Brace Classification Study Group (BCSG):
part one – definitions and atlas

Theodoros B. Grivas 1 , Jean Claude de Mauroy 2 , Grant Wood 3, Manuel Rigo 4 , Michael Timothy Hresko 5 , Tomasz Kotwicki 6 and Stefano Negrini 7,8
Received: 14 June 2016,
Accepted: 9 October 2016,
Published: 31 Octuber 2016.
DOI:
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Abstract

Background: The current increase in types of scoliosis braces defined by a surname or a town makes scientific classification essential. Currently, it is a challenge to compare braces and specify the indications of each brace. A precise definition of the characteristics of current braces is needed. As such, the International Society for Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) mandated the Brace Classification Study Group (BCSG) to address the pertinent terminology and brace classification. As such, the following study represents the first part of the SOSORT consensus in addressing the definitions and providing a visual atlas of bracing.

Methods: After a short introduction on the braces, the aim of the BCSG is described and its policies/general consideration are outlined. The BSCG endeavor embraces the very important SOSORT – Scoliosis Research Society cooperation, the history of which is also briefly narrated. This report contains contributions from a multidisciplinary panel of 17 professionals who are part of the BCSG. The BCSG introduced several pertinent domains to characterize bracing systems. The domains are defined to allow for analysis of each brace system.

Results: A first approach to brace classification based on some of these proposed domains is presented. The BCSG has reached a consensus on 139 terms related to bracing and has provided over 120 figures to serve as an atlas for educational purposes.

Conclusions: This is the first clinical terminology tool for bracing related to scoliosis based on the current scientific evidence and formal multidisciplinary consensus. A visual atlas of various brace types is also provided.

Keywords: Scoliosis, Spine, Nomenclature, Brace, Classification, Terminology, Definition, Brace Classification Study Group, BCSG

Background

There are many different spinal orthoses used for non-surgical treatment of various types of spinal deformities [14]. Most clinicians use the term brace instead of spinal orthotic/orthosis and bracing as the action of treating a patient with a brace. The simplest classification of braces is based on the anatomical region where the orthosis acts: cervical (C), thoracic (T), lumbar (L) and sacral (S). Using this naming system, two main families of braces have been classically used: a) Cervical-Thoraco-Lumbo-Sacral Orthotics or CTLSO and b) Thoraco-Lumbo-Sacral Orthotics or TLSO [4]. The anatomical classification is clear and simple; however, it is hardly acceptable nowadays for two reasons. First of all, each group includes very different types of braces and a variety of principles or concepts to treat many different disorders. Consequently, the anatomical classification does not allow establishment of any clear similarity or difference between two braces classified into a same group. Secondly, some well-known concepts might reasonably be attributed to both groups. For example, the Boston brace, one of the most popular concepts to treat adolescent idiopathic scoliosis (IS) in North America, is commonly classified as TLSO but in some cases it can be built with a super-structure to act also on the cervical spine, and classified then as CTLSO [1]. A different classification was introduced by Negrini et al. [5] and presented during the annual meeting of the International Society for Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) in Athens in 2008, under the acronym BRACE MAP. BRACE MAP derives from the following terms: Building, Rigidity, Anatomical classification, Construction of the Envelope, Mechanism of action, and Plane of action. Each item was composed of two to seven classificatory elements defined using one or two letters in order to refer specifically to the characteristics of the brace throughout the classification (e.g. SpineCor was classified as CpETAM3, meaning Custom positioning, Elastic, TLS, Asymmetric, Movement principle and 3D correction). Of the 13 braces considered, BRACE MAP provided the ability to differentiate between all but two of the braces. This was the first comprehensive brace classification system. However, the same authors concluded that despite its utility in distinguishing between most of the existing braces, a re-definition of this first proposal would be necessary through a consensus process. Until now, 12 consensus papers have been published by the SOSORT [617], including a consensus on terminology that was used initially to form the basis of this work [14]. During the SOSORT annual meeting in Wiesbaden, Germany in May 2014, a consensus group was formed, chaired by Dr. Theodoros B. Grivas, to develop a new brace classification. The Brace Classification Study Group (BCSG) is composed of active SOSORT members and members from the Non-Operative Committee of the Scoliosis Research Society (SRS) (listed alphabetically in Table 1).
Table 1. Alphabetical listing of BCSG members
Aulissa Angelo Gabriele (Italy)
De Mauroy Jean Claude (France)
Diers Helmut (Germany)
Glassman Steve (US)
Grivas Theodoros B (Greece)
Hresko Timothy (US)
Kotwicki Tomasz (Poland)
Knott Patrick (US)
Maruyama Toru (Japan)
Negrini Stefano (Italy)
O’Brien Joe (US)
Price Nigel (US)
Rigo Manuel (Spain)
Stikeleather Luke (US)
Thometz John (US)
Wood Grant (US)
Wynne James (US)
Zaina Fabio (Italy)

Aims

The charges of the BCSG include and address the following: the identification of all the relevant terms of characteristics of a brace for the non-operative treatment of spinal deformities, mainly IS, and the creation of a specific vocabulary with the definitions of these terms. Also the grouping of the braces according to their characteristics that is the anatomical region they cover, their function, the material of which they are made, the tolerance, the adaptability and the adherence to treatment (compliance) of the patients, the treated deformity, the monitoring, and the outcome measures to achieve unique identification of the characteristics of each existing brace according to the created terminology. Finally the aim was to plan the evaluation of the quality of outcomes according to each of the brace characteristics, with the ultimate aspiration to recognize the most suitable brace construction for each specific spinal deformity. The identification and definition of terms of brace characteristics and creation of a vocabulary will facilitate the communication among the specialists using a common language. Additionally the classification and assessment of effectiveness of existing braces within each domain of classification, and the study of outcomes according to each of these characteristics will optimize the brace treatment for spinal deformities. The terms that were identified in the first meeting of the BCSG are illustrated in Table 2. The initial steps of the group were to complete the preliminary list with any unnoticed term, grouping them and providing a definition and a proper figure, if applicable, for each of them. An atlas to accompany the terminology was one of the aims.
Table 2 List of domains suggested by BCSG members
3D
2D Frontal
2D Horizontal
2D Sagital
Aesthetics
Activities of Daily Living (ADL)
Anatomical Classification (C: CTLSO; T: TLSO; L: LSO)
Asymmetric
Building
Brace with Monitoring Device
Brace Wearing Monitor
CAD/CAM
Combined Frontal Horizontal
Combined Frontal Sagittal
Combined Horizontal Sagittal
Custom Made
Custom Position
Derotation
Driver
Elastic
Elongation
Long Brace
Mechanism of Action
Outcomes Related Words
Plane of Action
Plaster Mould
Prefabricated Envelop
Preliminary Plaster Cast
Pusher
Quality of Life (QoL)
Rib Hump
Rigid
Rigidity
Sagittal Plane Correction
Short Brace
Soft
Stopper
Symmetric
Three Point
Very Rigid

This part of the work (i.e. definitions and atlas) represents part one of a two-part project. Part two of our consensus statement will address brace classification and will be entitled, “Brace Classification Study Group (BCSG): part two – classification”.

Scope

Policies – general consideration

The BCSG members are all specialists involved in the non-operative treatment of IS comprised of orthopaedic surgeons, rehabilitation doctors, certified prosthetist – orthotists (CPOs), physiotherapists specialized in non-operative scoliosis treatment, colleagues working on brace development, bioengineers working on compliance monitoring electronics (gadgets), finite element study specialists related to braces application, etc. The acronym BRACE MAP was initially proposed at the 2008 SOSORT meeting and we resumed the six domains suggested [5]. However, the BCSG introduced 40 definitions for analysis as listed in Table 2. The first stage of this consensus has brought together the 139 definitions in 17 final domains.

Additionally, in a roundtable entitled “Braces: conceptual and technical approach to scoliosis”, held at SOSORT 2014, the biomechanical presentation was reviewed. It was the first approach to brace classification based on some of the domains proposed by the BCSG (Additional file 1). The majority of the work was carried out online on the SOSORT website and every three months a draft text was forwarded to the panel for survey. The time-course of the consensus process is noted in Table 3.

Table 3 Timeline of the consensus process.
Date Consensus processing
2007 Boston - Beginning of the SOSORT – SRS cooperation
2010 Montreal - 8th SOSORT consensus on terminology
2014 Wiesbaden - A consensus group was formed, chaired by Dr. Theodoros B. Grivas, to develop a new brace classification (BCSG):
Panel of 17 multidisciplinary experts: 7 surgeons, 6 non surgeons, 2 CPO, 1 Engineer, 1 Patient. (8 from North America, 8 from Europe and 1 from Japan)
Initial draft list of 40 terms to define. Roundtable entitled “Braces: conceptual and technical approach to scoliosis”
2015 Katowice - Evidence from the SOSORT guidelines and literature (2 relevant papers from 1547 papers with search terms ‘scoliosis’ and ‘brace’)
Elaboration of a secondary list of 139 provisional definitions arranged in a conceptual framework of 19 domains based on integration of research knowledge and clinical experience of the panel. Elaboration of an atlas to illustrate definitions.
2016 Banff - Final synthesis of the 139 definitions and illustration of 120 figures
2017 Lyon - Delphi Round-2 and Round-3 during the next Lyon SOSORT meeting
BCSG and SOSORT – SRS co-operation

Many surgeons and members of the SRS have gradually abandoned the non-surgical treatment for IS. Although the effectiveness of bracing was proven by the SRS [18], the lack of classification does not facilitate the indication and the prescription. Cooperation between the two societies is essential. The collaboration between the SOSORT and the SRS started in 2007 during the SOSORT meeting in Boston, chaired by Joe O’Brien and was established by Dr. Theodoros B. Grivas during the SOSORT meeting in Athens, Greece in 2008. At that time Dr. George Thompson, who had great experience with the providence brace, served for two years as President of the SRS and he was invited to both the Boston and Athens SOSORT meetings. During the 2014 SOSORT meeting, a joint SOSORT-SRS consensus on ‘Recommendations for Research Studies on Treatment of Idiopathic Scoliosis’ was presented and published for the first time [17]. This report contains contributions from SOSORT and SRS members who are part of the BCSG and are listed in alphabetical order (Table 1).

 

Definitions

Brace fabrication

Preliminary plaster cast
Refers to the Lyon management in two steps: (1) reduction in asymmetric non-removable plaster cast and (2) contention by a more symmetrical removable brace (Fig. 1).

Fig 01
Fig. 1 Preliminary plaster cast, example of the Lyon management: Reduction by plaster cast
Body cast, serial casting (Mehta casting)
A non-removable plaster cast, which is usually applied to an infantile scoliosis patient while under anesthesia and suspended from the ground in a Risser frame. The cast surrounds the chest, abdomen, pelvis, and may also include the shoulders. It may be used to correct scoliosis in very young patients or for postoperative spinal mobilization (Fig. 2).
Fig 02
Fig. 2 Body cast for Infantile Scoliosis. Serial or Mehta casting
Plaster mold The traditional method used to capture an impression of the trunk of a patient. A plaster or synthetic bandage is applied, which hardens and is removed from the patient. This plaster mold is used for the custom fabrication of the brace (Fig. 3).
Fig 03
Fig. 3 Plaster molds
Regional shape capture A shape capture obtained by the superposition of three specifically corrected shape captures of the same patient: the pelvic area, lumbar area, and thoracic area. The regional shape capture makes the sagittal plane normalization more accurate (Fig. 4).
Fig 04
Fig. 4 Regional shape capture, from top to bottom: a for pelvis and shoulders, b for lumbar region, c for thoracic region.
Negative cast The plaster or synthetic cast once it has been removed from the patient (Fig. 5).
Fig 05
Fig. 5 Negative cast in plaster of Paris or resin.
Positive mold
A solid mold formed from filling the negative cast with plaster (Fig. 6).
Fig 06
Fig. 6 Positive mold in polyurethane obtained by CAD/CAM carver.
CAD/CAM
The term is an acronym defined as “Computer-Aided Design/Computer-Aided Manufacturing.” The process of making a shape capture with 3D modeling tools and a milling machine for fabrication (Fig. 7).
Fig 07
Fig. 7 CAD/CAM system with shape capture and shape processing.
Custom-made
The term refers to “made-to-measure” (UK). A brace fabricated from a custom mold and measurements of the patient’s trunk (Fig. 8).
Fig 08
Fig. 8 Custom made positive mold.
Prefabricated envelope (Module)
A brace that is fabricated over a standardized body form instead of a specific patient. The prefabricated envelope is designed to fit a patient within a range of measurements (Fig. 9).
Fig 09
Fig. 9 Prefabricated Boston Module
Fig 10
Fig. 10 Axilla extension of a brace.
Fig 11
Fig. 11 TLSO scoliosis brace.
Fig 12
Fig. 12 Milling or carving machine.

 

References

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