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BRACE CLASSIFICATION STUDY GROUP – update April 8, 2016

  

Authors:

Theodoros B Grivas

Jean Claude de Mauroy

Grant Wood

Manuel Rigo

Michel Timothy Hresko

Tomasz Kotwicki

Stefano Negrini

Brace Classification Study Group

BRACE FABRICATION

Preliminary plaster cast

Refers to the Lyon management in two steps with

1. Reduction in asymmetric non-removable plaster cast

2. Contention by a more symmetrical removable brace

 

Body Cast

Serial casting (Mehta casting)

A non-removable plaster cast which is usually applied to an infantile scoliosis patient while under anesthesia and suspended from the ground in a Risser frame. The cast surrounds the chest, abdomen, pelvis, and may also include the shoulders. It may be used to correct scoliosis in very young patients or for postoperative spinal mobilization.

Plaster mold

The traditional method used to capture an impression of the trunk of a patient. A plaster or synthetic bandage is applied, which hardens and is removed from the patient. This plaster mold is used for the custom fabrication of the brace.

 

Regional mold

A mold obtained by the superposition of three specifically corrected digital molds of the same patient: the pelvic area, lumbar area, and thoracic area. The makes the sagittal plane normalization more accurate.

Negative cast

The plaster or synthetic cast once it has been removed from the patient.

Positive mold

A solid mold formed from filling the negative cast with plaster.

 

CAD/CAM

Computer-Aided Design/Computer-Aided Manufacturing. The process of making a positive mold with 3D modelling tools and a milling machine for fabrication.

 

Custom-made

Made-to-measure (UK)

A brace fabricated from a custom mold and measurements of the patient’s trunk.

 

Prefabricated envelope (Module)

A brace that is fabricated over a standardized body form instead of a specific patient. The prefabricated envelope is designed to fit a patient within a range of measurements.

 

Axillary /axilla extension

 

The lateral section of a thermoplastic brace that extends upward under the arm, on the concave side of the thoracic curve, towards the level of the upper end plate of the vertebra. The function of the axillary extension is to apply a counterforce to the apex of the curve with a longer lever-arm.

  

Scoliosis Brace

A general term commonly used to describe a TLSO, LSO, or other spinal orthoses.

 

Milling machine

 A computer-aided manufacturing mill, also referred to as a carver.

 

Cloth Gusset

Elastic cloth affixed to a window or area of relief to provide a gradual transition between areas of pressure and relief, to provide limited pressure, or to maintain tension between the posterior and anterior parts of the brace.

 

Null point

Radiographic term used to describe the apex of a curve based on standing radiograph

 

Trochanteric extension

A plastic extension covering the greater trochanter, generally placed on the side toward which L5 tilts. When needed, a pad is also used on the inner surface of the extension. It provides balance for the brace and avoids sideward tilting (decompensation) relative to the pelvis.

 

Crest Roll

The inward pressure between the iliac crest and the lower margin of the ribs. It prevents distal or proximal migration of the brace and aids in the positioning the pelvis

 

CONSTRUCTION OF A BRACE 

Trim line

The cut and finished edges of a spinal orthosis that allow the brace to fit and function comfortably and optimally.

 

Module

A prefabricated brace that is customized to the individual patient's blueprint. They come in various sizes, which are fit and adapted to the patient for treatment of scoliosis.

 

Blueprint

Determines the trim lines of the brace and also the position of corrective pads.

 

Brace window

An opening cut out of the plastic of a brace. Used to provide pressure relief, extra flexibility, or a reduction in brace weight.

 

Expansion room

A section of the brace that is built up and away from the patient’s body. It provides room for the body to be pushed by the brace pads and allows the brace to achieve a greater degree of correction than just pressure with no expansion.

 

Pelvic section

The section of a scoliosis brace that covers the pelvis. Stabilizes and controls the pelvis and suspends the brace via the pelvic grip of the waist.

 

Hyper-corrected positive-cast

The modified positive cast of a Chêneau brace in which aggressively rectified pressure points and expansion rooms can be clearly observed.

 

Contact 

Pressure points

Points of the brace that correct the deformity via physical force. They are produced either during the modification of the mold (and therefore built directly into the plastic of the brace) or by added Pelite or Plastazote pads. The pressure is applied to the convex side of the curve or to the prominences of the scoliotic deformity. Common pads are the lumbar, thoracic, axilla and trochanter pads.

 

Continuous Contact

The external surface of the brace is smooth. Motion within the brace (4D) is facilitated by the gliding.

 

Pad Contact

Pad

Contact with a pad and or pressure against the body.

   

Lumbar pad

This is a corrective pad used in scoliosis braces, which is adapted to the convex side of the lumbar curve.

 

Thoracic pad

This is a corrective pad used in scoliosis braces which is adapted to the convex side of the thoracic curve.

 

Pushes The area of the brace providing the corrective forces to the trunk with the aim to reduce the trunk and spine deformity. It can be developed by the envelope, or added through plastic material inside the envelope, or a combination of the two.  
Driver The material on the 3D concavities that prevents a hypercorrection of the curve. It changes the direction of the corrective forces, driving them up with the whole trunk. It is at the base of the push-up action of SPoRT braces.  
Stop Part of the brace that stops the movement of the body tissues, providing a counterpush in a 3-point system, whether three or bidimensional  
Escape The area of the brace where the body can freely move in consequence of the corrective forces applied. (Expansion)  
High pressure contact Characteristic of the Chêneau brace. The external surface of the brace is not symmetrical or smooth.

Axillary clamp

A section of the brace that wraps around the anterior and posterior axilla, allowing the application of derotational forces.
 

Pelvic clamp

The arrangement of two sidepieces in the lower part of the brace. The untwisting is carried out from this fixed point.

 

Dynamic contact

A principal of the Dynamic Derotation Brace. It may produce an derotational force or alter the neuro-motor response by constantly providing new somatosensory input to the patient.
For the Carbon brace, this mobility provides a permanent pressure, which varies depending on ribs and spine movements. The correction is obtained without spinal extension so that each respiratory movement takes part in a gradual return to dorsal kyphosis.

NON Contact 

Window

Cutting in the external surface of the brace. The opening does not allow for expansion, but reduces the weight of the brace and increase the effect or the support zone

 

Expansion room

No cutting, but the external surface is no longer in contact, leaving the movement in the opposite direction of the support zone.

  

BRACE TYPES 

Milwaukee brace A CTLSO scoliosis brace used to treat the coronal plane curve of the cervical, thoracic, lumbar and sacral regions of the vertebral column. It consists of a contoured pelvic girdle attached by three uprights to an occipital pad and throat mold of the chin piece.

 

Cheneau brace

A thermoplastic brace modeled on a hyper-corrected positive plaster cast of the patient. It follows the general correction principle of: “detorsion and sagittal plane normalization, which would affect correction of the coronal and transversal planes, resulting in some elongation of the spine, without any significant distraction force”.

 

WCR (Wood Cheneau Rigo) brace A thermoplastic TLSO, which is designed using the Rigo Classification of scoliosis and brace design. It follows the principal as the Chêneau brace, and is handmade by Grant Wood and it is his personal version of the Chêneau-Rigo brace

Boston brace

A thermoplastic TLSO used to treat the coronal plane curve and transversal rotation of the thoracic, lumbar and sacral regions of the vertebral column. This brace can either be prefabricated or custom-made.

 

Night overcorrecting brace A brace made with the principle of reverse bending or “over correcting” to treat the curve. An over correcting brace is a very tall under arm brace which pushes the patient too far to even stand up, and can only be worn at night
Sforzesco brace A brace created by Stefano Negrini using the SPoRT concept of bracing (three-dimensional elongation). Due to its overall symmetry, the brace provides space over pathological depressions and pushes over elevations. Correction is reached through construction of the envelope, pushes, escapes, stops, and drivers.
ARTbrace A brace created by Jean Claude de Mauroy, ART stands for Asymmetrical, Rigid, Torsion brace. It is constructed with 2 rigid asymmetrical lateral pieces of polycarbonate connected posteriorly at the midline by a duraluminium bar. Both anterior and lower ratcheting buckles are rigid, the upper third is Velcro. The asymmetry is obtained by superposition of 3 regional specific molds.

 

Dynamic Derotation Braces (DDBs)
A hard, custom-made, polyvinylchloride (PVC), underarm spinal orthoses, which opens at the back, equipped with specially designed blades set to produce a derotational force on the thorax and the trunk of the patient. There are three modules, the thoracic or thoraco-lumbar curve, the lumbar curve, and the double major curve pattern.

Passive correction brace

A scoliosis brace that does not have space or windows for active correction of the spine. Correction is passive with the spine being pushed into the corrected position and then being held there by the tight fitting brace without the need for active muscular effort.

 

Brace rigidity  

Rigidity

An orthotic classification ranging from flexible, semi rigid, rigid, high rigidity. It refers to the amount the brace is bendable. Not to be confused with hardness.

 

Elastic A brace primarily composed of elastic straps (Spinecor brace)  

High Rigidity brace

A thermoplastic brace made with polymetacrylate or polycarbonate. They require a posterior bar with hinges to open and close the brace. (Sforzesco & Lyon braces)

MATERIAL 

Polymetacrylate

A hard transparent thermoplastic, often used as a lightweight or shatter-resistant alternative to soda-lime glass. The old Lyon brace was made in polymetacrylate.

 

Polycarbonate

A particular group of thermoplastic polymers that are easily worked, molded, and thermoformed. They have high temperature and impact resistance.

Polypropylene (PP)

A semi-rigid thermoplastic used in a wide variety of applications It is rugged and resistant to many chemical solvents, bases and acids. Polypropylene is the most common material used in the manufacture of scoliosis bracing, specifically for young scoliosis patients who require correction of their curves.

 

Polyethylene (PE)

A common plastic which can vary greatly in flexibility and transparency depending on the density. Polyethylene is commonly used for adults and neurological scoliosis patients who require less correction and a more supportive or accommodative brace.

 

Thermoforming

A manufacturing process where a plastic sheet is heated to a pliable forming temperature, formed to a specific shape in a mold, and trimmed to create a usable product.

 

Vacuum thermoforming

A simplified version of thermoforming, whereby a sheet of plastic is heated to a forming temperature, stretched onto a single-surface mold, and forced against the mold by a vacuum. This is the standard process that orthotic technicians use to fabricate a custom made scoliosis brace.

 

Plastazote

A lightweight polyethylene foam used as padding sensitive pressure points, or used to increase pressures to the apexes of the scoliotic curves. It is thermoformable, and self-adhesive at forming temperature.

 

Skin protection garment

An undershirt used as an interface between the patient’s body and the scoliosis brace, which reduces friction and irritation to the skin.

 

BODY ANATOMY/LEVEL-S COVERAGE 

Anatomical classification (CTLSO, TLSO, LSO)

CTLSO: A cervicothoracolumbosacral orthosis.
TLSO: A thoracolumbosacral orthosis.
LSO: A lumbosacral orthosis.

 

Low profile A brace that does not significantly protrude from the body.  

Short brace

A brace that extends from the sacrum to lower thoracic regions of the spine. It’s usually classified as LSO or a low TLSO.

 

Long Brace

A brace that extends from the sacrum to the thoracic region of the spine, usually up to the axilla. This is usually classified as a TLSO.

 

Concave

A surface that curves inward. One of the objectives for scoliosis treatment would be to open the concave side of the scoliotic curve (i.e. to decrease the collapse of the spine).

 

Convex

A surface that curves outward. One of the objectives of a scoliosis brace is to apply a force to the convex side of the scoliotic curve.

 

SCOLIOSIS CLASSIFICATION USEFUL FOR BRACING

3-curve scoliosis

Presents as one long thoracic curve with the apical vertebra around T9 to T10 or a thoracolumbar curve with the apical vertebra around T11. This long thoracic or thoracolumbar curve has two small compensatory curves, one cephalic and the other caudal.

 

4-curve scoliosis

Presents as two main curves, one in the thoracic region and the other in the lumbar or low thoracolumbar region. These double curves have two small compensatory curves, one cephalic and the other caudal.

 

Pelvic obliquity

Difference in the height of pelvis. Possibly due do infrapelvic (LLD or contractures), intrapelvic (congenital bone abnormality), or suprapelvic (scoliosis)

 

Anteversion

An abnormal position of the hemi-pelvis that is rotated and torsioned anteriorly therefore the anterior superior iliac spine is more prominent than usual. The contralateral hemi-pelvis would be in retroversion. Anteversion of the pelvis usually refers to forward flexion of the pelvis on the femoral heads which places sacral plate in a more vertical position.

 

Retroversion

An abnormal position of the hemi-pelvis, which is rotated and torsioned posteriorly therefore the anterior superior iliac spine is less prominent than usual. The contralateral hemi-pelvis would be in anteversion.

 

Iliac rotation

A situation of relative retroversion of the convex side of the lumbar curve and anteversion of the concave lumbar side.

 

Compensatory curve

A curve, which can be structural or non-structural, above or below a major curve that tends to maintain normal body alignment. A compensatory curve is synonymous with the secondary curve.

 

Flat back

The physical appearance of the back surface in the sagittal plane of the thoracic region being “flat,” also called hypokyphosis.

 

Flat back effect

An effect produced by a TLSO in which the design of the brace produces hypokyphosis.

 

Major curve

Primary curve

The largest structural curve which is usually the first to appear.

 

Minor curve

Secondary curve

The smallest scoliotic curve, which is always more flexible than the major curve.

 

Apical vertebra

The most rotated vertebra in a curve; the most deviated vertebra from the vertical axis of the patient.

 

Hyperkyphosis

A sagittal alignment of the thoracic spine in which there is more than the normal amount of kyphosis.

 

Hypokyphosis

A sagittal alignment of the thoracic spine in which there is less than the normal amount of kyphosis, but it is not so severe as to be truly lordotic.

 

Non-progressive curve or scoliosis

A scoliotic curve in which the Cobb angle does not increase 5º or more during a six-month period.
Below 20°, most curves are non-progressive (chaotic scoliosis).

 

Progressive curve or scoliosis

A scoliotic curve in which the Cobb angle increases 5º or more during a six-month period. Progression is also considered to be a sustained increase if the Cobb angle increases by at least 10º.

 

Non-structural curve

A spinal curvature above or below the structural, primary curve that is fully corrected during side bending or in lying position. Reflects a compensatory mechanism by the posture controlling system. Follows in development or regression to the primary structural curve.

 

BRACE FUNCTION 

Orthosis An externally applied device used to modify the structural and functional characteristics of the neuromuscular and skeletal system  

3-D correction

The correction of the deformities in all three anatomical planes. This involves correction of the coronal plane deformities (i.e.: thoracic and lumbar curves), transverse plane deformities (i.e.: pelvic torsion and thoracic rotation) and sagittal plane deformities (i.e.: hypokyphosis). The objective is that the correction occurs simultaneously in three planes of the space, as a unique movement called torsion and not plane-by-plane correction.

 

Overcorrecting

 

A brace with strong enough pressure to reverse a scoliotic curve

PASSIVE MECHANISM OF ACTION

 

Three point pressure system

The correction of a scoliotic curve using 3 separate pressure points. This is achieved by one force applied in the center of the convex side of a curve, with two counter forces applied to each end of the contralateral side of the curve.

 

Axial elongation Motion along the vertical axis without trunk compression. The principle is to elongate the spine with the cervical collar. Another effect of axial elongation is disk decoaptation that favors the correction in the other plans.
Cherry stone effect "When tissues on a trunk are laterally pressed, in whatever place it is, they migrate in the directions which remain free. If only the high and low openings of the brace are free, it is in these directions that the ‘leakage’ of tissues is made. It is the direction of the normal growth.” Jacques Chêneau
Mayonnaise tube effect

 

Similar to the cherry stone effect, but the pressure is laterally applied to the whole trunk with a higher pressure at the thoracolumbar junction. The result is a vertical stretching of the spine. (ARTbrace)
Tissue transfer Pressure Expansion, Translation "Tissue transfer by means of the complex pressures-expansions is much more elective. It consists in making migrate a tissue slide from humps towards concavities. Convex-concave wandering of a slice of tissues." Jacques Chêneau
Clamp effect on the greater diameter of thorax "Reducing the oblique diameter of the thorax being squeezed is accompanied by an increase in small diameter and expansion of the concavity. The brace takes in clamp this large diameter. Let us take care to spare very vast spaces for expansion of the smaller diameter. It extends from the sternum to the area of the concavity behind." Jacques Chêneau

Pusher

A pushing force along the flanks. The possible actions at the flanks include:
• Shift: in the case of a low lumbar slope.
• Stop: when there is a lumbar curve on the side opposite to the main slope.
• Remodelling: to improve the aesthetics of a flattened flank.

 

Counter-force

A force directly opposed to another force, e.g. a brace’s corrective force against a scoliotic curve.
 

 

Thrust

A quick force delivered to a specific area.

 

3D CORRECTION

Plane of action

The plane on which a brace produces an effect (coronal, sagittal, etc.)

 

2D Frontal 

Deflexion

The action of straightening a scoliotic curve on the frontal plane.
A traditional Schroth Method term describing the straightening of a scoliotic curve.

 

Bending effect Lateral inclination of the trunk towards curve correction used for the upper thoracic region in most TLSO. Also, hyper-corrective position of the trunk in a night brace.
"One strongly presses from left towards right under the left armpit so that the spine bends towards the convexity. That carries out an inflection towards right, known as "bending". The patient thus inclined rectifies himself spontaneously with the following minutes." Jacques Chêneau

Shift or Shifting

Lateral displacement of a body part in the frontal plane used to obtain better curve correction or restore trunk balance.

 

2D Sagittal 

Sagittal plane normalization

Sagittal plane correction

Obtaining a normal physiological kyphotic curve in the thoracic region as well as normal physiological lordotic curve in the lumbar region, while maintaining the transition points of these regions. (Reharmonization after a Milwaukee brace)

 

Re-kyphosis:

Correction of the hypokyphosis by returning the vertebral column in the thoracic region to the normal physiological kyphosis of the sagittal plane.

Dekyphotization

The action of reduction of the kyphosis of the spine. Neologism: the act of correcting hyperkyphosis in a brace.

 

Delordosization

The action of reducing of the lordosis of the spine. Neologism: the act of correcting hyperlordosis in a brace.

 

2D Horizontal 

Derotation

Reduction of the vertebral rotation in a scoliotic curve, either manually or with a brace. Derotational forces are applied to specific areas of the spine.

 

Detorsion

Correction of the torsional aspect of the vertebral column. Detorsional forces are a global action on the whole spine.

 

Untwisting

The removal of twisting forces.

 

3D 

Alignment Arrangement or position in a straight line. Alignment doesn't mean balance.
Balance Ability of human body to maintain center of gravity within the base of support to prevent falling. Jean Dubousset, first introduced the concept of ‘cone of balance’, referring to a stable region of standing posture, deviating outside the cone pose challenges to balance mechanisms.

VISUAL SHAPE PERCEPTION

Symmetric

Brace construction for symmetric (Scheuermann) and some asymmetric pathologies.

 

Asymmetric

Regular pattern of corrective brace for idiopathic scoliosis. Enables selective application of pressures and unloading around the curve.

 

EVALUATION - OUTCOME MEASURE  1 - CLINICAL

Rib hump

Scoliotic convexity. A protruding rotated aspect of rib cage. The prominence of the ribs best exhibited on forward bending.

 

Double Rib Contour Sign (DRCS)

All lateral standing spinal radiographs in idiopathic scoliosis show a DRC sign of the thoracic cage, a radiographic expression of the rib hump. The outline of the convex ribs overlies the contour of the concave ribs. The rib-index is the ratio d1/d2. d1 is the distance between the posterior margin of the vertebral body and the most extended point of the most projecting rib contour. d2 is the distance between the posterior margin of the same vertebral body and the most protruding point of the least projecting rib contour.

 

Rib Index

A measure of the transverse deformity of ribcage extracted from DRCS. RI is the ratio d1/d2. d1 is the distance between the posterior margin of the vertebral body and the most extended point of the most projecting rib contour. d2 is the distance between the posterior margin of the same vertebral body and the most protruding point of the least projecting rib contour.

 

POTSI index (evaluation)

A parameter to assess deformity in the coronal plane. Eight specific points at the surface of the patient’s back are required. Ideal POTSI is zero, meaning full symmetry of the back surface. Normal values were reported to be below 27. The POTSI is very accurate in revealing any frontal plane asymmetry.

ATSI

A surface parameter describing frontal plane trunk asymmetry in scoliosis, equivalent of POTSI for the anterior trunk. Measurable on regular photography or surface topography scans. Ideal ATSI is zero, meaning full symmetry of the anterior trunk.

 

Quality of life  (QoL)

A multidimensional construct composed of functional, physical, emotional, social and spiritual wellbeing.
 

 

 

 

 

 

Activities of Daily Living (ADL) (brace, rehab)

The things normally done in daily living including any daily activity performed for self-care (eating, bathing, dressing, grooming), work, homemaking, and leisure.

Acceptability (brace)

Describes the patient’s desire to remain compliant with the brace.

Adaptability (brace)

Describes the brace’s ability to be modified to fit the patient.

Check (of a brace)

The process in which the new brace is tested for the interaction with the trunk of the patient in order to improve its efficacy and tolerance. It is the responsibility of the treating physician and is based on a strict collaboration between physician, orthotist, patient and family. Includes counselling to allow proper compliance.

EVALUATION - OUTCOME MEASURE  2 - RADIOLOGICAL

Microdose

New radiological standard for bracing. 25 times less radiation than a full spine radiography (AP and lateral.) Contains the equivalent of a week of Earth's natural radiation.

 

Severity Index

rognosis for minor scoliosis at first evaluation with Specificity & Sensibility near 100% with EOS. The index takes into account 6 measures:
1. The apical axial rotation
2. The intervertebral rotation in the upper junctional zone
3. The intervertebral rotation in lower junction zone
4. The torsion index
5. The apical hypokyphosis index.
6. The 3D Cobb angle

 

Upper View

New radiological standard to appreciate alignment & balance in a brace.

 

Global Torsion Index

Arithmetic average of the 17 segmental rotations of thoracic and lumbar vertebrae. This index quantifies the detorsion or untwisting.

 

EVALUATION - OUTCOME MEASURE  3 - BRACING

Commitment to treatment 

For the patient: the act of following procedure and wearing the brace.
For the treating team: the strong belief in treatment needed to allow patients to understand the importance of his or her treatment, a key element to achieve compliance, mainly in brace treatment.

 

 

 

 

 

Competence

The experience in a specific medical area necessary for making diagnoses, prescribing and/or applying a treatment, and following up with a patient. Adequacy and possession of required skill, knowledge, qualification, or capacity.

Compliance

The degree of concordance between the patient’s behaviour and recommendations of health professionals. Often appears to be a characteristic of the patient. In reality it can heavily depend on the behaviour of the treating team.

Monitorable brace

A brace which features a monitor device able to monitor compliance of brace wearing.

Thermobrace

Gadget incorporated into the brace for treatment compliance assessment using the body temperature of the wearer as a measurable parameter

Correction (of a brace)

The correction of all measurable parameters in all three body planes (frontal, sagittal, transverse).

 

 

 

In-brace correction

The percentage of correction of all measurable parameters in all three body planes (frontal, sagittal, transverse) while wearing a Brace.

Improvement

A change equal or more than the amount of the measurement’s reading error in an outcome’s measure, Cobb angle more or equal to 5º.

Cosmetic

Done to improve physical appearance. Also called cosmesis.

 

 

Aesthetics

Relating to a pleasing appearance, similar to cosmetic

PRESCRIBED TIME OF BRACING 

Dose-Response (curve) A range of bracing time over which response occurs. Bracing time lower than the threshold produce no response while those in excess of the threshold exert no additional response. The shape of the curve is usually hyperbolic when plotted with linear axes.

Total time

24 hours.

 

 

 

 

Full time

20-22 hours.

Part time

18-14 hours.

Night time

8 hours during night.

Concertina effect hypothesis According to this hypothesis, each time a brace is weaned the deformity gradually moves back from the maximal in-brace correction to the original out-of-brace situation; this reversal is due to a postural collapse that is correlated to the length of brace weaning and the rigidity (flexibility) of the spine

HEALTH PROFESSIONALS 

Orthotist

The professional for the production and application of Orthoses. “Orthotic care may include, but is not limited to, patient evaluation, orthosis design, fabrication, fitting and modification to treat a neuromusculoskeletal disorder or acquired condition” (ABCOP)

 

 

CPO

Certified Orthotic and Prosthetic professional.

ACRONYMS 

CAD-CAM

Computer Aided Design, Computer Aided Manufacture.

 

 

 

 

 

 

CPO

Certified Prosthetist Orthotist

TLSO

Thoracolumbosacral Orthosis

DRCS

Double Rib Contour Sign

RI

Rib Index