Nighttime Bracing Effective for Adolescent Idiopathic Scoliosis

Source: Charalampidis A , Diarbakerli E , Dufvenberg M , et al . Nighttime bracing or exercise in moderate-grade adolescent idiopathic scoliosis: a randomized clinical trial. JAMA Netw Open. 2024;7(1):e2352492; doi: 10.1001/jamanetworkopen.2023.52492.Investigators from multiple institutions in Sweden conducted a randomized clinical trial to assess the effectiveness of night-time bracing (NB) or a scoliosis-specific exercise (SSE) program, compared to a control of physical activity (PA), as conservative treatment for adolescent idiopathic scoliosis (AIS). Participants were youths 9–17 years old with previously untreated moderate-grade AIS, defined as a primary curve Cobb angle of 25° to 40° apex T7 or caudal. Only patients who were skeletally immature, based on an estimated remaining growth of ≥1 year, and not more than 1 year after menarche in females, were eligible. At enrollment, participants were randomized 1:1:1 to each of the 3 treatment groups. Those assigned to NB wore a scoliosis night brace at least 8 hours each night. Those in the SSE group were instructed on self-corrective procedures for posture and prescribed a 30-minute daily exercise program. These participants had monthly visits with a physiotherapist for 3 months, and as needed after that. Patients in the PA group were encouraged to engage in ≥60 minutes of exercise daily. Participants had study visits every 6 months after enrollment. At the study visits, radiographs were obtained to assess scoliosis curve progression; height also was measured. The primary outcome was curve progression of ≤6° by skeletal maturity (treatment success) or curve progression of >6° (treatment failure). Odds ratios (OR) for rate of treatment success for NB, or SSE, compared to PA were calculated. Patients with treatment failure were offered full-time braces and/or surgical correction. A main secondary outcome was need for surgical correction for AIS within 2 years after completing the study.A total of 135 youths were enrolled in the study, with 45 assigned to each of the 3 treatment groups. The mean age of participants was 12.7 ±1.4 years, 82% were female, and mean Cobb angle at baseline was 31°. There were 13 participants who dropped out of the study. Among youths assigned to NB, 34/45 (76%) had treatment success compared to 24/45 (53%) of those randomized to PA (OR, 2.7; 95% CI, 1.1, 6.6). Among participants randomized to SSE, 26/45 (58%) had treatment success, which was not a significantly higher success rate than for those in the PA group (OR, 1.2; 95% CI, 0.5, 2.8). For those with treatment failure, 9 participants in each of the 3 treatment groups had surgical correction within 2 years after completing the study.The authors conclude that NB was significantly more effective than PA in preventing curve progression of >6° degrees than PA.Dr Hennrikus has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.AIS develops in about 3 % of children, and about 10% of those with AIS need treatment.1,2 Full-time bracing of at least 13 hours per day is effective in treating AIS, with a treatment success rate of 90%.3 The goal of bracing is to stop the progression of the curve and prevent the scoliosis Cobb angle from exceeding 50 degrees—a curve size needing surgery.4 However, some patients refuse full-time brace wear due to the negative psychologic impact of wearing the brace during the day while at school.5Theoretically, wearing a brace only at night could counteract compliance issues and the impact on quality of life seen in some patients treated with full time bracing.2 The current study is the first randomized clinical trial evaluating NB for 8 hours/night vs a control group. The brace utilized was a custom designed, hyper-corrective, Boston scoliosis brace. An orthotist was available for brace fitting and adjustments as needed. Patients were entered into the study if they had refused full-time bracing and had an x-ray Cobb angle of 25–40 degrees, were skeletally immature, and were <1 year post menarche. Ten patients reported trunk pressure and skin problems related to the brace.Overall, the results of the current study demonstrated that the success rate of wearing a scoliosis brace for 8 hours at night was 76% compared to 49% for observation and 51% for patients undergoing an exercise program. The current study has 2 practical conclusions. First, bracing, not specific exercise therapy, is the non-operative treatment of choice for AIS. Second, part-time bracing (8 hours per night) stopped curve progression in 76% of patients.Nighttime bracing for moderate AIS appears to be an effective alternative treatment in patients who reject full-time brace wear. (See AAP Grand Rounds. 2017;37[4]:42.)6As noted in the accompanying editorial,4 successful bracing not only abrogates the need for surgery, it also prevents future back pain and impaired respiratory function and may improve adolescent psychological well-being.