Stefano Negrini 1, Gianfranco Marchini 2, Fabrizio Tessadri 3. Corresponding author. addresses: SN:

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1 - 1 - The Sforzesco and Sibilla braces, and the SPoRT (Symmetric, Patient oriented, Rigid, Threedimensional, active) concept: focused on worst idiopathic scoliosis curves correction Stefano Negrini 1, Gianfranco Marchini 2, Fabrizio Tessadri 3 1 ISICO (Italian Scientific Spine Institute), Milan, Italy 2 Centro Ortopedico Lombardo, Milan, Italy 3 Orthotecnica, Trento, Italy Corresponding author addresses: SN: stefano.negrini@isico.it GM: ortopediacol@col.fastwebnet.it FT: orthotecnica.tn@alice.it

2 - 2 - Abstract Background Bracing is an effective strategy for scoliosis treatment, but there is no consensus on the type of brace, nor on the way to act on the spine to achieve good correction. The aim of this paper is to present the family of SPoRT (Symmetric, Patient-oriented, Rigid, Three-dimensional, active) braces: Sforzesco (the first introduced), Sibilla and Lapadula. Methods The Sforzesco brace was developed in 2004 to avoid casting for worst patients, basing on specific principles of correction. Due to its symmetry, the brace provides space over pathological depressions and pushes over elevations. Correction is reached through construction of the envelope, pushes, escapes, stops, and drivers; the latter have been developed for the first time with the Sforzesco brace, and allow to reach its main action: a three-dimensional elongation pushing the spine in a down-up direction. Brace prescription is made plane by plane: frontal (on the slopes), horizontal, and sagittal. The brace is built modelling the trunk shape either on the cast mould or on the PC screen (CAD-CAM construction). Brace checking is fundamental, since SPoRT braces are adjustable and customisable according to any individual curve pattern. Brace treatment must achieve very good aesthetics and radiographic results compatible with good functioning in adulthood, while the quality-of-life and psychological impacts must be minimised. Treatment is individually tailored, starting by wearing the brace 18 to 23 hours per day until the period of rapid growth is over (Risser 3) and then gradually reduced. SEAS exercises are a key factor to achieve success.

3 - 3 - Results The Sforzesco brace has shown to be more effective than the Lyon brace (matched case/control), equally effective as the Risser plaster brace (prospective cohort with retrospective controls), more effective than the Risser cast + Lyon brace in treating curves over 45 Cobb (prospective uncontrolled cohort), able to improve aesthetics (prospective uncontrolled cohort). Conclusions Bracing is a demanding, slow, artisanal effort in the art of patience, and corresponds to the very slow pace of building oneself that humans usually have to face, contrary to the fast solution that he/she may tend to prefer and see as less demanding. Background Bracing is an effective strategy for scoliosis treatment, even if proof regarding its efficacy are currently still weak [1, 2]. Nevertheless, since the efficacy of bracing comes from both good quality construction and good compliance [3], bracing should never be interpreted only in terms of the brace applied, but also in terms of the management of patients [4].I In fact, compliance is a characteristic neither of the treatment only, nor of the patient alone, but of the good interaction between these two factors and an expert treatment team able to reduce the burden of the brace and increase the coping abilities of the patient. The expert members of the international Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) have not been able to reach any consensus on the type of brace, nor on the way to act on the spine to achieve good correction [5]; on the contrary, experts have quite easily reached a very good consensus on the management of patients to achieve good results [4]. According to studies performed according to the Scoliosis Research Society (SRS) methodological criteria, it appears clear that also respecting SOSORT criteria [6, 7] yields better results than not doing

4 - 4 - so [8]. So, the currently available international knowledge seems to agree that the type of brace used is less important than the way in which a brace is applied (SOSORT criteria) [4]. Nevertheless, this way of thinking could drive the field to a form of nihilism, where what you do (brace) is less important than how you do it (SOSORT criteria). Consequently, a comparison among the different tools applied by different physicians is mandatory, in order to understand these tools and to be able to separate their different indications. Until now, there have been very few comparison studies on different braces: one RCT [9], and some studies mainly with historical controls [10-16]. A critical assessment of some of these studies is vital, since in certain cases there has been doubt that the authors were experts in the use of the types of braces evaluated in the study. As a consequence, a more sound understanding of the basis behind the use of different braces is required to increase common background knowledge and to finally be able to safely compare the different instruments. The aim of this paper is to present the SPoRT braces, which today constitute a family of braces constructed following a single concept of bracing (SPoRT) which was developed after the first introduction of the Sforzesco brace (Fig. 1A). Subsequently, this also drove a change in the construction of the Sibilla (Fig. 1B) and Lapadula (Fig. 1C) braces which had been in use for many years [17-19]. History The Sforzesco brace was developed as a breakthrough involving two of the authors (SN and GM) in the autumn of We were searching for a way to avoid casting for our worst patients, because of the significant costs involved both at the individual (side effects including cast syndrome, skin problems, significant psychological impact, inability to shower for months, etc.) and social (repeated treatment of

5 - 5 - inpatients) levels. For that reason, we developed the new Sforzesco brace, which was named according to the two main cities of the experience of the main author (SN), Vigevano and Milano, that both have castles named Sforzesco after the Medieval Sforza family (Fig. 2). While applying the principles of bracing mentioned below, we ended up with a new, highly efficacious concept of bracing that we called SPoRT (Symmetric, Patient-oriented, Rigid, Three-dimensional, active) [11, 20, 21]. This method of correction has since then been applied to the previously existing Lapadula and Sibilla braces, the latter being a derivation of the first Cheneau-Toulouse-Munster [22-24] brace developed by our mentor, Paolo Sibilla, starting in the 1980s with continuing development to the beginning of this century [18, 19]. In the development and construction of the Sforzesco brace, it was possible to recognise favourable elements of various previously-developed braces: Risser cast [19, 25, 26] (Fig. 3A): gives the highest degree of correction through its localised pushes and rigidity, partly due to the material and partly due to the fact that it is a one-piece structure. Most of all, we tried to maintain rigidity, using only two large pieces and localising pushes through fully modifiable inserts. Lyon brace [27] (Fig. 3B): we used to think of this brace as the most effective one for scoliosis treatment, before developing the Sforzesco; it is fully based on a three-point concept, possibly three-dimensional, and with localised pushes on humps and curves. We maintained the material of this brace, as well as its vertical aluminium bar. Sibilla brace [18, 19] (Fig. 3C): the highest value of this brace was in the aesthetic modelling effect obtained through its symmetrical construction, which accompanies the whole body towards corrections. Nevertheless, in its

6 - 6 - previous construction, the three-point mode of correction of the Lyon brace was maintained, with big pushes and windows. Now, in the SPoRT concept, this brace is maintained as a less rigid alternative to the Sforzesco, even if modified according to the new understanding and insight we have developed. Milwaukee brace [28, 29] (Fig. 3D): this brace was not in our minds at the beginning, but we verified that the SPoRT concept achieves correction through an elongation obtained not with a traction, but by pushing from behind. This action allows for maintaining/restoring physiological curves while correcting scoliosis (three-dimensional action). After the development of the original Sforzesco brace, which was developed from the previously listed braces, we had the opportunity, through SOSORT, to compare our bracce with those of other expert builders from all over the world. As a consequence, we introduced one main change, that we called Cheneuisation which will be discussed below. This change allowed us to also consider among the progenitors of the Sforzesco the Cheneau brace in its last verion (Fig. 3E) [30-33]. This is in line with other innovations in the pelvis region that are developing from the Rigo Cheneau System (RCS) brace (Fig. 3F) [30, 32, 34]. The history of the development of the Sforzesco brace and the SPoRT concept is not yet finished. We are continuously developing it as our understanding grows; as a consequence, in a few years, there will hopefully be some more advances to be published. Theoretical principles From a theoretical perspective, we started this research with very well-established principles of correction that we had developed over the years. These principles are

7 - 7 - divided in terms of efficacy (type and quality of the brace) and acceptability (compliance). The efficacy principles of correction include [35, 36]: Mechanical efficacy. The active brace principle: the Milwaukee brace [28] has historically been considered an active brace because it required the patient to escape vertically through muscle action, while all other braces based on pushes were considered passive. Nevertheless, we discovered many years ago [37-39] that a passive brace can become active as the patient is encouraged to move freely, thus greatly increasing the corrective mechanical action of the brace through his/her movements (each time the patients tries to move incorrectly, he/she receives a corrective push). Moreover, if the brace can serve as a neurological resetter through esteroception and proprioception, this action is greatly increased by movements [40]. To make a brace active, it is necessary to ensure complete freedom of movement of the limbs, to have a perfect styling by the orthotist, to allow and even drive patients to perform physical activities at school and outside [41], and to train them through specific in-brace exercises [40]. For these reasons, we require patients to continue their sport activities also inside the brace [41] (Fig. 4) ( 1Yg&feature=player_embedded). Versatility and adaptability: this considers the possibility of adapting the action of the brace through inserts in order to refine it as continuously as desired. Pushes must be adapted when checking the brace at the first application, because the initial project most of the time is not confirmed by the

8 - 8 - interaction between the brace and the patient s trunk. Some rigid areas can require specific increases to the pushes, and some adaptations must also be made. Moreover, a theoretically perfect brace can be used for 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 due to the inherent costs. We think that all 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 orthotists (CPOs), physicians (MDs), and physiotherapists (PTs) and other healthcare and education professionals can achieve the best results, which are greatly increased by teamwork, thorough discussions and brace checks working together. This has also recently been stressed at an international level [4]. Compliance: Bracing is useless without compliance [3]. In turn, compliance is certainly due to the patient and his/her family, but also to the previous and following principles applied by the physician in developing and applying the brace. The acceptability principles of correction (meaning compliance as well as a human approach to the patient) include: Perfect body design and minimal visibility (Fig. 5): patients want correction and an invisible brace [42]. Therefore, if you make the brace visible you must carefully justify to the patient why, and be sure that this is really necessary. In our experience, this can be minimised. While checking the brace, this is our first concern, so that the patient understands that we are on his/her side. The

9 - 9 - Sforzesco brace was developed in a town of fashion (Milan), and some patients have stated that this is reflected in its design and wearability (Fig. 6). Maximum 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 (Fig. 4). Any unavoidable limitation must be explained and justified to the patient. The 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 can be risky with adolescents, but it is possible to achieve much better results. This means, for example, freedom in choosing 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 [43]: explain and you will obtain (useful behaviours and increased compliance). This is true in adults, but it is even truer in adolescents. The SPoRT acronym [11, 20, 21, 35, 44, 45], developed according to these principles, means: Symmetric: on the outside, the brace is almost symmetrical to reduce visibility and preserve as much as possible a good body shape (Fig. 1, 4-7) Patient-oriented: the brace is not visible, according to the acceptability principle. In our view, what patients care most about is having a brace that will be seen as little as possible, not to have less material (Fig. 4-6) [42].

10 Rigid: the chosen material and the fact that the brace is made in two large pieces strongly connected with aluminium have allowed us to achieve a high rigidity that gives rise to stronger pushes than in other braces. Three-dimensional: The brace aim is to have 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 (Fig. 7). Active: This is also a property of the brace, insofar as they allow total freedom of movement for all four limbs (Fig. 4, 5). The brace Three braces follow the SPoRT concept of correction, i.e. the Sforzesco brace, which was the first constructed and allowed the development of the concept, as well as the Sibilla and Lapadula braces, which existed before the Sforzesco brace and have now been adapted to follow the SPoRT concept. The Sforzesco brace (Fig. 7) is constructed with rigid polycarbonate, in two pieces, connected posteriorly at the midline by a vertical aluminium bar and anteriorly by a closure that is rigid over the breast and below is made of soft anelastic bands. While the brace appears to be in full contact, in reality due to its symmetry and according to the theoretical body shape the patient would have without scoliosis, it provides space over depressions and pushes over pathological elevations. Also, while the concept of symmetry is historically important, this has been replaced with a new development in which a slight corrective asymmetry has been established. This maintains the advantage of low brace visibility in the eye of the patient, but has the added advantage of providing greater correction.

11 The other two braces are made of polyethylene, which is more elastic than rigid polycarbonate. This allows for opening the brace without the need for a posterior aluminium bar, even if in some cases this has been done. In terms of construction and correction approach, the Sibilla (Fig. 8) and Lapadula braces (Fig. 9) are completely analogous to the Sforzesco brace, and therefore they will be considered together. The only difference between the two is that the Lapadula brace does not have the upper plastic part over the breast. This allows, on one hand, the treatment of lumbar and low thoracolumbar curvatures with less material, and on the other hand is able to also address kyphosis in combination with scoliosis through the use of acromion metallic pushes (Fig. 10). The main innovation of the SPoRT braces can be found in the concept of drivers. This was introduced for the first time in bracing with the Sforzesco brace [11, 35], and was discovered due to the abundance of material used to guarantee the rigidity that was necessary to emulate the strength of the Risser cast. This material no longer allowed the trunk to escape from the push as with, for example, the Lyon brace (Fig. 3c), but also the Cheneau brace (Fig. 3 e,f), where the spaces were key points of correction. We considered that, below the brace, since the only direct connection between the pelvis and the ground is through the lower limbs, the only real escape remaining to the spine as soon as the maximum external symmetry is achieved (i.e. the drivers are reached) is in elevation. This is exactly what we observed in our patients, such that during checks on the brace, the patients collapsed at least 2 cm when the brace was taken off. This was also confirmed after the first days of treatment, when the brace appeared in almost all cases to become shorter due to trunk lengthening (Fig. 11). The main two construction elements of the SPoRT braces are:

12 Envelope: like an exoskeleton, this must be constructed to give most of the correction. In the sagittal plane, it must allow a proper reconstruction; in the frontal plane, the modelling of the flanks must follow the required correction, but the thorax must also be shaped symmetrically to correct asymmetries; in the coronal plane, a symmetrical construction is envisaged so as to give space where there would have been if the thorax were normal, and to eliminate existing prominences. Pushes: even if the envelope is already able to correct a great deal, it is never possible to reach the maximum correction only with this approach. As a consequence, pushes are inserted to maximise the action in some areas, and to localise at best the action on the required areas. As a consequence, correction is reached through: Construction: the way in which the envelope is shaped. Pushes: the plastazote localisers must never be too thick to allow the proper action of the drivers that start immediately at the end of the push and drive the corrective forces. The pushes can be modified and adapted to increase the correction already achieved through the envelope. Drivers: these are the areas that control and drive pushes and escapes to obtain the real three-dimensional action so as to avoid incorrect deviations with respect to the desired correction, as well as over-pushes or over-escapes. This newly-introduced concept precludes the opening of big windows in the brace, since when overcorrection is reached and overcomes the external symmetry of the envelope, the driver is reached and the dispersion of forces is avoided by deviating them vertically by elevation.

13 Escapes: these appear almost automatically during construction to recreate symmetry, and depend on the body s asymmetries. Since they come from the external deformity of the patient, they are automatic according to the curvature characteristics and allow the desired three-dimensional correction. Braces built according to the SPoRT concept seemingly lack escapes because they finish with drivers so as to allow the most important correction, vertical escape. Stops: these are commonly referred to as counter-pushes. Practical issues How to prescribe the brace and principles of correction Prescribing the SPoRT braces requires a careful three-dimensional evaluation of the characteristics of single scoliosis. Clinical reasoning follows a systematic path by looking progressively at the single component of the deformity. A useful scheme for prescription is reported in Fig. 12. Frontal plane correction The slopes Correction on the frontal plane is based on the identification not of the curves (as usual), but of the slopes, that are the most frontally flexed segments of the spine. In fact, since the brace works by pushing the spine from behind, and due to the presence of the drivers that avoid undesired actions, pushes are focussed on the most severely flexed area of the spine (slopes). In a down-up direction, the following slopes can be described: Low lumbar (Fig. 13A): in a lumbar curve, below the apex. High lumbar (Fig. 13B): in a short thoracolumbar curve, below the apex; or in a very short lumbar curve, above the apex. Lumbar (Fig. 13C): in a wide thoracolumbar curve, below the apex.

14 Thoracolumbar (Fig. 13D): in a lumbar curve, above the apex; or in a low thoracic curve, below the apex. Thoracic (Fig. 13E): in a thoracolumbar curve, above the apex; or in a single thoracic curve, below the apex; or in a double thoracic curve, above the apex of the distal curve and below the apex of the proximal one. Distal thoracic (Fig. 13F): specified only in Double Moe curves where three thoracic slopes are present, below the apex of the distal curve. Proximal thoracic (Fig. 13G): in a thoracic curve, above the apex. When evaluating slopes, it is important to decide which is the most important to correct and where the CPO should focus in constructing the brace. Theoretically, any single curve scoliosis should have two slopes, and any double one should have three, but the reality is that many times one slope prevails over the other. A quick way to determine which slope is the most important is to look at the line drawn on the limiting vertebrae: the most inclined line indicates the most important slope. Some examples are reported in Fig. 14. Once the slope has been defined, the correction follows automatically as shown in an example in Fig. 15. In Table 1 the corrections to be made according to the identified slopes are reported. At the thoracic level, the ribs to be pushed must be identified, corresponding to the flexed vertebrae avoiding the apex. In the majority of cases, the levels immediately above and below should also be assessed since they are sometimes almost horizontal. The flanks Another point to be considered, and correlated with frontal plane correction, is the aesthetic action on the flanks and the eventual counter-pushes at this level. Usually, the flattened flank corresponds to the maximum slope: when the slope is low lumbar, the flattening is on the same side as the lumbar curve convexity,

15 when the slope is high lumbar, or thoracolumbar, the flattening is on the side the thoraco-lumbar or thoracic convexity; the latter can sometimes be true even in the case of a distal thoracic slope. The flattened flank requires remodelling on one side, on the other testify where the main slope is: in any case, it could be on the wrong side when compared to an eventually existing lumbar curve. Since SPoRT braces have material closing both flanks, there is no major problem or risk of the progression of such a lumbar curve controlateral to the flattened flank. However, it is mandatory to precisely instruct the CPO on what to do on these flanks. The possible actions (not mutually exclusive) at this level include: Shift: to be applied in the case of a low lumbar slope, which also corrects aesthetically. Stop: to be applied when there is a lumbar curve on the side opposite to the slope and the flattened flank; in this case, the lumbar curve should not be allowed to progress, even in front of the frontal correction proposed on the other side. Remodelling: to be applied in case one wants to improve the aesthetics of one flattened flank, independently from where the curves and slopes are. The action on the upper thoracic spine and Cheneauisation One main point to be carefully considered is the correction of high thoracic slopes. In fact, the described action of the SPoRT braces can at maximum reach the axillary level, corresponding to the T5 vertebra. What can be done above this level? Over the years, we have tried many possible solutions, including pushes on the cervical transverse processes, elevation of one shoulder, and finally what we called Cheneauisation, that is an inclination of the entire brace above the apex of the thoracic curve opposite to the proximal slope, together with an advancement of the

16 shoulder on the same side (Fig. 16). We used the term Cheneauisation to underline the fact that it derives from the contamination of our own brace with one of the other most well-known braces at the international level, the Cheneau brace. As previously stated, the SPoRT concept is based on a push from behind, but at the highest extreme of the brace, this can sometimes not be sufficient. We anticipated the possibility of acting posturally, as the Cheneau brace does, to overcome this limitation where the absence of drivers does not allow a proper push to be applied. This advancement is still underway; in fact, before the first good data were obtained (Fig. 15), we noticed an undue loosening of the thoracic distal drivers and a reduced correction on the distal thoracic slope. As a consequence, the current indication for Cheneauisation is the presence of a main thoracic proximal slope above T5. If the slopes are evenly distributed around the apical thoracic vertebra, then the action should be done only on the shoulders, and again this depends on T5 (Fig. 16): if the apex is at the L5 level or above, and there is no proximal curve, then the shoulder controlateral to the thoracic convexity must be elevated; if there is a proximal thoracic curve, the shoulder can be elevated only if it is totally reducible, which means that the patient will be able to maintain the head straight without controlateral flexion; in all the other cases, the shoulders must remain at the same level. A cervical push on the transverse process (Fig. 17) can be prescribed in many situations when it is deemed important to act on the cervico-thoracic junction. The drivers On the frontal plane, the main drivers are lateral on the concave side, i.e. at the level of the waist and/or the thorax. They act mainly in a down-up direction from the apex of the curve, even if their action starts where the contralateral push begins. They direct the forces above.

17 The coronal plane The correction on the coronal plane is totally based on the hump characteristics combined with the needs on the sagittal plane (together with the localisation of the apex of kyphosis). In the prescription, the MD must indicate on which hump he/she wants to act, while the CPO will autonomously develop the push that will be proposed during the check for final correction. Aside from the following considerations, in general the push is realised with a plastazote addition inside the external envelope following exactly the apparent prominence, as shown in Fig. 18. At the lumbar level, any horizontal derotatory push on the hump corresponds to a useful reconstruction of the lordosis usually needed in this area. There are no real concerns of sagittal damage. As a consequence, the push is directly on the transverse apophysis, which can potentially also add a frontal plane corrective action (Fig. 19A). Obviously, in the rare cases of associated hyperlordosis all the brace will be built in delordosis. At the thoracic level, on the contrary, the derotatory push can damage the sagittal plane, and must be carefully planned. In this respect, it is mandatory not to reach the transverse processes, so as to allow for possible leverage by the ribs that could even result in a kyphotisating action (Fig. 19B). This leverage is at the base of the derotation and possibly deflexion action of the push on the hump. Moreover, the push must be below the apex of kyphosis to avoid its flattening. Above it, the push should be on the proximal counter-rotation appearing as a consequence of the thoracic thrust on the hump. This will allow on one hand an action to reconstruct the kyphosis, and on the other hand will increase the direct derotating (and modelling) push on the hump, as well as a realignment of the shoulder girdle otherwise rotated opposite to the convex side of the curve, due to the push on the thoracic hump.

18 At the thoracolumbar level, the action is usually similar to that at the lumbar one. In fact, most of the cases in this region appear a junctional kyphosis, which is contrasted by a posterior push on the hump. In the few cases in which a junctional lordosis is present, the push must be present, but moderate so as to not increase the sagittal deformity. The drivers On the coronal plane, the main drivers are anterior, where they avoid the anterior escape of the trunk driving in rotation, and posterior on the opposite side of the push, which are reached only when complete derotation is achieved and the push is driven upward. The anterior drivers include the abdomen closure, which for this reason must be complete and reach under the breast, as well as the anterior closure above the breast itself. It is important that the anterior humps on the costal arch are compressed (in other concepts, a push is applied [5, 32, 46]) while on the opposite side is given space. Usually, symmetry is enough for this action. The sagittal plane This correction is almost completely done through the construction, since afterwards during checks it is almost impossible to really correct this point. As a consequence, in the prescription it is mandatory to state in which region a reconstruction of the sagittal plane must be achieved, and where, on the contrary, it is necessary to push to reduce the sagittal curve. The sagittal shaping of the brace during construction almost always changes according to the given patient s sagittal curve, even if there are some generalisations that can be made according to the pathology: 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

19 over the apex of lordosis, while the abdomen must also be allowed to escape anteriorly. Thoracolumbar scoliosis: this must usually be in lordosis, which is due to the tendency of this curve to evolve into 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. As already previously stated, the action of the derotatory pushes must also be considered in terms of sagittal plane correction. At the lumbar level, the direct push on the transverse processes leads to an increase of lordosis. At the thoracic level, the correlation between the pushes and the apex of kyphosis (one ipsilaterale to the convexity below the apex, the other contralateral and above), have a main kyphotisation effect while coupling efficiently. In the same region, it also appears to be crucial to avoid pushing directly on the transverse processes, to allow a possible posterior escape of the vertebrae due to the rib lever. And finally, not to be neglected, is the important role of the anterior drivers that, while allowing a good rotation of the whole trunk, also drive posteriorly the depressed hemithorax contralateral to the hump, thus allowing kyphosis reformation. The drivers On the sagittal plane, all the drivers previously listed for the other planes play a crucial role in driving the forces not only upward but also slightly backward at the thoracolumbar junction, and anteriorly over the apex of kyphosis.

20 How to build the brace The SPoRT concept always requires a customised construction of the brace according to the patient s individual requirements. CAD-CAM technologies usually allow us to obtain the best results, without using pre-built forms stored in databases, as is usually done by others. Orthotists must directly shape the scanned trunk according to the patient s requirements. 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. The brace is built through careful modelling of the trunk shape either on the cast mould or on the PC screen. In some experiences of ours, the cast is constructed in a step by step procedure in down-up direction already trying to achieve a good correction. At first, maximum symmetry is searched for among the trunk volumes in three dimensions, looking at circumferences (Fig. 20A) and shapes (Fig. 20B). Then, the lengthening of the spine due to the brace action is simulated through a stretching in the down-up direction of the model. Finally, the sagittal plane is shaped. Once the mould is ready, the plastic envelope is prepared, and put on the patient according to his/her needs, so to allow a good sitting position and a total freedom of movement. The pushes are finally added at the level of the humps (Fig. 18) according to the desired corrections. How to check the brace Brace checking is a fundamental step in any brace construction [4]. This is especially true in braces following the SPoRT concept, since they are adjustable and customisable according to any individual curve pattern. The reaction of the body to predisposed project of the brace should also be considered during prescription and building. In fact, the reality is that the CPO should propose to the MD the best choice correction to be checked and verified, and the MD should try to understand what more

21 can be done in that particular case, accordingly proposing (and after construction, also re-checking) possible modifications. Brace checking is moreover a key psychological intervention on the patient and family, mainly, but not only, with the first brace. In fact, this is the actual moment at which children finally face their treatment, and at which their parents face their doubts, concerns, and the real struggle starts. As a consequence, the first check must always initially be focussed on explaining to the patient (while parents are listening, but not speaking directly to them but only to the child, at least initially) what is happening and how; why the brace seems to block respiration and how this will be overcome in no more than 24 hours; why it hurts in some places and how long will it take the pain to subside; where problems could arise, and which these could be; where to take care of the skin and how. This is the time to stress the importance of continuing with everyday life, while explaining how to reach the prescribed hours of treatment (immediately, if 23 hours per day is prescribed, which will help with reducing the occasional tightness of the brace; gradually in other cases, but at least within one week) and to push the patient to move as much as possible with and without the brace. Then, it is time for the check. Again, this is done starting from where the brace unduly hurts; invisibility is then checked, and if there are places in which the brace can easily be seen without any clinical advantage to the patient, a correction is requested from the CPO. This must be done aloud, and explaining why, so that the patient and parents are made aware of the fact that you are concerned with comfort and the invisibility of the brace. This gives the treatment team more accountability and in the end will help increase compliance.

22 Technically, on the frontal plane, one has to search for the area in which correction is not ideal. This is done by following the spinous process with the fingertips through the posterior openings laterally to the aluminium bar, and looking at where the spine bends. If there are places in which it is apparent that spinal straightening is too loose, a correction may be required by increasing the pushes or by decreasing the drivers and counterpushes on the other side. Before deciding, the mechanical construction in that area must be carefully checked, as well as the skin, to verify if any other push can be accepted. On the sagittal plane, besides the appearance of the brace that must be properly aligned with respect to a normal kyphosis and lordosis, it is necessary to check inside the brace, and eventually either act on the posterior aluminium bar of the brace, or add plastazote pushes. In the Sibilla brace, it is possible to add externally an aluminium bar attached to the plastic that can be bent so as to create the desired effect on the spine. On the coronal plane, the check is made without the brace. After the patient has worn the brace for several minutes without a shirt on, the skin appears slightly reddened where the pushes are acting. It is possible in this way to follow exactly the path of these pushes and to check that they adequately cover the hump. If not, correction is required. Finally, the total balance of the braced trunk is assessed. In fact, sagittal or frontal shifts (and rarely coronal rotations) can appear. These can be corrected by adjusting the brace either distally (the most common situation) or proximally. Pushes can be added, or eventually some more space can be given to the pelvis base or (less commonly) to the shoulder girdle. Sometimes, a shoe lift can be prescribed to be used

23 only with the brace on as a consequence of a false leg length discrepancy resulting from the new body balance created by the brace-trunk interaction. Other technical points to be checked include the non-overlap of pushes. This must be done on a plane by plane basis. In fact, the pushes on the hump usually overlap with the contralateral push on the slope, but this is due to the different vectors that will finally combine in the three-dimensional required action (Fig. 21). There is a final concept that is very intrinsic to the Sforzesco brace and its complex action: the balance among the pushes. In fact, pushing too much on a secondary curve has the consequence of reducing the efficacy on the main one. This is true on the coronal plane, where the disappearance of the hump after the first brace means that the push is no longer necessary in that area. This is possible since the Sforzesco brace is in any case closed over the previous hump area, avoiding an unduly reappearance of the prominence, as well as acting as a driver of the correction forces. It is also true in the frontal plane, where the slopes are carefully evaluated to check where more pushing is required, again verifying the changes which have appeared after the first period of correction. One last word regarding radiographic checking: usually this is done almost one month after the initial fitting of the brace, and almost never results in a change to something in the construction, unless a deficit of correction clearly appears. In any case, we perform this assessment only with the first, most important brace (but sometimes also in other cases when facing some problems, or at crucial points in the treatment) to check the adequate construction of the brace, and to give a strong motivation to the patient and family.

24 Protocols and everyday usage Brace treatment must almost always achieve very good aesthetic body shaping (Fig. 22) [47]. 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 disturbances due to the brace must be minimised [5, 20, 48]. With respect to scoliotic disease, the goal of brace treatment varies according to the degree of curvature considered, and forces (in terms of the strength of the brace and the 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 exercises or SpineCor brace, the first aim is to avoid progression while allowing the maximum possible freedom in the activities of daily life and reducing the discomfort caused by the brace. In such cases, the chosen brace will be less rigid (Sibilla) and will have to be worn for 18 to 21 hours each day until the end of the progressive period (up to Risser stage 3). The patient will then enter the weaning period. In severe adolescent scoliosis (up to Cobb, 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 for at least one year, and the most rigid one is chosen (the Sforzesco brace). In juvenile and infantile scoliosis over Cobb, a brace is proposed for at least 18 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 Then, the brace is

25 progressively weaned with the aim of taking it off, possibly before the pubertal growth spurt, when a new history of this 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, imbalance, etc. Treatment is carried out by wearing the brace full-time until the period of rapid growth is over and other adjustments due to the pathology are not foreseen. 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 21 to 23 hours per day) [3, 49] and acceptability (18 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. Exclusive night-time bracing is not recommended [50, 51] because our experience has told us that we can achieve at least the same results with exercises or SpineCor bracing (which are in any case less invasive), while the possibility of controlling a progressive curve is not increased by wearing a rigid 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 previously achieved results, we must carefully consider what happens when we take off the brace. According to all current theories, the brace places the spine in the best possible correct orientation and causes it to grow in this position [52-55]. When the brace is taken off, the correction is progressively loosened, and the daily number of hours without the brace determines the real result achieved at that stage of treatment [56], which is why x-rays should be performed almost every year, but without the brace and after the weaning period. In fact, each

26 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 possibly 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 [56] (Fig. 23), 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 stabilising exercises are so crucial during this period. Weaning requires a two-hour reduction every six months. This protocol has been developed in our Institute over many years in order to help the postural neuromuscular system maintain the achieved correction [35] as well as to maximise compliance. In fact, while scoliosis is a bone deformity, there is also a postural component of the curve [57] that always increases it [58] and can be the basis of its progression [35, 59]. Moreover, while movement has been shown to be a crucial progression factor [53, 60], it can also be reorganised to become a stability factor [61]. Braces directly interfere with such neuromuscular functions [1, 2, 59]. Because posture and movement require long-term adaptations [59, 62], the longer the weaning phase, the better the neuromuscular system should adapt, hopefully maintaining the inputs received by the brace even after complete weaning. In this respect, proper stabilisation exercises should play a major role, as has recently been shown [35, 63]. All this should positively interfere with bone tissue formation [53, 60], even if the postural system per se is part of the problem to be corrected [57-59].

27 Exercises We apply the Scientific Exercises Approach to Scoliosis (SEAS) as developed by ISICO in these years [35]. The main goals of exercises in brace treatment are elimination or reduction of side effects caused by immobility (muscular hypotrophy), or the brace itself (reduction of sagittal curves, mainly kyphosis, and breathing impairment) and accentuation of brace corrective pushes [40, 64, 65]. Moreover, exercises aim at not loosing correction while weaning the brace [63]. Such goals are pursued through specific therapeutic modalities, subdivided into treatment phases: Preparation for bracing: we request the execution of exercises aimed at increasing the range of motion of the spine on all planes, so as to allow the brace to exert the maximum possible correction (Fig. 24A). We also continue proposing mobilisation exercises in the first phase of brace wearing, when it is worn for at least 21 hours per day. Brace wearing period: we initially propose exercises of wriggling out of supports by using the upper and lower limbs so as to facilitate adaptation to brace usage for the recommended number of hours (Fig. 24B). We require the execution of modelling exercises in order to increase brace pressure on humps (Fig. 24C) as well as muscular endurance strengthening exercises, requiring lumbar lordosis and thoracic kyphosis preservation, while frontal and crosssectional plane correction is guaranteed by brace pushes. We propose specific breathing activation exercises only when we detect some a significant reduction in vital capacity. Complete brace weaning: Active Self-Correction is the key point to actively stabilize the spine and avoiding regression of the obtained correction (Fig. 24D).

28 During brace treatment, it is of fundamental importance to continually pursue the other two goals of aerobic functioning and development of a positive body image. For that reason, we recommend intensifying participation in motor and sport activities, both agonistic and/or recreational, even with a brace that must be worn full time (Fig. 4). The presence of the brace should never force any limitation upon the young patient s personal and social life. We have recently shown in prospective controlled studies the importance of exercises in preparation for brace treatment so to increase its efficacy at first wearing [66], and in retrospective studies the usefulness of SEAS exercises in order to not lose correction while weaning the brace [63]. We have also shown which exercises are more useful in increasing the pushes of the brace [40]. Results and case reports The results that are currently available on the SPoRT concept relate to the Sforzesco brace and are necessarily short-term. This is due to the fact that the first treated patients have already reached the end of treatment, but there are not yet enough of them to be able to perform a formal study. Nevertheless, even if we are perfectly aware that clinical case reports are not comparable to strong scientific data coming from other studies, Figures 25 to 30 convey in our view an important message to the reader and allow a deeper understanding of the effectiveness of this brace. With specific studies we have shown that the Sforzesco brace: is more effective than the Lyon brace after six months of treatment, with a prospective matched case/control prospective study [11, 21] on 30 AIS patients aged 13 years and with curves of 38 Cobb on average: in the Sforzesco group 80% of patients improved and none worsened, while the Lyon group had results of 53% and 13%, respectively.

29 is equally effective as the Risser plaster brace to achieve the maximal correction after 18 months of treatment, with a prospective cohort study with a retrospective control group [45] on 41 AIS patients aged 14 years and with curves of 40 Cobb. The Sforzesco brace 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 reduction in kyphosis. is more effective than the Risser cast + Lyon brace in treating curves over 45 Cobb at the end of growth, with a prospective cohort study in patients who utterly refused surgery [67] on 28 AIS patients aged 14 years and with curves of in a range of from to 58 Cobb. The patients braced with the Sforzesco had better results than those treated with the Risser cast in the thoracic curves, without any sagittal plane worsening. For the other parameters, the results were similar. is able to improve aesthetics in scoliosis patients with a prospective not-controlled cohort study [68] on 34 consecutive AIS patients 13 years old with curves of 32 Cobb with Aesthetic Index (AI) [47] scores of at least 5/6. At baseline, median AI was 6 (95% IC 5-6), but the score decreased to 3 (95% IC 0-5; p<0.05) after six months with the brace, and this value was maintained in the 29 who completed the treatment (95% IC 1-6; p<0.05 with respect to baseline). Discussion The results that are currently available on the SPoRT concept relate to the Sforzesco brace and are necessarily short-term. This is due to the fact that the first treated patients have already reached the end of treatment, but there are not yet enough of them to be able to perform a formal study. Nevertheless, even if we are perfectly

30 aware that clinical case reports are not comparable to strong scientific data coming from other studies, Figures 25 to 30 convey in our view an important message to the reader and allow a deeper understanding of the effectiveness of this brace. With specific studies we have shown that the Sforzesco brace: is more effective than the Lyon brace after six months of treatment, with a prospective matched case/control prospective study [11, 21] on 30 AIS patients aged 13 years and with curves of 38 Cobb on average: in the Sforzesco group 80% of patients improved and none worsened, while the Lyon group had results of 53% and 13%, respectively. is equally effective as the Risser plaster brace to achieve the maximal correction after 18 months of treatment, with a prospective cohort study with a retrospective control group [45] on 41 AIS patients aged 14 years and with curves of 40 Cobb. The Sforzesco brace 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 reduction in kyphosis. is more effective than the Risser cast + Lyon brace in treating curves over 45 Cobb at the end of growth, with a prospective cohort study in patients who utterly refused surgery [67] on 28 AIS patients aged 14 years and with curves of in a range of from to 58 Cobb. The patients braced with the Sforzesco had better results than those treated with the Risser cast in the thoracic curves, without any sagittal plane worsening. For the other parameters, the results were similar. is able to improve aesthetics in scoliosis patients with a prospective not-controlled cohort study [68] on 34 consecutive AIS patients 13 years old with curves of 32

31 Cobb with Aesthetic Index (AI) [47] scores of at least 5/6. At baseline, median AI was 6 (95% IC 5-6), but the score decreased to 3 (95% IC 0-5; p<0.05) after six months with the brace, and this value was maintained in the 29 who completed the treatment (95% IC 1-6; p<0.05 with respect to baseline). Discussion The Sforzesco brace has been developed recently, but it is already one of the most tested instruments in the very weak scientific history of bracing. We are not able to compare this instrument with any other that we did not use personally, but we can already state according to our results that its efficacy is higher than that of the Lyon brace [44], and comparable (or even higher as well) to that of the Risser cast [69]. In fact, we use to think of the Sforzesco brace as a cast, with the great advantage on one hand that it can be removed to greatly increase patient comfort, and on the other hand that it can be used from the beginning to the end of treatment without problems, which cannot be done with the Risser cast. We cannot exclude in the future the possibility that the cast (or the Lyon brace) will still find a place in scoliosis treatment for some particular curves or patients, but we are not able now to exactly identify these clinical situations. According to the reported results, we have a strong basis for reasoning that this brace could be more effective in the worst curves than other braces. In fact, to our knowledge, there is only one published paper with good results on curves over 45 Cobb, and they have been obtained either with Risser casting or with Sforzesco bracing [67]. This conclusion needs to be supported by future evaluations and understanding, as well as study results reported by others with other braces. The main strength of this concept is that it was derived by the observation of a chance development, much like other discoveries in medicine, from the finding of penicillin

32 by Fleming to McKenzie treatment for low back pain, and in other fields, like the discovery of dynamite by Nobel. However, according to the correct scientific process, it has been thoroughly checked through scientific reports [44, 47, 67, 69], and it is still under observation and development. We are not closed to our own concept, and we are in fact developing new ideas like Cheneauisation following the early concept of Cheneau [22-24], or by looking at the pelvis base according to the ideas of Rigo [30, 32, 34]. Limitations can obviously be found today in the fact that the use of this brace use is limited to Italy; we can anyway already state that the usage of the Sforzesco brace has already spread outside the first orthotic manufacturer and the first physician and his team. Nevertheless, we need studies from other teams, as is common with instruments at their first stages of development. A typical disadvantage of this instrument is that it is apparently simple. In fact, to a superficial observer it could appear as a simple full-contact brace. In reality, there are complex mechanical concepts and understanding that must be developed to be able to correctly apply this family of braces. Its apparent simplicity could easily drive its spread but could also lead to misconduct in its application. Moreover, another disadvantage is that the messages given to the patients are key to success as well, and must be well understood. The SPoRT concept could also be applied to other braces beyond the ones presented here. Conclusions Bracing is very hard work, in terms of conceptualisation of the practical work to be done, and of the interaction with the whole team, starting from the MD-CPO relationship, to the PT, the patient and the family. It is a demanding, progressive, slow, artisanal effort in the art of patience. In this respect, it is quite the opposite of short, one-shot, quick, highly demanding, cruent surgical fusion. As we to say to our

33 patients, bracing corresponds to the very slow pace of building oneself that humans usually have to face, contrary to the fast solution that he/she may tend to prefer and see as less demanding. Bracing in this respect also becomes a philosophy of one s approach to life, and this is one reason why it is difficult that the slow pace of a good conservative physician can also be the fast speed of a good orthopaedic surgeon, and vice versa. As well, there will always be patients who prefer bracing and others who prefer surgery. This relates to those with high degree curves; in low degree curves, the choice is between bracing and a wait and see strategy, applied in cases in which bracing is too demanding for that particular patient. But, in our own experience, at least in Italy, this is very rare [70], even if not avoidable. Competing interests Stefano Negrini is a physician everyday prescribing braces; he also owns a 30% stock of ISICO. Gianfranco Marchini is an orthothist everyday building braces and owns Centro Ortopedico Lombardo. Fabrizio Tessadri is an orthothist everyday building braces and owns Orthotecnica. Authors' contributions SN drafted the text and figures GM and FT revised and accepted it, and contributed with some figures. Acknowledgements We wirsh to thank Michele Romano for drawings; all our patients, who allowed us to increase our knowledge and skill; our collaborators who, working with us in team, were continuously part of what we learned and were able to do.

34 References 1. Negrini S, Minozzi S, Bettany-Saltikov J, Zaina F, Chockalingam N, Grivas TB, Kotwicki T, Maruyama T, Romano M, Vasiliadis ES: Braces for idiopathic scoliosis in adolescents. Cochrane Database Syst Rev 2010(1):CD Negrini S, Minozzi S, Bettany-Saltikov J, Zaina F, Chockalingam N, Grivas TB, Kotwicki T, Maruyama T, Romano M, Vasiliadis ES: Braces for idiopathic scoliosis in adolescents. Spine (Phila Pa 1976) 2010, 35(13): Landauer F, Wimmer C, Behensky H: Estimating the final outcome of brace treatment for idiopathic thoracic scoliosis at 6-month follow-up. Pediatr Rehabil 2003, 6(3-4): Negrini S, Grivas TB, Kotwicki T, Rigo M, Zaina F: Guidelines on "Standards of management of idiopathic scoliosis with corrective braces in everyday clinics and in clinical research": SOSORT Consensus Scoliosis 2009, 4(1):2. 5. Rigo M, Negrini S, Weiss H, Grivas T, Maruyama T, Kotwicki T: 'SOSORT consensus paper on brace action: TLSO biomechanics of correction (investigating the rationale for force vector selection)'. Scoliosis 2006, 1: Negrini S, Atanasio S, Fusco C, Zaina F: Effectiveness of complete conservative treatment for adolescent idiopathic scoliosis (bracing and exercises) based on SOSORT management criteria: results according to the SRS criteria for bracing studies - SOSORT Award 2009 Winner. Scoliosis 2009, 4: Aulisa AG, Guzzanti V, Galli M, Perisano C, Falciglia F, Aulisa L: Treatment of thoraco-lumbar curves in adolescent females affected by idiopathic scoliosis with a progressive action short brace (PASB): assessment of results according to the SRS committee on bracing and nonoperative management standardization criteria. Scoliosis 2009, 4: Janicki JA, Poe-Kochert C, Armstrong DG, Thompson GH: A comparison of the thoracolumbosacral orthoses and providence orthosis in the treatment of adolescent idiopathic scoliosis: results using the new SRS inclusion and assessment criteria for bracing studies. J Pediatr Orthop 2007, 27(4): Wong MS, Cheng JC, Lam TP, Ng BK, Sin SW, Lee-Shum SL, Chow DH, Tam SY: The effect of rigid versus flexible spinal orthosis on the clinical efficacy and acceptance of the patients with adolescent idiopathic scoliosis. Spine 2008, 33(12): Atanasio S, Zaina F, Negrini S: The Sforzesco brace and SPoRT concept: a brace to replace cast in worst curves. Disabil Rehabil Assist Technol 2008, 3(3): Negrini S, Marchini G: Efficacy of the Symmetric, Patient-oriented, Rigid, Three-dimensional, active (SPoRT) concept of bracing for scoliosis: a prospective study of the Sforzesco versus Lyon brace. Eura Medicophys

35 12. Weiss HR, Weiss GM: Brace treatment during pubertal growth spurt in girls with idiopathic scoliosis (IS): a prospective trial comparing two different concepts. Pediatr Rehabil 2005, 8(3): Katz DE, Richards BS, Browne RH, Herring JA: A comparison between the Boston brace and the Charleston bending brace in adolescent idiopathic scoliosis. Spine 1997, 22(12): Howard A, Wright JG, Hedden D: A comparative study of TLSO, Charleston, and Milwaukee braces for idiopathic scoliosis. Spine 1998, 23(22): Bunnell WP, MacEwen GD, Jayakumar S: The use of plastic jackets in the non-operative treatment of idiopathic scoliosis. Preliminary report. J Bone Joint Surg Am 1980, 62(1): Climent JM, Sanchez J: Impact of the type of brace on the quality of life of Adolescents with Spine Deformities. Spine 1999, 24(18): Negrini S, Atanasio S, Zaina F, Romano M, Parzini S, Negrini A: Endgrowth results of bracing and exercises for adolescent idiopathic scoliosis. Prospective worst-case analysis. Stud Health Technol Inform 2008, 135: Sibilla P: Trent'anni di scoliosi. Lezione "non" magistrale. In: Rachide & Riabilitazione Edited by Negrini S, Rainero G, vol. 1. Vigevano: Gruppo di Studio Scoliosi e patologie vertebrali; 2002: Sibilla P: Il trattamento conservativo attivo della scoliosi idiopatica in Italia. In: Le deformità vertebrali: stato dell'arte. Edited by Negrini S, Sibilla P, vol. 2. Vigevano: Gruppo di Studio Scoliosi e patologie vertebrali; 2001: Negrini S, Marchini G, Tomaello L: Efficacy of the Symmetric, Patientoriented, Rigid, Three-Dimensional (SPoRT) concept of bracing for scoliosis: a pair-controlled retrospettive short-term study on the Sforzesco Brace. In: 3rd International SOSORT Meeting: 2006 April ; Poznan, Poland: SOSORT; Negrini S, Marchini G, Tomaello L: The Sforzesco brace and SPoRT concept (Symmetric, Patient-oriented, Rigid, Three-dimensional) versus the Lyon brace and 3-point systems for bracing idiopathic scoliosis. Stud Health Technol Inform 2006, 123: Hopf C, Heine J: [Long-term results of the conservative treatment of scoliosis using the Cheneau brace]. Z Orthop Ihre Grenzgeb 1985, 123(3): Cheneau J: Das Cheneau-Korsett. Ein Handbuch, vol. 1. Dortmund: Orthopadie Technik; Cheneau J: Corset-Cheneau. Manuel d'orthopèdie des scolioses suivant la technique originale, vol. 1. Paris: Frison Roche; Risser JC: Scoliosis treated by cast correction and spine fusion. Clin Orthop Relat Res 1976(116): Mammano S, Scapinelli R: Plaster casts for the correction of idiopathic scoliosis. Acta Orthop Belg 1992, 58 Suppl 1: Stagnara P: Les deformations du rachis. Paris: Expansion Scientifique Francaise; Blount WP, Schmidt A: The Milwaukee brace in the treatment of scoliosis. J Bone Joint Surg 1957, 37:

36 29. Moe JH: Indications for Milwaukee brace non-operative treatment in idiopathic scoliosis. Clin Orthop Relat Res 1973(93): Weiss HR, Rigo M: The cheneau concept of bracing--actual standards. Stud Health Technol Inform 2008, 135: Kotwicki T, Cheneau J: Passive and active mechanisms of correction of thoracic idiopathic scoliosis with a rigid brace. Stud Health Technol Inform 2008, 135: Rigo M, Weiss HR: The Cheneau concept of bracing--biomechanical aspects. Stud Health Technol Inform 2008, 135: Kotwicki T, Cheneau J: Biomechanical action of a corrective brace on thoracic idiopathic scoliosis: Cheneau 2000 orthosis. Disabil Rehabil Assist Technol 2008, 3(3): Rigo MD, Villagrasa M, Gallo D: A specific scoliosis classification correlating with brace treatment: description and reliability. Scoliosis 2009, 5(1): Negrini S: The Evidence-Based ISICO Approach to Spinal Deformities, 1st edition edn. Milan, Boston: ISICO; Negrini S: Bracing adolescent idiopathic scoliosis today. Disabil Rehabil Assist Technol 2008, 3(3): Negrini A, Sibilla P, Negrini S: La cinesiterapia nel trattamento della scoliosi: nuovi orientamenti metodologici. Riabilitazione oggi 1992, 9(4): Negrini S, Negrini A, Sibilla P: Reeducation of the scoliotic patient. In: 2nd meeting of the International Society for the Study and Research on the Spine (SIRER): 1996; Barcelona (ESP) Lyon (F); 1996: Negrini S, Sibilla P: Le deformità vertebrali dell'età evolutiva: stato dell'arte, vol. 1. Vigevano (PV): Gruppo di Studio della Scoliosi e delle patologie vertebrali; Romano M, Carabalona R, Petrilli S, Sibilla P, Negrini S: Forces exerted during exercises by patients with adolescent idiopathic scoliosis wearing fiberglass braces. Scoliosis 2006, 1: Romano M, Negrini S: Does bracing change the sport habits of patients? A controlled study. In: 4th International Conference on Conservative Management of Spinal Deformities: May ; Boston: SOSORT (Society on Scoliosis Orthopaedic and Rehabilitation Treatment); Bunge EM, de Bekker-Grob EW, van Biezen FC, Essink-Bot ML, de Koning HJ: Patients' preferences for scoliosis brace treatment: a discrete choice experiment. Spine (Phila Pa 1976) 2010, 35(1): Negrini S, Grivas TB, Kotwicki T, Rigo M, Zaina F: Guidelines on "Standard of management of idiopathic scoliosis with corrective braces in everyday clinics and in clinical research": SOSORT Consensus Scoliosis 2009, 4(1): Negrini S, Marchini G: Efficacy of the symmetric, patient-oriented, rigid, three-dimensional, active (SPoRT) concept of bracing for scoliosis: a prospective study of the Sforzesco versus Lyon brace. Eura Medicophys 2007, 43(2): ; discussion Negrini S, Zaina F, Negrini F, Marchini G, Aulisa AG: Sforzesco brace (SPoRT Concept) versus Risser cast in adolescent idiopathic scoliosis treatment: similar efficacy, with reduced spinal side effects for the brace. In: 4th International Conference on Conservative Management of Spinal

37 Deformities: May ; Boston: SOSORT (Society on Scoliosis Orthopaedic and Rehabilitation Treatment); Aubin CE, Dansereau J, de Guise JA, Labelle H: Rib cage-spine coupling patterns involved in brace treatment of adolescent idiopathic scoliosis. Spine 1997, 22(6): Zaina F, Negrini S, Fusco C, Atanasio S: How to improve aesthetics in patients with Adolescent Idiopathic Scoliosis (AIS): a SPoRT brace treatment according to SOSORT management criteria. Scoliosis 2009, 4: Negrini S, Grivas TB, Kotwicki T, Maruyama T, Rigo M, Weiss HR: Why do we treat adolescent idiopathic scoliosis? What we want to obtain and to avoid for our patients. SOSORT 2005 Consensus paper. Scoliosis 2006, 1: Wiley JW, Thomson JD, Mitchell TM, Smith BG, Banta JV: Effectiveness of the boston brace in treatment of large curves in adolescent idiopathic scoliosis. Spine 2000, 25(18): Gepstein R, Leitner Y, Zohar E, Angel I, Shabat S, Pekarsky I, Friesem T, Folman Y, Katz A, Fredman B: Effectiveness of the Charleston bending brace in the treatment of single-curve idiopathic scoliosis. J Pediatr Orthop 2002, 22(1): D'Amato CR, Griggs S, McCoy B: Nighttime bracing with the Providence brace in adolescent girls with idiopathic scoliosis. Spine 2001, 26(18): Lupparelli S, Pola E, Pitta L, Mazza O, De Santis V, Aulisa L: Biomechanical factors affecting progression of structural scoliotic curves of the spine. Stud Health Technol Inform 2002, 91: Stokes IA, Burwell RG, Dangerfield PH: Biomechanical spinal growth modulation and progressive adolescent scoliosis - a test of the 'vicious cycle' pathogenetic hypothesis: Summary of an electronic focus group debate of the IBSE. Scoliosis 2006, 1: Castro FP, Jr.: Adolescent idiopathic scoliosis, bracing, and the Hueter- Volkmann principle. Spine J 2003, 3(3): Weiss HR, Hawes MC: Adolescent idiopathic scoliosis, bracing and the Hueter-Volkmann principle. Spine J 2004, 4(4): ; author reply Negrini S, Fusco C, Romano M, Zaina F, Atanasio S: Clinical and postural behaviour of scoliosis during daily brace weaning hours. Stud Health Technol Inform 2008, 140: Duval-Beaupere G, Lespargot A, Grossiord A: Flexibility of scoliosis. What does it mean? Is this terminology appropriate? Spine 1985, 10(5): Torell G, Nachemson A, Haderspeck-Grib K, Schultz A: Standing and supine Cobb measures in girls with idiopathic scoliosis. Spine 1985, 10(5): Smania N, Picelli A, Romano M, Negrini S: Neurophysiological basis of rehabilitation of adolescent idiopathic scoliosis. Disabil Rehabil 2008, 30(10): Burwell RG, Aujla RK, Grevitt MP, Dangerfield PH, Moulton A, Randell TL, Anderson SI: Pathogenesis of adolescent idiopathic scoliosis in girls - a double neuro-osseous theory involving disharmony between two nervous systems, somatic and autonomic expressed in the spine and trunk:

38 possible dependency on sympathetic nervous system and hormones with implications for medical therapy. Scoliosis 2009, 4: Coillard C, Leroux MA, Zabjek KF, Rivard CH: SpineCor--a non-rigid brace for the treatment of idiopathic scoliosis: post-treatment results. Eur Spine J 2003, 12(2): Didier J: La plasticité de la fonction motrice, 1st edn. Paris: Springer; Zaina F, Negrini S, Atanasio S, Fusco C, Romano M, Negrini A: Specific exercises performed in the period of brace weaning can avoid loss of correction in Adolescent Idiopathic Scoliosis (AIS) patients: Winner of SOSORT's 2008 Award for Best Clinical Paper. Scoliosis 2009, 4(1): Nachemson AL, Peterson LE: Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. A prospective, controlled study based on data from the Brace Study of the Scoliosis Research Society. J Bone Joint Surg Am 1995, 77(6): Stagnara P, Mollon G, De Mauroy J: Reeducation des scolioses. Paris: Expansion Scientifique Francaise; Negrini S, Negrini A, Romano M, Verzini N, Parzini S: A controlled prospective study on the efficacy of SEAS.02 exercises in preparation to bracing for idiopathic scoliosis. Stud Health Technol Inform 2006, 123: Negrini S, Negrini F, Fusco C, Zaina F: Idiopathic scoliosis patients with curves over 45 Cobb degrees refusing surgery can be effectively treated through bracing with curve improvements. The Spine Journal 2011 (in press). 68. Zaina F, Negrini S, Atanasio S: TRACE (Trunk Aesthetic Clinical Evaluation), a routine clinical tool to evaluate aesthetics in scoliosis patients: development from the Aesthetic Index (AI) and repeatability. Scoliosis 2009, 4(1): Negrini S, Atanasio S, Negrini F, Zaina F, Marchini G: The Sforzesco brace can replace cast in the correction of adolescent idiopathic scoliosis: A controlled prospective cohort study. Scoliosis 2008, 3(1): Negrini S, Carabalona R: Social acceptability of treatments for adolescent idiopathic scoliosis: a cross-sectional study. Scoliosis 2006, 1:14. Figures Figure 1 - The SPoRT family of braces The SPoRT family of braces include the Sforzesco brace (A), the youngest one, but also the one that allowed to develop the SPoRT concept of correction [44, 69]; the Sibilla brace (B-D), previously developed by Paolo Sibilla according to the first Cheneau concepts [18, 19, 23, 24], and the Lapadula brace (C-E) as developed by Sibilla [18, 19]. The last two braces have been changed from those formerly

39 developed by Sibilla (D-E) and adapted to follow the SPoRT principles of correction (B-C). Figure 2 - The Sforzesco brace owns its name to the Sforesco castles of Milan and Vigevano The Sforzesco brace was named according to the two main cities of the experience of the main author (SN): Vigevano and Milano, which both have castles named Sforzesco for the Medieval Sforza family. Figure 3 - Braces at the base of the SPoRT concept development The concept of SPoRT bracing was developed from the following braces: Risser cast (A), Lyon (B), Sibilla (C) and Milwaukee (D). The last changes made to the SPoRT braces also allowed us to consider among their ancestors the last Cheneau brace (E) and the Rigo Cheneau brace (F). Figure 4 - The active brace principle of bracing: patients continue their sport activities normally To reach the active brace principle of bracing, we require patients to continue their sport activities also inside the brace [35, 41], as can also be seen in this film ( In this figure you can see patients practicing various sport while wearing the brace: volleyball, downhill ski, gymnastics, mountain bike, golf, free climbing, archery, horse riding, squat training, soccer, javelin throw, dance (the patient with the brace on is the middle one). Figure 5 - Patients want correction and an invisible brace Patients want correction and an invisible brace. This is the reason why we introduced the bracing principle Perfect body design and minimal visibility. These patients are wearing their braces in various everyday activities.

40 Figure 6 - The Sforzesco brace invisibility The Sforzesco brace was developed in a town of fashion (Milan), and some patients have stated that this is reflected in its design, that increases wearability. Figure 7 - The Sforzesco brace The Sforzesco brace: anterior (A), posterior (B), left (C), top (D), and bottom (E) views. Figure 8 - The Sibilla brace The Sibilla brace: anterior (A), posterior (B), left (C), top (D), and bottom (E) views. Figure 9 - The Lapadula brace The Lapadula brace: anterior (A), posterior (B), left (C), top (D), and bottom (E) views. Figure 10 - The Lapadula brace to treat scoliosis and hyperkyphosis The Lapadula brace has much versatility and can be adapted to treat an hyperkyphosis associated with scoliosis. Figure 11 - The first Sforzesco brace causes a sudden lengthening of the trunk requiring correction in 2 months Typical correction made to the first Sforzesco brace after a wearing period of 2 months in patients with important thoracic curves: it becomes too short under the concave shoulder and must be lengthen. Figure 12 - ScoliosisManager open access software module for SPoRT brace prescription Screens from the ScoliosisManager open-access free software to manage scoliosis patients, showing the module for a SPoRT brace prescription. Figure 13 - The slopes The slopes. Low lumbar (A); High lumbar (B); Lumbar (C); Thoracolumbar (D); Thoracic (E); Distal thoracic (F); Proximal thoracic (G).

41 Figure 14 - Identification of the main slope Examples of identification of the main slope in some curves looking at the x-ray, at the most inclined line drawn on the limiting vertebrae but also at the body shape. (A) prevalent high lumbar slope; (B) prevalent low thoracic slope; (C) double slope: thoraco-lumbar and thoracic; (D) prevalent high thoracic slope. Figure 15 - Example of correction on the frontal plane slopes Example of correction on the frontal plane slopes of one patient with a thoracolumbar curve of 48 (Risser 1). (A) X-ray pre-brace (48 ); (B) aesthetics pre-brace; (C) aesthetics after 4 months of bracing; (D) x-ray without the brace after 4 months of bracing: corrected to 23 (i.e. reduction of 25, -52%); (E) pre-brace planning with pushes on the right thoraco-lumbar and left thoracic slopes, as well as a lateral shift to the right of the flanks; (F) constructed brace; (G) application of the pushes in the constructed brace; (H) in-brace x-ray with a correction to 13 (i.e. 35 of correction, 73%). Figure 16 - The Cheneauisation of the Sforzesco brace The Cheneauisation of the Sforzesco brace. We used the term Cheneauisation to underline that it derives from the contamination of our own brace with the internationally well-known Cheneau brace: in fact it aims at posturally changing the scoliosis curve through a thrust at level of the convexity of the apical proximal curve and an elevation/medialization of the shoulder at the concave side. Due to our own SPoRT principles the Cheneuization also includes an anteposition of this same shoulder. First line, from left to right: (A) x-rays of the patient at start of treatment (12/07), (B) after 6 months (6/08), (C) in-brace without Cheneuization (4/09); (D) in-brace with Cheneuization (5/09), (E) in-brace with Cheneuization after two months of treatment (7/09).

42 Second line: graph of x-rays measurements. Third line, from left to right: (F) the first brace used; the brace trial: (G) without Cheneuization; (H) with Cheneuization; (I) the brace brace with Cheneuization at time of the 7/09 x-ray. This is the first situation in which we used the Cheneuization due to the absence of correction in a patient with an high-degree sacoliosis refusing surgery, and presenting with a curve possibly responding to such a change. We then made two braces and compared their results with in-brace x-rays, with favorable results for the Chenuization (5/09), that was even increase by time and brace corrections (7/09). The final out-of-brace progression of scoliosis (1/10) was due to a sudden decrease on brace usage that this specific patient suffered. Figure 17 - Cervical push on the transverse process of C7 and above Cervical push on the transverse process of C7 and above. Figure 18 - Identification of the prominence to localize the derotation pushes Identification of the prominence to add plastazote pushes to the envelope. On the left, tob down direction: anterior beding to previsely identify the hump height and ribs involved and mark them; markers on the skin in standing. On the right: marks reported on the brace. Figure 19 - Action of the derotation pushes at thoracic and lumbar levels At the lumbar level, the push on the hump helps to reconstruct lordosis, and as a consequence it is directly on the transverse apophysis, potentially also adding a frontal plane corrective action (A). At the thoracic level, on the contrary, the push can damage the sagittal plane, and must not reach the transverse processes, so to allow a possible leverage by the rib that could even result in a kyphotisating action (B).

43 Figure 20 - Modelling of the trunk shape during brace building During brace building a careful modelling of the trunk shape is made either on the cast mould or on the PC screen. In this figure the correction of circumferences (left) and shapes (right) of a single patient with a right thoraco-lumbar curve is reported. On the left there are the original (red) and corrected (blue) horizontal sections of the body at the level of the horizontal lines reported in the middle body shape, where the original laser scan of the trunk is represented. On the right the frontal contour of the original (red) and corrected (blue) body shapes are reported, while inside these lines, in grey, there is the final trunk shape from which the brace is going to be built. Figure 21 - Non overlap of the pushes, to be checked on a plane by plane basis The non-overlap of pushes is checked on a plane by plane basis: frontal (A) and coronal action (B). Figure 22 - Braces must always achieve good aesthetic results Braces must always achieve good aesthetic results, as it is shown in some final results of ours. Figure 23 - The concertina effect of brace correction The concertina effect [35] could explain the importance of patient s compliance. According to this hypothesis, each time a brace is weaned the deformity gradually moves back from the maximal in-brace correction to the original out-of-brace situation; this reversal is due to a postural collapse [57-59], that is correlated to the length of brace weaning and the rigidity (flexibility) of the spine [57] (itself correlated to the stage of growth, the bone age, the muscular endurance and the usual brace wearing). According to the concertina effect hypothesis, the deformity reached at the end of daily brace weaning gives the allowed compression of the wedged vertebrae, and consequently the final results. In fact, the more the brace is weaned

44 daily, the worst the results. We published some preliminary proves of this hypothesis [56]. Figure 24 - Examples of SEAS exercises to be performed during brace treatment SEAS exercises during brace treatment. (A) Preparation to bracing. Exercises aimed at increasing range of motion of the spine on all planes, in order to allow the brace to exert the maximum possible correction. (B) Modeling exercises in brace. The patient is in a relaxed position The patient moves away from sternal upright to do a maximum thoracic kyphotization movement. (C) Muscular endurance strengthening exercises. We propose strengthening exercises, requiring lumbar lordosis and thoracic kyphosis preservation, while frontal and cross-sectional plans correction is guaranteed by brace pushes. (D) Active Self-Correction (ASC) (autocorrection according to SEAS) during brace weaning. Figure 25 - First case report: adolescent thoraco-lumbar scoliosis patient over 45 who reached the end of treatment On the left, from left to right, in the first and then in the third line: all x-rays of this case report of a patient that reached the end of treatment (each x-ray is marked with the corresponding date). On the left, midline: graph with the results obtained, dates and Risser test. On the right, in top-down direction: the brace used, and the posterior and sagittal aesthetic appearance at the end of treatment. A.A. has been evaluated the first time in december 2004, presenting with a second x-ray showing a thoraco-lumbar left scoliosis progressed in 18 months from 44 (Risser 0) to 61 (Risser 2). Fusion had been proposed, but refused. She started treatment with the Sforzesco brace 23 hours per day and SEAS exercises 3 times a week (45 ): after 5 months she was 49 (Risser 3). Treatment continued other 6 months 23 hours per day, then 22 per 6 months, and brace was continously and gradually weaned 2 hours every 6 months

45 (ref): she improved after 3 years of treatment (41, Risser 4) and 4 years (38, Risser 4). At the last x-ray after 48 hours without the brace, and 5 years and 6 months of continuos Sforzesco brace treatment and SEAS exercises, she finished treatment at 39. Figure 26 - Second case report: adolescent thoraco-lumbar scoliosis patient still in treatment On the left: posterior (first line), and sagittal (second line) aesthetics, and the brace in use (posterior third line; lateral fourth line) of all evaluations (apart the first visit) are reported from left (oldest) to right (last one). On the right, top-down, left-right direction: all x-rays of this case report of a patient still in treatment, and the graph with obtained results. C.S. has been evaluated the first time in July 2007, presenting with the first x-ray showing a thoraco-lumbar left scoliosis of 41 (Risser 1): fusion had been proposed but refused. She started treatment with the Sforzesco brace 23 hours per day and SEAS exercises 3 times a week (45 per session): after 6 months she was 28 (Risser 2). Treatment continued 6 months 22 hours per day, then with a 1 hours progressive weaning every 6 months. At the last x-rays after 2 years of treatment, performed after 8 hours without the brace, she was improved to 15 (Risser 3). Now she is wearing the brace 14 hours per day. Figure 27 - Third case report: adolescent thoraco-lumbar scoliosis patient rapidly progressing still in treatment On the left: posterior (first line), and sagittal (second line) aesthetics. On the right: the brace used, and the graph with obtained results. On the bottom line: all x-rays of this case report of a patient still in treatment. G.B. presented in september 2009, 10 years old, with a first x-ray showing a thoracic left, thoraco-lumbar right curve of (Risser 0): parents stated that they had seen their daugther worsening in the 15 days span between the x-ray and the medical evaluation. At first a SpineCor brace has been

46 prescribed but the x-ray within brace showed such a bad situation (14-30 ) to suggest to re-evaluate a radiograph without the brace: scoliosis was rapidly worsening (26-39 ). We decided to move to a SPoRT brace and SEAS exercises (twice a week, 45 per session): Sibilla 23 hours per day. In 6 months, while growing 6 cm. (from 145 to 151), she corrected to 17-18, and in 6 more months wearing the brace 22 hurs per day, she arrived to 13-14, during an height increase of other 6 cm. (from 151 to 157). Now she continues to be Risser 0, and is wearing the brace 21 hours per day. Figure 28 - Fourth case report: adolescent double thoracic, lumbar scoliosis patient over 45 still in treatment On the left: posterior (first line), and sagittal (second line) aesthetics, and the brace in use (posterior third line; lateral fourth line) of all evaluations (apart the first visit, where aesthetics and first x-rays are shown) are reported from left (oldest) to right (last one). On the right, top-down, left-right direction: all x-rays of this case report of a patient still in treatment, and the graph with obtained results in the two curves: upper line, thoracic curve, lower one lumbar curve. C.F. has been evaluated the first time in September 2008, presenting with the first x-ray showing a thoracic right lumbar left scoliosis of (Risser 0). She started treatment with the Sforzesco brace 23 hours per day and SEAS exercises 2-3 times a week (45 per session): after 6 months, while growing 5.5 cm. (from to 164), she was (Risser 0). Treatment continued 6 more months 23 hours per day, then reduced to 22: in this year, while growing 4 cm. (to 168), she reduced her scoliosis to After 6 months at 20 hours, now she is wearing the brace 18 hours per day. Figure 29 - Fifth case report: juvenile thoracic scoliosis patient of 45 who weaned the brace but is still in treatment First line, left to right: x-rays at brace wearing (March 2005) and at brace weaning (October 2008), frontal and sagittal aesthetics in the last evaluations after brace

47 weaning. Second line: all frontal x-rays of this case report of a patient still in treatment. Third line: sagittal x-rays, and the graph with obtained results. B.C. infantile thoracic right scoliosis was discovered at the age of 13 months, and rapidly progressed without treatment from 27 to 40 in 4 months as soon as she reached the standing position. A Sibilla brace treatment was then started 23 hours per day per 4 months and 20 during the summer, with an immediate reduction to 16 in 8 months. Brace was then gradually reduced 2 hours every six months while maintaining correction, and finally weaned with the curve at 10. At the age of 6, as soon as was possible, everyday SEAS exercises (20 per session) have been started and are the only actual treatment. Figure 30 - Sixth case report: adolescent lumbar mature (Risser 4) scoliosis patient who reached the end of treatment First line, left to right: posterior aesthetics and brace used. Second line, left to right: sagittal aesthetics and brace. Third line: graph with obtained results. Fourth line: all frontal x-rays of this case report of a mature (Risser 4) patient who reached the end of treatment. D.F. discovered her 38 left lumbar scoliosis at 16.2 years of age, in October 2006 (Menarche October 2002). She had a totally flattened left flank (unfortunately we do not have the first photograph) and a Sforzesco brace for aesthetic purposes (and hopefully curve reduction) was proposed. She started with 23 hours per day and in 6 months immediately reduced the curve to 21. Brace wearing was reduced 2 hours every 6 months, and finally weaned in June 2010 with a curve of 19 and a complete recovery of the aesthetic appearance. Tables Table 1 - Corrective action according to the frontal plane identified slope Corrective action according to the frontal plane identified slope.

48 Slope Action Construction 1 Low lumbar shift of the trunk at the base 2 High lumbar elevation of the emithorax The whole trunk is shifted toward the concavity of the lumbar curve The last ribs on the side of the convexity are elevated with a gradually decreasing compression in a down-up direction 3 Lumbar shift of the trunk at Combination of 1 and 2, on the same side the base and elevation of the emithorax 4 Thoracic push on the distal ribs below the apex On the side of convexity of the curve. All the ribs involved in the slope must be pushed. The rib corresponding to the apical vertebra is not involved (and sometimes also that below the apical) 5 Distal thoracic push on the distal On the side of concavity of the curve 6 Proximal thoracic ribs above the apex push on the distal ribs above the apex On the side of concavity of the curve 7 Thoracolumbar elevation of the Combination of 2 and 4, on the same side emithorax and push on the distal ribs below the apex

49 Figure 1

50 Figure 2

51 A D Figure 3 B E C F

52 Figure 4

53 Figure 5

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59 Figure 11

60 Figure 12

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