Brace treatment effective for Cobb curves over 45 degrees

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Monia Lusini (ISICO—Italian Scientific Spine Institute, Milan, Italy) and others report in The Spine Journal that bracing and exercises are an effective treatment for still-growing patients with idiopathic scoliosis with a Cobb angle over 45 degrees who have refused surgery.

Lusini et al comment that brace treatment is considered to be a way of reducing the risk of curve progression rather than as a way of reducing curve itself, adding: “A consequence of this approach is that above 45 degrees of curve [when risks of health problems are high], attempts of brace treatment are generally considered at best, an almost desperate attempt and at worst, a waste of time.”


However, according to the authors, a recent retrospective uncontrolled cohort study found that brace treatment with exercises was associated with an improvement in 71% of 28 patients who had at least one curve above 45 degrees and who had refused surgery. They noted that the aim of their study was to verify these results through a prospective cohort controlled study in patients with adolescent or juvenile idiopathic scoliosis with a curve above 45 degrees who had refused surgery.


In a database of 8,717 patients who received a first evaluation at the authors’ centre between March 2003 and December 2010, 57 met the study’s inclusions criteria—idiopathic scoliosis with at least one curve of 45 degrees or more, Risser stage 0–4 and age above 10 years. Thirty-nine patients undertook full-time brace treatment as way of avoiding surgery and 18 patients who refused treatment or only came to the centre for a second opinion acted as controls. The braces used in the study were the Lyon brace (preceded by a Risser cast if patient agreed) between 2003 and 2004 and the Sforzesco brace from 2005 onwards. The main outccome of the study was radiographical improvement. Lusini et al explain: “We calculated the relative risk, the absolute risk, and the number needed to treat for success (improvement of five degrees or more) or failure (either progression of five degrees or more or fusion).”


The rate of failure in the bracing group was 23.5% vs. 100% for the control group in the efficacy analysis, and was 20.5% vs. 55.6% (respectively) in the intention to treat analysis. The authors state: “In practice, the control group had a 4.3 (efficacy analysis) or a 2.7 (intention to treat) times higher probability of failure than the bracing group.” Also, the results showed that the bracing group had double the probability of improvement than the control group.


Lusini et al conclude: “Brace treatment [plus exercises] proved to be useful for patients with curves above 45 degrees Cobb and still growing who were attempting to avoid surgery, provided that a good brace can be offered and a very good compliance achieved [in the study, the average rate of compliance was 94.7%]. In this situation, patients needed to know that a treatment of almost five years is offered.”


Study author Stefano Negrini (Phyisical and Rehabilitation Medicine, University of Brescia and IRCCS Don Gnocchi, Milan, Italy) told Spinal News International that they could not accurate monitor bracing compliance in the study as the data they used was based on self-reports from the patients. However, he adds that using a ‘Thermobrace’, which has a heat sensor that detects when the brace is being worn (or not being worn), close collaboration with the orthotist to check that a brace is correctly fitted for an individual patient, and cognitive-behavioural approaches can help to aid compliance.

 

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