Current Principles in Spinal Orthotics for Children*
SIEGFRIED W. PAUL, C.P.&O.
* Presented to the Annual Meeting of Amputee Clinic Chiefs, Committee on Prosthetics Research and Development of the National Research Council, at Emory University, Atlanta, Ga., Apr. 25, 1973.
Principles of adult patient care cannot be applied directly to the complex orthopaedic problems of children who require supportive or corrective devices. The child's basic orthopaedic problem is frequently associated with primary or secondary conditions involving medical or paramedical specialties other than orthopaedics.
During the past decade it has been demonstrated that the team approach can provide a more complete treatment program than can be offered by the individual specialties acting independently. Recent advances in orthotics materials and design, and in clinical management procedures, are direct results of close cooperation among team members.
During the past five years the precise identification of major orthopaedic problems and systematic concentration on the solution of these problems have led to the development of orthotic devices with improved fit and function.
Close supervision of these problem cases involves the recording of clinic notes and the exchange of data between team members and between clinics. This clinical approach takes into account not only the effectiveness of orthotic systems but also their limitations.
A centralized exchange of data and a systematic attack on specific problems could produce effective gains in the treatment of scoliosis, kyphosis, muscular dystrophy, myelomeningocele, and other lower-motor-neuron disturbances.
Selection of the type of treatment according to the severity and flexibility of the curve and the patient's age makes the orthosis most effective. If the curvature is greater than 45 degrees in ideopathic scoliosis, we no longer treat the patient conservatively but give consideration to surgical management. Both biomechanical studies and clinical experience have indicated that the correcting forces involved in the use of a Milwaukee orthosis are functional rather than passive, i.e., arise from patient activity rather than from brace control.
Thus traction has been ruled out as a correcting force and the pressure pad system is perceived as an encouragement to exercise-placing greater importance on the patient's cooperation.
The conventional mandible plate used earlier caused dental malocclusion and jaw flattening as a result of the traction force exerted as the patient rested his chin on the plate. This drawback demanded correction. The development of a "throat mold" which was fitted lower on the throat so as not to involve the jaw ( Fig. 1-A ) appears to have eliminated this problem. The hinged neck ring, developed at Newington Children's Hospital, provides a self-aligning mechanism ( Fig. 1-B ). The uprights can be raised or lowered without having to change the alignment. Application of the orthosis was made easier by placing the occipital opening in the center of the posterior neck ring and by attaching the pressure pads to the ipsilateral upright, i.e., the upright on the same side of the body as the pad. The strap is looped around the bar to bring the pad closer to the body (popup3]. Disposable pads and covers make wearing the orthosis more acceptable.
In essence, most of the changes made in the basic Milwaukee orthosis also apply to the use of this device in treating kyphosis, for which it has been found to be most effective. Two changes which make the three-point pressure system even more effective are:
- Two round pads located in the deltoid-pectoral triangle just below the clavicle are attached to a clavicular cross bar ( Fig. 2-A ) and provide a more even and effective force distribution which invites chest expansion, in contrast to the depressing force of a sternal pad.
- The wide dorsal pad, lateral straps, and anterior attachment bar are eliminated and two 2 x 6 inch vertically placed pads are attached to the posterior uprights ( Fig. 2-B ). Application and removal of the appliance are now very easy. Moreover, and most importantly, the patient is not able to loosen the tension on the strap. Fitting of the longitudinally arranged pads is unchanged from established principles.
Total-Contact Spinal Orthosis (T.C.S.O.)
Spinal problems in muscular dystrophy frequently become increasingly acute as the disease progresses, particularly at the stage when the patient is confined to a wheelchair ( Fig. 3-A , Fig. 3-B , and Fig. 3-C ). The severe scoliosis present will cause cardiopulmonary problems. The TCSO provides enough support to prevent total collapse of the spine.
Myelomeningocele and Other Lower-Motor-Neuron Disturbances
Total-Contact Spinal Orthosis (T. CS. 0.)
Scoliosis and, frequently, lordosis are major orthopaedic problems in the patient with lower-motor-neuron disturbances. Arthrodesis in the young child is limited to segmental fusions. Other means of support are required in order to achieve a functional status for the patient. A molded plastic TCSO as a separate entity, i.e., not attached to the lower-limb orthosis, has proven most effective ( Fig. 4-A and Fig. 4-B ). Its adjustability and ease of application and maintenance make this device superior to others now available.
A modification of the standard TCSO is achieved through the incorporation of thoracic suspension. In this modification the orthosis is contoured below the rib cage in the form of an undercut, and the lower ribs are used for partial weight-bearing. Suspension is achieved by attaching the TCSO to a wheelchair or to the lower-limb orthosis. The effect of this "traction" on difficult kyphotic or scoliotic curves is dramatic ( Fig. 5-A , Fig. 5-B , Fig. 5-C , Fig. 5-D , Fig. 5-E , and Fig. 6-A , Fig. 6-B , Fig. 6-C , Fig. 6-D , Fig. 6-E ). Pressure tolerances should be checked carefully in using this device.
Reclining Seating Device
The progressive flaccid paralysis characteristic of this disease will render the patient functionless and difficult for the parents to manage.
A plastic seating device ( Fig. 7-A and Fig. 7-B ) was developed as an activity and transportation aid. The seat, placed in a semi-reclining position and mounted on a platform, included head, arm, and foot rests. With this device the patient was able to feed himself and to participate in a limited number of activities of daily living; and, most importantly, cardiopulmonary and digestive functions were improved. The parents find it easy to transfer the child from wheelchair to car, etc. Eight applications of this seating device have been made during the past six years. It has been noted that the life expectancy of these patients was extended by several years.
Initially major changes in the selection of materials for orthotic applications occurred when thermosetting plastics demonstrated durability, improved cosmesis, and ease of use in prosthetics. Laminated segments are frequently used in today's orthotic applications. However, it was not until the introduction of economical and durable thermoplastic materials that plastics became recognized as the materials of choice for spinal orthoses. Polythene, polyethylene, and polypropylene are but a few of numerous compositions now used frequently.
The advantages of thermoplastics over thermosetting plastics are ease of application, superb durability, non-toxicity, excellent adjustability, light weight, and low cost. A very important feature is the simplified maintenance. The surface does not crack and remains smooth even after years of continued wear.
Our experience with a polythene plastic at Newington Children's Hospital began in 1965 with use of the material Vitrathene, a low-density compression-molded plastic manufactured in England. It is available through a local distributor in any dimension or color desired. (We have found pink to be most acceptable.) At 350 degrees F it can be molded to any contour. Over the years, as our experience has accumulated, we have used the material not only for upper- and lower-limb orthoses but also in spinal orthoses such as the TCSO, Milwaukee pelvic sections, and seating devices.
Our observations are as follows: Plastics which are to be used for spinal orthoses need to have adequate flexibility so that they may be applied easily. Rigidity can be provided in areas where it is needed by molding the plastic into channels and undercuts. These areas can be made sufficiently rigid to permit the elimination of certain metal components such as pelvic bands. For heat loss, perforation of the plastic is mandatory; ventilation should be provided by means of small pinholes. No cases of material fatigue were noted during the entire period of use of these materials. When orthoses had to be discarded because children had outgrown them, their appearance was still excellent. No skin reactions occurred and scoliotic patients appreciated the lack of odor. Vitrathene can be molded with soft linings of durable polythene or polyethylene foams, but linings should only be necessary if the subcutaneous tissue has low tolerance to pressure.
The techniques discussed in this paper are no longer considered to be experimental but rather are used as established procedures.
The progress made in orthotics practice has enabled us not only to provide improved patient care but also to treat conditions conservatively rather than surgically. Delivery of services has become more efficient, repairs have been diminished, and the unit cost of patient care has been lowered.
Continued development and research should be encouraged and conducted on a broader basis at centers with access to patients requiring both routine and problematic orthopaedic care.
Descriptors: Children: kyphosis; Milwaukee: muscular dystrophy; myelomeningocele; orthotics; scoliosis: spine: Vitrathene.
Director, Orthotics and Prosthetics, 181 East Cedar St., Newington, CT 06111. Newington Children's Hospital, Newington, Connecticut
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Photograph credits to Newington Children's Hospital.