Saturday, May 25, 2024

Summary: Thoracic pad style

zach harvey

Thank you to all who replied to my question regarding

thoracic pad style in idiopathic scoliosis bracing.

Your answers were all very informative. It appears as

though there is some discrepancy in the use of a

posterior rotation pad versus the use of a lateral pad

only. The problem is that hypokyphosis often

accompanies IS, and a posterior pad would only

encourage this, but a lateral pad may not warrant as

much coronal plane curve reduction. The question I’m

now asking in regards to my research is: which is more

important, maximal coronal plane curve reduction with

the use of a posterior rotation pad, or a balance

between some coronal plane curve reduction with a

lateral pad only and a reduced hypokyphosis? Please

feel free to email me with any other ideas or

suggestions.

Thanks again, Zach Harvey

Here are the responses in the order I received:

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

The question you might want to look into is , doesthe

use of the thoracic pad which provides an anteriorly

directed force andlateral forces create a thoracic

lordosis ? It could definately eccaserbate anexisting

thoracic lordosis and it would be prudent not to use

thisdesign on a patient with hypo Kyphosis. This

design was the only way it wastaught by Boston formany

years and perhaps thousands of these braces had

beenfit with this type of pad in the late 70’s and

early to mid 80’s.Data isavailable somewhere. Sometime

during the late 80’s or early 90’s Boston changedtheir

recommendation to only apply a lateral force In

thethoracic region.They changed this approach without

a lot of fanfare . Wehave not been using anteriorly

directed force pads in the thoracic regionfor years

because of this potential concern .I would hope that

aninstructor at your program would have pointed out

this possible contraindication, since it can

bepotentially dangerous.

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

I have tried both ways and found that simply

thelateral pads are sufficent. I had notice no

difference in derotation with theother pads.

Concurring with your belief. My patients like the

lateral pads muchbetter. I hope you well with this.

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

There are a number of things to considerhere.

Firstly, the most obvious is the reason it’s now

advocated to lateralizea thoracic pad. This stems

from a greater understanding andrealization that

all thoracic curves secondary to Idiopathic

Scoliosisare hypokyphotic. Point of fact, a thoracic

curve that’sNOT hypokyphotic is an indication that the

curve indeedmay not be idiopathic, but rather

secondary to some otheridentifiable pathology.

As for pad placement, then, the more posteriorly

athoracic pad extends, the greater the amount of

anteriorly directedforce is exerted. In a thoracic

segment that is alreadyhypokyphotic, this

anteriorly directed force actually accentuates

theproblem. This concept was well demonstrated in a

paper published inSPINE, 1997 by Aubin, showing

significant anteriordisplacement of the trunk in an

already hypokyphotic spine.Mathematical modeling of

the spine by researchers suchas Avinash Patwardhan,

Bunch and Tom Gavin havedemonstrated the positive

correlation with a simple transverse loadingof the

(thoracic) spine and the correction of a Cobb angle.

Thus, in a nutshell as there is again a lot toconsider

and reference with this type of inquiry, a good rule

of thumb is toavoid virtually any posterior thickness

on a thoracic pad whilsttreating a thoracic curve

secondary to Idiopathic Scoliosis. There can

becertain exceptions to this rule, but they should be

viewedthat way: as exceptions. A retrospective

review of this will be challenging. Are you hoping to

analyze the potential correlation that may exist

within-brace correction and pad design? The numerous

variablesthat may be associated with in-brace

correction (curve reduction)would make this virtually

impossible in a retrospective review. That said, I

commend you for posing the question and

havingthisinterest.

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

> Excellent questions. A lot of the answers you seek

> have been answered either directly, or in part bythe

> 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

IdiopathicScoliosis. SPINE, volume 14, number 6,

1989. The more recentpapers 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

applicationpoint 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).

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

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 coï]®°ïZÀ ï_ZìïT²

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