Reviewer's report
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.
Version: 2 Date: 23 August 2011
Reviewer: Martha Hawes
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:
I have provided alternate suggestions below. Suggested changes are in large
capitals. My comments are in italics.
Paragraph indent formatting needs to be checked throughout--errors probably
introduced by MS Word...
p. 1. paragraph 1.
However, idiopathic scoliosis BY DEFINITION is a disorder of unknown origin,
therefore treatment is IN RESPONSE TO SYMPTOMS.
DONE p. 1: However, idiopathic scoliosis by definition is a disorder of unknown origin,
therefore treatment is in response to symptoms.
p. 1. paragraph 2. last sentence--is there a word missing? 'including defects
attitude'
DONE p. 2 In author’s clinical practice,we receive children with various spinal deformities,
including defects of posture,……
p. 2. para 1. ...and corrective bracing, and SEVERE scoliosis (COBB ANGLE
GREATER THAN 50) who underwent...
DONE p. 2: In my clinical practice, I receive children with various spinal deformities, including
defects of posture, low moderate scoliosis (Cobb 10-25º), high moderate curvatures (Cobb 2640º) requiring physiotherapy and corrective bracing, and severe scoliosis (Cobb angle greater
than 50°), who underwent surgical treatment or who for various reasons are not operated
(refusal, contra-indication).
p. 2. para 2. ...this method could be PREDICTED FOR other ....
DONE p. 2: However, beneficial influence of this method could be predicted for other structural and in
non structural spinal deformities.
p. 2. para. 2. In the literature the PERCENTAGE of braced...
DONE p. 2: In the literature the percentage of braced patients who progressed significantly
and had to undergo surgery in the case of 26-45º scoliosis, oscillates between 8% and 41%
[12,13].
p. 2. para. 3. ...lower limb ASYMMETRIES.. ...published literature comprise A
methodological...
DONE p. 2: Effective scoliosis treatment involves radiological and clinical improvement
decreasing all the trunk, pectoral girdle, pelvic girdle and lower limb asymmetries. Currently,
certain instruments presented in the published literature comprise a methodological reference
framework Scoliosis Research Society (SRS) criteria [14] and clinical reference framework
Society of Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) criteria [15].
p. 2. para. 5. ...for diagnosis and therapy OF structural and NOT STRUCTURAL...
DONE p.2: This article describes FITS method, which was created and developed by the two
authors: Marianna Białek PT,PhD and Andrzej M’hango PT,MSc in 2004 for diagnosis and
therapy of structural and not structural scoliosis
p. 2. last line. 'To make THE child aware...'
DONE p.3: To make the child aware of existing deformation of the spine and the trunk as well as
indicate a direction of scoliosis correction.
p. 4. ATR needs to be spelled out in its first use. (maybe I've missed it...)
DONE p. 4: position of pelvis and measurement of angle trunk rotation (ATR) using Bunnell
scoliometer,
p. 4. last paragraph. ...the X-ray with THE child...
DONE p. 4 and 5: We analyze the X-ray with the child, the three-dimensional position of scoliosis
on the model of the spine and we show direction of correction (Figure 2).
p. 6. para. 1. ...is deformation of THE physiological shape of THE spine...
DONE p. 6: One of the first symptoms of scoliosis is deformation of the physiological shape of
the spine in sagittal plane (particularly flattening of thoracic kyphosis) [32].
p. 6. para. 2. .Correction in THE frontal plane...
DONE p. 6: Correction in the frontal plane is preceded by relaxation of contracted or very tight
muscles which is a part of LL (lateral line).
p. 6. para. 3. ..the apex of THE curve and...
DONE p. 6: In addition, the muscles between the apex of the curve and iliac crest make
corrective lateral shift more difficult (lower part of latissimus dorsi and erector spine, posterior
part of internal abdominal oblique muscle, posterior layer of quadrates lumborum and lateral
part Th/L fascia)
p. 6. para. 3. --sitting and standing. THIS WILL FACILITATE the corrective shift.
DONE p. 7: This will facilitate the corrective shift.
p. 7. para. 1. Derotation of THE scoliotic.... muscles work in different directions
(delete 'a')...
SO PRECISION IS IMPORTANT in myofascial release IN ORDER to obtain....
THIS IS FOLLOWED BY release OF short spinal rotators.
Derotational movement of THE trunk is...
The secondary curve of scoliosis should ALWAYS BE stabilized.
DONE p. 7: Derotation of the scoliotic spine is the most difficult corrective movement for
therapist as well as for child. There are two muscle groups responsible for this movement: SBL
(short paraspinal rotators) and SL (muscles of spiral line). At first we should release muscles of
SL, because they are more superficial. The crucial area of our therapy is the Anterior Superior
Iliac Spine (ASIS) area where we observe diversity of mechanical tension going out from it. The
force vectors of muscles work in different direction so precision is important in myofascial
release in order to obtain desired therapeutic effect. This is followed by release of short spinal
rotators – first in prone position, then in sitting (during this maneuver the patient actively
performs scoliosis derotation). Derotational movement of the trunk is particularly difficult in
double major scoliosis where two opposite directions of vertebral body rotation are located.
This is the reason why the relaxation of these muscles for Th segment should be performed by
patient’s shoulder movement, for Th/L segment by pelvis movement. The secondary curve of
scoliosis should always be stabilized.
p. 7. para. 2. It is responsible for THE profile of the spine in THE sagittal plane
but also HAS an impact on derotation....with THE anterior ligament which
changes its placement DEPENDING ON COBB ANGLE MAGITUDE.... THE
patient's POSTURE....
DONE p. 7 and 8: Significant therapeutic effects can be obtained by relaxation of deep frontal
line. It is responsible for the profile of the spine in the sagittal plane but also has an impact on
derotation of scoliosis by myofascial connection with the anterior longitudinal ligament, which
changes its placement depending on Cobb angle magitude and direction of corpus of vertebrae
rotation. The patient’s posture in correction when releasing muscles of deep front line can have
an impact on clinical change around costal hump (Figure 6).
p. 7. para. 3. ...lower trunk WHICH RESULTS IN...
DONE p. 8: Pelvis floor muscles (which is the part of DFL) improve stabilization of lower trunk
which results in correction of upper curve of scoliosis.
p. 7. para. 4. ...myofascial restrictions WHICH MAKE corrective movement
difficult, (REMOVE PARAGRAPH)... improving flexibility and moBility of scoliosis,
(ADD COMMA)...
DONE p. 8: After removing myofascial restrictions which make corrective movement difficult,
improving flexibility and mobility of scoliosis, we go on to the next stage of therapy.
P. 8. para. 1. TO BUILD AND STABILIZE... (ADD PERIOD AT END OF
SENTENCE).
DONE p. 8: To build and stabilize new corrective patterns of posture in functional positions we
start from correct foot loading using sensory motor balance training according to Greenman
[33] (Figure 7, 8).
p. 8. para. 3. Check the verbiage of this paragraph--doesn't make sense in a
couple of places. (...we can state enlarged lordosis..??). lower part of truck is
essential (is the basis)???
I changed p. 9: On clinical examination we observe enlarged lumbar lordosis. However, after
lateral X-ray analysis, the increased lordosis comprise lower lumbar spine while flattening of
lordosis is observed in the upper lumbar spine. Stabilization exercise of the lower part of trunk
is essential for the study of corrective patterns of the upper part of trunk and shoulder girdle.
p. 9. para. 1. ...children have PARTICULAR DIFFICULTY DOING LATERAL
SHIFT CORRECTION IN THE FRONTAL PLANE, MAINLY DUE TO
INCREASEED TENSION OF THE MYOFASCIAL TRACT.....
...be aware that the shift of THE primary curve...
DONE p. 9: In obtaining corrective movement children have particular difficulty doing lateral
shift correction in the frontal plane, mainly due to increased tension of the myofascial tract
between the iliac crest and the apex of scoliosis. It is recommended to exercise shift in
functional positions (sitting and standing). The technique of combination of isotonic
contractions is indicated. In case of double major scoliosis we need to be aware that the shift of
the primary curve should be done with stabilization (or correction) of secondary curve.
p. 9. para. 2. Facilitation to correct three-plane???? corrective breathing.... not
sure what is meant here.
DONE p. 9: Facilitation to three-plane corrective breathing should be done after diaphragm
release and restoring the best possible joint mobility in thoracic spine and thorax - derotation
breathing exercise.
p. 9. para. 3. ...is done in open and CLOSED kinematic...
DONE p. 10: Teaching patterns which correct scoliosis and all other trunk deformations
(associated with curvature) is done in open and closed kinematic chain exercise, with use of
Thera Band [40].
p. 10. Para. 2. These patterns are to be HELD until the moment when on THE
right side.
...the minor functional compensation WILL APPEAR.
'it means costal hump...' this sentence needs to be clarified, meaning not clear.
Also, cite reference 45 instead of 'bunnell'.
DONE p. 10. I changed all setence:
These patterns are to be held until the moment when on the concave side of the primary curve
(above and below this curve) the minor functional compensation will appear – less than 3-4
degree of rotation [45]
p. 10, last paragraph. ...elongation movement of THE upper trunk....
DONE p. 11: This modification of patterns will cause elongation movement of the upper trunk
and further building of compensation in lumbar spine in frontal and sagittal plane.
p. 11. para. 1. ...and MODIFIED in the apprpriate time according to clinical
CHANGES
DONE p. 11: For each child patterns should be chosen individually and modified in the
appropriate time according to clinical changes (figure 12,13,14)
p. 11. para. 2. ...the most desirable OUTCOME is correction..
DONE p. 11: In scoliosis treatment the most desirable outcome is correction of primary
structural curve in three planes.
p. 11. para. 2. ..and MORE AMENABLE.. to correction.
...THE MOST DESIRABLE WHEN, WHERE, AND IF TO DECREASE or add the
compensation...
DONE p. 11: . It is very important to be able to establish at which level the compensation is
the most desirable and more amenable to correction (the most desirable when, where, and if to
decrease or add the compensation).
p. 11. para. 3. Delete first sentence (redundant).
DONE p. 11.
p. 11. para. 3, sentence 2: FITS is a complex, asymmetrical and individual
therapy THAT can be used AT ANY AGE AND COBB ANGLE. It requires THE
child...guided by AN EXPERIENCED therapist. FITS therapy is conducted in AN
in-patient clinic and ON AN out-patient BASIS...
....to work in AN INTERDISCIPLINARY GROUP OF SPECIALISTS INCLUDING
...
DONE p.11 and 12: FITS is a complex, asymmetrical and individual therapy that can be used at
any age and Cobb angle. It requires the child to take an active part in the process of therapy
guided by an experienced therapist. FITS therapy is conducted in an in-patient clinic and on an
out-patient
basis (2-week course of treatment). It is recommended to work in an
interdisciplinary group of specialists including: physiotherapist, orthopedist and psychologist.
p. 11. last paragraph. ..this study suggest AN individually adjusted...
...preparing FOR SURGICAL INTERVENTION...
DONE p. 12: Considering trunk deformity due to scoliosis the authors of this study suggest an
individually adjusted program of exercises. There are two different types of goals: general (what
means decreasing of scoliosis angle, stabilization of scoliosis angle, preparing for surgical
intervention, clinical improvement after surgery) and specific (correction of shoulders, scapulas
and head position, pelvis derotation, facilitation of three-plane corrective breathing, facilitation
of corrected posture pattern, improvement of lumbo- pelvic stabilization.
p. 12. para. 2. ...criteria were RETROSPECTIVELY analyzed...
DONE p. 12: Out of 374 children who received treatment according to the FITS concept between
2005 and 2010, those who fulfilled the SRS and SOSORT criteria were retrospectively analyzed.
p. 14. para. 2. use 'percentage' in this context rather than 'percent'
DONE p. 15: The percentage of children in whom the Cobb angle decreased by more than 5°,
percentage of children in whom the Cobb angle was stable during the observation period (±5°)
and percentage of children in whom the Cobb angle increased by more than 5° were calculated
at follow-up.
p. 15. para. 1. The MEAN OBERVATION PERIOD WAS 2.08 YEARS (RANGE
1-5 YEARS). TWENTY-SIX patients...
DONE p. 15: The mean observation period was 2.08 years (range 1-5 years). Twenty-six
patients finished the treatment while 89 are still under treatment.
p. 19. last para. only one in eight HAS PROGRESSED TO >48 DEGREES, but
because SKELETAL MATURITY WAS REACHED, SURGERY WAS NOT
REQUIRED.
...so are at risk OF SURGICAL INTERVENTION.
DONE p. 20: In group B2 - only one in eight has progressed to > 48 degrees, but because
skeletal maturity was reached, surgery was not required. Three people from this group during
the observation period were Risser 0, so are at risk of surgical intervention (Table 11).
p. 23. discussion, first sentence. SCOLIOSIS IS A SYMPTOM THAT DEVELOPS
IN RESPONSE TO NUMEROUS CAUSES INCLUDING INJURY, INFECTION
AND GENETIC DISORDERS (CITE MOE'S TEXTBOOK AND/OR REFS
BELOW).
DONE p. 23 and p. 32: references 46, 47, 48
46. Moe's Textbook of Scoliosis and Other Spinal Deformities, Third Edition, WB
Saunders, Philadelphia.
47. Hawes MC, O'Brien JP 2006 Scoliosis 1: 3. The transformation of spinal
curvature into spinal deformity: pathological processes and implications for
treatment.
48. Hawes MC, O'Brien JP 2008 Stud Health Technol Inform 135:97-111. Review.
Scoliosis and the human genome project.
p. 23, para. 1. second sentence. IN MOST CASES, TREATMENT ADDRESSES
SYMPTOMS of scoliosis.... rather than its cause.
...proper loading OF THE LOWER LIMBS AND PELVIS BY PROPER
BALANCE...
...method meets these REQUIREMENTS...
...the patient can perform the correction patterns and THEN STABILIZE.
DONE p. 23: In most cases, treatment addresses symptoms 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 and pelvis by proper balance 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 [49, 50]. FITS method meets these requirements 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 stabilize.
p. 24. para. 1. the sentence structure here is rough, leading to confusion.
The sentence has been changed p. 24:
It is difficult to compare this manusript data to literature data, because only few papers
present detailed
p. 24. para. 2. ...properties of the brace, MORE SEVERE AND RIGID PRIMARY
scoliosis...
DONE p. 24: Possible reasons could be: stiffening properties of the brace, more severe and
rigid primary scoliosis, insufficient daily use of brace, weak proprioception or improper
approach of the child and its parents to exercising.
p. 24. last paragraph. ...to exercise and work on their HEALTH. In OUR
observation CLINICAL IMPROVEMENT occurs long...
DONE p. 25: I changed “ in our” on “in author’s”….
Clinical improvement itself motivates children to exercise and work on their health. In author’s
observation, clinical improvement occurs long before the radiological improvement can be
observed.
p. 25. para. 4. ..First, THE OBSERVATION PERIOD is limited to a mean follow-up
of 2.08 years. Many of the children DID NOT OBTAIN SKELETAL MATURITY...
THE FITS method has been IN use since 2005.
DONE p. 25: There are also weak points of this study. First, the observation period is limited to a
mean follow-up of 2.08 years. Many of these children did not obtain the skeletal maturity so
they should be subjected to further observation. The FITS method has been in use since 2005.
p. 25, para. 5. ...to what extent the children or THEIR parents were COMPLIANT
in...
DONE p. 26: Another weak point of the study is the lack of objective evaluation of the regularity
and precision in performing the ordered exercises. Some of the children exercise with their
parents while others work with therapists trained in the field of FITS concept. One cannot be
sure to what extent the children or their parents were compliant in terms of performing the
exercises or to what extent the therapists fulfilled recommendations.
p. 25, last para. FITS method WAS CORRELATED with ALTERED NATURAL
history. Further study with A LARGER GROUP and longer....
...progression was more COMMON in double scoliosis...
DONE p. 26:
1. FITS method was correlated with altered natural history. Further study with a larger group
and longer follow-up is necessary.
2. FITS therapy improved the external morphology (esthetics) of the patient in all cases.
3. Radiological progression was more common in double scoliosis than in single curves.
Level of interest: An article whose findings are important to those with closely
related research interests
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'