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Table 5 Comments received to the Recommendations of the Pre-Meeting Questionnaire.

From: Guidelines on "Standards of management of idiopathic scoliosis with corrective braces in everyday clinics and in clinical research": SOSORT Consensus 2008

Domain Recommendation Comments
Experience 1 Not all centres have this many patients but may still provide a local service? it is difficult to be so dogmatic with numbers
Competence   The number of treatments required is too high for a small country
   Many little centres are not able to fulfill these criteria
   Quantity is not always reflecting quality
   Experience is important but it is not the only thing behind correct clinical decisions
   This is an ideal, but if there is a good CPO and the MD do not fulfill this recommendation is this important?
   My concern is availability of master physicians (there aren't in some countries)
   You cannot prohibit prescriptions by graduated MDs
  2 Experience is important but it is not the only thing behind correct clinical decisions
   This can be a problem for little centres or to recruit new CPOs
   My concern is availability of master physicians (there aren't in some countries)
   You cannot prohibit construction by licensed CPOs
   Team work for private professionals can be a problem
Behaviours 3 Working as a team is difficult when you are not in the same place
   The team must include PTs specialized in the field
   Ideally the physician, orthotist and therapist should be seeing patients together in a clinic setting but outside of the clinic/hospital
based programs this occurs very rarely
   Although ideal, I believe this will seriously impede the development of scoliosis interest in US by independent individual
professionals (CPO and PT). This will run the risk of scoliosis only being able to be treated by bigger institutions and "directed" by MD.
It could really impede the motivation of new and very strong independents from getting involved with scoliosis and with SOSORT.
I believe you can have for instance a MD who is supportive of conservative management and refers to a very good CPO
and appropriately defers the brace making and corrections to the very skilled CPO.
   Quite frankly, although the MD is important in diagnosis and especially in medical differential diagnosis, once he/she
is done with that job, MUCH of the remaining hands-on conservative management is the responsibility of the CPO (and PT).
These people should be allowed to have some degree of independence. In order to attract and retain really great CPOs, and PTs, these
people will want to over time be more than just "technicians" They will want to have a decision making and larger role in the overall
management of the case... Of course along side the MD is best, but not under the order of the MD...
  4 To increase compliance MDs shouldn't change during treatment
   Sometimes psychologists can be useful
   Also PTs have an important role in this
   Sometimes CPOs can create problems if they do not satisfy previous recommendations
   Compliance is a problem when you receive negative messages inside the team
  5 If CPO knows his work is the MD that has to discuss with him
   CPOs should lead this action and not MDs
   In North America ortho surgeons do not write details of prescription
   US physicians are not trained in giving details of brace prescription and this should be done together by CPO and MD
   If an MD is not convinced and committed he should send the patient to another MD for treatment
   In some brace prescriptions you don't need to give details
   Any action to promote compliance should be not manipulative (e.g. "if you do not wear a brace you will finish in a chair"...)
   Don't mix compliance with prescription
Prescription 6 If CPO knows his work is the MD that has to discuss with him
   CPOs should lead this action and not MDs
   In North America ortho surgeons do not write details of prescription
   US physicians are not trained in giving details of brace prescription and this should be done together by CPO and MD
   If an MD is not convinced and committed he should send the patient to another MD for treatment
   In some brace prescriptions you don't need to give details
   Any action to promote compliance should be not manipulative (e.g. "if you do not wear a brace you will finish in a chair"...)
   Don't mix compliance with prescription
Construction 7 In US details are not given by the MDs
   Don't mix compliance with construction
   About compliance CPOs have not to act autonomously but eventually support the action of MDs
   Any action to promote compliance should be not manipulative (e.g. "if you do not wear a brace you will finish in a chair"...)
Brace check 8 MD has to check and the CPO only for his competence
   This is lead by CPO and MD is not necessary
   It's possible that the check by MD is not immediate
   The other members of the team should give their comments (PTs)
   What does "check aesthetic correction" mean?
  9 We do not check braces but patients in brace
   Clinical variance (no consensus)
   1.I check only clinically, rarely radiographically
   2.I check only radiographically
   3.I check radiographically only the first brace
   4.I check always radiographically a new brace
   The eventual radiographic check should be postponed one month after brace wearing
   We need more details on eventual x-ray check to have a standard
   Who evaluate the brace?
Follow-up 10 If PT treatment is twice a week, it is a waste of time to check every time
   PTs usually are not well prepared: this recommendation is possible only in Scoliosis Centres
   This is not research, is only clinics
  11 Follow-up must be maximum in 3 months, in growth spurt in 2 months (push loosening)
   Controls in 3 months in case of: 1. first brace; 2. growth spurt; 3. progressive curve; 4. atypical curve; 5. predicted poor compliance;
6. request of other team members (CPO, PT)
   It's important to give protocols or use recalls
  12 MDs have rarely enough time and knowledge: this should be responsibility of CPOs, that can judge it better
   This must be respected by Health National Services
   Some braces allow more adjustability and should be chosen
   Sometimes in specific braces less than 3 months is necessary
   Correction is another reason to change a brace
  13 Control should be made by MDs (CPOs should intervene autonomously only if the brace breaks)
   MD & CPOs should check the braces together
   It's enough that one of the team (MD, PT, CPO) checks the brace regularly (every 2–3 months)
   The problem is growth and not time: I suggest every 2–3 cm. or kg.
   First braces should be checked after 1 month
   Efficacy can be checked only through x-rays and this is not possible every 2–3 months
  14 It's not possible because PTs are not inside the hospital team
   PTs usually are not well prepared
   Sometimes PTs tell the patient something wrong !
   If PT treatment is twice a week it is a waste of time
   PTs should tell to physicians and not patients
   This is not research, is only clinics
General comments   SOSORT should offer training for MDs, CPOs and PTs
   It's better to compromise for compliance than to be very stiff and loose the patient
   SOSORT should develop methods to detect scoliosis (idiopathic and so on) as a brochure especially for general practitioner and pediatrician
   PTs should be trained in assessment of brace fit
   We need guidelines on x-ray assessment
   We need a group to evaluate brace efficacy and, at the same efficacy, brace compliance
   We need a way to certify MDs, CPOs and PTs prepared in scoliosis treatment
   We need objective questionnaires to evaluate psychological impact of treatments
  1. MD Medical Doctor; CPO Orhotist; PT Physiotherapist