Bracing for neuromuscular scoliosis: Orthosis construction to improve the patient's function

Efficacy of adaptive seating system for the management of neuromuscular scoliosis in a young adult with cerebral cavernous malformation: A case report

Cerebral cavernous malformations (CCMs) are vascular malformations causing seizures and cerebral hemorrhages. Neurological and functional profile can differ from each individual, and the management requires high complexity. The aim of the present case report was to explore the management of neuromuscular scoliosis in a young adult with CCM, comparing the use of a scoliotic brace with a customized adaptive seating system (AdSS). X-ray examinations were performed in three different situations: sitting in a flat bench without postural support, sitting in a flat bench with scoliotic brace, and sitting in an AdSS. For the analysis of the AdSS, an experimental radiolucent device was used. Differences in spine alignment and postural support were found. The best option to care was the use of the scoliotic brace. Nevertheless, the use of a customized AdSS offers a good solution for the management of neuromuscular scoliosis, with a difference of 10 degrees with respect to the scoliotic brace. Position was maintained at 3-month follow-up, with a reduction of the overhang of the spine. The use of an AdSS represents a valid attempt for the management of neuromuscular scoliosis in people with CCM. This approach can be considered when the patient suffers the scoliotic brace and/or when the brace interferes with breathing or other clinical conditions.

The effect of a flexible thoracolumbar brace on neuromuscular scoliosis: A prospective observational study

Neuromuscular scoliosis is a common deformity seen in patients with neuromuscular diseases. Although rigid thoracolumbosacral orthosis is the most frequently used brace, it has low compliance rates and can lead to complications including skin ulcers. Thus, alternative methods for treating neuromuscular scoliosis are needed. The purpose of this study is to evaluate the clinical effects of a novel flexible brace to prevent the progression of neuromuscular scoliosis.This study is a prospective observational study. Twenty-three patients with neuromuscular scoliosis were enrolled in the study. Among patients diagnosed with neuromuscular disease, spine radiographs were checked for a neuromuscular scoliosis diagnosis. The participants were treated with a novel flexible brace for 6 months. The control group (n = 46) was selected using propensity score matching method from a clinical data warehouse. The Cobb angle was measured and compared between the study and control groups.In the study group, the average Cobb's angle significantly decreased from 47.22 ± 18.9° to 31.8 ± 20.0 when wearing the flexible brace (P < .001). Thus, the correction rate was 36.9%. The annual progression rate was significantly lower in the study group than in the control group (P  < .05).The flexible brace showed a significant correction rate of scoliosis in patients with severe neuromuscular diseases. The flexible brace is an alternative treatment modality for patients with neuromuscular scoliosis. Daily application of the flexible brace during the growing period can reduce the degree of fixed deformity in the long term.

Neuromuscular Scoliosis: When, Who, Why and Outcomes

Scoliosis has a very high prevalence among patients with neuromuscular disease involving the thoracic spine and truncal muscles. Physical examination and radiographs are used to screen for presence of scoliosis and monitor progression. Management includes therapy participation, optimizing equipment and orthotic use, and possible surgical intervention. Unlike idiopathic adolescent scoliosis, curves tend to progress despite orthotic use compliance. Associated pelvic obliquity creates risk for pressure sores and pain. As such, education of caregivers is a key point of optimizing management.

Application of Fabric-Type Spinal Orthosis for Flexible Neuromuscular Scoliosis: A Preliminary Study

OBJECTIVE

This study used a 3-point pressure spinal orthosis made of fabric material in neuromuscular scoliosis patients with flexible spinal curve to evaluate the in-brace correction of the spinal curve and to estimate changes in pulmonary function associated with brace wearing.

DESIGN

Twenty-eight children with neuromuscular scoliosis with spinal curve flexibility of more than 50% were enrolled. A custom-made 3-point pressure spinal orthosis was fitted for each patient. The Cobb angles in sitting and supine positions, forced vital capacity, forced expiratory volume in the first second, and peak cough flow were measured before and after applying spinal orthoses. Each participant recorded the brace wearing duration, and questionnaires on brace tolerance were collected.

RESULTS

Cobb angles after application of orthosis decreased from 31.0 degrees (interquartile range = 21.9-45.0 degrees) to 16.6 degrees (interquartile range = 10.0-34.0 degrees) in the sitting position and from 13.3 degrees (interquartile range = 4.0-21.0 degrees) to 1.4 degrees (interquartile range = 0.0-19.0 degrees) while supine (P < 0.01, P = 0.04, respectively). Preorthosis and postorthosis application forced vital capacity, forced expiratory volume in the first second, and peak cough flow were unaffected. Caregivers reported improved sitting postures and manual activities.

CONCLUSIONS

In children with flaccid-type neuromuscular scoliosis, curve correction can be achieved using a simple fabric-type spinal orthosis when applied to patients with flexible scoliosis, without compromising lung function.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Describe the factors associated with the effects of spinal braces in neuromuscular scoliosis; (2) Discuss the characteristics of flaccid-type neuromuscular scoliosis; and (3) Discuss the benefits of fabric-type orthosis regarding pulmonary function and patient compliance.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Early onset scoliosis and current treatment methods

OBJECTIVE

Provide an update of the management options for early onset scoliosis patients, including general assessment, conservative and surgical options.

METHODS

We included the updated information about the assessment and management options of Early Onset Scoliosis, taking into consideration the non-fusion methods, including the burden on the patient and their family.

RESULTS

With the heterogeneity of this population, it is difficult to get a consensus about a unified protocol for management. Accordingly, the surgeon dealing with these cases needs to be aware of the broad range of surgical and non-surgical methods when treating these patients.

CONCLUSION

The main aim of early onset scoliosis treatment is to gain a flexible spine associated with normal lung development and thoracic growth. Management needs to be individualized between the surgeon and patient in relation to the etiology and patient conditions.

Promoting functional seated positioning and communication utilising a custom cervical and trunk orthosis in severe traumatic brain injury: a case report

BACKGROUND AND PURPOSE

Published evidence to guide therapists regarding positioning strategies for patients with TBI is limited. This case report describes the development of a custom cervical-thoracic-lumbar orthosis to improve functional seated positioning and communication for an individual with severe traumatic brain injury (TBI).

CASE DESCRIPTION

A man in his 20 s admitted to an inpatient rehabilitation hospital nine weeks after sustaining a TBI. Upon admission, he presented in a vegetative state with severe positioning and postural impairments.

INTERVENTION

Despite evidence of cognitive progression at 7 weeks post-admission, the patient demonstrated persistent postural deficits and limitations in functional activities and communication. To provide additional postural support, a custom cervico-thoracic-lumbar orthosis was fabricated to promote improved function and communication.

OUTCOMES

From the time of admission to post-admission weeks 7-8, the patient progressed on multiple measures: Rancho Los Amigos scale: level II to level VII; Coma Recovery Scale Revised 6 points to 15 points; Disability Rating Scale decreased from 25 points to 12 points. Functional Independence Measure 20 points at 6 weeks post-admission to 23 points at 8 weeks post-admission.

DISCUSSION

Custom cervico-thoracic-orthoses may provide additional postural support to promote improved function in individuals post-TBI. Further studies are needed to provide evidence of custom orthoses' effect on function and communication in this population.IMPLICATIONS FOR REHABILITATIONTo provide evidence of the influence of a custom orthosis on achieving a stable seated postureTo provide evidence of the influence of a custom orthosis on the functional use of an alternative communication device in the traumatic brain injury population.

Concept and treatment outcomes of dynamic spinal brace for scoliosis in cerebral palsy

We developed a novel device, dynamic spinal brace (DSB), with the basic concept of automatic correction by maximizing posture control. Herein, we report the structure of the DSB and preliminary treatment outcomes for scoliosis in patients with cerebral palsy. The study cohort comprised 219 patients with cerebral palsy treated for scoliosis with Cobb angle of at least 20° and follow-up of more than 3 years under the DSB. Cobb angle, trunk shift, and pelvic obliquity were assessed by semi-sitting radiography, and a questionnaire on daily lifestyle was collected. The immediate correction of these parameters by wearing DSB was demonstrated. In those who aged older than 15 years, the annual progression was 1.0°, and trunk shift was not deteriorated statistically. The questionnaire survey indicated that the DSB led to improvements in QOL and caregiving, and only 3.5% of the patients discontinued DSB because of intolerance. However, we could not find clear evidence that DSB affects the natural history of scoliosis in children with cerebral palsy.

Non-home discharge disposition after posterior spinal fusion in neuromuscular scoliosis-an analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric database

BACKGROUND

Despite an increasing trend of corrective surgery in patients with neuromuscular scoliosis, evidence regarding risk factors associated with non-home discharge destination following surgery remains limited.

METHODS

The 2012-2016 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric database was queried using Current Procedural Terminology codes for patients undergoing posterior spinal fusion (22802, 22804 and 22808) for neuromuscular scoliosis. Non-home discharge was defined as discharge to a skilled nursing facility, rehabilitation facility and/or separate acute care unit. Patients who expired during inpatient stay were excluded from the study sample. Only patients aged 2-18 years with a primary diagnosis of neuromuscular scoliosis were included in the final cohort.

RESULTS

Out of a total of 1,269 patients, 76 (6.0%) had a non-home discharge disposition. Following adjustment for baseline clinical characteristics, patients lying in the age bracket of 15-17 years {odds ratio (OR) 2.27 [95% confidence interval (CI): 1.01-5.08]; P=0.047} or >17 years [OR 2.29 (95% CI: 1.10-4.79); P=0.027], male gender [OR 1.75 (95% CI: 1.06-2.89); P=0.029], having structural pulmonary abnormality at time of surgery [OR 2.01 (95% CI: 1.17-3.43); P=0.011], a length of stay >4 days [OR 2.29 (95% CI: 1.15-4.55); P=0.018] and having a past history of childhood cancer [OR 4.50 (95% CI: 1.15-17.61); P=0.031] were significant independent predictors associated with a non-home discharge.

CONCLUSIONS

Providers can utilize these data to pre-operatively identify patients who might require continued high-level/inpatient care in a facility, and subsequently expedite discharge and reduce costs associated with a prolonged inpatient stay.

[Characteristics of neuromuscular scoliosis]

Usually, neuromuscular scolioses become clinically symptomatic relatively early and are rapidly progressive even after the end of growth. Without sufficient treatment they lead to a severe reduction of quality of life, to a loss of the ability of walking, standing or sitting as well as to an impairment of the cardiopulmonary system resulting in an increased mortality. Therefore, an intensive interdisciplinary treatment by physio- and ergotherapists, internists, pediatricians, orthotists, and orthopedists is indispensable. In contrast to idiopathic scoliosis the treatment of patients with neuromuscular scoliosis with orthosis is controversially discussed, whereas physiotherapy is established and essential to prevent contractures and to maintain the residual sensorimotor function.Frequently, the surgical treatment of the scoliosis is indicated. It should be noted that only long-segment posterior correction and fusion of the whole deformity leads to a significant improvement of the quality of life as well as to a prevention of a progression of the scoliosis and the development of junctional problems. The surgical intervention is usually performed before the end of growth. A prolonged delay of surgical intervention does not result in an increased height but only in a deformity progression and is therefore not justifiable. In early onset neuromuscular scolioses guided-growth implants are used to guarantee the adequat development. Because of the high complication rates, further optimization of these implant systems with regard to efficiency and safety have to be addressed in future research.

The effect of a spinal orthosis on posture and cardio-respiratory functions in progressive myopathic scoliosis

BACKGROUND

Historically, the orthotic treatment in progressive myopathic scoliosis has not been as effective as expected. The purpose of this study was to investigate the effect of a spinal orthosis on scoliotic curve correction, alignment of altered posture and cardio-respiratory functions.

CASE DESCRIPTION AND METHODS

An 11 year-old girl diagnosed with myopathy was fitted with a custom molded thoraco-lumbo-sacral orthosis to enhance the sitting ability. The cardio-respiratory tests were performed by a COSMED K4 b(2); metabolic analyzer. The anterior posterior radiographs were analyzed for measuring Cobb angle and Ferguson angle. A plumb line test was used to assess the postural improvements.

FINDINGS AND OUTCOMES

No significant difference was observed for variables such as O(2) consumption level, PaO(2), tidal volume, heart rate and energy expenditure/min. The improved posture was evident by shifting of the plumb line 18 mm towards the mid line with the use of orthosis. Very minor improvements in both angles were observed with the use of the brace.

CONCLUSION

The brace treatment cannot be expected to have a lasting corrective effect although it can be used as a sitting support and for maintaining posture Clinical relevance This case study provides an objective prescription of thoraco-lumbo-sacral orthosis as a sitting support and for improving posture in progressive myopathic scoliosis if suitably designed and properly fitted.

Management of spinal deformity in cerebral palsy

An understanding of the three-dimensional components of spinal deformity in children with cerebral palsy is necessary to recommend treatments that will positively affect these patients' quality of life. Management of these deformities can be challenging and orthopedic surgeons should be familiar with the different treatments available for this patient population. This article discusses the incidence, causes, natural history, and treatment of patients with scoliosis.