Throughout history man has tried to straighten out that which nature
has bent, twisted, or curved. Hippocrates not only gave a name to
scoliosis but he also tried to correct it. Over the centuries since
then physicians have used a wide, and
sometimes strange, variety of devices to straighten a crooked
In today's world when a growing adolescent is diagnosed with progressive
idiopathic scoliosis and the curve is between 25 and 40 degrees,
the physician will prescribe the wearing of a brace to keep the
curve from worsening. Depending on the severity of the curve, the
curve pattern, and the amount of growth remaining, the physician
may not wait to document progression but will prescribe bracing
on the initial visit.
In 1985, the Scoliosis Research Society (SRS) initiated a study
to investigate the effectiveness of bracing as a treatment for scoliosis.
Many previous studies of full time bracing showed that braces stop
about 80% of curves. All of these studies, however, were "uncontrolled"
which means there were no simultaneous groups of untreated, unbraced
patients for comparison. Therefore, there was some doubt that brace
treatment of scoliosis was effective, and concern that bracing may
be no different than "natural history" or what happens
when no treatment is undertaken. In the SRS controlled clinical
trial, involving centers from around the world and conducted by
Dr. Alf L. Nachemson Sahlgren Hospital, Gothenberg Sweden, patients
of the same age, curve pattern and curve severity were divided into
two groups, one treated with bracing, one not treated. As reported
in the 1993 issue of the Spinal Connection, results of this study
demonstrated with statistical certainty that bracing is effective
compared to natural history.
In another study by Drs. John Lonstein and Robert Winter, the records
and X-rays of 1,020 patients treated with the Milwaukee Brace were
reviewed and compared with the findings of a study by Drs. Lonstein
and J.M. Carlson which documented patients at the same hospitals
who had not been braced but who had been followed for progression
of the curve. This retrospective study also showed that bracing
is an effective treatment, halting the progression of the curve
in statistically significant numbers compared with those patients
While it is true that there are some patients (20-25%) for whom
bracing does not work and unfortunately, it is not possible to predict
who they will be parents and physicians can be reassured by these
recent findings that bracing for those youngsters who meet the generally
accepted criteria is a wise course of action.
What does bracing achieve?
It is important for parents and patients to realize that the purpose
of bracing is to keep the curve from progressing as a child grows.
While the curve will demonstrate improvement during the time the
child is braced, it will typically revert to its original degree
of severity when the use of the brace is eventually discontinued
at the cessation of growth. Some individuals do achieve permanent
correction, but holding the curve to an acceptable level, thus avoiding
surgery, should be deemed a success.
What Kinds of Braces are Used?
The Milwaukee Brace
The Milwaukee Brace was the first modern brace designed for the
treatment of scoliosis. Developed by Drs. Walter Blount and Albert
Schmidt of the Medical College of Wisconsin and Milwaukee's Children's
Hospital in 1945, it underwent design changes over the years, reaching
its present form around 1975. It is still used today, particularly
for high thoracic curves. Metal bars in the front and back of the
brace extend the length of the torso and are attached to a form-fitting
plastic pelvic girdle and to a throat mold or ring which encircles
the neck. Straps attached to the metal bars hold pressure pads,
which are precisely placed depending on the individual's curve pattern.
While the bars hold the body erect, the neck ring keeps the head
centered over the pelvis and the pads push against the curve. Everything
works together to keep the body straight and to prevent progression
of the curve while the patient is growing.
There are many TLSO (thoracic-lumbar-sacral orthosis) systems available
today. They are also often referred to as "underarm" or
"low profile" braces. They are made of modern plastic
materials and are contoured to conform to the patient's body. While
they all differ somewhat in construction, they work on basically
the same principle.
The Boston Brace
In the early seventies, the most popular of the TLSO systems, the
Boston Brace, was developed by Dr. John Hall and Dr. William Miller
of The Boston Children's Hospital. The Boston Brace was the first
brace to utilize symmetrical standardized modules eliminating the
need for casting. It was alsothe brace used in the Scoliosis Research
Society's bracing study. The Boston Brace extends from below the
breast to the beginning of the pelvic area in front and just below
the scapulae to the middle of the buttocks in the back. It is designed
to keep the lumbar area of the body in a flexed position by pushing
the abdomen in and flattening the posterior lumbar contour. Pads
are strategically placed to provide pressure to the curve, and areas
of "relief" or "voids" are provided opposite
the areas of pressure.
The Charleston Bending Brace
The Charleston Bending Brace was introduced in 1979. Developed by
Dr. Frederick Reed and Mr. Ralph Hooper, CPO, this brace is worn
only at night during sleep. It is molded to conform to the patient's
body while bending towards the convexity of the curve, thus "over-correcting"
the curve during the eight hours it is worn. A preliminary study
and subsequent longer term follow-up of those using the nighttime
bending brace are encouraging, particularly for a single curve.
Although the studies show no evidence of improved compliance the
potential for a patient to wear a part-time brace, especially while
sleeping, rather than the usual full-time (22-23 hours) regimen
is cited as an important benefit.
"The purpose of bracing is to keep the curve from progressing
as a child grows."
To achieve a successful outcome from bracing it is necessary that
a highly skilled orthotist or brace maker work hand in hand with
the orthopedist to craft a brace precisely tailored to the patient's
needs. In many cases an exercise pro- gram is also provided. After
that, the physician will have the patient return for routine checkups
and order X-rays to make sure the brace is doing its job. He will
prescribe periodic adjustments as necessary.
The brace is worn until the physician has determined that skeletal
maturity has been reached at which time the patient will be gradually
weaned from the brace.
Compliance on the patient's part in wearing the brace according
to the prescribed schedule is a crucial factor, of course. Several
studies have demonstrated the importance that the mother's attitude
has on the child's perception of her own condition and acceptance
of treatment. While no one would suggest that adapting physically
and psychologically to bracing is easy for children and teenagers,
many studies show that after an initial adjustment period, youngsters
who are braced live very normal lives, engaging in appropriate activities,
including sports, and that they have good psychosocial adjustment,
no matter which brace they wear.
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