Ultra-Thin TLSOs in Management of Neuromuscular Scoliosis

Nancy Hylton


Over the 36 years that I have been a pediatric physical therapist, I have recognized the tremendous difficulties with orthotic management of neuromuscular scoliosis with conventional stiff bracing. Even after becoming an Orthotist in 1998, comfortable ways of managing progressing curves were illusive.

Our use of TLSOs in the management of Neuromuscular scoliosis began approximately 5 years ago after an extended discussion with Claudia Eisert, O/P Meister regarding the use in Germany of the Cheneau de-rotational TLSO system. The Cheneau system has a more than 20 year history of use with Idiopathic scoliosis management in Germany, initially in the Munster area. Ms. Eisert, herself, had worn a Cheneau orthosis for 5 years, successfully reducing and holding a rapidly progressing iodiopathic S-curve beginning at 85 degrees, ultimately stabilized without surgery to less than 50 degrees. She indicated that this TLSO had also been comfortably worn by persons in their 70's and 80's with troublesome longstanding severe idiopathic curves. We discussed at length this system, how it might be adapted to children with neuromuscular problems, with even greater flexibility that could possibly used to manage typical collapsing C-curves seen in this population.

Upon returning to Seattle, we tentatively embarked on the fabrication of a very flexible TLSO for a 17 month old child with a 95 degree curve with arthrogyposis. The little boy was 18 months old. While wearing the TLSO over the next 1-2years, he learned to cough, crawl and walk independently.

The TLSO held his curve very well, but due to persistent GI issues, the decision was made, eventually, to move on to surgical control of his curve with rib spreaders. Though this has been successful preventing total spinal collapse, currently at age 7 y.o, the rotational deformities have continued to progress in severity.

Over the past 5 years, as we have attempted to comfortably provide curve containment and improved function, the TLSOs have become much thinner. We have become braver with additional modifications to both the plaster negatives and positive castings, as the exploration with this system of bracing has continued. The patient experiences are broad and extremely varied from managing good flexibility through rapid growth period for eventual very positive surgical reductions, to very successful on-going holding of curve progression in very young children with moderate to very severe neuro-motor deficits, and life-long conservative management of moderate to severe collapsing curves in young adults with very severe cerebral palsy quadriplegia. We are seeing children who would never be candidates for surgical intervention or anesthesia due to their very compromised respiratory status. We have seen a complete cessation of progression in rapidly progressing congenital curves, in some of these children, with this type of TLSO management. In fact, the more severely involved the patient, the better tolerated is the bracing appears to be.

My experience as pediatric PT with soft tissue release strategies and musculoskeletal responses to gradual manual stretching and elongation, has given me a particular advantage in preparing for and capturing a very corrected plaster negative mold with children who have even very severe curves. I continued to be surprised at how much derotation was possible using Dr. Cheneau's technique of curve management.

Starting at greater than a 110 degree curve, when full growth was achieved, this young lady went on to a very successful spinal stabilization surgery after 4 years of TLSO wear with an excellent curve correction o less than 50 degrees. While wearing her TLSO, she experienced numerous difficulties with seizures, leading to a functional hemispherectomy. She is currently 16 years old, uses supramalleolar DAFOs and walks easily with minimal assistance for balance.

I have seen first hand what can happen when curves are allowed to progress to full collapse of the thorax on the pelvis, in person's with severe neuromotor control impairments. With the use of custom contoured foam, comfortable sitting and lying has been possible for these people.

The young woman, Tracey, was able to immediately progress from zero sitting tolerance to 2 hour tolerance, permitting her to go on field trips and take maximum advantage of her school program. This system successfully and comfortably managed her 100+ degree curve from the age of 9 years until her death after graduating from High School.

Another young man was brought to my attention by his school PT as he was preparing to finish school. He had not had surgical intervention due to the family"s religious beliefs and at 21 years, he had a totally collapsed S-curve with severe CP quadriplegia. I recently asked his PT about him. 5 years later, he is still using the custom foam support which I made for him and continues to report that it permits him to sit comfortably.

Ultra flexible circumferential systems, fabricated from 2-3mm polyethylene with an upper abdominal cut-out covered by an adjustable elastic support to facilitate optimal respiration mechanics, are very well tolerated in a large percentage of patients form 15 months to 30 years of age. The very thin and flexible construction moves with the patient and is very well tolerated in even severely involved adults with either spastic or athetoid cerebral palsy.

Persons with many and varied diagnoses who have successfully worn this bracing, include, moderate to very severe cerebral palsy, Spinal Muscular Atrophy, Type II, Spina Bifida, and various moderate ot severe movement disorders with asymmetric axial hypotonia.

PREPARATION FOR CASTING

A thorough examination of the patient is made, including lying and sitting x-rays, maximum elongation and rotation of the curve with gentle soft tissue manipulation and manual support, and "dry run" trial positioning for optimal holding of curve reduction during the casting process. Optimal holding often includes the use of parents, the primary therapist and an additional 1 or 2 orthotic assistants, in order to manage maximum tone and position control, correction and patient comfort during the process. This process is also critical for mold rectification judgments that need to be made later, permitting a combination of maximum correction and maximum comfort wearing the TLSO. The molding orthotist always provides thoracic derotation control while others apply traction at the shoulders, assist with head control, stabilize and de-rotate the pelvis and legs. Decisions about where to provide support and each individual person's special role to play are made during this time including how the patient will be moved from prone to supine and how cast removal will take place. It is our experience that parents are most helpful in this process and children remain much calmer with parents close by and engaged in the process. The greater the information the parent and patient has about how the process will "feel", generally the more successful the casting is. Taking the needed time to help person's be as comfortable as possible with what is about to happen, reaps immense benefits in casting, rectification and fit.

Double layer stockinette is applied from the shoulders to below hips and secured with adhesive tape. Positioning marks for the iliac crest, lower ribs, zyphoid, sternal notch, sacrum, pubis, trochanters and scapulae are made in readiness for the plaster application.

PLASTER APPLICATION and NEGATIVE IMPRESSION

With older children or adults with moderate to very severe motor impairment, fabrication of a posterior followed by an anterior molding shell is usually the optimal method of plaster application with successive horizontal and vertical layers applied quickly. A clever technique of horizontal reinforcing bars, learned in a course in Germany, provides much greater medial-lateral and torsional stability of the posterior section in order to preserve maximum integrity of the cast during turning to supine. Any additional space at the sides of the posterior mold is filled with extra plaster for a more intimate total contact fit from axillae to the level of trochanters. Plaster strips are applied over the upper abdomen last in order to minimize stress on breathing.

For some very small children, using a circular technique provides more optimal compression control, followed by placing the child in prone for holding and setting of the plaster. Occasionally, with smaller children with Spinal Muscular Atrophy, Type II, circular wrapping of plaster, holding and setting is also helpful done in supported sitting to permit optimal balance active balance during later TLSO wear. These children have very tight parameters in which they have functional control. Finding this requires 3-dimensional precision and careful questioning of these very precocious little people. Circular molds are typically removed with a single anterior opening.

Full circumferential, AP and ML measurements are taken at axilla, 2nd rib, 10th rib, waist, ASIS, and trochanters to control later rectification of the positive.

NEGATIVE MOLD RECTIFICATION

With the above specific attention to detail in molding, we often are able to attain a very good balance in the plaster negative mold. Attaining this balance in the original negative is optimal and always our objective, however, wedging the negative cast model to achieve optimal center of gravity balance is done when necessary, before the positive mold is poured.

With this young boy, due to very strong tonic spasms collapsing his right side, the plaster negative required some wedging to achieve optimal balance in the mold, and this correction is very well tolerated in the subsequent TLSO.

POSITIVE MOLD RECTIFICATION

Typically, in the rectification process, excess plaster is removed according to the medial lateral measurements initially. This generally means further indention at the waist area, including evening any asymmetry of ASIS height. Trochanteric measurement is also usually too wide and is reduced bringing as much symmetry to the pelvis orientation as possible. Special care must be taken with hip dislocation or varus osteotomies to allow ample room for the deformity. There is almost always some degree of posterior pelvic rotation opposite to the convexity of the trunk curve which must be neutralized by removal of plaster over the posterior lateral aspect of the pelvis. Later addition of plaster over ASIS area anteriorly is needed on the same side. Sometimes plaster also needs to be added on the opposite posterior pelvic area to optimize pelvic symmetry, but this is done after all removal of excess volume is accomplished.

Precise control laterally above the waist to the 10th rib markers is managed in a way to optimize symmetry and natural physiologic elongation through this area. Plaster removal in this area is much greater on the convex side, evenly supporting the lateral collapse in this lower area. ML measurement at the level of the zyphoid process is also very helpful in monitoring width volume reduction with an objective of maximum symmetry and center of balance within the eventual brace.

Likewise, close attention to the axillary area of the concave side is required, especially to center the thorax precisely over the hips. This generally requires considerable plaster removal at the upper edge and sometimes a later addition of an axillary shelf which is bent over and flattened against the side at the time of fitting.

Very close attention is also given to the physiologic curves in the sagittal plane. Typically, the lumbar lordosis is exaggerated and often the thoracic kyphosis is flattened, requiring removal of some volume at the base of the posterior to the pelvic skirt area, sternum and anterior waist, with later addition of plaster posterior thorax to achieve a gentle physiologic kyphosis and at the posterior waist to better manage the lumbar lordosis. In persons with spastic or athetoid CP, tension in these areas is usually connected to dynamic tonal patterns, as well. Persons with Type II SMA also can over-use a lumbar lordosis to better manage stability. Both groups of individuals accept this control, assisting improved tone control in persons with CP and improved functional strength in active sitting balance in persons with SMA. This is most likely due to more effective mechanics for power generation in weak muscles.

With the following series of pictures the process of positive mold rectification for these ultra flexible TLSOs will be explained . Though the child is very severely involved with cerebral palsy and rapid progression of a congenital C-curve, and the style of his TLSO is not typical, the process of rectification is very typical.

Care is also taken to neutralize any residual shoulder counter-rotation to promote full symmetry and balance. Once plaster removal permits correct ML measurements, AP measurements especially at the pubis and sternum are controlled to help in the management of physiologic curves, in most cases, positively impacting active head control. Location of the anterior upper abdominal cut-out and the posterior thoracic cut-out on the side of the concavity are marked, Circumferential measures are used to control volume at various levels, recognizing that much plaster volume will usually be added in the area of the posterior cut-out to permit the possibility of further de-rotation of the curve as tolerated with time. A slight flare is made along the edge of the abdominal cut-out to prevent excessive skin pressure on the edges of this cut-out. As well, a small amount extra plaster is added over ASIS to flare the plastic and permit comfort in sitting.

Very precise modifications in and near the axillae are made to relieve the areas of brachial plexus and axillary arteries. This forms a somewhat exaggerated corners at the upper sides of the mold and later in fitting, care is taken to not apply direct pressure over vital structures in this area. Very precise fit in this area is also necessary for optimal function of the brace. Excess room permits the individual space to collapse inside the orthosis creating poor curve control and uneven pressure and skin irritation within the TLSO.

TLSO FABRICATION

When molds are finalized with approximate trimlines and exact straps and padding marked on the positive, our molds are sent by UPS to Cascade Prosthetics and Orthotics in Ferndale, WA for final fabrication. 2mm polyethylene is stretched over the mold and any specific padding which is requested. In some cases the entire TLSO is lined in 1/8 inch aliplast. Children and families are able to choose the colors of the padding, Velcro closures and a special design added to the straps. Undoubtedly, this customization to child and parent preferences helps in the high compliance to brace wear. With older individuals, the brace is often made unlined with ventilation holes drilled for extra comfort and cosmesis. Whether fully lined or unlined, specific protective 1/8 inch padding is added over the iliac crest and trochanteric areas, as well as over the sacrum. If the curve rotation is very large and can not be fully corrected, special 1/8 to 1/4 inch PPT padding in the area of thoracic protrusion is applied before the plastic is pulled. Additional posterior and anterior de-rotation padding is applied at the time of fitting.

Typically, an anterior closure is used with multiple D-ring straps and a padded tongue at the closure. We have also occasionally used a posterior closure when children continually play with the straps and loosen them. Plastic chafes and copper rivets minimize the need for strap repair with large tension forces generated, especially in larger individuals. An upper abdominal cut-out is covered with an adjustable elastic band, providing very flexible compression and assisting optimal respiratory mechanics and function. This also works very nicely in accommodating persons requiring gastric tube feeding.

The fit in the brace should be as intimate as possible. We have experienced positive changes in curve flexibility in some changes months after the initial fitting. These present, interestingly, as decreased balance control and sometimes as increased spot pressure. Parents also realize, after the fact, that the brace had become easier to put on. Addition of extra posterior and anterior de-rotational padding usually solves both active balance and even fit and pressure within the brace quickly. The bracing often permits 1 year of growth with minor modifications every 3-4 months to maintain optimal curve correction. Curve correction is verified by a sitting AP and if necessary lateral x-ray of the person in the brace, if possible, as these are most often worn in sitting.

TLSO FITTING and ADJUSTMENTS

The fit in the brace should be as intimate as possible. Final trimlines are made at the time of fitting, along with addition of 1/8th inch PPT pads at the center top of each side and posterior and anterior derotational padding. We have experienced positive changes in curve flexibility in some changes months after the initial fitting. These present, interestingly, as decreased balance control and sometimes as increased spot pressure. Parents also realize, after the fact, that the brace had become easier to put on. Addition of extra posterior and anterior derotational padding usually solves both active balance and even fit and pressure within the brace quickly. The bracing often permits 1 year of growth with minor modifications every 3-4 months to maintain optimal curve correction. Curve correction is verified by a sitting AP and if necessary lateral x-ray of the person in the brace, if possible, as these are most often worn in sitting.

The fit in the brace should be as intimate as possible. We have experienced positive changes in curve flexibility in some changes months after the initial fitting. These present, interestingly, as decreased balance control and sometimes as increased spot pressure. Parents also realize, after the fact, that the brace had become easier to put on. Addition of extra posterior and anterior de-rotational padding usually solves both active balance and even fit and pressure within the brace quickly. The bracing often permits 1 year of growth with minor modifications every 3-4 months to maintain optimal curve correction. Curve correction is verified by a sitting AP, and if necessary, lateral x-ray of the person in the brace. If possible, as x-rays are always taken in sitting to best assess its function.

The fit in the brace should be as intimate as possible. We have experienced positive changes in curve flexibility in some changes months after the initial fitting. These present, interestingly, as decreased balance control and sometimes as increased spot pressure. Parents also realize, after the fact, that the brace had become easier to put on. Addition of extra posterior and anterior de-rotational padding usually solves both active balance and even fit and pressure within the brace quickly. The bracing often permits 1 year of growth with minor modifications every 3-4 months to maintain optimal curve correction. Curve correction is verified by a sitting AP and if necessary lateral x-ray of the person in the brace, if possible, as these are most often worn in sitting.

COMBINING CUSTOM MOLDED/LYCRA COMPRESSION HYBRID TLSO

Our experience with SPIO Lycra Compression has permitted us to explore combinations of custom molded TLSO components and double layer Lycra Compression. The SPIO compression TLSO works amazingly well to support act self correction of dynamic scoliosis in persons with neuromotor deficits, including very young children with Type II or Type II SMA, children with Prader Willi, Angelmans, Rett and Down Syndrome, as well as, dynamic spinal curves in CP.

As these children grow, some of their curves are no longer as responsive to this very flexible system, often due to height and weight factors, and also mild curve progression. In these cases, we have had opportunity to explore the combination of custom mold elements with SPIO compression TLSO, permitting maximum possibilities for active trunk balancing. This girl with SMA II initially managed well in SPIO Lycra TLSO only.

Where less custom molded TLSO control is required, integrating a custom moldable low temperature (1/16th inch perforated Aliplast) section into a Neoprene back, has proven to provide excellent custom molded support in small children with a combination of dynamic and mild structural curves, in combination with the anterior portion of a SPIO compression TLSO. Benik, Inc. in Silverdale, Wa. fabricates these specialized Neoprene back with customized areas of low temperature plastic sewn in. Because this is a low temperature system and can be heated and molded directly to the individual using the SPIO compression element to stabilize positioning, children that would never tolerate a normal custom molding session, manage this quite well. It can be easily remolded as needed for growth.

We are very pleased to be able to share some information regarding our use of Ultra Flexible TLSOs with the hope that it will be of value to colleagues and other persons with similar motor control challenges.

Nancy Hylton, PT, CO