Every year, the National Scoliosis Foundation receives letters from individuals wondering about non-surgical treatment of idiopathic scoliosis. At present, adolescents across the country are using several types of rigid braces. To find out more about these, we interviewed Dr. John Emans, an orthopedic surgeon at Boston's Children's Hospital and Harvard Medical School.

Q: Dr. Emans, we know that the history of bracing is centuries old, but who deserves the credit for what we think of today as "modern" bracing techniques?
A: The forerunner of all so-called modern braces is the Milwaukee brace, developed by Drs. Walter Blount and the late Albert Schmidt of the Medical College of Wisconsin and Milwaukee's Children's Hospital. The brace consists of a pelvic circle, throat mold, and various bars, straps, and pressure pads that work together to hold a curvature, that is, to try to prevent it from worsening. (see drawing).

Q: What about the "low-profile" brace? What is it and who developed it?
A: Low profile braces are also know as "TLSO braces" (thoracic lumbar sacral orthosis) or under- arm braces. Other forms of underarm braces have been around for decades but the most popular modern underarm brace was originated in the early 70's by Dr. John Hall and Mr. Bill Miller of the Boston Children's Hospital.

Q: Is there any other type of low profile brace and how does it differ from the TLSO?
A: Yes, there are many kinds of TLSO braces in use today such as the Wilmington brace developed at the Dupont Institute by Drs. MacEwen and Bunnell and several different types of European braces referred to as Ponte, Riviera or Lyonnaise. Although each of these braces uses somewhat different construction and materials, they are all similar in principle.

Q: Is one type of brace-Milwaukee or TSLO-better than others?
A: Some orthopedists believe the Milwaukee is best for upper thoracic curves. Most of us agree a TLSO is sufficient for lower thoracic and thoracolumbar and lumbar curves. In my opinion, it matters less what kind of brace you have than how well it's made. A really well-made Milwaukee is much better, from my point of view, than a poorly made TLSO, and vice versa.

The Milwaukee Brace

Q: Would you explain what you mean by "well made"?
A: There are two basic ways to make the brace. One is to start with a prefabricated symmetric module which come in different sizes. The other is to make a cast and then make the module from the modified cast. Braces must be designed for an individual person and an individual curve and the orthotist must exercise skill, care and understanding. A well made brace is analogous to well-made custom clothing; it fits well and does the job it's supposed to do.

The Low-Profile Brace

Q: How can doctors tell whether a brace is 'doing' its job'?
A: One way is to look at an x-ray of the patient's spine while he or she is wearing the brace. We want to see that the pads are in the right place and whether the curve is straighter. If it isn't we know we either have a very bad, very rigid scoliosis, or that the brace isn't right.

Q: Do braces actually straighten curves?
A: While a youngster is wearing a brace during a course of treatment, the spine will be straighter (sometimes by as much as 50 percent) but this is not a lasting improvement. After treatment has ceased and the brace is removed, most curves return to their original status. There are sometimes patients who do get a lasting improvement in their curve but they are in the minority. It's important to remember that the purpose of a rigid brace is not to correct a curvature but rather to contain it, to keep it from worsening.

Q: What can you tell us about the Charleston "night-time" brace?
A: This new brace is similar to a low profile type, except that it attempts to `over-correct' the curvature by keeping a patient bent toward the convexity of their curve which is why it's used only while one sleeps. To my knowledge, it appears that the Charleston is not a good solution for double curves, while the data collected for single curves is encouraging. In general, though, it's too soon to be certain that it does as well as traditional day-time bracing.

Q: When the National Scoliosis Foundation was founded in 1975, braces were used to contain curves of 15 degrees or more in a growing child. At what point are doctors prescribing braces in the 1990's, and why?
A: Today, we tend to brace between 25 and 40 degrees. The reason for this range is fairly simple: many curves under 25 simply don't get worse or may even spontaneously improve or stabilize on their own; and very few curves over 45 degrees can be controlled. Those adolescent patients with curves beyond 45 degrees are usually candidates for surgery.

Q: How well does bracing work?
A: The data that currently exists argues that bracing is better than natural history (what happens to a curve if left untreated), but we are continuing to examine this. Currently, there is a multi-center study, sponsored by the Scoliosis Research Society. In the next few years, we hope this study will give us some answers.