**4.1 Clinical outcomes**

In patients with AIS (80–90% of all scoliosis patients) rarely suffer severe health problems [3, 19, 20]. The cosmetic outcome of brace treatment might be important rather than the Cobb angle which is visible on the X-ray only. However, there is only a small body of literature on brace treatment with a focus on cosmetic outcomes [75]. For more symmetrical braces mainly correcting the curve via trunk compression (**Figure 2**) no clinical evidence exists, that these would significantly influence

the trunk deformity. In one paper on a modified Boston brace changes of lumbar ATR were detected, but in the thoracic region obviously no improvements were obtained [72]. For asymmetrical high-quality full-time braces, there is evidence that cosmetic improvements can be gained [46, 47, 73–75, 79–82].

Trunk deformity can be improved when using asymmetrical CAD libraries [46, 47, 73–75]. This has recently been confirmed in another end-result study [79]. It has also been shown that improvements of the trunk deformity may stay stable years after brace weaning [46, 82] (**Figure 7**).

In a study with more mature patients, cosmetic improvements have been reported [71]. The treatment indication for these patients was to improve aesthetic/ cosmetic reasons and/or for curve reduction. Their Risser sign was 4–5 initially and by the end of treatment 34 females and 2 males, age 16.2 ± 1.6 years had a Cobb angle of 27.6° ± 8.9°. The Lyon or SPoRT (so called Symmetric, Patient oriented, Rigid, Three-dimensional, active) braces were used as treatment. A brace wearing prescription is of 18–24 hours daily, SEAS (Scientific Exercises Approach to Scoliosis) exercises, rapid weaning (2–3 hours every 6 months). 39% of this cohort improved and 46% of the group initially presented with curves over 30° cobb angle. Only one patient progressed 6°. Results were successful; statistically significant reductions of Cobb angle maximal (−4.4°), thoracic cobb angles (−6.0°), thoracolumbar cobb angles (−6.6°), and further statistically significant improvements for the Aesthetic Index outcome. The authors concluded that before 20 years of age, even in skeletally mature patients, it is possible to reach radiographic and aesthetic improvements, although it was not as significant as when during growth spurts. In a recent review, a case series is documented with obvious clinical corrections in patients treated with the Gensingen brace [75]. All patients from this case series had curvatures of 45° and over at the start of the treatment, whilst the patients were immature and were clearly recompensated after brace weaning (**Figures 8** and **9**).

### **Figure 7.**

*Clinical and radiological improvement 5 years after weaning off a Chêneau light brace. Initially the patient had 38° and a significant decompensation of the trunk. Five years without the brace the patients' trunk seems recompensated and the residual curve is 19° [80].*

*Brace Treatment for Children and Adolescents with Scoliosis DOI: http://dx.doi.org/10.5772/intechopen.91234*

### **Figure 8.**

*Male patients with a decompensated thoracic curve of 56° to the right. Slightly recompensated 2010 as the intermediate result during the treatment with a GBW. Six months after brace weaning (2012), the posture and X-ray are clearly compensated. The patients' residual deformity is hardly visible although the Cobb angle is still 43° as shown on the right. This case shows that significant cosmetic improvements can be achieved with modern asymmetric high-quality braces [75].*

### **Figure 9.**

*Clinical changes from the start of treatment with a GBW (left) to 3 months after brace weaning (right). Initially, the patient is decompensated to the right and at the end a mature woman is visible with a wellcompensated trunk [75].*

In rare cases, it is possible that these braces can improve the trunk deformity significantly, whilst the Cobb angle stays unchanged [75] or even shows a progression [83]. Therefore, for patients with AIS, using CAD libraries and specialists should be preferred [46, 47, 73–75, 79–82].

### **4.2 Outcomes of part-time bracing**

As early as in 1997 in a meta-analysis, it has been shown that part-time bracing is clearly inferior to full-time bracing [84]. Later, these findings have been confirmed [37, 85]. But night-time braces are still widely marketed [54, 55] despite of the fact that brace wearing time, along with in-brace correction determines the outcome of

brace treatment [37, 84]. The low success rate of night-time bracing would not make this a beneficial option. In the contrary, when the curve gets worse with night-time bracing, the patient will lose trust in bracing and the compliance with full-time bracing will probably be reduced. Furthermore, the bigger the curve and the more mature the patient, the longer the treatment might last with less possibility of a cosmetic improvement.

On the other hand, when brace treatment in the immature adolescent with a moderate degree of curvature starts with a high-quality brace full-time in the most important phase of growth drastic improvements can be achieved (see **Figure 7**) and part-time brace wearing can be offered to the patients when the intermediate curve is below 20°. It is logical to start with full-time treatment with an asymmetrical high-quality brace in the immature patient at risk for curve progression as this will usually lead to a final improvement of cosmetics and to the shortest possible treatment duration.

With respect to patient compliance, the bracing service besides reliable in-brace corrections should also offer braces with the best possible comfort. This means the brace should be made as small as possible without compromising its corrective effect. Compression effects in the brace should be minimised, whilst the corrective movement (shift) should be maximised (**Figures 3**–**5**).

In patients at risk of progression and curvatures between 15 and 25°, however, night-time bracing may be of benefit. In a paper by Seifert and Selle [69], 22 children ranging from 5 to 12 years old were provided with a Chêneau derivate brace. Patients with a Cobb angle of 20–25° and 15–19° in cases of progression, bracing was indicated and provided in this study. Follow-up was 25 months and in the main curves, a successful correction of 82.2% was attained. The mean Cobb angle prior to brace treatment was 20.2°. At the end of brace treatment, it was 15.8° Cobb angle. Three cases experienced Cobb angle progression measuring over the 25° limit and then part-time bracing had to be re-adjusted to full-time bracing. In 86.4% patients, either improved Cobb angle measurements or their halted progression and spinal fusion operations were avoided.

## **4.3 The sagittal profile**

AIS is a 3D deformity usually also compromising the sagittal profile of the spine and trunk. Structural thoracic curves lead to a flatback or even a hollow back in the thoracic region, whilst structural lumbar curves usually lead to loss of lumbar lordosis or to a lumbar kyphosis [1–3]. Whilst the long-term consequences of a thoracic flatback are yet to be determined, loss of lumbar lordosis is clearly correlated to non-specific chronic low back pain [86, 87]. Improvement of lumbar lordosis can also improve the frontal plane deformity (Cobb angle) [88–90]. A feature of a brace should also address the sagittal profile of the deformity [45, 47, 79, 91, 92]. It is concerning that braces are provided which reduce lumbar lordosis and increase thoracic flatback [32–35] (**Figure 10**).

### **4.4 Bracing in curves of 40° and over**

There is some evidence that asymmetrical high-quality braces may stop curve progression in patients with Cobb angles exceeding 40° [47, 74]. In addition, significant clinical and radiological improvements have been documented [47, 75, 79, 82]. Considering that in patients with AIS, there is no long-term evidence supporting spinal fusion surgery [10–14], and in view of its significant long-term complications [15–18], brace treatment for curves exceeding 40° should be of importance. According to literature, asymmetrical high-quality braces offer success rates of about

### **Figure 10.**

*Patient with a thoracolumbar curve pattern treated with a Boston brace (upper line of pictures) and later with a Gensingen brace (GBW, see lower line of pictures). For this curve pattern, the GBW is smaller compared to the Boston brace. It is also observed that the Boston brace reduces lumbar lordosis, whilst the GBW preserves lumbar lordosis (courtesy of Dr Marc Moramarco, Scoliosis 3DC, Woburn, MA, US).*

90% in this group of patients and can be regarded as the safest bracing approach for curves exceeding 40° when worn full-time at the start of treatment (**Figure 11**).

### **4.5 Comparing outcomes symmetrical versus asymmetrical braces**

There is a small body of literature comparing asymmetrical high-quality Chêneau style braces to symmetric Boston style braces [45, 47, 76, 79]. It has been shown that the outcome of Chêneau derivatives is significantly better with respect to the success rate [45, 47, 79]. Whilst in-brace corrections in the Rigo brace (RCO) were comparable to the in-brace corrections of the Boston brace [45], in-brace corrections in the Gensingen brace (GBW) at average have been significantly higher [47, 76, 79].

In research that implements the Rigo brace (RCO) and compares the outcome with a basic Boston-style TLSO brace (Thoraco-lumbar-orthosis) [45], a retrospective study was published over 15 years, up until 2014. The initial major curves included only those between 25 and 40° and included 108 patients (93 girls) with a mean (±standard deviation) age at brace initiation of 12.5 ± 1.3 years. Thirteen participants wore an RCO, and 95 participants wore a TLSO brace. Mean pre-bracing major curves were 32.7 ± 4.8° in the RCO group and 31.4 ± 4.4°, slightly lower in the TLSO patient group (p = 0.387). No RCO patient and 34% of TLSO patients progressed to spinal

### **Figure 11.**

*Immature patient with a thoracic curve exceeding 70° treated with a GBW with an additional shoulder retraction strap. Clinically mirroring of the deformity is clearly visible whilst the patient is decompensated to the right without the brace on and an overcompensation to the left in the brace. After 9 months of full-time treatment, a clear improvement (re-compensation) has been achieved [47].*

surgery (p = 0.019). After treatment ended, the main curves of patients improved by 6° or more in 31% of the RCO group and only 13% of the TLSO group (p = 0.100). Patients were comparatively similar at baseline and had similar compliance of in-brace time, but there was a significantly lower rate of spinal surgery in the RCO group [45].

### **5. Conclusions**

Asymmetric high-quality braces provide the highest rate of success and the best documented cosmetic outcomes. Symmetric braces correcting via compression should be abandoned and their worldwide provision reconsidered.

There is no indication for soft braces.

There is no indication for night-time braces in the normal range of brace indications (curves of 25° and over).

### **Acknowledgements**

Written informed consent for publication of the patient's information (X-rays, photos, records, etc.) has been obtained from both the patients and their parents. HRW provided the first draft and made the literature review. DT and JBS contributed to the improvement of the first draft and copyedited the final version.

### **Conflict of interest**

HRW is receiving financial support for attending symposia and has received royalties from Koob GmbH & Co KG. The company is held by the spouse of HR Weiss. DT is employed by an orthotic company that supplies a wide range of orthotics, including spinal braces.

*Brace Treatment for Children and Adolescents with Scoliosis DOI: http://dx.doi.org/10.5772/intechopen.91234*
