A comparative study of TLSO, Charleston, and Milwaukee braces for idiopathic scoliosis

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine which of TLSO, Charleston, or Milwaukee bracing best prevents curve progression and surgery in adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Bracing has been shown to prevent curve progression in idiopathic scoliosis, when compared with no treatment. However, there is little literature available comparing the effectiveness of different brace designs. METHODS: One hundred seventy patients who completed brace treatment for adolescent idiopathic scoliosis between 1988 and 1995 were studied. Forty-five thoracolumbosacral orthoses, 95 Charleston braces, and 35 Milwaukee braces were used. Thoracolumbosacral orthoses and Charleston braces were used on comparable curves, whereas Milwaukee braces were used in a subgroup in which the other brace designs were considered inappropriate. Evaluated were the absolute increase in curve severity, the percentage of curves that progressed beyond 6 degrees and 10 degrees thresholds, and the percentage of patients who underwent surgery. RESULTS: Age, Risser stage, curve size, and time braced and observed did not differ among groups. Mean progression of the curve during bracing was 1.1 degrees with thoracolumbosacral orthosis, 6.5 degrees with the Charleston brace, and 6.3 degrees with the Milwaukee brace (P = 0.012; analysis of variance). Proportion of patients with more than 10 degrees of curve progression was 14% with thoracolumbosacral orthosis, 28% with the Charleston brace, and 43% with the Milwaukee brace (P = 0.017; chi-square). The proportion of patients who underwent surgery was 18% with thoracolumbosacral orthosis, 31% with the Charleston brace, and 23% with the Milwaukee brace (P = 0.26; chi-square). CONCLUSIONS: The thoracolumbosacral orthosis was superior at preventing curve progression in adolescent idiopathic scoliosis.     

Milwaukee brace correction of idiopathic scoliosis. A biomechanical analysis and a restrospective study

We analyzed the biomechanics of Milwaukee brace treatment of idiopathic scoliotic patients through simulation in five computer-constructed model spines. The contributions to correction of each component of the brace were examined in these model spines, and some of the mechanical principles that determine the outcome of brace treatment were studied. The validity of the stimulation findings was then tested by a retrospective analysis. Simulation was used to predict the outcome of milwaukee brace treatment in sixty-eight patients. In 81 per cent of these patients, the actual outcome agreed with the prediction. The study suggests that careful adherence to mechanical principles in the use of a Milwaukee brace will result in successful treatment of more patients.     

Roentgenographic search for avascular necrosis of the head of the femur in alcoholics and normal adults

On the basis of new insights in sport-medicine active exercises in the Milwaukee brace have been developed which enable the patient to straighten out his spine "on command". The first exercises serves the straightening. A skin-stimulus (spearing) makes the patient straighten his spine actively. First the doctor, later the parents, stimulate with a prick near the thoracic bulge. The patients learn to withdraw the gibbus from it. To re-inforce muscular power, an isometric resistance is exerted after correction. The second exercise corresponds to the well-known active extension with the extension-bandage of Kr?mer, but this effect is achieved with a modification of the brace. The pelvic girdle contains two shallow holes into which grips can be inserted. The lenght of these grips is so arranged that the power of the arms can be used to best effect. This exercise, too, will later be carried out against the resistance of a sandbag weighing 2-4 kg which is put on the patient's head. Both exercises have the great advantage that they seem to make sense to the patient and will be gladly and regularly carried out. They also encourage the young girls to wear the brace with more hope for success.     

The Milwaukee brace for the treatment of adolescent idiopathic scoliosis. A review of one thousand and twenty patients

We reviewed the medical records and roentgenograms of 1020 patients who had been managed for adolescent idiopathic scoliosis, between January 1954 and December 1979, with a Milwaukee brace; we wished to determine whether use of the brace had effectively altered the natural history of the disease. The findings were considered with respect to a previous study of 727 children who had had comparable curves and had not initially been managed with the brace but had been followed for progression of the curve, during the same time-span as that in the current study. Of those 727 patients, 558 (77 percent) had no progression of the curve. The average age of the 1020 patients at the time that treatment with the brace was begun was thirteen and one-half years (range, ten to seventeen years). None of the patients had received any other treatment, and all had been managed only by the physicians participating in this study. In both the current and the earlier series, the outcome was considered a failure if the curve had increased 5 degrees or more; in the patients in the current study, who were managed with the brace, the outcome was also considered a failure if operative intervention had been needed. Of the 1020 patients in the current series, 229 (22 percent) had operative intervention; this rate was higher in the patients who had a curve of more than 30 degrees at the time of bracing and in those who had a Risser sign of 0 or 1. The 791 remaining patients, who were managed with the brace only, had a mild improvement of 1 to 4 degrees at the time that use of the brace was discontinued (the difference being within the margin of error of measurement). With respect to curves of between 20 and 39 degrees, the rate of failure was lower in the current series of patients who had been managed with the brace than in the earlier series of patients who had not been thus managed but had been followed for progression. Progression of the curve was found to be related to the pattern and magnitude of the curve; the age of the patient at the time of presentation; the Risser sign; and, in girls, the menarchal status. We recommend that immature adolescents who have a curve of more than 25 degrees and a Risser sign of 0 be managed with a brace immediately, rather than after progression has been documented.     

The role of the pulmonary circulation in the regulation of coagulation and fibrinolysis in relation to major surgery

A total of 18 competitive and recreational athletes were enrolled in a randomized, prospective study looking at the effect of pneumatic leg braces on the time to return to full activity after a tibial stress fracture. All patients had positive bone scans and 15 had positive radiographic findings by Week 12. There were two treatment groups. The traditional treatment group was treated with rest and, after 3 pain-free days, a gradual return to activity. The pneumatic leg brace (Aircast) group had the brace applied to the affected leg and then followed the same return to activity guidelines. The guidelines consisted of a detailed functional progression that allowed pain-free return to play. The brace group was able to resume light activity in 7 days (median) and the traditional group began light activity in 21 days (median). The brace group returned to full, unrestricted activity in 21 +/- 2 days, and the traditional group required 77 +/- 7 days to resume full activity. The Aircast pneumatic brace is effective in allowing athletes with tibial stress fractures to return to full, unrestricted, pain-free activity significantly sooner than traditional treatment.     

Salivary gland tumors after childhood radiation treatment for benign conditions of the head and neck: dose-response relationships

In this study the mechanisms were investigated whereby ACE-inhibitors improve pulmonary diffusion for carbon monoxide (DLco) in chronic heart failure. The two subcomponents of DLco are the alveolar-capillary membrane conductance (DM) and the capillary blood volume (VC). Stress failure of the membrane in chronic heart failure provides a mechanism for reduction of DM and, as a consequence, impairment of DLco. In 27 patients with chronic heart failure in NYHA functional class II to III and in 13 age- and sex-matched normal subjects, we evaluated the pulmonary function and determined DM and VC, according to the classic Roughton and Forster method, while they were given placebo, at 48 hours and 8 weeks after starting enalapril treatment (10 mg bid). ACE-inhibition had no effect in controls at both short- and mid-term. In chronic heart failure patients, a reduction in VC (likely consequence of a decrease in capillary pulmonary pressure) was the only change observed at 48 hours. At 8 weeks, DM was greatly increased even when the effective alveolar volume (VA) was accounted for (DM/VA), resulting in a significant improvement in DLco, despite a decrease in VC. The slow onset DM improvement makes it likely that the modulatory effect of ACE-inhibition on the membrane function emerges gradually, suggesting that it is likely dissociated from changes in pulmonary capillary pressure and VC. Thus, derangements of the alveolar-capillary membrane in chronic heart failure increase gas diffusion resistance; ACE-inhibition restores the diffusive properties of the membrane and gas transfer, and protects the lung when the heart is failing.     

The effects of functional knee braces on speed in collegiate basketball players

Knee braces are worn by many athletes following injury. The purpose of this study was to determine whether two functional knee braces (noncustom design) significantly affected straight line and successive turning trial running times in noninjured collegiate basketball players. Twenty-five coed basketball players completed 2 days of running trials. Subjects ran three full lengths of a basketball court and 10 lengths between the baseline and the foul line first without wearing a brace, then wearing either a DonJoy GoldPoint brace or an Omni OS-5 brace, and finally wearing the other brace. The results indicated no significant difference (p < .05) in straight line or successive turning running times when the two braces were compared with the nonbraced condition and when the two braces were compared with each other. The results implied that speed was not significantly affected by a functional knee brace in noninjured collegiate basketball players.     

Platelet activating factor (PAF) in memory formation: role as a retrograde messenger in long-term potentiation

A model of experimental infection with EV1, a British isolate of maedi-visna virus (MVV), has been developed. Twelve male Texel sheep were allocated to three groups and inoculated by the respiratory route with different inocula. Six of the animals received 10(7.2) tissue culture infective dose (TCID50) of MVV EV1 strain. Two sheep were inoculated with the same dose of heat inactivated MVV EV1 strain. An additional group of four sheep was sham-inoculated with identically prepared virus-free culture media. Experimental infection was followed for 16 weeks. Prior to inoculation, routine haematology, bronchoalveolar lavage (BAL) and flow cytometric analysis of bronchoalveolar lavage fluid (BALF) lymphocytes were performed in all animals to provide baseline parameters. Flow cytometric analysis of BALF lymphocytes and differential BALF cell counts were performed. Precipitating antibodies to MVV developed in all MVV-inoculated animals during the first 4 weeks post-inoculation, while the rest remained seronegative to MVV. MVV-infected animals had significantly decreased (P < 0.05) percentages of macrophages and significantly increased (P < 0.05) percentages of lymphocytes in BALF 4 weeks post-inoculation. Phenotypic changes in BALF T lymphocytes from MVV-inoculated animals, compared with the other two groups, showed significantly decreased (P < 0.05) percentages of CD4+ and gamma delta + T lymphocytes, significantly increased (P < 0.05) percentages of CD8+ lymphocytes and significant inversion (P < 0.05) of the CD4+/CD8+ ratio at different sampling times, but between 2 and 12 weeks post-inoculation. These findings indicate that during experimental MVV-infection an early, short-term cellular reaction occurs in the lung, that is characterised by T lymphocyte phenotypic changes that are very similar, if not identical, to those observed in natural MVV infection.     

The load applied to the foot in a patellar ligament-bearing cast

The purpose of this study was to determine whether a patellar ligament-bearing cast reduces the load applied to a foot in a cast. In a study of ten people who had no history of gait abnormalities, disease involving the motor system, or deformities of the lower extremities, we compared the load applied to the plantar aspect of a foot in a cast (as detected with F-Scan computer-monitored pedobarographic sensors) with the total load that an extremity in a cast receives relative to the ground (as detected with force-plates). Six trials were completed three times by each person. The trials consisted of walking (1) while wearing regular shoes; (2) with a patellar ligament-bearing cast on one leg; (3) with a patellar ligament-bearing cast and an overlying soft knee brace, locked in full extension, on the leg; (4) with only a below-the-knee cast on the leg; (5) with a below-the-knee cast and an overlying knee brace, locked in full extension, on the leg; and (6) with only a knee brace, locked in full extension, on the leg. The loads at peak heel-strike for all three trials were averaged and normalized to body weight. The load on the plantar aspect of the foot, as compared with the total load, was reduced a mean of 11 percent when the patellar ligament-bearing cast was worn alone, and it was reduced a mean of 26 percent when the patellar ligament-bearing cast was used with an overlying knee brace locked in full extension. This difference was significant (p = 0.007). With the numbers available, we could not detect a significant difference between the reduction in load when a patellar ligament-bearing cast was worn alone compared with that when a below-the-knee cast was worn alone or between the reduction when a below-the-knee cast was worn alone compared with that when a below-the-knee cast was used with a knee brace (p = 0.3). In conclusion, we could not demonstrate a significant reduction in the load on the foot when a patellar ligament-bearing cast was used in a traditional fashion; however, a significant (p = 0.007) reduction in load was found when a knee brace locked in full extension was worn in addition to the patellar ligament-bearing cast.     

Joint loading with valgus bracing in patients with varus gonarthrosis

The purpose of this study was to determine whether a brace designed to unload varus degenerative knees actually alters medial compartment loads by decreasing the adduction moment. Eleven patients who had arthrosis confined to the medial compartment were fitted with a valgus brace and tested before and after brace wear with pain and function scoring instruments and by automated gait analysis. The biomechanical data from these patients were compared with those from 11 healthy control subjects. Scores from an analog pain scale decreased 48% with brace wear, and function with activities of daily living increased 79%. Mean adduction moment without the brace measured 4.0 +/- 0.8% body weight times height versus 3.6 +/- 0.8% body weight times height when wearing the brace (10% decrease). The mean adduction moment for control subjects was 3.5 +/- 0.6% body weight times height. Thus, the mean adduction moment decreased from approximately one standard deviation from the normal mean to a value that is similar to the control value. Nine of 11 patients had a decrease in the adduction moment with the brace, five of 11 patients had a reduction higher than 10%, and decreases in this moment were as high as 32%. This study shows that pain, function, and biomechanical knee loading can be altered by a brace designed to unload the medial compartment of the knee.     

Diffusion disorders in patients with liver cirrhosis

In 17 patients with cirrhosis of theliver and in 11 controls the pulmonary diffusing capacity for CO (DLCO) was determined at three different levels of alveolar oxygen tensions. The diffusing capacity of the alveolar membrane (DMCO) and the intra-pulmonary capillary volume (VC) were calculated following the formula given by Roughton and Forster. The following results were obtained: 1) Both DLCO and DMCO were lower (p less than 0,01) in the patient group than in the controls. 2) VC showed larger variations in thepatient group than in the controls (p less than 0,01). The mean values did not differ, however. 3) There was a significant linear correlation (p less than 0,001) between DM and 1/VC in the patient group (DM and VC in % of the predicted value). The results suggest, that a change in the configuration of the capillary bed may be responsible for the transfer defect found in cirrhosis.     

Another view of schizophrenia subtypes. A report from the international pilot study of schizophrenia

We studied respiratory mechanics in young volunteers before and after 5-wk training programs limited to the ventilatory muscles. Four strength trainers (S) performed repeated static maximum inspiratory and expiratory maneuvers against obstructed airways. Four endurance trainers (E) performed voluntary normocarbic hyperpnea to exhaustion. Subjects spent 30-45 min each day in these exercises, 5 days a week. Four control subjects (C) did no training. We attempted to minimize the effect of learning. S increased pressure maximums by about 55%, but vital capacity and total lung capacity by only about 4%. Initially all subjects could sustain hyperpnea at about 81% of their control 15-s maximum voluntary ventilation (MVV) for 15 min; E increased this to about 96% and increased their MVV by 14% as well. No other statistically significant changes were recognized in any group. We conclude that ventilatory muscle strength or endurance can be specifically increased by appropriate ventilatory muscle training programs.     

Improved pulmonary function in systemic sclerosis after treatment with cyclophosphamide

OBJECTIVE: Pulmonary fibrosis is a common feature of systemic sclerosis (SSc) and a major cause of morbidity and mortality. Since alveolitis may be an essential step in the development of pulmonary fibrosis, we investigated the use of immunosuppressive drug therapy to improve pulmonary function in patients with SSc. METHODS: Eighteen patients with progressive pulmonary dysfunction, diminished vital capacity (VC), and/or decreased static lung compliance (Cst) were treated with cyclophosphamide and corticosteroids for 1 year. Eight patients had diffuse cutaneous SSc and 10 had limited cutaneous SSc. The median disease duration was 2.5 years (range 0.5-17 years). RESULTS: VC increased in 14 of 18 patients and the median VC rose from 74% to 80% of predicted. Cst improved in 8 of 12 patients and the median Cst increased from 59% to 66% of predicted. Pulmonary nonfibrotic opacities disappeared in 9 of 12 patients. The erythrocyte sedimentation rate (ESR) and serum concentrations of orosomucoid, C-reactive protein, and aminopropeptide type III collagen all improved. The patients were divided into 2 groups based on the presence or absence of elevations in acute-phase protein levels and ESR before therapy. Among the 12 patients with biochemical signs of inflammation, VC increased in 11, and Cst improved or was unchanged in 7 of the 8 who were tested. The median VC in this subgroup increased from 73% to 80% of predicted and the median Cst increased from 57% to 60% of predicted. In the group of 18 patients overall, the skin score decreased, while esophageal and renal function remained stable. CONCLUSION: Cyclophosphamide may have a beneficial effect on pulmonary fibrosis in patients with SSc and elevated levels of acute-phase proteins. Controlled trials of cyclophosphamide in pulmonary SSc should be performed and should focus on such patients.     

Clinical assessment of a new weight-relieving brace

A new cosmetic weight-relieving brace which utilises stainless steel and light alloy in its structure is described. A clinical assessment of thirty-six patients (four bilateral cases) has shown the Salford Cosmetic brace to be suitable for over 80 per cent of patients attending for assessment. Five patients rejected the brace, and the reasons are discussed. Contra-indications which emerged during the assessment included limb shortening of more than 5 centimetres; fixed equinus of more than 10 degrees; and fixed deformity of the knee of more than 10 degrees. The safety and durability of the brace, first demonstrated in laboratory tests, are confirmed. Further possible development is outlined.     

The effect of flumazenil on CNS oxygen toxicity in the rat

The effect of afferent cutaneous electrical stimulation on the spasticity of leg muscles was studied in 20 patients with chronic hemiplegia after stroke. Stimulation electrodes were placed over the sural nerve of the affected limb. The standard method of cutaneous stimulation, TENS with impulse frequency of 100 Hz, was applied. The tonus of the leg muscles was measured by means of an electrohydraulic measuring brace. The EMG stretch reflex activity of the tibialis anterior and triceps surae muscles was detected by surface electrodes and recorded simultaneously with the measured biomechanical parameters. In 18 out of 20 patients, a mild but statistically significant decrease in resistive torques at all frequencies of passive ankle movements was recorded following 20 min of TENS application. The decrease in resistive torque was often (but not always) accompanied by a decrease in reflex EMG activity. This effect of TENS persisted up to 45 min after the end of TENS. The results of the study support the hypothesis that TENS applied to the sural nerve may induce short-term post-stimulation inhibitory effects on the abnormally enhanced stretch reflex activity in spasticity of cerebral origin.     

Survival and pulmonary hemodynamics in patients with sequelae of pulmonary tuberculosis who received antituberculosis chemotherapy and home oxygen therapy

To date, the pulmonary hemodynamics of patients with sequelae of pulmonary tuberculosis have usually been examined as a unified set of criteria regardless of the treatments that patients undergo. Attracted by this subject, we studied the cerrelations between survival and pulmonary hemodynamics in patients with sequelae of pulmonary tuberculosis who were treated with antituberculosis drugs and home oxygen therapy (HOT). Our study examined 21 patients with a mean ages of 58.0 years, mean PaO2 of 59.3 +/- 11.4 mm Hg, and mean PaCO2 of 51.9 +/- 6.3 mm Hg. In pulmonary function tests, mean % VC was 44.1 +/- 16.3%, and mean FEV 1%, 66.6 +/- 23.0%. Twenty of the patients were given a diagnosis of pulmonary hypertension. Eighteen of the patients received HOT; as a group, their 3-year survival rate was 62.6%, which was not statistically significant compared to survival observed in post Japanese studies. Among the HOT patients, blood gases and pulmonary hemodynamics did not vary significantly between those who died within 2 years after right heart catheterization (short-term survivors) and those who lived for more than 5 years (long-term survivors). However, VC, % VC, and FVC values were significantly lower in the short-term survivors than in the long-term survivors. In conclusion, these findings revealed no statistically significant, differences compared with the data from past studies. Although pulmonary hypertension is associated with the poor prognosis for chronic obstructive pulmonary tuberculosis patients, in the patients we studied, the principle prognostic determinant was the seriousness of the restrictive ventilatory impairment, not pulmonary hypertension.     

Study on vascular calcification in patients on continuous ambulatory peritoneal dialysis (CAPD): special reference to active vitamin D (VD) treatment

Cardiovascular complications, such as vascular calcification (VC), have been a major concern in patients undergoing chronic dialysis. The pathogenesis of this VC has been attributed to the altered calcium and phosphate metabolism, but the contributing factors have not been clarified. In order to investigate these factors, 38 CAPD patients were divided into two sub-groups according to the absence of aortic calcification (Group-A; n = 18) or the presence of aortic calcification (Group-B; n = 20). The number of elderly patients was larger and the duration of CAPD was longer in Group-B than in Group-A. Calcium and phosphate metabolism and serum lipids levels did not differ significantly between groups and the number of patients given VD was 8/18 in Group-A and 14/20 in Group-B. In order to explore the progression of VC in CAPD patients given long-term treatment with VD, 22 patients who were matched for the duration of CAPD were analyzed. These were divided into two sub-groups according to whether they were treated with VD (Group-C; n = 11) or not treated with VD (Group-D; n = 11). Radiological findings (such as the degree of aortic calcification), bone mineral content, divalent ions, parathyroid hormone levels and lipid profiles were examined. The prevalence of patients with aortic calcification was significantly higher in Group-D than in Group-C (7/11 v. s. 2/11, P < 0.05). However, lipids, mineral and endocrinological parameters did not differ between the sub-groups. No significant difference in the calcium and phosphate balance was observed. The bone mineral content revealed no difference between both of the sub-groups. VD administration by conventional mode, even without significant suppression of PTH or increase of bone mineral content, may enhance vessel calcification in patients on long-term CAPD.     

Slow fusion of liposomes composed of membrane-spanning lipids

Vascular calcification (VC), which is described in the elderly and in diabetics, is frequently seen in uraemia. It is usually regarded as having little significance. We studied the roentgenological appearance of VC in a homogeneous group of 38 long-hours haemodialysis patients whose longevity on dialysis allowed sustained (10-25 years) follow-up, including annual skeletal surveys and thrice-yearly clinical examinations and biochemical profiles. We compiled a dossier of clinical and laboratory parameters from the start of dialysis to the present day. We were able to analyze the natural history of VC and to determine which clinical parameters were linked with progression. We found that VC became steadily more prevalent-at dialysis onset present in 39% of the patients, but in 92% after an average dialysis duration of 16 years, with a mean onset 9.7 years after starting dialysis. As well as becoming more prevalent, the calcification became progressively more severe in most patients. There were two patterns of VC: axial (aorta and iliac and femoral arteries), seen alone in 32% of the patients, and peripheral (digital arteries), seen alone in 3% of patients. Most patients (65%) had evidence of both types. Calcification was scored for site and severity. Patient age (r = 0.57, p < 0.001), systolic blood pressure (r = 0.54, p < 0.001), hyperparathyroidism (reduced progression after parathyroidectomy), plasma phosphate (r = 0.34, p = 0.042), and vitamin D concentrations (r = 0.53, p < 0.001) were the principal determinants of severity and rate of progression of VC in this population. There was a weak negative association between progression and serum ferritin (r = -0.33, p = 0.046). The reduced vessel compliance that results from VC is likely to be cardiovascularly deleterious. In severe cases, tissue perfusion or vascular access for haemodialysis can be compromised. VC and accelerated cardiovascular mortality are common to uraemia, diabetes, and systolic hypertension in the elderly. Better understanding of these pathological processes may permit intervention and possibly lead to a reduction in cardiovascular mortality.