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| SYMPOSIUM: ADOLESCENT IDIOPATHIC SCOLIOSIS |
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| Year : 2020 | Volume
: 3
| Issue : 2 | Page : 151-159 |
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Bracing in adolescent idiopathic scoliosis
Bhavuk Garg1, Kaustubh Ahuja2, Saumyajit Basu3
1 Department of Orthopaedic Surgery, All India Institute of Medical Sciences, New Delhi, India
2 Department of Orthopaedic Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
3 Department of Neurosciences, Park Clinic, Kolkata, West Bengal, India
| Date of Submission | 18-Mar-2020 |
| Date of Decision | 24-Apr-2020 |
| Date of Acceptance | 07-Jun-2020 |
| Date of Web Publication | 13-Jul-2020 |
Correspondence Address:
Dr. Kaustubh Ahuja
Department of Orthopaedic Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand.
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/isj.isj_21_20
Bracing constitutes the most widely practiced treatment method for nonoperative management of adolescent idiopathic scoliosis (AIS). Brace treatment has undergone a large number of variations from the time of its inception, and it has led to a number of available options to choose from in present times. The evidence for bracing has also evolved tremendously in the last few years from single-center cohort studies to multicenter randomized controlled trials. For bracing to be successful, proper patient selection is an important prerequisite. A coordinated team effort from the patient, parents, family, the surgeon, and orthotist is also essential for ensuring compliance and treatment success. This article is a narrative review and focuses on the role of bracing in the management of AIS in terms of the brace history, types, indications, results, and drawbacks with relevant literature. Keywords: Adolescent idiopathic scoliosis, bracing, conservative management
How to cite this article:
Garg B, Ahuja K, Basu S. Bracing in adolescent idiopathic scoliosis. Indian Spine J 2020;3:151-9 |
| Introduction | |  |
The progression of deformity in adolescent idiopathic scoliosis (AIS) depends essentially on the size and pattern of deformity and age of the patient. The treatment strategies for these patients can be broadly divided into either operative or nonoperative. Among the various modalities of nonoperative management, bracing constitutes the most commonly used treatment method. Other nonoperative treatment strategies such as electrical stimulation, biofeedback, manipulation, physical therapy, and exercise are less widely practiced owing to the lack of substantial evidence in literature.
The main aim of brace treatment is the prevention of progression of the deformity to an extent that needs surgery. Several studies in the past have reviewed the use of bracing in AIS and concluded positive treatment outcomes with respect to curve progression, pain control, and patient satisfaction.[1],[2],[3],[4],[5],[6] Brace treatment has undergone a large number of variations from the time of its inception, and it has led to a number of available options to choose from in present times. Apart from the preference of the treating physician, level and size of the curve and anticipated compliance have a major bearing on the selection of the type of brace.
This article is a narrative review and focuses on the role of bracing in the management of AIS in terms of the brace history, types, indications, results, and drawbacks with relevant literature.
| Bracing History | | |
The history of bracing dates back to 1924 when Lovett and Brewster[7] designed a plaster jacket split into cranial and caudal parts with a hinge centered over the convex side of the scoliotic curve. Risser[8] made a modification in this cast with a lighter material and it was called the localizer cast. Since then the art of bracing has seen a number of variations by various researchers, and the era was widely known as the “modern era” of bracing.[9] Milwaukee brace, which is the most commonly used brace today for curves with dorsal apex above D7, was introduced by Blount et al.[10] during this era in 1958. For curves with apex below D7, Watts et al.[11] introduced the low contact Boston brace in 1977. Further modifications were aimed at improving the brace compliance and efficacy.
| Types of Braces | | |
- Milwaukee Brace [Figure 1]—It is a type of cervico-thoracic-lumbar-sacral orthosis (CTLSO) consisting of a PVC pelvic section with one anterior metal upright connected to a neck ring with a throat mold superiorly and two posterior uprights connected to occipital pads or low-profile neck ring. It functions by the application of distracting forces to the mandible with lateral forces directed to the apex by straps and corrective pads. It is prescribed for a full-time wear; however, low compliance and the associated stigma limits its use.[12]
- Wilmington brace—It is a type of thoraco-lumbar-sacral orthosis (TLSO) designed to improve patient compliance by the virtue of it being low profile and light weight as compared to the Milwaukee brace. The most common form is a customized underarm TLSO made from orthoplast. It opens from the front and is held closed by Velcro straps. Corrective molds are commonly incorporated into the plastic body jacket.[13] Like Milwaukee, this is also prescribed for full-time wear; however, curves less than 40° may benefit from brace compliance for 12–16 h a day.[14]
- Boston brace [Figure 2]—It is also a TLSO-type brace, which uses both passive and active correction forces as opposed to Wilmington brace, which uses only passive correction forces.[15] Each brace is custom made from prefabricated polypropylene pelvic module with a soft foam polythene lining. Although it is suitable for almost all type of scoliosis, however, it is advisable to be fitted with Milwaukee brace superstructure for curves with apices above D7. It is also prescribed for full-time wear.
- Dynamic SpineCor brace—The brace is designed to provide curve-specific corrective movement and is applied according to definitions contained in the SpineCor assistant software based on the principle of active biofeedback. The brace is prescribed for a full-time wear for a minimum of 18 months for neuromuscular integration.[16]
- Charleston brace—This brace was developed to improve nighttime bracing. This brace is typically constructed from a mold with the deformity overcorrected by applying corrective forces at the apex of the curve in a supine patient.[17]
- Providence brace—This brace uses an acrylic frame to apply direct corrective forces to the scoliotic curve. The frame is used to apply controlled lateral and rotational forces to correct or overcorrect the spinal deformity. It is custom made using computer-based design and manufacture. It is prescribed for nighttime wear only.[18]
- Chêneau brace [Figure 3]—This brace is quite popular in certain European countries. It is based on the principle of detorsion and sagittal plane correction, resulting in the elongation of spine without excessive distraction forces. The Chêneau brace creates pressure on the convexity of the curve, and on the opposite side, there are wide expansion chambers in the frontal, sagittal, and horizontal planes, where the patient has to put his body mass through physiotherapy of deviation from pushes and respiratory kyphotic exercises for at least 1 h every day.[19]
- Computer-assisted design (CAD) brace—A majority of the conventional braces use a preexisting fabricated symmetric module with modifications with respect to padding, trim lines, and areas of relief based on individual’s anthropometry and physical dimensions or indirectly using plaster cast of the patient’s trunk. However, there are certain limitations associated with this technique such as consideration of a complex three-dimensional (3D) deformity in only a two-dimensional plane and subjectivity in terms of physician or orthotist’s decision for trim lines, padding, and areas of relief. Although the braces have been effective in reducing or limiting the curves in the coronal plane, however, an important drawback recognized with the use of these braces was the reduction in the sagittal curvatures of the spine. With the increasing utilization of computer-assisted technology in scoliosis management, it is now possible to design a topographic virtual 3D model of a scoliotic trunk. Further, it allows the physicians or orthotists to identify the areas of corrective padding along with postfabrication assessment of 3D pressure dimensions for final customization and validation of the brace design. Although a prospective trial for the evaluation of the efficacy of this brace is ongoing, nevertheless the initial results with respect to the in-brace correction in these braces have been encouraging.[20],[21]
 | Figure 2: Boston brace is typically useful if apex of the curve is at D7 or below
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 | Figure 3: Chêneau brace aims at all three planes of correction including coronal, transverse, and sagittal
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| Indications of Bracing | | |
Bracing is typically indicated in patients with curves with Cobb’s angle ranging from 25° to 40°, and having substantial growth remaining, that is, from Risser’s grade 0 to 2. Curves less than 25° under observation, showing significant progression from 5° to 10° degrees over a period of 6 months, are also good candidates for bracing. Another relative indication includes patients with 20°–25° curve with pronounced skeletal immaturity (Risser, 0; Tanner, 1 or 2).[9] The biomechanical rationale behind these indications was recognized by the findings suggesting minimal requirement of forces to deform a scoliotic spine with Cobb’s angle over 25°. In contrast, vertebral loading is more symmetrical in curves less than 25°.[22],[23]
Bracing has no role in patients with curves over 45° or less than 25° without documented progression. It is also ineffective in skeletally mature patients.[24] Bracing is also contraindicated in patients with thoracic lordosis due to the lordotic effects of bracing on thoracic spine. In addition, obesity in adolescence is also an important factor leading to failure of bracing due to poor transmission of corrective forces due to cushioning effect of body fat and soft tissues. Obese patients also have a greater chance of curve progression when compared to nonobese patients.[15]
He et al.[25] studied the flexibility of spine in standing, supine, prone, sitting with lateral bending, and prone with lateral bending positions, and correlated it with initial correction after bracing. The initial correction of the deformity after bracing most closely correlated to the spinal flexibility in prone position [Figure 4]. It indirectly suggests that prone position can be an effective indicator of the initial effect of bracing in patients with AIS.[25] | Figure 4: Initial correction after orthotic treatment as evident from full length standing radiographs
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| During Treatment | | |
Accepting a brace for an adolescent can be a daunting task due to the associated stigma and discomfort associated. An ideal bracing protocol should accommodate the first 2–3 weeks for initial adjustment to the new brace. During this adjustment period, bracing period should be gradually increased over time. In addition, the brace should also be gradually tightened over the first 2 weeks to reach the desired level of snugness allowing the patient to “fit in” the brace. Once this initial period is tided over, an X-ray should be done after 4 weeks to assess the corrective forces and the degree of curve correction. A repeat X-ray study should be performed every 4–6 months without the brace to assess the progression of deformity if any. The brace should be removed for 12–24 h to assess the true size of the deformity. Some researchers, however, prefer repeat X-rays in the brace to monitor effectiveness of the brace in controlling the deformity. X-rays outside the brace should be done only if there is curve progression despite compliant bracing or at the end of the brace treatment to make a definitive decision.[26] Surgical treatment is warranted if there is a progression of 5° or more on subsequent radiographs done 6 months apart.
A number of researchers have tried to predict the progression of the curve on the basis of initial correction rate (ICR) and early Cobb’s angle reduction velocity (ARV) during brace treatment. Radiographs done at the beginning of the treatment and 6 months later can be used to calculate the ICR and ARV. Mao et al.[27] in their article have concluded ARV to be better than ICR for the prediction of curve progression during brace treatment. They found significantly high risk of progression in patients with initial ARV less than 10° per year.[27]
Brace compliance is an important concern during the treatment period. Most braces used in routine are prescribed for full-time wear except a few braces designed specifically for nighttime bracing. A number of studies have reviewed the effect of part-time and full-time bracing and concluded better results with longer hours of bracing per day resulting in improved outcomes. Patients are encouraged outdoor sports while continuing brace wear, if possible. A period of 2–3 h is permitted for bathing, swimming, and physical education. A recent meta-analysis reviewing the factors responsible for failure of brace treatment concluded poor compliance, lack of skeletal maturity, higher Cobb’s angle, poor in-brace correction, vertebral rotation, osteopenia, and thoracic curve type as risk factors for poor outcome following brace treatment.[28]
Wiley et al.[29] compared the results of noncompliant (less than 12 h a day), part-time (12–18 h a day), and full-time brace wearing (between 18 and 23 h a day), and reported an improvement in Cobb’s angle at final follow-up in full-time brace wearers as opposed to former two groups where Cobb’s angle deteriorated by 15° and 4° in noncompliant and part-time groups, respectively. The rate of surgery was also significantly higher (73%) in noncompliant group as opposed to full-time group (9%).[29] However, in smaller curves both part-time and full-time brace wear yielded comparable results.[30] Similarly, Allington and Bowen[14] found comparable results between part-time and full-time brace wear on using Wilmington brace for curves between 30° and 40° Cobb’s angle.
| Cessation of Treatment | | |
Bracing should be continued till skeletal maturity has been attained and growth has stopped. This is indicated by no change in measured height when measured over 6 months apart, females with Risser 4 or males with Risser 5, 18–24 months post-menarchal, or skeletal maturity on bone age.[31] Once skeletal maturity is achieved, brace should be gradually weaned over time rather than sudden cessation of brace usage. Brace weaning is a process of gradually decreasing hours of bracing per day over a period of 2–3 months with monthly whole spine radiographs without the brace to check for residual curve and spinal stability. Deterioration of the residual curve at any stage of treatment may necessitate surgical management. A successful bracing is defined by the prevention of curve progression when measured on standing radiographs, cosmetic satisfaction to the patient, and avoidance of surgery [Figure 5]. | Figure 5: Successful outcome after 5 years of treatment with a Milwaukee brace. (Above) Standing radiograph at the beginning (left), during (center), and at the cessation of treatment (right). (Below) Clinical photographs. Note: Although Boston brace has a higher acceptability and compliance curves below D7, however, both Milwaukee and Boston braces have comparable efficacy in these curves
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| Complications | | |
The major obstacle associated with bracing is compliance to bracing. Noncompliance can either be due to lesser hours of bracing per day or premature cessation of bracing altogether. Noncompliance to bracing is maximum with Milwaukee brace when compared to other braces. The causes can be multiple. Poor image or low self-esteem in school-going children or discomfort from chin and throat contact or pelvic and axillary part of the brace are the most common reasons.[26] Noncompliance may also be due to poor guidance and inadequate time taken for initial adjustment period. According to one study, only 38% males are compliant with brace treatment, and nearly 74% progressed 6° with half reaching surgical cut-off of 50°.[32] To ensure compliance, a number of objective measures such as temperature sensor loggers and pressure transducers have been introduced for physicians and parents.[33] Rahman et al.[35] in their article compared objective compliance with efficacy. Temperature sensor loggers fitted with Wilmington brace were used to ensure compliance. For patients in whom curve progression was more than 5°, orthotic compliance was 62% as opposed to 85% compliance in patients with nonprogression of their curves.[34]
The psychological impact of bracing on patients with AIS can not be understated. The emotional impact of bracing on these adolescents can play a major role in shaping their social interactions apart from the issues associated with noncompliance. The emotional impact due to bracing is particularly significant at the start of the therapy, and it tends to improve with the progression of the therapy. Maximum noncompliance and failure of the brace treatment in the initial part of the treatment can be partly attributed to its psychological impact at the beginning of the treatment.[35] Moreover, full-time bracing is also known to have a much sinister psychological impact on patients as compared to part-time bracing.[36] An organized team effort with inputs from the treating surgeon, orthotist, parents, psychologists, and patients is crucial to increase the overall acceptability of bracing.
Other complications associated with bracing include chest wall and rib deformation. This commonly ensues when bracing is done for cases with profound skeletal immaturity when the chest wall is plastic and the ribs are more prone to drooping on the side of convexity due to continuous application of corrective forces. This deformation along with compartmentalization due to orthosis may also lead to an initial worsening of vital capacity. However, both the deformation and vital capacity undergo correction when the brace use is discontinued. Permanent deformation is only seen in patients undergoing bracing for more than 5–6 years.[37],[38],[39],[40] Other minor problems encountered due to bracing include skin irritation, which is more common in warm areas or during summer months due to increased perspiration. Frequent changing of cotton undergarment may reduce the likelihood of skin irritation.
| Evidence on Bracing in AIS | | |
There is overwhelming evidence supporting the use of various types of braces [Table 1]. Lonstein and Winter[5] analyzed the role of Milwaukee brace in 1020 patients, and they recommended the use of this brace in all patients with AIS under 25° Cobb’s angle and with a Risser sign of 0 without waiting for documentation of curve progression. Regarding Boston brace, Emans et al.[30] studied its effect on 295 patients for a mean period of 1.4 years and found AIS curves corrected or stayed unchanged in 93% of the patients, whereas only 11 patients needed surgery during the study period. In Europe, Negrini et al.[41] evaluated the effect of a new SPoRT (Symmetrical, Patient-oriented, Rigid, Three-dimensional, active) brace and compared it with the already famous Lyon brace. The authors found significantly better results with SPoRT brace when compared with Lyon brace, especially in curves with higher Cobb’s angles.[41]
A number of researchers have tried to study the effect of part-time bracing in the treatment of AIS. Allington and Bowen[14] studied the same with Wilmington brace in 188 patients. Although the progression of curves was seen in both the groups, however, the difference between the two groups was not statistically different.[14] In another prospective study, Price et al.[42] analyzed nighttime bracing only using Charleston brace in 191 curves. They found a meager failure rate of 17% in this cohort with Cobb’s angle progressing over 5° in 6 months. Thus, the authors recommended nighttime bracing with Charleston brace to be an effective method for the management of AIS.[42] Gepstein et al.[43] also found nighttime bracing for 8 h with Charleston brace equally effective to 18–22 h of TLSO bracing for AIS treatment. Another nighttime correction brace that has gained popularity among the surgeons of North America is the Providence brace. Yrjönen et al.[44] have found significantly better results with Providence nighttime brace as compared to Boston brace with respect to curve progression and failure rate. To improve the compliance, a number of flexible orthosis have also been designed for the management of AIS. Wong et al.[45] compared the rigid and flexible orthoses (SpineCor) in 43 patients. The authors found a high failure rate with SpineCor (32%) as compared to rigid orthoses (5%), and hence, did not recommend the flexible brace despite the initial enthusiasm.[45]
Despite the enormous available literature, a major criticism of bracing for AIS is the lack of a randomized and prospective study to review the efficacy of brace treatment. Sanders et al.[46] in their systematic review pointed out that a majority of studies in literature have supported the role of braces in achieving surrogate outcomes such as prevention of more than 6° progression; however, translation of these surrogate outcomes toward more patient-centric results such as the prevention of surgery cannot be proven with certainty. This lacuna in the literature was overcome by the BrAIST trial. BrAIST was started as a multicenter randomized prospective trial design. However, the recruitment was very slow owing to the preference for a particular treatment method, thus making informed randomization very difficult. This is the reason why a separate preference cohort had to be introduced in the trial, and thus it became an intention to treat trial. However, the trial had to be stopped early owing to the overwhelming efficacy of bracing. The rate of treatment success was 72% after bracing as compared to 48% after observation with a significant positive association between hours of brace wear and success of treatment. Subgroup analysis among the randomized patient group also yielded similar results. The authors concluded an important role of bracing in slowing the progression of high-risk curves and subsequently reducing the need for surgery.[17]
| Conclusion | | |
An important prerequisite for success of brace treatment is appropriate patient selection and timely recognition of failure of brace treatment. In the Indian context, appropriate patient selection is a major problem because of the lack of awareness of AIS and the absence of school screening program. A coordinated team effort from the patient, parents, family, orthopedic surgeon, and orthotist is also essential for ensuring compliance and treatment success. New material for brace fabrication, especially to tide over hot and humid climates, and newer designs that promote compliance leave lots of scope for further research.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1]
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