Bracing Scoliosis

Bildschirmfoto 2018-06-13 um 23.46.45

Bildschirmfoto 2018-06-13 um 22.32.13 Scoliosis is a lateral deviation of the spine commonly exhibiting different patterns of curvature [1]. The basic curve patterns are named after the location of the major curve (e.g., thoracic, lumbar, thoracolumbar, double major, and double thoracic), but other specific classifications have been described [2]. In structural scoliosis, there is usually a certain amount of spinal torsion and a disturbance of the sagittal profile coupled to the lateral deformation [1]. Therefore, scoliosis must be more accurately regarded as a three-dimensional (3D) deformity of the spine and trunk, which may progress quickly during periods of rapid growth [1]. There is some evidence for the use of physiotherapy in the treatment of patients with spinal deformities. However, during the pubertal growth spurt (high-risk phase for progression), brace treatment is the most important mode of treatment [1]. In-brace correction and compliance correlate with outcome [13]. More asymmetric braces with increased corrective effect are preferable (Cheneau style) to the more symmetric Boston braces [13]. Brace treatment can effectively halt progression. A recent randomized controlled trial [13] demontrated that 72% of the United States and Canadian population compliant with SRS inclusion criteria on bracing [14] did not progress using the standard thoracolumbosacral orthosis (TLSO, mainly Boston type).

A retrospective series using CBA (classification based approach = Gensingen brace according to Dr. Weiss) in a sample fulfilling the SRS inclusion criteria of the studies on bracing revealed a success rate exceeding 95% [1415]. This was confirmed in another study using the correction principles according to Cheneau [16]. Recently, it was reported that 33% of a population demonstrating improvements of Cobb angle exceeding 5 degrees after weaning off the CBA braces, with none of the subjects requiring surgery [17]. *taken from Today many different bracing concepts are on the market with very different approaches. However, scoliosis is not differing so much. Therefore, not all braces on the market today can be regarded as being efficient and effective (Fig. 1). Bildschirmfoto 2018-06-13 um 22.50.54 Fig. 1. Many different approaches for the same deformity: Which approach does really work? First of all we may acknowledge that independent studies (Fig. 2) have clearly shown that soft braces do not work, so there is no indication for this approach. The background on soft braces has been described in a paper by Weiss. More information on the background can be found here: A translation of this report can be found here. Bildschirmfoto 2018-06-13 um 22.52.49 Fig. 2. Independent prospective and randomized studies have shown that the SpineCor does not work as advertised. Scoliosis is a stiff deformity and a device allowing unlimited mobility will not correct scoliosis more than a t-shirt. Therefore a standardization of brace treatment is long overdue as many patients sacrifice their quality of life to a tool without or with limited effect. Additionally many patients still are suffering in the braces as most of them are very uncomfortable to wear. Most of the braces just aim at pressing against the humps visible on the patients' body and compress the patients trunk which may lead to pain and limitation of breathing. Today with the Gensingen brace according to Dr. Weiss a new area has begun. Scoliosis correction is no more achieved by compressing the patient, but with a corrective movement guided by the brace (Fig. 3). Bildschirmfoto 2018-06-13 um 22.55.00 Fig. 3. Corrective movement according the the original Schroth principles in the brace as in the exercise. With this new approach (Gensingen Brace according to Dr. Weiss / GBW) we achieve the best possible corrections with the smallest and most comfortable bracing series as available today. Patients in the range of the SRS inclusion criteria for brace treatment (20 - 40° Cobb) usually find the brace far more comfortable than other braces available today. And the patients treated with the GBW after treatment show a very good quality of life. With this new approach (GBW) we are able to not only stop curvature progression, but we may aim at final improvements as can be seen in the following. The GBW is a CAD / CAM brace provided by Koob GmbH & Co KG, Germany, constructed on the basis of a simple classification. Only these standardized CAD / CAM braces may be distributed using the trademark Gensingen Brace™! All official distributors can be found on the Schroth Best Practice Academy list. It can be made according to measurements and / or based on a patients' scan (Fig. 4 and 5): Bildschirmfoto 2018-06-13 um 22.33.16 Bildschirmfoto 2018-06-13 um 22.35.04 Fig. 4 & 5: Scan based construction and application of a GBW for a single thoracic curve nicely correctable (With kind permission of Nicos Tournavitis, SBPRS Thessaloniki and Athens) Of course in more mature patients especially with curvatures exceeding 50° some problems may arise but these can usually be solved in short time so as to allow also the treatment of patients with curvatures exceeding 50° (Fig. 6). Alexandra forbedring Fig. 6. 14.6 year old adolescent, progressive in her previous brace from outside Germany, left before treatment with a GBW and right 6 weeks wearing the GBW for a single thoracic curve full time. Nowadays there is evidence that final improvements can be achieved as well: Bildschirmfoto 2018-06-13 um 23.06.57 Bildschirmfoto 2018-06-13 um 23.10.43 Fig. 7 & 8: Clinical and radiological improvements after bracing with the GBW Bildschirmfoto 2018-06-13 um 23.12.57 Abb. 5 Fig. 9 & 10. Improvement of a boy with a curve exceeding 50° (56°) and improvement of an early onset scoliosis from 48 to 24° after growth. Bildschirmfoto 2018-06-13 um 23.18.06 Bildschirmfoto 2018-06-13 um 23.18.35 Fig. 11 & 12. Good in-brace correction leads to a good final result after treatment....... Bildschirmfoto 2018-06-13 um 23.17.27 Fig. 13. Also improvements of the rib hump are possible. Bildschirmfoto 2018-06-13 um 23.02.54 Fig. 14. Patient with 38° initially at the age of 11 with final result of 19° 5.6 years after brace weaning without any further treatment. This shows that stable corrections can be achieved when treatment starts early enough and if enough growth for correction can be expected. This case is described more deeply in a case report. Bildschirmfoto 2018-06-13 um 23.01.43 Fig. 15. Patient working as a wedding gown model after having had treatment with the GBW As a matter of fact in-brace correction depends on many factors. There is a clear negative correlation between age and in-brace correction. This means more mature patients at Risser 4 will not correct as easily as immature patients (e.g.. girls at 11 to 13 years of age). Bildschirmfoto 2016-02-24 um 21.00.33 Fig. 16. A big curve in a patient at growth will have moderate in-brace corrections. The patient received ECSW therapy due to functional tethered cord syndrome and had no more pains during her sportly activities Bildschirmfoto 2018-06-13 um 23.24.36 Fig. 17. Some patients do not want to undergo surgery even with curvatures exceeding 80°. So we try to achieve some corrections also in curvatures of that size although these braces are not as comfortable to wear as braces for curve up to 50°and may need additional tools In-brace correction also depends on the size of the curvature: The bigger the curve (Cobb angle) the smaller the in-brace correction. In-brace correction also depends on curve pattern: While single curve patterns are more easily to correct double or triple curves are harder to correct. Especially the curve patterns with a high lumbar apex and a low thoracic apex has not enough lever arm to be correctable to a high extent. Even if in this pattern of curvature big improvement of the x-ray cannot be achieved the cosmetic outcome is beneficial when the patient wears the brace as prescribed. More information can be gained here.

Bildschirmfoto 2015-08-12 um 23.15.29Fig. 18. Curve pattern where big radiologic gains cannot be expected, however, cosmetic improvements are regularly achieved when compliance can be gained. Rarely corrections like this can be achieved in double curves .

Bildschirmfoto 2016-02-04 um 22.01.06Fig. 19. Double thoracic curves also do not correct to a very high extent, however these combined curves are cosmetically less obvious. About 5% of the patients with Adolescent Idiopathic Scoliosis (AIS) do not correct well although the bracing standard does not allow huge variations. In these cases a functional tethering of the spinal cord may be the reason. This has been described in a paper by Weiss et al.. But also without a large in brace correction in most patients from this population progression can be prevented. A paper on MRI shows the subtle signs of functional tethering, which may be treated by special exercises and extra corporal shock wave therapy (ECSWT). We are proud to see more and more professionals are using this successful approach all over the world..... Bildschirmfoto 2018-06-13 um 22.34.01 Fig. 20. Sufficient in-brace correction in a single thoracolumbar curve treated with a GBW in Thessaloniki, Greece. Bildschirmfoto 2018-06-13 um 23.39.36Fig. 21. In uncomplicated single curve pattern scoliosis with a GBW sometimes an overcorrection can be achieved which will lead to a beneficial outcome. (with kind permission of Nicos Tournavitis, Thessaloniki, Greece) In a recent paper it has been shown that the GBW maybe beneficial also to patients with curves exceeding 40°. The members of our growing international team will be happy to serve you with the best possible bracing technology as available today....... More informations for patients can be found here and more information for professionals are available here.

What is most important, the Cobb angle in the x-ray or the trunk deformity?

Fig. 22.
The curve is reduced and a cervicothoracic curve has developed during brace treatment with a GBW now that the patient is more mature. The question arises: Is this an adverse development?

Fig. 23. (1) Clinically in this case certainly this is a great improvement for the patient and (2) radiologically it is beneficial as well, considering the fact that combined curves are far less progressive in adulthood than single thoracic curves. The initial ribhump is largely reduced and the (new) shoulder hump is hardly visible in upright posture.

More examples with clinical improvement can be found in the recent literature:

1. Hans-Rudolf Weiss, Nicos Tournavitis, Sarah Seibel, Alexander Kleban (2017)  A Prospective Cohort Study of AIS Patients with 40° and More Treated with a Gensingen Brace (GBW): Preliminary Results. The open orthopaedics journal 11:  1558-1567 12.

2. Hans-Rudolf Weiss, Deborah Turnbull, Sarah Seibel, Alexander Kleban (2019)  First end-result of a prospective cohort with AIS treated with a CAD Chêneau style brace. Journal of physical therapy science 31:  12.  983-991 Dec.

3. Hans-Rudolf Weiss, Deborah Turnbull (2020)  Brace Treatment for Children and Adolescents with Scoliosis [Online First] In: Spinal Deformities in Adolescents, Adults and Older Adults  Edited by:Bettany-Saltikoc J, Turnbull D.   IntechOpen.

4. Hans-Rudolf Weiss, Manuel Lay, Sarah Seibel, Alexander Kleban (2020)  Is it possible to improve treatment safety in the brace treatment of scoliosis patients by using standardized CAD algorithms? Der Orthopade Oct.

Finally some more pictures of short braces for single lumbar deformities one of them printed....
These examples have all been provided by Xiaofeng Nan, Xi'an, China