Braces optimized with computer-assisted design and simulations are lighter, more comfortable, and more efficient than plaster-cast braces for the treatment of adolescent idiopathic scoliosis

Study Design Feasibility study to compare the effectiveness of 2 brace design and fabrication methods for treatment of adolescent idiopathic scoliosis: a standard plaster-cast method and a computational method combining computer-aided design and fabrication and finite element simulation. Objectives To improve brace design using a new brace design method. Summary of Background Data Initial in-brace correction and patient's compliance to treatment are important factors for brace efficiency. Negative cosmetic appearance and functional discomfort resulting from pressure points, humidity, and restriction of movement can cause poor compliance with the prescribed wearing schedule. Methods A total of 15 consecutive patients with brace prescription were recruited. Two braces were designed and fabricated for each patient: a standard thoracolumbo-sacral orthosis brace fabricated using plaster-cast method and an improved brace for comfort (NewBrace) fabricated using a computational method combining computer-aided design and fabrication software (Rodin4D) and a simulation platform. Three-dimensional reconstructions of the torso and the trunk skeleton were used to create a personalized finite element model, which was used for brace design and predict correction. Simulated pressures on the torso and distance between the brace and patient's skin were used to remove ineffective brace material situated at more than 6 mm from the patient's skin. Biplanar radiographs of the patient wearing each brace were taken to compare their effectiveness. Patients filled out a questionnaire to compare their comfort. Results NewBraces were 61% thinner and had 32% less material than standard braces with equivalent correction. NewBraces were more comfortable (11 of 15 patients) or equivalent to (4 of 15 cases) standard braces. Simulated correction was simulated within 5° compared with in-brace results. Conclusions This study demonstrates the feasibility of designing lighter and more comfortable braces with correction equivalent to standard braces. This design platform has the potential to further improve brace correction efficiency and its compliance

Reconstruction simplifiée du tronc pour le traitement de la scoliose idiopathique par corset

RÉSUMÉ La scoliose idiopathique de l’adolescent (SIA) est une déformation tridimensionnelle de la colonne vertébrale, de la cage thoracique et du bassin qui apparaît lors de la croissance. Des déformations de la colonne vertébrale avec des courbes de 10° ou plus nécessitant un suivi ou un traitement affectent 0,23 % de la population. L’incidence est plus élevée chez les filles. Pour les patients en croissance avec des courbes entre 25° et 45°, le traitement prescrit habituellement est le corset orthopédique. En Amérique du Nord, le type le plus utilisé est le corset de Boston. Autrefois fabriqué avec des moules de plâtre, la production du corset a fortement été améliorée par l’ajout de technologies permettant la conception et fabrication assistées par ordinateur (CFAO). Ces nouvelles techniques de production incluent entre autres l’acquisition numérique de la forme externe du tronc du patient par topographie de surface et la modification de celle-ci à l’aide de logiciels de CFAO destinés à la fabrication d’orthèses. La conception des corsets repose par contre sur des processus empiriques et, de manière générale, les spécialistes n’arrivent pas à un consensus sur le design optimal. Afin d’améliorer l’efficacité du corset par la vérification de son effet immédiat avant que celui-ci ne soit fabriqué et porté par le patient, un outil de simulation exploitant une méthode de simulation par éléments finis des corrections du corset sur le tronc du patient a été développé. Plusieurs travaux de recherche utilisant cet outil de simulation ont été réalisés par le groupe du CHU Sainte-Justine et de l’École Polytechnique. Les résultats d’une étude clinique ont montré que la méthode de simulation du corset prédisait avec une précision de 5° d'angle de Cobb les corrections obtenues avec les corsets fabriqués par CFAO portés par les patients. Récemment, une étude par essai randomisé contrôlé a montré que l’ajout des simulations numériques par éléments finis du corset au processus de conception et fabrication assistées par ordinateur permettait d’obtenir des corsets plus légers et offrant une meilleure correction. L’outil de simulation requiert une reconstruction personnalisée du tronc du patient dont la modélisation des structures osseuses internes est obtenue minimalement à partir de radiographies coronale et latérale calibrées du patient. Cependant, plusieurs centres n’effectuent pas de calibrage des radiographies ou n’effectuent pas de radiographie latérale, ce qui limite l’utilisation de l’outil de simulation.----------ABSTRACT Adolescent idiopathic scoliosis (SIA) is a three-dimensional deformity of the spine, rib cage and pelvis occurring during growth. 0.23% of the population, mostly girls, is affected by progressing spinal curves of 10° or more. For growing patients with curves between 25° and 45 °, orthopedic brace is the treatment usually prescribed. In North America, the most common type is the Boston brace. Formerly made from plaster molds, the braces’ production efficiency has been greatly improved by adding computer-aided design and manufacturing (CAD / CAM) technologies. These new production techniques include the numerical acquisition of the external shape of the patient's trunk and the modification of the latter with a CAD / CAM software for orthosis production. However, braces’ design is the result of an empirical process and, in general, experts do not reach a consensus on the optimal design. In order to improve the effectiveness of the brace by testing its immediate effect before being manufactured and worn by the patient, a simulation tool using a finite element simulation method of the installation of the brace on a personalized patient’s trunk model was developed. Several research studies using this simulation tool were done by the CHU Sainte-Justine and Polytechnique group. Results of a clinical study showed that the brace simulation method predicted corrections obtained with the brace made by CAD/CAM and worn by the patient within 5° Cobb angle accuracy. Recently, a randomized controlled trial study demonstrated that adding finite element numerical simulations to computer-aided design and fabrication process provided lighter braces and achieved better correction by the brace. The simulation tool requires a personalized reconstruction of the patient's trunk which the internal bone structures’ modeling is obtained minimally from a coronal and a lateral calibrated X-rays of the patient. However, several healthcare centers do not calibrate the radiographs or do not perform lateral X-rays, which limits the use of the simulation tool. To undertake this need, the aim of this Master's project was to develop a simplified 3D reconstruction method of the patient's trunk with only a postero-anterior radiograph and a trunk surface scan. Clinical measurements differences were obtained before and after simulation of the installation of the brace on the finite elements model reconstructed with the simplified method and obtained with the reference method which included a lateral X-ray

Développement d’une méthode de conception des corsets pour améliorer le confort et l’efficacité du traitement de la scoliose idiopathique

RÉSUMÉ La scoliose idiopathique de l’adolescent (SIA) est une déformation tridimensionnelle (3D) qui affecte l’anatomie et la biomécanique de la colonne vertébrale, de la cage thoracique et du bassin. Environ 3 à 4% de la population, principalement des filles, en ait atteint lors de la poussée de croissance à l’adolescence. Dans le cas d’une progression de la déformation, une prise en charge de la maladie sera nécessaire. Pour les déformations modérées (angle de Cobb entre 20° et 45˚), un traitement préventif par corset est généralement prescrit pour stopper la progression des courbures scoliotiques, et éviter la chirurgie. Bien qu’il existe plusieurs types de corset, celui le plus utilisé en Amérique de Nord est une orthèse thoraco-lombo-sacrale (TLSO) de type Boston. Ces corsets doivent être portés 23 heures par jour durant toute la durée de la croissance. La participation et la tolérance du patient au traitement constitue un problème ayant un impact sur l’efficacité du traitement. En effet, le résultat à long terme du traitement dépend non seulement de la correction immédiate de la déformation scoliotique, mais aussi du temps de port de l’orthèse. Les facteurs considérés comme ayant le plus d’influence sur la participation au traitement sont le manque d’esthétisme et l’inconfort du traitement. Les éléments d’inconfort les plus souvent nommés sont de la douleur causée par de trop grandes pressions appliquées, de l’humidité et une restriction de mobilité du segment du tronc. Dans le cadre de travaux précédemment réalisés par le groupe du CHU Sainte-Justine et de l’École Polytechnique, une plateforme de conception de corset assistée par ordinateur a été créée. Cette plateforme combine l’utilisation d’un logiciel de design de corset (CFAO) et d’un outil de simulation permettant de simuler l’installation d’un corset sur un modèle éléments finis (MEF) personnalisé du tronc d’un patient. L’outil de simulation permet de tester itérativement plusieurs designs de corset et de sélectionner le design permettant d’atteindre une meilleure correction du rachis. En reliant le logiciel de design à une fraiseuse numérique, il est possible de fabriquer le corset sélectionné et de le tester cliniquement. La faisabilité de cette méthode a été validée cliniquement sur une cohorte de 6 patients SIA. Les résultats obtenus ont montré que la simulation prédisait des résultats réalistes et que l’efficacité des corsets conçus par cette plate-forme était comparable à l’efficacité des corsets de Boston standard. Toutefois, cet outil ne considérait pas les éléments de confort qui peuvent influencer la participation du patient et l’effet à long terme du traitement.----------ABSTRACT Adolescent idiopathic scoliosis (AIS) is a three-dimensional (3D) deformation that affects the anatomy and the biomechanic of the spine, rib cage and pelvis. Approximately 3-4% of the population, mainly girls, will be affected by this pathology. In the case of the progression of the curves, a treatment prescription will be necessary. For moderate cases (Cobb angle between 20˚ and 45˚), a preventive brace treatment is generally prescribed to stop the progression and avoid surgery. Although there are several types of brace, the most widely used in North America is a Boston-type thoraco-lumbo-sacral orthosis (TLSO). This brace has to be worn 23 hours per day during the patient growth. Patient’s participation and tolerance to the treatment remains a recurrent issue influencing brace treatment efficacy. The long-term treatment outcome depends not only on the immediate brace’s spinal correction but also on the brace wear time. Main factors having an influence on patients’ compliance to treatment are the treatment’s lack of aesthetics and the discomfort felt during the brace wear. The main discomfort parameters are the pressure applied which can be too strong and cause pain, humidity and a lack of mobility of the trunk segment. In previous work by research teams at both CHU Ste-Justine and Ecole Polytechnique de Montreal, a computer assisted brace design platform was created. The platform combines the use of a brace design software (CFAO) and a simulation tool which can simulate the brace installation using a finite element model (FEM) of the patient's torso. This simulation tool can be used to test several iterative brace design and to select the design that allows the best spine correction. By linking the brace design software to a 3D carver, it is possible to fabricate the brace and to test the clinical installation. The feasibility of this method has been clinically validated on a cohort of 6 SIA patients. The outcomes showed that the simulation results were reliable and that the effectiveness of the braces designed by this platform was equivalent to the effectiveness of the standard Boston-type brace. However, the simulation tool does not consider comfort parameters that can influence patients’ participation and the long-term treatment effectiveness. The objective of this study was to design and experimentally validate on a SIA patient cohort a more comfortable and biomechanically efficient orthopaedic brace by integrating comfor

Approche intégrée de conception biomécanique de corsets pour le traitement de la scoliose idiopathique de l'adolescent

RÉSUMÉ La scoliose idiopathique de l'adolescent (SIA) génère des déformations complexes tridimensionnelles (3D) de la colonne vertébrale, de la cage thoracique et du bassin. De 3 à 4 % de la population est atteint par cette maladie, principalement des filles adolescentes durant leur poussée de croissance. Cette pathologie peut mettre en danger la santé de l’individu, advenant une progression de la déformation du rachis. Dans ces cas, une chirurgie, permettant de redresser la colonne vertébrale grâce à des tiges et vis métalliques, est nécessaire. Cette chirurgie est très invasive et comporte certains risques (notamment vasculaire et nerveux). Des traitements moins invasifs sont disponibles pour prévenir la progression des courbures. Pour des courbures moyennes, un traitement par port de corset (orthèse pour le tronc) est généralement utilisé. Le corset de Boston est le traitement standard utilisé en Amérique du Nord. Sa conception est effectuée de façon empirique à l’aide de l’évaluation de radiographies. Il existe d’autres types de corsets disponibles sur le marché. Seulement, leur efficacité est variable et imprévisible. Cette grande variété de concepts de corset est dû au fait que l’action biomécanique de la correction des corsets est méconnue. Une plateforme, assistée par ordinateur, de conception de corset a été créée à la suite de travaux précurseurs sur le développement d’un modèle par éléments finis (MEF) du tronc humain. Cette plateforme permet d’effectuer la conception d’un corset à l’aide d’un outil de conception assistée par ordinateur (CAO) ainsi que de simuler son installation sur le MEF du tronc. La simulation permet de prédire l’efficacité immédiate du corset avant sa fabrication. Celui-ci peut dès lors être itérativement amélioré à l’aide de cet outil, jusqu'à ce que l’efficacité du corset soit jugée suffisante. Le corset peut alors être fabriqué avec un système de fabrication assistée par ordinateur (FAO) lié à une fraiseuse numérique 3D. Cette plateforme permet la rationalisation de la conception de corset. Cet outil a besoin de validation clinique afin d’être utilisé pour créer des corsets efficaces de façon constante. L’objectif de cette étude était de vérifier la faisabilité d’utiliser la nouvelle plateforme de conception pour fabriquer des corsets pour les patients SIA. L’efficacité des nouveaux corsets a été comparée ensuite aux prédictions de la simulation ainsi qu’à un système de corsets standards. Deux corsets ont été fabriqués pour six patients SIA. Le premier corset a été créé à l’aide de la nouvelle plateforme de conception (Nouveau Corset). Ce dernier est basé sur une reconstruction----------ABSTRACT Adolescent idiopathic scoliosis (AIS) generates complex tridimensional deformities of the spine, rib cage and pelvis. It affects around 3-4% of the population, mainly female adolescents during their growth spurt. This pathology can be health threatening. If severe spinal curvature progression occurs, a surgery is necessary to straighten the spine using metal rods and screws. This surgery is very invasive and involves certain risks (mainly vascular and nervous). Conservative treatments are available to prevent curve progression. For moderate curves, braces (torso orthosis) are generally used as treatment. The standard brace used in North America is the Boston brace system. Its design is currently done mostly empirically based on assessments of radiographs. Other brace designs are available on the market; however their efficacy is variable and unpredictable. This wide brace design variety is due to the fact that brace biomechanical actions are not fully understood. Based on previous work on the development of a personalized finite element model (FEM) of a human torso, a computer assisted brace design platform was created. This platform allows brace design through Computer Assisted Design (CAD) and brace installation simulation on the FEM of the trunk. The simulation allows predicting initial brace efficacy, prior to the brace fabrication. The brace design can be iteratively improved using this tool until brace efficacy is considered sufficient and the brace can be fabricated using Computer Assisted Manufacturing (CAM) linked to a 3D carver. This platform permits the rationalization of brace design. This tool needs to be clinically validated to be used to create consistently efficient braces for clinical use. The objective of this study is to assess the feasibility of using the new design platform to build braces for AIS patients. The effectiveness of the braces issued from this process need to be compared to the predicted outcome of the simulations and to a standard bracing system. To do so, two braces were fabricated for six AIS patients. The first brace was created using the new design platform (NewBrace). The latter is based on a 3D reconstruction of the spine, pelvis and rib cage of each patient, computed from bi-planar (postero-anterior and lateral) calibrated radiographs. The external torso surface geometry is acquired using a surface topography technology (Moiré fringe digitization system). The internal and external geometries are registered together using radiopaque markers and the registered geometries are converted to a biomechanical FEM. This model is used to virtually correct the spinal deformities in th

2011 SOSORT guidelines: Orthopaedic and Rehabilitation treatment of idiopathic scoliosis during growth

<p>Abstract</p> <p>Background</p> <p>The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT), that produced its first Guidelines in 2005, felt the need to revise them and increase their scientific quality. The aim is to offer to all professionals and their patients an evidence-based updated review of the actual evidence on conservative treatment of idiopathic scoliosis (CTIS).</p> <p>Methods</p> <p>All types of professionals (specialty physicians, and allied health professionals) engaged in CTIS have been involved together with a methodologist and a patient representative. A review of all the relevant literature and of the existing Guidelines have been performed. Documents, recommendations, and practical approach flow charts have been developed according to a Delphi procedure. A methodological and practical review has been made, and a final Consensus Session was held during the 2011 Barcelona SOSORT Meeting.</p> <p>Results</p> <p>The contents of the document are: methodology; generalities on idiopathic scoliosis; approach to CTIS in different patients, with practical flow-charts; literature review and recommendations on assessment, bracing, physiotherapy, Physiotherapeutic Specific Exercises (PSE) and other CTIS. Sixty-five recommendations have been given, divided in the following topics: Bracing (20 recommendations), PSE to prevent scoliosis progression during growth (8), PSE during brace treatment and surgical therapy (5), Other conservative treatments (3), Respiratory function and exercises (3), Sports activities (6), Assessment (20). No recommendations reached a Strength of Evidence level I; 2 were level II; 7 level III; and 20 level IV; through the Consensus procedure 26 reached level V and 10 level VI. The Strength of Recommendations was Grade A for 13, B for 49 and C for 3; none had grade D.</p> <p>Conclusion</p> <p>These Guidelines have been a big effort of SOSORT to paint the actual situation of CTIS, starting from the evidence, and filling all the gray areas using a scientific method. According to results, it is possible to understand the lack of research in general on CTIS. SOSORT invites researchers to join, and clinicians to develop good research strategies to allow in the future to support or refute these recommendations according to new and stronger evidence.</p

Évaluation biomécanique du corset de providence pour le traitement conservateur de la scoliose

RÉSUMÉ La scoliose idiopathique adolescente (SIA) est une déformation tridimensionnelle de la colonne vertébrale et de la cage thoracique. Elle touche 2-3 % de la population adolescente, dont 10% nécessiteront un traitement. Les patients avec une courbe entre 20-45° reçoivent un traitement conservateur par corset. Les forces correctrices agissant sur le rachis dépendent du design et de l’ajustement du corset, ainsi que de la posture et des sollicitations musculaires du patient. Les orthèses thoraco-lombo-sacrés (TLSOs) sont utilisés pour les courbes modérées avec un apex inférieur à la 8ème vertèbre thoracique (T8). Comme le corset est habituellement porté 23 heures par jour, son mécanisme d’action n’apparaît pas optimal. Des corsets "de nuit" existent, et ils visent à améliorer l’adhérence du patient et à introduire une correction active de nuit, et une plus grande latitude le jour, permettant au patient de participer aux activités sportives. Les corsets de nuit ont moins d’effets négatifs sur le fonctionnement psycho-social, le sommeil, le mal au dos, et l’image du corps. Le corset de nuit de Providence a été introduit en 1992. Des forces latérales et rotationnelles directes sont appliquées au sommet des courbes à travers un système de 3 points d’appui. Après la prise de mesures, le corset est fabriqué en utilisant une technique de conception/fabrication assistée par ordinateur (CFAO). Souvent, une surcorrection est observée sur les radiographies en position couchée dans le corset. Les premiers résultats de l’application du corset de Providence ont été présentés en 2001. Les concepteurs du corset rapportent une correction moyenne de 90% pour les courbes doubles, et encore une meilleure correction pour les courbes simples. Le taux de réussite global est de 50% à 75%. La position couchée est également connue pour réduire les courbes scoliotiques, en particulier lors de chirurgies d'instrumentation. De nouvelles approches de simulation de corset basées sur des modèles numériques par éléments finis permettent dorénavant de tester de façon virtuelle et d’optimiser l’effet des corsets pour des patients donnés avant leur fabrication. Les corsets TLSOs sont maintenant simulés avec une représentation réaliste de l'interface de contact entre le tronc et le corset du patient. Malgré le fait que le corset de Providence est disponible depuis plus de 20 ans, la biomécanique de ce traitement ainsi que l'effet des paramètres de conception de corset et de la position couchée ne sont toujours pas bien décrites. Le modèle CFAO est choisi parmi une banque de données de corset sur la base de l'inventaire de moule, puis soumis à une dérotation de la section thoracique. Cependant, l'impact de la conception et des ajustements du corset sur les résultats ne sont pas bien compris, car aucune méthode d'évaluation n’est utilisée avant la fabrication.L'objectif de ce projet était donc de modéliser la biomécanique et d'évaluer le corset de nuit de Providence pour le traitement de la scoliose idiopathique de l'adolescent afin de mieux comprendre son mode d'action.----------ABSTRACT Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformation of the spine and rib cage. It affects 2-3% of the adolescent population, of which 10% will require treatment. Patients with a curve between 20-45° usually receive a conservative treatment by brace. Corrective forces acting on the spine depend on the design and adjustment of the brace, as well as the posture and muscular activity of the patient. Thoracolumbosacral orthoses (TLSOs) are commonly used for moderate curves with an apex inferior to the 8th thoracic vertebra (T8). As the brace is usually worn 23 hours a day, its mechanism of action seems not optimal. “Nighttime” braces exist, and they are designed to improve patient adherence and to introduce an active correction by allowing the patient to participate in sports activities. Nighttime braces have less negative impact on the psycho-social functioning, sleep, back pain and body image. Providence nighttime brace was introduced in 1992. Direct lateral and rotational forces are applied on the summits of curves through a 3-point pressure system with bolsters. After taking measurements, the brace is manufactured using computer-aided design and manufacturing (CAD/CAM) technique. An overcorrection is often observed on supine in-brace radiographs. The first results of the application of Providence brace were presented in 2001. Its designers claim an average in-brace correction of 90% for double curves, and a better correction for simple curves. Overall success rate is 50% to 75%. The prone position is also known to reduce the scoliotic curves, especially during instrumentation surgeries. New brace simulation approaches based on numerical finite element models (FEM) are now used to test virtually and optimize the effect of braces on given patients before their manufacturing. TLSOs are now simulated with a realistic representation of the contact interface between the trunk and the patient's brace. Despite the fact that the Providence brace has been available for more than 20 years, the biomechanics of this treatment and the effect of the brace design parameters and supine position are still not well described. The CAD/CAM model is selected from a brace database based on mold inventory, then subjected to derotation of the thoracic section. However, the impact of brace design and adjustments on outcomes are not well understood, as no assessment method is used prior to brace fabrication. Hence the objective of this project was to model and evaluate the biomechanics of nighttime Providence brace for the treatment of idiopathic adolescent scoliosis to better understand its mode of action. The hypotheses we addressed were that the biomechanical simulation tool allows to realistically simulate the application of the nighttime brace for the treatment of scoliosis, and that the supine position has an important role in the correction mechanism

A Passive Brace for the Treatment of Scoliosis Utilizing Compliant Mechanisms

Adolescent idiopathic scoliosis is a deformity of the spine that affects 2-3% of the population and often requires treatment in the form of a brace. Most successful braces consist of a rigid plastic shell that can be uncomfortable and limit the patient\u27s ability to perform activities of daily living. The greatest cause of treatment failure is patient unwillingness to wear the brace for the prescribed amount of time, up to 23 hours each day. Other flexible braces have been designed to overcome this obstacle, but they have a lower success rate and other drawbacks. It was proposed in this thesis that compliant mechanisms can provide the lateral stiffness required for correction combined with compliance in other directions since they naturally offer relativestiffness and compliance directions. Throughout the process of designing the brace, multiple valuable contributions were generated for various fields of study. The development of the kinematic profile of the spine included determining the locations of the three primary spinal motions and specific axes of rotation for each motion. A corrective force paradigm was used for design rather than the standard displacement paradigm, therefore, requiring a complete understanding of the force profile applied by the brace, which is not found in literature. The force system was determined through an integration of the pressure applied to the torso by a brace. In order to design in 3-dimensions, the Building Block Approach for compliant mechanism synthesis was expanded. This method was used to design the overall mechanism topology. Finally, an iteration of the brace was designed, produced, and tested. Overall, the tools necessary to design a compliant scoliosis brace were developed and can now be easily used to iterate through designs

Estimating Symmetry/Asymmetry in the Human Torso: A Novel Computational Method

Asymmetry in human body has largely been based on bilateral traits and/or subjective estimates, with potential usage in fields such as medicine, rehabilitation and apparel product design. In case of apparel, asymmetry in human body has been measured primarily by estimating differential linear measurement of bilateral traits. However, the characteristics of asymmetry can be better understood and be useful for clinicians and designers if it is quantified by considering the whole 3D surface. To address the prevailing issues in measuring asymmetry objectively, this research attempts to develop a novel method to quantify asymmetry that is robust, effective and non-invasive in operation. The method discussed here uses 3D scans of human torso to estimate asymmetry as a numerical index. Furthermore, using skeletal landmarks, twist and tilt measurements of the torsos are computed numerically. Together, these three measures can characterize the asymmetric/symmetric nature of a human torso. The approach taken in this research uses cross sections of torso to estimate local plane of symmetry that equi-divides a given cross section on the basis of its area, and connecting those planes to form a global surface that divides the torso volumetrically. The computational approach in estimating the area of cross section is based on the Green's theorem. The developed method was validated by both testing it on a known geometric model and by comparing the estimated index with subjective ratings by experts. This method has potential applications in various fields requiring characterizing asymmetry i.e., in case of scoliosis patients as diagnostic tool or an evaluation metric for rehabilitation efficiency, for body builders, and fashion models as an evaluation tool.Design, Housing and Merchandisin

A review of the effectiveness of lower limb orthoses used in cerebral palsy

To produce this review, a systematic literature search was conducted for relevant articles published in the period between the date of the previous ISPO consensus conference report on cerebral palsy (1994) and April 2008. The search terms were 'cerebral and pals* (palsy, palsies), 'hemiplegia', 'diplegia', 'orthos*' (orthoses, orthosis) orthot* (orthotic, orthotics), brace or AFO