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Expert Editorial: Bracing for idiopathic scoliosis: Where do we go now?

Robert B. Winter, MD

Key Words: Idiopathic scoliosis, brace treatment, orthotic design

There was great doubt 10-15 years ago as to whether bracing was effective for the nonoperative management of idiopathic scoliosis in the growing child. Because the typical result of bracing was a curve the same at the end of treatment as at the beginning, the pessimist would say, "see-no benefit has been achieved." At the same time, the optimist said, "see-we have halted the curve's progression and prevented bad things."

During the past 10 years, many studies have confirmed that the natural history of adolescent idiopathic scoliosis can be positively effected by bracing.1-7,21-24,26 This is a scientifically proven fact that can no longer be questioned.

Now that the basic fact has been proven, we need to move on to more refined questions, such as the following: Why do some patients do well and others poorly? What is the best brace design? When is the best time to begin bracing? How long should bracing continue? What is the optimal number of hours per day that the brace should be worn? Is there any way that we can improve the results?

A careful examination of many available studies can answer many of these questions. The study of Milwaukee brace treatment of idiopathic scoliosis by Noonan et al. from Iowa City8 is quoted by the "pessimists" as showing the brace to be of no value. However, if one examines the article closely, the duration of bracing (20 months) was short compared with the 44 months of Lonstein and Winter.5 Also of significance was the very poor correction in the brace; it was only 8% for their "failed" group and 20% for their "successful" group compared with 30% overall for Lonstein and Winter.5 This article is of value when compared with other Milwaukee brace studies because it proves that a brace that does not effect significant correction and that is worn for too short a time does not give good results.

Studies on the number of hours per day of brace wearing clearly show that the more hours per day the brace is worn, the better the result.9,10 This seems to me to be a matter of common sense. How can a brace help someone if it's sitting in a closet? This point is further reinforced by the multitude of studies in compliant and noncompliant patients in which the results were always worse in the noncompliant patients.7,11-14

What brace design is best? Statistically, the results of Boston-style underarm braces are equal to Milwaukee braces for curves with apex at T8 or below and because the neck ring of the traditional Milwaukee brace is esthetically objectionable, the Milwaukee brace has virtually disappeared in most centers. This is sad because the Milwaukee has certain special advantages, especially its "open-frame" nonconstrictive design and stimulation of active extension by the patient. Studies have actually shown no better compliance in a thoracolumbar spinal orthosis than in a Milwaukee brace (Figures 1 , 2 , 3 , 4 , 5 , and 6 ).14

Not all underarm braces are the same. Some are well designed with force points in critical areas and relief in others to allow both passive and active correction. Adequate openings for full lung inspiration and breast development are critical but often forgotten in the desire to achieve a "better X-ray." No brace should be so constrictively constructed as to interfere with renal15 or pulmonary function.16,17

Bracing should begin when the curve is between 20° and 29°. Every study done that compares the results of bracing beginning with 20°-29° curves and bracing beginning with 30°-39° curves shows better results with the earlier start.1,4,5,18,25 To get at curves that have shown progression from 10°-19° values into the 20°-29° values, early detection is necessary; this is dependent on school screening programs.19

Finally, what can we do to improve our results? Right now, we are frustrated by the less than optimal situation because statistics basically show that with bracing, one-third of patients progress whereas without bracing, two-thirds of patients progress. We need to begin bracing with curves of 20°-29°. We need to design braces that achieve good correction in the brace. We need to impress upon patients and doctors that 20 hours/day of wearing will give better results than 8 hours/day. We need to be sure the brace stays on until growth has finished, as evidenced by cessation of height increase, at least a Risser 4 status, and in girls, until at least 18 months after onset of menses.

Can we not design braces that keep a constant pressure in the desired areas? How often do patients let the straps be a bit loose and lose all correction effect? Have we designed the very best possible? I doubt it.

The past 10 years have brought us out of the era of pessimism as to whether bracing does or does not have a positive effect on the natural history of progressive idiopathic scoliosis in growing children. Now that we know that braces do work, we need to pay careful attention to the details that make for a successful program. A well-designed orthosis that gives significant curve correction without compromising renal and pulmonary function and breast development, starting the brace program when the curve is between 20°-30°, a wearing schedule of at least 20 hours/day, no cessation of bracing until full growth has been achieved, and paying attention to the "whole person" and the psychological challenge of a teenager in an orthosis are all important details of a successful bracing program.20

The past 10 years have seen a serious decline in the close relationship of spine-oriented orthopedists and skilled spine orthotists in a special spine clinic setting. It used to be customary for the orthotist and doctor to see the patient together, to discuss brace design for the individual patient, and to jointly discuss modifications and alterations as treatment progresses. The "group therapy" value of the brace clinic was very important for its psychological advantage.

Progress will not be made without close cooperation between the surgeon, the orthotist, and the engineer. Now that we know braces can work, let's work together to make them work better.


References:

  1. Durand H. Faut-il abandonner le traitement orthopedique de la scoliose [doctoral thesis]. Tailouse, France; University Paul Sabatier; 1988.
  2. Fernandez-Filiberti R, Flynn J, Ramirez N, Trautmann M, Alegria M. Effectiveness of TLSO bracing in the conservative treatment of idiopathic scoliosis. J Pediatr Orthop. 1995;15:176-181.
  3. Giehl JD, Hesse B. Brace therapy in idiopathic adolescent scoliosis: Is it worth while? Eurospine meeting; June, 1998; Innsbruck, Austria.
  4. Landauer F, et al. Cheneau orthosis in treatment of right thoracic idiopathic scoliosis. Eurospine meeting; June, 1998; Innsbruck, Austria.
  5. Lonstein JE, Winter RB. The Milwaukee brace for the treatment of adolescent idiopathic scoliosis: A review of 1020 patients. J Bone Joint Surg Am. 1994;76:1207-1221.
  6. Nachemson A, Peterson L, and members of the Brace Study Group of the Scoliosis Research Society. Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. J Bone Joint Surg Am. 1995;77:815-822.
  7. Rowe DE, et al. A meta-analysis of the efficacy of non-operative treatments for idiopathic scoliosis. J Bone Joint Surg Am. 1997;79:664-674.
  8. Noonan KJ, Weinstein SL, Jacobson WC, Dolan LA. Use of the Milwaukee brace for progressive idiopathic scoliosis. J Bone Joint Surg Am. 1996;78:557-567.
  9. Howard AW, Wright JG, Heddon D. A comparative study of Boston, Charleston, and Milwaukee braces for idiopathic scoliosis. Presented to the Pediatric Society of North America; May, 1997; Banff, Canada.
  10. Katz DE, Richards S, Browne RH, Herring JA. A comparison between the Boston Brace and the Charleston Bending Brace in Adolescent Idiopathic Scoliosis. Spine. 1997;22:1302-1312.
  11. Andrews G, MacEwen GD. Idiopathic scoliosis: An 11-year follow-up study of the role of the Milwaukee brace in curve control and trunco-pelvic alignment. Orthopedics. 1989;12:809-816.
  12. Brancel P, Kaelin A, Hall J, Dubousset J. The Boston Brace: Results of a clinical and radiologic study of 401 patients. Proceedings of the French Society of Orthopedics and Traumatology. Orthop Trans. 1984;8:33-34.
  13. Carr WA, Moe JH, Winter RB, Lonstein JE. Treatment of idiopathic scoliosis in the Milwaukee brace. J Bone Joint Surg Am. 1980;62:599-612.
  14. Emans JB, Kaelin A, Bancel P, Hall JE, Miller ME. The Boston Bracing system for idiopathic scoliosis: Follow-up results in 295 patients. Spine. 1986;11:792-801.
  15. Berg U, Aoro S. Long-term effect of Boston brace treatment on renal function in patients with idiopathic scoliosis. Clin Orthop. 1983;180:169-172.
  16. Kennedy JD, Robertson CF, Olinsky A, et al. Pulmonary restrictive effect of bracing in mild idiopathic scoliosis. Thorax. 1987;42:959-961.
  17. Korovessis P, Filos K, Georgopoulos D. Long-term alterations of respiratory function in adolescent wearing a brace for idiopathic scoliosis. Spine. 1996;21:1979-1984.
  18. Bassett GS, Bunnell WP, MacEwen GD. Treatment of idiopathic scoliosis with the Wilmington brace; results in patients with a 20°-39° curve. J Bone Joint Surg Am. 1986;68:602-605.
  19. Winter RB, Lonstein JE. To brace or not to brace: The true value of school screening. Spine. 1997;22:1283-1284.
  20. Carlson JM, Winter RB. Biomechanics and orthotic design for the best outcome for idiopathic scoliosis patients. In press.
  21. Edelman P. Long term follow up of adolescent idiopathic scoliosis after conservative treatment with Boston and Cuxhaven brace. Presented to the Scoliosis Research Society.
  22. Kaelirc A. Brace treatment of idiopathic scoliosis. Guest Lecture, Meeting of the European Pediatric Orthopedic Society; October 15, 1997; Gothenberg, Sweden.
  23. Michel CR, Caton J, Allegre G, Allegre M. The place of a four-piece spinal support in the conservative treatment of scoliosis: A review of 700 cases over 10 years. Proceedings of the French Society of Orthopedic Surgery and Traumatology Orthop Trans. 1983;7:131.
  24. Olafsson Y, Saraste H, Soderlund V, Hoffsten M. Boston brace in the treatment of idiopathic scoliosis. J Pediatr Orthop. 1995;15:524-527.
  25. Price CT, Scott DS, Reed FE, Riddick MF. Nighttime bracing for adolescent idiopathic scoliosis with the Charleston bending brace. Spine. 1990;15:1294-1299.
  26. Roach JW. The non-operative treatment of scoliosis. Seminars in Spine Surgery. 1991;3:212-219.