Current Attitudes Toward the Milwaukee Brace
L. MERCER McKINLEY, M.A., M.B., B.CH. THOMAS A. MARTIN, C.P.O.
During the first nine months of 1976 we randomly surveyed 40 certified orthotic centers throughout the United States, of which 75 per cent replied to the questionnaire. This report presents the results of our survey.
Ten key questions were divided into the following categories:
- The fit of the Milwaukee girdle
- Superstructure and its accessories
- Participation in physical therapy.
The Milwaukee Girdle
In the questions dealing with the fit of the Milwaukee girdle, the first three dealt with the problem of lordosis.
How much lordosis do you permit in your Milwaukee? Twelve replied, "As little as possible." Six replied, "None." Five replied, "The maximum pelvic tilt." One replied that he tried to eliminate half, and the others said, "Minimal amount."
Referring to the guidelines laid out in the classic book, The Milwaukee Brace1, "With the pelvis tilted (flexed) and the lumbar lordosis flattened," it can be seen that most people follow the directions, but to varying degrees.
Do you know of any studies that one has made, eliminating all lordosis while taking the cast for a Milwaukee? To this, 20 replied, "No;" five alluded to the Boston System; two said, "Yes;" one referred to the Northwestern Teaching Manual; and two did not answer. We have found in our own facility that the posterior uprights determine the lordosis in the Milwaukee Brace. As an example, we made a Milwaukee girdle with all the lordosis removed, and also a girdle made without traction and permitting a slight amount of lordosis. It was interesting to note that the alteration of the posterior uprights allowed the girdles to be interchangeable on the plaster molds.
What is your opinion of such a procedure? More than half replied that they thought it was a good idea. From those who did not like this idea, two interesting points emerged:
- If the patient is held in maximum pelvic flexion, how can he achieve his pelvic tilt?
- Some orthotists preferred to modify the cast to eliminate the lordosis in the mold.
In the section on girdle procedures the final question dealt with casting technique. Do you take your casts with the patient in traction? Eighteen replied that they did not take their casts with the patient in traction. Of these 18, one said he only did it in severe cases. Ten said that they took the casts in traction, and two did not answer. It became apparent that the division of opinion was related to previous practice, since the more senior orthotists tended to cast the patients in traction. However, none of the orthotic schools appeared to be using traction to a great extent.
Superstructure and Accessories
The second section dealt with the superstructure and the accessories that may be applied to the superstructure.
What is the relationship of the posterior uprights in the A-P and lateral planes in regard to the girdle? The majority attempted to reduce the pelvic tilt and flatten the lumbar spine; and as regards the frontal plane, the majority commented that they like to separate the bars enough to permit easy roentgenographic visualization of the scoliotic spine in the brace.
Specifically where do you place the throat mold? The majority of people thought the ideal placement of the throat mold was 2.5 cm (1 in.) inferior to the mandible and 1 cm (3/8 in.) anterior to the soft tissues of the larynx and throat. One orthotist made the comment that he liked to fit his braces in an easy chair, three considered that the mold should be placed very close to the throat, and one person observed that this practice was exceedingly dangerous, since an injury to the soft tissues of the larynx could occur if the mold was driven into the neck with any force. One correspondent liked to use a wire frame rather than the conventional throat mold, and two pointed out that in the kyphosis brace perhaps 1) the anterior throat mold should be raised slightly, and 2) the occipital pads should be removed.
How do you advise eliminating pressure from the side of the neck ring? The first thing we noticed here was that six correspondents used the neck ring as a reaction point in their concept of the three-point fixation of the Milwaukee Brace. Two people used orthotist's tricks to manipulate the anterior bar 2 . The majority, however, recommend the use of an axilla sling or trochanteric pad.
What has been your experience with axilla rings? The experience reported in this section was diverse, ranging from excellent to extremely poor. About one quarter considered that axilla rings were good and were obviously pleased with their results, while nearly half had limited success, stating that they were "uncomfortable," "ineffectual," and "unrewarding." Four correspondents considered the axilla ring as the avenue of treatment for a high thoracic curve.
What has been your experience with shoe build-ups? We were relieved to find that the majority of people had no use for shoe build-ups except for cases of leg-length inequality. However, there were a few who used them for low lumbar curves, to encourage lateral tilt" and "in the treatment of mild scoliosis." We feel that those who advocate shoe build-ups as a method of treating scoliosis should review their procedures. We feel that it is very necessary to insure that the anterior-superior iliac spines are exactly level during the casting of the mold; and if leg-length inequality is present, the pelvis must be leveled prior to the taking of the cast.
The final section concerned participation in the exercise program that accompanies Milwaukee Brace treatment and explored the percentage of patients who participated in an exercise program. Most respondents agreed that those who participated in the exercise program gained the most correction. Fifty per cent believed that 100 per cent of their patients were involved in the exercise program, 25 per cent believed that 90 per cent participated in the exercise program, and the remainder believed that perhaps 50 or 60 per cent were doing their exercises as instructed. It might be interesting to study those who are getting 100 per cent participation, since we are sometimes appalled at how vague the children are about their exercises or even about when they last did them. Perhaps we as orthotists should be more aware of how the orthosis fits into the exercise program and the way in which it is used during the daily exercise periods.
There is little doubt that the Milwaukee Brace has many problems and pitfalls from the first moments of its fabrication to its final fitting. Some orthotic centers which we polled no longer made Milwaukee Braces because of central fabrication techniques or because to do so may have been financially unrewarding. Perhaps some of the impetus in the development of the low-profile, nonsuperstructure brace has resulted from problems people have had in contending with this brace. We hope to follow this article with another on the technical specifications and construction of our version of the Milwaukee Brace. We invite readers interested in this subject to forward us their ideas and opinions.
We wish to thank all those who participated in this survey by completing their questionnaires.
Note: Correspondence to the authors should be addressed to Orthotic-Prosthetic Facility, Kosair Crippled Children Hospital, 982 Eastern Parkway, Louisville, KY 40217.
1. Blount, W. P., and J. H. Moe, The Milwaukee Brace. The Williams & Wilkins Company, Baltimore, 1973.
2. Parmaley, A., Technical note: two common problems in application of the "Milwaukee Brace." Orth and Prosth,30:l:49, March 1976.