Assessment of angle velocity in girls with adolescent idiopathic scoliosis
 Ferran Escalada^{1}Email author,
 Ester Marco^{1},
 Esther Duarte^{1},
 Josep Ma Muniesa^{1},
 Roser Boza^{1},
 Marta Tejero^{1} and
 Enric Cáceres^{2}
DOI: 10.1186/17487161420
© Escalada et al; licensee BioMed Central Ltd. 2009
Received: 9 July 2009
Accepted: 16 September 2009
Published: 16 September 2009
The Erratum to this article has been published in Scoliosis 2009 4:23
Abstract
Background
Although it has been demonstrated that the peak height velocity (PHV) is a predictive factor of progression in adolescent idiopathic scoliosis (AIS), little is known about the usefulness of angle progression in clinical practice. The purpose of this study was to establish a relationship between height and angle velocities, as well as to determine if peak angle velocity (PAV) occurs at the same time than PHV.
Methods
A retrospective study of a cohort of girls with idiopathic scoliotic curves greater than 10°. Data of 132 girls who participated in a previous retrospective study about growth in AIS were used to calculate height and angle velocities. Relationship between height and angle velocities was estimated by the use of a Linear Mixed Model.
Results
PHV and PAV take place simultaneously 1 year before menarche in progressive curves managed with a brace in AIS. Changes in angle velocity are influenced by changes in height growth velocity, in such a way that as from 6 months postmenarche, height growth velocity in this group of girls estimates curve progression velocity (βcoefficient 0.88, p = 0.04).
Conclusion
As from 6 months postmenarche, there is an inverse relationship between height velocity and curve progression in the group of AIS girls with progressive curves managed with a brace. Because height velocity is decreasing from 1 year before menarche, this finding corroborates that at the end of puberty, there is still a risk of progression in this group of girls despite bracing. The assessment of both height and angle velocity might be useful in clinical practice at the time of assessing brace effectiveness and how long bracing has to be indicated.
Background
Many indicators of skeletal maturity and spinal growth have been proposed, such as chronological age, skeletal age of hand and wrist, Risser's sign, timing of menarche, peak height velocity (PHV) and others [1–8]. None of those has been proved to be accurate enough to predict spinal growth potential in adolescent idiopathic scoliosis (AIS). The PHV, defined as the most rapid growth rate during the early adolescent period, has been shown to have an important predictive value in curve progression much better than other maturity scales such as chronological age, age of menarche or Risser's sign [7]. Timing of the PHV provides valuable information on the likelihood of curve progression, but requirements for measuring the peak are difficult to achieve in clinical practice. Therefore, the search of new indicators is not over [9, 10] and their knowledge might contribute to develop new methods to evaluate the end of the spinal growth.
The relationship between growth and curve progression still remains a controversial question in idiopathic scoliosis research. Although it is widely accepted that curve progression is driven to a great extent by spinal growth [1, 11], we are not aware of any evidence reporting that angle growth occurs at the same time as height growth. Working on the hypothesis that there is a relationship between height growth and curve progression, it would be reasonable to expect to also find a correlation between height velocity and angular velocity in such a way that when height growth velocity increases, so does curve progression velocity. Arising questions such as if the timing of peak angle velocity could be predictive of curve progression or if the use of PAV could be an indication of success or failure of brace management can not be answered at present.
The purpose of this study was to demonstrate a statistical relationship between height growth and curve progression as well as to determine the time of occurrence of the peak of maximum angle progression in AIS.
Methods
Data on cohort of 132 girls controlled in a rehabilitation clinics from 1990 to 2001 who participated in a retrospective study about growth in AIS previously carried out in our institution were eligible for inclusion. Although the methodology and procedures are all described in detail in our previous report [12], the most interesting points regarding Material and Methods are summarized as follows.
There were 389 children evaluated during this period of time, from which only 132 met the inclusion criteria:
 Girls with AIS
 Curve magnitude of more than 10° as measured by the Cobb method[13]
 Date of menarche well documented
 Minimum of 4 visits to our institution over a at least 2 years around the time of occurrence of menarche
The time interval subject to study was from 2 years before to 5 years after menarche. Height and Cobb angle measurements were performed at 6 (±3) month intervals. Height measurements were recorded by the nursing stuff. Patients to be measured hat to be standing, looking straight ahead and without wearing shoes or brace. Height was recorded in centimeters using a wallmounted ruler with a perpendicular slide. The Cobb angle was measured from Xrays by a single senior clinician who carried out two measurements in order to reduce intraobserver variability [14]. All radiographs were posteroanterior projection with the patient standing and were always taken out of the brace in followup evaluations.

Height growth velocity (height increase divided by the time interval between two consecutive medical controls, expressed in centimetres per year):

Angular velocity (angle increase divided by the time interval between two consecutive medical controls, expressed in angle degrees per year):

Treatment management categorized into three groups: observation, bracing and/or surgical treatment

Progression of the curve, progressive curves being defined as those increasing by at least 5 degrees per year during the followup time
Treatment management was recorded as a variable with 3 categories: observation, bracing with a thoracolumbosacral orthoses (TLSO) and/or surgical treatment. Patients observed over a period of time who later required bracing were first included in the observation group until the time that the brace was prescribed, and then transferred to the orthosis group as of that time. There were 3 girls initially treated with a brace who dropped out of the study when surgical treatment was required.
General characteristics of the sample (n = 132).
Age at time of diagnosis  11.6 (SD 2.47) years 

Menarche age  12.8 (SD 1.18) years 
Curve type:  
Thoracic  25 (18.9%) 
Lumbar  51 (38.6%) 
Thoracolumbar  25 (18.9%) 
Double curves  31 (23.4%) 
Side  
Right  68 (51.5%) 
Left  64 (48.5%) 
Curve length (number of vertebrae)  
4 vertebrae  13 (9.8%) 
5 vertebrae  47 (35.6%) 
6 vertebrae  33 (25.0%) 
7 vertebrae  24 (18.1%) 
8 vertebrae  9 (6.8%) 
913 vertebrae  6 (4.5%) 
Cobb angle (at time of menarche)  20.3 (SD 11.42) 
Type of treatment:  
Observation  88 (66.7%) 
Bracing  44 (33.3%) 
Statistical analysis
Categorical variables are presented as percentage and absolute values. Quantitative variables are presented with their mean and standard deviation. Changes in angle velocity were evaluated in a Linear Mixed Model. The method used was a Restricted Maximum Lilkelihood where angle velocity was the dependent variable. Height growth velocity was included as a predictor, patient number as a random effect and moment as a fixed effect. Statistical analysis was performed by Rsoftware version 2.62 [15]. The level of statistical significance was 0.05 for all hypothesis comparisons.
Results
The mean followup time was 39.6 (SD 17.6) months (range: 1887 months). The mean age at the time of diagnosis was 11.6 (SD 2.5) years and the mean menarchal age was 12.8 (SD 1.9) years. The most frequently observed curves were lumbar (38.6%) with an average length of 6.0 (SD 1.5) vertebrae. Of the 132 participants in the study, 88 (66.7%) girls were managed with observation and only 44 girls (33.3%) were managed with a brace. The general characteristics of the sample are detailed in Table 1.
Distribution of curve patterns and Cobb angles (n = 132)
Observation group  Braced group  p  

(n = 88)  (n = 44)  
Curve type:  
Lumbar  41 (46.6%)  10 (22.7%)  
Thoracic  16 (18.2%)  9 (20.5%)  >0.05 
Thoracolumbar  17 (19.3%)  9 (20.5%)  >0.05 
Double curve  14 (15.9%)  16 (36.4%)  <0.001 
Cobb angle:  
 At time of maximal angle growth (1 year before menarche)  11.8 (SD 3.1)  25.0 (SD 6.21)  <0.001 
 At time of menarche  13.4 (SD 4.46)  24.0 (SD 12.28)  <0.001 
Relationship between angle and height velocities
Braced group  Observation group  

βcoef  p  βcoef  p  
Premenarche period (2 years to menarche)  0.17  0.704  0.14  0.345 
Postmenarche period (menarche to end of follow up)  0.88  0.043  0.12  0.193 
Discussion
This study examines the time of occurrence of peak angular velocity in a group of girls with AIS and looks for correlations between height velocity and angle velocity.
Before attempting any further discussion of these findings, some limitations of the present study should be noted. Many shortcomings appear whenever scoliosis and/or growth are studied [14, 16–20] and they are probably the reason for the shortage of prospective and conclusive studies on this subject. Prospective works are difficult to perform because of the long followup period and this is why most papers in medical literature are transversal studies or retrospective cohort studies. The work by Nachemson et al [14, 20] deserves especial mention as the only prospective work on the effectiveness of bracing in the treatment of AIS.
It is very difficult to form homogeneous samples as growth in girls with the same chronological age is very variable. Little [7] demonstrated that the height pattern is similar among girls with AIS when they are grouped according to PHV. Considering that in many cases, this PHV is unknown, for the purpose of this study girls were grouped using the date of menarche as the reference for comparing patients. Although mean age of diagnosis for this sample was 11.6 years (approximately 1 year before occurrence of menarche (mean 12.8, DE 1.2)), note that diagnosis was made in first evaluation 1 or 2 years after menarche in 50% of girls. Our results, as well as the data presented by Little [7] show that menarche occurs one year after PHV. Therefore, considering that the mean age of diagnosis was 11.6 years, this means that at the beginning of followup, the PHV had already taken place in 50% of cases.
Contrary to what the first observations [21] seemed to indicate, curve progression in idiopathic scoliosis is not linear. It is frequent to observe curves that remain stable for a time and from a point, and then start to progress. On the other hand, it is not unusual to observe short periods of progression in a growth spurt followed by stabilization. When studying angular velocities, a repeated angle increase of 0 was frequently observed, even in girls with progressive curves. This represented a handicap for the use of both parametric and nonparametric statistical tests and specially, those for univariate analysis. This conditioned the fact that, when searching for a correlation, calculations of r and R^{2} were not feasible and the authors had to make an approximation by using absolute values of height and angle instead of the height and angle velocities [10].
The authors would like to mention the inference of the brace in this sample. Although the period after menarche is a phase of growth deceleration, the effect of the brace is, in our opinion, partially responsible for the deceleration velocity after menarche in braced curves. As observed in Figures 1 and 3, there is an important decrease in angular velocities in the perimenarchal period followed by a second growth spurt which occurs during the 612 months after menarche. Even though a period called âge heureux (happy period) consisting of a period of a relative stabilization of the curve, followed by a second growth spurt has been described [22], we think that in the sample, this decreasing velocity was due to the brace effect. It is not unusual to observe important initial reductions with the use of the brace, and in posterior controls, to find that the curve has returned to its initial values. If the second peak of PAV observed in graphs correlates to the cessation of bracing in these patient is another question that deserves further research.
In this study, graphic assessment suggests a relationship between height growth velocity and curve progression velocity, though frequent progression in spurts did not allow a statistical relationship to be found between angle and height velocities. Nevertheless, this problem was partially solved by correlating absolute values of height and angle over a time interval. In our previous work [10], a statistically significant correlation between growth rates was noted up until 2.5 years after menarche, specially in AIS managed by observation (r = 0.632, p < 0.001).
Conclusion
In summary, we conclude that both PHV and PAV occur at the same time (1 year before menarche). Over this time is when most of bracing treatments are prescribed and when the brace is expected to have a maximum effect on angle velocity. Therefore, at 6 months postmenarche, there is an inverse relationship between height and angle velocities in the group of AIS girls with progressive curves managed with a brace. Considering this is a period of height deceleration, this finding indicates there is still a risk of progression in girls with moderatesevere curves despite bracing. The assessment of both height and angle velocity might be useful in clinical practice at the time of assessing brace effectiveness and how long bracing has to be indicated.
Notes
Declarations
Acknowledgements
The authors gratefully acknowledge Joan Vila (Biostatistics from the Institut Municipal d'Investigació Mèdica, Barcelona, Spain) for his expert statistical assistance and Rod V. Bowman for language revisions.
Authors’ Affiliations
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