Shriners Search for Best Treatment

Three to five of every 1,000 children develop spinal curves serious enough to warrant medical attention. And yet, in general terms, the cause of these curves – known as “scoliosis” – remains unknown, and the effectiveness of the most common treatment is in question.

Researchers at Shriners Hospitals for Children are working hard to discover answers to these questions, and to improve the quality of care and quality of life for children with scoliosis, a curvature of the spine greater than 10 degrees, which makes the spine look more like an “S” or a “C” than a straight line when viewed on an X-ray. Once scoliosis has been diagnosed, the primary concern is whether the curve will progress, and treatment is aimed at stopping that progression.

While scoliosis can occur at any age, the most common type, adolescent idiopathic scoliosis (AIS), affects 2 to 4 percent of children between the ages of 10 and 16, particularly girls. Treatment options include observation for small curves, bracing in hopes of preventing curve progression in patients felt to be at risk, and surgery to fuse the spine in larger and progressive curves.

For years, bracing has been the most frequent treatment method for growing patients with moderate-size curves. Despite the fact that bracing is so commonly used in this clinical situation, there is no good scientific data demonstrating that bracing actually slows or prevents curve progression.

“Bracing a child with scoliosis is not an easy task,” said Matthew Dobbs, M.D., orthopaedic surgeon at Shriners Hospitals for Children — St. Louis and associate professor of pediatric orthopaedic surgery at Washington University School of Medicine. “Adolescents do not want to wear a brace that makes them look and feel different from their friends. Bracing has been the accepted treatment for years for adolescents with a curve of 20 to 40 degrees, but there is no hard data to support that it works. We honestly don’t know what the right treatment is for patients with curves in this range. Some with braces do fine, as do some without. This is definitely a medical question that needs to be answered.”

Shriners Hospitals for Children, together with the National Institutes of Health, is conducting a multi-center research study, Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST), to answer this question. Dr. Dobbs is the lead investigator for the Shriners Hospitals for Children portion of this trial. The results could lead to improved care and treatment, improved screening efforts and programs, and improved quality of life for those with AIS, and help determine precisely which patients benefit from bracing and which do not.

A difficult issue surrounding bracing adolescents is compliance – determining whether patients are wearing the brace for the prescribed amount of time, which is often 20 hours a day. In the study, compliance will be determined through data provided by a heat sensor implanted in the brace.

“The braces are uncomfortable and awkward, and generally we are dealing with adolescent girls concerned about appearance and fitting in,” said Dr. Dobbs. “Every day in the scoliosis clinics we deal with tears from the adolescents not wanting to wear the brace and frustration from the parents trying to convince their teens to wear it.

“Bracing is very expensive, as are the school screening programs,” said Dr. Dobbs. “If we find that bracing is not effective, then screening programs to identify scoliosis in early stages could be stopped. On the other hand, if bracing is found to be effective, then more effort and resources could be employed toward improved screening programs to identify children with curves early enough that they can benefit from bracing.

“I believe the findings won’t be that simple. It is likely that we will identify a subset of scoliosis patients that benefit from bracing and others that don’t,” Dr. Dobbs said. “If we can define the patient population based on age and curve type that benefit from bracing, that would be a huge contribution. Whatever the findings, the results of the study will be a major step forward in our understanding of how to treat this relatively common disorder.”

Many children with other conditions, including spinal cord injuries, cerebral palsy and osteogenesis imperfecta, are at a very high risk for developing scoliosis, as well. The same question – whether bracing is the best treatment for scoliosis – needs to be answered for these cases. Studies, in varying stages of development, are also underway at Shriners Hospitals for Children to address these questions.

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