Brace therapy has often been used for the treatment of the most common spinal deformities in adolescence. To understand spinal bracing efficacy and clinical effectiveness in the conservative treatment of spinal deformities, it is essential to measure and record such confounding variables including compliance.
At puberty, physical appearance, the need to affiliate with peers and the need to assert one’s independence are very important. While mild spinal deformities itself may not interfere with these needs, treatment either conservative with orthoses or surgical often does.
The majority of adolescents, who wear brace for scoliosis are girls. For the girls, particularly in the adolescence, their external appearance due to the deformity, is of major importance and significantly affect on their social relations. Brace therapy may cause to the patient great emotional distress and different psychological reactions. This type of emotional distress seem to be very important since it probably shapes the social interaction of the patient.
Compliance with bracing by some adolescents with scoliosis is an ongoing problem with the orthotic management of scoliosis. Historically, compliance was measured using patient interviews, pad/strap forces, or temperature [15
]. These measurements are subjective, limited to laboratory or short-term monitoring only, required patient intervention, or lacked date/time recording. These authors [15
] found an objective average compliance ranging from 65 to 75%. These investigators [35
] found no correlation between compliance and prescribed regimen. This was also justified in the present study since there were no differences in compliance between scoliotics and kyphotics treated with different braces. The compliance reported by the individuals in this study is comparable to that reported by others. The measured average compliance of 57% indicated de facto part-time bracing. No patient completely adhered to the treatment protocol although of 41% testified to full compliance. There was a gender-related compliance in this study. More specifically, high average compliance was observed in 52% of boys and in 42% of the girls. In contrast to this study there a recent investigation disclosed low (average 38%) compliance in boys treated with brace for idiopathic scoliosis. The authors speculated that this poor compliance was due to the older age of the male patients and their refusal to cooperate with the orthotic programme [20
]. Age appears to be one of the factors that correlates with compliance; younger patients showed higher compliance. The present study showed higher compliance in the ages between 11 and 14 and less in older children. DiRaimondo and Green [9
] demonstrated higher compliance among grade school patients than among those in high school. They speculated that because menarche and Risser sign are age-related factors they may affect compliance. Additionally, there is a speculation that bracing has an effect on the psychosocial development of adolescent patients [14
]. In the present study, highly compliant patients wore the brace as recommended, being with only short periods out at home for reasons personal hygiene. Intermediate compliance resulted from reduced brace wear during school hours. In the present study, it was apparent that where there was poor compliance the patient clearly took her/his brace off during the most socially important hours of the day, i.e. when fashion was most important. During school hours, this was not such an issue as some patients said their uniform adequately hid their brace. These observations are very close to those previously reported by others [35
] in similar populations.
In the previous literature there is a high rate of subjectively overestimated compliance, which was obviously due to reports of bracing that derived from adolescents. However, objective measurement with actual monitoring of brace wear showed that actual brace compliance is much less than claimed by patients or parents [16
] so that some authors thought that <15% of their patients with scoliosis were fully compliant with a 23-h/day schedule [9
]. The reported poor compliance during brace therapy for idiopathic scoliosis seems to be directly linked with psychological reactions that have been reported by several authors [14
Non-compliance has been reported between 20 and 85% [3
]. In the present study, non-compliance ranged between 0 and 74%.
Lindeman and Behm [28
] looked at the psychological factors that predict poor brace-wear self-reported compliance. The authors found that girls who were noncompliant with the brace wearing were those who were anxious about the possibility of failure and did not expect to succeed in dealing with their scoliosis. They also found to have low self-esteem, and did not seek social support. However, boys who were noncompliant with brace wearing had high self-esteem, high expectations about the success of their bracing treatment, and sought social support. The only factor that predicted non-compliance across gender lines was sleeping problems.
Gender differences in compliance were also found in another study [36
]. The authors looked at perceptions of body image, happiness and satisfaction in male and female adolescents wearing the Boston brace. Although all adolescent subjects with scoliosis were found to have a poorer body image perception than did the control group, boys with scoliosis were found to have better body image perception than girls with scoliosis.
To author’s knowledge, emotional distress related to bracing has been reported only in adolescents with idiopathic scoliosis [17
], that in some cases reaches the 84% of the patients [30
]. The present study disclosed also the psychologic reactions in adolescents suffering not only from scoliosis but as well as from Scheuermann kyphosis.
It seems that besides spinal deformity, bracing itself induces emotional distress. Matsunaga et al. [31
] compared three groups of patients with idiopathic scoliosis, who had undergone either brace therapy, or surgical treatment or non-treatment and showed that the use of braces had markedly greater psychologic effects than the other treatments [31
A previous investigation [8
] measured quality of life was measured in 112 adolescents using the QLPSD instrument. Areas measured by the instrument included psychosocial functioning, sleep disturbances, body image and back flexibility. Results of the study [8
] found that, compared to the Milwaukee brace, the Charleston and Boston braces have a lower impact on overall quality of life and on the psychosocial functioning of adolescents with spine deformities. The impact of brace treatment on quality of life in patients with severe disease (i.e. idiopathic scoliosis and Scheuermann’s disease) was greater than in patients with less severe curves. Length of time wearing the brace was also a factor. The authors [8
] speculate that the transition from childhood to adolescence may have played a role in these results. Using the QLPSD instrument in the present study, the authors observed similar psychological reactions in individuals with both deformities. These psychological reactions were observed in this study more often among the girls and was increasing with the age independently from the type of brace used. This study justified the observation of Climent et al. [8
] that patients with larger curvatures developed greater emotional distress.
Another variable that appears to significantly affect the emotional distress in adolescents with scoliosis is the duration of bracing. Quality of life impact began after the initial stressful bracing period but began to decline during the course of time. Some authors [8
] reported that the emotional distress that appears at the start of bracing diminishes after the patient accepts brace treatment. This observation was justified in the present study. The explanation for the improvement of psychological function with time is possibly given by some investigators, who have noted psychological adaptation to wearing of brace [34
]. This study showed that the problem of adaptation with bracing was more evident in older adolescents because they felt ashamed of themselves at starting of bracing.
In the present study, the age of the patients was shown to have a twofold effect on the quality of the life of adolescents with spinal deformities. The positive effect was that older individuals showed a better adaptation to bracing, while the negative effect was that older adolescents worry about the future effect of the spinal deformity on their body stronger than younger adolescents. Similar observations regarding the effect of body deformity due to scoliosis on patients were made in similar populations by others [1
Another significant observation, which derived from this study was that girls with deformities faced problems with sleeplessness more often than boys. The theoretical explanation for these observations should be that these girls feel much more ashamed of their body because of their back deformity that makes their body is unattractive.
Previous studies [6
] compared the motion restriction and trunk stiffness provided by three thoracolumbosacral orthoses and showed that there were no difference in either subject-perceived or measured restriction of spine motion between the orthoses. This study justified that previous observation that bacing reduced capability of adolescents to perform common daily activities at home and outside, obviously by reducing spine mobility.
Back pain is not a rare complaint among adolescents [23
]. However, back pain is often reported by adolescents with scoliosis and kyphosis during bracing. The possible explanation for back pain is that bracing with the time reduces muscle mass and weakens their strength, thus inducing more stress on the discs, ligaments and facets. The increased incidence of back pain among girls with deformities vs. boys should be due to the constituently weaker muscle system of the girls as compared to that of the boys, which becomes even weaker because of bracing. Therefore, back muscle strengthening during bracing is strongly recommended.
The present study showed that the QLPSD is a useful instrument to test the psychological and physical impact of bracing on the quality of life of adolescents. Some authors [21
] evaluated the effectiveness of performing personality tests for patients with idiopathic scoliosis who underwent brace therapy and concluded that these tests are useful for evaluating psychological effects and ensuring continuation of therapy minimizing patient dropout.
This study disclosed several significant similarities in most of the quality of life domains and only few differences in the effects of each particular brace and spinal deformity itself on the quality of life of the individuals of each particular deformity.
When the patient is experiencing significant psychological distress, one-on-one psychological intervention is warranted [39
]. Because of the importance of family dynamics, therapy likely will include a family components. The effectiveness of peer support groups for adolescents has been researched, and no findings were positive. Wysocki et al. [42
] compared the perceived effectiveness of education/support groups to Behaviour Family Systems Therapy in the treatment of parent/adolescent conflicts. Behaviour Family Systems Therapy was rated significantly positively by parents and adolescents.
Interview and eventually psychological support for all patients who show reduced compliance should be as early as possible conducted. Physical training for all individuals being in brace treatment, particularly for older female adolescents, should be recommended to improve physical functioning, reduce back pain and subsequently to increase compliance (Tables , , ).