Academy Society Spotlight: Advancements in Adult Scoliosis Bracing Using a Custom-made Adult WCR Brace

Aim This case study presents a description and timeline of the results achieved by applying Schroth therapy (Barcelona Scoliosis Physical Therapy School) and a modified Chêneau-type brace using Rigo principles—a Wood-Chêneau-Rigo (WCR) brace—for the conservative treatment of a 68-year-old adult female with scoliosis. Conservative Treatment of Scoliosis in Adults Scoliosis bracing for adults has been limited for decades. The most common form of treatment is an accommodative TLSO, with variations that range from a custom-made brace fabricated from a mold and/or measurements of the patient, to an off-the-shelf, prefabricated TLSO fitted to the patient. The custom-made, accommodative TLSO usually addresses the concerns of the orthotist, physician, and patient; the type of material to be used for fabrication; and, in some cases, the amount of correction the brace should apply. The debate often centers on whether to use a soft foam with a semi-rigid interframe for patient support, or a semirigid or rigid thermoplastic brace. Addressing these factors alone is sometimes sufficient to meet the patient's needs. However, without further customization, these braces are often less effective and are uncomfortable and bulky. The adult WCR brace is used for adults with moderate to severe scoliosis. It is designed to reduce pain, provide alignment of the pelvis and trunk, and improve aesthetics and postural control. The adult WCR brace is fabricated from thin, semiflexible thermoplastic material; is custom made to each patient's specific curve pattern, pressure tolerance, and autocorrection; and holds the patient in his or her optimal corrected position. The axial loads and deforming forces to the vertebral column are supported by the adult WCR brace in a comfortable and natural way. The improved alignment of the pelvis and trunk reduces the imbalance of forces to the spine, which helps to control or slow the progression of the scoliosis by supporting it at the concavity of the thoracic spine, preventing collapse of the shoulder into the curve, aligning the lumbar spine and pelvis, and improving the patient's balance. WCR braces for children are different than those for adults, but both apply similar principles. The adult WCR brace has smaller pressures and expansion rooms, no clinical or radiological overcorrections, and different indications, treatment goals, and design and materials. Adult patients who have large curve magnitudes often experience poor balance of the pelvis and trunk (decompensation of the trunk/translation of the pelvis) and significant spinal rotations-each of which is often associated with pain. In cases with significant coronal and sagittal imbalances, there may also be a poor gait pattern. Therefore, the design, function, and fitting process of a scoliosis brace must be well thought out. To accomplish this, it is recommended that a specific physical evaluation of the patient be completed, as outlined by the author in 2014. 1 The result of the evaluation will guide the selection of the optimal brace type for the individual. When the WCR adult scoliosis brace is chosen, it is essential to assemble an experienced team of scoliosis professionals that includes an orthopedic surgeon, a physical therapist trained in the Schroth Method, and an orthotist. INDICATIONS FOR THE ADULT WCR BRACE ARE: A motivated patient No sensitivity to touch or light pressures Pain due to scoliosis A poor gait pattern due to poor trunk and pelvic alignment A good response to Schroth therapy The ability to hold an autocorrected Schroth-type correction and to feel a benefit from the improved posture Although the use of Schroth therapy has been well documented, the consensus regarding the appropriate age at which to start this treatment has varied. 2 However, it is safe to say that there are no upper age limitations for adult patients. Background This article shares the clinical presentation and brace design characteristics associated with the provision of optimal support and alignment for an adult with severe scoliosis. Scoliosis braces of all types utilize common principles of construction that ensure good fit and function. Equally important to the result is good patient follow-up care and brace quality control by the orthotist. 3 Case Presentation and Methods The patient is a 68-year-old female diagnosed with scoliosis, with right thoracic and left lumbar curves of 42 degrees and 51 degrees Cobb angles, respectively, and with thoracic and lumbar rotation of 14 degrees and 4 degrees, respectively. She also has degenerative disk disease and facet arthropathy. [caption id="" align="alignright" width="300"] Figure 1: The patient is wearing an adult WCR brace with the B1 curve pattern superimposed on the patient and brace. The three-point pressure system allows better alignment of the trunk over the pelvis. The expansion areas allow for improved breathing by providing space for the patient to move and breathe into the concave areas of the curves. This also provides a more normal physiological posture for the patient.[/caption] The patient was originally prescribed a custom TLSO, which she wore for five years, followed by use of a Spine-Cor® brace that she stated didn't help with the pain or improve her condition. She was later prescribed a WCR adult scoliosis brace. The Chêneau-Rigo handmade brace was a B1-type model using the Rigo classification of scoliosis. 4 However, the Rigo classification for brace design was adapted and modified specifically for an adult patient (Figure 1). Modifications were made to make the brace more applicable and tolerable for an adult patient. Adult patients with moderate or severe scoliosis typically have significant structural changes to the spine, which are impossible to change. However, it is possible to realign and balance the posture and thereby reduce stresses to the spine. The adult WCR brace allows the patient to apply corrections to the altered scoliotic posture and to reinforce what he or she learns during Schroth therapy, which helps to minimize progression of the spinal deformity, improve body alignment, and reduce pain. It does not apply the Chêneau brace principles of overcorrection, but rather focuses on good body alignment and positioning. Traditional TLSOs for adult scoliosis are made to accommodate the patient's deformity. This is difficult, because the accommodative brace often doesn't allow the patient's body to be put into a more normal physiological position, but instead serves as a supportive device to unload forces to the spine. It props up a deformed posture, compared to the adult WCR brace's ability to translate the trunk and pelvis, and positions the patient in his or her optimal physiological position. Results and Discussion The patient reported significant improvement in comfort and posture and a reduction in pain when compared to results of previous brace treatments. The adult WCR brace allowed the patient to apply corrections to the altered scoliotic posture, and reinforced what she learned during Schroth therapy, which helped to minimize progression of spinal deformity, improve body alignment, and reduce pain, as well as to improve her body image and increase her activities of daily living. Grant Wood, MS, CPO (UK), CO (US) is the cofounder of Align Clinic, San Mateo, California, and past chair of the Spinal Orthotics Society of the American Academy of Orthotists and Prosthetists. He is a specialist in scoliosis bracing with the Chêneau brace and the WCR brace. Acknowledgement: The author would like to thank Manuel Rigo, MD, of E. Salvá Spinal Deformities Rehabilitation Institute of Barcelona, Spain, for Rigo Classification of Scoliosis and brace design training. Academy Society Spotlight is a presentation of clinical content by the Societies of the American Academy of Orthotists and Prosthetists in partnership with The O&P EDGE. References Wood, G. I. 2014. Bracing efficacy in the patient with idiopathic scoliosis: Improvements in technique and care coordination. The Academy Today 10 (3):A-5-8. Wood, G. 2015. Five-year case study of an infant with scoliosis using Schroth Therapy and Chêneau-type bracing . The O&P EDGE 14 (7):56-66. Wood, G. 2014. Brace modifications that can result in improved curve correction in idiopathic scoliosis. Scoliosis 9 (1). doi:10.1186/1748-7161-9-2. Rigo, M. D., M. Villagrasa., and D. Gallo. 2010. A specific scoliosis classification correlating with brace treatment: Description and reliability. Scoliosis 5 (1).doi:10.1186/1748-7161-5-1.

Academy Society Spotlight: Advancements in Adult Scoliosis Bracing Using a Custom-made Adult WCR Brace

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