4 -         The SPoRT Concept of bracing for scoliosis

4.1      Why and when to apply brace treatment

Brace treatment must almost always achieve a very good aesthetic body shaping (Fig. 1). It is intended to achieve radiographic results that are compatible with good functioning of the spine in adulthood, while the quality-of-life impact and psychological disturbance due to the brace must be minimised.^109,111,134

Fig. 1. Brace treatment must almost always achieve a very good aesthetic body shaping. Elisa started her treatment pre-menarchial at Risser 1, with 58 and 59 degrees curve and refusing to be operated on. At the end of treatment she reached a very good aesthetic while reducing the curves. She has already had some experiences in the fashion world.

With respect to scoliotic disease, the goal of brace treatment varies according to the degree of curvature considered, and forces (in terms of strength of brace and hours of usage) are consequently administered.

The extreme cases to be considered are:

-        In mild progressive adolescent scoliosis (up to 30° Cobb) that cannot be controlled through SEAS exercises, the first aim is to avoid progression while allowing the maximum possible freedom in activities of daily life and reducing the discomfort caused by the brace. In such cases, the chosen brace will be less rigid (Sibilla) (Figure 2) and will have to be worn for eighteen to twenty-one hours each day until the end of the progressive period (up to Risser stage 3). The patient will then enter the weaning period;

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Fig. 2. The Sibilla brace.

-        In severe adolescent scoliosis (up to 45°-50°, and over if the patient doesn’t want to be operated on or if surgery is not possible) the aim is at least to avoid progression (and surgery) and possibly also to reduce the amount of curvature, which does not guarantee stability in adulthood. In these cases, a brace is worn all day long for at least one year, and the most rigid one is chosen (Sforzesco brace) (Figure 3). Afterwards, brace wearing is gradually reduced by one or two hours every six months, while maintaining the results, even if the hours are maintained up to 18 per day until Risser stage 3;

Fig. 3. The Sforzesco brace, whose study lead to the development of the SPoRT concept of scoliosis correction.

-        In juvenile and infantile scoliosis over 25°-30°, a brace is proposed for at least eighteen hours per day according to the degree of curvature. We almost always choose the less rigid version (Sibilla) because of the reduced forces necessary to possibly reach a stable curve of 10°-15° (see paragraph 4.4.2.1 and Fig. 49). Then the brace is progressively weaned with the aim of taking it out, possibly before the pubertal growth spurt, when the new history of adolescent scoliosis begins.

In all other cases between these extremes, treatment is tailored according to individual preferences, anthropometric characteristics and other risk factors such as rotation, hump, lumbar curve take-off, unbalance, etc.

Treatment is carried out by wearing the brace full-time until the period of rapid growth is over and we foresee not having to face other pushes of the pathology. This is usually achieved at Risser stage 3. Actually, the applied full-time concept is again tailored between 18 and 23 hours per day, where eighteen is considered a reasonable compromise between efficacy (full-time wearing twenty-one to twenty-three hours per day)^71,184 and acceptability (eighteen hours per day means half a day--e.g. school--without a brace) with the goal of obtaining compliance. Moreover, in this period it is already possible to start a partial weaning, and we think this is a crucial event for the final results. We don’t use night-time bracing^30,51 because our experience has told us that we can achieve at least the same results with SEAS exercises (which are in any case less invasive) while the possibility of controlling a progressive curve is not increased by wearing a brace for such a short time.

To understand the role of the weaning period at whichever age it is applied, and whose goal is to maintain the results previously achieved, we must carefully consider what happens when we take out the brace. According to all current theories, the brace places the spine in the best possible correction and causes it to grow in this position.^{19,77,158,174} Whenever the brace is taken out, correction is progressively loosened, and the daily number of hours without the brace determines the real result achieved in that stage of treatment (which is why we perform x-rays almost every year, only without the brace and after the weaning period). In fact, each time the spine regresses from the maximum correction the vertebrae are again pressed toward deformity. This explains why the maximum correction achieved through bracing is never maintained, but also why weaning the brace for a longer than usual period causes pain. In this way, scoliosis brace treatment can be seen as a concertina therapy (Fig. 4) in which we reach a correction that we allow to loosen to a certain degree in the unavoidable hours without the brace. The weaning period means gradually increasing the hours without the brace while allowing the patient to be able to maintain the achieved correction. This is why we reduce brace wearing by no more than two or three hours every six months, and why stabilizing SEAS exercises are so crucial during this period.

Fig. 4. The concertina effect hypothesis of scoliosis bracing. In these graphs two hypothetical clinical cases are represented: in both cases the out-brace starting point is a 40° curve, with an in-brace reduction to 20° that goes back to 30° as soon as the brace is taken out to reach 33° in one hour without the orthosis. Case 1 is a compliant patient, and he wears again the brace as prescribed after one hour; Case 2 is a not-compliant patient, that wait six hours before wearing the brace. The consequence in the latter is that the correction is loosen so to reach a 37° curve. Final result is that the deformity coming back compresses again the vertebrae and, according to the vicious cycle hypothesis, bones are not allowed to grow better. Result will be the one reported with the line touching the apex of worst correction: 33° for case 1, 37° for case 2.

4.2      Theoretical basis of the SPoRT concept

The SPoRT concept^110-112 was born while we were looking for a new brace, not for a new method of correcting scoliosis. We were searching for a way to avoid casting for our worst patients, because of the significant costs involved both at an individual (side effects including cast syndrome, skin problems, great psychological impact, no shower for months, etc.) and a social (inpatient repeated treatment) level. For that reason, we developed the new Sforzesco brace and, while applying and developing it, we ended up with a new, highly efficacious concept of bracing called SPoRT (Symmetric, Patient-oriented, Rigid, Three-dimensional, active).

From a practical point of view, we started on the basis of the following braces:

-        Risser cast^80,135,144 (Fig. 5): Gives the highest corrections through its localised pushes and rigidity, partly due to the material and partly to the fact that it is a one-piece structure. Most of all, we tried to maintain rigidity, using for the brace only two large pieces and localizing pushes through fully modifiable inserts;

Fig. 5. Risser plaster brace for a thoraco-lumbar scoliosis, with radiographs showing the correction obtained (the radio-opaque push can be clearly seen).

-        Lyon brace¹⁵⁰ (Fig. 6): We used to think of this brace as the most effective one for scoliosis treatment, fully based on a three-point concept, and with localised pushes on humps and curves. We maintained the material of this brace, as well as its vertical aluminium bar;

Fig. 6. The Lyon brace

-        Chêneau brace, modified by Sibilla^144,145 (Fig. 7): The highest value of this brace was in the modelling effect obtained through its symmetrical construction, which accompanies the whole body towards corrections. In the SPoRT concept this brace is maintained as a less rigid alternative to the Sforzesco one, even if modified according to new understanding and insight;

Fig. 7. The Sibilla-Cheneau brace in its last evolution.

-        Milwaukee brace^10,88 (Fig. 8): This brace was not in our minds at the beginning, but we verified that the SPoRT concept reaches correction through an elongation obtained by pushing from behind but not with a traction. This allows us to maintain/restore the physiological curves while correcting scoliosis (3-D action).

Fig. 8. The Milwaukee brace

4.2.1       Bracing and principles of correction

From a theoretical perspective, we started this search with very well established principles of correction that we had developed over the years, such principles being divided in terms of efficacy and acceptability.

The efficacy principles of correction include:

-        The active brace principle: The Milwaukee brace¹⁰ has historically been considered an active brace because it required the patient to escape vertically, while all other braces based on pushes were considered passive. This is theoretically correct, but a passive brace becomes more and more active as the patient is allowed (encouraged) to move freely, thus greatly increasing through his/her movements the corrective pushes against the brace (each time you try to move “incorrectly” you receive a corrective push; moreover, if the brace can serve as a neurological resetter through esteroception and proprioception, this action is greatly increased by movements)¹³⁶. To make a brace active, it is necessary to ensure complete freedom of movement to the limbs, to have a perfect styling by the orthotist, to allow and even drive patients to perform physical activities at school and outside, and to train them through specific exercises in braced condition;¹³⁶

-        Mechanical efficacy: This is achieved through the correct positioning of pushes, as well as through escape ways and proper drivers of the forces and stops, as described in the section on practical application;

-        Versatility and adaptability: A perfect brace can last a maximum of two or three months due to the continuous changes in the growing child, but clearly it is not possible to change a brace with such a rhythm. This means the possibility of adapting its action through inserts in order to refine its mechanical action as continuously as desired. Moreover, pushes must be adapted when checking the brace at first wearing, because the initial project is not always confirmed by the patient’s reaction and some rigid areas can require specific increases of pushes. Finally, in most important curvatures we sometimes need a couple of months before reaching the best possible correction, and many times it is necessary to adapt the brace. We think this precludes an orthosis based only on the external envelope for its action;

-        Teamwork: This is seemingly only a secondary element because only very well trained CPOs, MDs, PTs and other healthcare and education professionals can achieve the best results, which are greatly increased by teamwork and thorough discussions and braces controls working together;

-        Compliance: Bracing is useless without compliance. In turn, compliance is certainly due to the patient and his/her family, but also to all the previous principles and to the following acceptability principles.

The acceptability principles of correction (meaning compliance as well as a human approach to the patient) include:

-        Perfect body design and minimal visibility: Patients want correction and an invisible brace. Therefore, to make the brace visible you must carefully justify it and be sure that it’s really necessary. In our experience, this can be minimised and while checking the brace for the first time. This is our chief concern, so the patient understands that we are on his/her side. Afterwards, we can require everything necessary.

-        Maximal freedom in the ADL (Activities of Daily Life): This is part of the active principle (movements), but it also means comfort. It must be possible to walk, run, sit, carry, wash, exercise and so on, freely or with the smallest degree of limitation possible. Any unavoidable limitation must be explained and motivated to the patient. SPoRT concept braces allow total freedom of movement for the limbs while requiring trunk movements only inside the brace, so as to be corrective;

-        Assumption of responsibility: This way you run risks with adolescents, but it’s possible to achieve much better results. That means, for example, freedom in the strength of closure and/or in taking out the brace through an anterior opening, and so on;

-        Cognitive-behavioural approach by the entire professional team: “Explain and you will obtain (useful behaviours and increased compliance).” This is true in adults, but it’s even truer in adolescents.

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4.2.2       SPoRT brace concept

To achieve all these goals, the Sforzesco brace has been developed through progressive changes and verification, and consequently the Sibilla brace has been modified (and the Risser cast and Lyon braces abandoned) in order to achieve the SPoRT concept of correction. The starting point was rigidity and an almost complete exoskeleton that is totally adherent and symmetrical according to the theoretical shape that the patient’s body would have had without scoliosis. In practice, this is accomplished by reducing the space where there are pathological prominences and allowing room where there are undue depressions. This way, it is the deformity that creates pushes and spaces within this external envelope. The fact that this brace is a complete symmetrical wrap has added another key point since the beginning, which we called humility: there would have been pushes and spaces even if we had not considered this important in theory. In this way, we made ourselves ready to learn from the brace and gradually understood the concept of “drivers,” as is explained in the practical section. Afterwards, pushes are inserted. These are considered in a fully three-dimensional manner. Because three-dimensionality is too complex to be easily understood,^116,155 we split the different 3-D actions. However, since the beginning we have been very careful about each plan and curve, and in regard to total spinal morphology without conflict. Finally, we discovered we had something new, and summarised it in the SPoRT acronym, whose meaning is:

-        Symmetric: On the outside the brace is almost perfectly symmetrical, according to the starting hypothesis we have just explained. This was a good beginning, but it was gradually overcome as we furthered our understanding of the brace action. Nowadays, the external construction is not so symmetrical, even if it is grossly maintained to reduce visibility and preserve as much as possible a theoretically perfect body shape.

-        Patient-oriented: This brace is not visible, according to the acceptability principle. What patients care most about is having a brace that will be seen as little as possible, not to have less material on. This is why they would always choose a TLSO instead of a Milwaukee brace,²⁷ even if the first one causes the patient to feel hot during the summer. The Sforzesco brace has its own design (Fig. 9), which makes it somewhat fashionable, and this is how patients feel their braces. This is the most important achievement that allows us to increase acceptability, followed by compliance and efficacy;

-        Rigid: The chosen material and the fact that the brace is made in two large pieces strongly connected with aluminium allow us to achieve a high rigidity that gives rise to higher pushes than in other braces;

-        Three-dimensional: The brace has a three-dimensional action on the spine, and all its features have been developed with this purpose in mind, starting from its symmetrical and sagittal physiological external appearance. This is discussed extensively in the section on practical application.

Fig. 9. The Sforzesco brace has its own design, generally appreciated by patients, in particular if they already used another brace.

-        Active: This is also a property of the brace, in the sense that the Sforzesco allows total freedom of movement for all four limbs, as well as the complete possibility of normal behavior in activities of daily life, obviously with the exclusion of trunk flexion, bending and rotation (at least from the external point of view: inside the trunk moves only towards correction, while movements towards the progression of pathology are completely blocked).

4.3      Practical application of SPoRT concept

The SPoRT concept always requires a customised construction of the brace according to the patient’s individual requirements. In the opinion of Sibilla,^144,145 bracing is a meal served according to a “menu à la carte” in which one chooses all the elements needed to achieve the best individual result. It’s possible to apply CAD-CAM technologies, which usually allow us to obtain the best results in this case, but without using pre-built forms stored in databases, as is usually done. Orthotists must directly shape the scanned trunk according to the patient’s requirements, and the physician can check this first draft before final carving. Once done, a final test must be made on the patient so as to change the first theoretical project and adapt it in the best possible way, depending on the real interaction between the body and the brace. This check is made using eyes and hands because one single change is usually not enough, and because it isn’t possible to perform repeated radiographs to verify what has been done.

4.3.1       Elements of SpoRT braces

The brace is developed in consideration of the following key points:

-        Foundation: Like a building, at the base of the brace we need a fix point, which is the pelvis. On one hand, this is a theoretical concept because the pelvis is not a fixed point. On the other hand, proximally applied pushes will always produce counter-pushes on the pelvis, and provided that the brace does not rotate in any 3-D direction on the pelvis, pushes will be correctly applied. If the brace decompensates (i.e., it rotates or it flexes in an antero-posterior or lateral direction), this can be corrected by pushing on the pelvis or by changing pushes on the spine so as to regain a balanced action;

-        Construction: The brace must be carefully constructed on the sagittal plane, because once built it will not be possible to truly and effectively change this configuration;

-        Pushes: The brace is a somewhat rough instrument. We try to refine it as much as possible, but current research does not allow us to be as precise as we would like. Usually, we develop a project of correction and then check and change it on the patient. These thoughts and our experience have led us to believe that pushes are not points as conceived by others but are areas developed according to curvature characteristics;

-        Escapes: These are crucial, and are conceived according to curvature characteristics and desired correction. Therefore, they must be considered three-dimensionally. Braces built according to the SPoRT concept seemingly lack escapes because they finish with drivers so as to allow the most important one -- vertical escape;

-        Drivers: These are the areas that control and drive pushes and escapes to obtain the real 3-D action so as to avoid wrong deviations with respect to the desired correction, as well as over-pushes or over-escapes;

-        Stops: These are commonly referred to as counter-pushes.

The construction (sagittal shaping) of the brace almost always changes according to the curve, even if there are individual variations:

-        Lumbar scoliosis: The construction must be in lordosis, and with this objective we need an antiversion of the pelvis with a retro-positioning of the upper trunk over the apex of lordosis, while the abdomen must also be allowed to escape anteriorly;

-        Thoraco-lumbar scoliosis: This must usually be in lordosis, which is due to the tendency of this curve to evolve in junctional kyphosis. In this case, the apex of lordosis must coincide with T12-L1;

-        Thoracic scoliosis: This must be almost always in kyphosis, which is achieved through the previously described good construction in lordosis and through an important retro-positioning of the higher trunk so as to use the force of gravity to induce the spine to posteriorly “sit” in the given space while superiorly shaping the brace in an anterior direction.

4.3.2       Correction of a thoracic scoliosis

Because general brace action according to the SPoRT concept is too complex to be adequately described in these few pages, we will now give a complete example of the means to correct a thoracic scoliosis. The figures have been obtained from an actual case, so they do not always totally coincide with the theoretical description. However, as already stated, theory is always and continuously changed according to individual needs and reactions to the brace.

Terminology is defined according to a posterior-anterior radiograph. Accordingly, convexity and concavity refer to the considered scoliosis curve, not to trunk protuberances. This means that the convex side posteriorly coincides with posterior rib hump and anteriorly with rib depression, while the concave side coincides with anterior rib hump and posterior depression.

4.3.2.1        Action of deflection

The mechanisms needed to achieve deflection (Figg. 10 and 11) action are:

-        Lateral distal convex push (a): This is obtained through brace modelling and a direct pad; to reach the spine using the ribs it is necessary to have posterior (1) and anterior (2) convex drivers, while the counter-push is given by the lumbar lateral stop (3). This push drives the spine to the anterior-superior escape (A) through the concave lateral driver (4), which does not allow a direct lateral shift;

Fig. 10. Action of deflection according to SPoRT concept for thoracic scoliosis in the posterior-anterior and radiographic views. Pushes (lower-case letters), escapes (upper-case letters), drivers (numbers) and stops (numbers) are explained in the text. Black letters refer to pushes, drivers and stops on the surface considered, while white letters to controlateral surfaces: e.g. in the lateral view of the brace of next figure the push "a" and the stop "7" are on the right side of the brace (controlateral surface), while all the others are on the left side of it (surface represented).

-        Lateral proximal concave push (b): This is obtained by maintaining the brace high under the axilla through brace modelling and a direct pad. Again, to avoid rib flexion and apply the push to the spine we need the posterior (5) and anterior (6) superior concave drivers as well as the counter-push of the thoracic lateral stop (7). The spine is driven to the anterior-superior escape (A) and also to the convex-superior escape (B);

Fig. 11. Action of deflection according to SPoRT concept for thoracic scoliosis in the anterior-posterior and lateral views.

-        Posterior convex push (c): The main action of this push is derotation, but it also becomes deflexion due to the thoracic lateral stop (7), which allows a straightening (flattening) of the ribs with no lateral space but only medial space; and the anterior superior (6) and inferior (8) concave drivers, which avoid an anterior escape. Again, in terms of deflection the spine is driven to the anterior-superior escape (A) through the concave lateral driver (4), which does not allow a direct lateral shift.

4.3.2.2       Action of derotation

The mechanisms needed to achieve derotation action are:

-        Posterior convex push (a): This works through the thoracic lateral stop (1) and the posterior (5) and anterior (6) superior concave drivers, which really represent stops so as to avoid an anterior uncontrolled buckling of the spine (Fig. 12);

Fig. 12. Action of derotation according to SPoRT concept for thoracic scoliosis in the anterior-posterior and lateral views.

-        Anterior-inferior concave push (b): It joins the posterior convex push in a couple of forces posteriorly transmitted through the concave lateral driver (4). The lumbar posterior stop (5) avoids a posterior buckle of the spine;

-        Posterior concave escape (A): This is the only escape for this correction, even if it does not allow over-derotation due to the posterior concave driver (4) that, once reached, transforms the forces towards the anterior-superior escape considered in the deflexion action (Fig. 13);

Fig. 13. Action of derotation according to SPoRT concept for thoracic scoliosis in the posterior-anterior and radiographic views.

-        Superior concave push (c): The combined actions of previously reported forces almost always cause a contra-rotation of the upper girdle towards concavity, which must be controlled through this push (whose action is mainly towards kyphotisation) whenever necessary.

4.3.2.3       Action of kyphotisation

This is mainly realised through brace construction, but it is also achieved through other mechanisms as follows:

-        Anterior-inferior bilateral pushes (a): They posteriorly decompensate the upper trunk, creating a lordosis through the lumbar posterior bilateral stops (1) but also facilitating the formation of kyphosis (Fig. 14);

Fig. 14. Action of kyphotisation according to SPoRT concept for thoracic scoliosis in the anterior-posterior and lateral views.

-        Superior bilateral push (c): Once posteriorly unbalanced, the spine must be superiorly flexed to create kyphosis. The combined actions of previously reported forces almost always cause a contra-rotation of the upper girdle towards concavity, which must be controlled through this push (whose action is anyway mainly towards kyphotisation) whenever necessary (Fig. 15);

-        Posterior convex push (c): Again, the main action of this push is derotation, but it also becomes kyphotisation when it is allowed an adequate paravertebral escape to the medial side of the hump, together with the thoracic lateral drivers (2) that allow a straightening (flattening) of the ribs with no lateral space but only medial space; and the anterior superior (6) and inferior (8) concave drivers, which avoid an anterior escape. Again, in terms of deflection the spine is driven to the anterior-superior escape (A) through the concave lateral driver (4), which does not allow a direct lateral shift.

Fig. 15. Action of kyphotisation according to SPoRT concept for thoracic scoliosis in the posterior-anterior and radiographic views.

4.3.3       Correction of a thoracolumbar scoliosis

The pushes are:

-        Posterior convex, with derotation and lordosis actions;

-        Lateral distal convex, with deflection action;

-        Lateral proximal concave, with deflection action;

-        Anterior bilateral, with lordosis action.

The escapes include:

-        Vertical, with deflection action;

-        Posterior concave, with derotation action.

The drivers are:

-        Lateral median-proximal convex;

-        Lateral median-distal concave;

-        Anterior submammary convex;

-        Anterior bilateral;

-        Posterior proximal concave;

-        Posterior distal convex;

-        Posterior convex (escape).

4.3.4       Correction of a lumbar scoliosis

The pushes are:

-        Posterior paravertebral convex, with derotation and lordosis actions;

-        Lateral over-iliac convex, with deflection action;

-        Lateral proximal concave, with deflection action;

-        Anterior proximal bilateral, with lordosis action.

The escapes include:

-        Superior-posterior, with deflection and lordosis actions;

-        Posterior concave, with derotation action;

-        Lateral convex, with deflection action.

The drivers are:

-        Lateral over-iliac concave;

-        Anterior bilateral;

-        Posterior concave (escape).

4.3.5       Correction of a high thoracic scoliosis

The pushes are:

-        Posterior convex, with derotation and kyphosis actions;

-        Lateral distal convex, with deflection action;

-        Lateral proximal concave on C6-7 through a rigid hemi-collar;

-        Anterior concave or convex, as needed.

4.4      Results

4.4.1       Scientific results

The results that are today available on the SPoRT concept relate to the Sforzesco brace and necessarily are short-term, because the first treated patients are now reaching the third-year follow-up examination and haven’t yet completed their treatments. At an anecdotal level (not confirmed by formal studies), we can already state that results are at least maintained over time, according to what is reported below on the basis of preliminary results.

4.4.1.1         The Sforzesco brace is more effective than the Lyon brace after six months of treatment

We conducted a prospective cohort study^110,112 (Sforzesco brace, SPoRT correction concept) with a matched retrospective control group (Lyon brace, three-point correction concept) on thirty patients aged thirteen years and with curves of 38 ° Cobb. It was a study on the “best available practice,” because the proposed brace was considered the best at the moment of treatment execution. The Sforzesco brace obtained higher mean radiographic improvements (-10° Cobb vs. -5°), as well as a better cosmetic appearance of the flanks and shoulders, without the negative impact on kyphosis determined by the Lyon brace. In terms of Cobb degrees, in the Sforzesco group 80% of patients improved and none worsened, while the Lyon group had respective results of 53% and 13%. We did not notice a difference in regard to humps (Fig. 16).

Fig. 16. The number of improved patient in terms of Cobb angle is significantly higher in the Sforzesco group than in the Lyon one^110,112

4.4.1.2        Sforzesco brace equally effective as Risser plaster brace

Currently, the Risser plaster brace is also proposed by the Scoliosis Research Society (SRS) as the most effective tool for the conservative treatment of adolescent idiopathic scoliosis. We conducted a prospective cohort study¹²⁴ with a retrospective control group on forty-one patients aged four years and with curves of 40° Cobb . E. Eighteen were treated with the Risser plaster brace and thirty-three with the Sforzesco brace.

Fig. 17. The mean reduction of Cobb angle is higher in the Sforzesco group than in the Risser plaster brace one, even if not statistically significant, while the opposite happens for sagittal plane curves¹²⁴

It was a study on the “best available practice,” because until 2002 plaster had been our standard treatment for the largest curves, while since the midpoint of 2004 we have systematically used the Sforzesco brace.

The verification was scheduled at eighteen months, when the corrective phase of the treatment has finished (twelve months) and the first follow-up examination is available with complete clinical and radiographic data. The Sforzesco was shown to be more effective at reducing the thoracic curve, and its results were superimposable for the other regions. The Risser plaster brace was shown to be more effective on the thoracic hump and in regard to the cosmetic appearance of the flanks, but it also caused a serious kyphosis reduction. Considering the decrease of personal (quality of life) and social costs (outpatient treatment for brace, while plasters always require some kind of hospitalisation, at least in day-hospital), today we have a plastic brace that can take the place of the Risser plaster brace (Fig. 17).

4.4.2       Clinical results

We are perfectly aware that clinical cases are not comparable to scientific data, but they anyway have the benefit of the real life.

4.4.2.1        Maria C., juvenile idiopathic scoliosis

Maria (Fig. 18) has a juvenile idiopathic scoliosis discovered at the age of 5, with double curve of 26° and 42° (Fig. 18 A). She has been treated with a full time Chêneau brace 23 hours per day accompanied by SEAS exercises, with a first results without brace reported in Fig. 18 B. Gradually the brace was reduced (Fig. 18 C,D,E) until complete weaning at the age of 10, while she was still pre-menarchial, no signs of puberty. She continued with SEAS exercises alone to prevent progression until end of growth; she never required to be braced again, even if she had during puberty some progression (Fig. 18 F, G, H, I, J, K), controlled through SEAS exercises. Maria’s final aesthetic appearance is shown in Fig. 18 L. Today she is at three years follow-up, radiographically and clinically stable.

Fig. 18. Case history of Maria. In each radiograph month and year are represented, as well as Cobb degrees, Risser (R) stage and years (y). Bracing time is shown: 23/24 means 23 hours per day; PE: Physical Exercises treatment.

4.4.2.2       Simone S.: adolescent idiopathic scoliosis

Simone (Fig. 19) has a high degree adolescent idiopathic scoliosis, discovered at the age of 13.5, with a single thoracolumbar curve of 56° (Fig. 19 A); his aesthetic appearance is shown in Fig. 19 E. He (and his family) did not want to be operated on, and decided to try with bracing: he was then treated with a full time Sforzesco brace 23 hours per day, with first results without brace reported in Fig. 19 B. Gradually the brace has been reduced, with stable results in x-rays performed without the brace the same hours of weaning he had each day (Fig. 19 C,D), according to the “concertina effect” theory (Fig. 4). Today he is still wearing the brace 18 hours per day and his Risser stage is 4. Simone’s today aesthetic appearance is shown in Fig. 19 F.

Fig. 19. Case history of Simone. In each radiograph month and year are represented, as well as Cobb degrees. Bracing time is shown: 23/24 means 23 hours per day.