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

/pdf/2016-sosort-guidelines-orthopaedic-and-rehabilitation-wd47whqefo.pdf

2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth.

The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT), that produced its first Guidelines in 2005, felt the need to revise them and increase their scientific quality. The aim is to offer to all professionals and their patients an evidence-based updated review of the actual evidence on conservative treatment of idiopathic scoliosis (CTIS). All types of professionals (specialty physicians, and allied health professionals) engaged in CTIS have been involved together with a methodologist and a patient representative. A review of all the relevant literature and of the existing Guidelines have been performed. Documents, recommendations, and practical approach flow charts have been developed according to a Delphi procedure. A methodological and practical review has been made, and a final Consensus Session was held during the 2011 Barcelona SOSORT Meeting. The contents of the document are: methodology; generalities on idiopathic scoliosis; approach to CTIS in different patients, with practical flow-charts; literature review and recommendations on assessment, bracing, physiotherapy, Physiotherapeutic Specific Exercises (PSE) and other CTIS. Sixty-five recommendations have been given, divided in the following topics: Bracing (20 recommendations), PSE to prevent scoliosis progression during growth (8), PSE during brace treatment and surgical therapy (5), Other conservative treatments (3), Respiratory function and exercises (3), Sports activities (6), Assessment (20). No recommendations reached a Strength of Evidence level I; 2 were level II; 7 level III; and 20 level IV; through the Consensus procedure 26 reached level V and 10 level VI. The Strength of Recommendations was Grade A for 13, B for 49 and C for 3; none had grade D. These Guidelines have been a big effort of SOSORT to paint the actual situation of CTIS, starting from the evidence, and filling all the gray areas using a scientific method. According to results, it is possible to understand the lack of research in general on CTIS. SOSORT invites researchers to join, and clinicians to develop good research strategies to allow in the future to support or refute these recommendations according to new and stronger evidence.

/pdf/2011-sosort-guidelines-orthopaedic-and-rehabilitation-19z0wik8ea.pdf

2011 SOSORT guidelines: Orthopaedic and Rehabilitation treatment of idiopathic scoliosis during growth

Congenital Clubfoot: Fundamentals of Treatment

In recent decades, there has been a call for change among all stakeholders involved in scoliosis management. Parents of children with scoliosis have complained about the so-called “wait and see” approach that far too many doctors use when evaluating children’s scoliosis curves between 10° and 25°. Observation, Physiotherapy Scoliosis Specific Exercises (PSSE) and bracing for idiopathic scoliosis during growth are all therapeutic interventions accepted by the 2011 International Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT). The standard features of these interventions are: 1) 3-dimension self-correction; 2) Training activities of daily living (ADL); and 3) Stabilization of the corrected posture. PSSE is part of a scoliosis care model that includes scoliosis specific education, scoliosis specific physical therapy exercises, observation or surveillance, psychological support and intervention, bracing and surgery. The model is oriented to the patient. Diagnosis and patient evaluation is essential in this model looking at a patient-oriented decision according to clinical experience, scientific evidence and patient’s preference. Thus, specific exercises are not considered as an alternative to bracing or surgery but as a therapeutic intervention, which can be used alone or in combination with bracing or surgery according to individual indication. In the PSSE model it is recommended that the physical therapist work as part of a multidisciplinary team including the orthopeadic doctor, the orthotist, and the mental health care provider - all are according to the SOSORT guidelines and Scoliosis Research Society (SRS) philosophy. From clinical experiences, PSSE can temporarily stabilize progressive scoliosis curves during the secondary period of progression, more than a year after passing the peak of growth. In non-progressive scoliosis, the regular practice of PSSE could produce a temporary and significant reduction of the Cobb angle. PSSE can also produce benefits in subjects with scoliosis other than reducing the Cobb angle, like improving back asymmetry, based on 3D self-correction and stabilization of a stable 3D corrected posture, as well as the secondary muscle imbalance and related pain. In more severe cases of thoracic scoliosis, it can also improve breathing function. This paper will discuss in detail seven major scoliosis schools and their approaches to PSSE, including their bracing techniques and scientific evidence. The aim of this paper is to understand and learn about the different international treatment methods so that physical therapists can incorporate the best from each into their own practices, and in that way attempt to improve the conservative management of patients with idiopathic scoliosis. These schools are presented in the historical order in which they were developed. They include the Lyon approach from France, the Katharina Schroth Asklepios approach from Germany, the Scientific Exercise Approach to Scoliosis (SEAS) from Italy, the Barcelona Scoliosis Physical Therapy School approach (BSPTS) from Spain, the Dobomed approach from Poland, the Side Shift approach from the United Kingdom, and the Functional Individual Therapy of Scoliosis approach (FITS) from Poland.

/pdf/physiotherapy-scoliosis-specific-exercises-a-comprehensive-206pqlr8i3.pdf

Physiotherapy scoliosis-specific exercises: a comprehensive review of seven major schools

Background
Reported failure rates,(defined based on percentage of cases progressing to surgery) of corrective bracing for idiopathic scoliosis are highly variable. This may be due to the quality of the brace itself, but also of the patient care during treatment. The latter is sometimes neglected, even though it is considered a main determinant of good results among conservative experts of SOSORT. The aim of this paper was to develop and verify the Consensus on management of scoliosis patients treated with braces

/pdf/guidelines-on-standards-of-management-of-idiopathic-lf7j4vkwb8.pdf

Guidelines on "Standards of management of idiopathic scoliosis with corrective braces in everyday clinics and in clinical research": SOSORT Consensus 2008

The Lyon Brace, or adjustable multi-shell brace, has been used for more than 60 years The use and function of the Lyon Brace includes: - The utilization of one or two corrective plaster casts, which enables a true lengthening of the concave ligaments - An oriented CAD-CAM moulding in 3D auto correction after the removal of the plaster cast - A blueprint adapted to Lenke's classification - A specific physiotherapy program Pierre Stagnara created the Lyon Brace in 1947 The brace has the following characteristics: - It adjusts to allow for a child's growth of up to seven centimetres and for an increase in weight of up to seven kilograms - It is 'active' in that the rigidity of the PMM (polymetacrylate of methyl) structure stimulates the user to auto-correct The active axial auto-correction decreases the pressures of the brace on the trunk - It is decompressive in that the effect of extension between the two pelvic and scapular girdles decreases the pressure on the intervertebral disc allowing for more effective pushes in the other planes - It is symmetrical making it both more aesthetically pleasing and easier to build - It is stable at both shoulders and pelvic girdle, facilitating the intermediate 3D corrections - It is transparent The pressure of the shells on the skin can be directly controlled so "pads" are usually not necessary Two metal bars are fixed vertically, one anterior the other posterior and all shells are attached from the bottom to the top in this order: - Two pelvic shells ensure an optimal stability of the brace - One lumbar shell T12-L4, which can be either independent or extending, at the abdominal chondrocostal level - One thoracic shell at the level of the thoracic convexity - One opposite thoracic shell used as a counter push - One shoulder balance shell on the side of the thoracic convexity This is a retrospective study of 1,338 completed treatments checked a minimum of two years after weaning from the brace Only 5% of the curves progressed more than 5° from the initial magnitudes This translates to an effectiveness index of 095 A subset of 174 subjects who started treatment at Risser 0 was isolated The global progressive angular mean curve was superimposed on the statistic general curve and the effectiveness index was calculated at 080 The Surgery rate was just 2% of the patients presenting with an initial curve below 45° The Lyon Brace is the historical reference of bracing AIS To be fully effective, it requires the patient to wear a plaster cast for at least one month and receive specific physiotherapy training Although this is a retrospective study, the results are very positive, and clearly indicate a need for a prospective study

/pdf/brace-technology-thematic-series-the-lyon-approach-to-the-14hi3b65nr.pdf

"Brace Technology" Thematic Series - The Lyon approach to the conservative treatment of scoliosis

The Lyon Brace or adjustable multi-shells brace has been used for more than 60 years. Three types of braces have been developed: Lyon thoracic brace, Lyon thoraco lumbar brace and Lyon lumbar brace. Considering the conservative orthopaedic treatment of scoliosis we outline the results of this orthosis. The management of the Lyon Brace includes: (i) The use of one or two reductive plastered brace which enable a flow of the concavity ligaments; (ii) a moulding either hand-oriented or electronic after the resection of the plastered brace; (iii) a blueprint adapted to Lenke's classification; and (iv) a specific physiotherapy. The protocol of the wearing of the orthosis depends on the initial angulation of the scoliosis. The effectivity index of 1338 scoliosis checked at least two years after the weaning of the brace, is 0.95. The effectivity index is 0.80 when the Lyon brace is put in place at Risser 0. If the angulation is globally stabilized, the rib hump is, on average, half reduced. We get the best results for lumbar scoliosis and double major. The technological progresses allow a precise use. The adjustment becomes easy during puberty growth.

The Lyon brace.

Competing interests

JCdM, CL and SP are co-inventor of the ARTbrace.

AJ, FG and FB declare that they have no competing interests.



Authors’ contributions

JCdM planned the study and collected the data. FG contributed to the references. All authors participated in the design of the study and contributed to writing the text, read and approved the final manuscript.



Authors’ information

JCdM is the clinical manager and medical responsible of ARTbrace project.

AJ is orthopedic surgeon successor of JCdM.

FG is Italian resident orthopedic surgeon in Lyon for 1 year.

CL, FB SP are CPO technical managers of ARTbrace project.

/pdf/the-new-lyon-artbrace-versus-the-historical-lyon-brace-a-1aty6vjt1d.pdf

The new Lyon ARTbrace versus the historical Lyon brace: a prospective case series of 148 consecutive scoliosis with short time results after 1 year compared with a historical retrospective case series of 100 consecutive scoliosis; SOSORT award 2015 winner

Background
The symmetrical Lyon brace is a brace, usually used to maintain correction after a plaster cast reduction in the Cotrel’s EDF (Elongation-Derotation-Flexion) frame. The new Lyon brace or ARTbrace is an immediate corrective brace based on some of the principles of the plaster cast which are improved due to advances in CAD/CAM technology. The aim of this paper is to describe concepts of this new brace to be not only a replacement of the plaster cast, but also a definitive brace.

/pdf/prospective-study-and-new-concepts-based-on-scoliosis-2hqnh39901.pdf

Prospective study and new concepts based on scoliosis detorsion of the first 225 early in-brace radiological results with the new Lyon brace: ARTbrace

The conservative orthopaedic treatment of adult scoliosis is very disappointing. In a series of 144 patients; only 25 % (33 cases) were monitored at 2 years of treatment. (Papadopoulos 2013). Thereby the literature typically focuses on a small number of patients, which limits the usefulness and relevance of its results. The brace effect on pain has been systematically described, but there is no publication on the effect of treatment on the Cobb angle and main clinical parameters. From a prospective database started in 1998, we selected all 158 consecutive patients effectively treated conservatively with the Lyon management treatment and controlled five years after brace fitting. Lyon management includes a lordosing bivalve polyethylene overlapping brace in association with specific physiotherapy. The brace can either be short with anterior support under the chest or long with sterno-clavicular support when there is a high thoracic kyphosis. 1. For the rate of scoliosis controlled after 5 years, the follow-up was 24 % of the 661 patients accepting the treatment. Pain is almost the main reason for the medical consultation, generally correlating with an increase of the scoliotic angulation. 2. The descriptive data can be superimposed on general group with age (m=56 years, SD=13) but initial Cobb angulation is significantly higher (m=40°, SD=17). Ratio Female/Male=0.91. Generally, the scoliosis is stabilized at (m=39.74 °, SD=19.40), 8 years after the beginning of the treatment. 38 improvements of more than 5°= 24 %; 88 stable = 56 %; 32 worsening of more than 5° = 20 % The rib hump is improved of by 3 mm, (modelling effect of the brace). The occipital axis is improved by more than 6 mm. But the T1 plumb line distance is worsening by 7 mm (most braces are short without sterno-clavicular support). For the first time, the number of records and follow up after 8 years allows to study the radiological progression of adult scoliosis rigid bracing. Stability or improvement of more than 5° in 80 % of cases justify rigid bracing in adults. The accentuation of the thoracic kyphosis is the only negative element and a modified ARTbrace will soon be used.

/pdf/prospective-study-of-158-adult-scoliosis-treated-by-a-2hm8ywm3ul.pdf

Cyril Lecante

Papers

"Brace Technology" Thematic Series - The Lyon approach to the conservative treatment of scoliosis

The Lyon brace.

The new Lyon ARTbrace versus the historical Lyon brace: a prospective case series of 148 consecutive scoliosis with short time results after 1 year compared with a historical retrospective case series of 100 consecutive scoliosis; SOSORT award 2015 winner

Prospective study and new concepts based on scoliosis detorsion of the first 225 early in-brace radiological results with the new Lyon brace: ARTbrace

Prospective study of 158 adult scoliosis treated by a bivalve polyethylene overlapping brace and reviewed at least 5 years after brace fitting