Tag: Scoliosis bracing

Scoliosis specific exercise prevents loss of correction after bracing

When we think about scoliosis treatment we tend to focus on there here and now – normally this means concentrating on getting the correct diagnosis and making sure the right treatment program is put in place. What’s often less discussed however, are plans for going forward after you have completed your treatment.  This is especially the case when bracing – we know that bracing can offer a significant reduction in cobb angle, but what happens when it’s time to stop wearing the brace?

 

Does the end of bracing mean the return of scoliosis?

At our clinic we often encounter clients who wonder whether the end of bracing means a reversal in the correction achieved – will scoliosis start to develop again after bracing?  It’s a fair question – but thankfully research shows that a scoliosis specific exercise program – exactly the same kind of program which is usually used to support bracing – can actually be highly effective in reducing loss of correction after bracing.[1] The results of the study suggest that simply continuing with a scoliosis specific exercise program can, in fact, prevent any loss of correction.

Scoliosis specific exercises are already recommended not only as a compliment to bracing, but also as a means to avoid some of the pitfalls associated with wearing a brace – the most common issues being muscular stiffness loss of strength.[2] In fact, it’s common to use scoliosis specific exercises for a period before beginning bracing – as some research suggests this may promote a quicker correction.[3]

It’s therefore not surprising that exercises may have a valuable role to play during the weaning phase of treatment too. Brace weaning itself is a critical phase of treatment which can vary in both its nature and duration according to the patient. In some instances, clinicians reduce the daily hours of brace in a somewhat rapid way, shifting from full-time wearing (18 or more hours per day) to the point that the patient is totally free from the brace within a period of six to 12 months. Others progressively and slowly reduce the hours of brace use, with a mean reduction of two to three hours every six months.[4]  Researchers currently believe that a failure to properly support and train the trunk muscles during this period may be responsible for the loss of correction which sometimes accompanies the end of treatment – however, scoliosis specific exercises can be used to address this specific problem.

 

What does the research say?

Scoliosis SEAS treatment

SEAS exercises can reduce loss of correction in scoliosis cases

The results of one of the few studies on this specific issue were certainly encouraging– in the 2008 study, sixty-eight patients were monitored throughout their process of brace weaning. The patients were divided into two groups according to whether or not exercises were performed during the weaning period. The exercise group included 39 patients and was further divided into two sub-groups: a SEAS group, who performed SEAS exercise programs, and an “other” group – who performed a variety of other forms of scoliosis specific exercise.  29 patients were placed in the non- exercise group.

The study followed the patients for 2.7 years – at the end of treatment, Cobb angle had increased  in the non-exercise group (by approximately 3.5 degrees) – however both the SEAS and other exercise groups saw their cobb angles remain stable – no change was detected.

 

So does the end of bracing mean the return of scoliosis?

In short, it certainly does not have to! From a patient’s perspective it’s important to find a clinic which also provides a solid aftercare plan however. At the UK Scoliosis clinic, we take great care to plan a course of treatment which includes appropriate brace weaning support, so that maximum correction can be maintained. As new research becomes available in this regard, we’ll apply it to our programs wherever appropriate.

 

 

 

[1] Fabio Zaina et al. Specific exercises performed in the period of brace weaning can avoid loss of correction in Adolescent Idiopathic Scoliosis (AIS) patients: Winner of SOSORT’s 2008 Award for Best Clinical Paper,  Scoliosis 2009, 4:8

[2] Negrini S, Aulisa L, Ferraro C, Fraschini P, Masiero S, Simonazzi P, Tedeschi C, Venturin A: Italian guidelines on rehabilitation treatment of adolescents with scoliosis or other spinal

deformities. Eura Medicophys 2005, 41(2):183-201

[3] Negrini S, Negrini A, Romano M, Verzini N, Parzini S: A controlled prospective study on the efficacy of SEAS.02 exercises in preparation to bracing for idiopathic scoliosis. Stud Health Technol Inform 2006, 123:519-522.

[4] Negrini S: The Evidence-Based ISICO Approach to Spinal Deformities. 1st edition. Milan, Boston: ISICO; 2007.

Scoliosis Treatment – Scoliosis exercise Vs. Bracing, which is best?

Today the two main methodologies involved in the non-surgical treatment of scoliosis are Bracing, and Specialist exercise methodologies. In most cases we use both approaches throughout the course of treatment with our patients since both approaches have their strengths. We are however, often asked which treatment methodology is best – so let’s consider the latest research on this question.

 

Bracing vs Exercise – New research

The first thing to realise when comparing scoliosis treatment is that while many patients often want to know “which is best”, this question is often less explored in the scientific literature. For the most part, scoliosis practitioners want to focus their time and attention towards improving their methodologies of choice, rather than on making comparisons with other approaches. Because of this, few studies have tried to directly compare bracing and exercise approaches – although a recent 2017 study has done just this[1].

In the study conducted in China, 53 patients (age of 10 – 17 years, Cobb angle ≥ 20 – 40 degrees,) were randomly assigned to either a bracing group or exercise group. Twenty-four patients (19 females) were placed in the bracing group and 29 patients (22 females) in the exercise group.

Patients in the bracing group were provided with a rigid thoracolumbosacralorthosis (a Scoliosis brace – TSLO) and asked to wear their brace 23 hours a day, while patients in the exercise group were treated with the Scientific Exercise Approach to Scoliosis (SEAS) protocol. Data regarding angle of trunk inclination, Cobb angle, shoulder balance, body image, quality of life (QoL)[2] were collected every 6 months.

At the first visit, patients assigned to the bracing group were prescribed with a rigid (TLSO) and received an initial pre-treatment evaluation to allow for brace fabrication. To achieve optimum correction, patients were invited to the scoliosis clinic to check the fit and modify (if necessary) the brace after the first month of intervention and then every three months as recommended by SOSORT[3].

The SEAS patients took part in a session of 1.5 hours at which they learned and practiced the core content of their program every two to three months, in which they learnt their personalised exercise protocol. The patients continued treatment at the clinic once a week (40 minutes) plus one daily exercise session at home (10-15 minutes)[4].

 

 

Study Results

At this stage, it’s important to mention that while this study represents an important beginning in this comparative project, the results available at this time reflect only a year of treatment. It is likely that the trends illustrated here will hold good over a longer period, and thankfully we will be able to verify this since the study is still ongoing.

 

Cobb angle 

A 54 Degree Cobb angle (X-ray)

The bracing group achieved a significantly larger reduction in Cobb angle – at 6 months, the mean reduction of cobb angle in the bracing group was 3.13 degrees, and at 12 months the mean reduction was 5.88 degrees.  In the exercise group, the 6 months mean reduction was just 0.66 degrees, and at 12 months was 2.24 degrees.[5]

 

Quality of Life

The SRS-22 form used for gauging quality of life factors consists of a number of subsets of data, each of which was individually evaluated during this study. These include a score for pain, function, mental health and self-image. Taken as a whole, the results showed that for the bracing group, the SRS functional score (a measure of the impact of scoliosis on everyday life) as well as the total score (a broader measure of quality of life factors) all showed significant improvement between the initial consultation and 12-month evaluation as well as between the 6-month and 12-month evaluations.  The one exception to this was pain level, which did not differ significantly across the three evaluations.

The researchers also noticed that self-image was significantly improved in the bracing group, especially at the 12 months follow up, this was interesting given the negative self-image association which is sometimes linked to bracing.  Participants did report an increase in their overall satisfaction levels (taking all factors into account), although this was most apparent after passing the 6-month mark.

For the exercise group, all the SRS-22 quality of life subsets showed a slightly larger improvement across the three visits than bracing – especially in terms of the functional score. The exception here again was pain, where no significant change was detected[6].

 

 

Overall comparison

In comparing the two treatment groups, the study investigators noted it was interesting to find that the overall improvement of quality of life was more significant in the exercise group. Although the quality of life scores improved in both groups, at all three visits, the average scores of most subsets in the SRS-22 were higher in the exercise group.  By contrast, the improvement in cobb angle was significantly greater in the bracing group, although the exercise group did also show an improvement at the 12-month mark.

 

 

So which is better?

At this stage, it seems fair to suggest that the results of the study reflect what many scoliosis clinicians are already aware of – Scoliosis Bracing is by far the most effective way to reduce a cobb angle – Indeed, the authors note how “There is no doubt that bracing has proven efficacy in halting the progressive nature of the deformity and reducing the need for surgery”.

At the same time, scoliosis specific exercise has a more positive impact on functional capacity – this comes as no surprise to scoliosis practitioners, since scoliosis specific exercise is intended to reduce muscular imperfections and promote better everyday posture. Exercise approaches also seem to correlate with a greater improvement in quality of life factors than bracing, although this is also to be expected since it is almost universally accepted that any form of exercise serves to boost quality of life in most individuals.

Taking these two points, its easy to see how a combination approach is often the best possible option – by pursuing both treatment methodologies it is possible to achieve functional improvement, cobb angle correction and an improvement in quality of life in a flexible way which works for the patient.

More results from this particular study, as well as further research can be expected in this area and we will report it to you as soon as it becomes available!

 

scolibrace results

An example of successfull bracing with ScoliBrace

 

 

[1] Yu Zheng, MD PhD et al. Whether orthotic management and exercise are equally effective to the patients with adolescent idiopathic scoliosis in Mainland China? – A randomized controlled trial study SPINE: An International Journal for the study of the spine [Publish Ahead of Print]

[2] The SOSORT SRS-22 Form was used for this data collection.

[3] Negrini S, Aulisa AG, Aulisa L, et al. 2011 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis 2012;7:3.

[4] Romano M, Negrini A, Parzini S, et al. SEAS (Scientific Exercises Approach to Scoliosis):a

modern and effective evidence based approach to physiotherapic specific scoliosis exercises. Scoliosis 2015;10:3.

[5] Yu Zheng, MD PhD et al. Whether orthotic management and exercise are equally effective to the patients with adolescent

idiopathic scoliosis in Mainland China? – A randomized controlled trial study SPINE: An International Journal for the study of the spine [Publish Ahead of Print]

[6] Yu Zheng, MD PhD et al. Whether orthotic management and exercise are equally effective to the patients with adolescent idiopathic scoliosis in Mainland China? – A randomized controlled trial study SPINE: An International Journal for the study of the spine [Publish Ahead of Print]

Scoliosis bracing is becoming more effective

For some time now, scoliosis clinicians have broadly accepted the view that scoliosis bracing is an effective way to halt the progression of scoliosis, and (with the use of the correct brace) is also an effective way to reduce the curve.

The outlook for bracing was not always a positive as it is today – historically, studies suggested that bracing was only as effective as observation. Over time however, research has tended to show bracing to be more effective than was once thought, so that today the rates of success with bracing are very high.

In 2005, the Scoliosis Research Society (SRS) attempted to standardize the inclusion criteria and outcome measurements for bracing studies, to enable comparison among studies. In the guidelines, it was suggested that a curve progression of less than 5 degrees should be regarded as success. At the time, SRS did not even consider that bracing might actually serve to improve a curve – although it was quickly realised that this was possible. For this reason, the criteria for “improvement” (being a reduction of curve of at least 6 degrees) was established in 2009.

Despite some scepticism in the mid 2000’s however, some bracing studies today have demonstrated rates of surgery prevention as high as 100%[1][2] and the field is one of the major areas of study and advancement – so what caused such an improvement in the prognosis?

 

Braces are getting better

scoliosis braces

Scoliosis braces have come a long way!

One of the major reasons for the improvement in bracing effectiveness has been the improvement in braces themselves.  A recent review study conducted in 2016, attempted to explore this issue by examining 53 studies published between 1990 and 2016[3]. It showed that when comparing the percentage of patients eventually requiring surgery and the improvement rate in the past 26 years, we find that there is a trend towards reduction in surgical rate and an increase in improvement rate. Yet, close inspection showed that the change is strongly related to the type of brace used.

Key factors in bracing outcome are the amount of in-brace correction and comfort for the wearer. In the study, it was shown that large in-brace correction in excess of 50% would be accompanied by improvement at skeletal maturity[4][5] and hours of brace wear are positively associated with the rate of treatment success[6]. Simply put, an active correction brace which is also comfortable to wear is a key factor in significantly reducing surgical requirement[7]. This is why so much effort has been expended in ensuring that our ScoliBrace is the most comfortable brace available!

The study also showed that the effectiveness of a brace depended on the quality of its construction, not just its design[8]. In 2007 Danielsson et al pointed out the importance of the skill and dedication of the orthotist in creating a brace as a critical factor in the eventual success of treatment and similar views have been forwarded by other authors[9]. Today, advancements in technology mean that a higher quality of brace design and manufacture than ever before is available to us. Indeed, at the UK scoliosis clinic we use the latest laser scan and computer aided manufacture processes to create a brace for each client, which fits their needs perfectly.

 

Combination treatment is most effective

Today we also appreciate that in most instances an individualised treatment plan based on a number of complementary methods provides the best chance for a significant reduction of the curve. In fact, today it is generally accepted that bracing should not be employed alone in the management of Adolescent Idiopathic Scoliosis in particular – instead individualised scoliosis specific exercises should also be incorporated. This is because Scoliosis specific exercises improve the muscle strength of the trunk and the postural awareness of the patients. More importantly perhaps, when combined with bracing, evidence suggests the results are an improvement in curve reduction[10]. Properly tailored exercise programs may also help to reduce the loss of correction which frequently accompanies the end of brace treatment if not properly managed.[11]

 

Scoliosis clinicians are working hard to improve bracing technology.

scolibrace

Modern scoliosis braces are highly effective

At the UK scoliosis clinic, we respect and value the work that surgeons can do in correcting very serious cases of scoliosis which are unsuitable for conservative treatment. However, the 2016 review study has suggested that a conflict of interest in bracing development might be a negative factor for patients[12].

One of the lest effective forms of brace is the Boston brace – yet these are often favoured by orthopaedic surgeons (especially in the US)[13]. The Boston brace is at least outdated, and in some situations may complicate scoliosis treatment unnecessarily. Boston braces also encourage thoracic flat back, which has been shown to be detrimental to the correction of curves[14].

Why are these braces sometimes favoured then?  –  This maybe because in the event that the brace fails to achieve the objective, the surgeon can go on to treat the patient using surgery, although this might not be the patient’s preference. Conversely, the kinds of modern braces we use at our clinic and which are widely implemented throughout Europe today are predominantly used by physicians who treat patients conservatively. In this instance, failure of the brace requires an external referral for surgical treatment[15] – hence it is in the interest of non-surgical clinics to constantly develop and improve their braces, which results in highly advanced modern braces, like ScoliBrace.

 

 

 

 

[1] De Giorgi S, Piazzolla A, Tafuri S, Borracci C, Martucci A, De Giorgi G. Chêneau brace for adolescent idiopathic scoliosis: long-term results. Can it prevent surgery? Eur Spine J.2013;22(6):S815–22.

[2] Aulisa AG, Guzzanti V, Perisano C, Marzetti E, Falciglia F, Aulisa L.Treatment of lumbar curves in scoliotic adolescent females with progressive action short brace: a case series based on the Scoliosis Research Society Committee Criteria. Spine (Phila Pa 1976). 2012;37(13):E786-E791.

[3] Wing-Yan CHAN, Shu-Yan NG, Tsz-Ki HO, Yin-Ling NG (2016) Bracing – Halting Progression or Improving Curves in Adolescent Idiopathic Scoliosis. J Rheumatol Arthritic Dis 1(1): 1-8.

[4] Landauer F, Wimmer C, Behensky H. Estimating the final outcome of brace treatment for idiopathic thoracic scoliosis at 6-month follow-up.

[5] Appelgren G, Willner S. End Vertebra Angle – A roentgenographic method to describe a scoliosis. A follow-up study of idiopathic scoliosis treated with the Boston brace. Spine (Phila Pa 1976) 1990;15(2):71- 74.

[6] A large number of studies are cited in Wing-Yan CHAN, Shu-Yan NG, Tsz-Ki HO, Yin-Ling NG (2016) Bracing – Halting Progression or Improving Curves in Adolescent Idiopathic Scoliosis. J Rheumatol Arthritic Dis 1(1): 1-8.

[7] Wiley JW, Thomson JD, Mitchell TM, Smith BG, Banta JV. Effectiveness of the Boston brace in treatment of large curves adolescent idiopathic scoliosis. Spine. 2000;25(18):2326–2332.

[8] Rigo MD, Villagrasa M, Gallo. A specific scoliosis classification correlating with brace treatment: description and reliability. Scoliosis. 2010;5(1):1. doi:10.1186/1748-7161-5-1.

[9] For example see Rowe DE, Bernstein SM, Riddick MF, Adler F, Emans JB, Gardner- Bonneau D. Ameta-analysis of the efficacy of non-operative treatments for idiopathic scoliosis. J Bone Joint Surg Am. 1997;79(5):664-674.

[10] Monticone M, Ambrosini E, Cazzaniga D, Rocca B, Ferrante S. Active self-correctionand task-oriented exercises reduce spinal deformity and improve quality of life insubjects with mild adolescent idiopathic scoliosis. Results of a randomized controlled trial. Eur Spine J. 2014;23(6):1204-14. doi:10.1007/s00586-014-3241-y.

[11] Goldberg CJ, Dowling FE, Hall JE, Emans JB. A statistical comparison between natural history of idiopathic scoliosis and brace treatment in skeletally immature adolescent girls. Spine. 1993;18(7):902-9088.

[12] Wing-Yan CHAN, Shu-Yan NG, Tsz-Ki HO, Yin-Ling NG (2016) Bracing – Halting Progression or Improving Curves in Adolescent Idiopathic Scoliosis. J Rheumatol Arthritic Dis 1(1): 1-8.

[13] Wynne JH. The Boston brace and TriaC system. Disabil Rehabil Assist Technol2008; 3(3):130-135. doi:10.1080/17483100801903988.

[14] Wing-Yan CHAN, Shu-Yan NG, Tsz-Ki HO, Yin-Ling NG (2016) Bracing – Halting Progression or Improving Curves in Adolescent Idiopathic Scoliosis. J Rheumatol Arthritic Dis 1(1): 1-8.

[15] Ibid.

Is bracing an effective treatment for Adolescent Idiopathic Scoliosis? BRAIST study says yes!

Adolescent idiopathic scoliosis is characterized by a lateral curvature of the spine, with a Cobb angle of more than 10 degrees and vertebral rotation. Scoliosis develops in approximately 3% of children younger than 16 years of age, although rates of Scoliosis are typically much higher amongst at-risk groups such as dancers and gymnasts.  Curves larger than 50 degrees are typically associated with a high risk of continued worsening throughout adulthood and thus are most likely to be recommended for a surgical procedure.[1]

Scolibrace

Our Scolibrace is comfortable, effective and low-profile

Treatment with rigid bracing (thoracolumbosacral orthosis or TLSO) is the most common non-surgical treatment for the prevention of curve progression. There are many different brace designs, but with all of them, the objective is to restore the normal contours and alignment of the spine while preventing scoliosis progression. The most effective designs (like our Scolibrace system) seek to deliver superior outcomes by providing active correction of the curve.

But is bracing effective?  – Today you’ll still find some practitioners who are unclear on the outcomes you can expect from bracing. This is because although historical studies of bracing in adolescent idiopathic scoliosis had suggested that bracing decreases the risk of curve progression.[2] in some of these earlier studies results were inconsistent, the studies were observational, and only one prospective study enrolled both patients who underwent bracing and those who did not.[3] Thus, for some time the effect of bracing on curve progression and rate of surgery was unclear. This all changed thanks to the Bracing in Adolescent Idiopathic Scoliosis Trial (BRAIST), which finally determined the effectiveness of bracing – as compared with observation – in preventing progression of the curve to 50 degrees or more.

The BRAIST study was a large-scale endeavour, conducted in 25 institutions across the United States and Canada. Enrolment began in March 2007.  The target population for this study was patients with high-risk adolescent idiopathic scoliosis who met current indications for brace treatment – specifically this meant an age of 10 to 15 years, skeletal immaturity and a Cobb angle for the largest curve of 20 to 40 degrees.[4] To be eligible, patients could not have received previous treatment for adolescent idiopathic scoliosis.

 

Methods

During the BRAIST study, patients in the observation group received no specific treatment, whereas patients in the bracing group received a rigid brace, prescribed to be worn for a minimum of 18 hours per day. Participating centres prescribed the type of brace used in their normal clinical practice. Wear time was determined by means of a temperature logger embedded in the brace and programmed to log the date, time, and temperature every 15 minutes. A temperature of 28.0°C (82.4°F) or higher[5] indicated that the brace was being worn.

Both patients and clinicians were aware of the assigned treatment. However, all radiographic (x-ray) evaluations and outcome determinations which were made at the conclusion of the study were performed by experts without knowledge of the treatment protocol, to avoid bias.

 

Results

During the study, a total of 146 patients (60%) received a brace, and 96 (40%) underwent observation only. The two study groups were generally similar with respect to baseline characteristics, except that the patients in the bracing group were slightly taller on average than those in the observation group (156.5 cm vs. 153.6 cm).

The results shown at the end of the study were conclusive – the rate of treatment success was 72% in the bracing group and 48% in the observation group. By contrast, the rate of treatment failure was only 25% with bracing, but 58% with observation alone.[6]

Therefore, given a large sample set and a study carried out across reputable institutions, it was determined that adolescents with idiopathic scoliosis who were considered to be at high risk for curve progression that would eventually warrant surgery, bracing was associated with a significantly greater likelihood of reaching skeletal maturity with a curve of less than 50 degrees, as compared with observation alone.

The study also showed a significant association between the average hours of daily brace wear and the likelihood of a successful outcome. These findings corroborate those of previous prospective observational studies, which have shown a significantly lower rate of surgery among patients who wore a brace than among those who were untreated[7]and a strong relationship between wear time and outcome.[8]

 

Our analysis

The BRAIST study is without a doubt one of the most important pieces of research which informs our work here at the clinic. Since we’re strongly committed to providing the latest, most up to date treatment methodologies available we welcome any and all research which can assist us in fine turning our approach to non-surgical scoliosis treatment.

BRAIST has shown conclusively that bracing is an effective way to treat scoliosis non-surgically, and also confirms a link between correctly prescribed wear time and positive outcomes. At the UK scoliosis clinic, we’re also committed to helping to find ways to treat the 25% of individuals who didn’t get the result they would have liked from the BRAIST study. One of the ways we do this is by offering what we believe is the best scoliosis bracing system available, the Scolibrace system – which is an active correction, individually customised brace designed for maximum correction. Since a variety of braces were used during this study, we hypothesise that the successful treatment figures could have been even higher if more modern concepts in brace design had been adopted for the study. You can learn more about scolibrace here.

 

[1] Weinstein SL, Ponseti IV. Curve progression in idiopathic scoliosis. J Bone Joint Surg Am 1983;65:447-455

[2] Dolan LA, Weinstein SL. Surgical rates after observation and bracing for adolescent idiopathic scoliosis: an evidence-based review. Spine (Phila Pa 1976;32:Suppl:S91-S100

Dolan LA, Weinstein SL. Best treatment for adolescent idiopathic scoliosis: what do current reviews tell us? In: Wright JG, ed. Evidence-based orthopaedics: the best answers to clinical questions. Philadelphia: Saunders, 2009.

Focarile FA, Bonaldi A, Giarolo MA, Ferrari U, Zilioli E, Ottaviani C. Effectiveness of nonsurgical treatment for idiopathic scoliosis: overview of available evidence. Spine (Phila Pa 1976;16:395-401

Lenssinck ML, Frijlink AC, Berger MY, Bierman-Zeinstra SM, Verkerk K, Verhagen AP. Effect of bracing and other conservative interventions in the treatment of idiopathic scoliosis in adolescents: a systematic review of clinical trials. Phys Ther 2005;85:1329-1339

Negrini S, Minozzi S, Bettany-Saltikov J, et al. Braces for idiopathic scoliosis in adolescents. Cochrane Database Syst Rev 2010;1:CD006850-CD006850

Rowe DE, Bernstein SM, Riddick MF, Adler F, Emans JB, Gardner-Bonneau D. A meta-analysis of the efficacy of non-operative treatments for idiopathic scoliosis. J Bone Joint Surg Am 1997;79:664-674

Screening for idiopathic scoliosis in adolescents. Rockville, MD: Preventive Services Task Force, June 2004 (http://www.uspreventiveservicestaskforce.org/uspstf/uspsaisc.htm).

[3] Nachemson AL, Peterson LE. Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis: a prospective, controlled study based on data from the Brace Study of the Scoliosis Research Society. J Bone Joint Surg Am 1995;77:815-822

Danielsson AJ, Hasserius R, Ohlin A, Nachemson AL. A prospective study of brace treatment versus observation alone in adolescent idiopathic scoliosis: a follow-up mean of 16 years after maturity. Spine (Phila Pa 1976;32:2198-2207)

[4] Richards BS, Bernstein RM, D’Amato CR, Thompson GH. Standardization of criteria for adolescent idiopathic scoliosis brace studies: SRS Committee on Bracing and Nonoperative Management. Spine (Phila Pa 1976;30:2068-2075)

[5] Dolan LA, Weinstein SL, Adams BS. Temperature as a diagnostic test for compliance with a thoracolumbosacral orthosis. Presented at the Annual Meeting of the Pediatric Orthopaedic Society of North America, Waikaloa, HI, May 3–7, 2010 (poster).

Helfenstein A, Lankes M, Ohlert K, et al. The objective determination of compliance in treatment of adolescent idiopathic scoliosis with spinal orthoses. Spine (Phila Pa 1976;31:339-344

[6] Stuart L. Weinstein, M.D., Lori A. Dolan, Ph.D., James G. Wright, M.D., M.P.H., and Matthew B. Dobbs, M.D. Effects of Bracing in Adolescents with Idiopathic Scoliosis N Engl J Med 2013; 369:1512-1521

DOI: 10.1056/NEJMoa1307337

[7] Danielsson AJ, Hasserius R, Ohlin A, Nachemson AL. A prospective study of brace treatment versus observation alone in adolescent idiopathic scoliosis: a follow-up mean of 16 years after maturity. Spine (Phila Pa 1976;32:2198-2207

[8] Katz DE, Herring JA, Browne RH, Kelly DM, Birch JG. Brace wear control of curve progression in adolescent idiopathic scoliosis. J Bone Joint Surg Am 2010;92:1343-1352