Cost/Benefit of Non-Operative Treatment in Adults

[Pooka1]

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]

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]

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]

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]

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]

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]

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]

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]

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]

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]

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]

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]

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]

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]

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.