Development of the Charleston Bending Brace™
Side Bending Theory
The factors contributing to the success of time-modified side bending are unclear. Stretching the concavity and possibly a physiological contracture on the convexity of the curvature appears to play a role. Visuospatial impairment, EEG, and learning deficit disorders have all been identified in patients with scoliosis. Vestibular, cerebella and posterior column function may be challenged by re-orientation of body position. In theory, bending of the spinal column should add tensile and opposite compression forces to the vertebral epiphyses compared with forces at work in the upright posture. The benefits of uncompromised postural muscle tone during upright activities and the opportunity for the patient to remain athletically active during their brace treatment may enhance the phenomenon of spontaneous curve correction that occurs on a day-to-night basis.
All bracing systems depend on the nocturnal wear component as part of their programs. There are no harmful physiological, biomechanical, or clinical effects noted in the nocturnal wear program. With documented successful outcomes, the positive aspects of the Charleston Bending Brace™ system are evident even if the reasons for a success are not entirely clear.
The History of Side Bending as a Scoliosis Treatment
Non-operative treatment of scoliosis has a long and diverse history. The method of side bending as an orthotic treatment, while having such a lengthy past, has been a durable technique that remains in use today.
The Kalibis splint, also called the “spiral bandage”, was one of the earliest reported orthosis for scoliosis treatment found in the medical literature. Several braces designed in the nineteenth century by German orthotists Heine, Hessing, and Hoffa bear remarkable similarities to later designs by Barr-Buschenfeldt. Probably the most successful and widely accepted side bending device was the Risser turnbuckle cast, reported in the United States in 1931 by Hibbs, Risser and Ferguson. During the 1970s Lawrence Brown, M.D., of Greenville, South Carolina, utilized a bending brace in a full-time wear program. (Fig. 1)
Side bending orthosis are found throughout historical medical literature; bearing out the fact that, while subject to hardware development, the method of side bending is an effective technique for scoliosis treatment.a technique with a past, as well as a future.
Early Development of the Charleston Bending Brace™
C. Ralph Hooper Jr., C.P.O. and Frederick E. Reed, M.D. of Charleston, South Carolina, collaborated on the early development of a new side bending orthosis for nocturnal wear. This new brace was first fabricated in 1978 in Charleston for treatment of adolescent idiopathic scoliosis. Originally the new orthosis was used to treat patients in which other types of orthotic management had failed; patients who continued to show progressive curvatures, but whose skeletal maturity obviated full-time brace wear, and patients who had refused other treatment options. In these cases, time-modified brace wear seemed preferable to complete non-compliance, for obvious reasons.
In 1984 an investigational team was formed to study lateral bending time-modified brace wear. Team members included: Frederick Reed, M.D. of Charleston, South Carolina; Ralph Hooper, Jr. of Winter Park, Florida; Max F. Riddick, M.D. of Winter Park, Florida; and Charles T. Price, M.D. of Orlando, Florida.
Since 1984, there have been over 15 research articles published regarding the results of patients using the Charleston Bending Brace™ for the treatment of adolescent idiopathic scoliosis. Dr. Charles T. Price continues to be the lead investigator and research physician for scientific studies related to the Charleston Bending Brace™.
Guidelines for Use
Single curves are the easiest curves to treat with side bending because inadvertently increasing a secondary curve through bracing is not a concern. The single curve can be aggressively reduced in the CBB. Patients with single curves are considered the best candidates for treatment with the greatest likelihood of positive outcomes.
Treating double curves with the CBB is considered an advanced technique. Double curves respond well when treated correctly but a high level of expertise and care are required in the measuring and fitting processes. It is important to designate the primary and secondary curves beforehand when bracing double curves in the CBB. The primary curve is always the curve that indicates the direction to bend the patient.
Curvatures of 25 degrees to 40 degrees fall within standard orthotic treatment guidelines. There are no contraindications recognized for treating curves outside these parameters due to the high level of patient acceptance of the CBB program and many documented successful courses.
Concurrently, standard orthotic management of scoliosis calls for treatment of only skeletally immature curves. Some skeletally mature patients have benefited from CBB treatment. This is also reflected in the reporting.
A clinical examination is always conducted by the orthotist prior to the casting session. Patient flexibility can be assessed and a reasonable prediction of in-brace results may be determined from the clinical exam. This is also a good time to gauge the patient’s tolerance level and take appropriate action to alleviate fears and anxieties in order to help the procedure go smoothly.
Forward Bending – Have the patient stand facing away from you with weight equally distributed on both feet. With arms extended and palms together, bend the patient forward to 90 degrees and stop. Observe and note trunk rotation. Ask the patient to try and touch the floor to evaluate hamstring tightness.
Have the patient stand upright and then bend laterally at the waist. Note how much range the patient has. Now place your hand at the apex of the curvature. Ask the patient to bend laterally a second time. Apply resistive force at the apex. This is to determine relative flexibility or stiffness.
The Charleston Bending Brace™ Objectives
The goals of theCharleston Bending Brace™ program are to maintain the patient’s scoliotic curvatures at, or near, pre-brace values throughout the growth period and on to skeletal maturity. Other goals are to promote better brace wear compliance through the nocturnal wear aspect. This component alone may reduce patient and family conflict, while helping to eliminate negative self-image problems associated with brace wear in adolescents.
The Advantages of the CBB Program
There are several distinct advantages to the Charleston Bending Brace™ program, nearly all of which are related to the nightwear component:
- Allows full, unrestricted musculoskeletal development.
- Allows opportunity for athletic participation, if desired.
- Causes fewer and less severe complications.
- Delayed complications are negligible, since brace is worn less time than not.
- Results can be assessed without the customary long-term follow-up.
- Decision-making regarding success or failure of the program can be made earlier.
Non-Surgical, Nighttime, Scoliosis Management
The Charleston Bending Brace™ has been the benchmark for non-surgical, nighttime, scoliosis management for more than 35 years.
CBB clinical outcomes are guided by three principles:
- Growth Modulation (unbending). The rate of the epiphyseal growth plate is affected by pressure applied to its axes. An area of increased pressure inhibits growth and an area of decreased pressure accelerates growth.
- In Brace Correction: The amount of in brace correction is a predictor of long-term outcome of the treatment. CBB principles overcorrect a spinal curve in accordance with the spine flexibility.
- Patient Compliance: Patient comfort and compliance is promoted through nocturnal wear.