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Thread: SOSORT paper with discussion of Dolan's metanalysis

  1. #1
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    SOSORT paper with discussion of Dolan's metanalysis

    I just found a SOSORT paper with a discussion about Lori Dolans Metanalysis. They mention the ethics of a Random Controlled Trial and in a roundabout way, accuse Dolan of cherry picking. Very interesting.

    2009 SOSORT paper

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

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

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


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

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

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    Quote Originally Posted by concerned dad View Post
    because the Nachemson data did not include surgical rates.
    I must have missed something. Can you give me a recap of what is meant by this?

    Thanks.

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    Sure, The Nachemson study is the big 1995 SRS study that took 10 years to complete. It has been criticized (dismissed by some) because of several reasons. Two of the most important are

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

    and

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

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

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

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

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

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    Thanks for the very thorough response.

    in what forum does Dr. Dolan hang?

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    Well, perhaps I overstated it.
    She has 4 posts (her handle is Braist24)

    She replied to a thread on the Braist Study (for anyone following along, that's the current random controlled bracing study) at
    scoliosis-support
    specifically, her first post is number 12 in that thread.

    I really have to hand it to her for participating.

    but shhhhhh, dont tell Sharon

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

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    Quote Originally Posted by concerned dad View Post
    I just found a SOSORT paper with a discussion about Lori Dolans Metanalysis. They mention the ethics of a Random Controlled Trial and in a roundabout way, accuse Dolan of cherry picking. Very interesting.

    2009 SOSORT paper

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

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

    I don't see either exclusion as a problem.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
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    "We are all African."

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    Quote Originally Posted by tonibunny View Post
    Arghhh I'm a staff member on scoliosis-support.org and I really don't like the idea there's any rivalry between any of the scoliosis forums, there really isn't! We often send people over here (cos we're UK-based and know that here's usually the best place for US-based people to get info) or to Spinekids or the infantile scoli groups, and loads of us are members of this forum as well, and Spinekids too. I mean, we're all after the same goal aren't we, we just want to help people *shrug*
    Nobody is claiming a rivalry or a competition as such.

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

    That would be a big problem as there are so few folks on both fora to begin with.
    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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    Aw, I really can't see that happening, please don't worry! I think people like CD here are very happily settled here, but they might go and check things out over on SSO occasionally as well, just like our regular members sometimes come over here. I like reading this forum and pop by nearly every day, and I contribute if I think I can be helpful, but usually I don't know so much about issues outside of the UK to be able to do much.

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

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

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    Quote Originally Posted by tonibunny View Post
    Aw, I really can't see that happening, please don't worry! I think people like CD here are very happily settled here, but they might go and check things out over on SSO occasionally as well, just like our regular members sometimes come over here. I like reading this forum and pop by nearly every day, and I contribute if I think I can be helpful, but usually I don't know so much about issues outside of the UK to be able to do much.
    No I wasn't referring only to people like CD who post frequently [though I do live in near-constant fear of his loss to another forum.]

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

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

  12. #12
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    Well, that researcher only posted four times, and I think she's the only one we've had, so no need to panic Tell you what, if we get any more I'll tell them to come over here and discuss things with you chaps as well. To be honest I had assumed she was already here when she posted on SSO, but if she comes back I'll point her over here.

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

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

    Toni xx

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    Quote Originally Posted by Pooka1 View Post
    I'm sure Dolan also excluded studies on the effect of chanting to reduce curves.

    I don't see either exclusion as a problem.

    Stop and think carefully about this Sharon.

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

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

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

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

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    Quote Originally Posted by concerned dad View Post
    Stop and think carefully about this Sharon.

    If they were Chanting AND bracing the data is there (so long as surgical rates and proxies for surgery are reported.)
    As I mentioned, I think surgical rates is ridiculous when we know ahead of time that surgeons pull the trigger at a wide range of angles. when you add on top of that folks who don't take advice, the surgical rate metric is extremely NOT robust.

    It is like excluding a brace study because the kids were watching TV. It is irrelevant. And, if we argue that the exercise WAS relevant than it demonstrates that exercise positively affected the outcome.
    That's a good point. What was the stated reason she excluded exercise+Brace?

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

    It is essentially a method of analysis to exclude the brace studies from many SOSORT researchers.
    Okay I think I see what is going on here.

    I would challenge ALL surgical rates as being nearly meaningless for the reason I stated above. So I guess I agree with the SOSORT researchers but for a different reason.
    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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    To understand the "surgical rates" issue you need to read Dr Dolans discussion where she says that progression isnt the fear, progression to surgery is the fear.

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

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

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

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

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