Spine is one the most important parts of the human body, running along the center of the back, providing support to the head, shoulders and upper body. The spine also encases the spinal cord, which connects our brain, the message house, with the rest of body. The pivotal role played by a spinal cord can be compromised in various pathologies of the spine, affecting mobility and comfort and standards of living for a person. Amongst the various ailments of the spine, spinal scoliosis is one of the most common conditions. Spinal scoliosis is a three-dimensional deformity of the spine that causes it to twist out of shape. The most commonly affected age-group is that of children in their growth spurt, where their spine grows sideways. The most common signs of scoliosis are the improper alignment of the shoulders or a shoulder blade that sticks out. In severe cases, scoliosis can cause breathing problems, lower back pain, persistent pain in the body and other complications of the spinal cord and a permanent lifestyle change. There is no known cause of the deformity, but prevention can be done by wearing orthotic braces for support to maintain a straight shape of the spine to mitigate the abrupt curvatures.

Scoliosis can be qualified as functional and structural scoliosis. Functional scoliosis may be corrected, whereas it is harder to correct the curvature in structural scoliosis. Structural scoliosis further branches into idiopathic and pathological scoliosis. There is no known cause for idiopathic scoliosis, whereas underlying the former is some sort of pathology that can be diagnosed.

Scoliosis is a complex subject that needs a strong grip on the pathology and biomechanics of the subject, along with practical knowledge of how to administer the right kind of preventive care and deliver quality products to patients. To professionally train the prosthetists and orthotists in Pakistan on the subject, the Rehab Initiative in collaboration with the International Committee of the Red Cross and Human Study e.v (Germany) organized a blended learning module on Corrective Spinal Bracing- Scoliosis from March to June 2019.

The module consisted of an online theoretical learning period of five to six weeks which included the detailed study of the theory of scoliosis via a web platform as a pre-requisite to the practical knowledge. This schedule consisted of online interactive lectures delivered by trainers of Human Study followed by regular assessment through quizzes on the subject. The online lessons provide P&Os the opportunity to participate in the lectures during work hours with undisturbed practice. After completion of the online courses, the trainers then visited the Rehab Initiative Islamabad for a period of one week to practically train the P&Os in the field by real case stimulation in Pakistan.

This training exposed participating ortho-prosthetists to a latest concept on scoliosis bracing called soberheim technique, which has been designed by cooperation of experts with extensive experience in scoliosis and kyphosis to ensure optimal condition for patientcare. Soberheim technique is one of the most complex, yet effective techniques for the correction of scoliosis, which divides the spinal deformity into different classes starting from s1 to s5. A different orthosis is made for each classification. The following is a brief overview of the training for spinal orthotics and all the steps involved in fabrication of a spinal orthosis for patients with scoliosis.

• Assessment:

The first day concluded with a recap of the theory behind diagnosis of scoliosis along with its pathology and biomechanics. Scoliosis is a complex subject, and to produce good quality orthoses, one needs to master the theory along with the clinical side of it. The theoretical session was an interactive day-long exercise with P&Os inquiring about all their relevant queries. The next day of the training was the day when patients came in for assessment. During the assessment, the trainers and participants had a careful examination of their patients. For scoliosis, the patients had an X-ray of their spine along with them. By using the Soberheim technique, the P&Os assessed the patients by an in-depth examination of their X-ray. By making a cob’s angle on the x-ray and determining the curves, the P&Os can decide which design is to be made for the patient and what corrective forces need to be applied in accordance with their level of deformity. After careful assessment, the P&Os then prescribed the devices for each patient which were to be fabricated by them in the days to follow.

• Casting

After careful assessment of the patients, the trainers and participants performed casting on their patients. The patients mostly consisted of children and teenagers as best treatment is achieved when patients are treated in early age. As per procedure, the trainers demonstrated casting on a patient. They carefully wrapped a cellophane sheet around the patient’s thorax, abdomen and shoulders of the patient under observation. After marking the relevant places on the spine, where the pressure is to be applied, the trainers then wrapped soaked bandage of plaster of Paris around the targeted area of the patient.

POP bandage is then massaged to take an impression of the spine while applying corrective pressures to achieve a maximum corrected position in negative cast. Once the plaster was set and dried this negative cast was removed off of the patient’s body. The participant P&Os followed the steps as demonstrated by the trainers to achieve the perfect casts for their patients. The negative casts are then filled with a POP mix and then dried to create a positive cast or the model.

• Modification

One of the crucial steps in getting the most fitting spinal jacket is achieved through modification. In the modification process, the trainers demonstrated the various pressure areas on which pressure will be applied and how to achieve the exact impression accommodating all spaces and pressure areas. In the modification step, the P&O participants trimmed off the excess material built on their models to achieve the exact measurements as identified in the initial assessment by using various buffing tools. Once these models were ready, they were taken to the machine room for the fabrication of the orthosis.

• Molding

With each P&O having rectified replicas of their patients’ segment, they proceeded to the machine room for the molding of the device. In this step the individual P&Os under supervision by their trainers performed thermoforming by using heated pliable PP (Copolymer) sheets to mold onto the model. Once draped on to the model, a seam is formed vertically at the center in front and the excess sheet is trimmed off. All of this is done in the presence of vacuum suction so that the plastic sheet takes the exact shape of the model. After successful molding of the jackets, the P&Os then finished their spinal braces to give it a final shape.

• Finishing

Trim-lines corresponding to the needs of the patient are then drawn on the jacket. Excess PP is cut and buffed through router machines to create smooth edges. Protective wear needs to be worn on the eyes at this point due to the tiny particles of polypropylene being buffed off.

• Fitting & Gait training.

On day 5 of the training, all the patients were called again at the RI for the first fitting of the orthotic brace fabricated by the P&Os. The initial fittings were successful. After subjective feedback from the patients and trainers after first fittings, small re-adjustments were made to the jackets to achieve maximum correction with comfort of the patient. In the Soberheim technique, the patient does physio exercises while wearing the jacket. Spaces are left in the jacket to accommodate corrective forces. Once all readjustments have been made to the jacket, belts are buckled onto it to retain the pressure applying forces.

The training on scoliosis has been one of the most sought after modules in the P&O community in Pakistan because of the complex treatment it brings along with it. The trainers were thrilled at the students’ keen interest on the subject and enthusiasm in learning the Soberheim technique. After fabrication and fitting of the spinal brace, the students were then evaluated in an online exam which was conducted at the RI premises under supervision of the trainers.

This exam evaluates all the accumulated knowledge on the subject. The head of the department from the Indus Hospital Karachi and Ortho-prosthetist from Rehab Initiative scored the highest marks in the test. Following the online exam, the Rehab Initiative and the ICRC formally concluded the training by hosting a closing ceremony for all the trainers and the participants. Representatives from main departments of the ICRC were invited along with the board members of the RI. In the closing ceremony, the Head of Delegation of ICRC, Mrs. Dragana Kojic applauded the efforts of the Physical Rehabilitation department of the ICRC along with the RI for the successful conclusion of the training. Members of the board highlighted the significance of ortho-prosthetists in the continuum of physical rehabilitation and how initiatives like these in the long run will open the door for the modern technology in prosthetics and orthotics to seep into Pakistan. The participant P&Os now hold a specialized certification in spinal orthotics which they acquired by replicating the procedures in their own rehab centers/hospitals by providing treatment to the patients in the same way as learned here. These participant P&Os act as a key resource in proliferating the skills learned here in the training and disseminate it to other fellow P&Os, which will create a series of knowledge sharing among the P&Os, providing support to the physical rehabilitation sector.