Re: "Don't condemn bracing!" - Some results and publications on how bracing works!

[BZebra]

Hello all together,

I do not believe the future of scoliosis treatment lies in forced correction methodology. The threshold for scoliosis treatment "working" is so low that parents and patients have accepted a "good enough" mentality. The Cheneau brace may be more effective at stopping curve progression than others, but in reality, like all bracing/forced correction treatments, it makes no effort to reverse the condition.

I don't quite agree with this statement. Depending on the primary correction a brace achieves, it CAN reverse scoliosis, it CAN permanently reduce curves! In smaller curves even a complete correction (meaning under the scoliosis defining threshold of 10 degrees Cobb) is possible.

Example:



Source: http://www.rahmouni.de/skoliose/behandlung.htm

Description: Initial degree here was 45 degrees Cobb thoracic and 42 degrees Cobb lumbar. After three years of brace treatment and after weaning the curve is slightly overcorrected into the other direction.

Results like this can be attained when in brace an overcorrection is achieved and the patient is still in the process of growing. Once the spine stays on the other side, a weaning of the brace can be started. This can be after two years of brace treatment instead of otherwise e.g. 4-5 years until spinal growth is completed.

I can give you my own brace treatment results as another example for a stronger curve having been reduced by bracing:



Left: 13 years old, 58 degrees, before bracing therapy at the beginning of a 6-week rehabilitation program in Katharina-Schroth-Klinik (Bad Sobernheim, Germany)
Middle: 13 years old, still before bracing therapy after 4 weeks of rehabilitation program.
Right: 14 years old, after one year of bracing therapy (brace by Rahmouni http://rahmouni.de)

My x-rays:



Left: 13 years old, 58 degrees, before bracing therapy
Middle: 4 weeks later in the first brace, 18 degrees
Right: 25 years old, 38 degrees after two years without brace

What I have done:
I have been wearing my brace from 13 to 18 years between 21 and 23 hours a day. After that I continued to wear it during night time for another five years.

The rules are pretty simple:
In order to prevent progression, a primary correction of the initial curve of at least 40 % has to be achieved. Primary corrections of more than 40 % can lead to lasting corrective effects after brace weaning if the patient was young enough at the beginning of the brace treatment and had enough spinal growth ahead of him- or herself. Furthermore it seems that the brace must also correct below 30 degrees Cobb to prevent further progression during growth.

What is done here is using high enough corrective effects to reverse the progression which would otherwise take place. By doing this the growth is steered into the other direction.

There is also another apparently very successful approach in bracing therapy, which is to brace children very early from 15 degrees on with a brace only to be worn during night time (in bed).

The following passage was published in Weiss HR (1995). Standard der Ortheseversorgungen in der Skoliosebehandlung. Med Orth Tech. 115:323-330.

Nach unseren Erfahrungen haben Patienten mit früher Abschulung (Risserstadium 4-5 bei Mädchen) ungünstigere Verläufe als bei Spätabschulungen im Alter von 18-19 Jahren. Diese Erfahrung teilen wir auch mit anderen (RAHMOUNI, 1991). Eine Ursache hierfür könnte sein, dass auch nach Schluss der Epiphysenfuge der Hand und der Darmbeinkante ein signifikantes Wirbelsäulenwachstum besteht (HOWELL et al., 1992). Die Autoren geben an, dass das Wirbelsäulenwachstum auch nach Schluss der radiologisch sichtbaren Epiphysenfugen noch weitere 2 Jahre anhält. Diese Untersuchung bestärkt uns darin, die Abschulungsphase zumindest bei Patienten mit nicht überkorrigierten Skoliosen bis zum 18. oder 19. Lebensjahr herauszuschieben. Will man eine solch lange Korsetttragedauer vermeiden, so muss man die Patienten mit kleineren Cobb-Winkeln eben frühzeitig versorgen. Dies auch mit der Gefahr vielleicht einzelner auch unnötiger Behandlungen. Dieses Konzept wurde auf dem 9. Internationalen Phillip Zorab Symposium in Cambridge von PONTE (1993) vorgestellt. Der genannte Autor hat über die letzten 10 Jahre mehr als 200 Patienten mit Korsetten früh behandelt, wobei das nächtliche Tragen ausreichend war. Allerdings hat er hierzu einen Korrektureffekt von mindestens 60% gefordert. Bei keinem dieser Patienten ist langfristig eine ganztägliche Tragedauer des Korsetts notwendig geworden. Eine solche Nachtversorgung belastet den Patienten nicht wesentlich psychisch und verhindert möglicherweise die Notwendigkeit einer Ganztagestragezeit oder eventuell gar einer Operation. Auch hier finden wir wieder die Notwendigkeit einer ausreichenden Primärkorrektur dokumentiert.

I am trying to translate this into English:

According to our experiences, patients which are being weaned from brace at an early time (Risser sign 4-5 in girls) have less favourable outcomes than patients weaned later at the age of 18-19. We share this experience with others (RAHMOUNI, 1991). A reason for this could be that after closure of the apophysis of the illium and of the hand a significant growth of the spine is still remaining (HOWELL et al., 1992). The authors state that even after closure of the radiological visible iliac apophysis, spinal growth persists for another 2 years. This finding encourages us to postpone the weaning from brace to 18 or 19 years of age for patients without overcorrection. If one wants to avoid a brace treatment over such a long time, patients with smaller Cobb angles have to be braced at an earlier time, this including the risk of treating some patients which would not have to be treated. This concept was proposed by PONTE (1993) at the 9th International Phillip Zorab Symposium in Cambridge. The author had started early brace treatment in over 200 patients over the last 10 years, whereby only a nightly brace wearing time was sufficient. He however demanded a primary correction of at least 60%. None of his patients were consequently obliged to wear braces during daytime. Such a night time treatment does not put significant psychological stress on the patients and possibly avoids the necessity of having to wear a brace during daytime or even a surgery. Here as well we find the necessity of a sufficient primary correction documented.

A German Doctor (Dr. Kay Steffan) has braced 120 patients between 15 and 20 degrees Cobb with braces only to be worn during night time, as well. He is reporting similar results. The scoliosis of only one his patients has progressed, so that he had to wear his brace during daytime as well. Except for this one case all curves could be reduced to less than 10 degrees Cobb.

Sources:

Landauer F, Behensky H (2002). Korrekturmechanismus der Skoliose bei Korsett-Therapie. Orthopädie Technik, 6/2002. Online: http://www.ot-forum.de/OT/split2002/...h_Landauer.pdf

Hans-Rudolf Weiss. Best Practice in Conservative Scoliosis Care. Pflaum, 2006. ISBN 978-3790509410.

Weiss HR (1995). Standard der Ortheseversorgungen in der Skoliosebehandlung. Med Orth Tech. 115:323-330

http://www.skoliose-info-forum.de/viewtopic.php?t=13582

[Dr Kalla]

Welcome BZebra!

Thank you for you very informative post. There seems to be a great disparity between brace making and management between Germany and USA.

I see that you can bring valuable information to this forum and we are grateful for that.

Now, I personally don't believe that bracing is the solution we are looking for for patients, but then again I have not been presented with this kind of information/results either. I just think that bracing doesn't address neurophysiological aspect seen in many idiopathic scoliosis cases.

Myself and others can learn for you sharing your knowledge.

[BZebra]

Thank you for welcoming me!

I just think that bracing doesn't address neurophysiological aspect seen in many idiopathic scoliosis cases.

Actually, it does! The pressure applied by the brace is so uncomfortable and, in the first weeks to months of bracing when the patient isn’t used to it yet, even causes pain, that the patient will try to move away from the pressure zones.

The brain receives the information that this condition is no good at all (uncomfortable, hurtful). The result is that the patient will do something about it, he will actively move away from the pressure.
So, if you want neurophysiological aspects in it, there they are - at least when wearing a brace during daytime, under the condition that it achieves the necessary primary correction (the primary correction in brace has to be radiologically verified, always!).

The Chêneau brace generally is considered as a part active, part passive brace. The Passive component simply facilitates the movement into the correct (or better) position, which with muscular force alone, would otherwise not be possible, let alone over such a long period time over the whole day.

[DrStitzel]

Hi BZebra and please let me be the first to welcome you to the forum,

That is quite a post you put together.....thank you for putting the time and effort into making such a well documented position.

I'm thrilled you are doing well and that this bracing protocol has served you so well.....it appears this protocol is working under the same "guided growth" type principle (similar to vertebral body stapling). This innovative treatment concept does seem to providing some decent results in "some" AIS patients. However, this guided growth concept is based on controlling the secondary adaptation to the curvature through the manipulation of the Hueter-volkmann effect....stating that bone under stress (aka the inside part of the curve) will grow slower than bone not under stress (bone on the outside part of the curve). Therefore, guided growth is achieving it's results through controlling a secondary adaptation to the condition, and not controlling the actual environmental (when coupled with sufficient genetic factors) factors that lead to the condition..... which means it is only treating the symptoms of the condition (the curve) and not working towards a cure (reduction/elimination of the environmental factors).

Case in point.....the x-rays you included in your post show a reduction of the curvature via guided growth (Hueter-volkmann principle), but you hip rotation (evidenced by the "high" sacral base on the right) and your hip translation (again off to the right) remain unchanged. The mis-alignment of the center mass of the pelvis in relation to the torso is a big time environmental factor driving the spinal curvature and it still persists in your case. The bracing protocol simply found a way to "cheat the system" and manipulate the secondary adaptation system caused by the condition. Again, finding a cure for the condition needs to be rooted in reduction/elimination of the primary environmental factors causing the condition, not simply treating the curvature (which is a symptom of the condition).

Bracing is based on manipulating the secondary adaptations of the condition and not focused on reduction/elimination of environmental factors.......therefore it can only be considered a "treatment" and not working towards a cure.

Approximately, 3 weeks ago I flew to Salt Lake City, Utah and met with the developers of the Scoliscore genetic test for approximately 7 hours. It was a fascinating discussion and they gave us some insight to the "2.0" version they are currently working on.....I can't reveal any info they shared with us in regards to the newest version, but we will have a much better idea on which environmental factors each patient needs to focus on in the future and manpulating secondary adaptations through guided growth techniques only be necessary for the 1% of kids whom were dealt a bad genetic hand (Aka: considered "high genetic risk" via Scoliscore).

[DrStitzel]

Actually, it does! The pressure applied by the brace is so uncomfortable and, in the first weeks to months of bracing when the patient isn’t used to it yet, even causes pain, that the patient will try to move away from the pressure zones.......
The brain receives the information that this condition is no good at all (uncomfortable, hurtful). The result is that the patient will do something about it, he will actively move away from the pressure.

Hmmmm, spinal alignment is almost entirely controlled via reaction of the righting reflexes in response to gravity. It is involuntary and initiated by the postural control centers of the brain. Spinal feedback via voluntary movements to reduce discomfort from the brace aren't likely to create permanent plastic (establishing new neuro connections) changes in the brain. Sorry, but I don't feel that opinion is supported by literature or logic.

Neuro-Muscular Re-education of the postural control centers is completely different than "muscle memory" type training in which a specific movement pattern is reinforced by simply performing the same motion over and over again.

[BZebra]

This innovative treatment concept does seem to providing some decent results in "some" AIS patients.

I would say "most", and not only adolescent idiopathic scoliosis but also juvenile and - as far as the stability of the bones allows it - infantile idiopathic scoliosis as well. I myself have a juvenile idiopathic scoliosis.

It does not, however, work with all curve patterns. The curves must be located in positions where they are accessible to brace correction. High thoratic curves for example are very difficult to correct in a brace which does not include the neck. But corrections of 40 % and more can be achieved in the large majority of idiopathic scoliosis patients.

which means it is only treating the symptoms of the condition (the curve) and not working towards a cure (reduction/elimination of the environmental factors).

Isn’t it the only thing we need to treat? Deviations of the spine of less than 10 degrees are very common in the population and do not cause any problems. Even curves of a Cobb angle of less than 30 degrees rarely continue to progress during adulthood.

Again, finding a cure for the condition needs to be rooted in reduction/elimination of the primary environmental factors causing the condition, not simply treating the curvature (which is a symptom of the condition). Bracing is based on manipulating the secondary adaptations of the condition and not focused on reduction/elimination of environmental factors

Well, in the case of idiopathic scoliosis they are one and the same thing, aren’t they? The secondary adaptations of the condition are the causing factors at the same time. The development of a scoliosis is basically only the progression of a small initial deviation into larger curves. It occurs due to a vicious circle induced and driven by one sided postural strain (not only on the bones, but also on the soft tissue). What we diagnose as idiopathic scoliosis has next to nothing to do anymore with whatever it once caused. If you found the initial cause, which was responsible for let’s say a curvature of 5 degrees, and you removed it, the remaining 10, 20, 30, 40, 50 degrees would be left unchanged and eventually lead to further progression.

therefore it can only be considered a "treatment" and not working towards a cure.

Well, I had 58 degrees at the age of 13, half a year after first menarche. The curve had progressed from 32 degrees to 58 within the last 9 months. This was a highly progressive scoliosis, and given that I was still in the middle of my pubertal growth spurt, do you consider this treatment having been a “cure” against a dead certain further progression which would have occurred otherwise? To which degree, do you estimate, would this scoliosis have progressed if left untreated?

but we will have a much better idea on which environmental factors each patient needs to focus on in the future and manpulating secondary adaptations through guided growth techniques only be necessary for the 1% of kids whom were dealt a bad genetic hand (Aka: considered "high genetic risk" via Scoliscore).

This would be great. Imagine every patient with a bad prognosis could be treated early with a night time brace. Nobody would develop significant scoliosis any more. However, as far as I have read, only ¼ of idiopathic scoliosis patients have inherited theirs (have a larger occurrence of scoliosis in their families) and scoliosis has to be diagnosed early. Often the first visible signs already correspond to curves of 20 degrees, which most likely will then lead to further progression during the remaining growth, no matter what ever initiated them and no matter how well this could have been foreseen by genetic testing.

[BZebra]

Spinal feedback via voluntary movements to reduce discomfort from the brace aren't likely to create permanent plastic (establishing new neuro connections) changes in the brain. Sorry, but I don't feel that opinion is supported by literature or logic.

Not realy voluntary, it is more reflexive. You wouldn't get far if you had to learn these postural changes on a conscious level and think about them all the time. Once you have gotten used to your brace, you have taken on the new posture the brace forced you into, it does not hurt any more and it gets almost comforable (it should not, then it is time to improve the correction).

If you want to read more about the mechanisms, have a look at what Dr. Manuel Rigo publishes or what Dr. Jaques Chêneau has published.

[DrStitzel]

Hi BZebra,

Wow, where to start responding to this post. Let's start by managing expectations for this conversation. We need to reconize that I'm probably not going to change your mind and your probably not going to change mine, so this primarily an academic exercise to increase the knowledge base and provide a balance debate on the issue of spinal bracing for those readers whom honestly haven't made up their mind either way yet.

So, let me respond in a "bullet" format to make is easier for those "independent" readers to digest.

- AIS is a separate condition from infantile and juvanile scoliosis, but AIS makes up over 80% of the total scoliosis cases and bracing is primarily recommended for AIS cases....therefore discussion of infantile and juvanile cases and bracing is pretty much irrelevant.

- The accepted purpose of spinal bracing for AIS is to prevent the "need" for surgery. I have yet to see a published research paper that states that any particular bracing protocol is intented to permanently reverse the spinal curvature.

- I reject your notion that mild/moderate scoliosis curves to not have any impact on one's future health or life. Mild to moderate spinal curvatures can reduce one's quality of life in ways that reach far beyond what can be measured through standard organic health measures. Furthermore, I have to also reject your notion that we should stop looking for a cure if we somehow come up with a treatment that is effective enough at treating the symptoms. This would be a kin to stopping the search to cure cancer just because we found a really effective chemotherapy.....which probably made you sick as hell, but it worked. That doesn't sound like a step in the right direction to finding a better way.

- Family history (and as it turns out identical twin studies) are a poor way of deteriming one's genetic risk for developing scoliosis. The Scoliscore test is 99% accurate and they have determined that 1% of AIS patients are genetically at "high risk" for developing a severe scoliotic curvature.

[DrStitzel]

Not realy voluntary, it is more reflexive.

No, those muscle reactions are not sub-consciously reflexive, that may be considered "instinctive" reflexive, but they can't be regarded as reflexive on a sub-conscious level. I go into further explanation as to the difference below.

If you want to read more about the mechanisms, have a look at what Dr. Manuel Rigo publishes or what Dr. Jaques Chêneau has published.

I'm familiar with both authors and I'm pretty sure they would agree that those muscle reactions are "instinctive" (still a movement of voluntarily controlled muscle in response to a noxious stimulus that is artificially created), not part of a sub-consciously reflexive response generated in the postural control centers of the brain.

Think of it this way......standing more upright and straighter because you are carrying a book on top of your head is stimulating the sub-conscious postural control centers in the brain by providing "reactive" feedback via the righting reflex system.....it stimulates the normal righting reflexes, under non-forced correction conditions, to produce a 3-D auto corrective response......which will produce a plastic response (permanent neuro connections in the brain) if the stimulus is repeated multiple times a day over a long enough period of time (which varies from one individual to another). Really, it is just a clever way of tricking the sub-conscious reflex archs into thinking your center mass of you skull is somewhere other than where it really is. Pretty deep huh?

Here is the take home message.....the Neuro-muscular rehab has to recruit muscles (like the instrinsic muscles of the spine....multifidus, spinalis longus/brevis, ect) that can only be recruited sub-consciously. Think of it this way, you need to recruit, train, and re-educate the spinal muscles you can't voluntarily control/contract. For example, you probably can't wiggle your multifidus muscles.

Your example of an "instinctive" muscle reaction would be like moving your hand away from a burning stove.....your brain wants to change the location of your hand ASAP, but the brain hasn't really learned anything because the reflex arc went from hand, to 1 synapse link in the spinal cord only, and back to the motor unit of the hand. No permanent neuro connections will be made in the brain as a result since the instinctive spinal feedback never even ascended to the higher brain levels.

[BZebra]

AIS is a separate condition from infantile and juvanile scoliosis, but AIS makes up over 80% of the total scoliosis cases and bracing is primarily recommended for AIS cases....therefore discussion of infantile and juvanile cases and bracing is pretty much irrelevant.

The main difference between infantile, juvenile and adolescent scoliosis is - according their classification - the age of onset. Once the scoliosis has reached a certain degree and further progresses, the mechanism of progression is the same; for congenital scoliosis, as a result of wedged vertebra for example, with which the patients were born with, equally. These scoliosis all worsen in otherwise healthy children after the same biomechanical principles. But the earlier the scoliosis occurs, the worse is the prognosis.

When you are stating that bracing is primarily recommended for AIS cases, do you mean to say that, for cases of infantile and juvenile idiopathic scoliosis, which are worse off than the adolescent cases, bracing is not recommended? I would say it is even more recommended there! And one reads very often in literature that bracing is very strongly recommended in cases where surgery is almost unavoidable; this in order to slow progression and buy those children time to grow as much as they can before their spine gets fused. But you can achieve more than that.

The accepted purpose of spinal bracing for AIS is to prevent the "need" for surgery. I have yet to see a published research paper that states that any particular bracing protocol is intended to permanently reverse the spinal curvature.

If something is not published it does not exist? Braces are made by orthotists, and they don't announce in research papers that their braces (their products) from now on are not only designed to prevent surgery but aim at permanently correcting the scoliosis as well.

Personally I find it very acceptable if a brace does not only correct enough to prevent progression but also enough to reduce curves as well, or, if one starts early enough, to straighten them completely.

The results of bracing therapy are entirely dependent on the primary correction in brace. A brace which does not aim at correcting at least 40 % of the curvature’s Cobb angle is NOT designed to prevent progression. A brace which corrects less than 20 % does not even have any effect on the natural development of scoliosis any more (you will probably find primary corrections of less than 20 % in most Boston braces). Corrections over 40 % on the other hand can lead to permanent curve reductions after weaning, the higher the primary correction in brace the better the outcome. And primary corrections in brace are possible up to 100% und even into the other direction; the orthotist just has to be good enough to achieve this and the brace treatment has to be started early enough.

I am not saying that braces in general can do this, only braces which are good enough to reach the necessary primary correction. A study about the effectiveness of bracing, which does not include the primary corrections of the braces, does not say anything about the effectiveness of bracing in general; it merely shows the poor quality of the brace treatments which were being observed.

Furthermore, I have to also reject your notion that we should stop looking for a cure if we somehow come up with a treatment that is effective enough at treating the symptoms.

Well, if most scoliosis develop due to genetic defects or more general an unfavourable genetic constellation (it all boils down to the genes, one way or another): we don’t have a possibility to fix this. We can always only treat the symptoms. We might be able to predict more accurately whose scoliosis will progress. But what do you do with this knowledge? Treat the symptoms from an early stage on and prevent the condition from getting worse.

I'm familiar with both authors and I'm pretty sure they would agree that those muscle reactions are "instinctive" (still a movement of voluntarily controlled muscle in response to a noxious stimulus that is artificially created), not part of a sub-consciously reflexive response generated in the postural control centers of the brain.

Different reflexes! O.K., I can agree on this.

Patients who are corrected to 100% or overcorrected in brace end up with almost completely straight spines after brace weaning. What exactly do you suggest has happened there, that their brains not any more “believe” the scoliotic posture is the right one, but the straight one is the right one?

Wouldn't this be the neurophysiological change you were looking for? Their spines are not fused, they could go back into the old position, yet they don’t.