For more than seventeen years, bracing has been one of the most
important issues of the National Scoliosis Foundation. Thus, we
were elated with the results of recent findings of Dr. Alf L. Nachemson,
an orthopedic surgeon and scoliosis specialist, who practices at
Sahlgren Hospital, Gothenberg Sweden.
At the 1993 Annual Meeting of the Scoliosis Research Society, held
in Dublin, Ireland, Dr. Nachemson presented his summary report on
the "Effectiveness of Brace Treatment in Modern Adolescent Idiopathic
Scoliosis." What follows are excerpts taken from that summary, and
from Dr. Nachemson's remarks at the 1993 New England Spine Conference.
Upon publication of the full study, a more comprehensive report
will be provided in a future issue of the Spinal Connection.
Q: Why was this study undertaken?
A: This study was sponsored by the Scoliosis Research Society. Lack
of scientific evidence has lead many scoliosis specialists to disbelieve
the effect of bracing and has resulted in recommendations against
school screening in the U.S., Great Britain, Canada, and Sweden.
Q: Who was included in the study?
A: We studied girls 10 to 15 years old with idiopathic adolescent
thoracic and thoracolumbar scoliosis between 25 and 35 degrees.
Between April, 1985 and March, 1989, 294 patients were enrolled
in a prospective controlled study at a number of centers. Five centers
preferred observation, and contributed 131 patients; 3 centers preferred
brace treatment and contributed 115 patients; and 1 center preferred
electrical stimulation and contributed 49 patients. By the end of
1993 all of the girls will have reached 16 years of age.
Q: How were results measured?
A: A progression greater than 6 degrees on two different x-rays
was considered a failure. Patients lost to follow-up occurred in
6% of the observed cases, 20 % of the braced and 11% of the electrically
stimulated patients, for a total of 15%. Even in a worst case analysis
whereby all patients lost to follow up were considered failures
there was firm conclusion of the results.
Q: What about the electrically stimulated and observed patients?
A: After five years, 70% of those using electrical stimulation or
being observed had progressed 6 degrees or more. We found there
is no difference whatsoever between electrical stimulation and observation.
Electrical stimulation is now discarded as a method of treatment.
Q: What was the conclusion of the study with respect to bracing?
A: There was a very significant difference in braced patients. Bracing
failed in only about 20% of the girls; it stopped progression in
80%. This prospective study demonstrates that brace treatment has
a significant effect on the progression of adolescent idiopathic
scoliosis 16 years of age.
In response to Dr. Nachemson's report, Dr. John Lonstein, from
the Minnesota Spine Center, made the following comments at the SRS
"These are the long-awaited results of the SRS sponsored multicenter
prospective controlled study of the comparison of non-operative
treatment -i.e. bracing or electrical stimulation, versus natural
history -i.e. observation."
"The take home message is easy: Firstly, electrical stimulation
is no different from observation -it does not work. This in effect
gave a larger natural history group which included the observation
and electrical stimulation patients."
"Secondly, there is a statistical positive effect of bracing
in preventing curve progression, comparing the braced to the natural
history patients. In short, BRACING WORKS, even taking the "worst
case" analysis, calling every patient lost to follow up a failure."
"On the basis of these results and the retrospective studies
of Basset and the Minnesota Spine Center, it is incumbent on the
Canadians, British and U.S. Preventive Services Task Force to re-evaluate
their negative positions on scoliosis screening for adolescents
as there is now irrefutable proof that bracing is effective in preventing
curve progression in adolescent idiopathic scoliosis."
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