1 Postural Screening School Based Screening and Referral Decision MakingContent originally created by: Denise Lotufo PT, DPT, OCS, CSCI, CMT Mary Ann Wilmarth, PT, DPT , OCS, MTC, Cert. MDT Northeastern University Boston, MA Presentation format updated by: Therese Blain BSN, RN, Western MA regional consultant 10/13/16 Welcome to today’s presentation on postural screening, school-based screening and referral decision making. This presentation content was originally created by Dr. Denise [Lotufo] and Dr. Maryann Wilmarth who are Orthopedic clinical specialists from Northeastern University. I hope you enjoy this presentation as you are working become experts in postural screening and the decision-making process. Covering : Scoliosis Definition – Etiologies-Curve patterns, Diagnostic tools, Adams Forward Bending Test Postural Screening program- Observation
2 Scoliosis Scoliosis is derived from the Greek word Skoliosis, meaning curve Scoliosis is a description of the spines structural alteration Scoliosis is not a diagnosis Three broad categories: Neuromuscular Congenital Idiopathic Scoliosis is derived from the Greek word “skolios” meaning curved. Scoliosis is a description of the spine’s structural alteration stemming from three broad categories: Neuromuscular, Congenital, idiopatithic
3 Neuromuscular ScoliosisNeuromuscular scoliosis is the result of muscle imbalance and lack of trunk control due to neurologic or musculoskeletal problems stemming from issues such as cerebral palsy, myelomeningocele, muscular dystrophy or leg length discrepancy Neuromuscular Scoliosis makes up 10% of all patients Neuromuscular scoliosis is the result of muscle imbalance and lack of trunk control due to neurologic or musculoskeletal problems stemming from issues such as cerebral palsy, muscular dystrophy or leg length discrepancy. Neuromuscular scoliosis makes up ten percent of all patients.
4 Congenital Scoliosis Congenital Scoliosis is the result of a vertebral anomaly or asymmetry For example: a hemi vertebrae or failure of segmentation Congenital scoliosis usually occurs before adolescence Congenital Scoliosis makes up 15% of all patients (1,2,3,4,5) Congenital scoliosis is the result of a vertebral anomaly or asymmetry. For example, a hemi-vertebra or failure of segmentation can cause congenital scoliosis. Congenital scoliosis usually occurs before adolescence and congenital scoliosis makes up fifteen percent of all patients.
5 Idiopathic Scoliosis Idiopathic scoliosis refers to a spinal curve for which there is no discernible cause, and it typically occurs in children and adolescents who are otherwise healthy (6,7,8) It is therefore a diagnosis of exclusion Idiopathic Scoliosis makes up 65% of all patients (1) Three Subcategories for Idiopathic Scoliosis Infantile (early onset- 0-3years) Juvenile (early onset-4-9years) Adolescent (late onset- >10years) Idiopathic scoliosis refers to a spinal curve for which there is no discernable cause, and it typically occurs in children and adolescents who are otherwise healthy. It is therefore a diagnosis of exclusion. Idiopathic scoliosis makes up 65 percent of all patients. As you can see by this slide, the three subcategories also have other names. For example, the infantile and juvenile is also known as early onset. The adolescent is also known as the late onset. Infantile is known from zero to three years, the juvenile is four to nine years and adolescent is basically greater than a ten-year-old.
6 Adolescent Idiopathic ScoliosisAIS is the most common type of scoliosis and the leading cause of orthopedic problem in school aged children(6,7,10,11,12) Picture of a person with idiopathic scoliosis Of the 80% of those with scoliosis have idiopathic scoliosis a large majority of those are adolescent girls. Scoliosis is about two times more common in girls than boys affecting about 2% of females and 0.5% of males. Scoliosis can be seen at any age, but more common in those over 10 years old and may be in part due to the start at puberty or during a growth spurts
7 Adolescent Idiopathic ScoliosisAIS is defined as an abnormal side bending of the spine, causing the vertebral bodies to rotate toward the convexity of the curve and produce a distortion of the spine. (4,8,13-20) This distortion creates a 3-dimentional deformity of the spine. Furthermore, the 3 dimensional deformity occurs in the absence of congenital or neurological abnormalities (8) Picture of a spinal cord x ray from a Case Study: a 15 year old male with adolescent idiopathic scoliosis. (pdf) (idiopathic- of unknown origin) Adolescent idiopathic scoliosis is defined as the abnormal side bending of the spine causing the vertebral bodies to rotate towards the convexity of the curve and producing a “structural” distortion of the spine.
8 Spinal Alignment Structural vs. Non StructuralAIS is considered a structural scoliosis The presence of a rotary component to the spine curvature will determine if it is a structural or non structural Scoliosis With a structural scoliosis the spine will not correct in forward bending nor will it fully correct in a supine or bending radiograph (21,22) Structural versus non-structural. Adolescent idiopathic scoliosis is considered a structural scoliosis. The presence of a rotatory component to the spine curvature will determine if it a structural or a non-structural scoliosis. With a structural scoliosis the spine will not correct in forward bending, nor will it fully correct in a supine or bending radiograph.
9 Normal Spinal AlignmentCoronal View (Anteroposterior) 0° Curvature Sagittal (lateral) View Thoracic Kyphosis 20-40° Curvature Lumbar Lordosis 40-60° Curvature The normal spinal alignment in the coronal view, (The coronal plane, also called frontal plane, is a vertical cut that divide the body into front and back sections) that is if you’re looking at a person either from behind or from in front of them, you should not have any curvatures so there should be a zero degree of curvature in the coronal plane. *The coronal plane is looked at to evaluate scoliosis The sagittal, or median plane, is the vertical cut dividing into left & right sections. However, in the sagittal view you should see some curvatures, and that’s looking at the person from the side view. They should have a thoracic kyphosis. A slight curve should be about 20 to 40 degrees which is normal, and in the lumbar area there should be a lumbar lordosis and the curvature should be approximately 40 to 60 degrees. All this is normal.
10 Curvatures in the coronal plane are not part of the normal spine alignment and when they exist, with a minimum of 10 degrees, it is called scoliosis (23,24) Curvatures in the coronal plane are not part of the normal spine alignment and when they exist with a minimum of ten degrees it is called scoliosis.
11 Curve Patterns Curve direction either left or right is defined by its convexity Spinal location is defined by the vertebra that is most deviated and rotated from midline (2,25) Location Spinal Segments Thoracic T2-T11 Thoracolumbar T12-L1 Lumbar L2-L4 Curve patterns. Curve direction, either left or right, is defined by its convexity. Spinal location is defined by the vertebra that is most deviated and rotated from midline. Greater than 90 percent of all the adolescent idiopathic curves that occur in the thoracic region have a curve convexity that are to the right.
12 Curve Patterns R Convexity occur 90% of the time L ConvexityIn this slide you get an overview of the curve patterns, their common convexities and percentages. (READ convexities from slide) R Convexity occur 90% of the time L Convexity occurs 70% of the time R thoracic and L lumbar Convexities found 90% of the time R Convexity 80% of the time
13 Radiographic EvaluationCobb Method: Posterior-anterior radiographs of the full spine are used to assess lateral curvature Lateral curvature > 10 degrees measured with the Cobb method is diagnosed as scoliosis (23,25) To find measurement points locate the most tilted vertebrae above and below the apex of the curve is chosen. The angle between intersecting lines drawn perpendicular to the top of the top vertebrae and the bottom of the bottom vertebrae is the Cobb angle Radiographic evaluation and calculation. To confirm the diagnosis of scoliosis films are required. The films can also help determine the type of scoliosis, whether it’s congenital, neuromuscular or idiopathic. Adolescent idiopathic scoliosis is diagnosed by radiographic evaluation using the Cobb method that measure the degree of curve In the picture you can see how the Cobb angle is calculated by. Brief explanation is : using the most tilted vertebrae above and below the apex of the curve creates a triangular pattern – to find the angle intersecting perpendicular lines are drawn to the top of the top vertebrae and the bottom of the bottom vertebrae forming the Cobb angle. Films can also help evaluate skeletal maturity. The reason you need to know about skeletal maturity is because it will help determine the risks for the scoliosis progression.
14 Curve Progression Factors that can influence curve progression are:– Skeletal maturity – Curve patterns – Gender With AIS the skeletally immature patient has a greater risk of curve progression (29) Curve progression is determined by 2 sequential radiographs showing a greater than 5° change Curve progression. Facts that can influence curve progression are skeletal maturity, curve patterns and gender.
15 Risser Sign Stage 4 indicates >76%-100% ossification.The Risser sign is one measure used to assess skeletal maturity. It measures the apophysis ossification of the iliac crest The Risser staging process divides the maturing iliac crest into quarters and are staged form 0-5 Stage 4 indicates >76%-100% ossification. Stage 5 indicates the apophysis has fused to the iliac crest The iliac crest apophysis is one of the last ossification centers to appear and develop The Risser sign is one method used to assess skeletal maturity. It measures the epiphysis ossification of the iliac crest. The Risser staging process divides the maturing iliac crest into four quarters and are staged from zero to five. At stage five this indicates that the epiphysis has fused to the iliac crest. . (a·poph·y·sis (əˈpäfəsis) A lower Risser staging at the time of AIS diagnosis is a potential indicator for curve progression (29) Growth in females is usually complete in Risser stage 4 whereas males growth is compete in Risser stage 5
16 Curve Progression RiskSkeletal maturity Curve Sex Age Other Risser <2 Double curves Cobb >50° Girls 10x greater risk than boys Younger the patient is at diagnosis, greater the risk Pre-menarche girls In this slide you will see the curve progression risks as they pertain to skeletal maturity, curve, sex, age and if a girl is pre-menarche or not. Double curves tend to progress at a greater rate than single curves At first detection, the greater the curve magnitude the greater risk for curve progression Girls are 10x more at risk for curve progression than boys Diagnosis prior to the onset of menarche also places the girl at greater risk for curve progression (2,29,30)
17 Etiology Consensus at this time is that the etiology of AIS multifactorial It is widely accepted that there are genetic factors in the development of idiopathic scoliosis. Multiple epidemiological studies have shown that the prevalence of scoliosis is higher among individuals whose relatives have scoliosis than among the general population A family history of scoliosis is identified in approximately 30% of patients diagnosed with idiopathic scoliosis The identity of the affected gene in scoliosis is not known, nor is the normal gene in unaffected individuals known Monozygotic twins show a concordance rate of 73%, whereas dizygotic twins have a concordance rate of 36%. These findings suggest a single-gene disorder, but one that has variable penetrance and genetic heterogeneity (27, 28) Consensus at this time is that the etiology of AIS is multifactorial. It is widely accepted that there are genetic factors in the development of idiopathic scoliosis. Multiple epidemiological studies have shown that the prevalence of scoliosis is higher among individuals whose relatives have scoliosis than among the general population.
18 Evaluating Spinal CurvaturesThe first line of detection is the physical exam in the diagnosis of scoliosis Visual observation can best reveal scoliotic asymmetries Adolescents should be evaluated during their period of most rapid growth, and in which signs of curvature most often appear. Prevalence studies in England have found scoliosis was highest (1.2%) in patients aged years (9). Similar studies in the United States have found that AIS is present in 2 to 4 percent of children between 10 and 16 years of age The first line of detection is the physical exam in the diagnosis of scoliosis. Observation can best reveal scoliotic asymmetries.
19 What to look for : Visual inspectionIn the coronel view: Head: is it centered over the body? Shoulder: is one shoulder higher? Shoulder Blade: is it higher and or more prominent? Hip: is one hip higher and more prominent? Spine: is it obviously curved? Trunk: are there unequal gaps between the arms and the trunk? What to look for on first inspection? The student stands facing away from you, so you look at the head. Is it centered over the body? Next you would look at the shoulder. Is one shoulder higher? The next? The shoulder blade, is it higher or more prominent than the other? Hips. Is one hip higher or more prominent? The spine. Is it obviously curved? And then the trunk. Are there unequal gaps between the arms and the trunk?
20 Asymmetries of ScoliosisHead not centered over body? One shoulder higher? One shoulder blade higher, more prominent? Is there a notable curve in the spine? Unequal gaps between the arms? Asymmetries of scoliosis. Things to look for. Is the head not centered over the body? How about the shoulders? Is one shoulder higher than the other? The shoulder blade. Is it more prominent or is the spine obviously curved? Are there unequal gaps between the arms and the trunk? And is the hip more prominent than the other? One hip more prominent?
21 The Adams Forward Bend TestThe rotational component of scoliosis is quantified by measuring/observing the angle of trunk rotation (ATR) during the Adams forward bend test The subject bends maximally forward with knees extended, outstretched arms, palms facing each other, pointed towards the great toes with the feet together This brings the rib prominence or lumbar muscles into silhouette. A significant curve is likely if the difference between the height of the two sides is >1cm The Adams forward bend test is the most sensitive clinical examination The ability off the forward bent test to correctly identify individuals with and without scoliosis (sensitivity and specificity,, respectively) varies depending upon the skills off the examiner, location off the curve,, and the magnitude off the curve used as the gold standard (33-36) The Adams forward bend test. The rotation component of scoliosis is quantified by measuring or observing the angle of trunk rotation during the Adams forward bend test. The subject bends maximally forward with knees extended, outstretched arms, palms facing each other, pointed towards the great toes with the feet together. This brings the rib prominence or lumbar muscles into silhouette. A significant curve is likely if the difference between the height of the two sides is greater than 1cm.
22 Angle of Trunk Rotation (ATR)Here are a couple more views of the angle of trunk rotation. The one on your right is a posterior view looking at the student from behind. The one on the left is looking at the student from the side view which is also possible.
23 (R) Thoracic Curve What might you see?In a right (R) thoracic curve the R shoulder is elevated and the left (L) arm may appear longer. The R scapula moves upwards and laterally with a prominent medial edge Because off trunk rotation,, the L breast may be more prominent than the R Gaps between the dependent arms and the trunk are unequal If the left iliac crest (hip) is more prominent than the right, it may be signs off a thoracolumbar and lumbar curves In this slide we’re just going to take some time to think about what one might see. For example, in a right thoracic curve what might you see? In a right thoracic curve, the right shoulder may be elevated and the left arm may appear longer. The right shoulder blade, or scapula, moves upward and laterally with a prominent medial edge. Because of trunk rotation the left breast may be more prominent than the right. Gaps between the dependent arms and the trunk are unequal. If the iliac crest, the hip, is more prominent than the right, it may be signs of the thoracolumbar and lumbar curves.
24 Benign Torso AsymmetriesThe most common cause for false positives with the forward Bent Test is due to benign torso asymmetries. 40% of normal girls will have asymmetrical body growth/development During the AFBT there will be <1cm difference between the height of the two sides and all other signs of scoliosis are absent. It is also normal for the dominant upper extremity shoulder to be slightly lower then the non-dominant If you doubt there is a curve, then there probably is not one and the asymmetry is of no clinical significance. Benign torso asymmetries. The most common cause for false-positives with the forward bend test is due to benign torso asymmetries. Forty percent of normal girls will have asymmetrical body growth or development. During the Adams forward bend test there will be less than 1cm difference between the height of the two sides and all other signs of scoliosis are absent. It is also normal for the dominant upper extremity, shoulder, to be slightly lower than the non-dominant. If you doubt, there is a curve then there probably is not one and the asymmetry is one of no clinical significance.
25 Why might scoliosis go undetected?There are many reasons why scoliosis may be undetected until a substantial deformity has developed. These include: Nearly all cases are painless and produce no other symptoms Idiopathic scoliosis most often develops in the preadolescent or early adolescent period, an age of modesty which precludes parents from seeing their child's unclothed spines Routine physical examination of older children has been supplanted by episodic problem-related health care Currently popular loose clothing styles easily conceal significant deformity Why might scoliosis go undetected? There are many reasons why scoliosis may be undetected until a substantial deformity has developed, and these include nearly all cases are painless and produce no other symptoms. Idiopathic scoliosis most often develops in the pre-adolescent or early adolescent period and age of modesty, which precludes parents from seeing their child’s unclothed spines. Routine physical examination of older children has been superseded by episodic problem-related healthcare. Loose clothing styles easily conceal significant deformity.
26 Put it together Lets put it together and view a exam in progress (VIDEO)
27 MDPH POSTURAL SCREENING PROGRAMThe following is in accordance with the ‘Training Material for the Postural Screening Program from the Massachusetts Department of Health The purpose of postural screening is three fold: to detect early signs of spinal problems that should have further medical evaluation To provide regular monitoring (during periods of growth) To reduce the need for surgical remedies Screenings must be done annually in grades 5-9 due to MA general law Like other screening programs conducted in schools, this program is not intended to provide medical diagnosis, but rather detect possible signs for further medical evaluation The following is in accordance with the training material for the postural screening program from the Massachusetts Department of Health. A change in the regulations in April, 1980 requires all school systems in the Commonwealth of Massachusetts to begin providing postural screening in grades These grades cover the years in which adolescents experience most rapid growth, and in which signs of curvature most often appear. (READ SLIDE)
28 Planning phase 7. Prepare or duplicate copies of materials:Review the MDPH Training manual Are there current screening protocols or guidelines in place for your district/school? Read the "Questions and Answers on Postural Screening" section of the manual. Consult with other school staff regarding the program roles. Who is trained to conduct the screenings? School nurses role? - coordinating with PE?/conducting the screening? Arrange screening times, space, materials. Can it be planned to have the postural screening conducted with another mandated screening? Schedule times for initial contacts with class. Reminder notifications? Can Principal/Admin conduct an "All Call" to families Location/Privacy- set up by whom? 7. Prepare or duplicate copies of materials: A) Brochure B) Initial Letter to Parents C) Follow-up Letter to Parents D) Letter to Physician (referral) How & when are written notifications of Postural Screening program being provided to students families (Student Handbook Notification of Screenings, letters home) E) Postural Screening Worksheet
29 Implementation Notify Parent(s)/Letter Screen studentsObserve "No Hands On“ PRIVACY and autonomy Perform secondary screening as necessary Document screenings In students record On worksheet ???? Follow Up/Phone Call(s) for referred findings Document Submit "Postural Screening Final Report" form to DPH Boston Office. One form per school system Included in year-ending reports
30 Postural Screening Worksheet
31 Postural Screening ReviewPostural screening is a visual evaluation that will be evaluated from several views in accordance with the Massachusetts Department of Public Health Postural screening program training material Observation occurs over 5 different planes / views Postural screening review. Postural screening will be evaluated in several views in according with the Massachusetts Department of Public Health Postural Screening Program Training Manual. The following slides will address when a student should be referred to the MD.
32 Is the waistline the same on both sides orRefer to MD REFER IIF ANY 2 OUT OF 3 PRESENT A. Shoulder Is one shoulder higher than the other? B. Waist Is the waistline the same on both sides or is there a larger space between the arm and flank on one side? C. Hip Are the hips level and symmetrical or is one side higher and more prominent? In view number one, you refer to the MD if any two out of three are present of the following. A.) Shoulder. Is one shoulder higher than the other? B.) Waist. Is the waistline the same on both sides or is there a larger space between the arm and flank on one side? C.) Hip. Are the hips level and symmetrical or is one side higher and more prominent? In this view, if any two out of the three are present you refer to the MD.
33 Refer to MD REFER IF ANY 3 OUT OF 5 PRESENT A. HeadDoes the head line up over the crease in the buttocks or does it lean to one side? B. Shoulder Is one shoulder higher than the other? C. Scapula Is the wing on one shoulder blade higher or more prominent than the other? D. Spine Does there appear to be a curve when you observe the spine? E. Waist Is the waistline the same on both sides or is there a larger space between the arm and flank on one side? In view number two you refer to the MD if any three out of the following five are present. The head. Does the head line up over the crest of the buttocks or does it lean to one side? The shoulder. Is one shoulder higher than the other? The scapula. Is the wing on one shoulder blade higher or more prominent than the other? The spine. Does there appear to be a curve when you observe the spine? And finally, the waist. Is the waistline the same on both sides or is there a larger space between the arm and the flank on one side? So when you’re observing the student from behind if there are any three out of these five asymmetries you refer to the MD.
34 Refer to MD REFER IIF EIITHER PRESENT A. Round backIs there an exaggerated roundness in the upper back? B. Sway Back arch in the lower back? In view number three, you refer to the MD if either of these asymmetries appear. A.) A round back. Is there an exaggerated roundness in the upper back? Or B.) A swayback. Is there an exaggerated arch in the lower back? If either one of these are present you refer to the MD.
35 Refer to MD REFER IF PRESENT Chest Cage Hump Are both sides off theback symmetrical or is the chest cage prominent or bulging on one side? In view number four, you refer to the MD if there is a presence of a chest cage hump. Are both sides of the back symmetrical or is the chest cage prominent or bulging on one side?
36 Refer to MD REFER IIF PRESENT Spine Hump Is there an accentuatedmidline hump? In view number five, you refer to the MD if there is a presence of a spine hump. Is there an accentuated midline hump?
37 What do you think?
38 What do you think? Functional right thoratic scoliosis. Assymytric positioning of the trunk and back including rounded shoulders, prominent abdomen and forward head posture
39 What do you think? Final slide. What do you think A. / B.?Remember, observation is the key.
40 Congratulations! Factors that can influence curve progression are: Skeletal maturity, curve patterns and gender Consensus at this time is that the etiology of AIS multifactorial The first line of detection in the diagnosis of scoliosis is the physical exam Observation can best reveal scoliotic asymmetries-OBSERVATION IS KEY Inspection for asymmetries occurs within FIVE different views Curvatures in the coronal plane are not part off the normal spine alignment and when they exist, with a minimum off 10 degrees,, it is called scoliosis (23,24). . Hope that this has helped you become better postural screeners. Thank you for your time and for your attention. Good luck out there.
41 References 1. Orthopedic Interventions for Pediatric Patients: The Evidence for Effectiveness 2. UPTODATE WEB ADDRESS 3. Burwell RG. The British decision and subsequent events. Spine. 1988;13: Scaggs DL, Basset GS. Screening for idiopathic adolescent. Scoliosis. Am Fam Physician Mar;55(4): Reamy BV, Slakey JB. Adolescent idiopathic scoliosis: review and current concepts. Am Fam Physician 2001;64: Mirtz TA, Thompson MA, Greene L, Wyatt LA, Akagi CG. Adolescent idiopathic scoliosis screening for school, community, and clinical health promotion practice utilizing the PRECEDE-PROCEED model. Chiropr Osteopat Nov 30;13: Ashworth MA, Hancock JA, Ashworth L, Tessier KA. Scoliosis screening: an approach to cost/benefit analysis. Spine. 1988;13: Greiner KA. Adolescent idiopathic scoliosis: radio-logic decision-making. Am Fam Physician. 2002; 65: Stirling, AJ, Howel, D, Millner, PA, et al. Late-onset idiopathic scoliosis in children six to fourteen years old. A cross-sectional prevalence study. J Bone Joint Surg Am 1996; 78: McAlister, WH, Shackelford, GD. Classification of spinal curvatures. Radiol Clin North Am 1975; 13:93.
42 References (cont.) 11. Goldstein, LA, Waugh, TR. Classification and terminology of scoliosis. Clin Orthop Relat Res 1973; : Riseborough, EJ, Wynne-Davies, R. A genetic survey of idiopathic scoliosis in Boston, Massachusetts. J Bone Joint Surg Am 1973; 55: US Preventive Services Task Force. Screening for adolescent idiopathic scoliosis: policy statement. JAMA. 1993;269: DiGuiseppi C, ed, Atkins D, ed, Woolf SH, ed. US Preventive Services Task Force Guide to Clinical Preventive Services. 2nd ed. Alexandria, Va: International Medical Publishing Inc; Berg AO. Clinical guidelines and primary care: screening for adolescent idiopathic scoliosis: a report from the United States Preventive Services Task Force. J Am Board Fam Pract. 1993;6: Lonstein JE, Bjorklund S, Wanninger MH, Nelson RP. Voluntary school screening for scoliosis in Minnesota. J Bone Joint Surg Am. 1982;64: Lonstein JE. Why school screening for scoliosis should be continued. Spine. 1988;13: Gore DR, Passehl R, Sepic S, Dalton A. Scoliosis screening: results of a community project. Pediatrics. 1981;67: Soucacos PN, Soucacos PK, Zacharis KC, Beris AE, Xenakis TA. School screening for scoliosis: a prospective epidemiological study in northwestern and central
43 References (cont.) 20. Burwell RG. The British decision and subsequent events. Spine. 1988;13: Moe JH, Bradford DS, Winter RB, Lonstien JE. Classification and terminology. In: Mo JH, Bradnford DS, Winter RB, Lonstein JE, eds. Scoliosis and Other Spinal Deformities. Philadelphia, Pa. WB Saunders Co; 1978: Rieseborogh EJ, Herndon JH. Introduction and terminology. In: Rieseborogh EJ, Herndon JH,eds. Scoliosis and Other Deformities of the Axial Skeleton. Boston, Mass: Little Brown & Co Inc; 1975: Cobb, JR. Out line for the study of scoliosis: In Weinstein SL. Adolescent idiopathic scoliosis: prevalence and natural history. AAOS Instruct Course Lect 1989;38:115– Soucacos PN, Zacharis K, Soultanis K, Gelalis J, Xenakis T, Beris AE: Risk factors for idiopathic scoliosis: review of a 6-year prospective study. Orthop 2000, 23: Weinstein SL. Natural History. Spine. 1999;24: Inoue, M, Minami,S, Kitahara, H et al. Idiopathic scoliosis in twins studied by DNA fingerprinting: the incidence and type of scoliosis. J Bone Joint Surg Br 1998; 80: Kesling, KL, Reinker, KA. Scoliosis in twins. A meta-analysis of the literature and report of six cases. Spine 1997;22: Lonstein, JE, Carlson, JM. The prediction of curve progression in untreated idiopathic scoliosis during growth. J Bone Jojnt Surg AM 1984; 66:1061.
44 References (cont.) 29. Lonstein, JE, Winter, RB. The Milwaukee brace for the treatment of adolescent idiopathic scoliosis. A review of on thousand and twenty patients. J Bone Jojnt Surg AM 1994; 76: Rogala EJ, Drummond DS, Gurr J: Scoliosis: incidence and natural history. A prospective epidemiological study. J Bone Joint Surg Am 1978 Mar; 60(2): Karol LA, Johnston CE 2nd, Browne RH, Madison M: Progression of the curve in boys who have idiopathic scoliosis. J Bone Joint Surg Am 1993 Dec; 75(12): Cote, P, Kreitz, BG, Cassidy, JD,et al. A study of the diagnostic accuracy and reliability of the Scoliometer and Adam’s forward bend test. Spine 1993; 18: Goldberg, CJ, Dowling, FE, Fogarty, EE Moore, DP. School scoliosis screening and the United States Preventive Service Task Force. An examination of the longterm results. Spine 1995; 20: Krachalios, T Sofianos, J, Roidis, N, et al. Ten- year follow-up evaluation ofa school screening program for scoliosis. Is the forward-bending test an accurate diagnostic criterion fro the screening of scoliosis?. Spine 1999; 24: 2318