6 -         The rehabilitation ISICO approach to spinal deformities

ISICO was founded only recently, but since the beginning it has been planned to offer the best clinical answer to patients using the best possible tools, both clinical and organisational (Cap. 1 - Table 1). This gives rise to a new approach that fuses medical tradition with modern technologies both soft and hard, always from the clear perspective of Evidence-Based Medicine, as well as on the basis of research where we have no data on our traditional methods.

6.1      Complete multiprofessional evaluations on a scientific basis to treat and rehabilitate

A treatment without a careful evaluation should not be possible. Nevertheless, in the past this has been applied in rehabilitation, because of a lack of instruments needed to perform this careful evaluation. Today, this is no longer completely true in the field of scoliosis ¹⁰⁶. We have developed a complete and thorough clinical evaluation of scoliosis patients both for physicians and physiotherapists. This evaluation focuses on diagnosis and orthopaedic and rehabilitation treatment follow-up, and exercise planning and evaluation, respectively. We look at impairments along with disability and quality of life. In cases where clinical tools have not been previously validated, we have conducted specific research in order to identify their advantages and limits, as well as their normal parameters ^{56,92,115,193-195}. Moreover, we are very interested in new technologies that are useful in daily practice as a means to better understand the aspects of this pathology that aren’t yet fully understood, such as three-dimensionality ^98,99,116, body reactions to bracing¹³⁶, movement behaviour of scoliosis patients ^137-139 and so on.

Today, standard clinical measurements performed by every ISICO physician include the following for all patients at every examination (or radiographic exam):

-        Bunnell degrees and hump height56

-        Distances from the plumb line^82,195

-        Aesthetic Index¹⁹⁴ evolved into the TRACE (Trunk Aesthetic Clinical Evaluation)¹⁹³ measurement

-        ASIS, PSIS and iliac crest height

-        Anthropometric parameters

-        SRS-22⁹²

-        Cobb degrees

-        Raimondi degrees for rotation¹⁷¹

-        Lumbar take-off

-        Risser sign

-        Height differences between femoral heads

It is also possible, when necessary, to include measurements such as the Roland-Morris disability scale for pain or the EuroQol for quality of life. Moreover, at every examination some non-numerical evaluations are systematically performed: spine range of motion, rigidity of scoliosis curves and kyphosis, Romberg and Unterberger (Fukuda)^138,139 tests, strength and elasticity of the major muscle groups, and spine palpation.

Today, starting with the standard clinical measurements performed by physicians, each ISICO physiotherapist takes the following measurements in every patient at least twice a year (more often, if necessary):¹³⁷

-        Bunnell degrees;

-        Distances from the plumb line;

-        Anthropometric parameters;

-        Trunk range of motion in all directions and planes;

-        Range of motion in flexion of thoracic kyphosis;

-        Endurance of trunk extensors, abdominals;

-        Stretching of ileo-psoas, quadriceps and pectorals;

-        Neuromotorial measurements^138,139: Unterberger (Fukuda), Romberg (monopodalic, sensibilised), pendulum, oculo-manual control.

It is also possible, when needed, to include other measurements such as the Roland-Morris disability scale for pain or the EuroQol for quality of life. Moreover, at every examination some non-numerical evaluations are systematically performed, such as quality of Active Self-Correction and the districts involved in the limitation of trunk flexion.

We are working diligently through systematic research, from the physician and physios standpoints, to develop new evaluation tools and/or to refine existing ones.

6.2      Outpatient rehabilitation and consultation: how to reduce personal and social costs and achieve competence in the patient’s home

One of the main problems of the field is the fact that scoliosis patients who could benefit from treatment account for roughly 2%-3% of the interested population, and together with the high competencies required to effectively treat them, this causes a dramatic drop in treatment quality for patients who have not the good fortune to live near a centre dedicated to the conservative treatment and rehabilitation of scoliosis. To improve this situation, there are two ways:

-        Inpatient treatment one or two times a year, with high personal and social costs and the possible lack of compliance at home;

-        A new model allowing local people to apply the same high-quality treatments as are available in super-specialised centres.

We chose the latter model, and today the protocols prepared and applied by ISICO are exclusively of an outpatient nature. Protocols are characterised, in addition to content updates according to the latest developments in the international scientific community, by an innovative layout that allows us to apply them even in people who come from very far away. Today, each year the Milan and Vigevano Centres only are reached by more than 2.000 patients coming from every region of Italy (and even from elsewhere in Europe). The Centres require a low attendance on the premises (from a minimum of two to a maximum of five), lasting 90 minutes each to give patients all the materials and competencies to be locally treated by their physios. Each patient receives his/her own personalised treatment program, his/her own scheme and his/her own DVD with exercises. This way, people perform exercises at home or in a private or a national health service outpatient facility near home, doing so in the best possible way, according to the highest competencies made possible by a super-specialised centre.

The healthcare field has for some years had a tendency to invest a lot on domiciliary care in order to optimise the costs and the use of healthcare structures: ISICO is not only following this path but goes beyond, favouring the auto-administration of domiciliary care without the absolute need for intervention by an external operator (though it is generally recommended for compliance reasons). This intervention modality offers the following benefits:

-        For the patient: a reduced presence at the centres (less travel), with the implementation of therapy at home in the most appropriate ways and moments, according to family choice and preferences (and costs); there is a joint responsibility for therapy management of both the patient and the family; they can become autonomous and be free from “dependence” on the rehabilitator, which is often observed in cases of chronic pathology;

-        For the therapeutic structure: a strong commitment in every single treatment, which must be adequately prepared and guaranteed by a trained staff operating as a team in order to provide the patient with every necessary competence.

Protocols that are organised in this way are coherent with ISICO's fundamental principles, particularly the following:

-        Efficiency: With the same efficacy, efficient protocols, i.e., the less demanding ones in terms of time and cost;

-        Acceptability: Protocols adaptable to the needs and preferences of the patient, who is not the object but the subject of treatments;

-        Teamwork: All operators take part in the patient’s treatment, working in close collaboration.

We are also working hard on the brace construction side to develop the means to prevent patients from having to travel around the country in order to reach the best orthotists, and the actual technical developments should allow us to reach the correct answers in a few months.

6.3      Cognitive-behavioural approach and counselling: compliance and acceptability through humanisation

Chronic pathology tends to cause a change in behaviour and relationships with the outer world¹⁶⁵. Scoliosis can fall within the group of chronic pathologies because of the long time period required for its therapy, and due to the fact that treatment outcome will not be a complete patient recovery but the best possible control of the deviation⁴. The correct management of this disease is not always easy, because it usually appears in a frail period of life, i.e., the stage of pubertal growth spurt. When treatment includes a brace as well, the young patient’s reaction is rarely good.^25,81 The brace causes a sudden shock and modifies the adolescent’s human relationships during a period of dramatic physical change, when he/she is grappling with the acceptation of his/her rapidly changing body, this being the period involving the development of his/her personality and in which the young person is concentrated on weaving the first complex plot of relationships with the other sex. For the parents, it is also a difficult situation. Their natural ambition is to seek the utmost happiness for their children, but they are forced to struggle with the difficult problem of whether to ask the person they love most to make a big sacrifice that is necessary for the child’s health, or to try and find a different path with a doubtful efficacy that could be dangerous and create even bigger problems.

In the treatment of chronic pain, the importance of formulating the treatment on the basis of a far less mechanistic nature than before is shared internationally¹²⁷. Chronic back pain is described as a bio-psycho-social problem, i.e., a disorder that has a biologic origin, causes psychological implications of non-acceptance, growing fear and distrust towards problem resolution, until it finally results in depressive behaviours that eventually have repercussions even on relationship dynamics with the outer world. Thanks to this new awareness, we consider every facet of a condition that is much more complex than what we used to think.¹⁶⁸ This has suggested the use of integrated treatment techniques that draw on the experience of other medical disciplines as well. It is the case of cognitive-behavioural approach that originated from experiences developed in psychology field halfway through the past century.^18,48 The transposition of a cognitive-behavioural approach to scoliosis treatment is aimed at simplifying treatment acceptance, reassurance, looking for a solution to practical problems and stimulating faith towards the outcome.²²

The essential condition for an effective development of treatment is the definition of the clear and effective two-way communication necessary to win the trust of the patient¹⁶⁷ and family alike. This allows us to:

-        Carefully listen to doubts and explanation requests;

-        Let the patient/family feel that we understand his/her/their distress;

-        Solve practical problems that might arise.

For the practical application of these principles, treatment protocols used at ISICO include a family counselling meeting to be held at the end of each session. This meeting sees the participation of the patient, his/her family, the ISICO rehabilitator who has taught the new exercise plan and, if present, the therapist who in practice follows the patient each time he/she does exercises. It is a moment of utmost importance to reach the described objectives, to regularly consolidate the “therapeutic contract” agreed upon with the patient and his/her family, and to cement the “extended” therapeutic team. It is an indispensable element for an optimal attainment of the final outcome.

6.4      The strength of a multidisciplinary rehabilitation team approach

We strongly believe in the importance of the team in rehabilitation. Our entire organisation and overall clinical work are strongly based on multidisciplinary patterns of rehabilitation. The “team approach” means that everyone speaks the same language, even if with different professional perspectives, thus making treatment a continuous path for the patient and family, without interruption. Moreover, in the team we include the patient and his/her parents. Our approach is focused on involving the entire family in the team. We believe that no treatment is possible without the participation of all needed actors, and the entire approach to therapy has been conceived around this idea.

6.5      High-tech to help clinicians, improve quality, perform research and implement innovation

The wide use of technology, which has characterised ISICO’s organisation from the beginning, brings remarkable advantages in terms of clinical activity support and simplification of managerial processes.

In the first place, from the clinical point of view:

-        The entire team uses dedicated software for medical and rehabilitation evaluations and treatments. The software creates a digital medical record, is able to communicate with a single central database via the Internet, and allows us to overcome distances in time and space that often separate the physician’s and rehabilitator’s interventions;

-        The adoption of common standardised protocols for clinical data gathering allows us to perform research and quantitative evaluations of treatments outcomes in order to begin the process of constant improvement and benchmarking among the different structures;

-        The digital medical record, by accompanying the patient throughout the therapeutic process, provides a constant verification of compliance with defined protocols while permitting the room necessary for therapeutic process customisation, doing so by supporting all operators in the correct application of the shared diagnostic-therapeutic paths;

-        All this allows a strong centralisation of the technical decisional process for the planning of single rehabilitative and treatment protocols, whose production constantly remains under the control of the central technical management;

-        Data regarding research projects is available in real time, with an immediate transfer of outcomes to daily clinical practice.

From the organisational point of view, technology allows a high centralisation of every managerial process, realizing principles that today are often invoked but rarely accomplished in practice:

-        The application of Quality Management principles to clinical-rehabilitative activity, with a constant monitoring of fundamental process indicators;

-        The realisation of excellence networks, thanks not only to the establishment of a multicentric model but also to its progressive expansion to other field operators already present in the territory and who can fit into the pre-arranged informative-technological structure;

-        The concrete application of Knowledge Management principles: The adopted methodology and technology provide a common base of information recording and management on which to insert every improvement proposed by internal research and international scientific knowledge, doing so by defining a qualitative standard with continuous growth characteristics.