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    Angry Can a scoliosis brace make the rib hump worse?!

    Attached is a 3-D CAT scan of a patient out of and in (left to right) a scoliosis brace (I believe it was the Boston brace). It definitely forced the scoliosis spine straight, but it dramatically increases the rib cage deformity (rib hump). Not only will this increase the permanent body disfigurement, but it will most likely lead to more progression once the scoliosis brace is taken off!

    Forced correction cannot and will not work. Space needs to be created in the side and vertical dimensions, BEFORE the "extra" spine can be transferred out of the frontal dimension. Conservation of matter.....simply as that.

    I wonder if scoliosis brace treatment is still prescribed in the orthopedic world, because of a "cultural apathy" towards scoliosis treatment....most specialists already know bracing is worthless, but it may have become a matter of "that's the way we do things around here" syndrome......that is the only explanation I can think of, because the research certainly isn't giving a credence to the continued practice of scoliosis brace treatment.

    We need a better way......Early stage scoliosis intervention may be the key to a better way.

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    Could the image above be explained by a poorly constructed brace? Why does a single case always seem to determine the opinion of a treatment method? Bracing works all over the world, even for the orthotists I know here in the US. However, it doesn't work for everyone. Neither does SEAS, Schroth, Dobosceicwicz, Scoliosis3D, SpineCor, CLEAR, ESSI, or FITS concepts. But they all work for some.

    I believe that a better discussion to have is one where we're trying to figure the patient populations that are best served by each respective system.


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    Hi Dr. Morningstar,

    I knew you would be the one to challenge this post when I saw you were on the forum yesterday (Mark and I go WAY back in our friendship). Actually, a rather conclusive study by Drs. Dorlan and Weinstein found that forced correction/ rigid bracing does not make a clinically significant impact on the natural history of scoliosis. There article reviewed 15 brace studies vs 3 observation studies......their conclusion was that bracing doesn't work all over the world.

    "A 2007 study published in SPINE by Drs. Dolan and Weinstein concluded that observation only or bracing showed no clear advantage of either approach. Furthermore one can not recommend one approach over another to prevent surgery. They gave the recommendation for bracing a grade "D" relative to observation only because of "troublingly inconsistent or inconclusive studies on any level."

    Besides, orthotists only use cobb's angle to measure the effectiveness of a brace......they don't even consider it's effects on the rib cage rotation, or worse yet even know. Yes this one example, but we don't know that it doesn't represent most rigid braces. At the very least it warrents a complete re-evaluation of the effects of rigid braces on the spine in all dimensions.

    I am in agreement that no one has all the answers when it comes to the treatment of scoliosis, but we know enough to know that forced correction through bracing is flat out ineffective and possibly doing more harm than good. First do no harm, right? Who do I contact about issuing a recall of all rigid braces until we get this sorted out?

    EVERY PARENT AND PATIENT SHOULD INSIST ON A 3-D LOW DOSE IN BRACE CT SCAN BEFORE EVEN CONSIDERING BRACE TREATMENT.....and even then consider the research and theory supporting brace treatment is mixed at best.


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    Quote Originally Posted by DrStitzel View Post
    Hi Dr. Morningstar,

    I knew you would be the one to challenge.....
    Not challenge, discuss.


    Quote Originally Posted by DrStitzel View Post
    "A 2007 study published in SPINE by Drs. Dolan and Weinstein concluded that observation only or bracing showed no clear advantage of either approach. Furthermore one can not recommend one approach over another to prevent surgery. They gave the recommendation for bracing a grade "D" relative to observation only because of "troublingly inconsistent or inconclusive studies on any level."
    Could you provide those references here so I may look them up myself? Thank you!


    Quote Originally Posted by DrStitzel View Post
    Besides, orthotists only use cobb's angle to measure the effectiveness of a brace......they don't even consider it's effects on the rib cage rotation, or worse yet even know. Yes this one example, but we don't know that it doesn't represent most rigid braces. At the very least it warrents a complete re-evaluation of the effects of rigid braces on the spine in all dimensions.
    Untrue. Orthotists are often more concerned about compensation (global balance) before Cobb angle. However, I still don't let an orthotist dictate my treatment plan if I'm using a brace in concert with another exercise-based therapy.


    Quote Originally Posted by DrStitzel View Post
    EVERY PARENT AND PATIENT SHOULD INSIST ON A 3-D LOW DOSE IN BRACE CT SCAN BEFORE EVEN CONSIDERING BRACE TREATMENT.....and even then consider the research and theory supporting brace treatment is mixed at best.
    Not a bad idea, just expensive. There are ways of looking at an in-brace film for rib rotation, unit compensation, or vital capacity.

    I'll wait until I've viewed those references. I may already have, but I don't want to quote from the wrong studies. I will say this though. A review that only evaluates 18 studies is hardly a thorough review. I bet you can go to scoliosisjournal.com and find 18 bracing studies in there from 2009 alone, and that's from one journal.


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    Ask and ye shall recieve (I remember reading that somewhere), here is the reference to the bracing article.

    Surgical rates after observation and bracing for adolescent idiopathic scoliosis
    Dorlan and Weinstein. SPINE 2007, vol 32. 19s, pp S91-S100

    How many studies do you need to establish a statistical correlation? The editors of SPINE seem to think 18 was enough.

    I'm a little suspicious of being able to accurately evaluate in-brace rib rotation on x-ray.....I see enough docs who can't even measure the cobb angle accurately.


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    Default Seriously?!

    Quote Originally Posted by DrStitzel View Post
    Ask and ye shall recieve (I remember reading that somewhere), here is the reference to the bracing article.

    Surgical rates after observation and bracing for adolescent idiopathic scoliosis
    Dorlan and Weinstein. SPINE 2007, vol 32. 19s, pp S91-S100

    How many studies do you need to establish a statistical correlation? The editors of SPINE seem to think 18 was enough.
    Seriously? 17 of the 18 studies referenced were based upon either the Milwaukee brace or the Wilmington brace. Did you even read this study? Outside of the US, where of course bracing treatment is designed to fail so they can cut on the patients instead, the only places where you can find these two braces are in museums of natural history.

    As far as the editors go, most of them are surgeons. They rarely accept manuscripts at SPINE that show positive results for exercise-based therapies. So yes, this is a tremendously poor study and obviously has an agenda behind it.


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    Are you sure you got the right study? The article reviewed 18 studies total. Only 15 of them were bracing (7 of which used the Boston brace....See table 5 on page S96) and the other 3 studies were observation only.

    Key points of the study: The pooled surgical rate was 23% after bracing and 22% after observation....AKA: Bracing has no effect on the prevention of surgery vs doing nothing at all.....AND my original post on this thread demonstrated evidence that it may even cause an increase in the rib cage rotation which increases the cosmetic deformity.

    Sorry if I have to be dismissive of the "my brace is better then your brace" argument. Forced correction is forced correction.....regardless of the brace employed.


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    Default Oh Yeah........

    Scoliosis 2009, 4:19

    Scoliosis 2009, 4:17

    Scoliosis 2009, 4:8

    Scoliosis 2009, 4:2

    Scoliosis 2008, 3:15

    Scoliosis 2007, 2:2

    Scoliosis 2006, 1:12

    Scoliosis 2006, 1:11

    I'll let the readers of this forum decide for themselves. In the last citation here, of all the SOSORT participants in the entire world, the most used brace by far is the Cheneau and Cheneau variants. So no, the 2007 Weinstein/Dolan study does not apply to 'all over the world.' And this is only one journal!

    And to say the forced correction doesn't work, the citations above don't support that statement.

    Also, if you compare Cobb angle to Cobb angle in Table 4 of your study, it shows that the observation rate for surgery is double that of bracing. Also, as you and I have had conversations previously about this, because there is absolutely no consensus on when surgery is supposed to be performed, this study can't have any meaning. The authors admit in the Discussion section that half of the studies do not even disclose what they used as a surgical guideline, which makes me suspicious.

    If you would, please also explain how a scoliosis traction chair is not forced correction, and why it is not remotely possible that all it may be doing in at least some juvenile/adolescent cases is deforming the rib cage. Please compare/contrast this device from bracing for the readers, since active exercises can also be performed in properly made braces.

    BTW, your wife emailed the one-years of your daughter, they're outstanding.


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    The Dorlan and Weinstein study only included North American braces (probably because they only included studies written in English). The Cheneau brace may be the most used brace by SOSORT participants, but that makes up a very small portion of the world's scoliosis specialists. I don't know what the most commonly used brace in the world is, but I'm willing to bet it is the Boston brace.

    We can both produce a mountain of data on this topic that supports either side of the debate, but in the end the conclusion is controversial and inconclusive at best.

    The STC (Scoliosis traction chair) is significantly different than bracing. First of all, it is a mere part of a larger program, not the treatment in it's entirety. Second, I have yet to see a North American designed brace that allows for active rehabilitation of the spine....I can't comment on the Cheneau. And finally, it actually creates space in the horizontal and vertical dimensions in the whole spine (cervical spine included) as it transfers spine out of the side dimension (cobb angle).

    I will concede the point of a non-consensus on the surgical level is a continual problem when comparing the treatment effectiveness of bracing in AIS.


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    Quote Originally Posted by DrStitzel View Post

    The STC (Scoliosis traction chair) is significantly different than bracing. First of all, it is a mere part of a larger program, not the treatment in it's entirety. Second, I have yet to see a North American designed brace that allows for active rehabilitation of the spine....I can't comment on the Cheneau. And finally, it actually creates space in the horizontal and vertical dimensions in the whole spine (cervical spine included) as it transfers spine out of the side dimension (cobb angle).
    And your data that shows this is?


    Also, active movement can and does occur in Boston bracing. I have 4 patients in them right now, I can YouTube a video to you showing their exercises if you like.



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