Researchers at Texas Scottish Rite Hospital for Children recently found providing patients with adolescent idiopathic scoliosis and their families with objective information and feedback about brace compliance increased the number of hours patients wore their orthosis and was linked to less curve progression.
The researchers examined 222 patients with adolescent idiopathic scoliosis (AIS) who were fitted with compliance monitors and categorized into two groups. Patients in the first, or counseled, group were told the purpose of the monitor, given regular information on the downloaded data from the monitor and counseled on brace wear. Patients in the second, or non-counseled, group were only told the monitor recorded temperature and the physician and orthotist were not given access to their compliance data.
Focus on compliance
“The purpose was to see if we could influence brace wear, if we could get kids to wear their brace more by showing them a printout of their wear and going over it and counseling them at the time of their visits to the clinic,” Donald Virostek, CPO, director of Orthotics for the hospital and coauthor of the study, told O&P News. “Our overall goal was to improve brace wear on the team we were counseling.”
The researchers hypothesized the patients who knew they were being monitored would be less likely to “cheat” on brace wear, Virostek said.
“What we wanted to do was see if they knew they were being monitored and they wore their brace more, [whether] that resulted in better outcomes of the overall curve. [Would] we have [fewer] surgeries and better compliance that led to less curve progression of their scoliosis?”
Of the 222 patients enrolled in the study, 89 patients were counseled and 79 were not counseled. Overall, 27 were lost to follow-up before completing brace treatment; 25 were deemed ineligible due to diagnosis or sensor failure or resigned from the study; and two patients still were undergoing brace treatment when the study was reviewed. For the counseled group, the average curve magnitude when bracing began was 33.2°, while it was 33.7° for the non-counseled group.
Impact on curve progression
“Overall, we found that kids who were in the counseled group wore their brace, on average, over 3 hours a day more than those who were not counseled,” Virostek said.
Study results showed among the counseled patients who completed brace treatment, 55% did not have curve progression of at least 6°, whereas 27% had progression of at least 50° or to surgery. Among non-counseled patients, 41% did not have curve progression of at least 6°, whereas 35% had progression of at least 50° or to surgery.
Average daily brace wear throughout the study was 13.9 hours per day for counseled patients and 10.8 hours per day for non-counseled patients.
Counseled patients with a curve progression to a magnitude requiring surgery wore their brace an average of 12.6 hours per day in comparison with 9.6 hours per day for non-counseled patients who required surgery. Overall, patients who wore their brace more hours per day had less curve progression, and patients who required surgery wore their braces less often than those who did not require surgery.
Parent, patient involvement
All patients worked with a team that included a physician, orthotist and nurse, but only the counseled group received a detailed progress report on their wear. Parents were in attendance for all sessions for both groups of patients.
“Because we are a pediatric hospital and we are treating kids younger than 18 [years], all these kids come to appointments with a parent, so the parents are seen in the room with the physician and the orthotist and the nurse. They go over the X-ray,” Virostek said. “For the counseled kids, we had a printout [that] would have a graph showing how many hours a day they were wearing [the brace] and we would go over that with both the parents and the child. Sometimes the parents did not realize the patient had not worn it much” until they saw the data.
The possible emotional impact of compliance monitoring on patients was a concern for the researchers, and the study noted previous research has shown bracing leads to greater psychological stress for patients. But Virostek said the counseling did not appear to add to patient stress.
“Any time you are being asked to do something — whether it is to take a pill or go to physical therapy — there is some expectation about following through with that,” he said. “Kids, especially with scoliosis, it is a difficult period for them. They are adolescents. They are all going through a lot of changes in the preteen and early teen years, and it is mostly female [patients] we are treating. We originally thought [the compliance monitoring and counseling] was going to be a bit bigger of a deal than it turned out to be.”
In fact, the counseling showed a positive impact on some patients.
“The more we did it, the more we found that the kids wanted to [participate]. It was almost like their way of proving they are doing what is being asked of them. I do not think it was as big of a negative impact as we originally thought.”
He added the way a patient receives compliance information is affected by the way it is presented to them.
“It was incumbent upon the physician who was doing the counseling, because [the way] they relate their brace wear to the patient also has a big impact on how the child is going to follow with the treatment,” he said.
Based on the overall results of the study, Virostek and colleagues recommend compliance monitoring and counseling be incorporated into the clinical orthotic management of AIS patients. The study also noted the monitors are inexpensive and can be easily inserted into an orthosis.
“Our take-home message is we know that bracing for scoliosis can work, but what we have always struggled with is getting these kids to wear their brace for the amount of hours [needed] for the brace to be successful. Counseling, whether it is with a button that is monitoring their hours or some other method, is one tool to help us get these kids to wear the brace more,” Virostek said. “Our ultimate goal here is to reduce the number of surgeries kids with scoliosis have to undergo.” – by Amanda Alexander
- Virostek D, et al. J Bone Joint Surg Am. 2016;doi:10.2106/JBJS.O.00359.
Disclosure: The researchers report no relevant financial disclosures.