ORTHOTIC TREATMENT FOR IDIOPATHIC SCOLIOSIS
Thomas M. Gavin, C.O.
President, Director of Clinical Services
BioConcepts, inc.
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info@orthotic.com
(630) 986-0007
- Introduction
- History of Orthotic Treatment
- Nonoperative Treatment
- Desired Outcomes
- About Orthotic Treatment
- What We Don't Know - Treatment
- The Orthotist
- Surgical Treatment
- Conclusion
- References
INTRODUCTION
Spinal deformity means abnormality in the curves of the spine. All spines have certain normal curves such as the sway in the low back and neck and the round by the shoulder blades. Scoliosis is a lateral or sideways curvature of the spine with rotation to the concave side, creating the "hump" that is visually apparent (Figure 1). Kyphosis means "humpback" and is an abnormally large round of the back by the shoulder blades. Scoliosis and kyphosis can occur together.
Scoliosis, which tends to run in families and is more common in females (>90%) than males (<10%), usually is first detected in late childhood or during the early teen years. While there are many different causes for scoliosis, including polio, cerebral palsy, spina bifida, malformed vertebrae, spinal cord injury, and several other diseases, malformations and injuries to/of the neuro-musculoskelatal system, in the vast majority of cases there is no known cause. This is known as "idiopathic" (unknown origin) scoliosis. Over 90% of "idiopathic" curves are convex to the right in the thoracic spine and convex to the left in the lumbar spine.
Scoliosis can often be treated by wearing a brace, but if the angle of the spinal curvature goes beyond 40 degrees (Figure 2) in childhood, it may become even more pronounced in adulthood and continue to progress after growth has stopped. Since the spine and the rib cage are connected, a severe scoliosis affects the position of the ribs and can affect surrounding organs as well.
Severe scoliosis not only affects the individual's appearance, but it can also compromise her health and ability to function. Health risks from this severe spine curvature include neurological problems from pressure and tension on the spinal nerves, arthritis and lung and heart problems. A curve in the lower spine can make participation in sports or athletic activities difficult since it may limit normal motion in the most mobile section of the spine.
If the curve remains under 40 degrees, it probably won't get worse in adulthood and can be checked by x-ray on a yearly basis. Orthotic (brace) treatment is advocated for the skeletally immature with progressive curves of 25o-45o and spinal fusion surgery for curves over 45o.
History of Orthotic Treatment
The history of the usage of orthoses (braces) to correct and support deformities in the spines of children is long and respectable. Galen5 (131-201) who first used the words scoliosis, lordosis and kyphosis used dynamic bracing and an exercise program to treat spinal deformity. Ambroise Pare5 (1510-1590) wrote extensively on the use of spinal supports and braces. Nicholas Andry (1658-1742) who coined the word orthopaedia pertaining to the straightening of children, reported " If the spine be crooked in the shape of an S, the best method you can take to mend it is to have recourse to the whale bone bodice, stuffed parts shall exactly answer to those protuberances which ought to be repressed, and these bodices must be renewed every three months at least. "2
Throughout the nineteenth century the Europeans developed a vast amount of devices fashioned from steel, leather and plaster, designed to correct deformities of the spine5. The modern era of orthotic treatment for spinal deformities began with the development of the Milwaukee brace (cervico-thoraco-lumbo-sacral orthosis) by Drs. Blount and Schmidt in Milwaukee Wisconsin in the late 1940s3.
Scoliosis, or curvature of the spine, is a three dimensional, progressive deformity which has been treated non-operatively since the advent of the CTLSO (Milwaukee brace) in the 1950's in order to prevent progression of the curve for the remainder of growth in immature patients and thus prevent surgery. Currently, lower profile TLSO's (such as the Boston, Miami, Rosenberger, Lyonnaise, Wilmington, and Charleston orthoses), which eliminate the cervical component of the Milwaukee, are more often prescribed for cosmetic reasons.
The three primary categories of scoliosis are idiopathic (unknown origin), neuromuscular or "paralytic" (arises due to a muscular imbalance secondary to a neuromuscular disease), and congenital (arising due to a congenital anomaly).
Nonoperative Treatment
The Milwaukee brace (Figure 3) was first used to replace plaster casts after spinal fusion surgery and later was used for the nonoperative management of scoliosis and kyphosis3,4,5,6,8,9,16,18,20,22. With help from biomechanical engineers, orthopaedists and orthotists gained a better understanding of the biomechanical function (mechanisms of action) of spinal orthoses1,6,11.
Some of this resulted in the design and improvement of newer, shorter orthoses such as the TLSO (thoraco-lumbo-sacral-orthosis) which were used to treat curves lower in the spine. Some of these have names such as the Boston brace (figure 4)10,14,15,21, the Miami brace19, the Wilmington jacket (figure 5)7, and the Rosenberger orthosis (figure 6)12,. Although the shorter profile brace (TLSO) is standard for present day treatment of scoliosis because of the ability to completely conceal the brace with clothing, the Milwaukee is still the only orthosis that is best to treat curves higher in the spine (apex T-8 and up) and for the treatment of kyphosis which usually is in the mid and upper thoracic spine13.
Figure 4: Boston Brace |
Figure 5: Wilmington Jacket |
Figure 6: Rosenberger Orthosis |
Through computer modeling, engineers have shown theoretical results that the Milwaukee brace does work better for curves in the thoracic spine then the TLSO6. This does not mean that all children with thoracic scoliosis need a Milwaukee brace, it merely means that if a curve is large and won't reduce well in a TLSO that it may do better in a Milwaukee brace13.
Desired Outcomes
Sometimes it seems a bit confusing about what a brace should do for idiopathic scoliosis. If a 10 year old child comes into a clinic with a 30o curve and is prescribed a brace that reduces the curve to 15o and later weans out of the brace at 14 years of age and the curve returns all the way back to 30o, what has the brace done? The brace has essentially prevented spinal fusion surgery.
Spinal curves do not cause medical complication until they exceed 70o so a thirty degree curve is benign to the cardiopulmonary system. Lonstein and Carlson showed that a 30o curve in a 10 year old is almost always going to progress17 (Figure 7) however Weinstein and coworkers showed that a 30o curve in an adult almost never progresses27(figure 8). If the child mentioned previously with the 30o curve did not get an orthosis, the curve would have most likely progressed to a larger magnitude, probably over 45o and thus require surgery.
Figure 7 |
Figure 8 |
Dr. Patwardhan and his engineering colleagues did a theoretical computer modeling study on curves from 0o-60o that shows that the larger a curve is, the more likely it is to progress6 (figure 9). These modeling studies help to explain why we don't treat children with 15o and 20o spinal curves as they are not all going to progress and why we do begin orthotic treatment for children with progressive curves that are over 25o. This also helps to explain why children with curves over 45o are likely to progress even if they are braced and why someone with a spinal curve over 50o is likely to progress even as an adult.
Assuming that this child is skeletally mature when she weaned out of the orthosis, even though the curve returned to its original magnitude, it is very unlikely that it will progress and require a spinal fusion. Curve progression is directly related to growth and this is why younger children are more likely to progress with smaller curves than older children or adults.
Things We Know About Orthotic Treatment
We know that orthotic treatment works! In recent years, both retrospective and prospective clinical studies were conducted that led to the same conclusion; that orthoses do prevent long-term curve progression and therefore reduces the need for surgery18,24. We also know that the people included in these were prescribed either the Milwaukee brace or one of the current TLSO's for full-time (23 hours per day) wear. One may reach the conclusion from some of these studies that the more the curve reduced while in the orthosis, the better the outcome. In many cases, the residual curve after orthotic treatment ends up smaller than the curve was before treatment. However, it is unpredictable who will end up with a smaller curve after treatment and who will return to pre-orthosis magnitudes or greater.
Dr. Lonstein showed that children with larger curves had to have the curve reduced by at least 1/2 in the orthosis to have a good outcome18. However, In a recent study, Noonan and coworkers showed very poor outcomes using the Milwaukee brace. In this study, few of the curves were reduced by half in the orthosis25.
Upadhyay26 evaluated 85 patients with idiopathic scoliosis treated with spinal orthoses in order to determine new prognostic indicators for the final outcome of brace treatment. The results showed that patients who demonstrated a reduction of both the degrees of curvature and vertebral rotation on radiograph 1-2 months after initial brace wear had 97% good outcome at skeletal maturity (when bracing is halted), and none required surgery.
A recent study presented at the 1996 Scoliosis Research Society by Katz15 compared the effectiveness of the TLSO Boston brace versus the TLSO Charleston bending brace (figure 10). Both orthoses were statistically comparable in preventing curve progression and preventing surgery in patients with single curves of 25-35 degrees. However, they revealed that the Boston brace was statistically more effective in treating larger curves of 36-45 degrees and multiple curves.
The Charleston brace is prescribed for part-time wear and "unbends" curves during nightime usage (figure 11). The Boston brace is usually prescribed for full time wear (18-23 hours). Acceptable results have also been reported for this orthosis10,14,21,23. Katz's study indicates certain orthoses may be more appropriate for certain curvatures, and highlights the need for more research evaluating current TLSO's and their mechanisms of action, and the need to develop an accurate measurement for patient compliance to ensure that patients are wearing the orthosis for the prescribed time.
Figure 11A |
Figure 11B |
In conclusion, if orthosis performance is optimal (started early, worn full-time and the curve is reduced by at least half with minimal losses of correction throughout the duration of wear) the best outcome should result. Orthoses need constant attention to ensure that they are reducing the curves and should be readjusted or re-fabricated if any curve reduction is lost while wearing the brace13.
What We Don't Know About Orthotic Treatment
We don't know the role of wearing time. We can assume that a brace that is never worn will do nothing and that a brace that is worn for 24 hours per day is doing as much as a brace is capable of doing. The idea of wearing a brace for 23 hours a day as full-time wear was an intuitive decision and not based on hard objective data. In recent years, the Scoliosis Research Society has raised doubt as to whether part-time brace wearing is effective and if so, how many hours per day is enough. Also, we do not know how noncompliance has affected the outcomes of the recently published brace studies.
There is a lack of objective data defining what the compliance rate truly is at present or defining minimal acceptable wearing time. Presently several centers are designing new compliance monitors that will allow clinical studies to be carried out that will answer wearing time or "brace dosage" questions.
Currently, at the Rehabilitation Research and Development Center at Hines Veterans Administration hospital we have developed a highly accurate compliance monitor which is currently undergoing testing and will hopefully be used within the next two years.
Until accurate and precise methods are utilized to objectively measure compliance, it is impossible to analyze the effect of wearing time on good versus poor outcome. Therefore any current statements about the effects of brace compliance on outcome of treatment are purely speculative.
The Orthotist
Orthotists were previously craftsmen and artisans who merely provided a device which was then critiqued in clinic by the orthopaedist with the orthotist present and a list of adjustments which made the brace functional were made by the orthopaedist and were subsequently carried out by the orthotist. At every follow-up visit, the same process was repeated to keep the brace at maximum performance during growth. This system worked well for many years but is currently practiced in fewer settings.
The last few decades have seen an advancement in the clinical education of orthotists and the decentralizing of scoliosis management by physicians and Medical Centers. Many more private practice physicians see scoliosis patients in an office setting as opposed to a decade ago when most private practice physicians referred scoliosis patients to the scoliosis clinics in the larger medical centers. As long as someone in a brace sees an experienced orthotist at least every four months for a brace growth adjustment, this decentralizing does not present any problems for bracing. During follow-up, the patient's mom or dad should have either a copy of the most recent x-ray, a copy of the physicians note or a report on how many degrees the curves are currently and the patient's stage of skeletal maturity. This information will assist the orthotist in the brace adjustment process.
The orthotist plays a much greater role in helping to adjust to the idea of wearing a brace. Reassurance that the brace will become very routine after 10 days of wear, and that the brace is difficult to see through clothing are both helpful with someone new to a brace. Once the orthotists "nuts and bolts" role is completed, he or she should spend at least 30-45 minutes with the patient and present family members to answer questions and reassure the child that this is not the end of all of her/his social activity.
A file of pictures of other children wearing braces while participating in sports, school activities and social events are helpful. Arranging a meeting with other children who are more experienced wearers also can be comforting, and a brief speech on why she or he needs to wear a brace is important. All these interactions are helpful but do not seem to have as big of an impact as walking the child in her or his new brace to a room with a full length mirror and allowing them to have some privacy with their family. This helps them to realize that although they feel the brace under their arms, that it is almost invisible through the clothing.
In my experience, I have known children who wanted to share their experience with their peers so I have recommended, and helped with, many science fair projects on scoliosis. I have also known children who were more private about their experience, so I have assisted them by being sure the brace was extremely streamlined for cosmesis and let them know that a some time at the clothing store with the brace will help them completely conceal it under loosely fitted clothing. Many children have told me that only their best friend ever knew they had a brace (after more than a year of wearing) and this was usually because of "sleepovers" or "pajama parties".
Surgical Treatment
If surgery is required, it's best to do it while the patient is young. Younger patients heal more rapidly and easily than adults, and generally have better cosmetic results from the surgery than someone older with an advanced curve who already has a severe deformity.
To help people with severe curves, the entire area of the curve must be stiffened. This is done to prevent a more severe curve from developing as the patient grows older. During surgery, rods and hooks (Figure 13) are inserted into the spine to hold the spine in a corrected position while the individual segments of spine fuse together. Afterward, the spine is permanently straightened. (The rods can be removed later if the patient desires, but this is usually unnecessary, unless they break or cause pain).
Following surgery, almost all patients can return to school or work two to three weeks after leaving the hospital. In the past, people were placed in plaster of Paris body casts for six months to a year (Figure 14), but this technique is rarely used anymore. Instead, we use postoperative orthoses which can be removed for showering or sleep. Strenuous exercise, lifting or bending is not recommended for 3-6 months, though walking is highly recommended.
Because of recent advances in spinal fusion surgery today, success rates are much higher than they were just fifteen years ago.
Conclusion
For optimal performance, bracing needs to be started early (>25o and progressive) and must reduce the curves and maintain curve reduction (> 50%) throughout the duration of wear. The primary role of a brace for idiopathic scoliosis is to arrest curve progression and yield a post bracing curve that is of a magnitude that will not progress as an adult. A physician and orthotist team must assure the patient that a spinal brace is not impossible to wear, will not drastically alter social and athletic quality of life and will provide a good chance of preventing spinal fusion surgery. Since bracing is the only accepted conservative treatment for idiopathic scoliosis, it must be done meticulously. Follow-up adjustments must be done in a prompt manner and medical professionals, parents and the community should help ease the anxiety of the children who need to wear a brace.
Surgery should be done as a last resort for people who were unsuccessfully treated in an orthosis or when the curve was not detected early enough to treat with an orthosis.
References
1. Andriacchi TP, Schultz AB, Belytschko and DeWald RL: Milwaukee Brace Correction of Idiopathic Scoliosis. J Bone Jt Surg 58A,806, 1976.
2. Andry N: Orthopaedia., JB Lippincott Co (Facsimile reproduction of the first edition in English, London, 1743), Philadelphia, 1961.
3. Blount WP, Schmidt AC, Keever ED and Leonard ET: Milwaukee Brace in the Operative Treatment of Scoliosis. J Bone Jt Surg 40A: 511-525, 1958.
4. Blount WP and Moe JH: The Milwaukee Brace. Williams and Wilkens Co. Baltimore, 1973,
5. Bunch WH, Keagy R: Principles of Orthotic Treatment. CV Mosby Co. St. Louis, Mo 1975.
6. Bunch WH., Patwardhan AG.: Scoliosis; Making Clinical Decisions. CV Mosby Co. St. Louis, Mo 1989.
7. Bunnell WP, MacEwen GD and Jayakumar S: The Use of Plastic Jackets in the Nonoperative Treatment of Idiopathic Scoliosis. J Bone Jt Surg 62A: 31-38, 1980.
8. Carr W, Moe J, Winter R, and Lonstein J: Treatment of Idiopathic Scoliosis in the Milwaukee Brace. J Bone Joint Surg 62A: 599-612, 1980.
9. Edmonsson A and Morris J: Follow-Up Study of Milwaukee Brace Treatment in Patients with Idiopathic Scoliosis. Clin Orthop 126: 58-61, 1977.
10. Emans J: The Boston Bracing System for Idiopathic Scoliosis: Follow-Up Results in 295 Patients. Spine 11: 792-801, 1986.
11. Galante J., Schultz A.B., DeWald R.L. and Ray R.D., Forces Acting in the Milwaukee Brace on Patients Undergoing Treatment for Idiopathic Scoliosis. J.Bone Jt. Surg., 52A, 498, 1970.
12. Gavin TM, Bunch WH, Dvonch V: The Rosenberger Scoliosis Orthosis. J Assoc. Children's Prosthetic Orthotic Clinics. 21(3), 35-38, 1986.
13. Gavin TM, Shurr DG, Patwardhan AG: Orthotic Treatment for Spinal Disorders. Chapter 85, in ed Weinstein SL. The Pediatric Spine. 1795-1828, Raven Press, 1993.
14. Jodoin A., Hall JE., Watts H.G., Miller M.E., Micheli, L.J. and Riseborough, E.J.: Treatment for Idiopathic Scoliosis by the Boston Brace System; Early Results. Orthop. Trans., 5,22, 1981.
15. Katz DE, Richards S, Browne R and Herring JA: A Comparison Between the Boston Brace and the Charleston Bending Brace in Adolescent Idiopathic Scoliosis. Proceedings of the 31st Annual Meeting of the Scoliosis Research Society, pp. 142, Ottawa, Ontario, Canada, September 25-28, 1996.
16. Keiser RP and Shufflebarger HL: The Milwaukee Brace in Idiopathic Scoliosis: Evaluation of 123 Completed Cases. Clin Orthop 118: 19-24, 1976.
17. Lonstein JE and Carlson JM: The Prediction of Curve Progression in Untreated Idiopathic Scoliosis During Growth. J Bone Jt Surg 66A: 1061-1071, 1984.
18. Lonstein JE and Winter RL: Milwaukee Brace Treatment of Adolescent Idiopathic Scoliosis- Review of 1020 patients. J Bone Joint Surg, 76A:1207-21. 1994
19. McCollough NC III, Schultz M et al:Miami TLSO in the Management of Scoliosis: Preliminary Results in 100 Cases. J Ped Orth 1:141-152, 1981.
20. Mellencamp D, Blount W, and Anderson A: Milwaukee brace treatment of idiopathic scoliosis, Clin Orthop 126: 47-557, 1977.
21. Mitchell TM, Smith BG and Thomson JD: Effectiveness of the Boston Brace in the Treatment of Large Curves in Adolescent Idiopathic Scoliosis. Proceedings of the 31st Annual Meeting of the Scoliosis Research Society, pp. 141, Ottawa, Ontario, Canada, September 25-28, 1996.
22. Moe JH and Kettleson DN: Idiopathic scoliosis: analysis of curve patterns and the preliminary results of Milwaukee brace treatment in one hundred sixty-nine patients, J Bone Joint Surg 52A: 1509, 1970.
23. Mueller EB and Nordwall A: Brace Treatment of Scoliosis in Children with Myelomeningocele. Spine 19(2) 151-155, 1994.
24. Nachemson AL and 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 , 77(A):815-22, 1995
25. Noonan KJ, Weinstein SL, Jacobson WC and Dolan LA: Use Of The Milwaukee Brace for Progressive Idiopathic Scoliosis. J Bone Joint Surg 78A:557-567, 1996.
26. Upahday SS, Nelson IW, Ho EKW, Hsu LCS and Leong JCY: New Prognostic Factors to Predict the Final Outcome of Brace Treatment in Adolescent Idiopathic Scoliosis. Spine 20(5), 537-544, 1995.
27. Weinstein SL, Zavala DC, and Ponseti IV: Curve Progression in Idiopathic Scoliosis. J Bone Joint Surg 65A: 447-455, 1983.
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