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SRS new septembre 2013 HISTORIAN CORNER: REMEMBERING PIERRE STAGNARA (1917– 1995) Behrooz A. Akbarnia, M.D. Historical Committee Chair Stagnara médecins Massues 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 JC de Mauroy was his last Medical Assistant. 6

7 Since 2004 SOSORT

High Rigid Symmetrical Rigid Asymmetrical High Rigid Asymmetrical 10 years SOSORTresearch SOSORTresearch 8

Negrini et al – Scoliosis,

Bracing is recommended to treat adolescent idiopathic scoliosis. 1 10

Weinstein et al – NEJM,

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

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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 BrAIST Brace Types 14

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 BrAIST: Peripheral Findings 15

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 high- risk curves to the threshold for surgery BrAIST: Research Study Results 16

Population: 116 RCT; 126 QRCT treated 12 months; 20-40° Cobb, Risser 0-2Population: 116 RCT; 126 QRCT treated 12 months; 20-40° Cobb, Risser 0-2 Treatment: Bracing vs observationTreatment: Bracing vs observation Results: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 Nov 29. pii: S (13) doi: /j.spinee [Epub ahead of print] 18

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. 2 19

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

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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. 4 23

Chaos and Linearity Chaotic Scoliosis ( 20°) 24

25 Deviation Deformation

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. 5 26

Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6 Deviation Spinal curvature More & Asym- metrical Loading Asymmetrical Growth Discs Wedging Wedging of Vertebrae Structural Scoliosis 27

Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6 Correct deformity Reverse asymmetrical Load Reduced asymmetrical growth Reduced disc wedging improving movement Reduced vertebral wedging Scoliosis Stabilization at weaning 10/ /2013 4/2014 5/

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. 6 29

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 3rd week, the collagen fibers gradually realign themselves to conform with the original structure. Clinically, about 3 weeks of immobilization are necessary. 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 3rd week, the collagen fibers gradually realign themselves to conform with the original structure. Clinically, about 3 weeks of immobilization are necessary. 30

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

PosturePosture 32

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. 7 33

Daily Wear Treatment Success 20h/24 16h/24 12h/24 8h/ % 50 % 00 % 24h/24 BrAIST RCT: Weinstein - Dolan

< 25° 25-29° 30-34° 35-40° > 40° 23h / 24 20h / 24 16h / 24 12h / 24 8h / 24 35

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. 8 36

end 6 mths 23h / 24 20h / 24 16h / 24 12h / 24 8h / > 40°

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. 9 38

When the musculature is active, there is less risk of collapse of the vertebral body (Composite beam bone/muscles) 39

It is recommended that quality of the brace is checked through an in-brace x-ray

DON’T GUESS. SEE. 41

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

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

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

A chain is only as strong as its weakest link 45

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

47 Very precise ratcheting Buckle Adjustable (baby lift) Adjustable (baby lift)

It is recommended that the brace is specifically designed for the type of the curve to be treated

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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

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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

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Polycarbonate Polymethacrylate Polyethylene Soft = Total Failure 54

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

Risk of Failure culture 56

It is recommended that braces do not so restrict thorax excursion in a way that reduces respiratory function

Tubular thoracic cage after Lyon brace for juvenile scoliosis 58

It is recommended that braces are prescribed, constructed and fitted in an out- patient setting

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

Picture Castro ,20 = Minimum Applelgreen ,30 = Hope of final correction Landauer ,40 = 7° final correction Wong 2005 Cad/Cam better than plaster mould Bullmann ,43 = 52 cases of CTM But only Retrospective Studies 62

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

Lecture - Reading = 10 % Audiovisual = 20% Demonstration = 30 % Discussion = 50 % Practice doing = 75 % Teach others = 90 % Source: National Training Laboratories Bethel Maine 64