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Brace Wear Control of Curve Progression in Adolescent Idiopathic Scoliosis
Donald E. Katz, BS, CO1; J. Anthony Herring, MD1; Richard H. Browne, PhD1; Derek M. Kelly, MD2; John G. Birch, MD1
1 Department of Orthopaedics, Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-mail address for J.A. Herring: tony.herring@tsrh.org
2 Campbell Clinic Orthopaedics, 1400 South Germantown Road, Germantown, TN 38138
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from commercial entities (Medtronic and W.B. Saunders).

A commentary by David D. Aronsson, MD, and Ian A. F. Stokes, PhD, is available at www.jbjs.org/commentary and as supplemental material to the online version of this article.
Investigation performed at Texas Scottish Rite Hospital for Children, Dallas, Texas

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Jun 01;92(6):1343-1352. doi: 10.2106/JBJS.I.01142
The erratum to this article has been published | view the erratum
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Abstract

Background: 

The efficacy of brace treatment for patients with adolescent idiopathic scoliosis remains controversial, and effectiveness remains unproven. We accurately measured the number of hours of brace wear for patients with this condition to determine if increased wear correlated with lack of curve progression.

Methods: 

Of 126 patients with adolescent idiopathic scoliosis curves measuring between 25° and 45°, 100 completed a prospective study in which they were managed with a Boston brace fitted with a heat sensor that measured the exact number of hours of brace wear. Orthopaedic teams prescribed either sixteen or twenty-three hours of brace wear and were blinded to the wear data. At the completion of treatment, the number of hours of brace wear were compared with the frequency of curve progression of =6° and with curve progression requiring surgery.

Results: 

The total number of hours of brace wear correlated with the lack of curve progression. This effect was most significant in patients who were at Risser stage 0 (p = 0.0003) or Risser stage 1 (p = 0.07) at the beginning of treatment and in patients with an open triradiate cartilage at the beginning of treatment. Logistic regression analyses showed a "dose-response" curve in which the greater number of hours of brace wear correlated with lack of curve progression. Brace wear to school and immediately afterward was most successful. Curves did not progress in 82% of patients who wore the brace more than twelve hours per day, compared with only 31% of those who wore the brace fewer than seven hours per day (p = 0.0005). The number of hours of brace wear also correlated inversely with the need for surgical treatment (p = 0.0005). The number of hours of wear were similar for the patients who were advised to wear the brace sixteen or twenty-three hours daily.

Conclusions: 

The Boston brace is an effective means of controlling curve progression in patients with adolescent idiopathic scoliosis when worn for more than twelve hours per day.

Level of Evidence: 

Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    John A. Herring, MD
    Posted on June 18, 2010
    Dr. Herring and colleagues respond to Dr. Price
    Texas Scottish Rite Hospital for Children, Dallas, Texas

    I welcome this opportunity to reply to Dr. Price’s observations about our study relating brace wear to control of progression of adolescent idiopathic scoliosis. He notes, and I fully agree, that a simple correlation does not prove a conclusion, and I would add does not prove cause and effect.

    We began this study with true uncertainty of the effectiveness of bracing and only concluded that bracing altered progression when we discovered quite complex positive correlations between treatment and outcome. Many studies support the finding that curves progress most during the adolescent growth spurt, and that closure of the triradiate cartilage is a valid indicator of a decline in the growth velocity curve. Thus if bracing were ineffective, the least evident correlation should be in the patients entering treatment with open triradiate cartilages. We found, to the contrary, that these rapidly growing adolescents had the strongest correlation of curve control with hours of brace wear. We then dissected out the time of brace wear compared to curve control and found that night wear, which most patients find the most tolerable, had the least correlation with successful treatment. In the open triradiate group, the greatest effective wear occurred when the patient wore the brace while upright, with wear to and after school being the most important. We looked as well at those with closed triradiate cartilage at presentation, and found a clear dose response curve with different slope, representing the less progressive nature of scoliosis at this growth stage. The curves for time of wear were likewise of a different slope but with the same relationship of day wear being more important than night wear. In other words, we found consistent relationships between hours of wear and curve control through multiple analyses with different variables.

    Dr. Price suggests that a patient with a non-progressive curve will wear the brace because it is more comfortable. We recorded patient reported comfort at each visit and found no correlation between comfort and brace wear. We analyzed curve flexibility with the same hypothesis, but did not find greater wear in those with more flexible curves (therefore more comfortable in brace). Dr. Price also suggests that patients who were labeled as non-compliant would further reduce their brace wear. In this study the only patients considered non-compliant were a small number who gave back the braces. I would note here that the treating team and patients were blinded to wear data throughout treatment. The study of these patients previously published noted that the patient’s report of wear, and the orthotist’s and doctor’s estimations of wear did not correlate with actual wear. Dr. Price notes that bracing is not benign, and we agree completely. The successful patients in the study wore their braces for more than 12 hours per day averaged over 18 months; no small task. We in no way imply that bracing is easy, just that it is effective. At least now when we encourage a patient to wear the brace, we have evidence that it is worth the effort, and we have some concept of the required daily hours of wear.

    Finally, to the basketball analogy: a simple correlation would be “a tall person must play basketball.” A more complex correlation would compare prevalence of participants taller than 6’5” in basketball versus bowling and would rightly conclude that tallness and basketball are significantly related. Seriously, as mentioned in the Journal’s online review by Arronson and Stokes, level two studies such as this are of great importance in surgical fields, and provide information not otherwise obtainable because of the difficulties of patient accrual for level one studies.

    Charles T. Price, MD
    Posted on June 08, 2010
    Does Bracing Control Scoliosis Progression?
    Arnold Palmer Hospital for Children, Orlando, Florida

    To the Editor:

    Katz et al. (1) identified a correlation between greater brace wear time and lack of curve progression in adolescent idiopathic scoliosis. However, one must question their conclusion that bracing controls scoliosis progression. A simple correlation does not prove a conclusion. As an example, one should not conclude that playing more hours of basketball makes a person taller. Compliance may also reflect curve stability because the brace remains comfortable. Or, perhaps patients are willing to wear their brace as long as treatment appears to be successful. Those who observe their treatment to be failing may choose to stop that treatment and thus are labeled “non-compliant”. A potential false assumption of treatment methodology is that treatment is benign, without intolerable side effects, and correlates with outcomes.

    The true value of a treatment must be judged by the intent-to-treat for all patients who enter the study. All treated patients are then compared to a group of untreated patients. It should be noted that 28 of the 100 patients who entered this bracing study progressed to surgery during the period of study. Goldberg et al. (2), who did not utilize bracing as a treatment method, reported a 29% rate of surgery in premenarchal girls with scoliosis of 20°-40° at the time of presentation. Price et al. (3) reported a 22% rate of surgery in long-term study of night time bracing for scoliosis.

    While Katz et al. have demonstrated that compliance correlates with curve stability, that observation does not necessarily indicate that bracing influences the outcome of scoliosis.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

    References

    1. Katz DE, Herring JA, Browne RH, Kelly DM, Birch JG. Brace wear control of curve progression in adolescent idiopathic scoliosis. J Bone Joint Surg Am. 2010;92:1343-52.

    2. Goldberg CJ, Moore DP, Fogarty EE, Dowling FE. Adolescent idiopathic scoliosis: the effect of brace treatment on the incidence of surgery. Spine (Phila Pa 1976). 2001;26:42-7.

    3. Price CT, Scott DS, Reed FR Jr, Sproul JT. Nighttime bracing for adolescent idiopathic scoliosis with the Charleston Bending Brace: long-term follow-up. J Ped Orthop. 1997;17:703-7.

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