Q9 & 10 Title: With regards to bracing: What is your management and how do you prioritize it?
Results: Specific physiotherapy before (70/81 = 86%), Custom made (63/81 = 78%), Made to measure (47/81 = 58%), Cad Cam (35/81 = 43%), In day Hospital (32/81 = 39%), Plaster cast before (30/81 = 37%), Plaster cast moulding (29/81 = 36%), in Hospitalization (14/31 = 17%) [See figure 5]
Discussion: We have achieved a consensus for physiotherapy before bracing and no hospitalization {67/81 = 83%}.
Q16 Title: What are the physiological reasons for the patient to wear the brace and its priority?
Results: To avoid hyperflexion on the anterior wall (36/36 = 100%), discourage bad posture (19/36 = 53%), Pain (19/36 = 53%), Stretch(19/36 = 53%), relax (10/33 = 30%) [See figure 6]
Comment: To restore proper alignment of muscular forces. To give the thoracolumbar discs space again for proper development by reducing continuous loading.
Discussion: We have a consensus with the biomechanical approach of White and Panjabi.
Q17 Title: According to your experience and results -- what are the main criteria for an unsuccessful treatment (physiotherapy or brace) and their priority?
Results: Rigidity (33/33 = 100%), Angular curve (30/33 = 91%), Cobb degree (27/33 = 82%), High Risser (24/33 = 73%), high thoracic curve (19/33 = 58%), Scheuermann (17/33 = 52%), hypotonia, (15/33 = 45%), Thoraco-lumbar pattern (9/33 = 27%), Family history (9/33 = 27%), Pain (8/33 = 24%), Hypermobility (8/33 = 24%), Excess of sport (7/33 = 21%) [See figure 7]
Comment: Compliance is the main criteria. When there is a good compliance results are good regardless of curve rigidity and Cobb angle.
Discussion: The hierarchy of factors making the conservative treatment difficult is a valuable indicator to justify early treatment. The clinical examination should come before radiological findings.
Q18 Title: What is your most frequent protocol of wearing the brace in adolescent
thoracic
kyphosis?
Results: Permanent (7), Night & school (4) night & after school (4) after school only (1), School only (0), Night only (0) [See figure 8]
Discussion: The consensus for night and day wearing means that the intended effect of the brace is not only a mechanical support in the erect position but also concerns the Wolff's laws like scoliosis during nocturnal growth.
Q19 Title: What is your most frequent protocol of wearing the brace for adolescent
thoraco-lumbar
kyphosis?
Results: Permanent (3), Night & school (3) night & after school (1) after school only (1), School only (0), Night only (0) [See figure 9]
Discussion: For this pattern, there is a consensus with the sitting position.
Q20 Title: What is your most frequent protocol of wearing the brace for
pre-pubertal
kyphosis?
Results: Permanent (3), Night & school (2) night & after school (4) after school only (1), School only (0), Night only (0) [See figure 10]
Discussion: The majority of respondents are in favor of a part time protocol. Unlike scoliosis there is a consensus to exclude only wearing it at night which confirms the importance of factors related to postural vertical loading in kyphosis.
The following three questions were developed for the 3rd round. After the 2nd round, it became impossible to define patterns of braces. We have therefore tried to approach the consensus with the technical descriptors of these orthotics.
Q21 Title: Choose your ideal brace for adolescent
thoracic
kyphosis?
Results: material | plexidur (2), polypropylene (2), polyethylene low density (2), polyethylene high density (7)
Opening | lateral (5), posterior (2), anterior (4)
Level of the brace | Iliac crest (2), lateral pelvis (2), cervical (0), clavicular (3) sternal (5)
Pressure points | 3 anterior with pelvis, inferior thorax, and sternum (3), 2 anterior point with pelvis and sternum (7), 2 posterior with sacrum and apex kyphosis (9), one posterior with apex kyphosis only (1) [See figure 11
Discussion: There is slight consensus for polyethylene high density material, however no consensus for brace opening and consensus for a sternal support.
The biomechanical effects can be:
3 points: one posterior, 2 anterior like traumatic kyphosis
4 points: two posterior (lordosis control) and two anterior
5 points: two posterior and three anterior for better control of lordosis.
There is a consensus for a four points system, even if it is easier to control the sagittal posture of the spine with a 5 point system. This point deserves further discussion.
Q22 Title: Choose your ideal brace for adolescent
thoraco-lumbar
kyphosis?
Results: material | plexidur (2), polypropylene (1), polyethylene low density (2), polyethylene high density (3)
Opening | lateral (2), posterior (2), anterior (2)
Level of the brace | iliac crest (1), pelvic lateral (2), cervical (0), clavicular (1) sternal (0)
Pressure points | 3 anterior with pelvis, inferior thorax, and sternum (1), 2 anterior point with pelvis and sternum (6), 2 posterior with sacrum and apex kyphosis (5), one posterior with apex kyphosis only (3) [See figure 12]
Discussion: There is no consensus for material, no consensus for opening and consensus for a very logical 4 points system.
Q23 Title: Choose your ideal brace for
juvenile
kyphosis?
Results: material | plexidur (0), polypropylene (0), polyethylene low density (0), polyethylene high density (2)
Opening | lateral (0), posterior (3), anterior (0)
Level of the brace | iliac crest (0), pelvic lateral (2), cervical (1), clavicular (0) sternal (0)
Pressure points | 3 anterior with pelvis, inferior thorax, and sternum (0), 2 anterior point with pelvis and sternum (2), 2 posterior with sacrum and apex kyphosis (1), one posterior with apex kyphosis only (2) [See figure 13]
Discussion: There is consensus for polyethylene posterior opening brace, corresponding to the Milwaukee brace.
Q 24 Title: What is the best time for initiating bracing with a rigid kyphosis brace (boy)?
Results: < 12 years (0), 12y (3), 13y (3), 14y (1), 15y (1), 16y (0), 17y (0), >17y (0) [See figure 14]
Discussion: There is consensus; the best age for bracing seems to be at the beginning of puberty.
Q25 Title: What is your minimum period to maintain the brace?
Results: 6 months (1), 1 year (2), 18 months (2), 2 years (4), more (0) [See figure 15]
Discussion: Taking into account the age of onset to starting treatment (Q22) there is a consensus to maintain the brace till the end of growth but without waiting for definitive bone maturity at Risser 5.
Q26 Title: What is the best moment for brace weaning?
Results: 6 months (1), 18 months (1), end of growth (7), Risser 5 (3), other (0) [See figure 16]
Discussion: This question was asked to verify the consistency of responses. We can confirm that there is a consensus to maintain the brace till the end of growth but without waiting for definitive bone maturity at Risser 5.