New SOSORT Guidelines

Possible working team
Negrini S, MD, Aulisa AG, MD, Aulisa L, MD, Circo A, MD, Papadoupoulus, CPO, Parent E, PT, Romano M, PT, Wynne J, CPO
Zaina F, MD

During the SOSORT Board Meeting in Montreal it has been decided that we will start from the already published Guidelines retrievable in the literature. There are:
• The OLD SOSORT Guidelines: they have the advantage of giving immediate choices following diagnostic therapeutic pathways, but the limitation of not being methodologically sound.
• The Italian Guidelines: they have the advantaged of being methodologically sound, but too lengthy and detailed and organized through recommendations and not immediate therapeutic pathways.
• The Polish Guidelines, derivated from the SOSORT Guidelines
We all agreed that the New SOSORT Guidelines must be evidence based. As a consequence, we have to state the strength of evidence on all recommendations we are going to give, as it has been done in the previous Italian Guidelines (look at the attached document): this is the process that is always followed in any well-domeGuidelines, and that give stregth to a Guideline.

I prepared two different methodologies for the adjourning, that include on one side the writing of the document, on the other the Consensus procedure to re-define the flow-charts of the Old SOSORT Guidelines.
Writing of the New SOSORT Guidelines
I prepared a document merging the texts from the 3 previous Guidelines (using only the Scoliosis section of the Italian Guidelines) in a unique and uniform document. The proposal is to have at first a revision in these terms:
1. Adjourning of the literature search
2. Reduction of the recommendations to those essential
3. Eventually addition of new recommendations
4. Rewriting where it is necessary

Consensus on the flow-charts
I prepared an Excel file where each of us can give his own clinical pathways according to the different classifications of scoliosis. All these kind of scheme are usually based on Cobb degrees, type of scoliosis, and bone age. In the Old SOSORT Guidelines it was proposed the Lonstein and Carlson progression formula as the guide of clinical decisions for AIS. Since there was only the old paper by these authors and this formula has not been used in any other paper, there is no real evidence in favour of its use and, if we want to be evidence-based in this new edition of the SOSORT Guidelines, I strongly suggest to leave it out. I propose to continue to use a less precise, but more evidence-based, classical scheme as the one I’m sending to you, to which we will add a full list of the prognostic formulas (byond that of Lonstein, I’m aware of at least 5 more) and the other factors known as predictors of progression that can make clinicians consider a clinical situation worst than what could appear simply looking at the Cobb degrees: this should be stated together with the scheme on which we will reach a Consensus starting with voting in the attached Excel file.

Stages of work
We will follow as always a rigorous path. Authors of the Guidelines will be those of us who will maintain the required pace and contribute to each stage.

Stage one (DEADLINE October 15th):

1. Tell me on which of the following sections of the document you would like to work directly. You must chose one section you agree to modify. According to the different proposals, we will write each other to have at least two people for each section to be modified. This is the choices you have to make
a. To be modified (the revision function has already been activated in the text to be modified, so that I will see which modifications you are proposing)
     i. Introduction (the longest, but it do not require a lot of references adjourning: just re-reading)
     ii. Assessment
     iii. Specific exercises, respiratory exercises, specific exercises during brace and surgical treatment, sport activities
     iv. Brace treatment

2. Vote on the Excel file proposing your clinical everyday scheme of work, and answer also to what are your aims when you work (take a look on the other sheets to what is reported in the Old SOSORT and Polish Guidelines, as well as to an example of the Aim of treatment I proposed in a previous paper)

3. Approve or propose changes to the following “Strength of evidence” table (slightly modified from the previous Italian Guidelines table) to be inserted at start of the new Guidelines document. In practical terms the following table state that we will give the strength of evidence according to the available literature. Where we will not have any available evidence, but it is a recommendation about something we everyday do, or strongly believe important, we will vote by email and then in Barcelona according to the usual SOSORT Consensuses process and, if agreement will be over 70% these recommendations will be included in the final published document, otherwise it will be left behind

Scientific evidence Meaning
     A Very strong More than 1 randomized controlled study with comparable results
     B Strong At least 1 randomized controlled study with results comparable with other published studies
     C Fair No randomized studies but various controlled studies with comparable results
     D Poor 1 controlled nonrandomized study or various studies with divergent results
     E1 Strong scientific consensus among conservartive specialists Approved by SOSORT members through the describet  Consensus Process with more than 90% of votes
     E2 Fair scientific consensus Approved by SOSORT members through the describet Consensus Process with 70 t0 89% of votes

Stage two (DEADLINE November 30th):

Once everyone will know on which part he will have to work, we will proceed as follows:
4. Sections to be modified (one per person): everyone of us will work by himself on the part he must modify freely. The “revision” function has already been activated, so that your changes will be automatically highlighted
a. changing the text,
b. adding what he feels important including
     i. new text,
     ii. new references (a new and adjourned search MUST BE DONE and references MUST BE ADDED),
     iii. new recommendations
c. voting for the already existing recommendations according to the table I prepared in the text
d. approve of modify the strength of evidence according to the literature adjourning

Stage three (DEADLINE January 8th):
5. I will prepare a final draft document summarizing all your proposals. Moreover the premises and possible conclusions will be proposed

Stage four (DEADLINE February 28th):
6. Go through the draft document and write all modifications you propose to the final text, as well as giving your final votes on recommendations. Again, the “revision” function will be activated, so that your changes will be automatically highlighted

Stage five (DEADLINE March 31st):
7. Preparation of our final proposal by me and
8. Collection of suggestions from the SOSORT Board and Advisors

Stage six (DEADLINE April 30th):
9. Preparation of the final document to be sent to SOSORT members for voting, and for discussion during the Barcelona SOSORT Meeting