Does Bracing Work?

[concerned dad]

CD, I think that the take home message from your graph is that after skeletal maturity and in the long term, all curves progress in a parallel fashion. So maybe bracing helped some of those kids to prevent a surgery down the road.

Not sure I agree on that. They just have 3 points for each curve. It is possible that for the braced cohort, the curves soon (within 2 years say) went to prebrace amplitudes and stayed there.

Also possible that the observation group continued to progress for a short time after the study ended and then stabilized.

But, of course, your take home message may be true too. With just 3 points we dont know

The only other comment I would make regarding the figure is that "on average" none of the patients had curves greater than 45 degrees. So maybe this wasn't the best cohort to review.

On the UK forum someone made a really good case that by including the large curves you are loading the deck against demonstrating bracing efficacy since most 45 degree curves in a growing child would be expected to progress bracing or not.

[PNUTTRO]

Not sure I agree on that. They just have 3 points for each curve. It is possible that for the braced cohort, the curves soon (within 2 years say) went to prebrace amplitudes and stayed there.

Except for the early bracing group, on average, the last time point is higher the the pre-braced time point. So the brace in most cases "worked"--which I believe has been you point all along. The timing is irrelevant.

. . .but still the outcome is still the same. After skeletal maturity, there is little progression, on average, for all groups in the long term.

And unless any of these individuals had pain, surgery would not be indicated. So the question of bracing, seems to me, to be a decision of preference based on the data from this study.

On the UK forum someone made a really good case that by including the large curves you are loading the deck against demonstrating bracing efficacy since most 45 degree curves in a growing child would be expected to progress bracing or not.

I would think that it would be best to include all groups, don't you? Especially if you want to say that bracing "works".


WARNING My opinion:

I think that bracing can be an effective and inexpensive tool to prevent progression of curves. The user must decide if wearing a brace at this time of my life--which makes me self conscious or otherwise uncomfortable--outweights the risk of MAYBE having surgery or a different body image down the road. That's a hard concept for a teenager.

Having a discussion about the research that supports or refutes a brace "working" is futile, because the best indicator for a positive outcome after bracing is the compliance of the patient. . . .but I am sure that someone will disagree with that as well.

p

[christine2]

Having a discussion about the research that supports or refutes a brace "working" is futile, because the best indicator for a positive outcome after bracing is the compliance of the patient. . . .but I am sure that someone will disagree with that as well.

P
I think you are absolutley right! A brace is only going to have a chance to do something if the wearer is compliant. My daughter is too young to understand the stats, however everytime she sees the results of her compliance it motivates her. The Spinecor is working for us and it is so easy for her to wear that it is not even an issue. We do have an advantage that my daughter is so young and it is like 2nd nature for her to be in brace. I can not speak for AIS kids.

[mamandcrm]

I think sometimes that that is both the blessing and the heartbreak of the JIS kid--mine (and others) seems to tolerate it so well because she doesn't think about it, it's part of her life, but it breaks my heart to think about her in it for 7-8 years.

[Pooka1]

Having a discussion about the research that supports or refutes a brace "working" is futile, because the best indicator for a positive outcome after bracing is the compliance of the patient. . . .but I am sure that someone will disagree with that as well.

Compliance is certainly a confounder at this point but why do you think that perfect compliance will produce obvious evidence of efficacy?

[txmarinemom]

Having a discussion about the research that supports or refutes a brace "working" is futile, because the best indicator for a positive outcome after bracing is the compliance of the patient. . . .but I am sure that someone will disagree with that as well.

Okay, I know I said I was done commenting here, but I couldn't pass this one up ...

Regardless of whether or not I personally think bracing "works", I don't necessarily disagree with P's point. IF a brace is destined to be effective in the post-bracing period for a particular patient, efficacy will probably by increased by storing the brace on the patient's BODY (vs. a closet).

Pam ;-)

[PNUTTRO]

Compliance is certainly a confounder at this point but why do you think that perfect compliance will produce obvious evidence of efficacy?

Sharon
I think that logging compliance will give a better idea.

I had prepared in my head a hostile response to this thread, but I had a change of heart.


I get involved in these types of discussions, mostly because when anyone tries to take a absolutist's viewpoint on any topic, I cringe. I try to point out that we cannot put everyone in the same box. Not everything is black and white, right or wrong.

The things we do to help ourselves are the best we can do at the time. Maybe I could have worn a brace for years, maybe I could have avoided surgery, but the fact is that based on the recommendation of 3 doctors that my mother trusted I had surgery at 16. She hated it! I never realized the guilt she felt from it until I was much older. The doctors told her I was cured, but a short time later, she realized that I had pain. She had tremendous guilt and regret I don't blame her for what happened or the decisions she made on my behalf.

And yes we have come a long way since 1986, but really are there any guarantees when it comes to individuals.

People are people. I like that everyone is different. I like that we have different preferences. I like that I can decide what is best for me or my kid. I like the idea of a brace over surgery. But as I tried to point out earlier, bracing is an individual decision and one that I will not say is right or wrong.

p

[Pooka1]

I haven't seen anyone disagree with most of what you wrote.

W.R.T. absolutist positions, I don't think it's too early to say that the bracing literature is absolutely a miasma. Now there are very good reasons why it is a miasma in my opinion but it is still arguably a miasma.

Essentially, there are no positions, absolutist or otherwise, to extract from it. It is not dispositive of anything.

Others may disagree.

[debbei]

Compliance is certainly a confounder at this point but why do you think that perfect compliance will produce obvious evidence of efficacy?

I always wore my brace to the letter of the law. I was always one of those kids who did exactly as she was told; actually, I was afraid not to wear it when I was supposed to for fear I would get worse.

Anyway, a lot of good it did me......

[concerned dad]

when anyone tries to take a absolutist's viewpoint on any topic, I cringe

Me too.

but I dont think there we've seen absolutist's viewpoints expressed. There are always qualifiers implicitly or explicitly applied.

And when it comes to bracing efficacy, it's important for us to remember we are talking in a statistical sense about our (amateur) interpretation of the results. Individual results do vary.
There are a lot of confounders. Probably more than we have even thought of.
But, I think the key will involve carefully applied statistics along with good science (although I do think part of the good science does NOT necessarily HAVE TO involve a random trial. It would sure help, but there are still things we can learn w/o one).

[concerned dad]

Regardless of whether or not I personally think bracing "works", I don't necessarily disagree with P's point. IF a brace is destined to be effective in the post-bracing period for a particular patient, efficacy will probably by increased by storing the brace on the patient's BODY (vs. a closet).

Pam ;-)

Well said.

[Pooka1]

You know what I'd like to see?

I'd like to see ALL the individual trajectories plotted on three separate graphs, one for each of the the three groups and with error bars on each point, rather than just the averaged points for each of the three measurement times. It would be busy but might be informative as to the actual scatter and non normality in the data.

Then I'd like to see each of the three graphs broken out into curve type, again with all the individual trajectories plotted with error bars. So nine graphs.

[txmarinemom]

... Then I'd like to see each of the three graphs broken out into curve type, again with all the individual trajectories plotted with error bars. So nine graphs.

Curve type?

[Pooka1]

Curve type?

Thoracic
Lumbar
Both (S)

[txmarinemom]

I personally think 3 types of curves are an oversimplification. It sounds like your term "both" indicates double major/double structural curves: There's also thoracolumbar, but even the addition of that category isn't enough.

Thoracic curves alone can differ (at the very least) based on curve convexity, apex location, kyphosis, and axial rotation of the apical vertebra. How would you propose to assemble a "standard" study group?

Regards,
Pam