Authors’ reply to Kuru Çolak et al. comment on: “Intensive bracing management combined with physiotherapeutic scoliosis-specific exercises for adolescent idiopathic scoliosis patients with a major curve ranging from 40-60° who refused surgery: a prospective cohort study”

We have carefully read the comment regarding our recently published article reporting the treatment outcomes of intensive bracing management and physiotherapeutic scoliosis-specific exercises (PSSE) for adolescent idiopathic scoliosis (AIS) with major curves between 40 and 60 degrees.¹ We would like to thank the commentators for their interest in our study and for their affirmations.² However, several concerns were also raised, and we felt it necessary to be explained.

First of all, we had to explain that the braces used in our center were not same as the original version of Gensingen braces developed by Dr. Weiss. We referred the correction principles of Chêneau braces and design appearance of Gensingen braces in literature, and created our own treatment systems (Xinmiao Treatment System) with modifications.^{3, 4} We also established finite element models in the bracing treatment to perform biomechanical analysis and modify our corrective designs.⁵ In this study, we mainly focused on the methods of bracing management about how to achieve maximum corrective force, not emphasizing the specific type of braces. We thought it was crucial to offer sufficient in-brace correction rates for the successful treatment of AIS with curves more than 40 degrees, no matter what type of braces was used. In fact, the bracing protocol proposed in this study could be adopted along with different types of braces to treat relatively large curves in other centers. Therefore, the term “modified Gensingen braces” used in the study was intended for readers to easily understand since we thought it was unnecessary to describe the detailed features of our braces with considerable space in this cohort study that focused on the management methods and clinical outcomes. But we neglected the potential trademark conflicts. We appreciated the timely correction of this inaccurate description and would avoid such controversy in future publications. We stated that this term had never been used for commercial purposes. Besides, the word “modified” did not imply a better version compared with original Gensingen braces. Gensingen braces had been proved effective in literature and had many advantages for orthotists to learn from. Our modified ones were only more suitable for Chinese patients in clinical practice.

Second, the description of our braces in the article was not sufficient as the comment pointed out. According to the latest classification of scoliosis braces developed by the International Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT), which was an authoritative organization dedicated to the non-surgical treatment of scoliosis, the following features of braces needed to be described: the rigidity was rigid, the primary action was detorsion, the primary corrective plane was three-dimensional, the construction was monocot and the closure was ventral.

As for the part of literature review in the discussion section, we only searched similar topics in several widely known journals that frequently published research about the treatment of scoliosis. Since our article was not a narrative or systematic review, we did not include all relevant research and might ignore some papers. We chose some representative results in literature as a supplement of our clinical outcomes for further discussion. The article mentioned by the comment also indicated promising results for AIS patients with large curves receiving the original Gensingen braces, with curve magnitude decreasing from 49 degrees at baseline to 44.2 degrees after follow-up.⁶ The rate of successful treatment reached 92%, providing evidence that specific conservative treatment may be effective for AIS with curves more than 40 degrees.

At last, there were many approaches of PSSE currently practiced worldwide, such as Schroth, SEAS and BSPTS.⁷ The therapy of physical exercises used in this study was developed by our team with the aid of 3D scoliosis ultrasound imaging system, belonging to the Xinmiao Treatment System (XTS). It had been clearly described and its effectiveness had been proved by our previous study.⁸ It came along with our specific brace.

To conclude, this study firstly proposed an intensive method for bracing management to gradually achieve the maximum corrective force. It achieved satisfactory outcomes for the treatment of AIS patients in our cohorts. This method was different from the traditional bracing management in literature and could be a promising treatment for AIS patients with curves more than 40 degrees who unwilling to receive surgery. It mainly concerned the approaches of bracing wearing and could be used along with other different types of braces, not restricting specific type of braces. Any type of braces that met the criteria of in-brace correction rates, such as 50%, might indicate a better prognosis. Besides, effective PSSE were also indispensable to support the proper functions of paraspinal muscles. In this way, although different types of braces were used, the clinic centers dedicated to scoliosis worldwide still could cooperate with each other to improve the effectiveness of conservative treatment for AIS patients. We wished to promote more academic communications between us to share the latest developments. With the above explanations, we hope that problems were well addressed and our readers had better knowledge of this article.