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Thread: 2-Year Outcomes of Spinal Growth Tethering vs. Posterior Spinal Fusion for Scoliosis

  1. #1
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    2-Year Outcomes of Spinal Growth Tethering vs. Posterior Spinal Fusion for Scoliosis

    http://www.srs.org/UserFiles/file/IM...final-4web.pdf

    6. 2-Year Outcomes of Spinal Growth Tethering vs. Posterior
    Spinal Fusion for Scoliosis – Flexibility vs. Reliability†
    Peter O. Newton, MD; Dylan G Kluck, MD; Wataru Saito, MD, PhD; Burt Yaszay,
    MD; Carrie E. Bartley, MA; Tracey P. Bastrom

    Summary
    17 patients who underwent anterior spinal growth tethering (ASGT) were
    compared to 14 patients of similar age and comparable curve type/magnitude
    and skeletal maturity who underwent posterior spinal fusion (PSF). PSF had
    a greater operative time and estimated blood loss (EBL). At 2-year follow-up,
    ASGT resulted in larger residual curves, but avoided PSF in the majority of
    patients. The tether cohort had a higher reoperation rate. SRS-22 scores were
    similar pre-op and at 2 years post-op.

    Hypothesis
    ASGT will lead to similar scoliosis correction with comparable revision rates vs
    PSF at 2yrs.

    Design
    Retrospective cohort study
    Introduction
    ASGT has been shown to alter spinal growth with the potential to correct
    scoliosis while maintaining spine flexibility. Clinical experience with ASGT is
    limited, and there are no studies comparing 2yr outcomes between ASGT and
    PSF.

    Methods
    From 2011-2013, 17 patients with thoracic major scoliosis underwent
    thoracoscopic ASGT. 14 patients with PSF during a similar time period
    with comparable age, curve type/magnitude and skeletal maturity were
    retrospectively identified. Pre-op and 2-year post-op parameters and SRS-22
    scores were analyzed.

    Results
    All patients had Lenke 1 or 2 curve types and most were idiopathic. Age at
    tether was 11y (range 9-14y) vs 12y (range 11-14y) for PSF (p=0.04).
    Tether patients were Risser 0 and PSF patients were Risser ≤1. Pre-op Cobb
    was 5210 in tether vs 547 in PSF (p=0.6). Operative time in ASGT
    was 19435min, EBL 84ml (range 30-100ml) vs 27868min, EBL 939ml
    (range 300-2000ml) in PSF (p=0.001, p<0.001). ASGT had 5.80.5
    vertebrae tethered with a 5.51.4 day hospital stay vs 101 levels fused and
    a 5.51d stay in PSF (p<0.001, p=0.9). 2-year post-op Cobb after ASGT was
    2718 with 61% correction (range 5-173%) vs 148 with 73% correction
    (range 38-90%) in PSF (p=0.02, p=0.3). Revision surgery was performed
    in 7 tethers (4 removals due to complete/over correction, 1 lumbar added, 1
    replaced, 1 PSF). PSF was indicated in 3 additional patients due to progression.
    There were no revisions after PSF. SRS-22 total score at 2 years post-op was
    4.70.2 in tether (n=5) vs 4.60.3 in PSF (n=12) (p=0.3).

    Conclusion
    Although most patients still had some remaining skeletal growth, ASGT resulted
    in a large range of percent curve correction compared to PSF at 2 years postop.
    Operative time and EBL were greater with PSF, but reoperation rates were
    higher with ASGT. SRS-22 scores were similar. It is clear that the tether affects
    spinal growth and, importantly, avoided fusion for most patients at 2 year
    follow-up.
    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."

  2. #2
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    The fact that 7 of 17 tether patients required revision surgery within 2 years is a bit of a red flag. Hopefully, they'll continue to follow these patients so we can see what happens to them as they mature.
    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
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    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.

  3. #3
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    Well yes but at 2 year most has avoided fusion. If that holds for the out years then maybe it is work it.
    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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    55. Anterior Vertebral Body Tethering for the Treatment of
    Idiopathic Scoliosis: Feasibility, Outcomes, and Complications
    Firoz Miyanji, MD, FRCSC; Luigi Aurelio Nasto, MD, PhD; Eva Habib, BSc;
    Andrea M. Simmonds, MD, FRCSC

    Summary
    Spinal fusion remains the gold standard for progressive IS, however concerns
    about the long-term effect of spinal fusion have led to the development of
    growth-modulation techniques. We present early preliminary results in a cohort
    of 32 consecutive patients treated with AVBT and found the technique effective
    in preventing curve progression and obtaining curve correction with most curves
    reaching a clinical success of ≤30.

    Hypothesis
    Anterior vertebral body tethering (AVBT) may be limited in effectively
    preventing curve progression and obtaining curve correction to ≤30

    Design
    Retrospective single center review

    Introduction
    More recently AVBT has sparked interest as a possible alternative in the
    management of progressive idiopathic scoliosis (IS).To date limited available
    PAPER ABSTRACTS = Whitecloud Award Nominee Best Clinical Paper
    * = Whitecloud Award Nominee Best Basic Science Paper
    IMAST FINAL PROGRAM 2017 79
    data exists regarding the efficacy and complication rate with AVBT. The aim of
    our study was to evaluate the clinical, radiographic and perioperative outcomes
    and complication rates to determine the efficacy of AVBT in skeletally immature
    patients with IS.

    Methods
    A retrospective review of all consecutive patients treated with AVBT between
    2012 and 2016 was conducted after IRB approval. Demographic data was
    collected from chart review. Preop and most recent f/u radiographic parameters
    were measured by an independent reviewer. Periop outcome variables and
    complication data were obtained from chart review. Clinical success was set a
    priori as major coronal Cobb ≤30 at most recent f/u.

    Results
    32 patients with 34 procedures were analyzed. Mean age at surgery was
    13.61.4years with majority female (93.8%). Mean Risser grade was
    0.770.79 with a mean f/u of 9.4 10.9 months. Mean major pre-op
    Cobb of 50.68.6 improved to mean 18.39.5 at most recent f/u(%
    correction:64.3%, p<0.001).Significant spontaneous curve correction was
    also observed in the un-instrumented curves on average by 48.724.2%
    (p<0.001).Thoracic axial rotation significantly improved on average from
    15.0 4.2 to 8.04.1(p<0.001) as measured by scoliometer.
    Average number of instrumented levels was 6.80.9 with a mean OR time
    of 348.484min. Average EBL was 252.883.4cc with no patient requiring
    allogeneic blood. Length of hospital stay was mean 5.31.0 days with 84.3%
    of patients returning to full activity at 3 months. Clinical success was noted in
    94.1% of patients at most recent f/u. We noted a 23.5% complication rate
    however there were no re-admission to hospital or re-operations in this cohort.

    Conclusion
    AVBT is effective in obtaining clinical success in skeletally immature patients
    with IS. Early results appear promising, however longer-term follow-up is
    needed to determine the true clinical benefits of this technique.
    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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    7 out of 17 really is a red flag.....damn....with 4 of those being over corrected. Incorporate the Magec system to adjust the tethers and this problem would be eliminated....If you can adjust a rod, you can adjust a tether. This is worth a try, and Magec has got the bulk of it already done.

    The re-operative rates are higher with tethering.....but the tethering concept is worth the effort, and in looking back at the evolution of scoliosis treatment, these things take a long time....hopefully they can juggle through all the issues.

    I am positive on this idea but not because of my whole spine is fused....Most think that fusion is the worst thing, and I don't agree. As long as there is no pain, I am happy.....Most would think that Ray Charles was handicapped because he was blind, but his trust was set up for the deaf. He didn't think blindness was a handicap, but deafness was considerably worse.

    Ed
    49 yr old male, now 58, the new 53...
    Pre surgery curves C12,T70,L70
    ALIF/PLIF T2-Pelvis 01/29/08, 01/31/08 7" pelvic anchors BMP
    Dr Brett Menmuir St Marys Hospital Reno,Nevada

    Bending and twisting pics after full fusion
    http://www.scoliosis.org/forum/showt...on.&highlight=

    My x-rays
    http://www.scoliosis.org/forum/attac...2&d=1228779214

    http://www.scoliosis.org/forum/attac...3&d=1228779258

  6. #6
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    The tethered patients could still have fusion if they need it later. So although another surgery it is an option. Overcorrection seems to occur when the tethering takes place too early in the growth cycle. ( risser 0)

    I don't think enough studies have been done on the outcome of fusion patients. Once you get to a certain age fusion or non fusion doctors seem to deal with pain in the same way- i.e. relatively poorly

  7. #7
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    Quote Originally Posted by burdle View Post
    I don't think enough studies have been done on the outcome of fusion patients. Once you get to a certain age fusion or non fusion doctors seem to deal with pain in the same way- i.e. relatively poorly
    I believe the first fusion was done in 1914. That was a while ago....Over 103 years, I could imagine there have been a few studies. If it takes 103 years on fusion, how long will it take on tethering?

    Not all doctors are the same....that's for sure. I have been exposed to quack MD's to genius level MD's during my doctor tours. My scoliosis surgeon has proven himself to me several times on a high level. Dr M has made all the correct decisions on my case. I also have made all the correct decisions on selection, only after being exposed to everything else that comes in between. Chiro's, Osteopaths, Copes, drug dealing GP's. and expert advice from all the concerned untrained inner core people around me.

    There is a learning curve that we all go through....If only parents and patients could pick the correct or optimal doctor or procedure, that would be something. Maybe at some point, Facebook or someone will come up with a scoliosis APP, a protocol or set of procedures to direct medical patients. In other words, if you break your foot, don't go to the dentist. If your Cobb's are 50 at age 40, start thinking about your spine and visit with the correct doctor. (With a list supplied) A directional program to avoid whats in between.

    I have to thank Sharon for posting the studies on Magec rod breaks and on tethering....I am not reading as much anymore since I have cataracts and vision problems.

    Ed
    49 yr old male, now 58, the new 53...
    Pre surgery curves C12,T70,L70
    ALIF/PLIF T2-Pelvis 01/29/08, 01/31/08 7" pelvic anchors BMP
    Dr Brett Menmuir St Marys Hospital Reno,Nevada

    Bending and twisting pics after full fusion
    http://www.scoliosis.org/forum/showt...on.&highlight=

    My x-rays
    http://www.scoliosis.org/forum/attac...2&d=1228779214

    http://www.scoliosis.org/forum/attac...3&d=1228779258

  8. #8
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    Quote Originally Posted by titaniumed View Post
    7 out of 17 really is a red flag.....damn....with 4 of those being over corrected. Incorporate the Magec system to adjust the tethers and this problem would be eliminated....If you can adjust a rod, you can adjust a tether. This is worth a try, and Magec has got the bulk of it already done.

    The re-operative rates are higher with tethering.....but the tethering concept is worth the effort, and in looking back at the evolution of scoliosis treatment, these things take a long time....hopefully they can juggle through all the issues.

    I am positive on this idea but not because of my whole spine is fused....Most think that fusion is the worst thing, and I don't agree. As long as there is no pain, I am happy.....Most would think that Ray Charles was handicapped because he was blind, but his trust was set up for the deaf. He didn't think blindness was a handicap, but deafness was considerably worse.

    Ed
    Ed...

    The current trend in medicine is reduction of cost. I doubt we'll see too many American doctors working to combine two techniques.

    --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
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    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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    Quote Originally Posted by LindaRacine View Post
    Ed...

    The current trend in medicine is reduction of cost. I doubt we'll see too many American doctors working to combine two techniques.

    --Linda
    Linda, I have heard this "reduction of cost", a new general marketing buzzword for investors. Its all about the bottom line. (for the next quarter) This is not a financial issue, its a moral issue.

    FDR once said at Warm Springs, "Does everything always have to do with money?" when he set up the March of Dimes.

    Here is a better buzzword, "Developing spinal hardware that works, reduces costs".

    I waited a lifetime for scoliosis technology and spinal hardware....Many of us adult scolis have put up with unbelievable amounts of pain and suffering over many years waiting. The technology and hardware saved my life. The last thing I want to hear is that reduction of cost has delayed a medical device that reduces pain and suffering and saves lives.

    The improvements to ALL spinal systems have a high level of urgency. Correction, all medical hardware.

    Remember when Dr Harrington suggested his system in 1960 and was rejected by all the others? But something had to be done.....If it wasn't for him, nothing would have happened or would have been delayed. We need to thank him for his vision....

    The kids need better outcomes to happen right away.

    Mark Zuckerberg is selling off (a small chunk=huge money) of Facebook stock and he is pro-active in medical research. UCSF or Stanford could request funds. Stanford is across the street from Facebook headquarters.

    Spine research is everyone's problem. It affects just about everyone on the planet.

    Ed
    Last edited by titaniumed; 10-07-2017 at 11:53 AM.
    49 yr old male, now 58, the new 53...
    Pre surgery curves C12,T70,L70
    ALIF/PLIF T2-Pelvis 01/29/08, 01/31/08 7" pelvic anchors BMP
    Dr Brett Menmuir St Marys Hospital Reno,Nevada

    Bending and twisting pics after full fusion
    http://www.scoliosis.org/forum/showt...on.&highlight=

    My x-rays
    http://www.scoliosis.org/forum/attac...2&d=1228779214

    http://www.scoliosis.org/forum/attac...3&d=1228779258

  10. #10
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    Quote Originally Posted by titaniumed View Post
    Linda, I have heard this "reduction of cost", a new general marketing buzzword for investors. Its all about the bottom line. (for the next quarter) This is not a financial issue, its a moral issue.

    FDR once said at Warm Springs, "Does everything always have to do with money?" when he set up the March of Dimes.

    Here is a better buzzword, "Developing spinal hardware that works, reduces costs".

    I waited a lifetime for scoliosis technology and spinal hardware....Many of us adult scolis have put up with unbelievable amounts of pain and suffering over many years waiting. The technology and hardware saved my life. The last thing I want to hear is that reduction of cost has delayed a medical device that reduces pain and suffering and saves lives.

    The improvements to ALL spinal systems have a high level of urgency. Correction, all medical hardware.

    Remember when Dr Harrington suggested his system in 1960 and was rejected by all the others? But something had to be done.....If it wasn't for him, nothing would have happened or would have been delayed. We need to thank him for his vision....

    The kids need better outcomes to happen right away.

    Mark Zuckerberg is selling off (a small chunk=huge money) of Facebook stock and he is pro-active in medical research. UCSF or Stanford could request funds. Stanford is across the street from Facebook headquarters.

    Spine research is everyone's problem. It affects just about everyone on the planet.

    Ed
    You've heard me say it before... it's all about the insurance companies. Insurance companies want cheaper implants. Things like donations won't help.
    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
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    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.

  11. #11
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    Cheaper in the short term or cheaper in the long term. Ed is right- it is about perspective and vision.

    Insurance companies waste thousands because the medical paths are not clear. But it is the patients who suffer. For every patient who has been failed by the system and is unable to work there is a lost revenue to society. If those people cannot contribute the we all lose - insurance companies also.

    My big gripe is the' terminology' - the path is not clear because the terminology is not clear. SOSORT made it one of their aims in 2014. We have got Lenke classification and Risser and Sanders etc. but little has been done in the way of classifying scoliotic terms so that patients can go to the right doctor and receive the right information. Social media is making it ten times worse. I have lost count of the number of people who are muddling Function with Idiopathic scoliosis - Patients cannot help it because the medical profession starts it and propagates it through ignorance. Or parents calling for national screening because they do not understand the role of the brace... because the doctor misinforms. The list goes on and on. Patients need clear consistent terminology.

    I am so impressed with the VBT groups on Facebook. Nearly every candidate for VBT is a youngster who has pain and afterwards has no pain. . The VBT consultants are not denying their pain. They are recognising it and offering a solution to it as well as the curve. We do not know enough about pain science but what matters is that they think the pain has gone and can get on with their lives. Yet still general consultants will blithely say 'scoliosis doesn't hurt' , without context or diagnosis. But still people join and get confused about the sort of scoliosis they have, Too many people are fobbed off and then maybe having to have more expensive treatment later in the day as a result. So Insurance companies will lose out.
    Last edited by burdle; 10-09-2017 at 11:42 AM.

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    Hi Burdle. Nice to see you again posting.

    Did you folks on the FB group discuss the two recent podium presentations I posted here about VBT?

    In re screening and bracing, I hope folks are aware of the evidence case including what was considered a success in the BrAIST study. I hope they also know that when I asked a BrAIST study co-author about the range of Cobbs in the successful group, she ignored the question. As a scientist myself, I am shocked and ashamed for her behavior.
    Last edited by Pooka1; 10-09-2017 at 12:27 PM.
    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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    Quote Originally Posted by Pooka1 View Post
    Hi Burdle. Nice to see you again posting.

    Did you folks on the FB group discuss the two recent podium presentations I posted here about VBT?

    In re screening and bracing, I hope folks are aware of the evidence case including what was considered a success in the BrAIST study. I hope they also know that when I asked a BrAIST study co-author about the range of Cobbs in the successful group, she ignored the question. As a scientist myself, I am shocked and ashamed for her behavior.
    Hi,

    the facebook pages do not encourage debate about VBT. They are mostly parents who take the view that as it is available in some parts of the world then it should be available for all. Certainly in UK it is all about how to get VBT for your child. I can understand that and I can see that the last thing parents want is someone questioning the facts or the studies. They all seem convinced that it is a better operation. It is a little strange given that mostly they are just parents without medical training but the medics are partly to blame because those who do challenge VBT with the parents are definitely not informed and are not interested in the follow up of successful VBT. I am glad I am not a parent of a child with scoliosis.



    I once raised a question and got so many comments from people saying that I had upset them just by asking a question that I leave well alone. It is what it is. Some of the admin feel they have a 'hotline' to consultants who do VBT and certainly the consults seem happy to impart information to the group via the admins. The group is a support group and it does support extremely well.

    So there is nowhere to debate really.

    There is little about screening. Mostly people think that we should screen from an early rage. Since I read the study about how screening everyone might lead to unnecessary intervention I was not convinced. But we live in a world where everyone one wants perfection. It is odd because 'in theory' a child with a non-progressive scoliosis can lead a perfectly normal life but this seems to get completely overlooked with parents passion for their child to be a world famous dancer or gymnast etc. and having a curved spine does not fit in. Again it is the medics fault as far as I am concerned. get the terminology correct and the treatment paths clear and concentrate on those who have a severe curve that is going to progress without intervention. Certainly VBT being really for Juvenile Scoliosis ( is this the same as EOS?) bracing seems a fob off when there is an opportunity for VBT.

  14. #14
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    Quote Originally Posted by burdle View Post
    There is little about screening. Mostly people think that we should screen from an early rage. Since I read the study about how screening everyone might lead to unnecessary intervention I was not convinced. But we live in a world where everyone one wants perfection. It is odd because 'in theory' a child with a non-progressive scoliosis can lead a perfectly normal life but this seems to get completely overlooked with parents passion for their child to be a world famous dancer or gymnast etc. and having a curved spine does not fit in. Again it is the medics fault as far as I am concerned. get the terminology correct and the treatment paths clear and concentrate on those who have a severe curve that is going to progress without intervention. Certainly VBT being really for Juvenile Scoliosis ( is this the same as EOS?) bracing seems a fob off when there is an opportunity for VBT.
    I think infantile and juvenile were lumped into EOS but I am not sure.

    I would hope VBT will replace bracing in all age groups but there are parents who don't want any surgery.

    Are there any more mature VBT patients besides the one or two women?
    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
    I think infantile and juvenile were lumped into EOS but I am not sure.

    I would hope VBT will replace bracing in all age groups but there are parents who don't want any surgery.

    Are there any more mature VBT patients besides the one or two women?
    Hi,

    No- Because folk keep insisting that it is done on mature patients but just mean those who have fully grown which can mean anyone from a teenager upwards. I know it is well meant. Drs ABC apparently do mature spines, but they are technically mature, not 'old' like me. Shriner have specific criteria and are all juvenile. Of Drs ABC I do not know how many fully grown get VBT, again if you ask you will meet with replies such as - you don't know unless you ask'.

    I emailed a UK consult who used to do VBT before it was stopped ( it is awaiting further discussion) and he said it wouldn't work on adults because there is no growing left which makes sense. However these two ladies who have had it done mystify me as to why they had it etc. However things are different in US?

    With regard to EOS- SAUK had a day set up recently specifically to discuss EOS. I emailed them and asked if VBT was on the agenda and they emailed back saying it was for EOS only. Yet when I looked at the specifics it was clearly covering Juvenile scoliosis and treatments for it. I do blame SAUK for this. You can't be a charity set up for scoliosis and then give out inaccurate info. I appreciate their position - it isn't available in UK so they can't really comment. But they should not leave it to uninformed people to answer emails and they should be at least upto date with where it is being done etc. But of course they don't want to offend those in UK so they get it wrong. And so people turn to Facebook. They shouldn't have to but if the societies that are specifically set up to inform us - ultimately fail us - then you can see why social media takes over.

    I attended a Webinar yesterday run by SRS. Now I was late so I can't be sure but I'll bet that nothing about VBT was mentioned - it certainly wasn't after I joined They had 4 people giving talks and answering questions that had already been 'put' but nothing about VBT. Now I am sure that there are some for who the actual make of instrumentation is important but i'll wager that not many people are as interested in this as in where VBT is as a treatment; but we had instrumentation discussed!!! I don't think its a conspiracy- I think it is laziness and egos etc. Common sense tells me that the consults could publish more about their successes and pass it on to their colleagues.

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