Brief patient description:

R.S. is a teenager with adolescent ideopatic scoliosis. She was referred as AIS: Right thoracic curve (20 degrees). When she presented, pt. complained about back pain.

Orthotic/Prosthetic Aims/Requests: TLSO brace

Previous Visits: None

Subjective:

R. presented to our clinic with complaints of back pain. Pain is not limiting her in her daily activities but is present most of the time. She told me she wants to avoid surgery and is determined to do whatever it takes to avoid this.

Objective:
R. presented at her initial assessment as a drop-in. She had no idea what was going to happen and expected to be fitted with a brace when she walked in. I explained the process and the information needed to carry on fabricating her boston brace. I booked her in for a full initial assessment 3 days after this to be able to access and blueprint her Xrays.

Xrays show a combined curve with a right thoracic 22 degree curve with the apex on T10 and left lumbar 18 degree curve with the apex on L3.

The side bending test pointed out that the thoracic curve is the primary curve and the lumbar cuve is compensation. When assessing the forward bending, shoulders were asymmetrical, with a right prominent shouderblade, the curve was visible and a lower back hump showed.The scoliometer pointed out a 14 degreee thoracic rotation and a 9 degree lumbar rotation.

Mobility tests showed that the spine was mobile and correctable. R. had no shortening of hamstrings or hip flexors. Core stability was good. Patient was able to somehow correct her posture using tactile cueing.

Orthotic/Prosthetic Prescription:
Boston TLSO in 4mm light pink copoly with a 5mm aliplast white liner and posterior opening. 0.5 inches thickness corrective trochanter, lumbar and thoracic pads placed on apices of curve and a 20mm inset axilla with posterior extension to cover shouderblade and prevent winging.

Van den Bogaart, M., van Royen, B.J., Haanstra, T.M. et al. Predictive factors for brace treatment outcome in adolescent idiopathic scoliosis: a best-evidence synthesis. Eur Spine J 28, 511–525 (2019). https://doi.org/10.1007/s00586-018-05870-6

Predictive factors for brace treatment outcome in adolescent idiopathic scoliosis: a best-evidence synthesis

Manon van den Bogaart ¹, Barend J van Royen ², Tsjitske M Haanstra ¹, Marinus de Kleuver ³, Sayf S A Faraj ¹

Affiliations expand

• PMID: 30607519

• DOI: 10.1007/s00586-018-05870-6

Abstract

Purpose: To evaluate predictive factors for brace treatment outcome in adolescent idiopathic scoliosis (AIS) by a systematic review of the literature.

Methods: Eligible studies evaluating one or more predictive factors for brace treatment outcome were included following a systematic search in PubMed and EMBASE on October 23, 2017. Inclusion criteria were: (1) subjects diagnosed with AIS, (2) age ≤ 18 years, (3) treated with a thoraco-lumbo-sacral orthosis (TLSO), and (4) evaluated one or more predictive factors of treatment outcome (failure and/or success). The methodological quality of included studies was independently assessed by two authors. Pooling was not possible due to heterogeneity in statistical analysis. Predictive factors were presented according to a best-evidence synthesis.

Results: The literature search identified 26 studies that met the inclusion criteria, and multiple types of TLSO braces were identified (Boston, Wilmington, Chêneau, Osaka Medical College, Dresdner Scoliosis Orthosis and SPoRT). A total of 19 radiographic and 8 clinical predictive factors were reported. Strong evidence was found that lack of initial in-brace correction is associated with treatment failure. Moderate evidence suggests that brace wear time is associated with failure and success, whereas initial curve magnitude and curve type are not.

Conclusion: The results of this review suggest that lack of initial in-brace correction is strongly associated with brace treatment failure. Future studies on the threshold for minimal immediate in-brace correction, as a potential indication for brace treatment, are recommended. These slides can be retrieved under Electronic Supplementary Material.

Keywords: Adolescent idiopathic scoliosis; Brace; Outcome; Predictive; Treatment.

Take-away key-points regarding case and further practice:

·        Checking in-brace correction by using in-brace xrays is essential as initial in-brace correction is strongly associated with brace treatment success/failure

·        No differentiating between types of braces in this article. Multiple brace types are used. This article can be an indication that in-brace correction has to be assessed.

Nonsurgical Management of Adolescent Idiopathic Scoliosis

Jaime A Gomez ¹, M Timothy Hresko, Michael P Glotzbecker

Affiliations expand

• PMID: 27388720
• DOI: 10.5435/JAAOS-D-14-00416

Abstract

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.

Take-away key-points regarding case and further practice:

·       There is an indication that bracing and physical therapy can be helpful for nonsurgical management of AIS.

·       More research is needed

Bracing In The Treatment Of Adolescent Idiopathic Scoliosis: Evidence To Date

Nikos Karavidas ¹

Affiliations expand

• PMID: 31632169
• PMCID: PMC6790111
• DOI: 10.2147/AHMT.S190565

Free PMC article

Abstract

Brace effectiveness for adolescent idiopathic scoliosis was controversial until recent studies provided high quality of evidence that bracing can decrease likelihood of progression and need for operative treatment. Very low evidence exists regarding bracing over 40^ο and adult degenerative scoliosis. Initial in-brace correction and compliance seem to be the most important predictive factors for successful treatment outcome. However, the amount of correction and adherence to wearing hours have not been established yet. Moderate evidence suggests that thoracic and double curves, and curves over 30^ο at an early growth stage have more risk for failure. High and low body mass index scores are also associated with low successful rates. CAD/CAM braces have shown better initial correction and are more comfortable than conventional plaster cast braces. For a curve at high risk of progression, rigid and day-time braces are significantly more effective than soft or night-time braces. No safe conclusion on effectiveness can be drawn while comparing symmetrical and asymmetrical brace designs. The addition of physiotherapeutic scoliosis-specific exercises in brace treatment can provide better outcomes and is recommended, when possible. Despite the growing evidence for brace effectiveness, there is still an imperative need for future high methodological quality studies to be conducted.

Keywords: brace; evidence; non-operative treatment; orthosis; scoliosis.

© 2019 Karavidas.

Take-away key-points regarding case and further practice:

·       This is a high level of evidence study as it is a Cochrane review

·       Initial in-brace correction and compliance are the most important factors for brace success or failure. This points out that in-brace X-rays are a necessary tool for an orthotist to be able to design the best brace for the patient.

·       The article suggests physiotherapy in addition to bracing is recommended for better outcomes. Multidisciplinary teams for scoliosis management is the golden standard we have to try to work towards.

Subjective: Every now and then some discomfort, patient doesn’t want spinal surgery

Objective: Prior to appointment Xrays were reviewed: Xrays show a combined curve with a right thoracic 22 degree curve with the apex on T10 and left lumbar 18 degree curve with the apex on L3.

Visual inspection confirmed the xray findings: posterior an S curve was visible, head was cental so no lateral shift. Uneven waist crease, right higher than left. Anterior view right shoulder was hogher than left in the saggital plane left and right were different : more prominent shouderblade fron right side. Hyperkyphosis.

The side bending test pointed out that the thoracic curve is the primary curve and the lumbar cuve is compensation. When assessing the forward bending, shoulders were asymmetrical, with a right prominent shouderblade, the curve was visible and a lower back hump showed.The scoliometer pointed out a 14 degree thoracic rotation and a 9 degree lumbar rotation.

Mobility tests showed that the spine was mobile and correctable. R. had no shortening of hamstrings or hip flexors. Core stability was good. Patient was able to somehow correct her posture using tactile cueing.

Action

Took plaster mould and measurements to order a boston brace as we were still in the process of getting a structure sensor and the software program.

Plan

Fitting of boston brace ASAP an liaise with WDHB in regards to physio/inbrace Xrays and follow-up appointments.

Subjective  Patient happy that brace came in within a months time. She is kind of excited but knows it is going to be hard to be a full-time brace wearer.

Objective and Action Brace looked very good without any alterations. It seemed to nicely correct the curve and the lumbar and thoracic pad were sitting where I expected them to sit. Plenty of room in the brace for patient to move in to.
The trochanter pad was pushing patient off balance so I removed this. This balanced out her posture. Then I did some adjustments to the trimlines as the anterior superior was pushing up her breast and when sitting down the anterior inferior was pushing on her thigh as well the posterior part was hitting the seat. Posterior superior was catching on her shoulderblade on the right so flared this out a little bit. The axillary extension had to be trimmed down as well.

Gave patient advise on how to break in brace, how to care for it, made marks how tight the brace should be, donning doffing instructions, …

I tried to liaise with physio/orthopaesic surgeon but never received a response although I have written a boston brace protocol to give information about the golden standard process and thing we need as an orthotist to be able to do the best job.

Plan Trying to get an in-brace Xray order and physio referral through orthopaedic surgeon. Follow-up in 6-8 weeks.

S: Pt. is in her brace full-time without much trouble. No toruble sleeping in the brace and able to self-don and dof the brace. Sometimes the lumbar pad gives some discomfort and she has to take the brace off for half an hour before being able to put it back on.

O: Patient looks balanced in her brace. Trimlines are ok and don’t need adjustments, the pelvis is still in the brace so patient didn’t outgrow brace yet. When doffing brace there is some red marks visible where the pads sit, they are where they have to be when looking at her curve. Her brace definitely has usage marks so I believe definitely that pt. is using her brace. There were no in-brace Xrays done by the orthopaedic team after sending 2 letters.

A: Thinned the lumbar pad 5 mm, this felt much more comfortable for the pt.

P: Keeping on chasing up orthopaedics department for in-brace Xrays. Follow up in 4-6 months.

S: Pt. is in her brace full-time without much trouble. No toruble sleeping in the brace and able to self-don and dof the brace. Sometimes the lumbar pad gives some discomfort and she has to take the brace off for half an hour before being able to put it back on.

O: Patient looks balanced in her brace. Trimlines are ok and don’t need adjustments, the pelvis is still in the brace so patient didn’t outgrow brace yet. When doffing brace there is some red marks visible where the pads sit, they are where they have to be when looking at her curve. Her brace definitely has usage marks so I believe definitely that pt. is using her brace. There were no in-brace Xrays done by the orthopaedic team after sending 2 letters.

A: Thinned the lumbar pad 5 mm, this felt much more comfortable for the pt.

P: Keeping on chasing up orthopaedics department for in-brace Xrays. Follow up in 4-6 months.

S: Rang patient just before Christmas break. She is doing well in brace and has no concerns. Happy to come in for a check-up before school starts again.

O: Sounds like patient is doing well, no in brace xrays done yet after contacting orthopaedics again. Pt has follow-up in hospital in February. I will get in touch with orthopaedics and see if I can be present at the consultation.

A: Booked follow-up for January.

P: Go to orthopaedic clinic to request in-brace Xrays at pr. Follow-up appointment.

S: Pt. states to be doing well with brace, had a few hard days to reach the 1618h goal when the weather was hot. Had a small rash on her skin during the very hot weather. Otherwise doing well and no concerns.

O: Patients looks comfortable in brace. Checked trimlines, I felt anterior inferior edge was digging in her thigh when sitting down. Checked skin rash, was sitting right on thoracic pad edge. Patient still didn’t get a referral for physiotherapy.

A: Adjusted trimine and eased out over skin rash. I talked to patient and family about the benefits of physiotherapy when being a full-time boston brace user.

P: Go to orthopaedic clinic to request in-brace Xrays at follow-up appointment.

Process of assessment/fitting/follow-up boston braces. I have also learned that it is very hard to try and achieve the golden standard when there is not a real team that works together to get the job done. I feel there is not really a mentality of liaising with other therapists for this sort of cases. I feel that in Waikato there is not much belief in spinal bracing. We had a rush of approx. 8 referrals in 2 months time and after this rush we didn’t receive any referrals for spinal braces.

Optimizing the interdisciplinary teamwork and it would have been very good to be able to order in-brace Xrays. Although we are not allowed to order this. As an orthotist we often don’t have the tools or access to interdisciplinary teamwork to be able to get the result we want to achieve. I am sure we cannot perform at our best because of limitations in recources and ability to refer and work together with physiotherapists.

No, the golden standard procedure was not used.