Session 7: Brace

Adolescent Idiopathic Scoliosis (AIS) is a common spinal disorder in adolescents, characterized by a three-dimensional deformity that affects posture and lower limb mechanics. While specific exercises and orthopedic braces are established conservative treatments, there is limited evidence on the added benefits of combining these approaches with orthopedic insoles to improve force distribution and body alignment.

Randomized clinical trial

To verify the therapeutic effect of specific exercise with the use of an orthopedic brace combined with a 3D personalized insole in adolescents with idiopathic scoliosis: a randomized clinical trial. 

Fifty patients females with adolescent idiopathic scoliosis and moderate-high curves (45°-60°), were allocated into two groups: experimental group (EG; n=25), which received traditional conservative treatment with specific exercises combined with the use of an orthopedic brace and a 3D-customized insole; and control group (CG; n=25), treated only with specific exercises and an orthopedic brace. Assessments were performed at baseline and after 6 months of intervention. The primary outcome measures were spinopelvic parameters and the Cobb angle obtained by radiographs. Secondary measures included postural balance (Baiobit/Kinetec system) and quality of life (Scoliosis Research Society-22). The specific exercise program was applied once a week for 50 minutes over 6 consecutive months. The brace was used for 20-23 hours a day, and in the EG, the 3D-customized insole was used for 6-8 hours daily. 

Anthropometric aspects (age, mass, height, and BMI) remained stable in both groups, with no significant differences after the intervention, indicating no impact of the intervention on general body parameters. Regarding clinical parameters and pain: both groups showed a significant reduction in the Cobb angle of the principal curvature (GE: d=0.79; GC: d=0.78; p<0.01) and a reduction in pain (GE: d=0.85; p=0.024; GC: d=0.72; p=0.020). Only the GE showed an additional reduction in the lumbar Cobb angle (d=0.64; p=0.022), suggesting a benefit from the combined use of the customized insole and brace. In the spinopelvic parameters, there was a significant reduction in pelvic incidence in both groups (GE: p=0.041; GC: p=0.038). Only the experimental group (EG) showed significant reductions in sacral slope (p=0.033) and pelvic tilt (p=0.015), with moderate effect sizes, while the control group (CG) showed no differences in these variables. Regarding balance and quality of life, a reduction in anteroposterior sway and an improvement in the SRS-22 score were observed in both groups after 6 months, with larger effect sizes in the EG; there were no significant changes in mediolateral sway. 

Adding a customized insole enhances pain, balance and quality of life in AIS beyond Cobb angle reduction.

Custom insoles can improve alignment and load distribution, relieving pain, improving quality of life, and enhancing conservative treatment of AIS.

The BrAIST study established a dose-dependent relationship between brace wear and curve control in adolescent idiopathic scoliosis (AIS). Whether this relationship extends to juvenile idiopathic scoliosis (JIS) and persists across varying prescription regimens remains unclear. 

Retrospective single-center cohort.

To examine the BrAIST dose-response model using objective brace monitoring data across idiopathic subtypes (AIS and JIS) and brace prescriptions. Additionally, we aim to evaluate the relationships between compliance, in-brace correction (IBC), and bracing outcomes after adjusting for follow-up duration, diagnosis, and prescription. 

All patients were treated with Rigo Chêneau-style orthoses with thermal wear-time sensors. Treatment ‘failure’ was defined as coronal curve progression ≥10° at two years or progression to surgery within two years of brace initiation. Treatment ‘success’ was defined as <10° progression at two years or graduation from bracing within two years in the absence of ≥10° progression or surgical intervention. Radiographic data were documented at brace initiation and two-year follow-up or at the preoperative visit or final out-of-brace evaluation for patients who progressed to surgery or graduated from bracing, respectively. Percent compliance was calculated as average wear hours per day divided by prescribed hours and adjusted for prescription changes. Patients were stratified into quartiles based on percent compliance. Correlations and multivariable linear regression were performed to evaluate predictors of coronal curve change. 

52 patients (39 female, 75%) were included, of whom 18 (34.6%) had JIS. Mean age was 11.7±2.4 years. Pre-brace and latest follow-up major coronal curves were 26.6°±6.4° and 26.8°±13.8°, respectively, with a mean follow-up of 1.9±0.5 years (range: 0.5 to 3.0 years). Seven patients (14%) met ‘failure’ criteria. Both percent compliance (r = -0.603, p<0.001) and average wear hours (r = -0.461, p<0.001) demonstrated strong dose-response relationships with change in major coronal curve [Figure 1]. In multivariable linear regression, percent compliance (β = -0.47, p<0.001) and IBC (β = -0.42, p<0.001) independently predicted coronal curve changes, while follow-up had a smaller effect (β = -0.24, p=0.014). Prescribed hours (p=0.44) and diagnosis (p=0.59) were not significant predictors.

Figure 1. Change in major cobb with (A) percent compliance and (B) average wear hours 

This study demonstrates a strong dose-response relationship in bracing management across prescription regimens and idiopathic subtypes (AIS and JIS). Brace wear and IBC independently predict curve progression, whereas prescribed hours and diagnosis do not.

In both AIS and JIS, percent compliance relative to prescription and IBC serve as objective measures for the clinical assessment of bracing effectiveness. These metrics can be used to support patient and family counseling and to guide clinical decision-making for optimal treatment planning.

While bracing is considered the dominant nonoperative treatment for idiopathic scoliosis, prior literature has suggested that brace treatment may negatively impact sagittal alignment through reductions in thoracic kyphosis (TK) and lumbar lordosis (LL). However, previous reports are inconsistent and lack objective data on daily brace wear.

Retrospective cohort study at a single academic institution.

To characterize changes in sagittal parameters after two years of active bracing treatment and evaluate the association between objective brace wear and radiographic outcomes.

All patients were treated with Rigo Chêneau-style orthoses embedded with thermal wear-time sensors and followed for two years without brace discontinuation or progression to surgery. Radiographic data were obtained from standing anteroposterior and lateral radiographs at brace initiation and two-year follow-up. Sagittal parameters included TK, LL, pelvic tilt (PT), pelvic incidence (PI), PI-LL mismatch, sagittal vertical axis (SVA), and cervical SVA (cSVA). Percent compliance was calculated as average wear hours per day divided by prescribed hours and adjusted for documented prescription changes over time. Paired sample t-tests assessed longitudinal changes in radiographic parameters. Pearson correlations evaluated associations between sagittal changes, percent compliance, average brace wear hours, and major coronal curve progression.

32 idiopathic scoliosis patients were included (24 female, 75%), of whom 20 (62%) had AIS and 12 (38%) had JIS. Mean age was 11.1 ± 2.4 years, with a mean follow-up of 2.1 ± 0.3 years. At two years, LL decreased significantly (mean -6.1°, p = 0.013), while increases in PT (+3.4°, p = 0.002) and PI-LL mismatch (+7.1°, p = 0.015) were observed. No significant changes were observed in TK, PI, SVA, or cSVA. Major coronal curve demonstrated a trend toward improvement (-2.7°, p = 0.055), and two patients (6.3%) experienced coronal progression ≥10° without meeting surgical indications. Neither percent compliance nor average daily wear hours demonstrated significant correlations with changes in sagittal parameters despite strong correlations with change in major coronal curve (r = -0.67 and -0.57, respectively; p < 0.001).

Table 1. Pre-brace versus two-year radiographic outcomes  

In this study, two years of bracing for idiopathic scoliosis was not associated with clinically meaningful deterioration or remodeling of sagittal alignment. The observed sagittal changes were minimal and independent of objective brace wear.

These findings suggest that bracing does not significantly alter sagittal alignment during active brace treatment, even with high compliance. While bracing compliance remains critical for coronal curve control, its influence on sagittal alignment appears limited. Interpretation is limited by the current study’s sample size, and larger studies with expanded cohorts are needed to confirm these findings.