Good Night: Addressing Scoliosis with Nighttime Spinal Bracing

By James Benelli, CPO and Sandy Hargrave, CO Spinal Technology, Inc., West Yarmouth, Massachusetts, and Barry McCoy, CPO Northeast Prosthetics and Orthotics, Providence, Rhode Island

Bracing can be a burden. Just ask any adolescent who has had to spend upwards of 23 hours a day wearing a spinal orthosis. Or, ask that child's parents. Unfortunately, when noncompliance reigns, correction suffers.

Over the years, there have been numerous efforts to provide a more agreeable bracing regimen. Electrical stimulation, low-profile bracing and modified wearing schedules have all attempted to solve the issue of compliance by producing full-time results in a fraction of the in-brace time. These efforts have met with mixed results, at best.

However, recent advances in the understanding of juvenile and idiopathic scoliosis have led to the development of new bracing methods that may hold more hope for young patients. Nighttime bracing, in particular, may offer an exciting and viable alternative for many young scoliosis patients.

Past Efforts

No one has ever argued that the Milwaukee-style brace was particularly popular among young scoliosis patients. While the brace has offered thousands of patients a chance to avoid surgery, the prospect of wearing this brace on a full-time basis can be intimidating at best.

Electrical stimulation, which was used frequently during the early 1980s, attempted to free young people from the need to wear a full-time brace. The results of this approach seldom met expectations, and it has since faded from popular use as a sole method of correcting scoliotic curves.

Low-profile bracing has been somewhat successful in addressing patient concerns about mobility and cosmetic issues. However, that success has been limited; while newer, low profile braces do not have the metal superstructure of their Milwaukee predecessors, these braces remain awkward for image-conscious pre-teens and teens.

Night Time is the Right Time

   
The Providence Nighttime Scoliosis System in use.

Nighttime bracing provides a viable alternative for many juvenile and adolescent patients. Recent studies indicate that this type of regimen can yield impressive initial correction as well as long-term success.

Nighttime bracing capitalizes on several important factors. The first is related to an adolescent's hormonal schedule. The pituitary gland in the base of the brain releases a growth hormone throughout the day. However, studies have shown that in young people, the rate of release peaks between midnight and 2 a.m. This means that corrective action taken during this period stands the best chance of having the maximum impact on a young person's body.

Another positive aspect of nighttime bracing involves an aesthetic consideration: because the patient does not need to wear the brace during the daytime, it has less of an impact on his or her everyday life. Feeling less constrained and inconvenienced by their treatment than he or she might with a full-time brace, the patient may be more likely to achieve a higher degree of compliance. This, in turn, helps boost the chances of success.

In the case of juvenile scoliosis, orthotists can take advantage of the tendency of younger children to sleep more hours than their teenaged counterparts. An ongoing study involving 60 patients with juvenile scoliosis (aged 3.5 years to 9.5 years) indicates an average in-brace correction of 101% for major curves, and 96% for compensatory curves. The average curve improved by five degrees in all treated patients.

This study also revealed that more than one third of the participants improved to the point that they were able to spend time (up to a couple of years) out of the brace. The ability to provide a young patient with the hope of reducing or eliminating the time that they will have to spend in their brace can have a dramatic effect on the child's desire to comply with treatment. Although a long-term follow-up on this group of patients is a few years away, initial results look promising.

Additional Benefits

In addition to the patient benefits, orthotists may also find that they are able to treat an expanded range of conditions with nighttime bracing. For example, it can provide derotation of the thoracic section of the spine. Nighttime bracing also offers effective lateral and derotational control in the lumbar spine.

Nighttime bracing can also be a welcome alternative for young obese patients, who may find their body uncomfortably constrained when attempting to wear a traditional daytime brace. A nighttime brace can be designed with an anterior tongue without compromising the correctional ability of the brace. This allows for some pressure relief when it comes time to "compress" the child in the brace.

A night system may also be an option when treating neuromuscular patients. If confined to a wheelchair, these patients may not be able to tolerate a full-time bracing system. The nighttime system allows correction to take place while the patient is supine. So while the patient may require additional support to remain sitting upright during the day, correction can be relegated to nighttime.

Rest Assured

Some may be hesitant to use a nighttime bracing system because of a comparative study by D. Katz at Scotish Rite Hospital in Texas, that examined the Boston Brace (full time) and the Charleston Bending Brace (part time). While the Charleston's initial correction rates were impressive (73%), the aggressive nature of the bracing sometimes resulted in an unintentional worsening of the compensatory curve. This reduced the ultimate success of the system to 66% (Price et al.).

Building off of those results, a new type of nighttime bracing has emerged that offers 98% initial in-brace correction. The Providence Nighttime Scoliosis System features a double curve brace design, which provides an overlapping three-point pressure system approach. The three-point system helps control double curves and allows for treatment of apices as high as T-6 without the use of a neck extension (though a neck extension may be used for treating higher apices).

This particular nighttime system is also a strong contender when dealing with high-risk curves (e.g.; thoracic, double thoracic and double curves) and with low risk curves (e.g.; lumbar and thoraco lumbar). The Providence System can affect thoracic correction by pushing on the ribs to influence the thoracic vertebral bodies. Likewise, careful modification of the shape and position of the lumbar pad can help correct this particular part of the spine. Because the patient is in the recumbent position, there is an exaggerated space between the iliac crest and the twelfth rib, allowing for aggressive correction.

In a recent study reported in The Journal of Spine (September 2001), 102 female patients with Risser 0, 1, and 2 were treated using only the Providence brace. Patients wore the brace between eight and ten hours a night for six or seven days out of the week, a far cry from the time requirements traditionally associated with full-time spinal bracing. The brace achieved a 74% success rate.

A Wake-Up Call

The concept of nighttime bracing may at last be seeing the light of day. The high rate of success, coupled with the potential to reduce cosmesis-related noncompliance, may provide the necessary impetus for patients, orthotists and doctors to take a close look at this emerging option in spinal orthotic care.