Does bracing affect the quality of life of the patients with idiopathic scoliosis?

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1 Does bracing affect the quality of life of the patients with idiopathic scoliosis? Toru Maruyama 1), Katsushi Takeshita 2), Tomoaki Kitagawa 2), Yusuke Nakao 2) 1) Department of orthopaedic surgery, Saitama medical center, Saitama medical university 2) Department of orthopaedic surgery, The University of Tokyo Corresponding author: Toru Maruyama Address: 1981 Kamoda, Kawagoe, Saitama Japan Telephone: Fax: [Background] Effectiveness of bracing was demonstrated as it alters the natural history of curve progression in girls with adolescent idiopathic scoliosis (AIS) (Nachemson 1995) and it has been widely adopted as the standard care for non-operative treatment of AIS (Dolan 2007). On the other hand, bracing has been sometimes pointed out that it has negative impacts on the patients quality of life (QOL) and psychological state (Anderson 2006). QOL of the patients is one of the most important issues for physicians who treat patients with AIS because it affects otherwise healthy teenagers at the important period of life for their physical and psychological growth. We adopted part-time wearing of the brace, for at night (8 hours) or at home after school (16 hours) to reduce physical and psychological burden of the patients treated with brace. At the 2008 SOSORT meeting in Athens, we reported that QOL of the patients treated with Milwaukee brace (MB) was lower than that of the patients treated with under arm brace (UAB) or exercise (EX). However, in that study, Cobb angle of the patients was not matched and there were significant differences in the Cobb angle among the treatment groups.

2 [Objectives] The aim of this study is to re-investigate the quality of life of the patients with idiopathic scoliosis who underwent various kinds of conservative treatment among the groups whose Cobb angle was matched. [Methods] Female patients with idiopathic scoliosis who underwent conservative treatment at least for one year, whose age was between 14 and 29 years and whose Cobb angle was between 25 and 50 degrees were included in the study. The responses to the Scoliosis Research Society (SRS)-22 questionnaire, Oswestry disability index (ODI), and Roland-Morris disability questionnaire (RDQ) were analyzed according to the treatment they received. In the statistical analyses, ANOVA (analysis of variance), Fisher s PLSD (protected least significant difference), chi-square, and logistic regression were used. [Results] Eighty-four patients were included in the analysis. Of 84 patients, 19 were treated with MB, 37 were treated with Boston type UAB, and 28 were treated with exercise only. Most of the patients wore their brace for part-time and they underwent specific exercise treatment at the rest of the time. The average age of three groups was 17.6, 18.3, and 21.5 years, and the average Cobb angle was 38.8º, 37.8º, and 36.0º, respectively (Table 1). There were 25 thoracic curves, 23 thoracolumbar or lumbar curves, and 36 double curves; under arm brace was more frequently used for thoracolumbar or lumbar curves (Table 2). The average total score for SRS-22 was 3.9, 4.1, and 4.0 in MB, UAB, and EX group, respectively; there was no significant differences among the groups (Figure 1) The average score for the domains of SRS-22, that is, pain, function, self image, mental health, and

3 satisfaction was, 4.5, 4.0, 3.5, 3.9, and 3.4 in MB group, 4.7, 4.2, 3.5, 4.1, and 3.4 in UAB group, and 4.6, 4.4, 3.2, 3.9, and 3.4 in exercise group, respectively. The score for function domain was significantly lower in the MB group than in the other two groups (Figure 2). There was no difference among the three groups regarding other domains of SRS-22, ODI and RDQ score (Figure 3, 4). As the results of logistic regression, MB treatment was the only variable that affected the scores for the function domain of SRS-22 (Table 3). In the analysis of individual questions of the function domain, there were significant differences in question number 15 and 18 (Figure 5, 6).. [Discussion] Type of brace or length of time the brace must be worn are factors contributing negatively to coping with orthosis (Climents 1999). In order to lessen the burden of the patients, we adopted part-time brace wearing program. As the results of this study, even with the part-time wearing program, MB had statistically significant negative impacts on the patients function domain score. However, questions the score of which showed differences among the groups were question number 15 and 18 that had been pointed out as the least internally consistent questions (Asher 2003). Furthermore, minimal clinical important difference of SRS 22 questionnaire has not been established. Therefore, clinical relevance of the results of this study was difficult to be determined at the present time. [Conclusion] Scores of function domain of the SRS-22 questionnaire in female patients with idiopathic scoliosis treated with Milwaukee brace were significant lower than in patients treated with under arm brace or exercise only. Brace type was one of the factors that affect the QOL of the patients with idiopathic scoliosis.

4 Table 1: Age and Cobb angle MB n = 19 UAB n = 37 EX n = 28 Age (year) (14-29 ) (14-26) (14-29 ) Cobb (degree) (26-50) (25-50) (25-49)

5 Table 3: Logistic regression SRS-22 Function > 4 Coefficient p-value OR 95%CI Age Cobb Tx: MB Tx: UAB Curve: L Curve: T