1、METHODOLOGYOpen Access2011 SOSORT guidelines: Orthopaedic andRehabilitation treatment of idiopathic scoliosisduring growthStefano Negrini1,2,3*, Angelo G Aulisa4, Lorenzo Aulisa5, Alin B Circo6, Jean Claude de Mauroy7, Jacek Durmala8,Theodoros B Grivas9, Patrick Knott10, Tomasz Kotwicki11, Toru Maru
2、yama12, Silvia Minozzi13, Joseph P OBrien14,Dimitris Papadopoulos15, Manuel Rigo16, Charles H Rivard6, Michele Romano3, James H Wynne17,Monica Villagrasa16, Hans-Rudolf Weiss18and Fabio Zaina3AbstractBackground: The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatme
3、nt (SOSORT),that produced its first Guidelines in 2005, felt the need to revise them and increase their scientific quality. The aimis to offer to all professionals and their patients an evidence-based updated review of the actual evidence onconservative treatment of idiopathic scoliosis (CTIS).Metho
4、ds: All types of professionals (specialty physicians, and allied health professionals) engaged in CTIS havebeen involved together with a methodologist and a patient representative. A review of all the relevant literatureand of the existing Guidelines have been performed. Documents, recommendations,
5、and practical approach flowcharts have been developed according to a Delphi procedure. A methodological and practical review has beenmade, and a final Consensus Session was held during the 2011 Barcelona SOSORT Meeting.Results: The contents of the document are: methodology; generalities on idiopathi
6、c scoliosis; approach to CTIS indifferent patients, with practical flow-charts; literature review and recommendations on assessment, bracing,physiotherapy, Physiotherapeutic Specific Exercises (PSE) and other CTIS. Sixty-five recommendations have beengiven, divided in the following topics: Bracing (
7、20 recommendations), PSE to prevent scoliosis progression duringgrowth (8), PSE during brace treatment and surgical therapy (5), Other conservative treatments (3), Respiratoryfunction and exercises (3), Sports activities (6), Assessment (20). No recommendations reached a Strength ofEvidence level I;
8、 2 were level II; 7 level III; and 20 level IV; through the Consensus procedure 26 reached level V and10 level VI. The Strength of Recommendations was Grade A for 13, B for 49 and C for 3; none had grade D.Conclusion: These Guidelines have been a big effort of SOSORT to paint the actual situation of
9、 CTIS, starting fromthe evidence, and filling all the gray areas using a scientific method. According to results, it is possible tounderstand the lack of research in general on CTIS. SOSORT invites researchers to join, and clinicians to developgood research strategies to allow in the future to suppo
10、rt or refute these recommendations according to new andstronger evidence.PremiseMandateThe international Scientific Society on Scoliosis Ortho-paedic and Rehabilitation Treatment (SOSORT), thatproduced its first Guidelines during the 2005 MilanMeeting, and published them in 2006 in the JournalScolio
11、sis 1, felt the need to revise them and increasetheir scientific quality. During the SOSORT 2010 Meet-ing in Montreal the SOSORT Guidelines Commissionwas established, coordinated by Stefano Negrini. TheMandate to the Commission was to develop Guidelinesmethodologically sound and evidence based, givi
12、ng* Correspondence: stefano.negrinimed.unibs.it1Physical and Rehabilitation Medicine, University of Brescia, ItalyFull list of author information is available at the end of the articleNegrini et al. Scoliosis 2012, 7:3http:/ 2012 Negrini et al; licensee BioMed Central Ltd. This is an Open Access art
13、icle distributed under the terms of the Creative CommonsAttribution License (http:/creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly recommendations according to the strength of theactual evidence
14、.CommissionThe Commission was open to all SOSORT Memberswho decided to adhere to the project; it has beendecided to include also a methodologist (Silvia Minozzi),while a patient (Joe P OBrien), member of SOSORTand President of the US National Scoliosis Foundation,has been nominated as an external ju
15、dge with thepatients perspective.ContentThe contents of the document of the 2011 SOSORTGuidelines on “Orthopaedic and Rehabilitation Treat-ment of Idiopathic Scoliosis During Growth” are:1. Methodology2. Generalities on idiopathic scoliosis3. Approach to conservative treatment of idiopathicscoliosis
16、 in different patients, with practical flow-charts4. Literature review and recommendations on assess-ment, bracing, physiotherapy, Physiotherapeutic SpecificExercises and other conservative treatmentsAn Appendix (Additional File 1) has been added togive all details the Method used to develop theGuid
17、elines.Scope, purpose and applicationsThe aim of these Guidelines is to offer to all profes-sionals engaged in the conservative treatment of scolio-sis an evidence-based updated review of the actualevidence in the field, together with a series of evidence-based recommendations. The multiple gray are
18、as,important for the every day clinical practice, in which itis not possible to give an evidence-based recommenda-tion, have been covered through a formal and explicitconsensus methodology, as outlined in the Appendix(AdditionalFile1),toprovideaconsensusrecommendation.The Guidelines are meant to app
19、ly to all idiopathicscoliosis patients regardless of age. The main clinicalquestions that they cover are: Which assessment of the patient should beperformed? Which conservative treatment should be provided,and how? How and when should bracing be applied? How and when should exercises be used?Develop
20、ment of the GuidelinesAll types of professionals engaged in the conservativetreatment of scoliosis have been involved: specialty phy-sicians (orthopaedics, physical and rehabilitationmedicine, psychiatry.) and allied health professionals(orthotists, physiotherapists, chiropractors.); a metho-dologis
21、t and a patient representative have been includedas well.Nevertheless, it must be underlined that these Guide-lines have been developed by the SOSORT, that is theSociety on Scoliosis treatment that is focused exclusivelyin the conservative approach to scoliosis. The other twointernational Scientific
22、 Societies involved in scoliosistreatment, while considering also the conservativeapproach, focus mainly either in the surgical treatment(Scoliosis Research Society) or in general research(International Research Society on Spinal Deformities):the SRS and IRSSD have not been involved in thisGuideline
23、s development, even if members of theseSocieties are also members of the SOSORT andparticipated.Patients have been involved in the development of theGuidelines through the US National Scoliosis Founda-tion, representing 25,000 actual scoliosis patients.MethodsMethods are outlined in all details in t
24、he Appendix(Additional File 1).For the treatment sections we performed systematicreviews of the literature in February 2011. Medline wassearched from its inception, with no language limita-tions. The search strategies, the selection criteria, andthe number of retrieved papers are listed in the indiv
25、i-dual sections. We also searched: the abstracts of allSOSORT Meetings, from the first one in 2003 to 2010;the personal files and knowledge of all the authors; thepapers retrieved with all the other searches listed inthese Guidelines; the references sections of all retrievedpapers.To produce the act
26、ual Guidelines, a review of the pre-vious ones has been performed: these have beensearched through a comprehensive bibliographic searchon Medline with the key word “Scoliosis” and “Guide-lines” 1-4. The final documents, recommendations,and practical approach flow charts have been developedaccording
27、to a Delphi procedure carefully listed in theAppendix (Additional File 1). A methodological andpractical review have been made, and a final ConsensusSession held during the 2011 Barcelona SOSORTMeeting.A classical Strength of Evidence (SoE) table has beenadopted (Table 1). According to the Italian G
28、uidelines2, levels V and VI have been added according to theConsensus session held during the SOSORT Meeting. AStrength of Recommendation (SoR) scale has also beenused (Table 2), that assumes that each Recommendationshould have in the clinical everyday world, balancing allNegrini et al. Scoliosis 20
29、12, 7:3http:/ 2 of typical factors involved in this decision (patients, profes-sionals, social). The SoR scale is meant to accompanyand complement the Strength of Evidence scale.Target users of the GuidelinesUsers of these Guidelines are meant to be all profes-sionals involved in the Conservative Tr
30、eatment of Sco-liosis, but they also should serve as reference forpatients.UpdatesSince these Guidelines have been produced in 2011,they will be fully updated by SOSORT between 2016and 2021. If important changes in practice will intervenebefore, an update could be decided by the SOSORTBoard to be pu
31、blished before that date.ApplicabilityThese Guidelines will be published in the Internet OpenAccess Journal “Scoliosis” http:/. This is the most important way to ensure theiraccessibility to the worldwide community of Scoliosisconservative professionals. Moreover, this will guaranteevisibility to th
32、e patients. The Consensus process, invol-ving professionals from all over the world, should pro-vide an objective document that a wide variety ofinterested organizations and third party payers mayreview to gain insight into the treatment modalities. Inthe meantime, single national adaptations should
33、 even-tually be considered. The document in itself shouldserve ad the basis for these national documents.Translations in different languages have been alreadyplanned, including: French, German, Greek, Italian,Japanese, Polish, Spanish. These translations will bepublished in the Official SOSORT websi
34、te: http:/www.sosort.org. Moreover, process for National Organizationsapprovals have been planned, and will be reported in thenext Edition of these Guidelines.General information on idiopathic scoliosisDefinitionsScoliosis is a general term comprising a heterogeneousgroup of conditions consisting in
35、 changes in the shapeand position of the spine, thorax and trunk. The name,believed to have been introduced by Hippocrates (sco-lios, which means crooked or curved) 5 and used byGalen (scoliosis), means an abnormal lateral spinal cur-vature. Today, scoliosis is known not to be limited onlyto the fro
36、ntal plane, and can be defined as a “three-dimensional torsional deformity of the spine andtrunk“ 6-8: it causes a lateral curvature in the frontalplane, an axial rotation in the horizontal one, and aTable 1 Strength of Evidence grading used in these Guidelines.Strength ofevidenceQuestionMeaningIEff
37、ectiveness Multiple Randomized Controlled Trials or Systematic Reviews of such studiesDiagnosisMultiple Randomized Controlled Trials, or Cross-sectional Studies with verification by reference (gold) standard, orSystematic Reviews of such studiesIIEffectiveness One Randomized Controlled TrialDiagnosi
38、sOne Randomized Controlled Trial, or one Cross-sectional Study with verification by reference (gold) standardIIIEffectiveness Multiple Controlled nonrandomized Studies or Systematic Reviews of such studiesDiagnosisMultiple Cross-sectional Studies with incomplete & unbalanced verification with refere
39、nce (gold) standardIVEffectiveness Other studiesDiagnosisVEffectiveness SOSORT Consensus with more than 90% of agreementDiagnosisVIEffectiveness SOSORT Consensus with 70 to 89% of agreementDiagnosisQuestions on Effectiveness (treatment results) and Diagnosis (assessment) have been consideredTable 2
40、Strength of Recommendations grading used in these Guidelines.Strength of recommendationMeaningAit must be applied widely and to all patients with this specific needBit is important, but can be applied not to all patients with this specific needCless important, it can be applied on a voluntary basisD
41、very low importanceNegrini et al. Scoliosis 2012, 7:3http:/ 3 of disturbance of the sagittal plane normal curvatures,kyphosis and lordosis, usually, but not always, reducingthem in direction of a flat back.“Structural scoliosis”, or just scoliosis, must be differ-entiated from “functional scoliosis”
42、, that is a spinal cur-vature secondary to known extraspinal causes (e.g.shortening of a lower limb or paraspinal muscle toneasymmetry). It is usually partially reduced or completelysubsides after the underlying cause is eliminated (e.g. ina recumbent position). Functional scoliosis is not thesubjec
43、t of this paper.The term Idiopathic Scoliosis was introduced byKleinberg (1922) (ref), and it is applied to all patients inwhich it is not possible to find a specific disease causingthe deformity; in fact, it appears in apparently healthychildren, and can progress in relation to multiple factorsduri
44、ng any rapid period of growth. By definition, idio-pathic scoliosis is of unknown origin and is probablydue to several causes. Etiopathogenetically, the spinaldeformity caused by idiopathic scoliosis may be definedas a sign of a syndrome with a multifactorial etiology9-13. Nearly always, scoliosis m
45、anifests as a solitarydeformity, but further investigation may reveal other sig-nificant subclinical signs 14,15. Idiopathic Scoliosis hasbeen described as a torsional deformity of the spine,which combines a translation and rotation of a variablenumber of vertebrae, changing the 3D geometry of thesp
46、ine 16-18. Structural and sometimes a geometricalflat back is seen often, but the geometry of the spine inthe lateral radiograph is highly variable. Trunk deformityand back asymmetry correlates with the spinal defor-mity, but there can be significant discrepancies in somecases 19.The curvature in th
47、e frontal plane (AP radiograph inupright position) is limited by an upper end vertebraand a lower end vertebra, taken both as a referencelevel to measure the Cobb angle. The Scoliosis ResearchSociety (SRS) suggests that the diagnosis is confirmedwhen the Cobb angle is 10 or higher and axial rotation
48、can be recognized. Maximum axial rotation is measuredat the apical vertebra. However, structural scoliosis canbe seen with a Cobb angle under 10 20, with a poten-tial for progression. Progression is more common ingirls during the growth spurt at puberty and then it iscalled progressive Idiopathic Sc
49、oliosis. When untreated,it may lead to severe trunk deformities, which limit thecapacity and functional biomechanics of the chest, exer-cise capacity, general fitness and ability to work, all fac-tors related with impairment on quality of life.EpidemiologyIn approximately 20% of cases, scoliosis is
50、secondary toanother pathological process. The remaining 80% arecases of idiopathic scoliosis. Adolescent idiopathicscoliosis (AIS) with a Cobb angle above 10 occurs inthe general population in a wide range from 0.93 to 12%21-38: two to three percent is the value the most oftenfound in the literature
