As many of our readers know, the Scoliosis Research Society, the American Academy of Orthopaedic Surgeons, and over 23 states suggest or require school screening for abnormal spinal curvatures. In September of 1992, Dr. William P. Bunnell, Professor and Chairperson, Loma Linda University Medical Center, presented his paper, “Outcome of Spinal Screening” to members of the Scoliosis Research Society; his findings will also be published in an upcoming issue of Spine. Dr. Bunnell is a developer of the Scoliometer, a hand-held device used in assisting spinal screening programs across the country. What follows are excerpts from an interview that the NSF conducted with Dr. Bunnell about his study:

Q: Dr. Bunnell, would you start by giving us some background information about spinal screening as it pertains to your study?
A: The major criticism of spinal screening, as it is being practiced today, is that schools are referring too many students who do not require treatment. The primary cause of over-referral is lack of objective screening criterion; in the state of California, for example, any amount of asymmetry of the thoracic ribs or the lumbar area is an indication for referral. As a result of over-referral, many screening programs are cost ineffective. Youngsters who are referred–whether they need treatment or not–will be sent to a doctor for a medical consultation; they may have several x-rays taken; and then they’ll be asked to return to the doctor six months or a year later for another consultation. All of this adds up to skyrocketing costs.

Q: What were some of the goals you wanted to achieve by undertaking this study?
A: One of my many goals was to determine the prevalence of scoliosis–i.e., how many in the general population presently have it. Another was to use the data on prevalence in combination with previous studies to determine what is a reasonable level orcriterion for recommending referrals.

Q: What were some of your findings?
A: In our study of 1,000 physically mature high school students–in which we used the Scoliometer as the screening device–we found that only 16 out of 1,000 students (1.6%) had a clinically straight spine. Eighty percent had three or more degrees of rotation at one or more levels of the spine. We also learned that within this population, if “any degree of deformity” (i.e. one degree) is used as the criterion, then 98.4 % of students will be referred.

Q: Would you explain the criterion–the degree of deformity–that screeners currently look for, and tell us why you feel this criterion should be changed?
A: When I first started out in practice, everybody thought we should treat 20 degree curves with low profile braces. There is a direct correlation between 20 degree curve and a 5 degree Angle of Trunk Rotation (ATR), so screeners referred anybody with 5 degrees of ATR or greater, and they’re sill using 5 ATR as the criterion. Today, we know that at least 4 out of 5 kids with 20-degree idiopathic (causes unknown) curves will never get any worse. In fact, most doctors wait until a youngster with this type of curvature reaches 30 degrees before starting treatment. So it’s clear that we should be screening for these children in the 30 degree and above category.

Q: Based on the data from your study, what are some of your recommendations?
A: We know that spinal 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. In view of the new prevalence data from my study and the current recommendations to wait until scoliosis approaches 30 degrees (Cobb angle) before starting brace treatment, I am recommending changing the screening referral criterion to seven degrees ATR at any level of the spine and changing the definition of false-negative (treatment-eligible curves that are missed) to 30 degrees Cobb angle for the purposes of spinal screening.

Q: If it is implemented in screening programs across the country, what will your new recommendation accomplish?
A: It will accomplish a referral rate of 3% and detect 95% of all “treatment eligible” curvatures, thus preserving an acceptably low false-negative rate and helping maintain cost effectiveness of spinal screening programs.

Q: What about youngsters whose curves are below that “treatment eligible” line–let’s say, between 20 and 25?
A: Those youngsters should be rescreened within six months or a year. Rescreening would take place at school, which would keep it a public health issue.

Q: In light of your findings, how do you now view the importance of screening for spinal deformity?
A: Screening is vitally important, but we do not want to screen out a whole bunch of people who don’t need medical attention because it’s very costly. We’re not looking for the cheapest way to screen–we’re looking for a better quality outcome for our patients.

The post Outcome of Spinal Screening first appeared on National Scoliosis Foundation.

1. Can exercise correct or stop the progression of the scoliosis curve?
2. Are recreational exercise and sports participation advised?

In this article, we will present some of the advantages and limitations of exercise for adolescents with scoliosis. Adults with scoliosis, including those with corrective surgeries, often also seek advice about exercises, especially if they begin experiencing discomfort and stiffness in their backs. Therapeutic and recreational exercise for adults will be presented in a future article.

Programs

Several programs aimed at correcting or arresting scoliosis have been proposed over the decades. Through these programs one attempts to exert corrective forces on the spine by active contraction of trunk muscles in directions thought to reverse the scoliosis curves. Some approaches seek positions and postures which are noted to reduce the scoliosis deformity.
Additionally, stretches are often performed, which aim to increase the mobility of the spine in a corrective direction. After mastering these exercises, postures and stretches under the supervision of a physical therapist, attempts are made to maintain corrective muscle tone and postures during daily activities.

Some programs also include breathing exercises. Chest movements noted during deep breaths cause temporary rotation of the thoracic vertebrae in a corrective direction in some people with scoliosis. Minor reductions in measurable lung capacities are often found in people with scoliosis and large thoracic curves, and breathing exercises have also been directed at improving this.

Bracing and Exercise

Exercise programs have often been prescribed for those wearing corrective scoliosis braces. These are intended to help the wearer adapt to the brace, to encourage the active correction of the spinal deformity, and to maintain the trunk musculature during the bracing program. This is done by actively shifting laterally in the direction of the correction (away from the brace pad), by extending the trunk while in the brace, and by taking deep breaths.
Other trunk and pelvic exercises are also taught and the brace-wearer is instructed to perform these several times per day. Most programs are initially supervised by physical therapists, and are followed by the development of daily home exercise regimens.

Benefits of Exercise

In general, little scientific evidence exists about the effectiveness of exercise programs for preventing progression of scoliosis curves, or for reversing curves to any clinically or cosmetically significant degree.

By scientific evidence we refer to carefully designed clinical studies where a true effect of exercise has been demonstrated. Some short-term reduction of curve angles (by several degrees), and minor improvement in breathing volumes have been observed for small groups of people with scoliosis who have undergone exercise programs.

Others in these programs, however, were not helped, and some were noted to have curve progression during exercise. For those with slight improvement in curves, it was not determined whether these changes had any lasting effect, nor were these noted to be cosmetically or functionally noticeable.

Even for exercise programs directed at improving the results of scoliosis bracing, the results have been disappointing. Bracing alone has been found to be as effective as bracing and exercise.
Because of this, therapeutic exercise programs are not universally recommended by scoliosis experts. When prescribed, exercise programs are usually initiated in addition to, and not instead of bracing treatment. Careful monitoring of curve angles remains essential, regardless of exercise.

Therapeutic exercise should never be considered as an alternative to recommended surgery when a scoliosis curve is severe and progressive, and the patient and family have decided on surgical correction.
Fortunately, most people with scoliosis are completely normal in their ability to participate in sports and recreational exercises. For some with severe deformities leading to respiratory function changes, and for those post-scoliosis surgery patients, some sports restrictions may be advised. Your scoliosis specialist can make recommendations concerning these. No information exists to suggest that recreational exercise and sports participation worsens, or in any other way affects scoliosis curves.

“Scoliosis is not caused by a deficiency of strength or flexibility, and therefore exercise is relatively ineffective in correcting scoliosis. Equally important, scoliosis is not a result of exercise, and therefore normal physical activities can be enjoyed by people with scoliosis without concern”.

Children and adolescents with scoliosis can be expected to participate in organized sports, school physical education programs, and normal neighborhood recreational activities. For most, resistive exercise training to build muscle strength and endurance training to improve cardiovascular conditioning can be performed when desired.

Children enrolled in a scoliosis bracing program are generally allowed out of the brace for organized sports. In addition to the lack of adverse effects and improved fitness, regular recreational exercise can reinforce that one is normal and healthy despite scoliosis.

The causes of scoliosis appear to be independent of exercise. Scoliosis is not caused by a deficiency of strength or flexibility, and therefore exercise is relatively ineffective in correcting scoliosis. Equally important, scoliosis is not a result of exercise, and therefore normal physical activities can be enjoyed by people with scoliosis without concern.

The NSF would like to thank co-authors, James Rainville, M.D., and Frank Rand, M.D., for their work on this article. Dr. Rainville, a Physiatrist, is Assistant Clinical Professor, Department of rehabilitation Medicine, Tufts University Medical School-Boston, and also Director of rehabilitation, New England Spine Care Center, Chestnut Hill, MA. Dr. Rand is Instructor in Surgery (Orthopedics), Harvard Medical School, Boston, and Director of Orthopedic Programs, New England Deaconess Hospital, Boston

The post Exercise for Adolescents first appeared on National Scoliosis Foundation.

Q: Dr. Moskovich, would you give us a brief overview of early onset scoliosis?
A: It’s important to know that early onset scoliosis is idiopathic, which means we do not know what causes it. Early onset scoliosis occurs before the age of five, and occurs more often in boys than in girls, though we don’t know why. It was formerly referred to as ‘infantile scoliosis’, a term some people still use. It also must be stressed that early onset scoliosis is a very rare condition: the incidence of it is only 1 or 2 per 10,000 people. The vast majority of cases improve spontaneously, which means even fewer need to be treated.

Q: Is early onset scoliosis the same as congenital scoliosis?
A: Not at all. Whereas congenital scoliosis involves a curvature caused by an abnormality such as a hemivertebra or other bone structure problem, early onset scoliosis stems from no known cause-as we’ve said, it’s idiopathic. There is no obvious abnormality in the development of the vertebrae that we can identify in patients who have early onset scoliosis.

Q: How severe must a child’s curvature be before you would define it as an early onset scoliosis?
A: If a child under the age of five has a 10 to 15 degree curve or greater, we would say that child had early onset scoliosis.

Q: Once you’ve identified that the child’s curve is 10 degrees or more, what steps do you take?
A: Of course we would watch the curve closely; we’d also take an x-ray which would alert us to signs of an increased risk of progression. For example, we’d look for a larger curve or marked asymmetry of the ribs, both of which can be signs that a curve may progress. The x-ray could provide us other valuable information as well: whether the child had structural problems indicative of congenital scoliosis, or whether the child had abnormalities of the heart, kidneys, or hips, all of which are more common with early onset scoliosis.

Q: Are any special tests required apart from x-rays?
A: It is important to confirm that the patient is neurologically normal. Examination of the abdominal and plantar reflexes which may alert a physician to subtle neurologic abnormalities should not be neglected. In certain cases, a magnetic resonance imaging (MRI) may be used to evaluate the spinal cord and to exclude neurologic anomalies at the base of the skull if there is any suggestion of neurological problem.

Q: At what point do you begin treatment?
A: If a curve progresses beyond 15 to 20 degrees, we would treat the child by using a plaster cast to keep the curvature from progressing.

Q: Why plaster instead of plastic?
A: There are several reasons of that choice. it can be awfully difficult to keep a young child in a plastic brace which has to be put on and taken off each day. Also, plaster casts are actually more comfortable-they create less pressure on the body because they’re molded to the body. And because plaster casts are generally easier to deal with, we find we get better correction with them. The plaster cast will be changed every 3 to 4 months depending on the growth rate of the child. Plastic bracing is used once initial correction has been achieved or may be used from the outset on larger children.

Q: How successful is plaster casting?
A: Very-about 90-plus percent of patients get better due to casting.

Q: If the curve continues to progress despite the plaster cast, what other treatment options are available?
A: If a curve progresses, we’d do surgery involving an anterior and a posterior fusion.

Q: Why would you have to do two fusions?
A: If you only do a posterior fusion, two things happen: first, it may not fuse, because the back of the spine is the ‘tension’ side of the spine, and bone under tension tends not to heal very well. Second, the front of spine will continue to grow and will twist out, causing the spine to bend backwards into a lordosis.

Q: When surgery is necessary, is it important to fuse patients at the earliest age possible?
A: In many cases, we would try to delay surgery until the child had reached a reasonable size, say at the age of 10, but sometimes that’s not possible, and early surgical treatment is necessary. Also, it is well known that by the age of two, children have reached almost half of their adult spinal growth size. It’s better to have a relatively short, straight spine than a longer, crooked spine.

Q: When a curve is left untreated, what can happen?
A: An untreated curvature can progress rapidly-as much as 40 degrees or more in just months. As the curve progresses, the size of the actual chest cavity can diminish, affecting the developing lungs, which can create respiratory problems for the child that will persist throughout life.

Q: You mentioned earlier that early onset scoliosis is idiopathic-but do you have any thoughts about what might cause this condition?
A: Besides possible heritable factors, there may be an environment trigger. We’re not really sure why, but in low socioeconomic groups in England there’s a greater prevalence of this type of scoliosis, which may be due to post-natal positioning-the way that babies are positioned in their cribs. In England, mothers are taught to lay babies down on their sides. This can cause the spine to sag, and can cause molding of the head and an increased incidence of dislocation of the hip. By contrast, here in North American we tend to put babies down in a prone (face-down) or supine (face-up) position, which results in much more even pressure on the spine.

Q: Based on this knowledge, what do you recommend?
A: In my own practice, I recommend that swaddling babies so that they can’t move and putting babies persistently on one side should be avoided. However, infant positioning should be individualized and one should consult their pediatrician.

Q: Any other advice?
A: If there’s a family history of scoliosis, make sure the family pediatrician carefully examines the child: check for asymmetries. As with all types of idiopathic scoliosis, early detection and early treatment are imperative.

The post Early Onset Scoliosis first appeared on National Scoliosis Foundation.

Throughout history man has tried to straighten out that which nature has bent, twisted, or curved. Hippocrates not only gave a name to scoliosis but he also tried to correct it. Over the centuries since then physicians have used a wide, and sometimes strange, variety of devices to straighten a crooked spine.
In today’s world when a growing adolescent is diagnosed with progressive idiopathic scoliosis and the curve is between 25 and 40 degrees, the physician will prescribe the wearing of a brace to keep the curve from worsening. Depending on the severity of the curve, the curve pattern, and the amount of growth remaining, the physician may not wait to document progression but will prescribe bracing on the initial visit.

In 1985, the Scoliosis Research Society (SRS) initiated a study to investigate the effectiveness of bracing as a treatment for scoliosis. Many previous studies of full time bracing showed that braces stop about 80% of curves. All of these studies, however, were “uncontrolled” which means there were no simultaneous groups of untreated, unbraced patients for comparison. Therefore, there was some doubt that brace treatment of scoliosis was effective, and concern that bracing may be no different than “natural history” or what happens when no treatment is undertaken. In the SRS controlled clinical trial, involving centers from around the world and conducted by Dr. Alf L. Nachemson Sahlgren Hospital, Gothenberg Sweden, patients of the same age, curve pattern and curve severity were divided into two groups, one treated with bracing, one not treated. As reported in the 1993 issue of the Spinal Connection, results of this study demonstrated with statistical certainty that bracing is effective compared to natural history.

In another study by Drs. John Lonstein and Robert Winter, the records and X-rays of 1,020 patients treated with the Milwaukee Brace were reviewed and compared with the findings of a study by Drs. Lonstein and J.M. Carlson which documented patients at the same hospitals who had not been braced but who had been followed for progression of the curve. This retrospective study also showed that bracing is an effective treatment, halting the progression of the curve in statistically significant numbers compared with those patients not treated.

While it is true that there are some patients (20-25%) for whom bracing does not work and unfortunately, it is not possible to predict who they will be parents and physicians can be reassured by these recent findings that bracing for those youngsters who meet the generally accepted criteria is a wise course of action.

What does bracing achieve?
It is important for parents and patients to realize that the purpose of bracing is to keep the curve from progressing as a child grows. While the curve will demonstrate improvement during the time the child is braced, it will typically revert to its original degree of severity when the use of the brace is eventually discontinued at the cessation of growth. Some individuals do achieve permanent correction, but holding the curve to an acceptable level, thus avoiding surgery, should be deemed a success.

What Kinds of Braces are Used?

The Milwaukee Brace
The Milwaukee Brace was the first modern brace designed for the treatment of scoliosis. Developed by Drs. Walter Blount and Albert Schmidt of the Medical College of Wisconsin and Milwaukee’s Children’s Hospital in 1945, it underwent design changes over the years, reaching its present form around 1975. It is still used today, particularly for high thoracic curves. Metal bars in the front and back of the brace extend the length of the torso and are attached to a form-fitting plastic pelvic girdle and to a throat mold or ring which encircles the neck. Straps attached to the metal bars hold pressure pads, which are precisely placed depending on the individual’s curve pattern. While the bars hold the body erect, the neck ring keeps the head centered over the pelvis and the pads push against the curve. Everything works together to keep the body straight and to prevent progression of the curve while the patient is growing.

TLSO Braces
There are many TLSO (thoracic-lumbar-sacral orthosis) systems available today. They are also often referred to as “underarm” or “low profile” braces. They are made of modern plastic materials and are contoured to conform to the patient’s body. While they all differ somewhat in construction, they work on basically the same principle.

The Boston Brace
In the early seventies, the most popular of the TLSO systems, the Boston Brace, was developed by Dr. John Hall and Dr. William Miller of The Boston Children’s Hospital. The Boston Brace was the first brace to utilize symmetrical standardized modules eliminating the need for casting. It was alsothe brace used in the Scoliosis Research Society’s bracing study. The Boston Brace extends from below the breast to the beginning of the pelvic area in front and just below the scapulae to the middle of the buttocks in the back. It is designed to keep the lumbar area of the body in a flexed position by pushing the abdomen in and flattening the posterior lumbar contour. Pads are strategically placed to provide pressure to the curve, and areas of “relief” or “voids” are provided opposite the areas of pressure.

The Charleston Bending Brace
The Charleston Bending Brace was introduced in 1979. Developed by Dr. Frederick Reed and Mr. Ralph Hooper, CPO, this brace is worn only at night during sleep. It is molded to conform to the patient’s body while bending towards the convexity of the curve, thus “over-correcting” the curve during the eight hours it is worn. A preliminary study and subsequent longer term follow-up of those using the nighttime bending brace are encouraging, particularly for a single curve. Although the studies show no evidence of improved compliance the potential for a patient to wear a part-time brace, especially while sleeping, rather than the usual full-time (22-23 hours) regimen is cited as an important benefit.

“The purpose of bracing is to keep the curve from progressing as a child grows.”

To achieve a successful outcome from bracing it is necessary that a highly skilled orthotist or brace maker work hand in hand with the orthopedist to craft a brace precisely tailored to the patient’s needs. In many cases an exercise pro- gram is also provided. After that, the physician will have the patient return for routine checkups and order X-rays to make sure the brace is doing its job. He will prescribe periodic adjustments as necessary.
The brace is worn until the physician has determined that skeletal maturity has been reached at which time the patient will be gradually weaned from the brace.

Compliance on the patient’s part in wearing the brace according to the prescribed schedule is a crucial factor, of course. Several studies have demonstrated the importance that the mother’s attitude has on the child’s perception of her own condition and acceptance of treatment. While no one would suggest that adapting physically and psychologically to bracing is easy for children and teenagers, many studies show that after an initial adjustment period, youngsters who are braced live very normal lives, engaging in appropriate activities, including sports, and that they have good psychosocial adjustment, no matter which brace they wear.

The post Bracing for Adolescent Idiopathic Scoliosis first appeared on National Scoliosis Foundation.