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Thread: Oh Pooka... You're Gonna Love This One!!!

  1. #1
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    Oh Pooka... You're Gonna Love This One!!!

    http://www.josr-online.com/content/5/1/80

    J Orthop Surg Res. 2010 Nov 4;5(1):80. [Epub ahead of print]
    Spontaneous regression of curve in immature idiopathic scoliosis - does spinal column play a role to balance? An observation with literature review.

    Modi HN, Suh SW, Yang JH, Hong JY, Kp V, Muzaffar N.
    Abstract

    ABSTRACT:

    BACKGROUND: Child with mild scoliosis is always a subject of interest for most orthopaedic surgeons regarding progression. Literature described Hueter-Volkmann theory regarding disc and vertebral wedging, and muscular imbalance for the progression of adolescent idiopathic scoliosis. However, many authors reported spontaneous resolution of curves also without any reason for that and the rate of resolution reported is almost 25%. Purpose of this study was to question the role of paraspinal muscle tuning/balancing mechanism, especially in patients with idiopathic scoliosis with early mild curve, for spontaneous regression or progression as well as changing pattern of curves.

    METHODS: An observational study of serial radiograms in 169 idiopathic scoliosis children (with minimum follow-up one year) was carried. All children with Cobb angle <25degree and who were diagnosed for the first time were selected. As a sign of immaturity at the time of diagnosis, all children had Risser sign 0. No treatment was given to entire study group. Children were divided in three groups at final follow-up: Group A, B and C as children with regression, no change and progression of their curves, respectively. Additionally changes in the pattern of curve were also noted.

    RESULTS: Average age was 9.2 years at first visit and 10.11 years at final follow-up with an average follow-up of 21 months. 32.5% (55/169), 41.4% (70/169) and 26% (44/169) children exhibited regression, no change and progression in their curves, respectively. 46.1% of children (78/169) showed changing pattern of their curves during the follow-up visits before it settled down to final curve. Comparing final fate of curve with side of curve and number of curves it did not show any relationship (p>0.05) in our study population.

    CONCLUSION: Possible reason for changing patterns could be better explained by the tuning/balancing mechanism of spinal column that makes an effort to balance the spine and result into spontaneous regression or prevent further progression of curve. If this which we called as "tuning/balancing mechanism" fails, curve will ultimately progress.

    If this study is correct, it means that only 26% of kids with curves <25 degrees and who are Risser 0, will go on to need treatment (at least for the next 10 years).
    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Dilbert
    I'm sarcastic... what's your super power? --Unknown
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    Surgery 2/10/93 A/P fusion T4-L3
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    Good point.

    And we seemingly have some JIV cases mixed in here which is good news.

    This study backs up the paradigm of having 25* as the cutoff for treatment. Anyone claiming that treatment before 25* is necessary and effective better be able to show that with a far better success record than 75%. And they better have HUGE patient populations with to which to show it.

    The problem is lay folks don't know about this and unscrupulous alternative treatment purveyors (pardon that near total redundancy) can probably net a lot of bunnies with the claim that their treatment works most of the time or at least three quarters of the time. In fact sitting around and eating ice cream has the same success rate as these alternative treatments and is far more enjoyable that doing PT in whatever form or wearing a brace.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

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  3. #3
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    I just want to explicitly exempt folks like McIntire who have legit research degrees and do understand the issue of having to show efficacy over and above the natural history average.

    I make a distinction between "conservative" treatment RESEARCHERs like McIntire and the bracing researchers and "alternate" treatment PURVEYORS who have no legit degree including chiros, personal trainers touting various things, etc.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

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    Thumbs up Saliva test as scoliosis progression predictor featured on TV

    http://www2.nbc4i.com/lifestyles/201...nts-ar-231614/

    I was surprised to see this on our local network TV. I didn't realize it was in general use. This is a great way to avoid unnecessary bracing/interventions in those who do not need it.
    Original scoliosis surgery 1956 T-4 to L-2 ~100 degree thoracic (triple)curves at age 14. NO hardware-lost correction.
    Anterior/posterior revision T-4 to Sacrum in 2002, age 60, by Dr. Boachie-Adjei @Hospital for Special Surgery, NY = 50% correction

  5. #5
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    Quote Originally Posted by Karen Ocker View Post
    http://www2.nbc4i.com/lifestyles/201...nts-ar-231614/

    I was surprised to see this on our local network TV. I didn't realize it was in general use. This is a great way to avoid unnecessary bracing/interventions in those who do not need it.
    Yes, it's been around for about a year now. If you do a search here on ScoliScore or Axial Biotech, you'll see some discussion on the topic. Unfortunately, it only works for a rather narrow group of individuals, and most who are in the proper range don't test out at the top or bottom, which is where the test is helpful.

    --Linda
    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Dilbert
    I'm sarcastic... what's your super power? --Unknown
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    Surgery 2/10/93 A/P fusion T4-L3
    Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation
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    If you've signed up and are having trouble posting, please check your spam folder. An email was sent to the email address which you subscribed. You have to follow the instructions in that email. Done that and still having trouble posting? Contact Joe O'Brien at jpobrien@scoliosis.org.

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    growth spurt

    I'm always happy to see good news but I wonder why they focused on 9 & 10 year old kids who haven't had their growth spurt yet.

    ---

    Progression Risk of Idiopathic Juvenile Scoliosis During Pubertal Growth

    This study of 205 children found that if a curve reached 21 degrees before puberty there was a 75% chance that the spine would eventually be fused. Curves that reached 30 degrees before puberty were fused 100% of the time.

    Results. Of 205 patients, 99 (48.3%) were operated on. Of 109 curves ≤20 at onset of puberty, 15.6% progressed >45 and were fused. Of 56 curves of 21 to 30, the surgical rate increased to 75.0%. It was 100% for curves >30. Curves >20, which increased and were operated on, progressed significantly during peak growth velocity (P = 0.0014). Curves that progressed by 6 to 10/y were fused in 70.9%, curves which increased >10/y in 100% of cases (P = 0.0001). This risk was highest for primary thoracic curves: King V, III, and II (P = 0.0001).
    Last edited by Dingo; 11-07-2010 at 12:54 AM.

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    I think that is correct that some/most of those kids did not go through the growth spurt. For this to be publishable, I hope they cited some reference that these kids are not likely to need any treatment if they have a curve <25 at any age. Otherwise I don't think this is publishable but obviously my idea of what is publishable does not match the great run of what these medical journal editors think.

    I think the point is that no treatment is necessary (and certainly no treatment has shown efficacy) in this group that includes JIV (perhaps before the growth spurt) and (likely?) some AIS cases (ever).

    So if you have a kid, whatever age, whatever diagnosis, who is Risser 0 and has a curve<25*, most of the time no treatment is necessary. And certainly none has proven clearly effective.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

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    Here's a preprint pdf of the paper

    http://www.josr-online.com/content/p...-799x-5-80.pdf

    As I guessed, it's a mixed bag of JIS and AIS...

    Another criticism might be the age of enrolled children which was 5~11
    years, i.e. mixed juvenile and adolescent idiopathic scoliosis which may behave differently.
    Recall that the age of menarche is decreasing and I am guessing some of these patients started menses.

    Also, if the 26% of patients who progressed had mostly T curve then this study has inadvertently stacked patients like many other studies. I think there is enough known now on the issue of relative propensity of progression of various types of curves that if you don't control for this, the results will not be robust.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

  9. #9
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    Another quote

    We believe that in immature children if growth spurt exceeds the paraspinal muscle adaptation rate, the curve will ultimately show progression. And possibly that might be reason that prevalence of scoliosis increases during rapid growth spurt.
    There is plenty of comment on PT and paraspinal muscling. I hope McIntire comments. I think this is up his alley.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

  10. #10
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    Quote Originally Posted by Pooka1 View Post
    In fact sitting around and eating ice cream has the same success rate as these alternative treatments and is far more enjoyable that doing PT in whatever form or wearing a brace.
    Thanks, Sharon, for giving me my first chuckle of the day
    mariaf305@yahoo.com
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    Vertebral Body Stapling 3/10/04 for 40 degree curve (currently mid 20's)

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    Quote Originally Posted by Pooka1 View Post
    There is plenty of comment on PT and paraspinal muscling. I hope McIntire comments. I think this is up his alley.
    That's a really interesting quote about the paraspinal muscle adaption rate, and I also hope he comments.

  12. #12
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    muscle imbalance

    Literature described Hueter-Volkmann theory regarding disc and vertebral wedging, and muscular imbalance for the progression of adolescent idiopathic scoliosis.
    Evidently the theory of muscle imbalance has become mainstream.
    Last edited by Dingo; 11-07-2010 at 11:26 AM.

  13. #13
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    short term

    RESULTS: Average age was 9.2 years at first visit and 10.11 years at final follow-up with an average follow-up of 21 months.
    Over that period 32.5% got better, 41.4% stayed the same and 26% got worse.

    A) Everything I've read states that the typical course of Juvenile Scoliosis is slow, but steady progression. This was a short term study. My guess is that over a long period of time those ratios would have shifted towards progression. Obviously I hope I'm wrong but over the past couple of years I haven't found much variation in the literature.

    B) I wonder if the "progressing" kids got worse faster than the "regressing" kids got better. That would explain why over a long period of time the average Juvenile curve slowly increases.

    For example
    Age 7 - 2 degree improvement
    Age 8 - 1 degree improvement
    Age 9 - 1 degree improvement
    Age 10 - no progression
    Age 11 - 6 degree progression

    Add up the pluses and minuses over a long period of time and you find slight progression even if most of the time you are improving.

    For example part Deux
    Imagine the billions that Fannie Mae and Freddie Mac made over the past several decades. And yet it appears they may have lost trillions over just a few years which will ultimately dwarf all of their previous earnings. In this case Fannie Mae's balance sheet was improving or holding steady 98% of the time. But during the 2% time period that they were headed south they got wiped out and then some.
    Last edited by Dingo; 11-08-2010 at 12:32 PM.

  14. #14
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    That 74% of these kids either held or regressed is not consistent with the claim of slow but steady prorgession for JIS (assuming JIS cases made up the bulk of this study).

    This may be due to the fact that some AIS cases were mixed in.

    It might turn out that the 26% came mostly the AIS T curve cases who were in a growth spurt and all the regressions/holds were in JIS cases.

    The bottom line is that the majority of all cases, JIS and AIS, where the curve is <25* need no treatment. Now you could argue to treat everyone in the hopes of helping the 26% who will prorgess but that assumes there is some conservative treatment that accomplishes that. That assumption has not been shown to be true to date against the huge background of variation and the ocean of confounders.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

  15. #15
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    Quote Originally Posted by Pooka1 View Post
    There is plenty of comment on PT and paraspinal muscling. I hope McIntire comments. I think this is up his alley.
    The idea that the growth rate exceeds the ability of the paraspinal musculature to adapt and properly stabilize is part of my exact hypothesis.

    The order of events, as I see them.

    "Something" causes an imbalance in the spinal column. Under normal circumstances, the body can either recruit extra muscle to help stabilize and/or the imbalance is small enough so the muscles are able to 'catch-up' to the imbalance and continue doing their stabilizing thing. In abnormal circumstances, the muscles are not able to stabilize and the imbalance continues. The body will inevitably try to recruit other muscles to improve stability (if the body even senses the imbalance). Failing to correct the imbalance would then result in a spinal curve. At any point prior to permanent disc or vertebral damage/wedging, the body would, in theory, be capable of stabilizing with musculature, i.e. spontaneous correction or curve stability. If the growth is too fast and/or the body can not coordinate or train an effective spinal stability muscle pattern, the imbalance remains giving a progressive curve.

    There are a large number of assumptions and/or asterisks I would assign to every above sentence. For example, if the imbalance is due to asymmetrical vertebral growth because of a genetic or calcium receptor defect, the muscles might very well be powerless to do anything.

    My 2 biggest reasons for earlier treatment, i.e. <25, is 1. there is no (or at least very little) permanent wedging in curves this small as well as little rotation. And 2. muscles' ability to act on the spine is dramatically changed with altered biomechanics. Thus, the larger the curve, the larger the biomechanical disadvantage. So not treating early enough would make the treatment that much more difficult and possibly ineffective.

    I also understand the argument of overtreatment. 3 out of 4 patients would be treated unnecessarily which could add a lot of expense. So this is why something so simple as trunk rotations is attractive (and another reason we did our study). At least for the W&W period. This is a simple exercise that can be taught quickly and performed easily at home. I'm convinced that the larger the curve, the more complex the treatment protocol must be.

    As far as the number of patients needed to prove anything... yep.... With a progression risk of only 25%, you'd need at least 200 matched patients per curve type. In order to get a clinic(s) to work with you, there would need to be a lot of good physiology work to back it up. Is there a consistent muscle pattern for various curve types? Is there any pathology in the affected muscles? Do the prescribed exercises actually target and do what they are supposed to do, i.e. strengthen? Does that strengthening translate to improved function and stability? etc... And that doesn't even touch the idea that the imbalance could be a result of something unchangeable.

    The deal I'd make with a doctor is to let my grad student (assuming I'll have them one day) train the next 100 patients through the door who are prescribed W&W. At least in a home ex protocol. Any patient that has increased in 4 months has wasted and risked very little. Follow-up for at least 24 months; preferably until skeletal maturity. Compare these results to historical data from the clinic plus the literature. Assuming it shows an improvement in outcome, this wouldn't be a definitive result, but could go a long way to encouraging doctors to throw some thera-band and an exercise sheet at all of their W&W patients. This is would be practically zero cost and would allow the patients and families to be actively involved in their treatment from the beginning. For 75% of them the worst that happens is they improve their core strength. For the other 25%, they are given the best opportunity to stop the progression.

    At least, that's my perfect world. I'll have to read through the original reference to see how they describe their hypothesis.

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