Experience Key in Scoliosis Brace Decision
Monday March 15, 2010
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Her patient was a teen with a 33-degree curve in her mid back and a 35-degree curve in her lower back. Her pelvis was shifted right, and she had a right rib prominence. Despite wearing a traditional scoliosis brace, her scoliosis had worsened before seeing Marti, and the girl was worried.
The patient was fitted for a brace with a new design and saw Marti regularly to learn exercises to counteract the spinal asymmetry. After three years at Spinal Dynamics, the curves had decreased to 26 degrees in the mid back and 3 degrees in the lower back.
“Once scoliosis starts to worsen in adolescents, there is a risk that it will continue to worsen until skeletal maturity,” Marti says. “If we can stop a progressive curve from worsening, that is a clear sign of success.”
Although cases like this suggest that braces can be effective, a recent review of published research concludes that it is still unclear whether bracing is beneficial. Stefano Negrini, MD, lead author of the review, researched two studies that enrolled patients in different treatment groups and compared how they did. He concluded that “there is very low quality evidence in favor of using braces, making generalization very difficult,” according the study, which appeared in the Jan. 20, 2010 issue of the Cochrane Library.
However, Today in PT interviewed several PTs who work with scoliosis patients, and their experience points to a different conclusion.
Experience Over Data
Patrick Flanagan, CO, FAAOP, team lead for orthotics and prosthetics at Mercy Health System in Illinois, is not surprised by Negrini’s conclusions.
“Some studies show good results, and some show poor results,” he says. “It all depends on how you define success.” Successful bracing, for example, may be defined as preventing surgery, but the requirement for surgery may vary from study to study.
“If you do a study in which you operate on all scoliosis curves that hit 40 degrees, and you compare that to a group that operates at 50 degrees, this can skew what you are measuring and this can alter the results of the study,” Flanagan explains.
Although the data from studies is inconclusive, PTs such as Marti are convinced that bracing has clear benefits.
“I absolutely think good bracing can be effective because I’ve seen it,” she says. “I’ve been treating scoliosis for five years, and I’ve witnessed patients with progressive scoliosis show improvement in their curves when a good brace was introduced.”
She also believes that the physiology of teens supports the use of bracing.
“When you have a skeletally immature patient, the shape of the bone and soft tissues can change based on pressures applied to them while they are developing,” she says.
Even though Marti has seen the benefits of using a brace, she acknowledges that there are key factors that can influence the effectiveness of the device. For example, the amount of education patients and their families receive about the brace can have a noticeable impact on the outcome.
“We really underestimate the need to educate these kids about how to wear the brace and why they are wearing it,” Marti says. “If a patient understands these things, their compliance with wearing the brace will go up. And they have to wear a brace for it to work.”
To educate teens about their scoliosis, patients at Spinal Dynamics see an X-ray of their spine before bracing and then a second X-ray one to three months later showing the spine in the brace. This shows patients how the brace is improving the curve and why it is important to wear it, Marti says.
Although it may be difficult to prove in a study the benefits of physical therapy when it comes to scoliosis, several PTs attested to the fact that the right PT exercises seem to improve the odds that bracing will be beneficial.
“The brace has benefits, but the exercises that we teach can improve posture and muscle tone,” says Michelle Daniels, PT, patient therapy manager at Kernan Orthopedics and Rehabilitation in Baltimore. “We can teach exercises to exert corrective forces on the spine in the direction opposite to the curve.”
Marti traveled to Europe to learn exercises specifically for treating patients with scoliosis. She learned the Schroth method, which is based on the principle that scoliosis has a postural component that can be improved by altering the forces that act on the spine.
“There is more complexity in the Schroth exercises than any PT exercises I’ve done in my 24 years of experience,” Marti says.
Rewards of the Work
Although a brace can be emotionally costly to a teen because of the social awkwardness of wearing a piece of molded plastic on the torso, Marti believes that patients and their families usually are grateful for the opportunity to try to prevent a curve from worsening.
In the case of the girl who was one of Marti’s first patients, helping the teen avoid surgery was one of the most rewarding experiences of her practice.
“When the three-year follow-up X-ray showed such a dramatic improvement, the feeling was almost indescribable,” Marti says. “As a seasoned therapist, I entered this journey of treating scoliosis with excitement, but also with a practical understanding about how long it can take to see improvement. This case validated a lot of our efforts and encouraged me to say it is worth it to keep pressing on.” •
Heather Stringer is a contributing writer for Today in PT.
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