Lateral Electrical Surface Stimulation as an Alternative
To Bracing in the Treatment of Idiopathic Scoliosis
Treatment Protocol and Patient Acceptance
LYNN F. ECKERSON
and JENS AXELGAARD
The purpose of this article is twofold. The first is to describe the management by
physical therapists of patients using lateral electrical surface stimulation (LESS)
for the treatment of progressive idiopathic scoliosis. In this treatment, electrodes
are placed on the convex side of the curve in the region of the posterior to
midaxillary line to produce a corrective force. Stimulation is applied nightly as
the patient sleeps. Treatment is monitored by regular checkups and is stopped
at achievement of skeletal maturity. No other treatment or exercises are necessary. The second purpose is to present the results of a questionnaire given to
patients who had used LESS for at least six months. Fifty-seven patients and
their parents responded to questions on scoliosis, acceptance of LESS treatment,
and comparison of LESS treatment with previous brace treatment, if appropriate.
Results indicated that many of the brace-associated problems were eliminated,
and patient acceptance was high.
Key Words: Electrical stimulation, Physical therapy, Scoliosis.
Idiopathic scoliosis, lateral curvature
of the spine of unknown etiology, comprises approximately 75 to 80 percent of
all scoliosis in the United States.1 Because school screening programs are
mandated in more and more states,
many new cases of scoliosis are discovered each year. Those cases that demonstrate progression require treatment.
If left untreated, progressive curves increase in size and contribute to significant cosmetic deformities, such as a thoracic rib hump. In severe cases, late
complications include back pain, degenerative joint disease of the spine, and
impaired cardiopulmonary functions.2,3
One of the most common modes of
treatment for progressive curves between 20 degrees and 45 degrees has
been the Milwaukee brace. Proper use
of this brace requires that the patient
wear it for 23 hours every day until the
patient nears skeletal maturity and demonstrates curve stability. The patient can
Ms. Eckerson was Physical Therapy Supervisor
I, Rancho Los Amigos Hospital, Downey, CA,
when this research was conducted. She is currently
Clinical Education Specialist, Neuromedics, Inc,
Clute,TX 77531 (USA).
Dr. Axelgaard is Director, Spinal Research, Rancho Los Amigos Rehabilitation Engineering Center,
Downey, CA 90242.
This work was supported in part by NIHR Grant
23P-55442, 1979 and the Department of Education
Grant G008003002, 1980-1982.
This article was submitted January 17, 1983;
was with the authors for revision 22 weeks; and was
accepted November 18, 1983.
Volume 64 / Number 4, April 1984
then begin a weaning program.4,5 Although the Milwaukee brace has proven
to be effective in halting curvature progression,6"8 we have observed many associated problems that complicate brace
use. These problems, primarily caused
by the 23-hour-a-day application, include inability to participate in competitive or recreational sports and dance,
excessive wear and tear on clothing,
pressure sores, heat rashes, and difficulty
with reading and writing at a desk or
eating because of the chin piece. Parents
have noted negative psychological
changes in their children who are required to wear a brace during adolescence. Low profile braces, such as the
Boston brace, eliminate some but not
all of these problems and are not recommended in the treatment of curves
with apices above T8.9 All braces entail
a significant initial cost and must be
modified or a new brace must be fabricated as the child grows.
Severe curves that exceed 40 to 45
degrees usually require surgical correction. As with any major surgery, spinal
surgery carries with it significant risks,
such as cardiac arrest and infection.
Complications of spinal surgery also include paralysis and pseudarthosis.5 Postoperatively, the patient must wear a
body cast or brace for six to nine
months, and the patient has a large scar
for life. Vertebral body growth is halted
when a fusion is performed on an im-
mature spine,5 and this halt of growth
can lead to abnormal trunk size in relationship to the extremities. Additionally, spinal mobility is compromised,
and the patient may be unable to perform certain activities that require full
spinal bending and rotational flexibility
(eg, competitive sports, dancing, and
housekeeping).
Electrical stimulation as an alternative treatment for mild to moderate scoliotic curves was first attempted in 1974
by intermuscular electrodes implanted
in the paraspinal muscles.10 An antenna,
taped on the skin overlying a subcutaneous stimulator, was connected to an
external pulse-generating transmitter for
nighttime stimulation. Results showed
that progression of the major curve was
halted in 83 percent of the curves measuring 45 degrees or less. The patient,
however, had to undergo surgical procedures to implant, explant, or replace
malfunctioning equipment.
Research by Axelgaard et al in 1976
demonstrated that acute scoliosis of up
to 50 degrees could be induced in
straight cat spines from electrical surface
stimulation applied to the lateral trunk
musculature.11 Axelgaard et al showed
in another study that idiopathic scoliosis
in 30 patients could be acutely reduced
by surface stimulation.12 Medial (on the
paraspinal muscles), intermediate, and
lateral (on the midaxillary line) electrode positions were used; the greatest
483
LESS treatment compared with the acceptance of the brace treatment.
METHOD
Management of Lateral Electrical
Stimulation
Fig. 1. Results of screening study to determine most effective electrode position (M =
Medial, I = Intermediate, L = Lateral).
amount of correction was achieved
when stimulation was applied laterally
(Fig. 1). These results can be explained
biomechanically because the long lever
arms of the ribs and ilium at the midaxillary line can develop a greater moment
of force than the short lever arms of the
ribs in the paraspinal region. When the
lateral trunk muscles contract as stimulation is applied, the appropriate ribs
move toward each other (Fig. 2). Because the ribs articulate with the vertebrae, the corrective force is transferred
to the spine with resultant straightening.
Axelgaard and Brown, in consultation
with fellow scoliologists, devised strict
patient selection criteria for a study to
prove that laterally applied surface stimulation was an effective treatment for
those patients who were at the highest
risk for curve progression.13 These criteria required that the curves be idiopathic, progressive in nature, and between 20 to 45 degrees using the Cobb
method of measurement. The patient
also had to have at least one year of
skeletal growth remaining. Results show
that progression of the curvature was
halted in 84 percent of those patients
treated.13
The purpose of this paper is twofold:
1) to describe the ongoing physical therapy management of the patient using
lateral electrical surface stimulation
(LESS) for the treatment of scoliosis and
2) to present the results of a patient
questionnaire on the acceptance of the
484
The following describes the ongoing
protocol for subjects receiving LESS at
Rancho Los Amigos Hospital. The subjects are selected according to the previously mentioned criteria of Axelgaard
and Brown.13 The physical therapist
(PT) initiates treatment after examination and selection of the patient by the
physician. Initial roentgenograms include lateral and anteroposterior (AP)
films of the entire spine in the standing
position and one of the left hand and
wrist to determine bone age. The PT
records patient and family history of
scoliosis. The initial assessment by the
PT includes 1) measurement of sitting
Fig. 2. Muscle contraction and correcting
forces caused by application of LESS.
and standing height, weight, and leg
length from anterior superior iliac spine
to medial malleolus; 2) measurement of
trunk decompensation by dropping a
plumb line from C7 and recording the
distance from the gluteal cleft to the
plumb line; and 3) measurement of the
height and location of the rib hump or
lumbar prominence or both. A tracing
of the rib hump is obtained with a flex
curve molded to the patient's back at
the level of the highest point of the
hump. We are evaluating several devices
for this procedure, but the flex curve in
Figure 3 is one of the simplest and most
inexpensive to reproduce.
Stimulation is applied to a single-major curve with the ScoliTron®* stimulator and to double-major curves with a
dual-channel stimulator made at the
Rancho Los Amigos Rehabilitation Engineering Center. These stimulators deliver trains of rectangular constant current pulses with a pulse width of 220
µsec, a frequency of 25 pulses per second, and a duty cycle of six seconds on
and six seconds off. We use circular
carbon-rubber electrodes with snap connectors and various interface material
depending on individual patient response to stimulation and sensitivity of
the skin. Most patients use karaya pads,
gel pads, or gel.
The PT explains the ScoliTron® kit
(Fig. 4) or dual-channel unit and home
treatment program to the patient and
parents. Each patient receives a manual
that contains the necessary instructions
for proper use of LESS, a diagram showing the patient where to put the electrodes, a time schedule for the first week
of stimulation, and a graph where the
patient can record treatment progress.
Patients are requested to keep a diary
and record the time stimulation was
applied, at what amplitude, the time
stimulation was discontinued, and any
problems or comments. The diary is
reviewed by the PT at each follow-up
visit to assist in judging compliance and
to identify trends or problems. A compliance meter located behind a trap door
in the ScoliTron® also aids in determining compliance. The meter is a mercury
device that records the number of hours
that stimulation of an acceptable amplitude level is applied. The meter will not
record any time if the stimulator is
merely turned on; it must be outputting
at least 40 mA with a load (patient)
attached in order for the time to record.
Noncompliance is defined as less than
50 percent of prescribed usage.
The PT places electrodes on the patient in the appropriate position. Electrode position is critical for positive results when using this treatment technique.1314 The physician informs the
therapist which vertebra he selected
from the AP roentgenogram as the apical vertebra. For thoracic curves, this
vertebra is located by palpation by
counting down from C7. The apical rib
* Neuromedics, Inc, a subsidiary of Intermedics,
Inc, Freeport, TX 77541.
PHYSICAL THERAPY
RESEARCH
on the convex side of the curvature is
followed by palpation laterally to the
midaxillary line. Electrodes are then
placed symmetrically above and below
this point (Fig. 5). For lumbar curves,
the electrodes are placed symmetrically
above and below the point directly lateral to the apical vertebra in the region
of the midaxillary line on the convex
side of the curve (Fig. 6). The important
factor is that the electrodes remain
within the boundaries of the curvature.
(For example, in treating a curve from
T6 to T12, the upper electrode should
be no higher than the 6th rib and the
lower electrode no lower than the 12th
rib.) Individual physical characteristics
(ie, are the ribs nearly horizontal or do
they slant vertically?) require that the
PT try different electrode positions. The
PT selects the position that produces the
strongest muscle contraction and spinal
movement in a straightening direction.
Distance between the two electrodes depends on curve and trunk size. For most
curves that span five to seven vertebral
segments, 10 cm separates electrode
centers for average-size adolescent
trunks; an 8-cm separation is appropriate for smaller trunks. Curves with less
than five vertebrae involved or shorter
trunks necessitate decreasing this distance to a minimum of 6 cm. Patients
with long trunks or curves that span
more than eight vertebrae require a
greater distance between electrode centers; the maximum distance is 16 cm.
More than 16 cm or less than 6 cm
Fig. 3. Flex-curve molded to a patient's back at the highest point of her rib hump.
limits the effect of stimulation. The
same guidelines for electrode placement
are used in dual-channel stimulation;
however, two pairs of electrodes are
used. One pair is placed on the convex
side of each curve.
Polarity of the upper electrode is determined by the quality of spinal movement and patient comfort after a trial
with both options. Most patients prefer
stimulation with the negative lead at-
Fig. 4. ScoliTron® kit consisting of ScoliTron® stimulator, two rechargeable batteries, a battery
charger, gel, screwdriver, circular tape patches, karaya coupling disks, two carbon-rubber
electrodes, one 3-m lead for use during sleeping, and one 1-m lead for backup.
Volume 64 / Number 4, April 1984
tached to the upper electrode for thoracic curves and to the lower electrode
for lumbar curves. Spinal movement is
palpated by placing fingertips on the
spinous processes. When spinal movement is palpated, the PT is subjectively
grading the amount of acute straightening of the curvature when the stimulator
is in the six-second "ON" cycle. Grades
of Weak, Fair, and Strong, are assigned
subjectively. Changes in electrode placement or polarity are made if a grade of
Weak is assigned. A Fair grade is usually
the lowest acceptable grade. Palpation
of spinal movement of all curves, major
and compensatory, is necessary before
final electrode position and polarity can
be selected.
The electrodes are connected to the
ScoliTron® or the dual-channel stimulator by means of lead cables with snap
connectors. The stimulator is turned on,
and the current amplitude slowly increased until the patient notices the sensation of electrical stimulation. At this
point, the stimulator is given to the patient, who is instructed to increase the
level of stimulation. The patient works
with the stimulator for the next half
hour until he is stimulating at 30 to 40
mA with palpable muscle contraction
and spine movement. After treatment,
the PT marks electrode position with a
surgical skin marking pen and gives
measurements from spinous process C7
485
Fig. 5. Electrode placement for thoracic
curves.
Fig. 6. Electrode placement for lumbar
curves.
to electrode centers to the parents. Teenagers can apply electrodes and perform
this treatment at home independently,
but parental supervision is strongly encouraged. Parents are taught how to palpate spinal movement and measure
electrode position. They are requested
to perform both of these procedures at
least once a week.
The patient then returns home with
instructions for increasing the ampli486
tude of stimulation to an acceptable
level (50-70 mA) and for increasing the
treatment time. Amplitude and treatment time are increased gradually to
allow for sensory accommodation and
to avoid muscle soreness (similar to the
effects of an extended exercise workout).15 On thefirstday, one half-hour of
stimulation are applied three times, followed by 2 one-hour sessions on the
second day. Three hours of continuous
stimulation are applied on the third day,
and the stimulation is increased by one
hour on each subsequent day until eight
hours is reached. The patient is then
ready for regular nighttime stimulation
(Fig. 7). No other treatment or exercises
are required during the day.
The second clinic visit with the physician and PT takes place two weeks
later. The accuracy of electrode placement and effectiveness of stimulation
are determined radiographically. The
patient is positioned prone on the table
for the roentgenograms, with the forehead resting on a folded towel for comfort. The first roentgenogram is taken
with the electrodes in place from the
night before; their metal snaps are visible on the roentgenogram. If the electrode position is inaccurate, the PT corrects the position, and the second roentgenogram is taken while the patient receives 70 mA of stimulation. Both x-ray
films are measured by the physician or
the PT, if the physician has trained the
therapist. When the film taken during
stimulation is compared with the film
taken without stimulation, the stimulated curve should demonstrate 5 to 10
degrees of acute correction. No increase
in size of the compensatory curves
should occur. If the curve has worsened,
electrode position or polarity or both are
changed to eliminate this adverse progression. A second roentgenogram with
stimulation can then be taken to verify
correct movement of all curves, if indicated. It is critical that the patient remain immobile between these roentgenograms so that the PT or physician can
make an accurate comparison. This session is the only time until the patient
reaches spinal maturity that roentgenograms are taken in the prone position.
For the first year of treatment, the
patient returns to the clinic for review
by the physician and PT once every
three months. After thefirstyear, clinic
visits range from every four months to
six months, depending on patient compliance and treatment effectiveness.
During routine visits, an AP roentgenogram of the entire spine, with electrodes in place but without stimulation,
is taken in the standing position. The xray film demonstrates the status of the
curve and the correctness of the electrode placement. The PT checks the
stimulator with an oscilloscope to determine the amplitude of stimulation the
patient is receiving and to identify any
deterioration of the stimulus waveform
or any increase in impedance of the
electrodes. The PT palpates spinal
movement of major and compensatory
curves to verify proper correction of the
curves. Problems are solved as needed.
Skin rash is the problem that has to be
dealt with most often. We try different
coupling media and make suggestions
regarding skin hygiene and "over-thecounter" creams and ointments that
promote healing.
The PT checks the patient diary at
each visit and uses it to judge patient
compliance. Compliance is also determined by checking the compliance meter.
Once annually, the clinic visit also
includes a lateral roentgenogram to note
the status of the sagittal plane curves.
Measurement of leg length, trunk decompensation, and the rib hump or
lumbar prominence is repeated following the procedure we described for the
initial assessment.
Stimulation is continued until skeletal
maturity is reached. Maturity criteria
include closure of all ring apophyses,
Risser sign 4 or 5, complete closure of
the distal radius, and no change in
standing height over the past 18-month
period. When three out of the four criteria are met, a PA roentgenogram is
taken in the prone position. Decrease in
curve size of less than 5 degrees from
the standing to the prone position indicates that spine laxity of structure is
minimal, and discontinuation of the
treatment is safe. We do not wean the
patient from the treatment, and followup care consists of one AP roentgenogram in six months and annually thereafter.
Patient Survey
All patients (N = 57) seen in the LESS
clinic between May 1980 and November 1981 who had used this treatment
for at least six months were asked to
complete one of two questionnaires.
One questionnaire was prepared for
PHYSICAL THERAPY
RESEARCH
those patients who had worn a Milwaukee or other brace before using LESS,
and one was prepared for those patients
who had no previous brace treatment.
Both questionnaires consisted of the
same general questions, such as "How
did you discover that your child has
scoliosis?" and questions specific to the
LESS technique, such as "Is your child
able to sleep well with LESS?" The Brace
Prior (BP) questionnaire also included
questions specific to brace treatment,
such as "What type of brace did your
child wear?" and "Was your child active
in sports or other activities that he/she
could not continue once he/she started
wearing a brace?"
We recorded patient responses and
performed a percentage analysis of the
individual group, Brace Prior (BP) or
No Brace Prior (NBP), or of the total
groups (BP + NBP), as appropriate.
RESULTS
All 57 patients and their parents who
were given a questionnaire returned a
completed form. We received 45 No
Brace Prior (NBP) questionnaires and
12 Brace Prior (BP) questionnaires. The
BP Group was small (12) because only
patients who had significant problems
with brace wear were switched to the
LESS treatment. For example, one patient from the BP Group had repeated
skin breakdowns despite proper brace
modifications.
All 57 patients had used LESS for
periods ranging from 6 to 42 months.
Brace Prior patients had worn a brace
for a length of time ranging from 3 to
74 months; five patients wore Milwaukee braces and seven patients wore Boston or other underarm braces. The Table summarizes the results of the questionnaires.
All patients who wore a brace before
applying LESS had encountered at least
one significant problem with brace use.
Eleven of the 12 patients had skin problems, such as pressure sores or heat
rashes, and 10 patients had problems
with their clothing tearing or not fitting
properly. Other problems with brace
wear included excessive heat, perspiration, and odor; discomfort; hair torn
out; difficulty in application; bed wetting; and a "waddle" gait when the brace
was worn.
Seventy-nine percent of all patients
(85% of NBP and 58% of BP) chose
LESS because they did not want to wear
Volume 64 / Number 4, April 1984
Fig. 7. Patient using stimulator at night.
or continue to wear a brace. Reasons for
not wanting to wear a brace included
cosmesis, fear of ridicule at school, interference with activities, and physical
discomfort.
Competitive or recreational physical
activities were discontinued by 67 percent of those patients who wore a brace,
and 91 percent of the NBP patients said
they would have discontinued physical
activities had the LESS treatment not
been available. Patients included an
Olympic-class swimmer, a starting
pitcher on a high school team, cheerleaders, gymnasts, and a skilled ballerina.
Compliance with the LESS treatment
in the NBP Group, according to the
record, was 82 percent always compliant
and 7 percent usually compliant. One
hundred percent compliance was reported in the BP Group. Sixty-seven
percent of the BP patients were always
compliant with brace wear, and the remainder of the BP patients reported
usual compliance.
Seventy-four percent of all patients
reported that they slept well with LESS,
but only 58 percent of the BP patients
slept well with the brace. Of the 15
patients from both groups who reported
that they did not sleep well with LESS,
8 had difficulty falling asleep, but once
asleep, they had no problems.
Parents were asked whether they believed that their child demonstrated any
personality changes. No definitions or
guidelines were given; parents were simply asked their opinion. Most (74% of
all parents) responded that they had observed no changes, and 21 percent reported positive changes in their children
since beginning treatment with LESS.
The parents of three (7%) of the NBP
Group believed that their child displayed negative personality changes
since beginning treatment with LESS.
In the BP Group, no negative changes
were reported with LESS treatment, but
42 percent reported negative changes
while their children were wearing the
brace. Changes reported included the
patient being resentful towards parents,
unhappy all the time, and refusing to
leave the house.
Proper electrode placement, the key
to success with LESS, presented no
problem to 88 percent of all patients
and was difficult for the first month only
in another 5 percent.
Occasional skin irritation from the
coupling media or tape was reported by
54 percent and consistent irritation by
9 percent of all patients. No skin irritation was reported by the remaining 37
percent.
DISCUSSION
Treatment results indicate that treatment with LESS is at least as effective
as the Milwaukee brace in halting progression of mild to moderate curves in
the growing patient.13 Initially, Milwaukee brace users show rapid and significant correction of curvature, but gradually lose the correction once brace wear
is discontinued at skeletal maturity.6"8
Preliminary posttreatment results indi-
487
TABLE
Results of the Questionnaire Given to LESS Patients
Questionnaire
How scoliosis discovered
school
physician
parents
Problems with brace
skin
clothing
other (some patients listed
more than one)
Why LESS chosen
did not want brace
seemed more effective
night use only
skin problem brace
brace failure
no reason
Activities
would have to discontinue
did discontinue
Compliance with LESS
always
usually
noncompliant (less than 50%)
Compliance with brace
always
usually
noncompliant
Sleep well with LESS
Sleep well with brace
Personality changes
With LESS
positive
no change
negative
With brace
positive
no change
negative
Problems with electrode placement
Consistent problem
first month only
no problem
Skin irritation
consistent
occasional
no problem
No Brace Prior
(NBP) (n = 45)
No.
%
No.
%
% of Total
NBP and BP
(N = 57)
21
18
6
47
40
13
3
6
3
25
50
25
42
42
16
11
10
13
92
83
7
3
58
25
1
1
8
8
8
67
12
100
8
4
67
33
38
3
1
85
7
2
3
7
41
91
37
3
5
82
7
11
79
11
2
2
2
5
86
5
9
33
73
9
7
75
58
74
6
36
3
13
80
7
6
6
50
50
21
74
5
1
6
5
8
50
42
3
1
41
7
2
91
1
2
9
8
17
75
7
5
88
5
21
10
11
47
42
10
2
83
17
9
54
37
cate that the correction achieved with
LESS is maintained after treatment is
discontinued at skeletal maturity.13 This
preservation may be explained in part
by the muscle strengthening effect of
electrical stimulation,1516 which may
help hold the curve in the corrected
position until full spinal maturity and
stability are reached. Nachemson et al
found curve progression in women with
idiopathic scoliosis who were pregnant
488
Brace Prior
(BP)(n = 12)
before age 23 and no progression in
those who were pregnant after age 24.17
His findings suggest that full spinal stability does not occur before the midtwenties. Long-term posttreatment follow-up of LESS patients must be recorded before any conclusive statements
about curvature stabilization can be
made.
The research begun by Axelgaard and
Brown13 is being continued in a multi-
center study sponsored by Neuromedics, Inc. Qualified orthopedic surgeons
who have been approved by the chief
clinical investigator are trained in the
protocol by PTs who are experts in the
LESS technique. The selected physicians have submitted their data from
July 1977 to July 1982 for analysis. Results show that 72 percent of the patients
demonstrated reduction or halt of progression of their curvatures, 13 percent
demonstrated temporary progression
followed by stabilization, and 15 percent
continued to demonstrate curve progression.18
Treatment with LESS has certain advantages that are now obvious. A treatment requiring nighttime (8 hours) as
opposed to around-the-clock (23 hours)
use is more desirable, as it allows children to participate in a lifestyle that is
similar to that of their peers.
Physical activity is very important for
growing children and can be severely
limited by brace application. Sixtyseven percent of the BP patients discontinued competitive or recreational physical activities once a brace was applied.
Physically talented children with potential for amateur competition or careers
in sports or dance often practice many
hours a day; use of LESS allows them
16 hours of nontreatment time for
school, practice, and activities that comprise a healthy adolescent's day.
Psychological problems are commonly reported as a result of brace wear
and often lead to noncompliance.19,20
Psychological testing of LESS patients
has not been done, but according to
parent reports on the questionnaires, 42
percent of the BP patients exhibited negative personality changes while wearing
the brace, but only 5 percent of all LESS
patients (BP and NBP) exhibited negative personality changes. Formal psychological testing of LESS patients, similar to the testing of brace patients,
should be documented before conclusive statements can be made regarding
the psychological benefits of LESS over
brace treatment.
The cost of bracing varies across the
United States. At Rancho Los Amigos
Hospital, the cost of a Milwaukee brace
or a Boston type brace exceeds that of
the ScoliTron® (approximately $50
more for a Milwaukee and $30 more for
a Boston brace in December 1982). Clinicians must also consider the cost of
brace modifications or replacement
braces as the child grows. Only one stimPHYSICAL THERAPY
RESEARCH
ulator is required for the entire treatment period of a patient receiving LESS,
and the same stimulator may be reissued
to many different patients over the
years. The only additional expense with
the LESS treatment is the purchase of
electrode coupling media; their low cost
still makes this treatment less expensive
than treatment by brace or surgery. At
Rancho Los Amigos Hospital, the number of clinic visits and roentgenograms
are the same for patients treated with a
ScoliTron® or a brace. The initial visit,
during which the ScoliTron® is fitted,
requires at least one hour of a physical
therapist's time, and the follow-up visits
require approximately 20 minutes.
School screening programs for the detection of scoliosis are becoming more
prevalent throughout the United States.
Forty-two percent of the patients surveyed learned that they had scoliosis
through school screening programs.
Some of the important results of these
programs include an increase in the
early detection of small curves, a decrease in the magnitude of the most
severe curves detected, a decrease in the
percentage of patients requiring surgical
fusion, and an increase in the number
of patients being treated noninvasively.21,22 As the average age of the
patient at the time of diagnosis decreases, the length of treatment time,
whether with brace or LESS, increases.
Because of the problems associated with
bracing, many physicians may delay the
start of treatment until a curve reaches
25 to 30 degrees to reduce the amount
of time the patient will have to spend in
a brace.23 Because the problems associated with brace wear are eliminated by
the use of LESS, the physician may decide to start treatment earlier, which
lends strong probability to the likelihood
of more desirable end results. (Further
progression has been halted in 84 percent of our patients; thus, a curve corrected to 20 degrees remains at 20 degrees and a curve corrected to 30 degrees
remains at 30 degrees.)
Moe and Kettleson7 reported that
noncompliance with the brace treatment in 20 percent of their patients
resulted in curve progression, but Axelgaard and Brown13 found noncompliance with the LESS treatment and re-
Volume 64 / Number 4, April 1984
sultant curve progression in only 9 percent of their patients.
Compliance, determined through the
compliance meter, patient report, and
diary, appears to decrease after one and
one-half to two years of treatment. We
cannot shorten treatment duration in
order to improve compliance, but we
can work to eliminate some of the problems associated with LESS that contribute to noncompliance. None of our BP
patients responding to our questionnaire reported noncompliance with
LESS; their familiarity with brace-associated problems may have made them
more willing to work through the LESSassociated problems. Patient cooperation does not, however, give us license
to ignore the problems associated with
LESS.
Proper sleep is important for any
growing child; yet, 26 percent (15 patients) of those who filled out questionnaires reported that they were unable to
sleep well with LESS. Eight of these
patients had difficulty falling asleep. We
eliminated this problem by persuading
parents to turn up the amplitude of
stimulation only after the child had
fallen asleep. The 12 percent (7 patients)
who continued having problems sleeping is certainly preferable to the 42 percent of BP patients who could not sleep
well with their brace, but the number
with sleeping problems remains a statistic that must be further reduced and
finally eliminated. Research continues
to seek improvement in the electrodecoupling media and the overall comfort
of electrical stimulation. Sixty-three percent of patients reported either consistent (9%) or occasional (54%) skin irritation. Most of this is in reaction to the
coupling media. Stimulation is highly
uncomfortable when applied to an irritated area and may have to be discontinued for a night or two if irritation is
present. Stimulation is also uncomfortable when nonuniform adherence of the
electrode-coupling media to the skin exists. This problem can be solved by tape,
but many patients develop skin irritation from the tape. Some skin irritation
problems are decreased or eliminated by
good skin hygiene, by changing coupling
media, or by rotating electrode positions
one electrode diameter medially or lat-
erally. As a result of the rotation, a single
area of skin comes into contact with the
coupling media once every three nights.
This latter option is not the ideal solution because the stimulation's effectiveness may be limited by changing position of the electrodes. Continued effort
must be applied to find a coupling media that is truly nonallergenic, uniformly
adhesive to the skin, easy to apply and
remove, and reusable to be cost-effective.
The use of LESS is often contraindicated in the obese patient. Because adipose tissue is a poor conductor of electricity,15 the amplitude of stimulation
must be increased to stimulate the muscles sufficiently to cause adequate spine
movement. This higher amplitude also
stimulates the pain receptors in the skin
to a higher degree, with the result that
the stimulation becomes uncomfortable. Use of larger electrodes having less
stimulation current density may alleviate this problem in the future.
CONCLUSION
Electrical surface stimulation with
electrodes placed laterally is a viable and
effective alternative to brace wear in the
treatment of idiopathic scoliosis in children and adolescents. This treatment is
administered while the patients sleep at
night and does not require exercises or
any additional treatment during the day.
The patients are free to carry on regular
daily activities and to look like their
peers.
Diagnosis of a medical condition is
not welcomed by most patients, even if
the cure or control of this condition is
simple. When the method of control is
wearing a brace that is highly visible and
makes the children feel different from
their peers, acceptance of the condition
and the controlling device becomes even
more difficult. With LESS, treatment
visibility is eliminated, and acceptance
of the condition and the controlling device therefore improves. With improved
acceptance often comes improved compliance with the treatment, and improved compliance leads to a better end
result.
489
REFERENCES
1. Harrington PR: The etiology of idiopathic scoliosis. Clin Orthop 126:17-25,1977
2. Weinstein SL, Zavala DC, Ponseti IV: Idiopathic
scoliosis: Long-term follow-up and prognosis
in untreated patients. J. Bone Joint Surg [Am]
63:702-712,1981
3. Bjure J, Nachemson AL: Non-treated scoliosis.
Clin Orthop 93:44-52, 1973
4. Blount WP, Moe JH: The Milwaukee Brace.
Baltimore, MD, Williams & Wilkins, 1980, pp
76-82, 107-109
5. Moe JH, Winter RB, Bradford DS, et al: Scoliosis and Other Spinal Deformities. Philadelphia, PA, WB Saunders Co, 1978, pp 359-427
6. Mellencamp DD, Blount WP, Anderson AJ: Milwaukee brace treatment of idiopathic scoliosis:
Late results. Clin Orthop 126:47-57,1977
7. Moe JH, Kettleson DN: Idiopathic scoliosis:
Analysis of curve patterns and the preliminary
results of Milwaukee brace treatment in one
hundred sixty-nine patients. J Bone Joint Surg
[Am] 52:1509-1533, 1970
8. Carr WA, Moe JH, Winter RB, et al: Treatment
of idiopathic scoliosis in the Milwaukee brace.
J Bone Joint Surg [Am] 62:599-612,1980
9. Uden A, Willner S, Pettersson H: Initial correction with the Boston thoracic brace. Acta Orthop Scand 53:907-911, 1982
490
10. Bobechko WP, Herbert MA, Friedman HG:
Electrospinal instrumentation for scoliosis:
Current status. Orthop Clin North Am 10:927941,1979
11. Axelgaard J, Brown JC, Harada Y, et al: Lateral
Surface Stimulation for the Correction of Scoliosis. Proceedings of the 30th Annual Conference on Engineering in Medicine and Biology.
Los Angeles, CA, The Alliance for Engineering
in Medicine and Biology, 1977, p 282
12. Axelgaard J, McNeal DR, Brown JC: Lateral
Electrical Surface Stimulation for the Treatment of Progressive Scoliosis. In Popovic D
(ed): Proceedings of the 6th International Symposium on External Control of Human Extremities, Dubrovnik, Yugoslavia, 1978, pp 63-70
13. Axelgaard J, Brown JC: Lateral electrical surface stimulation for the treatment of progressive idiopathic scoliosis. Spine 8:242-260,
1983
14. Axelgaard J, Nordwall A, Brown JC: Correction
of spinal curvatures by transcutaneous electrical muscle stimulation. Spine 8:463-481,1983
15. Benton LA, Baker LL, Bowman BR, et al: Functional Electrical Stimulation: A Practical Clinical
Guide, ed 2. Downey, CA, Rancho Los Amigos
Rehabilitation Engineering Center, 1981
16. Laughman RK, Youdas JW, Garrett TR, et al:
Strength changes in the normal quadriceps
femoris muscle as a result of electrical stimulation. Phys Ther 63:494-499 1983
17. Nachemson AL, Cochran TP, Irstam L, et al:
Pregnancy after scoliosis treatment. Orthopedic Transactions 6:5, 1982
18. Brown JC, Axelgaard J, Howson DC: Multicenter trial of a noninvasive stimulation method for
idiopathic scoliosis: A summary of early treatment results. Spine, to be published
19. Wickers FC, Bunch WH, Barnett PM: Psychological factors in failure to wear the Milwaukee
brace for treatment of idiopathic scoliosis. Clin
Orthop 126:62-66, 1977
20. Myers B, Briedman S, Weiner I: Coping with a
chronic disability: Psychological observations
of girls with scoliosis treated with the Milwaukee brace. Am J Dis Child 120:175-181,1970
21. Torell G, Nordwall A, Nachemson AL: The
changing pattern of scoliosis treatment due to
effective screening. J Bone Joint Surg [Am]
63:337-341,1981
22. Lonstein JE: Screening for spinal deformities in
Minnesota schools. Clin Orthop 126:33-42,
1977
23. Keim HA: The Adolescent Spine. New York,
NY, Springer-Verlag New York Inc, 1982, p
160
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