Further evaluation of the Walter Reed Visual Assessment Scale: correlation with curve pattern and radiological deformity

Determination of predictors associated with pain in non‑surgically treated adults with idiopathic scoliosis

BACKGROUND

It is recognized that pain related to adult individuals with idiopathic scoliosis (IS) substantially impacts individuals' daily activities and quality of life. The objective of this study was to identify the possible predictors of pain intensity in non‑surgically treated adults with IS.

METHODS

This cross-sectional study included 58 adults individuals with Lenke type 1 IS. Participants' sociodemographic characteristics were recorded, and pain severity, curvature severity, trunk rotation angle, disability, spinal mobility, cosmetic deformity perception, and quality of life were assessed. Regression analyses with various models were performed to determine the predictors of pain severity and the best model was selected based on performance criteria.

RESULTS

Strong associations were found between pain severity with curvature severity, spinal mobility, trunk rotation angle, perception of cosmetic deformity, disability, and quality of life (p < 0.05). It was observed that Lasso regression was the best model based on the performance criteria considered. According to this model, the primary predictors of pain intensity in adult IS were determined as curvature severity, spinal mobility, trunk rotation angle, cosmetic deformity perception, back-related disability and quality of life, in order of importance.

CONCLUSION

In accordance with the findings of this study, which examined for the first time the determinants of pain intensity in adult individuals with Lenke type 1 IS, we suggest that mentioned possible factors affecting and determining pain should be taken into consideration when establishing evaluation and treatment programs.

Measuring Outcomes in Spinal Deformity Surgery

Outcome assessment in adult spinal deformity has evolved from radiographic analysis of curve correction to patient-centered perception of health-related quality-of-life. Oswestry Disability Index and the Scoliosis Research Society-22 Patient Questionnaire are the predominantly used patient-reported outcome (PRO) measurements for deformity surgery. Correction of sagittal alignment correlates with improved PRO. Functional outcomes and accelerometer measurements represent newer methods of measuring outcomes but have not yet been widely adopted or validated. Further adoption of a minimum set of core outcome domains will help facilitate international comparisons and benchmarking, and ultimately enhance value-based healthcare.

SRS-22r Self-Image After Surgery for Adolescent Idiopathic Scoliosis at 10-year Follow-up

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To examine SRS-Self Image scores at up to 10 years after surgery for adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Self-image is complex with implications for surgical and patient-reported outcomes after AIS surgery. Surgically modifiable factors that impact self-image are inconsistently reported in the literature with few longer-term reports. We examined the rate and durability of self-image improvement.

MATERIALS AND METHODS

An AIS registry was queried for patients with up to 10 years of follow-up after AIS surgery. A mixed effects model estimated change in SRS-22 Self Image from baseline to 6 weeks, 1 year, 2 years, 5 years, and 10 years. All enrolled patients contributed data to the mixed effects models. A sub-analysis of patients with 1-year and 10-year follow-up evaluated worsening/static/improved SRS-22 Self Image scores examined stability of scores over that timeline. Baseline demographic data and 1-year deformity magnitude data were compared between groups using parametric and nonparametric tests as appropriate.

RESULTS

Data from 4608 patients contributed data to the longitudinal model; 162 had 1-year and 10-year data. Mean SRS-Self Image improvement at 10-year follow-up was 1.0 (95% CI: 0.9-1.1) point. No significant changes in Self-Image domain scores were estimated from 1-year to 10-year (all P >0.05) postoperative. Forty (25%) patients had SRS-Self Image worsening from 1 year to 10 years, 36 (22%) improved, and 86 (53%) were unchanged. Patients who worsened over 10 years had lower SRS-Self Image at baseline than those unchanged at enrollment (3.3 vs. 3.7, P =0.007). Neither radiographic parameters nor SRS-Mental Health were different at baseline for the enrolled patients.

CONCLUSION

Ten years after surgery, 75% of patients reported similar or better SRS-Self Image scores than one year after surgery. Nearly 25% of patients reported worsening self-image at 10 years. Patients who worsened had lower baseline SRS-Self Image scores, without radiographic or mental health differences at baseline or follow-up.

Factors influencing of quality of life in adolescent idiopathic scoliosis

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is the lateral and horizontal deformity of the vertebral column which occurs idiopathically during adolescence. The aim of this study is to identify independent predictors of quality of life in AIS patients.

METHODS

In total, 31 adolescent patients diagnosed with AIS aged between 10 and 18 years old were included in the study. The scoliosis severity was determined for each patient according to the Cobb method, and their scoliosis perception using the Walter Reed Visual Assessment Scale, a pain assessment was conducted based on the Visual Analog Scale, quality of life using the Scoliosis Research Society-22 questionnaire, and depression level according to the Children's Depression Scale. Multiple Linear Regression analysis was then performed in order to determine the independent determinants of health-related quality of life.

FINDINGS

According to the Linear Regression analysis results, children's depression scale, walter reed visual assessment scale, cobb, and anterior trunk rotation explained 52.7% of the variance as independent determinants of SRS-22.

INTERPRETATION

The study examined the determinants affecting the quality of life in AIS patients. The results of the study showed that scoliosis severity, perception of cosmetic deformity, degree of rotation, and depression level to be predictors of quality of life in AIS patients. "This trail registered with NCT05242601."

Is self-image, in reference to the gravitational vertical, altered in adolescent idiopathic scoliosis? A multicenter, single-blind, case-control study

PURPOSE

Adolescent idiopathic scoliosis (AIS) is associated with perturbation of orthostatic postural control. In humans, orthostatic postural control is organized around the gravitational vertical (GV). Perception of the GV involves a bottom-up process (central integration of multisensorial information) and a top-down process that uses cognitive mechanisms relying on body image. This study hypothesized that AIS would be associated with an erroneous central representation of verticality. The objective was to demonstrate an altered top-down process of sense of verticality in AIS.

METHODS

This multicenter, single-blind, case-control study evaluated 63 adolescent girls with AIS divided into two groups (major AIS (n = 31) and minor AIS (n = 32)) and 30 matched non-scoliotic adolescents. Participants scored their perception of trunk appearance in an upright position using a pictographic scale. The outcome measure was the difference between perception score and real trunk deformity.

RESULTS

Participants with major AIS presented with misperception of their trunk appearance in an upright position when compared with those with minor AIS or controls.

CONCLUSION

Adolescents with major AIS underestimate their trunk deformity in an upright position. This suggests an altered representation of body image, affecting top-down control of sense of verticality.

2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth

BACKGROUND

The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) produced its first guidelines in 2005 and renewed them in 2011. Recently published high-quality clinical trials on the effect of conservative treatment approaches (braces and exercises) for idiopathic scoliosis prompted us to update the last guidelines' version. The objective was to align the guidelines with the new scientific evidence to assure faster knowledge transfer into clinical practice of conservative treatment for idiopathic scoliosis (CTIS).

METHODS

Physicians, researchers and allied health practitioners working in the area of CTIS were involved in the development of the 2016 guidelines. Multiple literature reviews reviewing the evidence on CTIS (assessment, bracing, physiotherapy, physiotherapeutic scoliosis-specific exercises (PSSE) and other CTIS) were conducted. Documents, recommendations and practical approach flow charts were developed using a Delphi procedure. The process was completed with the Consensus Session held during the first combined SOSORT/IRSSD Meeting held in Banff, Canada, in May 2016.

RESULTS

The contents of the new 2016 guidelines include the following: background on idiopathic scoliosis, description of CTIS approaches for various populations with flow-charts for clinical practice, as well as literature reviews and recommendations on assessment, bracing, PSSE and other CTIS. The present guidelines include a total of 68 recommendations divided into following topics: bracing (n = 25), PSSE to prevent scoliosis progression during growth (n = 12), PSSE during brace treatment and surgical therapy (n = 6), other conservative treatments (n = 2), respiratory function and exercises (n = 3), general sport activities (n = 6); and assessment (n = 14). According to the agreed strength and level of evidence rating scale, there were 2 recommendations on bracing and 1 recommendation on PSSE that reached level of recommendation "I" and level of evidence "II". Three recommendations reached strength of recommendation A based on the level of evidence I (2 for bracing and one for assessment); 39 recommendations reached strength of recommendation B (20 for bracing, 13 for PSSE, and 6 for assessment).The number of paper for each level of evidence for each treatment is shown in Table 8.

CONCLUSION

The 2016 SOSORT guidelines were developed based on the current evidence on CTIS. Over the last 5 years, high-quality evidence has started to emerge, particularly in the areas of efficacy of bracing (one large multicentre trial) and PSSE (three single-centre randomized controlled trials). Several grade A recommendations were presented. Despite the growing high-quality evidence, the heterogeneity of the study protocols limits generalizability of the recommendations. There is a need for standardization of research methods of conservative treatment effectiveness, as recognized by SOSORT and the Scoliosis Research Society (SRS) non-operative management Committee.

Physiotherapy scoliosis-specific exercises - a comprehensive review of seven major schools

In recent decades, there has been a call for change among all stakeholders involved in scoliosis management. Parents of children with scoliosis have complained about the so-called "wait and see" approach that far too many doctors use when evaluating children's scoliosis curves between 10° and 25°. Observation, Physiotherapy Scoliosis Specific Exercises (PSSE) and bracing for idiopathic scoliosis during growth are all therapeutic interventions accepted by the 2011 International Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT). The standard features of these interventions are: 1) 3-dimension self-correction; 2) Training activities of daily living (ADL); and 3) Stabilization of the corrected posture. PSSE is part of a scoliosis care model that includes scoliosis specific education, scoliosis specific physical therapy exercises, observation or surveillance, psychological support and intervention, bracing and surgery. The model is oriented to the patient. Diagnosis and patient evaluation is essential in this model looking at a patient-oriented decision according to clinical experience, scientific evidence and patient's preference. Thus, specific exercises are not considered as an alternative to bracing or surgery but as a therapeutic intervention, which can be used alone or in combination with bracing or surgery according to individual indication. In the PSSE model it is recommended that the physical therapist work as part of a multidisciplinary team including the orthopeadic doctor, the orthotist, and the mental health care provider - all are according to the SOSORT guidelines and Scoliosis Research Society (SRS) philosophy. From clinical experiences, PSSE can temporarily stabilize progressive scoliosis curves during the secondary period of progression, more than a year after passing the peak of growth. In non-progressive scoliosis, the regular practice of PSSE could produce a temporary and significant reduction of the Cobb angle. PSSE can also produce benefits in subjects with scoliosis other than reducing the Cobb angle, like improving back asymmetry, based on 3D self-correction and stabilization of a stable 3D corrected posture, as well as the secondary muscle imbalance and related pain. In more severe cases of thoracic scoliosis, it can also improve breathing function. This paper will discuss in detail seven major scoliosis schools and their approaches to PSSE, including their bracing techniques and scientific evidence. The aim of this paper is to understand and learn about the different international treatment methods so that physical therapists can incorporate the best from each into their own practices, and in that way attempt to improve the conservative management of patients with idiopathic scoliosis. These schools are presented in the historical order in which they were developed. They include the Lyon approach from France, the Katharina Schroth Asklepios approach from Germany, the Scientific Exercise Approach to Scoliosis (SEAS) from Italy, the Barcelona Scoliosis Physical Therapy School approach (BSPTS) from Spain, the Dobomed approach from Poland, the Side Shift approach from the United Kingdom, and the Functional Individual Therapy of Scoliosis approach (FITS) from Poland.

Patients' and Parents' Perceptions of Appearance in Scoliosis Treated with a Brace: A Cross-Sectional Analysis

The perspective of trunk deformity is a matter of special concern for adolescent idiopathic scoliosis (AIS) patients. No research group has ever reported interviewing patients and their parents regarding differences in perception of body appearance in the course of Cheneau brace treatment. We aimed to investigate the level of agreement in the field of concerns and perceptions of spinal appearance in relation to brace- and scoliosis-related data between parents and female patients with AIS, treated with a Cheneau brace, by means of the Spinal Appearance Questionnaire-pl (SAQ-pl). In this cross-sectional study forty-one pairs of parents and female patients with AIS were asked to separately complete the Polish versions of the Spinal Appearance Questionnaire-pl patient form (SAQ-pl patient form) and the SAQ-pl parent form. Age of patients was 13.60 years SD 1.60 (range 10-17). Patients scored 2.70 (SD 0.60) and parents scored 2.70 SD 0.60 in the total score of the SAQ-pl. The study groups do not differ significantly in regards to the SAQ-pl results. The percentage of consistent answers on SAQ-pl items ranges from 34.10 % (item 20) to 78 % (item 8). Height, age and brace-wearing time per day, were significantly related to the differences in the patient-parent General perception of body shape (r s  = -0.51, r s  = -0.34, r s  = 0.36, respectively). Parents and female patients with AIS have similar concerns and perceptions of spinal appearance. The discrepancies in General perception of spinal appearance between parents and AIS females decrease with age of patient. Parental emotional support may contribute to minimizing the risk factors of psychological impairment, especially in late adolescents with AIS.

Prospective Assessment of Scoliosis-Related Anxiety and Impression of Trunk Deformity in Female Adolescents Under Brace Treatment

The aim of this study is to make a prospective analysis of changes in anxiety levels and determining their associations with a longitudinal subjective assessment of trunk deformity in adolescent females with scoliosis, in relation to clinical, radiological and brace-related data. The study design was comprised of three questionnaire assessments, with the second and third evaluations taking place 6 and 12 months after the beginning of the study, respectively. 36 AIS females treated conservatively were asked to fill in the Polish versions of the Spinal Appearance Questionnaire (SAQ-pl) and the trait version of the Spielberger's Anxiety Inventory for Children (STAIC-trait). High anxiety was indicated in 16.6, 8.3 and 8.3% during the 1st, 2nd and 3rd evaluations. Patients' results differ in regards to the Curve domain; the discrepancies concern the 2nd and 3rd and the 1st and 3rd evaluations (p = 0.028 and p = 0.003, respectively). The only association between STAIC-trait and SAQ-pl regards Trunk shift in the 1st evaluation (rs = 0.48). The logistic regression revealed that the duration of brace-wearing in months has a statistically significant (p = 0.021) influence on the probability of diagnosing patients' low anxiety levels in the 2nd assessment. Special attention should be paid to patients' emotional reactions later on as brace-wearing continues as well as to the results which support the point that patients' perceptions of spinal deformity do not deteriorate with treatment time. Clinicians need to be aware how patients' appearance-specific cognitions might be associated with levels of emotional distress and relate to clinical and radiological, scoliosis-related data.

Outcome instruments to assess scoliosis surgery

PURPOSE

To review and summarize the current knowledge regarding the outcome measures used to evaluate scoliosis surgery.

METHODS

Literature review.

RESULTS

Outcome instruments should be tested to ensure that they have adequate metric characteristics: content and construct validity, reliability, and responsiveness. In the evaluation of scoliosis, generic instruments to assess health-related quality of life (HRQL) have been used, such as the SF-36 questionnaire and the EuroQol5D instrument. Nonetheless, it is preferable to use disease-specific instruments for this purpose, such as the SRS-22 Patient Questionnaire and the quality of life profile for spinal deformities (QLPSD). More recently, these generic and disease-specific instruments have been complemented with the use of super-specific instruments; i.e., those assessing a single aspect of the condition or specific populations with the condition. The patients' perception of their trunk deformity and body image has received particular attention, and several instruments are available to evaluate these aspects, such as the Walter-Reed Visual Assessment Scale (WRVAS), the Spinal Appearance Questionnaire (SAQ), and the Trunk Appearance Perception Scale (TAPS). The impacts of brace use can also be measured with specific scales, including the Bad Sobernheim Stress Questionnaire (BSSQ) and the Brace Questionnaire (BrQ). The available instruments to evaluate the treatment for non-idiopathic scoliosis have not been sufficiently validated and analyzed.

CONCLUSIONS

Evaluation of scoliosis treatment should include the patient's perspective, which can be obtained with the use of patient-reported outcome measures.

Body appearance and quality of life in adult patients with adolescent idiopathic scoliosis treated with a brace or under observation alone during adolescence

STUDY DESIGN

The Scoliosis Research Society (SRS) brace study (published in the JBJS-A, 1995) was comprised of patients with adolescent idiopathic scoliosis with moderate curve sizes (25°-35°). Forty observed and 37 braced patients (77% of the original group) attended a follow-up, a mean of 16 years after onset of maturity.

OBJECTIVE

To analyze whether the subjectively evaluated present body appearance affects outcome as measured by quality of life in adult patients, previously treated by observation alone (nonbraced) or with a brace during adolescence.

SUMMARY OF BACKGROUND DATA

Few reports exist where validated outcome measures for body appearance have been used.

METHODS

Two quality-of-life questionnaires, the Scoliosis Research Society-22 (SRS-22) questionnaire and the 36-Item Short-Form Survey Instrument (SF-36), were answered. The patient's opinion on body appearance was evaluated pictorially (i.e., sketches) using the spinal appearance questionnaire, in which 7 aspects of asymmetry are graded. These scores were compared with curve sizes, scoliometer measurements for grading trunk asymmetry, and quality-of-life measures.

RESULTS

At follow-up, both groups were similar in terms of age (mean = 32 years) and curve size (mean = 35°). Distortion was inversely related to SRS-22 total score and satisfaction/dissatisfaction with management subscore, but not related to the SRS-22 function subscore. No difference was found between the groups in terms of trunk rotation, where the means were 10.7° and 10.8° for the nonbraced and braced patients, respectively. The nonbraced patients estimated that their body appearance was significantly less distorted than the braced patients (mean = 12.9 and 15.0, respectively; P = 0.0028).

CONCLUSION

Patients who experienced less body asymmetry were more satisfied with treatment and had a better quality of life. In spite of similar curve sizes and trunk rotation in both groups, the nonbraced patients felt that their body appearance was less distorted than that of the braced patients.

2011 SOSORT guidelines: Orthopaedic and Rehabilitation treatment of idiopathic scoliosis during growth

BACKGROUND

The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT), that produced its first Guidelines in 2005, felt the need to revise them and increase their scientific quality. The aim is to offer to all professionals and their patients an evidence-based updated review of the actual evidence on conservative treatment of idiopathic scoliosis (CTIS).

METHODS

All types of professionals (specialty physicians, and allied health professionals) engaged in CTIS have been involved together with a methodologist and a patient representative. A review of all the relevant literature and of the existing Guidelines have been performed. Documents, recommendations, and practical approach flow charts have been developed according to a Delphi procedure. A methodological and practical review has been made, and a final Consensus Session was held during the 2011 Barcelona SOSORT Meeting.

RESULTS

The contents of the document are: methodology; generalities on idiopathic scoliosis; approach to CTIS in different patients, with practical flow-charts; literature review and recommendations on assessment, bracing, physiotherapy, Physiotherapeutic Specific Exercises (PSE) and other CTIS. Sixty-five recommendations have been given, divided in the following topics: Bracing (20 recommendations), PSE to prevent scoliosis progression during growth (8), PSE during brace treatment and surgical therapy (5), Other conservative treatments (3), Respiratory function and exercises (3), Sports activities (6), Assessment (20). No recommendations reached a Strength of Evidence level I; 2 were level II; 7 level III; and 20 level IV; through the Consensus procedure 26 reached level V and 10 level VI. The Strength of Recommendations was Grade A for 13, B for 49 and C for 3; none had grade D.

CONCLUSION

These Guidelines have been a big effort of SOSORT to paint the actual situation of CTIS, starting from the evidence, and filling all the gray areas using a scientific method. According to results, it is possible to understand the lack of research in general on CTIS. SOSORT invites researchers to join, and clinicians to develop good research strategies to allow in the future to support or refute these recommendations according to new and stronger evidence.

Spinal appearance questionnaire: factor analysis, scoring, reliability, and validity testing

STUDY DESIGN

Cross sectional.

OBJECTIVE

This study presents the factor analysis of the Spinal Appearance Questionnaire (SAQ) and its psychometric properties.

SUMMARY OF BACKGROUND DATA

Although the SAQ has been administered to a large sample of patients with adolescent idiopathic scoliosis (AIS) treated surgically, its psychometric properties have not been fully evaluated. This study presents the factor analysis and scoring of the SAQ and evaluates its psychometric properties.

METHODS

The SAQ and the Scoliosis Research Society-22 (SRS-22) were administered to AIS patients who were being observed, braced or scheduled for surgery. Standard demographic data and radiographic measures including Lenke type and curve magnitude were also collected.

RESULTS

Of the 1802 patients, 83% were female; with a mean age of 14.8 years and mean initial Cobb angle of 55.8° (range, 0°-123°). From the 32 items of the SAQ, 15 loaded on two factors with consistent and significant correlations across all Lenke types. There is an Appearance (items 1-10) and an Expectations factor (items 12-15). Responses are summed giving a range of 5 to 50 for the Appearance domain and 5 to 20 for the Expectations domain. The Cronbach's α was 0.88 for both domains and Total score with a test-retest reliability of 0.81 for Appearance and 0.91 for Expectations. Correlations with major curve magnitude were higher for the SAQ Appearance and SAQ Total scores compared to correlations between the SRS Appearance and SRS Total scores. The SAQ and SRS-22 Scores were statistically significantly different in patients who were scheduled for surgery compared to those who were observed or braced.

CONCLUSION

The SAQ is a valid measure of self-image in patients with AIS with greater correlation to curve magnitude than SRS Appearance and Total score. It also discriminates between patients who require surgery from those who do not.

Assessment of spinal appearance in female patients with adolescent idiopathic scoliosis treated operatively

BACKGROUND

Body deformities in patients with scoliosis significantly affect appearance perception. The majority of studies on this topic have analyzed the relation between radiological and clinical assessment performed by doctors, and patients' perception of deformity. The object of this study was to adapt the Spinal Appearance Questionnaire (SAQ) to Polish conditions and to explore the perception of trunk deformity by female patients with adolescent idiopathic scoliosis.

MATERIAL/METHODS

Forty female patients who underwent surgical treatment for adolescent idiopathic scoliosis using the Cotrel-Dubousset method were asked to complete a Polish version of the Spinal Appearance Questionnaire. The mean preoperative Cobb angle of the thoracic curve in the study group was 55.3 degrees (SD 9.7). In the final postoperative examination the Cobb angle was 29.1 degrees (SD 10.1).

RESULTS

The general results of the SAQ demonstrated that the patients achieved a median of 34.48 points, showing a positive assessment of their appearance. Patients rated themselves most critically in the general, chest, surgical scar, symmetry of shoulders and waist domains. The logistic regression model revealed that only the size of the thoracic apical translation, with a model coefficient of -0.9138 (SE=0.350; p=0.013), has a statistically significant (p=0.002) influence on a good general result in the SAQ.

CONCLUSIONS

Patients assessed their appearance positively after surgical treatment. A higher thoracic apical translation value is related to a lower probability of achieving a good general result in the Spinal Appearance Questionnaire.

Patient evaluation in idiopathic scoliosis: Radiographic assessment, trunk deformity and back asymmetry

Progressive adolescent idiopathic scoliosis (AIS) produces specific signs and symptoms, including trunk and spinal deformity and imbalance, impairment of breathing function, pain, progression during adult life, and psychological problems, as a whole resulting in an alteration of the health-related quality of life. A scoliosis-specific rehabilitation program attempts to prevent, improve, or minimize these signs and symptoms by using exercises and braces as the main tools in the rehabilitation treatment. Patient evaluation is an essential point in the decision-making process and determines the selection of the specific exercises and the specifications of the brace design. However, this article is not addressed to scoliosis management. In this present article, a complete definition and discussion of radiological aspects, such as the Cobb angle, axial rotation, curve pattern classifications, and sagittal configuration, follow a short description of the three-dimensional nature of AIS. The relationship between AIS and growth is also discussed. There is also a section dedicated to the assessment of trunk deformity and back asymmetry. Other important clinical aspects, such as pain and disability, changes in other regions of the body, muscular balance, breathing function, and health-related quality of life, are not discussed in this present article.

A review of the trunk surface metrics used as Scoliosis and other deformities evaluation indices

BACKGROUND

Although scoliosis is characterized by lateral deviation of the spine, a 3D deformation actually is responsible for geometric and morphologic changes in the trunk and rib cage. In a vast related medical literature, one can find quite a few scoliosis evaluation indices, which are based on back surface data and are generally measured along three planes. Regardless the large number of such indices, the literature is lacking a coherent presentation of the underlying metrics, the involved anatomic surface landmarks, the definition of planes and the definition of the related body axes. In addition, the long list of proposed scoliotic indices is rarely presented in cross-reference to each other. This creates a possibility of misunderstandings and sometimes irrational or even wrong use of these indices by the medical society.

MATERIALS AND METHODS

It is hoped that the current work contributes in clearing up the issue and gives rise to innovative ideas on how to assess the surface metrics in scoliosis. In particular, this paper presents a thorough study on the scoliosis evaluation indices, proposed by the medical society.

RESULTS

More specifically, the referred indices are classified, according to the type of asymmetry they measure, according to the plane they refer to, according to the importance, and relevance or the level of scientific consensus they enjoy.

CONCLUSIONS

Surface metrics have very little correlation to Cobb angle measurements. Indices measured on different planes do not correlate to each other. Different indices exhibit quite diverging characteristics in terms of observer-induced errors, accuracy, sensitivity and specificity. Complicated positioning of the patient and ambiguous anatomical landmarks are the major error sources, which cause observer variations. Principles that should be followed when an index is proposed are presented.

The Trunk Appearance Perception Scale (TAPS): a new tool to evaluate subjective impression of trunk deformity in patients with idiopathic scoliosis

Background

Outcome assessment in idiopathic scoliosis should probably include patients' perception of their trunk deformity in addition to self-image. This can be accomplished with the Walter Reed Visual Assessment Scale (WRVAS). Nevertheless, this instrument has some shortcomings: the drawings are abstract and some figures do not relate to the corresponding radiological deformity. These considerations prompted us to design the Trunk Appearance Perception Scale (TAPS).

Methods

Patients with idiopathic scoliosis and no prior surgical treatment were included. Each patient completed the TAPS and SRS-22 questionnaire and underwent a complete radiographic study of the spine. The magnitude of the upper thoracic, main thoracic, and thoracolumbar/lumbar structural curves were recorded. The TAPS includes 3 sets of figures that depict the trunk from 3 viewpoints: looking toward the back, looking toward the head with the patient bending over and looking toward the front. Drawings are scored from 1 (greatest deformity) to 5 (smallest deformity), and a mean score is obtained.

Results

A total of 186 patients (86% females), with a mean age of 17.8 years participated. The mean of the largest curve (CMAX) was 40.2°. The median of TAPS sum score was 3.6. The floor effect was 1.6% and ceiling effect 3.8%. Cronbach's alpha coefficient was 0.89; the ICC for the mean sum score was 0.92. Correlation coefficient of the TAPS mean sum and CMAX was -0.55 (P < 0.01). Correlation coefficients between TAPS mean sum score and SRS-22 scales were all statistically significant, ranging from 0.45 to 0.52 (P < 0.05).

Conclusions

The TAPS is a valid instrument for evaluating the perception patients have of their trunk deformity. It shows excellent distribution of scores, internal consistency, and test-retest reliability, and has good capacity to differentiate the severity of the disease. It is simple and easy to complete and score, the figures are natural, and a new frontal view is included.

The impact of patient self assessment of deformity on HRQL in adults with scoliosis

Background

Body image and HRQL are significant issues for patients with scoliosis due to cosmetic deformity, physical and psychological symptoms, and treatment factors. A selective review of scoliosis literature revealed that self report measures of body image and HRQL share unreliable correlations with radiographic measures and clinician recommendations for surgery. However, current body image and HRQL measures do not indicate which aspects of scoliosis deformity are the most distressing for patients. The WRVAS is an instrument designed to evaluate patient self assessment of deformity, and may show some promise in identifying aspects of deformity most troubling to patients. Previous research on adolescents with scoliosis supports the use of the WRVAS as a clinical tool, as the instrument shares strong correlations with radiographic measures and quality of life instruments. There has been limited use of this instrument on adult populations.

Methods

The WRVAS and the SF-36v2, a HRQL measure, were administered to 71 adults with scoliosis, along with a form to report age and gender. Preliminary validation analyses were performed on the WRVAS (floor and ceiling effects, internal consistency and collinearity, correlations with the SF-36v2, and multiple regression with the WRVAS total score as the predictor, and SF-36v2 scores as outcomes).

Results

The psychometric properties of the WRVAS were acceptable. Older participants perceived their deformities as more severe than younger participants. More severe deformities were associated with lower scores on the Physical Component Summary Score of the SF-36v2. Total WRVAS score also predicted Physical Component Summary scores.

Conclusion

The results of the current study indicate that the WRVAS is a reliable tool to use with adult patients, and that patient self assessment of deformity shared a relationship with physical rather than psychological aspects of HRQL. The current and previous studies concur that revision of the WRVAS is necessary to more accurately represent the diversity of scoliosis deformities. Ability to identify disturbing aspects of deformity could potentially be improved by evaluating each WRVAS items against indicators of pain, physical/psychosocial function, and self image from previous measures such as the SRS, SF-36 or BSSQ-deformity.