Our results confirm the findings of other researchers that the management of progressive idiopathic scoliosis with corrective bracing and physiotherapy alters the natural history of the disease. We were able to stop the progression in 48.1% of patients and to slow down the rate of progression in additional 39.2%. The percentage of patients in whom the Cobb angle exceeded 50 degrees (12.7%) and therefore had surgical recommendation may be considered comparable to the literature data. On the other hand, we were not fully satisfied with a relatively large percentage of patients in whom the intended therapeutic effect of stopping progression was not achieved (51.9%). Progression was observed mainly in the youngest and least skeletally matured children (Table 1.). The authors recognize that they have not followed the recommendation to consider the progression as the 10°of Cobb angle difference for the curves under 25°. However, there were only three patients with the curves of 20 to 24° (two of them had a curve of 22° and one had a curve of 23°of Cobb). Also, we cannot be sure that all patients being over 30° at the treatment initiation represented progressive scoliosis.
In the 1995 Nachemson's et al. study on wearing a brace demonstrated better outcome than observation alone . However, the research carried out by Goldberg et al. on the effectiveness of the Milwaukee brace and the TLSO showed that bracing did not influence the rate of surgical procedures. In the control group, the surgical procedures amounted to 28.1%, while in the braced group to 24%, which was not significantly different . Further publications demonstrated a lower rate of surgery in conservatively treated patients. Maruyama et al. studied a large group of 328 patients. In 20 patients (6.1%), scoliosis progression exceeding 50° was observed and those patients were qualified for surgery. The age of initiating the bracing in this subgroup was 13.4 years, the Cobb angle was 48.5°, the mean age of surgery was 16.0 years, whereas the angle of curvature after the bracing was 62.2° . Rigo et al. studied a group of 157 children qualified for bracing. During the observation period, 13 patients did not complete the therapy, whereas 6 were qualified for surgical treatment with the mean Cobb angle of 61.5°. Thus, the frequency of surgery was 3.8%. Assuming that the patients who did not complete the therapy would also undergo surgical treatment, the surgery rate would be of 12.1% . Negrini et al. conducted a prospective study of 112 patients; the complete data of 108 patients, aged 13.2 ± 1.8 years, with initial Cobb angle 23.4 ± 11.5° was available. One person underwent corrective spinal procedure, which makes the frequency of surgery at the level of 0.9%, and assuming that the patients who did not complete the treatment would also undergo surgery - at the level of 4.5% . Weiss et al. in a retrospective study of the patients treated with the Chêneau brace between 1993 and 1996 in Bad Sobernheim, analyzing 343 girls, having the angle of curvature of 33.4° found 41 patients having underwent operation, which makes the rate of surgery 11.9% . Lange et al. in a retrospective study reported good long-term results of Boston brace treatment with the rate of 6.5% of patients who underwent scoliosis surgery .
In this study, the number of patients that we initially debated to consider as the drop-outs seemed very high. In fact, in our opinion these patients do not fulfill the criteria for being considered the real drop-outs. They may be considered as the patients who were not treated in our institution. We disclosed their number for clarity, however we cannot feel responsible for their course of the disease. The issue concerns the organization and logistics of the health care services in our country, and the patients' attitude. Thus, it is not be used to assess the quality of conservative scoliosis treatment. We were aware that the parents of 56 patients continued managing their child at proximity of the place they lived, however we are not able to assess the quality and the outcome of such a management. Moreover, we had no data of the 54 patients who received brace recommendation but never appeared after the first visit. We suppose that some of them did not accept this form of therapy while some found the orthosis providers elsewhere. Unfortunately, we are afraid of the quality of the orthoses because we could observe examples of various constructions, often erroneous, of plastic devices delivered under the name of Chêneau by negligent producers. This made us express our opinion on the need for registering new patients receiving conservative scoliosis treatment and for the standardization of the orthotic treatment in our country.
We paid extreme importance to psychological support in order to decrease the stress and increase the compliance. We noticed that Chêneau brace was unwillingly accepted by adolescents because of aesthetic and functional reasons. The brace was considered, especially by girls, as an element making every day life activities difficult. In our opinion, the role of regular physiotherapy specifically adjusted to the type and degree of scoliosis is crucial. The lack of determination to wear the brace and to follow physician's recommendations was a regularly observed risk. The patients undergoing the brace treatment having scoliosis at the angle of 40° or more were referred for an orthopedic consultation in order to consider the plan of surgical intervention. Afterwards, we observed that the motivation of these patients and the family to continue the conservative treatment strengthened in most cases.