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Soft braces in the treatment of Adolescent Idiopathic Scoliosis (AIS) – Review of the literature and description of a new approach
© Weiss and Werkmann; licensee BioMed Central Ltd. 2012
- Received: 18 February 2012
- Accepted: 23 April 2012
- Published: 28 May 2012
The Retraction Note to this article has been published in Scoliosis 2013 8:7
The use of soft braces to treat scoliosis has been described by Fischer as early as 1876. With the help of elastic straps, as the authors suggested, a corrective movement for individual curve patterns should be maintained in order to inhibit curve progression. Today this concept has been revived besides soft 3 point pressure systems. Some shortcomings have been revealed in literature in comparison with hard braces, however the concept of improving quality of life of a patient while under brace treatment should furtherly be considered as valuable. Purpose of this review is to gather the body of evidence existent for the use of soft braces and to present recent developments.
A review of literature as available on Pub Med was performed using the key words ‘scoliosis’ and ‘soft brace’ at first. The search was expanded using ‘scoliosis’ and the known trademarks (1) ‘scoliosis’ and ‘SpineCor’, (2) ‘scoliosis’ and ‘TriaC’, (3) ‘scoliosis’ and ‘St. Etienne brace’, (4) ‘scoliosis’ and ‘Olympe’. The papers considered for inclusion were new technical descriptions, preliminary results, cohort studies and controlled studies.
When searching for the terms ‘scoliosis’ and ‘SpineCor’: 20 papers have been found, most of them investigating a soft brace, for ‘scoliosis’ and ‘TriaC’: 7 papers displayed, for ‘scoliosis’ and ‘St. Etienne brace’: one paper displayed but not meeting the topic and for ‘scoliosis’ and ‘Olympe’: No paper displayed. Four papers found on the SpineCor™ were of prospective controlled or prospective randomized design. These papers partly presented contradictory results. Two papers were on soft Boston braces used in patients with neuromuscular scoliosis.
There is a small but consistent body of evidence for the use of soft braces in the treatment of scoliosis. Contradictory results have been published for samples treated during the pubertal growth spurt. In a biomechanical analysis the reason for the lack of effectiveness during this period has been elaborated. Improved materials and the implementation of corrective movements respecting also the sagittal correction of the scoliotic spine will hopefully contribute to an improvement of the results achievable.
The treatment of scoliosis using soft braces is supported by some papers providing a small body of evidence. During the growth spurt the use of soft braces is discussed contradictory. There is insufficient evidence to draw definite conclusions about effectiveness and safety of the intervention.
- Adolescent Idiopathic Scoliosis
- Corrective Movement
- Lumbar Lordosis
- Shoulder Girdle
- Pelvic Girdle
However soft braces have been forgotten for long: Hard braces have been proposed by Wullstein (1902) not long after the first publications on soft braces. Later the Milwaukee brace has been proposed, the Chêneau brace[4, 5] and the Boston brace, all of them hard braces with reasonable impact on the quality of life of the patients treated.
While the Milwaukee brace was less effective, early outcome studies have described the Chêneau brace[4, 5] and the Boston brace as effective in the prevention of curve progression during growth. Prospective controlled multicenter and long-term studies have shown the Boston brace to be effective, but there were also outcome studies on the Chêneau brace clearly demonstrating that in-brace correction and compliance are crucial to the outcome of brace treatment.
During the late 80’es and early 90’es in France soft braces with the 3-point pressure approach have been described like the St. Etienne brace and the Olympe[10, 11], but these have not been investigated furtherly.
During the 90’es soft brace treatment was re-developed. The soft brace as presented by Coillard[12–14], comparable to the brace described by Schanz, was indroduced another time and the first results were published in 2003. A cohort of patients from 4 – 14 years of age have been treated successfully with the help of this brace. Later on more positive results have been published. However, as Coillard and Rivard have pointed out the group of patients at risk for progression (first signs of maturation, premenarchial) showed to have the least positive effects.
In two independend prospective controlled studies the soft brace as presented by Coillard[12–14] has been shown to be less effective than hard braces[15, 16]. This fact has been analyzed and the unsatisfactorily correction of the sagittal profile in the soft brace as presented by Coillard[12–14] has been accused to be the reason for this.
As a matter of fact a relordosation of the lumbar spine is not induced when using the soft brace as presented by Coillard[12–14]. Therefore the compressive forces generated in this application may destabilize the spine, while a restoration of the sagittal profile can stabilize and even correct scoliosis as has been described by van Loon in 2008. Other reviews, experimental studies or case series seem to support these findings[19–26].
Purpose of this development was to improve the corrective movements in frontal plane as have been described[12–14] and add a considerable correction of the sagittal plane in order to stabilize the spine while it is compressed by the elastic straps, wrapped around the entire trunk.
However, some shortcomings[15–17] have been revealed in literature in comparison with hard braces, however the concept of improving quality of life of a patient while under brace treatment should furtherly be considered as valuable. Purpose of this review is to gather the body of evidence existent for the use of soft braces and to present recent developments.
A review of literature as available on Pub Med was performed (January 31st. 2012) using the key words ‘scoliosis’ and ‘soft brace’ at first. The search was expanded using ‘scoliosis’ and the known trademarks (1) ‘scoliosis’ and ‘SpineCor’, (2) ‘scoliosis’ and ‘TriaC’, (3) ‘scoliosis’ and ‘St. Etienne brace’, (4) ‘scoliosis’ and ‘Olympe’.
A case report is presented to demonstrate the in-brace correction achievable in a recent development.
‘scoliosis’ and ‘SpineCor’: 20 papers have been found, most of them investigating a soft brace.
‘scoliosis’ and ‘TriaC’: 7 papers displayed.
‘scoliosis’ and ‘St. Etienne brace’: one paper displayed but not meeting the topic
‘scoliosis’ and ‘Olympe’: No paper displayed.
The idea of using soft braces and reducing the impact braces have on the patients is appreciated. However as there seem to be certain shortcomings, these should be ruled out to increase patients’ safety and enlarge the range of indications.
The corrective movement in frontal plane as described by Fischer and later by Coillard[12–14] should be preserved while lumbar lordosis should be augmented with the help of a newly designed soft brace. The first step into this direction was the development of a soft brace called “Universal Spine Orthosis (USO)™” (patent pending) in 2007, which has not been applied widely.
The harness for adjustment of the corrective ribbons provided using the soft brace as presented by Coillard[12–14] was replaced by a small plastic fixation element where the elastic ribbons can be adjusted to. This fixation element is adjusted to augment lumbar lordosis (Figure2).
The USO™ allows to adjust the corrective ribbons in multiple ways for different purposes and therefore can be used for other indications than scoliosis treatment as well.
However the USO, like other softbraces in use today[12–14] is not easy to adjust and also with this softbrace the patients may experience some problems in everday use (eg. clothes change, toilet use). Therefore we found further developments necessary to (1) make the brace easier to adjust, (2) easier to use and (3) to implement the corrective movements necessary in 3D.
Within the Scoliologic™ ‘Best Practice’ program of physiotherapy we have a simple 3D system of postural corrections. This consists of (1) pelvic girdle correction, (2) shifting of shoulder girdle against pelvic girdle, (3) spiral shoulder girdle correction and (4) correction of the sagittal profile[21, 22].
Therefore it was the aim of our recent development to implement all these principles of correction and by the same time make the new soft brace development smaller and more easy to adjust. The result of this development is demonstrated in the following.
A new soft brace for 3D correction of scoliosis – the Spinealite™
Correcting ribbon materials
The adjustment is described in more detail in the accompanying product description.
Case report of the in-brace correction possible in the Spinealite™
As the patient reported some problems with compliance in hard braces it was decided to offer the Spinealite™ soft brace additionally so she could change braces wearing the Spinealite™ for 12 hrs. over daytime and the Gensingen brace™ for 12 hrs. in the evenings and at night.
A video showing the adjustment of correction in this new soft brace is available.
There is a small body of evidence for the use of soft braces in the treatment of scoliosis[12–17, 27–44]. Contradictory results have been published for samples treated during the pubertal growth spurt[15–17, 30, 32, 34]. In a biomechanical analysis the reason for the lack of effectiveness during this period has been elaborated. Improved materials and the implementation of corrective movements respecting also the sagittal correction of the scoliotic curve will contribute to an improvement of the results achievable (Figure5 and9).
At this moment we apply the new soft brace system (Spinealite™) together with high corrective hard braces, 12 hrs. each, however with increasing numbers of patients and increased experience we do hope to offer this new soft brace as the sole form of treatment for adolescents during growth in the near future.
Although there is a small body of papers on soft brace treatment as found in literature[12–17, 27–44] we would not expose our patients to the risk of sole softbrace treatment as some of the papers reveal contradictory outcomes[15–17, 30, 32, 34] and restrictions to use certain types of braces with respect to curve patterns.
At this stage there is no evidence that the Spinealite™ can improve the outcome of soft bracing, however the principle of applying corrective movements as described by Fischer and later by Coillard[12–14] has been found to be beneficial to some extent. The trunk shift in combination with the other 3D corrective movements is a powerful corrective force as can be seen on Figure4. The addition of a sagittal corrective movement theoretically should enable to improve the outcome of soft bracing additionally[18–20], but this finally has to be proven in future studies.
This new soft brace has been shown to be able to correct a scoliosis to an extent comparable to high corrective hard braces. Therefore we expect beneficial outcomes when the brace can be worn as prescribed[9, 26].
In principle the Fischer brace, SpineCor and the Spinealite are using a certain corrective movement mainly derived from physical therapy approaches, while the only other soft brace on the market today, the TriaC is using the standard three-point system and can only be applied for certain single curves.
The full correction as possible should not be applied from the very start. A slight corrective movement should be visible in frontal and sagittal plane which can be increased every week. The application of this new system, however requires an experienced clinician able to distinguish between the different curve patterns of the ALS classification used for a proper adjustment of both, hard- and soft brace.
The Spinealite™ soft brace / biofeedback device is using certain corrective movements which have been described earlier on[21, 22, 48–51], however, according to a recent review it should be emphasized that the power of exercises should not be overestimated, see Figure six from that article. Nevertheless, we propose to perform the Scoliologic™ ‘Best Practice’ program as described by Borysov and Borysov extensively.
The treatment of scoliosis using soft braces is supported by some papers providing a small body of evidence.
During the growth spurt the use of soft braces is discussed contradictory.
There are shortcomings with respect to limitations of indication.
There is insufficient evidence to draw definite conclusions about effectiveness and safety of the intervention (soft brace treatment).
Written informed consent was attained by the patients and parents to permit the publication of the clinical pictures.
I wish to thank Pflaum Company for permitting the publication of pictures taken or modified from the book with the title Weiss HR: Best practice in conservative scoliosis care. 4th edition 2012.
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