Good brace compliance reduced curve progression and surgical rates in patients with idiopathic scoliosis

Discontinuation of brace treatment in adolescent idiopathic scoliosis (AIS): a scoping review

PURPOSE

Brace treatment for adolescent idiopathic scoliosis (AIS) is usually prescribed for 20-40° curves in patients with growth potential. The aim is to reduce the risk of curve progression during growth and to avoid the curve reaching a surgical threshold. Having as small a curve as possible at skeletal maturity will reduce the risk of curve progression during adult life. While evidence exists for brace treatment in AIS, there is disagreement on how and when to discontinue bracing. The purpose of this review was to investigate what criteria have been reported for initiating brace cessation and published weaning protocols and to look at estimates of the number of patients that may progress > 5 degrees after the end of growth.

METHODS

This scoping review summarizes existing knowledge on the best time to stop bracing in AIS patients, how to "wean," and what happens to spinal curves after bracing. Searches were carried out through MEDLINE, EMBASE, and PsycINFO in April 2022. A total of 1936 articles were reduced to 43 by 3 reviewers. Full papers were obtained, and data were extracted.

RESULTS

Weaning was most commonly determined by Risser 4 (girls) and 5 (boys). Other requirements included 2 years post-menarche and no growth in standing/sitting height for 6 months. Skeletal maturity assessed from hand and wrist radiographs, e.g., Sanders' stage; distal radius and ulnar physes, could determine the optimal weaning time to minimize curve progression. Complete discontinuation was the most common option at skeletal maturity; variations on weaning protocols involved gradual reduction of bracing over 6-12 months. Curve progression after weaning is common. The 12 studies reporting early curve progression after brace weaning found a mean Cobb angle progression of 3.8° (n = 1655). From the seven studies reporting early curve progression by > 5 degrees, there were 236/700 (34%) patients. There is limited information on risk factors to predict early curve progression after finishing brace treatment with larger curves, especially those over 40 degrees possibly having more chance of progression.

CONCLUSION

Curve progression after bracing cessation is a negative outcome for patients who have tolerated bracing for several years, especially if surgery is required. The literature shows that when to start brace cessation and weaning protocols vary. Approximately 34% of patients progressed by more than 5 degrees at 2-4 years after brace cessation or weaning. Larger curves seem more likely to progress. More research is needed to evaluate the risk factors for curve progression after brace treatment, defining the best time to stop bracing based on the lowest risk of curve progression and whether there is any benefit to weaning.

Using the Proximal Femur Maturity Index at Brace Initiation for Adolescent Idiopathic Scoliosis Predicts Curve Progression Risk

BACKGROUND

The Proximal Femur Maturity Index (PFMI) can be used to assess skeletal maturity on existing whole-spine radiographs without additional radiation. However, the relationship between the PFMI at the initiation of bracing for adolescent idiopathic scoliosis (AIS) and subsequent curve progression remains unknown. This study aimed to investigate the relationship between the PFMI and curve progression, and the predictability of risks to adulthood curve progression and surgical thresholds based on the PFMI grade at brace initiation.

METHODS

This was a prospective study of 202 patients with AIS who were prescribed underarm bracing according to the Scoliosis Research Society criteria and had good brace-wear compliance. The patients were followed from brace initiation until complete skeletal maturity. Longitudinal data on the coronal Cobb angle and skeletal maturity assessments using Risser staging, Sanders staging, the distal radius and ulna classification, and the PFMI were collected. Each patient was assessed on whether the major curve progressed to ≥40° (adulthood deterioration) and ≥50° (the surgical threshold). Logistic regressions were used to predict probabilities of curve progression to the 2 thresholds, adjusted for factors that were significant in univariate analyses.

RESULTS

The PFMI correlated with the other skeletal maturity indices (r s [Spearman rank correlation] = 0.60 to 0.72, p < 0.001 for all). The pre-brace PFMI grade correlated with progression to ≥40° (r rb [rank-biserial correlation] = -0.30, p < 0.001) and to ≥50° (r rb = -0.20, p = 0.005). Based on regression models (p < 0.001) adjusted for the pre-brace major Cobb angle and curve type, brace initiation at PFMI grades 2 and 3 for a curve of ≥30° had predicted risks of 30% (95% confidence interval [CI], 4% to 55%) and 12% (95% CI, 7% to 17%), respectively, for progression to the surgical threshold. Brace initiation at PFMI grade 5 had 0% progression risk.

CONCLUSIONS

The PFMI can be used for predicting curve progression and prognosticating brace outcomes in AIS. Patients with brace initiation at PFMI grade 4 for a curve of <30° or at grade 5 were unlikely to progress to the adulthood deterioration or surgical threshold. In comparison, skeletally immature patients initiating bracing at a PFMI grade of ≤3 for a major curve of ≥30° had a higher risk of progression despite compliant brace wear.

LEVEL OF EVIDENCE

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

Personal and Clinical Determinants of Brace-Wearing Time in Adolescents with Idiopathic Scoliosis

Adolescent idiopathic scoliosis (AIS) is a three-dimensional spine and trunk deformity. Bracing is an effective treatment for medium-degree curves. Thermal sensors help monitor patients' adherence (compliance), a critical issue in bracing treatment. Some studies investigated adherence determinants but rarely through sensors or in highly adherent cohorts. We aimed to verify the influence of personal and clinical variables routinely registered by physicians on adherence to brace treatment in a large cohort of consecutive AIS patients from a highly adherent cohort. We performed a cross-sectional study of patients consecutively recruited in the last three years at a tertiary referral institute and treated with braces for one year. To ensure high adherence, for years, we have provided specific support to brace treatment through a series of cognitive-behavioural interventions for patients and parents. We used iButton thermal sensor systematic data collection to precisely analyse the real brace-wearing time. We included 514 adolescents, age 13.8 ± 1.6, with the worst scoliosis curve of 34.5 ± 10.3° Cobb. We found a 95% (95CI 60-101%) adherence to the brace prescription of 21.9 ± 1.7 h per day. Determinants included gender (91% vs. 84%; females vs. males) and age < 14 years (92% vs. 88%). Brace hours prescription, BMI, and all clinical variables (worst curve Cobb degrees, angle of trunk rotation, and TRACE index for aesthetics) did not influence adherence.

Effectiveness of Orthotic Treatment on Clinical Outcomes of the Patients with Adolescent Idiopathic Scoliosis Under Different Wearing Compliance Levels: A Systematic Review

BACKGROUND

Wearing spinal orthosis for 16 to 23 hours a day during the teenage years could be challenging and stressful for patients with adolescent idiopathic scoliosis (AIS). The investigation of clinical outcomes under various orthosis-wearing compliances can provide helpful insight into orthotic treatment dosage. This systematic review aims to investigate actual orthosis-wearing compliance and evaluate the effectiveness of orthotic treatment in controlling scoliotic curvature and preventing surgery for patients with AIS under various levels of orthosis-wearing compliance.

METHODS

A literature search of 7 electronic databases, namely PubMed, MEDLINE, Cochrane Library, Scopus, CINAHL Complete, Web of Science, and Embase, was conducted on May 19, 2023. Participant characteristics, orthotic treatment protocols, compliance information, outcome measures, and key findings were extracted. The Newcastle-Ottawa Scales were used to evaluate the quality of included cohort and case-control studies.

RESULTS

This study systematically reviewed 17 of 1,799 identified studies, including 1,981 subjects. The actual compliance was inconsistent and ranged from 7.0 to 18.8 hours daily. The proportion of compliant subjects in each study varied from 16.0% to 78.6% due to the heterogeneity of calculation period, measurement methods, and orthosis prescription time. Thirteen studies were investigated to determine the effectiveness of orthotic treatment in controlling curve deformity under different compliance groups, and 2 studies compared the compliance under different treatment outcomes. The rate of curve progression, defined as surpassing the measurement error threshold of 5° or 6° after orthotic treatment, varied from 1.8% to 91.7% across the studies. Ten studies defined the treatment failure, surgery, or surgery indication as Cobb angle progressing to a certain degree (e.g., 40°, 45°, or 50°) and reported failure/surgery/surgery indication rates ranging from 0.0% to 91.7% among different compliance level groups.

CONCLUSION

This review found that the actual compliance with orthotic treatment was generally lower than the prescribed wearing time and exhibited wide variation among different studies. The electronic compliance monitors show promise in regular orthotic treatment practice. More importantly, the group with higher and consistent compliance has significantly less curve progression and lower surgery or failure rate than the group with lower and inconsistent compliance. Further studies are proposed to investigate the minimal orthosis-wearing compliance in patients with AIS treated with different types of orthoses.

LEVEL OF EVIDENCE

Level III, Systematic Review. See Instructions for Authors for a complete description of levels of evidence.

A new scoliosis brace padding method based on trunk asymmetry for scoliosis treatment

BACKGROUND

Pressure pads are used with scoliosis braces to adjust the magnitude and location of corrective forces that mechanically support the torso to correct the spine deformity. In the conventional brace (C.B.) design approaches, the location and shape of pads are determined based on the visual assessment of the clinician. The accuracy of this approach could be improved because it is limited to the clinician's expertise. The present study aimed to develop a new brace (N.B.) padding method based on trunk asymmetry for adolescents with idiopathic scoliosis and compare the efficacy of the developed method with C.B. in improving the Cobb angle and body posture symmetricity.

METHODS

The trunk surface geometry was scanned using a 3-dimensional scanner. The best plane of symmetry was determined, and the original trunk was reflected in the plane of symmetry, creating the reflected trunk. The difference between the reflected and original trunks was computed and color-coded using deviation contour maps. The boundary of deformed regions, with a minimum of 6-mm deviation contour maps, was identified as the trim lines for brace pads. Eight participants were recruited and divided into conventional and new padding groups. The variation of Cobb angle and torso asymmetry parameters, including the trunk rotation and back surface rotation, as well as the brace satisfaction and trunk appearance perception of the 2 groups, were compared after 3 months of treatment.

RESULTS

Cobb angle improved equally in the N.B. and C.B. groups. However, back surface rotation improved in the N.B. group (+49.6%) and worsened in the C.B. group (-6.8%). The mean trunk rotation was improved by 30% in the N.B. and further exacerbated by -2.2% in the C.B. group. The brace satisfaction and trunk appearance perception scores were higher in the N.B. than in the C.B. group, however not statistically significant.

CONCLUSIONS

The present study showed that the proposed brace padding system improved the trunk appearance without negatively affecting the Cobb angle correction.

Defining "successful" treatment outcomes in adolescent idiopathic scoliosis: a scoping review

PURPOSE

Adolescent idiopathic scoliosis (AIS) is the most common type of scoliosis that affects children aged 10-18 years old, manifesting in a three-dimensional spinal deformity. This study aimed to explore outcome measures used in defining AIS treatment success. Particularly, analyzing the extent of qualitative and quantitative (radiographic and quality of life domains) measures to evaluate AIS and whether AIS treatment approaches (surgical, bracing and physiotherapy) influences outcomes used as proxies of treatment success.

METHODS

EMBASE and MEDLINE databases were used to conduct a systematic scoping review with 654 search queries. 158 papers met the inclusion criteria and were screened for data extraction. Extractable variables included: study characteristics, study participant characteristics, type of study, type of intervention approach and outcome measures.

RESULTS

All 158 studies measured quantitative outcomes. 61.38% of papers used radiographic outcomes whilst 38.62% of papers used quantitative quality of life outcomes to evaluate treatment success. Irrespective of treatment intervention utilized, the type of quantitative outcome measure recorded were similar in proportion. Moreover, of the radiographic outcome measures, the subcategory Cobb angle was predominantly used across all intervention approaches. For quantitative quality of life measures, questionnaires investigating multiple domains such as SRS were primarily used as proxies of AIS treatment success across all intervention approaches.

CONCLUSION

This study identified that no articles employed qualitative measures of describing the psychosocial implications of AIS in defining treatment success. Although quantitative measures have merit in clinical diagnoses and management, there is increasing value in using qualitative methods such as thematic analysis in guiding clinicians to develop a biopsychosocial approach for patient care.

The natural history of curve behavior after brace removal in adolescent idiopathic scoliosis: a literature review

PURPOSE

Brace treatment is the most common nonoperative treatment to prevent curve progression in adolescent idiopathic scoliosis (AIS). The goal of this review and analysis is to characterize curve behavior after completion of brace treatment and to identify factors that may facilitate the estimation of long-term curve progression.

METHOD

A review of the English language literature was completed using the MEDLINE (PUBMED) database of publications after 1990 until September 2020. Studies were included if they detailed a minimum of 1 year post-brace removal follow-up of AIS patients. Data retrieved from the articles included Cobb angle measurements of the major curves at "in-brace," weaning, and follow-up visit(s) for all patients described and for subset populations.

RESULTS

From 75 articles, 18 relevant studies describing a follow-up period of 1-25 years following brace removal were included in the analyses. The reviewed literature demonstrates that curves continue to progress after brace treatment is completed with three main phases of progression: (i) immediate (upon brace removal) where a mean curve progression of 7° occurs; (ii) short term (within five years of brace removal) where a relatively high progression rate is evident (0.8°/year); and (iii) long term (more than five years after brace removal) where the progression rate slows (0.2°/year). The magnitude and rate of curve progression is mainly dependent on the degree of curve at weaning as curves weaned at < 25° progress substantially less than curves weaned at ≥ 25° at 25 years.

CONCLUSION

Curves continue to progress after brace removal and the rate and magnitude of progression are associated with the curve size at weaning, with larger curves typically exhibiting more rapid and severe progression. This analysis provides physicians and patients the ability to estimate long-term curve size based on the curve size at the time of weaning.

LEVEL OF EVIDENCE

IV.

Greek Adaptation and Validation of the Bad Sobernheim Stress Questionnaire-Brace and the Bad Sobernheim Stress Questionnaire-Deformity

Adolescent idiopathic scoliosis (AIS) is a progressive condition responsible for spinal deformity in all three planes. Spinal deformity and how the rib hump affects the aesthetics, and the functionality of the trunk can be a cause of psychological distress as well. Bracing as a treatment can have a negative impact on QoL, cause pain, affect participation levels in physical activities, and cause isolation and depression. Brace-induced stress may affect the patient's compliance with the treatment which may lead to scoliosis progression. The purpose of this study was to adapt and validate in the Greek language two instruments that can evaluate stress levels induced by bracing treatment and by deformity. The process of cross-cultural adaptation and validation of the Bad Sobernheim Stress Questionnaire-Brace (ΒSSQ-Brace) and the Bad Sobernheim Stress Questionnaire-Deformity (BSSQ-Deformity) followed the International Quality of Life Assessment Project (IQOLA) guidelines. Forty-seven AIS patients with a mean age of 14.4 ± 1.51 years, mean Cobb angle of 30.08 ± 9.25, and mean duration of the bracing treatment at 20.5 ± 12.2 months participated. The mean score for GR-BSSQ Brace was 14.04 ± 6.42, which is interpreted as medium stress, whereas the mean score for GR-BSSQ Deformity was 20.34 ± 3.78, which is interpreted as low stress. GR-BSSQ Brace demonstrated good internal consistency with Cronbach's α = 0.87. GR-BSSQ Deformity demonstrated acceptable internal consistency with Cronbach's α = 0.73. Both GR-BSSQ Brace and GR-BSSQ Deformity exhibited excellent test-retest reliability with ICC values of 0.94 (95% CI 0.89-0.97) and 0.92 (95% CI 0.86-0.95), respectively. BSSQ Brace and BSSQ Deformity questionnaires have been cross-culturally adapted into the Greek language and have been proven to be valid and reliable instruments measuring brace and deformity-induced stress. Both questionnaires can be used for clinical and research purposes in Greek-speaking population.

Why Don't Adolescents Wear Their Brace? A Prospective Study Investigating Psychosocial Characteristics That Predict Scoliosis Brace Wear

BACKGROUND

Although bracing for adolescent idiopathic scoliosis can prevent curve progression and reduce the risk for future surgery, children frequently do not wear their braces as prescribed. The purpose of this study is to investigate how a broad array of psychosocial characteristics predict future compliance with scoliosis brace wear.

METHODS

This was a single institution, prospective cohort study. All adolescents prescribed a first-time brace for adolescent idiopathic scoliosis were eligible. Patients and their parents completed a separate series of questionnaires that assessed baseline psychosocial characteristics across 6 domains: (1) brace-specific attitudes; (2) body image and self-esteem; (3) school performance and social relationships; (4) psychological health; (5) family functioning; and (6) demographics and scoliosis-specific details (242 total questions across 12 validated questionnaires). Objective brace compliance was collected using temperature-sensitive monitors. Defining compliance as percentage of brace prescription completed, comparative analyses were performed to identify baseline psychosocial characteristics that were associated with future wear. A composite measure (Bracing Fidelity Follow-Up Scale [BFFS]) of the 12 most predictive individual questions across all domains (both parent and adolescent) was constructed to help assess which adolescents were at highest risk of failure to wear their brace. Total BFFS score for each parent-adolescent dyad who completed all the included surveys was then determined by awarding one point for each factor that positively influenced future brace wear (maximum 12 points), and a correlation was calculated between total score and percent adherence to prescribed brace wear.

RESULTS

A total of 41 patients were included. On average, patients with high self-esteem, above average peer relationships and poor brace-specific attitudes had lower brace compliance, although patients with increased loneliness and parental religiousness had higher compliance. Body image, socioeconomic status, family dynamics, and school performance had no significant relationship with brace use. Total score on the Bracing Fidelity Follow-Up Scale (BFFS) was significantly associated with improved brace wear (r=0.687, P <0.001). Those with a score of 6 or above (n=15/33 [45%], median compliance 96%) were more reliable users (15/15 with compliance >75%), and those with a score of 5 or less (n=18/33 [55%], median compliance 50%) had less consistent brace wear (9/18 with compliance <50%).

CONCLUSION

This prospective study identifies numerous baseline psychosocial factors that are associated with future compliance with scoliosis brace wear. Although in need of further validation before widespread clinical application, the novel BFF scale offers a potential opportunity to partially discriminate between compliant and noncompliant scoliosis brace users such that supportive resources (eg, supportive counseling, peer-support groups, additional provider-based education, etc.) can be targeted to those patients most likely to benefit.

LEVEL OF EVIDENCE

II.

Scoliosis: Brace treatment - from the past 50 years to the future

OBJECTIVE

This paper deals with scoliosis treatment over the past 50 years. The review of the literature from the point of view of the current formation of opinion. From conservative forms of treatment, the pendulum has swung to surgical measures. To visualize this temporarily rejection of conservative treatment is the goal of this article.

MATERIALS AND METHODS

A review of the literature over the last 50 years was performed from the perspective of current opinion, this with a pinch of personal experience in bracing and scoliosis surgery since 1972. The MESH terms (scoliosis, idiopathic scoliosis, adolescent idiopathic scoliosis) are presented in their number in a flow diagram and the publications on conservative therapies (brace, physiotherapy) are compared to surgical therapies (surgery).Opinions of "eminences" in the 1980s have been replaced by the rules of evidence-based medicine (EBM) at end of the 1990s. This transition will be visualized in the graph of PubMed statistics. In a statement, the future scoliosis treatment is derived from history.

RESULTS

The total number of publications shows a ratio of brace to surgery of 13.9% and physiotherapy to surgery of 6.7% for the MESH terms "scoliosis". When "scoliosis" is supplemented with "idiopathic", the brace to surgery ratio changes from 24.5% and physiotherapy to surgery 8.2%. Focusing on adolescent scoliosis the addition of "adolescent" changes the brace to surgery ratio from 24.8% and physiotherapy to surgery 8.1%. In the total number of publications, "adolescent idiopathic scoliosis" is treated by 25.26%. The patient numbers of our own scoliosis outpatient clinic (1482 patients) over the last 15 years show a ratio of brace (Cobb angle 20°-50° brace-indication) to surgery (Cobb angle >50° indication to surgery) of 1 to 0.06. The scientific focus on surgical therapy is evident from the figures of PubMed mentioned. The number of conservative publications shows a depression in the 1990s. In the remainder of this article, opinion-forming developments are outlined and supported by literature citations, responsible for the recovery of publications on conservative scoliosis treatment. New technologies provide additional treatment options.

CONCLUSIONS

In this sense, brace therapy is a success story with a future in the digital world of AI (artificial intelligence), mathematical model calculations, and production perhaps from the 3D printer. The central message from the history of the last 50 years is: "The scientific review of treatment results is essential for the further acceptance of brace treatment."

The ISJ 3D Brace, a Providence Brace Evolution, as a Surgery Prevention Method in Idiopathic Scoliosis

Background: The high incidence of idiopathic scoliosis worldwide as well as the serious health problems it can cause in adulthood, make it necessary to seek effective treatments to prevent the progression of the disease to more aggressive treatments such as surgery and improve patients’ quality of life. The use of night braces, besides a less severe influence on the patient’s quality of life, is effective in stopping the progression of the curve in idiopathic scoliosis. Methods: A longitudinal study was performed with an experimental population of 108 participants who attended orthotic treatment at the University Hospital of Barcelona, with ages between 4 and 15 years old, with a main curvature greater than 25 degrees and a Risser between 0 and 3. The participants received treatment with Providence ISJ-3D night braces until their pubertal change (mean duration of 2.78 years for males and 1.97 years for females). Results: The implementation of night-time orthotic treatment in children with idiopathic scoliosis is effective in slowing the progression of the curve and in the prevention of more aggressive treatments such as surgery, maintaining the patient’s quality of life. Conclusions: The use of night braces is efficacious in the treatment of idiopathic scoliosis, although new studies including more sociodemographic data as well as curves from 20 degrees of progression are necessary.

Evaluation of night-time bracing efficacy in the treatment of adolescent idiopathic scoliosis: a systematic review

STUDY DESIGN

Systematic review of the literature.

PURPOSE

To systematically review the literature to assess the efficacy of night-time bracing in controlling curve progression with respect to traditional full-time thoraco-lumbo-sacral orthoses (TLSOs) in patient with adolescent idiopathic scoliosis.

METHODS

PubMed, Ovid, Cochrane Reviews and Google Scholar were all accessed and a combination of terms and keywords pertaining to the core concept was used in the research. Case reports, technical notes, instructional courses, literature reviews, biomechanical and/or in vitro studies were all excluded, as well as case series (level IV studies). The methodological quality of the selected articles was assessed using the MINORS methodology score. Given the overall level and quality of the available evidence, conclusions were drawn based on a summary of the evidence.

RESULTS

Seven studies were included. Five papers reported no differences in curve progression between traditional TLSOs and night-time braces and the remaining two studies reported TLSO to be superior.

CONCLUSION

The current available literature does not permit us to draw conclusions about night-time braces. The low methodological quality of the studies examined makes it impossible to compare the effectiveness of the night-time braces with that of traditional TLSOs. Prospective well-designed clinical trials applying SRS inclusion and evaluation criteria are mandatory to better define the role of night-time orthosis in the treatment of adolescent idiopathic scoliosis.

Completion of a formal physiotherapeutic scoliosis-specific exercise training program for adolescent idiopathic scoliosis increases patient compliance to home exercise programs

INTRODUCTION

Physiotherapeutic Scoliosis-Specific Exercise (PSSE) is a conservative approach for management of adolescent idiopathic scoliosis (AIS). Although there is Level I evidence for the efficacy of PSSE, compliance in the teenage population remains in question. The purpose of this study is to investigate the association between completion of formal PSSE training and compliance to prescribed home exercise programs (HEP).

METHODS

Patients with AIS evaluated at our institution between 2013 and 2015 with a minimum of one PSSE session were enrolled. A chart review and questionnaire completed by caregivers was utilized to assess HEP compliance following the final PSSE session at 1 week, 3 months, 1 year, and 2 years. Patients were divided into two groups, those completing formal training (10 or more PSSE sessions), and those who did not complete formal training (fewer than 10 sessions).

RESULTS

81 patients were identified (mean age of 13.1 years; major curve of 31.3°). Patients who completed training demonstrated 50% compliance at 1 week (vs. 25.6% for non-completers, Odds Ratio (OR): 2.9, p = 0.027), 41.2% at 3 months (vs. 18.9% for non-completers, OR: 3.0, p = 0.044), 23.5% at 1 year (vs. 13.5% for non-completers, OR: 2.0, p = 0.281), and 25.7% at 2 years (vs. 13.5% for non-completers, OR: 2.2, p = 0.197). The mean HEP duration (minutes) in patients who completed training was higher at 1 week (80.8 vs. 48, p = 0.010), 3 months (64.6 vs. 23.7, p ≤ 0.001), 1 year (35.3 vs. 22.7, p = 0.270), and 2 years (34.3 vs. 18.9, p = 0.140).

CONCLUSION

Patients who completed PSSE training maintained higher HEP compliance.

Quality of life of adolescent idiopathic scoliosis patients under brace treatment: a brief communication of literature review

PURPOSE

To identify the life domains that are most frequently reported to be affected in scoliosis patients undergoing brace treatment.

METHODS

A search within the PubMed database was conducted and a total of 60 publications were selected. We classified the studies based on the methods used to measure patients' quality of life (QoL) and categorized the life domains reported to be affected.

RESULTS

Self-image/body configuration was the most reported affected domain of patients' QoL, identified in 32 papers, whilst mental health/stress was the second most reported affected domain. Mental health was identified in 11 papers, and 11 papers using the BSSQ questionnaire reported medium stress amongst their participants. Vitality was the third most reported affected domain, identified in 12 papers.

CONCLUSIONS

Our review indicates that scoliotic adolescents treated with bracing suffer in their quality of life most from psychological burdens. To improve these patients' life quality, more attention should be focussed on supporting their mental health.

Can we predict the behavior of the scoliotic curve after bracing in adolescent idiopathic scoliosis? Τhe prognostic value of apical vertebra rotation

PURPOSE

We aimed to recognize radiographic and clinical prognostic factors of scoliotic curve behaviour after bracing.

METHODS

Our prognostic study was based on the 25 years outcomes of a Boston braced AIS cohort between 1978 and 1993 that were previously reported. All patients were followed-up during bracing, at short term and 25 years post-bracing. We evaluated the impact of socio-demographic, clinical and radiological parameters on the loss of curve correction after bracing.

RESULTS

Seventy-seven patients were reevaluated at 25 years post-brace. The mean scoliotic curve was significantly increased after bracing until the 25 years follow-up (p < 0.001). The mean loss of curve correction between the end of bracing and long-term follow-up was independent on the curve type, apical vertebra, premenarcheal status at bracing, time and duration of bracing, Cobb angle before or after bracing. The mean apical vertebral rotation after bracing was significantly related to the loss of curve correction (Spearman ρ = 0.2, p = 0.049). Apical vertebral rotation (Perdriolle method) greater than 20° post-bracing had a three times higher chance of progression > 5° compared with lesser apical vertebral rotation (OR 3.071, CI 0.99-9.51). The rotation of the apical vertebra, type and magnitude of the scoliotic curve after bracing explained 27.4% of the variance in the loss of curve correction post-bracing (R square = 0.274, p < 0.001).

CONCLUSION

A scoliotic curve is expected to lose some correction after bracing. The apical vertebral rotation post-bracing mainly affected the long-term curve behaviour. Adolescents with apical vertebral rotation greater than 20° after bracing may need further attention.

LEVEL OF EVIDENCE

Prognostic study, Level II.

Success Rate of Brace Treatment for Juvenile-Onset Idiopathic Scoliosis up to Skeletal Maturity

BACKGROUND

Natural history studies have reported that the progression rate of juvenile idiopathic scoliosis (JIS) curves larger than 20° is high and tends to progress. The aim of this study was to investigate the outcome of bracing on JIS and to determine the prognostic factors on the success rate of brace treatment.

METHODS

From March 1985 to February 2015, the clinical data of all JIS patients with referral age from 4 to 10 years who received brace treatment were reviewed. Those patients with a prebrace Cobb angle >20° and a Risser sign of 0 to 2 were included and followed up a minimum of 2 years after discontinuation of the brace or time of spinal fusion. The Cobb angle was recorded at the time of diagnosis, before initiation of bracing, weaning time, brace discontinuation, and final follow-up.

RESULTS

From 297 patients with JIS, a total of 75 cases (18 boys, 57 girls) with an average curve magnitude of 31.9° at the time of diagnosis met the inclusion criteria of the study. For successfully treated patients, the average best in-brace correction was 55% for Lenke I curves, 59% for Lenke II curves, 41% for Lenke III curves, and 62% for Lenke V curves. For a total of 27 patients (36%), the brace treatment failed. Of these, 21 patients (78%) reached spinal fusion, and curves of 6 patients (22%) increased to ≥50°. The progression rate was highest in patients with Lenke type III curves (67%), and also in those with a curve magnitude of ≥46° (94%).

CONCLUSIONS

Brace treatment is an effective strategy for controlling the curve progression and avoiding spinal fusion in JIS.

LEVEL OF EVIDENCE

4.

Predictors for long-term curve progression after Boston brace treatment of idiopathic scoliosis

BACKGROUND

Identifying factors that predict successful bracing in patients with idiopathic scoliosis may help planning treatment.

AIM

To assess predictors for long-term curve progression and health-related quality of life after Boston brace treatment.

DESIGN

Observational retrospective cohort study with analysis of brace treated patients followed from start until at least 10 years after treatment.

SETTING

Patients recruited from the country's entire population consecutively treated at the National Hospital.

POPULATION

365 patients (339 girls/26 boys) with idiopathic scoliosis. Mean (SD) chronological age/bone age at start bracing was 13.2 (1.9)/12.6 (1.9) years. The primary major curve measured 33.2 (7.4°), and the major levels were thoracic (N.=248), thoracolumbar (N.=78) and lumbar (N.=39). Mean bracing time was 2.8 (1.5) years. Long-term follow-up was in average 23.3 (4.1) years after weaning with a mean major curve of 33.0 (13.1°). Successful treatment was defined as a stable primary curve with progression ≤5°, and secondary the SRS-22 questionnaire assessed quality of life.

METHODS

We applied linear or logistic regression with backward elimination. Internal validation was assessed by bootstrapping. Twelve variables were included in the prediction models: age, bone age, scoliosis in close family, major curve size, level, shape, flexibility and in-brace redressement, compliance, curve magnitude after 1 year, treatment time and quality of life (SRS-22).

RESULTS

290 patients (79%) had rated good compliance using the brace >20 hours daily. Treatment failure was observed in 65 patients (18%), and 27 of them were operated. The best baseline predictors were age and brace redressement. During treatment compliance, major curve after 1 year, and treatment time were the best predictors, while thoracic major curve, curve size at start bracing and scoliosis in close family also contributed to the final model. The model's ability to predict quality of life was low.

CONCLUSIONS

The best predictors for a long-term success were good redressement and compliance, unchanged or reduced major curve after one year and short treatment time.

CLINICAL REHABILITATION IMPACT

Predictors at baseline and during early treatment can help identifying patients who benefit from bracing.

The effect of orthotic interventions on balance performance in adolescent idiopathic scoliosis: A systematic literature review

BACKGROUND

Spinal bracing is one form of conservative treatment used in the treatment of adolescent idiopathic scoliosis (AIS).

AIM

The aim of this review was therefore to evaluate the effect of brace treatment on balance in subjects with AIS.

METHOD

The search strategy was based on the Population Intervention Comparison Outcome (PICO). PubMed, Scopus, ISI web of knowledge, Ovid, the Cochrane library (CENTRAL) and Google scholar databases and also the reference lists of relevant articles were searched for articles of clinical trials with level of evidence of three or more of AIS that underwent spinal bracing treatment.

RESULTS

Ten studies, investigating a total of 282 subjects with AIS, met the inclusion criteria. AIS subjects were characterized by a significant increase in the excursion of their center of pressure position compared with healthy subjects. AIS subjects are able to control their quiet standing balance via muscle co-contraction and proprioceptive stimulation, but following a short period of brace wear, no further improvement in balance parameters has been observed.

CONCLUSION

There is a requirement to follow up the use and wear of orthoses and also studies with high quality in subjects with AIS.

The Effect of Bracing on Spinopelvic Rotation and Psychosocial Parameters in Adolescents with Idiopathic Scoliosis

STUDY DESIGN

Retrospective study.

PURPOSE

To evaluate the effect of bracing on spinopelvic rotation and psychosocial parameters in adolescents with idiopathic scoliosis (AIS).

OVERVIEW OF LITERATURE

Complex three-dimensional deformity in AIS is proposed to influence the spinopelvic parameters and psychosocial condition in adolescents; however, few studies have quantitatively evaluated these parameters.

METHODS

Thirty AIS who were prescribed a brace were included in the study. The patients' standing postero-anterior and total spine radiographs were used to measure the primary curve Cobb angle, vertebral rotation, and pelvic rotation. Apical vertebral rotation (AVR), upper AVR, and lower AVR were measured using the Nash-Moe method. Pelvic rotation was determined using the left-to-right hemipelvic width ratio. The curve pattern was classified as per the Lenke classification system. In all, 14 patients had a type I curve, five had type II, six had type III, one had type IV, and four had type V curves. Brace compliance was subjectively evaluated by interviewing the patients and their parents. The health-related quality of life (HRQOL) and stress level of the recruited patients were assessed using the Brace Questionnaire and Bad Sobernheim Stress Questionnaire, respectively.

RESULTS

The Cobb angle significantly decreased with at least 6 months of brace use. AVR correction changed significantly; however, no such results were observed for upper and lower AVR. Pelvic rotation and psychosocial parameters were not significantly affected by brace use. No statistically significant correlation was observed between brace compliance and curve correction.

CONCLUSIONS

The Cobb angle and AVR are crucial measurements that help evaluate the treatment efficacy in AIS with small curves who undergo brace treatment. HRQOL and pelvic axial rotation are not influenced by the brace treatment.

Brace treatment in adolescent idiopathic scoliosis: risk factors for failure-a literature review

Brace treatment is the most common nonoperative treatment for the prevention of curve progression in adolescent idiopathic scoliosis. The success reported in level 1 and 2 clinical trials is approximately 75%. The aim of this review was to identify the main risk factors that significantly reduce success rate of brace treatment. A literature search using the MEDLINE and Embase databases was conducted. Studies were included if they identified specific risk factor(s) for curve progression. Studies that looked at nighttime braces, superiority of one type of brace over another, the effect of physical therapy on brace performance, cadaver or nonhuman studies were excluded. A total of 1,022 articles were identified of which 25 met all of the inclusion criteria. Seven risk factors were identified: Poor brace compliance (eight studies), lack of skeletal maturity (six studies), Cobb angle over a certain threshold (six studies), poor in-brace correction (three studies), vertebral rotation (four studies), osteopenia (two studies), and thoracic curve type (two studies). Three risk factors were highly repeated in the literature which identified specific subgroups of patients who have a much higher risk to fail brace treatment and to progress to fusion. This data demonstrates that 60% to 70% of the patients referred to bracing are Risser 0 and 30% to 70% of this group will not wear the brace enough to ensure treatment efficacy. Furthermore, Risser 0 patients who reach the accelerated growth phase with a curve ≥40° are at 70% to 100% risk of curve progression to the fusion surgical threshold despite proper brace wear. Skeletally immature patients with relatively large magnitude scoliosis who are noncompliant are at a higher risk of failing brace treatment.

Bracing In The Treatment Of Adolescent Idiopathic Scoliosis: Evidence To Date

Brace effectiveness for adolescent idiopathic scoliosis was controversial until recent studies provided high quality of evidence that bracing can decrease likelihood of progression and need for operative treatment. Very low evidence exists regarding bracing over 40^ο and adult degenerative scoliosis. Initial in-brace correction and compliance seem to be the most important predictive factors for successful treatment outcome. However, the amount of correction and adherence to wearing hours have not been established yet. Moderate evidence suggests that thoracic and double curves, and curves over 30^ο at an early growth stage have more risk for failure. High and low body mass index scores are also associated with low successful rates. CAD/CAM braces have shown better initial correction and are more comfortable than conventional plaster cast braces. For a curve at high risk of progression, rigid and day-time braces are significantly more effective than soft or night-time braces. No safe conclusion on effectiveness can be drawn while comparing symmetrical and asymmetrical brace designs. The addition of physiotherapeutic scoliosis-specific exercises in brace treatment can provide better outcomes and is recommended, when possible. Despite the growing evidence for brace effectiveness, there is still an imperative need for future high methodological quality studies to be conducted.

Objective Monitoring of Brace Wearing Time in Adolescents with Scheuermann's Kyphosis

Study Design

This was a prospective cohort study.

Purpose

This study aimed to evaluate the potential differences between the objective and subjective bracing compliances of adolescents with Scheuermann’s kyphosis.

Overview of Literature

Bracing is a well-documented intervention for managing adolescents with progressive thoracic Scheuermann’s kyphosis, and the brace should be worn 23 hours every day. Most research studies that have investigated the efficacy of bracing have assumed that the patients wore the braces as advised or that the bracing time was measured subjectively. This may be one of the reasons for the conflicting reports regarding the efficacy of bracing.

Methods

Nineteen volunteers (11 girls and 7 boys, 12.89±1.77 years) who were prescribed Milwaukee braces for Scheuermann’s kyphosis were enrolled. Each brace was equipped with a miniature temperature logger to record the actual brace wearing time over a period of 3 weeks. The patients and their families were unaware of the mounted sensor. Each participants and/or parent was provided with a questionnaire to record the number of hours for which the brace was worn each day. In addition, the therapist asked each patient and/or his/her parent about the average number of hours that the brace was worn.

Results

The compliance rates measured using the temperature logger (16.00±4.90 hours daily) were significantly lower than those reported in the questionnaires (19.52±6.04 hours daily, p<0.001) and the verbal responses (20.21±6.05 hours daily, p<0.001). Moreover, there was no correlation of age, sex, and body mass index with brace compliance.

Conclusions

The braces were worn less often than reported by the patients and/or their parents. Therefore, objective compliance assessments of adolescents with Scheuermann’s kyphosis in a brace are recommended for future studies.

Effect of the Chêneau Brace in the Natural History of Moderate Adolescent Idiopathic Scoliosis in Girls: Cohort Analysis of a Selected Homogenous Population of 100 Consecutive Skeletally Immature Patients

STUDY DESIGN

Α series study.

OBJECTIVES

To evaluate the relationships between the effectiveness of brace in reduction of scoliosis angle, axial trunk rotation (ATR), and patients' compliance, in skeletally immature females with moderate adolescent idiopathic scoliosis (AIS), treated with Chêneau brace for a minimum of three years.

SUMMARY OF BACKGROUND DATA

According to some authors, braces are ineffective, whereas others find that braces stop scoliosis progression and that the outcome has been related to patient's compliance.

METHODS

From the 100 patients who were initially recruited, 88 patients were included in the final analysis. The average ± SD primary scoliosis angle before brace application was 36.8° ± 9.9°, 32.7° ± 6.3°, and 33.5° ± 11.5° for major thoracic, thoracolumbar, and lumbar curvatures, respectively. All patients were aged ≥10 years at treatment initiation, and their Risser index varied from 0 to II. Eighty-eight patients were followed for at least three years with brace treatment, whereas 43 patients were reevaluated 31 ± 7 months after brace weaning. In baseline and while in brace, the scoliosis Cobb angle, Risser index, menarche age, ATR, and patient's compliance were recorded.

RESULTS

In the 88 patients, the brace reduced the major thoracic, thoracolumbar, and lumbar scoliosis one month after brace onset while "in brace" to 26° ± 11° (29% ± 18%, p = .0006), 23° ± 8° (31% ± 20%, p = .00001), and 24° ± 11° (34% ± 21%, p = .00043), respectively; thereafter, no significant decrease of the curves was recorded. Total bracing time averaged at 45 ± 19 months (range 36-96) and brace weaning averaged at 17 ± 2 years (range 15-19). Six of the 88 (6.8%) individuals underwent surgery for scoliosis progression. In the 43 patients who were reevaluated 31 ± 7 months after brace weaning, scoliosis angle and ATR increased insignificantly, compared to the three years' values.

CONCLUSIONS

Chêneau orthosis reduced while "in brace" AIS in girls with sufficient compliance, with a low rate (6.8%) of patients who underwent surgery.

LEVEL OF EVIDENCE

Level 3.

Consistent and regular daily wearing improve bracing results: a case-control study

Background

In respect to the prescribed regimen and the regular daily pattern, investigate how short-term results are affected by wear time adherence in terms of hours per day.

Methods

This is a case-control study. The setting is outpatient clinic. There were 168 subjects, all of whom met the inclusion criteria: adolescent idiopathic scoliosis and Sforzesco brace prescription of 18 to 23 h/day. The minimum period of follow-up was 4 months, and the maximum was 6 months, which is the average time passing between the Thermobrace (TB) adoption and out-of-brace X-ray before treatment. The brace wear adherence rate, calculated from the ratio of brace wear time with the prescription, was considered in combination with the daily pattern compliance, classified as consistent (104 patients) or inconsistent according to the abnormal distribution of Thermobrace data. The short-term results were finally explored.

Results

Consistent brace wear is associated with a higher probability of improvement in curve magnitude (OR 1.96 CI 95% 1.22–3.14 chi-square 7.78 p = 0.0053). Inconsistent brace wear is more likely to progress (OR 0.14 CI 95% 0.30–0.75 chi-square 10.13 p = 0.0015). Results from the logistic regression show that the most influencing factor for improvement is Cobb degrees at the start.

Conclusions

In clinical everyday activity, patients must be encouraged to consistently follow their brace wear prescription, because this attitude is clearly associated with a higher probability of improvement.

2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth

BACKGROUND

The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) produced its first guidelines in 2005 and renewed them in 2011. Recently published high-quality clinical trials on the effect of conservative treatment approaches (braces and exercises) for idiopathic scoliosis prompted us to update the last guidelines' version. The objective was to align the guidelines with the new scientific evidence to assure faster knowledge transfer into clinical practice of conservative treatment for idiopathic scoliosis (CTIS).

METHODS

Physicians, researchers and allied health practitioners working in the area of CTIS were involved in the development of the 2016 guidelines. Multiple literature reviews reviewing the evidence on CTIS (assessment, bracing, physiotherapy, physiotherapeutic scoliosis-specific exercises (PSSE) and other CTIS) were conducted. Documents, recommendations and practical approach flow charts were developed using a Delphi procedure. The process was completed with the Consensus Session held during the first combined SOSORT/IRSSD Meeting held in Banff, Canada, in May 2016.

RESULTS

The contents of the new 2016 guidelines include the following: background on idiopathic scoliosis, description of CTIS approaches for various populations with flow-charts for clinical practice, as well as literature reviews and recommendations on assessment, bracing, PSSE and other CTIS. The present guidelines include a total of 68 recommendations divided into following topics: bracing (n = 25), PSSE to prevent scoliosis progression during growth (n = 12), PSSE during brace treatment and surgical therapy (n = 6), other conservative treatments (n = 2), respiratory function and exercises (n = 3), general sport activities (n = 6); and assessment (n = 14). According to the agreed strength and level of evidence rating scale, there were 2 recommendations on bracing and 1 recommendation on PSSE that reached level of recommendation "I" and level of evidence "II". Three recommendations reached strength of recommendation A based on the level of evidence I (2 for bracing and one for assessment); 39 recommendations reached strength of recommendation B (20 for bracing, 13 for PSSE, and 6 for assessment).The number of paper for each level of evidence for each treatment is shown in Table 8.

CONCLUSION

The 2016 SOSORT guidelines were developed based on the current evidence on CTIS. Over the last 5 years, high-quality evidence has started to emerge, particularly in the areas of efficacy of bracing (one large multicentre trial) and PSSE (three single-centre randomized controlled trials). Several grade A recommendations were presented. Despite the growing high-quality evidence, the heterogeneity of the study protocols limits generalizability of the recommendations. There is a need for standardization of research methods of conservative treatment effectiveness, as recognized by SOSORT and the Scoliosis Research Society (SRS) non-operative management Committee.

3D correction of AIS in braces designed using CAD/CAM and FEM: a randomized controlled trial

Background

Recent studies showed that finite element model (FEM) combined to CAD/CAM improves the design of braces for the conservative treatment of adolescent idiopathic scoliosis (AIS), using 2D measurements from in-brace radiographs. We aim to assess the immediate effectiveness on curve correction in all three planes of braces designed using CAD/CAM and numerical simulation compared to braces designed with CAD/CAM only.

Methods

SRS standardized criteria for bracing were followed to recruit 48 AIS patients who were randomized into two groups. For both groups, 3D reconstructions of the spine and patient’s torso, respectively built from bi-planar radiographs and surface topography, were obtained and braces were designed using the CAD/CAM approach. For the test group, 3D reconstructions of the spine and patient’s torso were additionally used to generate a personalized FEM to simulate and iteratively improve the brace design with the objective of curve correction maximization in three planes and brace material minimization.

Results

For the control group (CtrlBraces), average Cobb angle prior to bracing was 29° (thoracic, T) and 25° (lumbar, L) with the planes of maximal curvature (PMC) respectively oriented at 63° and 57° on average with respect to the sagittal plane. Average apical axial rotation prior to bracing was 7° (T) and 9° (L). For the test group (FEMBraces), initial Cobb angles were 33° (T) and 28° (L) with the PMC at 68° (T) and 56° (L) and average apical axial rotation prior to bracing at 9° (T and L). On average, FEMBraces were 50% thinner and had 20% less covering surface than CtrlBraces while reducing T and L curves by 47 and 48%, respectively, compared to 25 and 26% for CtrlBraces. FEMBraces corrected apical axial rotation by 46% compared to 30% for CtrlBraces.

Conclusion

The combination of numerical simulation and CAD/CAM approach allowed designing more efficient braces in all three planes, with the advantages of being lighter than standard CAD/CAM braces. Bracing in AIS may be improved in 3D by the use of this simulation platform. This study is ongoing to recruit more cases and to analyze the long-term effect of bracing.

Trial registration

ClinicalTrials.gov, NCT02285621

Brace Success Is Related to Curve Type in Patients with Adolescent Idiopathic Scoliosis

BACKGROUND

Curve magnitude and skeletal maturity are important factors in determining the efficacy of bracing for the treatment of adolescent idiopathic scoliosis, but curve morphology may also affect brace success. The purpose of this study was to determine the influence of curve morphology on the response to bracing with a thoracolumbosacral orthosis (TLSO).

METHODS

A retrospective review of patients managed with an orthosis for the treatment of adolescent idiopathic scoliosis who were prospectively enrolled at the initiation of brace wear and followed through completion of bracing or surgery was performed. Inclusion criteria were main curves of 25° to 45° and a Risser stage of 0, 1, or 2 at the time of brace prescription. Compliance with bracing was measured with Maxim Integrated Thermochrons. Radiographs made at brace initiation, brace cessation, and final follow-up were used to retrospectively categorize curves with use of the modified Lenke (mLenke) classification system and more broadly to categorize them as main thoracic or main lumbar. The effect of morphology on outcome was evaluated using chi-square and Fisher exact tests.

RESULTS

One hundred and sixty-eight patients were included. There was no difference in curve magnitude at the time of brace initiation (p = 0.798) or in average hours of daily brace wear (p = 0.146) between groups. The rate of surgery or progression of the curve to ≥50° was 34.5% (29 of 84) in mLenke-I curves, 54.5% (6 of 11) in mLenke-II curves, 29.4% (10 of 34) in mLenke-III curves, 17.6% (3 of 17) in mLenke-V curves, and 13.6% (3 of 22) in mLenke-VI curves. There were no mLenke-IV curves at the time of brace initiation. The rate of surgery or progression to ≥50° was 34.1% (44 of 129) in the combined thoracic group and 15.4% (6 of 39) in the combined lumbar group (p = 0.0277). In brace-compliant patients (>12.9 hours/day), the rate of surgery or progression to ≥50° was 30.3% (20 of 66) in main thoracic curves and 5.3% (1 of 19) in main lumbar curves (p = 0.0239). One-tenth of curves changed morphology during bracing. The rate of surgery or progression to ≥50° was 35.8% (43 of 120) in persistent main thoracic curves, 20.0% (6 of 30) in persistent main lumbar curves, 12.5% (1 of 8) in main thoracic curves that became main lumbar curves, and 0% (0 of 9) in main lumbar curves that became main thoracic curves (p = 0.0383).

CONCLUSIONS

Thoracic curves are at greater risk for brace failure than lumbar curves are despite similar initial curve magnitudes and average amount of daily brace wear. A change in curve pattern may imply flexibility and is associated with brace success. Patients with thoracic curves should be counseled accordingly.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Adolescents with idiopathic scoliosis and their parents have a positive attitude towards the Thermobrace monitor: results from a survey

Background

A temperature monitor is used to objectively measure brace wear time in adolescent idiopathic scoliosis. The reliability of this device have been demonstrated, and some specialists introduced the use of a compliance monitor as a standard of care in everyday clinical practice, as we did since 2010 with the Thermobrace (TB). The attitude towards these objective monitors has never been investigated.

The present study aims to investigate the attitude of parents and patients towards the use of temperature sensors for measuring brace wear compliance.

Methods

Three hundred one consecutive girls and 63 boys and their parents have been interviewed. The inclusion criteria were as follows: brace wear full-time prescription at first visit and at least one visit with download and discussion of TB data.

Usefulness, acceptability, reliability, and feeling related to data download were the investigated domains. Patients were invited by the administrative staff to complete anonymously the questionnaire. The European Commission was informed about the present survey and approved it (ICT-37-2015-1). Descriptive statistic was used to present the results.

Results

Among the 364 invited patients and parents, 336 adhered by completing it (rate of responders was 93.2%). The mean age was 14.65 (SD 2.36), the mean Cobb angle was 34.18 (SD 13.57), and the average brace wear prescription was 21.76 h per day (SD 2.53). We did not ask parents about their age, profession, nor other personal data.

Globally, the interviewed patients and parents showed a very positive attitude towards the TB monitor: the mean rate of parents stating a completely or at least partially positive attitude towards this electronic device was 94.0% while among patients, it was 85.6%.

Conclusions

This is the first study investigating the attitude of parents and patients towards a brace wear compliance monitor. People who experienced this objective monitoring are aware of the advantages related to it and support its usefulness not only for clinicians but also for patients and parents to respect the hours prescribed without any affection on the children and parents or the patient-physician relationship. The present results should encourage the spread of these tools in daily clinical practice.

Electronic supplementary material

The online version of this article (doi:10.1186/s13013-017-0119-x) contains supplementary material, which is available to authorized users.

Is Brace Treatment Appropriate for Adolescent Idiopathic Scoliosis Patients Refusing Surgery With Cobb Angle Between 40 and 50 Degrees

STUDY DESIGN

A retrospective study to determine whether brace treatment is appropriate for adolescent idiopathic scoliosis patients with Cobb angle between 40 and 50 degrees who utterly refuse surgery.

OBJECTIVE

To investigate whether it is possible to halt the curve progression of adolescent idiopathic scoliosis patients with Cobb angle between 40 and 50 degrees through bracing, and to identify factors that could influence the effectiveness of brace treatment in such patients.

SUMMARY OF BACKGROUND DATA

Despite of the great achievements in treating patients with mild curve, bracing has been considered to be inappropriate for those with curves of >40 degrees. However, in clinical practice surgeons could encounter a series of patients who utterly refused surgery and insisted on wearing brace despite having a curve >40 degrees.

METHODS

A cohort of 54 patients with Cobb angle between 40 and 50 degrees were reviewed in the current study. All the patients refused surgery at their first visit and insisted on receiving brace treatment. Each patient was followed up at an interval of 3-6 months. Variants such as initial Risser sign, initial age, sex, curve pattern, and initial curve magnitude were compared between patients with and without curve progression. A logistic regression analysis was performed to determine the independent predictors of the curve progression.

RESULTS

On the whole, the curve progressed in 35 patients, remained stable in 12 patients, and improved in the else 7 patients. All the patients with curve progression finally received surgical intervention. The mean grade of initial Risser sign in patients with curve progression was significantly lower than that in patients with stable or improved curve (0.3±0.8 vs. 1.2±1.4, P=0.02). In terms of sex, age, curve pattern, and curve magnitude, there were no significant differences between the 2 categories. The results of the logistic regression analysis showed that initial Risser sign of grade 0 or 1 had significant associations with the curve progression of patients with curves >40 degrees (odds ratio, 7.51, 95% confidence intervak, 1.27-24.43, P=0.02).

CONCLUSIONS

The effectiveness of brace treatment significantly decreases when applied to patients with curve magnitude between 40 and 50 degrees. Although a majority of these patients will inevitably undergo a surgical intervention, and thus wearing a brace may not be the best alternative to surgical intervention; there are patients who will stabilize with the brace until skeletal maturity thus warranting this option for those patients refusing surgical intervention with curves between 40 and 50 degrees.

Biomechanical Assessment of Providence Nighttime Brace for the Treatment of Adolescent Idiopathic Scoliosis

STUDY DESIGN

Biomechanical study of the Providence brace for the treatment of adolescent idiopathic scoliosis (AIS).

OBJECTIVES

To model and assess the effectiveness of Providence nighttime brace.

SUMMARY OF BACKGROUND DATA

Providence nighttime brace is an alternative to traditional daytime thoracolumbosacral orthosis for the treatment of moderate scoliotic deformities. It applies three-point pressure to reduce scoliotic curves. The biomechanics of the supine position and Providence brace is still poorly understood.

METHODS

Eighteen patients with AIS were recruited at our institution. For each patient, a personalized finite element model (FEM) of the trunk was created. The spine, rib cage, and pelvis geometry was acquired using simultaneous biplanar low-dose radiographs (EOS). The trunk surface was acquired using a three-dimensional surface topography scanner. The interior surface of each patient's Providence brace was digitized and used to generate an FEM of the brace. Pressures at the brace/skin interface were measured using pressure sensors, and the average pressure distribution was computed. The standing to supine transition and brace installation were computationally simulated.

RESULTS

Simulated standing to supine position induced an average curve correction of 45% and 48% for thoracic and lumbar curves, while adding the brace resulted in an average correction of 62% and 64% (vs. real in-brace correction of 65% and 70%). Simulated pressures had the same distribution as measured ones. Bending moments on apical vertebrae were mostly annulled by the positioning in the supine position, and further overcorrected on average by 10% to 13%, but in the opposite direction.

CONCLUSIONS

The supine position is responsible for the major part of coronal curve correction, while the brace itself plays a complementary role. Bending moments induced by the brace generated a rebalancing of pressure on the growth plates, which could help reduce the asymmetric growth of the vertebrae.

LEVEL OF EVIDENCE

Level II.

Efficacy of corrective spinal orthoses on gait and energy consumption in scoliosis subjects: a literature review

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is a progressive growth disease that affects spinal anatomy, mobility, and left-right trunk symmetry. As a consequence, AIS can modify human gait. Spinal orthoses are a commonly used conservative method for the treatment of AIS.

OBJECTIVE

This review evaluated the AIS spinal orthosis literature that involved gait and energy consumption evaluations.

STUDY DESIGN

Literature review.

METHOD

According to the population intervention comparison outcome measure methods and based on selected keywords, 10 studies met the inclusion criteria.

RESULTS

People with AIS who wore a spinal orthosis, compared with able-bodied participants, walked slower with decreased hip and pelvic movements, decreased hip mediolateral forces, ground reaction force asymmetry, and excessive energy cost. Pelvis and hip frontal plane motion decreased when wearing an orthosis. Hip and pelvis movement symmetry improved when using an orthosis. Ankle and foot kinematics did not change with orthotic intervention. People with AIS continued to have excessive energy expenditure with an orthosis.

CONCLUSION

Spinal orthoses may be considered for improving the walking style, although energy cost does not decline following the orthotic intervention. Implications for Rehabilitations Problems related to scoliosis include reduced quality of life, disability, pain, postural alterations, sensory perturbations, standing instability and gait modifications. Wearing corrective spinal orthoses in AIS subjects produce a reduction in walking speed and cadence, increase in stride length and reduction of gait load asymmetry compared to without brace condition. Spinal orthoses do not decline excessive energy expenditure to walk versus without it.

THE INFLUENCE OF TRUNK BRACING ON TIME, SPATIAL PARAMETERS, SYMMETRY OF GROUND REACTION FORCE AND LOADING RATE IN ADOLESCENT IDIOPATHIC SCOLIOSIS

Background: Adolescent Idiopathic Scoliosis (AIS) leads to change between body segments, right-left trunk symmetry and produce pathological gait pattern. The influence of trunk bracing on symmetry of ground reaction force components and loading rate on idiopathic scoliosis has not been well documented. Therefore, the aim of this study was to examine the effect of trunk bracing on symmetry of forces in adolescent with idiopathic scoliosis. Method: A total of 10 patients with AIS and 10 healthy subjects with comparable age, height and weight were recruited in this study. The force applied on the right and left sides in both groups of subjects were recorded by use of a Kistler force plate while walking. The peak of the vertical force (the first and second peaks) and the force applied on the leg in anteroposterior direction (progression and breaking forces) and mediolateral force were collected in this study. Results: The results of this study showed that there was a significant difference between the asymmetry index of anteroposterior force of normal and scoliotic patients [Formula: see text]. Moreover, trunk bracing decreased asymmetry index of loading rate of scoliotic patients significantly [Formula: see text]. There was no significant difference between the other examined kinetic variables. Conclusion: There are some degrees of asymmetry between the forces applied on the leg in scoliotic subjects. Orthosis decreased the forces applied on the leg in patients with scoliosis. Clinicians are to be aware of these findings as orthotic devices may be of value to patients with idiopathic scoliosis.

Bracing and exercise-based treatment for idiopathic scoliosis

BACKGROUND

Various conservative therapies are available for treating adolescent idiopathic scoliosis (AIS), however, the disparities between them and the evidence of their efficacy and effectiveness is still unclear.

OBJECTIVES

To evaluate the effectiveness of different conservative treatments on AIS.

METHODS

A literature-based narrative review of the English language medical literature.

RESULTS AND CONCLUSIONS

The most appropriate treatment for each patient should be chosen individually and based on various parameters. Bracing has been found to be a most effective conservative treatment for AIS. There is limited evidence that specific physical exercises also an effective intervention for AIS. Exercise-based physical therapy, if correctly administered, can prevent a worsening of the curve and may decrease need for bracing. In addition, physical exercises were found to be the only treatment improving respiratory function. Combining bracing with exercise increases treatment efficacy compared with a single treatment. Additional, well-designed and good quality studies are required to assess the effectiveness of different conservative methods in treating AIS.

Early weaning in idiopathic scoliosis

Background

Many years of bracing represent a burden to the patients. Early weaning may be the result of poor compliance, but may also be planned in patients with a long expected treatment time and a reduced stable primary curve during bracing. The aim of the present cohort study was to compare curve size, health related quality of life and surgical rates at long-term follow-up after ordinary bracing, planned and unplanned early weaning.

Methods

Three hundred eighty-one patients (353 girls/28 boys) with late-onset juvenile (n = 30) and adolescent (n = 351) idiopathic scoliosis and a mean primary major curve of 33.1 (range 20–57)° were treated with Boston brace and followed prospectively.

Results

Ordinary brace treatment was completed in 290 (76 %) patients, planned early weaning at bone age <14 years in 59 (16 %), and unplanned early weaning in 32 (8 %), while 14 (5 %), 1 (2 %), and 12 (38 %) had surgery, respectively. Forty-eight (81 %) of the patients had a primary curve ≤ 25° at planned early weaning. Six-teen (27 %) of those who had planned early weaning, resumed bracing after a mean time of 2.0 years. The mean curve size at long-term follow-up in average 23.4 years after weaning, was smaller (p < 0.001) in patients with planned early weaning (25.1°) compared with ordinary bracing (34.0°) and unplanned early weaning (34.8°). Patient satisfaction and self-image at long-term was better in the planned early weaning group (p < 0.05), but differences were small.

Conclusion

The benefit of planned early weaning was the shortened bracing time and good clinical results. This procedure may be attempted if curve reduction is stable over time and the primary curve is 25° or less in patients with several years of expected bracing. The patients should be monitored carefully and regularly at 4-6 months intervals until maturity, and a new brace should be prepared if the curve increases significantly.

Braces for idiopathic scoliosis in adolescents

BACKGROUND

Idiopathic scoliosis is a three-dimensional deformity of the spine. The most common form is diagnosed in adolescence. While adolescent idiopathic scoliosis (AIS) can progress during growth and cause a surface deformity, it is usually not symptomatic. However, in adulthood, if the final spinal curvature surpasses a certain critical threshold, the risk of health problems and curve progression is increased.

OBJECTIVES

To evaluate the efficacy of bracing for adolescents with AIS versus no treatment or other treatments, on quality of life, disability, pulmonary disorders, progression of the curve, and psychological and cosmetic issues.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, five other databases, and two trials registers up to February 2015 for relevant clinical trials. We also checked the reference lists of relevant articles and conducted an extensive handsearch of grey literature.

SELECTION CRITERIA

Randomized controlled trials (RCTs) and prospective controlled cohort studies comparing braces with no treatment, other treatment, surgery, and different types of braces for adolescent with AIS.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included seven studies (662 participants). Five were planned as RCTs and two as prospective controlled trials. One RCT failed completely, another was continued as an observational study, reporting also the results of the participants that had been randomized.There was very low quality evidence from one small RCT (111 participants) that quality of life (QoL) during treatment did not differ significantly between rigid bracing and observation (mean difference (MD) -2.10, 95% confidence interval (CI) -7.69 to 3.49). There was very low quality evidence from a subgroup of 77 adolescents from one prospective cohort study showing that QoL, back pain, psychological, and cosmetic issues did not differ significantly between rigid bracing and observation in the long term (16 years).Results of the secondary outcomes showed that there was low quality evidence that rigid bracing compared with observation significantly increased the success rate in 20° to 40° curves at two years' follow-up (one RCT, 116 participants; risk ratio (RR) 1.79, 95% CI 1.29 to 2.50). There was low quality evidence that elastic bracing increased the success rate in 15° to 30° curves at three years' follow-up (one RCT, 47 participants; RR 1.88, 95% CI 1.11 to 3.20).There is very low quality evidence from two prospective cohort studies with a control group that rigid bracing increases the success rate (curves not evolving to 50° or above) at two years' follow-up (one study, 242 participants; RR 1.50, 95% CI 1.19 to 1.89) and at three years' follow-up (one study, 240 participants; RR 1.75, 95% CI 1.42 to 2.16). There was very low quality evidence from a prospective cohort study (57 participants) that very rigid bracing increased the success rate (no progression of 5° or more, fusion, or waiting list for fusion) in adolescents with high degree curves (above 45°) (one study, 57 adolescents; RR 1.79, 95% CI 1.04 to 3.07 in the intention-to-treat (ITT) analysis).There was low quality evidence from one RCT that a rigid brace was more successful than an elastic brace at curbing curve progression when measured in Cobb degrees in low degree curves (20° to 30°), with no significant differences between the two groups in the subjective perception of daily difficulties associated with wearing the brace (43 girls; risk of success at four years' follow-up: RR 1.40, 1.03 to 1.89). Finally, there was very low quality evidence from one RCT (12 participants) that a rigid brace with a pad pressure control system is no better than a standard brace in reducing the risk of progression.Only one prospective cohort study (236 participants) assessed adverse events: neither the percentage of adolescents with any adverse event (RR 1.27, 95% CI 0.96 to 1.67) nor the percentage of adolescents reporting back pain, the most common adverse event, were different between the groups (RR 0.72, 95% CI 0.47 to 1.10).

AUTHORS' CONCLUSIONS

Due to the important clinical differences among the studies, it was not possible to perform a meta-analysis. Two studies showed that bracing did not change QoL during treatment (low quality), and QoL, back pain, and psychological and cosmetic issues in the long term (16 years) (very low quality). All included papers consistently showed that bracing prevented curve progression (secondary outcome). However, due to the strength of evidence (from low to very low quality), further research is very likely to have an impact on our confidence in the estimate of effect. The high rate of failure of RCTs demonstrates the huge difficulties in performing RCTs in a field where parents reject randomization of their children. This challenge may prevent us from seeing increases in the quality of the evidence over time. Other designs need to be implemented and included in future reviews, including 'expertise-based' trials, prospective controlled cohort studies, prospective studies conducted according to pre-defined criteria such as the Scoliosis Research Society (SRS) and the international Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) criteria. Future studies should increase their focus on participant outcomes, adverse effects, methods to increase compliance, and usefulness of physiotherapeutic scoliosis specific exercises added to bracing.

The effectiveness of combined bracing and exercise in adolescent idiopathic scoliosis based on SRS and SOSORT criteria: a prospective study

BACKGROUND

Recently an RCT confirmed brace efficacy in adolescent idiopathic scoliosis (AIS) patients. Previously, a Cochrane review suggested also producing studies according to the Scoliosis Research Society (SRS) criteria on the effectiveness of bracing for AIS. Even if the SRS criteria propose a prospective design, until now only one out of 6 published studies was prospective. Our purpose was to evaluate the effects of bracing plus exercises following the SRS and the international Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) criteria for AIS conservative treatment.

METHODS

STUDY DESIGN/SETTING

prospective cohort study nested in a clinical database of all outpatients of a clinic specialized in scoliosis conservative treatment.

PATIENT SAMPLE

seventy-three patients (60 females), age 12 years 10 months ±17 months, 34.4±4.4 Cobb degrees, who satisfied SRS criteria were included out of 3,883 patients at first evaluation.

OUTCOME MEASURES

Cobb angle at the end of treatment according to SRS criteria : (unchanged; worsened 6° or more, over 45° and surgically treated, and rate of improvement of 6° or more).Braces were prescribed for 18-23 hours/day according to curves magnitude and actual international guidelines. Weaning was gradual after Risser 3. All patients performed exercises and were managed according to SOSORT criteria. Results in all patients were analyzed according to intent-to-treat at the end of the treatment. Funding and Conflict of Interest: no.

RESULTS

Overall 34 patients (52.3%) improved. Seven patients (9.6%) worsened, of which 1 patient progressed beyond 45° and was fused. Referred compliance was assessed during a mean period of 3 years 4 months ±20 months; the median adherence was 99.1% (range 22.2-109.2%). Employing intent-to-treat analysis, there were failures in 11 patients (15.1%). At start, these patients had statistically significant low BMI and kyphosis, high thoracic rotation and higher Cobb angles. Drop-outs showed reduced compliance and years of treatment; their average scoliosis at discontinuation was low: 22.7° (range 16-35°) at Risser 1.3 ± 1.

CONCLUSIONS

Bracing in patients with AIS who satisfy SRS criteria is effective. Combining bracing with exercise according to SOSORT criteria shows better results than the current literature.

Correlation between compliance and brace treatment in juvenile and adolescent idiopathic scoliosis: SOSORT 2014 award winner

Background

Over the last years, evidence has accumulated in support of bracing as an effective treatment option in patients with idiopathic scoliosis. Yet, little information is available on the impact of compliance on the outcome of conservative treatment in scoliotic subjects. The aim of the present study was to prospectively evaluate the association between compliance to brace treatment and the progression of scoliotic curve in patients with idiopathic adolescent (AIS) or juvenile scoliosis (JIS).

Methods

Among 1.424 patients treated for idiopathic scoliosis, 645 were eligible for inclusion criteria. Three outcomes were distinguished in agreement with the SRS criteria: curve correction, curve stabilization and curve progression. Brace wearing was assessed by one orthopaedic surgeon (LA) and scored on a standardized form. Compliance to treatment was categorized as complete (brace worn as prescribed), incomplete A (brace removed for 1 month), incomplete B (brace removed for 2 months), incomplete C (brace removed during school hours), and incomplete D (brace worn overnight only). Chi square test, T test or ANOVA and ANOVA for repeated measures tests were used as statistical tests.

Results

The results from our study showed that at follow-up the compliance was: Complete 61.1%; Incomplete A 5.2%; Incomplete B 10.7%; Incomplete C 14.2%; Incomplete D 8.8%. Curve correction was accomplished in 301/319 of Complete, 19/27 Incomplete A, 25/56 Incomplete B, 52/74 Incomplete C, 27/46 Incomplete D. Cobb mean value was 29.8 ± 7.5 SD at beginning and 17.1 ± 10.9 SD at follow-up. Both Cobb and Perdriolle degree amelioration was significantly higher in patients with complete compliance over all other groups, both in juvenile, both in adolescent scoliosis. In the intention-to-treat analysis, the rate of surgical treatment was 2.1% among patients with definite outcome and 12.1% among those with drop-out. Treatment compliance showed significant interactions with time.

Conclusion

Curve progression and referral to surgery are lower in patients with high brace compliance. Bracing discontinuation up to 1 month does not impact on the treatment outcome. Conversely, wearing the brace only overnight is associated with a high rate of curve progression.

Design of the Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST)

STUDY DESIGN

Descriptive.

OBJECTIVE

To describe the design and development of Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST).

SUMMARY OF BACKGROUND DATA

Bracing has remained the standard of care for the nonoperative treatment of adolescent idiopathic scoliosis since the introduction of the Milwaukee brace in the late 1940s, but it has never been subjected to a rigorous evaluation of either its efficacy or its effectiveness. The BrAIST was designed to address the primary question: Do braces (specifically a thoracolumbosacral orthosis) lower the risk of curve progression to a surgical threshold (≥50°) in patients with adolescent idiopathic scoliosis relative to watchful waiting alone?

METHODS

The authors describe the rationale for BrAIST, including the limitations of the current literature evaluating bracing for adolescent idiopathic scoliosis. Second, the authors describe the preliminary work, including the preparation of the National Institutes of Health clinical trials planning grant. Finally, the authors describe the trial design in detail.

RESULTS

BrAIST was conducted in 25 sites in North America. Subjects were treated either with a thoracolumbosacral orthosis or watchful waiting and followed every 6 months until they reached skeletal maturity or the surgical threshold of 50° Cobb angle.

CONCLUSION

Clinical decision making will be improved by translation of the BrAIST results into evidence-based prognosis and estimates of how the prognosis, specifically the risk of progressing to surgery, may be altered by the use of bracing.

LEVEL OF EVIDENCE

N/A.

Very short-term effect of brace wearing on gait in adolescent idiopathic scoliosis girls

PURPOSE

Adolescent idiopathic scoliotic (AIS) deformity induces excessive oxygen consumption correlated to a bilateral increase of lumbo-pelvic muscles timing activity (EMG) during gait. Wearing a brace, the usual treatment for AIS, by supporting the spine and the pelvis, would generate lumbo-pelvic muscular relaxation and consequently reduce excessive oxygen consumption. The purpose of this study was to evaluate the short-term effect of bracing on gait biomechanics in scoliotic spine when compared with normal braced spine.

METHODS

Thirteen healthy volunteers were compared to 13 AIS girls. In both samples, gait analysis was assessed using a three-dimensional motion analysis, including synchronous kinematic, electromyographic, mechanical and energy measurements, first without brace, then wearing a brace.

RESULTS

For scoliotic patients, comparison of in-brace and out-brace situations revealed a significant decrease of frontal pelvis (p < 0.001), hip (p < 0.001) and shoulder (p = 0.004) motion in brace associated with a significant reduction of pelvis rotation (p = 0.003). However, the brace did not change significantly the lumbo-pelvic muscle activity duration (EMG) or the mechanical and energetic parameters. Transversal pelvis motion was reduced by 39% (p = 0.04), frontal hip and shoulder motions by 23% (p = 0.004) and 30% (p = 0.01) respectively, and energy cost of walking remained increased by 37% in braced AIS girls relatively to braced healthy subjects. Mechanical and electromyographic variables were not significantly different between the two braced populations during gait except for the gluteus medius muscle that showed bilaterally an increase of duration of electrical activity in healthy subjects and contrarily a decrease in AIS patients (healthy: -3.5 ± 9.6% of gait cycle vs. scoliotic: 3.7 ± 7.7% of gait cycle; p = 0.04).

CONCLUSIONS

Bracing changed neither the oxygen consumption nor the timing of the lumbo-pelvic muscles activity in both groups during gait. However, in brace the timing activity of bilateral gluteus medius muscles tended to decrease in AIS patients and increase in healthy subjects. Moreover, braced AIS patients had more restricted frontal hips and shoulder motion as well as pelvis rotation than braced healthy subjects.

Scoliosis detection, patient characteristics, referral patterns and treatment in the absence of a screening program in Norway

BACKGROUND

Early diagnosis of idiopathic scoliosis allows for observation and timely initiation of brace treatment in order to halt progression. School scoliosis screening programs were abolished in Norway in 1994 for lack of evidence that the programs improved outcome and for the costs involved. The consequences of this decision are discussed.

OBJECTIVES

To describe the detection, patient characteristics, referral patterns and treatment of idiopathic scoliosis at a scoliosis clinic during the period 2003-2011, when there was no screening and to compare treatment modalities to the period 1976-1988 when screening was performed.

METHODS

Patient demographics, age at detection, family history, clinical and radiological charts of consecutive patients referred for scoliosis evaluation during the period 2003-2011, were prospectively registered. Patients were recruited from a catchment area of about 500000 teenagers. Maturity was estimated according to Risser sign and menarcheal status. Severity of pain was recorded by a verbal 5-point scale from no pain to pain at all times. Physical and neurological examinations were conducted. The detector and patient characteristics were recorded. Referral patterns of orthopedic surgeons at local hospitals and other health care providers were recorded. Patient data was obtained by spine surgeons. Treatment modalities in the current period were compared to the period 1976-1988.

RESULTS

We registered 752 patients with late onset juvenile and adolescent idiopathic scoliosis from 2003-2011. There were 644 (86%) girls and 108 (14%) boys. Mean age at detection was 14.6 (7-19) years. Sixty percent had Risser sign ≥ 3, whilst 74% were post menarche with a mean age at menarche of 13.2 years. Thirty-one percent had a family history of scoliosis. The mean major curve at first consultation at our clinic was 38° (10°-95°). About 40% had a major curve >40°. Seventy-one percent were detected by patients, close relatives, and friends. Orthopaedic surgeons referred 61% of the patients. The mean duration from detection to the first consultation was 20(0-27) months. The proportion of the average number of patients braced each year was 68% during the period with screening compared to 38% in the period without screening, while the proportion for those operated was 32% and 62%, respectively ( p=0.002, OR 3.5, (95%CI 1.6 to 7.5).

CONCLUSION

In the absence of scoliosis screening, lay persons most often detect scoliosis. Many patients presented with a mean Cobb angle approaching the upper limit for brace treatment indications. The frequency of brace treatment has been reduced and surgery is increased during the recent period without screening compared with the period in the past when screening was still conducted.