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Short communication

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For citation purposes: Weiss HR. History of soft brace treatment in patients with scoliosis: a critical appraisal. Hard Tissue 2013 Jul 01;2(4):35. Co

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History of soft brace treatment in patients with scoliosis: a critical appraisal

HR Weiss*

AbstractIntroductionSoft/dynamic braces today are used all over the world under the name of SpineCor. The marketing concept is very effective in promoting the soft brace as the first and only ‘dynamic’ brace. A short review has been un-dertaken, investigating the history of dynamic braces and devices available today.Short communicationThe use of soft braces to treat scolio-sis has been documented by Schanz as early as 1904. In his book, various soft and hard braces with soft add-ons are described as state of the art in the nineteenth century. Many of these soft braces were developed by Fischer.

Today, shortcomings of the dynam-ic brace have been revealed in litera-ture in comparison with hard braces; however, the concept of improving the quality of life while under brace treatment should be considered fur-ther. The purpose of this review is to highlight the history of soft braces and to present recent developments. ConclusionThere is more than one soft brace used today and the history of soft bracing is long (over 120 years). Claims made by a company to dis-tribute the first and only soft/dy-namic brace may be misleading.

IntroductionSoft/dynamic braces today are pre-scribed all over the world. The mar-keting concept of the most popular

device (SpineCor) is very effective. After a brief certification course, the device is sold predominantly to chiropractors, while other scoliosis specialists have stopped prescribing it. The device is simple to attach, and unlike hard bracing no construction is necessary. It can be fit to the pa-tient in a short period of time, and the patient believes to have received a wonder—free mobility and comfort. However, later they may recognize problems when using the restroom. This matter has always been played down by the authors. The marketing strategy promotes this soft brace as the most widely worn and the first and only ‘dynamic’ brace. Therefore, a short review has been undertaken, reviewing the history of dynamic braces and the devices available today.

Short communicationThe author has referenced some of his own studies in this short com-munication. These referenced stud-ies have been conducted in accord-ance with the Declaration of Helsinki (1964), and the protocols of these studies have been approved by the relevant ethics committees related to the institution in which they were performed. All human subjects, in these referenced studies, gave in-formed consent to participate in these studies.

The use of soft braces to treat scoliosis has been documented by Schanz as early as 19041. In his book, various soft braces (Figure 1) and hard braces with soft add-ons are described as state of the art in the nineteenth century (Figure 2). Many of these soft braces had been devel-oped by Fischer. Also, when review-ing other bracing concepts, we find

the precursor of the Milwaukee brace in the textbook by Schanz1 (Figure 3).

One of these soft braces to treat scoliosis as described by Fischer (1876, cited by Schanz1) looks very similar to a product sold today un-der the name of SpineCor. With the application of elastic straps, as the authors Rivard and Coillard suggest, a corrective movement for individual curve patterns should be maintained in order to inhibit curve progression (Figure 4).

However, soft braces have been ob-solete for quite some time: hard brac-es had been proposed by Wullstein (1902) not long after the first publi-cations on soft braces2. Later, the Mil-waukee brace had been proposed3, then the Chêneau brace4,5 and the Boston brace6, all hard braces with reasonable impact on the patients’ quality of life.

While the Milwaukee brace was less effective4, early outcome studies have described the Chêneau brace4,5 and the Boston brace as effective in the prevention of curve progression during growth6. Prospective con-trolled multicenter7 and long-term studies8 have shown the Boston brace to be effective. In addition, there were outcome studies on the Chêneau brace, clearly demonstrat-ing that in-brace correction and com-pliance are crucial to the outcome of brace treatment9.

During the late 1980s and early 1990s in France, soft braces with the three-point pressure approach had been described. These would include the St. Etienne brace and the Olympe10,11, but these have not been further investigated.

During the late 1990s, soft brace treatment was re-developed12. The soft brace as presented by

* Corresponding Author E-mail: [email protected]

Orthopaedic Rehabilitation Services, D-55457 Gensingen, Alzeyerstr. 23, Germany

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risk for progression (first signs of maturation, premenarchial) had the least positive effects14.

In two independent prospective controlled studies, the soft brace as presented by Coillard12–14 has been shown to be less effective than hard braces15,16. This fact has been ana-lysed, and the unsatisfactory correc-tion of the sagittal profile in the soft brace as presented by Coillard12–14 was pointed out as the cause17.

Relordosation of the lumbar spine is not induced when using the soft brace as presented by Coillard12–14. Therefore, the compressive forces generated in this application may destabilize the spine, while a resto-ration of the sagittal profile can sta-bilize and even correct scoliosis as has been described by van Loon in 200818. To improve the results of soft braces during the high-risk phase of the pubertal growth spurt, focus must be on the sagittal plane since this is important in order to improve treatment results.

Furthermore, a soft brace for treat-ing scoliosis aimed at curve correc-tion on the basis of a three-point pressure system had been intro-duced in 200219–21. This device called the TriaC can solely by used for cer-tain single-curve patterns and has not been proven to be effective in pa-tients during the growth spurt with a high risk for progression.

A soft Boston brace has also been described for patients with neuro-muscular scoliosis, but this has not been mentioned in recent litera-ture22,23.

DiscussionThe concept of using soft braces and reducing the impact braces have on patients is appreciated. However, there appears to be certain short-comings; these should be ruled out to increase patients’ safety and enlarge the range of indications.

The corrective movement in the frontal plane as described by Fischer1 and later by Coillard12–14

Figure 1: Dynamic braces taken from the textbook by Schanz 19041. The names of Fischer and Hoffa are often cited there.

Figure 2: Dynamic braces taken from the textbook by Schanz 19041. The combi-nation of hard and soft components was already known at the time.

Coillard12–14, comparable to the brace described by Schanz1 (see Figure 4), was introduced in the 1990s of the last century, and the first results

were published in 200313. Later, more positive results were published14. However, as Coillard and Rivard have pointed out, the group of patients at

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corrected movement. In principle, the materials should be of endelastic entity (similar to the material used in a Spinealite®-soft brace/biofeed-back device) and should not lose the tension force after a few weeks in order to achieve a sustainable cor-rection. The correction is maintained by constant traction on the shoulder on the thoracic convex side. Howev-er, there is no unlimited freedom of movement like in the SpineCor12–14; this new soft brace/biofeedback de-vice (Spinealite®) is not as comfort-able to wear24. Also, less comfort is outweighed by a constant force of correction, leading to the best pos-sible results as achievable with soft braces (Figure 7). Consider the evi-dence-based fact that curvature cor-rection in brace treatment is crucial to the outcome9.

In light of the lack of independent evidence for the application of soft (dynamic) braces, there seems to be no indication for a regular applica-tion in the treatment of progressive scoliosis. It has been demonstrated that after the progression of a curve in the SpineCor, a real in-brace cor-rection could be achieved with a hard brace of current standard (Figure 5).

This can be considered proof that unlimited mobility in a brace is not compatible to correction urgently needed to preserve a beneficial out-come. During the pubertal growth spurt, soft braces should not be used unless in combination with a high-correction hard brace when compli-ance otherwise cannot be gained. The RCT from Hong Kong (also in-cluding postmenarchial girls) has shown that hard braces are clearly superior to SpineCor soft bracing16. Even worse results were obtained in our prospective controlled study because, as pointed out within the article, the sample of patients was in the most risky phase of growth (all premenarchial, Risser 0 with the first signs of maturation15). All SpineCor adjustments in our group of patients were made under the

Figure 3: A distraction brace like the Milwaukee brace was also described in the textbook by Schanz 19041.

Figure 4: The soft brace as described by Fischer 1876 (left) and a soft brace of current standard as distributed today (middle and right). Unfortunately, no pic-ture from the rear exists for the Fischer brace; however, the adjustment of the corrective ribbon from the front seems rather identical. (With kind permission by Pflaum, Munich.)

should be improved (Figures 5 and 6), while lumbar lordosis should be augmented with the help of a newly designed device. This approach has been described in a paper published recently24 but was retracted by the publisher25 due to a complaint by

Spinecorporation, the company dis-tributing the SpineCor12–14.

Contrary to the elastic ribbon ma-terial used in the SpineCor as pre-sented by Coillard12–14, materials have to be applied with much less elasticity in order to maintain the

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Figure 5: Patient from Macedonia starting SpineCor treatment at the age of 10 with the first signs of maturation and a curve of approximately 30° Cobb. No real correction visible in the SpineCor (upper line). After 2 years of SpineCor treatment, the curve had progressed to 60°. She was treated with a hard brace of actual standard with a significant in-brace correction, although the curve now is bigger and more stiff (lower line).

unfortunately there are failures pos-sible with every brace.

Negrini has pointed out the use of SpineCor as an adjunct to physiother-apy28; however the author dares to doubt that the payment of $3,500 is needed for efficient Physical Therapy (PT). In contrary, it has been shown that the latest approaches of PT in scoliosis management are effectively performed without the need of addi-tional devices29,30.

ConclusionThere is more than one soft brace used today, and the history of soft bracing is long (over 120 years). Claims made by a company to dis-tribute the first and only soft/dy-namic brace may be misleading. Soft braces according to the latest evi-dence should be used with caution and never without part-time hard brace treatment in patients with a high risk for progression.

Competing interests HRW is advisor of Koob-Scolitech, Abtweiler, Germany (Director Grita Weiss) which holds the patent appli-cation PA DE 10 2011 055 333.9 of the Spinealite® Biofeedback device (Inventor of this device is HRW).

Conflict of interestsHRW is advisor of Koob-Scolitech, Abtweiler, Germany (Director Grita Weiss) which holds the patent appli-cation PA DE 10 2011 055 333.9 of the Spinealite® Biofeedback device (Inventor of this device is HRW).

ConsentWritten informed consent was at-tained by the patients and parents to permit the publication of the clinical pictures.

AcknowledgementsI thank Pflaum Company for permit-ting the publication of pictures taken or modified from the book with the title Weiss HR. Best practice in con-servative scoliosis care. 4th edition.

close supervision of Dr. Rivard and Dr. Coillard, and the adjustment was attempted to be improved by the first author after the patients had progressed.

Two other independent studies concluded that there is no advantage of soft bracing with the SpineCor over hard braces and that compliance is no better with the SpineCor26,27.

Therefore, all claims made pre-viously by Coillard and Rivard12–14 have been ruled out. Nevertheless, the SpineCor is a success story with

respect to marketing. It is sold to chi-ropractors mainly for about $500.00 to $800.00 each and resold to the pa-tients for $3,500. The authors have sold the system themselves for the full price to patients in their offices and Dr. Rivard as well as Dr. Coillard holds stock in the company, two facts never disclosed in their papers12–14. Patients pay because they trust and believe the physician that free mobil-ity like in a t-shirt may be compatible with spinal curve correction. When they fail, they are informed that

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Figure 7: A patient in a Spinealite™ biofeedback device. Spinealite™ device was leading to an overcorrection. The initial angle of curvature was 27° and in device correction was –16°. The lumbar counter curve in frontal plane does not seem to be corrected much; however, the axial load of this system when applied to the maximum correction leads to increased rotation. Therefore, this system should not be implemented alone. A hard brace should be worn in conjunction with this system, and we will always propose regular clinical controls.

Figure 6: Left immature patient with a curvature of 41° Cobb. Middle, no vis-ible correction, obviously the curve has not changed in the SpineCor, but the angle measured was 24°, which was also documented into the patient’s history (right).

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