School Screening for Scoliosis
Valuable or a HUGE waste of resources?
If scoliosis screening in school is ineffective, unreliable, has no real impact on the treatment or ultimate patient outcomes…. why are over half our states still wasting time and money to continue to pretend it has value?
Or…. Are there effective early stage treatment systems that can dramatically reduce scoliosis curve progression through specific scoliosis exercise programs? If so, why are schools specifically prohibited from referring students to anyone who offers an early stage treatment? Why are most of these exercise based protocols lacking in peer reviewed basic research?
Since the 1960s early detection of idiopathic scoliosis has become an expanding cause in the United States. Screening for scoliosis began in Minnesota in 1963 and in 1973 the state of Minnesota enacted a statewide voluntary program. The American Academy of Orthopedic Surgeons currently recommends screening girls at ages 11 and 13, and screening boys once at 13 or 14 years of age. The American Academy of Pediatrics has recommended scoliosis screening with the Adam’s forward bending test (see figure above) during routine health visits at 10, 12, 14 and 16 years of age, although evidence does not exist to support these recommendations. The 2007 Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) Consensus Paper on School Screening for Scoliosis that was discussed at the 4th International Conference on Conservative Management of Spinal Deformities states that, as of 2003, 21 States have legislated school screening. Of the remaining states, 11 recommend school screening without legislation and the rest either have volunteer screenings or recommend not to conduct screening in the schools.
They offer a few insights into this discrepancy. First, many programs have fallen out of favor because of “over-referral of adolescents with insignificant curves” which has been the source of much controversy for this issue. However, they also specify that there is a lack of research on the outcome of treatment as a result of early detection.
In 1996, the U.S. Preventive Services Task Force stated that “there is insufficient evidence for or against routine screening of asymptomatic adolescents for idiopathic scoliosis” but in 2004, they recommended against routine screening of asymptomatic adolescents for idiopathic scoliosis. Their reasoning: 1) that over-referrals add considerably to the costs of the health system 2) the belief that scoliosis patients have no greater danger for significant lung problems than the general population until their curves reach 60 – 100 degrees, making early screening unnecessary and 3) the standard medical approach to early treatments will not prevent curve progression or surgery. As stated in the SOSORT paper, this change was not due to new research but by changing the method of rating the existing evidence.
The SOSORT paper goes on to state that “the policy not to screen because of lack of cost effectiveness is based on the obsolete assumption, derived from an early study that surgery is the only proven treatment option and the cited study does not justify scientifically this conclusion”. The paper continues suggesting that intensive in-patient exercise programs can alter the symptoms of scoliosis and that the rate of progression can be reduced significantly. Where conservative treatment is available at a high standard the incidence of surgery can be significantly decreased. They also reference articles that suggest school screening does reduce the number of surgically treated idiopathic scoliosis patients and emphasize the importance of recognizing the voluntary basis of the program, in order to reduce the financial cost. They suggest that these findings support the idea that school screenings are a justified means of detecting mild and reversible spinal curvatures so that they can be treated before they develop into spinal deformities with lifelong consequences.
They go on to address the dissimilarity and inconsistency of these programs as being one of the major hindrances of research:
“In the USA, not all legislated screening programs are the same today. We can not take a broad-brush approach to whether or not a state has screening, but must look further at screening protocol details, including age and gender screened, screener education and support, scoliometer usage, reporting and follow-up methodologies etc, to evaluate the effectiveness of a program.”
Typical screening tests are not accurate and depend too much on the skill of the examiner. Also, there is no national standard, which makes comparative research difficult and therefore difficult to gauge what screening programs should be improved or done away with. In addition, some schools have one nurse for every 700 students and others one nurse for 2000 students and use health aides and volunteer parents to perform scoliosis screening. In New York, the nurses are mandated to only refer the child back to a pediatrician or to an orthopedist, and are legally prevented from referring to anyone else who may be offering an early stage corrective program.
A 2011 study, that was conducted with 4000 Norwegian children who were screened for scoliosis at age 12, found:
“….acceptable sensitivity and specificity and low referral rates…age of 12 years only was not effective for detecting patients with indication for brace treatment. Screening should probably be initiated one year earlier for girls and one year later for boys, or be conducted more than once.”
This study used community nurses and physical therapists who completed educational courses to improve their knowledge of AIS, the Adam’s Forward Bending Test and measurement of any rib arch using a scoliometer.
The goal of scoliosis screening is to detect scoliosis at an early stage when the deformity is likely to go unnoticed and there is an opportunity for a less invasive method of treatment or less surgery. School screening programs aim to detect surface deformity. They do not attempt to predict which curves will progress to a type that will require treatment. Therefore, children with mild to moderate curves who are genetically predisposed to large curves might be diagnosed late, when curve progression has already accelerated to a level beyond 30 degrees, making conservative management more challenging.
The recommendations for improvement expressed were: redefinition of what actually constitutes a ‘significant’ scoliosis for screening, diagnostic, and outcome purposes; selective screening of only immature females; the use of objective referral criteria; and re-screening patients rather than referring borderline cases .
Screening programs must have defined referral criteria and “treatment-eligible” degrees of scoliosis, in order to judge their effectiveness. The ideal criteria will minimize both the number of referrals and the number of false-negative examinations.
Universal screening is useful for producing information on scoliosis that can contribute to future research. Not only that but early treatment can be important and essential. Without screening, the chances of early stages of scoliosis being diagnosed are small as family doctors and pediatricians often do not check for scoliosis and, if they do, they may only use the forward bend test which only shows a possible rib arch. The Adam’s forward bending test, also known as the Adams “Too Late” test is a very poor test to evaluate early stage scoliosis as it relies on rib cage distortion.
Should screenings be conducted in schools? If so what is to be done to ensure that they are consistently conducted and with the same standards and protocols without increasing an already diminishing school budget?
On a lighter note, here is a satirical article from The Onion that pokes fun at school scoliosis screening and may even conjure up some memories of what, for many, was an awkward and uncomfortable experience.