Definition/Description
Milwaukee brace
The Milwaukee brace is an active corrective spinal orthosis. It consists of a neck ring with a throat mold and two bolsters to avoid high pressure on the neck. Other elements include plastic pelvic girdle, aluminum uprights, leather L-shaped chest pad and front and rear metal bars return. [1][2]
Indication for use
The Milwaukee brace is used to treat postural disorders such as idiopathic scoliosis or Scheuerman’s disease.
Braces are often used in children with postural disorders who have not yet reached their growth spurt or are in a period of rapid growth. It is not for use in adults or adolescents who have passed their growth spurt because it will have no effects. [3]
It is especially recommended in cases of fear of exacerbation during the adolescent growth spurt. Spinal curvature with a Cobb angle between 20° and 40° indicates the need for a brace. [1]
At this Cobb angle interval, the patient’s curve remains under observation. Beyond this interval, the surgeon will intervene rather than wear a brace. [4]
Principle and technique of the brace
The brace consists of a pelvic corset chest pad neck ring and rib pressure pads.
- The pelvic corset fits snugly around the iliac crest around the waist and curves up in the front direction to support the abdomen. It is cut lower on the sides to avoid stress on the costal margins. It also keeps the pelvis in a retroverted position, reducing lumbar lordosis (excessive lumbar Lordosis is common in patients with scoliosis).
- Metal bars are attached to the leather pelvic corset to form a base from which a front metal upright and two rear metal uprights pass up through the ring around the neck. The ring is inclined at 20 degrees from the horizontal. Uprights are adjustable to accommodate growth.
- The throat cast is placed just below the chin. If it fits well, it won’t touch the mandible. Its purpose is to remind the patient to retract the chin and keep the head back on the occiput pad. The pelvic girdle and throat work together to center the head pelvis.
- Rib rotation is corrected by pressure pads located on the rib protrusions. The pressure pad is secured to a heavy, wide belt secured to the uprights at the desired level by bolt fasteners. The belt goes over the rear bar on the convex side so that Pressure is applied directly from the sides. [5][1]
[6]
Milwaukee Bolster Pressure Measurement
The interfacial forces of the four pads were measured in 73 roundback patients (mean age 14.04±1.97 years [range 10–18]; mean initial Cobb angle 67.70°±9.23° [range 50°–86°]). Modified aneroid sphygmomanometer for shoulder and Kyphosis pad pressure. Each patient was measured standing and sitting during inspiration/expiration. [7]
Aims of the brace
The Milwaukee brace is used in the conservative treatment of postural disorders.
Its purpose is to keep the body upright and prevent progression of the curvature as the patient grows and waits for possible surgical intervention. [2]
The goals of conservative treatment for scoliosis are to:
- To stop curve progression at puberty[4]
- Prevention or treatment of respiratory dysfunction [4]
- Prevent or treat spinal pain[4]
- Improve aesthetics[4]
It is important to note that not everyone receives lasting discipline. It is possible that the brace works well when the patient is braced but if the patient stops wearing the brace the curve may return to its original state. [2] .
BRACE PROGRAM
It is recommended that the Milwaukee brace be worn 23 hours a day.[8] The hour the child is out of the brace should be used for exercise. Studies have shown this program to be effective for conservative treatment of adolescent idiopathic scoliosis.[2][1]
It is important to check and change the brace regularly as the child grows and curve correction progresses. The activity ceases with bone maturation and if the curve is initiated. A gradual approach to releasing the brace system should be developed and followed take care. If there is a sign that if the curve deteriorates the patient should wear the brace again as before.[1]
Activities and exercise are recommended and possible with the brace. Sports are also recommended but the patient should avoid contact sports where the brace can injure opponents.
This system has been shown to have mental and body image data on the patients.[9] Some patients wear their braces much less than recommended: instead of 23 hours a day, they wear them for 15.[8][10][2]
Physical Therapy Management
Movement activities and promotion of sports should be an important part of physical activity. A holistic approach should be taken and not just focused on scoliosis management.[11]
Physiotherapy aims:
- Maintain flexibility[12]
- Self correcting posture[4]
- Stabilising the correct posture[4]
- Patient education[4]
- Activities of daily living training [4]
Exercise can include:
- Stretches and flexibility
- Specifically strengthens the trunk and core muscles
- Posture management and retraining[13]
- Spinal stabilisation exercises[14]
Regular exercise and postural retraining interventions by a physical therapist can have a positive psychological impact on people with scoliosis. [13] Regular physical therapy has also been shown to reduce pain scores compared to a home exercise program alone. [14]
Exercise and brace use had positive outcomes in terms of functional pain and reduced surgical rates. [15] Specific exercises for the Milwaukee brace can be used, but they follow similar principles to the exercises above. [16]
Manual therapy, such as gentle movement combined with stabilization exercises, can be used. [17] However there is; no good evidence to support manual therapy as an independent conservative treatment for scoliosis. [18]
Resources
2016 Scoliosis rehab guidelines
Clinical Bottom Line
In the long-term, scoliosis patients had a similar quality of life compared with surgical treatment, but reported more pain in patients wearing braces. [10] After treatment with the Milwaukee brace, adult scoliosis patients had more problems with body image and emotional well-being than Have pain or function (compared with the surgery group). [9]
Despite this support (Milwaukee or otherwise) is still the recommended conservative treatment for scoliosis. Combined with physical therapy it has been shown to reduce pain, improve function and reduce Cobb’s angle in patients. [4]
References
- ↑ Jump up to:1.0 1.1 1.2 1.3 1.4 Milwaukee brace non-operative treatment for scoliosis; Agnes Chow; Journal of the Hong-Kong physiotherapy association; 1978; Volume 2; p26-32 (A1)
- ↑ Jump up to:2.0 2.1 2.2 2.3 2.4 Maruyama T, Takeshita K, Kitagawa T. Milwaukee brace today. Disability and Rehabilitation: Assistive Technology. 2008 Jan 1;3(3):136-8.
- ↑ Postural Disorders and Musculoskeletal Dysfunction. Gill Solberg; Vardita Gur; Eli Adar. Churchill Livingstone Elsevier; 2005. (book)
- ↑ Jump up to:4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 Negrini S, Donzelli S, Aulisa AG, Czaprowski D, Schreiber S, de Mauroy JC, Diers H, Grivas TB, Knott P, Kotwicki T, Lebel A. 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis and spinal disorders. 2018 Dec;13(1):3.
- ↑ John D.M Stewart, Jeffrey P. Hallett, Traction and Orthopaedic Appliances; B.I.Churchill Livingstone New Delhi, Second Edition; Spinal Orthosis, Milwaukee brace; Page No.141.
- ↑ Braced Life. Ada Milwaukee Brace Fitting. Available from: https://www.youtube.com/watch?v=J5GD3CMe4Gc [Last accessed 07/04/2017]
- ↑ Measurement of Milwaukee Brace Pad Pressure in Adolescent Round Back Deformity Treatment. Taher Babaee,Mojtaba Kamyab, Amir Ahmadi, Mohammad Ali Sanjari, and Mohammad Saleh Ganjavian. Published online 2017 Aug 7. doi: 10.4184/asj.2017.11.4.627.Asian Spine Journal.PMC.NCBI
- ↑ Jump up to:8.0 8.1 Maruyama T, Takesita K, Kitagawa T, Nakao Y. Milwaukee brace. Physiotherapy theory and practice. 2011 Jan 1;27(1):43-6.
- ↑ Jump up to:9.0 9.1 Misterska E, Głowacki J, Głowacki M, Okręt A. Long-term effects of conservative treatment of Milwaukee brace on body image and mental health of patients with idiopathic scoliosis. PloS one. 2018 Feb 23;13(2):e0193447.
- ↑ Jump up to:10.0 10.1 Andersen MO, Christensen SB, Thomsen K. Outcome at 10 years after treatment for adolescent idiopathic scoliosis. Spine. 2006 Feb 1;31(3):350-4.
- ↑ de Mauroy JC, Lecante C, Barral F. ” Brace Technology” Thematic Series-The Lyon approach to the conservative treatment of scoliosis. Scoliosis. 2011 Dec;6(1):4.
- ↑ Weiss HR, Negrini S, Hawes MC, Rigo M, Kotwicki T, Grivas TB, Maruyama T. Physical exercises in the treatment of idiopathic scoliosis at risk of brace treatment–SOSORT consensus paper 2005. Scoliosis. 2006 Dec;1(1):6.
- ↑ Jump up to:13.0 13.1 Choi J, Kim HS, Kim GS, Lee H, Jeon HS, Chung KM. Posture management program based on theory of planned behavior for adolescents with mild idiopathic scoliosis. Asian nursing research. 2013 Sep 1;7(3):120-7.
- ↑ Jump up to:14.0 14.1 Zapata KA, Wang-Price SS, Sucato DJ, Thompson M, Trudelle-Jackson E, Lovelace-Chandler V. Spinal stabilization exercise effectiveness for low back pain in adolescent idiopathic scoliosis: a randomized trial. Pediatric Physical Therapy. 2015;27(4):396-402.
- ↑ Negrini S, Grivas TB, Kotwicki T, Rigo M, Zaina F. Guidelines on” Standards of management of idiopathic scoliosis with corrective braces in everyday clinics and in clinical research”: SOSORT Consensus 2008. Scoliosis. 2009 Dec;4(1):2.
- ↑ Maruyama T, Takeshita K, Kitagawa T. Side-shift exercise and hitch exercise. Studies in health technology and informatics. 2008;135:246-9.
- ↑ Morningstar MW, Woggon D, Lawrence G. Scoliosis treatment using a combination of manipulative and rehabilitative therapy: a retrospective case series. BMC Musculoskeletal Disorders. 2004 Dec;5(1):32.
- ↑ Romano M, Negrini S. Manual therapy as a conservative treatment for adolescent idiopathic scoliosis: a systematic review. Scoliosis. 2008 Dec;3(1):2.
