Physiotherapy Theory and Practice, 27(1):26–42, 2011Copyright & Informa Healthcare USA, Inc.ISSN: 0959-3985 print/1532-5040 onlineDOI: 10.3109/09593985.2010.503989

SYSTEMATIC REVIEW

Effectiveness and outcomes of brace treatment:A systematic review

Toru Maruyama, MD, PhD,1 Theodoros B Grivas, MD,2 and Angelos Kaspiris, MD, MPhil3

1Department of Orthopaedic Surgery, Saitama Medical Centre, Saitama Medical University, Kawagoe, Saitama, Japan2Scoliosis Clinic, Department of Trauma and Orthopaedics, ‘‘Tzanio’’ General Hospital–NHS, Piraeus, Greece3Department of Trauma and Orthopaedics, ‘‘Thriasio’’ General Hospital–NHS, Magoula, Attica, Greece

ABSTRACT

Bracing has been widely used for the treatment of adolescent idiopathic scoliosis (AIS). However, effectiveness of

brace treatment remains controversial. A systematic review was conducted to investigate evidence that brace

treatment is effective in the treatment of AIS. A total of 20 studies, including randomized controlled trials, non-

randomized clinical controlled trials, or case-control studies, were included. Studies comparing the results of

brace treatment with no-treatment, other conservative treatments, or surgical treatment were included. Outcomes

of the studies included radiological curve progression, incidence of surgery, pulmonary function, quality of life

(QOL), and psychological state. The results from the systematic review are difficult to interpret. There are quite a

number of varying parameters between studies that make it very difficult to reach any firm conclusions. In addition,

the quality of evidence is limited because most of the studies included in this review were of low methodological

quality. However, the available data suggest that, compared to observation, bracing is more potent in preventing

the progression of scoliosis and may not have a negative impact on patients’ QOL. Therefore, bracing can be

recommended for the treatment of AIS, at least for female patients with a Cobb angle of 25–358. Compared to

other conservative treatments, bracing seems to be more effective than electrical stimulation, although an

advantage of bracing over side-shift exercise or casting has not been established. Comparison between bracing

and surgery is difficult because in most studies, the curve magnitude at baseline was considerably larger in the

surgery group. We recommend that future studies have clearer and more consistent guidelines.

INTRODUCTION

Scoliosis is a three-dimensional deformation of the

spine combined with a shift of the vertebrae in the

distortion curve (Lou, Hill, and Raso 2008).

Although scoliosis is considered a lateral curvature

of the spine with concordant vertebral rotation,

asymmetry involves some other structures, such as

the rib cage, muscles, viscera, and skin, in a unique

manner that changes as the deformity progresses

(Grivas, Vasiliadis, Mihas, and Savvidou, 2007).

The correlation between the rib cage and spinal

deformity appears clinically as trunk asymmetry

(Grivas, Vasiliadis, Rodopoulos, and Kovanis, 2008).

Scoliosis may be due to congenital disorders in the

formation of vertebrae, trauma, or diseases affecting

the vertebral canal (e.g., tumour, syringomyelia, and

degenerative diseases) (Angevine and Deutsch, 2008).

In the majority of patients, we find no specific cause

for the appearance of scoliosis. In these cases, the

condition is classified as idiopathic scoliosis (IS).

Idiopathic scoliosis is classified according to age of

appearance into four subcategories: (1) Children from

birth to 3 years are classified as having infantile IS;

(2) Children from 4 years to 9 years as juvenile IS;

(3) Adolescent IS (AIS) affects those between 10 and

18 years of age; and (4) Adult idiopathic scoliosis is

a deformity presented after 18 years of age (Angevine

and Deutsch, 2008). The prevalence of AIS, which

Address correspondence to Toru Maruyama, MD, PhD, Associate

Professor, Department of Orthopaedic Surgery, Saitama Medical

Centre, Saitama Medical University 1981 Kamoda Kawagoe, Saitama

350-8550, Japan.

E-mail: tmaruyama17@yahoo.co.jp

Accepted for publication 27 January 2010.

26

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includes cases in which curve magnitude (measured by

using the Cobb angle) over 10o, is between 2% and

12% of the population (Grivas et al, 2006; Nissinen,

Heliovaara, Ylikoski, and Poussa, 1993), of which only

10% require treatment (Lou, Hill, and Raso, 2008).

Large curves present at a much lower frequency than

smaller ones so that cases with deformities of over 40o

make up only 0.1% of the total AIS population

(Angevine and Deutsch, 2008; Weinstein, 2001),

whereas the frequency of curvatures between 208 and

408 is 0.3–0.5% (Weiss and Rigo, 2008). Although

infantile IS occurs most frequently in boys (Fernandes

and Weinstein, 2007), with age the trend is reversed,

and during puberty the female to male incidence ratio is

3.6:1 (Angevine and Deutsch, 2008). In cases where

the deformation is around 108, the female to male ratio

is 1:1; however, when the disorder is over 308, the ratio

changes and can rise to 10:1 in favour of females

(Angevine and Deutsch, 2008; Weinstein, 2001).

Untreated AIS does not increase mortality rate, even

though on rare occasions it can progress to greater than

1008 and cause premature death (Asher and Burton,

2006).

Hormonal imbalance, asymmetric growth, muscle

imbalance, or undiagnosed neuromuscular conditions

have been implicated as causal factors in IS (Kim,

Blanco, and Widmann, 2009; Wang, Qiu, and Zhu,

2007). About 30% of IS patients have a family history

of AIS, and current research is focusing on the

identification of the genes that play a role in the

development of scoliosis and ultimately determine

curve progression (Kim, Blanco, and Widmann, 2009).

The clinical approach to diagnosis requires special

attention. The complete examination of AIS includes a

detailed family and paediatric history, emphasising the

growth and development of the child, and primary and

secondary sexual characteristics including the menarche

for girls. Although pain in AIS is very mild and self-

limited, recording its appearance, frequency, duration,

location, and severity is necessary to investigate possible

underlying causes. The age, weight, height, and BMI of

adolescents should be consistently recorded during a

paediatric examination, especially in children with

immature skeletons. Examination of posture and gait

of adolescents noting asymmetries of the shoulders and

iliac crests and the presence of lumbar lordosis or

thoracic kyphosis is important. In parallel, asymmetrical

disorders, such as leg length discrepancy, should be

noted and managed (Timgren and Soinila, 2006;

Walker and Dickson, 1984; Zabjek et al, 2001).

Any asymmetry of the waistline at thoracic and

thoracolumbar level is examined with the adolescent in

an upright sitting position and with a slight straightening

of their back. Any noted asymmetry is confirmed with

the use of a scoliometer at standing and forward sitting

bent position. A neurological examination is also

important. In cases of atypical curves (sharply angular

or left thoracic) or coexistence with other clinical signs,

such as cafe-au-lait spots, it is important to proceed

to a thorough systematic examination (Angevine and

Deutsch, 2008).

The main imaging method used for the diagnosis of

scoliosis is the standing whole-spine radiograph,

measuring the Cobb angle (Cobb, 1948; Lou, Hill, and

Raso, 2008). The use of the Cobb angle as the main

diagnostic tool is unfortunate because newer techno-

logies in imaging could provide 3D versus 2D data,

which would allow investigators a better understanding of

the changes mediated by bracing. The Risser sign is used

as an indication of skeletal maturity. Magnetic resonance

imaging (MRI) of the spine is mainly indicated in cases

of: atypical scoliotic deformities that manifest as pain; left

thoracic curves; rapid deterioration of the deformity; or

coexistence of neurological symptoms (Angevine and

Deutsch, 2008). MRI is also recommended in cases

with curves greater than 20o because of the potential

coexistence of spinal cord disorders, such as syringo-

myelia and Chiari I malformations (in up to 20% of

cases) (Gupta, Lenke, and Bridwell, 1998). Surface

topography systems are an alternative and comple-

mentary methodology. Current systems include ISIS 1

and 2, Quantec, and COMOT techniques (Zubovic et al,

2008). Surface topography systems are noninvasive, low-

cost, three-dimensional measurements that can be used

for scoliosis assessment and follow-up.

Despite the wide use of bracing for AIS over

the past 40 years, treatment effectiveness remains

questionable (Helfenstein et al, 2006). The purpose of

this systematic literature review was to investigate

the evidence regarding bracing effectiveness in the

treatment of AIS.

Indications for brace treatment

The ultimate aim of scoliosis treatment is to restore

normal structure and function. Several nonsurgical

treatments have been implemented, such as physical

exercises, lateral electrical stimulation, physiotherapy,

and rehabilitation programmes as well as the use of

braces (Focarile et al, 1991). The most common

nonsurgical treatment for AIS is bracing, either on its

own, or in combination with exercise (Rigo et al,

2006). The primary aim for brace treatment of

scoliosis is to stop or limit progression of abnormal

spinal curves during growth until skeletal maturation.

In addition, bracing has been reported to change the

natural history of AIS. Nachemson and Peterson

(1995) reported that 66% of patients with IS and

curves between 208 and 358 progressed by only 68

Physiotherapy Theory and Practice 27

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following bracing intervention. The number of surgical

procedures is also reduced when bracing is applied

(Rigo, Reiter, and Weiss, 2003). Specifically, from 106

braced cases out of which 97 were followed up, 6 cases

(5.6%) ultimately progressed to surgery. A worst-case

analysis, which assumes that all 9 cases that were lost

to follow-up had operations, brings the maximum

number of cases that could have undergone spinal

fusion to 15 (14.1%). Either percentage is statistically

significant compared to the 28.1% reported surgeries

from a centre with the nonintervention policy.

In general, bracing is used for skeletally immature

patients with a curve magnitude of 25–458, but it may

be used in curves smaller than 258, especially if a

patient has a high likelihood of curve progression

(Kim, Blanco, and Widmann, 2009; Mak et al, 2008).

The last indication for bracing, which is based on

potential prognosis, can be roughly estimated from

several natural history surveys (Lonstein and Carlson,

1984), according to the following formula:

Progression factor

5 ðCobb angle� 33Risser signÞ=chronological age

Lonstein and Winter (1994) showed that patients with

a Risser sign of 0 or 1 are threefold more likely to undergo

progression of the curve than patients with a Risser sign

between 2 and 5 and that curves over 208 are also

threefold more likely to progress. In addition, a

prospective study by the Scoliosis Research Society

(SRS) showed that in 66% (85 of 129 skeletally

immature female) of AIS patients with curves between

258 and 358 that did not use braces suffered from a greater

than 58 progression of the curve (Rowe et al, 1997).

A review of the literature revealed that inclusion

criteria such as age, Risser sign, the size and type of the

curve, and the degree of maturity differ among studies

rendering comparisons between research reports

difficult at best. Moreover, appropriate criteria to judge

whether a treatment is successful or not is a subject of

extensive debate and often there are conflicting views.

Guidelines and specific indications for the conservative

management of scoliosis have been published by

SOSORT (Weiss et al, 2006). These include brace wear:

> In children with no signs of maturity and Cobb

Angle greater than 258;> In children and adolescents with Risser 0–3 and

first signs of maturation, but less than 98% of

mature height, part-time application (12–16

hours) when the risk of progression is 60%, and

full-time wear when the risk is 80% (23 hours);> In children and adolescents with Risser 4 but

more than 98% of mature height and Cobb angle

greater than 358 (part-time about 16 hours); and

> In adolescents and adults of any degree of

scoliosis and chronic pain when a positive effect

has been proven.

Moreover, SOSORT has recommended specific

criteria of management of AIS with correcting braces

for clinical guidance (Negrini et al, 2009). These can

be divided into the following domains:

> Experience and competence: Continuing education

and clinical practice are important factors in a

successful treatment;> Behaviours: Good technical approach combined

with compliance may be the core of the procedure;> Prescription: The physician must have a complete

knowledge about the issue and follow accurately

the subsequent steps;> Construction: The orthotist must follow certain

steps in the development of the module;> Brace check: The design of the module must be

controlled for its efficiency to interact correctly

with the pathological curves and the body of the

patient; and> Follow-up: Has to be continuing and to be

accurate.

Inclusion and assessment criteria for studies on the

use of braces also have been proposed by the SRS

Committee on bracing and nonoperative manage-

ment (Table 1) (Richards, Bernstein, D’Amato, and

Thompson, 2005; Thompson and Richards, 2008).

Therefore, menarche, type of curve, and rotatory

deformity must be recorded. The most popular

methods of measurement for the vertebral rotation

are either the Nash-Moe or the Perdriolle methods.

The Nash and Moe method is a radiological method

that is based on the presence of pedicles in the convex

and concave side of the vertebrae for determining

vertebral rotation. Specifically, Grade 0 has no

asymmetry of the pedicles on the convex or concave

side. In Grade 2, the pedicle migrates to second

segment on the convex side and gradually disappears

on the concave side. In Grade 3, the pedicle migrates

to the middle segment and is not visible on the concave

side, and in Grade 4, the pedicle migrates past the

midline to the concave side of vertebral body and not

visible on the concave side (Nash and Moe, 1969).

TABLE 1 New SRS inclusion criteria for bracing studies

> 10 years of age and older> Risser sign 0–2> Primary curve magnitude 25–408> No prior treatment> Females—premenarcheal or less than one year postmenarcheal

28 Maruyama et al.

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The determination of the effectiveness of bracing

includes the criteria listed in Table 2. Skeletal maturity

is considered to have been achieved when we observe a

height change in the upright position of less than 1 cm

in two consecutive measurements over 6 months. If we

do not have these increases of height change, skeletal

maturity is considered to have been achieved in the

presence of a Risser sign 4, or in the case of female

patients after 2 years from the menarche.

METHODS

A computer-aided search of the Pub Med database

(www.ncbi.nlm.nih.gov/pubmed/) was performed by

using the keywords ‘‘scoliosis’’ and ‘‘brace’’ up to

November 2009. From a total of 1,161 abstracts,

studies were selected according to the inclusion criteria

to be reviewed. There were no language restrictions.

Randomized controlled trials (RCT), nonrandomized

clinical controlled trials (CCT), and retrospective

case-control studies regarding AIS were included.

Studies comparing the results of brace treatment with

no-treatment, other conservative treatments, or surgi-

cal treatment were included. Comparisons among the

various types of brace treatment or comparisons

between the brace-treated patient and healthy control

were excluded.

Participant descriptive data, type of intervention,

outcomes, and results were extracted from the studies.

Outcomes included radiological curve progression,

incidence of surgery, pulmonary function, quality of

life (QOL), and psychological state. The methodological

quality of the studies was assessed by using the criteria

list indicated by Cochrane collaboration back review

group (Table 3) (van Tulder, Furlan, Bombardier, and

Bouter, 2003). A score of 1 point is given to each item,

resulting in a maximum score of 11 points for the overall

methodological quality score. Level of evidence was

determined according to the definition by Cochrane

collaboration back review group (Table 4) (van Tulder,

Furlan, Bombardier, and Bouter, 2003).

RESULTS

From 1,161 abstracts, we retrieved 28 studies, from

which 20 were finally included in this systematic

review. There was no randomized controlled trial.

There were 2 CCTs and 18 case-control studies.

Methodological quality score of the studies ranged

from 0 to 4, which indicated that no study fulfilled

50% of the validity criteria.

Comparison: Bracing versus observation(Table 5)

Six studies were found comparing bracing to observa-

tion (no treatment provided). Three focused on

radiological outcomes or incidence of surgery, and

the remaining three focused on quality of life (QoL).

Based on the list of criteria for the methodological

quality of the studies as shown in Table 3, a low-quality

CCT study by Nachemson and Peterson (1995), with

TABLE 2 New SRS assessment criteria for brace effectiveness

> Percentage of patients with ,58 curve progression at skeletal

maturity> Percentage of patients with .68 curve progression at skeletal

maturity> Percentage of patients who had surgery or recommended

before skeletal maturity> Percentage of patients with curve progression 458 indicating

possible need for surgery> Minimum 2 years follow-up past skeletal maturity for each

patient who has been successfully treated

TABLE 3 Criteria list for the assessment of methodological

quality

Was the method of randomization adequate?

Was the treatment allocation concealed?

Were the groups similar at baseline regarding the most important

prognostic indicators?

Was the patient blinded to the intervention?

Was the care provider blinded to the intervention?

Was the outcome assessor blinded to the intervention?

Were cointerventions avoided or similar?

Was the compliance acceptable in all groups?

Was the dropout rate described and acceptable?

Was the timing of the outcome assessment in all groups similar?

Did the analysis include an intention-to-treat analysis?

TABLE 4 Level of evidence

Strong: consistent findings among multiple high quality RCTs

Moderate: consistent findings among multiple low-quality RCTs

and/or CCTs and/or one high-quality RCT

Limited: one low-quality RCT and/or CCT

Conflicting: inconsistent findings among multiple trials (RCTs

and/or CCTs)

No evidence from trials: no RCTs or CCTs

Physiotherapy Theory and Practice 29

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30 Maruyama et al.

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a methodological quality score 3/11 showed a lower

failure rate with brace treatment than observation or

nighttime electrical stimulation. This study included

only girls with a skeletal age between 10 and 15 years,

with a Cobb angle between 258 and 358. Treatment

failure was defined as an increase of the Cobb angle

beyond 68 in two consecutive roentgenograms.

Of the 286 patients, 129 were managed with regular

observation, 111 were managed with a brace, and

46 received nighttime electrical stimulation. According

to the analysis followed after 3 years, treatment with

brace had a success rate of 80%, observation only

46%, and electrical stimulation only 39% (Nachemson

and Peterson 1995).

Another low-quality CCT study, by Danielsson,

Hasserious, Ohlin, and Nachemson (2007) with a

methodological quality score 4/11 and a follow-up

period of 16 years, showed a slower progression rate

and less incidence of surgery with brace treatment than

with observation, in girls with Cobb angles around 308.

Of the total 106 patients included in this study, 41

received a Boston brace and 65 were observed without

treatment. None of the 41 showed a curve increase of

greater than 68, whereas in the observation group of 65,

26 patients (i.e., 40%) showed an increase of greater

than 68. Of these 26 patients with progression, 13

were treated with brace treatment and 6 by surgery

(Danielsson, Hasserious, Ohlin, and Nachemson, 2007).

One study showed no differences between bracing

and observation. Goldberg, Dowling, Hall, and Emans

(1993) with a methodological quality score 3/11

assessed Cobb angle and incidence of surgery after

2.2 years of bracing or 2.5 years of observation. There

was no statistically significant differences between the

two groups, although the observation group had 16%

undergo surgery compared to 6% in the braced group.

The effect of brace application on quality of life was

investigated by Ugwonali et al (2004) methodological

quality score 1/11, Pham et al (2008) methodological

quality score 0/11, and Kahanovitz and Weiser (1989)

methodological quality score 1/11 leading to interest-

ing results. The first study included children aged

between 10 and 18 years with spinal curvature of at

least 10 degrees, of which 136 had followed only

observation and 78 had applied bracing. To study

the QoL, the adolescents’ parents completed a Child

Health Questionnaire (CHQ) and the American

Academy of Orthopaedic Surgeons Paediatric Outcomes

Data Collection Instrument (PODCI). The results ana-

lysis did not reveal any statistically significant differences

in any of the 12 CHQ domains between observed and

braced patients. However, two PODCI domains were

found to be significantly different between the two patient

groups. Braced patients had a much higher Expectations

score, but the observed patients had a higher Global

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nage:

12.5

y

Mea

nC

ob

b:

26.5

8

CC

T:

con

trolled

clin

ical

tria

l.

Physiotherapy Theory and Practice 31

Physiotherapy Theory and Practice

Phys

ioth

er T

heor

y Pr

act D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y 94

.64.

227.

64 o

n 01

/22/

11Fo

r pe

rson

al u

se o

nly.

Function and Symptoms score, which is a domain that is

computed as a composite of the three function domains

and the pain and comfort domain (Ugwonali et al, 2004).

On the other hand, the second study included 108

children aged 10–20 years with IS. Thirty-two were

only observed, whereas a Cheneau brace was applied

to the others (in 41 full-time 23/24 hours and in 35

only at night). The Quality of Life Profile for Spine

Deformities (QLPSD) Questionnaire was used for the

measurement of QoL. The results analysis showed

that, except for sleep disturbances, the score of each

QoL area was higher in the full-time than in the part-

time treated group. However, contrary to the report by

Ugwonali et al (2004), these scores were lowest for the

group without braces. In addition, the overall QoL

score followed the same distribution, by descending

order from the full-time group, to the part-time treated

group, and finally to the group without braces (Pham

et al, 2008).

Kahanovitz and Weiser (1989) assessed several QoL

measures using the Social Perception Scale, Profile

of Mood States, Multidimensional Health Locus of

Control Scale, and the Psychiatric Epidemiology

Research Interview for females (aged 12–16) with idio-

pathic scoliosis either being braced or just observed

over a 3-month period. There was no difference

between the groups in any of the measures regarding

how well the patient adjusts to scoliosis.

Therefore, there are few low-quality studies resulting

in a moderate level of evidence supporting that brace

treatment is more effective than observation in

preventing the progression of the curve with AIS.

There is conflicting evidence that brace treatment

affects the QOL of AIS patients, compared with their

observed counterparts.

Comparison: Bracing vs. other conservativetreatments (Table 6)

There were seven studies comparing the brace treat-

ment with exercise (n51), lateral electrical surface

stimulation (n55), or casting (n51). Five of the studies

focused on radiological outcomes and two on QOL.

The low-quality (methodological quality score 3/11)

CCTof Nachemson and Peterson (1995) demonstrated

a lower failure rate with brace treatment than with

electrical stimulation in girls with Cobb angles of

25–358, as already reported in the previous section.

A low methodological quality study (score 2/11)

compared electrical stimulation and bracing using a

Milwaukee brace (Fisher, Rapp, and Emkes, 1987).

Fifty patients were treated with Medronics Electro

Spinal Orthosis (ESO) and 50 with a Milwaukee

brace. Patients were followed for over 3 years during

treatment. At the final evaluation, the average curve in

the electrical stimulation group was 278 and 12 of the

42 patients (28%) were classified as failures, whereas

in the bracing group the average curve was measured

at 288, and 10 of the 33 patients (30%) were classified

as failures. In the study, failure was defined as a greater

than 108 progression of curvature over the pretreat-

ment value. The comparison of these results was not

statistically significant.

In contrast, however, in the study by Allington and

Bowen (1996) with methodological quality score 3/11,

the part-time (49 patients) or full-time (98 patients)

use of a Wilmington brace was more effective in curve

progression than electrical stimulation, applied to

41 patients (p,0.02 and,0.04, respectively).

Kahanovitz and Weiser (1989) assessed several QoL

measures using the Social Perception Scale, Profile

of Mood States, Multidimensional Health Locus of

Control Scale, and the Psychiatric Epidemiology

Research Interview for females (aged 12–16) with

idiopathic scoliosis either being braced or receiving

electrical stimulation over a 3-month period. There

was no difference between the groups in any of the

measures regarding how well the patient adjusts to

scoliosis. In a previous study Kahanovitz, Snow, and

Pinter, (1984) with methodological quality score 0/11,

found that the patients undergoing electrical stimula-

tion had significantly better psychological outcomes

than the braced group.

An advantage of bracing over side-shift exercise or

casting has not been established on the basis of the

available evidence. Specifically, the study by den Boer,

Anderson, v Limbeek, and Kooijman (1999), with a

methodological quality score 2/11, compared side-shift

therapy (an autocorrection method introduced by

Mehta in the early 1980s), with bracing. The

inclusion criteria were children suffering from IS,

aged between 10 and 15 years, with an initial Cobb

angle between 208 and 328 and treatment duration of

greater than 4 months. Failure was defined as

progression by more than 108 during the treatment

and the presence of a Cobb angle greater than 358 at

the time of treatment interruption. The results analysis

showed no statistically significant difference in either

the success rates or the progression of the Cobb angles

between the two groups.

Another conservative treatment for AIS is the

application of casts, mainly in the corrective phase.

However, the use of braces in this phase gives equally

good results. According to the study of Negrini et al

(2008), with a methodological quality score 3/11, the

Sforzesco brace can replace casts in the correction of

AIS. In this investigation, 32 patients were prospec-

tively followed up with a Sforzesco brace and compared

with a group of 18 patients treated with a Risser cast.

32 Maruyama et al.

Copyright & Informa Healthcare USA, Inc.

Phys

ioth

er T

heor

y Pr

act D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y 94

.64.

227.

64 o

n 01

/22/

11Fo

r pe

rson

al u

se o

nly.

TA

BL

E6

Bra

cin

gvs.

oth

erco

nse

rvati

ve

trea

tmen

ts

Stu

dy

Qu

ality

Sco

reS

am

ple

Inte

rven

tion

Follow

-up

Ou

tcom

esR

esu

lts

Det

ails

Fis

her

1987

2B

race

:N

550

Milw

au

kee

bra

ce36

mon

ths

Failu

re:

10

8,p

rogre

ssio

nN

od

iffe

ren

ces

Lost

Mea

nage:

12.7

yB

race

Bra

ce:

17

(34%

)

Mea

nC

ob

b:

28.4

8M

ean

Cob

b:

28

8E

S:

8(1

6%

)

ES

:N

550

Failu

re:

10

(30%

)

Mea

nage:

12.8

yS

urg

ery:

5(1

5%

)

Mea

nC

ob

b:

26.8

8E

S

Mea

nC

ob

b:

26.7

8

Failu

re:

12

(28%

)

Su

rger

y:

7(1

7%

)

Nach

emso

n&

Pet

erso

n1995

(CC

T)

3G

irls

on

lyU

nd

erarm

pla

stic

bra

ce

Un

til

matu

rity

Failu

reB

race

:b

ette

rL

ost

Cob

b:

25

to35

8or

failu

re6

8,p

rogre

ssio

nB

race

:23

(21%

)

Mea

nage:

12

y7

mB

race

:17

(19%

)E

S:

7(1

5%

)

Bra

ce:

N5

111

ES

:22

(56%

)

ES

:N

546

Allin

gto

n1996

3A

ge

at

least

9y

Wilm

ingto

nb

race

3–5

yea

rsF

ailu

re:

58,

pro

gre

ssio

nB

race

:b

ette

r

Bra

ce23

hou

rsF

ull-t

ime:

49

(50%

)

Fu

ll-t

ime:

N5

98

12–16

hou

rsP

art

-tim

e:23

(47%

)

Part

-tim

e:N

549

ES

:32

(78%

)

ES

:N

541

den

Boer

1999

2B

race

:N

5120

23

hou

rs2–3

yea

rsF

ailu

re:

No

dif

fere

nce

Mea

nage:

13.6

yP

rogre

ssio

nor

non

-com

plian

ce

Mea

nC

ob

b:

27

8B

race

38:

(32%

)

Sid

e-sh

ift:

N5

44

Sid

e-sh

ift:

15

(34%

)

Mea

nage:

13.6

y

Mea

nC

ob

b:

26

8

Neg

rin

i2008

3M

ean

age:

14.1

yS

forz

esco

bra

ce19

mon

ths

Failu

re:

58,

pro

gre

ssio

nN

od

iffe

ren

ce

Mea

nC

ob

b:

46.7

823

hou

rsB

race

:2

(6%

)

Bra

ce:

N5

32

Ris

ser

cast

:1

(6%

)

Ris

ser

cast

:N

518

Kah

an

ovit

z&

Wei

ser

1989

1G

irls

on

lytr

eatm

ent

Soci

al

Per

cep

tion

Sca

leN

op

sych

olo

gic

al

Mea

nage:

14

y.

3m

on

ths

Pro

file

of

Mood

Sta

tes

dif

fere

nce

s

Physiotherapy Theory and Practice 33

Physiotherapy Theory and Practice

Phys

ioth

er T

heor

y Pr

act D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y 94

.64.

227.

64 o

n 01

/22/

11Fo

r pe

rson

al u

se o

nly.

The Sforzesco brace showed results comparable to the

Risser cast, having only minor differences in terms of

scoliosis correction, and could be used in the corrective

phase of AIS treatment.

Once again, there are few low-quality studies resulting

in a moderate level of evidence supporting that brace

treatment is more effective than electrical stimulation in

preventing the progression of the curve with AIS, but no

difference compared with side-shift exercise and casting,

respectively. In addition, there is conflicting evidence

that brace treatment negatively affects the QOL of AIS

patients compared with electrical stimulation.

Comparison: Bracing versus surgery (Table 7)

There were ten studies in this section. One focused on

radiological outcomes, seven focused on QOL, one

focused on range of motion and muscle endurance,

and one focused on pulmonary function. Comparison

between bracing and surgery is difficult because in

most of the studies curve magnitude at baseline was

considerably larger in the surgery group.

In the study of Danielsson and Nachemson (2001a)

with methodological quality score 3/11, patients who

underwent surgery showed thoracic or thoracolumbar

curves of 458 or more and lumbar curves of 608 or

more, whereas patients treated with bracing showed

thoracic or thoracolumbar curves of 24 to 508 and

lumbar curves of less than 608. Surgery was performed

in 156 patients and braces were applied to 127

patients. The radiological results were better in

patients who had undergone surgery; specifically, the

average reduction of the Cobb angle from immediately

before treatment until the end of the treatment was

46.4% for the surgically treated patients and 10.5% for

the brace-treated patients. The mean Cobb angle

increase from the end of treatment to the last follow-up

evaluation was 3.58 for the surgery group and 7.98 for

the brace group over a 20-year period following

intervention. Altogether, 44 patients demonstrated a

Cobb angle increase by more than 108. Of these, 5

(4%) belonged to the surgically treated group and 39

(36%) to those treated with braces. Five patients, all

brace-treated, showed an increase of over 208 in the

last follow-up. In addition, surgically treated patients

had smaller thoracic kyphosis and lumbar lordosis

than brace-treated patients. Furthermore, no

significant differences in degenerative disc changes

were found between the two groups.

Of the seven studies evaluating quality of life

comparing AIS patients undergoing surgery or treated

with bracing, a majority of the studies indicated that

the QoL is not different between groups. The studies

finding no difference between treatments on quality ofTA

BL

E6

Bra

cin

gvs.

oth

erco

nse

rvati

ve

trea

tmen

ts

Stu

dy

Qu

ality

Sco

reS

am

ple

Inte

rven

tion

Follow

-up

Ou

tcom

esR

esu

lts

Det

ails

Bra

ce:

N5

30

Mu

ltid

imen

tion

al

Hea

lth

Locu

s

Mea

nC

ob

b:

26

8of

Con

trol

Sca

le

ES

:N

510

Psy

chia

tric

Ep

idem

iolo

gy

Mea

nC

ob

b:

22.7

8R

esea

rch

Inte

rvie

w

Kah

an

ovit

z1984

0G

irls

on

lyM

ilw

au

kee

bra

cetr

eatm

ent

MM

PI

ES

:b

ette

r

Age:

9.5

to16.5

yor

TL

SO

.3

mon

ths

Pro

file

of

Mood

Sta

tes

Bra

ce:

N5

15

Mu

ltid

imen

tion

al

Hea

lth

Locu

s

of

Con

trol

Sca

le

Psy

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Res

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ES

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ical

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CC

T:

con

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clin

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l.

34 Maruyama et al.

Copyright & Informa Healthcare USA, Inc.

Phys

ioth

er T

heor

y Pr

act D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y 94

.64.

227.

64 o

n 01

/22/

11Fo

r pe

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al u

se o

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TA

BL

E7

Bra

cin

gvs.

surg

ery

Stu

dy

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ality

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reS

am

ple

Inte

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tion

Follow

-up

Ou

tcom

esR

esu

lts

Det

ails

Dan

iels

son

&

Nach

emso

n2001a

3B

race

:N

5127

Milw

au

kee

or

Bost

on

bra

ce

22

yea

rsC

urv

ed

eter

iora

tion

Bra

ce:

wors

eL

ost

Mea

nage:

14.3

yB

race

:7.9

8B

race

:18

(14%

)

Mea

nC

ob

b:

33.2

822–24

hS

urg

ery:

3.5

8S

urg

ery:

17

(11%

)

Su

rger

y:

N5

156

Harr

ingto

n

Mea

nage:

15.0

y

Mea

nC

ob

b:

61.8

8

Fallst

rom

1986

2B

race

:N

595

Milw

au

kee

bra

ce

5,

yea

rsIn

terv

iew

Su

rger

y:

bet

ter

Lost

Su

rger

y:

N5

100

att

itu

des

an

dre

act

ion

toth

e

trea

tmen

t

Bra

ce:

30

(32%

)

att

itu

des

tow

ard

the

hosp

ital

staff

Su

rger

y:

8(8

%)

bod

yim

age

con

cep

t

Kah

an

ovit

z&

Wei

ser

1989

1A

llfe

male

trea

tmen

tS

oci

al

Per

cep

tion

Sca

leN

op

sych

olo

gic

al

Mea

nage:

14

y3

mon

ths

,P

rofi

leof

Mood

Sta

tes

dif

fere

nce

s

Bra

ce:

N5

30

Mu

ltid

imen

tion

al

Hea

lth

Locu

s

Mea

nC

ob

b:

26

8of

Con

trol

Sca

le

Su

rger

y:

N5

17

Psy

chia

tric

Ep

idem

iolo

gy

Mea

nC

ob

b:

48.6

8R

esea

rch

Inte

rvie

w

Peh

rsso

n2001

3B

race

:N

5110

Milw

au

kee

or

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on

bra

ce

20

,yea

rsV

ital

Cap

aci

ty,

FE

V1

No

dif

fere

nce

Mea

nage:

14.3

yB

race

:89%

VC

,91%

FE

V1

Mea

nC

ob

b:

33

822–24

hS

urg

ery:

84%

VC

,84%

FE

V1

Su

rger

y:

N5

141

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ingto

n

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nage:

15.0

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Mea

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b:

62

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Dan

iels

son

&

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n2001b

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male

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au

kee

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ari

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statu

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ctio

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Su

rger

y:

N5

136

Harr

ingto

n

Mea

nage:

14.9

y

Physiotherapy Theory and Practice 35

Physiotherapy Theory and Practice

Phys

ioth

er T

heor

y Pr

act D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y 94

.64.

227.

64 o

n 01

/22/

11Fo

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al u

se o

nly.

TA

BL

E7

Bra

cin

gvs.

surg

ery

(con

tin

ued

)

Stu

dy

Qu

ality

Sco

reS

am

ple

Inte

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tion

Follow

-up

Ou

tcom

esR

esu

lts

Det

ails

Dan

iels

son

2001

3B

race

:N

5127

Milw

au

kee

or

Bost

on

bra

ce

20

,yea

rsS

F-3

6N

od

iffe

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ceL

ost

Mea

nage:

14.4

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sych

olo

gic

al

Gen

eral

Bra

ce:

11

(9%

)

Mea

nC

ob

b:

33.2

822–24

hW

ell-

Bei

ng

Ind

exS

urg

ery:

10

(6%

)

Su

rger

y:

N5

156

Harr

ingto

nO

swes

try

Dis

ab

ilit

yIn

dex

Mea

nage:

15.0

y

Mea

nC

ob

b:

61.8

8

Wei

ger

t2006

2B

race

:N

544

Bost

on

bra

ce2

,yea

rsS

RS

-24

Bra

ce:

Mea

nage:

14.7

yC

otr

el-

Du

bou

sset

bet

ter

act

ivit

y

Mea

nC

ob

b:

33.6

8H

arr

ingto

nle

sssa

tisf

act

ion

Su

rger

y:

N5

41

Kan

eda

Mea

nage:

16.7

y

Mea

nC

ob

b:

49.5

8

Both

:N

533

Mea

nage:

14.3

y

Mea

nC

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b:

48.5

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An

der

sen

2006

2B

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:N

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on

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ce10

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ack

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S)

No

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fere

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Lost

Mea

nage:

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-36

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18

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N5

115

Su

rger

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16

(14%

)

Mea

nage:

14.9

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Dan

iels

son

2006

3B

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:N

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,yea

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inal

ran

ge

of

moti

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Su

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Lost

Mea

nage:

14.4

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usc

leen

du

ran

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du

ced

moti

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ce:

25

(20%

)

Mea

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b:

33.2

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21

(13%

)

Su

rger

y:

N5

156

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ingto

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nage:

15.0

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Mea

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2007

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:N

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SR

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:

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less

pain

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nC

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b:

39

8le

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36 Maruyama et al.

Copyright & Informa Healthcare USA, Inc.

Phys

ioth

er T

heor

y Pr

act D

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oade

d fr

om in

form

ahea

lthca

re.c

om b

y 94

.64.

227.

64 o

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/22/

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rson

al u

se o

nly.

life indicators were (1) Andersen, Christensen, and

Thomsen (2006) methodological quality score 2/11;

(2) Danielsson and Nachemson (2001b) methodological

quality score 3/11; (3) Danielsson, Wiklund, Pehrsson,

and Nachemson (2001) methodological quality score

3/11; and (4) Kahanovitz and Weiser (1989). One study

found that surgery produced better outcomes than

bracing (Fallstrom, Cochran, and Nachemsson, 1986)

methodological quality score 2/11, and two studies

found mixed results with some factors better following

bracing and some following surgery (Bunge et al, 2007;

Weigert et al, 2006).

Andersen, Christensen, and Thomsen (2006) found

that there was no statistically significant difference in

back and leg pain (VAS assessed) or the ADL activity

questionnaire. Furthermore, no statistically significant

differences emerged when analyzing the results of the

SF-36 on health-related quality of life.

Danielsson and Nachemson (2001b) followed

the population described in the radiological study

(Danielsson and Nachemson, 2001b) over a 22-year

period and assessed quality of life using the SF-36,

Psychological General Well-Being Status, and the

Oswestry Disability Index. They found no differences

between the two groups for these measures. These

investigators also studied a subgroup of the population

(brace group n5111; surgery group n5136) for

marital status, childbearing, and sexual function and

once again found no difference between the groups

over the long term (Danielsson, Wiklund, Pehrsson,

and Nachemson, 2001).

Kahanovitz and Weiser (1989) assessed several QoL

measures using the Social Perception Scale, Profile of

Mood States, Multidimensional Health Locus of Control

Scale, and the Psychiatric Epidemiology Research

Interview for females (aged 12–16) with idiopathic

scoliosis either having surgery or being braced over a

3-month period. There was no difference between the

groups in any of the measures regarding how well the

patient adjusts to social and psychological factors.

Fallstrom, Cochran, and Nachemsson (1986)

conducted interviews with patients followed over

5 years of treatment postsurgery (n5100) or post-

bracing (n595) and found that the patients who had

undergone surgery had better attitudes toward their

treatment, health staff, and ultimately had a better

body image concept. The brace-treated patients

reported more frequent feelings of fear and anxiety

(53%) than those who had undergone surgery (38%).

Furthermore, 50% of patients in the brace group had

signs of a negative body image concept, while the

emotional stress of surgical patients was only 33%

(Fallstrom, Cochran, and Nachemson, 1986).

Bunge et al (2007) methodological quality score

1/11, using the Dutch SRS-22 patient questionnaire,

found better function and less pain, but less satis-

faction with bracing (n545) compared to the surgery

group (n564). This study was conducted 3.5 years

following surgery and bracing. Finally, Weigert et al

(2006) methodological quality score 2/11, using the

SRS-24, found that the brace group (n544) reported

more activity but had less satisfaction with their

treatment than the group that had undergone surgery

(n541). This study was a conducted 2 years following

surgery and bracing.

Danielsson, Romberg, and Nachemson (2006)

methodological quality score 3/11, conducted another

study following their patient population that was

conducted at least 20 years postsurgery or bracing

intervention. The focus of this study was to determine

the long-term effect of bracing (n5102; original

n5127) and surgery (n5135; original n5156) on

spinal range of motion and muscle endurance.

The range of motion (measured with a Debrunner

kyphometer) of the lumbar spine was significantly

decreased for both patient groups compared with

controls. There was a reduction of 61% for the group

of surgically treated patients and 37% for those treated

with bracing. In addition, the surgically treated patients

were significantly stiffer than the control or brace-

treated patients, with a nonsignificantly smaller thoracic

and lumbar range of motion and fingertip-floor

distance. Muscle endurance was measured for lumbar

trunk flexors using the modified Kraus-Weber Test and

for lumbar trunk extensors using the modified Sorensen

test. Muscle endurance for both lumbar flexors and

extensors was decreased for the group of surgically

treated patients by 31% and 41%, respectively and for

the brace-treated patients by 30 and 29%, respectively

(Danielsson, Romberg, and Nachemson, 2006).

In addition, lung function seems to improve

equally after the surgery and after the application of

braces. Vital capacity (VC) increased from 67% to

73% immediately after surgery and to 84% 25 years

after surgery. The VC in patients treated with braces

increased, from 77% before treatment to 89% 25 years

after initiation of brace intervention (Pehrsson,

Danielsson, and Nachemson, 2001) methodological

quality score 3/11.

As with the comparison of bracing to observation and

conservative interventions, there are few low-quality

studies comparing bracing and surgery. It appears

surgery may have a better effect in controlling curve

progression. There is conflicting evidence regarding the

comparison between brace treatment and surgery on

QOL of AIS patients. Decreased range of motion and

stiffness appear to be a greater problem as a long-term

effect for surgery than treatment with bracing. Both

surgery and bracing improve cardiorespiratory function

as assessed via vital capacity.

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DISCUSSION

The following discussion will elaborate upon the

change of the natural history of AIS by the use of

braces and the factors that can lead to success or

failure of the treatment. The results come either from

prospective studies (Emans, Kaelin, and Bancel, 1986;

Peltonen, Poussa, and Ylikoski, 1988), which provide

important data for comparison; series of case reports

(Rigo, 2003; Weiss, 2006), which show the effect of

braces on the natural evolution of AIS; retrospective

studies (Helenious et al, 2005; Sucato, Hedequist, and

Karol, 2004; Yrjonen, Ylikoski, Schlenzka, and

Poussa, 2007) containing information on the factors

influencing the evolution of the treatment; or meta-

analyses (Rowe et al, 1997), examining the efficacy of

nonoperative treatments.

Orthotics have been well documented as a non-

operative management for scoliosis since the Milwaukee

brace was developed by Blount and Schmidt in 1945

(Wong and Liu, 2003). The Milwaukee brace is the

most common form of the CTLSO (Cervical-Thoracic-

Lumbar-Sacral Orthosis) and it is classified as a rigid

module. Some degrees of movement are allowed in

common types of TLSO (Thoracic-Lumbar-Sacral

Orthosis) braces such as Boston, Charleston, and

Cheneau orthoses. Currently, the Cheneau brace and

its derivates are regarded as superior by some clinicians

(Weiss and Rigo, 2008; Weiss and Rigo, 2010).

There were no high methodological quality studies

comparing brace treatment with other conservative

treatments or observation. This is probably because of

the difficulty of conducting randomized controlled

trials in the treatment of AIS. Bracing cannot be

concealed because the patient and care provider

cannot be blinded to the intervention. The more

logical and practical design that is feasible in the

clinical setting is having a control group, where the

untreated, observed patient is followed and compared

to a braced patient. However, as mentioned above, this

is not a blinded randomized controlled design, but it

does provide a comparison that could indicate the

effectiveness of the brace treatment. However, even

this design contains clinical challenges, in that

physicians who believe brace treatment is effective

are reluctant to allow patients to remain untreated at a

critical moment for the progression of their deformity.

Yet, because some physicians and surgeons do not

believe in brace treatment, this design is a clinical

possibility. One limitation to the present systematic

review is that well-constructed prospective studies that

use historical controls for comparison were excluded.

Future systematic reviews may need to include this

type of design. Another limitation to this systematic

review is the conflicting and problematic variables

underlying undefined clinical homogeneity. The type

of brace utilized was different among the studies.

Diagnosis of IS was made by exclusion. Finally,

scoliosis with different causes is likely to have been

included in all the various studies.

Nevertheless, several studies published since the

introduction of bracing have concluded that bracing

use affects the natural history of the disease (Nachemson

and Peterson, 1995; Peterson and Nachemson, 1995;

Rowe et al, 1997). Furthermore, with the Cheneau

brace corrections of the curve are possible (Rigo, 2003;

Weiss and Rigo, 2008). These curve corrections are

accompanied by clinical improvements, such as signi-

ficant changes of the radiological and cosmetic

deformations and a significantly reduced rate of curve

progression. The frontal corrections with braces were on

average about 30–40% for the major curve but also

showed a significant reduction of vertebral rotation

(22%) (Weiss and Rigo, 2008). The above findings

have been documented by surface topography, angle of

trunk rotation, the measurement of the Cobb angle and

angles of vertebral rotation according to Raimondi

(Rigo, 2003; Weiss, 2006; Weiss and Rigo, 2008).

In addition, a significant reduction of incidence of

surgery has also been reported (Weiss, 2006; Weiss,

Weiss, and Schaar 2003).

Various factors can influence the effect that bracing

can have on scoliosis. These include initial angle prior

to bracing; amount of daily time for bracing; gender

(Bunnell, 1986); body weight (O’Neill et al, 2005);

and compliance (Karol, Johnston, and Brown, 1993).

Most studies of brace efficacy focus their use on

small and moderate scoliosis (,30) or heterogeneous

population groups ranging from 208 to 408 (Emans,

Kaelin, and Bancel, 1986; Jonasson-Rajala, Josefsson,

and Lundberg, 1995) where the results are very positive

and corrections of up to 158 are documented. Bracing

can also be effective in the case of larger curves of

around 35–458 (Wiley et al, 2000). However, effective-

ness appears to be directly related to the amount of

brace-wearing time. Patients who wore braces full-time

showed a decrease of the curve by approximately 38

during the 3.3 years of the average follow-up (Wiley

et al, 2000). Conversely, those who wore the brace only

on a part-time basis (at least 12 but less than 19 hours

per day), experienced a 3.68 progression compared to

the prebracing period.

As indicated above, the required wearing time is

also controversial. According to Green (1986), part-

time bracing around 16 hours a day is sufficient to

reduce the likelihood of curve increase. It was found

that only 5 of 55 curves increased by 58 or more with

this regimen. The problem with this study was that the

population was mixed, with curves from 23 to 498,

which were treated by using Boston and Milwaukee

38 Maruyama et al.

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braces with minimal follow-up. Another study

(Peltonen, Poussa, and Ylikoski, 1988) found that

the results after 12 hours of application are similar to

those after 23 hours of application. Specifically, from

the 162 patients treated for AIS using Boston Braces,

12 patients discontinued treatment while 14 wore the

brace for 12 hours without a different effectiveness

compared to those with full-time bracing. Conversely,

other studies (Rowe et al, 1997) reached the conclu-

sion that 23 hours of application had more beneficial

results than any other schedule. The latest study was a

meta-analysis of 1,910 patients treated with bracing

culled from 20 studies. In conclusion, it appeared

braces that were worn for 23 hours per day were

significantly more successful than those that were worn

for 8 or 16 hours per day (p,0.0001 for both

comparisons). Another study used a load monitor

system with transducers to determine the effect of

time on brace force exertion. Mak et al (2008)

compared 1, 2, and 5 hours of wear during the day or

night and revealed that the force exerted by the brace

drops during the first 2 hours of application. This

decrease in force exertion was increased during daytime

wear. If the findings can be generalised across brace

wearing, the brace acts not solely as the force applied

by the pads but also through passive and active

mechanisms working to produce corrective forces

during its treatment.

Gender may also influence the effectiveness of

treatment. Although the incidence of AIS is higher in

girls, the risk of progression of curves seems to be

increased among boys (Karol, Johnston, and Brown,

1993). In addition, Sucato, Hedequist, and Karol

(2004) reported that surgical treatment is less success-

ful in boys. Specifically, according to this study, male

and female patients had a similar deformity in the

coronal plane at the time of presentation, but at the

time of surgery, male patients had greater coronal

curve magnitudes with greater truncal imbalance in

the coronal plane. They also showed a smaller surgical

correction of the coronal plane deformity postopera-

tively and at the time of final follow-up. The

comparison of the male patients with the matched

group of female patients demonstrated that the

operative procedure was longer and resulted in

greater blood loss in male patients, even though the

curves in the two groups were similar and the number

of fused levels was the same. Few studies comparing

brace treatment in boys and girls are available

in literature. Katz, Richards, Browne, and Herring

(1997) studied 25 boys using Boston and Charleston

braces. They found that 80% of boys showed

progression of greater than 58 compared with 36% of

girls. Specifically, of the 10 boys managed with Boston

braces, 2 had successful outcomes but six required

surgical correction. Of the 15 boys treated with

Charleston braces, 4 had a successful outcome and

seven required surgical correction. In contrast, 64% of

girls (75 of 117) of those treated with Boston braces

achieved successful treatment. This difference was

statistically significant (p50.001). In another study

including just boys, Karol, Johnston, and Brown

(1993), found that 74% showed progression of

curves, whereas a more recent study by Yrjonen,

Ylikoski, Schlenzka, and Poussa (2007) found that

31.4% (16 of 51) boys compared with 21.6% (11 of

51) girls showed curve progression of greater than 58.

These studies, of course, have a significant difference.

In the first, only 61 boys of the entire 210 were treated

with a different type of bracing (Boston, Milwaukee,

Charleston etc), whereas the second study used

Boston braces with an average bracing period of 2.1

years. One reason that would explain this gender

difference could be curve stiffness. Yrjonen, Ylikoski,

Schlenzka, and Poussa (2007) found an average curve

correction after use of a Boston brace of 41% for boys

compared with 49% for girls. These findings support

the conclusion that the scoliotic curves in boys are

stiffer, as has been reported by Mellin, Harkonen, and

Poussa (1988), although this conclusion has not been

definitely proven. Another factor that can interpret

these results in boys is poor compliance with brace

wear. Karol, Johnston, and Brown (1993) reported

that only 38% of boys were compliant with bracing

throughout the course of intervention, while Yrjonen,

Ylikoski, Schlenzka, and Poussa (2007) supported

these results indicating that 35% of braced males were

noncompliant.

Increased weight may be another cause of ineffective

treatment with the use of braces. A study by O’Neill

et al (2005) found a significant difference between

overweight patients and those that were not overweight

(p,0.05). The mean curve progression was 9.6867.38

for overweight patients, compared with 3.6869.48 for

those who were not overweight. The mean in-orthosis

correction was 26%621.5% for overweight patients,

compared with 41%620.1% for those who were not

overweight (p,0.01). The success rate was 26% (8 of

31 for overweight patients, compared with 52% (127 of

245) for the patients who were not overweight

(p,0.01). The rate of curve progression to greater

than 458 was 45% (14 of 31) for overweight patients,

compared with 28% (69 of 245) for the patients who

were not overweight (p,0.05). Based on the odds ratio,

orthotic treatment was 3.1 times more likely to be

unsuccessful in overweight patients than those who were

not overweight (O’Neill et al, 2005). The above results

were significantly lower than the rates reported for other

patients, ranging from 36% to 62% (Bunnell, 1986;

Emans, Kaelin, and Bancel, 1986; Katz and Durrani,

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2001, Laurnen, Tupper, and Mullen, 1983). The reason

for this less desirous result may be mechanical in nature.

The important relationship between the Cobb angle,

pad pressure, and strap tension has already been stressed

(Wong et al, 2000). In overweight patients with a large

volume of soft tissue and a large body surface, the

corrective forces of the pads and straps to the spine are

broken up and weakened, resulting in reduced

effectiveness. In addition, the vertebral column receives

the highest compressive load due to the body weight.

Finally, metabolic factors associated with increased

BMI, such as insulin resistance and hyperinsulinism,

may also be involved. During puberty, this can affect the

development process due to the secretion of growth

hormone, insulin-like growth factor 1, and leptin. These

biochemical changes lead to a longer puberty period and

thus a longer time of skeletal system immaturity, which

is more likely to change in a negative fashion (Roemmich

et al, 2002). Finally, the incidence of overweight patients

requiring spinal surgery is higher than that of normal

weight individuals (O’Neill et al, 2005).

CONCLUSION

The results from the systematic review are difficult to

interpret. There are quite a number of varying

parameters between studies that makes it very difficult

to reach any firm conclusions. In addition, the quality of

evidence is limited because most of the studies included

in this review were of low methodological quality.

However, the available data suggest that, compared to

observation, bracing is more potent in preventing the

progression of scoliosis and may not have a negative

impact on patients’ QOL. Therefore, bracing can be

recommended for the treatment of AIS, at least for

female patients with a Cobb angle of 25–358. Compared

to other conservative treatments, bracing seems to be

more effective than electrical stimulation, although an

advantage of bracing over side-shift exercise or casting

has not been established. Comparison between bracing

and surgery is difficult because in most studies, the

curve magnitude at baseline was considerably larger in

the surgery group. We recommend that future studies

have clearer and more consistent guidelines.

Declaration of Interest: We declare that there are

no conflicts of interest.

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