Rehabilitation of adolescent patients with scoliosis—what do we know?

[skevimc]

I have some thoughts and questions about RTC studies. Firstly, it looks like Weiss is not a big fan of RTC studies in regards to bracing. He outlines why in an oral presentation given at SOSORT found Here. It is beneath Lori Dolan's presentation (also a good listen).

What are your thoughts on that? I am truly interested on what your take is.

I'm just a lay patient and know nothing about the politics of the game, but if it is lack of RTC studies that is keeping a method such as Weiss' from finding implementation into our established medical system - when there does exist evidence galore in Europe, then I suppose, as is said at the space center - Houston, we have a problem.

[COLOR="Navy"]

[*]In light of the unknown long-term effects of surgery, a randomised controlled trial (RCT) seems necessary.

[*]Due to the presence of evidence to support conservative treatments, a plan to compose a RCT for conservative treatment options seems unethical.

[*]But it is also important to conclude that the evidence for conservative treatments is weak in number and length.[/LIST]

I struggle with the concept of RCT's as well. I understand why they are needed and I understand their strength from a statistical point of view. But I personally don't think they are a good idea to do when you have limited resources and/or patients to enroll. I also am if-y when it comes to a treatment versus the natural history of a disease. Particularly if there is already a clinically accepted alternative. I usually don't 'win' discussion on this with colleagues but I also think that there's a bit of dogma involved with this as well. Personally, I think blinding as many people as possible in the study is the most important thing.

That being said, what Weiss wrote above displays my overall critique. He wants to apply the RCT design to surgeries but not to conservative therapies. He places requirements/critiques on certain treatments and not on others. Also, he says that there isn't any long term data on surgical outcomes and that isn't true. There are several really nice studies following surgical and bracing patients for at least 20 years.

Now I'll reiterate that I think Schroth is a good therapy. But I also think other treatments have validity as well. I'm very dedicated to rehab in general no matter what the disease or condition. I want to see the best science done.

[mamamax]

RCT Studies - The debate within The Literature

I struggle with the concept of RCT's as well. I understand why they are needed and I understand their strength from a statistical point of view. But I personally don't think they are a good idea to do when you have limited resources and/or patients to enroll. I also am if-y when it comes to a treatment versus the natural history of a disease. Particularly if there is already a clinically accepted alternative. I usually don't 'win' discussion on this with colleagues but I also think that there's a bit of dogma involved with this as well. Personally, I think blinding as many people as possible in the study is the most important thing.

That being said, what Weiss wrote above displays my overall critique. He wants to apply the RCT design to surgeries but not to conservative therapies. He places requirements/critiques on certain treatments and not on others. Also, he says that there isn't any long term data on surgical outcomes and that isn't true. There are several really nice studies following surgical and bracing patients for at least 20 years.

Now I'll reiterate that I think Schroth is a good therapy. But I also think other treatments have validity as well. I'm very dedicated to rehab in general no matter what the disease or condition. I want to see the best science done.

Yes :-)

Reading the Scoliosis Journal literature, in reference to RCT studies, is almost like watching a conversation (or "debate") unfold within the literature itself. Historically, first mention of it , begins with Negrini in 2006 as a suggestion towards support of evidence based medicine relative to patient choice of treatment. Next mention of RCT studies in the Scoliosis Journal comes from the University Medical Center Rotterdam, Rotterdam, The Netherlands/2007. Here the authors reference the first Dutch led RCT study - using bracing and a controlled treatment trial. The same authors from the Netherlands publish (the same year) an Editorial in The Pediatrics Review: where they give Weiss a little heat in reference to his 1994 publication: Application of the case-control method in the evaluation of screening. The Netherlands editorial in The Pediatrics Reviews seems to almost make a case against bracing and further alludes to the fact that (in their opinion), bracing studies would be best conducted by surgeons (as I read it). Following these three publications, Weiss publishes an Editorial in the Scoliosis Journal on the topic of RTC studies relative to scoliosis.

In reading all four of these articles, I see a debate within the literature itself. And basically, I think, Weiss is saying if RCT studies are going to be applied to bracing treatments - then they should also be applied to all treatments, including surgical treatments. I can also see how reading Weiss, out of historical context, could lead to some misunderstanding.

It is all quite interesting.

In his editorial, Weiss makes a good case as to how RCT studies do not apply to scoliosis - based upon the standardized criteria established by CEBM (The Centre for Evidence Based Medicine). This editorial bty turns out to be a very good outline of EBM guidelines.

Case against RCT relative to scoliosis:

Although randomized controlled trials (RCT's) provide the highest evidence the application of this study design is unrealistic for complex disorders like scoliosis. While pharmacological studies are the main field for RCT's until now no RCT on treatment outcomes for scoliosis is available.

In pharmacological studies one can easily standardise the treatments (drugs) to be investigated. Body weight of the patients and dosage of drugs can easily be measured [12].

Scoliosis on the other hand is not a uniform condition. Even the subset of patients suffering from Adolescent Idiopathic Scoliosis (AIS) appears to include multiple variations in curve pattern, maturity, curve stiffness and sexual differences all influencing the outcome of treatment [13]. Recently claims have been made for an RCT on bracing [11,14,15], but the question remains to be answered; what brace, with what set amount of time, should be monitored and in which particular patient? It seems even difficult to define what exactly may be referred to as a "brace" as there is a wide variability of applications (Fig. 1). Treatment and subject treated are of such high variability that an RCT for bracing seems to be a very complex task.

His ethical viewpoint of RCT & scoliosis:

In the light of this evidence already available, an RCT is not only a complex task but an unethical one. To allow growing patients to continue without conservative treatment (a control group) until nothing except surgical intervention can help them, is completely unethical. Especially when one considers the problems with surgery, such as; primary risks; a re-surgery rate, which might be higher than 30% in the long-term [17-19] and future complications [17]. This type of approach cannot be regarded as patient-oriented. This is why the SOSORT offers clinicians and scientists to take part in prospective controlled studies on bracing. Within this society there is a unique opportunity to test different bracing approaches against each other in order to find the "Best Practice" of bracing. This will enable clincians in the near future the opportunity to give their conservatively treated patients the best possible advice and offer the best possible treatment in a more standardized way. Research on living patients should only be done in order to develop a useful treatment, this is why we need to be able to measure brace quality. We know that in-brace correction and compliance are the two main determinants of outcome [16,20,21]. Therefore in-brace correction might serve as a measure for brace quality and compliance as a measure for quality of management. Efforts have to be made to improve both of these.

Unfortunately many studies on bracing, mainly coming from the US, do not attempt to find ways to improve this measurement [10,11,14,22]. Whether a brace works or not seems to depend upon the fate of the individual patient and not on brace quality. Some SRS Surgeons introduced the term "brace responder" or "non-responder" [23] as if it was the patients fault when there is no successful outcome. No one attempts to explain why some patients are "non-responders" and with another brace the same patients are "responders" [24] (Fig. 2).

His vision of Scoliosis Journal & surgery:

To help to develop the body of research regarding the outcome of surgery and to highlight the problems of treatment indications in patients with AIS and other spinal deformities we would like to open the Scoliosis Journal to papers that discuss surgical procedures.

One of our aims is to improve patients' safety in surgery by producing evidence-based information that can be used to develop guidelines that could aid both professionals and patients in making decisions about surgical and conservative options.

Within this society we have well known spinal surgeons who are specialists in conservative management of scoliosis as well. This is why I am confident that to include papers with surgical content, is a step towards an equilibrated and balanced view on scoliosis management.

So in reading (historically), it becomes clearer why some statements are made in the literature (in that they are often retorts) and also how sometimes when not read within historical context - they may be misunderstood. As a lay patient, I can see both sides of the fence, RCT studies are scientifically valuable - and difficult if not inappropriate to bracing. The debate will no doubt continue, and be supported on both sides by some very well educated people on the subject.

Do I, as a patient care about these debates? No. As a patient, my needs are results based in terms of well written and well presented studies and when possible, first hand knowledge of other patients who have experienced successful treatment.

Over the last year, a bracing method brought me through the most difficult time in my life (in dealing with scoliosis). There were no RCT studies on my chosen method at the time, there still are none. My medical doctor however, did read a few well presented studies on my chosen method, and based on those, wrote an Rx for me. So as a patient, if I wait for RCT studies, or if my medical doctor waits for RCT studies, before making a medical decision - we will be doing much waiting and less treating.

Agree with you skevimc, there are appearing many non surgical methods showing promise. None of them are something easily accessed by this patient. Currently, only one of them seems well designed for use in hospital affiliated physical therapy departments - and that is the Schroth-based SSTR which steps beyond offering lifetime exercise in order to maintain benefits - and where seems found more hope than all of the current studies in the literature (in my opinion) for both adolescents and adults. I am so longing to see the upcoming SSTR study which will be available in a few months.

I applaud your efforts in the area of rehabilitation skevimc, somehow sense you will also be making contributions :-)

Long term data on surgical outcomes - I suppose I must now go look at the historical context of that. Maybe more revealing also.

[Ballet Mom]

Wow, I have whiplash from the 180 degree turnaround! From scam to Nobel prize in record time! Personally, I think anyone who wins a Nobel prize for physical therapy treatment of scoliosis would have to share it with the Europeans....I think they have at least eighty years on the Americans...

Who knows...I think Dingo might end up beating everyone to the Nobel...hee hee!

[Ballet Mom]

mamamax,

I agree with Weiss on this issue of randomized controlled trials. And in fact, most parents do also, seeing as Braist ended up having to get rid of that little problem of RCT in order to possibly get enough patients enrolled to do a study.

I think RCT is going to be an issue in a lot of medical areas. Even Linda was unhappy when they introduced it into a surgical trial for adult scoliosis.

Randomized controlled trials are nice in theory until you are actually the patient being randomized and losing control of your treatment options. Welcome to the real world, statisticians.

[Pooka1]

the standardized criteria established by CEBM (The Centre for Evidence Based Medicine).

That is a very interesting site. I found this there...

http://www.ncbi.nlm.nih.gov/pubmed/1...t=AbstractPlus

BMJ. 2007 Feb 17;334(7589):349-51.
When are randomised trials unnecessary? Picking signal from noise.

Glasziou P, Chalmers I, Rawlins M, McCulloch P.

Centre for Evidence-Based Medicine, Department of Primary Health Care, University of Oxford, Oxford OX3 7LF. paul.glasziou@dphpc.ox.ac.uk

Comment in:

* BMJ. 2007 Mar 3;334(7591):440.
* BMJ. 2007 Mar 3;334(7591):440.

Abstract

Although randomised trials are widely accepted as the ideal way of obtaining unbiased estimates of treatment effects, some treatments have dramatic effects that are highly unlikely to reflect inadequately controlled biases. We compiled a list of historical examples of such effects and identified the features of convincing inferences about treatment effects from sources other than randomised trials. A unifying principle is the size of the treatment effect (signal) relative to the expected prognosis (noise) of the condition. A treatment effect is inferred most confidently when the signal to noise ratio is large and its timing is rapid compared with the natural course of the condition. For the examples we considered in detail the rate ratio often exceeds 10 and thus is highly unlikely to reflect bias or factors other than a treatment effect. This model may help to reduce controversy about evidence for treatments whose effects are so dramatic that randomised trials are unnecessary.

This is preciously the reason why randomized trials are always going to be necessary for bracing and PT. There has never been a dramatic effect that stood. Moreover, the signal to noise ratio is always so low even in well-designed trials because the noise (intrinsic variability) of scoliosis is known to be huge.

Showing efficacy is one thing. Another is these researchers have to contend with the over-treatment aspect also which has been estimated in at least one study to be ~70%. Bracing is a difficult treatment and they have their work cut out to show it is worth it for a given patient. In fact that is not likely to ever be shown until they get a handle on what drives the large variability.

For PT, the issue seems to be just getting folks to commit. Again, unless they can eventually show that a given patient doing X number of exercises Y number of times a week for Z months will avoid fusion surgery for life, I doubt some people will try.

It is very easy to see why Dr. McIntire's adviser warned him not to do scoliosis research. And the more I read about it, the more it seems to unfold that way.

[mamamax]

mamamax,

I agree with Weiss on this issue of randomized controlled trials. And in fact, most parents do also, seeing as Braist ended up having to get rid of that little problem of RCT in order to possibly get enough patients enrolled to do a study.

I think RCT is going to be an issue in a lot of medical areas. Even Linda was unhappy when they introduced it into a surgical trial for adult scoliosis.

Randomized controlled trials are nice in theory until you are actually the patient being randomized and losing control of your treatment options. Welcome to the real world, statisticians.

Ballet Mom - Yep. Theory and practice are entirely two different things. RCT seems not appropriate in surgical or non surgical methods of scoliosis treatment - as BrAist has discovered. I wonder what happened with that surgical trial - hope they were able to toss it out the window as well. Your one-liner .... Priceless

[LindaRacine]

I think RCT is going to be an issue in a lot of medical areas. Even Linda was unhappy when they introduced it into a surgical trial for adult scoliosis.

Don't think I said I was unhappy. And, interestingly, I was thinking at it from both approaches. I can't imagine that you would agree to put your child through surgery unless it became absolutely necessary, and I can't imagine others considering not having surgery. While we all want the data from RCTs, there aren't that many people who are actually willing to let the toss of a coin determine their treatment.

[mamamax]

While we all want the data from RCTs, there aren't that many people who are actually willing to let the toss of a coin determine their treatment.

Yes - that is it in a nutshell (in addition to the ethics), and what it all boils down to from the patient perspective. Agree 100%

Great signature bty :-)

[mamamax]

Evidence Based Medicine (Terms & Definitions)

Reading of the Literature can truly be confusing when historical context and definitions are not obvious. So, as lay patients and parents we must often haul out dictionaries, etc. After all, it seems to me, the Literature or Body of Evidence is not written for patients and parents, but experts in the field. Lacking definitions, and historical context has proven to give cause for misunderstanding - making the reading of the literature something more complex than the simple scanning of any one article.

Just posting this for myself and others as we attempt to unravel publications that are becoming ever more available to us. The following is a brief outline of the purpose, terms, and definitions that are standard use in the literature as provided by the Center for Evidence Based Medicine ... as well as a brief explanation as to how this relates to various treatments available for scoliosis. The Source: Orthopedic Surgeon, Hans-Rudolph Weiss - Editorial, Scoliosis Journal 2007.

The Centre for Evidence Based Medicine (EBM) [1] provides guidelines to spread the knowledge about EBM and its use. There is a special hierarchy of evidence based knowledge:

1. Smallest evidence is provided by "expert opinion"

2. Case reports/case series

3. Un-controlled studies

4. Controlled studies

5. Randomized controlled studies (RCT) and

6. Meta analyses from RCT

The quality and types of evidence help to segregate research into levels. They are graded (IV [lowest] – I [highest]) and from those levels recommendations for treatment are derived (Grade D [lowest] – Grade A [highest]).

Grade B recommendations for conservative treatment of scoliosis are justified. There are prospective controlled studies (level II) [2-4] and enough data from level III or IV, which are generally consistent [5] when taking into account studies from central Europe or Asia [6-9]. These levels of evidence seem not to have been reached in the United States [10,11].

Although randomised controlled trials (RCT's) provide the highest evidence the application of this study design is unrealistic for complex disorders like scoliosis. While pharmacological studies are the main field for RCT's until now no RCT on treatment outcomes for scoliosis is available.

In pharmacological studies one can easily standardise the treatments (drugs) to be investigated. Body weight of the patients and dosage of drugs can easily be measured [12].

Scoliosis on the other hand is not a uniform condition. Even the subset of patients suffering from Adolescent Idiopathic Scoliosis (AIS) appears to include multiple variations in curve pattern, maturity, curve stiffness and sexual differences all influencing the outcome of treatment [13]. Recently claims have been made for an RCT on bracing [11,14,15], but the question remains to be answered; what brace, with what set amount of time, should be monitored and in which particular patient? It seems even difficult to define what exactly may be referred to as a "brace" as there is a wide variability of applications (Fig. 1). Treatment and subject treated are of such high variability that an RCT for bracing seems to be a very complex task.

[mamamax]

Step by Step Fitting - Chêneau light™ (SSTR)

SSTR (Scoliosis Short Term Rehabilitation) could be viewed as a new method in scoliosis rehabilitation, and as one that becomes the current generation of PT specific to curvature pattern - previous generations being The Schroth Method, and Scoliosis In-Patient Rehabilitation (SIR). While The Schroth Method, and SIR have not necessarily been eliminated, SSTR becomes a refinement based on The Best Practice Method (developed by Dr. Weiss) and a method seemingly well designed for hospital affiliated Physical Therapy departments - and a method useful to both those patients seeking non surgical rehabilitation, as well as for certain surgical patients for whom pain has become an unresolved issue. As I currently understand it, this method uses both bracing (for adolescents, and for some adults where pain is an issue) and exercises which are designed to not be required over the course of a lifetime in order to maintain results and benefits. The literature on this is forthcoming over the next few months.

SSTR uses two braces. One is the Chêneau light™

A demonstration of the step-by step fitting

[mamamax]

The Data Debate

<snip>

Also, he says that there isn't any long term data on surgical outcomes and that isn't true. There are several really nice studies following surgical and bracing patients for at least 20 years.

Now I'll reiterate that I think Schroth is a good therapy. But I also think other treatments have validity as well. I'm very dedicated to rehab in general no matter what the disease or condition. I want to see the best science done.

I think this may be one of the most often mis-quoted Weiss-isms :-)

Does he state that there is no long term data - or does he state that the data is questionable? There is a difference.

Personally, I think that until such time as "data" becomes required vs voluntary ... the evidence remains, questionable. From the infamous (and very detailed) 2008 debate: Adolescent idiopathic scoliosis – to operate or not? A debate article

No evidence for surgery in prospective controlled trials
There are in fact prospective controlled studies comparing the outcome of patients with AIS treated conservatively with a series of patients treated surgically [48,69-73]. Nevertheless no study is available comparing surgery to the natural history prospectively [74-76]. The Gothenburg's papers do not offer any evidence that the long-term outcome of surgery is superior to the long-term outcome of patients treated conservatively [48,69-73].

The studies relating to HRQL/SRS-22 questionnaires do not demonstrate differences between the two groups of patients [70], pain and function do not differ [48,73], nor does degeneration [71], sexual function [72] or restrictive ventilation disorder [69]. As early as 1973, Paul Harrington envisioned in the future a common database or registry of all Scoliosis Research Society (SRS) members' patient's treatment results [51]. Unfortunately the SRS failed to follow this vision until recently. Instead of achieving long-term evidence for surgical treatment on a higher level and addressing the problems after surgery to attempt to improve patient safety, the surgical community is presenting large numbers of papers describing HRQL after surgery and related research [26,77-81].

The problem with such studies is that they lack validity as they do not investigate the actual signs of scoliosis or the post-surgery symptoms of the patient [82]. Those studies containing psychological questionnaires may be compromised by the dissonance effect [74-76,82,83].

[skevimc]

[QUOTE=mamamax;106071]

• In light of the unknown long-term effects of surgery, a randomised controlled trial (RCT) seems necessary.
  

[COLOR="Navy"]I think this may be one of the most often mis-quoted Weiss-isms :-)

Does he state that there is no long term data - or does he state that the data is questionable? There is a difference.

I was referring to the above quote. Saying "In light of the unknown long-term effects" implies to me that no data exists.

After reading the other info I think I can understand the point he is trying to make. He's saying that crossing out conservative studies because they lack controlled trials against the natural history of the curve is an unfair critique because there are no trials comparing the natural history to surgery either??

[LindaRacine]

Sharon...

Well said.

I'm gradually becoming convinced that even long-term studies aren't all they're cracked up to be in terms of scoliosis. This is the latest in studies out of the Swedish group once led by Alf Nachemson:

http://www.ncbi.nlm.nih.gov/pubmed/20038869

Health-related quality of life in untreated versus brace-treated patients with adolescent idiopathic scoliosis: a long-term follow-up.

Danielsson AJ, Hasserius R, Ohlin A, Nachemson AL.

Department of Orthopedics, Sahlgrenska University Hospital, Göteborg, Sweden. danielsson.aina@telia.com
Abstract

STUDY DESIGN: The previous Scoliosis Research Society brace study (JBJS-A, 1995) included patients with adolescent idiopathic scoliosis (AIS) with moderate curve sizes (25 degrees -35 degrees). The Swedish patients in this study were examined in a long-term follow-up.

OBJECTIVE: The aim was to analyze and compare quality of life in adulthood between AIS patients who were only observed or treated with a brace during adolescence.

SUMMARY OF BACKGROUND DATA: Quality of life as measured by the SRS-22 has not previously been presented for adult untreated AIS patients.

METHODS: Forty patients who were only observed (due to a curve increase of less than 6 degrees until maturity), and 37 brace-treated patients attended the complete follow-up, including clinical and radiologic examination, and answered 2 quality of life questionnaires (SRS-22 and Short Form-36 [SF-36]).

RESULTS: No differences were found between the groups in terms of age at follow-up (mean: 32 years), follow-up time after maturity (mean: 16.0 years), and curve size at inclusion (mean: 30 degrees) or at follow-up (mean: 35 degrees). The SRS-22/total score was a mean of 4.2 for braced patients and 4.1 for only observed patients. Neither total scores/subscales of the SRS-22 or SF-36 differed significantly between the groups. For the SF-36, no differences in relation to the Swedish age-matched norm scales were found for either group.

CONCLUSION: Patients with moderate AIS report good quality of life in their 30s, as measured by both the SRS-22 and SF-36, regardless of whether they received no active treatment or were brace treated during adolescence. Neither of the groups displayed any difference compared with the age-matched norm groups for the SF-36.

While that sounds great, we don't yet know what's going to happen to any of these people when they hit their 60's.

And, this is from the same group that published the following just 3 years ago:

http://www.ncbi.nlm.nih.gov/pubmed/17873811

Spine (Phila Pa 1976). 2007 Sep 15;32(20):2198-207.
A prospective study of brace treatment versus observation alone in adolescent idiopathic scoliosis: a follow-up mean of 16 years after maturity.

Danielsson AJ, Hasserius R, Ohlin A, Nachemson AL.

Department of Orthopedics, Sahlgrenska University Hospital, Göteborg, Sweden. danielsson.aina@telia.com
Abstract

STUDY DESIGN: The Swedish patients included in the previous SRS brace study were invited to take part in a long-term follow-up.

OBJECTIVE: To investigate the rate of scoliosis surgery and progression of curves from baseline as well as after maturity.

SUMMARY OF BACKGROUND DATA: Brace treatment was shown to be superior to electrical muscle stimulation, as well as observation alone, in the original SRS brace study. Few other studies have shown that brace treatment is effective in the treatment of scoliosis.

METHODS: Of 106 patients, 41 in Malmö (all Boston brace treatment) and 65 in Göteborg (observation alone as the intention to treat), 87% attended the follow-up, including radiography and chart review. All radiographs were (re)measured for curve size (Cobb method) by an unbiased examiner. Searching in the mandatory national database for performed surgery identified patients who had undergone surgery after maturity.

RESULTS: The mean follow-up time was 16 years and the mean age at follow-up was 32 years The 2 treatment groups had equal curve size at inclusion. The curve size of patients who were treated with a brace from the start was reduced by 6 degrees during treatment, but the curve size returned to the same level during the follow-up period. No patients who were primarily braced went on to undergo surgery. In patients with observation alone as the intention to treat, 20% were braced during adolescence due to progression and another 10% underwent surgery. Seventy percent were only observed and increased by 6 degrees from inclusion until now. No patients underwent surgery after maturity. Progression was related to premenarchal status.

CONCLUSION: The curves of patients with adolescent idiopathic scoliosis with a moderate or smaller size at maturity did not deteriorate beyond their original curve size at the 16-year follow-up. No patients treated primarily with a brace went on to undergo surgery, whereas 6 patients (10%) in the observation group required surgery during adolescence compared with none after maturity. Curve progression was related to immaturity.


It all makes my head spin.

[Ballet Mom]

Linda,

I think both those studies you post are great news for kids who were braced during their growth spurt! I'm sure, as long as the people are willing, that you will continue to get updates late into their lives which will be very interesting.

What wonderful conclusions...I am very happy for the good outlook for my daughter! They're so good, I'm going to repost them.

"CONCLUSION (Study 2): Patients with moderate AIS report good quality of life in their 30s, as measured by both the SRS-22 and SF-36, regardless of whether they received no active treatment or were brace treated during adolescence. Neither of the groups displayed any difference compared with the age-matched norm groups for the SF-36."


"CONCLUSION (Study 1): The curves of patients with adolescent idiopathic scoliosis with a moderate or smaller size at maturity did not deteriorate beyond their original curve size at the 16-year follow-up. No patients treated primarily with a brace went on to undergo surgery, whereas 6 patients (10%) in the observation group required surgery during adolescence compared with none after maturity. Curve progression was related to immaturity."

[Pooka1]

I'm gradually becoming convinced that even long-term studies aren't all they're cracked up to be in terms of scoliosis. This is the latest in studies out of the Swedish group once led by Alf Nachemson:

http://www.ncbi.nlm.nih.gov/pubmed/20038869

Health-related quality of life in untreated versus brace-treated patients with adolescent idiopathic scoliosis: a long-term follow-up.

Danielsson AJ, Hasserius R, Ohlin A, Nachemson AL.


CONCLUSION: Patients with moderate AIS report good quality of life in their 30s, as measured by both the SRS-22 and SF-36, regardless of whether they received no active treatment or were brace treated during adolescence. Neither of the groups displayed any difference compared with the age-matched norm groups for the SF-36.[/INDENT]

While that sounds great, we don't yet know what's going to happen to any of these people when they hit their 60's.

Yes and these results could be fairly interpreted as meaing the braced kids were treated unecessarily. It looks like most if not all were. A previous study estimated ~70% were braced who didn't need to be. That is really sad. At some point, they have to identify the majority(?) of kids who do not need bracing for ethical reasons.

And, this is from the same group that published the following just 3 years ago:

http://www.ncbi.nlm.nih.gov/pubmed/17873811

Spine (Phila Pa 1976). 2007 Sep 15;32(20):2198-207.
A prospective study of brace treatment versus observation alone in adolescent idiopathic scoliosis: a follow-up mean of 16 years after maturity.

Danielsson AJ, Hasserius R, Ohlin A, Nachemson AL.


RESULTS: The mean follow-up time was 16 years and the mean age at follow-up was 32 years The 2 treatment groups had equal curve size at inclusion. The curve size of patients who were treated with a brace from the start was reduced by 6 degrees during treatment, but the curve size returned to the same level during the follow-up period. No patients who were primarily braced went on to undergo surgery. In patients with observation alone as the intention to treat, 20% were braced during adolescence due to progression and another 10% underwent surgery. Seventy percent were only observed and increased by 6 degrees from inclusion until now. No patients underwent surgery after maturity. Progression was related to premenarchal status.

CONCLUSION: The curves of patients with adolescent idiopathic scoliosis with a moderate or smaller size at maturity did not deteriorate beyond their original curve size at the 16-year follow-up. No patients treated primarily with a brace went on to undergo surgery, whereas 6 patients (10%) in the observation group required surgery during adolescence compared with none after maturity. Curve progression was related to immaturity.


It all makes my head spin.

Mine too!

This is a potentially valuable report on the mid-years years. I hope they follow everyone into the out years.

The two sentences I bolded seem important and should have been directly related to the other conclusions and not just stated.

A major problem I see here is using the metric of having surgery. We know very well that some people in surgical range refuse it. This paper would be much stronger if they reported the number of people who reach 50* in each group rather than the sugical rates. The groups might be small enough such that the vagaries of which people will agree to surgery may have affected the results.