SOSORT

Educational Course

May 6, 2015

Katowice, Poland

Luke Stikeleather, CONational Scoliosis CenterFairfax, Virginia

Disclosure: For the purpose of this presentation, no financial

agreements exist between the presenter and any of the individuals who are affiliated with the braces or research studies being presented.

Some Content in this presentation was published

In “Bracing for scoliosis in 2014: state of the art”

Acknowledgements I express my gratitude to those who contributed to and

assisted in developing this presentation: Manuel Rigo, MD

Jean Claude de Mauroy, MD

Stefano Negrini, MD

Fabio Zaina, MD

Theodore Grivas, MD

Angelo Aulisa, MD

Jim Wynne, CPO

Michael Hawkins, DPT

Innovation

Innovative: introducing new ideas; original and creative in thinking (Oxford Dictionary)

For the conservative management of spinal deformities to progress, we must be innovative; not only in brace design, but in the framework we use to approach treatment

Recognition of Great Polish innovators

Nicolaus Copernicus (1473-1543)

Mathematician, astronomer, physician, classical scholar

Developed the model that earth is not the center of universe

Published the book De Revolutionibus orbium coelestium

which was a major contribution to the scientific revolution

Fryderyk Chopin (1810-1849)

Composer and virtuoso pianist during Romantic era

Renowned as one of the leading musicians of his era

Invented the concept of instrumental ballade , later

used by composers including Johannes Brahms & Franz Liszt

Recognition of other Polish innovators

Marie Sklodowska-Curie (1867-1934) Physicist and chemist; Pioneered research on radioactivity

Arguably the most famous female scientist

First woman to win a Nobel Prize

Only person with Nobel Prizes in two different sciences

Lech Walesa (1943-) Credited with changing the Polish political system

Founded Poland’s first independent trade union “Solidarity”

which facilitated the fall of the communist regime

Awarded Nobel Peace Prize in 1983 for human rights activism

Recognition of inspirational Polish innovators

Pope John Paul II (Karol Wojtyla) (1920-2005)

Youngest Pope elected since 1846; served for 26 years

Fluent in 10 languages; visited 129 countries (most of any Pope)

Has been made a Saint by the Catholic church

Helped end communist rule in Poland and across Europe

Significantly improved the Catholic Church's relations with Judaism, Islam, the Eastern Orthodox Church, and the Anglican Communion

University of Iowa, NIH Funded, 2007 - 2013 Principle Investigator: Stuart Weinstein, MD

Study Director: Lori Dolan, PhD

Purpose:

“To compare the risk of curve progression in adolescents with AIS who wear a brace versus those who do not and to determine whether there are reliable factors that can predict the usefulness of bracing for a particular individual with AIS.”

BrAIST Study:Bracing in Adolescent Idiopathic Scoliosis Trial

Bracing is effective in stopping or slowing the progression of curves

Correlation between bracing outcome and orthotist skill and competence

Highlights need for advancement in research, orthotist training, and brace design

BrAIST: Peripheral Findings

72% of all braced participants had a successful outcome (stabilized or improved curves were considered success) 75% of randomized participants had successful outcome

48% of all non-braced participants had successful outcome (45% of randomized participants)

A significant positive association between hours of brace wear and rate of success exists

Bracing significantly decreased the progression of high-risk curves to the threshold for surgery

BrAIST: Research Study Results

365 total braces reviewed in case reports:

• 208 Boston (+46 “Boston-like” braces)

• 26 Wilmington (+13 “Modified Wilmington” braces)

• 22 Rosenberger

• 26 Hospital For Sick Children design (Cheneau variation)

• 8 Minnesota

• 4 Mortensen technique design

• 1 LA Brace

• 11 unspecified designs

BrAIST Brace Types

Asymmetrical

Chêneau / Rigo-Chêneau

Progressive Action Short Brace

ART Brace

Thoracolumbar LordoticIntervention

ScoliOlogic Braces

LA Brace

Gomez

Strap-Based

SpineCor

Symmetrical

Milwaukee

Lyon

Boston

SPoRT

Types of OrthosesGroupings based on design

Nocturnal

Charleston

Providence

nBrace

Common Scoliosis Bracing Designs1. Milwaukee CTLSO2. Lyon Brace3. Chêneau Brace4. Boston Brace5. Progressive Action Short Brace (PASB)6. The SPoRT Brace7. ART Brace8. TLI brace9. ScoliOlogiC® Braces 10.L.A. Brace11. Gomez Orthotic Spine System 12.Charleston Bending Brace13.Providence TLSO14.nBrace

Milwaukee CTLSO Walter Blount, MD & Albert Schmidt, MD

Milwaukee, Wisconsin, 1945

Anterior & posterior metal bars

Pads & straps on bars direct pressure

Form-fitting leather girdle

Plastic neck ring

1975: Added thermoplastic LSO base

Still used today for kyphosis and high thoracic curves

Lyon Brace Created by Pierre Stagnara, MD Lyon, France, 1947

Modified by Allègre and Lecante (1958)

Father of modern day bracing concepts and designs

Utilizes Aluminum and plexidur (high rigidity material)

Symmetrical, anterior-opening, Adjustable with no collar

Two main phases of treatment:

• Plaster cast to stretch the deep ligaments before the Lyon brace

• Adjustable brace designed to accommodate patient’s growth

Lyon Brace

Indication: • AIS patients 11-15 years • treatment in younger patients is not indicated to

prevent tubular deformation of the thoraxDesign:

• 14 variations according to Lenke classification

Lyon Brace

Dr. Jacques Chêneau (Photo by Sanomed)

The Chêneau Brace Concept• Jacques Chêneau, MD initially designs

brace in 1960s and 1970s in France

• 1979: Dr. Chêneau publishes successes with novel brace design incorporating 3-D correction and regional derotation

• 1985 & 2004: Long-term follow up studies published demonstrating stable curve patterns

• Many design variations exist internationally

• Manuel Rigo, MD

• Developed in 1990s in Barcelona, Spain

Rigo-Chêneau Brace

• Asymmetrical, anterior-opening

• Custom fabricated from plaster cast or scan

• Elaborates on Chêneau’sregional derotation concepts with expansion spaces and three-dimensional correction principles

• Growing use by Rigo-educated orthotists in North America since 2004

Rigo-Chêneau Brace

• Curve patterns are categorized and respond consistently

• The categories provide a framework for brace fabrication

Rigo-Chêneau Brace

A corrected positive mould is created in order to provide highly selective pads and expansion rooms

Rigo-Chêneau BracePrinciples of Correction

A. Three-points systems in the frontal plane. Alignment inthe frontal plane

B. Regional derotation and pair of forces in the transversalplane for local derotation

C. Sagittal balance and physiological alignment

D. Breathing mechanics against the morphologicallordotization of the main thoracic spine

Rigo-Chêneau BracePrinciples of Correction

’

A. Frontal plane(alignment)

B. Transversal plane(derotation)

C. Sagittal balance

D. Breathing mechanics

3D Correction

Rigo-Chêneau Brace

A. Frontal plane (alignment)

B. Transversal plane (derotation)

C. Sagittal balance

D. Breathing mechanics

a

b

Regional Derotation

LUMBAR (RED)

a

b

Regional Derotation

THORACIC (YELLOW)

3D Correction

Rigo-Chêneau Brace

Boston Brace

John Hall, MD &

William Miller, CO

Developed in 1972 atBoston Children’s Hospital, Boston, Massachusetts

Symmetrical, Posterior opening

Prefabricated modules or custom fabricated from measure, scan, or cast

Most commonly used and copied scoliosis brace in North America

Approx. 4,000 (made by Boston Brace, Inc) fit annually in North America

Boston Brace

• Lumbar spine/pelvis positioned in flexion

• Pad pressure at the apex and below

• Active as well as passive correction

• Rotational force couples where possible

• Coordinated physical therapy program

• Team approach:

Boston Brace: Principles of Correction

•Patient/Family•Orthotist•Physical Therapist•Nurse•Physician

• Brace blueprint focuses attention on tilt of individual vertebrae, not Cobb angle

• Pad pressure at the apex and below

Boston Brace

• Completed Blue Print

• The Curve dictates the brace design

Boston Brace

• Posterior view of a typical Boston Thoracic Brace

Boston Brace

Progressive Action Short Brace (PASB)

• Developed by Dr. Lorenzo Aulisa

• Rome, Italy, 1976

• Institute of Orthopedics at the Catholic University of the Sacred Heart

• Treatment of lumbar/thoracolumbar curves

Progressive Action Short Brace (PASB)

• Asymmetrical, Anterior-opening

• Custom-made polypropylene brace from plaster mold

• Designed specifically for treatment of lumbar/thoracolumbar curves

Progressive Action Short Brace (PASB)Principles of Correction

Constrained dynamic of the spine

Inversion of the stress-loading distribution

Cast geometry

Deflexion DerotationTraction

Progressive Action Short Brace (PASB)

Two Phases of Treatment

Phase I: Plaster Cast Application of external actions

Progressive Action Short Brace (PASB)

Phase II: Brace Application The high upper margin of brace at concavity

prevents side bending toward concavity

The upper margin of brace at convexity ends just beneath apex, deflecting scoliotic curve during side bend toward convexity

Inferior margins reach pelvic/trochanteric region stabilizing the brace on pelvis

transverse profile of the superior brace consists of asymmetrical ellipses. This allows the spine to rotate towards the concave side only, providing continuous generation of derotation moments

S Symmetric

Po Patient-oriented

R Rigid

T Three-dimensional

The SPoRT ConceptSforzesco and Sibilla Braces

Developed by Stefano Negrini, MD with Gianfranco Marchini, CPO

Milan, Italy, 2004

Dr. Stefano Negrini

SPoRT Brace

Symmetric , Anterior-Opening

Sforzesco brace utilizes plastic of high rigidity

Brace rigidity replaces traditional plaster casting

Sibilla brace utilizes less rigid plastic than Sforzesco

Efficacy

Mechanical efficacy

Active brace

3D action

Versatility & adaptability

Teamwork

Compliance

Perfect body design

Minimal visibility

Maximum freedom in ADL

Individual responsibility

Cognitive-behavioural team approach

The SPoRT Concept

The SPoRT concept utilizes unique terminology to describe the mechanism of action . To learn more about the SPoRT brace, contact Stefano Negrini, MD or Gianfranco Marchini, CPO

The SPoRT ConceptPrinciples of Correction

• Definition of the main slope(s)

• Definition of the derotation pushes

• Waist correction

• Elevation of the hemi-thorax

• Pushes on the ribs

• Shoulders

• Sagittal construction(change in kyphosis/lordosis)

The SPoRT ConceptPrinciples of Correction

Construction (external shape)

Drivers (new concept of SPoRT braces)

Pushes: Lateral Distal convex, lateral proximal concave, posterior convex

Escapes: Superior-Anterior & Lateral Superior

ART Brace(New Lyon Brace)

A Asymmetric

R Rigid

T Torsion

Jean Claude de Mauroy, MD, 2013

Asymmetrical, anterior-opening

2 Variations (not based on Lenke classifications)

C Shape

S Shape

ART Brace:Principles of correction

Correction occurs in Frontal and Horizontal plane

Axial Elongation and global detorsion

Detorsion is carried out with a fixed sagittal plane

ART Brace

Mobility takes place in frontal expansions and in torsion opposite to the curve

2 Axilla and Pelvic adjustable “clamps”

TLI brace (Thoracolumbar Lordotic Intervention)

Developed in 2002 by

Dr. Piet van Loon

Symmetric, posterior opening

based on concept described by M. Jansen in 1913

hypothesis that both thoracolumbar kyphotic & scoliotic spinal deformities are due to a dislocation of the thoracolumbar joint from its normal/optimal position

Mechanically, The TLI bracing concept is a Ponseti-type intervention, repositioning the joint in its optimal position to reduce shear, stress and deformative force.

TLI brace (thoracolumbar lordotic intervention)

Christine Colliard, MD and Charles Rivard, MD

St. Justine Hospital, Montreal, Canada, 1998

“Results are achieved not so much by the brace but by the

interaction of the brace with the patients Corrective Movement”

Corrective principles significantly different from traditional

thermoplastic TLSOs

SpineCor Brace

ScoliOlogiC® Braces Invented by Dr. Hans-Rudolph Weiss

Patent Application April 2005

First braces built May 2005

Asymmetric, anterior opening

Incorporates pads and expansions

ScoliOlogiC® Braces

“Chêneau light” Brace

Utilizes offset aluminum bar anteriorly and posteriorly

Less coverage than traditional Chêneau brace

Gensingen Brace

One piece plastic construction

Opens Anteriorly

L.A. Brace Gez Bowman, CO

Los Angeles, California, 2007

Measurement-based, centrally-fabricated

Asymmetrical, anterior-opening

Emphasis on three-dimensional correction

Rigid polypropylene construction

Limited use and available through LA Brace certified orthotists

Gomez Orthotic Spine System (GOSS)

Miguel Gomez, MD

Houston, Texas, 2009

Adapted from Rosenberger TLSO

Asymmetrical, anterior-opening

Emphasis on three-dimensional correction

Custom to measurements

Central fabrication through Friddle’sO&P

Nocturnal Braces

- Charleston Bending Brace

- Providence TLSO

- nBrace (Ortholutions)

Charleston Bending Brace

Frederick Reed, MD & Ralph Hooper, CPO

Charleston, South Carolina, 1979

Over-correction through side-bending

Anterior-opening, true bending brace

First nocturnal bracing system

Introduced as alternative design for non-compliant patients

Approx. 1,400 fit annually in North America

Charles d’Amato, MD and Barry McCoy, CO

Children’s Hospital of Rhode Island, Providence, RI, 1992

Nocturnal brace system

Anterior-opening

Custom-made from measurements or cast

Patented process provided exclusively by Spinal Technologies

Providence TLSO

Dino Gallo, CO, Jenny Voit, CO & Manuel Rigo, MD

Rosenheim, Germany, 2011

Nocturnal brace system

Asymmetric, Anterior-opening

Utilizes Rigo-Chêneau principles Pads and expansion spaces

nBrace (Ortholutions)

The success of any bracing regimen depends on competence of the orthotist, proper construction of the brace, and compliance of the wearer

Objectives for the future:

Greater emphasis on training competent orthotists

Sustained financial support for research and development of biomechanically-sound brace designs

Intentional international collaboration between SRS, SOSORT, ISPO, others

Summary of Scoliosis Bracing

Imagination, Innovation, and Inspiration are powerful and positive forces for change.

Concluding thought

Thank you

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