1. Are there any specific physio/exercise regimes we need to ask for when referring to Physio?
There are some specific/ recommended regimes endorsed by Boston Brace however generally the Physiotherapist attached to the clinic will manage the patient’s requirements as clinically indicated.


2. What would be the advantages of using hand/wrist x-rays, to judge skeletal maturity, versus Risser sign method?        
It gives an accurate assessment of the skeletal age of the child rather than the chronological age. It is compared to charts so can give an estimate of how much growing there is left. So, if the skeletal age is older than the chronological age it suggests that there is less growing left than the chronological age suggests. Also vice versa. not used often as it is another bout of ionising radiation.


3. What are views on night bracing vs full time wear?
Night bracing is used for those patients who are only willing to wear a brace part time. However, there has not yet been a study to compare the effects of night bracing with full time bracing so comparisons cannot be made about which is the most effective.


4. We don’t have a dedicated Physio for our Scoliosis clinic, but I can see how important having them on board is. When completing referrals for your patients, is there anything in particular that you ask for?
It's unfortunate that you don't have a dedicated physio in the scoliosis clinic. However, if there are paediatric physios with a special interest in spines then you could ask for a referral to be made to them. As exercise is the expertise of the physiotherapists, I would hesitate in offering my opinions on which exercises to do other than those already recommended by Allard (Boston Brace).

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5. What are your thoughts on the use of Lycra Scoliosis Suits for management of early neuromuscular scoliosis? Are they effective? for who? and what degree of curve ?
Lycra garments have been used more frequently in recent years to achieve some degree of curve correction. It’s a complex topic and at Allard we do have our own range of Lycra garments (Elements Body) and would be happy to discuss this topic further directly with you. Please email customerservice@allarduk.co.uk. 
Gordon also reported clinically that he started using Lycra in the late 1990s and at the same time did three casting sessions a year to make braces for NM curves. He stopped doing them about 2 to 3 years afterwards. However, there has never been any audit to say that the use of the lycra was the reason for this. All he can say is that Lycra is extremely useful in improving the seating posture of children with such curves. The best results are when the child, any curve and tone is small. Teenagers with height tone and very poor posture will be difficult to correct with Lycra.

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6. Is it common that the vertebral hump is in the same direction as the vertebral rotation?
That is correct. A right loin or rib hump is so far, without exception comes with a right lateral deviation in AIS.

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7. Gordon tended to refer to typical patients as girls, is Idiopathic Scoliosis more common in girls?
Yes, Adolescent Idiopathic Scoliosis is much more prevalent in females as opposed to males. There have been several theories as to why it affects girls more than boys including that society is more accepting of boys with some deformities. But it is true that AIS generally affects girls more than boys to a ratio of between 4:1 and up to 10:1 depending on which study is looked at. In ages 0-5yrs, it is much more even.

8. Any suggestion on software to help with generating a blueprint?
There are no software packages available to produce the Boston Brace Blueprint. The process is unique and repeatable and produces an individual design that allows an asymmetric patient to fit into a corrective symmetrical brace.

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9. With a left lumbar curve, with a trochanter extension, could you end up counteracting the lower counter corrective force on the 3-point force system?
A left lumbar curve should have the trochanter extension on the left side when L5 is also tilted into the curve. The extension helps push the crest roll into the waist and so exert a corrective force to centre the lumbar spine. If the curve is decompensated to the right already (head off to the right of the centre line), then you might run the risk of pushing the head further out beyond the centreline in which case you might want to add a thoracic extension as well. This would be called a thoracolumbar brace.

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10. When ordering a brace to measurement, what would you recommend for tension when taking the hip circ / width?
Hip and Chest circumference measurement should be taken snug. The waist measurement should be taken very tight.

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11. Are there any considerations on the medial/lateral position of the thoracic pad? I have seen some thoracic pads very lateral and some which are much closer to the midline?
Boston used to advocate the thoracic pads extending onto the posterior of the brace but not as far as the midline. However, they found that rather than decreasing the rotation, the forward acting force tended to encourage a hypokyphosis in the thorax. Rotation is quite often very stiff and doesn't readily respond to direct force. However, by reducing the lateral deviation, the rotation is often reduced as well.

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12. I have seen some orthotists who are working with plaster modifications rather than computer systems, to reduce more materials from pad locations on the plaster meld. I do not know how much is correct, but the point is that they are saying is to avoid pads. Do you have any idea on that?
There are bracing systems that do indeed modify the plaster moulds in order to external the corrective forces. The Cheneau brace is such an example. They also build up the cast equally large to give the voids needed to allow for translation of the spine. The braces are still lined so they are not 'without' any padding, it's just their way of making their braces asymmetrical opposite to the scoliosis asymmetry.  

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13. Can the Boston Brace be used for Neuromuscular Scoliosis or only for scoliosis in typically developing children?
The Boston Brace is typically used in the treatment of AIS, as opposed to treating neuromuscular. Those children with underlying neuromuscular conditions are generally not able to tolerate a rigid polypropylene brace. Often there are also comorbidities such as poor breathing and difficulties with feeding such as reflux. However, some can tolerate rigid braces, but they are more the exception. Boston soft braces or even lycra are good alternatives to consider in these cases.

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14. For a lumbar curve, would you ever consider removing more material above the iliac crest on the side the corrective pad is placed, to assist with your corrective force?
Yes, I have considered this in the past and I will consider doing it again but what I have learned is that the lumbar spine needs to be very flexible for it to be acceptably comfortable. If not flexible enough, it just causes too much pressure on the convexity to be tolerated.

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15. Is this something supplied via the NHS? If going through private, what is the cost?
Allard UK do not provide any direct clinical services. The brace is most widely supplied through the NHS. However, there are some private orthotic companies that can provide this treatment for AIS, but we would have no information as to costs associated with that. 

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16. Do you have blueprints for single major left lumbar curve - apex L2 with head decompensation on the left?                       
The blueprint is an individual design for each brace and so all curve types and magnitudes etc. will have their own individual blueprint.

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17. If we ask Children to do hanging on the monkey bar as an exercise, to stretch and do traction of the curve, is that helpful?
There may well be some traction advantage to that but as an exercise I am not sure of its benefits. I would consult a spinal specialist physio for that. My thoughts are that the shoulder musculature that would be used to hold the body in place extends down to the lower spine (Latissimus dorsi) and might counteract the traction advantage. Holding them by the upper chest will remove this muscular effort but would be difficult to do for any length of time. I suspect that using a halter could cause cervical issues rather than solve lower spine position and wouldn't recommend it.

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18. On the lateral trimlines, would you follow rib slope?
Yes, where we have a thoracic extension, we follow the line of the rib that corresponds to the vertebra at the apex of the thoracic curve.

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19. What is the incidence of AIS between girls and boys?
At the adolescent stage, then is approx. 80% - 20% in favour of females >ALSO see question 7.

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20. How often to use the brace after skeletal maturity? what is the weaning out timeline?
In some respects, it is almost the reverse of weaning in but instead of gradually wearing it less during the day, first thing is to stop wearing it at night. Then it's use during the day can be reduced as gradually as comfort will allow. There may be some aches as the body adjust to its unbraced position and the muscles having to work harder.

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21. What evidence is there to suggest taking the brace off 24 hrs before an out of brace x-ray is good practice?
As far as I am aware there is no evidence. However, I feel that to take a brace off then immediately x-ray someone you will not allow the spine to 'relax' into its natural scoliotic position. 24hours seems reasonable. To be sure how long would be best, you would need scoliosis x-rays being taken regularly over a period until the curves stopped changing. That would be a lot of high doses of radiation for an academic exercise. I don't think ethics committees would allow this!

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22. Why would you want them to wear the brace during sleep, when gravity has no effect on their posture?
True, the effects of gravity are reduced when lying down, but the shape of the spine and growth remain constant factors.

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23. At follow-up, complains the brace is too loose, any solutions? Do you change the pads as the curve progresses?
If the brace is too loose at any follow up, then the likely hood is that weight might have been lost. If so, then another brace is indicated to new measures. The new measures can be checked against the originals to see any differences.

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24. Would you add an anterior dog ear trim above the breast line on a brace where you wanted a counter rotational force for a high thoracis curve?
This is an interesting question as it has not been posed before. I assume this would be to come above the breast tissue in the diagonally opposite region of the rib hump. So, for a right rib hump the 'dog ear' extension would be on the left front. There are braces that do indeed have such shapes, but the Boston modules are not designed for this and the system doesn't incorporate it either.

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25. In absence of physio in the team, are there any competencies available for the orthotist to coach the patient in stretching/mobility of the spine?
Please refer to questions 1 & 4.

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26. Did you say that the pads are delivered lose at the first fitting stage?
That is correct, they are delivered loose as this allows for any brace trimming that might be needed to get the anatomical fit as comfortable as possible. Pads are then secured after the trimming.

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27. How do you accommodate young girls changing bodies with these braces? and what kind of underwear can they use?
Accommodating any breast development is important as it is a further 'niggle' that might reduce compliance. They already look asymmetrical and so we don’t want to give them more of an asymmetrical look. It can also be tender as the breasts developed. As for underwear, most wear their normal underwear, but some do get underwear to wear over the braces.

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28. When you talked about swimming, could you please clarify if you meant that the children swim without the brace and it still counts as if they were wearing one, or do they swim with their braces?
They can swim without their brace and it counts as if they were in their brace as the water is supporting them.

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29. What is the experience with children whose compliance cannot be relied upon, because of their mental age or associated behavioural issues?
This is very much down to the individual patient and their families. My experience is that some just get on with it and others fight every time an attempt is made to don the brace. If they cannot wear it for the recommended time, then it really serious consideration to discontinue bracing should be undertaken. The statistics show that 1 in three braces fail and that can be one of the reasons.

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30. If there is not enough space for the crest roll, maybe on one side more than the other, what would be done ?.
This would mean that the lower ribs are very low which would suggest the curve is quite large and possibly outside the parameters of bracing. If not, then the deviation from the centre would be very large. If the spine is flexible enough then hopefully space will be achieved when the brace is donned improving the alignment and reducing the lateral deviation. However, if not flexible enough then the brace would be too uncomfortable to wear.

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31. When taking the width measurements, are we wanting to make the waist measurements very very tight, like the circumference measurement?
Yes, as this gives the technicians the correct shape of the waist, i.e. circular or more oval. Too circular a brace for an oval waist shape will make the crest rolls too narrow for comfort.

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32. I either hand cast or scan for Boston Braces, unfortunately I don’t have access to traction/de-rotation. Would you advise allowing for elongation of the spine with my pad placement?
This is not part of the Boston Brace System for brace manufacture. You could indeed allow for this bit you would have to check on the in-brace x-ray to see how accurate you have been. In my experience, this has been not necessary.

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33. Does it make it easier for your team to fabricate a brace if they had a spinal cast of the patient?
This can be beneficial in the case where the patient is quite asymmetrical, but otherwise, a cast is not necessary.

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34. I assume that you are aware of the trail to look at full time versus part time bracing. The trial incudes the use of monitors to be fitted to the braces. Are you able to add these monitors to the brace? and are you involved in the study?
Yes, we are aware of the study and we are in the process of being accepted into the study. There is no issue with adding the monitors to the Boston Night Brace. At present some of our customers use compliance monitors to assess for how long and at what part of the day the brace is worn. Depending on the type of monitor we can create a pocket to hold the sensor in the brace. This is done by placing a dummy sensor onto the mould during the fabrication process. When the customer receives the brace, they will place the actual monitor into the pocket created by the dummy in the brace.

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35. Should the measurements for the night brace be done lying down?
All measurements for the Boston Night Brace need to be taken whilst the patient is standing.

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36. What material is the Soft Boston Brace made out off?
The Soft Boston Body Jacket is manufactured from 3mm firm polyethylene foam outside and 4.5mm soft polyethylene foam inner lining. This is both lightweight, flexible and easy to trim.

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37. With regards to the Night Brace, would there be a preferred position for sleeping ?
The Boston Night brace holds the patient in an overcorrected position, so the position that they lie in is simply a matter of individual choice.

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38. Would you advocate including an abdominal window in a Boston Brace for a patient that is struggling with breathlessness at times if the patient has a high thoracic curve?
Not usually as the reduction of the intra-abdominal pressure will lessen the effect of propping up the spine from the distal region. Making sure the window is big enough would be my first thought but if properly breathless then it could be worth a try to get them to wear something rather than exclude them from bracing. Otherwise it would be classed as a contraindication.

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