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  • electrical stimulation

    What follows as an extract from a recent (august 2005) extract from a policy document from Aetna. Now, I do not know what Aetna is but i assume it is a medical insurer in the USA. What surprised me is that they are funding electrical stimulation treatment fro scoliosis because of its proven benefits. I thought this was old hat, and the general opinion was that it didn't work. I would have thought that an insurer would look very careful at the available evidence before paying out for anything. Have they got it wrong, or is this method still used succesfully??

    This Clinical Policy Bulletin expresses Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). Policy



    Aetna considers surface electrical muscle stimulators (direct or alternating current, not high-voltage galvanic current) medically necessary durable medical equipment (DME) for the management of idiopathic scoliosis when all of the following criteria are met:

    Member has juvenile or adolescent idiopathic scoliosis that has not been surgically treated and the scoliosis is not currently being treated with bracing, and
    Spinal curvature is between 20 and 45 degrees (Cobb measurement based on radiographic studies), and
    Spinal curvature is highly progressive, with documented progression of curvature of 5 degrees or more within the past 12 months for curves between 20 and 30 degrees. (With skeletally immature members, curves of 30 degrees or more are presumed to be highly progressive.), and
    There is a minimum of 50% correction on forced lateral bending, and
    Member has a minimum of 1 year of bone growth remaining, as judged by the treating physician.

    Note: Since treatment may last from 6 to 18 months, purchase of the equipment in some cases may be more cost effective than rental of the equipment.

    Background


    The traditional treatment for adolescent idiopathic scoliosis is the use of a supportive brace, (e.g., the Milwaukee brace, the Boston brace). Torso exercises to increase muscle strength should be used in conjunction with braces. Since bracing is restrictive and must be worn 23 hours a day for up to several years, non-compliance has been estimated to be 20 to 50 % (Moe and Kettelson, 1970). Additionally, this method is associated with side effects such as anxiety, depression, and sleep disturbance. Another non-invasive method to straighten abnormal lateral curvature is surface electrical muscle stimulation. In this approach, muscles on one side of the spine are stimulated electrically (direct or alternating current, not high-voltage galvanic current) to contract and pull the vertebrae into a more normal position. Surface electrical muscle stimulation is usually applied for 8 to 10 hours during sleep. Treatment is terminated when patients reach skeletal maturity and structural stability. It is postulated that electro-muscular stimulation in the scoliotics may produce changes in muscle structure resulting in more fatigue-resistant muscles which increase the ability for postural stabilizing muscle activity in the spine (Grimby et al, 1985). Advantages of surface electrical muscle stimulation include freedom from bracing, the need for only part-time therapy, and an improvement of self-image in the affected adolescents. In severe cases, spinal fusion with instrumentation is effective in halting progression of the curve(s).

    Surface electrical muscle stimulation has been shown to be effective in reversing or arresting progression of spinal curvatures in adolescents with idiopathic scoliosis. Brown et al (1984) reported the findings of a multicenter study on the use of night-time lateral electrical surface stimulation (LESS) for the treatment of juvenile or adolescent idiopathic scoliotics (484 girls and 64 boys, mean ages of 12.8 and 13.9 years, respectively). Only individuals with rapidly progressing scoliosis and at least 1 year of growth remaining were selected for this trial. The mean treatment time was 12 months, and the longest follow-up was 51 months. During the initial 6 months of therapy, a pre-treatment curvature progression rate of 1 degree/month was reversed to a reduction rate of 0.5 degree/month. Overall, 395 (72 %) patients had either reduced or stabilized their scoliosis. Seventy-one (13 %) patients had experienced temporary progression with subsequent stabilization and treatment continuation, while 82 (15 %) patients dropped out because of progression of their conditions. The major problem with LESS was skin irritation. The authors concluded that LESS treatment is a viable alternative to bracing for patients with idiopathic scoliosis.

    Dutro and Keene (1985) performed a literature review on surface electrical muscle stimulation in the treatment of progressive adolescent idiopathic scoliosis. Patient selection criteria for studies reviewed were as follows: (i) Cobb angle of 25 to 45 degrees as indicated by radiographic studies, (ii) documented history of progression, (iii) minimum of 50 % correction on forced lateral bending, and (iv) minimum of 1 year of bone growth remaining. The authors concluded that electro-muscular stimulation is equally effective as bracing in treating progressive adolescent idiopathic scoliosis -- progression was arrested in 60 to 84 % of treated curves. For juvenile scoliosis, if treatment begins early enough and progression is not too severe, a curve cannot only be arrested, but reversed. Surface electro-muscular stimulation can also be employed to halt progression while patients await surgery.

  • #2
    Yikes! They seem to have totally disregarded the other studies that show that electrical stimulation is worthless.
    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    Surgery 2/10/93 A/P fusion T4-L3
    Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

    Comment


    • #3
      Seems that they totally disregarded the Nachemson/SRS study that showed that electrical stimulation had about the same effect as no treatment at all, which is generally regarded to be definitive:

      J Bone Joint Surg Am. 1995 Jun;77(6):815-22. Related Articles, Links

      Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. A prospective, controlled study based on data from the Brace Study of the Scoliosis Research Society.

      Nachemson AL, Peterson LE.

      Department of Orthopaedics, Goteborg University, Sweden.

      In a prospective study by the Scoliosis Research Society, 286 girls who had adolescent idiopathic scoliosis, a thoracic or thoracolumbar curve of 25 to 35 degrees, and a mean age of twelve years and seven months (range, ten to fifteen years) were followed to determine the effect of treatment with observation only (129 patients), an underarm plastic brace (111 patients), and nighttime surface electrical stimulation (forty-six patients). Thirty-nine patients were lost to follow-up, leaving 247 (86 per cent) who were followed until maturity or who were dropped from the study because of failure of the assigned treatment. The end point of failure of treatment was defined as an increase in the curve of at least 6 degrees, from the time of the first roentgenogram, on two consecutive roentgenograms. As determined with use of this end point, treatment with a brace failed in seventeen of the 111 patients; observation only, in fifty-eight of the 129 patients; and electrical stimulation, in twenty-two of the forty-six patients. According to survivorship analysis, treatment with a brace was associated with a success rate of 74 per cent (95 per cent confidence interval, 52 to 84) at four years; observation only, with a success rate of 34 per cent (95 per cent confidence interval, 16 to 49); and electrical stimulation, with a success rate of 33 per cent (95 per cent confidence interval, 12 to 60).(ABSTRACT TRUNCATED AT 250 WORDS)
      Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
      ---------------------------------------------------------------------------------------------------------------------------------------------------
      Surgery 2/10/93 A/P fusion T4-L3
      Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

      Comment


      • #4
        Just playing devils advocate (i am not even remotely thinking of using this method) what makes one study more definite then others? With only 46 in the electrical stimulation group statistical significance must be low. Could their methods of selectring patients have been different, or their way of applying the technology. Reversely, would the positive results from previous studies have been due to fraudulent reporting?? And why is this insurance company still funding it? People must be using it somewhere and for a reason?

        Feel free to answer if you have clear answers, but happily accept "don't knows" as this might all be a bit too complicated.

        Comment


        • #5
          Since all of the studies mentioned in the Aetna document were 1985 and earlier, I don't have access to them.

          The SRS study was a multi-center study, and looked at long term outcome.

          I've not heard of anyone (other than chiropractors) using electrical stimulation in recent years, I'm guessing that most of the mainstream scoliosis specialists believe that it's worthless.

          --Linda
          Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
          ---------------------------------------------------------------------------------------------------------------------------------------------------
          Surgery 2/10/93 A/P fusion T4-L3
          Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

          Comment


          • #6
            fair enough, must be pretty uncomfortable anyway as I assume that stimulation must be strong enough to make the muscle contract

            gerbo

            Comment


            • #7
              I passed this information along to a few of the local scoliosis specialists here and got this from Dr. Sigurd Berven at UCSF:
              The issue of insurance companies determing standards of care and influencing care by reimbursement policies is interesting, and in many cases concerning. For example, if a provider is reimbursed for electrical stimulation over bracing, then this will have an impact on clinical practices. Similarly, the differential in reimbursement for circumferential surgery compared with posterior surgery influences behavior without influencing outcome. I am preparing a talk on this now, and I think this could be worth studying in a project entitled an evidence-based approach to CPT-coding. Please let me know as you come across examples of reimbursement schemes that are not promoting evidence-based practice. I will share my ideas with you as the talk develops.

              --Linda
              Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
              ---------------------------------------------------------------------------------------------------------------------------------------------------
              Surgery 2/10/93 A/P fusion T4-L3
              Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

              Comment


              • #8
                interesting, please keep me informed

                merry xmas

                gerbo

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