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Thread: Brace Treatment Controls Progression in Adolescent Idiopathic Scoliosis - (The Proof)

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    Brace Treatment Controls Progression in Adolescent Idiopathic Scoliosis - (The Proof)

    For those who have followed the Bracing vs. Not Bracing controversy in this research section:

    Here is a video of the lecture presented at the latest 2010 POSNA meeting by John A. Herring, MD of Texas Scottish Rite Hospital for Children.

    It shows that bracing is effective if worn for enough hours each day and has some very interesting insights including:


    Success Rates (progession <6 degrees):

    >12 hours of wear per day - 82%

    7-12 hours per day - 61%

    <7 hours per day - 32%



    Flexibility of the curve did not seem to alter the success rate or the frequency with which the brace was worn!


    72 patients did not have surgery, average wear 8.1 hours per day!

    28 patients had surgery, average wear of 4.3 hours per day.



    Whether the patients were told to wear the brace 23 hours per day or 16 hours per day didn't matter, both groups ended up wearing the brace the same average total number of hours! There was no difference between the number of hours of brace wear of boys and girls.

    Most important slide in my opinion:


    Results vs. Natural History

    Lonstein, Carlson results (Risser 0,1 Curves 20-29 degrees) i.e. the natural history:

    68% progressed


    Katz, Herring et al (this study) (Risser 0,1 Curves 25-45 degrees) curves larger and therefore more likely to progress:

    Brace > 12 hours 18% progressed

    Brace < 7 hours 69% progressed (back to the natural history)

    Therefore, bracing alters the natural history!!



    http://posna.gmetonline.com/Presenta...onpackageid=44

    Click on the link for Scientific Program Day 3, and then the sixth presentation at 9:04 a.m.


    One item of concern for me:

    Brace treatment was discontinued at Risser 4, 18 months post menarche in the girls, boys until growth ceased. This is very interesting because my daughter is already two years post menarche and is at Risser 4 and she will continue to wear her brace until her growth has ceased completely. She had 3/4 of an inch of growth in the last six months. I ran across a study recently that showed that Risser 5 isn't even an exact measure of completion of growth as growth has occurred in some patients even after reaching Risser 5.

    Unfortunately, I am unable to come up with the right search terms to find that paper again. It seems to me girls should also stop bracing when growth has ceased. It seems a shame to stop bracing too early in some cases, after all the effort, and have the unintended consequences of continued progression.
    Last edited by Ballet Mom; 12-03-2010 at 06:48 PM. Reason: fixed link

  2. #2
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    Interesting study, but well short of proof.
    I couldnt find this trial in Clinicaltrials.gov. It would be interesting to know many more details.
    I would be very interested to hear if the endpoint analysis was pre-defined or if this was a post-hoc analysis of the data.
    And, I am sure I'm not the first to point this out but .... it is possible that the patients who wore their brace, wore it because it was not as uncomfortable for them as those who did not wear their brace. And, if the reason for that uncomfort is a progressing curve, then the trial didnt proove anything. In such a case, all it proved was that people with progressing curves are uncomfortable in their brace and therefore dont wear it as much.

    Let's not forget the failed Nachemson trial where they declared bracing efficacious only to find out that the two arms were stacked with a differential amount of lumbar and thoracic curves (each with different natural histories of progression).

    Roosters crow when the sun rises but Roosters crowing does not cause the sun to rise.

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    Hi CD.

    This study has been discussed in commentary published by the journal and on a few threads on the forum.

    You might be interested in either or both of those.

    The problem is the variability which the authors did not show except in one supplemental graph. I blame the reviewers/editors.

    The bottom line is that it is not possible to use these results to predict much for any individual. The small dose-response curve was swamped by the variability essentially. So they got a result but is is not very useful for any individual patient.

    Finally, about 75% of these kids would be expected to have been braced unnecessarily. And the small dose-response curve does not rule out that bracing only delayed rather than avoided surgery. This point was made in one of the letters to the editor and of course the authors can't have a response.

    I think the BrAIST study ended and they will be publishing at some point though I'm not sure. In the end, they had at least 26 institutions participating. That study would have been deemed ethical even with the Katz et al. results in hand in my opinion.
    Sharon, mother of identical twin girls with scoliosis

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    By the way, the comparison the authors make with the Lonstein and Carlson natural history is ill-informed and therefore misleading.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

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    Quote Originally Posted by concerned dad View Post
    And, I am sure I'm not the first to point this out but .... it is possible that the patients who wore their brace, wore it because it was not as uncomfortable for them as those who did not wear their brace. And, if the reason for that uncomfort is a progressing curve, then the trial didnt proove anything. In such a case, all it proved was that people with progressing curves are uncomfortable in their brace and therefore dont wear it as much.
    Nice to hear from you CD....I hope your daughter is doing well.

    I do have to say that what you have stated is a huge assumption. There are all sorts of reasons kids wouldn't wear their brace. My daughter had a rapidly progressing curve and she wore her brace...guess what...the brace stopped the progression.

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    Quote Originally Posted by Pooka1 View Post
    Finally, about 75% of these kids would be expected to have been braced unnecessarily.
    Please in the future refer to that quote as your own opinion. You don't care about the size of kids deformities. Just admit it.

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    Quote Originally Posted by Ballet Mom View Post
    Please in the future refer to that quote as your own opinion. You don't care about the size of kids deformities. Just admit it.
    You've become unhinged. Just admit it.

    Conspiracy theories? Really? You appear to be so imbued in dogmatic programmed thought that you can't imagine that there is any free thought out there driven by EVIDENCE.
    Last edited by Pooka1; 12-27-2010 at 06:38 PM.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

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    Quote Originally Posted by Pooka1 View Post
    You've become unhinged. Just admit it.

    Conspiracy theories? Really? You appear to be so imbued in dogmatic programmed thought that you can't imagine that there is any free thought out there driven by EVIDENCE.
    Cut the commie talk.

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    What Dr. Cobb told us about bracing.

    The famous Dr. John R. Cobb--of "Cobb Angle" fame, as my original surgeon in 1956 told us "bracing doesn't work". Maybe because my curve was significant at the time; I don't know.
    He had seen enough curves which progressed and didn't progress. Bracing/exercises was all they had. Surgery was a last ditch option.

    I always wonder whether the bracing success are genetically the ones whose curves would not progress to surgical levels no matter what.

    During chiropractic "care" my curves progressed terribly. I often wonder whether that loosened up my spine to make it curve more. After all that I have less than 50% pulmonary function as a direct result of my original deformity.
    Original scoliosis surgery 1956 T-4 to L-2 ~100 degree thoracic (triple)curves at age 14. NO hardware-lost correction.
    Anterior/posterior revision T-4 to Sacrum in 2002, age 60, by Dr. Boachie-Adjei @Hospital for Special Surgery, NY = 50% correction

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    Quote Originally Posted by Karen Ocker View Post
    The famous Dr. John R. Cobb--of "Cobb Angle" fame, as my original surgeon in 1956 told us "bracing doesn't work". Maybe because my curve was significant at the time; I don't know.
    He had seen enough curves which progressed and didn't progress. Bracing/exercises was all they had. Surgery was a last ditch option.

    I always wonder whether the bracing success are genetically the ones whose curves would not progress to surgical levels no matter what.
    There are three independent lines of evidence that all support this claim:

    1. Statements from many experienced orthopedic surgeons like Cobb that bracing doesn't appear to work.

    2. The study that concluded that ~70% of kids are braced unnecessarily, ~20% are apparent failures (though compliance is an open question), and 10% appear to hold the curve at least for a few years.

    3. Scoliscore where ~75% of AIS cases in girls with small curves will not progress to surgery territory.

    All independent evidence and all pointing at the same conclusion. That is getting harder and harder to knock down.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

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    Quote Originally Posted by Pooka1 View Post
    There are three independent lines of evidence that all support this claim:

    1. Statements from many experienced orthopedic surgeons like Cobb that bracing doesn't appear to work.

    2. The study that concluded that ~70% of kids are braced unnecessarily, ~20% are apparent failures (though compliance is an open question), and 10% appear to hold the curve at least for a few years.

    3. Scoliscore where ~75% of AIS cases in girls with small curves will not progress to surgery territory.

    All independent evidence and all pointing at the same conclusion. That is getting harder and harder to knock down.
    Please don't start this again. This is beyond ridiculous.

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    Quote Originally Posted by Ballet Mom View Post
    Please don't start this again. This is beyond ridiculous.
    Please explain why it is "ridiculous."
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

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    I was thinking about this last night (when I ought to have been sleeping).

    I often feel like you two are talking past each other. There's a central point in BalletMom's argument that's being ignored, and that is "what is an acceptable amount of progression?"

    Surgeons (almost by definition) consider it acceptable right up until the point that it becomes surgical, and that's what points #2 and 3 are based on (#1 is pointless, since there are at least an equal amount of surgeons who do find bracing effective).

    Without some agreement on the acceptable amount of progression, the numbers simply don't make any sense. So, if the acceptable curve is 35 degrees instead of 50 or 60, how effective is bracing then?

    Discuss among yourselves

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    There is nothing to discuss in terms of acceptable amount of progression until someone actually shows that there is some conservative method than can reduce or hold a subsurgical curve to even more sub-surgical territory.

    They can't even show that for keeping curves sub-surgical FULL STOP.

    I suggest it will be very, very, very, very hard to show that a conservative method keeps a sub-surgical curve even more subsurgical than it would otherwise become. On the other hand, they are dealing with huge numbers of kids (~75%) as potential study subjects so there is that.

    The constant mentions of keeping sub-surgical curves even more subsurgical are completely imaginary at this point. It might be the case but nobody has shown it or even come close.

    Correct me if I have expounded outside my area too much.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

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    Actually, I was thinking it would be easier to show, since the group that's likely to progress from 25 to 35 degrees is larger than the group that's likely to progress from 25 to 50 or 60.

    So, if you tool a bunch of people with 25 degree curves and through a conservative treatment kept them all at 25, that would be of greater significance then just keeping them from advancing to surgery.

    But that's only part 2 of the question. Part 1 is, whether or not science can prove it, is it *desireable* to keep a 25 degree curve from getting to 35 for reasons of cosmetics/pain/further progression in adulthood.

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