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Pancake
15th September 2009, 04:00 PM
WITH REGARD TO AIS...

Bracing is an experimental treatment despite being the standard of care. I have come to appreciate how truly weird this situation is. It results in many kids, perhaps 70% to 80% who are treated unnecessarily. It also results in some kids being treated uselessly. Just ask all the kids who wore braces and still needed surgery. If there is a population who we know FOR A FACT have avoided surgery in their lifetime due to bracing, it can't be large and it has yet to be rigorously identified. We know that much whether or not it is admitted honestly by some.

I am uncomfortable with using kids as experimental subjects in studies that are not designed to get a robust answer. I admit it is hard to do a good study with human subjects. It's worse when the treatment isn't benign as for bracing. The only way to justify it is if the kids are part of a study that will likely yield answers. Repeating studies that are not well-designed, even if that's the best that can be done, is not fair to the braced kids in the study. How many times do you need to get a number that is of unknown accuracy and precision? Multiple such numbers never add up to a better accuracy and precision.

These are going through a treatment that has a very uncertain chance of efficacy. That certainly seems unethical. In my opinion.

In the case of bracing for scoliosis, a randomized control study is ethical because there is no good evidence bracing works. Hence, BRAIST.

Your conclusion is only as good as your assumptions. If you start out assuming the conclusion ("bracing works") as we have seen over and over again then you aren't likely going to design good studies or interpret results fairly. The jury is out on bracing efficacy and pretending it is not is not supportive to parents trying to figure this out. Lashing out at the BRAIST study researchers for honestly stating the facts simply because it undermines wishful thinking on this point is not productive. That's why it got past the ethicists and is recruiting patients NOW.

Tables purporting to show natural history that don't have any way to assess the accuracy or precision of those risk of progression percentages are of limited value, especially since we know that this condition is highly variable.

So the claim let's say is there is a 30% risk with a certain curve magnitude in a given age range. Well is that 30% +/- 1% or 30% +/- 10%? or 30? +/- 30%? How about 30% +/- 100%?

And how accurate is that 30%? Was it determined on a relative handful of patients? In a condition as variable as AIS, there is going to be some minimum number of patients to include before you have any real confidence in the data. What is that minimum number? Does anyone know? Does anyone how any idea how to calucate it?

All of this is Science 101 and just because AIS plus bracing is hard to study doesn't mean it is immune from these universal issues in trying to know anything real.

hduggan
15th September 2009, 06:14 PM
I'd be interested in going through the ethical foundations of the BRAIST study. I don't have a horse in this race either way - my son is too old for bracing - but I did feel like the researchers were doing some kind of odd footwork in their explanation of how they determined equipose. My memory of it isn't too clear (in my pre-caffine state) but I do recall feeling a little uncomfortable about how they kept redesigning their survey of the doctors mid-study, and also about how they evaluated the doctors' responses as variable, when it seemed as if the variation was in *how much* difference the Dr's thought bracing made, and not in whether or not they thought it made a difference.

On efficacy in medicine in general: I think there's a widespread tendency to err in giving too much medicine instead of too little, especially when the alternatives are serious.

Pancake
15th September 2009, 06:21 PM
I'd be interested in going through the ethical foundations of the BRAIST study. I don't have a horse in this race either way - my son is too old for bracing - but I did feel like the researchers were doing some kind of odd footwork in their explanation of how they determined equipose. My memory of it isn't too clear (in my pre-caffine state) but I do recall feeling a little uncomfortable about how they kept redesigning their survey of the doctors mid-study, and also about how they evaluated the doctors' responses as variable, when it seemed as if the variation was in *how much* difference the Dr's thought bracing made, and not in whether or not they thought it made a difference.

On efficacy in medicine in general: I think there's a widespread tendency to err in giving too much medicine instead of too little, especially when the alternatives are serious.

Good points.

On the re-design on the fly issue, I think they had no choice. They would have been crucified by the reviews if they went forward with a survey with such a small response. I think when it's that small, you might be able to assume self-selection on issues that will be relevant to the survey interpretation and therefore garbage in, garbage out. Just because you have some numbers in a spreadsheet doesn't mean they necessarily mean a damn thing as I know you are well aware.

Pancake
15th September 2009, 06:30 PM
Forgot to add, I doubt the ethicists who okayed the study did it solely on the one "equipoise" paper.

The literature is what it is and all you have to do is gesture in its general direction to get something like BRAIST okayed it seems.

I am coming to think all these non-controlled studies are the unethical ones. I wouldn't let a kid participate in a study with a treatment such as 23 h/d bracing that is not able to yield robust results. On that basis, it can be argued that BRAIST appears to be the only truly ethical game out there at the moment although we know with some certainly many subjects will be treated unnecessarily and some will be treated ineffectively. That much we know for a fact at this point.

The goal to to identify what we know is likely a relativgely small group who will reliably avoid surgery due to bracing. Thtis hasn't been done to date for known reasons.

tonibunny
15th September 2009, 06:51 PM
Hi everyone,

I've split these posts off from the Spinecor thread so that we can have a separate, critical debate regarding the efficacy of bracing. I think there are some useful points being made, but I don't want everything to end up as a big argument again, so please try to remain respectful even if you don't agree. This way our members will be able to read the arguments against bracing whilst those who are currently happy with various forms of bracing can continue to support each other on other threads :) I hope that sounds sensible!

Toni xx

Pancake
15th September 2009, 07:03 PM
Hi everyone,

I've split these posts off from the Spinecor thread so that we can have a separate, critical debate regarding the efficacy of bracing. I think there are some useful points being made, but I don't want everything to end up as a big argument again, so please try to remain respectful even if you don't agree. This way our members will be able to read the arguments against bracing whilst those who are currently happy with various forms of bracing can continue to support each other on other threads :) I hope that sounds sensible!

Toni xx

Thanks for doing this.

I think all you have to do is delete all posts that talk about posters as opposed to the ideas in the post.

That means, when you have a post that states "A" and a response that is entirely devoid of any rational engagement of "A" but instead consists entirely of, "Poster X is ignorant " plus this... ":D", then delete it.

Also, you can separate the science posts from the support posts and not allow intermingling. That is, don't allow wishful thinking or sloppy thinking in the science section and don't allow scientific stuff in the support section.

I think that will help solve the present problems.

hduggan
15th September 2009, 08:16 PM
Hi Toni. I'm pretty safe in arguments - I haven't called anyone a poo poo head in well over 14 hours :)

Pooka, I understood their reasons why they changed their methods, but this seems like a much more serious flaw when you're trying to determine whether or not it's ethical to withhold treatment.

Going from their definition of equipoise from this paper - http://braiststudy.com/files/folders/public/entry6.aspx:

"Clinical equipoise has been defined as the state of honest, professional disagreement in the community of expert practitioners as to the preferred treatment. Other similar definitions of equipoise include the state of uncertainty on the part of the pertinent community, the opinion that no one arm of the trial is known to offer greater harm or benefit, and the lack of consensus within the expert community about the comparative merits of the treatments being tested."

it doesn't seem as if their survey supports this definition if the Dr's agree that roughly 30% of their premenarcheal patients will benefit from bracing. Equipoise would be if the survey showed that they expected *the same* results from bracing or not bracing.

Am I missing something here?

Good points.

On the re-design on the fly issue, I think they had no choice. They would have been crucified by the reviews if they went forward with a survey with such a small response. I think when it's that small, you might be able to assume self-selection on issues that will be relevant to the survey interpretation and therefore garbage in, garbage out. Just because you have some numbers in a spreadsheet doesn't mean they necessarily mean a damn thing as I know you are well aware.

concerned dad
15th September 2009, 08:36 PM
This is a difficult topic to discuss objectively (and perhaps civilly) because our children are impacted by our decisions.

I think it is an important discussion to have.

A parent of a newly diagnosed child is likely unaware of the controversy surrounding treatment options. I had no idea there was a valid debate regarding bracing when my daughter was first diagnosed. There are so many issues to learn about and try to understand. I think it is invaluable to hear and understand both sides of the argument. It is only after you understand both sides that you can hope to make an informed decision about what is best for your child in their particular circumstance.

So, a new parent coming here would greatly benefit from a civil discussion of the issues.

Posting the abstract of a paper without discussing the strengths and weaknesses of the study can be misleading. I think Pancake’s questions about the paper are all worthwhile things to discuss. I agree with many of the shortcomings she noted and disagree on some others. She and I have discussed/debated some of these issues at NSF. If you post an abstract you should not necessarily be compelled to defend it but you should be open to hearing a valid critique. The absence of discussion can lead to an implied rubberstamp from the forum participants on the merits of the study and the scientific abstract is transformed into little more than a youtube commercial.

But, I think that Pancake and Sealy have some history between themselves that makes the discussion almost impossible to have. It is unfortunate because it would be enlightening to hear the two strongly opposing views further explored.

Regarding the abstract and Pancakes comments: Most of Pancake's comments relates to the fact that this paper was written before the SRS instituted their guidelines for bracing studies. The SRS recognized these weaknesses and made suggestions for future bracing studies. I'm pretty sure that this paper predates that.

tonibunny
15th September 2009, 08:42 PM
Hi CD, I moved your post across to this thread as it seems to fit better here, I hope that is OK :)

mark
15th September 2009, 08:43 PM
Thanks for such a reasoned post concerned dad, i think you have hit the nail right square on the head

Pancake
15th September 2009, 10:07 PM
Regarding the abstract and Pancakes comments: Most of Pancake's comments relates to the fact that this paper was written before the SRS instituted their guidelines for bracing studies. The SRS recognized these weaknesses and made suggestions for future bracing studies. I'm pretty sure that this paper predates that.

CD, this study post-dates the SRS guidelines as far as I know. If you can believe it.

The first patients were braced in 2000 and the main paper will come out in 2011. I don't know if what was posted is an abstract for a presentation or what. If so, it is grey literature at best at this point. That is NOT a knock... I have plenty of published abstracts that contained statements that did NOT appear in the final paper. Peer-review... not just a good idea. :)

I mean they have a total of 56 skeletally immature patients scattered among IIS, JIS and AIS. What would the results mean even if they were all one type and even if it was controlled at that point? This type of comment is completely lost within the noise here. A study of 56 patients might be unethical per se.

BTW, which comments did you disagree with? I'm interested. Maybe I can learn something. It wouldn't be the first time you taught me something. :)

concerned dad
15th September 2009, 10:41 PM
Thanks Mark.

Hdugger, regarding "Agreement" the equipoise paper says

We divided the range of RR estimates into 3 intervals: small effect (0%-39% fewer failures with bracing), medium effect (40%-69% fewer failures with bracing), and large effect (70%-100% fewer failures with bracing). Clinical agreement was present if more than 80% of the experts estimates were within 1 of the 3 intervals.


Now, if clinical agreement was defined as the percent of respondents who think bracing would have a positive affect (irregardless of just how positive), well then they would have achieved equipoise.

Hdugger you are right. This is odd.

And Pancake, I'm suprised you didnt call for the disclosure of just exactly what the respondents had to say (not the expert panel, just the original survey respondents that were summarily dismissed - wouldnt you like to know? I sure would)

concerned dad
15th September 2009, 10:54 PM
Pancake, you're right. The study Sealy posted does post date the publishing of the SRS Bracing Study Guidelines.

Gotta run - My daughter has a soccer game I want to catch.

mark
15th September 2009, 10:58 PM
Pancake, you're right. The study Sealy posted does post date the publishing of the SRS Bracing Study Guidelines.

Gotta run - My daughter has a soccer game I want to catch.

Hope she wins :D:):D

hduggan
15th September 2009, 11:10 PM
Yes, I found that very odd. And, taken along with the constant revisions of the study method, I just got a feeling that they were working to get a specific result (equipoise) and they just kept fiddling with the numbers until they got there.

I have to look at it again tonight to see if the RR estimates" were built into the study from the start, or added on later. That would make a difference in my response.

I don't think it's a big conspiracy or anything, but I do know that when you're all ready to do some big research study, you tend to look at the data from just about every perspective until you can get it to stack up the way you'd like to have it stack up. That's OK, I guess, if you're doing something relatively benign, but less OK if you're asking doctors to withhold treatment that *they* believe to be effective for a serious condition.


Hdugger, regarding "Agreement" the equipoise paper says

We divided the range of RR estimates into 3 intervals: small effect (0%-39% fewer failures with bracing), medium effect (40%-69% fewer failures with bracing), and large effect (70%-100% fewer failures with bracing). Clinical agreement was present if more than 80% of the experts estimates were within 1 of the 3 intervals.


Now, if clinical agreement was defined as the percent of respondents who think bracing would have a positive affect (irregardless of just how positive), well then they would have achieved equipoise.

Hdugger you are right. This is odd.

Pancake
15th September 2009, 11:25 PM
I don't think it's a big conspiracy or anything, but I do know that when you're all ready to do some big research study, you tend to look at the data from just about every perspective until you can get it to stack up the way you'd like to have it stack up. That's OK, I guess, if you're doing something relatively benign, but less OK if you're asking doctors to withhold treatment that *they* believe to be effective for a serious condition.

The key word for me in your last sentence is "believe." They may "know" it but they have to "show" it.

Maybe if the survey asked explicitly:

Do you think bracing works?

Do you have evidence bracing works?

things would be cleared up immediately. The literature is what it is.

I don't want to put too fine a point on this but an MD is NOT a research degree as far as I know. Many of these guys do publish, however, but there appears to be a different standard in the clinical literature compared to other hard science. I'm not saying these guys couldn't work under the standard of the rest of hard science and obviously there are constraints in clinical studies that don't apply in other science areas. I'm just saying it's different. And once you realize how it is different, how their hands are tied, it shouldn't be surprising to discover that most published research results are false. It's probably inevitable at that point.

I'm re-reading the paper but w.r.t. the opinions of the surgeons, I would weigh the answers, if not throw some out, on the basis of their answer to this one question:

"and a self-rating of their familiarity with the literature
concerning bracing and AIS on a scale ranging from 1 to 3."

In fact I think the answers would correlate HIGHLY with this one answer. The literature is what it is. Everyone is stuck with it, including the "believers."

Last, I doubt any surgeon would participate if they had evidence bracing works. I'm sure some declined because they were convinced it works even without formal evidence. But I'd like to draw your attention to the sheer number of medical centers that are participating. Irrespective of the amount of "equipoise" documented in that one Dolan paper, we seem have a boatload of folks who think BRAIST is ethical enough to participate.

The literature is what it is. The Dolan paper is just a bow on top of it in my opinion.

hduggan
15th September 2009, 11:29 PM
Well, I thought I was going back to my work, but I noticed one more thing in the study. The 70 - 80% numbers for when bracing may be ineffective are only in the postmenarcheal. In the younger patients, the estimated success is much higher. There are some curve types where 21% of the doctors estimate 70 to 100% rate of success, and 34% estimate 30 to 69% success. So, less then half of them think there's only a 30% chance of success (if that makes any sense).

Pancake
15th September 2009, 11:33 PM
Well, I thought I was going back to my work, but I noticed one more thing in the study. The 70 - 80% numbers for when bracing may be ineffective are only in the postmenarcheal. In the younger patients, the estimated success is much higher. There are some curve types where 21% of the doctors estimate 70 to 100% rate of success, and 34% estimate 30 to 69% success. So, less then half of them think there's only a 30% chance of success (if that makes any sense).

Yes but these "success" rates necessarily include those who would not have progressed anyway because there is no way for them to know either way. They just see the result. They don't know if the brace did anything outside of a well-designed study.

hduggan
16th September 2009, 03:04 AM
Yes, agreed. I'd just heard the numbers quoted before about bracing only helping 20 to 30% (based on this survey) and I wanted to correct those numbers to something more like 40% premenarcheal, also based on this study. If this study is all we have, I wanted to quote the numbers more consistently.

Yes but these "success" rates necessarily include those who would not have progressed anyway because there is no way for them to know either way. They just see the result. They don't know if the brace did anything outside of a well-designed study.

For the study itself, I'm so far down the rabbit hole (and having a nice old tea party with the mad hatter!) I no longer know whether it would be better or worse if they'd read the research. But I am inclined to lay a fair amount of weight on what Dr's believe is true, since that's pretty much all we have not only for bracing but for surgery as well.

At this point in medicine, we're relying on Dr's beliefs (w/o much if any backup from research) to guide them in when to operate, which equipment to use, what level to fuse to, how much curve to put in the rods, etc. I'm guess I'm equally comfortable/uncomfortable with the unscientific state of affairs in surgery as I am in bracing.

Pancake
16th September 2009, 04:09 AM
For the study itself, I'm so far down the rabbit hole (and having a nice old tea party with the mad hatter!) I no longer know whether it would be better or worse if they'd read the research. But I am inclined to lay a fair amount of weight on what Dr's believe is true, since that's pretty much all we have not only for bracing but for surgery as well.

Be careful with that... doctors (as well as engineers) also have an alarmingly high rate of religious belief for science majors. That is consistent with their degree not being a research degree and them not being as immersed as you would think/want in evidenced-based approaches.

At this point in medicine, we're relying on Dr's beliefs (w/o much if any backup from research) to guide them in when to operate, which equipment to use, what level to fuse to, how much curve to put in the rods, etc. I'm guess I'm equally comfortable/uncomfortable with the unscientific state of affairs in surgery as I am in bracing.I'd say it's different because the surgical results are more decipherable. And these guys do so many of them. Despite the apparent "equipoise" in that one taped seminar we listened to recently on what folks would do with various 50* curve, I think the state of surgery is far more advanced and more is actually intrinsically knowABLE than for bracing which frankly seems like a holdover from the Dark Ages. Scoliosis bracing needs an Enlightenment just like the world did. Note to the medical "believers." :)

tonibunny
16th September 2009, 12:04 PM
I don't want to put too fine a point on this but an MD is NOT a research degree as far as I know. Many of these guys do publish, however, but there appears to be a different standard in the clinical literature compared to other hard science.

I don't know about other countries, but here in the UK medical degrees contain a hell of a lot of research, and research methodologies are taught from the very beginning. A lot of medical degrees also include a year of study for a research degree (this is called an intercalated degree) that results in the additional award of a traditional research degree qualification here, such as MA or PhD. This means that, after they have finished their medical degree, any subsequent research they do will be of the same standard as any other post-research degree researcher.

In addition to this, the hospital doctors who are undergoing specialist training ("house officers") do a lot of research.

As I said, I have no idea about how much research doctors do in other countries, but I have great confidence in any research projects undertaken by doctors in the UK, especially those at highly respected institutions such as Sheffield, which is one of the country's top universities and teaching hospitals.

Pancake
16th September 2009, 12:26 PM
I don't know about other countries, but here in the UK medical degrees contain a hell of a lot of research, and research methodologies are taught from the very beginning. A lot of medical degrees also include a year of study for a research degree (this is called an intercalated degree) that results in the additional award of a traditional research degree qualification here, such as MA or PhD. This means that, after they have finished their medical degree, any subsequent research they do will be of the same standard as any other post-research degree researcher.

In addition to this, the hospital doctors who are undergoing specialist training ("house officers") do a lot of research.

As I said, I have no idea about how much research doctors do in other countries, but I have great confidence in any research projects undertaken by doctors in the UK, especially those at highly respected institutions such as Sheffield, which is one of the country's top universities and teaching hospitals.

I'm not clear on what's going on with this issue.

They also have "joint" programs in the US wherein you get an MD and a PhD but that is a full-blown, stand alone PhD, not something that exists as an add-on to the MD. These joint programs take a number of years to complete as far as I know, the same number of years as if you add the MD years to the PhD years.

Now I have to wonder why these joint programs exist if the MD had much research training and experience in the curriculum.

I agree these medical school professors do a ton of publishing and they advance their fields. But they are also doing a ton of surgeries. I wonder how they get up the ladder... it can't be straight pubs because that wouldn't be fair compared to other departments since they are in the clinic so much in addition to teaching I assume. Maybe there is a system unique to the medical school. There probably is.

Clearly I have no idea what I'm talking about! But I would like to know.

concerned dad
16th September 2009, 03:12 PM
The key word for me in your last sentence is "believe." They may "know" it but they have to "show" it.



The equipoise paper is all about "beliefs". The title of the paper is:
Professional Opinion Concerning the Effectiveness of Bracing Relative to Observation in Adolescent Idiopathic Scoliosis.

It would have been interesting to sit in on the meetings where they discussed the ethics of the Braist study.

I am aware of two main lines of arguments used to justify the Braist study
1. The Metanalysis paper
2. The Equipoise paper.

There are valid concerns about both papers.

With the metanalysis paper they excluded studies (mostly european) where bracing was employed coincident with excercise (They designed the study to ONLY include bracing and observation) I read a SOSORT paper where they were very critical of this exclusion. (I have to agree with them, I mean, why exclude bracing studies that combined excercise with bracing? Even if (especially if) you dont think excercise has an effect, there are still braced patients in those studies to use in the statistical analysis.

With the Equipoise paper the definition of "clinical agreement" is, as hduggen pointed out, open to debate.

Now, it would be wonderful to have Dr Dolan back here to the forum to help us understand the details of these issues.

Pancake
16th September 2009, 08:25 PM
Okay I re-read Dolan et al. (2007)

My opinions follow:

1. Clinical agreement - They cite two published papers using the same definition. Rather I think Dolan et al. adopted this previously published definition. To critique it at this point would seem to require getting both those papers and reading the defense of the "clinical agreement" definition. It's possible that it is some standard definition at this point and Dolan et al. would have been crucified had they not used it. Don't know. Not my field.

2. What would have been the hot ticket is if the survey included the following question: "Would you be willing to randomize children to one of these two treatment options?" That would cut to the chase though we see from the large list of participating institutions that a fair number would likely have answered, "yes" to this question.

3. If you look at Figure 3, the median and average risk reduction for all scenarios is less than or equal to about 30%. Furthermore, note the overlaps for the middle two quartile ranges and also take a gander at those huge error bars. With the caveat about lumping various type of curves together than are thought to have different progression potentials, I interpret those findings together to suggest the authors have shown that there is a large contingent out there who seems to feel bracing is effective somewhat less than half the time and that equipoise exists.

Last, again, the literature is what it is. Any shortcomings in this paper aren't going to make that situation any better.

concerned dad
23rd September 2009, 09:42 PM
Well, this post is somewhat on topic.
While researching an eye condition my sister was just diagnosed with I came across a technical paper exploring what the author feels are myths about a particular eye disorder. I’m reading though it, maybe understanding like 10% of what I read (you gotta start somewhere). Anyway, I come across a section discussing a myth titled (emphasis added is mine):

5.9. That the natural history of CRVO does not usually involve spontaneous visual improvement

This is the most common myth. The most commonly cited study is that by the Central Vein Occlusion Study Group (1997). That study concluded that: ‘‘Visual acuity at baseline is a strong predictor of visual acuity at 3 years for eyes with good vision and eyes with poor vision, but a poor predictor for intermediate acuities.’’ Unfortunately, in that study nonischemic and ischemic CRVO were lumped into one group for the data analysis—that is like combining benign and malignant tumors into one disease to determine the final outcome. This serious flaw invalidates the conclusions, because the visual outcome in the two types of CRVO is totally different.

Well, I suppose the similarities goes to one of the criticisms of the large 1995 SRS (Nachemson) Bracing study where, it turned out, the kids in the braced group were more heavily weighted with curve types less likely to progress than those in the observation group.


Dickson put it better
From a 1999 paper by Dickson in Spine discussing the Nachemson study.....

One hundred and eleven braced patients were compared to 129 observed and 46 electrically stimulated. The failure rate was an increase in Cobb angle by 6°. On this basis 36% of the braced, 52% of the observed, and 63% of the stimulated failed and these differences achieved statistical significance. The next paper in the same journal looked at factors that affect natural history and one of the most compelling features was that thoracic curves had a much worse prognosis than thoracolumbar curves. Looking now at the proportions of the more progressive thoracic curves in the three trial groups, 89% were thoracic in the stimulated group, 81% in the observed group, and a mere 68% in the braced group. Meanwhile, in the paper originating in Puerto Rico, 70% of the untreated group had thoracic curves and 46% of the treated group. It would be difficult to stack the odds better.

The author (of the eye paper) goes on to end the section with the text:

It is essential to know correctly the natural history of a disease before judging the effectiveness of various advocated treatments for it.

And, of course, this last sentence goes to the whole need for the current BRAIST trial so we can know (hopefully once and for all) the natural history of scoliosis.

sg-ni
24th September 2009, 12:57 AM
If its any use, I was cast from the age of 2 and then braced several years later up until ~18 and it managed to hold off the need for surgery. ~5 years on being out of the brace and ive had no real problems now to complain about bar the occasional morning with a stiff back.

When just thinking on my own experiences on whether the ends - all my growing up years braced; justify the means - no surgery but not 'cured' so to speak. I have to say im still a bit mixed, though now having passed through it all I would lean a bit more to the surgery route rather than bracing.

concerned dad
24th September 2009, 11:48 PM
The perspective of those adults who were braced as children is extremely important. It is a voice that parents of children need to hear when deciding on the best course of treatment for their kids.
Thank you for sharing.