Points Of Consensus

IMPORTANT CONSIDERATIONS FOR THE ORTHOTIST'S ROLE IN THE CLINICAL EVALUATION OF THE PATIENT

Consistent with general clinical practice, a relevant history should be taken by interviewing the patient and caregiver and reviewing any available medical records.

The orthotist should evaluate the following for patients with IS:

Rib hump or paraspinal prominence (Adam's forward bending test; scoliometer documentation may be helpful in record keeping);
Trunk balance and decompensation (plumb-bob C7 in relation to the natal cleft);
Evaluate head and trunk alignment and shoulder symmetry and compare the findings to the standing posterior-anterior (PA) radiograph;
Evaluate for curve flexibility by lateral bending;
Assess sagittal alignment (ie, thoracic hypokyphosis and/or lumbar lordosis).

Privacy issues/emotional comfort of the patient: During all contact with the patient, an adult family member or caregiver must be present. Every effort should be made to put the patient and family at ease. Suggestions include:

For appointments that are scheduled in advance, advising a patient to wear a swimsuit may serve to make the patient feel more at ease with a clinical exam or orthotic assessment.
Each evaluation, measurement or casting procedure should be preceded by a detailed description of why it is necessary and how it will be done.
For patient photography, a signed release must be obtained, and the patient's identity should be concealed, with the content of the photograph illustrating only what is clinically relevant.

IMPORTANT ORTHOTIC CONSIDERATIONS FOR RADIOGRAPHIC EVALUATION OF SCOLIOSIS

A recent standing PA radiograph and lateral x-ray should be used as tools to design an orthosis. Thus, it is essential for the orthotist to have access to and use these films. Just as when an orthosis is newly prescribed orthosis, when an orthosis needs to be replaced because of patient growth, a recent standing PA radiograph with the patient out of an orthosis should be used as a resource for orthotic design. The orthotist should study the history of post-treatment films and use the information to consider any potential changes in orthotic design.

X-ray orientation: It is critical for the orthotist to confirm the proper orientation of a standing radiograph. For a standing PA radiograph, it should be oriented in a manner as if the patient is being viewed from behind. The heart shadow and stomach bubble (standing films only) should be identified on the left side of the film. Care also should be taken to make sure what is seen radiographically correlates with the clinical observations of the patients (eg, a convex right thoracic scoliosis should correlate with a right rib prominence on clinical examination).

The orthotist should be able to:

Using the Cobb method of measurement, identify the limits and magnitude of the curve; identify the curve apex and convexity orientation of left or right; define a curve by the location of its apex; assess vertebral rotation; and evaluate residual trunk shift, decompensation, and the general balance of the spine. The drawing of a vertical, center sacral line that bisects the body of S1 is instrumental for this evaluation.
Identify maturity indicators, including the Risser sign and other indicators such as open versus closed triradiate cartilage.
Assess thoracic kyphosis for lateral films by using the Cobb method to aid in determining application of forces.

CONSENSUS STATEMENT ON THE TEAM APPROACH

A team approach to treating those with IS or Scheuermann's kyphosis increases the likelihood of a successful outcome with the least amount of distress or anxiety to the patient and/or family. The team is defined as a patient and his or her family, the physician, orthotist, and a registered nurse with the ability to easily refer patients to physical therapy and psychology professionals when deemed appropriate. Other clinic team members, such as the office staff, and the physical environment itself should convey a caring, comfortable, and supportive atmosphere.

PATIENT EDUCATION GUIDELINES

GENERAL

The patient and family should be provided general information about the nature of the disorder diagnosed (ie, IS or Scheuermann's kyphosis). At the time of diagnosis, time should be spent explaining the reasons for any physical manifestations of the disorder, such as the existence of a rib or paraspinal prominence in scoliosis or concerns about trunk asymmetry or a prominent hip.

ORTHOTIC EDUCATIONAL GOALS

Treatment goals should be explained and emphasized with education materials in language understandable to the patient and family.

Short-term goals: To provide an orthosis that returns the spine to an alignment that is as normal as possible without significantly compromising cosmesis or comfort to the patient.
Long-term goals: For IS, stop curve progression and prevent the need for surgical stabilization; for Scheuermann's kyphosis, reduce the deformity within a normal range.
X-ray explanation: A patient's radiograph can be used as a teaching tool to educate the patient regarding the strategy of orthotic design for his or her particular curve pattern
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Appointment logistics: Educate the patient and family regarding how they can prepare for future appointments (eg, appointment durations [fitting appointments may take several hours, so advising a patient and parent to bring homework or reading material may be appreciated and helpful for all involved], anticipated frequency of return visits, and advice on what to wear for fittings).
Physical activity: Education material should encourage the advantages of physical activity throughout the time of orthotic treatment. The orthotist should also take note of individual patient interests and accomplishments to demonstrate a personal interest in the patient's overall well-being. These initiatives can significantly influence a patient's willingness to adhere to a treatment regimen.
Wearing information: Verbal instruction should be reiterated frequently throughout a treatment regimen; written instruction may improve treatment adherence.
Skin care: Educating the patient and caregiver on the importance of skin care is critically important for successful orthotic treatment. The patient should understand that erythema is expected only in key pressure areas that provide a corrective force. The skin should routinely be inspected at the time of orthosis removal, especially in the several days after the delivery of a new orthosis. The erythema should be well distributed and last no longer than 30 minutes. The patient should be provided a written list of recommendations on how to address any concerns about erythema, such as the use of rubbing alcohol or tea bags; wearing a clean, snug-fitting shirt; and avoiding lotions.
Orthosis care: The patient should be instructed to keep the orthosis clean and to always wear a snug-fitting undershirt beneath the orthosis. In warmer climates, the undershirt may need to be changed more than once per day.
Donning the orthosis: The orthotist should demonstrate the proper donning technique for a given orthosis at the time of delivery and have the patient and/or caregiver demonstrate this action to confirm an appropriate level of understanding.
Tips on outer clothing: The patient should be made aware that choosing clothing to wear over an orthosis can be challenging. In general, the patient may typically wear the same kind of clothing to which he or she is accustomed, but in a slightly larger size.
"Weaning in" to the orthosis: To minimize the risk for skin problems and to aid in patient acceptance, the patient should be instructed to gradually increase the wear schedule after receiving a new orthosis. Although individual tolerances vary, the patient should be expected to be able to wear the orthosis at the prescribed wear schedule within 7 to 14 days.

RECOMMENDATIONS FOR FOLLOW-UP

THE TIMING OF IN-ORTHOSIS X-RAYS

For orthoses worn in the upright position, an initial in-orthosis film should be taken and critiqued by the clinic team within 4 weeks from the date of delivery. For nocturnal orthosis designs that are treating double curves, the initial in-orthosis film should be scheduled within 7 days. The tighter control for nocturnal orthosis design is to allow the prescribing orthopedist and orthotist to agree that the primary curve of concern has been properly identified and is being addressed in a satisfactory way. NOTE: It is helpful to show the patient the in-orthosis film, as compared to an out-of-orthosis film, because it provides the opportunity for a teaching session regarding the rationale behind the orthotic design and the treatment's intent.

FOLLOW-UP FREQUENCY

The prescribing orthopedist and orthotist should agree upon the most appropriate frequency of follow-up radiographs for each patient. This is in an effort to balance the need for evaluating the efficacy of an orthotic treatment modality with the need for routine follow-up evaluation of the fit of an orthosis caused by patient growth. That stated, patients typically are seen by the team every 4 months. Issues to be assessed at each follow-up visit, with impressions for each being shared with the patient to fulfill his or her role as part of the health care team, include:

Curve magnitudes and spine balance parameters.Maturity, both radiographic and physiologic; provide the patient updates on an estimated duration of wear in response to maturity assessment.
The orthosis: evaluate 1) the location and perceived magnitude of the application of corrective forces, as indicated by either in-orthosis radiograph and/or patterns and significance of skin erythema; 2) the dimensions of the orthotic design with respect to growth, and 3) the cleanliness and care of the orthosis.
Patient interview: note the patient's perception of overall comfort and cosmesis of the orthosis and self-reported wear schedule. The patient should be given the opportunity to voice any questions or concerns with respect to orthosis wear.

APPROPRIATE USE OF THE COBB METHOD FOR COMPARING RADIOGRAPHS

The recommended method for measuring the Cobb angle in-orthosis to compare with the most recent film taken of the patient out of an orthosis is to identify curve endpoints as defined by the Cobb method for each film independently. This provides the most accurate analysis of the size and location of a structural curve that remains within a properly donned orthosis. In general, the maximum amount of spinal balance and Cobb angle correction should be sought, while not significantly compromising patient comfort or sagittal alignment. The location of the curve and the maturity of the patient can significantly influence the ability to correct the magnitude of the curve in-orthosis. All other treatment goals, such as spine balance and minimizing the lateral translation of the curve also should be verified.

RADIATION EXPOSURE

Despite considerable improvements in diagnostic imaging techniques in recent years, the orthotist should still partner with other clinic team members to strategically minimize the number of x-rays taken in conjunction with orthotic treatment.

POST-TREATMENT FOLLOW-UP

Although most curves successfully treated during adolescence will not demonstrate curve progression after skeletal maturity has been achieved, a risk for progression may exist into early adulthood. Post-treatment follow-up is recommended at 6 months after discontinuation of orthosis use, and then annually for 3 to 5 years. These intervals should be determined by the clinic team's impression of a given patient's risk for curve progression as based on curve size, pattern, and other potentially relevant factors.