Is Nighttime Bracing Enough to Prevent Curve Progression of Adolescent Idiopathic Scoliosis?

Adolescent idiopathic scoliosis (AIS), which leads to truncal deformation, is a common spinal disability among adolescents. The purpose of bracing treatment for patients with AIS is to halt progression of the scoliotic curve and consequently prevent risk of the scoliosis Cobb angle exceeding 50°, whereby surgical intervention is indicated. If the curve progresses to become large, in the majority of patients with scoliosis this may result in back pain by early adulthood.¹ Moreover, a Cobb angle exceeding 90° is associated with ventilatory impairment.² However, regarding life expectancy, scoliosis that develops after the age of 10 years has an unaltered prognosis for life³ and is different from early-onset scoliosis with a congenital or neuromuscular background. In the US, the 50-year survival rate for patients with AIS is comparable with that of a healthy population.¹

Early-onset or congenital scoliosis can be associated with reduced life expectancy.³ Thus, the purpose of bracing for early-onset scoliosis is to delay surgery until the pulmonary system matures. By contrast, the aim of bracing treatment for AIS diagnosed after the age of 10 years is to achieve a functional outcome and may not be necessarily directly related to life expectancy. Another essential factor in AIS treatment is the psychological context. Adolescent idiopathic scoliosis is associated with children’s or adolescents’ development not only physically but also psychologically, including their self-esteem and mental well-being.⁴ The psychological effects of bracing may be related to cosmetic circumstances.

In 2013, Weinstein et al⁵ revealed that a full-time brace was superior to a part-time brace in terms of preventing curve progression. In that randomized clinical trial (RCT), patients were instructed to wear a brace for at least 18 hours each day.⁵ The rates of treatment success in brace-wearing patients were 40% for less than 6 hours each day, 70% for 6 to 12 hours each day, and 90% for more than 13 hours each day, suggesting that full-time bracing is ideal. However, physicians may encounter patients who have difficulty adhering to full-time use or who refuse to use a full-time brace. The psychological impact of using a whole-day brace is far from negligible. Historically, some patients have adamantly refused treatment despite extensive counseling because of their fear of ridicule.⁶

The RCT by Charalampidis et al⁷ compared self-mediated physical activity combined with either nighttime bracing or scoliosis-specific exercise with self-mediated physical activity alone for the prevention of Cobb angle progression in patients with moderate AIS who rejected full-time bracing. The RCT included 135 patients (111 females and 24 males), aged 9 to 17 years (mean [SD] age, 12.7 [1.4] years), who were followed up for 2 years. Charalampidis et al⁷ reported a 76% success rate in the nighttime brace group. In comparison with the previous RCT by Weinstein et al⁵ of approximately 70% treatment success in the equivalent nighttime brace (ie, 8 hours) group, the result achieved by Charalampidis et al⁷ was reasonable, although the primary outcome was different. The success rates found in the trial by Charalampidis et al⁷ were 53% in the physical activity–alone group and 58% in the scoliosis-specific exercise group, and the authors concluded that while scoliosis-specific exercise did not prevent Cobb angle progression, treatment with the nighttime brace prevented curve progression of more than 6° to a significantly higher extent than physical activity alone. However, it must be noted that 9 patients in each of the 3 groups underwent surgery up to 2 years after the primary outcome.⁷

The insightful work presented by Charalampidis et al⁷ offered 2 important points. First, it was reaffirmed that the basis of scoliosis treatment is bracing and not a specific exercise therapy. Second, nighttime bracing can be an effective alternative intervention for patients rejecting full-time bracing. It should be emphasized, however, that nighttime bracing alone is not clinically sufficient. Physicians should explain to patients with AIS and to their guardians the significant association between hours of brace wear and treatment success.⁵ Simultaneously, physicians should also recognize the sensitive minds of youths when prescribing the bracing treatment. Some patients, for example, have fear of ridicule in their school life.⁶ For such specific cases, presenting alternative methods may be purposeful. The RCT by Charalampidis et al⁷ presented meaningful data related to the specific clinical situation of patients with moderate AIS who rejected full-time bracing.

The goals of bracing treatment for AIS are manifold: avoiding surgical treatment, preventing future back pain, maintaining respiratory function, and reducing the psychological impact of the deformity. Physicians should understand these aspects and take a balanced view of patients who refuse full-time bracing. Because compliance with bracing treatment is affected by the patient’s state of mind, the imposition of bracing treatment by the physician can have a negative impact on the patient’s mental status. Important considerations for the future of bracing therapy for AIS are continued improvements in brace design and the innovation of nonrigid alternatives. These advances should help to maximize patient comfort and compliance and more precisely determine the efficacy and indications of bracing.⁶

Published: January 29, 2024. doi:10.1001/jamanetworkopen.2023.52733

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Nagata K. JAMA Network Open.

Corresponding Author: Kosei Nagata, MD, PhD, Department of Orthopaedic Surgery and Spine Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan 113-8655 ([email protected]).

Conflict of Interest Disclosures: None reported.