Does Bracing Work?

[debbei]

The data doesn't mean squat when you have a fairly sizable group who, like Debbe, weren't NEAR 50° when released from bracing, but progressed anyway. The studies say *I* should have progressed and she shouldn't have. As long as there are cases like us, I will always believe the research is inherently flawed.

Pam

Unfortunately there are no guarantees with this. When I brought my 9 year old daughter to the orthopedic dr. for her slight scoliosis last summer, he told me (referring to my history) that curves ending up in the mid 30 degrees are iffy. Some progress.....others do not. It's kind of a grey area. I guess this is where the genetic test will come in handy. When I bring my daughter back to be rechecked later this month, I will ask (and insist) that she have the genetic test. I don't care what I have to pay for it.

[txmarinemom]

Unfortunately there are no guarantees with this. When I brought my 9 year old daughter to the orthopedic dr. for her slight scoliosis last summer, he told me (referring to my history) that curves ending up in the mid 30 degrees are iffy. Some progress.....others do not. It's kind of a grey area.

Exactly my point. There are SO many layers of complexity (and variability) to this, I simply can't see how a bracing study would ever be effective.

Your daughter may very well be predisposed to progress (I hope not), but another point I'm trying to make is I really think we're ALL predisposed one way or another.

Yes, it looks like bracing MAY be more effective in SOME cases of early JIS ... but I haven't seen the long term outcomes of THAT either. It's pure conjecture at this point to say correction in a 7 year old will hold water in 20 years for the adult that child becomes.

As far as my case, I don't know of anyone else here who KNOWS for certain their curve didn't progress at the size mine was (maybe there are and they don't post). How would a study be able to separate a curve of my nature of from everyone else's typical curve? It didn't LOOK any different when I was diagnosed with AIS (since deemed JIS) and braced ...

Pam

[nate03]

When I bring my daughter back to be rechecked later this month, I will ask (and insist) that she have the genetic test. I don't care what I have to pay for it.

Hi,
Just thought I would pass along the info I have learned regarding the genetic test, Axial Scoli Score.

Only girls diagnosed with a curve of 10 -25 degrees, between the ages of 9 - 13 are eligible. The test is only being offered at certain hospitals - not sure of any other than Philadelphia Shriner's Hospital. Shriners Hospitals provide free care - so there would be no charge if you could do it through a Shriner's Hospital near you. It is a spit test - no blood work. The results are given with a score between 1 - 200,

The higher the number you get between 1-200, the more likely it is that the scoliosis will progress.

1-40 - low risk or chance of curve progression
41-180 - moderate risk of curve progression - higher number/higher risk
181-200 - high risk/aggressive curve progression

I am currently researching this test for my daughter with a very mild curve because of her brother's scoliosis. She is age 11, curve 11 degrees so she just qualifies.

-Cara

[debbei]

Hi,
Just thought I would pass along the info I have learned regarding the genetic test, Axial Scoli Score.

Only girls diagnosed with a curve of 10 -25 degrees, between the ages of 9 - 13 are eligible. The test is only being offered at certain hospitals - not sure of any other than Philadelphia Shriner's Hospital. Shriners Hospitals provide free care - so there would be no charge if you could do it through a Shriner's Hospital near you. It is a spit test - no blood work. The results are given with a score between 1 - 200,

The higher the number you get between 1-200, the more likely it is that the scoliosis will progress.

1-40 - low risk or chance of curve progression
41-180 - moderate risk of curve progression - higher number/higher risk
181-200 - high risk/aggressive curve progression

I am currently researching this test for my daughter with a very mild curve because of her brother's scoliosis. She is age 11, curve 11 degrees so she just qualifies.

-Cara

Cara,

Thanks for the info. We are close to philadelphia, so maybe I will go to Shriner's, depending on what her curve is. She will be 10 in June, and each of her 2 curves were 5 degrees each last summer. I'll see what the doc says next week. The pitty of this whole thing is that, she, her two brothers and I ALL participated in the study last summer, but you can't get your individual results. I really wish I could.

[concerned dad]

Just another clarification to my original post above.
When I ask if Bracing works, I mean in an epidemiological sense. Not in an individual sense.

The data doesn't mean squat when you have a fairly sizable group who, like Debbe, weren't NEAR 50° when released from bracing, but progressed anyway. The studies say *I* should have progressed and she shouldn't have. As long as there are cases like us, I will always believe the research is inherently flawed.

Pam

It has been proven (or at least suggested) that baby aspirin can prevent a second heart attack. It doesn’t work for everyone, but statistically, on a large population, it has been shown to have an effect.

How large of an effect? I don’t know, but if all it takes is swallowing a small baby aspirin the added benefit is likely worth the trouble. It doesn’t guarantee you're not going to have a second heart attack though.

If I had a second heart attack even though I took a daily baby aspirin does that mean the research is "inherently flawed"?

I said above that I believe the data shows that bracing has an effect. How large an effect I don’t know. I agree that science has not been able to quantify the effect. But, I do believe that science has shown that there is an effect. Does it reduce the need for surgery? We dunno.

Regarding the 6 degree issue - let me ask you this: If you could (statistically) have a lower chance of your (or your child’s) scoliotic curve progressing from 20 degrees to 26 degrees by taking a baby aspirin. Would it be worthwhile to you? Or, would it only be worthwhile taking that baby aspirin if you knew that (again statistically) you had a better chance of avoiding surgery.

another point, a bit off topic.............

A very important result from Dr. Dolans systematic review paper is the data showing the incidence of surgery for braced patients. It is from a large sample and she says it is significant.

The fact that a large number (n = 1814) of braced patients from many different institutions were available for this review is evidence for the reliability of the pooled surgical rate of 22%.

If someone came up with a new brace (or even a baby aspirin) and showed that by using this treatment in the same population as Dolan used, the surgical rate dropped to 5%, would that mean the new treatment worked? Wouldnt that be an example of proving the efficacy of a new treatment in the absence of a random controlled trial?

Now the obvious question for anyone who has been following this and other discussions about bracing and the SpineCor is: What is the surgical rate for the SpineCor? From Dr. Coillard's 2007 paper, it is 22.9%.
Oh well.

But, what about the SpineCor's effect on the curve. What about the 6 degree metric? No time now to dig into it. But someone (Sharon?) if you could address my question two paragraphs up I would appreciate it.

[2kids]

Hi,
Just thought I would pass along the info I have learned regarding the genetic test, Axial Scoli Score.

Only girls diagnosed with a curve of 10 -25 degrees, between the ages of 9 - 13 are eligible. The test is only being offered at certain hospitals - not sure of any other than Philadelphia Shriner's Hospital. Shriners Hospitals provide free care - so there would be no charge if you could do it through a Shriner's Hospital near you. It is a spit test - no blood work. The results are given with a score between 1 - 200,

The higher the number you get between 1-200, the more likely it is that the scoliosis will progress.

1-40 - low risk or chance of curve progression
41-180 - moderate risk of curve progression - higher number/higher risk
181-200 - high risk/aggressive curve progression

I am currently researching this test for my daughter with a very mild curve because of her brother's scoliosis. She is age 11, curve 11 degrees so she just qualifies.

-Cara

Cara,
Can anyone request to have this test if they fall into the age range? They are not doing this test in the Washington area, but our doctor did mention it last week. Perhaps it would be worthwhile to drive to Philadelphia. Please PM me any details you have to share.

Thanks!

[Pooka1]

How about this

success = preventing a curve from advancing 6 degrees.

That is what Nachemson used. Radically different in its implications.

CD,

I think you are confusing what they can say is a change versus what change is significant.

The 6* change is simply the smallest change they can say occurred due to the measurement error. It is part of the "Methods" of the study.

Neither Nachemson nor anyone is claiming 6* all alone and by itself is significant to what really matters... avoiding surgery now and in the future. That would be in the "Conclusions" section.

Nachemson is NOT saying 6* is magical; He is just saying it happens to be the minimum increase they can measure (because the errror bars are +/- 5*). That is, if they measure an increase of at least 6*, they can say the curve increased. They are not ascribing a significance to "6*" beyond that being their precision.

Think of it as a "yes/no." If the curve measures at least 6* more than the previous measurement, then they say "yes" it increased. If it increased, they then can say how much it increased. After they determine that, they can then decide if that increase is significant in terms of avoiding surgery.

[Pooka1]

Isnt this exactly what Dr Dolan did in her meta-analysis paper. Same methodology. Only difference was the definition of the outcome.

The patients are still stacked. Or at least they don't know with the averaged data if the patients are stacked.

GIGO.

[Pooka1]

How about the attached figure from the 2007 Danielson Spine Paper.
Note that here we are looking at bracing "altering" the natural history without looking at incidence of surgery.

No. I could write a paragraph or two on that figure that disagrees with your conclusion.

The biggest issue is patient stacking and error bars. If you put error bars on those points I'm guessing the three curves are not different. Also look at the scale of the Y-axis and think about the measurement precision. Those are the same lines.

Last, connecting three points over that many years is questionable. I realize two points determine a line and there are three there but at some point, you have to take a breath and think about that.

[Pooka1]

Regarding the 6 degree issue - let me ask you this: If you could (statistically) have a lower chance of your (or your child’s) scoliotic curve progressing from 20 degrees to 26 degrees by taking a baby aspirin. Would it be worthwhile to you? Or, would it only be worthwhile taking that baby aspirin if you knew that (again statistically) you had a better chance of avoiding surgery.

No the 6* is just the precision of the measurement. It doesn't have importance beyond that. This is simply the smallest increase they can confidently PHYSICALLY measure on a radiograph. It then has to be interpreted in the context of the study.

If someone came up with a new brace (or even a baby aspirin) and showed that by using this treatment in the same population as Dolan used, the surgical rate dropped to 5%, would that mean the new treatment worked? Wouldnt that be an example of proving the efficacy of a new treatment in the absence of a random controlled trial?

In my opinion, if they can eventually show that there is a 5% less chance of needing surgery with a brace, it wouldn't justify wearing one unless it dropped from 100% avoidance of surgery to 95% avoidance or dropped from 95% avoidane of surgery to 90%. But we know a priori that bracing is nowhere near that effective to start with.

But, what about the SpineCor's effect on the curve. What about the 6 degree metric? No time now to dig into it. But someone (Sharon?) if you could address my question two paragraphs up I would appreciate it.

Six degress is only the measurement precision, nothing more.

[Pooka1]

How about the attached figure from the 2007 Danielson Spine Paper.
Note that here we are looking at bracing "altering" the natural history without looking at incidence of surgery.

By the way, even if the error bars didn't overlap (and they will if only from the measurement precision), you'll note that the observation only and the braced from the start group showed similarly trajectories (within measurement error). Only the observation then braced group had a significant increase in the 18 years and even then, it was small. This seems to be a different cohort from the other groups in terms of curve proression.

Also, we have to wonder about data selection (as always).

[concerned dad]

Originally Posted by concerned dad => How about the attached figure from the 2007 Danielson Spine Paper.
Note that here we are looking at bracing "altering" the natural history without looking at incidence of surgery.

No. I could write a paragraph or two on that figure that disagrees with your conclusion.

The biggest issue is patient stacking and error bars. If you put error bars on those points I'm guessing the three curves are not different. Also look at the scale of the Y-axis and think about the measurement precision. Those are the same lines.

Last, connecting three points over that many years is questionable. I realize two points determine a line and there are three there but at some point, you have to take a breath and think about that.

Not sure that I agree with you on that.
The data points in the graph represent the mean of a group of measurements (each with a standard deviation of say 5 degrees).
The uncertainty of a single point would be 5 degrees and yes, if N=1 for each of the 3 lines there would be little/no significance.
But, since we are dealing with means, the uncertainty decreases as a function of N. (the square root of N actually).
So, instead of standard deviation, what should be plotted as error bars is standard deviation of the mean (also called Standard Error). As N gets larger, the Standard Error gets smaller, which means you have more confidence in your measurement.
So, for the Danielson curve, for the 40 patients who were treated with observation, the standard error of the points plotted on that line is 5/sqrt(40)=0.8 degrees (assuming the standard deviation of a single measurement is 5 degrees).

Could be wrong on this, I’m not a statistician, but I did sleep in a Holiday Inn Express last night.

[Pooka1]

That figure has no business being published without error bars period.

[Pooka1]

I am not a stats person but I have had occasion to deal with data of this type.

AIUI, you have to account for the error about each point and also the error of the mean.

Let's say you have three points, 5, 20, and 35 which averages to 20. Each has a precision of +/- five degrees.

Those errors bars about the average point are going to dwarf those for the average of 19, 20, and 21, again with the precision of +/- 5.

I don't do this type of research but I am guessing, betting, whatever, that the data that go into those average points is scattered like crazy and the error bars are HUGE when considering even just the standard deviation about the mean and not even considering the precision.

A stats person is invited to dope-slap me on this if this is incorrect.

[macky]

Concerned dad look, I had my operation as you can see in 1966, 43 years ago,. You cannot state things as fact, until enough of a period of time has gone by then you can have a look and say well, that was the correct way. I had Harrington rods inserted and they were the first to be used in scoliosis operations and I was the 8th person I think or the seventh to be operated on in Australia. I have been FINE, I have also been able to have two great sons and have led a perfectly normal life, ok 12 years ago the pain started and it does get me down sometimes, but would I change things ABSOLUTELY NO WAY. In fact if I didnt have the operation I would be dead a long time ago.

I get so darn sick and tired of people on these forums confusing young people to the extent that they do not have any idea at all what is the right thing to do because of all the conflicting messages.

Pookah1 I so agree with you, so admire you, and so many others but please concerned dad there is proof from people on these forums that bracing does not work, it works while the brace is on but sure enough, a few years down the track, the curve starts to get worse and worse and all years of wearing the brace could have been spent enjoying life if they had opted for surgery, in the first place.

The modern surgery nowadays is so ,much better than in my day but hey I am still here, and lifes OK.
Give your son/daughter a break and go ahead and let whatever has got to be done, be done ,as they are the one that is going to go through all the maybes and ifs, and shall we's as far as bracing, schroth method, chiro, and so on and so on, just get it over with.
I am not being catty or nasty I have lived it, just remember that.
Macky