Deformities observed with Pes cavus includes :
*clawing of the toes
*posterior hind foot deformity (described as an increased calcaneal angle)
*contracture of the plantar fascia
*cock-up deformity of the great toe
Following References were used to prepare this powerpoint presentation which makes the slides accurate and relaible for studying purpose; Therapeutic Exrercise – Carolyn Kisner
Orthopaedic Physical Assessment – Magee
Orthopaedic Medicine – L. Ombregt
Campbell’s Operative Orthopaedics
Slides includes following headings;
DEFINITION
TYPES
ORTHOPAEDIC ASSESSMENT
MEDICAL MANAGGEMENT
PHYSIOTHERAPY MANAGEMENT
SURGICAL MANAGEMENT
Deformities observed with Pes cavus includes :
*clawing of the toes
*posterior hind foot deformity (described as an increased calcaneal angle)
*contracture of the plantar fascia
*cock-up deformity of the great toe
Following References were used to prepare this powerpoint presentation which makes the slides accurate and relaible for studying purpose; Therapeutic Exrercise – Carolyn Kisner
Orthopaedic Physical Assessment – Magee
Orthopaedic Medicine – L. Ombregt
Campbell’s Operative Orthopaedics
Slides includes following headings;
DEFINITION
TYPES
ORTHOPAEDIC ASSESSMENT
MEDICAL MANAGGEMENT
PHYSIOTHERAPY MANAGEMENT
SURGICAL MANAGEMENT
This presentation is very beneficial for those who are in the field of prosthetics & orthotics. I have covered the basics of prosthetic foot, its mechanisms & its types. I have mentioned advanced prosthetic foot also. Hope this will help you all.
Over the past decade, technology and research have greatly expanded the functionality and aesthetics of prosthetic feet. Today, amputees have a wide array of feet from which to choose. Various models are designed for activities ranging from walking, dancing and running to cycling, golfing, swimming and even snow skiing.
A complete description of the lower limb orthosis is available in the following presentation with an in depth understanding of the same.It covers the ankle foot orthosis,Knee orthosis the knee ankle foot orthosis and hip orthosis.
1) Various types of neurodynamic examination and mobilization techniques.
2) The proposed mechanisms behind the neurodynamic examination and mobilization techniques
3) Apply knowledge of the various neurodynamic mobilization techniques in the planning of a comprehensive rehabilitation program
presentation is about Orthosis and prosthesis. It gives Classification of Orthosis. It describes structure, function, Indication and uses of Orthosis. Also describes different types of Prostheses, their parts and function.
This presentation is very beneficial for those who are in the field of prosthetics & orthotics. I have covered the basics of prosthetic foot, its mechanisms & its types. I have mentioned advanced prosthetic foot also. Hope this will help you all.
Over the past decade, technology and research have greatly expanded the functionality and aesthetics of prosthetic feet. Today, amputees have a wide array of feet from which to choose. Various models are designed for activities ranging from walking, dancing and running to cycling, golfing, swimming and even snow skiing.
A complete description of the lower limb orthosis is available in the following presentation with an in depth understanding of the same.It covers the ankle foot orthosis,Knee orthosis the knee ankle foot orthosis and hip orthosis.
1) Various types of neurodynamic examination and mobilization techniques.
2) The proposed mechanisms behind the neurodynamic examination and mobilization techniques
3) Apply knowledge of the various neurodynamic mobilization techniques in the planning of a comprehensive rehabilitation program
presentation is about Orthosis and prosthesis. It gives Classification of Orthosis. It describes structure, function, Indication and uses of Orthosis. Also describes different types of Prostheses, their parts and function.
Brace treatment for Adolescent Idiopathic Scoliosis (AIS) and Scheuermann Kyp...Nikos Karavidas
SRS gives clear indication for bracing in AIS and Scheuermann kyphosis. However, these indications are not followed in Greece and this results in a high percentage of overtreatment for patients.
Case Review #B: 20 year old with Adolescent Idiopathic ScoliosisRobert Pashman
20 year old female with a 48° primary thoracolumbar curve with a compensatory 34° thoracic curve. Dr. Pashman treated the patient with a thoracolumbar anterior spinal fusion.
Scoliosis 101 describes the condition of scoliosis, how it is evaluated, traditional treatment recommendations,andt he most recent developments in non-invasive
rehabilitation based treatment. For more information visit http://www.treatingscoliosis.com or call
—Kyphosis and lordosis changes might be related to back extensor weakness and osteoporosis. The purpose of this study was to find out the correlations between thoracic kyphosis, lumbar lordosis with back extensor strength (BES) and bone mineral density (BMD). Methods: Thoracic kyphosis, lumbar lordosis, maximal isometric strength of the back extensors and BMD of the lumbar vertebral were evaluated in 47 elderly (50-75 years old)women. BMD of the lumbar vertebral was measured using Dual-Energy X-Ray Absorptiometry (DEXA) and kyphosis and lordosis degree were assayed using a flexible ruler. The maximal isometric strength of the back extensors was measured using an isometric manual muscle tester (MMT). Data were analyzed using ANOVA and independent t-test at p≤0.05 level of acceptance. Results: A significant reverse correlation was shown between BES and kyphosis (p=0.044, r=-0.30). No significant correlation were found between BES and lordosis degree, nor between lumbar vertebral BMD and, both, kyphosis and lordosis degrees. However, there was a significant difference in BES between three groups with various degree of kyphosis (p≤ 0.05). Conclusion: It can be concluded that the severity of thoracic kyphosis may be influenced by BES. So, stronger back extensor can prevent thoracic kyphosis despite decreased BMD.
Cervical Arthritis, Cervical Spondylotic Myelopathy by Pablo Pazmino MDPablo Pazmino
This video explains Cervical Stenosis and Cervical Spondylosis/Arthritis. When stenosis begins to affect the spinal cord this is called Cervical Spondylotic Myelopathy. This video highlights the history, epidemiology, and treatment options both conservative and surgical. If you or someone you know needs to be seen in regards to Cervical Stenosis/Arthritis feel free to look us up online www.beverlyspine.com or www.santamonicaspine.com OR call toll free 1-8SPINECAL-1
This video explains Cervical Stenosis and Cervical Spondylosis/Arthritis. When stenosis begins to affect the spinal cord this is called Cervical Spondylotic Myelopathy. This video highlights the history, epidemiology, and treatment options both conservative and surgical. If you or someone you know needs to be seen in regards to Cervical Stenosis/Arthritis feel free to look us up online www.beverlyspine.com or www.santamonicaspine.com OR call toll free 1-8SPINECAL-1
Dynamic Stabilization in the Surgical Management of Painful Lumbar Spinal Dis...Alexander Bardis
Current surgical management of the painful lumbar motion segment is imperfect.
Improvements are necessary :
in the predictability of pain relief, the reduction of treatment related morbidities, and an overall improvement in the clinical success rates of :
pain reduction and functional improvement.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Maxilla, Mandible & Hyoid Bone & Clinical Correlations by Dr. RIG.pptx
Braces scoliosis
1. Thoracolumbar braces forThoracolumbar braces for
the treatment ofthe treatment of
Adolescent IdiopathicAdolescent Idiopathic
ScoliosisScoliosis
George Sapkas
Professor in Orthopaedics
Director of the
Orthopaedic dpt for Spinal Disorders
&
Musculoskeletal Diseases
Metropolitan Hospital
2. Adolescent
idiopathic scoliosis,
as defined by the
Scoliosis Research
Society, is
diagnosed when a
lateral spinal curve
of at least 11o
is
observed in a
patient who is
between ten years
old and skeletal
maturity
3. Natural historyNatural history
Without intervention, the curve is likely to progress
between the time of detection and the time of
skeletal maturity; the risk of progression increases as
the degree of curvature increases
Montgomery et al, Act. Orth. Scan, 1989
4. The risk of progression
increases with the
magnitude of the curve at
the time of detection
decreases with
increased age at the time
of detection
Younger girls
(ten, eleven, or twelve
years old) who had a
curve of at least 30o
at the time of detection
had the highest
likelihood of
progression, ranging
from 90% to 100%.
Nachemson et al, 1982
5. Current Options for
Treatment
Curves that are 20o
or less before the
time of skeletal
maturity are
considered mild and
generally are
re-evaluated
every six months.
6. Curves that
progress 5o
to 10o
and
those that are more
than 30o
at the time
of diagnosis
(considered
moderate)
usually are treated
with a brace, as
early and intensive
bracing is believed
to preclude the need
for an operation in
most instances.
7. Curves
of less than 30o
rarely
progress after maturity
but larger curves may
continue to increase
throughout the life of
the patient
Weinstein et al, JBJS(am), 1994
8. Scoliosis’
correction with
spinal
instrumentation is
the treatment of
choice
for curves of more
than 45o
in children
who are still
growing,
for curves of more
than 60o
in patients
who have reached
skeletal maturity,
and for curves that
have continued to
progress even
after treatment
with bracing
10. By aBy a judiciousjudicious
combination ofcombination of
pressures applied topressures applied to
the torsothe torso
over a prolongedover a prolonged
period, braceperiod, brace
treatment attempts totreatment attempts to
modify mechanicallymodify mechanically
the scoliotic spinethe scoliotic spine
morphologymorphology
and to controland to control
progression of spinalprogression of spinal
curvaturecurvature
Peterson et al, JBJS, 1995
11. The degree of spinalThe degree of spinal
correction is related tocorrection is related to
many interconnectedmany interconnected
parameters such asparameters such as
the correct abilitythe correct ability
(or flexibility) of the spinal(or flexibility) of the spinal
curvescurves
The shape and stiffnessThe shape and stiffness
of the brace shellof the brace shell
The location, size andThe location, size and
thickness of brace partsthickness of brace parts
The strap tensionThe strap tension
adjustmentadjustment
The biomechanicalThe biomechanical
properties of truncalproperties of truncal
tissues to transmit thetissues to transmit the
brace forces to the spinebrace forces to the spine
The duration of braceThe duration of brace
forces applied on theforces applied on the
torsotorso
12. The effectivenessThe effectiveness
of bracingof bracing
with a TLSO in thewith a TLSO in the
treatment oftreatment of
idiopathic scoliosisidiopathic scoliosis
has always been ahas always been a
highly disputedhighly disputed
topictopic
13. Conflicting opinionsConflicting opinions
in the literaturein the literature
stem fromstem from
inconsistencyinconsistency
In the patientIn the patient
populationpopulation
The evaluationThe evaluation
methodsmethods
Selection criteria forSelection criteria for
treatment amongtreatment among
different studiesdifferent studies
14. Ideally, bracesIdeally, braces
should beshould be
prescribed toprescribed to
patients withpatients with
idiopathic scoliosisidiopathic scoliosis
with curves betweenwith curves between
3030oo
and 40and 40oo
, or with, or with
curves less than 30curves less than 30oo
who have a historywho have a history
of curve progressionof curve progression
with a high risk forwith a high risk for
continuedcontinued
progressionprogression
Edgar et al, JBJS, 1985
Kehl et al , Clin Orth, 1988
Lonstien et al. JBJS(Am), 1994
Nachemson et all, JBKS(Am), 1995
15. By bracing scolioticBy bracing scoliotic
curves that are notcurves that are not
likely to progress, thelikely to progress, the
brace may bebrace may be
erroneously deemederroneously deemed
effectiveeffective
16. Regardless of the betterRegardless of the better
understanding of theunderstanding of the
prognosticatorsprognosticators
for progressionfor progression
of scoliotic curves,of scoliotic curves,
brace treatmentbrace treatment
still failsstill fails
and clinician disagreeand clinician disagree
about its usefulnessabout its usefulness
Aubin et al, Spine, 1997
Carr et al, Spine 1989
Edelman et al, Act Orthop Belg, 1992
Winter et al, Spine, 1986
17. In adolescent girlsIn adolescent girls
with right thoracicwith right thoracic
curves between 25curves between 25oo
and 35and 35oo
the treatment withthe treatment with
a brace wasa brace was
successfulsuccessful
in preventingin preventing
progressionprogression
of more than 6of more than 6oo
Nachemson et all, JBJS, 1995
19. When looking in long termWhen looking in long term
effectseffects
of bracing found that theof bracing found that the
Boston brace did notBoston brace did not
improve,improve,
but prevented, progression ofbut prevented, progression of
Vertebral rotationVertebral rotation
TranslationTranslation
Rib humpRib hump
Cobb angleCobb angle
The immediate improvementsThe immediate improvements
of Cobb angle and vertebralof Cobb angle and vertebral
rotation were lost at follow uprotation were lost at follow up
Wilers et al., Spine 1993
20. Wrong indication for bracing due to magnitude ofWrong indication for bracing due to magnitude of
the scoliotic curve and the type bracethe scoliotic curve and the type brace
21. PressurePressure
distribution anddistribution and
forces generatedforces generated
by braces on theby braces on the
scoliotic deformitiesscoliotic deformities
were measured towere measured to
characterizecharacterize
bracingbracing
biomechanicalbiomechanical
action on the torsoaction on the torso
Chase et al., Spine, 1989
Cote et al, Scol. Deform., 1995
Jiang et al, Scol. Deform, 1992
22. Measuring meanMeasuring mean
brace forces exertedbrace forces exerted
locally by the bracelocally by the brace
found that correctionfound that correction
of curves was notof curves was not
solely depended onsolely depended on
the level of forcethe level of force
applied by the braceapplied by the brace
The patients with theThe patients with the
greatest curvesgreatest curves
achieved littleachieved little
correction despitecorrection despite
significant levels ofsignificant levels of
applied forceapplied force
Chase et al, Spine 1989
23. For the purpose of the studyFor the purpose of the study
A flexible tissue matrixA flexible tissue matrix
was developed,was developed,
composed of thincomposed of thin
circular sensors thatcircular sensors that
measure themeasure the
pressures generatedpressures generated
at the entire skin-at the entire skin-
brace interface.brace interface.
It was suggested thatIt was suggested that
Boston brace action isBoston brace action is
limited mainly tolimited mainly to
specific regions ofspecific regions of
pressurepressure
Cote et al, Scol. Deform., 1992 - 1995
24. Measurement ofMeasurement of
magnitude,magnitude,
locationlocation
and direction of pressuresand direction of pressures
generated by the bracegenerated by the brace
and the forces present in theand the forces present in the
straps fastening the bracestraps fastening the brace
while the pts assumedwhile the pts assumed
different positions,different positions,
found thatfound that
posterior thoracic padsposterior thoracic pads
provided scoliotic correctionprovided scoliotic correction
and derotation and thatand derotation and that
brace interface pressurebrace interface pressure
were present in all positionswere present in all positions
Jiang et al, Scol. Deform, 1992
25. It was found that patientsIt was found that patients
withwith low strap forceslow strap forces hadhad
scoliotic curves thatscoliotic curves that
progressed while in theprogressed while in the
bracebrace,, whereas thosewhereas those
with high strap forces hadwith high strap forces had
a reduction in curvaturea reduction in curvature
It was concluded thatIt was concluded that
although high strap forcesalthough high strap forces
are necessary to ensureare necessary to ensure
lateral and derotationallateral and derotational
forces on the spineforces on the spine theythey
also cause undesirablealso cause undesirable
forces that induceforces that induce
lordosislordosis
Jiang et al, Scol. Deform, 1992
26. Clearly theClearly the
biomechanical actionsbiomechanical actions
of the TLSO are still notof the TLSO are still not
well understoodwell understood
Considering that bracesConsidering that braces
are prescribedare prescribed
empirically, relying n theempirically, relying n the
experience andexperience and
observations of theobservations of the
orthopedist andorthopedist and
orthotist, it is possibleorthotist, it is possible
that treatment fails inthat treatment fails in
some patients becausesome patients because
of the inadequate forcesof the inadequate forces
exerted by the braceexerted by the brace
27. AnAn increase inincrease in
strap tension bystrap tension by
50% resulted in50% resulted in
an increase ofan increase of
20% in the20% in the
mean forcemean force
exerted throughexerted through
thethe
compressioncompression
padspads
Chase et al, Spine 1989
28. Strap forces influenceStrap forces influence
progression of scolioticprogression of scoliotic
curvescurves
Therefore it would seemTherefore it would seem
that the effectiveness of thethat the effectiveness of the
brace depends to a certainbrace depends to a certain
extend onextend on how tightly it ishow tightly it is
adjusted and fastenedadjusted and fastened
Currently, there is noCurrently, there is no
standardized strap tensionstandardized strap tension
at which the brace shouldat which the brace should
be fastened to obtainbe fastened to obtain
optimal resultsoptimal results
Jiang et al, Scol. Deform, 1992
29. Some patients wereSome patients were
wearing their braceswearing their braces
less tight thanless tight than
others wereothers were
A great deal ofA great deal of
variability in thevariability in the
strap tension alsostrap tension also
was found thewas found the
patients were takingpatients were taking
different positionsdifferent positions
regardless of howregardless of how
tightly the strapstightly the straps
were originallywere originally
fastenedfastened
Aubi et al, Spine 1999
30. Even when theEven when the
patients returned inpatients returned in
the standing positionthe standing position
after havingafter having
performed other tasksperformed other tasks
these were alsothese were also
significant decreasessignificant decreases
in strap tensionin strap tension
Aubi et al, Spine 1999
31. Several authorsSeveral authors
believe that thebelieve that the
Heuter-VolkmannHeuter-Volkmann
principle contributesprinciple contributes
to the developmentto the development
of adolescentof adolescent
idiopathic scoliosisidiopathic scoliosis
(A.I.S.)(A.I.S.)
Machida et al, Spione, 1999
Dickson et al, JBJS, 1984
Stokes et al, Spine, 1996
32. Briefly stated,Briefly stated,
asymmetricasymmetric
loading orloading or
compression ofcompression of
the growth platesthe growth plates
on the concaveon the concave
side of the curvesside of the curves
inhibit growthinhibit growth
leading toleading to
wedging of thewedging of the
vertebral bodiesvertebral bodies
33. Bracing a scolioticBracing a scoliotic
curve should, incurve should, in
theory, unload thetheory, unload the
growth plates on thegrowth plates on the
concave side of theconcave side of the
vertebral bodiesvertebral bodies
near the curve’snear the curve’s
apexapex
34. Growth stimulationGrowth stimulation
leading to structuralleading to structural
remodelingremodeling
of the vertebral bodies,of the vertebral bodies,
on the curve’s concaveon the curve’s concave
side may explain theside may explain the
improvementimprovement
or lack of curveor lack of curve
progression,progression,
as measured by Cobbas measured by Cobb
angles, reported withangles, reported with
successful bracesuccessful brace
management of A.I.S.management of A.I.S.
Lonstein et al, JBJS, 1994
Korovesis et al, Spine 2000
36. To our knowledge,To our knowledge,
no longitudinalno longitudinal
study of thestudy of the
Hueter-VolkmannHueter-Volkmann
principle andprinciple and
vertebral bodyvertebral body
growth rate ingrowth rate in
patients with A.I.S.patients with A.I.S.
has beenhas been
publishedpublished
37. The threshold andThe threshold and
limit of the forcelimit of the force
magnitudesmagnitudes
necessary for thenecessary for the
Hueter-VolkmannHueter-Volkmann
principle to applyprinciple to apply
in A.I.S. have notin A.I.S. have not
been delineatedbeen delineated
38. Because the spineBecause the spine
simultaneouslysimultaneously
experiencesexperiences
compressive andcompressive and
tensile forces,tensile forces,
it is unlikely that allit is unlikely that all
compressive forcescompressive forces
inhibit growthinhibit growth
and all tensile forcesand all tensile forces
stimulate growthstimulate growth
39. Adolescent idiopathic scoliosisAdolescent idiopathic scoliosis
bracing and thebracing and the
Hueter – VolkmannHueter – Volkmann
principleprinciple
Frank et al Spine Journal, 2003
The purpose of thisThe purpose of this
investigation was toinvestigation was to
determine whetherdetermine whether
long-term bracelong-term brace
treatment stimulatedtreatment stimulated
asymmetricasymmetric
chondrogenesis in thechondrogenesis in the
apical three vertebraeapical three vertebrae
40. Successful brace
treatment has been
positively correlated
with the total number
of brace-wear hours
per day
Successful brace
treatment may now
also be positively
correlated with the
ability of the brace to
initiate significant
positional changes
Rowe et al, JBJS, 1986
Howard et al, Spine 1998
41.
42.
43.
44. Measurement error,
as well as the lack of
documented brace
wear, may represent
weaknesses of the
study.
Vertebral body
rotation is
notoriously
inaccurate on
unidimensional
radiographs.
A measuring error of
1 mm may
significantly change
a concave-to-convex
height ratio.
46. In conclusion, the
retrospective
analysis of the data,
compared with the
prospective
analysis,
was more insightful
in determining the
importance of curve
flexibility as a
predictor of
successful brace
outcome.
47. Brace application
was a successful
treatment when
the initial
vertebral body
derotations were
maintained until
skeletal maturity
49. A side-bending
radiograph to
assess curve
flexibility may be
cost effective in
preventing TLSO
application to
patients, with rigid
curves, unlikely to
benefit from its
use
50. Larger cohorts with
spiral computed
tomographs may
someday elucidate
whether the
Hueter-Volkmann
principle and
vertebral body
remodeling (if any)
occur in brace-
treated patients
with AIS.
51. A Meta-Analysis ofA Meta-Analysis of
the Efficacythe Efficacy
of Non-Operativeof Non-Operative
Treatments forTreatments for
Idiopathic ScoliosisIdiopathic Scoliosis
Dale et al, JBJS(Am), 1997
52. Graph showing the unadjusted mean proportions of success, with 95
per cent confidence intervals, for the twenty studies. LESS = lateral
electrical surface stimulation.
53.
54.
55. Although bracing
has long been the
mainstay of
conservative
treatment of
scoliosis,
its efficacy has not
been demonstrated
definitively in
prospective or
randomized clinical
studies in which it
has been compared
with other forms of
non-operative
treatment
56. The United States
Preventive Services
Task Force, in 1993,
stated: “There is
inadequate evidence
to determine
whether brace
therapy limits the
natural progression
of the disease
in a significant
proportion of cases”
57. In a 1994 study of the
long-term results of
scoliosis screening in
Dublin, noted: “Since
the incidence of
significant scoliosis
and of surgery is
independent of
changes in bracing
policy, the efficacy of
bracing in causing
significant change in
natural history must
be challenged.”
Goldberg et al, Orth. Trans. 1995-1996
58. In 1993, the
Prevalence and Natural
History Committee of
the Scoliosis Research
Society decided to
compare, with use of
meta-analysis, the
results of non-
operative treatment of
idiopathic scoliosis
59. The selected three important variables
for which sufficient information was
available across studies:
the type of treatment,
the level of maturity,
the criterion used to determine
progression of the curve (or failure of
treatment)
60. The type of
treatment was the
most straightforward
variable, as all of the
patients
had been managed
with bracing,
lateral electrical
surface stimulation,
observation
61. For the purpose of
analysis, the braces
were subdivided into
Milwaukee braces,
Charleston braces,
and all other types of
braces (primarily
thoracolumbosacral
orthoses),
and the bracing
regimens were
classified on the basis
of whether the brace
was worn for
eight,
sixteen,
or twenty-three hours
per day
62. On the basis of the
variables just cited,
the studies were
grouped into four
categories
according to the
predominant level
of maturity of the
patients
63. Juvenile (composed of
children who were nine
years old or less),
immature adolescent
(composed mostly of
children who were ten
to thirteen years old and
had a Risser sign of 2
or less),
mature adolescent
(composed mostly of
children who were more
than thirteen years old
and had a Risser sign
of 3 or 4),
mixed (composed of a
mixture of immature
and mature adolescent
patients, with no clear
majority).
64. The criterion for
failure
ranged from 3 to 10 o
of progression; the five
studies in which no
criterion was specified
were classified as
unspecified in the
analysis. Progression
of the curve was
measured with use of
the Cobb method in all
studies
Bradford et al, Spine, 1983
65. The type of brace
had a significant
effect on the
outcome (QB = 58, p
< 0.0001; QW = 262,
p < 0.0001),
although this effect
was small compared
with the effects of
other variables
66. The daily duration for which
the brace was worn also had
a significant effect on the
outcome
67. The outcome was
significantly influenced
by the level of maturity
as well (QB = 160, p <
0.0001; QW = 161, p
< 0.0001).
The weighted mean
proportions of success
were 0.99, 0.88, 0.71,
and 0.60 for the
studies of mature
adolescent, mixed,
immature adolescent,
and juvenile groups,
respectively
Graph showing the weighted mean
proportions of success according to the level
of maturity. Curves generally were less likely to
progress as the level of maturity increased.
68. The criterion for
failure also
significantly affected
the outcome
Criterion for failure
was 6o
of
progression;
studies in which the
criterion was 5o
or
10o
had higher
proportions of
success
69. This additional
analysis also
demonstrated that
the type of brace
had a significant
effect on the
outcome
The weighted mean
proportions of
success were 0.99
for the Milwaukee
brace
Graph showing the weighted mean proportions of
success for the control condition and various bracing
regimens. Braces that were worn for twenty three
hours per day were significantly more effective than
all other treatments (p < 0.0001). TLSO =
thoracolumbosacral orthosis.
70. ConclusionsConclusions
The results of this
meta-analysis
support the
efficacy of bracing
compared with
lateral electrical
surface stimulation
and observation
only
Graph showing the weighted mean proportions of
success for the control group and for the groups
treated with lateral electrical surface stimulation
(LESS) and bracing
72. The age of the patient at
the start of treatment,
the criterion for failure,
and the bracing regimen
all had effects on
the statistical model
73. In practice, the
type of brace and
the daily duration
for which it is
worn cannot be
separated
completely
74. These data were not
adjusted to account for
compliance of the
patient with the
prescribed period of
brace wear.
We can only state that
when patients are told
to wear the brace
longer each day, they
have a better chance of
preventing progression
of the curve