Initial Correction in Providence and Charleston Brace for Idiopathic Scoliosis
Dr. Charles T. Price
Purpose of Study:
To determine whether the Charleston Brace or Providence Brace provides greater initial inbrace correction of the major curve in adolescent idiopathic scoliosis (AIS) and to determine whether the Charleston Brace (CBB) or Providence (PB) provides greater initial in-brace correction of the minor curve in adolescent idiopathic scoliosis. [Image ]
Initial in-brace correction of AIS has been shown to correlate with successful brace management of AIS. Thus, greater in brace correction is associated with improved prevention of progression. Successful Milwaukee Brace management has been associated with greater than 20% correction of the initial major curve. The Boston Brace and other daytime TLSO's are judged to be adequate when initial correction in the brace is 50% or greater. Brace wear with the Milwaukee or TLSO braces is recommended during daytime and at night for a minimum of 23 hours. The CBB and PB are designed to provide maximum in-brace correction during night-time-only brace wear with a recommended 8 hours. Advocates for both of these braces have indicated that in-brace correction should approach 80-100% of the initial curvature. The concept of these braces is that maximum correction provided over a shorter time period during recumbent sleep may affect growth and avoid daytime brace wear.1,7,9,5,6,11,12,13
The Charleston Brace utilizes bending to obtain maximum correction. Several studies have reported success with single curves equal to success rates with full-time braces. Some authors have reported success with double curves using the CBB as long as rigorous criteria are applied for the initial in-brace radiograph. On the other hand, the Providence Brace provides maximum correction by direct pressure on the apex of the major and minor curvatures. In theory, the Charleston Brace would provide greater in-brace correction of the major curve with less correction of the minor curve. In theory, the Providence will provide slightly less in-brace correction of the major curve compared to the Charleston Brace, but there would be improved in-brace correction of the minor curves in the Providence Brace.1,7,9,5,6,11,12,13
If the above hypothesis is correct, then the Charleston Brace may be a better choice for single curves while the Providence Brace may be a better choice for double curves. However, other findings may be identified and may include:
- Equal in-brace correction of major curves with improved minor curve correction in the Providence Brace. This may imply that the Providence Brace is the best choice for single or double curves to reduce the risk of progression in all minor curves. Or, there may be a need for improvement in Charleston Brace manufacturing methods to increase correction of the major curve without risk to the minor curvatures.
- Greater in-brace correction of the major curve with the Charleston Brace without any reduced correction of minor curves even for double curves compared to the Providence Brace. This finding may indicate that the Charleston Brace is a better choice for all AIS patients, or that the Providence Brace manufacturing techniques need to be improved.
All patient data were recorded retrospectively from patients that have been previously braced for adolescent idiopathic scoliosis. Data was collected from both before and after initial brace fitting using either the Providence or the Charleston Bending Brace. Major and minor scoliosis curve magnitude was recorded before and after initial bracing. The number of patients for this study total fifty-two, of which twenty six Providence and twenty-six Charleston Brace patients. Additional subcategories for both Providence and Charleston patients were divided by the apex of the major scoliosis curvatures, i.e. thoracic, thoracolumbar, and lumbar. Data for every category include; percentage of curvature correction based on initial curve, median, range, magnitude of curve correction, and the number of patients in each category.
The initial major scoliosis curve magnitude before bracing of all fifty-two patients was an average of 27° with the median of 25.5° and a range of 16°-49°. The initial minor scoliosis curve magnitude before braces of thirty-two total patients were 22° with a median of 22° and a range of 12°-40°. Average curve magnitude before bracing of only CBB patients (n=26) were 25° and minor curve magnitude before bracing of the CBB patients (n=8) were 18°. Average curve magnitude before bracing of only Prov patients (n=26) were 29° and minor curve magnitude before bracing of the Prov patients (n=24) were 24°. See Initial Scoliosis Curve Magnitude Average Graph [Figure 1 ], Curve Magnitude average before bracing Graph [Figure 2 ], and Patient Populations for CBB and Prov Overall Groupings Graph [Figure 3 ] below.
Average major curve correction for all Charleston patients (n=26) are 105%, median of 112%, range of 13%-183%, and an average magnitude correction of 25°.
Average minor curve correction for Charleston patients (n=8) are 5%, with a median of 0%, range of -38%- 45%, and minor curve magnitude correction of 1°. Average curve correction of major thoracic apex curves for CBB patients (n=12) are 84%, with a median of 93%, range of 13%- 152%, and magnitude correction average of 20°. Average minor curve correction of thoracic apex major curves for CBB patients (n=5) are 8% with a magnitude correction of the minor curve at 2°. Average curve correction of major thoracolumbar apex curves for CBB patients (n=7) are 128%, with a median of 128%, range of 100%-158%, and a magnitude correction average of 32°. There are no minor curves in the thoracolumbar apex major curve category for CBB patients. Average curve correction of major lumber apex curves for CBB patiens (n=7) are 116%, with a median of 117%, range of 73%-183%, and a magnitude correction average of 26°. Average minor curve correction average of lumbar apex major curves for CBB patients (n=3) are 0%.
Average major curve correction for all Providence patients (n=26) are 59%, with a median of 68%, range of 6%-100%, with an average major curve correction magnitude for all Prov braces of 16°. The average minor curve correction for all Prov patients (n=24) are 52%, with a median of 52%, range of 0%-100%, with an average minor curve magnitude correction of 12°. Average major curve correction of thoracic apex Prov patients (n=20) are 62%, with a median of 68%, range of 6%-100%, with an average magnitude of 17°. Average minor curve correction of thoracic apex major curve Prov patients (n=19) are 51%, with a median of 52%, range of 0%-100%, with an average magnitude of 13°. Average major curve correction for thoracolumbar apex Prov patients (n=4) are 43%, with a median of 35%, range of 16%-88%, and an average magnitude of correction of 10°. Average minor curve correction for thoracolumbar apex major curve Prov patients (n=3) are 35%, with a median of 30%, range of 21%-56%, and an average magnitude of correction of 6°. Average major curve correction for lumbar apex Prov patients (n=2) are 84%, with a median of 84%, range of 82%-87%, and an average magnitude of correction of 26°. Average minor curve correction for lumbar apex major curve Prov patients (n=2) are 92%, with a median of 92%, range of 84%-100%, with a magnitude correction of 22°. See the Correction Average per Category Graph [Figure 4 ], Patient Population per Category Graph [Figure 5 ], and the Magnitude of Curve Correction Graph [Figure 6 ].
(Note: There are no patients with minor curves in the Thoracolumbar Minor Curve CBB category. Additionally see Patient Population Chart!)
There are several factors to consider when looking over the statistical information in this case study. The statistical outliners of this study were not removed for either of the two categories of braces. The individuals that are considered outliners of the data would in some cases not be considered a successful fitting of a brace and would need the brace to be remade or the patient's lack of flexibility would not allow for the desired amount of spinal correction. These two factors of outliner data and patient flexibility are factors to be considered when interpreting the data. Further study and careful translation of the data is particularly important when considering minor curve corrections for major lumbar curves which tend to have the apex above that of the major curve. Patient population size is incredibly important when attempting to make conclusions of specific AIS treatment modalities if there are too few data entries, see the Providence data on major thoracolumbar and lumbar curves. This type of an error is an imprecise representation of the specific patient population as a whole. There has been some continuing discussion as to the either the conservative or aggressive nature to which the overall rehabilitation team uses orthotic spinal braces. Additionally treatment aggressiveness by means of the ability and skill of the orthotists to appropriately fulfill the patients brace prescription, along with the level of communication with both the treating physicians and manufactures of the orthotic devices will be key factors in any spinal bracing situation. Patient spinal flexibility plays a key role when deciding if a specific treatment goal can be successfully achieved and the use of a bending film may be extremely valuable to help determine what the boundaries of successful bracing can be.
Wolf's Law describes how bone tissue in humans and animals adapts directly to the forces placed upon it.14 Wolf's Law is the standard by which we as clinicians have been using to illustrate the natural ability of bone to remodel itself to better oppose the physical forces placed upon it and to provide the scientific efficacy for bracing our patients with AIS. The Charleston Bending Brace system will provide a higher magnitude of corrective curvature force and a higher percentage of correction to most AIS patient populations vs. the Providence Brace. The natures of most minor scoliosis curvatures of the spine seem to be compensatory curves of which should be considered of secondary importance to the primary major spinal curves. The different treatment methods of the CBB, maximum major curve correction with minor curve stability, vs. the Providence Brace, which splits the corrective force between the major and minor curves, have become apparent. This data strongly indicates that with the Providence Scoliosis Brace minor curve correction is achieved at the expense of major curve correction (See Magnitude of Curve Correction Graph [Figure 6 ] and Correction Average per Category Graph [Figure 4 ]). Overall the Providence Brace achieves 52% minor curve correction and 59% correction respectively for major curves. The Charleston Brace conversely achieves an average overall of 5% correction of minor curves and 105% on major curves. There is a difference of 55% between minor curves from the Providence to the Charleston brace and a major curve difference of 53% from the Charleston Brace to the Providence. As you can see, there are distinct advantages of both designs, yet there have been clinical indications of minor curve correction within and exceeding the initial curvature correction percentage of some patients using the Charleston Bending Brace. The data also indicates that the Charleston Bending Brace is extremely successful in treating high thoracic major curves, thoracolumbar major curves, and lumbar major curves respectively for each category of patient.
It must also be noted that the overall correction factors of the Providence Brace for the lumbar minor and major curve category (patient population n=2) and thoracolumbar minor curves category (patient population n=3) do not have statistically relevant patient populations to make any conclusions or generalizations about their bracing effectiveness. Please see the appendix for the statistical analysis t-test for this paper.
To further gain knowledge about AIS we need to duplicate this study in other regions of the United States in order to accumulate enough data to properly make value assessments of current brace treatments. A study needs to complete with the long term outcomes of braced AIS patients that will enable everyone to come to a more complete understanding of how exactly we affect the spinal deformity process relative to initial brace correction.
First and foremost, I thank God for making this study possible. Secondly we very thankfully acknowledge the combined and collaborative works of Orlando Regional Healthcare, Hanger Prosthetics and Orthotics, Denise Lopez and Joanne Soto. Without their contributions this study would not have been possible. We acknowledge the willingness of all those involved to work successfully together, to go above and beyond, in order to help those we serve on a daily basis. Thank you also for the fortitude of the patients who require our services. Special thank you to the Orlando Regional Healthcare and their Internal Review Board approval which made this study possible. Thank you D. M. Bouch for the statistical analysts of this paper.
References and Related Articles:
- Allington, N. J., & Bowen, J. R. (1996). Adolescent idiopathic scoliosis: treatment with the Wilmington brace. A comparison of fulltime and part-time use. Journal of Bone and Joint Surgery American, 78, 1056-1062.
- Andrea, L., Betz, R. R., Lenke, L. G., Clements, D. H. Lowe, T. G., Merola, A., Haher, T., Harms, J., Huss, G. K., Blanke, K., & McGlothlen, S. (2000). Do radiographic parameters correlate with clinical outcomes in adolescent idiopathic scoliosis? Spine, 25, 1795-1802.
- Bunnell, WP. (1986). The natural history of idiopathic scoliosis before skeletal maturity. Spine, 11, 773-776.
- Carr, W. A., Moe, J. H., Winter, R. B., Lonstein, J. E. (1980). Treatment of idiopathic scoliosis in the Milwaukee brace. Journal of Bone and Joint Surgery American, 62, 599-612.
- D'Amato, C. R., Griggs, S., & McCoy, B. (2001). Nighttime bracing with the providence brace in adolescent girls with idiopathic scoliosis. Spine, 26, 2006-2012.
- Emans, J. B., Kaelin, A., Bancel, P., Hall, J. E., Miller, M. E., (1986). The Boston bracing system for idiopathic scoliosis follow-up result for 295 patients. Spine, 11(8), 792-801.
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- Gepstein, R., Leitner, Y., Zohar, E., Angle, I., Shabat, S., Pekarsky, I., Friesem, T., Folman, Y., Katz, A., & Fredman, B. (2002). Effectiveness of the Charleson Bending brace in the treatment of single-curve idiopathic scoliosis. Journal of Pediatric Orthopedics, 22, 84-87.
- Green, N. E. (1986). Part-time bracing of adolescent idiopathic scoliosis. Journal of Bone and Joint Surgery American, 68, 738-742.
- Lonstein, J. E., & Carlson, J. M. (1984). The prediction of curve progression in untreated idiopathic scoliosis during growth. Journal of Bone and Joint Surgery American, 66, 1061-1071.
- Price, C. T., Scott, D. S., Reed, F. R., Sproul, J. T., & Riddick, M. F. (1997). Nighttime bracing for adolescent idiopathic scoliosis with the Charleston Bending Brace: long term follow-up. Journal of Pediatric Orthopedics, 17, 703-707.
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- Trivedi, J. M., M. Ch., & Thomson, J. D. (2001). Results of Chrleston bracing in skeletally immature patients with idiopathic scoliosis. Journal of Pediatric Orthopaedics, 21, 277-280.
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- Wolff J. (1986). The Law of Bone Remodeling. Berlin Heidelberg New York. (Translation of the German 1892 edition).
Matthew Paruch, BEO
Dr. Charles T. Price, MD
Darrell Geyer, CO
Alistair Gibson, CPO