Volume 11 Supplement 2
Bracing for Adolescent Idiopathic Scoliosis (AIS) and Scheuermann Kyphosis: the issue of overtreatment in Greece
© The Author(s). 2016
Published: 14 October 2016
Most recent publications have provided evidence for brace treatment in spinal deformities. The purpose of this study was to evaluate the rate of overtreatment for AIS and Kyphosis in Greece, according to the Society on Scoliosis Orthopedic Rehabilitation Treatment (SOSORT) and the Scoliosis Research Society (SRS) guidelines for brace treatment. To date, this is the first study to investigate overtreatment percentage in a group of patients with spinal deformities.
Cross-sectional study design and data analysis were performed in a group of patients that received treatment in a private clinic, in 2014. Of 289 patients treated with a brace, 167 young adolescents (126 females - 41 males, mean age 15, 7 years) were eligible for inclusion criteria (age 9–18 years, brace wearing). Overtreatment was defined as the unnecessary use of brace according to the international indications for brace treatment. Overtreatment was assessed by a BSPTS - Schroth certified physiotherapist. The brace prescription was made by 34 medical doctors from different geographical areas of Greece.
The data analysis revealed that 71 out of 167 subjects (42,5 %) had received some kind of overtreatment. A further analysis showed that in the AIS subgroup, 20 subjects (16,9 %) had Cobb angles < 20°, 7 subjects (5,9 %) had Cobb angles 20 – 25° but good prognosis, 12 subjects (10,2 %) started bracing after Risser 4, and 12 subjects (10,2 %) had delayed brace weaning. It is noticeable that 8 subjects (6,8 %) were at Risser 5 with Cobb angle < 20° and were prescribed a brace. In the Kyphosis subgroup, 11 subjects (22,5 %) showed no signs of Scheuermann’s disease, 3 subjects (6,1 %) started bracing after Risser 4 or 5, and 6 subjects (12,2 %) had delayed brace weaning.
An extremely high rate of overtreatment (42, 5 %) was identified in a random group of adolescents treated with a brace for AIS and Kyphosis. Overtreating a child with a brace can cause social, financial and psychological problems. The present study pinpoints the need for an evidence-based approach to conservative treatment of idiopathic scoliosis and kyphosis. Overtreatment can be avoided when the indications are strictly based on the guidelines published internationally.
SRS and SOSORT guidelines for bracing
SRS guidelines for bracing
• AIS: Cobb angle > 25° (25 – 45°), Risser sign 0-3
• Scheuermann Kyphosis: Cobb angle 55 – 80°, Risser sign 0-3, Scheuermann findings on x-ray (vertebra wedging, Schmorl nodes)
• Brace weaning: At Risser sign 4, approximately 2 years after menarche for girls
SOSORT guidelines for bracing
I. No signs of maturity: Cobb angle >25°
II. Risser sign 0-3: Cobb angle > 30°, Cobb angle 20 – 29° and progression risk over 60 % (Lonstein formula)
III. Risser sign 4: Cobb angle > 35°
A recent multicentered Randomised Controlled Trial (RCT) in United States confirmed the efficacy of brace treatment for AIS , while another RCT in Italy confirmed the efficacy of the PSSE to halt the progression in mild scoliosis . Only a few studies have commented on the existence of the overtreatment of AIS and pinpointed the importance to follow the international guidelines of the SRS and SOSORT [2, 6, 7].
However, to date, there is no study to estimate the exact percentage of overtreatment with bracing in a population with AIS and Scheuermann kyphosis. The aim of this study is to investigate the overtreatment rate of bracing for spinal deformities in Greece, according to the SRS and SOSORT published guidelines.
Cross-sectional study design and data analysis were performed in a random group of patients that received treatment in a private clinic for conservative treatment of spinal deformities, in Athens during the year 2014. A total of 289 people were treated in the clinic, but only those who were eligible for the inclusion criteria of the study were analyzed. The inclusion criteria were age 9–18 years old and brace prescription for AIS or Scheuermann kyphosis.
Simple chi square test results
Marginal row totals
67 (67.83) [0.01]
29 (28.17) [0.02]
51 (50.17) [0.01]
20 (20.83) [0.03]
Marginal Total Columns
167 (Grand Total)
Results for AIS
Results for scheuermann kyphosis
Incidence of progression of untreated adolescent idiopathic scoliosis with the cross-correlation of curve magnitude and Risser sign
Using the Cobb angle
20 – 29°
Another significant factor might be the still unknown role of the PSSE in the treatment of mild scoliosis. After the recent RCT of Monticone et al. (2014) , there is strong evidence that in many cases the PSSE can halt the progression of mild scoliosis (Cobb < 25°), so the PSSE can prevent the overuse of brace for this population. Other possible explanations could be the delayed diagnosis due to the poor school screening and potentially some unspecified non-scientific reasons.
A limitation of the present study could be considered the fact that the assessment was made by only one therapist, which means low inter-reliability. However, the results of the study can be generalized, because the brace prescription was made by 34 MDs from different geographical areas all over Greece.
Optimal treatment for AIS
This study highlights the imperative need for an evidence-based approach to conservative treatment of idiopathic scoliosis and Scheuermann kyphosis. The undesired effects of overtreatment can be avoided when the indications for brace treatment are strictly based on the international guidelines. Moreover, the implementation of the PSSE for mild scoliosis could decrease even more the overtreatment rate. Future research in other countries could be useful for comparability of the results.
Adolescent Idiopathic Scoliosis
Barcelona Scoliosis Physical Therapy School
Angle trunk rotation
Physiotherapeutic Scoliosis Specific Exercises
Randomised Controlled Trial
Society On Scoliosis Orthopedic Rehabilitation Treatment
Scoliosis Research Society
I would like to thank my instructors in BSPTS-Schroth method, Dr Manuel Rigo and Beth Janssen, especially Beth for correcting my English, and the SOSORT board for giving me the chance to present my research in the SOSORT meeting in Katowice.
This article has been published as part of Scoliosis and Spinal Disorders Volume 11 Supplement 2, 2016. Research into Conservative Management of Spinal Deformities: Short Articles from the SOSORT 2015 Meeting. The full contents of the supplement are available online http://scoliosisjournal.biomedcentral.com/articles/supplements/volume-11-supplement-2.
Availability of data and materials
All data and materials that were used in the results for this study are already present in this paper. There is no restriction for their distribution and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source.
NK carried out the data collection, the variables assessment and the interpretation of the results.
The author declares that he has no competing interests.
Consent for publication
Written consent was obtained from the parents of the patients for publication of the figures.
Ethics approval and consent to participate
The methods used for the present research were in compliance with the Helsinki Declaration.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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