Introduction
Hippocrates first used the term scoliosis which implies abnormal curvature of the spine. This skeletal problem is primarily a disorder of children whose spine is still growing. Scoliosis is the most common and serious of the spinal curvature disorders. It is defined as a lateral curvature of the spine greater than 10 degrees accompanied by vertebral rotation (1).
Numerous theories exist on the origin of scoliosis, but the true causative factors remain unknown; thus this disorder cannot be prevented. Treatment essentially consists of early recognition, correction of existing curves, and prevention of the further progression of the curves.
Treatment is considered when a lateral curvature of more than 10 degrees is present. Lateral curvature of the spine is often accompanied by rotation of the vertebral bodies. Functional scoliosis is flexible and can be caused by poor posture, leg length discrepancy, poor postural tone, hip contractures, or pain. Congenital scoliosis is usually structural in nature, caused by abnormal spinal or spinal cord structure.
Most scoliosis has no known cause (2). Idiopathic scoliosis is a complex three-dimensional deformity of the trunk, characterized by lateral deviation and axial rotation of the spine, usually accompanied by a rib cage deformity. Adolescent idiopathic scoliosis is present in 2 to 4 percent of children between 10 and 16 years of age (1).
Literature Review
Over the years, many forms of treatment have been supported for scoliosis, and supporters of every form of treatment are found in various literature. Treatment strategies for idiopathic scoliosis include conservative treatment and surgery (3). Some aspects and principles of most concepts of treatment have merit and influence today’s concept of correct treatment.
The objective of the treatment is to make sure that the person with scoliosis (usually a child) reaches maturity with a straight, balanced, and stable spine. In minimal scoliosis that has been diagnosed early, this objective is accomplished by treatment aimed at preventing progression of the deformity. In more advanced cases of scoliosis the treatment objectives are correction of the lateral curving and rotational deformity to the greatest possible degree and holding the correction achieved for the remainder of the spinal growth. Treatment either for prevention or correction of scoliosis is either nonoperative or operative.
External orthotic devices advocated in the treatment of scoliosis are numerous and many have therapeutic value. These appliances include various forms braces. These kinds of external devices are intended to correct curvatures or to maintain correction achieved by other means.
External orthotic devices have their effect on the scoliosis by application of corrective forces. From the literature, orthotic devices generally present pressure that is exerted against the convex side of the curve with counterpressure applied against a fixed portion of the skeleton such as the pelvis and rib cage. Pressure is also applied against the convex aspect of rib rotation in an attempt to cause derotation.
External correction devices can be divided into passive and kinetic in their action. Passive devices apply the principle of steadily applied pressure with no effort required on the part of the patient. Kinetic correction involves active participation by the patient. The passive form of correction is used in the nonoperative-treatment approach but also has significant application in preoperative correction and postoperative maintenance of scoliosis correction. Passive corrective devices include braces and casts.
Braces are constructed of many materials such as leather, metal, or plastic. They may be constructed so as to be worn constantly or they may be removable. Treatment interventions in the form of braces include the Milwaukee Brace, Boston and TLSO Braces, The Charleston Bending Brace, and some new braces like TriaC.
A kinetic form of brace correction is currently exemplified by the Milwaukee brace – a custom-built brace that embodies pelvic support and static correction of the rotatory deformities such as rib angulation and pelvis rotation. Cervical distraction against the occipital pad elongates the spine and by traction decreases the curves. The lateral pads tend to prevent further lateral curving and rotation by a restraining pressure. It is conceivable that these pads also exert corrective passive forces but restraint of progression of curves is their more probable effect. Thus, all that can be expected of these lateral pads is that they hold curves, not necessarily correct them. These braces are made upon plaster positive mold made from a cast accurately applied to the patient. The positive mold is poured into the cast, which is then bivalved and removed; the brace is then made upon this mold. The Milwaukee brace is used in high thoracic and cervical curves, most often for congenital and juvenile-onset scoliosis (4).
The value of the Milwaukee brace lies primarily in maintenance of the current curve status and the prevention of further progression. Various authors have claimed correction of scoliosis of both the lateral curves and rotational deformities, but this correction is minimal. Prevention of progression, however, of both lateral curving and especially rotational deformity is extremely desirable and justifies the use of the Milwaukee brace.
The Boston brace is a low-profile thoracolumbar-sacral orthosis (TLSOs) that provides passive correction while the brace is worn, generally 16 hours a day (4). It comes up to beneath the underarms and can be fitted to be worn close to the skin so that they don’t show under clothes like that of the Milwaukee Brace. It appears to be effective for mid-back and lower curves and is worn only for 16 hours a day to achieve benefits. The Milwaukee Brace on the other hand has to be worn 23 hours in a day.
Single thoracolumbar curves can be treated with nighttime bracing with the Charleston side-bending brace (4). Since this kind of brace is worn only at nights, it appears to be suitable only for small, flexible curves.
In one literature, it mentions of a new orthotic device in the non-operative treatment of idiopathic scoliosis – the TriaC brace. Based from the literature, its name is derived of the three C’s of comfort, control and cosmesis. In this new orthosis, continuous correction forces on the trunk need to be applied, with the aim to reverse the progression process during the growth period. The result of the study regarding the use of the TriaC brace shows that it has prevented further deterioration of scoliotic curves in 28 out of 35 patients. This type of brace is extra effective as a result of the greatly increased comfort it offers.
These braces are constructed so that it is adjustable to curve changes of the scoliosis and to height growth and change in weight of the child. A brace is worn until skeletal maturity is reached (Risser grade 4 or 5) or until no growth has occurred for 6 months. Brace fit and curve progression are evaluated every 4 to 6 months (4). Wearing the brace for the prescribed time is difficult but is essential for any success.
A team approach, with several health professionals involved, is beneficial and often necessary to support the patient through the process of wearing a brace. Each member of the treatment team plays an important role in the success of the bracing program.
A physician or orthopedic surgeon interprets the x-rays, assesses the potential progression of the scoliosis, performs a clinical assessment, and plans the treatment with the patient and family. Through both a physical evaluation and an x-ray assessment, the physician determines whether any orthotic treatment is recommended, and if so, which treatment. It is the physician’s responsibility to recognize curve patterns, growth potential, and coronal and sagittal balance.
If a brace is used, an orthotist measures, facilitates and fits the patient with the device. The orthotist is responsible not only for providing the product but also for following through with the entire treatment plan. The orthotist should have knowledge of the referring physician’s treatment protocol and be able to provide a full physical examination to allow the orthosis to fit correctly. The orthosis design and fit will be a key factor in patient compliance. The more streamlined and comfortable the orthosis is, the more likely it will be worn as prescribed.
The physical therapist performs a comprehensive assessment, interprets the results, and tailors an individual exercise program best suited for the patient based on the findings. A nurse may also get involved to coordinate the treatment plans. The nurse coordinates the clinic, instructs the patient in brace application and skin care, and provides the patient with a schedule for adjusting to the brace. The nurse also provides support and information and is the patient’s and family’s contact for any questions or concerns. The nurse often provides written information with regard to diagnosis and treatment plan.
The team makes the long-term management of these patients not only successful but also very rewarding. Each team member provides a great deal of emotional support to both the patient and family throughout the course of treatment. A highly motivated, enthusiastic team can have a very positive influence on both patients and families. Patients and their families gain knowledge and support from the professional team as well as from other children and families undergoing similar treatment.
The education of the patient and family starts even before the initial fitting of the orthosis. There should be a complete understanding of what the patient is being treated for and what is expected of the patient and the family.
One study implied that in order for an orthosis to be effective in the management of scoliosis in the long term, it must at least demonstrate the ability to control the curve in the short term while the patient is wearing the orthosis. Overall efficacy is dependent on many additional factors that include compliance, length of time the patient is compliant with a bracing program, weaning, as well as numerous selection criteria in the first place, such as curve size, and skeletal and endocrinologic maturity (5).
Conclusion
The literature found are rich in information of the various orthotic devices used in the treatment of scoliosis. Although there are many types of braces to be used for the patient with scoliosis, they all use the same working principle – to use the orthotic device in order to obtain correction by applying forces on the sides of the body. The correction forces induce a bending movement on the spine in order to correct the lateral curves. Continued wearing of the brace will facilitate prevention of further curving of the spine.
A complete disappearance of the curve after wearing the brace for a significant period of time is not an end result of wearing braces. Therefore, it is important for patients and families to understand that a brace will not correct the curve but may prevent the curve from progressing. In order to achieve progression, compliance is an important factor. The patient has to follow what his or her care team instructed. The number of hours for which it is to be worn should be followed.
Aside from that, another important factor in the treatment of scoliosis with the use of orthotic devices is the team that manages the patient. There should be an all-out support from the team and the patient should be guided and educated with his or her condition and also with the orthotic device that is used. After all, it is not easy to be wearing an orthotic device – physically or emotionally.
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