To Brace or Not to Brace?
There are several types of commonly used scoliosis braces:
1. Thoraco-Lumbo-Sacral-Orthosis (TLSO) The most common form of a TLSO brace is called the "Boston brace", and it may be referred to as an "underarm" brace. This brace is fitted to the child's body and custom molded from plastic. It works by applying three-point pressure to the curvature to prevent its progression. It can be worn under clothing and is typically not noticeable. The TLSO brace is usually worn 23 hours a day. This type of brace is usually prescribed for curves in the lumbar or thoraco-lumbar part of the spine.
2. Cervico-Thoraco-Lumbo-Sacral-Orthosis (known as a Milwaukee brace) The Milwaukee brace is similar to the TLSO described above, but also includes a neck ring held in place by vertical bars attached to the body of the brace. It is also usually worn 23 hours a day. This type of brace is often prescribed for curves in the thoracic spine.
3. Charleston Bending Brace This type of brace is also called a "nighttime" brace because it is only worn while sleeping. A Charleston back brace is molded to the patient while they are bent to the side, and thus applies more pressure and bends the child against the curve. This pressure improves the corrective action of the brace. This type of brace is worn only at night while the child is asleep. Curves must be in the 20 to 40 degree range and the apex of the curve needs to be below the level of the shoulder blade for the Charleston brace to be effective.
Effectivity of Scoliosis Brace
As early as 1993, a report by the US Preventive Services Task Force noted that, "Beyond temporary correction of curves, there is inadequate evidence that braces limit the natural progression of the disease."13 Then again, a 1984 study on scoliosis braces noted a "slight but insignificant" improvement in those who had been braced, "suggesting that bracing reduced the overall probability of progression in the braced curves." The study authors went on to report, "However, noting that nearly 75% of the control group curves were non-progressive, it is possible that a similar proportion of the braced curves need not have been braced."14 Years later, in 1995, a third study done by the Scoliosis Research Society found bracing to be effective.15 However it is important to note that the study was sponsored by the Scoliosis Research Society, an industry body of orthopedists who could have had a definite monetary interest in continuing to prescribe bracing as a major treatment option for scoliosis. I personally think it is always prudent to view studies such as these, where the people funding the research stand to profit monetarily from the study findings, with a healthy dose of skepticism. A 2007 study published in Spine by Drs. Dolan and Weinstein concluded that "observation only or scoliosis brace treatment showed no clear advantage of either approach. Furthermore one can not recommend one approach over another to prevent scoliosis surgery. They gave the recommendation for bracing a grade "D" relative to observation only because of "troublingly inconsistent or inconclusive studies on any level."
The rational way of gauging the effectivity of brace strategy will incorporate comparing results obtained in patients using brace against the expected genetic outcome of non0treated patients. Ogilvie et al. at Axial Bio-Tech performed a similar study and reported in 2009 in the journal Scoliosis that spinal brace has absolutely no positive effect on scoliosis. Research thus far has failed to prove definitively that bracing works, the investigators conclude. As reported by Dr. Stefano Negrini of the Italian Scientific Spine Institute of Milan, Italy, and colleagues report in The Cochrane Library (2010), the evidence for bracing is weak, as is the evidence of any long-term benefits of bracing. The available literature cumulatively constitutes "low quality evidence" in favor of using braces. Questions and uncertainties about the effectiveness and need for use of brace for scoliosis will be more definitively answered once the five-year, multimillion-dollar study funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases results are analyzed impartially. The Spine Journalof September 2001 reported in an article titled 'Effectiveness of Bracing Male Patients with Idiopathic Scoliosis' that "Progression of 6 degrees occurred in 74% of boys and 46% reached surgical thresholds.
Bracing of male patients with Idiopathic Scoliosis is ineffective." In another article the 'Children's Research Center in Dublin, Ireland' states "Since 1991 bracing has not been recommended for children with AIS (Adolescent Idiopathic Scoliosis) at this center. It cannot be said to provide meaningful advantage to the patient or the community."16 On the other hand, Musculoskeletal Disorders reported a study on September 14th, 2004 titled, "Scoliosis treatment using a combination of manipulative and rehabilitative therapy," by Mark Morningstar, D.C., Dennis Woggon, D.C., and Gary Lawrence, D.C. 22 scoliosis patients with Cobb angles between 15 to 52 degrees were subjected to a rehabilitation protocol involving specific spinal adjustments, exercise therapy, and vibratory stimulation. Of the 19 patients completing the study, the average reduction in Cobb angle after 6 weeks was 62% (ranging between 8 to 33 degrees reduction and not even a single case of increase). This warrants further expansion and testing of such innovative and non-invasive procedure that target the causes of scoliosis and not the manifested symptoms alone. Despite all these studies, the standard non-surgical treatment for moderate curves (24 to 40 degrees) is still a body brace. Its non-cosmetic appearance is a major deterrent and the main reason for non-compliance, especially among girls.
Conventional brace therapy carries several significant drawbacks. Because the brace stabilizes the spine by exerting pressure on the chest at critical points, it must envelop the trunk, and in so doing, can be bulky and uncomfortable. A brace also restricts body movement, which can over time cause atrophy and weakness of the chest and spinal musculature. As a result, the child's spine begins to lose some of its earlier flexibility and is prone to injury whenever the brace is taken off. When the muscles around the spine weaken, this can further complicate the scoliosis. Worse, in some cases the constant pressure of the brace can cause permanent deformation of the rib cage or the soft tissues directly under the pressure points. In a recent study on the psychological impact of bracing on a growing child, it was revealed that "60% felt that bracing had handicapped their life and 14% considered that it had left a psychological scar."18 Surely, you don't want any of those effects for your child?
Could Surgery Be An Option?
Obviously, if bracing was truly as effective as it is made out to be, then the need for spinal surgery would be reduced quite significantly. Unfortunately this is not the case. Of the 30,000 to 70,000 spinal surgery procedures done each year, about a third is performed for severe scoliosis.19 There are different forms of scoliosis surgery as underlined below.
1. Harrington Procedure:This procedure was the most standard technique involved in scoliosis surgery until 10 years ago. The process involves use of a steel rod that extends from the bottom to the top of the curve, which in turn is supposed to support the fusion of the vertebrae. Pegs are inserted in the bones and serve as the anchors for the suspended rod(s). Of note, a full body cast and complete bed rest for 3-6 months is a pre-requisite post-surgery. Inexplicably, even though the rod is not required after 1-2 years, surgeons never think of taking out the rods until infection or other complications strike. The standout disadvantages of the Harrington procedure are: 1. Extremely tough, especially for adolescents. 2. 10-25% loss of curve correction over time (which is 50% at best); additionally, the procedure is ineffective in correcting the spine rotation and hence does not alleviate the resultant rib hump. 3. Flat back syndrome in upto 40% of patients undergoing the procedure as it removes the normal inward curving of the lower back (lordosis). Prolonged duration of flat back syndrome might incapacitate a person by inhibiting a person to stand erect. 4. Chances of crankshaft phenomenon in kids younger than 11 years having the surgery. The underlying reason is continuing ossification process of the skeleton during the age of the surgery, and the front of the fused spine outgrows after the surgery. The spine curves as it cannot grow straight due to the traction.
2. Cotrel-Dubousset Procedure:Slightly better than Harrington procedure in that it remedial in principle for both the curve and the rotation of the spine, and flat back syndrome is not a complication. The procedure involves cross-linking parallel rods to render more stability to the fused vertebrae. The recovery time is around 3 weeks. The major disadvantages are the complexity of the surgery itself and the number of hooks and cross-links involved (Humke et al., 1995).
3. The Texas Scottish-Rite Hospital (TSRH) Instrumentation:This is very similar in design to the Cotrel-Dubousset procedure, the only difference being use of smoother textured hooks and rods, which are supposed to make subsequent removal or readjustment in case of post-operative complications. Disadvantages also mimic the Cotrel-Dubousset protocol. Other instrumentation that has been used is the Luque instrumentation, which can maintain normal lordosis and was initially thought to circumvent the need of post-surgery brace use. But the flip side was curve correction achieved through surgery was completely reversed in the absence of brace usage and also resulted in incremental incidences of spinal cord injuries. Among others, Wisconsin Segmental Sine Instrumentation (WSSI) is often used but seems to inherit the problems associated with the Luque as well as the Harrington rod procedures and is thus very problematic. Surgeons have classically used the Posterior Approach (access the surgical area through incision at the back of the patient), whereas Anterior Approach(access the surgical area by opening the chest wall) finds lot of supporters among surgeons these days. The major complications arising out of the posterior approach are increased risk of occurrence of the crankshaft phenomenon, where the curve increases with time; and, not amicable to the thoracolumbar region. For the anterior approach, kyphosis (increasing outer curve), increased susceptibility to lung and chest infection, and pseudoarthrosis (pseudo joint at the fusion locale) are the major associated complications. All this and more can be avoided simply by working on the health of the person through making some dietary changes and following an exercise routine, as described in this book. I've worked with hundreds of scoliosis patients and have come to the conclusion that often the cure does not lie in a one-stop surgery or uncomfortable bracing. Often, all that is needed is for the patient to be willing to take a proactive role in the improvement of their own health.
Complications rate were estimated at 15% in children and 25% in adults for all fusion procedures in a study conducted between 1993 and 2002. The major complications were as follows:
Blood loss: Like for any surgical procedure there is significant blood loss which necessitates blood transfusion and so patients are encouraged to donate blood in the pre-operative period, causing further stress on the already suffering patient. Newer endoscopic techniques and use of recombinant human erythropoietin (rhEPO) to boost increased hematopoiesis are being examined to counter the blood loss.
Prone to infection: As with any other surgical procedure, chances of infection are pertinent in scoliosis surgery. Infection in the urinary tract and pancreas are most common and an antibiotic-coverage post-surgery is usually recommended.
Neuronal complications:Neuronal damage occurs in ~1% of patients undergoing surgery, with adults at a considerable higher risk than younger patients. Muscle weakness and/or paralysis are the usual outcome of nerve damage.
Pseudoarthrosis: Happens if the fusion does not heal and a pseudo joint develops at the site of surgery. It is a very painful condition. The anterior approach has higher chances of causing this complication, occurring upto in 20% of all surgery cases.
Low back pain and disk degeneration: The stress on the lower back as a result of the fusions in the lumbar region can ultimately result in disk degeneration. Additionally, compromised muscle strength, lower limb mobility, and balance can also cause excruciating back pain.
Pulmonary function: Younger adults and kids have high risk of developing pulmonary problems post-surgery upto about 2 months after the surgery. The risk is considerably higher in patients where scoliosis is a secondary outcome of neuromuscular problems. Other than the above, gallstones, pancreatitis, intestinal obstruction and hardware injury (resulting from dislodged hooks, breakage of hooks and rusting, or a fracture in a fused vertebrae) are also associated with scoliosis surgery. To alleviate some of the major concerns, few different forms (growing rod technique, vertebral body stapling and anterior spinal tethering) of minimally invasive surgery has been devised. Even though these techniques have shown short-term encouraging results, long term observance of effects and improvements are required for them to be considered seriously.
The Untold Truth about Scoliosis Surgery
The approximate average cost of scoliosis surgery in the U.S. is $120,000 per operation and there are roughly 20,000 such operation each year20. Shockingly, 8000 patients who had underwent scoliosis surgery become disabled each year, and in those who do not become disabled total recourse to the pre-operative condition happens within 22 years of surgery.22 Additionally, there are follow-up surgeries to take care of loosened hooks, broken rods, rust formation!24 Worse, 25% of patients having surgery have compromised motor control post-surgery.23 In some quarters it is suggested that the pitfalls of remedial surgery is actually worse than scoliosis itself. Are these not reasons enough to avoid surgery as the treatment regimen, until of course it is the last resort and pertinent? Do we not have a social responsibility to utilize and incorporate ways in our lifestyle that can significantly cut down on the critical and serious disadvantages of surgery? Precisely, my technique will lead you to just taking that first step towards your rehabilitation without even needing to resort to any of the dangers associated with scoliosis surgery. Alongside, it will improve your overall quality of life as understanding your disease and its cause is the beginning of the end of scoliosis in you.
Some true-life examples and case studies discussed here will reinforce my aforementioned assertions.
[I] Stuart Weinstein, MD, University of Iowa reported in 2003 in the Journal of the American Medical Association(JAMA) "Many with curvature of spine go on to lead normal lives. Many adolescents diagnosed with spine curvatures can skip braces, surgery or other treatment without developing debilitating physical impairments, a 50 year study suggests." Do we really need to incorporate bracing or surgery in young patients?
[II] Dr. J. Steinbeck reported in 2002 that "Forty percent of operated treated patients with idiopathic scoliosis were legally defined as severely handicapped persons 16.7 years after the surgery." Does surgery really improve quality of life over time?
[III] Dr. Sponseller reported back in 1987 that "Frequency of pain was not reduced...pulmonary function did not change... 40% had minor complications, 20% had major complications, and... there was 1 death [out of 45 patients]. In view of the high rate of complications, the limited gains to be derived from spinal fusion should be assessed and clearly explained to the patient." Why have we still persisted as surgery the method of choice?
[IV] Dr. H Moriya reported in 2005 that "Corrosion was seen on many of the rod junctions (66.2%) after long-term implantation." Why are effective and less dangerous alternatives not being embraced?
[V] Reuters Health (New York) reported on Jan 29, 2008: "Screening for scoliosis and subsequent brace treatment appears to be of no utility in avoiding surgery, Dutch researchers report in the January issue of Pediatrics for Parents. "We think that abolishing screening for scoliosis seems justified," lead investigator Eveline M. Bunge told Reuters Health. This is "because of the lack of evidence that screening and/or early treatment by bracing is beneficial."
[VI] Dr. M. Hawes reported in The Journal of Pediatric Rehabilitation that "Pediatric scoliosis is associated with signs and symptoms including reduced pulmonary function, increased pain and impaired quality of life, all of which worsen during adulthood, even when the curvature remains stable. In 1941, the American Orthopedic Association reported that for 70% of patients treated surgically, the outcome was fair or poor.... Successful surgery still does not eliminate spinal curvature and it introduces irreversible complications whose long-term impact is poorly understood. For most patients there is little or no improvement in pulmonary function.... The rib deformity is eliminated only by rib resection which can dramatically reduce respiratory function even in healthy adolescents. Outcome for pulmonary function and deformity is worse in patients treated surgically before the age of 10 years, despite earlier intervention. Research to develop effective non-surgical methods to prevent progression of mild, reversible spinal curvatures into complex, irreversible spinal deformities is long overdue."
Do we really need surgery? Why Follow my Regimen?
Hereditary pre-disposition: James W. Ogilvie's group discovered genetic markers, two major genetic loci and 12 minor loci that are related to the development of scoliosis. 95% of patients having a curve greater than 40 degrees had a correlation to the identified genetic markers. Hence, it is now possible to predict the hereditary predisposition to scoliosis and based on the same, individualized management regimen can be laid out using my comprehensive care therapeutic strategy, which has the added advantage of being completely non-invasive. The main reason for all these procedures not working is that they try to cure the condition and not the cause. While we are powerless to change our genes we can still change the way it interacts with the environment and thus suppress these genetic faults and how they are ultimately expressed through disease. This is where my proposed regimen of balancing metabolic, neurological and biochemical homeostatic factors using of customized nutrition, exercises and lifestyle regime will be most effective-weed out the cause of scoliosis.
About Dr Kevin LauDr Kevin Lau DC is the founder of Health In Your Hands, a series of tools for Scoliosis prevention and treatment. The set includes his book Your Plan for Natural Scoliosis Prevention and Treatment, a companion Scoliosis Exercises for Prevention and Correction DVD and the innovative new iPhone application ScolioTrack. Dr Kevin Lau D.C. is a graduate in Doctor of Chiropractic from RMIT University in Melbourne Australia and Masters in Holistic Nutrition from Clayton College of Natural Health in USA. In 2006 I was awarded the "Best Health-care Provider Awards" by the largest Newspaper publication in Singapore on October 18 2006 as well as being interviewed on Primetime Channel News Asia as well as other TV and Radio. For more information on Dr Kevin Lau, watch his interviews or get a free sneak peek of his book, go to: http://www.hiyh.info.
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