Abstract
While we found the study by Yagci et al (2019) ‘In-brace alterations of pulmonary functions in adolescents wearing a brace for idiopathic scoliosis’ very interesting, we have concerns regarding the study methods and conclusions. 1 To evaluate the effects of bracing on pulmonary function is an important aim, but only if the appropriate orthosis is applied to children who require it.
The participants had a mean age of 14.5 ± 1.5 years with mean Cobb angles of 28.6° ± 7.0° and 24.3° ± 6.6° for the thoracic and lumbar regions, respectively. In mediterranean girls, 14.5 years of age usually complies with a Risser of 4. According to Lonstein and Carlson, 2 the average patient from this cohort would have a risk for progression of 10% or less, and according to international guidelines, there was no indication for any treatment at all.
When the low risk for progression is combined with the relatively low mean Cobb angles, we believe that the authors did not comply with the criteria for bracing adolescent idiopathic scoliosis proposed by the Scoliosis Research Society (SRS) or Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT). There are many implications for a child wearing a brace including physical, emotional and social considerations. It is our opinion that these children should not have been subjected to brace treatment. Surely the well-being of the children should be the first priority in any study, regardless of how noble its aims are. Second, the results may have been different in children that required a brace according to established international guidelines.
In-brace correction
While we accept that this study focused on pulmonary function, the authors did not discuss in detail the primary reasons for prescribing a brace or the results achieved in this cohort. The amount of in-brace correction as achieved with the brace is missing. In-brace correction and brace wearing time in a patient at risk for curvature progression determine the outcome of brace treatment. 3 Without the full results, and limited justification for prescription of the brace in the first place, the reader does not have all the information necessary to evaluate the outcome. Regardless of the aim of the study, the aim of the brace is to limit curvature progression and attempt to correct the scoliosis where possible, and this should have been demonstrated.
Brace design
I acknowledge and mirror the concerns of a previous letter on the same study regarding the brace design and suitability; therefore, I will not go into further detail in this letter. However, I do not feel that the brace design was detailed adequately and share their concerns with the suitability of the brace used in this study for its intended purpose. Figure 1 in the study shows an image of a symmetric thoracic-lumbo-sacral orthosis (TLSO) brace with little room for the wearer to breath as the brace will exert a symmetrical corset-like pressure on the thorax. In comparison, an asymmetric brace has large breathing voids and encourages over-correction of the curvature; utilising this type of brace may yield different results in terms of pulmonary function. It would be interesting for the authors to compare the two different types of brace (symmetric TLSO and asymmetric Chêneau style braces) in terms of pulmonary function and muscle wastage. If the results demonstrated that the TLSO brace reduces pulmonary function more than asymmetric braces, then an asymmetric, pattern–specific brace may need to be investigated to become the new gold standard conservative treatment in moderate to severe idiopathic scoliosis.
Kind regards
