Until recently, five fundamental questions regarding the orthotic treatment of idiopathic scoliosis have eluded a clear answer:
Does bracing prevent the progression of scoliosis?
If so, in which patients?
What type of brace works best?
How many hours per day must the brace be worn in order to be effective?
Why do some patients have successful control of their curves while others do not?
The first question was addressed in 1995 by a prospective controlled multicenter study sponsored by the Scoliosis Research Society, which showed that only 27% of patients treated with a brace had curve progression versus 63% in a control group1. Subsequently, another well-designed and executed prospective controlled multicenter study, the Bracing in Adolescent Idiopathic Scoliosis Trial (BRAIST)2, confirmed that bracing is effective in controlling the progression of scoliosis. Nevertheless, in that study, brace treatment was (once again) unsuccessful in 27% of patients.
It is appropriate to ask why the curve progressed in 27% of the patients despite bracing and what measures might be taken to improve the results of bracing. One logical explanation is that the problem is compliance. Logic tells us that a brace will not work unless the patient wears it. Can improving compliance, then, bring some of these patients into the fold of success?
This study of the effect of counseling regarding compliance with a brace-wear regimen sheds light on the answers to at least questions 1, 2, and 4 above. It suggests that improved counseling can improve both compliance and outcomes, but it leaves plenty of room for future researchers to answer the remaining questions regarding bracing for idiopathic scoliosis.
What Does This Study Show?
Compliance can be a major problem. The more compliant patient group in the study (i.e., the patients who were counseled on the basis of compliance data derived from sensors in the brace) wore their brace for only an average of 13.8 hours per day.
Counseling can improve compliance with brace wear. Those who were not counseled with use of compliance data wore the brace less, an average of 10.8 hours per day.
The counseled group was told, in essence, that if they cheated, their doctors would be able to tell. This gentle warning had only a modest effect on brace wear, resulting in three hours of additional brace use per day. Nevertheless, counseling improved outcomes: 25% of those counseled had curve progression to a magnitude requiring surgery compared with 36% of those who were not counseled.
Increased brace wear improved outcomes. Those who did not have curve progression requiring surgery wore their brace significantly longer per day (p = 0.029) than those who did have such progression.
Effective counseling can be valuable. In modern medicine, effective counseling is in danger of becoming a lost art. The physician of fifty years ago had few effective treatments to offer, but he/she could still counsel and was beloved for that ability. Now, we emphasize treatment and tend to give counseling short shrift.
What Does This Study Not Show?
Even in the counseled group, 25% of the curves progressed to a magnitude requiring surgery. This percentage is not very different from the 27% failure rate noted by Peterson and Nachemson1 or by Weinstein et al.2. We still do not know why approximately a quarter of patients have curve progression despite bracing.
These results cannot be generalized to other types of braces—e.g., the Chêneau brace, the Providence brace, or the SpineCor brace.
We can make no judgments regarding the efficacy of nighttime bracing versus daytime bracing, as the study did not address that issue.
Forty percent of Risser stage-0 patients had curve progression to a magnitude requiring surgery. The study does not explain the poor results in this younger age group.
The study did not address the reasons for noncompliance.
What Might Be Worthwhile Topics for Further Study?
Compliance, counseling, and outcome data should be obtained for other braces.
Additional study of the patients for whom brace treatment failed, particularly those in the Risser-stage-0 group, should be undertaken in an attempt to define the reasons for the failures.
Wear data should be analyzed to determine the relative value of nighttime versus daytime brace usage.
We need data regarding the reasons for noncompliance. What other steps might be taken to improve brace wear?
↵* The author did not receive payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. The author, or his institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. The author has not had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
- Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated