Title: Conservative treatment of idiopathic scoliosis according to FITS
concept: presentation of the method and preliminary radiological and clinical
results respecting SOSORT and SRS criteria.
Reviewer: Martha Hawes
Answer to the Reviewer’s report:
I thank very much for the careful reading of my paper and for the revisions which
improve the final text. All the questions and suggestions for change have been
addressed.
The changes introduced in the final manuscript have been marked with violet color.
Reviewer's report:
General response:
This research paper describes results over an average followup of 2+ years,
among 115 children treated using a specific therapeutic approach. The
introduction succinctly outlines the need for approaches that treat scoliosis in
the absence of diagnostic information regarding its cause.
Methods are outlined in a straightforward manner, with an emphasis on general
principles of scoliosis development and progression. Because scoliosis is a
symptom that develops in response to many injuries, infections and genetic
issues, there is a need for patients to be treated as individual cases, a strategy
that is implicit here within the name of the treatment and executed in the
practice.
Most important, in the absence of curative strategies, is a need to educate and
engage patients in the effort to manage symptoms over a lifetime. The
strategies implicitly recognize and build on the established body of research on
molecular and biochemical underpinnings of spinal deformity. These studies
have revealed that in most cases (with the exception of congenital bone
deformities) attention to soft tissue imbalances will be critical for curvature
stabilization and/or improvement in
clinical symptoms (e.g. Will RE, Stokes IA, Qiu X, Walker MR, Sanders JO.
2009
Cobb angle progression in adolescent scoliosis begins at the intervertebral
disc. Spine (Phila Pa 1976). 34(25):2782-6; and Villemure I, Stokes IA. 2009.
Growth plate mechanics and mechanobiology. A survey of present
understanding. J Biomech. 42(12):1793-803.)
I thank very much for the crucial comments on scoliosis pathology. I allowed myself to use
some of the ideas in the Discusssion section, as follows: (page 22)
According to Hawes, scoliosis is a symptom that develops in response to numerous injuries,
infections and genetic problems. Since the formation of a direct cause of scoliosis is still
unknown, it forces us to plan treatment of symptoms of scoliosis (any asymmetry of the trunk,
incorrect loading of the lower limbs and pelvis asymmetric adjustment) rather than its cause.
Improving the proper loading of the lower limbs, pelvis proper setting gives a good basis for
uniform loads discs and cartilage growth maturing of the spine, which is so vulnerable to
asymmetric loads. Based on the study of molecular and biomechanical basis of deformation of
the spine can be concluded that in most cases (except for congenital deformities of bones), soft
tissue balance will be crucial to the stabilization of the curvature and / or improvement of
clinical symptoms [46, 47]. FITS method meets these requirement with a view to relaxation of
soft tissue to reach as far as possible balanced tension. After removing soft tissue restrictions
the patient can perform the correction patterns and then to stabilize.
As the author points out, improvement in magnitude of Cobb angle does not
reliably result in improvement in clinical symptoms including pain, respiratory
impairment and psychological distress. Therefore it is important that this study
includes a comprehensive analysis of outcome beyond curvature magnitude.
As pointed out, a longer evaluation would be of benefit, and this study can
provide a foundation for such (i.e. in the manner of the Iowa series, for
example). The inclusion of >100 patients is well beyond the size of the majority
of studies on scoliosis outcome. For example, among 82 studies of surgery
patients, the majority included fewer than 50 subjects (reviewed in Disability
and
Rehabilitation 30: 808-817, PDF attached, see table 1).
……………
Revisions:
compulsory
1. The style and content are good, but the English grammar and spelling
throughout the manuscript need to be repaired.
Answer: the manuscript has been rechecked for grammar and spelling.
2. RE: conclusion #3—I’m not sure of the meaning here.
Answer: the conclusion 3 was improved in sense
discretionary:
1. RE: ‘conclusions’ #1—some will argue that this has not been documented
since some argue that any changes that occur in immature patients would
have occurred anyway. A more important conclusion, in my view, is that this
study documents changes occurring in correlation with FITS, and this will
provide a baseline to examine whether long-term changes follow.
Answer: The conclusions of the paper have been modified.
Level of interest: An article of importance in its field
Quality of written English: Needs some language corrections before being
published
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I declare that I have no competing interests.