Controversies with nonoperative management for adolescent idiopathic scoliosis: Study from the APSS Scoliosis Focus Group

Cheung, Jason Pui Yin; Cheung, Pty; Shigematsu, Hideki; Takahashi, Shinji; Kwan, Mun Keong; Chan, Chris Yin Wei; Chiu, Chee Kidd; Sakai, Daisuke

doi:10.1177/2309499020930291

Cited by 3 publications

(4 citation statements)

References 38 publications

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“…The Risser staging system is often criticized for its inaccuracy [38], but it is still commonly used for guiding brace prescription and weaning. Many clinicians may use other skeletal maturity indices in addition to the Risser staging system to improve and facilitate more precise growth assessments, such as using the physeal closure at the knee, the phalanges, and the distal radius and ulna visible on the handwrist radiograph [8,12,16,32]. This can only be achieved by understanding how skeletal maturity indices behave and their effectiveness in evaluating growth.…”

Section: Discussionmentioning

confidence: 99%

Does the Use of Sanders Staging and Distal Radius and Ulna Classification Avoid Mismatches in Growth Assessment with Risser Staging Alone?

Cheung

2021

Clin Orthop Relat Res

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Background Although Risser stages are visible on the same radiograph of the spine, Risser staging is criticized for its insensitivity in estimating the remaining growth potential and its weak correlation with curve progression in patients with adolescent idiopathic scoliosis. Risser staging is frequently accompanied by other skeletal maturity indices to increase its precision for assessing pubertal growth. However, it remains unknown whether there is any discrepancy between various maturity parameters and the extent of this discrepancy when these indices are used concurrently to assess pubertal growth landmarks, which are important for the timing of brace initiation and weaning. Questions/purposes (1) What is the chronologic order of skeletal maturity grades based on the growth rate and curve progression rate in patients with adolescent idiopathic scoliosis? (2) What are the discrepancies among the grades of each maturity index for indicating the peak growth and start of the growth plateau, and how do these indices correspond to each other? (3) What is the effectiveness of Risser staging, Sanders staging, and the distal radius and ulna classification in assessing peak growth and the beginning of the growth plateau? Methods Between 2014 and 2017, a total of 13,536 patients diagnosed with adolescent idiopathic scoliosis were treated at our tertiary clinic. Of those, 3864 patients with a radiograph of the left hand and wrist and a posteroanterior radiograph of the spine at the same visits including initial presentation were considered potentially eligible for this study. Minimum follow-up was defined as 6 months from the first visit, and the follow-up duration was defined as 2 years since initial consultation. In all, 48% (1867 of 3864) of patients were eligible, of which 26% (485 of 1867) were excluded because they were prescribed bracing at the first consultation. These patients visited the subsequent clinics wearing the brace, which might have affected body height measurement. Six percent (117 of 1867) of eligible patients were also excluded as their major coronal Cobb angle reached the surgical threshold of 50° and had undergone surgery before skeletal maturity. Another 21% (387 of 1867) of patients were lost before minimum follow-up or had incomplete data, leaving 47% (878) for analysis. These 878 patients with 1139 skeletal maturity assessments were studied; 74% (648 of 878) were girls. Standing body height was measured in a standardized manner by a wall-mounted stadiometer. Several surgeons measured curve magnitude as per routine clinical consultation, skeletal maturity was measured according to the distal radius and ulna classification, and two raters measured Risser and Sanders stages. Reliability tests were performed with satisfaction. Data were collected for the included patients at multiple points when skeletal maturity was assessed, and only up to when brace wear started for those who eventually had bracing. The growth rate and curve progression rate were calculated by the change of body height and major coronal Cobb angle over the number of months elapsed between the initial visit and next follow-up. At each skeletal maturity grading, we examined the growth rate (in centimeters per month) and curve progression rate (in degrees per month) since the skeletal maturity assessment, as well as the mean age at which this maturity grading occurred. Each patient was then individually assessed for whether he or she was experiencing peak growth and the beginning of growth plateau at each timepoint by comparing the calculated growth rate with the previously defined peak growth rate of ≥ 0.7 cm per month and the beginning of growth plateau rate of ≤ 0.15 cm per month in this adolescent idiopathic scoliosis population. Among the timepoints at which the peak growth and the beginning of growth plateau occurred, the median maturity grade of each maturity index was identified as the benchmark grade for comparison between indices. We used the McNemar test to investigate whether pubertal growth landmarks were identified by specific maturity grades concurrently. We assessed the effectiveness of these skeletal maturity indices by the difference in proportions (%) between two benchmark grades in indicating peak growth and the growth plateau. Results For girls, the chronological order of maturity grades that indicated peak growth was the radius grade, ulna grade, Sanders stage, and Risser stage. Curve progression peaked between the age of 11.6 and 12.1 years at a similar timing by all maturity indices for girls but was inconsistent for boys. For both sexes, radius (R) grade 6, ulna (U) grade 5, Sanders stage (SS) 3, and Risser stage 0+ were the median grades for peak growth, whereas Risser stage 4, R8/9, U7/8, and SS6/7 indicated the beginning of the growth plateau. The largest discrepancy between maturity indices was represented by Risser stage 0+, which corresponded to six grades of the Sanders staging system (SS2 to SS7) and to R6 in only 41% (62 of 152) of girls in the whole cohort. Despite Risser stage 0+ corresponding to the wide range of Sanders and distal radius and ulna grades, none of the R6, U5, SS3, and Risser stage 0+ was found more effective than another grade in indicating the peak growth in girls. R6 most effectively indicated the peak growth in boys, and Risser stage 0+ was the least effective. For the beginning of the growth plateau in girls, SS6/7 was the most effective indicator, followed by U7/8. Risser stage 4 was the least effective because it indicated 29% (95% CI 21% to 36%; p < 0.001) fewer patients who reached the beginning of the growth plateau than did those with R8/9. Risser stage 4 also indicated 36% (95% CI 28% to 43%; p < 0.001) fewer patients who reached the beginning of the growth plateau than those indicated by U7/8, and it identified 39% fewer patients than SS6/7 (95% CI 32% to 47%; p < 0.001). For boys, similarly, R8/9, U7/8, and SS6/7 were all more effective than Risser stage 4 in identifying when the growth plateau began. Conclusion Risser stage 0+ corresponds to a wide range of Sanders and distal radius and ulna grades. Risser stage 0+ is least effective in indicating the peak growth in boys, and Risser stage 4 is the least effective maturity grade for indicating when the growth plateau starts in both sexes. The concurrent use of R6 and SS3 can be useful for detecting the peak growth, and SS6/7 in conjunction with U7/8 is most effective in indicating the beginning of the growth plateau. Using a combination of specific grades of Sanders staging and the distal radius and ulna classification can indicate pubertal growth landmarks with reduced risk of underestimating or overestimating skeletal maturity. These findings may aid in refining clinical decision-making of brace initiation and weaning at a more precise timing. Among Risser stage 0, the appearance of R6, U5, and SS3 provide the most effective assessment of peak growth that can indicate the most effective bracing period within which curve progression occurs. For initiation of the growth plateau, Risser 4 is not useful, and SS6/7, R8/9 and U7/8 should be used instead. Level of Evidence Level III, diagnostic study.

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Section: Discussionmentioning

confidence: 99%

Does the Use of Sanders Staging and Distal Radius and Ulna Classification Avoid Mismatches in Growth Assessment with Risser Staging Alone?

Cheung

2021

Clin Orthop Relat Res

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“…Brace weaning can be a slow process whereby daily brace-wear hours are gradually reduced or changed to night use only vs a rapid immediate brace removal. Some clinicians err on the side of gradual weaning to be certain that curves remain stable after some months of reduced brace hours, whereas others prefer immediate weaning for earlier return to normality with complete resumption of exercises, muscle training, and activity level . The main rationale for gradual weaning over a 6-month period is to allow spine adaptation to the unloaded environment while still maintaining the corrective posture.…”

Section: Introductionmentioning

confidence: 99%

“…Some clinicians err on the side of gradual weaning to be certain that curves remain stable after some months of reduced brace hours, whereas others prefer immediate weaning for earlier return to normality with complete resumption of exercises, muscle training, and activity level. The main rationale for gradual weaning over a 6-month period is to allow spine adaptation to the unloaded environment while still maintaining the corrective posture. The benefit of gradual weaning is unclear, but immediate weaning may lead to worse Cobb angle and truncal imbalance and may be associated with worse HRQoL.…”

Section: Introductionmentioning

confidence: 99%

Immediate vs Gradual Brace Weaning Protocols in Adolescent Idiopathic Scoliosis

Cheung,

Chan,

et al. 2024

JAMA Pediatr

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ImportanceLack of evidence and consensus for brace weaning protocol in adolescent idiopathic scoliosis (AIS) results in clinicians prescribing gradual weaning in the hope of avoiding curve deterioration after weaning. However, gradual weaning contributes to prolonged brace wear, which can affect spinal stiffness and health-related quality of life (HRQoL).ObjectiveTo determine whether gradual weaning results in better curve magnitude and truncal balance maintenance after brace weaning vs immediate brace removal for patients with AIS.Design, Setting, and ParticipantsThis was an open-labeled randomized clinical trial commenced in April 2017 with 24-month follow-up completed in January 2023. Outcome assessors were masked to weaning protocol assigned. The study took place at a territory-wide tertiary scoliosis clinic serving the largest number of referrals in the local population. Patients with AIS ready to wean off of brace wear were eligible (402 were screened; 33 were excluded [15 for &lt;18 hours/day of brace-wear compliance before weaning, 11 were treated with Milwaukee brace, and 7 declined to participate]; and 369 were included), and those who were treated with a custom molded thoracolumbosacral orthosis and had reached skeletal maturity were consecutively recruited.InterventionsPatients were randomized to gradual weaning protocol (n = 176) with an additional 6 months of nighttime wear before completely stopping or immediate weaning protocol (n = 193) with immediate brace removal at recruitment.Main Outcomes and MeasuresChanges in major curve Cobb angle and truncal balance from the time of weaning to 6-month, 12-month, and 24-month follow-up. HRQoL was also assessed using the refined Scoliosis Research Society 22-item and EuroQol 5-dimension questionnaires.ResultsA total of 369 patients (mean [SD] age, 14.9 [1.1] years; 304 [83.4%] girls) were randomized with 284 (77.0%) completing 24-month longitudinal follow-up. Immediate and gradual weaning groups had no significant differences in change of major Cobb angle at postweaning 6-month (difference, −0.6°; 95% CI, −1.4 to 0.2; P = .17), 12-month (difference, −0.3°; 95% CI, −1.2 to 0.6; P = .47), and 24-month (difference, −0.3°; 95% CI, −1.2 to 0.7; P = .60) follow-up. The number of curve progression, nonprogression, and rebound cases were comparable (χ22 = 2.123; P = .35). Postweaning changes in truncal balance and HRQoL demonstrated no significant differences between groups.ConclusionsGradual weaning did not demonstrate superiority to immediate weaning with predefined criteria of Cobb angle and truncal balance maintenance and HRQoL after brace weaning. Gradual and immediate weaning achieved very similar maintenance of brace outcomes in AIS. We therefore recommend the consideration of immediate brace weaning, which aims to benefit patients with earlier time for increased exercises and activity level.Trial RegistrationClinicalTrials.gov Identifier: NCT03329716

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“…Previous studies have suggested that nonsurgical therapy is an effective treatment for scoliosis, particularly AIS ( Dufvenberg et al, 2021 ; Ng et al, 2017 ). However, the prevalence of scoliosis is increasing, and many researchers argue that current treatments for AIS are insufficient ( Cheung et al, 2020 ; Płaszewski and Bettany-Saltikov, 2014 ).…”

Section: Introductionmentioning

confidence: 99%

Efficacy of conservative treatment on exacerbation of adolescent idiopathic scoliosis

Kim¹

2022

J Exerc Rehabil

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Scoliosis is defined as a deviation from the normal vertical line of the spine and consists of a lateral curvature in which the spine rotates within the curvature. Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis and the cause is unknown. In this study, it was investigated whether conservative treatment for adolescent idiopathic scoliosis (CONTRAIS) reduced the patient’s Cobb angle, and the effect of CONTRAIS according to the severity of idiopathic scoliosis and the efficacy of CONTRAIS by spinal region were also verified. Idiopathic scoliosis patients with a Cobb angle of 10° or more were recruited and classified into mild, moderate, and severe groups according to the Cobb angle (°). Cobb angle was measured radiographically before and after 10 weeks of treatment. A combination of CONTRAIS, including physical therapy, exercise therapy, manual therapy, and home exercise was prescribed for all patients. The patients visited the hospital 3 times a week for 10 weeks for treatment, and exercised at home for 20 min every day. In this study, the effect of reducing Cobb angle of CONTRAIS did not differ according to the spinal region. Also, the Cobb angle reduction effect of CONTRAIS was more effective in severe group. This study may suggest that early detection and treatment through CONTRAIS enables successful correction of AIS.

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Controversies with nonoperative management for adolescent idiopathic scoliosis: Study from the APSS Scoliosis Focus Group

Cited by 3 publications

References 38 publications

Does the Use of Sanders Staging and Distal Radius and Ulna Classification Avoid Mismatches in Growth Assessment with Risser Staging Alone?

Does the Use of Sanders Staging and Distal Radius and Ulna Classification Avoid Mismatches in Growth Assessment with Risser Staging Alone?

Immediate vs Gradual Brace Weaning Protocols in Adolescent Idiopathic Scoliosis

Efficacy of conservative treatment on exacerbation of adolescent idiopathic scoliosis

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