Academy Society Spotlight: Influencing Compliance in Adolescent Idiopathic Scoliosis
March 2020 Issue
It is logical that a scoliosis TLSO that spends more time in a closet—or shoved in a locker— probably isn't doing its owner with adolescent idiopathic scoliosis (AIS) much good. With the publication of several studies that have used temperature sensors to measure wear time, we now understand that compliance is the most important factor affecting the success of scoliosis treatment.1,2
Both landmark studies found that wear time is directly correlated to orthotic treatment outcome, and in fact was the only controllable factor that affected success. Patients can't control their age, curve magnitude, or curve apex, but they can control their wear time. Even in-brace correction, which has been shown previously to be correlated to outcome, did not statistically affect curve progression in either study.3 With the amount of hours I spend trying to maximize in-brace correction, that's a little distressing to read. However, it's not that in-brace correction isn't important, but rather that wear time is more important.
But how do we convince our patients to wear their orthoses? Patients with AIS typically start orthotic treatment at 10-12 years old. This time of life is challenging enough without adding in a scoliosis brace. We can't duct tape them in—though I have seen a parent try that before—and neither we nor their parents can watch them 24 hours per day. The patients need to make a personal decision to wear their braces, and the information we provide can influence that decision. Here are some tactics to consider.
Give them the science.
The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST), published in 2013, is a multicenter, randomized, controlled trial that provided the scoliosis community with level 1 evidence that rowing patients with spinal curves of 20-40 degrees should be treated with an orthosis.2 In fact, the study was stopped early at the recommendation of the data and safety monitoring board because of the compelling evidence in favor of bracing as well as the strong positive association of wear time with success. Figure 2 of the BrAIST article in the New England Journal of Medicine titled "Rate of Treatment Success According to Average Hours of Daily Brace Wear" can be used to show any science-minded patient and family that brace wear time will affect treatment outcome. It shows that wear time of less than seven hours per day had essentially the same probability of success as those patients who did not receive a brace. However, wear time over 12.9 hours per day was associated with 90-93 percent success rates.
Set up a schedule.
The first part of setting a schedule is defining the goal wear time. The Katz and BrAIST studies found more than 12 and 12.9 hours average wear time, respectively, to be associated with success.1,2 However, someone who is instructed to wear his or her brace 13 hours per day is unlikely to achieve an average of 13 hours per day over the course of treatment. First of all, we know that people grossly overestimate their wear time; one study showed that although parents and children estimated they were 80 percent compliant with their recommended wear time, measured wear time was only 47 percent of the prescribed amount.4 Also, wear time is likely to decline as kids become teenagers and treatment fatigue takes its toll.1 However, a goal of 23 hours per day is very limiting for sports and extracurricular activities, and has not been shown to increase actual wear time.4,1 Aiming for a minimum of 18 hours per day is a good goal for skeletally immature patients, and juvenile patients likely need more than 20 hours per day.2 Patients who can commit to wearing their brace every day for school and to sleep are more likely to consistently hit their wear time goals and more likely to achieve treatment success.1
Add a sensor.
Just like my Fitbit keeps me honest to my exercise goals, a sensor keeps patients aware of their actual wear time. Temperature sensors like the iButton and orthotimer are easy to install. At each visit, a report card of sorts can be generated with average wear time as well as wear trends such as weekday versus weekend and night versus day wear. Skipping even one day can take the patient's average down considerably. Compliance counseling can significantly increase wear time.6
Scare them...just a little.
Although AIS patients are young, every day they make a decision that could affect them for the rest of their lives. They only get one spine, and it's up to them to take care of it. It is important that they understand the consequences. Even young patients and their parents can understand the cause and effect relationship that more wear equals less likelihood of surgery. Some patients may benefit from knowing more about what scoliosis surgery means. One surgeon I work with sends patients a YouTube video link of a spine fusion. If that's too much, even explaining the magnitude of spine surgery can help. It's not like their friend's tonsillectomy. After a several-hour surgery, patients will spend 3-7 days in the hospital, 3-5 weeks at home, and will be out of sports for 3-6 months. The necessity of missing a season of their preferred sport can be a powerful incentive for young athletes.
It is our role as orthotists to provide the knowledge base to enable patients to make an individual, informed decision regarding wear time. In building relationships, we can flex our education strategies to each patient/family interaction, and continue to adjust as treatment continues. With open dialogue, we can work together to give each patient the best shot at successful treatment of his or her scoliosis.
Leigh Davis, MSPO, CPO, FAAOP, is immediate past president of the American Academy of Orthotists and Prosthetists (the Academy) and is an orthotist/prosthetist with Children's Healthcare of Atlanta. She is a member of the Academy's Spinal Orthotics Society.
Academy Society Spotlight is a presentation of clinical content by the Societies of the Academy in partnership with The O&P EDGE.
1. D. E. Katz, J. A. Herring, R. H. Browne, D. M. Kelly, and J. G. Birch. 2010. Brace wear control of curve progression in adolescent idiopathic scoliosis. Journal of Bone and Joint Surgery American volume 92:1343-52.
2. S. L. Weinstein, L. A. Dolan, and J. G. Wright. 2013. Effects of Bracing in Adolescents. The New England Journal of Medicine 369(16): 1512-21.
3. D. E. Katz, B. S. Richards, R. H. Browne, and J. A. Herring. 1997. A Comparison Between the Boston Brace and the Charleston Bending Brace in Adolescent Idiopathic Scoliosis. Spine 22(12).
4. Morton, R. Riddle, R. Buchanan, D. Katz, and J. Birch. 2008. Accuracy in the Prediction and Estimation of Adherence to Bracewear Before and During Treatment of Adolescent Idiopathic Scoliosis. Journal of Pediatric Orthopedics 28(3): 336-41.
5. L. Karol, D. Virostek, K. Felton, C. Jo, and L. Butler. 2016. The Effect of the Risser Stage on Bracing Outcome in Adolescent Idiopathic Scoliosis. Journal of Bone and Joint Surgery 98-A(15): 1253-9.
6. L. Karol, D. Virostek, K. Felton, and L. Wheeler. 2016. Effect of Compliance Counseling on Brace Use and Success in Patients with Adolescent Idiopathic Scoliosis. Journal of Bone and Joint Surgery 98(1): 9-14.