BRACE TREATMENT FOR ADOLESCENT IDIOPATHIC

SCOLIOSIS (AIS) AND SCHEUERMANN KYPHOSIS: THE

ISSUE OF OVERTREATMENT IN GREECE

NIKOS KARAVIDASPT, MSc

Certified Schroth Therapist (BSPTS)Certified SEAS Therapist

McKenzie Therapist

SRS – SOSORT guidelines SRS guidelines for AIS treatment with brace:

Cobb angle >25ο (25ο – 45ο), Risser sign 0-3 SRS guidelines for Scheuermann kyphosis with brace:

Cobb angle 55ο-80ο , Risser sign 0-3, Scheuermann findings on x-ray (vertebra wedging, Schmorl nodes)

SRS guidelines for brace weaning:Brace weaning at Risser 4, approximately 2 years after menarche in girls

SOSORT guidelines for AIS treatment with brace: I. No signs of maturity: Cobb angle >25ο II. Risser 0-3 : Cobb angle >30ο , Cobb angle 20ο -29ο and

Progression risk over 60% (Lonstein formula)III. Risser 4 : Cobb angle > 35ο

[SOSORT guidelines 2006 by Weiss et al]

Overtreatment Health care provided with a higher volume or cost

than the appropriate The unnecessary use of brace to treat AIS and

Scheuermann Kyphosis Subjects that should have never started wearing a

brace or subjects that should have finished their therapy earlier

Overtreatment estimation by measuring Cobb angle, Risser sign, menarche, Scheuermann vertebra wedging

Further analysis according to risk prognostic factors: ATR, Kyphotic angle, family history, curve type

Methods Cross-sectional study From 289 patients totally treated in a private

clinic in 2014, 167 subjects fulfilled the inclusion criteria

Inclusion criteria:- Age 9-18 years- Brace prescription for AIS and Scheuermann kyphosis

126 females – 41 males, mean age 15,7 years 118 AIS patients, 49 Kyphosis patients Brace was prescribed by 34 MDs from different

geographical areas of Greece

ResultsTOTAL

OVERTREATMENT

GOOD TREATMENT

71/167(42,5%)96/167

(57,5%)

AISOVERTREATMENTGOOD TREATMENT

51/118(43,2%)67/118

(56,8%)

KYPHOSISOVERTREATMENTGOOD TREATMENT

20/49(40,8%)29/49

(59,2%)

AIS Group

No brace weaning

Brace after Risser 4

20 < Cobb angle <25

Cobb angle < 20

0 5 10 15 20 25

OVERTREATMENT

16,9%

5,9%

10,2%

10,2%

8/118 subjects (6,8%) had Cobb angle < 20ο at Risser 5 and they were prescribed a brace!!

Kyphosis group

No brace weaning

Brace after Risser 4

No Scheuermann

0 2 4 6 8 10 12

OVERTREATMENT

22,5%

6,1%

12,2%

16 years old, First brace at 15 years, 1 ½ year post-menarche, Risser 4, Th (R) 11ο ,Lu (L) 18ο , ATR Th (R) 3ο, Lu (L) 4ο . Brace prescription for 20h

Case n1

15 years old, Lu (L) 18ο , ATR 5ο , Risser 5, 4 ½ years post-menarche, Brace prescription for 15-16h, After 2 PSSE sessions she complained for pain only when she wore her brace

Case n2

17 years old, First brace 12 years, initially (2009) Th-Lu (R) 16ο , Risser 0. 03/14 Th-Lu (R) 8ο , ATR 4ο , Risser 5, continue wearing the brace for 15-16h, no brace weaning, 4 years post-menarche

Case n3

15 years old, 1 ½ years post-menarche , Risser 4, Th (L) 13ο , Lu (R) 15ο , ATR Th 2ο , Lu 4ο . Brace prescription for 18h (12/14)

Case n4

Incidence of progression of untreated AIS patients Lonstein and Carlson 1984, The prediction of curve

progression in untreated idiopathic scoliosis during growth J Bone Joint Surg Am. 1984 Sep;66(7):1061-71

Conclusions An extremely high rate of overtreatment (42,5%) was observed in the brace

treatment for AIS and Scheuermann kyphosis, in Greece

Possible reasons:- Ignorance of SOSORT and SRS guidelines for AIS and Scheuermann kyphosis

treatment- Ignorance of the important role of PSSE (Physiotherapeutic Scoliosis Specific

Exercises) in the treatment of mild scoliosis (Cobb angle < 25ο) [RCT – Monticone et al 2014]

- Lack of adequate education of MDs in the treatment of spinal deformities- Profit reasons

Overtreating a child with a brace can cause serious psychological, social and financial problems (Korovessis et al 2007)

Conclusions

Patient Care

Patient Needs Observe Exercise Brace

Surgery

Observe Overtreatment Overtreatment Overtreatment

Exercise Undertreatment Overtreatment Overtreatment

Brace Undertreatment Undertreatment Overtreatment

Surgery Undertreatment Undertreatment Undertreatment

Thank you for your attention

NIKOS KARAVIDASPT, MScCertified Schroth Therapist (BSPTS)Certified SEAS TherapistMcKenzie Therapist