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Risk of Non-Adherence of Bracewear in Adolescent Idiopathic Scoliosis Should Be Assessed Prior to Treatment

Posted on: 04/10/2008
Adolescents with idiopathic scoliosis are often treated with bracing to prevent further curvature of the spine. Unfortunately, as with most treatments, non-adherence to the bracing affects the treatment outcome.

Studies done previously to assess patient adherence involved the use of sensor technologies. The findings were that, on average, 65 percent to 75 percent of the adolescents were treatment compliant. Other studies have shown non-adherence rates of 25 percent to 50 percent among diverse patient populations.

Knowing that many patients will be non-adherent means that physicians need to be more able to identify the patients who may fall into that category. The authors of this study wanted to test the findings of a new pretreatment questionnaire, the predictions of physicians and orthotists regarding potential non-adherence, and the ability of patients, parents, doctors, and orthotists in accurately estimating how long the braces were actually worn during the first year of treatment.

The study began with 124 patients (108 girls), aged between 10 and 15 years. All patients were treated with a Boston brace for 16- (49 patients) or 23-hour (75 patients) periods per day.

Before the study, the patients completed the Brace-Beliefs Questionnaire (BBQ) to predict the likelihood of wearing the brace as prescribed. The results were measured on a five-point scale, ranging from "strongly agree" to "strongly disagree." Before the patients were fitted for their braces, the physicians and orthotists also predicted the adherence of each patient, using a five-point scale of one (not likely) to five (highly likely), when answering if they believe the patient will be compliant with the wear schedule.

During follow-up visits, the patients were asked about how many hours per day they were wearing their brace, while the parents, doctor and orthotist were asked to estimate their idea of how long the patient wore the brace. At the same time, the braces had been fitted with temperature sensors. The patients were not aware of the true purpose of the sensors (to log the amount of time the brace was worn) but were told that the sensors were evaluating comfort. The sensors recorded data every 15 minutes.

When analyzing the results, the researchers found that there was no difference between the 16-hour and 23-hour groups in terms of adherence so the results were combined into one. the results from the BBQ ranged from 47 to 88 and the adherence to bracewear was positive. In respect to the physicians' and orthotists' ratings, the correlation between the physicians was very weak, but was slightly stronger with the orthotists.

The results of the follow-up visits showed that family estimates of adherence "significantly exceeded those of the treatment team, as child and parents reported that the brace was worn an average of 74 percent of the time recommended during the first year, whereas physicians and orthotists reported a mean estimate of 65 percent. The actual average percent adherence in the first year was 47 percent."

One quarter of the non-adherent patients were not identified by the physicians as indicated by the sensors. The average physician overestimated the actual wear of the non-adherent patients by 28 percent.

The authors state that predicting adherence is difficult to accomplish, with many healthcare professionals unable to accurately say who will adhere to the bracewear schedule and who will not. Use of the pretreatment questionnaire, the BBQ, did help improve the odds of being accurate, however. Interestingly, the researchers learned that of the adolescents who were not compliant, many were this way because of mistaken beliefs about the brace and its use or effectiveness. The authors suggest that the patients should be specifically asked about their beliefs and explain the issues before treatment begins.

For on-going treatment follow-ups, the results showed that there was at least 10 percent to 20 percent overestimation by the physicians and orthotists about adherence, with patients and parents overestimating by 25 percent.

In conclusion, the authors suggest that although estimating possible or probable adherence to treatment remains difficult, the use of a pretreatment questionnaire could be beneficial. They point out that healthcare professionals should keep in mind the tendency to overestimate the use of the brace all those involved, not just the patients themselves.

References:
Anne Morton, PhD, et al. Accuracy in the Prediction and Estimation of Adherence to Bracewear Before and During Treatment of Adolescent Idiopathic Scoliosis. In Journal of Pediatric Orthopaedics. April/May 2008, Vol. 28. No. 3. pp. 336-341.

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