Throughout
history man has tried to straighten out that which nature has bent
twisted, or curved. Hippocrates not only gave a name to scoliosis but he also tried to correct it. Over the centuries since
then physicians have used a wide, and sometimes strange, variety of
devices to straighten a crooked spine.
In today's world when a growing
adolescent is diagnosed with progressive idiopathic scoliosis and the curve is between 25 and 40 degrees, the physician
may prescribe the wearing of a brace to keep the curve from worsening.
Depending on the severity of the curve, the curve pattern, and the amount
of growth remaining, the physician may not wait to document progression
but will prescribe bracing on the initial visit.
In 1985, the Scoliosis Research
Society (SRS) initiated a study to investigate the effectiveness of
bracing as a treatment for scoliosis. Many previous studies of full time
bracing showed that braces stop about 80% of curves. All of these studies,
however, were "uncontrolled" which means there were no simultaneous groups
of untreated, unbraced patients for comparison. Therefore, there was some
doubt that brace treatment of scoliosis was effective, and concern that
bracing may be no different than "natural history" or what happens when no
treatment is undertaken. In the SRS controlled clinical trial, involving
centers from around the world and conducted by Dr. Alf L. Nachemson of
Sahlgren Hospital, Gothenberg Sweden, patients of the same age, curve
pattern and curve severity were divided into two groups, one treated with
bracing, one not treated. As reported in the Fall 1993 issue of the Spinal
Connection, the results of this study demonstrated, with statistical
certainty that bracing is effective compared to natural history.
In another study by Drs. John
Lonstein and Robert Winter, the records and X-rays of 1020 patients
treated with the Milwaukee Brace were reviewed and compared with the
findings of a study by Drs. Lonstein and J.M. Carlson which documented
patients at the same hospitals who had not been braced but who had been
followed for progression of the curve. This retrospective study also
showed that bracing is an effective treatment halting the progression of
the curve in statistically significant numbers compared with those
patients not treated.
While it is true that there are some
patients (20-25%) for whom bracing does not work - and unfortunately, it
is not possible to predict who they will be - parents and physicians can
be reassured by these recent findings that bracing for those youngsters
who meet the generally accepted criteria is a wise course of action
What does bracing
achieve?
It is important for parents
and patients to realize that the purpose of bracing is to keep the curve
from progressing as a child grows. While the curve will demonstrate
improvement during the time the child is braced, it will typically revert
to its original degree of severity when the use of the brace is eventually
discontinued at the cessation of growth. Some individuals do achieve
permanent correction but holding the curve to an acceptable level, thus
avoiding surgery, should be deemed a success.
What kinds of braces are
used?
The Milwaukee Brace
The Milwaukee Brace was the first modern brace
designed for the treatment of scoliosis. Developed by Drs. Walter Blount
and Albert Schmidt of the Medical College of Wisconsin and Milwaukee's
Children's Hospital in 1945, it underwent design changes over the years,
reaching its present form around 1975. It is still used today,
particularly for high thoracic curves.
Metal bars in the front and back of
the brace extend the length of the torso and are attached to a
from-fitting plastic pelvic girdle and to a throat mold or ring which
encircles the neck- Straps attached to the metal bars hold pressure pads,
which are precisely placed depending on the individual's curve
pattern.
While the bars hold the body erect
the neck ring keeps the head centered over the pelvis and the pads push
against the curve. Everything works together to keep the body straight and
to prevent progression of the curve while the patient is
growing.
TLSO Braces
There are many TLSO (thoracic-lumbar-sacral orthosis) systems
available today. They are also often referred to as "underarm" or
"low-profile" braces. They are made of modem plastic materials and are
contoured to conform to the patient's body. While they all differ somewhat
in construction, they work on basically the same
principle.
The Boston Brace
In the early seventies, the most popular of the TLSO systems, the
Boston Brace, was developed by Dr. John Hall and Mr. William Miller of The
Boston Children's Hospital. The Boston Brace was the first brace to
utilize symmetrical standardized modules eliminating the need for casting.
It was also the brace used in the Scoliosis Research Society's bracing
study.
The Boston Brace extends
from below the breast to the beginning of the pelvic area in front and
just below the scapulae to the middle of the buttocks in the back. It is
designed to keep the lumbar area of the body in a flexed position by
pushing the abdomen in and flattening the posterior lumbar contour. Pads
are strategically placed to provide pressure to the curve, and areas of
"relief" or "voids" are provided opposite the areas of pressure.
The Charleston Bending
Brace
The Charleston Bending
Brace was introduced in 1979. Developed by Dr. Frederick Reed and Mr.
Ralph Hooper, CPO, this brace is worn only at night during sleep. It is
molded to conform to the patient's body while she is bent towards the
convexity, of the curve, thus 'over-correcting" the curve during the eight
hours it is worn.
A preliminary study and
subsequent longer term follow-up of those using the nighttime bending
brace are encouraging, particularly for a single curve. Although the
studies show no evidence of improved compliance the potential for a
patient to wear a part-time brace, especially while sleeping, rather than
the usual full-time (22-23 hours) regiment is cited as an important
benefit. At this time the scoliosis community awaits definitive long-term
studies on the Charleston Bending Brace, and on part- time bracing in
general.
"The purpose of bracing
is to keep the curve from progressing as a child grows."
"The purpose of bracing is to keep
the curve from progressing as a child grows." To achieve a successful
outcome from bracing it is necessary that a highly skilled orthotist or
brace maker work hand in hand with the orthopedist to craft a brace
precisely tailored to the patient's needs. In many cases an exercise
program is also provided. After that the physician will have the patient
return for routine checkups and order X-rays to make sure the brace is
doing its job. He will prescribe periodic adjustments as necessary. The
brace is worn until the physician has determined that skeletal maturity
has been reached at which time the patient will be gradually weaned from
the brace.
Compliance on the patient's part in
wearing the brace according to the prescribed schedule is a crucial
factor, of course. Several studies have demonstrated the importance that
the mother's attitude has on the child's perception of her own condition
and acceptance of treatment. While no one would suggest that adapting
physically and psychologically to bracing is easy for children and
teenagers, many studies show that after an initial adjustment period,
youngsters who are braced live very normal lives, engaging in appropriate
activities, including sports, and that they have good psychosocial
adjustment no matter which brace they
wear
