Long-term effects of conservative treatment of Milwaukee brace on body image and mental health of patients with idiopathic scoliosis
Long-term effects of conservative treatment of Milwaukee brace on body image and mental health of patients with idiopathic scoliosis
Ewa Misterska 0 1
Jakub Gøowacki 1
Maciej Gøowacki 1
Adam Okręt 1
0 Department of Pedagogy and Psychology, University of Security, Poznan, Poland, 2 HCP Medical Centre, Poznan, Poland, 3 Department of Pediatric Orthopaedics and Traumatology, Poznan University of Medical Sciences , Poznan , Poland
1 Editor: Yih-Kuen Jan, University of Illinois at Urbana-Champaign , UNITED STATES
We aimed to provide a complex assessment of adult females with adolescent idiopathic scoliosis (AIS) after a minimum of 23 years after completed Milwaukee brace treatment. In the present study, a comparison between healthy female and AIS patients' perception of trunk disfigurement, self-image, mental health, pain level and everyday activity was made. Thirty AIS patients with a mean of 27.77 yrs (SD 3.30) after the treatment were included in the study. The control group consisted of 42 females, matching the age profile of the patient group. Study participants from both groups were examined using the same protocol, except for the radiological evaluation. Patients and healthy controls completed the Polish versions of the Scoliosis Research Society (SRS-22) and Spinal Appearance Questionnaire (SAQ). Patients additionally filled the Bad Sobberheim Stress Questionnaire-Deformity (BSSQDeformity) and Bad Sobberheim Stress Questionnaire-Brace (BSSQ-Brace). The study group's SAQ results differ significantly in regard to the total score and all individual domains, indicating better functioning among healthy controls. Except for the General domain (p = 0.002), among the remaining subscales the study group's results differed significantly at p<0.001. Considering SRS-22 results, it was revealed that the patient group scored higher, signaling better functioning with reference to pain level (p = 0.016), function/activity (p< 0.001) and the total score (p<0.001). The findings add to the complexity of long-term effect evaluations of AIS, particularly amongst females treated with a Milwaukee brace. Long-term results were not conclusive in terms of nonverbal assessment of body image and emotional tension regarding the experiences of brace-wearing. Future patients can be reassured that scoliosis treated conservatively does not negatively affect everyday activity, pain level, childbearing and mental health. Subjects who declared to have psychological problems due to scoliosis had a bigger curve size after treatment and in this study than the other AIS patients.
Data Availability Statement: All data are fully
available in the manuscript and in the Supporting
Funding: The authors received no specific funding
for this work.
Competing interests: The authors have declared
that no competing interests exist.
A number of studies have been conducted to investigate a long-term follow-up after surgical
or conservative treatment for adolescent idiopathic scoliosis (AIS), concerning different types
of brace treatment, among other subjects [1±7]. Danielsson and Nachemson [
] indicated that
adults with scoliosis might be further concerned about their appearance, leading to some
restriction of social and sexual activity. On the other hand, Noonan et al. [
] showed that, after
reaching adulthood, there were no differences of a psychosocial nature in patients treated for
AIS compared with healthy controls. It must be emphasized, most studies with long-term
results regarding AIS refer to patients treated surgically [10±13].
The Milwaukee brace has been a standard of nonsurgical treatment for scoliosis since
]. It was indicated that wearing the Milwaukee brace for 23 hours was the most
effective treatment method for moderate scoliosis. Despite the effectiveness, a study conducted by
Climent et al. concerning the impact of the type of brace on the health-related quality of life
(HRQoL) of adolescents with spine deformities showed that the
Cervico-Thoraco-Lumbosacral Orthosis (CTLSO) (e.g. Milwaukee brace) leads to a significantly greater impairment of
the patient's functioning during treatment than other types of orthoses [
Apter et al.  investigated the psychosocial sequelae of treatment using the Milwaukee
brace in females with AIS and found they were able to cope well after an initial critical period.
The authors indicated that only minor disturbances to body image and sexual attitudes were
observed and, in general, no specific psychiatric intervention was needed in those patients
]. In addition, Gratz et al. [
] suggested that after the initial shock of learning about the
condition and treatment, the negative effects of the Milwaukee brace-wearing experience
were minimal. The experience of "being different" was reported to be constructive by 12.5%
of the patients. The negative aspects reported by the study group were related to buying
clothing, limited movement, and the rudeness shown toward them by others. Meanwhile,
Maruyama et al. [
] adopted part-time wearing of the Milwaukee brace in order to maintain its
effectiveness and at the same time to reduce the physical and psychological burden on the
patients. Their findings indicated that this was effective and did not affect the patients'
Unfortunately, some of the studies mentioned above had shortcomings, such as patients
not being precisely defined nor consecutively selected or the lack of a comparison group
consisting of healthy controls, which may restrict the generalizability of the findings [1±5, 19].
Moreover, most of research concerning the long-term results of conservative treatment
concerns patients treated with the Boston brace [20±22].
To date, none of the mentioned studies have used validated questionnaires for nonverbal
assessment of the perception of trunk disfigurement or scoliosis-specific stress connected to it
and experiences related to wearing the Milwaukee brace. Taking into account the
unambiguous results of a significant long-term psychological impairment related to conservative
treatment, we aimed to provide a complex assessment of adult females with AIS minimum 23 years
after completed Milwaukee brace treatment. In the present study, a comparison between
healthy females' and AIS patients' perception of trunk disfigurement, self-image, mental
health, pain level and everyday activities was performed. Our hypothesis was that significant
differences between these groups would be confirmed, indicating better psychosocial
adaptation in the healthy controls. Furthermore, we aimed to evaluate patients' memories of
braceand deformity-related emotional stress levels. We hypothesized that most of the patients
would indicate a moderate or severe stress level, and that Milwaukee brace-related stress
would be higher than the emotional tension related to body deformity. The last purpose was to
identify socio-demographic and clinical factors affecting patients' functioning, with the
2 / 21
hypothesis that there is no or a weak association between radiological and clinical data and
patients' well-being. We have achieved the study objectives that have been set.
Material and methods
Structure of the study
In the present study, results concerning the implications of brace treatment in adult AIS
females (scoliosis group-SG) treated with a Milwakee brace were evaluated. Based on an
extensive search of Pediatric Orthopedics and Traumatology Clinic charts, we retrospectively
reviewed the clinical records and radiographs of all female patients who had successfully
completed a course of treatment with the Milwaukee orthosis between 1974 and 1990. Forty
patients met the criteria for inclusion, but due to a change in personal details (such as address
or family name after marriage), not all of them were contacted. Finally, 30 women participated
in the evaluation.
A control group of healthy females (healthy controls group-HG) was selected for
comparison based on random sample choice. The study and control group have been tested for
equivalence in regard to their size and the quantitative and qualitative characteristics.
The groups were interviewed for age, work, marital status, number of children and how
they were delivered, rate of caesarian sections and complications during delivery, place of
residence and active hobby. In addition, all study participants were asked to fill in questionnaires
to compare long-term brace-wearing's psychosocial implications.
All study participants were examined using the same protocol, except for the radiological
evaluation performed in scoliosis patients only. They were informed in detail on the objective
of the study. They understood that they would be anonymous and that their personal
information would not be disclosed. All participants signed written informed consent to participate in
the study. The study design was approved by the Bioethics Comission of Poznan University of
Medical Sciences and was carried out in accordance with universal ethical principles.
Clinical and radiological examination
Clinical and radiological examinations were performed at three time points: before, after
completed treatment and then in the current follow-up and were taken in an upright
position with the iliac ala exposed in an anterior-posterior projection. Data concerning former
treatment regimens and radiological findings were gathered from a chart and radiograph
review. The physical examinations were performed by AO, the 4th study author, and the
radiographic measurements were conducted by JG and MG, the 2nd and the 3rd study
The success rate at maturity was calculated according to Nachemson and Peterson, who
defined success of treatment as an increase in the curve of less than 6Ê from the start of bracing
]. The curve change from end of treatment to the present follow-up was assessed as well.
Thirty AIS patients with a minimum of 23 years after completed Milwaukee brace treatment
were included in the study. All treatments were completed before the patients reached 19 years
of age. In all cases, the scoliosis was not detected before 10 years of age and was not combined
with any major spine deformities at the time when brace treatment was implemented. In
addition, patients were excluded from the study if at the present study they suffered from any other
disease leading to trunk deformity.
3 / 21
The control group consisted of 42 females, matching the age profile of the patient groups. The
exclusion criteria for the control group were: previous back surgery or significant scoliosis,
which was ruled out by clinical examination, including the use of the Perdriolli's scoliometer.
None of the controls had a trunk rotation of more than 5Ê, according to Danielsson et al. [
Questionnaires used in this study
To capture the impact of the disease and its treatment, suitable and specific questionnaires
were selected. Patients and healthy controls completed the Polish versions of Scoliosis
Research Society (SRS-22), and Spinal Appearance Questionnaire (SAQ). In addition, to assess
memories of brace- and deformity-related stress experience, only patient group was
additionally asked to fill in the Bad Sobberheim Stress Questionnaire-Deformity (BSSQ-Deformity)
and Bad Sobberheim Stress Questionnaire-Brace (BSSQ-Brace), which directly concern AIS or
the use of braces [24±26].
SRS-22 is a well-recognized self-assessment instrument used in the clinical evaluation of
patients with AIS, which reflects the subjective perception of the patient's health and measures
health-related quality of life (HRQoL) [
]. SRS-22 contains 22 questions, which are grouped
to form the following subscales (domains): intensity of pain; self-image; function/activity;
mental health and satisfaction from treatment. The scores for each answer range from 1 to 5
points and in each domain the recipient can score from 5 to 25 points, except for the
satisfaction from treatment subscale, on which patients can score from 2 to 10 points. The overall
score can range from 22 to 110 points. However, the mean values in each domain are usually
]. Higher values indicate better patient functioning.
BSSQ-Deformity and BSSQ-Brace consider specific requirements related to the necessity of
conservative treatment and stress related to body deformation, connected with AIS.
BSSQ-Brace and BSSQ-Deformity have a very similar structure and both consist of eight
questions. BSSQ-Deformity relates to the effect of spine deformity on patients' mood, interactions
with their social environment and, as a result, the effect of the experienced stress. The
BSSQ-Brace focuses on the psychological burden connected with the necessity of conservative
treatment and assesses the extent to which brace wearing affects mood, distorts social
interactions and, in consequence, leads to an increase in the stress level [
]. Possible answers on
the Bad Sobberheim Stress Questionnaires are marked on a four-point scale: from 0 to 3;
general scores range from 0 to 24. The results are interpreted as follows: the higher the score, the
lesser the stress, thus 0 signifies the greatest stress, whereas 24 signifies the least stress. The
following subdivision of the score values is proposed by Botens-Helmus et al.: 0±8 (strong stress),
9±16 (moderate stress) and 17±24 (little stress) .
The SAQ, a modified version of the Walter Reed Visual Assessment Scale (WRAS), is used
to assess the perception of trunk deformity by scoliosis patients [
]. It comprises of trunk
profiles depicting various degrees of trunk deformity caused by scoliosis, as included in the
WRAS scale. Moreover, the SAQ includes close-ended questions, pertaining to the degree
patients' satisfaction or dissatisfaction with their appearance. To summarize, the SAQ
consists of 20 items which form the following subscales that reflect various forms of body
deformity: general, curve, prominence, trunk shift, waist, shoulders, kyphosis, chest and surgical
scar (this domain was omitted in our analyses). The items are scored from 1 to 5 points. The
higher the score, the worse the patients' perception of appearance. Items no. 8, 18 and 20 are
open-ended questions that focus on which aspect of deformity is the most bothersome to
4 / 21
With respect to the statistical quantitative (numerical) features, e.g. age, apical translation,
Cobb angle, number of children or questionnaire results, we determined the mean, 95%
confidence intervals, range and standard deviations. Regarding the qualitative features,
(information that has aspects that are impossible to be measured), e.g. curve type, educational level,
marital status or place of residence, we gave the number of units that belong to described
categories of a given feature and respective percentages. To determine if the investigated sample
sizes were equivalent, the chi-square test was used. The chi-square test was used to compare
qualitative features between persons with scoliosis and healthy controls. In addition, a
MannWhitney test was utilized to compare differences between both groups in regard to quantitative
characteristics. To establish relations between quantitative data such as e.g. age, duration of
brace application, apical translation, Cobb angle, and questionnaire results, we used
Spearman's rank correlation (marked as rS). To determine dependency between quantitative and
qualitative characteristics, e.g. between questionnaire numerical data and marital status, place
of residence or curve type, ANOVA Kruskal-Wallis test was used. To protect against Type I
errors, a Bonferroni adjustment for multiple comparisons was made in that way the accepted
alpha level (p = 0.05) was divided by the number of tests conducted in each section.
As the border level of statistical significance, we adopted p = 0.05; test results whose p value
exceeded this level were treated as insignificant. For test results whose p value did not exceed
the level of 0.05, effect size (ES) was calculated by means of Cramer's V or Glass's Δ.
Statistical calculations were performed by Statistica software. calculations were performed
by Statistica software. See the supplementary material file containing clinical, radiological,
socio-demographic and questionnaire data. See the supplementary material file containing
clinical, radiological, socio-demographic and questionnaire data.
Clinical and radiological data
The sample sizes are equivalent (p = 0.157). The patients' mean follow-up period was 27.77
yrs. SD 3.30 (range 23±35 years). The Milwaukee brace was worn for a mean of 22.9 hrs. daily
SD 0.31 (range 22±23). The average length of brace application was 45.47 months SD 20.00
Radiographic examination at the beginning of brace treatment resulted in Risser Grade 0 in
19 patients (63.33%), Risser Grade I in 2 patients (6.67%), and Risser Grade II in 9 patients
(30%). Risser Grade IV was identified after completed treatment in all study patients (100%).
In accordance with the criteria of the Scoliosis Research Society regarding the location of
], thoracic scoliosis was identified in 21 patients (70%), thoracolumbar in 2 patients
(6.67%) and lumbar curves were identified in 7 AIS females (23.33%). The success rate at
maturity, according to Nachemson and Peterson [
], was identified in 16 patients (53.33%).
Five patients (16.67%) were qualified for scoliosis surgery after completed brace treatment, but
refused to undergo an operation. The curve change from the end of treatment to the present
study was 9.1 angles SD 7.64 (range 0±27). For additional clinical and radiological
characteristics of the patient group, see Table 1.
The mean age of patients (SG±study group) at the follow-up was 41.13 yrs. SD 3.87 (range 35±
55), whereas mean age of controls (HG±healthy group) was 42.05 yrs. SD 7.41 (range 22±61).
Twenty-eight females with AIS (93.4%) and 29 healthy controls (69%) were married. Of 30
5 / 21
female patients, 29 (96.67%) had delivered babies and the mean number of children was 2.0
SD 0.83 (range 0±4), whereas in the control group 33 females (78.57%) had delivered babies
and the mean number of children in this subgroup was 1.48 SD 0.99 (range 0±3). The rate of
caesarean section was 30% (9 patients) in SG and 27.3% (9 controls) in HG. Ten patients
(34.48%) and 8 controls (23.53%) had experienced problems during delivery (for additional
data, see Table 2).
Analysis of questionnaires data
Mean scores and standard deviations, the minimum, maximum, and 95% confidence intervals
of SRS-22, BSSQ-Deformity, BSSQ-Brace and the SAQ were calculated and are summarized in
Patients experienced a moderate level of stress connected with memories of conservative
treatment; the mean value was 11.1 SD 4.73, however, the stress level related to perceived
trunk deformation was high and the mean value was 7.40 SD 3.71. This difference is
statistically significant (p = 0.001).
6 / 21
p < 0.05
out of 29 patients and 34 participants who had delivered a child
out of 13 patients and 17 healthy controls with an active hobby; standard deviation (SD); effect size (ES)
The highest number of patients (n = 14, 46.67%) experienced moderate stress related to
body disfigurement. However, a similar number of patients (n = 12, 40%) reported severe
stress concerning body deformity. Only 4 patients (13.33%) experienced a low stress level.
Concerning the memories of stress related to completed brace treatment, 20 patients (66.7%)
reported a strong stress level regarding this experience, whereas 10 females (33.33%) reported
a moderate stress level.
In respect to the total scores of the SAQ, patients scored 2.91 SD 0.77. Patients exhibited the
most self-criticism in the following order: General, Waist, Chest, Curve and Shoulders
(average scores respectively: 3.33, 3.02, 2.97, 2.93 and 2.83). Kyphosis, Prominence and Trunk shift
were the elements that are assessed the least critically by patients (average scores respectively:
2.70, 2.53 and 2.45) (Table 3).
Whereas, considering the general results of the SAQ achieved in the HG, individuals scored
1.45 SD 0.41. Healthy controls exhibited the greatest self-criticism in the following order:
7 / 21
p < 0.05; standard deviation (SD); confidence intervals (CI); effect size (ES); Scoliosis Research Society-22 (SRS-22); Spinal Appearance Questionnaire (SAQ); Bad
Sobberheim Stress Questionnaire-Deformity (BSSQ-Deformity); Bad Sobberheim Stress Questionnaire-Brace (BSSQ-Brace).
General, Waist, Shoulders, Chest And Kyphosis (average scores respectively: 2.68, 1.29, 1.21,
1.13, 1.12). Curve, Prominence and Trunk Shift were the least critically elements assessed by
the controls (average scores respectively: 1.10, 1.08 and 1.08) (Table 3).
Table 4 shows the interpretation of answers given to open-ended questions on the SAQ.
From the interpretation of answers given to question 8, it appears that most patients (n = 13
and n = 9, that is 43.33% and 26.67%) indicated rib and flank prominence, respectively, as the
elements of trunk deformity most disturbing to them. (Table 3). In the HG, 39 healthy controls
(92.86%) indicated that none of listed forms of body deformity bothered them the most.
From the interpretation of answers given to question 18, it appears that 12 patients (40%)
would like to be more even, but another 12 patients pointed out that none of the listed items
concerning body appearance was the most important to them. Interestingly, thirty-four
8 / 21
(80.10%) healthy controls indicate that none of the listed items concerning body appearance
are the most important to them.
The distribution of answers to question 20 seems interesting. It appears that as many as 14
patients (46.68%) would not change anything in their body shape, whereas 5 of them (16.67%)
would like to change their body appearance in general (For details see Table 5). In the control
group, most of the females (n = 34, 80.10%) would not change anything in their physical
The total score of the SRS-22 was 2.71 (SD 0.38) and 2.39 (SD 0.29) in the patient and
healthy controls group, respectively (Table 2). Females from both study groups scored highest
in the mental health domain (3.05 SD 0.41 in the SG and 3.0 SD 0.35 in the HG). In the HG,
the worst score regards the function/activity domain (1.89 SD 0.66), whereas in the SG it
regards the self-image subscale (2.14 SD 0.47).
Curve change from end of treatment to present study
according to Nachemson and Peterson, success of treatment was defined as an increase in the curve of less than 6Ê from the start of bracing
the degree of the apical translation of center sacral vertical line (CSVL) according to the Harms Study Group; effect size (ES); Spinal Appearance Questionnaire
HG; the Bonferroni correction also revealed that study groups differ statistically in incidence
of having occupational and university level of education at p = 0.003:, participants from SG
had less often university than occupational level of education than healthy controls. There is
10 / 21
also a statistical difference between subgroups among place of residence (p = 0.001): the
Bonferroni correction revealed that study groups differ statistically in incidence of living in the
country and a city over 20 000 inhabitants at p = 0.002, participants from SG lived more often
in the country.; a Bonferroni correction also revealed that study groups differ statistically in
incidence of living in a city below 25 000 inhabitants and city over 20 000 inhabitants at
p = 0.001, participants from SG lived more often in in a city below 25 000 inhabitants. Results
showed that subgroups statistically differ in terms of working time per week (p = 0.013,
patients from SG spend less time on their occupational activity per week), no. of children (p =
0.046, patients from SG had delivered more children) and active hobby per week (p = 0.038,
patients from SG spend fewer hours weekly on an active hobby). There was also revealed a
statistical difference between subgroups in marital status (p = 0.037), however, a Bonferroni
correction revealed that the particular comparisons between selected categories (single, married,
divorced, widowed) are statistically insignificant. For details, see Table 2.
Regarding SAQ results, the study groups differ significantly in the total score and all
individual domains, indicating better functioning among participants from HG. Except for the
General domain (p = 0.002), the study groups differed significantly on the remaining subscales
at p<0.001. Regarding the distribution of answers to open-ended questions, our study
confirmed statistically significant differences for question 8, as well as questions 18 and 20 (p<
0.001, p = 0.005 and p = 0.013, respectively). A Bonferroni correction revealed that, regarding
question 8, the study groups differ significantly (at p < 0.0001) in incidence of pointing which
form of deformity bothers them most (answer none vs rib prominence), indicating a better
assessment of body shape among the healthy controls. Concerning question 18, the Bonferroni
correction revealed that the study groups differ significantly (at p = 0.0005) in incidence of
pointing which of questions 9±17 are the most important to participants, indicating that
healthy controls more often indicated that none of questions is the most important to them,
compared to indicating question no. 9 (on the desire to have a correct trunk shape) than
scoliosis patients. Finally, concerning question 20, the Bonferroni correction revealed that the
study groups differ significantly (at p = 0.002) in pointing what would they most like to change
about their body's shape indicating that scoliosis patients more often pointed rib hump than
their body shape in general, compared to healthy controls (see Table 4).
Considering SRS-22 results, it was revealed that the SG group scored higher, signaling
better functioning with reference to the pain level (p = 0.016), function/activity (p<0.001) and the
total score (p<0.001) (for details see Table 3).
Correlation between the radiographic and clinical data and patients' wellbeing
Having analyzed the correlations concerning the results on specific subscales and the general
results of the SAQ, after implementing a Bonferroni correction for multiple comparisons, test
results whose p value exceeded the level of 0.0056, were treated as insignificant. Associations
were identified between the Cobb angle after completed treatment and Prominence and
Trunk Shift domains and the Total score (rs = 0.56, rs = 0.53 and rs = 0.50, respectively). In
addition, significant associations were also revealed between apical translation after treatment
and Shoulders and Chest domains and the Total score (rs = 0.53, rs = 0.53 and rs = 0.53,
respectively) (see Table 5).
Considering the associations between BSSQ, SRS-22 and radiographic and clinical data,
after implementing a Bonferroni correction for multiple comparisons, test results whose p
value exceeded the level of 0.0063, were treated as insignificant. Finally, we did not reveal any
significant associations. For details, see Table 6.
11 / 21
according to Nachemson and Peterson, success of treatment was defined as an increase in the curve of less than 6Ê from the start of bracing
the degree of the apical translation of center sacral vertical line (CSVL) according to the Harms Study Group; Scoliosis Research Society-22 (SRS-22); Bad Sobberheim
Stress Questionnaire-Deformity (BSSQ-Deformity); Bad Sobberheim Stress Questionnaire-Brace (BSSQ-Brace).
12 / 21
Correlation between the socio-demographic data and patients' well-being
After implementing a Bonferroni correction for multiple comparisons, test results whose p
value exceeded the level of 0.0056, were treated as insignificant. Finally, we did not reveal any
significant associations. For details, see Table 7.
Associations between questionnaire results
As seen in Table 8, after implementing a Bonferroni correction for multiple comparisons, test
results whose p value exceeded the level of 0.0125, were treated as insignificant. It was revealed
Note Scoliosis Research Society-22 (SRS-22); Spinal Appearance Questionnaire (SAQ); Bad Sobberheim Stress Questionnaire-Deformity (BSSQ-Deformity); Bad
Sobberheim Stress Questionnaire-Brace (BSSQ-Brace).
13 / 21
p < 0.0125; Scoliosis Research Society-22 (SRS-22); Spinal Appearance Questionnaire (SAQ); Bad Sobberheim Stress Questionnaire-Deformity (BSSQ-Deformity);
Bad Sobberheim Stress Questionnaire-Brace (BSSQ-Brace).
that only BSSQ-Deformity displays a significant correlation with SRS-22 (rs = -0.48) (see
A number of long-term follow-up studies on AIS have been published [2±5,33±34]. Many of
those studies only focus on one topic, mostly on radiological findings in one plane, with no
comparison group of straight individuals. A non-consecutive patient series and a high number
of dropouts in these studies limit the conclusions that can be drawn [
Bearing in mind the results of these studies, we assumed that monitoring the functioning of
adult females with AIS should be routinely implemented after brace treatment is completed.
The longitudinal exploration of the perception of disease and possible psychopathological
implications would allow determining useful practical implications for the clinicians. In
addition, we believe that long-term follow-up studies can provide reliable information for patients
who will undergo conservative or surgical treatment due to AIS.
To our knowledge, this is the first study of long-term effects after more than two decades of
completed Milwaukee brace treatment, concerning patient's complex evaluation of
disfigurement by means of trunk profiles depicting various degrees of scoliosis-related trunk deformity,
or memories of stress experienced during wearing the brace and regarding body deformity.
A control group of randomly selected from a larger sample healthy females, assembled for
comparison purposes, enabled a comprehensive assessment of scoliosis patients, and, owing to
this fact, our study results add to the complexity of long post-treatment evaluations of brace
treatment in AIS. It was confirmed that adult scoliosis patients, despite over 20 years after
completed Milwaukee brace treatment, are further concerned about their appearance, when
questioned about nonverbal assessment of e.g. their own shoulder level, waist asymmetry,
body curve or rib prominence. At the same time, emotional tension regarding the experience
of brace-wearing was reported at a very high level. Moreover, adult patients questioned about
their memories of emotional tension, reported higher stress levels due to brace application
when compared to the stress related to trunk deformation alone.
Considering the issue of progression of scoliosis, Negrini et al. [
] summarized the results
of conservative treatment. They referred to eg Weinstein et al.  who found that the rate of
success (curves remaining below 50 degrees) was 38/51 in the brace group and 27/65 in the
observation group. The results were in favor of brace. In addition, they indicated Coillard et al.
] work, in which the authors reported the rate of success (correction or stabilization,
recognized as 58 degrees or less of curve progression) as 21/26 in the brace group and 9/21 in the
14 / 21
control group. The results were also in favor of brace. Those data are consistent with results of
Milwaukee brace treatment referred in the current study and enters at issue of natural
differential effects of conservative treatment due to adolescent idiopathic scoliosis.
Questions arise as to the long-term effects of bracing on the psyche, on the curve and on
the everyday activity of adult scoliosis patients. In our opinion, such variables as social
functioning, satisfaction with appearance, feeling of attractiveness, or stress level regarding body
deformation also required more in-depth investigation in adult scoliosis populations. In a
similar study, Noonan et al. [
] evaluated the psychosocial characteristics of patients treated for
AIS at an average follow-up of 7 years. They found that patients' perceptions of discrimination
and a lower satisfaction with their overall appearance was recalled during the brace treatment
phase, but on reaching adulthood there were no more differences in those characteristics in
patients compared with healthy controls. Interestingly, in their study concerning scoliosis
patients at least 20 years after treatment, Danielsson et al. [
] indicated the mean curve in the
long-term follow-up was slightly increased when compared with the original curves and the
curve after weaning. In addition, no major impact on patients' HRQoL was observed.
Furthermore, Gabos et al. analyzed long-term outcomes in females with AIS who had been treated
with the Wilmington orthosis and indicated that 93% of them reported no subjective
deterioration in their physical appearance, the cosmetic appearance of the back, or their self-image in
the period since they discontinued using the brace [
Our study findings partly confirm the outcomes referred to by e.g. Danielsson et. Al,
Noonan et. al, or Gabos et al. [
], since in view of SRS-22 results, adult patients scored
surprisingly higher in the intensity of pain and function/activity domains, as well as in the total
score, indicating even better functioning in those areas. Those findings might result from
recommendations for scoliosis patients during and after completed brace treatment by doctors.
Those recommendations focus mainly on physical activity and/or participating in
rehabilitation programmes. However, we did not observe any discrepancies concerning the remaining
domains, such as mental health or self-image domains. This indicates that our study
hypothesis, regarding SRS-22 findings, could not be supported.
FaÈllstroÈm et al. [
], in a series of 157 patients treated surgically and/or with Milwaukee
braces, revealed that 9 years after treatment was completed, one-half of the brace group had
definite signs of a negative body image concept. Those data are consistent with results derived
from our study by means of the SAQ that the experience of wearing the Milwaukee brace has a
long-term negative effect on patients' perceptions of their appearance, including particular
aspects of scoliosis-related deformity, e.g. curve, prominence, kyphosis, chest, shoulder level or
waist asymmetry. Those results supported our primary assumption.
However, some interesting and apparently contradictory results concerning self- and
bodyimage assessment in scoliosis patients must be discussed. As pointed out above, the study
groups do not differ regarding the SRS-22 self-image domain, but, at the same time, significant
discrepancies relating to the total score and all individual domains of the SAQ have been
confirmed. A possible explanation of such an inconsistency might be that SRS-22 represents the
traditional verbal assessment of the patient's feeling of attractiveness and appearance, such as
their appearance in clothes, or influence of body appearance on personal relationships,
whereas the SAQ provides trunk profiles depicting various degrees of body deformity, which
gives patients a direct, nonverbal assessment of e.g. their own shoulder level, waist asymmetry,
body curve or rib prominence. In addition, the lowest score among SRS-22 domains regards
the self-image subscale. Furthermore, as our study presents the first long-term evaluation of
body image in Milwaukee brace-treated adult patients by means of the SAQ, we cannot
compare results derived from current study to similar patients' evaluations, also performed by
means of SAQ. In addition, some explanation of those study results might question the validity
15 / 21
of SAQ and SRS-22 in particular when used in healthy individuals. On the other hand, many
authors, e.g. Berven et al., Lonner et al. or Chaib et al. [41±43] determined the effect of spinal
deformity on patients quality of life by means of comparison of results of SRS-22 in adolescent
idiopathic scoliosis, and healthy controls. For example, Berven et al. [
] determined the
validity and reliability of the modified SRS-22 for use in the assessment of deformity in adults and
demonstrated good discriminate validity of the SRS-22 in differentiating between affected and
unaffected adults, whereas Chaib et al. [
] analyzed postoperative perceived health status in
adolescent following idiopathic scoliosis surgical treatment by means of French SRS-22, which
was also completed by healthy controls.
Especially interesting results were obtained when adult scoliosis patients were questioned
about their memories of emotional tension experienced during brace treatment and
concerning scoliosis-related deformity. It must be emphasized that body deformities related to
scoliosis, such as rib hump or decomposition of the trunk, are sources of stress and fear and disturb
the development of body image. At the same time, many authors, e.g. Clayson et al. [
emphasize that the necessity of wearing an orthopedic brace may cause the patient emotional
distress. They highlight the fear that patients have regarding using a brace in relation to their
social life. Our study results indicated most of the patients had experienced moderate or severe
stress related to body disfigurement and regarding the Milwaukee brace treatment
implemented in puberty, which confirms our primary hypothesis. Furthermore, our results are in
accordance to observations of Botens-Helmut et al. and Kotwicki et al. [
higher stress levels due to brace application when compared to the stress related to trunk
deformation alone. This suggests that patients experiencing stress related to body
disfigurement often experience additional stress related to conservative treatment.
Considering correlations between the evaluation of body appearance and scoliosis
parameters, such as Cobb angle, Asher et al. reported that the trunk deformity during the last control
visit did not correlate with the treatment satisfaction level [
]. Haher et al. also reported that
the radiological status did not correlate with the satisfaction level [
]. Benli et al. pointed out
that patients had high treatment-satisfaction scores, irrespective of their final curve patterns,
and all with a neurological deficit, except for one patient, said ``yesº when asked if they would
have accepted the same course of treatment [
Interestingly, contrary to those reports, our study revealed significant associations between
the nonverbal evaluation of body appearance and Cobb angle after completed treatment, or
apical translation after completed treatment. Our study findings are of special importance,
since, as indicated in many previous studies, negligible or weak relationships exist between the
size or severity of disfigurement and psychological dysfunction [
]. In addition, we did not
reveal any significant associations between the duration of the follow-up period or
Dyl et al. and Ferguson et al. [
] indicated that clinically significant body image
concerns are associated with higher levels of depression, anxiety or mood disorders in general. In
addition, dissatisfaction with body image may play a significant role in the development of low
self-esteem, emotional problems and depression . Therefore, we assumed the emotional
tension regarding disfigurement or conservative treatment, may be related to patients'
assessment of spinal appearance. However, our study results did not support the evidence of
relationships between patients' perception of body image, as measured by the SAQ, and stress
level due to body deformity.
One of the greatest concerns for females with AIS is whether they will be able to give birth
through a normal delivery [
]. The finding that scoliosis patients do not differ significantly
in terms of sociodemographic measures was also reported in previously published studies
]. Danielsson and Nachemson reported long-term outcomes regarding childbearing and
16 / 21
sexual life in AIS women, compared with matched control subjects who did not have scoliosis
] and found that patients appeared to function well with regard to marital status and number
of children. In addition, Danielsson et al [
] revealed no major impact of scoliosis on marriage,
childbearing, or the degree of physical strain during work or leisure time. Similarly, like Benli
et al. [
], in a group of patients treated conservatively, we summarized that scoliosis and
brace treatment regimen did not affect patients' marital status or childbearing negatively.
However, significant differences with regard to educational levels, hours spent on the
occupational activity and active hobby per week in favor of the healthy controls were confirmed.
The results of our study indicated that the patients' quality of life, as measured by the SRS-22,
is associated with levels of emotional distress due to body disfigurement. It is particularly
important as far as practical implications are concerned, since the emotional distress might
constitute a potential risk leading to decrease of patients' general well-being. It ought to be one
of the factors taken into account when considering psychological screening and in providing
appropriate support for AIS females.
It was also revealed that entire domain of patients treated nonoperatively with the
Milwaukee brace, when followed into middle age, is more concerned about body appearance, but less
with back pain and everyday activities, than healthy females. Nevertheless, patients must be
aware that bigger curves after completed treatment might still be associated in the future with
more concerns about their appearance and satisfaction with treatment results. Thus, those
patients should be routinely supported by means of group or individual session, since their
positive influence in the prevention of psychosocial impairment has been confirmed [
To summarize, it is necessary to carefully investigate the emotional burden of adult females
with AIS experience due to spinal disfigurement and orthosis wearing, to provide them with
the appropriate individual psychological support and reliable information for patients
qualified to undergo conservative treatment.
There are some limitations to the present study. Firstly, in view of the fact that validated
scoliosis-specific assessment tools were not available 20 years ago, long-term assessment of
conservative treatment of AIS must be retrospective. Secondly, the response rate was relatively low. Our
study group consisted of 30 study participants. However, this is expected in a study with a very
long-term follow-up assessment. Thirdly, as the patient group and the controls were different
in number of children, working time, and living area, the differences in the results of the
questionnaires of this study might not be due to the presence of scoliosis alone. In addition, we are
aware that those differences might have influenced the study results in regards to e.g. body
image disturbances or mental health. To sum up, further studies with a longer follow-up and
in a group of patients treated surgically for comparative purposes in terms of nonverbal
assessment of spinal appearance and trunk deformity-related emotional stress are needed to expand
the results of our research.
The findings of the current study add to the complexity of long follow-up evaluations of AIS,
amongst females treated with a Milwaukee brace. We conclude that long-term results were not
conclusive regarding the nonverbal assessment of body image and emotional tension
regarding the experiences of brace-wearing. In addition, future patients can be reassured that
scoliosis does not negatively affect everyday activities, pain level, childbearing and mental health.
17 / 21
However, the subjects in our study who declared to have psychological problems due to
scoliosis had bigger curve size after completed treatment.
S1 File. Study participants data and SRS-22, SAQ, BSSQ-Brace and BSSQ-Deformity.
Conceptualization: Ewa Misterska, Jakub Gøowacki, Maciej Gøowacki, Adam Okręt.
Data curation: Jakub Gøowacki, Adam Okręt.
Formal analysis: Ewa Misterska, Maciej Gøowacki.
Investigation: Jakub Gøowacki, Adam Okręt.
Methodology: Ewa Misterska, Jakub Gøowacki, Maciej Gøowacki.
Project administration: Jakub Gøowacki.
Resources: Maciej Gøowacki.
Supervision: Ewa Misterska.
Validation: Ewa Misterska, Jakub Gøowacki, Maciej Gøowacki.
Visualization: Ewa Misterska.
Writing ± original draft: Ewa Misterska, Maciej Gøowacki.
Writing ± review & editing: Ewa Misterska, Jakub Gøowacki, Maciej Gøowacki.
18 / 21
19 / 21
Weinstein SL, Dolan LA, Wright JG, et al. Effects of bracing in adolescents with idiopathic scoliosis. N
Engl J Med 2013; 369: 1512±1521. https://doi.org/10.1056/NEJMoa1307337 PMID: 24047455
20 / 21
1. Cordover AM , Betz RR , Clements DH , Bosacco SJ . Natural history of adolescent thoracolumbar and lumbar idiopathic scoliosis into adulthood . J Spinal Disord 1997 ; 10 : 193 ± 196 . PMID: 9213273
2. Dickson JH , Erwin WD , Rossi D. Harrington instrumentation and arthrodesis for idiopathic scoliosis. A twenty-one-year follow-up . J Bone Joint Surg Am 1990 ; 72 : 678 ± 683 . PMID: 2141336
3. Moskowitz A , Moe JH , Winter RB , Binner H . Long-term follow-up of scoliosis fusion . J Bone Joint Surg Am 1980 ; 62 : 364 ± 376 . PMID: 6444950
4. Nachemson A. A long term follow-up study of non-treated scoliosis . Acta Orthop Scand 1968 ; 39 : 466 ± 476 . PMID: 5726117
5. Nilsonne U , Lundgren KD . Long-term prognosis in idiopathic scoliosis . Acta Orthop Scand 1968 ; 39 : 456 ± 465 . PMID: 5726116
6. Weinstein SL , Zavala DC , Ponseti IV . Idiopathic scoliosis: long-term follow-up and prognosis in untreated patients . J Bone Joint Surg Am 1981 ; 63 : 702 ± 712 . PMID: 6453874
7. Danielsson AJ , Wiklund I , Pehrsson K , Nachemson AL . Health-related quality of life in patients with adolescent idiopathic scoliosis: a matched follow-up at least 20 years after treatment with brace or surgery . Eur Spine J 2001 ; 10 : 278 ± 88 . https://doi.org/10.1007/s005860100309 PMID: 11563612
8. Danielsson A , Nachemson A Childbearing, curve progression, and sexual function in women 22 years after treatment for adolescent idiopathic scoliosis. A case-control study . Spine 2001 ; 26 : 1449 ± 56 . PMID: 11458150
9. Noonan KJ , Dolan LA , Jacobson WC , et al. Long-term psychosocial characteristics of patients treated for idiopathic scoliosis . J Pediatr Orthop 1997 ; 17 : 712 ± 717 . PMID: 9591971
10. Fowles JV , Drummond DS , L'Ecuyer S , Roy L , Kassab MT . Untreated scoliosis in the adult . Clin Orthop 1978 ; 134 : 212 ± 217 .
11. Goldstein JM , Nash CL Jr, Wilham MR . Selection of lumbar fusion levels in adult idiopathic scoliosis patients . Spine 1991 ; 16 : 1150 ± 1154 . PMID: 1754935
12. Gortmaker S , Perrin J , Weitzman M , Homer C , Sobol A. An unexpected success story: transition to adulthood in youth with chronic physical health conditions . J Res Adolesc 1993 ; 3 : 317 ± 336 .
13. Grevitt M , Khazim R , Webb J , Mulholland R , Shepperd J . The Short Form-36 health survey questionnaire in spine surgery . J Bone Joint Surg Br 1997 ; 79 : 48 ± 52 . PMID: 9020444
14. Maruyama T , Takesita K , Kitagawa T , Nakao Y. Milwaukee brace . Physiother Theory Pract 2011 ; 1 : 43 ± 46 .
15. Tones MJ , Moss ND . The impact of patient self assessment of deformity on HRQL in adults with scoliosis . Scoliosis 2007 ; 2 : 14 . https://doi.org/10.1186/ 1748 -7161-2-14 PMID: 17935634
16. Climent JM , Sanchez J . Impact of the type of brace on the quality of life of adolescents with spine deformities . Spine 1999 ; 24 : 1903 ± 1908 . PMID: 10515014
17. Apter A , Morein G , Munitz H , Tyano S , Maoz B , Wijsenbeek H. The psychosocial sequelae of the Milwaukee brace in adolescent girls . Clin Orthop Relat Res 1978 ; 131 : 156 ± 159 .
18. Gratz RR , Papalia-Finlay D . Psychosocial adaptation to wearing the Milwaukee brace for scoliosis. A pilot study of adolescent females and their mothers . J Adolesc Health Care 1984 ; 4 : 237 ± 242 .
19. Danielsson AJ , Nachemson AL . Back pain and function 22 years after brace treatment for adolescent idiopathic scoliosis: a case-control study-part I . Spine 2003 ; 18 : 2078 ± 2086 .
20. Danielsson AJ , Hasserius R , Ohlin A , Nachemson AL . A prospective study of brace treatment versus observation alone in adolescent idiopathic scoliosis: a follow-up mean of 16 years after maturity . Spine 2007 ; 32 : 2198 ± 2207 . https://doi.org/10.1097/BRS.0b013e31814b851f PMID: 17873811
21. Wiley JW , Thomson JD , Mitchell TM , Smith BG , Banta JV . Effectiveness of the Boston brace in treatment of large curves in adolescent idiopathic scoliosis . Spine 2000 ; 25 : 2326 ± 2332 . PMID: 10984784
22. Andersen MO , Christensen SB , Thomsen K. Outcome at 10 years after treatment for adolescent idiopathic scoliosis . Spine 2006 ; 31 : 350 ± 354 . https://doi.org/10.1097/01.brs. 0000197649 .29712. de PMID : 16449910
23. Nachemson AL , Peterson LE . Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. A prospective, controlled study based on data from the Brace Study of the Scoliosis Research Society . J Bone Joint Surg Am 1995 ; 77 : 815 ± 822 . PMID: 7782353
24. Glowacki M , Misterska E , Laurentowska M , Mankowski P . Polish adaptation of scoliosis research society-22 questionnaire. Spine 2009 ; 10 : 1060 ± 1065 .
25. Misterska E , Gøowacki M , Harasymczuk J . Assessment of spinal appearance in female patients with adolescent idiopathic scoliosis treated operatively . Med Sci Monit 2011 ; 7 : CR404 ± 410 .
26. Misterska E , Gøowacki M , Harasymczuk J . Polish adaptation of Bad Sobernheim Stress QuestionnaireBrace and Bad Sobernheim Stress Questionnaire-Deformity . Eur Spine J 2009 ; 12 : 1911 ± 1919 .
27. Asher M , Min Lai S , Burton D , Manna B. The reliability and concurrent validity of the scoliosis research society±22 patient questionnaire for idiopathic scoliosis . Spine 2003 ; 28 : 63 ± 69 . https://doi.org/10. 1097/01.BRS. 0000047634 .95839.67 PMID: 12544958
28. Asher M , Min Lai S , Burton D , Manna B . Discrimination validity of the scoliosis research society-22 patient questionnaire: relationship to idiopathic scoliosis curve pattern and curve size . Spine 2003 ; 28 : 74 ± 78 . https://doi.org/10.1097/01.BRS. 0000047636 .95839.F5 PMID: 12544960
29. Ch Botens-Helmus, Klein R , Stephan C. The reliability of the Bad Sobernheim Stress Questionnaire (BSSQbrace) in adolescents with scoliosis during brace treatment . Scoliosis 2006 ; 1 : 22 . https://doi. org/10.1186/ 1748 -7161-1-22 PMID: 17176483
30. Weiss HR , Reichel D , Schanz J , Zimmermann-Gudd S . Deformity related stress in adolescents with AIS . Stud Health Technol Inform 2006 ; 123 : 347 ± 351 . PMID: 17108450
31. Sanders JO , Harrast JJ , Kuklo TR , Polly DW , Bridwell KH , Diab M , et al. The Spinal Appearance Questionnaire: results of reliability, validity, and responsiveness testing in patients with idiopathic scoliosis . Spine 2007 ; 32 : 2719 ± 2722 . https://doi.org/10.1097/BRS.0b013e31815a5959 PMID: 18007251
32. Wiggins CG , Shaffrey CI , Abel MF , Menezez AH . Paediatric spinal deformities . Neurosurg Focus 2003 ; 14 : E3 .
33. Connolly PJ , Von Schroeder HP , Johnson GE , et al. Adolescent idiopathic scoliosis: Long-term effect of instrumentation extending to the lumbar spine . J Bone Joint Surg Am 1995 ; 77 : 1210 ± 1216 . PMID: 7642667
34. Danielsson AJ , Nachemson AL . Radiologic findings and curve progression 22 years after treatment for adolescent idiopathic scoliosis: comparison of brace and surgical treatment with matching control group of straight individuals . Spine 2001 ; 26 : 516 ± 525 . PMID: 11242379
35. Negrini S , Minozzi S , Bettany-Saltikov J , Chockalingam N , Grivas TB , Kotwicki T , Maruyama T , Romano M , Zaina F. Braces for Idiopathic Scoliosis in Adolescents . Spine (Phila Pa 1976 ). 2016 Dec 1 ; 41 ( 23 ): 1813 ± 1825 .
37. Coillard C , Circo AB , Rivard CH . A prospective randomized controlled trial of the natural history of idiopathic scoliosis versus treatment with the Spinecor brace . Sosort Award 2011 Winner. Eur J Phys Rehabil Med 2014 ; 50 : 479 ± 87 . PMID: 25251736
38. Noonan KJ , Weinstein SL , Jacobson WC , Dolan LA . Use of the Milwaukee brace for progressive idiopathic scoliosis . J Bone Joint Surg Am 1996 ; 78 : 557 ± 567 . PMID: 8609134
39. Gabos PG , Bojescul JA , Bowen JR , Keeler K , Rich L . Long-term follow-up of female patients with idiopathic scoliosis treated with the Wilmington orthosis . J Bone Joint Surg Am 2004 ; 86 - A ; 1891 ± 1899 . PMID: 15342750
40. FaÈllstroÈm K , Cochran T , Nachemson A. Long-term effects on personality development in patients with adolescent idiopathic scoliosis. Influence of type of treatment . Spine 1986 ; 11 : 756 ± 758 . PMID: 3787349
41. Berven S , Deviren V , Demir-Deviren S , Hu SS , Bradford DS . Studies in the modified Scoliosis Research Society Outcomes Instrument in adults: validation, reliability, and discriminatory capacity . Spine 2003 ; 28 : 2164 ±9. https://doi.org/10.1097/01.BRS. 0000084666 .53553.D6 PMID: 14501930
42. Lonner B , Yoo A , Terran JS , Sponseller P , Samdani A , Betz R , et al. Effect of spinal deformity on adolescent quality of life: comparison of operative scheuermann kyphosis, adolescent idiopathic scoliosis, and normal controls . Spine 2013 ; 38 : 1049 ± 55 . https://doi.org/10.1097/BRS.0b013e3182893c01 PMID: 23370683
43. Chaib Y , Bachy M , Zakine S , Mary P , Khouri N , Vialle R . Postoperative perceived health status in adolescent following idiopathic scoliosis surgical treatment: results using the adapted French version of Scoliosis Research Society Outcomes questionnaire (SRS-22) . Orthop Traumatol Surg Res . 2013 ; 99 : 441 ±7. https://doi.org/10.1016/j.otsr. 2013 . 03 .012 PMID: 23639761
44. Clayson D , Luz-Alterman S , Cataletto M , Levine DB. Long term psychological sequalae of surgically versus nonsurgically treated scoliosis . Spine 1984 ; 12 : 983 ± 986 .
45. Kotwicki T , Kinel E , Stryøa W , Szulc A . Estimation of the stress related to conservative scoliosis therapy: an analysis based on BSSQ questionnaires . Scoliosis 2007 ; 2:1 . https://doi.org/10.1186/ 1748 -7161-2-1 PMID: 17201928
46. Asher M , Min Lai S , Burton D , Manna B . Spine deformity correlates better than trunk deformity with idiopathic scoliosis patients' quality of life questionnaire responses . Stud Health Technol Inform 2002 ; 91 : 462 ± 464 . PMID: 15457777
47. Haher TR , Gourup JM , Shin TM , Homel P , Merola AA , Grogan DP , Pugh L , Lowe TG , Murray M. Results of the scoliosis research society instrument for evaluation of surgical outcome in adolescent idiopathic scoliosis. A multicenter study of 244 patients . Spine 1999 ; 24 : 1435 ± 1440 . PMID: 10423788
48. Benli IT , Ates B , Akalin S , Citak M , Kaya A , Alanay A . Minimum 10 years follow-up surgical results of adolescent idiopathic scoliosis patients treated with TSRH instrumentation . Eur Spine J 2007 ; 16 : 381 ± 391 . https://doi.org/10.1007/s00586-006 -0147-3 PMID: 16924553
49. Robinson E. Psychological research on visible difference disfigurement . In: Lansdown R , Rumsey N , Bradbury E , Carr A , Partridge J , editors. Visibly different: Coping with disfigurement . Oxford: Butterworth-Heinemann; 1997 . pp. 102 ± 111 .
50. Dyl J , Kittler J , Phillips KA , Hunt JI . Body dysmorphic disorder and other clinically significant body image concerns in adolescent psychiatric inpatients: prevalence and Clinical Characteristics . Child Psychiatry Hum Dev 2006 ; 36 : 369 ± 382 . https://doi.org/10.1007/s10578-006 -0008-7 PMID: 16741679
51. Ferguson CHJ , Munoz ME , Contreras S , Velasquez K . Mirror, mirror on the wall: peer competition, television influences, and body image dissatisfaction . J Soc Clin Psychol 2011 ; 30 : 458 ± 483 .
52. Mori K , Sekine M , Yamagami T , Kagamimori S. Relationship between body image and lifestyle factors in Japanese adolescent girls . Pediatr Int 2009 ; 51 : 507 ± 513 . https://doi.org/10.1111/j. 1442 - 200X . 2008 . 02771 . x PMID : 19400815
53. Gotze C , Liljenqvist UR , Slomka A , Gotze HG , Steinbeck J . Quality of life and back pain: outcome 16.7 years after Harrington instrumentation . Spine 2002 ; 27 : 1456 ± 1463 . PMID: 12131746
54. Helenius I , Remes V , Yrjonen T , Ylikoski M , Schlenka D , Helenius M , Poussa M. Comparison of longterm functional and radiologic outcomes after Harrington instrumentation and spondylodesis in adolescent . Spine 2002 ; 27 : 176 ± 180 . PMID: 11805664
55. Ascani E , Bartolozzi P , Logroscino CA , Marchetti PG , Ponte A , Savini R , et al. Natural history of untreated idiopathic scoliosis after skeletal maturity . Spine 1986 ; 11 : 784 ± 789 . PMID: 3810293
56. Cochran T , Irstam L , Nachemson A. Long-term anatomic and functional changes in patients with adolescent idiopathic scoliosis treated by Harrington rod fusion . Spine 1983 ; 8 : 576 ± 584 . PMID: 6228016
57. Reichel D , Schanz J . Developmental psychological aspects of scoliosis treatment . Pediatr Rehabil 2003 ; 6 : 221 ± 225 . https://doi.org/10.1080/13638490310001644593 PMID: 14713589