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

[Pooka1]

I am wondering what the starting curves were either at surgery or at bracing.

Bingo.

You're good.

[mamamax]

Clarification of Terms: Degeneration (clinical use)

[COLOR="Navy"]My original question/statement[/COLOR] was: there is nothing in the literature that states surgery halts deterioration 10 years post operatively (by either old or new methods and instrumentation).

Now in reading some literature - I thought deterioration primarily meant progression - looks like a few others did also :-)

I asked an orthopedic surgeon about the use of the term in the literature in reference to spinal surgery. Turns out the clinical use of the term deterioration is: when signs of osteoarthritis of the little spinal joints are visible (on x-ray). This does not correlate with pain.

Just wanted to clarify that term - still, we had a great discussion!

[tonibunny]

Hi Mamamax,

You sound as though you're disappointed because we didn't talk about what you wanted to talk about, but surely that can't be true? After all, you were asking about "deterioration" and it was quite clear that what you meant was "deterioration of curvature". I'm sure if you were interested in osteoarthritis or anything else then you'd have said that explicitly at the time, and let me know that the paper I found for you wasn't the sort of thing you were after? I can't believe you'd let me take time trying to help you by discussing curve progression if this isn't actually what you were asking about.

It seems to me that deterioration is probably synonymous with degeneration in terms of spinal surgery in general, but when you are specifically discussing deterioration of scoliosis it will mean progression of the curvature first and foremost. Does that sound sensible?

Do you think there could be some unscrupulous practitioners out there who might try to put patients off surgery by claiming that "there is no proof that surgery halts the deterioration of scoliosis" because they know that most people will assume this means that surgery doesn't stop the curvature from progressing? I do. Luckily, we've had this discussion so it hasn't been a waste of time - they'll be able to read all about it here

[skevimc]

I am wondering what the starting curves were either at surgery or at bracing.

Surgical patients started at ~62, corrected to ~31, last follow up ~36.

Bracing patients started at ~33, corrected to ~24, last follow up ~37.

These are all averages with std ~10. The table listing all the data has several time point checks and has everything broken down by curve type. Both groups have pretty equal numbers of each curve type.

[Pooka1]

Surgical patients started at ~62, corrected to ~31, last follow up ~36.

Bracing patients started at ~33, corrected to ~24, last follow up ~37.

These are all averages with std ~10. The table listing all the data has several time point checks and has everything broken down by curve type. Both groups have pretty equal numbers of each curve type.

+2 points for Karen Ocker

[mamamax]

Hi Mamamax,

You sound as though you're disappointed because we didn't talk about what you wanted to talk about, but surely that can't be true? After all, you were asking about "deterioration" and it was quite clear that what you meant was "deterioration of curvature". I'm sure if you were interested in osteoarthritis or anything else then you'd have said that explicitly at the time, and let me know that the paper I found for you wasn't the sort of thing you were after? I can't believe you'd let me take time trying to help you by discussing curve progression if this isn't actually what you were asking about.

Really Toni - I thought deterioration as used in the literature related to curvature progression (and a lot of other things) - I was really surprised to find out it meant something else. And posted the clarification when I got it - which was after the discussion. And the reason I posted the clarification was to avoid confusion in the future, if the term came up in other papers discussed. I would never purposely waste your time. And I don't think the paper, and discussion of it was a waste of time either.

It seems to me that deterioration is probably synonymous with degeneration in terms of spinal surgery in general, but when you are specifically discussing deterioration of scoliosis it will mean progression of the curvature first and foremost. Does that sound sensible?

Yeah - I think it's sensible and that most lay-people would consider that deterioration is defined by progression - but it seems the clinical term used in the literature, means something else. So in reading the literature as we often do, best to know the difference (I think).

Do you think there could be some unscrupulous practitioners out there who might try to put patients off surgery by claiming that "there is no proof that surgery halts the deterioration of scoliosis" because they know that most people will assume this means that surgery doesn't stop the curvature from progressing? I do. Luckily, we've had this discussion so it hasn't been a waste of time - they'll be able to read all about it here

If there are - I think their peer reviewed submissions would be rejected for clarification of terms. Am I being naive in that assumption?

I don't understand the comment: Luckily, we've had this discussion so it hasn't been a waste of time - they'll be able to read all about it here

[mamamax]

Surgical patients started at ~62, corrected to ~31, last follow up ~36.

Bracing patients started at ~33, corrected to ~24, last follow up ~37.

These are all averages with std ~10. The table listing all the data has several time point checks and has everything broken down by curve type. Both groups have pretty equal numbers of each curve type.

Thanks again skevmic - good to know. Is there a link to this information - or is it available on-line?

[skevimc]

Thanks again skevmic - good to know. Is there a link to this information - or is it available on-line?

The article is available online but only with subscription (yay university/medical library). I know when I was at KU, the library was open to the public because it was a state funded school. No ID required for entry. If you are near a State University they might have a hard copy of many articles you come across.

[mamamax]

Surgical patients started at ~62, corrected to ~31, last follow up ~36.

Bracing patients started at ~33, corrected to ~24, last follow up ~37.

These are all averages with std ~10. The table listing all the data has several time point checks and has everything broken down by curve type. Both groups have pretty equal numbers of each curve type.

I don't think a truly good comparison can be made as treatment recommendations for surgery and bracing have such a wide variance. We wouldn't see a group bracing at 62 degrees, or a large surgical group starting at 33 degrees.

I'm not sure what we gather from this study other than at the time (40 years ago) - progression rates 22 years post treatment for both groups was, minimal.

Would it be reasonable to conclude that IF a similar study were done today, that the outcome might conceivably be similar? I don't know ... just pondering. I'm thinking we could debate it forever - but in the end, we probably couldn't prove anything.

[mamamax]

The article is available online but only with subscription (yay university/medical library). I know when I was at KU, the library was open to the public because it was a state funded school. No ID required for entry. If you are near a State University they might have a hard copy of many articles you come across.

Darn - but good information for those close to State Universities ... about an hour round trip for me. Sweet to have a subscription :-)

[tonibunny]

It's OK, I don't think you'd waste my time I'm glad you found the discussion interesting.

This discussion has shown that it's definitely good to know that "deterioration" in literature doesn't refer to progression of curves. It would probably be a good idea for any practitioners out there to explain that explicitly to patients if they can see those patients being confused by it, don't you think?

Sadly I have seen unscrupulous practitioners out there who do try to deliberately mislead people, in order to scare them off surgery and get them to pay for alternative treatments instead They are just a tiny minority - I do believe that most practitioners everywhere are honest and trustworthy - but they are out there. And well, you'd think that there would be no problem with them publishing stuff in their own peer-reviewed journals because they would, amongst themselves, understand what "deterioration" means. The difficulty simply lies in if they pass this information to a patient without making sure that patient is fully aware of what it means, and purposefully allow them to be misled.

For instance, it bothers me that such a practitioner could say to a patient "Don't have surgery! There's absolutely no evidence that it will stop your curve from deteriorating!" when the context of their conversation clearly shows that the patient wants to know about progression. And then, supposing the patient goes on somewhere like Facebook and misguidedly tells other patients "Don't have surgery! My practitioner told me that there's no evidence that it stops your curve from progressing anyway! So you just keep curving up!" That would be terrible, wouldn't it?

What I meant by "our discussion hasn't been a waste of time, they'll be able to read about it all here" refers to the fact that now we've had this discussion, anyone who has been led to believe that surgery doesn't prevent one's curve from progressing can take a look at the results of this study, and be reassured

And yes, it's an old study - but it has to be, for there to be longterm results! I think people will look at it logically to try to work out what they think the likely outcome would be for someone having surgery today. The study refers to people having spinal fusions (the result of which is exactly the same in today's surgery) and refers to those fusions being done with Harrington Rods. Harringtons generally only attach to the spine at the ends, so they are a lot less stable than the rod and pedicle screw constructs of today, which attach very solidly into nearly, if not all, of the fused vertebrae and are very robust. I think a lot of people would think it sensible to assume that a spine instrumented with modern hardware is going to be far less likely to continue to curve than a spine instrumented with a Harrington, and longterm results will be even better for people having surgery today

BTW I'm not really reading this study as a comparison between bracing and surgery, as I would have expected the braced patients to have subsurgical curves anyway so they can't really be compared.

[mamamax]

The Literature ...

Thanks Toni ... I would say your time is never wasted :-) As for the study we discussed, it was designed to be a comparison of methods, so that's how I tried to read it. Literature can be difficult for lay people to read, for certain. Here are my thoughts on "the literature."

The literature, seems an entity unto itself (guess that is why it is called a "body of evidence"), it is interesting from the standpoint that firstly, I don't think it is written for lay-people, but rather for the scientific community looking to provide evidence towards justification of treatments. With today's technology however, more lay-people have access to these presentations. It is interesting to watch debates within the literature itself, between contributors who seem not all that different than ourselves in that they sometimes take from these studies what they want and leave out other things that would not support their own positions. For example, the numerous studies that are done on quality of life (on both sides of the fence) are flawed by the fact that the dissonance effect was neither discussed or ruled out and therefore faulty evidence is presented. So basically, I see the literature as its own forum, so to speak, with its own unique language that is sometimes difficult to interpret and which is designed for its own debate of methods - and oftentimes I wonder if the best studies are simply a matter of who has the best grant writer making them even possible in the first place. Now that patients have access to these presentations, I wonder how this may change design and presentation in the future, as patients become more aware that they even have the ability to research findings.

Martha Hawes being a unique example of a patient who has researched the literature, and even contributed to it, resulting in contribution to a growing body of evidence supporting non surgical methods. Her contributions found Here, Here, Here, and Here - in addition to her book Scoliosis and the Human Spine, and for those who seek it, her memoir. This helps patients and parents, not so much judge which method is better - but provides them with more information in making individual choices for themselves, or loved ones. It is good to have choices, and it is good to have supportive literature as the body of evidence grows.

[Pooka1]

With today's technology however, more lay-people have access to these presentations.

This is a huge, dangerous problem in my opinion. I think access should remain open but the downside is lay folks completely misunderstanding the literature and acting on it.

Martha Hawes being a unique example of a patient who has researched the literature, and even contributed to it, [...]

Hawes holds a PhD in a scientific field (plant pathology IIRC). She is well aware of how the scientific method works and how to honestly write up research results. She seems to have done a considerable amount of reading in the field of scoliosis which is like starting virtually from scratch when starting with a degree in plant path..

It is good to have choices, and it is good to have supportive literature as the body of evidence grows.

Oh geez...



The literature conclusions are often false for many reasons despite the vast majority of researchers being intellectually honest. Coming upon the correct answer in uncontrolled studies would just be a chance occurrence. There is a reason uncontrolled studies are unpublishable in non-medical fields.

[mamamax]

Mirror work

Time for Mirror work ...

http://www.bing.com/videos/watch/vid...-talk/20ajmekq

[Ballet Mom]

Time for Mirror work ...

http://www.bing.com/videos/watch/vid...-talk/20ajmekq

I love that link mamamax!

I think the benefits of people having more access to the literature FAR outweighs any negatives. I am happy that people can be more informed and more responsible for knowing about their own medical conditions and helping to make good decisions regarding their health, in conjunction with their medical professionals. Most doctors visits are very short with very limited information provided.

And it should help keep science intellectually honest. See Climategate for an example.

Anyone worried about lay people reading these studies should realize that most people who lack the capacity to make sense of them will probably not have the inclination to read them in the first place. Most people's eyes would glaze over unless they have some familiarity with science and statistics.