Do the effects of bracing last?

Do the effects of bracing last?

Written and reviewed for scientific and factual accuracy by Dr. Jelcick, PhD and Dr. Janzen, DC

For someone who has been diagnosed with scoliosis, or for parents who just learned their child has scoliosis, the topic of bracing can be an emotional one. Considering the amount of time and money that goes into making and wearing a brace for several years, the most important question that patients and parents ask is whether or not braces are effective at treating scoliosis without surgery. Do scoliosis braces work or are they only delaying the inevitable, with surgery being the only option?

CLAIM: The benefits of scoliosis bracing are lost once the brace is removed.

EXAMPLE: “Whether spinal bracing helps stop progression or not, the benefits are lost once the brace is removed.”

ORIGIN: Seen on various scoliosis info pages including Dr. Axe, ScoliSmart, and various non-surgical clinics as of October 2019.

CONCLUSION: FALSE: The effects of bracing have been shown by numerous scientific studies to last after the brace is removed, even 15-20+ years later.

BRACING IS PROVEN TO WORK, SO WHY DO SOME DOCTORS DISAGREE?

We have discussed this topic in detail throughout our page dedicated to non-surgical treatment, citing numerous scientific and medical research studies that all came to the same conclusion: bracing is not only effective at treating scoliosis, but it is the ONLY proven method of successfully treating scoliosis non-surgically with lasting results. Many studies refer to “altering the natural history” of scoliosis, simply meaning that the “natural history” (what would happen if the curve was left untreated) has been significantly changed due to treatment (successful treatment result preventing surgery and/or reducing the curve). So why is the idea that “bracing doesn’t work” still persist despite so much research that shows that it works and is an effective treatment?

Bracing is the only proven non-surgical treatment for curves 25º and above

The answer is complicated; however misinformation is a major contributor. One commonly stated “fact” that is nothing more than misinformation is that any curve reduction or result achieved with a brace is lost as soon as the brace is removed. This blatantly false claim is frequently used by doctors, chiropractors, and other clinicians that claim bracing doesn’t work and instead try to sell treatment plans that do not use bracing. To be fair, there is research 18 that supports treating scoliosis without a brace for small curves, but that is the key factor: non-surgical treatment without a brace helped small curves, not big ones. But for curves 25º and above, and ESPECIALLY for children and teens who are actively growing, treating scoliosis without a brace is dangerous and risky and is precisely why the well known BRAIST study 21 was ended prematurely: randomly assigning a child with scoliosis to a non-braced treatment group for research purposes isn’t ethical when the data shows that they have a significant risk of getting worse.

MISINFORMATION AND MISLEADING CLAIMS

If we look at the phrases and statements that are claiming the effects of bracing go away once bracing stops, we seem to strangely find that no matter the source, the claim seems to be the same. For example, if we look at the Health section of the website for Dr. Axe, we find an article about scoliosis exercises and natural treatment. Dr. Axe’s website claims that “all corrective benefits are lost very quickly once the patient stops wearing the brace.” The article even goes on to say that “Some studies have even found that some children need surgery even more often after having spinal bracing.” Dr Axe talks again about scoliosis bracing on another page/blog post where he again claims that “Whether spinal bracing helps stop progression or not, the benefits are lost once the brace is removed, and surgery is still commonly needed.”

The idea that all results/progress is lost once the brace is removed is FALSE

Another group called ScoliSmart that regularly publishes articles about scoliosis and non-surgical treatments claims that “the curve rapidly worsens once the brace is removed” and continues on to later in the article state that “using braces by themselves to guide bone growth doesn’t make sense.” While the second part doesn’t sound like it much to do with a curve worsening, it’s important to point out that a 2005 study entitled “Growth as a corrective force in the early treatment of progressive infantile scoliosis” actually looked at this topic and found that you can use growth to your advantage and utilize it as a force to straighten the spine in a growing child. In addition to these misleading claims, this same website again states that “any positive effects will often reverse themselves once the bracing stops – even if the spine has reached skeletal maturity.”

This same claim that a curve will worsen after bracing is again repeated on another website, this time a scoliosis treatment center which claims that “as soon as the brace is removed, the scoliosis quickly and rapidly progresses beyond where it was before the brace was used.” Despite the fact that multiple websites seem to say the same thing, it is virtually impossible to find supporting evidence in the form of current scientific and medical research, while these websites will show older studies which agree with their claims.

So why on earth would doctors say that results are lost once the brace comes off? Why would they claim that scoliosis rapidly worsens and positive effects reverse themselves once bracing stops, even when the spine is skeletally mature? The cynical answer is that they may be trying to convince people that braces don’t work so that they instead choose their no-brace, non-surgical treatment program. After all, what better explanation as to why a doctor would ignore scientific and medical research other than they are trying to make money off people who don’t understand the research? The less cynical answer would be that they are simply cherry picking data, and ignoring the large quantity of data and studies that support bracing, while emphasizing the studies that show bracing has questionable benefit.

FACT CHECKING LASTING RESULTS FROM BRACING

We’ve discussed how many doctors, chiropractors, and clinicians all seem to be saying the same thing, but let’s get to the fact check. What evidence shows that the effects of bracing last? Are their studies that contradict this? Most importantly, what is the general consensus on the topic based on all the current and available research?

You may have heard of a “meta analysis” or “meta study” where researchers dig through current literature and come up with a conclusion based on all of that research combined. You can think of a meta analysis like a large book report: each book (study) is summarized and an analysis is performed to see what conclusions can be made based on all of the information from all of the books. Essentially the “take home message” that can be made based on all of the information, research and studies that were analyzed.

The effectiveness of bracing was still under debate in 2007

Back in 2007, a meta analysis was done 6 looking at bracing, and concluded that there wasn’t really an advantage to bracing, and that when bracing and doing nothing (observation) were compared, those who did bracing had a 1% greater incidence of going to surgery. This meta analysis of the literature was probably the source Dr. Axe was referencing when he claimed that some kids need surgery more after bracing, and that surgery is still commonly needed. However, in 2007 a scientifically thorough study with proper control groups, blinding (not knowing which group is treated or not until AFTER the analysis is done) and other rigors of good reproducible scientific research was not available… YET.

It was the groundbreaking 2013 study by Dr. Weinstein that found that bracing was in fact highly effective at treating idiopathic scoliosis. This is the same study 21 which was terminated early due to the effectiveness of bracing versus the ineffectiveness of observation deeming random placement (due to the study being properly “blinded”) into the observation group as unethical. In fact, the 2013 BRAIST study by Dr. Weinstein has been cited by more than 110 science and medical research papers since it was first published and is now used by SOSORT (Society On Scoliosis Orthopaedic and Rehabilitation Treatment) as evidence for the most recent (2016) treatment guidelines 16 which state bracing is important and recommended to treat adolescent idiopathic scoliosis.

Bracing was proven to work through a thorough, multi-center, randomized, blinded, controlled scientific study

One important thing to note is that one of the two authors of that 2007 meta analysis was the same Dr. Weinstein that conducted the 2013 BRAIST study. Why is this important? As any good scientist or researcher will tell you, your opinions and conclusions should change based on the data which is exactly what they did. Dr. Weinstein and his colleagues updated their conclusions and findings as the data supported bracing being effective, and conducted a rigorous study as well which was subsequently cited by numerous researchers. Good science, and well done Dr. Weinstein; scoliosis patients and the scoliosis research community are in debt to your relentless pursuit of good data.

Weinstein’s 2013 BRAIST study was included in a 2018 review of the literature 9 which found nine additional studies meeting the Scoliosis Research Society’s criteria which showed bracing was a successful treatment. The success rate for each study varied from 59%-100%, with an average success rate of 85.4% 4, 8, 10-12, 15, 19, 25-26. While bracing may not have been proven to work in 2007, as of 2019 the evidence is certainly there supporting the fact that bracing is effective at treating adolescent idiopathic scoliosis for a majority of patients.

DEBUNKING ANTI-BRACE DOGMA: REALISTIC EXPECTATIONS

So we once again know that bracing has been proven to work, but the dogma that seems to appear online is that bracing effects don’t last. But what does current research say about this? Before we can determine if results last, we need to understand how scoliosis progresses (gets worse) when it is left untreated.

Untreated scoliosis progresses after maturity

We know from long term (40-50 year studies) 22, 23 that when left untreated, scoliosis can progress and get worse and that the risk of progression is relative to the size of the curve and skeletal immaturity. We also know that many curves will continue to progress after the patient reaches skeletal maturity, especially those that are large (>50 degrees) 3. So our take home conclusion here is that when nothing is done to treat scoliosis, it tends to get worse over time, and can continue to get worse even after reaching adulthood and skeletal maturity.

Scoliosis can still progress after surgery

So if we know a scoliosis curve can continue to progress after maturity, what about surgery? Surgery should stop progression completely considering there are screws and rods and bone fusion right? Well, not exactly. Some older studies 5 looking to see what happens 20 years after surgery found that curves still can progress even after surgery and maturity, about 3.5 degrees. So what does this and the untreated data tell us? We can expect some deterioration over time, but our goal should still be to reduce the scoliosis as much as possible.

RESEARCH SHOWS SCOLIOSIS BRACING RESULTS LAST LONG TERM

Dr. Axe and other doctors claim that a curve will go right back to where it was or even worse as soon as you remove the brace. Yet a mountain of scientific evidence 1, 7, 13, 17, 20, 24 shows that they are wrong and that this claim is false when good bracing practices are performed.

One of the best scientific studies proving this is a 2017 study by Aulisa et al. 1 which tracked patients after they completed bracing for 15-20 years. On average, bracing reduced their patient’s curves by 13 degrees, but the results lasted for 15-20+ years. No matter if the curve was smaller than 30º before treatment, or larger than 30º before treatment, all curves stayed around the same size even 15 years after treatment! The average progression after treatment was 3 degrees, meaning that a curve starting at 32 degrees, which was reduced to 19 degrees, was 22 degrees 15+ years after bracing stopped.

The effects of bracing have been shown to last for 15-20+ years

The fact is, while a curve may progress after adulthood and after the brace comes off, all progress is not lost. When good bracing principles are used that achieve good in-brace correction with brace weaning being performed gradually, curves can be reduced significantly through bracing. When the brace comes off, only a few degrees are lost over time, not all of the progress achieved. Hardly matches the “benefits are lost after the brace comes off” that Dr. Axe and others would have you believe.

REFERENCES

1.  Aulisa, Angelo G.; Guzzanti, Vincenzo; Falciglia, Francesco; Galli, Marco; Pizzetti, Paolo; Aulisa, Lorenzo (2017): Curve progression after long-term brace treatment in adolescent idiopathic scoliosis. Comparative results between over and under 30 Cobb degrees – SOSORT 2017 award winner. In Scoliosis and spinal disorders 12, p. 36. Read the article.

2.  Bjerkreim, I.; Hassan, I. (1982): Progression in untreated idiopathic scoliosis after end of growth. In Acta orthopaedica Scandinavica 53 (6), pp. 897–900. Read the article.

3.  Cheung, Jason Pui Yin; Cheung, Prudence Wing Hang; Luk, Keith Dip-Kei (2019): When Should We Wean Bracing for Adolescent Idiopathic Scoliosis? In Clinical Orthopaedics and Related Research 477 (9), pp. 2145–2157. Read the article.

4.  Coillard, Christine; Vachon, Valerie; Circo, Alin B.; Beauséjour, Marie; Rivard, Charles H. (2007): Effectiveness of the SpineCor brace based on the new standardized criteria proposed by the scoliosis research society for adolescent idiopathic scoliosis. In Journal of pediatric orthopedics 27 (4), pp. 375–379. Read the article.

5.  Danielsson, A. J.; Nachemson, A. L. (2001): Radiologic findings and curve progression 22 years after treatment for adolescent idiopathic scoliosis. Comparison of brace and surgical treatment with matching control group of straight individuals. In Spine 26 (5), pp. 516–525. Read the article.

6.  Dolan, Lori A.; Weinstein, Stuart L. (2007): Surgical rates after observation and bracing for adolescent idiopathic scoliosis: an evidence-based review. In Spine 32 (19 Suppl), S91-S100. Read the article.

7.  Giorgi, S. de; Piazzolla, A.; Tafuri, S.; Borracci, C.; Martucci, A.; Giorgi, G. de (2013): Chêneau brace for adolescent idiopathic scoliosis. Long-term results. Can it prevent surgery? In European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society 22 Suppl 6, S815-22. Read the article.

8.  Janicki, Joseph A.; Poe-Kochert, Connie; Armstrong, Douglas G.; Thompson, George H. (2007): A comparison of the thoracolumbosacral orthoses and providence orthosis in the treatment of adolescent idiopathic scoliosis. Results using the new SRS inclusion and assessment criteria for bracing studies. In Journal of pediatric orthopedics 27 (4), pp. 369–374. Read the article.

9.  Kuroki, Hiroshi (2018): Brace Treatment for Adolescent Idiopathic Scoliosis. In Journal of clinical medicine 7 (6). DOI: 10.3390/jcm7060136. Read the article.

10.  Kuroki, Hiroshi; Inomata, Naoki; Hamanaka, Hideaki; Higa, Kiyoshi; Chosa, Etsuo; Tajima, Naoya (2015): Efficacy of the Osaka Medical College (OMC) brace in the treatment of adolescent idiopathic scoliosis following Scoliosis Research Society brace studies criteria. In Scoliosis 10, p. 12. Read the article.

11.  Lee, Choon Sung; Hwang, Chang Ju; Kim, Dong-Jun; Kim, Jae Hyan; Kim, Yung-Tae; Lee, Mi Young et al. (2012): Effectiveness of the Charleston night-time bending brace in the treatment of adolescent idiopathic scoliosis. In Journal of pediatric orthopedics 32 (4), pp. 368–372. Read the article.

12.  Maruyama, T.; Yamada, H.; Nakao, Y. (2013): Outcome of Rigo-Chêneau type brace treatment for adolescent idiopathic scoliosis – using the Scoliosis Research Society brace studies inclusion criteria. In Scoliosis 8 (S1), p. 2068. Read the article.

13.  Misterska, Ewa; Głowacki, Jakub; Głowacki, Maciej; Okręt, Adam (2018): Long-term effects of conservative treatment of Milwaukee brace on body image and mental health of patients with idiopathic scoliosis. In PloS one 13 (2), e0193447. Read the article.

14.  Nachemson, A. L.; Peterson, L. E. (1995): 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. In The Journal of bone and joint surgery. American volume 77 (6), pp. 815–822. Read the article.

15.  Negrini, Stefano; Atanasio, Salvatore; Fusco, Claudia; Zaina, Fabio (2009): Effectiveness of complete conservative treatment for adolescent idiopathic scoliosis (bracing and exercises) based on SOSORT management criteria. Results according to the SRS criteria for bracing studies – SOSORT Award 2009 Winner. In Scoliosis 4, p. 19. Read the article.

16.  Negrini, Stefano; Donzelli, Sabrina; Aulisa, Angelo Gabriele; Czaprowski, Dariusz; Schreiber, Sanja; Mauroy, Jean Claude de et al. (2018): 2016 SOSORT guidelines. Orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. In Scoliosis and spinal disorders 13, p. 3. Read the article.

17.  Pellios, Stavros; Kenanidis, Eustathios; Potoupnis, Michael; Tsiridis, Eleftherios; Sayegh, Fares E.; Kirkos, John; Kapetanos, George A. (2016): Curve progression 25 years after bracing for adolescent idiopathic scoliosis. Long term comparative results between two matched groups of 18 versus 23 hours daily bracing. In Scoliosis and spinal disorders 11, p. 3. Read the article.

18.  Romano, Michele; Negrini, Alessandra; Parzini, Silvana; Tavernaro, Marta; Zaina, Fabio; Donzelli, Sabrina; Negrini, Stefano (2015): SEAS (Scientific Exercises Approach to Scoliosis): a modern and effective evidence based approach to physiotherapic specific scoliosis exercises. In Scoliosis 10. Read the article.

19.  Shakil, Halima; Iqbal, Zaheen A.; Al-Ghadir, Ahmad H. (2014): Scoliosis. Review of types of curves, etiological theories and conservative treatment. In Journal of back and musculoskeletal rehabilitation 27 (2), pp. 111–115. Read the article.

20.  Shi, Benlong; Guo, Jing; Mao, Saihu; Wang, Zhiwei; Yu, Fiona W. P.; Lee, Kwong Man et al. (2016): Curve Progression in Adolescent Idiopathic Scoliosis With a Minimum of 2 Years’ Follow-up After Completed Brace Weaning With Reference to the SRS Standardized Criteria. In Spine deformity 4 (3), pp. 200–205. Read the article.

21.  Weinstein, Stuart L.; Dolan, Lori A.; Wright, James G.; Dobbs, Matthew B. (2013): Effects of bracing in adolescents with idiopathic scoliosis. In The New England journal of medicine 369 (16), pp. 1512–1521. Read the article.

22.  Weinstein, S. L. (1999): Natural history. In Spine 24 (24), pp. 2592–2600. Read the article.

23.  Weinstein, Stuart L. (2019): The Natural History of Adolescent Idiopathic Scoliosis. In Journal of pediatric orthopedics 39 (Issue 6, Supplement 1 Suppl 1), S44-S46. Read the article.

24.  Weniger, Carmen Dorothea; Fujak, Albert; Hofner, Benjamin; Fuchs, Markus; Forst, Raimund; Richter, Richard Heinrich (2019): Long-term Results of Conservative Therapy of Adolescent Idiopathic Scoliosis Using the Cheneau Brace. In Klinische Padiatrie 231 (5), pp. 248–254. Read the article.

25.  Yamazaki K., Murakami H., Yoshida S., Kikuchi T., Shimamura T. Outcome of brace treatment for adolescent idiopathic scoliosis. Orthop. Surg. 2013;64:806–811. (In Japanese)

26.  Zaborowska-Sapeta, Katarzyna; Kowalski, Ireneusz M.; Kotwicki, Tomasz; Protasiewicz-Fałdowska, Halina; Kiebzak, Wojciech (2011): Effectiveness of Chêneau brace treatment for idiopathic scoliosis. Prospective study in 79 patients followed to skeletal maturity. In Scoliosis 6 (1), p. 2. Read the article.

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About Dr. Jelcick

PhD in Genetics, BS in Biology, research based scientist with a passion for distilling peer-reviewed literature into easily digestible information to educate and empower.