For more than 50 years, orthopedic surgeons at Boston Children’s Hospital and elsewhere have prescribed rigid back braces for some kids with scoliosis. In theory, bracing prevents worsening of the curvature and might allow the child to avoid surgery to correct the curve. But the treatment can be challenging. Subjecting a child to a bulky back brace during the emotionally vulnerable teen years is not high on any parent’s or physician’s wish list. Plus, until last week’s study published in New England Journal of Medicine, some physicians weren’t sure if bracing was effective.
“Although Boston Children’s Orthopedic Center always believed bracing worked and recommended it for appropriate patients, we wanted to have robust controlled data that prove or disprove that bracing is worth the efforts of the family and adolescent, as well as being cost efficient to the health care system,” says Daniel Hedequist, MD, orthopedic surgeon. In 2007, Hedequist and the Boston Children’s orthopedic center team joined the Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) to help answer questions about the effectiveness of bracing.
The results published Sept. 19 provide parents, physicians and teens with scoliosis, who are typically girls, a much-welcome answer. Bracing works.
Researchers enrolled 242 children from 25 sites across the U.S. in the study. Children included in the study were considered high risk, with spinal curvatures between 20 and 40 degrees, and still growing, thus their curves might reach 50 degrees―the threshold for scoliosis surgery. A total of 146 patients were prescribed a brace to be worn a minimum of 18 hours per day, and 96 patients were observed for an average follow up of nearly two years without bracing. The trial was stopped early because researchers realized bracing is effective.
Treatment success was defined as skeletal maturity without progression to a curvature of 50 degrees or more. Progression to a curvature of 50 degrees or more, at which point corrective surgery is recommended, was defined as treatment failure.
Overall, 72 percent of patients in the bracing group were successfully treated. A total of 48 percent of patients in the observation group were successfully treated. However, success in the bracing group depended on compliance with the doctor’s orders.
Only 41 percent of teens who wore the brace between zero and six hours daily were successfully treated. Those who wore the brace for at least 12.9 hours daily had success rates between 90 and 93 percent.
“Compliance is always a challenge,” says Hedequist, who recommends empowering patients about when to wear the brace. Patients can participate in sports without the brace and attend important social events like dances sans brace.
“We suggest parents let their children do things that are important to them without the brace … within reason.”
Another aspect of successful bracing is a team approach, says Hedequist. Nurses play a key role, fielding questions, looking at braces with patients and managing skin and compliance issues. A talented orthotist to make the brace also is essential. And finally, surgeon buy-in and belief that bracing works is also needed.
The primary care provider also plays a crucial role in the process. “The positive confirmation of bracing reinforces the need for primary care provider to diagnose and evaluate patients with scoliosis at an early stage,” says M. Timothy Hresko, MD, orthopedic surgeon. “This way a brace program can be considered and implemented in a timely fashion.”
“Using this team approach, which is the model we’ve used at Boston Children’s, the study clearly shows that bracing is effective,” says Hedequist.