Copyright © 2005 by The Journal of Bone and Joint Surgery, Inc.

Commentary & Perspective

Commentary & Perspective on
"Decreased Orthotic Effectiveness in Overweight Patients with Adolescent Idiopathic Scoliosis"
by Patrick J. O'Neill, MD, et al.

Commentary & Perspective by
Stuart L. Weinstein, MD, and Lori A. Dolan, PhD*,
University of Iowa Healthcare, Iowa City, Iowa

This article provides valuable evidence for a phenomenon that is widely acknowledged by those who make use of braces in the treatment of adolescent idiopathic scoliosis: curves in overweight children don't respond to the same degree as those in children of normal weight. The forces created on the spine by a brace are indirect at best, and when adipose tissue further dissipates these forces, less curve correction is achieved. While this mechanical explanation for decreased brace effectiveness is intuitively the most obvious, O'Neill and colleagues offer additional biological considerations that may be contributing to curve progression in overweight children. Because natural-history studies have not addressed body mass index as a risk factor, it is difficult to quantify the relative roles of mechanics and biology in the progression of these curves.

Increased weight can be added to a list of other factors that are associated with either an increased risk of curve progression or a decreased effectiveness of bracing; these factors include skeletal and sexual maturity, rib-vertebral angle, thoracic apex, spinal imbalance, Cobb angle, curve rotation, in-brace curve correction, and time in brace1-3.

Sufficient work has been done concerning these risk factors to recognize that bracing is not a "one size fits all" therapy, and questions still remain concerning the ability of bracing to prevent the need for surgery4. Despite this research, it is still tempting to offer bracing as the only nonsurgical option. There is, however, another option: to offer patients the opportunity to make an informed decision on the basis of all available information and in light of their own preferences. This approach to clinical decision-making, termed evidence-based patient choice (EBPC)5, is a practical extension of evidence-based medicine. A recent systematic review of trials by O'Connor and colleagues6 found that the application of EBPC models improved patients' knowledge of their options, reduced their decisional conflict, and increased their participation in treatment decisions without increasing their anxiety concerning their condition or their decisions. Our experience with the EBPC model in a study concerning preferences for scoliosis treatment was surprising: contrary to our clinical experience, patients and parents who had been given detailed information about natural history and bracing effectiveness studies tended to prefer watchful waiting to bracing (60% of parents and 93% of children)7. Clearly, when presented with evidence-based information, subjects did not feel bracing was the only viable option.

O'Neill and colleagues have contributed important information that we should be discussing with patients as they make treatment decisions. Bracing can be an onerous therapy, and one that may not work for all children. Therefore, we have a responsibility to discuss with patients what we know (and don't know) about bracing, and to allow them to decide whether the treatment and its likely outcomes are in line with their own personal preferences.

*The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

References

1. Peterson LE, Nachemson AL. Prediction of progression of the curve in girls who have adolescent idiopathic scoliosis of moderate severity. Logistic regression analysis based on data from The Brace Study of the Scoliosis Research Society. J Bone Joint Surg Am. 1995;77:823-7.
2. Lonstein JE, Carlson JM. The prediction of curve progression in untreated idiopathic scoliosis during growth. J Bone Joint Surg Am. 1984;66:1061-71.
3. Rowe DE, Bernstein SM, Riddick MF, Adler F, Emans JB, Gardner-Bonneau D. A meta-analysis of the efficacy of non-operative treatments for idiopathic scoliosis. J Bone Joint Am. 1997;79:664-74.
4. 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.
5. Edwards A, Elwyn G, editors. Evidence-based patient choice: inevitable or impossible? New York: Oxford University Press; 2001.
6. O'Connor AM, Rostom A, Fiset V, Tetroe J, Entwistle V, Llewellyn-Thomas H, Holmes-Rovner M, Barry M, Jones J. Decision aids for patients facing health treatment or screening decisions: systematic review. Br Med J. 1999;319:731-4.
7. Dolan LA. Prospective efficiency evaluation of the bracing in adolescent idiopathic scoliosis trial. Dissertation Abstracts International. 2004;65:3365. http://wwwlib.umi.com/dissertations/fullcit/3139346.