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LindaRacine
02-07-2010, 01:38 PM
Spine (Phila Pa 1976). 2010 Jan 28. [Epub ahead of print]
The Costs and Benefits of Nonoperative Management for Adult Scoliosis.

Glassman SD, Carreon LY, Shaffrey CI, Polly DW, Ondra SL, Berven SH, Bridwell KH.

From the *Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, KY; daggerLeatherman Spine Center, Louisville, KY; double daggerDepartment of Neurological Surgery, University of Virginia, Charlottesville, VA; section signDepartment of Orthopaedics, University of Minnesota, Minneapolis, MN; paragraph signDepartment of Neurosurgery, Northwestern University, Chicago, IL; parallelDepartment of Orthopaedic Surgery, University of California, San Francisco, CA; and **Department of Orthopedic Surgery, WA University School of Medicine, St. Louis, MO.

STUDY DESIGN.: A prospective cohort of adult scoliosis patients treated nonoperatively had a minimum of 2-year follow-up during which time data were collected on the type and quantity of nonoperative treatment used. OBJECTIVE.: To quantify the use, cost, and effectiveness of nonoperative treatment for adult scoliosis. SUMMARY OF BACKGROUND DATA.: A 2007 systematic review of nonsurgical treatment in adult scoliosis revealed minimal data, and concluded that evidence for nonoperative care was lacking. METHODS.: Duration of use and frequency of visits were collected for 8 specific treatment methods: medication, physical therapy, exercise, injections/blocks, chiropractic care, pain management, bracing, and bed rest. Costs for each intervention were determined using the Medicare Fee schedule. Outcome measures were the SRS-22, SF-12, and ODI. Analysis was performed for the entire group, and for subsets of high (ODI, >40), mid (ODI = 21-40) and low (ODI, </=20) symptom patients. RESULTS.: A total of 123 patients (111 females, 12 males) with a mean age of 53.3 (18-79) years were evaluated. In 55 scoliosis patients who received no treatment, the only significant change in HRQOL measures over the 2-year period was in SRS satisfaction subscore (0.3 points, P = 0.014). Among the 68 adult scoliosis patients who used nonoperative resources, there was no significant change in any of the HRQOL outcome parameters. Mean treatment cost over the 2-year period was $10,815. Mean cost over the 2-year period averaged $9704 in the low symptom patients, $11,116 in the mid symptom, and $14,022 in the high symptom patients. CONCLUSION.: This study questions the value of nonoperative treatment commonly used for adult scoliosis patients. Documented costs are substantial and noimprovement inhealth status was observed. An important caveat is that treatment was not randomized and therefore the treatment group might have deteriorated if not for the treatment they received.

Pooka1
02-07-2010, 01:46 PM
I wish they included chanting and prayer...

hdugger
02-07-2010, 02:03 PM
I'm not sure how to evaluate this data without a control group of similarly-aged patients who have had surgical treatment. Also, are these people who have *never* had any scoliosis surgery? Or does it include people who are being recommended revision surgery?

mamamax
02-07-2010, 02:37 PM
This study was designed to weigh the benefits of non operative methods against the costs of non operative methods.

A study design in 2007 that does not define what type of physical therapy, what type of exercise, what type of bracing, or what type of chiropractic care .. leaves me with a lot of questions.

Can we presume that the treatment referrals were from surgical practices? In which case I would expect the referral treatments to be ultra conservative methods which we already know are not highly successful. With a mean age of 54 - all mature spines and no adolescents, the results are not telling us anything we don't already know about ultra conservative non operative methods. About the most this small piece of the larger study tells me - is that the cost of everything is going up. I wonder how much money was spent on a study to document that?

The only value of this study, that I see - is that this should be telling the medical community to spend some research dollars to investigate new (previously unexplored through research study) non operative methods.

I would be most interested a future similar study which would include Physical Therapy specific to scoliosis, Exercise specific to scoliosis, Schroth, Spincor (and other European bracing methods) SEAS, and Clear ... I'm guesstimating that will be about 50 years down the road unless someone with the money of Bill Gates gets a wild hair.

hdugger
02-07-2010, 02:59 PM
Yes, exactly. There is no way to evaluate any of these treatments unless you're talking about a specific protocol. What, exactly, does "medicine" mean, for example? What exercises are included with physical therapy? The only protocol that's clear is "bed rest" :)

Also, the numbers are tiny. They're splitting 68 patients across 8 different kinds of treatment. That's about 8 people in each overall method. And, given the lack of any clear protocol, it likely means one person for each specific protocol.

I said this about the other study comparing "non surgical treatments," but this simply is not how good science is done. It's the kind of science one does when one has some kind of ax to grind - the same thing I'd call out Weiss for in his review of surgical treatments.

If you want to know if alternate treatments work, pick the most promising one and compare it to surgery. But these kinds of studies really get us nowhere.

LindaRacine
02-07-2010, 05:24 PM
It's not up to a bunch of surgeons to evaluate the cost effectiveness of any single alternative method. The science of this study is not flawed. It's very simple. The people who tried the alternative method of their own choice are evaluating it as having no impact on the quality of life.

Pooka1
02-07-2010, 05:30 PM
It's not up to a bunch of surgeons to evaluate the cost effectiveness of any single alternative method. The science of this study is not flawed. It's very simple. The people who tried the alternative method of their own choice are evaluating it as having no impact on the quality of life.

This is a penetrating glimpse into the obvious. If there was an effective non-operative alternative treatment we would know about it by now. These authors are putting a number on the obvious.

The world is still waiting.

hope404
02-07-2010, 06:56 PM
The world is still waiting....

And I for one, HOPE,people don't quit trying!!

hdugger
02-07-2010, 07:42 PM
It's not up to a bunch of surgeons to evaluate the cost effectiveness of any single alternative method. The science of this study is not flawed. It's very simple. The people who tried the alternative method of their own choice are evaluating it as having no impact on the quality of life.

They don't have to design a valid study if they're interested in keeping informal notes. But, if they're actually interested in doing science and finding out something, then they do have to design a valid study.

Maybe it would be more obvious if it was the CLEAR people doing the study. So, they keep notes on everyone who didn't take their treatment and, at the end of 2 years, they publish the results. They have a category they call "Physician treated" which includes eight medically-treated patients (who may have had bracing, or been given prescriptions, or had surgery), then another category for all the different physical therapy treatments, then one for bed rest, then (hearing Pooka's request) one for chanting and praying. In all, they have 68 patients, of which maybe two got surgery. I'm guessing they'd have overall results much like the one these doctors posted (except, with a few surgeries thrown in, the costs would be much, much higher). At the end of two years, all of the different valid and invalid methods would average out into "no change."

That gives you a nice study to point to when someone comes in and tells you they're going to try something different - "Oh, no need to do that. We did a study and the rest of the methods don't do anything and cost a bunch." Sale made.

OTOH, if you're honestly looking to see what non-surgical treatment might make a difference in scoliosis patients lives because, even though you're a surgeon, you understand that not everyone wants or needs to take that risk - then you design a study where you include things that you've heard are effective. If it's just pain management you're after, there are functional restoration programs that help a good deal with pain. Schroth has also shown some promise. Maybe some bracing. And you clearly describe the protocols for all of the other treatments. *That's* a scientific study - i.e., one in which you go in with a genuine sense of inquiry to learn something. You *don't* include obvious non-treatments like "bed rest" and try to pretend that that's a valid form of treatment which differs significantly from no treatment at all. I'll eat my hat (which I am currently wearing) if *any* of these doctors honestly thought that the bed rest patients were going to improve. To throw that in to their "everything but the kitchen sink" protocol just reaks of a kind a cynicism and hackery.

mamamax
02-07-2010, 08:10 PM
I have to agree with this. And the fact that it appears that a blind eye (in terms of serious research funding) is being turned towards methods showing much promise - does a huge dis-service to us all.

LindaRacine
02-07-2010, 08:15 PM
They don't have to design a valid study if they're interested in keeping informal notes. But, if they're actually interested in doing science and finding out something, then they do have to design a valid study.

Maybe it would be more obvious if it was the CLEAR people doing the study. So, they keep notes on everyone who didn't take their treatment and, at the end of 2 years, they publish the results. They have a category they call "Physician treated" which includes eight medically-treated patients (who may have had bracing, or been given prescriptions, or had surgery), then another category for all the different physical therapy treatments, then one for bed rest, then (hearing Pooka's request) one for chanting and praying. In all, they have 68 patients, of which maybe two got surgery. I'm guessing they'd have overall results much like the one these doctors posted (except, with a few surgeries thrown in, the costs would be much, much higher). At the end of two years, all of the different valid and invalid methods would average out into "no change."

That gives you a nice study to point to when someone comes in and tells you they're going to try something different - "Oh, no need to do that. We did a study and the rest of the methods don't do anything and cost a bunch." Sale made.

OTOH, if you're honestly looking to see what non-surgical treatment might make a difference in scoliosis patients lives because, even though you're a surgeon, you understand that not everyone wants or needs to take that risk - then you design a study where you include things that you've heard are effective. If it's just pain management you're after, there are functional restoration programs that help a good deal with pain. Schroth has also shown some promise. Maybe some bracing. And you clearly describe the protocols for all of the other treatments. *That's* a scientific study - i.e., one in which you go in with a genuine sense of inquiry to learn something. You *don't* include obvious non-treatments like "bed rest" and try to pretend that that's a valid form of treatment which differs significantly from no treatment at all. I'll eat my hat (which I am currently wearing) if *any* of these doctors honestly thought that the bed rest patients were going to improve. To throw that in to their "everything but the kitchen sink" protocol just reaks of a kind a cynicism and hackery.
Surgeons have published hundreds of studies on what works in terms of surgery. And, they've published dozens of long-term follow up studies on surgical methods. There's a real benefit to knowing which methods provide the best results. On the other hand, there is zero benefit to them from finding what specific, if any, alternative treatments work. If CLEAR or Schroth wants to prove that their specific treatment works, the onus is on them.

If you want to blame someone for coming up with the result of the referenced study, blame the patients whose answers showed no improvement in quality of life.

hdugger
02-07-2010, 08:29 PM
On the other hand, there is zero benefit to them from finding what specific, if any, alternative treatments work.

That's a very troubling statement. Is that just your own sense? Or do you feel that represents the outlook of the surgeons you work with. Children and adults with scoliosis are routinely told that they need to have their cases managed by orthopedic surgeons. If your contention is that orthopedic surgeons are deliberately turning a blind eye to any alternate treatments because there's no cost benefit to them . . . that's just a very, very shocking statement.

LindaRacine
02-07-2010, 08:36 PM
That's a very troubling statement. Is that just your own sense? Or do you feel that represents the outlook of the surgeons you work with. Children and adults with scoliosis are routinely told that they need to have their cases managed by orthopedic surgeons. If your contention is that orthopedic surgeons are deliberately turning a blind eye to any alternate treatments because there's no cost benefit to them . . . that's just a very, very shocking statement.

Interesting jump from no benefit in a surgeon studying CLEAR or Schroth methods to keeping alternative treatments to themselves because there's no benefit. If an alternative treatment is ever proved to be beneficial, I'm sure that most surgeons will tell their patients about it.

mamamax
02-07-2010, 08:37 PM
Surgeons have published hundreds of studies on what works in terms of surgery. And, they've published dozens of long-term follow up studies on surgical methods. There's a real benefit to knowing which methods provide the best results. On the other hand, there is zero benefit to them from finding what specific, if any, alternative treatments work. If CLEAR or Schroth wants to prove that their specific treatment works, the onus is on them.

If you want to blame someone for coming up with the result of the referenced study, blame the patients whose answers showed no improvement in quality of life.

Regarding the study in question - I blame a flawed design from the start - using ultra conservative methods, on an adult population, that we already know are of little value. What the heck was the point on spending money on such a study - which tells us nothing whatsoever, that wasn't already known? Complete and utter waste of research dollars.

I'm not so concerned with what benefits our surgeons. I am very concerned with what benefits patients and future generataions. Both surgical and non surgical.

The research should be fair and equitable - and the scales not financially tipped in favor of one over the other. And certainly not blinded by the past to the ignorance of present and future realities.

Pooka1
02-07-2010, 08:46 PM
[...] hackery.

Excellent.


If your contention is that orthopedic surgeons are deliberately turning a blind eye to any alternate treatments because there's no cost benefit to them . . . that's just a very, very shocking statement.

They are turning a blind eye to treatments that don't have a lick of evidence that they are efficacious. After decades and decades in some cases.

There is no benefit to them and especially to their patients if they recommend ineffective treatments. They are prfessionals with reputations but beyond that, they want to help people. That's largely why they go into medicine.

Surgeons are the good guys. If an effective alternative treatment appeared, it would go in the science column and then surgeons would recommend it. If there was even a faint glimmer of hope like with bracing, they would eventually consider it.

LindaRacine
02-07-2010, 08:48 PM
Regarding the study in question - I blame a flawed design from the start - using ultra conservative methods, on an adult population, that we already know are of little value. What the heck was the point on spending money on such a study - which tells us nothing whatsoever, that wasn't already known? Complete and utter waste of research dollars.

I'm not so concerned with what benefits our surgeons. I am very concerned with what benefits patients and future generataions. Both surgical and non surgical.

The research should be fair and equitable - and the scales not financially tipped in favor of one over the other. And certainly not blinded by the past to the ignorance of present and future realities.


I'm fairly certain that this data came as a result of questions that are asked on standard questionnaires. (For example, if you've tried alternative therapies, how effective have they been?) I've never heard of or seen any questionnaire that was specifically designed to rate alternative treatment. Where did you get the notion that the study looked at "ultra conservative methods, on an adult population, that we already know are of little value."? I'm willing to bet $ that there was no targeting of specific methods.

This discussion is beyond bizarre as far as I'm concerned. Using the flawed thinking that is going on, why aren't chiropractors publishing studies on surgical methods?

Pooka1
02-07-2010, 08:49 PM
I just want to caution folks at this point that some rhetorical flourishes on this thread and the rhetorical flourishes of certain blatantly counterfactual positions are starting to converge...

Pooka1
02-07-2010, 08:52 PM
This discussion is beyond bizarre as far as I'm concerned. Using the flawed thinking that is going on, why aren't chiropractors publishing studies on surgical methods?

Actually, the Clear types comment routinely on surgical issues like they have training in that. Talk about bizarre.

I agree about the bizarrality of the rhetoric upthread which is an allusion to the thinking. It is scaring this little bunny.

hdugger
02-07-2010, 08:56 PM
Interesting jump from no benefit in a surgeon studying CLEAR or Schroth methods to keeping alternative treatments to themselves because there's no benefit. If an alternative treatment is ever proved to be beneficial, I'm sure that most surgeons will tell their patients about it.

I'm not leaping. You said:

"zero benefit to them from finding what specific, if any, alternative treatments work"

Meaning, that if the treatment did not garner them financial gain, then there is no benefit in finding out about it. I don't think I'm misreading that. That is not, in general, how the lay public understands doctors to be evaluating the "benefit" of a treatment. The lay understanding is that the benefit of a treatment is in its effectiveness for the patient. *Not* in how it financially benefits the doctor. So, I'm asking. Is that just your personal sense? Or, since you actually work with orthopedic surgeons, is it just generally understood that they are not interesting in finding "what specific, in any, alternative treatments" work because there's no financial gain in it for them.

The patients are not to blame for their reports. The study was specifically designed to find the results that it found. And, apparently, for precisely the reasons you suggest - that they have nothing to gain from finding any other result.

For a different view on the topic, look at the study that Kevin designed, which had, as one of the criteria, that the researchers did not stand to gain financially.

LindaRacine
02-07-2010, 09:03 PM
I'm not leaping. You said:

"zero benefit to them from finding what specific, if any, alternative treatments work"

Meaning, that if the treatment did not garner them financial gain, then there is no benefit in finding out about it.

No, what that means is there's no payoff for a surgeon to perform a study on a specific alternative treatment. If someone else studies it, than there would be a benefit to patients, and surgeons would tell their patients about it. I've heard plenty of surgeons tell patients that they might get some pain relief from things like chiropractic, physical therapy, and acupuncture.


The study was specifically designed to find the results that it found.
I didn't realize you were there when the study was designed as well as having the full text of the article. ;-)

hdugger
02-07-2010, 09:13 PM
They are turning a blind eye to treatments that don't have a lick of evidence that they are efficacious. After decades and decades in some cases.

I think that's a different argument :)

You're arguing about whether other methods can reverse or stop the progression of a curve. So far, surgery is the gold standard for that. I *believe* this study only addressed pain (or, maybe I don't know my abbreviations). And, in many of the patients, just mild or moderate pain. I don't believe surgery *is* the gold standard for mild to moderate pain in adult patients. Do other, non-surgical methods, show promise for pain. Well, yes, I think they do. However *bed rest!!* would not be one of those treatments. Good lord! It's counter-indicated even for mild back problems because it *increases* pain and *slows down* recovery! (Sorry for shouting, the whole health care thing is just really getting on my nerves.)

I don't have anything against surgeons - I have a kid who is likely going under the knife (and, again, stupid health care system, on the fast train before he loses our coverage). But, that doesn't change the fact that *these* surgeons have designed a crappy study which says absolutely nothing while pretending to say something. As a scientist, that just annoys the hell out of me.

Pooka1
02-07-2010, 09:16 PM
I think all surgeons would acknowledge surgery is not the best solution to pain. It is sometimes used as a last resort I imagine, though.

Are these authors surgeons?

ETA: Bridwell is for sure. Maybe the others are too, don't know.

mamamax
02-07-2010, 09:19 PM
Where did you get the notion that the study looked at "ultra conservative methods, on an adult population, that we already know are of little value."? I'm willing to bet $ that there was no targeting of specific methods.

Taking a look at where the study data came from - it looks pretty obvious that referrals would have been in keeping with the kind of non surgical referrals people receive every day from such institutions - and such referrals are ultra conservative. This study however gives us little detail to go on. It was an adult population from the information posted:


RESULTS.: A total of 123 patients (111 females, 12 males) with a mean age of 53.3 (18-79) years were evaluated. In 55 scoliosis patients who received no treatment, the only significant change in HRQOL measures over the 2-year period was in SRS satisfaction subscore (0.3 points, P = 0.014).

This discussion is beyond bizarre as far as I'm concerned. Using the flawed thinking that is going on, why aren't chiropractors publishing studies on surgical methods?

The study is bizarre as far as I'm concerned - and useless.

hdugger
02-07-2010, 09:20 PM
No, what that means is there's no payoff for a surgeon to perform a study on a specific alternative treatment. If someone else studies it, than there would be a benefit to patients, and surgeons would tell their patients about it. I've heard plenty of surgeons tell patients that they might get some pain relief from things like chiropractic, physical therapy, and acupuncture.

But, apparently, there was a benefit to them doing *this* study. What was that benefit?



I didn't realize you were there when the study was designed as well as having the full text of the article. ;-)

See above.

Pooka1
02-07-2010, 09:28 PM
But, apparently, there was a benefit to them doing *this* study. What was that benefit?

I think they were being hounded by patients who don't know the score. At all. They wanted something neutral and unbiased, unlike the drivel that comes out of certain alternative hot spots.

They make no money from these treatments but still want to know if they work so they can start recommending them if they do. The audience for this paper is surgeons to give them numbers to tell patients when they come in with chiropractic stars in their eyes...

And if this is about pain then folks are screwed... surgery is known not to be the answer in most pain cases apart from scoliosis as far as I know.

mamamax
02-07-2010, 09:32 PM
But, apparently, there was a benefit to them doing *this* study. What was that benefit?


A research reference in a future grant request of some kind? I don't know - just guessing, things generally boil down to finances and budgets.

LindaRacine
02-07-2010, 09:36 PM
I can guarantee this was not a specific study conducted on non-surgical treatments. This probably came from the Adult Deformity Outcomes database, from a question or two about how much benefit each patient got from specific treatments (e.g., injections, physical therapy, chiropractic, etc.)

hdugger
02-07-2010, 09:40 PM
I think they were being hounded by patients who don't know the score. At all. They wanted something neutral and unbiased, unlike the drivel that comes out of certain alternative hot spots.

They make no money from these treatments but still want to know if they work so they can start recommending them if they do. The audience for this paper is surgeons to give them numbers to tell patients when they come in with chiropractic stars in their eyes...

No (and, yes, I can go into the past and read minds . . . oh my God, Napoleon wants to invade Russia!)

If you want to help your patients, then you pick a few things that really seem to work (or, alternately, a few things that really don't seem to work). And you study them separately, and help guide your patients towards the good ones and away from the bad ones. But, just knowing basic math, you don't jumble together things that seem to work with things that don't seem to work because the average is always likely to be "no change." And you don't throw "bed rest" into the "treatment" category as if it were somehow different from getting no treatment at all.

hdugger
02-07-2010, 11:12 PM
Are these authors surgeons?

ETA: Bridwell is for sure. Maybe the others are too, don't know.

Yes, all surgeons. One neurologic, the rest orthopedic (to the best of my knowledge)

mamamax
02-08-2010, 06:06 AM
Generally speaking - I'm sure such studies are done with future patient care in mind ... along with an eye to funding and budgetary concerns. And everybody is worried about budgets today. I wonder if the facilities involved in this project, have PT departments etc attached to their centers. If so, Like many other institutions across the country - then where the money goes is a concern. I'm just saying ... there could be way more involved in this than we may see on the surface. A study such as this could be used to justify cut backs or cost saving methods.

Pooka1
02-08-2010, 06:08 AM
A study such as this could be used to justify cut backs or cost saving methods.

If something is nonsense, should it be maintained or cut back?

mamamax
02-08-2010, 06:39 AM
Exactly Watson ;-)

Ideally, the funds should be reinvested - in more promising methods. More ideally (to my way of thinking) in more promising non surgical methods.

But that ain't gonna happen. The sad truth is, there is no entity yet established that would make such adequate funds available in that area.

A need not yet filled

Thinking a bit outside the box .. this study could also be used to justify the creation of said missing entity. Something to ponder.

Pooka1
02-08-2010, 09:31 AM
I agree the funds should be invested in more promising approaches.

To date, that list includes only surgical methods.

Continuing to fund anything in the current panoply of alternative approaches that show almost no promise after decades just because surgery has a high fear factor and high ick factor among some is not a wise use of limited monies in my opinion. Evidence, rather than emotion, should drive research funding.

Now if there are new alternative approaches that look promising, I think those should possibly be funded.

mamamax
02-08-2010, 09:58 AM
We could not disagree more over what defines promising.

I find the MedX for therapeutic use promising, I find Schroth promising, I find Spinecor (and other European bracing methods) promising, I find SEAS promising, and it would appear that even Clear is promising.

Here's my question.

Does something have to be promising to become a medically recommended conservative method in the US?

Obviously not, based on this study and history over the last several decades.

hdugger
02-08-2010, 10:30 AM
I think we're drifting off-track here. This study examines treatments for pain/lifestyle issues in mild to severe scoliosis patients. It is *not* tracking curve progression, to the best of my knowledge.

Does *anyone* think that surgery is the best option for mild pain in adult scoliosis patients? Likewise, does *anyone* think that "medication" (I'm assuming this means any pain-killing drugs, but I'll wait for the full report to clarify) is *not* effective for dealing with mild pain in scoliosis patients? If so, could you go and inform everyone on the forum that they should stop taking their painkillers because, apparently, they don't help to relieve pain?

Many treatments appear to be effective for dealing with mild to moderate pain in scoliosis patients, based, again, on reading posts from scoliosis patients. That is not the question that this study asks. Instead, the question that this study asks, and answers is, "If you average every single thing that anyone with scoliosis might do to deal with pain, other then surgery, how does that turn out?" It turns out, not surprisingly, that it pretty much averages out to nothing. I don't happen to think that that's a very interesting question, and I have no idea how you'd apply the results of such a study (except, maybe to suggest to patients that they not try every single thing that might pop into their head, but, instead, use a few methods that appear to reduce pain.)

The danger I see in a study like this is that it leads to discussions like the one I'm seeing here, where people use the study to make claims which this design absolutely cannot support - as an indictment of a specific form of treatment. This study says *nothing whatsoever* about that. It can't. There are simply too few people spread across too many treatments with absolutely no specifics about the protocols of the treatments.





I agree the funds should be invested in more promising approaches.

To date, that list includes only surgical methods.

Continuing to fund anything in the current panoply of alternative approaches that show almost no promise after decades just because surgery has a high fear factor and high ick factor among some is not a wise use of limited monies in my opinion. Evidence, rather than emotion, should drive research funding.

Now if there are new alternative approaches that look promising, I think those should possibly be funded.

hdugger
02-08-2010, 10:52 AM
OK, I double-checked all the abbrevations. Yes, the measurement tools studied only include pain/lifestyle/self-image/mental health type questions.

Pooka, are you really recommending surgery as the gold standard for adult scoliosis patients with mild to moderate pain? Is it your belief that *no* other treatment is effective in treating pain, and that no research money should be spent on anything other then surgical methods for these patients?

Pooka1
02-08-2010, 11:05 AM
OK, I double-checked all the abbrevations. Yes, the measurement tools studied only include pain/lifestyle/self-image/mental health type questions.

Pooka, are you really recommending surgery as the gold standard for adult scoliosis patients with mild to moderate pain? Is it your belief that *no* other treatment is effective in treating pain, and that no research money should be spent on anything other then surgical methods for these patients?

While I think it is acknowledged that surgery for non-scolisis-related pain is a last resort and has a less than stellar record, I am not so sure that is the case for moderate-severe pain in scoliosis patients. While surgery carries no guarantee to relieve pain for these patients, it can and has relieved pain in perhaps in the majority of patients when conservative approaches have failed.

For mild-modertate pain in scoliosis cases, I think PT and bracing, in addition to meds/injections/etc., have been shown to be effective in many cases. If that works then it is clearly superior to surgery even if surgery has a high efficacy rate in these patients.

I take issue with funding things based on wishful thinking versus an honest regard for the evidence to date. We shouldn't fund things that only have the fact that they are not surgery going for them. After decades and decades.

hdugger
02-08-2010, 11:30 AM
I'm in complete agreement on patients with severe pain. I have not seen any of the alternative treatments prove effective for these patients, and, if I had a loved one in severe pain, I'd recommend surgery as the gold standard with no hesitation. Not related to this study, but I'd likewise recommend surgery without hesitation to any adult with an aggressively progressing curve. It's just not worth messing around with anything else, IMO.

Like you, I've seen lots of anecdotal success with conservative treaments for patients in mild to moderate pain who are not progressing. My son (study of one), had a huge improvement in his self-image, appearance, and pain level with three massage and two physical therapy sessions. Total cost: around $600.

Non-surgical methods have not been adequately studied, for a variety of reasons that must include, as Linda points out, that there's no benefit to doctors studying them. (Although, interestingly, there *is* benefit to doctors doing poorly-designed studies of non-surgical methods which obscure any positive results in a chaos of protocols. Apparently, there's just no benefit to doing good studies.) Those non-surgical methods that have managed to get a few studies out have shown some good results. That's not hope or wishful thinking. It's just science moving at its leisurly pace.



While I think it is acknowledged that surgery for non-scolisis-related pain is a last resort and has a less than stellar record, I am not so sure that is the case for moderate-severe pain in scoliosis patients. While surgery carries no guarantee to relieve pain for these patients, it can and has relieved pain in perhaps in the majority of patients when conservative approaches have failed.

For mild-modertate pain in scoliosis cases, I think PT and bracing, in addition to meds/injections/etc., have been shown to be effective in many cases. If that works then it is clearly superior to surgery even if surgery has a high efficacy rate in these patients.

I take issue with funding things based on wishful thinking versus an honest regard for the evidence to date. We shouldn't fund things that only have the fact that they are not surgery going for them. After decades and decades.

mamamax
02-08-2010, 11:35 AM
I think we're drifting off-track here. This study examines treatments for pain/lifestyle issues in mild to severe scoliosis patients. It is *not* tracking curve progression, to the best of my knowledge.

Does *anyone* think that surgery is the best option for mild pain in adult scoliosis patients? Likewise, does *anyone* think that "medication" (I'm assuming this means any pain-killing drugs, but I'll wait for the full report to clarify) is *not* effective for dealing with mild pain in scoliosis patients? If so, could you go and inform everyone on the forum that they should stop taking their painkillers because, apparently, they don't help to relieve pain?

Many treatments appear to be effective for dealing with mild to moderate pain in scoliosis patients, based, again, on reading posts from scoliosis patients. That is not the question that this study asks. Instead, the question that this study asks, and answers is, "If you average every single thing that anyone with scoliosis might do to deal with pain, other then surgery, how does that turn out?" It turns out, not surprisingly, that it pretty much averages out to nothing. I don't happen to think that that's a very interesting question, and I have no idea how you'd apply the results of such a study (except, maybe to suggest to patients that they not try every single thing that might pop into their head, but, instead, use a few methods that appear to reduce pain.)

The danger I see in a study like this is that it leads to discussions like the one I'm seeing here, where people use the study to make claims which this design absolutely cannot support - as an indictment of a specific form of treatment. This study says *nothing whatsoever* about that. It can't. There are simply too few people spread across too many treatments with absolutely no specifics about the protocols of the treatments.

Yes .. all true.

And from that clear headed perspective - I do think this study has the potential to stage some pretty dramatic changes that are not necessarily in the best interests of all patients. It may however serve the best interests of certain troubled budgets. This is top priority everywhere in the current economy.

Looks to me like this study is really about one thing only - money, and its potential use during an economically troubling time.

The purpose of this study can be found in its title ... the results of it will without a doubt, help to dictate future funding.

LindaRacine
02-08-2010, 11:48 AM
As I suspected, the data comes from the Adult Deformity Outcomes database. It's one question, regarding what non-surgical treatments have been tried. The options are No Treatment, Aerobic Exercise, Analgesics, Aquatics, Bed Rest, Epidural Block, Facet Block, Nerve Root Block, Body Mechanics Education, Bracing, Lower Extremity Orthotics, Narcotics, NSAIDs, Pain Management Program, Physical Agent Modalities (e.g., moist heat, ultrasound, electrotherapy), Postural Training, Stabilization Exercise, Strength Training, Stetching Exercise, Other. According to one of the authors, both Chiropractic and Physical Therapy were write-in answers to Other.

hdugger
02-08-2010, 12:22 PM
So, I revise, 68 patients spread across at least 22 general categories, each of which could have tens to hundreds of individual protocols. And 53 people in a a "no treatment" control group, which, apparently, managed to not engage in any of the "treatment" categories (including aerobic exercise or bed rest) for two years. No wonder they felt so crappy :)

mamamax
02-08-2010, 12:49 PM
We know 55 patients received no treatment whatsoever. Near 50% right there with no significant change in outcome parameters.

What did the other 68 adult patients use that produced a mean (per patient) treatment cost of $10,815 (using a Medicare fee schedule) over a two year period?

That would be good to know.

May medically advised non surgical treatments be revised to include more promising methods within my lifetime - Amen.

Why can't we have a good MedX with Schroth trained PTs study? Oh yeah ... money (and politics). I feel a back ache coming on.

What did we learn from this study?

hdugger
02-08-2010, 12:59 PM
Those two groups (treatment vs. no treatment) are kept separate in the analysis. The cost benefit analysis was only done on the "treatment" patients. That's correctly designed. The problem (or, one of the problems) is that "treatment" is so loosely categorized that it would appear to cover normal activities likely carried out by the "no treatment" group. That's an incorrect design. You should be able to clearly distinguish the experimental group from the control group. If you can't tell them apart, you cannot really make any comparisons between the groups, nor can you verify that the treatment group actually received more treatment then the control group.

mamamax
02-08-2010, 01:11 PM
Thanks for clarifying that. I have little knowledge of how these things are really tallied. With "no treatment" on the option list - I incorrectly assumed it was included in the tally. Appreciate your experience and knowledgeable input.

hdugger
02-08-2010, 01:51 PM
It's been over 20 years since I did a lick of research, so I'm not really all that knowledgeable. But I'm pretty sure my analysis is correct.

Pooka1
02-08-2010, 02:05 PM
May medically advised non surgical treatments be revised to include more promising methods within my lifetime - Amen.

If that turns out to be blood from a stone, do we continue searching? How long?


Why can't we have a good MedX with Schroth trained PTs study?

Because there isn't enough evidence that it could work and plenty of evidence that is it not likely to work to commit the money?

This is distinguishable from H. pylori.

Pooka1
02-08-2010, 02:08 PM
Mamamax, I'm beginning to doubt that you think it is even possible that this universe DOESN'T contain an effective alternative/conservative treatment.

Isn't it at least possible that NO alternative/conservative treatment will work?

I am actually wondering what you will say to this. :confused:

hdugger
02-08-2010, 02:20 PM
Because there isn't enough evidence that it could work and plenty of evidence that is it not likely to work to commit the money?


According to Linda, the only one of us actually working with orthopedic surgeons, the overarching reason is that surgeons have no interest in studying anything other then surgery because those other methods hold no financial gain for them. End of discussion.

I'm still just knocked over by the implications of that statement, but it would go a long way to explaining why there's been so much focus on bracing (which requires a doctor's oversight) and so little on a simple exercise like torso rotation or side shifting (which does not). And that explanation has absolutely nothing to do with evidence.

I would certainly like to think better then that of my surgeon, but I'll defer to Linda's better knowledge.

mamamax
02-08-2010, 02:21 PM
It's been over 20 years since I did a lick of research, so I'm not really all that knowledgeable. But I'm pretty sure my analysis is correct.

Yes - but (and/or however :-) ... one of my pet theories is: given the mind inclined towards research, with added education and experience ... the ability never fades as is simply - ready and waiting to kick in at a moments notice. I think your analytical abilities have survived well in tact :-)

hdugger
02-08-2010, 02:24 PM
Mamamax, I'm beginning to doubt that you think it is even possible that this universe DOESN'T contain an effective alternative/conservative treatment.

Isn't it at least possible that NO alternative/conservative treatment will work?

I am actually wondering what you will say to this. :confused:

I feel like I'm entering a wormhole. Didn't we just agree that non-surgical treatments were effective for mild to moderately-painful scoliosis which is not progressing? How did those treatments just exit the universe?

mamamax
02-08-2010, 02:29 PM
Mamamax, I'm beginning to doubt that you think it is even possible that this universe DOESN'T contain an effective alternative/conservative treatment.

Isn't it at least possible that NO alternative/conservative treatment will work?

I am actually wondering what you will say to this. :confused:

I can't believe you don't know what I will say to this.

Martha Hawes

Seriously if people believed the same way you are proposing that I should believe - then folks would still be spending several months in plaster casts following surgery - or surgical methods would have never been developed much less refined year after year.

Myself on the other hand Sharon - acknowledges that you firmly believe there can be no non surgical rehabilitation whatsoever possible. But the knowing of that does not confuse me.

Serial casting of infants has proven successful. Thank God Min Mehta did not believe as you propose I should.

Pooka1
02-08-2010, 02:30 PM
I feel like I'm entering a wormhole. Didn't we just agree that non-surgical treatments were effective for mild to moderately-painful scoliosis which is not progressing? How did those treatments just exit the universe?

Mamamax is not limiting her claims, as I understand them, to that subset.

Pooka1
02-08-2010, 02:32 PM
I can't believe you don't know what I will say to this.

Martha Hawes

Seriously if people believed the same way you are proposing that I should believe - then folks would still be spending several months in plaster casts following surgery - or surgical methods would have never been developed much less refined year after year.

Myself on the other hand Sharon - acknowledges that you firmly believe there can be no non surgical rehabilitation whatsoever possible. But the knowing of that does not confuse me.

Serial casting of infants has proven successful. Thank God Min Mehta did not believe as you propose I should.



Belief doesn't enter into this. If we all believe hard enough, can we build a perpetual motion machine?

mamamax
02-08-2010, 02:38 PM
Mamamax is not limiting her claims, as I understand them, to that subset.

Well for crying out loud - I think some very grand wide sweeping assumptions are being made here :eek:

hdugger
02-08-2010, 02:40 PM
Mamamax is not limiting her claims, as I understand them, to that subset.

It might be useful to test that theory :)

I suspect that if we went through a few theoretical cases, the three of us would roughly agree on whether the cases should be referred to surgical or conservative treatment. I think you (Pooka) might recommend surgery earlier in some teen patients, but, beyond that, I think we're all pretty much in agreement.

That Mamamax or I might believe that surgery is permenently avoidable (with ongoing treatment) doesn't really affect the surgery vs. conservative treatment question on a case-by-case basis. It's only a theoretical divide.

mamamax
02-08-2010, 02:41 PM
Belief doesn't enter into this. If we all believe hard enough, can we build a perpetual motion machine?

Did I say something about belief? No. I said I couldn't believe that you wouldn't know how I would react to some very interesting comments.

Anyway - why are we doing this?

mamamax
02-08-2010, 02:43 PM
It might be useful to test that theory :)

I suspect that if we went through a few theoretical cases, the three of us would roughly agree on whether the cases should be referred to surgical or conservative treatment. I think you (Pooka) might recommend surgery earlier in some teen patients, but, beyond that, I think we're all pretty much in agreement.

That Mamamax or I might believe that surgery is permenently avoidable (with ongoing treatment) doesn't really affect the surgery vs. conservative treatment question on a case-by-case basis. It's only a theoretical divide.

Agreed ...

Pooka1
02-08-2010, 02:44 PM
Did I say something about belief?

"Seriously if people believed the same way you are proposing that I should believe" -- Mamamax

This word is not necessary. People ACCEPT evidence in science. People WITHHOLD acceptance absent evidence in science.

Can I assume we are trying to be scientific here?

Pooka1
02-08-2010, 02:57 PM
I can't believe you don't know what I will say to this.

Martha Hawes


Why are so many people still needing fusion in your opinion now that the world has Hawes?

hdugger
02-08-2010, 03:00 PM
"Seriously if people believed the same way you are proposing that I should believe" -- Mamamax

This word is not necessary. People ACCEPT evidence in science. People WITHHOLD acceptance absent evidence in science.

Can I assume we are trying to be scientific here?

What if we subsituted the word "theory" for "belief"? In the sense that it's a viewpoint supported by some emperical evidence, and logically coherent, but not yet scientifically tested.

hdugger
02-08-2010, 03:02 PM
Sorry, I feel like we're ganging up on you. That's not my intention. I'm going to step back for a bit.

Pooka1
02-08-2010, 03:06 PM
What if we substituted the word "theory" for "belief"? In the sense that it's a viewpoint supported by some emperical evidence, and logically coherent, but not yet scientifically tested.

That would be a hypothesis, not a theory, yes?

A theory captures all or most of the data and there is little if any data in opposition. An example is the theory of evolution which seeks to explain the FACT of evolution over a few billion years.

I agree hypothesis fits.

Pooka1
02-08-2010, 03:06 PM
Sorry, I feel like we're ganging up on you. That's not my intention. I'm going to step back for a bit.

Is this addressed to me?

I do not feel ganged up on. Should I? :D

mamamax
02-08-2010, 03:43 PM
Sharon -

Is the word believe and all derivatives thereof a word to be avoided in conversation with those with research backgrounds? I don't know. I'm not a research scientist. If I were to change the word to something else, for the sake of getting along - the word attitude comes to mind.

Let me revise my answer to Sharon (who takes exception, for some reason, to the word believe).


I have difficulty comprehending how you would not know what I would say to this. I would say ...

Martha Hawes

Seriously if people adopted the same attitude that you are proposing I adopt - then folks would still be spending several months in plaster casts following surgery - or surgical methods would have never been developed much less refined year after year.

Myself on the other hand Sharon - acknowledges that you firmly assume the attitude that there exists absolutely no non surgical rehabilitation methods. But the knowing of that does not confuse me.

Serial casting of infants has proven successful. Thank God Min Mehta did not assume the same attitude as you propose I should.

Is this better?

Pooka1
02-08-2010, 03:48 PM
Nice cartoon!

I am not saying conservative solutions shouldn't be sought. I am characterizing the state of evidence as woeful which is compounded by the length of time some have been under study.

I am also pointing out the obvious that just because a conservative approach is sought doesn't mean one exists to be discovered for any particular condition. Hence the perpetual motion machine example.

mamamax
02-08-2010, 04:02 PM
Nice cartoon!

Thanks - thought you would like :-)


I am not saying conservative solutions shouldn't be sought.

But, are you saying that those that currently exist (Schroth, SEAS, et al) are not deserving of research and funding?


I am characterizing the state of evidence as woeful which is compounded by the length of time some have been under study.

And I would say that the state of documented evidence is woeful due to lack of research funding


I am also pointing out the obvious that just because a conservative approach is sought doesn't mean one exists to be discovered for any particular condition. Hence the perpetual motion machine example.

That just sounds like a bit of psychobabble to me.

hdugger
02-08-2010, 04:05 PM
Is this addressed to me?

I do not feel ganged up on. Should I? :D

No, I just creeped myself out writing about what "we believe," like it was some kind of organized religion or something :)

mamamax
02-08-2010, 04:13 PM
Hence forth ... I'll have a new attitude :cool:

Pooka1
02-08-2010, 04:15 PM
But, are you saying that those that currently exist (Schroth, SEAS, et al) are not deserving of research and funding?

Correct. For example Schroth has been at it for ~90 years. How many more years do they need to rule it in or out? I'm actually asking that seriously, not rhetorically.


And I would say that the state of documented evidence is woeful due to lack of research funding

That is an interesting hypothesis. I think some of these conservative methods have been studied quite a bit. What's holding Weiss back?

Pooka1
02-08-2010, 04:17 PM
No, I just creeped myself out writing about what "we believe," like it was some kind of organized religion or something :)

"I wouldn't want to belong to any club that would have me as a member." -- G. Marx

:D

hdugger
02-08-2010, 04:21 PM
Nice cartoon!

I am not saying conservative solutions shouldn't be sought. I am characterizing the state of evidence as woeful which is compounded by the length of time some have been under study.

I am also pointing out the obvious that just because a conservative approach is sought doesn't mean one exists to be discovered for any particular condition. Hence the perpetual motion machine example.

I really think we're going at the whole study of conservative treatments in the wrong way, and I suspect that's bogging down the research. All we need to show is that conservative treatments help reduce the pain of mild to moderate scoliosis. I think that's pretty well agreed upon (current study notwithstanding!)

I'm pretty sure Weiss already has some studies in this area, and I suspect the SEAS people could pull one together if they haven't already. I'd hope the simpler exercise protocols (particularly torso rotation and side-shifting) could do the same.

The research would test these treatments as a *pain reduction* alternative, and not as a *treatment* alternative. Unlike scoliosis progression, pain is simple and non-invasive to measure, and you can do a simple comparison of pain before treatment and pain after treatment in the same patients.

If my hypothesis is correct, this *pain reduction* will also slow progression. But, even without that, the conservative treatments are legitimized and patients have a safe method to use to treat pain.

hdugger
02-08-2010, 04:30 PM
Correct. For example Schroth has been at it for ~90 years. How many more years do they need to rule it in or out? I'm actually asking that seriously, not rhetorically.

Is that a trick question? :)

For the same reason that the bracing people can't rule it in or out, even with the force of the medical community behind it. Because you'd need a very large number of people randomly assigned, and you can't get a very large number of people randomly assigned unless the medical commuity is already behind it, and you can't get the medical community behind it because it hasn't been proven. I thought Kevin's summary of this was pretty succinct.

You *can* do it on problems that tend to reverse themselves normally, like lower back pain, where you can show that one group got better faster. But, for a disease which does not reverse itself, it's very, very hard to show that people who are still suffering from the disorder are suffering "less" because of your intervention. Only very large numbers will show that. Hence, Catch-22.

Pooka1
02-08-2010, 04:31 PM
All we need to show is that conservative treatments help reduce the pain of mild to moderate scoliosis.

I think that is settled, no?

That's why I keep shifting back to the case of halting or regressing large curves and I think Mamamax has joined me in that with her reference to Hawes.

Wanting an effective conservative treatment for that is not, perforce, going to make one possible if that isn't in the cards of the universe.

Pooka1
02-08-2010, 04:34 PM
Is that a trick question? :)

For the same reason that the bracing people can't rule it in or out, even with the force of the medical community behind it. Because you'd need a very large number of people randomly assigned, and you can't get a very large number of people randomly assigned unless the medical commuity is already behind it, and you can't get the medical community behind it because it hasn't been proven. I thought Kevin's summary of this was pretty succinct.

You *can* do it on problems that tend to reverse themselves normally, like lower back pain, where you can show that one group got better faster. But, for a disease which does not reverse itself, it's very, very hard to show that people who are still suffering from the disorder are suffering "less" because of your intervention. Only very large numbers will show that. Hence, Catch-22.

WELL! So you are ruling out proof of efficacy of conservative approaches in principle!

Alrighty then!

I tend to agree but I have to think about it some more. There could be some slick way devised to measure things that we can't measure now.

hdugger
02-08-2010, 04:38 PM
I think that is settled, no?

It's not settled until it's routinely prescribed/paid for by insurance.

hdugger
02-08-2010, 06:29 PM
I think that is settled, no?

That's why I keep shifting back to the case of halting or regressing large curves and I think Mamamax has joined me in that with her reference to Hawes.

Wanting an effective conservative treatment for that is not, perforce, going to make one possible if that isn't in the cards of the universe.

I guess I'm thinking now that climbing this wall doesn't matter. (And maybe I'll think something else tomorrow.

If, on a case-by-case basis, we'd make exactly the same decisions about whether someone should seek surgical care or whether they should seek conservative care, what does it matter *what* our (varying) hypotheses are? If an adult shows up in the forum in alot of pain with a rapidly progressing curve, we'd all say they should start looking seriously at surgery. If an adult shows up with mild to moderate pain and a non-progressing curve, we'd all say they should look into conservative care. I think we'd differ about when to recommend surgery/bracing/conservative care for younger patients, but I don't sense that any of us are very adamant about those differences - non-adult patients are just trickier.

So, where we differ *is* just in belief/hypothesis, and not in practice. I believe/hypothesize that some more-then-randomly-expected number of patients using that conservative care for pain treatment will stop progressing. You don't. Given the state of medical knowledge, we'll probably never know which of us is right. :)

Wow, I've gone Zen!

skevimc
02-08-2010, 06:33 PM
Correct. For example Schroth has been at it for ~90 years. How many more years do they need to rule it in or out? I'm actually asking that seriously, not rhetorically.

That is an interesting hypothesis. I think some of these conservative methods have been studied quite a bit. What's holding Weiss back?

He's already getting paid for Schroth in Germany. He doesn't need to show its effectiveness. He's convinced it works and it's up to the US clinicians to catch up. At least, this is the general impression I got from him.

Pooka1
02-08-2010, 06:50 PM
He's already getting paid for Schroth in Germany. He doesn't need to show its effectiveness. He's convinced it works and it's up to the US clinicians to catch up. At least, this is the general impression I got from him.


Do you know what type of degree Weiss has? Is he an orthopedic surgeon? Does he still operate?

skevimc
02-08-2010, 08:15 PM
Do you know what type of degree Weiss has? Is he an orthopedic surgeon? Does he still operate?

I know for a fact that he doesn't operate. I can't remember specifically if he has surgical training or not. I am thinking he does not. Don't remember what Asher told me.

I just read what this thread was about. :D

A couple of thoughts.

First, studies like this will be used to say conservative methods are useless. Even though that is not the finding of the study because they don't collect enough information to show that. They mention some weaknesses in the abstract and the discussion but the take-home message is obvious.

On the one hand I see the general information as beneficial. Don't prescribe treatments that don't show any effectiveness, e.g. QOL, disability, etc...

On the other hand, I think studies that support the general clinical dogma are held to a different standard of proof. I can't help but wonder if a PT could publish a report on ~100 surgical outcomes and didn't mention or list the specific surgeries each patient received (or any other patient data) and then use that as evidence to question the cost effectiveness of surgery. As further proof, a well controlled placebo trial on arthroscopic knee surgery was published a year or so ago and showed no difference between groups. Yet arthroscopic knee surgeries are still performed.

Second, As far as surgeons funding exercise based studies. Dr.'s Asher and Burton funded the torso-rotational study from their clinical practice research fund. I would give the majority of surgeons the benefit of the doubt that if a conservative method was shown to work they would prescribe it in a heartbeat. Are they going to fund the study? Most likely not. Our study is the exception to the rule. But surgeons are not hurting for work. If they can sign a patient up for some PT and know that it'll work, they'll do it. There will always be another surgery to schedule.

Third, I blame the PT world for the basic finding of the original study. While I strongly support the PT and rehab world I am disappointed with the quality of research PT's are doing, although it is getting better. Over the last decade I've watched PT's begin shifting to a DPT (clinical doctorate) because they want direct access. Yet they make very little effort to show that their methods and techniques are effective. Some of that has to do with the relative newness of PT. At least from the stand point of being viewed as having meaningful contribution. From BS to MS to DPT without slowing down and really studying their treatments from a physiological standpoint. In that sense, MD's and related research are decades ahead. If ANY exercise based therapy wants to be taken seriously, then it's up to the clinicians and researchers. They have to give MD's a reason why PT is different than chiropractors. Sloppy studies just prolong the battle.

mamamax
02-08-2010, 08:45 PM
Good thoughts, as always. I remember reading about the meeting with Dr. Weiss. I think it is a true pity that some sort of study didn't result. I understand he no longer is Director of that Clinic and is now in private practice.

Anyway - For Sharon, Weiss' credentials: http://www.scoliosisxpert.com/uk/pageuk.php?va=1


Physical Therapy School (University of Mainz, Germany 1977 – 1979);
Physical therapy examination 1979;
Studies of medical science 1979 – 1985 in Regensburg, Mainz and Frankfurt; Examination 1985.
M.D. 1986;
Residency in traumatology 1986;
Residency in orthopedic surgery 1987 – 1992.
Orthopaedic surgeon since 1992,
Specialist for manual medicine and physical therapy 1992;
Specialist for physical and rehabilitative medicine 1996,
Trained in psychosomatic medicine 1996;
Specialization for traditional chinese medicine 2000.

Pooka1
02-09-2010, 03:22 PM
Mamamax, I am not so sure that was necessarily translated correctly.

I am not convinced he is an orthopedic surgeon equivalent to those in the US.

I also have questions about if he can still practice medicine since he subsequently got some "interesting" training (if that is translated correctly).

If he is a surgeon presently, I think that other surgeon would have referred to him as such. But that didn't happen so I have my doubts, especially after what McIntire said and he met the guy and visited his facility.

Pooka1
02-09-2010, 03:25 PM
I just read what this thread was about. :D

I just want to thank you for continuing to take the time to edify us bunnies. It's remarkable.

hdugger
02-09-2010, 03:27 PM
Thanks, Kevin. That was helpful.

It's been a long time since I was in medical research, but, when I was deciding on what further training to get after my MPh, my advisors told me that although I could participate in research projects with a masters or doctorate in Public Health, I would have a very hard time ever getting a project funded unless I got a medical degree. That's the reason I've put more of the onus on the physicians - because I believe they have to get involved if any of this work is going to get funded.

Have things changed in the intervening decades? Will you be able to get research funded on your own?

Pooka1
02-09-2010, 03:35 PM
Can I just ask if you did a thesis for your MPh and what the subject of it was if you did? I mean if it isn't a secret. :)

hdugger
02-09-2010, 03:52 PM
Can I just ask if you did a thesis for your MPh and what the subject of it was if you did? I mean if it isn't a secret. :)

Well, I went to Berkeley, and we don't do things the way everyone else does :)

I was in an experimental program that gave a joint epidemiology and biostatistics degree. Because it was largely aimed towards medical students from UCSF, with a smattering of students like myself who didn't have a medical background, it focussed on teaching the skills necessary for designing and making sense of research and didn't require a thesis. It should probably have been offered as an adjunct to the medical program at UCSF, but they didn't have the faculty for it, and we did.

skevimc
02-09-2010, 05:19 PM
I just want to thank you for continuing to take the time to edify us bunnies. It's remarkable.


Thanks, Kevin. That was helpful.



I'm glad you are finding it helpful. I debated myself for several months about whether I'd want to 'out' myself if I signed up on this board. Especially since scoliosis research is something I'd like to eventually return to within the next decade. Everything I do and say on here is basically public and so I'd hate form something to be taken out of context or to experience any push-back if I choose to criticize the wrong person/study.



It's been a long time since I was in medical research, but, when I was deciding on what further training to get after my MPh, my advisors told me that although I could participate in research projects with a masters or doctorate in Public Health, I would have a very hard time ever getting a project funded unless I got a medical degree. That's the reason I've put more of the onus on the physicians - because I believe they have to get involved if any of this work is going to get funded.

Have things changed in the intervening decades? Will you be able to get research funded on your own?

Certainly having a clinical degree helps tremendously. If I were a better classroom type of student I would go back and get my MD. Luckily, it's fairly easy to recruit an MD or two for your grant. In many cases they just need to write a letter of support saying "we'll refer patients to you". As a non-clinician I think there is enough preliminary work that I could write a grant to NIH and get it funded for a conservative AIS management study (there are pilot study funding lines specifically for "new technologies/treatments"). There are two barriers. The first is to get a couple of doctors on board. The second is to collect enough data to make it worthwhile. NIH favors sexy data. MRI's, muscle biopsies, fine wire EMG, etc... A strong stance on physiology and mechanisms. It's why I'm doing the postdoc I am doing. I'm getting training in basic muscle phys. Molecular analysis, pathways, gene expressions, etc... Applying for funding looking only at clinical outcomes for conservative management will not get funded.

That being said, clinical outcomes are the only thing most MD's care about. As well, having a practicing clinician with a vested interest in the study is CRUCIAL for a clinical trial to succeed. I've coordinated 3 clinical trials of varying size. Only one met its recruitment goal. The trial where the doctor/nurse was the active recruiter. If a PhD student or postdoc or research assistant has to sit in clinic every week and 'beg' for patients, the study will fail (unless you can pay an official clinical coordinator (SF Bay Area $80-100k plus benefits). MD's have to be engaged. Clinical practices have to develop a research mindset (e.g. The clinicians need to automatically ask "what study(s) does this patient qualify for?" for every patient). Some say that MD's are too busy to remember every study. To an extent that is true. The US healthcare system is troubled in many ways. But I've sat in on clinics where the doctor remembers 3 of his own trials and continues to forget my trial unless I 'pester' him/her about every single patient every single week. Unless you have a great working relationship with a practicing MD, doing anything clinical will be incredibly difficult.

txmarinemom
02-09-2010, 07:50 PM
Just a few comments on this thread for now ... but I'll probably have more. The wheels are turning.

It seems to me a lot of emphasis has been placed on the 8 individual non-operative methods as *separate* methods. Isn't it feasible that every patient in this study *could* have tried all 8 ... maybe even concurrently? I know *I* did at times throughout my pre-op career (with the exception of adult bracing).

Also, the definition of "bed rest" is amazingly variable: I don't (simply based on experience) think it entails a stand alone modality. I certainly would be hesitant to equate it to something like "doing nothing".

Slapping Tiger Balm/Biofreeze/etc. on your back - and going to bed with an ice pack or heating pad as a end-day desperate measure - isn't all that rare in response to chronic back pain. As far as I know, no one really believes heat/ice/topical analgesic will permanently remedy chronic pain. Is it likely to become a day-to-day attempt at relief when nothing else works? Probably. BTW, it's tough to ice your back while you're walking around: Maybe it became "bed rest" simply because you can't comfortably DO it anywhere else. I seriously doubt it's just the same as "If I lie down, it'll go away". To me, "bed rest" describes "Enough with the gravity!".

Also, in my opinion, ODI is a poor gauge for all scoliosis pain. Looking at the questions, I can't even *answer* some of them. How do you rate activities that give you EXTRA pain when you hurt no matter *what* you do? I really want to stress here how used to chronic pain a person can become: Time and again, I see people post here about how badly they hurt - immediately followed by (genuine, I believe) apologies because "there are people who hurt worse". Only at the very end of my pre-op period was I in touch with HOW extreme my pain was: For me, it was tough to note progression over decades in something that began in childhood. It screws with your head when you can play ball like I do - but going into my office - and facing the phantom hands that pried my scapulae in opposite directions - put me in tears. Daily.

I don't think I can explain how stupid you feel about admitting you can't perform "sedentary work" (which is somehow the generally accepted rating for a valid disability) when you can slide into home plate. I never did (until the very end ... and when I'd stopped playing ball to get ready for surgery) because it sounded so absolutely asinine. Nevermind it was dead-on valid.

Reason #2,382 I will always be grateful for finding Dr. Hanson: He believed I hurt ... and he didn't ask me crap like "Well, how can you do that - but not *that*?".

Reason #2,383, he NEVER pushed me for surgery. He suggested yoga and Advil, gave me a non candy-coated run down of surgery, told me to get Wolpert's book ... then wished me well if he didn't see me again, and encouraged me to email him with any questions that might come to mind. In my heart, I KNOW the human in him hoped I never came back.

It really disturbs me when I read how surgeons only want to do surgery ... and I think *some* of that perception must stem from what the patient/parent is originally expecting to hear. That's just my $.02.

Pam

hdugger
02-09-2010, 08:12 PM
It seems to me a lot of emphasis has been placed on the 8 individual non-operative methods as *separate* methods. Isn't it feasible that every patient in this study *could* have tried all 8 ... maybe even concurrently? I know *I* did at times throughout my pre-op career (with the exception of adult bracing).

Hi Pam,

I think, based on Linda's description, that it's a single question on a form with checkboxes. So, if you checked *anything* other then the "no treatment" box, you were in the "alternate treatment" group. I think it's likely that many patients (especially those in a lot of pain) checked more then one box.

Individually, that provides good information to a doctor about what their patient is trying. It's just when you jumble them all together and try to say something meaningful that you run into a problem. The example I gave above is that you could make "surgery" one of those boxes and have several patients who had completely reversed their pain with surgery, and still have an overall measurement showing that the *average* result was no improvement in pain. If you were selling pink lemonade to cure scoliosis, and someone told you they wanted to try surgery instead, you could say "Oh, no, we studied everything other then pink lemonade, including surgery, and noone got any better."

I happen to think that surgery *is* a good treatment for patients who are in a lot of pain. But this study in no way suggests that's it's any better then any other *specific* treatment. It only shows that it's better then the *average* of everything else. Which is really going to bum out the "Everything But Surgery for Scoliosis" Clinic.

txmarinemom
02-09-2010, 08:53 PM
I think, based on Linda's description, that it's a single question on a form with checkboxes. So, if you checked *anything* other then the "no treatment" box, you were in the "alternate treatment" group. I think it's likely that many patients (especially those in a lot of pain) checked more then one box.

Individually, that provides good information to a doctor about what their patient is trying. It's just when you jumble them all together and try to say something meaningful that you run into a problem.

Oh, I absolutely agree - and without more specificity, I don't believe the study is really even a semi-useful tool. Aside from one of the main points I already listed (no one knows what combination of alternative or "other" treatments patients tried), for how long - and under what parameters - were alt/other treatments implemented?

What I will say, is I doubt *many* adult patients in self-rated pain (pain enough to land them in an ortho's waiting room) have NOT tried conservative treatment.

And did I convey (clearly enough for understanding) the issues I have with pre-op scoliosis and the ODI questionaire?


I happen to think that surgery *is* a good treatment for patients who are in a lot of pain. But this study in no way suggests that's it's any better then any other *specific* treatment. It only shows that it's better then the *average* of everything else. Which is really going to bum out the "Everything But Surgery for Scoliosis" Clinic.

Surgery CAN be a good treatment. It was in my instance, although that doesn't make it a universal panacea. I can argue in favor of it a ~whole~ lot more when there's progression, or years of other attempts at relief have been a waste. In my mind, there's absolutely nothing that compares as a solution in a moving adult curve ...

... but pain was the issue here. I tried to retain my comments to that arena.

Which puts us right back to what I think about this study:

A) It was too poorly structured (or just non-structured) to be of use,

B) Chronic pain patients are probably poor "self-raters", and;

C) I DO agree with Linda that surgeons aren't responsible for giving data on other treatment modalities: What I'm unsure of, however, is why someone felt this study was useful to publish.

Again, just my bubble gum change.

Pam

hdugger
02-09-2010, 09:32 PM
And did I convey (clearly enough for understanding) the issues I have with pre-op scoliosis and the ODI questionaire?


Yes, absolutely. That would be very useful feedback to the scoliosis research community. I know they love their surveys, because they're so simple to administer, but actually putting people through a few simple tests and rating their pain would allow a better classification.



C) I DO agree with Linda that surgeons aren't responsible for giving data on other treatment modalities: What I'm unsure of, however, is why someone felt this study was useful to publish.


Yes, exactly. It's like Randy Newman's "God Song," "Lord, if you won't take care of us, won't you please please let us be?." I suspect the reason has to do with justifying the cost of surgery - so they can say to insurers "Yes, we're expensive, but, over the years, you'll spend the same amount on these conservative therapies."

txmarinemom
02-09-2010, 10:41 PM
I suspect the reason has to do with justifying the cost of surgery - so they can say to insurers "Yes, we're expensive, but, over the years, you'll spend the same amount on these conservative therapies."

I'm not sure that's it either. I would HOPE if that were the point, someone would have documented things more clearly.

Then again, as we all know, insurance companies aren't all that bright. :)

Just thinking back to what I spent on pain management in the 10-15 years before surgery ... and I'm going to have to try to put a dollar figure to it.

Easily, off the top of my head, I can tally about $40K from a period that ran '98 to maybe '01. It included an MRI series (or two ... I'd started protruding at C5/C6-C6/C7), several facet joint injections, multiple rhizotomies, Botox injections into knotted/spastic areas ... and I can't even calculate meds.

We almost went to a Baclofen pump, but my history of resistance (to the protocols at that time) indicated it wouldn't be helpful.

I'm pretty sure I'm glad I was able to skip that little bit of fun.

jrnyc
02-26-2010, 04:48 AM
wow...alot of talk & back & forth...but, just from me, and i will state the obvious and say i have no science/medicine/research training (beyond having to take research & statistics each time i went for a graduate degree :p)...i know quite well that my particular choice of "alternative tx" , i.e. pain management injections of various sorts, is buying me time to see whether certain surgical techniques change in the near future...it is also helping me until i can make a huge, life changing decision...(one that i am struggling with, as is obvious, i guess) but i am under no delusions about what works & what i need! my graduate degrees are in education, administration, & social work....they dont help me to understand some of the intricate scientific discussions you guys are having...but they do help me to understand myself & others....behavior and such, etc etc :)

my own opinion, & only my own..nothing will work except for surgery...everything else is a stopgap..if it helps reduce my pain for awhile, thank goodness for that...but i know quite well that the pain will come back...always does, darn it!! :(

so debate on...it amazes me the energy you guys have! i get exhausted reading it go back & forth, & back & forth...& envy the energy some of you guys seem to have...boy, do i wish my pain would let me have just a fraction!

best regards to all of you...some of you amaze me with your knowledge, skills, & quality of reasoning!

jess

hdugger
02-26-2010, 10:16 AM
Jess,

You're in the category of people (large curve with pain) for whom surgery is absolutely the best route. Nothing else has shown much promise. I think even those of use who look at conservative methods don't think they're appropriate once you're in alot of pain.

jrnyc
02-27-2010, 01:56 AM
hi hdugger
i know.. i know... i know...sigh.....heavy sigh!
i know...i am only HALF in denial! :rolleyes:

i am just not ready to do something so extremely permanently fused to my body without considering more surgery options...& do the pain managment to buy time...of course, by now, i have been buying time for a while...and the clock is ticking louder! :eek:

thanks for your reply...really appreciated it :)

jess

hdugger
02-27-2010, 12:08 PM
Oh, I totally get the denial part! I'm just willing my son's curve to be in the low 40s so we don't have to think about surgery in the near-term.

I don't know if US hospitals have a similar program (or if you've tried them already), but in the British hospitals there's a "Functional Restoration Program" for people in pain which seems to decrease the level of disability significantly. Here's the link to Claire's thread about it on the Scoliosis Support forum - http://www.scoliosis-support.org/showthread.php?t=8758. It won't resolve the curve, but, at least for Claire, it substantially improved her ability to get around and made her more comfortable while she waits for her surgery.

jrnyc
02-27-2010, 10:50 PM
thanks for the interesting link..i think everyone would enjoy reading it...as far as in the U.S., we have physical therapy & we have pain management, which is, in my experience, injections & oral pain meds...i have not seen the 2 combined, but that has just been my experience in NYC & CT...so elsewhere in the states it could be different...

i never got any help from P.T., cause they told me there "isnt much we can do for such a structural problem"...

best regrds
jess

dailystrength
02-28-2010, 09:34 PM
I agree the funds should be invested in more promising approaches.

To date, that list includes only surgical methods.

Continuing to fund anything in the current panoply of alternative approaches that show almost no promise after decades just because surgery has a high fear factor and high ick factor among some is not a wise use of limited monies in my opinion. Evidence, rather than emotion, should drive research funding.

Now if there are new alternative approaches that look promising, I think those should possibly be funded.

AMEN!!! My SURGEON recommended alternative treatments: PT and massage. Now, if he sends me to massage, and I have to pay like I'm just out to pamper myself, something is amiss. I am also going to look into coverage for Schroth.

dailystrength
02-28-2010, 09:45 PM
The danger I see in a study like this is that it leads to discussions like the one I'm seeing here, where people use the study to make claims which this design absolutely cannot support - as an indictment of a specific form of treatment. This study says *nothing whatsoever* about that. It can't. There are simply too few people spread across too many treatments with absolutely no specifics about the protocols of the treatments.

I think the study is not making any claims yet, but hooray for the Doctors involved (one of which is mine!) for being open to other options. If a certain treatment is recommended for pain management, then it needs to be funded. Surgery is funded 100% in my health plan but I pay a whopping co-pay for therapies that alleviate my pain, and there is no break for massage, even if Doctor recommended-- $80 is out of reach and I don't really want to see a chiropractor. Perhaps this study might help here. Scoliosis needs to be recognized, and any pain management techniques that work, paid for.

dailystrength
02-28-2010, 09:58 PM
Anyway - why are we doing this?



Coming late to the scene here but I agree! I don't know why either there needs to be such concern over the legitimizing of alternative treatments... each case is so unique. How wonderful that some can benefit from conservative treatment, if it is working! And also good that some can get surgically corrected if need be. Most of all we need to be supportive each other as we are all dealing with the same constant issue.

dailystrength
02-28-2010, 10:05 PM
The research would test these treatments as a *pain reduction* alternative, and not as a *treatment* alternative. Unlike scoliosis progression, pain is simple and non-invasive to measure, and you can do a simple comparison of pain before treatment and pain after treatment in the same patients.

If my hypothesis is correct, this *pain reduction* will also slow progression. But, even without that, the conservative treatments are legitimized and patients have a safe method to use to treat pain.

Good comments! Pain management is the key, and it is indeed measurable. I would love to hear your hypothesis about pain reduction effecting curve progression as I missed it somewhere. Also, as surgery is done on patients at all ages, it is always a future consideration I presume, so no harm in trying alternatives.

jrnyc
03-01-2010, 03:59 AM
hmmmmm...i definitely missed something big! cause i WISH my pain management reduced my curves...or progression...or anything about them, besides some...often just a tiny bit for a tiny amount of time....of the pain!

oh, how i wish!!

jess

hdugger
03-01-2010, 10:07 AM
sorry, I wrote that badly. What I meant is that I've been tracking cases (I think I'm up to 8 or 10) where some kind of exercise treatment reduced a curve. So, if those exercise treatments were prescribed for pain management (since they're also effective for that), then in some number of cases they would also reduce the curve (unlikely) or halt or slow progression (more likely).

dailystrength
03-01-2010, 09:22 PM
sorry, I wrote that badly. What I meant is that I've been tracking cases (I think I'm up to 8 or 10) where some kind of exercise treatment reduced a curve. So, if those exercise treatments were prescribed for pain management (since they're also effective for that), then in some number of cases they would also reduce the curve (unlikely) or halt or slow progression (more likely).

Would you share your findings - your list of 8-10 effective cases - and what type of exercise was used? I am looking into Schroth. I have heard good things about that. Yes, it needs to be in-network (insurance)- the rigamarole to find out if I'm covered at all is a mountain to get over! :rolleyes:

jrnyc
03-01-2010, 10:44 PM
insurance companies just LOVE to label things as not covered...the latest surgery is "experimental"...so they can refuse to cover something like dr anand's surgery...massage is "elective" or un-needed or such...they love the word "alternative" cause everything they can give that label to they can then refuse to cover! it is just their usual M.O.!! i fear it will take a looooong time to change it..even as the President tries to get "pre-existing conditions" eliminated from their excuse making machine of refusal!!


jess

hdugger
03-02-2010, 12:47 AM
It's been a little bit since I gathered them together. I *think* it's

1 for yoga (Elisa Miller)
1 for some kind of unspecified exercise/massage (Martha Hawes)
1 - 3 for SEAS (exercise clinic in Italy)
1 for Schroth (someone on this board)
2 or 3 for torso rotation (although, with very short follow-up)

I'd have to look through my posts to remember. My criteria was any study with more then a temporary (i.e, it didn't just go away after a few hours) decrease of at least 10 degrees in a substantial curve (above 35 degrees) in an adolescent or adults.

The thing to remember with exercise, though, is that you have to continue exercising to get the benefit. Also, although I'm noting reductions, I'm really just using them to indicate a method that could stabilize a curve or slow progression.

dailystrength
03-03-2010, 09:55 PM
Thanks, Hdugger. I appreciate it the "short list". I am submitting my Schroth PT papers to my insurance tomorrow. A clinic in MD has it all typed out. I hope to be on your list one day.

hdugger
03-04-2010, 12:20 AM
That would be great! At the least, there is some thought that exercise can slow progression.

Let us know how it turns out. One thing that Martha Hawes recommends, due to the sparseness of research in this area, is keeping detailed notes on everything you can measure. In addition to the Cobb angle, I'd try to track your height, your rotation (I hear there's a scoliometer app for the iphone), your breathing capacity, level of pain, etc. Anything you can measure to determine what effect the exercise has had.

We didn't do any of that, of course, so all we have is our subjective sense that our son's curve *looks* better after regular exercise and stretching. I guess time will tell on the progression.

dailystrength
03-04-2010, 09:49 PM
Thanks! I measure my height on the bathroom wall, but I will also look into that scoliometer - that sounds great. Just to know if I am doing the right thing! In the meantime also, and you may laugh, but I am going to try an ab. machine from TV. Why not - "free" trial with return shipping costs....but it seems that the core muscles are the focus of scoliosis PT therapy. It did get good reviews. I know, I'm a sucker. Or desperate.:p Schroth, if approved, won't be for a few more months as she's full until July. Oh, and btw, I got my paperwork off today, including a nice copy of my x-ray. Praying for mercy.