The effectiveness of scoliosis treatment is not a matter of the type of brace

We congratulate the authors of the paper “Providence night-time brace is as effective as fulltime Boston brace for female patients with adolescent idiopathic scoliosis: A retrospective analysis of a randomized cohort” [[1]Capek V Westin O Brisby H Wessberg P Providence nighttime brace is as effective as fulltime Boston brace for female patients with adolescent idiopathic scoliosis: a retrospective analysis of a randomized cohort.N Am Spine Soc J. 2022; 12100178https://doi.org/10.1016/j.xnsj.2022.100178Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar]. However, there are some important considerations about this paper and, more broadly, about how research is performed in this specific field. In synthesis: results do not depend on the type of brace but on the treating team and how compliance issues are managed. The demonstrated factors which influence the effectiveness of brace treatment include: its design, the correction ability, the applied dosage, and the aggressiveness of scoliosis. In research, we can control the latter element with study design and well-balanced groups, the other 3 elements depend on the treating team. The correction of a brace is judged through in-brace radiography. While the lack of radiographic in-brace correction is a strong negative predictive factor for treatment success [[2]van den Bogaart M van Royen BJ Haanstra TM et al.Predictive factors for brace treatment outcome in adolescent idiopathic scoliosis: a best-evidence synthesis.Eur Spine J. 2019; 28: 511-525https://doi.org/10.1007/s00586-018-05870-6Crossref PubMed Scopus (36) Google Scholar], experts suggest focusing more on the 3-dimensional action of the brace [[3]Guy A Labelle H Barchi S Aubin CÉ The impact of immediate in-brace 3D corrections on curve evolution after two years of treatment: preliminary results.Stud Health Technol Inform. 2021; 280: 163-167https://doi.org/10.3233/SHTI210459Crossref PubMed Scopus (1) Google Scholar]. Nevertheless, the optimal level of correction is still to be determined. Unfortunately, in this case, the 2 studied braces will provide not comparable radiographic in-brace information because of their overall action: overcorrective bending versus 3-point. According to the internationally accepted brace classification, the overall action of the Providence brace is “bending” to achieve overcorrection on the “frontal” plane, possible because the brace is not meant to be worn standing. Contrarily, the Boston brace is done during activities of daily life and the action is “3-point” on the “frontal and transverse” planes [[4]Negrini S Aulisa AG Cerny P et al.The classification of scoliosis braces developed by SOSORT with SRS, ISPO, and POSNA and approved by ESPRM.Eur Spine J. 2022; 31: 980-989https://doi.org/10.1007/s00586-022-07131-zCrossref PubMed Scopus (7) Google Scholar]. The decision about brace dosage is the other key and even more complicated decisional factor [[2]van den Bogaart M van Royen BJ Haanstra TM et al.Predictive factors for brace treatment outcome in adolescent idiopathic scoliosis: a best-evidence synthesis.Eur Spine J. 2019; 28: 511-525https://doi.org/10.1007/s00586-018-05870-6Crossref PubMed Scopus (36) Google Scholar]. It depends on risk assessment, goals and the beliefs of the treating physician, the family's commitment and acceptance of the prescription by the adolescent. Recent evidence suggests the role of numerous baseline psychosocial factors associated with future compliance [[5]Gornitzky AL England P Kiani SN et al.Why don't adolescents wear their brace? a prospective study investigating psychosocial characteristics that predict scoliosis brace wear.J Pediatr Orthop. 2023; 43: 51-60https://doi.org/10.1097/BPO.0000000000002272Crossref PubMed Scopus (1) Google Scholar] It's clear that compliance goes beyond factors related to the “brace tool” [[6]Shaughnessy WJ Advances in scoliosis brace treatment for adolescent idiopathic scoliosis.Orthop Clin North Am. 2007; 38 (v): 469-475https://doi.org/10.1016/j.ocl.2007.07.002Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar]. Other members of the treating team can make a difference in helping compliance. The orthotist, in addition to being skilled and well trained, should have the ability to properly interact with the patient in the delicate moments of brace building, fitting, and check [[7]Negrini S Grivas TB Kotwicki T et al.Guidelines on “Standards of management of idiopathic scoliosis with corrective braces in everyday clinics and in clinical research”: SOSORT consensus 2008.Scoliosis. 2009; 4: 2https://doi.org/10.1186/1748-7161-4-2Crossref PubMed Scopus (85) Google Scholar]. Another fundamental element too often underestimated is the physiotherapist who isn't just the “exercise expert,” but also someone whose evaluation of the brace can move the balance from increasing to reducing the compliance [[8]Tavernaro M Pellegrini A Tessadri F et al.Team care to cure adolescents with braces (avoiding low quality of life, pain and bad compliance): a case-control retrospective study. 2011 SOSORT award winner.Scoliosis. 2012; 7: 17https://doi.org/10.1186/1748-7161-7-17Crossref PubMed Scopus (34) Google Scholar]. Full-time brace wear showed to be more effective than part time and dosage of brace wear showed to be the principal factor leading to better end of growth results. All these factors involved in compliance can explain different results [[9]Dolan LA Donzelli S Zaina F et al.AIS bracing success is influenced by time in brace: comparative effectiveness analysis of BrAIST and ISICO cohorts.Spine. 2020; 45: 1193-1199https://doi.org/10.1097/BRS.0000000000003506Crossref PubMed Scopus (20) Google Scholar]. Sometimes it's hard for parents to accept such demanding treatment, and they must be well-informed about the risks of scoliosis and the potential benefits of treatment [[10]Motyer G Dooley B Kiely P Fitzgerald A Parents’ information needs, treatment concerns, and psychological well-being when their child is diagnosed with adolescent idiopathic scoliosis: a systematic review.Patient Educ Couns. 2020; 104: 1347-1355https://doi.org/10.1016/j.pec.2020.11.023Crossref PubMed Scopus (11) Google Scholar]. All the team at large (therapeutic and family) should support the adolescent along this journey to make it successful, applying the principles of psychologically informed clinical practice [[11]Provost M Beauséjour M Ishimo M-C et al.Development of a model of interprofessional support interventions to enhance brace adherence in adolescents with idiopathic scoliosis: a qualitative study.BMC Musculoskelet Disord. 2022; 23: 406https://doi.org/10.1186/s12891-022-05359-wCrossref PubMed Scopus (1) Google Scholar]. When necessary, the team should include a psychologist for further help. Implementing all these elements cannot guarantee a 100% success rate. Still, the association of well-designed and built braces, together with the commitment of the treating team, can raise compliance up to 95% even with full-time braces [[12]Donzelli S Zaina F Negrini S In defense of adolescents: they really do use braces for the hours prescribed, if good help is provided. Results from a prospective everyday clinic cohort using thermobrace.Scoliosis. 2012; 7: 12https://doi.org/10.1186/1748-7161-7-12Crossref PubMed Scopus (46) Google Scholar]. These are the keys to the success of conservative scoliosis treatment. One or more of the authors declare financial or professional relationships on ICMJE-NASSJ disclosure forms.