**5. Discussion**

The criteria for using suits designed specifically for a person with scoliosis is like the use of rigid bracing, in that best outcomes are achieved in early intervention when children have good spinal mobility. When used in older adolescents and adults, it is sensible to encourage the patient to complete a course of physiotherapeutic scoliosis specific exercises (PSSE), which includes auto-correction in 3D, training in activities of daily living (ADL), stabilising the corrected posture and patient education. These exercise protocols have level II evidence, both for independent use and in conjunction with spinal bracing in patients with curves less than 45° Cobb angles and are also suggested prior to surgery to help improve outcomes [9].

In a testimonial, one patient reported improved balance, upright standing and patient confidence. The use of PSSE, combined with an enhanced power scoliosis DEFO suit provided a mechanism to ensure maximum vertebral movement, combined with the unique proprioceptive and long term low level force, known to be the most effective for muscle stretching [46]. When the suit was first applied the patient reported loss of balance, which indicated that the suit was having the desired effect and her mother reported a reduction in the pain she was experiencing [52]. After 3 years, the suit reduced the scoliosis progression and scoliosis surgery at the end of DEFO treatment was no longer required (**Figure 16**).

**Figure 16.** *Sixteen-year-old lady in structural scoliosis suit.*

Improvements in walking have shown that improved proprioception and provision of a flexible supportive exoskeleton can improve image of self, reduced hip sway, hip force closure and to reduce the known mechanisms of increased lordosis to lock the spine, enabling smother movement [33, 40, 53]. People with scoliosis can learn a new sitting position by the mechanism of continual motor learning carried on throughout life. This can be initiated by external forces including poor sitting position, spinal injuries, strokes as well as left or right-handed wheelchair controls. The use of dynamic orthoses, therefore, have an important role to play in centralising the spine without the use of rigid force.

The mechanisms utilised in DEFOs dynamic orthotics became more objective than subjective, with more research and reports of use. It is important to understand the mechanism for the changes observed in the patients and their reaction to the intervention. For a number of years, the outcomes detected were put down to improved patient stability from the compressive forces on the hip and shoulder, coupled with the distraction of the shoulders as seen in proprioceptive neuromuscular facilitation (PNF) [54]. There is evidence that PNF on the trunk can reduce chronic low back pain in adult women, if applied in the sitting position [55]. There are two commonly used exercises. Rhythmic stabilisation training (RST) which uses isotonic (muscle working within normal contraction range) contraction of the agonistic (opposing) muscle patterns which results in co-contraction of the antagonists. The isometric contraction of the muscles is provoked into working by pushing or pulling an immovable object. This prevents muscles shortening in length and improves fitness and builds up strength. It is used where weakness is a primary factor. The combination of isotonic exercises (COI) is used to evaluate and develop the ability to carry out purposeful and controlled movements, involving alternating concentric (circular), eccentric (non-circular) and isometric movement to treat strength deficiency and range of motion. Four weeks of RST and COI proprioceptive neuromuscular facilitation have shown increased muscle endurance, decrease in back pain intensity, as well as improved functional ability.

There are several different mechanisms that appear to be working together to provide the DEFO's positive reported outcomes and therefore it is important to understand the different concepts of treatment. The orthoses initiate change where the effect is likely to be constrained by the linear range of elasticity of the fabric or "dynamic" [56]. The fabrics are designed to grip the skin while allowing air and moisture through without slippage. A DEFO uses these properties by griping onto the skin and therefore transfers the torsional resistance from the different reinforced fabric layers, which are designed to have different linear orientations. These forces are conveyed through the skin and soft tissue directly to the muscles and skeleton beneath with set movements expectations. For instance, if there is a long spinal curve to the right, set pattern options are applied to the left side of the trunk to resist stretch, therefore providing a stiffer area in the suit resulting with less of a lean to the right.

It is understood that slight compression of the trunk rather than distraction (as used in rigid and semi rigid spinal orthoses) can provide a stabilising effect on low core stability in children presenting with cerebral palsy. The same effect can be initiated in adults.

New innovations are signaling that the use of textile fabric materials can have positive spinal correction. Computer modeling has been developed to geometrically model scoliosis through finite element modeling (FEM). It is a numerical technique used to perform finite element analysis (FEA) of any given phenomenon (https:// www.simscale.com/blog/2016/10/what-is-finite-element-method/)*.* The use of 2D x-ray clinical data on appropriate textile materials, measuring physical and mechanical properties were used to determine the performance of the textile brace in terms of Cobb angle through FEM simulation. The results showed that textile

### *The Use of a Dynamic Elastomeric Fabric Orthotic Intervention in Adolescents and Adults… DOI: http://dx.doi.org/10.5772/intechopen.96391*

materials with banded parallel fabric layers provide good softness and air permeability (key for compliance in hot climates). There was high capacity to provide a 14.4% Cobb angle improvement, when used on a teenage patient with adolescent idiopathic scoliosis presenting with a 62° typical double curve [57]. This provides some medical and biological engineering evidence of the orthotic effect.

This study also highlighted the need for cosmetic appearance and the effects on patient compliance. Rigid braces have been proven to be effective in reducing scoliosis progression [4], however there have been issues with compliance particularly from discomfort caused by the brace and psychological stress from the visual impact. Patient involvement in brace design and aesthetics have shown improved compliance [58], so the use of elastomeric fabrics will further enhance this patient based involvement and provide scoliosis suits which are more comfortable in both adolescents and adults alike thereby improving activities of daily life.

There is evidence for the use of DEFO scoliosis management in neuropathic onset scoliosis and early indicators that the same orthoses can be effective in adolescent idiopathic scoliosis. The key thing to remember is the need for flexibility of the spine to be able to use dynamic movement to facilitate a spinal scoliosis angle reduction, vertebral rotational control and improved cosmetic outcome. The most effective treatment plan would be to combine PSSE with the use of scoliosis specific DEFO suits to start the treatment early in the onset rather than wait for the 25° Cobb angle starting point, that has historically been suggested. This highlights the need for early intervention and further research on this specific scoliosis presentation.
