Scoliosis affects 1% to 3% of adolescents in the United States - a significant number of young people with a deformity that impairs their physical appearance and brings a potential risk for complications. Precisely those, who are at risk from complications, usually need bracing, which may be equally aesthetically unacceptable for an adolescent as the deformity itself.
So is the back support for scoliosis worth it? Is it possible to make an improvement? What are the current scientific views on the topic? Continue reading to learn this and more.
A scoliosis is a group of medical conditions characterized by abnormal position and shape of the spine and trunk. It is typically defined as a lateral curvature of the spine, which means that the spine is twisted and distorted to aside. A doctor can easily see this curving when the patient bends over, and the degree of deformity is assessed by measuring the so-called Cobb’s angle on X-ray images. When this angle is above 10 degrees, a diagnosis of scoliosis is made.
In 20% of the cases, an underlying condition causing scoliosis can be identified. The remaining 80% of the cases have no apparent cause, and this is therefore known as idiopathic scoliosis. Genetics, hormonal status, asymmetric growth, and muscle imbalance may be involved in developing this most common scoliosis type.
The condition develops during growth spurts: between 6 and 24 months, between 5th and 8th year, and during puberty. This last growth spurt is when the curvature of the spine changes the most, especially in girls – although both sexes are equally prone to developing the deformity, it is more likely to progress in girls. A progression exists if Cobb’s angle increases for at least 5-10 degrees.
Due to the spine curving, the upper body becomes asymmetric. The teenager or their parents can notice that one shoulder is higher than the other or that one hip is higher than the other, that ribs are more prominent on one side, that the upper body is leaned to a side, and/or that the clothes fit unevenly. For a person at the most sensitive age, this abnormal posture and asymmetry represent a huge problem themselves, but severe and progressive scoliosis may also cause pain and affect lung functioning. Therefore, proper and forehand management of the condition is of crucial importance.
According to the International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT), the severity of scoliosis is determined concerning Cobb's angle as follows:
| Cobb’s angle | Scoliosis severity |
| 10-20 degrees | Low |
| 21-35 degrees | Moderate |
| 36-40 degrees | Moderate to severe |
| 41-50 degrees | Severe |
| 51-55 degrees | Severe to very severe |
| over 56 degrees | Very severe |
Though scoliosis can be classified in several other ways (for example, based on the localization of the deformity), the angular classification shown above is the most important for determining whether or not the treatment is needed.
In general, curves below 25 degrees don’t require any particular treatment. Instead, the patients are being monitored via X-ray scanning on regular check-ups in 3, 6, or 12-month intervals - the so-called ‘’wait and see’’ strategy – and treatment options are proposed only if the curve shows progression. Curves over 25 degrees require instant treatment, and this means bracing in the vast majority of patients. Only rare cases of curves over 40-45 degrees require surgical treatment.
Several approaches in the surgical management of scoliosis are implantation of growing rods, growth guidance systems, or convexity compression devices. As mentioned, these are reserved only for the most severe cases of scoliosis, which are few.
Bracing implies wearing a rigid orthotic device (i.e., a brace) for a certain number of hours each day until maturity. The goal is to prevent the curve from progressing, and it is the therapy of choice for most patients with moderate or severe scoliosis.
PSSE is an exercise program specially developed to reduce the curve, prevent its progression, and reduce the need for bracing and/or surgery. To achieve these goals, the program must be individually adapted to each patient and their deformity and done under the supervision of trained medical professionals. Classical physiotherapeutic exercises are ineffective, and studies have shown that once widely recommended sports activities, such as swimming, are even counterproductive! Due to the complexity, PSSE is rarely used in Western countries, although SOSORT recommends it – especially as an add-on to bracing and during postoperative recovery. A 2017 study by Cheung and associates showed that bracing with PSSE was superior to the effects of bracing alone.
A brace is an orthotic device worn around the torso, either from the upper back to the hips or from the neck to the hips. It is designed to apply more pressure to the body in some points than in others. The idea is that the bone tissue will grow slower if more pressure is applied to it, and the other way around – it will grow faster if no pressure is applied. Theoretically, this could help straighten the curve by making the spine grow faster in its concave and faster in its convex part. In practice, braces are mainly used for stabilizing the curve and preventing it from progressing, improving the posture and appearance, and reducing the need for surgery.
Because the mechanism of bracing is based on stimulation and inhibition of bone tissue growth, bracing only makes sense in skeletally immature patients, i.e., in those whose bones haven’t finished growing yet. The optimal time is just before the pubertal growth spurt, both because that’s when correction of the deformity is the most likely (due to intensive growth) and because that’s when the curve is most likely to progress rapidly. Bracing in adults is ineffective, although some studies reported that back support could be helpful in terms of relieving back pain in adults with scoliosis.
There are many different types of scoliosis braces, each having its virtues and flaws. Most of the braces are intended to be worn during the day, but there are also braces that are worn during sleep only. Boston brace is by far the most prescribed nowadays, and several other types such as Milwaukee, Wilmington, Rigo-Cheneau, or Charleston (nighttime) are also a frequent choice. Some of the braces are rigid, like a suit of armor. Others are soft, flexible, comfortable, and, unfortunately, less effective. More advanced braces, such as ScoliBrace, combine comfort and effectiveness but at a higher price. The type of the brace that will be prescribed in a particular case depends on various factors, such as the type of the curve, Cobb’s angle, location of deformity, as well as the doctor’s experience with different types of braces.
Generally speaking, the longer the brace is worn during the day, the better the effects. Therefore, rigid braces are typically prescribed to be worn for 12 to 23 hours a day, depending on the growth stage and the deformity. However, wearing a brace is impractical and unpleasant for many adolescent patients, which leads to non-compliance with doctor's instructions. In such cases, if the deformity is moderate, a concession can be made, and the patient can be prescribed a nighttime brace which is only worn for 8-10 hours in bed.
In order to be effective, scoliosis braces must be customized and fitted for each patient and their deformity individually. This is done by a doctor, who will conduct detailed physical and X-ray examinations to take all the relevant factors into account. The doctor will also determine the number of hours the brace has to be worn, the frequency of checkups for further monitoring and adjustments, etc. The patient must know that the key to successful treatment lies in adherence to the doctor’s instructions.
Related Article: A posture corrector, as an early intervention can also help to avoid further complications to one's spine.
The latest SOSORT guidelines pointed out four major goals of non-surgical treatment of scoliosis:
If only some of these goals are met, the quality of life improves drastically. But the candidates for scoliosis treatment are teenagers, and although the treatment options are existent and pretty effective, in reality, treatment often fails. A 2019 study by Betz and associates reported that the main factors for a below-expectations treatment outcome were a lack of skeletal maturity, a great Cobb’s angle at the beginning of treatment, and by far the most important, poor brace compliance.
On the other hand, more and more studies demonstrate the superiority of bracing compared to the ‘wait and see' approach, physiotherapy, and other less-used treatment options. In fact, a study by Dobbs and associates was published in The New England Journal of Medicine in 2017, in which the trial had to be stopped due to the obvious advantage of bracing. The efficacy of treatment in this study was 75% among patients assigned for bracing and only 42% among those who were only observed. As previously mentioned, the outcome of bracing treatment can be further improved if Schrot’s exercises are being conducted simultaneously.
To sum up, there is great potential for improvement. Although the brace may be uncomfortable, the baggy clothes may not be the latest style, or the peers may find it funny; this should be the motivation for the teenager to persist in adhering to the therapeutic plan. The parents and other family members must show compassion, understanding, and be a great support during this sensitive period. If the doctor, the patient, and their family each play their role properly, the treatment will result in a great outcome.
