Brace Adjustment Research Articles

Do live-stream telemedicine follow-up appointments for a Ponseti-treated clubfoot caseload compare favourably with a face-to-face review? Observed clinical outcomes and treatment provision during the COVID-19 pandemic

Restrictions on face-to-face (F2F) healthcare services during the recent COVID-19 pandemic necessitated novel provision of care for Ponseti-treated clubfoot patients. This retrospective review compares the effectiveness of telemedicine (TM) using live-stream videoconferencing compared to conventional F2F review, in two cohorts of 78 patients attending routine follow-up, during Ponseti-treated clubfoot bracing in their first 5 years. Rates of compliance, recurrence of deformity, and type of intervention provided were compared between cohorts. The TM cohort was re-evaluated F2F as part of routine follow-up care. Attendance rates were compared between cohorts and with an equivalent time period the previous year. There was no significant difference in the rate of compliance between cohorts (77% in the TM group, 74% in the F2F group), or in the rate of recurrence. Subsequent F2F review of the TM cohort showed that compliance had improved in some patients, indicating successful TM intervention. There were no missed cases of recurrence. TM follow-up appointments offered similar rates of management of skin problems, brace adjustment, and provision of exercises. At least one element of intervention was provided in 64% of the TM group, and 72% of the F2F group. TM connection was successful in 74% of booked appointments. The number of patients attending was similar to F2F bookings one year prior. The use of TM for routine follow-up of Ponseti-treated clubfoot patients can be as clinically effective as F2F assessment, and has potential for integration into routine follow-up care.

Lack of in-brace x-rays in compliant AIS patients wearing full-time TLSO braces associates with failure

BackgroundIn-brace correction and brace compliance with thoraco-lumbo-sacral orthotic (TLSO) braces are associated with successful treatment of adolescent idiopathic scoliosis (AIS). This paper compares patients who had consistent radiographic documentation of in-brace correction to those who did not.MethodsAll skeletally immature (Risser 0-2) patients were treated for AIS (25-45°) with full-time TLSO braces that had compliance temperature monitors. All patients wore their braces at least 12 h a day. Brace failure was defined as curve progression to a surgical magnitude (≥ 50°). All patients were followed until brace discontinuation.ResultsNinety patients (F 82, M 8) with an average age of 12.1 (10.1-15.0) years, Risser grade 0 (0-2), BMI percentile 48.5 (0.0-98.8), and daily brace wear of 16.5 (12.1-21.6) h/day were treated for 24.3 (8.0-66.6) months. Patients went through 1.7 (1-4) braces on average. Forty-two out of 90 (46.7%) patients had some amount of brace time with an unknown in-brace correction, which, on average, was 66.1% of their total treatment course (11.5-100). On univariate analysis, patients that did not have a repeat in-brace x-ray with major brace adjustments or new brace fabrication tended to be more skeletally immature (Risser 0 and tri-radiate open, p = 0.028), wear more braces throughout their treatment (2.0 vs 1.4, p < 0.001), were treated for a longer period of time (27 vs 22 months, p = 0.022), and failed bracing more often (47.6% vs 22.9%, p = 0.014).ConclusionsPatients who did not have new in-brace x-rays with major brace adjustments and/or new brace fabrication were 3.1 (95% CI 1.2-7.6) times more likely to fail bracing than patients who were re-checked with new in-brace x-rays.Trial registrationClinicalTrials.gov—NCT02412137, initial registration date April 2015Level of evidenceIII

What's Important: What I Learned as My Spouse's "Recovery Partner" Following Rotator Cuff Surgery.

What's Important: What I Learned as My Spouse's "Recovery Partner" Following Rotator Cuff Surgery.

A Tale of Two Cities: Evolution of Academic Physiatry in Boston and Baltimore: Part 1: The Boston Marathon

A Tale of Two Cities: Evolution of Academic Physiatry in Boston and Baltimore: Part 1: The Boston Marathon

Workflow of CAD / CAM Scoliosis Brace Adjustment in Preparation Using 3D Printing.

Background:High correction bracing is the most effective conservative treatment for patients with scoliosis during growth. Still today braces for the treatment of scoliosis are made by casting patients while computer aided design (CAD) and computer aided manufacturing (CAM) is available with all possibilities to standardize pattern specific brace treatment and improve wearing comfort.Objective:CAD / CAM brace production mainly relies on carving a polyurethane foam model which is the basis for vacuuming a polyethylene (PE) or polypropylene (PP) brace. Purpose of this short communication is to describe the workflow currently used and to outline future requirements with respect to 3D printing technology.Method:Description of the steps of virtual brace adjustment as available today are content of this paper as well as an outline of the great potential there is for the future 3D printing technology.Results:For 3D printing of scoliosis braces it is necessary to establish easy to use software plug-ins in order to allow adding 3D printing technology to the current workflow of virtual CAD / CAM brace adjustment. Textures and structures can be added to the brace models at certain well defined locations offering the potential of more wearing comfort without losing in-brace correction.Conclusions:Advances have to be made in the field of CAD / CAM software tools with respect to design and generation of individually structured brace models based on currently well established and standardized scoliosis brace libraries.

Results of ultrasound-assisted brace casting for adolescent idiopathic scoliosis

BackgroundFour factors have been reported to affect brace treatment outcome: (1) growth or curve based risk, (2) the in-brace correction, (3) the brace wear quantity, and (4) the brace wear quality. The quality of brace design affects the in-brace correction and comfort which indirectly affects the brace wear quantity and quality. This paper reported the immediate benefits and results on using ultrasound (US) to aid orthotists to design braces for the treatment of scoliosis.MethodsThirty-four AIS subjects participated in this study with 17 (2 males, 15 females) in the control group and 17 (2 males, 15 females) in the intervention (US) group. All participants were prescribed full time TLSO, constructed by either of the 2 orthotists in fabrication of spinal braces. For the control group, the Providence brace design system was adopted to design full time braces. For the intervention group, the custom standing Providence brace design system, plus a medical ultrasound system, a custom pressure measurement system and an in-house software were used to assist brace casting.ResultsIn the control group, 8 of 17 (47%) subjects needed a total of 11 brace adjustments after initial fabrication requiring a total of 28 in-brace radiographs. Three subjects (18%) required a second adjustment. For the US group, only 1 subject (6%) required adjustment. The total number of in-brace radiographs was 18. The p value of the chi-square for requiring brace adjustment was 0.006 which was a statistically significant difference between the two groups. In the intervention group, the immediate in-brace correction as measured from radiographs was 48 ± 17%, and in the control group the first and second in-brace correction was 33 ± 19% and 40 ± 20%, respectively. The unpaired 2 sided Student’s t test of the in-brace correction was significantly different between the US and the first follow-up of the control group (p = 0.02), but was not significant after the second brace adjustment (p = 0.22).ConclusionsThe use of the 3D ultrasound system provided a radiation-free method to determine the optimum pressure level and location to assist brace design, resulting in decreased radiation exposure during follow-up brace evaluation, increased the in-brace correction, reduced the patients’ visits to both brace adjustment and scoliosis clinics. However, the final outcomes could not be reported yet as some of patients are still under brace treatment.Trial registrationNCT02996643, retrospectively registered in 16 December 2016

Measurement of Milwaukee Brace Pad Pressure in Adolescent Round Back Deformity Treatment.

Study DesignIn this prospective study, we measured the pad pressures of the Milwaukee brace in adolescent hyperkyphosis treatment.PurposeWe evaluated the skin-brace interface forces exerted by the main pads of the Milwaukee brace.Overview of LiteratureA fundamental factor associated with brace effectiveness in spinal deformity is pad force adjustment. However, few studies have evaluated the in-brace force magnitude and its effect on curve correction.MethodsInterface forces at four pads of the Milwaukee brace were measured in 73 patients withround back deformity (mean age, 14.04±1.97 years [range, 10–18]; mean initial Cobb angle,67.70°±9.23° [range, 50°–86°]). We used a modified aneroid sphygmomanometer to measure the shoulder and kyphosis pad pressures. Each patient underwent measurement in the standing and sitting positions during inhalation/exhalation.ResultsThe mean pad pressures were significantly higher in the standing than in thesitting position, and significantly higher pressures were observed during inhalation compared toexhalation (p=0.001).There were no statistically significant differences between right and left shoulder pad pressures (p>0.05); however, the pressure differences between the right and left kyphosis pads were statistically significant (p<0.05). In a comparison of corrective forces with bracing for less or more than 6 months, corrective force was larger with bracing for less than 6 months (p=0.02). In the standing position, there were no statistically significant correlations between pad pressures and kyphosis curve correction.ConclusionsIn the sitting position, there was a trend toward lower forces at the skin-brace interface; therefore, brace adjustment in the standing position may be useful and more effective. There was no significant correlation between the magnitude of the pad pressures and the degree of in-brace curve correction.

Ultrasound-assisted brace casting for adolescent idiopathic scoliosis, IRSSD Best research paper 2014.

BackgroundBrace treatment is the most effective non-surgical treatment for AIS. High initial in-brace correction increases successful brace treatment outcomes. The objective of this study was to investigate if real-time ultrasound (US) can aid orthotists in selecting the pad pressure level and location resulting in optimal in-brace correction of the spine.MethodsTwenty six AIS subjects participated in this pilot study with 17 (2 M, 15 F) in the control group and 9 (2 M, 7 F) in the intervention group. For the control group, the standard method was used to design their braces. In addition to the standard of care, a medical 3D ultrasound (US) system, a custom pressure measurement system and in-house software were used to select pad placement and pressure levels for the intervention group. The orthotist used a custom standing Providence brace design system to apply pressures against the patient’s torso. The applied pad pressures were recorded. A real-time US spinal image was displayed. Cobb angle measurements from the baseline and the assessment scan were performed. The orthotist then decided if an adjustment was needed in terms of altering the pad locations and pressure levels. The procedures may be repeated until the orthotist attained the best simulated in-brace correction configuration to cast the brace.ResultsIn the control group, 8 of 17 (47%) subjects needed a total of 16 brace adjustments after initial fabrication requiring a total of 33 in-brace radiographs. For the intervention group, the orthotist tried additional configurations in 7 out of 9 cases (78%). Among these 7 revised cases, 5 showed better stimulated in-brace corrections and were subsequently used to cast the brace. As a result, only 1 subject required a minor adjustment after initial fabrication. The total number of in-brace radiographs in the intervention group was 10.ConclusionsThe use of the 3D ultrasound system provided a radiation-free method to determine the optimum pressure level and location to obtain the best stimulated in-brace correction during brace casting. The average number of radiographs per subject taken prior to final brace implementation with the interventional group was significantly lower than the control group.

Ultrasound-assisted brace casting for adolescent idiopathic scoliosis

Objectives There is a short period during rapid growth when a scoliosis brace is most effective. In standard practice, the inbrace correction is not measured during brace casting. The first assessment of the in-brace correction in the follow-up clinic may trigger brace adjustment for improved spinal alignment resulting in delay of effective treatment and increased number of radiographs. The objective was to investigate if real-time ultrasound (US) can aid orthotists in determining the pad pressure level and location resulting in optimal in-brace correction of the spine.

Brace modifications that can result in improved curve correction in idiopathic scoliosis

Background and aimThe purpose of this paper is to share with scoliosis professionals the X-rays of different pad placement levels associated with improved curve correction in a case of idiopathic scoliosis (IS). Scoliosis braces of all types and brands utilize common principles of construction that ensure good fit and function. Equally important to the end result is good patient follow-up care and brace quality control by the orthotist.Design and methodsThis report reviewed the case of an 11-year-old girl diagnosed with IS, focusing on the in and out-of-brace x-rays, as well as the fit and function of the braces. The first brace was a TLSO-type, the second a Cheneau-type brace using a B1 model following the Rigo classification of scoliosis.ResultsThe first TLSO-type brace presented an in-brace X-ray that showed a curve increase. The Cheneau-type scoliosis brace reduced the Cobb angles over 50%.ConclusionsThe biomechanical changes consequent to modifications in brace design and pad placements appeared to have improved the scoliosis and reduced the Cobb angles in this case. An orthotist must provide optimal fit and function of the brace which was prescribed by the referring physician. Adherence to certain basic design principles, and close follow up by the orthotist-especially during growth spurts - are critical to its effectiveness. Specifically, a skilled orthotist must be experienced with the particular brace-type, apply these principles, maintain a good working relationship with both physician and patient to ensure timely brace adjustments essential to continued brace comfort and efficacy.

Bracing According to Best Practice Standards – Are the Results Repeatable?

Background: As has been demonstrated before bracing concepts in use today for the treatment of scoliosis include symmetric and asymmetric hard braces usually made of polyethylene (PE) and soft braces. The plaster cast method worldwide seems to be the most practiced technique for the construction of hard braces at the moment. CAD/ CAM (Computer Aided Design/Computer Aided Manufacturing) systems are available which allow brace adjustments without plaster. As in the Ukraine the CAD/CAM technology is not affordable, we have tried to build our hand made braces according to this standard via cast modelling. Aim of this study is to compare in-brace corrections of our brace built according to Best Practice Cheneau standards by hand with the published results available in literature on Cheneau braces. In-brace correction and compliance clearly determine the outcome of bracing. Therefore the inbrace correction is one of the most important parameters to estimate brace quality. Materials and methods: In-brace correction and compliance clearly determine the outcome of bracing. Therefore the in-brace correction is one of the most important parameters to estimate brace quality. We have been looking at the results achieved in our department after having been trained in the construction, adjustment and use of Best Practice CAD/CAM Cheneau braces. All braces (of 207 patients) made between January 2009 and December 2010 have been reviewed for in-brace correction. As not all of the patients were in the normal range of brace indication, (Cobb 20-45°; age 10-14 years) we have been looking for the appropriate subset from our database fulfilling the following inclusion criteria: Girls only; diagnosis of an Adolescent Idiopathic Scoliosis (AIS); Cobb 20-45°; age 10-14 years). Results: 92 Patients fulfilled the inclusion criteria (Cobb 20-45°; age 10-14 years). Average Cobb angle was 29.2° (SD 6), Average in-brace Cobb angle was 12.8° (SD 6.2). In-brace correction in the whole sample was 56%. Conclusion: After appropriate training the experienced CPO is able to provide a hand made standard of braces comparable to the recent CAD/CAM standard of bracing. In principle the results may be repeatable. Further studies on our hand made series of braces are necessary (1) to evaluate brace comfort and (2) effectiveness using the SRS inclusion criteria.

"Brace Technology" Thematic Series - The ScoliOlogiC® Chêneau light™ brace in the treatment of scoliosis.

BackgroundBracing concepts in use today for the treatment of scoliosis include symmetric and asymmetric hard braces usually made of polyethylene (PE) and soft braces. The plaster cast method worldwide seems to be the most practiced technique for the construction of hard braces at the moment. CAD (Computer Aided Design) systems are available which allow brace adjustments without plaster. Another possibility is the use of the ScoliOlogiC™ off the shelf system enabling the Certified Prosthetist and Orthotist (CPO) to construct a light brace for scoliosis correction from a variety of pattern specific shells to be connected to an anterior and a posterior upright. This Chêneau light™ brace, developed according to the Chêneau principles, promises a reduced impediment of quality of life in the brace. The correction effects of the first 81 patients (main diagnosis Adolescent Idiopathic Scoliosis (AIS) [n = 64] or Early Onset Scoliosis (EOS) [n = 15]), treated according to the principles of the Chêneau light™ brace have shown a satisfactory in-brace correction exceeding 50% of the initial Cobb angle.Brace descriptionThe ScoliOlogiC® off the shelf bracing system enables the CPO to construct a light brace for scoliosis correction from a variety of pattern specific shells to be connected to an anterior and a posterior upright. This brace, when finally adjusted is called Chêneau light™ brace. The advantage of this new bracing system is that the brace is available immediately, is easily adjustable and that it can also be easily modified. This avoids construction periods of sometimes more than 6 weeks, where the curve may drastically increase during periods of fast growth. The disadvantage of this bracing system is that there is a wide variability of possibilities to arrange the different shells during adjustment.ResultsThe Cobb angle in the whole group was reduced by an average of 16,4°, which corresponds to a correction effect of 51%. The differences were highly significant in the T-test (T = 17,4; p < 0,001). The best correction effects achieved with Chêneau braces reported in literature so far are about 40% in two different studies. The correction effect was highest in lumbar and thoracolumbar curve patterns (62%; n = 18). In thoracic scoliosis the correction effect was 36% (n = 41) and in double major curve patterns 50% (n = 22). The correction effect was affected in a slightly negative way due to age (r = -0,24; p = 0,014), negatively with the Risser stage (-0,29; p = 0,0096) and correlated negatively with the Cobb angle measured before treatment (r = -0,43; p < 0,0001).ConclusionsThe use of the Chêneau light™ brace leads to correction effects above average when compared to correction effects of other braces described in literature. The reduction of material seems to increase patient's comfort and reduces the stress patients may suffer from whilst in the brace.80% of the adolescent population of scoliosis patients can be braced with the Chêneau light™ brace. In certain patterns of curvature and in the younger population with an age of less than 11 years, other approaches have to be used, such as plaster based bracing or the application of CAD/CAM based orthoses.

Treatment of chronic low back pain in patients with spinal deformities using a sagittal re-alignment brace

BackgroundFor adult scoliosis patients with chronic low back pain bracing is initially indicated before spinal surgery is considered. Until recently there has been a lack of research into the effect upon pain reductions in the mid and long-term. Promising results have been documented in short-term studies for the application of a sagittal re-alignment brace in patients with spinal deformities and along with pain; however mid-term and long-term results are not yet available. The purpose of this study is to investigate the mid-term effects of this brace with respect to pain control.Materials and methods67 patients (58 females and 9 males) with chronic low back pain (> 24 months) and the diagnosis of scoliosis or hyperkyphosis were treated with a sagittal re-alignment brace (physio-logic brace™) between January 2006 and July 2007. The indication for this kind of brace treatment was derived from a positive sagittal re-alignment test (SRT) and the exclusion of successful conservative treatment during the last 24 months. The aim of this type of conservative intervention was to avoid surgery for chronic low back pain.ResultsThe average pain intensity was measured on the Roland and Morris VRS (5 steps) before treatment. This was 3.3 (t1), at the time of brace adjustment it was 2.7 (t2) and after at an average observation time of 18 months it was 2.0 (t3). The differences were highly significant in the Wilcoxon test.DiscussionShort-term measurements showed that a significant pain reduction is possible in chronic postural low back pain using a sagittal re-alignment brace inducing lumbar re-lordosation. In a preliminary report at adjustment (t2), highly significant improvements of pain intensity have also been demonstrated. At 6 months of treatment however, no improvement was measured. The improvement of the mid-term effects (18 months) found in this study compared to the preliminary report may be due to the changed approach to compliance: whilst the bracing standard was not changed; the patients in this study were obligated to wear the brace for a minimum of 20 hrs per day for the first 6 months of treatment.ConclusionThe effect of the sagittal re-alignment brace leads to promising short-term improvements in patients with chronic low back pain and spinal deformities. Contrary to unspecific orthoses, which after a short period without persistent pain reduction are omitted by the patients, the sagittal re-alignment brace (physio-logic™ brace) leads to an effective reduction of pain intensity in mid-term even in patients who have stopped brace treatment after the initial 6 months of treatment. In conservative treatment of chronic low back pain specific approaches such as the sagittal re-alignment brace are indicated prior to considering the surgical options.

Correction effects of the ScoliOlogiC "Chêneau light" brace in patients with scoliosis.

BackgroundDifferent bracing concepts are used today for the treatment of scoliosis. The plaster cast method worldwide seems to be the most practiced technique at the moment. CAD (Computer Aided Design) systems are on the market which allow brace adjustments without plaster. The latest development however, is the use of the ScoliOlogiC™ off the shelf system enabling the orthopaedic technician to construct a light brace for scoliosis correction from a variety of pattern specific shells to be connected to an anterior and a posterior upright. This „Chêneau light" brace, developed according to the Chêneau principle, promises a reduced impediment of quality of life in the brace. However, material reduction should not result in reduced effectiveness. Therefore the primary correction effect in the „Chêneau light" brace has been evaluated and compared with that of other braces used today.MethodsThe correction effects of the first 81 patients (main diagnosis Adolescent Idiopathic Scoliosis (AIS) [n = 64] or Early Onset Scoliosis (EOS) [n = 15]), treated according to the principle of the „Chêneau light" brace were evaluated after an average treatment time of 6 weeks by a full-body X-ray made in the standing position whilst wearing the brace and compared with the last X-ray before bracing. The average curvature angle of the whole group was 35,6°, the average age was 12,9 years (SD 1,9), average Risser sign was 1,3 (SD 1,5), average Tanner rating 2,75 (SD 0,7).ResultsThe Cobb angle in the whole group was reduced by an average of 16,4°, which corresponds to a correction effect of 51%. The differences were highly significant in the T-test (T = 17,4; p < 0,001). The best correction effects reported in literature so far are about 40% in two different studies. The correction effect was highest in lumbar and thoracolumbar curve pattern (62 %; n = 18). In thoracic scoliosis the correction effect was 36 % (n = 41) and in double major curve pattern 50 % (n = 22). The correction effect correlated slightly negative with age (r = -0,24; p = 0,014), negatively with the Risser stage (-0,29; p = 0,0096) and correlated negatively with the Cobb angle measured before treatment (r = -0,43; p < 0,0001).ConclusionThe use of the „Chêneau light" brace leads to correction effects above average when compared to the correction effects of other braces described in literature. The reduction of material seems to affect the desired correction in a positive way.

A 3D visualization tool for the design and customization of spinal braces

A new tool was developed and validated on an X-ray dummy to allow personalized design and adjustment of spinal braces. The 3D visualization of the external trunk surface registered with the underlying 3D bone structures permits the clinicians to select pressure areas on the trunk surface for proper positioning of correcting pads inside the brace according to the patient's specific trunk deformities. After brace fabrication, the clinicians can evaluate the actual 3D patient–brace interface pressure distribution visualized simultaneously with the 3D model of the trunk in order to customize brace adjustment and validate brace design with respect to the treatment plan.

Nonoperative Correction of Pectus Carinatum with Orthotic Bracing

This study sought to evaluate the efficacy of nonoperative compression in correcting pectus carinatum in children. Children presenting with pectus carinatum between August 1999 and January 2004 were prospectively enrolled in this study. The management protocol included custom compressive bracing, strengthening exercises, and frequent clinical follow-up. There were 30 children seen for evaluation. Their mean age was 13 years (range, 3-16 years) and there were 26 boys and 4 girls. Of the 30 original patients, 6 never returned to obtain the brace, leaving 24 patients in the study. Another 4 subjects were lost to follow-up. For the remaining 20 patients who have either completed treatment or continue in the study, the mean duration of bracing was 16 months, involving an average of 3 follow-up visits and 2 brace adjustments. Five of these patients had little or no improvement due to either too short a follow-up or noncompliance with the bracing. The other 15 patients (75%) had a significant to complete correction. There were no complications encountered during the study period. Compressive orthotic bracing is a safe and effective alternative to both invasive surgical correction and no treatment for pectus carinatum in children. Compliance is critical to the success of this management strategy.

Dr. Szigethy and Colleagues Reply

Back to table of contents Previous article Next article Letter to the EditorFull AccessDr. Szigethy and Colleagues ReplyEVA M. SZIGETHY, M.D., Ph.D., PEDRO RUIZ, M.D., DAVID R. DeMASO, M.D., and WILLIAM R. BEARDSLEE, M.D., EVA M. SZIGETHYSearch for more papers by this author, M.D., Ph.D., PEDRO RUIZSearch for more papers by this author, M.D., DAVID R. DeMASOSearch for more papers by this author, M.D., and WILLIAM R. BEARDSLEESearch for more papers by this author, M.D., Houston, Tex.Published Online:1 Dec 2002https://doi.org/10.1176/appi.ajp.159.12.2117AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: We thank Dr. Wystanski and Dr. Fishbain for their thoughtful comments on our recent case report of an adolescent with complicated emotional and physical illness complaints. We wholeheartedly agree with Dr. Wystanski that it is not diagnoses we treat but the patient. He raises two additional important issues: 1) Was the diagnosis of depression accurate? 2) Would diagnosing Angela with either an anxiety or conversion disorder have changed the treatment algorithm used? Clearly, in all patients we identify target symptoms to guide our treatment approach. Angela had a symptom cluster most consistent with a depressive disorder. She did have additional symptoms in the realm of anxiety and even somatoform disorder. However, she only met full DSM-IV diagnostic criteria for depression, which provided us a framework around which to organize treatment. Having such a framework was important from two perspectives: 1) it allowed us to integrate empirically driven interventions for depression, such as paroxetine, cognitive behavior therapy, and family psychoeducation; and 2) it allowed us to organize the complex information for her family to help them develop a more cohesive illness narrative. Certainly, had Angela not shown progress in both physical and emotional symptom remission, we would have reformulated the case to consider other diagnostic possibilities and other treatment approaches. Using depression as the illness model allowed Angela’s family to recognize the early signs of a more clear-cut depressive episode 1 year after her hospital discharge and to reseek the appropriate treatment after they had self-terminated treatment. Although on the surface, similar medications and therapeutic approaches could be used to treat anxiety or somatoform symptoms, we argue that there would have been subtle differences in the interventions, such as the specific manual-based cognitive behavior therapy modality used, the psychoeducational approaches used with the family, and the target symptoms tracked to determine the medication algorithm used.We agree with Dr. Fishbain that Angela’s chronic neck pain in the context of neck torticollis was essential to address as part of a comprehensive treatment, and we did. We are fortunate to have a first-rate inpatient pain service at our children’s hospital, and as stated in the case report, pain treatment staff were consulted and involved in treatment decisions. The pain management physician also helped medicate the patient with intravenous methohexital for neck brace adjustments so the patient could practice relaxation techniques without distraction from pain. The integration of the pain treatment with the psychiatric and medical care Angela received led to a full remission of her symptoms, and thus it was not necessary to refer her to an outside pain treatment facility, a reasonable option had her pain not remitted. FiguresReferencesCited byDetailsCited ByNone Volume 159Issue 12 December 2002Pages 2117-2117 Metrics History Published online 1 December 2002 Published in print 1 December 2002

Brace treatment of Colles' fracture.

Twenty patients with Colles' fractures were treated with a functional brace that allows wrist motion. The result was compared with a similar group of patients treated with a plaster cast. Dorsal displacement of the fracture was less and wrist function was better in the brace group. Swelling of the hand during the early stages was observed in the brace group; and because this may necessitate brace adjustment, increased medical supervision is necessary for this period.