The uncertain change sources.
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In the pursuit of smart manufacturing, to satisfy the customer needs with quality, responsiveness and cost-effectiveness become the major challenge of nowadays factories [1]. The market demands are uncertain [2] and prone to be influenced by the composite effects of the driven forces, including the following:
To effectively fulfill the business model of uncertain sales orders ensuring the product responsive delivery, the factory must prepare adequate resources, including the material and the workforce in advance. The more prepared resources are in advance, the more cost will be incurred; thus the revenue shrinks [8]. In the manufacturing practice, the bill of material (BOM) is an information to keep the product structural data of materials, such as part numbers, the quantity of need, and the associated specification [9]. To manage the material requisition, the total material needed shall be aggregated by the queued sales orders; the minimal quantity of a material is the required product quantities multiply the usage of that material in the BOM, respectively. The supplier material replenishment schedule may not be equivalent to one another due to their various conditions of production and delivery [10]. In most cases, the procurement of material in an economic scale will impact the production cost. This implies that the factory needs provision more and in advance for those materials that have greater variability in delivering.
\nOf those manufacturing automation equipment products, the sales may not aware of the gaps between the customer’s expectations and the equipment limitations, including the required working environment, the excess inputs, and the unsynchronized outputs to the next step of productions. The factory product development team must customize the equipment in order to fit in the customer’s application. The dilemma is whether the development team just tweaks the design for this specific case or puts more efforts on triggering the whole engineering change process to enhance the product features. If the decision is to enhance the product, that means a new BOM will be created, and some parts must be replaced; inevitably, the development team will commence a series of rigorous test on this design change; some tests take time. Consequently, the objective of material planning is to find the appropriate cost-effective solution under the constraints of order fulfillment and economic scale of the procurement.
\nThe objective of this chapter is to articulate how the firm’s material forecasting under the uncertain business environment can be improved from both management and advanced analytics perspectives.
\nApparently, it is a challenge to articulate the overall processes in which the aforementioned uncertainties might occur. Without a comprehensive expression, the firm cannot effectively collaborate on and make contribution to solve the problem. Thus, this chapter applied the problem frame analysis framework to disclose the complexity of the material planning in this smart manufacturing theme. Through this framework, all task-related participants can elaborate their actions to improve the forecast within and also look the problems a bigger firm-level picture. Essentially, the material forecast is an overall optimization in the firm. Such an optimization requires the synergy of the participants through the analytical models among tasks.
\nThe problem frame is a method often used in the requirement engineering to describe a complicated problem’s boundary and analyze the mutual influences among the problem factors in rigorous mathematic logic expressions [11]. One of the advantages of applying this method is these mathematic logic expressions can be easily transformed into the analytical forecast models. But it also brings its major disadvantage that the problem frames are not friendly to the business process improvement. Therefore, this chapter seeks to describe the essential framework of the material planning problem (Figure 1) in a more intuitive fashion, by using an expanded “Business Process Model and Notation” (BPMN).
\nMaterial planning problem frame.
The sales orders usually are not placed at the same time, but in a certain “random” way instead. If the materials take longer time in preparation than the order requested delivery time, consequently, the requested orders cannot be fulfilled, and the business responsiveness (one of the essentials of the smart manufacturing) will be compromised. Therefore, the factory must procure these materials in advance based on the market forecast. This forecast must be able to reflect the confidence level on the estimated quantities of the following: (1)
Each product type may share common parts (materials) with one another. For example, if a new product is an enhanced version of the existing mature product, it will share many common parts with its predecessor. As product versions upgraded, a long-tailed product line is formed, the common parts usually will gradually decrease through generations. To keep as many common parts as possible in the new product design so that the material requisition planning can be further optimized is the key to lower the overstock risk. Nevertheless, in many occasions, the suppliers may discontinue to supply their legacy materials that will force the firm to change the design accordingly.
\nAfter the material preparation process completes, the inventory should be adequate to support the following procedures, including the production, shipping products as the sales orders requested, and deploying the products to the customers.
\nFormula (1) depicts the \n
The material aggregation is to calculate the required quantity for each material in the BOM; this chapter uses the column vector notation of \n
Using common parts across the BOMs is a key to manage the risk and costs; this means, in the simplest case of two products \n
Furthermore, in some cases, the material \n
In the smart manufacturing theme, the production planning is a multiperiod, multiproduct problem; the factory makes appropriate schedules based on a scenario tree containing all possible combinations to build the products optimally under the resource constraints. Both demand and supply uncertainties are driven by dynamic stochastic processes. The optimality is to satisfy the minimal resource consumed and the stochastic uncertainty of changes [12]. When multiple manufacturers at different sites collaborate to build products, the uncertainty may root from various external changes, illustrated in Table 1.
\nSource of change | \nReasons | \n
---|---|
Workforce size | \nThe suppliers shrank their operation and impacted the replenishment, or the workers went on the strike | \n
Production rate | \nAdditional or unexpected cost incurred, the suppliers increased their material prices, or the rival lowered down their market prices | \n
Seasonal overstocked | \nBased on the previous experience on business cycle, the firms had overprovisioned their resources than expected | \n
Back orders | \nThe suppliers canceled the procurement orders owing to their poor capacity planning, or the customers postponed the purchase plans for business reasons; and these numbers were counted in the forecast | \n
Regulations | \nThe authorities imposed new regulations that increased the firm additional costs, such as taxation or the equipment replacement | \n
Extreme weather | \nThere is no doubt that the extreme weather, including heavy snow, flood, or tsunami, has impacted the economic growth globally | \n
The uncertain change sources.
This problem can be resolved as multiobjective linear programming functions to minimize the total costs of supply chain and the total order fulfillment gaps across the factory sites [13]. However, both aforementioned approaches did not answer the fundamental question: how to determine the uncertainty of each forecast? This uncertainty causing the poor performance may be attributed from (1) over- or underprovisions on the different market demand prospects; (2) planning with the limited information; (3) misperception of customers’ operating environment; and (4) quality of decision-making [14]. Therefore, this chapter incorporates the concepts from the multiobjective method with the consideration of overcoming the information asymmetry to present a novel approach as follows to tackle the problem.
\nThe participants in the supply chain can reach the consensus about the market demand prospects of coming period, if information visibility is improved. This improved visibility will also relieve the information asymmetry side effect on the participants’ planning. Fully documented product specifications and well-trained field engineers will overcome the deployment obstacles at customers’ operating environment. The consented market demand prospect and the visible information are the tangible artifacts of the decision-making which is a collaborative process within the factory’s departments and even with the external participants of the supply chain. Therefore, the more effective collaboration in improving the quality of decision-making, the less uncertainty bias shall be incurred.
\nThe objective of conducting the collaborative decision-making process is to reach the consensus on the scale of the demand forecast in the next period. The diversity of this collaborative team is essential. The team members should cover the roles from (1)
Figure 2 illustrates this collaborative decision process; after the group decision reaches the consensus on the material planning, the participants draft a couple of proposals and submit it to the material planning committee composed of the firm executives, the decision group participants, and the external industry professionals. The committee will make the final decision on the material planning. It is worth noting that the data analyst plays the backbone role facilitating the tasks of other participants throughout the process.
\nCollaborative decision process.
To make the aforementioned collaboration more effectively to elaborate the material planning proposals, this chapter presents a generic form for the group decision participants to discuss with. Table 2 illustrates a sample form for the forecasting. The form consists of two portions, the target product and its critical components.
\nCategory/product | \nInventory | \nTurnover | \nBuild/suppler | \nAccuracy/forecast | \nSource | \n||
---|---|---|---|---|---|---|---|
CA | \nPD | \nPI | \nPT | \nBQ | \nAM | \nFM | \nMarketing | \n
MR1 | \nMI1 | \nMT1 | \nMS1 | \nAS | \nFS | \nSales | \n|
MR2 | \nMI2 | \nMT2 | \nMS2 | \nAC | \nFC | \nChannels | \n|
MR3 | \nMI3 | \nMT3 | \nMS3 | \nAP | \nFP | \nSuppliers | \n|
MR4 | \nMI4 | \nMT4 | \nMS4 | \nAF | \nFF | \nFinance | \n
Material forecast sample form.
In this sample form, the product
The final agreed decision on the forecast of the product can be systematically measured by Formula (5). The outer summation adds up the forecast of the five groups and multiplies by their \n
The reason why previous forecast accuracy rates were excluded from
The material readiness is essential to the production, especially for those scarce and/or valuable ones. There are several reasons causing the material scarcity: (1) usually these are subcomponents which required the outsourcing, customized design; (2) those materials are provided by the single source or the oligopoly market; and (3) the materials are common but essential in many products, and when these products are hot in the market, these materials become very difficult to acquire the adequate quantities to support the firm’s production. To prevent the shortage of materials, reserving and maintaining the materials at some level of quantities in stock are common measures in practice.
\nThe challenge of making the decision on the quantities of these safe stocks is that the procurement and the planner must be aware of the supply market’s movements and take action in a proactive manner at all times. Formula (6) illustrates the general material acquired function; when \n
The estimation of \n
The “bullwhip effect” is a classic problem in the supply chain management; the obvious symptom is the overstocking in the whole supply chain. When the market demand declines not as the forecast expected, it will potentially impose the financial risk significantly. More overproduced products will push to the distribution channels, and the channels might sacrifice their margin in order to attract the consumers to buy more until the demand has saturated. Both the product and the material inventory levels will hike and thus incur the warehouse management cost and the value depreciation. This symptom will impact more when the optimistic supply chain tiers are deep. It is simply because the suppliers in each tier might magnify their forecasts under the asymmetric market demand information [18]. The root cause of this effect is that the market demand does not always follow the trend derived from the past. It is very challenging to forecast the demand of the individual product because the order quantity is slim. But the products in the same category may share a common component structure in the majority. In the configure-to-order model, let the consumer to optionally select the components from the configuration of the product; the differences among these products can be as simple as just a few components vary than one another [19]. This implies that the forecast model can be applied to reduce the inventory overstock and understock risk, as long as the quantity volatile product demands shares common materials.
\nThe increasing economic disturbance such as the trade barriers has annoyingly amplified the market demand uncertainty. For instances, recently, the US-China trade tensions [20] and the Brexit [21] are the perfect examples of this. In order to assess business potential risk, we must consider the big picture and be aware of the impact of various economic parameter through the use of PEST analysis: (1)
This chapter proposes the material planning committee to set the confidence levels (a sort of weights) on these firm external perspectives to adjust the demand forecast. The \n
where \n
The empirical case is about a global production automation equipment manufacturer. Their flag-fleet products are the Computer Numerical Control (CNC) category which is widely used in the production to provide more precise, complicated and repeatable control than just manning the equipment. Basically, each CNC consists of five major components: (1) input, receiving the signals/status from the controlled equipment via various handshaking interfaces; (2) output, sending a set of instructions to the equipment to proceed the next action; (3) control, a number of electrical mechanical units to convert or transform the input signals to the processor and translate the electrical magnetic signals into the output instruction set; (4) processor, performing the signal predefined computations accordingly; and (5) human, providing the interface, usually is through keypad panel, to let worker interact or intervene with the control process.
\nThe empirical case adopted the stock market performance information as their foundation of setting the \n
Figure 3 illustrates a sample economic factor parameter analysis against the stock performance of Nasdaq and the rival’s in 2018. The
A sample economic factor parameter analysis.
Formula 11 defines a composite scoring function for the economic factors. The \n
The proposed fixed input material requisition model (Figure 5) makes the following assumptions (1) suppose the sample material fulfillment lead time takes three terms (usually in weeks); (2) suppose the sample material economic scale of supply is 1000 units; (3) the predicted loss ratio is set on 5% of each procurement quantity; (4) when the inventory is below the safety stock, an economic scale purchase will be made; (5) when the inventory is short to fill the order, a purchase of the lead time multiply the economic scale will be made (3000 units in this model); and (6) the supplier will deliver the sample material after the lead time of the purchase.
\nIn Figure 4, the sales orders related to this sample material have shown the demand, with the star markers, slumped from the expected 1000 units down to near 750. The triangle markers represent the purchases, and the round markers are the remained inventory. The green circle represents the stock on hand at the end of the forecast period. With the exception of the last circle (leftover stock), they coincide with every purchase made (triangle). By applying this model, the production may stop because of the material shortage; finding the sufficient safety stock quantity is a challenge to prevent the disruption of production:
\nSample material fixed input requisition model.
This chapter applies the iterative method by changing the \n
An enhanced variable input of the material requisition model is illustrated in Figure 5. It has the same configuration as the fixed input, but (1) suppose the sample material economic scale of supply is per 1000-unit; (2) when the inventory is below the safety stock; an economic scale purchase will be made; (3) when the inventory is short to fill the order; a purchase of the lead time multiply the economic scale will be made; and (4) each purchased quantity will be based on the moving average of the quantities of the previous lead time of the orders, illustrated in Formula 17. When \n
Sample material variable input requisition model.
The final proposed model, illustrated in Figure 6, is based on the aforementioned variable input, but each purchased quantity will consider the trend about the previous lead time of \n
Sample material trend variable input requisition model.
The customers buying preferences stimulate and inspire a new way of manufacturing. It has been a trend that the manufacturers are heading toward their ultimate goals of smart manufacturing. Many firms put the equipment automation as the first step of their smart manufacturing initiatives. But soon they found out that the current business challenge is on the uncertain market demand rather than just focusing on the operation automation. In addition, the smart manufacturing initiative is a sort of business reengineering process; it requires all participants to be aware in the problems in a holistic view. This is where this chapter would like to address.
\nIn the smart manufacturing theme, the material planning is a challenging task under the uncertain demand environment. The task is not just the responsibility of the planner nor the data analyst but the synergy of all related participants. This chapter presents three material requisition models, for those materials having short lead times or being able to apply the pull model (vendor managed inventory, VMI), the fixed input model is adequate enough; for those materials having the same trend for a period of time, the variable input model can compensate the trend difference and prevent the excessive purchase; and for those volatile demand materials, the trend variable input model has the lowest inventory level than the others.
\nFinally, all proposed modes treat the loss ratio \n
Lyon has always had a great tradition of orthopedic, and Charles Gabriel Pravaz was not only the inventor of the syringe, but he also created in Lyon a great orthopedic institute to treat scoliosis 200 years ago. The first Lyon brace, which was made of leather and steel, was created by Stagnara 70 years ago. It undergone a first change with the replacement of leather by polymethacrylate. This brace was used in adults in addition to surgery while waiting for the graft fusion, at a time when osteosynthesis did not have the current quality. In 2013, the use of adult ARTbrace in Europlex’O in polyamide and asymmetry allowed to avoid the plaster cast which has always been the characteristic of the Lyon management. The use of polyamide and digital allows treatment of thoracic and double major curves.
Vanderpool et al. [1] shows that the frequency of scoliosis in adults increases steadily with age, from 6% of scoliosis after the patient reaches 40 years until it reaches 10% of the population at age 65. The sex ratio was 2 females to 1 male. It is women who have the most painful instabilities and imbalances. Their bone mass is lower than that of men with a vertebral fracture threshold at age 65. Pregnancy and menopause could be also aggravating factors [2].
Akbarnia et al. [3] described the key features as curve stiffness, degeneration of the discs, osteoporosis, spinal imbalance both coronal and sagittal, rotary subluxation, spinal stenosis, and higher rate of complications (pulmonary, etc.). The esthetic aspect is not negligible, and even surgery performed during adolescence does not solve everything. Edgar and Mehta [4] has shown that self-image representation and social life is different after surgery in adolescence. 82% of adult scoliosis without surgery was married compared to 60% of scoliosis operated in adolescence. O’Brien [5] analyzes the consequences of scoliosis in adulthood. He noted that for adult scoliosis abnormal physical appearance and diminished self-esteem may always be present, but breathing limitations, inability to function, and other quality of life issues generally become the driving forces for clinical examination, diagnosis, and treatment.
The complications were analyzed by many authors. For Baron and Albert [6] the incidence of medical complications ranges between 40 and 86%. Local complications include infection, pseudarthrosis or failure of instrumentation, and neurological and adjacent-level degeneration or instability. Common medical complications include pneumonia, atelectasis, ileus, delirium, and cerebrovascular incidents. Smith et al. [7] studied the incidence of complications according to age. His conclusions were the following: the oldest age group (65–85 years) has nearly four times the number of minor complications and nearly five times the number of major complications when compared with the youngest age group (25–44 years). As invasive surgical therapy needs a perfect understanding of risk/benefit, Ogilvie [8] suggests that the decision to proceed with surgical treatment even if justified in many cases must be based on a thorough understanding of the anticipated benefits from surgical treatment and the risk of serious complications. These potential complications lead to multiple surgeries with results that can be less desirable than the original condition. The results of conservative orthopedic treatment are more difficult to assess. Kluba et al. [9] compares surgical and conservative treatment for degenerative lumbar scoliosis. He finds a significantly higher rate of spinal stenosis and degenerative spondylolisthesis in the group of patients with surgery. However no significant difference was evident between the two groups in terms of lumbar back pain after 4 years, respectively.
Everett and Patel [10] conducted a systematic review of non-operative treatment. There is indeterminate, level III/IV evidence on the effectiveness of any conservative option; level IV evidence on the role of physical therapy, chiropractic care, and bracing; and level III evidence for injections in the conservative treatment of adult deformity. The use of rigid or hard bracing in adult scoliosis is generally not recommended. This is due to the risk of muscle weakening effects from hard bracing and the fact that this could accelerate the degenerative process in some cases. Chuah et al. [11] notes that bracing may sometimes help the symptoms, but it has no effect on curve progression.
Pain is not synonymous with deformity progression. Some stable scoliosis patient report pain, and others evolve without pain. It will be necessary to try to make the difference between the “physical” pain and the “emotional” suffering when the patient does not support his deformation anymore.
Thoracolumbar pain often corresponds to minor joint instability.
The pain of convexity is of muscular origin.
The pain of the concavity is posterior: facet syndrome.
The lumbosacral pain is of ligament origin.
These pains respond perfectly to physiotherapy.
When scoliosis progresses, it is either (1) the evolution in adulthood of an adolescent idiopathic scoliosis, (2) a de novo scoliosis usually of discal origin, or (3) a camptocormia of muscular origin. In all cases, there may be a disc disease with sometimes rotatory dislocation, postural impairment with imbalance, extrapyramidal muscle involvement, and bone involvement (osteoporosis). In these progressive cases of instability, bracing or surgery may be necessary.
From 20 to 30 years old, the main problem is the anatomical pain.
From 30 to 50 years old, the main problem is the discal decompensation.
After 50 years old, there are two main problems: degenerative scoliosis very rigid with arthrosis and camptocormia reducible with paravertebral muscular atrophy.
Early works on scoliosis progression in adulthood were pessimistic [12], but at this time, idiopathic scoliosis, especially rachitic infantile, is mixed with neurological poliomyelitis that no longer exists.
In 2003 Weinstein published the spontaneous evolution of 117 idiopathic scolioses over more than 50 years [13]. Thoracic curves of more than 50 degrees at skeletal maturity progressed with an average of 29.4 degrees. Thoracolumbar curves between 50 and 75 degrees increased with an average of 22.3 degrees. Lumbar curves had the most progression, especially when the L5 vertebra was not well seated and when the apical rotation was greater than 33%. He does not observe a functional respiratory or painful repercussion below 70°. This angulation could be currently the functional surgical Cobb limit. Pregnancy does not change the progression of scoliosis in adulthood, except in cases of twin pregnancy.
In 2007 Marty-Poumarat [14] describes two specific adult scoliosis entities: adolescent scoliosis in adult (ASA) and degenerative de novo scoliosis (DDS).
Group A (ASA) = adult progression of AIS > 40° with first dislocation at 45 years. The progression can be sometimes regular, sometimes chaotic.
Group B (DDS) = de novo scoliosis with low Cobb after 50°, first dislocation at 52 years after menopause. DDS is more progressive than AIS. Because DDS is a result of degenerative disc instability, it is almost always progressive. Lumbar and thoracolumbar are the most progressive degenerative curves. Duval-Beaupere and Dubousset [15] have first described the mechanism of rotatory subluxation. Following their work, many authors have insisted on the importance of the lumbo-pelvic parameters [16, 17, 18].
The radiological risk factors for instability are (1) rotatory dislocation with lateral olisthesis (Figure 1), (2) L3–L4 inclination, (3) hypolordosis, and (4) increased thoracolumbar kyphosis [19, 20].
De novo scoliosis with constitution of a rotatory dislocation in 2 years, then scoliosis worsening by osteoporotic cuneiformization.
The physical activity and fracture rate of adult scoliosis is identical to that of the general population, except for operated patients who have less physical activity [21]. Unlike adolescence, when bracing is systematic when scoliosis progresses, the corrective bracing indication in adults is less related to Cobb angulation but more to the instability which results in pain, abnormal angular evolution, or imbalances (Figure 2).
Clinical imbalances in the frontal and the sagittal planes.
From a database started in 1998, we selected all adult scoliosis in which conservative orthopedic treatment has been proposed to, even if the treatment had not been achieved by the patient. Scoliosis treated during adolescence and monitored in adulthood were excluded [22]. In this case series study, we analyzed 779 patients referred for nonsurgical treatment, and we correlated three parameters: the etiology, age, and Cobb angulation (Table 1).
Indications ARTbrace adult (n = 779) | Rate % | Mean age | Mean angulation |
---|---|---|---|
Rotatory dislocation (n = 361) | 46.5% | 59.73 y ± 13.50 | 39.08° ± 16.56 |
Segmental instability (n = 150) | 19% | 46.03 y ± 15.49 | 25.29° ± 12.29 |
Instability post-surgery (n = 86) | 11% | 53.09 y ± 12.91 | 40.49° ± 15.38 |
Camptocormia (n = 68) | 9% | 69.78 y ± 12.19 | 38.09° ± 14.23 |
Kyphosis (thoracolumbar) (n = 62) | 8% | 60.73 y ± 15.51 | 43.34° ± 21.48 |
Disabling pain (n = 33) | 4% | 48.36 y ± 13.73 | 36.45° ± 21.48 |
Spondylolisthesis and spinal stenosis (n = 19) | 2.5% |
Main indications for adult scoliosis bracing with frequency classification.
The rate of dropout patients not wearing the brace is 17% which is not excessive, especially since the plaster cast at that time was made before the brace discouraged patients.
A tentative classification according to etiology, age, and angulation is proposed (Figure 3).
Indications of nonsurgical treatment by etiology (n = 739).
More than half of the indications concern the rotational dislocation, which is the specific complication of adult scoliosis. The rotary dislocation is visible on the CT scan with subluxation and joint narrowing on the sliding side and widening of the articular space on the opposite side.
One-fourth of the indications concern disc instability, which can be considered as the early stage of rotational dislocation.
The other etiologies are less frequent: lumbar-pelvic-femoral kyphosis, secondary instability under arthrodesis, root pain, and rarely spinal stenosis which requires neurosurgery. Camptocormia is linked to weakness of the deep posterior musculature [23]. The patient increases kyphosis gradually to tighten his weak paravertebral muscles. There is often an extrapyramidal context of Parkinson’s disease [23]. MRI cross sections highlight the fatty degeneration. Some authors have mentioned paravertebral myopathy [24].
According to age, there is no Cobb angle difference between patients aged 39 and 80 years old, even if we notice a slight worsening between patients aged 80 and 90 years old. It can be concluded that after 40 years, for the same angulation, the risk of decompensation does not depend on age [22].
If we examine in more detail the distribution of patients according to Cobb angle, we find that Cobb angle is not a discriminating factor like aging.
One of the bracing eligibility tests especially for camptocormia is self-correction by using the hands on the thighs, even if this self-correction does not last long in time. The second test of reducibility is carried out in supine position. The occipital patient must rely on the plane of the examination table. The placement of the ARTbrace is performed by the patient who stabilizes the brace at the pelvic level then unrolls the spine using the rigidity of the posterior bar and finally blocks the upper part. As for children, the “mayonnaise tube” effect of the two lateral hemi-valves completes the correction in the sagittal plane.
Adult scoliosis bracing is performed only in technically equipped medical clinics. Hospitalization is not essential because the use of the brace must be integrated into the patient’s environment. On the other hand, physiotherapy scoliosis-specific exercises (PSSE) is mandatory.
The brace wearing time protocol is a total time of 24 hours a day during 3 weeks with a plaster cast (or digital cast) to adjust the length of the ligaments with plastic deformation and, then, at least 4 hours per day for a minimum of 6 months, including systematically for 2 hours after the practice of sports activity (Table 2).
Management | Wearing time | Particularity | Follow-up examination |
---|---|---|---|
First 3 weeks | Total time 24/24 | Only 10′ for shower, no work interruption | At the end of total time without X-ray |
First 6 months | 4 hours/24 | Systematically for 2 hours after physical activity | At 6 months with X-ray |
6 m to 2 years | On demand and 2 hours after sport | In case of pain, in prevention before major efforts | At 2 years with X-ray |
After 2 years | No specific indication | Brace is kept for safety | AT 5 years with X-ray, then every 5 years |
Adult bracing management (Lyon ARTbrace).
Wearing the brace for a “total time” allows the patient to relearn all the gestures of daily living in a good posture, for example, the sitting writing posture with feet behind the chair and buttocks in front of the seat. The lower part of the chest touches the anterior edge of the table, and the forearms rest on the desktop.
The digital cast is made in three blocks according to the deviations as in the teenager, but in deep inspiration. In many cases, only a scan in maximum corrective posture perfectly balanced is performed. The corrective posture is derived from Schroth. The sagittal plane and the frontal plane are simultaneously corrected, ensuring the overall balance of the spine. The spine is placed in maximum extension to promote lumbar lordosis and reduce thoracic hyperkyphosis. The convex hand is placed on the vertical support, the concave hand is placed on the head, and the operator supports the patient’s elbow (Figure 4).
Digital cast with simultaneous correction in the frontal and in the sagittal planes.
The thickness of Europlex’O used in adults is 3 mm. The digital cast is made in blocks according to the deviations as in the teenager, but in deep inspiration. The advantages are manifold: (1) The patient can maintain the maximum corrected position for a few seconds while standing; (2) breathing is controlled, and the patient can be asked to perform maximum inspiration; and (3) the accuracy of the eight structure sensors is less than 1 mm. The 3 mm Europlex’O with very high rigidity can be used instead of polyethylene. It is possible to work bare skin, but the thin optical vest in jersey allows the use of landmarks for the superposition of the three blocks. The processing with a specific software allows the creation of a positive which will be milled by a digital milling machine. The CPO has all the tools to rework on the captured shapes. After a period of 3 weeks of “total time,” the brace is worn for a minimum of 4 hours/24 for 6 months, then on demand.
Instability pain management is obtained by:
A skin contact of the brace like a massage.
A discharge of the lumbar discs and vertebral body by the “composite beam effect.” The discharge of 30% is provided by the waist grip in the frontal plane, while the sagittal plane is free to prevent an excessive abdominal pressure.
A rebalancing spine in the frontal and sagittal plane.
A limitation of extreme postures.
The rigid brace is an active brace. The patient spontaneously tends to contract the paravertebral musculature in the sense of self-active axial elongation. Associated physiotherapy is however essential.
The brace can reshape the waist. It can also symmetrize the body for the largest scoliotic curves by the adjunction of a foam cushion in the concavity.
The lock automatically performed by the brace facilitates motion and strengthens the musculature of the lower limbs. There is also a better mobility of shoulder girdle because of the stabilization of shoulder blades in a more physiological position.
The wearing of a rigid brace is obligatorily supplemented by physiotherapy scoliosis-specific exercises. The ideal is to act when the spine begins to disrupt or becomes painful, indicating instability. The therapeutic progression is usual:
Analgesia.
Preventing muscle atrophy lumbo-abdominal strengthening in isometric and improving paravertebral deep muscles (Figure 5).
Promoting more flexible self-active axial elongation (Figure 6).
Correcting 3D spine balance: in the frontal plane, rebalance of the occipital axis; in the sagittal plane, restoration of sagittal lumbar and pelvic curvatures (pelvic anteversion and lumbar lordosis (strengthening of the iliopsoas)); and in the horizontal plane, dissociation of pelvic and shoulder girdles.
Developing compensation at the lower and upper limbs: relaxation under pelvic extension (hamstring stretching) (Figure 7).
Stimulating the mechanisms of postural correction with reharmonization of the paravertebral tensions (muscular chains) (Figure 8).
Isometric strengthening of the deep front line with correction of thoracolumbar kyphosis.
Self-active axial elongation in closed kinetic chain (hands/espalier).
Posture of stretching posterior chains of the lower limbs.
Reharmonization of paravertebral tensions with mirror control.
The main differences between adolescent and adult scoliosis are demonstrated in Table 3.
Physiology and biomechanics | Adolescent | Adult |
---|---|---|
No specific pain in adolescents. Painful instability in adults | No pain relief techniques | Pain relief techniques, massage, and others |
Flat back in the teenager. Loss of lordosis and hyperkyphosis in adults | Restoration of physiological sagittal curves (arms projected forward) | Physiotherapy in lumbar lordosis (hands crossed in the back) |
The brace aims to stiffen the spine (rust the spring). Spine mobilization in adults can lead to curve progression | Spine mobilization during cast and brace in all the amplitudes | No spine mobilization beyond the corrected posture |
Strengthening muscle fibers (adult sarcopenia) | Reinforcement of the reticulospinal system (aerobic) | Reinforcement of voluntary musculature in anaerobic metabolism. |
Translation along the vertical axis | Active axial self-elongation in standing position (grand porter) Open kinetic chain | Active axial self-elongation trunk bent at 90°, hands resting on the espalier. Closed kinetic chain |
Lumbo-pelvic region | Opening the iliolumbar angle | Anterior lumbo-pelvic strengthening (iliopsoas, abdo, quad) |
Lower limbs | No specific stretching. Global training without excessive resistance | Stretching of the posterior chain at the level of the lower limbs |
One-third of the thorax volume develops after the end of the stature growth | Resistance breathing exercises (inflating a balloon) | Breathing exercises in forced expiration |
Main differences between adolescent and adult scoliosis Lyon method physiotherapy.
First week. Physiotherapy is for analgesic purposes and is performed in the supine position by soft traction and a muscular work with irradiation of the short external rotators. Breathing is controlled because of the limitation of the abdominal expansion. The thoracic breathing is facilitated by the mobilization of the intercostal muscles.
Second week. The iliolumbar angle is mobilized to adjust tension at the iliolumbar level. The hump can be modeled with progressive closure of the ratcheting buckle. Physiotherapy is performed in sitting position.
Third week. Physiotherapy is more global, more general, more tonic, and stronger. The lever arm of shoulder and pelvic girdles is used. The sessions are made in standing position.
We first determine the sagittal direction of muscular work, usually lordosis for lumbar and thoracolumbar scoliosis. For each session there is a progression from supine to sitting and standing position.
In case of major disc degeneration, physiotherapy will be conducted in physiological lordosis, rather than in a standing position.
In case of major facet joint degeneration, physiotherapy will be conducted in physiological lordosis in prone position, legs bent or in a sitting position.
In case of leg length discrepancy, the feet imbalances adjustment with a shoe lift of 5 mm if it improves both pelvic and spine alignment.
In the sagittal plane, one can use small high heel stubs from 3 to 5 cm to reduce a lumbar kyphosis.
The food control helps to reduce overweight.
The postural control concerns mainly the workstation.
The regular practice of physical activity outside is essential. It is necessary to insist on the strict brace wearing during 2 hours after the sports activity.
Excessive mobilization of passive structures may lead to a progression of scoliosis, so the hyper flexibility is avoided and a position closest to that of the brace is better.
High thoracic breathing is less efficient than the usual abdominal breathing, and we must insist on improving the vital capacity for thoracic or double major curves. If lumbar scoliosis is treated, the risk of an increase of scoliosis during inspiration is low; however, breathlessness is to be avoided.
As the brace can be asymmetrical in the direction of the rebalancing of the spine, it will, however, always ensure the balance of the shoulder girdle.
When the body is fully developed, we advise high-impact sports such as running and dance, to favor the fixation of the calcium on the bone and the constitution of an important bony mass.
In a specific way when ribs are asymmetric, we recommend avoiding deep and quick inhalation which favors the vertebral rotation and therefore the breathlessness during the practice of sports.
For lumbar curves, we advise, as well, against the quick flexions of the trunk forward or the position extending with an anterior flexion of the trunk.
During the period of maximal tensegrity up to 40 years, all sports can be performed at a high level as long as the spine is straight.
After 40 years, decreased intervertebral disc height and sarcopenia reduce the body’s performance.
After 65 years, osteoarthritis is predominant. Swimming avoids overloading the lower limbs and helps maintain lumbar lordosis (Table 4).
Age (girls) | Physiology | Activity (example) |
---|---|---|
15–21 years | Before complete bone mass | Jogging and running Axial impact and spiral chains |
21–40 years | Before sarcopenia and osteopenia (tensegrity) | Fitness, sports reinforcing spiral chains |
40 to retirement | Before extrapyramidal weakness (postural system) | Nordic walking, cycling |
Retirement | Osteoarthritis, Pisa syndrome | Swimming |
Sports activity according to the age.
Immobilization braces made of polyethylene have been used for more than 50 years in case of mechanical pain. They complement classical physiotherapy by reducing load by 30% at the lumbar spine. We specifically studied the 158 patients with 5-year follow-up from our prospective database [25].
The principle of bracing is completely different from that of adolescent scoliosis. Indeed, we try to:
Decompress the discs with the “sandglass effect” lifting the trunk under the ribs and transferring the load on the pelvis.
Rebalance the spine in both the frontal plane and in the sagittal planes, mostly by recreating lumbar lordosis.
Relieve pain by the analgesic effect of rigid low back brace.
A specific frame is used to stabilize the patient in the most corrective posture in the frontal and the sagittal plane.
For those patients who had a progressive scoliosis, Cobb angle is stabilized or improved by more than 5° in 80% of cases, and only 20% of scoliosis remain candidates for surgery [25].
The frontal and horizontal clinical parameters are improved, but not the sagittal parameters with the forward trunk projection (Figure 9).
Insufficient correction in the sagittal plane.
The sternoclavicular support is poorly tolerated, and due to reduced dexterity in the older person, lateral closure is a handicap for elderly patients, even if adaptations are possible, that is why we currently use the 3 mm Europlex’O.
Instability in adulthood is frequent, and surgery is the most frequently offered solution despite the high rate of complications, as there was no alternative to date for thoracic and thoracolumbar curves. Only overlapped bivalve polyethylene braces were used for lumbar scoliosis with good frontal stabilization but no control in the sagittal plane (Figure 9). The ARTbrace in Europlex’O which allows an average reduction of 70% for the children has been used since 2015 in the adult for all the deviations.
The results of a consecutive series of 62 patients (6.2% of all ARTbrace patients) were treated between 2015 and 2016, as an alternative to surgery.
Nine patients (15%) which constitute the dropout were not seen at 6 months, which is very little considering the general condition and age of patients. The percentage of dropouts is identical to the previous series of lumbar curves treatments. Despite the very high rigidity, Europlex’O which needs a precision of 1 mm is therefore as well tolerated as polyethylene.
In the frontal plane, the average in-brace reduction is 27%, slightly higher for lumbar and thoracolumbar curvatures. The reduction to 2 years without brace is 15%, and especially the symptomatology of instability disappears. It is now possible to stabilize all thoracolumbar, thoracic, and double major scoliosis (Figure 10).
Reduction in the frontal plane after decompensation upon arthrodesis.
In the sagittal plane, the average in-brace reduction is 32% and at 2 years without brace of 25% (Figure 11).
Correction of kyphosis in the sagittal plane.
In the horizontal plane, some characteristic case study with EOS 3D confirms that adult ARTbrace is indeed, as in the child, a detorsion brace. Adult ARTbrace is the only brace to correct kyphosis and thus compensate for the insufficiency of polyethylene whose sternoclavicular support was not tolerated (Figure 12).
EOS 3D confirms thoracolumbar spine detorsion in ARTbrace.
Adult deformity is a major demographic health issue in the geriatric population. Surgeons are often very conservative in the treatment of adult scoliosis because of the complication rates associated with the surgeries and the marginal bone quality endemic to this population. Medical complications are a major concern in adult spinal deformity surgery [26]. The incidence ranges between 40% and 86%, but there is indeterminate level III/IV evidence on the effectiveness of any usual conservative care option. There is currently a lack of consensus on the most efficacious conservative treatments for adult deformity.
Very few results have been published concerning scoliosis adult bracing. Most of them only concern low back pain [27, 28]. Pain is the usual reason of medical consultation. Pain means instability when combined with the following clinical signs:
Frontal and sagittal Imbalance. The lumbar kyphoscoliosis is due to pelvic retroversion. The hips are extended under a retroverted pelvis, femurs were oriented downward and forward, and knees and ankles compensate with flexion deformity. Pelvic retroversion is limited by osteoarthritis of the hip, flexion deformity of the knee is poorly tolerated, and the patient will use a walking stick to walk. The thorax can enter in conflict with the pelvis at the concavity level pushing the viscera down. The patient suffers from breathing difficulty; digestive disorders are common and promote abdominal hypertension and sphincter disorders. The loss of lumbar lordosis has multiple causes: a decrease in the anterior height of the disc, hypertrophy of the facet joints and spinous process increasing the posterior height, and loss of extensors muscle strength [29].
In the horizontal plane, there is a rotation of the shoulder girdle as if the patient looks on the concave side of thoracic scoliosis. The pelvis is drawn by lumbar scoliosis. The convex hemi-pelvis moves back, and the hip is placed in internal rotation, while the concave hemi-pelvis moves forward, and the hip is placed in external rotation.
On each occasion when examining a patient at least every 5 years, verification X-ray is necessary in order to define a progression while being aware that in many cases the progression is chaotic.
The most characteristic sign of decompensating is the disc height loss that can sometimes exceed 10 mm. The disc corruption results in loss of physiological lordosis and ligament instability by hypermobility.
The losses of the gluteal muscles are very distinct when we make the plaster cast. It explains in part the pelvic retroversion; the spine tends to relocate along the line of gravity.
Muscular atrophy is a common criticism for rigid braces. In fact, the conservative orthopedic treatment does not suffer approximation. Its teamwork incorporates a specific physical therapy, the continuation of normal activity, and the practice of regular physical activity. No patient is wearing the brace for pleasure. The risk of overtreatment is zero.
Usually the total time bracing relieves pain, and the partial time bracing extends the improvement obtained. When the patient is not relieved, we can discuss the surgery with better arguments. The nonsurgical treatment treats the cause of lumbar instability mainly by discharging the pressure in the disc and stabilizing the lumbar area in lordosis to restore the tensegrity of the spine.
The esthetic improvement of the rib hump and asymmetrical waist is logical; the orthopedic brace is the best way to remodel a trunk. The cosmetic result continues 5 years after starting the treatment, with improvement of the rib hump measured with the plumb line and the Bunnel angle of trunk rotation (Figure 9).
The nonsurgical treatment can fit into a therapeutic progression. The indications may be progressive: observation, physiotherapy, medicine, conservative orthopedic Treatment, and surgery.
The good surgical indications concern the degenerative scoliosis not relieved by bracing, or relieved by total time, but insufficiently by partial time and especially if there is a spinal stenosis. It can also be used to complete surgery if remaining instability.
The Greek study [30] associating Schroth and Chêneau brace shows that patients have great difficulty to follow the protocol. For the quarter of patients following the protocol, the results are correct on pain and posture, but in 39% of patients, Cobb angle continues to increase.
Josette Bettany [31] confirms that for adult scoliosis, there are only a few studies on the effectiveness of PSSEs and a conclusion cannot yet be drawn. Recently a RCT proves the effectiveness of a motor and cognitive rehabilitation [32].
The motivation of the patient is fundamental. The brace should be designed as a tool to facilitate physiotherapy.
The use of an instantaneous and accurate CAD/CAM is better because the adult patient can only maintain the corrected position for a few seconds.
The scan is made in deep inspiration to not limit the vital capacity.
The management is 4 hours a day including systematically for 2 hours after any physical activity. Physiotherapy is even more important than during adolescence [33].
The frequency of adult scoliosis makes it a public health problem. The new digital technologies have changed the adult scoliosis bracing, and conservative care in general may be a helpful option for adult deformity, but evidence for this decision was lacking. Lyon nonsurgical treatment is effective and offers new perspectives to adult scoliosis bracing. Not only does the brace relieve pain and support the spine, but for the first time, it corrects deviations in the frontal, sagittal, and horizontal planes. Immobilization braces in polyethylene allow a treatment of the cause of pain without side effects. Worn a few hours in the day, they complement physiotherapy. The first results confirm the excellent tolerance of Europlex’O adult ARTbrace with its ease of implementation and corrections unmatched to date in adults. These corrections make it possible to restore stability of the deviations without surgery. Adult scoliosis bracing as an alternative to surgery could be possible. Initially reserved for the most severe cases, this management deserves to be more widely used for adult scoliosis. The increasing number of CPO using the most modern CAD/CAM technologies should facilitate research in the field of very high rigidity.
Thanks to my daughter Agnès Thornton de Mauroy, for proofreading in English.
asymmetrical rigid torsion brace
adolescent scoliosis in adult
computer-aided design/computer-aided manufacturing
certified prosthetist/orthotist
computed tomography scan
degenerative de novo scoliosis
low-dose X-ray imaging
magnetic resonance imaging
physiotherapy scoliosis-specific exercises
randomized controlled trial
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",metaTitle:"About Open Access",metaDescription:"Open access contributes to scientific excellence and integrity. It opens up research results to wider analysis. It allows research results to be reused for new discoveries. And it enables the multi-disciplinary research that is needed to solve global 21st century problems. Open access connects science with society. It allows the public to engage with research. To go behind the headlines. And look at the scientific evidence. And it enables policy makers to draw on innovative solutions to societal challenges.\n\nCarlos Moedas, the European Commissioner for Research Science and Innovation at the STM Annual Frankfurt Conference, October 2016.",metaKeywords:null,canonicalURL:"about-open-access",contentRaw:'[{"type":"htmlEditorComponent","content":"The Open Access publishing movement started in the early 2000s when academic leaders from around the world participated in the formation of the Budapest Initiative. They developed recommendations for an Open Access publishing process, “which has worked for the past decade to provide the public with unrestricted, free access to scholarly research—much of which is publicly funded. Making the research publicly available to everyone—free of charge and without most copyright and licensing restrictions—will accelerate scientific research efforts and allow authors to reach a larger number of readers” (reference: http://www.budapestopenaccessinitiative.org)
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\\n"}]'},components:[{type:"htmlEditorComponent",content:'The Open Access publishing movement started in the early 2000s when academic leaders from around the world participated in the formation of the Budapest Initiative. They developed recommendations for an Open Access publishing process, “which has worked for the past decade to provide the public with unrestricted, free access to scholarly research—much of which is publicly funded. Making the research publicly available to everyone—free of charge and without most copyright and licensing restrictions—will accelerate scientific research efforts and allow authors to reach a larger number of readers” (reference: http://www.budapestopenaccessinitiative.org)
\n\nIntechOpen’s co-founders, both scientists themselves, created the company while undertaking research in robotics at Vienna University. Their goal was to spread research freely “for scientists, by scientists’ to the rest of the world via the Open Access publishing model. The company soon became a signatory of the Budapest Initiative, which currently has more than 1000 supporting organizations worldwide, ranging from universities to funders.
\n\nAt IntechOpen today, we are still as committed to working with organizations and people who care about scientific discovery, to putting the academic needs of the scientific community first, and to providing an Open Access environment where scientists can maximize their contribution to scientific advancement. By opening up access to the world’s scientific research articles and book chapters, we aim to facilitate greater opportunity for collaboration, scientific discovery and progress. We subscribe wholeheartedly to the Open Access definition:
\n\n“By “open access” to [peer-reviewed research literature], we mean its free availability on the public internet, permitting any users to read, download, copy, distribute, print, search, or link to the full texts of these articles, crawl them for indexing, pass them as data to software, or use them for any other lawful purpose, without financial, legal, or technical barriers other than those inseparable from gaining access to the internet itself. The only constraint on reproduction and distribution, and the only role for copyright in this domain, should be to give authors control over the integrity of their work and the right to be properly acknowledged and cited” (reference: http://www.budapestopenaccessinitiative.org)
\n\nOAI-PMH
\n\nAs a firm believer in the wider dissemination of knowledge, IntechOpen supports the Open Access Initiative Protocol for Metadata Harvesting (OAI-PMH Version 2.0). Read more
\n\nLicense
\n\nBook chapters published in edited volumes are distributed under the Creative Commons Attribution 3.0 Unported License (CC BY 3.0). IntechOpen upholds a very flexible Copyright Policy. There is no copyright transfer to the publisher and Authors retain exclusive copyright to their work. All Monographs/Compacts are distributed under the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0). Read more
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\n\nAll scientific works are Peer Reviewed prior to publishing. Read more
\n\nOA Publishing Fees
\n\nThe Open Access publishing model employed by IntechOpen eliminates subscription charges and pay-per-view fees, enabling readers to access research at no cost. In order to sustain operations and keep our publications freely accessible we levy an Open Access Publishing Fee for manuscripts, which helps us cover the costs of editorial work and the production of books. Read more
\n\nDigital Archiving Policy
\n\nIntechOpen is committed to ensuring the long-term preservation and the availability of all scholarly research we publish. We employ a variety of means to enable us to deliver on our commitments to the scientific community. Apart from preservation by the Croatian National Library (for publications prior to April 18, 2018) and the British Library (for publications after April 18, 2018), our entire catalogue is preserved in the CLOCKSS archive.
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After obtaining a Master's degree in Mechanical Engineering, he continued his PhD studies in Robotics at the Vienna University of Technology. Here he worked as a robotic researcher with the university's Intelligent Manufacturing Systems Group as well as a guest researcher at various European universities, including the Swiss Federal Institute of Technology Lausanne (EPFL). During this time he published more than 20 scientific papers, gave presentations, served as a reviewer for major robotic journals and conferences and most importantly he co-founded and built the International Journal of Advanced Robotic Systems- world's first Open Access journal in the field of robotics. Starting this journal was a pivotal point in his career, since it was a pathway to founding IntechOpen - Open Access publisher focused on addressing academic researchers needs. Alex is a personification of IntechOpen key values being trusted, open and entrepreneurial. 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