Clinical Features, Debates & Research / DĂŠbats, recherche et articles cliniques (continued from page 28)
being a disorder of spinal growth that occurs over many years, the development of a successful brace that is tolerated by growing patients is challenging. Children with scoliosis may need to wear a brace for many years. Also, a direct association has been drawn between daily hours of wear and effectiveness, with part-time strategies being less effective5,6,7. We also understand that in order for the brace to be effective, it must alter future spinal growth. That may require alteration of the patient’s spinal position, which renders the device more challenging to construct and wear. In-brace correction does appear to be of major importance in successful management, with many physicians and orthotists having a goal of 50% deformity correction in-brace8,9. In-brace correction is not only dependent on brace design, but also highly dependent on the flexi- Figure 1 bility and location of the curve 40-degree right thoracic idiopathic (Figure 1). scoliosis with a curve apex at T8. As the success rate of surgical correction increased, clinicians who questioned the evidence for the effectiveness of bracing adopted a strategy of observing patients and correcting those that progressed to an unacceptable deformity with surgery. Recent developments in surgical techniques have created excellent cosmetic results for patients and allowed most patients to participate in all activities. Surgeons also became more concerned about the psychosocial effects of bracing teens, who in some cases had to tolerate bracing 23 hours a day over many years. Males, in particular, may have greater difficulty as they are usually older at the time of brace treatment and would have to wear the brace in high school10. In addition, males prolonged adolescent growth requires a longer duration of brace wear, which contributes to lower success rates and a higher progression rate after brace cessation10. These concerns, along with the success of surgical correction and lack of evidence for the effectiveness of bracing, led some clinicians to significantly reduce the use of bracing in their management of idiopathic scoliosis. Interestingly, at the same time, the Bracing in Adolescent Idiopathic Scoliosis Trial (BRAIST) was completed and published, demonstrating a clear benefit of bracing in idiopathic scoliosis11. This study, funded by the National Institute of Health, compared the use of various types of rigid thoracolumbarsacral orthoses with observation alone, with the purpose of evaluating the efficacy of bracing as a treatment option. It enrolled 242 patients, involving patients from a number of Canadian centres. Enrollment was halted by the
data safety monitoring board when interim analyses reached an a priori level of efficacy. The primary finding was that 72% of the patients treated with bracing until maturity had a curve below the surgical threshold of 50 degrees, while only 48% of the observation group were below the threshold. The study also reinforced the association between the effectiveness of bracing and hours of use. Based on temperature monitors embedded in the brace, patients who wore the brace for more than 12.9 hours a day had success rates of greater than 90%. In addition, the bracing group was found to have quality of life scores equivalent to the observation group. Other studies have similarly demonstrated that bracing does not appear to change the patient’s quality of life in the short- or long-term12. Many different scoliosis bracing systems have been designed. Most commonly, the original brace designs were the result of collaborations between surgeons and orthotists at scoliosis centres. Common examples include the Milwaukee brace, the Boston brace, the Providence brace, the Charleston brace and the Wilmington brace. Local orthotists may also modify designs in consultation with treating surgeons. Recently, CADCAM systems have grown in popularity. These braces are all manufactured to achieve some degree of physical correction of the deformity. Flexible brace systems have been proposed as a method of controlling the scoliotic deformity while improving compliance and quality of life13. However, followup studies with flexible brace systems have demonstrated higher rates of curve progression than that seen with rigid orthoses14,15. As a result, interest in flexible bracing has decreased. Many other nonsurgical techniques have been used to try to resolve or prevent progression of scoliotic deformities. The most widely known program is the Schroth method16. Katharina Schroth, born 1894 in Dresden, Germany, developed scoliosis in her teenage years and was treated with a rigid metal brace. She experimented with breathing and postural exercises, often using a mirror, to manage her deformity. Later in life, she further developed the method and, with the assistance of her daughter, opened a large clinic in Germany where the method is still in use. Although there are many proponents of exercise management, most studies have low levels of evidence, being retrospective and lacking appropriate controls. Consequently, a 2013 systematic review concluded that there was a lack of
Figure 2 In brace correction to 26 degrees. Thoracic curves with higher apex locations, above T9, may be more challenging to manage with bracing. COA Bulletin ACO - Spring / Printemps 2017
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