What a school screening program could contribute in clinical research of idiopathic scoliosis aetiology

Screening for scoliosis - New recommendations, old dilemmas, no straight solutions

This opinion review considers the prevailing question of whether to screen or not to screen for adolescent idiopathic scoliosis. New and improved standards of people-oriented care and person-centredness, as well as improved principles of preventive screening and guideline development, have been postulated and implemented in health care systems and cultures. Recommendations addressing screening for scoliosis differ substantially, in terms of their content, standards of development and screening principles. Some countries have discontinued issuing recommendations. In the last decade, a number of updated and new recommendations and statements have been released. Systematically developed guidelines and recommendations are confronted by consensus and opinion-based statements. The dilemmas and discrepancies prevail. The arguments concentrate on the issues of the need for early detection through screening in terms of the effectiveness of early treatment, on costs and cost-effectiveness issues, scientific and epidemiologic value of screenings, and the credibility of the sources of evidence. The problem matter is of global scale and applies to millions of people. It regards clinical and methodological dilemmas, but also the matter of vulnerable and fragile time of adolescence and, more generally, children's rights. The decisions need to integrate people's values and preferences - screening tests need to be acceptable to the population, and treatments need to be acceptable for patients. Therefore we present one more crucial, but underrepresented in the discussion, issue of understanding and implementation of the contemporary principles of person-centred care, standards of preventive screening, and guideline development, in the context of screening for scoliosis.

Effectiveness of school scoliosis screening and the importance of this method in measures to reduce morbidity in an Italian territory

Although several procedures for treating scoliosis have been developed, the most effective treatment is still based on early detection. For early diagnosis of idiopathic scoliosis, many authors have proposed methods of school screening; however, there is still no standardized screening program. The aim of this study was to evaluate a school screening method and the prevalence and distribution of scoliosis in Italian school children, aged 9-14 years, and to determine if the screening method can reduce morbidity in an Italian territory. The screening program consisted of three steps: the first step was a clinical examination carried out by the school physician and two specialists. In the second step, doubtful cases (presence of a hump between the two sides of the torso, in the thoracic or thoracolumbar region, measured using a hump meter) were evaluated by an orthopedic specialist and subsequently controlled every 6 months either clinically or by radiographic examination. The third step was the classification of the scoliosis and procedures for treatment. All patients were scheduled for a follow-up program and were evaluated during the subsequent 3 years. Statistical analyses were performed with GraphPad Prism 6. A total of 8995 children were screened for scoliosis. Of these, 487 showed clinical signs of scoliosis, and 181 were referred for anteroposterior radiographs because of a positive result on the forward-bending test (hump>5 mm). No significant statistical difference was observed by the three clinical examiners. Of the 181 patients who were referred, 69 were radiographed, and the clinical diagnosis was confirmed in 94.2% of the cases. The prevalence of scoliosis (defined as a curve of ≥10°) was 0.76% (65 of 8995 children), and most of the curves (44; prevalence 67.69%) were small (<20°). The overall ratio of boys to girls was 1 : 3.3, but varied according to the magnitude of the curve (1 : 3 for curves of <20°, 1 : 3.25 for curves of 20-29°, and 1 : 4 for curves of ≥30°). Double curves were the most common type identified, followed by thoracolumbar curves; specifically, of the 65 children who had a curve, 21 (32.30%) had a double curve, 18 (27.6%) had a thoracolumbar curve, 17 (26.1%) had a lumbar curve, and nine (13.84%) had a thoracic curve. In the following 3 years, only four patients were found to have curves more than 20° and none more than 30°. Our results show that the school screening program was accurate and repeatable. Moreover, screening children for scoliosis using a simple test appears to be an effective means of early detection. Above all, the screening process effectively decreased morbidity in the territory at a negligible cost.

School scoliosis screening by Moiré topography - Overview for 33 years in Miyazaki Japan

BACKGROUND

Since 1981, we have performed school scoliosis screening (SSS) using Moiré topography in Miyazaki, Japan and attained a certain result in detecting scoliosis. However, this screening system was discontinued due to cessation of repair and production of Moiré topographic equipment. The purpose of this study was to make clear both the results and the problems of SSS by Moiré topography on the basis of our past 33 years' experiences.

METHODS

The subjects were 689,293 students (5th grade boys in 200,329, 5th grade girls in 191,919, 8th grade boys in 151,351, and 8th grade girls in 145,694) who were screened by Moiré topography between 1981 and 2013. The number of students received SSS, the positive rate of Moiré topography, the discovery rate of scoliosis greater than 20°, the reference rate to the second screening, and the positive predictive value of Moiré topography to detect scoliosis greater than 20° were investigated.

RESULTS

The number of students received SSS achieved a peak in 1992. The positive rate of Moiré topography and the discovery rate of scoliosis were highest in 8th grade girls. The reference rates to the second screening were 49.8% in 5th grade students and 41.4% in 8th grade students. The positive predictive values were 2.1% in 5th grade students and 7.6% in 8th grade students.

CONCLUSION

SSS by Moiré topography seemed to be effective in detecting scoliosis although both the positive predictive value and the reference rate to the second screening were low.

Trunk and craniofacial asymmetry are not associated in the general population: a cross-sectional study of 1029 adolescents

Background

The literature did not show clearly if a correlation between trunk and facial asymmetry exists. The aim of this study was to verify the association between trunk and facial asymmetries, and trunk and facial sagittal configuration in adolescents.

Methods

This is a cross-sectional screening study. It was carried out in a small town in Northern Italy, from February to April 2014. Healthy children met the inclusion criteria. Exclusion criteria were subjects with physical and cognitive disability, genetic disease, and polymorphism. All subjects underwent a three phases for postural screening program.

Results

1029 healthy children were 491 females and 538 males with mean age: 12 (range 11–16) years. The association of facial and trunk asymmetry had a point prevalence rate around 1% for the various regions of the spine, the association on the sagittal plane of almost 1.3% for hyperkyphosis and hyperlordosis. Overall, results showed a very low sensitivity, specificity, and predictive values of facial anomalies for trunk asymmetry and sagittal spinal posture.

Conclusion

While correlations between jaw position and body posture for cervical spine can exist, our study denied association with trunk and back in a general population: postural compensatory mechanism may have minimized the effects of one area on the other, if any existed.

H-reflex changes in adolescents with idiopathic scoliosis: a randomized clinical trial

[Purpose] To detect H-reflex asymmetry and investigate the effect of direction sensitive exercise therapy protocol among patients with thoracolumbar and/or lumbar scoliosis. [Subjects and Methods] Fifty patients (10-17 years), Cobb's angle 10-20 degrees with thoracolumbar and lumbar scoliosis participated in the study. Soleus H-reflex was tested on both sides during prone lying position and standing position. Patients were randomly assigned into two groups. Group I received direction sensitive exercise therapy while the participants in group II received traditional exercise. Exercises were applied three times per week for twelve successive weeks. [Results] There were significant differences indicating asymmetry in the H-reflex amplitude on concave side. Cobb's angle significantly decreased and the H-reflex amplitude on concave side as well as H concave/convex ratios in both lying and standing significantly increased in both groups. Direction sensitive exercise therapy showed a more significant increase in the measured outcomes than traditional exercises therapy protocol. [Conclusion] H-reflex test was effective in discovering the asymmetry between concave and convex sides. Based on H-reflex test, direction-sensitive exercise therapy was more effective than traditional exercises in decreasing Cobb's angle and increasing H-reflex values as well as H/H percent in concave side in patients with adolescent idiopathic scoliosis.

A Comparison of Patient-Reported Outcome Measures Following Different Treatment Approaches for Adolescents with Severe Idiopathic Scoliosis: A Systematic Review

Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of the spine which is usually not symptomatic and which can progress during growth and cause a surface deformity. In adulthood, if the final spinal curvature surpasses a certain critical threshold, the risk of health problems and curve progression is increased. Although surgery is usually recommended for curvatures exceeding 40° to 50° to stop curvature progression, recent reviews have shed some light on the long-term complications of such surgery and to the lack of evidence for such complicated procedures within the scientific literature. Furthermore, a number of patients are very fearful of having surgery and refuse this option or live in countries where specialist scoliosis surgery is not available. Other patients may be unable to afford the cost of specialist scoliosis surgery. For these patients the only choice is an alternative non-surgical treatment option. To examine the impact of different management options in patients with severe AIS, with a focus on trunk balance, progression of scoliosis, cosmetic issues, quality of life, disability, psychological issues, back pain, and adverse effects, at both the short-term (a few months) and the long-term (over 20 years). We searched CENTRAL, MEDLINE, EMBASE, CINHAL and two other databases up to January 2016 with no language limitations. We also checked the reference lists of relevant articles and conducted an extensive hand search of the grey literature. We searched for randomised controlled trials as well as prospective and retrospective controlled trials comparing spinal fusion surgery with no treatment or conservative treatment in AIS patients with a Cobb angle greater than 40°. We did not identify any evidence of superiority of effectiveness of operative compared to nonoperative interventions for patients with severe AIS. Within the present literature there is no clear evidence to suggest that a specific type of treatment is superior to other types of treatment.

A population-based cohort study of 394,401 children followed for 10 years exhibits sustained effectiveness of scoliosis screening

BACKGROUND CONTEXT

The value of scoliosis screening has been recently shown in a multicenter randomized controlled trial. However, the long-term sustainability of the clinical effectiveness of scoliosis screening as a routine health service remains unknown.

PURPOSE

The aim of this study was to assess the sustainability of the clinical effectiveness of school scoliosis screening.

STUDY DESIGN/SETTING

A large population-based cohort study with a 10-year follow-up was conducted.

PATIENT SAMPLE

A total of 394,401 students who were in the fifth grade during the five academic years from 1995/1996 to 1999/2000 formed five consecutive annual cohorts. The students were eligible for the Hong Kong scoliosis screening program, with their screening history and medical records until their nineteenth birthdays being assessed.

OUTCOME MEASURES

The outcome measures considered in the study were development of adolescent idiopathic scoliosis by the 19 years of age and the Cobb angle.

METHODS

The clinical effectiveness of scoliosis screening was assessed by referral rate for radiographic diagnosis, sensitivity, specificity, and predictive values.

RESULTS

A total of 306,144 students (78%) participated in scoliosis screening, which used a two-tier system. The prevalence of curves of 20° or greater was 1.8% (95% confidence interval [CI], 1.7-1.8%), whereas the referral rate for radiography, the sensitivity, and the positive predictive value (PPV) for curves of 20° or greater were 4.1% (95% CI, 4.0-4.2%), 91% (95% CI, 90-92%), and 40% (95% CI, 39-41%), respectively. Across the five consecutive annual cohorts, the prevalence and sensitivity for curves of 20° or greater increased by 0.23% (95% CI, 0.21-0.25%; p<.001) and 0.76% (95% CI, 0.43-1.04%; p<.001) per year, respectively; however, the PPV was reduced by 1.71% (95% CI, 1.09-2.33%; p<.001) per year.

CONCLUSIONS

This report describes the first large population-based study with a long-term follow-up indicating that a scoliosis screening program can have sustained clinical effectiveness in identifying patients with adolescent idiopathic scoliosis needing clinical observation. As the prevalence of adolescent idiopathic scoliosis increases, scoliosis screening should be continued as a routine health service in schools or by general practitioners if there is no scoliosis screening policy.

Surgical versus non-surgical interventions in people with adolescent idiopathic scoliosis

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of the spine. While AIS can progress during growth and cause a surface deformity, it is usually not symptomatic. However, if the final spinal curvature surpasses a certain critical threshold, the risk of health problems and curve progression is increased. Interventions for the prevention of AIS progression include scoliosis-specific exercises, bracing, and surgery. The main aims of all types of interventions are to correct the deformity and prevent further deterioration of the curve and to restore trunk asymmetry and balance, while minimising morbidity and pain, allowing return to full function. Surgery is normally recommended for curvatures exceeding 40 to 50 degrees to stop curvature progression with a view to achieving better truncal balance and cosmesis. Short-term results of the surgical treatment of people with AIS demonstrate the ability of surgery to improve various outcome measures. However there is a clear paucity of information on long-term follow-up of surgical treatment of people with AIS.

OBJECTIVES

To examine the impact of surgical versus non-surgical interventions in people with AIS who have severe curves of over 45 degrees, with a focus on trunk balance, progression of scoliosis, cosmetic issues, quality of life, disability, psychological issues, back pain, and adverse effects, at both the short term (a few months) and the long term (over 20 years).

SEARCH METHODS

We searched the Cochrane Back Review Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, four other databases, and three trials registers up to August 2014 with no language limitations. We also checked the reference lists of relevant articles and conducted an extensive handsearch of the grey literature.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs) and prospective controlled trials comparing spinal fusion surgery with non-surgical interventions in people with AIS with a Cobb angle greater than 45 degrees. We were interested in all types of instrumented surgical interventions with fusion that aimed to provide curve correction and spine stabilisation.

DATA COLLECTION AND ANALYSIS

We found no RCTs or prospective controlled trials that met our inclusion criteria.

MAIN RESULTS

We did not identify any evidence comparing surgical to non-surgical interventions for AIS with severe curves of over 45 degrees.

AUTHORS' CONCLUSIONS

We cannot draw any conclusions.

Rib index

This article analyzes the double rib contour sign (DRCS) and the rib index (RI). The analyzed topics are 1. the history of presentations - publication of DRCS-RI, 2. the study source origin: school screening for idiopathic scoliosis (IS), 3. what the DRCS and the RI are- Description, 4. the quantification of the DRCS - RI, 5. a reliability study for RI 6. how much the rib index is affected by the distance between the radiation source and the irradiated individual, 7. the implications on IS aetiology, 8. the applications of Rib index for a. documentation of the deformity, b. assessment of physiotherapy, c. assessment of brace treatment and d. pre- and post-operative assessment; assessment of the rib-cage deformity correction on the transverse plane, 9. the use of RI and implications for screening policies 10. the reference of the RI method in spinal textbooks and finally 11. the citations in Google Scholar.

The prevalence of idiopathic scoliosis in eleven year-old Korean adolescents: a 3 year epidemiological study

PURPOSE

School screening allows for early detection and early treatment of scoliosis, with the purpose of reducing the number of patients requiring surgical treatment. Children between 10 and 14 years old are considered as good candidates for school screening tests of scoliosis. The purpose of the present study was to assess the epidemiological findings of idiopathic scoliosis in 11-year-old Korean adolescents.

MATERIALS AND METHODS

A total of 37856 11-year-old adolescents were screened for scoliosis. There were 17110 girls and 20746 boys. Adolescents who were abnormal by Moire topography were subsequently assessed by standardized clinical and radiological examinations. A scoliotic curve was defined as 10° or more.

RESULTS

The prevalence of scoliosis was 0.19% and most of the curves were small (10° to 19°). The ratio of boys to girls was 1:5.5 overall. Sixty adolescents (84.5%) exhibited single curvature. Thoracolumbar curves were the most common type of curve identified, followed by thoracic and lumbar curves.

CONCLUSION

The prevalence of idiopathic scoliosis among 11-year-old Korean adolescents was 0.19%.

The pendulum swings back to scoliosis screening: screening policies for early detection and treatment of idiopathic scoliosis - current concepts and recommendations

This editorial article initiates the school scoliosis screening thematic series of the Scoliosis journal. The various issues on screening policies are discussed; clinical and practical recommendations of setting up school screening programs are also described.

Scoliosis detection, patient characteristics, referral patterns and treatment in the absence of a screening program in Norway

BACKGROUND

Early diagnosis of idiopathic scoliosis allows for observation and timely initiation of brace treatment in order to halt progression. School scoliosis screening programs were abolished in Norway in 1994 for lack of evidence that the programs improved outcome and for the costs involved. The consequences of this decision are discussed.

OBJECTIVES

To describe the detection, patient characteristics, referral patterns and treatment of idiopathic scoliosis at a scoliosis clinic during the period 2003-2011, when there was no screening and to compare treatment modalities to the period 1976-1988 when screening was performed.

METHODS

Patient demographics, age at detection, family history, clinical and radiological charts of consecutive patients referred for scoliosis evaluation during the period 2003-2011, were prospectively registered. Patients were recruited from a catchment area of about 500000 teenagers. Maturity was estimated according to Risser sign and menarcheal status. Severity of pain was recorded by a verbal 5-point scale from no pain to pain at all times. Physical and neurological examinations were conducted. The detector and patient characteristics were recorded. Referral patterns of orthopedic surgeons at local hospitals and other health care providers were recorded. Patient data was obtained by spine surgeons. Treatment modalities in the current period were compared to the period 1976-1988.

RESULTS

We registered 752 patients with late onset juvenile and adolescent idiopathic scoliosis from 2003-2011. There were 644 (86%) girls and 108 (14%) boys. Mean age at detection was 14.6 (7-19) years. Sixty percent had Risser sign ≥ 3, whilst 74% were post menarche with a mean age at menarche of 13.2 years. Thirty-one percent had a family history of scoliosis. The mean major curve at first consultation at our clinic was 38° (10°-95°). About 40% had a major curve >40°. Seventy-one percent were detected by patients, close relatives, and friends. Orthopaedic surgeons referred 61% of the patients. The mean duration from detection to the first consultation was 20(0-27) months. The proportion of the average number of patients braced each year was 68% during the period with screening compared to 38% in the period without screening, while the proportion for those operated was 32% and 62%, respectively ( p=0.002, OR 3.5, (95%CI 1.6 to 7.5).

CONCLUSION

In the absence of scoliosis screening, lay persons most often detect scoliosis. Many patients presented with a mean Cobb angle approaching the upper limit for brace treatment indications. The frequency of brace treatment has been reduced and surgery is increased during the recent period without screening compared with the period in the past when screening was still conducted.

School screening and point prevalence of adolescent idiopathic scoliosis in 4000 Norwegian children aged 12 years

BACKGROUND

School screening for adolescent idiopathic scoliosis (AIS) is discussed. The aim of the present study was to describe the point prevalence of AIS and to evaluate the effectiveness of school screening in 12-year- old children.

METHODS

Community nurses and physical therapists in the Southern Health region of Norway including about 12000 school children aged 12 years were invited to participate. All participating community nurses and physical therapists fulfilled an educational course to improve their knowledge about AIS and learn the screening procedure including the Adam Forward Bending Test and measurement of gibbus using a scoliometer.

RESULTS

Sub-regions including 4000 school children participated. The prevalence of idiopathic scoliosis defined as a positive Adam Forward Bending Test, gibbus > 7° and primary major curve on radiographs > 10°, was 0.55%. Five children (0.13%) had a major curve > 20°. Bracing was not indicated in any child; all children were post menarche; four had Risser sign of 4, and one with Risser 1 did not have curve progression > 5° at later follow-up. In one of these 5 children however, the major curve progressed to 45° within 7 months after screening and the girl was operated.

CONCLUSION

The point prevalence of AIS in 12- year old children is in agreement or slightly lower than previous studies. The screening model employed demonstrates acceptable sensitivity and specificity and low referral rates. Screening at the age of 12 years only was not effective for detecting patients with indication for brace treatment.

Early onset scoliosis: what the primary care provider needs to know and implications for practice

PURPOSE

The purpose of this article is to discuss the role of the primary care provider in the detection of and referral for early onset scoliosis. An overview of scoliosis including etiology, natural history, guidelines for physical examination, current practice for scoliosis screening, and available treatments will be discussed.

DATA SOURCES

PubMed, OVID Medline, Psychinfo. Search terms: juvenile scoliosis, childhood onset scoliosis, early onset scoliosis, idiopathic scoliosis, and infantile scoliosis.

CONCLUSIONS

Scoliosis is classified depending on the magnitude, location, direction, and cause of the curve, and can lead to a variety of health effects if not treated. The greater the scoliosis curve and the earlier it presents, the more likely it may affect thoracic growth, inhibit cardiopulmonary function, and cause psychosocial distress.

IMPLICATIONS FOR PRACTICE

Routine scoliosis screening should be incorporated into each healthcare maintenance visit beginning in infancy and continue into adolescence until the child reaches skeletal maturity. Curves with a scoliometer reading greater than 5° should be referred, and conservative treatment should be considered for curves that surpass 20°. If scoliosis is detected early, it may be possible to stabilize the curve from progressing and even prevent thoracic deformity and secondary complications from occurring.

Referral criteria for school scoliosis screening: assessment and recommendations based on a large longitudinally followed cohort

STUDY DESIGN

This study was a retrospective cohort study.

OBJECTIVE

To examine the criteria recommended in the literature for the school-based scoliosis screening program in Hong Kong.

SUMMARY OF BACKGROUND DATA

School-based screening for scoliosis has been a controversy. Objectors to the policy were concerned about the high over-referral and false-positive rates. Recommendations were then made for improvement, but the feasibility of these recommendations has not been studied.

METHODS

The cohort consisted of students in Grade 5 in 1995/1996 or 1996/1997 who underwent scoliosis screening in Hong Kong. Participants who had an angle of trunk rotation (ATR) ≥15°, 2 or more moiré lines, or presented significant clinical signs were referred for radiography. Screening histories and radiography records before the age of 19 years were extracted. The accuracy measures for different combinations of screening tests were examined.

RESULTS

There were 115,178 students in the cohort, of which 3228 (2.8%) were referred for radiography. Among the 1406 students who displayed a curve ≥20° during screening, 257 (18.3%) were boys and 336 (23.9%) were identified as 16 years or older, ruling out the suggestion of screening only 10-year-old girls. The sensitivity and positive predictive value for the current referral criteria were 88.1% and 43.6%, respectively. The sensitivity would drop substantially if the use of moiré topography (39.8%) or clinical signs (55.5%) were discarded. With the inclusion of these 2 tests, the clinical effectiveness measures were robust to the cutoff for ATR, unless it was set below 10°.

CONCLUSION

Selectively screening only premenarche girls was not feasible, as this screen would have missed a significant proportion of children with significant curvature. No refinement of the current protocol was necessary, although boys could be screened beginning at 12 years of age. The tandem use of ATR, moiré topography, and clinical signs was recommended for future studies.

Clinical effectiveness of school screening for adolescent idiopathic scoliosis: a large population-based retrospective cohort study

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate the clinical effectiveness of school scoliosis screening using a large and long-term-followed cohort of students in Hong Kong.

SUMMARY OF BACKGROUND DATA

School screening for adolescent idiopathic scoliosis has been criticized as resulting in over-referrals for radiography and having low predictive values. Indeed, all but one previous retrospective cohort studies had no follow-up assessments of students until their skeletal maturity, leaving any late-developed curves undetected. The one study that completed this follow-up was well conducted but had low precisions due to its small sample size.

METHODS

A total of 157,444 students were eligible for a biennial scoliosis screening, and their screening results and medical records up to 19 years of age were available. Students first had forward bending test and angle of trunk rotation (ATR) performed. Those with ATR between 5 degrees and 14 degrees or signs of adolescent idiopathic scoliosis were assessed by moiré topography regularly. Students with an ATR >or=15 degrees , >or=2 moiré lines, or significant clinical signs were referred for radiography and had their Cobb angle measured.

RESULTS

Of the 115,190 screened students in the cohort, 3228 (2.8%, 95% confidence interval [CI] = 2.7%-2.9%) were referred for radiography. At the final follow-up, the positive predictive values were 43.6% (41.8%-45.3%) for a Cobb angle >or=20 degrees and 9.4% (8.4%-10.5%) for needing treatment, while the sensitivities were 88.1% (86.4%-89.6%) and 80.0% (75.6%-83.9%), respectively.

CONCLUSION

This is the largest study that has demonstrated that school scoliosis screening in Hong Kong is predictive and sensitive with a low referral rate. Screening should thus be continued in order to facilitate early administration of conservative treatments.

Reversal of childhood idiopathic scoliosis in an adult, without surgery: a case report and literature review

BACKGROUND

Some patients with mild or moderate thoracic scoliosis (Cobb angle <50-60 degrees) suffer disproportionate impairment of pulmonary function associated with deformities in the sagittal plane and reduced flexibility of the spine and chest cage. Long-term improvement in the clinical signs and symptoms of childhood onset scoliosis in an adult, without surgical intervention, has not been documented previously.

CASE PRESENTATION

A diagnosis of thoracic scoliosis (Cobb angle 45 degrees) with pectus excavatum and thoracic hypokyphosis in a female patient (DOB 9/17/52) was made in June 1964. Immediate spinal fusion was strongly recommended, but the patient elected a daily home exercise program taught during a 6-week period of training by a physical therapist. This regime was carried out through 1992, with daily aerobic exercise added in 1974. The Cobb angle of the primary thoracic curvature remained unchanged. Ongoing clinical symptoms included dyspnea at rest and recurrent respiratory infections. A period of multimodal treatment with clinical monitoring and treatment by an osteopathic physician was initiated when the patient was 40 years old. This included deep tissue massage (1992-1996); outpatient psychological therapy (1992-1993); a daily home exercise program focused on mobilization of the chest wall (1992-2005); and manipulative medicine (1994-1995, 1999-2000). Progressive improvement in chest wall excursion, increased thoracic kyphosis, and resolution of long-standing respiratory symptoms occurred concomitant with a >10 degree decrease in Cobb angle magnitude of the primary thoracic curvature.

CONCLUSION

This report documents improved chest wall function and resolution of respiratory symptoms in response to nonsurgical approaches in an adult female, diagnosed at age eleven years with idiopathic scoliosis.

Relatively lower body mass index is associated with an excess of severe truncal asymmetry in healthy adolescents: Do white adipose tissue, leptin, hypothalamus and sympathetic nervous system influence truncal growth asymmetry?

BACKGROUND

In healthy adolescents normal back shape asymmetry, here termed truncal asymmetry (TA), is evaluated by higher and lower subsets of BMI. The study was initiated after research on girls with adolescent idiopathic scoliosis (AIS) showed that higher and lower BMI subsets discriminated patterns of skeletal maturation and asymmetry unexplained by existing theories of pathogenesis leading to a new interpretation which has therapeutic implications (double neuro-osseous theory).

METHODS

5953 adolescents age 11-17 years (boys 2939, girls 3014) were examined in a school screening program in two standard positions, standing forward bending (FB) and sitting FB. The sitting FB position is thought to reveal intrinsic TA free from back humps induced by any leg-length inequality. TA was measured in both positions using a Pruijs scoliometer as angle of trunk inclinations (ATIs) across the back at each of three spinal regions, thoracic, thoracolumbar and lumbar. Abnormality of ATIs was defined as being outside 2 standard deviations for each age group, gender, position and spinal region, and termed severe TA.

RESULTS

In the sitting FB position after correcting for age,relatively lower BMIs are statistically associated with a greater number of severe TAs than with relatively higher BMIs in both girls (thoracolumbar region) and boys (thoracolumbar and lumbar regions).The relative frequency of severe TAs is significantly higher in girls than boys for each of the right thoracic (56.76%) and thoracolumbar (58.82%) regions (p = 0.006, 0.006, respectively). After correcting for age, smaller BMIs are associated with more severe TAs in boys and girls.

DISCUSSION

BMI is a surrogate measure for body fat and circulating leptin levels. The finding that girls with relatively lower BMI have significantly later menarche, and a significant excess of TAs, suggests a relation to energy homeostasis through the hypothalamus. The hypothesis we suggest for the pathogenesis of severe TA in girls and boys has the same mechanism as that proposed recently for AIS girls, namely: severe TAs are initiated by a genetically-determined selectively increased hypothalamic sensitivity (up-regulation, i.e. increased sensitivity) to leptin with asymmetry as an adverse response to stress (hormesis), mediated bilaterally mainly to the growing trunk via the sympathetic nervous system (leptin-hypothalamic-sympathetic nervous system (LHS) concept). The putative autonomic dysfunction is thought to be increased by any lower circulating leptin levels associated with relatively lower BMIs. Sympathetic nervous system activation with asymmetry leads to asymmetries in ribs and/or vertebrae producing severe TA when beyond the capacity of postural mechanisms of the somatic nervous system to control the shape distortion of the trunk. A test of this hypothesis testing skin sympathetic responses, as in the Rett syndrome, is suggested.