The history of scoliosis therapy can be traced all the way back to ancient Greece.
More specifically, scoliosis treatment has its roots in the 5th century BC and one man in particular: Greek physician Hippocrates (c. 460 – 370 BC).
Who was Hippocrates?
The mid-to-late 5th century BC was a turbulent time for the Hellenic people.
From 431 to 404 BC, the country was entrenched in a titanic war between the Delian League of Athens and the Peloponnesian League of Sparta. Meanwhile, Athens was also suffering from a devastating plague, which wreaked havoc in the city periodically between 430 and 426 BC.
In short, it was a dark time for Greece. But this was also the period that gave us Hippocrates, often referred to as the ‘father of medicine’.
Born on the island of Kos around 460 BC, Hippocrates was the son of a physician and is believed to have learned the trade from his father. Among his long list of medical achievements, Hippocrates is heralded as the first person to theorise that diseases and ailments were caused by environmental factors and not the result of superstition or an act of the gods.
He’s also the namesake of the ‘Hippocratic Oath’: the pledge taken by doctors declaring their moral and ethical obligations to their patients as medical practitioners.
Hippocrates and Scoliosis
Separating medicine from religion would probably have been enough on its own to secure Hippocrates’s place in history, but his achievements go far beyond that. Notably, he was also a key figure in the history of spinal treatment, and he is believed to have been the first physician to focus on the anatomy and pathology of the human spine.
Through his revolutionary study of the spinal structure and vertebrae, Hippocrates’s work led to the pioneering identification of many spine-related diseases – including scoliosis.
Hippocrates is commonly credited as the person who coined the term ‘scoliosis’ and the first to try treating this condition.
Hippocratic Scoliosis Treatment
From his unprecedented study of orthopaedics, Hippocrates created three pieces of equipment to treat spinal ailments: namely the Hippocratic ladder, the Hippocratic board, and the Hippocratic bench.
Hippocratic Ladder
Intended to reduce spinal curvatures, the Hippocratic ladder treatment required the patient to be elevated and tied to the ladder upright or head down (depending on the where the curvature lay). The patient would then be shaken on the ladder, with the gravitational pull theoretically straightening the spine.
Hippocratic Board
Similar to the ladder, treatment via the Hippocratic board involved the patient being tied to the board; however, this time, the patient was required to be prone, lying face down and flat. The physician would then apply pressure to the affected area of the spine using a hand, foot, or even the entire weight of the body.
Hippocratic Bench
Also known as the Hippocratic scamnum, the bench technique saw the patient lie face down on a bench similar to the board technique above. A smaller wooden board was then inserted into a pre-made hole in the wall, leaving the plank protruding out above the patient’s back. An assistant would then apply pressure on the end of the plank while the physician manoeuvred the board along the body.
Like many ancient treatments, these techniques naturally seem archaic, even barbaric by today’s standards. Nevertheless, these apparatuses – based on the principles of axial traction and three-point correction – were hugely innovative at the time, and they had a profound influence on the direction of spinal treatment to follow.
Luckily, medical science has come a long way since the days of Hippocrates, and there are now a variety of comfortable and safe non-surgical scoliosis treatments available. At Scoliosis SOS, our team of friendly, skilled therapists offer patients specialised scoliosis treatment that’s specifically designed to enhance your quality of life.
Our Treatment Method Contact Scoliosis SOS
Erika Maude, our Clinic Principal, delivered a scientific presentation to the 2019 SOSORT conference in San Francisco last week.
Watch the video below to see her presentation in full.
Video Transcript
Erika Maude: Hello everybody, and thank you for having me along today. This is a continuation of the research that my colleague Jason Black first presented in Lyon two years ago looking at the cost-effectiveness of exercise therapy for adults with scoliosis.
Introduction – Health Economics
Adult patients with idiopathic scoliosis have been shown to present with impaired health-related quality of life. Therefore, in health systems globally, a key objective of treatment is to improve quality of life whilst maintaining cost-effectiveness. The cost-effectiveness of PSSEs [physiotherapeutic scoliosis-specific exercises] has not been researched, and thus conclusions about whether or not they are a viable economic alternative to surgery or bracing for healthcare systems cannot be made.
In the UK, the National Health Service offers spinal fusion surgery as the only treatment for adults with idiopathic scoliosis. They treat about 360 cases per year, each costing £24,853. Under cost-utility analysis, cost-effective analysis estimates the cost of treatment. It is used to inform funding decisions based on the benefit of treatment versus how much it costs. It requires extrapolation of data because it estimates the lifetime benefits of treatment.
Introduction – QALYs
The primary outcome of cost-utility analysis is the cost per quality-adjusted life year, or ‘QALY’ for short – otherwise known as the incremental cost-effectiveness ratio, which I’ll come onto a bit more in a moment. QALYs analyse both the quality and the quantity of life years, where (rather morbidly) 0 equals death and 1 equals perfect health. QALY are accumulative, and thus a 0.2 QALY improvement lasting for 5 years equals 1 QALY for the patient.
The ICER [incremental cost-effectiveness ratio] is calculated as the difference in the expected cost of Intervention A compared to Intervention B divided by the difference in the expected QALYs produced by Intervention A and Intervention B. Generally, it is considered that the interventions costing the UK’s National Health Service less than £30,000 per QALY gained are deemed to be cost-effective.
Introduction – EQ-5D
The EQ-5D is the measure preferred by the UK’s National Institute of Clinical Excellence [NICE] for comparing cost-effectiveness. It’s a descriptive system, and it defines health-related quality of life in terms of five dimensions:
- Mobility
- Self-care
- Usual activities
- Pain and discomfort
- Anxiety and depression
Responses to each of these dimensions are divided into three levels (1st, no problems; 2nd, some to moderate problems; and 3rd, severe to extreme problems), thus generating a total of 243 possible health states. On the left is an example EQ-5D form, which can only be used with licensed permission.
Objectives
The aim of this study was to explore the cost-effectiveness of physiotherapeutic scoliosis-specific exercises for adult patients with idiopathic scoliosis using an intensive, group-based therapy approach.
Method
183 consecutively-recruited UK-based adult patients (with an average age of 38.5 years at the start of treatment) attending the Scoliosis SOS Clinic in London for intensive ScolioGold treatment filled out the EQ5D5L questionnaire at 5 different time points:
- Before treatment
- After treatment
- 6 months check-up
- 12 months check-up
- 18 months check-up
The EQ-5D results were then converted into QALYs using assumptions about the duration of treatment effect. A linear regression model was then used to statistically analyse the results.
Results – Response Rate
Due to the method of data collection, consecutive nature of patient recruitment, and time limitations imposed by the 3-year EQ5D5L licence, 100% of the participants completed the questionnaire pre-treatment, 91% immediately post-treatment, 68% at their 6-month check-up, with 51% at both 12- and 18-month check-ups.
Results – EQ5D5L Scores
Before treatment, the average EQ-5D score was 0.773, and immediately after treatment, this increased to an average of 0.881. At 6 months, the average was 0.862, and at both 12 and 18 months check-up, the average was maintained at 0.863. All of these changes were statistically significant.
Results – Calculation of QALYs
Although patient scores were statistically much improved at 12 and 18 months post-treatment, due to the fewer number of patients who reached the later time points, reliable data was only available up to 6 months following treatment, and therefore an assumption on the persistence of the treatment effect is required for later time points. To look at both extremes: assuming that the treatment benefit ended after just six months, additional QALYs were 0.045, which means that the ICER would be £90,000 per QALY. However, assuming that the treatment effect continued for 43.8 years (the average life expectancy of the patients in this study), then additional QALYs were 3.899, meaning the ICER would fall to just £1,000 per QALY.
Therefore, to meet NICE’s requirements for health economics, the effects of treatment would need to persist for 1.5 years.
Conclusion
In conclusion, EQ-5D results improved with PSSE in adult patients with idiopathic scoliosis. If the treatment effect of the PSSEs persists for only 1.5 years, it is expected to be cost-effective in UK-based adults. Further long-term research is required to start planning for PSSE to become available within national healthcare services; with publication of these results, we hope to highlight that the input of physiotherapy in this patient group should warrant funding.
Limitations
We are aware that there are several limitations to this study, namely lack of a control group, limited long-term follow-up, and no data on cost savings from exercise therapy.
Thank you for listening.
More Scoliosis Research > About Erika and the Team >
“Traditionally, scoliosis has been considered to be a disease affecting bone, cartilage, or neuromuscular activities. We were surprised to find an immune response associated with idiopathic scoliosis.”
Idiopathic scoliosis is a condition that affects people all over the world, yet the underlying cause is still unknown. Researchers have made great progress in recent years, however – we’ve explained previously on this blog that zebrafish can be very useful when researching scoliosis and other congenital defects that occur in humans, and scientists at The Hospital for Sick Children have been examining zebrafish to try to identify factors that contribute to the onset of idiopathic scoliosis.
While looking for abnormal genes or genetic pathways that could be responsible for idiopathic scoliosis, the researchers instead noticed that immune cells liked to inflammatory conditions had accumulated around the area where the spinal curvature occurred. Using genetic tools, they found that stimulating pro-inflammatory signals in the spines of zebrafish could induce idiopathic scoliosis.
Interestingly, the team were also able to demonstrate that blocking these signals using NAC (an over-the-counter supplement that has anti-inflammatory properties) reduced the severity of scoliosis in the zebrafish. If these findings can be applied successfully to humans, then these Toronto-based scientists may have discovered a treatment that is less invasive than some of the treatments currently available to people with scoliosis.
Image source: advances.sciencemag.org/content/4/12/eaav1781
The research team are now planning to explore the genetic causes of idiopathic scoliosis in human patients and attempt to determine whether inflammatory signals like those found in the zebrafish can be identified and proven to accelerate the onset or progression of spinal curvature.
Read the Research Article > How We Treat Scoliosis >
