Posts Tagged "Bracing"

Case – Infantile Bracing

Posted on March 19th, 2018 by Belinda Andrews

Treatment of an infantile scoliosis using a 3D designed scoliosis brace

Case Background

The 3-year-old female patient presented to the ScoliCare clinic with postural deformity and lateral shifting of her trunk. The deformity had been picked up by the child’s parents who had then consulted with a GP. X-ray imaging ordered by the GP revealed a left thoracolumbar curve measuring 40° and a mild (10°) compensatory right thoracic curve (Figure 1). The GP had made a diagnosis of infantile scoliosis and referred the patient on to an orthopaedic surgeon for an appraisal. After assessing the patient and reviewing the x-rays, the surgeon suggested that bracing would be the most suitable treatment in this case.

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Figure 1: Posteroanterior postural photograph (Left), Initial posteroanterior x-ray (Middle),
In-Brace [Hospital TLSO] posteroanterior x-ray (Right)

The patient was subsequently issued with a rigid brace (thoraco-lumbo-sacral orthosis [TLSO]) that had been designed and fitted by the hospital orthotist. In-brace x-rays taken soon after the TLSO fitting showed a reduction in the size of the primary curve from 40° to 33° (Figure 1). While a reduction in the curve was evident, the parents of the patient had concerns that there was still significant deformity present despite wearing the TLSO. This prompted them to seek a second opinion from the ScoliCare clinic.

Examination Findings

The history and physical examination performed at the ScoliCare clinic aligned with the findings from the previous imaging results. The patient’s trunk was significantly translated to the left during both the postural and gait analyses, without evidence of leg length discrepancy or pelvic anomaly. The primary curve appeared flexible (Figure 2) which was a favourable sign for brace therapy.

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Figure 2: Photograph of the patient side-lying
over a traction fulcrum orthotic device

Intervention

A new custom 3D designed scoliosis brace was prescribed for the patient along with some home based stretching and exercises to help with the abnormal trunk shift. The patient was advised to wear the brace full-time (up to 23 hours per day) and perform the rehabilitation exercises on a daily basis.

Outcomes

In-brace x-rays taken at the time of the brace fitting revealed that the deformity could be completely reduced (Figure 3). The patient continued to wear the brace with good self-reported compliance from the parents. Unfortunately, the daily exercises were performed on a more haphazard basis. Bracing treatment continued for approximately 24 months. Several modifications were made to the brace along the way to accommodate the patient’s growth.

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Figure 3:  In-Brace (Custom 3D designed brace)
posteroanterior x-ray

By the end of the bracing period, the patient’s scoliosis had been reduced from 40° down to 14° out of the brace (Figure 4).At this point in time the patient is still under care, however the recommendation is for the patient to wear a more flexible style brace to maintain the correction achieved with the custom 3D designed brace, and also to further reduce the left postural shift.

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Figure 4: Out-of-brace x-ray

 Discussion

This case highlights the management of an infantile idiopathic scoliosis (IIS) case using a custom 3D designed scoliosis orthosis. Patients with IIS typically present before the age of 3 years and are classified into two categories – resolving and progressive. Curves in patients with the resolving type tend to reduce spontaneously over time, whereas curves in patients with the progressive type continue to worsen leading to crippling deformity and reduced quality of life if not treated. Casting is typically initiated before the age of two years in these patients as it is more difficult to attain a complete resolution of the deformity if treatment is initiated after this point. After a significant result has been obtained with casting, the patient is usually placed into a rigid brace to stabilise the correction.

There are unique features to this particular case. Thoracolumbar presentations are less common compared to thoracic presentations in IIS patients, and the presence of compensatory curves is also somewhat unusual in this population. In this case, bracing has been used as a first-line management approach versus the more traditional approach involving serial casting. The patient’s initial hospital-made-brace was substandard as evidenced by the small (17.5% reduction) in-brace correction, and had the patient continued with this brace it is likely that the curve would have continued to progress.

At this point in time the evidence to support the use of bracing as a primary treatment in patients with IIS is sparse, however the results observed in this case would suggest that a more comprehensive investigation of ‘over corrective’ 3D bracing is justified.

Conclusion

This case demonstrates the reduction of a severe thoracolumbar scoliosis in a young child using a custom 3D designed scoliosis orthosis.

NB: Results vary from case to case. Our commitment is to recommend the most appropriate treatment based on the patients type and severity of scoliosis.

© ScoliCare & The ScoliCare Clinic Sydney

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Case – Bracing & Exercise Rehab

Posted on February 16th, 2018 by Belinda Andrews

Reduction of a severe scoliosis in a young female gymnast using a 3D designed scoliosis brace

Case Background

The patient was a 14-year-old, high-level, competitive gymnast. The patient’s mother had noticed a curvature in her daughter’s spine and taken her to see a manual therapist. The therapist had made a diagnosis of Adolescent Idiopathic Scoliosis (AIS) and treated the patient for three months. Unfortunately, the patient had not responded to treatment and was referred to the ScoliCare clinic for an assessment.

Examination Findings

The examination revealed some significant postural changes. Specifically, notable curvature in the middle and lower sections of the patient’s spine, uneven heights of the pelvic bones, and torsion of the rib cage (Figure 1). X-rays taken at the time showed a large 71° curve in the thoracic spine and a secondary curve, measuring 40°, in the lumbar spine (Figure 1). The patient was only Risser 2, indicating that she still had a significant amount of growing to do.

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Figure 1: A) Posterior-anterior view highlighting the scoliosis and pelvic tilt.
B) Superior to inferior view highlighting torsion of the rib cage associated with the thoracic spine curvature.
C) Posterior-anterior x-ray demonstrating the curvature of the spine and changes in the rib cage.
  

Intervention

As both the curves were quite large, and the patient was skeletally immature, it was recommended that the patient be seen by an orthopaedic surgeon. The surgeon’s recommendation was that the patient undergo surgery to correct the abnormal spinal curvatures. After careful consideration, both the patient and her parents declined the surgeon’s recommendation. Instead, they decided to go with a more conservative approach.

The patient was subsequently prescribed a customised 3D designed rigid brace , and rehabilitation exercises based on the SCHROTH principles. The recommendation was that the patient be braced for two years until she stopped growing. A daily scoliosis specific exercise program was designed for the patient to support the corrections being made by the brace. New exercises were added to the program as the patient progressed. Regular follow-ups were scheduled to ensure that A) the patient was responding to the treatment, and B) to monitor compliance with the bracing and exercise program.

Outcomes

The patient’s spine responded favourably to the treatment with one-month x-rays showing that the larger curve could be reduced from 71° down to 40° with the patient wearing the brace (Figure 2).

In total, the patient was braced for 18 months. The patient also participated in supervised exercise sessions at the clinic and performed similar exercises at home. At the end of the treatment period, the patient’s curves had reduced significantly (71° to 56°) as demonstrated in the out-of-brace x-rays in Figure 3. The patient’s posture was also notably improved.

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Figure 2: In-brace frontal x-rays taken one
month after the brace fitting.

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 Figure 3: A) Post-treatment posterior-anterior view posture photo B) Post-treatment frontal x-rays.

Discussion

Normally, brace treatment is reserved for AIS patients with moderate (20-45°) scoliotic curves. Scoliosis specific exercise rehabilitation is used in mild (10-20°) scoliosis as a standalone treatment, and as a supplement to bracing in patients with moderate scoliosis. Patients with more severe scoliosis are typically managed surgically. There is very little research to support the use of bracing or exercise in patients with curves exceeding 45°. This case is unique in the sense that the patient/parents refused surgery and elected to try a more conservative option. Care was taken to explain to the patient/parents that surgical treatment is the recommended pathway for AIS patients with severe curves. The is a scarcity of evidence to support the use of bracing in curves >60° in this population.

Conclusion

This case demonstrates the reduction of a severe scoliosis in an AIS patient who declined surgical intervention.

NB: Results vary from case to case. Our commitment is to recommend the most appropriate treatment based on the patients type and severity of scoliosis.

© ScoliCare & The ScoliCare Clinic Sydney

 

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Case – Infantile Bracing

Posted on February 16th, 2018 by Belinda Andrews

Resolution of a moderate scoliosis in an infant patient using a 3D designed scoliosis brace

Case Background:

The patient presented to the ScoliCare clinic at 11 weeks of age with a marked ‘C’ shaped scoliosis. The patient’s mother had noticed the curvature in her daughter’s spine soon after birth. The child had been delivered naturally, however the child had “gotten stuck” and support staff had needed to intervene. The child’s shoulder was dislocated at this time, and later relocated. The mother had taken her daughter to the local chiropractor approximately 1.5 months after the birth for an assessment. The chiropractor had provided a short course of treatment and prescribed gentle bending exercises to help reduce the scoliosis. Unfortunately, the scoliosis had not responded to treatment and was referred to the ScoliCare clinic.

Examination Findings

The examination performed at the ScoliCare clinic revealed a single, large, left ‘C’ curve (Figures 1A & B). The patient also had difficulty turning their head to the right. The curve was very stiff with little correction during side-bending or traction. The neurological exam was normal except for a slight reduction in the abdominal reflexes. X-rays ordered soon after confirmed the findings from the physical exam. The single, left, thoracolumbar curve measured 44° Cobb with an apex at T11. The patient was diagnosed with infantile idiopathic scoliosis and was referred to an orthopaedic surgeon for an evaluation.

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 Figure 1: Postural photographs of the infant at the time of the initial consultation

 

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Figure 2: Frontal and lateral x-rays

Intervention

There was a long wait before the patient could be seen by the surgeon, and as a result the parents decided to start with conservative treatment.

A customised 3D designed rigid brace was prescribed and the patient was advised to continue with the exercises that had been advised by the chiropractor. The patient was instructed to wear the brace for short periods of time at first and then build up the time wearing the brace up to a maximum of 8 hours.

The parents were advised that the brace was only to be worn under supervision, and only during the day. Eventually, the infant was seen by the orthopaedic surgeon who recommended physiotherapy. The parents however chose to continue with the bracing and exercise program.

Outcomes

The patient wore the custom scoliosis brace on a part-time schedule for eight months. At the end of the bracing period, the child’s scoliosis had been reduced from 44° down to 7° (Figure 4).

A follow-up examination was performed 23 months after the initial presentation. The angle of trunk rotation measured 0° at this time and there was no evidence of scoliosis or movement abnormalities.

The parents were very happy with the result and reported that, although challenging at times, the treatment was tolerated by the child.

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Figure 4: Frontal x-ray taken after the patient
had been out of the brace for four months

Discussion:

Infantile idiopathic scoliosis presents before the age of 3 years and is classified into two types – resolving and progressive. Curves in patients with the resolving type tend to reduce spontaneously over time, whereas curves in patients with the progressive type continue to worsen leading to crippling deformity and reduced quality of life if not treated. There are x-ray markers that can be used to differentiate between the two types. However, the difficult aspect for clinicians dealing with patients with idiopathic infantile scoliosis is that the two types can present identically in the initial stages.

Observation is recommended as the initial action, however this can be challenging for parents and clinicians as they wait for a worsening in the patient’s deformity, which, may already be quite significant. For patients with the progressive type of infantile scoliosis, the standard treatment involves placing the infant in a straightened position then applying a plaster cast.

As the child grows, the casts are removed and replaced. This process is repeated, for years in some cases, until the scoliosis has been reduced. The casting process involves intubating and placing the infant under a general anaesthetic. A surgeon, anaesthetist, nursing staff and a specialist table are required for the procedure, which takes approximately 90 minutes. While casting is successful in the management of most cases of infantile idiopathic scoliosis, there are concerns that the frequent exposure to anaesthetising agents may be damaging to the developing brain of the infant. Treatments such as bracing may represent a safer alternative, but further research is required in this area.

Conclusion:

This case study demonstrates the reduction of a moderate infantile idiopathic scoliosis using a customised 3D designed scoliosis brace.

NB: Results vary from case to case. Our commitment is to recommend the most appropriate treatment based on the patients type and severity of scoliosis.

© ScoliCare & The ScoliCare Clinic Sydney

 

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