Dynamic Compression Brace for Pectus Carinatum
Dynamic Compression Brace for Pectus Carinatum
Pectus carinatum (PC) is a deformity of the anterior chest wall which is a common pediatric
 condition, characterized by an idiopathic overgrowth of the costal cartilages resulting in
 protrusion of the sternum. Chest pain or discomfort, especially when lying in prone position,
 increased respiratory effort during exercise, scoliosis, impaired shoulders and kyphotic
 position are some of the physical signs and symptoms. Unlike pectus excavatum, PC is rarely
 associated with significant cardiopulmonary involvement except in severe cases. Pectus
 carinatum is not just a simple aesthetical problem. The effect of patient's self-esteem, body
 image and confidence can be variable and lead to significant deterioration in mental health.
 It can be responsible of physical signs and symptoms and also has significant psychological
 impact. Deformity and its psychological impact tend to worsen during pubertal rapid phases of
 growth and even during adult life. The management of pectus deformities used to include
 surgical techniques, however, recently compression brace which is a dynamic orthosis which is
 custom-fitted, rigid aluminum brace that is adjustable to any thoracic shape is widely
 applied instead of surgery. Pressure applied to the patient, in the most protruding area of
 the chest, needed to accomplish a proper shape of the thorax, the pressure of correction can
 be measured via a pressure measuring device in pounds per square inches (PSI). Treatment
 choices of surgery or bracing is determined according to pressure of correction and type of
 deformity. Surgical correction is indicated if the presence of chondro-manubrial type PC and
 pressure of correction > 10 PSI. Chest pain or discomfort, especially when lying in prone
 position, increased respiratory effort during exercise, scoliosis, impaired shoulders and
 kyphotic position are some of the physical signs and symptoms. Despite the fact that patients
 with PC have impaired posture, exercise intolerance and increased scoliosis occurrence, there
 is no consensus on the exercise program for patients with PC. Also, there is not enough
 scientific evidence about the wear time of orthosis. The aim of this study is to investigate
 the effects of exercises and compression brace in children with PC.
Pectus carinatum (PC) is a deformity of the anterior chest wall which is a common pediatric
 condition, characterized by an idiopathic overgrowth of the costal cartilages resulting in
 protrusion of the sternum. There are two subtypes of PC: the chondro-gladiolar variant, which
 is the most common type, and presents with protrusion of the sternal body, and the
 chondro-manubrial variant, showing protrusion of the component of the sternum (manubrium). PC
 usually involves the lower sternal costal cartilages, pushing the sternum forwards and can be
 symmetrical (bilateral) or often asymmetrical (unilateral) with the right for some reason
 being more obviously affected. PC may occur as a solitary abnormality or in association with
 other genetic disorders or syndromes (eg, trisomy 18, Marfan syndrome, homocystinuria,
 Morquio syndrome, and Ehlers-Danlos syndrome). Of the musculoskeletal abnormalities,
 scoliosis is most frequently associated with PC.

 Chest pain or discomfort, especially when lying in prone position, increased respiratory
 effort during exercise, scoliosis, impaired shoulders and kyphotic position are some of the
 physical signs and symptoms. Unlike pectus excavatum, PC is rarely associated with
 significant cardiopulmonary involvement except in severe cases. Pectus carinatum is not just
 a simple aesthetical problem. It can be responsible of physical signs and symptoms and also
 has significant psychological impact. Deformity and its psychological impact tend to worsen
 during pubertal rapid phases of growth and even during adult life. It has been demonstrated
 that patients with PC are at risk for a disturbed body image and reduced quality of life and
 many patients refer feelings of discomfort, shame, shyness, anxiety, and even depression.

 The classical management of pectus deformities, both carinatum and excavatum, has been
 primarily surgical. Modification of the Ravitch technique involves resection of the deformed
 costal cartilages along with sternal osteotomy. Because the results of this technique
 resulted in worse cosmetic results, a new less invasive procedure, the Nuss procedure was
 developed. Nuss procedure includes remodeling of the chest wall cartilage with an internal
 support bar. These techniques have demonstrated the plasticity of the chest wall and led
 clinicians to hypothesize that carinatum defects would also remodel in response to chronic
 pressure, leading to a cosmetically superior, nonoperative technique: compression brace.
 Compression brace is a dynamic orthosis which is custom-fitted, rigid aluminum brace that is
 adjustable to any thoracic shape. Complications of brace use include uncommon (4.6%), mild
 and easy to resolve: back pain, hematoma and skin ulceration. Pressure of correction is the
 pressure applied to the patient, in the most protruding area of the chest, needed to
 accomplish a proper shape of the thorax. It is an indirect parameter of the chest wall's
 flexibility. It can be measured with a pressure measuring device in pounds per square inches
 (PSI). Some special designed braces contain a part in which pressure measuring device can be
 docked. This enables measuring of pressure of treatment. Pressure of treatment can be
 different from pressure of correction since skin breakdown occurs with corrections at high
 pressure.

 In the Calgary protocol, wearing brace 23 hours a day during the correction phase until the
 development of the axial skeleton is completed and afterwards 8 hours of wear is recommended
 in the continuation phase.Martinez-Ferro et al developed pressure measuring device and
 special designed braces contain a part in which pressure measuring device can be docked. They
 suggested that patients with pressure of correction <10 should be braced. De Beer et al. also
 recommended the surgical treatment in the presence of chondro-manubrial type PC and pressure
 of correction > 10 PSI. However, recommendations are based on prospective or retrospective
 cohort studies other than randomized controlled trials which corresponds to low level of
 evidence.

 Despite the fact that patients with PC have impaired posture, exercise intolerance and
 increased scoliosis occurrence, there is no consensus on the exercise program for patients
 with PC. Postural impairment aggravates psychological burden caused by disease itself.
 Patients with pectus carinatum may get benefit from exercises to improve posture. Also,
 disease itself or compression brace use may result in abdominal flare and increased lateral
 diameter of chest wall as an unwanted effect. Strengthening of abdominal muscles may prevent
 from abdominal flare. Strengthening of chest wall muscles, strengthening the pectoralis and
 sacrospinalis muscles as well as expanding the chest through deep breathing, strengthening
 core muscles including abdominal muscles, increasing flexibility of muscles, manipulation and
 mobilization of costae may lead improvements in the management of PC.

 There is no consensus about exercises, and there is not enough scientific evidence about the
 wear time of orthosis. The existing treatment protocols are non-standardized protocols
 developed by the researchers of previous studies investigating the effectiveness of orthosis.
 Martinez-Ferro et al., the developer of the dynamic compression brace, recommends the daytime
 wear of orthosis for patients with low pressure of correction. They recommend duration of
 clothing to be shorter and the pressure of treatment should be kept lower in patients with
 high pressure of correction. However, every compression brace may not contain dock and
 pressure of treatment cannot be measured. In the present study we aimed to investigate the
 effects of exercises and compression brace in children with PC. Also, safety and feasibility
 of the orthosis will be evaluated. Patients with chondro-gladiolar, symmetrical or
 asymmetric, compressible PC (compression test positive) and with correction pressure ≤10 PSI,
 aged 5-18 years old will be included to study. They will be randomized to three groups using
 closed envelope system. All groups will be given exercises to strengthen the muscles of the
 respiratory muscles of the posture exercises, deep breathing exercises, ribs manipulation and
 mobilization exercises and core exercises for 1 hour a day, five days a week for 3 weeks. The
 first group will use the orthosis for 8 hours during the night and the second group for 23
 hours except for sports activities, exercise and bath. The control group who will receive
 exercise therapy only will be selected from the wait-in list for the orthosis. Pectus
 carinatum protrusion, pressure of correction, anteroposterior and lateral diameter of thorax
 at the most protruded part of deformity, Haller index, Cobb and kyphosis angle, Pectus
 Evaluation Questionnaire will be assessed at before treatment and after treatment, 1 month
 and 3 months and 6 months after treatment.
Inclusion Criteria:

 1. Male patients with pectus carinatum

 2. Symmetric or asymmetric pectus carinatum

 3. Compression test positive

 4. Pressure of correction <10 PSI

 Exclusion Criteria:

 1. History of orthosis use

 2. Chondro-manubrial pectus carinatum

 3. Concomitant severe scoliosis (Cobb angle>20)

 4. Having history of chronic disease

 5. History of surgery for scoliosis or pectus carinatum