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Research and studies on bracing for scoliosis has had a checkered past up to this point to say the least. The growing concensus among the experts is the back bracing for scoliosis has no effect on the natural course of the condition and doesn't effectively reduce the number of patients reaching the surgical threshold.
The search for a better way in the future is on and in order to do so we need to understand where we have already been. Those whom don't know the history are doomed to repeat it.
SYMPOSIUM: PEDIATRIC SPINE
Brace Management in Adolescent Idiopathic Scoliosis
Jonathan R. Schiller MD, Nikhil A. Thakur MD,
Craig P. Eberson MD
Published online: 30 May 2009
_ The Association of Bone and Joint Surgeons1 2009
Abstract Skeletally immature patients with adolescent
idiopathic scoliosis are at risk for curve progression.
Although numerous nonoperative methods have been
attempted, including physical therapy, exercise, massage,
manipulation, and electrical stimulation, only bracing is
effective in preventing curve progression and the subsequent
need for surgery. Brace treatment is initiated as
either full-time (TLSO, Boston) or nighttime (Charleston,
Providence) wear, although patient compliance with either
mode of bracing has been a documented problem. We
review the natural history of adolescent idiopathic
scoliosis, identify the risks for curve progression, describe
the types of braces available for treatment, and review the
indications for and efficacy of brace treatment.
Level of Evidence: Level IV, therapeutic study. See the
Guidelines for Authors for a complete description of levels
of evidence.
Introduction
The Scoliosis Research Society (SRS) has defined adolescent
idiopathic scoliosis as occurring in patients 10 years
or older with an idiopathic structural lateral curve of at
least 10_ measured with the Cobb technique and vertebral
rotation on a standing longitudinal radiograph of the spine
combined with asymmetry on forward bending [28]. It is
seen in 1% to 3% of the adolescent population, more
commonly in girls and, as suggested by the name, has no
known etiology. This definition provides a starting point
for treatment decisions in the growing spine. Left untreated
in the growing child, numerous studies have demonstrated
the negative long-term prognosis a progressive curve fosters
into adulthood, including back pain, pulmonary
compromise, cor pulmonale, psychosocial effects, and even
death [8, 9, 43, 54–56]. Curve progression is the most
important factor in the natural history of idiopathic scoliosis.
The risk of curve progression in idiopathic scoliosis
has been associated with factors that predict potential
remaining spinal growth; therefore, skeletally immature
patients with idiopathic scoliosis and major curves are
at risk for progression and warrant some form of treatment
[3, 4, 29, 57].
Bracing has been the mainstay of nonoperative treatment
for idiopathic scoliosis for nearly 50 years. However,
because bracing has not gained complete acceptance,
Each author certifies that he or she has no commercial associations
(eg, consultancies, stock ownership, equity interest, patent/licensing
arrangements, etc) that might pose a conflict of interest in connection
with the submitted article.
This work was performed at the Department of Orthopaedics, The
Warren Alpert Medical School of Brown University and Rhode Island
Hospital, Providence, RI.
Clin Orthop Relat Res (2010) 468:670–678
DOI 10.1007/s11999-009-0884-9
numerous other treatment modalities have been attempted,
including electrical stimulation, biofeedback, manipulation,
physical therapy, and exercise [10]. Although a
complete discussion of these modalities is beyond the
scope of this article, convincing evidence of their effectiveness
does not exist. Although Goldberg reported similar
surgery rates for unbraced patients compared with braced
patients [14, 15], other studies demonstrate bracing is an
effective nonoperative treatment modality preventing curve
progression compared with no bracing or treatment with
electrical stimulation [32, 44].
We reviewed three core areas of the nonoperative
(bracing) treatment of patients with idiopathic scoliosis:
(1) the natural history of idiopathic scoliosis and risk factors
associated with curve progression; (2) the various
types of braces and the efficacy of each brace treatment in
an evidenced-based approach; and (3) the indications for
brace treatment with respect to the type of brace and wear
schedule, including our recommendations.
Search Strategy and Criteria
To review the literature regarding the topic of bracing in
adolescent idiopathic scoliosis, we used multiple search
engines, including Ovid1, MedLine1, and PubMed1,
using the search string ‘‘Brace OR Bracing’’ AND ‘‘Adolescent
Idiopathic Scoliosis.’’ We searched for every article
available in the literature without restriction of publication
date and language of publication. We identified 464 citations.
We eliminated inappropriate articles comparing
bracing with surgical treatment and brace treatment as an
adjunct to surgical treatment because the scope of this
article was to evaluate bracing as the only mode of treatment.
Additionally, we eliminated articles on brace
treatment in patients with scoliosis other than adolescent
idiopathic scoliosis. Bracing technique articles and other
unrelated studies were eliminated as well, except those for
historical purposes, leaving 75 citations. Currently, there is
no standard for reporting results on bracing studies; thus,
we have included all 75 of the citations for full review.
Natural History
To determine the need for treatment of scoliosis, it is
important to understand the natural history of curve progression.
Progression is defined by either a 5_ or 10_
change in curve magnitude, depending on the initial curve
magnitude, on a standing radiograph [28]. The two key
factors in curve progression are the size of the curve at the
initiation of bracing and the amount of spinal growth
remaining. According to both Bunnell [3] and Lonstein and
Carlson [29], nearly 70% of patients with a Risser sign of 0
progressed greater than 5_ for curves between 20_ and 30_.
Weinstein and Ponseti [55] followed curves for an average
of 40 years and nearly 70% of curves measuring a minimum
of 30_ progressed after skeletal maturity. Similarly,
Nachemson and Peterson [32] demonstrated 66% of
observed patients with idiopathic scoliosis curves measuring
20_ to 35_ progressed 6_. Karol et al. [23] found 32% of
boys presenting with a curve of at least 25_ and all Risser
stages progressed 10_ or more. Boys tend to have curves
that progress beyond Risser 4 into late adolescence,
whereas girls’ growth has begun to decelerate by this time.
Curve progression is also related to curve pattern,
whereby double curves progress more than single curves
with the least amount of progression seen in single lumbar
curves [3, 29]. Large curves (30_–40_) will progress more
than small curves (20_–29_) and will continue to progress
even after skeletal maturity has been reached should the
curve reach a large enough magnitude [3, 4, 38, 55].
Females progress more than males as evidenced by larger
curves seen more often in females compared with males
[3, 4, 55].
Determining maturity and risk of progression may be
achieved with several methods. Tanner staging, although
quite familiar to pediatricians, is often not accurately
gauged by orthopaedic surgeons. Girls typically reach peak
height velocity (PHV), the maximum increase in growth
rate during the adolescent growth spurt, 18 to 24 months
earlier than boys, typically between Tanner stages 2 and 3,
whereas boys do so between stages 3 and 5 [45–47]. This
phase of growth represents a period of increased risk of
curve progression. Menarche can be useful in girls,
although it is reached most commonly after peak height
velocity and can be variable. Measuring height at each visit
is important; however, because growth is often in spurts, a
period of substantial growth may be missed and PHV
determined only in retrospect. The most commonly used
radiographic marker is the Risser sign and this can be
determined without the need for additional radiographs if
the iliac crest is routinely included on spinal radiographs.
The probability of progression has been calculated by both
Lonstein and Carlson [29] and Nachemson and Peterson [32]
using curve magnitude, and Risser sign and age, respectively,
and both authors concluded the younger the child,
measured as Risser sign or age, and the larger the curve, the
greater the probability the curve would progress. The PHV is
reached when the triradiate cartilage is still open; thus, it is
important radiographs include the entire pelvis.
Sanders et al. [47] used Tanner-Whitehouse-III staging
on hand radiographs to predict the period of rapid curve
progression (curve acceleration phase [‘‘CAP’’]). Their
findings are interesting, because they demonstrated patients
who are Risser 0 may have different estimated CAP scores,
which resulted in substantially different rates of progression.
However, all patients who are Risser 0 may not have
the same likelihood of progression: patients whose Tanner-
Whitehouse-III stage is before the CAP are at higher risk
than those beyond the CAP. Thus, a larger study may yield
helpful information pertaining to the need for bracing
immature patients and may in fact allow better analysis of
bracing studies [45].
The natural history of the untreated patient with scoliosis
may involve curve progression and lead to spine
surgery. The rationale for surgery is based on evidence
supporting morbidity unrelated to the musculoskeletal
system as curve magnitude increases [33, 36, 37, 56].
Moderate and severe thoracic curves are associated with
reduced vital capacity and total lung capacity [20, 21, 27,
48]. Untreated adolescent patients with major scoliotic
curves have a mortality rate slightly higher than the general
population of the same age [56]. The mechanism believed
responsible for respiratory failure in idiopathic scoliosis is
alveolar hypoventilation, potentially caused by decreased
lung volume, increased elastic load in the thoracic cage,
and impaired respiratory muscle function [21, 26]. The
literature regarding pulmonary function after bracing
remains controversial. Some studies demonstrate total lung
capacity and forced expiratory volume reduced to 80% of
prebracing level [41, 50]. However, Korovessis et al. [26]
analyzed pulmonary function in 30 patients with idiopathic
scoliosis treated with continuous wearing of a Boston brace
and demonstrated substantial yet reversible reduction in
vital capacity, forced vital capacity, functional residual
capacity, and residual volume over 2 years.
Long-term follow up of patients with idiopathic scoliosis
has demonstrated more thoracic and lumbar back pain and
degenerative disc disease [8, 54]. Danielsson et al. [8] followed
127 patients 22 years after brace treatment and found
degenerative lumbar disc changes were more common than
in control subjects. Additionally, brace-treated patients had
more back pain than the control group; however, there was
minimal functional impairment or impact on daily life.
Similarly, Weinstein et al. [54] found, in a 50-year follow
up of 117 untreated patients with idiopathic scoliosis, 61%
of patients had low back pain, although nearly 70% of those
patients reported little or moderate back pain and with little
physical impairment. Haefeli et al. [17], in their review of
121 patients with idiopathic scoliosis treated nonoperatively
and followed over an average of 23 years, reported substantially
more pain in patients with curves greater than 45_
compared with those whose curves were smaller. This
suggested curve size, rather than treatment, predicted back
pain in nonoperatively treated patients.
Bracing
A brace is designed to apply an external force to the trunk
during the adolescent growth phase to prevent progression.
As demonstrated subsequently, there are a myriad of brace
treatments available, differing in fabrication, area of curve
treatment, duration of wear, and wear protocols (Table 1).
Brace Types
The Milwaukee brace [30] is a cervico-thoracic-lumbarsacral
orthosis developed in the 1940s. It is used for thoracic
and double curves. It consists of a plastic pelvic
section with an anterior and two posterior uprights connected
superiorly by a neck ring with a throat mold
anteriorly and occipital pads posteriorly or a plastic contoured
low-profile neck ring; corrective pads are also used.
The Milwaukee brace is prescribed for full-time wear with
time out for sports and extracurricular activities. Given the
stigma attached to this brace and the availability of other
effective braces, the use of this brace is limited.
The Wilmington brace [18] is a TLSO (thoracic-lumbarsacral
orthosis) type of brace. It was designed by G. Dean
MacEwen to improve patient compliance by making the
brace less bulky and more lightweight as compared with
the Milwaukee brace. It is a custom-made plastic underarm
TLSO fabricated with several plastics, the most common
being Orthoplast. It is designed as a body jacket, which
opens in the front and is easily removable. It is held closed
with adjustable Velcro straps. Corrective molds are fabricated
into the plastic of the body jacket. The Wilmington
brace is typically prescribed for full-time wear (23 hours/
day), although some studies indicate 12 to 16 hours a day is
satisfactory for curves measuring 40_ or less [1].
The Boston brace [35] was developed in the 1970s at
Harvard University. It is also a TLSO-type brace and is
made from prefabricated polypropylene pelvic module
with a soft foam polyethylene lining. Modules are designed
with lumbar flexion. The Boston brace can be used to treat
all scoliosis; however, it is recommended to be fitted with
the Boston Milwaukee brace superstructure when a thoracic
curve has an apex above T-10. The Boston brace is a
full-time brace.
The Dynamic Spine-Cor brace [6], developed in 1992-
1993, uses a specific Corrective Movement dependent on
the type of the curve. The curve-specific Corrective
Movement is performed, and the brace is applied according
to definitions contained in the Spine-Cor Assistant software.
To be effective and to obtain a neuromuscular
integration, the brace must maintain and amplify the corrective
movement over time. The brace must be worn
20 hours a day for a minimum of 18 months to create a
neuromuscular integration of the Corrective Movement
through active biofeedback. Generally, the brace is stopped
at skeletal maturity (at least Risser 4).
The Charleston brace [53] is a custom-molded spinal
orthosis that holds the patient in an overcorrected position.
The patient is casted supine in a bending position opposite
the curvature while corrective force is applied at the apse
of the curve. This brace is a nighttime brace only.
The Providence brace [7] was developed when it was
observed that substantial correction of scoliotic curves
could be achieved using an acrylic frame to apply direct
corrective forces to the patient. The brace can be used to
treat all single and double curves. The frame was originally
developed to demonstrate radiographic supine spinal flexibility
for preoperative planning. The frame works by the
application of controlled, direct, lateral, and rotational
forces on the trunk to move the spine toward the midline or
beyond the midline. A plaster impression of the patient is
taken on the frame with corrective forces applied to the
spine. The brace is now fabricated using computer-aided
design and manufacturing techniques. The brace is fabricated
of polypropylene plastic from measurements or a
plaster impression. The Providence brace is a nighttimeonly
type of brace.
Bracing Efficacy
Defining ‘‘success’’ from brace treatment of scoliosis can
be a challenge. The majority of the literature uses curve
progression of more than 5_ before skeletal maturity as a
benchmark for bracing failure rather than spine surgery
[49]. Some use 10_ of curve progression or preventing the
curve from reaching 45_ at skeletal maturity [42].
To compare the effectiveness of various braces, standardized
research protocols are needed. The variability
defining success of brace treatment in idiopathic scoliosis
was addressed by Richards et al. and the SRS Committee
on Bracing and Nonoperative Management [42] in an
attempt to standardize parameters for effective and reliable
comparisons of bracing studies. The recommendations for
bracing study inclusion were patients 10 years or older,
Risser sign 0 to 2, initial curve magnitude of 25_ to 40_,
and no prior treatment at the initiation of brace treatment.
The outcome data should be determined from the percentage
of patients with: less than 5_ or greater than 6_ of
progression at maturity, curves exceeding 45_ at maturity,
and progression resulting in the recommendation for surgery.
Bracing studies should have a minimum of 2 years
follow up beyond skeletal maturity. The first study to use
these criteria determined a brace should prevent progression
in 70% of patients to be considered effective [19].
Patient compliance, subjective or objective, is not factored
into the analysis of the data. Regardless of the recommended
standardized parameters, the goal of bracing
idiopathic curves remains consistent: control the curve,
prevent progression, and avoid surgical intervention.
Although some of the new studies are based on the SRS
guidelines for bracing studies, others are not. Hence, the
results of different types of bracing are varied (Table 2).
Several studies have compared full-time bracing [8, 13,
18]. Lonstein and Carlson [29] observed, in 1020 patients
treated with the Milwaukee brace for adolescent idiopathic
scoliosis, 78% had improvement of 1_ to 4_ when the brace
was discontinued. Twenty-two percent required surgery.
The rates of failure were lower than in previous series for
patients with curves between 20_ and 39_. Bassett et al. [2]
reported 75 patients treated with the Wilmington brace
with follow up over 2 years 6 months. The average curve
was 20_ to 39_ at Risser 0 or 1. The magnitude of the
curves was reduced by 50% with initial brace application.
There was some loss of correction (28%) with removal of
brace on subsequent follow up; however, only 11% of
patients needed surgery. They concluded the Wilmington
brace favorably altered the natural history of 20_ to 39_
curves. Katz et al. [25] reviewed 51 patients who had
average curves sizes of 36_ to 45_ treated with the Boston
brace. Treatment was successful in 61% of patients,
although 16% progressed more than 5_ and 31% required
surgery. Coillard et al. [6] reported results of 170 patients
treated with the Spine-Cor brace. Fifty-nine percent of
patients were treated successfully, whereas 23% required
surgery. Furthermore, 95.7% of patients treated in the brace
stabilized or corrected the end of bracing Cobb angle up to
2 years after bracing. They concluded the Spine-Cor brace
was effective for treatment of adolescent idiopathic scoliosis.
However, as a result of the paucity of literature on the
Spine-Cor brace, future studies are needed to confirm these
results. Despite success with the Milwaukee, Wilmington,
Spine-Cor, and Boston braces, at present none is demonstrably
superior to the others with regard to treatment
success, curve progression, or need for surgery.
However, part-time bracing studies using the Providence
and Charleston brace have also been compared with
full-time bracing models with equivalent or superior
results (Table 2) [19]. Price et al. [39] reported the results
with the Charleston brace in 98 patients in which 63%
had excellent results and, overall, 85% curves had
acceptable results. Curve correction was 87% for major
curves and 33% for compensatory/secondary curves.
Thirteen percent of curves progressed more than 5_ and
1% of patients required surgery. Trivedi and Thomson
[52] reported on 42 patients treated with the Charleston
brace over a period of 10 years. Patients were Risser 0 or
1 and were followed a mean of 3.3 years after brace
discontinuation. Average age at the start of bracing
was 12.5 years and the average curve was 30.3_ (range,
25_–40_). Bracing was successful preventing progression
of the curves in 60% of patients. Thoracic curves had the
same success as thoracolumbar and lumbar curves. The
authors concluded the Charleston brace was effective
preventing progression of the curve.
Using the Providence brace, D’Amato et al. [7] reported
in-brace correction of 96% for major curves and 98% for
minor curves. Seventy-four percent of patients did not
progress more than 5_, whereas 26% of patients progressed
more than 6_ or went on to have surgery. Seventy-six
percent of patients with curve apices between T8 and L1
had successful outcomes. Overall 63% of thoracic curves,
65% of double curves, 94% of lumbar curves, and 93% of
thoracolumbar curves were treated successfully using the
Providence brace.
This may in fact be purely a reflection of compliance; it
is much more tolerable for most adolescents to wear a
brace that they are not required to wear to school. Currently,
the literature supports initiating nighttime bracing
for curves measuring less than 35_ with an apex below T9,
although centers with experience with these braces may
choose to expand the indications [14, 19, 27, 33–35].
Hence, future studies, like the Level 1 BrAIST study [53],
will be needed to compare full-time versus part-time
bracing using SRS guidelines to determine efficacy of each
bracing model to prevent progression of curvature and
improve function.
Bracing Difficulties
Multiple factors can be obstacles to successful brace
treatment. Poor compliance with wear schedules is a major
recurring theme in the braced patient, particularly males.
Karol [22] found only 38% of males were compliant with
brace wear, and 74% progressed 6_ with nearly half
reaching a surgical threshold of 50_. Immature Risser status
related to both progression and surgery with greater than
80% progressing a minimum 6_ and half reaching surgery.
Similarly, 55% of curves measuring greater than 30_ at
brace prescription progressed to surgery or greater than
50_. Yrjonen et al. [59] supported these results finding 35%
of braced males were noncompliant. However, although
compliant males progressed greater than 5_ 10% more
frequently than the females (21%), they concluded brace
treatment for idiopathic scoliosis was beneficial for both
genders.
Curve magnitude correlates with curve progression;
thus, larger curves are more likely to progress than smaller
curves. Likewise, the probability brace treatment will
prevent curve progression is inversely proportional to the
initial size of the curve [11, 25, 30]. Although brace
treatment limits curve progression for curves larger than
35_, success has been less predictable compared with
curves between 20_ and 35_ [1, 11, 25, 30].
Bracing success is similar to any prescribed treatment in
orthopaedics; it relies on patient compliance. Although
casts are not easily removable, braces are easily removed,
not surprising given the negative cosmetic appearance,
which fosters poor self-esteem and body image, as well as
functional discomfort resulting from pressure points, irritation
in hot weather, and restriction of movement [5, 33].
The discomfort caused by the external biomechanical forces
applied by a brace, in an effort to alter spine growth, is
determined by brace characteristics such as size, location,
and thickness of the pads; tension of the straps; molding;
and stiffness of the brace. It is these characteristics that
cause bracing in the overweight patient to be ineffective
and lead to increased curve progression compared with
patients who are not overweight [31, 35]. Brace compliance
was potentially responsible for the disparity of
success between males and females treated with bracing
[22, 59] and may explain the similar results of noncompliant
patients with the natural history. Numerous studies
have demonstrated compliant brace wear leads to successful
results, yet much of the data, as acknowledged by
the authors, is subjective based on incomplete assessments
of compliance such as office notes, questionnaires, or
phone or office interviews [22, 30, 34, 58]. Thus, this has
led some to doubt the efficacy of bracing and the need for
objective compliance measures [51].
To answer the question of compliance, objective compliance
measures using temperature sensor loggers and
pressure transducers have been developed to ascertain
compliance [24, 33]. These authors used temperature data
loggers at the brace-skin interface to measure time in the
brace and found patients overestimated their time in brace
nearly 150%. Patient compliance was best in 10-year-old
patients (84%) compared with 12-year-old patients (77%)
and 14-year-old patients (60%). However, Rahman was the
first to correlate objective compliance with efficacy [40]. A
temperature sensor and logger were placed in a Wilmington
TLSO brace and patients were monitored for the
duration of their treatment. Compliance for those whose
curve progressed more than 5_ was 62%, whereas those
that did not progress showed 85% compliance, indicating
patient compliance improves the chance for a successful
result.
Treatment Recommendations
Brace treatment for idiopathic scoliosis in the skeletally
immature child remains the only effective modality limiting
curve progression and the potential need for surgical
intervention [1, 11, 12, 32, 39, 43]. Current recommendations
from the SRS include the initiation of brace treatment
in skeletally immature patients who present with curves
greater than 30_ on initial presentation or in patients who
progress greater than 10_ to a magnitude greater than 25_
[42]. Braces are usually worn 18 to 23 hours a day,
although evidence exists demonstrating the effectiveness
part-time or nighttime bracing to address patient compliance
issues [7, 11, 16, 39, 43]. Part-time or nighttime
bracing (Charleston, Providence) may be effective for
curves less than 35_; however, curves greater than 35_
often require full-time bracing to reliably limit curve progression.
Bracing should continue until growth has
stopped, indicated by unchanged height measured consecutively
6 months apart, Risser sign 4 (females) or 5
(males), postmenarchal 18 to 24 months, or skeletal
maturity on bone age determination [49]. Although Karol
has stated bracing in boys should be continued until Risser
5 as a result of the prolonged growth period during the
Risser 4 phase, 46% of her patients had curves progress to
surgical correction despite brace wear [23]. She found
nearly 80% of curves will progress when not braced
compared with similarly braced patients and are four times
as likely to require spinal instrumentation and fusion,
whereas compliant patients will show minimal progression
and most likely not require surgery. Bracing success is
measured by preventing curve progression on standing
radiographs and the avoidance of surgical management.
Inadequate time prescribed in the brace and a poor-fitting
brace certainly will lead to poor results and are beyond
control of the patient. However, compliance appears to be the
greatest concern for any treating physician and the primary
cause for poor results from brace treatment. Additionally,
bracing in males and obese, skeletally mature, and nonidiopathic
patients is less effective. Long-term follow up
suggests bracing may be beneficial into adulthood, improving
life expectancy, patient satisfaction, and function,
although there is a higher incidence of back pain [9, 17, 55].
At our institution, Providence bracing is initiated for
curves between 25_ and 35_ in patients with substantial
growth remaining. Occasionally, patients seen before peak
height velocity with curves that are already becoming
cosmetically objectionable (ie, thoracolumbar curves) will
be braced for curves over 20_, although this is a relative
indication. For patients presenting with larger curves, or for
patients who progress with nighttime-only bracing, we
prefer to add a TLSO for daytime use (total 18–20 hours
per day). Assuming appropriate in-brace correction in the
Providence brace, the addition of a Boston brace should be
additive in terms of forces applied to the spine as opposed
to changing brace treatment completely. We have found
the combination of braces is well tolerated, putting pressure
on slightly different locations to avoid brace irritation.
Bracing continues until growth stops or curve progression
cannot be controlled and spine surgery is indicated. For
successful treatment, this is usually through Risser 4 in
girls and Risser 5 in boys. A review of patients followed to
maturity at our institution is underway to determine the
effectiveness of our combined brace protocol.
Discussion
The natural history of idiopathic scoliosis has been well
documented throughout the literature. Left untreated, the
younger the patient (i.e., the amount of skeletal growth
remaining) and the larger the curve at the initiation of bracing,
the greater the chance of curve progression, thus necessitating
surgery. Brace treatment with full-time (Boston,Wilmington,
and Milwaukee) or nighttime (Charleston and Providence)
bracing continues to be the only efficacious mode of nonoperative
treatment in idiopathic scoliosis.
To date, a major criticism of the bracing literature
remains the absence of a prospective, randomized study to
determine the efficacy of brace treatment. The ongoing
Level-1 BrAIST study will hopefully address the limitations
of prior work. Nonetheless, assumptions can be made based
on the existing literature. Newer methods of determining the
period of rapid curve progression may help guide treatment
decisions. The availability of successful nighttime treatment
regimens has the potential improve compliance and, thus,
success rates. However, brace treatment demands participation
from the patient and their support network; parents,
family, and friends; the orthopaedist; and the orthotist. Each
has an integral part in fostering bracing success and potentially
is the difference in preventing curve progression and
the need for spine surgery.
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