I. SRS and SOSORT guidelines for treating AIS and Scheuermann kyphosis with braces based on Cobb angle and Risser sign. II. A cross-sectional study of 167 patients treated with braces for AIS or kyphosis found an overtreatment rate of 42.5%, with 43.2% of AIS patients and 40.8% of kyphosis patients overtreated. III. Possible reasons for high overtreatment rates include ignorance of treatment guidelines, overreliance on bracing without exercise, and lack of physician education in treating spinal deformities. Overtreatment can cause psychological, social, and financial problems for children.

1. NIKOS KARAVIDAS
PT, MSc
Certified Schroth Therapist (BSPTS)
Certified SEAS Therapist
McKenzie Therapist

2. SRS – SOSORT guidelines
 SRS guidelines for AIS treatment with brace:
Cobb angle >25ο (25ο – 45ο), Risser sign 0-3
 SRS guidelines for Scheuermann kyphosis with
brace:
Cobb angle 55ο-80ο , Risser sign 0-3, Scheuermann
findings on x-ray (vertebra wedging, Schmorl nodes)
 SRS guidelines for brace weaning:
Brace weaning at Risser 4, approximately 2 years after
menarche in girls
 SOSORT guidelines for AIS treatment with brace:
I. No signs of maturity: Cobb angle >25ο
II. Risser 0-3 : Cobb angle >30ο , Cobb angle 20ο -29ο
and Progression risk over 60% (Lonstein formula)
III. Risser 4 : Cobb angle > 35ο
[SOSORT guidelines 2006 by Weiss et al]

3. Overtreatment
 Health care provided with a higher volume or cost
than the appropriate
 The unnecessary use of brace to treat AIS and
Scheuermann Kyphosis
 Subjects that should have never started wearing a
brace or subjects that should have finished their
therapy earlier
 Overtreatment estimation by measuring Cobb
angle, Risser sign, menarche, Scheuermann
vertebra wedging
 Further analysis according to risk prognostic
factors: ATR, Kyphotic angle, family history, curve
type

4. Methods
 Cross-sectional study
 From 289 patients totally treated in a
private clinic in 2014, 167 subjects fulfilled
the inclusion criteria
 Inclusion criteria:
- Age 9-18 years
- Brace prescription for AIS and Scheuermann kyphosis
 126 females – 41 males, mean age 15,7
years
 118 AIS patients, 49 Kyphosis patients
 Brace was prescribed by 34 MDs from
different geographical areas of Greece

5. Results
TOTAL
OVERTREAT
MENT
GOOD
TREATMENT
71/167
(42,5%)96/167
(57,5%)
AIS
OVERTRE
ATMENT
GOOD
TREATME
NT
51/118
(43,2%)
67/118
(56,8%)
KYPHOSIS
OVERTRE
ATMENT
GOOD
TREATME
NT
20/49
(40,8%)29/49
(59,2%)

6. AIS Group
0 5 10 15 20 25
No brace weaning
Brace after Risser 4
20 < Cobb angle <25
Cobb angle < 20
OVERTREATMENT
16,9%
5,9%
10,2%
10,2%
8/118 subjects (6,8%) had Cobb angle < 20ο at Risser 5 and they were
prescribed a brace!!

7. Kyphosis group
0 2 4 6 8 10 12
No brace weaning
Brace after Risser 4
No Scheuermann
OVERTREATMENT
22,5%
6,1%
12,2%

8. 16 years old, First brace at 15 years, 1 ½ year post-menarche,
Risser 4, Th (R) 11ο ,Lu (L) 18ο , ATR Th (R) 3ο, Lu (L) 4ο .
Brace prescription for 20h
Case n1

9. 15 years old, Lu (L) 18ο , ATR 5ο , Risser 5, 4 ½ years post-
menarche, Brace prescription for 15-16h, After 2 PSSE
sessions she complained for pain only when she wore her
brace
Case n2

10. 17 years old, First brace 12 years, initially (2009) Th-Lu (R)
16ο , Risser 0. 03/14 Th-Lu (R) 8ο , ATR 4ο , Risser 5,
continue wearing the brace for 15-16h, no brace weaning,
4 years post-menarche
Case n3

11. 15 years old, 1 ½ years post-menarche , Risser 4, Th (L)
13ο , Lu (R) 15ο , ATR Th 2ο , Lu 4ο . Brace prescription
for 18h (12/14)
Case n4

12. Incidence of progression of
untreated AIS patients
 Lonstein and Carlson 1984, The prediction of curve
progression in untreated idiopathic scoliosis during
growth J Bone Joint Surg Am. 1984 Sep;66(7):1061-71

13. Conclusions
 An extremely high rate of overtreatment (42,5%) was
observed in the brace treatment for AIS and Scheuermann
kyphosis, in Greece
 Possible reasons:
- Ignorance of SOSORT and SRS guidelines for AIS and
Scheuermann kyphosis treatment
- Ignorance of the important role of PSSE (Physiotherapeutic
Scoliosis Specific Exercises) in the treatment of mild scoliosis
(Cobb angle < 25ο) [RCT – Monticone et al 2014]
- Lack of adequate education of MDs in the treatment of spinal
deformities
- Profit reasons
 Overtreating a child with a brace can cause serious
psychological, social and financial problems
(Korovessis et al 2007)

14. Conclusions
Patient Care
Patient
Needs Observe Exercise Brace Surgery
Observe
Overtreatment Overtreatment Overtreatment
Exercise
Undertreatment Overtreatment Overtreatment
Brace
Undertreatment Undertreatment Overtreatment
Surgery
Undertreatment Undertreatment Undertreatment

15. Thank you for
your attention
NIKOS KARAVIDAS
PT, MSc
Certified Schroth Therapist (BSPTS)
Certified SEAS Therapist
McKenzie Therapist