June - Scoliosis Awareness Month

Yet again I've left it over a year between posts! There are probably many reasons. Busyness, less changes in Evelyne, more stability as she ages, or maybe I don't 'need' to put my feelings and thoughts down like I used to. Not sure. But I have been again reminded recently how helpful my blog has been to others over the years. I started this blog as there was little to no info out there about Beals Syndrome. Now 8 years later not much has changed. There is still barely anywhere to find out about Beals Syndrome, and even less helpful information for a new parent faced with an unknown diagnosis.

I am frequently contacted my young mums and dads faced with a baby who doctors 'suspect' has Beals Syndrome. They turn to google to look for answers to no avail, just as I did. It brings me straight back to the uncertainty I felt. Holding my little baby and unsure of the future. I have been encouraged by them to continue writing our story down, so here I am!

Evelyne - enjoying mushroom picking in the forest this Autumn

I have spent the last month looking back through photos as I was thinking of writing a post about how far Evie has come. But where do I start! The early years of casting and bracing, the photos of her in appointments and procedures, or the photos of her showing her determination to be a kid despite her physical struggles. She has been through so much and continues to amaze me.

With June being scoliosis awareness month I am again motivated! Whilst there is so much more to Beals Syndrome, for Evie, her scoliosis has been by far the biggest impact to her life.
When she was just a tiny baby, 10 weeks old, I noticed a bump on her back and realised something was not right. It did not take long before we realised she had a rapidly progressing kyphoscoliosis, which meant her spine was curving outwards as well as sideways. 

Over the past 10 years Evie has gone through 4 casts, 9 braces, 2 major surgeries and 12 lengthenings. The years of casting and bracing were not easy with the effect to her lungs, mobility and energy levels. Whilst surgeries and lengthenings are also hard and risky, Evie is now growing taller, stronger, has more lung capacity and thrives in so many ways. You would not know what she has been through to see her now, and many new friends are astounded when I share her story. She loves singing, debating, public speaking, musical theatre, art and craft, and brings joy to so many people. We are so grateful for the amazing medical assistance we get here in Australia, our wonderful Orthopaedic Surgeon and the new technology that is available.

Dr Min Mehta

Dr Min Mehta passed away yesterday in the UK. She was a pioneer in the understanding of infantile scoliosis and her research into scoliosis and treatment has changed the outcomes for many children across the world.

The below is an excerpt from the Infantile Scoliosis Project website on her life and achievements.

Min H. Mehta, M.D., F.R.C.S

“From the age of six, I always knew I wanted to be a doctor. That is true; it has never changed” says Dr. Min Mehta about her life’s work. “Miss” Mehta, as she is respectfully called by her British colleagues, is the world’s foremost expert on infantile scoliosis.

Miss Mehta tells the story of discovering her own adolescent scoliotic curve. “At about age 11 ½,” she recounts, “my parents and other adults began to tell me to ‘sit up straight.’ At last a family friend–a nurse–said, ‘the child can’t sit up straight – she has a scoliosis.’” And, Dr. Mehta observes, the process of detecting scoliosis hasn’t changed much over the years.

Dr. Mehta attended medical school in her native Calcutta, India. During the course of her training, she discovered that she was interested in surgery, and had a natural aptitude for it. After completing a three-year surgical training program in Calcutta, she moved to Britain to continue her studies and gain further qualifications. There, she took her Fellow Royal College of Surgeons (FRCS) examination, which is necessary to become a surgical specialist, intending at that time to practice neurosurgery.

Miss Mehta was required to study orthopaedics as well, to pass her examinations. She had the good fortune to work with Mr. Wiles and Mr. Batchelor, two of the foremost orthopaedic surgeons of the time at London teaching hospitals. As a result, she became so intrigued by orthopaedics that she changed her specialty focus.

Quickly, Dr. Mehta began to appreciate the challenge she had taken on. “It will be tough because you’re a woman,” one of her teachers cautioned. “But you must go for it, because you are good.” It was the 1950s. Miss Mehta, because of her gender, faced enormous difficulties securing interviews for the positions she needed to advance her career. There were few female surgeons practicing in Britain at the time, and the establishment was eager to maintain status quo. She made dozens of applications and received no calls to interview. Eventually, Miss Mehta received an application form that did not ask the formidable “gender” question. She returned it and, due to her impressive credentials, was invited immediately to interview. Although they were surprised to see a woman, it happened that none of the other three applicants for the post showed up for their appointments. She landed the position.

In 1968, Miss Mehta was the second woman in history to be awarded the prestigious Robert Jones Prize and Gold Medal in Orthopaedics for her work on “A Study of Infantile Scoliosis.” By then, she had already discovered the Rib Vertebral Angle Degree (RVAD), which is the standard and routinely accepted measurement approach employed today to determine whether a scoliotic curve is progressive. She had also come to understand the benefits of early treatment of progressive infantile scoliosis. However, the journals would not publish this work because they felt there was not enough evidence.

A year later in 1969, still struggling to climb the London surgical ladder due to her gender, Dr. Mehta returned to India. She worked in major teaching hospitals in New Delhi and Calcutta for five years. Her paper on the RVAD was published in the Journal of Bone and Joint Surgery in 1972, while she was practicing in India. In 1974, Miss Mehta moved back to England, stepping into a hard-earned and well-deserved position:
Senior Lecturer in Clinical Research at the Institute of Orthopaedics, University of London. She also served as an Honorary Consultant in Scoliosis at the Royal National Orthopaedic Hospital during this time, until 1992 (this is the British equivalent to the American “Chief of Surgery” position).

Since then, Dr. Mehta has continued her research on non-surgical methods of treatment for infantile, congenital and adolescent idiopathic scoliosis at the Royal National Orthopaedic Hospital. Although Dr. Mehta has “officially” reached the British obligatory age of retirement, she continues to passionately pursue her life’s work. She continues to see private patients. The paper, “Growth as a corrective force in the early treatment of progressive infantile scoliosis,” published in September 2005 in the British Editorial Society of Bone and Joint Surgery, chronicles years of infantile scoliosis case studies.

Now, Dr. Mehta knows, her challenge is to spread the message about her findings and methods; to educate as many doctors and to help as many children as possible. “It is easy to learn how to apply a plaster jacket,” she says about the casting technique she has perfected. “The trick is to learn to look critically at each child and understand how it can be assisted. The earlier you treat children, the greater the chance of making them straight. But all children are different: their build, tissues, size, and shape vary. Some can be straightened completely and, for some, it may be too late. They are like little drooping flowers. Braces don’t work, and the flower will just flop back to the way it was. It needs to get is own sap, so it can hold itself straight.”

“I intend to keep on and on, to see that these messages are delivered,” Miss Mehta insists. And the Infantile Scoliosis Outreach Program is determined to help her achieve that goal.
Copyright 2017 Ability Connection Colorado. All rights Reserved

Growth as a corrective force in the early treatment of progressive infantile scoliosis 

by Min H. Mehta, M.D., F.R.C.S. Published in The Journal of Bone and Joint Surgery (Br) Sept 2005

The story of Mehta casting being brought to US
The Greatest Gift - Dec 19 2000

The time is drawing near

Evelyne had a spinal appointment this week. We have been plodding along since last winter with the current brace, but can tell she is growing more uncomfortable. Evie has had a few issues with redness and pressure on the point of her kyphosis, and occasionally issues with pain, but it's been pretty non-eventful. Every time we see the specialist we get asked "...and how old is she now?"... with the underlying question being "is she old enough for growing rods yet?". This time was no different, however, I think I knew that now Evie is aged 6 we are getting closer. 

They first mentioned surgery when she was 3, and we have persisted in casts and braces for the past 3 years to try to hold off until she is bigger. Basically, the older/bigger they are, the less complications and the more successful the surgery.

The specialist is wanting to try another brace design first, to see if we can hold off slightly longer, however it looks like surgery will be in the near future rather than the distant future. In his words "I'd rather put growing rods in an 8 yr old than a 6 yr old, however we have done well to be putting them in a 6 yr old rather than a 4 yr old". We have a brace review at the end of January to discuss options for a new design which might help, however it is clear surgery is not too far away.

Evie, brace free, with her cousin Lydia

One positive is that it looks like she is eligible for Magec rods - magnetic growing rods. This means she will not have to have surgery every 6 months, but the rods can be lengthened via magnets. I wrote about it here over 3 years ago when I heard of it, hoping it may be an option for Evie. 

I am nervous for what the future holds, but I trust our specialist and his experience, and I am happy with how long we have managed to delay surgery so far.

A catch up and a birthday

It has again been a long time since I've posted. Thank you to those who sent lovely messages asking asking how we were going. In my last post Evelyne was in a cast and we were praying she could last until the 6-week check without developing pressure sores. 
And she did! 
It was a hard 6 weeks, and we went through various times when we thought we might need to cut the cast off. I always find it difficult to know what to do. As you cannot see what's under the cast, it is up to us to decide if we think she has a pressure sore or not. Which is ultimately based on if we think her pain and discomfort is increasing. 
She got the cast cut off at the follow up appointment, revealing a few surface sores developing, but no need for dressing. It was wonderful news!

The next day she was cast for a new brace and then fit the day after that. The quick turn around this time was great, with her new brace x-ray measuring the same as her cast x-ray at 53 degrees for the lumbar curve in the brace.

Note that her new brace is plain purple this time, as she is apparently now too grown up for butterflies and bunny rabbits.









MY BIG 6 YEAR OLD

This week my 'grown up' girl celebrated her 6th birthday. I've included a couple of photos from her 'Frozen' themed party with school friends.

Another winter, another cast

Last Friday Evelyne had another spinal cast applied in Sydney.
It is always tough leading up to casting, emotionally preparing for pain, discomfort and sleepless nights. I am usually a mess the week before. And this time was no different. But as usual Evie was relatively calm and although she admitted she was not looking forward to the cast "because it hurts more, and you cant take it off!", she was her normal happy, positive self before (as you can see from the photo).

She recovered after the general anesthetic much better than her last cast, and was able to stand and walk quicker also. However she still needed pain killers and was in alot of pain if they wore off. She also slept very well the first few days and managed the 3 hr car trip home to Bathurst the next day with only one stop. 

We again decorated her cast in her choice of print, and her doll Milly (now renamed Annabelle) again shared the same design.

One week on she is still struggling to sit for periods of time and prefers to stand, kneel, use a bean bag or lie on her tummy. And at times she still needs pain medication. Evelyne attempted school for a few hours each day Tues-Fri, with the help of her aide, and although the first few days went well she only lasted half an hour Friday before her back was hurting too much and she needed to come home.

I'm not sure what the next few weeks will hold. It's hard not thinking that she may already have a pressure sore, but maybe she is still just adjusting to the change in her spine position. I recall it taking about a week to recover last year also. We are also awaiting the x-ray results to see what angle the cast has achieved. In the meantime we continue to pray for her to be more comfortable and that this cast will last longer than the others.

Another short-lived cast

On Friday we had Evelyne's cast cut off. It had been on for 5 weeks this time, so I was happy that it was a longer stint than the last one. We had three good weeks after she got used to the new cast. She was happy, independent and enjoyed playing at home and preschool. However over the last week she started complaining of pain. In particular she found sitting in chairs and in her carseat difficult, and she started waking in pain through the night also.

As a result we had the cast cut off locally. It was a very hard decision, as we really wanted this one to last longer. The ordeal of travel, general anaesthetics and xrays mean that the longer a cast can last, the better. However the change in her mood was demonstrating that something was wrong. We found that again there was a pressure sore on the point of her kyphosis. In the same spot as the last one. This sore was slightly wider, but thankfully not as deep as the previous sore. 

It is disappointing, but I am glad that we made the right decision. Leaving it longer would have meant a deeper sore, and a longer time for it to heal without any sort of support. On the positive side, Evelyne is enjoying her 'freedom' and she can now put on her shoes and socks by herself. The sore is healing well and we may even be able to put her brace back on her this week. Plus the first bath in 5 weeks was exciting!

P.S. Milly had her 'cast' cut off too. Evie talked her through the procedure and she was very brave.

Curve progression and casting

Evelyne's last x-ray in her quad brace showed that the curve had again progressed. It was not a huge surprise to us, as we could visually see the spine not staying in place in her brace.  Her scoliosis had progressed to 57 degrees in the brace. As a result we decided to go ahead with casting while we are still in the cooler months. I was quite optimistic about how the casting would go this time around. She is older, walking, not in nappies, feeding herself. All factors that made the cast when she was 12 months difficult. I continue to forget however that each new step brings it's own challenges!

Last week Evelyne was fitted for the new cast.  It was done by our new specialist on the 'risser frame' in the same style as the 'Mehta' casts. She was put under a general anaesthetic and they needed at least an hour to mould it to shape.

Waiting                                                                     Recovery

Leaving the hospital

The next few days were very hard.

Day 1 was especially as she struggled to learn to balance again under the weight. Simple things like walking and sitting up were difficult.

By day 2 she was up and walking and even trying to run a little, but still unable to get on and off the toilet herself, turn over in bed, and get on and off chairs.

Day 5 I took her back to our local physio to trip some of the plaster from around her arm holes to improve movement in her shoulders.

Day 6 She was at preschool playing in the playground with the other kids.


Today, 10 days on and she is her normal happy self. 
She is sleeping in her own bed, playing, running, dancing (although she still needs help for the toilet).  She copes better than I do when she goes through a new stage. 

It takes me a while to get used to seeing her struggling. It is also hard getting used to seeing how bulky it is on her. However she has the determination to work at it until she achieves what she wants. She's my little trooper!

New specialist, new brace

A few months ago we had an assessment with a new specialist. We discovered a spinal surgeon in Sydney that has hands on training in Mehta casting and wanted his option on Evelyne's spine and the possibility of casting in order to postpone surgery.

He informed us that bracing is not very effective in controlling the curve once it's over 40 degrees (as we knew). When he examined her the curve was over 50 degrees in the brace, and so he suggested the best way forward was to try Mehta casting to attempt to get the curve under control.  We decided that over the summer before using Mehta casting that we would have one more attempt at bracing with a new design methodology. 

The new brace has been more uncomfortable and restrictive with numerous complaints from Evelyne when putting it on and more when traveling in the car. It also has a tendency to put holes in her clothing. However after 4 weeks in this new brace, today we had an x-ray. The x-ray showed a curve of only 41 degrees! It is encouraging to see that the brace has reduced the curve, however we will still have to monitor how well she is tolerating the discomfort and watch for any pressure areas. The next few years will be a juggle between wanting treatment to be effective, but making sure it is able to be tolerated by Evelyne.

Brace shirts

Evelyne has had frequent problems with rubbing from her brace. This has significantly worsened in the new higher design, in particular under her arms. Through a couple of my online contacts, I heard of shirts specially made for under casts and braces. There are different types, one brand called 'knit-rite' which make a cast t-shirt (to be worn under a plaster cast), and another 'the Boston T' or 'the Boston Silver T' (made for boston braces). They reduce perspiration, bacteria, are cooler in summer, and can be changed to reduce smelling and itching. 


I tried to find the shirts online and always hit brick walls. The main being that they would not ship to Australia. In a last attempt to find one I posted a request on an online forum for infantile scoliosis. Success! Within a week I had an offer to post some to me from the US and not long after they arrived. The shirts we got sent are the Boston Silver T and are specifically designed for a brace. They even have flaps under the arms to reduce rubbing in that area. They have made a phenomenal difference to Evelyne's comfort levels. She is kept cooler, less sweaty and smelly, and most importantly - no sores under the arms or on her spine!


Here is a picture of her showing off her new singlet.

Reflux and pressure sores

Unfortunately, there are many 'side effects' of having a brace or cast on.

Two we are dealing with daily are reflux and pressure sores.

Both my kids had reflux as babies, Samuel took until he was 4 to grow out of his and wean him off his medication. Evelyne's reflux was not as severe as a baby, and it wasn't until we applied the cast that it became much worse and medication was needed. The tightness of the casts and braces squeeze and put pressure on the tummy and can cause the contents to be pushed back into the oesophagus. It is also uncomfortable to eat big meals and I've heard others with spinal braces as teenagers recommend smaller, more frequent meals. At the moment Evelynes reflux is managed with medication, leaving more time between meals and bed, and avoiding some foods close to bedtime.

Pressure sores are also reasonably common on the bony prominences of the kyphosis of the spine (the hump), and sometimes on the hips where the brace or cast sits. Evelyne has a constant red area on her back which occasionally breaks open and requires something like duoderm to dress it. Fortunately in a brace, you can check it and dress it if needed, in a cast often sores are open and remain untreated. In the picture you can see the gel dressing with a groove in it from the brace digging in! (The red area is a birth mark).

Both these issues can be painful for her, but unfortunately, they are the lesser of the two evils. The treatment of her spine and attempting to manage the progression of her scoliosis is more important at this stage. So for now, we attempt to alleviate the symptoms as best we can.

Casting for a new brace

Evelyne was casted for her new brace yesterday.  It was our third casting without a general anaesthetic.  I took the camera in this time as it's been hard to explain exactly how it all happens. 

She was amazing! She was clearly not very keen, but stayed still and whimpered only when the plaster first went on.  I was very proud of her! Sam sang songs to her while it was happening, and watched with interest. I should have taken a photo of him too!

Getting ready with a stocking type covering against her skin

Strapping her on the bed

My mum calls the 'bed' a 'rack'

Applying the plaster bandages

 Waiting for the plaster to dry

Cutting the plaster off

We will pick up the new brace next week. She picked pink butterflies! It will be a lot higher than her last brace and therefore more restrictive. We are hoping and praying she will tolerate it and also that it may be effective in holding off operating for a bit longer.

Casts and Braces

I'm by no means an expert in this area.
All I know is what I've experienced and a few snippits I've learnt recently from my Beals connections. The braces and casts vary depending on the height of the curve and the specialist team.  Some examples of braces and casts I've seen recently:

In infantile scoliosis a cast or brace is used to control the curve.  In some cases of infantile scoliosis, the curve can be improved.  One of my new 'facebook friends' has a son in this situation.  Her son does not have Beals Syndrome, but was born with infantile scoliosis.  He is responding well to casting.  See his progress here. 


Unfortunately, in Beals Syndrome, the curve tends to continue to develop regardless. 
As you can see from Evelynes x-rays in my post on scoliosis.
Casting or bracing can still be used however in an attempt to slow down the progress of the curve.  I've learned recently that a plaster cast tends to get better results than a brace.


As you may imagine, casts in babies or toddlers can be difficult.  
They can be hot, heavy, and uncomfortable. They make fitting clothes difficult. 
If they're not walking yet it is difficult to hold them and carry them around. 
Casts can't be removed, so no baths.  
It's also important to try and keep them clean and dry. 
Fun with a toddler!


Some ways I managed were:

• Gorgeous, large, waterproof bibs made by my mum
• Still allowing some 'controlled' waterplay with a smock
• Antiseptic powder for those nappy explosions
• Smaller nappies, changed more frequently to fit under the cast
• Larger, elasticised clothing such as leggings
• Clothes with higher necklines
• Unfortunately avoiding things like sandpits and the beach
• A portable air conditioner in her room in summer
• A lightweight pram in the boot at all times.  Other mums I know have used slings or backpacks.

The last picture is of course what not to do!!

Scoliosis

One of the possible features of Beals Syndrome is scoliosis.  It does not develop in all Beals cases, and some cases will only develop in adolescence or later in life. Due to the connective tissue disorder the scoliosis will continue to worsen with age if not treated.  One article I read, stated it has a 'tendancy to rapid progression'.  If not treated this can result in restrictive lung disease and the possibility of other issues with internal organs. 

In Evelyne, we discovered the scoliosis at 4 months of age. The first x-rays showed a small but distinct scoliosis (first x-ray below). She was booked into the spinal clinic to monitor the curve. Each x-ray showed the curve clearly worsening.  


At this stage they wanted to monitor the curve, and await the diagnosis before proceeding with any treatment.  The hope was that the spine might stabilise. The physios made a special chair for Evelyne in order to try to protect her spine and limit degeneration. She was known as "Queen Evelyne" at playgroup - sitting on her throne! 

In December 09, when the diagnosis of Beals was confirmed, the Doctors went into overdrive!  We had a meeting with about 5 specialists in the room to discuss treatment.  It was decided that Evelyne should be put straight into a plaster cast. 


Evelyne was in the cast for 3 months. This was an extremely difficult time.  The cast was made from plaster covered with fibreglass.  It was heavy and hot, and difficult to change nappies and keep her clean.  She could not bath or swim and struggled under its weight as she tried to master standing and walking.


We moved onto a fibreglass brace from this point which can be removed for about an hour a day. In this first brace the curve was reduced to 35 degrees.  Although I was surprised it was still so high, the doctors were happy with 'maintaining' the curve at this level. In Evelyne's case, the aim to cast or brace was not to 'cure' or 'fix' the curve, but to maintain it to a safe level until they operate at some stage in the future. In the second brace the curve had worsened to 40 degrees. The third brace was thus organised.  We will find out how the curve is progressing in this brace later this week.

Brace 1                           Brace 2                        Brace 3 - with brother Sam 


I plan to write more in the future about: my tips and tricks for living with casts and braces; dealing with general anaesthetics; casting without sedation; future surgery.