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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