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concerned dad
04-21-2009, 08:33 AM
I just found a SOSORT paper with a discussion about Lori Dolans Metanalysis. They mention the ethics of a Random Controlled Trial and in a roundabout way, accuse Dolan of cherry picking. Very interesting.

2009 SOSORT paper (http://www.scoliosisjournal.com/content/pdf/1748-7161-4-2.pdf)

In discussing the meta analysis they say (emphasis added is mine):

The authors concluded that "Based on the evidence presented here, one cannot recommend one approach over the other to prevent the need for surgery in AIS." Nevertheless, the authors elected to exclude from the study the groups with bracing plus exercises. Under the conditions of their analysis, therefore, according to the Material and Methods of the paper, their conclusion should have been as follows: "Based on the evidence presented here, according to the English literature and excluding the combined approach of bracing and exercises, one cannot recommend one approach over the other to prevent the need for surgery in AIS.". In fact, according to the same criteria used in the previously mentioned metanalysis [7], the papers published by some members of the international Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) [8-12], that are in the English literature but include also exercises, have yielded results that are in conflict with those of the reported systematic review [7] (Figure 1).

The world of treatment of scoliosis is gradually changing [2] and two main ideas are facing each other: one is more surgically oriented, with the prevalent idea that bracing is not an effective treatment [6]. This position has been used to justify the ethical approval of a Randomised Clinical Trial now underway in the US. The SOSORT is more conservatively oriented, and their members have presented a substantial body of data on the effectiveness of conservative treatment in general [8-12], and of exercises and bracing in particular [13-26]. Consequently, a formal debate among this Society concluded that a Randomised Controlled Study on brace efficacy would be ethically unacceptable [27].

I would attach their Figure 1 but the whole text is available at the link above. The bottom two bars on the chart are from the Dolan metanalysis paper showing no difference between braced and observation. The upper bars show the results from studies that were excluded because exercise therapy was used in conjunction with bracing. It seems to me that, even if we assume exercise therapy does nothing, we still have data from those studies showing braced patients and the point the SOSORT author makes is valid. Looks a bit like cherry picking to me.

Note: I earlier criticized Dolan for excluding the Nachemson data (the failed 1995 SRS bracing study) in her analysis. I later conceded I was dead wrong about that criticism because the Nachemson data did not include surgical rates. This is a different issue. And, of course, I could be wrong once again. Nevertheless, seeing the debate/argument discussed in the technical literature is fascinating.

LindaRacine
04-21-2009, 12:42 PM
because the Nachemson data did not include surgical rates.
I must have missed something. Can you give me a recap of what is meant by this?

Thanks.

concerned dad
04-21-2009, 01:12 PM
Sure, The Nachemson study is the big 1995 SRS study that took 10 years to complete. It has been criticized (dismissed by some) because of several reasons. Two of the most important are

1. It turned out that their unbraced group had a higher amount of curves (lumbar?) deemed less likely to progress. This was the stratification of curve issue (ironic that in the very same journal issue where they published the paper someone else published a paper showing that different curves types have different chances of progression, oh well)

and

2. Their criteria for observation failure was an increase in curve of more than 5 degrees. Some argue that an unbraced curve progressing from 20 to 26 degrees should not be considered a "failure". But they counted it as such and put the kid in a brace.

Dolan argued that people didnt fear progression per se, they feared progressin to the point where surgery was necessary. She then did her metanalysis by looking for all brace study papers where surgery rates (or a Cobb angle used as a proxy for surgery) were reported. Because of this inclusion criteria (surgery), the Nachemson data were excluded from her metanalysis.

Now, the folks from SOSORT in the paper I linked above say, wait a second. Thats fine to exclude the Nachemson study, but why exclude our studies where excercises were used in conjunction with bracing (and yet surgery rates were reported). To me, their argument makes sense. Even assuming (especially assuming) that excercise does nothing, why make that a reason to exclude the data.

It would be fascinating to hear Dr Dolans response. Unfortunately, she hangs out at the other forum, not here.

(Linda, I answered your question plus added stuff I realize you already know, just wanted to bring anyone else up to speed so they could join in a discussion if they wish)

LindaRacine
04-21-2009, 01:27 PM
Thanks for the very thorough response. :)

in what forum does Dr. Dolan hang?

concerned dad
04-21-2009, 01:36 PM
Well, perhaps I overstated it. :o
She has 4 posts (her handle is Braist24)

She replied to a thread on the Braist Study (for anyone following along, that's the current random controlled bracing study) at
scoliosis-support (http://www.scoliosis-support.org/showthread.php?t=6954)
specifically, her first post is number 12 in that thread.

I really have to hand it to her for participating.

but shhhhhh, dont tell Sharon
:D

tonibunny
04-21-2009, 02:21 PM
Arghhh I'm a staff member on scoliosis-support.org and I really don't like the idea there's any rivalry between any of the scoliosis forums, there really isn't! We often send people over here (cos we're UK-based and know that here's usually the best place for US-based people to get info) or to Spinekids or the infantile scoli groups, and loads of us are members of this forum as well, and Spinekids too. I mean, we're all after the same goal aren't we, we just want to help people *shrug* :o

Pooka1
04-21-2009, 02:46 PM
I just found a SOSORT paper with a discussion about Lori Dolans Metanalysis. They mention the ethics of a Random Controlled Trial and in a roundabout way, accuse Dolan of cherry picking. Very interesting.

2009 SOSORT paper (http://www.scoliosisjournal.com/content/pdf/1748-7161-4-2.pdf)

In discussing the meta analysis they say (emphasis added is mine):

[COLOR="Blue"]The authors concluded that "Based on the evidence presented here, one cannot recommend one approach over the other to prevent the need for surgery in AIS." Nevertheless, the authors elected to exclude from the study the groups with bracing plus exercises. Under the conditions of their analysis, therefore, according to the Material and Methods of the paper, their conclusion should have been as follows: "Based on the evidence presented here, according to the English literature and excluding the combined approach of bracing and exercises, one cannot recommend one approach over the other to prevent the need for surgery in AIS."

I'm sure Dolan also excluded studies on the effect of chanting to reduce curves.

I don't see either exclusion as a problem.

Pooka1
04-21-2009, 02:48 PM
Arghhh I'm a staff member on scoliosis-support.org and I really don't like the idea there's any rivalry between any of the scoliosis forums, there really isn't! We often send people over here (cos we're UK-based and know that here's usually the best place for US-based people to get info) or to Spinekids or the infantile scoli groups, and loads of us are members of this forum as well, and Spinekids too. I mean, we're all after the same goal aren't we, we just want to help people *shrug* :o

Nobody is claiming a rivalry or a competition as such.

But there is the danger that certain folks who contribute greatly on one forum may just plain be enamored of the other forum and jump ship.

That would be a big problem as there are so few folks on both fora to begin with.

tonibunny
04-21-2009, 03:03 PM
Aw, I really can't see that happening, please don't worry! I think people like CD here are very happily settled here, but they might go and check things out over on SSO occasionally as well, just like our regular members sometimes come over here. I like reading this forum and pop by nearly every day, and I contribute if I think I can be helpful, but usually I don't know so much about issues outside of the UK to be able to do much.

I know no-one is claimed any rivalry, but I didn't want anyone to browse by and get the impression that there might be one, if you see what I mean? Just like, well, someone might get the impression that you could definitely correct adult scoliosis by bracing ;)

concerned dad
04-21-2009, 03:08 PM
Arghhh I'm a staff member on scoliosis-support.org and I really don't like the idea there's any rivalry between any of the scoliosis forums, there really isn't! We often send people over here (cos we're UK-based and know that here's usually the best place for US-based people to get info) or to Spinekids or the infantile scoli groups, and loads of us are members of this forum as well, and Spinekids too. I mean, we're all after the same goal aren't we, we just want to help people *shrug* :o

Absolutely. I meant it entirely in jest.

Pooka1
04-21-2009, 03:08 PM
Aw, I really can't see that happening, please don't worry! I think people like CD here are very happily settled here, but they might go and check things out over on SSO occasionally as well, just like our regular members sometimes come over here. I like reading this forum and pop by nearly every day, and I contribute if I think I can be helpful, but usually I don't know so much about issues outside of the UK to be able to do much.

No I wasn't referring only to people like CD who post frequently [though I do live in near-constant fear of his loss to another forum.] :eek::D

I think if scoliosis researchers only post in one forum versus the other as we have seen, that will sway some folks.


I know no-one is claimed any rivalry, but I didn't want anyone to browse by and get the impression that there might be one, if you see what I mean? Just like, well, someone might get the impression that you could definitely correct adult scoliosis by bracing ;)

With comments like that I would follow you to any forum you went to. :D

tonibunny
04-21-2009, 03:20 PM
Well, that researcher only posted four times, and I think she's the only one we've had, so no need to panic :D Tell you what, if we get any more I'll tell them to come over here and discuss things with you chaps as well. To be honest I had assumed she was already here when she posted on SSO, but if she comes back I'll point her over here.

We don't have many people who are so interested in research over on SSO, mainly because our membership is mostly made up of young UK based scoli patients themselves rather than parents or ex-patients who have got interested in the background stuff. I'm fascinated by research but I'm having to deal with a lot of problems to do with my own back at the moment and have more surgery coming up so I haven't been paying as much attention to, for instance, the stuff Dingo has been posting to both forums. My brain is a bit fuzzled from morphine! I have mentioned that there is more of a debate about his posts over here, in case anyone would like to read your perspectives too.

Anyway, I must rush off as it is dinnertime here in the UK and I'm starving! cheers Sharon :D

Toni xx

concerned dad
04-21-2009, 03:20 PM
I'm sure Dolan also excluded studies on the effect of chanting to reduce curves.

I don't see either exclusion as a problem.


Stop and think carefully about this Sharon.

If they were Chanting AND bracing the data is there (so long as surgical rates and proxies for surgery are reported.)

It is like excluding a brace study because the kids were watching TV. It is irrelevant. And, if we argue that the excercise WAS relevant than it demonstrates that excercise positively affected the outcome.

You see, they're not challenging the unbraced surgical rate. They (SOSORT) are challenging the braced surgical rate. They have a bunch of studies showing a much lower braced surgical rate. The only problem is they not only braced, they also included excercises in the therapy.

It is essentially a method of analysis to exclude the brace studies from many SOSORT researchers.

Pooka1
04-21-2009, 03:29 PM
Stop and think carefully about this Sharon.

If they were Chanting AND bracing the data is there (so long as surgical rates and proxies for surgery are reported.)

As I mentioned, I think surgical rates is ridiculous when we know ahead of time that surgeons pull the trigger at a wide range of angles. when you add on top of that folks who don't take advice, the surgical rate metric is extremely NOT robust.


It is like excluding a brace study because the kids were watching TV. It is irrelevant. And, if we argue that the exercise WAS relevant than it demonstrates that exercise positively affected the outcome.

That's a good point. What was the stated reason she excluded exercise+Brace?


You see, they're not challenging the unbraced surgical rate. They (SOSORT) are challenging the braced surgical rate. They have a bunch of studies showing a much lower braced surgical rate. The only problem is they not only braced, they also included excercises in the therapy.

It is essentially a method of analysis to exclude the brace studies from many SOSORT researchers.

Okay I think I see what is going on here.

I would challenge ALL surgical rates as being nearly meaningless for the reason I stated above. So I guess I agree with the SOSORT researchers but for a different reason.

concerned dad
04-21-2009, 03:50 PM
To understand the "surgical rates" issue you need to read Dr Dolans discussion where she says that progression isnt the fear, progression to surgery is the fear.

I agree surgical rates alone are non robust, but if you also report what Cobb angle triggers surgery in your study, it becomes robust.

I want to (and will) look at the SOSORT studies that were excluded and see if I can determine (in my amateurish way) how they compare to the studies that were included.

At face value, that SOSORT paper shows a much lower surgery rate after bracing than the ones Dr Dolan included. Wonder why? Maybe their proxy for surgery was 90 degrees. Maybe they braced 16 year old kids who were done growing. Maybe they braced 10 degree curves. I dunno, but I want to find out.

Dr Dolan mentioned in her paper that her confidence in the braced surgical rate was high. These SOSORT guys seem to disagree.

Pooka1
04-21-2009, 04:05 PM
At face value, that SOSORT paper shows a much lower surgery rate after bracing than the ones Dr Dolan included. Wonder why? Maybe their proxy for surgery was 90 degrees. Maybe they braced 16 year old kids who were done growing. Maybe they braced 10 degree curves. I dunno, but I want to find out.

I suggest your guesses are likely to be correct and largely explain their data.


Dr Dolan mentioned in her paper that her confidence in the braced surgical rate was high. These SOSORT guys seem to disagree.

Either there is or isn't a commonly accepted trigger angle for surgery. If one exists, I think it's ~50.*

Now if everyone was framing their discussion around the rate at which folks hit 50*, that would be valuable I think.

If the angles can be found in these studies, and if everyone can agree on 50* as a surgical trigger, I don't think there would be any disagreement whatsoever on "surgical rates" between Dolan and the SOSORT types.

And last, I think the SOSORT surgical trigger is not 90* but 9000*. :D

Dingo
04-21-2009, 08:42 PM
Here is my not entirely scientific 2 cents on bracing

1) There are studies that indicate bracing works, marginally works or doesn't work at all.
Analysis: Bracing just barely comes out ahead on this one.

2) Bracing lowers Calmodulin levels which are the prime mover in curve progression.
Analysis: Clear evidence that bracing could work.

3) I've read at least 100 posts that give me anecdotal evidence that bracing works.
Analysis: Not scientifically strong but still believable evidence that bracing works for some kids.

Add it all up and I say bracing works.

It would take a half dozen good studies to prove this or disprove it so until then I have to go with my gut.

concerned dad
04-23-2009, 08:35 AM
Sorry Dingo, not exactly what I was after.

I wanted to explore what we know from the literature and the ethical implications. (not that I dont value your 2 cents, it's just that we already have two diametrically opposing assertions)

Dolan says we dont know if bracing works to reduce the incidence of surgery.
SOSORT says bracing and excercise works to reduce the incidence of surgery.

Dolan says a RCT is ethical.
SOSORT says a RCT is unethical.

I would think this topic would garner more discussion.
I'm not much help because I seem to flip flop all over the place on the issue.
We really need someone to dig through the SOSORT references and look at how valid the studies were relative to things like

Maybe their proxy for surgery was 90 degrees. Maybe they braced 16 year old kids who were done growing. Maybe they braced 10 degree curves.

concerned dad
04-23-2009, 01:07 PM
Dickson does a better job at discussing the stratification issue in the Nachemson paper.

From a 1999 paper by Dickson in Spine discussing Nachemson.....

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

Of course, by recognizing that "the next paper in the same journal" revealed the issue of stratification, Dickson is not suggesting malfeasance. How could anyone have known before hand. It must have been a heartbreaking revealation to the folks working on the research.

PNUTTRO
04-23-2009, 04:41 PM
Dolan says a RCT is ethical.
SOSORT says a RCT is unethical.



RCT? randomized clinical trial?

Can you comment on the ethical question? In what way is it unethical?

Dingo
04-23-2009, 04:43 PM
concerned dad

I would bet that the more a scientist digs into previous studies the more problems they'll find.

Even though many of these (or all of these) studies contain flaws they taught us a lot about Scoliosis in general.

Somebody needs to take this info, use a large sample and compare apples to apples.

100 twelve year old girls with a 20ish degree Thorocolumbar curve in a Providence brace for 1 year versus the same type of girls in a nonbraced group. Oh yeah and put a chip in the brace to make sure it's being used.

It's the only way to end the debate once and for all.

LindaRacine
04-23-2009, 07:02 PM
Dingo...

Yes, RCT = Randomized Controlled Trial.

All I know for certain about the RCT debate is that I personally wouldn't want my child to end up in the control group, at least assuming that s/he was in a curve range/Risser that would put her at risk. Having gone through surgery, it's not something I would wish my child to go through, if there was a chance it could be avoided.

I honestly think we're not far from knowing which children (genetically) are at risk. Perhaps we could take a cohort of these children who are genetically at risk, prescribe a brace at the appropriate time (cobb angle/Risser value), monitor compliance, and evaluate results by compliance range.

No matter what we do, I think we're still a long way away from knowing the truth. In the time being, should our kids be braced or not? There are pros and cons for both sides of this debate, so I guess each parent has to make their own informed decision.

Regards,
Linda

PNUTTRO
04-23-2009, 07:43 PM
I think that a trial could be ethical but not random. Since there are those that choose not to brace and those that don't comply, researcher should be able to find a good control group.

A problem may arise when a clinician influences the decision after inclusion in the trial.

Additionally, there are those that opt not to have surgery (for various reasons) even after it is recommended.

It would have to be longitudinal cohort study.

Is the Braist study really randomized?

Pooka1
04-23-2009, 08:28 PM
I would not let my kid participate in a RCT at this point because there is no good evidence bracing works.

It's my daughter's decision to try the Charleston, not mine.

That said, I think RCTs are ethical even though bracing is a very difficult treatment compared to surgery.

Pooka1
04-23-2009, 08:42 PM
And one other thing...

If it is true that virtually all adults develop other problems simply from having scoliosis for years then bracing will become obviously unethical if it works to delay surgery rather than avoid it.

As of now, though, because there is no good evidence bracing works and because nobody who knows what they are talking about ever says longstanding scoliosis causes all these other problems that ofter trigger surgery, I think RCTs can be considered ethical. But I think the days are numbered when it can be so considered for several reasons.

LindaRacine
04-23-2009, 09:02 PM
If it is true that virtually all adults develop other problems simply from having scoliosis for years then bracing will become obviously unethical if it works to delay surgery rather than avoid it.

Hi Sharon....

I doubt that all people with scoliosis will develop other problems as they age. I know of dozens of people in their 30s and 40s, who were braced as kids, but who have no problems with their spines now.

That being said, they have a significant chance of problems later in life anyway. I've seen several references over the last 10-20 years, that show that something like 85% of the general adult population will have one or more instances of back pain in their lifetimes.

Additionally, a significant number of people who have normal spines to start with, will have some degree of scoliosis in later years:

http://www.ncbi.nlm.nih.gov/pubmed/15864163?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Regards,
Linda

Pooka1
04-24-2009, 06:08 AM
Hi Sharon....

I doubt that all people with scoliosis will develop other problems as they age. I know of dozens of people in their 30s and 40s, who were braced as kids, but who have no problems with their spines now.

That being said, they have a significant chance of problems later in life anyway. I've seen several references over the last 10-20 years, that show that something like 85% of the general adult population will have one or more instances of back pain in their lifetimes.

Additionally, a significant number of people who have normal spines to start with, will have some degree of scoliosis in later years:

http://www.ncbi.nlm.nih.gov/pubmed/15864163?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Regards,
Linda

Okay that's really interesting. I knew a majority of (non-fused) people develop back problems if they live long enough but I didn't know it was 85%!

I'm just putting various statements our surgeon made into some logical framework.

I asked why the big difference in recovery between kids and adults and he said adults almost never just have a curve... they almost always have other issues which complicates the recovery. Now I see that it's going to be dicey to sort out which problems may be attributable to the scoliosis and which to just being older because as you say, most adults will eventually have back problems. I don't know.

concerned dad
04-24-2009, 07:17 AM
Can you comment on the ethical question? In what way is it unethical?

We touched on the ethical issue starting at about post 12 of this thread (http://www.scoliosis.org/forum/showthread.php?t=8136)

If you take a close look at Figure 1 in the paper linked at the front of this thread you see Dolan shows no difference between surgery rates of braced and unbraced kids.

Note: There is only one bar there showing unbraced results.

Then you look at the results reported by the SOSORT guys (the Top Bars), they show a marked difference between their braced results and the ones reported by Dolan.

If a doctor believes a better treatment is available, it is unethical to withold it for research purposes. Dolan doesnt think that we know a better treatment is available, SOSORT believes that there is a better treatment (bracing).

And Pnuttro, you are absolutely correct about the possibility of designing a trial that is ethical but not random. That is precisely what they did in the big (failed) 1995 SRS Nachemson bracing study. They got around the ethics by noticing the different "standards of care" at different institutions. Some didnt brace. They felt it didnt work. They were the control. It was, however, not random.

the Braist Trial is indeed Random. If you agree to participate, they essentially flip a coin and put you in a brace or watch till you hit 50 degrees. (Some of the participating centers in the 1995 studies watched for 6 degrees and then wrote watching off as a failure for that patient and then braced)

I dont know, I find the whole thing really interesting to explore the ethics and the scientific method and the science. The fact that it is relevant to my daughter helps too, for sure. I think all the researchers invo9lved are doing the darndest to get the right answers in an ethical and scientifically correct fashion.

And Dingo

100 twelve year old girls with a 20ish degree Thorocolumbar curve in a Providence brace for 1 year versus the same type of girls in a nonbraced group. Oh yeah and put a chip in the brace to make sure it's being used.
it's not as easy as all that. Dolan reports on the other website that they only have 100 girls so far in their study across all curve types and all amplitudes.
And, I dont know if I would brace my 12 year old with only a 20 degree curve. I would be inclined (now) to wait to see if it is an advancing curve.
All it takes is to live with a kid for a couple of months (or even review the posting in the bracing forum) to discover that bracing is no small inconvienence, it is a pretty dramatic change in their lives (albeit, hopefully short lived and only till skeletal maturity). A parent looks to see if there is evidence that it will "work", both in the literature (highly variable results reported) and in your particular case (decent in brace correction).
If it were as simple as taking a pill or turning off a night lite, well, then yes, the treatment would be worth the chance even if there is no good evidence it works. But bracing is not trivial. It has to be a bummer to have surgery, but even more of a bummer to wear a brace for 2 years and then still have surgery.
As surgery methods improve, it makes the decision harder (or, in a strange way easier perhaps).
In my opinion anyway

And just to recap my daughters situation - we are not bracing her 38 degree curve. That decision was based on lots of things, but largely on the indications that she is almost skeletally mature and she did not obtain a good inbrace correction when we tried bracing. And we never would have come to that decision without this forum and ALL the participants as a resource.

Pooka1
04-24-2009, 07:31 AM
(snip good points)

And just to recap my daughters situation - we are not bracing her 38 degree curve.

My daughter hit and passed 38* and bracing was never discussed at any point by either our referring surgeon or the surgeon who did the fusion. I'm guessing they knew through experience that a curve that is moving that fast and twisting up that earlier is not likely to respond. She was spared a brace and luckily had a relatively easy time with the surgery.

Because of the quick/smooth recovery, she has said she was glad to have the surgery and was glad not to have to wear a brace after seeing just the Charleston on her sister. I can only imagine how grateful she would be to not have to wear a 23/7 hard brace. :eek:

Dingo
04-26-2009, 08:59 PM
concerned dad

Dolan reports on the other website that they only have 100 girls so far in their study across all curve types and all amplitudes.

Hmmm... interesting. Until technology advances research might not be able to give us a definitive answer on bracing. Ironically by the time science advances far enough to give is an accurate answer Scoliosis might be cured or treated with drugs (http://www.medent.umontreal.ca/nouvelles/Communiqu%C3%A9_laboratoire_Viscogliosi_ENG.pdf).

All it takes is to live with a kid for a couple of months (or even review the posting in the bracing forum) to discover that bracing is no small inconvienence

I am under no illusions about bracing. It breaks my heart to think of my son in a brace. But if his curve progresses I don't see another option. To me 23/7 bracing sounds at least 10 times more difficult than night bracing.

concerned dad
05-01-2009, 09:19 AM
Finally had a chance to look at one of the bracing studies that did not make Dolans metanalysis (because they included excercise therapy with bracing).

I looked at the Japan study (Maruyama, their Table 1 is attached. They had a 6% surgical rate (indication for surgery was 50*). Much better than the results of the metanalysis would suggest (23*). Both Dolans Table is attached as well as Table 1 from Japan (Which is Dolan's number 11 on her chart).

Dingo
05-01-2009, 11:38 AM
Are you saying that the Maruyama sample was children treated with bracing plus exercise?

My doctor instantaneously slammed the idea of exercise to slow or stop curve progression. I googled for a while and came to the conclusion that he was correct.

Maybe not.

concerned dad
05-01-2009, 12:39 PM
Are you saying that the Maruyama sample was children treated with bracing plus exercise?

That is what I am saying.

I am not attributing the difference in results to the excercise, simply saying that this sample was excluded from the metanalysis solely because of the excercise.



My doctor instantaneously slammed the idea of exercise to slow or stop curve progression. I googled for a while and came to the conclusion that he was correct.

Maybe not.

All depends what you google. Most US doctors would agree with your doctors opinion. Many (most?) European doctors may disagree with him.

Which sort of has me thinking about Sharons comment in the closed (or vanished?) thread about why are americans susceptable to woo woo treatments. Hmmmm, maybe our stubborn insistence against excercise is the woo woo part. Maybe we shouldnt be totally closed minded about the europeans approach. I dunno. But looking at results like this 6% surgery rate makes you think a bit anyway.

Dingo
05-01-2009, 01:44 PM
But looking at results like this 6% surgery rate makes you think a bit anyway.

All 4 of these studies found that torso rotation exercises stopped and even reversed curve progression at least temporarily. The studies weren't longterm and some period of time after exercise stopped curve progression resumed. One thing I found interesting was that children with Scoliosis have a strong side and a weak side. Exercise eliminated that symptom.

April 2000 - A preliminary report on the effect of measured strength training in adolescent idiopathic scoliosis. (http://www.ncbi.nlm.nih.gov/pubmed/10780683?dopt=Citation)

2003 - The Role of Measured Resistance Exercises in Adolescent Scoliosis (http://www.medxonline.com/downloads/articles/measuredresistanceinscoliosis.pdf)

2006 - Trunk rotational strength training for the management of adolescent idiopathic scoliosis (AIS). (http://www.ncbi.nlm.nih.gov/pubmed/17108439?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed)

July 2008 - Treatment of adolescent idiopathic scoliosis with quantified trunk rotational strength training: a pilot study. (http://www.ncbi.nlm.nih.gov/pubmed/18600146?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_RVXml)

concerned dad
05-01-2009, 02:01 PM
I cant wait to hear what the rest of the villagers think about those papers.
:D

Pooka1
05-01-2009, 03:33 PM
In re the Japanese study... is that the rate at which folks actually got the surgery or the rate at which they hit or exceeded 50*?

Pooka1
05-01-2009, 03:37 PM
I cant wait to hear what the rest of the villagers think about those papers.
:D

How this villager feels about those papers (http://www.youtube.com/watch?v=DtMV44yoXZ0)

Love,
a villager

concerned dad
05-01-2009, 04:26 PM
In re the Japanese study... is that the rate at which folks actually got the surgery or the rate at which they hit or exceeded 50*?

That is the surgical rate. They said they wait till 50 degrees for surgery. They also mentioned that others used 45 degrees as an indication for surgery which might explain a bit of their low rate.

I didnt read it carefully enough to see if any people refused surgery once they passed 50 degrees. But looking at the non-surgery column in their table, the after bracing number plu one standard deviation was still below 50 degrees so it couldnt have been many (if any) I suppose.

tonibunny
05-01-2009, 04:46 PM
All depends what you google. Most US doctors would agree with your doctors opinion. Many (most?) European doctors may disagree with him.




I've been talking to a German guy who runs a scoliosis forum. Apparently, Schroth and other exercises for scoliosis are still seen as very much a "fringe" treatment in Germany and other European countries, rather than being the norm. I thought that was quite interesting to note.

Pooka1
05-01-2009, 05:57 PM
I've been talking to a German guy who runs a scoliosis forum. Apparently, Schroth and other exercises for scoliosis are still seen as very much a "fringe" treatment in Germany and other European countries, rather than being the norm. I thought that was quite interesting to note.

That is entirely to be expected. Europe isn't a backwater. They are out ahead of the US on a lot of things.

If Schroth et al. was efficacious, the world would know it by now.

Yet the world is still waiting.

txmarinemom
05-01-2009, 06:51 PM
Here is my not entirely scientific 2 cents on bracing

1) There are studies that indicate bracing works, marginally works or doesn't work at all.
Analysis: Bracing just barely comes out ahead on this one.

2) Bracing lowers Calmodulin levels which are the prime mover in curve progression.
Analysis: Clear evidence that bracing could work.

3) I've read at least 100 posts that give me anecdotal evidence that bracing works.
Analysis: Not scientifically strong but still believable evidence that bracing works for some kids.

Add it all up and I say bracing works.

You left out #4; There are many times more than 100 posters (not posts) in the adult surgical area who were braced kids.

It's my belief when someone claims a brace worked it's PURELY anecdoctal: There's no way to gauge what a curve would have done on its own. The stories of brace failure told by those who have worn braces, and gone on to have surgery as a juvenile, adolescent, or many years down the road as an adult, however, are as far from anecdoctal as it gets. We did it ... and it didn't work.

You certainly can't claim a child who was braced, thought to be stabilized, yet later requires surgery as an adult, a "bracing success".

I think the only correct leap of logic you've made is bracing *may* be effective in kids who are susceptible to bracing. And I'll stop there ... there's already a huge thread devoted to this debate.

Pam

txmarinemom
05-01-2009, 07:27 PM
Dr Dolan mentioned in her paper that her confidence in the braced surgical rate was high. These SOSORT guys seem to disagree.

It stands to reason Dolan can state she has more faith in the braced surgical rate. Kids don't typically show up for an initial consult with an SRS doc with a 60 curve: They generally show up early, and unless there are mitigating circumstances (curve too large, bone age too mature, patient/parent refuses to brace), they are usually braced as a first measure. There's a lot of documentation on kids who go on to need surgery after first being braced.

From what I've read here over the years, it's my perception a higher number of patients who elect to go the alt route (and futz around with a non-surgical SOSORT types) are no more or less likely to end up having surgery. They do, however, seem to present with a higher degree of curvature when they finally see a *real* doctor, are usually unclear how severe their curve even IS, and later feel they wasted a lot of valuable time trying to exercise their curves away.

In no way am I saying exercise hurts - even I had prescribed exercises (in brace and out) back in 1978. I still don't understand precisely why Dolan excluded that group, and what exactly is her definition of exercise that warrants exclusion?