Walter Ramos, CO, PT, on Scoliosis Bracing FAQs, interviewed by Dr. Derek Lee

Understanding Scoliosis Bracing with Walter Ramos

Introduction to Walter Ramos

• Dr. Derk Lee introduces Walter Ramos, who holds dual certifications as an orthotist and a physical therapist specializing in scoliosis-specific exercises.

• Walter is noted for his rare qualifications, with only about ten individuals worldwide sharing this designation.

• He works at the National Scoliosis Center in Fairfax, Virginia, and runs his own practice called Scoliosis Today in Florida and St. Louis.

Common Questions About Scoliosis Bracing

• The discussion will cover frequently asked questions regarding scoliosis bracing, including its effectiveness and consequences of not using braces.

• Walter expresses gratitude for the opportunity to connect parents, clients, and healthcare professionals through this platform.

Addressing Family Concerns

• Walter aims to alleviate anxiety and discomfort families experience upon learning their child has scoliosis.

• He acknowledges feelings of guilt among parents regarding missed opportunities for early intervention when a diagnosis is made.

Consequences of Not Treating Scoliosis

• One major question addressed is what happens if scoliosis is left untreated; he references Dr. Winston's work on the natural history of scoliosis.

• The discussion includes whether bracing works effectively; again referencing studies conducted by Dr. Winston.

Types of Braces Explained

• Walter differentiates between traditional braces and European designs like the Rigo concept developed in Barcelona.

• He discusses factors influencing brace effectiveness, noting that some are controllable while others are not.

Personal Insights on Treatment Decisions

• Walter shares a personal story about his daughter’s scoliosis diagnosis during COVID; they chose not to pursue bracing due to her maturity level at age 13.5.

Understanding Scoliosis Treatment Options

Retrospective Study on Untreated Adolescent Scoliosis

• Dr. Wayson initiated a retrospective study, later following patients with untreated adolescent scoliosis, revealing that many led successful lives despite their condition.

Patient Experiences and Desires

• Interviewed patients expressed regret over not having treatment options during childhood, wishing they could have addressed body asymmetry earlier.

Current Opportunities for Parents

• The speaker emphasizes that parents today have access to effective information and treatments for scoliosis, marking a significant advancement in care compared to the past.

Skeletal Maturity and Surgery Considerations

• Discussion of skeletal maturity assessments (e.g., Risser sign or Sanders classification) indicates surgery is typically considered necessary when curves reach 50 degrees or more.

Bracing Effectiveness in Adolescents

• A study by Dr. Weinen and Lori Doan examined bracing effectiveness in adolescents with idiopathic scoliosis, focusing on curves between 20 and 40 degrees.

Bracing Studies: Methodology and Findings

Study Design Overview

• The study involved different centers collecting data from patients; success was defined as maintaining a curve of 50 degrees or less at skeletal maturity.

Randomization Challenges

• Initially randomized, the study faced challenges recruiting participants who were uncomfortable with random assignment; it shifted to an elective model allowing parental choice regarding bracing.

Outcomes of Observation vs. Bracing

• Results indicated that children under observation had over a 50% chance of requiring surgery compared to those using braces who had significantly lower chances of surgical intervention.

Insights on Bracing Duration

Understanding Bracing Hours Impact

• A chart discussed shows varying success rates based on hours worn; however, it's crucial to understand these percentages represent ranges rather than guarantees tied to specific hours.

Recommended Bracing Duration

Understanding Scoliosis Treatment and Bracing

The Importance of Brace Wear Time

• A child with a 30-degree curve who wears a brace for 18 hours has an 80% chance of avoiding surgery, but reducing wear time to 12 hours drops success to 60%.

• If the wear time decreases further to just 6 hours, the likelihood of avoiding surgery falls to approximately 26%, similar to those under observation.

Effectiveness of Braces

• A review indicated that most braces used in studies did not achieve the expected 50% correction; actual averages were around 33% between Canada and the US.

• While some children may achieve over 50% correction, others may only reach about 30-40%, which is still considered acceptable.

Correction vs. Compliance

• The amount of time spent wearing the brace is more critical than the degree of correction achieved; consistent use can lead to better outcomes even with lower correction percentages.

• Statistics indicate that longer wear times correlate with higher chances of avoiding surgery across all levels of correction.

Patient Responsibility and Family Involvement

• Patients must take ownership of their treatment; family support plays a crucial role in encouraging adherence to wearing schedules.

• Children are often fascinated by their ability to influence their health outcomes through commitment and participation in treatment.

Types of Patient Attitudes Towards Treatment

Group Dynamics in Patient Responses

• Three types of families/patients are identified:

• Group One: Dismissive ("No thank you, we're okay").

• Group Two: Followers who rely on experts without questioning them.

• Group Three: "Spoon Benders," who are open but need guidance.

Challenges with Different Groups

• The first group often feels overwhelmed or uncertain about taking action regarding treatment options.

Understanding Spoon Benders and Scoliosis Treatment

The Concept of Spoon Benders

• A "spoon bender" is described as someone who actively seeks information beyond what medical professionals provide, often engaging in discussions and research to understand their condition better.

• These individuals typically belong to communities (e.g., Facebook groups, local churches) where they share experiences and seek solutions for health issues.

Family Experience with Scoliosis Diagnosis

• A family shares their journey of discovering scoliosis during an annual physical examination when a physician noticed a spinal bend.

• After receiving X-rays, the family was referred to an orthopedist who suggested a wait-and-see approach due to the initial 14-degree curve.

Active Approach to Treatment

• The family explored alternative treatments through online communities, leading them to pursue Schroth therapy instead of passive observation.

• They eventually sought bracing options after follow-up X-rays indicated progression into bracing territory, specifically preferring the Rego brace based on research.

Positive Experiences at the National Scoliosis Center

• The family's visit to the National Scoliosis Center was marked by positive interactions, including hands-on participation in creating the brace.

• The child expressed enjoyment in customizing her brace and even using extra materials creatively for personal projects.

Importance of Timely Adjustments and Collaboration

• Continuous communication between therapists ensures that families receive timely feedback on treatment progress; this collaborative model enhances patient care.

• Utilizing advanced imaging technology like EOS machines allows for quicker adjustments post-evaluation compared to traditional methods that involve longer waiting periods.

Goals of Scoliosis Management

• Medical professionals aim not only to prevent surgery but also to maintain curve stability until skeletal maturity; success is defined by preventing curve progression during growth phases.

Understanding Scoliosis Treatment Goals

Different Goals in Scoliosis Treatment

• The discussion highlights varying treatment goals for scoliosis, such as maintaining a specific curve angle (30-35 degrees) versus achieving a higher goal (40-45 degrees) without surgery.

• A local doctor at an SRS meeting noted that some patients have shown decreased cup angles after using braces, suggesting potential outcomes not widely documented in literature.

• Patients may prioritize different goals based on personal aspirations, like becoming an athlete or pilot, which influences their treatment choices and willingness to undergo surgery.

Types of Braces and Their Mechanisms

• The speaker categorizes braces into traditional types (e.g., Milwaukee, Wilmington Bost) and newer designs influenced by the Regal concept.

• Traditional braces are often symmetrical with posterior openings, while newer designs focus on asymmetry and 3D concepts to improve effectiveness.

Historical Context of Scoliosis Treatment

• The history of scoliosis treatment is traced back to Katherine Schroth in the 1920s, who developed methods to reposition the spine through manual manipulation rather than relying solely on bracing or surgery.

• Schroth's approach involved intensive hands-on training for patients over extended periods, contrasting sharply with modern expectations for treatment efficacy.

Insights from Historical Practices

• The severity of curves treated historically was greater than what is typically seen today; exercises were used instead of surgical interventions common now.

Understanding Scoliosis Treatment Techniques

Overview of Treatment Approaches

• The speaker discusses the role of a practitioner in controlling the pelvis and thoracic block during treatment, emphasizing the importance of trunk derotation.

• Observations are made on patients with varying levels of experience, highlighting how some require assistance while others have already undergone training.

Historical Context

• A historical perspective is provided, tracing the evolution of scoliosis treatment from East to West Germany over several decades.

• Dr. Sheno's influence on casting techniques for scoliosis is noted, along with his adaptation of brace systems based on knowledge from East German practitioners.

Development of Bracing Techniques

• The speaker reflects on inconsistencies in braces used for different types of curves and the motivation behind developing better solutions.

• It took 70 years for treatment methods to evolve from Europe to the United States, indicating a significant lag in knowledge transfer.

Clinical Assessment Procedures

• The initial steps in treating a patient using traditional TLSO involve creating a blueprint based on X-ray analysis rather than direct patient assessment.

• Emphasis is placed on understanding that an X-ray represents only a moment in time and may not accurately reflect ongoing conditions.

Practical Application and Patient Interaction

• The final product involves designing braces that accommodate body movement while addressing specific spinal curves.

• Clinical assessments precede X-ray evaluations to ensure accurate diagnosis and treatment planning based on physical examination findings.

Postural Analysis Insights

• A detailed observation reveals trunk rotation and pelvic translation during patient assessment, illustrating common postural challenges faced by individuals with scoliosis.

• The speaker shares personal anecdotes about patient experiences related to posture correction, drawing parallels between self-perception and physical alignment.

Diagnostic Techniques

• The Adam's test is introduced as a method for assessing spinal rotation without relying solely on X-ray images.

Understanding Pelvic Rotation and Brace Design

Analysis of X-ray Findings

• The iliac crest on the left side appears wider than the right, indicating a derotation of the pelvis to the left. This observation may influence visible rotation in longer structures.

Importance of Training and Classification

• The speaker emphasizes their background in physical therapy and training from Barcelona school, which aids in recognizing pelvic rotation nuances. Collaboration with partners like Christian Christensen enhances diagnostic accuracy.

Scoliosis Brace Classification

• Dr. Rigo's classification system for scoliosis treatment is introduced, focusing on specific brace types tailored to curve classifications (three or four blocks). This approach allows for customized treatment plans based on individual patient needs.

Customization of Braces Based on Curve Types

• Different brace designs are necessary for various curve types (e.g., A1, A2, A3), emphasizing that not all braces fit every patient. Clinical findings dictate specific design requirements.

Effectiveness of Brace Design

• After six months of consistent brace use, a 30-degree curve reduced to an 18-degree curve in a 16-year-old patient, showcasing the effectiveness of proper brace application and adherence.

Design Features of European Style Braces

Asymmetry in Brace Segments

• European-style braces incorporate asymmetrical segments to accommodate different body shapes; this design helps create necessary rotations by allowing one side more freedom while containing another.

Three-point Pressure System Mechanics

• The three-point pressure system is highlighted as effective for scoliosis correction. Proper placement and adjustment are crucial for achieving desired outcomes through counter forces applied at strategic points.

Areas of Expansion Considerations

• Insufficient areas for expansion can limit brace effectiveness; examples illustrate how inadequate design can hinder patient movement and breathing during treatment.

Challenges with Current Brace Designs

Limitations Observed in Patient Cases

• Specific cases demonstrate that existing braces may not provide adequate contact or expansion areas needed for effective treatment; adjustments must be made based on individual anatomical needs.

Understanding Scoliosis Treatment Techniques

Representation of Spinal Structure

• The discussion begins with a representation of the spine and trunk using wood blocks, illustrating concepts from Katherina Sh and her daughter, later expanded by Dr. Rego. This visual aids in understanding spinal classification and treatment approaches.

Importance of Derotation in Surgery

• A critical observation is made regarding the rotation of spinal blocks; surgeons will not perform scoliosis surgery without first derotating the spine to correct posture effectively. This highlights the necessity for precise manipulation during treatment.

Role of Mentorship in Treatment

• Emphasizing mentorship, the speaker reflects on their experience working independently versus collaborating with an experienced mentor like Luke at Fair Fox and National Scoliosis Center, underscoring how guidance enhances treatment efficacy.

Pelvic Correction Techniques

• The conversation shifts to pelvic corrections within physiotherapy specific to scoliosis exercises (PSSC), noting that five different pelvic corrections can be achieved through bracing techniques while considering both coronal and transverse planes.

Clinical Evidence and Experience

Trauma and Orthotics in Scoliosis Treatment

Overview of Pediatric Orthopedic Care

• Discussion on the specialization required for treating trauma in lower extremities, emphasizing the need for pediatricians with fellowship training in scoliosis surgery.

• Mention of specialized clinics focusing solely on scoliosis treatment, highlighting the limited frequency of patient consultations by orthotic specialists.

Fabrication and Customization of Braces

• Description of a visit to Dr. Ringo's orthotic shop, where modifications to braces are made after patient consultations.

• Insight into the collaborative process at the National Scoliosis Center, where practitioners are involved in every step from evaluation to brace fabrication.

Case Presentations and Outcomes

Case 1: Adolescent Idiopathic Scoliosis

• Introduction of a case involving a 13.5-year-old female with adolescent idiopathic scoliosis treated with a Regal brace; initial curve measured at 40 degrees.

• Emphasis on evaluating both clinical presentation and X-ray results, noting significant rib rotation affecting lumbar curvature.

Treatment Results

• The brace led to an impressive correction from 40 degrees to 10 degrees over time; however, this was not achieved instantaneously but gradually within weeks.

• Monitoring revealed that while she initially wore the brace for only 50% of her target time (20 hours), compliance improved over three months.

Long-term Considerations

• Despite achieving some correction (down to 30 degrees), concerns were raised about sustainability due to reduced wear time (13 hours/day).

Case 2: Juvenile Scoliosis

Patient Background

• Introduction of a second case involving a 10-year-old girl diagnosed with juvenile idiopathic scoliosis; family history indicated high risk for surgical intervention due to curve severity.

Clinical Observations

• Notable challenges observed during clinical assessment regarding lumbar posture correction; difficulty noted in maintaining proper alignment without compensatory movements like knee flexion.

Brace Design and Correction Techniques

Initial Brace Assessment and Adjustments

• The first brace design aimed to correct a thoracic curve from 55 degrees to 34 degrees, showing decent correction but revealing an elevation in the right shoulder compared to the left.

• Adjusting the left shoulder's position allowed for better pressure application through the brace, leading to improved alignment of both shoulders.

Follow-Up and New Brace Creation

• A follow-up after three to four months indicated that the patient was not outgrowing the brace; instead, she was gaining height while wearing it, suggesting missed corrections on upper blocks.

• A new brace was created at no additional cost to the patient, reflecting a commitment to orthotic care. This new design achieved significant correction from 55 degrees down to 15 degrees.

Out-of-Brace Results and Patient Engagement

• Post-treatment X-rays showed that the patient moved from being a candidate for surgery back into a safe range. However, there is concern about regression if treatment stops.

• Emphasizing patient involvement, it was noted that success relies heavily on their commitment— likened to being "spoon benders" who actively engage with their treatment.

Conceptual Framework of Treatment Approach

• The speaker contrasts two approaches: simply providing braces versus engaging patients in their journey (the "Rioo concept"), which involves understanding their goals before delivering solutions.

Clinical Observations and Case Studies

• The current case study highlights how well patients can stand with proper knee alignment while wearing braces. One patient proudly showcased her results at a meeting.

Addressing Complex Curves in Adolescent Patients

Case Study of Male Patient with Thoracic Curve

• A male patient aged 12.5 years presented with an existing curve of 22 degrees; he had been under previous care by another provider before seeking further assistance.

• Clinical observations revealed rotation associated with his curvature, prompting adjustments in his custom brace design.

Modifications for Effective Correction

• The speaker discusses implementing demodification techniques within the brace design aimed at correcting specific areas without resorting to more invasive options like Milwaukee frames.

Successful Outcomes and Patient Attitude

• After modifications were made, significant improvements were observed not only in rotation but also in overall curve correction. The patient actively engaged by personalizing his experience (e.g., using stickers).

Challenges Faced by Competitive Athletes

Case Study of Competitive Wrestler

• A 15-year-old male competitive wrestler presented with lumbar spondylolisthesis; despite nearing skeletal maturity (Risser stage four), he opted against surgery due to his active lifestyle.

Patient-Centric Decision Making

• The athlete took charge of his health decisions rather than relying solely on parental guidance; he committed himself fully to wearing the prescribed brace for effective management.

Focus on Alignment Awareness

Understanding Scoliosis Treatment and Bracing

Overview of Patient Experience with Bracing

• A patient, 16 years old, expresses dissatisfaction with his current brace correction, seeking single-digit curvature.

• Discussion on skeletal maturity indicates that while the patient is male and skeletally mature, intervertebral disc maturity may take longer to develop.

Factors Influencing Brace Effectiveness

• An article reviews various studies on scoliosis treatment with braces, identifying compliance as the primary factor for treatment failure.

• The study included 25 main articles; compliance and brace type are highlighted as modifiable factors affecting outcomes.

Importance of Correct Brace Usage

• A case study illustrates a patient's worsening curve despite good initial brace correction due to improper usage.

• The importance of correct strap tension is emphasized; incorrect application leads to loss of corrective forces.

Compliance and Correction Interrelation

• Compliance and proper brace fit are interrelated; even if worn for 18 hours, improper use can negate benefits.

Insights from Comparative Studies

• The speaker appreciates comparisons between traditional TLSO braces and European styles in terms of effectiveness.

Bracing Effectiveness: Perspectives and Research

Bracing Efficacy Based on Curve Angles

• Dr. Weinstein's research suggests bracing is effective primarily for curves between 20° to 40°, with diminishing returns beyond this range.

Exploring New Frontiers in Treatment

• An analogy about exploring uncharted territories highlights the potential for extending bracing effectiveness beyond conventional limits (up to 50°).

International Practices in Scoliosis Treatment

• Observations from Russia indicate ongoing bracing practices for skeletally mature patients aged 15 to 20, suggesting a need for further exploration in this area.

Emphasis on Patient Compliance

Understanding the Role of Goals in Bracing

The Importance of Goals in Treatment

• The type of equipment or shoes used for running is less significant when the goal is modest, such as completing a 5K or marathon.

• For some individuals, like aspiring college athletes, the primary concern may be avoiding surgery rather than achieving peak performance.

• The relevance of braces depends on individual goals; if minimal intervention suffices, any brace can be acceptable.

Customization and Expertise in Brace Making

• The effectiveness of a brace hinges on two factors: the patient's goals and the expertise of the trainer or manufacturer.

• There are varying approaches to brace creation, from simple data collection to hands-on fabrication tailored to patient needs.

Expertise Levels in Brace Fabrication

Classification of Practitioners

• A presentation categorized practitioners into five levels based on their expertise in making scoliosis braces, with Level 5 being top-tier experts like Manuel Rigo.

• Level 4 includes those with extensive training under experts who can evaluate and fabricate braces independently after years of experience.

Intermediate and Basic Levels

• Level 3 practitioners see multiple patients weekly and are learning to create braces under mentorship but lack formal specialization.

• Level 2 practitioners collect data for others to fabricate braces without understanding how they work themselves.

Generalists vs. Specialists

Expertise in Orthotics and Scoliosis Treatment

Understanding Expertise in Bracing

• The speaker questions the level of expertise among practitioners, specifically regarding their experience with braces, orthotics, prosthetics, and scoliosis treatment.

• Emphasizes that while initial training may provide basic information capture, further education is essential for effective brace creation.

Importance of Practical Experience

• Highlights the risk of physicians lacking knowledge about bracing differences; suggests they should visit facilities to understand practices better.

• Compares dedication levels between professionals; mentions a colleague who works hands-on and is deeply involved in the process rather than just overseeing it.

Evaluating Flexibility Assessment Techniques

• Discusses the need for high-level trainers and practitioners who can perform thorough evaluations beyond mere measurements.

• Shares insights from a conference on assessing flexibility; notes that even surgeons struggle with reliable methods for evaluating flexibility.

Physical Assessment Skills

• Mentions Dr. Rigo's approach to physical assessment, which involves tactile evaluation to gauge patient flexibility.

• Critiques current reliance on x-ray techniques due to their unreliability in assessing body mechanics.

Patient Engagement and Treatment Goals

• Reflects on different therapeutic approaches; some therapists engage physically while others focus solely on documentation.

• Expresses frustration over patients not adhering to treatment plans, emphasizing the importance of commitment for successful outcomes.

Intentions Behind Practice

• Discusses personal intentions when meeting with colleagues or patients; stresses clarity of purpose as crucial for effective communication and care delivery.