Scoliosis is a deformity of the spine in all three planes. The most common types emerge in otherwise healthy children during adolescent growth. Spine imaging is required for diagnosis and surveillance to determine whether the deformity is progressing. Epidemiologic studies that looked at the long-term effects of receiving multiple spine x-rays in childhood showed a concerning increase in adult malignancy. However, many of those studies were based on exposure from x-ray equipment 50 or more years ago. This paper examines the current risk of receiving necessary spinal x-rays using modern equipment and up to date exposure recommendations from the leading medical organizations. Using example treatment scenarios, children are receiving x-ray exposure that is well below the safe limits. Results show that cumulative radiation doses in adolescents with typical AIS range from 2.04 – 12.21 mSv, a safe cumulative dosage, while the most extreme cases would reach up to 28.45 mSv, a slight increase in risk.

Introduction: The evaluation of spinal range of motion is paramount in the context of spinal disorders, especially considering emerging surgical techniques focused on motion preservation and circumventing spinal fusion. Manual measurement techniques, which utilize a goniometer and tape measure, demand proficiency to accurately assess spinal motion. This becomes further complicated in patients with spinal deformities. Inertial sensors emerge as a potential clinical solution. By assessing electronic inertial sensor performance in capturing thoracolumbar spinal range of motion, this study evaluates the level of association observed between the range of motion measurements captured by manual and sensor methods. Methods: Participants included 19 healthy young adults (74% female, average age 20 years [range 15-26]) without spinal conditions. Each performed a series of manual spinal motion evaluations quantified using a standard goniometer and a tape measure. Participants repeated the motions with an electronic inertial sensor attached to their C7 spinous process. Each manual and electronic motion sequence was performed three times. Data were analyzed with a Pearson’s correlation to assess congruence between the datasets, and a paired t-test compared the mean values between the two groups to examine the two motion measurement methodologies. Results: Association between the different planes of motion for manual and electronic repeated clinical motions were moderate (r=0.44) to strong (r=0.70). Manual measurements showed similar levels of variation to that of the electronic measurements. Upon comparing the manual and electronic measurement sets through a paired t-test, the mean values exhibited no statistically significant differences. Conclusion: The electronic motion measurements were congruent with manual measurements based on the correlation values and t-tests presented. Thus, inertial sensors can approximate the measurements of manual methods in assessing spinal range of motion. This demonstrates the potential for clinical adaptation of these sensors into spine centers to objectively assess patient outcomes in spinal motion preserved surgeries.

Purpose Studies have shown that bracing is an effective treatment for patients with idiopathic scoliosis. According to the current classification, almost all braces fall in the thoracolumbosacral orthosis (TLSO) category. Consequently, the generalization of scientific results is either impossible or misleading. This study aims to produce a classification of the brace types. Methods Four scientific societies (SOSORT, SRS, ISPO, and POSNA) invited all their members to be part of the study. Six level 1 experts developed the initial classifications. At a consensus meeting with 26 other experts and societies’ officials, thematic analysis and general discussion allowed to define the classification (minimum 80% agreement). The classification was applied to the braces published in the literature and officially approved by the 4 scientific societies and by ESPRM. Results The classification is based on the following classificatory items: anatomy (CTLSO, TLSO, LSO), rigidity (very rigid, rigid, elastic), primary corrective plane (frontal, sagittal, transverse, frontal & sagittal, frontal & transverse, sagittal & transverse, three-dimensional), construction—valves (monocot, bivalve, multisegmented), construction—closure (dorsal, lateral, ventral), and primary action (bending, detorsion, elongation, movement, push-up, three points). The experts developed a definition for each item and were able to classify the 15 published braces into nine groups. Conclusion The classification is based on the best current expertise (the lowest level of evidence). Experts recognize that this is the first edition and will change with future understanding and research. The broad application of this classification could have value for brace research, education, clinical practice, and growth in this field.

To develop a protocol for assessing spinal range of motion using an inertial sensor device. The baseline error of an inertial sensor was assessed using a bicycle wheel. Nineteen healthy subjects (12 females and 7 males, average age 18.2 ± 0.6 years) were then prospectively enrolled in a study to assess the reliability of an inertial sensor-based method for assessing spinal motion. Three raters each took three measurements of subjects’ flexion/extension, right and left bending, and right and left rotation. Afterwards, one trial from each set of measurements was excluded. Correlations and the ICC (3,1) were used to assess intra-rater reliability, and ICC (3,2) was used to assess inter-rater reliability of the protocol. The baseline error of the sensor was 1.45°. Correlation and ICC (3,1) values for the protocol all exceeded 0.888, indicating high intra-rater reliability. ICC (3,2) values for the protocol exceed 0.87, indicating high inter-rater reliability. Our study presents both a paradigm for assessing the baseline error of inertial sensors and a protocol for assessing motion of the spine using an inertial sensing device.

Previous work has suggested that surface topography can be used for repeated measurements of deformity during curve monitoring following an initial radiograph. Changes in deformity during natural curve progression may be subtle. An important preemptive question to answer is whether topography can follow a large change in spine deformity, as in scoliosis correction. We assess the ability of surface topography to track the evolution of spine deformity during anterior scoliosis correction relative to traditional radiographs. Anterior scoliosis correction was chosen for this analysis because it changes the shape of the trunk without leaving a surgical scar and muscle atrophy along the posterior spine. Following IRB approval, 18 patients aged 14.6 ± 2.0 years at surgery were enrolled in a retrospective review of coronal radiographs and topographic scans acquired before and after scoliosis correction. Radiographic and topographic measures for the coronal curve angle before and after surgery were compared. Surface topography estimates correlate with radiographic measures of the pre- (r = 0.7890, CI = [0.4989 0.9201], p < 0.00001), postsurgical (r = 0.7485, CI = [0.4329 0.9006], p = 0.0004), and the change in the coronal curve angle (r = 0.6744, CI = [0.3028 0.8680], p = 0.0021) due to surgery. We provide evidence open for further extension that topography can follow changes in the coronal curve angle comparably to radiographs. Level IV.

The Adams Forward Bend Test recognizes the rotational aspect of the curve with the spine in flexion, and the AP X-ray measures the coronal plane deviation by using the Cobb Angle. However, modern techniques including CT-scan, biplanar radiograph, ultrasound, and surface topography allow the clinician to better evaluate and visualize the true 3-D nature of the spine. Surface Topography imaging uses the surface of the trunk to estimate the spine position using a mathematical algorithm that has been found to be accurate when compared to the radiologic Cobb Angle. The sagittal balance of the spine measured by surface topography is compared in three different situations, namely, "standing up straight," "standing relaxed," and "walking," which will help to best assess posture and risk of proximal junctional kyphosis before and after the treatment. Coronal imbalance (lateral deviation) and a range of maximal vertebral surface rotation (amplitude in either direction) are considered as the parameters with an excellent to good reproducibility. COP displacement or symmetry from the midline is used to measure the stability of the trunk. Therefore, those selected spine shape parameters and COP deviation would be considered as the best descriptors in the assessment of postural sway and outcome of PSSE in children with AIS.

PurposeWe aimed to provide a perspective review of the available quantitative imaging modalities of the spine for prognostic evaluation of the adolescent idiopathic scoliosis (AIS). MethodsA technical description of the current imaging technologies for quantitative assessment of the pediatric spine with scoliosis was provided, and the pros and cons of each method were discussed. Imaging modalities that quantify the overall 3D alignment of the spine as well as the structural specification of the spinal bone, intervertebral disc, endplates, and ligaments as it pertains to development and progression of the idiopathic spinal deformities in adolescents were discussed. ResultsLow-dose and microdose stereoradiography, ultrasound, and rasterstereography provide quantitative imaging of the 3D spinal alignment with low or no radiation in standing posture which allows repetitive imaging for early detection of the curve development. Quantitative magnetic resonance imaging, including ultrashort dual-echo time and T1-rho can provide quantitative assessment of the spinal tissues relevant to development of idiopathic spinal deformity in pediatric population. New computed tomography scans that uses dual-energy can provides high-resolution measure of the current-state of the bone quality and morphology as well as the osteogenic properties of the bone by quantitative evaluation of the bone marrow. ConclusionThe presented imaging modalities can provide a wide spectrum of quantifiable information relevant to development and progression of the spinal deformity. Clinical application of these technologies can change the paradigm in clinical assessment of the pediatric scoliosis by improving our understanding of the pathogenesis of the idiopathic scoliosis.

Purpose:To investigate the prevalence of hip pain from labral tears and femoroacetabular impingement (FAI) in karate athletes using a statewide online survey.Methods:An anonymous electronic survey was distributed via Qualtrics to all registered members of a statewide karate organization who were a purple belt or higher. Basic demographic information was collected as well as belt level, competitive level, and information regarding hip pain and treatment for hip pain. Microsoft Excel was used to store and analyze data.Results:Of 180 respondents, 123 (68.3%) never had hip pain when practicing karate, and 54 (30.0%) had hip pain at some point in their karate career. Three subjects did not provide an answer and were excluded. Furthermore, of the symptomatic individuals, 52 reported the location of their hip pain, whereas 2 subjects did not. Of the symptomatic individuals (54), 32 had formal diagnoses by a medical professional, 4 (12.5%) were diagnosed with FAI of the hip, 6 (18.8%) diagnosed with a hip labral tear, 3 (9.4%) diagnosed with hip bursitis, 3 (9.4%) diagnosed with hip arthritis, and 16 (50%) had other diagnoses. The remaining 22 participants have not received a formal diagnosis by a medical professional.Conclusions:The prevalence of hip pain in karate athletes in this survey was lower compared to athletes of other martial arts and kicking sports. No differences in the percentage of injuries were found between sex and years practiced; however a higher incidence of hip pain was found between elite status and age group. When evaluating hip pain in the karate population, orthopaedic surgeons should maintain an index of suspicion for FAI and hip labral tears.Level of Evidence:Level IV, retrospective cross-sectional study.

Background: The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) produced its first guidelines in 2005 and renewed them in 2011. Recently published high-quality clinical trials on the effect of conservative treatment approaches (braces and exercises) for idiopathic scoliosis prompted us to update the last guidelines' version. The objective was to align the guidelines with the new scientific evidence to assure faster knowledge transfer into clinical practice of conservative treatment for idiopathic scoliosis (CTIS). Methods: Physicians, researchers and allied health practitioners working in the area of CTIS were involved in the development of the 2016 guidelines. Multiple literature reviews reviewing the evidence on CTIS (assessment, bracing, physiotherapy, physiotherapeutic scoliosis-specific exercises (PSSE) and other CTIS) were conducted. Documents, recommendations and practical approach flow charts were developed using a Delphi procedure. The process was completed with the Consensus Session held during the first combined SOSORT/IRSSD Meeting held in Banff, Canada, in May 2016. Results: The contents of the new 2016 guidelines include the following: background on idiopathic scoliosis, description of CTIS approaches for various populations with flow-charts for clinical practice, as well as literature reviews and recommendations on assessment, bracing, PSSE and other CTIS. The present guidelines include a total of 68 recommendations divided into following topics: bracing (n = 25), PSSE to prevent scoliosis progression during growth (n = 12), PSSE during brace treatment and surgical therapy (n = 6), other conservative treatments (n = 2), respiratory function and exercises (n = 3), general sport activities (n = 6); and assessment (n = 14). According to the agreed strength and level of evidence rating scale, there were 2 recommendations on bracing and 1 recommendation on PSSE that reached level of recommendation "I" and level of evidence "II". Three recommendations reached strength of recommendation A based on the level of evidence I (2 for bracing and one for assessment); 39 recommendations reached strength of recommendation B (20 for bracing, 13 for PSSE, and 6 for assessment). The number of paper for each level of evidence for each treatment is shown in Table 8. Conclusion: The 2016 SOSORT guidelines were developed based on the current evidence on CTIS. Over the last 5 years, high-quality evidence has started to emerge, particularly in the areas of efficacy of bracing (one large multicentre trial) and PSSE (three single-centre randomized controlled trials). Several grade A recommendations were presented. Despite the growing high-quality evidence, the heterogeneity of the study protocols limits generalizability of the recommendations. There is a need for standardization of research methods of conservative treatment effectiveness, as recognized by SOSORT and the Scoliosis Research Society (SRS) non-operative management Committee.

Purpose Little is known about the natural history of spinal deformities in Coffin-Lowry syndrome (CLS). Our goal was to evaluate the spinal deformity progression and clinical impact. Methods In this institutional review board-approved study, we performed a multinational retrospective review of six male CLS patients, aged 13 to 22 years at final follow-up, for a mean of 7.25 years (3 to 13). Results All showed delayed skeletal maturity. Three had calcifications of their lower cervical ligamentum flavum, all experienced neural axis abnormalities, including lower extremity weakness, numbness and tingling and in one, quadriparesis. Only two were ambulatory at final follow-up. All had significant spinal abnormalities, including severe progressive thoracic lordosis, thoracolumbar kyphosis and scoliosis. All had undergone spinal fusion or were being evaluated for surgery. Conclusion CLS is a rare X-linked mutation in the RSK2 gene, affecting between 1/50 000 to 100 000 people. There are two reports in the literature of patients with calcifications of their ligamentum flavum. Both had neural axis abnormalities and one had acute onset quadriplegia. Analysis of their ligamentum flavum found abundant central calcifications. Despite our small cohort we found 50% had calcifications and 100% had neurologic consequences associated with those calcifications. There was a 100% rate of deformity progression. They all exhibited delay in skeletal maturity, which mandates longer follow-up and has implications for surgical planning. From our cohort and literature review, the natural history of CLS supports frequent patient evaluation and a lower threshold for correction of spinal deformities. Aiming to avoid spinal cord compression and improve or avoid neurological deterioration. Level of Evidence IV - retrospective study

Education in the health professions occurs at the graduate level, increasing the barriers to underrepresented and first-generation students. Some programs attempt to alleviate these barriers by streamlining passage from the undergraduate campus to the medical campus within a university or by accelerating entry to the professions by bypassing the bachelor's degree. These solutions each have their own limitations for students, including added pressure to maintain grades and a limited ability to explore multiple professions. The Alliance for Health Sciences, a partnership between DePaul University and Rosalind Franklin University of Medicine and Science (RFUMS), was formed to address these issues and has created the Pathways Honors program. Through this program, current DePaul students may apply for an early admission decision to one of 6 of RFUMS's programs and, if qualified, pursue an accelerated entry. They have the option to apply for early decision at any time during their undergraduate career to encourage exploration of career options and to allow students to adjust to college rigor with lower stakes. In addition, collaborative, innovative advising contributes to creating well-rounded students and admissions committee decisions not dictated solely by test metrics. The Pathways Honors program has continued to attract a diverse student pool to DePaul, and early indications are that many of these students are making a successful transition to professional programs. Currently, we have data on our first cohort of students. Continued development of this program will be necessary to ensure that it is preparing students for rigorous graduate programs and helping to diversify the health care workforce.

sagittal balance and predictive equations to determine lumbopelvic compensatory patterns (LPCP).These equations are used to guide surgical decision making and technique selection.Although other lumbopelvic compensation equations are available, these have not been compared with the SRS-Schwab equation. ObjectivesThe aim was to evaluate sagittal balance and LPCP in younger and older adults with scoliosis and to compare the two most commonly used LPCP predictive equations (SRS-Schwab and Legaye).Methods EOS radiographic data from 41 adults with scoliosis (coronal Cobb > 10°; 51 ± 19 years) stratified into younger (n = 20) and older (n = 21) groups above and below the mean age was retrospectively analysed.T-tests were used to compare group characteristics and Fisher's exact tests were used to evaluate differences in SVA (sagittal vertical axis), PT (pelvic tilt) and PI (pelvic incidence)-LL (lumbar lordosis) mismatch thresholds.Agreement between SRS-Schwab and Legaye classification was evaluated using Kappa tests and Bland Altman plots.Results and discussion 62% of the older group and 10% of the younger group exceeded the SVA threshold of 40 mm (p < .001).86% of the older group and 20% of the younger group exceeded the 20°pelvic retroversion threshold (p < 0.001).Normal PI-LL mismatch ranges were more prevalent in the younger group (70%) than the older group (28%) (p < .001)when analysed through the SRS-Schwab equation.Legaye equation analysis revealed no difference in the prevalence of normal PI-LL ranges between the younger (15%) and older group (10%) (P = .66).Lumbar hyperlordosis was more prevalent in the younger (25%) than older group (5%) (p < .001)when analysed through the SRS-Schwab equation but no difference was observed between the younger (10%) and older group (0%) (p > .05)when analysed through the Legaye equation.Lumbar hypolordosis was more prevalent in the older (67%) than the younger group (5%) (p < .001)but no difference was observed between the older (90%) and younger group (75%) when analysed through the Legaye predictive equation (P = .33).Agreement between the SRS-Schwab and Legaye equations was poor for the whole (κ = 0.148), older (κ = 0.277) and young groups (κ = 0.039). Conclusion and significanceThis study confirms that older patients more often exhibit higher SVA and pelvic retroversion than younger patients.Whilst analysis through SRS-Schwab classification reveals that younger patients more often exhibit lumbar hyperlordosis than older patients who more often exhibit lumbar hypolordosis, analysis through the Legaye equations revealed no differences.There is poor agreement between the SRS-Schwab and Legaye classification equations.Clinicians are cautioned to exercise clinical judgement when evaluating their patients with these equations until more research is done.

Background: Clinicians who assess and treat patients for scoliosis typically use parameters that are all visible from the posterior view. Radiographs assess the internal spinal deformity, but do not directly evaluate body shape, either posterior or anterior. This is problematic, as the patient is most concerned about the way they appear in the mirror. An objective set of anterior measurements is needed to help quantify the anterior asymmetry that is present in scoliosis.Methods: The design of this system of assessment was developed as a consensus of thinking from four points of view. A spine surgeon provided the musculoskeletal structural perspective. A plastic surgeon specializing in breast reconstruction provided the aesthetic and soft tissue perspective. A surface topography researcher provided the imaging perspective, and a scoliosis patient provided the self-perception and emotional perspective. Using an iterative process, a series of potential measurement parameters using surface topography measurements were considered, debated, and ultimately selected to be part of a system of measurement that provides an overall assessment of anterior trunk asymmetry.Results: An anterior surface topography scan in the relaxed, standing position was taken of the scoliosis patient. The computer provides a 3D topographical model that is used to complete measurements that can be combined to achieve an Anterior Aesthetic Deformity Score. Shoulder parameters, including shoulder height difference and shoulder slope difference, make up 40 % of the total score. Breast asymmetry, including nipple height difference and sternal notch-to-nipple distance, make up 30 % of the total score. Waist asymmetry makes up the final 30 % of the score, providing an objective and quantifiable measure of anterior trunk deformity.Conclusions: These measurements provide an objective, systematic evaluation of anterior trunk asymmetry that can be used in the assessment of patients with scoliosis. Clinical research should now be done to validate this system and show that it is reproducible in a variety of settings and patients.

Growth estimates and demographic shifts of the population of the United States foreshadow a future heightened demand for musculoskeletal care. Although many articles have discussed this growing demand on the musculoskeletal workforce, few address the inevitable need for more musculoskeletal care providers. As we are unable to increase the number of orthopaedic surgeons because of restrictions on graduate medical education slots, physician assistants (PAs) and nurse practitioners (NPs) represent one potential solution to the impending musculoskeletal care supply shortage. This American Orthopaedic Association (AOA) symposium report investigates models for advanced practice provider integration, considers key issues affecting PAs and NPs, and proposes guidelines to help to assess the logistical and educational possibilities of further incorporating NPs and PAs into the orthopaedic workforce in order to address future musculoskeletal care needs.

In pediatric spinal deformity the gold standard for curve surveillance remains standing full-column radiographs, but repeated exposure to ionizing radiation motivates us to look for nonradiographic solutions. This study tests a modern system of surface topography (ST) to determine whether it is reliable and reproducible. Patients from 6 pediatric spinal deformity clinics were recruited for enrollment. Inclusion criteria were age 8–18; diagnosis of scoliosis measuring ≥10 and <50 degrees or increased kyphosis of ≥45 degrees. Standing radiographs and ST scans (DIERS Formetric, Diers Medical Systems, Chicago, IL) were obtained on all patients and then measured and compared. A single investigator using a validated electronic measurement tool performed all radiographic measurements. Analysis of reproducibility and comparison of ST and radiographs were done. A total of 193 patients were enrolled (148 F [77%]). The mean age was 13.25 years (range 8–18). The scoliosis magnitude was as follows: thoracic average 22.7 ± 10 degrees; lumbar average 19.6 ± 9 degrees. The kyphosis magnitude was 54.0 ± 11 degrees. The reproducibility for each ST parameter for 3 repeated scans was strong (interclass correlation = 0.855–0.944). Comparison to radiographic measurements was strong in the thoracic (r = 0.7) and moderate in the lumbar curve (r = 0.5). There was an average difference of 5.8 degrees in the thoracic spine and 8.8 degrees in the lumbar spine between ST Cobb angle estimates and radiographs. Thoracic kyphosis also had a strong correlation (r = 0.8) with radiographs. Although the results are intended to measure similar aspects of deformity as the traditional Cobb angle, the measurement is not intended to be an exact estimation. The utility of ST is in the reproducible quantification of deformity after the initial radiograph has been taken. This has the potential to make longitudinal assessment of change in deformity without serial radiographs.

Barefoot running is increasing in popularity within the running community, yet the biomechanical differences compared to traditional shod running are not well understood. This study investigates the changes in spinal dynamics during the gait cycle of runners wearing traditional running shoes (shod) compared to those wearing no shoes (barefoot). Pedal force distribution, kyphotic angle, lordotic angle, and trunk inclination were measured during shod and barefoot gait at three different speeds on a treadmill. Subjects were examined using the DIERS Formetric 4D system and DIERS Pedoscan system. While running barefoot, pedal force distribution analysis showed that 21.0% more force load goes through the forefoot vs. a 10.2% increase in forefoot force with shod (p = 0.0006). At 8.0 km·h-1 the average kyphotic angle was 1.6 degrees greater under barefoot conditions vs. shod conditions (p = 0.008). At 8.0 km·h-1 the average lordotic angle was 0.8 degrees greater under barefoot conditions vs. shod conditions (p = 0.05). Trunk inclination was 0.6 degrees and 0.8 degrees greater under barefoot conditions compared to shod conditions at natural speeds (p = 0.005) and 8.0 km·h-1 (p = 0.015), respectively. Barefoot runners show an increased force load in the forefoot, eliciting a forefoot strike pattern while running barefoot compared to shod running, and it was also found that barefoot runners have reduced trunk inclination. These dynamic changes allow for a more spring-like effect for barefoot runners creating a less transient and slower rise in force. In contrast, a heel strike pattern yields a rapid and high impact collision between heel and ground. As a result, barefoot running translates into less stress on the joints of the lower extremity and back and therefore less risk of injury.

Background: Attitudes regarding non-operative treatment for adolescent idiopathic scoliosis (AIS) may be changing with the publication of BRAiST. Physiotherapeutic Scoliosis Specific Exercises (PSSE) are used to treat AIS, but high-quality evidence is limited. The purpose of this study is to assess the attitudes of members of the Scoliosis Research Society towards PSSE.Methods: A survey was sent to all SRS members with questions on use of Physical Therapy (PT) and PSSE for AIS.Results: The majority of the 263 respondents were from North America (175, 67 %), followed by Asia (37, 14 %) and Europe (36, 14 %). The majority of respondents (166, 63 %) prescribed neither PT nor PSSE, 28 (11 %) prescribed both PT and PSSE, 39 (15 %) prescribe PT only and 30 (11 %) prescribe PSSE only. PT was prescribed by 67 respondents, as an adjunct to bracing (39) and in small curves (32); with goals to improve aesthetics (27) and post-operative outcomes (25). Of the 196 who do not prescribe PT, the main reasons were lack of evidence (149) and the perception that PT had no value (112).PSSE was prescribed by 58 respondents. The most common indication was as an adjunct to bracing (49) or small curves (41); with goals to improve aesthetics (36), prevent curve progression (35) and improve quality of life (31). Of the respondents who do not prescribe PSSE, the main reasons were lack of supporting research (149), a perception that PSSE had no value (108), and lack of access (63). Most respondents state that evidence of efficacy may increase the role of PSSE, with 85 % (223 of 263) favoring funding PSSE studies by the SRS.Conclusion: The results show that 22 % of the respondents use PSSE for AIS, skepticism remains regarding the benefit of PSSE for AIS. Support for SRS funded research suggests belief that there is potential benefit from PSSE and the best way to assess that potential is through evidence development.

The publication of research in the field of conservative treatment of scoliosis is increasing after a long period of progressive decline. In 2014, three high quality and scientifically sound papers gave new strength to the conservative scoliosis approach. The efficacy of treatment over observation was demonstrated by two RCTs for bracing, and one for scoliosis-specific exercises provided by a physical therapist. It is difficult to design strong studies in this field due to the long time needed for follow up and the challenge of recruiting patients and families willing to be involved in the decision process. Nevertheless, the main methodological errors are not related to the study design but rather on the way it is performed, which very frequently affects the reliability of results. The most common errors are: selection bias, with many studies including functional rather than a true structural scoliosis; inappropriate outcome measures, utilizing parameters not related to scoliosis progression or quality of life; inappropriate follow up, reporting only immediate results and not addressing end of growth results; an incorrect interpretation of findings, with an overestimation of results; and missing the evaluation of skeletal maturity, without which results cannot be considered stable. Being aware of these errors is extremely important both for authors and for readers in order to avoid questionable practices based on inconclusive studies that could harm patients.

Spine surgeons have historically been skeptical regarding the role of nonoperative treatment for adolescent idiopathic scoliosis (AIS). However, attitudes may be changing with the publication of the BRAiST study, which demonstrated efficacy of bracing for AIS. Scoliosis specific exercises (SSE) are widely accepted in Europe, but not in North America or Asia. Acceptance is limited by the availability of high-quality evidence to support its use. To address this issue, the Scoliosis Research Society (SRS) is considering conducting a large multicenter trial of SSE for AIS.