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Generally speaking, the importance given to usual clinical and radiographic measurements decreased, while that given to QoL-related issues including Aes and Dis increased. We performed a multifaceted study that included a bibliometric analysis, a questionnaire, and then a careful Consensus reaching procedure between experts in conservative treatment of scoliosis SOSORT members , to analyse an unusual topic in the literature, such as the motivation for treatment, that is in any case undoubtedly strictly related to everyday clinical behaviours.
Looking in general to the results, it seems that in the literature data on radiographic, but also clinical outcome criteria, prevail, while they were considered of the lowest importance in the answers to the questionnaire, and even lower after the Consensus Meeting. These results presumably reflect the actual absence of means to measure this outcome, that was encountered by some authors who anyway produced very interesting studies , and the fact of being compelled to rely only on simple observation and individual judgement[ 42 ]: there have been some proposals in the literature, including questionnaires[ 36 , 39 , 43 - 45 ], and high-tech high-cost instruments [ 46 - 50 ], but none reached any kind of a consensus nor is actually extensively used in everyday clinical practice.
Today, the SRS questionnaire[ 43 , 51 - 53 ], that includes questions on this topic, even if mainly in a psychological perspective, has been validated in different languages [ 54 - 57 ] and could be useful in the future to have valuable data. Aes is considered when both surgical[ 42 , 45 , 46 , 58 ] or conservative[ 38 , 59 - 63 ] treatment results are reviewed; wearing of braces can give rise to Aes concerns, that have been faced in the literature[ 62 , 64 ]; moreover, the implication of Aes on PWB in scoliosis patients has been thoroughly discussed[ 44 , 65 , 66 ].
Surgical treatments have been proposed for cosmetic appearance [ 67 - 69 ]. In summary, Aes is a priority one reason to treat our patients: results can be achieved both with bracing and surgery, but also with exercises [ 20 ]. QoL is considered of primary and high importance by SOSORT members, with an increase of rank after Consensus, while in the literature this outcome is almost neglected 1. Data on QoL in the literature appear strictly related sometimes even confused with data on Dis, but this is not true only for scoliosis; in fact this outcome is almost new in the field of spine research [ 70 ] and should be better understood and deepened.
To check QoL, disease-specific scales have been applied, like the SRS[ 43 , 51 - 53 ], but also Oswestry and Roland-Morris[ 37 , 38 , 71 ], even if these should be regarded mainly as Dis scales, or general health evaluations for children[ 72 ] and adults [ 73 - 76 ] ; other scales have rarely been used[ 37 - 39 , 72 , 76 ].
New instruments should be developed, and already well established ones should be used even if they are usually prepared for adult populations. Dis is considered so important by the general community that since the World Health Organisation, with the aim of better understanding health conditions, proposed a companion classification of the International Classification of Diseases ICD , named International Classification of Impairment, Disability and Handicap ICIDH [ 78 , 79 ]; it became the conceptual basis of the medical specialty of Rehabilitation, and it has recently been totally revised with the new International Classification of Function ICF [ 80 - 82 ]: this means that Rehabilitation in general, but also physicians looking at scoliosis patients as persons with an health problem, cannot neglect Dis.
It can be measured generally or in a disease-specific way, but only recently a scoliosis specific questionnaire has been developed by SRS [ 43 ]. The literature refers to Dis and scoliosis mainly while evaluating BP[ 71 , 83 - 85 ], because in the field of BP Dis evaluation is a far more established tool. Looking only at deformity, even if actual and future Dis are well understood as an outcome both by patients and parents[ 44 ] , there is very few literature: curiously, brace wearing Dis[ 77 , 86 , 87 ] is considered, while the immediate effect of being fused is not at least, we did not find any study ; long term studies refer both to previous surgery[ 37 , 39 , 74 , 75 , 88 ] and bracing[ 38 , 39 ].
Patients with severe untreated curves in the long-term reveal some Dis, even if not measured with disease-specific scales[ 36 ]. After 20 years, treated patients, both braced and fused, have been considered to have almost the same function as matched controls[ 37 , 38 ], but looking at the data it appears that physical functioning, social activities more in the surgically-treated than in the braced group and work sick-leave are reduced, while general health only in the operated ones[ 39 ].
Dis should be better addressed in the future also by the scoliosis treating community, with more disease-specific scales and looking at short as well as long term results. It is definitively a good reason to treat our patients. In the literature BP is an important issue associated with idiopathic scoliosis 8. Papers are mostly split in two between adulthood Risk factors include gender women , pregnancy, fatigue[ 89 ], age, degree of scoliotic curvature, lumbar curves[ 90 ], smoking[ 91 ], and not pre-surgery characteristics, degree of surgical correction, distal level of fusion, degree of Dis[ 84 ].
Also, braced patients have more BP and disk degeneration than controls[ 38 ]. When compared to braced patients, fused ones have a similar Oswestry score[ 39 ], but a higher limitation of social activities partially due to BP[ 39 ].
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These papers lack a control group, but their results are similar to the actual data on BP in children[ 96 , 97 ]. Risk factors during adolescence are Risser sign, gender, pelvic tilt and bracing [ 95 ], particularly progression during brace treatment[ 94 ], but not severity of scoliosis[ 95 ] or other clinical data[ 93 ]. In summary, BP is a good reason to treat our patients on a literature basis looking at adulthood, while, as far as we know today, it is not immediately necessary in adolescents. Presumably, exercises are the best treatment of actual BP, while bracing can have a detrimental effect; conservative treatments seem to have better results on the future than surgery.
PWB was not included in the first questionnaire, while after Consensus its importance was considered as primary and the priority ranked significantly fifth according to SOSORT members. Some non systematic reviews have been dedicated to PWB [ 66 , 99 ]. In a large population-based case-control study 34, adolescents, with scoliosis scoliosis showed to be an independent risk factor for suicidal thought, worry and concern over body development, and peer interactions, with gender differences[ ].
PWB has been evaluated during brace treatment [ 64 , , ]: the high negative psychological impact of Milwaukee brace has been pointed out[ 65 , , ], in particular when compared to TLSOs[ 77 ]. Curiously, the more the patients experienced sleeping problems, the less they used the brace[ ]. PWB predicts satisfaction with final results of surgery[ 58 ] and it is used also to evaluate surgery[ 39 , ] and bracing [ 39 , 65 ] in the long term.
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Scoliosis has been considered as associated with eating disorders, which were not measured[ ]. PWB is very important to be evaluated in children as well as in adults: bracing and surgery have a high impact, but also exercises performed for years can have it. While lowering this impact is a key for success, this outcome cannot be neglected in research studies.
PiA is a rather important primary outcome criterion and is present in as far as 4. In the past there was the general belief that after the end of growth there was no progression of scoliosis[ 33 ]. Many studies beginning from 's begun to show that this was not the case[ 33 , 36 , 89 , ]. Obviously PiA correlates with all other outcome criteria and, as far as we know today, it is reasonable to consider this as a primary outcome criterion. We were not able to create a valid Medline search strategy for this outcome criterion, so we lack the data on the literature; anyway, in this respect we could consider those coming from issues that could need a treatment if they appear, such as reduced BF or BP or PiA; the same could be done looking at the data from natural history[ 36 ] and long term results of treatment [ 37 - 39 ].
According to those data and our results, NTA seem to be a good reason to treat our patients. The outcome "Exercise efficiency", added after Consensus, refers to the same bibliographic references. BF has been used as a means to evaluate patients before and after surgery[ , ], and even the type of surgery to be performed[ ], but it has also been evaluated during bracing, both while wearing it [ - ] and in the long term[ ].
Many studies focused on exercises and rehabilitation means to improve this function in adolescent idiopathic scoliosis [ - ], while the most related to biomechanics and physiologic studies on pulmonary function in patients[ , ]. Two cornerstone papers have been published by Pehrsson and Nachemson. They found that in the long term mortality for pulmonary deficit is increased with respect to the normal population only in infantile and juvenile scoliosis, not in the adolescent type [ - ], even if subgrouping could have decreased the power of the statistical analysis.
In fact, in the 50 year natural history study by Weinstein, patients with severe thoracic curves have a decreased pulmonary function, with an increased risk of shortness of breath[ 36 ]. Sponseller raised some questions on the possibility that there may exist a correlation between pulmonary function and mortality since at least 4 persons in Weinstein's series could have died because of that and the cause for too many others is unknown[ 11 ]. Long-term data on braced and surgically treated comparable patients are actually lacking.
In summary, BF seems to be a good reason to treat our patients, even if the literature does not fully support this idea at least for adolescent idiopathic scoliosis and only when looking at mortality data, not when looking at pulmonary function and well-being. The universally recognized Gold Standard of measurements for scoliosis, SCD to measure radiographic lateral flexion of the spine, ranked first in the literature, with as far as Looking at the literature, it is not possible to go in great details, because papers with these outcomes relate to almost all possible topics in idiopathic scoliosis.
The hump increased to the actual 36 mm thoracic and 24 mm lumbar in 50 years[ 36 ]. In summary, all radiographic and clinical data that are considered as so important on a literature basis have been rejected in a corner by SOSORT members, excluding the particular cases of SCD presumably because of the well established literature tradition and RH presumably because of its high Aes impact. In fact, we have always to split outcomes in primary and secondary, being the first ones those that are directly perceived by patients and that change their life, and the second ones those that give rise to the former.
Looking in this way, all radiographic and clinical data are secondary, because they are clues to possible future or even actual BP, Dis, reduced Aes, BF and QoL. Anyway, even if secondary, they for sure are important outcomes, because easily measurable. Summary of radiographic and clinical results reported in the three studies by Danielsson and Nachemson.
All these outcome criteria have been added in the final questionnaire according to first submission and Consensus discussion. The posture-related outcome included "Self control of posture" and "Sensory motor integration of the corrective ideal pattern"; the balance-related outcome included "Balance", "Improved processing of vestibular input" and "Equality of weight bearing"; the movement-related outcome included "Movement of the vertebral column sagittal plane " and "Improved body motor awareness and motor learning skills".
In the literature 6. Posture is the biomechanical representation of a neurological function in which balance and movement are fully included. Posture and balance have been widely considered in studies on aetiology and pathogenesis of scoliosis [ - ], where scoliosis is considered as a neurological disease with a mechanical representation. Studies on these aspects can be split in those mainly neurological[ - , - ] and mainly biomechanical, that evaluated standing position[ , ], sitting [ , ], but also gait [ - ] or the relation with backpacks[ , ].
Balance is usually evaluated through force platforms[ - , , - ], while movement requires high-cost complex instruments[ - , ]. The evaluation of posture is thought to be made through x-rays, not considering that posture is dynamic while x-rays are static: anyway, surface measurements [ 46 - 50 ] are not easily usable in clinics yet; an interesting x-ray approach to posture is comparing supine and standing for SCD [ - ], but also PD[ ]. Posture, balance and movement can be increased only with rehabilitation through exercises. Surgery abolishes movement, creates a correct position, but eliminating the dynamic intrinsic to posture, while balance can be impaired.
Bracing too impacts negatively on movement and balance, while there could be a positive neurological impact contributing to posture change. The outcome "Knowledge and understanding of scoliosis in general and their specific pattern" was added in the final questionnaire according to first submission and Consensus discussion. In spinal rehabilitation the importance of cognitive-behavioural approaches is very well known, mainly in BP. In scoliosis, coping strategies and cognitive-behavioural approaches have not been widely studied, even if there are researches mainly on surgery [, , , , , ], but also on bracing [ ] as well as on exercises [ 66 ].
This outcome is important also because it relates to compliance, and should be better studied in the future. Why do we treat? What do we want for our patients? In the literature, outcome criteria driven by the contingent treatment needs or the possibility to have measurement systems even if it seems that usual clinical and radiographic methods are given much more importance than Dis or QoL instruments prevail: these results could be biased by the method used, that did not include a complete analysis of each single paper, even if the authors' knowledge of the literature and the international Meetings on the topic confirm the idea that we are used to thinking much more to how to do then to why we do[ 13 ].
Experts in conservative treatment SOSORT members give importance to a wide range of outcome criteria, in which clinical and radiographic issues apart from SCD, that in any case ranked in a mid position have the lowest importance. It should be very interesting to propose the same methodology in a sample of high level experts in surgical care, to verify the answers to the same questions.
Today, research recommendations should be made to develop valid, reliable and possibly low-cost instruments to evaluate Aes, PWB, posture, balance and movement, while existing QoL and Dis scales should be improved. Moreover, on the basis of our results, we advocate a multidimensional, comprehensive evaluation of scoliosis patients, to gather all necessary data for a complete therapeutic approach, that goes beyond x-rays to reach the person and the family. National Center for Biotechnology Information , U. Journal List Scoliosis v. Published online Apr Author information Article notes Copyright and License information Disclaimer.
Corresponding author. Stefano Negrini: ti. Received Dec 14; Accepted Apr This article has been cited by other articles in PMC. Abstract Background Medicine is a scientific art: once science is not clear, choices are made according to individual and collective beliefs that should be better understood. Aim of the study To verify the philosophical choices on the final outcome of a group of people believing and engaged in a conservative treatment of idiopathic scoliosis. Methods We performed a multifaceted study that included a bibliometric analysis, a questionnaire, and a careful Consensus reaching procedure between experts in the conservative treatment of scoliosis SOSORT members.
Results The Consensus reaching procedure has shown to be useful: answers changed in a statistically significant way, and 9 new outcome criteria were included. Discussion In the literature prevail outcome criteria driven by the contingent treatment needs or the possibility to have measurement systems even if it seems that usual clinical and radiographic methods are given much more importance than more complex Disability or Quality of Life instruments. Conclusion We treat our patients for what they need for their future Breathing function, Needs of further treatments in adulthood, Progression in adulthood , and their present too Aesthetics, Disability, Quality of life.
Introduction Medicine is art: a scientific art, but always art [ 1 , 2 ]. Systematic literature search First, we aimed at identifying all papers that could have faced the philosophical topic of our paper. Table 1 Pre-Meeting questionnaire. Needs of further treatments in adulthood Back Pain Perdriolle degrees radiographic rotation Progression in adulthood Quality of life Rib hump Scoliosis Cobb degrees radiographic lateral flexion.
Open in a separate window. Table 2 Bibliometric analysis: number and percentage of papers in Medline on idiopathic scoliosis related to the outcome considered, and search strategy used. Outcome Word used for Medline search combined with idiopathic scoliosis Papers found Number Percentage Scoliosis Cobb degrees radiographic lateral flexion Cobb Questionnaire preparatory to the Consensus Meeting The questionnaire has been prepared through a Consensus between the authors of the study.
Consensus Meeting A summary document[ 41 ], prepared by the authors and containing the results of the questionnaire, was sent out by e-mail to all participants 15 days before the Consensus Meeting to prepare discussion. Final questionnaire According to the results of the Consensus Meeting, a final questionnaire was prepared and proposed to the participants to the Consensus Meeting. Statistical analysis All data were managed using Microsoft Excel Results Literature search For the purposes of this article we considered papers, while the bibliometric analysis considered a base of papers published in Medline.
Table 3 Priorities for each outcome, listed from the highest to the lowest in rank, pre and post Consensus Meeting. Table 4 Motivation for the choice of each outcome, listed according to the median of responses. Table 5 Importance given to each outcome, listed according to the median of responses. Discussion We performed a multifaceted study that included a bibliometric analysis, a questionnaire, and then a careful Consensus reaching procedure between experts in conservative treatment of scoliosis SOSORT members , to analyse an unusual topic in the literature, such as the motivation for treatment, that is in any case undoubtedly strictly related to everyday clinical behaviours.
Progression in Adulthood PiA PiA is a rather important primary outcome criterion and is present in as far as 4. Radiographic and clinical data The universally recognized Gold Standard of measurements for scoliosis, SCD to measure radiographic lateral flexion of the spine, ranked first in the literature, with as far as Table 6 Summary of radiographic and clinical results reported in the three studies by Danielsson and Nachemson.
Treatment Surgery Brace Controls Years follow-up The posture, balance and movement related outcomes All these outcome criteria have been added in the final questionnaire according to first submission and Consensus discussion. Cognitive outcome The outcome "Knowledge and understanding of scoliosis in general and their specific pattern" was added in the final questionnaire according to first submission and Consensus discussion. Conclusion and research recommendation Why do we treat?
References Lawn B. L'arte perduta di guarire. Italian Edition. Milano, Garzanti Editore; Milano, Adelphi Edizioni; Evidence-based medicine. From best evidence to best practice: effective implementation of change in patients' care. The art and science of clinical knowledge: evidence beyond measures and numbers. Grey zones of clinical practice: some limits to evidence-based medicine. Pediatr Rehabil. Surgical treatment of idiopathic adolescent scoliosis.
Spinal deformity--adolescent idiopathic scoliosis. Nonoperative treatment. Sizing up scoliosis. Italian guidelines on rehabilitation treatment of adolescents with scoliosis or other spinal deformities. Eura Medicophys. Scoliosis Making Clinical Decisionsed. Louis, C. Mosby Company; Idiopathic scoliosis. Screening for scoliosis. Bracing and screening --yes or no? J Bone Joint Surg Br. A statistical comparison between natural history of idiopathic scoliosis and brace treatment in skeletally immature adolescent girls.
An examination of long-term results. Health and function of patients with untreated idiopathic scoliosis. The use of exercises in the treatment of scoliosis: an evidence-based critical review of the literature. Physical exercises as a treatment for adolescent idiopathic scoliosis. A systematic review. Effect of conservative management on the prevalence of surgery in patients with adolescent idiopathic scoliosis. Conservative management in patients with scoliosis--does it reduce the incidence of surgery? Stud Health Technol Inform. To brace or not to brace: the true value of school screening.
Incidence of surgery in conservatively treated patients with scoliosis. The father of spine surgery. Scoliosis at less than 30 degrees. Properties of the evolutivity risk of progression Spine. The Milwaukee Brace.
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Baltimore, The William and Wilkins Company; Les deformations du rachis. Paris, ; Controversial issues in spinal deformity surgery. J Pediatr Orthop. Scoliosis and other deformities of the axial skeleton. Boston, Little, Brown and Company; Natural history. Long-term follow-up of pediatric orthopaedic conditions. Natural history and outcomes of treatment. J Bone Joint Surg Am.
Health and function of patients with untreated idiopathic scoliosis: a year natural history study. Back pain and function 23 years after fusion for adolescent idiopathic scoliosis: a case-control study-part II. Back pain and function 22 years after brace treatment for adolescent idiopathic scoliosis: a case-control study-part I. Health-related quality of life in patients with adolescent idiopathic scoliosis: a matched follow-up at least 20 years after treatment with brace or surgery. Eur Spine J.
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Childbearing, curve progression, and sexual function in women 22 years after treatment for adolescent idiopathic scoliosis: a case-control study. What we want to obtain and to avoid for our patients. Do you see what I see? Looking at scoliosis surgical outcomes through orthopedists' eyes. The reliability and concurrent validity of the scoliosis research society patient questionnaire for idiopathic scoliosis. Parents' and patients' preferences and concerns in idiopathic adolescent scoliosis: a cross-sectional preoperative analysis.
Analysis of patient and parent assessment of deformity in idiopathic scoliosis using the walter reed visual assessment scale. Rasterstereographic back shape analysis in idiopathic scoliosis after anterior correction and fusion. Clin Biomech Bristol, Avon ; 18 :1—8.
Functional classification of patients with idiopathic scoliosis assessed by the Quantec system: a discriminant functional analysis to determine patient curve magnitude. Quantifying the cosmetic defect of adolescent idiopathic scoliosis. Back shape in brace treatment of idiopathic scoliosis.
Clin Orthop Relat Res. ISIS scanning: a useful assessment technique in the management of scoliosis. Trunk deformity correction stability following posterior instrumentation and arthrodesis for idiopathic scoliosis. Discrimination validity of the scoliosis research society patient questionnaire: relationship to idiopathic scoliosis curve pattern and curve size. Scoliosis research society patient questionnaire: responsiveness to change associated with surgical treatment.
Reliability of the Scoliosis Research Society Patient Questionnaire Italian version in mild adolescent vertebral deformities. The Spanish version of the SRS patient questionnaire for idiopathic scoliosis: transcultural adaptation and reliability analysis. Adolescents undergoing surgery for idiopathic scoliosis: how physical and psychological characteristics relate to patient satisfaction with the cosmetic result.
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Long-term follow-up of female patients with idiopathic scoliosis treated with the Wilmington orthosis. The effect of a modified Boston brace with anti-rotatory blades on the progression of curves in idiopathic scoliosis: aetiologic implications. Radiological and cosmetic improvement 2 years after brace weaning--a case report.
A new orthotic device in the non-operative treatment of idiopathic scoliosis. Med Eng Phys. Long-term results of Boston brace treatment on vertebral rotation in idiopathic scoliosis. Vertical transmission of the hip rolls due to wearing of TLSO for scoliosis. J Spinal Disord. Long-term psychosocial characteristics of patients treated for idiopathic scoliosis. Developmental psychological aspects of scoliosis treatment. Costoplasty in adolescent idiopathic scoliosis. Objective results in 55 patients. Surgery is performed for cosmetic reasons. Costectomy as the first stage of surgery for scoliosis.
Assessment of back-related quality of life: the continuing challenge. Low back pain after spinal fusion and Harrington instrumentation for idiopathic scoliosis.
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