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Upon recommendation of our orthopedist, we met with
Dr. Miguel Gomez here in Houston. Naturally, I went
into this first meeting very apprehensive, already close-minded
to using a brace after the great results we had previously
achieved with
casting. After evaluating Lexi, Dr. Gomez went to work,
taking measurements with nothing more than a standard
tape measure and a caliper. I thought to myself, “this
is never going to work. How can something be made from
mere measurements that will achieve any reduction in
her curve?” Two weeks later, we returned to pick
up her brace and have it fitted. Much to my surprise,
it fit well and it looked like it had been taken from
a plaster mold. I felt a little better at that point
about what we might expect from this brace.
Since January, I’ve had the opportunity to learn
a little more about Dr. Gomez, his approach to treating
scoliosis, and the use and fabrication of his braces.
To make this an easier read, I will present it an interview
format. I think the questions I asked are easy for us,
as parents, to understand.
Those of you who know me from the CAST Support Group
know I am, in no way, opposed to serial plaster casting.
It is just that we, like others out there for various
reasons, had to explore an alternative to casting. Although
Lexi’s hand operations have been postponed, we
have chosen at this point to continue with the bracing
since we are getting positive results.
I’ll begin with some history on Dr. Gomez, and
share the story of how he came into this field. I feel
it would be an injustice to him to not share this story
with you--it lends a lot of validity to his work to
understand how he came to be, as we affectionately refer
to him, “our brace guy.”
Eighteen years ago, Dr. Miguel Gomez was chief of the
emergency department in one of the biggest hospitals
in Bogotá, Columbia, his native country. He had
a change of heart in his practice of medicine when he
diagnosed his daughter, who was one year old at the
time, with progressive infantile scoliosis. He began
a two-year search for alternatives to surgery. Since
he had been a surgeon, he accepted surgery as a viable
practice when needed. However, faced with the thought
of his own daughter undergoing surgery to correct her
spine, he became determined to find an alternative.
At the time of her diagnosis, her curve was 14°.
By the time they had finally exhausted their search
for options in Columbia and South America two years
later, her curve had progressed to 48°. At this
time, they were accepted at Shriners Hospital in Minneapolis
and his child was treated with a brace. Dr. Gomez played
a role in her treatment as well, assuming the positions
of physician and father simultaneously. Happily, his
daughter is now 22 years old. Her spine is healthy and
stable, and she never needed to have surgery to correct
her scoliosis.
I asked Dr. Gomez a series of questions about the treatment
of infantile scoliosis with braces-questions that any
of you who are faced with exploring this option might
share. He was kind enough to take the time to answer
them, both from a clinical standpoint and from the perspective
of a parent, who has traveled the road of progressive
infantile scoliosis, just like the rest of us.
Question: You have shared your own story of
your daughter’s experience with scoliosis. You
said that her curve was managed and she never needed
surgery to correct her spine. That is an inspiration
to me and gives me faith in you treating my daughter.
However, various members of the orthopedic community
have stated the following about braces: “In children
with Progressive Infantile Scoliosis, if the curve continues
to progress, the infant or toddler will be fitted with
a brace. These external devices are designed to slow
or arrest the progression of the curve. Unfortunately,
they cannot correct the problem and only hold the curve
until the child has achieved skeletal maturity.”
What is your reaction to this statement? Do you believe
that, in some cases, bracing can correct the curve and
eliminate the need for surgical intervention in adolescence?
Are there any positive statistics out there in which
braces have corrected and managed an infantile/juvenile
curve so surgery is not needed?
Dr. Gomez: What
I learned through my daughter’s case and many others
(3,000 so far) is that a good orthotic treatment is
more demanding and difficult than surgery itself in
some ways. I hope I will not be in trouble saying this:
you need to have many steps and professionals involved;
that some times or many times, we are losing our goal
and role on this treatment. On the one hand, surgery
is a very passive procedure for the patient, quite demanding
for the surgeon, and after four to eight hours, is done.
Orthotic treatment demands from the patient and the
entire group. This is a sacrifice as it is a long, long
treatment. If we, the orthotists, will not provide the
right treatment, and it is not the brace, it is the
biomechanical information that the brace has to have.
Talking about conservative treatment of idiopathic scoliosis,
there are several studies that demonstrate that orthotic
treatment and surgery are the only two ways to change
the natural history of the idiopathic scoliosis. Yes,
the orthotic goal is to prevent progression from the
first measurement (COBB angle) that was taken and compare
with the last one after the treatment. The way that
I see this is how much we will be able to control that
deformity. I don’t feel bad because we didn’t
reduce the curve, as long as the patient is well-balanced
and stable in the end, it’s fine to have curves
that are well-compensated on the spine. It is true that
in many of my cases, the ones that I had the opportunity
to follow up closely, (every month to three months)
for the entire treatment I saw a permanent reduction
on the end between 10 to 25% of the initial curve. Again,
this is a very difficult and demanding treatment that
will take more time. Providing this treatment as a group,
it is necessary to reeducate new generations of doctors,
orthotists and physical therapists to believe and understand
this treatment. A great possibility to find the right
treatment is through a group like ISOP. I wish I had
this option when I was searching around. I would love
to be a part of this “Infantile Scoliosis Group”
and be more aggressive about education. In the end you
are the one who is responsible to choose the treatment
for your own child, and will be sure that you are taking
the right way. Bad braces can be as dangerous as bad
surgeries. Unfortunately, there is no turning back when
the spine loses the flexibility factor. Like I say,
“this will be our best player or our worst enemy.”
It depends how we will use it!
Question: I have
shared my story of Lexi, and our experience with you,
with the other parents in my group. I’ve told them
that your approach to treating Lexi is based on more
than just her curve; that you also look at the patient’s
balance and symmetry. Some of the parents that I have
communicated with, who have used bracing in the past
with miserable results said their orthotists never looked
at those factors in their children. This may be a tricky
question, but do you feel there is a population of orthotists
out there who do not know how to properly treat progressive
infantile scoliosis and concentrate only on the degree
of the curvature rather than the patient as a whole?
Dr. Gomez: I do
respect every clinician (orthotist) in this field, and
I know that they will do the best for their patients.
I also know that they will use whatever treatment is
available: the most common, and is supported with studies.
There are a few companies that provide this information.....
Unfortunately, I have to say that some orthotists are
treating spine deformities focusing more on the type
of the brace than the real biomechanics of the deformity
and the treatment. We have to treat every single case
differently, and that takes a lot of thinking and planning.
If we review the components of the scoliosis, it is
always described as a three-plane deformity (coronal,
saggital, transverse). Well, many orthosis (braces)
that are available do not approach these components
properly, or some of them are more concentrated to reduce
the COBB angle degree in one plane (mainly coronal)
and that’s it. Spine orthosis can create other
deformities (flat back, hypolordosis), and those can
be as bad as the scoliosis. Again, we have to train
doctors and the orthotists as a group to see the same
picture and establish the same goals in every single
case.
Question: I read
in a newsletter that you have developed a technique
using CAD/CAM technology to eliminate the need for making
a mold when measuring for a brace. Do you feel this
method gets more accurate measurements and allows you
to make a better- fitting brace?
Dr. Gomez: Yes,
in the last four years, I’m using more and more
a CAD/CAM program to be sure that we can use good clinical
signs, radiological signs and measurements to establish
the biomechanical approach for every single case. Now
days I’m taking more time to evaluate the patient,
testing range of motion, flexibility, rather than molding
the patient. Many times when I took the plaster mold
I wasn’t comfortable because I saw many times a
good correction in one plane but also hypercorrection
in other planes, principally on the saggital. So modifying
the mold by hand took me a lot of time to fix this.
With the computer it is easier, more reliable, and I
can measure every single modification. Also the file
will be in my computer, so I will have the perfect way
to compare the shape of the spine and deformity during
the entire treatment. This is a dynamic treatment and
very often the shape of the curve(s) change; many times
we will see at the end of the treatment a single curve
will end with one or two compensatory curves. This will
sound crazy but some times we will allow the spine to
create a small curve or curves to get the most stable
position, keeping balance and stability.
*CAD – computer aided design
*CAM – computer aided manufacturing
Question: I did
read that you are still perfecting this technique. Will
other orthotists around the country eventually become
aware of this method and start to implement it in their
practices, or are you keeping this secret all to yourself?
Dr. Gomez: Tracey,
more than anything I’m an educator. I fully understand
the value of good conservative or surgical treatment.
Any time that I have an invitation to lecture about
this system “the Gomez orthotic system,” I’m
taking the time to participate. I had the opportunity
to lecture at the national meeting of the American Academy
of Orthotists and Prosthetists in 2004. I also lectured
at a workshop in 2005 at the Texas chapter of the American
Academy of Orthotists and Prosthetists in Austin TX.
This year I will lecture again and have a workshop that
is completely related with this new approach. I would
love to teach more and more clinicians to evaluate the
patients properly, find the right information, take
good measurements. And if they want, I will modify the
case by computer and send back to them the file so they
can fabricate the brace or ask a central fab company
to do it. My expertise to use CAD/CAM is the best tool
so far, to modify the templates that I create, considering
every case unique, and treating every case in a different
way. This is not a cookbook recipe! I modified the plaster
molds for 15 years, and I had great results like Angela’s
(my daughter). But to store and modify the cast was
a big problem. Quite often, I had to take more cast
molds to change some forces that I was applying.
Question: Regarding
x-rays taken during treatment, how often do you feel
a film is needed in looking at the curve? As a mom,
I would love to be able to see my daughter’s spine
as often as possible during treatment. Considering the
risks of exposure, how necessary are films during treatment
of scoliosis?
Dr. Gomez: X-rays
during treatment--good question. Of course the most
important will be the first one and the last one after
treatment without the orthosis. We will be sure that
the orthotic treatment accomplished the goals. Between
these, two x-rays [should be] taken every four to six
months. In the beginning with the brace on, and when
the doctor decides the x-rays will be taken with and
without the brace on, so it will be the way to compare
if the spine still buckles and how much, comparing COBB
angles. Unfortunately, you will check just the spine.
And sometimes the technique used to take the x-rays
isn’t appropriate, so the information is not real.
I like to take digital pictures every visit. To me cosmetic
appearance is very important as well as balance and,
of course, stability. Again, clinical signs are more
important in some ways than radiological signs! In other
words, we have to treat the patient and not the x-rays.
If the information from these doesn’t match, we
have to trust the clinical signs. That is why it is
so important to evaluate the patient in detail.
Question: Failure
to comply with wearing the brace as prescribed: would
you say this is a big issue, especially with your younger
patients? And if so, what do you say to parents who
do not enforce the time needed wearing the brace?
Dr. Gomez: This
part of the treatment is one of the most important.
We can provide the best treatment through an individual
brace, but if the patient doesn’t wear it, it will
not do the job! I always compare brace wearing to taking
an antibiotic. If your child has an infection and the
doctor prescribes an antibiotic with a specific dose,
say 250 mgs every eight hours for five days, it is best
to follow the instructions. It is still very confusing
how much time the patient has to wear the brace--and
much more now that there are companies offering night
time braces and strapping techniques and many other
treatments that may not accomplish the real treatment
goal. Of course it will be easier for the patient and
the family [not to adhere to the prescribed amount of
time], but how many of these patients are ending up
in surgery? Surely more than the ones who wear the brace
following the instructions from the doctor.
Question: What
is the age of the youngest child you have treated for
scoliosis?
Dr. Gomez: The
youngest idiopathic scoliosis case that I have treated
so far was a case from Colombia--she was one year old.
She is now 16 and never required surgery. With congenital
scoliosis (hemi vertebras and unsegmented bars), which
is more involved, I started to treat a boy when he was
seven months old; he is now 14 and had just one surgery.
And neuromuscular scoliosis (cerebral palsy), around
two years old; the braces for this population are to
provide the best sitting support and prevent progression
in the curves.
Question: What
is your best advice to the mothers on the ISOP group
who are considering a brace when they go out to find
an orthotist to treat their children? What do they need
to look for in that person? What are the questions they
really need to ask him/her?
Dr. Gomez: First,
parents need to read together as much as they can about
infantile idiopathic scoliosis. Second, find a web page
like you have, and find a good advisor. Many times this
is another mom that had the same problem or situation
with her child. She or he will give you their personal
experience, good or bad, with this particular device
or company. Third, visit at least two doctors that you
search and you know that they are in favor of the conservative
treatment using braces. Fourth, visit at least two orthotic
companies and find out who is in charge of the spine
services or department. Just remember that this treatment
may take several years, and your child has to be comfortable
with all the people involved in their treatment.
Question: I want
to thank you so much for your time in answering these
questions. The mothers on the ISOP group have listened
to me rant and rave about you since you have been treating
Lexi. Some of their children cannot wear a series of
plaster casts at this time for different reasons, and
want to explore bracing as a temporary treatment. Hopefully,
they will gain some insight from your expertise in this
field.
Dr. Gomez: Tracey,
I really appreciate this opportunity to share my knowledge
and experience in this. I completely understand how
stressful it is for the child and the family in dealing
with the braces every day. It is worse because we, as
parents, don’t know if the brace is doing the job.
Parents are the best clinicians if they know what to
look for and how to evaluate in simple ways. Part of
my goal is to train parents on this treatment, so they
will now what to look for and expect!
Question: If there
is anything you would like to add that I did not think
of, please share it with us. As a mother, I know we
all want to be as informed as possible.
Dr. Gomez: I just
want to add that the sociological part of this process
is very important and it depends on how we as parents
accept this challenge. We can create problems or be
a factor in prohibiting them. I always recommend involving
the child from the beginning. Ask for their opinion;
let them decide on the color of the brace etc, in the
end they are the ones who have to wear this device.
Just think for a moment, are you willing to wear the
brace as your child is? Keep in mind that these braces
are not torturing devices. Do not use it if it is creating
damage to the skin, ulcers, or any other problems. To
avoid these problems it is necessary to visit the orthotist
who is following the case at least every two months.
If you would like to contact Dr. Miguel Gomez in regards
to brace wearing, his e-mail address is:
jmgomezmd@hotmail.com
jmgomezmd@gorthoticsystems.com
For those of you, like my family, who have to consider
options besides casting, I hope this information is
useful to you. Let me be clear about the fact that Dr.
Gomez is simply sharing his experience with treatment
using braces. None of the information provided is meant
to reflect at all on early treatment with serial plaster
casting. This information is intended to educate
those of us who may have to explore bracing as an alternative
to casting for our children.
I want to say that I am still a proponent of casting.
We had great results with Lexi’s early treatment
with serial corrective plaster casting, and I will continue
to support the work of Miss Mehta and the other doctors
practicing this technique. I am convinced that Lexi’s
original curves would have never decreased to the point
of where bracing was even an option, had we not chosen
to go the “early treatment” route. My
personal thought at this time is that we are getting
positive results with our choice in treatment and we
feel comfortable with this. We have been very fortunate
to find Dr. Gomez and to have the benefit of his wonderful
expertise in orthotics and his exceptional approach
in using these devices in the treatment of scoliosis.
Remember that we are all in this for one reason and
one reason alone: to find the best treatment out there
for our children in hopes that they can each be corrected
to a position where surgery is always the last option
for them.
Please don’t hesitate in contacting me via e-mail,
should you have any questions related to our scoliosis
experience.
Sincerely,
Tracey
(Lexi’s mom)
pthahn@sbcglobal.net
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