Bracing for Adult Scoliosis
If you’re looking for an opportunity to “poke the bear”, look no further than asking an orthopedist specializing in spinal disorders what he or she thinks of adult bracing for scoliosis…Doctors absolutely hate this. Most will immediately tell you that you will get weaker and your scoliosis will get worse if you are an adult and start wearing a brace.
Why?
I’m not here to totally refute the docs. They are an integral part of our care team! I greatly respect their knowledge and skill for any of my patients who need them. I will, however, offer you insight into this issue, as well as a nuanced approach to adult bracing.
It’s helpful to first dive into why we brace scoliosis in the first place, when it often pops up, in adolescence. The onset of adolescent idiopathic scoliosis can be as early as 10 years old. Think of most 10 year olds’ body type: child-like and flexible, “bones made of rubber” as they say. Because of this pliability of the bones, joints, ligaments, and other soft tissues, teens are “moldable”. If we make them a great brace that pushes in the right places and provides counterforce, we can quite literally reshape their spines into a straightened, non-rotated position.
As teens become skeletally mature, their bodies begin to “stiffen”. Our goal is to allow their spines to stiffen up in the straightest position possible. Many teens, even those ultra-compliant ones in great braces, will be left with some residual curvature when they are done growing. If we can keep the curve under 30 degrees by the time they reach skeletal maturity, we feel as though we have succeeded in conservative management of scoliosis.
The other main goal of adolescent bracing is preventing progression. The risk of progression of scoliosis is highest during growth spurts, typically peaking around the time of puberty. If we have them wear a custom-made rigid brace that keeps their spine straight for 21 hours per day, it makes it difficult for the curve to progress. Once a teen is done growing, the risk of scoliosis progression becomes almost zero. When x-ray imaging of the hand (called a Sanders Score) confirms skeletal maturity, the teens are instructed to discontinue bracing.
Now let’s discuss the adult body type: if you are over 35 years old and reading this, I believe this will resonate: we are stiff compared to our teenage selves! What happened to the days where we could sleep flat out on our backs for 8 hours straight without complaint upon waking, or spend hours hunched over a puzzle without having to un-kink ourselves afterwards. After skeletally maturity, our flexibility is on a slow decline for the rest of our lives. Even a top notch customized brace will not provide much curve correction in adult scoliosis: we are simply too stiff; we’ve lost our ability to be molded into a desired shape.
But wait, how about adult scoliosis progression, and preventing progression? Doesn’t it progress?
Yes, but verrrrrrrry gradually: 0.5-0.75 degrees per year for scoliosis under 30 degrees, and 1 degree per year for scoliosis between 31-50 degrees. (This is nothing compared to the progression we see in adolescent scoliosis: we’ve seen 20 degrees of progression in a 6 month period in teenage scoliosis. Again, it happens during growth spurts.)
To finally answer the question of why we don’t brace adults to prevent the gradual progression we know is unavoidable: the risk versus the reward is too high.
If we were to brace an adult 21 hours per day, there would be profound back and core muscle atrophy, or weakening. As the brace assumes the responsibility of muscles like the erector spinae and the transversus abdominis, those muscles stop working to erect and stabilize the spine, because there’s no need for them to do so anymore. The rate at which adults lose muscle mass is rapid compared to their younger counterparts. So, yes, the orthopedists are right, but…
We believe there is a middle ground here. We certainly don’t recommend full-time bracing for adults for the reasons listed above, but we are open to part-time, activity-based bracing for adults. This typically translates to a maximum wear time of 2-3 hours per day, only during activities that are known to flare up symptoms.
The number one reason I am open to part-time adult bracing is because it can facilitate better quality of life for our patients. Real-life examples of this include wearing a brace to be able to wash and vacuum your floors, to garden, or to go out to a meal with friends, without having pain during or after the activity.
One of our patients picks up “expired” flowers from Trader Joe’s and then makes arrangements for a local Hospice House – she was having back pain from moving the buckets of water for the flowers around her garage – despite her regimented core and back strengthening program. Once we discussed part-time bracing, she ordered a brace, began wearing it for her flower-arranging hours, and felt immediate relief. She’s been given a strict time limit per day, and does not exceed that.
Another patient is a busy internal medicine physician who sees patients for 8+ hours a day. She stated that once she got home after a workday, she had to immediately lie down due to back pain and fatigue, despite needing and wanting to make dinner and visit with her family in the evenings. Again, this person was doing consistent core and back exercises, yet needed just a little extra support. Once she began wearing a brace in the evenings after work, she no longer felt the need to lie down; she was free to spend time cooking with and enjoying her family.
So now that we have established appropriate parameters for adult bracing, what kind of braces should be considered? Custom-made? Off-the-rack? We turned to chief Orthotist at National Scoliosis Center, Luke Stilkeleather, for his recommendations. Luke says that although custom-made braces for adults can work, they can be extremely costly (in the thousands) to make. His suggestion is to first do a trial-run with a $110 off-the-rack brace to see if it helps. Most of the examples I discussed above involve patients wearing this type of brace (off-the-rack) versus a custom-made brace. If the $110 brace works well to relieve spinal symptoms, then one can consider beginning the process of having a custom brace made for them.
Aspen Horizon 627 Lumbar Brace
Here is the $110 brace we most often recommend to patients: Aspen Horizon 627 Lumbar Brace.
Bottom line: bracing for adult scoliosis is not an end all and be all. It should always be used in conjunction with a core and spine strengthening program and used sparingly so as not to allow these muscles to weaken further. But if it makes your life a little fuller, a little brighter, a little easier, we are all for it. We are rooting for you.