For many patients with idiopathic scoliosis, wearing a brace can be a stressful and challenging endeavor. Throughout this process, supporting and encouraging your patient can be just as crucial to their treatment’s success as monitoring the brace-wearing regimen.
Michael Glotzbecker, MD, an orthopedic surgeon in the Spinal Program at Boston Children’s Orthopedics and Sports Medicine Center, and Deborah Cranford, RN, a nurse at Boston Children’s who works closely with scoliosis patients, provide insights and tips on how clinicians can help patients better manage their scoliosis treatment.
Do pediatric primary care providers (PCPs) tend to manage patients with scoliosis or refer them to a specialist?
Glotzbecker: It’s highly variable. I think that PCPs have a lot to worry about as far as vaccinations, colds and other illnesses, so they have a lot of other things going on and may or may not choose to refer a patient with a minor curve. It’s certainly rational for many PCPs and pediatricians to follow smaller curvatures, and I often try to send back patients with smaller curves to be followed with the idea that they’ll be referred back to me if they get bigger — it can be a team effort.
Is there a certain point that you usually suggest a pediatrician refer to a spine specialist?
Glotzbecker: We tell them that they should refer if they see a scoliometer reading greater than 7, or certainly a child that has a curve and is under the age of 10.
Some pediatricians will even get x-rays on kids who have a scoliometer reading greater than 7, and when they see in the x-rays that the curve isn’t that bad, they may continue to observe the patient and not refer until the curve is more in the range of bracing criteria. It’s important to remember that what’s significant in clinical screening differs from what’s significant in radiologic screening.
For patients referred to you from a pediatrician, do you see any common miscommunications between them and their physician?
Glotzbecker: I wouldn’t say that there are things that are miscommunicated, but I’d say that there are common misconceptions.
One of the biggest misconceptions is that scoliosis is associated with back pain, so a lot of patients get those two diagnoses confused. Also, some patients that are in the “gray zone” between brace treatment and surgical treatment can get misinformation, because there may be big differences in the way certain physicians treat those patients. There needs to be a clear understanding of what the indications are for bracing and what they are for surgery.
Cranford: One of the most important things is just communication between everyone involved — between the physician, family, patient and a school nurse when possible. It’s imperative that everybody is on the same page and the expectations for the patient are clear.
What are some challenges patients face after they are diagnosed with idiopathic scoliosis?
Cranford: If they are prescribed a brace to wear — and especially if they need to wear it at school — it can be hard for a lot of teens to stick to the plan. This is usually happening at a time when their bodies are already changing, and you’re adding this on top of it all. It can be overwhelming for a child or adolescent to deal with this change.
How would you advise other physicians or nurses to help their patients have the most success with bracing?
Cranford: It’s important to really be understanding and supportive of the patient, and also know the statistics and the data behind the success of bracing. Knowing that — for the most part — this treatment actually works, is very valuable information for a patient.
Don’t underestimate what they are going through and their struggles. Sometimes there are kids who just refuse to wear the brace to school, so make sure that the patient and family understand why we are doing this and why it’s important they wear the brace at this time. Also, don’t underestimate seemingly minor things, such as what type of clothes to wear over the brace, as they can really become major issues.
There are times when you’ll be talking to the parents about the treatment plan, but you should also be reiterating to the child the importance of following the plan.
Do athletes struggle to balance their time between wearing the brace and playing sports?
Cranford: We encourage them to be able to do their sports and activities without any restrictions. We recently had a patient who is a professional dancer — dancing 4-6 hours after school — who was struggling to get in her brace-wearing time while also participating in gym class at school. We worked with her family and came to the decision to keep her out of gym for the remainder of the school year. This allows her to dance while also completing her bracing.
Ultimately, we really don’t want to inhibit any activities, as they’re good for a child’s well-being and self-confidence. And working together with the family and patient to make these types of decisions can be really important as well, it can help them feel like they have some control over their situation.
Learn more about Boston Children’s Spinal Program.