Can conservative treatment permanently reduce or eliminate AIS curves?

[Dustin76]

I just had to jump in here. Kids who hit maturity with curves in the 30s don't progress at "maybe 2 degrees per year" as adults. Kids below 35 degrees or so usually don't progress, or if they do, it's well under half a degree per year. Kids over 45 degrees do progress, normally in the 0.5-1.0 degree range. Most will probably need surgery at some point, but that point could be twenty years down the road. Kids between 35 and 45 are a huge gray area. It's probably safe to say that most (not all) will progress as adults, but it's a math problem at that point. If they're say 38 degrees at maturity and are progressing a third of a degree per year, that puts them hitting 50 degrees when they're in their early 50s, and a lot of docs wouldn't recommend surgery at that point unless the curves are very symptomatic. (On the other hand, if they're progressing at 2/3 of a degree per year, that puts them hitting 50 in their early 30s, and most docs probably would recommend surgery then. Though I've been talking to people lately, and apparently the thinking with some docs now is that well-balanced S-curves just shouldn't be operated on after maturity unless they are causing symptoms, even if they are above 50 or even 60 degrees, because they tend to be pretty stable and any adult progression is slow and intermittent.)

THE NATURAL HISTORY OF SCOLIOSIS
IN THE SKELETALLY MATURE PATIENT
by
Stuart L. Weinstein, M.D.
Professor of Orthopaedic Surgery
University of Iowa
Iowa City, Iowa


This is the study with the most extensive look at curve progression after skeletal maturity that I have found. Weinstein looked at progression over a 40-year period and broke it down by curve types. Looks like less-than-30 degree curves generally did not progress except for thoracolumbar curves. Looks like no one in the study progressed much more than half a degree per year over 40 years, but the average progression was around 1 degree per year for the first 20-30 years in some categories. So, yeah, my saying up to 2 degrees/year seems to be pushing it according to this study. This study still seems to indicate somewhat of a rough "cut-off" around 30 degrees - less than 30 and no progression, over 30 and some level of progression somewhere between 1/4 degree and 1 degree on average. Of course there is a range of variable outcomes to get a average or mean, so there probably are some that did not progress at all and a few that progressed by multiple degrees per year.

[Dustin76]

The .pdf is in my post. Here it is again...

http://scanscoliosis.com/wp-content/...s/in_brace.pdf

It's in the trainwreck.

Sorry, got it now.

[Dustin76]

And then consider the BrAIST study where they COUNTED a 49* curve with up to 25% growth remaining a "success". And they were allowed to omit mention of the ending range of curves. While these results are not false, they certainly are potentially irrelevant to patients and their parents whose sole role and goal is to avoid surgery with bracing.

I asked one of the authors what percent of the "successes" were north of 40* and she IGNORED MY QUESTION. Let that sink in. As a scientist myself, I was ashamed and embarrassed for her. Still am.

ps. Katz et al. (2006) found no correlation between in-brace correction percentage and success. P. 1349. They used in-brace correction as a proxy for curve flexibility which makes one wonder about these hyper-corrections in braces and if that is exquisitely painful in kids with stiff spines.

http://scanscoliosis.com/wp-content/...s/in_brace.pdf

The Katz 2006 study kind of mentions in-brace correction in passing. They were mainly looking at hours in brace and Risser score. They say they recorded in-brace correction but did not report it in the study. Being that they were using Boston braces, they probably didn't get great in brace correction on any of them - maybe that's why they didn't report it. They mention that their unreported findings were in contrast to what other researchers, who did report their in-brace measures data, found. I guess I wouldn't put a lot of weight on this study as far as in-brace correction goes. They are consistent with other studies in finding that more time in brace = better results, so I would put more weight on that. They make it seem like they didn't aim for progressively improving curve flexibility. The good bracing practitioners will get halfway decent curve correction at initial bracing and then improve in-brace correction percentage as the curve becomes more flexible, in my opinion - maybe getting at least 60-70% correction on a stiff curve and getting close to 100% correction within 6 months to a year as the curve relaxes.

As a side note, the lack of compliance in these studies surprises me when there is a chance of avoiding surgery. Are the Boston braces that uncomfortable? I don't know. Our kids sleep through the night without getting up and hardly ever complain about their braces. The parents that we have got to know make me want to say that most of the kids we have come across are 80-100% compliant. I just don't get trying it half way. Either follow the prescribed hours or don't do it at all is kind of my thinking. But anyway....

[Pooka1]

Hours in brace, percent correction in brace, Risser, etc. etc.

Everything is confounding everything. Despite doing their best, it's still a train wreck.

The sole role and goal of these conservative treatments is avoidance of surgery for life. I asked a BrAIST coauthor how many "successes" were north of 35 with growth remaining or north of 40 with no growth remaining. I asked how many of the relatively few cases in the dose-response curve fell in those categories. While my other questions were answered, these questioned were conspicuously ignored.

It is highly likely that at least some of those "successes" went on to surgery. I am not saying they can't set thresholds for their study. Certainly they must or it wouldn't be publishable. But for these bracing studies to actually matter to patients, the results must include how many patients are north of 40* or north of 35* with growth remaining so patients can adjust their expectations and make a more informed decision about bracing.

While most parents would probably brace with as low as a 0.001% chance of success, I suspect many kids would have a more reasoned risk-benefit approach.

[Pooka1]

Check this out... make sure you are sitting down when you read it...

http://www.scoliosis.org/forum/showt...ey-for-Parents