Postural Screening School Based Screening and Referral Decision

Postural Screening School Based Screening and Referral Decision Making Content originally created by: Denise Lotufo PT, DPT, OCS, CSCI, CMT Mary Ann Wilmarth, PT, DPT , OCS, MTC, Cert. MDT Northeastern University Boston, MA Presentation format updated by: Therese Blain BSN, RN, Western MA regional consultant 10/13/16

Scoliosis • Scoliosis is derived from the Greek word Skoliosis, meaning curve • Scoliosis is a description of the spines structural alteration • Scoliosis is not a diagnosis Three broad categories: • Neuromuscular • Congenital • Idiopathic

Neuromuscular Scoliosis • Neuromuscular scoliosis is the result of muscle imbalance and lack of trunk control due to neurologic or musculoskeletal problems stemming from issues such as cerebral palsy, myelomeningocele, muscular dystrophy or leg length discrepancy • Neuromuscular Scoliosis makes up 10% of all patients

Congenital Scoliosis • Congenital Scoliosis is the result of a vertebral anomaly or asymmetry For example: a hemi vertebrae or failure of segmentation • Congenital scoliosis usually occurs before adolescence • Congenital Scoliosis makes up 15% of all patients (1, 2, 3, 4, 5)

Idiopathic Scoliosis • Idiopathic scoliosis refers to a spinal curve for which there is no discernible cause, and it typically occurs in children and adolescents who are otherwise healthy (6, 7, 8) • It is therefore a diagnosis of exclusion • Idiopathic Scoliosis makes up 65% of all patients (1) Three Subcategories for Idiopathic Scoliosis • Infantile (early onset- 0 -3 years) • Juvenile (early onset-4 -9 years) • Adolescent (late onset- >10 years)

Adolescent Idiopathic Scoliosis • AIS is the most common type of scoliosis and the leading cause of orthopedic problem in school aged children(6, 7, 10, 11, 12)

Adolescent Idiopathic Scoliosis • AIS is defined as an abnormal side bending of the spine, causing the vertebral bodies to rotate toward the convexity of the curve and produce a distortion of the spine. (4, 8, 13 -20) This distortion creates a 3 -dimentional deformity of the spine. • Furthermore, the 3 dimensional deformity occurs in the absence of congenital or neurological abnormalities (8)

Spinal Alignment Structural vs. Non Structural • AIS is considered a structural scoliosis • The presence of a rotary component to the spine curvature will determine if it is a structural or non structural Scoliosis • With a structural scoliosis the spine will not correct in forward bending nor will it fully correct in a supine or bending radiograph (21, 22)

Normal Spinal Alignment • Coronal View (Anteroposterior) o 0° Curvature • Sagittal (lateral) View o Thoracic Kyphosis o 20 -40° Curvature o Lumbar Lordosis o 40 -60° Curvature

Curvatures in the coronal plane are not part of the normal spine alignment and when they exist, with a minimum of 10 degrees, it is called scoliosis (23, 24)

Curve Patterns • Curve direction either left or right is defined by its convexity • Spinal location is defined by the vertebra that is most deviated and rotated from midline (2, 25) Location Spinal Segments Thoracic T 2 -T 11 Thoracolumbar T 12 -L 1 Lumbar L 2 -L 4

Curve Patterns R Convexity occur 90% of the time L Convexity occurs 70% of the time R thoracic and L lumbar Convexities found 90% of the time R Convexity 80% of the time

Radiographic Evaluation • Cobb Method: o Posterior-anterior radiographs of the full spine are used to assess lateral curvature o Lateral curvature > 10 degrees measured with the Cobb method is diagnosed as scoliosis (23, 25) o To find measurement points locate the most tilted vertebrae above and below the apex of the curve is chosen. o The angle between intersecting lines drawn perpendicular to the top of the top vertebrae and the bottom of the bottom vertebrae is the Cobb angle

Curve Progression • Factors that can influence curve progression are: – Skeletal maturity – Curve patterns – Gender • With AIS the skeletally immature patient has a greater risk of curve progression (29) • Curve progression is determined by 2 sequential radiographs showing a greater than 5° change

Risser Sign • The Risser sign is one measure used to assess skeletal maturity. It measures the apophysis ossification of the iliac crest • The Risser staging process divides the maturing iliac crest into quarters and are staged form 0 -5 Stage 4 indicates >76%-100% ossification. Stage 5 indicates the apophysis has fused to the iliac crest • The iliac crest apophysis is one of the last ossification centers to appear and develop

Skeletal maturity Risser <2 Curve Progression Risk Curve Sex Age Other Double curves Cobb >50° Girls 10 x greater risk than boys Younger the patient is at diagnosis, greater the risk Pre-menarche girls

Etiology • Consensus at this time is that the etiology of AIS multifactorial • It is widely accepted that there are genetic factors in the development of idiopathic scoliosis. Multiple epidemiological studies have shown that the prevalence of scoliosis is higher among individuals whose relatives have scoliosis than among the general population o A family history of scoliosis is identified in approximately 30% of patients diagnosed with idiopathic scoliosis o The identity of the affected gene in scoliosis is not known, nor is the normal gene in unaffected individuals known o Monozygotic twins show a concordance rate of 73%, whereas dizygotic twins have a concordance rate of 36%. These findings suggest a single-gene disorder, but one that has variable penetrance and genetic heterogeneity (27, 28)

Evaluating Spinal Curvatures • The first line of detection is the physical exam in the diagnosis of scoliosis • Visual observation can best reveal scoliotic asymmetries • Adolescents should be evaluated during their period of most rapid growth, and in which signs of curvature most often appear.

What to look for : Visual inspection In the coronel view: • Head: is it centered over the body? • Shoulder: is one shoulder higher? • Shoulder Blade: is it higher and or more prominent? • Hip: is one hip higher and more prominent? • Spine: is it obviously curved? • Trunk: are there unequal gaps between the arms and the trunk?

Asymmetries of Scoliosis Head not centered over body? One shoulder higher? Is there a notable curve in the spine? One shoulder blade higher, more prominent? Unequal gaps between the arms? One hip more prominent?

The Adams Forward Bend Test • The rotational component of scoliosis is quantified by measuring/observing the angle of trunk rotation (ATR) during the Adams forward bend test • The subject bends maximally forward with knees extended, outstretched arms, palms facing each other, pointed towards the great toes with the feet together • This brings the rib prominence or lumbar muscles into silhouette. A significant curve is likely if the difference between the height of the two sides is >1 cm The Adams forward bend test is the most sensitive clinical examination The ability off the forward bent test to correctly identify individuals with and without scoliosis (sensitivity and specificity, , respectively) varies depending upon the skills off the examiner, location off the curve, , and the magnitude off the curve used as the gold standard (33 -36)

Angle of Trunk Rotation (ATR)

(R) Thoracic Curve What might you see? • In a right (R) thoracic curve the R shoulder is elevated and the left (L) arm may appear longer. • The R scapula moves upwards and laterally with a prominent medial edge • Because off trunk rotation, , the L breast may be more prominent than the R • Gaps between the dependent arms and the trunk are unequal • If the left iliac crest (hip) is more prominent than the right, it may be signs off a thoracolumbar and lumbar curves

Benign Torso Asymmetries • The most common cause for false positives with the forward Bent Test is due to benign torso asymmetries. • 40% of normal girls will have asymmetrical body growth/development • During the AFBT there will be <1 cm difference between the height of the two sides and all other signs of scoliosis are absent. • It is also normal for the dominant upper extremity shoulder to be slightly lower then the non-dominant • If you doubt there is a curve, then there probably is not one and the asymmetry is of no clinical significance.

Why might scoliosis go undetected? • There are many reasons why scoliosis may be undetected until a substantial deformity has developed. These include: o Nearly all cases are painless and produce no other symptoms o Idiopathic scoliosis most often develops in the preadolescent or early adolescent period, an age of modesty which precludes parents from seeing their child's unclothed spines o Routine physical examination of older children has been supplanted by episodic problemrelated health care o Currently popular loose clothing styles easily conceal significant deformity

Put it together

MDPH POSTURAL SCREENING PROGRAM The following is in accordance with the ‘Training Material for the Postural Screening Program from the Massachusetts Department of Health The purpose of postural screening is three fold: 1. to detect early signs of spinal problems that should have further medical evaluation 2. To provide regular monitoring (during periods of growth) 3. To reduce the need for surgical remedies • Screenings must be done annually in grades 5 -9 due to MA general law • Like other screening programs conducted in schools, this program is not intended to provide medical diagnosis, but rather detect possible signs for further medical evaluation

Planning phase • Review the MDPH Training manual o Are there current screening protocols or guidelines in place for your district/school? o Read the "Questions and Answers on Postural Screening" section of the manual. • Consult with other school staff regarding the program roles. o Who is trained to conduct the screenings? o School nurses role? - coordinating with PE? /conducting the screening? • Arrange screening times, space, materials. o Can it be planned to have the postural screening conducted with another mandated screening? o Schedule times for initial contacts with class. o Reminder notifications? Can Principal/Admin conduct an "All Call" to families o Location/Privacy- set up by whom? • 7. Prepare or duplicate copies of materials: A) Brochure B) Initial Letter to Parents C) Follow-up Letter to Parents D) Letter to Physician (referral) How & when are written notifications of Postural Screening program being provided to students families (Student Handbook Notification of Screenings, letters home) E) Postural Screening Worksheet

Implementation • Notify Parent(s)/Letter • Screen students o Observe "No Hands On“ o PRIVACY and autonomy o Perform secondary screening as necessary • Document screenings o In students record o On worksheet ? ? • Follow Up/Phone Call(s) for referred findings o Document • Submit "Postural Screening Final Report" form to DPH Boston Office. o One form per school system o Included in year-ending reports

Postural Screening Worksheet

Postural Screening Review • Postural screening is a visual evaluation that will be evaluated from several views in accordance with the Massachusetts Department of Public Health Postural screening program training material • Observation occurs over 5 different planes / views

Refer to MD REFER IIF ANY 2 OUT OF 3 PRESENT • A. Shoulder Is one shoulder higher than the other? • B. Waist Is the waistline the same on both sides or is there a larger space between the arm and flank on one side? • C. Hip Are the hips level and symmetrical or is one side higher and more prominent?

Refer to MD REFER IF ANY 3 OUT OF 5 PRESENT • A. Head Does the head line up over the crease in the buttocks or does it lean to one side? • B. Shoulder Is one shoulder higher than the other? • C. Scapula Is the wing on one shoulder blade higher or more prominent than the other? • D. Spine Does there appear to be a curve when you observe the spine? • E. Waist Is the waistline the same on both sides or is there a larger space between the arm and flank on one side?

Refer to MD REFER IIF EIITHER PRESENT • A. Round back Is there an exaggerated roundness in the upper back? • B. Sway Back Is there an exaggerated arch in the lower back?

Refer to MD REFER IF PRESENT • Chest Cage Hump Are both sides off the back symmetrical or is the chest cage prominent or bulging on one side?

Refer to MD REFER IIF PRESENT • Spine Hump Is there an accentuated midline hump?

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References 1. Orthopedic Interventions for Pediatric Patients: The Evidence for Effectiveness 2. UPTODATE WEB ADDRESS 3. Burwell RG. The British decision and subsequent events. Spine. 1988; 13: 11921194. 4. Scaggs DL, Basset GS. Screening for idiopathic adolescent. Scoliosis. Am Fam Physician. 1997 Mar; 55(4): 1073 -4. 5. Reamy BV, Slakey JB. Adolescent idiopathic scoliosis: review and current concepts. Am Fam Physician 2001; 64: 111 -6. 6. Mirtz TA, Thompson MA, Greene L, Wyatt LA, Akagi CG. Adolescent idiopathic scoliosis screening for school, community, and clinical health promotion practice utilizing the PRECEDE-PROCEED model. Chiropr Osteopat. 2005 Nov 30; 13: 25. 7. Ashworth MA, Hancock JA, Ashworth L, Tessier KA. Scoliosis screening: an approach to cost/benefit analysis. Spine. 1988; 13: 1187 -1188. 8. Greiner KA. Adolescent idiopathic scoliosis: radio-logic decision-making. Am Fam Physician. 2002; 65: 1817 -1822. 9. Stirling, AJ, Howel, D, Millner, PA, et al. Late-onset idiopathic scoliosis in children six to fourteen years old. A cross-sectional prevalence study. J Bone Joint Surg Am 1996; 78: 1330. 10. Mc. Alister, WH, Shackelford, GD. Classification of spinal curvatures. Radiol Clin North Am 1975; 13: 93.

References (cont. ) 11. Goldstein, LA, Waugh, TR. Classification and terminology of scoliosis. Clin Orthop Relat Res 1973; : 10. 12. Riseborough, EJ, Wynne-Davies, R. A genetic survey of idiopathic scoliosis in Boston, Massachusetts. J Bone Joint Surg Am 1973; 55: 974. 13. US Preventive Services Task Force. Screening for adolescent idiopathic scoliosis: policy statement. JAMA. 1993; 269: 2664 -2666. 14. Di. Guiseppi C, ed, Atkins D, ed, Woolf SH, ed. US Preventive Services Task Force Guide to Clinical Preventive Services. 2 nd ed. Alexandria, Va: International Medical Publishing Inc; 1996. 15. Berg AO. Clinical guidelines and primary care: screening for adolescent idiopathic scoliosis: a report from the United States Preventive Services Task Force. J Am Board Fam Pract. 1993; 6: 497 -501. 16. Lonstein JE, Bjorklund S, Wanninger MH, Nelson RP. Voluntary school screening for scoliosis in Minnesota. J Bone Joint Surg Am. 1982; 64: 481 -488. 17. Lonstein JE. Why school screening for scoliosis should be continued. Spine. 1988; 13: 1198 -1199. 18. Gore DR, Passehl R, Sepic S, Dalton A. Scoliosis screening: results of a community project. Pediatrics. 1981; 67: 196 -200. 19. Soucacos PN, Soucacos PK, Zacharis KC, Beris AE, Xenakis TA. School screening for scoliosis: a prospective epidemiological study in northwestern and central

References (cont. ) 20. Burwell RG. The British decision and subsequent events. Spine. 1988; 13: 11921194. 21. Moe JH, Bradford DS, Winter RB, Lonstien JE. Classification and terminology. In: Mo JH, Bradnford DS, Winter RB, Lonstein JE, eds. Scoliosis and Other Spinal Deformities. Philadelphia, Pa. WB Saunders Co; 1978: 7 -12. 22. Rieseborogh EJ, Herndon JH. Introduction and terminology. In: Rieseborogh EJ, Herndon JH, eds. Scoliosis and Other Deformities of the Axial Skeleton. Boston, Mass: Little Brown & Co Inc; 1975: 1 -19. 23. Cobb, JR. Out line for the study of scoliosis: In Weinstein SL. Adolescent idiopathic scoliosis: prevalence and natural history. AAOS Instruct Course Lect 1989; 38: 115– 27 24. Soucacos PN, Zacharis K, Soultanis K, Gelalis J, Xenakis T, Beris AE: Risk factors for idiopathic scoliosis: review of a 6 -year prospective study. Orthop 2000, 23: 833838. 25. Weinstein SL. Natural History. Spine. 1999; 24: 2592 -2600. 26. Inoue, M, Minami, S, Kitahara, H et al. Idiopathic scoliosis in twins studied by DNA fingerprinting: the incidence and type of scoliosis. J Bone Joint Surg Br 1998; 80: 212. 27. Kesling, KL, Reinker, KA. Scoliosis in twins. A meta-analysis of the literature and report of six cases. Spine 1997; 22: 2009. 28. Lonstein, JE, Carlson, JM. The prediction of curve progression in untreated idiopathic scoliosis during growth. J Bone Jojnt Surg AM 1984; 66: 1061.

References (cont. ) 29. Lonstein, JE, Winter, RB. The Milwaukee brace for the treatment of adolescent idiopathic scoliosis. A review of on thousand twenty patients. J Bone Jojnt Surg AM 1994; 76: 1207. 30. Rogala EJ, Drummond DS, Gurr J: Scoliosis: incidence and natural history. A prospective epidemiological study. J Bone Joint Surg Am 1978 Mar; 60(2): 173 -6 31. Karol LA, Johnston CE 2 nd, Browne RH, Madison M: Progression of the curve in boys who have idiopathic scoliosis. J Bone Joint Surg Am 1993 Dec; 75(12): 180410 32. Cote, P, Kreitz, BG, Cassidy, JD, et al. A study of the diagnostic accuracy and reliability of the Scoliometer and Adam’s forward bend test. Spine 1993; 18: 1572 33. Goldberg, CJ, Dowling, FE, Fogarty, EE Moore, DP. School scoliosis screening and the United States Preventive Service Task Force. An examination of the longterm results. Spine 1995; 20: 1368. 34. Krachalios, T Sofianos, J, Roidis, N, et al. Ten- year follow-up evaluation ofa school screening program for scoliosis. Is the forward-bending test an accurate diagnostic criterion fro the screening of scoliosis? . Spine 1999; 24: 2318