Boston Brace vs. SpineCor Brace
Adolescent idiopathic scoliosis: the effect of (Rigid) brace treatment on the incidence of surgery.
Children’s Research Centre and Orthopaedic Department, Our Lady’s Hospital for Sick Children, Dublin, Ireland. caroline.goldberg@ucd.ie
STUDY DESIGN: Retrospective analysis of outcome in terms of incidence of surgery for adolescent idiopathic scoliosis during a period when bracing was not practiced.
OBJECTIVES: To determine whether centers with an active bracing policy have lower numbers undergoing surgery for adolescent idiopathic scoliosis than a center where nonintervention is the practice.
BACKGROUND DATA: Two major recent publications have claimed that bracing significantly improves the outcome in adolescent idiopathic scoliosis. However, one had no control subjects and the other did not examine the final status of the subjects under review. While statistically significant differences in progression have been observed, what will convince patients to submit to an onerous treatment is the conviction that it will make a substantial difference, such as the avoidance of surgery.
METHODS: Since 1991, bracing has not been recommended for children with adolescent idiopathic scoliosis at this center. The scoliosis database was searched for patients with adolescent idiopathic scoliosis who were at least 15 years of age at last review and who had adequate documentation of curve parameters. The incidence of surgery was compared with that of published data from other centers.
RESULTS: A total of 153 children, 11 boys and 142 girls, fitted the criteria. Forty-three of these (28.1%) have undergone surgery. This was not statistically different from the surgery rate reported from an active bracing center.
CONCLUSIONS: If bracing does not reduce the proportion of children with adolescent idiopathic scoliosis who require surgery for cosmetic improvement of their deformity, it cannot be said to provide a meaningful advantage to the patient or the community. Recent studies notwithstanding, the question of the efficacy of orthoses in idiopathic scoliosis remains unresolved.
Rigid bracing with the Boston Brace, the Providence Brace, and the Wilmington Brace all utilize a three point pressure system to reduce the cobb angle measurement. The mechanism of action is to maintain a more corrected posture during the growth spurts to reduce the forces which promote curvature progression. Unfortunately the constraints of a hard brace may reduced muscle activity and restriction of movement, which may contribute to cortical depression, clinical depression, and a decreased awareness of body position and muscle control.
Dynamic bracing, such as SpineCor, uses muscle activity to enhance cortical activation while encouraging the bodies natural reflexes to improve muscle recruitment patterns, thereby potentially rehabilitating the postural support systems.
Studies now confirm in Adolescents, SpineCor has a 93% success rate after 5 years post brace wearing, whereas the Boston Brace has not been able to show any success in creating curvature reduction after the same time frame.
The question needs to be asked, “If the spinal deformity associated with scoliosis were the sole result of bone deformity, then how does a rigid brace reduce scoliosis immediately when applied to a patient? The logical explanation is simply the curvature is more so a result of a postural muscle failure. Obviously the bones of the spine do not instantaneously change during an active side bend, or if an orthosis is applied. A rigid brace artificially substitutes a lateral pressure for the loss of supportive muscle tone.
Adult treatment has long be assumed to be ineffective due to the attempt to apply the same paradigm of treatment which is successful in adolescents. Adult management of scoliosis requires an active neuro-muscular rehabilitation program which can be managed effectively by a Doctor of Chiropractic.
To simplify this concept, consider that bones are moved by muscles, and muscles are activated by nerves. Peripheral nerves create the connection between the muscle and the spinal cord. But muscle control of the vertebra and ribcage extends beyond its segmental (spinal) innervation. The postural muscles are influenced by brainstem and cerebellum sensory systems which transmit information about gravity and acceleration via receptors in joints, muscles and the inner ear (vestibular system). Brainstem connections to the spinal muscles called the Reticulospinal and vestibulospinal systems, which create tonic and phasic activation of the postural muscles. Without this appropriate suprasegmental activation muscle tissue type changes are inevitable. Much like the muscles of a birds wings, spinal postural muscles are resistant to fatigue, without vestibulospinal, reticulospinal and corticospinal activation, these fibers will become more like the biceps muscle which is highly fatigable. Coupled with the reduced amount of muscle spindles and mechanical disadvantage due to vertebral rotation, patients with scoliosis require a comprehensive approach to non surgical care. Furthermore, brainstem or cerebellar damage is well known to cause scoliosis. Imbalances in muscle recruitment has also been shown to be prevalent in patients with scoliosis. This can be explained by two mechanisms. Obviously vertebral rotation creates a mechanical disadvantage and therefore would require the patient to recruit lateral flexors to bend forward or backward, and the opposite is also true. The other mechanism which must be explored is the motor planning systems of the higher cortical brain. Studies do support a higher cortical imbalance as an etiological factor in scoliosis. Language processing imbalances and eye movement disorders support this hypothesis.
The reason the orthopedic community continues to believe scoliosis isn’t manageable without the use of surgery and rigid bracing is because they are not doing enough to be successful. Martha Hawes supports these claims quite clearly. Click here.