D e a n Miller, Carol Sue Lever

Scoliosis Screening: An Approach Used In the School

Scoliosis, a common deformity of the musculo- skeletal system, can be extremely severe and crippling. Characterized by lateral curvature of the spine and rota- tion of the vertebral column around its long axis, it causes the ribs on the convex side of the curve to become prominent, pushes the scapulae backward and often throws the spine off balance so the head and shoulders lean to either side of the gluteal cleft.

Forms of scoliotic disease can be classified as postural or structural. I In postural scoliosis, the curve results from an incorrect relationship between parts of the body and the center of gravity. The curve which is usually small and will correct when the person bends demonstrates that no fixed rotation is present in the spine. Structural scoliosis cannot be corrected actively by the person and indicates bony changes with fixed rotation toward the convexity of the curve and the necessity of early treatment. Three main categories are congenital, paralytic/neuromuscular and idiopathic.

Keim’ found that idiopathic scoliosis occurs about seven times more in females than males and classified i t by age; infantile, juvenile and adolescent.

The most common type, adolescent idiopathic scoliosis, begins in the pre-pubertal and adolescent growth years.

The Ohio Department of Health estimates that 3 to 6 children of 1,000 will have sufficient curvature to re- quire treatment. Further, it recommends an annual scoliosis screening program for boys and girls in the sixth, seventh and eighth grades.’

The objectives in preventing and controlling scoliosis are early detection and prompt treatment. School

screening has proven to be a n effective mechanism for early d i a g n ~ s i s . ~

Follow-up includes observation, visual and/or radio- grapical assessment of progression of the curve(s) and external bracing with body jacket or plaster techniques and/or surgery.

Recent surveys report 3 to 22% of the children examined with a minor asymmetry of the spine undergo spontaneous resolution. Since predicting which minor curves will progress is impossible, i t is important that these children be carefully observed until they have stopped growing.

According to Gurr,6 curves of less than 15 degrees tend to stabilize as the skeleton matures. Thoracic curves of 45 degrees or more and lumbar curves of 36 degrees or more may continue to increase at the rate of one degree/a year even after maturity. Observations should continue throughout life, especially during pregnancy.

Therefore, the aim of any screening program is to observe youngsters prior to or into their adolescent growth spurt and notice early deformities so that bracing may be effective and surgical treatment avoided.’

DESCRIPTION OF THE PROJECT A screening program for detecting scoliosis symptoms

was initiated in four schools in the Toledo area. These schools did not previously have a scoliosis screening program and were all covered by the same school nurse. Sixth, seventh and eighth graders were invited to partici- pate and parents and teaching staff were informed

98 THE JOURNAL OF SCHOOL HEALTH FEBRUARY 1982

about the scope and treatment of scoliosis. After a second screening, referrals were made to the family phy- sician or to a spinal deformities clinic if two or more symptoms were exhibited. Follow-up conferences with parents and referred students were held to ensure that medical attention had been obtained.

GOALS OF THE PROJECT The project sought to: 1) bring to parents’, students’ and teachers’ attention

the need to detect the signs of scoliosis. 2) screen all students in the sixth, seventh and eighth

grades in the above mentioned four schools for symptoms of scoliosis.

3) refer students who, after a second screening, exhibited two or more signs of scoliosis one of them being the characteristic “hump,” to the family physician or to a spinal deformities clinic. 4) follow through on the referrals with parent and

student conferences to ensure that medical attention had been obtained.

METHODOLOGY During the initial interview for the school year with

the principals of each school, numerous screening pro- grams for the school health program were presented. One of these, new to each school and supported by each principal, was a screening program for detecting scoliosis signs. In order for any health screening program to be successful it is imperative to have the principal’s approval.

Next, a letter was sent to the Ohio Department of Health, Bureau of Crippled Children Services, stating that a scoliosis screening program was being initiated and requested their Scoliosis Screening Package which included sample letters, specific techniques for screen- ing and a list of Ohio Postural Screening Program Resources.

Thus, the anatomy and physiology of the normal spinal column and changes that occur in scoliosis were reviewed as well as the resumes of several scoliosis screening programs in the United States and Canada.

Six weeks before the proposed screening each teacher received a one-page description of scoliosis, its scope and treatment and the Ohio Department of Health’s suggested screening procedure. Literature was available to answer questions.

At the beginning of the month the screening was to be done, an article on scoliosis and the screening dates were published in the school newsletter which was sent t o each parent and, in two of the schools, to every family in the parish.

Further preparation included observing screening techniques at a school with an established scoliosis screening program. Also, St. Vincent Hospital, Spinal

Deformities Clinic, was contacted to obtain information on the clinic and necessary requirements for referral.

A week before the proposed screening, sixth, seventh and eighth graders were given information on scoliosis, a demonstration of the screening technique and a letter for their parents giving them the same information. The letter, revised from the sample sent in the Ohio Postural Screening Package, included the option for the parent or guardian to exclude the young person from the screening.

The first screening took place in the health room. A list of pass or recheck was kept and symptoms were noted to aid the second screening. All students with one or more symptoms were placed on the recheck list.

A second screening of three students with “rechecks” was made two weeks later. An experienced nurse scoliosis screener used the same procedure to examine these students. Students requiring referrals received a letter for their parents and family physicians. These letters were revised from the sample letters in the Ohio Postural Screening Package.

A list was also made of students with one finding to be followed in three months.

Two weeks after referrals were sent home, student conferences were held to ascertain status. Parent conferences were held if nothing had been done.

A summary of the program and results were included in the yearly report to each principal and a statistic report was sent to the Ohio Postural Screening Program.

SPECIFIC PROGRAM DATA Of the 261 students, 254 (97%) were screened. Of the

seven parents or guardians who refused to have their children screened, five said their children had received a physical examination within the last month which in- cluded a scoliosis check. Two others who refused be- cause they deemed it unnecessary were given personal conferences.

The primary screening in the health room provided privacy. Each teacher was contacted and asked to send students in groups of three to the room at a pre- determined time. The boys were screened with their shirts off. The girls were screened individually and were allowed to wear bras.

Care was taken to put the students at ease since they tend to be modest at this age. Many times parents d o not notice scoliosis symptoms because they seldom see their children undressed. Several times exercises were done with the boys to help them relax. Details were explained if observation of a discrepancy was made and students were told that they would be seen a second time.

Students were observed from the back and side while standing erect and as they bent forward halfway. From

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the back, observation of the torso: shoulder, scapula, and hip levels was made. Examination was made as to whether one shoulder was higher than the other. Hip’s were noticed to determine i f they were level: protrusion of the scapula was noted.

The following signs can be seen and are important in scoliosis screening:

1) Shoulders and scapula on the convex side of the curve tend to be higher;

2) Hip on the opposite side of the curve may be more prominent at the waist;

3) Arm on the convex side of the curve may be closer to the body. The eibow level with arms at 90 degrees should appear horizontal.

The alignment of the spinous processes was then assessed.The observer might wish to mark the spine lightly with colored ink in order t o see it in difficult cases.The scapula may be marked as well. The apex of most thoracic curves is t o the right and most lumbar curves are to the left. Any deviation of the spine may be observed from the occiput to the gluteal cleft. If devia- tion is present, the line will fall t o one side o r the other, over the gluteal fold. A plumb line may be useful here.6

Assessment from the side may uncover kyphosis, lordosis, “teen slouch”, or asymmetry in the level of the scapula. During the screening when one possible kyphosis was observed, a parent conference was held and subsequent doctor’s appointment scheduled for the summer. Eight students were advised on good posture.

Students were then asked to bend forward from the waist, with head and arms falling freely, feet slightly apart and finger tips touching each other. The chin was tucked up toward the chest. The screener looked first from the front and then from the back; standing directly in front or back with eyes level with the back. Looking at this level any difference in elevation of the rib cage on one side or the other of the spine could be observed. Scoliosis is detected in the forward bending position. The earliest consistent sign is a rotational prominence on forward bending. Ribs with a thoracic rib “hump” or a para-vertebral muscle mass in the lumbar area may be noted.4 All youngsters with an observable “hump” on one side of the spine are candidates for referral. Those with asymmetry of shoulder, hip or scapula but a normal bending forward test should be observed again in three months.

After two weeks, a nurse experienced in scoliosis screening used the same test to examine those needing to be rechecked. Age and progress in skeletal maturity were taken into account during assessment. Wallace suggests referral for the following reason^:^

1) shoulders not level or even 2) obvious spinal curvature 3) ribs prominent on one side

4) increased round back 5) increased sway back 6) unequal hip prominence 7) arm to body space unequal

In order to be conservative in the referrals, those youngsters exhibiting one or more signs on the forward bending test were referred. A watch list was made for 22 students who exhibited one or more suspicious findings of scoliosis when having a negative bending test. Another 11 were referred and three were assessed as normal. Three on the watch list and one of the referrals had a diagnosed scoliotic in the immediate family.

TABLE 1 Summary of Data

Girls Boys Totals Grades 6 7 8 6 7 X

Numbers Checked 37 44 50 37 46 40 254

Findings: One or more

Type of Follow-up I ) Need Rechecks 5 7 6 5 7 6 36

2) Watch 2 5 3 4 4 4 22

3) Refer to Med~cal Care 3 2 3 1 1 1 I I

signs of scoliosis 5 7 6 5 7 6 36

TOTALS 15 21 18 I 5 19 17

54 51

CONCLUSIONS AND RECOMMENDATIONS A scoliosis screening program implemented in four

Toledo area schools according to Ohio Depatment of Health recommendations, invited sixth, seventh and eighth grade students t o participate. lnformation was given to students and teaching staff and sent to parents. After two screenings, the second with an experienced scoliosis screener, eleven students (4.2%) out of 254 were found to have two or more signs of scoliosis and were referred to their family physician or a spinal deformities clinic for further evaluation. One additional referral was made for kyphosis. Follow-up with parents and referred students was made. All had doctors’ appointments by the end of the school term and will be followed in the fall. Information on two of these suggests bracing treatment may be required, four are being observed in three to six months and one was told she had no spinal deformity. Four had first appointments during the summer. A watch list was made during screening of students exhibiting one symptom of scoliosis who will be rescreened in three months.

100 THE JOURNAL OF SCHOOL HEALTH FEBRUARY 1982

Idiopathic adolescent scoliosis has no obvious cause aside from familial tendency but accompanies the pre- pubertal growth spurt. The area of the spine where the scoliosis develops and the age of onset are important guides to treatment and prognosis. Three types of follow-up care are available: observation, external bracing and/or surgery. The method selected is chosen according to progression of the curve and individual patient considerations. With early detection, prompt referral and continuous perfecting of treatment, surgery is usually preventable and the future for the scoliotic is bright.

The school nurse can be a positive force in scoliosis screening as an initiator of the program, a skilled detector of spinal changes, a resource liason between parent, school and community and in subsequent counseling for teachers, students and the scoliotic teen. As a result of this screening project the following recommendations were made:

1) Scoliosis screening should be included in the yearly school health program for selected classes or age groups.

2 ) All siblings of scoliotic youngsters regardless of age should be screened during future programs.

3) Thought should be given to including the fifth grade in screening. Several articles suggest this because of earlier puberty in some children.

4) A movie on scoliosis, available through St. Vincent Hospital, Spinal Deformities Clinic, should be shown to fifth through eighth grade students next year and made available for parent presentation.

1 . deToledo CH: The defect: Classification and detection. A m J NurcinX 79(9):1588-1591, 1979.

2. Keim H : Clinical LTwnpo.tiu: Scolio.si.c 30( I ) , Summit, New Jersey:CIBA Pharmaceutical Co., 1978.

3 . Scolio.ric - Cirrvulure " / [ h e Spine, published by Ohio Dept of Health, Bureau of Crippled Children Services, 246 N . High St., P.O. Box 118, Colurnbuu, Ohio 43216.

4. Lonstein J E : Screening for rpinal deformities in Minneyota xhools. Clrn Orrho & Relaled Re.$ 126:33-42, 1977.

3. No A U \ ~ O T \denliTied: A d o h c e n l idiopathic scoliosi\. Hrl/ M r d J 1(6176):1446, 1979.

6 . Gurr JF: A school xreening program that works. The Cunudiun Nirrre 73( 12):24-29, 1977.

7 . Dwyer AP et al: School wreening for scoliosiu: Our challenging respon5ibility. Aii.slrulrun & New ZeuluntlJ Sur,q 48(4):439-443, 1978.

8 . I h n n BH: Scoliosi\ screening. fecliulricr 61(5):794-797, 1978. 9. Wallace AP: A scoliosis screening program. J Sch Heulih

47( 10):619-620. 1977.

Dean F. Miller k a professor a( The University of Toledo, Department of Health Education, 2801 W. Bancro f t Street, Toledo, Ohio 43606. Carol Sire Lever, R N , MEd is a school nurse with the Airxiliarv Services Program of Toledo Public Schook, Toledo, Ohio.

FEBRUARY 1982 THE JOURNAL OF SCHOOL HEALTH 101