The ethics of bracing (and PT) with a Scoliscore <41

[Pooka1]

I'm still puzzled about the story in the video. She scored 16 on the test, but had a 25 degree curve to begin with and then had a big curve increase during her growth spurt (again, according to the video). I'm not sure what that adds up to, but I'm guessing she has to be at least over 30 degrees (25 + "unnamed big increase")

That doesn't sound familiar. I have to review the video yet again...

If that's a low-risk case, I'm a little puzzled about what a medium-risk case would look like.

The definitions are arbitrary in the sense that their exact value is chosen for a separate reason. Low is <50, medium is >50 and <180.

The scoliscore seems to predict a scoliosis "FAIL" irrespective of what the curve has done. It seems similar to my daughters' cases of pectus excavatum which were more than mild and less than severe. They resolved completely on their own and the chest walls are normal. I think of this as a pectus excavatum "FAIL." The development and disappearance of the PE seemed clearly under genetic (and likely not epigenetic) control because it happened simultaneously in both kids at the same stage of growth. N.B. My entire family was simultaneously NOT praying for the PE to resolve so I suppose I can't prove it wasn't due to no prayer whatsoever so there's that.

I'm also not sure why she was put in the brace *after* the growth spurt. Aren't kids at 25 degrees-but-still-growing mostly already in brace?

Don't know on either count.

[Pooka1]

It keeps occurring to me that the opposition voiced on this forum to Scoliscore might actually rise to Neo-Luddism.

Sorry to say.

[hdugger]

If an argument is wrong (in your opinion), engage the argument. Calling people luddites does nothing to elucidate or engage the ideas - it only elucidates your opinion of the motivations of the other people involved in the discussion. That's pop psychology at its worst.

[Pooka1]

If an argument is wrong (in your opinion), engage the argument. Calling people luddites does nothing to elucidate or engage the ideas - it only elucidates your opinion of the motivations of the other people involved in the discussion. That's pop psychology at its worst.

Suggesting Luddism is part of the argument against your position because I can't find anything else in support. Yes I am at the bottom of the barrel because there is nothing else. In my opinion, that is the underlying "reason" driving every argument against Scoliscore at this point now that the data are out there. That is my counterargument.

Scoliscore, if it stands, appears to be the best thing to happen to ~75% of kids with AIS. What is your scientific argument against it other than it is new? The only thing you have is a on-starter about the cutoff being 40* and not 30*. The argument that bracing might keep sub-surgical curves even more sub-surgical is bolstered by even less evidence than for bracing to avoid surgery. It might be true but, knowing the precision and the range, it might be impossible to ever demonstrate. See my sig file.

[hdugger]

It's never necessary to ascribe odd emotional motivations to people simply because you disagree with them. Unless, you know, you like that sort of thing. If you do, hey, I have a degree in psychology.

Your position, as I understand it, is that Scolioscore is a success because children can forgo bracing. My position is that forgoing bracing may not turn out to be a blessing if it means that a child's 20 degree curve turns into a 40 degree curve.

You can agree or disagree with my position, but I don't think it's a diagnosable indication of my precarious psychological condition, nor am I particularly interested in discussing whether or not I *have* a precarious psychological condition. If that's the crux of your argument against my position, we probably don't have anything further to discuss on this subject.

[Pooka1]

It's never necessary to ascribe odd emotional motivations to people simply because you disagree with them.

How do you personally counter a non-argument? I'm now interested in light of what you wrote.

If you have advanced a viable argument in opposition then I don't know what it is. So far I think we have the following:

1. 40* versus 30* and the claim that braces might hold small curves smaller. The world seems so constructed such that while people might claim to know that, they might never be able to show it. And when we are talking 23 hour/day bracing, ethics intrude as they must.

2. Vague suggestions that the need and efficacy of Scoliscore might be illusory and that unconnected surgeons somehow have improved the data set.

I am not aware of any other positions.

These are non-arguments.

Your position, as I understand it, is that Scolioscore is a success because children can forgo bracing.

Epic win for them.

My position is that forgoing bracing may not turn out to be a blessing if it means that a child's 20 degree curve turns into a 40 degree curve.

That is neither here nor there if, as is actually the case in reality, that there is no conservative treatment that can change that natural history. You can't just KNOW it, you have to SHOW it when discussing 23-hour/day hard bracing of baby kids. You might also want to consider the people on here whose signatures suggest they were told they were done and the bracing worked. A rational explanation if the braces did indeed work (big "if") is that bracing only delayed surgery. In the past before the third generation instrumentation, that was a good thing. As the instrumentation improves, that argument that braces may only delay not avoid surgery will become increasingly harder to make.

You can agree or disagree with my position, but I don't think it's a diagnosable indication of my precarious psychological condition, nor am I particularly interested in discussing whether or not I *have* a precarious psychological condition. If that's the crux of your argument against my position, we probably don't have anything further to discuss on this subject.

We may not have anything to discuss then if you don't advance an argument.

[Ballet Mom]

It is my opinion that this test may take a little money away from pediatric surgeons, but the real effect of this test (if used as proposed) will be to transfer the revenue from the large bracing market that helps children who would like not to have an increased deformity, to Scoliscore, its insiders and its venture capital backers plus enormous additional profits when Axial Biotech is taken public.

I predict the adult orthopedic surgeons will get increased business due to the increased progression rates of the larger resulting curves, leading to many more adult surgeries and much greater additional cost.

Once again, this is my opinion.

After further thought, I need to adjust this opinion to reflect that I don't believe this will decrease pediatric surgeons revenues at all. It should increase them. The reason is that apparently this Scoliscore test will be used not only to not brace kids, it appears this test is also hooked with the notion that those who do score high on Scoliscore will be sent to get vertebral stapling...even though results have shown that the same percentages progress to surgery with vertebral stapling as they do with bracing, at much greater cost and risk.

[Ballet Mom]

I'm still puzzled about the story in the video. She scored 16 on the test, but had a 25 degree curve to begin with and then had a big curve increase during her growth spurt (again, according to the video). I'm not sure what that adds up to, but I'm guessing she has to be at least over 30 degrees (25 + "unnamed big increase")

If that's a low-risk case, I'm a little puzzled about what a medium-risk case would look like.

I'm also not sure why she was put in the brace *after* the growth spurt. Aren't kids at 25 degrees-but-still-growing mostly already in brace?

Can you post a link to this video? I cannot find this video that keeps getting tossed around. Thanks.

[Ballet Mom]

How do you personally counter a non-argument? I'm now interested in light of what you wrote.

If you have advanced a viable argument in opposition then I don't know what it is. So far I think we have the following:

1. 40* versus 30* and the claim that braces might hold small curves smaller. The world seems so constructed such that while people might claim to know that, they might never be able to show it. And when we are talking 23 hour/day bracing, ethics intrude as they must.

2. Vague suggestions that the need and efficacy of Scoliscore might be illusory and that unconnected surgeons somehow have improved the data set.

I am not aware of any other positions.

These are non-arguments.



Epic win for them.



That is neither here nor there if, as is actually the case in reality, that there is no conservative treatment that can change that natural history. You can't just KNOW it, you have to SHOW it when discussing 23-hour/day hard bracing of baby kids. You might also want to consider the people on here whose signatures suggest they were told they were done and the bracing worked. A rational explanation if the braces did indeed work (big "if") is that bracing only delayed surgery. In the past before the third generation instrumentation, that was a good thing. As the instrumentation improves, that argument that braces may only delay not avoid surgery will become increasingly harder to make.

We may not have anything to discuss then if you don't advance an argument.

The fact that science can't prove that bracing is or isn't effective is a limitation of the science, not the bracing.

You are absolutely ignoring all the very valid statistics I have shown you over and over again. There is a reason for this. People can make their own judgments as to what that reason is.

[leahdragonfly]

After further thought, I need to adjust this opinion to reflect that I don't believe this will decrease pediatric surgeons revenues at all. It should increase them. The reason is that apparently this Scoliscore test will be used not only to not brace kids, it appears this test is also hooked with the notion that those who do score high on Scoliscore will be sent to get vertebral stapling...even though results have shown that the same percentages progress to surgery with vertebral stapling as they do with bracing, at much greater cost and risk.

BalletMom, I just have to ask, how did you make the leap from scoliscore to VBS? I have read quite a bit of the scoliscore info and I have not seen a high score as an indicator that a child would be sent to VBS. VBS is simply an alternative to bracing (in some case years worth of bracing, such as my daughter was facing at age 6). Can you please provide a link?

And really, I try to ignore your more negative comments, but why do you insist on bashing VBS at every opportunity? Yes it is surgery and it carries risks and costs and is incredibly scary for the parents, but since you have no direct experience whatsoever with VBS, why do you feel it necessary to continually bad-mouth it? Not all kids will be nearly so lucky as your daughter to reach skeletal maturity with just a few years of night bracing. The rest of us are happy to have other options for our kids.

Gayle

[Ballet Mom]

BalletMom, I just have to ask, how did you make the leap from scoliscore to VBS? I have read quite a bit of the scoliscore info and I have not seen a high score as an indicator that a child would be sent to VBS. VBS is simply an alternative to bracing (in some case years worth of bracing, such as my daughter was facing at age 6). Can you please provide a link?

And really, I try to ignore your more negative comments, but why do you insist on bashing VBS at every opportunity? Yes it is surgery and it carries risks and costs and is incredibly scary for the parents, but since you have no direct experience whatsoever with VBS, why do you feel it necessary to continually bad-mouth it? Not all kids will be nearly so lucky as your daughter to reach skeletal maturity with just a few years of night bracing. The rest of us are happy to have other options for our kids.

Gayle

I am not bad-mouthing VBS. I think it has its uses, especially for those high curves that bracing is not very effective and for kids who absolutely will not stand for bracing.

I am concerned with the VBS link to Scoliscore because it is mentioned in the articles posted touting Scoliscore, as the end result for those who obtain high Scoliscores by the doctors who are promoting Scoliscore...even though VBS isn't effective on the same percent as bracing. The Scoliscore results aren't going to change the failure rate of either bracing or VBS.

[hdugger]

Can you post a link to this video? I cannot find this video that keeps getting tossed around. Thanks.

Sure, here's one - http://www.youtube.com/watch?v=FnxYxPk3b58

It's all over the web (again, one of those things that makes me cringe about entrepreneurship in medicine). Googling on Isabelle and Scoliscore brings up about 8 pages worth of entries, most of them separate postings of this video.

[hdugger]

I am concerned with the VBS link to Scoliscore because it is mentioned in the articles posted touting Scoliscore, as the end result for those who obtain high Scoliscores by the doctors who are promoting Scoliscore...even though VBS isn't effective on the same percent as bracing. The Scoliscore results aren't going to change the failure rate of either bracing or VBS.

I had the sense, and it may be completely wrong, that VBS was preferentially offered to the JIS crowd. If that's true at all, then the Scoliscore test isn't going to affect that, since it has only been tested in the AIS population.

I do wonder, in a kind of early morning not enough coffee way, if the Scoliscore is measuring, in part, a receptiveness to bracing. Are the low risk kids unlikely to progress with no treatment? Or, since it was a retrospective study, are they just the kids who are most likely to respond to brace treatment. And, conversely, are the high risk kids the ones who are most likely to not respond to brace treatment (that is, not because they have aggressive curves, but because something in their curve growth makes bracing fail.)

This is just a thought experiment - there's no data one way or the other, as far as I know. But it does seem possible that Scoliscore is measuring something other than just likelihood of progression outside of any treatment protocol.

[mariaf]

...even though VBS isn't effective on the same percent as bracing. The Scoliscore results aren't going to change the failure rate of either bracing or VBS.

Before you accuse me of anything, let me state that I am not asking this sarcastically, but can you please show us where you came across the data about the failure rate being the same for VBS and for bracing. I would really like to see it.

At this point, I'm not even getting into whether your data is right or wrong, but I have seen lots of data on VBS and have not seen the figures you refer to - hence, my interest.

Does anyone even know, or agree on, the failure rate of bracing?

One would need that to make the comparison to VBS, no?

[Pooka1]

Maria,

I don't think the bracing failure rate is known with any certainty. That is a big part of the problem.

I have seen it estimated as ~20%, a number which comports with the extremely rough calculation based on bracing rate and fusion rate in AIS.

The rate of needless bracing seems more well known from Scoliscore and also other sources as ~70% - 75%.