Bracing and exercise: how the decision is made, how many hours a day

Short answer: A brace is prescribed by the physician who follows your child, and that decision rests on more than the size of the curve. How much growth is left, and the direction the curve has taken between two appointments, weigh just as heavily. The strongest answer available today to the question of whether bracing does anything comes from the BrAIST trial: 72 per cent of the children in the brace group finished growing without the curve reaching the surgical threshold, against 48 per cent of those who were only watched. What decided the outcome was the number of hours a day the child had the brace on. The make and the type of brace mattered far less. In the same trial, children wearing it for an average of less than six hours a day had a success rate of 41 per cent, which is close to the 48 per cent seen in the children who wore no brace at all. Scoliosis-specific exercise does not stand in for a brace. In a child who needs one, it is added alongside it.

Who decides on a brace, and on what basis

A brace is a physician's decision. The person who writes the prescription, chooses the type of brace and sets the daily wearing time is the orthopaedic or physical medicine and rehabilitation physician following the child. The brace itself is measured and made by an orthotist, who is a separate professional from both the physician and the physiotherapist. A physiotherapist does not prescribe a brace, does not alter the prescribed hours and cannot decide whether one is needed at all. What physiotherapy does is make the decision that has already been taken workable inside the child's day.

For a family who has not used this health system before, it is worth knowing which door to knock on first, because the order here is not the order used in every country. The first step is the family physician at a family health centre (aile sağlığı merkezi), or a paediatrician, who examines the child and refers them onward. The referral goes to orthopaedics and traumatology (ortopedi ve travmatoloji) or to physical medicine and rehabilitation (fiziksel tıp ve rehabilitasyon, usually shortened to FTR), and imaging follows only if the physician asks for it. The state route and the private route both end at the same two specialties; what mainly differs between them is how long the wait is, and which of the two suits a household is not something a guide can decide for you. The diagnosis and follow-up page sets out that route and explains what the X-ray report contains.

The information the decision rests on falls under three headings. The first is the size of the curve, measured on the X-ray as the Cobb angle (the degree of curvature between the most tilted vertebrae at each end of the curve). The second is the growth that is left. Four things build that picture between them: the Risser stage, which shows how far the growth cartilage on the rim of the pelvis has turned to bone; height measurements; the stage of puberty; and, in girls, the date of the first period. The third is the direction the curve has taken between two appointments. A curve of 24 degrees that has stood still for a year and a curve that has gone from 18 to 24 degrees in six months carry the same number and do not carry the same clinical meaning.

The 2016 guideline of SOSORT, the international society for the rehabilitation treatment of scoliosis, remains its most recent full clinical guideline for the conservative treatment of idiopathic scoliosis. It asks for two conditions together before scoliosis is diagnosed: the Cobb angle measured on the X-ray must be 10 degrees or more, and rotation of the spine around its own axis must be recognisable. Where one of those two is missing, the guideline says the diagnosis should not be made. A brace comes into the discussion in progressive curves during growth, above roughly 25 degrees. The guideline also separates the goals of treatment by the size of the curve: in low-grade curves the primary goal is to stay under 20 degrees, in moderate curves to stay under 30 degrees, and in both the secondary goal is to stay under 45 degrees. In severe curves the primary goal is to stay under 45 degrees and the secondary goal is to postpone surgery.

What those goals have in common is worth pausing on. Every one of them describes staying below a limit. Reversing the curve appears nowhere among them, and that is the frame a conversation about bracing has to start from.

Does a brace really do anything: the BrAIST trial

Whether bracing was effective was argued over for many years. The study that largely closed that argument is the multicentre trial published in the New England Journal of Medicine in 2013 and known in short as BrAIST. It enrolled children aged between 10 and 15 who had not reached skeletal maturity (Risser 0, 1 or 2) and whose largest curve measured between 20 and 40 degrees on the Cobb angle. In total 1,183 patients were screened and 242 who met the criteria entered the trial. Of those children, 116 were randomly assigned to the brace or the observation arm, while the remaining 126 families decided for themselves which arm they would be in. That dual structure is a known limitation of the trial and is kept in mind when the results are read. Children in the brace arm were told to wear the brace for at least 18 hours a day.

The trial's measure of success was defined explicitly and in advance: reaching skeletal maturity before the curve got to 50 degrees counted as success, and progression to 50 degrees or above counted as failure. The success rate came out at 72 per cent in the brace group and 48 per cent in the group that was only watched. In the analysis that counted every child in the arm they had originally been assigned to, whether or not they kept to the plan, those rates were 75 and 42 per cent.

The most striking feature of the trial is that it was stopped before the planned period was over. The data and safety monitoring board judged that keeping the remaining children in the observation arm was no longer ethical once the benefit of the brace had emerged, and ended the study early. In a medical trial that is the mark of a strong result.

Translated into the language a parent actually uses, the number needed to treat reported in the trial was 3.0, and with the margin of uncertainty around it that value lies between 2 and 6. Put roughly, in about one out of every three children given a brace, reaching the surgical threshold is prevented. Some of the rest would not have reached that threshold without a brace either, and some will reach it despite one. Since there is no way of knowing in advance which child falls into which group, the brace is offered to all of them together.

Honesty requires one more line. The scope of BrAIST is ages 10 to 15, Risser 0 to 2, and curves of 20 to 40 degrees. An eight-year-old child, an adolescent who has finished growing, and a curve of 55 degrees all lie outside that scope, and the results cannot be carried over to them directly.

The thing that decides it: daily wearing hours

The detail that separates BrAIST from an ordinary bracing study is that wearing time was not taken from what the family reported. It was measured by a heat sensor placed inside the brace. The answer to "how many hours did the child wear it" therefore became independent of anyone's account, and the relationship between hours and outcome could be seen.

The first row of that table is the row that changes the whole conversation about bracing. A brace worn for fewer than six hours a day gave the same result as a brace never worn. The family bought it, carried it, argued with their child every evening for three years, and the result they got was no different from the observation group's. Against that, in children who passed roughly 13 hours a day the success rate rose to between 90 and 93 per cent.

This is why a family's first question ought to be whether the prescribed hours can genuinely be met in this particular household. Comparing makes of brace matters far less. If the hours cannot be met, saying so early is far more use than saying so three years later.

Wearing patterns are defined in the guideline by ranges of hours.

Which pattern is chosen is decided by the physician according to the type of curve, where it sits and the stage of growth. A family cannot change that choice on its own. What a family can discuss is how the chosen pattern will settle into daily life.

What a brace does and what it does not do

The purpose of a brace is to limit the progression of the curve while growth is still going on. It has no aim of removing the curve that is already there or of returning the spine to its earlier shape, and no such outcome can be promised. When the brace comes off, the trunk does not hold the position it had inside the brace by itself. That is precisely where exercise enters the picture.

So if the curve is not reversed, why go through all this trouble? The natural course of adult life supplies the answer. The SOSORT guideline states that in curves exceeding 30 degrees at skeletal maturity the risk of progression in adulthood increases, and that for curves above 50 degrees there is consensus that progression in adulthood is almost certain. The number of degrees a child finishes growing with therefore sets the direction of the next fifty years. The aim of the brace is to bring the child to skeletal maturity at as low a degree as can be managed. Changing how the back looks today is not among its aims. What happens after growth is dealt with on the scoliosis in adults page.

Part of what parents fear about adult life has no counterpart in the evidence, and that should be said out loud. In a study that followed 117 patients with untreated late-onset idiopathic scoliosis for fifty years and compared them with 62 people of similar age, chronic back pain was reported in 61 per cent of the patients and 35 per cent of the comparison group, but most of that pain was mild to moderate in severity. In the same study, length of life was no different from what would have been expected. Scoliosis is not a condition that shortens life.

How the day of a braced child is put together

The number of hours written on the prescription is an abstract figure in a parent's eyes. Making it concrete means working out what is left of the day. A child prescribed 20 hours has four hours out of the brace in total. Those four hours have to cover a shower, the physical education lesson or a training session, the exercise programme, and the breaks that let the skin breathe.

In practice the day gets built like this. The brace goes on in the morning before school and stays under the clothes through the school day. At school the only thing that usually calls for taking it off is the physical education lesson or a sports activity. When the child comes home in the afternoon the brace comes off for a shower, and if the exercise programme is done out of the brace that time is taken from here too. It goes back on in the evening and stays on through the night's sleep.

The hours that get lost almost always pile up in the evening. Homework, visitors, tiredness, a bloated stomach and the sentence "I will put it on in an hour" pull the weekly average down without anyone noticing. Keeping a simple chart of the hours is what turns compliance into something that can be talked about. A chart shows where the hours go. Once you can see which hour of the day the loss collects in, the answer usually shows itself.

The school day also sets the appointment time in families who are running a brace and an exercise programme side by side. For most households the hours between the end of school and the evening are the only workable window, and that window fills quickly. The practice is in Erzene Mahallesi, in the same neighbourhood as Evka 3 station, the eastern terminus of the M1 metro line, so for families living in and around Bornova, Erzene and Kazımdirik the travel time is one of the things that decides whether a weekly programme can be kept up, and it is taken into account from the start when an appointment time is chosen. Consultations can be held in English. Arrangements for school and for daily life are taken up separately on the school, sport and daily life page.

Compliance is a real problem, and a technical one

Most of the reasons a brace gets abandoned are not medical. The four things families describe most often are reddening and irritation of the skin, sweating in hot weather, the worry that the brace shows through clothing, and flat refusal by the adolescent. None of these can be dismissed as an uncooperative child, because each of them has its own separate answer.

• Skin irritation: A cotton undergarment with no seams, fitting the trunk closely, is worn under the brace, because an undergarment that rucks up will open a sore at the pressure points. Mild reddening in the first days is expected. If the reddening does not fade shortly after the brace comes off, if the skin is taking a lasting mark, or if an open wound is forming at a pressure point, the fit of the brace has to be reassessed by the physician or the orthotist.
• The break-in period: A brace is not taken up to the prescribed hours on the first day. It usually starts at a few hours a day and the time is increased in steps. A bloated stomach and shallower breathing are common in this period, and both are part of the trunk adjusting to a new pressure.
• Heat: In the summer months sweating is the biggest enemy of compliance. Carrying a spare undergarment and cleaning the inner surface of the brace every day both help. Timing the daytime breaks to fall in the hottest part of the day may also come up, but those breaks are part of the prescription, so a change of that kind is put to the physician at a review appointment.
• Visibility: Under loosely cut and patterned tops a brace largely goes unnoticed. The moment adolescents dread most is usually changing for the physical education lesson, and making a plan for that one moment at school is a much smaller intervention than letting the brace go altogether.

Refusal itself is also open to discussion. Bringing the adolescent into the decision is one of the ways of making compliance a negotiable subject, and explaining why the brace is needed aims to make the process intelligible to the child rather than something done to them. Giving them a say over which hours are spent out of the brace may support compliance. The total number of hours and how the breaks are distributed through the day, however, belong to the prescription. The aim is that the adolescent gains some sense of control over the process, while the plan itself stays where it belongs.

When a period of poor compliance does happen, there is nothing to be gained by hiding it from the physician. When the real hours are known the plan can be rebuilt. When they are not, the progression that shows up on the follow-up X-ray gets read wrongly.

What scoliosis-specific exercise is

Scoliosis-specific physiotherapy exercises are known in the international literature by the abbreviation PSSE. The 2016 SOSORT guideline defines them as those forms of outpatient physiotherapy shown to have an effect on scoliosis outcomes, and states that they must rest on four principles: three-dimensional active self-correction, meaning that the person brings their own trunk into a more symmetrical position through their own effort (autocorrection); training in the activities of daily living; stabilising the position that has been gained; and patient education. The Schroth method is the most widely known school of practice under that definition.

This is where PSSE differs from a general strengthening or stretching programme. The movements are chosen according to the pattern of the individual curve, and the same exercise is applied differently in a curve that opens to the right in the upper back (the thoracic spine) and a curve that opens to the left in the lower back (the lumbar spine). The programme is therefore built for one person and changes over time as the curve changes.

The guideline defines session frequency as between two and seven days a week depending on the complexity of the technique, the person's motivation and their ability, with long-term programmes typically running two to four days a week.

Where the evidence for exercise is strong and where it is weak

Both sides of the evidence have to be given together. There are randomised trials showing a benefit from exercise, and there are reviews that set out the limits of those trials. Read on its own, neither side gives the full picture.

The positive side is real. In a randomised trial in which the assessor and the statistician were blinded, a six-month Schroth programme added to standard care produced a decrease of 1.2 degrees in the largest curve while the control group showed an increase of 2.3 degrees, giving a difference between the groups of 3.5 degrees. The same team also calculated how many patients would need to be treated to prevent one deterioration and arrived at a figure of about 4. In a randomised trial from Turkey, the group doing Schroth in the clinic under the supervision of a physiotherapist showed significant improvement in the Cobb angle and in the trunk rotation angle, while the curve progressed in the untreated control group. In that same trial no significant difference was found between the groups on the quality-of-life measures, which means the improvement on the X-ray did not carry over directly into how the child felt. Perhaps its most instructive finding was that the group working under supervision in the clinic did better than the group doing the same programme alone at home. In mild curves, a programme made up of task-oriented movements that teaches the child to position their own trunk through their own effort was found superior to conventional spinal exercises.

The weak side is real to exactly the same degree. Most of these trials are small. The blinded Schroth trial had 25 children in each arm and the trial from Turkey about 15 in each group; both were run at a single centre and neither followed the children beyond six months. The Monticone trial in mild curves is larger at 110 participants and reports that the effect lasted at least a year after the programme ended, but it too was single-centre and it covered only curves under 25 degrees, and its control group was doing conventional exercise. The upper limit of the confidence interval around the number needed to treat to prevent one deterioration reaches as high as 28, which is to say the uncertainty around that estimate is considerable. The reviews that pool results are more cautious still. A 2024 Cochrane review bringing together 13 randomised trials and 583 participants concluded that the benefits of therapeutic exercise in idiopathic scoliosis are uncertain and that the evidence is of low or very low certainty. A 2025 meta-analysis pooling 11 randomised trials found the average improvement from Schroth exercises to be about 3.2 degrees, and its authors state plainly that this does not reach the five-degree threshold accepted as clinically meaningful. In the same analysis the change in the trunk rotation angle was not statistically significant, while a significant improvement was seen in quality of life.

There is one further limit. A large 2024 review of PSSE trials found that the effect of exercise on the Cobb angle was not significant compared with controls in patients whose curve was 30 degrees or more. Exercise gives its clearest answer in mild curves. Where a curve sits above 30 degrees, the discussion needs to turn to bracing.

What follows from all of this is that there are randomised trials showing that scoliosis-specific exercise contributes to slowing the progression of a curve, to trunk symmetry and to quality of life, but those trials are small and the certainty of the evidence is low. There is no evidence that it removes a structural curve. A change of three degrees in a group average is not a promise made to one particular child.

How a brace and exercise are run together

The place where the evidence looks most consistent is the one in which the two are used together. Among the numerical results of the Cochrane review, adding exercise to a brace in participants who were wearing one was reported to be associated with a reduction of 2.2 degrees in the Cobb angle. The overall judgement of that review stays cautious, but its authors state that adding exercise in participants wearing a brace may reduce the progression of the curve.

The reverse direction matters just as much. In guideline practice a brace comes into the discussion above roughly 25 degrees in progressive curves during growth. For a child above that threshold, the generally accepted approach is that scoliosis-specific exercise should not be used on its own in place of a brace, unless a physician experienced in scoliosis specifically prescribes such a programme. Where a brace has been indicated, exercise is an addition to it and never a substitute.

In practice the two programmes are tied to each other at these points:

• Directing the breath inside the brace: The regions where the brace applies pressure and the regions where it leaves space are known. The programme aims to teach the child to direct their breath into the space that has been left. There is no strong study showing how far this approach changes the outcome of the brace itself.
• Trunk control in the hours out of the brace: For the part of the day spent without the brace, the aim is for the trunk to be able to hold its position using its own muscles. When the brace comes off, that capacity is the only thing left.
• Keeping muscle strength: Whether long-term brace use weakens the trunk muscles is asked often, and no strong study can be pointed to that answers it clearly. What has been shown is that regular movement improves outcomes in braced children, and the next section takes that up.
• Regular contact: Sessions are also regular appointments at which a problem with the brace can be raised at the moment it appears. A skin problem or a loss of compliance is usually voiced here first, and where necessary the referral back to the physician starts here.

General sport and scoliosis-specific exercise are not the same thing

Confusing these two does harm in both directions. On one side, general sport is taken to stand in for treatment. On the other, a child is pushed away from sport because of the scoliosis. Both are mistaken.

On the question of banning sport the evidence says the opposite. In a study of 785 children and adolescents wearing a full-time brace, those doing sport twice a week or more often were reported to have better results over eighteen months of follow-up. Sport improved the outcome even in a braced child. The study was not randomised and the possibility that children who play sport differ in other ways cannot be set aside, but the direction of the finding makes the advice that a child with scoliosis should stay away from sport impossible to defend.

Swimming needs a section of its own, because it has been recommended here for years as though it were a treatment for scoliosis, and a family arriving from elsewhere will hear that advice from neighbours and colleagues soon enough. In a study comparing competitive young swimmers with students of the same age, swimming was found to increase the risk of trunk asymmetry. This does not mean a child should not swim; the study looked at high-volume competitive swimmers, and a child who swims twice a week for pleasure is not in that group. Swimming is a good sport, it is not a treatment for scoliosis, and it does not take the place of scoliosis-specific exercise. The same holds for pilates, yoga and general strength work, which are valuable for trunk strength and general health and do not replace a programme built around the pattern of the curve.

The real load is at home

The hour spent in the clinic makes up only a small part of the programme. In the randomised trial where the positive results described above were obtained, the programme consisted of one supervised session of an hour a week together with 30 to 45 minutes of home exercise a day. In the same trial 82.5 per cent of the prescribed home exercises were completed and attendance at the sessions was 85 per cent. Those results, in other words, were obtained at a level of adherence in which the home programme was largely being done.

A family needs to hear that figure at the start of the programme and not once it has stalled. Expecting the same result in a child who comes to one session a week and does nothing at home would not be realistic. At the same time, a programme done alone at home has been shown not to substitute for supervised work in the clinic: in the randomised trial from Turkey, the reduction in the rib hump (the ridge that appears on the back when the child bends forward) and in waist asymmetry was seen only in the group working under supervision. Neither of the two replaces the other. Each one needs the other to work.

The place to discuss this load is at the beginning. A programme built without taking account of the family's weekly timetable, the care of a younger sibling, travel time and exam periods will stop within a few months. Exam periods deserve a word for a reader who has not lived through them here: school places and university places are decided by national examinations, and in the year of one of those examinations a household's whole routine is reorganised around study, which is exactly when a weekly appointment is most likely to be dropped. How a session runs and how the home programme is built are described on the what a session involves page.

When and how a brace is stopped

A brace is brought to an end by the physician's decision once skeletal growth is largely complete. In a consensus study involving 27 international experts, the recommendation for the decision to stop was to use the Sanders stage (a bone age measurement calculated from an X-ray of the wrist and hand), the Risser stage, change in height, the size of the curve and the course of the curve together. That recommendation carries the weight of expert consensus, and no randomised trial stands behind it, which means the timing of stopping does not sit on ground as firm as the case for the brace itself.

The item of that consensus that proves most useful in practice is gradual weaning. The recommendation is that once the decision to stop has been taken, the daily hours come down step by step over months according to the physician's plan, and the brace is not dropped in a single day. How long the reduction takes is determined by the child's stage of maturity and by the course of the curve, and that timetable is set by the physician.

Follow-up does not end the moment the brace does. The curve may move a little in the last part of growth, and the degree at which skeletal maturity is reached is what determines the course in adult life. Reviews therefore carry on at set intervals after the brace is stopped, and the programme that maintains trunk strength continues at a reduced frequency.

Where physiotherapy stops, and when to go back to the physician

What was written at the top of this page is repeated here, because this is the point parents most often get tangled in. Physiotherapy does not make the diagnosis, does not request X-rays, does not prescribe a brace and does not change the hours a brace is worn. Its work is to carry out the physician's decision and to help the child sustain it.

A few findings fall outside the scope of a physiotherapy programme and call for assessment by a physician directly. In a study of 2,442 patients with idiopathic scoliosis, roughly a quarter had back pain at their first presentation, and in 9 per cent of those with pain another underlying pathology was identified. If a child has marked back pain, it should not be dismissed as "the pain of the scoliosis". Four findings mean the programme stops and the child goes back to the physician: pain that wakes the child from sleep at night, weakness or numbness in the legs, a change in the way the child walks, and loss of bladder control.

When a curve approaches the limit at which surgical assessment is discussed, the route runs through a spine surgeon. Where that limit falls is set out on the surgery decision page. The role of physiotherapy does not disappear at that point, although it does change, and the decision belongs to the physician.

A parent who has got this far usually wants to know something this page cannot tell them: how many degrees an operation actually changes, what the rates of complication and of risks such as nerve injury or infection are, how long the scar is, whether the rods and screws stay in the back for life, what happens to height, how much movement and what sport are possible afterwards, how long the hospital stay and the recovery take, and how the surgical techniques differ from one another. Those questions are named here and not glossed over, because this page has no sound evidence on which to base an answer to any of them. They belong to the spine surgeon, and the surgery decision page gathers them into a list to take into that appointment. Questions that stay in a parent's head after all this are collected on the parents' questions page.