitude., Conclusions: ESPB is effective for postoperative analgesia, can reduce opioid consumption in patients undergoing scoliosis surgery, and reduces the stress response to surgery. ESPB does not interfere with neuromonitoring., Level of Evidence: Level I., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Adolescent idiopathic scoliosis (AIS) is a pathology that changes the three-dimensional shape of the spine and trunk. While AIS can progress during growth and cause cosmetic issues, it is usually asymptomatic. However, a final spinal curvature above the critical threshold of 30° increases the risk of health problems and curve progression in adulthood. The use of therapeutic exercises (TEs) to reduce the progression of AIS and delay or avoid other, more invasive treatments is still controversial., Objectives: To evaluate the effectiveness of TE, including generic therapeutic exercises (GTE) and physiotherapeutic scoliosis-specific exercises (PSSE) in treating AIS, compared to no treatment, other non-surgical treatments, or between treatments., Search Methods: We searched CENTRAL, MEDLINE, Embase, four other databases, and two clinical trials registers to 17 November 2022. We also screened reference lists of articles., Selection Criteria: Randomised controlled trials (RCTs) comparing TE with no treatment, other non-surgical treatments (braces, electrical stimulation, manual therapy), and different types of exercises. In the previous version of the review, we also included observational studies. We did not include observational studies in this update since we found sufficient RCTs to address our study aims., Data Collection and Analysis: We used standard Cochrane methodology. Our major outcomes were progression of scoliosis (measured by Cobb angle, trunk rotation, progression, bracing, surgery), cosmetic issues (measured by surface measurements and perception), and quality of life (QoL). Our minor outcomes were back pain, mental health, and adverse effects., Main Results: We included 13 RCTs (583 participants). The percentage of females ranged from 50% to 100%; mean age ranged from 12 to 15 years. Studies included participants with Cobb angles from low to severe. We judged 61% of the studies at low risk for random sequence generation and 46% at low risk for allocation concealment. None of the studies could blind participants and personnel. We judged the subjective outcomes at high risk of performance and detection bias, and the objective outcomes at high risk of detection bias in six studies and at low risk of bias in the other six studies. One study did not assess any objective outcomes. Comparing TE versus no treatment, we are very uncertain whether TE reduces the Cobb angle (mean difference (MD) -3.6°, 95% confidence interval (CI) -5.6 to -1.7; 2 studies, 52 participants). Low-certainty evidence indicates PSSE makes little or no difference in the angle of trunk rotation (ATR) (MD -0.8°, 95% CI -3.8 to 2.1; 1 study, 45 participants), may reduce the waist asymmetry slightly (MD -0.5 cm, 95% CI -0.8 to -0.3; 1 study, 45 participants), and may result in little to no difference in the score of cosmetic issues measured by the Spinal Appearance Questionnaire (SAQ) General (MD 0.7 points, 95% CI -0.1 to 1.4; 1 study, 16 participants). PSSE may result in little to no difference in self-image measured by the Scoliosis Research Society - 22 Patient Questionnaire (SRS-22) (MD 0.3 points, 95% CI -0.3 to 0.9; 1 study, 16 participants) and improve QoL slightly measured by SRS-22 Total score (MD 0.3 points, 95% CI 0.1 to 0.4; 2 studies, 61 participants). Only Cobb angle results were clinically meaningful. Comparing PSSE plus bracing versus bracing, low-certainty evidence indicates PSSE plus bracing may reduce Cobb angle (-2.2°, 95% CI -3.8 to -0.7; 2 studies, 84 participants). Comparing GTE plus other non-surgical interventions versus other non-surgical interventions, low-certainty evidence indicates GTE plus other non-surgical interventions may reduce Cobb angle (MD -8.0°, 95% CI -11.5 to -4.5; 1 study, 80 participants). We are uncertain whether PSSE plus other non-surgical interventions versus other non-surgical interventions reduces Cobb angle (MD -7.8°, 95% CI -12.5 to -3.1; 1 study, 18 participants) and ATR (MD -8.0°, 95% CI -12.7 to -3.3; 1 study, 18 participants). PSSE plus bracing versus bracing alone may make little to no difference in subjective measurement of cosmetic issues as measured by SAQ General (-0.2 points, 95% CI -0.9 to 0.5; 1 study, 34 participants), self-image score as measured by SRS-22 Self-Image (MD 0.1 points, 95% CI -0.3 to 0.5; 1 study, 34 participants), and QoL measured by SRS-22 Total score (MD 0.2 points, 95% CI -0.1 to 0.5; 1 study, 34 participants). None of these results were clinically meaningful. Comparing TE versus bracing, we are very uncertain whether PSSE allows progression of Cobb angle (MD 2.7°, 95% CI 0.3 to 5.0; 1 study, 60 participants), changes self-image measured by SRS-22 Self-Image (MD 0.1 points, 95% CI -1.0 to 1.1; 1 study, 60 participants), and QoL measured by SRS-22 Total score (MD 3.2 points, 95% CI 2.1 to 4.2; 1 study, 60 participants). None of these results were clinically meaningful. Comparing PSSE with GTE, we are uncertain whether PSSE makes little or no difference in Cobb angle (MD -3.0°, 95% CI -8.2 to 2.1; 4 studies, 192 participants; very low-certainty evidence). PSSE probably reduces ATR (clinically meaningful) (MD -3.0°, 95% CI -3.4 to -2.5; 2 studies, 138 participants). We are uncertain about the effect of PSSE on QoL measured by SRS-22 Total score (MD 0.26 points, 95% CI 0.11 to 0.62; 3 studies, 168 participants) and on self-image measured by SRS-22 Self-Image and Walter Reed Visual Assessment Scale (standardised mean difference (SMD) 0.77, 95% CI -0.61 to 2.14; 3 studies, 168 participants). Further, low-certainty evidence indicates that 38/100 people receiving GTE may progress more than 5° Cobb versus 7/100 receiving PSSE (risk ratio (RR) 0.19, 95% CI -0.67 to 0.52; 1 study, 110 participants). None of the included studies assessed adverse effects., Authors' Conclusions: The evidence on the efficacy of TE is currently sparse due to heterogeneity, small sample size, and many different comparisons. We found only one study following participants to the end of growth showing the efficacy of PSSE over TE. This result was weakened by adding studies with short-term results and unclear preparation of treating physiotherapists. More RCTs are needed to strengthen the current evidence and study other highly clinically relevant outcomes such as QoL, psychological and cosmetic issues, and back pain., (Copyright © 2024 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Background: Adolescent idiopathic scoliosis and its treatments can severely impact health-related quality of life. The Italian Spine Youth Quality of Life (ISYQOL) questionnaire, initially developed in Italian and tested on Italian people, was created to measure quality of life in young persons with spine changes. ISYQOL was created using the Rasch analysis, a modern psychometric technique for questionnaires' assessment and development, which showed that the ordinal scores of the ISYQOL Italian version provide sound quality of life measures., Aim: The current work aims to evaluate the cross-cultural equivalence of the ISYQOL questionnaire in seven different countries., Design: Cross-sectional, international, multi-centre study., Setting: Outpatient clinic., Population: Five hundred fifty persons with adolescent idiopathic scoliosis from English Canada, French Canada, Greece, Italy, Spain, Poland, and Türkiye., Methods: The ISYQOL Italian version was translated into six languages with the forward-backwards procedure. The conceptual equivalence of the items' content was verified, and any inconsistency was resolved by consensus. The Rasch analysis was used here to evaluate that ISYQOL translations retained the good measurement properties of the Italian version of the questionnaire. In addition, the Differential Item Functioning (DIF) was checked to assess the psychometric equivalence of the ISYQOL items in patients from different countries., Results: Four items of the translated ISYQOL were dropped from the questionnaire since they did not contribute to measuring due to their poor fit to the model of Rasch. Seven items were affected by DIF for nationality, a finding pointing out that these items do not work the same (i.e. are not equivalent) in the different countries. Thanks to the Rasch analysis, the DIF for nationality was amended, and ISYQOL International was eventually obtained., Conclusions: ISYQOL International returns interval quality of life measures in people with adolescent idiopathic scoliosis with high cross-cultural equivalence in the tested countries., Clinical Rehabilitation Impact: Rigorous testing showed that ISYQOL International ordinal scores return quality of life measures cross-culturally equivalent in English and French Canada, Greece, Italy, Spain, Poland, and Türkiye. A new, psychometrically sound patient-reported outcome measure is thus available in rehabilitation medicine to measure health-related quality of life in idiopathic scoliosis.

Idiopathic scoliosis (IS) is a multifactorial disease with a genetic background. The association of Ladybird Homeobox 1 (LBX1) polymorphisms with IS has been proven in multiple studies. However, the epigenetic mechanisms have not been evaluated. This study aimed to evaluate the LBX1 methylation level in deep paravertebral muscles in order to analyze its association with IS occurrence and/or IS severity. Fifty-seven IS patients and twenty non-IS patients were examined for the paravertebral muscles’ methylation level of the LBX1 promoter region. There was no significant difference in methylation level within paravertebral muscles between patients vs. controls, except for one CpG site. The comparison of the paravertebral muscles’ LBX1 promoter region methylation level between patients with a major curve angle of ≤70° vs. >70° revealed significantly higher methylation levels in 17 of 23 analyzed CpG sequences at the convex side of the curvature in patients with a major curve angle of >70° for the reverse strand promoter region. The association between LBX1 promoter methylation and IS severity was demonstrated. In patients with severe IS, the deep paravertebral muscles show an asymmetric LBX1 promoter region methylation level, higher at the convex scoliosis side, which reveals the role of locally acting factors in IS progression.

This review presents the state of the art according to the current evidence on nonoperative treatment for adolescent idiopathic scoliosis, focusing on bracing. The definition of braces for the treatment of adolescent idiopathic scoliosis and a short history are provided. The analysis includes biomechanics, types, existing classifications, indications for treatment, time of brace wear and weaning, adherence, three-dimensional modeling, use of ultrasound imaging for bracing, management of treatment, issue of immediate in-brace correction, and documentation of the outcomes usually assessed for brace treatment, including the quality-of-life issues. According to the current evidence, there are two randomized control trials in favor of bracing. There are insufficient data on the superiority of one brace over another, although it is possible to classify and grade braces for efficacy from nonrigid to rigid and very rigid. Nevertheless, there is consensus on patients' management on the need for teamwork focusing on adherence to treatment, acceptability, and family and patient involvement., (Copyright © 2022 International Society for Prosthetics Orthotics.)

The study aimed to detect the presence and assess the expression levels of the estrogen receptors type 1 (ESR1) and type 2 (ESR2) within paravertebral skeletal muscles of female patients with idiopathic scoliosis (IS) in relation to phenotype parameters. Intraoperatively, the muscle samples were obtained from 35 adolescent females. The RT-qPCR, western blot and immunohistochemistry techniques were applied. The ESR1 and ESR2 were detected within paravertebral skeletal muscle cells, either the superficial or the deep ones. The ESR1 expression level was significantly higher in the deep muscles compared to the superficial ones. A left-right asymmetry of the ESR1 and ESR2 expression level was demonstrated in the deep muscles. There was a significant relationship between the expression asymmetry and either the Cobb angle or the progression risk factor: both parameters decreased to the smallest values in the case of symmetric ESR1 or ESR2 expression, while they increased with increasing expression asymmetry. In conclusion, the ESR1 and ESR2 presence was confirmed in skeletal paravertebral muscles of patients with idiopathic scoliosis. The increased expression level and asymmetry of estrogen receptors in deep skeletal muscles was related to increasing scoliotic deformity magnitude or increasing risk of deformity deterioration. These findings may highlight the etiopathogenesis of IS in children.

Purpose: Studies have shown that bracing is an effective treatment for patients with idiopathic scoliosis. According to the current classification, almost all braces fall in the thoracolumbosacral orthosis (TLSO) category. Consequently, the generalization of scientific results is either impossible or misleading. This study aims to produce a classification of the brace types., Methods: Four scientific societies (SOSORT, SRS, ISPO, and POSNA) invited all their members to be part of the study. Six level 1 experts developed the initial classifications. At a consensus meeting with 26 other experts and societies' officials, thematic analysis and general discussion allowed to define the classification (minimum 80% agreement). The classification was applied to the braces published in the literature and officially approved by the 4 scientific societies and by ESPRM., Results: The classification is based on the following classificatory items: anatomy (CTLSO, TLSO, LSO), rigidity (very rigid, rigid, elastic), primary corrective plane (frontal, sagittal, transverse, frontal & sagittal, frontal & transverse, sagittal & transverse, three-dimensional), construction-valves (monocot, bivalve, multisegmented), construction-closure (dorsal, lateral, ventral), and primary action (bending, detorsion, elongation, movement, push-up, three points). The experts developed a definition for each item and were able to classify the 15 published braces into nine groups., Conclusion: The classification is based on the best current expertise (the lowest level of evidence). Experts recognize that this is the first edition and will change with future understanding and research. The broad application of this classification could have value for brace research, education, clinical practice, and growth in this field., (© 2022. The Author(s).)

Idiopathic scoliosis (IS) is a multifactorial disease with epigenetic modifications. Tissue dependent and differentially methylated regions (T-DMRs) may regulate tissue-specific expression of the estrogen receptor 1 gene ( ESR1 ). This study aimed to analyze methylation levels within T-DMR1 and T-DMR2 and its concatenation with ESR1 expression of IS patients. The study involved 87 tissue samples (deep paravertebral muscles, both on the convex and the concave side of the curve, and from back superficial muscles) from 29 girls who underwent an operation due to IS. Patient subgroups were analyzed according to Cobb angle ≤70° vs. >70°. Methylation was significantly higher in the superficial muscles than in deep paravertebral muscles in half of the T-DMR1 CpGs and all T-DMR2 CpGs. The methylation level correlated with ESR1 expression level on the concave, but not convex, side of the curvature in a majority of the T-DMR2 CpGs. The T-DMR2 methylation level in the deep paravertebral muscles on the curvature's concave side was significantly lower in patients with a Cobb angle ≤70° in four CpGs. DNA methylation of the T-DMRs is specific to muscle tissue location and may be related to ESR1 expression regulation. Additionally, the difference in T-DMR2 methylation may be associated with IS severity.

Idiopathic scoliosis (IS) is one of the most common spinal disorders in adolescents. Despite many studies, the etiopathogenesis of IS is still poorly understood. In recent years, the role of epigenetic factors in the etiopathogenesis of IS has been increasingly investigated. It has also been postulated that the development and progression of the disease is related to gender and puberty, and could be associated with estrogen action. Estrogen hormones act via estrogen receptor 1 (ESR1) and estrogen receptor 2 (ESR2). It has been suggested that ESR2 expression is dependent on methylation within its gene promoter. So far, no studies have evaluated local, tissue-specific DNA methylation in patients with IS. Thus, our study aimed to analyze the methylation and expression level of ESR2 in the paraspinal muscles of the convex and concave side of the IS curvature. The methylation level within ESR2 promoter 0N, but not exon 0N, was significantly higher on the concave side of the curvature compared to the convex side. There was no significant correlation between ESR2 expression and methylation level in the promoter 0N on the convexity of thoracic scoliosis, whereas, on the concave side of the curvature, we observed a moderate negative correlation. There was no difference in the methylation levels of the ESR2 promoter and exon 0N between groups of patients with Cobb angle ≤ 70° and > 70° on the concave and convex side of the curvature. We also found no statistically significant correlation between the Cobb angle value and the mean methylation level in either the ESR2 promoter or exon 0N on the convex or concave side of the curvature. Our findings demonstrate that DNA methylation at the ESR2 promoter in deep paravertebral muscle tissue is associated with the occurrence but not with the severity of idiopathic scoliosis.

Background: Three-dimensional idiopathic scoliosis cannot be accurately assessed with the aid of a single plane parameter - the Cobb angle. We propose a novel method for evaluating the three-dimensional (3D) pattern of scoliosis based on two X-rays (PA and lateral). The proposed method consists of the measurements of the angles between the upper endplate of the upper-end vertebra and the lower endplate of the lower-end vertebra (3D scoliosis angle)., Methods: The 3D-angles of thirty scoliosis curves were measured with either computed tomography (CT) or digitally reconstructed radiographs (DRRs): PA and lateral. CT was used as a reference. In the case of CT, the 3D angle was calculated based on the coordinates of three points situated on the upper endplate and those of three points situated on the lower endplate of the scoliosis curve. In the case of the DRR, the 3D angle was calculated using the four-angle method: the angles formed by the endplates of the curve with the transverse plane. The results were tested with the Student's t-test, and the agreement of measurements was tested with the intraclass correlation coefficient., Results: There was no significant difference between the 3D-angle measurements obtained with DRRs versus CT, p > 0.05. There was, however, a significant difference between the 3D-scoliosis angle and the Cobb angle measurements performed based on the X-rays. The reproducibility and reliability of 3D angle measurements were high., Conclusions: Based on two standard radiographs, PA and lateral, it is possible to calculate the 3D scoliosis angle. The proposed method facilitates 3D-scoliosis assessment without the use of sophisticated devices. Considering the 3D nature of AIS, the 3D parameters of the spine may help to apply a more effective treatment and estimate a more precise prognosis for patient with scoliosis.

Background: The CHD7 (chromosome domain helicase DNA binding protein 7) gene has been associated with familial idiopathic scoliosis (IS) in families of European descent. The CHD7 single-nucleotide polymorphisms have never been studied in Polish Caucasian IS patients., Methods: The aim of this study was to investigate the relationship of CHD7 gene polymorphisms with susceptibility to or progression of IS in Polish Caucasian females. The study group comprised 211 females who underwent clinical, radiological and genetic examination. The study group was analyzed in three subgroups according to: (1) Cobb angle (Cobb angle ≤30° vs. Cobb angle ≥35°), (2) age of diagnosis (adolescent IS vs. early-onset IS) and (3) rate of progression (non-progressive vs. slowly progressive vs. rapidly progressive IS). The control group comprised 83 females with no scoliosis and with a negative family history who underwent clinical and genetic examination. In total six CHD7 gene polymorphisms were examined. Three polymorphisms (rs1017861, rs13248429, and rs4738813) were examined by RFLP (restriction fragment length polymorphism) analysis, and three were quantified by Sanger sequencing (rs78874766, rs4738824, and rs74797613)., Results: In rs13248429, rs78874766, and rs74797613 polymorphisms only the wild allele was present. The rs1017861 polymorphism demonstrated an association with IS susceptibility (p < 0.01). Two polymorphisms, rs1017861 and rs4738813, were associated with curve severity and progression rate (p < 0.05). None of the evaluated polymorphisms in CHD7 gene showed any association with the age of IS onset., Conclusions: The polymorphism rs1017861 in CHD7 gene showed an association with IS susceptibility. Two polymorphisms (rs1017861 and rs4738813) were associated with curve severity and progression rate. None of the evaluated polymorphisms in CHD7 gene showed any association with the age of IS onset. Further evaluation of CHD7 gene should be considered as IS modifying factor.

The aim of this work was to analyze postural stability of girls having progressive form of idiopathic scoliosis and undergoing specific period of the adolescent growth spurt. Twenty-seven girls, aged 13.4 ± 1.2 years, presenting structural idiopathic scoliosis, thoracic or thoracolumbar pattern, radiological Cobb angle 41.7 ± 17.4° (study group) and 37 healthy girls (control group) were included. The groups were sex, age, height, weight, and BMI matched. Postural stability examination was performed using two stabilometric platforms with visual control (eyes open) at three stages: (1) both legs' stance, (2) left leg stance, and (3) right leg stance. The Center of Pressure (COP) sway path length, the area and the displacement amplitude were compared. For the double stance, no difference in postural stability parameters between the groups was found. However, for the right leg stance, the total sway path length was longer ( p = 0.04) and the mean amplitude of the lateral COP displacement was increased ( p = 0.03) in the scoliotic group. In conclusion, for double stance, the adolescent girls with progressive form of idiopathic scoliosis revealed fair postural stability compared to control group. An impaired postural control was observed during right leg stance., Competing Interests: The authors declare that there is no conflicts of interest regarding the publication of this paper., (Copyright © 2019 Marzena Wiernicka et al.)

Idiopathic scoliosis (IS) etiology remains unclear, but strong genetic background is suggested. Previously reported TIMP2 study indicates an association of genic rs8179090 with IS progression in a Han Chinese population. However, there has been a lack of investigation into intragenic TIMP2 polymorphisms in IS patients. We recruited 100 Caucasian females with IS and 100 controls. Patients were subdivided accordingly to: progression rate, curve severity, joint mobility, and curve pattern. Allele-specific-polymerase chain reaction based on fluorescence resonance energy transfer was applied to evaluate nine TIMP2 polymorphisms. Distribution of genotype and allele frequency in only one polymorphism (rs11658743) differed in case-control study. Four of the polymorphisms (rs2277700, rs11077401, rs2376999, and rs4789934) showed non-equal distributions either in genotype or/and allele distributions in the patients of different progression rates. The rs11077401 was related to curve severity patients distinction and the rs8179090 distinguished patients with different joint mobility level. Two polymorphisms either differed statistically in case of curve patterns subgrouping (rs8068674 and rs8179090) or showed a slight tendency toward significance in the recessive model of allele distributions (rs9916809 and rs8179090). The remaining two polymorphisms (rs2377005, rs11658743) showed no association with either clinical or radiographic IS characteristics. The influence of the G allele of the rs8179090 on the clinical course of IS has not yet been confirmed. We identified four TIMP2 polymorphisms (rs11077401, rs2376999, rs2277700, and rs4789934) that were associated with a higher risk of the progressive IS form. Further genetic association studies based on suggested clinical criteria would be necessary to validate TIMP2 polymorphisms associated with the curve progression. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2217-2225, 2019., (© 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

Background: Body height (BH) measurement is an important part of the clinical evaluation of children with idiopathic scoliosis (IS) as its progression is defined based on the observation of a growth spurt., Objective: The aim of the study is to assess diurnal variation of BH in children with IS., Methods: BH was measured in 98 children with IS (Cobb angle: 10∘-52∘, mean 21.2∘± 9.9∘) both in standing and sitting position. The measurements were performed 4 times a day - between: (1) 7:00 and 8:00; (2) 11:00 and 12:00; (3) 15:00 and 16:00 and (4) 19:00 and 20:00., Results: A significant decrease in BH during the day was observed in both standing and sitting positions (p< 0.001). The highest decrease in height was observed between the measurements performed between 7:00 and 8:00 and measurements carried out in the evening (19:00-20:00). For standing, the mean loss of height was 0.7 cm (± 0.7), i.e. 0.43% of initial standing height, for sitting the mean decrease in height was 0.7 cm (± 0.7), i.e. 0.79% of initial sitting height., Conclusions: BH decreases in children with IS during daytime. Due to diurnal BH variation, the time of the day should be recorded when measuring patients with IS.

Study Design: A Cochrane systematic review., Objective: To evaluate the efficacy of bracing for adolescents with AIS versus no treatment or other treatments, on quality of life, disability, pulmonary disorders, progression of the curve, psychological, and cosmetic issues., Summary of Background Data: Idiopathic scoliosis is a three-dimensional deformity of the spine. The most common form is diagnosed in adolescence. Although adolescent idiopathic scoliosis (AIS) can progress during growth and cause a surface deformity, it is usually not symptomatic., Methods: We searched CENTRAL, MEDLINE, EMBASE, five other databases, and two trials registers up to February 2015. We also checked reference lists and hand searched grey literature. Randomized controlled trials (RCTs) and prospective controlled cohort studies comparing braces with no treatment, other treatment, surgery, and different types of braces for adolescent with AIS. We used standard methodological procedures expected by the Cochrane Collaboration., Results: We included seven studies. Five were planned as RCTs, two as prospective controlled clinical trials. One RCT failed completely, another was continued as an observational study. There was very low quality evidence from one small RCT that quality of life (QoL) during treatment did not differ significantly between rigid bracing and observation., Conclusion: Two studies showed that bracing did not change QoL during treatment, and QoL, back pain psychological and cosmetic issues in the long term (16 years.) All articles showed that bracing prevented curve progression. The high rate of failure of RCTs demonstrates the huge difficulties in performing RCTs in a field where parents reject randomization of their children., Level of Evidence: 1.

Purpose: The aim of this study was to detect and assess the estrogen receptor (ESR) coactivator PELP1 expression within human paraspinal skeletal muscles in patients suffering from idiopathic scoliosis., Methods: During surgical correction of scoliosis the muscle biopsies harvested in 29 females. Presence of PELP1, ESR1 and ESR2 genes transcripts was studied using RT-qPCR technique while immunohistochemistry and western blot methods were used to detect the PEPL1 protein presence., Results: PELP1 expression in deep paraspinal muscles revealed higher than in superficial back muscles (p = 0.005). Positive immunohistochemical staining for PELP1 was observed in the nuclei of the paraspinal muscle cells. Western blot revealed PELP1 protein in all samples. No significant difference in PELP1 expression between the convex and the concave scoliosis side (p>0.05) was found. In deep paraspinal back muscles, a significant correlation between the PELP1 expression level on the concave side and the Cobb angle (r = 0.4; p<0.05) was noted as well as between the PELP1 and ESR1 expression level (r = 0.7; p<0.05) while no correlation between PELP1 and ESR2 expression level was found., Conclusion: To our knowledge, three techniques for the first time demonstrated the presence of the PELP1 in paraspinal muscles of patients with idiopathic scoliosis. The PELP1 potential regulatory impact on back muscle function is to be further investigated.

Background: Idiopathic scoliosis is a three-dimensional deformity of the spine. The most common form is diagnosed in adolescence. While adolescent idiopathic scoliosis (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., Objectives: To evaluate the efficacy of bracing for adolescents with AIS versus no treatment or other treatments, on quality of life, disability, pulmonary disorders, progression of the curve, and psychological and cosmetic issues., Search Methods: We searched CENTRAL, MEDLINE, EMBASE, five other databases, and two trials registers up to February 2015 for relevant clinical trials. We also checked the reference lists of relevant articles and conducted an extensive handsearch of grey literature., Selection Criteria: Randomized controlled trials (RCTs) and prospective controlled cohort studies comparing braces with no treatment, other treatment, surgery, and different types of braces for adolescent with AIS., Data Collection and Analysis: We used standard methodological procedures expected by The Cochrane Collaboration., Main Results: We included seven studies (662 participants). Five were planned as RCTs and two as prospective controlled trials. One RCT failed completely, another was continued as an observational study, reporting also the results of the participants that had been randomized.There was very low quality evidence from one small RCT (111 participants) that quality of life (QoL) during treatment did not differ significantly between rigid bracing and observation (mean difference (MD) -2.10, 95% confidence interval (CI) -7.69 to 3.49). There was very low quality evidence from a subgroup of 77 adolescents from one prospective cohort study showing that QoL, back pain, psychological, and cosmetic issues did not differ significantly between rigid bracing and observation in the long term (16 years).Results of the secondary outcomes showed that there was low quality evidence that rigid bracing compared with observation significantly increased the success rate in 20° to 40° curves at two years' follow-up (one RCT, 116 participants; risk ratio (RR) 1.79, 95% CI 1.29 to 2.50). There was low quality evidence that elastic bracing increased the success rate in 15° to 30° curves at three years' follow-up (one RCT, 47 participants; RR 1.88, 95% CI 1.11 to 3.20).There is very low quality evidence from two prospective cohort studies with a control group that rigid bracing increases the success rate (curves not evolving to 50° or above) at two years' follow-up (one study, 242 participants; RR 1.50, 95% CI 1.19 to 1.89) and at three years' follow-up (one study, 240 participants; RR 1.75, 95% CI 1.42 to 2.16). There was very low quality evidence from a prospective cohort study (57 participants) that very rigid bracing increased the success rate (no progression of 5° or more, fusion, or waiting list for fusion) in adolescents with high degree curves (above 45°) (one study, 57 adolescents; RR 1.79, 95% CI 1.04 to 3.07 in the intention-to-treat (ITT) analysis).There was low quality evidence from one RCT that a rigid brace was more successful than an elastic brace at curbing curve progression when measured in Cobb degrees in low degree curves (20° to 30°), with no significant differences between the two groups in the subjective perception of daily difficulties associated with wearing the brace (43 girls; risk of success at four years' follow-up: RR 1.40, 1.03 to 1.89). Finally, there was very low quality evidence from one RCT (12 participants) that a rigid brace with a pad pressure control system is no better than a standard brace in reducing the risk of progression.Only one prospective cohort study (236 participants) assessed adverse events: neither the percentage of adolescents with any adverse event (RR 1.27, 95% CI 0.96 to 1.67) nor the percentage of adolescents reporting back pain, the most common adverse event, were different between the groups (RR 0.72, 95% CI 0.47 to 1.10)., Authors' Conclusions: Due to the important clinical differences among the studies, it was not possible to perform a meta-analysis. Two studies showed that bracing did not change QoL during treatment (low quality), and QoL, back pain, and psychological and cosmetic issues in the long term (16 years) (very low quality). All included papers consistently showed that bracing prevented curve progression (secondary outcome). However, due to the strength of evidence (from low to very low quality), further research is very likely to have an impact on our confidence in the estimate of effect. The high rate of failure of RCTs demonstrates the huge difficulties in performing RCTs in a field where parents reject randomization of their children. This challenge may prevent us from seeing increases in the quality of the evidence over time. Other designs need to be implemented and included in future reviews, including 'expertise-based' trials, prospective controlled cohort studies, prospective studies conducted according to pre-defined criteria such as the Scoliosis Research Society (SRS) and the international Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) criteria. Future studies should increase their focus on participant outcomes, adverse effects, methods to increase compliance, and usefulness of physiotherapeutic scoliosis specific exercises added to bracing.

Background: Scoliosis, the most prevalent orthopaedic condition affecting children and adolescents, may have lasting physical, psychological and social consequences. With limited evidence-base, scoliosis-specific exercise therapies are an option., Objective: An overview of the subject and description of a long-term follow-up study including adults who in adolescence were treated with a scoliosis-specific exercise programme investigating the association of the exercise regime with present physical activity, physical functioning and subjective wellbeing. To the authors' best knowledge, this is the first long-term outcome study on scoliosis-specific exercises, in opposition to a number of studies in adults who were braced or treated surgically in adolescence., Methods: Observational, registry-based case-control study. Adult subjects who in adolescence were treated with an exercise programme or were under observation are invited. Spine and trunk deformity, respiratory function, physical capacity and trunk muscles' function are measured. Health-related quality of life with generic and condition-specific instruments, general mental health, depression and anxiety symptoms, disability due to low back problems and physical activity are assessed., Conclusions: The report is believed to provide the readers with an overview of this controversial aspect of rehabilitation, and that the proposed protocol will assist researchers designing their studies.

Study Design: A genetic association study of estrogen receptor 2 gene (ESR2) polymorphisms in idiopathic scoliosis (IS)., Objective: To investigate association of the ESR2 polymorphisms with either predisposition to or progression of IS in Central European population., Summary of Background Data: In ESR2 the rs1256120 polymorphism was described to be associated with predisposition to and severity of IS in Chinese population. This observation has not been confirmed in Japanese population. The ESR2 rs4986938 and rs1256049 polymorphisms were described to present association with breast cancer, rheumatoid arthritis, and bone mineral density, however the association with IS has not been evaluated., Methods: Case-control study of 248 females with IS and 243 healthy females was performed. Three single-nucleotide polymorphisms were studied using polymerase chain reaction-restriction fragments length polymorphism technique with the restriction enzymes: AlwNI (C/T rs1256120), AluI (A/G rs4986938), and RsaI (A/G rs1256049). The patients' medical history was evaluated, Cobb angle was measured and surgery rate established. The patients were analyzed in 3 subgroups according to curve progression velocity., Results: Neither the genotypes nor alleles distribution showed significant differences between patients with IS and healthy controls. There was no significant difference in genotype or allele frequency. In the AluI site polymorphism a significant difference in mean Cobb angle between genotypes was found: (AA, 31.9° ± 14.2°; AG, 43.2° ± 17.8°; and GG, 38.9° ± 19.0°), P = 0.002. There was significant difference in genotype distribution between patients with moderate (<40°) versus severe (≥40°) scoliosis, P = 0.0011; the minor allele frequency (AA) in recessive model of penetration was over-represented in patients with Cobb angle below 40°, P = 0.0075, odds ratio = 3.65., Conclusion: No association between ESR2 polymorphism and predisposition to IS was found in Caucasian females. None of the previously reported associations of AlwNI site polymorphism could be confirmed. ESR2 AluI site polymorphism may be associated with curve severity., Level of Evidence: N/A.

Background: The age at menarche (AAM) is commonly in use in patients with IS as one of the maturity indicator suggesting deceleration of the growth velocity. The AAM was suggested to be related to predisposition and curve progression potential of IS. The late age at menarche was reported to be associated with higher prevalence of adolescent idiopathic scoliosis. The age at menarche is determined by both genetic and environmental factors as well as their interactions. Estrogen receptors 1 and 2 polymorphism were reported to be associated with AAM: in ESR1 XbaI and PvuII site polymorphism and in ESR2 AluI site polymorphism.The purpose of the study was to investigate associations of the ESR1 and ESR2 polymorphisms with AAM in IS patients and to evaluate association of AAM with IS severity., Methods: 208 females with IS Caucasian females from Central Europe underwent clinical, radiological and genetic examinations. Four SNPs were selected XbaI (A/Grs9340799) and PvuII (C/T rs2234693) in ESR1and AluI (A/G rs4986938) and RasI (A/G rs1256049) in ESR2. Samples were analyzed with polymerase chain reaction followed by restriction fragments length polymorphism analysis (PCR-RFLP). The age of a menarche was established during personal interview with the patients and in case of children with their parents. The Cobb angle was measured., Results: All genotypes followed HWE. Mean AAM for patients was 154.8 ± 14.7 months (12.9 ± 1.2 years). The earliest AAM was 121 and latest 192 months. There was no statistically significant difference between AAM mean values in each genotype, for the XbaI, PvuII, AluI and RsaI site polymorphisms the p values were p=0.7141, p=0.9774, p=0.7973 and p=0.2282, respectively. Patients divided according to Cobb into mild (<30°), moderate (30°-49°) or severe (≥ 50°) IS revealed tendency to delay AAM: 151.9 ± 14.7; 155.2 ± 14.8 and 157.9 ± 14.0 months, respectively. There was statistical significant difference between patients with mild <30° and severe ≥ 50° IS, p=0.0267., Conclusions: In IS patients estrogen receptors polymorphisms did not show association with the AAM. Patients with severe IS form revealed delayed AAM than patients with mild IS form.

According to the Scoliosis Research Society (SRS), idiopathic scoliosis (IS) is a curvature of more than 10° Cobb angle, affecting 2-3% of pediatric population. Idiopathic scoliosis accounts for 80% of all scoliosis cases. Non-operative principles in the therapy of idiopathic scoliosis, including Scoliosis Research Society (SRS) criteria and guidelines proposed by the experts of the Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORTS) were presented. The possibility to carry out quality of life assessments in a conservative procedure was also demonstrated. Based on the natural history of idiopathic scoliosis, SRS criteria, SOSORT 2008 experts' opinion and the knowledge of the possibilities of psychological assessment of conservative IS treatment, rules were proposed regarding nonsurgical IS therapy procedures, with special consideration being paid to the proper treatment start time (age, Risser test, biological maturity, Cobb angle), possibility of curvature progression, the importance of physiotherapy and psychological assessment. The knowledge of SRS criteria and SOSORT guidelines regarding the conservative treatment of IS are essential for proper treatment (the right time to start treatment), and supports establishment of interdisciplinary treatment teams, consisting of a physician, a physiotherapist, an orthopedic technician and a psychologist.

Purpose: The aim of the study was to analyze four radiographic methods of calculating the loss of body height associated with scoliosis., Methods: Thirty patients with right thoracic idiopathic scoliosis were examined with standing postero-anterior radiographs. Cobb angles of the upper thoracic, main thoracic and lumbar curves were measured. The loss of body height due to scoliosis was measured directly on the radiographs and then calculated using the methods of Bjure, Kono, Stokes and Ylikoski, respectively. The reproducibility of calculations was tested. Detailed analysis of two patients with similar Cobb angle but different trunk height was performed., Results: The mean Cobb angle of the main thoracic curve was 46° (21°-74°). The mean loss of body height was 23 mm (11-43 mm) calculated by method of Bjure, 7 mm (-24 to 46 mm) by Kono, 20 mm (5-47 mm) by Stokes, 14 mm (3-36 mm) by Ylikoski, versus 18 mm (3-50 mm) measured directly on radiographs. The overall difference between the loss of body heights was significant (p < 0.0001), with significant differences in pairs for: Bjure versus Kono (p < 0.0001), Stokes versus Kono (p = 0.0002), Kono versus measured (p = 0.0061) and Bjure versus Ylikoski (p = 0.0386). Strong linear correlation between the methods was found (r ≥ 0.92; p < 0.0001). High reproducibility of height loss calculations was noticed. The two patients with similar Cobb angle and different trunk height revealed similar height loss calculated, while different loss measured on radiographs., Conclusions: There existed no overall agreement between the four methods of calculation of the loss of body height associated with scoliosis. Calculations based on the Cobb angle produced inaccuracy and could be supplemented with data considering trunk size.

Objective: To examine general mental health in adult males and females, who in adolescence participated in a scoliosis-specific therapeutic exercise program or were under observation due to diagnosis of scoliosis., Design: Registry-based, cross-sectional study with retrospective data collection., Methods: Sixty-eight subjects (43 women) aged 30.10 (25-39) years, with mild or moderate scoliosis (11-36° Cobb angle), and 76 (38 women) nonscoliotic subjects, aged 30.11 (24-38) years, participated. The time period since the end of the exercise or observation regimes was 16.5 (12-26) years. Beck Depression Inventory (BDI) and General Health Questionnaire (GHQ-28) scores were analyzed with the χ(2) and U tests. Multiple regression analyses for confounders were also performed., Results: Intergroup differences of demographic characteristics were nonsignificant. Scoliosis, gender, participation in the exercise program, employment, and marital status were associated with BDI scores. The presence of scoliosis and participation in the exercise program manifested association with the symptoms. Higher GHQ-28 "somatic symptoms" subscale scores interacted with the education level., Conclusions: Our findings correspond to the reports of a negative impact of the diagnosis of scoliosis and treatment on mental health. The decision to introduce a therapeutic program in children with mild deformities should be made with judgment of potential benefits, risks, and harm.

Introduction: XbaI single nucleotide polymorphism (SNP) (A/G rs934099) in estrogen receptor 1 gene (ESR1) was described to be associated with curve severity in Japanese idiopathic scoliosis (IS) patients and in Chinese patients with both curve severity and predisposition to IS. PvuII SNP (C/T rs2234693) of ESR1 was described to be associated with the occurrence of IS in the Chinese population; however, two replication studies did not confirm the findings. The ESR1 SNPs have never been studied in Caucasian IS patients., Methods: Case-control study. 287 females with IS underwent clinical, radiological and genetic examinations. The patients were divided into three groups according to curve progression velocity: non-progressive IS, slowly progressive IS (progression <1° per month), and rapidly progressive IS (progression ≥1° per month). The radiological maximum Cobb angle was measured and surgery rate established. A control group consisted of 182 healthy females., Results: All results followed Hardy-Weinberg equilibrium. In the case-control study, genotype frequency in the patients did not differ for the XbaI (AA = 33.5%, AG = 49.1%, GG = 17.4%), nor for the PvuII (TT = 26.8%, TC = 50.2%, CC = 23.0%) comparing to controls (AA = 33.5%, AG = 50.5%, GG = 15.9%) and (TT = 23.1%, TC = 51.1%, CC = 25.8%), respectively, p = 0.3685, p = 0.6046. The haplotype frequency for the patients (AT = 47.1%, GC = 39.2%, AC = 8.9%, GT = 2.8%) did not differ from the controls (AT = 44.8%, GC = 37.4%, AC = 14.0%, GT = 3.8%), p = 0.0645. No difference was found either in XbaI (p = 0.8671) or PvuII (p = 0.3601) allele distribution between the patients and the controls. In the case study, there was no significant difference in genotype frequency for the non-progressive, slowly progressive, and rapidly progressive scoliosis. No difference was found in genotype or haplotype distribution for the mean maximum Cobb angle or the surgery rate., Conclusions: No association was found between ESR1 XbaI or ESR1 PvuII SNP and idiopathic scoliosis in Caucasian females. None of the previously reported associations could be confirmed, regarding curve severity, progression or operation rate.

Study Design: Systematic review of interventions., Objective: To evaluate the efficacy of scoliosis-specific exercise (SSE) in adolescent patients with adolescent idiopathic scoliosis (AIS)., Summary of Background Data: 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. The use of SSEs to reduce progression of AIS and postpone or avoid other more invasive treatments is controversial., Search Methods: The following databases (up to March 30, 2011) were searched with no language limitations: CENTRAL (The Cochrane Library 2011, issue 2), MEDLINE (from January 1966), EMBASE (from January 1980), CINHAL (from January 1982), SPORTDiscus (from January 1975), PsycINFO (from January 1887), and PEDro (from January 1929). We screened reference lists of articles and conducted an extensive hand search of gray literature., Selection Criteria: randomized controlled trials and prospective cohort studies with a control group comparing exercises with no treatment, other treatment, surgery, and different types of exercises., Data Collection and Analysis: Two review authors independently selected studies, assessed risk of bias and extracted data., Results: Two studies (154 participants) were included. There is low-quality evidence from 1 randomized controlled study that exercises as an adjunctive to other conservative treatments to increase the efficacy of these treatments (thoracic curve reduced: mean difference 9.00, [95% confidence interval, 5.47-12.53]; lumbar curve reduced: mean difference 8.00, [95% confidence interval, 5.08-10.92]). There is very low-quality evidence from a prospective controlled cohort study that SSEs structured within an exercise program can reduce brace prescription (risk ratio, 0.24; [95% confidence interval, 0.06-1.04]) as compared with "usual physiotherapy" [many different kinds of general exercises according to the preferences of the single therapists within different facilities])., Conclusion: There is a lack of high-quality evidence to recommend the use of SSE for AIS. One very low-quality study suggested that these exercises may be more effective than electrostimulation, traction, and postural training to avoid scoliosis progression, but better quality research needs to be conducted before the use of SSE can be recommended in clinical practice., Level of Evidence: 2.

Background: Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of the spine . While 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. The use of scoliosis-specific exercises (SSE) to reduce progression of AIS and postpone or avoid other more invasive treatments is controversial., Objectives: To evaluate the efficacy of SSE in adolescent patients with AIS., Search Methods: The following databases (up to 30 March 2011) were searched with no language limitations: CENTRAL (The Cochrane Library 2011, issue 2), MEDLINE (from January 1966), EMBASE (from January 1980), CINHAL (from January 1982), SportDiscus (from January 1975), PsycInfo (from January 1887), PEDro (from January 1929). We screened reference lists of articles and also conducted an extensive handsearch of grey literature., Selection Criteria: Randomised controlled trials and prospective cohort studies with a control group comparing exercises with no treatment, other treatment, surgery, and different types of exercises., Data Collection and Analysis: Two review authors independently selected studies, assessed risk of bias and extracted data., Main Results: Two studies (154 participants) were included. There is low quality evidence from one randomised controlled study that exercises as an adjunctive to other conservative treatments increase the efficacy of these treatments (thoracic curve reduced: mean difference (MD) 9.00, (95% confidence interval (CI) 5.47 to 12.53); lumbar curve reduced:MD 8.00, (95% CI 5.08 to 10.92)). There is very low quality evidence from a prospective controlled cohort study that scoliosis-specific exercises structured within an exercise programme can reduce brace prescription (risk ratio (RR) 0.24, (95% CI 0.06 to1.04) as compared to usual physiotherapy (many different kinds of general exercises according to the preferences of the single therapists within different facilities)., Authors' Conclusions: There is a lack of high quality evidence to recommend the use of SSE for AIS. One very low quality study suggested that these exercises may be more effective than electrostimulation, traction and postural training to avoid scoliosis progression, but better quality research needs to be conducted before the use of SSE can be recommended in clinical practice.

Purpose: The aim of the study was to undertake the process of cultural adaptation of the Brace Questionnaire (BrQ) into Polish., Methods: The BrQ is an instrument for measuring the quality of life of scoliotic adolescents who are being treated conservatively with wearing a corrective brace. The BrQ consists of 34 Likert-scale items related to eight domains. The translation from the original Greek into Polish was performed. The process of cultural adaptation of the questionnaire was in accordance with the guidelines of the International Quality of Life Assessment Project. It involved 35 adolescents, aged between 10.0 and 16.0 years, all with adolescent idiopathic scoliosis with mean Cobb angle of 35.1 ± 10.6 degrees, and all wearing the same kind of brace (Chêneau orthosis) for more than 3 months. Statistical analysis calculated the reliability (internal consistency), floor and ceiling effects of the BrQ., Results: The internal consistency was satisfactory; Cronbach's alpha coefficient was 0.94. There was no floor or ceiling effects., Conclusions: Polish version of the BrQ is reliable and can be used in adolescents with idiopathic scoliosis wearing the brace to assess their quality of life.

Introduction: Idiopathic scoliosis affects the locomotor system; however, it can considerably impair the function of cardiovascular and respiratory systems. The aim of the study was to assess parameters indicating the physical capacity of adolescent girls with mild or moderate idiopathic scoliosis., Materials and Methods: The study included 97 girls, aged 10-18 years: 70 girls, aged 13.84 ± 2.2 years, with idiopathic thoracic scoliosis (Cobb angle 10°-40°) formed the study group and 27 healthy girls, aged 13.2 ± 1.9 years, formed the control group. The girls underwent the Physical Work Capacity 170 (PWC170) test on a cycle ergometer based on two 5-min submaximal physical effort events. The maximum oxygen intake was calculated and expressed in l/min and ml/kg/min. The impact of the curvature angle value, of the number of vertebrae within the curve and of the number of the curves on the physical capacity parameters was analyzed., Results: The maximal oxygen intake (l/min) and PWC170 (W; W/kg) values were considerably lower in girls with scoliosis of 25°-40° than in the control group. No significant differences were observed between girls with mild scoliosis (10°-24°) and the control group. Statistical analysis did not show any significant impact of the number of vertebrae affected by scoliosis and the number of curvatures on VO(2)max (l/min; ml/kg/min) and the PWC170 (W) indicator. In the group of girls with scoliosis involving more than nine vertebrae, the PWC170 (W/kg) indicator was significantly lower than in the control group. A similar correlation was observed between girls with double-curved scoliosis and the control group (p < 0.05)., Conclusion: The maximum oxygen intake and the output during the PWC170 test is lower in girls with moderate scoliosis than in the control group. The value of maximum oxygen intake and output obtained during the PWC170 test in girls with mild scoliosis does not differ significantly from the values obtained in the control group. The number of vertebrae involved in scoliotic deformation and the number of curvatures cause significant decrease in only the relative value of the output obtained during an exercise test.

Aim. The aim of the work was to study whether wearing a corrective brace by adolescent girls with severe idiopathic scoliosis can influence external shape of the trunk. Methods. Comparison of clinical deformity of two groups of girls matched for age and Cobb angle: group (1) of 23 girls, aged 14.9 ± 1.3 years, Cobb angle 55.0° ± 6.8°, who refused surgical treatment and have been wearing Chêneau brace for more than 6 months, compared with group (2) of 22 girls, aged 14.1 ± 1.8 years, Cobb angle 59.7° ± 14.6° never treated with corrective bracing. Clinical deformity was assessed with the Bunnell scoliometer (angle of trunk rotation ATR) and surface topography (posterior trunk symmetry index POTSI and Hump Sum HS). Results. The ATR in the primary curvature was 11.9° ± 3.4° (5°-18°) in group 1 versus 15.1° ± 5.6° (6°-25°) in group 2 (P = 0.027). The HS was 16.8° ± 3.8 versus 19.2° ± 4.6, respectively, P = 0.07. The POTSI value did not differ between groups. Conclusion. Girls with Cobb angle above 45 degrees, who have been subjected to brace treatment, revealed smaller clinical deformity of their back comparing to nontreated girls having similar radiological curvatures.

Deep paravertebral muscles and female sex hormones are potential elements participating in idiopathic scoliosis development. Estrogen acts through estrogen receptors: ESR1 and ESR2. There are no studies describing ESR2 expression in back muscles in girls with idiopathic scoliosis. The aim of this study was to evaluate ESR2 expression levels in back muscles on both sides of the spinal curve and correlation between the expression level and scoliosis parameters. Asymmetrical ESR2 expression in deep paravertebral muscles was found: 11 girls had higher expression level on the convex side and 5 girls had higher expression level on the concave side of the curvature. Patients with ESR2 (convex/concave) ratio ≥ 1 presented positive correlation between ESR2 ratio and Cobb angle.

Quality of life (QoL) and stress level of adolescents with idiopathic scoliosis is under growing consideration by physicians, physiotherapists and other specialists (psychologist, nurses). The aim of the study was to evaluate the quality of life and stress level in adolescents with idiopathic scoliosis who are under brace treatment. It involved 45 adolescents, ages ranging between 10.0 and 15.0 years, all with Adolescent Idiopathic Scoliosis (AIS) with Cobb angle between 20-45 degrees. The adolescents were wearing the same kind of brace (Chêneau orthosis) for more than 3 months for at least 12h per day. Two questionnaires were used: the Brace Questionnaire (BrQ) and Bad Sobernheim Stress Questionnaire (BSSQ). The analysis considered the type of treatment, curve location, correlation of the total score with age, Cobb angle and Bunnell rotation angle. The age was 13.6 ± 1.3 years. Cobb angle was 31.7 ± 7.6 degrees. The mean score for BrQ was 78.1 ± 11.3 points. Adolescents revealed higher score with BSSQ Deformity (median = 15) comparing to BSSQ Brace (median = 12). Conservative treatment does not severely impact on the quality of life of scoliotic adolescents. The adolescents who were under brace treatment suffered moderate level of stress from the deformity.

Stress level due to existing body deformity as well as to the treatment with a corrective brace is one of factors influencing the quality of life of children with idiopathic scoliosis undergoing non-surgical management. The purpose of the study was to evaluate the stress level among children suffering from idiopathic scoliosis in relation to the method of treatment and the parameters of the deformity. Seventy-three patients with idiopathic scoliosis participated in the study. Fifty-two children were treated by means of physiotherapy, while 21 patients were treated with both Cheneau corrective brace and physiotherapy. To assess the stress level related to the deformity itself and to the method of treatment with corrective brace, the two Bad Sobernheim Stress Questionnaires (BSSQs) were applied, the BSSQ Deformity and the BSSQ Brace, respectively.

Spine deformations and faulty posture may be evaluated by assessing trunk surface deformation. POTSI index (Posterior Trunk Symmetry Index) was introduced in 2003 to assess asymmetry of the trunk seen from the back. However, deformations may also affect the anterior surface of the trunk and this can be noticed more easily by the patient owing to the visual accessibility of the anterior surface. This study a new parameter called ATSI (Anterior Trunk Symmetry Index) in order to assess the anterior trunk deformation. study was conducted on fifty primary school children, boys and girls aged 6-7 years. One photograph of each child in a spontaneous standing position was taken with a digital camera. The photographs were analysed to obtain a quantitative assessment of the new parameter, ATSI, by means of computer software developed in collaboration with an IT specialist. The intra-observer error found in the analysis was 1.23. The interobserver error was 3.08. The average ATSI value for 50 children was 25.3 ± 10.6. The threshold value norm defined as mean+2SD was 46.5.

Screening for idiopathic scoliosis is not very popular in Poland. Some Polish towns and cities have prevention programmes aimed at discovering spine dysfunctions and disorders in children and adolescents. An assessment of the angle of trunk rotation (ATR) is a reliable, effective and non-invasive action that allows use to determine trunk asymmetry. Since then the scoliometer has spread throughout the United States and other countries, where it is a popular device in the clinical practice of diagnosing scoliosis. 9,500 children aged 7-10 were examined as part of a disease prevention programme entitled "Poznan Chooses Health - Bad Posture Prophylaxis in Class I-IV Primary School Children in Poznan". The analysis included results obtained in 2010 during initial posture assessment in 1000 children, Trunk asymmetry was measured by means of the Bunnell scoliometer. The measurement of the angle of trunk rotation was the spontaneous standing position with use the scoliometer during bending (Adams forward test) at three levels: proximal thoracic, main thoracic and lumbar. For the proximal thoracic section the 0° ATR value was found in 6 children, values of 1°-3° were recorded in 883 children, values of 4°-6° in 108 children, 7° or higher in 3 of the examined children. For the main thoracic section the 0° ATR value was found in 101 children, values of 1°-3° were recorded in 735 children, 4°-6° in 155 children, 7° or higher in 9 of the examined children. For the lumbar section ATR values of 0°, 1°-3°, 4°-6°, and 7° or higher were found, respectively, in 147, 883, 108 and 11 of the examined children.

Study Design: Cochrane systematic review., Objective: To evaluate the efficacy of bracing in adolescent patients with adolescent idiopathic scoliosis (AIS)., Summary of Background Data: 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., Methods: 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., Results: 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., Conclusion: 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.

In subjects with scoliosis the thoracic cage deformity is a complex 3D phenomenon. There is a deficiency of simple clinical methods of thorax shape evaluation. The study aimed to introduce and assess an anthropometric technique measuring transverse plane deformity of the thorax in patients with idiopathic scoliosis. Thirty scoliotic girls, aged 14.4+/-1.5 years, thoracic scoliosis type Lenke 1, mean Cobb 54.1+/-24.7 degrees, and 30 healthy volunteers matched for sex and age were examined. Using a Martin anthropometric caliper the length of the long and the short horizontal axes of the thorax were measured at the level of the xiphoid process (upper index) and of the costal arch (lower index), both on maximum inspiration and expiration. Asymmetry index, defined as difference of the length of the long and the short axes expressed as the percentage of the short one, was calculated. The upper asymmetry index in the study group was 35.2+/-18.6 (inspiration) while in the control group it was 13.6+/-13.6, difference significant, p<0.001. The lower asymmetry index in the study group was 26.2+/-12.9 (inspiration) while in the control group it was 12.5+/-11.7, difference significant, p<0.001. In conclusion, thorax asymmetry index revealed significantly higher values in scoliotic patients. Asymmetry of respiratory movements could be measured. This simple technique may be used as a helpful tool for clinicians.

Background: In recent years pedicle screw based constructs have been increasingly used in the operative management of scoliosis. The current principles of screw placement are based on normal anatomy and therefore may not be applicable in cases of severe vertebral deformity due to torsion. The aim of this study was to evaluate the usefulness of computer tomography (CT) in preoperative planning and outcome assessment in operative management of idiopathic scoliosis with severe internal vertebral deformity., Material and Methods: The study presents our own experiences based on analysis of diagnostic and therapeutic decision-making in two patients treated surgically due to Lenke type 1A idiopathic scoliosis. Due to extensive vertebral rotation and radiological appearance suggesting thin pedicles, spine CT with 3D reconstruction was performed as part of extended preoperative work-up in order to determine screw length and diameter, the point of screw introduction and angle of introduction in three planes. Vertebral rotation was evaluated according to the Aaro-Dahlborn method. Segments were also identified where pedicle screws could not be applied due to severe rotation or small pedicle diameter., Results: Preoperative planning of screw placement enabled safe and accurate screw application, as confirmed by postoperative spine CT evidence. Satisfactory correction was achieved in both patients in the coronal and frontal planes., Conclusions: CT allows detailed preoperative planning of scoliosis surgery and identification of segments in which pedicle screws cannot be safely placed. This may lower the incidence of complications associated with inaccurate pedicle screw placement.

Background: Idiopathic scoliosis, defined as a lateral curvature of the spine of above 10 degrees (Cobb angle), is seen in 2-3% of the growing age population, while curves above 20 degrees , requiring conservative treatment, are found in 0.3-0.5%. In our observation, both under-treatment of progressive curves and over-treatment of stable cases are common during conservative management of scoliosis., Material and Methods: A model of therapeutic management is presented based on the experience of Polish clinicians specialising in the treatment of scoliosis as well as the effects of work of a panel of experts of SOSORT (Society on Scoliosis Orthopaedic and Rehabilitation Treatment). The model comprises the indications for conservative treatment according to age, curve type and size and Risser grading. The aetiology, classifications, usefulness of the Lonstein and Carlson factor of progression and other methods of determining the probability of scoliosis progression, as well as the psychological aspects of conservative management are presented., Results: Based on the knowledge of the natural history of idiopathic scoliosis, factors of progression and on the SOSORT experts' opinion, guidelines are proposed for clinicians treating children and adolescents with idiopathic scoliosis, including the timing and course of brace treatment and the types of exercises., Conclusions: Uniform practical guidelines developed by experts may represent an essential step towards establishing standards of conservative scoliosis care in our country.

Purpose: To present technical particularities of construction and application of trunk orthosis in non-ambulatory patients with severe neuromuscular spinal deformity. Unlike in the idiopathic scoliosis, the aim of bracing was not morphological (decrease of Cobb angle) but functional., Methods: Specially designed orthosis, resting against the seat, not leaned against the pelvic, partially suspending the trunk, was applied to 45 children aged 2.0 - 15.0 years. The construction of the orthosis, based on the achievements of the Society of Scoliosis Orthopaedic and Rehabilitation Treatment SOSORT, is presented, and the technical details of manufacturing are discussed and illustrated with clinical cases., Results: The orthosis was able to partially correct the spinal curvature and pelvic obliquity, provide stable sitting position, balance the trunk, facilitate breathing, discharge the abdomen, unload soft tissues of the buttocks. Complications comprised skin intolerance in 36 patients, requiring modification of orthosis, and progression of the curve under orthotic management in 22 children, requiring surgical indication. None of the patients reported worsening of the subjective symptoms of the respiratory discomfort while sitting in the orthosis., Conclusion: Correctly designed and fitted, the orthosis can markedly improve the function, prevent some of threatening complications and partially postpone the need for surgical treatment.

Purpose: To provide a detailed description of the mechanisms responsible for the corrective effect of the rigid brace Cheneau 2000., Methods: Morphology of thoracic scoliosis is presented, including surface trunk asymmetries and radiological deformation. Biomechanical rules, applied to achieve curve correction in the three planes, are the subject of a comprehensive review., Results: Tissue transfer in the three dimensions, elongation effect, rib cage 'derotation' and bending are the passive mechanisms of correction. Restoring of physiological thoracic kyphosis is promoted by a special combination of pads and free spaces in the brace. Hypercorrection is achievable in some clinical situations, especially for the trunk imbalance. Attention is attached to the active mechanisms of corrective bracing, comprising the modeling of vertebral growth, asymmetrically guided respiratory movements, repositioning of the spatial arrangement of trunk muscles and the anti-gravitational effect., Conclusions: Contemporary corrective orthosis for idiopathic scoliosis should take advantage of specific passive and active mechanisms. Preservation of the function of the vertebral column as a flexible framework for the human body, as well as the preservation of the respiratory function of the thorax stay ambitious goals to approach, and a significant progress over recent years has been observed.

Background: The scoliotic vertebrae are submitted to (1) the displacement in the 3-dimensional space and (2) the bone remodeling, which results in a 3-dimensional intrinsic vertebral deformation. Both phenomena are most expressed inside the apical zone of the curve and can be measured in a computer tomographic (CT) scan. A comparative study of CT thoracic scans in scoliotic and normal children was performed to provide a better description of the altered anatomy with respect to patomechanism of scoliosis., Methods: Twenty-three scoliotic girls, aged 14.3 +/- 2.1 years, a case of a right thoracic curve with a Cobb angle of 60.6 +/- 19.3 degrees, and 24 controls, free of spinal deformity, sex- and age-matched, underwent CT examination of the thorax at the level of Th8 to Th9 vertebra. The rotation angle of the apical vertebra and the sagittal to coronal rib cage diameters ratio were measured. The intravertebral deformation was assessed by measuring the angles between the axis of the whole vertebra and the axes of the spinous or transverse processes., Results: The ratio of sagittal to coronal chest diameter was reduced in scoliosis patients (P < 0.001) and correlated with the Cobb angle. The angle between the axis of vertebra and the spinous process increased (P = 0.008), and its value was positively correlated with the rotation angle of the vertebra (r = 0.78, P < 0.05); however, the rotation was oriented clockwise, whereas the spinous process deviation was counterclockwise. The angle between the spinous and the transverse process revealed greater values on the concave side (P < 0.001), whereas the transverse processes were not deviated from the axis of vertebra (P = 0.469)., Conclusions: A constant pattern, previously not described, of the alteration of morphology of the apical vertebra due to the intravertebral bone remodeling was identified. The intravertebral deformation accompanied the displacement of the vertebra with a linear correlation; however, the 2 phenomena were developing in the opposite directions., Clinical Relevance: Level III, cross-sectional study.

The method developed since 1979, comprises active 3-dimensional auto-correction, concerning the primary curve mobilization towards the correction of the curvature, with special emphasis on the kyphotization of the thoracic spine, carried on in closed kinematic chains, and developed on a symmetrically positioned pelvis and shoulder girdle, followed by active stabilization of the corrected position, and endured as postural habit. The positions for exercising and the movements involved are described in details. Small, moderate and important curves can be managed with DoboMed, however the effectiveness of the therapy depends on the curve flexibility and patient's compliance. DoboMed has been used as a single therapy or together with bracing, as well as preparation for scoliosis surgery. The published results demonstrated that the DoboMed has a positive influence on inhibition of the curve progression in idiopathic scoliosis, the improvement of respiratory functions, assessed by the spirometric values, and the general exercise efficiency evaluated using ergospirometry.

Contemporary bracing developed numerous novel technical solutions to most of main aspects of the correction of structural progressive idiopathic scoliosis. This paper presents a short review on principal biomechanical rules for the three dimensional scoliosis correction. Apart from the tissue transfer, which is a known passive mechanism of rigid bracing, the other passive mechanisms are described, containing the "cherry stone" distraction effect, the thoracic derotation and the bending. A demanding technical construction of the orthosis enables active mechanisms to develop: the corrective factor of the vertebral growth, hypercorrection-oriented trunk movements and respiration, as well as the anti-gravitational mechanism, by which postural reflexes maintain the curve correction, proximally and distally out of the limits of the brace. We believe that systematic investigations unfolded in the area of neurophysiological aspects of postural control of the spinal balance will continuously improve the fascinating capabilities of the active scoliosis autocorrrection assisted by the brace.

Purpose: The principles of conservative management of neuromuscular scoliosis in childhood and adolescence are presented., Methods: Analysis of personal experience and literature review. The topic is discussed separately for patients with flaccid or spastic paresis., Results: These demonstrate that conservative management might be proposed for patients with neuromuscular scoliosis in many clinical situations. In spastic disorders, it maintains the symmetry around the hip joints. Bracing is technically difficult and often is not tolerated well by cerebral palsy children. In patients with flaccid paresis, the fitting and the use of brace is easier than in spastic patients. The flexibility of the spinal curvature is more important. Functional benefits of conservative management of neuromuscular scoliosis comprise stable sitting, easier use of upper limbs, discharge of the abdomen from the collapsing trunk, increased diaphragm excursion, and, not always, prevention of curve progression., Conclusions: Specific natural history and multiple medical problems associated with the disease make the treatment of children with neuromuscular scoliosis an extremely complex issue, best addressed when a team approach is applied. Continuously improving techniques of conservative management, comprising bracing and physiotherapy, together with correctly timed surgery incorporated in the process of rehabilitation, provide the optimal care for patients.

The paper presents the review of pathological changes which develop within the respiratory system in patients with structural progressive idiopathic scoliosis. The impairment of the function of the respiratory system is one of the principal impact of idiopathic scoliosis on the general health and function, as well as on the quality of life. Although the fatal outcomes of respiratory failure are usually prevented by a successful conservative treatment or by the spinal surgery, the reduction of the volume of the thorax, the restriction of the thorax, as well as decreased efficacy of the respiratory muscles are still a major issue (problem) for many patients with structural scoliosis that may lead to respiratory insufficiency or failure. The papers presents main functional tests to assess the respiratory impairment and the basic rules for interpretation of the results of the examination.

Purpose: The purpose of this paper is to provide an overview of the techniques of evaluation of patients, suffering from idiopathic scoliosis., Methods: The presentation is provided, concerning the medical history, clinical examination, conventional radiography, stereo-radiography, surface topography, ultrasounds, computer tomography, and magnetic resonance imaging, focusing on the points specific for the pathology of idiopathic scoliosis., Results: Use of the scoliometer became systematic in the clinical evaluation. Quality of life questionnaires, including those endorsed by the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT), oriented towards scoliotic patients, gain on popularity and are extremely helpful to objectively evaluate the disability related to scoliosis. Classical radiography serves as the basic exam to determine the curve type and magnitude. Ultrasounds, computer tomography and magnetic resonance imaging are indicated in precisely defined clinical situations. Stereo-radiography and surface topography seem to be the most promising techniques, however requiring standardisation., Conclusions: Apart from sophisticated measurements, the experience of a physician cannot be underestimated. High standard clinical evaluation will probably continue to serve as a reference for other methods of assessment of patients with scoliosis. Stereo-radiography and surface topography deserve common use, after standardization is achieved.

This guideline has been discussed by the SOSORT guideline committee prior to the SOSORT consensus meeting in Milan, January 2005 and published in its first version on the SOSORT homepage: http://www.sosort.org/meetings.php. After the meeting it again has been discussed by the members of the SOSORT guideline committee to establish the final 2005 version submitted to Scoliosis, the official Journal of the society, in December 2005. This chapter is a republication from the original paper published in "Scoliosis" BioMed journal and it is included in this book due to its high importance.

Unlabelled: Direct comparison of the correction of scoliosis achieved by different surgical methods is usually limited by the heterogeneity of the patients analyzed (their age, curve pattern, curve magnitude, etc.). The hypothesis is that an analysis of comparable scoliotic curves treated by different implant systems could detect subtle differences in outcome. The objective of this study was therefore: (1) to measure the 3D radiological parameters of scoliotic deformity and to quantify their postoperative changes, and (2) to compare the radiographic results achieved with one anterior and one posterior instrumentation methods applied to similar curves but representing different mechanisms of correction., Material and Methods: The clinical notes and radiographs of 46 patients operated on for adolescent idiopathic scoliosis were reviewed. The inclusion criteria consisted of: a single thoracic curve, right convex, a frontal Cobb angle minimum of 45 degrees and a maximum of 65 degrees , flexibility on a lateral bending test of more than 30%, and a Risser test value of between 1 and 4. The operative procedures were: Cotrel-Dubousset instrumentation (CDI) for 25 patients (the CD group) and correction by anterior instrumentation (Pouliquen plate) for 21 patients (the ANT group). Preoperative and postoperative long cassette standing antero-posterior and lateral radiographs were examined. The frontal and sagittal thoracic Cobb angle, apical vertebra transposition (AVT), apical vertebra rotation (AVR), lowest instrumented vertebra (LIV) tilt, C7 vertebra shift and rib cage shift (RCS) were all compared. A computed reconstruction was produced with Rachis-91 software. Vertebral axial rotation angle was evaluated throughout the spine., Results: Postoperative assessment revealed a mean correction of the frontal Cobb angle of 37.0 degrees for the CD group and 41.0 degrees for the ANT group. The AVT operative correction was 45.8 and 42.7 mm, respectively, and AVR correction was 1.8 and 12.6 degrees , respectively. The postoperative change of the sagittal Th4-Th12 Cobb angle was not significant for any method but it was significant (P=0.05) for the CD group if the curves were divided preoperatively into hypokyphotic and normokyphotic subgroups and then analyzed separately. Computed assessment demonstrated a correction of segmental axial rotation of more than 50% in the main thoracic curve in the ANT group, significantly more than that in the CD group (P<0.001)., Conclusions: Anterior instrumentation provided better correction of the vertebral axial rotation and of the rib hump. CD instrumentation was more powerful in translation and more specifically addressed the sagittal plane: the postoperative thoracic kyphosis angle increased in the hypokyphotic curves and slightly decreased in the normokyphotic curves.