Current practices in the orthotic treatment of idiopathic scoliosis (IS) and Scheuermann’s kyphosis do not always focus on implementing a team approach, nor do they constantly strive to maintain a coordinated communication process. Coordination among all care team members is critical to the patient’s success in orthotic treatment. But good communication is just the beginning of a successful treatment process. Establishing education guidelines so the patient and family can easily understand and anticipate the steps in the care process is critical. This education process helps eliminate many fears and concerns patients and their families experience when beginning a treatment that is filled with many unknowns. Adhering to follow-up guidelines can also increase the chances of successful treatment and the patient’s comfort with the process. It is important for both physician and orthotist to work together during follow-up treatments. Because radiographic evaluation is a part of the follow-up process, understanding the risks of radiation exposure and modifying treatment to limit risks is key to successful treatment.
More physicians are treating patients with scoliosis in small settings, rather than referring them to large spine centers for their care. Although this trend in patient care exists throughout the country, this does not mean the team approach is lost. To ensure that proper care is delivered to the patient, the team still needs to be present and have a good communication process in place. The team may not necessarily be located in the same center, but with specific roles defined and communication tools in place, the team can ensure proper treatment for the patient. Each member of the care team plays a critical role not only in the patient receiving the appropriate treatment, but also feeling comfortable and educated on all aspects of the process. In addition, along with playing a key role in the care team, the orthotist is required to provide a quality service.
A complete physical and neurological examination should be performed to exclude any secondary causes to ensure a correct diagnosis and to determine what classification of scoliosis is present. Through both a physical evaluation and an x-ray assessment, the physician determines whether any orthotic treatment is recommended, and if so, which treatment. It is the physician’s responsibility to recognize curve patterns, growth potential, and coronal and sagittal balance. It is important for the physician to have a thorough knowledge of the natural history of IS to determine the proper treatment plan. In the case of Scheuermann’s kyphosis, it is important to determine the amount of wedging, flexibility, potential growth of endplates, and location of the apex of the deformity.
The physician begins the orthotic treatment process and plays an important role in compliance. It is critical that the physician believes in what is being prescribed and provides the patient and family with as much information as possible regarding their options and choices.
The nurse or assistant provides support and information and is the patient’s and family’s contact for any questions or concerns. The nurse is responsible for knowing the physician’s protocol and prepares the patient for what procedures will be a part of the treatment plan. The nurse often provides written information with regard to diagnosis and treatment plan.
The orthotist is responsible not only for providing the product but also for following through with the entire treatment plan. The orthotist should have knowledge of the referring physician’s treatment protocol and be able to provide a full physical examination to allow the orthosis to fit correctly. Knowledge in determining structural versus compensatory curves and recognizing sagittal and coronal imbalances is crucial to the orthosis design. The orthosis design and fit will be a key factor in patient compliance. The more streamlined and comfortable the orthosis is, the more likely it will be worn as prescribed. The orthotist should provide information to the patient and family on what is to be done at the initial and subsequent visits. The patient should be made aware of any time factors and should be given the short- and long-term goals of the treatment. It is the orthotist’s responsibility to provide a safe and comfortable environment for the evaluation, measurements, and molding to take place. Written information regarding timing of fitting and the proposed treatment plan should be available to every patient.
The clinical staff helps provide a comfortable and professional environment. There should be communication between the physician clinic staff and the orthotic clinic staff so that patients feel they are getting consistent information and care. Questions regarding insurance coverage, clinic hours, length of visits, and availability of staff should also be answered.
Physical therapy is prescribed at the discretion of the referring physician. The therapist should provide emotional support and encourage activity with the orthosis. Stretching exercises should also be provided, particularly for the hip flexors, because of the pelvic tilt position caused by the orthosis. In the case of Scheuermann’s kyphosis, the physical therapist may provide some extension exercises to be performed in and out of the orthosis. In most cases, the physical therapist is seen on a one-time basis. It is important to note that physical therapy treatment alone has not been shown to alter the natural history of scoliosis. 1
There may be local support groups for scoliosis through the Scoliosis Society (Scoliosis Association, PO Box 811705, Boca Raton, FL 33481). It is often helpful for the patient and family to be given names of previous patients who have offered to speak with children who are starting their treatment.
The education of the patient and family starts even before the initial fitting of the orthosis. There should be a complete understanding of what the patient is being treated for and what is expected of the patient and the family. Short-term (correction in the orthosis) and long-term (stopping curve progression; permanent correction in the case of kyphosis) treatment goals should be explained. The initial orthotic visit should consist of an orthotist evaluation of the patient and x-rays, followed by the taking of proper measurements and/or mold. It is important at this time to answer any questions and listen to any of the patient’s concerns regarding the process or future visits. The patient and family should be made aware of the length of time for the fitting visit and the time frame for future follow-up visits. It is helpful at this time to reinforce that the patient should continue to participate in normal physical activities during orthotic treatment. In addition, information should be given concerning the natural history of risk of curve progression so the patient and family understand the importance of beginning the treatment process. This is also the perfect opportunity for the orthotist to find out what activities the patient is interested in and get to know the patient as a person, not just an x-ray.
At the time of the initial fitting, all aspects of wearing and caring for the orthosis should be explained. The patient should check the skin for any pressure points. Pinkness where pads are placed is acceptable, but any redness that does not disappear when the orthosis is removed is not. The patient should be instructed to gradually wean into the orthosis as tolerated. Some muscle soreness is expected, but the orthosis should not be painful. The weaning process should be completed in 10 to 14 days. The importance of donning the orthosis correctly and proper donning techniques should be explained. It is critical to in-brace correction to have the straps tightened to the proper tension and the orthosis donned in the correct position. 2 The orthotist should mark the straps for proper tightness. Cleaning and care instructions should be given. Because the amount of information the patient and family are required to remember and follow can be overwhelming, written instructions, whenever possible, should be supplied. The patient should be allowed time to wear the orthosis at the initial visit and spend time with the family in private. It is very helpful to let the patient see how the orthosis looks with clothes on, and the orthotist should give any clothing suggestions to help the patient feel more comfortable. At this time, the orthotist should encourage the patient and family to deal with their experiences as they would like. Many choose to share their experience with their friends, and others choose to keep the experiences private.
The x-ray can be a great teaching tool. Once the orthosis is fitted, the x-ray can be used to explain why the orthosis is designed as it is and the reason for that design. This will help explain why physical appearances such as rib prominences and asymmetry of pelvis and sagittal alignment are present. The more the patient understands why the physician and orthotist are doing something, the easier it is for the patient to accept it. The x-ray can be used to explain potential for growth and how the Risser sign is determined. This will help the patient understand how the length of wear is determined. The x-ray can be used to motivate compliance when the curve progresses. The orthotist should stress the importance of follow-up visits, be available for questions and concerns, and encourage the patient and family to call or return if there are concerns regarding fit or comfort.
OPTIONS FOR SUPPORT
There are local support groups through the Scoliosis Association that may be available to the patient and family. It may be beneficial for them to speak with someone who is in an orthosis or has gone through the same process. It is helpful to have available for their referral the names of patients who are willing to speak with new patients of a similar age. Many patients have become great pen pals and learn how to support each other through the treatment process. The patients’ perception of how they look is also very important. Encourage them to rely on friends and family members. Parents should be made aware of the need to be patient and encouraging, especially during the first few weeks of the wearing process.
The orthosis should be checked for trim-line design, pad placement, pad pressure, compensation, sagittal alignment, and adequate room opposite pads. Skin should be checked for proper pressure. An in-brace x-ray should be evaluated for adequate correction, balance, and verification of pad placement. This x-ray can be taken per physician protocol, either the day of the initial fitting or 4 to 6 weeks after initial fitting, to allow the patient to wean into the orthosis. It is important at this time to evaluate not only the Cobb angles but also the fit of the orthosis. In-brace sagittal alignment should be evaluated so that the brace does not induce thoracic lordosis. It is a mistake to compromise sagittal alignment for increased coronal correction. It is the option of the physician to take side-bending x-rays. Side-bending x-rays at this time can be used to verify structural versus compensatory curves and also to compare flexibility at a later date. In the event of progression, these x-rays are used when surgical intervention is being considered to determine the fusion levels and amount of correction.
For IS, it is recommended to follow up with the orthotist in 4 to 6 weeks after the initial fitting. This allows the patient to wean into the orthosis. The purpose of this visit is to evaluate alignment and comfort in the orthosis. Encourage the patient to give negative and positive feedback regarding the experience. This can be a time to address any noncompliance concerns. This is also an opportunity to make any necessary pad adjustments. In Scheuermann’s kyphosis, there should be follow-up visits with the orthotist 2 weeks and 4 weeks after the initial fitting to gradually add more correction, as tolerable. In both cases, the patient should be encouraged to return at any time if there is a concern with fit or function.
PHYSICIAN AND ORTHOTIST FOLLOW-UP
The patient should follow up with the physician every 4 months for evaluation of brace fit, current x-ray, growth, and compliance. There may be exceptions to this, depending on patient age and magnitude of curve. For example, a juvenile whose curve is being corrected and is holding may follow up every 6 months until the onset of puberty and then return to the 4-month follow-up intervals. It is important to have good communication between physician and orthotist regarding the patient’s progress, growth, and recommended brace adjustments. At the 4-month follow-up visit, the physician documents growth since the last visit; current status of fit of the brace, including any skin issues; and overall alignment in the orthosis. Posteroanterior x-rays should be taken. If sagittal alignment, such as thoracic hypokyphosis, is a concern, a lateral x-ray should be taken.
There have been no studies showing the advantage of taking the 4-month x-rays with the patient in the brace or out of the brace. When a physician chooses to take the x-rays with the patient in the brace, he/she is evaluating how the brace is holding the curve. This allows the patient to remain in the orthosis full time. This also allows the physician to evaluate in-brace pad positioning, which may have changed since the previous visit because of patient growth. If the physician chooses to take the x-rays with the patient out of the brace, he/she is evaluating what the curve is doing out of the brace. In most cases, the out-of-brace x-ray is taken after the patient has been out of the orthosis at least 4 hours.
The patient should follow up with the orthotist every 4 months to coincide with the physician visit. At such visits, it is beneficial for the orthotist to document the patient’s progress relating to current Risser sign, amount of growth since last visit, and most recent Cobb angles so the orthotist will know the patient’s status for current and future visits. Any adjustments or recommendations regarding pad placement or pressure should be documented and communicated to the referring physician to provide continuity of care. This is also an opportunity to discuss any issues regarding activities or wearing schedule.
RISKS OF RADIATION EXPOSURE IN ADOLESCENTS
The management of IS and Scheuermann’s kyphosis requires the use of full spine radiographs. Radiographs are taken at 4- to 12-month intervals and require monitoring until the end of growth, which may be anywhere from 3 to 5 years for adolescents and even longer for juveniles. 3 Exposure to radiation in this population is occurring when growth is rapid and breast tissue is immature. Studies have shown that, with the exception of radiation dose, age at exposure is the single most important determinant of risk. These data suggest that frequent exposure to low-level diagnostic radiation during childhood or adolescence may increase the risk of breast cancer. 4 One study has shown a twofold excess risk of breast cancer among patients with scoliosis who received treatment from 1925 to 1965. 3
Since the 1960s, there have been considerable improvements in diagnostic imaging techniques, leading to substantial reductions in x-ray doses. For anteroposterior radiographs, the organs receiving the highest doses were the thyroid gland and the female breast. Doses to the female breast and thyroid gland from the posteroanterior view were reduced between 94 percent and 96 percent. 3 It has been shown that shifting the beam direction from anteroposterior to posteroanterior could reduce the breast cancer risk by a factor of 28. 5 With more recent techniques, a full-spine posteroanterior view provides a breast dose approximately 20 times lower than that of the old anteroposterior view. 6 Although the use of three-phase x-ray machines, high-speed x-ray films, and more sensitive rare earth screens have resulted in additional reductions in dose, accumulating doses from repeat exposure remain a concern.
NEW RESEARCH AND METHODS
Attempts to limit radiation exposure to adolescents during their high-risk developmental years have resulted in a variety of alternative methods of measuring scoliosis and kyphosis. These noninvasive methods have included scoliometer, Moire topography, integrated spinal imaging system scanning, stereotopography, and thermography. 7 Modern technologies for assessing scoliosis are based on assessment of the surface topography of the back. The technologies are either based on direct measurement of the patient’s back or reconstruction of surface shape from scanned light or photographic techniques. Position, body build, and fat folds contribute to the inaccuracies of surface topography. 8 With the clinical experience acquired using these methods, it has not been proven that these options have enough clinical precision to substitute for radiographic assessment of scoliosis. 6 A system providing radiation-free monitoring that is repeatable and reliable would be of great clinical value and is being researched.
RECOMMENDED FOLLOW-UP AFTER MATURITY
The recommended follow-up with the physician after complete weaning from the orthosis is 6 months and then yearly for the next 5 years. The incidence of curve progression before skeletal maturity has been well documented in recent studies. 9–11 The fact that curves progress after skeletal maturity was first established by Collis and Ponseti 12 and by Duriez. 13 A later long-term follow-up by Weinstein and Ponseti 14 demonstrated that many curves continue to progress throughout adult life. In patients with adolescent IS whose curves measure less than 30° at skeletal maturity, the curves tend not to progress, regardless of cure pattern. Progression of curves greater than 30° appears to be related to the amount of vertebral rotation. Thoracic curves between 50° and 70° progress most rapidly, at approximately 0.75° to 1° per year. 14
It is important to begin establishing clinical standards of practice for orthotic treatment. Establishing guidelines will not only result in a better experience for the patient and the family but will also improve the efficiency and care provided by the physician and orthotic clinical staffs. Patients and their families should be confident the orthotic profession will provide consistent quality care. Clarifying these standards will allow the profession to determine what areas are in need of additional research.
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