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Thread: When is it too late to brace?

  1. #1
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    When is it too late to brace?

    What does the literature say about when is it too late to brace, or put another way, When is it time to stop bracing?

    There is a lot of controversy surrounding bracing but the answer to this question seems pretty clear. All the “experts” agree that once skeletal maturity is reached bracing is not going to provide any benefit.

    But not to disappoint, there is controversy about even this statement. The question is “When is skeletal maturity reached”. On that point, there is some discussion and work to be done. I was hoping you folks could help me explore the literature/evidence. For the sake of this discussion, let’s just assume that bracing “works” (and that, in my opinion, is by no means a proven fact).

    Lori Dolan in her “Equipoise” paper made the case that among the “experts” there is very little agreement when it comes to bracing and scoliosis. The only thing they agreed on was the relative risk faced by girls diagnosed after their first period (post menarche). I asked her about this on the UK forum and you can click this link to see her response. She is "Braist24"

    My motivation for asking this is to explore our own reasons for not bracing our 14 year old daughter. Someone on this forum posted their philosophy and I found it very poignant, they said, regarding bracing, something to the effect of “It’s her job to wear the brace and it’s my job to get her out of it”. To do that, we need to understand the issues surrounding skeletal maturity.

    Doctors seem to rely mostly on age, Risser sign, and menarche status to determine skeletal maturity. For my daughter, these don’t jibe, she is 14, 1 year post menarche and Risser 0. Not surprisingly I got different advice from different doctors. Now, I’m sure if we talk to enough doctors we’re ultimately going to find one that tells us what we “want to hear”. I’m hoping that is not the case for us. Just to summarize, this is a boiled down version of what the doctors have said to us.

    • The first doctor said – 38 degree curve, Risser 0 => Boston brace for 2 years
    • The second doctor (a colleague of the first doctor) said – 38 degree curve, 1 year post menarche => She is probably too old to brace effectively, wait 6 months and come back.
    • The third doctor said - $3500 please (OK, maybe that’s not fair, but it is funny)
    • The fourth doctor said – let’s x-ray her hand and more accurately determine her skeletal age. If she has completed most of her growth you may want to consider not bracing at all.


    Well, long story short (and the above is very abbreviated) my daughter really liked the 4th doctor (wonder why). Her hand x-ray suggested she was much further along on her growth than the Risser sign indicated. We made the decision not to brace (actually we abandoned the third doctors brace) after her hand x-ray showed she was Stage 6 and her curve was essentially stable between 38 and 34 degrees (based on two out of brace xrays 4 months apart). I’ve attached 2 Tables from Sanders 2008 showing the probability of curve progression based on curve amplitude and skeletal age. A note on the attached table 3, the author includes 95% confidence intervals in parenthesis and notes many of these are large due to the small sample size.

    So, what do you folks think?
    Last edited by concerned dad; 05-07-2009 at 09:25 PM. Reason: added link to previous discussion about Equipoise paper

  2. #2
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    Quote Originally Posted by concerned dad View Post
    So, what do you folks think?
    What do I think?

    I think I'm going to need ten minutes (at least) to stop giggling like an idiot over your comment about doctor #3.

    Interesting data. My one kid is 36-40* and I believe is a Risser ~3. She is 14.5 yo and that presumably puts her at:

    6. Adolescent steady - late

    from Table 1.

    Then we go to Table 3. and note that she has a 0% (0% - 83%; 95% C.I.) chance of needing surgery.

    Hmmmm. Were it so. Were it even likely.

    I do have to say this table seems to agree with what our surgeon is telling us in re only 5% (or some small number) experience progression later in life at any point if they are sub-surgical at Stage 8 (maturity).

    That 5% is well represented in this sand box it seems.

    I'm going to show these table to my little (tall!) Willow. I think it will cheer her.

    Thanks.
    sharon
    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."

  3. #3
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    Quote Originally Posted by concerned dad View Post
    What does the literature say about when is it too late to brace, or put another way, When is it time to stop bracing?
    Hi Concerned Dad
    I just found this recent SOSORT presentation that has an opinion on your question.
    Efficacy of bracing immediately after the end of growth: final results of a retrospective case series.
    Objectives: verifying the efficacy of bracing for adolescent idiopathic scoliosis (AIS) after the end of growth (Risser 4 and 5, until 20 years of age).
    Here's the link for the details:
    http://www.sosort-lyon.net/pdf/saa29...f703cf6e46a965
    Conclusion: Before 20 years of age, even in skeletal mature patients, it is possible to reach radiographic and aesthetic improvements, although not as good as during growth. Correction is based on bone growth, but also ligaments and neuromuscular control of posture can be involved.

  4. #4
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    Thanks for that link to the SOSORT abstracts.
    They sure do approach things different in Europe than in the states.

    So, these guys in Italy looked at 25 kids average age of 16.5 years. The thing that struck me was the average initial Cobb angle was 27.4 degrees. This is a pretty small curve, and presenting in a skeletally mature (Risser 4 or 5) kid, one wouldn’t really expect much of an increase. Without a control group (I had to say this before Sharon) we are left to wonder what would have been the outcome for these young adults without bracing.

    I would offer the following consensus (Figure 2) from the Dolan Equipoise paper. The group reported in the SOSORT paper best matches Profile 2 (small curve post menarchal). The consensus opinion is that for this group there is very little difference in expected outcomes whether or not you brace. (again, I am not a big consensus guy but this is all we have to go on, presumably their opinions are based at least on some years of experience).

    This goes to the question of whether or not one thinks it is ethical to brace a child (or in this case, a young adult) if you don’t think it will make much of a difference. If treatment were as trivial as taking a pill at bedtime, that would be one thing. But wearing a brace for 23 hours is another. (I wonder how they got a 95% compliance in a group of kids that old)
    Last edited by concerned dad; 05-11-2009 at 01:32 PM. Reason: spelling

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    Quote Originally Posted by concerned dad View Post
    Thanks for that link to the SOSORT abstracts.
    They sure do approach things different in Europe than in the states.
    In more ways than one.

    So, these guys in Italy looked at 25 kids average age of 16.5 years. The thing that struck me was the average initial Cobb angle was 27.4 degrees. This is a pretty small curve, and presenting in a skeletally mature (Risser 4 or 5) kid, one wouldn’t really expect much of an increase. Without a control group (I had to say this before Sharon) we are left to wonder what would have been the outcome for these young adults without bracing.
    Nothing like setting the bar low to guarantee a particular outcome.

    I would offer the following consensus (Figure 2) from the Dolan Equipoise paper. The group reported in the SOSORT paper best matches Profile 2 (small curve post menarchal). The consensus opinion is that for this group there is very little difference in expected outcomes whether or not you brace. (again, I am not a big consensus guy but this is all we have to go on, presumably they’re opinions are based at least on some years of experience).
    The Italian study is a penetrating glimpse into the obvious in my little opinion.

    This goes to the question of whether or not one thinks it is ethical to brace a child (or in this case, a young adult) if you don’t think it will make much of a difference. If treatment were as trivial as taking a pill at bedtime, that would be one thing. But wearing a brace for 23 hours is another. (I wonder how they got a 95% compliance in a group of kids that old)
    How did they know they got 95% compliance?
    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."

  6. #6
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    Quote Originally Posted by concerned dad View Post
    This goes to the question of whether or not one thinks it is ethical to brace a child (or in this case, a young adult) if you don’t think it will make much of a difference. If treatment were as trivial as taking a pill at bedtime, that would be one thing. But wearing a brace for 23 hours is another.

    Hi CD,

    Interesting, thoughtful thread. As a formerly braced individual, I personally think it IS unethical to brace a child or young adult if you don't think it will make a difference. Why would you? No one would ever consider surgery if they didn't think it would make a difference. Remember the Hippocratic oath, first do no harm. Bracing is not benign. Just check out all the posts in the teen bracing section titled "I hate my brace" and "I want to burn my brace" etc. And just because a child complies fairly well with bracing doesn't mean it's not having a negative affect on them psychologically. BTW I am not so much speaking about night bracing, which I think is great if it works and the child tolerates it and it is effective. I am speaking about full-time bracing, which I believe is a very difficult burden to bear.

    And to this end I for one can't wait for the results of the BrAIST study. Doesn't it end this year?

    Take care,

    Gayle
    Last edited by leahdragonfly; 05-12-2009 at 11:20 PM. Reason: typos
    Gayle, age 50
    Oct 2010 fusion T8-sacrum w/ pelvic fixation
    Feb 2012 lumbar revision for broken rods @ L2-3-4
    Sept 2015 major lumbar A/P revision for broken rods @ L5-S1


    mom of Leah, 15 y/o, Diagnosed '08 with 26* T JIS (age 6)
    2010 VBS Dr Luhmann Shriners St Louis
    2017 curves stable/skeletely mature

    also mom of Torrey, 12 y/o son, 16* T, stable

  7. #7
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    Gayle, Thank you for your post. We parents need to hear the well articulated viewpoints from someone like yourself who has worn a brace to help us make decisions.

    I have another figure I wanted to share relating to the issue of timing of curve progression.

    Attached is a figure from a paper from Sanders that shows the timing of the curve acceleration phase (CAP) relative to some maturity markers. He says that the TWIII RUS Score best correlates with the CAP (attached Table 1). This figure 5 shows the start of the curve acceleration phase starting, on average, 12 months before menarche.

    Details of Figure 5 are worth some contemplation. It makes sense that (if you decide to brace) you would want to brace for sure during the curve acceleration phase. However, you cant say, “I’ll put my daughter in a brace 12 months before her menarche”. Who knows when that will be? It is only available retrospectively. However, the TWIII RUS Score is something you can determine before the CAP is reached. The curve also seems useful to determine when it is already too late to brace and/or when is it reasonable to stop bracing.

    I think information like this would be helpful to someone contemplating watching and waiting. Maybe it would just confuse things, I dunno. What we really need is a way to determine which of the three trajectories a particular curve might follow (again, Figure 5 is a schematic, for illustration, the 3 trajectories shown are a simplification). If you KNEW your childs curve was in the LOW group (dashed line) then perhaps you wouldn’t brace. I wonder if information like this could be effectively tied with the Axial ScolioScore test.

    For us, we are about 24 months past ECAP (18 months past menarch). Her curve amplitude would put her (schematically) in the moderate group. It seems any benefit of bracing would be small as significant progression is not expected this late in growth.


    Also within this Sanders paper is a discussion about Risser Sign and xrays that may be of interest to some. They say:

    The Risser sign is simple, is readily available, and provides a general measurement of maturity, but it should not be used as a primary method of maturity determination when more specific measurement of skeletal maturity is required. The Oxford method uses other pelvic markers to measure skeletal maturity but, since a hand radiograph provides more accurate and useful information, routinely including the pelvis on spine radiographs used for the evaluation of idiopathic scoliosis unnecessarily increases radiation to the gonads.

    Basically they make the case that they should exclude the pelvis on xrays and do a hand radiograph.

  8. #8
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    That's exactly what we have begun to do with our daughter. After we re-expressed our concerns re radiation (especially given how many years of it she has ahead of her), her ortho agreed that the wrist x-ray is a good if not a better measure of growth, and it is not necessary to do an x-ray that includes the pelvis (at least not on a regular basis). Her last one did not include the pelvic area. I think more orthos would do this if parents specifically (and persistently) request it.
    mamandcrm

    G diagnosed 6/08 at almost 7 with 25*
    Providence night brace, increased to 35*
    Rigo-Cheneau brace full-time 12/08-4/10
    14* at 10/09 OOB x-ray
    11* at 4/10 OOB x-ray
    Wearing R-C part-time since 4/10
    latest OOB xray 5/14 13*
    currently going on 13 yrs old

    I no longer participate in this forum though I will update signature from time to time with status

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    Hi Chris,

    That's great you got your ortho to agree to that. Our ortho rolled his eyes a little recently when I insisted upon shielding front and back. I can only imagine what they will say when I tell them I want the pelvis left out! (Do I need a new ortho??)

    When they took Gillian's latest film, how low did they go, and did they have her wear a wrap-around pelvic shield, or did they collimate the beam down? I am very interested, and I think that's a great idea.
    Gayle, age 50
    Oct 2010 fusion T8-sacrum w/ pelvic fixation
    Feb 2012 lumbar revision for broken rods @ L2-3-4
    Sept 2015 major lumbar A/P revision for broken rods @ L5-S1


    mom of Leah, 15 y/o, Diagnosed '08 with 26* T JIS (age 6)
    2010 VBS Dr Luhmann Shriners St Louis
    2017 curves stable/skeletely mature

    also mom of Torrey, 12 y/o son, 16* T, stable

  10. #10
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    X-rays

    leahdragonfly

    My son had his followup today and they took an x-ray. Unless I missed it (possible because I was behind a wall) they didn't give him anything. They lined him up in front of the wall and took the x-ray. Maybe, and I'm not sure of this they put something small over his waist area.

    Right now I'm overjoyed. At his initial diagnosis he had a 12 degree curve. Today is 8 months later and his x-ray showed an 11 degree curve. I swear I thought it was getting worse but it's basically stable. I should note that when I look at the x-ray his 11 degrees looks frightening. It looks like 60 degrees to my eyes.

    I just watched a movie of Scott when he was about 1.5 years old and he had no curve at all. When and why this curve showed up is a mystery to me. He is almost 6 and we know it's been hanging around at least since his 3's.
    Last edited by Dingo; 05-19-2009 at 01:15 AM.

  11. #11
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    Quote Originally Posted by Dingo View Post
    Right now I'm overjoyed. At his initial diagnosis he had a 12 degree curve. Today is 8 months later and his x-ray showed an 11 degree curve. I swear I thought it was getting worse but it's basically stable. I should note that when I look at the x-ray his 11 degrees looks frightening. It looks like 60 degrees to my eyes.
    Very good that the curve has stabilized. Small curves can and do stabilize and even spontaneously correct completely on their own. Hopefully your son will be in that category.
    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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    stabilized

    Pooka1

    I hope so. About 2 months after Scott was diagnosed we "blacked out" his room at night. His sleep improved immediately. I'll never know if that helped his Scoliosis but we're definitely sticking with it.

    About a week ago we started him on the balance board during TV shows, light strength training and nightly stretching before bed. I hope this has a positive impact even though once again I'll never know for sure.

    I read somewhere that about half of nonprogressive cases eventually reconcile. I would pay a million dollars for that.... if I had a million dollars.

  13. #13
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    Quote Originally Posted by Dingo View Post
    Pooka1
    I would pay a million dollars for that....
    I'd pay it too to help my daughter

    Perhaps part of the reason for the existence of questionable alternative treatments.

    Certainly reason to subject all treatments to scrutiny

  14. #14
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    Hi Gayle,

    OK, I don't know what collimate (sp?) is and I'm too lazy to look it up so I'll just tell you what they did. The x-ray looks like it is from just below her hips up. They have only a small digital x-ray machine where we go (they prefer long film, but I asked for the digital)--it is not big enough to capture the full length of her spine so I think it was dictated a bit by that. Surprisingly enough they had no physical shields there. Instead they have a kind slide that goes on the machine that supposedly blocks the beam in the area that they guess the ovaries are (which I guess is hard to identify with any certainty). It looked a bit hokey to me but what do I know? Anyway, I insisted they put the slide in anyway and it did not show up on the x-ray so the beam was above that. She should fit on that machine for a little while longer but once she's too big we probably will bring a lead skirt with us and insist it be used. I'll probably do it for the next x-rays anyway as an extra precaution.

    It took a bit of back and forth communication with the ortho to get to this (and probably won't be the last time we discuss it). Every now and then I think she'll want a full film but she acknowledged that while she thinks the radiation is safe she really can't say for sure and so our concerns were not unreasonable.
    mamandcrm

    G diagnosed 6/08 at almost 7 with 25*
    Providence night brace, increased to 35*
    Rigo-Cheneau brace full-time 12/08-4/10
    14* at 10/09 OOB x-ray
    11* at 4/10 OOB x-ray
    Wearing R-C part-time since 4/10
    latest OOB xray 5/14 13*
    currently going on 13 yrs old

    I no longer participate in this forum though I will update signature from time to time with status

  15. #15
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    Chris,

    Thanks for the info--I am definitely going to pursue this for Leah. These young'uns have SO many x-rays in the years ahead...To me it makes perfect sense to omit the plevis on at least some of the x-rays, we know these young ladies will be Risser 0 for a LONG time yet (my old x-ray reports placed me at Risser 0 at age 13.5-yikes)!


    Dingo,

    That's great news about Scott's curve. I know you could visibly see the curve, but with the margin of error, it barely qualifies as scoliosis, so for that I know you are very glad. I know you will all sleep well tonight!
    Gayle, age 50
    Oct 2010 fusion T8-sacrum w/ pelvic fixation
    Feb 2012 lumbar revision for broken rods @ L2-3-4
    Sept 2015 major lumbar A/P revision for broken rods @ L5-S1


    mom of Leah, 15 y/o, Diagnosed '08 with 26* T JIS (age 6)
    2010 VBS Dr Luhmann Shriners St Louis
    2017 curves stable/skeletely mature

    also mom of Torrey, 12 y/o son, 16* T, stable

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