**Abstract**

The aim of brace treatment in patients with scoliosis during growth is (1) to stop curve progression and (2) to improve appearance/cosmesis. There is high quality evidence available supporting brace treatment. According to recent publications, the outcomes of different braces vary to a high extent. Although most of the scoliosis cases will not affect the patient's health, the impact of braces on the cosmetic outcome to date is not well determined. Standardised asymmetric braces (mainly Chêneau derivatives) have better outcomes than symmetric compression braces and may also lead to significant improvements of the deformity. For symmetric braces, no evidence exists that these could significantly change the deformity. Soft braces have no indication and the use of night-time braces should be largely restricted due to poor outcomes when compared to current standards of full-time bracing.

**Keywords:** scoliosis, deformity, progression, brace treatment

## **1. Introduction**

Scoliosis is a three-dimensional deformity of the trunk and spine which may deteriorate quickly during phases of rapid growth [1–3]. Scoliosis may be caused by neuromuscular disorders and mesenchymal disorders, and it may be congenital and caused by other rare conditions, but for most cases (80–90%), it is referred to as idiopathic because no underlying cause has been identified [1–4]. Idiopathic scoliosis is further distinguished by the age at the onset of the condition. Infantile idiopathic scoliosis (IIS) is defined as starting at the age of 1.6–3 years, juvenile idiopathic scoliosis (JIS) at the age of 4–6 years and adolescent idiopathic scoliosis (AIS) at the age of 10–14 years old [1, 4]. The treatment of scoliosis consists of observation, exercises, brace treatment and spinal fusion surgery [1–3]. When considering surgery versus conservative treatment, high-quality evidence exists for the application of pattern specific exercises (PSE for example, Schroth) [5, 6] and spinal bracing [7–9]. No long-term evidence exists to support spinal fusion surgery [10–14]. Further comparisons are not possible when there is a lack of publicised surgical outcomes. High rates of complication have been reported in the mid and long terms [15–18], whilst no long-term complications have been publicised regarding PSE and brace treatment. AIS is a relatively benign disorder in most cases [19, 20] and therefore the long-term complications of spinal fusion surgery may outweigh the long-term consequences of the deformity [15–18, 21].

**Figure 1.** *Many different braces as still applied today for the treatment of scoliosis.*

Consequently, the indication for spinal fusion surgery in patients with AIS is controversial [22] as is for most of the other scoliosis conditions [12, 23, 24]. When comparing surgery versus bracing and PSE, there is evidence for conservative treatment, but no published evidence for spinal fusion surgery for AIS.

It is well established in literature that pattern-based or pattern-specific exercises do have a positive impact on the course of the disease [5, 6, 25–27]. Obviously, general exercises or sport activities also reduce the incidence of progression in small curvatures [28] or in patients with a low risk for progression [29]. However, there is only one relevant randomised controlled trial (RCT) with an untreated control group [5], whilst other RCTs involving PSE have major flaws (amongst other things not providing an uncontrolled control group) and therefore would not contribute to high quality evidence [30, 31].

Brace treatment is supported by high-quality evidence as well [7–9]; however, the approach to bracing differs significantly in design (**Figure 1**). There are many types such as symmetrical braces [7, 9, 32–35], asymmetrical braces [8, 36–49], night-time braces [50–55] and soft braces [56, 57]. It has been shown that soft braces have no advantage over hard braces [8, 58–60]. The authors and company owners have published a body of literature [61], but independent high-quality papers have concluded that soft braces in patients at risk of progression, will not benefit from such treatment [8, 58–60]. Therefore, only hard braces should be used in patients at risk for progression.

Purpose of this review is to discuss the best possible approach for bracing scoliosis patients with respect to (1) rate of success and (2) impact on the deformity.
