A Program Manual - Gillette Children's Specialty Healthcare · 2019. 3. 17. · Scoliosis is a...

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2014 Scoliosis Manual REV_Scoliosis Manual Layout 4/7/14 2:36 PM Page 2

A PDF of Scoliosis Screening: A Program Manual is available at www.gillettechildrens.org/Center for Pediatric Orthopaedics.


SCOLIOSIS SCREENING

A Program Manual

Prepared by:Gillette Children’s Specialty Healthcare and Minnesota Department of Health

in conjunction with Twin Cities Spine Centerand Shriners Hospitals for Children – Twin Cities

Supported in part by:John E. Lonstein Spine Care Fund at

Gillette Children’s Foundation

Originally published in 1975 Minnesota Department of HealthRevised and updated in 2009 byMinnesota Department of Health

Gillette Children’s Specialty Healthcare and Shriners Hospitals for Children – Twin Cities

Printed and distributed by:Gillette Children’s Specialty Healthcare

200 University Avenue EastSt Paul, MN 55101

Copyright 2009


Scoliosis is a medical term that describes a lateral (sideways) curve of the spine.About 2 to 5 percent of children between the ages of 10 and 15 — the growth-spurtyears — have such curves. Although the incidence of scoliosis is equal in boysand girls, it is more common for curves toprogress in girls. Progressive scoliosisrequires monitoring and possible treatment.

Although most curves are small, progressivescoliosis can lead to disabling spinedeformities. To prevent such complications,scoliosis must be detected early. Treatmentmay include observation (for mild curves),bracing (for moderate curves), or surgery(for severe curves). Bracing can preventcurves from progressing and mighteliminate the need for surgery.

Families are unlikely to detect curves at anearly stage. In addition, many children ages10 to 15 do not see a primary-care providerroutinely.

For those reasons, Minnesota Department ofHealth (MDH) recommends that schooldistricts — in collaboration with localprimary-care providers — screen forscoliosis.

Gillette Children’s Specialty Healthcare, MDH Division of Community and FamilyHealth, Shriners Hospital for Children –Twin Cities and Twin Cities Spine Centerprovide ongoing guidance, as necessary, forthe Minnesota scoliosis screening programin schools. MDH recommends screeninggirls in the fall of fifth grade and again inthe spring of sixth grade. Scoliosisscreening is not recommended for boys.

For more information and rationaleregarding recommendation changes, see the MDH Web site:http://www.health.state.mn.us/divs/fh/mch/scoliosis/index.html.

2

Scoliosis Screening


3

Step 1: PlanningThe school nurse, health coordinator andscreener(s) should familiarize themselveswith this manual, Scoliosis Screening: AProgram Manual.

AdministrationScoliosis screening should be integrated intothe school’s overall health program. Theschool nurse or health coordinator in chargeof the scoliosis screening program shoulddiscuss its importance with the admin-istrator and other appropriate personnel.

MDH encourages collaboration with localprimary-care providers who might receivereferrals from the screening program.Discuss screening procedures with them andencourage them to support the program.

Staff OrientationAll screeners — school nurses, physical-education and other teachers, volunteers,doctors, nurse practitioners and anyone else involved in the screening program —should consider attending the scoliosisscreening seminar. It is held annually in the Twin Cities. Go towww.gillettechildrens.org for moreinformation.

The half-day seminar generally includes:• Presentations by specialists• Demonstrations of the scoliometer (a

device that measures spinal curves) andother techniques of the screening process

• Discussions of program planning andreferral sources

In this manual are a letter to parents orguardians about screening and a referralletter for students who need an additionalmedical examination. (See appendices Aand B.) Additional resources appear inAppendix C.

SchedulingThe school nurse or health coordinatorshould schedule screening times. Screeningduring physical-education classes oftenworks well, because numerous students areavailable during a relatively short time.Consider test schedules, field trips andother school activities that could conflictwith the screening. When dates are set,inform parents/guardians of the scheduledscreening, using the sample letter found inAppendix A.

Parent and Student OrientationBefore the screening, consider teachingstudents about scoliosis and demonstratingthe screening process. Such activitiesminimize apprehension of screening andincrease students’ knowledge of theirhealth.

Set-UpThe screening area must be large enough for screeners, students being screened andstudents waiting to be screened. Makecertain the area has adequate lighting. Ifwalls in the screening rooms are white oryellow, set up a bright, solid-coloredbackdrop to make observation easier.Tagboard works well. Gymnasiums, lockerrooms, large nurse’s offices and emptyclassrooms are common sites. Using roomdividers helps ensure maximum privacy.

Setting Up a Screening Program


4

Step 2: Performing the ScreeningOverviewThe screening might have two parts:• An optional subjective visual inspection as

the child bends • An objective measure of any asymmetry

using a scoliometer

Identifying Students for ScreeningUse class rosters to identify female studentsand record results. Students who have beentreated with a brace or surgery for scoliosisdo not need screening.

What Students Should WearClothing can hide subtle signs of scoliosis.It is best to screen students when their backsare bare. Girls might be more comfortablewearing a sports bra, swimsuit, or camisoletop. Instruct them in advance to bring suchitems.

Girls unwilling to be screened with a bareback may wear a plain colored T-shirt. Forbest results, however, minimal clothing isrecommended.

Performing the ScreeningStudents stand erect, with their feet 2 to 3inches apart and their backs toward thescreener.

Students then bend forward 90 degrees atthe waist, with their knees straight, armshanging and palms slightly together. Theirheads should be down.

Screeners should use a scoliometer toobjectively measure spinal asymmetry. Withthe student in a forward-bending position,the screener moves the scoliometer alongthe vertebral column, starting at the cervicalarea and moving down the spine. Observethe scoliometer for changes in curvemeasurements, noting the highest degree ofasymmetry.

Although subjective evaluation is no longerrecommended in school screening, it can bea helpful component. If time allows, the

screener might observe each student’s back,looking for abnormalities such as:• An obvious curve• Shoulders unequal in height• One protruding shoulder blade• An uneven waistline• Uneven hips• An unequal distance between the arms

and body when the arms are hangingstraight down at the sides

Although these are not diagnostic signs,they might indicate a problem.

Step 3: ReferralsA referral to a primary-care provider shouldoccur if a student exhibits unequal lumbaror thoracic areas of 6 degrees or greater asmeasured by a scoliometer.

Notifying Parents/Guardians andRequesting ReferralsCommunicate — by telephone, e-mail orletter — with parents/guardians of studentswho meet the criteria for referrals. Whenreferring a student for further evaluationwith a primary-care provider, the schoolnurse or screener should explain toparents/guardians why the referral isrecommended. Appendix B provides asample letter to use when notifying parentsor guardians.

Discuss the screening results and emphasizethe importance of further medicalevaluation. It is essential for parents/guardians and students to understand thatthe student’s condition might requiretreatment.

Emphasize that the screening identifies onlya possible spinal problem; it is not adiagnostic service. Be prepared to discussfears and answer student and familyquestions.

Primary-care providers or orthopaedicspecialists provide follow-up treatment asneeded, depending on the severity of thecurve.


5

Monitoring Students and DocumentationSchools are encouraged to keep track ofstudents who have a positive screening (seeAppendix E). Such students might requireclassroom and scheduling adaptations toaccommodate the prescribed scoliosistreatment (such as braces). Schools shouldalso follow up with students who havescoliosis to make sure they are seeing aprimary-care provider regularly.

Note all findings on the student’s schoolhealth record, including the date of thescreening and the name of the health-careprovider to whom the referral was made.Record results of the subsequent medicalevaluation.

Data Collection and Program EvaluationKeeping data on scoliosis school-screeningprograms demonstrates the outcomes ofscoliosis screening and referrals in schools.It also demonstrates accountability forschool nurses and enhances documentationof screening.

Schools are encouraged to record totalnumber of students eligible for screening,total screened, number passed, numberreferred and information on resultingreferrals, diagnoses and treatments. It isimportant to not only document referralsand outcomes, but also to record denom-inators including how many were eligible tobe screened and how many were actuallyscreened. Schools might want to use theSchool Scoliosis Screening Report(Appendix E) provided in this scoliosisscreening manual to document this data.

Scoliosis school screening is voluntary. The MDH does not collect or report thisdata. Instead it can be included in annualreports to school administrators aboutschool health programs.


Dear Parents/Guardians:

In the next few weeks, we will conduct a screening program to identify female students whomight have an abnormal curve of the spine (scoliosis). Studies estimate that two to five ofevery 100 children develop scoliosis, and some require treatment. Early detection andtreatment helps prevent or minimize the development of severe spinal problems.

The screening procedure is simple. It consists of a brief test in which the screener — usually aschool nurse or physical-education teacher — looks at the girl’s bare back while she isstanding and bending forward. A simple, painless device called a scoliometer is used tomeasure any spine unevenness. We will make every effort to ensure each girl’s privacy.Recommended clothing for this screening is a camisole, sports bra or swimsuit.

If your daughter appears to have an abnormal curve, we will notify you. Then you will beencouraged to make an appointment with your primary health-care provider for furtherevaluation of your daughter’s condition.

Please complete the form below if you do not wish to have your daughter participate in thescreening program. Detach the form and return it to the school.

Sincerely,

School Nurse Phone Number

Detach here and return this form to your child’s school.

I do not wish to have my daughter, , screened for scoliosis. (Name)

Parent/Guardian Signature

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Appendix A: Letter to Parents/Guardians Regarding Screening

This letter is available as a Word document on the Gillette Web site at www.gillettechildrens.org/Center for Pediatric Orthopaedics.


Dear Parents/Guardians:

recently participated in our school scoliosis-screening (Student name) program.

Although this screening program is not a diagnostic service, screening results indicate thatyour daughter needs further evaluation to determine whether she has a spinal abnormalityand, if so, what treatment might be necessary. It is strongly recommended that you take yourdaughter to your primary health-care provider for further evaluation.

Scoliosis is a side-to-side curvature of the spine that can cause complications if left untreated.Although the cause is unknown, the condition becomes more apparent after the adolescentgrowth spurt. If detected early, scoliosis can be treated.

If you have additional questions, please do not hesitate to call me.

School Nurse Phone Number

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Appendix B: Referral Letter

This letter is available as a Word document on the Gillette Web site at www.gillettechildrens.org/Center for Pediatric Orthopaedics.


8

Books, Journal Articles and EducationalPamphlets

Postural Screening: Guidelines for School NursesNational Association for School Nurses163 U.S. Route 1P.O. Box 1300Scarborough, ME 04070-1300Cost: No charge

McLain, R.F., Karol, L. (1994). ConservativeTreatment of the Scoliotic and Kyphotic Patient.Archives of Pediatric Adolescent Medicine,148, 646-651.

Lonstein, J.E. (1989). Managing SchoolScreening Referrals. Journal ofMusculoskeletal Medicine, July, 37-54.

Lonstein, J.E., Winter, R.B. (1994)The Milwaukee Brace for the Treatment ofAdolescent Idiopathic Scoliosis.Journal of Bone and Joint Surgery, 76-A, 1207-1221.

Lonstein, J.E., Winter, R.B., Moe, J.H., Bianco, A.J., Campbell, R.G., Norval, M.A.(1998). School Screening for the EarlyDetection of Spine Deformities: Progress andPitfalls. Minnesota Medicine, 59, 51-7.

Renshaw, T.S. (1988). Screening SchoolChildren for Scoliosis. Clinical Orthopaedicsand Related Research, 229, 26-33.

Richards, B.S. & Vitale, M.G. (2008).Screening for Idiopathic Scolisis in Adolescents,An Information Statement. The Journal ofBone and Joint Surgery, 90, 195-198.

Winter, R., and Lonstein, J. The Spine:Juvenile and Adolescent Scoliosis (thirdedition., volume 1), chapter 14, pp. 273-423.Check your local library for this publication.

Winter, R., Perra, J., and Lonstein, J. (2009).Scoliosis: The Case for Screening and Referral.Minnesota Physician, 12 (10),www.tcspine.com/sites/default/files/MPWinter0109rev.pdf.

Audiovisual Materials/Tools

School Screening With Dr. Robert KellerLength: 60 minutesA training video that teaches propertechnique for school spinal screening.National Scoliosis Foundation5 Cabot PlaceStoughton, MA 02072Fax: 781-341-8333800-NSF-MYBACK (800-673-6922)Cost: $19.95 plus shipping and handling

Scoliometer: A Tool for Measuring Spinal Curvature National Scoliosis Foundation5 Cabot PlaceStoughton, MA 02072www.scoliosis.orgCost: $48.00

*Resources current as of 2009

Appendix C: Suggested Professional References and Resources*


Suggested Parent/Guardian References and Resources

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Books and Educational Pamphlets

One in Every 10 Persons Has Scoliosis A pamphlet illustrating what scoliosis is andhow screenings workNational Scoliosis Foundation5 Cabot PlaceStoughton, MA 02072Fax: 781-341-8333Cost: No charge

Stopping ScoliosisA book on scoliosis and treatmentNational Scoliosis Foundation5 Cabot PlaceStoughton, MA 02072Fax: 781-341-8333Cost: $19.95 plus shipping and handling

Audiovisual Materials

Scoliosis Screening for Early Detection Length: 15 minutesDescribes the screening process for scoliosisand stresses the importance of earlydetectionGillette Children’s Specialty Healthcare200 University Avenue EastSt. Paul, MN 55101For questions, please 651-325-2320.

Internet/Web Sites

American Academy of OrthopaedicSurgeonswww.aaos.org

Gillette Children’s Specialty Healthcarewww.gillettechildrens.org/Center forPediatric Orthopaedics

Mayo Clinicwww.mayoclinic.com/health/scoliosis/DS00194

Medtronicwww.iscoliosis.com

Minnesota Department of Healthhttp://www.health.state.mn.us/divs/fh/mch/scoliosis/index.html

National Scoliosis Foundation:www.scoliosis.org

Pediatric Orthopaedic Society of NorthAmericawww.posna.org

Scoliosis Associationwww.scoliosis-assoc.org

Scoliosis Research Society: www.srs.org

Scoliosis Worldwww.scoliosis-world.com

Shriners Hospitals for Children – TwinCitieswww.shrinershospitals.org

Twin Cities Spine Centerwww.tcspine.com


Q. What is scoliosis?A. Scoliosis is a medical term describing a

lateral curve of the spine. Although mostcurves are small, progressive scoliosis canlead to disabling spine deformities.

Prevalence

Q. What percentage of people has scoliosis?A. Idiopathic scoliosis (scoliosis with an un-

known etiology) prevalence varies by theseverity of the curve:• Curves of 10 degrees or greater are present

in 2 to 3 percent of people• Curves of 20 degrees or greater are present

in 0.5 percent of people• Curves of greater than 30 degrees are

present in 0.2 percent of peopleA health-care provider should evaluatechildren who have a scoliometer reading of 6degrees or higher.

Cause

Q. Can poor posture cause scoliosis?A. No. Poor posture does not cause scoliosis or

have an effect on the way a curve progresses.

Q. Can overuse of one side of the body causescoliosis (e.g., carrying a backpack over oneshoulder)?

A. No. Overuse of one arm or leg will not causescoliosis.

Q. Do curves progress after the spine stopsgrowing?

A. After the spine stops growing, at approx-imately 14-16 years of age in girls, usuallyonly severe curves progress. That is why it isimportant to detect the curves early andprevent them from increasing.

Screening

Q. Why should schools screen for scoliosis?A. Scoliosis is most likely to be identified early

when schools screen for it. Scoliosis mayotherwise go undetected because:• Students are unlikely to receive physical

exams at this age unless they have health problems.

• Scoliosis is essentially painless, producing no symptoms other than an abnormal curve in the back

• Idiopathic scoliosis most often develops during preadolescence or early adolescence, when modesty may preclude parents/

guardians from seeing their children unclothed.

• Long hair and loose clothing styles can conceal significant deformities.

Q. How can we make our screenings moreaccurate and prevent over-referring forquestionable spinal deformities?

A. For new programs, the most efficient way toobtain screenings that correlate with clinicalresults is to have help.

Invite someone who has helped with otherscreenings, who is experienced in visualscreenings and who has used a scoliometer to be present. An experienced person can helpestablish criteria for normal and abnormalcurves. Experienced screeners, such as nurseswho attend the scoliosis screening seminar, areexcellent resources. The use of a scoliometerpromotes more accurate assessments andreferrals.

Q. Do I need to attend training to conductscreening for scoliosis?

A. While training is not required, it is availablethrough Gillette Children’s SpecialtyHealthcare in conjunction with ShrinersHospitals for Children – Twin Cities, the TwinCities Spine Center and the MinnesotaDepartment of Health.

Q. Why is screening boys for scoliosis notrecommended?

A. In the past, screening boys in eighth or ninthgrade for scoliosis at school was recom-mended. However, it is much less commonfor boys to have curves that require treatment.Because the curves do not require treatmentvery often, screening for boys for scoliosis inschools is no longer recommended.

Q. If someone has scoliosis, is it important toevaluate family members?

A. Yes. Heredity may be a factor in the mostcommon type of scoliosis (idiopathic).Therefore, all siblings of a child diagnosedwith scoliosis should also be evaluated.

Q. Can a difference in leg lengths mimicscoliosis?

A. Differences in leg lengths may cause a variancein the sides of the back when a student bendsforward. A primary-care provider candiagnose scoliosis. Schools should screen thestudent using a scoliometer regardless of leglength differences and refer students with a

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Appendix D: Frequently Asked Questions About Scoliosis


11

scoliometer reading of 6 degrees angle oftrunk rotation (ATR) or greater for furtherevaluation.

Q. Should a screener use blocks of wood forstudents with leg length discrepancy toprevent an unnecessary referral?

A. No. Using blocks of wood is no longerrecommended during the screening process.Perform the standard screening with ascoliometer. Refer students whoseasymmetry measures 6 degrees or greatereven if there is a leg length discrepancy.

Q. Some children with disabilities cannot bendforward. How do we screen those children forscoliosis?

A. Such children may need help undressing orbending forward. They might need to sit ona tabletop, with their legs swinging free andapart. Although screening children who havedisabilities requires patience and additionaltime, it is critical to perform such screenings.The incidence of scoliosis requiring treatmentis higher among children who havedisabilities than it is in others.

Q. Is it necessary to keep a watch list or torescreen students?

A. No. Students with an ATR of 6 degrees orgreater should be referred to a primary-careprovider. No further action is needed forstudents with an ATR of fewer than 6degrees.

Signs of Scoliosis

Q. I am a parent, and suspect my child hasscoliosis. What should I do?

A. If you suspect a child may have scoliosis, thebest thing is to contact the child’s primary-care provider. If that is not possible, contactthe school nurse or your local public healthagency.

Q. What is the major sign of scoliosis?A. A scoliometer result of 6 degrees ATR or

greater is a sign of possible scoliosis.Students who have such resuslts should bereferred to a primary-care provider.

Q. What signs indicate that a curve isprogressing?

A. The most accurate sign is that, when standingX-rays are taken three to six months apart,they show an increasing curve. It is almost

impossible to note such a progression just byexamining the back.

Prevention and Treatment

Q. Is there any way to prevent scoliosis?A. There is no known way to prevent scoliosis

from developing. The best ways to preventscoliosis from becoming a severe problem areby early detection and prompt treatment.Treatment may include observation for mildcurves, bracing for moderate curves, andsurgery for severe curves.

Q. Can chiropractors help treat scoliosis?A. There is no long-term study showing that

chiropractic treatments and adjustments canstop scoliosis or prevent it from progressing.

Q. Does exercise prevent mild scoliosis fromgetting worse?

A. No. There is no evidence that physicalexercise affects curves or prevents curvesfrom progressing.

Q. Does scoliosis treatment prevent women frombecoming pregnant or having children?

A. No, treatment for scoliosis will not preventwomen from becoming pregnant or havingchildren.

Other Spinal Deformities

Q. What is kyphosis?A. Kyphosis (“roundback” or “hunchback”) is an

abnormally convex curve in the thoracic areaof the spine. In most instances, it is causedby poor posture. It also can be caused byScheuermann’s disease. Children withexcessive kyphosis should see a primary-careprovider for further evaluation.

Q. What is lordosis?A. Lordosis (“swayback”) is an increased

concave curve in the lumbar and cervicalareas of the spine of 6 degrees or greater asmeasured by a scoliometer. In adolescence, it is usually caused by poor posture.


12

Appendix E: Scoliosis-Screening Recommendations

2003 Recommendations

Girls in fifth and eighth grades

Boys in eighth or ninth grade

Adam’s Forward Bending Testwith scoliometer

At 7 degrees ATR* or greater,lordosis or kyphosis

To primary-care provider

Watch list for 5-6 degrees ATR*:rescreened within three months

Periodicity

Instrument

Referral

2008 Recommendations

Girls in fall of fifth grade andspring of sixth grade

Not recommended for boys

Scoliometer, used according toinstructions

At 6 degrees ATR* or greater

To primary-care provider

No watch list

*ATR is the angle of trunk rotation as measured by the scoliometer.


13

Appendix E: School Scoliosis-Screening ReportS

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14

Appendix F: Photos

This photo demonstrates thepositioning of the scoliometer.

This photo demonstrates a positive screening of an 8-degree thoracic spine asymmetry usingthe scoliometer. This student should be referred to her primary-care provider.


15

This photo shows thoracic asymmetry. Note the uneven shoulders and thedifference in width between the armsand waistline.

The standing posterior spineexamination demonstrates leftthoracolumbar scoliosis and milddecompensation to the left. Note theshoulder asymmetry, left shoulderlower than right, prominence of the leftscapula, and wider space between leftarm and side as compared to the right.


16

These photos show the Adam’s ForwardBending test, side view.

This photo shows the Adam’s ForwardBending test, back view. Note thethoracic asymmetry.


17

This is the front view of the high profilethoracolumbosacral orthosis (TLSO).

This is the back view of the high profileTLSO.


18

This patient is wearing the high profileTLSO.


19

This is a side view of a high profileTLSO.

This photo shows aCervicothoracolumbosacral orthosis(CTLSO) with neck ring.


20

This is a front view of the low-profilethoracolumbosacral orthosis (TLSO).

This is a back view of the low-profileTLSO.


21

This photo shows a patient without abrace.

This is a back view in a low-profileTLSO.


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