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A Refined Concept In The Orthotic Management Of Scoliosis: A Preliminary Report

John Hall, M.D. *
M.E. Miller, C.P.O. *
William Schumann, C.P. *
William Stanish, M.D. *

Idiopathic scoliosis is a medical enigma. It exists presently as a clinical entity without a known etiology. Several experimental manipulations in animal models have been successful in reproducing spinal curvatures, but to date none of these experiments, it seems, has advanced significantly the remedy for scoliosis.

Valuable contemporary contributions to the surgical amelioration of spinal deformities have been made by Harrington and Dwyer . These techniques for spinal fusion afford the surgeon new confidence in achieving and maintaining an enhanced degree of correction of the scoliosis.

Although ancient and twentieth century medical literature offered an awesome array of spinal orthoses, it was fundamentally the pioneering of Dr. Walter Blount and Dr. Albert Schmidt that has provided the medical profession with the "Milwaukee Brace," an orthosis that can successfully abort the progression of scoliosis. When fabrication and fitting of the Milwaukee Brace are carried out properly, carefully selected individuals suffering from scoliosis can be treated successfully without surgery. These vital prerequisites must be combined with a structured exercise program in order for the treatment to yield optimum results.

The conventional Milwaukee Brace has undergone many modifications since its creation, but the metal vertical superstructure with a pelvic foundation still comprises the basic components.

The Milwaukee design has been well received, in spite of its unconventional approach, but even its innovators will admit the Milwaukee Brace still leaves something to be desired. It requires considerable time to fabricate and fit. With the superstructure its appearance is ungainly—a very real factor in the age group for which treatment is generally needed.

In an effort to overcome some of the well-recognized problems associated with the "Milwaukee Brace," a design that has been designated the "Boston System for Non-Operative Control of Scoliosis" has been developed and applied at the Children's Hospital Medical Center, Harvard University.

The system is based on the Milwaukee Brace concept but the necessity to take a cast, pour, and rectify a positive model is eliminated in an estimated 95 percent of the cases by use of prefabricated plastic pelvic girdles (Fig. 1 ). The girdle is fitted so that its entire inner surface is in contact with the skin (Fig. 2 ). A superstructure may or may not be used, depending upon the severity and type of case (Fig. 3 and Fig. 4 ).

The pelvic girdles are molded of sheet polypropylene and lined with Ali-Med, a synthetic sponge. Pelvic tilt is incorporated and the lumbar pad is an integral part of the structure.

"Total contact" is provided, but the pressure is not distributed uniformly, since relief areas are incorporated so as to allow the pathological curve to move to a more ideal position. Static correction of the curve is achieved by direct stress via orthosis, and dynamic correction is accomplished by exercises executed while in the orthosis. These static and dynamic stresses encourage the pathological curve to migrate to the relief area.

The pelvic girdle is available in 16 sizes. Six of these sizes seem to be all that are needed to fit 80 percent of patients for whom an orthosis is prescribed. All 16 sizes make it possible to fit about 95 percent of the cases, and the remainder require a custom-made girdle.

Although fabrication and delivery times are shortened, proper application requires a great deal of knowledge and skill, and therefore should not be attempted until the team has had adequate training.

The advantages of the Boston System are:

1.  A reduction in fitting and fabrication times
2.  A reduction in delivery time
3.  A reduction in skin problems owing to the intimate fit which tends to decrease the degree of shear between orthosis and skin.
4.  Improved control of lumbar and thoracolumbar curves owing to the intimate fit of the girdle.
5.  A reduction in maintenance problems, owing mainly to the properties of polypropylene.
6.  Improved cosmesis (when the superstructure can be eliminated).

EVALUATION

At the Scoliosis Clinic of the Children's Hospital Medical Center approximately 2000 patients with various forms of spinal deformities are followed at any one time. About 500 new patients are seen annually. For approximately three years our team has used the Boston System in an effort to determine its effectiveness.

OBJECTIVES OF STUDY

The study was carried out in an effort to assess two major areas:

1.  Toleration of the Device: It was an objective to ascertain whether the patient could tolerate the rigid construction of the orthosis designed for total contact. Also, an attempt was made to gain some insight into the greater ease of socialization for the child fitted with this type of orthosis.
2.  Curve Correction and Maintenance of Correction: It was felt to be imperative that a report be offered on the degree of correction achieved with the Boston System, and also to offer a preliminary report on the maintenance of the correction.

COMPOSITION OF THE GROUP STUDIED

A group of 200 patients was selected on a random basis from the files of the Scoliosis Clinic at the Children's Hospital Medical Center.

Each of these two hundred patients met the following criteria:

1.  Had scoliosis that has been diagnosed as idiopathic.
2.  Had been fitted with the Boston System, with or without superstructure.
3.  Would be a participant in a follow-up program conducted by the orthopaedic staff in conjunction with the personnel of the National Orthotic and Prosthetic Company who operate the orthotics facility on the premises of the Children's Hospital Medical Center.

SOURCES OF DATA

The data were obtained from chart and radiological review, questionnaire, personal interview, and examination.

The clinic and hospital charts of all patients were reviewed completely. Roentgenograms were also reviewed and measurements recorded according to the Cobb method . Patients were categorized according to curve patterns as follows:

1.  Thoracic
2.  Thoracolumbar
3.  Lumbar
4.  Double curve

The questionnaire was administered to the patient and the parent attending. This was carried out at the time of personal interview and examination of the patient in most instances. Telephone interviews were employed to augment the data when needed for completeness.

Table 1

Comments:

1.  Skin problems are deemed to be mild when there is merely hyperemia without blistering; moderate is defined as skin irritation to the point of blistering in one focus; severe skin problem is defined as blistering in more than one focus.
2.  Mild pain is that discomfort which does not promote removal of the orthosis for any portion of the prescribed wearing time; severe pain is when the brace cannot be tolerated whatsoever.
3.  Socialization is abnormal when either the child or a parent confesses that wearing the Boston System handicaps the child from doing activities that she has a desire to do, i.e., school activities, athletics, and coeducational social activities.
4.  One patient weaned with progression of her curve progressed three deg. from 12 deg. to 15 deg., over a two-year period. On her last visit she had arrested at 15 deg.

Table 2

Comments:

1.  One patient who absolutely refused to wear the Boston System with the metal superstructure also refused to wear the modified pelvic girdle alone, and progressed to spinal fusion with Harrington instrumentation.
   The second patient was converted to the Boston System without superstructure and has been controlled since that time.
2.  Of the two patients who progressed following weaning, one patient has lost three deg. of correction which is considered negligible at the present time. However, one patient who presented with a 30- deg. curve had a prime correction of 12 deg. after an insidious weaning period progressed to 35 deg., and went on to spinal fusion with Harrington instrumentation.

Table 3,Table 4

Comments:

The one patient who has progressed following weaning deteriorated from an 18-24 deg. curve to a 20-30 deg. curve over a one-year period. This progression occurred after a program using the Boston System without a superstructure.

CONCLUSIONS

The Boston Scoliosis Orthosis is a prefabricated appliance for the nonsurgical treatment of idiopathic scoliosis. Constructed, primarily, from sheet polypropylene, the orthosis is designed to offer a total-contact fit.

In patients selected properly, the need for the metal superstructure is obviated. Preliminary report of 200 patients with idiopathic scoliosis treated with the Boston System reveals, after a mean follow-up period of 17 months, a 28 deg. curve (mean) can be corrected to a 14 deg. curve (mean) yielding a 50 percent correction. While wearing the brace 20 hours per day (mean), 85 percent of the patients enjoyed a completely normal life style.

References:

1. Blount, Walter P., and John H. Moe, The Milwaukee Brace, Williams and Wilkins, 1973.
2. Cobb, J. R., Outline for the Study of Scoliosis, pp. 261-275, in Instructional Course Lectures, W. P. Blount, ed., AAOS, Vol. V, J. Edwards, Ann Arbor, 1974.
3. Dwyer, A. F., F. C. Newton, and A. A. Sherwood, An anterior approach to scoliosis, Clin. Orthop., 62: 192-202, 1969.
4. Dwyer, A. F., Experience of anterior correction of scoliosis. Clin. Orthop., 93:191-206, 1973.
5. Dwyer, A. F., and F. F. Schaefer, Anterior approach to scoliosis. J. Bone & Joint Surg.. 56B:218-224, May 1974.
6. Harrington, P.R., Treatment of scoliosis-Correction and internal fixation by spine instrumentation, J. Bone & Joint Surg., 44A.591, 1962.