Bracing Plus Exercise to Promote Bone Mineral Growth Is Key to Managing Scoliosis in Adolescents
While brace treatment has been shown to slow down curve progression in adolescents with idiopathic scoliosis, physical activity—particularly in the form of weight-bearing activities—should also be prescribed to prevent bone mineral loss and promote bone mineral gain, according to a “Perspective” editorial in the June 1 issue of The Spine Journal.
“I was very happy when this editorial was published in such an important journal, since there is some kind of a negative dogma against the usefulness of exercises for scoliosis treatment, even if randomized controlled trials [on this topic] have been published. This paper is a step forward in this respect,” commented Stefano Negrini, MD, Associate Professor of Physical and Rehabilitation Medicine at the University of Brescia-Don Gnocchi Foundation, Italy, and Scientific Director of ISICO (Italian Scientific Spine Institute).
In a commentary to the editorial, Dr. Negrini and colleagues underscored the need to add sports activities (in addition to scoliosis-specific exercises) to bracing to reduce muscle mass loss, and improve mobility, aesthetics, and the effects of bracing on reducing curve progress.
Currently, bracing is the treatment of choice for patients with moderate curves. The authors noted that this practice is supported by recent research, which demonstrates the effectiveness of bracing in significantly decreasing curve progression and avoiding surgery in patients with high-risk curves.
Potential Harms of Bracing
“Numerous studies have demonstrated that adults with scoliosis have low bone mineral density [BMD],” said lead author Bareket Falk, PhD, Professor, Department of Kinesiology, Brock University Faculty of Applied Health Sciences in Ontario, Canada. However, it is unclear whether this low BMD is the cause or result of scoliosis in this population, the authors noted in the editorial.
“We postulated that bracing, while often used to manage scoliosis and slow brace progression, may interfere with growth-related accrual of bone mineral during adolescence—the period during which over 50% of adult bone mineral is accrued. Therefore, while bracing may well be effective in slowing down curve progression, it also may have what we termed, a ‘physiological cost,’ in that it interferes with bone accrual,” Dr. Falk told SpineUniverse.com.
“This interference may occur in two ways,” Dr. Falk said. “First, the brace itself is not comfortable and may discourage girls from taking part in any physical activity. As is, adolescent girls, in particular, are not physically active. In fact, physical activity level decreases drastically during adolescence, especially in girls. Thus, bracing may exacerbate this decrease,” Dr. Falk noted.
“Secondly, the brace also immobilizes the trunk and minimizes the use of core muscles,” Dr. Falk said. “These muscles insert at the spine and pelvis. The muscle-bone unit concept illustrates that muscle action has a potent influence on bone strength. Therefore, by immobilizing the trunk and minimizing the use of the relevant muscles, less stimulus is applied to the axial bones, possibly resulting in lower bone accrual,” Dr. Falk said.
Prescription for Physical Activity Recommended
“Clinically, we suggest that brace treatment should be accompanied by a ‘prescription’ of weight-bearing physical activity (ie, activities [not exercises] that promote bone accrual),” Dr. Falk said. “Realistically, this may mean that, rather than recommend that the brace be worn 23 hours per day, perhaps the recommendation should be to wear the brace 22 hours per day, with 1 hour devoted to weight-bearing physical activity,” Dr. Falk said.
“To be clear, we do not know whether such an approach would prevent the low BMD characteristic of adults with scoliosis, but it makes clinical sense,” Dr. Falk said. “This is certainly a topic for future study.”
Adding Sports Activities to Bracing May Improve Muscle Mass and Mobility
“The probability of BMD loss due to bracing is still not well defined in the literature,” Dr. Negrini told SpineUniverse.com. “However, it is true that bracing could impair bone mass accrual and impair physical activity, and that physical activity does improve bone mass. So, based on the last certainty, it is definitely helpful to ask braced patients to continue, if not increase, their physical activities to help [increase] their bone mass as well as their muscle mass, coordination, mobility, and balance. All these factors can be impaired by a reduced mobility and a brace,” Dr. Negrini said.
He added that while physiotherapeutic scoliosis-specific exercise have shown effectiveness improving the efficacy of the orthosis, general sport activities are equally important and may have a greater effect in increasing BMD because of greater bone impact and aerobic activation.
“Moreover, it has been shown that it is possible to continue participating in sports normally even with a prescription of bracing 23 hours per day; however, the brace must be well designed and well tightened,” Dr. Negrini said. He added that the brace must allow freedom of limb movements to permit free movement and physical activity.
Commentary by Baron Lonner, MD
Baron Lonner, MD
Chief Division of Spine Surgery
Mount Sinai Beth Israel, NY
Attending Mount Sinai Hospital
Professor of Orthopaedic Surgery
This commentary is a response to an interview by SpineUniverse.com of Drs. Falk and Negrini, as well as a published article by Falk et al.1
Drs. Falk and Negrini make many important points in their interview with Spineuniverse.com; however, the main premise of their discussion on the impact of bracing in adolescent idiopathic scoliosis (AIS) on bone mineral density (BMD) is incorrect. In Falk’s article,1 he incorrectly states that the accrual of BMD is adversely affected, or potentially so, by full-time brace wear. In fact, in a study by Snyder, et al, there is no evidence of that occurring.2 BMD was actually found to increase in brace-treated adolescents at a rate similar to published controls. Therefore, this theoretical concern does not appear to be important. Nevertheless, the fact is that individuals with AIS have reproducibly been shown to have low BMD compared to normal controls in a number of reports and are at risk for osteoporosis as a result in adulthood (References 3-8 from Dr. Falk’s article).3-8 Therefore, high-intensity sports activities should be encouraged in this group as for the adolescent population as a whole due to its effect on increasing bone mass.
The authors make a number of points that should be emphasized. Bracing is effective in preventing curve progression to a magnitude in which surgery might be considered as shown by Weinstein et al in the BRAIST study (Bracing in Adolescent Idiopathic Scoliosis Trial) published in the New England Journal of Medicine.9 This study was a randomized controlled trial, although not all patients were randomized (only 40% agreed to randomization), with a high level of scientific evidence showing the efficacy of bracing for skeletally immature (Risser 0-2) individuals with curves between 20-40 degrees. This study showed a dose-response to bracing with a high rate of success (>90%) for brace wear of more than 12.9 hours per day on average. Based on this, it would appear that wearing a brace for 23 hours per day is not required and in fact, unlikely to be complied with in any event. I typically recommend 16-20 hours per day on average in the brace in my practice and encourage sports participation and core-strengthening activities such as yoga, Pilates, and swimming. Patients have ample time given these brace recommendations to perform athletic activities and exercises with their associated benefits of maintaining core muscle strength and enhancing bone mineral density. I am in full agreement that patients should be encouraged to engage in physical exercise.
Dr. Falk, in his published study, refers to a report by Lusini, et al on the efficacy of bracing in curves greater than 45 degrees.10 Although the authors of that paper report success in terms of prevention of curve progression in patients braced and treated with scoliosis-specific exercise therapy (SPET) versus controls, their conclusions require careful scrutiny. A number of the subjects in their study reached Risser 3 or 4 in skeletal maturity at the time of bracing and were unlikely to have curve progression, and some were casted rather than braced. The role of SPET in the treatment of the scoliosis patients requires careful study. There may be modest effects in terms of prevention of curve progression or slight improvement of curves based on a number of reports, but high quality randomized, controlled trials will be definitive in answering the question of their role in the nonoperative treatment of AIS.11
In my practice, patients are told that postural realignment, improved breathing mechanics, and decreased fatigue pain may be benefits of this type of therapy, but that data is needed. Many families are eager to be pro-active and pursue a program of therapy in addition to bracing or for those who do not have a bracing indication as part of their treatment plan, and they should not be discouraged. Whether this will have an additive effect to bracing really has not been scientifically answered. Third party payors have not consistently supported SPET for their insured customers, and more data will perhaps compel them to do so.
In summary, I concur with Drs. Negrini and Falk that there are benefits to sports participation and possibly to SPET in the AIS patient. Further studies of the impact of these activities on BMD, core strength, and curve progression are required.
References Cited in Dr. Lonner’s Commentary
- Falk B, Rigby WA, Akseer N. Adolescent idiopathic scoliosis: the possible harm of bracing and the likely benefit of exercise. Spine J. 2015;15(6):1169-1171.
- Snyder BD, Katz DA, Myers ER, Breitenbach MA, Emans JB. Bone density accumulation is not affected by brace treatment of idiopathic scoliosis in adolescent girls. J Pediatr Orthop. 2005;25:423-428.
- Cheng JC, Tang SP, Guo X, Chan CW, Qin L. Osteopenia in adolescent idiopathic scoliosis: a histomorphometric study. Spine. 2001;26:E19–23.
- Cheng JC, Qin L, Cheung CS, Sher AH, Lee KM, Ng SW, et al. Generalized low areal and volumetric bone mineral density in adolescent idiopathic scoliosis. J Bone Miner Res. 2000;15:1587–1595.
- Lam TP, Hung VW, Yeung HY, Tse YK, Chu WC, Ng BK, et al. Abnormal bone quality in adolescent idiopathic scoliosis: a case control study on 635 subjects and 269 normal controls with bone densitometry and quantitative ultrasound. Spine. 2011;36:1211–1217.
- Sadat-Ali M, Al-Othman A, Bubshait D, Al-Dakheel D. Does scoliosis cause low bone mass? A comparative study between siblings. Eur Spine J. 2008;17:944–947.
- Lee WT, Cheung CS, Tse YK, Guo X, Qin L, Lam TP, et al. Association of osteopenia with curve severity in adolescent idiopathic scoliosis: a study of 919 girls. Osteoporos Int. 2005;16:1924–1932.
- Cheng JC, Guo X, Sher AH. Persistent osteopenia in adolescent idiopathic scoliosis. A longitudinal followup study. Spine. 1999;24:1218–1222.
- Weinstein SL, Dolan LA, Wright JG, Dobbs MB. Effects of bracing in adolescents with idiopathic scoliosis. N Engl J Med. 2013;369:1512-1521.
- Lusini M, Donzelli S, Minnella S, Zaina F, Negrini S. Brace treatment is effective in idiopathic scoliosis over 45 degrees: an observational prospective cohort controlled study. Spine J. 2014;14:1951-1956.
- Romano M, Minozzi S, Zaina F, Saltikov JB, Chockalingam N, Kotwicki T, et al. Exercises for adolescent idiopathic scoliosis: a Cochrane systematic review. Spine. 2013;38:E883–893.