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Am Fam Physician. 2003;67(1):32-35

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.

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.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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