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 Table of Contents  
Year : 2021  |  Volume : 13  |  Issue : 1  |  Page : 11-16

Gender difference in health-related quality of life of adolescent idiopathic scoliosis patients between the 2nd and 5th year of bracing treatment using scoliosis research society-22 questionnaire

Department of Orthopaedics and Traumatology, Chinese University of Hong Kong, Sha Tin, Hong Kong

Date of Submission16-May-2020
Date of Acceptance11-Apr-2021
Date of Web Publication16-Jun-2021

Correspondence Address:
Dr. Bobby Kin-Wah Ng
Department of Orthopaedics and Traumatology, Chinese University of Hong Kong, Sha Tin
Hong Kong
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jotr.jotr_37_20

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Background: Offering brace for moderately suffering adolescent idiopathic scoliosis (AIS) patients is a recognized intervention to control further curve progression, and the treatment period varies from each patient. Some AIS patients required to wear longer than expected with different clinical reasons. Health-related quality of life (HRQOL) of AIS patients who have undergone bracing from the 2nd year to 5th year has not been discussed. The aim of this study is to evaluate the HRQOL of patients who have undergone bracing between their 2nd to 5th year of treatment using Scoliosis Research Society-22 (SRS-22) questionnaire. Materials and Methods: One hundred and twenty-six AIS patients who were under brace treatment completed SRS-22 questionnaire at their 2nd, 3rd, 4th, and 5th year on brace. Five SRS-22 domain scores (function, pain, self-image, mental health, and satisfaction with management) collected longitudinally were compared among the 4-time points. Gender-specific analysis was performed to look for any difference between boys and girls. Results: Mean numbers of months among visits were 8.99 (between 2nd and 3rd), 8.42 (between 3rd and 4th), and 7.89 (between 4th and 5th). Function, pain, and satisfaction with management scores were significantly decreased in the 3rd year during bracing and increased steadily afterward. Gender-specific analysis showed female patients experienced similar changes in function, pain and satisfaction at the 3rd year. Conclusions: Function, pain, and satisfaction scores were much affected at the 3rd year and recovered afterward. Gender difference was found and the same significant changes were found in female patients but not in male patients.

Keywords: Adolescent idiopathic scoliosis, bracing, gender, quality of life, Scoliosis Research Society-22 questionnaire

How to cite this article:
Chau WW, Hung AL, Ng BK. Gender difference in health-related quality of life of adolescent idiopathic scoliosis patients between the 2nd and 5th year of bracing treatment using scoliosis research society-22 questionnaire. J Orthop Traumatol Rehabil 2021;13:11-6

How to cite this URL:
Chau WW, Hung AL, Ng BK. Gender difference in health-related quality of life of adolescent idiopathic scoliosis patients between the 2nd and 5th year of bracing treatment using scoliosis research society-22 questionnaire. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2022 Aug 10];13:11-6. Available from: https://www.jotr.in/text.asp?2021/13/1/11/318409

  Introduction Top

Adolescent Idiopathic Scoliosis (AIS) is a three-dimensional deformity presenting with back deformity, rib hump and/or shoulder asymmetry.[1] Brace treatment is a physical intervention on the spine aiming at controlling the possibility of curve progression by exerting external force to rib hump and spine.[2],[3],[4] Longitudinal follow-up of health-related quality of life (HRQOL) of postoperative AIS after years of follow-up has been actively reported.[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18] However, changes in HRQOL of AIS patients underwent bracing for long periods have yet to be reported. We expect gender difference in HRQOL would observe after years of bracing and clinical management would need to adjust to cope with the changes.

Longitudinal follow-up on the HRQOL of bracing AIS patients who have undergone bracing more than 2 years has yet to be discussed. Literatures on AIS bracing patients mainly focused on (1) the effectiveness of bracing,[19],[20],[21] (2) HRQOL of bracing patients in cross-sectional setting and <2 years of follow-up,[22],[23],[24] and (3) comparison of HRQOL among braced, unbraced, and observed.[25] The effect of prolonged bracing on patient-reported outcomes has not been reported yet. There are clinical reasons for them to wear brace for that long, for example, they suffer from (1) congenital spinal deformity, (2) infantile and congenital neurophysiological disorder, or (3) late peak skeletal maturity.[26] The effects of prolonged bracing on patients' function (activity daily living), pain (continuous external force exertion), self-image (self-esteem), and mental health (pressure from self, peer or other parties, and satisfaction with management (clinical process and management) are worth exploring. Our previous study reported gender difference in HRQOL after surgery.[27] We speculate there was gender difference after years of undergoing brace treatment.

Scoliosis Research Society-22 questionnaire (SRS-22) is a well-established questionnaire to evaluate quality of life and health outcomes in AIS patients.[28] It was developed by SRS.[28] SRS-22 is proven to be a valid and reliable instrument for assessing patients with AIS that is sensitive to changes following surgery. The questionnaire is reliable with internal consistency and reproducibility. It is shorter and more focused on the health issues related to idiopathic scoliosis than standard form-36.[29]

The aim of this study is to evaluate the longitudinal gender difference in HRQOL of AIS patients under continuous bracing from the second to the 5th year using SRS-22 questionnaire.

  Materials and Methods Top

Study design

This is a retrospective longitudinal study on bracing AIS patients.


AIS patients who have undergone bracing for around 2 years visiting a specialized clinic at a tertiary hospital in 2013 were invited to join the study. Ethical approval was obtained from the ethics review board (Research Ethics Committee approval number: 2019.213). Informed consent was signed and obtained from every study participant and their legal guardians when required. Criteria for patients wearing braces followed BrAIST recommendations.[30] The inclusion criteria were (1) age ≥10, (2) major Cobb angle between 20 and 29, (3) TOCI stage ≤4,[26],[31] and (4) menarche not yet started or less than 6 months since menarche. Exclusion criteria were (1) non-AIS, (2) any congenital orthopedic disorder, and (3) any neurophysiological defect.

General treatment plan

Every patient took an anteroposterior thoracic X-ray before visiting the clinic. Patients with major Cobb angle 20° or above started brace treatment. Other factors were also considered when offering bracing treatment, for example, TOCI stage (stage 4 or lower), onset of menarche (not yet started, within 1 year of menarche). Milwaukee brace was advised for apical levels T7 or above, and Boston or underarm brace for apical levels lower than T7. Surgical decision was recommended when the major Cobb angle was 55 or above.

Bracing treatment discontinued based on the following criteria (1) major Cobb angle remained stable (curve progression <5 degrees in consecutive follow-ups), (2) more than 2 years' postmenarche, and (3) reaching skeletal maturity in terms of TOCI stage 6-8. Brace treatment was still offered for Cobb angle at or above 55 degrees despite surgery would be planned (tried to control the progression during surgical waiting time).

Certain types of AIS patients required to brace for up to 5 years, for example, very late onset of menarche,[32] skeletal maturity still at TOCI stage 5 or below after years of bracing. Admitted the bracing compliance could be reduced with time, patients requiring “long-term” brace treatment were well informed about their underlying conditions and bracing compliance was still good. Parents or legal guardians were encouraged to support their children to carry on with promising compliance.

Scoliosis Research Society-22 questionnaire

Patients filled out the SRS-22 questionnaire through a mobile platform.[33] The original version is copyright by SRS.[28] The refined version of SRS-22 was adopted. The questions and answers in the electronic version were the same as in the original version. Patients could choose either English (original version) or Traditional Chinese language (translated and validated version)[34] to complete the questionnaire (language switchable through the system). SRS-22 was self-administered and completed by the patients.

Longitudinal follow-up between the 2nd and 5th year of bracing

All patients were followed for 3 years with 4 data collection time points. SRS-22 questionnaires were filled out at the 2nd (at recruitment), 3rd, 4th, and 5th year of bracing treatment. All patients administered the SRS-22 questionnaire every time they visited the clinic.

Statistical analysis

Demographic characteristics were described using mean ± standard deviation (SD) or number (percentage) where appropriate. Patient distributions across the 4-time points were tabulated. Mean values of the five SRS-22 domain scores (function, pain, self-image, mental health, and satisfaction with management) per visit were calculated and tabulated. SRS-22 ”satisfaction” score was not calculated because this domain was associated with question 21 and 22 which were targeted for health quality outcomes of surgical patients, leaving the 5 domain scores to discuss further (function, pain, self-image, mental health, and satisfaction with management). Numbers of months between visits were expressed by mean ± SD and range (minimum and maximum numbers of months). Longitudinal SRS-22 domain scores were analyzed using ANOVA. post hoc Bonferroni correction analyses were also carried out to look for the significant differences in multiple comparisons. Gender-specific analysis was carried out to look for any difference between male and female patients. Data analysis was carried out using IBM SPSS 25.0 (Armonk, New York, USA). A two-sided P ≤ 0.05 was considered statistically significant.

  Results Top

Demographic characteristics

One hundred and twenty-six patients were recruited in this study and completed a total of 399 questionnaires. Numbers of completed questionnaires were 126 at the second, 112 at the third, 89 at the fourth, and 72 at the 5th year. The losses were mainly due to (1) lost to follow-up or (2) drop-out because of curve progression and surgery offered. Bracing compliance was reported from the patients or parents/legal guardians. Average numbers of bracing hours per day were 17.1, 16.3, 14.2, and 11.9 in the 2nd, 3rd, 4th and 5th year respectively. The average major Cobb angles were 23.0, 30.8, 33.6, and 34.0 in the 2nd, 3rd, 4th, and 5th year respectively. Their demographic characteristics are tabulated in [Table 1]. Thoracic curve was found in 39.6% of patients, and thoracolumbar/lumbar curve for the rest.
Table 1: Demographic characteristics of the 126 adolescent idiopathic scoliosis patients at recruitment (mean±standard deviation [range], or n [%] where appropriate)

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Longitudinal Scoliosis Research Society-22 domain scores in all patients

No significant correlation between the Cobb angle and SRS-22 scores was found. Longitudinal SRS-22 domain score analyses were carried out by comparing the scores among the 4 visits [Table 2] and [Figure 1]. Mean numbers of months among two-time points were 8.99 (between 2nd and 3rd year), 8.42 (between 3rd and 4th year), and 7.89 months (between 4th and 5th year). In general, all scores were dropped at the 3rd year (the second time point), and increased and remained stable after the 3rd year, except “mental” which continued to drop until the 4th year (the third time point) and raised in the 5th year (the fourth time point) (mental: 4.26 [2nd], 4.23 [3rd], 4.21 [4th], and 4.39 [5th]). Significant differences were found in function, pain, and satisfaction. Post hoc comparative analyses showed the above scores were significantly decreased between the 2nd year and the 3rd year.
Table 2: Longitudinal Scoliosis Research Society-22 domain scores from the second to fifth year of adolescent idiopathic scoliosis patients undergone bracing

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Figure 1: Longitudinal Scoliosis Research Society-22 domain scores across the 5 years of bracing treatment

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Gender-specific data analysis was followed. In male patients, all scores were decreased from the 2nd year to the 3rd year [Table 3] and [Figure 2]. Function, pain, and self-image were increasing from the 3rd year onwards. Mental and Satisfaction scores were kept decreasing until the 4th year and raised in the 5th year. No statistical significance was found in any comparison. In female patients, all scores were dropped on the 3rd year, particularly in function, pain, and satisfaction which showed statistical significances (all P < 0.01) [Table 3 and [Figure 3]. All scores, except mental, were increased at the 3rd year of bracing. Mental started to increase in the 4th year.
Table 3: Longitudinal Scoliosis Research Society-22 domain scores from the second to fifth year of adolescent idiopathic scoliosis patients undergone bracing by gender

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Figure 2: Longitudinal male Scoliosis Research Society-22 domain scores across the 5 years of bracing treatment

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Figure 3: Longitudinal female Scoliosis Research Society-22 domain scores across the 5 years of bracing treatment

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  Discussion Top

This study described longitudinal characteristics of HRQOL in terms of SRS-22 domain scores in AIS bracing patients who had braced for more than 2 years. Longitudinal comparisons showed all SRS-22 domain scores were decreased until the 3rd year of bracing, and generally increased in the fourth and 5th year. Function, pain, and satisfaction domain scores were observed to be significantly dropped from the second to 3rd year. Gender difference was found in female patients but not in male patients.

HRQOL in terms of function, pain, and satisfaction with management is found to be affected across the bracing treatment period. Function and pain have been reported to be relatively easier and faster to accept and adapt.[24] Previous reports on the effects of bracing on body function and pain were carried out in nonlongitudinal studies. In a Swedish study of 1187 adults with juvenile or AIS, function scores were significantly lower when surgically treated group was compared with the brace-treated group and the untreated group.[22] Another study about bracing subjects on trunk perception using SRS-22 could only draw limited findings being a case-control study of 32 subjects.[35] A study on 36 Polish AIS girls treated with Cheneau braces using SRS-22 and another 2 instruments assessing the changes over time in the perception of trunk deformity and other HRQOL scale was carried out. Data were collected in the beginning, 6 and 12 months of follow-up, meaning a 1-year follow-up study.[36] The results from a survey using in-house questionnaire was conducted in 51 Polish AIS patients with a thoracolumbar brace suggested increasing the number of brace-wearing hours per day did not interfere with the socioeconomic relations and the number of hours did not correlate with pain and epidermal injury.[37] The advantage of our study is the longitudinal follow-up approach, which is superior to cross-sectional design. This study is also unique in choosing the specific type of AIS patients who have braced for at least 2 years. Pediatric orthopedic physicians are recommended to review their SRS-22 scores during patient visits and relate the scores with bracing compliance (average number of bracing hours per day).

We found no significant correlation between the Cobb angle and SRS-22 scores in all comparisons. Our results were in line with a study carried out in AIS patients in the Netherlands.[38] However, Climent et al. found that patients treated with a brace were less satisfied with management than patients treated surgically.[39] This observation could not be applied in our specific group of patients undergone brace for a long period. A similar study with a larger sample size was recommended to warrant the findings.

Gender difference on HRQOL of bracing patients has been reported without considering the longitudinal changes when they have braced for more than 2 years. A European study comparing the HRQOL of 127 (122 females and 5 males) braced AIS patients and 100 age-and gender-matched control group showed significantly reduced function.[8] No significant difference in pain and mental was found between these two groups. HRQOL of male AIS found to be higher than female patients in a New York-based study, although using a different instrument.[40] In our study, SRS-22 scores were similar between males and females from the beginning of this study (braced for 2 years) until the 3rd year of bracing, and males generally scored higher than females in the 4th year. Gender was not one of the relevant effects on HRQOL assessed by Dutch version of SRS-22 questionnaire.[38] However, the Dutch SRS-22 questionnaire was conducted by AIS patients who had finished brace treatment. Our patients completed SRS-22 since the 2nd year of bracing and followed for 3 years. The data captured by the Dutch study represented our data collected closed to the 5th year (The Dutch study recruited patients who finished brace treatment). The present study reported longitudinal gender difference in HRQOL in those requiring prolonged bracing treatment. Similar report found none probably limited by the study design, workforce, and difficulty in collecting longitudinal data in terms of data collection and management. Further study introducing a large or multi-center cohort on gender- and age at baseline-differences in HRQOL of AIS patients stratified by initial Cobb angle was recommended to look for the effect of baseline Cobb angle in categories leading to long-term HRQOL under different kinds of treatments (under observation, bracing for years, surgery despite bracing). Moreover, large scale population-based cohort study on males following through from before the onset of scoliosis (e.g., through regular school screening program at early childhood) to different clinical outcomes (under observation, bracing for years, surgery despite bracing) was also important to investigate the prognostic factors on the onset of scoliosis specific on male population.


Loss to follow-up bias and recall bias was inevitable in this study. Some patients might have missed filling out the questionnaires once or twice in the 4-time points with the following reasons: (1) busy schedule, (2) felt negative to non-medical related activities, or 3) simply refused to fill out SRS-22. We still include them in the cohort despite data inconsistency that occurred because the number of long-term bracing patients was few. The missing data were not counted in that time point. The above reasons caused data inconsistency. Bracing compliance measured by thermo-sensor was not discussed in the present study because the use of sensor was not routinely adopted during the study period, being a limitation of retrospective study.

The ceiling effect in SRS-22 questionnaire was well acknowledged. This was very classically seen in the “Pain” and “Function” domains administered to AIS patients. AIS patients were normally pain-free and have good function. Findings from SRS-22 would tend to be clustered around the higher scores of the questionnaire. In such a scenario, the sensitivity of the questionnaire to pick up changes in these domains was compromised. We admitted the ceiling effect happening in our study although this was inevitable in long-term cohort studies.

  Conclusions Top

This study described the gender difference in changes of longitudinal HRQOL of AIS patients who have braced for at least 2 years. General speaking, function, and pain were affected in their 3rd year of bracing, and relieved at subsequent years. Females showed the same significant drops at their 3rd year of bracing and maintained similar throughout the rest of the study. No statistical significance was found in males despite showing similar changes.

Patient declaration statement

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3]


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