**Abstract**

The bracing indication for adults with spinal deformities is two-fold: (1) pain and (2) deformity. Although pain is more frequent in the adult population with scoliosis, there is no correlation between the angle of curvature and pain intensity. Pain is reportedly more frequent in patients who were operated. Non-specific pain can successfully be treated with stabilisation exercises; however, some patients may need brace treatment to improve their pain. Today, with the help of a simple clinical test, we can distinguish between different types of lower back pain allowing a differential approach to the symptom. There is some evidence that pain can successfully be reduced by these approaches mainly influencing the sagittal profile. In patients with bigger deformities and in patients aiming at reducing their deformity, pattern-specific scoliosis braces are a successful choice according to published research cases. The different specific brace types/designs along with the differential indication for these brace types will be described in this chapter.

**Keywords:** adult scoliosis, deformity, pain, brace treatment

## **1. Introduction**

General remarks regarding chronic back pain have been reviewed in a previous study focussing on brace treatment for patients with spinal deformities [1]: within the adult population, certain complaints and diagnoses are increasing such as low back pain, degenerative scoliosis and spinal stenosis. The number of symptomatic patients with spinal stenosis complaints is not known but the main aims of interventions are to improve pain management, functional and lifestyle choices [2]. Spinal stenosis surgery is increasing, and in the 1980s and early 1990s, it is suggested by Ciol et al. [3] that the numbers increased eight-fold. It is controversial to assume that sedentary lifestyles contribute to back pain, but few discussions continue in this topic of research. It is hypothesised that there are negative consequences to this type of lifestyle, initially within muscles, which ultimately lead to compensation in the structure and function of connective tissue [4].

A sedentary choice in lifestyle may initially lead to a negative change in posture, such as a loss of lumbar lordosis. This postural position correlates significantly with a prevalence of lower back pain (LBP) and spinal claudication. In the adult population, lower back pain and spinal claudication can progress to degenerative, de novo scoliosis [5].

Research focusing on younger adolescent female patients [6] demonstrated that non-specific LBP is reported even in this younger age group, especially those reporting a family member with lower back pain.

In 60% of secondary school pupils and 32% of students, lower back pain was a reported symptom. A correlation between lower back pain and displaying a sedentary position (p < 0.001 for pupils, and p < 0.02 for other students), and smoking (p < 0.001 for students and p < 0.02 for pupils) has shown to be statistical significant in analysis [7].

Furthermore, a beneficial consequence of an increase in physical activity and leisure time has shown to reduce musculoskeletal morbidity in patients of working age, specifically in those who have sedentary jobs [8].

Postmenopausal women who have sedentary lifestyles may benefit from regular weight-bearing exercise not only to reduce their back complaints but also to slow down the loss of bone mass.

Some studies argue the contrary and do not support the hypothesis that sedentary lifestyle contributes to lower back pain [9–11]. In one study, the lordotic angle seemed to have no influence on the prevalence of low back pain [9]. The presence of lordosis and the angle of lordosis alone may not be the only influential cause, but more specifically, it is the location of lordosis and shape of the posture, specifically the lordosis in the upper lumbar section of the spine that has the most effect upon reported pain levels [12, 13].

'Chronic low back pain' is an umbrella term and relates to patients reporting pain in the lumbar or sacral region or even in the sacroiliac pelvic joints. As the pelvis may be involved, the iliolumbar ligaments and even some radicular symptoms may also add to the complexity of the source of pain. With the presence of radicular symptoms, the nerve root affected would determine the origin of the lower back pain [14].

Without the presence of radicular symptoms, chronic lower back pain cannot be caused by a specific nerve root and may have a more complex cause involving L5/S1 or L4/5, and or the pelvis joints or ligaments [14].

Chronic low back pain without radicular symptoms and without any other specific clinical finding (for example, spondylolisthesis) is not classified and attributed in international research as being 'unspecific' or 'non-specific'. For bracing of this group of patients with chronic non-specific low back pain, simple physical tests have been published to predict the brace type the patient might benefit from. Based on the results of physical tests, a simple functional classification of 'non-specific' lower back pain has been developed [1].

In patients with scoliosis, besides the common cosmetics issues, pain is also a reported common issue [15]. Although back pain in patients with scoliosis is not related to the size of the curvature (Cobb angle) [16, 17], there is evidence that scoliosis patients experience statistically more back pain in later adulthood than agematched controls [18–21]. This back pain is not always disabling [19–21] and can be treated conservatively with reasonable success [16, 17, 22, 23]. While low back pain increases after surgery [24], pain in patients with scoliosis without surgery can be reduced with exercises, be it core stabilisation exercises [22, 23] or pattern-specific exercises (for example, Schroth) [16, 17].

In rare cases, the pain cannot be reduced using the functional exercise approach. For these cases, bracing can be successful [1, 12, 13, 25–27].

As outlined above in patients with scoliosis, we distinguish between different kinds of chronic back pain [28]. Most complaints come from the lower back region. Specific chronic low back pain stems from the lumbosacral region and can usually be referred to an injured or inflamed nerve root. This type of pain mainly is caused by a disc prolapse with compression of a nerve root. Specific low back pain needs a

### *Brace Treatment for Adults with Spinal Deformities DOI: http://dx.doi.org/10.5772/intechopen.92321*

specific treatment in order to reduce the nerve compression and, commonly, surgical decompression in case of significant impairment of the nerve [28].

But as already outlined, non-specific chronic low back pain cannot be referred to a single nerve root. In patients with chronic non-specific low back pain, there may be functional impairments of the sacroiliac joints, lumbar facet joints, overuse of the iliolumbar ligament and spinal stenosis, relative or absolute. Psychological issues also play a role in the development of chronic non-specific low back pain [14, 28]. This also applies to patients with spinal deformities.

Functionally, we may distinguish between postural low back pain (PLBP) and instability low back pain (ILBP) [1] (**Figure 1**). While PLBP mainly is related to loss of lumbar lordosis in later adulthood, ILBP is related to joint laxity or a definite instability like in patients with spondylolisthesis. Combinations of both entities are also possible [1].

In a study from 2009 [26], 130 patients presenting with spinal deformities (ranging from middle aged to older adults of 69 years old) and chronic unspecific low back pain were tested, using brace treatment for their chronic lower back pain. 16 of these patients presented with symptoms of spinal claudication. The sagittal re-alignment test (SRT) was applied (a lumbar hyperextension test) and a 'sagittal de-lordosation test' (SDT) to each participant. In addition, three female patients with spondylolisthesis were tested, including one female with symptoms of spinal claudication. 117 of the 130 patients reported a significant pain reduction when the SRT was applied. 13 patients, when applying the SDT also had significant reductions in pain. Three out of 130 patients had no significant change in their pain levels in either test. Pain intensity for all participants was high prior to the physical tests (VRS scale 0–5) and low while performing the physical test. These differences in pain scores were highly significant in analysis. There was an exception in three patients (2.3%): a clear distribution to one of the two classes was possible.

### **Figure 1.**

*The sagittal realignment test (SRT) seen on the left and the de-lordosation test (DT) with patient in the standing position. The sagittal realignment test (SRT)—a positive result in this test will present with an immediate reduction in chronic postural LBP (PLBP). The de-lordosation test (DT) pictured on the right—a positive result on this test will present with an immediate reduction in chronic LBP if this is due to instability low back pain (ILBP). Taken from [1] (Creative Commons Attribution Licence).*

117 patients were supplied successfully with a sagittal realignment brace and 13 with a sagittal de-lordosing brace. A clear distribution of the patients from this sample to either chronic postural or chronic instability back pain was possible. In 2.3%, a combined chronic low back pain was found. The authors concluded that chronic non-specific low back pain may be classified physically. The functional classification described is necessary to decide which specific conservative approach (lordosation/de-lordosation of the lumbar spine) should be used [1]. However, the topic spinal deformities in conjunction with brace treatment is not well established in the international literature and research. Therefore, a systematic PubMed review has been undertaken in order to find more studies with the aim to establish a scientific basis for treatment suggestions for this group of patients [15].
