Bracing the Curve
April 2021 Issue
when it comes to the effectiveness of bracing as a treatment for adolescent idiopathic scoliosis (AIS), the experts agree: It works and the more the better.
"If they are younger kids, their growth plate has not completely closed yet, and if you don't give them proper treatment, they may be going to have a rough life," says Sun Hae (Sunny) Jang, PhD, CO, FAAOP, associate professor in the Master of Science in Orthotics and Prosthetics program at Eastern Michigan University. "We don't want these patients to have surgery; that will limit their spine movement. Appropriate orthotic treatment can prevent patients from needing surgery and improve the overall
quality of their life."
Studies have shown that bracing can have a positive impact on these patients. The 2013 Bracing in Adolescent Idiopathic Scoliosis Trial found that 76 percent of the AIS curve could be stabilized by brace treatment, and it reduces the risk of curve progression by about 50 percent.1 The maximum benefit of bracing came when the patient wore the brace between 16 and 23 hours per day.1
According to the experts, the question in treating scoliosis is not whether to brace, but rather how to do it effectively while keeping the patient comfortable and motivated enough to continue through many hours of bracing.
The orthotists we spoke with warn not to fall into the trap of braces' name brands. Rather, they say, scoliosis should be treated by experts with proven methods.
"Too often we are focused on the product, when the emphasis needs to be on the patients, the process, and the protocol," says Luke Stikeleather, CO, president and chief orthotist of the National Scoliosis Center, headquartered in Fairfax, Virginia.
What's in a Name?
If you ask an orthotist who specializes in scoliosis to name the best brace, the answer is likely to be, "It's complicated."
"It's a frustrating topic for me because I think brace names confuse a lot of people," says Kara Davis, CPO/L, FAAOP, clinical coordinator at Texas
Scottish Rite Hospital for Children in Dallas.
"People ask, ‘What is the best brace because I want that one.' It's changed over the years."
Instead of asking which brand of brace is best, a better question would be "What makes a scoliosis brace effective?" The experts agree on the right answer to that question—fabricating a customized brace that takes all three planes—coronal, sagittal, and axial—into account.
"Really I think that the name isn't as important as the mechanics," says Leigh Davis, MSPO, CPO, FAAOP, Children's Healthcare of Atlanta. "What is important is that they have to have thoughtful correction on all three planes. That's the important thing for bracing, not the name or where you order it."
While scoliosis is a 3D deformity, it is not always treated as such. Often, the 2D x-rays used for brace measurement don't take into account all three planes. With 2D x-rays, a symmetrical brace design is ordered from measurements, and an orthotist adds pads to gain a correction. That type of brace is outdated and not as effective, experts say.
"Over the years scoliosis brace design has evolved, but they still sell that brace design because there are folks who don't have surface scanners or can't get the technology they need," says Kara Davis. "That might be their only option, but bracing technology has evolved quite a bit over the last decade and a half as our understanding of scoliosis has evolved. You really need to understand the rotational component of scoliosis, which you don't see from a two-dimensional x-ray. Whether it's a Boston Brace or a Rigo Cheneau, what's important is to have a good biomechanical brace that addresses all three planes of motion and it needs to be fit by a scoliosis expert. You can't pull a brace out of a box and put it on a child and expect it to be good."
For a brace to truly fit well, the experts say that orthotists have to go beyond the x-ray. Jang says she takes the x-ray into account, but she also puts her hands on the patient to apply pressure and see how the body reacts before she takes a mold or scan.
"Each patient has a different flexibility, a different curve type, and a different stage of deformity," she says. "We don't know how the spine reacts until we apply corrective forces on the AIS spine."
For optimal results, the brace should be made from a body cast or scan of the patient and have integrated corrective forces, says Denise Larkins, MSPO, CPO/L, Children's Healthcare of Atlanta. "I think there's certainly something to be said in getting a custom mold of a patient's body, in order to put corrective forces and reliefs exactly where you want them," she says. At Children's Hospital of Atlanta, they use computer-aided design to assist in the brace design.
Another major choice in brace wear is whether to give patients a nighttime or all-day brace.
In most cases, scoliosis patients should wear their braces almost all the time, the experts say. For some patients however, a nighttime brace is a possibility, says Leigh Davis.
In a 2019 study in which Leigh Davis was the lead author, the team found that if a patient had a Cobb angle of less than 35 degrees, a Risser of one or higher, and a curve apex of T10 or lower, those patients had 100 percent success with nighttime bracing.2 If patients had two out of three of those factors, they had 75 percent success, she says.
"To me, curve magnitude is an important factor in choosing a nighttime-only brace," Leigh Davis says. "If a curve is less than 35 degrees, then in general I think it's reasonable to see if we can contain the curve with nighttime bracing first."
Another factor to consider is the patient's overall compliance, Leigh Davis says. Some patients who should wear a daytime brace simply refuse. In those cases, even though it is not ideal, a nighttime brace may be necessary.
"There is a risk-benefit analysis that is individual to the person," she says. "I think that it's better to wear a nighttime brace well than have a daytime brace that doesn't get worn at all."
The True Test of Success
While fabricating a complex brace based on 3D scans is difficult, perhaps equally difficult is getting patients with scoliosis to wear the brace on a long-term, consistent basis when compliance is essential for success.
The best results come when patients wear their braces almost all day for a few years. That's a lot to ask, Leigh Davis says.
"We're all experiencing COVID fatigue; it's been a year," she says. "We are asking these patients to do this for a few years and be in a brace almost all of the time. Even if they are really good their first and second year, for most patients, we will see a decline in their compliance."
Compliance monitors, sensors that use heat detection to tell when a brace is being worn, have been found effective to help motivate patients to keep wearing their braces.
"They have shown to be quite effective in helping patients be more compliant," Larkins says. "You can physically pull up the data and show them: This is how much you may think you are wearing it, versus how much you are actually wearing it."
However, the monitors still only work if the patients are on board. That buy-in often depends on the age of the child.
"Younger kids love it. They are psyched and think it is cool," Stikeleather says. "As they transition to the tween and teen years, depending on their personality, they will either be on board or they will have more reluctance and pushback."
For these ages, the orthotist needs to have the child participate in her or his healthcare decisions, Larkins says.
"The challenge is often in getting patients to take ownership of their treatment process along the way," she says. "Making a connection with your patients, empathetically listening to their concerns, and properly educating them are all important actions to turn brace wear from something patients have to do into something they want to do. Being a participant will often mean a bit of give and take with the orthotist."
"They should work through with you what type of brace they will have, when they will wear it, and how long," Leigh Davis says. "Together, we should look at their goal wear time and their activities and work through it in a logical way. We can talk through their scenarios and help them get their hours in." Unfortunately, some patients will never be compliant. Some may be stubborn and refuse, while for others the stigma of wearing a brace may just be too much. In some cases, wearing a brace is so traumatizing for patients that it can impact their mental health or cause depression.
"Sometimes you can't motivate them to wear the brace and overcome the hurdles," Stikeleather says. "Sometimes you have to recognize that wearing a brace is traumatizing them in a way they can't deal with."
In those cases, psychologists or counselors should be brought onto the healthcare team and alternatives to bracing may have to be found.
Next Steps in Scoliosis Treatment
While there have been advances in brace technology, there is still room for orthotists to improve, the experts say.
One of the biggest hurdles is obtaining advanced, in-depth scoliosis treatment
training for orthotists. The most advanced bracing techniques are not taught in any schools in the United States, Kara Davis and Leigh Davis say. Rather, those who want to learn have to seek out mentors to teach them.
"It's very difficult to find someone," she says. Luckily, she found a mentor in Stikeleather, whom she calls a Cheneau master.
"It would be nice to have more formalized scoliosis training so that anyone could have access to a senior practitioner,
but I don't think that's available right now," Kara Davis adds.
Stikeleather is a proponent of mentoring and says the real need is for more orthotists who specialize in scoliosis. "You cannot dabble as a generalist and expect to get good results when you only fit a couple of patients a month."
Fabricating the braces is a complex process that takes expertise. Stikeleather says he sees many subpar braces and wishes more orthotists had the ability to fabricate and fit these braces correctly.
"A good 3D brace addresses all three planes of motion. When it comes to scoliosis, coronal balance, sagittal balance, and de-rotation is as important as Cobb angle reduction," he says. "Many orthotists don't have a good grasp of this, and they don't learn that in school effectively."
Stikeleather advocates for orthotists to become specialists in their area of interest. He suggests that practices that do not have the skills to effectively brace scoliosis patients should consider referring the patients to practices that do have the expertise.
"In my estimation, there are far more people acting like pharmacies, filling prescriptions and dispensing braces, than there are competent, skilled practitioners who really have a passion for doing it well."
Jang says that she hopes orthotists are able to build an orthosis based on the AIS deformities and general concepts of spinal biomechanics, just like when they build orthoses for any lower-limb deformities.
"I know it's hard," Jang says. "It's more complicated, but we are smart, and we can learn how to effectively apply optimal corrective forces in a three-dimensional way and how to utilize the spine biomechanics through constant and continuous education, training, and clinical practice."
Maria St. Louis-Sanchez can be contacted at firstname.lastname@example.org.
L. A. Dolan, J. G. Wright, and M. B. Dobbs. 2013. Design of the Bracing in Adolescent Idiopathic
Scoliosis Trial (BrAIST). Spine, 38(21), 1832-41.
Davis L., J. S. Murphy, and K. A. Shaw, et al. 2019. Nighttime bracing with the providence thoracolumbosacral orthosis for treatment of adolescent idiopathic scoliosis: A retrospective consecutive clinical series. Prosthetics and Orthotics International 43(2): 158-62.