[Evaluation of the efficacy of a carbon brace ("Corset monocoque carbone respectant la respiration" [CMCR]) preserving lung capacity to treat idiopathic scoliosis in children and adolescents: a retrospective study of 115 patients]

Braces for idiopathic scoliosis in adolescents

BACKGROUND

Idiopathic scoliosis is a three-dimensional deformity of the spine. The most common form is diagnosed in adolescence. While adolescent idiopathic scoliosis (AIS) can progress during growth and cause a surface deformity, it is usually not symptomatic. However, in adulthood, if the final spinal curvature surpasses a certain critical threshold, the risk of health problems and curve progression is increased.

OBJECTIVES

To evaluate the efficacy of bracing for adolescents with AIS versus no treatment or other treatments, on quality of life, disability, pulmonary disorders, progression of the curve, and psychological and cosmetic issues.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, five other databases, and two trials registers up to February 2015 for relevant clinical trials. We also checked the reference lists of relevant articles and conducted an extensive handsearch of grey literature.

SELECTION CRITERIA

Randomized controlled trials (RCTs) and prospective controlled cohort studies comparing braces with no treatment, other treatment, surgery, and different types of braces for adolescent with AIS.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included seven studies (662 participants). Five were planned as RCTs and two as prospective controlled trials. One RCT failed completely, another was continued as an observational study, reporting also the results of the participants that had been randomized.There was very low quality evidence from one small RCT (111 participants) that quality of life (QoL) during treatment did not differ significantly between rigid bracing and observation (mean difference (MD) -2.10, 95% confidence interval (CI) -7.69 to 3.49). There was very low quality evidence from a subgroup of 77 adolescents from one prospective cohort study showing that QoL, back pain, psychological, and cosmetic issues did not differ significantly between rigid bracing and observation in the long term (16 years).Results of the secondary outcomes showed that there was low quality evidence that rigid bracing compared with observation significantly increased the success rate in 20° to 40° curves at two years' follow-up (one RCT, 116 participants; risk ratio (RR) 1.79, 95% CI 1.29 to 2.50). There was low quality evidence that elastic bracing increased the success rate in 15° to 30° curves at three years' follow-up (one RCT, 47 participants; RR 1.88, 95% CI 1.11 to 3.20).There is very low quality evidence from two prospective cohort studies with a control group that rigid bracing increases the success rate (curves not evolving to 50° or above) at two years' follow-up (one study, 242 participants; RR 1.50, 95% CI 1.19 to 1.89) and at three years' follow-up (one study, 240 participants; RR 1.75, 95% CI 1.42 to 2.16). There was very low quality evidence from a prospective cohort study (57 participants) that very rigid bracing increased the success rate (no progression of 5° or more, fusion, or waiting list for fusion) in adolescents with high degree curves (above 45°) (one study, 57 adolescents; RR 1.79, 95% CI 1.04 to 3.07 in the intention-to-treat (ITT) analysis).There was low quality evidence from one RCT that a rigid brace was more successful than an elastic brace at curbing curve progression when measured in Cobb degrees in low degree curves (20° to 30°), with no significant differences between the two groups in the subjective perception of daily difficulties associated with wearing the brace (43 girls; risk of success at four years' follow-up: RR 1.40, 1.03 to 1.89). Finally, there was very low quality evidence from one RCT (12 participants) that a rigid brace with a pad pressure control system is no better than a standard brace in reducing the risk of progression.Only one prospective cohort study (236 participants) assessed adverse events: neither the percentage of adolescents with any adverse event (RR 1.27, 95% CI 0.96 to 1.67) nor the percentage of adolescents reporting back pain, the most common adverse event, were different between the groups (RR 0.72, 95% CI 0.47 to 1.10).

AUTHORS' CONCLUSIONS

Due to the important clinical differences among the studies, it was not possible to perform a meta-analysis. Two studies showed that bracing did not change QoL during treatment (low quality), and QoL, back pain, and psychological and cosmetic issues in the long term (16 years) (very low quality). All included papers consistently showed that bracing prevented curve progression (secondary outcome). However, due to the strength of evidence (from low to very low quality), further research is very likely to have an impact on our confidence in the estimate of effect. The high rate of failure of RCTs demonstrates the huge difficulties in performing RCTs in a field where parents reject randomization of their children. This challenge may prevent us from seeing increases in the quality of the evidence over time. Other designs need to be implemented and included in future reviews, including 'expertise-based' trials, prospective controlled cohort studies, prospective studies conducted according to pre-defined criteria such as the Scoliosis Research Society (SRS) and the international Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) criteria. Future studies should increase their focus on participant outcomes, adverse effects, methods to increase compliance, and usefulness of physiotherapeutic scoliosis specific exercises added to bracing.

The carbon brace

Background

The CMCR brace (Corset MonocoqueCarbone respectant la Respiration –which means Monoshell Carbon Brace respecting Breathing) is an innovative brace, used in orthopaedic treatment for progressive thoracic, thoraco-lumbar or combined scoliosis, whatever their etiology. It can be used at the very young age without disrupting the chest growth, but should be kept for reducible scoliosis in older teenagers.

Brace description and principles

The CMCR brace is monoshell while retaining the corrective principle of the polyvalve Lyon brace with one or two supports (brace “pads”) located on hump(s).In contrast to Lyon brace made of plexidur and structured by metal reinforcement with adjustable but fixed localized supports, the CMCR brace is made of polyethylene and carbon with adjustable and mobile supports. This mobility provides a permanent pressure, which varies depending on ribs and spine movements.

The correction is obtained without spinal extension so that each respiratory movement takes part in a gradual return to dorsal kyphosis.

Results

Results were presented in two published analysis:

• In the first retrospective study about 115 patients, French-published in the Annals of Physical Medicine and Rehabilitation (2005), the CMCR brace stabilized moderate scoliosis, decreased the vital capacity (VC) of 13% compared to the VC without brace, and did not have sufficient impact on the hump reduction. Treatment had better results when started at Risser 3 or 4 than Risser 0, 1, 2. The brace was then modified to increase the dorsal pad pressure and the location of correction forces was defined more precisely through the use of 3D analysis.

• The second study published in Scoliosis (2011) mainly focused on the impact on VC at brace setting up and followed a cohort of 90 patients treated with CMCR. Girls as well as boys increased VC during treatment, and at brace definitive removal, VC had increased of 21% from the initial value, whereas the theoretical VC at the same time rose by 18%.

The difference between the time where the child actually wears its brace and the time asked by the clinician for the brace to be worn is only 1 hour, which means that this brace is accepted by teenagers.

Conclusions

Orthopaedic treatment is still a heavy treatment for teenagers in growth period. This orthosis is designed to partly maintain spine and chest mobility. We hope so to have part in improving life conditions of these teenagers, compared to those treated with rigid braces.

Quality of life and brace-treated idiopathic scoliosis: a cross-sectional study performed at the Centre des Massues on a population of 120 children and adolescents

OBJECTIVES

To determine the influence of orthopedic treatment on quality of life (QoL) in children and adolescents with idiopathic scoliosis and treated with either the carbon brace (CMCR, corset monocoque carbone respectant la respiration) or the Lyon brace. To compare these braces.

PATIENTS AND METHODS

A cross-sectional study on a population of 120 patients with idiopathic scoliosis, visiting for routine evaluation following the onset of an orthopedic treatment at the Centre des Massues in Lyon. Eighty-two patients used the carbon brace and 38 patients used the Lyon brace. The patients completed the SRS-22 questionnaire (where a low score means a bad QoL), an evaluation scale of QoL specific to spinal deformities, and visual analogue scales (VAS) for pain, motivation and QoL ranging from 0 to 100mm.

RESULTS

The QoL of Lyon brace-treated patients is significantly worse than that of patients treated with a carbon brace for the overall score (mean±SD, 4.05±0.37 vs 3.77±0.46, P=0.002) as well as for function (P=0.01), pain (P=0.001), and appearance (P=0.004). These results are confirmed by the VAS for QoL (P=0.001).

CONCLUSION

The use of the carbon brace and of the Lyon brace induces a reduction in QoL whatever the evaluation tool, either SRS-22 or VAS. However, the use of the Lyon brace impairs QoL more than the use of the carbon brace.

Vital capacity evolution in patients treated with the CMCR brace: statistical analysis of 90 scoliotic patients treated with the CMCR brace

SUMMARY

OBJECTIVE

To study the evolution of pulmonary capacity during orthopaedic treatment of scoliosis with the CMCR brace.

BACKGROUND

Investigating the impact of moderate scoliosis on respiratory capacity and its evolution during CMCR brace treatment with mobile pads.

CONTEXT

Several studies demonstrate the impact of scoliosis on respiratory capacity but few of them focus on the impact of bracing treatment. We studied the evolution of the pulmonary capacity of a cohort of 90 scoliotic patients.

METHODS

This retrospective study included 90 scoliotic patients treated since 1999 with a brace with mobile pads called CMCR (n = 90; mean age: 13 years; 10-16). These patients were diagnosed with an idiopathic scoliosis (mean angulation 20.6°). All patients underwent a radiographic and respiratory evaluation at the beginning, the middle and the end of treatment.

RESULTS

Mean age at treatment start was 13. Before treatment, our patients did not have a normal pulmonary capacity: Forced Vital Capacity (FVC) was only 75% of the theoretical value. All curvature types (thoracic, thoraco-lumbar and combined scoliosis) involved this reduced pulmonary capacity, with moderate-angulated scoliosis having a negative impact. At the beginning of brace treatment, the loss of real vital capacity with brace (0.3 litres) was 10% lower than without brace.At CMCR removal, the FVC had increased by 0.4 litre (21% +/- 4.2% compared to the initial value). The theoretical value had increased by 3%. This positive evolution was most important in girls at a low Risser stage (0,1,2), and before 11 years of age.

CONCLUSION

These results supported our approach of orthesis conception for adolescent idiopathic scoliosis which uses braces with mobile pads to preserve thorax and spine mobility.

Idiopathic scoliosis: relations between the Cobb angle and the dynamical strategies when sitting on a seesaw

The aim of this study was to determine the influence of the severity of the spinal curve on the postural regulation when self-imposed disturbances occur in a seated position in anteroposterior (AP) and mediolateral (ML) orientations. Twelve female adolescents with a right thoracic scoliosis (Cobb = 30.4° ± 9.7) were included in this study. The ground reaction forces (GRF) were studied while the subjects were maintaining their sitting on a seesaw (ML or AP destabilisation). Five conditions were tested: eyes open; with additional loads placed onto the subject's right or left shoulder; or onto the subject's right or left pelvis. We tested the correlation between the Cobb angle and the postural parameters (index of performance and GRF variability) for each condition. When the destabilisation was AP, the Cobb angle was significantly correlated with GRF variability and anterior and concavity index of performance. Two conditions showed higher correlations: stabilisation with the concavity pelvis load (GRF variability) and the open eyes (index of performance). In contrast, whatever the condition tested was, no link was found when the destabilisations were applied in ML direction. The destabilisation in a seated position highlights the influence of the curve severity on the postural organisation. In seated position, the postural control strategies specific to the scoliotic patients were always correlated by severity of curve, especially when the destabilisation is applied in AP directions. This study showed that the unstable seating position can be considered as a pertinent paradigm to help finding a postural clinical index for adolescent idiopathic scoliosis.

Idiopathic scoliosis and balance organisation in seated position on a seesaw

The aim was to determine the biomechanical processes involved in postural regulation when self-imposed disturbances occur in the seated position in the antero-posterior direction. Twelve female adolescents with right thoracic scoliosis (SG) (Cobb = 30.4 degrees +/- 9.7) and 15 control adolescents (CG) were included in this study. The ground reaction forces (GRF) were studied whilst the subjects maintained their balance in the sitting position on a seesaw. Six conditions were tested: eyes open and closed; with an additional load placed on the subject's right or left shoulder; and with an additional load on the subject's right or left pelvis. The SG showed significantly higher force amplitudes and variability and fewer oscillations than the CG in all the conditions. In the SG, the time analysis showed that the duration of the GRF was significantly higher in forward and left directions. Whatever the condition tested, the intra-group differences were not significant. The scoliotic patients in seated position were characterised by larger changes of the GRF, especially with a postural control in the forward and left directions, corresponding to that on the concave side of their spinal curvature. No significant differences were found to exist between the various conditions (load and unload, eyes open and eyes closed). Clinical tests and rehabilitation methods should include assessments of seated patients' spatio-temporal adaptation to GRF.

Braces for idiopathic scoliosis in adolescents

BACKGROUND

Adolescent Idiopathic Scoliosis (AIS) is a three-dimensional deformity of the spine. While AIS can progress during growth and cause a surface deformity, it is usually not symptomatic. However, in adulthood, if the final spinal curvature surpasses a certain critical threshold, the risk of health problems and curve progression is increased. Braces are traditionally recommended to stop curvature progression in some countries and criticized in others. They generally need to be worn full time, with treatment extending over years.

OBJECTIVES

To evaluate the efficacy of bracing in adolescent patients with AIS.

SEARCH STRATEGY

The following databases (up to July 2008) were searched with no language limitations: the Cochrane Central Register of Controlled Trials, MEDLINE (from January 1966), EMBASE (from January 1980), CINHAL (from January 1982) and reference lists of articles. An extensive handsearch of the grey literature was also conducted.

SELECTION CRITERIA

Randomised controlled trials and prospective cohort studies comparing braces with no treatment, other treatment, surgery, and different types of braces.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

We included two studies. There was very low quality evidence from one prospective cohort study with 286 girls that a brace curbed curve progression at the end of growth (success rate 74% (95% CI: 52% to 84%)), better than observation (success rate 34% (95% CI:16% to 49%)) and electrical stimulation (success rate 33% (95% CI:12% to 60%)). There is low quality evidence from one RCT with 43 girls that a rigid brace is more successful than an elastic one (SpineCor) at curbing curve progression when measured in Cobb degrees, but there were no significant differences between the two groups in the subjective perception of daily difficulties associated with wearing the brace.

AUTHORS' CONCLUSIONS

There is very low quality evidence in favour of using braces, making generalization very difficult. Further research could change the actual results and our confidence in them; in the meantime, patients' choices should be informed by multidisciplinary discussion. Future research should focus on short and long-term patient-centred outcomes, in addition to measures such as Cobb angles. RCTs and prospective cohort studies should follow both the Scoliosis Resarch Society (SRS) and Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) criteria for bracing studies.

Treatment of thoraco-lumbar curves in adolescent females affected by idiopathic scoliosis with a progressive action short brace (PASB): assessment of results according to the SRS committee on bracing and nonoperative management standardization criteria

BACKGROUND

The effectiveness of conservative treatment of scoliosis is controversial. Some studies suggest that brace is effective in stopping curve progression, whilst others did not report such an effect.The purpose of the present study was to effectiveness of Progressive Action Short Brace (PASB) in the correction of thoraco-lumbar curves, in agreement with the Scoliosis Research Society (SRS) Committee on Bracing and Nonoperative Management Standardisation Criteria.

METHODS

Fifty adolescent females (mean age 11.8 +/- 0.5 years) with thoraco-lumbar curve and a pre-treatment Risser score ranging from 0 to 2 have been enrolled. The minimum duration of follow-up was 24 months (mean: 55.4 +/- 44.5 months). Antero-posterior radiographs were used to estimate the curve magnitude (CM) and the torsion of the apical vertebra (TA) at 5 time points: beginning of treatment (t1), one year after the beginning of treatment (t2), intermediate time between t1 and t4 (t3), end of weaning (t4), 2-year minimum follow-up from t4 (t5). Three situations were distinguished: curve correction, curve stabilisation and curve progression.The Kruskal Wallis and Spearman Rank Correlation tests have been used as statistical tests.

RESULTS

CM mean value was 29,30 +/- 5,16 SD at t1 and 14,67 +/- 7,65 SD at t5. TA was 12.70 +/- 6,14 SD at t1 and 8,95 +/- 5,82 at t5. The variation between measures of Cobb and Perdriolle degrees at t1,2,3,4,5 and between CM t5-t1 and TA t5-t1 were significantly different.Curve correction was accomplished in 94% of patients, whereas a curve stabilisation was obtained in 6% of patients.

CONCLUSION

The PASB, due to its peculiar biomechanical action on vertebral modelling, is highly effective in correcting thoraco-lumbar curves.

Determination of the influence of the Chêneau brace on quality of life for adolescent with idiopathic scoliosis

OBJECTIVE

The main objective is to determine the influence of treatment by Chêneau brace on the quality of life (QoL) of adolescents with idiopathic scoliosis.

MATERIAL AND METHOD

We used the QoL scale of Climent et al. "the Quality of Life Profile for Spine Deformities" (QLPSD, in which a higher score means a worse QoL) and visual analogue scales (VAS) for pain and for QoL ranging from 0 to 100mm. The study includes 108 subjects divided in three groups, a control group of 32 patients without brace, a full-time treated group (wearing a Chêneau brace 23/24 hours) of 41 patients, and a part-time treated group (wearing the brace during the night only) of 35 patients.

RESULTS

The QoL is significantly worse in the full-time treated group than in the group with night treatment and in the group without brace for the psychosocial functioning, the sleep disturbances, the back flexibility (P<0.001), the body image (P<0.01), as well as the overall score (P<0.001). On the other hand, there was no difference for the back pain. Among patients wearing the brace, the girls had an average QLPSD score higher than the boys for the psychosocial functioning, the body image, the overall score (P<0.05) and the back flexibility (P<0.01). Whereas there was no significant difference between the sexes for the sleep disturbances and the back pain. The QoL of patients who wear the brace was significantly correlated with degrees corrected wearing the brace and the patient's satisfaction on his or her health status. However, this correlation was very weak. On the other hand, there was no correlation between the quality of life and the age, the duration of brace treatment or the skeletal maturity (Risser sign). On VAS, the patients without brace have the highest score of QoL, followed the part-time treated patients while the full-time treated patients have the lowest score.

CONCLUSION

The wearing of the Chêneau brace involves a significant reduction in the QoL whatever instruments of evaluations of QoL, QLPSD or VAS. The QoL of the full-time treated patients was the lowest followed part-time treated patients while the QoL of the patients without brace was the highest. However, the brace does not influence the back pain in idiopathic scoliosis at teenage.

Est–il trop tard pour entreprendre un traitement orthopédique pour scoliose idiopathique à Risser 4 ?

Orthopaedic treatment for idiopathic scoliosis in adolescence is indicated with a curve of > or =20 degrees and a Risser score< or =4, because progression of curve is low with Risser scores >4. We present the case of a young man with a left lumbar idiopathic scoliosis (T12-L4) with a curve of 10 degrees, which was stable from 13 years (Risser 0) to 16 years old (Risser 4). The scoliosis progressed quickly after a Risser score of 4 was achieved. The man had been wearing a lift on the left foot since he was 13, because of a leg length discrepancy, and had been under clinical and radiological monitoring. When the boy reached 17 years, the scoliosis rapidly progressed, to a curve of 22 degrees and a Risser score of >4. The scoliosis was effectively treated with a Boston brace. At 20 years, the Risser score was 5, and the left lumbar curve was 13 degrees after discontinuing the use of the brace. To our knowledge, no scientific reference indicates a time limit to orthopaedic treatment for idiopathic adolescent scoliosis. Despite the experts' recommendations, a brace might be indicated with a Risser score > or =4 to stop the progression of the curve.

[Evaluation of the Chêneau brace in adolescent idiopathic scoliosis]

OBJECTIVE

We aimed to evaluate the Chêneau brace in the orthopedic treatment of adolescent idiopathic scoliosis to better determine the indications under which it could be prescribed.

MATERIALS AND METHODS

This was a retrospective study including 63 patients treated by Chêneau brace for adolescent idiopathic scoliosis between 1997 and 2006. The Cobb angles of the curves in the frontal and sagittal planes as well as rotations and rib hump were measured at the beginning of treatment, with the brace, at the end of treatment and 2 years after discontinuing the brace. A variation of+/-10 degrees in angle was selected to judge the results.

RESULTS

At the end of the treatment, 25.4% of the curves were improved and 60.3% stabilized, with 14.3% aggravated; 5 patients (7.9%) required surgery. At 2 years, the reduction in angle was 1.8 degrees, on average. The best results were obtained for the lumbar and dorsolumbar curves. A significant improvement was noted for the dorsal curves; the major double curves are not as accessible to the treatment. For curves whose initial angle was less than 30 degrees , an initial reduction of higher than 50% with the brace presented the best improvement at the end of the follow-up. We note a significant reduction of the rib hump but not accompanied by a reduction of rotation. Finally, we note a deleterious effect in the sagittal curves, with a slight flatness of the spinal profile.

CONCLUSION

The continuous wearing of the Chêneau brace can stabilize the evolution of adolescent idiopathic scoliosis, apart from the forms with major double curves, which are not as accessible to the treatment. However, the improvement comes at the price of a slight flatness of the curves of the spine in the sagittal plane. The loss of the correction after discontinuing the brace is minor. We emphasize, therefore, the necessity to monitor the sagittal aspect of the spine as well as the possibility of early treatment, strict surveillance and prolonged follow-up.