Scoliosis is a sideways curvature of the spine, most frequently diagnosed during adolescence, which can progress as a child grows. A back brace is a recognized and often highly successful non-surgical intervention used to manage the progression of moderate scoliosis in growing patients. The primary goal of this orthotic device is to reduce the risk of the curve worsening to the point where surgical correction becomes necessary.
How Bracing Works to Halt Curve Progression
A back brace does not typically correct the existing spinal curve, but rather works to prevent the curve from progressing further during the patient’s remaining growth period. The mechanism of action relies on the principle of a three-point pressure system. This system applies corrective forces to the torso through strategically placed pads within the rigid shell.
The three-point system involves two points of pressure applied to the convex, or outward-curving, side of the spine, and a counter-pressure point applied to the concave side. This mechanical force pushes the spine toward a straighter alignment while the brace is worn. By immobilizing the spine and applying consistent pressure, the brace guides the spine’s growth to minimize the increase in the Cobb angle, which is the standard measurement for spinal curvature.
Clinical research has demonstrated that bracing significantly reduces the likelihood of curve progression to the surgical threshold of 50 degrees or more. Studies, such as the Bracing in Adolescent Idiopathic Scoliosis Trial (BRAIST), reported success rates ranging from 64% to 77% in preventing progression past 50 degrees. These favorable outcomes are strongly associated with the duration of daily brace wear. Patients who wore the brace for a minimum of 12.9 hours per day showed a significantly lower rate of curve progression compared to those observed without bracing.
Criteria for Starting Brace Treatment
The decision to begin brace treatment is based on a specific set of medical criteria used by specialists to assess the risk of a curve worsening. Bracing is generally reserved for patients who are still skeletally immature, meaning they have a significant amount of growth remaining. Skeletal maturity is often assessed using the Risser sign, a grading system from 0 to 5 based on the ossification of the pelvis, where a Risser grade of 0 to 2 indicates remaining growth potential.
The spinal curve magnitude, measured by the Cobb angle, is a primary indicator for treatment. Bracing is typically recommended for curves that fall within the moderate range, generally between 25 and 40 degrees. Curves less than 25 degrees are usually managed through observation and regular monitoring to track any potential progression.
Treatment is also indicated if the curve is progressing rapidly, even if the Cobb angle is on the lower end of the moderate range. The goal is to stabilize the curve before it reaches 40 to 45 degrees, which is the point where the risk of progression becomes much higher.
Different Types of Orthotic Devices
The type of brace prescribed depends on the location and severity of the spinal curvature. The most common orthotic device is the Thoraco-Lumbo-Sacral Orthosis (TLSO), which is a low-profile, custom-molded plastic shell that fits under the arms and extends down to the hips. The Boston Brace is a well-known example of a TLSO, designed for full-time wear, typically 18 to 23 hours per day.
Other brace designs offer different wearing schedules or apply different corrective forces. The Charleston Bending Brace, for instance, is a nighttime-only orthosis. This brace is designed to apply a hyper-corrective force while the patient is lying down, which is only possible because the brace is not worn during daily activities.
The Milwaukee Brace is an older, high-profile design that includes a neck ring and chin pad, making it a Cervical-TLSO (CTLSO). This type is now less common but may be used for very high thoracic curves. The choice between a full-time brace like the Boston and a nighttime brace like the Charleston is determined by the curve’s pattern and magnitude; full-time bracing shows greater effectiveness in preventing curve progression.
Compliance and Daily Life with a Brace
The success of bracing treatment is highly dependent on patient adherence, known as compliance, to the prescribed wearing schedule. Full-time braces are often prescribed for 18 to 23 hours daily, and consistent wear is the single most important factor in achieving a positive outcome. Many modern braces include a temperature sensor or other monitoring technology to track the actual hours of wear, providing objective data for the medical team.
Adjusting to daily life with a brace requires attention to skin care and physical activity. Patients must wear a clean, moisture-wicking shirt, such as a cotton tank top, underneath the brace at all times to protect the skin. Lotions and powders should be avoided under the brace, as they can soften the skin and lead to irritation or breakdown at pressure points.
While the brace is worn most of the day, it is typically removed for bathing and for participation in sports or strenuous physical activity. The emotional adjustment to wearing a brace is also a factor, and support from family and the medical team is helpful in navigating social situations and body image concerns throughout the treatment period.