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BRIEF REPORT
Effects of Bracing in Adult With Scoliosis: A
Retrospective Study
Cle
´mence Palazzo, MD, PhD,
a,b
Jean-Paul Montigny, MD,
c
Fre
´de
´ric Barbot, MD,
d
Bernard Bussel, MD, PhD,
a
Isabelle Vaugier, MD,
d
Didier Fort, MD,
e
Isabelle Courtois, MD,
f
Catherine Marty-Poumarat, MD
a
From the
a
Department of Spinal Rehabilitation, Raymond Poincare
´Hospital, Garches;
b
INSERM U1153, Faculty of Medicine Paris-Descartes,
Department of Physical Medicine and Rehabilitation, Cochin Hospital, Paris;
c
Department of Physical Medicine and Rehabilitation, Foch
Hospital, Suresnes;
d
INSERM CIC 1429, Raymond Poincare
´Hospital, Garches;
e
Institute of Physical Medicine and Rehabilitation, Nancy; and
f
Department of Spinal Rehabilitation, Saint Etienne Hospital, Saint-Etienne, France.
Abstract
Objective: To assess the effectiveness of bracing in adult with scoliosis.
Design: Retrospective cohort study.
Setting: Outpatients followed in 2 tertiary care hospitals.
Participants: Adults (NZ38) with nonoperated progressive idiopathic or degenerative scoliosis treated by custom-molded lumbar-sacral
orthoses, with a minimum follow-up time of 10 years before bracing and 5 years after bracing. Progression was defined as a variation in
Cobb angle 10between the first and the last radiograph before bracing. The brace was prescribed to be worn for a minimum of 6h/d.
Interventions: Not applicable.
Main Outcome Measure: Rate of progression of the Cobb angle before and after bracing measured on upright 3-ft full-spine radiographs.
Results: At the moment of bracing, the mean age was 61.38.2 years, and the mean Cobb angle was 49.617.7. The mean follow-up time was
22.011.1 years before bracing and 8.73.3 years after bracing. For both types of scoliosis, the rate of progression decreased from 1.28.79/y
before to .21.43/y after bracing (P<.0001). For degenerative and idiopathic scoliosis, it dropped from 1.47.83/y before to .24.43/y after
bracing (P<.0001) and .70.06/y before to .24.43/y after bracing (PZ.03), respectively.
Conclusions: For the first time, to our knowledge, this study suggests that underarm bracing may be effective in slowing down the rate of
progression in adult scoliosis. Further prospective studies are needed to confirm these results.
Archives of Physical Medicine and Rehabilitation 2017;98:187-90
ª2016 by the American Congress of Rehabilitation Medicine
Adult scoliosis is a prevalent disease,
1
which can be painful, and
negatively affects quality of life.
2
With the growing age of the
population,
3
it is fast becoming a public health concern. There
are 2 types of adult scoliosis: (1) idiopathic scoliosis, which is
an adolescent scoliosis which continues to progress regularly
during adulthood (mean progression rate, .82/y); and (2)
degenerative scoliosis, which typically appears or lately pro-
gresses during adulthood, mainly around menopause (mean
progression rate, 1.64/y).
4
The current treatment of adult
scoliosis is not well codified. First-line treatment is usually
conservative, including rehabilitation and bracing, with the main
objectives to reduce symptoms
3
and slow down disease pro-
gression to avoid surgery.
5,6
However, the evidence of the
effectiveness of conservative treatments is very low.
6
Two o p en
studies have assessed the effectiveness of braces on pain with
encouraging results,
7,8
but its effects on progression rates have
never been studied. The present study aimed to assess the
effectiveness of an underarm plastic brace on progression rates
in adult scoliosis.
Disclosures: none.
0003-9993/16/$36 - see front matter ª2016 by the American Congress of Rehabilitation Medicine
http://dx.doi.org/10.1016/j.apmr.2016.05.019
Archives of Physical Medicine and Rehabilitation
journal homepage: www.archives-pmr.org
Archives of Physical Medicine and Rehabilitation 2017;98:187-90
Methods
Participants
We retrospectively reviewed the medical records of patients 18
years of age with a progressive nonoperated idiopathic or degen-
erative lumbar scoliosis, or with an S curve with a progressive
lumbar curve, followed in 2 French tertiary care hospitals, and
who had at least 1 prescription of custom-molded lumbar-sacral
orthosis between 2004 and 2014. Progression was defined as a
variation in Cobb angle 10between the first and last radiograph
before bracing.
9
Bracing started as soon as the progression of
scoliosis was confirmed. It could be at the first medical visit when
the patient had prior radiographs or during the follow-up when the
patient had no previous radiographs. We included patients with a
minimum follow-up time of 10 years before and 5 years after
bracing, with at least 3 radiographs before and 3 radiographs after
bracing. The last radiograph corresponds to the last medical visit
(patients are still followed). We excluded patients who had un-
dergone a spine surgery, scoliosis associated with a camptocormia,
and scoliosis secondary to another disease (fracture or neurologic
or rheumatologic disorder). The brace was made according to the
Vesinet method (fig 1). It was prescribed to be worn for a mini-
mum of 6h/d. The Cobb angle was measured manually on upright
3-ft full-spine radiographs by the same trained senior physician in
each center. The limits of the curve were characterized by the
point at which the angle no longer increased.
Definition of scoliosis
The type of scoliosis was deduced from a graph representing Cobb
angles (yaxis) against age (xaxis) that was plotted for each patient
(fig 2).
4
The scoliosis was considered as idiopathic if the Cobb
angle regularly increased from the end of skeletal maturity until
bracing and as degenerative if the Cobb angle quickly worsened
later (around the age of the menopause).
Outcome criteria
The main outcome was the comparison of the curve progression
before and after bracing. The rate of progression was estimated
based on the graph that we used to define the type of scoliosis,
representing Cobb angles (yaxis) against age (xaxis) for
each patient.
Statistical analysis
The characteristics of the population were summarized as
mean SD because they were continuous variables. A
segmented linear-mixed effects regression model with random
intercept and random slopes was used to analyze changes over
time in the Cobb angle. The time variable was partitioned at the
date of bracing into 2 intervals, and a separated line segment
was fit to each interval. Pre- and postbracing values were esti-
mated with their 95% confidence intervals, and the paired ttest
was chosen to compare pre- and postbracing slopes. The level of
significance was set at 5%.
This study was approved by the National Commission for Data
Protection and Liberties (no. DR-2014-594).
Results
The medical records of 271 patients were retrospectively
reviewed, but only 38 patients (29 with degenerative and 9 with
idiopathic scoliosis) were included in the study. Their character-
istics are reported in table 1. All of the participants were women.
The reasons of exclusion were as follows: follow-up time too short
and/or an insufficient amount of radiographs (83%), previous
surgery (7%), and scoliosis secondary to another disease (10%).
The selected patients consulted either for pain, sagittal or coronal
imbalance, aesthetic reasons, or for the follow-up of a known
scoliosis. The most frequently reported brace-related side effect
was discomfort; this was unusual and improved by brace
adjustment.
Figure 3 illustrates the individual progression of scoliosis
before and after bracing. For the 38 patients we observed a
breakpoint of the progression rate at the time of bracing.
Considering all types of scoliosis, the mean rate of progression
was significantly higher before bracing (1.28.79/y) than after
bracing (.21.43/y, P<.0001). For degenerative scoliosis, the
progression rate decreased from 1.47.83/y before to
Fig 1 Underarm plastic brace made according to the Vesinet method: the brace was prepared from a plaster cast in the upright position,
correcting sagittal and coronal imbalance, supporting the gibbosity, and underlying the waistline. The quality of bracing was controlled by a
trained senior physician during its confection, after 3 months, and each year.
188 C. Palazzo et al
www.archives-pmr.org
.24.43/y after bracing (P<.0001), and for idiopathic scoliosis
it dropped from 0.7.06/y before to .24.43/y after
bracing (PZ.003).
Discussion
This study suggests for the first time, to our knowledge, the
effectiveness of custom-molded lumbar-sacral orthoses in slowing
down the progression of adult scoliosis. Considering its limited
side effects, it represents an interesting treatment option and an
alternative to surgery that is associated with a high rate of com-
plications and technical difficulties related to the marginal bone
quality in this older population.
5,6
The minimum number of hours of daily wear to observe the
effectiveness of bracing is unknown. We empirically considered
the threshold of 6 hours, but we do not know yet if there is a dose-
effect relation, as was described in adolescent idiopathic scoli-
osis,
10
or a ceiling effect, which is no additional effect once a
threshold is reached. Among our 38 patients, 4 reported to wear
their brace <6h/d; they improved less than patients who wore their
brace >6 hours. Because observance was self-reported, there is a
risk of recall bias, and patients may have overestimated the
average daily brace wear.
10
Future studies might include a tem-
perature logger embedded in the brace
10
to clarify this point and
help assess the dose-effect relation to define the appropriate
wearing time. Contrary to widespread belief, the effect of bracing
on core strength is unknown. The literature shows that bracing
could improve muscle strength in low back pain and after verte-
bral fracture. To our knowledge, it has never been specifically
studied in adult scoliosis.
11
One strength of our work is the long follow-up time of patients.
Whereas the mean progression rate per year is .82for idiopathic
adult scoliosis and 1.64for degenerative scoliosis,
4
the fluctua-
tions of the Cobb angle measurements range from 4to 7,
especially when old and nonstandardized radiographs are used.
9
Consequently, a long follow-up time and a sufficient number of
radiographs were necessary to ensure progression irrespective of
the variations in Cobb angle measurement. This explains why we
included a low proportion of patients in comparison with the high
number of outpatients in the participating centers. This also makes
it difficult to develop prospective studies.
Study limitations
This study has the usual limitations of a retrospective study. First,
patients may be not be wholly representative of the population
with adult scoliosis. All of our patients were women; however,
adult scoliosis also occurs in men. However, it is less frequent, and
degenerative scoliosis appears later, around male andropause.
None of the men had a sufficient follow-up to be included in this
study. Second, confounders were not taken into account; therefore,
we cannot exclude that patients who regularly consulted were
those who were satisfied with bracing. Finally, the lack of a group
Fig 2 Graph used to defined the type of scoliosis (idiopathic or degenerative).
Table 1 Characteristics of the study population
Characteristic
Idiopathic
(nZ9)
Degenerative
(nZ29)
Total
(NZ38)
Cobb angle (deg) 63.111.5 45.317.6 49.617.7
Age (y) 58.39.5 62.07.7 61.38.2
Follow-up time
before bracing (y)
33.38.1 19.09.4 22.011.1
Follow-up time after
bracing (y)
9.03.6 8.63.4 8.73.3
No. of radiographs
before bracing
4.31.6 4.31.9 4.31.8
No. of radiographs
after bracing
5.82.6 5.52.4 5.62.4
NOTE. Results are expressed as means SDs. Fig 3 Individual progression of degenerative and idiopathic adult
scoliosis before (black line) and after bracing (gray line).
Effects of bracing in adult with scoliosis 189
www.archives-pmr.org
without scoliosis prevents a conclusion that the slowdown of the
progression rate was really attributable to bracing and was not just
the result of the natural history of scoliosis. In fact, certain
scoliosis, particularly those associated with an important spinal
osteoarthritis, may stiffen. However, we did not observe any
change in the progression of scoliosis before bracing (even
without assessing the progression rate by a linear model, but
representing all of the available measures of Cobb angles by pa-
tient) (fig 4). Moreover, we assessed the progression rate of
scoliosis for 13 women who declined surgery and were either
noncompliant (nZ6) or declined bracing (nZ7) (fig 5). The
progression rate did not decrease, and we did not observe any
breakpoint for 11 of the patients. For 2 of the patients, the pro-
gression could have slowed down somewhat for the last years of
follow-up, but we lack follow-up to draw any conclusions. Future
cohort studies should be performed to identify predictors of spine
stiffening.
Conclusions
This study suggests that custom-molded lumbar-sacral orthoses
are effective in slowing down the progression of adult scoliosis.
Considering its limited side effects, bracing should be proposed as
the first-line treatment in association with physiotherapy. It rep-
resents an acceptable alternative to surgery for patients who
cannot or do not want to be operated on. These results must be
confirmed by prospective trials.
Keyword
Braces; Orthotic devices; Rehabilitation; Scoliosis
Corresponding author
Cle
´mence Palazzo, MD, PhD, Department of Physical Medicine
and Rehabilitation, Cochin Hospital, 27 rue du Faubourg Saint
Jacques, 75014 Paris, France. E-mail address: clemence.palazzo@
aphp.fr.
References
1. Anwar Z, Zan E, Gujar SK, et al. Adult lumbar scoliosis: under-
reported on lumbar MR scans. AJNR Am J Neuroradiol 2010;31:
832-7.
2. Schwab F, Dubey A, Pagala M, et al. Adult scoliosis: a health
assessment analysis by SF-36. Spine (Phila Pa 1976) 2003;28:602-6.
3. Aebi M. The adult scoliosis. Eur Spine J 2005;14:925-48.
4. Marty-Poumarat C, Scattin L, Marpeau M, et al. Natural history of
progressive adult scoliosis. Spine (Phila Pa 1976) 2007;32:1227-34.
5. Grubb SA, Lipscomb HJ, Suh PB. Results of surgical treatment of
painful adult scoliosis. Spine (Phila Pa 1976) 1994;19:1619-27.
6. Kluba T, Dikmenli G, Dietz K, et al. Comparison of surgical and
conservative treatment for degenerative lumbar scoliosis. Arch Orthop
Trauma Surg 2009;129:1-5.
7. Weiss HR, Dallmayer R. Brace treatment of spinal claudication in an
adult with lumbar scoliosisea case report. Stud Health Technol Inform
2006;123:586-9.
8. Weiss HR, Dallmayer R, Stephan C. First results of pain treatment in
scoliosis patients using a sagittal realignment brace. Stud Health
Technol Inform 2006;123:582-5.
9. Carman DL, Browne RH, Birch JG. Measurement of scoliosis and
kyphosis radiographs. Intraobserver and interobserver variation. J
Bone Joint Surg Am 1990;72:328-33.
10. Weinstein SL, Dolan LA, Wright JG, et al. Effects of bracing in ad-
olescents with idiopathic scoliosis. N Engl J Med 2013;369:1512-21.
11. van Poppel MN, de Looze MP, Koes BW, et al. Mechanisms of action
of lumbar supports: a systematic review. Spine (Phila Pa 1976) 2000;
25:2103-13.
Fig 4 Individual progression of degenerative adult scoliosis
according to age (y).
Fig 5 Individual progression of scoliosis for controls. The control
group included patients who declined bracing and surgery.
190 C. Palazzo et al
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