http://informahealthcare.com/idt ISSN 1748-3107 print/ISSN 1748-3115 online Disabil Rehabil Assist Technol, Early Online: 1–6 ! 2014 Informa UK Ltd. DOI: 10.3109/17483107.2014.908245

RESEARCH PAPER

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The influence of thoracolumbosacral orthoses on standing balance in patients with adolescent idiopathic scoliosis: a pilot study Minoo Khanali, Mokhtar Arazpour, Stephen William Hutchins, Reza Vahab Kashani, Heidar Sadeghi, and Hossein Vahid Tari Department of Orthotics and Prosthetics, University of Social Welfare and Rehabilitation Science, Tehran, Iran

Abstract

Keywords

Background and aim: The objective of this study was to assess the effect of thoracolumbosacral orthoses (TLSOs) on antero-posterior (AP) sway, medio-lateral (ML) sway and displacement of the center of pressure (COP) during a longitudinal study in patients with adolescent idiopathic scoliosis (AIS). Methods: Eight females aged between 12 and 14.5 years participated in this study. Evaluations were performed prior to the TLSO intervention as a baseline condition, after 1 month, and after 4 months of orthosis use by assessing balance when standing statically on different surfaces. Results: When standing on both lower limbs on a solid surface there were significant differences in ML sway with the eyes both open and closed, and also in A/P sway but only when standing on a solid surface with the eyes open and also when standing on a foam surface with the eyes closed with TLSO use. When standing on the dominant leg, ML sway significantly improved, but AP sway only improved with a foam base surface with the eyes open. Conclusion: This study demonstrated positive effects of wearing a TLSO in improving quiet standing balance and standing on the dominant lower extremity in subjects with AIS after 4 months of brace use.

Adolescent idiopathic scoliosis, spinal orthosis, standing balance History Received 1 October 2013 Revised 28 January 2014 Accepted 21 March 2014 Published online 9 April 2014

ä Implications for Rehabilitation 

 

Due to a change in body shape such as that caused by scoliosis, human posture changes and spinal deformities affect the position of the center of support, and thus balance ability may change. AIS subjects have poor standing stability compared to a healthy matched control group. Brace wearing had positive effect in improving quiet standing balance and standing on the dominant lower extremity in subjects with AIS undergoing brace treatment after 4 months of TLSO use.

Introduction Adolescent idiopathic scoliosis (AIS) has a prevalence of between 2–4% in children aged between 10 and 16 years [1,2]. The etiology of AIS, where the spine develops lateral curvature, is reported as unknown, but genetic factors, melatonin pituitary secretion rate, muscle imbalance and neurophysiological factors have been cited [1–3]. Thermoplastic thoracolumbosacral orthoses (TLSOs) are one design of orthotic device utilized to treat AIS. These are rigid spinal orthoses used as a conservative approach to treat patients with lateral spinal curves with Cobb angles of typically between 25 and 35 . The positive clinical effects of this type of orthosis have been reported in the literature [4–7]. One design used

Address for correspondence: Mokhtar Arazpour, PhD in Orthotics and Prosthetics, Department of Orthotics and Prosthetics, University of Social Welfare and Rehabilitation Science, Kodakyar st., Daneshjo Blvd., Evin, Tehran 1985713834, Iran. Tel: 0098 (21) 22 18 00 10. Fax: 0098(21) 22 18 00 49. E-mail: [email protected]

extensively is the Boston brace, which was designed for patients with AIS who have scoliotic curves with apexes at level T8 or below. This orthosis has various trim lines depending on the curves presented, but is designed to apply corrective forces to apply transverse plane loading at or below the curve apex being targeted and also to apply de-rotational forces. It uses the pelvic section of the orthosis as a base of support and stabilization to facilitate the application of the corrective forces via specificallyplaced corrective pads. Postural stability is one of the important parameters in maintaining the body’s center of gravity (COG) in a suitable position. People need to move forwards, backwards and side to side in order to perform actions such as standing, moving, walking and running, and should therefore be able to maintain their stability when performing various activities. This means that maintenance of balance is an integral part of activities of daily living (ADLs). There is a bilateral relationship between the structure of the human body and balance. Due to any change in body shape such as scoliosis, human posture changes [8] and spinal deformities affect the position of the center of support, and thus balance may be altered.

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Spinal orthoses are one of the methods used in the treatment of idiopathic scoliosis [9–11]. Orthoses used in the treatment of scoliosis encapsulate the spine and pelvis and can affect lower extremity movements during walking [12]. However, the positive effect of the immediate use of spinal orthoses on balance while in the sitting position has been reported. Smith et al. in evaluation of the sitting pressure distribution and balance of 100 subjects with both normal and scoliotic spines demonstrated that patients with AIS have an imbalance while sitting; especially in subjects with lumbar curves and severe scoliosis, but this may be improved by bracing [13]. However, in a prospective longitudinal study on 25 subjects (23 females and 2 males, mean age 13 years) with AIS designed to assess the effect of orthosis on postural equilibrium, De Gauzy et al. demonstrated the there was no significant difference in static balance performance between baseline and after 90 d with or without orthosis use [14]. Chow et al. evaluated the balance of 20 female AIS subjects with and without a brace in situ while carrying different backpack loads, and demonstrated that wearing a TLSO had no effect in reducing the sway area measured when standing on a solid base, but did increase the sway area, displacement and medio-lateral (ML) amplitude when standing on a foam base [15]. Children with AIS have been shown to have poor postural stability control compared to normal subjects [16]. In an evaluation of the static postural equilibrium of AIS patients compared to controls, AIS patients have been shown to have increased amounts of sway, in both anteroposterior and lateral directions compared to healthy subjects [17]. In evaluation of standing balance in 15 AIS girls when fitted with a Boston brace at the 4-month follow-up, Sadeghi et al. reported no difference in the movement of the centre of pressure (COP) and sway area in AIS patients when wearing a spinal orthosis compared to without one. They demonstrated increased stiffness in the antero-posterior (AP) direction and less control in the ML axis during standing balance tests [18]. This phenomenon was confirmed in a recent study which compared AIS subjects (n ¼ 13) to a control group and concluded that the patient group had significantly higher postural instability which was improved when wearing a TLSO [19]. The evidence available to date therefore demonstrates that TLSOs have the potential to offer increased postural stability during static testing for subjects with AIS. However, the evidence of this effect following longer term brace wear is limited and the implications of increased risk of reduction of balance in AIS patients when using spinal orthosis is an important consideration. Therefore, the objective of this study was to assess the effect of TLSOs on movement of the COP and AP and ML sway during a longitudinal evaluation in patients with AIS.

Materials and methods Inclusion criteria included subjects with a diagnosis of AIS who were deemed to be suitable for wearing a thermoplastic TLSO as part of their treatment plan by an experienced spinal surgeon, and

who had either a single right thoracic or thoracolumbar curve, or a right thoracic and left lumbar scoliotic curve pattern. Patients also needed to have enough flexibility in the spine to be suitable for spinal orthosis management and had not used any orthosis before participation in the study. The presence of a spinal pathology other than AIS or subjects who had undergone previous spinal surgery was excluded from the study. Subjects The patients were referred by an orthopedic surgeon. Eight females aged between 12 and 14.5 years participated in this study. All patients had a Cobb angle of between 25 and 34 degrees and an apical vertebra below T8 level. Table 1 shows demographic data of subjects. Eight healthy subjects (girls, age 13 (SD 1.33) years, BMI 21.76 (0.576) kg/m2), without any symptoms neuromuscular and orthopedic disorders, and without history of ankle, knee or hip pain, were also recruited as a control group. All the healthy subjects were matched according to age and BMI with subjects with AIS. Patients were referred to an orthotics and prosthetics rehabilitation center to be assessed and supplied with TLSOs. A bespoke TLSO was manufactured from a corrected positive cast of each subject using polypropylene of 5-mm thickness and designed and fitted by an experienced orthotist. The width of the posterior straps was 5 cm. Figure 1 shows the design of TLSO used in this study. Instrumentation and procedure Informed consent was used to collect demographic and physical information of the volunteer subjects. The Human ethical committee of University of Social Welfare and Rehabilitation Sciences approved performance of this study. Two force platforms (Advanced Mechanical Technology, Inc., Watertown, MA) were used to collect data. Data collection for each test condition was performed three times in a gait laboratory. The patients stood on the force platform and were asked to look forwards for 20 s with their eyes open and also with their eyes closed in a randomized order. This procedure was performed while standing on both lower limbs or when standing on their dominant lower leg and also while standing on 10 cm thick soft foam placed over the force plates with the arms relaxed at the sides [20,21]. The feet were placed apart matching the approximate width of the subject’s shoulders, with an approximate rotational turn-out angle of 14 between both feet [22]. A 10-min rest time was allowed between test conditions to prevent the volunteer subjects getting tired. The first evaluation of patients was performed prior to TLSO intervention as a baseline condition. Further evaluations were performed with the TLSO in situ when subjects had worn the orthosis for 1 month and also after 4 months of use. The patients were instructed to use the spinal orthosis 23 h a day.

Table 1. Details of the anthropometry and scoliotic curvature of the volunteer subjects. No.

Gender

Age (year)

Weight (kg)

Height (m)

Curve pattern

Cobb angle (degree)

Apex level

1 2 3 4 5 6 7 8

Female Female Female Female Female Female Female Female

13 13.5 14.5 13.5 12 13 12 12.5

51 55 56 56 47 48 47 46

1.58 1.59 1.59 1.60 1.45 1.48 1.47 1.45

Left lumbar Left lumbar Right thoracolumbar Right thoracolumbar Left lumbar Right thoracolumbar Left lumbar Left lumbar

25 30 35 26 27 32 34 29

L2 L2 T12-L1 T12-L1 L2 T12-L1 L2 L2

The influence of TLSOs on standing balance

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Figure 1. The TLSO used in this study.

Table 2. Mean ± SD and comparison of parameters in the subjects with AIS and the control group at baseline. Standing on both feet Parameters Medio-lateral sway on solid base (mm)

Test condition Subjects with AIS Control group

Eyes Eyes Medio-lateral sway on foam base (mm) Eyes Eyes Anterior posterior sway on solid base (mm) Eyes Eyes Anterior posterior sway on foam base (mm) Eyes Eyes Displacement of center of pressure Eyes on solid base (mm) Eyes Displacement of center of pressure Eyes on foam base (mm) Eyes

open closed open closed open closed open closed open closed open closed

0.022 ± 0.008 0.024 ± 0.002 0.010 ± 0.009 0.025 ± 0.001 0.063 ± 0.002 0.063 ± 0.003 0.046 ± 0.003 0.041 ± 0.001 0.114 ± 0.006 0.142 ± 0.001 0.180 ± 0.001 0.304 ± 0.003

0.045 ± 0.011 0.065 ± 0.004 0.024 ± 0.006 0.035 ± 0.005 0.057 ± 0.005 0.033 ± 0.004 0.076 ± 0.001 0.082 ± 0.003 0.163 ± 0.003 0.196 ± 0.001 0.093 ± 0.007 0.126 ± 0.005

Standing on dominant foot P1 0.273 0.176 0.473 0.619 0.0719 0.161 0.008 0.000 0.277 0.627 0.125 0.060

Subjects with AIS Control group 0.073 ± 0.003 0.109 ± 0.009 0.086 ± 0.003 0.093 ± 0.005 0.049 ± 0.001 0.069 ± 0.003 0.039 ± 0.001 0.042 ± 0.001 0.332 ± 0.003 0.278 ± 0.002 0.274 ± 0.002 0.263 ± 0.001

0.065 ± 0.004 0.073 ± 0.003 0.053 ± 0.001 0.046 ± 0.007 0.043 ± 0.005 0.038 ± 0.002 0.077 ± 0.001 0.070 ± 0.004 0.228 ± 0.008 0.137 ± 0.005 0.152 ± 0.008 0.127 ± 0.001

P2 0.798 0.037 0.488 0.068 0.410 0.072 0.000 0.013 0.510 0.012 0.086 0.077

P1: Comparison between the subjects with AIS and the control group at baseline when standing on both feet. P2: Comparison between the subjects with AIS and the control group at baseline when standing on the dominant side only.

Data analysis Anterior–posterior displacement, ML displacement and displacement of the COP were calculated for each patient in each test condition. The mean of these variables were computed for each of the three primary intervention points (baseline, after 1 month, and after 4 months). Normality of data confirmed with the Kolmogrov–Smirnov method. The repeated measuring analysis test as a parametric test was used to evaluate differences in parameters for all eight subjects. SPSS version 16 (SPSS Inc., Chicago, IL) was used for data analysis. The significant level considered was  0.05.

Results Comparison between participants with AIS and healthy controls Table 2 demonstrates the mean and SD of the primary outcome measures in the first observation for subjects with AIS and the healthy control group while standing on both feet and also when standing on their dominant lower leg extremity with their eyes either open or closed when standing on solid and foam-based surfaces. ML sway on both the solid base and foam bases,

anterior–posterior sway on the foam base and displacement of COP on the solid base were all reduced in subjects with AIS when standing with both feet and also standing on their dominant lower leg during opened and closed eye conditions compared to the healthy control group (Table 2), but not significantly in most parameters. Anterior–posterior sway on the solid base and displacement of COP on the foam base were both increased in subjects with AIS when standing on both feet and standing on their dominant lower leg with their eyes open and shut compared to the healthy control group (Table 2). Performance of participants with AIS over time when standing on both feet Table 3 demonstrates the mean and SD of the parameters measured in AIS subjects at baseline, after 1 month and after 4 months of TLSO use during standing on both feet on the solid and foam-based surfaces. ML sway was increased when standing on the solid base with the eyes open and shut increased significantly following 4 months of orthosis use, but when standing on the foam-based surface, there were only significant differences noted between the first observation and after 1 month of TLSO use (p value ¼ 0.034). In addition, there were significant differences

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Table 3. Mean and SD of differences after 1 month and 4 months of TLSO use when standing on both feet compared to baseline. Parameters Medio-lateral sway on solid base (mm) Medio-lateral sway on foam base (mm) Anterior posterior sway on solid base (mm) Anterior posterior sway on foam base (mm)

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Displacement of center of pressure on solid base (mm) Displacement of center of pressure on foam base (mm)

Test conditions

Base line

after 1 month

after 4 months

p Value 1

p Value 2

p Value 3

Eyes open Eyes closed Eyes open Eyes closed Eyes open Eyes closed Eyes open Eyes closed Eyes open Eyes closed Eyes open Eyes closed

0.021 ± 0.006 0.027 ± 0.009 0.014 ± 0.003 0.003 ± 0.006 0.051 ± 0.004 0.041 ± 0.001 0.040 ± 0.005 0.026 ± 0.005 0.184 ± 0.003 0.168 ± 0.005 0.210 ± 0.005 0.219 ± 0.007

0.048 ± 0.009 0.027 ± 0.003 0.028 ± 0.008 0.018 ± 0.009 0.071 ± 0.001 0.045 ± 0.002 0.047 ± 0.003 0.037 ± 0.004 0.188 ± 0.002 0.158 ± 0.003 0.093 ± 0.002 0.191 ± 0.006

0.094 ± 0.007 0.055 ± 0.002 0.030 ± 0.004 0.025 ± 0.004 0.071 ± 0.001 0.029 ± 0.006 0.084 ± 0.003 0.041 ± 0.007 0.312 ± 0.002 0.317 ± 0.001 0.412 ± 0.009 0.312 ± 0.004

0.085 0.014 0.034 0.034 0.006 0.798 0.429 0.002 0.949 0.854 0.176 0.735

0.00 0.00 0.496 0.218 0.004 0.336 0.375 0.000 0.400 0.296 0.166 0.579

0.011 0.046 0.031 0.029 0.843 0.027 0.411 0.077 0.396 0.162 0.011 0.456

P1: Comparison of parameters between first observation and after 1 month of TLSO use. P2: Comparison of parameters between in the first observation and after 4 months of TLSO use. P3: Comparison of parameters between after 1 month and 4 months of TLSO use.

Table 4. Mean and SD of the difference between the first observation, after 1 month and after 4 months of TLSO use when standing on the dominant lower leg. Parameters Medio-lateral sway on solid base (mm) Medio-lateral sway on foam base (mm) Anterior posterior sway on solid base (mm) Anterior posterior sway on foam base (mm) Displacement of center of pressure on solid base (mm) on solid base (mm) Displacement of center of pressure on foam base(mm) on foam base (mm)

Test conditions

Baseline

Eyes open Eyes closed Eyes open Eyes closed Eyes open Eyes closed Eyes open Eyes closed Eyes open Eyes closed Eyes open Eyes closed

0.113 ± 0.008 0.108 ± 0.001 0.080 ± 0.002 0.084 ± 0.003 0.056 ± 0.002 0.084 ± 0.001 0.048 ± 0.008 0.076 ± 0.002 0.371 ± 0.008 0.358 ± 0.002 0.324 ± 0.007 0.398 ± 0.008

After 1 month After 4 months p Value 1 p Value 2 pValue 3 0.100 ± 0.006 0.031 ± 0.003 0.072 ± 0.001 0.002 ± 0.004 0.065 ± 0.002 0.052 ± 0.008 0.037 ± 0.002 0.036 ± 0.009 0.269 ± 0.002 0.236 ± 0.005 0.211 ± 0.004 0.323 ± 0.002

0.018 ± 0.084 0.031 ± 0.0740 0.056 ± 0.006 0.076 ± 0.001 0.059 ± 0.005 0.160 ± 0.002 0.034 ± 0.007 0.045 ± 0.008 0.370 ± 0.005 0.318 ± 0.006 0.279 ± 0.003 0.425 ± 0.008

0.040 0.021 0.032 0.030 0.035 0.385 0.000 0.388 0.179 0.286 0.190 0.655

0.010 0.021 0.000 0.000 0.643 0.553 0.000 0.491 0.993 0.741 0.675 0.889

0.036 0.947 0.040 0.033 0.032 0.360 0.051 0.077 0.518 0.458 0.557 0.588

P1, Comparison between the first observation and after 1 month of TLSO use. P2, Comparison between in the first observation and after 4 months of TLSO use. P3, Comparison between 1 month and 4 months of orthosis use.

noted following 1 month and after 4 months of TLSO use (Table 3). The anterior–posterior sway on both the solid and foam bases increased after 4 months of orthosis use. There were significant increases between first observation and after 1 month of TLSO use, and also between the first observation and after 4 months when standing on the solid base for both eye test conditions (Table 3). There were also significant increases between the first observation and after 1 month of TLSO use for all test conditions. However, between the first observation and after 4 months of TLSO use, this was only demonstrated with the eyes closed for the foam-based condition (Table 3). When analyzing alteration to the displacement of the COP, using the orthosis for 1 month reduced the mean displacement on both solid and foam-based conditions with the eyes both open and closed, but after 4 months of wearing the orthosis this parameter increased compared to baseline and after 1 month of orthosis use. There were no significant differences when comparing open and closed eye conditions during solid and foam-based test conditions (Table 3).

There were significant differences between 1 month and 4 months of orthosis use and baseline in ML sway. Orthosis use increased ML sway of the centre of pressure (COP) when standing on the solid base in both open and closed eye conditions. The mean of ML sway on the foam base was however reduced compared to baseline in both open and closed conditions after 4 months orthosis use. There were significant reductions between 1 month and 4 months orthosis using compared to baseline. In A/P sway of the COP, there was no significant difference noted between the first observation and after 4 months using the TLSO on the solid based during open and closed eyes conditions. However, when standing on the foam-based surface, there were significant differences between after 1 month and 4 months of orthosis use and the baseline, but only when the eyes were open. As when standing on both lower limbs, when standing on the dominant lower leg, the mean of the COP excursion reduced after 1 month of orthosis use, but after 4 months of wearing the TLSO the rate of this parameter for both eye test conditions on the solidand foam-based conditions increased. There were no significant differences demonstrated between 1 and 4 months of orthosis using and baseline (Table 4).

Performance of participants with AIS over time when standing on their dominant foot

Discussion

Table 4 demonstrates the mean and SD of the primary outcome measures at the first observation, after 1 month and after 4 months of TLSO use during standing on the dominant lower leg with both eye test conditions on both solid and foam-based surfaces.

This study investigated the effect of wearing a custom molded thermoplastic TLSO on postural stability in subjects with AIS. These devices by definition, encapsulate the relevant areas of the spine while correcting alignment and restricting movement and

The influence of TLSOs on standing balance

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DOI: 10.3109/17483107.2014.908245

enhance spinal stability. Consequently, this restriction may affect the contribution of spinal and pelvic motion to provision of postural stability in AIS subjects. The results of this study demonstrated that at baseline, ML sway on both a solid and foam base and anterior posterior sway on the foam base was reduced compared to healthy normal subjects. Excursion of the COP on the solid base also decreased during all standing conditions when wearing the TLSO. This reduction may have been associated with the reduction in trunk movement when the spinal orthosis was worn. The results of this present study indicate that AIS subjects have poor standing stability compared to a healthy matched control group and confirm the findings of previous studies. Chen et al. reported that scoliosis subjects had poor balance compared to normal healthy subjects. Chow et al. when comparing the standing posture and balance of young female subjects with AIS and normal controls while using a backpack type weight demonstrated that wearing the backpack produced a negative effect on the standing posture and balance in the AIS subjects. In comparison between the two groups, the subjects with AIS had poor standing posture and balance compared to the healthy control group [15]. In addition, during evaluation of balance control while sitting, Bent et al. reported subjects with AIS demonstrated a reduction of trunk sway, which provided stability [23]. Conventional TLSOs are fabricated to be worn for relatively long time periods for correction for realignment of the spine in persons with AIS. All the parameters analyzed in this study after 4 months of orthosis use improved compared to the baseline condition. Improvement in the scoliotic curves and spinal alignment, plus stimulation of spinal muscle activity, may have caused improvement of the ML and AP sway in subjects with AIS in this study [24]. However, these causes need to be analyzed in a future study. In addition, an ankle strategy may have maintained balance because this joint motion is needed to keep the COP within the base of support which is provided predominantly around the ankles [25]. When standing on a solid base an ankle joint strategy may be enough to provide balance because the proprioceptive feedback mechanism is not influenced and increased rigidity of the pelvis and trunk in wearing the TLSO will not affect the balance performance. The results of this study demonstrate there was no statistically significant alteration when wearing a TLSO on the balance function of subjects with AIS when the visual (e.g. open and close eyes) and proprioceptive systems (e.g. solid and foam base) are simultaneously challenged. Balance is challenged when standing on the foam base, because the ankle strategy may not be sufficient to provide balance, and therefore balance may be maintained by increasing motion of the pelvis and trunk. This study demonstrated that wearing an orthosis affected patients with AIS in standing on the foam base when proprioception was challenged by causing a reduction of static balance function in AIS subjects compared to when standing on a solid base. Adler et al. [25] found that AIS subjects who used spinal orthosis had better function in balance evaluation compared to AIS subjects who did not use spinal orthosis. They proposed that the orthosis might have a therapeutic effect in providing balance in patients with AIS. This present study showed that the spinal orthosis produced a longterm training effect in gradual improvement of balance function. Wearing the orthosis for 1 month reduced the displacement of the COP when challenging of the visual and proprioceptive systems. This may have been due to the effect of the immediate correction of the spine by the TLSO, but after 4 months of wearing the orthosis this parameter increased compared to baseline and after 1 month of orthosis use. This point may have occurred due to accommodation of the spine to the correction forces applied by the orthosis. There were no significant

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differences in test conditions when the visual system was simultaneously challenged. During standing on both legs, to maintain adequate balance while subjects wear a TLSO, step width may be increased. This could have been caused by limitation and decreased hip abduction–adduction ROM, which may have prevented the subjects’ ability to achieve an increase in step width. However this needs to be confirmed in a future study. Weaknesses and limitation of this present study This study has some limitations. The sample size was small, which makes generalizations difficult. Additionally, this research performed on only AIS subjects with a single major scoliotic curve, as no subjects with double major curves were recruited. The daily orthosis wear time was not controlled during the study although all subjects were recommended to wear the orthosis for 23 h per day.

Conclusion Brace wearing had positive effects in improving quiet standing balance (M/L sway with their eyes both open and closed, A/P sway only when standing on a solid surface with the eyes open and also when standing on a foam surface with the eyes closed) and standing on the dominant lower extremity (M/L sway in all conditions, A/P sway in a foam base surface with their eyes open) in subjects with AIS undergoing brace treatment after 4 months of TLSO use.

Declaration of interest The authors declare no conflicts of interests. The authors alone are responsible for the content and writing of this article.

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The influence of thoracolumbosacral orthoses on standing balance in patients with adolescent idiopathic scoliosis: a pilot study.

Abstract Background and aim: The objective of this study was to assess the effect of thoracolumbosacral orthoses (TLSOs) on antero-posterior (AP) sway...
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