Principal Director, Orthopaedics, Fortis Flt. Lt. Rajan Dhall Hospital, Vasant Kunj, New Delhi
Part 6 of 8 in Adolescent Idiopathic Scoliosis
Why Bracing Has Real Limits: Brace Types, Compliance and When It Fails
August 4, 2024
Bracing's role is narrowly defined: it can slow the rate of curve progression, but it cannot correct or reverse an existing deformity. Several brace types exist, the Milwaukee brace (extending to the neck, effective but cosmetically difficult, so poorly tolerated), the Boston brace (a snug underarm brace, cosmetically acceptable under clothing but only usable when the curve's apex is at T8 or below), the Charleston bending brace (worn only at rest, holding the spine acutely bent opposite the curve), and flexible strap-based braces like the SpineCor brace.
The compliance problem
For a brace to meaningfully slow progression, it needs to be worn 22 to 23 hours a day, a bar most children and even most adults struggle to meet. Asked directly how many hours a brace should be worn and what counts as treatment failure, Dr. Miglani's answer was blunt: 22 hours a day is the target, and failure is defined by continued clinical and radiological progression despite that level of use.
When bracing is the wrong choice
Bracing is not appropriate for a skeletally mature patient, since it can no longer meaningfully affect the curve. It's also not appropriate once a curve already exceeds 40 degrees, since surgery is a better use of the patient's time at that point. A further concern: the Milwaukee-style brace can straighten thoracic kyphosis, encroaching on the space needed for normal heart and lung function, and poor compliance simply lets the deformity progress anyway while the family believes something is being actively managed.
This article is based on a Jivo Masterclass session conducted by Dr. Manoj Miglani, Principal Director, Orthopaedics, Fortis Flt. Lt. Rajan Dhall Hospital, Vasant Kunj, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass: Dr. Manoj Miglani taught doctors across Africa on August 4, 2024.
FROM THE LIVE Q&A
Moderator
Is adolescent idiopathic scoliosis hereditary?
Dr. Manoj Miglani
Around 30% of adolescent idiopathic scoliosis cases have a family member with scoliosis, suggesting some hereditary or familial component, though it's far from universal. Congenital scoliosis and some neuromuscular or syndromic forms of scoliosis have a much stronger chance of being hereditary, since they involve clearer genetic transmission.
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Frequently Asked Questions
For a patient being observed with a curve between 10 and 20 degrees, is it okay to start some physiotherapy or rehabilitation exercises, or does one have to wait?▼
At 10 to 20 degrees, the focus should just be on exercises to keep the back muscles healthy and avoiding extremes of posture, that is all that is needed. Follow-up frequency with X-rays, whether every 3 months, 6 months or a year, depends on the child's age and Risser sign, not on whether they are doing exercises.
You said between 3 to 6 months for the X-ray follow-up. Can you clarify how that's decided?▼
If the child is young, say 10 years old with a 20-degree deformity, X-rays should be done every 3 months since they are likely to progress more. If the child is 13-14 years old with the same 20-degree curve, X-rays every 6 months to a year are enough, just to confirm the deformity isn't progressing rapidly.
Is there any preventive treatment, such as exercises, bed positioning or diet, that can help avoid developing scoliosis or keep it from progressing?▼
No, there are no preventive measures for idiopathic scoliosis, because the actual cause isn't known. The only genuinely useful advice is for the child to stay physically active, which most children naturally are.
Is there a difference between true scoliosis and scoliosis attitude?▼
Yes. Scoliotic attitude is purely a postural thing, not a structural curve. A true structural curve is distinguished from a postural presentation using standing X-rays and bending views, which show whether the curve is rigid or fully correctable.
As a traumatic scoliosis patient from DRC with a Cobb angle of 22 degrees, should I wear a custom-made corset or a removable corset with physiotherapy sessions?▼
At a Cobb angle of 22 degrees, correction may not be needed at all. If there is no pain in the affected area of the spine, the curve is unlikely to progress further and has likely already stabilised, so no bracing or active intervention is required. X-ray pictures and clinical photos would be needed for a fuller review of the specific case.
How many hours a day does a scoliosis brace need to be worn?▼
22 to 23 hours a day to meaningfully slow curve progression, a compliance level most patients struggle to maintain.
Can a brace correct an existing scoliosis curve?▼
No. A brace can only slow the rate of progression; it cannot correct or reverse an existing deformity.
In This Series: Adolescent Idiopathic Scoliosis
- 1.Adolescent Idiopathic Scoliosis
- 2.What Is Adolescent Idiopathic Scoliosis? Epidemiology and the Unknown Cause
- 3.Diagnosing and Classifying Scoliosis: Cobb Angle, Curve Types and True vs Postural Deformity
- 4.The Risser Sign: Predicting Whether a Scoliosis Curve Will Progress
- 5.Treatment Thresholds: Observation, Bracing and Surgery by Curve Severity
- 6.Why Bracing Has Real Limits: Brace Types, Compliance and When It Fails
- 7.Surgical Correction: From the Harrington Rod to Modern Pedicle Screw Fixation
- 8.Scoliosis Complications: Untreated Progression, Surgical Risk and a Post-Traumatic Case