Scoliosis Bracing Interview: the New Chêneau Brace in the US
Dr. MORAMARCO: Here I am in Gensingen, Germany with Dr. Hans-Rudolf Weiss who is a scoliosis expert and I’m here in Gensingen learning about his bracing system the Chêneau - Gensingen brace. And so I thought I’d interview him and ask him some questions about bracing. What I’ve learned this week is his brace is quite impressive and I’ve seen some terrific corrections in patients.
Okay, so that being said, for parents and patients: I get a lot of phone calls and I get a lot of questions about symmetrical braces versus asymmetrical braces - overcorrection and just bringing the spine to symmetry - could you just shed a little light on that for patients and parents. Dr. WEISS: Well, we do know that the amount of in-brace correction determines the end result. Of course if the brace is not worn you can’t have good in brace correction and it’s worth nothing but if you correct more than mid-line, it’s better in-brace corrections all the outcomes are much better. And symmetric braces are only symmetric and Chêneau braces and the Chêneau Gensingen brace, which is the latest development of the Chêneau brace, is more asymmetric than all other braces.
And you can see that here especially if you have a right thoracic curvature going here and a left lumbar curvature and this is vice versa, you know. You have a left lumbar and right thoracic, so it is the opposite of what’s actually in the trunk so this is a brace for a double major curve pattern with a right thoracic rib hump / left lumbar hump. If you look at a three-curve scoliosis - functional three curve - it is a term by my mother, Lehnert-Schroth - so we only have three blocks to correct against each other and what is obvious, you have a real big shifting over, you keep the pelvis as it is shift over in the thoracic area and bend back the shoulder girdle area. And so, we do have overcorrections of course in very flexible curvatures, also in curvatures exceeding 40 degrees, but they must be young we put the same brace on in patients with 14 years-old and they do not correct as much as in the younger population. This is lately published in Hard Tissue that even in curvatures exceeding 50º you can have very good results with respect to cosmetic appearance but only if you go over the mid-line. Dr. MORAMARCO: Studies show that you want to achieve at least a 30% correction in the brace for it to be a positive outcome, correct, at least… DR.
WEISS: I would not determine say 30%, it’s 50% [noise] in the normal population of curvatures about 30º. So, this would be correction to 15 but I’m not satisfied with a 15 degree curvature if I can overcorrect. So sometimes in the rare conditions, you know, 5% of our patients do not correct even they have the same sculpture on their body like here because this is standardized CAD/CAM: it’s always the same just adjust to width and size of patients. And sometimes, in 5% of my population, it does not correct satisfyingly. So these curvatures can be stopped, usually, but they have no end-result correction which is sad because these patients also sacrifice their quality of life for years in-brace, but at least we have no deterioration of the curvature. But, usually, we gain, if the patient’s compliant, impressive corrections with respect to cosmetic appearance, clinical, and radiologically as well. Dr. MORAMARCO: Okay.
So, now there are some braces out there that are two- dimensional, yours is a three-dimensional brace. Dr. WEISS: Yes, you can easily see that, if you have [noise] if you have a rib hump here, this is… DR. MORAMARCO: Yes. Right thoracic. Yes. Dr. WEISS: Right thoracic.
You push it in front. Dr. MORAMARCO: Correct. Dr. WEISS: And if you see, there is room in front, so this is a de-rotation. We have a ventral rib hump - usually on this side… DR. MORAMARCO: Right.
Dr. WEISS: This works, and squeeze this together backwards and have room backwards here. So this is a de-rotation, in frontal plane of course, you clearly see the shifting of the blocks against each other, but if you look at the brace like this here. Dr.
MORAMARCO: rotation - De-rotation. Dr. WEISS: Room here, and squeeze here. Not squeeze together, it’s just pressure, because every time I apply pressure area here...I need to have room on the opposite. Otherwise, it is only a compression brace and compression braces lead to sores, lead to skin problems and this brace, also correcting much more - they don’t. Dr. MORAMARCO: Okay, We’ve been talking about hard braces.
Now, there are soft braces out there. What’s the big difference between hard bracing and soft bracing? DR. WEISS:[noise] Hard braces, in principle, keep correction and soft braces at the moment are advertised to leave unlimited movement. So, in principle, if we do know, from the first part of our talk, in-brace correction is crucial to the outcome. Dr. MORAMARCO: Correct. Dr.
WEISS: We need something which is resistant. And if you have a brace allowing unlimited freedom of movement, you can even wear a shirt because this also allows unlimited movement. I have been developing a soft brace myself, I don’t call it soft brace, I call it biofeedback device. Dr. MORAMARCO: Biofeedback device. Dr.
WEISS: Because the long term results are not available at this stage, but this biofeedback device at least has been proven to be effective with respect to correction. Dr. WEISS: But, of course it is not as comfortable to wear as a shirt, so if you have correction you have - may have - discomfort - if you don’t have correction, you can wear a shirt. And the other thing is, that scientifically, the dependent studies always show we have very good results, but this was done by the people who were involved in the company and selling the braces themselves. Independent studies, one from my former working group, but also independently from Wong, which is in Hong Kong, comparing hard to soft braces clearly show there is absolutely no advantage of soft bracing, currently, soft bracing to hard bracing. Dr.
MORAMARCO: Another question: now, some adolescents wear a brace just at nighttime, some wear it 20 hours a day some wear it 22, some wear it 18, some wear it 16, just briefly - I know you can go into great detail on this but parents want to know, why do some kids wear it 20 hours and some wear it overnight? DR. WEISS: So nighttime bracing we do in small curvatures of less than 20 degrees and we have 99%, even more, have not experienced that one was getting worse. These are small curvatures in immature patients. Dr. MORAMARCO: Can I ask a question here? So, if you have a patient who is 35º and you have them wearing the brace 20 hours a day and they’ve worn it for a year and a half and then they come in and they are 18º, do you switch them off into a nighttime brace at that point? DR. WEISS: No. If they start with current exceeding 30 degrees I go with 16 hours, at first, and then slowly we go down.
But for a girl who has worn the brace for more than 20 hours a day, 16 hours is very good. But, with our bracing technology, we have the possibility for even 16 hours brace wearing time to stop curvature progression, but this is not what we are aiming at, we are aiming at improvements and I try my best to motivate my patients to wear more than 23 hours, if possible. Some come here and tell me that they wear the brace for 24 hours.
Dr. MORAMARCO: Um, Don’t they take a shower? [laughter] DR. WEISS: No, Don’t take a shower...or shower with the brace on...sometimes..I ask, when do you wash? You know? “Only 10 minutes a day. [laughter] it’s not a problem, usually I only brush my teeth.” DR.
WEISS: But, fun aside...We have more than 90% chance of success with our bracing system. But, I unfortunately, do not have more than 95% of patients who are fully complaint. So with this bracing technology we have learned that also patients wearing only 16 hours, which is quite something, you know, have good results with respect to stop curvature progression. But, when they tell me in the end, see Dr. Weiss, I did not wear my brace full time and I stopped curvature progression, I say, well, you could have been better! But, to come back to nighttime bracing. I repeat myself, for curvatures in immature patients less than 20 degrees, or maybe up to 20º, but of course in the end in the weaning phase we go over nighttime, and for a longer time. And if we start with a curvature of maybe 35 degrees and she ends up below 30 degrees, we can go fast but if we start with curvature exceeding 45 degrees we usually make the weaning phases longer. The last step would be for these patients, maybe one or one and a half years just nighttime, just to keep cosmetic issues as they are.
But, I would not suggest nighttime bracing for the main population with a curvature of 30 degrees, and high risk because there is also - my, not only my theory - it’s also a meta-analysis of Rowe et al. Clearly showing the brace wearing time is of very big importance. And to make a brace which costs quite a bit and to have no result - this is not reasonable. I’m trying to get most of the wearing time possible. Dr. MORAMARCO: In a patient who’s seven-years-old, and they have a very mild curve, and it’s 12 or 14 degrees, and so the patient is a juvenile, and technically they are diagnosed with scoliosis because they are greater than 10º - according to the definition of scoliosis. Do you wait and see until they get just before they hit puberty and consider bracing then, or do you, are you, proactive with bracing? DR. WEISS: In such mild curvatures at that stage, there is not the most important growth spurt [noise] so I leave them alone and it’s a flat phase, you know, before the onset of puberty and in that phase, just observe and tell the patients, maybe you’ll get a bigger curvature in the end, so I prepare them that for the pubertal growth spurt they might have a brace.
Dr. MORAMARCO: I am a Best Practice practitioner, Scoliologic® BestPractice practitioner, and I know - you talk about this also - at 15 degrees adolescent, you do Physiologic®, activities of daily living and you can do some mobilization with the patient. Dr. MORAMARCO: And so we’re proactive with the patient, teaching them simple things to do. For instance, with an ADL - if they have a right thoracic curve - we don’t want this. We teach them how to overcorrect. Dr. WEISS: Yea, that is absolutely true.
Dr. MORAMARCO: So there are some things a patient can do at that mild curve. Dr. WEISS: In this case you do not need the full Schroth program. [right] It’s very important you can use from Best Practice only the smaller, smaller modules of physical therapy.
Dr. MORAMARCO: Exactly. I agree.
Dr. MORAMARCO: Now, I have to ask you, this is quite a brace here. Have you seen this? DR. WEISS: [laughing] It’s the American flag on it. Dr. MORAMARCO: It’s an American flag.
And this is my first brace that I made, today. Just feel that, just feel the edges. How do they feel, Pretty good? DR. WEISS: Well. Yes. The edges here… DR. MORAMARCO: yeah…[laughing] DR.
WEISS: It could be better. Hmm, but it would be wearable. So, this is the brace from a foam of an Italian patient, a little boy, who was operated on for, for congenital scoliosis and getting worse after operation. I had a problem, I first did not make the full correction because operation, you know, may fail, so he increased in my first brace a bit and had not very good in brace correction, but, the second brace [cough] I dared to make a full correction and right now he had a very good in-brace correction and he is four or five years. He’s still in the growing phase, until six, but right now I think he is doing well. This was a special case because if operated [pause] full correction can be dangerous, so we had to try first half year with a semi-corrective brace.
Dr. MORAMARCO: So, last question. Dr. WEISS: Last question. Finally. Dr.
MORAMARCO: There are different braces out there and I’ve had patients who have been in a Chêneau brace and patients who have been in another brace previous to a Chêneau and they tell me that the Chêneau brace feels more comfortable. And so, do you want to shed some light on that. Why is the Chêneau more comfortable, Gensingen Cheneau, why is that more comfortable as opposed to other braces? DR.
WEISS: Well, the general Chêneau brace should be comfortable because automatically you have opposite of the pressure areas - repeat myself - DR. MORAMARCO: That’s good. Dr. WEISS: Opposite of the pressure areas you have voids, to fill in, where the body can move to.
And this not only applies to the lateral deviation, this also applies in frontal, and sagittal plane. So, there are multiple three point pressure systems built in the Chêneau system, original Chêneau. And, our braces today are the most comfortable ones, it is not because I make them, but because when I have in certain pattern, maybe this one, a certain pattern, I had some problem. We solve the problem easily, and next patient comes with same pattern, gets same brace, because it is the same standard, has same problem. So I say, okay, this is a general problem with the brace. So, I relieve the problem here, and the next generation has this problem no more.
And this is why you have high correction and highest comfort at the same time. It is not a compression effect. Some surgeons have told me you make aggressive bracing. We make the least aggressive bracing because we do not torture our patients compared to squeezing together, adding pads, and no room. You squeeze together, you cannot breathe, having pressure sores and everything. And, from my conservative point of view, I would say aggressive is the surgery and not bracing.
Dr. MORAMARCO: Well, that concludes this interview with Dr., Dr. Weiss. [pause] Danke. Dankeschön. Dr.
WEISS: Dankeschön. [laughter].
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