Nighttime bracing may be effective for moderate-grade adolescent idiopathic scoliosis
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Key takeaways:
- Nighttime bracing with self-mediated physical activity may be an effective treatment for adolescent idiopathic scoliosis.
- Nighttime bracing may be an alternative to full-time bracing.
Nighttime bracing with self-mediated physical activity may be an effective alternative to full-time bracing in patients with moderate-grade adolescent idiopathic scoliosis, according to published results.
Anastasios Charalampidis, MD, PhD, and colleagues from the Conservative Treatment for Adolescent Idiopathic Scoliosis randomized clinical trial analyzed 135 patients (mean age of 12.7 years) who had adolescent idiopathic scoliosis with a primary Cobb angle of 25° to 40°, apex T7 or caudal and skeletal immaturity.
Researchers analyzed outcomes for patients who were prescribed self-mediated physical activity combined with either nighttime bracing (n= 45) or scoliosis-specific exercise (n = 39). They compared outcomes to a control group of patients who were prescribed to physical activity alone (n = 45). According to the study, the primary outcome was a Cobb angle progression of 6° or less, deemed as treatment success, or a Cobb angle progression of more than 6°, deemed as treatment failure, on consecutive posteroanterior standing radiographs.
Researchers found nighttime bracing prevented a curve progression of more than 6° to a “significantly higher extent” than physical activity alone, while scoliosis-specific exercise did not. According to the intention-to-treat analysis, 34 patients (76%) in the nighttime bracing group, 26 patients (58%) in the scoliosis-specific exercise group and 24 patients (53%) in the physical activity control group had treatment success.
Researchers found the number needed to treat to prevent curve progression with nighttime bracing was 4.5. They noted nine patients in each of the three groups had undergone surgery by 2 years after the primary outcome time point.
“These results suggest that nighttime bracing may be an effective alternative intervention in patients rejecting full-time bracing,” the researchers wrote in the study.
Perspective
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In the Conservative Treatment for Adolescent Idiopathic Scoliosis study by Anastasios Charalampidis, MD, PhD, and colleagues, we see a demonstrable effect of nighttime bracing for moderate scoliosis vs. a control group (physical activity alone) and scoliosis specific exercises. In this group of skeletally immature children from Sweden with average curves of 30°, treatment success with a nighttime brace was seen in 76% vs. roughly 50% in the controls. The authors are to be congratulated for conducting a randomized clinical trial with excellent methodology and follow-up. While the evidence is clear from the Bracing in Adolescent Idiopathic Scoliosis Trial study that full-time bracing (18 to 20 hours per day) is superior to observation alone, what is less clear is the value, if any, of nighttime bracing (8 hours). This real-world evidence of the more likely situation (nighttime or parttime brace wear) is encouraging for patients, families and practitioners, because data now indicate a substantial effect of avoiding progression and perhaps avoiding surgery for progressive, severe scoliosis. Thus, in a shared decision-making model for treatment recommendations for control of moderate scoliosis in children and adolescents, the evidence for bracing can be discussed in the context of the patient’s desire for compliance. In situations dictated by other medical, behavioral or social circumstances that may reject full-time bracing, a nighttime protocol can be a compromise with considerable efficacy over observation alone.
In terms of limitations, there was a lack of measurement of brace therapy compliance with a compliance monitor and measurement of skeletal age by chronologic age. In addition, Risser staging is not as accurate as the Sanders skeletal maturation method, and the scoliosis-specific exercise protocol was not standardized or assessed for compliance. The adverse events (although mild) were higher in the brace group, and we are not given data on whether certain curve types are more responsive to nighttime bracing vs. others.
Reference:
Weinstein SL, et al. N Engl J Med. 2013;doi:10.1056/NEJMoa1307337.
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