Treating Adolescent Scoliosis Without A Brace Maybe Deemed Unethical
There are a lot of mixed opinions out there about whether or not braces are valuable in the treatment of scoliosis. Some conservative treatment methods nevertheless tout in their advertising that “No Braces” are necessary, or that bracing is outdated or already unhealthy. Many orthopedic surgeons seem to have little confidence in the ability of a brace to help, and may recommend them with a “fingers-crossed” attitude of “maybe we’ll get lucky”. however some specialists insist that scoliosis patients should be wearing a brace 23 hours a day. Who is right? How can you determine who is giving you the best advice?
What would be really useful for answering this question is a mega-study to compare the results of patients who DO use a brace against those scoliosis patients who do NOT use a brace. This is exactly what the publishers of the “BRAIST” study (Bracing in Adolescent Idiopathic Scoliosis Trial) set out to do- and did1. The results of this study may startle you.
The very first sentence of the BRAIST study declares, “The role of bracing in patients with adolescent idiopathic scoliosis who are at risk for curve progression and eventual surgery is controversial”. This is why the study was done. To target those “at risk for curve progression” the study specifically focused on growing adolescents aged 10-15 years old with curves between 20 to 40 degrees. Such a group is known to be at extremely high risk for progressing beyond 50 degrees. A “successful” outcome was defined as this: The curve staying below 50 degrees in size when the child was finished growing. A failed outcome was defined as: “Any child that progressed beyond the 50-degree mark. This threshold was chosen because curve progression as an adult is highly probable when the Cobb angle has grown this harsh in adolescence. This is the point at which most surgeons recommend surgery.
By splitting these children into two groups – those who received a brace and those who did not, the study was able to confidently measure the difference in success between wearing a brace and not wearing one. It is important also to observe, that only stiff braces were allowed in this study. Soft braces did not qualify. The shocking consequence of the study is this: Wearing a brace had a success rate so much greater than not wearing a brace, that the ethics review board deemed it unethical to continue the study. The study had to be stopped far before the intended time because the results were so overwhelmingly obvious: To refuse a stiff brace to the non-braced children in the study was harming the children and making it unethical to treat high-risk scoliosis situations without a brace!
Two substantial conclusions came out of the BRAIST study, and one shocking number:
stiff bracing considerably reduces worsening of curves in the 20-40 degree range (High-risk curves as defined above)
The more you use the brace, the better it works! Go figure – kids that truly wore their brace the most had the best results.
There was a 58% FAILURE RATE in the watch and wait for observation groupSo what is the shocking number? Fifty-eight percent of the no-brace “observation only” group progressed to surgical-need, worsening beyond the 50-degree mark at which surgery is considered “needed”. Fifty-eight percent is huge – that’s over half the kids in the 20-40 degree range, nevertheless growing, ended up needing surgery! The number had before been reported as low as 22%2, the BRAIST authors had expected as high as 30%, but no one already realized the failure rate of “watch and wait – observation only” was as high as 58%! This is a enormous failure in the current care standard of “Observation – wait and see” for managing scoliosis!
One would think that such substantial findings in favor of stiff bracing would send shockwaves throughout the orthopedic world and throughout the non-surgical camps that treat scoliosis. The controversy is dead… right? What is left to argue? Shouldn’t everyone be recommending stiff braces? Shouldn’t all doctors now agree that this is clearly the best course of action?
It has been nearly 5 years since the publication of the BRAIST study, however sadly non-surgical clinics and methods are nevertheless telling parents that wearing a stiff brace is unhealthy, outdated, and/or does not work. It would seem as though they either did not get the BRAIST memo or perhaps they just refuse to see the evidence. in any case the reason, the confusion that anti-brace messages bring to the public is indeed harming children with scoliosis. Don’t let your child be a casualty of misinformation. Read up on the BRAIST study, and you will find the jury is in- stiff braces work, and remarkably so, especially when truly worn by the patients.
A final observe about the BRAIST study: While we know that wearing the brace more than 18 hours a day yields a better consequence, the study failed to provide data on the quality of the brace itself; meaning the study did not track how straight the brace made each spine. Logically the straighter the brace can keep up the spine, the better the chances of spine growing straighter. There is emerging research which indicates that focusing on developing braces which provide better in-brace correction will provide better clinical outcomes (straighter spines).3-6
If you would like to know how you can receive the most assistance possible from a brace for your child, we invite you to inquire regarding our Silicon Valley MethodTM and how it is possible to receive surgical-like straightening of the spine, without the surgery.
Weinstein SL, Dolan LA, Wright JG, Dobbs MB. Effects of bracing in adolescents with idiopathic scoliosis. N Engl J Med 2013;369:1512-21.
Dolan LA, Weinstein SL. Surgical rates after observation and bracing for adolescent idiopathic scoliosis: an evidence-based review. Spine (Phila Pa 1976) 2007;32:S91-S100.
Negrini S, Marchini G, Tessadri F. Brace technology thematic series – The Sforzesco and Sibilla braces, and the SPoRT (Symmetric, Patient-oriented, stiff, Three-dimensional, active) concept. Scoliosis 2011;6:8.
Aulisa AG, Mastantuoni G, Laineri M, et al. Brace technology thematic series: the progressive action short brace (PASB). Scoliosis 2012;7:6.
Mauroy JC de, Pourret S, Barral F?d?r. Immediate in-brace correction with the new Lyon brace (ARTbrace), Results of 141 consecutive patients in accordance with SRS criteria for bracing studies. Ann Phys Rehabil Med 2016;59:e32.
Minsk MK, Venuti KD, Daumit GL, Sponseller PD. Effectiveness of the Rigo Cheneau versus Boston-style orthoses for adolescent idiopathic scoliosis: a retrospective study. Scoliosis Spinal Disord 2017;12:7.