Effectiveness of the boston brace in treatment of large curves in adolescent idiopathic scoliosis

Discontinuation of brace treatment in adolescent idiopathic scoliosis (AIS): a scoping review

PURPOSE

Brace treatment for adolescent idiopathic scoliosis (AIS) is usually prescribed for 20-40° curves in patients with growth potential. The aim is to reduce the risk of curve progression during growth and to avoid the curve reaching a surgical threshold. Having as small a curve as possible at skeletal maturity will reduce the risk of curve progression during adult life. While evidence exists for brace treatment in AIS, there is disagreement on how and when to discontinue bracing. The purpose of this review was to investigate what criteria have been reported for initiating brace cessation and published weaning protocols and to look at estimates of the number of patients that may progress > 5 degrees after the end of growth.

METHODS

This scoping review summarizes existing knowledge on the best time to stop bracing in AIS patients, how to "wean," and what happens to spinal curves after bracing. Searches were carried out through MEDLINE, EMBASE, and PsycINFO in April 2022. A total of 1936 articles were reduced to 43 by 3 reviewers. Full papers were obtained, and data were extracted.

RESULTS

Weaning was most commonly determined by Risser 4 (girls) and 5 (boys). Other requirements included 2 years post-menarche and no growth in standing/sitting height for 6 months. Skeletal maturity assessed from hand and wrist radiographs, e.g., Sanders' stage; distal radius and ulnar physes, could determine the optimal weaning time to minimize curve progression. Complete discontinuation was the most common option at skeletal maturity; variations on weaning protocols involved gradual reduction of bracing over 6-12 months. Curve progression after weaning is common. The 12 studies reporting early curve progression after brace weaning found a mean Cobb angle progression of 3.8° (n = 1655). From the seven studies reporting early curve progression by > 5 degrees, there were 236/700 (34%) patients. There is limited information on risk factors to predict early curve progression after finishing brace treatment with larger curves, especially those over 40 degrees possibly having more chance of progression.

CONCLUSION

Curve progression after bracing cessation is a negative outcome for patients who have tolerated bracing for several years, especially if surgery is required. The literature shows that when to start brace cessation and weaning protocols vary. Approximately 34% of patients progressed by more than 5 degrees at 2-4 years after brace cessation or weaning. Larger curves seem more likely to progress. More research is needed to evaluate the risk factors for curve progression after brace treatment, defining the best time to stop bracing based on the lowest risk of curve progression and whether there is any benefit to weaning.

Comparison of the efficacy of thoracolumbosacral and lumbosacral orthosis for adolescent idiopathic scoliosis in patients with major thoracolumbar or lumbar curves: a prospective controlled study

Introduction

Thoracolumbosacral orthosis (TLSO) is the most commonly used type of brace for the conservative treatment of adolescent idiopathic scoliosis (AIS). Although lumbosacral orthosis (LSO) is designed to correct single thoracolumbar or lumbar (TL/L) curves, its effectiveness remains underexplored. This novel article aims to compare the effectiveness of LSO with TLSO in treating AIS with main TL/L curves.

Methods

This prospective controlled cohort study enrolled patients with AIS with main TL/L curves and minor thoracic curves who were treated with either TLSO or LSO. Demographic and radiographic data were compared between the two groups. Treatment outcomes were also assessed. Risk factors for minor curve progression were identified, and a cut-off value was determined within the LSO group.

Results

Overall, 82 patients were recruited, including 44 in the TLSO group and 38 in the LSO group. The initial TL/L curves showed no difference between both groups. However, the baseline thoracic curves were significantly larger in the TLSO group compared to the LSO group (25.98° ± 7.47° vs. 18.71° ± 5.95°, P < 0.001). At the last follow-up, LSO demonstrated similar effectiveness to TLSO in treating TL/L curves but was less effective for thoracic curves. The initial magnitude of thoracic curves was identified as a risk factor for minor curve outcomes in the LSO group. The ROC curve analysis determined a cut-off value of 21° for thoracic curves to predict treatment outcomes.

Discussion

In contrast to TLSO, LSO exhibits comparable effectiveness in treating main TL/L curves, making it a viable clinical option; however, it is less effective for thoracic minor curves. The initial magnitude of the minor thoracic curves may guide the selection of the appropriate brace type for patients with AIS with main TL/L curves.

Effectiveness of bracing to achieve curve regression in adolescent idiopathic scoliosis

Aims

To systematically evaluate whether bracing can effectively achieve curve regression in patients with adolescent idiopathic scoliosis (AIS), and to identify any predictors of curve regression after bracing.

Methods

Two independent reviewers performed a comprehensive literature search in PubMed, Ovid, Web of Science, Scopus, and Cochrane Library to obtain all published information about the effectiveness of bracing in achieving curve regression in AIS patients. Search terms included "brace treatment" or "bracing," "idiopathic scoliosis," and "curve regression" or "curve reduction." Inclusion criteria were studies recruiting patients with AIS undergoing brace treatment and one of the study outcomes must be curve regression or reduction, defined as > 5° reduction in coronal Cobb angle of a major curve upon bracing completion. Exclusion criteria were studies including non-AIS patients, studies not reporting p-value or confidence interval, animal studies, case reports, case series, and systematic reviews. The GRADE approach to assessing quality of evidence was used to evaluate each publication.

Results

After abstract and full-text screening, 205 out of 216 articles were excluded. The 11 included studies all reported occurrence of curve regression among AIS patients who were braced. Regression rate ranged from 16.7% to 100%. We found evidence that bracing is effective in achieving curve regression among compliant AIS patients eligible for bracing, i.e. curves of 25° to 40°. A similar effect was also found in patients with major curve sizes ranging from 40° to 60° when combined with scoliosis-specific exercises. There was also evidence showing that a low apical vertebral body height ratio, in-brace correction, smaller pre-brace Cobb angle, and daily pattern of brace-wear compliance predict curve regression after bracing.

Conclusion

Bracing provides a corrective effect on scoliotic curves of AIS patients to achieve curve regression, given there is high compliance rate and the incorporation of exercises.

The influence of night-time bracing on curve progression is not affected by curve magnitude in adolescent idiopathic scoliosis: a study of 299 patients

BACKGROUND AND PURPOSE

The efficacy of bracing larger curves in adolescent idiopathic scoliosis (AIS) patients is uncertain. We aimed to assess the influence of night-time bracing in AIS patients with main curves exceeding 40° Cobb angle at brace initiation.

METHODS

We reviewed AIS patients treated with nighttime braces between 2005 and 2018. Patients with curves ≥ 25° and estimated growth potential were included. Patients were monitored with radiographs from brace initiation until brace weaning at skeletal maturity. Patients were grouped based on curve magnitude at initial evaluation: a control group (25-39°) and a large-curves group (≥ 40°). Progression was defined as > 5° increase.

RESULTS

We included 299 patients (control group, n = 125; large-curves group, n = 174). In the control group, 65 (52%) patients progressed compared with 101 (58%) in the large-curves group (P = 0.3). The lower-end vertebra (LEV) shifted distally post-bracing in 41 (23%) patients in the largecurves group. Patients with progressive large curves were younger (age 13.2 [SD 1.5] vs. 13.9 [SD 1.1], P = 0.009) and more premenarchal (n = 36 [42%] vs. n = 6 [9%], P < 0.001) compared with non-progressive large curves.

CONCLUSION

Progression risk in patients with curves exceeding 40° treated with night-time bracing is similar to smaller curves. The LEV moved distally in almost one-fourth of the larger curves, possibly affecting fusion levels in cases of surgery.

Effectiveness of Orthotic Treatment on Clinical Outcomes of the Patients with Adolescent Idiopathic Scoliosis Under Different Wearing Compliance Levels: A Systematic Review

BACKGROUND

Wearing spinal orthosis for 16 to 23 hours a day during the teenage years could be challenging and stressful for patients with adolescent idiopathic scoliosis (AIS). The investigation of clinical outcomes under various orthosis-wearing compliances can provide helpful insight into orthotic treatment dosage. This systematic review aims to investigate actual orthosis-wearing compliance and evaluate the effectiveness of orthotic treatment in controlling scoliotic curvature and preventing surgery for patients with AIS under various levels of orthosis-wearing compliance.

METHODS

A literature search of 7 electronic databases, namely PubMed, MEDLINE, Cochrane Library, Scopus, CINAHL Complete, Web of Science, and Embase, was conducted on May 19, 2023. Participant characteristics, orthotic treatment protocols, compliance information, outcome measures, and key findings were extracted. The Newcastle-Ottawa Scales were used to evaluate the quality of included cohort and case-control studies.

RESULTS

This study systematically reviewed 17 of 1,799 identified studies, including 1,981 subjects. The actual compliance was inconsistent and ranged from 7.0 to 18.8 hours daily. The proportion of compliant subjects in each study varied from 16.0% to 78.6% due to the heterogeneity of calculation period, measurement methods, and orthosis prescription time. Thirteen studies were investigated to determine the effectiveness of orthotic treatment in controlling curve deformity under different compliance groups, and 2 studies compared the compliance under different treatment outcomes. The rate of curve progression, defined as surpassing the measurement error threshold of 5° or 6° after orthotic treatment, varied from 1.8% to 91.7% across the studies. Ten studies defined the treatment failure, surgery, or surgery indication as Cobb angle progressing to a certain degree (e.g., 40°, 45°, or 50°) and reported failure/surgery/surgery indication rates ranging from 0.0% to 91.7% among different compliance level groups.

CONCLUSION

This review found that the actual compliance with orthotic treatment was generally lower than the prescribed wearing time and exhibited wide variation among different studies. The electronic compliance monitors show promise in regular orthotic treatment practice. More importantly, the group with higher and consistent compliance has significantly less curve progression and lower surgery or failure rate than the group with lower and inconsistent compliance. Further studies are proposed to investigate the minimal orthosis-wearing compliance in patients with AIS treated with different types of orthoses.

LEVEL OF EVIDENCE

Level III, Systematic Review. See Instructions for Authors for a complete description of levels of evidence.

The effect of brace on apical vertebral derotation in adolescent idiopathic scoliosis

PURPOSE

The current study aims to evaluate the effect of Boston brace treatment on apical vertebral derotation in adolescent idiopathic scoliosis (AIS) patients receiving conservative treatment.

METHODS

The study included 51 AIS patients, consisting of 8 males and 43 females, with Cobb angles between 25° and 45° and Risser's findings ranging from 0 to 4. The mean age of the participants was 12.20 ± 1.34 years. All patients were treated with the Boston brace for a minimum of 2 years and evaluated before the brace, during early brace use, and at the last follow-up. Radiographs were assessed to measure apical vertebral rotation (AVR) and vertebral translation (AVT). The SRS-22 questionnaire was used to evaluate patient outcomes.

RESULTS

The radiographs of patients were evaluated over a mean follow-up period of 32.42 ± 8.65 months. Before the brace, the mean AVR was 2.1 ± 0.6, while it was 1.1 ± 0.5 with the brace. At the last follow-up, the mean AVR was 1.3 ± 0.5 (p < 0.001). Before the brace, the mean AVT was 36.4 ± 9.6 mm, which decreased to 16.7 ± 7.3 mm with the brace (p < 0.001). At the last follow-up, the mean AVT was 19.8 ± 8.1 mm (p < 0.001). The use of the brace had a significant corrective effect on thoracolumbar and lumbar curvatures compared to before the brace (p < 0.001).

CONCLUSION

The findings of the current study suggest that the use of a Boston brace in the conservative treatment of AIS is effective in correcting the coronal and sagittal plane deformities, including thoracic, thoracolumbar, and lumbar curvatures, and in reducing apical vertebral rotation and translation.

Patient Adherence to Wide Abduction Brace Treatment for Legg-Calvé-Perthes Disease

BACKGROUND

A wide abduction brace called the A-frame brace is used to contain the deformed femoral head and improve femoral head remodeling in patients with Legg-Calvé-Perthes disease (LCPD). While there is some data showing the efficacy of brace treatment, little is known about patient adherence. The purpose of this study was to measure A-frame brace adherence using temperature sensors and to identify factors that influence adherence.

METHODS

This is an IRB-approved retrospective study of 61 patients with LCPD treated with an A-frame brace between ages 5 and 11. Brace wear was measured using built-in temperature sensors. Pearson correlation coefficient and multiple regression were used to determine relationships between patient characteristics and brace adherence.

RESULTS

Of 61 patients, 80% were male. Mean age at LCPD onset was 5.9±1.8 years and the mean age at initiation of brace treatment was 7.1±1.5 years. Fifty-eight patients (95%) were in the fragmentation or reossification stage at the start of bracing, with 23 patients (38%) having lateral pillar B, 7 (11%) lateral pillar B/C, and 31 (51%) lateral pillar C. Forty-two (69%) patients were treated with a Petrie cast for 6 weeks before the A-frame brace. Mean adherence, defined as the ratio of measured over prescribed brace wear, was 0.69±0.32. Mean adherence improved with age (P<0.05), increasing from 0.57 in patients less than 6 to 0.84 in patients aged 8 to 11. Patients first treated with a Petrie cast had significantly better adherence than those without (0.77 vs. 0.50; P<0.005). Adherence was negatively associated with the amount of prescribed brace wear per day (P<0.005). Adherence did not change significantly between the start and end of treatment and was not significantly associated with sex or attention deficit hyperactivity disorder.

CONCLUSIONS

A-frame brace adherence was significantly associated with age at treatment, prior Petrie casting, and the amount of daily prescribed brace wear. These findings provide new insight into A-frame brace treatment, which will lead to better patient selection and counseling to optimize adherence.

LEVEL OF EVIDENCE

III Therapeutic Study.

Evaluation of Brace Treatment Using the Soft Brace Spinaposture: A Four-Years Follow-Up

The braces of today are constructed to correct the frontal plane deformity of idiopathic adolescent scoliosis (AIS). The Spinaposture brace© (Spinaposture Aps, Copenhagen, Denmark) is a soft-fabric brace for AIS and is designed to enhance rotational axial stability by inducing a sagittal plane kyphotic correction. This prospective observational study evaluated the brace in fifteen patients with AIS. The initial average CA was 16.8° (SD: 2.8). They were followed prospectively every 3 to 6 months during their brace usage until skeletal maturity of 25 months and at long-term follow-up of 44 months. In- and out-of-brace radiographs were performed in six subjects at inclusion. This resulted in an immediate in-brace correction of 25.3 percent in CA (14.3°→10.8°) and induced a kyphotic effect of 14.9 percent (40.8°→47.9°). The average in-brace improvement at first follow-up was 4.5° in CA, and the CA at skeletal maturity was 11° (SD: 7.4°) and long-term 12.0° (SD: 6.8°). In conclusion, the Spinaposture brace© had an immediate in-brace deformity correction and a thoracic kyphotic effect. At skeletal maturity, the deformities improved more than expected when compared to that of the natural history/observation and similar to that of other soft braces. No long-term deformity progression was seen. To substantiate these findings, stronger designed studies with additional subjects are needed.

Brace treatment for scoliosis secondary to chiari malformation type 1 or syringomyelia without neurosurgical intervention: A matched comparison with idiopathic scoliosis

PURPOSE

To evaluate the effectiveness of brace treatment in patients with Chiari malformation type 1 (CM-1) or syringomyelia associated scoliosis without neurosurgical intervention.

METHODS

This was a retrospective case-control study. 34 CM-1 or syringomyelia (CMS) patients who received brace treatment without neurosurgical intervention were recruited. Another 68 matched patients with idiopathic scoliosis who received bracing served as the control group. The matching criteria included gender, age (± 1 years), Risser sign (± 1 grade), initial curve magnitude (± 5°), curve patterns and follow-up time (± 6 months). Patients who encountered curve progression and scoliosis surgery were compared between different groups.

RESULTS

Until the last visit, 16 (47%) patients in CMS group and 18 (26%) patients in IS group occurred curve progression; 9 (26%) patients and 15 (22%) patients underwent scoliosis surgery, respectively. Compared to idiopathic scoliosis, patients with CMS-associated scoliosis had a significantly higher rate of curve progression (P = 0.038). However, no significant difference was observed between two groups regarding to the rate of surgery (P = 0.867). Patients with combined CM-1 and syringomyelia had a higher rate of surgery than patients with isolated CM-1 or syringomyelia (P = 0.049). The double major curve pattern was identified as the risk factor for curve progression.

CONCLUSION

Brace treatment is effective for CMS-associated scoliosis without neurosurgical intervention. Compared to idiopathic scoliosis, brace can provide similar prevention for scoliosis surgery in CMS patients, but slight or moderate curve progression may occur. Specifically, patients with combined CM-1 and syringomyelia should be followed closely with a higher expectation of curve progression.

[The preliminary clinical application of a smart orthosis personalized management system for the treatment of patients with adolescent idiopathic scoliosis]

Objective

To develop a smart orthosis personalized management system for the treatment of patients with adolescent idiopathic scoliosis (AIS) and to evaluate the feasibility and efficiency through clinical preliminary applications.

Methods

The smart orthosis personalized management system consists of a wireless force monitor, a WeChat Mini Program, a cloud-based storage system, and a website backstage management system. Twenty-two patients with AIS who underwent orthosis treatment and met the selection criteria between March 2020 and December 2020 were enrolled. The follow-up time was 4 months. The parameters used to evaluate patients' compliance were as follows (back and lumbar): baseline force value, measured force value, force compliance (measured force value/baseline force value×100%), measured wearing time (wearing time of force value was more than 0 N), and time compliance (measured wearing time/prescribed wearing time×100%), in which the prescribed wearing time was 23 hours/day. The baseline force values were measured at initiation, while the measured force value, measured wearing time, force compliance, and time compliance were measured during follow-up. The differences of these parameters between back and lumbar, and the differences among these parameters at 1, 2, 3, and 4 months after orthosis wearing were analyzed.

Results

The average measured force value of 22 patients (back and lumbar) was (0.83±0.34) N, the average force compliance was 68.5%±17.9%, the average measured wearing time was (15.4±1.7) hours, and the average time compliance was 66.9%±7.7%. The baseline force value and measured force value of back were significantly higher than those of lumbar ( P<0.05); the measured wearing time, force compliance, and time compliance between back and lumbar showed no significant difference ( P>0.05). The measured force value, measured wearing time, force compliance, and time compliance at 1 month after wearing were significantly lower than those at 2, 3, and 4 months after orthosis wearing ( P<0.05), no significant difference was found among 2, 3, and 4 months after orthosis wearing ( P>0.05). At different time points after wearing, the measured force value of back were significantly higher than that of lumbar ( P<0.05), while there was no significant difference between back and lumbar on the other parameters ( P>0.05).

Conclusion

The smart orthosis personalized management system has high feasibility to treat AIS, and can improve the compliance of such patients with orthosis wearing.

mHealth for the Monitoring of Brace Compliance and Wellbeing in Adolescents with Idiopathic Scoliosis: Study Protocol for a Feasibility Study

Attempts to optimize monitoring of brace adherence prescribed to adolescents with idiopathic scoliosis (IS) have generally relied on sensors. Sensors, however, are intrusive and do not allow the assessment of psychological and physical consequences of brace use that might underlie poor adherence. Mobile applications have emerged as alternatives to monitor brace compliance. However, the feasibility and utility of these app-based systems to assess key psychological and physical domains associated with non-adherence remain unexplored. This feasibility study aims to test the usability, acceptability, and clinical utility of an app-based system that monitors brace use and related psychological and physical factors. Forty adolescents with IS daily respond to the app for 90 days. The patient responses may generate clinical alarms (e.g., brace non-adherence, discomfort, or distress) that will be sent daily to the medical team. Primary outcomes will be app usability, acceptability, and response rates. Secondary outcomes will include brace adherence, the number of side effects reported, number and type of clinical alarms, stress, quality of life, perceived health status, and mood. If accepted by patients and clinicians, apps may allow rapid detection and response to undesired events in adolescents undergoing brace treatment.

Efficacy of Computer-Aided Design and Manufacturing Versus Computer-Aided Design and Finite Element Modeling Technologies in Brace Management of Idiopathic Scoliosis: A Narrative Review

The efficiency and design quality of scoliosis braces produced by the conventional casting method depends highly on the orthotist's experience. Recently, advanced engineering techniques have been used with the aim of improving the quality of brace design and associated clinical outcomes. Numerically controlled machine tools have provided enormous opportunities for reducing the manufacturing time and saving material. However, the effectiveness of computer-aided brace manufacturing for scoliosis curve improvement is controversial. This narrative review is aimed at comparing the efficacy of braces made by the conventional method with those made by two computer-aided methods: computer-aided design and manufacturing (CAD-CAM), and computer-aided design and finite element modeling (CAD-FEM). The comparison was performed on scoliosis parameters in coronal, sagittal, and transverse planes. Scientific databases were searched, and 11 studies were selected for this review. Because of the diversity of study designs, it was not possible to decisively conclude which brace-manufacturing method is most effective. Similar effectiveness in curve correction was found in the coronal plane for braces made by using advanced manufacturing and conventional methods. In the sagittal plane, modern braces seem to be more effective than traditional braces, but there is an ongoing debate among clinicians, about which CAD-CAM and CAD-FEM brace provides a better treatment outcome. The relative effectiveness of modern and conventional methods in correcting deformities in the transverse plane is also a controversial subject. Overall, advanced engineering design and production methods can be proposed as time- and cost-efficient approaches for scoliosis management. However, there is insufficient evidence yet to conclude that CAD-CAM, and CAD-FEM methods provide significantly better clinical outcomes than those of conventional methods in the treatment of scoliosis curve. Moreover, for some factors, such as molding and the patient's posture during the data acquisition, in brace curve-correction plan, the orthotist's experience and scoliosis curve flexibility should be explored to confidently compare the outcomes of conventional, CAD-CAM, and CAD-FEM methods.

Novel questionnaire to enhance brace wear adherence in patients with adolescent idiopathic scoliosis and the relationship of the quality of life

Bracing is an effective non-operative treatment, in patients with adolescent idiopathic scoliosis (AIS). The relationship between patients’ quality of life (QOL) and brace wear adherence has been reported. This study aims to determine brace wear adherence for AIS patients with novel questionnaire. A nested case-control study was conducted, included patient age 10-18 years, coronal Cobb angle 20-50°, and Risser grade 0-3. Correlation between patients’ QOL and the average hours of daily brace-wear were determined. Patients were divided into 3 groups based on brace wear adherence and were compared. QOL domains associated with the incompleteness of brace-wearing were determined by Cox proportional-hazards regression. Mean age of patients was 13.3 years (range 11-17.3 years) with initial Cobb angle of 33.5° (range 20-48°). There were significant negative correlations between total QOL scores and brace wearing time. Increased social domain scores was significantly associated with less brace wearing time (HR 1.5, 95% CI 1.12-2.04). Significant correlations between patients’ QOL and the average hours per day of brace wear. Poor social QOL have a significant impact on brace wear adherence.

A compliance real-time monitoring system for the management of the brace usage in adolescent idiopathic scoliosis patients: a pilot study

Background

Patient compliance is essential to the effectiveness of brace treatment for adolescent idiopathic scoliosis (AIS) patients. Subjective measurements like questionnaires and inquiries proved to be arguably inaccurate. Although some scholars have applied temperature/force monitors to measuring patient compliance objectively, few studies to date could monitor patient compliance in real time. The objective of this study is to describe and evaluate a compliance real-time monitoring system of the brace usage in AIS patients.

Methods

A compliance real-time monitoring system (specifically consisting of a compliance monitor, a WeChat Mini Program, a cloud-based storage system and a website backstage management system) was designed to manage the brace treatment. Thirty patients receiving brace treatment were enrolled. They were told to upload the data at least once a day. Clinicians downloaded the compliance data and communicated with the patients online based on their analysis of data at least once every 3 months. The measured force, quality compliance (measured force / baseline force), measured time, and quantity compliance (measured time/ prescribed time) were used to evaluate patient compliance. Patients were also asked to rate their satisfaction at the final follow-up.

Results

Twenty-eight patients were included in the final analysis. The mean baseline force was 1.23 ± 0.28 N. The mean measured force was 0.79 ± 0.29 N. The mean quality compliance was 64.8 ± 22.2%. The prescribed time of all patients was 23 h. The mean measured time was 14.1 ± 2.9 h. The mean quantity compliance was 61.3 ± 12.6%. Both the quality and quantity compliance during the first 3 months of treatment was significantly lower than the latter 3 months. In this study, 96.4% (27/28) patients were satisfied with the use of the monitoring system, among whom 21.4% (6/28) are very satisfied and 75.0% (21/28) are somewhat satisfied.

Conclusions

The compliance real-time monitoring system, without evaluating the clinical and radiographic outcomes for now, has already shown some feasibility and effectiveness for the management of the brace usage in AIS patients. This system, as a useful tool for online patient management and patient-clinician communication, would be potentially employed on a large scale in future for clinicians to improve the compliance and satisfaction of AIS patients who have received brace treatment.

Can we predict the behavior of the scoliotic curve after bracing in adolescent idiopathic scoliosis? Τhe prognostic value of apical vertebra rotation

PURPOSE

We aimed to recognize radiographic and clinical prognostic factors of scoliotic curve behaviour after bracing.

METHODS

Our prognostic study was based on the 25 years outcomes of a Boston braced AIS cohort between 1978 and 1993 that were previously reported. All patients were followed-up during bracing, at short term and 25 years post-bracing. We evaluated the impact of socio-demographic, clinical and radiological parameters on the loss of curve correction after bracing.

RESULTS

Seventy-seven patients were reevaluated at 25 years post-brace. The mean scoliotic curve was significantly increased after bracing until the 25 years follow-up (p < 0.001). The mean loss of curve correction between the end of bracing and long-term follow-up was independent on the curve type, apical vertebra, premenarcheal status at bracing, time and duration of bracing, Cobb angle before or after bracing. The mean apical vertebral rotation after bracing was significantly related to the loss of curve correction (Spearman ρ = 0.2, p = 0.049). Apical vertebral rotation (Perdriolle method) greater than 20° post-bracing had a three times higher chance of progression > 5° compared with lesser apical vertebral rotation (OR 3.071, CI 0.99-9.51). The rotation of the apical vertebra, type and magnitude of the scoliotic curve after bracing explained 27.4% of the variance in the loss of curve correction post-bracing (R square = 0.274, p < 0.001).

CONCLUSION

A scoliotic curve is expected to lose some correction after bracing. The apical vertebral rotation post-bracing mainly affected the long-term curve behaviour. Adolescents with apical vertebral rotation greater than 20° after bracing may need further attention.

LEVEL OF EVIDENCE

Prognostic study, Level II.

Long-term results after brace treatment with Progressive Action Short Brace in adolescent idiopathic scoliosis

BACKGROUND

In the literature, there are few papers on long-term results after brace treatment and there is no consensus on whether scoliotic curves stop progressing at skeletal maturity. To date the factors that could influence curve behaviour following bracing have not been fully determined.

AIM

The aim of this study was to evaluate the results and the loss of the scoliotic curve correction in a cohort of patients treated with Progressive Action Short Brace (PASB) brace during adolescence and to compare patient outcomes of under and over 30 Cobb degrees 10 years after brace removal.

DESIGN

This is an observational controlled cohort study nested in a prospective clinical on-going database including 1536 patients with idiopathic scoliosis.

SETTING

Inpatients and outpatients in Rome.

POPULATION

The study enrolled 163 patients with idiopathic adolescent scoliosis who had been treated with the PASB brace at a 10 years minimum long-term follow-up examination.

METHODS

One hundred sixty-three (female) patients with adolescent idiopathic scoliosis (AIS) treated with the Progressive Action Short Brace (PASB) at a mean age of 13.4 years (range 10-34) had accepted to undergo long-term follow-up examination. All patients had clinical and radiological examinations, but only 62 replied to some simple questions (including work status, pregnancy and pain) the population was divided into two groups based on Cobb degrees (< 30° and ≥ 30°). Statistical analysis was applied to test the efficacy of our hypothesis.

RESULTS

The patients underwent a long-term follow-up after brace removal at a mean age of 13.46 years (±3.4). The prebrace mean curve was 28.98° (±7.918); after treatment, the mean was 13.88° and increased to a minimum of 15.35° in the 10 years following brace removal. However, there was no significant difference between the mean Cobb angle at the end of weaning and the mean Cobb angle at long-term follow-up. The curve angle at baseline of patients who were treated with a brace was reduced by 15° during the treatment, but at follow-up the curve size was found to have lost 2°. The over 30° group showed a prebrace scoliotic mean curve of 37.26°; at the end of weaning, the mean curve angle was 22.98° which increased to a mean of 25.07° at follow-up. The <30° group showed a prebrace scoliotic mean curve of 24.40° which, at the end of weaning, had reduced to a mean of 8.69°, increasing to 9.98° at follow-up. There was no significant difference in the mean progression of curve magnitude between the ˂ 30° and ≥ 30° groups at the long-term follow-up. Work status was 62% full-time and 11% part-time. 24% had given birth. Three percent presented back pain related to instability of the spine. No patients underwent surgery after maturity but one patient had indication to surgical treatment.

CONCLUSIONS

The PASB brace is effective for the treatment of lumbar and thoracolumbar scoliosis and is characterized by positive long-term outcomes, including in patients demonstrating moderate curves. In both groups, at 10-years minimum follow-up after bracing, scoliotic curves did not deteriorate beyond their original curve size after bracing in both groups at the 10-years minimum follow-ups.

CLINICAL REHABILITATION IMPACT

At 10 years follow-up after bracing, scoliotic curves had not deteriorated beyond their original curve size.

Adolescent idiopathic scoliosis: indications for bracing and conservative treatments

Adolescent idiopathic scoliosis (AIS) represents the most frequent tridimensional spinal deformity. Progression of curves is linked mainly to the rapid growth around puberty. The natural history can lead to large spinal and thoracic deformities, which could impose surgical treatments. In that specific adolescent period, it is possible with very accurate treatments to alt curves progression. We describe the different types of braces used worldwide their indications, technical applications, results and failures, as well our own experience. The literature agrees that with proper indications that means, still growing patients, and documented progressive curves between 20° and 45°, a well-designed and adapted brace providing a correction of 50% can stop the curve's progression in most of the cases.

Effective factors on brace compliance in idiopathic scoliosis: a literature review

Objectives: Compliance plays a major role in the success of brace treatment and is influenced by factors such as the kind of brace, measurements method, regimen for brace wear, pattern wearing at night/day or full/part time and another factor is also psychological condition of the wearer. The objective of this review is to assess affecting factors on compliance of spinal braces in idiopathic scoliosis.Materials and methods: The guideline of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) was used for conducting review and assessing the quality of evidence. The search in Pubmed databases had 175 results of which 17 articles met the inclusion criteria. Effective factors on compliance were extracted and categorized into six groups based on type of brace, measurement method, age, day/night time pattern wearing, full/part time wearing and psychological aspect that can improve the result of spinal brace treatment in idiopathic scoliosis.Results: The results demonstrated that the type of braces determines structure and appearance and affects compliance. Psychological aspects, age, brace wear pattern (daytime or nighttime or part-time versus fulltime) and the assessment method (using temperature versus pressure sensors) can affect recorded compliance.Conclusions: Compliance can be augmented by considering factors in the design and delivery of the brace. Superior appearance and comfortable within the brace can improve psychological acceptance and improve the compliance. Lower age, involving the patient in treatment procedure, considering the child habits, and improved family awareness of the treatment plan of idiopathic scoliosis can also improve overall compliance of the brace.Implications for rehabilitationThis article reviews factors that affect compliance with orthotic treatment in idiopathic scoiliosis.

INVESTIGATION OF ROBOTIC BRACES OF PATIENTS WITH IDIOPATHIC SCOLIOSIS (IS) — REVIEW OF THE LITERATURE AND DESCRIPTION OF A NOVEL BRACE

Idiopathic scoliosis (IS) is a complex three-dimensional (3D) deformity. The non-operative treatments for IS have been developed for a long time. According to current studies, hard braces are more effective than soft braces for the treatment of scoliosis. Though current braces are proved to be effective for the treatment of IS, there are several shortcomings needed to be overcome: (i) Braces cannot realize precise control over a specific vertebra. (ii) Braces affect cardiopulmonary efficiency (braces limit maximal exercise performance). (iii) The brace is not modulated based on user’s needs. (iv) Braces, including motions during eating, tying shoes, sitting, and standing. (v) Braces apply forces on skin, which causes pain, skin breakdown, and abnormal deformation of bone. In order to solve these boring problems of the current braces, this paper proposed a new intelligent robotic spine brace based on the principle of human biomechanics, three point pressure treatment theory and parallel mechanism theory. This novel brace can offer 3D active dynamic adjustable corrective forces for the treatment of IS and some experiments are employed for verifying the effect of the proposed brace.

Consistent and regular daily wearing improve bracing results: a case-control study

Background

In respect to the prescribed regimen and the regular daily pattern, investigate how short-term results are affected by wear time adherence in terms of hours per day.

Methods

This is a case-control study. The setting is outpatient clinic. There were 168 subjects, all of whom met the inclusion criteria: adolescent idiopathic scoliosis and Sforzesco brace prescription of 18 to 23 h/day. The minimum period of follow-up was 4 months, and the maximum was 6 months, which is the average time passing between the Thermobrace (TB) adoption and out-of-brace X-ray before treatment. The brace wear adherence rate, calculated from the ratio of brace wear time with the prescription, was considered in combination with the daily pattern compliance, classified as consistent (104 patients) or inconsistent according to the abnormal distribution of Thermobrace data. The short-term results were finally explored.

Results

Consistent brace wear is associated with a higher probability of improvement in curve magnitude (OR 1.96 CI 95% 1.22–3.14 chi-square 7.78 p = 0.0053). Inconsistent brace wear is more likely to progress (OR 0.14 CI 95% 0.30–0.75 chi-square 10.13 p = 0.0015). Results from the logistic regression show that the most influencing factor for improvement is Cobb degrees at the start.

Conclusions

In clinical everyday activity, patients must be encouraged to consistently follow their brace wear prescription, because this attitude is clearly associated with a higher probability of improvement.

Long-term effects of conservative treatment of Milwaukee brace on body image and mental health of patients with idiopathic scoliosis

We aimed to provide a complex assessment of adult females with adolescent idiopathic scoliosis (AIS) after a minimum of 23 years after completed Milwaukee brace treatment. In the present study, a comparison between healthy female and AIS patients’ perception of trunk disfigurement, self-image, mental health, pain level and everyday activity was made. Thirty AIS patients with a mean of 27.77 yrs (SD 3.30) after the treatment were included in the study. The control group consisted of 42 females, matching the age profile of the patient group. Study participants from both groups were examined using the same protocol, except for the radiological evaluation. Patients and healthy controls completed the Polish versions of the Scoliosis Research Society (SRS-22) and Spinal Appearance Questionnaire (SAQ). Patients additionally filled the Bad Sobberheim Stress Questionnaire-Deformity (BSSQ-Deformity) and Bad Sobberheim Stress Questionnaire-Brace (BSSQ-Brace). The study group’s SAQ results differ significantly in regard to the total score and all individual domains, indicating better functioning among healthy controls. Except for the General domain (p = 0.002), among the remaining subscales the study group’s results differed significantly at p<0.001. Considering SRS-22 results, it was revealed that the patient group scored higher, signaling better functioning with reference to pain level (p = 0.016), function/activity (p<0.001) and the total score (p<0.001). The findings add to the complexity of long-term effect evaluations of AIS, particularly amongst females treated with a Milwaukee brace. Long-term results were not conclusive in terms of nonverbal assessment of body image and emotional tension regarding the experiences of brace-wearing. Future patients can be reassured that scoliosis treated conservatively does not negatively affect everyday activity, pain level, childbearing and mental health. Subjects who declared to have psychological problems due to scoliosis had a bigger curve size after treatment and in this study than the other AIS patients.

Curve progression after long-term brace treatment in adolescent idiopathic scoliosis: comparative results between over and under 30 Cobb degrees - SOSORT 2017 award winner

Background

The factors influencing curve behavior following bracing are incompletely understood and there is no agreement if scoliotic curves stop progressing with skeletal maturity. The aim of this study was to evaluate the loss of the scoliotic curve correction in patients treated with bracing during adolescence and to compare patient outcomes of under and over 30 Cobb degrees, 10 years after brace removal.

Methods

We reviewed 93 (87 female) of 200 and nine patients with adolescent idiopathic scoliosis (AIS) who were treated with the Lyon or PASB brace at a mean of 15 years (range 10–35). All patients answered a simple questionnaire (including work status, pregnancy, and pain) and underwent clinical and radiological examination. The population was divided into two groups based on Cobb degrees (< 30° and > 30°). Statistical analysis was performed to test the efficacy of our hypothesis.

Results

The patients underwent a long-term follow-up at a mean age of 184.1 months (±72.60) after brace removal. The pre-brace scoliotic mean curve was 32.28° (± 9.4°); after treatment, the mean was 19.35° and increased to a minimum of 22.12° in the 10 years following brace removal. However, there was no significant difference in the mean Cobb angle between the end of weaning and long term follow-up period (p = 0.105). The curve angle of patients who were treated with a brace from the beginning was reduced by 13° during the treatment, but the curve size lost 3° at the follow-up period.

The groups over 30° showed a pre-brace scoliotic mean curve of 41.15°; at the end of weaning, the mean curve angle was 25.85° and increased to a mean of 29.73° at follow-up; instead, the groups measuring ≤ 30° showed a pre-brace scoliotic mean curve of 25.58°; at the end of weaning, it was reduced to a mean of 14.24° and it increased to 16.38° at follow-up.

There was no significant difference in the mean progression of curve magnitude between the ≤ 30° and > 30° groups at the long-term follow-up.

Conclusions

Scoliotic curves did not deteriorate beyond their original curve size after bracing in both groups at the 15-year follow-ups. These results are in contrast with the history of this pathology that normally shows a progressive and lowly increment of the curve at skeletal maturity. Bracing is an effective treatment method characterized by positive long-term outcomes, including for patients demonstrating moderate curves.

Effect of Group Exercising and Adjusting the Brace at Shorter Intervals on Cobb Angle and Quality of Life of Patients With Idiopathic Scoliosis

OBJECTIVE

The aim of the study was to evaluate the effect of group exercise with brace adjustment at shorter intervals than used in routine practice in late-onset idiopathic scoliosis patients.

DESIGN

This was a quasi-experimental study. Thirty patients with progressive scoliosis curves of 15-50 degrees and a prescription for a brace were divided into experimental and control groups, both of which participated in an 11-wk treatment program. Those in the experimental group underwent brace adjustment twice per week and performed group exercise, whereas those in the control group received a routine protocol. The quality of life and Cobb angle of patients in both groups were evaluated based on baseline and final results of the 22-item Scoliosis Research Society questionnaire and primary and secondary radiographs.

RESULTS

In the experimental group, the improvement in Cobb angle and patient satisfaction was greater than that in the control group (P < 0.05). Moreover, in patients with Cobb angles of less than 30 degrees, the self-image and satisfaction domains and the total scores of patients in the experimental group were significantly different from those in the control group at the final assessment (P < 0.05).

CONCLUSIONS

Brace adjustment at shorter intervals combined with group exercise increases patient satisfaction and reduces scoliosis Cobb angles.

Initial Correction Rate Can be Predictive of the Outcome of Brace Treatment in Patients With Adolescent Idiopathic Scoliosis

STUDY DESIGN

A retrospective study.

OBJECTIVE

To determine the definite cut-off value of initial correction rate (ICR) that could be predictive of bracing outcome in patients with adolescent idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

Earlier studies showed that braced patients with a better ICR could finally have a higher probability of successful outcome. However, it remains controversial what definitive cut-off value of ICR is required to accurately predict the outcome.

MATERIALS AND METHODS

A cohort of 488 adolescent idiopathic scoliosis patients who have completed the brace treatment with a minimum of 2-year follow-up were included in the current study. Curve progression of ≤5 degrees was used to define the success of brace treatment. The success group and the failure group were compared in terms of initial Risser sign, initial age, sex, curve pattern, initial curve magnitude, and ICR. The receiver operating characteristics curve was used to define the definite cut-off point of initial curve correction rate. A logistic regression model was created to determine the independent predictors of the bracing outcome.

RESULTS

At the beginning of brace treatment, the mean age of the cohort was 13.2±1.5 years, and the mean curve magnitude was 29.5 ± 6.6 degrees. At the final follow-up, 368 patients were successfully treated by bracing. Compared with the success group, the failure group was found to have significantly younger age, lower Risser sign, and lower ICR. According to the receiver operating characteristic curve, the best cut-off value of ICR was 10%. The logistic regression model showed that ICR was significantly associated with the outcome of brace treatment with an odds ratio of 9.61.

CONCLUSIONS

Patients with low ICR, low Risser sign, and young age could have a remarkably high risk of bracing failure. A rate of 10% was the optimal cut-off point for ICR, which can be used to effectively stratify braced patients.

Adolescents with idiopathic scoliosis and their parents have a positive attitude towards the Thermobrace monitor: results from a survey

Background

A temperature monitor is used to objectively measure brace wear time in adolescent idiopathic scoliosis. The reliability of this device have been demonstrated, and some specialists introduced the use of a compliance monitor as a standard of care in everyday clinical practice, as we did since 2010 with the Thermobrace (TB). The attitude towards these objective monitors has never been investigated.

The present study aims to investigate the attitude of parents and patients towards the use of temperature sensors for measuring brace wear compliance.

Methods

Three hundred one consecutive girls and 63 boys and their parents have been interviewed. The inclusion criteria were as follows: brace wear full-time prescription at first visit and at least one visit with download and discussion of TB data.

Usefulness, acceptability, reliability, and feeling related to data download were the investigated domains. Patients were invited by the administrative staff to complete anonymously the questionnaire. The European Commission was informed about the present survey and approved it (ICT-37-2015-1). Descriptive statistic was used to present the results.

Results

Among the 364 invited patients and parents, 336 adhered by completing it (rate of responders was 93.2%). The mean age was 14.65 (SD 2.36), the mean Cobb angle was 34.18 (SD 13.57), and the average brace wear prescription was 21.76 h per day (SD 2.53). We did not ask parents about their age, profession, nor other personal data.

Globally, the interviewed patients and parents showed a very positive attitude towards the TB monitor: the mean rate of parents stating a completely or at least partially positive attitude towards this electronic device was 94.0% while among patients, it was 85.6%.

Conclusions

This is the first study investigating the attitude of parents and patients towards a brace wear compliance monitor. People who experienced this objective monitoring are aware of the advantages related to it and support its usefulness not only for clinicians but also for patients and parents to respect the hours prescribed without any affection on the children and parents or the patient-physician relationship. The present results should encourage the spread of these tools in daily clinical practice.

Electronic supplementary material

The online version of this article (doi:10.1186/s13013-017-0119-x) contains supplementary material, which is available to authorized users.

Presentation of Adolescent Idiopathic Scoliosis: The Bigger the Kid, the Bigger the Curve

BACKGROUND

It is our clinical suspicion that children with higher body mass index (BMIs) who are diagnosed with scoliosis tend to have larger curves on presentation. The purpose of this study was to determine the effect of BMI on severity of curve at initial presentation of adolescent idiopathic scoliosis.

METHODS

This is a retrospective, descriptive cohort study of consecutive patients age 10 or greater referred to a single large tertiary care center with concern for spinal asymmetry. Patients were separated into 3 BMI categories as measured on the presenting visit: normal weight-≥5th and <85th percentile, overweight-≥85th and <95th percentile, and obese-≥95th percentile. In addition to demographic information, data collected included BMI, curve magnitude, curve location, Risser stage, and where or by whom spinal asymmetry was noted.

RESULTS

A total of 150 patients, 50 in each the normal weight, overweight, and obese categories, were included in this study. Average curve at presentation for normal weight patients was 18.1 degrees, for overweight patients 23.9 degrees (P=0.02), and for obese patients 24.5 degrees (P=0.02). As compared with the normal weight group, odds ratio of presenting with a curve of 40 degrees or above was 10.8 for the overweight group (95% confidence interval, 1.3-88.5, P=0.03) and 12.2 for the obese group (95% confidence interval, 1.5-99.8, P=0.02). Assuming a cut-off of 45 degrees as surgical range, no normal weight patients presented in surgical range (0%), but 7/50 (14%, P=0.01) overweight and 8/50 (16%, P<0.01) obese patients did. Moreover, higher BMI patients were significantly more likely to present at a higher degree of skeletally maturity, with an average Risser of 1.8 for normal weight patients, 2.7 (P=0.01) for overweight patients, and 2.9 (P=0.01) for obese patients.

CONCLUSIONS

Overweight and obese patients with adolescent idiopathic scoliosis present at significantly larger curve magnitudes and significantly higher degrees of skeletal maturity. Moreover, these patients were significantly more likely to present with very large curves and, in our study, all patients presenting with a surgical range curve were either overweight or obese.

LEVEL OF EVIDENCE

Level III-Retrospective case-control.

It's not just the big kids: both high and low BMI impact bracing success for adolescent idiopathic scoliosis

PURPOSE

Bracing is a common treatment for patients with adolescent idiopathic scoliosis (AIS) and is recommended for most skeletally immature patients with a curve of 25-45° in order to prevent or delay curve progression. The aim of this study was to determine at which body habitus orthotic management for AIS becomes less effective. We hypothesize that overweight children are more likely to fail brace treatment.

METHODS

This was a retrospective cohort study involving consecutive patients with AIS treated with a thoracolumbosacral orthosis at a large pediatric tertiary care center. Patients were divided into three groups based on BMI: (1) high-BMI group (BMI >85th percentile); (2) low-BMI group (BMI <20th percentile); (3) mid-BMI group (BMI 20th-85th percentile). Successful orthotic treatment was defined as an increase in the primary curve of <5°, prevention of progression past 45°, and avoidance of surgery.

RESULTS

The study cohort comprised 182 patients with a mean age of 12.5 years at brace prescription and a mean follow-up of 2 years. Compared to the mid-BMI group, high- and low-BMI patients were significantly more likely to fail orthotic management. The association between high-BMI and orthotic failure disappeared when compliance and in-brace correction were taken into account, but the association between low-BMI and each poor outcome remained significant.

CONCLUSIONS

Based on our results, children on either end of the BMI spectrum are more likely to fail brace treatment for scoliosis than their mid-BMI counterparts. In high-BMI patients, this appears to be in large part attributable to an inadequacy of in-brace curve correction as well as to poorer brace compliance, while a low BMI appears to be an independent risk factor for brace failure.

Nonsurgical Management of Adolescent Idiopathic Scoliosis

Pediatric patient visits for spinal deformity are common. Most of these visits are for nonsurgical management of scoliosis, with approximately 600,000 visits for adolescent idiopathic scoliosis (AIS) annually. Appropriate management of scoliotic curves that do not meet surgical indication parameters is essential. Renewed enthusiasm for nonsurgical management of AIS (eg, bracing, physical therapy) exists in part because of the results of the Bracing in Adolescent Idiopathic Scoliosis Trial, which is the only randomized controlled trial available on the use of bracing for AIS. Bracing is appropriate for idiopathic curves between 20° and 40°, with successful control of these curves reported in >70% of patients. Patient adherence to the prescribed duration of wear is essential to maximize the effectiveness of the brace. The choice of brace type must be individualized according to the deformity and the patient's personality as well as the practice setting and brace availability.

Curve progression 25 years after bracing for adolescent idiopathic scoliosis: long term comparative results between two matched groups of 18 versus 23 hours daily bracing

Background

Scoliotic curves do not necessarily stop progressing at skeletal maturity. The factors that influence curve behavior following bracing are not fully determined. Our objectives were to evaluate the loss of the scoliotic curve correction in a cohort of patients treated with bracing during adolescence and to compare the outcomes of 18 versus 23 h of bracing at a mean of 25 years post brace removal.

Methods

Seventy-seven patients, who were successfully treated for Adolescent Idiopathic Scoliosis with Βoston brace, were re-evaluated 25 years after the end of their treatment. Patients were further divided in 2 matched groups; those wearing the brace for 23 h and those not wearing the brace at school-time, limiting the application of the brace to 18 h. The mean scoliotic curve was compared between groups before, during, just after bracing and 25 years post bracing. Validated in patients’ native language forms of Short Form 36 and Oswestry Disability Index questionnaires were used to compare the quality of life between groups 25 years post bracing.

Results

The mean age of the cohort was 40.4 (±3.2) years. They underwent long term follow up at a mean of 25.16 (±2.69) years after brace removal. The mean cohort scoliotic curve increased by 3.9 (±6.69) at 25 years since brace removal. There was however no significant difference in the mean Cobb angle of the cohort between pre brace and long term follow up period (p = 0.307).

The 18 and 23 h application groups were comparable according to demographics and several bracing and scoliotic curve parameters. There was no significant difference in the mean curve magnitude between 18 and 23 h application groups at brace removal (p = 0.512) and at 25 years follow-up (p = 0.878). There was also no significant difference in the mean score of Quality of Life questionnaires between groups at long term follow up.

Conclusion

Scoliotic curves do not necessarily stop progressing after bracing. Bracing is effective treatment method with good long term results in appropriate patients. Since compliance was not objectively measured, we don’t feel confident to give any indication about everyday dosage.

Scoliosis may be the first symptom of the tethered spinal cord

BACKGROUND

Tethered cord syndrome (TCS) is a progressive clinical entity that arises from abnormal spinal cord tension. Scoliosis may be a unique symptom in TCS. The aim of this study is to investigate prognosis after releasing the filum terminale in scoliosis due to TCS with/without findings in magnetic resonance imaging (MRI) and to draw attention to the importance of somatosensorial evoked potentials (SSEP) on the differential diagnosis of idiopathic scoliosis versus scoliosis due to TCS with normal appearance of filum terminale and conus medullaris.

MATERIALS AND METHODS

Eleven female and seven male patients with progressive scoliosis were included in the study. They were evaluated radiologically, SSEP and urodynamical studies. Preoperative and postoperative anteroposterior full spine X-rays were obtained for measuring the Cobb's angle. MRI was performed in all cases for probable additional spinal abnormalities. All patients underwent filum terminale sectioning through a L5 hemilaminectomy. The resected filum terminale were subjected to histopathological examination.

RESULTS

The mean Cobb angle was 31.6° (range 18°-45°). Eight patients (44.45%) had a normal appearance of filum terminale and normal level conus medullaris in MRI, but conduction delay and/or block was seen on SSEP. In the histopathological examination of filum terminale dense collagen fibers, hyaline degeneration and loss of elastic fibers were observed. Postoperatively none of the patients showed worsening of the Cobb angle. Three patients showed improvement of scoliosis.

CONCLUSION

In TCS presented with scoliosis, untethering must be performed prior to the corrective spinal surgery. Absence of MRI findings does not definitely exclude TCS. SSEP is an important additional guidance in the diagnosis of TCS. After untethering, a followup period of 6 months is essential to show it untethering helps in stopping the progress of the scoliotic curve. In spite of non progression (curve stopped lesser than 45°) or even improvement of scoliosis, there may be no need for major orthopedic surgical intervention.

Electronic monitoring of orthopedic brace compliance

PURPOSE

Brace compliance measurement in adolescent idiopathic scoliosis (AIS) has been the subject of a few recent studies. Various sensors have been developed to measure compliance. We have developed a temperature-based data logger-the Cricket-specifically for scoliosis braces, with associated custom software, that is embedded directly in the brace. The purpose of this study was to analyze patterns of brace wear and patient compliance among children with AIS using the Cricket.

METHODS

Fifty-five AIS patients prescribed various brace-time regimens were monitored using the Cricket. All subjects were treated with the Wilmington brace. The compliance rate for each group was determined.

RESULTS

Overall compliance among subjects was 69.9 ± 31.5 %. Only 14.5 % met or exceeded prescribed brace time. This is consistent with previous compliance monitoring results.

CONCLUSION

The results of this study objectively show the difference between prescribed and actual brace wear time and reaffirm the Cricket sensor as an accurate and comfortable brace-monitoring device.

Braces for idiopathic scoliosis in adolescents

BACKGROUND

Idiopathic scoliosis is a three-dimensional deformity of the spine. The most common form is diagnosed in adolescence. While adolescent idiopathic scoliosis (AIS) can progress during growth and cause a surface deformity, it is usually not symptomatic. However, in adulthood, if the final spinal curvature surpasses a certain critical threshold, the risk of health problems and curve progression is increased.

OBJECTIVES

To evaluate the efficacy of bracing for adolescents with AIS versus no treatment or other treatments, on quality of life, disability, pulmonary disorders, progression of the curve, and psychological and cosmetic issues.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, five other databases, and two trials registers up to February 2015 for relevant clinical trials. We also checked the reference lists of relevant articles and conducted an extensive handsearch of grey literature.

SELECTION CRITERIA

Randomized controlled trials (RCTs) and prospective controlled cohort studies comparing braces with no treatment, other treatment, surgery, and different types of braces for adolescent with AIS.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included seven studies (662 participants). Five were planned as RCTs and two as prospective controlled trials. One RCT failed completely, another was continued as an observational study, reporting also the results of the participants that had been randomized.There was very low quality evidence from one small RCT (111 participants) that quality of life (QoL) during treatment did not differ significantly between rigid bracing and observation (mean difference (MD) -2.10, 95% confidence interval (CI) -7.69 to 3.49). There was very low quality evidence from a subgroup of 77 adolescents from one prospective cohort study showing that QoL, back pain, psychological, and cosmetic issues did not differ significantly between rigid bracing and observation in the long term (16 years).Results of the secondary outcomes showed that there was low quality evidence that rigid bracing compared with observation significantly increased the success rate in 20° to 40° curves at two years' follow-up (one RCT, 116 participants; risk ratio (RR) 1.79, 95% CI 1.29 to 2.50). There was low quality evidence that elastic bracing increased the success rate in 15° to 30° curves at three years' follow-up (one RCT, 47 participants; RR 1.88, 95% CI 1.11 to 3.20).There is very low quality evidence from two prospective cohort studies with a control group that rigid bracing increases the success rate (curves not evolving to 50° or above) at two years' follow-up (one study, 242 participants; RR 1.50, 95% CI 1.19 to 1.89) and at three years' follow-up (one study, 240 participants; RR 1.75, 95% CI 1.42 to 2.16). There was very low quality evidence from a prospective cohort study (57 participants) that very rigid bracing increased the success rate (no progression of 5° or more, fusion, or waiting list for fusion) in adolescents with high degree curves (above 45°) (one study, 57 adolescents; RR 1.79, 95% CI 1.04 to 3.07 in the intention-to-treat (ITT) analysis).There was low quality evidence from one RCT that a rigid brace was more successful than an elastic brace at curbing curve progression when measured in Cobb degrees in low degree curves (20° to 30°), with no significant differences between the two groups in the subjective perception of daily difficulties associated with wearing the brace (43 girls; risk of success at four years' follow-up: RR 1.40, 1.03 to 1.89). Finally, there was very low quality evidence from one RCT (12 participants) that a rigid brace with a pad pressure control system is no better than a standard brace in reducing the risk of progression.Only one prospective cohort study (236 participants) assessed adverse events: neither the percentage of adolescents with any adverse event (RR 1.27, 95% CI 0.96 to 1.67) nor the percentage of adolescents reporting back pain, the most common adverse event, were different between the groups (RR 0.72, 95% CI 0.47 to 1.10).

AUTHORS' CONCLUSIONS

Due to the important clinical differences among the studies, it was not possible to perform a meta-analysis. Two studies showed that bracing did not change QoL during treatment (low quality), and QoL, back pain, and psychological and cosmetic issues in the long term (16 years) (very low quality). All included papers consistently showed that bracing prevented curve progression (secondary outcome). However, due to the strength of evidence (from low to very low quality), further research is very likely to have an impact on our confidence in the estimate of effect. The high rate of failure of RCTs demonstrates the huge difficulties in performing RCTs in a field where parents reject randomization of their children. This challenge may prevent us from seeing increases in the quality of the evidence over time. Other designs need to be implemented and included in future reviews, including 'expertise-based' trials, prospective controlled cohort studies, prospective studies conducted according to pre-defined criteria such as the Scoliosis Research Society (SRS) and the international Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) criteria. Future studies should increase their focus on participant outcomes, adverse effects, methods to increase compliance, and usefulness of physiotherapeutic scoliosis specific exercises added to bracing.

Braces Optimized With Computer-Assisted Design and Simulations Are Lighter, More Comfortable, and More Efficient Than Plaster-Cast Braces for the Treatment of Adolescent Idiopathic Scoliosis

STUDY DESIGN

Feasibility study to compare the effectiveness of 2 brace design and fabrication methods for treatment of adolescent idiopathic scoliosis: a standard plaster-cast method and a computational method combining computer-aided design and fabrication and finite element simulation.

OBJECTIVES

To improve brace design using a new brace design method.

SUMMARY OF BACKGROUND DATA

Initial in-brace correction and patient's compliance to treatment are important factors for brace efficiency. Negative cosmetic appearance and functional discomfort resulting from pressure points, humidity, and restriction of movement can cause poor compliance with the prescribed wearing schedule.

METHODS

A total of 15 consecutive patients with brace prescription were recruited. Two braces were designed and fabricated for each patient: a standard thoracolumbo-sacral orthosis brace fabricated using plaster-cast method and an improved brace for comfort (NewBrace) fabricated using a computational method combining computer-aided design and fabrication software (Rodin4D) and a simulation platform. Three-dimensional reconstructions of the torso and the trunk skeleton were used to create a personalized finite element model, which was used for brace design and predict correction. Simulated pressures on the torso and distance between the brace and patient's skin were used to remove ineffective brace material situated at more than 6 mm from the patient's skin. Biplanar radiographs of the patient wearing each brace were taken to compare their effectiveness. Patients filled out a questionnaire to compare their comfort.

RESULTS

NewBraces were 61% thinner and had 32% less material than standard braces with equivalent correction. NewBraces were more comfortable (11 of 15 patients) or equivalent to (4 of 15 cases) standard braces. Simulated correction was simulated within 5° compared with in-brace results.

CONCLUSIONS

This study demonstrates the feasibility of designing lighter and more comfortable braces with correction equivalent to standard braces. This design platform has the potential to further improve brace correction efficiency and its compliance.

Correlation between compliance and brace treatment in juvenile and adolescent idiopathic scoliosis: SOSORT 2014 award winner

Background

Over the last years, evidence has accumulated in support of bracing as an effective treatment option in patients with idiopathic scoliosis. Yet, little information is available on the impact of compliance on the outcome of conservative treatment in scoliotic subjects. The aim of the present study was to prospectively evaluate the association between compliance to brace treatment and the progression of scoliotic curve in patients with idiopathic adolescent (AIS) or juvenile scoliosis (JIS).

Methods

Among 1.424 patients treated for idiopathic scoliosis, 645 were eligible for inclusion criteria. Three outcomes were distinguished in agreement with the SRS criteria: curve correction, curve stabilization and curve progression. Brace wearing was assessed by one orthopaedic surgeon (LA) and scored on a standardized form. Compliance to treatment was categorized as complete (brace worn as prescribed), incomplete A (brace removed for 1 month), incomplete B (brace removed for 2 months), incomplete C (brace removed during school hours), and incomplete D (brace worn overnight only). Chi square test, T test or ANOVA and ANOVA for repeated measures tests were used as statistical tests.

Results

The results from our study showed that at follow-up the compliance was: Complete 61.1%; Incomplete A 5.2%; Incomplete B 10.7%; Incomplete C 14.2%; Incomplete D 8.8%. Curve correction was accomplished in 301/319 of Complete, 19/27 Incomplete A, 25/56 Incomplete B, 52/74 Incomplete C, 27/46 Incomplete D. Cobb mean value was 29.8 ± 7.5 SD at beginning and 17.1 ± 10.9 SD at follow-up. Both Cobb and Perdriolle degree amelioration was significantly higher in patients with complete compliance over all other groups, both in juvenile, both in adolescent scoliosis. In the intention-to-treat analysis, the rate of surgical treatment was 2.1% among patients with definite outcome and 12.1% among those with drop-out. Treatment compliance showed significant interactions with time.

Conclusion

Curve progression and referral to surgery are lower in patients with high brace compliance. Bracing discontinuation up to 1 month does not impact on the treatment outcome. Conversely, wearing the brace only overnight is associated with a high rate of curve progression.

DEVELOPMENT AND EVALUATION OF AN AIRBAG BRACE SYSTEM FOR IDIOPATHIC SCOLIOSIS SUBJECTS

There are disadvantages, especially from biomechanical viewpoint, to treating idiopathic scoliosis (IS) patients using traditional Boston braces with pressure pads. The major problem is the higher stiffness of the pressure pad as compared to the soft-tissue of the trunk. The aim of this study was to evaluate the effectiveness of Boston braces in which the pressure pad was replaced by the deformable airbag. A custom-made airbag brace which was designed based on the three-point compression principle of the Boston brace was prescribed to each of the 20 IS subjects with a mean age of 11.8 ± 2.8 years old. To evaluate the effectiveness of the treatment, the scoliosis Cobb angles before the treatment and after a follow-up period were measured from AP X-rays. The mean follow-up period was 11.5 ± 6.6 months. In addition, three interface parameters — contact pressure, contact area, and contact force — under seven postures — upright, flexion, extension, left side bending, right side bending, left side rotation and right side rotation — were measured using pressure mats to investigate interface conditions between airbags and skin. During the follow-up, all scoliosis curves showed Cobb angle reduction except one thoracic curve, which increased by one degree. The Cobb angle in the thoracic region decreased from 37.3 ± 10.6° to 27.3 ± 10.1° with a mean decreasing of 9.9 ± 5.9°. The Cobb angle in the lumbar region decreased from 30.1 ± 6.9° to 17.7 ± 8.6° with a mean decreasing of 12.4 ± 4.9°. Changes in the three interface parameters for the seven postures were insignificant. This indicated that the airbag brace could provide sufficient continuous corrective force. Using the airbag, instead of the pressure pad to provide the corrective force in the brace system can effectively correct the spinal curve caused by scoliosis. Easy adjustment and direct control of airbag pressure might be the key factor to the success of the airbag brace.

Design of the Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST)

STUDY DESIGN

Descriptive.

OBJECTIVE

To describe the design and development of Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST).

SUMMARY OF BACKGROUND DATA

Bracing has remained the standard of care for the nonoperative treatment of adolescent idiopathic scoliosis since the introduction of the Milwaukee brace in the late 1940s, but it has never been subjected to a rigorous evaluation of either its efficacy or its effectiveness. The BrAIST was designed to address the primary question: Do braces (specifically a thoracolumbosacral orthosis) lower the risk of curve progression to a surgical threshold (≥50°) in patients with adolescent idiopathic scoliosis relative to watchful waiting alone?

METHODS

The authors describe the rationale for BrAIST, including the limitations of the current literature evaluating bracing for adolescent idiopathic scoliosis. Second, the authors describe the preliminary work, including the preparation of the National Institutes of Health clinical trials planning grant. Finally, the authors describe the trial design in detail.

RESULTS

BrAIST was conducted in 25 sites in North America. Subjects were treated either with a thoracolumbosacral orthosis or watchful waiting and followed every 6 months until they reached skeletal maturity or the surgical threshold of 50° Cobb angle.

CONCLUSION

Clinical decision making will be improved by translation of the BrAIST results into evidence-based prognosis and estimates of how the prognosis, specifically the risk of progressing to surgery, may be altered by the use of bracing.

LEVEL OF EVIDENCE

N/A.

Osteopenia predicts curve progression of adolescent idiopathic scoliosis in girls treated with brace treatment

BACKGROUND

Previous studies have shown a significant association between osteopenia and adolescent idiopathic scoliosis (AIS). And initial bone mineral density (BMD) was proposed to serve as a new prognostic factor of curve progression in AIS. However, it remains unknown whether there is a link between the initial bone mineral status and the outcome of brace treatment. This study aimed to investigate whether the initial bone mineral status could influence the final outcome of brace treatment in AIS.

METHODS

Girls with AIS treated with brace treatment were recruited. These patients either completed brace treatment, or were indicated for correction surgery with a curve magnitude of >45 degrees. Patients with a progressed scoliosis (group A) and those with a nonprogressed scoliosis (group B) were identified. The associations between the bracing outcome and the indices before bracing, including growth status, anthropometric measurements, BMD status, curve magnitude, and curve pattern were evaluated using univariate analysis and regression analysis.

RESULTS

Sixty-eight patients were included. There were 17 girls (25%) in group A and 51 girls (75%) in group B, respectively. The girls in group A had a significantly larger initial Cobb angle (32.3±6.6 vs. 29.1±5.3 degrees), a significantly lower BMD of lumbar spine from L2 to L4 value (0.80±0.11 vs. 0.88±0.12 g/cm), and a marginally significantly lower Risser grade (1.4±1.5 vs. 2.2±1.4), than in group B. In comparison with group B, more girls in group A were found to be premenarche (P=0.008), osteopenic (P=0.003), with a lower Risser grade (P=0.079), a greater curve magnitude (P=0.159), and a main thoracic pattern (P=0.122) before the initiation of bracing treatment. As revealed by the multiple logistic regression analysis, osteopenia (P=0.002) was identified as an independent risk factor in curve progression in AIS girls, during the total duration of bracing treatment.

CONCLUSIONS

Osteopenia is identified to serve as a new independent risk factor in the curve progression during the duration of bracing treatment. The evaluation of initial BMD status before bracing may help to predict the outcome of brace treatment.

LEVEL OF EVIDENCE

Level II.

Effectiveness of brace treatment of Chiari malformation-associated scoliosis after posterior fossa decompression: a comparison with idiopathic scoliosis

STUDY DESIGN

Retrospective case-control study.

OBJECTIVE

To evaluate the effectiveness of bracing in patients with Chiari malformation-associated scoliosis (CMS) after posterior fossa decompression (PFD).

SUMMARY OF BACKGROUND DATA

The effectiveness of bracing has been poorly studied in patients with CMS who have undergone PFD.

METHODS

A retrospective study was conducted on 22 patients with CMS who received brace treatment of scoliosis after PFD. Forty-four age- and sex-matched patients with idiopathic scoliosis (IS) who were treated with bracing served as the control group. The bracing outcome was considered a failure if the curve worsened 6° or more; otherwise, the treatment was considered to be successful.

RESULTS

The age and Risser sign were similar between patients with CMS and IS at brace initiation. The initial curve magnitude of patients with CMS (mean, 32.9° ± 6.3°; range, 20°-45°) was marginally significantly larger than that of patients with IS (mean, 29.6° ± 6.4°; range, 20°-45°). Until the final follow-up, a 6° or more worsening of the major curve occurred in 8 patients with CMS (36%) and in 15 patients with IS (34%). Overall, 7 patients with CMS (32%) and 13 patients with IS (30%) underwent spinal fusion surgery. No significant differences were observed between the 2 groups in the surgery rates or the bracing success rates (P > 0.05). In patients with CMS, neither the performance of syringosubarachnoid shunting nor the extent of tonsillar descent correlated with the bracing outcomes, whereas a double major curve pattern was found to be predictive for the failure of bracing.

CONCLUSION

Brace treatment subsequent to PFD is effective in preventing curve progression for 64% of patients with CMS, which is comparable with the rate that is observed in patients with IS. Double major curve pattern may be a risk factor in predicting treatment failure in patients with CMS.

LEVEL OF EVIDENCE

3.

Bracing in adolescent idiopathic scoliosis

The article reviews the present knowledge about brace treatment for adolescent idiopathic scoliosis (AIS). Indications, technique, problems, and results, are presented based on the literature. It is stressed by the authors that more scientific evidence is needed to reach a final conclusion whether brace treatment in AIS is effective or not.

Current concepts and controversies on adolescent idiopathic scoliosis: Part I

Adolescent idiopathic scoliosis is the most common spinal deformity encountered by General Orthopaedic Surgeons. Etiology remains unclear and current research focuses on genetic factors that may influence scoliosis development and risk of progression. Delayed diagnosis can result in severe deformities which affect the coronal and sagittal planes, as well as the rib cage, waistline symmetry, and shoulder balance. Patient's dissatisfaction in terms of physical appearance and mechanical back pain, as well as the risk for curve deterioration are usually the reasons for treatment. Conservative management involves mainly bracing with the aim to stop or slow down scoliosis progression during growth and if possible prevent the need for surgical treatment. This is mainly indicated in young compliant patients with a large amount of remaining growth and progressive curvatures. Scoliosis correction is indicated for severe or progressive curves which produce significant cosmetic deformity, muscular pain, and patient discontent. Posterior spinal arthrodesis with Harrington instrumentation and bone grafting was the first attempt to correct the coronal deformity and replace in situ fusion. This was associated with high pseudarthrosis rates, need for postoperative immobilization, and flattening of sagittal spinal contour. Segmental correction techniques were introduced along with the Luque rods, Harri-Luque, and Wisconsin systems. Correction in both coronal and sagittal planes was not satisfactory and high rates of nonunion persisted until Cotrel and Dubousset introduced the concept of global spinal derotation. Development of pedicle screws provided a powerful tool to correct three-dimensional vertebral deformity and opened a new era in the treatment of scoliosis.

Does brace treatment impact upon the flexibility and the correctability of idiopathic scoliosis in adolescents?

PURPOSE

Brace treatment has served as a vital non-surgical procedure for immature adolescent idiopathic scoliosis (AIS) patients with a mild or moderate curve. For the patients who fail in bracing and resort to surgery, it is unclear whether prior full-time brace treatment significantly influences outcomes. This study aims to investigate whether prior brace treatment has a negative impact upon the flexibility and correctability of the main curve in patients with AIS.

METHODS

The participants were collected from female AIS patients who underwent posterior correction surgery with pedicle screw instrumentation from August 2006 to December 2010, with or without prior brace treatment. Patients included in Group A had prior brace treatment over a 1-year period, and underwent surgery within 6 months after cessation of bracing; those in Group B received no prior treatment and were randomly selected from our database. Curve flexibility pre-surgery and curve correctability post-surgery were computed and compared between both groups and subgroups according to the curve location.

RESULTS

Each group consisted of 35 patients. Age, curve magnitude and location were comparable between the two groups. Before surgery, patients in Group A had a slightly lower curve flexibility than those in Group B (52 vs. 60 %, P = 0.036). After surgery, satisfactory correction results were observed in both groups, but the average post-operative main curve magnitude of patients in Group B was 4° less than that of Group A (10° vs. 14°, P = 0.010). The curve correctability in Group B was significantly higher than that in Group A (80 vs. 74 %, P = 0.002). No matter what curve pattern the patient had, having a prior history of brace treatment resulted in a trend of lower flexibility and correctability of their scoliosis.

CONCLUSIONS

Good surgical correction can be achieved in AIS patients who have been unsuccessful with prior brace treatment. However, a history of prior brace treatment leads to a trend of lowering the curve flexibility, and in turn, negatively impacts upon the curve correctability.

In defense of adolescents: They really do use braces for the hours prescribed, if good help is provided. Results from a prospective everyday clinic cohort using thermobrace

BACKGROUND

The effectiveness of bracing relies on the quality of the brace, compliance of the patient, and some disease factors. Patients and parents tend to overestimate adherence, so an objective assessment of compliance has been developed through the use of heat sensors. In 2010 we started the everyday clinical use of a temperature sensor, and the aim of this study is to present our initial results.

METHODS

POPULATION

A prospective cohort of 68 scoliosis patients that finished at least 4 months of brace treatment on March 31, 2011: 48 at their first evaluation (79% females, age 14.2±2.4) and 20 already in treatment.

TREATMENT

Bracing (SPoRT concept); physiotherapic specific exercises (SEAS School); team approach according to the SOSORT Bracing Management Guidelines.Methods. A heat sensor, "Thermobrace" (TB), has been validated and applied to the brace. The real (measured by TB) and referred (reported by the patient) compliances were calculated.Statistics. The distribution was not normal, hence median and 95% interval confidence (IC95) and non-parametric tests had to be used.

RESULTS

Average TB use: 5.5±1.5 months. Brace prescription was 23 hours/day (h/d) (IC95 18-23), with a referred compliance of 100% (IC95 70.7-100%) and a real one of 91.7% (IC95 56.6-101.7%), corresponding to 20 h/d (IC95 11-23). The more the brace was prescribed, the more compliant the patient was (94.8% in 23 h/d vs. 73.2% in 18 h/d, P < 0.05). Sixty percent of the patients had at least 90% compliance, and 45% remained within 1 hour of what had been prescribed. Non-wearing days were 0 (IC95 0-12.95), and involved 29% of patients.

CONCLUSION

This is the first study using a TB in a setting of respect for the SOSORT criteria for bracing, and it states that it is possible to achieve a very good compliance, even with a full time prescription, and better than what was previously reported (80% maximum). We hypothesize that the treating team (SOSORT criteria) plays a major role in our results. This study suggests that compliance is neither due to the type of treatment only nor to the patient alone. According to our experience, TB offers valuable insights and do not undermine the relationship with the patients.

Evolution of the curve patterns during brace treatment for adolescent idiopathic scoliosis

The curve pattern of idiopathic scoliosis is important for making decisions concerning bracing. However, whether the curve pattern changes during brace treatment have not been fully documented. The aim of this study was to investigate the changes of curve pattern during brace treatment in skeletally immature patients with adolescent idiopathic scoliosis (AIS).

METHODS

From January 2002 to January 2011, AIS patients treated with a Boston or Milwaukee brace were recruited after meeting the following inclusion criteria: older than 10 years of age at initiation of bracing; having a Cobb angle of 25°-40°; with a Risser sign 0-2; being regularly followed until the weaning of brace or the necessity of surgical treatment; and without history of previous treatment. A total of 130 female and 11 male AIS patients were included. The mean age was 12.9 years at initiation of bracing, and the female patients were, on average, 2.7 months past menarche. The mean follow-up period was 2.6 years (range 1.0-5.5 years). The definitions of changes in curve patterns were divided into four categories as follows: (1) shift of the apex of the main curve; (2) change in the curve span of more than two vertebrae; (3) change in the main curve type with regard to the apex location; and (4) change of curve direction. The patients were divided into two groups. Group A was comprised of patients who had experienced one or more categories of curve pattern changes, and Group B was comprised of those who had not.

RESULTS

Of these 39 patients, 14 had apex shifting, 2 underwent curve span changes, 22 experienced changes in the main curve type, and one female had both changes in the apex and curve span. At the initiation of bracing, patients in Group A demonstrated significantly lower menarchal status (P = 0.018) and lower Risser grade (P = 0.025) than those in Group B. The difference in the percentage of patients who underwent Boston bracing between the two groups was statistically significant (41.5 % for Group A vs. 24.0 % for Group B, P = 0.023).

CONCLUSION

Changes in curve pattern can occur during brace treatment. Patients with less skeletal maturity and those treated with a Boston brace are more susceptible to this phenomenon.

A comparative study of axis-line-distance technique and Cobb method on assessing the curative effect on scoliosis

PURPOSE

To compare the axis-line-distance technique (ALDT) and Cobb method for therapeutic evaluation of scoliosis.

METHODS

Fifty-seven patients with scoliosis were treated in our hospital, 47 underwent conservative bracing therapy and 10 underwent surgery. Based on 171 full-spine X-ray images obtained from these 57 cases before treatment, during conservative treatment or surgery, and at final follow-up after removing the brace or after surgery, two radiologists independently measured and calculated the correction rate during treatment and at final follow-up and the rate of correction loss after treatment with the ALDT and Cobb methods. Paired t-test and correlation analysis were performed.

RESULTS

Based on the ALDT, the lateral deviations of the apical vertebrae before treatment, during treatment, and at final follow-up were 31 ± 14 mm, 16 ± 8 mm, and 20 ± 8 mm, respectively; the correction rates during treatment and at final follow-up were 48.7 ± 21.2% and 37.6 ± 14.2%, respectively, and the rate of correction loss after treatment was 11.3 ± 6.5%. The Cobb angles of scoliosis before treatment, during treatment, and at final follow-up were 34 ± 14°, 19 ± 7°, and 22 ± 6°, respectively; the correction rates during treatment and at final follow-up were 44.4 ± 17.3% and 33.9 ± 14.4%, respectively, and the rate of correction loss after treatment was 11.4 ± 4.3%. Calculation of the correction rate during treatment differed significantly between the two radiologists when using the Cobb method (P < 0.05); their calculations of the correction rate and rate of correction loss were not different (P > 0.05). The measurement data of the two radiologists using the Cobb method showed a weak to moderate correlation (r = 0.49, 0.57, and 0.51, respectively). When using the ALDT, there were no significant differences between the radiologists in their measurements of the correction rate during and after treatment (P > 0.05) or in the rate of correction loss. The measurement data of the two radiologists using the ALDT showed a good to excellent correlation (r = 0.92, 0.93, and 0.90, respectively).

CONCLUSION

The ALDT is better than the Cobb method for therapeutic evaluation of scoliosis during treatment and at follow-up visits.

Adolescent idiopathic scoliosis treatment using pettibon corrective procedures: a case report

OBJECTIVE

To investigate the possible benefits of using Pettibon corrective procedures to reduce the curvature associated with idiopathic scoliosis. These procedures were tested to determine potential effectiveness in a single patient.

CLINICAL FEATURES

A patient with a 35 degrees left convex thoracolumbar scoliosis was treated using Pettibon corrective procedures. Initial and follow-up outcome measures included a Borg pain scale, a Functional Rating Index, a balance test, and radiographic analysis.

INTERVENTION AND OUTCOME

The patient was treated using a combination of manipulative and rehabilitative procedures designed to restore normal sagittal curves and reduce the severity of the coronal curvatures. After six weeks of treatment, the post treatment radiograph revealed a 20 degrees left convex thoracolumbar scoliosis, as well as decreases in the Borg pain scale from six to two, and Functional Rating Index score from 18/40 to 7/40 after the trial period. Her balance time increased from 18 seconds to 56 seconds.

CONCLUSION

Pettibon corrective procedures seemed to be effective at reducing the thoracolumbar scoliosis 15 degrees (43%) after six weeks. The subjective and objective results of this case study warrant further such investigations.

Brace technology thematic series - The Sforzesco and Sibilla braces, and the SPoRT (Symmetric, Patient oriented, Rigid, Three-dimensional, active) concept

BACKGROUND

Bracing is an effective strategy for scoliosis treatment, but there is no consensus on the best type of brace, nor on the way in which it should 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 following specific principles of correction. Due to its overall 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 real novelty is the drivers, introduced for the first time with the Sforzesco brace; they allow to achieve the main action of the brace: a three-dimensional elongation pushing the spine in a down-up direction.Brace prescription is made plane by plane: frontal (on the "slopes", another novelty of this concept, i.e. the laterally flexed sections of the spine), horizontal, and sagittal. The brace is built modelling the trunk shape obtained either by a plaster cast mould or by CAD-CAM construction. Brace checking is essential, since SPoRT braces are adjustable and customisable according to each individual curve pattern.Treatment time and duration is individually tailored (18-23 hours per day until Risser 3, then gradual reduction). SEAS (Scientific Exercises Approach to Scoliosis) exercises are a key factor to achieve success.

RESULTS

The Sforzesco brace has shown to be more effective than the Lyon brace (matched case/control), equally effective as the Risser plaster cast (prospective cohort with retrospective controls), more effective than the Risser cast + Lyon brace in treating curves over 45 degrees Cobb (prospective cohort), and is able to improve aesthetic appearance (prospective cohort).

CONCLUSIONS

The SPoRT concept of bracing (three-dimensional elongation pushing in a down-up direction) is different from the other corrective systems: 3-point, traction, postural, and movement-based. The Sforzesco brace, being comparable to casting, may be the best brace for the worst cases.