Bracing continues to be used for children and teens with adolescent idiopathic scoliosis (AIS) but does it work? What's the evidence for brace treatment and who should it be used with? In this review article, Dr. Paul D. Sponseller from Johns Hopkins University Department of Orthopaedic Surgery brings us up-to-date on the practice of bracing for AIS.
Dr. Sponseller presents both the results of various studies published in the past 25 years on this topic as well as current opinions on the use of bracing from orthopedic surgeons using this treatment tool. Adolescent idiopathic scoliosis refers to a condition of spinal curvature and deformity in children and teens that has no apparent cause.
The word "idiopathic" means "cause unknown". Another word for the underlying cause of a disease or condition is etiology. There are many theories about the etiology of adolescent idiopathic scoliosis (AIS) but no clear single cause. Most experts consider AIS to have multiple linked causes including genetics, environment and lifestyle, and nervous system dysfunction with biologic and hormonal influences.
Treatment specific to the cause is usually the most effective approach. Without that, the symptoms become the focus and that's where bracing comes in. The idea is that by placing the spine in an upright position, the forces causing the curvature can be stopped -- or at least slowed. Has that ever been the case? How well does it really work?
A review of all the studies done on this topic doesn't really answer the questions. There are many different study designs so comparing one study to another is like comparing apples to oranges. And there are many different types and styles of braces with the same problem comparing results.
What we do know is that bracing seems to work the best when the brace is worn 16 or more hours a day and that girls with smaller curves (25 to 35 degrees) have the best results. Comparing children who are braced with children who do not wear a brace seems to offer some consistent evidence that observation alone (no bracing) isn't as effective as bracing. Long-term results (what happens five-to-10 years later) in both groups are unknown.
Waiting too long before using bracing may be a factor. Studies that show a 50 to 60 per cent success rate still leave 40 to 50 per cent of patients turning to surgery for correction. That leads researchers looking for reasons why some patients have a successful outcome in hopes of selecting patients in the future who would be good candidates for bracing.
Before we look at how surgeons decide to use bracing, it should be pointed out that when asked why surgeons use bracing without convincing evidence that it works, there is agreement that the chance to reduce the risk of needing surgery is worth the effort.
Bracing may not improve (decrease) the curve but it appears to keep the curve from progressing (getting worse) in many cases. In 25 per cent of cases, bracing does seem to reduce the risk of surgery. Most likely what is happening is the brace alters the effect of growth on the curve. Parents and even children jump at the chance to be able to do something (anything!) that might create a straight spine. Fear of deformity, pain, and surgery often leads to bracing as a nonoperative option.
That brings us back to the question of when to use bracing. Right now, based on the best evidence available, it looks like bracing should be offered to patients with curves between 25 and 45 degrees. They should be in a phase of rapid bone growth (based on X-rays). Larger curves in children with more mature skeletal growth can be offered bracing but with the warning that there is less chance to really change things.
Patients who are not likely to benefit from bracing include children who are overweight, those who have reached skeletal maturity (no further growth expected), and anyone with a high thoracic curve (above T8). Most girls have reached their peak growth rate around 11 to 12 years old. Boys are a little later at 13 to 14 years old. Curve progression is likely to be the greatest during these years. This requires close monitoring even when wearing a brace.
Other risk factors that predict no change with bracing include 1) the presence of other major health problems that could interfere with wearing the brace, 2) children who do not want to wear a brace, or 3) parents who do not accept the idea of bracing.
Once the decision has been made to use bracing, the next natural question is: which one or what kind? The brace maker (called an orthotist because orthosis is the more modern name for brace) helps guide the decision. This is done in communication with the parent, surgeon, and physical therapist. A team approach is best when looking at the whole child and taking into consideration spine, surrounding soft tissues, general health, and activity level.
Some of the more commonly used braces for adolescent idiopathic scoliosis include the Boston brace, the Wilmington brace, the SpineCor brace, the Milwaukee brace, the Triac brace, the Sforzesco brace, the Charleston brace, the Providence brace, and the Cheneau brace. Does that give you any idea of how many different ways there are to approach this problem?
Some of these braces are intended to derotate the vertebrae. Others force the spine to bend in the opposite direction of the developing curve. The Charleston bending orthosis provides this type of overcorrection and is worn only at night. Most of today's braces are made of plastic with either metal uprights or velcro or canvas straps to hold them in place. With the exception of the braces intended only for night-use, most braces used for adolescent idiopathic scoliosis are designed for use 23 of each 24 hours. The brace is removed only for bathing, swimming, and dressing.
One of the first questions often asked when getting a brace is "How long do I have to wear this?" Braces are meant to be worn primarily during the growing phases of childhood and adolescence. Once skeletal maturity has been reached (confirmed by X-ray), the brace can be removed. All girls should be at least 2 years past the point of beginning their menstrual cycle (period). The brace can be stopped gradually or all at once. It doesn't seem to matter but each child is monitored closely to make sure the curve doesn't start getting worse again.
Dr. Sponseller concludes by reminding us that there is some evidence that bracing can be effective. But it is unpredictable as to how much or who might benefit the most (or at all). There is a great need for more research and especially a way to determine which patients are at risk for surgery but could benefit from bracing.
Reference: Paul D. Sponseller, MD. Bracing for Adolescent Idiopathic Scoliosis in Practice Today. In The Journal of Pediatric Orthopaedics. January/February 2011. Vol. 31. No. 1. Supplement. S53-S60.