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In April this year, I was fortunate enough to travel to San Francisco for the 15^th annual SOSORT (Society on Scoliosis Orthopaedic and Rehabilitation Treatment) conference through support from the OETT. I have worked as an orthotist for the past 5 years and throughout my career, as well as during training, I have been lucky to garner significant and varied experience in an area I am passionate about: idiopathic scoliosis bracing.

Idiopathic scoliosis has been treated with external bracing for centuries, using principles that are familiar to this day, such as 3-point-pressure, derotation and distraction. Thankfully, methods of treatment and brace design have become more sophisticated during this time. This has happened because of dedicated practitioners and researchers gathering clinical data over months, years and sometimes decades in order to augment global knowledge of the aetiology of idiopathic scoliosis (IS) and therefore develop protocols for bracing (as well as other conservative treatment and surgery) in order to achieve the best possible outcomes for patients. There is plenty of diversity in clinical evidence and practice however. This can make things a little confusing when trying to decide which is the best treatment for our patients.

This is what led me to the conference in San Francisco. SOSORT have developed globally recognised bracing guidelines which are reviewed every year. The conference has been held annually all over the world since 2004 and is an opportunity for delegates to present papers on the research they have undertaken, as well as educational lectures. The committee boasts names familiar to anyone who has researched IS and/or IS bracing – Weinstein, Negrini, Zaina. Et al.

The conference this year took place at the Parc 55 Hilton hotel, in the middle of Embarcadero, the bustling financial district of the city. Day 1 was a pre-conference education day to kick off proceedings; the next 3 days the conference itself. The main event room was accessed through a concourse area populated with posters of various studies submitted by SOSORT members. Once inside the conference room one could easily find a seat amongst the rows of desks and chairs adorned with information packs, paper and pens. The room was fronted with 2 projector screens, a podium for the speakers and seating for the moderators and presenters.

The first day was no gentle introduction, as from 8am to 5.30pm were rigorously timetabled lectures on the natural history of adolescent idiopathic scoliosis (AIS), a background on normal 3D vertebral growth and the patho-biomechanics of growth and development in IS to name but a few. Meticulously scheduled coffee and lunch breaks allowed the participants to review the posters and mingle, networking with professionals from all over the globe. The main aim of the pre-conference day was to focus on growth and development in scoliosis and the biomechanical, physiological and psychological intricacies thereof. The lectures on this first day were delivered mainly by members of the committee. Following each lecture was a question and answer session and audience members  were able to express ideas and discuss the lectures with each presenter.

The first day of the conference started with a welcome from the local host (an orthotist practising in the area, a Salford alumnus in fact) and then further presentations, only this time of clinical and technical research papers. Over 30 papers were presented by a mix of doctors, orthotists and physiotherapists on the first day alone. Subjects included psychological complexities associated with bracing, development of an AIS patient decision aid, quality of life questionnaires, physiotherapeutic scoliosis-specific exercises (PSSE), brace design analysis for upper thoracic curves, biomechanical spinal simulation/models for curve and correction prediction and many more. Again there was opportunity to question and discuss the topics presented. In the midst of the papers being presented was a lecture on PSSE by Dr Manuel Rigo (of Rigo-Cheneau fame!) a lecture by Dr Stuart Weinstein (renowned researcher and practitioner in the field of IS) and further opportunity to review the posters. Alongside these posters were 5-6 stalls set up and manned by various commercial sponsors of the event. These included brace suppliers such as Boston and Aspen, and more technical companies such as EOS Imaging and ScolioScan. This allowed introduction to new or alternative methods of curve detection and analysis, as well as a range of brace types.

The second conference day continued with the presentation of papers interspersed with discussion, the theme of the papers covering lung function, long term bracing results, de novo scoliosis and surface topography. In addition there was an address by the SOSORT president, a choice of two symposia over lunch and a guest lecture by Dr Scott Haldeman on the Global Spine Care Initiative, a charity providing management of spinal disorders in developing countries.

The last day (which was just a morning session) started with a guest lecture from Rachel Mulvaney, VP of Curvy Girls Scoliosis Foundation, a US support group. Papers presented on this day were relating to bracing and treatment adherence and further analyses of PSSE effectiveness.

The conference was closed with the announcement of award winners for papers and posters.

Overall the three and a half days were jam-packed and very intensely timetabled. The information presented in the papers was from evidence gathered in the last few years, or if over a long time, then the evidence was analysed and conclusions drawn in the last year ensuring the data was up to date. I have been able to take comfort in the papers reinforcing the evidence behind rigid bracing, ensuring I am committing fully to evidence-based practice. Auxiliary areas such as long-term effects of scoliosis after bracing, bone development, aerobic capacity and pulmonary function will augment the breadth and depth of my knowledge in the subject and help me hone my skills in assessment and individual case management.

On the whole, attending SOSORT was a very worthwhile endeavour from which I learned a great deal. This will be implemented in my own practice and the information has been presented to and disseminated amongst my colleagues. It is experiences like this which not only expose one to new clinical data and innovation, but to different cultures, processes and practitioners who all have a common goal: to improve clinical outcomes and the patient experience.

Date course was held
2/7/19

Venue
London Road Community Hospital, Derby

Speaker / Presenter(s)
NCORE, Alison Middleditch

Key learning points

• MDT course. In attendance physios, orthotics and OT.
• Diagnostic Criteria of HSD and EDS
• Clinical Presentation
• Impact on function
• Assessment
• Practical Framework for Management

Criticisms
Could have done with more papers to back up practical session/discussion

Application of new knowledge to current and future working practice

Sharing knowledge within Orthotics and MDTs I work within. Increased confidence in discussion of treatment plan with EDS aptients.

Feedback

The course was organised by NCORE. This group have been organising courses for 20 years now for MDTs. Looking on their website the list of courses available are wide spread and varied covering multiple professional disciplines, different skill sets or focussing on different conditions.

This course was attended by approximately 20 people including physios, OTs myself (Orthotist) and a physio from Canada.

Alison is a physio working in NHS and private physiotherapy. Her initial interest in HSD came from working with ballerinas and she has been working with EDS literature since.

The initial part of the course looked into different subsection, diagnoses and classifications of hypermobility disorders, including hypermobility spectrum disorder, hypermobility EDS, hereditory connective tissue disorders. Looking at the varying presentations and systemic impact.

The clinical skills workshop section covered physical assessment of different joints and strengthening programs which can be given in clinic by all in attendance.

Finally a discussion occurred across the different professions highlighting areas of concern and how to work across the teams for these patient groups.

Would recommend this course to anyone in Orthotics or other professional disciplines.

Date course was held
20/5/19

Venue
QEUH LEARNING CENTRE

Speaker / Presenter(s)
Prof Sebastian Chastin,
Dr Val Blair (Programme Director, Allied Health Professionals, NHS Education for Scotland)
Claire Ritchie (Director of Allied Health Professionals NHS Greater Glasgow & Clyde,
Dr Judith Lane,
Dr Wendy Cohen,
Prof Jim Woodburn (Assistant Vice Principal, Research Excellence, Glasgow Caledonian University)
Prof Emerita Ann P Moore (Director of the Council for Allied Health Professions Research (CAHPR)

Key learning points

The importance of a positive research culture within orthotics to improve engagement with research.

Linking with professional researchers and other professionals to improve impact of work.

Criticisms
Some talks repetitive

Application of new knowledge to current and future working practice

• Promoting a positive research culture within the department. I think an effective and manageable way of doing this would be to start a journal club within the department. Our department has already begun the planning of organising this.
• We intend to improve links with GCU particularly via Jim Woodburn and his facilities
• I have signed up to a Future Learn course called School for Agents of Change which was being promoted by one of the speakers and seems interesting. It is 6 weeks of lectures to encourage culture change within organisations
• Linking more with the University of Strathclyde – this has already begun with staff having input into student project titles.
• It is strongly recommended that departmental projects go through NHS GGC R&D. To
• Co-Creation was discussed by Seb Chastin from GCU who developed the PRODUCES framework. I intend to feed this back to our KAFO specialist who plans to redesign how the KAFO patients are seen within the department and is very keen to have stakeholders involved from the beginning.

I had the opportunity this year to attend the annual Society of Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) conference in San Francisco, USA. I was able to attend the conference due to the generous contributions of Opcare and the Orthotic Education Training Trust
(OETT). SOSORT is an international society that focuses on the conservative treatment options for spinal deformity; its aim is to be a platform for researching and presenting on the best non-surgical treatments for scoliosis but also to encourage a multidisciplinary approach to the questions that need answering. Previously I have attended the annual meeting in Dubrovnik, Croatia and the preconference education day in Lyon, France both of which were invaluable in my knowledge and care of patient with spinal deformity so I was greatly looking forward to another informative and enlightening experience.

The pre-conference education day this year was themed on the growth and development of scoliosis and was kicked off with a fantastic talk from Dr Stuart Weinstein who has been instrumental in changing the landscape of conservative treatment for scoliosis since his paper in 2013 proving the
efficacy of bracing. He spoke about the natural history of adolescent idiopathic scoliosis (AIS) and how important it is to keep the natural history in mind as clinicians, specifically the risk of progression and how this should influence the decision to treat and what treatment options should be offered. Dr Weinstein outlined some work he has done on the likelihood of progression based on long term follow up to study the natural history of non-surgically treated scoliosis patients and determined that coronal curves under 30° that reached maturity did not get worse into adulthood. This long term follow up also showed that adults with a 30° scoliosis did show any increased chance of functional disability – this conclusion is a bold one, and certainly one that until further evidence is gathered should be treated with caution as his BrAIST paper was.

The rest of the Pre conference education day went on to talk about the less commonly discussed sagittal and transverse plane deformities, and how we should be looking at these in more detail both in research as well as clinical practice, how the anatomy of growth can predict the progression of scoliosis, and also the evidence supporting the reintroduction of screening for scoliosis.

The first day of the conference kicked off with a session on patient centred care and pulmonary issues. The theme of the talks was generally related to quality of life and adherence to treatment and how this can affect the outcomes of treatments. Ideas were presented on how to improve these two areas including patient decision tools and community education. Later in the day a session on physiotherapy scoliosis specific exercise (PSSE) and scoliosis screening brought talks on starting conservative treatment earlier on in the natural history of scoliosis and how this might affect need for treatment later. There were also talks on the evidence behind PSSE which is brilliant to see as historically PSSE has been very low in evidence and is hopefully going to be the next big push in research now bracing has been successfully identified as a conservative treatment for scoliosis. The rest of day one was made up of talks on flexibility of the trunk and how bracing can affect this as well as the accuracy of current measuring tools for axial trunk rotation and the development of new tools.

Day two started with the papers that had been nominated for the best SOSORT paper. There was a good range of topics, specifically of interest to me as an orthotist were the talks on long term follow up after brace treatment which confirmed Dr Weinsteins results that curves under 30° at end of growth did not progress in adulthood. There was also a recommendation that late risser patients of 3-5 should still be treated despite them being outside guidelines for brace treatment based on the results of long term follow up for cobb angles over 30°. Later in the day was a session on adult deformity, despite not seeing patients in this cohort myself it was and interesting insight into a different aspect of scoliosis care. I learnt the effectiveness of the same treatments I am confident with in the paediatric population and how treatment must change for the adult one.

Day two finished with the consensus report from the brace classification working group. Of the whole conference, this topic was one of the ones I was most looking forward to. The working group failed to come to a consensus last year and so was reformed this year to attempt the same
challenge. That challenge was to bring together the definitions of as many braces used worldwide and try and classify them with a system that will be universally recognised. If successful, this will improve the reliability of future studies into brace treatment as braces with the same classification can be directly compared on a cross centre basis. The consensus report was the early stages of this process and has narrowed down the technical factors of bracing into 5 key principles; Overall action e.g. elongation, Rigidity, Anatomy e.g. TLSO, Planes (the primary corrective plane) and Construction. This consensus will hopefully lead the way for better quality research and therefore lead to better treatment recommendations from official establishments, for us in the UK this will hopefully lead to NICE guidelines specifically related to treatment on scoliosis – at the moment the only mention of scoliosis under NICE is that of one specific surgical technique.

The last day of the conference focussed on the bracing and treatment adherence which had been briefly covered earlier on day one, some centres have developed information booklets and others are looking at validating online questionnaires to get more information on why patients are not
compliant with treatment. One particularly interesting talk was on the development of clinical practice guidelines based on the 2006/2008 SOSORT guidelines on brace biomechanics and clinical management and the mandatory training of clinicians on these guidelines.

Compared to the previous years conference in Dubrovnik, there was less quantity of talks on bracing however the talks that were present were of incredible quality and have a large impact on clinical practice in the next few years. I look forward to the continued work into the Consensus project and look forward to hearing updates on this at SOSORT 2020. It is also fantastic to hear the increased support for research into PSSE which is the next stage in cementing the importance of conservative treatment in scoliosis, specifically the essential part the MDT needs to play in getting successful outcomes. It was also important to remember the benefit of looking back at the natural history of scoliosis, how this informs us on the evolution of treatment and how losing sight of this can be detrimental to our long-term goals of scoliosis research and our short terms aims of individuals treatment.