Idiopathic scoliosis is the most common spinal deformity in adolescents, with a prevalence of 2%–4% in the general population (1). The treatment of Adolescent Idiopathic Scoliosis (AIS) is determined based on the severity of the spinal curvature and may include observation, exercise, brace therapy, or surgical intervention (2, 3). The goals of scoliosis treatment are to correct spinal deformities early, prevent curvature progression, alleviate pain, and enhance patients' quality of life (QoL) (3).

Brace treatment is recommended for individuals with a Cobb angle between 20 and 45 degrees who have not yet reached skeletal maturity. Brace treatment is the routinely applied conservative treatment method for AIS and can yield effective results when correctly administered (2, 4). The multicenter BrAIST trial conducted by Weinstein et al. (2013) demonstrated that bracing significantly reduces the risk of curve progression to the surgical threshold (Cobb angle of ≥50 degrees) in high-risk adolescents with idiopathic scoliosis (5).

The application of a variety of brace concepts, distinguished by the prescribed wearing time and rigidity of the brace, has been described in the literature. These concepts include full-time, part-time, and night-time braces, as well as rigid and soft braces (6). Despite using various brace designs in AIS treatment, the fundamental objective is to restore normal spinal alignment and correct the aesthetic appearance through external forces (4, 6, 7). A review of the literature reveals a number of studies that attest to the efficacy of braces in preventing the progression of curvature and even in reducing their severity (8). A recent systematic review has demonstrated that bracing may be an effective intervention for patients with AIS curves ≥40° who are unwilling to undergo posterior spinal fusion (9).

Brace treatment, often initiated during adolescence, can cause individuals to face various challenges in their daily lives (3). The success of the brace depends on the specific design tailored to the treated curvature, the follow-up process, the patient's compatibility with and adherence to the brace, and the duration of wear. In the literature, QoL assessments have been based on the perspectives of individuals using brace, and reliability of these studies relies solely on the responses provided by users. There are limited studies in the literature that explore the opinions of both brace users and their parents. We also aimed to understand the views of individuals with AIS and their parents regarding brace use, including the difficulties they experienced, the negative impacts they perceived, and the complaints they expressed throughout the treatment process.

This study was a prospective explanatory sequential mixed-methods investigation. Quantitative data were collected and analyzed first, followed by qualitative data obtained through in-depth individual interviews. This design was adopted to gain a deeper understanding of the quantitative findings concerning the impact of brace treatment on the QoL individuals with AIS. The Istanbul Medipol University Ethics Committee approved the study (decision number 946, E-10840098-772.02-66608, dated 30.12.2020), which was conducted between January 2021 and April 2021. The research was carried out in accordance with the Declaration of Helsinki.

The demographic information of the participants, along with the mean values of the BS, BrQ (total), and the subparameters of the participants, is displayed in Table 1.

Pearson's correlation analysis between BS and BrQ revealed a positive correlation between the BrQ total score and the sub-parameters of physical function, emotional function, self-esteem, vitality, bodily pain, and social life with BS (p = 0.008, p = 0.038, p = 0.000, p = 0.007, p = 0.009, p = 0.017, p = 0.045, respectively). The correlation analysis results for BS and BrQ are presented in Table 2.

The results of the first 12 questions of the PEF are presented in Table 3. In response to the 13th question, which addressed participants' exercise programs, 84% (n = 37) of participants mentioned the Schroth method, 5% (n = 2) mentioned Pilates, and 11% (n = 5) reported receiving only brace treatment. The results of the four questions of the PAEF, evaluated using a 5-point Likert scale, are also presented in Table 3. Regarding the relationship of the interviewees to individuals with AIS, 80% (n = 35) were mothers, 16% (n = 7) were fathers, and 4% (n = 2) were others. When asked about the presence of scoliosis or spinal deformities in other siblings, 82% (n = 36) reported “no,” while 18% (n = 8) reported “yes.” In the 10th question, when parents were asked about the reasons for their children's unwillingness to use a brace, 18% (n = 8) mentioned difficulty in breathing, 27% (n = 12) reported problems in social activities, 7% (n = 3) indicated sleep problems, 16% (n = 7) reported material discomfort, 9% (n = 4) felt embarrassed while using the brace, 2% (n = 1) stated difficulty attending to toilet needs, and 27% (n = 12) reported excessive sweating. Additionally, 24% (n = 11) indicated that their children had no issues using the brace.

In the qualitative part of the study, the responses to the individual interviews conducted using interview forms were analysed under three themes in order to examine the factors affecting brace satisfaction in individuals with AIS receiving brace treatment. These themes are as follows: opinions related to daily life activities involving orthosis use; opinions about the material of the orthosis; and opinions about the use of orthosis. The results of the semi-structured individual interviews are shown in Figure 3.

This study evaluated the impact of orthotic treatment on the QoL, recorded opinions, and problems encountered regarding braces by individuals with AIS using braces for at least 6 months and their parents. Our study results indicated that the QoL of individuals with AIS improved with increased brace satisfaction. Furthermore, brace design, weight, and materials, leading to problems such as sweating, balance issues, and chest pain, were the most significant factors affecting brace satisfaction. In the qualitative part of the study, all the participants reported sweating caused by the closed brace design as the most significant issue. They mentioned having to change clothes constantly because of the excessive sweating caused by the brace, which caused problems. Individuals using braces for 6–7 months reported pain in the chest and axillary region, and those using braces for 8–18 months mentioned sleep problems and difficulty during various daily activities (eating, using toilets, sitting, and standing). They also pointed out that using plastazole for pads causes sweating, odor, and dermal problems. The participants especially complained about the color of the brace, with all participants using white orthoses expressing a preference for darker colors.

Literature supports brace treatment as an effective and conservative method for stopping or reducing the progression of scoliosis in AIS (5). Despite the positive effects of brace treatment, it causes stress in individuals and has a significant negative impact on their QoL (18, 19). Design and rigidity (soft, semirigid, and rigid) of braces in individuals with AIS have different effects on QoL (2, 6). Our study participants used rigid braces, and their QoL and brace satisfaction were above average, with a positive relationship identified between brace satisfaction and QoL (20). Additionally, brace satisfaction was revealed to have a determining effect on QoL, physical function, emotional function, self-esteem, vital signs, school life, pain, and social life. Those with AIS who experience difficulties or challenges while wearing a brace have a detrimental effect on their quality of life. Thus, it can be concluded that individuals with AIS experience better QoL with increasing duration of brace use (in months), provided that brace satisfaction is maintained.

Brace treatment has been shown in the literature to be directly correlated with treatment effectiveness when the brace is worn consistently for the recommended duration (21). Furthermore, recent studies have highlighted that in-brace correction is a key predictor of treatment success, as greater initial correction may enable reduced wear time while still achieving comparable clinical outcomes and improved quality of life (22, 23). In our study, daily brace wear time was reported by participants and their parents through self-report. It is important to note that previous research has demonstrated that self-reported wear time often overestimates actual brace usage when compared to objective monitoring tools such as temperature or force sensors (24). Despite this, participants in our study reported wearing the brace for an average of 20 h per day over a period of 18 months, indicating high compliance. This was associated with observed improvements in Cobb angles. Our findings further suggest that long-term brace use did not negatively impact quality of life (18), supporting the view that consistent compliance, especially when combined with effective in-brace correction, may help reduce potential negative effects on QoL. Moreover, although our study did not directly investigate psychological coping predictors, recent evidence suggests that variables such as age, gender, and prescribed brace duration may influence individual adaptation to bracing (25). Future research may benefit from exploring these characteristics in relation to brace satisfaction and long-term QoL outcomes.

The brace design, primarily focusing on spinal deformity correction, can lead to physical and aesthetic discomfort in individuals using braces (16, 26). In our study, most participants reported being able to put on their braces independently and use them throughout the planned duration. Their primary complaints related to braces included difficulty breathing, sleep problems, dissatisfaction with brace color, perceiving the brace as heavy, chest pain, and balance problems. Our study results indicate that the participants had physical complaints related to the use of rigid braces, aligning with the literature (27, 28). Aesthetic concerns about the color and/or appearance of braces may stem from the fact that participants used plain white braces, and our country does not commonly apply patterns to braces. In individuals with AIS, providing braces in the desired color/pattern and actively involving them in the brace design may enhance brace compliance, consequently improving treatment effectiveness. In addition to color and pattern preferences, considering the visual design aesthetics of the brace (such as transparency, texture, and shape) may further support user satisfaction and acceptance.

Adolescents with spinal deformities encounter significant obstacles throughout the treatment process, which can ultimately impact the outcomes and the efficacy of brace intervention (29). Active participation of patients and their families in the treatment process is crucial in conservative treatments (30, 31). In our study, the parents of individuals with AIS receiving brace treatment were questioned about their adherence to daily brace use protocols and the difficulties they and their children experienced with bracing in daily life. Parents reported the following as factors affecting brace use; difficulty breathing, problems in social activities, sleep problems, discomfort with the material, feeling ashamed of using brace, difficulty in toilet needs, and sweating. However, 14% of the participants reported no problems related to the brace. Their interview results reveal consistent and common complaints expressed by individuals with AIS and their parents.

All participants lived in Istanbul, Turkey. The city has a humid subtropical climate, characterized by hot and humid summers and mild, rainy winters. In individual interviews, most participants reported excessive sweating and physical discomfort while wearing the brace. While these complaints may be partially attributed to the local climate, we do not consider it to be the sole contributing factor. In addition to climatic influences, the material properties of the braces themselves may also contribute to discomfort, particularly in terms of heat retention and limited breathability. In our study, the Rigo-Chêneau braces were custom-fabricated using 4 mm thick polyethylene for the external shell and 3–4 mm thick plastazote for the internal padding. This material combination is widely used in scoliosis bracing due to its favorable balance between structural support and user comfort. However, to the best of our knowledge, there is limited research specifically addressing the role of materials used in orthotic brace construction in relation to user comfort. Scoliotic braces are composed primarily of thermoplastic materials. Increased sweating is inevitable because of the material thickness and the closed design of the braces. While soft braces are often criticized for being less biomechanically effective (32), we believe that integrating lightweight, breathable, and user-friendly materials into rigid orthosis design without compromising corrective forces could help alleviate user discomfort. For example, plastazole pads commonly used for derotation may cause skin irritation due to their airtight and abrasive nature. Alternative materials and thoughtful design concepts, such as asymmetrical shell structures that eliminate the need for pads, may offer both biomechanical and comfort advantages.

Exercise programs, particularly three-dimensional scoliosis exercises applied with brace therapy, positively affect QoL and Cobb angle (33–36). In our study, participants self-reported their exercise engagement, with 84% (n = 37) performing three-dimensional scoliosis exercises and 5% (n = 2) reporting Pilates practice, while 11% (n = 5) received only brace therapy. These data were collected descriptively and not intended to evaluate the efficacy of individual exercise modalities. Nevertheless, they suggest that exercise, when combined with bracing, may play a role in improving QoL. These findings also reflect the variability of treatment experiences and highlight the importance of a multidisciplinary approach in managing AIS.

Our study indicates that brace therapy positively affects the QoL of individuals with AIS, and brace satisfaction is a significant factor in treatment outcomes. Similar to the suggestion of Joarder et al. of qualitative research yielding more meaningful results with limited quantity, especially in individuals with AIS (37). Similarly, our qualitative research yielded more data, with individuals expressing their problems more effectively. In this context, we believe our study to serve as a guiding resource for clinicians and researchers to focus on the effectiveness of brace treatment and the experiences of patients with AIS.

It is also important to acknowledge that this study was conducted during the COVID-19 pandemic, specifically between January and April 2021, when schools in Turkey were largely operating in a hybrid format and various social restrictions were in place. These circumstances may have had both positive and negative impacts on brace wear time and compliance. For some participants, spending more time at home may have facilitated more consistent brace use, while for others, the lack of daily routine and increased emotional stress may have negatively affected adherence. In addition, Asad et al. identified social criticism as a key stressor in AIS brace treatment (28). In our study, participants reported relatively high satisfaction with brace use in the school context, which may be partly explained by reduced exposure to societal and peer judgment during the period of hybrid education. These contextual factors should be considered when interpreting the findings.

Our study had several limitations, including the inability to compare different brace designs or the effects of short- vs. long-term brace use. Additionally, all assessments were based on self-reported data, which may be subject to recall or reporting bias. The study was also conducted during the COVID-19 pandemic (January–April 2021), when hybrid schooling and social restrictions in Turkey may have influenced participants' routines and brace compliance. These factors should be considered when interpreting the findings.

In our study, we observed a decrease in complaints as the duration of brace use increased. In particular, the brace design significantly affects orthosis satisfaction. Individual interviews with the participants suggested that increased satisfaction could be achieved by improving the physical characteristics of the brace. Therefore, the development of better braces and treatment strategies has the potential to enhance patients' QoL and treatment effectiveness. Continuous development in this area underscores the importance of prioritizing user feedback and observations from families. We believe the determining factors influencing brace use may positively affect brace compliance, treatment effectiveness, and QoL.