TSRH research shows that bracing IS effective!

[skevimc]

What surgeons cannot do with this is tell patients that if they wear their brace for X hours they will not progress or if they don't wear their brace for X hours they will progress. The huge variability prevents them from saying that.

What treatment for scoliosis exists where a doctor can say what you just suggested?

Plus you add the known difference between T and L curves to these results and then the surgeon might say that although the average is slightly lower for 12 hours for 7 hours, that was developed by lumping curves. Your curve is an L so you would expect a lower risk of progression. Or your curve is T so your risk might more resemble the risk for people who wear the brace for 7 hours even if you wear it for 12.

I think this is a moot point due to the low number of L curves in the study.

Basically, I would say this study might (if it stands) provide some support for the surgeons who say they feel bracing is effective. But they have to translate that into something concrete for patients and parents and I don't think this study will help much in that regard.

This is what the author said in the letter to the editor comment. That the paper provides some support to say "if you wear your brace for XX hours/day you stand the best chance". They aren't trying to suggest anything more than that.

I hate complex statistical analyses because it is very easy to fool yourself. When I design an experiment, if an answer doesn't come out cleanly one way or another, I redesign the experiment. For that bar graph, I would say the final results are not obviously different and move on. Some of my colleagues would run stats on the data until they eke out a small result. That is how I think this paper went.

Starting over isn't a luxury clinical studies have. A repeated measures ANOVA (the bar graph) isn't a complex statistical analysis.

The last thing is something that the commentary mentioned that is very bothersome... 60% of the girls were beyond the growth spurt. If you are testing something (bracing) with a mechanism that is supposed to be active during the growth spurt, you need to separate those two groups in the analysis or abandon the hypothesis that bracing works only during the growth spurt. Can't have both.

The growth spurt issue is a good point. I'm blanking on the exact reason but I think I'm remembering that they used skeletal maturity (TRC and risser) to link progression. Why do you think their hypothesis is 'bracing works only during the growth spurt'?

[hdugger]

(posted this in the wrong thread)

I looked up Charles Price (the researcher disputing the validity of the Herring results), and it appears that he's "the lead investigator and research physician for scientific studies related to the Charleston Bending Brace" (according to this site - http://www.cbb.org/The-History-of-Side-Bending-2009.asp).

The Charleston Bending Brace is a night-time only brace. That is, a brace designed for exactly the kind of wear pattern (night only) which Herring's research claims is ineffective for slowing curve progression.

So, one might assume that Price has a dog in this fight.

[Ballet Mom]

(posted this in the wrong thread)

I looked up Charles Price (the researcher disputing the validity of the Herring results), and it appears that he's "the lead investigator and research physician for scientific studies related to the Charleston Bending Brace" (according to this site - http://www.cbb.org/The-History-of-Side-Bending-2009.asp).

The Charleston Bending Brace is a night-time only brace. That is, a brace designed for exactly the kind of wear pattern (night only) which Herring's research claims is ineffective for slowing curve progression.

So, one might assume that Price has a dog in this fight.

I also posted a response to this in the other thread and will repost here for those who don't read other sections of this site. Sorry to any who have to read it twice! :-)
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That's interesting about Dr. Price. I was also surprised that this study seemed to show that bracing at night wasn't as important as bracing before and after school.

My daughter was prescribed the Charleston bending brace when she was first diagnosed at 35 degrees, Risser 0, 12 years and pre-menarchal and progressing in front of my eyes, so I have nothing but good feelings about the Charleston brace. That brace stopped my daughter's curve cold.

Unfortunately, I think it was only luck, or exceptional skill on the part of her initial orthopedist that she was successful in the Charleston brace. Thirty-five degrees is the maximum size of curve to be used in the Charleston brace and she also had a 21 degree compensatory curve. Charlestons should only be used on a single curve. I think the only reason this brace worked on my daughter with this magnitude curve and the amount of progression is because she was very thin with a super-flexible spine and the brace managed to achieve over-correction with it.

After having read the studies on it, I actually went on a hunt for a full-time brace such as the Cheneau brace but didn't follow through because one of the orthopedists we visited convinced my daughter that she wouldn't want to wear a full-time brace!

Luckily, it seems to have all worked out although it would have been nice to see some of the curve reduction that these Cheneau braces seem to be able to give through growth...and my daughter has certainly had many years of growth since diagnosis. I won't complain though, and I certainly thank the orthopedists we went to for managing to get her through this really stressful time successfully.

If my daughter is one of the few who continue to progress after bracing due to her hyperlax ligaments....there is nothing I can do about that. But it was certainly worth the shot...and she has been able to continue ballet and performing all this time. And that is worth everything.

[hdugger]

I haven't read the original report in detail, but my sense is that the researchers think the nighttime bracing is less effective (not that it isn't important).

Given that Price is still cited as the main researcher on the Charleston site, my guess is that his complaint with this research is that they're reporting a dose-dependent response. Unless he's somehow published some conflicting research, I'd interpret his complaint as stating that this research *underreports* the effectiveness of bracing, and that *even shorter bracing times* than those recommended in this research are effective.

I'm not a bracer (my child is an adult) but it might be worthwhile for someone who is still bracing to write to Dr. Price and have him clarify his letter.

[hdugger]

Based on some more googling, I think I've understated Price's involvement with the Charleston brace. He's listed in several references as one of the developers of the brace, suggesting a financial involvement with its success.

[Pooka1]

Based on some more googling, I think I've understated Price's involvement with the Charleston brace. He's listed in several references as one of the developers of the brace, suggesting a financial involvement with its success.

Oh wow.

On the one hand, I think that should have been mentioned in the disclosure.

On the other hand, I suspect most folks in this field know exactly who he is. Plus the third reference in his letter identifies him as someone possibly connected to the Charleston brace. I hope going to that reference includes reference that he is one of the developers.

So it's not like he is hiding anything but it could have been much clearer.

[Pooka1]

What treatment for scoliosis exists where a doctor can say what you just suggested?

How do you think this will change how surgeons talk to patients if you think it will change how they talk to patients?

I think this is a moot point due to the low number of L curves in the study.

Yes. There were hardly any L curves so this study really doesn't address those curves.

This is what the author said in the letter to the editor comment. That the paper provides some support to say "if you wear your brace for XX hours/day you stand the best chance". They aren't trying to suggest anything more than that.

Yes that is technically true but I think folks think this study provides better predictive power than it does.

Starting over isn't a luxury clinical studies have. A repeated measures ANOVA (the bar graph) isn't a complex statistical analysis.

No I wasn't referring to that bar graph as complex. Bars graphs are simplicity itself. I was referring to your comments and those of the commentary.

The growth spurt issue is a good point. I'm blanking on the exact reason but I think I'm remembering that they used skeletal maturity (TRC and risser) to link progression. Why do you think their hypothesis is 'bracing works only during the growth spurt'?

Isn't that the claim of bracing and the reason why adults are not braced?

[Ballet Mom]

I think in the reading that I've done, lumbar curves are much more successfully braced than other curves. This is true also in vertebral stapling. Therefore, it follows that any lumbar curves should be even more successful than the thoracic curves with bracing.

It seems to me it's a good thing there are mainly thoracic curves in the study, as those would be the hardest and most difficult to stop the progression in. It makes the study even better in my mind.

[Pooka1]

I think in the reading that I've done, lumbar curves are much more successfully braced than other curves. This is true also in vertebral stapling. Therefore, it follows that any lumbar curves should be even more successful than the thoracic curves with bracing.

How do you rule out that they simply have a lower potential for progression which has been shown and is one of the main reasons invalidating one of the few controlled bracing studies.

Just because someone is wearing a brace doesn't mean it is doing anything. The few controlled studies seem to indicate that many kids would not have progressed anyway.

In the Q&A session for Betz's talk at the Posna 2009 talks ( IIRC) that you posted (one of the most informative/valuable posts ever by the way), Betz got this exact comment... a possible reason VBS appears to work better in L curves is that the risk of progression is lower for L curves versus other types of cuves whewre VBS has a lower efficacy. It's a good point and Betz can't in principle answer it with any specificity. I don't remember what he said... I'm guessing he conceded the point.

Just because someone is stapled doesn't mean the curve would have progressed absent the stapling.

Do you think this TSRH paper is sufficient to halt the BRAIST Study?

It will be interesting to see if that happens or if it doesn't happen. Either way.

[Pooka1]

It seems to me it's a good thing there are mainly thoracic curves in the study, as those would be the hardest and most difficult to stop the progression in. It makes the study even better in my mind.

Forgot about this...

The majority by far were double major curves...

62 double major
26 single T
8 T/L or L
3 double T
1 triple.

And the majority of patients were skeletally mature per the commentary (which I have to read again).

I am not sure where double majors fall out in terms of progression risk but I think T curves have the highest risk. Anyone know?

To the extent that most curves are T, this study might be less applicable to the general population than if the patient population reflected the general population much more closely.

How prevalent are double majors compared to the other curve types anyway? Anyone know?

[Ballet Mom]

Forgot about this...

The majority by far were double major curves...

62 double major
26 single T
8 T/L or L
3 double T
1 triple.

And the majority of patients were skeletally mature per the commentary (which I have to read again).

I am not sure where double majors fall out in terms of progression risk but I think T curves have the highest risk. Anyone know?

To the extent that most curves are T, this study might be less applicable to the general population than if the patient population reflected the general population much more closely.

How prevalent are double majors compared to the other curve types anyway? Anyone know?

In that case, they have been very conservative as double majors are the MOST LIKELY to progress, as I recall. I'm actually not going to look for data, because I'm done with that here.

If you can't trust someone whose research CV looks like this and is Chief of Staff of a major children's orthopedic center,

http://www.tsrhc.org/downloads/PDF/CVs/herring_2010.pdf

http://www.tsrhc.org/downloads/PDF/C..._Herring_1.pdf (please notice all the research journals he's editor and reviewer of,

or a woman who has cured untold numbers of children with scoliosis...who are you going to be willing to believe? Apparently you know better than all these renowned orthopedic surgeons. Apparently they're trying to pull the wool over these poor kids eyes and torture them, because they like to torture kids.

[Pooka1]

Here's a Lenke study with over 600 consecutive AIS cases that were surgical...

http://www.ncbi.nlm.nih.gov/pubmed/11884908

Type 1, main thoracic (n = 305, 51%)
Type 2, double thoracic (n = 118, 20%)
Type 3, double major (n = 69, 11%)
Type 4, triple major (n = 19, 3%)
Type 5, thoracolumbar/lumbar (n = 74, 12%)
Type 6, thoracolumbar/lumbar-main thoracic (n = 17, 3%).

So of the curves that became surgical which is the end game here (i.e., avoiding fusion), half are T and only about 10% are double majors. Thus the study population which was almost 2/3 double major and only about 1/4 T, does not resemble the surgical cases at least.

For a worst case study, you would have to have at least half (and indeed all for absolute worst case) be T curves because half of his large consecutive surgical cohort was T.

So these are what becomes surgical but I want to also know what the prevalence is of all curves, not just the surgical ones. I can't seem to find a good reference for that.

[Pooka1]

If you can't trust someone whose research CV looks like this and is Chief of Staff of a major children's orthopedic center,

The case of Linus Pauling invalidates this point.

[Ballet Mom]

The case of Linus Pauling invalidates this point.

I don't agree.

[Pooka1]

It is important to compare those surgical rates for curve type with general prevalence. I mean it could be that although double majors are only a small component of the surgical cases, it could still be the case that most of them progress.

I can't seem to find curve type prevalence in the general AIS population to compare.

There are two different questions to ask and answer.