One of the keys to the successful orthotic management of scoliosis is appropriate patient selection.
With an incidence of 2% to 3% in the general population, scoliosis affects approximately 6 million individuals in the United States. The most common type of scoliosis, adolescent idiopathic scoliosis, accounts for 80% of cases, with curvature generally appearing between the ages of 10 and 13. For patients with curvature that requires treatment, orthotic management represents one option.
A long history
The term scoliosis is derived from the Greek word “skoliosis,” which means crookedness. The ancient Greek physicians Hippocrates and Galen both used the word scoliosis to describe curvature of the spine.
The history of spinal bracing dates back even further, with evidence indicating that spinal bracing has been in existence for thousands of years, said Thomas Gavin, CO, president and director of clinical services for BioConcepts.
“King Tut was unearthed with a scoliosis brace. From the pre-Columbian era, in the Nubian Desert, they found scoliosis braces made of tree bark in cave dwellings,” Gavin said. “Chances are something embraced by society and used continuously for that period of time does have some value. What we need to do is understand what the value is and fully exploit it.”
By the mid-1500s, metal corsets were used to straighten the spine. In later centuries, braces made from leather and then plaster emerged, representing the forerunners of modern-day orthoses.
In the mid-1900s, the Milwaukee brace was developed and became widely used to manage scoliosis. Since then, other orthoses have been developed as evidence continued to mount that orthotic management of scoliosis was effective in stopping curve progression.
One of the keys to the successful orthotic management of scoliosis is appropriate patient selection, which depends on several factors. Initially, the degree value of the curve as measured by the Cobb angle and the location of the curve apex are considered, said James H. Wynne, CPO, director of education and training for Boston Brace and National Orthotic Prosthetic Company.
There is a certain threshold level where we want to treat, and there is some debate on that, Wynne said. Curves ranging from 25° to 45° are, according to studies, at risk of progression so conservative intervention is recommended.
Another factor that is considered is the flexibility of the curve, which is related to the age of the patient. Curves in younger children are more likely to progress and are directly related to the amount of remaining growth.
What we really look at is to get as much of the curve reduced and as much balance restored as possible while they are wearing the orthosis, and we cannot put a generic expectation on that, Gavin said. What we really need to focus on is the fact that older children are not going to reduce as well and their curves will not get as straight as in younger children. The tradeoff is older children are less likely to progress at curves that are really likely to progress in the younger children. The younger you are, the more likely you are to progress.
Orthotic assessment of patients includes a functional evaluation in which the radiographs are reviewed to assess the curvature and rotation of the spine. In addition, a physical examination is performed to evaluate assymetries, rib hump, acquired leg length inequality and flexibility, said Kaia Busch, CPO, national director of orthotics for Hanger Orthopedic Group Inc.
Because there are many styles of orthoses for scoliosis, selection has a significant impact on the success of orthotic management.
It is important to remember not every orthosis is appropriate for every patient. Orthotic selection is dependent upon patient presentation, including the severity of the curve, single versus double curves, flexibility, age and remaining growth, Busch said.
One low-profile orthosis widely used for managing scoliosis is the Boston Bracing System. The Boston brace has always been considered a dynamic system because of its low profile design with areas of force at the apex of the curve and below as well as built-in areas of release opposite those forces to maximize shift and correction, Wynne said. The design of the orthosis is dictated by the curve. We want to treat only those vetebra that are angled or shifted from the center sacral line.
Depending on the style of Boston Brace that is used, most curves can be addressed, generally anywhere from an apex of T7 down to L4. Wynne noted the Boston brace has evolved somewhat over the years, moving from being anti-lordotic to building in 15° to 20° of lordosis as well as some kyphosis. In addition, more attention is given to the sagittal plane.
We are paying more attention to overall balance rather than just the sole reduction of Cobb angle, Wynne said. We are paying more attention sagittally, and since scoliosis is a triplanar deformity, you want to pay attention in your overall patient assessment in brace to all three as well. You really have to constantly be thinking of 3-D the entire time you are going through the treatment.
Another dynamic low profile scoliosis orthosis recently introduced by Boston Brace is the TriaC, which is a tension-based system. The lumbar portion of the TriaC is separate from the thoracic portion, with a unique coupling mechanism that allows patients freedom of motion in three planes, Wynne said. With the TriaC, forces acting on the spine move in conjunction with the spine.
With the tension-based systems, as with any system, patient selection is the key, and finding a suitable candidate for a particular system, that is where you are going to have success regardless of the device that you use, Wynne said.
|Boston Brace has developed a device to take an infrared reading on the position of an orthosis. About the size of a quarter, the heat/inclinometer sensor can be fit into any style TLSO, and will show the patient their average hours worn per day.|
|Image reprinted with permission of Boston Brace and James H. Wynne, CPO.|
The orthotists skill and training also can impact the success of scoliosis bracing. A retrospective study conducted by Wendy Moon, MS, RN, CPNP, a pediatric nurse practitioner in pediatric orthopedics at the Mayo Clinic, found orthotist retraining significantly improved the outcomes of bracing.
In an effort to improve scoliosis bracing results, several orthotists at the Mayo Clinic went to Scottish Rite Hospital in Atlanta for training. The study compared 30 patients who underwent bracing before retraining with 42 patients who were braced after orthotist retraining. Average correction prebrace to the first radiograph in the orthosis was 5.9° of improvement before retraining compared with 11.9° of improvement after retraining.
We attributed a lot of these changes in outcomes to the improvement in the bracing technique and the fact that the orthotists were able to make a more powerful brace that had a better ability to put forces on the curve to correct it, Moon told O&P Business News. Certainly, if you just look at the curve numbers, which is what I studied, if you look at those curve numbers you see that the before bracing compared to after bracing and then the final outcomes, the numbers are all hugely statistically improved.
The pretraining curve progression was an average of 9.4° compared with 1.5° after training, indicating improved long term outcomes from bracing. Moon noted that getting a good amount of correction in the first radiograph in the orthosis has been demonstrated to be a favorable prognostic indicator, which was also borne out in their study.
Equally important to successful bracing for scoliosis is using a multidisciplinary team approach.
It is hard wearing a brace and you need a program with a system in place, and you need to have a system in place, Wynne said. It is not just the brace but it is the clinical team. It is involving the patient, educating the patient, having a team leader, the physician educated on the bracing system, and directing the program. Having a skilled orthotist on board, in addition to a nursing and physical therapy staff is a vital component to the team approach, Wynne said.
We try to have all our kids see physical therapy. They will develop an individual program to be followed at home, he said. It makes it easier to wear the orthosis, and another voice reinforcing the program, it is important we are all delivering the same message.
Going hand in hand with a team approach is patient education. Talking to patients and their families about their diagnosis and the goals of treatment from the beginning gets them invested in the process.
The biggest term I use when I talk about this with patients and families is anticipatory guidance, and that is to educate the family on what to expect, troubleshooting in terms of when things happen and how do they deal with it, Moon said. This is important in both the physical and emotional components of this adjustment to brace wear.
Moon noted the first visit after patients receive their orthosis generally takes an hour. All aspects of orthotic treatment are discussed and patients are given a booklet on wearing their orthosis. The orthotist also participates in this initial visit.
There are a couple of little quiz questions as we go along, and one is, Do you think this brace will change your life? The correct answer to that, what I would like to hear from these kids is, No. No, it really should not change their life. We encourage them to participate in every activity they participated in before they got their brace, Moon said.
Idiopathic scoliosis accounts for four of every five scoliosis cases and is categorized into the following four types based on patient age when curvature first manifests:
Infantile idiopathic scoliosis
This type of scoliosis appears before age 3 and is rare in the United States.
Juvenile idiopathic scoliosis
In this type of scoliosis, curvature manifests between the ages of 3 and 10. Except for the age at onset, juvenile idiopathic scoliosis is considered equivalent to adolescent idiopathic scoliosis.
Adolescent idiopathic scoliosis
Curvature firsts manifests in adolescent idiopathic curvature near the beginning of puberty, approximately ages 10 to 13. This type of scoliosis is the most common form.
Adult idiopathic scoliosis
In adult idiopathic scoliosis, curvature begins after physical maturation is reached. Curve progression may be marked and significant in adult idiopathic scoliosis, which may represent adolescent idiopathic scoliosis that was not diagnosed in childhood.
One aspect of scoliosis bracing that can be difficult to overcome is patient noncompliance. Bracing can be uncomfortable, and frequently, brace wear is prescribed for 23 hours a day, which can further complicate compliance.
To take a preteen or an adolescent child and expect them to wear a large device on their torso when they feel fine going into it is not an easy concept. If you are not sure what you are doing is really helpful or going to be effective, you yourself, your own attitude, can complicate this, Gavin said. What I mean by that is if you cannot somehow influence the patient that what you are doing is necessary and real, they will not wear it. That is a big task to ask them.
Gavin noted the approach he takes initially is to try and calm patients down because their fear of the orthosis often is worse than the orthosis itself. On the day the mold is taken, patients and their parents are shown the deformity before the mold is taken and then they are shown the deformity reduced in the mold, which helps translate the theoretical into reality.
The children get a little overwhelmed, Gavin said. We are asking them to be mature beyond their years and understand that they are preventing bad things from happening in their future in terms of the curve getting worse or preventing the need for a big surgery.
Another approach that may help improve compliance is to encourage patients to talk to their friends. Moon has found one of the characteristics that make brace wear easier for some patients is peer support and being able to talk to friends about their scoliosis. She also encourages patients to call any member of the clinical team if any problems come up rather than waiting for a follow-up visit.
Because patient compliance with scoliosis can be low, a device to monitor compliance is being developed for the Boston bracing system. The device, which will take an infrared reading on the position of a brace, should be available commercially within the next several months. About the size of a quarter, the heat/inclinometer sensor can be fit into any style TLSO.
The device has a LCD read, which shows the patient their average hours worn per day, Wynne said. It is easily downloadable into a printable program. This will allow us to talk more intelligently to our patients regarding wearing trends and perhaps adjust protocol.
In the first visit after patients receive their orthosis, Wendy Moon, MS, RN, CPNP, a pediatric nurse practitioner in pediatric orthopedics at the Mayo Clinic, spends roughly an hour going over details that she calls the nitty gritty nuts and bolts to help patients successfully adjust to wearing it. During the visit, in which an orthotist also participates, Moon covers the answers to the following questions associated with brace wear:
How do we make this work for you?
How many hours do you wear the orthosis?
How do you take care of your skin?
What do you do if you have skin irritation?
What do you do when you go to school?
How do you wear it to bed?
What do you do about someone who teases you?
Have you talked to your friends about the brace?
What have you told your friends?
How did your friends respond?
If you have not told your friends yet, why not?
Initially, follow-up with patients will take place monthly to ensure patients are getting accustomed to the brace and wearing the orthosis as prescribed. After approximately 4 months, patients should have regular follow-up visits to monitor their progress and ensure the orthosis accommodates growth, Busch said.
We also put markers in an orthosis so you can see where your pad placement is when you look at it on an x-ray, Busch said. We will put markers to give us a definitive yes, we have that pad in the correct position or no, we need to raise or lower it according to where the curvature and the apex of the curve presents.
Another tool that can help not only in monitoring progress but also with fabricating the orthoses is digital scanning. The scans provide objective information that can be compared over time, Busch said.
Finally, in bracing scoliosis, orthotists need to be aware of the fact that their work will impact the future of their patients lives. While it would be ideal to predict the future, it is imperative to be aware of the bracing results, and more research is needed to be able to identify various factors that affect scoliosis curve magnitude, brace wear compliance, and most importantly, patient outcomes.
The current state of the art is we do know that they work. We just do not know how well, we just do not know for whom, and we do not know if there might be screening criteria for those who are maybe more likely to wear their orthosis or more likely not to wear their orthosis, Gavin said. As orthotists, we are capable of accomplishing much more than I had ever imagined. We just have to be open-minded and frequently think outside of the box.
The incidence of scoliosis in the families of children with scoliosis has been found to be anywhere from six to ten times higher than in the general population. Furthermore, an increased risk for scoliosis is present not only for children who have a parent with scoliosis but also for siblings of children with scoliosis, causing researchers to long suspect a genetic component in the etiology of scoliosis.
Earlier this year, a group of researchers from Texas Scottish Rite Hospital for Children, Washington University School of Medicine, University of Texas Southwestern Medical Center, Rutgers State University of New Jersey and University of Iowa announced they had identified a gene with a link to scoliosis. Their research, published in the May 2007 issue of the American Journal of Human Genetics, identified a defect in the CHD7 gene that was associated with a susceptibility to idiopathic scoliosis. Their study encompassed a cohort of 52 families in which at least two family members had scoliosis and entailed analyzing genomewide scans to identify the defect, which is subtle and located in the genes non-encoding region. Although much more research is needed, the finding may represent one of the first steps in determining the etiology of scoliosis and developing treatments to treat scoliosis before any spinal curvature develops.
For more information:
- Arbanas C. Scientists identify first gene linked to scoliosis. Available at: http://mednews.wustl.edu/tips/page/normal/9599.html. Accessed Aug. 24, 2007.
- Gao X, Gordon D, Zhang D, et al. CHD7 gene polymorphisms are associated with susceptibility to idiopathic scoliosis. Am J Hum Genet. 2007;80:957-965.
For more information:
- Neuwirth M, Osborn K. The Scoliosis Sourcebook. New York, NY: Contemporary Books; 2001.
- Roggenbuck J. Scoliosis. In: Narins B, ed. The Gale Encyclopeida of Genetic Disorders. 2nd ed. Farmington Hills, MI: Thomson Gale; 2005.
- Schommer N. Stopping Scoliosis. 2nd ed. New York, NY: Avery; 2002.
Mary L. Jerrell, ELS, is a correspondent for O&P Business News.
This story includes a small representative sample of individual companies and products. O&P Business News does not intend to promote individual companies or their products, nor to achieve an industry-wide consensus on the issue. Sources contacted in developing this story were randomly selected.