Friday, May 20, 2022

Summary: Part II- Thoracic Pads

zach harvey

> Excellent questions. A lot of the answers you seek

> have been answered either directly, or in part by

the following papers:–Labelle, H, et al.

Three-dimensional Effect of the Boston Brace on the

Thoracic Spine and Rib Cage. SPINE, volume 21, Number

1, pp. 59-64, 1996.–Aubin, C-E. et al. Rib

Cage-Spine Coupling Patterns Involved in Brace

Treatment of Adolescent Idiopathic Scoliosis. SPINE,

Volume 22, Number 6, pp. 629-635, 1997.–Chase, AP, et

al. The Biomechanical Effectiveness of the Boston

Brace in the Management of Adolescent Idiopathic

Scoliosis.

> SPINE, volume 14, number 6, 1989. The more recent

papers also have bibliographies that you may find

> helpful. I hope you find this helpful, and good

> luck with your research!

*******************************************************

> I’m sorry that I can’t give you exact numbers, but

> here is some of my experience with scoliosis races:>

> 1.. Make always a difference in pad positioning

> between the thoracal or thoracolumbar and the lumbar

> spine section! In the lumbar section you have no

> ribs. So you should be very careful with lateral

> pressure there. Only a very small percentage of the

> corrective force will realy reach the spine. You

> will lose the most of it in the soft tissues. And

> with a strong pressure you can harm for example the>

kidney.

> So in the lumbar spine section the application

> point of the corrective force should be placed much

> more posteriorly and should aim to the transverse

> process. This way you can effectively derotate the

> vertebras and also correct the curve through that.

> 2.. It’s different in upper spine sections. There

> you have the ribs, and you can expect a spine

> manipulation by pushing the ribs. Here I place my

> pads always “in between” the lateral side and the

> posterior. But I place it according to the X- ray

> more lateraly if I have a strong curve (bending-)

> component (characterized by a high Cobb ankle) or

> more posteriorly if I have a strong component of

> rotation (higher rotation signs at the X- ray and a

> stronger rib hump in the clinical).

> I hope it helps a little bit.

*******************************************************

By pushing from the lateral component only, there area

few problems:First and foremost, the resultant force

issub-optimal. Since scoliosis is a deflection,

rotation and column shortening and wedo not directly

load the column logitudinall to lengthen it (ala

Halostyle) we only have transverse forces to work

with. With transverse, wecan use coronal plane

force (lateral pad only) sagittal plane

transverseforce (derotation only) or both. Since

recent years have brought aboutliterature showing

that at least 50% in orthosis curve corrections

areoptimal (Lonstein Winter, JBJS 1995..Rowe (Spine

1997) and others) wecan consider anything less than

50% as sub-optimal so we need to takeadvantage of

loading 2 of the three components to achieve the BEST

result.(Lateral and posterior). Secondarily, lateral

force only is applied beyond theapex of the rib arc

and therefore tends to apply large bending

moments(Force X Distance expressed in Newtons per

meter) to the apex of the ribarc and may detract from

the force directly translated to thespine. It is also

my experience that the initial discomfort is because

theforce is so desperately necessary in those regions

and thisdiscomfort will subside in a few days as the

spine undergoes a viscoelasticrelaxation and then

creeps to a lesser magnitude (corrects). At thispoint,

it is also my experience that the pad needs tightened

again (like anorthodontic apparatus requires interim

tightening) to bring it toa discomfort level again

(which will also subside in a few days) toachieve

greater correction. Remember, in-orthosis corrections

are thebest prognosticator of outcomes (Chapter 13,

Scoliosis: Making ClinicalDecisions, Bunch W,

Patwardhan AG, Mosby 1989). So a lateral pad only

maybe more comfortable but it only takes advantage of

1 of the threemechanisms of the curve and a

posterior-lateral pad will take care of 2 and

willusually provide better correction. Andres was

correct a few hundredyears ago, Press on all of the

deformity.

*******************************************************

I work directly with the Twinm Cities Spine center (

Lonstein, Winter, etc) and have been doing so for

many years. I very much believe in placing the

thoracic pad laterally. Almost every idiopathic scoli

is hypokyphotic and that is as much a concern or more

even, than more correction on the coronal plane.

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