BioConcepts,inc.
Orthotic-Prosthetic Center
Burr Ridge, Illinois
http://www.orthotic.com
History of Brace Treatment
The history of the usage of orthoses (braces) to correct and support
deformities in the spines of children is long and respectable. Galen5
(131-201) who first used the words scoliosis, lordosis [[threesuperior]] and
kyphosis used dynamic bracing and an exercise program to treat spinal
deformity. Ambroise Pare5 (1510-1590) wrote extensively on the use of spinal
supports and braces. Nicholas Andry (1658-1742) who coined the word
orthopaedia pertaining to the straightening of children, reported " If the
spine be crooked in the shape of an S, the best method you can take to mend
it is to have recourse to the whale bone bodice, stuffed parts shall exactly
answer to those protuberances which ought to be repressed, and these bodices
must be renewed every three months at least."2 Throughout the nineteenth
century the Europeans developed a vast amount of devices fashioned from
steel, leather and plaster, designed to correct deformities of the spine5.
The modern era of orthotic treatment for spinal deformities began with the
development of the Milwaukee brace (cervico-thoraco-lumbo-sacral orthosis)
by Drs. Blount and Schmidt in the late 1940s3.
Current Bracing For Nonoperative Treatment
The Milwaukee brace (figure 1) was first used to replace plaster casts after
spinal fusion surgery and later was used for the nonoperative management of
scoliosis and kyphosis 3,4,5,6,8,9,15,17,19,20,21. With help from
biomechanical engineers, orthopaedists and orthotists gained a better
understanding of the biomechanical function (mechanism of action) of spinal
orthoses1,6,11. Some of this resulted in the design and improvement of
newer, shorter orthoses such as the TLSO (thoraco-lumbo-sacral-orthosis)
which were used to treat curves lower in the spine. Some of these have names
such as the Boston brace (figure 2)10,14, the Miami brace18, the Wilmington
jacket (figure 3)7, and the Rosenberger orthosis (figure 4)12,. Although the
shorter profile brace (TLSO) is standard for present day treatment of
scoliosis because of the ability to completely conceal the brace with
clothing, the Milwaukee is still the only orthosis that is best to treat
curves higher in the spine (apex T-8 and up) and for the treatment of
kyphosis which usually is in the mid and upper thoracic spine13. Through
computer modeling, engineers have shown theoretical results that the
Milwaukee brace does work better for curves in the thoracic spine then the
TLSO6. This does not mean that all children with thoracic scoliosis need a
Milwaukee brace, it merely means that if a curve is large and won't reduce
well in a TLSO that it may do better in a Milwaukee brace13.
The Role a Brace Plays in Treating Scoliosis
Sometimes it seems a bit confusing about what a brace should do for
idiopathic scoliosis. If a 10 year old child comes into a clinic with a 30
curve and is prescribed a brace that reduces the curve to 15 and later weans
out of the brace at 14 years of age and the curve returns all the way back
to 30, what has the brace done? The brace has essentially prevented spinal
fusion surgery.
Spinal curves do not cause medical complication until they exceed 70 so a
thirty degree curve is benign to the cardio-pulmonary system. Lonstein and
Carlson showed that a 30 curve in a 10 year old is almost always going to
progress16 however Weinstein and coworkers showed that a 30 curve in an
adult almost never progresses23. If the child mentioned previously with the
30 curve did not get a brace, the curve would have most likely progressed to
a larger magnitude, possibly over 45 and require surgery.
Dr. Patwardhan and his engineering colleagues did a theoretical computer
modeling study on curves from 0-60 that shows that the larger a curve is,
the more likely it is to progress6. These modeling studies help to explain
why we don't brace children with 15 and 20 spinal curves as they are not all
going to progress and why we do begin bracing on progressive curves that are
over 25. This also helps to explain why children with curves over 45 are
likely to progress even if they are braced and why someone with a spinal
curve over 50 is likely to progress even as an adult.
Assuming that this child is skeletally mature when she weaned out of the
brace, even though the curve returned to its original magnitude, it is very
unlikely that it will progress and require a spinal fusion. Curve
progression is directly related to growth and this is why younger children
are more likely to progress with smaller curves than older children or
adults.
What We Know About Bracing
We know that bracing works! In recent years, both retrospective and
prospective clinical studies were conducted that led to the same conclusion;
that bracing does prevent long-term curve progression and therefore reduces
the need for surgery17,21. We also know that the people included in these
were prescribed either the Milwaukee brace or one of the current TLSO's for
full-time (23 hours per day) wear. One may reach the conclusion from some of
these studies that the more the curve reduced while in the brace, the better
the outcome. In many cases, the residual curve after bracing ends up smaller
than the curve was before bracing however, it is unpredictable who will end
up with a smaller curve after bracing and who will return to pre-brace
magnitudes or greater.
Dr. Lonstein showed that children with larger curves had to have the curve
reduced by at least 1/2 in the brace to have a good outcome17. In a recent
study, Noonan and coworkers showed very poor outcomes using the Milwaukee
brace. In this study, few of the curves were reduced by half in the brace22.
In conclusion, if brace performance is optimal (started early, and the curve
is reduced by at least half with minimal losses of correction throughout the
duration of wear) the best outcome should be the result. Braces need
constant attention to ensure that they are reducing the curves and should be
re-adjusted or re-fabricated if any curve reduction is lost while wearing
the brace13.
What We Don't Know About Bracing
We don't know the role of wearing time. We can assume that a brace that is
never worn will do nothing and that a brace that is worn for 24 hours per
day is doing as much as a brace is capable of doing. The idea of wearing a
brace for 23 hours a day as full-time wear was an intuitive decision and not
based on hard objective data. In recent years, the Scoliosis Research
Society has raised doubt as to whether part-time brace wearing is effective
and if so, how many hours per day is enough. Also, we do not know how
noncompliance has affected the outcomes of the recently published brace
studies.
There is a lack of objective data defining what the compliance rate truly is
at present or defining minimal acceptable wearing time. Presently several
centers are designing new compliance monitors that will allow clinical
studies to be carried out that will answer wearing time or brace dosage
questions.
Currently, at the Rehabilitation Research and Development Center at Hines
Veterans Administration hospital we have developed a highly accurate
compliance monitor which is currently undergoing testing and will hopefully
be used within the next two years.
Until accurate and precise methods are utilized to objectively measure
compliance, it is impossible to analyze the effect of wearing time on good
versus poor outcome. Therefore any current statements about the effects of
brace compliance on outcome of treatment are purely speculative.
The Role of the Orthotist in the Bracing Process
Orthotists were previously craftsmen and artisans who merely provided a
device which was then critiqued in clinic by the orthopaedist with the
orthotist present and a list of adjustments which made the brace functional
were made by the orthopaedist and were subsequently carried out by the
orthotist. At every followup visit, the same process was repeated to keep
the brace at maximum performance during growth. This system worked well for
many years but is currently practiced in fewer settings.
The last few decades have seen an advancement in the clinical education of
orthotists and the decentralizing of scoliosis management by physicians.
Many more private practice physicians see scoliosis patients in an office
setting as opposed to a decade ago when most private practice physicians
referred scoliosis patients to the scoliosis clinics in the larger medical
centers. As long as someone in a brace sees an experienced orthotist at
least every four months for a brace growth adjustment, this decentralizing
does not present any problems for bracing. During followup, the patient's
mom or dad should have either a copy of the most recent x-ray, a copy of the
physicians note or a report on how many degrees the curves are currently and
the patient's stage of skeletal maturity. This information will assist the
orthotist in the brace adjustment process.
The orthotist plays a much greater role in helping to adjust to the idea of
wearing a brace. Reassurance that the brace will become very routine after
10 days of wear, and that the brace is difficult to see through clothing are
both helpful with someone new to a brace. Once the orthotists nuts and bolts
role is completed, he or she should spend at least 30-45 minutes with the
patient and present family members to answer questions and reassure the
child that this is not the end of all social activity.
A file of pictures of other children wearing braces while participating in
sports, school activities and social events are helpful. Arranging a meeting
with other children who are more experienced wearers also can be comforting,
and a brief speech on why she or he needs to wear a brace is important. All
these interactions are helpful but do not seem to have as big of an impact
as walking the child in her or his new brace to a room with a full length
mirror and allowing them to have some privacy with their family. This helps
them to realize that although they feel the brace under their arms, that it
is almost invisible through the clothing.
In my experience, I have known children who wanted to share their experience
with their peers so I have recommended, and helped with, many science fair
projects on scoliosis. I have also known children who were more private
about their experience, so I have assisted them by being sure the brace was
extremely streamlined for cosmesis and let them know that a some time at the
clothing store with the brace will help them completely conceal it under
loosely fitted clothing. Many children have told me that only their best
friend ever knew they had a brace (after more than a year of wearing) and
this was usually because of sleepovers or pajama parties.
Discussion
For optimal performance, bracing needs to be started early (>25 and
progressive) and must reduce the curves and maintain curve reduction (> 50%)
throughout the duration of wear. The primary role of a brace for idiopathic
scoliosis is to arrest curve progression and yield a post bracing curve that
is of a magnitude that will not progress as an adult. A physician and
orthotist team must assure the patient that a spinal brace is not impossible
to wear, will not drastically alter social and athletic quality of life and
will provide a good chance of preventing spinal fusion surgery. Since
bracing is the only accepted conservative treatment for idiopathic
scoliosis, it must be done meticulously. Followup adjustments must be done
in a prompt manner and medical professionals, parents and the community
should help ease the anxiety of the children who need to wear a brace.
References
1. Andriacchi TP, Schultz AB, Belytschko and DeWald RL: Milwaukee Brace
Correction of Idiopathic Scoliosis. J Bone Jt Surg 58A,806, 1976.
2. Andry N: Orthopaedia., JB Lippincott Co (Facsimile reproduction of the
first edition in English, London, 1743), Philadelphia, 1961.
3. Blount WP, Schmidt AC, Keever ED and Leonard ET: Milwaukee Brace in the
Operative Treatment of Scoliosis. J Bone Jt Surg 40A: 511-525, 1958.
4. Blount WP and Moe JH: The Milwaukee Brace. Williams and Wilkens Co.
Baltimore, 1973,
5. Bunch WH, Keagy R: Principles of Orthotic Treatment. CV Mosby Co. St.
Louis, Mo 1975.
6. Bunch WH., Patwardhan AG.: Scoliosis; Making Clinical Decisions. CV Mosby
Co. St. Louis, Mo 1989.
7. Bunnell WP, MacEwen GD and Jayakumar S: The Use of Plastic Jackets in the
Non-Operative Treatment of Idiopathic Scoliosis. J Bone Jt Surg 62A: 31-38,
1980.
8. Carr W, Moe J, Winter R, and Lonstein J:Treatment of Idiopathic Scoliosis
in the Milwaukee Brace. J Bone Joint Surg 62A: 599-612, 1980.
9. Edmonsson A and Morris J:Follow-Up Study of Milwaukee Brace Treatment in
Patients with Idiopathic Scoliosis. Clin Orthop 126: 58-61, 1977.
10. Emans J: The Boston Bracing System for Idiopathic Scoliosis: Follow-Up
Results in 295 Patients. Spine 11: 792-801, 1986.
11. Galante J.,Schultz A.B., DeWald R.L. and Ray R.D., Forces Acting in the
Milwaukee Brace on Patients Undergoing Treatment for Idiopathic Scoliosis.
J.Bone Jt. Surg., 52A, 498, 1970.
12. Gavin TM, Bunch WH, Dvonch V: The Rosenberger Scoliosis Orthosis. J
Assoc Children's Prosthetic Orthotic Clinics. 21(3), 35-38, 1986.
13. Gavin TM, Shurr DG, Patwardhan AG: Orthotic Treatment for Spinal
Disorders. Chapter 85,in ed Weinstien SL. The Pediatric Spine. 1795-1828,
Raven Press, 1993.
14. Jodoin A., Hall JE., Watts H.G., Miller M.E., Micheli, L.J. and
Riseborough, E.J.: Treatment for Idiopathic Scoliosis by the Boston Brace
System; Early Results. Orthop. Trans., 5,22, 1981.
15. Keiser RP and Shufflebarger HL: The Milwaukee Brace in Idiopathic
Scoliosis: Evaluation of 123 Completed Cases. Clin Orthop 118: 19-24, 1976.
16. Lonstein JE and Carlson JM: The Prediciton of Curve Progression in
Untreated Idiopathic Scoliosis During Growth. J Bone Jt Surg 66A: 1061-1071,
1984.
17. Lonstein JE and Winter RL: Milwaukee Brace Treatment of Adolescent
Idiopathic Scoliosis- Review of 1020 patients. J Bone Joint Surg,
76A:1207-21. 1994
18. McCollough NC III, Schultz M et al:Miami TLSO in the Management of
Scoliosis: Preliminary Results in 100 Cases. J Ped Orth 1:141-152, 1981.
19. Mellencamp D, Blount W, and Anderson A: Milwaukee brace treatment of
idiopathic scoliosis, Clin Orthop 126: 47-557, 1977.
20. Moe JH and Kettleson DN: Idiopathic scoliosis: ananlysis of curve
patterns and the preliminary results of Milwaukee brace treatment in one
hundred sixty-nine patients, J Bone Joint Surg 52A: 1509, 1970.
21. Nachemson AL andPeterson LE: Effectiveness of treatment with a brace in
girls who have adolescent idiopathic scoliosis. A prospective, controlled
study based on data from the Brace Study of the Scoliosis Research Society.
J Bone Joint Surg , 77(A):815-22, 1995
22. Noonan KJ, Weinstein SL, Jacobson WC and Dolan LA: Use Of The Milwaukee
Brace for Progressive Idiopathic Scoliosis. J Bone Joint Surg 78A:557-567,
1996.
23. Weinstein SL, Zavala DC, and Ponseti IV: Curve Progression in Idiopathic
Scoliosis. J Bone Joint Surg 65A: 447-455, 1983
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