A new orthotic device in the non-operative treatment of idiopathic scoliosis

Actuator and Contact Force Modeling of an Active Soft Brace for Scoliosis

Scoliosis is an abnormality of the spinal curvature that severely affects the musculoskeletal, respiratory, and nervous systems. Conventionally, it is treated using rigid spinal braces. These braces are static, rigid, and passive in nature, and they (largely) limit the mobility of the spine, resulting in other spinal complexities. Moreover, these braces do not have precise control over how much force is being applied by them. Over-exertion of force may deteriorate the spinal condition. This article presents a novel active soft brace that allows mobility to the spine while applying controlled corrective forces that are regulated by varying the tensions in elastic bands using low-power light weight twisted string actuators (TSAs). This article focuses on the actuator and contact force modeling of the active soft brace (ASB). The actuator modeling is required to translate the twisting of string in terms of contraction of the string’s length, whereas the contact force modeling helps in estimating the net resultant force exerted by the band on the body using single point pressure/force sensors. The actuators (TSAs) are modeled as helix geometry and validated using a laser position sensor. The results showed that the model effectively tracked the position (contraction in length) with root mean square error (RMSE) of 1.7386 mm. The contact force is modeled using the belt and pulley contact model and validated by building a custom testbed. The actuator module is able to regulate the pressure in the range 0–6 Kpa, which is comparable to 0–8 Kpa pressure regulated in rigid braces. This makes it possible to verify and demonstrate the working principle of the proposed active soft brace.

Active Soft Brace for Scoliotic Spine: A Finite Element Study to Evaluate in-Brace Correction

Scoliosis is a spinal disorder that is conventionally treated using rigid or soft braces. Computational methods such as finite element-based models are used to investigate the mechanics of the spine and the effect of braces. Most spinal braces are either passive, static, or rigid and do not allow mobility to the spine, resulting in muscle atrophy, skin deterioration and other spine complexities. Lack of control over the amount of force being exerted by braces on the human spine could have adverse effects. Therefore, developing an active soft brace which allows mobility to the spine while applying controlled corrective forces could be a promising solution. This study presents finite element analysis (FEA) of an active soft brace that applies corrective forces using elastic bands. The pressure exerted by the brace on the spine can be controlled by varying the tensions in the elastic bands. The elastic band tensions are controlled using low-power, lightweight, and twisted string actuators (TSAs). This study aims to demonstrate the immediate corrections induced by the soft active brace using a scoliotic spine finite element (FE) model. A FE model of the patient’s trunk was created and validated with in vitro study. The brace model was installed on the simulated trunk to evaluate in-brace correction in both sagittal and coronal planes. The brace was evaluated under various load cases by simulating the actuator action.

Spinal Deformities and Advancement in Corrective Orthoses

Spinal deformity is an abnormality in the spinal curves and can seriously affect the activities of daily life. The conventional way to treat spinal deformities, such as scoliosis, kyphosis, and spondylolisthesis, is to use spinal orthoses (braces). Braces have been used for centuries to apply corrective forces to the spine to treat spinal deformities or to stabilize the spine during postoperative rehabilitation. Braces have not modernized with advancements in technology, and very few braces are equipped with smart sensory design and active actuation. There is a need to enable the orthotists, ergonomics practitioners, and developers to incorporate new technologies into the passive field of bracing. This article presents a review of the conventional passive braces and highlights the advancements in spinal orthoses in terms of improved sensory designs, active actuation mechanisms, and new construction methods (CAD/CAM, three-dimensional (3D) printing). This review includes 26 spinal orthoses, comprised of passive rigid/soft braces, active dynamics braces, and torso training devices for the rehabilitation of the spine.

INVESTIGATION OF ROBOTIC BRACES OF PATIENTS WITH IDIOPATHIC SCOLIOSIS (IS) — REVIEW OF THE LITERATURE AND DESCRIPTION OF A NOVEL BRACE

Idiopathic scoliosis (IS) is a complex three-dimensional (3D) deformity. The non-operative treatments for IS have been developed for a long time. According to current studies, hard braces are more effective than soft braces for the treatment of scoliosis. Though current braces are proved to be effective for the treatment of IS, there are several shortcomings needed to be overcome: (i) Braces cannot realize precise control over a specific vertebra. (ii) Braces affect cardiopulmonary efficiency (braces limit maximal exercise performance). (iii) The brace is not modulated based on user’s needs. (iv) Braces, including motions during eating, tying shoes, sitting, and standing. (v) Braces apply forces on skin, which causes pain, skin breakdown, and abnormal deformation of bone. In order to solve these boring problems of the current braces, this paper proposed a new intelligent robotic spine brace based on the principle of human biomechanics, three point pressure treatment theory and parallel mechanism theory. This novel brace can offer 3D active dynamic adjustable corrective forces for the treatment of IS and some experiments are employed for verifying the effect of the proposed brace.

2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth

BACKGROUND

The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) produced its first guidelines in 2005 and renewed them in 2011. Recently published high-quality clinical trials on the effect of conservative treatment approaches (braces and exercises) for idiopathic scoliosis prompted us to update the last guidelines' version. The objective was to align the guidelines with the new scientific evidence to assure faster knowledge transfer into clinical practice of conservative treatment for idiopathic scoliosis (CTIS).

METHODS

Physicians, researchers and allied health practitioners working in the area of CTIS were involved in the development of the 2016 guidelines. Multiple literature reviews reviewing the evidence on CTIS (assessment, bracing, physiotherapy, physiotherapeutic scoliosis-specific exercises (PSSE) and other CTIS) were conducted. Documents, recommendations and practical approach flow charts were developed using a Delphi procedure. The process was completed with the Consensus Session held during the first combined SOSORT/IRSSD Meeting held in Banff, Canada, in May 2016.

RESULTS

The contents of the new 2016 guidelines include the following: background on idiopathic scoliosis, description of CTIS approaches for various populations with flow-charts for clinical practice, as well as literature reviews and recommendations on assessment, bracing, PSSE and other CTIS. The present guidelines include a total of 68 recommendations divided into following topics: bracing (n = 25), PSSE to prevent scoliosis progression during growth (n = 12), PSSE during brace treatment and surgical therapy (n = 6), other conservative treatments (n = 2), respiratory function and exercises (n = 3), general sport activities (n = 6); and assessment (n = 14). According to the agreed strength and level of evidence rating scale, there were 2 recommendations on bracing and 1 recommendation on PSSE that reached level of recommendation "I" and level of evidence "II". Three recommendations reached strength of recommendation A based on the level of evidence I (2 for bracing and one for assessment); 39 recommendations reached strength of recommendation B (20 for bracing, 13 for PSSE, and 6 for assessment).The number of paper for each level of evidence for each treatment is shown in Table 8.

CONCLUSION

The 2016 SOSORT guidelines were developed based on the current evidence on CTIS. Over the last 5 years, high-quality evidence has started to emerge, particularly in the areas of efficacy of bracing (one large multicentre trial) and PSSE (three single-centre randomized controlled trials). Several grade A recommendations were presented. Despite the growing high-quality evidence, the heterogeneity of the study protocols limits generalizability of the recommendations. There is a need for standardization of research methods of conservative treatment effectiveness, as recognized by SOSORT and the Scoliosis Research Society (SRS) non-operative management Committee.

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.

DEVELOPMENT AND EVALUATION OF AN AIRBAG BRACE SYSTEM FOR IDIOPATHIC SCOLIOSIS SUBJECTS

There are disadvantages, especially from biomechanical viewpoint, to treating idiopathic scoliosis (IS) patients using traditional Boston braces with pressure pads. The major problem is the higher stiffness of the pressure pad as compared to the soft-tissue of the trunk. The aim of this study was to evaluate the effectiveness of Boston braces in which the pressure pad was replaced by the deformable airbag. A custom-made airbag brace which was designed based on the three-point compression principle of the Boston brace was prescribed to each of the 20 IS subjects with a mean age of 11.8 ± 2.8 years old. To evaluate the effectiveness of the treatment, the scoliosis Cobb angles before the treatment and after a follow-up period were measured from AP X-rays. The mean follow-up period was 11.5 ± 6.6 months. In addition, three interface parameters — contact pressure, contact area, and contact force — under seven postures — upright, flexion, extension, left side bending, right side bending, left side rotation and right side rotation — were measured using pressure mats to investigate interface conditions between airbags and skin. During the follow-up, all scoliosis curves showed Cobb angle reduction except one thoracic curve, which increased by one degree. The Cobb angle in the thoracic region decreased from 37.3 ± 10.6° to 27.3 ± 10.1° with a mean decreasing of 9.9 ± 5.9°. The Cobb angle in the lumbar region decreased from 30.1 ± 6.9° to 17.7 ± 8.6° with a mean decreasing of 12.4 ± 4.9°. Changes in the three interface parameters for the seven postures were insignificant. This indicated that the airbag brace could provide sufficient continuous corrective force. Using the airbag, instead of the pressure pad to provide the corrective force in the brace system can effectively correct the spinal curve caused by scoliosis. Easy adjustment and direct control of airbag pressure might be the key factor to the success of the airbag brace.

The current status of bracing for patients with adolescent idiopathic scoliosis

Adolescent idiopathic scoliosis affects about 3% of children. Non-operative measures are aimed at altering the natural history to maintain the size of the curve below 40° at skeletal maturity. The application of braces to treat spinal deformity pre-dates the era of evidence-based medicine, and there is a paucity of irrefutable prospective evidence in the literature to support their use and their effectiveness has been questioned. This review considers this evidence. The weight of the evidence is in favour of bracing over observation. The most recent literature has moved away from addressing this question, and instead focuses on developments in the design of braces and ways to improve compliance.

Soft braces in the treatment of Adolescent Idiopathic Scoliosis (AIS) - Review of the literature and description of a new approach

BACKGROUND

The use of soft braces to treat scoliosis has been described by Fischer as early as 1876. With the help of elastic straps, as the authors suggested, a corrective movement for individual curve patterns should be maintained in order to inhibit curve progression. Today this concept has been revived besides soft 3 point pressure systems. Some shortcomings have been revealed in literature in comparison with hard braces, however the concept of improving quality of life of a patient while under brace treatment should furtherly be considered as valuable. Purpose of this review is to gather the body of evidence existent for the use of soft braces and to present recent developments.

METHOD

A review of literature as available on Pub Med was performed using the key words 'scoliosis' and 'soft brace' at first. The search was expanded using 'scoliosis' and the known trademarks (1) 'scoliosis' and 'SpineCor', (2) 'scoliosis' and 'TriaC', (3) 'scoliosis' and 'St. Etienne brace', (4) 'scoliosis' and 'Olympe'. The papers considered for inclusion were new technical descriptions, preliminary results, cohort studies and controlled studies.

RESULTS

When searching for the terms 'scoliosis' and 'SpineCor': 20 papers have been found, most of them investigating a soft brace, for 'scoliosis' and 'TriaC': 7 papers displayed, for 'scoliosis' and 'St. Etienne brace': one paper displayed but not meeting the topic and for 'scoliosis' and 'Olympe': No paper displayed. Four papers found on the SpineCor™ were of prospective controlled or prospective randomized design. These papers partly presented contradictory results. Two papers were on soft Boston braces used in patients with neuromuscular scoliosis.

DISCUSSION

There is a small but consistent body of evidence for the use of soft braces in the treatment of scoliosis. Contradictory results have been published for samples treated during the pubertal growth spurt. In a biomechanical analysis the reason for the lack of effectiveness during this period has been elaborated. Improved materials and the implementation of corrective movements respecting also the sagittal correction of the scoliotic spine will hopefully contribute to an improvement of the results achievable.

CONCLUSIONS

The treatment of scoliosis using soft braces is supported by some papers providing a small body of evidence. During the growth spurt the use of soft braces is discussed contradictory. There is insufficient evidence to draw definite conclusions about effectiveness and safety of the intervention.

2011 SOSORT guidelines: Orthopaedic and Rehabilitation treatment of idiopathic scoliosis during growth

BACKGROUND

The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT), that produced its first Guidelines in 2005, felt the need to revise them and increase their scientific quality. The aim is to offer to all professionals and their patients an evidence-based updated review of the actual evidence on conservative treatment of idiopathic scoliosis (CTIS).

METHODS

All types of professionals (specialty physicians, and allied health professionals) engaged in CTIS have been involved together with a methodologist and a patient representative. A review of all the relevant literature and of the existing Guidelines have been performed. Documents, recommendations, and practical approach flow charts have been developed according to a Delphi procedure. A methodological and practical review has been made, and a final Consensus Session was held during the 2011 Barcelona SOSORT Meeting.

RESULTS

The contents of the document are: methodology; generalities on idiopathic scoliosis; approach to CTIS in different patients, with practical flow-charts; literature review and recommendations on assessment, bracing, physiotherapy, Physiotherapeutic Specific Exercises (PSE) and other CTIS. Sixty-five recommendations have been given, divided in the following topics: Bracing (20 recommendations), PSE to prevent scoliosis progression during growth (8), PSE during brace treatment and surgical therapy (5), Other conservative treatments (3), Respiratory function and exercises (3), Sports activities (6), Assessment (20). No recommendations reached a Strength of Evidence level I; 2 were level II; 7 level III; and 20 level IV; through the Consensus procedure 26 reached level V and 10 level VI. The Strength of Recommendations was Grade A for 13, B for 49 and C for 3; none had grade D.

CONCLUSION

These Guidelines have been a big effort of SOSORT to paint the actual situation of CTIS, starting from the evidence, and filling all the gray areas using a scientific method. According to results, it is possible to understand the lack of research in general on CTIS. SOSORT invites researchers to join, and clinicians to develop good research strategies to allow in the future to support or refute these recommendations according to new and stronger evidence.

Brace technology thematic series - The Sforzesco and Sibilla braces, and the SPoRT (Symmetric, Patient oriented, Rigid, Three-dimensional, active) concept

BACKGROUND

Bracing is an effective strategy for scoliosis treatment, but there is no consensus on the best type of brace, nor on the way in which it should act on the spine to achieve good correction. The aim of this paper is to present the family of SPoRT (Symmetric, Patient-oriented, Rigid, Three-dimensional, active) braces: Sforzesco (the first introduced), Sibilla and Lapadula.

METHODS

The Sforzesco brace was developed following specific principles of correction. Due to its overall symmetry, the brace provides space over pathological depressions and pushes over elevations. Correction is reached through construction of the envelope, pushes, escapes, stops, and drivers. The real novelty is the drivers, introduced for the first time with the Sforzesco brace; they allow to achieve the main action of the brace: a three-dimensional elongation pushing the spine in a down-up direction.Brace prescription is made plane by plane: frontal (on the "slopes", another novelty of this concept, i.e. the laterally flexed sections of the spine), horizontal, and sagittal. The brace is built modelling the trunk shape obtained either by a plaster cast mould or by CAD-CAM construction. Brace checking is essential, since SPoRT braces are adjustable and customisable according to each individual curve pattern.Treatment time and duration is individually tailored (18-23 hours per day until Risser 3, then gradual reduction). SEAS (Scientific Exercises Approach to Scoliosis) exercises are a key factor to achieve success.

RESULTS

The Sforzesco brace has shown to be more effective than the Lyon brace (matched case/control), equally effective as the Risser plaster cast (prospective cohort with retrospective controls), more effective than the Risser cast + Lyon brace in treating curves over 45 degrees Cobb (prospective cohort), and is able to improve aesthetic appearance (prospective cohort).

CONCLUSIONS

The SPoRT concept of bracing (three-dimensional elongation pushing in a down-up direction) is different from the other corrective systems: 3-point, traction, postural, and movement-based. The Sforzesco brace, being comparable to casting, may be the best brace for the worst cases.

Beyond the classic correction system: a numerical nonrigid approach to the scoliosis brace

BACKGROUND CONTEXT

Adolescent idiopathic scoliosis (AIS) causes a spine and rib cage three-dimensional (3D) deformity previously treated by bracing. Whatever the manufacturing process, this rigid system acts biomechanically on the patient through the "three-point bending" mechanical principle. It applies corrective forces to a limited area and acts especially in the frontal plane. It seemed to us that a nonrigid system, called "Cbrace," with 3D action allowing distribution of forces could increase compliance and provide better long-term correction prospects.

PURPOSE

The aim of this study was to design a nonrigid brace by numerically testing in a finite-element model developed here.

STUDY DESIGN

A finite-element model has been developed to simulate brace effect on AIS right thoracic deformation of a 10-year-old patient.

METHODS

A two-step method was needed; first, the reliability of our model is evaluated, and then, the ability to use distributed forces to correct scoliosis deformation is tested. To obtain a 3D correction, several treatments are experimented, leading to a comparison test between the best combination to the "three-point bending" principle.

RESULTS

The numerical model developed here shows good qualitative answers for the treatment of brace forces. The first results demonstrate numerically that distributed forces may be of interest in brace treatment design. Overall force of 40 N above cartilage of the last nonfloating ribs associated to two posterior asymmetrical areas appears to be the best way to correct scoliosis deformation with nonrigid action.

CONCLUSION

The results show numerical efficacy of distributed forces to correct spinal deformities and raises the prospect that a new numerical brace, called "Cbrace," could be a starting point in the search for a nonrigid system.

A comparison of thoracolumbosacral orthoses and SpineCor treatment of adolescent idiopathic scoliosis patients using the Scoliosis Research Society standardized criteria

BACKGROUND

SpineCor is a relatively new bracing system that uses dynamic bracing concepts in the treatment of adolescent idiopathic scoliosis (AIS). Limited data are available regarding its effectiveness. This study compared treatment outcomes of 2 groups of AIS patients treated via either a conventional rigid thoracolumbosacral orthoses (TLSO) or a SpineCor nonrigid orthosis.

METHODS

We identified 2 scoliosis patient cohorts: 35 patients treated with a TLSO and 32 patients treated with a SpineCor orthosis. All patients included in these groups conformed with the Scoliosis Research Society (SRS) standardized criteria for AIS bracing: (1) Risser < or =2, (2) curve magnitude 25 to 40 degrees, (3) age > or =10 years. Outcomes were SRS standardized with failure being defined as curve progression > or =6 degrees, or ever exceeding 45 degrees, or having surgery recommended before skeletal maturity. All patients were followed through the completion of brace treatment or attainment of other treatment end points. The Yates corrected chi test and unpaired t test were used for data analysis.

RESULTS

The 35 patients (32 girls, 3 boys) in the TLSO group had an average age of 13 years (range: 11.1-16.8) and an average primary curve magnitude of 33 degrees (range: 25-40 degrees). Follow-up averaged 2 years (range: 8-61 m) from the beginning of brace treatment. The 32 patients (28 girls, 4 boys) in the SpineCor group had an average age of 13 years (range: 11-15.2) and an average primary curve magnitude of 31 degrees (range: 25-40 degrees). Follow-up for this group averaged 2 years and 6 months (range: 13-73 mo) from the beginning of brace treatment. No significant difference (P=0.75) was found using the more strict outcome measure (< or =5-degree curve progression) as the success rates were 60% (21/35) for TLSO and 53% (17/32) for SpineCor. Similarly, no significant difference (P=0.62) was found using the more liberal outcome measure (never reached 45 degrees) as the success rates were 80% (28/35) for TLSO and 72% (23/32) for SpineCor.

CONCLUSIONS

We were unable to identify any significant differences in brace treatment outcomes when comparing TLSO and SpineCor treated patients.

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.

Adolescent idiopathic scoliosis

Adolescent idiopathic scoliosis (AIS) affects 1-3% of children in the at-risk population of those aged 10-16 years. The aetiopathogensis of this disorder remains unknown, with misinformation about its natural history. Non-surgical treatments are aimed to reduce the number of operations by preventing curve progression. Although bracing and physiotherapy are common treatments in much of the world, their effectiveness has never been rigorously assessed. Technological advances have much improved the ability of surgeons to safely correct the deformity while maintaining sagittal and coronal balance. However, we do not have long-term results of these changing surgical treatments. Much has yet to be learned about the general health, quality of life, and self-image of both treated and untreated patients with AIS.

Clinical effect of continuous corrective force delivery in the non-operative treatment of idiopathic scoliosis: a prospective cohort study of the TriaC-brace

A prospective cohort study of skeletally immature idiopathic scoliotic patients treated with the TriaC brace. To determine if the TriaC brace is effective in preventing curve progression in immature adolescent idiopathic scoliotic patients with a very high risk of curve progression based on reported natural history data. The aim of the newly introduced TriaC brace is to reverse the pathologic transverse force pattern by externally applied and continuously present orthotic forces. In the frontal plane the force system used in the TriaC brace is similar to the force system of the conventional braces. However, in the sagittal plane the force system acts only on the thoracic region. In addition, the brace allows upper trunk flexibility without affecting the corrective forces during body motion. In a preliminary study it is demonstrated that the brace prevents further progression of both the Cobb angle and axial rotation in idiopathic scoliosis. Skeletally immature patients with idiopathic scoliosis with curves between 20 and 40° were studied prospectively. Skeletally immature was defined as a Risser sign 0 or 1 for both boys and girls, or pre-menarche or less than 1-year post-menarche for girls. Curves of less than 30° had to have documented progression before entry. The mean age of the patients at the start of treatment was 11.3 ± 3.1 years. All measurements were collected by a single observer, and all patients were followed up to skeletal maturity. Treatment was complete for all participants when they had reached Risser sign 4 and did not show any further growth at length measurements. This was at a mean age of 15.6 ± 1.1 years, with a mean follow-up of 1.6 years post bracing. In our study a successful outcome was obtained in 76% of patients treated with the TriaC brace. Comparing our data to literature data on natural history of a similar cohort shows that the TriaC brace significantly alters the predicted natural history. The current study demonstrates that treatment with the TriaC brace reduces the scoliosis, and that the achieved correction is maintained in some degree after skeletal maturity is reached and bracing is discontinued. It also prevents further progression of the Cobb angle in idiopathic scoliosis. The new brace does not differ from the conventional braces as far as maintaining the deformity is concerned.

The use of dynamic Lycra orthosis in the treatment of scoliosis: a case study

Treatment of scoliosis has been under discussion in relation to surgical intervention since the Boston brace was presented by Hall in 1976 (Hall et al. 1976; Watts et al. 1977). The effects of rigid bracing on thoracic skeletal integrity and the possible deformation of ribs due to the high localized pressure due to prolonged wear (Biorthex 1999; Coillard et al. 1999) have been highlighted. The lack of compliance (Houghton et al. 1987) has encouraged clinicians to investigate other options for non-surgical treatment. The Spinecor and Triac bracing systems have been developed as a result of this research; however, both of these orthoses had been designed with idiopathic scoliosis in mind. Little research has been done into the effects of bracing on the neuropathic curve. The use of dynamic Lycra garments in the treatment of neurological scoliosis offers the advantage of deformity correction without the bulk and discomfort of rigid braces. Recent clinical experience has shown that the Lycra suits have a positive effect in the treatment of scoliosis. This study discusses the treatment of a child presenting with a spinal tumour and although not truly of neurological presentation indicates that the garment can be used for the different scoliotic presentations.

Effects of lateral trunk support on scoliotic spinal alignment in persons with spinal cord injury: a radiographic study

OBJECTIVE

To develop a radiographic method for measuring the spinal alignment of a person in a seated position and with which to investigate the effects of lateral trunk supports (LTS) in special seating on the frontal and sagittal spinal alignment in persons with spinal cord injury (SCI).

DESIGN

Before-after trial.

SETTING

University-based research laboratory.

PARTICIPANTS

Ten men and 7 women who had SCI with scoliosis (age, 35.4+/-9.4y; injury level, C5-T11) voluntarily participated.

INTERVENTION

An adjustable seating system with LTS.

MAIN OUTCOME MEASURES

Radiographs of the spine in the anteroposterior (AP) and lateral directions were taken while sitting on an adjustable seating system without and with LTS. The Cobb angles and scoliotic indices based on the AP radiographic images and the angles of the thoracic and lumbar spine based on lateral were calculated. The relative change in angle (RCA) with LTS in terms of the percentage reduction of the Cobb angles was also obtained.

RESULTS

The Cobb angles and scoliotic indices while sitting with LTS were significantly smaller than those without, the mean difference of Cobb angles +/- standard error (SE) being 9.12 degrees +/-1.64 degrees (P<.001) and those for the scoliotic indices being .09+/-.04 (P=.027). The mean RCA +/- SE was 26.16%+/-4.23%. The RCA correlated weakly with the original Cobb angles (r=-.347, P=.172). The LTS caused a significant reduction in the lumbar angles (P<.001), but no significant effects on the thoracic angles were found.

CONCLUSIONS

The radiographic findings demonstrate improved scoliotic spinal alignment in the frontal plane and reduced lumbar angles in the sagittal plane in persons with SCI when seated in a special seat and using LTS.

The experience of brace treatment in children/adolescents with scoliosis

BACKGROUND

Idiopathic scoliosis is a chronic illness with several different braces used for its treatment. Brace treatment during childhood/adolescence can produce stress. There are studies supporting that it can decrease body-image perception while other studies support that it has no such effect.The purpose of this study was to explore the experience of brace treatment in children/adolescents with scoliosis. The aim was to investigate which feelings are created by the bracing experience in children/adolescents with scoliosis and what are the children/adolescents' with scoliosis opinions of the support provided to them by health-care professionals and by their families.

METHODS

We conducted interviews with the help of a semi-structured interview guide in order to address the topic of the experience of brace treatment. A convenient sample of twelve children and adolescents with scoliosis was selected from patients attending follow-up appointments at the Outpatient Scoliosis Clinics of two Greek hospitals. The data was analysed using the method of content analysis.

RESULTS

Patients in the sample were 10-16 years old and they were mainly females (71%). Almost all of the participants reported having to deal with stress, denial, fear, anger, and shame. They were satisfied with the information they received regarding their condition and therapy. However, the information was not accompanied by support from the health care professionals. They reported that they were receiving support mainly from their families, friends, and classmates.

CONCLUSION

The present study is contributing to the development of a better understanding of significant issues related to the experience of bracing therapy. It is clear that scoliosis children/adolescents have to be provided with support during the long period of bracing. It is apparent that those children/adolescents have unmet needs for care and health professionals and policy makers should try to find a way to address those needs.

Why do we treat adolescent idiopathic scoliosis? What we want to obtain and to avoid for our patients. SOSORT 2005 Consensus paper

Background

Medicine is a scientific art: once science is not clear, choices are made according to individual and collective beliefs that should be better understood. This is particularly true in a field like adolescent idiopathic scoliosis, where currently does not exist definitive scientific evidence on the efficacy either of conservative or of surgical treatments.

Aim of the study

To verify the philosophical choices on the final outcome of a group of people believing and engaged in a conservative treatment of idiopathic scoliosis.

Methods

We performed a multifaceted study that included a bibliometric analysis, a questionnaire, and a careful Consensus reaching procedure between experts in the conservative treatment of scoliosis (SOSORT members).

Results

The Consensus reaching procedure has shown to be useful: answers changed in a statistically significant way, and 9 new outcome criteria were included. The most important final outcomes were considered Aesthetics (100%), Quality of life and Disability (more than 90%), while more than 80% of preferences went to Back Pain, Psychological well-being, Progression in adulthood, Breathing function, Scoliosis Cobb degrees (radiographic lateral flexion), Needs of further treatments in adulthood.

Discussion

In the literature prevail outcome criteria driven by the contingent treatment needs or the possibility to have measurement systems (even if it seems that usual clinical and radiographic methods are given much more importance than more complex Disability or Quality of Life instruments). SOSORT members give importance to a wide range of outcome criteria, in which clinical and radiographic issues have the lowest importance.

Conclusion

We treat our patients for what they need for their future (Breathing function, Needs of further treatments in adulthood, Progression in adulthood), and their present too (Aesthetics, Disability, Quality of life). Technical matters, such as rib hump or radiographic lateral alignment and rotation, but not lateral flexion, are secondary outcomes and only instrumental to previously reported primary outcomes. We advocate a multidimensional, comprehensive evaluation of scoliosis patients, to gather all necessary data for a complete therapeutic approach, that goes beyond x-rays to reach the person and the family.

Critical review on non-operative management of adolescent idiopathic scoliosis

There are a number of different non-operative interventions which aim to control moderate adolescent idiopathic scoliosis (AIS) from progression. Clinicians may find difficulties in the selection of appropriate interventions for AIS. A comprehensive literature review was carried out to study all contemporary non-operative interventions, it was noted that rigid spinal orthoses apparently give more curve control; however, it would compromise the patient's quality of life via those inevitable factors--physical constraint, poor acceptance and psychological disturbance. There is a trend to develop more effective, acceptable and user-friendly interventions. Under such an aspiration, the theories and clinical evidence of different interventions should be developed along the clinical pathway of early intervention with reliable indicators/predictors, patient's active participation, dynamic control mechanism, holistic psychological and psychosocial considerations, and effective and long-lasting outcome.