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Bracing for Scoliosis

- See: Idiopathic Scoliosis:

- Discussion:
    - bracing has been the mainstay of non operative treatment of significant curves which have a potential to progress;
    - progression is related to size of curve, area of spine involved, & physiologic age of child;
           - size of curve:
                  - larger curves progress to > deg than smaller curves (many curves less than 30 degrees don't progress);
                  - thoracic and double primary curves progress more than single lumbar or thoracolumbar curves.
           - physiologic age (based on menarche & risser status);
                  - Risser stage 0-1: curves between 20-29 deg have > 65% risk of progression;
                  - Risser grade 2-4: curves between 20-29 deg have > 20% risk of progression;
    - the major controversy surrounding bracing is whether or not it can influence the natural history of scoliosis;
           - in the review article by Dickson RA and Weinstein SL (1999), the authors make several points;
                  - the authors note that the Cobb angle remains the main determinate of curve severity eventhough this is a two demensional
                         measurement of a three demensional deformity (it may not be the most optimal measurement of curve severity and correction);
                  - use of a brace in flexible curves may actually reduce the Cobb angle by flattening the lumbar lordosis which negatively affects
                         the saggital component of the scoliotic curve;
                         - hence ensure that use of a brace is not actually worsening thoracic lordosis (which is often the predominant aspect of scoliosis;
                  - authors note that there is some evidence that bracing is ineffective in treating scoliotic curves;
                         - reference: Bracing and screening - Yes or No? 
                         - A statistical comparison between natural history of idiopathic scoliosis and brace treatment in skeletally immature adolescent girls
                         - Brace compliance in adolescent idiopathic scoliosis.  
                         - Use of the Milwaukee brace for progressive idiopathic scoliosis.  

- Guidelines for Brace Use:
    - less than 30 deg:
         - curves < 20 deg are treated by observation alone;
         - patients presenting w/ idiopathic spinal curves < 30 deg should be observed for progression ( > 5 deg change in 6 mo) before instituting bracing.
                - ie, curves between 20 and 29 deg that show progression need to be treated w/ orthosis;
    - greater than 30 deg;
         - curves between 30 and 40 deg are treated w/ orthosis on first visit to office if they are less than Risser 3;
                - hence, skeletally immature patients w/ significant curves (greater than 30 deg) require bracing even if there is no evidence of progression;
    - greater than 45 deg;
         - although some flexible curves between 40 and 45 deg can be treated successfully, bracing is not used for most curves > 45 deg;

- Vital Capacity: (see cardiopulmonary function in scoliosis)
    - application of brace results in a significant reduction in vital capacity (14%), functional residual capacity (22%), & total lung capacity (12%);
    - bracing will reduce lung function by 10 to 15%;

- Special Considerations:
    - infantile scoliosis:
            - bracing is the primary treatment for pts with infantile and juvenile idiopathic scoliosis;
    - types of braces:
            - curves w/ apices lower than T-8 or lower may be treated w/ underarm braces,
                   such as Wilmington brace (custom made) or Boston brace (prefabricated)
            - these curves cannot be except to treat higher curves;
            - high thoracic curves may require the Milwaukee Brace;
    - how many hours per day is necessary?
            - as noted by Rowe et al, probability of a successfull result was directly related to number of hours  braces was worn per day;
            - 23 hours was more effective than 16 hours which was more effective than 8 hrs; 
            - ref: A meta-analysis of the efficacy of non-operative treatments for idiopathic scoliosis

 - example of mature riser stage

A statistical comparison between natural history of idiopathic scoliosis and brace treatment in skeletally immature adolescent girls.

Effectiveness of braces in mild idiopathic scoliosis.                      

Influence of the Wilmington brace on spinal decompensation in adolescent idiopathic scoliosis.

The Milwaukee brace for the treatment of adolescent idiopathic scoliosis. A review of one thousand and twenty patients.

Idiopathic scoliosis: Long term follow up and prognosis in untreated patients.  

Treatment of idiopathic scoliosis in the Milwaukee brace.

Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. The prediction of curve progression in untreated idiopathic scoliosis during growth

Bracing and screening - Yes or No?  

Long-Term Follow-up of Female Patients with Idiopathic Scoliosis Treated with the Wilmington Orthosis.

The Association Between Brace Compliance and Outcome for Patients With Idiopathic Scoliosis.