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.
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?
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?
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