Indications for Treatment and Outcomes Evaluation for the
Orthotic Management of Idiopathic Scoliosis Thomas M. Gavin, C.O.
BioConcepts, inc. Burr Ridge, Illinois, USA Musculoskeletal
Biomechanics Laboratory. Veterans Administration Hospital, Hines,
Illinois, USA Thomas M. Gavin, C.O. BioConcepts, inc. Burr Ridge,
Illinois, USA Musculoskeletal Biomechanics Laboratory. Veterans
Administration Hospital, Hines, Illinois, USA AOPA Seattle
2009
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Timothy J. Newton, C.O. January 4 th 1949-September 13 th
2009
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SRS Definition of Terms ACCEPTEDNOMENCLATURE FOR SPINAL RELATED
CONDITIONS AND PROCEDURES RELATED TO SPINAL DEFORMITIES.
ACCEPTEDNOMENCLATURE FOR SPINAL RELATED CONDITIONS AND PROCEDURES
RELATED TO SPINAL DEFORMITIES.
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IDIOPATHIC SCOLIOSIS
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ORTHOTIC TREATMENT FOR IDIOPATHIC SCOLIOSIS n Why use an
orthosis? n When do we use an orthosis? n How does an orthosis
work? n How long should it be worn? n Which orthosis should I use?
n Is part-time treatment effective? n What is the chance of still
needing surgery after orthotic management? n Why use an orthosis? n
When do we use an orthosis? n How does an orthosis work? n How long
should it be worn? n Which orthosis should I use? n Is part-time
treatment effective? n What is the chance of still needing surgery
after orthotic management?
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CURVE PATTERNS AND MEASUREMENTS
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Left Lumbar Curve King Type I
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Right Thoracic Primary Left Lumbar Compensatory Curves. King
Type II
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KingRight Thoracic Curve King Type III
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Thoracolumbar Curve King Type IV
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Cobb Angle 51
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ABCDE A. 0 Rotation. Neutral. No Rotation. B. +1 Rotation.
Pedicle Towards Midline. Concave Direction. C. +2 Rotation. Pedicle
2/3 to Midline. D. +3 Rotation. Pedicle at Midline. E. +4 Rotation.
Pedicle Beyond Midline. A. 0 Rotation. Neutral. No Rotation. B. +1
Rotation. Pedicle Towards Midline. Concave Direction. C. +2
Rotation. Pedicle 2/3 to Midline. D. +3 Rotation. Pedicle at
Midline. E. +4 Rotation. Pedicle Beyond Midline. Vertebral
Rotation.
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Maturation and Development n Vertebral Ring Apophyses. n Line
of Risser. n Development of Secondary Sex Characteristics. n
Menarche. n Growth Velocity. n Vertebral Ring Apophyses. n Line of
Risser. n Development of Secondary Sex Characteristics. n Menarche.
n Growth Velocity.
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VERTEBRALRING APOPHYSES
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A BC A. Ring Apophysis Begins To Form. B. Ossification
Complete, Not United With Body. C. Ossified and United With Body.
Mature.
From Bunch and Patwardhan: Scoliosis; Making Clinical
Decisions. CV Mosby Company, 1989 Bracing initiated at 6- 18 months
Premenarchal
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From Bunch and Patwardhan: Scoliosis; Making Clinical
Decisions. CV Mosby Company, 1989 Bracing Initiated 6 Months
Premenarchal to 6 Months Post Menarche
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From Bunch and Patwardhan: Scoliosis; Making Clinical
Decisions. CV Mosby Company, 1989 Bracing Initiated 6-18 Months
Post-Menarche
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Determining Clinical Curve Stiffness. n Side Bending Correction
of Each Curve. n Expressed As % Correction From Normal. n %
Correction Thoracic: % Correction Lumbar = Flexibility Index As
Reported by King Et Al. n Side Bending Correction of Each Curve. n
Expressed As % Correction From Normal. n % Correction Thoracic: %
Correction Lumbar = Flexibility Index As Reported by King Et
Al.
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A. B.C. A. Normal Coronal Alignment. B. Right Side Bending.
Primary Thoracic Curve Resists Corrective Forces. C. Left Side
Bending. Compensatory Lumbar Curve Corrects To Nearly 0. A. Normal
Coronal Alignment. B. Right Side Bending. Primary Thoracic Curve
Resists Corrective Forces. C. Left Side Bending. Compensatory
Lumbar Curve Corrects To Nearly 0.
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Biological Changes in Bone Morphology Epiphyseal Growth Is
Slowed When Epiphyses Are Compressed. (Hueter-volkman Principle)
Epiphyseal Growth Is Slowed When Epiphyses Are Compressed.
(Hueter-volkman Principle)
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HUETER-VOLKMAN WEDGING. WEDGING. Concave Side Epiphysis
Develops at a Slower Rate Than Convex Side Due to Compression.
HUETER-VOLKMAN WEDGING. WEDGING. Concave Side Epiphysis Develops at
a Slower Rate Than Convex Side Due to Compression.
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Clinical Evaluation and Mechanism of Action n Orthoses must be
designed and fitted to: u Reduce Curve Maximally. u Reduce Any
Decompensation. u Be Easily Adjusted. u Keep Constant Force On
Curves. u Be As Comfortable As Possible.
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NATURAL HISTORY: RISK OF CURVE PROGRESSION.
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CURVE PROGRESSION n Age. u Older Children Are Less Likely to
Progress at Curve Magnitudes That Are Progressive in Younger
Children. n Magnitude. u Larger Curves Are More Unstable Than
Smaller. n Curve Pattern. u Thoracic and Double Primary Curves
Progress Less Than Single Lumbar or Thoracolumbar Curves. n Age. u
Older Children Are Less Likely to Progress at Curve Magnitudes That
Are Progressive in Younger Children. n Magnitude. u Larger Curves
Are More Unstable Than Smaller. n Curve Pattern. u Thoracic and
Double Primary Curves Progress Less Than Single Lumbar or
Thoracolumbar Curves.
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Risk of Progression by Risser Sign. Lonstein and Carlson 1984
JBJS
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Risk of Progression by Chronological Age. Lonstein and Carlson
1984 JBJS
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LONG-TERM CURVE PROGRESSION. (Avg. F/U 40 Years Post Diagnosis)
From Weinstein et. al. 1984 JBJS
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Weinstein Zavala and Ponsetti 1984 JBJS n 68% progressed > 5
degrees. n 37% progressed in last 10 years. (avg. F/U 40 years post
diagnosis.) n 68% progressed > 5 degrees. n 37% progressed in
last 10 years. (avg. F/U 40 years post diagnosis.)
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TREATMENT OUTCOME EXPECTATIONS.
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Moe and Kettleson. 1970 JBJS n 169 Patients Treated With
Milwaukee Brace. n 23% Average Correction of Thoracic Curves
Post-treatment. n 18% Average Correction of Lumbar and
Thoracolumbar Curves Post- treatment. n Short Term Results. n 169
Patients Treated With Milwaukee Brace. n 23% Average Correction of
Thoracic Curves Post-treatment. n 18% Average Correction of Lumbar
and Thoracolumbar Curves Post- treatment. n Short Term
Results.
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Carr et. al. JBJS 1980 n Re-Reviewed Moes Patients From 1970. n
Reported on Late Losses of Correction. n Showed Late Losses of
Correction. n Results Showed Residual Curves Still Less Than
Pre-orthosis Magnitude. n Re-Reviewed Moes Patients From 1970. n
Reported on Late Losses of Correction. n Showed Late Losses of
Correction. n Results Showed Residual Curves Still Less Than
Pre-orthosis Magnitude.
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Residual Curve 5-Years Post-Treatment By Menarche Value at
Initiation Of Orthosis. Bunch and Patwardhan, Chapter 13,
Scoliosis; Making Clinical Decisions. 1989.
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Surgical Rates Following Orthotic Treatment Based on Initial
Risser Sign. From: Milwaukee Brace Treatment Of Ais. Lonstein and
Winter. JBJS 1994
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Bunch Reported Best Curve Reduction for Youngest Group and
Lonstein Reported Highest Surgical Rates for Youngest Group?
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Orthotic Outomes; Failure Boundary
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PART-TIME VERSUS FULL-TIME
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A META-ANALYSIS OF THE EFFICACY OF NONOPERATIVE TREATMENT FOR
IDIOPATHIC SCOLIOSIS. Rowe et al. - J Bone and Joint Surgery [Am].
79-A (5) 664-674, 1997.)
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A Comparison Between The Boston Brace And The Charleston
Bending Brace In Adolescent Idiopathic Scoliosis. Katz DE, Richards
S, Browne RH, Herring JA. Spine, 22(12); 1302-1312,1997.
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Primary Goals. n Correct Curves >50%. n Maintain Correction
Throughout Duration of Wear. n Address Psycho-social Issues. n
Fulltime Until Proven Otherwise. n Maximal Comfort. n Minimal
Structure. n Correct Curves >50%. n Maintain Correction
Throughout Duration of Wear. n Address Psycho-social Issues. n
Fulltime Until Proven Otherwise. n Maximal Comfort. n Minimal
Structure.
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SummarySummary n Orthoses Must Improve Stability To Yield
Optimal Outcome! Optimizing Orthotic Treatment Requires; 1. Proper
Patient Selection (Age, Magnitude, Documented Progression). 2.
Utilization of All Mechanisms of Action to Improve Stability. 3.
Frequent Follow-Up Adjustments To Restore Orthosis to Optimal Fit
and Function. 3. Frequent Follow-Up Adjustments To Restore Orthosis
to Optimal Fit and Function. 4. Sound Clinical Procedures! 4. Sound
Clinical Procedures! n Orthoses Must Improve Stability To Yield
Optimal Outcome! Optimizing Orthotic Treatment Requires; 1. Proper
Patient Selection (Age, Magnitude, Documented Progression). 2.
Utilization of All Mechanisms of Action to Improve Stability. 3.
Frequent Follow-Up Adjustments To Restore Orthosis to Optimal Fit
and Function. 3. Frequent Follow-Up Adjustments To Restore Orthosis
to Optimal Fit and Function. 4. Sound Clinical Procedures! 4. Sound
Clinical Procedures!
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n In-Orthosis Correction of the Curve Should Always Exceed 50%
n Orthosis Should NOT Increase Decompensation. n When Curve Appears
to Progress From Best In Brace Magnitude, Orthosis Should Be
Adjusted To Restore Curve Reduction. n Weaning Should Be Gradual!
SummarySummary