School screening for scoliosis

The Effect of the Schroth Rehabilitation Exercise Program on Spinal and Feet Alignment in Adolescent Patients with Idiopathic Scoliosis: A Pilot Study

Background: This study investigated the therapeutic effects of 12-week Schroth rehabilitation exercises (SRE) in improving Cobb’s angle, scoliometer readings, lumbar lordosis, and the calcaneal valgus angle of patients with idiopathic scoliosis. Methods: This pilot study included 60 adolescent patients diagnosed with idiopathic scoliosis by a rehabilitation physician based on a Cobb’s angle of ≥10° using total anteroposterior plain radiography. Patients were classified into groups with a Cobb’s angle of 10–19° (G1), 20–29° (G2), and ≥30° (G3). Cobb’s angle, scoliometer readings, lumbar lordosis, and calcaneal valgus angles were analyzed before and after the 12-week SRE. Results: SRE improved Cobb’s angle (−6.85), scoliometer readings (−2.80), lumbar lordosis (4.23), and calcaneal valgus angles (left, −3.76; right, −2.83) regardless of the initial scoliosis angle, and within-group changes were significant (p < 0.001). In this study, participants in all three groups had undergone SRE, regardless of initial scoliosis severity, and the findings were significant. Conclusion: SRE can be used for patients with idiopathic scoliosis to improve asymmetric musculoskeletal morphology and the patient’s quality of life.

Postural habits and weight of backpacks of Portuguese adolescents: Are they associated with scoliosis and low back pain?

BACKGROUND

The adoption of incorrect postures or carrying overweight backpacks may contribute to the development of musculoskeletal disorders in school children.

OBJECTIVE

This study evaluated the weight of backpacks and the postural habits adopted in schools by Portuguese adolescents, and their association with scoliosis and low back pain (LBP).

METHOD

The sample comprised 966 Portuguese students, aged between 10 and 16 years. The instruments included a questionnaire to characterize the presence of LBP and the postural habits adopted by students, the weighing of backpacks and a scoliometer to evaluate scoliosis.

RESULTS

No association was observed between assuming incorrect postures and carrying overweight backpacks, in students with scoliosis. Students who adopted incorrect sitting postures had 1.77 times the risk (95% CI: 1.32-2.36; p < 0.001) of developing LBP; those positioned incorrectly whilst watching TV and playing games had 1.44 times the risk (95% CI: 1.08-1.90; p = 0.012) of developing LBP; and those standing incorrectly had 2.39 the risk (95% CI: 1.52-3.78; p < 0.001) of developing LBP.

CONCLUSIONS

The results revealed that students who sat with the spine positioned wrongly, as well as those who were standing incorrectly, were more likely to present with LBP.

The correlation between calcaneal valgus angle and asymmetrical thoracic-lumbar rotation angles in patients with adolescent scoliosis

[Purpose] This study aimed to provide a predictable evaluation method for the progression of scoliosis in adolescents based on quick and reliable measurements using the naked eye, such as the calcaneal valgus angle of the foot, which can be performed at public facilities such as schools. [Subjects and Methods] Idiopathic scoliosis patients with a Cobb’s angle of 10° or more (96 females, 22 males) were included in this study. To identify relationships between factors, Pearson’s product-moment correlation coefficient was computed. The degree of scoliosis was set as a dependent variable to predict thoracic and lumbar scoliosis using ankle angle and physique factors. Height, weight, and left and right calcaneal valgus angles were set as independent variables; thereafter, multiple regression analysis was performed. This study extracted variables at a significance level (α) of 0.05 by applying a stepwise method, and calculated a regression equation. [Results] Negative correlation (R=−0.266) was shown between lumbar lordosis and asymmetrical lumbar rotation angles. A correlation (R=0.281) was also demonstrated between left calcaneal valgus angles and asymmetrical thoracic rotation angles. [Conclusion] Prediction of scoliosis progress was revealed to be possible through ocular inspection of the calcaneus and Adams forward bending test and the use of a scoliometer.

School Scoliosis Screenings: Family Experiences and Potential Anxiety After Orthopaedic Referral

STUDY DESIGN

Cross-sequential study design that used data from Texas Scottish Rite Hospital for Children (TSRHC).

OBJECTIVE

Examine anxiety symptoms and family experiences subsequent to school scoliosis screening (SSS) referrals.

SUMMARY OF BACKGROUND DATA

Use of SSS remains controversial. Prior research suggested that SSS programs may result in anxiety for both children and parents. Unfortunately, no study has examined the SSS referral processes and anxiety in families.

METHODS

Study consisted of 2 groups-patients/parents from TSRHC evaluated for Adolescent Idiopathic Scoliosis (AIS) (n = 27) and control participants/parents (n = 27) between ages 9 and 17. All participants completed the primary outcome measure (State-Trait Anxiety Inventory) before and after the scoliosis evaluation or controlled wait time. Parents also rated experience and satisfaction with SSS.

RESULTS

Compared with the control group, children/parents in patient group experienced significantly elevated levels of state-anxiety at preappointment. Children/parents in the patient group not diagnosed with AIS experienced a significant decline in state-anxiety. Children/parents in the patient group diagnosed with AIS continued to report elevated levels of anxiety. The control group remained consistent, reporting of low levels of anxiety pre to post. More than half (55.5%) of families indicated they received no information from the school about scoliosis. A third of the families who received information indicated it did not adequately address their concerns. Nonetheless, most families reported overall satisfaction with SSS.

CONCLUSION

This study suggested that children and parents referred through the SSS program experienced significantly elevated levels of state-anxiety. This supports the subjective concerns of anxiety experiences in families voiced by researchers previously. However, families deemed the costs of the SSS referral process as worth the benefits. Though challengers of SSS programs were accurate in observing anxiety in families, it may not constitute significant burden to eliminate SSS programs altogether. Improvements to the current system may be warranted.

LEVEL OF EVIDENCE

3.

Idiopathic Scoliosis Prevalence Is 5 Times Less in Roma Than Greek Children and Adolescents

STUDY DESIGN

Serial screening of Roma children for idiopathic scoliosis.

OBJECTIVE

To confirm or reject the observation that the prevalence of scoliosis is reduced in the Roma population and possibly to explain it.

MATERIALS AND METHODS

The authors conducted serial screening for idiopathic scoliosis of 1,034 indigenous Roma children (542 boys and 492 girls), aged 4-18 years (857 children were aged 8-18 years) from 1997 to 2011. Age, height, weight, body mass index, years of schooling, and menarche for girls were recorded. Children were clinically examined for body asymmetries and a standing posteroanterior spinal radiograph was obtained in selected cases.

RESULTS

Sixty Roma children (6%) had clinical humps. Single humps, according to location, were mostly benign and not related to progressive scoliotic curves. In children with right thoracic humps a left lumbar component could be overlooked. Of 60 children, only 4 (3 girls and 1 boy) with right thoracic and left lumbar or thoracolumbar humps had true progressive scoliotic curves with greater than 10° Cobb angle (prevalence rate, 0.35%). This is 5 times less than the rate of 1.5% in Greek children. One of these 4 children was young and had possible congenital scoliosis; the other 3 were early adolescents.

CONCLUSIONS

A substantial difference in the prevalence of scoliosis between Roma and Greek children was documented. The usual percentage of adolescent scoliosis found in the Greek population (approximately 15-17 cases/1,000 children) was not seen in this sample of Roma children.

The effectiveness of scoliosis screening programs: methods for systematic review and expert panel recommendations formulation

BACKGROUND

Literature on scoliosis screening is vast, however because of the observational nature of available data and methodological flaws, data interpretation is often complex, leading to incomplete and sometimes, somewhat misleading conclusions. The need to propose a set of methods for critical appraisal of the literature about scoliosis screening, a comprehensive summary and rating of the available evidence appeared essential.

METHODS

To address these gaps, the study aims were: i) To propose a framework for the assessment of published studies on scoliosis screening effectiveness; ii) To suggest specific questions to be answered on screening effectiveness instead of trying to reach a global position for or against the programs; iii) To contextualize the knowledge through expert panel consultation and meaningful recommendations. The general methodological approach proceeds through the following steps: Elaboration of the conceptual framework; Formulation of the review questions; Identification of the criteria for the review; Selection of the studies; Critical assessment of the studies; Results synthesis; Formulation and grading of recommendations in response to the questions. This plan follows at best GRADE Group (Grades of Recommendation, Assessment, Development and Evaluation) requirements for systematic reviews, assessing quality of evidence and grading the strength of recommendations.

CONCLUSIONS

In this article, the methods developed in support of this work are presented since they may be of some interest for similar reviews in scoliosis and orthopaedic fields.

Optimal management of idiopathic scoliosis in adolescence

Idiopathic scoliosis is a three-dimensional deformity of the growing spine, affecting 2%-3% of adolescents. Although benign in the majority of patients, the natural course of the disease may result in significant disturbance of body morphology, reduced thoracic volume, impaired respiration, increased rates of back pain, and serious esthetic concerns. Risk of deterioration is highest during the pubertal growth spurt and increases the risk of pathologic spinal curvature, increasing angular value, trunk imbalance, and thoracic deformity. Early clinical detection of scoliosis relies on careful examination of trunk shape and is subject to screening programs in some regions. Treatment options are physiotherapy, corrective bracing, or surgery for mild, moderate, or severe scoliosis, respectively, with both the actual degree of deformity and prognosis being taken into account. Physiotherapy used in mild idiopathic scoliosis comprises general training of the trunk musculature and physical capacity, while specific physiotherapeutic techniques aim to address the spinal curvature itself, attempting to achieve self-correction with active trunk movements developed in a three-dimensional space by an instructed adolescent under visual and proprioceptive control. Moderate but progressive idiopathic scoliosis in skeletally immature adolescents can be successfully halted using a corrective brace which has to be worn full time for several months or until skeletal maturity, and is able to prevent more severe deformity and avoid the need for surgical treatment. Surgery is the treatment of choice for severe idiopathic scoliosis which is rapidly progressive, with early onset, late diagnosis, and neglected or failed conservative treatment. The psychologic impact of idiopathic scoliosis, a chronic disease occurring in the psychologically fragile period of adolescence, is important because of its body distorting character and the onerous treatment required, either conservative or surgical. Optimal management of idiopathic scoliosis requires cooperation within a professional team which includes the entire therapeutic spectrum, extending from simple watchful observation of nonprogressive mild deformities through to early surgery for rapidly deteriorating curvature. Probably most demanding is adequate management with regard to the individual course of the disease in a given patient, while avoiding overtreatment or undertreatment.

Heated indoor swimming pools, infants, and the pathogenesis of adolescent idiopathic scoliosis: a neurogenic hypothesis

BACKGROUND

In a case-control study a statistically significant association was recorded between the introduction of infants to heated indoor swimming pools and the development of adolescent idiopathic scoliosis (AIS). In this paper, a neurogenic hypothesis is formulated to explain how toxins produced by chlorine in such pools may act deleteriously on the infant's immature central nervous system, comprising brain and spinal cord, to produce the deformity of AIS.

PRESENTATION OF THE HYPOTHESIS

Through vulnerability of the developing central nervous system to circulating toxins, and because of delayed epigenetic effects, the trunk deformity of AIS does not become evident until adolescence. In mature healthy swimmers using such pools, the circulating neurotoxins detected are chloroform, bromodichloromethane, dibromochloromethane, and bromoform. Cyanogen chloride and dichloroacetonitrile have also been detected.

TESTING THE HYPOTHESIS

In infants, the putative portals of entry to the blood could be dermal, oral, or respiratory; and entry of such circulating small molecules to the brain are via the blood-brain barrier, blood-cerebrospinal fluid barrier, and circumventricular organs. Barrier mechanisms of the developing brain differ from those of adult brain and have been linked to brain development. During the first 6 months of life cerebrospinal fluid contains higher concentrations of specific proteins relative to plasma, attributed to mechanisms continued from fetal brain development rather than immaturity.

IMPLICATIONS OF THE HYPOTHESIS

The hypothesis can be tested. If confirmed, there is potential to prevent some children from developing AIS.

Idiopathic scoliosis in Korean schoolchildren: a prospective screening study of over 1 million children

Cross-sectional epidemiologic scoliosis screening was carried out to determine the current prevalence of scoliosis in the Korean population and to compare with the results of previous studies. Between 2000 and 2008, 1,134,890 schoolchildren underwent scoliosis screening. The children were divided into two age groups, 10-12-year-olds (elementary school) and 13-14-year-olds (middle school), to calculate age- and sex-specific prevalence rates. Children with a scoliometer reading ≥5° were referred for radiograms. Two surgeons independently measured curve types, magnitudes, and Risser scores (inter-observer r = 0.964, intra-observer r = 0.978). Yearly and overall prevalence rates of scoliosis were calculated. There were 584,554 boys and 550,336 girls in the sample, with a male to female ratio of 1.1:1. There were 77,910 (6.2%) children (26,824 boys and 51,086 girls) with scoliometer readings >5°, and 37,339 of them had positive results with Cobb angles ≥10° (positive predictive value, 46.4%). The overall scoliosis prevalence rate was 3.26%; girls had a higher prevalence (4.65%) than boys (1.97%). Prevalence rates increased progressively from 1.66 to 6.17% between 2000 and 2008, with the exception of 2002. According to age and gender, 10-12-year-old girls had the highest scoliosis prevalence rates (5.57%), followed by 13-14-year-old girls (3.90%), 10-12-year-old boys (2.37%), and 13-14-year-old boys (1.42%). In girls and boys, prevalence rates dropped by 64.53 and 60.65% among 10-12-year-olds and 13-14-year-olds, respectively (P = 0.00). The proportion of 10°-19° curves was 95.25 and 84.45% in boys and girls, respectively; and the proportion of 20°-29° curves was 3.91 and 11.28%, which was a significant difference (P = 0.00). Thoracic curves were the most common (47.59%) followed by thoracolumbar/lumbar (40.10%), double (9.09%), and double thoracic (3.22%) curves. A comparison of the curve patterns revealed significant differences between genders (P = 0.00). We present this report as a guide for studying the prevalence of idiopathic scoliosis in a large population, and the increasing trend in the prevalence of idiopathic scoliosis emphasizes the need for awareness.

Costs of school scoliosis screening: a large, population-based study

STUDY DESIGN

This was a population-based retrospective study.

OBJECTIVE

To fully estimate the costs of the Hong Kong scoliosis screening program through a large, population-based study.

SUMMARY OF BACKGROUND DATA

School screening for scoliosis has often been criticized for having high costs. In fact, the screening cost that has reported varied widely, from less than 1 to more than 30 US dollars (USD) per child screened. This variation is mainly due to the incomplete inclusion of cost items.

METHODS

We examined the screening and medical histories of a cohort of 115,190 screened students who were in Grade 5 in 1995/96 or 1996/97. The average costs spent on screening, diagnosing, following, and treating this cohort of students were calculated.

RESULTS

The total expenses in the screening centers increased steadily from USD 380,930 in 1995/96 to USD 2,417,824 in 2005/06. Based on the 115,190 students who were followed up until they were 19 years old or they left school, the costs of screening and diagnosing 1 student during adolescence were USD 17.94 and USD 2.08, respectively. Of the 1311 referrals who attended the specialist hospitals for diagnosis, 264 and 39 had been braced and operated on, respectively. The medical care cost averaged USD 34.61 per student screened. The cost of finding 1 student with a curvature ≥20° and 1 treated case were USD 4475.67 and USD 20,768.29 respectively.

CONCLUSION

This was the largest study that has evaluated school scoliosis screening on students who were followed during their adolescence and accounted for all relevant costs. The cost per student screened in the scoliosis screening program in Hong Kong was comparable to that in Rochester, which had a similar protocol and was evaluated in a similar manner. The estimated costs can help the policy makers when they allocate healthcare resources.

A meta-analysis of the clinical effectiveness of school scoliosis screening

STUDY DESIGN

A meta-analysis that systematically reviewed the evaluation studies of a scoliosis screening program reported in the literature.

OBJECTIVE

To evaluate the best current evidence on the clinical effectiveness of school screening for adolescent idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

The use of school scoliosis screening is controversial, and its clinical effectiveness has been diversely reported.

METHODS

Data sources included 3 databases, namely, PubMed, Google scholar, CINAHL database, and the references from identified reviews and studies. Studies were included if: (1) they adopted a retrospective cohort design; (2) were screened using either the forward bending test (FBT), angle of trunk rotation, or Moiré topography; (3) reported results of screening tests and radiographic assessments; (4) screened adolescents only; (5) reported the incidence of curves with a minimum Cobb angle of 10 degrees or greater; and (6) reported the number of referrals for radiography. Reviews, comments, case studies, and editorials were excluded.

RESULTS

Thirty-six studies, including 34 from the 775 initially identified studies and 2 from the references, met the selection criteria. The pooled referral rate for radiography was 5.0%, and the pooled positive predictive values for detecting curves > or =10 degrees , curves > or =20 degrees , and treatment were 28.0%, 5.6%, and 2.6%, respectively. There was substantial heterogeneity across studies. Meta-regression showed that programs using the FBT alone reported a higher referral rate (odds ratio [OR] = 2.91) and lower positive predictive values for curves > or =10 degrees (OR = 0.49) and curves > or =20 degrees (OR = 0.34) than programs using other tests. Only one small study followed students until skeletal maturity and reported the sensitivity of screening; however, the specificity was not reported. No severe publication bias was noted.

CONCLUSION

The use of the FBT alone in school scoliosis screening is insufficient. We need large, retrospective cohort studies with sufficient follow-up to properly assess the clinical effectiveness of school scoliosis screening.

The use of exercises in the treatment of scoliosis: an evidence-based critical review of the literature

The loss of flexibility in a spinal curvature defines it as a structural spinal deformity; a curvature sufficiently mobile to resolve with a change in posture is a non-structural or 'functional' scoliosis which is within the normal limits of movement for a human spine. It, therefore, seems logical that exercise-based therapies designed to improve and/or maintain flexibility and range of motion of the spine and thorax would be useful in the treatment of scoliosis. Recognition of the importance of maintaining flexibility of the thoracic spinal column to avoid scoliosis-associated pulmonary dysfunction made the use of exercise-based therapies a topic of clinical interest in ancient Greece. In recent years, successful prevention of polio epidemics has resulted in a stable change in patient populations such that most individuals diagnosed with scoliosis do not suffer from irreversible central nervous system compromise. As a result, realistic opportunities to examine the role of exercise in treatment of scoliosis are available for the first time in history. A growing body of evidence from independent sources is consistent with the hypothesis that exercise-based approaches can be used effectively to reverse the signs and symptoms of spinal deformity and to prevent progression in children and adults.

Idiopathic scoliosis

Idiopathic scoliosis (IS) most commonly develops during adolescence, but may present at any age from infancy through adulthood. Patients with IS are evaluated clinically and radiographically to determine whether the deformity is, in fact, idiopathic, to elucidate any symptoms related to the scoliosis, and to characterize the deformity itself. In patients who have not yet reached skeletal maturity, the treatment of IS is often prophylactic, with the aim of preventing the curve from reaching a magnitude that would make continued progression in adulthood likely. Adult patients with IS are most frequently treated because of symptoms, usually back or leg pain. IS is typically treated with anterior or posterior spinal fusion; treatment of very young patients is complicated by the need to allow growth to continue while controlling the scoliosis.

Children at risk identified in an urban scoliosis school screening program: a new model

School-based scoliosis screening programs, although controversial, remain well established. Our hypothesis was that with the addition of several inexpensive and simple measurements (height/weight, questionnaire), the overall impact of our screening program could be dramatically increased. Of the 1,058 children screened, 30 (2.8%) were positive for scoliosis. We found that 284 children (27%) were overweight and 468 (44%) children were overweight or at risk for overweight. Additionally, 61% of children did not have an identified primary health provider. These additional measurements did not change the efficacy of scoliosis screening but dramatically increased the number of children identified at risk for significant health problems.

SOSORT consensus paper: school screening for scoliosis. Where are we today?

This report is the SOSORT Consensus Paper on School Screening for Scoliosis discussed at the 4th International Conference on Conservative Management of Spinal Deformities, presented by SOSORT, on May 2007. The objectives were numerous, 1) the inclusion of the existing information on the issue, 2) the analysis and discussion of the responses by the meeting attendees to the twenty six questions of the questionnaire, 3) the impact of screening on frequency of surgical treatment and of its discontinuation, 4) the reasons why these programs must be continued, 5) the evolving aim of School Screening for Scoliosis and 6) recommendations for improvement of the procedure.

Impact of spine surgery on signs and symptoms of spinal deformity

Paediatric scoliosis is associated with signs and symptoms including reduced pulmonary function, increased pain and impaired quality of life, all of which worsen during adulthood, even when the curvature remains stable. Spinal fusion has been used as a treatment for nearly 100 years. In 1941, the American Orthopedic Association reported that for 70% of patients treated surgically, outcome was fair or poor: an average 65% curvature correction was reduced to 27% at >2 year follow-up and the torso deformity was unchanged or worse. Outcome was worse in children treated surgically before age 10, despite earlier intervention. Today, a reduced magnitude of curvature obtained by spinal fusion in adolescence can be maintained for decades. However, successful surgery still does not eliminate spinal curvature and it introduces irreversible complications whose long-term impact is poorly understood. For most patients there is little or no improvement in pulmonary function. Some report improved pain after surgery, some report no improvement and some report increased pain. The rib deformity is eliminated only by rib resection which can dramatically reduce respiratory function even in healthy adolescents. Outcome for pulmonary function and deformity is worse in patients treated surgically before the age of 10 years, despite earlier intervention. Research to develop effective non-surgical methods to prevent progression of mild, reversible spinal curvatures into complex, irreversible structural deformities, is long overdue.

Social acceptability of treatments for adolescent idiopathic scoliosis: a cross-sectional study

Background

There are no data on social acceptability of scoliosis. Aim. To elicit evidence-based opinions on therapeutic strategies for adolescent idiopathic scoliosis in a sample of families with not affected children, so to understand the social perception of this issue.

Methods

Design. Cross-sectional study. Setting. Secondary schools in 4 northern Italian regions. Participants. Parents of children in the age group at risk of and not affected by scoliosis (Pre-test group = 100, Study group = 3,162). Interventions. Questionnaire: five specific and evidence-based questions regarding scoliosis treatment options and a socio-demographic section. Methodology. "Role-playing" in which it was required to normal people to answer what they would have chosen if they had been in the situation proposed. Main outcome measures. Perception of acceptability of treatments for adolescent idiopathic scoliosis in the general population (social acceptability)

Results

The families support the use of screening (94.8%) at school, immediate bracing (76.4%) for scoliosis with a 60% risk of progression, but also therapeutic exercises (86.9%) in cases with a 25% risk of progression.

Conclusion

There is a growing tendency to consider not only the efficacy, effectiveness and efficiency of treatments, but also their acceptability. This patient-centred aspect is especially more important in areas (like adolescent idiopathic scoliosis) in which there is some evidence on the efficacy of treatments, but not strong and definitive (RCTs). Adolescent idiopathic scoliosis treatments should thus be carefully considered also in the light of their social acceptability.

Quantifier variables of the back surface deformity obtained with a noninvasive structured light method: evaluation of their usefulness in idiopathic scoliosis diagnosis

New noninvasive techniques, amongst them structured light methods, have been applied to study rachis deformities, providing a way to evaluate external back deformities in the three planes of space. These methods are aimed at reducing the number of radiographic examinations necessary to diagnose and follow-up patients with scoliosis. By projecting a grid over the patient's back, the corresponding software for image treatment provides a topography of the back in a color or gray scale. Visual inspection of back topographic images using this method immediately provides information about back deformity, but it is important to determine quantifier variables of the deformity to establish diagnostic criteria. In this paper, two topographic variables [deformity in the axial plane index (DAPI) and posterior trunk symmetry index (POTSI)] that quantify deformity in two different planes are analyzed. Although other authors have reported the POTSI variable, the DAPI variable proposed in this paper is innovative. The upper normality limit of these variables in a nonpathological group was determined. These two variables have different and complementary diagnostic characteristics, therefore we devised a combined diagnostic criterion: cases with normal DAPI and POTSI (DAPI < or = 3.9% and POTSI < or = 27.5%) were diagnosed as nonpathologic, but cases with high DAPI or POTSI were diagnosed as pathologic. When we used this criterion to analyze all the cases in the sample (56 nonpathologic and 30 with idiopathic scoliosis), we obtained 76.6% sensitivity, 91% specificity, and a positive predictive value of 82%. The interobserver, intraobserver, and interassay variability were studied by determining the variation coefficient. There was good correlation between topographic variables (DAPI and POTSI) and clinical variables (Cobb's angle and vertebral rotation angle).

Mass-casualty events at schools: a national preparedness survey

OBJECTIVE

Recent school shootings and terrorist events have demonstrated the need for well-coordinated planning for school-based mass-casualty events. The objective of this study was to document the preparedness of public schools in the United States for the prevention of and the response to a mass-casualty event.

METHODS

A survey was mailed to 3670 school superintendents of public school districts that were chosen at random from a list of school districts from the National Center for Education Statistics of the US Department of Education in January 2004. A second mailing was sent to nonresponders in May 2004. Descriptive statistics were used for survey variables, and the chi2 test was used to compare urban versus rural preparedness.

RESULTS

The response rate was 58.2% (2137 usable surveys returned). Most (86.3%) school superintendents reported having a response plan, but fewer (57.2%) have a plan for prevention. Most (95.6%) have an evacuation plan, but almost one third (30%) had never conducted a drill. Almost one quarter (22.1%) have no disaster plan provisions for children with special health care needs, and one quarter reported having no plans for postdisaster counseling. Almost half (42.8%) had never met with local ambulance officials to discuss emergency planning. Urban school districts were better prepared than rural districts on almost all measures in the survey.

CONCLUSIONS

There are important deficiencies in school emergency/disaster planning. Rural districts are less well prepared than urban districts. Disaster/mass-casualty preparedness of schools should be improved through coordination of school officials and local medical and emergency officials.

Selective screening for scoliosis

Scoliosis screening has been practiced for nearly 50 years and has provided valuable knowledge about the prevalence and natural history of scoliosis. Early diagnosis allows for nonoperative treatment, like wearing an orthosis that has been shown to be effective by numerous outcome studies. Challenges in scoliosis screening include the low prevalence rate of clinically significant scoliosis, the inverse relationship of sensitivity and specificity in the screening process because of the poor correlation of clinical deformity and radiographic abnormality, and the inflated cost of these programs because of overreferral. Recommendations for improvement include redefinition of what actually constitutes a "significant" scoliosis for screening, diagnostic, and outcome purposes; selective screening of only immature females; the use of objective referral criteria; and re-screening patients rather than referring those who have borderline cases.

The relation of joint laxity and trunk rotation

A study was designed to evaluate the joint laxity during scoliosis screening, and to show if there is a relation of joint laxity values to the trunk rotation. One thousand, two hundred and seventy-three children (598 females, 675 males) with an average age of 10.4 years were screened with a scoliometer and forward bending for trunk rotations. Scapular and shoulder elevations, flexible pes planus were recorded and joint laxity was evaluated with the Beighton score. There was high inter-observer and intra-observer reliability for both scoliometer and Beighton scores. In 41 children (3.2%) with Beighton score 7 or higher, trunk rotation measurements were higher than for the rest of the children. Trunk rotation measurements of 7 degrees or higher were found in 30 children, who were more lax than the rest of the group and were invited for radiography, with a detection of curves between 11 and 18 degrees in 10 of them. The Beighton score is a practical and reliable method for defining joint laxity. Although the number of patients with scoliosis was limited, there are findings supporting the relation between joint laxity and scoliosis. Moreover, there was increased laxity in children with increased trunk rotations. Ligamentous laxity may be one of the causes changing the contour of the back.

The effect of shoulder-girdle loading by a school bag on lung volumes in Chinese primary school children

BACKGROUND

Heavy loading of the spine may induce musculoskeletal problems in children. Local surveys reported frequent overloading of school bags carried by primary school children. The effect of an overweight school bag on the child's lung function has not been reported.

AIMS

To investigate the effect of shoulder-girdle loading on forced expiratory lung volumes in primary school children and to compare this effect with that of an assumed kyphotic posture.

STUDY DESIGN AND SUBJECTS

Forty-three primary school children, mean age 9.6 years underwent spirometry lung-function measurements, while adopting the following five conditions in random order: free standing; kyphotic standing; standing wearing a backpack weighing 10%, 20% and 30% of their body weight.

OUTCOMES MEASURES

Forced expiratory volume in the first second (FEV1), forced vital capacity (FVC) and peak expiratory flow rate (PEF).

RESULTS

There were no significant differences in FEV1 and FVC between free standing and the 10% body weight load. However, both FEV1 and FVC decreased significantly when the student adopted the kyphotic posture and when the load in the backpack was increased to 20% and 30% of body weight.

CONCLUSIONS

This study demonstrates a restrictive effect on lung volumes when a school-bag load is heavier than 10% of a child's body weight. Our results also confirm the detrimental effect of a kyphotic posture on pulmonary mechanics and the necessity for health-care professionals to advocate proper postural advice to school children, teachers and parents.