Julia M. Balboni, B.S.¹; Aaron Kavanaugh, B.S.²; Fabrizio Billi, Ph.D.^2
1University of New England College of Osteopathic Medicine
²University of California Los Angeles

Declaration of Conflict of Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. This study was funded in its entirety by the University of California, Los Angeles.

Abstract

Although bracing is a valuable tool in the conservative management of adolescent idiopathic scoliosis, this approach often requires the brace be worn for a minimum of 18 hours per day.  Children and adolescents are the recipients of these requisites, and the impact that such demands may have on psychological functioning and quality of life is often overlooked. This narrative review summarizes the potential drawbacks of an otherwise effective and conservative approach to treatment. The results of this analysis show that quality of life in adolescents with AIS is not only influenced by pain, but also by social interaction and aesthetic appraisal. Poor body image and low self-esteem are likely risk factors in the development of mental health disorders, particularly among adolescent females. Evidence suggests that many adolescents with AIS have unmet mental health needs, with few reporting an opportunity to discuss their emotional concerns with a healthcare provider, despite many having the desire to do so. Adolescence is a vulnerable time during which many children lack the resilience to ward off the potentially lasting consequences of adverse life events. The incorporation of psychological screening and intervention into treatment protocols as well as strategies that address the aesthetics of brace wear may improve the clinical outcomes of patients with AIS.

Background
Idiopathic Scoliosis is one of the most common forms of spinal pathology among adolescents. While the exact etiology of the disease remains unclear, it has been suggested that hormonal imbalance and asymmetric growth are chiefly responsible for the observed disruption in normal spinal curvature.^[1]  

The sex-specific differences within Adolescent Idiopathic Scoliosis (AIS) are marked; when Cobb angles exceed 30°, girls become eight times more likely than boys to develop AIS.^[2] While a causative relationship between estrogen and AIS has yet to be established, there appears to be increased expression of Estrogen Receptor 1 within the paraspinal muscles on the concave side of the curvature, the severity of which coincides with increasing Cobb angle.^[2]  AIS is known to cluster in families and may be linked to a female-specific gene known as PAX1. Genetic variants in PAX1 appear to decrease collagen deposition within the vertebral growth plate and may explain the apparent heritability and sexual dimorphism of AIS.^[3] In addition to hormonal and genetic sex-specific differences, other theories suggest that a lower body mass and less time spent playing sports and exercising make females more likely than males to develop AIS.^[4]

Treatment for AIS depends upon the patient’s potential for growth and degree of curvature. The Risser Classification System is used to operationalize a child’s skeletal maturity on a scale of 0 to 5; a score of 0 is assigned to a child growing rapidly, while a score of 5 indicates that the child’s growth is complete.^[5] The Cobb angle, which quantifies the magnitude of the curvature, is obtained through direct measurement of patient radiographs. While a minimum Cobb angle of 10 degrees is required for the initial diagnosis of scoliosis, growth is rapid during adolescence, and scoliotic curves tend to worsen as the child’s spine matures.^[6] Bracing is clinically indicated to correct and prevent further progression of the disease in patients with a Cobb angle between 25-45° and a Risser score between 0-2.^{[ 7,8]} While numerous studies have demonstrated that bracing can slow curve progression,^{[ 9,10,11]} far fewer have examined the negative implications of bracing on the psychological well-being of the adolescent patient.

Despite the evolution of new paradigms in the management of spinal disorders, scoliosis braces remain a relatively unchanged orthotic device, with few advancements taking place since their conception. Braces have failed to evolve outside the scope of hard, non-malleable plastics, and some patients report significant physical discomfort when wearing the brace for up to 20 hours per day, as is often required. Due to the nature of bracing, there is also potential for restricted lung function and development.^[12] Furthermore, current brace designs are far from discrete. The physical appearance of the child while wearing the brace is a known hindrance to patient compliance and may contribute to social alienation and negative psychosocial functioning.^[13,14] With changing attitudes toward mental health in recent years, greater emphasis has been placed on the interplay between metal health and physical disease. In recognition of this, members of the pediatric spine community are starting to explore the mental health burden associated with AIS.

The evidence amassed on the efficacy of bracing is clear: thoracolumbosacral orthotics can correct moderate spinal curvatures and slow the progression of those that are more severe.^[8,15,16] However, less is known about the effects of bracing on quality of life. By analyzing the current state of the literature, this review aims to summarize the potential drawbacks of an otherwise effective and conservative approach to treatment and recommend strategies for a more supportive adolescent care plan.

Methods

Literature Search Strategy
A bibliography search was conducted in PubMed, Google Scholar, and Scopus from 2014 to 2024. Key words utilized in the search included: adolescent idiopathic scoliosis, teenagers, brace treatment, bracing, psychosocial, psychological, quality of life.

Inclusion Criteria
Prior to beginning this search, criteria for inclusion were pre-specified. Any study that examined the psychological impact of brace treatment in adolescents with idiopathic scoliosis was included. Any criteria used in the diagnosis of AIS was eligible. All articles were required to be written in English.

Exclusion Criteria
Studies that examined forms of scoliosis other than adolescent idiopathic scoliosis were omitted. Studies that evaluated the effects of surgical intervention were excluded as this study focused on the effect of brace treatment. Case studies, systematic reviews, meta-analyses, clinical commentaries, books, expert opinion articles, and abstracts without full-text were excluded. Any study published prior to 2014 or earlier was also excluded due to being outside the scope of this review.

Article Screening Process
Following retrieval, articles were first screened for duplicates. After title and abstract screening, articles were subject to full-text screening. All articles that met the inclusion criteria were selected for further review.

Results

Study Characteristics
A total of 99 studies were identified during the initial search. Two duplicates were removed by hand. Following initial title and abstract screening, 31 articles were assessed for eligibility. 11 studies were ultimately included in this review (1 randomized controlled trial, 9 prospective studies, and 1 retrospective study). Across all studies, 665 patients met the inclusion criteria (536 females and 34 males). The mean age was 13 years and the mean duration of bracing was 21.2 months. All 11 studies assessed the psychological effects of brace wear in adolescents with AIS. Of these, 8 studies supported the notion that adverse psychological effects are associated with brace wear, while 3 studies^[17,18,19] failed to find a significant difference in psychological outcomes among those treated with brace treatment compared with controls. 5 studies included in this review also examined how brace-related psychological stress influences brace compliance. Data was collected using the following patient reported outcome measures: Bad Sobernheim Stress Questionnaire-Brace (4 studies), Scoliosis Research Society-22 (4 studies), Brace Questionnaire (2 studies), Spinal Appearance Questionnaire (1 study), PedsQL4.0 (1 study), Trunk Appearance Perception Scale (1 study), and Center for Epidemiological Studies Depression Scale for Children (1 study).

Table 1

Table 1.   Characteristics of included studies.

Effect of Brace Wear on Adolescent Quality of Life
The current literature states that 72% of teens diagnosed with AIS report feeling psychologically affected by having to wear a brace.^[20] Schwieger et al.^[21] carried out a multicenter trial that incorporated both random assignment and self-selection to divide participants into two treatment groups (brace or observation) and evaluated the relationship between body image and quality of life in female patients with AIS. Body image was assessed using the Spinal Appearance Questionnaire (SAQ), a 33-question assessment used to evaluate perceived appearance, degree of deformity, and overall expectations. Quality of life (QOL) was assessed using the PedsQL 4.0 Generic Corse Scale in which patients rate their quality of life on a scale from 0 to 100 with a score of 100 being the highest possible quality of life. Results showed a significant negative correlation between quality of life and all three body image domains (appearance, deformity, and expectations) in the brace treatment group at baseline, 6, 12, and 18 months. Based upon these findings, the authors concluded that increased brace wear was associated with worse body image and quality of life. Two additional studies performed by Piatoni et al.^[20] and Chan et al.^[22] utilized the Brace Questionnaire (BrQ) to explore the effects of brace treatment among adolescents. The BrQ is a tool designed to evaluate the quality of life of AIS patients who wear a brace. Both studies showed that brace treatment negatively affects quality of life.

While psychological stress from brace wear is a primary concern, patients with AIS may also struggle with additional sources of anxiety related to disease progression, spinal deformity, and the possibility of future surgery. After examining various sources of psychological stress among 31 patients with AIS, the authors of Zimon et al.^[23] found that while stress level is related to disease severity irrespective of treatment method, brace-related stress was significantly greater than deformity-related stress. Results of the aforementioned four studies included in this review directly contradict those of an earlier study^[24] in which brace wear was not found to decrease quality of life in patients with AIS.

It is important to recognize that many patients who undergo brace treatment are school-aged, and it is not uncommon for patients to worry about the aesthetic implications of wearing a rigid plastic shell underneath their clothing while in the presence of peers. The results of an exploratory factor analysis performed by Asada et al.^[25] showed that a major source of brace-related psychological distress in adolescents arises from concerns about how they will be perceived by others. The fear of looking different from peers and the subsequent embarrassment that adolescents experience results in social withdrawal. In a study conducted by Piantoni et al.^[20] in which 43 females undergoing brace treatment were evaluated, 42% reported staying home because they felt embarrassed, 35% admitted to being absent from school because of their brace, and 41% found it more difficult to socialize with peers while wearing the brace. Additionally, 75% of patients changed the clothes they wore due to the brace and 69% felt noticeably different from their peers. Although the psychological effects of brace wear cannot be discounted, there is evidence to suggest that symptoms may improve over time with continued brace wear as patients become more accustomed to wearing the brace. Di Maria et al.^[19] found that patients who had undergone brace treatment for more than six months reported lower levels of psychological distress and a higher quality of life compared to patients who had undergone brace treatment for less than six months.

Only recently has AIS been recognized as a risk factor for the development of mental health disorders, with symptoms of anxiety and depression shown to be more common in patients with AIS compared to healthy controls.^[26] Lin et al.^[27] identified sex-specific differences among patients with AIS with respect to levels of depression, with females exhibiting a greater degree of depression than males. The results of this study showed that larger cobb angle and longer duration of bracing resulted in more severe depression. In addition, females were found to face greater emotional and behavioral difficulties than males, as was evidenced by their scores on the peer problems, prosocial behaviors, emotional symptoms, and total difficulties domains in the Strengths and Difficulties Questionnaire (SDQ) Scale. The authors concluded that female patients with AIS are at greater risk of developing depressive symptoms related to their condition given that females tend to have more severe spinal deformities that require longer periods of brace treatment. Additionally, a study conducted by Sapountzi-Krepia et al.^[28] found that girls with AIS possessed a worse body image compared to boys. Most importantly, only 5% of adolescents in this study stated that they had been afforded an opportunity to discuss their emotional concerns with a healthcare provider, despite 90% reporting the desire to do so.

Discussion
Low adherence to recommended brace-wear schedules is one of the primary challenges of conservative treatment. Adolescent girls in particular may exhibit decreased brace compliance compared to boys due to concerns regarding their appearance. Studies have shown that males with AIS report better self-image, less pain, and better mental health.^[29,30] Females with AIS tend to be more concerned with their physical appearance and are more likely to avoid social activities due to negative body image.^[28] When asked why they did not wear their brace as prescribed, girls with AIS stated that the brace interfered with their ability to fit in with their peers due to their altered appearance.^[31,32] More research is needed to better understand how sex-specific differences in body image influence brace compliance.

When brace wear is accompanied by social embarrassment or discomfort, patient compliance drops off precipitously, which in turn compromises treatment success.^[17] In recognition of this, different bracing modalities have been considered, such as the use of soft braces and nighttime-only bracing schedules. Current evidence suggests that nighttime-only bracing is associated with increased brace compliance. In a 2023 study conducted by Asada et al.,^[17] 41 patients undergoing brace treatment for AIS were divided into daytime bracing and nighttime bracing groups. Results demonstrated significantly higher rates of compliance among the nighttime brace group compared to daytime brace group. While soft bracing may be a more comfortable and less obvious treatment alternative for daytime use, a robust study that compares the efficacy of soft bracing to that of hard bracing, or the combination of both, has yet to be performed. As a result, it is possible that additional alternatives do exist for mild cases in particular that are not being utilized.

The concept of nighttime-only bracing was founded upon the idea that patient compliance largely determines brace treatment success. If nighttime bracing offers the advantage of heightened compliance, then this may explain its comparable efficacy to traditional full-time brace wear.^{[33, 34]} Still, it remains difficult to accurately assess compliance. Despite evidence suggesting that many patients overreport hours of brace wear,^[33] there is a lack of technology available to objectively monitor patient compliance. Yet, the ability to measure patient adherence may be the key to developing novel brace designs that mitigate the psychological effects of treatment.

Adolescence is a unique and formative time, one that is often difficult to navigate, even in the absence of a disfiguring condition. Brace treatment can deleteriously affect the quality of life of adolescents with AIS, and this added source of psychological stress is a cause for concern. While adolescence is a challenging time irrespective of gender, the emotional burden carried by females with AIS appears to differentially impact their trajectory not only physically but also psychologically. Adolescent females are particularly sensitive to body image and peer acceptance, and the use of a brace can greatly compromise a young woman’s self-esteem. This increased susceptibility to the effects of social alienation and body dissatisfaction may explain why females are more likely to develop co-morbid mental health disorders.

In the absence of technology capable of objectively monitoring compliance, it remains difficult to evaluate the true efficacy of alternative approaches to brace treatment. The incorporation of psychological screening and intervention into treatment protocols as well as the development of strategies that accurately monitor brace wear are needed to allow for improvements in the clinical management of patients with AIS.

Conclusion
While bracing is undoubtedly an appealing, non-invasive treatment option for patients with AIS, it is important to acknowledge the inadvertent psychological effects that brace treatment can have on a vulnerable adolescent population. In doing so, opportunities for prevention can be identified that not only mitigate risk, but also improve treatment efficacy.

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