Beyond the Curve and on the Spectrum

The study by Amaral et al. represents the first rigorous effort to quantify how autism spectrum disorder (ASD) influences bracing outcomes in adolescents with adolescent idiopathic scoliosis (AIS). Given the dramatic rise in ASD diagnoses, from 1 in 88 eight-year-olds in the U.S. in 2008 to 1 in 44 in 2018, and to 1 in 36 in 20201, this work is timely, clinically relevant, and highly needed. Orthopaedic surgeons are increasingly encountering patients who present with both conditions, and this study brings much-needed clarity to a neglected intersection of developmental medicine and musculoskeletal care. Amaral et al. demonstrate that adolescents with both AIS and ASD were more likely to progress to the surgical threshold compared with matched controls (40% versus 20%)—indeed, >3 times more likely even after adjustment for baseline curve magnitude and compliance. Noncompliance with brace wear was more common in the ASD group than in the control group (36% versus 22%), as were brace-related tolerance issues (22% versus 8%). Despite these challenges, 60% of patients with ASD avoided progression to the surgical threshold, and improvements were seen in SRS-22r (Scoliosis Research Society-22 revised) quality-of-life scores within the ASD subgroup. These findings reinforce 2 points: first, that ASD may represent an independent risk factor for bracing failure, and second, that bracing remains a viable treatment option that clinicians should not dismiss in this population. The methodological rigor of the study deserves recognition. By using BrAIST-Calc predicted probabilities and Firth logistic regression, the authors mitigated the biases common to retrospective studies. The matched cohort approach ensured comparability, while the inclusion of patient-reported outcomes broadened the scope beyond radiographic end points. This is a rare combination in the orthopaedic literature on neurodiverse populations. Equally important is the clinical relevance of the study findings. The study highlights that bracing is not futile in ASD but instead requires adaptation and closer follow-up. In an era in which orthopaedics is shifting toward individualized care, the message is clear: neurodevelopmental context matters. The limitations, however, temper the conclusions. Compliance was assessed by self-report or caregiver report, a method that is known to overestimate brace wear. Prior research using temperature or force sensors has suggested that actual wear may be half of the reported value2. Incorporating objective monitoring is essential for future work, particularly in ASD, where caregiver or patient perceptions of treatment adherence may diverge from reality. Second, the heterogeneity of ASD was not fully addressed. Although the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) support level was reported for 74% of the patients, the small sample size precluded a robust subgroup analysis. Bracing outcomes appeared to worsen with increasing support needs, but the study lacked the power to confirm this pattern. For clinicians, the absence of stratification by ASD severity limits the direct application of these findings to individual patients. Finally, surgical decision-making was not standardized. Although a ≥45° curve was used as the surgical threshold, the ultimate decision to recommend surgery remained provider-dependent, introducing variability that complicates interpretation. Beyond its orthopaedic implications, this study sits within a broader societal conversation about autism. The reported prevalence of ASD among 8-year-olds in the U.S. more than doubled from 2008 to 20201. This rise has been attributed to evolving diagnostic criteria, increased awareness, and improved access to evaluation, although whether it reflects a true increase in incidence remains debated. Regardless, orthopaedic surgeons are now far more likely to care for adolescents with diagnosed ASD than in previous generations. The present study, therefore, is not an academic exercise but a reflection of a shifting patient population. For clinicians, the take-home message is twofold. First, bracing should remain the standard of care for AIS in patients with ASD, but expectations must be realistic and tailored. Families should be counseled that the rates of noncompliance and surgical progression are higher in these patients, particularly in children requiring greater support. Second, orthopaedic teams should partner with behavioral health experts, occupational therapists, and orthotists to optimize brace tolerance. Structured caregiver engagement, sensory-adapted brace environments, and individualized education may all help to reduce distress and improve adherence. The next step consists of prospective, multicenter research with objective compliance monitoring and stratification by ASD severity. Such studies could clarify which subgroups of patients with ASD are the most at risk for bracing failure and which strategies best support adherence. Equally pressing is the development of validated patient-reported outcome measures that are tailored to neurodiverse populations, as the SRS-22r may not fully capture ASD-specific experiences. Amaral et al. provide a valuable and timely contribution by highlighting how ASD influences bracing outcomes in AIS. Their findings challenge orthopaedic surgeons to look beyond curve magnitude and skeletal maturity and to consider the neurodevelopmental context of each patient. At a time when ASD diagnoses are rising sharply, this study underscores the importance of individualized care and opens the door for future work that can refine how we support these patients. Bracing in ASD is not a futile endeavor, but it demands flexibility, collaboration, and empathy—qualities that should define modern orthopaedic practice.