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SOSORT
Educational Course
May 6, 2015
Katowice, Poland
Luke Stikeleather, CONational Scoliosis CenterFairfax, Virginia
Disclosure: For the purpose of this presentation, no financial
agreements exist between the presenter and any of the individuals who are affiliated with the braces or research studies being presented.
Some Content in this presentation was published
In “Bracing for scoliosis in 2014: state of the art”
Acknowledgements I express my gratitude to those who contributed to and
assisted in developing this presentation: Manuel Rigo, MD
Jean Claude de Mauroy, MD
Stefano Negrini, MD
Fabio Zaina, MD
Theodore Grivas, MD
Angelo Aulisa, MD
Jim Wynne, CPO
Michael Hawkins, DPT
Innovation
Innovative: introducing new ideas; original and creative in thinking (Oxford Dictionary)
For the conservative management of spinal deformities to progress, we must be innovative; not only in brace design, but in the framework we use to approach treatment
Recognition of Great Polish innovators
Nicolaus Copernicus (1473-1543)
Mathematician, astronomer, physician, classical scholar
Developed the model that earth is not the center of universe
Published the book De Revolutionibus orbium coelestium
which was a major contribution to the scientific revolution
Fryderyk Chopin (1810-1849)
Composer and virtuoso pianist during Romantic era
Renowned as one of the leading musicians of his era
Invented the concept of instrumental ballade , later
used by composers including Johannes Brahms & Franz Liszt
Recognition of other Polish innovators
Marie Sklodowska-Curie (1867-1934) Physicist and chemist; Pioneered research on radioactivity
Arguably the most famous female scientist
First woman to win a Nobel Prize
Only person with Nobel Prizes in two different sciences
Lech Walesa (1943-) Credited with changing the Polish political system
Founded Poland’s first independent trade union “Solidarity”
which facilitated the fall of the communist regime
Awarded Nobel Peace Prize in 1983 for human rights activism
Recognition of inspirational Polish innovators
Pope John Paul II (Karol Wojtyla) (1920-2005)
Youngest Pope elected since 1846; served for 26 years
Fluent in 10 languages; visited 129 countries (most of any Pope)
Has been made a Saint by the Catholic church
Helped end communist rule in Poland and across Europe
Significantly improved the Catholic Church's relations with Judaism, Islam, the Eastern Orthodox Church, and the Anglican Communion
University of Iowa, NIH Funded, 2007 - 2013 Principle Investigator: Stuart Weinstein, MD
Study Director: Lori Dolan, PhD
Purpose:
“To compare the risk of curve progression in adolescents with AIS who wear a brace versus those who do not and to determine whether there are reliable factors that can predict the usefulness of bracing for a particular individual with AIS.”
BrAIST Study:Bracing in Adolescent Idiopathic Scoliosis Trial
Bracing is effective in stopping or slowing the progression of curves
Correlation between bracing outcome and orthotist skill and competence
Highlights need for advancement in research, orthotist training, and brace design
BrAIST: Peripheral Findings
72% of all braced participants had a successful outcome (stabilized or improved curves were considered success) 75% of randomized participants had successful outcome
48% of all non-braced participants had successful outcome (45% of randomized participants)
A significant positive association between hours of brace wear and rate of success exists
Bracing significantly decreased the progression of high-risk curves to the threshold for surgery
BrAIST: Research Study Results
365 total braces reviewed in case reports:
• 208 Boston (+46 “Boston-like” braces)
• 26 Wilmington (+13 “Modified Wilmington” braces)
• 22 Rosenberger
• 26 Hospital For Sick Children design (Cheneau variation)
• 8 Minnesota
• 4 Mortensen technique design
• 1 LA Brace
• 11 unspecified designs
BrAIST Brace Types
Asymmetrical
Chêneau / Rigo-Chêneau
Progressive Action Short Brace
ART Brace
Thoracolumbar LordoticIntervention
ScoliOlogic Braces
LA Brace
Gomez
Strap-Based
SpineCor
Symmetrical
Milwaukee
Lyon
Boston
SPoRT
Types of OrthosesGroupings based on design
Nocturnal
Charleston
Providence
nBrace
Common Scoliosis Bracing Designs1. Milwaukee CTLSO2. Lyon Brace3. Chêneau Brace4. Boston Brace5. Progressive Action Short Brace (PASB)6. The SPoRT Brace7. ART Brace8. TLI brace9. ScoliOlogiC® Braces 10.L.A. Brace11. Gomez Orthotic Spine System 12.Charleston Bending Brace13.Providence TLSO14.nBrace
Milwaukee CTLSO Walter Blount, MD & Albert Schmidt, MD
Milwaukee, Wisconsin, 1945
Anterior & posterior metal bars
Pads & straps on bars direct pressure
Form-fitting leather girdle
Plastic neck ring
1975: Added thermoplastic LSO base
Still used today for kyphosis and high thoracic curves
Lyon Brace Created by Pierre Stagnara, MD Lyon, France, 1947
Modified by Allègre and Lecante (1958)
Father of modern day bracing concepts and designs
Utilizes Aluminum and plexidur (high rigidity material)
Symmetrical, anterior-opening, Adjustable with no collar
Two main phases of treatment:
• Plaster cast to stretch the deep ligaments before the Lyon brace
• Adjustable brace designed to accommodate patient’s growth
Lyon Brace
Indication: • AIS patients 11-15 years • treatment in younger patients is not indicated to
prevent tubular deformation of the thoraxDesign:
• 14 variations according to Lenke classification
Lyon Brace
Dr. Jacques Chêneau (Photo by Sanomed)
The Chêneau Brace Concept• Jacques Chêneau, MD initially designs
brace in 1960s and 1970s in France
• 1979: Dr. Chêneau publishes successes with novel brace design incorporating 3-D correction and regional derotation
• 1985 & 2004: Long-term follow up studies published demonstrating stable curve patterns
• Many design variations exist internationally
• Asymmetrical, anterior-opening
• Custom fabricated from plaster cast or scan
• Elaborates on Chêneau’sregional derotation concepts with expansion spaces and three-dimensional correction principles
• Growing use by Rigo-educated orthotists in North America since 2004
Rigo-Chêneau Brace
• Curve patterns are categorized and respond consistently
• The categories provide a framework for brace fabrication
Rigo-Chêneau Brace
A corrected positive mould is created in order to provide highly selective pads and expansion rooms
Rigo-Chêneau BracePrinciples of Correction
A. Three-points systems in the frontal plane. Alignment inthe frontal plane
B. Regional derotation and pair of forces in the transversalplane for local derotation
C. Sagittal balance and physiological alignment
D. Breathing mechanics against the morphologicallordotization of the main thoracic spine
Rigo-Chêneau BracePrinciples of Correction
’
A. Frontal plane(alignment)
B. Transversal plane(derotation)
C. Sagittal balance
D. Breathing mechanics
3D Correction
Rigo-Chêneau Brace
A. Frontal plane (alignment)
B. Transversal plane (derotation)
C. Sagittal balance
D. Breathing mechanics
a
b
Regional Derotation
LUMBAR (RED)
a
b
Regional Derotation
THORACIC (YELLOW)
3D Correction
Rigo-Chêneau Brace
Boston Brace
John Hall, MD &
William Miller, CO
Developed in 1972 atBoston Children’s Hospital, Boston, Massachusetts
Symmetrical, Posterior opening
Prefabricated modules or custom fabricated from measure, scan, or cast
Most commonly used and copied scoliosis brace in North America
Approx. 4,000 (made by Boston Brace, Inc) fit annually in North America
Boston Brace
• Lumbar spine/pelvis positioned in flexion
• Pad pressure at the apex and below
• Active as well as passive correction
• Rotational force couples where possible
• Coordinated physical therapy program
• Team approach:
Boston Brace: Principles of Correction
•Patient/Family•Orthotist•Physical Therapist•Nurse•Physician
• Brace blueprint focuses attention on tilt of individual vertebrae, not Cobb angle
• Pad pressure at the apex and below
Boston Brace
Progressive Action Short Brace (PASB)
• Developed by Dr. Lorenzo Aulisa
• Rome, Italy, 1976
• Institute of Orthopedics at the Catholic University of the Sacred Heart
• Treatment of lumbar/thoracolumbar curves
Progressive Action Short Brace (PASB)
• Asymmetrical, Anterior-opening
• Custom-made polypropylene brace from plaster mold
• Designed specifically for treatment of lumbar/thoracolumbar curves
Progressive Action Short Brace (PASB)Principles of Correction
Constrained dynamic of the spine
Inversion of the stress-loading distribution
Cast geometry
Deflexion DerotationTraction
Progressive Action Short Brace (PASB)
Two Phases of Treatment
Phase I: Plaster Cast Application of external actions
Progressive Action Short Brace (PASB)
Phase II: Brace Application The high upper margin of brace at concavity
prevents side bending toward concavity
The upper margin of brace at convexity ends just beneath apex, deflecting scoliotic curve during side bend toward convexity
Inferior margins reach pelvic/trochanteric region stabilizing the brace on pelvis
transverse profile of the superior brace consists of asymmetrical ellipses. This allows the spine to rotate towards the concave side only, providing continuous generation of derotation moments
S Symmetric
Po Patient-oriented
R Rigid
T Three-dimensional
The SPoRT ConceptSforzesco and Sibilla Braces
Developed by Stefano Negrini, MD with Gianfranco Marchini, CPO
Milan, Italy, 2004
Dr. Stefano Negrini
SPoRT Brace
Symmetric , Anterior-Opening
Sforzesco brace utilizes plastic of high rigidity
Brace rigidity replaces traditional plaster casting
Sibilla brace utilizes less rigid plastic than Sforzesco
Efficacy
Mechanical efficacy
Active brace
3D action
Versatility & adaptability
Teamwork
Compliance
Perfect body design
Minimal visibility
Maximum freedom in ADL
Individual responsibility
Cognitive-behavioural team approach
The SPoRT Concept
The SPoRT concept utilizes unique terminology to describe the mechanism of action . To learn more about the SPoRT brace, contact Stefano Negrini, MD or Gianfranco Marchini, CPO
The SPoRT ConceptPrinciples of Correction
• Definition of the main slope(s)
• Definition of the derotation pushes
• Waist correction
• Elevation of the hemi-thorax
• Pushes on the ribs
• Shoulders
• Sagittal construction(change in kyphosis/lordosis)
The SPoRT ConceptPrinciples of Correction
Construction (external shape)
Drivers (new concept of SPoRT braces)
Pushes: Lateral Distal convex, lateral proximal concave, posterior convex
Escapes: Superior-Anterior & Lateral Superior
ART Brace(New Lyon Brace)
A Asymmetric
R Rigid
T Torsion
Jean Claude de Mauroy, MD, 2013
Asymmetrical, anterior-opening
2 Variations (not based on Lenke classifications)
C Shape
S Shape
ART Brace:Principles of correction
Correction occurs in Frontal and Horizontal plane
Axial Elongation and global detorsion
Detorsion is carried out with a fixed sagittal plane
ART Brace
Mobility takes place in frontal expansions and in torsion opposite to the curve
2 Axilla and Pelvic adjustable “clamps”
TLI brace (Thoracolumbar Lordotic Intervention)
Developed in 2002 by
Dr. Piet van Loon
Symmetric, posterior opening
based on concept described by M. Jansen in 1913
hypothesis that both thoracolumbar kyphotic & scoliotic spinal deformities are due to a dislocation of the thoracolumbar joint from its normal/optimal position
Mechanically, The TLI bracing concept is a Ponseti-type intervention, repositioning the joint in its optimal position to reduce shear, stress and deformative force.
TLI brace (thoracolumbar lordotic intervention)
Christine Colliard, MD and Charles Rivard, MD
St. Justine Hospital, Montreal, Canada, 1998
“Results are achieved not so much by the brace but by the
interaction of the brace with the patients Corrective Movement”
Corrective principles significantly different from traditional
thermoplastic TLSOs
SpineCor Brace
ScoliOlogiC® Braces Invented by Dr. Hans-Rudolph Weiss
Patent Application April 2005
First braces built May 2005
Asymmetric, anterior opening
Incorporates pads and expansions
ScoliOlogiC® Braces
“Chêneau light” Brace
Utilizes offset aluminum bar anteriorly and posteriorly
Less coverage than traditional Chêneau brace
Gensingen Brace
One piece plastic construction
Opens Anteriorly
L.A. Brace Gez Bowman, CO
Los Angeles, California, 2007
Measurement-based, centrally-fabricated
Asymmetrical, anterior-opening
Emphasis on three-dimensional correction
Rigid polypropylene construction
Limited use and available through LA Brace certified orthotists
Gomez Orthotic Spine System (GOSS)
Miguel Gomez, MD
Houston, Texas, 2009
Adapted from Rosenberger TLSO
Asymmetrical, anterior-opening
Emphasis on three-dimensional correction
Custom to measurements
Central fabrication through Friddle’sO&P
Charleston Bending Brace
Frederick Reed, MD & Ralph Hooper, CPO
Charleston, South Carolina, 1979
Over-correction through side-bending
Anterior-opening, true bending brace
First nocturnal bracing system
Introduced as alternative design for non-compliant patients
Approx. 1,400 fit annually in North America
Charles d’Amato, MD and Barry McCoy, CO
Children’s Hospital of Rhode Island, Providence, RI, 1992
Nocturnal brace system
Anterior-opening
Custom-made from measurements or cast
Patented process provided exclusively by Spinal Technologies
Providence TLSO
Dino Gallo, CO, Jenny Voit, CO & Manuel Rigo, MD
Rosenheim, Germany, 2011
Nocturnal brace system
Asymmetric, Anterior-opening
Utilizes Rigo-Chêneau principles Pads and expansion spaces
nBrace (Ortholutions)
The success of any bracing regimen depends on competence of the orthotist, proper construction of the brace, and compliance of the wearer
Objectives for the future:
Greater emphasis on training competent orthotists
Sustained financial support for research and development of biomechanically-sound brace designs
Intentional international collaboration between SRS, SOSORT, ISPO, others
Summary of Scoliosis Bracing
Imagination, Innovation, and Inspiration are powerful and positive forces for change.
Concluding thought