Letters to the Editor

Why Is Aspirin a Contraindication for Trigger-Point Injections?

TO THE EDITOR: In the article entitled, "Trigger Points: Diagnosis and Management,"¹ Table 3 lists aspirin therapy as a contraindication to trigger-point injections. Given the current recommendations for aspirin therapy to prevent coronary artery disease events, large portions of the adult population in the United States are currently taking or should be taking aspirin on a regular basis. If aspirin therapy is truly a contraindication to trigger-point injections, then trigger-point injections would be off limits to a large percentage of the adult population.

The only information presented in the article to support this contraindication is the citation of two textbook chapters.^2,3 What evidence, if any, indicates that trigger-point injections are dangerous to patients taking aspirin?

BARRY D. WEISS, M.D.
University of Arizona College of Medicine
1450 North Cherry
Tucson, AZ 85719

REFERENCES

1. Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am Fam Physician 2002;65: 653-60.
2. Simons DG, Travell JG, Simons LS. Travell & Simons' Myofascial pain and dysfunction: the trigger point manual. 2d ed. Baltimore: Williams and Wilkins, 1999:94-173.
3. Ruoff GE. Technique of trigger point injection. In: Pfenninger JL, Fowler GC, eds. Procedures for primary care physicians. St. Louis: Mosby, 1994:164-7.

EDITOR'S NOTE: A copy of this letter was sent to the author of "Trigger Points: Diagnosis and Management," who declined to reply.

How Effective Is Bracing for Treatment of Scoliosis?

TO THE EDITOR: In the article "Adolescent Idiopathic Scoliosis: Radiologic Decision-Making,"¹ Dr. Greiner states: "Moderate curves between 25 and 45 degrees in patients lacking skeletal maturity used to be treated with bracing, but this treatment has never been proven to prevent curve progression."¹ We wholeheartedly agree with that statement and would further propose that watchful waiting be considered an alternative treatment to bracing.

According to the results of one study,² there is a strong possibility that bracing does not decrease the incidence of surgery in patients with adolescent idiopathic scoliosis. Furthermore, the psychologic impacts of bracing are not well articulated, nor is the impact on family relationships as children and parents negotiate brace-wearing schedules. In a document³ reviewing the effectiveness of screening for adolescent idiopathic scoliosis, the U. S. Preventive Services Task Force (USPSTF) states: "Studies have shown an association between brace wear and adverse psychological effects, diminished self esteem, and disturbed peer relationships." Therefore, not only is this treatment not proven to prevent curve progression, it can result in psychosocial difficulties for patients and their families.

We are in the process of applying for funding to launch a multi-center, randomized trial of bracing compared with watchful waiting in patients with adolescent idiopathic scoliosis. It is imperative that the public is educated about the controversy surrounding bracing for this study to effectively recruit subjects. More importantly, patients and their families need to know that bracing is not necessarily the best treatment for adolescent idiopathic scoliosis. We appreciate Dr. Greiner's position and hope that he continues to share these viewpoints with patients and colleagues.

MELANIE J. DONNELLY, M.P.H.
LORI A. DOLAN, B.S.N., M.A., PH.D.(C)
STUART L. WEINSTEIN, M.D.
University of Iowa Hospitals and Clinics
200 Hawkins Drive
Iowa City, Iowa 52242

REFERENCES

1. Greiner KA. Adolescent idiopathic scoliosis: radiologic decision-making. Am Fam Physician 2002; 65:1817-22.
2. Goldberg CJ, Moore DP, Fogarty EE, Dowling FE. Adolescent idiopathic scoliosis: the effect of brace treatment on the incidence of surgery. Spine 2001; 26:42-7.
3. U.S. Preventive Services Task Force. Guide to clinical preventive services. 2d ed. Washington, D.C.: Office of Disease Prevention and Health Promotion, U.S. Government Printing Office, 1996.

IN REPLY: The points made in this letter are well taken. The issue of bracing for moderate curves is important for family physicians, orthopedists, pediatricians, and other clinicians seeing adolescents and children who may be skeletally immature. I am in complete agreement with Ms. Donnelly and associates "that watchful waiting be considered an alternative treatment to bracing." In fact, based on the lack of evidence supporting bracing, there should probably be a stronger call for avoiding brace use in these patients. As the authors point out, there is some evidence of adverse psychologic effects from wearing a brace.^1,2

Unfortunately, evidence against the wearing of a brace and other active forms of treatment for adolescent idiopathic scoliosis often has been overshadowed by the huge volume of work performed by those who were convinced 30 or 40 years ago that the best treatment for scoliosis was aggressive intervention. As we assess new evidence and make clinical recommendations, we must remember that all of the early work in scoliosis treatment was conducted among a mixed population of polio survivors and patients with neurologic conditions and congenital scoliosis. Many of these patients responded to surgery and bracing differently than patients with adolescent scoliosis do. These facts must be faced as new cohort data are made available and show that most of the interventions performed on patients with idiopathic scoliosis are making a cosmetic difference rather than a physiologic difference. Only randomized trials will be able to tell us whether these interventions are harmful in psychologic and other ways.

Scoliosis researchers, organizers of school screenings, physicians, and organizations that provide lay information need to reconsider approaches to adolescent scoliosis. Family physicians and public health scientists may need to play a role in this process. As has happened with other high-profile issues, such as hormone replacement therapy (HRT), new information may throw a cloud over years of medical activity and necessitate re-evaluation of clinical strategies.³ Treatment concerns are always complex, and they are rarely resolved quickly. Scoliosis has a lower profile than HRT. Persons who produce, interpret, and rely on evidenced-based medicine will need to avoid the temptation of deferring to renowned experts as they attempt to do what is best for patients and families exposed to information, both biased and objective.

K. ALLEN GREINER, M.D., M.P.H.
University of Kansas Medical Center
Department of Family Medicine
3901 Rainbow Blvd.
Kansas City, KS 66160

REFERENCES

1. Noonan KJ, Dolan LA, Jacobson WC, Weinstein SL. Long-term psychosocial characteristics of patients treated for idiopathic scoliosis. J Pediatr Orthop 1997;17:712-7.
2. Andersen MO, Andersen GR, Thomsen K, Christensen SB. Early weaning might reduce the psychological strain of Boston bracing: a study of 136 patients with adolescent idiopathic scoliosis at 3.5 years after termination of brace treatment. J Pediatr Orthop B 2002;11:96-9.
3. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA 2002;288:321-33.

Correction

The answer block for the "Clinical Quiz" in the April 1, 2002 issue (page 1470) contained an incorrect answer for Question 22. The correct answers to the question, pertaining to the article "Radiologic Bone Assessment in the Evaluation of Osteoporosis," are A (increased age), C (tobacco use), and D (low body mass index). Question 22 is reprinted below.

Q22.	Which of the following is/are risk factors for osteoporosis?
	A.	Increased age.
	B.	History of falls.
	C.	Tobacco use.
	D.	Low body mass index.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@ aafp.org. Please include your complete address, telephone number, and fax number. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.