Learning curve in 20 years of brace treatment F. Landauer

Learning curve in 20 years of brace treatment F. Landauer University Clinic of Orthopedics (PMU) Salzburg General Hospital Muellner Hauptstr. 48, 5020 Salzburg Austria

Purpose Objectification of his own learning curve in brace treatment Design: Retrospective case study of adolescent scolosis Methods: I compared a group of 100 outpatients treated 20 years ago with a further group of 100 outpatients treated recently. The brace indication depends on the SOSORT-criteria. Cobb angle was measured before treatment, primary correction and follow up >1 years after weaning of the brace. Compliance was estimated by our own compliance score (Lit. 1). All braces are made by one orthotist. Paracelsus Medizinische Privatuniversität / SOSORT-Scientific-2014-Wiesbaden / 20 years of experience / F. Landauer 2

First presentation Cobb angle Range: 20-56 20-46 Risser < II New facts Schoolscreening becomes better. But there are some poor results. Paracelsus Medizinische Privatuniversität / SOSORT-Scientific-2014-Wiesbaden / 20 years of experience / F. Landauer 3

First presentation Cobb angle Range: 20-56 20-46 Risser < II New facts Pretreatement 8% without any orthopaedic examiation. Refuse bracing 10% Paracelsus Medizinische Privatuniversität / SOSORT-Scientific-2014-Wiesbaden / 20 years of experience / F. Landauer 4

First presentation Cobb angle Range: 20-56 20-46 Risser < II n- 84 New facts Non idiopathic 6% MRI is available A generous indication of MRI rises the number of non idiopathic scoliosis Paracelsus Medizinische Privatuniversität / SOSORT-Scientific-2014-Wiesbaden / 20 years of experience / F. Landauer 5

Primary correction Cobb angle Primary correction becomes better Facts 20 to 16 inaccuracy of measurement Not significant Paracelsus Medizinische Privatuniversität / SOSORT-Scientific-2014-Wiesbaden / 20 years of experience / F. Landauer 6

Primary correction Primary correction becomes better % of correction New facts Selection Handcraft? Differentiation? Cobb angle at brace indication Influenced by the indication: idiopathic / non idiopathic scoliosis Paracelsus Medizinische Privatuniversität / SOSORT-Scientific-2014-Wiesbaden / 20 years of experience / F. Landauer 7

Bracing Brace wearing-time per day: Requirement as fulltime bracing : 20 years ago 23 hours current max. 20 hours My personal experience and rules: 20 hours is realistic (measured with a sensor) scoliosis remains flexible 4 hours for sports and free movement Paracelsus Medizinische Privatuniversität / SOSORT-Scientific-2014-Wiesbaden / 20 years of experience / F. Landauer 8

Compliance GOOD compliance interview of patients regular examination in the OPD (clinical control every three month s and x-ray every six month s) signs of brace wear skin reaction The compliance is unchanged over 20 years of treatment The arrangement are modulatd by the patients: But now: approximately 10% refuse bracing or don t accept fulltime bracing Patient communicate their dicission This data are still without sensor-measurement BAD compliance irregular bracing therapy break (>three month s) irregular control

Who is responsible for? Medical doctor: Indication, diagnostics, control, compliance, etc Physiotherapist: Quality of the training program, compliance, etc Orthotist: Relatives: Patient: Quality of the brace, compliance Well beeing, compliance Compliance Compliance is the connecting buzzle. Communication is the important factor for success! Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Factors success and failure / F. Landauer 10

Follow up Cobb angle Follow up: 28 23 inaccuracy of measurement n- 86 Paracelsus Medizinische Privatuniversität / SOSORT-Scientific-2014-Wiesbaden / 20 years of experience / F. Landauer 11

Follow up Cobb angle Follow up: 28 23 inaccuracy of measurement n- 86 Progression > 50 : 12% 3% Influenced by: Diagnostics Bracing Paracelsus Medizinische Privatuniversität / SOSORT-Scientific-2014-Wiesbaden / 20 years of experience / F. Landauer 12

Summary Now scoliosis is diagnosed earlier, but the number of unskilled pretreatment and rejection of treatment increases. Improvement of diagnostic: lowers the number of idiopathic scoliosis (MRI, genetics, etc.). Bracing becomes more effective: in primary correction and at follow up despite of a lower wearing time per day. Compliance: We could not influence compliance significantly. We adapted bracing to a realistic treatment concept. Paracelsus Medizinische Privatuniversität / SOSORT-Scientific-2014-Wiesbaden / 20 years of experience / F. Landauer 13

Conclusion Patients increasingly influence therapeutic regime. Part time bracing becomes the main option in outpatient treatment (<20 hours). There is still potential to improve brace-management. In outpatient treatment compliance of the staff seems to be a problem. To many different statements! An experienced orthopedic technician leads to a good standard, but it lacks on comparison and competition. The endresult did not become much better, but with less treatment! Consequences: My peronal focus changed from the bracing to the diagnostics. I have to tighten the bracing. I have to tighten the organization of the outpatient management. Paracelsus Medizinische Privatuniversität / SOSORT-Scientific-2014-Wiesbaden / 20 years of experience / F. Landauer 14

Literatur Hans-Rudolf Weiss, Stefano Negrini, Manuel Rigo, Tomasz Kotwicki, Martha C Hawes, Theodoros B Grivas, Toru Maruyama, Franz Landauer (SOSORT guideline committee) Indications for conservative management of scoliosis (guidelines) SOSORT consensus meeting in Milan in January 2005. Ladauer F, Wimer C, Behensky H. Estimating the final outcome of brace treatment for idiopathic thoracic scoliosis at 6-month follow-up. Pediatr Rehabil. 2003 Jul-Dec;6(3-4):201-7. Paracelsus Medizinische Privatuniversität / SOSORT-Scientific-2014-Wiesbaden / 20 years of experience / F. Landauer 15

Paracelsus Medizinische Privatuniversität / SOSORT-Scientific-2014-Wiesbaden / 20 years of experience / F. Landauer 16

Primary correction Primary correction becomes better % of correction New facts Selection Handcraft? Differentiation? Cobb angle at brace indication Influenced by a better differentiation: idiopathic / non idiopathic scoliosis Paracelsus Medizinische Privatuniversität / SOSORT-Scientific-2014-Wiesbaden / 20 years of experience / F. Landauer 17

Feasibility of diagnosis Early onset scoliosis Adolescent Adult scoliosis gray zone % gray zone Age Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 18

20 years of experience Cobb angle Paracelsus Medizinische Privatuniversität / SOSORT-Scientific-2014-Wiesbaden / 20 years of experience / F. Landauer 19

Primary correction % of correction Cobb angle at brace indication 30 ±1 90 and Risser 0 Primary n-10± correction 80 becomes better 70 60 50 40 30 20 10 New facts Selection Handcraft? Differentiation? 0 30 20 years ago current Patient start brace earlier: age 11y6m to 11y1m Paracelsus Medizinische Privatuniversität / SOSORT-Scientific-2014-Wiesbaden / 20 years of experience / F. Landauer 20

First presentation Cobb angle Range: 20-56 20-46 Risser < II New facts Pretreatement 8% without any orthopaedic examiation. Refuse bracing 10% Paracelsus Medizinische Privatuniversität / SOSORT-Scientific-2014-Wiesbaden / 20 years of experience / F. Landauer 21

Paracelsus Medizinische Privatuniversität / SOSORT-Scientific-2014-Wiesbaden / 20 years of experience / F. Landauer 22