by Tyler Cymet, DO, FACOFP

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    00:01 When it comes to bracing, in the past we used to brace everybody.

    00:05 Now, bracing has been moved towards those in the early phases of growth who still have a lot of growth to go. Those who have a disease serious enough to where you think that in the future they're going to need surgery; or you see a progression that's going more rapid than you would like.

    00:22 Those are times when you consider bracing for the potentially pushing back of the worst thing of the disease. Again, it does not correct the curvature.

    00:34 It is something that is time limiting. We don't do in patients who have reached skeletal maturity because your benefit is going to be minimal.

    00:44 So if the Riser score shows that there is a 4 or a 5 and growth is complete, bracing is no longer going to be of benefit. If the angle is severe and they've already reached the need for surgery, bracing is not going to have a benefit. It's contraindicated in patients who have a thoracic lordosis. The other thing is with bracing, if you don't have a compliant patient, it's not something you should look at doing.

    01:10 The underarm orthoses are what's used, underarm down to the pelvic area.

    01:16 It does stabilize motion as well as work on straightening the back.

    01:22 There are other braces out there like the Charleston brace or the Wilmington jacket that have metal inserts to keep the back stable.

    01:30 That's how the benefit is provided.

    01:34 The Milwaukee brace was the most common and the most studied but it's rarely used now. That's a flared brace that has the stabilization on the top and bottom.

    01:44 Data shows that its benefit is present when it's used for 23 hours a day.

    01:49 If you're using it less than 16 ½ or 17 hours, you're not going to get the benefit you want.

    01:55 But the other nice thing about the brace is within six months, you'll see a slowing of progression.

    02:00 Then it does have some benefit as long as you're using it for 23 hours a day.

    02:05 So, a bracing has mixed results.

    02:07 There are some good studies out there that will tell you what to think about bracing. The NIH had the BrAIST study going on, which is the bracing in adolescent idiopathic scoliosis trial.

    02:18 It's a five-year, multi-center, prospective, randomized trial that compares bracing with observation in a young patient whose skeletal hasn't fully fused yet.

    02:28 It's been for patients with a Cobb angle between 25 to 40 degrees.

    02:33 What that does show is that bracing treatment is effective when used greater than 23 hours a day.

    02:41 The proportion of success in those patients was 0.93.

    02:45 When the brace was used less than 16 hours, the effect was much lower at 0.62 and much less effective at 8 hours as well.

    02:57 So, you see bracing is effective when used constantly and paid attention to.

    03:04 If you don't have a patient who's going to use the brace for 23 hours a day, your benefit is not going to be as great.

    03:12 We also know that most patients will use a brace 65% of the time that they are told to use the brace.

    03:19 So, if they're told to use it for 20 hours a day, you may only get 13 to 14 hours’ worth of bracing.

    03:25 This was done with the study with a temperature monitor in the brace so that people weren't asked, they were monitored.

    03:32 So it is more accurate information than if were self-reported.

    03:36 The patient may need to wear the brace during sports or they’re going to refrain from sports.

    03:42 It can only be removed for short periods of time.

    03:45 The other issue with the brace is it needs to be monitored routinely for proper fit.

    03:51 If a person is growing, they need to return more frequently to make sure that the fit is appropriate and that it's not going to be causing chafing or discomfort in other ways.

    04:01 It's also worn under or over the clothes which are decisions and choices that can affect the look and how a person feels about their own health.

    04:10 With the brace, you want to continually monitor how it's affecting the curvature.

    04:15 If the goal is a 20% reduction when the brace is being worn, that's the goal you're going to use to see if you have a success.

    04:23 The bracing should continue until the end of the growth period.

    04:26 For girls, it's two years after menarche or when their Risser score is 4 or 5.

    04:31 For boys, it's a Risser score of 5 when there’s complete termination of growth because they've grown to their full height.

    04:38 With the bracing, you can either stop completely or you can just wean it down to using the brace at night.

    04:43 That is when people feel that they have a limitation of symptoms, or they feel better with the brace, or more comfortable.

    04:50 Sometimes people start using the brace as a crutch, feeling they need it or they're not going to be comfortable.

    04:56 You should generally have a follow-up six months post-bracing and make sure you know what is happening to the curve.

    05:04 Sometimes people do report a rapid deterioration or worsening of the curve after they stopped bracing. That's something you need to measure to have a good answer to know what's going on.

    05:14 You need to monitor the brace treatment every 6 to 8 months both clinically and with follow-up radiographs.

    05:20 When you get the radiographs after the bracing, you want to check for any curve progression and note whether it's speeding up or slowing down.

    05:29 Progression of the Cobb angle more than 5 degrees during bracing treatment is a poor sign and says that the person is not going to do well and surgery may be needed.

    05:40 With surgery, the primary goal in spinal fusion is to prevent curve progression because of potential damage to the organs.

    05:48 You want to protect their functioning and protect cardiac and pulmonary functioning.

    05:52 The secondary goal is curve correction.

    05:57 What you're doing is straightening out the curvature and putting rods in place.

    06:01 So it is going to correct the curve.

    06:04 The indication is for skeletally immature patients.

    06:07 At diagnosis, the patient should have a Cobb angle of greater than or equal to 50 degrees. That's when you know that damage is occurring.

    06:16 Sometimes a skeletally immature patient with a Cobb angle of between 40 to 50 degrees may need surgery.

    06:23 That should be determined on a case-by-case basis.

    06:26 The surgical procedure done for adolescent idiopathic scoliosis is a posterior spinal fusion. That's bone grafting and rodding.

    06:37 The rod is put in the spine to straighten it out.

    06:39 Bone grafting is put to cement it in place.

    06:42 Instrumentation has evolved from the Harrington rods which were full-body corrections to the more modern segmental instrumentation, which are hooks, screws, wires, and much shorter.

    06:53 So there's much less metal going much fewer segments in order to stabilize the back.

    06:59 The modern instrumentation provides your orthopedic surgeon with control of positioning so they can fix the specific vertebrae and help maintain the angle that's needed for proper functioning.

    07:14 The other important part of the surgery is the bony fusion with grafts or allografts that allow the bones to heal so that the issue of infection isn't there and the person can go on in a functional manner.

    07:27 Postoperatively for 9 to 12 months, this person is not supposed to participate in sports because the risk of injury is much greater.

    07:37 Once the spine has fused and we know that each canaliculus takes about three months, and it's usually about a year before you have full fusion of the bone around this area, once it's fused, you can go ahead and start sports.

    07:49 Long-term follow up data on these procedures is still being collected.

    07:54 So we don't have the answers we would like to have for you.

    07:58 We do know that untreated curves may continue to progress after skeletal maturity.

    08:03 This occurs in two-thirds of patients.

    08:06 When the curves even are less than 30 degrees, you're going to see some progression even though it's less likely than the larger curves.

    08:14 One 50-year follow up showed patients had little impairment other than back pain and cosmetic concerns with the smaller curves which is why we do not suggest surgery for them.

    08:27 Curves treated with bracing and surgery can also progress.

    08:31 There are studies showing bracing patients followed for 22 years and they had an average curve progression of about 8 degrees.

    08:41 So while it does progress, it doesn't progress to the point of causing organ damage.

    08:46 In the surgical treatment in patients who followed for 23 years, we saw an average progression of about 3.5 degrees.

    08:55 So these are important concepts to keep in mind when patients bring up whether or not they should get surgery earlier or when they don't meet criteria for surgical intervention.

    09:05 The back pain from scoliosis can be treated to make the patient more comfortable.

    09:09 Untreated, there's no evidence that there's going to be a greater occurrence of progression or change. There may be a correlation between the initial magnitude of the curve and later back pain but that's a different issue.

    09:22 Patients with adolescent idiopathic scoliosis who are treated with bracing or surgery may have an increased risk of degenerative joint disease, osteoarthritis later on in life.

    09:33 When patients who have scoliosis get pregnant, they do need increased monitoring and awareness.

    09:41 It's important to note the number of pregnancies and the age of the first pregnancy because these could affect curve stability and curve progression.

    09:50 The scoliotic curve itself does not seem to affect the outcome of the pregnancy.

    09:54 The patient is still able to get pregnant and carry to term.

    09:56 There is no increase in cesarean section or other complications in patients with scoliosis who had pregnancy.

    10:04 So to summarize, scoliosis treatment for patients with a 20 to 30 degree curve is generally orthotics, fixing the area around, and documenting progression to see if things are going to change. In children with a 30-40 degree curve, again you're going to treat with orthotics. You're going to continue monitoring with particular attention to people in a growth phase and in children who are continuing to grow.

    10:31 That's when you monitor more closely.

    10:34 If a scoliosis has a 40-50 degree curve, you do know that there's going to be some organ involvement and surgical intervention should be looked at and prepared for.

    10:44 You also may consider orthotics particularly if there's a double major curve in the spine.

    10:49 In patients with a curvature of greater than 50 degrees, surgery is going to be needed.

    10:54 That's our talk on scoliosis. I hope you found it useful.

    About the Lecture

    The lecture Bracing by Tyler Cymet, DO, FACOFP is from the course Osteopathic Treatment and Clinical Application by Region. It contains the following chapters:

    • Bracing
    • Surgery for AIS
    • Scoliosis Treatment – Summary

    Included Quiz Questions

    1. Patients who have reached skeletal maturity
    2. Patients with a Cobb angle greater than or equal to 50 degrees
    3. Patients older than 10 years of age
    4. Patients who are participating in swimming and/or gymnastics
    1. Halt curve progression
    2. Reduce the curve
    3. Reduce pain and neurological symptoms
    4. Preventing future arthritic and degenerative disc changes
    5. Completely eliminating back pain
    1. False
    2. True

    Author of lecture Bracing

     Tyler Cymet, DO, FACOFP

    Tyler Cymet, DO, FACOFP

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