Spinal deformity - Adolescent idiopathic scoliosis - Nonoperative treatment

Various modalities of treatment have been applied to adolescent idiopathic scoliosis (AIS) over the years including physical therapy, manipulation, and electrical stimulation to name a few. There is no scientific evidence supporting the effectiveness of these methodologies. The most commonly used method of nonoperative management of adolescent idiopathic scoliosis is bracing. Orthoses have been used to treat AIS for over 100 years. Modern day treatment began with the Milwaukee brace used on a full- time (23 hours a day) basis in the 1950s. This treatment was then modified to the use of various underarm orthotics in the 1970s. Today, numerous custom- made and 'off the shelf' varieties of TLSOs are in widespread usage worldwide with part-time regimes gaining in popularity. Many questions about the orthotic management of AIS remain unanswered. These include: Is brace treatment effective in preventing curve progression? How do braces actually work to prevent progression? What parameters determine a successful outcome with brace treatment, and what are the negative effects of bracing? Although braces are widely used, the exact mechanism of action of braces is not actually known. Although braces can apply loads to the spine, as has been studied in a patient with an instrumented spine, the actual biologic effects of these loads are unknown, and how this alters natural history has yet to be determined. Despite the widespread use of orthotics in the management of AIS, there have been no randomized controlled prospective studies on brace treatment for AIS. Thoracic or thoracolumbar curves in a skeletally immature patient are known to be at high risk of curve progression. Other natural history factors (mechanical and biological) in curve progression are not known. The indications for treatment of AIS are further hampered by the paucity of natural history data. It is clear, however, that bracing has been overutilized in the past, and that it may cause significant psychological distress. There is some evidence from a single nonrandomized study that bracing may affect the natural history of AIS in immature patients with thoracic and thoracolumbar curves. It is imperative that we learn more about the natural history of AIS in order to learn about additional factors in curve progression that will allow more selective indications for orthotic treatment. We must also ascertain what are the factors that will predict success with orthotic management. In addition, we must continually strive to develop more effective methods of nonsurgical management of AIS.