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Thread: The Bracing Debate

  1. #1
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    The Bracing Debate

    I found a very interesting article written by Robert B Winter, MD. It's about the Milwaukee brace and its history.

    http://www.acpoc.org/library/1992_01_016.asp

    The Milwaukee kind of looks like it was effective when: it was used in conjunction with a good patient care program accompanied by physiologic and psychologic support systems. And was not effective when applied too late, worn too little & removed too soon.

    Poor results apparently attributed to half-assed programs leading to half-assed results.

    Good results = Good treatment protocols.

    Good article which I think pretty much sums up most bracing methods - and explains both the current and past bracing controversies in general.



    Robert B. Winter, MD, is one of the founders of the Twin Cities Spine Center, and currently serves as a research consultant there. He is a clinical professor in the University of Minnesota Department of Orthopaedic Surgery.
    Last edited by mamamax; 01-28-2010 at 08:46 PM.

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    Quote Originally Posted by mamamax View Post
    I found a very interesting article written by Robert B Winter, MD. It's about the Milwaukee brace and its history.

    http://www.acpoc.org/library/1992_01_016.asp

    The Milwaukee kind of looks like it was effective when: it was used in conjunction with a good patient care program accompanied by physiologic and psychologic support systems. And was not effective when applied too late, worn too little & removed too soon.

    Poor results apparently attributed to half-assed programs leading to half-assed results.

    Good results = Good treatment protocols.

    Good article which I think pretty much sums up most bracing methods - and explains both the current and past bracing controversies in general.



    Robert B. Winter, MD, is one of the founders of the Twin Cities Spine Center, and currently serves as a research consultant there. He is a clinical professor in the University of Minnesota Department of Orthopaedic Surgery.
    Interesting as you may find this 18 year old article, Maxene, I respectfully suggest your summary is quite possibly the most liberal over-simplification I may have ever read.

    Pam
    Last edited by txmarinemom; 01-28-2010 at 10:24 PM.
    Fusion is NOT the end of the world.
    AIDS Walk Houston 2008 5K @ 33 days post op!


    41, dx'd JIS & Boston braced @ 10
    Pre-op 53, Post-op < 20
    Fused 2/5/08, T4-L1 ... Darrell S. Hanson, Houston


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  3. #3
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    Quote Originally Posted by txmarinemom View Post
    Interesting as you may find this 18 year old article, Maxene, I respectfully suggest your summary is quite possibly the most liberal over-simplification I may have ever read.

    Pam
    The respectful suggestion duly noted ;-)

    The article in question, while written some time ago (by a well respected surgeon), I suggest - is just as true today (regarding patient care programs and support systems), as it was then. Perhaps Dr. Winter also liberally oversimplified the situation - then again - maybe he knew what he was talking about. His discussion on the subject, certainly worth more than one read.
    Last edited by mamamax; 01-29-2010 at 05:17 AM.

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    Folks, including researchers, can't just know bracing works. They have to show it.

    The world is still waiting.
    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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    Dr. Winter points to two independent studies showing excellent results with the Milwaukee - proper patient care programs and support systems in place: (1) Lonstein & Winter (1988) 1030 patients (2) Andrew & MacEwen 1989. May prove an interesting read. His article also covers - scientific evidence. One illustration (attached) for sake of discussion.

    Referenced article: http://www.acpoc.org/library/1992_01_016.asp
    Last edited by mamamax; 01-29-2010 at 06:09 AM.

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    Studies, whether they show excellent results or otherwise, will always be limited by their design. If they are poorly designed, anyone using the results is just fooling them self. There is a reason you can't publish an uncontrolled study in all other fields of science. And that reason doesn't include a magic exemption for medical research just because adequately controlled studies are difficult to do.

    And I'd like to hear from the people here who wore their Milwaukee brace and still required fusion. I think a case can be made that bracing often just delays fusion as opposed to avoiding it. Someone should study that.
    Last edited by Pooka1; 01-29-2010 at 03:00 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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    I got busy with school and forgot about this thread ...

    Maxene, look up the study Lori Dolan was involved with in 1996.

    *One* key finding:

    "The findings of this study do not agree with previously reported favorable results with bracing and raise questions about whether the natural history of progressive idiopathic scoliosis is truly altered by use of the Milwaukee brace."

    (speaking of the 1992 study)

    Personally, I couldn't care less about the *history* of the Milwaukee. It's barely relevant (if at all) to anything modern (except maybe itself - and typically only for high thoracic curves).

    As a braced adult, you may *think* you understand JIS/AIS bracing ... but you don't (and you can't). FYI, I disagree with the past AND current bracing protocols (AS a braced child), and *I* sit on my fingers more often than you when it comes to this topic. Some of the stuff you post is really insulting.

    If you're a pinkie swear kind of girl, I'll zip it if you will. Exceptions may only be granted by a consensus - and only on FIRST HAND experience.

    Do we have a deal?

    Pam
    Fusion is NOT the end of the world.
    AIDS Walk Houston 2008 5K @ 33 days post op!


    41, dx'd JIS & Boston braced @ 10
    Pre-op 53, Post-op < 20
    Fused 2/5/08, T4-L1 ... Darrell S. Hanson, Houston


    VIEW MY X-RAYS
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    Can I see your surgery photos? But it says password required.
    Thanks.

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    Mamamax,

    I'm not sure why you dug up such an old article. The Milwaukee brace has been pretty much abandoned by modern orthopedists and orthotists alike. They realize, apparently more than you, what an incredible burden the Milwaukee brace is. Especially given that there are PLENTY of other, more palatable options, including the boston and the providence.

    I wore a boston brace for about 2 years. Can I tell you how much I hated it?? There is no support or psychological care I could have received that would have made it any better, and I truly can not imagine how I would have coped with being made to wear a Milwaukee. My dear daughter hates her boston brace tremendously, but for now, she must endure it. But I would NEVER make her wear a Milwaukee, for any reason.

    I was psychologically scarred by bracing. I still, nearly 30 years later, clearly remember the utter anguish I felt when I got my brace and had to wear it to school. You can not imagine what that is like if you never wore a brace as a child.

    And BTW, the brace did contain my curves (32T/33L before bracing), but I now have major degenerative changes, arthritis, spinal stenosis, and pan-lumbar disc disease in my early 40's. This is all attributed to the uneven loading from the scoliosis. And my lumbar curve is just a hair under 40 degrees now, still being watched because it is slowly creeping up. Is this really a bracing success--I don't know. I have already been recommended to have the rest of my lumbar fused to treat my myriad problems there.

    So please, if you want to make a point about bracing, please make it on a credible study on a modern brace, and please, don't try to downplay the psychological burden of brace-wearing on children.

    Regards,
    Last edited by leahdragonfly; 02-06-2010 at 07:27 AM. Reason: typo
    Gayle, age 49
    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)
    5/10 VBS Dr Luhmann Shriners St Louis
    5/16 6 yrs post-op, 24*T/ 22* L, mild increase in curves, watching

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

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    Gayle (and anyone else I may have offended) - you have my apologies, please know offense was not my intent. And Gayle, thank you for your candid (and yet gentle) comments on this.

    I dug up this old article while researching late into the night and thought there were some significant things in it from a historical point of view. Dr. Winter had pointed out that this brace required some strict attention to detail - namely frequent medical observation along with a patient care program which included both physiologic and psychologic support systems. Interestingly enough, the only study showing an impressive outcome is one in which Dr. Winter himself was involved in (from 1988 involving 1,030 patients). From that study it was discovered that the most ideal candidate for Milwaukee brace treatment was a Risser 0, girl with a documented progressive right thoracic idiopathic scoliosis of 20 to 29. This study was duplicated (using the same protocols) by Andrew and MacEwen in 1989 (with the same results). The article briefly touches on the historical modifications of this brace - due to reduction in vital capacity. Dr. Winter implies that poor results were obtained when the strict treatment protocols (of the original designers) were not followed to the letter. I find that noteworthy and perhaps an implication that crosses into all bracing treatments. I have not been able to find a patient follow up for those who were in the two referenced studies ... but I'll keep looking.

    Why would anyone care about all this? Because while not a popular brace, it is still being used today (chiefly for very high thoracic curves): http://www.cincinnatichildrens.org/h.../milwaukee.htm

    I have no experience with this brace personally. The closest I maybe came was at a time when I wore something similar (from pictures and descriptions I have found). Following hospital treatment for a fractured neck (using chin strap traction), I as sent home in a neck brace made of leather which had metal posts around the neck, with the head supported by a chin pad. I only wore this for a week (24 hours a day) prior to an appointment with a neurosurgeon which resulted in emergency treatment in ICU. It was most unpleasant and I have a difficult time imagining a young child dealing with such a cumbersome orthotic as the Milwaukee brace.

    I do not pretend to know all about bracing across the wide spectrum of its use for juveniles and adults. And I know even less about infantile scoliosis outside of some articles I have researched which are showing some very promising results with serial casting. My personal experience is limited to simply surviving juvenile scoliosis into adulthood and bracing at the age of 59. I'm not a parent of a child with scoliosis - at the age of 29, my daughter seems to have escaped my fate (a simple prayer so far answered). In the future, I could be the grandparent of a child with scoliosis - and that alone finds me researching late into the night. And that is why I posted this information - for others like myself, with an eye into the future. In hindsight - posting in the research section would have been a better choice. My sincere apologies for any upset this may have caused anyone. Hope I will be forgiven.
    Last edited by mamamax; 02-06-2010 at 08:40 AM.

  11. #11
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    Just wanted to add a few thoughts.

    First, Mamamax - apology accepted. Some of us who have either been braced, or have a child who has been braced, feel strongly that sometimes folks minimize the challenges of brace wearing. I'm not directing this at you personally so please don't feel I am attacking you as I assure you my post is not meant that way

    That said, a lot of us still cringe thinking of how well-meaning family and friends would say (about brace wearing) things like "oh, it's not that bad", to which a friend of mine gave me a good reply - she suggested I respond "no, it's not, unless it's YOUR kid".

    With regard to the Milwaukee brace in particular, I second Gayle's sentiment that I would NEVER make my child wear a Milwaukee for ANY reason. Period.

    To give some idea of the emotional impact on a child who feels they are being perceived as different in ANY way, when my daughter who was 13 at the time, was about to graduate from 8th grade and begin high school she was distraught because the braces on her teeth still weren't off. All I heard the entire summer was things like "can't they take them off", "most kids get them off by 6th or 7th grade and I have to start high school with them on - I feel like a freak" - maybe that's not verbatim but you get the idea. Luckily, for her (and me - LOL!) they came off midway through her freshman year.

    I don't think I have to point out to anyone the difference between braces on one's teeth (which lots of kids have) and walking into any school with a Milwaukee brace!

    As for Cincinnati Children's Hospital, I have to wonder - even though the Milwaukee is listed on their website, how many children, if any, do they actually prescribe it for these days?

    One last point - it was stated above that the ideal candidate for a Milwaukee brace is a Risser 0 girl with a curve between 20 and 29 degrees. That same girl would also be an excellent candidate for VBS. The success rate for curves under 30 degrees is extremely high. In fact, I know one girl who was a Risser 0 with a high thoracic curve who was stapled at 42 degrees (nearly 4 years ago before they changed the criteria) and I would definitely consider her a success so far with a curve that continues to hold in the mid 20's, and she "could" gain additional correction as she grows. This same girl (who is now around 9 or 10) HATED bracing when it was tried for a short time prior to her having VBS. Again, her curve started above 40 degrees! Many curves that are stapled in the 20's are reduced into the single digits, something no brace can do. My point is - if I had a daughter who fit this criteria, it wouldn't even be a consideration to put her in a Milwaukee for several years when she could probably get better results (and no emotional scars) by having VBS.

    Again, just my two cents.
    Last edited by mariaf; 02-06-2010 at 10:34 AM.
    mariaf305@yahoo.com
    Mom to David, age 17, braced June 2000 to March 2004
    Vertebral Body Stapling 3/10/04 for 40 degree curve (currently mid 20's)

    https://www.facebook.com/groups/ScoliosisTethering/

    http://pediatricspinefoundation.org/

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    Like Gayle and Maria - who are both, admittedly, more tactful than I hope to be in this lifetime - I'd NEVER put my child in a Milwaukee.

    There are really only a few circumstances where I'd even place my kid in a Boston ... and it would *still* kill me to buckle the straps. If there's anyone I've related with around here or VBS, it's Gayle. Leah's time "in-brace" hasn't been the solution (on its own), as far as I know. With her, it's been the stop gap to halt progression - and rally other options.

    Unfortunately, some doctors *do* still prescribe Milwaukees (or Bostons with superstructures) as THE treatment: The ones that do, aren't familiar with the current protocols. My curve apex was T9 (T9 and above is what split out the Milwaukee vs. Boston candidates back in the day), and as Gayle said, I don't know how I would have stood a Milwaukee. Like Gayle, I will ALWAYS wear the mental scars of a Boston ...

    While I'm a huge proponent of VBS, I DO understand parents who seek the non-invasive options. I just wish people would consider the long-term results ... mental and physical ... and not wait until the timeframe (to consider all options) has passed. If it sounds too good to be real, don't look at 18 year old articles: LOOK at those of us who went that route ... and where we are now.

    Think about it ... a Boston is *still* the same damn Boston for which I was fit in 1979.

    Is it any easier to "save" your 10 year old from surgery (which could be as minor as VBS) - only to watch them go on to have full fusion (with other spine issues from years of abuse) at 30-40+?

    I haven't seen ANY positive data on bracing that matches VBS. My opinion, sure ... but it's also based on scientific data that isn't 18 years old.

    The results I've seen are significant enough to me, I nagged my surgeon to become the first one in the 4th largest US city to start performing it. I'm grateful the option is now available here. At the risk of getting blasted again (I said this *before* I had fusion, and still mean it), I wish the option had been available for me - and my eligible 35 curve - 31 years ago ...

    Regards,
    Pam
    Fusion is NOT the end of the world.
    AIDS Walk Houston 2008 5K @ 33 days post op!


    41, dx'd JIS & Boston braced @ 10
    Pre-op 53, Post-op < 20
    Fused 2/5/08, T4-L1 ... Darrell S. Hanson, Houston


    VIEW MY X-RAYS
    EMAIL ME

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    Quote Originally Posted by txmarinemom View Post
    There are really only a few circumstances where I'd even place my kid in a Boston ... and it would *still* kill me to buckle the straps.
    I think any parent who has ever "buckled the straps" was probably nearly brought to tears by that line.

    I know I was.
    mariaf305@yahoo.com
    Mom to David, age 17, braced June 2000 to March 2004
    Vertebral Body Stapling 3/10/04 for 40 degree curve (currently mid 20's)

    https://www.facebook.com/groups/ScoliosisTethering/

    http://pediatricspinefoundation.org/

  14. #14
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    Quote Originally Posted by mariaf View Post
    I think any parent who has ever "buckled the straps" was probably nearly brought to tears by that line.

    I know I was.
    Maria, I was crying when I typed it ... and crying again when I read what you wrote.

    I know everyone in my house was in tears at brace-time.
    Fusion is NOT the end of the world.
    AIDS Walk Houston 2008 5K @ 33 days post op!


    41, dx'd JIS & Boston braced @ 10
    Pre-op 53, Post-op < 20
    Fused 2/5/08, T4-L1 ... Darrell S. Hanson, Houston


    VIEW MY X-RAYS
    EMAIL ME

  15. #15
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    Quote Originally Posted by txmarinemom View Post
    Unfortunately, some doctors *do* still prescribe Milwaukees (or Bostons with superstructures) as THE treatment: The ones that do, aren't familiar with the current protocols.
    Hi...

    I don't think that's correct. I don't know for certain, but I asked maybe 8-10 surgeons at the last SRS meeting, about whether they were still bracing. These weren't surgeons from Podunk, they were pretty much the movers and shakers of the industry. Their answers were pretty much all along the line of "yes, we haven't proved that bracing is effective, but we also haven't proved it isn't."

    I think if you surveyed kids, they'd opt for no brace. But, most parents want to do something. Check out all of the posts on this forum, where you have parents of kids with curves well under 25 degrees, but who don't want to "wait and see." If you were to tell those parents that their only option was to wait until the curves hit 50 degrees, I think their heads would explode. (I know Dingo's would at least ;-)

    If I had a child with a 25-30 degree curve, I'd try to convince her (or him) that the brace might help them avoid surgery. However, if I got a lot of push back, I wouldn't force the issue. While surgery has gotten a lot better, it's still imperfect, and will always come with some pretty significant risks. If my child was one of the small number of kids who has surgery and ends up with a major complication, I would certainly be kicking myself that she didn't at least try bracing.

    I'm not insensitive to those of you who were braced and who had to have surgery anyway. That really sucks. But, I know there are huge numbers of kids who haven't progressed, and who hopefully won't progress when they're much older. It's possible that those kids have curves that wouldn't have progressed anyway. But, it's also possible that their curves would have progressed. Until we know more, I think it's best to err on the side of the more conservative treatment.

    This debate may be meaningless in the not-too-distant future, as we're moving rapidly toward a society where only proven effective treatments are paid for by insurance companies (or the government).

    --Linda

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