Braces and Other Noninvasive Treatments:

Braces are generally prescribed to prevent further progression of curves 20 - 25 degrees, and no more than 40 degrees. Patients should have documented progression of the curve, and the child should still be growing. Braces are used to stop progression rather than to reverse a curve.

Results vary widely depending on the length of time the brace is worn, the type of brace, and the severity of the curve. Determining how effective braces are has been difficult for researchers. Most studies evaluate whether the curve has progressed. There is much less information about whether brace usage actually reduces the amount of patients who eventually have surgery.

The great majority of subjects in scoliosis studies are girls. Limited data suggest that in boys compliance rates are low, and braces are not effective. However, compliance with wearing a brace correlates strongly with success rate.

In overweight patients with adolescent idiopathic scoliosis, braces appear to be less effective than in those who are not overweight.

A brace is one type of treatment for scoliosis. The brace works by exerting pressure on the back and ribs to push the spine in a straighter position. The brace usually fits snugly around the torso and can come in many styles. In a child who is still growing, bracing is usually recommended to help slow the progression of the curve. The brace is usually worn full-time until the growth of the bones has stopped.

Many experts have questioned whether a brace is any better than nature in halting curvature progress. Early studies found that braces were successful in halting progression in only half of cases (the same rate as no treatment at all). In recent years, however, braces have improved. Many now fit under the arms and can be worn under clothing, so that patients are much more likely to use them for longer periods during the day, which greatly affects their success rates.

Team Approach

Wearing the brace for the prescribed time is difficult but essential for any success. A team approach, with several health professionals involved, is beneficial and often necessary to support the patient through the bracing process. An orthopedic surgeon interprets the x-rays, assesses the potential progression of the scoliosis, and plans the treatment with the patient and family. If a brace is used, an orthotist measures and fits the patient with the device. A physical therapist tailors an exercise program best suited for the patient. A nurse may also coordinate the treatment plans and provide physical and emotional support.

Types of Braces

Full Torso Brace. A full torso brace called the Milwaukee brace was the standard treatment until a decade ago. It is still used particularly for high curves.

The device contains a wide flat bar in front and two smaller ones in back. These bars attach to a ring around the neck that has rests for the chin and back of the head. One study determined that correcting the curve occurs best if the patient lies on their chest when wearing the brace. Some researchers suggest that increasing the tension on the chest straps might add benefit. The brace is also periodically adjusted for growth.

The brace needs to be worn 23 hours a day, with relief during bathing and exercise only. Compliance is a major problem. In one study, only 15% of patients wore the Milwaukee brace as directed. It is a particularly difficult brace to endure wearing; one woman who had worn it for 7 years during adolescence remembered being invisible during her school years, ignored and shunned by other children.

Thoracolumbar-Sacral Orthoses (TLSO). Molded braces called thoracolumbar-sacral orthoses (TLSOs), most often the Boston brace, come up to beneath the underarms and can be fitted close to the skin so they do not show beneath clothing. It appears to be effective for mid-back and lower curves. The risk for curve progression is significantly higher the less time the brace is worn. These braces have several problems: they are hot, reduce lung capacity by nearly 20%, and cause mild, temporary changes in kidney function.

Nighttime Braces. The Charleston Bending brace and the Rosenberg brace are worn only at night. Some doctors question their value, although they appear to be suitable for small, flexible curves. In a 2002 study, these braces were equally effective as the Boston brace. Other studies have reported success rates of 56 - 66% in patients who wore the brace as directed. Still, more than 10% of the patients using either the Boston brace or nighttime braces eventually needed surgery.

Newer braces are being developed in an attempt to improve compliance and results. Some examples are:

• The Providence brace is a computer-fitted device that is worn only at night. It is specifically designed for the individual curvature abnormalities, and early studies are showing promise.
• A bracing method called the SpineCor uses adjustable bands and a cotton vest that allows flexibility.
• The custom-fitted TriaC brace exerts pressure in specific areas of the back to allow greater comfort and flexibility. It may be less conspicuous than some of the older braces.

Studies are needed to determine if these or other new braces provide any additional value over existing ones.

Braces and Quality of Life

Compliance in wearing the brace varies widely. Patients are more likely to wear them at night but often wear them sporadically during the day. Quality of life can vary by the type of brace worn. In one study, patients who had the Milwaukee brace reported greater impairment than patients with the Boston, other TSLO, or Charleston braces. The choice of brace should be one that will be the most effective for a particular patient with the lowest impact on the patient's quality of life. Young people often refuse to wear braces, even the newer models, and emotional support from family and professionals is extremely important to help a child accept the process and stay compliant.

Exercise and Physical Therapy While Wearing Braces

For children who need braces, an exercise program helps boost well-being, improves compliance with treatment, and keeps muscles in tone so that the transition period after brace removal is easier.

An exercise and physical therapy program is important to maintain or achieve the following:

• Chest mobility.
• Proper breathing. In one study, young girls who wore the Boston brace and performed aerobic exercises for 30 minutes four times a week had better lung function, whereas lung function declined in girls who did not exercise.
• Muscle strength (especially in the abdominal muscles).
• Flexibility in the spine. One small study showed that patients who performed exercises improving flexibility in the torso had less spinal twisting and improved curvature.
• Correct posture. Practicing correct posture, especially in front of a mirror, is an extremely important part of any physical therapy program. A patient who is accustomed to a curved spine may have the sensation of being crooked when first taught to properly align the spine. Practicing in front of a mirror provides a reality check.
• Patients must also learn to conduct daily activities while wearing the brace. Patients tend to comply with physical therapy in the period when the brace is first being used. They typically stop exercising when they have gotten used to the brace, however, and resume exercising only near the time the brace is being removed. Patients who don't stay with the program throughout the duration of brace use experience a weakening in the back at the time of removal.

Casting

Serial casting is something that may be used in children with infantile scoliosis only. Candidates are generally those whose scoliosis is progressing. Depending on how quickly the child is growing, casts are changed around every two months for children younger than 2, around every 3 months for those aged 3 years, and every 4 months for children 4 years and older.

Alternative Nonsurgical Procedures

Exercise. Exercise has many health benefits and is important for maintaining strength and muscle tone and stabilizing weight. Stretching exercises may be beneficial in children whose scoliosis is due to uneven leg lengths or a shortened tendon.

ASCO Scoliosis Treatment Method. ASCO Scoliosis Treatment Method is a Russian approach that consists of isometric and stretching exercises, vibration, spinal manipulation, and electrical muscle stimulation. Some U.S. centers are reporting success in halting curve progression, but more research is needed to determine the possible benefits of this method.

Chiropractic Care. Several case reports suggest that chiropractic manipulation of the spine may help stop progression of mild curves. However, no rigorous studies have proved this.

Improving Lung Function

Airway Ventilation at Night. Some research has focused on the use of airway systems, such as nasal continuous positive airflow pressure, for patients with severe scoliosis and reduced lung capacity. Patients use such systems during the night to force air into the upper airways and lungs. Such systems also can treat sleep apnea, a common sleep disorder.

Breathing Exercises. Breathing exercises may help improve lung function in children with scoliosis and signs of lung problems.

Heel Lifts for Secondary Scoliosis

Heel Lifts and Underfoot Wedges. When a difference in leg lengths causes secondary scoliosis, adding lifts to the heels or other shoe wedges may be tried. It is not clear whether these devices reduce spince curvature.