Pelvic tilt and trunk inclination: new predictive factors in curve progression during the Milwaukee bracing for adolescent idiopathic scoliosis

Introduction

Previous studies had shown that sagittal spinal and pelvic morphology may be associated with the development and progression of adolescent idiopathic scoliosis, but the predictive value of initial spinal and pelvic morphology on the curve progression during brace treatment is unknown. The objective of this study was to evaluate the relation between initial spinopelvic morphology and the risk of curve progression of adolescent idiopathic scoliosis with the Milwaukee brace.

Materials and methods

From 2002 to 2007, adolescent idiopathic scoliosis (single thoracic curve with apex at or above T8) was treated with the Milwaukee brace in 60 girls. Initial standing, full-length lateral radiographs were made and seven sagittal radiographic parameters of spinal and pelvic alignment were measured. Patients were followed until skeletal maturity or progression of Cobb angle >45°. The progression of curve was defined as an increase of Cobb angle ≥6° at final follow-up or progression to surgery during brace treatment.

Results

The 45 patients (75.0 %) who had successful control of curve progression were initially significantly more skeletally mature (higher mean Risser sign) than the 15 patients (25.0 %) who had curve progression. The initial mean Cobb angle was similar between the stable and progressed groups. The mean pelvic tilt, T1-spinopelvic inclination and T9-spinopelvic inclination angles were significantly greater in the stable group than in the progressed group and these three angles were independent predictors for curve progression during brace treatment. There were no significant differences between the stable and progressed groups in initial mean pelvic incidence, sacral slope, thoracic kyphosis or lumbar lordosis angles. Pre-bracing pelvic tilt ≤?0.5° was strongly predictive and T1-spinopelvic inclination ≤3.5° was moderately predictive of curve progression during the Milwaukee brace treatment.

Conclusions

Initial pelvic tilt and spinopelvic inclination angles may predict the curve progression and treatment outcome of adolescent idiopathic scoliosis with the Milwaukee brace.     

Idiopathic scoliosis: transcutaneous muscle stimulation versus the Milwaukee brace

This paper compared 3-year results of electrical stimulation with the Milwaukee brace for the treatment of idiopathic scoliosis. Fifty patients in each group were compared retrospectively and matched for age, sex, Risser sign, and curve morphology. Evaluations were performed at 6-month intervals with radiographs and examinations. Skin irritation was the most common complication with electrical stimulation. Using survivorship analysis methods, no significant differences were found in rates of curve progression or failure. Overall, 70% of the patients in each group were successfully maintained over a course of 3 years. Electrical stimulation is comparable to the Milwaukee brace in managing idiopathic scoliosis.     

Role of exercises in the Milwaukee brace treatment of scoliosis

Specific exercises designed to strengthen trunk muscles are an integral part of most Milwaukee brace treatment protocols. To assess the effectiveness of these exercises, we established a prospective study evaluating a closely monitored exercise program coordinated with the use of a Milwaukee brace. Between 1973 and 1979, 24 girls treated with a Milwaukee brace for documented progression of primary right thoracic idiopathic scoliosis were selected for the study. All patients were instructed to perform a standard set of exercises based on the program of Blount and Moe (The Milwaukee Brace [Williams and Wilkins, 1973]). Twelve patients who were regular exercisers constituted the exercise group; 12 patients noncompliant in performing regular exercises composed the control group. Both groups remained faithful brace wearers. No significant difference was found between the two groups regarding age at onset, initial curve degree, skeletal maturity, total time in brace, or general activity level. There was no statistically significant difference in curve improvement between the two groups (p = 0.95). This preliminary study suggests that the Milwaukee brace alone is as effective in halting curve progression as a Milwaukee brace plus standard prescribed exercises.     

Effectiveness of braces in mild idiopathic scoliosis

Despite the wide use of bracing for the treatment of idiopathic scoliosis, controlled studies apparently have not been performed to examine whether bracing, in fact, alters the natural history of spine lateral curves. We studied 255 female patients, ages 8-17 years, with idiopathic scoliosis who had curves with initial Cobb measures from 15-30 degrees. They were divided into two groups: one group consisted of 144 patients who had received a Milwaukee or Boston brace; and the other, a control group, consisted of 111 patients who remained untreated through a mean period of 1.9 years. The groups had similar mean ages, ages of menarche and curve severities. The results showed a slight but nonsignificant trend, suggesting that bracing reduced the overall probability of progression in the braced curves. However, noting that nearly 75% of the control group curves were nonprogressive, it is possible that a similar proportion of the braced curves need not have been braced. Moreover, bracing failed to prevent eight curves in seven patients (5%) from progressing. These curves progressed at a mean rate of 8 degrees per year. Our retrospective results suggest that bracing probably is not necessary in a large proportion of patients who meet current, clinical criteria for bracing. Given the limitations of retrospective studies like this one, a controlled prospective trial of bracing effectiveness in idiopathic scoliosis seems warranted.     

Follow-up study of Milwaukee brace treatment in patients with idiopathic scoliosis

Milwaukee brace treatment for patients with idiopathic scoliosis very rarely accomplishes improvement approaching that of successful surgery. Prpgression of small and medium-sized curves (60 degrees or less) has been routinely halted. Few curves progress with adequate brace treatment. Occasionally, improvement in deformity and curve measurement is significant, but loss of improvement seems to be gradual and almost uniformly present to some degree after cessation of treatment. A much longer follow-up period will be necessary if the improvement seen with Milwaukee brace treatment can be considered "permanent." Milwaukee brace treatment is effective in skeletally immature patients with small, flexible and nondeforming curves. Corrective surgery is recommended for deforming curves in all patients for whom permanent improvement is the goal.     

Role of the triradiate cartilage in predicting curve progression in adolescent idiopathic scoliosis

Braces are commonly used to treat progressive adolescent idiopathic scoliosis. Several previous studies have reported a correlation between the success of brace treatment and skeletal maturity markers. These studies have not focused on the status of the triradiate cartilage (TRC) as it relates to successful brace treatment for adolescent idiopathic scoliosis. The authors retrospectively evaluated all patients at their institution from 1990 to 1997 with a diagnosis of adolescent idiopathic scoliosis who were treated in a Boston brace. Sixty-two patients met inclusion criteria. At presentation, the average age was 12.87 years, the average Risser sign was 0.56, and 45% of patients had an open TRC. The average follow-up was 2.92 years. Greater than 5 degrees of progression at discontinuation of bracing was considered a failure. Curves with a closed TRC failed bracing 21% of the time, whereas those with an open TRC failed 54% of the time (P = 0.0069). Those curves with a closed TRC progressed 3.12 degrees on average, whereas curves with an open TRC progressed 6.86 degrees. Curves associated with a closed TRC at initiation of bracing progressed less frequently and to a lesser degree than those associated with an open TRC (P = 0.027). Although the TRC is not an independent predictor of curve stability, it is an additional indicator of skeletal maturity and may prove most useful in patients with otherwise borderline indications for brace treatment.     

Nighttime bracing with the Providence brace in adolescent girls with idiopathic scoliosis

STUDY DESIGN: A prospective study was conducted of 102 consecutive female patients with adolescent idiopathic scoliosis. Those patients with Risser 0, 1, and 2 met the criteria for inclusion and were treated only with the Providence brace. OBJECTIVES: To report the authors' experience with a hypercorrective nighttime brace and to evaluate the results with respect to risk factors for progression. Second, the study compares results with expectations from the natural history as reported by others. SUMMARY OF BACKGROUND DATA: Compliance with full-time brace treatment for adolescent idiopathic scoliosis has been a problem. Since the introduction of the Milwaukee brace, alternatives such as low-profile braces, reduced wearing schedules, and nighttime only bracing have been tried. However, many factors influence the success or failure besides compliance. These include in-brace correction, brace design, and the orthotist's skills. This is the first report of the results of treatment with a new nighttime brace that is made with CAD/CAM technology that can achieve higher initial in-brace corrections than other reported methods. METHODS: Results were analyzed with respect to curve size, curve pattern, maturity, and level of the primary curve apex. Both compliant and noncompliant patients were included in the analysis. A univariate analysis was done on those factors thought to influence success with bracing using the Pearson chi2 test. RESULTS: The average initial in-brace correction with a supine radiograph was 96% for major curves and 98% for minor curves. Seventy-five patients (74%) did not progress >5 degrees and 27 patients (26%) progressed > or =6 degrees or went on to surgery. Twenty-nine percent of Risser 0 or 1 patients progressed and 17% of patients Risser 2 progressed. The risk of progression anticipated by natural history data, which included all curve patterns, was 68% for Risser 0 and 1 and 23% for Risser 2. Risser 3 and 4 patients were excluded from the study. Seventy-six percent of patients with curve apexes between T8 and L1 had successful outcomes using the Providence brace. This is compared with a 74% success rate in the prospective Scoliosis Research Society study of patients wearing a thoraco lumbar sacral orthosis for 16 hours per day with curve apexes between T8 and L1. With the Providence brace, 63% of thoracic curves and 65% of double curves were successful. Ninety-four percent of lumbar curves and 93% of thoracolumbar curves were successful. CONCLUSION: Excellent initial in-brace correction of adolescent idiopathic scoliosis was observed with this computer-designed and manufactured recumbent brace. Patients with high apex curves cephalad to T8 (n = 31) had a success rate of 61% compared with a success rate of 79% (n = 71) if the apex was at or below T9. Compared with previous natural history and the prospective study data, the Providence brace is effective in preventing progression of adolescent idiopathic scoliosis for curves <35 degrees. It was effective for larger curves with a low apex. The authors' experience with patients with curves >35 degrees (n = 8) is too small to validate its effectiveness for larger curves with a higher apex.     

The influence of elastic orthotic belt on sagittal profile in adolescent idiopathic thoracic scoliosis: a comparative radiographic study with Milwaukee brace

Background  

The effectiveness of bracing on preventing curve progression in coronal plane for mild and moderate adolescent idiopathic scoliosis (AIS) patients has been confirmed by previous radiographic researches. However, a hypokyphotic effect on the sagittal plane has been reported by a few studies. A relatively increasing number of AIS patients were noticed to wear a new kind of elastic orthotic belt for the treatments of scoliosis without doctors' instructions. We postulate the correcting mechanism of this new appliance may cause flattening of the spine. To our knowledge, no study has investigated the effects of this new orthosis on the sagittal profile of AIS patients. The aim of this study was to evaluate and compare the effects of elastic orthotic belt and Milwaukee brace on the sagittal alignment in AIS patients.     

Efficacy of a new computer-aided design/computer-aided manufacture orthosis in the treatment of adolescent idiopathic scoliosis

To report on the initial experience with the Los Angeles brace, a new computer-aided design/computer-aided manufacture brace used in the treatment of idiopathic scoliosis. This was a retrospective review of 40 idiopathic scoliosis patients who completed treatment with this new computer-aided design/computer-aided manufacture brace. In-brace correction averaged 51% for the primary curves, with corrections of 53 and 22% for girls and boys, respectively. Only six patients (15%) had curve progression at brace completion. This preliminary study suggests that the new Los Angeles brace is effective in the treatment of scoliosis in girls, while avoiding some obstacles involved in traditional bracing.     

Prognosis of brace-treated scoliosis: Comparison of the Boston and Milwaukee methods in 244 girls

Totally, 244 females with adolescent idiopathic scoliosis treated by brace were followed for at least 2 years after treatment. The initial curve magnitude correlated with failure, notably thoracic curves. The Boston brace was more successful than the Milwaukee brace irrespective of initial curve magnitude and skeletal maturity.     

Prognosis of brace-treated scoliosis. Comparison of the Boston and Milwaukee methods in 244 girls

Totally, 244 females with adolescent idiopathic scoliosis treated by brace were followed for at least 2 years after treatment. The initial curve magnitude correlated with failure, notably thoracic curves. The Boston brace was more successful than the Milwaukee brace irrespective of initial curve magnitude and skeletal maturity.     

Evolution of the curve patterns during brace treatment for adolescent idiopathic scoliosis

Summary of background data

The curve pattern of idiopathic scoliosis is important for making decisions concerning bracing. However, whether the curve pattern changes during brace treatment have not been fully documented. The aim of this study was to investigate the changes of curve pattern during brace treatment in skeletally immature patients with adolescent idiopathic scoliosis (AIS).

Methods

From January 2002 to January 2011, AIS patients treated with a Boston or Milwaukee brace were recruited after meeting the following inclusion criteria: older than 10 years of age at initiation of bracing; having a Cobb angle of 25°–40°; with a Risser sign 0–2; being regularly followed until the weaning of brace or the necessity of surgical treatment; and without history of previous treatment. A total of 130 female and 11 male AIS patients were included. The mean age was 12.9 years at initiation of bracing, and the female patients were, on average, 2.7 months past menarche. The mean follow-up period was 2.6 years (range 1.0–5.5 years). The definitions of changes in curve patterns were divided into four categories as follows: (1) shift of the apex of the main curve; (2) change in the curve span of more than two vertebrae; (3) change in the main curve type with regard to the apex location; and (4) change of curve direction. The patients were divided into two groups. Group A was comprised of patients who had experienced one or more categories of curve pattern changes, and Group B was comprised of those who had not.

Results

Of these 39 patients, 14 had apex shifting, 2 underwent curve span changes, 22 experienced changes in the main curve type, and one female had both changes in the apex and curve span. At the initiation of bracing, patients in Group A demonstrated significantly lower menarchal status (P = 0.018) and lower Risser grade (P = 0.025) than those in Group B. The difference in the percentage of patients who underwent Boston bracing between the two groups was statistically significant (41.5 % for Group A vs. 24.0 % for Group B, P = 0.023).

Conclusion

Changes in curve pattern can occur during brace treatment. Patients with less skeletal maturity and those treated with a Boston brace are more susceptible to this phenomenon.     

Clinical effect of continuous corrective force delivery in the non-operative treatment of idiopathic scoliosis: a prospective cohort study of the triac-brace

A prospective cohort study of skeletally immature idiopathic scoliotic patients treated with the TriaC brace. To determine if the TriaC brace is effective in preventing curve progression in immature adolescent idiopathic scoliotic patients with a very high risk of curve progression based on reported natural history data. The aim of the newly introduced TriaC brace is to reverse the pathologic transverse force pattern by externally applied and continuously present orthotic forces. In the frontal plane the force system used in the TriaC brace is similar to the force system of the conventional braces. However, in the sagittal plane the force system acts only on the thoracic region. In addition, the brace allows upper trunk flexibility without affecting the corrective forces during body motion. In a preliminary study it is demonstrated that the brace prevents further progression of both the Cobb angle and axial rotation in idiopathic scoliosis. Skeletally immature patients with idiopathic scoliosis with curves between 20 and 40° were studied prospectively. Skeletally immature was defined as a Risser sign 0 or 1 for both boys and girls, or pre-menarche or less than 1-year post-menarche for girls. Curves of less than 30° had to have documented progression before entry. The mean age of the patients at the start of treatment was 11.3 ± 3.1 years. All measurements were collected by a single observer, and all patients were followed up to skeletal maturity. Treatment was complete for all participants when they had reached Risser sign 4 and did not show any further growth at length measurements. This was at a mean age of 15.6 ± 1.1 years, with a mean follow-up of 1.6 years post bracing. In our study a successful outcome was obtained in 76% of patients treated with the TriaC brace. Comparing our data to literature data on natural history of a similar cohort shows that the TriaC brace significantly alters the predicted natural history. The current study demonstrates that treatment with the TriaC brace reduces the scoliosis, and that the achieved correction is maintained in some degree after skeletal maturity is reached and bracing is discontinued. It also prevents further progression of the Cobb angle in idiopathic scoliosis. The new brace does not differ from the conventional braces as far as maintaining the deformity is concerned.     

TLSO treatment of idiopathic scoliosis. An analysis of the Wilmington jacket

A retrospective study of one hundred female patients treated for idiopathic scoliosis using an underarm plastic thoracolumbar-sacral orthosis (TLSO) jacket was undertaken. The purpose of the study was to evaluate the efficacy of the Wilmington jacket, to search for clinical variables which could statistically predict success, and to evaluate preliminary results of parttime bracing in 25 patients. The following parameters were statistically evaluated by multiple regression analysis: age, sex, curve location, number of vertebrae in curve, Cobb angle, maturity (Risser sign, menarche), curve flexibility, and hours in the jacket. The overall success rate was 81%, and onset of menarche and Risser sign were statistically significant prognostic variables. Ten patients (10%) underwent posterior spinal fusion for curve progression. Bracing with an underarm scoliosis jacket is a successful method of treatment of idiopathic scoliosis in the immature spine. We do not recommend brace treatment for postmenarchal patients or patients with a Risser sign of Grade 1 or greater until curve progression has been observed. Furthermore, the Wilmington jacket appears to give similar results for part-time brace wearers.     

Results of brace treatment of adolescent idiopathic scoliosis in boys compared with girls: a retrospective study of 102 patients treated with the Boston brace

The aim of the study was to compare the results of brace treatment of adolescent idiopathic scoliosis (AIS) in male patients with matched female patients and to assess the effectiveness of bracing of boys in AIS and to discuss the results with published data. Between 1987 and 1995, 51 consecutive male patients with AIS were treated with the Boston brace. The patients were advised to wear the brace 23 h/day. The medical records of all patients were reviewed. Cobb angles and Risser signs were measured before bracing, in brace, at brace discontinuation and at final follow-up. Everyone of 51 male patients was compared with a female patient who was treated by the same method and matched by Risser sign, curve pattern, curve magnitude and duration of treatment and follow-up time. Compliance with brace was noted at every visit. Fourteen boys had worn the brace only during nighttime or occasionally and were considered non-compliant. Only compliant patients with treatment period > 1 year and follow-up > 1 year after treatment were accepted for the analyses of effectiveness of brace treatment and its prognostic factors. Thirty-three boys met these inclusion criteria. Bracing was considered to have a failure if > 5° progression occurred or if surgery was performed. At the final follow-up study progression > 5° was found in 16/51 (31.4%) of male patients. Corresponding figures of female patients were 11/51 (21.6%), respectively. In compliant boys progression > 5° occurred in 6/33 boys compared with 9/33 girls. The association between risk of progression and correction% in brace was statistically significant. The overall results of brace treatment of idiopathic scoliosis in male patients were inferior compared with matched females. One reason for inferior overall results in boys was poor compliance with brace wear. However, brace treatment in AIS may be recommended with the same principles in both genders.     

Adolescent idiopathic scoliosis managed by a nighttime bending brace.

This study evaluated and compared the effectiveness of managing adolescent idiopathic scoliosis with a total contact bending spine orthosis worn only during nighttime sleep with established bracing programs and electrical stimulation treatment. Brace treatment was prescribed for 30 patients with adolescent idiopathic scoliosis for the management of 50 spinal curvatures averaging 28.5 degrees (range: 13 degrees-40 degrees). Average patient age at the initiation of brace wear was 12+/-10 years (range: 9+/-10 to 16+/-8 years). All 30 patients were skeletally immature (Risser sign, 0-3) at initiation of orthotic treatment and underwent follow-up to maturity. Patients were instructed to wear the braces for at least 8-10 hours a day during nighttime sleep. Eighteen of 30 patients were compliant with the bracing program. Compliance with the nighttime bending brace was no better than the reported compliance with established thoracolumbosacral orthosis programs. Moreover, noncompliant patients and those treated by the ineffective electrical stimulation program also did not differ in curve progression. Curve progression was controlled in 56% of the compliant patients, and the nighttime bending brace was considered as effective as the Wilmington brace in controlling adolescent idiopathic scoliosis. Both braces were more effective than the ineffective electrical stimulation treatment.     

Results of Charleston bracing in skeletally immature patients with idiopathic scoliosis

Previous studies have reported varying success rates with the use of the Charleston brace in idiopathic scoliosis. However, these studies have included patients from multiple centers, those with double curves, and those still undergoing treatment. This article presents the results of Charleston bracing in 42 skeletally immature patients (Risser 0/1) treated at one institution and followed up for a mean of 3.3 years after brace discontinuation. Selection criteria included a diagnosis of idiopathic scoliosis, Risser stage 0 or 1, at least 10 years of age at the time of bracing, female gender, a single curve between 25 degrees and 40 degrees, and no prior treatment. The average age at the time of bracing was 12.5 years (range 10-15) and the average curve was 30.3 degrees (range 25 degrees -40 degrees ). Outcome was considered a failure if the curve had increased more than 5 degrees at last follow-up, if surgical intervention was required, or if there was a change of orthosis during treatment (e.g., Charleston to Boston). In 25 of the 42 patients (60%), the brace was successful in preventing progression of the curve (mean follow-up 3.4 years; range 1.1-11.7). Thoracic curves had the same success as thoracolumbar and lumbar curves. Based on these results, the authors conclude that the Charleston brace is effective in preventing progression of curve. Proper patient selection is important.     

Advances in scoliosis brace treatment for adolescent idiopathic scoliosis

Orthotic treatment with a brace remains the treatment of choice for adolescent idiopathic scoliosis in the immature patient with documented progression or a curve magnitude of 25 degrees to 40 degrees . Studies of natural history and bracing consistently show high rates of curve progression and surgery with observation and significantly less so with brace treatment. Brace treatment is difficult in overweight patients and challenging in males. Many of the variations in brace study results may be attributable to differing rates of compliance with brace wear, a parameter that is becoming easier to measure.     

Effectiveness of the Providence nighttime bracing in adolescent idiopathic scoliosis: a comparative study of 36 female patients

The aim of the study was to assess the results of treatment of adolescent idiopathic scoliosis (AIS) with the Providence nighttime brace at 1.8 years after discontinuation of bracing. A total of 36 consecutive female patients with an average Cobb angle of 28.4° and an apex below T 10 were studied prospectively. For comparisons, 36 matched patients treated with the Boston full-time brace were studied retrospectively. With the Providence night brace an average of 92% for brace correction of the primary curve was achieved and during follow-up progression of the curve >5° occurred in 27% of the patients. In the control group of the Boston full-time brace patients, brace correction was 50% and the progression of the major curve occurred in 22% of the patients. We conclude that the Providence night brace may be recommended for the treatment of AIS with curves less than 35° in lumbar and thoracolumbar cases.     

The effect of lumbar flexion and Boston Thoracic Brace on the curves in idiopathic scoliosis

The correction of scoliosis induced by pure lumbar flexion was compared with the correction with the so-called Boston Thoracic Brace. Ten patients with idiopathic scoliosis were studied. There were 11 primary curves (31 +/- 6 degrees) (mainly thoracic) and four secondary curves (22 +/- 1 degree). Pure lumbar flexion reduced the primary curves by 6 +/- 2 degrees and the secondary curves by 8 +/- 3 degrees. The brace reduced the curves by 16 +/- 6 degrees and 14 +/- 5 degrees, respectively. Lumbar flexion per se produces a correction of the scoliosis of the same degree as the Milwaukee brace. Our results emphasize the importance of reduction of the lumbar lordosis in the conservative treatment of scoliosis.