ART brace Training s e n i l

ART brace Training s& e n i l e Guid ed s a B ce n e d i Ev ne i c i d Me 0 ° N ule d o M 1

A long tradition of bracing: Ambroise Paré (Middle-Age) Iron brace by Ambroise Paré Which is going to be used for century 2

First half of the 20 th century The plaster cast reduction Sayre Calot - Berck 3

Brace by Shanz and Milwaukee 4

2° half of the 20 th century Modern braces Stagnara – Bouillat-Terrier 5

http: //www. srs. org/enews/2013/09/articles. php? content=2 SRS new septembre 2013 HISTORIAN CORNER: REMEMBERING PIERRE STAGNARA (1917– 1995) Behrooz A. Akbarnia, M. D. Historical Committee Chair Stagnara founded the Department of Pathology of the Spine of the University of Lyon, before becoming Chef of the "Centre des Massue" from 1959 until his retirement in 1982. JC de Mauroy was his last Medical Assistant. 1978 Stagnara médecins Massues 6

SOSORT Since 2004 7

High Rigid Asymmetrical Torsion brace High Rigid Symmetrical Rigid Asymmetrical 10 years SOSORT research High Rigid Asymmetrical 8

Guidelines 2011 Negrini et al – Scoliosis, 2012 9

Guidelines SOSORT 2011 1 Bracing is recommended to treat adolescent idiopathic scoliosis. 10

Weinstein et al – NEJM, 2014 11

Br. AIST Study: Bracing in Adolescent Idiopathic Scoliosis Trial �University of Iowa, NIH Funded, 2007 - 2013 � Principle Investigator: Stuart Weinstein, MD � Study Director: Lori Dolan, Ph. D �Purpose: �“To compare the risk of curve progression in adolescents with AIS who wear a brace versus those who do not and to determine whethere are reliable factors that can predict the usefulness of bracing for a particular individual with AIS. ” 12

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Br. AIST Brace Types � 365 total braces reviewed in case reports: • 208 Boston (+46 “Boston-like” braces) • 26 Wilmington (+13 “Modified Wilmington” braces) • 22 Rosenberger • 26 Hospital For Sick Children design (Cheneau variation) • 8 Minnesota • 4 Mortensen technique design • 1 LA Brace • 11 unspecified designs 14

Br. AIST: Peripheral Findings �Bracing is effective in stopping or slowing the progression of curves �Correlation between bracing outcome and orthotist skill and competence �Highlights need for advancement in research, orthotist training, and brace design 15

Br. AIST: Research Study Results • 72% of all braced participants had a successful outcome (stabilized or improved curves were considered success) – 75% of randomized participants had successful outcome • 48% of all non-braced participants had successful outcome (45% of randomized participants) • A significant positive association between hours of brace wear and rate of success exists • Bracing significantly decreased the progression of highrisk curves to the threshold for surgery 16

Weinstein (US) 2014 • Population: 116 RCT; 126 QRCT treated 12 months; 20 -40° Cobb, Risser 0 -2 • Treatment: Bracing vs observation • Results: – The trial was stopped early owing to the efficacy of bracing in avoiding 50° curves – Treatment success 72% after bracing vs 48% – RCT 75% vs 42% – Significant positive association between hours of brace wear and rate of treatment success (P<0. 001) 17

Brace treatment is effective in idiopathic scoliosis over 45°: an observational prospective cohort controlled study. Lusini M, Donzelli S, Minnella S, Zaina F, Negrini S. Spine J. 2013 Nov 29. pii: S 1529 -9430(13)01935 -9. doi: 10. 1016/j. spinee. 2013. 11. 040. [Epub ahead of 18 print]

Guidelines SOSORT 2011 2 Bracing is recommended to treat juvenile and infantile idiopathic scoliosis as the first step in an attempt to avoid or at least postpone surgery to a more adequate age. 19

Modified Milwaukee brace with polyethylene bars and cervical collar without hyoid support 20

Guidelines SOSORT 2011 3 Casting is recommended to treat infantile idiopathic scoliosis to try stabilizing the curve. 21

The first aim of the ARTbrace was to avoid the plaster cast 22

Guidelines SOSORT 2011 4 It is recommended not to apply bracing to treat patients with curves below 15 ± 5° Cobb, unless otherwise justified in the opinion of a clinician specialized in conservative treatment of spinal deformities. 23

Chaos and Linearity Chaotic Scoliosis (<20°) | Linear Scoliosis (>20°) 24

Deformation Deviation 25

Guidelines SOSORT 2011 5 Bracing is recommended to treat patients with curves above 20 ± 5° Cobb, still growing, and demonstrated progression of deformity or elevated risk of worsening, unless otherwise justified in the opinion of a clinician specialized in conservative treatment of spinal deformities. 26

Vicious Bone circle of Ian Stokes Stage 4 Wedging of Vertebrae Stage 3 Stage 5 Discs Wedging Asymmetrical Growth Stage 2 More & Asymmetrical Loading Stage 1 Deviation Spinal curvature Stage 6 Structural Scoliosis 27

Virtuous Bone circle case n° 90 Stage 4 Reduced vertebral wedging Stage 5 Reduced disc wedging improving movement Stage 3 Reduced asymmetrical growth Stage 2 Reverse asymmetrical Load 4/2014 Stage 6 Scoliosis Stabilization at weaning 10/2013 Stage 1 Correct deformity 5/2015 10/2013 28

Guidelines SOSORT 2011 6 It is recommended that braces are worn full time or no less than 18 hours per day at the beginning of treatment, unless otherwise justified in the opinion of a clinician specialized in conservative treatment of spinal deformities. 29

Fluage - Creep: a specimen is instantaneously loaded with a stress which is maintained. The tissue elongates rapidly at first and then continues to elongate more slowly. (This property may be put to use in the treatment of deformities of the skeleton such as clubfoot or scoliosis (lateral curvature of the spine) where a constant load with a plaster cast may be arranged to cause creep of the tissue in the appropriate direction. . F&N, p. 97). Remodelling and maturation. From 3 rd week, the collagen fibers gradually realign themselves to conform with the original structure. Clinically, about 3 weeks of immobilization are necessary. 30

Nonlinear Viscoelasticity Nonlinear viscoelasticity is phenomenologically observed in all soft connective tissues. 31

Posture 5 weeks = structural scoliosis 32

Guidelines SOSORT 2011 7 Since there is a "dose-response" to treatment, it is recommended that the hours of bracing per day are in proportion with the severity of deformity, the age of the patient, the stage, aim and overall results of treatment, and the achievable compliance. 33

Rate of Treatment Success according to average hours of Daily Brace Wear Treatment Success 100 % 50 % 00 % 8 h/24 12 h/24 Br. AIST RCT: Weinstein - Dolan 16 h/24 20 h/24 24 h/24 Daily Wear

Brace wear time depending on the initial angulation 23 h / 24 20 h / 24 16 h / 24 12 h / 24 > 40° 8 h / 24 35 -40° 30 -34° 25 -29° < 25° 35

Guidelines SOSORT 2011 8 It is recommended that braces are worn until the end of vertebral bone growth and then the wearing time is gradually reduced, unless otherwise justified in the opinion of a clinician specialized in conservative treatment of spinal deformities. 36

Brace wear time depending on the curve elasticity (in-brace & out of brace) > 40° 23 h / 24 20 h / 24 16 h / 24 12 h / 24 6 mths 8 h / 24 6 mths end 37

Guidelines SOSORT 2011 9 It is recommended that the wearing time of the brace is gradually reduced, while performing stabilizing exercises, to allow adaptation of the postural system and maintain results. 38

Bracing & Sport . 9 . 12 . . 3 . . 6 . . When the musculature is active, there is less risk of collapse of the vertebral body (Composite beam bone/muscles) 39

Guidelines SOSORT 2011 10 It is recommended that quality of the brace is checked through an in-brace x-ray. 40

Imaging Spine at a week’s natural exposure (/25) DON’T GUESS. SEE. 41

Guidelines SOSORT 2011 11 It is recommended that the prescribing physician and the constructing orthotist are experts according to the criteria defined in the SOSORT Guidelines for Bracing Management. 42

Technicity increased Capteur CAD/CAM Full 3 D instantané Ultra low dose EOS 43

Guidelines SOSORT 2011 12 It is recommended that bracing is applied by a well trained therapeutic team, including a physician, an orthotist and a therapist, according to the criteria defined in the SOSORT Guidelines for Bracing Management. 44

The Scoliosis Team A chain is only as strong as its weakest link 45

Guidelines SOSORT 2011 13 It is recommended that all the phases of brace construction (prescription, construction, check, correction, follow-up) are carefully followed for each single brace according to the criteria defined in the SOSORT Guidelines for Bracing Management. 46

Advantage of a Lyon ADJUSTABLE brace Adjustable (baby lift) Very precise ratcheting Buckle 47

Guidelines SOSORT 2011 14 It is recommended that the brace is specifically designed for the type of the curve to be treated. 48

True Design is given during segmental moulding Infinity of lumbar shifts & lordosis Infinity of thoracic bendings & Kyphosis Two curves One curve 49

Guidelines SOSORT 2011 15 It is recommended that the brace proposed for treating a scoliotic deformity on the frontal and horizontal planes should take into account the sagittal plane as much as possible. 50

One of the fundamental characteristics of the ARTbrace is Sagittal plane overlayering 51

Guidelines SOSORT 2011 16 It is recommended to use the least invasive brace in relation to the clinical situation, provided the same effectiveness, to reduce the psychological impact and to ensure better patient compliance. 52

For lumbar scoliosis short braces are less invasive 53

Step by step Rigidity Strategy 4 3 2 1 Polycarbonate Polymethacrylate Polyethylene Soft = Total Failure More rigid don’t mean more invasive 54

Soft Contact Discontinuous concept High Pressure • • Three point system Limited contact area Medium Pressure • • Three point system Internal pads Low Pressure • Contact over the entire thoracic area 55

The two concepts Risk of Failure culture 56

Guidelines SOSORT 2011 17 It is recommended that braces do not so restrict thorax excursion in a way that reduces respiratory function. 57

Night Milwaukee bracing Tubular thoracic cage after Lyon brace for juvenile scoliosis 58

Guidelines SOSORT 2011 18 It is recommended that braces are prescribed, constructed and fitted in an outpatient setting. 59

In-patient 60

Evidence Based Clinical practice Definition Systematically developed statement to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances Best Evidence EBCP Team Approach Clinical skills Patient Compliance 61

Fundamental References In-brace Reduction Picture Castro 2003 Landauer 2003 0, 20 = Minimum 0, 40 = 7° final correction Applelgreen 1990 0, 30 = Hope of final correction Picture e Pictur Bullmann 2004 Wong 2005 Cad/Cam better than plaster mould 0, 43 = 52 cases of CTM But only Retrospective Studies 62

Conclusions ØBraces are effective ØBrace efficacy can be distinguished according to material (elastic, rigid, high rigidity) and symmetry ØThe best BRACE does not exist, but the best in-brace correction does ØThe best APPROACH to patients has been defined 63

1 st Training Course: 25 -28 September 2015 – Lyon (Fr) = 75 % (Learning Pyramid) Lecture - Reading = 10 % Level 3 Level 2 Audiovisual = 20% Demonstration = 30 % Discussion = 50 % Practice doing = 75 % Teach others = 90 % Level 1 Source: National Training Laboratories Bethel Maine 64