A new scoliosis brace padding method based on trunk asymmetry for scoliosis treatment.

BACKGROUND: Pressure pads are used with scoliosis braces to adjust the magnitude and location of corrective forces that mechanically support the torso to correct the spine deformity. In the conventional brace (C.B.) design approaches, the location and shape of pads are determined based on the visual assessment of the clinician. The accuracy of this approach could be improved because it is limited to the clinician's expertise. The present study aimed to develop a new brace (N.B.) padding method based on trunk asymmetry for adolescents with idiopathic scoliosis and compare the efficacy of the developed method with C.B. in improving the Cobb angle and body posture symmetricity. METHODS: The trunk surface geometry was scanned using a 3-dimensional scanner. The best plane of symmetry was determined, and the original trunk was reflected in the plane of symmetry, creating the reflected trunk. The difference between the reflected and original trunks was computed and color-coded using deviation contour maps. The boundary of deformed regions, with a minimum of 6-mm deviation contour maps, was identified as the trim lines for brace pads. Eight participants were recruited and divided into conventional and new padding groups. The variation of Cobb angle and torso asymmetry parameters, including the trunk rotation and back surface rotation, as well as the brace satisfaction and trunk appearance perception of the 2 groups, were compared after 3 months of treatment. RESULTS: Cobb angle improved equally in the N.B. and C.B. groups. However, back surface rotation improved in the N.B. group (+49.6%) and worsened in the C.B. group (-6.8%). The mean trunk rotation was improved by 30% in the N.B. and further exacerbated by -2.2% in the C.B. group. The brace satisfaction and trunk appearance perception scores were higher in the N.B. than in the C.B. group, however not statistically significant. CONCLUSIONS: The present study showed that the proposed brace padding system improved the trunk appearance without negatively affecting the Cobb angle correction.

Coronal deformity angular ratio as a predictive factor for in-brace curve correction and long-term outcome of brace treatment in adolescents with idiopathic scoliosis.

PURPOSE: To investigate the relationship between coronal deformity angular ratio (C-DAR) and in-brace correction (IBC) and their role in predicting the long-term bracing outcome in adolescents with idiopathic scoliosis (AIS). METHODS: In this retrospective multicenter study, the patient's sex, age, primary curve Cobb angle (at initiation of brace treatment, best in-brace, before spinal fusion, and final follow-up), curve pattern, duration of brace treatment, brace type, and C-DAR at initiation of bracing were recorded. The C-DAR values were classified as < 5, 5 ≤ to ≤ 6, and > 6. The IBC values were classified as ≥ 50%, 40% ≤ to ≤ 49%, and < 40%. We classified the patients into two groups of success and failure according to the Cobb angle at the final follow-up. RESULTS: A total of 164 patients (25 boys and 119 girls) were included. Bracing was successful in 60.4% of them. There was a significant association between C-DAR and bracing outcome (p < 0.0001). 63.9% of the patients with C-DAR < 5 had an IBC ≥ 50%. However, when C-DAR was 5 ≤ to ≤ 6 and > 6, 29.2% and 16.9% of the patients had an IBC of ≥ 50%, respectively. For patients with IBC ≥ 50%, the success rate of bracing was 89.2%. Results of logistic regression analysis revealed that the strongest predictor for brace treatment outcome was the C-DAR, with an odds ratio of 2.11. CONCLUSION: C-DAR may be used as a predictive factor for the long-term outcome of brace treatment in AIS. LEVEL OF EVIDENCE: IV.

Validity and test-retest reliability of photogrammetry in adolescents with hyperkyphosis.

BACKGROUND: A variety of noninvasive instruments have been introduced in the literature to assess thoracic curvature, although the psychometric properties of many of these instruments have not been satisfactory. Photogrammetry is a safe, accessible, and reliable technique. However, its validity in adolescents with hyperkyphosis has not yet been investigated. OBJECTIVES: To investigate the validity and test-retest reliability of photogrammetry in the measurement of thoracic kyphosis among adolescents with hyperkyphosis. METHODS: Fifty adolescents with hyperkyphosis participated in this study. The kyphosis angle was measured using radiography and photogrammetry. A two-way random model of the intraclass correlation coefficient (ICC2,3) was used to estimate relative reliability. Absolute reliability was assessed by calculating the standard error of the measurements (SEM) and the minimal detectable change (MDC). Pearson's correlation coefficient was calculated to evaluate the validity of the photogrammetry technique. Bland-Altman plots were plotted to determine the agreement between the angles measured by radiography and photogrammetry. RESULTS: There was a strong correlation between the values obtained from the photogrammetry technique and those from the radiography method (r = 0.94). The 95% limits of agreement indicated that the photogrammetric measurements of thoracic kyphosis angle might range from 2.4 degrees greater to 10.2 degrees lower than the Cobb radiographic angle. Photogrammetric measurements of thoracic kyphosis showed excellent test-retest reliability (ICC = 0.97; SEM = 1.67; MDC = 4.62). CONCLUSION: High reliability of photogrammetry technique and its strong correlation with radiographic Cobb angle support the application of this technique for the measurement of thoracic kyphosis in clinical practice.

School Time Experiences of Adolescents with Spinal Deformities during Brace Treatment: A Qualitative Study.

Background: Adolescent idiopathic scoliosis (AIS) and Scheuermann kyphosis (SK) are the most common spinal deformities in adolescents aged 10 to 16. During the past 50 years, brace treatment has been suggested as the most common nonsurgical treatment for AIS and SK. The brace efficacy strongly depends on wearing time. Also, previous studies indicated that patients with spinal deformities undergoing brace treatment experience deformity-related emotional distress. This study aimed to comprehend the experiences of braces-treated adolescents during school time using a qualitative approach. Methods: This descriptive qualitative research was used with an interpretative framework and enlisted the help of children with spinal deformities who have been prescribed "brace wearing." This study was conducted using semi-structured, face-to-face, in-depth interviews and phone conversations from September 2020 to May 2021. Additionally, content analysis was employed. Results: A total of 64 participants were interviewed, including 32 adolescents with spinal deformities under brace treatment and their parents (27 mothers, and 5 fathers). Three main categories-concerns, actual problems, received support-6 subcategories, and 278 codes were discovered following data analysis about participants' experiences. Conclusion: Special school-based programs are required for such tortious conditions. This qualitative study motivates a better understanding of these special children and their hidden problems and suggests developing a supportive protocol.

The Effect of Brace Treatment on Large Curves of 40° to 55° in Adolescents With Idiopathic Scoliosis Who Have Avoided Surgery: A Retrospective Cohort Study.

OBJECTIVE: To evaluate the effect of Milwaukee brace treatment on adolescents with idiopathic scoliosis (AIS) with large curves (40° to 55°) who refuse to do surgery. METHODS: In this retrospective cohort study, we gathered the clinical records of all adolescents with AIS with an initial curve of 40° to 55°. They had been referred to our center from December 1990 to January 2017. Although they had been advised to do surgery, they had all refused to do it. Their clinical data were recorded, such as sex, age, Risser sign, scoliosis, and kyphosis curve magnitude (at the beginning of brace treatment, weaning time, brace discontinuation, and minimum of 2 years after the treatment). Based on treatment success, the patients were divided into 2 groups: progressed and nonprogressed. RESULTS: Sixty patients with an average initial Cobb angle of 44.93° ± 4.86° were included. The curve progressed in 57%, stabilized in 25%, and improved in 18% of the patients. In the progressed group (34 patients), 31 patients had undergone surgery. There was no significant association between the age of beginning the brace treatment and the final Cobb angle of nonprogressed group (p > 0.05). However, in-brace correction and initial Risser sign had a significant correlation with curve magnitude at the final follow-up (p < 0.05). CONCLUSION: Brace treatment seems to be effective in controlling the further curve progression in AIS with 40° and 55° curves. Our results can help physicians make sound decisions about the patients with larger curves who refuse to do surgery.

Infantile Idiopathic Scoliosis: Outcomes of Brace Treatment until Skeletal Maturity or Spinal Fusion.

BACKGROUND: Serial casting under general anesthesia, which is considered as a gold standard of treatment for patients with infantile idiopathic scoliosis (IIS), can lead to significant negative neurodevelopmental effects. Therefore, the appropriateness of this type of treatment is controversial. Brace treatment is one alternative method of treatment for IIS patients. However, long-term studies have not yet verified its effectiveness. Thus, the present study aimed to evaluate the effectiveness of brace treatment in patients with IIS until skeletal maturity or spinal fusion. METHODS: The medical records of all IIS patients with the referral age of 0-3 years who received brace treatment from June 1986 to November 2013 were reviewed. Those patients with pre-brace Cobb angle > 20° were included and followed up to skeletal maturity or the time of spinal fusion. The Cobb angle was recorded at the time of diagnosis before the initiation of bracing, weaning time, brace discontinuation, and final follow-up. In addition, the maximum in-brace curve correction was measured. RESULTS: Out of 87 patients with IIS, a total of 29 cases (19 males and 10 females) with the average curve magnitude of 35.62° at the time of diagnosis were included in the study. The average best in-brace correction was 57.32% for successfully treated patients and 36.97% for progression/surgery patients. Based on the results, brace treatment failed for a total of 20 patients (69%), with a scoliosis curvature progress ≥ 45°. Of these patients, 12 cases (60%) reached spinal fusion. Finally, four patients (13%) in the surgery-treated group underwent surgery before the age of 10. CONCLUSION: The results revealed that bracing was successful for more than two-thirds of patients with IIS curves, preventing surgery before the age of 10.

The effects of bracing on sagittal spinopelvic parameters and Cobb angle in adolescents with idiopathic scoliosis: A before-after clinical study.

OBJECTIVES: This study aims to evaluate the effects of bracing on the Cobb angle and sagittal spinopelvic parameters in adolescent idiopathic scoliosis (AIS) patients. PATIENTS AND METHODS: A total of 25 adolescents (2 males, 23 females; mean age 12.7±1.6; range, 10-15 years) with AIS who received bracing between January 2000 and June 2017 were retrospectively analyzed. The initial and final out-of-brace radiographs of 25 AIS patients were analyzed with regard to the spinopelvic parameters. The pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), Cobb angle, thoracic kyphosis (TK), and lumbar lordosis (LL) were measured. RESULTS: The mean age at the initiation of bracing was 12.7±1.6 years. The mean initial Cobb angle was 31.8°±5.9°. There were no statistically significant differences between the baseline and the final measurements of the PI, PT, and SS. However, there were statistically significant differences between the baseline and the final measurements of the TK, LL, and Cobb angle. A significant correlation was observed between the PI and Cobb angle and TK and between the LL and SS. CONCLUSION: Our study results show significant associations between the sagittal pelvic parameters and the spinal parameters during the brace treatment of adolescents with idiopathic scoliosis.

Success Rate of Brace Treatment for Juvenile-Onset Idiopathic Scoliosis up to Skeletal Maturity.

BACKGROUND: Natural history studies have reported that the progression rate of juvenile idiopathic scoliosis (JIS) curves larger than 20° is high and tends to progress. The aim of this study was to investigate the outcome of bracing on JIS and to determine the prognostic factors on the success rate of brace treatment. METHODS: From March 1985 to February 2015, the clinical data of all JIS patients with referral age from 4 to 10 years who received brace treatment were reviewed. Those patients with a prebrace Cobb angle >20° and a Risser sign of 0 to 2 were included and followed up a minimum of 2 years after discontinuation of the brace or time of spinal fusion. The Cobb angle was recorded at the time of diagnosis, before initiation of bracing, weaning time, brace discontinuation, and final follow-up. RESULTS: From 297 patients with JIS, a total of 75 cases (18 boys, 57 girls) with an average curve magnitude of 31.9° at the time of diagnosis met the inclusion criteria of the study. For successfully treated patients, the average best in-brace correction was 55% for Lenke I curves, 59% for Lenke II curves, 41% for Lenke III curves, and 62% for Lenke V curves. For a total of 27 patients (36%), the brace treatment failed. Of these, 21 patients (78%) reached spinal fusion, and curves of 6 patients (22%) increased to ≥50°. The progression rate was highest in patients with Lenke type III curves (67%), and also in those with a curve magnitude of ≥46° (94%). CONCLUSIONS: Brace treatment is an effective strategy for controlling the curve progression and avoiding spinal fusion in JIS. LEVEL OF EVIDENCE: 4.

Objective Monitoring of Brace Wearing Time in Adolescents with Scheuermann's Kyphosis.

STUDY DESIGN: This was a prospective cohort study. PURPOSE: This study aimed to evaluate the potential differences between the objective and subjective bracing compliances of adolescents with Scheuermann's kyphosis. OVERVIEW OF LITERATURE: Bracing is a well-documented intervention for managing adolescents with progressive thoracic Scheuermann's kyphosis, and the brace should be worn 23 hours every day. Most research studies that have investigated the efficacy of bracing have assumed that the patients wore the braces as advised or that the bracing time was measured subjectively. This may be one of the reasons for the conflicting reports regarding the efficacy of bracing. METHODS: Nineteen volunteers (11 girls and 7 boys, 12.89±1.77 years) who were prescribed Milwaukee braces for Scheuermann's kyphosis were enrolled. Each brace was equipped with a miniature temperature logger to record the actual brace wearing time over a period of 3 weeks. The patients and their families were unaware of the mounted sensor. Each participants and/or parent was provided with a questionnaire to record the number of hours for which the brace was worn each day. In addition, the therapist asked each patient and/or his/her parent about the average number of hours that the brace was worn. RESULTS: The compliance rates measured using the temperature logger (16.00±4.90 hours daily) were significantly lower than those reported in the questionnaires (19.52±6.04 hours daily, p<0.001) and the verbal responses (20.21±6.05 hours daily, p<0.001). Moreover, there was no correlation of age, sex, and body mass index with brace compliance. CONCLUSIONS: The braces were worn less often than reported by the patients and/or their parents. Therefore, objective compliance assessments of adolescents with Scheuermann's kyphosis in a brace are recommended for future studies.

Effect of exercise on static balance and Cobb angle during the weaning phase of brace management in idiopathic scoliosis and hyperkyphosis: A preliminary study.

BACKGROUND: Exercises are usually prescribed in association with orthotic intervention for management of idiopathic scoliosis, however the role of these exercises on the efficacy of brace and/or balance is not clear yet. OBJECTIVES: To investigate the role of exercise (the Blount and Moe protocol) on static balance and Cobb angle changes in adolescents with spinal deformities during weaning from brace. METHODS: Seventeen brace users were allocated into 3 groups (good, moderate, and weak), according to their exercise quality and quantity static balance was evaluated on 4 conditions (standing on a platform/foam; with/without brace) using a force platform. Center of pressure displacement parameters were compared among the 3 groups. The mean Cobb angles of scoliosis and kyphosis at the beginning of brace use and at the start of the weaning phase were compared in general and among the 3 analogous groups. RESULTS: No significant difference was found in the static balance parameters and also in Cobb angles among the 3 groups. However, scoliosis and kyphosis Cobb angles were improved significantly as a result of using the brace (p< 0.01). CONCLUSIONS: The exercise quantity and quality in association with bracing, up to the weaning phase, has no effect on static balance and changes in scoliosis and kyphosis, but the curvature of scoliosis and kyphosis is reduced after wearing a brace.

The intra- and inter-observer reliability of interface pressure measurements of the Milwaukee brace in adolescents with hyperkyphosis.

BACKGROUND: There is a lack of evidence in reliability of the modified sphygmomanometer to measure the brace-interface pad pressure in adolescents with Scheuermann's kyphosis (SK). OBJECTIVES: To evaluate the intra- and inter-observer reliability of modified sphygmomanometer for measuring interface pad pressure in the Milwaukee brace. METHODS: Two observers measured the pressure of the shoulder and kyphosis pads in Milwaukee brace on 33 adolescents with SK with an average age of 14.67 ± 1.72 years and Cobb angle 64.48∘± 7.53∘. All measurements were obtained in one day. The measurements were done in the inhalation and exhalation of tidal breathing during standing and sitting positions. The intraclass correlation coefficient (ICC), 95% confidence interval (CI), and linear mixed model ANOVA effects were calculated. RESULTS: The intra-observer reliability varied from a good ICC of 0.81 (0.66-0.90) to an excellent of 0.97 (0.95-0.98). The inter-observer reliability also varied from a good ICC of 0.82 (0.67-0.91) to an excellent of 0.96 (0.93-0.98). The linear mixed model ANOVA analysis showed that the rater, position, and breathing had a significant effect on the pad pressure measurements. CONCLUSIONS: The modified sphygmomanometer is a reliable tool to measure the pad pressure of the Milwaukee brace for adolescents with SK.

Effect of Group Exercising and Adjusting the Brace at Shorter Intervals on Cobb Angle and Quality of Life of Patients With Idiopathic Scoliosis.

OBJECTIVE: The aim of the study was to evaluate the effect of group exercise with brace adjustment at shorter intervals than used in routine practice in late-onset idiopathic scoliosis patients. DESIGN: This was a quasi-experimental study. Thirty patients with progressive scoliosis curves of 15-50 degrees and a prescription for a brace were divided into experimental and control groups, both of which participated in an 11-wk treatment program. Those in the experimental group underwent brace adjustment twice per week and performed group exercise, whereas those in the control group received a routine protocol. The quality of life and Cobb angle of patients in both groups were evaluated based on baseline and final results of the 22-item Scoliosis Research Society questionnaire and primary and secondary radiographs. RESULTS: In the experimental group, the improvement in Cobb angle and patient satisfaction was greater than that in the control group (P < 0.05). Moreover, in patients with Cobb angles of less than 30 degrees, the self-image and satisfaction domains and the total scores of patients in the experimental group were significantly different from those in the control group at the final assessment (P < 0.05). CONCLUSIONS: Brace adjustment at shorter intervals combined with group exercise increases patient satisfaction and reduces scoliosis Cobb angles.

Measurement of Milwaukee Brace Pad Pressure in Adolescent Round Back Deformity Treatment.

STUDY DESIGN: In this prospective study, we measured the pad pressures of the Milwaukee brace in adolescent hyperkyphosis treatment. PURPOSE: We evaluated the skin-brace interface forces exerted by the main pads of the Milwaukee brace. OVERVIEW OF LITERATURE: A fundamental factor associated with brace effectiveness in spinal deformity is pad force adjustment. However, few studies have evaluated the in-brace force magnitude and its effect on curve correction. METHODS: Interface forces at four pads of the Milwaukee brace were measured in 73 patients withround back deformity (mean age, 14.04±1.97 years [range, 10-18]; mean initial Cobb angle,67.70°±9.23° [range, 50°-86°]). We used a modified aneroid sphygmomanometer to measure the shoulder and kyphosis pad pressures. Each patient underwent measurement in the standing and sitting positions during inhalation/exhalation. RESULTS: The mean pad pressures were significantly higher in the standing than in thesitting position, and significantly higher pressures were observed during inhalation compared toexhalation (p=0.001).There were no statistically significant differences between right and left shoulder pad pressures (p>0.05); however, the pressure differences between the right and left kyphosis pads were statistically significant (p<0.05). In a comparison of corrective forces with bracing for less or more than 6 months, corrective force was larger with bracing for less than 6 months (p=0.02). In the standing position, there were no statistically significant correlations between pad pressures and kyphosis curve correction. CONCLUSIONS: In the sitting position, there was a trend toward lower forces at the skin-brace interface; therefore, brace adjustment in the standing position may be useful and more effective. There was no significant correlation between the magnitude of the pad pressures and the degree of in-brace curve correction.

Treatment stability of Milwaukee brace in idiopathic hyperkyphosis.

BACKGROUND: The Milwaukee brace is an efficient method for correcting hyperkyphosis before skeletal maturity. However, loss of correction in long-term follow-up is inevitable. OBJECTIVES: To determine loss of correction and factors affecting the loss of correction. STUDY DESIGN: Retrospective study. METHODS: A total of 49 corrected patients by Milwaukee brace participated minimum 2 years after treatment completion. The participants were categorized into two groups based on their roentgenograms: Group 1 (n = 36) had kyphotic curves of 45° or less and Group 2 (n = 13) had kyphotic curves of more than 45°. RESULTS: The mean loss of corrections for Group 1 and Group 2 were 3.80° (ranges = 0°-13°) and 12.92° (ranges = 8°-22°), respectively. Group 1 showed no significant difference between the average hyperkyphosis of the patients for the part-time and full-time treatment duration (p = 0.02). By contrast, a significant difference was observed between the average hyperkyphosis of patients in Group 2 for the part-time and full-time treatment duration (p < 0.05). CONCLUSIONS: Patients with kyphosis of 60° or less who can save the correction in full-time orthotic treatment in part-time treatment may have the least loss of correction over time. CLINICAL RELEVANCE: As the orthotic treatment is a time-consuming method that needs the close collaboration of patient and treatment team, it is possible that clinicians predict the probable result of treatment and efficiency of orthotic treatment. Thus, a clinician can abandon orthotic treatment and refer the patient for an operation.

Results of Milwaukee and Boston braces with or without metal marker around pads in patients with idiopathic scoliosis.

Bracing is the non-operative treatment of choice for adolescent idiopathic scoliosis (AIS) and careful application of pads on apical segment of curve is very important for correction. Control of pads` appropriate site in brace is not easy by clinical evaluation. Therefore, we decided to compare results of braces which for better control of pads by radiographs, metal marker inserted around pads with those without metal marker. We evaluated 215 consecutive cases (182 female, 33 male) of AIS with 342 major curves from 1993 to 2003. Mean initial age was, 13.2 ± 1.8 years (9-16) and mean duration of follow-up was, 16.1 ± 16.4 months (0-114) that treated by 4 type of brace; 89 with type 1(Milwaukee with metal pads), 87 with type 2 (Milwaukee with simple pads), 17 with type 3 (Boston with metal pads) and 22 with type 4(Boston with simple pads). Cobb angle recorded at 5 stages (initial, best, wean, stop and final follow-up). Mean initial Cobb was 36.2°, at stop stage, 35.2° and reached 38° at final follow-up. Overall, 21.3% improved, 42.2% were the same and 36.5% failed. Failure for braces type 1 to 4 were, 40.5%, 34%, 38% and 24% at final follow-up. A total of 59 patients (27.4%) underwent spinal fusion that for brace type 1 to 4 , was, 33, 21, 2 and 3 patients respectively. From 16 cases with initial Cobb of 50°, at follow-up, 12 were ≥50° or had spinal fusion. Correction of lumbar (P=0.008) and main thoracic curves (P=0.002) was better by Boston than Milwaukee, however, In general difference between 4 types of braces was not significant and metal marker had no significant effect on results. Two important predictors of brace failure were, initial curve magnitude and brace type, but using metal marker around pads had no effect in results. It seems that bracing did not alter the natural history of scoliosis in early Risser stages with large magnitude of initial curves. Insertion of metal marker around pads is easy and cheap way that facilitate control of pad sites well, so, we recommend to use.