Journal of Medical and Biological Engineering, 32(1): 29-35

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Using Finite Element Method to Determine Pad Positions in a Boston Brace for Enhancing Corrective Effect on Scoliotic Spine: A Preliminary Analysis
Wen-Kai Chou1 Chien-Lin Liu2 Yi-Ching Liao3 Fang-Hsin Cheng1,4 Chen-Sheng Chen1,*

Zheng-Cheng Zhong1
1

Department of Physical Therapy and Assistive Technology, National Yang Ming University, Taipei 112, Taiwan, ROC 2 Department of Orthopedic Surgery, Veterans General Hospital-Taipei, Taipei 112, Taiwan, ROC 3 Department of Rehabilitation, Mackay Memorial Hospital, Taipei 104, Taiwan, ROC 4 Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei 112, Taiwan, ROC Received 22 Mar 2010; Accepted 9 Sep 2010; doi: 10.5405/jmbe.758

Abstract
Scoliosis, the three-dimensional (3D) deformation of the spinal column, is likely to worsen without early intervention. The Boston brace has been widely used to correct abnormal spinal curvature and prevent deformity progression. However, two-dimensional (2D) X-ray images and an experienced therapist are required for a proper Boston brace to be fabricated. There has been little research on how to determine the pad positions of a Boston brace to yield a better corrective effect on a scoliotic spine. This study uses the finite element (FE) method to determine the optimal pad positions for a Boston brace. The software ANSYS 11.0 is employed to establish an FE model of the trunk and brace from S-shaped scoliosis. After the FE model is validated, fifteen FE models with pad positions rotated in a range of 0 to 30 degrees and translated in a range of 0 to 30 mm are created to investigate the effects on correcting a scoliotic spine. A 3D FE model of a scoliotic spine is established to calculate the corrective effect of a Boston brace. The FE analysis indicates that the brace pad at the rib of the apex vertebra should be rotated 20 posteriorly for the optimal corrective effect. Compared to a traditional brace, the modified brace increases the corrective effect on the thoracic and lumbar spine, and lowers the mean contact pressure of the thoracic pad. Additionally, the comfort of the modified brace is comparable to that of a traditional brace, as measured using the visual analogue scale. Keywords: Scoliosis, Boston brace, Finite element method (FEM), Spine

1. Introduction
Scoliosis, the three-dimensional (3D) deformation of the spinal column, includes abnormal lateral deviation and a tilt of more than 10 in the frontal plane, displacement in the sagittal plane, and rotation in the transverse plane [1]. If left untreated, the condition cause backaches and functional impairment in daily activities [1-4]. The Boston brace has been proven to slow down the natural progression of scoliosis and reduce the need for surgical intervention [5-7]. Compared with other treatment methods (therapeutic exercise, positional exercise, and lateral-body electronic stimulation), the Boston brace yields a better corrective effect on a scoliotic spine [8]. A previous study noted that the more the Cobb angle (CA) can be lowered,
* Corresponding author: Chen-Sheng Chen Tel: +886-2-28267353; Fax: +886-2-28270140 E-mail: cschen@ym.edu.tw

the less chance there is for aggravation of the condition during early brace wearing [9]. Clinically, 2D posterior-anterior X-ray images and an experienced therapist are required for a proper Boston brace to be fabricated. However, few studies have investigated how to position the pads within the brace to produce the optimal corrective effect on a scoliotic spine. Because of the difficulty associated with human testing and the ethical problem of repetitive radiation exposure for the examination of a scoliotic spine, previous studies analysed the biomechanical interactions between the spine and brace using finite element (FE) models. An FE model, including the ribs and spinal column, composed of 3D elastic beam elements, was developed to determine the magnitude and direction of the applied force in a scoliotic spine and to predict the effect of wearing a Boston brace before brace fabrication [10]. Using a detailed human trunk model and a parametric brace model, it was found that scoliotic correction is associated with the tensile force of the straps and the brace geometry [11].

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Additionally, when the sagittal curve of the brace was reduced, both the lordosis and the kyphosis of the patient decreased [12]. To remove redundant material in a Boston brace, an FE model with topology optimization was implemented to reduce the braces weight [13]. Although many studies have examined the relationship between the application of a Boston brace and the correction of scoliosis, few studies have considered the effect of pad placement. The corrective force on the scoliotic spine is transferred from the strap force to the scoliotic spine via the brace pad. Therefore, the pad position is the loading point for the interaction between the scoliotic spine and the brace strap. However, previous studies have not addressed how to determine optimal pad positions. Most FE studies have instead focused on the calculation of the directly applied force to the spine and the effect of the brace strap force. For manufacturers, more information is needed for determining optimal pad position. Therefore, the present study employs an FE model to analyse the relationship between pad positions and the corrective effect on scoliosis.

Table 1. Translation and rotation of each vertebral body relative to the L5 vertebral body. Tx (mm) -25 -25 -25 -25 -25 -21 -13 -7 -4 -5 -11 -16 -23 -27 -26 -21 -9 0 Ty (mm) -78 -79 -80 -82 -81 -81 -79 -79 -76 -68 -63 -52 -44 -31 -18 -8 -2 0 Tz (mm) 404 387 370 353 334 313 293 272 250 226 204 183 157 128 98 67 36 0 Rx (degrees) 0 0 0 0 -1 -3 -5 -5 -3 -1 0 5 13 20 16 12 5 0 Ry (degrees) -3 -2 -2 -4 -3 1 6 10 14 15 14 13 15 16 15 6 0 0 Rz (degrees) 0 0 0 0 9 18 15 9 1 -13 -16 -9 -4 3 11 17 13 0

C7 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5

2. Materials and methods

2.1 Reconstruction of scoliotic trunk and brace model Two subjects provided written informed consent prior to participation in the study, which was approved by the Institutional Review Board of National Yang Ming University (#IRB970042). One teenage girl (13 years old, Lenke-type 2C, 37.4 right thoracic and 34.3 left lumbar CAs) with adolescent idiopathic scoliosis was enrolled in this study. A traditional Boston brace was custom-made for this girl. The translation and rotation of each vertebral body, relative to the midpoint of the upper endplate of the L5 vertebral body, were measured from an X-ray image; the results are listed in Table 1. The rotational measurement method of the vertebral body was adopted from a previous study [14]. The geometry and material properties of the vertebral body were adopted from a previously validated FE model [15-17]. After acquiring the location data, the FE model of a scoliotic spine was reconstructed using the ANSYS parametric design language (APDL) of the FE software package ANSYS 11.0 (ANSYS Inc., Canonsburg, PA, USA), as shown in Figs. 1(a) and 1(b). The vertebral body of the spinal FE model, comprising cortical and cancellous bone and posterior elements, was constructed using 8-node solid hexahedral element. The intervertebral disc, comprising nucleus pulposus, annulus fibrosus, and an endplate, was constructed using a 2-node cable and 8-node hexahedral solid elements. The material properties of the disc model were simulated as linear elastic, homogenous, and solid monophasic behaviour. Spinal ligaments, namely the anterior longitudinal ligament, the posterior longitudinal ligament, the interspinous ligament, the supraspinous ligament, the ligamentum flavum, the transverse ligament, and the facet capsular ligament, were constructed using 2-node cable elements.

Note: Tx: translation in the medio-lateral direction; Ty: translation in the antero-posterior direction; Tz: translation in the vertical direction. Rx: rotation in the transverse plane; Ry: rotation in the sagittal plane; Rz: rotation in the frontal plane.

(a)

(b)

(c)

(d)

(e)

(f)

Figure 1. FE models of scoliotic spine and Boston brace. (a) FE model from C7 to L5 vertebral body, (b) motion segment, (c) measurement of trunk, (d) trunk FE model, (e) measurement of brace shape, and (f) brace FE model.

FE Analysis of Boston Brace

31

The geometries of the thoracic cage and abdominal cavities were reconstructed according to the trunk space coordinates recorded by an optic motion analysis system (PTI Visualeyez 4000, PhoeniX Technologies Incorporated, Canada). 53 markers were attached to the ribs, the xiphoid process and the seventh cervical spinous process around the posterior, and the lateral and anterior-lateral regions of the thoracic cavity, as shown in Fig. 1(c). In addition, 12 markers were attached to the abdominal cavity and pelvis. The FE model of the trunk with a scoliotic spine consisted of 40608 elements and 22792 nodes, as shown in Fig. 1(d). The FE model of the brace was also reconstructed using the optic motion analysis system. To obtain an accurate shape of the Boston brace, 205 markers were attached on the brace and nine markers were attached to the thoracic and lumbar pads to measure brace geometry, as shown in Fig. 1(e). The pads and shell of the FE model of the brace were simulated using four-node solid elements and four-node shell elements, respectively, and reconstructed using 19852 elements and 8869 nodes, as shown in Fig. 1(f). The thickness of the brace model was 4 mm, measured from a traditional Boston brace. The contact behaviour between the brace pads and trunk was simulated using 8-node surface-to-surface contact elements. The normal penalty stiffness and penetration tolerance factor were set to 5 107 and 0.1, respectively. The material properties of the spinal components and the brace shell and pads were adopted from previous studies [15-21]. 2.2 Loading and boundary conditions The boundary conditions were set such that the fifth lumbar vertebra was immobilised in order to simulate little mobility in the fifth lumbar vertebra when the brace is worn. When the actual brace was worn, a displacement of 2 mm was measured at the C7 cervical vertebra from an X-ray image. A displacement of 2 mm was thus applied in the medial-lateral direction in the FE model. The forces of the three straps of the actual Boston brace were 57, 88, and 93 N, respectively, as measured using a tensile meter (Japan Instrument System Co., Ltd, Japan) in 30 seconds; these values were applied to the FE model as the loading condition. The brace put on the patient as follows: (1) the relative positions of the brace and pads were confirmed; (2) a displacement was applied at the positions of the straps to open the brace; (3) the displacement was removed to make the brace close to the trunk; (4) the strap force measured by a tensile meter was applied (Fig. 2). 2.3 Validation of the FE model For model validation, the calculation of the FE model was compared to measurements obtained from an X-ray image in terms of vertebral body displacement, CA, and contact pressure between the torso and brace [19,20]. For each vertebral body displacement, the correlation coefficient (CC), the mean error, and the maximum error between the X-ray image measurement and FE calculation were compared using.
CC 18 i 1{(T _ D i T _ D) (FE _ D i FE _ D)}
2 18 2 18 i 1 (T _ D i T _ D) i1 (FE _ D i FE _ D)

(a)

(b)

(c) Figure 2. Loading conditions used to simulate the wearing of a brace. (a) Confirmation of the relative positions between the brace and trunk. (b) Opening of the brace and moving brace to trunk. (c) Tensile force applied to the strap to install the brace.

Mean

error
18

18 i 1

FE _ Di T _ Di 18

(2)

T_D

i1 T _ Di
18

(3)

FE _ D

i1 FE _ Di
18

18

(4)

Where T_D: vertebral displacement measured from X-ray image; FE_D: vertebral displacement calculated from FE simulation; T _ D : average vertebral displacement measured from X-ray image; FE _ D : average vertebral displacement calculated from FE simulation; i: vertebral body in the scoliotic spine. Additionally, an X-sensor pad (XSENSOR Technology Corporation, Florida, USA) was used to measure the contact pressure at the lumbar and thoracic pads. The mean contact pressures of the X-sensor measurement and FE calculation were compared for further validation. 2.4 Parametric analysis of pad positions To investigate the effect of pad position, a parametric analysis of pad movement and posterior rotation along the inner lining of the shell was conducted. The displacements along the Z-axis (DZ) on the frontal plane were 0, 10, 20, and 30 mm, respectively, as shown in Fig. 3(a). A DZ of zero indicates no change in the pad height, which was originally set at the rib of the apex vertebra by an experienced therapist, and a DZ of 10 indicates a 10-mm downward movement of the pad. The rotations (ROs) along the transverse plane were 0, 10, 20, and 30 posterior to the original pad position, respectively, as shown in Fig. 3(b). A total of sixteen FE models with various pad positions were used to analyse the corrective effect on a scoliotic spine, measured in terms of the correction rate (CR). A higher CR represents a better corrective effect.

(1)

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CR={(CA without brace-CA with brace)/(CA without brace)}*100% (5)

Table 2. Comparison of the vertebral displacement between X-ray measurement and FE analysis for a patient with and without a brace. Vertebral displacement Vertebral displacement Error from measurementmm from FE analysismm mm C7 1.47 2.50 1.03 T1 1.10 2.23 1.13 T2 0.90 2.44 1.54 T3 1.57 2.64 1.07 T4 2.67 2.80 0.13 T5 3.93 2.96 -0.97 T6 3.40 3.03 -0.38 T7 3.43 3.10 -0.34 T8 2.23 3.05 0.81 T9 1.73 2.83 1.10 T10 1.26 2.67 1.41 T11 1.80 2.40 0.60 T12 3.53 3.17 -0.36 L1 4.90 3.80 -1.10 L2 4.70 2.95 -1.75 L3 4.60 2.86 -1.74 L4 2.20 0.36 -1.84 L5 0.00 0.00 0.0
*error = measured vertebral displacement - calculated vertebral displacement

DZ

(a)

RO
(b) Figure 3. Parameters for pad position. (a) Displacement along Z-axis (DZ) on the frontal plane. (b) Rotations (RO) along the transverse plane.

2.5 Human test After the optimal pad positions were determined using FE simulations, another teenage girl with a similar scoliotic type (11 years old, Lenke-type 2C, 37 right thoracic and 38.9 left lumbar CAs) was recruited to compare the traditional and modified Boston braces. Under a given set of strap forces, the biomechanical effects of the two braces were compared in terms of CA, contact pressure between the torso and brace, and discomfort using a visual analogue scale (VAS) questionnaire. The VAS score ranged from 0 to 10, where 0 indicates the highest comfort, and 10 indicates the highest discomfort.

3. Results
3.1 Validation of scoliotic spine FE model 3.1.1 Comparison of vertebral body displacement and CA For vertebral body displacement, the mean error, maximum error, and CC were 0.96 0.55 mm, 1.84 mm, and 0.99, respectively. The FE results were consistent with the measurements from X-ray images in terms of vertebral body displacement. The maximum vertebral displacement occurred at the L1 vertebral body, as shown in Fig. 4 and Table 2. For X-ray image measurement, the CAs of the thoracic and lumbar spine were respectively reduced to 27.4 (from 37.4) and 27.7 (from 34.3). However, in the FE analysis, the CAs of the thoracic and lumbar spine only reduced to 30.9 and 31.9, respectively. Although the FE analysis results and X-ray image measurements exhibited similar trends in terms of vertebral body displacement, the stiffness of the FE model was higher than that of the real scoliotic spine.
Figure 4. Comparison of vertebral body displacement between X-ray image measurement and FE simulation.

3.1.2 Comparison of mean pad pressure The mean contact pressure under the right thoracic pad, measured using the X-sensor, was 61.62 mmHg; that from the FE model simulation was 67.71 mmHg. The mean contact pressure under the left lumbar, measured using the X-sensor, was 56.36 mmHg; that from the FE model simulation was 60.26 mmHg. The contact pressures in the FE simulation were greater than those from X-sensor measurements by 7 to 10%. 3.2 FE analysis of pad positions For the thoracic spine, the FE analysis results show that rotating the pad 20 posteriorly yielded the best corrective

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effect in terms of the CR, as shown in Fig. 5(a). For the lumbar spine, rotating the pad 10 or 20 with a displacement of 30 mm yielded the best corrective effect in terms of the CR, as shown in Fig. 5(b). Considering the corrective effect of the thoracic and lumbar spine simultaneously, rotating the pad 20 posteriorly yielded the best corrective effect, as shown in Figs. 6(a) and 6(b).

Table 3. Comparison of traditional and modified braces in a human test. Without brace Thoracic Cobb angle (degrees) (CR, %) Lumbar Cobb angle (degrees) (CR, %) Thoracic apex rotation (grade) Lumbar apex rotation (grade) Mean pressure of thoracic pad (mmHg) Mean pressure of lumbar pad (mmHg) VAS (grade) 37 38.9 1-2 1 Traditional brace 31.4 (15%) 29.4 (24%) 1 0 78.9 53.5 6 Modified brace 24.3 (34%) 22 (43%) 0 0 57.3 55.3 5

Note: Thoracic and lumbar apex rotations were graded from 1 to 4 based on a previous study [14]. Grades 1, 2, 3, and 4 refer to vertebral body rotations of 5, 15, 30, and 40, respectively.

(a) (a) (b)

(c)

(d) Figure 6. Comparison of traditional and modified braces in terms of pad position and contact pressure. (a) Traditional brace, (b) modified brace (pad rotated 20 posteriorly), (c) contact pressure distribution of traditional brace, and (d) contact pressure distribution of modified brace (left circle for the lumbar pad; right circle for the thoracic pad).

(b) Figure 5. Comparsion of CR for FE models with various DZs and ROs for (a) thoracic spine and (b) lumbar spine (arrow indicates the highest CR value).

4. Discussion
This study established a scoliotic spine FE model to predict the optimal pad locations for enhancing the corrective effect of the Boston brace. To validate the FE model, each vertebral body displacement from FE analysis and X-ray image measurements was compared. The results indicate that the maximum error is equal to or less than that obtained in a previous study [20], as shown in Fig. 7. To further validate the proposed scoliotic spine FE model, the X-sensor device was employed to measure contact pressure between the brace pad and the torso. Good agreement with FE calculations was obtained, which can be attributed to a detailed construction of the FE model (disc and vertebral body solid model was used rather than a simple beam model). As a result, the calculation of the rotation of the scoliotic spine was more accurate than

3.3 Human test wearing traditional and modified braces The second patient respectively wore traditional and modified braces. The strap forces were measured to be 35, 40, and 45 N. Under a given set of strap forces, the CR of the modified brace was higher than that of the traditional brace in both the thoracic and lumbar spine, as listed in Table 3. From the X-sensor measurements, the mean contact pressure of the thoracic pad for the modified brace was about 27% lower than that of the traditional brace, as listed in Table 3 and shown in Figs. 6(c) and 6(d). However, the mean contact pressure of the lumbar pad was slightly increased in the modified brace. Additionally, the VAS score for wearing the modified brace was reduced from 6 to 5.

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that in a previous FE model [20]. Furthermore, the shape of the FE model of the brace was more accurate than that in a previous study [11]. However, the mean pad pressures in the proposed FE model were about 10% higher than those measured using the X-sensor, which may be attributed to active muscle contraction during X-sensor measurement.
7 6 5.9 4.4

Present study Case 1 (P'eri'e et al._2004) Case 2 (P'eri'e et al._2004) Case 3 (P'eri'e et al._2004)
1.84 2 0.96 2.2 0.9 1.8

5 4 3 2 1 0 Max. error

Mean error

Figure 7. Comparison of vertebral body displacement between this study and previous studies in terms of the mean and maximum errors. Note: Perie et als study was performed on three teenage girls (case 1,case 2 and case 3) with idiopathic scoliosis (1313.5 years old; 3550 right thoracic and 2140 left lumbar Cobb angles) and treated by a Boston brace. A personalized biomechanical FE model was built for each patient without brace. The scoliotic model contains 1356 nodes and 2801 elements representing the osseo-ligamentous structures of the torso. The thoracic and lumbar vertebrae, intervertebral discs, ribs, sternum and cartilages were represented by 3D elastic beam elements.

that the FE results are only suitable for the S-type scoliotic spine case, rather than for the C-type case. The proposed FE model makes some simplifications, such as ignoring active muscle contraction and simplifying the articular surface of the facet joint in cervical and thoracic vertebrae. As to the material properties of the spine, the mechanical behavior of the spine varies with each scoliotic spine case. Additionally, a scoliotic spine is mostly observed in teenagers, whose immature spines should be relatively flexible. However, the material properties of the current FE spine model are adopted from an adult spine, making it more rigid than a real scoliotic spine. Each vertebral shape adjusted in this scoliotic spine model referred to the shape of the fifth lumbar vertebral body, so the specific shapes of the thoracic and cervical spine and wedged vertebrae and discs of a scoliotic spine are neglected. The rotation of each vertebral body was measured using 2D X-ray images [14], so the rotation of each vertebral body may include measurement error. In addition, the human test only included one case and evaluated the immediate corrective effects of wearing traditional and modified braces. However, daily human activities have an impact on the brace treatment effect. Therefore, the long-term corrective effects of the modified brace must be investigated and more cases must be examined in future studies.

Displacement (mm)

5. Conclusions
This study constructed a parametric human scoliosis FE model including detailed vertebral structures, ribs, and soft tissue of the chest and abdominal cavities. A Boston brace FE model with various pad positions was also constructed to parametrically analyse the correction of S-shaped scoliosis. The FE analysis and human test results show that a pad located at the rib of the apex vertebra and rotated 20 posteriorly had the best corrective effect on a scolioitc spine in terms of the Cobb angle for a Lenke-type 2C case.

The Boston brace offers three-point bending correction for the scoliotic spine, as shown in 2D radiographic images (Fig. 1(a). Under a given set of strap forces, this study showed that the modified brace could achieve a better corrective effect as well as reduce mean contact pressure on the thoracic pad compared to the traditional brace. Rotating the pad 20 posteriorly allowed the modified Boston brace to generate a de-rotation effect of the scoliotic spine, thus providing good 3D deformity correction. Especially in thoracic apex rotation, the human test results indicate that the vertebral body rotation while wearing a traditional brace was about 5, whereas that while wearing the modified brace was 0, as listed in Table 3. Therefore, pad positions can be adjusted without increasing the brace strap force to generate an axial rotation effect. Combining three-point bending with rotation effects should allow the Boston brace to provide a better corrective effect on a scoliotic spine without increasing the contact pressure between the torso and brace. This study employed a detailed scoliotic spine FE model to determine the optimal pad positions for correcting scoliotic spines without increasing contact pressure. However, some assumptions were made in this study. The cases examined in this study were thoracic-lumbar S-type moderate idiopathic scoliosis, but scoliosis has many types and degrees of severity. The proposed FE model could accommodate changes in the scoliotic type and degree of severity using parameter control. Brace effectiveness for various types of scoliosis can be investigated in future studies using this FE model. It is notable

Acknowledgements
This research was supported in part by the Veterans General Hospitals University System of Taiwan Joint Research Program (VGHUST99-P6-34) and by the National Science Council (NSC 97-2314-B-010-057-MY3).

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