A new randomized study provides the best evidence yet that wearing a back brace will slow the progression of the most common form of scoliosis in adolescents, helping them avoid painful spine surgery.
Physicians have recommended bracing for more than 50 years but, until now, studies of its effectiveness had produced mixed results.
The U.S. Preventive Services Task Force recommended against scoliosis screening in schools partly, it said, because there was insufficient evidence that bracing and other conservative treatments relieved back pain or improved the quality of life in such children.
The new study, headed by a University of Iowa professor and reported on Thursday in the New England Journal of Medicine, should end the long-standing debate, several experts said, and may spur the task force — an independent panel of non-federal health care experts — to reconsider its stand.
The trial is “very convincing,” said Dr. B. Stephens Richards, a pediatric orthopedic surgeon at Texas Scottish Rite Hospital in Dallas. “It scientifically proves that brace treatment works for adolescents with scoliosis who are at risk of curve worsening to the point of needing surgery.”
Adolescent girls are more likely than boys to have idiopathic scoliosis, or curvature of the spine from no known cause. Rigid bracing is worn to externally force spine realignment.
It is a demanding treatment at a vulnerable time of life.
“When you have a teenager who is anxious about wearing a brace to school or what their friends will think, it gave us a bit of heartache to try to convince them if we weren't certain ourselves,” said Dr. Paul D. Sponseller, the director of orthopedic surgery at Johns Hopkins Children's Center who was not involved in the study. “In light of this new evidence, we can say we really do have a basis for putting them through bracing.”
In the study, researchers analyzed data on 242 patients at 25 sites across the United States and Canada. The children were all ages 10 to 15 and still growing, and each had a spinal curvature of 20 to 40 degrees.
Of those patients, 116 were randomly assigned to observation or bracing at least 18 hours daily. Because too few families agreed to randomization, the researchers added a group of 126 adolescents who chose for themselves between bracing and observation. The trial was stopped early because of the apparent efficacy of bracing.
In the analysis that included both groups, the rate of treatment success was 72 percent among children with bracing compared with 48 percent among those under observation. The benefit increased the longer bracing was worn.
More than 90 percent of the children who were successfully treated wore their braces more than 13 hours a day.
“There were a lot of doctors like me — who treat scoliosis as the primary focus of their practice — who had doubts about whether bracing was effective,” said Dr. Stuart L. Weinstein, the lead author of the report and a professor of orthopedic surgery at the University of Iowa. “Now the jury is in.”
Bracing has been the standard of care since the 1940s. It took so long to perform a rigorous trial of its effectiveness not only because it was “a gargantuan task,” said Joe O'Brien, the president of the National Scoliosis Foundation, but also because parents did not want to “just sit there and wait and watch.”
When her daughter Maddie was diagnosed with scoliosis at age 10, Becky Houser of North Liberty, Iowa, wanted to avoid surgery “at all costs.” So Maddie, a participant in Weinstein's study, chose to wear a brace.
“We didn't want to not do anything,” said Houser. Thirty years ago, she underwent surgery for scoliosis herself, spending nine months in an upper-body cast.
After three years of wearing baggy tops and yoga pants to accommodate the brace, Maddie, now 13, was thrilled to learn her spinal curvature was holding steady at 28 degrees. With no more major growth spurts left, she no longer needs bracing.
“We are extremely relieved,” Houser said.