AIS SUPPLEMENT
Bracing for Adolescent Idiopathic Scoliosis
in Practice Today
Paul D. Sponseller, MD
Background: The use of orthoses in adolescent idiopathic
scoliosis has a long history. The purpose of this article is to
summarize the current practice of bracing in the treatment of
adolescent idiopathic scoliosis.
Methods: The literature from the past 25 years was reviewed for
primary papers that contained accepted inclusion criteria for
bracing, meta-analyses, and summaries of existing opinion. Recent
literature was also reviewed for current bracing practices.
Results: The highest level of existing evidence comes from a
prospective center-randomized study by Nachemson et al, which
showed that bracing was effective for single curves of 25 to 35
degrees in female patients with a starting Risser score of 0 to 2.
Two other studies with meta-analyses came to opposite conclu-
sions because of variations in the examined investigations.
Although there are few studies that compare different types of
treatment, most show an improved outcome versus historical
controls. The yearly number of peer-reviewed papers on the topic
has increased markedly over this time. Two prospective random-
ized multicenter trials are underway. Reviews suggest that most
orthopaedic specialists recommend bracing but that they differ on
expected results. There is also a proliferation of interest in bracing
by nonorthopaedists, with more varied indications. There are
many types of full-time and part-time braces, and their designs and
indications are described.
Conclusions: Brace treatment for adolescent idiopathic scoliosis
continues to be frequently used, and the number of brace types
has increased. Predicting progressive curves and refining
indications requires additional investigation.
Key Words: adolescent idiopathic scoliosis, brace, orthoses
(J Pediatr Orthop 2011;31:S53–S60)
T he use of orthoses in adolescent idiopathic scoliosis
(AIS) has a long and much studied history. The
rationale for their use has been that external forces
can guide the growth of the spine. Experimental work
by Aronsson et al1 has shown this concept to be valid.
From the Department of Orthopaedic Surgery, The Johns Hopkins
University, Baltimore, MD.
Supported by none.
Reprints: Paul D. Sponseller, MD, c/o Elaine P. Henze, BJ, ELS,
Medical Editor and Director, Editorial Services, Department of
Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, 4940
Eastern Avenue, #A665, Baltimore, MD 21224-2780. E-mail:
ehenze1@jhmi.edu.
Copyright r 2011 by Lippincott Williams & Wilkins
J Pediatr Orthop  Volume 31, Number 1 Supplement, January/February 2011
Although parents and caregivers hope that curves can be
straightened, this goal is not often achieved. However,
there has been continued evidence to suggest that the
natural history of progression can be changed and that
progression can be prevented in some patients. Standards
of modern clinical evidence-based medicine have prompted
a critical review of the evidence and exposed possible
weaknesses in methodology. This article reviews evidence
on the efficacy of bracing, places it in modern perspective,
and assesses the current practice of bracing.
EVIDENCE FOR BRACE TREATMENT
In 1993, the United States Preventive Services Task
Force2 analyzed the evidence for the efficacy of bracing.
They concluded that there was “insufficient evidence to
determine whether bracing altered the natural history
of idiopathic scoliosis in a significant proportion of
cases.”2 However, the use of orthoses has continued and
increased. Why do many physicians treating scoliosis
prescribe a brace? There is some clinical evidence of
efficacy. Some of the best evidence came from a meta-
analysis of 20 qualifying studies done by Rowe et al.3
They analyzed 1910 patients in those studies who had
nonoperative treatment for idiopathic scoliosis, including
129 who had observation only.3 They showed that bracing
altered the natural history of scoliosis and that full-time
bracing was significantly more effective than part-time
bracing; the weighted mean proportion of success was 0.93
for full-time bracing, 0.62 for 16 or more hours per day,
and 0.42 for observation alone.3
Even more noteworthy was the prospective, center-
randomized, international study by Nachemson and
Peterson4 published in 1995, in which 86% of enrolled
patients completed the study. This project showed that
bracing [using the Boston thoracolumbosacral orthosis
(TLSO)] was effective in girls with 25-degree to 35-degree
curves, and survivorship analysis showed that the success
rates of bracing and observation alone were 74% and
34%, respectively.4
More recently, Danielsson et al5 completed a 16-year
follow-up of the Swedish patients who had been included
in the study by Nachemson and Peterson.4 The 65 patients
from Goteborg who were initially unbraced were com-
pared with 41 patients from Malmo who were treated with
bracing.5 Of the 65 Goteborg patients, 14 were later braced
for progression and 6 were treated operatively.5 At 16-year
follow-up, the 65 Goteberg patients had a mean increase of
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Sponseller J Pediatr Orthop
6 degrees.5 The 41 braced Malmo patients underwent no
surgery and had no mean progression.5 The investigators
commented that the commitment to bracing in Malmo was
strong and might not be representative of every center.5 An
earlier study by the Malmo group analyzed the rate of
scoliosis surgery in this relatively stable population during
the periods before and after the introduction of school
screening within the space of a decade.6 They showed that
the risk of a patient presenting to the scoliosis clinic
needing surgery declined more than 3-fold after school
screening was introduced.6 They attributed this finding to
the effects of earlier bracing.6
A counterpoint came from a study by Noonan et al,7
who showed that of 88 patients who underwent treatment
with a Milwaukee brace, 42% later became surgical candi-
dates. Factors that may have led to the results in this study,
however, were the rather large mean curve of 34 degrees
at the start of bracing.7 The investigators also reported
a rather low 15% in-brace correction,7 lower than that
reported in most brace studies (30% to 73%).4,8–16
More recent research includes a meta-analysis by
Dolan and Weinstein.17 They analyzed 18 studies meeting
inclusion criteria to focus on the rate of patients reaching a
curve size at which a surgical recommendation was made.17
This analysis included many types of braces, including
part-time braces such as Charleston and Providence.17 The
investigators showed no difference in surgical rates for
braced patients (23%) and unbraced patients (22%).17
They also confirmed that the highest risk of progression
was in single thoracic curves, followed by double curves,
then thoracolumbar curves.17 One weakness of the study
was that they had unbraced (observation) data from only
2 centers, and the progression rates differed widely.17 The
difference between the conclusion of this study and that of
Rowe et al3 may stem from a wider range of bracing
practices and a more selective series of controls.
In a survey of professional opinion, Dolan et al18
queried orthopaedic experts who had practices in which
more than 25% of their patients had idiopathic scoliosis.
The responses showed that most of those experts still
recommended bracing for scoliosis, and the investigators
estimated that the surgical risk reduction attributable to
bracing was 20% to 25%.18 They found the least agreement
in the estimates for premenarchal patients and used this
conclusion to advocate that there is equipoise on the role of
bracing among experts.18 This conclusion was one of the
foundations for the development of the ongoing National
Institutes of Health-funded BrAIST study,18,19 a prospec-
tive randomized trial of bracing in AIS. A prospective,
randomized study is underway in the Netherlands to
compare treatment with a Boston brace versus observation
for patients with curves of 22 to 35 degrees.20
Other studies have provided evidence regarding
bracing by focusing on subpopulations of patients with
AIS or specific aspects of the treatment.21–23 Karol21
studied male patients with AIS and found that compli-
ance was good in only 38% of patients. Those with curves
of >30 degrees had a 50% chance of reaching the surgical
threshold.21 The results were inferior to those for bracing
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 Volume 31, Number 1 Supplement, January/February 2011
in comparable populations of female patients; reasons
given include a longer period of adolescent growth and
lower compliance rates.21 In-brace correction is also highly
correlated with brace success, as shown in multiple studies.
Correction of a curve by more than 33% to 50% using an
orthosis is highly predictive of success in bracing.22 O’Neill
et al23 studied the effect of being overweight on the results
of bracing using multivariate logistic regression analysis
of a large braced population followed to maturity. The
overweight patient (body mass index >85th percentile)
had a 2.6 times greater risk of failure of brace treatment
than that of patients whose weight was below this threshold,
and the surgical rate was nearly double.23
Compliance is measurable with temperature and
pressure sensors. Studies have shown that braces are worn
approximately half (47%) of the prescribed time.24,25 Use
declines with the patient age, especially after menarche,
and is less in male patients, but it is highly correlated with
the success of bracing in several studies.23,26 Monitoring
can also increase the rate of compliance with bracing.
There is also the possibility that genetic studies may be
able to stratify the risk of progression and brace failure.
To make conclusions of future studies more compar-
able, the Scoliosis Research Society Committee on Bracing
and Nonoperative Management has suggested that all
research on the topic of bracing for AIS meet standard
criteria for inclusion and outcome reporting.27 Inclusion
criteria should be: age >10 years, Risser sign 0 to 2,28
female patients <2 years postmenarche, and curve size 20
to 40 degrees.27 All patients should be followed in the
study, regardless of compliance with the brace (“intention
to treat”).27 The committee recommends follow-up of
at least 2 years after skeletal maturity.27 Results should
be reported as percentage of patients who progressed
<5 degrees, percentage who progressed beyond 45 degrees,
and percentage for whom surgery was recommended.27
Possible negative effects of bracing have also been
studied. A temporary decrease in urinary sodium excre-
tion has been shown, which reverts to normal within
a year of brace wear.29 In light of studies showing that
bone mineral density is diminished in some patients with
AIS, Snyder et al30,31 initiated a case-control study that
carefully measured bone mineral density. They showed
that braces do not reduce bone density in AIS. However,
in the short term, the Boston brace has been shown to
reduce lung volumes and pulmonary compliance com-
pared with prebrace values.32 Bracing has well-known
psychologic effects on teens,33 but these effects may wane
in the long term.34
After balancing the costs and benefits, it seems that
many parents have a classical view of pediatric orthopae-
dics, that is, that adolescence is the time to use the unique
properties of growth to create a “straight child” and alter
his or her natural history. Some parents and children
are willing to make a short-term sacrifice in lifestyle if they
can expect that they will have better health outcomes
(less deformity, less pain, and lower risk of surgery) in the
future. This interest in nonoperative treatment remains
strong. Orthopaedic surgeons have struggled to interpret
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J Pediatr Orthop  Volume 31, Number 1 Supplement, January/February 2011
evidence of brace efficacy to alter the natural history.
In general, they do not show great enthusiasm for a
treatment that seems to alter the natural history only
approximately 25% of the time. At the same time, this
reluctance has been interpreted as evidence lack of interest,
on the part of orthopaedists, in nonoperative treatment or
as a rush toward surgery. Strikingly, Negrini35 has stated
that “The existing prevalence of a single society (orthopae-
dic surgeons) in AIS treatment could be creating distortions
in patient care and/or cure.y other specialists wholly
devoted to conservative treatmentFparticularly, but not
exclusively, PRM specialistsFshould enter the field more
and more to create better treatment teams.” This sentiment
led to the formation of an International Society on Scoliosis
Orthopaedic and Rehabilitation Treatment in 2004. Society
on Scoliosis Orthopaedic and Rehabilitation Treatment
has focused on nonoperative treatments and has established
a journal, “Scoliosis.” In parallel, a PubMed search of the
number of articles on bracing for AIS has showed a
continuous increase over the years, but much more in the
general literature than in the orthopaedic surgery literature
(eg, Spine, Journal of Bone and Joint Surgery, Journal of
Pediatric Orthopaedics, Clinical Orthopaedics and Related
Research, European Spine Journal, and the Journal of
Spinal Disorders) (Fig. 1). Most of these articles continue
to present no better evidence than that in earlier years, but
some practitioners seem to be more enthusiastic about the
application of nonoperative treatments. Most do not yet
meet the guidelines of the Scoliosis Research Society for
bracing studies.
Therefore, what is the role of bracing? There still is
no level-I evidence, although the study by Nachemson
and Peterson4 comes close. Although very few studies are
stratified by curve type or maturity, there is indirect
evidence for an effect, including the relationship of results
to compliance, to in-brace correction, and to patient
weight.23,24,26 All of these statistically significant observa-
tions lend support to the possibility that bracing may alter
the natural history of a progressive curve. However,
although bracing may modulate the effect of growth,
there is, on the whole, no meaningful curve correction of
FIGURE 1. The yearly number of peer-reviewed articles on bracing for adolescent idiopathic scoliosis in orthopaedic journals
versus those in the general literature.
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Bracing for Adolescent Idiopathic Scoliosis
curve. Nonetheless, there may be some exceptions and
some reduction of risk for surgery. On account of this
possibility, the physician should convey these concepts
to the patient’s family to help reach a decision about
treatment. Families must understand that there is a risk
that brace wear may not be successful, but that success is
increased with discipline and compliance. After these
concepts are understood by the patient and the parents,
the caregiver should ask the patient, “is this worthwhile to
you?” Sometimes time is required for the patient and
parents to weigh the facts and make a decision. In such
cases, a follow-up visit may be a good method to
consolidate the plan and formulate the next steps.
INDICATIONS FOR BRACING
Deciding when to use a brace involves assessing the
risk of progression if untreated, including growth-related
risk (estimated from radiographs and physical examina-
tion); sex-related risk (with female patients having a
greater risk); genetically determined risk (there may be a
blood test, based on empirical data and study of genetic
markers, for this risk); and curve-related risk (curve size
and immaturity are the 2 most widely appreciated risk
factors, and curve type, with thoracic and double major
curves having the highest rate of progression).
A synthesis of the best evidence and of current
practice suggests that patients with curves of 25 to 45
degrees in the most rapidly growing Risser 0 to 1 years,
and some patients with smaller curves showing recent
progression, should be offered a brace on initial evalua-
tion. Patients who have a Risser score of 2 or 3 and curves
of 30 to 45 degrees may be offered a brace on initial
evaluation, although there is less proven chance to alter
the natural history.
Groups for whom bracing may be less useful include
overweight patients (for whom a greater risk of failure
has been shown),23 patients with a high thoracic curve
(a major curve apex above T8), patients with a lordotic
thoracic spine, and patients with any other major medical
problem (that may deter brace wear) or who do not
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Sponseller J Pediatr Orthop
FIGURE 2. The Milwaukee (cervicothoracic lumbosacral
orthosis) brace.
accept the concept of bracing. Patients who have passed
the peak height velocity, are within a year of skeletal
maturity, or are 1-year postmenarche are unlikely to have
an alteration in the natural history by beginning brace use
at that time.
Despite its widespread use, the Risser sign is
notoriously variable as a radiographic marker of matur-
ity.28 Critical analysis has shown that the Risser sign is no
better a predictor of maturity than is chronologic age.
The entire rapid phase of growth is contained within the
Risser 0 period, limiting the ability of this sign to help
determine the peak height velocity. It is sometimes helpful
to use bone age to determine the rapid phase of growth
or the curve acceleration phase. Sanders et al36 has shown
that the early phase of adolescent rapid growth is when
most digits are capped and metacarpal epiphyses are
wider than the metaphyses. This scenario occurs in female
patients 11 to 12 years old and in male patients 13 to
14 years old. It also corresponds to the peak height
velocity, still within Risser 0 with an open triradiate
cartilage. This is the beginning of the curve acceleration
phase and should be followed closely.
The late phase of adolescent rapid growth is when
any distal phalanges are closing, which happens in female
patients at a skeletal age of about 13 years and in male
patients at 15 years. The triradiate cartilage may just
be closing, which probably signifies the end of the most
important period for bracing.
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 Volume 31, Number 1 Supplement, January/February 2011
FIGURE 3. The Boston brace has a posterior-opening design,
made from a prefabricated module that is customized for a
given patient.
THE PRACTICE OF BRACING
The practice of bracing requires a dedicated
orthotist-orthopaedist relationship. Having the 2 profes-
sionals see the patient together at brace visits is ideal. If
this arrangement is not practical, there should at least be
a means of communicating about the brace results. The
first radiograph after a brace is prescribed should be
obtained with the patient in the brace, and the goal is
30% in-brace correction of thoracic curves and 50%
in-brace correction of thoracolumbar and lumbar curves.
If these values are not achieved, the brace should be
analyzed and modified as needed with the orthotist.
Follow-up visits occur every 4 months during peak height
velocity and then approximately every 6 months there-
after; at each visit, an out-of-brace radiograph is obtained.
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FIGURE 4. The Wilmington brace is made from a flexible
thermoplastic material.
The ability of exercises to improve on the results of bracing
has not been shown conclusively.37
For many types of braces, the evidence of efficacy
consists of case series. The Milwaukee cervicothoracic
lumbosacral orthosis (Fig. 2) is as effective as any orthosis
but its use has declined because of patient preference.
The Milwaukee brace may still have a limited role for
curves with a high apex or failures. The TLSO worn full-
time is the current standard. TLSOs can be custom
braces, Boston braces, or others. The Boston brace (Fig. 3)
is the most widely studied TLSO in the literature.4,8,20 It
is made from an “off-the-shelf” module chosen using
measurements from the patient. Pads are added at areas
needed to produce correction. Trim lines are made to
produce relief areas.
There are many other full-time TLSO types of
braces. One of the earlier alternatives was the Wilmington
brace (Fig. 4),9 a circumferential thermoplastic brace that
is less rigid than the Boston brace and is easier to custom-
make rapidly for patients. The SpineCor brace (Fig. 5) is
a flexible derotational brace designed to produce dynamic
detorsion. It is made with derotation straps attached to
pelvic and shoulder harnesses. It was studied by the
originators,38 who showed that 60% of patients stabilized
and only 23% required surgery. However, in a prospective
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Bracing for Adolescent Idiopathic Scoliosis
FIGURE 5. The SpineCor brace is flexible and incorporates
derotation straps attached to shoulder and pelvic harnesses.
randomized study, Wong et al39 showed that the SpineCor
brace had more failures and no better tolerance than other
brace types. The Cheneau brace (Fig. 6), developed in
Barcelona, has been used for more than 30 years. It
incorporates a contoured, gradual force distribution. The
originator described the corrective mechanism as providing
a convex-to-concave tissue transfer, elongation, derotation,
and bending.10,40 Force couples include anterior pressure
on 1 side of the trunk along with posterolateral pressure on
the other to produce detorsion. An important aspect of
the Cheneau brace is the use of “spaces” directly across
from the pressure areas to allow the trunk to shift,
designed to produce dynamic correction during respira-
tion. A “light” version of the brace is also available.10,40
The Triac brace is a dynamic brace with spring tension
that uses a thoracic and a lumbar portion coupled
together.11,12 The Sforzesco brace is a rigid, symmetrical
brace used in combination with an exercise protocol. It
has shown a mean 6-degree improvement in large curves
at short-term follow-up.13 For all of the above full-time
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Sponseller J Pediatr Orthop
FIGURE 6. The Cheneau brace (A) is custom-made with “force-couples” (B and C) of open spaces opposite pressure areas to
encourage tissue transfer.
braces, 23 hours wear per day is the goal and 16 to
23 hours of wear may have some benefit.
There are several “hypercorrective” braces that are
meant to be worn only at night. The first was the
Charleston bending orthosis (Fig. 7). It produces a focal
side-bending moment at the apex of the curve. Price
et al14 used it for all curves meeting standard brace
indications and showed that a 66% success rate, with
surgery indicated for only 17% of patients (follow-up, at
least 1 year after maturity). Double curves had the lowest
percentage of success. However, in a randomized study,
Katz et al15 compared Boston and Charleston bracing
for comparable curves and found that the Boston brace
had better results. They recommended that the use of the
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 Volume 31, Number 1 Supplement, January/February 2011
Charleston brace be confined to single curves of 25 to
35 degrees.15 Howard et al41 found similar results in
a retrospective study. The Providence brace (Fig. 8), a
nighttime brace, produces bending and derotation moments.
A case series by d’Amato et al16 showed improved results of
the Providence brace compared with historical controls.
For many experts, the role of these hypercorrective part-
time braces is to provide bracing for patients who are
unwilling to wear orthoses full-time.
Criteria for stopping brace use relate to skeletal
maturity. The most widely used is the Risser sign: 4 to 5
and growth <1 cm in a 6-month interval. Female patients
should be 1.5 to 2 years postmenarche, or the bone age
should show the distal radial physis closing. There seems to
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J Pediatr Orthop  Volume 31, Number 1 Supplement, January/February 2011
FIGURE 7. The Charleston night brace incorporates forced
bending.
be no difference between weaning versus stopping im-
mediately, but patients should be followed until their
curves are stable, especially if they are >40 degrees.
In general, approximately two-thirds of the patients
braced according to standard criteria progress <5 degrees,
whereas approximately 20% to 25% of the same group
progress to the range considered for surgery.17 Patients
undergoing orthotic treatment may benefit from support
sources such as other patients, websites, and national
patient groups. The experienced physician will let the
patient “own” the decision, because he or she will, anyway.
CONCLUSIONS
In summary, bracing may decrease the risk of curve
progression but it begs an accuracy of prediction that
physicians can only approximate. The desire among
patients for effective, nonoperative scoliosis treatment
shows no signs of fading. The goal of the profession
should be to more accurately determine which curves are
at risk of worsening and which of these can be influenced
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Bracing for Adolescent Idiopathic Scoliosis
FIGURE 8. The Providence brace is intended to produce
derotation.
by a brace, versus those curves that are at high risk
of requiring surgery. Although we seek this knowledge,
the current state of practice is to match the patient’s
personality with the treatment. Managing nonoperative
treatment requires team dedication.
REFERENCES
1. Aronsson DD, Stokes IAF, Rosovsky J, et al. Mechanical
modulation of calf tail vertebral growth: implications for scoliosis
progression. J Spinal Disord. 1999;12:141–146.
2. US Preventive Services Task Force. Screening for adolescent
idiopathic scoliosis. JAMA. 1993;269:2667–2672.
3. Rowe DE, Bernstein SM, Riddick MF, et al. A meta-analysis of the
efficacy of non-operative treatments for idiopathic scoliosis. J Bone
Joint Surg Am. 1997;79:664–674.
4. Nachemson AL, Peterson LE, The Brace Study Group of the
Scoliosis Research Society. Effectiveness of treatment with a brace in
girls who have adolescent idiopathic scoliosis: a prospective,
controlled study based on data from the Brace Study of the
Scoliosis Research Society. J Bone Joint Surg Am. 1995;77:815–822.
5. Danielsson AJ, Hasserius R, Ohlin A, et al. A prospective study of
brace treatment versus observation alone in adolescent idiopathic
scoliosis: a follow-up mean of 16 years after maturity. Spine. 2007;
32:2198–2207.
www.pedorthopaedics.com | S59
Sponseller J Pediatr Orthop
6. Montgomery F, Willner S. Screening for idiopathic scoliosis:
comparison of 90 cases shows less surgery by early diagnosis. Acta
Orthop Scand. 1993;64:456–458.
7. Noonan KJ, Weinstein SL, Jacobson WC, et al. Use of the
Milwaukee brace for progressive idiopathic scoliosis. J Bone Joint
Surg Am. 1996;78:557–567.
8. Emans JB, Kaelin A, Bancel P, et al. The Boston bracing system for
idiopathic scoliosis: follow-up results in 295 patients. Spine. 1986;
11:792–801.
9. Allington NJ, Bowen JR. Adolescent idiopathic scoliosis: treatment
with the Wilmington brace. A comparison of full-time and part-time
use. J Bone Joint Surg Am. 1996;78:1056–1062.
10. Weiss HR, Rigo M. The Cheneau concept of bracing: actual
standards. In: Grivas TB, ed. The Conservative Scoliosis Treatment.
1st SOSORT Instructional Course Lectures Book. The Netherlands:
IOS Press; 2008:291–302.
11. Zeh A, Planert M, Klima S, et al. The flexible Triac-Brace for
conservative treatment of idiopathic scoliosis: an alternative
treatment option? Acta Orthop Belg. 2008;74:512–521.
12. Bulthuis GJ, Veldhuizen AG, Nijenbanning G. Clinical effect of
continuous corrective force delivery in the non-operative treatment
of idiopathic scoliosis: a prospective cohort study of the TriaC-
brace. Eur Spine J. 2008;17:231–239.
13. Negrini S, Atanasio S, Negrini F, et al. The Sforzesco brace can
replace cast in the correction of adolescent idiopathic scoliosis:
a controlled prospective cohort study. Scoliosis. 2008;3:15.
(doi:10.1186/1748-7161-3-15).
14. Price CT, Scott DS, Reed FR Jr, et al. Nighttime bracing for
adolescent idiopathic scoliosis with the Charleston Bending Brace:
long-term follow-up. J Pediatr Orthop. 1997;17:703–707.
15. Katz DE, Richards BS, Browne RH, et al. A comparison between
the Boston brace and the Charleston bending brace in adolescent
idiopathic scoliosis. Spine. 1997;22:1302–1312.
16. d’Amato CR, Griggs S, McCoy B. Nighttime bracing with the
Providence brace in adolescent girls with idiopathic scoliosis. Spine.
2001;26:2006–2012.
17. Dolan LA, Weinstein SL. Surgical rates after observation and
bracing for adolescent idiopathic scoliosis: an evidence-based
review. Spine. 2007;32(19 suppl):S91–S100.
18. Dolan LA, Donnelly MJ, Spratt KF, et al. Professional opinion
concerning the effectiveness of bracing relative to observation in
adolescent idiopathic scoliosis. J Pediatr Orthop. 2007;27:270–276.
19. Dolan LA, Sabesan V, Weinstein SL, et al. Preference assessment of
recruitment into a randomized trial for adolescent idiopathic
scoliosis. J Bone Joint Surg Am. 2008;90:2594–2605.
20. Bunge EM, de Koning HJ, The Brace Trial Group. Bracing patients
with idiopathic scoliosis: design of the Dutch randomized controlled
treatment trial. BMC Musculoskelet Disord. 2008;9:57. (doi:10.1186/
1471-2474-9-57).
21. Karol LA. Effectiveness of bracing in male patients with idiopathic
scoliosis. Spine. 2001;26:2001–2005.
22. Winter RB, Lonstein JE. Use of the Milwaukee brace for
progressive idiopathic scoliosis (letter to the editor). J Bone Joint
Surg Am. 1997;79:954.
23. O’Neill PJ, Karol LA, Shindle MK, et al. Decreased orthotic
effectiveness in overweight patients with adolescent idiopathic
scoliosis. J Bone Joint Surg Am. 2005;87:1069–1074.
S60 | www.pedorthopaedics.com
 Volume 31, Number 1 Supplement, January/February 2011
24. Morton A, Riddle R, Buchanan R, et al. Accuracy in the prediction
and estimation of adherence to bracewear before and during
treatment of adolescent idiopathic scoliosis. J Pediatr Orthop. 2008;
28:336–341.
25. Rahman T, Bowen JR, Takemitsu M, et al. The association between
brace compliance and outcome for patients with idiopathic scoliosis.
J Pediatr Orthop. 2005;25:420–422.
26. Lonstein JE, Winter RB. The Milwaukee brace for the treatment of
adolescent idiopathic scoliosis: a review of one thousand and twenty
patients. J Bone Joint Surg Am. 1994;76:1207–1221.
27. Richards BS, Bernstein RM, D’Amato CR, et al. Standardization
of criteria for adolescent idiopathic scoliosis brace studies: SRS
Committee on Bracing and Nonoperative Management. Spine.
2005;30:2068–2075.
28. Little DG, Sussman MD. The Risser sign: a critical analysis.
J Pediatr Orthop. 1994;14:569–575.
29. Berg U, Aaro S. Long-term effect of Boston brace treatment on
renal function in patients with idiopathic scoliosis. Clin Orthop Relat
Res. 1983;180:169–172.
30. Snyder BD, Zaltz I, Breitenbach MA, et al. Does bracing affect bone
density in adolescent scoliosis? Spine. 1995;20:1554–1560.
31. Snyder BD, Katz DA, Myers ER, et al. Bone density accumulation
is not affected by brace treatment of idiopathic scoliosis in
adolescent girls. J Pediatr Orthop. 2005;25:423–428.
32. Katsaris G, Loukos A, Valavanis J, et al. The immediate effect of a
Boston brace on lung volumes and pulmonary compliance in mild
adolescent idiopathic scoliosis. Eur Spine J. 1999;8:2–7.
33. Matsunaga S, Hayashi K, Naruo T, et al. Psychologic management
of brace therapy for patients with idiopathic scoliosis. Spine.
2005;30:547–550.
34. Noonan KJ, Dolan LA, Jacobson WC, et al. Long-term psycho-
social characteristics of patients treated for idiopathic scoliosis.
J Pediatr Orthop. 1997;17:712–717.
35. Negrini S. Approach to scoliosis changed due to causes other
than evidence: patients call for conservative (rehabilitation) experts
to join in team orthopedic surgeons. Disabil Rehabil. 2008;30:
731–741.
36. Sanders JO, Khoury JG, Kishan S, et al. Predicting scoliosis
progression from skeletal maturity: a simplified classification during
adolescence. J Bone Joint Surg Am. 2008;90:540–553.
37. Negrini S, Fusco C, Minozzi S, et al. Exercises reduce the
progression rate of adolescent idiopathic scoliosis: results of a
comprehensive systematic review of the literature. Disabil Rehabil.
2008;30:772–785.
38. Christine C, Alin C, Rivard CH. Treatment of early adolescent
idiopathic scoliosis using the SpineCor System. Stud Health Technol
Inform. 2008;135:341–355.
39. Wong MS, Cheng JCY, Lam TP, et al. The effect of rigid versus
flexible spinal orthosis on the clinical efficacy and acceptance of the
patients with adolescent idiopathic scoliosis. Spine. 2008;33:1360–1365.
40. Kotwicki T, Cheneau J. Passive and active mechanisms of correction
of thoracic idiopathic scoliosis with a rigid brace. In: Grivas TB, ed.
The Conservative Scoliosis Treatment. 1st SOSORT Instructional
Course Lectures Book. The Netherlands: IOS Press; 2008:320–326.
41. Howard A, Wright JG, Hedden D. A comparative study of TLSO,
Charleston, and Milwaukee braces for idiopathic scoliosis. Spine.
1998;23:2404–2411.
r 2010 Lippincott Williams & Wilkins