A Scoliosis Screening Program
Asha P. Wallace, MD Scoliosis is generally a painless condition in which there are one or more lateral-rotatory curvatures of the spine. However, if left untreated, it may progress to a severe crippling deformity with impairment of heart and lung function. When detected early, scoliosis often can be treated conservatively, the deformity minimized and its consequences prevented. Scoliosis is of concern to a school system because most cases are found first in young adolescents. The incidence in this age group is estimated to be ~ * ~the incidence in girls approximately 4.5 p e r ~ e n t , ' *with being five times greater than in boys. If cases are discovered early before growth is complete, non-surgical treatment can often be used successfully to correct deformities. A screening program was set up in the Needham Public Schools with the cooperation of the Massachusetts Department of Public Health. It was decided to screen boys and girls in grades 5, 6, 7 and 8 using existing personnel - school nurses and physical education instructors. Training was provided by an orthopedist, a physical therapist and other staff from the Massachusetts Department of Public Films and demonstrations were used. Prior to actual screening, parental permission was obtained using a negative consent form. The simple screening procedure was described to parents, as well as the method of referral to their private physician in the event an abnormality was detected. Parents were asked to sign and return the form only if they did not wish to participate in the program. Students were prepared for the screening by the school nurse, who explained the purpose of the examination and reassured them that it simply entailed DECEMBER 1977
observation while standing up straight and while bending over. For additional information, the nurse also recommended Judy Blume's Deenie, a book for this age group about a girl who has scoliosis and needs to wear a brace. In order to bring this new program to the attention of the community and encourage participation, short articles were published in the local newspapers. Primary care physicians in the area were assured in individual letters that the school personnel conducting the screening were trained by a well-known orthopedist specializing in this field, and that the school physician would recheck all initial referrals to reduce the number of unnecessary final referrals. The letter also stated that any child found to have a postural abnormality would be referred to hidher private physician. The actual screening was carried out during regularlyscheduled physical education classes. Each student was individually examined in privacy by the school nurse or physical education instructor. Referrals were made to the school physician for the following reasons: 1. 2. 3. 4. 5. 6. 7.
shoulders not level or even obvious spinal curvature ribs prominent on one side increased roundback increased swayback unequal hip prominence arm to body space unequal
When there was any question at all, referral was encouraged because of the newness of the program. The school physician rescreened every referral student individually, in privacy, and then made referrals as THE JOURNAL OF SCHOOL HEALTH
619
indicated to the student’s personal physician. This was done in a letter sent home by the school nurse, followed by a telephone call to the parents.
RESULTS Enrollment in grades 5 , 6, 7 and 8 2001 Number screened 1914 Number referred to school physician 252 Number referred by school physician 29 (9 boys, 20 girls) Eighty seven students did not participate in the program because many of their parents felt that they were receiving excellent preventive medical care from their private physicians and that a screening program would be redundant for them, Some of these students were already under treatment for scoliosis. DISCUSSION Needham is a suburban community of 30,000 with excellent medical services. The public school system requires every new student (kindergarten and transfer students) to have a thorough physical examination on entering, but no further physicals for the rest of the school career aside from sports physicals. Approximately 98 percent of kindergarten physicals are done by private physicians in the community. Since routine physicals are not required every three years, it was deemed advisable to screen the population at risk for scoliosis; although it was argued that many students have private annual physicals prior to attending camp and that very few new cases would be detected. The results show that, out of 1914 students screened, 29 were referred to private physicians - one for kyphosis and 28 for scoliosis. Two cases were severe enough to necessitate surgical correction. There were several advantages to this screening program. It was relatively simple to set up the program, and the training was provided without charge by the Massachusetts Department of Public Health. The screening procedure was simple and fast and could be scheduled during regular physical education periods. No new staff was necessary.
620
THE JOURNAL OF SCHOOL HEALTH
There were two interesting developments as a result of this program. First, the physical education instructors were alerted to the differences between apparent orthopedic defects due to poor posture and scoliosis or other back problems due to structural abnormalities, and they began to devise exercises to help those with poor posture. Second, a great deal of interest was aroused at the junior high level among ninth grade students who felt that they should have been included in the program. Many of these students went individually to their school nurse to be screened, and some of them did turn out to have scoliosis. In the future, this program will be conducted annually for grades 5-9. In addition, because of the familial nature of this condition: the siblings of those referred for scoliosis will be screened, regardless of grade level, after parental permission has been obtained.
1. Personal communication from Sandra Lezberg, MPH. 2. Moe JH, Winter RB: A plea for the routine school examination of children for spinal deformity. Minn Med 57:419, 1974. 3. Azen SP, Brooks HL et al: Scoliosis: a prospective epidemiological study. J Bone Joint Surg (Am) 57A2:968, 1975. 4. Lezburg SF: Screening for scoliosis: preventive medicine in a public school. Phys Ther 54:371, 1974. 5. Cowelk HR, Hensinger RN et al: Orthopaedic screening of school age children - a review of a 10 year experience. Orthopaedic Review 4:1, 1975. 6. Wynoe-Davies R: Genetic aspects of Idiopathic Scoliosis. Dev Med Child Neurol 15:809, 1973.
Asha Wallace, MD, is apart-time director of the School Health Services Department in the Needham Public Schools, Needham, Massachusetts. She is also an associate physician at Simpson Infirmary, Wellesley College, Wellesley, Massachusetts.
DECEMBER 1977
Asha P. Wallace, MD Scoliosis is generally a painless condition in which there are one or more lateral-rotatory curvatures of the spine. However, if left untreated, it may progress to a severe crippling deformity with impairment of heart and lung function. When detected early, scoliosis often can be treated conservatively, the deformity minimized and its consequences prevented. Scoliosis is of concern to a school system because most cases are found first in young adolescents. The incidence in this age group is estimated to be ~ * ~the incidence in girls approximately 4.5 p e r ~ e n t , ' *with being five times greater than in boys. If cases are discovered early before growth is complete, non-surgical treatment can often be used successfully to correct deformities. A screening program was set up in the Needham Public Schools with the cooperation of the Massachusetts Department of Public Health. It was decided to screen boys and girls in grades 5, 6, 7 and 8 using existing personnel - school nurses and physical education instructors. Training was provided by an orthopedist, a physical therapist and other staff from the Massachusetts Department of Public Films and demonstrations were used. Prior to actual screening, parental permission was obtained using a negative consent form. The simple screening procedure was described to parents, as well as the method of referral to their private physician in the event an abnormality was detected. Parents were asked to sign and return the form only if they did not wish to participate in the program. Students were prepared for the screening by the school nurse, who explained the purpose of the examination and reassured them that it simply entailed DECEMBER 1977
observation while standing up straight and while bending over. For additional information, the nurse also recommended Judy Blume's Deenie, a book for this age group about a girl who has scoliosis and needs to wear a brace. In order to bring this new program to the attention of the community and encourage participation, short articles were published in the local newspapers. Primary care physicians in the area were assured in individual letters that the school personnel conducting the screening were trained by a well-known orthopedist specializing in this field, and that the school physician would recheck all initial referrals to reduce the number of unnecessary final referrals. The letter also stated that any child found to have a postural abnormality would be referred to hidher private physician. The actual screening was carried out during regularlyscheduled physical education classes. Each student was individually examined in privacy by the school nurse or physical education instructor. Referrals were made to the school physician for the following reasons: 1. 2. 3. 4. 5. 6. 7.
shoulders not level or even obvious spinal curvature ribs prominent on one side increased roundback increased swayback unequal hip prominence arm to body space unequal
When there was any question at all, referral was encouraged because of the newness of the program. The school physician rescreened every referral student individually, in privacy, and then made referrals as THE JOURNAL OF SCHOOL HEALTH
619
indicated to the student’s personal physician. This was done in a letter sent home by the school nurse, followed by a telephone call to the parents.
RESULTS Enrollment in grades 5 , 6, 7 and 8 2001 Number screened 1914 Number referred to school physician 252 Number referred by school physician 29 (9 boys, 20 girls) Eighty seven students did not participate in the program because many of their parents felt that they were receiving excellent preventive medical care from their private physicians and that a screening program would be redundant for them, Some of these students were already under treatment for scoliosis. DISCUSSION Needham is a suburban community of 30,000 with excellent medical services. The public school system requires every new student (kindergarten and transfer students) to have a thorough physical examination on entering, but no further physicals for the rest of the school career aside from sports physicals. Approximately 98 percent of kindergarten physicals are done by private physicians in the community. Since routine physicals are not required every three years, it was deemed advisable to screen the population at risk for scoliosis; although it was argued that many students have private annual physicals prior to attending camp and that very few new cases would be detected. The results show that, out of 1914 students screened, 29 were referred to private physicians - one for kyphosis and 28 for scoliosis. Two cases were severe enough to necessitate surgical correction. There were several advantages to this screening program. It was relatively simple to set up the program, and the training was provided without charge by the Massachusetts Department of Public Health. The screening procedure was simple and fast and could be scheduled during regular physical education periods. No new staff was necessary.
620
THE JOURNAL OF SCHOOL HEALTH
There were two interesting developments as a result of this program. First, the physical education instructors were alerted to the differences between apparent orthopedic defects due to poor posture and scoliosis or other back problems due to structural abnormalities, and they began to devise exercises to help those with poor posture. Second, a great deal of interest was aroused at the junior high level among ninth grade students who felt that they should have been included in the program. Many of these students went individually to their school nurse to be screened, and some of them did turn out to have scoliosis. In the future, this program will be conducted annually for grades 5-9. In addition, because of the familial nature of this condition: the siblings of those referred for scoliosis will be screened, regardless of grade level, after parental permission has been obtained.
1. Personal communication from Sandra Lezberg, MPH. 2. Moe JH, Winter RB: A plea for the routine school examination of children for spinal deformity. Minn Med 57:419, 1974. 3. Azen SP, Brooks HL et al: Scoliosis: a prospective epidemiological study. J Bone Joint Surg (Am) 57A2:968, 1975. 4. Lezburg SF: Screening for scoliosis: preventive medicine in a public school. Phys Ther 54:371, 1974. 5. Cowelk HR, Hensinger RN et al: Orthopaedic screening of school age children - a review of a 10 year experience. Orthopaedic Review 4:1, 1975. 6. Wynoe-Davies R: Genetic aspects of Idiopathic Scoliosis. Dev Med Child Neurol 15:809, 1973.
Asha Wallace, MD, is apart-time director of the School Health Services Department in the Needham Public Schools, Needham, Massachusetts. She is also an associate physician at Simpson Infirmary, Wellesley College, Wellesley, Massachusetts.
DECEMBER 1977
