Balance-Beam Exercises for Milwaukee-Brace Wearers: An Adjunct to Regular Recreational and Physical-Education Activities

WILTON H. BUNCH, M.D. RONALD C. ADAMS


The treatment of scoliosis and kyphosis in teen-agers is usually associated with considerable morbidity. If surgery is required most centers will impose a long period of recumbency postoperatively and even those children who are allowed to be up soon after surgery are required to wear cumbersome casts and have excessive restrictions placed on their life style. Unfortunately, patients treated by a nonopera-tive approach, i.e., the Milwaukee brace, are often subjected to the same requirement of inactivity. As a result, significant physical and psychological morbidity is often associated with this form of treatment also.

The purpose of this paper is to describe ways in which this center is attempting to reduce this morbidity by placing emphasis on a balance-beam program. To the best of our knowledge this type of approach has not been previously reported. In an attempt to lessen the psychological impact of the brace, we are continually modifying the device to make it more and more cosmetically acceptable ( Fig. 1 ). At the present time it is possible for the girl with an inventive mother to dress in such a way that the brace is not apparent. In an attempt to provide psychological support, as well as to study the effect of the brace, all children are admitted to the Children's Rehabilitation Center for a week at the time the brace is applied. They are given perceptual and body-image tests by the psychologist and interviewed by the psychiatrist. These tests are repeated at appropriate intervals as necessary for the study or if requested by the child. Thus far the psychiatrist has been well accepted by the patients and is viewed as a neutral person to whom complaints and problems may be aired. This part of the program is designed to make the child look and feel as normal as possible.

The second part is designed to make the child act as normal as possible. In this phase we encourage active participation in all activities of the school program including physical education. These activities may be divided into two groups, those which we believe have therapeutic value and those which are strictly recreational and of value primarily in maintaining peer relationships. We will consider this latter group first.

Recreational Activities

The idea of encouraging the patient to take part in recreational activities is not unique with us. Blount, in a movie made in 1968, showed his patients working on gymnastic equipment and engaging in horseback riding. Moe also has encouraged his large group of patients to participate in physical exercise. After the application of the brace our patients are urged to engage in all activities that they had enjoyed before the diagnosis of scoliosis was made. The only restrictions are related to those activities which would be impossible in the brace, such as tumbling, and those in which the brace might constitute a real danger to others, as in football. Some of our patients have excelled in ballet, gymnastics, and horsemanship while wearing the brace.

Intensive Encouragement

The unique part of our program is the intensity with which we have encouraged these activities. In our patients we have found that it is not sufficient to merely permit activities?they must be strongly promoted. To do this, it has been necessary to establish close communication with physical-education instructors in the schools. At the time the child is discharged after a week's stay at the hospital for brace fitting, a form is sent to the teacher, outlining the physical-activity program desired (Appendix I). Special enquiries or comments are requested and frequently received. If no response is obtained, follow-up phone calls are made so that we have an indication of problems which may require additional assistance from the physician or director of therapeutic recreation. At the same time that the approved activities are listed, specific instructions are given about the correctional activities planned.

Therapeutic Program

The therapeutic exercise program is divided into two parts. The standard Milwaukee-brace exercises as described by Blount and Moe are taught by the physical therapist. These include postural and back and abdominal strengthening exercises including pelvic tilts, push-ups, and leg raises ( Fig. 2 and Fig. 3 ), and lateral bending of the trunk. These exercises are done daily in and out of the brace. The second exercise program consists of low balance-beam exercises under the direction of the therapeutic recreation/adapted physical-education department. The use of the low balance beam directly influences the balance muscles (particularly the abdominal muscles which are stabilizers of the trunk and pelvis) and improves self-awareness of general body alignment in the performance of motor movements.

Best results are achieved with a sequence of exercises of graded difficulty (Appendix II). Two heights are used as standard references: the low board is 3 to 7 in. high, and the high board 15 to 24 in. high. Variations in these heights can be made depending on individual problems. It is advisable to start at the lower level and then progress to the higher.

In using the balance beam the following procedures are recommended:

  1. Remove shoes and stockings. If this is impractical then sneakers or tennis shoes should be worn ( Fig. 4 ).
  2. Always approach the beam with the dominant foot.
  3. Walk the board slowly.
  4. Use a heel-to-toe gait.
  5. Place the whole foot straight on the board.
  6. Keep the head up and do not watch the feet.
  7. Arms may be extended to shoulder level to assist in keeping the center of gravity over the base when starting to walk the beam or when performing dynamic balance exercises.
  8. Students should focus their eyes on a given target area when performing all exercises, unless otherwise stated.

After these fundamentals are mastered, progressively more difficult exercises may be added, such as retrieving objects from the floor ( Fig. 5 ), or bouncing a basketball while balancing on the beam. Naturally, balance movements increase in difficulty with increased height of the board and even more if a weight is carried on the head. The therapist or instructor-should observe each student for form, response to command, and exactness of movement. Shifting the feet, tilting the head, extraneous movements of the arms and other faults of form should be checked. A record of daily balance routines and accomplishments should be kept for each student.

The balance beam is an excellent tool for testing precision of movement, but even more important it can teach students the value of good posture as an expression of personality. A well-poised body, gracefully controlled in its actions and positions, is very expressive. When a boy or girl realizes this, there is an added incentive to extend the achievement of such poise and control of the body into more advanced physical activities.

If the child has good balance and coordination he is encouraged to enroll in a program of recreational exercises which includes bowling, badminton, equitation, canoeing, swimming, and archery. However, if the child has poor balance skills (which may or may not be secondary to the brace) then further training on the low balance beam is indicated. We find that children with significant balance difficulties improve with training on the beam and progress rapidly to recreational activities.

Summary

It is very important that children in Milwaukee braces enjoy a life style similar to that of their classmates. Despite brace modifications, psychiatrists and clever mothers, these children are not able to participate automatically in all peer-group activities. The use of the balance beam helps the child gain the confidence and self-awareness which will allow him to participate in regular recreational and physical-education activities.

* Letter sent to physical-education teacher

Children's Rehabilitation Center University of Virginia Hospital Charlottesville, Virginia

References:
Blount, W. P., The Milwaukee brace in non-operative scoliosis treatment. Acta Orthop.
Scand., 33:399-401, 1963. Blount, W. P., The Milwaukee brace in the treatment of the young child with scoliosis.
Archiv fur Orthopadische und Unfall Chirurgie, 56:363-369, 1964. Blount, W. P., The non-operative treatment of scoliosis and round back with the Milwaukee brace. Prosth. Internatl., 3:9:3-10, 1969. Blount, W. P., and J. Bolinske, Physical therapy in the nonoperative treatment of scoliosis. Phys. Ther., 47:919-925, 1966. Blount, W. P., and J. H. Moe, The non-operative treatment of scoliosis and round back with the Milwaukee brace and exercises in the brace. Lecture Notes, August 1, 1969. Blount, W. P., A. C. Schmidt, E. D. Keever, and E. T. Leonard, The Milwaukee brace in the operative treatment of scoliosis. J. Bone and Joint Surg., 40-A:511-525, June 1958.
Galante, J., el al, Forces acting in the Milwaukee brace on patients undergoing treatment for idiopathic scoliosis. J. Bone and Joint Surg., 52-A:498-506, April 1970.
Moe, J. H., The fundamentals of the scoliosis problem for the general practitioner. Post-Grad. Med., 23:518-532, May 1958.
Moe, J. H., and R. B. Winter, Congenital scoliosis. Prosth. Internatl., 3:9:19-24, 1969.
Nonoperative treatment of scoliosis with Milwaukee brace: Part I. Marquette University and Pope Foundation, 1963, 38 min., color, sound, 16 mm.
The nonoperative treatment of scoliosis and round back by the Milwaukee brace: Part II. Marquette University, 1968, 30 min., color, sound, 16 mm.